You are a foundation year doctor in A&E. A patient presents with increasing breathlessness.
1. Take a focused history from the patient.
2. Explain your differential diagnoses and management plan to the examiner.
Checklist
Checklist "RespiratoryHistory" not found
Management
Internally Approved
Surname/Nom (1)
Mikey
Given names/Prenoms (2)
Sasha
Date of birth/Date de naissance (4)
12 NOV 2005 (19)
Sex/Sexe (5)
f
PRESENTING COMPLAINT
You've been feeling increasingly short of breath over the past 24 hours. You're finding it difficult to complete sentences and feel very tight in your chest.
IDEAS, CONCERNS AND EXPECTATIONS
You're worried because this feels worse than your usual asthma attacks. You've had to sit up all night and couldn't get to university today. You want to know if you need to be admitted to hospital.
SYSTEMS REVIEW
Worsening wheeze and cough. Using inhaler every 2-3 hours but minimal relief. No fever or chest pain. No leg swelling. Unable to lie flat. Difficulty sleeping and speaking in full sentences.
PAST MEDICAL HISTORY
Asthma since childhood. Two previous hospital admissions for asthma, last one 8 months ago. Hay fever.
DRUG HISTORY
Salbutamol inhaler PRN (using much more frequently lately), Clenil Modulite 100mcg inhaler (admits poor compliance). No allergies.
FAMILY HISTORY
Mother and brother have asthma.
SOCIAL HISTORY
First-year university student. Lives in student accommodation. Non-smoker. No pets. Studies law.
