Name
David Anderson
DOB
10/10/1956 (58 years)
Occupation
Banker
History
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.
Past Medical History
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.
Drug History
Nil
Family History
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.
Social History
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.

Introduces self
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
Establishes site
0
1
Asks about onset
0
1
Elicits character of pain
0
1
Asks if pain radiates
0
1
Asks for associated symptoms of nausea, sweating, loss of consciousness and shortness of breath
0
1
2
Excludes palpitations, fever, cough, recent calf pain
0
1
Excludes heartburn and abdominal pain
0
1
Enquires about exacerbating factors including physical activity, chest tenderness
0
1
Enquires about alleviating factors including rest and GTN spray
0
1
Asks patient to rate severity of pain
0
1
Asks about previous chest pain
0
1
Asks about recent illnesses and past medical history
0
1
Asks specifically for previous heart disease, stroke, diabetes, high cholesterol, hypertension
0
1
2
Asks about any family history of disease
0
1
Asks specifically if any family members have had cardiac disease below <55 years, diabetes, high blood cholesterol
0
1
2
Establishes any drugs patient is on
0
1
Asks if patient has any allergies
0
1
Asks if patient smokes, drinks or takes recreational drugs
0
1
2
Asks about diet and lifestyle
0
1
Elicits patients occupation
0
1
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 (myocardial infarction, acute coronary syndrome, aortic dissection etc)
0
1