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Location: You are a medical student in General Practice.

Patient: This is Emily Fulflood. She has booked an urgent appointment at the family practice. Please take a history prior to her seeing the doctor.

Task:
– Take a history from the patient
– After 6 minutes you will be asked a series of questions by the examiner
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested.

 

Your role

Your name is Emily Fulflood. You are 22 year old student. You are in your family practice to see a doctor because you have had diarrhoea. You quite distressed because of your troubling symptoms.

 

History of presenting symptoms

Information to be volunteered at the start

You have come in because of diarrhoea. Its been going on for 2 weeks and you feel awful. Its very loose and you are going 8-10 times a day. It contains fresh red blood mixed in with it. You feel like you need to go to the toilet most the time, even when you have just been. You often need to rush to the toilet. You have ‘never had a tummy bug like this before’.

 

Information to be given if asked

You have also had a mild intermittent crampy abdominal pain but you have not felt sick. You have not had a fever but do feel really tired. Your weight is stable. You have no other symptoms.

 

You have not eaten anything funny and everyone else in your hall is fine as far as you know.

 

Background information

Past medical history

None.

Medications and allergies

‘The pill’. No allergies.

Family history

Parents fit and well. No siblings.

Social and personal circumstances

You are a university student studying economics. You do not smoke. You drink 1-2 bottles of wine when you go on a night out, which is usually 2-3 times each week. Your mum and dad live 5 hours away and you have a good relationship. You are single and have had unprotected sex with 2 different partners this year. You went on a weekend away in Dublin 3 weeks ago but have not travelled anywhere else.

Your ideas, concerns and expectations

You have not told anyone about this problem because its so embarrassing. You have got the the point where you are now missing university lectures because you might need to get up and rush to the toilet. You are worried that one of these times you may not make it.

 

Questions for the doctor

None.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Washes hands
Introduces self
Checks patient’s name
Gains consent


PC Presenting complaint
Time frame
How much, how often
Consistency
Colour, blood/mucus


SR Relevant systems reviews
General: fever, fatigue
Gastrointestinal: weight loss, appetite, nausea/vomiting, abdominal pain


PMH Past Medical History
Past medical history appropriately explored


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
General social history
Food/intake risk factors
STI risk factors
Travel history


FH Family history
Asks specifically about cardiovascular history


Comms Communication
Builds rapport
Starts with open questions and then progresses to closed questions (coning)
Uses signposting
Avoids leading questions
Avoids jargon
Empathetic
Summarises at end
Thanks patient


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Question What is the differential diagnosis?
Ulcerative Colitis
Crohn’s disease
Microscopic colitis
Infective diarrhoea
Sexually-transmitted proctitis


Question What investigations would you consider and why?
Bloods: FBC (anaemia), ESR/CRP (inflammatory markers), B12/folate/ferritin (malabsorption or blood loss), U&E (dehydration), LFTs, blood culture
Orifice tests: stool culture (rule out infective diarrhoea), faecal calprotectin, swabs for STIs
X-rays: abdominal X-ray (rule out toxic megacolon)
Special tests: sigmoidoscopy/colonoscopy with biopsy


Question What histology might you see in Crohn’s vs UC?
Crohn’s: granulomas, cobblestone appearance, trans-mural inflammation
UC: crypt distortion/abscesses, goblet cell depletion, granular mucosa


Question What are the extraintestinal features of inflammatory bowel disease?
Eyes: conjunctivitis, episcleritis, iritis
Joints: sacroiliitis, arthropathy
Skin: pyoderma gangrenosum, erythema nodosum
Other: PSC, colon CA, renal/GB stones, venous thrombosis


Question What are the management options for IBD?
Acute Crohn’s: 1. steroids
Maintenance Crohn’s: 1. azathioprine/5-MP, 2. methotrexate, 3. anti-TNF
Acute UC: 1. 5-ASA, 2. steroids, 3. anti-TNF
Maintenance UC: 1. 5-ASA, 2. azathioprine/5-MP



Submit your answers to get your score.

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