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Name
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Charles Riley
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DOB
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11/04/1989 (25 years)
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Occupation
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History student
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History
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I am very untalkative and give single
word answers. 3 days ago I began experiencing pain under my left nipple. It
is a sharp stabbing pain. The pain does not move anywhere. It is better when I
am resting and worse when I am lifting things. If asked specifically, I admit
it is worse when I press it and that it began right after I went gym for the
first time. It is about 4/10 severity. I have no other symptoms.
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Past Medical History
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I had my appendix removed 3 years
ago. Nil else.
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Drug History
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I take vitamin A, C and D
supplements. I want to know what other supplements I should take to remain
healthy.
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Family History
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My mother killed herself, but she was
otherwise healthy and I don't know my father.
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Social History
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I have been in foster care for 2
years. I smoke 10 a day and drink heavily on the weekends. I smoke cannabis
most weekdays.
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Introduces yourself
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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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Excludes associated symptoms
including fever, cough, nausea, shortness of breath and palpitations
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0
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1
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2
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Enquires about exacerbating factors
including physical activity, lying down, coughing and chest tenderness
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0
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1
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2
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Enquires about alleviating factors including
rest, leaning forward, painkillers
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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
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0
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1
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Asks specifically for recent illness,
surgery and calf pain or leg swelling
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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 any pulmonary embolisms or clots
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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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Asks about any recent travel
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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 (musculoskeletal injury, anxiety, pericarditis etc)
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0
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1
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