• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor in general practice

Patient: 45 year old male patient. The GP booking system comment says “right toe 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 are an 45 year old male patient.

Open with “My toe has been playing up, i think i need some painkillers.” If asked to elaborate on the pain say “it’s been there for a while and it has just been getting worse.”

You have finally now come to the doctors because you are struggling at work to get down on your knees and have problems walking because of the pain. You work as a skirting board hand painting restorer at the national trust, so this requires you to be on the floor a lot. You are self employed, so it is important you are able to work as you have two children and a partner to support.

You have a two week history of foot pain, if specifically asked state this is the right big toe. It is swollen and is hot to touch, you have been struggling to put on shoes because of the pain.

You have been taking paracetamol regularly which at first seemed to help with the pain but now isn’t even touching it.

If specifically asked you drink an excessive amount of fruit juice each day because your partner is getting on about you being more healthy. Your partner makes you sardine sandwiches as she gets a discount at work, people at work are not the biggest fan of this.

If asked you are overweight but you have been loosing weight over the past month or so.

You have had no recent fall or injury. No previous history of cancer.

If directly asked about your ideas, concerns or expectations, you have delayed coming to the doctors as you are worried about needing a foot operation and having to have time of work. A person at work said you probably have a fracture  and will need an operation.

PMH

Gastro oesophageal reflux disease

DH

Gaviscon PRN

No known drug allergies

FH

Your dad always had problems with his joints but you do not know what this was.

Your mum has problems with her kidneys but you do not know anymore than that.

SH

You are a non-smoker and have never smoked

You drink a pint of beer each evening

You live with your partner and two children

ou work as a skirting board hand painting restorer at the national trust

ICEF

As above

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


HPC History of presenting complaint 1
Appropriate opening question
Site
Onset
Character


History of presenting complaint 2
Timings of pain - when is it worse
Exacerbating factors
Relieving factors


Lifestyle
Diet explored
Alcohol explored
High BMI


Red flags Red flags 1
Rashes or skin lesions
Stiffness
Previous malignancy


Red flags 2
Night pain
Thoracic pain
Saddle anaesthesia
Trauma


Extra-articular manifestation of joint disease
Red / painful eyes
Dry eyes
Urethritis
Fever


Impact on life
Impact on activities of daily living
Impact on occupation


Constitutional
Weight loss
Fevers / night sweats
Anorexia


PMH Past medical history
Past medical history appropriately asked about


DH Drug history
Drug history appropriately asked about
Drug allergies


SH Social History
Alcohol
Smoking
Occupation
Living situation


FH Family history
Family history appropriately asked about


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


Patient Patient score
Good rapport with patient
Active listening skills
Appropriate use of body language
Avoids medical jargon
Logical structure / does not jump around topics in consultation
Summarises and checks patient understanding


Question
Please review the following image and your most likely diagnosis?

Gout


Question What blood tests would you request?
FBC
Rh factor
U&Es
HbA1c
Lipid profile
Uric acid level
CRP


Question What single medication would you prescribe to treat this patients gout?
Naproxen (or other appropriate NSAID)


Question What side effect is this patient most at risk with Naproxen?
Gastric irritation / gastric ulcer


Question What medication can be prescribed to counteract this side effect?
Omeprazole (or other PPI)


Question Apart from medications what would be your management of this patients gout in general practice?
Dietary advice regarding fruit juice and sardines
Weight loss
Safety netting
Follow up


Question What medications are a risk factor for developing gout?
Diuretics
Aspirin
Other appropriate answer


Question What are the risk factors for gout?
Alcohol
Chronic kidney disease
Cardiovascular risk factors (hypertension, hyperlipidaemia, diabetes)



Score