Reset 10 mins Pause Candidate instructionsActor instructionsMark sheet Score Location: You are a foundation doctor in a GP practice. Task: Please see Brenda Berry who has come in for a consultation regarding her daughter Julia Berry, who is a 14 year old also registered at the practice. 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 You are a Brenda Berry, a high-flying businesswoman who works in the city. You have come to talk to a general doctor about your daughter, Julia. Demeanour: You are a very busy person and you are angry with the GP surgery because they don’t offer enough evening appointments so you had to take a morning off work. Be quite short with the doctor and offer snappy answers. You’re not really interested in talking in detail about the problem because you were called in late for your appointment (despite arriving early) and you’ve got an important meeting. You just want to get some medication to stop the vomiting. If the doctor does not give you a plan by the 2 minutes remaining bell, tell them you’ve really got to leave in a minute and push them for what they are going to do. History of presenting symptoms Information to be volunteered at the start You have come in because Amelia (the nanny) keeps nagging you about Julia (your 14 year old daughter) who she often hears vomiting in the upstairs toilet. You want some medicine for her so you can ‘put this to bed’. Information to be given if asked If pushed for more information, Amelia first told you about Julia vomiting a few months ago. You put it down to ‘a tummy bug’ and told her not to worry. Despite this Amelia keeps undermining your judgement and regularly brings it up. Amelia says she hears Julia vomiting once/twice everyday. She says Julia doesn’t eat much and particularly avoids eating carbohydrates or fatty foods. You don’t see that this is a problem because she’s a skinny girl so doesn’t need many calories. You asked Julia what the problem was once but she wouldn’t talk about it. Julia is a shy girl and doesn’t seem to have many friends. You think she is progressing OK at school but you were working during the last parent’s meeting. If asked, Julia exercises a lot, she goes for a long run (2-3 hours) every day. She spends a lot of time in front of the mirror getting ready but ‘that’s normal for a girl her age’. If asked, she hasn’t started her periods yet but seems to have normal pubertal development otherwise. If asked about whether Julia would ever harm herself, look alarmed and ask where this question came from. If asked specifically about laxatives, thinking about it, you did find some empty senna tablets in her room a few months ago but you assumed these were Davids (your ex-husband) as Julia has never had problems with constipation. Julia’s background information Past medical history No medical problems/medications. Normal birth and normal vaginal delivery at 38 weeks. No neonatal problems. Normal growth and development. Medications and allergies None. Family history None relevant. Social and personal circumstances Julia’s dad had problems with alcohol and you left him 1 year ago. Julia now has no contact with him and you don’t know where he lives. He was never violent towards yourself or Julia, he was just ‘a waste of space’. There are no siblings. You do not have a current partner. You don’t smoke or drink and neither does Julia. Your ideas, concerns and expectations You need to get the anti-sickness tablets quickly because you are late for an important business meeting. If the doctor tries to tell you this may be a psychological problem, become defensive and tell them ‘my daughter’s not crazy’. If they tell you they need to do more tests then reluctantly say OK but ask if can Amelia bring her to have them done. Questions for the doctor None. Category Question Done Excellent Intro Introduction Washes hands Introduces self Checks patient’s name Gains consent PC Exploring presenting complaint and identification of eating disorder symptoms Vomiting: time frames, any blood/bile Weight and height Avoidance of weight gain Pre-occupation with appearance Excessive exercise Laxative use Diet/food diary Menstrual cycle disturbance Self harm SR Relevant systems reviews GI: appetite, weight loss, abdominal pain, bowel habit, blood/mucus in stool Psychiatric: depression screen, risk to self PMH Past Medical History Past medical history appropriately explored DH Drug History Drug history appropriately explored Drug allergies FH Family history General family history SH Social History General social history Family unit Drug and Alcohol use School performance 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 most likely diagnosis? Anorexia nervosa Submit your answers to get your score.