Context: You are a medical student on placement in the Accident & Emergency department
Task: Please take a history from this patient presenting with chest pain
Essential Background: Mr Thomas (DoB 23/05/70) has come in to the A&E departement complaining of chest pain
Presenting Complaint
Chest pain – 45 year old A&E
History of Presenting Complaint
You had sudden onset of right-sided ‘sharp’ pleuritic chest pain while sitting down a few hours. Pain had a severity score of 7/10, there is no radiation or exacerbating/alleviating factors. There was an associated shortness of breath, you can still complete sentences and it has only lasted the duration of the chest pain. There is no haemoptysis, unexplained weight loss, pyrexia, hoarse voice or sputum. No nausea no vomiting no palpitations . Pain ongoing but a bit less than before
Past Medical History
Cholecystectomy August 2014
Hypertension 2007
No diabetes, asthma, COPD IHD
Drug History
Ramipril 2.5mg OD
Bisoprolol 2.5mg OD
No known drug allergies
Family History
Mum died of M.I. aged 70
Brother has COPD
Social History
Smoker 15 per day for 20 years
No alcohol consumption
Retired nurse
Widowed, now living home alone
No recent travel or pets
Healthy diet, cooks and cleans daily
Systemic Review
General – No weight loss, no fatigue, no loss of appetite
Cardiovascular – Swollen warm right leg, no palpitations
Gastrointestinal – no loss of appetite, no nausea, vomiting, abdominal pain or change of bowel movements
Musculoskeletal – no notable muscle or joint pain
DD – Pulmonary Embolism , Pneumothorax
Ideas Concerns expectations
You think this may be a heart attack. You smoke and have high blood pressure and your mum died of a heart attack. You are anxious that the dr covers this, and if he does not, you will ask him directly “do you think this could be my heart?”Accuracy
Does the student do the right thing?
Pleuritic pain
Check for other respiratory symptoms.
Considers cardiac symptoms as well
Elicits concern re MI
Elicits risk factors – smoker and hypertension
Skilfulness
Does the student perform the essential tasks in a skilful manner?
All students should allow the patient to talk and listen
All students should facilitate responses both verbally and non-verbally
All students should use open and closed questions to good effect
Good students will respond to cues, clarify points of uncertainty, summarise appropriately and invite correction
Supportiveness
Is the student appropriately supportive of the patient, relative or colleague?
All students should display some empathy/care/concern
All students should display good active listening skills
Good students will explore the patient’s concerns
Good students will alleviate concerns as far as is possible
Good students will put the patient at ease and engender trust through the consultation
Address concern of MI. by patient
Supportive during pain and breathlessness
Efficiency
Does the student display an appropriate level of control and is the encounter timely and well-structured? Does the student clarify the point of the interaction at the start and is the conclusion clear?
All students should clarify the tasks of the consultation at the start with the patient
All students should complete the tasks in the time allocated
All students should allocate appropriate time to each element of the consultation
Good students will have a well-structured consultation with student taking appropriate level of control
Good students will reach a conclusion and enable next steps to be discussed
Safety
Does the student display appropriate levels of both patient and professional safety for this context?
All students should identify self and role, and ensure the patient’s identity is clear
All students should ensure the consultation enhances health and wellbeing of patient(s)
All students should act and within their competence and professional boundaries
All students should ensure specific features of the consultation relating to safety are met: details
Good students may ask about symptoms of serious complications or consequences: details
Good students will ensure the patient is clear regarding appropriate management/follow up
Asks for haemoptysis/weight loss. Recognises need for further investigations (CXR / D Dimer / CTPA)
Context: You are a medical student on placement in a General Practice
Task: Please take a history from this patient presenting with breathlessness
Essential Background: Mr Smith (DoB 11/09/75) has presented today complaining of SoB.
Patient details (DOB AGE GENDER)
➢ 40 years old
➢ Gender neutral
Reason for interaction
Increasing breathlessness
Background
You have been getting increasingly breathless over the last few weeks. You first noticed it when out for a day trip in Edinburgh where you had to climb some steps and felt rotten. The breathing really got to you and you had to stop for a rest on a bench half way up a long flight, which made you feel old. The only other thing of note was a sensation of fluttering in your chest which came on and off for the rest of that day.
Since that day trip you have had similar problems with exercise and breathing – having to take things easy much more than you are used to doing. Currently you can walk a good distance on the flat just so long as you don’t go too fast. Any stairs puff you out.
The fluttering has been apparent on a few more occasions – and just last night you noticed a rather erratic thumping in your chest which lasted for a few minutes. It was quite fast, and difficult to know whether it was regular or not.
Additional information (if specifically asked for)
If the student asks: Your breathing does not change if you lie down flat. Nor have you not been waking gasping for breath. You have not had any pains or tightness in your chest. You have had no swelling in your ankles. You are not coughing anything up. You have no cough. You have had no fevers and you do not feel unwell. You are not losing blood from anywhere. You eat a normal diet.
Past Medical History
You have never had a problem with your heart. You do not have diabetes. You do not have any lung disease.
Feel free to ‘create’ other medical issues in the past which are unlikely to be connected with this one!
Medication
None
Allergies
Nil
Lives with
Spouse
Employment history
Feel free to create appropriate employment
Lifestyle
Smokes 10 per day, occasional alcohol (max 4 units) on Fridays / Saturdays
Family History
None that you are aware of
Ideas Concerns Expectations
You think that the breathlessness may be due to an infection in your chest, and you are wondering whether some antibiotics would help to sort it out. You have had a chest infection before and did get antibiotics then.
You have not really considered this to be to do with your heart. Yes you are having some palpitations – but you suspected the infection was causing them, rather than the other way round (in reality it could be either). If the student expresses that it might be connected with your heart please ask them to explain what they mean and what you have to do to find out for sure
Accuracy
Does the student do the right thing?
Effectively gathers appropriate and relevant history
Check for Dyspnoea mainly on stairs.
Palpitations – gathers details – regularity, speed, onset, duration etc
Other respiratory symptoms – cough, sputum, wheeze etc
Covers cardiac symptoms – chest pains, orthopnoea ankle swelling
Smoking history
Skilfulness
Does the student perform the essential tasks in a skilful manner?
Use of open / closed questions to gather history
Active listening
Signpost and summarises
Explores ICE – patient thinking chest infection, thinks antibiotics will help
Supportiveness
Is the student appropriately supportive of the patient, relative or colleague?
Gains rapport with patient.
Acknowledges patient’s ideas of chest infection
Supports patient if informed may be related to the heart
Efficiency
Does the student display an appropriate level of control and is the encounter timely and well-structured? Does the student clarify the point of the interaction at the start and is the conclusion clear?
Structures the consultation well using signposting, summarizing.
Closes with clear idea of what is happening next
Safety
Does the student display appropriate levels of both patient and professional safety for this context?
Check for symptoms of haemoptysis and chest pains.
Make sure palpitations and breathlessness not present during consultation.
Context: You are a medical student on placement in a General Practice
Task: Please take a history from this patient presenting with Abdominal pain.
Essential Background: Mr Smith (DoB 11/09/60) has presented today complaining of Abdominal pain.
Presenting Complaint
Abdominal pain – GP practice
History of Presenting Complaint
55-year old overweight person with a 2-day history of severe, sudden onset right upper quadrant abdominal pain whilst sitting down, which is ‘dull’ but has occasional ‘spasms’. The pain has no radiation and lying down exacerbates the pain. The pain has been constant for the past 2 days, initially given a severity score of 7/10 but has now reached 10/10 on day 2. There is also a 2-day history of fever, malaise and nausea. You have vomited six times since the onset, not keeping much down, with no blood present in the vomit. There has been no change in bowel habits, abdominal bloating, tenesmus, weight loss or change in appetite. No recent travel and patient does not recall eating any ‘dodgy food’.
Past Medical History
Transient Ischaemic Attacks 2013 and 2014
GORD 2008
No hypertension, diabetes or recent surgery
Drug History
Clopidogrel PO 75mg OD
Simvastatin PO 40mg OD
Omeprazole PO 40mg OD
No known drug allergies
Family History
Brother and mother both have had cholecystectomies
Father died of heart attack
Social History
Smoker of 10 per day for 30 years = 15 pack years
Drinks, around 10-15 units per week
Unemployed, lives with husband who is a support worker
No recent travel
Patient admits to relying a lot on takeaways and ready meals
Systemic Inquiry
General – no weight loss, lethargy, malaise
Respiratory – no SOB, sputum, wheeze, chest pain
Cardiovascular – no palpitations, chest pain
Musculoskeletal – no notable muscular pain
DD – Gallstones causing biliary colic, cholecystitis
Ideas concerns and expectations
Quite laid back, thinks it heartburn and just wants some strong tablets for it (the Rennies are Rubbish) – shocked if needs to see surgeon – will it be ok to have an operation with my stroke?
Laid back about smoking but may think twice if linked with gallstones or anaesthetic risk
Accuracy
Does the student do the right thing?
RUQ pains – nature of pain
Associate GI symptoms.
History of TIA
Family history of cholecystectomies.
Skilfulness
Does the student perform the essential tasks in a skilful manner?
All students should allow the patient to talk and listen
All students should facilitate responses both verbally and non-verbally
All students should use open and closed questions to good effect
Good students will respond to cues, clarify points of uncertainty, summarise appropriately and invite correction
Elicits laid back attitude to this.
Supportiveness
Is the student appropriately supportive of the patient, relative or colleague?
All students should display some empathy/care/concern
All students should display good active listening skills
Good students will explore the patient’s concerns
Good students will alleviate concerns as far as is possible
Good students will put the patient at ease and engender trust through the consultation
Considers support for smoking and diet
Manages shock of requiring further referral if mentioned.
Manages concern re anaesthetic
Efficiency
Does the student display an appropriate level of control and is the encounter timely and well-structured? Does the student clarify the point of the interaction at the start and is the conclusion clear?
All students should clarify the tasks of the consultation at the start with the patient
All students should complete the tasks in the time allocated
All students should allocate appropriate time to each element of the consultation
Good students will have a well-structured consultation with student taking appropriate level of control
Good students will reach a conclusion and enable next steps to be discussed
Safety
Does the student display appropriate levels of both patient and professional safety for this context?
All students should identify self and role, and ensure the patient’s identity is clear
All students should ensure the consultation enhances health and wellbeing of patient(s)
All students should act and within their competence and professional boundaries
All students should ensure specific features of the consultation relating to safety are met: details
Good students may ask about symptoms of serious complications or consequences: details
Good students will ensure the patient is clear regarding appropriate management/follow up
Consider admission to hospital
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Context: You are a medical student on placement in a General Practice
Task: Please take a history from this patient presenting with Ankle swelling.
Essential Background: Mr/Mrs Smith (DoB 11/09/55) has presented today complaining of Ankle swelling.
Background
You have come to see your GP because your ankles are swollen. You first noticed this about 10 days ago. They are swollen all the time, but tend to be more swollen towards the end of the day. When you wake in the morning, your face is swollen, but this improves during the day.
Additional information (if specifically asked for)
For about 2 weeks, you’ve noticed that your urine has been frothy (only mention this if asked). You haven’t noticed any blood or any change of colour in your urine.
You have not been breathless, and don’t have a cough. Your weight has increased by about 5kg (10-11lb) over the last 2 weeks, and your trousers are a little tight. Until 2 weeks ago, your weight had been steady for years. Your appetite is good, and you feel generally well, but a bit more tired than usual.
Past Medical History
You had regular medicals as a police officer, and there were never any concerns about your blood pressure or your general health. You have had no serious illnesses or operations in the past.
Medication
None
Allergies
None
Lives with
Wife
Employment history
You have recently retired, having been a police officer for many years.
Lifestyle
You don’t smoke and don’t drink alcohol excessively. You have a healthy lifestyle and are keen on golf (handicap of 4) and fishing.
Family History
Nil relevant
Ideas Concerns Expectations
You are concerned about these symptoms, but not too much. If you had had blood in your urine you would have been much more worried. However you are not pleased to be unwell as you have retired with the expectation of enjoying yourself and that means being fit enough to play golf and go fishing most days.
You want to know what the likely diagnosis might be and what needs to be done by way of investigations and possible treatment. You are keen to be given as much information as possible even though it is the first visit to the doctor. You can push the student with questions around, “if this, then what?” or, “if that, then what?”. Be very pleasant but persistent in getting explanations around the options.
Accuracy
Does the student do the right thing?
Effectively gathers appropriate and relevant history
Elicits ankle and face swelling
Elicits frothy urine
Elicits weight gain
Otherwise well and fit.
Skilfulness
Does the student perform the essential tasks in a skilful manner?
appropriately utilises open/closed questioning.
Explain possible diagnoses and investigations (urine test, blood tests)
Shares managements options with patient and reaches a plan
Supportiveness
Is the student appropriately supportive of the patient, relative or colleague?
Elicits expectation to be well now retired.
Addresses possible effects on golf and fishing
Builds good rapport with patient
Efficiency
Does the student display an appropriate level of control and is the encounter timely and well-structured? Does the student clarify the point of the interaction at the start and is the conclusion clear?
Explains reason for consultation.
Signposts and summarises
Clear outcome of consultation and next steps
Safety
Does the student display appropriate levels of both patient and professional safety for this context?
Check patient name and DOB
Checks for weight loss, appetite.
Also checks for symptoms of heart failure
Safety net – “if things get worse…”
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Context: You are a medical student on placement in a General Practice
Task: Please take a history from this patient who is becoming increasingly forgetful.
Essential Background: Mr/Mrs Smith (DoB 11/09/65) has presented today complaining of becoming increasingly forgetful, and his/her son has persuaded them to see the doctor.
Background
You have noticed that you are becoming increasingly “forgetful” and people are beginning to comment on this. You are puzzled why as you have always being a little vague about minor and boring details about day to day living. You are a Professor of English Literature and specialise in Shakespearean sonnets. You can recite many of them easily still.
You have recently lost your wife/husband (she/he died of a stroke suddenly, six months ago) and she/he used to do all the day to day things, running the house, the bank accounts etc. She/he started doing all this when the children came along as your career was more important. It paid more and she/he was only too happy to give up working to be a house wife/husband.
As far as you’re concerned your absent mindedness is only a little bit worse and is not a problem, but your son has insisted you come along to see the doctor today. Your son plays golf with this doctor and has spoken to him/her about you to make sure he/she knows you are becoming forgetful. He cannot come today however as he is away on business and, anyway, you would not have allowed him to come with you. After all you’re not senile!
You are not sleeping well and know you are very tired a lot of the time. You have just gone back to work after compassionate leave, and your head of department is very understanding and has allowed you to continue in an administrative capacity with very few lectures and no tutorials.
Last week you were lecturing and did seem to lose your place a little, but it was alright as you decided to end the lecture early and the students were mostly pleased, although one did complaint to your head of department.
Additional information (if specifically asked for)
If asked – you are not weepy, you eat OK, you wake at about 6am after your disturbed nights – but always have done. You admit that you are not happy, but you would deny being depressed. You do look forward to seeing your son and his family. You have never thought about harming yourself.
Note to actors;
Past Medical History
Fracture shin from bicycle accident 30 years ago
Medication
None
Allergies
None
Lives with
Alone – bereaved 6 months ago – wife died of stroke
Employment history
Professor of English
Lifestyle
Doesn’t smoke. Very occasionally alcohol (a couple of times a month, when visiting friends or family)
Having trouble looking after self. House untidy, skips meals or makes easy ready made foods.
Family History
Nil of note
Ideas Concerns Expectations
You expect that the doctor will understand that there is nothing wrong with you other than understandable stress at losing your wife/husband, and will tell your son that when he/she next sees him at golf.
Accuracy
Does the student do the right thing?
Elicit Forgetfulness with examples
Recent bereavement
Issues at work
Skilfulness
Does the student perform the essential tasks in a skilful manner?
Empathises with bereavement
Supportive of patient’s memory difficulties
Supportiveness
Is the student appropriately supportive of the patient, relative or colleague?
Considers implications for work
Elicits patient’s lack of concern for symptosm
Approaches subject of memory loss with sensitivity
Identify and explores issues of living alone
Efficiency
Does the student display an appropriate level of control and is the encounter timely and well-structured? Does the student clarify the point of the interaction at the start and is the conclusion clear?
Uses signposting and summarising effectively to help steer conversation
Safety
Does the student display appropriate levels of both patient and professional safety for this context?
Checks patient’s identification
Makes a management plan to include patient returning for further review, if patient agrees
Check for symptoms of depression – low mood, weepiness, early morning awakening etc.
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Greet patient, obtain patient’s name
Introduce self, role, nature of interview and obtain consent.
Attend to the patient’s physical comfort
Opening questions
Listen attentively to opening statement
Confirm list screen for further problems
Listen and show you are doing so
Clarify details of the story
Explore
Summarise and invite correction of inaccuracies
Providing the correct amount and type of information
Aims: to give comprehensive and appropriate information to assess each individual patient's information needs to neither restrict or overload
• Chunks and checks: gives information in assimilated chunks, checks for understanding, uses patient's response as a guide to how to proceed
• Assesses patient's starting point: asks for patient's prior knowledge early on when giving information, discovers extent of patient's wish for information
• Asks patients what other information would be helpful e.g. aetiology, prognosis
• Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely
Aiding accurate recall and understanding
Aims: to make information easier for the patient to remember and understand
• Organises explanation: divides into discrete sections, develops a logical sequence
• Uses explicit categorisation or signposting (e.g. "There are three important things that I would like to discuss. 1st..." "Now, shall we move on to...")
• Uses repetition and summarizing to reinforce information
• Uses concise, easily understood language, avoids or explains jargon
• Uses visual methods of conveying information: diagrams, models, written information and instructions
• Checks patient's understanding of information given (or plans made): e.g. by asking patient to restate in own words; clarifies as necessary
Achieving a shared understanding: incorporating the patient's perspective
Aims: to provide explanations and plans that relate to the patient's perspective
to discover the patient's thoughts and feelings about information given to encourage an interaction rather than one-way transmission
• Relates explanations to patient's illness framework to previously elicited ideas, concerns, and expectations
• Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately
• Picks up verbal and non-verbal cues: e.g. patient's need to contribute information or ask questions, information overload, distress
• Elicits patient's beliefs, reactions and feelings: re information given, terms used; acknowledges and addresses where necessary
Planning: shared decision making
Aims: to allow the patient to understand the decision-making process to involve the patient in decision-making to the level they wish to increase the patient's commitment to plans made
• Shares own thoughts: ideas, thought processes, and dilemmas 46. Involves patient by making suggestions rather than directives
• Encourages patient to contribute their thoughts: ideas, suggestions and preferences
• Negotiates a mutually acceptable plan
• Offers choices: encourages patient to make choices and decisions to the level that they wish
• Checks with patient if plans are acceptable, if concerns have been addressed
If discussing options and significance of problems
• Offers opinion of what is going on and names if possible
• Reveals rationale for opinion
• Explains causation, seriousness, expected outcome, short long term consequences
• Elicits patient's beliefs, reactions and concerns, e.g. if opinion matches patients thoughts, acceptability, feelings
If negotiating mutual plan of action
• Discusses options e.g. no action, investigation, medication or surgery, non- drug treatments, preventative methods
• Provides information on action or treatment offered, e.g. name, steps involved, how it works, benefits and advantages, possible side-effects
• Obtains patient's views, advocates alternative viewpoint as necessary
• Accepts patients views, advocates alternative viewpoint as necessary
• Elicits patients reactions, concerns about plans and treatment, including
acceptability
• Takes patients lifestyles, beliefs, cultural background and abilities into
consideration
• Encourages patient to be involved in implementing plans, to take
responsibility and be self-reliant
• Asks about patient support systems, discussed other support available
If discussing investigations and procedures
• Provides clear information on procedures, including what patient might experience and how patient will be informed of results
• Relates procedures to treatment plan; value and purpose
• Encourage questions about, and discussion of, potential anxieties or
negative outcomes
Context: You are a medical student on placement in yje Accident and Emergency department.
Task: Please take a history from this patient who has been brought into A&E following a collapse.
Essential Background: Mr/Mrs Robert (DoB 11/09/60) has been brought into A&E following a collapse.
Presenting Complaint
Sudden faint – 55 year old A&E presentation
History of Presenting Complaint
You have known angina and aortic stenosis (scheduled for valve replacement in 4 weeks) was playing golf 4 days ago, was feeling completely fine with no recent illness and suddenly collapsed while walking up a hill, s/he did not use his GTN spray. You friend says unconscious for 10 minutes and regained consciousness feeling light-headed and dizzy with very cold peripheries but rousable and orientated. There was no accompanying chest pain, ankle oedema, palpitations or shortness of breath. No tongue biting no incontinence.
Past Medical History
GORD 1987
Fundoplication (for GORD) 1995
Angina 2002
No hypertension, asthma, diabetes or recent surgery
No allergies
Family History
Mother had open-heart surgery for 2 “leaky valves” aged 65 and is asthmatic
Drug History
PRN: GTN – 2 puffs
Over-the-counter paracetemol for headaches (stress-related)
No drug allergies
Social History
Previously professional footballer / hockey player, now desk-job
Smokes 30 cigarettes a day for past 30 years (45 pack-year history)
Currently a social-drinker (2 units per week)
Lives with spouse, meat-rich and low-fibre diet
No longer exercises due to anginal pains
Systemic Enquiry
General – no weight loss, fatigue, fever
Respiratory – no shortness of breath, cough, wheeze or sputum
Cardiovascular – As above; no PND, no orthopnoea
Gastrointestinal – no loss of appetite, abdominal pain, nausea or vomiting; normal bowel movements
Musculoskeletal – no notable muscular pain
DD – Aortic Stenosis, Unstable Angina
Ideas concerns and expectations
Worried about his heart, can you hurry up the surgery sooner? – will it happen again, it was very embarassing
Reluctant to give up smoking as gets very stressed
Accuracy
Does the student do the right thing?
Elicits history of angina and aortic stenosis
Checks risk factors for IHD
Considers epilepsy
Skilfulness
Does the student perform the essential tasks in a skilful manner?
All students should allow the patient to talk and listen
All students should facilitate responses both verbally and non-verbally
All students should use open and closed questions to good effect
Good students will respond to cues, clarify points of uncertainty, summarise appropriately and invite correction
Supportiveness
Is the student appropriately supportive of the patient, relative or colleague?
All students should display some empathy/care/concern
All students should display good active listening skills
Good students will explore the patient’s concerns
Good students will alleviate concerns as far as is possible
Good students will put the patient at ease and engender trust through the consultation
Manages concern re hurrying up surgery and risk of further episodes
Appropriately supportive re smoking
Efficiency
Does the student display an appropriate level of control and is the encounter timely and well-structured? Does the student clarify the point of the interaction at the start and is the conclusion clear?
All students should clarify the tasks of the consultation at the start with the patient
All students should complete the tasks in the time allocated
All students should allocate appropriate time to each element of the consultation
Good students will have a well-structured consultation with student taking appropriate level of control
Good students will reach a conclusion and enable next steps to be discussed
Safety
Does the student display appropriate levels of both patient and professional safety for this context?
Red flags – ongoing chest pain or dyspnoeic at presentation,
Weight loss and appetite loss (heavy smoker risk of malignancy)
Safety netting with appropriate info re symptoms of MI or prolonged collapse