Location: You are an FY1 on the acute surgical take
Patient: You are a 75 year old patient who has been referred by his General Practitioner with increasing difficulty swallowing
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 to 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 75 year old patient. This morning you went to your GP and he has asked you to come to the hospital to see the surgical team. Over the past couple of months you’ve found it difficult to swallow solid foods and more recently it feels like it is getting stuck and this is happening at the lower part of the breast bone (sternum). This is usually accompanied by a sharp pain that lasts for a couple of minuets. On a couple of occasions you’ve vomited what you’ve recently tried to swallow.
If asked, you don’t have problems swallowing liquids, as a consequence you have been having a lot more soups. You have lost about 2 stone in weight although you feel you could probably do with loosing weight. You are lethargic and have low energy.
If asked, you’ve suffered with pain for many years, burning in nature (make a fist starting from your epigastric region and move up to your larynx. Repeat this movement several times). The pain is much worse after meals and it used to wake you up at night if you ate close to bedtime. You had to stop drinking alcohol as you found this made the pain much worse.
No change in bowel habit.
Your partner has encouraged you to see your doctor for quite some time but you don’t like going to the doctors so you’ve avoided it.
PMH = Nothing. No previous operations.
DH = You buy Rennies over the counter. NKDA
SH = You do not drink. You smoke about 15 a day but you have cut down from 30 about 3 months ago. You have been a smoker for 30 years. You live with your partner at home.
FH = Nothing runs in the family that you are aware of