Rajit's Breathlessness

December 04, 2015 Print Friendly Version of this page Print Get a PDF version of this webpage PDF
Name
Rajit Kumar
DOB
22/09/82 (32 years)
Occupation
Typist
History
I have had 6 weeks of worsening breathlessness, cough, mild fever and in the last 2 weeks night sweats additionally. The breathlessness isn't associated with wheeze, is there all the time but worse when I exert myself. Not made worse by lying down or being at work or in the cold. It isn't severe just annoying. The cough is there all the time and I produce some yellow sputum when I cough. I sometimes wake up completely drenched. Some of the people living with me have had a bad cough too so it is probably just something going around and I need antibiotics. I have not had any chest pain, palpitations, leg swelling or have I been waking up gasping for breath. I have not been in contact with any sick animals or odd chemicals.
Past Medical History
I did have some treatment for some chest infection (in India) but never took all the antibiotics beyond the first month's dose because the pharmacy closed down. I have never been ill for this.
Drug History
Paracetamol recently. Nil else.
Family History
Nil
Social History
I am from India but came here 1 year ago to study and work. I smoke 5 cigarettes a day and have smoked for 10 years. I don't drink and have never taken recreational drugs. I live in a crowded flat with 10 other people. I am quite poor and have never seen a doctor in this country before. I deny any unprotected sex or having sex with men.

Introduces yourself
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1
Confirms name & age of patient
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1
Explains reason for consultation & builds rapport
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Gains consent
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Asks open question
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Asks about onset (gradual/sudden)
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Asks about duration and changes to breathlessness
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Enquires about exacerbating factors including exertion, chemicals/pollen, lying flat
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Asks about variability over the day: constant/progressively worse/worse in the morning or night
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Enquires about severity by asking about exercise tolerance on flat and up stairs and on rest
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Asks about any recent illness or previous shortness of breath
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Asks for cough and sputum and if present explores further
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Asks for orthopnoea and paroxyasmal nocturnal dyspnoea and if present explores further
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1
Asks for added breath sounds such as wheeze and if present explores further
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1
Asks for chest pain and characterises chest pain if present
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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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Checks for red flags: haemoptysis, weight loss, night sweats and hoarseness
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Checks if patient is current or ex-smoker and number of pack years
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Asks about past medical history (specifically hayfever, eczema, COPD and heart attacks)
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Asks about any family history of disease (specifically eczema, asthma, lung cancer/fibrosis)
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1
Establishes any drugs or over the counter medication patient is on
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Asks if patient has any allergies
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1
Asks if patient drinks or takes recreational drugs
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1
Elicits patients occupation and any possible exposure to asbestos
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1
Asks if patient has travelled anywhere recently
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Explores impact of shortness of breath on activities of daily living
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Explores and responds to ideas
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Explores and responds to concerns
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Explores and responds to expectations
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Shows empathy
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Avoids jargon
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Summarises back to patient
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Thanks patient
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Patient global score
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Gives reasonable differential diagnosis (tuberculosis, typical pneumonia, asthma, lung cancer)
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