asthma - new diagnosis
Doctor Information
Jake Halliwell age 22
New patient registered to practice one week ago
New patient registered to practice one week ago
Patient Information
Jake Halliwell age 22
History: You have a cough, it is not all the time but is getting annoying. You don't think it is an infection because it has been there on and off for about a year, but you haven't had time to see a doctor. Your breathing is 'ok' generally, the only time you have problems is when you play rugby. No history of chest pain and you haven't noticed a wheeze.
If asked only: you cough most nights, it gets you up, and you always seem to have more phlegm in the mornings. You just cough for about 5 minutes and clear it all then you are fine for the day. The phlegm is clear. You had to come off the rugby pitch a couple of times during training as you had a coughing fit and your chest felt tight. Your symptoms are usually a bit better when you go home, but you still cough at night.
Social/PMH: You are a student at Nottingham University, studying sociology. You play rugby for the university team and train twice a week. You live in student housing with three other people. If asked, there is some damp around the house and one of your housemates has a budgie in his room. There are no other pets in the house.
You have smoked occasionally, mainly in social circumstances but not regularly. You go on a night out every friday and drink ‘a lot’, and you also have a few pints at the pub midweek. Your parents and younger brother are healthy, but your dad gets quite bad hay fever in the summer months.
Ideas: You think it is the damp and mould in your student house, but you are not worried about that because you move out soon and are planning to ‘upgrade’ to a studio apartment with your girlfriend.
Concerns: You are worried about the symptoms during rugby, your feel the coach is getting annoyed and you don’t want to be removed from the team.
Expectations: The doctor will probably tell you that things will improve when you move to your new place.
History: You have a cough, it is not all the time but is getting annoying. You don't think it is an infection because it has been there on and off for about a year, but you haven't had time to see a doctor. Your breathing is 'ok' generally, the only time you have problems is when you play rugby. No history of chest pain and you haven't noticed a wheeze.
If asked only: you cough most nights, it gets you up, and you always seem to have more phlegm in the mornings. You just cough for about 5 minutes and clear it all then you are fine for the day. The phlegm is clear. You had to come off the rugby pitch a couple of times during training as you had a coughing fit and your chest felt tight. Your symptoms are usually a bit better when you go home, but you still cough at night.
Social/PMH: You are a student at Nottingham University, studying sociology. You play rugby for the university team and train twice a week. You live in student housing with three other people. If asked, there is some damp around the house and one of your housemates has a budgie in his room. There are no other pets in the house.
You have smoked occasionally, mainly in social circumstances but not regularly. You go on a night out every friday and drink ‘a lot’, and you also have a few pints at the pub midweek. Your parents and younger brother are healthy, but your dad gets quite bad hay fever in the summer months.
Ideas: You think it is the damp and mould in your student house, but you are not worried about that because you move out soon and are planning to ‘upgrade’ to a studio apartment with your girlfriend.
Concerns: You are worried about the symptoms during rugby, your feel the coach is getting annoyed and you don’t want to be removed from the team.
Expectations: The doctor will probably tell you that things will improve when you move to your new place.
Examination Findings
Pulse 65 regular, BP 121/71
Oxygen saturations 99% ra, RR 17
Chest clear, no abnormal findings
Peak flow 510 (expected Peak flow 520)
Oxygen saturations 99% ra, RR 17
Chest clear, no abnormal findings
Peak flow 510 (expected Peak flow 520)
Mark scheme
Data Gathering
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POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently, or use instruments proficiently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
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POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and possible referral to the in-house asthma nurse, or to pharmacy for inhaler technique) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions. Explains inhaler technique correctly Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Encourages the patient to participate in appropriate health promotion and disease prevention strategies |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed |
Inter Personal Skills
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POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation |
Management
Explanation: Asthma is a common condition that affects the airways. At times it causes them to narrow or go in spasm, and this can lead to coughing, feeling breathless, having a tight chest and noisy breathing. With treatments we can get good control of the symptoms.
Diagnosis: The diagnosis of asthma in adults is initially based on the probability of asthma versus other respiratory diseases, and from spirometry. Although not tested in this case, can you interpret spirometry? As this chap has a high probability of asthma, you can reasonably start treatment and monitor response. The main challenge in this case is making a decision about diagnosis and treatment, and explaining things to the patient. Recent guidelines by BTS/SIGN in 2016 state that there is no perfect test for asthma, and actually your diagnosis should be based more on history rather than anything else:
We are aware that NICE have recently come out with their own guidelines - which appear, in part, to offer a different approach to diagnosing asthma, with a heavier reliance on FeNO testing. Depending on where you practice within the country, this facility may, or may not be available to you. Here is the link to the NICE Asthma Guidance. For ease of learning, we prefer the BTS guidance, as it is less complicated, and simpler to understand. Therefore all further recommendations are based off the BTS, and not the NICE guidance.
Diagnosis: The diagnosis of asthma in adults is initially based on the probability of asthma versus other respiratory diseases, and from spirometry. Although not tested in this case, can you interpret spirometry? As this chap has a high probability of asthma, you can reasonably start treatment and monitor response. The main challenge in this case is making a decision about diagnosis and treatment, and explaining things to the patient. Recent guidelines by BTS/SIGN in 2016 state that there is no perfect test for asthma, and actually your diagnosis should be based more on history rather than anything else:
We are aware that NICE have recently come out with their own guidelines - which appear, in part, to offer a different approach to diagnosing asthma, with a heavier reliance on FeNO testing. Depending on where you practice within the country, this facility may, or may not be available to you. Here is the link to the NICE Asthma Guidance. For ease of learning, we prefer the BTS guidance, as it is less complicated, and simpler to understand. Therefore all further recommendations are based off the BTS, and not the NICE guidance.
Management: Initial management of asthma has now changed. The recent guidelines no longer suggest a trial of a Short acting beta agonist (Salbutamol) as a sole treatment for asthma. They now recommend that we start with a 6 week trial of an inhaled Corticosteroid appropriate to the age of the individual. When first diagnosing suspected asthma, ensure that you teach good inhaler technique, prescribe a spacer and a peak flow to the patient. Also ensure to teach the patient how to use the peak flow. Reviews of asthma deaths found that there was a significant under-use of the Personalised Asthma Action Plans (PAAP), therefore ensure that if you do diagnose asthma, that you fill this out (or refer to your in-house asthma nurse to complete this) and the patients know how to use it. Click here to access a blank PAAP form that you can print out and fill in with patients.
Outlined below are the referral criteria for suspected asthma, and the red flags you need to know about:
Please see current treatment steps / guidelines below: (Taken from BTS/SIGN 2016 153)
Outlined below are the referral criteria for suspected asthma, and the red flags you need to know about:
- Prominent systemic features
- Abnormal CXR
- Marked blood eosinophilia
- Suspected occupational asthma
- Persistant, non-variable breathlessness
- Unexplained restrictive spirometry
- Unexpected clinical findings (clubbing, crackles, excessive sputum production etc...)
- Unclear diagnosis or poor response to treatment.
Please see current treatment steps / guidelines below: (Taken from BTS/SIGN 2016 153)
