• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in A&E

Patient: Mr Daniel Davies, 36 years old, has attended with severe upper abdominal pain

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 a 36 year old man named Daniel Davies who works as a financial consultant. You have the worst upper abdominal pain that you’ve ever experienced. It’s 10/10 and excruciatingly painful. It’s going straight through your upper abdomen to your back. You have noticed that leaning forwards helps with the pain slightly. This morning you’ve vomited three times with the pain. You have been unable to keep any paracetamol down.

Last night you were at a corporate drinks event and there was an open bar. You lost count of how many drinks you had and you can’t really remember what happened last night.

If asked, you have an extensive history with alcohol, most nights after work you’ll have about 5 pints and you go out every weekend. You’re not concerned about your drinking as drinking is vital to your job. You’ve tried to cut back in the past but you miss job opportunities. You’re young so you’re not too concerned about the drinking.

You have no chest pain / SOB

No change in bowel habits / no lower urinary tract symptoms

You have no recent travel / not eaten anything unusual

PMH

– Nothing of note

– No previous operations

DH

– Occasionally take paracetamol for headaches

– No known drug allergies

SH

– Alcohol history as above

– You smoke about 20 cigarettes per day for the past 20 years

– If asked you occasionally take ecstasy (MDMA)

– You live at home alone, in a ground floor flat

FH

– Your dad was a big drinker

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


HPC History of Presenting Complaint
Site
Onset
Character
Radiation
Timing
Exacerbating and relieving factors
Severity


Associated features
Vomiting
Anorexia
Weight loss
Recent illness / contact with someone unwell


Gallstone symptoms
Pain worse after eating
History of colicky upper abdominal pain
Pale stool
Dark urine


Alcohol history
Amount / units
Candidate attempts to determine alcohol dependency = early morning drinking, withdrawal symptoms, increasing tolerance


PMH Past Medical History
Candidate elicits no significant PMH


DH Drug History
Paracetamol for headaches
NKDA


SH Social History
Smoke about 20 cigarettes per day for the past 20 years
Occasional use of ecstasy (MDMA)
Live at home alone, in a ground floor flat


Question Given the history what are your differentials?
Acute pancreatitis
Perforated peptic ulcer
Acute gastritis
Acute cholecystitis / cholangitis / hepatitis
Acute coronary syndrome
Other appropriate answer


Question Given the history you have taken, what investigations would you like to perform?
Routine bloods = FBC, U&E, LFT, CRP
Amylase
Blood gas
Erect CXR
AXR
Abdominal ultrasound


Question Given your history what is your management of this patient in A&E
ABCDE approach
NBM
IV fluids
Analgesia = appropriate IV analgesia
Escalation to senior
Regular nursing observations


Question What are the causes of acute pancreatitis
Gallstones
Alcohol
Trauma
Post-ERCP
Steroids
Mumps
Autoimmune
Other appropriate answer - no mark for 'scorpion bites'


Question What scoring criteria can be used to grade the severity of acute pancreatitis?
Modified Glasgow criteria
APACHE II
Ranson's Criteria
Balthazar Score following CT scan



Score