Gen Med Station 7

 

Station 7

I can’t breathe!

 

Candidate Instructions

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.

Simulated Patient Instructions

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.

    Patient Results

    Name:Samuel Brown

    Age: 57

    Date of Study:

    ECG source (spoiler alert!): https://litfl.com/anterior-myocardial-infarction-ecg-library/

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     

    Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     

    Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Examiner Instruction

     

    At this point please direct the candidate to move on to providing their differentials, investigations and management that they would like. When appropriately requested please provided the attached results.

    Diagnosis

     

    Assessment and Management

     

    Investigations:

    Definitive Management - 'LMNOP':

    Summary

     

    Christian’s flare of OA was treated using simple analgesics, rest, and physiotherapy input. After a few more years of increasing oral pain regimes he arranged steroid injections through the GP. Having failed this treatment he decided to lose weight, and having lost 10kg his symptoms improved significantly, despite this his OA continued to slowly progress and he went on to have a left total knee replacement 4 years after your first consultation. Luckily this allowed him to enjoy his retirement with his farm dogs and he was able to hill walk in the surrounding countryside.

    The first question to ask in these scenarios would be “has there been any trauma”. Once that’s been ruled out you can start digging down into your arthropathies. Initially you should be going back to pre-clinical knowledge of arthritis classification. We have inflammatory and non-inflammatory arthritides. Looking for systemic features such as weight loss, fever, malaise, iritis, polyarthropathy, psoriasis (psoriatic arthritis), urinary upset or penile discharge (reactive arthritis is often from gonorrheal infection), and bowel upset (RA is linked to IBD) or local symptoms such as a hot, red, swollen joint can point you towards inflammatory arthritis. Whereas a lack of these symptoms may point you towards chronic non-inflammatory arthropathies such as OA (although it’s worth noting severe OA can also present with a hot, red, swollen joint in real practice). It’s worth noting that OA typically asymmetrically impacts weight bearing joints such as hips and knees, such as in this case with the right hip and left knee causing pain.

    In clinical practice there are many differentials outside of arthritis for knee pain such as; DVT, radicular pain, popliteal cysts, tendonitis, and os-good schlatter disease to name a few. In OSCEs illness scripts tend to be more typical and a DVT for example would present with classic calf pain and not referred knee pain.

    Submit for Scoring

    Tags | ADD TAGS HERE e.g. “Cardiology | Heart Failure | Exacerbation of Heart Failure | CCF” then update these in the settings of the page too

    Station Written by: Dr _______

    Peer Reviewed by: Dr ________

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