Focussed History Take

Name	Andrew Clark
DOB	09/11/1963 (52 years)
Occupation	Financial director
History	I am quite frustrated to have been kept waiting, as I am very important within my firm and cannot afford to waste time. I have been experiencing pain in the centre of my chest for 2 months, however I do not think this is a big deal. It affects me when I exert myself, doing things such as running to catch a bus or walking briskly particularly when it is cold. Once I sit down, the pain resolves quite quickly. The pain has worsened over the last 2 months and is about 4-5/10, however it does not occur at rest. The pain does not move anywhere. I have not had any shortness of breath, palpitations, nausea, vomiting, cough, fever or any other symptoms.
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 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
Establishes site	0	1
Asks about onset	0	1
Elicits character of pain	0	1
Asks if pain radiates	0	1
Asks for nausea and sweating	0	1	2
Asks for shortness of breath	0	1
Asks for palpitations	0	1
Excludes loss of consciousness and dizziness	0	1	2
Excludes heartburn	0	1	2
Asks for fever, cough	0	1
Asks for heartburn/abdominal pain	0	1
Enquires about exacerbating factors including physical activity	0	1
Enquires about alleviating factors including rest	0	1
Asks about duration and changes to pain over time	0	1
Checks severity of pain	0	1
Asks about previous chest pain	0	1
Asks about recent illness and past medical history	0	1	2
Asks specifically for previous heart disease, stroke, diabetes, high cholesterol, hypertension and asthma	0	1
Asks about any family history of disease	0	1
Asks specifically if any family members have had cardiac disease below <55 years, cardiac disease, pulmonary embolism or sudden death	0	1
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
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	2
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 (angina pectoris,  aortic valve disease, myocardial infarction)	0	1