USING THE
CALGARY-CAMBRIDGE FRAMEWORK IN
THE CLINICAL ENVIRONMENT:
HISTORY TAKING
Year 3
Introduction to Clinical Learning (ICL)
Communication Session 1
September 2014
TUTOR NOTES 2014-15
Original authors: Dr Chris Harrison & Dr Jo Hart



Changes for 2013
ILOs modified to reflect changes in the Phase 1 consultation skills curriculum (students now
have prior experience of medical history-taking, systems review, and making a written
record).
All students now have an opportunity to practise history-taking.
Six scenarios are provided, with each SP playing two of these.
Sarah Collins, Nicky Barr and Sigrun Baier
If as a tutor you are feeling rusty regarding facilitating small groups, working with Simulated
Patients, feedback rules, etc., then please refer to the Communication Tutor Resource Pack (the
Site Administrator for Communication can email you a copy).
1
Contents
page
General information for tutors and simulated patients (context,
outline, intended learning outcomes, staff requirements, other
requirements)
Session outline
SP role 1 - Foster
SP role 2 - Bell
SP role 3 - Openshaw
SP role & model history 4 - Wilson
SP role & model history 5 - Dixon
SP role & model history 6 - Ahmed
The Calgary-Cambridge framework
Integrating the traditional history and Calgary-Cambridge framework
3-4
5-6
7-8
9-10
11-12
13-16
17-19
20-22
23
24
Notes for administrators 2013
There are now six SP roles for this session (five of which to be
played in any one group), with each SP playing two of these roles
and rotating round the groups as depicted in the table below. As for
previous years, three SPs per three student groups are required, and
age and gender specification are unchanged.
When sending out roles and student instructions to the SPs, please
also include pages 3-4 which now include information for SPs.
Thank you.
interval
Group
A
Group
B
Group
C
Role 1
Role 2
Role 3 Role 4
Role 5
Role 2
Role 3
Role 1 Role 5
Role 6
Role 3
Role 1
Role 2 Role 6
Role 4
1 SP (age 35-60, male or female) plays roles 1 and 4
1 SP (age 20-50, female) plays roles 2 and 5
1 SP (age 20-40, female) plays roles 3 and 6
2
ICL Communication Session 1
Information for tutors and simulated patients
CONTEXT
This is the first communication session in ‘Introduction to Clinical Learning’ for 3rd year
students.
In the first two years at Manchester, students attend hospital visits, community visits, and up to
24 consultation skills sessions, including: information-gathering, exploring the patient’s
perspective, physical examination, medical history-taking, review of all systems, making a
written record. All these sessions involve feedback: from simulated patients, other students,
and clinician and communication tutors.
Some students have not done their first 2 years at Manchester; they come mainly from St
Andrews or a Malaysian medical school. They will have attended a review session, but their
prior learning experiences and styles of training may differ.
OUTLINE OF SESSION [3 hours including a 15 minute break]
 Introduction in small groups [5 min]
 General discussion and review of history-taking and gathering information, working in pairs
then feeding back to group [15 min]
 5 scenarios. Each scenario involves two students so that all have a chance to practise. 25
minutes for practice and feedback for each of the first 3 scenarios, and 30 minutes for each
of the fourth and fifth scenarios which involve note-taking to record the content of the
history [2 hour 15 min]
 Conclusion in small groups [10 min]
The session provides the students with opportunities to reflect on, practise and develop
consultation skills they learned in Early Clinical Experience (including information gathering,
review of all systems, and making a written record) to prepare them for medical history taking
in their clinical placements.
Students will be in groups with a tutor in each. 3 simulated patients will rotate round the
groups. There are 6 SP roles, 5 of which will be played in any one group. Each group will do
scenarios 1, 2, 3 in varying order, and then two of three further scenarios (4, 5, 6). Your site
administrator will provide details of the rota. This document includes student instructions for
each scenario, and model written histories for tutors to refer to during discussion of recording
a history for scenarios 4, 5 and 6.
STAFF REQUIREMENTS
One tutor for each group: each in an appropriate room. 3 simulated patients for every 3 groups.
OTHER REQUIREMENTS
- Tutor notes
- Stickers for name badges and flip chart and pens for each group room
- Calgary Cambridge guides (1 per student plus 1 per tutor)
- Pendleton’s Feedback Rules (A3 – one to display each room)
- Intended Learning Outcomes (A3 – one to display in each room)
- Yellow individual student feedback forms for role playing students (one per student)
- Session Evaluation forms, one per tutor, for the communication team to keep
- Student feedback forms, for the tutor to keep (one per student)
3
INTENDED LEARNING OUTCOMES
By the end of the session students will have:
1. Reviewed their prior experience and understanding of what’s involved in taking a history;
2. Observed and participated in taking a full medical history using the adapted CalgaryCambridge framework;
3. Demonstrated understanding that the patient’s perspective is integral to history-taking;
4. Demonstrated effective use of communication to gather information;
5. Started to record the content of a history effectively during the interview, appreciating the
importance of chronology;
6. Appreciated that there are four stages of information processing:
i.
Gathering information;
ii.
Recording information;
iii.
Synthesising information to arrive at a differential diagnosis;
iv.
Presenting information (to be taught in another session).
Setting: Small groups, preferably 8, max 10 students (in PBL groups if possible)
Notes for Simulated Patients:
Students will be working in pairs, each doing one half of the history. Each role-play will be paused
halfway (by the tutor or the interviewing student), for the group to take stock, and for another
student to take up the interview. Please reserve your feedback for both students until the end of
the whole interview.
Students will practise how to gather information while maintaining good communication skills:
please
give feedback on both aspects. In the final two role-plays, students practise making a written
record: please comment on how they managed taking notes alongside their communication with
you.
Each scenario is constructed to allow students to gather information and integrate content
(symptoms, concerns) with process (how they ask/ listen). For the first two scenarios, please keep
your story relatively simple to allow students to get the hang of taking a history (e.g. downplay
emotions and concerns).



Student interviewer
Other students, with tutor input
Simulated Patient (in role)
 Student interviewer
 Other students, with tutor input
 Simulated Patient (in role)
Simulated Patient (out of role) on both the above.
General learning points for the students.
4
Time
Start
0
Takes
5 min
Start
5
Takes
15
min
SESSION OUTLINE
What do you do?
Introduce yourself. Use an ICEBREAKER for student introductions: e.g. pairs of students
talk together for 1 min and then introduce each other to the group (hobbies, favourite holiday
or film…).
Introduce the Intended Learning Outcomes (ILOs) – see p.4
Outline the session:
 General discussion and review of content and process of Medical Interviewing [15
min]
 5 role plays: 1, 2 and 3 for interview alone [25 min each]; then two of 4, 5, 6 to
practise note-taking while conducting the medical interview [30 min each]
 Conclusion [10 min]
Arrange students in different pairs from above (students remain in these pairs for the role
plays). Ask them to spend 5 minutes discussing questions 1 and 2 with each other. Then 5
minutes as a whole group gathering key points (see suggestions below) on flipchart paper.
NB: all Manchester and St Andrew’s students have been introduced to history taking, incl.
systems review and note-taking.
1. Why take a history?
to obtain information which helps in diagnosis and medical care, accommodating the
patient’s perspective. The history is the start point for medical care .
How can communication skills help in this process?
What have you learnt so far about how to communicate effectively with patients?
e.g. introduction, rapport building, open/closed questions, room arrangement, body
language, summarising, reflecting, pausing, clarifying, forward planning, appropriate
closure.
What problems might you encounter when trying to elicit a history?
e.g. patient’s ideas, concerns, expectations; hidden agenda; difference between focused
and full history.
2. What needs to be covered in a consultation as a whole? (including systems
review*):
*Systems review will be revisited in depth on firms over the year.
o Remind students to use the Calgary-Cambridge Framework (See p.23)
initiating the session / gathering information / physical examination (not today) /
explanation and planning (later in the year) / closing the session
o Highlight differences between the traditional history taking approach, and the
Calgary-Cambridge framework which integrates medical information gathering with
the patient’s perspective, while providing structure and building the relationship. (See
handouts pp23-24)
Then spend 5 minutes as a whole group considering 3 and 4:
3. Note taking during the interview and writing up the history in the notes:
o Explain difference between writing up the history in the traditional way (presenting
complaint, history presenting complaint etc.), and using the Calgary-Cambridge
framework as the process by which the information is gathered
Use flipchart with 2 columns to illustrate the difference and how to combine these.
4. Next steps (not practised in this session; but to be practised throughout students’ clinical
years):
Making sense of the information, synthesising it, considering differential diagnoses,
presenting the information to someone else.
Start
20
takes
5 min
Introduce the individual student feedback form,
o A yellow feedback form for each student interviewer. A colleague records a summary of
points of individual feedback from the session, for the student interviewer for their
portfolio.
Prepare the group for interviewing:
First three role-plays involve practising taking a history (with some systems review). Final
two role-plays involve taking a history and making notes at the same time.
All students will interview, in their pairs (doing half each).
5
Start
25
Takes
25
min
Start
50
takes
25
min
Start
at 75
Start
at 90
takes
25
min
Start
at 115
takes
30
Start
145
Takes
30
min
Every student completes a yellow feedback form for another student.
All observers can be given tasks, e.g. individual observers focus on specific areas, e.g. body
language, involving the patient, Ideas Concerns & Expectations, questioning style, attending
to flow/ structure, chronology, summarising, making organisation overt/signposting, rapport
building, etc.
You can also ask the interviewing students to identify areas for specific feedback.
The interviewing student can use the pause button at any time for suggestions from group.
Encourage students to focus on both content and process. Explain that each student, when
interviewing, is a “mouthpiece” for the group, and that each role-play builds on learning from
prior.
Explain the format:
 One student begins the interview, continuing until they or tutor pauses it after 5
minutes.
 Then allow 5 minutes for all students, including the pair doing the role-play, to
comment on information gathered so far, and how, and how the interview might
continue from here.
 Second student resumes interview, with a prompt from tutor after 5 min to close
interview.
 Feedback for both students (5 minutes) – to provide at least one “what went well” and
one “what could be done differently” for each student.
Role 1
Set up chairs, allocate feedback/observer roles, interviewing pair read out instruction. SP
waits outside until the first student comes to call them in. SP visits group for 20 min (FAO
TUTOR – keep to time!) – for the students to practise a complete medical interview (format
as above).
Role 2
As for Role Play 1, building on learning points and observations made.
Break (15 minutes)
Role 3
As for Role Plays 1 and 2, building on learning points and observations made.
The first of two further role plays to practise taking the history and writing it up at the
same time
o The first student in the pair interviews SP for a maximum of 4 min and takes notes at
the same time. Then first student presents a 1min summary of their notes, and hands
their notes to the second student, who resumes and completes interview in 4min,
adding to the notes.
o Ask up to 4 students to also take notes throughout the interview (as if conducting it).
o Other students observe for content/process /flow e.g. chronology, open/closed
questions.
o One student could write up the emerging history on the flipchart.
After role
o Debrief the student and group using the Pendleton Rules of Feedback, with everyone
contributing including SP in and out of role.
o Ask note-taking students about the notes they have taken and how they have
ordered them
o Discuss taking and recording notes – effect on interview, how to manage eye
contact, explaining to patient why taking notes, writing notes after each minisummary, what to record, how to record ICE, how to develop a structure, etc.
The second of two role plays to practice taking the history and writing it up at the
same time
o Follow the same format as above, implementing some of the learning points that
came out of this, especially in terms of note-taking whilst interviewing
6
o You may also pause the interview and move it on to focus on a different section (e.g.
Start
170
Takes
5 min
End
180
mins
past medical history) if the students haven’t covered these issues so far.
o Discuss: purpose of patient notes; what would be recorded; student notes and
confidentiality and anonymising (purpose of students notes is for the learner).
Close of Session
Ask each student to state one point they have learnt from today.
Give out evaluation forms for the students to complete, to be handed back to the tutor.
Remind student doing a detailed evaluation to complete in 2 weeks and email to the
administrator.
After the students have left, fill in the tutor evaluation form, including comments on each
individual student, and hand to the administrator.
All tutors please debrief with site leads (SPs to join in if time permits) after the
session.
7
Simulated Patient Role 1
Patient’s
name
Setting
Janice/Jeremy
Openshaw
GP Surgery
Course/Session
ICL 1
Role
Age
Sex
Other info
1
35-60
M or F
Background
You are Mrs Janice/Mr Jeremy Openshaw.
You live with your wife/husband and dog. You have two teenage/grown up children.
You are the manager of a busy restaurant in the town centre.
You do not smoke.
You don’t have time for any kind of formal exercise but walk the dog daily.
You share 2/3 bottles of wine with your husband at weekends.
Previous Medical Problems
No previous health problems.
Current Health Problem
You have come to see your GP, as you have been finding it difficult to open your bowels recently.
This has been getting gradually worse for the last 2/3 weeks. Now you only open your bowels
every 3 or 4 days.
It’s really uncomfortable. You feel bloated and have pain in the lower right area of your stomach,
which is relieved after passing some motions. When you do manage to pass a stool, it’s painful as
it seems hard and often like small rabbit droppings.
You are quite embarrassed going into details, but will do if need be. If asked, you have not had
any loss or gain in weight. You have not noticed any blood in your motions or on the toilet paper.
You feel well otherwise, and your energy levels are good.
You have been working long shifts and irregular hours over the last month. You have also been
indulging probably a little too much in rich foods and treats recently (restaurant leftovers) and
you’ve probably not been getting as much fruit and veg as you should.
As you are very busy at work you only drink about 3 glasses of water a day, if that. At breakfast
you just have a cup of coffee.
You have never had any problems with your bowels before.
If asked, you have no other symptoms.
Medical Problems in the Family (if asked)
Your Mother and Father are alive and well. Your Dad has diabetes, controlled by diet only.
You have no siblings.
Medication
You occasionally take paracetamol for headaches. No other medication.
Concerns and Questions
Although you think you are probably constipated and could have just bought something from the
pharmacy, you are worried and want to discuss your concerns with the doctor.
You know from recent public health adverts on the TV & radio that this symptom could be down to
bowel cancer, and you are a little worried that this could be the problem.
You have read a leaflet that was posted through your door offering a "lifescan" - some sort of scan
that can pick up some types of cancer early- is it worth having that scan? You were going to ask
the GP this.
8
Instructions for Medical Student
Role 1
You are a third year medical student.
You are currently on placement in a GP surgery.
Your GP has asked you to take a history from Mr/Mrs Openshaw.
You have been told that he/she made this appointment to see the GP today, but you
have not been given any other information.
Please take a full history including systems review if appropriate from Mr/Mrs
Openshaw, to find out why he/she has come to see the GP today.
Remember you can pause at any time to ask for suggestions from the group.
The tutor may need to stop you if time is short.
9
Simulated Patient Role 2
Patient’s
name
Setting
Mrs Miriam Bell
Course/Session
ICL 1
GP surgery
Role
Age
Sex
Other info
2
25-50
Female
Background
You are aged 25-50 and happily married with children (ages to suit your own). You are employed
in a baker’s. In your spare time you love to garden. You have recently (3 months ago), acquired a
kitten. Several years ago your partner was medically retired due to a back injury, the result of a car
crash. Thus, you are the main bread-winner and need to work because your pension scheme is
poor.
Previous Medical Problems
Other than the usual head colds and flus, you’ve noticed that you’ve been prone to winter coughs
over the last few years. These coughs tend to accompany a head cold and settle after 2-3 weeks.
You cannot remember coughing anything up during these spells. You have never consulted your
GP regarding the coughs, which you consider to be ‘normal’ for you. You are a non-smoker.
Current Health Problem
For about two months now, you have been bothered with a dry cough and sometimes with strange
(noisy) breathing (wheezing). Sometimes you’ve noticed you’ve been getting slightly breathless
when digging in the garden.
In the last couple of weeks you’ve noticed your cough has got worse, and you’ve been coughing
up small amounts of horrible green stuff. Your breathing is getting noisier and you are feeling more
breathless. Most forms of exercise seem to leave you short of breath, e.g. climbing the stairs, and
carrying the shopping in from the car.
Night-times are worst of all: you and your husband are frequently awakened by your coughing and
wheezing, despite being propped up on several pillows.
In addition, you have become aware of an odd feeling in your chest (a tightness in the front of your
chest when you get breathless). The tightness is accompanied by a burning feeling, which spreads
all over your chest.
Other Medical Problems (if asked)
Your weight, appetite, etc. remain unchanged. You do not suffer from hay fever or any allergies
(e.g. house dust). There is no family history of respiratory or heart problems.
Medication
You only take over-the-counter cough syrups.
Current concerns and emotions
You have no real idea what is causing your problems.
You wonder if it could be related to your heart, (angina), because of the tight feeling across your
chest.
You worry about having to take time off work, because you need to provide for your husband and
children.
OBJECTIVES:
•
Students are practising how to gather information while maintaining good communication
skills: please ensure that you give feedback on both of these.
10
Instructions for Medical Student
Role 2
You are a third year medical student.
You are currently on placement in a GP surgery.
Your GP has asked you to take a history from Mrs Miriam Bell.
You have been told that Mrs Miriam Bell made this appointment to see the GP
today, but you have not been given any other information.
Please take a full history including systems review if appropriate from Mrs Bell, to
find out why she has come to see the GP today.
Remember you can pause at any time to ask for suggestions from the group.
The tutor may need to stop you if time is short.
11
Simulated Patient Role 3
Patient’s
name
Setting
Sian Foster
Course/Session
ICL 1
GP surgery
Role
Age
Sex
Other info
3
25-40
Female
Background
You live with your husband (who is a full-time teacher) and your two children, aged 4 and 1.
Your in-laws live nearby and they are a great help with the children.
You work part-time as a medical laboratory scientific officer in the haematology department at
Manchester Royal Infirmary.
You are a non-smoker, and you drink alcohol only very occasionally (about once or twice in a
month).
Current health problem
Yesterday afternoon you developed backache whilst driving home from work. It got worse during
the evening and you went to bed early after having a hot bath. When you woke this morning your
back was very painful and stiff. You had to roll out of bed. Bending to dress provoked severe pain.
You have taken 4 Paracetamol already today and the pain is still bad. The pain is in the lower part
of your back and across the top of your buttocks.
Earlier in the week you lifted a large box of equipment across the laboratory; you wonder now if it
was too heavy for you and has caused an injury.
Other medical problems (if asked)
You are generally healthy, you had piles (haemorrhoids) 3 years ago but this resolved with an
ointment. No past history of back problems. No other health problems or previous illnesses.
Family history:
Mother has angina. Your father died last year; he had a recurrent back problem throughout his life
and attended an osteopath, though you really aren`t sure what the underlying problem was. You
wonder if you have inherited a weakness or predisposition to back problems.
Medication:
You take Paracetamol occasionally for headaches. You have taken 4 tablets this morning with
only partial relief of the backache. You have no known allergies.
Current concerns and emotions
You’re worried about not being able to look after your young children – not being able to lift them
or to play with them. A friend has recently had surgery for a persistent back problem and, after
nearly 6 months off work, is still on lots of painkillers and unable to cope with everyday tasks such
as bathing the children and mowing the lawn.
You are going on a camping holiday in 2 weeks time; you need to be fit and well to be able to
enjoy it.
Your husband is also busy at work and you are worried that recurrent problems with your back
might put greater pressure on him.
You would like to be given something to relieve the pain, and possibly some further investigation.
OBJECTIVES:
•
Students are practising how to gather information while maintaining good communication
skills: please ensure that you give them feedback on both of these.
12
Instructions for Medical Student
Role 3
You are a third year medical student.
You are currently on placement in a GP surgery.
Your GP has asked you to take a history from Mrs Sian Foster.
You have been told that Mrs Foster made this appointment to see the GP today, but
you have not been given any other information.
Please take a full history from Mrs Foster (including systems review if appropriate),
to find out why she has come to see the GP today.
Remember you can pause at any time to ask for suggestions from the group.
The tutor may need to stop you if time is short.
13
Simulated Patient Role 4
Patient’s
Mr/Mrs. Wilson
name
Setting
Surgical ward
Course/Session
ICL 1
Role
Age
Sex
Other info
4
35 – 60
M or F
Post op
Background
Married, with three children (pick suitable ages to fit in with your age). You work for a bank on the
counter. You don’t smoke, and you share a bottle of wine with your spouse approximately three
times per week.
Recent Past
For a few months you had recurrent attacks of tummy pain. It was high up, just below your ribs
(pointing below ribs on right side). The pain often went through to your back, and would last an
hour or two. You had wondered whether it was a stomach ulcer, but hadn’t got round to seeing
your GP. About 6 weeks ago, you had a much more severe version of the pain. It was constant,
and any movement was very uncomfortable. You were vomiting, had a high fever and felt very
unwell. You were sent into hospital by your GP, where they diagnosed an inflamed gallbladder,
caused by gallstones. They put you on a drip, and painkilling injections for a few days. The
surgeon said that they would remove the gallbladder a few weeks later.
Other Medical Problems (if asked)
You’ve usually been fit and well, apart from an under active thyroid, for which you take thyroxine
(100 micrograms per day). This has never bothered you, as this seems to run in your family. You
have blood tests each year to make sure you are on the right dose.
About three years ago you were depressed, and took Prozac for about 8 months. This happened
after your mother died of breast cancer. You were close to her. Since then, you have felt mentally
fine, although your family keep you busy.
Now
You were admitted to hospital 3 days ago to have your gallbladder taken out by keyhole surgery.
Unfortunately, the surgeon was unable to remove it through the keyhole, so instead they had to
make a much bigger scar underneath your right ribcage. It is painful and you have a drain coming
out of the scar. You feel bloated and your bowels haven’t properly worked after the operation- you
have only been once and passed a very small amount. You feel constipated. You are on oral
painkillers that the nurses give to you – you do not know what they are called.
Current Concerns and Emotions
You feel very disappointed that you have had to have the bigger scar, as the surgeon implied this
was very unlikely. He also said you’d be up and about in no time, and would barely realise you’d
had an operation. Now you are worried about when you will be able to get back to work. With
these concerns and your discomfort, you feel quite low and, at times, even tearful. You are not
angry with the surgeon, just sad and frustrated.
OBJECTIVES:
•
•
Students are practising how to gather information while maintaining good communication
skills: please ensure that you give them feedback on both of these.
In this part of the session, students are learning how to record the content of a history
effectively: please comment on how their taking notes affected the interview.
14
Instructions For Medical Student
Role 4
You are a third year medical student.
You are based on a surgical ward.
Your consultant has asked you to take a history from Mr/Mrs Wilson.
You have been told that he/she has had an operation recently but you have not
been given any other information.
Please take a full history including systems review if appropriate from Mr/Mrs
Wilson, to find out why he/she has had an operation, as well as discovering what
has happened since coming in to hospital.
If you have been asked to take notes during the interview, please do that also.
Remember you can pause at any time to ask for suggestions from the group.
The tutor may need to stop you if time is short.
15
Model History for Role 4 – Information For Tutor
Mr /Mrs Wilson
Age: YY
Date of birth: A/B/C
[today’s date] Seen on Ward QQ
Presenting complaint(s):
Post-op open cholecystectomy
History of Presenting Complaint:
Recurrent episodes of epigastric pain for several months
- each episode lasts 1-2 hours
- radiates through to back
6/52 ago, much more severe episode of pain
- same location
- constant, made much worse by any movement
- associated with vomiting and high fever
- admitted by GP to hospital
- put on drip and parenteral analgesia
- advised by surgeon it was due to inflamed gallbladder/gallstones, listed for admission to
remove gallbladder
Admitted here 3 days ago for planned laparoscopic cholecystectomy
Laparoscopic approach unsuccessful so converted to open cholecystectomy
Now recovering, drain still in place. Still in significant discomfort.
Currently constipated – bowels have opened once since op, but small amount only. Passing flatus.
Not vomiting. Eating small amounts only.
Patient’s Perspective (Beliefs and Concerns)
Initially thought recurrent episodes were due to ulcer
Disappointed by larger scar – had expected laparoscopic approach would have been
successful
Concerned about level of pain and when can return to work
Low and tearful at times, not angry or clinically depressed
Past Medical and Surgical History
Hypothyroidism, on replacement Rx.
(Has annual thyroid function tests to monitor this)
Episode of depression 3 years ago
- took prozac (fluoxetine) for 8 months
- associated with life events (death of mother)
- been fine since, but busy with family
Drug History
Levothyroxine 100mcg daily (takes regularly, no side effects)
Currently on oral analgesics while in hospital – unsure of name
No herbal or over-the-counter remedies
Allergies
None known
Family History
Mother died of breast cancer 3 years ago (?age)
16
Thyroid problems run in family (unsure of details)
Nil else relevant
Personal and Social History
Married, 3 children
Counter Assistant at local bank
Non-smoker (lifelong)
9-12 units alcohol/week (3-4 units, 3 times per week – wine)
Systems Review
NS* current low mood, tearful
Nil of note in other systems
Examination Findings
Not examined
* NS = Neuro System
17
Simulated Patient Role 5
Patient’s
name
Setting
Mrs. Dixon
Dermatology OutPatient Department
1st outpatient
appointment
Course
ICL 1
Role
5
Age
Sex
Other info Wear a hat, skirt that covers knees, long sleeved top
20-50
Female
You are married – your husband says he understands your feelings about having psoriasis but
you are not sure that anyone does really. You work in a factory, which is fine because you have to
wear a cap to cover your head – it is a sweet factory. You worry that someone will say that you
cannot work if they find out. You have no children – your husband cannot have them so when the
doctor told you that you both agreed not to do any other tests. You have always been happy with
that, as you would not want to pass psoriasis on to any children. You think it is hereditary as an
aunt and a cousin have it but they do not seem bothered by it. There is no family or previous
personal history of anything else.
Current Problem and how it affects you
You have psoriasis – a scaly, thickened skin disorder on your elbows, knees and scalp. It comes
as red thick patches with a silver scale. The patches are itchy and the scales come off causing
you great embarrassment because it looks like you have very bad dandruff most the time. You
feel you have to cover up your arms and legs always even in very hot weather and you have not
been swimming for years even though you enjoyed it. You cannot wear dark clothes because of
your scalp and you find it very awkward going to the hairdresser even though you know it is not
contagious at all but just looks awful. In the past one hairdresser insisted on wearing gloves to cut
your hair. No-one knows that you have psoriasis until you feel you can trust them and you feel it is
because of the psoriasis that your social life is very limited even though you feel you would
naturally like to go out more (to the pub, for meals with friends, etc.). So you don’t drink at all, and
have never smoked.
You do not know what caused it and you have had it since you were late teenage which was awful
at the time because you felt everyone was looking at you. You are sometimes better than at other
times but you do not know why – when you are particularly stressed in life it is possibly worse, but
even this is not clear cut.
Now Your psoriasis is very bad right now. You have come to the dermatology clinic as your GP
has referred you. You suspect because she doesn’t know what else to do. You have seen various
GPs in the past - but feel they have always been interested in the skin as a condition, rather than
in you and the effect if has on your life. Consequently you have never really listened much to what
they have said especially as the creams and shampoos they have prescribed have always smelt
so much and have not helped much anyway and you have given up using them. There is an
element in you that would love there to be a magic cure but expect that you’ll get the usual brush
off from the doctors.
OBJECTIVES:
•
•
Students are practising how to gather information while maintaining good communication
skills: please ensure that you give them feedback on both of these.
In this part of the session, students are learning how to record the content of a history
effectively: please comment on how their taking notes affected the interview.
18
Instructions for Medical Student
Role 5
You are a third year medical student.
You are based in a dermatology out-patient clinic.
Your consultant has asked you to take a history from Mrs Dixon, who has been
newly referred. The consultant will see her afterwards.
You have been told that she has been referred to the clinic by her GP for psoriasis
but you have not been given any other information.
Please take a full history from Mrs Dixon including an appropriate systems review, to
find out why she been referred.
If you have been asked to take notes during the interview, please do that also.
Remember you can pause at any time to ask for suggestions from the group.
The tutor may need to stop you if time is short.
19
Model History for Role 5 - Information for Tutor
Mrs X Dixon
Age: YY
Date of birth: A/B/C
[today’s date] Seen in Dermatology Outpatients
Presenting complaint(s):
Psoriasis
History of Presenting Complaint:
Extensive psoriasis for many years
Affects extensor surfaces of knees and elbows, also scalp
Patches are red and scaly - can be itchy
Has tried numerous creams and shampoos in past (unsure of details, some had strong odour), but
none have helped. Unsure whether has she been compliant with treatment. Remains sceptical that
any doctor will be able to help
Has had very significant impact on her life
- embarrassed by scales coming off (manifesting as ‘severe dandruff’)
- feels has to keep covered up, even in hot weather
- avoids swimming, wearing dark clothes
- some hairdressers have stigmatised her in past (implied it was contagious)
GP has referred her here to Dermatology Outpatients for second opinion
Patient’s Perspective (Beliefs and Concerns)
Knows she has psoriasis
Hopes for ‘magic cure’ but recognises this is unlikely
Not felt doctors have previously taken her seriously – treated her skin rather than her as
whole person
Past Medical and Surgical History
Nil of note
Drug History
Nil at present. Has tried numerous creams in past for psoriasis, unsure of details
No herbal or over the counter remedies
Allergies
Nil known
Family History
Aunt and cousin both have psoriasis (are less severely affected)
No other relevant family history
Personal and Social History
Married, no children (infertility in husband)
Assistant in sweet factory
Limited social life – tends only to tell very close friends about psoriasis
Non-smoker
No alcohol intake currently
Systems Review
M Skel: No joint symptoms
Nil relevant
Examination Findings
Not examined
20
Simulated Patient Role 6
Patient’s
name
Setting
Lisa Ahmed
Course
ICL 1
A&E
Role
Age
Sex
Other info
6
20 – 40
Female
Background
Teacher/ nursery nurse. Just got married [previous name – Ball] and arrived back from 2 week
honeymoon in Australia a few days ago. Travelling out you were upgraded to business class as
you were honeymooners, but coming back you were stuck in economy. You had a fair amount of
wine on the way back and slept for a large part of the journey. (NB This may not seem relevant to
the case but it does fit in well with the subsequent diagnosis.) Smoke 20 per day – know you
should give up really. Normally rarely drink, but shared a bottle of wine with your husband most
nights during your honeymoon.
Current situation
You have come to A&E after you coughed up blood several times in the last 24 hours– darkish
red, small amounts, and have been feeling a bit short of breath. Also had a sharp pain in the back
of your chest. Felt like a knife in your back, especially when you take a deep breath in. If asked
your left leg is slightly swollen, at the calf, and feels uncomfortable – this has only come on since
the flight home.
Concerns
When initially noticed blood, wondered if you had contracted TB during plane journey. Or whether
this is lung cancer (as you recognise you are at risk as a smoker). You are very frightened.
Expects to be examined and uncertain what might be the outcome
When you first coughed up blood, you thought it might have been TB, as you’d heard that there’s
more about these days – maybe you picked it up from the air conditioning on the plane. At the
back of your mind you wondered about lung cancer as you smoke.
Previous Medical Problems
Had grommets in your ears when you were young, because of recurrent ear infections. Hearing
fine now.
Gets headaches and neck ache at the end of the day. GP said it was it was tension which you can
believe as your job is very hectic. Swimming helps the headaches. Hay fever in summer.
Medication
Femodene – contraceptive pill (take 21 out of 28 days). Been on this for about 4 months. You took
a different type of pill before that (microgynon) but you thought it was making your headaches
worse. Take Zirtek antihistamines in the summer for your hayfever.
OBJECTIVES:


Students are practising how to gather information while maintaining good communication
skills: please ensure that you give them feedback on both of these.
In this part of the session, students are learning how to record the content of a history
effectively: please comment on how their taking notes affected the interview.
21
Instructions for Medical Student
Role 6
You are a third year medical student.
You are based on A & E.
Your consultant has asked you to take a history from Ms Lisa Ahmed
She has presented to A&E complaining that she is coughing up blood.
Please interview Ms Ahmed to find out about the symptoms and take a full history
including a systems review.
If you have been asked to take notes during the interview, please do that also.
Remember you can pause at any time to ask for suggestions from the group.
The tutor may need to stop you if time is short.
22
Model History for Role 6 – Information for Tutor
Mrs Lisa Ahmed
Age: YY
Date of birth: A/B/C
[today’s date] Seen in A +E
Presenting complaint(s):
haemoptysis
History of Presenting complaint:
- 24 hr history of several episodes of haemoptysis
- small amounts of dark red blood
- no fever or purulent sputum
- associated with sharp, stabbing pain in back (interscapular region)
- pain aggravated by deep inspiration, and causing some shortness of breath
- this occurred within 2 days of returning from long-haul flight from Australia (had slept most
of time, drank large quantity of alcohol)
- also left leg swollen and uncomfortable
Patient’s perspective (beliefs and concerns): patient initially thought it might be TB following
plane journey
Past Medical and Surgical History
Recurrent ear infections as child – treated surgically by grommet insertion. Hearing now fine
Recurrent tension-type headaches
Hay fever
Drug History
Femodene for last 4/12 – now been told to stop
Cetirizine once daily as required (for hay fever)
No herbal or over the counter remedies
Allergies
No drug allergies known
Family History
Nil relevant
Personal and Social History
Nursery nurse
Married (2/52 ago)
Smokes 20 per day for x years, aware needs to stop ‘at some stage’
Patient concerned about long- term risk of lung cancer, aware is at risk
Alcohol normally only on rare occasions, but drank 3-4 units per night for last 2/52 (honeymoon) –
ie ½ bottle wine
Drank on plane journey, long haul, stationary for several hours in economy class
Systems Review
Nil relevant
Examination Findings
Not examined
23
24
THE TRADITIONAL HISTORY
AND CALGARY-CAMBRIDGE FRAMEWORK
INTEGRATED
STRUCTURE FOR TAKING, RECORDING AND PRESENTING A HISTORY
PRESENTING COMPLAINT(PC)
HISTORY OF PC(HPC)
Add Patient’s Perspective
PREVIOUS MEDICAL HISTORY(PMH)
PREVIOUS SURGICAL HISTORY
Drug History (DH)
Allergies
SYSTEMS REVIEW (SR)
SOCIAL HISTORY
FAMILY HISTORY
PATIENT’S PRESENTING
COMPLAINT(S):
1.
2.
3.
4.
BIOMEDICAL PERSPECTIVE
(DISEASE)
sequence of events
symptom analysis
relevant systems review
PATIENT’S PERSPECTIVE & experience
(ILLNESS)
ideas
concerns
expectations
effects on life
feelings
BACKGROUND
INFORMATION/CONTEXT
DIFFERENTIAL DIAGNOSIS
MANAGEMENT PLAN
DIFFERENTIAL DIAGNOSIS
MANAGEMENT PLAN
25