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Name
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Mihir Yunker
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DOB
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10/11/62 (52 years)
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Occupation
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Probation officer
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History
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I am angry that I have been waiting
so long to see someone about my breathlessness. It started 6 days ago and has
got progressively worse to the point I had to stop several times walking here
from my car. Usually I can run pretty far! I can't think of what caused it
and haven't been in contact with anyone with similar symptoms. The
breathlessness is much worse when I exert myself but nothing else seems to
change it. I have had to take quite a few days of work and I can't do that as
there isn't much support for me. Apart from the breathlessness, I have had a
cough and been producing some rusty coloured sputum a few times per day,
sharp chest pain which is worse on coughing and breathing in and fever for
the last 2 days. I have not been travelling anywhere. There is air
conditioning where I work which is quite humid and hasn't ever been checked.
I have had no contact with any animals apart from the birds I keep. The place
I work is very crowded. No diarrhoea, vomiting or other symptoms.
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Past Medical History
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Nil. No recent surgery or recent
illness.
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Drug History
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Nil
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Family History
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Nil
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Social History
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I live in a small badly kept flat. I
smoke 10 cigarettes a day and drink occasionally. I smoke a little cannabis
occasionally.
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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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Asks about onset (gradual/sudden)
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0
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1
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Asks about duration and changes to
breathlessness
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0
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1
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Enquires about exacerbating factors
including exertion, chemicals/pollen, lying flat
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0
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1
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2
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Asks about variability over the day:
constant/progressively worse/worse in the morning or night
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0
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1
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Enquires about severity by asking
about exercise tolerance on flat and up stairs and on rest
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0
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1
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2
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Asks about any recent illness or
surgery or previous shortness of breath
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0
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1
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Asks for cough and sputum and if
present explores further
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0
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1
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2
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Asks for orthopnoea and paroxyasmal
nocturnal dyspnoea and if present explores further
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0
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1
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Asks for added breath sounds such as
wheeze and if present explores further
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0
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1
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Asks for chest pain and characterises
chest pain if present
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0
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1
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Asks for any fever or contact with
anyone with similar symptoms or sick animals
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0
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1
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Asks for any palpitations or
dizziness
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0
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1
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Checks for red flags: haemoptysis,
weight loss, night sweats and hoarseness
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0
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1
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2
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Checks if patient is current or
ex-smoker and number of pack years
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0
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1
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2
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Asks about past medical history
(specifically hayfever, eczema and COPD)
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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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Establishes any drugs or over the
counter medication 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 drinks or takes
recreational drugs
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0
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1
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Elicits patients occupation and any
possible exposure to asbestos
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0
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1
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Asks if patient has travelled
anywhere recently
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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 (pneumonia, atypical pneumonia [Legionalla], asthma)
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0
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1
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