Jung's Breathlessness

Name	Jung Trombley
DOB	19/01/47 (67 years)
Occupation	Taxi driver
History	For at least 8 months I have been experiencing worsening shortness of breath, excessive coughing and I have been producing a lot of mostly clear sputum which is occasionally green. If pressed this is above what I usually do as a smoker. I can only walk about 200 metres now but I'm not surprised by this as I am old. I also notice that I'm wheezing so I must have asthma. I deny any other symptoms including chest pain, waking up at night gasping for breath, palpitations, fainting, weight loss, night sweats and fever.
Past Medical History	Type 2 Diabetes and high blood pressure for 5 years controlled by diet alone
Drug History	Vitamin D tablets
Family History	Father had heart attack at 70 years. Nil else
Social History	In third floor flat with no lift. I struggle to get shopping and therefore also cook for myself. I am okay with all other activities. My neighbour sometimes helps me with food. I smoke 40 a day and have done so all my life since I was 18. I drink occasionally. I smoked a lot of cannabis during my teenage years.

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
Asks about onset (gradual/sudden)	0	1
Asks about duration and changes to breathlessness	0	1
Enquires about exacerbating factors including exertion, chemicals/pollen, lying flat	0	1	2
Asks about variability over the day: constant/progressively worse/worse in the morning or night	0	1
Enquires about severity by asking about exercise tolerance on flat and up stairs and on rest	0	1	2
Asks about any recent illness or previous shortness of breath	0	1
Asks for cough and sputum and if present explores further	0	1	2
Asks for orthopnoea and paroxyasmal nocturnal dyspnoea and if present explores further	0	1
Asks for added breath sounds such as wheeze and if present explores further	0	1
Asks for chest pain and characterises chest pain if present	0	1
Asks for ankle oedema	0	1
Asks for any fever or contact with anyone with similar symptoms or sick animals	0	1
Asks for any palpitations or dizziness	0	1
Checks for red flags: haemoptysis, weight loss, night sweats and hoarseness	0	1	2
Checks if patient is current or ex-smoker and number of pack years	0	1	2
Asks about past medical history (specifically hayfever, eczema, COPD and heart attacks)	0	1	2
Asks about any family history of disease (specifically eczema, asthma, lung cancer/fibrosis)	0	1
Establishes any drugs or over the counter medication patient is on	0	1
Asks if patient has any allergies	0	1
Asks if patient drinks or takes recreational drugs	0	1
Elicits patients occupation and any possible exposure to asbestos	0	1	2
Asks if patient has travelled anywhere recently	0	1
Explores impact of shortness of breath on activities of daily living	0	1	2
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 (COPD, asthma, lung cancer, pneumonia)	0	1