Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year 2 Doctor on placement at the Emergency Department. Your next patient is Yamato Takahashi, a 55-year-old male presenting with shortness of breath. Please take a history and perform a relevant examination.
Patient History:
Yamato Takahashi, a 55-year-old male, Engineer.
You’ve been short of breath for the past few months, particularly worse when exerting yourself. In the few days, it has worsened to the point where it has stopped you from doing your hobbies like golf, and you've not been leaving the house often. In fact, the last time you left was 6 weeks ago. You feel incredibly tired all the time! The breathlessness is worse when you're lying flat, but you don't wake up in the middle of the night gasping for breath or anything. You have slept on 2 pillows in the last few weeks.
You've had no recent chest pain – you normally have angina, but thankfully, this hasn't been coming on recently.
You started coughing up light yellow sputum with bubbles since last week. You now cough up a few times daily, bringing up about a teaspoon each time. Yuck!
Your ankles have been swollen a lot lately, but they are normally swollen anyway, and you think the swelling is getting worse. They are not red or warm, and you don’t have any calf pain.
No wheeze, palpitations, faints. No fever or rash. You haven't noticed any change in your weight, but you don't normally measure your weight.
Ideas, Concerns, Expectations:
You have no idea what this might be but are worried it could keep getting worse, and you feel like you might be approaching your last days. You don't want to die like your father did. You ask the doctor if you are about to die?
Past Medical History:
Angina for 2 years
DVT 3 years ago
Hypertension
Drug History:
GTN spray. Amlodipine
NKDA
Family History:
No lung problems. Your father died of gastric cancer.
Social History:
You are a retired petroleum engineer from Japan.
You've smoked 20 cigarettes daily since you were 20.
You drink no alcohol.
You live with your wife in a bungalow.
Your wife does a lot of the housework, but now you're not even able to help, and she is increasingly frail herself.
Though she doesn't complain, you know she's struggling to cope.
You have one son who works abroad, so no one visits except the occasional friend.
Examination Findings:
RR 24. HR 84bpm regular
Cold peripheries
Elevated JVP
Apex beat palpitated in the axilla.
Bibasal crepitations.
Bilateral pitting oedema up to the ankles with haemosiderin staining.
Differentials:
Acute heart failure
Underlying COPD with exacerbation
Pneumonia
Interstitial lung disease
To rule out deep vein thrombosis / pulmonary embolism
Investigations: