CCE-CBD-188

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How would you differentiate between cardiac and respiratory causes?
• Prompt: What features suggest COPD versus asthma?

Q2. What are your initial management steps?

• Prompt: What pharmacological and non-pharmacological measures would you implement?
• Prompt: When would you consider hospital referral?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address his concerns about COPD?
• Prompt: What smoking cessation advice would you provide?

Q4. What preventive measures can help reduce worsening of his symptoms?

• Prompt: What vaccinations should he receive?
• Prompt: What lifestyle modifications would you recommend?

Q5. What are the red flags that would necessitate urgent escalation of care?

• Prompt: What signs suggest an exacerbation requiring immediate intervention?
• Prompt: How would you manage a severe COPD exacerbation?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

A structured approach to dyspnoea involves considering cardiac, respiratory, and systemic causes.

Differential Diagnoses:

1. Chronic Obstructive Pulmonary Disease (COPD)
   • Key features: Progressive dyspnoea, chronic cough, smoking history, wheezing, reduced FEV1/FVC ratio.
   • Supporting investigations: Spirometry showing airflow obstruction.
2. Congestive Heart Failure (CHF)
   • Key features: Dyspnoea, bilateral ankle oedema, exertional limitation.
   • Supporting investigations: BNP normal (less likely but still consider in early CHF).
3. Asthma (Less Likely in This Age Group)
   • Key features: Intermittent wheezing, reversible airway obstruction.
   • Supporting investigations: Spirometry shows reversibility with bronchodilators.
4. Pulmonary Embolism (PE) (Unlikely Here but Must Be Considered in Acute Cases)
   • Key features: Sudden-onset dyspnoea, pleuritic chest pain, risk factors (DVT, immobility).
5. Lung Malignancy
   • Key features: Chronic cough, weight loss, haemoptysis (not present here but needs exclusion).

Most Likely Diagnosis:

• Moderate COPD based on progressive dyspnoea, smoking history, wheeze, and spirometry findings.

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Q2: What are your initial management steps?

Answer:

1. Non-Pharmacological Management:

• Smoking cessation counselling: Key to slowing disease progression.
• Pulmonary rehabilitation: Improves exercise tolerance and quality of life.

2. Pharmacological Therapy:

• Short-acting bronchodilator: Salbutamol (SABA) PRN or Ipratropium (SAMA).
• Long-acting bronchodilator: Tiotropium (LAMA) or Salmeterol (LABA) if symptoms persist.
• Inhaled corticosteroids (ICS): Consider if frequent exacerbations.

3. Referral & Investigations:

• Chest X-ray: To exclude malignancy.
• Full blood count: Rule out anaemia.
• Pulmonary function testing: Confirm severity.

4. Safety-Netting & Follow-Up:

• Urgent referral if symptoms worsen (e.g., increasing hypoxia, respiratory distress).
• Regular review every 3-6 months.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms and lung function tests indicate Chronic Obstructive Pulmonary Disease (COPD), a condition affecting airflow in your lungs.”
• “Your history of smoking has contributed, but stopping now will slow disease progression.”

Treatment Plan:

• “We will start with a bronchodilator inhaler to help your breathing.”
• “It’s important to quit smoking, and I will support you with nicotine replacement or medications if needed.”

Safety-Netting:

• “If your breathlessness worsens, if you develop chest pain, or if you feel faint, seek urgent care.”
• “We will review your response in 4 weeks and adjust treatment as needed.”

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Q4: What preventive measures can help reduce worsening of his symptoms?

Answer:

• Smoking cessation: Most effective intervention to slow COPD progression.
• Vaccinations:
  • Influenza vaccine annually
  • Pneumococcal vaccine (Pneumovax 23) every 5 years
• Pulmonary rehabilitation: Improves function and reduces hospitalisation.
• Regular exercise: Helps lung function and cardiovascular health.

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Q5: What are the red flags that would necessitate urgent escalation of care?

Answer:

• Severe dyspnoea at rest or worsening respiratory distress.
• Hypoxia (O₂ saturation < 90% on room air).
• Haemoptysis, unexplained weight loss, or progressive cough (suggestive of malignancy).
• Signs of right heart failure: Worsening oedema, increasing fatigue.
• Acute confusion or drowsiness, suggesting CO₂ retention.

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SUMMARY OF A COMPETENT ANSWER

• Systematically considers respiratory and cardiac causes of dyspnoea.
• Correctly identifies moderate COPD as the most likely diagnosis.
• Recommends appropriate initial management, including inhalers and smoking cessation.
• Provides a clear and empathetic explanation to the patient.
• Identifies preventive measures to slow disease progression.
• Recognises red flags requiring urgent intervention.

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PITFALLS

• Failing to differentiate between COPD and CHF.
• Not emphasising smoking cessation as the primary intervention.
• Overlooking vaccinations as preventive measures.
• Delaying referral for further assessment if symptoms worsen.
• Neglecting to provide clear safety-netting advice.

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REFERENCES

• RACGP Guidelines – Heart Failure Management
• GP Exams – Shortness of breath/dyspnoea

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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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to shortness of breath.
2.2 Identifies red flag symptoms requiring urgent escalation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between cardiac, respiratory, and other causes of dyspnoea.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including oxygen therapy if required.
4.2 Recognises when urgent hospital referral is necessary.

5. Preventive and Population Health

5.1 Educates the patient on smoking cessation and lifestyle modifications.

Competency at Fellowship Level

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