Infective Exacerbation of COPD (IECOPD)


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor on the ambulatory assessment unit

Patient: 70 year old patient has been referred by their General Practitioner to hospital with 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 70 year old patient who has been having worsening shortness of breath over the past 4 days. You have gone to see your GP this morning and they’ve sent you up to the hospital.

You are usually breathless but never this bad. If asked you have been brining up green sputum. Your doctor said if you ever have these symptoms then you need to take some tablets they prescribed and you have done this. If asked what the tablets are you say prednisolone and antibiotics. You have been taking the tablets for the past 3 days and you aren’t getting any better.

If asked you have COPD, you take nebulisers at home. You do not have any home oxygen. Your exercise tolerance is about 100 yards.

DH
– Adcal
– Alendronic acid 70mg one per week
– Atorvastatin 20mg OD
– Budesonide 400mcg
– Co-codamol 30/500mg
– Salbutamol 100mcg
– Symbicort inhaler
– Tiotropium

PMH
– COPD – emphysema

– Osteoarthritis

– Osteoporosis

SH
– You live at home with your husband
– You used to smoke 20 per day for 20 years but you stoped 10 years ago
– You do not drink alcohol
– You are a retired cleaner

FH
– Nothing runs in the family that you are aware of

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

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


History History
Onset
Cough present
Cough productive
Change over time
Blood in sputum


History Additional symptoms
Breathlessness
Wheeze
Pleuritic pain
Chest pain
Fever
Urine colour and output (signs of dehydration)


COPD Assesses if COPD patient uses:
Nebulisers at home
Home oxygen
Use of NIV / ITU or hospital admission
Used rescue packs in the community
Previously cultured pseudomonas


Systems review Systems review
General = fever, rigors, night sweats, weight loss
Cardiorespiratory = chest pain, palpitations, SOB, sputum, leg swelling
Gastrointestinal = dysphagia, N&V, indigestion / reflux, abdominal pain, change in bowel habit


PMH Past Medical History
Past medical history appropriately explored
Excludes patient does not have a lung disease (e.g COPD / asthma)


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
Alcohol
Smoking
Occupation
Living situation


FH Family history
Family history appropriately explored


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


Question
Please review this patients auscultation. What are your findings?

Coarse crackles
Inspiratory


Question What are your differential diagnosis?
Infective exacerbation of COPD
Community Acquired Pneumonia (CAP)
Non-infective exacerbation of COPD
Pulmonary embolus
Other appropriate answer


Question Given your history what investigations would you do?
FBC, LFTs
U&Es
CRP
CXR
Atypical pneumonia screen
ABG
Sputum culture
ECG


Question
Review the following image and state your findings

Chest X-Ray
Hyper-inflated lung field
Emphysematous lungs
Interstitial shadowing
Left basal consolidation present
Mild scoliosis of the spine


Question What is your management plan?
Admission
Regular observations
Antibiotics (IV Augmentin + PO Clarithromycin)
Prednisolone (30mg OD)
Chest physiotherapy
Sputum culture
COPD team review
Target saturations 88-92%
VTE
Regular medications


Question What special investigations are included in a atypical pneumonia screen
Urinary legionella pneumophila
Urinary mycoplasma pneumoniae



Score