“Have the tests shown anything, doctor?” — interpreting spirometry

Candidates: do not open until you have consulted.

Persona and manner

• Maureen Gallagher, 67, retired school cook. Widowed three years ago — your husband Frank died of lung cancer. You live alone; your daughter Siobhan is ten minutes away. Friendly, uncomplaining, quietly anxious today.
• You get a little breathless if you talk for a long time. You are holding your handbag on your knee.

Opening line — say this verbatim

• “The nurse said you’d go through my tests with me. Have they shown anything, doctor?”

Volunteer freely if given the space

• Your breathing has got worse over the last year. You now stop for breath on the way to the corner shop — about a hundred yards — and you take the stairs one step at a time.
• You cough most mornings and bring up a little white phlegm. You are wheezy on cold days.
• You take your capsule inhaler every morning without fail, and the blue one through the spacer “more than I used to”.

Only if asked

• Flare-ups: the one in January, when the practice gave you steroids and antibiotics. If asked whether you have had any others, or whether you have used your rescue pack: yes — in June you had a bad week with green phlegm and took the tablets from the pack in your cupboard. You did not tell anyone: “I didn’t want to be a nuisance.” You have not asked for a replacement. No hospital admissions, ever.
• Blue inhaler: four to six puffs most days now.
• Smoking: stopped completely four years ago, when Frank was diagnosed. No vaping. Nobody smokes in the house.
• No blood in the phlegm, ever. Weight steady; appetite fine. No chest pain, no swollen ankles, you sleep on two pillows as you always have, no night sweats.
• No asthma, hay fever or eczema — as a child or since. Your breathing is much the same from day to day; mornings are a bit worse. No pets, no new exposures, no foreign travel, no new medicines.
• Mood: you miss Frank, and you worry, but you are not low — you enjoy bingo on Fridays and minding your grandson. The breathlessness frightens you sometimes on the stairs.
• You enjoyed the rehabilitation classes three years ago and would go again.

Impact on daily life (only if asked)

• You have stopped walking to bingo — Siobhan drives you. You do the housework in stages and have moved your bedroom things downstairs “just in case”.
• You can no longer carry your grandson upstairs; you dread not being able to mind him.
• You have stopped going into town on the bus because of the hill from the stop.

Ideas, concerns and expectations

• Idea: that the X-ray and blood tests were done because someone suspects cancer — “that’s how it started with Frank: a cough and an X-ray”.
• Concerns: that it is cancer; failing that, that you will end up on oxygen and be a burden to Siobhan.
• Expectation: to be told the truth. Perhaps a stronger inhaler. You half expect to be told nothing can be done.

Cues to deliver, timed

• Minute 2, if the X-ray result has not yet been given: “Did the X-ray show a shadow? You can tell me.”
• Minute 4, if flare-ups have not been asked about: “I’ve had a couple of bad spells this year, mind.”

If the doctor summarises and asks whether you want to add anything

• If the June flare-up has not come out: “I ought to say — I took those emergency tablets in June when I was bad. I never rang anyone. Does that matter?”
• If it has: “Will I end up on oxygen, doctor? I don’t want to be a burden to Siobhan.”

How to respond to the doctor

• If told early and plainly that the X-ray shows no sign of cancer: your shoulders drop — “Oh, thank God.” You can then take in the rest. If the doctor works through the breathing test first and leaves the X-ray until late, you stay tense and take in very little.
• If the numbers are explained in plain words — narrowed airways, the air comes out slowly, the lungs are working at about half of what is expected, and the blue inhaler makes little difference: you follow it. If given percentages and ratios with no explanation: “I’m sorry, doctor, I don’t understand all that.”
• If a new inhaler is offered with a clear reason — the flare-ups, and the blood test that suggests you will benefit — and you are told it replaces the capsule inhaler: you are pleased. If you are not told to stop the capsule inhaler, ask: “So I take this one as well as my capsule one?”
• When an inhaler containing a steroid is proposed, ask: “Has it got a steroid in it? Frank was on steroids at the end and he blew up like a balloon.” If it is explained honestly — a small dose that goes straight to the lungs, not like Frank’s tablets; rinse your mouth; a slightly higher chance of chest infection to watch for: reassured.
• If the oxygen worry is answered — your level is satisfactory, and oxygen helps only when the level is low: “So I don’t need it?” — relieved.
• If told “nothing much has changed” with no plan: deflated — “So I’ve just got to live with it.”

Do not

• Volunteer the June flare-up or the rescue pack unless asked about flare-ups — or invited to add anything (apart from the minute-4 cue).
• Say the word “cancer” before the doctor has either given the X-ray result or asked what is worrying you.

Findings to give the candidate — only if asked for

If the candidate asks for examination findings, observations, symptom scores, or for her inhaler technique or prescription record to be checked, read out the relevant part. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)

Domain marks — with the key facts that earn a 4 at this station

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory   ☐ Borderline   ☐ Satisfactory   ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. Reading spirometry in five steps: (1) right patient, acceptable and repeatable blows; (2) FEV₁/FVC — below 0.7 after a bronchodilator (or below the lower limit of normal) means airflow obstruction; (3) FEV₁ % predicted grades severity — NICE NG115 table 4: stage 1 mild 80% or more, stage 2 moderate 50–79%, stage 3 severe 30–49%, stage 4 very severe below 30%; (4) FVC — reduced with a normal or high ratio suggests restriction; (5) bronchodilator response and the shape of the curve. Here: 0.44, 47%, FVC normal, +70 mL — severe fixed obstruction.
2. Reversibility (NICE NG115 recs 1.1.18 and 1.1.21): routine reversibility testing is not needed to diagnose COPD and can mislead; only a change in FEV₁ of more than 400 mL strongly suggests asthma. The conventional threshold for a significant response is 12% and 200 mL (the 2021 ERS/ATS standard uses more than 10% of the predicted value — hers is about 3%). A 70 mL change is within the test’s own repeatability. She had taken her tiotropium that morning — correct for a monitoring test, but it means the ‘before’ blow is not a true baseline and a small response is expected; “fixed” obstruction rests on the history as well as the 70 mL. The point tested is reading the post-bronchodilator values and not over-calling 7%.
3. Features suggesting steroid responsiveness (NICE NG115): a previous secure diagnosis of asthma or atopy, a higher blood eosinophil count, variation in FEV₁ over time of at least 400 mL, or diurnal peak-flow variation of at least 20%. The GOLD report uses 0.3 × 10⁹/L (300 cells/µL) or more as the level that strongly favours an inhaled steroid in people who exacerbate, and below 0.1 as the level at which benefit is unlikely; NICE now uses the same 0.3 threshold to define raised eosinophils (NG115 rec 1.2.54, 2026).
4. Stepping up (NICE NG115 recs 1.2.10–1.2.16): after a short-acting bronchodilator the next step is LAMA + LABA — or LABA + ICS when there are features of steroid responsiveness. Triple therapy is offered to people on LABA + ICS with persisting day-to-day symptoms, one severe or two moderate exacerbations in a year; and considered for people on LAMA + LABA with one severe or two moderate exacerbations (or as a three-month trial for symptoms alone). LAMA monotherapy is not a step on NICE’s algorithm (rec 1.2.12 allows it to continue only while symptoms are controlled). Mrs Gallagher has symptoms, two exacerbations and raised eosinophils, so moving to a single triple inhaler is justified — GOLD recommends the same for exacerbations with eosinophils of 0.3 or more, and NICE CKS says a step-up to triple therapy may be considered from a single bronchodilator when eosinophils are raised. Strictly, NICE reaches triple therapy through a dual inhaler, and the triple inhalers are licensed for people not adequately treated by dual therapy — so the F2 proposes this step and the supervising GP or respiratory nurse decides. A reasoned step-up to LAMA + LABA with an early review is also acceptable.
5. Before triple therapy, NICE requires a clinical review (rec 1.2.13): non-drug management optimised, tobacco dependence treated, and the symptoms and exacerbations genuinely due to COPD — hence the X-ray, the full blood count, the technique check and the red-flag questions.
6. Prescribing: single-inhaler triples in the UK — Trelegy Ellipta (dry powder, one inhalation once a day), Trimbow (metered-dose or NEXThaler, two doses twice a day), Trixeo Aerosphere (metered-dose, two puffs twice a day). Stop the existing LAMA — duplicate antimuscarinics add side effects (dry mouth, urinary retention, glaucoma risk), not benefit. Prescribe by brand and device; minimise the number and types of inhaler (recs 1.2.18–1.2.19); document the reason for the inhaled steroid and review it at least yearly (rec 1.2.17). Inhaled steroids in COPD increase the risk of pneumonia (MHRA).
7. Rescue packs (NICE NG115 recs 1.2.128–1.2.130): for people who have had an exacerbation in the last year, who understand when to use them and who know to tell their healthcare professional when they have. An exacerbation that is not reported is not counted — and the count drives treatment. Three or more courses a year: investigate why.
8. Oxygen (NICE NG115): assess for long-term oxygen therapy if SpO₂ is 92% or less on air, FEV₁ is below 30% predicted, or there is cyanosis, polycythaemia, peripheral oedema or a raised jugular venous pressure — and consider it when FEV₁ is 30–49%. Oxygen treats hypoxaemia, not breathlessness. Pulmonary rehabilitation is offered at MRC grade 3 and above, and can be repeated.

Where candidates lose marks at this station

• Explaining the spirometry while she waits to hear about the X-ray.
• Quoting the pre-bronchodilator figures.
• Calling a 70 mL change “reversible”.
• Not noticing the eosinophil count — twice.
• Counting one exacerbation because the record says one.
• Adding a triple inhaler on top of the tiotropium.

Guidelines for this station

• NICE NG115 — Chronic obstructive pulmonary disease in over 16s: diagnosis and management
• NICE NG115 — Visual summary: non-pharmacological management and use of inhaled therapies
• Global Initiative for Chronic Obstructive Lung Disease — 2026 GOLD report
• Association for Respiratory Technology and Physiology — spirometry
• NICE CKS — Chronic obstructive pulmonary disease
• Asthma + Lung UK — Inhaler technique videos

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-20