Hello. Please, have a seat.
Thank you.
My name’s Elisa Rose. I’m a nurse practitioner and I’m going to take your medical history today.
What’s your name?
Jack Thornton.
Mr Thornton, would you prefer me to call you by your first name or surname?
Jack is fine.
Thanks. Now, Jack, for me to be able to help you today, I’m going to take your medical history,
so I need to ask you questions about your health and also your social circumstances. Is that OK with you?
Sure.
Good. Before we start, I just want to confirm your details. So, it's Jack Thornton, and you are 32 years old, and is this your address? …
Ah, … yes. That’s right.
Perfect. Thanks. So, how can I help you today?
Well, I've had a cough for a few days, and it's um, … annoying because it doesn’t seem to be getting any better.
I see. How long have you had the cough?
I suppose about three or four days now.
Three or four days. And have you got any other symptoms with this cough?
Well, I've a sore throat, and that's quite bad as well.
Right. And the sore throat, have you had it for the same amount of time?
Yes, pretty much the same time.
OK. So, the cough and the sore throat, …
is it worse at any particular time of the day or night?
Well, the cough is worse first thing in the morning
and the sore throat is fairly constant.
And is it difficult to swallow with your sore throat?
Ah, no. I can still swallow OK.
You can. You can drink. OK.
And the cough, can you describe it for me?
Well, it's a loose kind of cough, and I cough up stuff, .. you know, like phlegm.
Right. OK. And what colour is the phlegm that you’re coughing up?
I think it’s sort of green.
Is it. I see. Is it in large amounts or ....
Ah, yeah, a fair amount.
A fair amount. Is there any blood in it?
No, there's no blood.
OK, and how bad, on a scale of one to ten, is the cough for you?
Ten being the worst possible cough.
I’d say about a seven.
Right.
And is there any other part of your chest that is painful?
Well, my throat and my neck are quite sore when I cough.
I see.
... but apart from that it's just the sore throat.
Now,
what makes the cough or sore throat better for you?
Nothing really.
I've tried some over-the-counter things from the chemist, but that didn't help.
For the throat, a warm drink seems to help.
Is there anything that makes it worse?
Not really.
Well, maybe when I lie down,
like when I’m in bed.
So, what do you think it is, … the cause of the cough?
I don’t know. I think I need some antibiotics to get rid of it.
I see. OK. … I just want to ask you more specific questions now.
You said that there’s no blood in the phlegm, …
but is there any fever, any shivering or anything like that?
Maybe on the first day I had a bit of a fever. Yeah.
OK.
And what about breathlessness? Have you had any breathing problems or pains in your chest?
No.
Nothing at all.
OK.
Now I want to go through some of your key body systems, Jack, just to find out about your overall health.
Do you suffer from headaches at all?
I sometimes get headaches.
Do you.
How often do you have headaches?
About once a month.
I see.
And have you seen your doctor about that?
No, I usually just take some painkillers and it goes away.
Fine.
Do you ever have nasal congestion or sinus problems?
Ah, … well it does happen sometimes when I’m around cats.
They can make me sneeze a bit.
Right. Are you allergic to cats?
Yeah, I think so.
I think I might be.
Oh, … pity. OK. Um,
what about your taste when you eat? Any change in your taste?
No, not that I’ve noticed.
Do you get mouth ulcers at all?
Sometimes I do. … like when I’m really busy at work, or something, and get a bit stressed.
Right. OK. So, you have a sore throat now.
Do you have recurrent sore throats?
No, I don’t.
Maybe every year or two.
Not often.
Now a little bit about your surgical past.
Have you ever had any operations?
Well, I had an operation … it must be about 12 years ago now, …
some sort of operation on my back.
I see. Do you remember what exactly was done?
Um, it was a while ago now. Ah I think it was a lami… something …
A laminectomy?
Yes, that’s right.
OK.
And has it been all right since then?
Yes, fine. No problems at all.
And have you had any other operations?
No. That was the only one.
Good.
What about your blood pressure? Do you check it regularly?
Yes, well … I’ve got high blood pressure.
I see.
And when was that diagnosed?
Well that was diagnosed about three or four years ago now.
And is it well controlled?
Well I go …
yeah, I think so. I go to the doctor regularly to have my blood pressure checked and it seems OK.
Perfect.
When was it last checked?
It was last checked about two weeks ago.
OK.
And what about diabetes? Do you have any diabetes, or anybody in your family?
Ah, yes, yes. I’m diabetic.
Right. And do you know what type?
Ah, it’s the one with the tablets.
OK, so you take tablets.
When were you diagnosed with diabetes?
That was about three years ago now.
OK, and when was your last check-up?
Ah, I had that at about the same time I had the blood pressure check-up.
Right. Perfect. And that was all fine?
Yes, that was all fine.
OK, good. Brilliant.
Do you take any prescribed medicines?
I know you’ve got diabetes and high blood pressure.
I do. I take um, … I take Ramipril, and I take Metformin,
and there’s another one I take, one that begins with g, for diabetes. Gluco…
Glucoside.
Yes.
Glucoside. Good. And do you know the dosage of the Ramipril?
I think it’s 5 milligrams.
5 milligrams. And do you take it regularly?
Oh yeah.
Good.
Do you know if you have any drug allergies?
No, I don’t think so.
OK.
And any food allergies, like nuts or anything like that?
Ah, … no. I eat just about everything.
Now, a bit about your social background, if you don’t mind me asking. What’s your occupation?
Well, I work in construction.
Right. OK.
Have you been exposed to dust lately or toxic substances?
No, not recently.
And are you happy at work?
Yes. Plenty of work at the moment, so that’s good.
And do you smoke at all?
Yes, I do.
How many cigarettes do you smoke a day?
Well, about a packet every two days.
I see.
And at what age did you start smoking?
Ah, when I was about 18.
Age 18.
I just want to sum up, Jack, if you don’t mind.
Please correct me if I have any of this wrong.
You’ve had this cough and sore throat for the last three days.