• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor in the emergency department

Patient: 80 year old patient has presented with right sided blurry vision

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 80 year old patient. You developed a blurry right eye which came on today. When your carers arrived they were worried about you, so they called an ambulance. You think this is all very silly and do not like causing a fuss.

You do usually have glasses but your vision but your vision isn’t usually this bad. You have had no floaters or flashes or light.

If prompted you have had a right sided headache over the past week. You do get headaches from time to time but this felt different. The pain was most present in the right temple and radiates to the jaw. You noticed the pain was there when you were brushing your hair this morning. Yesterday you had some co-codamol but this did not help with the pain.

Over the past couple of days your jaw has been hurting when you have been eating.

You also have associated pain and stiffness in your beck and shoulders.

You have fatigue and you have noticed your clothes have been more lose recently.

PMH
– High blood pressure
– High cholesterol

DH
– Amlodipine
– Simvastatin
– No known drug allergies

SH
– Ex-smoker. Smoked when you were 16 years old, 15 a day for about 10 years
– You do not drink alcohol
– You live at home with carers four times a day

ICEF
– You are worried that your vision is not improving. You want to know when your sight will come back

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
Change in vision
1 or both eyes
Temporary/permanent loss
Painful / painless
Blurring/loss of vision
Double vision


GCA features
Scalp pain and tenderness: pain on combing hair
Jaw claudication


PMR features
Difficulty turning in bed/getting out of bed or chair/climbing stairs
Shoulder pain and stiffness (when lifting arms)


Neurological symptoms
Weakness
Sensory symptoms
Balance
Speech
Pain
Incontinence


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


Systemic review
Fever
Night sweats
Weight loss
Anorexia
Myalgia
Fatigue


PMH Past medical history
High blood pressure
High cholesterol
Previous ophthalmological surgery


DH Drug history
Drug history appropriately asked about
Drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


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


Question What focused examination would you do given this patients history?
Temporal arteries = tender/thickened/beaded/reduced or absent pulsation
Scalp tenderness
Ask to raise arms- any pain/stiffness
Examine eyes = VA, eye movements, visual fields, RAPD, fundoscopy


Question Given your history what are your differentials?
Giant cell arteritis (temporal arteritis)
Polymyalgia rheumatica
Migraine
TIA / Stroke
Takayasu's arteritis
Other appropriate answer


Question Given your history what blood investigations would you do?
Bloods - FBC, U&Es, LFTs, CRP
Clotting
ESR


Question What investigation is required to make a diagnosis?
Temporal artery biopsy


Question What is the most important management in this patient
Prednisolone (high dose corticosteroids)


Question What are the side effects of prednisolone?
Insomnia
Increased hunger
Cushing’s appearance
Psychosis
Osteoporosis
Hypokalaemia
Hyperglycaemia
Leukocytosis
Infections
Other appropriate answer



Score