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Acute assessment – shortness of breath II


You are a junior doctor in the emergency department. You are asked to see a 40 year old female with shortness of breath. Please assess the patient discuss you management plan with the examiner. You will have 8 minutes.

Please note a full ABCDE assessment is not required.

Your role

You are Carol Whitcome, a 40 year old. You came to the A&E because you have been feeling more short of breath over the last few days.

 

History of presenting compliant

Information to be volunteered at the start

You started to notice you are a bit more breathless over the last few days.

 

Information to given if asked

You can normally walk 100 yards before becoming breathless, but now you are breathless after just a few steps. Your chest feels very wheezy and tight (but no pain). You also have a cough and green coloured sputum.

 

You do not have any other symptoms.

 

Background information

Past medical history

  • COPD (if asked: you have inhalers but no home nebulisers or oxygen. You have had 3 admissions to hospital last year. You have never been to intensive care but have to go to a high-dependence unit once for a tight fitting face mask that blowed air into your lungs at high pressure)

Medications and allergies

  • Trimbow 87 micrograms/5 micrograms/9 micrograms 2 puffs BD
  • Salbutamol inhaler PRN
  • No allergies

Family history

  • None

Social history

  • You smoke 30 cigarettes a day
  • You do not drink alcohol
  • Your daughter does the shopping but you do everything else at home

 

Examination findings to simulate

Act breathless and as if you are using accessory muscles.

Breath through pursed lips.

After the candidate auscultates your chest, play this sound:

 

Patient observations (give when asked for by candidate)

  • Blood pressure 140/80
  • Heart rate 78
  • Respiratory rate: 22
  • Oxygen saturations: 87% on air
  • Temperature: 36.6
Category Question
Done
Excellent
Consent Candidate appropriately introduced themselves with:
Washes hands
Introduces self
Clarifies patient name and DOB
Gains consent


History Focussed history
Explore the breathlessness (duration, when noticed, exercise tolerance baseline and currently)
Asks general symptoms (fever)
Asks cardiorespiratory system review questions (cough, haemoptysis, chest pain, wheeze, palpitations, leg pain/swelling)
Asks past medical history
When patient mentions COPD, ask further questions to determine severity (treatment, previous exacerbations, and previous ICU and HDU admissions)
Asks drug history and allergies


Examination Focussed examination
Asks for observations
Performs a general assessment to determine how unwell patient is (capillary refill, pulse rate/volume, pallor/sweatiness/clamminess, cyanosis, dry mucus membranes)
Inspects chest
Chest expansion
Percusses chest
Auscultates heart sounds
Auscultates lung sounds (front + back)
Looks for calf tenderness/swelling


Examination - pathology If the candidate asks for observations: Blood pressure 140/80, Heart rate 78, Respiratory rate 22, Oxygen saturations 87% on air, Temperature: 36.6
Identifies tachypnoea
Identifies hypoxia


Examination - pathology Inspection pathology
Identifies accessory muscle use
Identifies breathing through pursed lips


Examination - pathology photo_camera Play this sound after the candidate auscultates chest
Identifies wheeze


Investigations Ask the candidate about appropriate investigations
Blood tests (including inflammatory markers, full blood count, renal function)
ABG (to assess oxygenation and exclude type 2 respiratory failure)
ECG
Chest x-ray (exclude pneumonia, pneumothorax etc)
Sputum MC&S


Management Ask the candidate their differential/diagnosis and management plan
Diagnosis = exacerbation of COPD
Oxygen, starting at 24-28% ventri mask (titrate to saturation target of 88-92%)
Prednisolone
Salbutamol nebulisers back-to-back initially
Ipratropium nebuliser
Consider antibiotics, e.g. doxycycline
Refer to medical team, or respiratory HDU if in type 2 respiratory failure



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