• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a psychiatry F1 doctor in A&E

Patient: Matthew is a 25 year old man, who has taken an overdose of paracetamol and was brought to A&E

The A&E consultant has declared the patient medically fit for discharge

Task:
– Take a focused history from the patient around the suicide attempt in order to determine risk of self harm if discharged
– Consider the need for hospital admission
– 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 to 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 Matthew a 25 year old man.

Overall: you are low in mood, you struggle to make eye contact, you look at the floor a lot. You do not lead the conversation but if asked a specific question will answer appropriately.

Everything has been really crap recently, you do not see the point in living anymore. You have nothing to live for and you want it all to end. The only solution is to kill yourself.

Event: yesterday you wanted to kill yourself, you left your flat where your housemate gives and bought as much paracetamol as you could (if asked 45 x 500mg tablets taken all in one go).  You went to a local river to avoid being found, you had all the tablets and you drank a liter of vodka and then passed out. After this point everything was a bit of a blur, you remember a dog walker calling an ambulance, next thing you remember is waking up in A&E. You are annoyed that you weren’t able to kill yourself and you still believe there is no point in living.

Leading up to the event:

  • You been having thoughts about harming yourself for the past month
  • Your partner has recently left you for your best friend, they had been sleeping together for a couple of months. You are unable to cope thinking about the two of them together.
  • Mood has been really low for a few months, you randomly cry for no reason.
  • Your sleep has been poor, you struggle to get to sleep and wake up really early
  • You cannot concentrate at work
  • You have little energy or motivation
  • You used to enjoy playing football but since then you have not been playing
  • You just stay in your room and don’t do a lot
  • You feel worthless and think negative thoughts about yourself “no one will ever love you,” “you’d be better off dead”
  • You wrote a letter to your ex partner and parents. You closed all your bank accounts. You gave all your stuff away to friends or charity shops

Past psychiatric history

  • You have never attempted suicide before
  • Never attended mental health services or seen your GP about mood issues
  • Your granddad had bad depression and committed suicide

Personal history

  • Your are close to your mum, dad left when you were 16
  • You live with flat mate
  • You are a student but you have stopped attending university

Social history

  • You usually drink socially
  • You do not do any recreational drugs
  • You smoke about a pack of cigarettes a day

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school, year or grade
Clarifies who they are talking to
Asks patient for preferred name


During
Avoided being found by going to river
Alcohol use – 1 liter of vodka
Intention to die
Found by dog walker to called ambulance


After
Intention was to die
Regrets failure
Would try to commit suicide again


Depression symptoms
Low mood
Anhedonia
Lack of energy


Past psychiatric history
Past psychiatric history
Past history of self harm


Psychiatric history review
Hallucinations (visual / auditory / olfactory)
Paranoid thoughts
Harm to others
Patient ever been elated


Ability to establish rapport with a distressed patient
Candidate seems interested in how you feel
Responds to information you provide
Allows appropriate gaps and allows you to give information at your own pace
Conversation flows naturally / are not provided with a load of closed questions


Sensitively asks questions
Appropriately asks questions
Avoids medical jargon
There are no instances where you find questions bazar or inappropriately asked


What are the risk factors for suicide?
Previous suicide attempt
Substance abuse (drugs / alcohol)
Male
Mental health condition
Access to lethal means
Chronic illness
Unemployed
Lack of social support


Would you let this patient leave hospital?
No
High risk to self
Likely to harm self again


What risk level is this patient?
High
No regret
No social support
Untreated depression



Score