• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

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 SOB

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

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


HPC Dysphagia symptoms
Onset
Progression of symptoms – sudden or gradual
Elicits pain with dysphagia
Worse with solids or liquids
Recent chest infection? (aspiration pneumonia)


Red flag symptoms
Unintentional loss of weight
Anorexia
Progression of symptoms from solids to liquids
Melaena or haematemesis


Associated features
Food stuck at the level of lower sternum
Halitosis
Explores if regurgitated food is digested and how soon after eating this occurs
Hematemesis
Change in bowel habit


GORD symptoms
Worse after meals
Central radiating chest pain
Worse laying flat
Relieved with antacids


Excludes other causes
Neurological – weakness anywhere
Autoimmune – cold hands, dry eyes or mouth, tight skin


DH Drug History
Rennies
Specifically asks about NSAIDs or steroids
NKDA


FH Family History
Family history appropriately explored


SH Social History
Enquires about smoking
Enquires about alcohol
Lives at home with partner Chris


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


Question Given the history what are your differentials?
Oesophageal cancer
Benign oesophageal structure
Oesophageal spasm
Achalasia
Other appropriate answer


Question Given the history what investigations would be appropriate?
FBC
U&E
LFTs / Clotting / Bone profile
CXR
Upper GI endoscopy + biopsy
Barium swallow
CT Chest/Abdomen/Pelvis


Question
What type of imaging is this? What is shown? Given this what is your diagnosis?

Barium swallow
‘Apple core’ appearance
Oesophageal cancer


Question What are the red flag features for dysphagia?
Unexplained anaemia
Unintentional loss of weight
Anorexia
Recent and progressive symptoms
Melaena or haematemesis
Swallowing difficulties
> 55 years old


Question What conditions are risk factors for the development of oesophageal cancer?
Barrett’s oesophagus
Strictures
Achalasia
Plummer-vinson syndrome



Score