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STATION NUMBER: 2 HISTORY TAKING, CLINICAL REASONING, DATA INTERPRETATION AND PATIENT CONSULTATION CANDIDATE INSTRUCTIONS You are the FY2 attached to the general practice. This patient has presented with increasing fatigue and lack of energy. Please take a history from the patient. The examiner will then present you with their blood results from a previous visit and will ask you questions related to these. • History taking (17 marks): Take a history of the presenting complaint from the patient • Clinical Reasoning (4 marks): Answer the examiner’s three questions • Data Interpretation (3 marks): The examiner will present you with another patient’s blood results from a previous visit to the GP and ask you to interpret these. • Patient Consultation (6 marks): Marks awarded for appropriate and effective patient interactionSTATION NUMBER: 2 HISTORY TAKING, CLINICAL REASONING, DATA INTERPRETATION AND PATIENT CONSULTATION EXAMINER INSTRUCTIONS 1 Station timings: All stations are thirteen minutes in duration (ten minutes for undertaking the task, plus an additional three minutes to allow for feedback). You must not move candidates to additional tasks during the station; they are responsible for managing their own time. A whistle will be sounded during the station as follows: • At the start: candidates have 60 seconds to read the candidate instructions outside the room • At one minute: candidates must enter the room and can commence their station tasks • At eight minutes: candidates must have two minutes remaining to complete their tasks • At ten minutes: candidates must end their tasks immediately. You have 3 minutes to provide feedback on their performance and suggest areas of improvement if possible (help em’ out) • At thirteen minutes: candidates must leave the room and move onto their next station. This is the same whistle as Whistle 1, and candidates will have 60 seconds to read the candidate instructions outside the room If a candidate finishes the station early, they must remain in the station until the whistle is sounded at thirteen minutes. Feedback: During the station before the feedback session, you must not provide feedback to candidates at any time. If a candidate clearly misunderstands the instructions, simply ask them to “please re- read the instructions.” If, using your better judgement, you feel the candidate is struggling considerably during the station,youmayinsteadopttousethetimetoteachthestationhowtoundertakethetaskbeing assessed, and pass on any advice you may have. While examining candidates, only give a mark if the task is completed accurately by shading the appropriate circle. If the task is not attempted, incomplete or inadequately performed do not award the mark. Please fill in the mark sheet contemporaneously as the candidate is performing the task. Grade the candidate as fail, borderline, pass, or good pass.STATION NUMBER: 2 HISTORY TAKING, CLINICAL REASONING, DATA INTERPRETATION AND PATIENT CONSULTATION EXAMINER INSTRUCTIONS 2 This information is also found on the marking scheme and is provided here for reference. If you wish, you may refer solely to the marking scheme after reading this page for information. Clinical Reasoning: Once the candidate has completed their history, you should ask them the following four questions. Q1. Based on the history, what is your differential diagnosis? Q2. What further investigations would you like to request? Q3. What management options are available for this patient? Data Interpretation: Once the candidate has answered the questions, please present them with the following blood results, stating the following: “These results are from another patient at the practice. Please review these and describe the abnormal findings” Ask the patient to interpret the results and suggest a probable diagnosis.STATION NUMBER: 2 HISTORY TAKING, CLINICAL REASONING, DATA INTERPRETATION AND PATIENT CONSULTATION ACTOR INSTRUCTIONS th Name: Ahmed/Samira Omar Date of birth: 16 June 1990 Age: 33 Occupation: Officer worker Briefing: You have presented to your GP after feeling increasingly tired over the last few months. No amount of sleep or changes to your lifestyle have helped. Also, you’re quite embarrassed to admit but you’ve noticed parts of your skin appear darker than usual. The doctor has been asked to take a history from you Appearance: Low energy, feel free to yawn. Information that you may give on direct questioning: History of presenting complaint: • You have been feeling very tired for the last few months • You’re not entirely sure when it started but that it has been going on for at least 2 months • Sleep isn’t helping you feel refreshed • You’re quite embarrassed to admit but you’ve noticed that parts of your skin look darker, especially your palms. You think this is because you’re working on restoring a friends’ car so you think the oil may have stained your hands • You’ve recently started a new diet and think it has led you craving more salt than usual • You have tried melatonin which hasn’t worked Systemic enquiry: • You deny any fevers or nausea • You have lost a bit of weight but have been going to the gym quite regularly • You deny any weight gain, cold intolerance, coarse hair • You deny any pallor • You haven’t noticed any blood in your urine or stool • Urinary and bowel habits are normal • If appropriate to be asked, your menstrual cycle is normal (no menorrhagia) • You deny any polydipsia, polyuria, nocturia • You deny any shortness of breath, chest pain Past medical history: • You’ve suffered from Depression since you were 19-years-old but recently you feel as though you are managing fine with it Drug history: • Citalopram • No allergies Family history: • Your mother has Hashimoto’s • Your dad had a heart attack and passed away when he was 62-years-old Social history: • You work in an office, you don’t mind your job but hope to move soon • You don’t smoke • You drink socially, mainly for special events • You do not consume any illicit substances • You live in a flat alone with your dog, who keeps you quite active • You enjoy going to the gym ICE: • Ideas: You think you may be working too hard at work and at the gym but you’re not sure why it has lasted this long • Concerns: You’re worried about how long this is going to last as it’s starting to affect your energy levels and you pride yourself on being very active • Expectations: You are wanting sleeping pills to help you get to sleep Patient assessment 0 1 I did not feel confident and the student did Student’s behaviour and manner were what I not listen and respond appropriately to my would expect of a doctor and made me feel views and concerns confident and listened to. They responded to my views and concernsSTATION NUMBER: 2 HISTORY TAKING, CLINICAL REASONING, DATA INTERPRETATION AND PATIENT CONSULTATION Task Done/Correct Introduces self; Identifies patient; Explains purpose of interview and obtO1ns consent Dons/Doffs PPE OR ‘washes hands’ O1 History Taking (enquires about): Establishes reason patient has attended hospital O1 Establishes what patient means by feeling tired O1 Establishes severity of fatigue (whether it prevents patient from performiO1 normal daily tasks) Establishes onset of fatigue O1 Establishes duration of fatigue O1 Screens for depression O1 Rules out differential diagnoses, one mark for any of: O1 Cold intolerance; Pallor; Polyuria, Polydipsia, Nocturia Enquires about symptoms implying underlying malignancy, two marks for O1 O1 any two of: Weight loss, change in appetite, night sweats, nausea, bony pain Enquires about blood loss, two marks for any two of: O1 O1 Irregular heavy periods, bleeding per rectum, haematuria, haematemesis, or haemoptysis Past medical history O1 Drug history and allergies O1 Family history O1 Social history (smoking AND alcohol for the mark) O1 ICE O1 Appropriate summary O1 Clinical reasoning Once the candidate has completed their history, you should ask them the following four questions. Q1. Based on the history, what is your differential diagnosis? O1 Addisons Disease; Due to the tiredness/fatigue, weight loss, salt craving, hyperpigmentationQ2. What further investigations would you like to request? O1 O1 Two marks for: Short Synacthen test Two marks if two of: FBC (to rule out anaemia); TFTs (to rule out hypothyroidism); U&Es (rule out CKD); Blood glucose (rule out diabetes) Q3. What management options are available for this patient? O1 Glucocorticoid and mineralocorticoid replacement therapy (hydrocortisone and fludrocortisone) Data Interpretation Once the candidate has answered the questions, please present them with the following blood results, stating the following: “These results are from another patient at the practice. Please review these and describe the abnormal findings” Award 2 marks for the following: Identifying positive anti-intrinsic factor antibodies and suggesting a diagnosiO1 O1 of Pernicious Anaemia. How would you manage this patient in a GP setting? O1 Intramuscular B12 replacement Patient consultation Non-verbal skills: eye contact/body posture/appropriate physical contact O1 Balance of questions: open/closed/reflective O1 Structure: appropriate structure to interview O1 Rapport/empathy/patient concern: appropriate responses to patient O1 statements Language: clear/understandable/no jargon O1 Patient assessment: from actor O1STATION NUMBER: 2 HISTORY TAKING, CLINICAL REASONING, DATA INTERPRETATION AND PATIENT CONSULTATION Patient name: Ahmed/Samira Omar CHI: 1606908976 Date: 05/06/23 Antibody Screen Antibody Result Rheumatoid factor Negative Anti-intrinsic factor antibodies Positive Anti-gastric parietal cell antibodies Positive Anti-CCP Negative TSH receptor stimulating antibodies Negative Anti-thyroid peroxidase antibodies Negative