Shortness of Breath OSCE - COPD Exacerbation

Case Overview

• Age/Sex: 79-year-old male
• Occupation: Retired factory worker
• Setting: Lives alone, brought in by neighbor after progressive breathlessness
• Chief complaint: "Shortness of breath"

Patient Script

Who I Am

I'm 79, used to work in a factory, and I live on my own down the road.

What Brings Me In

I can't catch my breath like I used to — it's been getting worse over the last few days.

My Story

It started about 3 days ago with more cough than normal and a bit more breathlessness when I walk to the shops. Over the last 24 hours I've got a lot worse — I feel breathless at rest and I'm wheezy. My cough makes green sputum sometimes. I notice it's worse than my usual chest problems, and today my neighbour brought me in because I looked very breathless. I have had a cough on and off for years and used to smoke a lot; I still smoke a bit. I had a small fall in the garden about a week ago and bruised my ribs, but the pain is only mild and worse on one side when I twist. I also had a long drive to see family about 2 weeks ago but I felt OK then. I haven't been very feverish — maybe a small temperature once or twice.

My Medical Background

• Past medical history: long-standing chest problems ("emphysema"/"bronchitis"), diagnosed years ago; high blood pressure.
• Medications: occasional blue inhaler (salbutamol) as needed; takes aspirin sometimes for aches; stopped regular inhalers a while ago because they were expensive.
• Allergies: none known.
• Social: currently smokes ~20 cigarettes/day; lives alone; drinks socially (about 5–7 units/week); retired; neighbor helps sometimes.
• Family history: father died of a heart problem in older age.

What I Think & Worry About

• I think I have a chest infection and that's making my breathing worse.
• I'm worried I might not be able to breathe and need to go to hospital or be put on a machine.
• I'm worried I might not be able to look after myself at home if this keeps up.

If You Ask Me About Other Symptoms...

• Cough: "It's been worse — I cough up greenish stuff sometimes."
• Fever/chills: "I felt a bit hot once yesterday, but not proper shivering fevers."
• Chest pain: "Just a sore spot where I bruised my ribs last week — it's worse when I move, not when I breathe in deeply."
• Leg swelling: "My ankles are a bit puffier than usual, especially at the end of the day." (mild, not new)
• Orthopnea / paroxysmal nocturnal dyspnea: "I sleep okay — I don't need extra pillows, just coughs me a bit at night."
• Recent immobilisation or long flight: "I had a long car ride two weeks ago but I was fine after it."
• Medication adherence: "I don't use any regular inhalers, I only use the blue one when I feel bad."
• Home oxygen: "No, I don't have oxygen at home."

---

Clinical Summary

Examination

• General: elderly male, alert but in moderate respiratory distress
• Respiratory rate: 28/min
• Oxygen saturation: 88% on room air
• Heart rate: 110 bpm, regular
• Blood pressure: 135/78 mmHg
• Temperature: 37.8 °C
• Chest inspection: use of accessory muscles, hyperinflated chest
• Percussion: hyperresonant bilaterally
• Auscultation: diminished breath sounds with diffuse expiratory wheeze; no focal crepitations
• Cardiovascular: no raised JVP, no new murmurs
• Peripheral: mild dependent ankle oedema, no unilateral leg swelling or calf tenderness
• Neurological: oriented, no focal deficit

Investigations

• Chest X-ray: hyperinflation, flattened diaphragms, no lobar consolidation or focal airspace opacity (no overt pneumothorax)
• Arterial blood gas (on room air): pH 7.33, pCO2 56 mmHg, pO2 55 mmHg, HCO3- 30 mmol/L (consistent with acute on chronic respiratory acidosis)
• Pulse oximetry after controlled oxygen (28% Venturi): SpO2 91% (target 88–92%)
• Full blood count: WCC 12.0 x10^9/L (mild leucocytosis)
• CRP: 28 mg/L (mildly elevated)
• Serum electrolytes/renal function: Na 139 mmol/L, K 4.2 mmol/L, creatinine 90 µmol/L
• BNP: 45 pg/mL (normal)
• ECG: sinus tachycardia, no ischemic changes
• Sputum sent for culture: pending

Diagnosis

Primary diagnosis:

• COPD exacerbation, likely infective in origin (history of increased dyspnoea, increased sputum purulence and volume; long smoking history; CXR without consolidation; mild fever and elevated inflammatory markers; ABG shows CO2 retention consistent with chronic lung disease and acute on chronic respiratory acidosis).

Differential diagnoses and reasoning:

• Community-acquired pneumonia: less likely given absence of focal consolidation on CXR and only mild systemic signs, but still possible if early or radiograph insensitive.
• Acute heart failure: less likely due to normal BNP, lack of pulmonary oedema on CXR, and absence of orthopnea/PND; mild ankle oedema likely chronic/dependent.
• Pulmonary embolism: less likely given subacute progressive symptoms, presence of productive cough and wheeze, and no pleuritic chest pain or limb DVT signs; still considered if clinical deterioration unexplained.
• Pneumothorax: unlikely because CXR shows no pneumothorax and there is no sudden unilateral collapse or severe pleuritic pain.

Management

• Immediate
  • Give controlled oxygen to target SpO2 88–92% (start 24–28% Venturi and titrate), avoid high flow oxygen.
  • Administer inhaled bronchodilators: nebulised salbutamol + ipratropium or combined metered-dose inhaler with spacer if appropriate.
  • Start systemic corticosteroids: oral prednisolone 40 mg once daily for 5 days (or IV if unable to take orally).
  • Consider empirical antibiotics for suspected bacterial exacerbation (e.g., amoxicillin 500 mg TDS for 5 days or doxycycline 200 mg loading then 100 mg daily if penicillin allergic) given increased sputum purulence and systemic features.
• Monitoring and escalation
  • Repeat ABG after bronchodilator and oxygen therapy to assess for worsening hypercapnia.
  • Admit to hospital for observation and treatment given age, hypoxia, and hypercapnia; consider high-dependency monitoring if pCO2 rising or pH falling further.
  • Consider non-invasive ventilation (NIV) if persistent hypercapnic respiratory failure (pH <7.35 with rising pCO2 despite initial treatment).
• Secondary care and discharge planning
  • Review and optimize inhaler therapy (initiate or resume long-acting bronchodilator and consider inhaled corticosteroid if indicated); provide inhaler teaching and spacer.
  • Smoking cessation advice and referral to cessation services.
  • Influenza and pneumococcal vaccination counselling if not up to date.
  • Arrange physiotherapy assessment and referral to pulmonary rehabilitation on recovery.
  • Follow-up within 48–72 hours after discharge or earlier if worsening.

Key Learning Points

• In COPD exacerbations, aim oxygen saturations to 88–92% to avoid worsening CO2 retention; give controlled oxygen rather than high-flow.
• Acute on chronic respiratory acidosis (elevated pCO2 with partially compensated HCO3-) suggests underlying COPD — monitor ABGs and consider NIV if deterioration.
• Initial management includes bronchodilators, systemic corticosteroids, and selective antibiotics if increased sputum purulence or clinical infection is suspected; also review and optimize baseline inhaler therapy and provide smoking cessation support.