Asthma exacerbation

  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 and have been paged by the ward sister to review a patient

Patient: 45 year old patient, has acutely become short of breath

– Take a focused history from the patient
– Perform a full ACDE assessment, a nurse will be available to help you with investigations or management that you require.
– After 6 minuets you will be asked a series of questions by the examiner.
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

This is an ABCDE assessment.

You are a 45 year old male who has presented to accident and emergency with shortness of breath and are now finding it difficult to talk in complete sentences. You are known to have asthma and it is well controlled with a blue and brown inhaler but you do not know the names of these. This started a couple of hours ago, you realised you were using your blue inhaler a lot, when your wife came home from getting the shopping she called an ambulance.

If asked you have not recently been unwell. You have never had to come to hospital with your asthma and have never been admitted to intensive care unit.

PMH = asthma

Drugs = blue inhaler, brown inhaler. No allergies

Social history = smoker, non-drinker

You are unable to provide anymore information than this.

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Clarifies who they are talking to
Asks patient for preferred name

History History
Known asthmatic
Asks about infective symptoms = e.g cough, fever
Current medications
Drug allergies

Severity of asthma
Ever been admitted to hospital?
Ever been admitted to ITU?

A Airway assessment
Patient able to talk
Not in complete sentences

B Breathing assessment
Oxygen saturation = 88%
Respiratory rate = 26
Position of trachea = central
Chest expansion = equal
Chest sounds = bilateral expiratory wheeze

B Breathing investigations
Requests ABG

Please interpret the following imaging

No consolidation
No acute changes

Please interpret the following ABG

Correctly interprets ABG as Uncompensated Respiratory Acidosis
Type 2 respiratory failure

B Breathing treatment
Oxygen 15L through non-rebreathing mask
Salbutamol 5mg nebulised
Ipratropium 500 micrograms nebulised
Oxygen driven nebs
Hydrocortisone 100mg IV STAT

C Circulation assessment
Blood pressure – 90/87
Heart rate – 110
Peripheral and central cap refill – < 2 seconds
Heart sounds = I + II + 0

C Circulation investigations
2 large bore IV cannulae
Bloods = FBC, U&E, CRP

C Circulation treatment
500ml of 0.9% normal saline STAT

D Disability assessment
Blood glucose = 6.7
Temperature = 37
Pupils equal and reactive to light

Candidate offers to phone medical registrar

Question In a patient with an asthma exacerbation, what ABG features are worrying?
Hypercapnia is a sign the patient is starting to tire

Question What clinical features suggest a life-threatening asthma attack?
PEFR < 33% predicated
Oxygen saturations <92%
Silent chest

Question What other treatment could a senior clinician provide in a severe attack of asthma?
Aminophylline infusion
Magnesium sulphate
Intubation and ventilation