MBChB Clinical Scenarios

Show Learning Points most relevant to Phase 1:

Chronic shortness of breath

Clinical Discipline(s)/Organ System(s)
Respiratory Medicine, Respiratory System, Cardiology, Cardiovascular System, Infectious Diseases

Progress Test Topic(s)
Respiratory

Description

A 65 year old Tongan woman presents to the Emergency Department with worsening shortness of breath over the last 24 hours. She is well known to the department needing hospital admissions two to three times per year. She says that she is always short of breath and has difficulty getting to the shops but things are currently much worse than usual. She is breathless at rest today. There has been an increase in her daily sputum production. She has a 30 pack-year smoking history but stopped 5 years ago.

Applied Science for Medicine
   - Anatomy of respiratory tract (pleura, trachea, bronchi, lungs and diaphragm)
   - Physiology of gas exchange and interpretation of arterial blood gas results
   - Mechanics including lung volumes, flows and compliance; work and physiological control of breathing
   - Pathophysiology of dyspnoea, airflow obstruction and hyperinflation
   - Physiology of non-invasive ventilation (NIV)
   - Work and control of breathing
   - Pathophysiology and differentiation of chronic obstructive pulmonary disease /asthma
   - Pharmacology of glucocorticoids (e.g. prednisone), and inhaled therapy including beta-2 adrenoceptor agonists (e.g. salbutamol, eformoterol, salmeterol), inhaled anti-cholinergics (e.g. tiotropium, ipratropium) and inhaled corticosteroids (beclomethasone, budesonide, fluticasone)
   - Pharmacology of antivirals (oseltamivir)
   - Microbiology and virology of coronavirus (SARS-CoV2) and other respiratory pathogens
   - Immunology of vaccines used to control respiratory disease including live, inactivated, mRNA and vector based vaccine technologies

Clinical and Communication Skills
   - History from a patient with chronic shortness of breath (including impact on day to day function, current treatment, level of control, morbidity, co-morbidities)
   - Perform and interpret Peak Expiratory Flow (PEF), spirometry and arterial blood gas
   - Examination of the respiratory system, recognise respiratory distress
   - Interpret chest X-ray
   - Indications for high resolution CT, detailed pulmonary function tests, bronchoscopy
   - Differential diagnosis of chronic shortness of breath
   - Differentiate between cardiac and respiratory causes of shortness of breath
   - Management of acute exacerbation of chronic airways disease including evidence and indications for non-invasive ventilation
   - Management of chronic airflow obstruction; pharmacological and non-pharmacological
   - Evidence for and indications for respiratory rehabilitation
   - Evidence for and indications for oxygen therapy - acute and chronic
   - Role of respiratory nurse specialist, respiratory physiotherapist and other health professionals
   - Complications of chronic obstructive airways disease
   - Prognosis of chronic obstructive airways disease
   - Management principles of complications of SARS-CoV2 including non-invasive ventilation

Personal and Professional Skills
   - Managing chronic disease including inter-professional practice and recognising appropriate time to refer to palliative care
   - Self-management of airways disease
   - Patient education; evidence for, strategies
   - Brief intervention for smoking cessation
   - Understand the variability of symptom sensation, perception and reporting shortness of breath
   - Role of advance care planning and palliative care

Hauora Māori
- Awareness of differing risk profiles for Māori compared with non-Māori
- Understanding of inequities in access to health services and quality of medical care for Māori, and application of this to clinical decision-making and management

Population Health
   - Global health; causes and epidemiology of chronic obstructive pulmonary disease and asthma in different countries
   - Role as an advocate in tobacco control
   - Influenza, COVID and pneumococcal vaccination programmes
   - Notifiable diseases, professional and legal obligations for communicable disease reporting (eg: COVID)

Conditions to be considered relating to this scenario

Common
chronic obstructive pulmonary disease, asthma, cardiac failure, acute infective exacerbation (including COVID and other respiratory viruses), bronchiectasis, pneumothorax

Less common but 'important not to miss'
alpha-1-antitrypsin deficiency, pulmonary hypertension (primary, secondary to pulmonary embolus), bullous lung disease

Uncommon
bronchiolitis obliterans, inflammatory bronchiolitis