• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a Foundation Doctor in General Practice

Patient: 50 year old male patient has come to discuss chest pain they have been experiencing

– 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 50 year old male patient.

Over the past 3 months you have been experiencing with some chest pain (it’s more like a dull ache) that comes and goes. You thought at first you had pulled a muscle, as you work as a builder but the pain is sometimes there even when you aren’t at work. You have come to the doctors as the pain hasn’t gone away after several months and seems to be getting worse!

The pain is over the center of your chest. These happen most of the time when you are at work, particularly when moving bricks and walking materials upstairs. You have noticed the pain comes on at home when you climb the stairs. The pain is a dull ache in the center of your chest. The pain does not go anywhere else or radiate through to your back or shoulder. The pain lasts for about 5 mins and goes away when you sit down. You have not experienced this pain when you are sitting down or when not exercising.

You have not experienced any nausea or vomiting / loss of consciousness / dizziness / palpitations. You do not experience any shortness of breath when laying flat or at night. You have no swelling in your legs.

Past Medical History
You have not seen a doctor about anything
You have not been diagnosed with: stroke, ischemic heart disease, peripheral vascular disease, diabetes, hypertension (high blood pressure)

Drug History
You have no prescribed medications but you do take a liquid for heart burn and paracetamol when you get headaches
You have no known drug allergies.

Social History
You live at home with your partner
You smoke 5 per day but you are trying to stop
You drink 6 pints of beer on a Friday and Saturday
You work as a builder, you are self employed and own the business

Family history
Your father died of heart problems but you don’t know any more details than this

Ideas, concerns, expectations and feelings
You are worried you have a heart problems but you are hoping the doctor will say this is muscular. Because you run a business, you are worried that you have to take some time off work.

If the candidate appears to have finished early remind them how long is left at the station and inquire 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
Introduction Candidate appropriately introduced themselves with:
Full name
Clarifies who they are talking to
Asks patient for preferred name

PC 1 Presenting complaint 1

PC 2 Presenting complaint 2
Relieving factors

Associated features 1
Dyspnoea (shortness of breath)

Associated features 2
Syncope / dizziness

Systems review Systems review
General = fever, rigors, night sweats, weight loss
Gastrointestinal = dysphagia, N&V, indigestion / reflux, abdominal pain, change in bowel habit

PMH Past Medical History
Past medical history appropriately explored
Specifically asks for 3 of: hypertension, myocardial infarction, hyperlipidaemia, diabetes, lung disease

DH Drug History
Drug history appropriately explored
Drug allergies

SH Social History
Living situation

FH Family history
Family history appropriately explored

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

Question Given your history what are your differentials?
Ischemic heart disease
Myocardial infarction
Musculoskeletal chest pain
Dyspepsia / reflux
Biliary colic
Peptic ulcer

Please interpret this patients ECG

HR = 100
Sinus rhythm
Normal axis
No ST segment changes

Question For a typical patient with Angina, what medications would you expect them to be on?
Sublingual glyceryl trinitrate (GTN) for the rapid relief of symptoms of angina
Beta-blocker or calcium channel blocker (depending on commodities)
Aspirin (for secondary prevention)

Question What lifestyle advice would you provide this patient with?
Stop smoking
Weight reduction
Increased exercise
Stop alcohol intake
Stress reduction / meditation