CASE INFORMATION

Case ID: PNEU-2025-13
Case Name: Robert Henderson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R81 (Pneumonia)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to assess respiratory symptoms 1.3 Explains the diagnosis, treatment, and follow-up plan clearly 1.5 Uses shared decision-making regarding hospital admission vs. outpatient treatment
2. Clinical Information Gathering and Interpretation	2.1 Conducts a thorough history and examination to assess pneumonia severity 2.3 Identifies risk factors for complications and poor outcomes
3. Diagnosis, Decision-Making and Reasoning	3.1 Diagnoses pneumonia based on history, examination, and investigations 3.5 Recognises when hospital admission or urgent referral is required
4. Clinical Management and Therapeutic Reasoning	4.2 Prescribes appropriate antibiotic therapy based on severity and local guidelines 4.5 Provides supportive care including analgesia, fluids, and oxygen if needed
5. Preventive and Population Health	5.1 Encourages smoking cessation and vaccination (influenza, pneumococcal) 5.3 Provides education on pneumonia prevention strategies
6. Professionalism	6.1 Provides empathetic care, addressing patient concerns and anxieties
7. General Practice Systems and Regulatory Requirements	7.1 Documents pneumonia severity scoring and management plan clearly 7.2 Ensures appropriate follow-up and safety netting
9. Managing Uncertainty	9.1 Uses a structured approach to diagnosing pneumonia and ruling out differentials
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and escalates care for respiratory failure or sepsis

CASE FEATURES

Older male with cough, fever, and dyspnoea for five days.
History of COPD and smoking, increasing risk of severe pneumonia.
Concerned about whether he needs antibiotics, hospitalisation, or further tests.
Examination suggests possible right lower lobe pneumonia.
Needs assessment of severity, management plan, and preventive measures.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Robert Henderson
Age: 67
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Salbutamol inhaler PRN
Tiotropium inhaler daily

Past History

COPD (moderate severity, FEV1 55%)
Ex-smoker (quit 5 years ago, 40 pack-year history)
No previous hospitalisations for pneumonia

Social History

Lives with his wife, previously independent in daily activities
No recent travel, known sick contacts, or hospital exposure
Non-drinker, former smoker

Family History

No known family history of lung disease or immune deficiencies

Smoking

Quit smoking 5 years ago (40 pack-year history)

Alcohol

Vaccination and Preventative Activities

No pneumococcal vaccine received
Last influenza vaccine 3 years ago

SCENARIO

Robert Henderson, a 67-year-old ex-smoker with COPD, presents with a five-day history of cough, fever, and shortness of breath. His phlegm has become yellow-green, and he feels more breathless than usual.

He is unsure if he needs antibiotics or hospital admission. He has had no recent sick contacts or travel, and no known COVID-19 exposure.

On examination, he appears mildly dyspnoeic but alert. His chest auscultation reveals reduced air entry and coarse crackles in the right lower zone.

He seeks advice on diagnosis, treatment, and whether hospital admission is needed.

EXAMINATION FINDINGS

General Appearance: Mild respiratory distress, alert
Vital Signs:

Temperature: 38.2°C
Heart Rate: 94 bpm
Blood Pressure: 128/80 mmHg
Respiratory Rate: 22 breaths per minute
Oxygen Saturation: 93% on room air

Respiratory Examination:

Diminished air entry on the right lower lung field
Coarse crackles over the right lower zone
No wheeze, no tracheal deviation

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this patient’s pneumonia?

Prompt: How do you assess pneumonia severity in a patient with COPD?
Prompt: What risk factors indicate a need for hospital admission?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: How do you differentiate pneumonia from other causes of breathlessness (e.g., COPD exacerbation, heart failure, pulmonary embolism)?
Prompt: When would a chest X-ray or other investigations be required?

Q3. How would you manage Robert’s pneumonia?

Prompt: What antibiotics would you prescribe based on severity and COPD status?
Prompt: When would hospital referral or oxygen therapy be needed?

Q4. How would you counsel Robert on his illness and preventive strategies?

Prompt: How do you explain the treatment plan and expected recovery timeline?
Prompt: What advice would you give on vaccination and smoking cessation?

Q5. What follow-up plan would you implement?

Prompt: When should he return for review?
Prompt: How do you monitor for complications or treatment failure?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this patient’s pneumonia?

A structured history and focused examination are essential to assess pneumonia severity, risk factors, and need for hospital admission.

1. History

Symptom onset and progression:
- Duration of cough, fever, dyspnoea (acute vs. chronic).
- Sputum characteristics (purulent, blood-streaked).
- Pleuritic chest pain (suggests lobar pneumonia or pleuritis).
Risk factors for severe pneumonia:
- Age >65 years, COPD, smoking history.
- Immunosuppression (diabetes, steroid use, malignancy).
- Recent hospitalisation or antibiotic use (risk of resistant organisms).
Red flag symptoms suggesting severe disease:
- Altered mental status, confusion (sepsis, hypoxia).
- Tachypnoea, severe dyspnoea, haemoptysis.
- Dizziness or hypotension (septic shock).
Vaccination history:
- Pneumococcal and influenza vaccination status.

2. Examination

General assessment:
- Respiratory distress, cyanosis, accessory muscle use.
Vital signs:
- Tachypnoea (>20 breaths/min), tachycardia, hypotension.
- Oxygen saturation <92% (hypoxia).
Respiratory examination:
- Diminished breath sounds, crackles, bronchial breathing (lobar pneumonia).
- Dullness to percussion (consolidation or effusion).

A structured approach ensures early identification of severe pneumonia requiring hospital admission.

SUMMARY OF A COMPETENT ANSWER

Elicits symptom onset, risk factors, and red flag symptoms.
Assesses pneumonia severity using clinical signs and risk factors.
Performs a focused respiratory examination to confirm pneumonia features.
Considers the need for hospitalisation based on CURB-65 or similar criteria.

PITFALLS

Failing to assess for red flags, potentially missing severe pneumonia.
Not considering COPD as a risk factor for bacterial pneumonia.
Overlooking the importance of vaccination history in a high-risk patient.
Not assessing respiratory distress or oxygen saturation adequately.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough history and examination to assess pneumonia severity.
2.3 Identifies risk factors for complications and poor outcomes.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD