Infective Exacerbation of COPD (IECOPD)

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

Chest Pain 1