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Name
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Tina Black
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DOB
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04/03/1997 (22 years)
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Occupation
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History Student
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History
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She freaked out this morning when she saw some blood in her phlegm. She has had occasional fevers and has been feeling quite sweaty at night, occasionally waking up drenched. Was previously very fit and well. She denies any chest pain but has some back pain which she puts down to how much she has been coughing recently. She denies any weight loss, leg pain or swelling. No breathlessness or palpitations either.
Only if asked, 12 weeks ago she returned from a volunteer programme in rural India as part of her gap year. She met many of the locals there and there were definitely quite a few people coughing a lot. |
Past Medical History
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Appendix taken 4 months ago. Very frustrated how this was initially missed so will talk angrily and at great length about this
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Drug History
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NKDA. On the pill
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Family History
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Father has Diabetes and grandfather had heart attack
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Social History
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She just finished her gap year and is starting a masters in History after the summer. She started smoking during her gap year 5 cigarettes a day. Binges on the occasional weekend
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Introduction & consent
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Name, age, occupation
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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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Establishes character: fresh, streaks in phlegm, clots
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Establishes amount and frequency
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Establishes 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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Checks risk factors for pulmonary embolism (calf pain/swelling, recent surgery, long flight or coach trip, malignancy, oral contraceptive/pregnancy)
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Elicits past medical history (specifically asking for lung disease, heart disease, autoimmune disorders, clotting problems)
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Elicits family history (specifically asking for lung disease, vasculitis, clotting problems)
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Elicits drug history
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Asks if patient has had BCG vaccination
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Asks for any foreign travel
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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 (Tuberculosis, Viral respiratory tract infection, pulmonary embolism)
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