• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor in general practice

Patient: Tim is a 10 year old boy with an itchy rash, who is accompanied by his parent

Task:
– Take a focused history from Tims parent
– After 5 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 Tims mum. Tim is a 10 year old boy.

You have brought him into clinic as he has developed an itchy rash over the last 4-6 weeks and you want someone to take a look at it.

If asked further, the rash started on the elbows but has been getting bigger and worse over the weekends, now it is mainly on his arms and face. His skin is very dry and rough. Over the last week he has been constantly scratching and sometimes there has been bleeding because of this. He is struggling to sleep and is waking up more than usual. This is starting to also impact on both you and your partner.

You have noticed that this is worse in hay fever season and when he is around pets (as you do not have these at home).

If asked you have never noticed any lip swelling or breathing issues. You have not noticed the rash to be worse with any particular foods.

Tim has not come into contact with any other unwell children. Tim has not recently been on holiday.

You are worried because this has been going on so long you went online and have read that itchy skin can be highly contagious. You are worried about going to play dates, swimming lessons and other play groups you attend.

Past Medical History (PMH)
Usually fit and well

Drug History (DH)
No regular medications
No known drug allergies

Family History (FH)
You have asthma

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


Duration
Onset (when / sudden or gradual / acute or ongoing)
Previous episodes


Description
Attempts to understand how condition started
Change over time
Location (flexural or extensor surfaces / sun-exposed areas / ‘sweaty’ areas


Variability
Aggravating factors
Relieving factors


Associated features
Itchy
Tender / pain
Bleeding
Discharge
Swelling


Systemic features
Pyrexia
Joint pain
Weight loss
Malaise


Response to treatment
Prescribed medications
Over the counter treatments
Herbal remedies


Skin history extended
Exposure to chemicals
Travel history
History of atopy i.e. asthma, allergic rhinitis,


Psychological impact
Candidate attempts to understand psychological impact on both patient and family


PMH Past Medical History
Candidate appropriately explores past medical history


DH Drug History
Past medical history appropriately explored
Specifically asks about new medications
Specifically asked about over the counter medications including herbal
Drug allergies


FH Family history
Family history of skin disease explored


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


Question
Review the following photograph of Tims elbow, describe the appearances and give your working diagnosis

Dry
Red
Scaly
Scratch makers


Question What is your working diagnosis?
Eczema


Question What are your differentials for this patient
Atopic eczema
Scabies
Seborrhoeic dermatitis
Contact dermatitis
Drug eruption


Question What is your pharmacological management of this patient in general practice?
Emollients frequently (liberal use)
Stop soap (use emollients as soap)
Topical steroid (thin layer)
Anti-histamine


Question What other information would you provide this patient during your consultant?
Book appointment in couple of weeks to review treatment
Information leaflet / website
Support group


Question The parent wishes to know if the treatment given is a cure, how would you reply to this?
Aim is control not cure
Aim to reduce itch and redness
Will require ongoing treatment


Question Please explain what a finger tip unit is
Used to dose topical corticosteroids
1 fingertip unit covers the area of two palms


Question Is Tims skin condition contagious?
Not contagious


Question What features would you expect in this history if Tims allergy was due to food?
Lip swelling or hives



Score