S2 Sample4
S2 Sample4
S2 Sample4
Please read the letter printed below. When the bell sounds, enter the room. You have 14 minutes
to take a history from the patient, 1 minute to collect your thoughts and 5 minutes for discussion.
You may make notes if you wish.
Referral text:
Dear Doctor,
I would be grateful if you would see this patient who was found to have type 2 diabetes mellitus 2
weeks ago. She was previously overweight with a body mass index of 28 kg/m 2 (normal range: 18–
25); however, she has been losing weight recently. She is taking bendroflumethiazide, and
beclometasone and salbutamol inhalers.
Her urea and electrolyte results are entirely normal. However, her liver function tests are as
follows:
Her fasting plasma glucose has remained around 12.0–13.0 mmol/L (normal range: 3.0–6.0) over
the past 2 weeks.
I am unsure why this patient has abnormal liver function tests and would value your assessment.
Yours faithfully,
Your task is to interview the patient and, based on the history you obtain, construct a differential
diagnosis and plan for investigation. You should explain these to the patient and answer any
questions they may have.
Any notes you make must be handed to the examiners at the end of the station.
You were told 2 weeks ago that you have type 2 diabetes mellitus, and were advised about cutting
out sugar from your diet. You were shown how to test your blood sugar and given a meter to do
this but your blood sugar in the morning has remained high at around 12–13 mmol/L (normal
range: 3–6). Your family doctor has just prescribed a drug called gliclazide for you to take for this.
Background information
Past medical and surgical history
Your gallbladder was removed when you were 42 years old and at that time you were jaundiced.
You have had high blood pressure for the past 5 years.
You have been told that you have mild chronic obstructive pulmonary disease (COPD).
Other complaints
None.
Personal history
Lifestyle
You have smoked 10–15 cigarettes per day since you were 18 years old. You have been drinking
very little alcohol recently because this seems to upset your stomach. However, in the past you
tended to drink about a bottle of wine at the weekends.
Occupational history
You are a housewife but you also look after your two young grandchildren 3 days per week.
Travel history
You visited Greece 10 months ago but apart from that have not recently travelled overseas.
Family history
There is no family history of diabetes, haemochromatosis or coeliac disease.
You have some specific questions for the doctor at this consultation:
Why do I have this pain in my stomach?
What has caused the diabetes?
Will I need insulin injections to control the diabetes?
Why am I losing so much weight?
I regularly look after my grandchildren during the day – will I still be able to do this?
Examiners should advise candidates when there are 2 minutes remaining (i.e. after 12 minutes). If
the candidate appears to have finished early remind them how long is left at the station and
enquire if there is anything else they would like to ask, or whether they have finished. If they have
finished, please remain silent and allow the candidate that time for reflection. The surrogate should
remain until the end of the 14-minute period.
A good candidate would be expected to take a history which includes a detailed social history and
activities of daily living; and to particularly focus on the questions raised in the referral letter. At the
end of the consultation the candidate should have discussed solutions to the problems posed by
the case. A good candidate would also give the patient the opportunity to ask any further questions
before closure. It is not necessary for candidates to agree a summary with the patient during their
interview.
Examiners are encouraged to make a rough record of the candidate’s consultation with the patient
as it progresses. This may highlight omissions in history taking, ambiguities that remain unresolved,
and additional points that were not ‘in the script’.
The examiner is expected to ask the candidate whether they have formed a problem list or
preferred diagnosis and answer the questions in the family doctor’s letter. Following discussion of
the answer to these questions the discussion should explore the issues raised.
Examiners should refer to the marking guidelines in the five skill domains on the marksheet.
Examiners are reminded that, during the calibration process, the surrogate should be rehearsed
and specific aspects of the scenario that require clarification or emphasis should be discussed. The
boxes on the next page indicate areas of potential interest in this case which both examiners should
consider, along with any other areas they feel appropriate. Examiners must agree the issues that a
candidate should address to achieve a Satisfactory award for each skill and record these on the
calibration sheet provided. Examiners should also agree the criteria for an Unsatisfactory award at
each skill.
NOT TO BE SEEN BY CANDIDATES
INFORMATION FOR EXAMINERS
Scenario No: Sample 4
Problem: Weight loss, diabetes mellitus and abnormal liver function tests
Candidate’s role: The doctor in the general medical outpatient clinic
Surrogate’s role: The patient, Mrs Betty Drake, a 56-year-old woman
Examiners are reminded the areas below indicate areas of potential interest, but are not intended
as absolute determiners of Satisfactory performance. It is for the examiners to agree and record the
specific criteria they will assess the candidate on during the calibration process.