• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor in general practice

Patient: 85 year old female patient. The GP booking system comment says “right hip 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 85 year old female patient.

Open with “My hip has been playing up, i think i need some more 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 to walk your dog Tilly as much as you would like because of the pain. The pain is not allowing you to socialise as much and your dog getting more upset.

You have been having left hip pain for the past 6 months. It is a nagging sort of pain which has been getting gradually worse. The pain is worse on exertion and seems to get worse throughout the day. You have noticed sitting down and watching TV helps the pain.

You are starting to struggle to get out of the bath and embarrassingly you have had to call your daughter a couple of times to help you get out.

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

You have no joint swelling or redness. There is no clicking or locking of the joint. You have had no recent fall or injury. No weight loss or 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 hip operation. You neighbour had to have a knee operation and she has never been the same since, you are worried this is going to happen to you. You do not want an operation and would prefer to be managed by the GP. You think an x-ray and painkillers would be the solution.

PMH
– High blood pressure

DH
– Ramipril 10mg
– No known drug allergies

FH
– Nill

SH
– You started smoking when you were 15 and gave up at the age of 30, you used to smoke 10/day
– You drink a glass of port each Sunday
– You live alone  in a bungalow with your dog Tilly
– You have no carers but your daughter lives around the corner
– You are a retired factory workers making pencils

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


Red flags Red flags 1
Night pain
Thoracic pain
Previous history of cancer


Red flags Red flags 2
Recent onset bladder or bowel dysfunction
Saddle anaesthesia
Trauma


Impact on life
Impact on activities of daily living
Impact on dog walking


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


Question
Please review the following image and state your finding

Heberden’s nodes


Question
Please review the following hip x-ray and comment on your findings

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral bone cysts
Deformity of femoral head of the acetabulum


Question
Please review the examination findings. Given your history and examination findings, what is your most likely diagnosis?

Osteoarthritis (do not accept OA)


Question What is your management plan given your history and examination?
Simple analgesia
Physiotherapy
Weight loss
Supportive footware
Exercise
Aids and appliances at home (for example help with bathing)


Question What are the risk factors for developing osteoarthritis?
Increasing age
Obesity
Family history
Female gender
Trauma, rheumatoid arthritis, gout, (other acceptable joint disease)
Acromegaly, haemochromatosis (other acceptable metabolic disease)



Score