Mark Anderson
Age: 65 years old male
Full Case
Patient’s Data
Patient’s name: Mark Anderson
Age: 65-year old male
Past medical history
- COPD
- Hypertension
- Hypercholesterolaemia
Drug history/Repeat template
- Salbutamol PRN
- Anoro Ellipta (Umeclidinium with vilanterol) one puff daily
- Amlodipine 10mg OD
- Ramipril 2.5mg OD
- Atorvastatin 20mg OD.
- Allergic to penicillin
Recent consultation
Seen by Ann Coleman (Nurse practitioner access role) 6 Months ago
Presenting complaints: Reports cough, wheeze and SOB
Examination findings: scattered wheeze ++ and left crackles. Vitals stable.
Impression: treat as IECOPD
Plan: For Doxycycline and steroids. Worsening advice given.
Booked urgent appointment to discuss issues
Patient's Story (Role player’s brief)
Patient’s Story
You are Mark Anderson, a 65-year-old man. You’ve been feeling more short of breath than usual for the past 4 days, along with a wheezy chest and a persistent cough. The cough is bringing up brownish phlegm and just isn’t settling.
You’ve not had any fever or chest pain, and you were feeling completely fine before this started.
You don’t have any other symptoms.
Social history: You smoke about 40 cigarettes a day and don’t drink alcohol. You live alone—your wife sadly passed away from breast cancer 3 years ago. However, you currently have a girlfriend
You’ve had a COPD flare-up once before, around 6 months ago, and needed steroids at that time.
You believe you might need antibiotics and have booked this appointment to get help. You’re currently staying with a friend who lives about 9 miles from the surgery, so getting in for a face-to-face appointment would be difficult right now.
Ideas: You think this might be another flare-up of COPD, similar to the one he had 6 months ago.
Concerns: You are worried that the symptoms aren’t settling and might get worse if left untreated.
Expectations: You are hoping to be prescribed antibiotics and/or steroids to help manage the flare remotely and feels reassured if something can be done without needing to come in.
When the doctor explains the diagnosis to you: volunteer the below
Tell the doctor that your girlfriend—who also has COPD—gave you a finger oxygen monitor to check your levels. You used it this morning and it read 92%.
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
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.