Reset 10 mins Pause Candidate instructionsActor instructionsMark sheet Score 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: https://oscestop.education/wp-content/uploads/2019/01/ExpiratoryWheeze.mp3 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 Submit your answers to get your score.