1. Family history
1.1. No diseases run in the family
1.2. His dad had a heart attack at 64
2. Introduction
2.1. Greeted the patient
2.2. Introduced myself and the team
2.3. Took the patient's date of birth
2.3.1. Abdulkareem Sami
2.3.2. He said he's 27
2.3.3. His birthday does not match
2.3.3.1. 12-3-1407 = 15-11-1986
2.3.3.2. 25 years old
2.4. The patients general look
2.4.1. Smiling
2.4.2. Cooperative
2.4.3. Looks healthy and young
2.4.4. Good clothing
2.4.5. No face discolouration or jaundice
2.4.6. Normal hand shake
3. Chief complaint
3.1. What seems to be the problem?
3.2. Chest pain, and he's worried it's from his heart
4. History of present complaint
4.1. Pain assessment (SOCRATES)
4.1.1. Site
4.1.1.1. Middle of the chest
4.1.2. Onset
4.1.2.1. Does not remember, it was usual then it got worse in the last 2 weeks
4.1.3. Character
4.1.3.1. Sharp, stabbing pain
4.1.4. Radiation
4.1.4.1. None
4.1.5. Associated symptoms
4.1.5.1. Difficulty taking deep breath
4.1.6. Timing
4.1.6.1. 30 minutes episodes, comes twice a week
4.1.7. exacerbating and relieving factors
4.1.7.1. None Mentioned
4.1.8. severity
4.1.8.1. Sever (8 out of 10)
4.1.9. effects on life style
4.1.9.1. Stops him during work to take a rest during the attacks
4.2. FIFE
4.2.1. The patient is worried
4.2.2. He thinks he might have a heart problem because his dad had one, and because he smokes
4.2.3. The pain affects his functioning a little, as he has to take a rest during the pain attack when he's at work
5. Past medical history & surgery
5.1. None
6. Drug history
6.1. Only multiple vitamins supplement, 1 pill a day
6.2. Forgot to ask about allergies!!
7. Social and occupational history
7.1. Understanding the patient's context & social history
7.1.1. Occupation
7.1.1.1. Banker
7.1.2. Diet
7.1.2.1. Regular diet
7.1.3. Exercise
7.1.3.1. Does aerobic exercise 3-4 times a week
7.1.4. Relationship statues
7.1.4.1. Married with no children
7.1.5. Home life
7.1.5.1. Lives with his wife with no problems
7.1.6. Leisure activities
7.1.6.1. Travelling in vacations
7.1.6.1.1. Canada
7.1.6.1.2. Europe
7.1.6.1.3. Indonesia
7.1.6.1.4. Dubai
7.1.7. Substance misuse
7.1.7.1. Tobacco (15 cigarettes a day)
7.1.7.2. Alcohol
7.1.7.2.1. gets drunk twice a week in parties
7.1.7.3. Cannabis in parties too
7.1.8. Sexual history
7.1.8.1. No other partners, only his wife
8. Systematic inquiry
8.1. General symptoms
8.1.1. Well being
8.1.2. appetite
8.1.3. wight change
8.1.4. sleep
8.2. Cardio
8.2.1. No chest pain on exertion
8.3. Respiratory
8.3.1. Shortness of breath when taking deep breath during the pain attack
8.3.2. No cough
8.3.3. No wheeze
8.4. Gastrointestinal
8.4.1. No Nausea or vomiting
8.4.2. No indigestion
8.4.3. No heartburn
8.4.4. No abdominal pain
8.4.5. No change in bowl habit
8.5. Genitourinary
8.5.1. regular urine habits
8.5.2. No difficulty starting or dribbing
8.5.3. No multiple Sexual partners
8.6. Neurological
8.6.1. No headaches
8.6.2. No dizziness
8.6.3. No faints or blackouts
8.6.4. No weakness
8.7. Musculoskeletal
8.7.1. No Joint pain, stiffness or swelling
8.7.2. No Mobility problems
8.8. Skin
8.8.1. No skin rash
8.9. Endocrine
8.9.1. No Heat or cold intolerance
8.9.2. No change in sweating
8.9.3. No excessive thirst
9. Impression
9.1. Isolated musculoskeletal chest pain syndromes
9.1.1. Costochondritis fits
9.2. Differential diagnosis
9.2.1. Cardia causes
9.2.2. Pulmonary causes
9.2.3. GI causes
9.2.4. Skin and sensory nerves
9.2.5. Rheumatic disease
9.2.6. Non-rheumatic systemic disease
9.2.7. Psychogenic causes