Procedure Station 1

Setting:

You are an FY2 doctor working in A&E. This patient has presented with shortness of breath.

Mr Dennis Summers

Tasks:

1. Take a focussed history from the patient.

2. Take a blue and gold top blood bottle from the patient

3. Give your differential and preferred diagnosis with reasoning to the examiner.

4. Give your initial investigation and management plan to the examiner.

You are not required to examine the patient, you should take blood from the patient.

Briefing

Diagnosis: Infective exacerbation of COPD presenting with increasing shortness of breath
You are Dennis Summers (Age 74 years old)
You have come to the Emergency Department with increasing shortness of breath

Appearance and Behaviour

Whilst you aren't in a lot of pain you should act breathless and look worried..

Opening statement

“Well doctor, I’ve just haven’t been able to get my breath over the last week.”

Information to Give Freely

You have been coughing and bringing up more sputum than normal (you have COPD) over the last week and feeling generally unwell.

Presenting Complaint

Symptom - Increased sputum production
Onset - As above (last week)
Character:

How much? - 4 tablespoons of mucus daily (vs 1-2 tbsp before)

What colour? - Dark green (it used to just be pale)

Any blood? - No

Associated symptoms - candidate may ask about the following:

Fever - Yes. You haven’t measured, it started about 3 days ago

Cough - Yes

Chest pain - No

Palpitations - No

Worsening on lying down - No

Wakes you up at night - No

Long journeys/recent surgeries - No

Time/evolution - It isn’t worse at any specific point in the day, but it has progressively gotten worse over the last week
Exacerbating factors - It’s present at rest but exertion does make it worse. No particular triggers that you’ve noticed
Alleviating factors - Your normal inhalers haven’t helped
Severity (ie impact on your life) - You used to be able to walk to the shops and back again but now you can’t that without getting out of breath. It’s gradually making you housebound.

Past Medical History

Previous episodes - Never
Medical conditions:

COPD - diagnosed 8 years ago

High blood pressure - diagnosed 5 years ago

Previous surgeries - None

Drug History

Prescribed:

Fostair inhaler - 2 puffs twice a day

Salbutamol inhaler - you take as needed when you feel more breathless (you’ve been using it daily this last week)

Ramipril and amlodipine for high blood pressure

OTC - Nil
Allergies - None

Family History

No family history of any conditions

Social History

Smoking - Smoked 35 a day for 40 years. Stopped 8 years ago
Alcohol - 1 glass (250ml) of white wine on Saturdays and Sundays
Home:

Who else - Your wife lives at home with you

Type of home - 2 floor house

Stairs - Yes. Normally you don’t have an issue with them and can get to the top without getting too breathless

Mobilisation - You don’t need to use any walking aids

ADLs - You normally manage to dress yourself, clean the house and do your shopping without much issue. You have your children nearby should you need help

Pets - No. If specifically asked, you’ve never owned any birds
Occupation - Retired lawyer. You’ve never had any occupational exposure to chemicals or dust as far as you’re aware
Baseline - You and your wife are both very happy at home. You’ve been married 52 years and enjoy spending time together playing board games and watching movies. You regularly get out to meet with friends.

Systems Review

General/red flags - You’ve had a fever over the last week but no weight loss or night sweats
Neuro - No stroke symptoms, fits, faints or visual changes
ENT - No dizziness, tinnitus or hearing loss
Resp - No symptoms aside from coughing up sputum and increasing breathlessness
Cardio - No arrhythmia, chest pain, swelling, or dizziness on exertion
GI - No D+V, vomiting blood or blood in your bowel motions
Urinary - No infective symptoms or blood
Joints - No history of fractures, joint pains

Ideas / Concerns / Expectation

Ideas - “Could it be to do with my COPD?”
Concern - “That I won’t be able to leave the house to go to the shops or into town anymore”
Expectations - “Maybe you could give me a new inhaler to help with this?”

Discussion / Questions

After taking the history the candidate may explain that they need to take some blood from you to investigate what’s wrong.
You should be receptive to this, but should ask if there are any risks associated with the procedure it if the candidate does not cover this themselves in their explanation. Aside from this you have no questions.