• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor in general practice

Patient: 50 year old male patient has come to see you with a mole on his back

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 50 year old man who has come to see his GP. You are really only here because your wife has nagged you into coming. You have been told you have a mole on your back which is getting larger.

You have a lot of moles all over your body including your back, you have seen your GP a couple of years ago and were told it was nothing to worry about but if there was any change to return.

If asked, when you are exposed to the sun more often than not you will burn and not tan. You work as a gardener and because it is warm you will often not wear a shirt in summer. You do not wear any sun protection (sun tan lotions / hats). You personally like the look of tanned skin.

You used lived in South Africa as a child for 10 years, you often remember burning and having blisters as a child. But that’s just what happened back then.

You have not been previously diagnosed with any skin cancers.

Past Medical History (PMH)
– Usually fit and well

Drug History
– No regular medications
– No known drug allergies

Family History (FH)

Your father died of cancer, you do not know what type but it was in his ‘bones’

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


Presenting complaint
Onset of lesion (when / sudden or gradual / acute or ongoing)
Previous lesions


Evolution
Change over time
Location


Associated features
Itchy
Tender / pain
Bleeding
Discharge
Swelling


Systemic features
Pyrexia
Joint pain
Weight loss
Malaise


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


Sun exposure
Burn or tan
Use of sun protection
Use of sun beds


Psychological impact
Candidate attempts to understand psychological impact on patient


PMH Past Medical History
Candidate appropriately explores past medical history
Specifically asks about autoimmune conditions
Specifically asks about previous skin lesions


DH Drug History
No regular medications
Specifically asks about new medications
Specifically asked about over the counter medications including herbal
Drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


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 for this patient and comment on your findings

Asymmetry
Border irregularity
Colour - two or more
Diameter > 6mm


Question What is your working diagnosis given your history and reviewing the image
Melanoma


Question What is your management of this patient in general practice
Inform patient of likely diagnosis and referral to specialists for further investigation / treatment
Urgent referral to dermatology under the 2 week wait rule


Question The lesion has been removed, what is the most important histological determinants of prognosis?
Depth / thickness of lesion
Breslow thickness


Question What advice would you give the patient in order to reduce the chance of getting further skin cancer?
Avoid sun burns
Sun protection - sun block
Cover up with clothing / hats
Avoid sun in middle of day
No sun beds
Monitor moles, attend early if any changes


Question What are the risk factors for melanoma?
Burns easily
Fair skin
Time spend abroad (living / holidays)
Sun bed use
Family history
Medications
Occupation/hobbies



Score