Simulated Patient Instructions



Patient Instructions

Name of Patient: Matt Smith age 60

Description of the patient & instructions to simulator:

You have had rheumatoid arthritis for 10 years. You had in the past frequent flare up but none in the last 6 years since starting methotrexate.

Your are a retired car mechanic and your look after your wife (age 65) who has MS causing her to be wheel chair bound. You have no carer input. Your children live abroad.

You have always coped well with cooking, shopping, laundry and helping you wife (although wheelchair bound is able to shower herself in the wet room and can feed and wash herself).

If asked in the last 24 months you have struggled with certain tasks e.g. doing up shirt buttons, pulling on socks, gripping a full kettle when you pour the boiling water to make tea, undoing jars and bottle tops.

You are not depressed and love walking your dog Tess twice a day.

Your wife is not depressed.

You have had a text inviting you in for your annual rheumatoid arthritis review.

You never miss a tablet and they have never caused any side effects

If asked you will disclose the difficulty you have been having with the kettle and fine manual dexterity. You have dropped the kettle and scolded yourself on one occasion.

You have no hot or red joints

You have no morning stiffness

The shape of your hands, especially your fingers have changed over the years

Ideas = You had a text to see the nurse for some bloods test and were told to see the GP for your annual Rh A review. It’s the rheumatoid arthritis causing the weakness in your hands

Concerns = Impact on life re dropping the kettle and struggling with buttons and socks

Expectations = Physio or aids and appliances which might help

Psycho-social impact = Risk of injury through scolding, struggling with ADLs

NB Your are keener for something to be done about your hands today wehereas you would be happy to come back re FRAX score and QRISK2 if you knew that they were not time critical

Doctor’s (GP ST) Instructions

Name & age of patient

Summary Card

PMH: Rheumatoid arthritis

DH: Methotrexate 15mg a week and Folic acid 5mg a day but not on the day of taking methotrexate

Allergies: None

Case Notes - Last few entries in records:

Seen by PN for Rheumatoid arthritis bloods etc

FBC, CRP, Cr&Es, LFTs + lipids sent to lab

BP 110/70 non smoker 8 units per week

BMI 23

FRAX score 12 % (upper limit 10%)

See GP with results

Results

Q Risk 12%

FRAX 12%

FBC, Cr &Es and LFTs and CRP normal

CSA EXAMINATION CARD

Patient Name: Matt Smith

Examination findings:

Chronic deformation at MCPs and PIPs with ulnar deviation of the fingers and some small muscle wasting in the hands.

No evidence of active inflammation

Reduced grip strength

CSA Case Marking Sheet

Data Gathering

Positive indicators

Enquires re symptoms of active Rh A

ICE explored

Enquires re physical and psychosocial impact of Rh Arthritis for him and his wife

Enquires re medication concordance

Enquires re medication side effects

Realises FRAX is abnormal

Realises QRISK2 is abnormal

Examines hands appropriately

Negative indicators

Lack of a structured Rh A review

SPICE not explored

Fails to appreciate significance of FRAX and QRISK

No examination

Interpersonal

Positive indicators

Establishes and maintain rapport

Shows empathy

Shared decision making

Interested in him as a person

Negative Indicators

Lacks rapport

No empathy

Show no interest in social impact

No shared decision making

Clinical Management

Positive Indicators

Offers referral for increased Home Care

Offers referral to physio and for aids and appliances e.g. rocker kettle, reachers & grabbers, bottle openers, jar openers, sock slider etc

Explains FRAX and QRISK2

Able to agenda set QRISK2 and FRAX interventions into a follow up consultation

Arranges rev

Negative indicators

Tries to manage everything and is rushed. Superficial as a consequence

No social interventions offered

FRAX and QRISK2 not explained

No review arranged

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