Medical simulation scenario

Duration (time allotted to this station): - 20 minutes

The end result (outcomes) that is evaluated:

 Conducting a psychiatric interview, collecting a subjective medical history and physical
examination of a patient with depression.
 Clinical diagnosis of aggressive syndrome in the emergency room.
 Interpretation of objective signs of aggression.
 Describe aggressive behavior.
 Determination of indications for hospitalization in an acute psychiatric ward.

Situational task: You are an emergency room doctor on duty at a multi-specialty hospital. A
48-year-old man was taken to the emergency room by a specialized ambulance team, which was
called by his wife. Externally, he looks excited, talks a lot, his facial expressions are active, he
can't sit still, and periodically grabs his right side. Objectively: The face is hyperemic,
hyperhidrosis, signs of dry mouth, tremor of the fingers, tongue, eyelids, sclera shine, state of
excitement. Gross blunders when performing a finger test, I asked to remove the "ropes" from
my hands. Blood pressure 160/120mm Hg. The pounding symptom is sharply positive on the
right.

Time – 23.00.
 Perform anexamination of patient.
 Analyze the psychiatric interview, subjective medical history, and mental neurological
and somatic status of the patient.
 Formulate a diagnosis.
 Complete the necessary treatment measures at the admissions office stage
 Determine the management strategy and treatment plan.

Script text for a standardized actor (patient) and a description of their role:
In the emergency room of a multi-specialty hospital.
From the data of the outpatient observation card, it is known that he has been systematically
drinking alcohol for more than 20 years, has become irritable, aggressive, and has binge drinking
lasting up to 10 days or more. Previously, there were similar conditions after a forced break in
binge drinking. There was a case of attacking his wife with accusations of infidelity, following
her, suddenly showing up at work with unfounded accusations of infidelity.
For two days, he couldn't find alcohol (he was on a binge) – everyone refused to give him a
"loan", his wife left home. On the second day, the neighbors called his wife, as the sounds of
falling objects and her husband's screams could be heard from the apartment. When he saw his
wife, he rushed at her and shouted, " My death has come, I'm going to kill you myself." The
spouse called the police, who, after familiarizing themselves with the situation, called an
ambulance, which was taken to a multi-specialty hospital.
Delivered to the emergency room with soft fixation in the area of the hands. From the
moment he appears in the emergency room, the man shouts, threatens to "throw everyone out",
suddenly hits the table with his hands, takes a threatening pose in front of the doctor, demands to
immediately "let me go home", shouts insulting words to the medical staff of the emergency
room. Looks at the faces of others, thinks about something, then kicks the chair in the direction
of the paramedic with shouts - " you brought me here!". Expresses remarks in the direction of the
doctor – "what do you know about life, you sit here writing, let me go home, I'm healthy, I'm not
an alcoholic."
To the doctor's question "Where it hurts, what bothers" - points to the right side and answers
sharply, rudely.
 Objectively: Visible areas of the skin, the surface of the head without visible damage. The
face is hyperemic, hyperhidrosis, signs of dry mouth, tremor of the fingers, tongue, eyelids,
sclera shine, state of excitement. Gross blunders when performing a finger test, I asked to
remove the "ropes" from my hands.
After a conversation with a senior doctor, he agreed to take a blood pressure measurement,
asked for water, complains of heaviness in the head and palpitation, anxiety, irritability. AD –
160 /120mmHg After a conversation with the senior doctor of the emergency room, his
aggression noticeably decreased, and he spoke a little about his state of health. He promised not
to show aggression. He agreed to be hospitalized. He agreed with the treatment.

Questions your doctor may ask you and your answers

The essence of the question Answer
Clarification of the onset of The pain began suddenly in the evening
the disease
Identification of symptoms Excited mood, active motor reactions, talkativeness - with
of aggression rude phrases, threats. Everything is annoying and
infuriating.
Loud speech or shouting
Swearing / verbal insults
Excessive sensitivity to what is being said
Aggressive posture, unwillingness to sit down.
Walking / threatening to leave
Pacing up and down
Raising the pitch of your voice
Shaking/clenching your fists
Changing eye contact (for example, suddenly looking
down)
Frowning
Identifying symptoms that Was a case of assaulting his wife with accusations of
indicate aggressive behavior infidelity, following her, suddenly showing up at work with
unfounded accusations of infidelity.
For two days, he couldn't find alcohol (he was on a binge)
– everyone refused to give him a "loan", his wife left home.
On the second day, the neighbors called his wife, as the
sounds of falling objects and her husband's screams could
be heard from the apartment. When he saw his wife, he
rushed at her and shouted, " My death has come, I'm going
to kill you myself."
Additional complaints Everything around is annoying

In the anamnesis: Heredity is not burdened with mental illnesses. Often uses alcohol for the last
20 years, there were episodes of binge drinking up to 10 days. Secondary education – locksmith,
currently unemployed. Previously, there was a history of urolithiasis. He considers himself
healthy. He is married and has 1 child.

Objectively: answers questions in short sentences, with dissatisfaction, and is rude. The voice is
raised. The face is hyperemic, hyperhidrosis, signs of dry mouth, tremor of the fingers, tongue,
eyelids, sclera shine, state of excitement. T° -37.0. Heart tones are muted. AD 160/120. Gross
blunders when performing a finger test, I asked to remove the "ropes" from my hands.
Mental status-looks aggressive.
 Provided by the examiner after the appointment of this survey by the examinee
Assessment sheet for the examiner
for the clinical task: "Aggressive patient"
Full name of the examinee: _________________________________________________
Group: ____________________Specialty: __________________________
Full name of the examiner__________________________________________________

How to deal with an aggressive patientом - checklist

Opening the 1 Wash your hands and wear PPE if necessary 1

consultation Introduce yourself to the patient, including your name and role
1
Confirm the patient's name and date of birth
2 Explain the reason for the consultation 1
3 Get consent to continue the consultation
Conditions 4 Conduct the consultation in a comfortable, quiet and private place (if 1
possible)
Prepare the room accordingly (for example, avoid physical barriers
between you and the patient)
Suggest the presence of another person (a healthcare professional or
family member) with the patient's consent.
Recognize that 5 It is important to identify that the person you are talking to is angry. 1
the patient is 6 Once the emotion is identified, start responding accordingly, showing 1
angry empathy, reassurance, or apologies, depending on how the patient feels
and what events have occurred. The earliest possible detection of
aggression helps to prevent the patient from aggravating emotions.
Change your 7 Adjust the tone, speed, and volume of your voice. 1
communication Try to maintain a calm tone and composure (this can be difficult when
style when the you are being yelled at). Speak those words slowly and clearly. Do not
patient is angry raise your voice if the patient screams.
8 Adopt a professional but relaxed pose. For example, if you are sitting, 1
you can cross your arms and legs with both feet flat on the floor.
Sit back in your chair to avoid confrontation.
Acknowledge 9 Provide information in large "chunks", using simple and clear language 1
the patient's to explain medical concepts.
anger Use pauses and allow the patient to understand what you have said
after each "fragment".
10 Answer any questions properly, without giving false hopes or 1
inaccurate information.
Avoid using medical jargon or euphemisms
Try to 11 Ask open-ended questions to determine the reason why the patient is ill 1
understand why Listen to the explanation of why he is angry
the patientthe 12 Demonstrate active listening skills, such as eye contact, nods, verbal 1
patientandis ill responses
If necessary, let the patient fully splash out on you – they may need to
remove some things from their chest. Give them enough space to
perform. Don't interrupt the patient
Respond to 13 Emotions and Empathy 1
Anger Demonstrate empathy for the patient
 You can use the following empathic phrases:
"Given everything you've told me, it's understandable that you feel that
way", "It looks like you have a lot to do right now, and it's only natural
that you're angry"
When you show empathy, it can help patients feel that they are being
cared for and listened to. This helps build rapport between you and the
patient, potentially dispelling their anger and creating a safe
environment in which the patient can speak openly.
14 When making an apology if an error has occurred, acknowledge the 1
severity of the mistake. However, if you are not at fault, be careful
with apologies, try not to take responsibility
15 Thank patient. Sometimes it is appropriate to thank the patient (for 1
example: "Thank you for sharing your feelings with me, it is important
that I understand how you feel so that we can work together to help
you").
16 Encourage questions/solutions. 1
You can ask the patient if there is anything you can do for them. This
shows once again that you care enough about the situation and want to
help fix it. Sometimes, when people are angry, they find it difficult to
come up with a solution, and so they may welcome your attempt to
suggest such a solution.
Strategy and 17 End the consultation by thanking patient for her time. 1
Summary 18 Summarize and verify the patient's understanding 1
19 Clarify any misunderstandings or misunderstandings (if required) 1
Completion and 20 Take stock 1
definition
Key Glob Active Listening A
communication alAu Empathy (verbal and non-verbal) B
skills dien Establishing mutual C
ce* understanding Summing D
up key points E
* - Overall rating. Points can be reduced or added depending on
The maximum score for each stage is 20 points

The time allocated for the task is 15-20 minutes

References:

1. "On amendments to Orders of the Minister of Health and Social Development of the Republic of
Kazakhstan No. 44 dated January 30, 2015 "On Approval of the Rules for conducting medical and social
expertise" and No. 983 dated December 21, 2015"On Approval of the forms of documents formed during
medical and social expertise". Order of the Minister of Labor and Social Protection of the Population of the
Republic of Kazakhstan dated September 22, 2022 No. 381.
2. Markova A. A., Barsukova M. I. TACTICS OF REPORTING BAD NEWS IN PROFESSIONAL
COMMUNICATION BETWEEN A DOCTOR AND A PATIENT. Archive of Internal Medicine. 2022;
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formation. Personality in a changing world: health, adaptation, development. 2016; 4(15): 66-71. doi:
10.23888/humJ2016466-71 Kazaeva A.V., Noskova M.V. The culture of delivering bad news in practical
health care: a concept of formation. Personality in a changing world: health, adaptation, development. 2016;
4(15): 66-71. doi: 10.23888/humJ2016466-71[In Russian].
4. Ercan G., Karlite pe A., Ozpolat B. Pancreatic cancer stem cells and therapeutic approaches.
Anticancer Research. 2017; 37 (6): 2761- 2775. doi: 10.21873/anticanres.11628
5. Barsukova M..I., Sheshneva I..V., Ramazanova A..Ya. Рискогенность общения . Riskogenicity of
doctor -patient communication пациента: a communicative aspect. The world of science, culture, and
education. 2019; 3(76): 486-487. Barsukova M.I., Sheshneva I.V., Ramazanova A.Ya. Risks of doctorpatient
communication: a communicative aspect. The world of science, culture and education. 2019; 3(76): 486-487
[In Russian].