Candidate’s instructions:
Where are you:
FY2 in acute medical unit
Who the patient is:
Carl farmer is a 70-year-old man who was admitted with myocardial infarction 5 days ago.
Other information you have about the patient:
He has been treated successfully and needs to be discharged home. He has history of hypertension and he is taking simvastatin, aspirin, amlodipine and paracetamol. The dose of Amlodipine has been reduced from 10mg to 5mg.
He was about to be discharged but the nurses have noticed that he has short term memory loss and they have asked you to see the patient.
What you must do:
Assess the cognition of the patient and discuss management with the examiner.
Candidate’s instructions:
Where are you:
You are the Foundation Year 2 doctor in care of the elderly.
Who your patient is:
Your next patient is Mr. Smith is a 70 years old man who was found wandering in the park and brought to the hospital by 2 policemen.
Other information:
None
What the doctor must do:
Assess the patient’s confusion and discuss management with examiner after 6 minutes.
Patient`s information
You are Mr. Anthony Smith, a 70 year old man who was found wandering in the park.
You have been brought to hospital by 2 police officers.
The doctor will be here to perform an assessment on you.
You do not have any hearing problems.
You can write, read and listen with no problems.
When asked questions, respond as follows:
- Which floor are we on? This floor – use your leg to demonstrate
- Which country are we in? France
- Which county are we in? Yorkshire
- Apple, Penny, Table: repeat after each word unless the doctor stops you from doing so
- When asked to spell the word WORLD backwards say it as “DAWARD”
- Tell the patient and spell it for him like. W for whisky, O for Oscar, R for Rose, L for Lima, D for delta.
- Recall: When asked to recall the three words respond which “Which words did you tell me?”
- W- Whisky
- O-Oscar
- R-Rose
- L-Leema
- D-Delta
- When the doctor asks you to name 2 objects, you are able to name 1 object but on the second object reply “I know this but I’ve forgotten the name”
- When asked to repeat no ifs, ands or buts reply as “no ifs, buts, buts”
- When the candidate asks you to write something during assessment write: “Good luck in your exam”
- When asked to take a piece of paper, fold it into two and give back, follow the first two instructions correctly but do not give the paper back.
- If the doctor asks you to read a sentence CLOSE YOUR EYES and do what it says correctly, do it correctly but keep your eyes closed until the doctor asks you to open your eyes
- When asked to draw two pentagons that intersects with each other on two points draw the two pentagons but do not intersect them. If the doctor asks you to try again tell them you are tired you don’t want to do it.
EMOTIONS AND ATTITUDE:
- During the interview, you get distracted easily and you make comments:
“Very nice weather today”
“Doctor why are you asking these questions?”
“A lot of cars passing around”
“Who are you?”
“What are we doing?”
“Where are we doctor?”
Examiner`s prompt:
When 2 minutes remaining, the examiner should stop the candidate and discuss management. The patient is cognitive impairment.
APPROACH:
GRIPS. (loud, clear, smile, maintain eye contact)
I am here to perform an assessment on you. This will help us assess how much you understand about what is happening around you. In order to do this, I will be asking you few questions, some questions will be very simple while others can sound silly, please bear with me. Before we start can I just ask, do you have any hearing problems? Any problems with writing or reading? Or any problems with your vision?
Are you ready for your first question?
Prepare patient before asking a question.
Questions to ask:
- What is your assessment? (Patient has memory impairment)
- Complete the MMSE
- Perform systemic examination and neurological examination
- Take a history and Past Medical Hx
- Accurate patient cognitive impairment, when he lost.
- Perform a dementia screen
- How will you manage this patient? (i will perform dementia screening)
-Full Blood Count (anaemia, acute infection).
-TFT, LFTs, U&Es
-Infection screening (Syphillis, HIV, Hepatitis)
-CT scan head looking for atrophic changes or Subdural hematomas.
-Blood Glucose.
-Investigate for UTI.
-CXR
-Iron, Folate levels, B12, Ferritin (haematemes)
-Urine Dipstick
-Ceruloplasmin (for wilsons disease)
-CJD Disease (check for prion)
-Refer the patient to the memory clinic.
Approach:
1.Slow and fluent.
- Assess patient and discuss mgt with examiners.
*GRIPS
*Smile,nice to patient, friendly.
*Bring attention of patient back.
- Prepare patient, ask following before you start:
Can I just check, do you have any…?
*Hearing problem.
*Able to read and write.
*Visual problems.
Short, clear questions.
To Examiner:
Dementia: screen the patient
Blood test : HIV,SYPHILIS SCREEN.
Thyroid Test: CT scan.
Chest x-ray.
ceruloplasmin.
Discuss Mx with the examiner:
-
Complete the cognition assessment
-
Neurological and systemic assessment
-
Perform Ixs
NB:
- Use piece of paper and pen to record your marks.
- Be ready to repeat information e.g. who are you ? where are we?
Thank you very much. Are you ready for the first question? Speak slow and clear.
3.Please ensure to use a pen and piece of paper to mark his score. Ask patient to repeat the information.