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Name
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Stoyan Vanfossen
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DOB
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04/07/42 (72 years)
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Occupation
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Retired ship worker
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History
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I am a slow and soft spoken man. I
have had worsening non-productive cough and breathlessness for about 2 years.
Now I can't stand it and need it fixed. There isn't any blood when coughing,
it affects me all of the time and isn't worse at any time of day. The
breathlessness is mainly when I exert myself but nothing else makes it worse
or better. I haven't got any issues sleeping flat nor do I wake up gasping
for breath. I have not noticed any hoarseness of voice or changes to
sensation or weakness in my arms or hands. I have not had any fever but I
have had a little weight loss of 2kg over 6 months, felt a bit under the
weather, fatigued and some joint and muscle pain but then I am quite old now.
I have not had any other symptoms including swelling of my legs,
palpitations, chest pain or rash.
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Past Medical History
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Benign enlargement of prostate and
hypertension. Denies childhood infection of whooping cough.
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Drug History
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Ramipril
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Family History
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Father had type 2 diabetes, had 2
strokes, heart attack but died of bowel cancer. My mother had depression
because her parents died in a car accident, underactive thyroid, type 2
diabetes and hypertension
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Social History
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Nil smoker, alcohol or recreational
drugs. I live on the second floor and I am finding it difficult to even leave
the house, cook, get ready in the morning. I need help desperately.
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Introduces self
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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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Asks about onset (gradual/sudden)
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0
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1
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Asks about duration and changes to
breathlessness
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0
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1
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Enquires about exacerbating factors
including exertion, chemicals/pollen, lying flat
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0
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1
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2
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Asks about variability over the day:
constant/progressively worse/worse in the morning or night
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0
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1
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Enquires about severity by asking
about exercise tolerance on flat and up stairs and on rest
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0
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1
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2
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Asks about any recent illness or
previous shortness of breath
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0
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1
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Asks for cough and sputum and if
present explores further
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0
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1
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2
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Asks for orthopnoea and paroxyasmal
nocturnal dyspnoea and if present explores further
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0
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1
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Asks for added breath sounds such as
wheeze and if present explores further
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0
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1
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Asks for chest pain and characterises
chest pain if present
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0
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1
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Asks for ankle oedema
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0
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1
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Asks for any fever or contact with
anyone with similar symptoms
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0
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1
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Asks for any palpitations or
dizziness
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0
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1
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Checks for red flags: haemoptysis,
weight loss, night sweats and hoarseness
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0
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1
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2
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Checks if patient is current or
ex-smoker and number of pack years
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0
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1
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2
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Asks about past medical history
(specifically COPD and heart attacks)
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0
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1
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2
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Asks about any family history of
disease (specifically asthma, lung cancer, fibrosis)
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0
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1
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Establishes any drugs or over the
counter medication 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 drinks or takes
recreational drugs
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0
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1
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Elicits patients occupation and any
possible exposure to asbestos
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0
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1
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2
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Asks if patient has travelled
anywhere recently
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0
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1
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Explores impact of shortness of
breath on activities of daily living
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0
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1
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2
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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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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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1
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Summarises back to patient
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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 (fibrosis, asthma, COPD, lung cancer)
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0
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1
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