Location: You are a medical student in General Practice.

Patient: 19 year old student who has had poor attendance at university.

– 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

You are a 19 year old, currently at university. You did not want to come to the general practice doctor today but your hall counsellor has made you come because you have missed over 50% of your lectures. As far as you are concerned you don’t have a medical problem and you don’t know why they made you come to the doctors.


Demeanour: Speak slowly and quietly and avoid eye contact as much as possible. Look down in your lap. Occasionally look around the room suspiciously. Initially act scared of the doctor and only give short, one line answers. Make the candidate build some rapport and trust before you divulge any information.


History of presenting symptoms

Information to be volunteered at the start

Your hall counsellor has made you come because you have missed over 50% of your lectures.


Information to be given if asked

When probed about why you have missed lectures, divulge that you try not to leave your room because your hallmates gang up on you and are trying to get you evicted. Sometimes they are able to put thoughts into your head and control your actions. You keep the curtains closed because they sometimes shine rays into your room to try and burn you. Ask if the doctor can help you get a protection order.


If probed, admit that you do sometimes hear voices talking about you. They never speak directly to you or give you instructions.


If asked about harming yourself or suicide, get angry with the doctor and ask them if they think you’re mad. You have no intention of hurting yourself or committing suicide. You do not want to hurt anyone else but have brought a knife with you today for protection, incase you hallmates try to harm you. If the doctor speaks about treatment, refuse because you are not ill.


Background information

Past medical history

Type 1 diabetes; you once cut your wrists 1 year ago if asked specifically about self harm.

Medications and allergies

Insulin injections (novorapid 5 units with meals, lantus 20 units in evenings). No allergies.

Family history

None relevant.

Social and personal circumstances

You are at university studying English. You drink 2-3 cans of beer each evening in your room. You do not smoke cigarettes but occasional smoke cannabis. Your mother died when you were young of an overdose and you were brought up by your stepfather who you don’t get on with. You never met your father and have no siblings.


Your ideas, concerns and expectations



Questions for the doctor


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

PC Presenting complaint
Explore and challenge the delusion
Voice detail
1st/2nd/3rd person
What they say
Any commands

SR Relevant systems reviews
Schizophrenia 1st rank symptoms
Depression screen

Risk Risk assessment
Assess risk (to self and others)
Assess insight

PMH Past Medical History
Past medical and mental health history appropriately explored

DH Drug History
Drug history appropriately explored
Drug allergies

SH Social History
General social history
Living situation

FH Family history
Relevant family history

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

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

Question What is the most likely diagnosis and why?
The patient has acute psychosis, most likely schizophrenia because he/she has all of Schneider's first rank symptoms which are strongly suggestive of this diagnosis (3rd person auditory hallucinations, running commentary, delusions of thought, delusions of control, delusional perception)

Question What would you do now?
The patient is at risk to others and must be sectioned and admitted to a mental health unit

Question What are the treatment options in the short and long term?
Atypical anti-psychotics (e.g. risperidone or olanzapine)
Admission to mental health unit
CBT/psychoeducation/family therapy
Multidisciplinary support (very important as this patient also has insulin-dependent diabetes)
Social support and drug and alcohol team involvement

Question What are the side effects of antipsychotics?
Extrapyrimidal effects (dyskinesias, akathisia)
Weight gain
Hyperprolactinaemia (galactorrhoea/oligomenorrhoea/infertility)

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