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Name
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Amir Chakma
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DOB
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27/05/1945 (71 years)
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Occupation
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Retired Receptionist
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History
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I have COPD and have less than a year left. It is managed with
many inhalers which I take regularly. I have been admitted to ITU several
times with pneumonia, however they said they will not admit me to ITU if this
happens again preferring to support me at home to die.
I have been feeling really breathless over the last week, more
than usual. I also have had a sharp chest pain over the same amount of time.
I have no other symptoms to report except my usual symptoms of COPD including
cough with some white sputum. I am not able to walk whereas previously I
could walk to the bathroom 20 steps away. I have not lost any weight. I am
very keen on oxygen to treat this and I demand it frequently. I have not
tried anything for it as I am sure nothing apart from oxygen will work.
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Past Medical History
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Hypothyroidism
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Drug History
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Levothyroxine, Salbutamol, Tiotropium, Ipratropium and various
other inhalers I don't remember. Allergy to Penicillin causing anaphylaxis.
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Family History
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Nil
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Social History
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I am a current smoker of 5 per day. I am supported by my wife
who does the daily activities. I am able to usually eat, get dressed and get
to the toilet but have been having difficulties doing this. I usually spend
most my time in the chair. I am keen on speaking to people from the Christian
faith to see if they can help support me spiritually.
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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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Briefly clarifies long
term diagnosis, management and prognosis
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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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Onset and time course
of breathlessness
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0
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1
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Duration and changes to
breathlessness
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0
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1
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Exacerbating/alleviating
factors of breathlessness
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0
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1
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Asks about exercise
tolerance
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0
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1
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Asks about
cough/sputum, orthopneoa/paroxysmal nocturnal dyspnoea, chest pain
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0
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1
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Checks for red flags: haemoptysis,
weight loss, night sweats
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0
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1
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Screens for pain
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0
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1
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Screens for
constipation
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0
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1
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Screens for anorexia
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0
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1
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Screens for nausea
& vomiting
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0
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1
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Elicits past medical
history
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0
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1
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Elicits drug history
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0
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1
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Checks for allergies
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0
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1
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Establishes what
patient has tried so far for symptoms
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0
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1
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Discusses
breathlessness management (fan/opening windows/positioning/physiotherapy,
oxygen/benzodiazepines/opiates)
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0
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1
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Suggests to patient
that they may need further tests to identify cause (giving examples)
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0
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1
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Asks about spiritual or
religious beliefs and whether support is wanted
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0
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1
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Asks about social
support and mentions services available (e.g. McMillan)
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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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