INFORMATION FOR THE CANDIDATE

Scenario N EX1

MRCP(UK) PACES Station 2: HISTORY TAKING

Patient details: Your role: Presenting complaint: Mrs Heba Kamel, a 54-year-old woman The doctor in the general medical outpatient clinic Progressively worsening dyspnoea

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, This retired nurse has had progressively worsening dyspnoea for the past 18 months. She has a history of recurrent urinary tract infections and is on long-term antibiotic therapy. She smokes 20 cigarettes per day and has done so for the past 20 years. She has no past respiratory history. She has hypertension and is known to have right bundle branch block on her ECG. Examination reveals definite bi-basal crackles on auscultation of the chest. Full blood count and urea and electrolytes are normal. Please see and advise on her management. Your sincerely,

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.

DO NOT EXAMINE THE PATIENT Any notes you make must be handed to the examiners at the end of the station

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX1

MRCP(UK) PACES Station 2: HISTORY TAKING

Mrs Heba Kamel, a 54-year-old woman The general medical outpatient clinic

Your role: Location:

History of presenting symptoms

Information to be volunteered at the start of the consultation You present with an 18 month history of progressively worsening breathlessness. Now you get breathless on walking 100 yards on the flat or after doing housework such as vacuuming. The breathlessness does not get worse at night and you sleep with 1 pillow. You have no history of chest pain, palpitations, cough or ankle swelling. Your sputum is normal and you have never coughed up blood. Information to be given if asked Not applicable.

Background information
Past medical and surgical history Your past history includes high blood pressure, varicose vein surgery and recurrent urinary tract infections. Apparently youve been told you have an abnormal heart tracing but you do not think you have any heart problems. Other complaints Your only other symptoms of note are nocturnal leg cramps and occasional flushes. You sometimes get constipated but this doesnt bother you.

Medication record
Current medications Your have been on bendroflumethiazide 2.5 mg daily and lisinopril 20 mg daily for your hypertension for a few years. Your doctor prescribed an antibiotic for your urinary tract infections 10 years ago and you take this religiously, the dose being 50 mg at night. You are dreadful at remembering names. Allergies and adverse reactions You are allergic to elastoplasts.

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX1

Personal history
Lifestyle You smoke 20 cigarettes per day and have done so for the past 20 years. You dont like the t aste of alcohol.

Social and personal circumstances You are a retired nurse (you retired to act as a carer for your son). Your husband is a mechanic and suffers from diabetes. He also had TB as a child. You have two sons. The eldest has a history of diabetes also but this is well controlled and he is at university. The younger son has a history of cerebral palsy and still lives at home. You have a dog. Your eldest son keeps pigeons and you have been looking after them for the past few years when he is away on holiday or away at weekends. This usually involves you feeding them and cleaning out their cages a few days each month, several months a year. Travel history You have never been abroad. Family history Your mother died of breast cancer aged 72 and your father had angina and died of a stroke aged 77. Patients concerns, expectations and wishes Your breathlessness now makes it more difficult to care for your younger son. This concerns you. You have some specific questions for the doctor at this consultation: What could be causing my symptoms? Could it be related to my smoking? Will it get worse and interfere with my ability to care for my son?

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS Scenario N EX1

DATE

CYCLE

MRCP(UK) PACES Station 2: HISTORY TAKING

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 candidates 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 Doctors 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 four skill domains on the mark sheet. The box on the following page indicates areas of potential interest in this case. Both examiners should consider these, and any other areas they feel appropriate, and agree the issues that a candidate should address to achieve a Satisfactory award for each skill. These should be recorded on the calibration sheet provided. Examiners should also agree the criteria for an Unsatisfactory award for each skill.

Continued on next page

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS Scenario N EX1

Problem: Candidates role: Surrogates role:

Progressively worsening dyspnoea The doctor in the general medical outpatient clinic Mrs Heba Kamel, a 54-year-old woman

Examiners are reminded the boxes 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.

Clinical skill
Differential Diagnosis (D):

Key issues
Probable diagnosis:

Nitrofurantoin induced pulmonary fibrosis.

Plausible alternative diagnoses: Extrinsic allergic alveolitis Chronic obstructive pulmonary disease Chronic heart failure

Clinical Communication Skills (C)

Obtain sufficient information from the history to draw up a list of differential diagnoses Identify risk factors

Managing Patients Concerns (F):

Addresses patients concerns

Clinical Judgement (Skill E):

Plan investigations including: CXR ECG Pulmonary function tests High resolution CT scan of chest Immunological tests

Maintaining Patient Welfare (Skill G):

See mark sheet.

INFORMATION FOR THE CANDIDATE MRCP(UK) PACES Station 2: HISTORY TAKING

Patient details: Your role: Presenting complaint:

Scenario N EX2

Ms Donna Jones, a 47-year-old woman The doctor in the general medical outpatient clinic Fatigue

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 most grateful if you could see this woman who presents with increasing fatigue over the last one year. I checked her full blood count and she has a haemoglobin of 7.8 g/dl with an MCV of 112 fl. Please advise on her investigation and management. Your sincerely,

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.

DO NOT EXAMINE THE PATIENT Any notes you make must be handed to the examiners at the end of the station

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX2

MRCP(UK) PACES Station 2: HISTORY TAKING

Your role: Location: Ms Donna Jones, a 47-year-old woman The general medical outpatient clinic

History of presenting symptoms

Information to be volunteered at the start of the consultation You have been feeling increasingly tired particularly over the last year. As a consequence you have stopped going out so much and rather than walking to the shops, half a mile away, you now tend to take the car. There have been times when you have felt rather breathless on walking up even relatively gentle inclines. You have had no headache, dizziness, nausea or vomiting. There is no history of abdominal pain or alteration in bowel habit. There is no history of change in your weight or any mouth ulceration. Information to be given if asked Not applicable.

Background information
Past medical and surgical history You have never been particularly unwell before. In particular there is no history of any heart or chest problems. You were therefore very surprised when your Family Doctor told you that you have anaemia (a low blood count).

Medication record
Current medications You are not prescribed any medication but because of your fathers bowel tumour, a nurse friend had suggested that taking a small dose of Aspirin might prevent the chances of developing something similar and you have been doing this over the last 5 years.

Personal history
Lifestyle You are a non-smoker. You take a moderate amount of alcohol (approximately 15 units per week but mainly all at the weekend: equivalent to a bottle and a half of wine over the weekend period) and have never taken any more than that.

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX2

Social and personal circumstances You have a generally good diet although you tend towards being almost vegetarian. You do have a good intake of fruit and vegetables with little in the way of red meat. Family history In your family history both your mother and grandmother had thyroid problems and you recall a great aunt had to wear a wig because of premature hair loss. Your father had bowel cancer. Patients concerns, expectations and wishes You are anxious that your anaemia may be an indication of a more serious problem. You have some specific questions for the doctor at this consultation: What could be causing you to be anaemic? If you could have a bowel cancer like your father as you remember he too was anaemic? Could it be related to the Aspirin you have been taking yourself? What tests will you need to have?

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS Scenario N EX2

DATE

CYCLE

MRCP(UK) PACES Station 2: HISTORY TAKING

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 candidates 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 Doctors 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 four skill domains on the mark sheet. The box on the following page indicates areas of potential interest in this case. Both examiners should consider these, and any other areas they feel appropriate, and agree the issues that a candidate should address to achieve a Satisfactory award for each skill. These should be recorded on the calibration sheet provided. Examiners should also agree the criteria for an Unsatisfactory award for each skill.

Continued on next page

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS Scenario N EX2

Problem: Candidates role: Surrogates role:

Fatigue The doctor in the general medical outpatient clinic Ms Donna Jones, a 47-year-old woman

Examiners are reminded the boxes 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.

Clinical skill
Differential Diagnosis (D):

Key issues
Probable diagnosis:

Pernicious anaemia
Plausible alternative diagnoses: Gastrointestinal disease Alcohol excess Dietary insufficiency

Clinical Communication Skills (C)

Obtains a history of symptomatic anaemia. Identifies a significant family history of autoimmune disease.

Managing Patients Concerns (F):

Addresses patients concerns

Clinical Judgement (Skill E):

Indicates a likely diagnosis and explain further investigations for this (antibody tests and possible Schilling test) Indicates likely treatment options with parenteral B12 supplementation.

Maintaining Patient Welfare (Skill G):

See mark sheet.

INFORMATION FOR THE CANDIDATE

Scenario N EX3

MRCP(UK) PACES Station 2: HISTORY TAKING

Patient details: Your role: Presenting complaint: Miss Geraldine Pearson, a 25-year-old woman The doctor in the general medical outpatient clinic Hypoglycaemia

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 as she is having increasing problems with hypoglycaemia. She has had type 1 diabetes for 19 years and generally has not been troubled by it. Over the last 6 months she has had increasingly frequent and more severe episodes of hypoglycaemia and she says she is now getting no warning symptoms. Her partner has had to force feed her jam at night to resuscitate her on a number of occasions. He is particularly concerned about the effect on her work. Her latest HbA1c was 8.5% (IFCC: 69 mmol/mol) which is an improvement from 9.8% (IFCC: 84mmol/mol) last year.

Your sincerely,

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.

DO NOT EXAMINE THE PATIENT Any notes you make must be handed to the examiners at the end of the station

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX3

MRCP(UK) PACES Station 2: HISTORY TAKING

Miss Geraldine Pearson, a 25-year-old woman The general medical outpatient clinic

Your role: Location:

History of presenting symptoms

Information to be volunteered at the start of the consultation You have had type 1 diabetes since the age of 8. You have never taken particularly close care of your diabetes, but it has never caused you any obvious problems. Over the last 6 months you have been experiencing frequent episodes of hypoglycaemia both at night and during the day. Previously you got warning symptoms of feeling hungry and shaky and sweating, but these do not now occur and you find that you suddenly cannot function at work or at home when, you test your blood sugar it is 2-3 mmol/L. You have also been woken at night by your partner trying to feed you because you are restless, incomprehensible and your sugar is low. On one occasion recently you lost consciousness after having got up to get some food. Your partner is concerned about you and what he can do to help you. Information to be given if asked Not applicable.

Background information
Past medical and surgical history You have been told that you have normal changes of diabetes in your eyes, but have never had laser treatment, and have eye examinations every year by the mobile screening service. You have also been told that you have some loss of sensation in your feet when they are tested and you tend to get hard skin which can crack, but otherwise do not have problems with your feet. You have never been told that there are any kidney problems from diabetes, but you have not provided a urine sample for testing for the last few years because you check your blood instead. Your blood pressure is said to be normal. Other complaints You use a cartridge pen injector to give your Insulin. You always inject in your thighs because that is easiest. There is some lumpiness at your commonly used injection sites.

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX3

Medication record
Current medications You take insulin 4 times daily, Human Actrapid 24 28 units with meals and Human Insulatard 38 units at bedtime. You are on the standard oral contraceptive pill and have been for 4 years.

Personal history
Lifestyle You have started going to the gym to exercise regularly 4 evenings a week for the last 8 months to try and help you to lose weight. You also enjoy going to the cinema and eating out. You eat regularly but have been trying to miss extras to help lose weight. Social and personal circumstances You have been living with your present partner for 8 months, and have been thinking about getting married and starting a family. Occupational history You have been in your present job for 6 years and are happy in it. Friends and colleagues at work know you have diabetes but until recently it hasnt caused problems. Recent re-staffing has made it more difficult to get regular fixed breaks for meals and snacks, the timing of these will vary between days.

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS Scenario N EX3

DATE

CYCLE

MRCP(UK) PACES Station 2: HISTORY TAKING

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 candidates 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 Doctors 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 four skill domains on the mark sheet. The box on the following page indicates areas of potential interest in this case. Both examiners should consider these, and any other areas they feel appropriate, and agree the issues that a candidate should address to achieve a Satisfactory award for each skill. These should be recorded on the calibration sheet provided. Examiners should also agree the criteria for an Unsatisfactory award for each skill.

Continued on next page

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS

Problem: Candidates role: Surrogates role:

Scenario N EX3

Hypoglycaemia The doctor in the general medical outpatient clinic Miss Geraldine Pearson, a 27-year-old woman

Examiners are reminded the boxes 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.

Clinical skill
Differential Diagnosis (D):

Key issues
Probable diagnosis:

Plausible alternative diagnoses:

Clinical Communication Skills (C) Gains a clear view of the current situation with the patients diabetes and its complications, and elucidates possible precipitation factors for the increased hypoglycaemia and impaired hypoglycaemia awareness, including: Meal patterns Exercise patterns including sexual activity Lipohypertrophy Autonomic neuropathy Improving glycaemic control on soluble and isophane insulins. Other endocrine causes e.g. Addisons disease, thyrotoxicosis, (renal failure) Discusses the issue of the patients future marriage and potential plans for pregnancy in the setting for poor glycaemic control. Discusses education for the partner Explains the need to vary injection sites, have an insulin regime to match a regular meal pattern, modify diet and insulin around exercise. Explains the roles of other members of the diabetes team, and agrees a course of action with the patient. Understands the use of analogue insulins in type I diabetes. Explains the causes of changes in hypoglycaemia and hypoglycaemia awareness. Elucidates the problems of night time hypoglycaemia. Understands and explains the evidence for good glycaemic control preventing complications in type I diabetes; along with the importance of glycaemic control in and around pregnancy in type I diabetes.

Managing Patients Concerns (F):

Clinical Judgement (Skill E):

Maintaining Patient Welfare (Skill G):

See mark sheet.

INFORMATION FOR THE CANDIDATE

Scenario N EX4

MRCP(UK) PACES Station 2: HISTORY TAKING

Patient details: Your role: Presenting complaint: Miss Lily Kwan, a 28-year-old woman The doctor in the general medical outpatient clinic Diarrhoea and weight loss.

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, Thank you for seeing this woman who presented to my surgery complaining of a one-month history of diarrhoea and weight loss. On examination she has a soft and non-tender abdomen. Rectal examination is normal. I have sent routine bloods including full blood count, urea and electrolytes and glucose, which have all been normal. Furthermore, urine culture showed no growth. She is otherwise well with no past medical history and is not taking any regular medications. She works as an IT consultant. I would be grateful for any advice on the possible diagnosis and immediate. Your 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.

DO NOT EXAMINE THE PATIENT Any notes you make must be handed to the examiners at the end of the station

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX4

MRCP(UK) PACES Station 2: HISTORY TAKING

Miss Lily Kwan, a 28-year-old woman The general medial outpatient clinic

Your role: Location:

History of presenting symptoms

Information to be volunteered at the start of the consultation You have been feeling generally unwell for about three months. Over the last month you have developed diarrhoea, which is loose but formed stool, with no blood or mucus. If asked the stool does not float in the pan and is not offensive smelling. You open your bowels approximately 5-6 times a day and occasionally need to open your bowels once at night. You have no urinary symptoms of any sort. You have also noticed that youve lost weight unintentionally, having dropped from a size 12 to a size 10 in the last three months. You do not weigh yourself to be able to comment on exact weight loss. Your appetite has not been affected and in fact you feel that if anything, you seem to be eating more than usual. Information to be given if asked Your periods have become erratic over the last 6 months with only occasional, scanty blood loss. You feel warm and sweaty a lot of the time and havent enjoyed the recent warm weather which is not like you. Recently your hands feel somewhat shaky, and sometimes your writing has been difficult to read. You have not noticed any problems with your eyes and have not developed any skin rashes. You wonder if your neck has become a little swollen.

Background information
Past medical and surgical history You have otherwise always been well. You have only been to hospital once before, for a termination of pregnancy at the age of 19. You do not take any prescribed medications, but have been taking vitamin supplements recently. You have no allergies.

Medication record
Current medications None.

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE SURROGATE Scenario N EX4

Personal history
Lifestyle You smoke 5-10 cigarettes a day. If asked admit to occasionally smoking cannabis. You drink about two gin and tonics a day (a generous measure if asked). Social and personal circumstances You live with your partner and have been trying to start a family recently. Occupational history You work as an IT consultant. Family history Both your parents died in their 80s. Your father had a heart attack, and your mother had colon cancer. There is no family history of inflammatory bowel disease or coeliac disease. Patients concerns, expectations and wishes You are concerned that you may have cancer as your mother had diarrhoea and lost weight before she was diagnosed with cancer. Also you have concerns about your fertility, which is causing some friction between you and your partner.

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS Scenario N EX4

DATE

CYCLE

MRCP(UK) PACES Station 2: HISTORY TAKING

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 candidates 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 Doctors 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 four skill domains on the mark sheet. The box on the following page indicates areas of potential interest in this case. Both examiners should consider these, and any other areas they feel appropriate, and agree the issues that a candidate should address to achieve a Satisfactory award for each skill. These should be recorded on the calibration sheet provided. Examiners should also agree the criteria for an Unsatisfactory award for each skill.

Continued on next page

NOT TO BE SEEN BY CANDIDATES INFORMATION FOR THE EXAMINERS Scenario N EX4

Problem: Candidates role: Surrogates role:

Diarrhoea and weight loss The doctor in the general medical outpatient clinic. Miss Lily Kwan, a 28-year-old woman

Examiners are reminded that the boxes 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.

Clinical skill
Differential Diagnosis (D):

Key issues
Probable diagnosis: Thyrotoxicosis

Clinical Communication Skills (C)

Collects information regarding the nature of the diarrhoea, specifically history consistent with fast transit and not with inflammatory change or malabsorption. Elucidates weight loss in the context of increased appetite and neck swelling. Clarifies diagnosis, noting: Tremor Heat intolerance Oligomenorrhoea Neck swelling Eye problems Skin rashes

Managing Patients Concerns (F):

Explores and addresses the patients concerns

Clinical Judgement (Skill E):

Plans investigations that must include thyroid function tests. Discusses likely initial management plan: block (carbimazole) and replace (with thyroxine when euthyroid); beta blockers for temporary symptomatic relief.

Maintaining Patient Welfare (Skill G):

See mark sheet.