Print
PDF
Name
|
Jung Trombley
|
DOB
|
19/01/47 (67 years)
|
Occupation
|
Taxi driver
|
History
|
For at least 8 months I have been
experiencing worsening shortness of breath, excessive coughing and I have
been producing a lot of mostly clear sputum which is occasionally green. If
pressed this is above what I usually do as a smoker. I can only walk about
200 metres now but I'm not surprised by this as I am old. I also notice that
I'm wheezing so I must have asthma. I deny any other symptoms including chest
pain, waking up at night gasping for breath, palpitations, fainting, weight
loss, night sweats and fever.
|
Past Medical History
|
Type 2 Diabetes and high blood
pressure for 5 years controlled by diet alone
|
Drug History
|
Vitamin D tablets
|
Family History
|
Father had heart attack at 70 years.
Nil else
|
Social History
|
In third floor flat with no lift. I
struggle to get shopping and therefore also cook for myself. I am okay with
all other activities. My neighbour sometimes helps me with food. I smoke 40 a
day and have done so all my life since I was 18. I drink occasionally. I
smoked a lot of cannabis during my teenage years.
|
Introduces yourself
|
0
|
1
|
|
Confirms name & age of patient
|
0
|
1
|
|
Explains reason for consultation
& builds rapport
|
0
|
1
|
|
Gains consent
|
0
|
1
|
|
Asks open question
|
0
|
1
|
|
Asks about onset (gradual/sudden)
|
0
|
1
|
|
Asks about duration and changes to
breathlessness
|
0
|
1
|
|
Enquires about exacerbating factors
including exertion, chemicals/pollen, lying flat
|
0
|
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
previous shortness of breath
|
0
|
1
|
|
Asks for cough and sputum and if
present explores further
|
0
|
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 ankle oedema
|
0
|
1
|
|
Asks for any fever or contact with
anyone with similar symptoms or sick animals
|
0
|
1
|
|
Asks for any palpitations or
dizziness
|
0
|
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, COPD and heart attacks)
|
0
|
1
|
2
|
Asks about any family history of
disease (specifically eczema, asthma, lung cancer/fibrosis)
|
0
|
1
|
|
Establishes any drugs or over the
counter medication patient is on
|
0
|
1
|
|
Asks if patient has any allergies
|
0
|
1
|
|
Asks if patient drinks or takes
recreational drugs
|
0
|
1
|
|
Elicits patients occupation and any
possible exposure to asbestos
|
0
|
1
|
2
|
Asks if patient has travelled
anywhere recently
|
0
|
1
|
|
Explores impact of shortness of
breath on activities of daily living
|
0
|
1
|
2
|
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 (COPD, asthma, lung cancer, pneumonia)
|
0
|
1
|