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CSA scenarios with REAL CSA actors

AsclosetotheCSAexamaspossible
SIX CSA Cases with 4 different CSA
actors for less than 400
Individualised feedback from course facilitators & CSA actors on your performance

CANDIDATES BRIEF

CSA course cases


Patient medical records

Name:

Past medical history: Hypertension, back pain with sciatica

Drug history:

Last consultation 2 years ago

Paul Phillips (42 year old)

Ramipril 2.5mg od, amitriptyline 50mg on

Dr Singh: MRI scan back shows small bulge at level L4/L5. Pt complaining of ongoing back pain for
several years. Has only tried paracetamol. Keen to try other medications. Pain shoots to his left leg. No
red flags. Offered anitriptyline tablets and rw

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CSA course case CSA prep 2011

CSA scenarios with REAL CSA actors


AsclosetotheCSAexamaspossible
SIX CSA Cases with 4 different CSA
actors for less than 400
Individualised feedback from course facilitators & CSA actors on your performance

CSA course cases Snoring

ACTORS BRIEF

Background: You are Paul Phillips a 42 year old Taxi driver

Approach: You are casually dressed, and speak with a cockney accent. You have a laid back persona

Opening statement: Doc I need some help with my ZZZs

History
Open history:

Your misses thinks you snore loudly everyday but you do not think you have a problem. She reports
that it wakes the baby and kids up all night

Your misses reports its been going on for several years but now for the last 1 year it is intolerable. She
has had to purchase ear plugs but feels it doesnt work. She has been shaking me or kicking me a few
times but you are completely unaware

Now she is sleeping in the next room with the kids as she cannot take it anymore. She is exhausted by
having disturbed sleep and attending to the kids who wake up all time throughout the night. She is
feeling tired all the time because of your snoring

CUE: You are getting worried about the number of nights she is spending away from your bed

Reveal history if asked:

You are working longer hours driving your taxi to pay for the bills with the new baby and feeling
drained and run down all the time

CUE: You have a lingering headache when you get up and can find it difficult to concentrate so you
get a quick nap at work and it disappears

You get a quick nap by parking the car on the hard shoulder on the motorway to get twenty winks

Your wife states she has had to shake you because she swears that you hold you breath when you
sleep but you thinks she is making it up as thats just daft. It happens about twice a night but shes
making it up as its nonsense

After a hard days work you go to the pub and enjoy a drink and a bit with your mates most week days.
You have a bit more on the weekend with friends watching the football

CUE: Your mood is so-so. You are a bit down how your marriage is on a downward path because of
the snoring

You do not have any fever sweats, cough or colds. You do not suffer from sore throats

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CSA scenarios with REAL CSA actors


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SIX CSA Cases with 4 different CSA
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You do not feel colder than normal, or have dry skin or neck swellings

You do not have any nasal congestion or nasal problems

Ideas: You dont think you have a snoring problem (in denial) but only came because the misses
forced you.

Concerns: You are worried it is affecting your marriage and may eventually lead to a separation. You
are growing apart since she is sleeping away from your bed

Expectations: You would like some sleeping tablets so that you can go into a deeper sleep so it would
not bother your wife. Also you would like some ear plugs of your own to stop your wife whining about it
so much!

Medical history

You were told you have a back problem and find the only way to ease the pain is lying on your back
without pillows

You have high blood pressure and started on medication for it

You do not suffer from tonsillitis, hypothyroidism or hayfever or rhinitis

Drug history

You take amitriptaline tablets regularly for the back and finds it works well. You take 1 tablet regularly
at night

You take blood pressure medicines

Social history

You smoke 25 cigarettes a day since you were a teenager. It helps relaxes the nerves before you get
home

You have 2 children, Andrew aged 6months and Kevin aged 5 years. Your older child also moan about
how much you snore. He has started calling you the Noisy Gruffalo

You drink 2 pints of beer a day with friends and think that you are just under the limit when you drive
home. You drink 3 pints on the weekends with mates.

You have a small nightcap (1 shot of whisky) just before you sleep

Diet: You eat food on the go. Mostly fast food burgers, chips and bacon and eggs.

Occupation: you work as a taxi man and mainly do the airport routes so on the motorways all the time

Family history

You are not aware of any medical problems in your family

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CSA course case CSA prep 2011

CSA scenarios with REAL CSA actors


AsclosetotheCSAexamaspossible
SIX CSA Cases with 4 different CSA
actors for less than 400
Individualised feedback from course facilitators & CSA actors on your performance

If the doctor suggests you have sleep studies then accept but suggest he is may be taking his snoring
too seriously and some sleeping tablets should do the trick

You are happy to take on board lifestyle advice given to you i.e. reduce alcohol, loose weight, stop
smoking

If doctor says he is worried that your symptoms are affecting your driving reassure the doctor and be
dismissive

If the doctor suggests it can affect your health i.e. inc risk of IHD, CVA etc then be surprised and be
attentive to the advice

You are willing to bring your wife to the next appointment, but think referrals to couples therapy or
counselling is for weak people

Snoring

EXAMINER

DATA GATHERING
Positive indicators:

Gathers information regarding presenting complaint. i.e. OSA morning headaches, apnoea, lack of
freshness in the morning

Attempts to excludes other pathology i.e. tonsillitis, hypothyroidism

Makes likely diagnosis of OSA

Request to perform a targeted examination i.e. examine neck (goitre), neck circumference, BP, neck
circumference etc

Negative indicators:

Fails to identify based on probabilities a likely diagnosis of OSA

Fails to take a history of precipitants analgesia, sleep posture, alcohol and nightcap

INTERPERSONAL SKILLS
Positive indicators:

Develops good rapport with the patient for patient to feel comfortable to discuss health beliefs

Allows for an environment to discuss marital strain as well as impact at work

Explores ICE and request for sleeping tablets

Negative indicators:

Fails to explore the social context of the symptoms and impact on marriage or work

Fails to develop rapport with the patient and is doctors centred

2 FOR TWO COURSE ONE 2 ONE FEEDBACK - 10 CSA CASES EACH ROLEPLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 599
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CSA course case CSA prep 2011

CSA scenarios with REAL CSA actors


AsclosetotheCSAexamaspossible
SIX CSA Cases with 4 different CSA
actors for less than 400
Individualised feedback from course facilitators & CSA actors on your performance

CLINICAL MANAGEMENT SKILLS:


Positive indicators:

Offers lifestyle advice re: dietary (cut down chocolates, caffeine), advise about sleep hygiene and link
of diet and sleep in making headaches worse

Recommend patient to complete Epworth sleepiness scale

Advice posture advice avoid sleeping on back use pillows to ensure sleeps on one side

Consider changing or stopping TCAs

Advice reduce or stop smoking and particularly alcohol

Advise about risk associated health problems with OSA (IHD, CVAs)

Negative indicators:

Fails to offer adequate lifestyle advice

Offers sedatives to patient to improve sleep

CARDS

Vitals
BP
Pulse
BMI
Weight

135 / 74
65 bpm
32
89 kg

Examination
Cardiovascular exam normal
Respiratory exam normal

Neck circumference 47cm


Throat no enlarged tonsils or
nasal polyps
No goitre

2 FOR TWO COURSE ONE 2 ONE FEEDBACK - 10 CSA CASES EACH ROLEPLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 599
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CSA course case CSA prep 2011