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 Doctor working in Accident & Emergency. Mrs Cheryl Thompson, a 66-year-old female, is brought into the department by her daughter for shortness of breath. Please take a history from Cheryl and perform a relevant examination.
Patient History:
Cheryl Thompson - a 66-year-old female - retired, brought to the emergency department by your daughter.
Your daughter brought you to the hospital due to concerns of shortness of breath and chest tightness over the past 5 days; occuring even at rest, which stops you getting out of bed and doing activities of daily living. You don't usually have chest issues and there is no chest pain.
You have a cough bringing up green sputum (no blood) and you've been feeling cold/shivery lately. You feel warm to touch but don't have a thermometer to record your temperature.
Your daughter was distraught this morning because your speech was all jumbled up, and you didn't recognise her. You insist it was just because you couldn't find your glasses.
You've noticed no wheeze, ankle swelling, palpitations, or syncope. No weight loss. No calf pain, recent hospitalisations or foreign travel. No dysuria or change in bowel habits. No worsening SoB while supine. No urinary/bowel symptoms.
Ideas, Concerns, Expectations:
You have no idea what this might be. You are not too worried, but your daughter is concerned about you. You want to find out what is going on and reassure your daughter.
Past Medical History:
No previous chest issues
Depression
Atrial fibrillation
Overactive bladder
Drug History:
Warfarin, fluoxetine, oxybutynin.
Allergic to penicillin (swollen lips)
Family History:
Your father had emphysema and Alzheimer’s in his later years. Your brothers both died of a heart attack in their 60s.
Social History:
You live at home with your daughter.
You worked as a housewife in your younger years. Now, retired.
You stopped smoking 10 years ago but previously smoked 20 cigarettes daily for 30 years.
You've always needed your daughter's help with shopping but usually could do the basic chores like cooking & cleaning in your bungalow.
Examination Findings:
At the time of examination; mild disorientation to time, place and person
Heart rate 100. Respiratory rate 28. BP 100/70
Dullness to percussion and reduced air entry to the right apex. Audible crackles at the right apex on the back.
Differentials:
Community-acquired pneumonia - Infective picture & fits with examination findings and it is an acute history
Bronchitis - This usually has normal examination findings
Pulmonary oedema - This is unlikely as symptoms are not worsened on lying flat
Exacerbation of underlying COPD - Can present similarly, however
To rule out PE - Does have Shortness of breath, but no chest pain, but you could
To Rule out Cardiac Cause - to assess for ACS, and CXR may show pulmonary oedema if there was any in heart failure
Bronchiectasis - Unlikely as no chest symptoms before, acute presentation & not producing copious quantities of sputum
Confusion - delirium, depression, dementia, drugs (oxybutynin)
Investigations:
Bedside:
Well's score calculation for PE
Sputum sample = (MC&S)
ECG = (exclude ACS)
Urine sample = (MC&S, avoid dipstick in >65yrs. Also for pneumococcal & legionella urinary antigen tests).
Bloods:
FBC = (infection, haemolytic anaemia & lymphopenia can be a feature of certain atypical pneumonia)
U&E = (urea is a component of CURB-65 score)
LFT = (before antibiotic treatment)
CRP = (infection)
Blood culture
BNP = (<100 makes the diagnosis of heart failure unlikely as per NICE guidance; hence has a good -ve predictive value)
ABG = (if low sats)
Consider Troponin to rule out ACS
Consider D-Dimer if suspecting PE
Imaging/Specialist Test:
CXR = (focal consolidation, to be repeated 6 weeks after resolution to exclude hidden malignancy)
Consider CTPA if suspecting PE
Consider CT Angiogram if suspecting ACS
Other possible tests = include an echocardiogram, pulmonary function tests
Data Interpretation: