• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor in general practice

Patient: 70 year old male patient can come to see you with lack of energy and feeling stiff

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 70 year old male patient.

You have come to see the doctor as you have no energy at the moment and you feel very stiff. You live at home with your dog Alex, who you usually walk everyday. At the moment you feel so stiff that you are struggling to take her for a walk. You are getting annoyed with yourself as your son is having to come around to take her for a walk.

This has been worse over the past month. The pain and stiffness is present in both shoulders and hips and is worse overnight and in early morning. The stiffness usually lasts about 1 hour in the morning. You have been struggling to use the stairs, particularly in the morning. You cannot get out of the bath and have had to get your son around to help you out the tub. You cannot also brush your hair in the morning.

You have no joint swelling or redness. You have no scalp tenderness or visual problems.

PMH
– High blood pressure

DH
– Amlodipine 10mg
– No known drug allergies

SH
– You used to be a heavy smoker but now you only have one or two a day
– You drink a glass of port each evening
– You live alone with your dog Alex
– You are a retired butterfly farmer

ICEF
– You are worried this is all in your head and you are wasting everyones time.

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


PC Presenting complaint
Appropriate opening question
Site
Onset
Character
Timings of pain - when is it worse
Exacerbating factors
Relieving factors


Screens for temporal arteritis
Scalp tenderness
Jaw claudication


Associated features
Joint swelling
Clicking / locking of joints
Recently unwell
Rashes


Associated features 2
Uveitis / iritis
Back pain
Mouth ulcers
Dry eyes or dry mouth


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


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


Question What is your most likely diagnosis?
Polymyalgia rheumatica


Question What are your differential diagnosis?
Giant cell arteritis
Rheumatioid arteritis
Hypothyroidism
Fibromyalgia
Polymyositis
Other appropriate answer


Question What is the most important investigation in this patient?
ESR


Question Why is a full blood count checked?
Myeloproliferative diseases present in a similar way to PMR (fatigue, bony pain)


Question Given this patient has polymyalgia rheumatica, what medication would you prescribed?
Prednisolone


Question What side effect of prednisolone is this patient most susceptible to?
Osteoporosis


Question How would you minimise the osteoporotic effect of prednisolone?
Alendronic acid



Score