Gen Med Station 7

Setting:

You are a junior doctor working on the medical assessment unit. This patient has presented with shortness of breath.

Name: Joshua Taylor

Tasks:

1. Take a history from the patient.

2. State your differential diagnosis to the examiner.

3. Outline your investigations and management to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Exacerbation of heart failure - SoB
You are Joshua Taylor (age 74)
You have presented to the medical assessment unit with shortness of breath

Appearance and Behaviour

You are a well kept, well-mannered gentleman. You should appear breathless and worried - it feels like you're drowning and you just can't breathe. .

Opening statement

“I’ve had this shortness of breath for a while, but it’s gotten so much worse recently doctor.”

Information to Give Freely

You’ve been short of breath for a while, but over the last week it’s been really interfering with your daily life. You’re quite worried it’s something serious.

Presenting Complaint

Symptom – shortness of breath
Onset - 2 months ago initially, but only worsened over the last week
Character – You feel like you can’t catch your breath, you don’t feel wheezy or have difficult breathing air out.
Associated symptoms:

Cough (ONLY IF candidate asks, you should inform them that you’re coughing up frothy pink sputum).

Bilateral leg swelling and you’ve gained weight

You wake up at night feeling breathless (ONLY IF candidate asks, state you’ve had to use 3 pillows to prop yourself up while sleeping).

No sharp pain when breathing, no haemoptysis, no chest pain, no throat swelling.

Timing – No worse at any particular point in the day, but it has worsened since you first noticed it
Exacerbating (/triggers)/relieving factors - Worse on lying flat and exercising. Relieved on sitting upright and resting.
Severity – It’s now started interfering with your daily activities like washing and cooking.

Past Medical History

Previous similar episodes - Nil prior to onset 2 months ago
Other medical conditions - Hypertension, previous heart attack 3 years ago
Previous surgeries - Umbilical hernia repair 15 years ago - no issues since.

Drug History

Prescribed - You’re on aspirin, atorvastatin, bisoprolol and ramipril. You have a GTN spray but you don’t use it very often.
Over the counter - Nil
Allergies - Flucloxacillin. If candidate asks about reaction, you get a rash with no difficulty breathing.

Family History

Your aunt had lung cancer.

Social History

Smoking - You quit 20 years ago. You smoked 15 a day for 10 years.
Alcohol - drink 8 or more cans of lager a night. You’ve done so for more years that you can remember. If the candidate attempts to counsel on alcohol reduction during scenario - You aren’t in the right mindset to quit right now. If candidate informs you your alcohol intake is high but you can discuss it later you are receptive to the idea.
Home - Lives in a Bungalow. Just you, you’re amicable with the neighbours but no other support. No care package.
Mobility - Normally independent, but you’ve been using furtniture to support you over the last week because of breathlessness.
ADLs - Now unable to cook proper meals or clean the house due to breathlessness

Systems Review

General/red flags - No Fevers, weight loss or night sweats
Neuro - No Loss of consciousness or dizziness
Resp - Productive cough of pink frothy sputum, No frank haemoptysis, no throat swelling.
Cardio - No Palpitations or chest pain
GI - No recent haematemesis or malaena
GU - No lower urinary tract symptoms
Joints - Bilateral leg swelling to knees, no erythema. No red, hot or swollen joints.

Ideas / Concerns / Expectation

Ideas - “Is it something to do with my heart attack?”
Concerns - “Is it lung cancer like my aunt?”
Expectations - “Could you maybe organise for me to get a bit of help at home”

Discussion / Questions

If you feel the candidate does not address your concerns adequately (or does not ask ICE at all) you should continue to bring up the point until it has been acknowledged and addressed in a sensitive and appropriate manner.