S2 Scenario Examples

8/12/2019 S2 Scenario Examples

1/20

INFORMATION FOR THE CANDIDATE Scenario N EX1

MRCP(UK) PACES

Station 2: HISTORY TAKING

Patient details: Mrs Heba Kamel, a 54-year-old woman

Your role: The doctor in the general medical outpatient clinic

Presenting complaint: Progressively worsening dyspnoea

Please read the letter printed below. When the bell sounds, enter the room. You have 14minutes to take a history from the patient, 1 minute to collect your thoughts and 5 minutes for

discussion. You may make notes if you wish.

Referral text:

Dear Doctor,

This retired nurse has had progressively worsening dyspnoea for the past 18 months. She hasa history of recurrent urinary tract infections and is on long-term antibiotic therapy.

She smokes 20 cigarettes per day and has done so for the past 20 years. She has no pastrespiratory history.

She has hypertension and is known to have right bundle branch block on her ECG.Examination reveals definite bi-basal crackles on auscultation of the chest. Full blood count andurea and electrolytes are normal.

Please see and advise on her management.

Your sincerely,

Your taskis to interview the patient and, based on the history you obtain, construct adifferential diagnosis and plan for investigation. You should explain these to the patient and

answer any questions they may have.

DO NOT EXAMINE THE PATIENT

Any notes you make must be handed to the examiners at the end of the station


2/20

NOT TO BE SEEN BY CANDIDATES

INFORMATION FOR THE SURROGATE Scenario N EX1

MRCP(UK) PACES


Your role: Mrs Heba Kamel, a 54-year-old woman

Location: The general medical outpatient clinic

History of presenting symptoms

Information to be volunteered at the start of the consultationYou present with an 18 month history of progressively worsening breathlessness. Now you getbreathless on walking 100 yards on the flat or after doing housework such as vacuuming. Thebreathlessness does not get worse at night and you sleep with 1 pillow. You have no history ofchest pain, palpitations, cough or ankle swelling. Your sputum is normal and you have nevercoughed up blood.

Information to be given i f askedNot applicable.

Background information

Past medical and surgical historyYour past history includes high blood pressure, varicose vein surgery and recurrent urinary tractinfections. Apparently youve been told you have an abnormal heart tracing but you do not thinkyou have any heart problems.

Other complaintsYour only other symptoms of note are nocturnal leg cramps and occasional flushes. Yousometimes get constipated but this doesnt bother you.

Medication record

Current medicationsYour have been on bendroflumethiazide 2.5 mg daily and lisinopril 20 mg daily for yourhypertension for a few years. Your doctor prescribed an antibiotic for your urinary tract infections10 years ago and you take this religiously, the dose being 50 mg at night. You are dreadful atremembering names.

Allergies and adverse reactionsYou are allergic to elastoplasts.


3/20



Personal history

LifestyleYou smoke 20 cigarettes per day and have done so for the past 20 years. You dont like the tasteof alcohol.

Social and personal circumstancesYou are a retired nurse (you retired to act as a carer for your son). Your husband is a mechanicand suffers from diabetes. He also had TB as a child. You have two sons. The eldest has a

history of diabetes also but this is well controlled and he is at university. The younger son has ahistory of cerebral palsy and still lives at home. You have a dog.

Your eldest son keeps pigeons and you have been looking after them for the past few yearswhen he is away on holiday or away at weekends. This usually involves you feeding them andcleaning out their cages a few days each month, several months a year.

Travel historyYou have never been abroad.

Family historyYour mother died of breast cancer aged 72 and your father had angina and died of a stroke aged

77.

Patients concerns, expectations and wishesYour breathlessness now makes it more difficult to care for your younger son. This concernsyou.

You have some specific questions for the doctor at this consultation:

What could be causing my symptoms?

Could it be related to my smoking?

Will it get worse and interfere with my ability to care for my son?


4/20


INFORMATION FOR THE EXAMINERS Scenario N EX1

DATE CYCLE

MRCP(UK) PACES


Examiners should advise candidates when there are 2 minutes remaining (i.e. after 12 minutes). Ifthe candidate appears to have finished early remind them how long is left at the station andenquire if there is anything else they would like to ask, or whether they have finished. If they havefinished, please remain silent and allow the candidate that time for reflection. The surrogate shouldremain until the end of the 14-minute period.

A good candidate would be expected to take a history which includes a detailed social history andactivities of daily living; and to particularly focus on the questions raised in the referral letter. At theend of the consultation the candidate should have discussed solutions to the problems posed bythe case. A good candidate would also give the patient the opportunity to ask any further questionsbefore closure. It is not necessary for candidates to agree a summary with the patient during theirinterview.

Examiners are encouraged to make a rough record of the candidates consultation withthe patientas it progresses. This may highlight omissions in history taking, ambiguities that remainunresolved, and additional points that were not in the script.

The examiner is expected to ask the candidate whether they have formed a problem list orpreferred diagnosis and answer the questions in the Family Doctors letter. Following discussion ofthe answer to these questions the discussion should explore the issues raised.

Examiners should refer to the marking guidelines in the four skill domains on the mark sheet.

The box on the following page indicates areas of potential interest in this case. Both examinersshould consider these, and any other areas they feel appropriate, and agree the issues that acandidate should address to achieve a Satisfactory award for each skill. These should berecorded on the calibration sheet provided.

Examiners should also agree the criteria for an Unsatisfactory award for each skill.

Continued on next page


5/20



Problem: Progressively worsening dyspnoeaCandidates role: The doctor in the general medical outpatient clinic

Surrogates role: Mrs Heba Kamel, a 54-year-old woman

Examiners are reminded the boxes below indicate areas of potential interest, but are not intended asabsolute determiners of Satisfactory performance. It is for the examiners to agree and record thespecific criteria they will assess the candidate on during the calibration process.

Clinical skill Key issues

DifferentialDiagnosis (D): Probable diagnosis:

Nitrofurantoin induced pulmonary fibrosis.Plausible alternative diagnoses:

Extrinsic allergic alveolitis Chronic obstructive pulmonary disease

Chronic heart failureClinical

CommunicationSkills (C)

Obtain sufficient information from the history to draw up a list of

differential diagnoses Identify risk factors

Managing PatientsConcerns (F):

Addresses patients concerns

Clinical Judgement(Skill E):

Plan investigations including:

CXR

ECG

Pulmonary function tests

High resolution CT scan of chest

Immunological tests

Maintaining PatientWelfare (Skill G):

See mark sheet.


6/20


MRCP(UK) PACES


Patient details: Ms Donna Jones, a 47-year-old woman


Presenting complaint: Fatigue



Referral text:

Dear Doctor,

I would be most grateful if you could see this woman who presents with increasing fatigue overthe last one year. I checked her full blood count and she has a haemoglobin of 7.8 g/dl with anMCV of 112 fl.

Please advise on her investigation and management.

Your sincerely,

Your taskis to interview the patient and, based on the history you obtain, construct adifferential diagnosis and plan for investigation. You should explain these to the patient andanswer any questions they may have.




7/20



MRCP(UK) PACES


Your role: Ms Donna Jones, a 47-year-old woman



Information to be volunteered at the start of the consultationYou have been feeling increasingly tired particularly over the last year. As a consequence youhave stopped going out so much and rather than walking to the shops, half a mile away, you nowtend to take the car. There have been times when you have felt rather breathless on walking upeven relatively gentle inclines. You have had no headache, dizziness, nausea or vomiting. Thereis no history of abdominal pain or alteration in bowel habit. There is no history of change in yourweight or any mouth ulceration.



Past medical and surgical historyYou have never been particularly unwell before. In particular there is no history of any heart orchest problems. You were therefore very surprised when your Family Doctor told you that youhave anaemia (a low blood count).

Medication record

Current medications

You are not prescribed any medication but because of your fathers bowel tumour, a nurse friendhad suggested that taking a small dose of Aspirin might prevent the chances of developingsomething similar and you have been doing this over the last 5 years.

Personal history

LifestyleYou are a non-smoker. You take a moderate amount of alcohol (approximately 15 units perweek but mainly all at the weekend: equivalent to a bottle and a half of wine over the weekendperiod) and have never taken any more than that.


8/20



Social and personal circumstancesYou have a generally good diet although you tend towards being almost vegetarian. You do havea good intake of fruit and vegetables with little in the way of red meat.

Family historyIn your family history both your mother and grandmother had thyroid problems and you recall agreat aunt had to wear a wig because of premature hair loss. Your father had bowel cancer.

Patients concerns, expectations and wishesYou are anxious that your anaemia may be an indication of a more serious problem.

You have some specific questions for the doctor at this consultation:

What could be causing you to be anaemic?

If you could have a bowel cancer like your father as you remember he too was anaemic?

Could it be related to the Aspirin you have been taking yourself?

What tests will you need to have?


9/20



DATE CYCLE

MRCP(UK) PACES




Examiners are encouraged to make a rough record of the candidates consultation with the patientas it progresses. This may highlight omissions in history taking, ambiguities that remainunresolved, and additional points that were not in the script.







10/20



Problem: FatigueCandidates role: The doctor in the general medical outpatient clinic

Surrogates role: Ms Donna Jones, a 47-year-old woman



DifferentialDiagnosis (D): Probable diagnosis:

Pernicious anaemiaPlausible alternative diagnoses:

Gastrointestinal disease Alcohol excess

Dietary insufficiencyClinical

CommunicationSkills (C)

Obtains a history of symptomatic anaemia.

Identifies a significant family history of autoimmune disease.


Addresses patients concerns


Indicates a likely diagnosis and explain further investigations for this(antibody tests and possible Schilling test)

Indicates likely treatment options with parenteral B12 supplementation.


See mark sheet.


11/20


MRCP(UK) PACES


Patient details: Miss Geraldine Pearson, a 25-year-old woman


Presenting complaint: Hypoglycaemia



Referral text:

Dear Doctor,

I would be grateful if you would see this patient as she is having increasing problems withhypoglycaemia.

She has had type 1 diabetes for 19 years and generally has not been troubled by it. Over thelast 6 months she has had increasingly frequent and more severe episodes of hypoglycaemiaand she says she is now getting no warning symptoms. Her partner has had to force feed herjam at night to resuscitate her on a number of occasions. He is particularly concerned about theeffect on her work.

Her latest HbA1c was 8.5% (IFCC: 69 mmol/mol) which is an improvement from 9.8% (IFCC:84mmol/mol) last year.

Your sincerely,

Your taskis to interview the patient and, based on the history you obtain, construct a

differential diagnosis and plan for investigation. You should explain these to the patient andanswer any questions they may have.




12/20



MRCP(UK) PACES


Your role: Miss Geraldine Pearson, a 25-year-old woman



Information to be volunteered at the start of the consultationYou have had type 1 diabetes since the age of 8. You have never taken particularly close care ofyour diabetes, but it has never caused you any obvious problems.

Over the last 6 months you have been experiencing frequent episodes of hypoglycaemia both atnight and during the day. Previously you got warning symptoms of feeling hungry and shaky andsweating, but these do not now occur and you find that you suddenly cannot function at work orat home when, you test your blood sugar it is 2-3 mmol/L. You have also been woken at night byyour partner trying to feed you because you are restless, incomprehensible and your sugar is low.On one occasion recently you lost consciousness after having got up to get some food. Yourpartner is concerned about you and what he can do to help you.



Past medical and surgical historyYou have been told that you have normal changes of diabetes in your eyes, but have never hadlaser treatment, and have eye examinations every year by the mobile screening service. Youhave also been told that you have some loss of sensation in your feet when they are tested and

you tend to get hard skin which can crack, but otherwise do not have problems with your feet.You have never been told that there are any kidney problems from diabetes, but you have notprovided a urine sample for testing for the last few years because you check your blood instead.Your blood pressure is said to be normal.

Other complaintsYou use a cartridge pen injector to give your Insulin. You always inject in your thighs becausethat is easiest. There is some lumpiness at your commonly used injection sites.


13/20



Medication record

Current medicationsYou take insulin 4 times daily, Human Actrapid 2428 units with meals and Human Insulatard 38units at bedtime.

You are on the standard oral contraceptive pill and have been for 4 years.

Personal history

LifestyleYou have started going to the gym to exercise regularly 4 evenings a week for the last 8 monthsto try and help you to lose weight. You also enjoy going to the cinema and eating out. You eatregularly but have been trying to miss extras to help lose weight.

Social and personal circumstancesYou have been living with your present partner for 8 months, and have been thinking aboutgetting married and starting a family.

Occupational historyYou have been in your present job for 6 years and are happy in it. Friends and colleagues at

work know you have diabetes but until recently it hasnt caused problems. Recent re-staffing hasmade it more difficult to get regular fixed breaks for meals and snacks, the timing of these willvary between days.


14/20



DATE CYCLE

MRCP(UK) PACES











15/20



Problem: Hypoglycaemia

Candidates role: The doctor in the general medical outpatient clinicSurrogates role: Miss Geraldine Pearson, a 27-year-old woman



Differential

Diagnosis (D):Probable diagnosis:

Plausible alternative diagnoses:

ClinicalCommunicationSkills (C)

Gains a clear view of the current situation with the patientsdiabetes and itscomplications, and elucidates possible precipitation factors for theincreased hypoglycaemia and impaired hypoglycaemia awareness,including:

Meal patterns

Exercise patterns including sexual activity

Lipohypertrophy

Autonomic neuropathy Improving glycaemic control on soluble and isophane insulins.

Other endocrine causes e.g. Addisons disease, thyrotoxicosis, (renalfailure)


Discusses the issue of the patients future marriage and potential plansfor pregnancy in the setting for poor glycaemic control.

Discusses education for the partner

Clinical Judgement

(Skill E):

Explains the need to vary injection sites, have an insulin regime tomatch a regular meal pattern, modify diet and insulin around exercise.

Explains the roles of other members of the diabetes team, and agrees acourse of action with the patient.

Understands the use of analogue insulins in type I diabetes. Explains the causes of changes in hypoglycaemia and hypoglycaemia

awareness. Elucidates the problems of night time hypoglycaemia. Understands and explains the evidence for good glycaemic control

preventing complications in type I diabetes; along with the importanceof glycaemic control in and around pregnancy in type I diabetes.

Maintaining Patient

Welfare (Skill G):

See mark sheet.


16/20


17/20



MRCP(UK) PACES


Your role: Miss Lily Kwan, a 28-year-old woman

Location: The general medial outpatient clinic


Information to be volunteered at the start of the consultationYou have been feeling generally unwell for about three months. Over the last month you havedeveloped diarrhoea, which is loose but formed stool, with no blood or mucus. If asked the stooldoes not float in the pan and is not offensive smelling. You open your bowels approximately 5-6times a day and occasionally need to open your bowels once at night. You have no urinarysymptoms of any sort.

You have also noticed that youve lost weight unintentionally, having dropped from a size 12 to asize 10 in the last three months. You do not weigh yourself to be able to comment on exactweight loss.

Your appetite has not been affected and in fact you feel that if anything, you seem to be eatingmore than usual.

Information to be given i f askedYour periods have become erratic over the last 6 months with only occasional, scanty blood loss.You feel warm and sweaty a lot of the time and havent enjoyed the recent warm weather which isnot like you. Recently your hands feel somewhat shaky, and sometimes your writing has beendifficult to read. You have not noticed any problems with your eyes and have not developed anyskin rashes. You wonder if your neck has become a little swollen.


Past medical and surgical history

You have otherwise always been well. You have only been to hospital once before, for atermination of pregnancy at the age of 19. You do not take any prescribed medications, but havebeen taking vitamin supplements recently. You have no allergies.

Medication record

Current medications

None.


18/20



Personal history

LifestyleYou smoke 5-10 cigarettes a day. If asked admit to occasionally smoking cannabis. You drinkabout two gin and tonics a day (a generous measure if asked).

Social and personal circumstancesYou live with your partner and have been trying to start a family recently.

Occupational historyYou work as an IT consultant.

Family historyBoth your parents died in their 80s. Your father had a heart attack, and your mother had coloncancer. There is no family history of inflammatory bowel disease or coeliac disease.

Patients concerns, expectations and wishesYou are concerned that you may have cancer as your mother had diarrhoea and lost weightbefore she was diagnosed with cancer. Also you have concerns about your fertility, which iscausing some friction between you and your partner.


19/20



DATE CYCLE

MRCP(UK) PACES











20/20



Problem: Diarrhoea and weight lossCandidates role: The doctor in the general medical outpatient clinic.

Surrogates role: Miss Lily Kwan, a 28-year-old woman

Examiners are reminded that the boxes below indicate areas of potential interest, but are not intendedas absolute determiners of Satisfactory performance. It is for the examiners to agree and record thespecific criteria they will assess the candidate on during the calibration process.


DifferentialDiagnosis (D): Probable diagnosis: Thyrotoxicosis

ClinicalCommunicationSkills (C)

Collects information regarding the nature of the diarrhoea, specificallyhistory consistent with fast transit and not with inflammatory change ormalabsorption.

Elucidates weight loss in the context of increased appetite and neckswelling.

Clarifies diagnosis, noting:

Tremor Heat intolerance

Oligomenorrhoea

Neck swelling

Eye problems

Skin rashes


Explores and addresses the patients concerns


Plans investigations that must include thyroid function tests.

Discusses likely initial management plan: block (carbimazole) andreplace (with thyroxine when euthyroid); beta blockers for temporarysymptomatic relief.


See mark sheet.

Date post:	03-Jun-2018
Category:	Documents
Upload:	ali-alison
View:	219 times
Download:	0 times

S2 Scenario Examples

Documents