• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor on the acute medical team

Patient: 55 year old patient has presented with a cough

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 55 year old patient, you have been having a horrible cough for the last 2 weeks. At first you thought you had a cold but after a week it still wasn’t getting any better. You went to the walk in centre and they prescribed you some antibiotics but said they probably wouldn’t make a difference as this is viral. You are a bit annoyed as you feel they didn’t properly examine you. This week you have still had the cough and it’s not getting better. You have tried everything, cold and flu drinks, tickly cough medicine and humidifiers.

You are feeling really run down. You have no energy at all, you are struggling to leave the house. You don’t have much appetite. You have not been going to work either, which is a problem because you are self employed, so you aren’t making any money.

If asked you have bringing up a lot of green stuff. There is no blood in the sputum. You are not breathless at rest but are when you try to climb the stairs which does not happen usually.

PMH
– You are usually fit and well

DH
– You take Citalopram 20mg OM (for anxiety)
– You are allergic to codeine (when you take this you vomit)

SH
-You are a self employed accountant
– You live with your partner
– You used to smoke 5/day but you gave up 3 months ago
– You drink socially

FH
– Nothing runs in the family that you are aware of

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


History History
Onset
The type of cough (dry or productive)
Change over time
Blood in sputum


Additional symptoms
Breathlessness
Wheeze
Pleuritic pain
Chest pain
Fever
Urine colour and output (signs of dehydration)


Systems review Systems review
General = fever, rigors, night sweats, weight loss
Cardiorespiratory = chest pain, palpitations, SOB, sputum, leg swelling
Gastrointestinal = dysphagia, N&V, indigestion / reflux, abdominal pain, change in bowel habit


PMH Past Medical History
Past medical history appropriately explored
Excludes patient does not have a lung disease (e.g COPD / asthma)


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
Alcohol
Smoking
Occupation
Living situation


FH Family history
Family history appropriately explored


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


Question
Please review this patients auscultation. What are your findings?

Coarse crackles
Inspiratory


Question Given your history what investigations would you do?
FBC, LFTs
U&Es
CRP
Sputum culture
CXR


Question
Review the following image and state your findings

CXR
Airspace consolidation
Air bronchograms present
Both present in the right lower zone
Most likely right middle lobe


Question Given your history, auscultation & CXR findings what is your most likely diagnosis?
Pneumonia / Lower respiratory tract infection / Community acquired pneumonia


Question What is your management plan?
Admission
Antibiotics
Chest physiotherapy
Await blood results
VTE
Regular medications


Question What scoring system is used to determine the severity of Community Acquired Pneumonia?
CURB-65


Question What special investigations are included in a atypical pneumonia screen
Urinary legionella pneumophila
Urinary mycoplasma pneumoniae


Question What is the issue in prescribing Citalopram and Clarithromycin?
QT prolongation



Score