Woman Discharged After A COPD Admission Asking for Home Oxygen — Free SCA Practice Case

Character Overview: You are Edwina Pargeter, a 70 year old retired school secretary. You live with your husband Walter, who is 73 and fit, in a two storey house with the bedroom upstairs. Your daughter Lindsay lives twenty minutes away and drops in most days. Your son Adrian lives abroad. You were in hospital for four nights with a bad chest and came home five days ago. You feel much better than you did, but you are frightened of going back in. In hospital the oxygen mask made you feel calmer and your breathing eased, so you have decided you need a machine at home to keep you safe. You are polite and organised, you like to have things written down, and you do not like to be told off. Your voice is a little breathy on longer sentences and goes quiet and defensive when smoking comes up.

Opening Sentence: "Hello, doctor. I came out of hospital last week with my chest and the letter says to ask you about oxygen. I'd like an oxygen machine at home, please, because I felt so much better on it."

History if Asked (Data Gathering Phase)

• ●The admission: "I got a cold and then my chest tightened up and I couldn't get a sentence out. Lindsay called an ambulance. They kept me four nights, gave me steam machines, a mask, steroid tablets and antibiotics. The steroids and the antibiotics finished yesterday."
• ●How you are now: "Better than in hospital, but not back to normal. I get out of puff walking to the end of the road, about a hundred yards, and on the stairs I have to stop halfway. Before this I could do the whole road."
• ●Cough and phlegm: "Back to my usual white phlegm in the morning, not much. It was green and thick last week. No blood."
• ●Fever and chest pain: "No fever now. No chest pain. I feel a bit wheezy at night but I sleep all right with two pillows."
• ●Ankles and weight: "My ankles are fine. I've not noticed swelling. I've lost a little weight, maybe half a stone this year, because I'm not eating much when I'm breathless."
• ●Oxygen at home: "Walter bought a little finger gadget online. It says 90 or 91 most of the time, and once it said 88 when my hands were cold. That's what made me ask. The hospital letter says 89 to 90 as well."
• ●Headaches or drowsiness: "No morning headaches, and I'm not drowsy."
• ●Past chest history: "I've had two courses of steroid tablets and antibiotics from the surgery in the last year, and now this admission. I was told I have COPD six years ago."
• ●Inhalers: "A blue one when I need it, about four times a day at the moment, and a daily one in the morning that I take from a grey device. I think I do it properly, a quick breath in. Nobody in hospital watched me."
• ●Vaccinations: "I had the flu jab in the autumn. I think I had a pneumonia one years ago, but I'm not sure. I haven't had a covid one for a while."
• ●Rehabilitation: "I've never been sent to any classes. I think exercise would make me more breathless."
• ●Mood and nights: "I get panicky when I can't catch my breath, mostly in the evening, and I lie awake worrying about it. I'm not low and I enjoy my days when I can breathe."

Ideas, Concerns, Expectations

Gating note: Edwina does not raise any of the following unless the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

• ●Ideas: She thinks her lungs are now weaker and not getting enough oxygen, because the finger gadget and the letter both say 89 or 90. She believes oxygen at home would top her up and stop another admission. "If the number's low, surely I need more oxygen, don't I? It's like a top up."
• ●Concerns: She is terrified of another night like the one that led to the admission, and of being breathless on her own when Walter is out. She is also afraid of becoming an invalid on a machine, though she will not say so first. "I thought I was going to die in that ambulance. I can't go through that again."
• ●Expectations: She expects the doctor to arrange delivery of an oxygen machine this week, because that is what the letter seems to say. She would accept something that stops it happening again. "I thought you'd just order it. Walter's already cleared a space by the settee."

If Asked: Medical History and Medications

Gating note: Edwina answers these plainly when asked.

• ●Other illnesses: "Just the blood pressure, for years. No heart trouble, no diabetes, no kidney problems."
• ●Medicines: "The blue puffer, the grey daily inhaler and the amlodipine for my pressure. Nothing from the chemist apart from paracetamol now and again. No herbal things."
• ●Allergies: "None."
• ●Hospital tests: "They did a chest X-ray and blood tests and said there was no pneumonia. I don't know what the blood tests showed."

Social History and Lifestyle Impact

• ●Smoking: Gating note: Edwina does not mention smoking unless asked about it. If asked, she is guarded at first. She started at 16. She smoked about 15 a day until the admission and now has about 8 a day, on the back step so Walter does not complain. She did not tell the ward staff the true number. She does not use a vape. Walter does not smoke. "I've cut right down. I know I should stop, but I've got the lungs I've got now, haven't I? What's the point?" She tried patches once, ten years ago, and they gave her vivid dreams and she gave up after a week. She has never been to a stop smoking service. She smokes first thing and after meals. If asked whether she smokes near a gas cooker or in the house, she says never in the house.
• ●Home and support: Lives with Walter, who drives. Lindsay helps with shopping. A gas hob and a gas fire in the lounge. She is not sure the smoke alarm batteries have been changed.
• ●Daily life: Washing and dressing take longer now. She used to walk to the shop and now takes the car with Walter.
• ●Availability to be seen: She can come to the surgery any day with Walter driving. She prefers mornings.

If Asked: Associated Symptoms

Gating note: Edwina answers these only when asked. Every one is negative unless stated.

• ●If asked about breathlessness at rest or when lying flat: "Not at rest now. I'm only breathless when I'm doing things."
• ●If asked about blue lips, confusion or being unusually sleepy: "No. Walter would say if I was muddled."
• ●If asked about leg swelling or pain in a calf: "No."
• ●If asked about coughing up blood or night sweats: "No."
• ●If asked about loss of appetite or tiredness: "I've no appetite when I'm breathless, and I get tired by the afternoon."

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that oxygen is not started straight away after a flare up, and that the saturations need rechecking when she is well:
  • ●Reaction: Disappointed and worried. "But the letter says to consider it, and the number's low. Why can't I have it now just in case?" She accepts if told that readings are often lower in the weeks after a flare up, that oxygen is given only if the levels stay low once she is stable, that a specialist team does the assessment, and that it is not a refusal. "So when would that be? And who does it?"
• ●If the doctor says smoking affects whether home oxygen is possible:
  • ●Reaction: Stung, then tearful. "Nobody told me that. I've cut down. I'm not a bad person." She asks: "Is it because of fire?" If told oxygen makes fires burn faster and that people who keep smoking are not given it: "And if I stopped, would I definitely get it?" She is told it depends on the results, and she says: "Right. I don't want to be the reason the house burns down, with Walter in it."
• ●If the doctor offers help to stop smoking:
  • ●Reaction: Doubtful, then willing. "I tried patches and they were horrible." She will try again if told that there are different kinds, that a stop smoking service gives regular support, and that cutting down helps but stopping is the aim. She asks: "Can I use one of those vapes? Walter's brother swears by them." If told they could be an option but they still carry a fire risk around oxygen: "Hmm, I'll think about that."
• ●If the doctor suggests pulmonary rehabilitation or reviewing her inhalers:
  • ●Reaction: Surprised. "Exercise classes? Won't it make me worse?" She is reassured to hear it is supervised, tailored and helps breathlessness, and that she could start within a month of discharge. She is happy for her inhaler technique to be checked: "Perhaps I haven't been doing it right. Can you show me?" She asks whether she should get another jab.
• ●If the doctor asks to see her in person for her chest, oxygen levels and ankles:
  • ●Reaction: Relieved to be taken seriously. "Yes, please. Nobody has listened to my chest since I came out. Can Walter bring me tomorrow morning?" If asked to show the doctor her finger reading or check herself on camera, she says she will read it out but would rather be checked properly.
• ●If the doctor gives safety netting or an action plan:
  • ●Reaction: Wants specifics. "What's an emergency, though? I'm always breathless." If told only to come back if worse: "Worse how? When do I call an ambulance and when do I ring you?" She repeats back clearly when given specific symptoms with a time frame, and asks whether she can keep tablets at home for a flare up.