Mark Anderson

Age: 65 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis   

  • Ask about the cough – when it started, if it’s dry or producing sputum, and whether there’s any blood in it.
  • Ask about shortness of breath – is it constant, worse with activity, or does it occur even at rest?
  • Check for any symptoms of breathlessness when lying flat (orthopnoea) or waking up breathless at night (PND).
  • Ask if the patient has had any fever, chills, or recent infections.
  • Ask about any bluish lips or fingers, which could suggest low oxygen levels.
  • Ask if anyone has noticed the patient being more confused or muddled than usual.
  • Ask about chest pain or palpitations.
  • Check if there’s been any swelling in the neck veins or signs of fluid retention.
  • Ask about medication use – whether they’re taking their inhalers and other prescriptions as advised.
  • Ask about any recent travel, especially long journeys that could increase the risk of clots.
  • Ask if the patient has had their flu jab, pneumococcal vaccine, and COVID booster.
  • Ask if he’s had any previous flare-ups, and whether they’ve needed steroids, antibiotics, or hospital treatment before.
  • Explore social history – whether he smokes (and how much), drink alcohol, live alone, and if he has support at home.
  • Make a diagnosis of COPD flare

Example of explanation To Patient​

Mark, from what you’ve told me;  the cough with brownish sputum, the wheezing, and the increased breathlessness over the past four days, it sounds like you’re having an exacerbation or flare-up of your COPD.

These flares can be triggered by things like a chest infection, a change in the weather, or even irritants like smoke. The good news is, this seems to be a moderate flare, as you’ve had similar symptoms before, and your oxygen level of 92%, while not perfect,  is still safe, especially since you’re feeling well otherwise and not experiencing chest pain, confusion, or severe fatigue.

Because of your penicillin allergy, I’ll prescribe an alternative antibiotic, a medication we call doxycycline which is   safe and effective for COPD flares. You’ll also need a short course of steroids, prednisolone 30 mg once daily for 5 days, to help reduce the inflammation in your lungs and improve your breathing. Can I just check that you do not have any other allergies asides penicillin? 

You mentioned you’re staying with a friend 9 miles away and can’t come in, that’s absolutely fine. Given your symptoms and the fact that your oxygen reading is stable, it’s safe to treat you remotely this time. But if things get worse,  like if you develop chest pain, get confused, feel very drowsy, or your oxygen level drops below 90%, I need you to call 111 or 999 straight away.

I’ll also arrange a follow-up call in 3–4 days to check on how you’re doing. And when you’re next able to, it would be good to see our COPD nurse , they can review your inhaler technique, consider giving you a rescue pack (a standby supply of antibiotics and steroids), and help create a personalised COPD action plan so you feel more in control during future flare-ups.

Lastly, I wanted to ask if you’ve had your flu jab, pneumococcal vaccine, and the latest COVID booster, these are all really important to help prevent infections that could trigger more flare-ups.

And Mark, I know you mentioned you’re still smoking 40 cigarettes a day. I can only imagine how hard things have been for you since your wife passed. If you’re ever open to talking about cutting down or getting support to quit, we can absolutely help with that — no pressure at all, just something to think about.

For now, let’s get these medications started today and I’ll send them to your local pharmacy. Does that all sound okay?

Management 

  • Offer a face-to-face review to examine his chest, check oxygen saturation, and confirm diagnosis.
  • Since the patient is unable to attend, remote management is appropriate, provided he remains clinically stable.
  • Prescribe Doxycycline (or Clarithromycin if Doxycycline is not suitable), as he is allergic to penicillin. Confirm any other allergies before prescribing.
  • Prescribe Prednisolone 30mg once daily for 5 days to help reduce airway inflammation.
  • Arrange a follow-up call in 3–4 days to reassess symptoms, monitor progress, and ensure he is improving.
  • Refer to the COPD nurse for review, including a discussion about setting up a rescue pack (antibiotics + steroids) and creating a personalised self-management COPD plan.
  • Offer to arrange vaccinations if not already up to date – Pneumococcal, Influenza, and COVID vaccines.
  • Safety net: Advise him to call 111 or seek urgent medical attention if he develops worsening breathlessness, chest pain, high fever, confusion, or his oxygen levels drop.
  • Explain that his oxygen saturation reading of 92% is acceptable for now, but if it drops below 90%, this could indicate a need for hospital admission.

Learning point from this station:

As GPs, it’s important to learn to take reasonable clinical risks when the situation calls for it. While a face-to-face assessment is usually preferred for someone with a COPD flare, in certain cases, such as this one, where the patient is clinically stable, has normal oxygen saturations, currently unable to attend the surgery and can be safely followed up, a remote management plan is acceptable.

According to NICE guidelines, emergency hospital admission should be considered in a COPD exacerbation if the patient exhibits:

  • Severe breathlessness
  • Inability to cope at home or living alone
  • Deteriorating general condition or significant comorbidities (e.g. cardiac disease, insulin-dependent diabetes)
  • Rapid onset of symptoms
  • Acute confusion or impaired consciousness
  • Cyanosis
  • Oxygen saturation less than 90% on pulse oximetry (Oxygen saturations from 89% and below) 
  • Worsening peripheral oedema
  • New arrhythmia
  • Failure to respond to initial treatment
  • Already receiving long-term oxygen therapy

In this case, the patient had an oxygen saturation of 92%, was clinically stable, and did not meet any of the criteria warranting urgent hospital admission.

For patients preferring to remain at home, hospital-at-home services, where available, can also be considered as an alternative to inpatient care.

This station highlights the importance of:

  • Judging when a patient can be managed safely without physical examination.
  • Applying clinical reasoning based on history, previous flare patterns, and self-reported vitals.
  • Ensuring robust safety netting and early follow-up and offering longer-term support like COPD nurse referral and a rescue pack.