How to run this case
One run: 28 minutes
- Read the door note 1 min
- Encounter with the patient 15 min
- Oral presentation 2 min
- SOAP note 10 min
Three roles
- Candidate reads the door note, runs the encounter, then presents the case and writes the note.
- Patient plays Ms. Whitfield from the script and reads each exam finding when the candidate performs that maneuver. No medical knowledge is needed.
- Examiner and timer keeps time, calls 5 minutes and 1 minute left, and ticks the checklist as items happen. With two people, the patient does this too.
The candidate sees only the door note. Everything else is for the partner: print the packet or open this page on a second device, and agree on times before you start. The times here are suggestions, so use your program's if you know them.
Working alone, ask each question out loud before you read its answer in the script, and announce each maneuver before you read its finding. You lose the practice of drawing answers out of a person, but you keep the order, the timing and the note. Afterward, score yourself with the checklist, then read the model presentation, the annotated note and the debrief.
The clinical content follows the 2026 report of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the Rome proposal for grading exacerbations, which GOLD adapts.1,2 The case is original and fictional.
Door note
Door note for the candidate
Doris Whitfield, 66-year-old woman. Primary care clinic, same-day visit. Chief complaint: shortness of breath.
- Temp
- 37.8 °C (100.0 °F)
- Heart rate
- 106/min
- BP
- 142/86 mm Hg
- Resp
- 26/min
- SpO2
- 88% on room air
You have 15 minutes.
- Take a focused history.
- Perform a focused physical exam. Order any treatment or test you would give here, and the examiner will tell you the result.
- Explain your assessment and plan to the patient.
- Afterward, give a 60 to 90 second oral presentation and write a SOAP note.
This is all the candidate sees before the encounter. Use the minute to read it twice and plan. For shortness of breath at this age, write down the causes you cannot miss: pneumonia, pulmonary embolism, acute heart failure, acute coronary syndrome and pneumothorax, along with a flare of any known lung disease. Read the vital signs as a set: the respiratory rate and the saturation tell you how sick the patient is before you walk in.
Then decide what you will do early. Some treatment cannot wait until the history is finished, and the examiner will be watching for it. Plan how you will explain your thinking to the patient in plain words.
Candidate: stop here. Everything below is for the patient and the examiner, including the answers. Come back to it after you have run the case.
Patient script
For the person playing Ms. Whitfield. Read it through once before the encounter, answer only what the candidate asks, and stay in character until the examiner calls time.
Show the patient script
Patient script for the partner
You are Doris Whitfield, a 66-year-old retired postal worker. You are short of breath: pause for a breath every few words, and purse your lips as you breathe out. You are frustrated that your inhaler is not working, and you want to stay out of the hospital. Answer in plain words. If a question is vague, give a short answer and wait.
Opening statement
I can't get my breath. This cold went to my chest, and my inhaler isn't working.
If the candidate asks an open question such as "Tell me more," add: "It's like the flare I had last winter, but worse." Say nothing else unless asked.
The history, only if asked
- Onset
- My grandson had a cold last week. I got a runny nose and a sore throat 5 days ago. My breathing started getting worse 3 days ago, and it's been much worse since last night.
- Breathing now
- I'm short of breath just sitting here. I can't finish a sentence without stopping.
- Severity
- If 10 is the worst, it's an 8 right now. On a normal day, about a 3.
- Compared with usual activity
- Normally I can walk around the grocery store if I go slowly. Today I had to stop twice walking in from the parking lot.
- Cough and sputum
- I'm coughing much more. Usually I bring up a little white phlegm in the morning. Now it's thick and green, and a lot more of it, all day.
- Wheezing
- Yes. I can hear it, especially at night.
- Rescue inhaler
- My albuterol, every 2 hours since yesterday. It helps for maybe 20 minutes.
- Sleep
- I slept sitting up in my recliner last night. Lying flat made me cough, and I couldn't catch my breath.
Other symptoms, only if asked
- Fever or chills
- I felt hot and had chills last night. I didn't check my temperature.
- Chest pain
- My chest feels tight when I cough a lot. No pressure, and it doesn't hurt to take a breath in.
- Coughing up blood
- No.
- Leg swelling, calf pain, travel, surgery or a past clot
- No to all of those. My legs feel fine.
- Before this cold: lying flat, ankle swelling, weight
- I slept flat on one pillow. My ankles are fine, and my weight hasn't changed.
- Palpitations
- My heart has been racing since I started using the inhaler so much.
- Confusion, sleepiness or morning headaches
- No. I'm thinking clearly, just worn out.
Background, only if asked
- COPD history
- I've had COPD for 7 years. My lung doctor says my breathing test is about half of normal.
- Usual oxygen level
- I don't use oxygen at home. At my lung doctor's office, my oxygen is usually 93 or 94.
- Past flares and hospital stays
- One flare last winter. My doctor gave me prednisone and an antibiotic, and I got better at home. I've never been in the hospital for my lungs, and never on a breathing machine.
- Other medical history
- High blood pressure. No heart problems that I know of.
- Medicines
- A once-a-day inhaler with two medicines in it, tiotropium and olodaterol, every morning. Albuterol when I need it. Amlodipine, 5 mg, for my blood pressure.
- Allergies
- None.
- Vaccines
- I had my flu shot last month.
- Smoking, alcohol and drugs
- I smoked a pack a day for 40 years. I quit 2 years ago. A glass of wine now and then. No drugs.
- Home
- I live alone with my dog. My daughter lives about 40 minutes away.
Your question for the candidate
When the candidate starts explaining the plan, ask: "Can't you just give me the prednisone and the antibiotic like last time? I don't want to go to the hospital. Who will look after my dog?"
If the candidate explains clearly why you need the emergency department and an ambulance, agree, and if they offer to call your daughter, say yes; she can take care of the dog. If they send you home with prescriptions, say "Thank you" and nothing more; the examiner will note it.
Physical exam findings
For the patient or the examiner. Read a finding only when the candidate performs the maneuver or clearly names it. Anything not listed is normal. The clinic has oxygen, an air-driven nebulizer, inhalers with spacers and an ECG machine. Give a treatment or test result only when the candidate orders it.
Show the exam findings
Exam findings read each one only when it is examined
- General
- Sitting upright and leaning forward with her hands on her knees. Pursed-lip breathing. Speaks in short phrases. Lips pink.
- Work of breathing
- Neck muscles tighten with each breath. Respiratory rate counted at 26/min.
- Mental status
- Alert and oriented to person, place and date. No tremor or asterixis.
- Neck
- No jugular venous distention. Trachea midline.
- Chest, inspection and percussion
- Increased front-to-back diameter. Hyperresonant on both sides, equal.
- Lungs, auscultation
- Diffuse expiratory wheezes on both sides with a prolonged expiratory phase. Air movement decreased at both bases, equal side to side. No crackles. No egophony.
- Heart
- Fast and regular. Heart sounds distant. No murmur or gallop.
- Legs
- No edema. Calves soft, nontender and equal in size.
- Hands
- No clubbing. Fingertips pink.
Tests, only if the candidate asks
- Oxygen by nasal cannula
- At 1 L/min, SpO2 90%. At 2 L/min, SpO2 91%.
- After one albuterol and ipratropium nebulizer
- Wheezing slightly less. Still speaking in short phrases. Heart rate 110/min, respiratory rate 24/min, SpO2 91% on 2 L/min.
- 12-lead ECG
- Sinus tachycardia at 106/min. Normal axis. No ST changes. No arrhythmia. No prior ECG for comparison.
- Chest x-ray, blood tests or blood gas
- Not available at this clinic.
Examiner checklist
Score each item done or not done, one point each. The examiner ticks items as they happen, not from memory at the end. A history item counts if the candidate asked it in any wording; an exam or treatment item counts only if the candidate performed, ordered or clearly named it.
Three items are marked critical: they are the actions that keep this patient safe. For practice, call a run a pass when the candidate scores at least 27 of 38 and completes every critical action. Programs set their own standards, so use yours when you know it. After scoring, the examiner names two things done well and two to work on.
Examiner checklist tick each item the candidate does
History
- Onset, and the cold that came before it
- Shortness of breath now, at rest and with walking, compared with her usual
- Cough, and the change in sputum volume and color
- Fever or chills
- Rescue inhaler use: how often, and how long it helps
- Chest pain, and whether it is pleuritic
- Coughing up blood
- Leg swelling, calf pain, travel, surgery or a past clot
- Orthopnea, ankle swelling or weight gain before this illness
- Confusion or sleepiness
- COPD history: usual saturation, home oxygen, past flares, hospital stays or intubation
- Medicines, including the maintenance inhaler, and allergies
- Smoking, enough to estimate pack-years, and who is at home
Exam
- Reviews the vital signs and counts the respiratory rate
- Observes the work of breathing: accessory muscles, pursed lips, speech in phrases
- Checks mental status
- Inspects the chest and percusses both sides
- Listens to the lungs in all fields, comparing sides
- Listens to the heart
- Looks at the neck veins
- Checks the legs for edema and calf tenderness
Treatment in the clinic
- Names the saturation as below her baseline and starts oxygen titrated to 88 to 92 percent Critical
- Gives a short-acting bronchodilator: albuterol, with or without ipratropium, by air-driven nebulizer or inhaler with spacer Critical
- Gives prednisone 40 mg by mouth, or hands it on to the emergency department
- Gets a 12-lead ECG
- Rechecks the saturation, rates and work of breathing after treatment
- Names the antibiotic indication: more dyspnea, more sputum and purulent sputum
Communication
- Introduces self, confirms the patient's name, cleans hands
- Opens with an open-ended question
- Asks short, closed questions once her breathing limits long answers
- Summarizes the history back to the patient
- Asks what worries the patient
- Uses plain language, without jargon
Closure and counseling
- Explains that this flare, with low oxygen, needs hospital testing and treatment today
- Arranges transfer to the emergency department by ambulance, on oxygen Critical
- Answers the request for prescriptions like last time, with the reason
- Addresses her worry about home, such as offering to call her daughter
- Checks understanding and asks for questions
Score: ______ of 38 Critical actions: ______ of 3 Practice pass: 27 or more, and every critical action
Model oral presentation
Model presentation about 70 seconds aloud
Ms. Whitfield is a 66-year-old woman with COPD and a 40 pack-year history, quit 2 years ago, not on home oxygen, who presents with 3 days of worsening shortness of breath after a cold.
Her cough has increased, and her sputum is green and more abundant, with wheezing, subjective fever and chills. She is using albuterol every 2 hours with brief relief and slept upright last night. She denies pleuritic pain, hemoptysis, leg swelling, orthopnea before this illness and confusion. She lives alone.
Temperature is 37.8, heart rate 106, respiratory rate 26 and saturation 88 percent on room air, against her usual 93 to 94. She speaks in short phrases with accessory muscle use, is alert and oriented, and has diffuse expiratory wheezes without crackles or edema. The ECG shows sinus tachycardia.
My leading diagnosis is a COPD exacerbation, at least moderate. Pneumonia, pulmonary embolism and heart failure are less likely but not excluded. She is on oxygen to a target of 88 to 92 percent, has had albuterol, ipratropium and prednisone, and EMS is taking her to the emergency department.
A good presentation follows the order of the note and leaves out what does not change the assessment. Open with one sentence that carries the key features: the age, the lung disease, the smoking history and the trigger. Someone who hears only that sentence should already be thinking of a COPD exacerbation, and the next sentences should tell them how sick she is.
Give the history in the order that supports your reasoning: the cardinal symptoms of an exacerbation (more dyspnea, more sputum and purulent sputum) first, then the negatives that argue against each dangerous alternative. Report the exam as specific findings, including the saturation against her baseline, the respiratory rate and how she talks, since those set the severity.
End with a ranked assessment and a plan that says what you did, not what you might do. Practice it against a timer until you can finish in under 90 seconds without notes.
Keep two vocabularies. Hypoxemia, accessory muscle use and exacerbation belong in the presentation to the examiner; "your oxygen is low," "you are working hard to breathe" and "a flare of your COPD" belong in the room with the patient. If the examiner asks a question afterward, answer with the finding first and the reasoning second.
Annotated model SOAP note
A note the candidate could write in 10 minutes, with what each part is doing beside it. It uses common abbreviations; follow your program's rules.
Model SOAP note with what each part is doing
Chief complaint and history
CC: "I can't get my breath."
HPI: 66F with COPD; URI symptoms (rhinorrhea, sore throat) for 5 days after exposure to her grandson, then 3 days of worsening dyspnea, much worse since last night. Now dyspneic at rest, 8/10 vs usual 3/10; stopped twice walking in from the parking lot (usually walks a grocery store slowly). Increased cough; sputum changed from scant white in the mornings to thick green, increased volume. Wheezing. Subjective fever and chills. Albuterol q2h since yesterday, relief about 20 min. Slept upright in a recliner last night (cough and dyspnea when flat).
What graders look for. The cardinal symptoms carry the diagnosis: more dyspnea, more sputum and purulent sputum after a viral trigger. Graders look for the onset and trigger, the change from her usual breathing and activity, and how often she uses her rescue inhaler and how long it helps.
Common miss. Writing "SOB x 3 days" without her baseline, the sputum change or the albuterol use.
Pertinent negatives
No pleuritic or pressure-like chest pain; chest tight with coughing only. No hemoptysis. No leg swelling, calf pain, recent travel, surgery or prior VTE. Before this illness slept flat on 1 pillow; no ankle swelling or weight gain. No confusion, somnolence or morning headache. Palpitations since frequent albuterol use.
What graders look for. Each negative answers a dangerous alternative: pleuritic pain and hemoptysis for pulmonary embolism, orthopnea and edema before this illness for heart failure, confusion and sleepiness for CO2 retention, though these are late signs and normal mentation does not exclude it.
Common miss. Recording "slept upright" with no note that it began with this illness.
Background
PMH: COPD x 7 yr, lung function about half of normal by patient report; no home O2; usual SpO2 93 to 94% at pulmonology visits; 1 exacerbation last winter treated at home with prednisone and an antibiotic; never hospitalized or intubated for COPD. HTN.
Meds: tiotropium/olodaterol inhaler daily; albuterol MDI PRN; amlodipine 5 mg daily. Allergies: NKDA. Vaccines: influenza last month.
SH: 40 pack-years, quit 2 yr ago; occasional wine; no drugs. Retired postal worker. Lives alone with her dog; daughter 40 min away.
What graders look for. The baseline is what makes the severity: her usual saturation, her lung function, her past flares and whether she has ever been hospitalized or intubated. Home support belongs here too, because it changes where she can be treated.
Common miss. No usual saturation, so "88% on room air" cannot be compared with anything.
Objective
Vitals: T 37.8 °C, HR 106, BP 142/86, RR 26, SpO2 88% RA.
General: upright, leaning forward, pursed-lip breathing, speaks in short phrases, accessory muscle use; no cyanosis. Mental status: alert, oriented x3, no asterixis. Neck: no JVD, trachea midline. Chest: increased AP diameter, hyperresonant bilaterally. Lungs: diffuse expiratory wheezes, prolonged expiration, decreased air movement at both bases, symmetric; no crackles or egophony. CV: tachycardic, regular, distant heart sounds, no murmur or gallop. Ext: no edema, calves nontender and symmetric, no clubbing.
ECG: sinus tachycardia 106, normal axis, no ST changes, no arrhythmia; no prior for comparison. After O2 2 L/min NC and 1 albuterol/ipratropium neb: SpO2 91%, RR 24, HR 110, wheeze slightly improved, still speaking in phrases.
What graders look for. Specific findings that grade the severity: the respiratory rate you counted, how she talks, accessory muscle use and mental status. Then the findings that argue against alternatives, such as symmetric breath sounds, no crackles and no edema. Record the response to treatment with numbers.
Common miss. "Lungs: wheezes" with no respiratory rate, mental status or saturation after treatment.
Assessment
66F with COPD, 40 pack-years, with 3 days of increased dyspnea, sputum volume and sputum purulence after a viral URI, now with resting hypoxemia (SpO2 88% RA vs usual 93 to 94%), RR 26, HR 106 and accessory muscle use. Mentation normal. Lives alone.
1. Acute exacerbation of COPD, likely viral trigger, possible bacterial infection: at least moderate by GOLD's adaptation of the Rome criteria (dyspnea 8/10, RR 24 or more, HR 95 or more, SpO2 below 92% and a fall of more than 3 points; CRP unavailable). Severe cannot be excluded without a blood gas, and normal mentation does not exclude hypercapnia.
2. Community-acquired pneumonia: possible; fever and purulent sputum; no focal crackles or egophony. Needs a chest x-ray; a normal film alone does not necessarily exclude it.
3. Pulmonary embolism: less likely; infectious trigger, no pleuritic pain, hemoptysis, leg findings or VTE risk factors. PERC is positive (age, HR, SpO2), so it cannot rule out PE. Hand off for probability-guided testing in the ED.
4. Acute heart failure: less likely; no orthopnea before this illness, no edema, JVD, gallop or crackles. A normal chest x-ray alone does not exclude it; BNP and cardiac ultrasound if suspicion persists.
5. Pneumothorax: unlikely; gradual worsening, no sudden pleuritic pain, symmetric breath sounds and percussion. Needs a chest x-ray; CT or ultrasound if suspicion persists after a normal film.
6. ACS or arrhythmia: unlikely; no chest pressure; ECG shows sinus tachycardia without ST changes. One nondiagnostic ECG does not exclude ACS; serial ECG and troponin in the ED as indicated.
What graders look for. Open with a summary sentence, then a ranked differential with the evidence for and against each diagnosis. Grade severity with named criteria rather than adjectives: GOLD grades it with an adaptation of the Rome proposal's five clinical variables, and saying which ones she meets is more useful than calling the flare "bad."1,2
Common miss. Calling it "severe" without a blood gas, or "mild" because her mind is clear. Write "at least moderate" and say what would settle it.
Plan
1. O2 by nasal cannula, titrated to SpO2 88 to 92% (91% on 2 L/min).
2. Albuterol 2.5 mg with ipratropium 0.5 mg by air-driven nebulizer x 1; wheeze slightly improved. Repeat albuterol while awaiting EMS if needed.
3. Prednisone 40 mg PO given.
4. EMS called for transport to the ED on O2; ED notified; note, ECG and medication list sent. Continuous pulse oximetry and observation until EMS arrives.
5. For the ED: blood gas on arrival despite normal mentation, repeated 30 to 60 min after any oxygen change; chest x-ray, CBC and BMP. PE: probability-guided testing (D-dimer or CT angiography). ACS: serial ECG and troponin as indicated. Antibiotic indicated by GOLD criteria (increased dyspnea, sputum volume and purulence, with fever); start promptly without waiting on a delayed chest x-ray, and adjust coverage if pneumonia is found. No drug allergies.
6. Counseled: serious COPD flare with low oxygen that needs hospital tests and treatment today; reason for an ambulance. Plan to call her daughter, with the patient's permission, to care for the dog. Patient agrees.
What graders look for. Each treatment with its dose and target, the response, then the disposition with the mode of transport and what she was told. Oxygen gets a target: 88 to 92 percent for a patient at risk of CO2 retention, with a blood gas within 30 to 60 minutes.3
Common miss. Prednisone and an antibiotic from the clinic and home again, because that worked last winter. This time she has signs that GOLD lists as indications for hospitalization.1
Debrief: ranking the differential
The differential, ranked
-
COPD exacerbation Most likely; at least moderate
For: Known COPD; a cold, then more dyspnea, more sputum and purulent sputum; wheezing; albuterol every 2 hours.
Against: Nothing that excludes it. Its mimics still need an answer.
-
Pneumonia Dangerous; address it
For: Fever, purulent sputum, tachycardia.
Against: No focal crackles, egophony or pleuritic pain. Needs a chest x-ray; a normal film alone may not exclude it.
-
Pulmonary embolism Dangerous; address it
For: Hypoxemia, tachycardia.
Against: An infectious story; no pleuritic pain, hemoptysis, leg swelling or clot risk factors. PERC is positive, so it cannot exclude PE.
-
Acute heart failure Less likely
For: Slept upright last night; hypertension.
Against: No orthopnea before this illness; no edema, raised neck veins, gallop or crackles.
-
Pneumothorax Less likely; dangerous
For: COPD; worse since last night.
Against: Gradual worsening, no sudden pleuritic pain, symmetric breath sounds and percussion.
-
ACS or arrhythmia Less likely
For: Tachycardia; smoking history and hypertension.
Against: No chest pressure; ECG shows sinus tachycardia without ST changes.
Rank a dyspnea differential on two scales at once: how likely each diagnosis is, and how much harm a miss would do. GOLD defines an exacerbation as an acute event in which dyspnea, cough and sputum worsen over up to 14 days, sometimes with tachypnea and tachycardia, and names respiratory viral infections as the main trigger. It also warns that pneumonia, pulmonary embolism, acute heart failure and pneumothorax can mimic or worsen an exacerbation.1 Ms. Whitfield's story fits the definition closely: a cold from her grandson, then more breathlessness, more sputum and sputum that turned green.
Severity comes next, and GOLD grades it with an adaptation of the Rome proposal. A moderate exacerbation meets at least three of five criteria: dyspnea of 5 or more on a 0 to 10 visual analog scale, a respiratory rate of 24 or more, a heart rate of 95 or more, a resting saturation below 92 percent or a fall of more than 3 points from baseline when known, and a CRP of 10 mg/L or more. In GOLD's version, a severe exacerbation shares those criteria, and a blood gas may show a PaO2 of 60 mm Hg or less, hypercapnia with acidosis (PaCO2 over 45 mm Hg and pH below 7.35), or both.1 The original Rome proposal reserves severe for hypercapnia with acidosis: a PaCO2 over 45 mm Hg and a pH below 7.35.2 She meets four of the five clinical criteria; only the CRP is unavailable. That makes her at least moderate under either scheme, and whether she is severe depends on a blood gas this clinic cannot run.
The mimics each need a sentence. Pneumonia needs a chest x-ray: she has fever and purulent sputum, though no focal crackles or egophony. For pulmonary embolism the PERC rule cannot help: it applies only when clinical suspicion is already low and all eight criteria are met, and she fails three of them, age under 50, heart rate under 100 and saturation of 95 percent or more.4 The ED should assess her clinical probability of PE and test accordingly, with D-dimer or CT angiography, and one nondiagnostic ECG does not settle ACS, so ECG and troponin are repeated as indicated. Heart failure is less likely without earlier orthopnea, edema, raised neck veins or a gallop, and pneumothorax is less likely with symmetric breath sounds and percussion. A normal chest x-ray alone does not necessarily exclude pneumonia, heart failure or pneumothorax: GOLD lists natriuretic peptides and cardiac ultrasound for heart failure, and chest CT or ultrasound for pneumonia and pneumothorax, to use as suspicion warrants.1
The red flags in this case: a saturation of 88 percent against a usual 93 to 94, a respiratory rate of 26, accessory muscle use, speech in short phrases, a rescue inhaler that works for only 20 minutes and no one at home. Together they take this patient out of a home treatment plan and into the emergency department.
Debrief: why the emergency department, by ambulance
Common mistakes on this case
- Reading the saturation on the door note without comparing it with her usual, or never counting the respiratory rate.
- Giving high-flow oxygen with no target, or holding back oxygen for fear of CO2 retention.
- Leaving the bronchodilator until the history is finished.
- Sending her home with prednisone and an antibiotic because that worked last winter.
- Never asking about pleuritic pain, leg swelling or orthopnea before this illness, so pulmonary embolism and heart failure go unaddressed.
- Skipping the mental status check, or reading a clear mind as proof of a normal CO2. Confusion is a late sign; only a blood gas measures CO2.
- Never asking who is at home, or letting her wait for her daughter to drive her.
- Never answering her question.
GOLD's guide to the place of care weighs five things: the severity of the exacerbation, mental status and hemodynamic stability, serious comorbidities, home support and the response to initial treatment. Its indications for hospitalization are signs of respiratory failure, such as an increased respiratory rate, accessory muscle use, worsening hypoxemia or hypercarbia, or a change in mental status; failure to respond to initial management; serious comorbidities such as heart failure or arrhythmias; and insufficient home support. Ambulatory care fits a mild exacerbation in a cooperative patient with few comorbidities and good support at home.1 Ms. Whitfield has a respiratory rate of 26, accessory muscle use and a saturation well below her usual, and she lives alone. Her flare last winter could be treated at home. This one cannot.
Treat while you wait. GOLD recommends short-acting beta2-agonists, with or without short-acting anticholinergics, as the initial bronchodilators, delivered by air-driven rather than oxygen-driven nebulizer to avoid raising the PaCO2, and systemic corticosteroids at 40 mg of prednisone or its equivalent daily for 5 days. It recommends antibiotics when at least two of increased dyspnea, fever, increased sputum volume and increased sputum purulence are present and purulence is one of them.1 She has all four, so she should start one promptly. Arrange the chest x-ray quickly, but do not hold the antibiotic if imaging is delayed; if the film shows pneumonia, adjust the coverage.
Give oxygen with a target. The British Thoracic Society recommends a saturation target of 88 to 92 percent for patients at risk of hypercapnic respiratory failure, including those with COPD.3 In a randomized trial of prehospital care for suspected COPD exacerbations, oxygen titrated to that range reduced mortality, hypercapnia and respiratory acidosis compared with high-flow oxygen.5 The target works in both directions: do not leave her hypoxemic for fear of CO2 retention. It does not replace a blood gas. Confusion is a possible late sign of hypercapnia, and normal mentation does not exclude it, so BTS recommends a blood gas within 30 to 60 minutes for patients on an 88 to 92 percent target and a repeat 30 to 60 minutes after any increase in oxygen.3
Why an ambulance: she needs continuous oxygen and monitoring on the way, which a private car cannot give, and her daughter is 40 minutes away. Then say it plainly: "Your oxygen is lower than your normal, and you are working hard to breathe. This flare needs hospital tests and treatment today, and the safest way there is an ambulance with oxygen." Answer the prescriptions and the dog directly, offer to call her daughter, and check that she agrees.
