• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an foundation doctor in A&E

Patient: 60 year old patient presents to A&E with severe lower 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’re a 60 year old patient.

Over the last week you’ve been having worsening abdominal pain. Last night it was so bad you took your partner’s co-codamol they take for their back pain. This helped a little but you’re still unable to sleep with pain. In the morning your partner called 111 and you were brought to hospital by ambulance.

Over the past week your stools have been looser and you’ve been going about 3 times a day. You’ve not experienced any rectal bleeding or mucus discharge.

You have no urinary symptoms: dysuria, haematuria or frequency.

You’re nauseated but not vomiting.

PMH
– High blood pressure (hypertension)
– Type 2 diabetes mellitus
– High cholesterol
– Depression

SH
– You live at home with your partner
– You are a non-smoker
– You have one glass of alcohol on the weekends

FH
– You are adopted and you do not know your family history

DH – you are unsure of the doses
– Metformin
– Atorvastatin
– Ramipril
– You have been using your partners co-codamol
– You have no known drug allergies

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
Role
Clarifies who they are talking to
Asks patient for preferred name


PC Presenting complaint - abdominal pain
Appropriate opening question
Site
Onset
Character
Radiation
Timings of pain
Exacerbating factors
Relieving factors


Loose stools
Onset of symptoms
Elicits how bowel habit has changed
Establishes stool frequency
Change in lifestyle / diet
Blood or mucus in stool


Colorectal cancer red flags
Change in bowel habit
Rectal bleeding
Unexplained weight loss
Abdominal pain
Iron deficiency anaemia (tiredness / dizziness etc...)
Loss of appetite


Associated features
No lower urinary tract symptoms
Nauseated but not vomiting
No back pain
IBD symptoms - No rashes, joint pain or eye symptoms
No previous abdominal symptoms


PMH Past Medical History
Past medical history appropriately explored


DH Drug History
Drug history appropriately explored
No known drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history appropriately explored


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


Question Given your history what are your differentials?
Diverticulitis
Infective gastroenteritis
Perforation
Appendicitis
IBD - e.g. acute UC
UTI
Pyelonephritis
Other appropriate answer


Question Given the history, what examinations would you like to perform?
Abdominal examination
PR examination


Question On examination, the patient has tenderness in the left lower abdomen and an empty rectum with no blood stained stool on the glove. Given the history and examination findings what bloods would you like to request?
FBC
U&Es
CRP
Amylase
LFTs
Clotting profile
2 x G&S


Question Given your history and examination what other investigations apart from bloods would you do?
Urine dip
Stool culture
Arterial / Venous blood gas (for lactate)
CXR
AXR


Question
Please review the following bloods and comment on your findings

Raised WCC
Neutrophilia
Raised CRP


Question
Your registrar has reviewed the patient and has requested a CT scan. They have asked you to review the result and start initial management as they are busy in theatre. What management will you initiate?

Appropriate IV antibiotics
IV fluids
NBM (Nil By Mouth)
Analgesia
Blood cultures
VTE prophylaxis
Regular medications
Regular observations



Score