• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor on the acute medical take

Patient: A 65 year old gentleman presents to hospital with acute onset weakness

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 65 year old supplies company business owner, who developed sudden onset left leg weakness 1 hour ago. You first noticed this when you got up to walk to the printer and you were struggling to walk. Your business partner said you were struggling to talk right as well so he called and ambulance and you were brought into A&E. You think the whole thing is a bit silly because it feels like you’ve crossed your leg over and it has “gone to sleep”

You only give information if prompted:

  • Weakness started 1 hour ago
  • You have weakness in your left leg and left arm only
  • The weakness has stayed the same since you first noticed it, it has not gotten any better or worse
  • Nothing obvious has caused these symptoms. You have no experienced any trauma.
  • You have no headache
  • You have no neck stiffness or rash
  • You did not have a seizure / loose consciousness / no incontinence

PMH

  • No ongoing health issues
  • No previous operations

DH

  • GTN spray – you are not sure why this is prescribed and you don’t use it
  • No known drug allergies

SH

  • You smoke 20 cigarettes a day for the past 50 years
  • You drink 1 pint of beer during the week and 5 pints on a Saturday
  • You live at home with your partner and son
  • No recreational drug use

FH

  • Mum had diabetes and died of ‘old age’
  • Dad died of heart attack age 56

ICEF

You think the whole thing is a bit silly because it feels like you’ve crossed your leg over and it has “gone to sleep.”

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
Onset
Duration of weakness
Affected region
Weakness elsewhere



Change in weakness since started - better / worse
Relieving factors
Exacerbating factors
What is patient currently able to do with weakness


Associated features:
Sensory symptoms
Balance
Speech
Headaches
Pain
Incontinence


Red flags:
Neck stiffness / rash
Decreased level of consciousness
Sudden onset, worst headache ever / ‘clapping headache’
Seizure or neurological deficit
Reduced visual acuity
Headache worse when laying down with early morning nausea


Constitutional symptoms
Weight loss
Night sweats +/- fever
Loss of appetite


PMH Past medical history
No medical issues
Specifically asks about one of the following - Diabetes, myocardial infarction, ischaemic heart disease
No previous operations


DH Drug history

GTN spray
No known drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history appropriately asked about


ICEF
Explores ideas, concerns, expectations, feelings


Question
Review this patients examination findings. Given the history and examination, what are your differentials?

Stroke (ischaemic or hemorrhagic)
Cerebral tumour
Cerebral abscess
Todd’s palsy
Migrane
Myasthenia gravis
Peripheral neuropathy
Other appropriate answer


Question Given your history and examination, what investigations would you like to do?
Bloods = FBC, U&Es, LFTs, CRP
Clotting
BM
Head CT
ECG
Carotid doppler
Echocardiogram


Question
Review this patients results. What is your management of this patient assuming presentation is within 4.5 hours

ABCDE approach
Recombinant tissue palminogen activator - accept tPA
Aspirin 24 hours after tPA
Admission to stroke unit
Salt assessment / swallowing assessment
VTE prophylaxis
Physiotherapy for early mobilisation



Score