• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in General Practice

Patient: Miss Ruth Jones is a 19 year old university student. Appointment was made by her mother who wants her to talk to a doctor about her eating habits.

Task:

  • Take a focused history from the patient surrounding eating habits
  • 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.

Overall feeling

You aren’t thrilled to see the GP but you need do this to get your mum off your back.

Historical problems

  • You used to be a little overweight and the girls in school / college used to make fun of you. You were teased but you don’t think it was bullying
  • You read online that you could eat whatever you like and throw up what you’ve eaten.
  • You love eating and are a good cook. You think about food most of the day. You enjoy fizzy drinks and sweet foods the most.
  • You have been doing this for about a year and a half
  • In a typical day you will have; breakfast – full English breakfast, 1L of orange juice. Snack – 1 family sized bag of crisps. Lunch – 1 large pizza to yourself and 1L of fizzy drink. 2nd snack – fast food. Dinner – family sized lasagna, garlic bread, cheese. Dessert – sticky toffee pudding, full fat cream and an apple
  • When you do eat a lot of food you are worried you will get fat again and be picked on so you decide to throw up by putting your fingers to the back of your throat. You have noticed that sometimes you get so full you do not need to put your fingers down your throat you just throw up by yourself.

Body image perception

  • You avoid looking at mirrors because you hate to see yourself
  • Constantly think you are fat and need to go on a diet
  • You avoid doing activities where you have to get changed or wear little clothing such as swimming

Mood

  • You have been tearful, feel low in mood, sleep poorly and constantly think people are making fun of you about your weight, although no one has said anything to your face in many years.
  • Your concentration is fine and you have no problems studying.
  • You have no thoughts of suicide or self-harm

Associated problems

  • You are social but avoid group activates that involve little clothing such as swimming
  • You try to be social but you feel people are going to make fun of you
  • If asked, you have periods and they are regular – there are no problems]
  • You run as much as possible to try and get rid of weight
  • You have used your mums laxatives in the past to try and reduce weight

Past psychiatric history

  • You have seen your GP about being low in the past, you did not have any treatment and it got better by its self

Social history

  • You are a university student, you are happy with your studies
  • You have great flat mates but you have not discussed any of this although you suspect they know
  • Non-smoker
  • You drink usually to get drunk about once per week but throw up at the end of the night

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


PC Explores eating habits
Establishes when symptoms first started
Discovers cause of teasing when younger
Ascertains how much food is eaten in a typical day to understand overall calorie intake
Uncovers that after meals patient vomits


SCOFF screening tool
Sick – do you often make yourself dick because you feel uncomfortably full?
Control – do you worry you have lost control over how much you eat?
One stone – have you lost more than 1 stone (6kg) in the last 3 months?
Feel fat – Do you feel you are fat when others think you are thin?
Food dominates – do you believe food dominates your life?


WAIF questions
Weight – current weight
Amenorrhea – do you currently have your periods?
Induced vomiting – do you ever make yourself vomit after eating on purpose
Fat fear – do you worry about gaining weight?


Establishes other behavior traits
Exercises as much as possible
Use of laxatives


PMH Past medical history
Previously seen GP for low mood but no treatment
Candidate specifically asks about hyperthyroidism
Candidate specifically asks about diabetes


DH Drug history
Not on any regular medications
NKDA


SH Social History
Student
Non-smoker
Drinks excessively once a week
Lives with student flatmates


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


Actor feedback
Candidate approaches station in sensitive way
Establishes rapport and empathy with patient
Actor would want a repeat appointment with patient with same issue


Question
What is this patients BMI given this patients height is 5’6” and weight 63.5kg

BMI = normal BMI


Question Given your history and BMI, what is your most likely diagnosis?
Bulimia nervosa


Question What abnormal blood results would you expect in a urea and electrolyte blood test in a bulimia nervosa patient and why?
Low potassium and low sodium
Electrolyte imbalance caused by vomiting.



Score