Rajit's Breathlessness

Name	Rajit Kumar
DOB	22/09/82 (32 years)
Occupation	Typist
History	I have had 6 weeks of worsening breathlessness, cough, mild fever and in the last 2 weeks night sweats additionally. The breathlessness isn't associated with wheeze, is there all the time but worse when I exert myself. Not made worse by lying down or being at work or in the cold. It isn't severe just annoying. The cough is there all the time and I produce some yellow sputum when I cough. I sometimes wake up completely drenched. Some of the people living with me have had a bad cough too so it is probably just something going around and I need antibiotics. I have not had any chest pain, palpitations, leg swelling or have I been waking up gasping for breath. I have not been in contact with any sick animals or odd chemicals.
Past Medical History	I did have some treatment for some chest infection (in India) but never took all the antibiotics beyond the first month's dose because the pharmacy closed down. I have never been ill for this.
Drug History	Paracetamol recently. Nil else.
Family History	Nil
Social History	I am from India but came here 1 year ago to study and work. I smoke 5 cigarettes a day and have smoked for 10 years. I don't drink and have never taken recreational drugs. I live in a crowded flat with 10 other people. I am quite poor and have never seen a doctor in this country before. I deny any unprotected sex or having sex with men.

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 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
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 (tuberculosis, typical pneumonia, asthma, lung cancer)	0	1