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Patient medical records Name: Robert Learner (49 year old)

CANDIDATES BRIEF

Past medical history: Hypertension Drug history: Ramipril 5mg od Zopiclone 7.5mg prn (7 tablets)

Last consultation (6 weeks ago) Patient reports being quite stressed. Works as businessman for an international company and trying to close important deal. Also moving house. Requested for some sleeping tablets. Promises to take time off work to recuperate. Short course of zopiclone offered

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CSA course cases Chest pain

Background: You are Robert Learner a 49 year old businessman

ACTORS BRIEF

Approach: You are dressed professionally, politely spoken and well mannered Opening statement: Hi doctor. Thank you for seeing me but I am worried about this chest pain I have been suffering with.

History Open history: You have had this pain in your chest for the last 7 days You feel it in the middle of your chest Initially it was a niggling pain and now it is quite painful and got you worried enough to see the doctor It is not linked with meals and happens any time during the day Its now affecting your ability to focus at work and is getting worse CUE: You do not think it is down to stress as you have recently travelled to Spain 4 weeks ago on holiday which you enjoyed

Reveal history if asked: Ideas You are worried that it could be a pulmonary embolism as you spoke to your friend who was diagnosed with one. You typed your symptoms into the computer and had a fright as you read that people who travel on planes are at risk of pulmonary embolisms (blood clot in the lung) Concerns You are worried that you have only recently travelled to Spain 4 weeks ago by plane and think it could be related. The journey was for 3 hours and you were sitting in economy class. You also had some calf pain 2 weeks later Expectations You would like to know if the pain you re suffering is caused by a blood clot in your lung There is no shortness of breath or coughing up blood. It does not move anywhere The pain is sharp and worse when you breath in It varies in intensity and can come on any time. Typically last for 1 hour at a time You are not sure if it is related to movement Paracetamol has not helped the pain You have had some calf pain 2 weeks ago but you had been doing some gardening at the time

2 FOR TWO COURSE HALF DAY MINI-CSA EXAM WITH 8 CSA CASES EACH ROLE-PLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 500
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Individualised feedback from course facilitators & CSA actors on your performance If the doctor has been thorough in history taking admit that you have been doing several odd jobs around the house that you have always been promising the wife to do since you moved in. You had tried to put a small chandelier in the front room. You had been in the garden as well as trying to fix it up as it was left in a state

Medical history Hypertension you always take your medication as prescribed and eat a healthy low salt diet Nil else i.e. diabetes

Drug history Ramipril one tablet a day with good compliance You were on short course of sleeping tablets that you finished. They helped at the time and you have no recent sleep disturbances Nil else

Social history You smoke 3 cigarettes a day but plan to give up You work as a businessman selling electronic goods to retail shops. Recently you had a large order from Currys for your PCs which you secured You enjoy your work but not under any stress especially as you went abroad recently

Family history Dad died of heart attack aged 75 No family history of DVT or PEs If the doctor suspects it is a blood clot in the lung (PE), appear anxious and worried. Ask if you are going to die If the doctor reassures you it is musculoskeletal pain then enquire about the risk of your recent flight and calf pain you experienced You are happy to accept taking ibuprofen tablets only if the doctor gives you 100% reassurance that it is not a pulmonary embolism You enquire as to what you should do if you travel on a plane again to reduce your risk of a PE and whether you should be wearing special leg stockings in future on plane journeys

2 FOR TWO COURSE HALF DAY MINI-CSA EXAM WITH 8 CSA CASES EACH ROLE-PLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 500
Contact us: csaprep123@gmail.com visit us www.csaprep.co.uk CSA course cases chest pain - CSA prep 2011

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CSA course case Chest pain

DATA GATHERING Positive indicators:

EXAMINER

Gathers information and clarifies problem. A focussed history will ascertain probability of MSK pain than PE Elicits history of calf pain but linked to gardening Ascertain other risk factors of PE smoking history, immobility, FH of DVTs or PEs etc

Negative indicators: Fails to identify based on probabilities a likely diagnosis of MSK Fails to elicit risk factors for PE i.e. travel abroad and history calf pain

INTERPERSONAL SKILLS Positive indicators: Explores ICE (concern that symptoms are caused by PE due to recent travel abroad) Develops rapport with the patient

Negative indicators: Fails to reassure the patient regarding their symptoms

CLINICAL MANAGEMENT SKILLS: Positive indicators: Inform the patient of your working diagnosis and offer reassurance Advised to trial analgesia Offers advice regarding measure to reduce the risk of PEs when travelling i.e. Fluid intake on plane, exercises, avoid alcohol, compression stockings

Negative indicators: Falsely reassure patient of symptoms and increases anxiety by suggesting symptoms are a PE Fails to offer analgesia Fails to give advice re travelling and PEs

2 FOR TWO COURSE HALF DAY MINI-CSA EXAM WITH 8 CSA CASES EACH ROLE-PLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 500
Contact us: csaprep123@gmail.com visit us www.csaprep.co.uk CSA course cases chest pain - CSA prep 2011

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

Bookyourplaceonthecoursefor350
4 CSA Cases with 4 different CSA actors for less than 400

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CSA course case Chest pain

CARDS

Vitals BP Pulse BMI Sats 132 / 74 68 bpm 23 99%

Examination Cardiovascular and respiratory examination normal No calf pain or swelling noted

Examination if requested Chest wall tender to palpate on left 5th rib

2 FOR TWO COURSE HALF DAY MINI-CSA EXAM WITH 8 CSA CASES EACH ROLE-PLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 500
Contact us: csaprep123@gmail.com visit us www.csaprep.co.uk CSA course cases chest pain - CSA prep 2011

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

Bookyourplaceonthecoursefor350
4 CSA Cases with 4 different CSA actors for less than 400

Individualised feedback from course facilitators & CSA actors on your performance

CSA course case Chest pain

MX NOTES

Pulmonary Embolism Pulmonary embolus is a common problem and may affect a person of any age. The embolus occurs when the arteries supplying the lungs are blocked by a blood clot usually resulting from a deep vein thrombosis; but fat, air, and tumour tissue can be implicated as well. Symptoms include, sudden onset sharp stabbing chest pain, worsened by deep breathing and coughing. The patient may also have haemoptysis, tachycardia and shortness of breath at rest. Risk factors for pulmonary embolus include prolonged bed rest or immobility, oral contraceptive use, surgery, child birth, cancer, stroke, recent surgery and fractures of the hips or femur.

Facts about Venous Thromboembolism & flying

Evidence suggests increased risk of DVT with flights >4 hours duration Risk includes other long journeys such as coach journey, train or car i.e. immobility Patients with hip or knee replacement should not travel on long journey flights for up to 3months Patients with a plaster cast should not fly for up to 1-2 days (depending on length of journey) Compression stockings can reduce the risk of DVTs (recommended in moderate risk patients). LMWH should be reserved for high risk patients. No supportive evidence for aspirin If a patient notes that they have painful, swollen legs or short of breath post flight they should seek urgent medical attentions

Risk and Management of Venous Thromboembolism & flying

Based upon British Heart Foundation (Sept 2010)

Low risk

no PMH or risk factors Advice - Drink plenty of (non-alcohol) fluids. Avoid caffeine, sleeping tablets Keep mobile: if seated do stretches every 30 min. Press the ball of the foot against the foot rest to increase blood flow to leg. Have breaks and walk up and down aisle

Medium risk High risk

PMH DVT/PE, recent surgery, clotting disorders, pregnancy, or BMI>30 Advice Above including compression stockings (graduated class 2) PMH DVT + risk factors i.e. cancer, recent surgery Advice - Above including LMWH before the flight and on next day

2 FOR TWO COURSE HALF DAY MINI-CSA EXAM WITH 8 CSA CASES EACH ROLE-PLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 500
Contact us: csaprep123@gmail.com visit us www.csaprep.co.uk CSA course cases chest pain - CSA prep 2011