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Patient consultation setting:
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Verbal
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Body language
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OSCE Domains
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Introduce yourself
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Hi, I am doctor Abc.
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Smile, nod, lean forward slightly to show interest but look professional
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A: courtesy consideration
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Take a history
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How can I help you today?
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Again nod you head and look as you are interested in what the patient has to say, look at the patient not anywhere else! Listen carefully
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A: Full focused history
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Encourage the patient.
Hunt for the hidden diagnosis if the history is nebulous or psychiatric. If the patient provides a problem assess their iedas by asking them what they think is the cause, they might think eczema is contagious hence they are not going out in which case you can address their worries or correct through education their ideas. If after 1 minute you can see they are rambling and they pause this is probably a heart sink patient and you need to ask what their expectations are so you can work out what they want you to do?
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You mentioned (pain/ walking difficulty/ dizziness / thirst/ chest discomfort / breathing problems etc), can you tell me a bit more about it?
Is there anything else on your mind? Are you worried about anything else? [Concerns] What do you think is causing it? [Ideas]. What would you like me to do for you today? What would you like to see happen today? [Expectations]
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Listen for the cues, the role playing patients will give them and expect you to pick them up! Remember the patients will be talking in layman’s language.
The actors will try and look uncomfortable or hesitate – this is a cue to a hidden agenda, they may avoid eye contact or say something like ‘There was something else but it’s not important’.
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B: sensitivity to patient, facilitates free expression of ICE (ideas, concerns and expectations)
C: Good communication skills
E: Considers implications for the patient and others.
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You have a diagnosis in mind, think is anything serious, ask the important questions, red flags, things that will sift important from less important. Think red flags: Upper GI: weight loss, dysphagia. Lower GI: Change in bowel habits >6w Resp: Weight loss, sweating at night, cough >2 weeks. Cauda equine lesion: weaknes, bladder bowel control loss, pain raditing to tip of toe etc. Check the NICE fast track referral guidelines!
Ask the socio-economic impact of the problem.
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Back pain: Do you have numbness in between your legs. Any problems with passing urine such as difficulty controlling it?
Clarify difficult questions.
Is this affecting your life or work? Do you find it difficult to deal with the children?
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Use your fingers to demonstrate what you mean by in between. Try and use body language to help your questions.
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A: takes a history sufficient to exclude a serious condition.
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Examine appropriately, don’t do a full exam, concentrate on the bits you need, and don’t miss postural hypotension if they are dizzy!
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I would like to examine your back / hands is that okay?
I will need you to (mention what you need them to do)
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Pause after asking permission!
Demonstrate the exam procedure if simple with your own body, i.e. position your hands etc.
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A: Examines patient appropriately and efficiently.
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Diagnosis
Make your diagnosis, and add 2 differentials if appropriate. If the diagnosis is obvious just state it and do not add differentials unless the patient asks could it be anything else. Don’t forget to rule out any concerns that patient had said at the beginning. Don’t forget to assess for understanding at the end by asking for any questions.
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Let me explain what I think, From what you have said and the exam I think you have A or B or C. I think A is likely but we will need to do some tests to work out if it is A or B or C. Let me explain what A is …
You mentioned you were worried about skin cancer, I can reassure you that this is not related to skin cancer but is eczema.
Do you have any questions?
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C: Offers clear explanation of symptoms and diagnosis to the patient.
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Management
Start with the least expensive (show correct resource management), and offer a couple of options quickly explain the pros and cons of each and then hand over to the patient. Be prepared to negotiate i.e. I want CBT and medication – say we have limited resources and we should try one and then the other
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For the depression we can use talking therapies or medications or herbal therapies. Talking therapies work as well but take time, tablets work quickly while herbal remedies can work but can also be unpredictable. What would you like to do?
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C: Negotiates management of patient. Involves them in decision.
D: Treats and investigates appropriately, offers range of options, safe prescribing.
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Summarise and Safety Net.
Health promote – tag this on here.
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Let me summarise so I am sure I have explained things well: You have depression. We’ll treat it with an anti-depressant which is one tablet per day. I would like to review in one week to see how you are getting along. If you have any problems don’t hesitate to come back and see on the on call doctors or if it out of hours one of the out of hours services. Just one more thing I would like to add: have you had your cervical smear / do you smoke? (if they say yes) Could we please talk more about this, could you book an appointment in the next few weeks whenever is convenient?
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You could write down basic points on a sheet of paper and give them to the patient. Your prescriptions will be assessed so write fully and legibly.
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E: Arranges follow up requirements
E: Arranges health promotion.
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