Pulmonary Embolism


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a Foundation Doctor on the Acute Medical Team

Patient: 72 year old patient was brought into hospital by ambulance with red flag sepsis. Patient had fallen at home and was short of breath when the ambulance arrived.

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 72 year old man who was admitted with a fall and shortness of breath. You bent down this evening and fell forwards feeling dizzy and hit your forehead, you managed to break your fall with out-stretched hands. You have not experienced any chest pain or palpitations. You think this is because you have not been drinking as much water as usual as you are less hungry than usual.

You have been short of breath for the last two weeks, you went to your GP with shortness of breath and they started you on antibiotics. Although this does not seem to of helped you.

Past medical history

Lung cancer – not for active treatment, this has been slow growing and your consultant does not think you would do well with treatment, so this is being monitored

Type 1 diabetic

Triple heart bypass

x4 fem/pop leg bypass

Drug history
Lantus insulin

Novorapid insulin

No known drug allergies

Social history
You live at home with your partner
You do not drink or smoke

Family history
You have no conditions that run in your 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
Site
Onset
Nature of breathlessness
Timings
Exacerbation
Severity


Respiratory Respiratory features
Cough
Wheeze
Fever


Cardiology Cardiology features
Nausea / Sweating
Orthopnoea
Paroxysmal nocturnal dyspnoea
Palpitations
Weight loss


PMH Past Medical History
Past medical history appropriately explored
Diagnosed with 3 of: (COPD, heart failure, diabetes, hypertension, GORD)


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 Given your history what are your differentials?
Pulmonary embolism
Angina
Myocardial infarction
Pneumonia
Congestive cardiac failure
Pericarditis
Pneumothorax


Question Given your history what investigations would you like to order?
FBC, U&Es, CRP
ECG
D-dimer
ABG
Chest X-Ray
Clotting


Question
Review the following Chest X-Ray and comment on your findings:

Previous  operative  intervention – sternal rings present

Right hilum enlargement right-sided. Hilar surgical clips present
The left lung appears clear

Tenting of the right diaphragm
No consolidation present


Question
Review the following bloods

Main anomalies identified


Question What is your working diagnosis?
Pulmonary Embolism


Question What investigation would you like to order now?
CT Pulmonary Angiogram (CTPA)


Question
Review the follow CTPA result and state what your management is

Treatment dose Dalteparin


Question What are the risk factors for a Pulmonary Embolism?
Recent surgery
Previous thromboembolic event
Family history of venous thromboembolic event
Active cancer
Pregnancy / postnatal period
Paralysis of lower extremities
Antiphospholipid antibody syndrome




Score