• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an F1 junior doctor working in A&E

Patient: Patient has presented to A&E with a sore throat

Task:
– Take a focused history from the patient.
– After 6 minuets 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 a 17 year old male / female who has attended A&E with a sore throat. This began 5 days ago and has been getting worse. If asked the swelling is on both sides at the back of the throat. It is extremely painful to swallow and you have been spitting out your saliva into a cup. You have had tonsillitis before but nothing as bad as this. If asked you feel extremely tired and have found it extremely difficult to get out of bed and have been unable to attend collage.

You have seen your GP 2 days ago and prescribed some medications but have been unable to swallow the tablets given as they are too big and you cannot even swallow water. If asked you cannot remember what the doctor was treating.

You do not regularly see your doctor about anything and have not had any past operations. You do not take any regular medications and do not have any drug allergies

You do not drink or smoke

Nothing like this runs in your family.

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


HPC History of presenting complaint
Appropriate opening question
Onset
Characteristic
Radiation
Timing – does the pain come and go or is it constant?
Exacerbating and relieving factors
Severity


Associated features
Fever / night sweats
Malaise
Absence of a cough
Headache, nausea, vomiting and abdominal pain
Asks about fluid intake and pain on swallowing


Additional
Recently been in contact with anyone unwell
Previously had tonsillitis
Asks how many episodes of tonsillitis the patient has had each year for the past 3 years.


Features requiring admission
Stridor present
Dehydration or difficulty swallowing fluids
Acute abdominal pain


System review
Ear = otalgia, discharge, change in hearing / tinnitus
Nose = rhinnorrhoea, epistaxis


PMH Past Medical History
Appropriate past medical history questions
Asks about previous operations


DH Drug History
Asks appropriate questions about past medical history
Asks about any drug allergies


SH Social History
Smoking
Alcohol
Place of residence
Occupation


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


Question
Review the following image and comment on the appearance of the oropharynx

Tonsils are symmetrically enlarged
Tonsils are erythematous
Purulent exudate is seen bilaterally over both tonsils.
Uvula not deviated


Question Examination findings: Pyrexia of 39°C, multiple enlarged painful anterior neck lymph nodes, but no other lymphadenopathy and no splenomegaly. Given the history you have taken and the examination findings, what are your differentials for this patient?
Acute tonsillitis
Infectious mononucleosis (glandular fever)
Scarlet fever
Diptheria
Agranulocytosis
HIV


Question What are the most common infectious causes of an acute sore throat?
Rhinovirus
Parainfluenza virus
Influenza A and B
Group A beta-haemolytic streptococcus (streptococcus pyogenes)
Adenovirus
Epstein-Barr virus (causing infectious mononucleosis)


Question Given your history, the picture you have seen and the examination findings provided to you, what blood investigations would you like to do as a junior doctor in A&E?
FBC
U&E
LFT
CRP
Monospot test (or allow glandular fever screen)


Questions What would be your management of this patients bacterial tonsillitis as a junior doctor in A&E
Analgesia – paracetamol, ibuprofen, codeine PRN
Difflam mouthwash
Antibitoics (prescribe according to trust policy)– e.g phenoxymethylpenicillin PO 500mg QDS or if severe and unable to swallow benzylpenicillin IV 1.2G QDS
IV fluids if unable to swallow, encourage hydration
Senior review
Admission under ENT team


Question What are the complications of tonsillitis?
Suppurative complications = otitis media (most common), acute sinusitis, peri-tonsillar abscess (quinsy)
Non-supprative complications = acute rheumatic fever, acute glomerulonephritis


Question What scoring system used in general practice determines the likelihood that a sore throat is likely to be due to a bacterial infection?
FeverPAIN score (accept old scoring system: Centor score)



Score