• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor in general practice

Patient: 18 year old female has made an appointment to talk about her skin

Task:
– Take a focused history from the patient
– After 6 minutes you will be asked a series of questions by the examiner.
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are an 18 year old female university student who is really embarrassed about talking about your skin. You have recently moved to the area, so you have not seen a GP here yet but you have seen another GP in a different area of the country several times who said you would grow out of it and it was not that bad.

You believe you have bad acne on your face. You get a lot of blackheads and white bumps. You get some sore red bits and these are very painful.

Your acne is worse around the time of your period (if asked your cycles are regular). You noticed when you have been on holiday in the sun, your skin has much improved and you have on occasion used a sun bed as well to get the same effect, although you try to avoid doing this to often as you are aware of the risk of skin cancer.

You have gotten to the point now where you do not want to go out in pubic, you have stopped attending university as you are worried that new people will judge you because of your skin. Everyone you see at university has great skin.

You are worried because your mother had terrible acne as a child at it has left some quite large scars on her face and you are worried this is going to happen to you.

Your mum is convinced your bad skin is due to not washing properly. You have started using face wash with the gritty bits in them to help, although this seems to of made things worse! Your mum also believes that foods such as burgers, fries and chocolate cause spots, so you have cut these out your diet all together.

You have been prescribed an antibiotic by your previous GP for about 2 weeks but this did not seem to help. You have tried all the spot treatments from the supermarket but these have not appeared to make a difference.

PMH
– Usually fit and well

DH
– No regular medications
– No known drug allergies

FH
– Mum had severe acne

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


Duration
Onset (when / sudden or gradual / acute or ongoing)
Previous episodes


Description
Attempts to understand how condition started
Change over time
Location (flexural or extensor surfaces / sun-exposed areas / ‘sweaty’ areas


Variability
Aggravating factors
Relieving factors


Associated features
Itchy
Tender / pain
Bleeding
Discharge
Swelling


Systemic features
Pyrexia
Joint pain
Weight loss
Malaise


Response to previous treatment
Prescribed medications
Over the counter treatments
Herbal remedies


Skin history extended
Occupation
Exposure to chemicals
Travel history
History of atopy i.e. asthma, allergic rhinitis, eczema


Sun exposure
Burn or tan
Use of sun beds


Psychological impact
Candidate attempts to understand psychological impact


PMH Past Medical History
Candidate appropriately explores past medical history


DH Drug History
Drug history appropriately explored
Specifically asks about new medications
Specifically asked about over the counter medications including herbal
Drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history of skin disease explored


ICEF ICEF
Explores ideas, concerns, expectations, feelings


Question
Review the following photograph and describe each of your findings for the blue, black and green arrows

Blue arrow = comedones
Black arrow = pustules
Green arrow = excoriated lesions


Question
Given this photo, does the patient have mild, moderate or severe acne?

Mild acne


Question What are the potential treatment options in this patient?
Benzoyl peroxide
Topical retinoids
Topical antibiotics
Oral antibiotics
OCP (oral contraceptive pill)


Question This patient states she tried antibiotics for 2 weeks without side effects and they did not improve her skin. How would you reply to this patient?
Course not long enough
Oral antibiotics can take up to 1-4 months to achieve a maximal response



Score