Reset 10 mins Pause Candidate instructionsActor instructionsMark sheet Score Location: You are a medical student in General Practice. Patient: 19 year old student who has had poor attendance at university. 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 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 None 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 Explore and challenge the delusion Voice detail Real/pseudo 1st/2nd/3rd person What they say Any commands SR Relevant systems reviews Schizophrenia 1st rank symptoms Hallucinations 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 Occupation 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 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 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 Diabetes Sedation Hyperprolactinaemia (galactorrhoea/oligomenorrhoea/infertility) Submit your answers to get your score.