Sabine's Cough

Name	Sabine Edmund
DOB	02/12/1989 (25 years)
Occupation	Speech therapist
History	I have been coughing every night for the last few weeks since I came back from Greece. I think I must have caught something from there! The cough is non-productive. If asked directly, I have noticed some shortness of breath which affects me when I am outside and sometimes my eyes get a little itchy. It really bothers me because I cannot sleep and I need some cough medicine to stop it. Deny chest pain or other symptoms.
Past Medical History	If asked directly, eczema as a child. Denies recent surgery or past clotting events
Drug History	Nil
Family History	If asked directly, mother had bad hayfever and eczema
Social History	5 cigarettes per day. Occasional alcohol. No recreational drug use.

Introduces yourself	0	1
Confirms name & age of patient	0	1
Explains reason for consultation & builds rapport	0	1
Gains consent	0	1
Asks open question	0	1
Establishes onset and duration	0	1
Asks for variability in the day e.g. diurnal/worse at night (asthma)	0	1
Asks for alleviating factors (e.g. being at home/work)	0	1
Asks for exacerbating factors (e.g. exercise, seasonal (asthma, COPD), pollen (asthma), chemicals, posture)	0	1	2
Establishes if dry or productive	0	1
Establishes severity and impact on life	0	1
Asks about any recent illnesses	0	1
Screens for red flags (haemoptysis, weight loss, hoarseness, night sweats)	0	1
Screens for associated respiratory symptoms (fever, shortness of breath, wheeze, chest pain - clarifying if pleuritic/burning suggestive of reflux disease)	0	1	2
Screens for associated cardiovascular symptoms (orthopnoea, ankle oedema, calf pain or swelling)	0	1
Screens for ENT associated symptoms (throat, coryza, rhinitis)	0	1
Elicits past medical history (specifically asthma, tuberculosis) and recent surgery	0	1
Elicits family history (specifically asking for atopy, tuberculosis, pulmonary fibrosis, clotting problems)	0	1
Elicits drug history (including use of ACE inhibitors, beta-blockers, methotrexate)	0	1
Checks for allergies	0	1
Checks if patient smokes or drinks	0	1
Checks occupation of patient	0	1
Asks if occupation or other involves exposure to dust or animals	0	1
Explores and responds to ideas	0	1
Explores and responds to concerns	0	1
Explores and responds to expectations	0	1
Shows empathy	0	1
Avoids jargon	0	1
Summarises back to patient	0	1
Thanks patient	0	1
Patient global score	0	1	2
Gives reasonable differential diagnosis (Asthma, Reactive airway disease, Viral upper respiratory tract infection)	0	1

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