• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location:

Patient: 21 year old male has become suddenly short 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.

Background: you are a tall thin male who plays a lot of sports

You are a 21 year old male who started to get left sided chest pain last night whilst playing rugby. At the time you thought you had pulled a muscle and you continued to finish the game but you were very short of breath. When you woke up this morning you were still short fo breath and the pain was still there, so you decided to come into hospital.

If asked the pain is worse when you breathe in, it is worse over the left hand side. You are in mild discomfort but you do not require any painkillers if asked.

Rest of systems review unremarkable.

PMH = NAD

DH = no regular medications, NKDA

SH

  • You work at a car dealership
  • You smoke socially, maybe once a day since you were 16 years old

If asked you are worried that you have had a heart attack, you have seen the posters at work about central chest pain at work. You asked the doctor “Do you think this could be a heart attack.” You push the candidate to provide you with a yes or no answer if you could be having a heart attack and you do not let this go.

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


PC Presenting complaint
Establishes patient has breathlessness and chest pain
Onset sudden
Clarifies what patient was doing at the time


Breathlessness Candidate explores breathlessness symptom
Asks patient if able to talk in complete sentences
What limit this has no exercise tolerance - able to climb stairs ect.
Able to sleep laying flat


Pain Candidate attempts to explore pain symptom:
Site
Onset
Character
Worse on inhalation


AF Associated features
Recently been unwell
Cough
Wheeze
Fever
Palpitations


BMI Candidate asks for heigh and weight
Height
Weight


Systems review Systems review
Candidate carries out appropriate systems review


PMH Past medical history
No past medical history


DH Drug history
No regular medications
NKDA


SH Social History
Socially drinks alcohol
Smokes socially, about 1 per day
Works in a car dealership
Living with friends currently


FH Family History
No medical conditions run in the family


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Directly addresses question about heart attack as yes or no
Provides adequate assurance that this will be looked into


Question Patient observations are within normal range. Given your history and the observations, what are your differentials?
Pnemothorax
Musculoskeletal pain
Pleural effusion
Pulmonary embolus
Pneumonia
Pericarditis
Other appropriate answer


Question Given the history, what investigations would you like to do?
ABG
CXR
Bloods = FBC, U&E, LFTs, CRP, Clotting, D-dimer
ECG


Question
Please review the following CXR and state the most likely diagnosis

Primary / spontaneous pneumothorax (do not allow pneumothorax on its own)


Question What clinical signs could you expect when examining this patient
Tachycardia
Tachypnoea
Tracheal deviation
Hyper-resonance to percussion
Decreased breath sounds


Question
Given this is a spontaneous pneumothorax, please review the BTS management plan and state what the management plan should be

Aspirate 16-18G cannula
If breathing not improved chest drain 8-14 Fr



Score