Practice Station History: Breathless

Instructions to Candidates:

You are a Foundation doctor in the Emergency Department.

Carly/Carl White has presented because she/he is breathless.

Please take a history.

At 6 minutes the examiner will ask you questions.

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Practice Station History: Breathless

Station Information
Station Reference Practice Station History: Breathless

Station Title Practice Station History: Breathless

Student Description none

Author Heidi Northover

Year Group Practice 1Med Stations

Clinical Domain Respiratory

Clinical Competency Patient Assessment (History Taking)

Information for Site Organisers

Type of patient required:
Simulated patient (history only).

Patient information:
Male or female aged 30-45

Resources and equipment needed:

Alcogel

Candidate pink notepaper, black pens and clipboard in case the candidate wishes to make notes

Chairs x 3

Setting up the station:

The examiner’s chair should be positioned so that he/she can observe faces of both candidate and
patient/relative/colleague.

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Practice Station History: Breathless

Information for the Examiner

What is the overall aim of this station?
This station assesses the candidate's ability to take a structured, clinically reasoned history relating to the
presentation of breathlessness.

Examiner’s role:
• 0 minutes: candidate enters station. Check their ID card, then observe & assess the candidate.
• 6 minutes: ask the candidate:
1. What is your differential diagnosis?
2. Which is the most likely diagnosis?
3. What investigations may help to confirm this diagnosis?
If however the candidate answers question 2 incorrectly, ask instead:

3. What investigations may help to confirm a diagnosis of acute asthma?

• 8 minutes: politely ask the candidate to move on to the next station. Complete marking.

Standardisation is important. Whilst you may clarify the candidate’s responses to the questions above, please
do not ask supplementary questions of your own.

What is expected of the candidate?

This is a straightforward presentation of asthma. The candidate should explore the presenting symptoms,
elicit associated symptoms and identify any contributing risk factors. Alongside this, they should take a
patient-centred approached, exploring the patient's ideas, concerns, expectations and feelings.
Key symptoms that should be explored include:
• Age <50
• Past history of asthma & hayfever
• Family history of atopy (asthma & peanut allergy)
• Breathless on exertion
• Nocturnal cough and sleep disturbance
• Wheezing
• Non productive cough
• No chest pain
• No haemoptysis
• No occupational risk factors
• No weight loss
• No orthopnoea or paroxysmal nocturnal dyspnoea

Marking Guidance: if you award a global judgement below 'Excellent', it is

extremely important you provide constructive feedback on key areas the candidate
should develop further i.e feedback which justifies the grade awarded.
The excellent / good candidate

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Practice Station History: Breathless

• Will take a structured & clinically reasoned history, quickly exploring key and red flag symptoms.
• Will explore all or almost all of the key associated symptoms, and will enquire about symptoms of
differentials.diagnoses as part of a rule in/rule out reasoning approach.
• Will, in the time allocated, complete the history including asking about past medical history, drug
history, family history, social history, etc.
• Will consider the impact of the condition on the patient/family and elicit and address the patient's
ideas, concerns, feelings and expectations.
• Will demonstrate excellent communication skills, using a structured but sensitive approach and
avoiding jargon.
• (If required) will provide a sensible ordered differential list and/or arrive at the likely diagnosis.
• Will be able to describe and justify the required next steps.
The satisfactory candidate
• Will take a structured history, although will miss asking about some key or red flag symptoms.
• Will attempt to rule in/rule out possible differentials.
• Will, at times, be unstructured in their approach but generally will have a sensitive and patient-
centred manner.
• May not fully cover all aspects of the history in the allocated time.
• Will still identify some of the likely differentials and be able to describe some of the required next
steps.
• Will demonstrate good communication skills, using a largely sensitive and structured approach, and
using minimal jargon
• (If required) will provide a reasonable differential list/ arrive at the likely diagnosis
• Will be able to describe and justify most of the required next steps.
The failing candidate
• Will have a disorganised manner throughout with an unstructured & unsystematic approach to
history taking, missing most or all key or red flag symptoms.
• Will demonstrate cognitive biases that influence their clinical reasoning
• Will NOT identify likely diagnoses (or if they do, do so in an unstructured manner/ through
guesswork).
• Will adopt a doctor-centred, disjointed approach, or show lack of compassion/sensitivity.
• Will demonstrate poor or limited communication skills, without a structured approach and using
frequent jargon.
• (If required) they will be unable to provide a reasonable differential list/arrive at the likely diagnosis.
• Will be unable to describe and/or justify most of the required next steps.

Although potential examples are provided for examiner reference, please still accept clinically sensible
alternatives that are in line with the information/history obtained by the candidate.

As this station involves a patient (simulated or real), the candidate should follow standard infection control
practices (e.g. clean hands with alcogel upon entering AND before leaving / clean stethoscope if used / bare
below elbows etc).If the candidate is in breach of any OR multiple infection control measures, then their
global judgement should be no more than 'GOOD', and remind them of the importance of this in their
written feedback.

Clinical information relevant to the station:

1. What is your differential diagnosis and why?
• Differential diagnosis for this patient would be asthma, pneumothorax, panic attack, pneumonia,
anaphylaxis, heart failure (less likely as young age, no cardiac disease & patient can lie flat)
overweight (less likely as patient also has a cough and weight is steady) pulmonary fibrosis (less
likely as young patient and no history of exposure), TB (but less likely as weight steady, no systemic
symptoms, no travel abroad.
• Please accept any sensible differentials based on the history obtained by the candidate
2. Which is the most likely diagnosis?

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Practice Station History: Breathless

• The most likely diagnosis is asthma.

3. What investigations may help to confirm this diagnosis?
The diagnosis of asthma is a clinical one. The absence of consistent gold-standard diagnostic criteria means
that it is not possible to make unequivocal evidence-based recommendations on how to make a diagnosis of
asthma, however reversibility on spirometry can be supportive of this diagnosis. Initial evaluation should also
include CXR to exclude other diagnoses, FBC (to identify anaemia or polycythaemia) and BMI calculation. If
the cough is productive, sputum culture to rule out infective causes.
• There is no single diagnostic test for asthma; the diagnosis is based on a combination of history,
examination and confirmation of the presence of reversible airflow obstruction, using spirometry.
• The presence of airflow obstruction should be confirmed by performing post-bronchodilator
spirometry.
• FENO testing is now mentioned in recent national guidance

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Practice Station History: Breathless

Information for the Simulated Patient

Opening statement for the patient:
'I've been feeling really breathless lately, but it's much worse today'

About you:
• Carl or Carly White, M/F (30-45).
• You work as a primary school teacher.
• You live in your own house, with your spouse. (Jon or Jackie)
• You have a 12 year old daughter, Megan.
• You have smoked 10 cigarettes a day from the age of 16.
• You drink alcohol at the weekend – either few beers or few glasses of wine per week.
• You don’t usually do much exercise apart from walking your dog (a small terrier) 3 or 4 times a
week, but recently you have started to play cricket/rounders at a local club with some friends
• Your mood is normal (not anxious or depressed).

Current health problem:

• You have been getting increasingly short of breath and 'wheezy' over the last 2-3 days, especially on
exertion.
• You have also been coughing, especially at nighttime. The cough is dry, with no phlegm.
• Over the last 6-9 months, you have noticed that you are gradually getting more breathless when you
try to do anything.
• You think the final straw was a chest infection 3 months ago. The green phlegm improved with
antibiotics (given by your GP) but you are still struggling with your breath, especially when you try to
run for cricket or rounders.
If asked specifically
• Looking back, you realise that you have found it increasingly hard to talk while walking over the last
6-9 months. Then you started gradually walking a bit more slowly than your spouse (you put it down
to age, but you are actually both the same age).
• Now you have to stop while climbing more than a single flight of stairs because you get so short of
breath.
• The half-mile walk to the local pub is more difficult now. You need to stop a couple of times (or get
the car instead!)
• You have coped at work as you only have to walk short distances.
• You sometimes make wheezing noises when you are walking (but this doesn’t happen at rest)
• Your weight is steady; you haven't lost or gained more than a few pounds (a couple of kg) over the
last 5 years.
• You have never coughed up any blood.
• You do not have pain in your chest at any time.
• The cough or breathlessness sometimes disturbs your sleep (but you only need to use 1 pillow and
you can lie flat).
• You are not breathless when sitting doing nothing.
• The breathlessness is worse on exertion, even when you walk your dog, Milly, who you walk for
about half an hour 3-4 times a week.
• You have never worked with any chemicals, coal dust or asbestos.
• Your last trip abroad was to the South of France (Nice) about 2 years ago. Previously you went to
New York 4 years ago.
• You had asthma as a child and asthma runs in the family.
• You also suffer from hay fever but you have never had eczema.
• Your ankles have not swelled up.

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Practice Station History: Breathless

Your ideas, concerns, feelings and expectations:

• You realise the smoking has probably made your symptoms worse. You feel a bit guilty about this,
and plan to try to stop smoking (again!)
• You are concerned that these symptoms may be indicate that you haven't got over the chest
infection you had 3 months ago.
• You are expecting that the doctor might arrange a chest x-ray.

Questions:
Nil

Previous medical history:

You were diagnosed with asthma as a child and you used to have an blue inhaler, but have not used one
regularly for about 10 years.
You suffer with back ache from time to time, but nothing else really.

Medical problems in the family:

Your mother died from heart problems in her 60s.
Your father has had breathing problems (emphysema) since you can remember- this has always been put
down to him smoking 30 cigarettes per day.

Medication:
You used to have an blue inhaler as a child but have not used one regularly for about 10 years.
You take paracetamol occasionally for a bad back.
You had a course of antibiotics about 3 months ago for a chest infection (you can’t remember what they were
called but think that they were penicillin based).
You have no known drug allergies.

How to play the role:

You are generally quite easy to talk to. You may express your concerns, as above, but do not directly ask the
candidate what they think the diagnosis is. This will be covered by the examiner towards the end of the
station.

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Practice Station History: Breathless

Marking Domains
01. Overall conduct of the consultation with patient/relative/carer
Introduces self, states own role and checks identity of patient/ relative/ carer
Explains and agrees the purpose of consultation
Establishes and maintains rapport
Attends to the comfort, safety and dignity of the patient if applicable
Demonstrates empathy and sensitivity
Discusses patient information sensitively and with awareness of confidentiality if applicable
Maintains a fluent, coherent and competent approach
Manages time, completes task and closes appropriately
Follows appropriate infection control measures throughout

02. History Taking Skills

Appropriately uses a combination of open, probing and closed questions
Adopts a clinically reasoned approach, demonstrating the ability to differentiate relevant from irrelevant
information in order to narrow the differential diagnosis
Enquires about red flag features in order to rule in and rule out serious/ significant pathology
Uses a patient-centred and structured approach throughout
Appropriately elicits and acknowledges the patient’s feelings, ideas, concerns and expectations
Explores the impact on the patient’s life
Clarifies and summarises as appropriate
Avoids inappropriate reassurance
Demonstrates responsiveness to the social, cultural and ethnic background of the patient, and their
abilities and disabilities

04. Non-verbal Communication

Maintains appropriate body language and eye contact
Maintains a calm and composed demeanour
Demonstrates active listening (e.g. remaining focused on the patient)
Uses or offers visual methods for conveying information e.g. diagrams
Uses appropriate seating position

14. Clinical Knowledge and Diagnosis

Identifies the underlying problem(s)
Demonstrates an appropriate depth of understanding of the clinical condition/pathology
Applies reasoning skills to interpret information in the clinical context
Applies knowledge to the patient’s current situation
Generates a plausible list of differential diagnoses and if required, is able to identify which is most likely
Provides a clear justification and rationale for their diagnosis or differential diagnosis

15. Providing information to the examiner

Communicates findings clearly, if applicable
Summarises accurately and concisely if applicable
Answers examiner questions clearly and competently
Provides and prioritises answers that are reflective of routine clinical practice
Justifies answers in context of the patient’s problem

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