Simulated Patient Script History-Collapse Morning, Candidate instructions: This patient has come to casualty after collapsing at an all- night party, with loss of consciousness. Gather a focussed history of this collapse and present your differential diagnosis to the examiner. Summary for SP The candidate needs to ask you questions about this recent event. This is a § minute station and you will be asked to rate the student's performance against the reference you have been given below for his/her ability to communicate with you. Background: You are Msir Lewis, aged less than 40 years and preferably thin. It is momning and your friends have brought you to Accident and Emergency because you collapsed after a night out, but they have left to go to get ready for work. Your clothes are casual and you are either unshaven or with smudged make-up. Please only give details to specific questions Medical history You have no idea about what happened. You had no waming The friend who brought you to Casually said that you suddenly just collapsed on the floor. The friend said you made a mess kicking at the fumiture You don't think that you were incontinent — if asked without explanation check meaning i.e. passed urine Your tongue feeis OK - not bitten. You feel sore on the side of the head You just wanted to curl up and sleep in the car and still feel very tired Past Medical History You are usually fit and well. Never been to hospital. You have annual BUPA heaith checks —everything fine. No previous collapses/ blackouts’ history of epilepsy Social history- City trader, long hours over past year —work hard, play hard’ Medication- nil . Alcohol- a bottle of wine most evenings. Not sure how much last night- it was a long night. Non-smoker Pérsonality- usually very energetic, now feel weird nd tired. Prompts- ASK each candidate, near the end, what happens now/what s/he is going to do with the information? en globat ee of candidate’s ability to communicate jood pass 2 borderline 1 fai Pioase tell the Exaither your opinion —do not confer&e pion History - Collapse Station [*] tre &Centre Circuit — &Circuit &Session 7 podidate Name &CandName &Canc oF miner instructions: Please assess the candidate on each of the following E¥ptia. Please note the prompt for a differential diagnosis (item 15). In the am a ci¥ sits this will be @ seizure and in the pm circuits it wil be a faint. = oi be) Appropriate introduction to patient, giving own name, greeting, role and patient's name and explains | [7. 0.0] fi _ what she is going todo (all required to score) : Establishes if any winess 1.0) 005} Explores if a seizure - aura, injury: both to score 1.0] 0.0=] Explores if a seizure - incontinence, tongue biting: both fo Score > 101094 Explores fa seizure abnormal movements 10=]00—4 Explores i syncopal episode - warning i re Explores if syncopal episode -no injury 105) .9—| ‘Condition after episode v 1.0} 0.0—>} Enquires about previous episodes , ~ 1.0] 00—5| Past medical history; diabetes, epilepsy (2 fo score) a 1.0} 0.05} [(°_-“Medication r 19] 005) acter : sacfoo ["2,_—Recrealional drugs 194 004) (3 ‘Social history 1.0} 00: ['4_-“EXAMINER PROMPT: differential - AM Selaure more Ikély than Syncopal episod: PM the ‘opposite | | 10] oo) "9 _Taentfies patients fees about what has happened 10} 00=4 [1 Wakes empathic slaiements af ((Q Continms scton pian 7 or Global Rang: candldatas compatency at elcHing w weal Riiory & Good Pass || 30>} Bordertine |p| 20—) Fall || 10) yloted Patient Global Rating: overall ability of candidate to communicate jee sit Good |g} 4.0} Pass || 3.0—] Bordertine |g) 2.0] Fail EI) 1.0]Simulated Patient Script History- Collapse Afternoon Candidate instructions: This patient has come to casualty after collapsing at an all- night party, with loss of consciousness, Gather a focussed history of this collapse and present your differential diagnosis to the examiner. Summary for SP The candidate needs to ask you questions about this recent event. This is a 5 minute station and you will be asked to rate the student's performance against the reference you have been given below for hishher ability to communicate with you. Background: You are Ms/r Lewis, aged less than 40 years and preferably thin. {tis moming and your friends have brought you to Accident and Emergency because you collapsed after a night out, but they have left to go to get ready-for work. Your clothes are casual and you are either unshaven or with smudged make-up. Please only give details to specific questions Medical history You are puzzled about what happened. You were listening to your friends arguing and began to see stars and then blackness. The fiend who brought you to Accident and Emergency said that you seemed to crumple up on the floor. You don't think that you were incontinent ~ if asked without explanation check meaning i.e. passed urine Your tongue feels OK - not bitten. You feel fine otherwise and need to get to work Past Medical History You are usually fit and well. Never been to hospital. You have annual BUPA health checks -everything fine. No previous collapses/ blackouts’ history of epilepsy Social history- City trader, long hours over past year —‘work hard, play hard’ Medication- nil . Aicohol- a bottle of wine most evenings. Not sure how mucti last night- it was a long night. Non-smoker Personality- usually very energetic, now feel weird and tired. Prompts- ASK each candidate, near the end, what happens now/what s/he is going to do with the information? Patient’s global rating of candidate’s ability to communicate ‘4.good 3pass 2 borderline 1 fail Please tell the Examiner your opinion —do not confer 23History - Vomit Station 1 Centre &Centre Circuit = Circuit Session &Session Candidate Name ‘&CandName Candidate No. &CandNo Candidate instructions: see sheet Examiner: Please rate the candidate on each of the following criteria. See prompts below for items 20 & 21, history gathering skills section at end and simulated patient sheet. Communication Skills ft Introduction: greeting, own name, fullname of patient, role - all fo score 2 States purpose of interview History details When did vornfing occur if Desoription of nature of vomiting, IS Amount of blood loss {6 History of drug ingestion including OTC - both fo score _ [7 History of alcohol habits icluding Blood ‘Occupation 7 'S Domestic and social creumstances __ 10 Smoking 7 [11 Appetite 7 [i2 Abdominal pain/discomfon, nature, site and aggravation - 2 to score [13 Weight loss 114 Abdominal swelling [75 Bieading elsewhere 116 Character of motions, including change in habit HT Systematic Enquiry 118 Previous history - no endoscopy, hypertension 19 —}00.—| [19 Treatment and advice in the past 19—]00—| Diagnosis: examiner to prompt [20 A differential diagnosis any 3 of - upper Gi bleed, alcoholic gastritis, DU, gastric ulcer, Mallory Wess tear, Ca. stomach, varices, erosions [21 Investigation of choice: upper GI endoscopy History gathering: (22 Asks open-ended question eariy in interview 123 Avoids asking more than one question at a time [24 Demonstrates active listening 125 Open to dosed-ended questioning 135 Makes transition statements or signposts, Piease continue on sheet two se eweHistory - vomit (ctd) Station A Centre &Centre Circuit — &Circuit Session &Session Candidate Name &CandName_ Candidate No. &CandNo Candidate instructions: see sheet Examiner: Please rate the candidate on each of the following criteria 27 Doss not use jargon/explains fused wap] 26 Uses summaries * accurate 10] 0.0 29 Appropriate closure - thanks and goodbye Examiner overall rating: was the approach that expected of a professional? good pass borderline pass borderline fail fall Examiner overall rating: overall ability of the candidate to gather the history good pass borderline pass borderline fail fail Simulated patient rating: overall ability of candidate to ask questions good pass borderline pass borderline fail fail eePractical skill - Use of inhaler Station 7 Centre &Centre Circuit —&Circuit Session &Session Candidate Name &CandName Candidate No. &CandNo Candidate instructions: see sheet. Examiner: Please rate the candidate on each of the following criteria and see separate simulated patient instructions. [t- Appropriate introduction (full name and role) [2. Explains to patient what smhe is going to do Checks peak flow Gives patient instructions which include: ‘Standing up Deep breath in (5. Blow hard and fast [6. Indicates should repeat x3 (stop simulated patient doing this) i7. Checks PFR against norm referencing chart ‘Comments on normalifyicompares to predicted value Explains to patient that s/he will talk through correct inhaler technique ‘Student demonstrates effectively how to: (10. Shake inhaler 111 Breathe out fully Before using inhaler 112. Coordinate inhaler action with breathing in 113. Take slow deep breath in [14. Holds for count of 10 15. Rest then repeat (stop simulated patient from repeating) [16. Checks that patient has understood 117. Uses approriateljargon free terminology Examiner overall rating: Overall ability of candidate to explain equipment use ‘Simulated patient overall score: The explanation was clear Good Pass Borderline Pass Borderline Fail Fail Good |: Pass Borderline Pass Borderline Fail Fail Tape] 19 00-—| jee | t r a eeHistory - Pain in leg Station 2 Centre &Centre Circuit &Circuit Session &Session Candidate Name aCandName Candidate No, &CandNo Candidate instructions: see sheet Examiner: Please rate the candidate on each of the following criteria. See prompts below, history gathering skills section at end and Simulated patient sheet Communication skills Introduction - greeting, own name, full name of patient, role ~all to score [2 States purpose of interview History details ‘Age f Occupation ‘Asks about pain in leg B Site calf 6 Site: esks about both thigh and buttock [7 Duration of Symptoms ‘When does it occur (on walking) (0 How far can patient walk [10 Asks if gets rest pain [77 Agaravating factors (by walking uphill and into the wind) |12 Alleviating factors (relieved by stopping walking) [13 History of MI (7 yrs ago had clot dissolved by thrombolysis) [14 History of hypertension 10.) 00—| [15 Angina (no) 19.]00— [76 Diabetes (no) 10—]00—| li7 GVA (roy [18 History of back pain (no) ~ Social History - — [ig How does problem affect ife 19—|00— [20 Alcohol (glasses of red wine in evening, sometimes luncitime, whisky before bed) 19.|00—| [21 Smoking (60 cigarettes a day) ~ a 10—|00—| j22 Medication (Aspirin and atenolol) 1000 —| [23 Does the patient have any other symptoms 10) 00] faa Asks specifically about impotence 10—| 00] [25 Does the patient wish to add anything History gathering: — 19—|00| [26 Asks open-ended question early in interview 1000 Please continue on sheet two esesiaaes ee eeHistory - Headache Station 14 Centre &Centre Circuit &Circuit Session &Session Candidate Name &CandName Candidate No. &CandNo Candidate instructions: see sheet, Examiner: Please rate the candidate on each of the following criteria. See prompts below. [!- Appropriate infroduction- greeting, own name, patient full ame, tole alte Score 2 States purpose of interview Establishes characteristics of the headache B Onsetfrequency (both to scarey Hi Duration 9. Sitevradiation (both to score) [B. Exacerbating factors (@.g. coughing, laughing) 10 [Relieving factors (e.g. analgesia) 10] Establishes associated features: asks about east) Nausea 10] Vomiting 19-—| i {10. Blurred vision/photophobia (both to score) 10] 117. Loss of concentration 10. ' 2. Seizures 10—]00—| [73. Funny tums to—J00—) 1 (14. Other features: paraesthesiae, weakness, numbness - 7 10 score tooo] 5 115. Neck stiffness to—loo—| | 116. Incontinence 19f00—} 5 Enquires about (emesis) (I7. Recent head injury 10] 118. Family history of headache 19/00) 5 18. Relevant past medical history (e.g, migraine) 0 Joo) » 20. Relevant medication history 10 Joo) » [21. Uses appropriate questioning sivie 10 J00—) 9 222. Elicts patient's concams 10/00] 9 23: Responds appropriately to concems ooo) 9 224. Sumimarises history back to patient 10/00 25, Exeminer prompt mos! likely diagnosis? (brain tumour or Space-occupying lesion or ralsed lWVaGranlal ' ooo} yressure) P ——— ' 1 ' " £26. Examiner prompt: most relevant investigation? (CT scan or MRI) 1000 —| Please continue on sheet 2 --—History- Headache (etd) Station Centre Centre Circuit it Session &Session ct Candidate Name &CandName Candidate No. &CandNo Fail ‘Simulated patient to mark: The candidate was empathic Pass Borderline pass Borderline fail FailHistory - Diarrhoea Station Centre &Centre Circuit — &Circuit Session &Session Candidate Name &CandName Candidate No. &CandNo Candidate instructions: see sheet. Examiner: Please rate the candidate on each of the following criteria. See prompts below, history gathering skills section at end and simulated patient sheet. Communication skills [i- Introduction - greeting, own name, full name of patient, role - all fo score [2. States purpose of interview History details ‘Checks what patient means by diarrhoea &. Duration of symptoms |S. Stool consistency |6. Stool frequency [7. Previous bowel habit Presence of blood in stools . Presence of mucous in stools [f0. Abdominal pain [T7. Vomiting r2. Recent meals, [73. Weight loss [74. Foreign travel [15. Do friends or family have symptoms 16. Family history of bowel problems (inflammatory, neoplasia) li7. Current medication History gathering ['8. Asks open-ended question early in interview 118. Demonstrates active listening [20. Open to closed-ended questioning 21. Makes transition statements or signposts, [22. Does not use jargon! explains if used 23. Uses summaries + accurate [24. Appropriate closure - thanks and goodbye Examiner to prompt 25. A differential diagnosis - 2 to score (ulcerative or infective colifisigastroenteritis, inflammatory bowel isease, colorectal carcinoma) Examiner overall rating: Was the approach that expected of a professional? Good 19=|00-| 195|00.J 19|00-} 195|00—| 19<|00—| 104 00—| 10) 00—| 10) 00—| 10<|00_| 10)00—| 10—00—| 10=|00—] 10=|00-| 19..|00-|History: Diarrhoea (etd) Station 5 Centre &Centre Circuit &Circuit Session &Session ctd Candidate Name ‘&CandName Candidate No. &CandNo Pass [i Borderline Pass Borderline Fail Fall Examiner overall rating: Overall ability of the candidate to gather the history. Good Pass Borderline pass Borderline fall Fail ‘Simulated patient rating: Overall ability of candidate to question without interrogating. Good Pass Borderline Pass Borderline Fail FailStation History - Collapse Station { 10 Gente —&Centre Circuit &Circuit Session Candidate Name — &CandName Candidate Examiner instructions: Please assess the candidate on each of the following criteria. Please note the prompt for a differential diagnosis (item 15). In the am circuits this will be a seizure and in the pm circuits it will be a faint, &Session No. &Cane What sihe is going to do (all required to score) [Appropriate introduction fo patient, giving own name, greeting, role and patient's name and explains Establishes W any witness y Explores if@ seizure - incontinence, tongue biting: both fo score Va Explores if a seizure - abnormal movements Sey They 1, Explores W eyncopal episode - warning —[ a. 1 L — 1 y Explores if syncopal episode —no injury f » Explores ia seizure aura, injury Both to score 77 5 Condition after episode joo Voor Vaud pail 3 Enquires about previous episodes [fo Past medical History diabetes, enlepey oscars) 7T 1S (Gone [MI [ft Medication Tce Abn Valite S 12 Alcohol ae 3 Recreational drugs [14 Social history NRG arya Wo lis EXAMINER PROMPT: differential - AM seizure more likely than Syncopal episode; PM the ‘opposite He — ideniifies patients ideas about whal has happened | [(@__Mekes empathic statements 8 — Confirms action plan Examiner Global Rating: candidate's competency at eliciting a medical history ‘Simulated Patient Global Rating: overall ability of candidate to communicate Good Borderline Fail Good Pass Borderfine Fail 10 Jo0>] on sooo toxdooe] 10Joo| 1900] 19 00-| 19,o0=| 10-00} 10-004] 104004} ee] 10] 00=| 10520] BS 05) BES 20>) BH] 105) BE] 0—| S| 305) Bo|204 ES] =|Station Blood Pressure measurement Station [ 5 Centre Centre Circuit &Circuit Session Session CandidateName — &CandName Candidate No. &Canc Examiner instructions: Please assess the candidate on each of the following criteria and note examiner prompt (item '2). Please check each patient's blood pressure and use the double-headed stethoscope to check the candidates’ readings. what sihe is going to do (all required to score) [' Appropriate introduction fo patient, giving own name, greeting, role and patents name and expla EXAMINER PROMPT: Ask the candidate how they would choose the correct cuff sae- 8 Puts cuff on correcily - neally with correct postion of tubes Correct position of arm (antecubital fossa in ine with heart and arm slightly Rexed) Feels the brachial or radial pulse Checks the approximate systolic pressure by palpation or auscultation [7 __ inflates the cuff (within reason) to above the sysiolic pressure. P___Cowers the column of mercury at an appropriate speed Tess than Smim/sec Gels the correct systolic BP (within 6mm of examiners reading) 0_Gets the correct diastolic BP (within 6mm of examiners reading) [11 Gives the result to the examiner, Interpreting findings correctly [12 General approach to the patient - courteous, good rapport and eye conlacl [13 ASK patient if the candidate caused discomfor! Examiner Global Rating: overall ability of the candidate to take a blood pressure Borderline 10>] 10. 10 10. oo} oo 10] 19] 10) sofas] ou: O04 0.04 on: 404 30] 20-]Station Examination of the abdomen Station Centre &Centre Circuit &Circuit Session ‘BSession CandidateName — &CandName Candidate No. &Canc Examiner instructions: Please assess the candidate on each of the following criteria. This examination should be gentle and not protracted, a because the patient is in pain. If necessary, please prompt the students Be to have completed questions 15-17 before the bell. = ‘Appropriate introduction to patient, giving own name, greeting, role and patient's name and explains | [7.0—]o0<) what sihe is going to do (all required to score) 2 Confirms with patient the locality of the pain Confirms with patient the severity of the pain ‘Observes and describes general appearance ofthe abdomen e Examines abdomen with palient correclly positioned F Establishes maximal tendemess in RIF/LIF E ‘Comments on voluntary or involuntary guarding Briefly examines the Iver Briefly examines for splenic enlargement [10 Briefly examines for left Kidney [1 Briefly examines for right Kidney [72 Listens for bowel sounds 1 Walches patient's face and noljces discomfort when shown 4 Suggests rectal examination Examiner prompt items 15 - 17 if candidate does not offer answer [if Presents findings correctly Presents findings logically 6 Oifers an appropricte differential diagnosis (am: appendicits; pm: divertculfisy 8 Leaves the patient comfortable “ [7S General approach to patient (aware that the patient is in pain and responds to this). Examiner Global Rating: overall ability of candidate to examine a patient In pain Good |g Pass Borderline Feit‘Simulated Patient Script Examination - Abdomen Candidate instructions: This patient complains of pain in the abdomen. Please examine the patient’s abdomen, Summary: ‘The candidate needs to cary out a physical examination of your abdomen in § minutes. Background You have come to Casualty with pain in the abdomen that has been worsening over the past 12 hours, Personality The pain distresses you. You should appear tense even when not being examined and when Moving about. Medical Presentation Indicate tendemess with facial gtimaces when the candidate presses, ‘especially more deeply: in the morning you are tender on the right lower abdomen in the afternoon you are tender on the left lower abdomen ‘Show more grimacing if the candidate taps your abdomen or Presses and then feleases the pressure rapidly in the above area Decline to answer any other questions ~Say: ‘I've told the other doctor’ Between candidates, please sit up and rearrange clothing. Candidates will be marked for positioning you correctlyStation Centre Candidate Name Examiner instructions: Please assess the candidate on éach of the following criteria. &Cente Respiratory system uit &CandName Circuit Station | 19 Session Session Candidate No. &Canc [Appropriate introduction to patient, giving own name, greeting, role and patient's name and explains what sihe is going to do (all required to score) 2 Examination of hands - dubbing, nicotine stains, anaemia, peripheral cyanosis (2 to score) [i Comments on central cyanosis presence/absence fi __ Examines Iymph nodes: cervical, supraclavicular Inspection of chest (for scars, deformity, abnormal veins: 1 fo Score) [P__ Tests chest expansion anteriory with correct use of hands @_Techea- checks positon of rachea 8 Checks position of apex beat Percussion: Comect technique - position of fingers and sound elicited 10 Percussion: Correct areas - side-to-side, anterior, laleral and axlias Hi Percussion: Correct areas ~ side-to-side, posterior H2 Tests vocal fremitus - tactile or auditory [13 Auscuitation: Correct technique and effective instructions to patient (14 Auscultation: Correct areas - side-to-side, anterior, lateral and axllae is Auscultation: Correct arees - posterior [16 Treats patient courteously and maintains dignity i? Performs examination in a fluent and professional manner Examiner Global Rating: overall ability of the candidate to examine the respiratory systemClinical Skills - Cardiovascular System Station 17 Centre Centre Circuit &Circuit Session &Session Candidate Name &CandName Candidate No. &CandNo Candidate instructions: see sheet. Examiner: Please rate the candidate on each of the following criteria. fi. Appropriate introduction and explains what sihe is going to do i2. Inspection for general appearance (cyanosis, anaemia, arcus - any 2 to score) 1.05) 0.0] inspection for clubbingleplinters 10|00— ff, Examination of pulse at appropriate site for rate 5. Comments on rhythm of pulse 10] 00-3} 10) 00—| 6 Comments on character/quality of carotid/brachiel pulse 1.0) 00.—| [7. Examination of JVP at 45 degrees with head support Inspection of chest - comments looking for scars, deformities, abnormal veins, respiratory rate, respiratory distress - score for any 2. Paipation for apex beat H10. Auscultation in all four cardiac areas H1-Times cardiac cycle against pulse 412, Auscultation over apex beat with bell for MS on left side [13. Examination for AR with diaphragm and patient bending forward Hi4. Auscultation of tung bases 1. States intention to examine peripheral pulses [16. States intention to examine for dependent oedema [17. Orderly manner and progression throughout examination [18. Attends to patient's dignity and privacy throughout examination Examiner overall rating: Candidate's ability to examine the cardiovascular system Good Pass | Borderline Pass“Station Breast Examination Station Centre &Centre Circuit &Circuit Session &Session CandidateName — &CandName Candidate No. &Canc Examiner instructions: Please assess the candidate on each of the following criteria: [' Appropriate introduction to patient, giving own name, greeting, role and patient's name and explains ‘what sfhe is going to do (all required to score) 2 Asks patient about presence oflumps [5 Asks patient about nipple discharge 7 Asks patient about paindiscomfort 5 Inspects breast and comments on shape Inspects breast and comments on nipple |7___ Inspects breast and comments on shape with arms above head — gps vcues fecrseac ) Tnepecis breast and comments on hippie wih arms above head Raccue?¥ TEA ARE 9 __ Palpation of left breast (one plane) 0 Palpation of felt breast (bimanual) |11_Palpation of right breast (one plane) }i2 Palpation of right breast (Gimanval) 173 Palpation of right exila (all sections) lid Palpation of left axita (allS sections) [15 Palpation of supraclavicular fossae [16 Palpation of infradavicular fossa 7 Performed examination fuenty & EXAMINER PROWPT: Please demonstrate how you examine for fixiy to deep stuckres. (Tensing of pectoral muscles). (18 EXAMINER PROMPT: What other structures would you examine f you had found a lump? (Liver). @ Giraisiner Giotal Rating: Was the overall approach to the patient that ‘expected of a professional?