Chronic obstructive pulmonary disease


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are the clerking FY1 on the acute medical take

Patient: 75 year old patient has come into A&E with increasing shortness of breath

Task:

– Take a focused history from the patient

– After 6 minutes 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.

You are a 75 year old patient who has been feeling terribly breathless recently and you have started coughing a lot. Your daughter came to visit and called an ambulance.

If asked you can usually walk to the shops about 200m away, you do become a little breathless but this does not bother you, you now struggle to move from the bed to the chair, stairs are almost impossible at the moment but you used to be able to climb them. You have to stop walking because you become so breathless. Your GP a couple of years ago gave you a blue inhaler which you use occasionally but now you are using it all the time. You usually cough a lot but you have noticed over the past week you are bringing up a lot more than usual, this is white clear mucus with no blood.

You have not noticed a temperature, nor have you been around anyone else unwell and you have not experienced any night sweats. You have no weight loss. No history of DVT / PE (long-haul flights, recent operations, swollen legs). The shortness of breath is not made worse by laying flat and you have never been woken up at night with this. Your legs have not been swollen and your claves are not tender. 

PMH

  • Your GP has treated you for a ‘chest infection’ a couple of times over the past year and has given you antibiotics which seems to of solved the problem. You did not require hospital admission

DH

  • Blue inhaler
  • No known drug allergy

SH

  • You are a retired customer service agent
  • You smoker 15 cigarettes a day for the past 60 years
  • You do not drink alcohol
  • You live at home with your partner in a 2 storey house

ICEF

You are concerned about your breathing because it has never been this bad before and you are worried you wont be able to do all the housework or shopping like you used to. You enjoy living with your partner and you are worried if you cannot do these tasks then you might have to go into a nursing home which you do not want. You are willing to do what the doctor thinks is best.

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


HPC Explores presenting complaint
Onset
Frequency
Relieving factors
Exacerbating factors


AF Associated features
Cough
Wheeze
Fever / night sweats
Weight loss / appetite


Exercise tolerance assessed
Current functional status
Previous functional status
Establishes breathlessness causes cessation of exercise


Excludes
Chest pain
Palpitations
Paroxysmal nocturnal dyspnoea
Leg swelling
Signs of DVT / PE = long-haul flights, recent operation, painful legs


PMH Past Medical History
Recurrent chest infections


DH Drug History
Blue inhaler
NKDA


SH Social history
Occupation
Smokes 15 cigarettes a day for the past 60 years
No alcohol
Lives at home with your partner in a 2 storey house


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Question Given the history you have taken what are your differentials?
Non infective exacerbation of chronic obstructive pulmonary disease
Infective exacerbation of chronic obstructive pulmonary disease
Interstitial lung disease
Lung cancer
Pulmonary embolism
Heart failure
Angina
Other appropriate answer


Question What venous blood tests would you like to do in this patient?
FBC
U&Es
LFTs
CRP
D-dimer
B type natriuretic peptide


Question Apart from venous blood tests, what other investigations would you like to do?
ABG / CBG
Chest x-ray
ECG


Question
Please interpret the following chest x-ray

Hyperinflated lungs (> 10 ribs posteriorly)
Flattened diagram
Hyperlucenecy through lung fields bilaterally
Narrow mediastinum
No focal areas on consolidation noted


Question
Please interpret the following blood results

Normal blood results


Question Given the history, chest x-ray and blood results, what is your most likely diagnosis?
Non-infective exacerbation of COPD


Question If you were allowed to only prescribe one medication what would it be including name, dose, route and duration?
Prednisolone 30mg (allow 40mg) PO 5 days (allow 7 days)


Question What value would you be looking for on spirometry for chronic obstructive pulmonary disease
FEV1 : FVC ratio should be <0.70



Score