Cord compression


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor on the acute medical take

Patient: A 50 year old female patient has come in problems moving her legs

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  50 year old retired call centre manager. You went to see your GP this morning because you have “no strength in your legs”. Your GP saw you and then called you an ambulance. He did not explain much to you and you are not to sure why you are here.

You only give information if prompted:

  • The weakness first started about a month ago
  • The weakness has gradually been getting worse
  • Last week you had to start using a walking stick for the first time, you are struggling now to stand up from sitting down, from a chair and bed ect.
  • You are usually fit and well, you used to play tennis 2 months ago but now you are barely able to walk
  • Since this morning you suddenly cannot move your legs at all. You have been using your partners wheelchair
  • You have noticed some weight loss over the past 6 months and your appetite has been poor, you have put this down to being less active
  • Balance normal
  • No headaches
  • No pain
  • No loss of consciousness
  • No incontinence
  • No neck stiffness / rash
  • No decreased level of consciousness
  • No sudden onset, worst headache ever / ‘clapping headache’
  • No seizure or neurological deficit
  • No reduced visual acuity
  • No headache worse when laying down with early morning nausea

PMH

  • You have had a heart attack about 10 years ago
  • High blood pressure
  • High cholesterol
  • No previous operations

DH

  • Aspirin
  • Simvastatin
  • No known drug allergies

FH

  • Both of your sisters have had breast cancer
  • Your mother died of ovarian cancer

SH

  • You are a lifelong smoker, but only 5 per day now, your partner has forced you to cut down
  • You do not drink alcohol at all
  • You live with your partner
  • No recreational drug use

ICEF

  • You do not know what is causing the weakness
  • You do not understand how you can go from tennis a couple of months ago to being unable to walk now
  • You feel embraced about wasting everyones time, you feel this is a whole lot of nothing.

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
Medical school / year / grade
Clarifies who they are talking to
Asks patient for preferred name


PC Presenting complaint
Onset
Duration
Affected region
Isolated or spreading



Change in weakness since started
Relieving factors
Exacerbating factors
Effect on patients activities of daily living


Associated features
Sensory symptoms
Balance
Speech
Headaches
Pain
Incontinence


Red flags
Neck stiffness / rash
Decreased level of consciousness
Sudden onset, worst headache ever / ‘clapping headache’
Seizure or neurological deficit
Reduced visual acuity
Headache worse when laying down with early morning nausea


Constitutional symptoms
Weight loss
Night sweats +/- fever
Loss of appetite


Systems review
General = fever, rigors, night sweats, weight loss
Cardiorespiratory = chest pain, palpitations, SOB, sputum, leg swelling
Gastrointestinal = dysphagia, N&V, indigestion / reflux, abdominal pain, change in bowel habit


DH Drug history

Aspirin / Simvastatin /No known drug allergies
No known drug allergies
No recreational drug use


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history appropriately asked about


ICEF ICEF
Explores ideas, concerns, expectations, feelings


Question
Review the examination for this patient. What dermatomal level does the umbilicus represent?

T10 dermatome


Question Given your history and examination, what are your differentials?
Spinal cord compression
Transverse myelitis
Guillain barre syndrome
Amyotrophic lateral sclerosis
Diabetic neuropathy
Other appropriate answer


Question What are the potential causes of this patients spinal cord compression?
Spinal tumour (tumour alone scores no mark)
Disc herniation
Spondylolisthesis
Spinal abscess
Spinal haematoma


Question What imaging would you like to do in this patient?
MRI whole spine
Staging CT thorax, abdomen and pelvis


Question What would be your management in this patient?
Dexamethasone 16mg (+ PPI)
Bed rest with log roll
Immediate referral to oncology
Immediate referral to neurosurgery



Score