CASE NO.

PATIENT INSTRUCTIONS
Name of Patient:

Andrew Smith

Description of the patient & instructions to simulator:

You are a 42 year old male, who is usually fit and well. You have a
wife and small child at home, you work full time in an office.

For the last 5 days you have been feeling unwell with a runny
nose, sore throat and dry cough. If asked you have not had any
chest pain, not had any fevers, not coughed blood up, not
coughing any sputum up, no recent weight loss, no night sweats.

You had a similar problem about 4 years ago and was given
antibiotics for a ‘chest infection’, you think that you have the same
thing again and that this will make it get better quickly.

You are already annoyed and angry at the surgery due to a

telephone assessment earlier in the week telling you that you had
a cold and that nothing needs to be done. Having not been
properly assessed you feel fobbed off and angry that no-one saw
you, if this isn’t acknowledged by the doctor then your rapport
with them will be limited.

You are particularly concerned about a wedding at the weekend,

you are the best man and don’t want to look like an idiot coughing
and spluttering everywhere. You feel that a course of antibiotic is
the only treatment that could possibly work and unless explained
to properly that you have a viral illness and that antibiotics will be
ineffective you will be argumentative if they are denied
DOCTOR’S (GP ST) INSTRUCTIONS

patient Andrew Smith 42 years old with complaint ,

take history ,relevant examination and make a management plan
CSA EXAMINATION CARD

Examination findings:

HR 75, BP 132/68, RR 16, SpO2 98%, T 36.8

Chest – clear, normal percussion note, equal air entry

Heart sounds normal

Throat and ears – normal

No cervical lymphadenopathy
CSA Case Marking Sheet

Case Name: Smith – Angry, Case Title: Angry viral illness

antibiotics
Context of case
 42 yr old, wanting abx for
viral symptoms, gets
angry if denied and
doesn’t understand
Assessment Domain:
1. Data-gathering, technical and assessment skills
Positive descriptors: Negative descriptors:
 ICE and Psycho-social  Doesn’t exclude red flags
impact explored  Doesn’t acknowledge
 Excludes red flags, consultation earlier in
appropriate focused week
questions  Doesn’t examine
 Acknowledges and
discusses frustration of
tele triage
 Examines appropriately
Assessment Domain:
2. Clinical Management Skills
Positive descriptors: Negative descriptors:
 Doesn’t prescribe antbx  Give antibiotics
 Clear explanation of  Fails to explain viral illness
illness and reasons for not  Fails to safety net/offer
prescribing antbx follow up
 Suggests OTC remedies or
prescription of cough
suppressants
 Clear safety net, offers
early follow up
Assessment Domain:
3. Interpersonal skills
Positive descriptors: Negative descriptors:
 Allows ventilation.  Doesn’t elicit ICE
 Listens to concerns and  Doesn’t establish rapport
shows empathy of  Doesn’t listen or show
situation empathy or understanding
 Explores social worries and  Uses complex medical
looks to offer solutions language
 Builds and maintains
rapport

Other aspects e.g. time keeping,

consultation structure, comment
on consultation skills etc Negative descriptors:
Positive descriptors:





Grading: Clear pass = 3, Marginal Pass = 2, Marginal Fail = 1,

Clear Fail = 0
Case no.2

Information given to candidates

Steven Pinner is a 54-year-old electrician for consultation .

Take focused hx ,relevant examination and make a management

plan .

Information given to simulated patient

Basic details – You are Steven Pinner, a Caucasian 54-year-old
male electrician. Appearance and behaviour – You have a packet of
cigarettes in the breast pocket of your shirt.

First words spoken to doctor – ‘The hospital said that I should

come and see you about what happened

history

Freely divulged to doctor –Your breathing has been getting worse

over the last 3 months. Your partner said that she could hear you
wheezing when you arrived back from the corner shop. You know
that this is probably because you have started smoking again. You
went to the emergency department 5 days ago as you were
finding it difficult to get your breath when you woke up one
morning. They gave you oxygen and some medication through a
mask. Your symptoms improved so you were sent home with a
supply of steroid tablets (8 daily for 5 days).

Divulged to doctor if specifically asked –You did not make a

conscious decision to start smoking again but just ‘fell into it’
when you moved in with your partner 3 months ago
and this ‘set off’ your asthma. You were waking with a cough two
or three times a night and you felt short of breath and wheezy
climbing a flight of stairs. You have not coughed up any blood or
phlegm, but your chest felt tight when the breathing was bad. You
felt much better after having the treatment in hospital. Your
breathing has been good since you were discharged and you went
back to work 2 days after attending the hospital without any
problems. You have cut down to about 10 cigarettes a day since
leaving hospital. You meant to respond to the asthma nurse review
letters but find it difficult to get time off work to attend
appointments. You cannot remember the last time you had your
peak flow checked or what it was. Twenty years ago a family friend
who smoked heavily died of lung cancer and when you heard this
you decided to quit smoking, which you did the same day without
any help.
Ideas, concerns and expectations –

You were frightened by the asthma attack last week

as nothing like that has ever happened before. You were taking the
steroid tablets given to you by the hospital at night but you felt
they disturbed your sleep so you stopped taking them after 3 days
(you had been told to take eight tablets each day for 5 days).

You want to stop smoking but feel you need help with this,
especially as your partner smokes but does not want to stop, and
this is causing arguments at home. Since you started smoking
again you have been thinking about the family friend who died of
lung cancer and how you might go the same way if you don’t quit.
You did try to make an appointment to see the practice nurse who
runs the smoking cessation clinic but you could not get through on
the telephone.

You are hoping that the doctor today will be able to give you some
help with stopping smoking; you have heard about nicotine
patches and gum. .’

Medical history –You had keyhole surgery on your left knee 12

years ago to remove damaged cartilage after you slipped and
fell.You have had antibiotics from the GP for chest infections on a
couple of occasions over the last 5 years. Otherwise you are
normally fit and well.

Drug history – You have two inhalers: a blue salbutamol inhaler

and a brown beclomethasone inhaler. You rarely used either of
them until 3 months ago.Then you
had been using them up to eight times a day each, but you don’t
really understand the difference between the two.You are not
allergic to any medication.You have used the blue and brown
inhalers only twice each since leaving hospital.

Social history –You are divorced from the mother of your two sons
and had been living on your own for 5 years until you moved into
your female partner’s terraced house 3 months ago.You have been
in the same job for more than10 years.You drink 5 or 6 pints of
beer over the weekend at the pub with friends.

Family history – You have two adult sons. Neither has asthma but
one has eczema.

Review your approach to this station:

Tested at this station:

1. Understanding a patient’s illness experience.

2. Data gathering and examination.

3. Chronic disease management.

4. Smoking cessation advice.

5. Reaching a shared management plan.

Domain 1 – Interpersonal skills

understanding a patient’s illness experience

The patient has had a recent scare with the deterioration of his
breathing and an asthma attack. How you elicit the patient’s story
and address his fears and concerns are key skills:

 ●● Start with open questions to allow his story to unfold.

 ●● How does he feel after the hospital visit? What was it like
being rushed to

hospital? Has it affected how he views his asthma?

 ●● What are his thoughts about having starting smoking

again? Does he have any

worries about this, e.g. concerns about lung cancer?

 ●● Have recent events impacted on his work or home life,

e.g. arguing with his

partner?

 ●● What does the patient want from the appointment today?

What is his agenda?
 ●● Are there any specific questions he wants answered, e.g.
concerns about steroid

use?

Domain 2 – Data gathering, technical and

assessment skills

Data gathering and examination

Although the consultation needs to be patient-centred, you

will have your own agenda too, with specific questions about
the history and examination to cover before you feel happy
to come to a shared management plan:
 ●● Elicit the history building up to his attendance at hospital.
How was he sleeping? Was he wheezy or short of breath? Any
chest pain? Was he bringing up phlegm?
 ●● Explore why his asthma has deteriorated over the last few
months. Find out about triggers, e.g. smoking, recent chest
infections, moving house, new job, pets, new drugs or over-
the-counter medications (aspirin, non-steroidal anti-
inflammatory drugs [NSAIDs] and β-blockers can all make
asthma worse).

 ●● A good screening question if you suspect that his

symptoms are related to his occupation is: ‘Do your
symptoms improve when you are not at work or are on
holiday?’

 ●● Any red flag signs, e.g. weight loss or haemoptysis?

 ●● Given the patient’s age, history of smoking and chest

tightness, it may be worth

quickly asking some cardiac screening questions.

 ●● How have things been since leaving hospital? Has he

been using his inhalers and has he taken the tablets
prescribed?
 ●● Checking his peak flow could give both you and the
patient further reassurance and help establish a baseline
reading.

 ●● If his symptoms have resolved and you are happy with his
peak flow, further examination is probably not required.

Domain 3 – Clinical management skills

Chronic disease management

This station will test key clinical skills in working in

partnership with patients to improve their chronic disease
management:
 ●● Assess the patient’s understanding of his condition.
 ●● What are his thoughts about managing his condition?

 ●● What is important to him about his asthma – e.g.

symptom management?

 ●● Does he understand how his inhalers work? What is his

inhaler technique like?

 ●● Does he ever use a peak flow meter to monitor his

asthma? Can he use one

correctly?

 ●● Are there any barriers to prevent him from coming to

regular asthma review

appointments?

 ●● Does he understand what to do if his symptoms worsen?

 ●● You could motivate the patient in self-management by
empowering him to

adjust his medication as appropriate.

 ●● Providing details of self-help support groups and national

organizations – e.g.

Asthma UK www.asthma.org.uk – would allow him to access

peer support and

advice.

 ●● You could offer to provide written material to reiterate the

points above – e.g.

a personalized, written asthma action plan – or use diagrams

or models to aid explanations. Check what is in front of you
on the desk at this station.

Smoking cessation advice

 Smoking cessation advice is a proven cost-effective
intervention in primary care, and is all the more important for
those with chronic respiratory conditions:

 ●● Where is the patient on the ‘cycle of change’? In this case

he has relapsed but is contemplating trying to stop again.
 ●● Be extremely positive about any comments he makes
about wanting to quit.

 ●● Explore his reasons for stopping smoking previously and

emphasize the benefits

for his health – use the example of the recent asthma attack
to reinforce this

point.

 ●● Did he find anything useful last time that helped him stop
smoking? His

concerns about lung cancer acted as a powerful motivator

previously.

 ●● Does he know about the help available now, e.g. nicotine

replacement therapy,

oral pharmacotherapy and external smoking cessation

programmes or nurse-run

practice smoking cessation clinics?

 ●● You could reassure him that many people relapse but can
still quit again and stay

a non-smoker.

reaching a shared management plan (overlap with domain 1)

The key here is to come to an acceptable management plan that

suits this patient’s particular life circumstances:
  ●● Try to incorporate the patient’s health beliefs into the
management plan, e.g. ‘Yes, you’re right that smoking is
making your asthma worse – trying to stop would be the best
thing you could do for your health’.
 ●● Present options that are both realistic and fit with the
patient’s agenda and priorities. Discussing his thoughts about
the way forward is essential. Options might include:
●●Referral to the smoking cessation clinic.

●●Agreeing to review whether to step up or step down his

medication after he has attempted to stop smoking (see
Knowledge base below).

●●Prescribing a peak flow meter with diary card to allow self-

monitoring. ●●Reassurance that nothing suggests a sinister
cause of his recent deterioration, e.g. lung cancer. You could
offer to let him know when you receive the results

of the formal chest x-ray report.

●●Reassurance that steroid tablets for short-term use are
safe but best taken in

the morning to avoid insomnia.

●●Referral to the nurse for spirometry to assess whether
there is any component

of chronic obstructive pulmonary disease (COPD) to his

condition. ●●Providing information on what to do if his
symptoms worsen. ●●Regular follow-up at the nurse-led
asthma clinic.

take-home messages

 It is important to discover and address the patient’s health

beliefs and behaviours.
 In chronic health conditions such as asthma, patient
education, motivation and encouraging self-management are
key.
  Safety-netting and appropriate follow-up are essential when
dealing with potentially life-threatening conditions.

Tasks

 ●● Re-run the scenario with the patient having recently

started work in a bakery alongside the smoking issue.
Consider what aspects in the history would point to a
diagnosis of occupational asthma.
 ●● Re-run the scenario with the patient attending with an
acute exacerbation
of asthma using the discharge information regarding PEFR,
etc. as your examination findings. (See annex 2 in BTS/SIGN
guideline.) How would you manage the patient in your
surgery?

 ●● Re-run the scenario with the patient having been

successful with smoking cessation and wondering whether
the time is right to step down the medication.

Summary of stepwise management in adults

Patients should start treatment at the step most appropriate to the

initial severity of their asthma. Check concordance and reconsider
diagnosis if response to treatment is unexpectedly poor

Inhaled short-acting β2 agonist as required

good response to
LABA – continue LABA benefit from LABA but control still
inadequate – continue LABA and increase inhaled steroid dose to
800 mcg/day* (if not already on this dose) no response to LABA
– stop LABA and increase inhaled steroid to 800 mcg/day. * If
control still inadequate, institute trial of other therapies, leuko-
triene receptor antagonist or SR theophylline

Refer patient for specialist care

STEP 1
Regular preventer therapy

Mild intermittent asthma

* BDP or equivalent

Add inhaled steroid 200–800 mcg/day* 400 μg is an appropriate

starting dose for many patients

2. Assess control of asthma:

addition of a fourth drug e.g leukotriene receptor antagonist, SR

theo- phylline, 2 agonist tablet

Consider other treatement to minimize the use of steroid tablets

Start at dose of inhaled steroid appropriate to severity of disease

STEP 2

Initial add-on therapy

SYMPTOMS

vs TREATMENT

1. Add inhaled long-acting β2 agonist (LABA)

increasing inhaled steroid up to 2000 μg/day*

Maintain high dose inhaled steroid at 2000 mcg/day*

STEP 3

Persistent poor control

Consider trials of:

in lowest dose providing adequate control

STEP 4
Continuous or frequent use of oral steroids

1-minute explanations for patients

●● Explain the pathophysiology of asthma and the mode of action

of the reliever and preventer medication.

 ●● Educate a patient on the correct way to use a metered

dose inhaler.
 ●● Explain the mode of action and dosing regimen of
Varenicline (Champix®).

Ideas for further revision

In the Clinical Skills Assessment (CSA) there will be a balance

of acute and chronic presentations. This station is an example
of an acute exacerbation of a chronic condition. Chronic
disease management is a key skill expected of GPs, so you
should ensure that you feel confident with the management
of common chronic conditions seen in primary care, such as
diabetes, COPD, asthma and osteoarthritis.
Case no.3

32 McCarthy Road came to see you regarding four yours son .

Take hx , and make mx plan ,examination not required

Patient history

You are Jonathan Adams Senior, an eloquent man insistent on an

URGENT referral for your son, Jonathan Adams Junior to a
respiratory consultant. You have been in with your son twice with
similar complaints and your wife has brought him in on one other
occasion as well. You will not be happy unless a referral is made
today. You can be quite pushy and arrogant to achieve this if need
be. You may consider other options, only if you feel like your
concerns have been addressed appropriately by the doctor.

Opening statement

Hello Doctor. I am here to get my son referred to a respiratory

consultant today. This wheezing and coughing has been going on
long enough and I want to get to the bottom of this. This has gone
on long enough with no real diagnosis. I didn’t want to take him
out of school again so I’m here to sort out this referral.

Openly revealed

Your son has been complaining of wheezing on and off over the
last year. He has been previously healthy and a number of visits to
the practice have not resulted in any progress (in your opinion). He
has been seen by a number of different doctors and you feel this
has hampered his diagnosis. He does not get any symptoms with
exercise and participates fully in all school activities and plays
football regularly. You think he has asthma and want a referral to a
specialist to confirm this. You do not have much faith in the
doctors at this surgery as an adequate explanation of his
symptoms has not been provided.

Only revealed on questioning

His symptoms of wheeze only present when he gets a cough or a
cold. He is symptom free in between episodes. He does not
complain of a nocturnal cough or wheezing/cough when he
exercises/when emotional. He does not bring up any sputum or
blood with his cough. There is no personal or family history of
asthma/eczema or hay fever. He does not have any allergies nor
any pets. He has not been abroad on holiday over the last year. He
had a trial with a blue inhaler twice last year with no relief of his
symptoms. He is not losing weight and has a good appetite. He is
doing well at school and his teachers have no concerns. He does
not smoke and there are no smokers at home either. He has not
started any new medications. He is fully up to date with all his
immunizations.

ICE

You are convinced your son has asthma although you know little
about the condition. One of your colleagues children had a serious
asthma attack and was ventilated as a result. You are worried
this may happen to your son but only disclose this if the
doctor is kind and understanding and you feel comfortable
enough to discuss this with them. You feel that your concerns
about your son have not been taken seriously by any of the
doctors who have seen him. There have been occasions when your
son hasn’t even been examined by a GP and you have been told
he has a simple cold. You cannot understand how a doctor can
make this diagnosis without examining your son’s lungs. You don’t
really understand what his recent test results meant although the
nurse said it was normal and nothing to worry about. You would
like an expert opinion to convince you that all is well with your
son.

You expect the doctor to refer your son urgently and will
get quite upset if they refuse. If the doctor listens
appropriately, you may agree to bringing your son back after
school for a more detailed examination with the same doctor later
on that day.
PMH

Nil of note.

DH

NKDA

No regular medication.

SH

Lives at home with his younger sister

Fully upto date with immunisation schedule.

FH

Nil significant.

No history of any lung conditions in the family.

Examination
Your son is currently at school so cannot be examined in the
current consultation.
Data gathering

1. Takes a detailed history, including factors that make asthma

less likely as a diagnosis: symptoms only with URTIs, tingling
in peripheries, no history or family history of atopy, isolated
cough in absence of wheeze, moist cough, repeated normal
spirometry or physical examination of chest when
symptomatic. Also includes triggers of symptoms.
2. Elicits what the father means by ‘wheeze’ and whether is it
compliant with the medical definition of wheeze.

3. Determines the presence of any red flags such as weight loss,

anorexia and hemoptysis.

4. Explores the fathers understanding of asthma and why he is

so sure of the diagnosis.

Clinical management

1. Makes a working diagnosis of viral associated wheeze.

2. Explains the diagnosis to the patient’s father in an
appropriate manner.

3. Addresses the father’s concerns about his son not being

examined adequately and attempts to calm him down.

4. Attempts to reach a shared management plan with the father.

5. Offers options which may include examining the child when

he’s not at school, making a follow up appointment to allow
continuity of care, discussing the issues at a practice meeting
and informing the father of the result.

6. It may also be reasonable to refer this patient to a respiratory

consultant if the father is insistent, although a careful
explanation and adequate follow up arrangement may enable
 this to be deferred for additional discussion at a follow up
appointment.

7. Offer written material/websites that the patient could refer to

such as patient.co.uk and explain why the diagnosis is highly
unlikely to be asthma.

Interpersonal skills

1. Acknowledges the father’s concerns and apologises as

appropriate for the lack of care as perceived by the patient.
2. Identifies the father’s underlying fear of his son being
ventilated and discusses the reasons behind this sensitively.
Case no.4

57 yrs old Tina Hathaway came fort consultation ,

Take relevant hx , focused examination and make a shared mx

plan .
Sp information :

Patient history

You are Tina Hathaway, a retired school teacher. You are seeing
your doctor today because you’ve had a sore throat for a few days
and you are struggling to swallow your food. You’ve tried salt
water gargles and paracetamol with no improvement. You think
you need antibiotics and want your doctor to give you some
immediately.

Opening statement

Hello Doctor, I’m sorry to bother you but I think I need pills for my
sore throat.

Openly revealed

You first noticed your symptoms about 3 days ago. Your main
concern is difficulty swallowing your food as it hurts. You are going
for a university reunion in 2 days and want to be able to enjoy
your expensive 6 course dinner. You know you’ve had antibiotics
and aspirin gargles previously for similar symptoms and want the
doctor to give you some so you can be on your way.

Only revealed on questioning

Your throat is quite painful but you are able to swallow liquids
easily. It started gradually 3 days ago and has got worse over the
last 24 hours. You do not have a fever/cough/runny nose/nausea or
vomiting/headache. You have no problems breathing. You do not
have a headache or any problems with balance/hearing/walking.
You took your methotrexate as per usual 5 days ago. Your
rheumatoid arthritis is well controlled and you are monitored by
your GP. You have been on methotrexate for 4 years. However, you
missed your last blood test 3 months ago as you were on holiday
and didn’t think you needed to rebook as you ‘feel perfectly well’
from an arthritis point of view. You think this infection will clear up
with a course of antibiotics and you’d like some aspirin as well to
help the soreness.

ICE

You are convinced you need antibiotics and expect the doctor to
give you some. You never paid much attention to your arthritis as
you are a positive person and don’t like to ‘dwell’ on your
ailments. You haven’t had a sore throat in the last 10 years and
you are certain you had antibiotics and aspirin when you saw the
doctor last for a similar issue.

As a result you will be very unhappy if the doctor doesn’t provide

you with these medications. If the doctor suggests referring you to
the specialist you will initially be very unhappy and ‘wonder what
all the fuss is about’ as it’s only a sore throat. If the GP explains
why this needs to be done and conveys the seriousness of the
issue in a suitable manner, you will consider seeing the specialist.
You do take a while to decide if you will see the specialist and are
more likely to do so if you understand the explanation and
establish confidence in the GP’s judgment.

PMH

Rheumatoid arthritis, diagnosed 7 years ago. It has mainly

affected your hands but your function is well preserved. You did
see a specialist for this problem but were discharged from clinic
about 6 months ago. You also have problems with dry eyes
occasionally but this hasn’t been a problem for a while.

DH
Methotrexate, 7.5 mg by mouth once weekly and folic acid 5mg
once weekly the following day. You do not have any drug allergies
and have never suffered with side effects from your medications.

SH

You live with your husband of 27 years in a small house nearby.

You enjoy walking daily with your dog. You like to have a small
glass of wine 1-2/week with your evening meal. You have never
smoked.

FH

Your mother had rheumatoid arthritis but she died 5 years ago.

Examination

If the doctor requests to examine you, allow to continue. The

examiner will provide clinical information as appropriate.

An examination is assessed at this station. The following

information may be elicited.

ENT examination

Ears: NAD

Nose: NAD

Throat: Slightly erythematous/enlarged tonsils bilaterally with no

exudate, erythematous oropharynx

Neck: No cervical lymphadenopathy, no abnormal masses

Observations
Pulse 70 regular

BP 120/80

Temperature 37.0°C

All other examinations

NAD

Data gathering

1. Takes an appropriate history.

2. Explores the patients health care beliefs including the need
for blood test monitoring with DMARDs.

3. Performs a focused examination.

Clinical management

1. Recognises the need for urgent action.

2. Conveys the potential seriousness of the situation to the
patient.

3. Enters into a discussion actively involving the patient in the

consultation.

4. Stops medication and arranges an urgent full blood count as

well as an urgent specialist opinion due to the risk of blood
dyscrasias.
 5. Arranges suitable follow-up to further educate about the side-
effects and monitoring requirements of methotrexate.

Interpersonal skills

1. Appreciates the strong views of the patient and her beliefs

about the cause of her symptoms.
2. Listens to the patient and takes on board her views.

3. Uses negotiation skills to develop a management plan.

4. Conveys the potential gravity of the situation while remaining

calm and professional.
Case no.5

18 yrs old Audrey Horne for. Consultation

Focused hx examination. And shared mx plan

Patient history

You are Audrey Horne, an 18 year old final year A-Level student.
You are academically gifted and are looking forward to studying
Economics at Cambridge University in a few months time. You like
socialising within your close network of school friends and are
currently in an active sexual relationship with John, another
student at your college. You are using a contraceptive method
called Depro-Provera which is administered every 3 months by
your usual GP. Things are going well at school and with your
relationship with John.

Opening statement

Sorry to trouble you doctor, but my throat is really sore and I

wondered if you could look at it.

Openly revealed

You noticed that you began to develop symptoms of a sore throat

two days ago. The most important symptom for you is pain when
you swallow food or liquid. You have been managing to keep down
fluids without too much trouble, although it does hurt. You have
also noted a high temperature last night, although you did not
measure it.

Only revealed on questioning

You remember having tonsillitis a few years ago and it feels the
same. Antibiotics helped then. You believe that you would have no
problems swallowing tablet medication. You do not have any
problems swallowing your own saliva and are able to open your
jaw. You have no cough. You have noted a bit of ear ache, more on
the left side than the right. You have been feeling generally weak
and run down for one day. You have no breathing difficulties. You
do not have any abdominal pain. You do not have any rashes,
aversion to bright light or neck stiffness. You have no other
symptoms to report. If the doctor asks about why you have chosen
a depot contraceptive you will remind them that you’re not very
good at remembering to take tablet contraceptives every day and
don’t like the idea of having an implant contraceptive. Your
boyfriend doesn’t like using condoms either. You don’t want to
change your current contraceptive method for the time being but
will listen to any advice given to you. You do remember that one of
the doctor did mention ‘bone thinning’ when you first started on
Depo-Provera last year but said that it should be fine to use for a
few years.

ICE

You think you have tonsillitis, although after reading some

information on the internet you think that glandular fever might be
a possibility and are a bit worried about this and any effect it
might have on going to University in a few months time. You
expect to get some antibiotic tablets today that you are sure won’t
interfere with your contraceptive injection. If the doctor states it
might affect your injection you will reluctantly accept the
antibiotics anyway and abstain from sex for as long as
recommended.

PMH

You don’t have any other medical problems.

DH

Apart from Depo-Provera you are not taking any other mediation.
You have no allergies.

SH

You live at home with your father who is a local businessman who
manages a nearby hotel. You smoke 5 cigarettes per day while
socialising with friends. You like to drink 1-2 glasses of wine at the
weekend.
FH

You are an only child. Your father is well as far as you’re aware.
Your mother died in a car accident when you were 5 years old and
do not know much about her.

Examination

If the doctor wants to examine you, allow them to proceed. The

examiner will provide clinical information as appropriate. Decline
any intimate examination.

If the candidate requests to perform an examination the following

information will be made available on specific request.

Observations

Pulse 70 regular

BP 105/65

Temperature 38.0°C

Additional information

If throat exam requested, examiner to reveal picture of classic

tonsillitis, uvula central.

No clinical signs of dehydration

Few palpable, tender anterior cervical lymph nodes

Abdominal system NAD (no splenomegaly)

All other examinations

NAD

Data gathering

1. Takes a concise but adequate history of the sore throat

2. Determines agenda to get antibiotics but concerns about
interference with contraceptive efficacy

3. Requests to examine the patient and in particular the throat

Clinical management

1. Realises that symptoms and signs are consistent with the

diagnosis of tonsillitis and meets the criteria for antibiotics
2. Explains the diagnosis of tonsillitis but also explains the
nature of glandular fever to the patient

3. Issues first line antibiotic choice of phenoxymethylpenicillin

(Penicillin V) 500mg for 10/7

4. Avoids the use of amoxicillin if the diagnosis could be

glandular fever

5. Recommends simple analgesic and anti-pyretic options such

as paracetamol or ibuprofen

6. Encourages fluid intake

 7. Discusses safety netting regarding worsening of symptoms
and the red flags of severe tonsillitis requiring admission for
fluids and IV antibiotics

8. Reassures patient that broad spectrum antibiotics do not

affect the efficacy of Depo-Provera

9. Mentions that Depo-Provera may cause osteoporosis which is

more likely when started in the teenage years. It may be
worthwhile considering alternatives, especially after 2 years
of continuous use

Interpersonal skills

1. Sensitive to the underlying concerns regarding glandular

fever and efficacy of contraception on the patient’s lifestyle
2. Respects patients choice of contraception and understanding
of risks and benefits
Case no.6

58 years Harry Broughton came to see you

Take focused hx, relevant examination and make a mx plan

Patient history

You are Harry Broughton, a 58 year old shopkeeper. You are very
angry that you have been waiting for almost an hour to see the
doctor. You have seen the TV ads about a cough and feel you may
have lung cancer. You want to have a scan of your chest to make
sure. You are very forceful and aggressive if you feel the doctor
patronises you in any way.

Opening statement

What’s the point in having a booking system? Finally you call me.
It’s an absolute disgrace waiting so long to see you. Now give me
the scan of my lungs and I will be on my way. I have far better
things to do with my time than sit around waiting for you!

Openly revealed

You have seen the TV commercials about the possibility of lung

cancer if you have a cough for a few weeks. You have had a cough
for most of the last few years and you always put it down to
‘bronchitis’. However after doing some research on the internet,
you are now convinced that you may have lung cancer. You also
read the only way to be certain it isn’t lung cancer is to have a CT
scan so you want this done urgently.

Only revealed on questioning

You have smoked 20-30 cigarettes a day for the last 40 years. Your
cough can be quite chesty in the winter where you produce a lot of
yellow sputum. During the summer it improves. You are
occasionally short of breath when you have to run for the bus. On
occasions you have noticed that you do get wheezy when you
physically exert yourself. You do no physical exercise and lead
quite a sedentary lifestyle. You have never coughed up any blood.
You have never coughed up any blood. You are not losing weight
and your appetite is good. There is no family history of cancer. You
do not suffer with any chest pain.

ICE

You are worried that you may have lung cancer. You know you
should stop smoking but don’t know how to go about doing this.
Smoking is a social experience for you as all your friends and your
wife does it. You have never entertained the idea of your mortality
previously and watching the TV ad stating that a cough for longer
than 3 weeks could mean cancer has scared you. You are
adamant that you won’t leave unless the doctor agrees to do a
scan. You may be cajoled into other investigations if the doctor
addresses your concerns and appears to take your views seriously.

PMH

ou have had bouts of bronchitis during the winter for the last few
years. These have cleared up with a course of antibiotics.

DH

You are not on any regular medication.

SH

You live in a flat above the shop you own with your wife and 13
year old daughter. You enjoy going to the pub 3 nights a week and
have 2-4 pints of lager each time. You also smoke 20-30 cigarettes
a day.
FH

You are not aware of any relevant family history.

Examination

You agree to be examined by the doctor if they request to do so.

An examination is assessed at this station. The following

information will be made available at the end of the examination if
the candidate has performed an adequate assessment.

Observations

Pulse 78 regular

BP 135/87

Temperature 37.0°C

Oxygen saturations 98% on air

Chest

No evidence of respiratory distress. Chest expansion normal with

no obvious deformity. No wheeze but a few creps noted at bases
bilaterally.

All other examinations

NAD

Data gathering

1. Obtains a relevant history.

2. Ensures all red flag symptoms are elicited.

3. Acknowledges the patient’s concerns but ensures an

appropriate history is covered including exploring alternate
diagnoses.

4. Competently performs a relevant clinical examination.

Clinical management

1. Uses techniques such as summarising to ensure a

comprehensive history has been obtained.
2. Provides the patient with a possibility of differential
diagnoses.

3. Explains possible consequences of any serious diagnoses.

 4. Explains the possibility of a COPD diagnosis.

5. Offers investigations as appropriate as well as justifying the

rationale behind this tests.

6. Offers smoking cessation advice.

7. Ensures follow up is booked appropriately.

8. Provided safety netting advice.

Interpersonal skills

1. Maintains a professional appearance whilst dealing with the

patient’s anger.
2. Gains a good understanding of the patient’s concerns.

3. Reassures the patient as necessary.

4. Involves the patient in the decision making process.

5. Explains why a CT may not be the primary investigation of

choice. Depending on local circumstances, it may not also be
possible to book directly.