SimMan: Acute Exacerbation of Asthma

Casebank Simman
1

Where you are:
You are F2 working in A & E.

Who the patient is:
Mr. Tory Jones 35 year old male came with acute shortness of breath.

Other Information:
None

Special Note:
Mr. Tory Jones is represented as a High Fidelity

What you must do:
Take talk to the patient, assess his condition, examine him, do relevant management and discuss with the examiner if management plan is asked after 2 minutes bell.

Opening

  1. Candidate Identification:
    To examiner: I'm [First & Last Name], My GMC reference number is 7970822.
  2. Universal precaution:
    Think loud: I assume, I've taken all the universal precautions.
  3. Introduction & Pt Identification:
    To pt: Hello, I'm Dr [Last Name], one of the junior doctors here in the emergency department. Are you Tory Jones? Can you please confirm your age?
  4. PC:
    To pt: Tory, How can I help you today?
  5. Acknowledge & Reassure: If pt is conscious
    To pt: Tory, I see that you're in distress, but don't worry you are in safe hands now.
  6. Check Monitor: If not attached
    Think loud: I would like to attach my patient to the monitor.
    Observe vitals. Think loud: My pt O2 saturation is __.
  7. HPC: If patient is able to speak take HPC
    To pt: Signpost Tory, I'll be asking you few questions regarding your compliant of shortness of breath.
    To pt: Onset When did this start? What were you doing when it started? Has this happened before?
    To pt: DDs Any Cough? Any Fever? Any Chest pain? Any Calf Pain?
    To pt: MMA Do you have any medical condition? Are you taking any regular medication? Are you allergic to anything?
    To pt: Is any trigger that has happened?
    To pt: Have you taken any medication before coming here?
    Risk factors: Exercise? Smoking? Home condition (Pets? Carpets?) Job? Surgery? Travel? smoker’s cough?
  8. Consent & Chaperone:
    To pt: Tory, to help you better, I'll be doing some examination, which involve exposing different parts of your body and I'll also be listening, touching, tapping and feeling them. Is that okay with you?
    To pt: We also have chaperone, for your privacy.
  9. Position:
    Think loud: Ideally I would like to place my patient on semi seating position.
  10. Signpost ABCDE:
    Think loud: I would like to manage my patient according to ABCDE approach.

Airway

  1. Signpost Airway:
    Think Loud: Now, I'm going to start with A, which is airway.
  2. Check Airway Patency:
  • If pt can talk: Airway patent
    Think loud: As my patient is talking to me his/her airway is patent.
  • If pt can’t talk:
    Think loud: I would like to perform the Head Tilt-Chin Lift maneuver.
  1. Check O2 Saturation & Any Swelling:
  • Think loud: My pt O2 saturation is __.
    • (If O2 <94%)
      Think loud: Target O2 saturation is 94%, therefore I would like to start my patient on 100% O2 via Non-rebreathable mask (NRBM) at flow of 15L/min.
      From Trolley: Collect NRBM mask.
      To pt: Tory, I'm putting this mask on you, it'll help you breathe better.
      To pt: Tory, are you feeling a little bit better now?

Breathing

  1. Signpost Breathing:
    Think loud: Now, I'm moving to B, which is breathing.
  2. Check RR & Trachea Position
    Think loud: My pt RR is __
    To pt: Tory, I’m going to feel you over the neck now.
    Think loud: Trachea is centrally placed.
  3. Chest Examination:
    From Trolley: Collect stethoscope.
    To pt: Tory, I'm going to uncover your chest & examine you now.
    • Inspection:
      Think loud: I'm looking for surgical scar mark, rashes or abnormal chest movement.
    • Palpation: compare temperature, B/L chest expansion
      To pt: Tory, Can you breathe for me?
    • Percussion: 6 sites
      To pt: I'm going to tap on your chest now.
    • Auscultation: 6 sites, also auscultate heart: 4 sites.
      To pt: I'm going to listen to your lung and heart sounds now.
      Think Loud: My pt is having added sound in ..(location).., therefore I would like to change the mask to O2-driven Nebuliser mask at 6L/min and give medication through the mask, 5mg Salbutamol.
      From Trolley: Collect Nebuliser mask and 5mg Salbutamol.
      To pt: Tory, I'll be changing your mask now and giving you some medication through it, this'll help you breathe better.
  4. Ix: (ACE)
    Think loud: I would like to do few Ix for my pt: ABG, CXR & 12 lead ECG.
  5. Remaining History: Pt stabilised.
    To pt: Tory, How are you feeling now? Do you think you can answer my few question?

Circulation

  1. Signpost Circulation:
    Think Loud: Now, I'm moving to C, which is Circulation.
  2. Check BP & Examine CRT and peripheral pulse.
    Think loud: My pt BP is __ .
    To pt: Tory, I’m going to press your finger nail now.
    Think loud: Ideally I would do this for 5 seconds.
    To pt: Tory, I’m going to feel your pulse now.
    Think loud: My pt's pulse volume is (adequate/ low) & rhythm is (regular/ irregular)
  3. Insert IV Cannula, Collect Blood sample and Start Fluids:
    From Trolley: Collect IV cannula, vacutainer and fluids.
    • Insert IV Cannula:
      Think loud: I’m going to maintain one large bore (16G) Grey colour IV cannula in the arm.
      To pt: Tory, a sharp scratch is coming.
    • Collect Blood sample:
      Think loud: I would like to collect blood sample for FBC, RFT, LFT, U&E, ESR & CRP.
    • Start Fluids:
      Think loud: I'm going to start my pt on Normal Saline 500ml in 15 min, 1L in 30 min and 2L in 1hr. Maximum 2L.
  4. Reassess O2: If not improved
    Think loud: Assuming 20 minutes has passed I would like to give another dose of 5 mg Salbutamol via O2-driven Nebuliser mask.
    Think loud: I would like to give 0.5 mg Ipratropium Bromide via O2-driven Nebuliser mask.

Disability

  1. Signpost Disability
    Think Loud: Now, I'm moving to D, which is Disability.
  2. Check Temperature:
    Think loud: My pt temperature is __
  3. Check Blood Sugar:
    Think loud: I would like to collect blood sugar now.
    From Trolley: Collect glucometer, strips & torch.
    To pt: Tory, a sharp scratch is coming.
  4. Check GCS-
    To pt: Tory, can you please move your leg?
    Think loud: My pt is opening his eyes spontaneously, he is speaking and following verbal commands, hence his GCS is normal.
  5. Check Pupillary Reflex:
    To pt: Tory, I'm going to shin light in your both eyes now.
  6. Reassess O2: If not improved
    Think loud: I would like to give Hydrocortisone 100mg IV

Exposure

  1. Signpost Exposure
    Think Loud: Now, I'm moving to E, which is Exposure.
  2. Full exposure:
    To pt: Tory, I'm going to expose your leg now.

Final 2 minutes

  1. To examiner: ISBAR
    – Introduction: I'm Dr [Last name] one of the doctor in the A&E department. My pt named Tory Jones 35 years old, male..
    – Situation: ..presented with the acute SOB.
    – Background: After having a chat with him, I came to know he is a KCO Asthma on regular medication.
    – Assessment: I started his treatment through ABCDE approach. His O2 saturation was low, therefore gave O2 via NRBM mask. On Auscultation of her chest, I heard added sound. Therefore, I switched to O2 driven nebuliser mask at 6L/min and gave 5mg Salbutamol 2 times, along with 0.5mg Ipratropium bromide and 100mg Hydrocortisone IV.
    – Recommendation: I'll recommend to admit him, I'll involve my senior for further investigation like PEFR. Also, if his O2 saturation doesn't improve, they might consider giving him IV salbutamol, magnesium sulphate or theophylline.
  2. To pt: 3P
    How are you feeling now?
    – Past: How are you feeling? Narrate story & Explain condition
    – Present: PEFR, Senior
    – Future: Admit, ITU if not improving
    Advice regarding (Attacks. Triggers. Inhalers)
    On discharge > Refer toAsthma Clinic > Safety Netting.
3 Likes
2

We have to add prednisolone 30mg OD for 3days and blue inhaler as per need as discharge medicine too??

3

This patient is being admitted so this will be the advise.

If stable then, “after consulting with my senior, you’ll be discharged and they will advise …” what you mentioned, plus refer to Asthma Clinic & advice for attacks & triggers.

4 Likes
4

What are the triggers and safety netting here?can anybody plz post that as well?

1 Like