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Name
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Steve French
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DOB
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11/10/1945 (72 Years)
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Occupation
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Farmer
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History
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Noticed that there has occasionally been streaks of blood in his sputum for the last month. Sputum is usually white. Had a cough for the last 2 years which has become progressively more frequent. Cough gets worse with viral illnesses and on exertion. He gets more breathless on exertion now, can only walk to the kitchen (10m) before needing to stop to take a break where he could previously walk 200m. Unintentional weight loss if asked, two belt holes in the last 6 weeks. No foreign travel. Possibly hoarse voice but no other symptoms
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Past Medical History
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COPD, Hypertension
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Drug History
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Allergy to Penicillin. Takes Amlodipine, Simvastatin and 2 inhalers
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Family History
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None
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Social History
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Smokers 30 cigarettes per day for over 50 years. Drinks a can of cider each night. Lives alone
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Introduction & consent
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Name & age
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Asks open question & clarifies it is not haematemesis
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Establishes duration and trigger (if present)
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Type: fresh, streaks in phlegm, clots
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Amount and frequency
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Time course (worsening, continuous, intermittent)
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Alleviating or exacerbating factors (specifically exertion, dust, smoke)
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Associated symptoms: chest pain, cough, fever, shortness of breath (pulmonary embolism), ankle swelling, wheeze, bone pain, nosebleeds (vasculitis)
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Screens for red flags (haemoptysis, weight loss, hoarseness, night sweats)
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Establishes if symptoms of anaemia are present: lethargy, palpitations, shortness of breath
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Asks for any recent illness, bleeding from elsewhere or any family members/contacts with similar symptoms
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Asks if patient smokes and clarifies how much and for how long
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Asks for any foreign travel
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Checks occupation of patient & checks for asbestos exposure
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Drug history and allergies
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Alcohol and illicit drug use
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Ideas
"Was there anything you thought it might be?" | |
Concerns
"What about it is worrying you in particular?" | |
Expectations
"Is there anything in particular you were hoping we would to today?" | |
Communication skills (empathy and avoids jargon)
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Summarises back to patient
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Gives reasonable differential diagnosis (lung cancer, COPD exacerbation, pneumonia, fibrosis)
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