1. Drug history
1.1. Only multiple vitamins supplement, 1 pill a day
1.2. Forgot to ask about allergies!!
2. Social and occupational history
2.1. Understanding the patient's context & social history
2.1.1. Occupation
2.1.1.1. Banker
2.1.2. Diet
2.1.2.1. Regular diet
2.1.3. Exercise
2.1.3.1. Does aerobic exercise 3-4 times a week
2.1.4. Relationship statues
2.1.4.1. Married with no children
2.1.5. Home life
2.1.5.1. Lives with his wife with no problems
2.1.6. Leisure activities
2.1.6.1. Travelling in vacations
2.1.6.1.1. Canada
2.1.6.1.2. Europe
2.1.6.1.3. Indonesia
2.1.6.1.4. Dubai
2.1.7. Substance misuse
2.1.7.1. Tobacco (15 cigarettes a day)
2.1.7.2. Alcohol
2.1.7.2.1. gets drunk twice a week in parties
2.1.7.3. Cannabis in parties too
2.1.8. Sexual history
2.1.8.1. No other partners, only his wife
3. Systematic inquiry
3.1. General symptoms
3.1.1. Well being
3.1.2. appetite
3.1.3. wight change
3.1.4. sleep
3.2. Cardio
3.2.1. No chest pain on exertion
3.3. Respiratory
3.3.1. Shortness of breath when taking deep breath during the pain attack
3.3.2. No cough
3.3.3. No wheeze
3.4. Gastrointestinal
3.4.1. No Nausea or vomiting
3.4.2. No indigestion
3.4.3. No heartburn
3.4.4. No abdominal pain
3.4.5. No change in bowl habit
3.5. Genitourinary
3.5.1. regular urine habits
3.5.2. No difficulty starting or dribbing
3.5.3. No multiple Sexual partners
3.6. Neurological
3.6.1. No headaches
3.6.2. No dizziness
3.6.3. No faints or blackouts
3.6.4. No weakness
3.7. Musculoskeletal
3.7.1. No Joint pain, stiffness or swelling
3.7.2. No Mobility problems
3.8. Skin
3.8.1. No skin rash
3.9. Endocrine
3.9.1. No Heat or cold intolerance
3.9.2. No change in sweating
3.9.3. No excessive thirst
4. Impression
4.1. Isolated musculoskeletal chest pain syndromes
4.1.1. Costochondritis fits
4.2. Differential diagnosis
4.2.1. Cardia causes
4.2.2. Pulmonary causes
4.2.3. GI causes
4.2.4. Skin and sensory nerves
4.2.5. Rheumatic disease
4.2.6. Non-rheumatic systemic disease
4.2.7. Psychogenic causes
5. Plan
5.1. Ruling out life-threatining diseases
5.2. Confirming Musculoskeletal pain
6. Personal reflection over the experience
6.1. Was a great start and a pleasant experience. I think I did will and only forgot to ask about the allergies
6.2. For improvement I must not use my list to remind me of some points, although I maintained good eye contact
6.3. I enjoyed my time
6.4. Asked about date of birth and found he's lying
6.5. Good communications skills and eye contact
6.6. Asked about alcohol, drugs, sex, life stressors
6.7. Summarized
7. Family history
7.1. No diseases run in the family
7.2. His dad had a heart attack at 64
8. Introduction
8.1. Greeted the patient
8.2. Introduced myself and the team
8.3. Took the patient's date of birth
8.3.1. Abdulkareem Sami
8.3.2. He said he's 27
8.3.3. His birthday does not match
8.3.3.1. 12-3-1407 = 15-11-1986
8.3.3.2. 25 years old
8.4. The patients general look
8.4.1. Smiling
8.4.2. Cooperative
8.4.3. Looks healthy and young
8.4.4. Good clothing
8.4.5. No face discolouration or jaundice
8.4.6. Normal hand shake
9. Chief complaint
9.1. What seems to be the problem?
9.2. Chest pain, and he's worried it's from his heart
10. History of present complaint
10.1. Pain assessment (SOCRATES)
10.1.1. Site
10.1.1.1. Middle of the chest
10.1.2. Onset
10.1.2.1. Does not remember, it was usual then it got worse in the last 2 weeks
10.1.3. Character
10.1.3.1. Sharp, stabbing pain
10.1.4. Radiation
10.1.4.1. None
10.1.5. Associated symptoms
10.1.5.1. Difficulty taking deep breath
10.1.6. Timing
10.1.6.1. 30 minutes episodes, comes twice a week
10.1.7. exacerbating and relieving factors
10.1.7.1. None Mentioned
10.1.8. severity
10.1.8.1. Sever (8 out of 10)
10.1.9. effects on life style
10.1.9.1. Stops him during work to take a rest during the attacks
10.2. FIFE
10.2.1. The patient is worried
10.2.2. He thinks he might have a heart problem because his dad had one, and because he smokes
10.2.3. The pain affects his functioning a little, as he has to take a rest during the pain attack when he's at work