Start-Stop Methodology

Scenario 1

Consultation 1 (Primary Care) (14:40-15:10)

James Jones is a 56 year-old lorry driver. He lives at 3 George St, Luton, LU7 4AD
He presents to his GP as he has noticed that he seems to be passing “a lot of urine”. He says that
he drinks a lot, and keeps a bottle of water with him while at work. A fasting glucose test reveals a
glucose of 9 mmol/l and a BP 160/100. His height is 1.6 m and he weighs 105 kg. He is a smoker –
10 a day. His dad is diabetic.

Facilitator questions which student group brainstorm and discuss (groups can be asynchronous,
students do not have these questions):
1. Which problems can you identify from the history?
a. Polydipsia, polyuria, obesity, raised BP, smoker, FH diabetes

2. What are the top differential diagnosis for this patient?

a. T2DM, AKI, Hypertension, Bladder cancer, metabolic syndrome

3. Which tests would you like to request?

a. Only present the items they request to the student groups. Do this by posting in their
teams channel.
b. If they ask for something not available, say that test is not available at this time.
(cystoscopy is not available)

All of these results can be provided to the group if they are asked for.
 Urinalysis- labelled consultation 1
 BP monitoring- labelled consultation 1
 CT of bladder/kidneys- labelled consultation 1
 FBC (full blood count)- labelled consultation 1
 U+E (Urea and Electrolytes)- labelled consultation 1
 LFT (liver function tests- labelled consultation 1
 Lipid profile (for cholesterol and triglycerides)- labelled consultation 1
 Glucose tests- labelled consultation 1
 CRP- labelled consultation 1

Need to present test results and then continue discussion and repeat until they get all the test
results we have or are happy to move on.
Not getting all the information in the simulation/discussion is OK and will allow them to learn and
reflect on the experience for next week (see final section).

Once they have completed the ‘ask’ for test results please ask the groups- to discuss the following:
1. What problems do these tests highlight?
a. Raised FBS and HbA1c
b. Raised cholesterol
c. Elevated BP
 2. What is his most likely diagnoses?
a. Diabetes type 2 confirmed if HbA1c equal to or more than 48 mmol/mol)
b. Hypertension
c. Hypercholesterolemia
d. Metabolic syndrome

3. How would you manage this condition?

Manage type 2 diabetes:
a. Lifestyle issues: smoking, alcohol, exercise.
b. Body weight (BMI); reduce weight, dietary advice and monitoring.
c. BP: Monitor BP. If lifestyle advice does not reduce BP to below 140/80 add
medication. (Below 130/80 if there is kidney, eye or cardiovascular damage: NICE
2009: start ACE inhibitor)
d. Urine testing (fasting): glucose, ketones, microalbuminuria (renal function and CV
risk).
e. Biochemistry: Renal (? Hypertension), liver (may need statins baseline testing to
ensure LFT ok and not elevated with statin starting), thyroid function, and lipid
profile (to assess CV risk). Should be on a statin due to cardiac risk factors
f. Glycaemic control: HbA1c, (home glucose monitoring when appropriate)
g. Eye examination: acuity, ophthalmoscopy, digital photography (? any diabetic/
hypertensive changes).
h. Legs/ feet: signs of peripheral neuropathy, ulceration, deformity.

4. How would you assess his cardiovascular risk?

 HBPM (How to carry out)
For each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart
and with the person seated.
Blood pressure is recorded twice daily, ideally in the morning and evening.
Blood pressure recording continues for at least 4 days, ideally for 7 days — discard the
measurements taken on the first day and use the average value of all the remaining measurements
to confirm the diagnosis of hypertension.

 Introduce QRISK2, and ask them to calculate: https://qrisk.org/2017

QRISK2 uses the following factors: Age, Sex, ethnicity, smoking, FH CHD < 60, Diabetes, CKD, AF, BP
Rx, Cholesterol, BP, BMI.
James has a QRISK2 score of 47 % (i.e. his risk of having a heart attack or stroke within the next 10
years). Get students to discuss what this means
The QRISK2 highlights that James has significant risk for cardiovascular disease, and it is important to
address his risk factors. Lipid lowering medications are indicated in patients with a 10 year risk of
cardiovascular disease >10%, as they stand to benefit most from drug treatment.

5. What pharmacological treatment would you recommend for the CVS issues?
Ramipril- ACE inhibitors ACE should be started first line treatment for HTN in all patients with T2DM
irrespective of age/ethnicity
Commence statin – Qrisk >10% therefore should be on statin (atorvastatin 20mg)

Consultation 2 (Primary care) (15.10-15.30)

James returns to his GP practice two year later to discuss the management of his diabetes.
James reports that “I have drastically changed his lifestyle, taken up exercise and I know I am losing
weight as I went down a trousers size! I have tried giving up smoking but its not going to happen, its
my only naughty habit.”

James reports that “I didn’t have any changes at my last annual review to my medications and I do
not want to take any new medication. I have been taking the Ramipril and Atorvastatin since they
was prescribed but I really do not want any more if it can be helped..”

Facilitator questions which student group discuss and reach some conclusions as a group:
1. What examinations and questions will you ask the patient in a Diabetes Annual Review?
Once you have a definitive list from the group give them the results from their list if
available. Only give what’s available to you.
a. height and weight (BMI- under or overweight)
b. blood pressure
c. blood glucose control adherence to medication
d. HbA1c and cholesterol levels and renal function (include ACR as looking for CKD)
e. Any change in regimen, lifestyle or medication – including any side effects
f. Mood screen (no changes in mood)
g. Erectile dysfunction (no dysfunction)
h. Examine injection sites if on insulin (images not available as not taking insulin)
i. Check feet (not available but feet fine)
j. Urine sent for microalbuminuria

All of these results can be provided to the group if they are asked for.
 FBC (full blood count)- labelled consultation 2
 U+E (Urea and Electrolytes)- labelled consultation 2
 LFT (liver function tests- labelled consultation 2
 Lipid profile (for cholesterol and triglycerides)- labelled consultation 2
 Glucose tests- labelled consultation 2
 CRP- labelled consultation 2
 Urinanalysis-labelled consultation 2
 Blood pressure monitoring- labelled consultation 2
 Patient responses to lifestyle questions- video clip labelled consultation 2
 Patient responses to medication questions- video clip labelled consultation 2

2. “No medication if he can help it” How do you discuss the potential need for further changes
with this patient?

3. What changes to James management plan would you like to implement and why?

Consultation 3 (Accident and Emergency) (15:30-15:45)

5 years later James experiences chest pain and goes to his local hospital A&E department.
The A&E duty doctor takes a history.

James reports: “I saw my GP a week ago after I found that he was getting short of breath when
walking my dog. My chest got a bit tight at the same time, and his doctor gave him a spray to use
under my tongue. My doctor asked me to come back in a few days. The spray helped and I have not
yet had time to see the GP again. This morning, when taking my dog for a walk, I had tightness in my
chest, but this time the spray didn’t work and I felt quite short of breath. I managed to get home, but
I still felt “rough” so I drove to the hospital to get checked out.”

Facilitator questions which student group brain storm and present back to the room:
1. Which features could help you to differentiate the different causes of chest pain?
2. Are there any follow up questions you would ask?
3. What is the possible differential diagnosis, in a patient of this age?
a. Acute coronary syndrome: Central chest pain, radiates to jaw, neck, and arm;
constricting, crushing, choking, and heavy, burning or aching, SOB, pain takes
minutes to develop. Not eased by rest/GTN. Can come on wit exertion or at rest

b. Stable angina: central chest pain, discomfort or SOB comes on with exertion or
stress, relieved by rest in less than 5 min.

c. Muscular skeletal: pain on movement, tenderness of chest wall, tends to be felt

after exertion, not during. Bornholm’s disease (inflammation of intercostal
muscles due to coxsackie B virus)

d. Indigestion: heartburn and regurgitation often provoked by bending, patient often

overweight, may be woken at night choking as refluxed fluid irritates larynx, Sx may
mimic angina.

e. Pulmonary embolism: Faintness or collapse, central chest pain, severe SOB,

tachycardia, hypotension.

f. Pleuritic: discomfort related to breathing, often related to infection

Dissection aorta: abrupt, severe onset of pain, often radiates to back

Consultation 4 (Accident and Emergency) (15:45-16.15)

As James is waiting for the consultant, the A&E nurse reports that James has suddenly deteriorated.
He has suddenly developed severe crushing central chest pain that radiates to his jaw. He is pale,
sweating and breathing rapidly.

Facilitator questions which student group brain storm and discuss:

1. What immediate response and test would you want completed?
a. Immediate management: ABCDE approach
i. Assessment and initial resuscitation: Airway and Breathing; if he is talking,
then the airway is clear. Check for breath sounds and oximetry to see if he
needs oxygen. Maintain sats 94-96%
ii. Circulation: feel carotid pulse, and peripheral pulses. Venous access and
monitor BP. Cardiac monitoring if available.
iii. Assess conscious level
iv. Glucose check
b. Immediate treatment:
i. Morphine for pain (plus anti emetic)
ii. (Oxygen: see NICE guidelines), maintain sats 94-96%
iii. Nitrates (eg GTN, isosorbide mononitrate infusion) for vasodilatation,
 iv. Aspirin 300mg
v. Urgent referral to cardiology catheter lab for PCI
c. Investigations:
i. ECG (either 2 ECGs 30 min apart, or in continuing chest pain repeat ECGs
until diagnosis is made) Look for signs of ischaemia and arrhythmias
(causing reduced cardiac output).
ii. Troponin: measure on admission and 12 hours after the onset of pain. Highly
sensitive and specific for damage to cardiac muscle (but not 100% specific
for acute coronary syndrome: rise can be caused by coronary artery spasm,
aortic dissection causing ischaem, or renal failure)
iii. Serum cholesterol: Hypercholesterolaemia is a risk factor for cardiovascular
disease, and can be treated. Cholesterol level may be depressed for 2
months post MI, so should be tested as soon as possible.
iv. FBC: anaemia from any cause will reduce cardiac perfusion, resulting in IHD.
v. U&E: abnormal potassium can cause arrhythmia.
vi. Inflammatory markers; CRP, ESR, and WCC are all inflammatory markers
that may be elevated in pericarditis, Bornholm’s disease and MI.
vii. Glucose: Important to diagnose diabetes, as significantly increases
cardiovascular risk

All of these results can be provided to the group if they are asked for.
 ECG trace if discussed- labelled consultation 4
 FBC (full blood count)- labelled consultation 4
 U+E (Urea and Electrolytes)- labelled consultation 4
 LFT (liver function tests- labelled consultation 4
 Lipid profile (for cholesterol and triglycerides)- labelled consultation 4
 Glucose tests- labelled consultation 4
 CRP- labelled consultation 4
 Troponin levels- labelled consultation 4

2. What is the likely diagnosis? As well as possible differential diagnoses?

a. Likely diagnosis: STEMI (ST elevation Right precordial STEMI; Right Coronary artery
occlusion on ECG)
b. Differentials: arrhythmias, coronary artery spasm, aortic dissection, anemia,
hypo/hyperkalemia, pericarditis, Bornholm’s disease

3. What immediate treatment can be offered?

a. Coronary stent procedure
b. Multi-disciplinary recovery

Consultation 5 (primary care) (16:15-16:30)

James returns to his GP after recovering from his coronary stent procedure.

James reports “I feel like I have made a full recovery after having the stent inserted into the artery
around my heart, I can now walk the dog without any chest pain!”

Facilitator questions which student group brain storm and discuss:

 1. What secondary prevention / management should be offered and discussed?
a. Facilitator questions which student group brain storm and discuss:
b. Cardiac rehabilitation programme (exercise programme)
c. Lifestyle changes: Smoking, low salt diet, exercise and weight loss.
d. Blood pressure control: (age<55 ACE if Caucasian; age> 55 or non- Caucasian then
calcium channel blockers) (He is on Ramipril for BP) If diabetic all patients first line is
ACEi
e. Cholesterol reduction (statin) (he is on a statin) Diabetic control
f. Reduced thromboembolic risk: aspirin for life, clopidogrel for a year.
g. Beta-blocker: reduce cardiac demand (avoid where contraindicated)
h. ACE inhibitors (reduce recurrence and long term heart failure) He is on Ramipril
i. Glyceryl trinitrate sublingual

Consultation 6 (Primary care) (16.30-16.45)

James has regular check-ups and remains quite well.
A year later he is attending an appointment, when he asks the nurse to look at his feet.
James reports “could you have a look at my foot, I have an area on the bottom at the beginning of
my toe that has is red, although it doesn’t really hurt.”

Provide the groups with the following:

 Picture of foot- labelled consultation 6

Facilitator questions which student group brain storm and present back to the room:
1. What is the likely cause of the early skin ulcer?
a. Neuropathy (diabetic)
b. Ischaemia (diabetic)

2. What advice would you give diabetic patients about foot care?
a. Inspect feet daily, Avoid walking barefoot, Well-fitting shoes, check free of objects,
Regular review by podiatrist
b. Regular check on diabetic control

3. Which health care professionals could help in managing his condition?

a. Podiatrist
b. Diabetic nurse both in primary and secondary care
c. Endocrinologist
d. Cardiologist
e. GP

Exercise 7: Reflective Exercise at the end of the session (or via SDL): SNAPPS (16:45-17:00)
This is a six step technique for structuring student case presentations and the clinical
reasoning required in the process:
S ummarise the findings
N arrow the differential diagnosis
 A nalyse the differential diagnosis by comparing and contrasting alternatives
P robe the tutor to clarify any uncertainties
P lan management
S elect an area for further learning related to this patient

Consider your analysis of the scenario and whether you completed the SNAPPS process
during the session, exploring the why and how for each step will allow you to understand
your clinical reasoning and hone your skills. Also look at final S (select an area for further
learning related to this patient) and report to the team, using the linked form, what your ‘S’
for today is.