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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