Reset 10 mins Pause Candidate instructionsActor instructionsMark sheet Score 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.