Anamaria's Cough

Name	Anamaria Pascucci
DOB	11/12/1952 (62 years)
Occupation	Lift engineer
History	I have progressively been coughing more and more and felt more and more short of breath for the last few months. It is even worse when I get a chest infection as I can\'t even get any sleep then! It is usually always productive and (if asked directly) tends to improve when I smoke and is worst in the morning. I have never had blood in my sputum it is usually always white or yellow. I deny any weight loss, hoarseness or any other symptoms.
Past Medical History	Asthma. Never been admitted and well controlled.
Drug History	Salbutamol and steroid inhalers
Family History	Nil
Social History	30 cigarettes per day. Occasional alcohol. No recreational drug use. No exposure to asbestos.

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 onset and duration	0	1
Asks for variability in the day e.g. diurnal/worse at night (asthma)	0	1
Asks for alleviating factors (e.g. being at home/work)	0	1
Asks for exacerbating factors (e.g. exercise, seasonal (asthma, COPD), pollen (asthma), chemicals, posture)	0	1	2
Establishes if dry or productive	0	1
Elicits character of sputum (bloodstained, clots, green/yellow, offensive smell)	0	1
Establishes severity and impact on life	0	1
Asks about any recent illnesses	0	1
Screens for red flags (haemoptysis, weight loss, hoarseness, night sweats)	0	1
Screens for associated respiratory symptoms (fever, shortness of breath, wheeze, chest pain - clarifying if pleuritic/burning suggestive of reflux disease)	0	1	2
Screens for associated cardiovascular symptoms (orthopnoea, ankle oedema, calf pain or swelling)	0	1
Screens for ENT associated symptoms (throat, coryza, rhinitis)	0	1
Elicits past medical history (specifically asthma, tuberculosis) and recent surgery	0	1
Elicits family history (specifically asking for atopy, tuberculosis, pulmonary fibrosis, clotting problems)	0	1
Elicits drug history (including use of ACE inhibitors, beta-blockers, methotrexate)	0	1
Checks for allergies	0	1
Checks if patient smokes or drinks	0	1
Checks occupation of patient	0	1
Asks if occupation or other involves exposure to dust or animals	0	1
Asks for exposure to asbestos	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 (Chronic obstructive pulmonary disease, Lower respiratory tract infection, Asthma)	0	1