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Name
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David Anderson
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DOB
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10/10/1956 (58 years)
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Occupation
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Banker
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History
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5 hours ago I developed a central
crushing chest pain. It began whilst I was watching TV, snacking on some
crisps, and became really severe really quickly. It moves to my left
shoulder. At first I thought it was heart burn because I was feeling quite
sick, but I think it might be a stomach bug because I've also been sweating.
I do not have any other symptoms. I don't usually do physical activity to
know if I get chest pain when I exercise. The only thing that made it better
was this spray thing and oxygen I was given in the ambulance. I don't think
it could get any worse.
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Past Medical History
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I have never been tested for diabetes
or had my cholesterol checked. My blood pressure is high so I have been
trying to cut down on my salt. I have no other medical conditions.
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Drug History
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Nil
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Family History
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My parents both had diabetes. My
mother died of a stroke and my father died of a heart attack in his early
fifties. I don't have any siblings. There are no other medical conditions
that run in the family.
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Social History
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I smoke 20 cigarettes a day. I have
to drink quite frequently when I see clients or go out after work. I am not
sure exactly how much I drink but it's probably not a lot. I don't take any
recreational drugs. I don't exercise much and my diet consists of a lot of
take outs because I am very stressed for time.
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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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Establishes site
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0
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1
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Asks about onset
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0
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1
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Elicits character of pain
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0
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1
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Asks if pain radiates
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0
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1
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Asks for associated symptoms of
nausea, sweating, loss of consciousness and shortness of breath
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0
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1
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2
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Excludes palpitations, fever, cough,
recent calf pain
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0
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1
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Excludes heartburn and abdominal pain
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0
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1
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Enquires about exacerbating factors
including physical activity, chest tenderness
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0
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1
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Enquires about alleviating factors
including rest and GTN spray
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0
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1
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Asks patient to rate severity of pain
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0
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1
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Asks about previous chest pain
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0
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1
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Asks about recent illnesses and past
medical history
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0
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1
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Asks specifically for previous heart
disease, stroke, diabetes, high cholesterol, hypertension
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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
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0
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1
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Asks specifically if any family
members have had cardiac disease below <55 years, diabetes, high blood
cholesterol
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0
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1
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2
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Establishes any drugs 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 smokes, drinks or
takes recreational drugs
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0
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1
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2
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Asks about diet and lifestyle
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0
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1
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Elicits patients occupation
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0
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1
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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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0
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1
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Summarises back to patient
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0
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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 (myocardial infarction, acute coronary syndrome, aortic dissection
etc)
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0
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1
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