Practice Station Acute Care Hx + Ex

Instructions to Candidates:

You are a Foundation doctor in the Emergency Department.

This patient has arrived feeling short of breath.

Please take a brief focussed history. Then examine his chest

from the front telling the examiner what you are doing and why
as you proceed.

At six minutes, the examiner will ask you questions.

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Practice Station Acute Care Hx + Ex

Station Information
Station Reference Practice Station Acute Care Hx + Ex

Station Title Practice Station Acute Care Hx + Ex

Student Description none

Author no author

Year Group Practice 1Med Stations

Clinical Domain Respiratory

Clinical Competency Patient Assessment (Acute Care)

Information for Site Organisers

Type of patient required:
Simulated patient (history only).

Patient information:
SP, male, aged 30-50yr willing to have chest examined

Resources and equipment needed:

Print out of blood results (attached)
1 examination couch with pillow and sheet/blanket
Alcogel

Chairs x 2

Setting up the station:

This station should be set up in the usual patient examination format: 2 chairs and examining couch or chair.
The candidate should be able to examine the patient from the patient's RIGHT side. The examiner’s chair
should be positioned so that he/she can observe both candidate and patient.

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Practice Station Acute Care Hx + Ex

Information for the Examiner

What is the overall aim of this station?
This station tests the candidate’s ability to combine a brief focussed history and examination around an acute
clinical situation to come to a diagnosis.

Examiner’s role:
If the candidate asks, the following information can be given to them:
• Blood Pressure 105/65
• Pulse 95
• Saturations 96% on air
At 6 minutes stop the candidate and ask:
1. What is your differential diagnosis and why?
2. Then show the blood results and ask: What do these blood result show?
3. What is the most likely diagnosis?

Standardisation is important. Whilst you may clarify the candidate’s responses to the questions above, please
do not ask supplementary questions of your own.

What is expected of the candidate?

This is a station designed to test the candidate’s ability to examine a patient simulating an acute chest
condition, consider blood results and reach a straightforward diagnosis.
The candidate should ask a few pertinent questions such as:
• PC: what is the symptoms(s), when did it start, how has it changed
• Associated symptoms: cough, no sputum, repeated streaky haemoptysis, no wheeze, pleuritic type
chest pain, no temperatures
• Nature of pain - sudden, right-sided, sharp, hurts to take deep breaths (pleuritic)
• Recent travel – came off flight from Dubai last week
• Leg swelling – nil
• PMHx: Previously fit and well
• Smoking status: Smokes 20 cigarettes daily.
Then examine the chest in a focussed manner. The candidate is directed in their instructions to examine the
front only for the purposes of time:
• Global assessment – resp rate, pulse, sats, distress etc
• Chest expansion,
• Tracheal deviation
• Percussion
• Breath sounds

Marking Guidance: if you award a global judgement below 'Excellent', it is

extremely important you provide constructive feedback on key areas the candidate
should develop further i.e feedback which justifies the grade awarded.
The excellent / good candidate typically…

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Practice Station Acute Care Hx + Ex

• Will take a structured & clinically reasoned history.

• Will explore almost all of the key symptoms and elicit and address the patient's ideas, concerns,
feelings and expectations.
• Will demonstrate excellent communication skills, using a structured approach and avoiding jargon.
• Will conduct a systematic yet focused examination in a confident and structured manner covering all
expected steps.
• Will take note of, and accurately interpret any observation charts etc, if provided.
• Will respect and attend to the comfort, safety and dignity of the patient.
• Will be able to identify the key clinical findings.
• Will be able to answer the examiner’s questions confidently and accurately.
The satisfactory candidate typically …
• Will take a structured history though will miss asking about some key symptoms.
• May appear unstructured at times.
• Will perform most of the expected examination steps though may omit some aspects, or be
unstructured at times.
• May take note of, and correctly interpret most of the data on observation charts etc, if provided.
• Will not always respect and attend to the comfort, safety and dignity of the patient, eg by allowing
them to remain exposed unnecessarily.
• May not provide a structured differential diagnosis, and may not identify all the clinical findings.
• Will be able answer most of the examiner’s questions.
The failing candidate typically …
• Will be unstructured and flustered throughout with a disorganised, scatter gun approach to the
history.
• Will miss important questions in the history.
• Will neglect key steps in the examination and/or be unable to offer a sensible and clinically
appropriate differential diagnosis and/or management plan.
• Will fail to take note of, or incorrectly interpret the data on observation charts etc, if provided.
• Will struggle to answer the examiner’s questions.

As this station involves a patient (simulated or real), the candidate should follow standard infection control
practices (e.g. clean hands with alcogel upon entering AND before leaving / clean stethoscope if used / bare
below elbows etc).If the candidate is in breach of any OR multiple infection control measures, then their
global judgement should be no more than 'GOOD', and remind them of the importance of this in their
written feedback.

Clinical information relevant to the station:

Nil additional needed

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Practice Station Acute Care Hx + Ex

Information for the Simulated Patient

Opening statement for the patient:
”I’m glad you’re here doctor. I’ve been having problems with my breathing”

About you:
Your name is Steven Smithson
You are 40 years old – work as an actuary for a large consulting company.
No siblings
You live with your wife. 2 children aged 7 and 9.

Current health problem:

You recently returned from Dubai 4 days ago following a business trip.
You initially felt fine on your return but in the past 2 days you have feel increasingly short of breath especially
if exerting yourself. You also have a dry cough and quite a few times there have been streaks of blood.
Other symptoms
• Right sided
• Sharp pain worse on taking a deep breath
• No fever symptoms
• No leg swelling
• You are becoming increasingly breathless and concerned.
The candidate will examine your chest front and back.
They will then look at the blood results.
If they do not treat you appropriately make some comment so that the examiner picks it up.
They should expose your chest only and then cover you again at the end. If they do not do so make some
comment for the examiner.

Your ideas, concerns, feelings and expectations:

If asked, you simply want to know what is causing these symptoms. You do not have any idea yourself as to
what it could be. You hope the doctor can find out what is going on and treat it accordingly.

Questions:
Nil

Previous medical history:

Previously fit and well. No previous operations and you have not had any reason to go and see your GP for
anything recently.

Medical problems in the family:

No family history of chest pain, lung disease, asthma. You smoke 20 cigarettes daily.
No family history of any medical conditions.

Medication:
You take no prescribed medication and do not take anything regulalry over the counter.
You have no allergies.

How to play the role:

Give the impression that you are mildly short of breath (it is difficult to maintain this throughout so you can
do this at the start and then intermittently)

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Practice Station Acute Care Hx + Ex

Marking Domains
01. Overall conduct of the consultation with patient/relative/carer
Introduces self, states own role and checks identity of patient/ relative/ carer
Explains and agrees the purpose of consultation
Establishes and maintains rapport
Attends to the comfort, safety and dignity of the patient if applicable
Demonstrates empathy and sensitivity
Discusses patient information sensitively and with awareness of confidentiality if applicable
Maintains a fluent, coherent and competent approach
Manages time, completes task and closes appropriately
Follows appropriate infection control measures throughout

02. History Taking Skills

Appropriately uses a combination of open, probing and closed questions
Adopts a clinically reasoned approach, demonstrating the ability to differentiate relevant from irrelevant
information in order to narrow the differential diagnosis
Enquires about red flag features in order to rule in and rule out serious/ significant pathology
Uses a patient-centred and structured approach throughout
Appropriately elicits and acknowledges the patient’s feelings, ideas, concerns and expectations
Explores the impact on the patient’s life
Clarifies and summarises as appropriate
Avoids inappropriate reassurance
Demonstrates responsiveness to the social, cultural and ethnic background of the patient, and their
abilities and disabilities

05. Physical (Clinical) Examination Skills

Uses alcohol rub before and after examination and, when appropriate, uses gloves
Explains the nature of examination
Seeks consent to examine
Offers/asks for chaperone where appropriate
Guides the patient in positioning themselves appropriately
Asks the patient if any areas to be palpated or moved are painful
Uses a methodical, fluent and correct technique
Examines, or suggests examining, all the relevant areas
Correctly identifies clinical signs
Attends to the comfort, safety and dignity of the patient throughout

14. Clinical Knowledge and Diagnosis

Identifies the underlying problem(s)
Demonstrates an appropriate depth of understanding of the clinical condition/pathology
Applies reasoning skills to interpret information in the clinical context
Applies knowledge to the patient’s current situation
Generates a plausible list of differential diagnoses and if required, is able to identify which is most likely
Provides a clear justification and rationale for their diagnosis or differential diagnosis

15. Providing information to the examiner

Communicates findings clearly, if applicable
Summarises accurately and concisely if applicable
Answers examiner questions clearly and competently
Provides and prioritises answers that are reflective of routine clinical practice
Justifies answers in context of the patient’s problem

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