• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an F1 working on-call in medicine

Patient: 70 year old presented with shortness of breath

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 a 70 year old retired accounts manager. Over the past month you have noticed you are increasingly finding it more difficult to get around the house. You now become very breathless when walking between rooms. You used to be able to walk down the road to your friends house with little problem. Now you struggle to make it to your front door.

You are not breathless when you are resting, it is only on exertion. You have had problems with sleeping, you struggle to sleep laying flat and so have starting sleeping in your reclining chair in your living room. If asked you have woken up at night gasping for breath and this has worried you a lot.

If asked your ankles have been more “puffy” and swollen than usual over the past month.

You have no fever, cough, wheeze, chest pain. You have not noticed any weight loss.

Past Medical History (PMH)
– High blood pressure
– High cholesterol
– Type 2 diabetes

Drug History (DH)
– Simvastatin
– Amlodipine
– You have no allergies

Social History (SH)
– You used to smoke 20 per day for 30 years, you gave up 10 years ago
– You have a glass of champagne once a week at brunch with your friends
– You live in a two storey house. You live alone, your partner left you 10 years ago. You have a good support network with lots of friends on the street and your daughter lives a 5 min drive away and sees you everyday

Family History (FH)
– No conditions run in the family that you are aware of

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school, year or grade
Clarifies year or grade
Asks patient for preferred name


HPC Dyspnea history
Onset
Frequency
Duration
Severity
Timing
Precipitating factors
Relieving factors


Targeted questions
Recent illness or previous surgery
Sleeping upright
Ankle oedema
Paroxysmal nocturnal dyspnea


Exercise tolerance
Exercise distance
Effect on daily living
Previous exercise tolerance


Associated features
Cough
Hemoptysis
Wheeze
Fever
Weight loss / change in appetite
Chest pain
Palpitations or dizziness
Anxiety


PMH Past Medical History
Appropriately asked about


DH Drug History
Medications asked
Allergy status asked


SH Social History
Retired, previous account manager
You used to smoke 20 per day for 30 years, you gave up 10 years ago
You have a glass of champagne once a week at brunch with your friends
You live in a two storey house. You live alone, your partner left you 10 years ago. You have a good support network with lots of friends on the street and your daughter lives a 5 min drive away and sees you everyday


FH Family History
No conditions run in the family that you are aware of


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


Question Given this history and investigations you have been provided with, what are your differentials?
Heart failure
COPD
Pulmonary fibrosis
Anemia
Value disease
Nephrotic syndrome
Other sensible answer


Question Given the history, what investigations would you like to do in this patient
Bloods = FBC, U&Es, LFTs, CRP
BNP (Brain natriuretic peptide)
CXR
ECG
Echocardiogram


Question
Please comment on the pathology following x-ray

Cardiomegaly
Kerley B lines (horizontal lines in the periphery of the lower posterior lung fields)
Upper lobe pulmonary venous congestion
Interstitial oedema


Question Given this history and investigations you have been provided with, what is your most likely differential?
Heart failure


Question What pharmacological therapy can be used to treat chronic heart failure
Diuretics: Furosemide / Spironolactone
ACEi: Ramipril
Beta-blocker: Bisoprolol



Score