Our notes are now found under OSCE Learning! Click here

Background

Patient’s name, age, relevant chronic conditions

Where and when they were seen

‘Mr Blogs is a 44 year old male with a background of COPD who self-presented to A&E one hour ago.’

History

PC and HPC

‘He presented with a cough, which started three days ago. It is productive of a moderate amount of thick green sputum – he has produced about a table-spoon full today.’

Other positive findings and important negative findings from relevant systems review

‘He has also been feverish and experiences shortness of breath on walking 50 yards. His normal exercise tolerance is 200 yards. He has not had any haemoptysis, chest pain or leg swelling.’

PMHx

‘Mr Blogs’ past medical history includes COPD and hypertension. His COPD was diagnosed two years ago and is currently well controlled with inhalers. He has never been admitted to hospital for his COPD.’

DHx

‘Mr Blogs takes tiotropium 18mcg inhaled once daily and salbutamol 100-200mcg inhaled as required for COPD. He also takes ramipril 2.5mg orally once daily for hypertension. He has no drug allergies.’

FHx

‘He has no significant family history.’

SHx

‘In terms of social history, Mr Blogs is a farmer and currently smokes 20 cigarettes daily with a 40 pack year history. He has never drunk alcohol. He lives at home with his wife and is normally fully independent and mobile.’

Examination

Observations

‘I examined Mr Blogs and he was hypoxaemic, with oxygen saturations of 87% on room air. He had a respiratory rate of 22. He was pyrexial at 38˚. Heart rate and blood pressure were normal.’

General state

‘Clinically, Mr Blogs appeared well but was slightly short of breath when speaking sentences. He was alert and orientated.’

General inspection

‘On general inspection, there was evidence of accessory muscle use and breathing through pursed lips. There was about 2mls of green sputum in the sputum pot.’

Major findings from relevant system examination

‘Examination of the respiratory system revealed a capillary refill time of 3 seconds, cool peripheries and conjunctival pallor but no peripheral or central cyanosis. The trachea was not deviated and there was no cervical lymphadenopathy. On examination of the chest, there were no scars or chest deformities. Chest expansion was normal. The lungs were resonant to percussion. On auscultation, there were normal vesicular breath sounds with a mild wheeze throughout but no other added sounds. Vocal resonance was normal. The calves were not swollen or tender.’

Findings from other system examinations

‘On examination of the cardiovascular system, the apex beat was non-displaced and there were no heaves or thrills over the precordium. Heart sounds one and two were present with no added sounds. There was no evidence of pulmonary or peripheral oedema. On examination of the abdomen, it was soft and non-tender with no organomegaly. Bowel sounds were normal.’

Summary, impressions and plan

Summary

‘In summary, Mr Blogs is a 44 year old male with COPD who presented with a three day history of a green productive cough and fever. He is currently stable but did have an audible wheeze on examination.’

Impressions and differentials

‘My impression is that this is an infective exacerbation of COPD. However, a differential is community-acquired pneumonia.’

Investigations and plan

‘I would like to take bloods including a full blood count, U&Es, LFTs and a C-reactive protein. I would like to obtain an arterial blood gas sample to more accurately assess his type and degree of respiratory failure and guide oxygen therapy. I would also like to send sputum for MC&S to guide antimicrobial therapy, and get a chest radiograph. I would like to admit Mr Blogs and start him on controlled oxygen therapy, IV amoxicillin, oral clarithromycin and oral prednisolone to treat an infective exacerbation of COPD. In view of his wheeze, I would also like to prescribe nebulised salbutamol and ipratropium.’

Try summarising at the end of these histories

  1. Abdominal pain
  2. Chest pain
  3. COPD
  4. There’s loads more!
image