Simulated Patient Scenario

Chest Infection / Pneumonia

Scenario Details

Scenario: Suspected Community-Acquired Pneumonia (CAP)

Simulated Patient: 76-year-old Female

Actor/Actress: Student Actor (Patient), Student Actor (Daughter)

MDT Information

Urgent Response - Difficulty Breathing / Generally Unwell
76-year-old female, increasingly unwell over past few days
Productive cough, feverish, short of breath
Daughter called, concerned about confusion
Location: Patient's home

On Arrival

You arrive at a neat suburban house. The patient's daughter meets you, appearing worried. She leads you to the bedroom where her mother, a 76-year-old female, is propped up in bed with several pillows. The patient appears flushed, lethargic, and is breathing rapidly and shallowly. She coughs occasionally, producing thick greenish sputum into a tissue. She looks at you but seems slow to respond and slightly confused.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Elderly female, appears unwell, lethargic, tachypnoeic, flushed, potentially septic.
Response	Opens eyes to voice, confused conversation, obeys commands but slow. (AVPU = V / Confused, GCS ~13-14: E3-4 V4 M6)
Airway	Clear and self-maintaining, occasional productive cough noted.
Breathing	Rapid, shallow respirations. Increased work of breathing evident (mild accessory muscle use). Complains of shortness of breath.
Circulation	Skin flushed and warm centrally, peripheries slightly cool. Tachycardic. Radial pulse palpable.
Disability	Altered mental state (confusion, lethargy).
Exposure/Environment	Indoor bedroom environment. Patient wearing nightclothes. Assess temperature, check for rashes.

Secondary Survey and Simulation Progression

History (obtained from patient - may be limited, and daughter)

Allergies	Penicillin (causes rash)
Medications	Amlodipine, Atorvastatin, Metformin, Ventolin MDI PRN (for mild COPD).
Past Medical History	Hypertension, Type 2 Diabetes Mellitus, Mild COPD (ex-smoker), Osteoarthritis. Had pneumonia 2 years ago requiring hospitalisation.
Last Oral Intake	Poor intake over last 2 days, minimal fluids today. Daughter concerned about dehydration.
Events Preceding / Current Illness:	Daughter reports patient developed a "cold" about 4-5 days ago. Over the last 2-3 days, developed worsening cough productive of thick green/yellow sputum, fevers (measured 38.5°C yesterday), chills, and increasing shortness of breath. Became more lethargic and confused this morning, prompting daughter to call. Patient complains of right-sided chest pain, worse on deep inspiration or coughing (pleuritic). Has been using Ventolin more often with little effect. Denies recent travel or sick contacts other than "cold".

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	26 (Tachypnoeic)
Lung Sounds (L/R)	Coarse crackles and bronchial breathing sounds heard over Right Lower Lobe. Possible scattered wheeze. Left side clear.
Percussion Note (L/R)	Dullness over Right Lower Lobe.
SpO2 (%)	91% (Room Air)
EtCO2 (mmHg)	32 mmHg (Low due to tachypnoea)
Pulse Rate (/min.)	110, regular
CRT (sec.)	3 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus Tachycardia. No acute ischaemic changes.
BP (mmHg)	105/60 (Hypotensive relative to history/age - sign of sepsis?)
Skin	Flushed, warm/hot to touch centrally, peripheries cool. Dry mucous membranes.
Pain (/10)	6/10 right-sided pleuritic chest pain.
GCS (/15: E,V,M)	14/15 (E4, V4 - confused, M6)
BGL (mmol/L)	9.5 (May be elevated due to infection/stress)
Pupils (mmL/mmR)	Equal and Reactive (PERL).
Temp. (°C)	38.8°C (Febrile)

Physical Examination

General Appearance: Elderly female, appears unwell, lethargic, flushed, mild-moderate respiratory distress.
Respiratory: Tachypnoeic, shallow breathing, productive cough (purulent sputum). Focal chest signs: Decreased expansion on right, dull percussion RLL, bronchial breathing and coarse crackles RLL on auscultation. Mild accessory muscle use.
Cardiovascular: Tachycardia, potentially hypotensive. Skin warm centrally, cool peripheries. Delayed CRT.
Neurological: GCS 14 (confused). No focal deficits.
Hydration: Signs of dehydration (dry mucous membranes, poor turgor).

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Recognize likely pneumonia with hypoxia, potential dehydration, and sepsis (based on RR, HR, Temp, Confusion, BP - consider NEWS2/qSOFA criteria).
Oxygen Therapy: Apply oxygen via nasal prongs or face mask to maintain target SpO2 ≥ 94%. Titrate flow rate accordingly.
Positioning: Assist patient into comfortable position (usually sitting upright).
Monitoring: Continuous SpO2, ECG monitoring. Frequent vital signs reassessment (including temperature). Monitor mental status closely.
IV Access: Establish IV access.
Fluid Therapy: Consider cautious IV fluid bolus (e.g., 250-500mL Sodium Chloride 0.9%) for suspected dehydration/hypotension/sepsis, reassessing frequently for response and signs of fluid overload (especially given HF history).
Consider Bronchodilators: If significant wheeze present (due to underlying COPD or reactive airways), administer nebulised Salbutamol +/- Ipratropium per protocol, driven by air or oxygen maintaining target SpO2.
Pain Management: Provide analgesia for pleuritic chest pain (e.g., Paracetamol IV/oral). Opioids generally used cautiously due to risk of respiratory depression.
Antibiotics: Prehospital antibiotics generally not administered unless specific sepsis protocols exist and transport time is prolonged. Focus on supportive care and rapid transport.
Transport Decision: Urgent transport to ED is required due to hypoxia, tachypnoea, fever, confusion, potential sepsis, and need for further investigation/treatment (antibiotics, imaging).
Teamwork & Communication: Communicate plan clearly to patient and daughter. Provide comprehensive pre-notification to ED (Suspected pneumonia/sepsis, vitals, SpO2, key findings, treatments given). Detailed handover.

Debrief Focus Points

Recognizing the clinical presentation of pneumonia in the elderly (may be atypical).
Key physical examination findings in pneumonia (focal crackles, bronchial breathing, dullness).
Assessing for and recognizing potential sepsis using vital signs and clinical criteria (e.g., NEWS2/qSOFA).
Appropriate oxygen therapy targets and delivery methods.
Rationale for cautious fluid administration in elderly patients/those with comorbidities.
Indications for bronchodilators in chest infections (co-existing COPD/wheeze).
Importance of monitoring mental status as an indicator of severity/hypoxia/sepsis.
Comprehensive handover including sepsis concerns.