• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 working in the emergency department. You have been asked by the nurse in charge to talk to a patient admitted with hematemesis.

Patient: Matthew is a 35 year old man who has had multiple attendance in A&E with alcohol related problems.

– Take a focused history from the patient to determine if he has an alcohol dependence problem, focusing on the symptoms of dependency
– You are NOT expected to take a medical history, the patient has been determined as medically fit by the consultant
– Assess the patients mental state and determine if there is an underlying mental health problem
– After 6 minutes you will be asked a series of questions by the examiner.

– You are anxious, your hands are shaking, you can’t keep them still. You are on edge. You become emotional when talking about personal topics and struggle to talk about them. You answer questions but only when specifically asked

Alcohol history
– Started drinking at 15 years old, vodka in the park most weekends
– At 18 years old you joined the army and started drinking after work socially
– Currently you drink alone. Typical day: breakfast 3 cans of lager to get you up, you’ll go to the park and have a bottle of vodka in a plastic bottle, evening you’ll go home put the TV on and have a bottle of whisky and pass out in front of the TV
– You have been drinking like this for the past 5 years
– Drinking in the morning to stop the shaking and sweating
– You have noticed you now have to drink much more to get tipsy
– You have not tried to have a day without alcohol in a while, it is the most important thing in your life at the moment and you have no idea what to do about it

– Only if specifically asked what might have caused your drinking
– You were in the army, all of your unit were killed whilst out on exercise including all your best friends. You were the only one to survive
– You keep having flashbacks, the thoughts are so vivid it’s like reliving the experience. You become very emotional when this happens. You cannot control these thoughts and use alcohol to stop this from happening. Triggered when you hear a loud noise like a door slamming or a car back firing
– When you got back home after this happened you struggled to adjust back to civilian life and were discharged from the army on medical grounds but was lost to follow up with regards to problems. You couldn’t leave the house, had an inner restlessness
– Your sleep is awful, 4 hours a night. You have to pass out drunk in order to do it. You eat 1 meal a day, a ready meal. You struggle to do anything but drink. You don’t enjoy anything and only leave the house to buy more alcohol and drink
– Forensic: never been involved with the police
– Risk to self and others: no thoughts of suicide or harm to others

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school, year or grade
Clarifies who they are talking to
Asks patient for preferred name

Alcohol history
Type of alcohol (beer / spirits)
Amount consumed
Typical day outlined
Socially / alone
When first started drinking alcohol

Alcohol dependency screening CAGE questionnaire
Ever thought about Cutting down on your drinking?
Annoyed when people comment on your drinking?
Ever felt Guilty about your drinking?
Have you ever had an Eye opener to get rid of a hangover?

History of dependence syndrome
Compulsion to drink
Early morning drinking, continuing throughout the day
Symptoms of withdrawal: shaking, anxiety. Alcohol relieves symptoms
Increasing tolerance to alcohol
Persistence in drinking despite repeated admission to hospital with related complications

Mood Symptoms

PTSD symptoms
Exposure to stressful event with strong emotional impact (team being killed in army)
Recurrent reliving the stressor by intrusive flashbacks, vivid memories, recurring dreams
Actual or preferred avoidance of circumstances resembling the stressor
Difficulty falling or staying asleep

Risk Risk assessment
No risk of harm to self
No risk of harm to others

DH Drug History
You take no regular medications
You have no allergies

SH Social History
Asks if other substances used (drugs)
Where the patient currently lives
Family or friends nearby

FH Family History
Inquires if family history of mental health problems

Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions

What is your most likely diagnosis?
Chronic alcoholism secondary to Post Traumatic Stress Disorder (PTSD). (Alcoholism on its own is not worth a marking point)

Question Given this patient has PTSD, how would you manage this patient as an FY1 in A&E
ABCDE approach
Refer to mental health liaison team
IV thiamine and chlordiazepoxide
Increased nursing observations
Request nurses to put on a section 5.4 if patient tries to leave department if before RAID review
Call security if absconds

Question What are the treatment options for a patient with PTSD
Trauma focused cognitive behavioral therapy
Pharmacotherapy: SSRI
Eye movement desensitisaiton and reprocessing (EMDR)