Mihir's Breathlessness

December 07, 2015 Print Friendly Version of this page Print Get a PDF version of this webpage PDF
Name
Mihir Yunker
DOB
10/11/62 (52 years)
Occupation
Probation officer
History
I am angry that I have been waiting so long to see someone about my breathlessness. It started 6 days ago and has got progressively worse to the point I had to stop several times walking here from my car. Usually I can run pretty far! I can't think of what caused it and haven't been in contact with anyone with similar symptoms. The breathlessness is much worse when I exert myself but nothing else seems to change it. I have had to take quite a few days of work and I can't do that as there isn't much support for me. Apart from the breathlessness, I have had a cough and been producing some rusty coloured sputum a few times per day, sharp chest pain which is worse on coughing and breathing in and fever for the last 2 days. I have not been travelling anywhere. There is air conditioning where I work which is quite humid and hasn't ever been checked. I have had no contact with any animals apart from the birds I keep. The place I work is very crowded. No diarrhoea, vomiting or other symptoms.
Past Medical History
Nil. No recent surgery or recent illness.
Drug History
Nil
Family History
Nil
Social History
I live in a small badly kept flat. I smoke 10 cigarettes a day and drink occasionally. I smoke a little cannabis occasionally.

Introduces yourself
0
1
Confirms name & age of patient
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1
Explains reason for consultation & builds rapport
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1
Gains consent
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1
Asks open question
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1
Asks about onset (gradual/sudden)
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1
Asks about duration and changes to breathlessness
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1
Enquires about exacerbating factors including exertion, chemicals/pollen, lying flat
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1
2
Asks about variability over the day: constant/progressively worse/worse in the morning or night
0
1
Enquires about severity by asking about exercise tolerance on flat and up stairs and on rest
0
1
2
Asks about any recent illness or surgery or previous shortness of breath
0
1
Asks for cough and sputum and if present explores further
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1
2
Asks for orthopnoea and paroxyasmal nocturnal dyspnoea and if present explores further
0
1
Asks for added breath sounds such as wheeze and if present explores further
0
1
Asks for chest pain and characterises chest pain if present
0
1
Asks for any fever or contact with anyone with similar symptoms or sick animals
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1
Asks for any palpitations or dizziness
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1
Checks for red flags: haemoptysis, weight loss, night sweats and hoarseness
0
1
2
Checks if patient is current or ex-smoker and number of pack years
0
1
2
Asks about past medical history (specifically hayfever, eczema and COPD)
0
1
2
Asks about any family history of disease
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1
Establishes any drugs or over the counter medication patient is on
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1
Asks if patient has any allergies
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1
Asks if patient drinks or takes recreational drugs
0
1
Elicits patients occupation and any possible exposure to asbestos
0
1
Asks if patient has travelled anywhere recently
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 (pneumonia, atypical pneumonia [Legionalla], asthma)
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1