• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

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

Patient: A 60 year old female patient has come in with 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  60 year old retired mail centre manager. You were at your granddaughters christening. You were sitting down about to eat some food and you realised you were struggling to pick up your fork, the whole of your right arm was week. And your daughter said your speech sounded like you were drunk enough though you had not had any alcohol. An ambulance was called but after 10 mins you were completely back to normal. The ambulance have taken you to the hospital.

In the hospital you feel completely back to normal

You only give information if prompted:

  • Balance normal
  • No headaches
  • No pain
  • No loss of consciousness
  • No incontinence
  • No neck stiffness / rash
  • No decreased level of consciousness
  • No sudden onset, worst headache ever / ‘clapping headache’
  • No seizure or neurological deficit
  • No reduced visual acuity
  • No headache worse when laying down with early morning nausea

PMH

  • You are fit and well, you have not been to the doctors in many years
  • No previous operations

DH

  • No regular medications
  • No known drug allergies

SH

  • You used to smoke when you were 16 but you didn’t like it, so you stopped
  • You drink 1 glass of white wine a week.
  • You live with your partner
  • No recreational drug use

ICEF

  • You do not know what happened really
  • You feel embraced about wasting everyones time, you feel this is a whole lot of nothing.

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 - acute / chronic
Duration
Affected region
Weakness elsewhere



Change in weakness since started - better / worse
Relieving factors
Exacerbating factors
What was 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 past medical history
No previous operations


DH Drug history

No regular medications
No known drug allergies
No recreational drug use


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history appropriately asked about


ICEF
Explores ideas, concerns, expectations, feelings


Question Given your history, what are your differentials?
Transient ischaemic attack (TIA)
Hypoglycaemia
Seizure with post seizure paralysis
Migraine without headache
Space occupying lesion
Peripheral neuropathy
Multiple sclerosis
Other appropriate answer


Question Given the history what investigations would you like to do?
ECG
BM (blood glucose)
Bloods = FBC, U&Es, LFTs, CRP
Clotting including INR
Fasting lipid profile


Question
Read the following ECG and comment on your findings:

Absence of P waves
Irregular irregular rhythm
Diagnosis: atrial fibrillation


Question What scoring system is used to assess the risk of stroke and anti-coagulation?
CHADS2 or CHA2DS2VASc


Question What pharmacological management should this patient have?
Anticoagulation = warfarin / dabigatran / rivaroxaban / apixaban / edoxaban
Statin = e.g atorvastatin / simvastatin
Anti-hypertensives if raised blood pressure = amlodipine



Score