Ramsay's Breathlessness

Name	Ramsay Tucker
DOB	13/08/42 (72 years)
Occupation	Retired Mechanic
History	For the last 2 months I have been feeling more breathless, particularly when I do any form of activity. I can only walk around 50 metres now where as 3 months ago I was fine! I don't feel breathless when I have been resting though unless I'm lying down when it can get so bad I wake up gasping for breath. I haven't noticed any wheeze or other odd breath sounds. I have a cough with some frothy sputum but no blood. Also been feeling some nausea from time to time. I have also had some leg swelling for around the same time. I deny any other symptoms including chest pain, palpitations, fever, night sweats or weight loss.
Past Medical History	Previous heart attack 4 years ago. Hypertension, diabetes, high blood cholesterol. Nil else.
Drug History	Aspirin, Ramipril, Simvastatin
Family History	Father died of heart attack at 60. Nil else.
Social History	I am an ex-smoker that used to smoke 10 a day for 40 years. Nil alcohol or recreational drug use. I am having a lot of trouble with my daily activities. I cannot shop or dress myself among many other things.

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
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 surgery 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	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 COPD and heart attacks)	0	1	2
Asks about any family history of disease	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
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 (congestive heart failure, valve disease, nephrotic syndrome)	0	1