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Name
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Rohit Clark
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DOB
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09/11/1953 (61 years)
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Occupation
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Financial director
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History
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I am a talkative person who needs to
be interrupted. I had a really sudden, really painful pain in the centre of
my chest. It was so bad that I lost consciousness which was embarrassing as I
was in a meeting at the time. It was a tearing pain that moved to my back.
The pain was 10/10 in severity if not 11/10. Nothing made it worse or better.
If pressed, I remember feeling a little dizzy before I collapsed and this
feeling that I was going to die. When I regained consciousness I was not
confused. I cannot think of anything that triggered this pain.
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Past Medical History
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I have never suffered from chest pain
or any other diseases. I am not aware of having high blood pressure but the
rest of my family does have it.
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Drug History
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Nil
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Family History
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My father, mother and brother all
have very high blood pressure. I have been meaning to get it checked.
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Social History
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I do smoke around 10 per day but I
don't drink. The smoking is just to cope with stress. I do not take
recreational drugs. I live with my wife who I would really like to call and
have so far been unable to do so.
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Introduces yourself
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0
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1
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Confirms name & age of patient
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0
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1
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Explains reason for consultation
& builds rapport
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0
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1
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Gains consent
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0
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1
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Asks open question
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0
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1
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Establishes site
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0
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1
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Asks about onset
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0
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1
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Elicits character of pain
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0
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1
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Asks if pain radiates
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0
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1
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Asks for nausea and sweating
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0
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1
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2
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Asks for shortness of breath
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0
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1
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Asks for palpitations
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0
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1
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Asks for loss of consciousness and
dizziness
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0
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1
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2
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Asks for loss of sensation, balance,
vision and weakness
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0
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1
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2
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Asks for seizure and confusion
following waking up
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0
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1
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Asks for fever, cough
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0
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1
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Asks for heartburn/abdominal pain
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0
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1
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Enquires about exacerbating factors
including physical activity
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0
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1
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Enquires about alleviating factors
including rest
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0
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1
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Asks about duration and changes to
pain over time
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0
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1
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Checks severity of pain
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0
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1
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Asks about previous chest pain
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0
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1
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Asks about recent illness and past
medical history
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0
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1
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2
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Asks specifically for previous heart
disease, stroke, diabetes, high cholesterol, hypertension and asthma
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0
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1
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Asks about any family history of
disease
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0
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1
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Asks specifically if any family
members have had cardiac disease below <55 years, cardiac disease,
pulmonary embolism or sudden death
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0
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1
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Establishes any drugs patient is on
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0
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1
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Asks if patient has any allergies
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0
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1
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Asks if patient smokes, drinks or
takes recreational drugs
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0
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1
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Asks about diet and lifestyle
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0
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1
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Elicits patients occupation
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0
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1
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Explores and responds to ideas
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0
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1
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Explores and responds to concerns
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0
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1
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2
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Explores and responds to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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Gives reasonable differential
diagnosis (aortic dissection, myocardial infarction, aortic valve disease)
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0
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1
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