Patient Focus Flashcards
1
Q
- Mavis has recently been widowed and has a history of mild dementia.
She was admitted several weeks ago with pneumonia, which
has gradually resolved. She worked hard with the physiotherapy team
and has returned to her functional baseline level of activity. Despite this,
her family highlights several concerns which the nurses are keen for you
to address before Mavis is discharged.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Assist Mavis’s daughter-in-law, who feels that Mavis requires a lot of
help with looking after her bungalow.
B Address her son’s concerns about possible fi nancial exploitation by a
neighbour, using the appropriate assessment tools.
C Address her brother’s concerns that her memory loss is becoming
much worse and she needs further medical treatment.
D Discuss the family’s concerns with Mavis, and obtain her perspective
fi rst.
E Assist the nephew who has asked you to arrange a nursing home for
Mavis, where she can be supervised, in case she falls.
A
- D, C, A, B, E
Doctors must work in their patients’ interests, while respectfully considering
the valuable input of family and friends. The best answer is
(D) because it is essential to gain the patient’s perspective on each concern
in order to address the need for intervention. (C) has the possibility
of resolving all of the family’s concerns if the patient’s cognitive decline
is remediable, although it obviously neglects involving the patient in your
eff orts. You can consider arranging the remaining options in terms of
their order of severity and the likelihood of you being able to help. An
assessment by the occupational therapist usually identifi es and addresses
any potential problems with ability to function at home (A). Financial
exploitation lies outside the immediate remit of the clinical team; however,
it would be inappropriate for you to ignore any legitimate concerns
(B). A local vulnerable adults’ nurse or social worker is most qualifi ed
to make the appropriate assessments, not a foundation doctor. (E) is a
wrong answer as there is no objective evidence of falls in the question,
and, in any event, a nursing home would not be the fi rst step to avoiding
these in future.
2
Q
- You have arranged some bedside teaching for a group of six
medical students with a patient on your ward who is suff ering from
multiple sclerosis. On arrival you fi nd her to be in emotional distress
due to worsening of symptoms and a recent fi nancial dispute with her
family. You had previously agreed to spend 45 minutes with the patient
and students, and do not have any other patient with whom you could
teach the students.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Teach the students clinical theory in a classroom instead.
B Explain that emotional turbulence is a normal part of chronic disease,
and continue with the bedside teaching as planned.
C Attempt teaching, but agree that if she continues to be upset you are
happy to discontinue.
D Teach the students a lesson in communication skills by exploring her
family issues.
E Ignore the issue altogether and restrict your teaching to brief examination
of the patient’s neurological system.
A
- A, C, E, B, D
While it is unfortunate to compromise your teaching commitments,
hospitals exist for patient well-being fi rst and foremost. There are other
ways in which the teaching time can be eff ectively utilized and therefore
(A) would be the most preferable. A willingness to discontinue is less
ideal (C), but better than the remaining options as it acknowledges the
patient’s vulnerability. (E) makes no attempt to even acknowledge the
patient’s distress and is therefore worse, but has the benefi t of being
brief and focused on examination which will not necessarily antagonize
the patient. In contrast, (B) is an incorrect response; the patient’s distress
is trivialized into a generic statement about chronic disease, and
teaching continues completely unaltered, prolonging the distress for the
patient. (D) represents the worst response, as it is likely to worsen the
situation by exploring personal family problems in an inappropriate setting
with an audience of six medical students.
3
Q
- You are a foundation doctor working in a GP surgery and have
spent the morning assessing an infant with possible meningitis,
admitting a young man with suicidal ideation, and breaking the news of a
pancreatic malignancy to a previously healthy 55-year-old. Prior to your
lunchtime home visits, a 60-year-old man visits your practice for the
fourth time in two months with generalized worsening ‘aches’, despite
normal examination, investigations, and maximal medical therapy. Your
ten-minute consultation fails to assuage him.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain that you must see other patients with serious life-threatening
conditions, and you do not have the time he requires.
B Ask whether he would be interested in the services of complementary
health providers.
C Refer the patient to a rheumatologist.
D Spend ten minutes focusing on the patient’s psychological and social
well-being.
E Off er the patient the advice of another doctor at the practice.
A
- D, C, B, E, A
In any frequently attending patient, it is important to address their background
and beliefs to identify any underlying concerns that might be
bringing them back. (D) is therefore the best answer, as although the
appointment is likely to overrun, it is sometimes necessary to off er additional
time, and you may be able to deal with this otherwise complex
problem. It is obviously better that you are able to resolve the patient’s
problems yourself, but if this is not possible, seeking the input of aspecialist colleague might be sensible in case you and your colleagues
have missed something (C). A trial of non-traditional therapy (B) implies
that you have exhausted all appropriate medical therapy (provided of
course the diagnosis is correct), and would be a correct option once
you had fully explored the patient’s psychosocial well-being or sought
specialist advice as above. A fourth colleague at the practice is unlikely
to be able to add anything further to the patient’s current management
and represents a misuse of the practice’s resources (E). You should treat
each patient independently of other cases; your previous clinical encounters
during the day are irrelevant to the care you should provide to this
patient. Hence informing your patient about more ‘serious’ cases would
obviously be the least appropriate option (A).
4
Q
- A patient appears to be worried during your surgical ward round,
and the consultant suggests the need to ‘get to the bottom of these
worries before we explore the diff erent treatment options’. You consider
how you might go about doing this.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Allow the patient to express their concerns when they choose and
without directly asking.
B Ask the nurse looking after the patient today to explore any concerns.
C Ask the healthcare assistant (HCA) looking after the patient today to
explore any concerns.
D Speak to the family to identify any concerns that the patient may have.
E Set aside 20 minutes to speak with the patient to establish any underlying
concerns.
A
- E, D, A, B, C
It is your responsibility to work in partnership with your patients and
establish and maintain eff ective relationships with them. (E) is an arbitrary
time to spend with the patient, but it does what is necessary to
address your consultant’s request. (D) is less direct, although a collateral
history from the family may shed some light on the patient’s concerns.
(A) does not really address the problem as no questions are asked and
is therefore the least eff ective ‘correct’ answer. (B) and (C) are incorrect
and represent inappropriate delegations which are unlikely to lead
to the desired outcome, with a nurse (B) being only slightly preferable
to an HCA (C).
5
Q
- One of your patients appears to be very depressed, which she
believes to have been precipitated by a recent bereavement. You
realize that her loss parallels one of your own experiences and wonder
how this might be used to develop rapport with your patient.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Describe your own loss and subsequent feelings in detail.
B Explain how you can empathize with her because of your own
similar loss.
C Acknowledge her understandable sadness from experiencing a
personal loss.
D Change the subject, as dwelling on it may make her more upset.
E Encourage her to discuss her feelings with a friend, family member, or
religious leader.
A
- C, E, B, D, A
In caring for any patient, you should show compassion and develop rapport
whilst maintaining an adequate professional distance. This balance
is best made by (C). Nothing in the question invites the response in (E),
but it might be helpful to share her personal feelings with someone close
whom she trusts. (B) is generally wrong, as it involves disclosing some
personal information about yourself, but it may not always be wrong
and it could have a positive eff ect in some patients. (D) is worse as it
is dismissive and misses an opportunity to explore an important issue.
The worst answer is (A), as it is very unprofessional, irrelevant, and may
disrupt the relationship with your patient.
6
Q
- You are working as an FY1 doctor on the gastroenterology
ward. Maureen has early dementia and declines further treatment,
despite the medical team’s recommendations and her daughter’s
insistence. Her daughter explains about a previous protracted debate
between other doctors and her mother, which led to Maureen eventually
being ‘overruled’, and asks you to avoid a similar delay and initiate
treatment straight away.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Assess Maureen’s capacity for refusing this treatment.
B Read through the notes and establish whether Maureen lacks capacity.
C Ask the daughter to help in your assessment of Maureen’s capacity.
D Just get on and treat Maureen irrespective of her wishes.
E Avoid the decision and seek the input of a superior.
A
- A, E, B, C, D
The patient’s wishes must always be followed, even when contrary to
their perceived best interests, provided that the patient has capacity
to make their own decisions. No diagnosis (e.g. dementia) precludes a
patient having capacity, which must be assessed in each case in a time- and
decision-specifi c manner. Therefore (A) is the only correct answer. (E) is
unnecessary but it is not incorrect or dangerous. (B) implies an incorrect
defi nition of capacity, although the medical notes may be able to shed
some light onto the patient’s previous state, e.g. prior loss of capacity,
known dementia, Abbreviated Mental Test Scores on admission, and istherefore not completely useless. (C) places an unfair burden on the
daughter and is inappropriate and incorrect, and it is unhelpful to involve
a family member in this way. However, (D) is the worst answer as it
completely ignores the patient’s autonomy, and is possibly illegal.
7
Q
- You are seeing Derek, a 45-year-old man. He specifi cally mentions
to you his relative who has recently been diagnosed with cancer.
This news has concerned him, and Derek is worried about his own risk
of developing cancer. Having done some reading on the internet, he is
requesting a full-body CT scan.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain the dangers of X-radiation and the associated increased risk
of cancer.
B Explain that his absolute risk of developing cancer is low.
C Take a history and examination.
D Off er a full-body CT scan.
E Prescribe anxiolytics.
A
- C, B, A, E, D
This question requires you to address patient concerns while also providing
reassurance when appropriate. Derek has not off ered a suitable
indication for a CT scan, but the correct response is to conduct a full
assessment, as other decisions can’t be made without this (C). While the
patient’s risk of developing cancer may be low, you are given no information
to be certain of this; it is quite possible the patient may have a cancer
syndrome that predisposes him, which makes (B) a less appropriate
response. (A) is a fair thing to explain but does not address the patient’s
anxieties. (E) is obviously incorrect without further clinical information,
and not very much better than ordering an inappropriate scan (D).
8
Q
- You are reviewing a man who is troubled about his weight. Despite
having tried various dieting and exercise plans, he is now requesting
medication for weight loss. His body mass index (BMI) is currently 35,
and under local policy guidelines he has not yet reached the BMI required
to commence this treatment.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Write him a prescription, as he has exhausted alternative options.
B Explain the high cost of this medication, and encourage him to seek it
from wholesale online distributors instead.
C Write to the Clinical Commissioning Group (CCG) asking permission
to prescribe the medication.
D Inform the patient that he is not of a high enough weight to benefi t
suffi ciently from the medication.
E Refer the patient to another doctor in the practice.
A
- D, A, E, C, B
GMC guidance states that drugs should be prescribed to meet the needs
of patients and not simply because a patient demands them. (D) represents
the honest answer and follows evidence-based/locally agreed
guidelines. (A) is an alternative approach and your prerogative, although
you would need to have good reasons for doing something diff erent to
the consensus of your colleagues. (E) is likely to be unhelpful, as it simply
defers the decision-making to a colleague, although it is not incorrect.
(C) might be necessary if you wanted funding for a drug, but it is not
necessary to prescribe it. (B) is the only explicitly wrong answer, as it
may be unsafe for the patient to purchase medication from an unlicensed
supplier.
9
Q
- You are asked by one of the nursing staff to see Heather, a patient
who is refusing elective coronary angiography following a non-ST
elevation myocardial infarction.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Establish her concerns.
B Take the patient to see a coronary angiography being performed.
C Discuss her decision with family members if Heather agrees.
D Explore alternative treatment options, their risks and benefi ts.
E Explain the benefi ts of the procedure and insist that she must have it done.
A
- A, D, C, E, B
It is necessary to foster a professional relationship with every patient by
establishing rapport and understanding their concerns, and this may lead
to identifying why the patient is refusing the procedure, and possibly how
to overcome this (A). (D) is not incorrect and might allow the patient’s
concerns about the procedure to be answered, albeit indirectly, but is
less eff ective than (A). (C) is also not incorrect but is unlikely to achieve
a resolution, and is less appropriate than exploring the patient’s concerns
directly with the patient. (B) and (E) are clearly incorrect answers and it
is diffi cult to decide which is worst. It is never appropriate to insist on a
patient having a treatment unless they do not have capacity and a ‘best
interests’ decision has been made (E); instead the pros and cons of each
option should be discussed with the patient. This option is probably not
the very worst action, as it stops short of actually going ahead with the
procedure without the patient’s consent (i.e. battery). (B) is probably
marginally worse than (E), as it is completely inappropriate for the patient
and breaches the confi dentiality of another patient at the same time.
10
Q
- You are about to share a list of ward jobs after the consultant
ward round with your SHO on the oncology ward. You both have
plenty of tasks to keep you busy until the end of your shift. The SHO tells
you to delay referring Mrs Wilson to the palliative care team until tomorrow,
as she is likely to need infusion pumps and will create other tasks which
will take too long. You are concerned as she seems to be in pain.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Complete the list of jobs that your SHO has assigned to you before
referring the patient to the palliative team at the end of the day.
B Delegate the task of referring the patient to a nurse although you
know that ‘doctor to doctor’ referrals are expected.
C Complain to your consultant that the SHO is neglecting Mrs Wilson.
D Explain the importance of adequate analgesia in terminal patients to
your SHO and suggest that the jobs be reprioritized.
E Follow your colleague’s instructions and make the referral to the palliative
care team tomorrow.
A
- D, C, B, A, E
Your fi rst duty should be towards your patient; Good Medical Practice also
reminds us to work with colleagues eff ectively to best serve patients’
interests. In this instance you should aim to get the patient referred as
early as possible, even if this means involving the consultant. Clearly,
speaking to the SHO directly is better than involving the consultant if
this can be avoided, hence (D) is better than (C). Involving the nurses
(B) requires that they become involved in a task they are not supposed
to do, and this is therefore less preferential. However, it is better than
(A) which leaves the task (and therefore the patient) until the end of the
day. (E) is clearly the worst as it leaves the patient in pain for the longest
duration.
11
Q
- You are working in a genitourinary medicine clinic. A patient
attends because she believes that she may have contracted an
infection following a recent sexual encounter outside of her long-term
relationship.
Choose the THREE most appropriate actions to take in this situation
A Advise her to begin contact tracing, i.e. informing her regular partner.
B Suggest you will have to inform her long-term partner if she does not.
C Test for HIV as HIV testing is mandatory.
D Advise a blood test for syphilis antibody.
E Promote safe sexual practices.
F Discuss the morality of multiple sexual partners.
G Inform the patient’s GP to ensure adequate community follow-up.
H Ask a phlebotomist to draw the blood sample to avoid the risk of a
needle-stick injury.
A
- A, D, E
Confi dentiality is central to the trust between patients and doctors. The
disclosure of information in the interest of public safety is a complex
issue, requiring a balanced and thoughtful clinical judgement in discussion
with the patient. In this scenario, it is recommended to complete a
sexual diseases screening to rule out common or serious infections (D),
although no disease must be tested for (C). It would be unfair to defer
phlebotomy to another healthcare professional (H) simply because you
are worried. At this stage, it is not appropriate to consider disclosure of
the patient’s sexual encounter to her partner or GP (B) (G), although she
might be encouraged to share this information herself (A). Such clinical
encounters provide the opportunity to promote safe sexual practices
(E), but personal opinions about patients’ sexual practices should remain
private (F).
12
Q
- You have arrived on a ward to review a medical outlier. You
retrieve the patient’s notes from the treatment room after
several wasted minutes searching for them in the notes trolley. You
are exasperated as you risk missing lunch, again, if not en route to the
canteen within ten minutes. The telephone at the nurses’ station rings.
There is no ward clerk. Although the surgical FY1 doctor and his registrar,
a staff nurse, and a physiotherapist are standing at the desk, no one
answers after 20 rings.
Choose the THREE most appropriate actions to take in this situation
A Tell the surgical FY1 doctor to answer the phone.
B Tell the staff nurse that you are in a great hurry and that she/he
should answer the phone.
C Move away from the nurses’ station quickly and let the phone be
answered by someone else.
D Ask the staff nurse whether you can answer the phone and let her/
him know what is needed.
E Pick up the phone and give the handset straight to the staff nurse saying
‘It’s for you’.
F Ask people at the desk whether someone is waiting for a call and
answer the phone if no one volunteers.
G Ask the nurse in charge whether there is a policy on answering phones
on the ward.
H State to all around the desk that the call might be very important for a
relative/carer or directly related to patient care.
A
- D, F, H
This common scenario represents many priorities which must be balanced,
the most important of which is patient care. Ward telephones
should be answered promptly even if it is not an individual’s direct
responsibility because they carry a bleep. The staff nurse may be more
persuaded to help if you have their prior agreement (D). It might just
be easier to answer the phone quickly, work out what the call is about,
and move on (F). You may have unrealistically expected to see a patient
within ten minutes as well as making it to lunch on time. It is often useful
to lead by example, in which case simply expecting others to act may
be unhelpful (A) (B) (C). Only if the diffi culty persists and/or this is a
ward that you are likely to visit again should you need to fi nd out the
policy on answering telephones (G). Giving the handset directly to the
staff nurse (E) would be bad manners and unlikely to provoke a positive
response, particularly as you do not know the urgency of the task he is
currently managing. Ultimately the call might be important and should be
answered, and although (H) is imposing and it might be diffi cult to interrupt
others in the middle of their own jobs, it is the least worst of the
remaining options after (D) and (F).
13
Q
- During your fi rst month working on the neurosurgery ward,
you have become increasingly troubled by your registrar’s ability.
You have seen him misinterpret basic clinical signs. On one occasion
you tried to share your concerns with the consultant in charge
but he discounted them, highlighting the registrar’s natural ability in the
operating room.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask your consultant again to consider the registrar’s overall
performance.
B Inform your Educational Supervisor.
C Approach the registrar and ask him whether he would be willing to
receive teaching from you after work.
D Inform the Clinical Director.
E Share your thoughts with another FY1 colleague.
A
- A, B, D, C, E
You must ensure patient safety by raising your concerns, and there is a
fairly clear order of escalation. In this scenario, (A) is better than (B), as it
is more appropriate to formally raise the issue again with the consultant
and reiterate your concerns with specifi c examples of what you believe
has been done incorrectly. It is possible that your assessment is inaccurate
or disproportionate, and discussion with a senior colleague may be helpful
in this respect. In any event, if the evidence is unequivocal, the registrar
will benefi t from the input of a senior clinician. Informing the Clinical
Director (D) represents a greater escalation than your Educational
Supervisor (who is another consultant typically responsible for fewer staff
than the clinical director). It may eventually be appropriate to inform the
Clinical Director, although you should escalate stepwise through the local
hierarchy. It would be ideal to approach the registrar himself; however,
off ering him teaching is unlikely to be constructive and in this case would
not be appropriate (C). If, however, the option was to approach the registrar
and to discuss your concerns further with him, this would have been
the best option. (E) is the worst option as it amounts to gossiping and will
not lead to the problem being resolved.
14
Q
- You are the paediatric FY1 doctor. A nurse asks if you could
speak with the family of a 13-year-old patient, Lenka, who does
not speak any English. Lenka’s family is very angry and they demand that
she is moved away from the neighbouring patient who has been coughing
vigorously throughout the night. You also notice that Lenka appears
to be upset.
Choose the THREE most appropriate actions to take in this situation
A Acknowledge the family’s concern and try to move the patient into a
side room.
B Explain to the patient’s family the low risk of contracting an infection
from neighbouring patients in open bays on the ward.
C Try to establish Lenka’s concerns.
D Try to address the concerns of Lenka’s family fi rst.
E Ask the neighbouring patient if they would be willing to move into a
side room.
F Provide the patient and her family with face masks.
G Ask the ward nurse to address these nursing concerns.
H Provide the neighbouring patient with a face mask.
A
- B, C, D
Good Medical Practice reminds us to listen to patients, and to spend
time with relatives and respond to their concerns and preferences. In
this scenario, where the child does not speak English, you should try to
understand the family’s particular health beliefs before communicating
via them with Lenka to identify her concerns (C) (D). The family may
be unsettled by conditions on the ward, but the neighbouring patient is
unlikely to pose a risk to Lenka (B) and any patients who are at risk of
transmitting infectious diseases would already be isolated. Therefore it is
unnecessary and an inappropriate use of resources to isolate Lenka or
the neighbouring patient (A) (E), or to provide face masks (F) (H). Since
you have begun to speak to the patient’s family, and can respond to their
concerns, it would be unfair to refer them to the ward nurse (G).
15
Q
- You are clerking patients in the Medical Admissions Unit
(MAU). A former colleague approaches and informs you that
his father is one of the patients waiting to be clerked. He asks you to see
his father fi rst.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Report your medical colleague to his Educational Supervisor.
B Refuse your colleague’s request outright.
C Ask the registrar whether he has any preference for which patient you
should see next and, if not, begin with your colleague’s father.
D See your colleague’s father last, as punishment for his unfair request.
E Establish if there is any particular reason why he wants you to see his
father straight away.
A
- E, B, C, A, D
The GMC requires doctors to treat patients fairly and not to discriminate
unfairly between them. In this instance, your colleague may be
abusing his position to gain preferential treatment, but it is possible that
his professional insight has raised a concern which should expedite his
father’s care. For this reason (E) is the best option.
(B) and (C) are diffi cult to choose between and will depend on several
factors not discussed, e.g. the department or other patients. It is important
to weight fairness against working with colleagues, and your registrar
may be able to off er additional insight and help triage the patients
waiting to be clerked (however, this requires involving a likely very busy
registrar with a query that is questionable at best). On balance most
doctors would say it is better to decline your former colleague’s request
if there is no good reason. (A) is unfair and excessive, while (D) is all of
the above and dangerous, and is clearly the worst option.
16
Q
- Lucy is a 24-year-old with Crohn’s disease. On reviewing her
drug chart, you fi nd that multiple doses of medication have
not been given. On questioning the nurse who has been looking after
Lucy since her admission, she says that the patient has been refusing to
take the medication when off ered. However, you have always found the
patient to be pleasant and cooperative. Lucy denies being off ered any
medication by the nurse.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Report the nurse to the Royal College of Nursing.
B File a clinical incident form for failing to satisfactorily encourage Lucy
to take her medication.
C Suggest that the nurse sits with Lucy and encourages her to take her
medication.
D Change all her medication to intravenous forms.
E Inform the Ward Sister that Lucy has not been receiving her medications,
and ask her to investigate further.
A
- E, B, C, A, D
Failing to give Lucy her medications could put her at unacceptable risk.
There is a suggestion that the nurse has neglected an important duty, and
the Ward Sister should be requested to investigate the matter further,
hence (E) is the best option. (C) also raises the concern with nursing
staff , but only with the nurse involved, and would address the matter if
the problem was patient compliance but not if there was an issue with
the nurse’s dispensing of medication. (B) does not resolve the situation
immediately but goes about initiating the same processes that the Ward
Sister would begin in (E) therefore (B) can be justifi ed as being better
than (C). (A) is incorrect without further corroboration/information.
(D) does not adequately address the failure by the nurse or the patient’s
non-compliance for the future and is potentially dangerous, introducing
unnecessary risk to the patient.
17
Q
- Mr Stevenson has recently been diagnosed with terminal mesothelioma.
During his admission for a chest infection, you are
handed an indefi nite DNACPR (Do Not Attempt Cardio-Pulmonary
Resuscitation) order that has been in place since a previous admission.
On speaking to Mr Stevenson and his family, they do not appear to be
aware that this order is in place.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tear up the DNACPR order.
B Explain the futility of cardiopulmonary resuscitation in Mr Stevenson’s
case as the logic of the DNACPR order.
C Apologize for the insuffi cient explanation given by Mr Stevenson’s
previous clinicians.
D Inform your registrar immediately.
E Do not inform Mr Stevenson and his family about the DNACPR order
at this time, but wait to discuss the matter with Mr Stevenson alone.
A
- E, D, B, C, A
It is essential that there is adequate communication between the patient
and the clinical team. The revelation that Mr Stevenson and his family do
not know about the DNACPR order warrants a discussion with your
senior, but the scenario does not imply any immediate imminent danger,
hence this is not immediately necessary. (E) would therefore be preferable
to (D) as it allows you to establish what the patient has already discussed
(perhaps in private away from his family), and discuss the matter
with your seniors further if necessary. (B) is probably not a discussion
that should be undertaken by a FY1 doctor, particularly if the issue had
never been raised before. (C) is the fi rst wrong answer as you cannot
apologize for colleagues and do not know what he was previously told
and why. (A) is the worst answer as you do not know why the DNACPR
was put in place, or by whom, and you are not in a good position to
make DNACPR decisions.
18
Q
- You are taking a history from the mother of 11-year-old Clara
who has presented with shoulder pain. When you are left alone
with Clara, she admits that her mother often gets upset with her and has
occasionally hit her in the past. The mother has appeared completely
appropriate in her interaction with Clara.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Clara is most likely referring to reasonable chastisement, and the issue
should not be pursued.
B Confront Clara’s mother about the accusation, and ask her to volunteer
any explanations.
C Document the comments clearly, and attempt to gain more information
from Clara, alone if possible.
D Begin a thorough head-to-toe examination of Clara once her mother
has returned and, if asked, explain that you are looking for bruises.
E Inform the police.
A
- C, D, B, E, A
Although Clara’s description may represent reasonable chastisement,
the issue should be explored as it might indicate non-accidental injury.
(C) is the best option as it ensures the comments have been recorded
and allows further detail to be established which may clarify what she
means, or else highlight further concerns which can then be shared
with an appropriate senior colleague. Accurate contemporaneous
documentation is always key, and such cases might be followed up by
external agencies and your information relied upon in court. (D) is not
ideal and risks antagonizing the mother if she probes further, but it is
important to assess the patient, and in this instance your honesty would
not be unacceptable. (B) would generally be considered incorrect for an
FY1 doctor to undertake independently and is therefore worse. (E) is a
disproportionate and excessive response that is by no means justifi ed
at this stage, although it is marginally better than (A) which completely
ignores the potential seriousness of Clara’s disclosure.
19
Q
- You are about to discharge Terence following his admission
for treatment for recurrent epileptic seizures. On getting up to
leave the bedside, you overhear his wife’s surprise at the doctors allowing
him to return to work as a heavy goods vehicle driver. You feel sure
that Terence has no intention of relinquishing his driving responsibilities,
despite promises to the contrary.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Seek assurances from Terence’s wife that he will not return to work.
B Inform Terence’s GP.
C Ask Terence to sign an agreement not to return to work in the
medical notes.
D Disclose his diagnosis to the Driver and Vehicle Licensing Agency
(DVLA).
E You are not responsible for the patient’s actions once you have
appropriately instructed him.
A
- D, B, A, C, E
Although confi dentiality is necessary to maintain patient trust in doctors,
it may be breached to protect others from serious harm. Terence has a
legal duty to inform the DVLA, which is likely to ask him to surrender his
licence. The best answer would be to encourage the patient to disclose
his disability and, failing this, to do so yourself. (D) represents the safest
option available and is therefore the best option. The remaining options
are generally inappropriate. (B) at least informs another colleague that
there is an issue, who could follow the issue up further. (A) is worse
as the wife might not be trusted, given her confl ict of interest, and this
represents an unfair burden as she might not be able to control her husband,
although there is a possibility she would be able to prevent him
from driving. (C) is tantamount to doing nothing, and adds nothing on
top of a verbal reassurance. (E) is obviously wrong and neglects a duty
to protect public safety.
20
Q
- A 40-year-old mother of two children stops you as you are
walking by her side room and asks to speak with you. She is visibly
worried about the results of her pancreatic biopsy and asks, ‘What
will happen if I have cancer?’
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Reassure the patient that the medical team will do everything they can
to try to treat her.
B Reassure her that everything will be fi ne.
C Ask the patient to wait and ask your senior any questions.
D Echo her concern: ‘I can see that you are worried that you might have
cancer.’
E Do not say anything, but instead look away in an eff ort to communicate
the grave nature of her problem non-verbally.
A
- A, D, C, B, E
It is often necessary to strike a careful balance between reassurance and
fostering a realistic outlook that does not compromise the patient’s faith
in the profession. At this stage you cannot fully reassure the patient,
and instead must be honest about her situation (A). (D) is the next best
answer; although it would be odd and unlikely to help the patient, it is a
neutral statement. (C) is worse as it burdens your seniors unnecessarily,
particularly since the patient has not asked for any specifi c information. It
is diffi cult to discriminate between the last two options. (B) is incorrect,
and (E) is ambiguous, confusing, and unfair to the patient. The implication
of a poor outcome without explicitly stating so is perhaps worse
than a falsely reassuring comment made in passing.
21
Q
- Iris is 87 and one of your patients on the care of the elderly
ward. She has mild dementia but tells you that she doesn’t like
being dressed by the nursing staff each morning. At home, her carer just
stands by in case she needs help, although she concedes that this ‘takes
longer’ than allowing the carer to dress her.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell Iris that as soon as she goes home she’ll be able to go back to her
old routine.
B Tell Iris that she can dress herself each morning if she prefers, with
help if necessary.
C Pass on Iris’s request to the Ward Sister and ask that it be passed on
during the nursing handover.
D Explain that this is probably not possible as the nursing staff are busiest
in the mornings.
E Tell Iris that you can’t interfere with how the ward is run.
A
- C, B, A, D, E
All healthcare professionals should respect patient autonomy and
empower patients as far as possible. It is better to speak to the nurses
before promising anything directly to the patient; therefore (C) is a better
option than (B). It is unfair not to pass on the patient’s (reasonable)
request to the nursing staff ; therefore the remaining answers are incorrect.
(A) is probably the better of those remaining, as it might be good
for the patient’s morale. (D) is less eff ective than (A) as it fails to address
the problem and represents a less positive, more neutral statement.
(E) has the same failings as (D), possibly carrying a more negative undertone,
but more importantly is factually incorrect.
22
Q
- You are asked by the nurses to site a urethral catheter for Arthur
who is an elderly man who needs to urinate frequently. He has
known prostate trouble and reduced mobility. It takes at least fi ve minutes to
get him to the toilet, after which he often does not need to urinate after all.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask Arthur for his views and whether he is troubled about multiple
visits to the toilet.
B Off er other options such as a commode or a male external catheter.
C Speak to the urology team to ask if there is anything further that can
be done to minimize Arthur’s lower urinary tract symptoms.
D Explain the problem to Arthur and then insert a urethral catheter
once he consents.
E Tell Arthur that he needs a urethral catheter and then site it carefully.
A
- A, B, C, D, E
You should only off er invasive treatment if it is in the patient’s interest
and you have consent. (A) is the most patient-focused response and will
help guide you to the correct management for the patient. (B) is less
eff ective as it fails to establish a history and the patient’s perspective
about his symptoms, although he is involved in the decision-making, and the options off ered are less invasive. (C) is likely to be unnecessary in
this case, but it is not harmful, although it may delay a speedier resolution
which could be achieved without having to involve another specialist
team. (D) is less eff ective than (C) as it is mildly harmful to insert a catheter,
but it is done correctly by explaining the procedure and obtaining
consent. For this reason (D) is better than (E), as the consent obtained
with this option (E) is somewhat dubious.
23
Q
- You arrive on the ward one morning to fi nd a student nurse
washing a male patient with the curtains open. The patient does
not appear to be obviously concerned.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Pull the curtains closed.
B Ask the patient for his preference and leave the curtains open if he
chooses.
C Explain the need to ensure patient privacy to the student nurse afterwards
if she is unclear.
D Tell the student nurse in front of the patient that she should learn to
respect privacy.
E Carry on with your job as there is not a problem and you shouldn’t
interfere.
A
- A, C, D, E, B
You should take steps to protect patient dignity whenever possible.
(A) is the most immediate way to achieve this. (C) is a less immediate
action but still off ers a sensible approach. (D) is unprofessional as it
undermines your nursing colleague, but it is not completely incorrect as
the underlying issue is still addressed. For this reason, (D) is better than
(E) as ignoring the issue is slightly worse. Patient choice is important, but
other patients and visitors to the ward need to be considered as well,
and it would be considered poor judgement to attempt to address the
issue only to go on and leave the curtains open (B).
24
Q
- You are on a fast-paced surgical ward round. Your consultant tells
a patient that she will need a ‘Hartmann’s procedure which will
leave a colostomy’ and she signs a consent form. You can tell from her body
language that she wants to ask questions but does not feel able to do so.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain that you will come back after the ward round in case she
wants to ask any more questions.
B Insist that the consultant stays until he has answered her questions.
C Tell the patient that your consultant will come back later to answer
questions.
D Let the ward round continue but remain behind to draw a picture for
the patient illustrating Hartmann’s procedure.
E Continue with the ward round but return later to answer questions.
A
- A, E, D, B, C
It is important that patients have an opportunity to ask questions, particularly
about such an important issue. In this case, indicating to the
patient that you will come back addresses the main issue raised in the
question, without disrupting the ward round, and is the best answer (A).
This is preferable to simply going back later (E), as it will reassure the
patient immediately to know there will be an additional opportunity to
ask further questions, although (E) does still deal with the underlying
issue. (D) is good for the patient but inevitably disrupts the ward round
and is therefore less preferable. (B) is worse than (D) as it is unprofessional
and causes maximum disruption to the rest of the ward round.
(B) and (C) are diffi cult to discriminate, and arguments can be made for
both being the worst answer. One can argue that (B) carries a greater
risk of jeopardizing your professional relationship with the consultant by
insisting on his cooperation in front of the patient, compared to falsely
promising a meeting with the consultant (C) (a meeting that you might be
able to eff ectively negotiate more politely than is implied in option (B)).
They are both unprofessional, but for the patient (C) is worse as you
cannot guarantee that the consultant will return, and this risks leaving the
patient’s questions entirely unanswered.
25
Q
- As you are sitting at the nurses’ station completing a discharge
summary, you see a 55-year-old patient walking away from you
with his gown fl apping open at the back.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Shout to the patient by name so that he can be alerted to his state of
undress.
B Catch up with the patient and let him know that he is partially
undressed.
C Help him tie up the gown correctly.
D Find a nurse and let them know the patient needs assistance.
E Catch up with the patient and tell him that he should be more careful
in case he embarrasses other patients or visitors.
A
- B, C, D, E, A
You should take action as necessary to protect patient dignity. In this
case, (B) is the most helpful and polite response. (C) is a reasonable
action, but it would be preferable to speak to him as in (B) fi rst. It would
be better to deal with the patient’s immediate (and easily correctable,
be it non-life-threatening) problem yourself and avoid delay, rather than
seeking a nurse (D). The two remaining options are incorrect, with
(A) being impolite and (E) being even more unkind by blaming the patient
for a genuine mistake.
26
Q
- Your Trust occasionally authorizes use of protective mittens for
certain patients. These are large gloves that essentially prevent
patients from using their hands. You are asked to prescribe mittens for a
patient out of hours and agree to do so only under specifi c conditions.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A The patient is confused.
B The patient lacks capacity.
C The patient lacks capacity and is at risk of pulling out essential lines
and tubes.
D The patient lacks capacity and has pulled out lines and tubes, and
alternative strategies have been unsuccessful.
E The patient lacks capacity and is at risk of pulling out essential lines
and tubes. The patient’s next of kin are fi ercely opposed to the use of
mittens.
A
- D, E, C, B, A
Mittens risk causing patients signifi cant distress and should only be used
in limited circumstances. Most Trusts have strict criteria and rules for
their use, for example: the patient should either consent or lack capacity,
and had previously pulled out lines and tubes, and alternative strategies
have been unsuccessful. Hence (D) is the correct answer. The hostile
family members are likely to dissuade you from the use of mittens, but
cooperation is not a requirement and therefore (E) is an appropriate
(albeit less ideal) response. (C) represents a partial requirement, whilst
(B) is even less appropriate as it represents less fulfi lment of the required
conditions for using mittens. (A) is not really necessary even for the use
of mittens, and is therefore the worst answer.
27
Q
- A patient admitted to your ward with pneumonia is shown to
have tuberculosis (TB). He is asked to wear a face mask when he
leaves his side room and told that the case must be reported to the Health
Protection Agency. He refuses to allow information about his illness to be
sent externally and is often seen outside his side room without a mask.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explore the reasons for this patient’s non-compliance.
B Explain that TB is potentially dangerous and very easily spread to others
in the hospital.
C Explain that you will not send his details externally but that his GP
must be informed.
D Explain to the patient but submit his details to the Health Protection
Agency (HPA), regardless of whether he gives consent.
E Discharge the patient from hospital without further treatment as he is
a danger to other patients.
A
- B, D, A, C, E
(B) is the best answer as it is most likely to resolve the problem and
off ers appropriate counselling to the patient. It is obviously preferable to
resolve the problem with the patient and obtain his consent for sharing
information with the HPA, but telling the patient that you will be informing
them is a fair and reasonable response (D). However, (D) is not as
eff ective as (B) as the immediate risk to other people is minimized by
explaining the seriousness of the condition and why the restrictions are
being imposed on him. While you should generally explore all reasons
for non-compliance (as patients might be amenable to persuasion), you
are unlikely to impart the essential information that he has a communicable
disease which might currently risk others, and that this should be
reported to the HPA (A). (C) is incorrect as the HPA must be informed,
while (E) is both incorrect and represents a failure to treat the patient,
putting him and others at considerable risk from untreated tuberculosis.
28
Q
- Ron is an elderly man with bowel obstruction. He is delirious
and keeps pulling out intravenous cannulas as well as occasionally
tugging on his nasogastric tube. Reinserting cannulas is becoming
increasingly time-consuming and he is running out of suitable veins.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Resite cannulas in areas less likely to be disrupted (e.g. feet).
B Prescribe gloves/mittens according to hospital policy.
C Try taping and bandaging tubes for additional security.
D Ask whether a ‘special’ nurse can be assigned for one-to-one care.
E Tape incontinence pads around Ron’s hands to stop him pulling
out lines.
A
- C, A, D, B, E
Ron may cause himself considerable harm by inadvertently pulling out
lines and tubes. You should ensure Ron’s safety using the minimum
amount of restrictions. The order of answers suggested here is an
appropriate order of escalation and so almost by defi nition the next
stage is ‘less appropriate’ than the one before. Bandages (C) are less
invasive than resiting cannulas (A), while specialist one-to-one nursing
(D) might be able to obviate the more restrictive option which is often
a last resort—mittens (B). Mittens should only be used as a last resort
when other strategies have failed and according to Trust policy. Taping
pads to Ron’s hands would be undignifi ed and uncomfortable, and may
worsen his agitation (E). If hands must be constrained, specially designed
mittens should be used according to policy.
29
Q
- Ivy has dementia and often screams out all night. Her clinical
condition has recently improved and she has become mobile
by ‘furniture walking’ around the ward. She is violent and abusive when
stopped by members of staff .
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Try to reason with Ivy, explaining as far as possible that it is unsafe for
her to move around the ward.
B Suggest distracting interventions, such as playing music.
C Prescribe ‘as required’ (PRN) sedation.
D Ask whether a ‘special’ nurse can be assigned for one-to-one care.
E Prescribe sedation when Ivy becomes particularly agitated and endangers
herself or others.
A
- A, B, D, E, C
The correct order of answers here represents a clear order of escalation,
beginning with the more conservative least invasive methods fi rst.
Sedation should only be prescribed when it is in your patient’s interests The interests of colleagues and other patients are secondary in this case.
Although Ivy has dementia, attempts should be made to explain to her
that she is unsafe to mobilize (A). Other alternatives to sedation can
then be explored, such as distraction (B). One-to-one nursing might be
required and may be successful, but it is obviously resource intensive and
this needs to be considered (D). Sedation may be considered when Ivy
becomes particularly agitated and a risk to herself (E), although prescribing
the medication when necessary would be favoured over ‘PRN’ sedation
(C) to avoid the patient being oversedated by nursing staff .
30
Q
- You are hoping to fi nish your ward round quickly before meeting
your Educational Supervisor an hour later. You see Rose,
who is very overweight and disabled with osteoarthritis, sitting in a chair.
You are told that she developed severe abdominal pain overnight and so
will need to be examined in bed. This will require considerable time as
she must be hoisted.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask the nursing staff if they can help Rose into bed while you see
other patients fi rst.
B Ask Rose whether she would mind lying in bed so that you can examine
her thoroughly.
C See Rose later as you are pressed for time.
D See Rose now but feel her abdomen while she is sitting in the chair
instead.
E Go to your meeting with a view to assessing Rose afterwards.
A
- B, A, D, E, C
Patient care must be prioritized, even above educational commitments.
The concern is that Rose has a possible acute abdomen and therefore
needs to be examined properly. The best answer is (B) which informs
her about your intentions and is clearly a better use of resources than
(A). Both options are, however, preferable to conducting an inadequate
examination of a patient who has potentially become very unwell (D).
(E) and (C) are the worst answers as they both neglect any assessment
of Rose. (E) is only marginally better as you are at least making an eff ort
to attend your meeting.
31
Q
- Flora is 73 and suff ering from hospital-acquired pneumonia.
She has been receiving intravenous antibiotics, but is no longer
confused and is becoming unhappy with your continued attempts at
cannulation.
Choose the THREE most appropriate actions to take in this situation
A Tell Flora that she will probably die without intravenous antibiotics.
B Stop the antibiotics and resite the cannula if Flora deteriorates
without them.
C Prescribe oral antibiotics and document clearly that Flora refused
cannulation.
D Off er to ask a colleague to try if the next attempt fails.
E Explain carefully why a cannula is necessary.
F Tell Flora that the next attempt will be successful.
G Persist with cannulation attempts as Flora does not have capacity.
H Consider whether antibiotics can be de-escalated to oral equivalents
A
- D, E, H
Competent adults can refuse any treatment, including cannulation.
However, you have a duty to ensure that they understand the reason
it is necessary and the likely consequences of refusal (E). This might be
an appropriate time to consider converting to oral antibiotics (H) or a
compromise might be necessary, such as off ering to seek help from a colleague
after another attempt (D). You should not accept Flora’s refusal
of further attempts without clear discussion of the need for intravenous
antibiotics (C). This discussion should be realistic and not calculated to
coerce the patient (A). You cannot guarantee that the next attempt will
be successful (F) and there is no reason to think that Flora does not
have capacity (G). Antibiotics should not be stopped in their entirety
(B) simply because Flora is declining cannulation—oral equivalents may
confer some benefi t.
32
Q
- Randhir is 50 and was admitted under the orthopaedic team
with severe back pain. MRI shows only degenerative change.
Your consultant says that the patient cannot be kept in hospital ‘forever’
because of pain and should be discharged with spine surgeon follow-up.
The patient and his family do not believe that he can go home because
he cannot work and is in severe pain.
Choose the THREE most appropriate actions to take in this situation
A Delete the patient from your list so that he can stay in hospital for a
few more days without your consultant knowing.
B Explore Randhir’s concerns about going home.
C Promise that you will ensure that the back pain appointment is made
within two weeks.
D Tell Randhir that the bed is needed for more urgent cases.
E Carefully explain the nature of mechanical back pain.
F Ensure that the pain team is involved with discharge planning so that
appropriate analgesia can be provided in the community.
G Prescribe ‘as required’ (PRN) oral morphine until the patient is
discharged.
H Tell Randhir he needs to learn to accept the pain as there may be
nothing that can be done to help.
A
- B, E, F
Compromise is always preferable and can only be achieved by understanding
Randhir’s concerns (B) and clarifying any misunderstandings
(E). Regardless of confl ict persisting, the discharge should be managed
like any other with eff ective analgesia and follow-up (F). You should not
make unhelpful statements, for example that nothing can be done to
help (H) or that the bed is needed for ‘more urgent’ cases (D).
You should never mislead your consultant over which patients are
under their care (A). It is unlikely that you can guarantee the timescale
on which outpatient appointments are made (C). Regular strong opiate
analgesia may be unhelpful if this cannot be continued in the community
(G). This strategy should only be considered on specialist advice.
33
Q
- Archie is a 70-year-old man admitted six days previously for an
acute coronary syndrome. He has always been polite and pleasant
to speak to. However, today he seems unwilling to answer questions
directly and you fi nd yourself becoming increasingly annoyed about having
to repeat every question to keep him on track.
Choose the THREE most appropriate actions to take in this situation
A Calculate an Abbreviated Mental Test Score (AMTS).
B Tell Archie that you will come back later after you have seen some
other patients.
C Document in the notes that Archie is a ‘diffi cult patient’.
D Consider requesting blood tests, urinalysis, and a chest X-ray.
E Just ‘eyeball’ Archie the following day rather than seeing him thoroughly
on the ward round as this took a long time the day before.
F Take a full history and examine Archie, even if it is taking longer
than usual.
G Ask your consultant if Archie can be discharged soon as he seems to
be fed up with being in hospital.
H Move on quickly so that you can continue the ward round.
A
- A, D, F
It is important not to let feelings cloud your professional judgement. The
concern here is that Archie has become confused, which might be apparent
objectively on calculating his AMTS (A). Otherwise unexplained personality
changes warrant a full history, examination (F), and septic screen (D).
Your personal feelings should not cause you to move on prematurely
(B) (H) or avoid seeing Archie (E) the following day. Documenting that
Archie is a ‘diffi cult patient’ (C) adds little to his care. Conspiring to promote
an early discharge is also unhelpful if Archie’s personality change is
the result of a pathological event (G).
34
Q
- The nurses inform you that one of your patients has died. He
had metastatic lung cancer and had been ‘do not resuscitate’ for
weeks. As you arrive at the patient’s side room to confi rm death, you
are aware that the patient’s family are all present, having been called by
the Ward Sister.
Choose the THREE most appropriate actions to take in this situation
A Go straight into the room in case another FY1 doctor gets there fi rst.
B Explain why you have arrived and what you intend to do.
C Ask the relatives to leave as there is a bed crisis and the patient has to
be moved to the mortuary.
D Ask everyone present for identifi cation to prove they are close
relatives.
E Give the relatives some space and come back later, introducing yourself
if they are still there.
F Tell the relatives this is probably what the patient ‘would have
wanted’.
G Let the relatives choose whether to be in the room or outside while
you confi rm death.
H Enter the room and commence chest compressions if the patient is
pulseless.
A
- B, E, G
Although formal confi rmation of death should be done promptly, other
considerations may be prioritized. The relatives may appreciate some
time with the patient, after which you should introduce yourself (E) and
explain what the process involves (B). You should let the relatives
choose whether to vacate the room (G), as some aspects (e.g. checking
for pupillary refl exes) might distress them.
There is no need to ask for identifi cation (D), make trite comments
which may cause off ence (F), or commence chest compressions (H) if
there is a valid ‘do not resuscitate’ instruction. Financial (A) and bed management
considerations (C) have no place at this time.
35
Q
- Mike is an intravenous drug user on the gastroenterology ward
with liver failure secondary to hepatitis C. He is currently prescribed
intravenous methadone, but healthcare staff are struggling to
administer this as his veins are overused. He wants to inject his own
methadone as he would do at home.
Choose the THREE most appropriate actions to take in this situation
A Discuss with the Ward Sister as to whether self-injecting is acceptable
on the ward.
B Explain that it is never acceptable for patients to administer their own
medication.
C Ensure that Mike is familiar with the NHS equipment and safety rules
(e.g. sharps disposal).
D Off er Mike oral morphine if he agrees to forgo methadone injections.
E Only agree if the procedure is supervised by a member of staff .
F Explain that this is not possible as he is hepatitis C positive.
G Give Mike a supply of needles and tell him to ‘make himself at home’.
H Ask Mike what dose of methadone he usually takes and prescribe this
amount.
A
- A, C, E
Any decisions about behaviour on the ward should be made in
collaboration with the nursing staff (A). If it is agreed that Mike can
administer his own methadone, he must be familiar with the equipment
and safety requirements (C), and supervised (E) to ensure that sharps
are appropriately discarded.
It would be inadvisable to alter Mike’s regimen (D) without specialist
advice or to give him needles (G) without addressing the issues above.
Patients are often allowed to administer their own medication (B) (e.g.
self-injecting insulin) when this is agreed with the nursing staff .
Hepatitis C emphasizes the importance of disposing of sharps safely
but does not alter whether the process of self-injecting is permissible
(F). Doctors should not usually accept the dose of methadone
that someone who is drug-dependent has said they are usually prescribed
(H). Independent verifi cation is necessary (e.g. from a GP or
pharmacy).
36
Q
- Roger was admitted to your ward following a stroke which
has left him with severe weakness down his left side. He was
referred to a local rehabilitation hospital three weeks ago and is currently
waiting for a bed to become available.
Choose the THREE most appropriate actions to take in this situation
A Ask the ward physiotherapists if they could spend extra time with
Roger before a rehabilitation bed becomes available.
B Ensure that daily infl ammatory markers are sent in case Roger develops
hospital-acquired pneumonia.
C Call the rehabilitation hospital and insist that they fi nd a bed as Roger
is at risk of complications (e.g. pressure sores).
D Cross off the routine prescription for daily low molecular weight
heparin to reduce the number of injections he receives.
E Call the rehabilitation hospital to check Roger’s position on the waiting
list and ensure that they know that he has waited for three weeks.
F Keep Roger informed of his progress up the waiting list.
G Discharge Roger home to bypass the rehabilitation hospital.
H Suggest that Roger’s family keep calling the rehabilitation hospital to
push his name further up the waiting list.
A
- A, E, F
Doctors must advocate appropriately for their patients. If the wait is
unusual, you should contact the rehabilitation hospital to check that
Roger has not been missed (E). You should keep Roger informed (F) and
ask the ward physiotherapists to do their best to mitigate the disadvantage
of remaining in an acute hospital bed (A).However, you should be sensitive to the resource allocations of other
healthcare providers. Asking Roger’s family to campaign (H) at the
expense of other patients or insisting that the rehabilitation hospital fi nd
a bed (C) may be unhelpful. Daily infl ammatory markers are inappropriate
in a ‘well’ patient (B), but low molecular weight heparin should probably
continue as his mobility is impaired (D). Discharge would only be
appropriate if the multi-disciplinary team agree that Roger has returned
to baseline and no longer requires prolonged rehabilitation (G).
37
Q
- Tom is a bus driver admitted with an epileptiform seizure. Your
consultant tells Tom that he must inform the DVLA. Later in the
day, Tom says that he can’t tell the DVLA as driving is his job and he has
never had a seizure before this one.
Choose the THREE most appropriate actions to take in this situation
A Call his employer anonymously to let them know he is unsafe to drive.
B Tell Tom that you must inform his employer and call them even if he
refuses consent.
C Document clearly any driving advice given to Tom.
D Agree that he is probably not a danger but tell Tom that he should
probably let the DVLA know anyway.
E Call the DVLA anonymously but keep this from Tom so that your
relationship is not disrupted.
F Explain that there is a reasonable possibility of a second seizure.
G Ask Tom’s wife to bring in his driving licence and surrender this to the
Ward Sister.
H Explain that you will have to contact the DVLA if he refuses
A
- C, F, H
Tom has a legal duty to inform the DVLA. Although this legal duty does
not extend to doctors, you have a professional duty to balance the need
for confi dentiality against harm occurring to others. Therefore you cannot
conspire with Tom to keep his driving secret (D).
You should ensure that Tom is fully informed about the risk of a second
seizure (F) and that this advice is documented carefully (C). Your
professional duty probably requires informing the DVLA if Tom refuses
(H), but this should be made clear to him (E). Although it could be justifi -
able to inform Tom’s employer, this is a more radical step and probably
unnecessary if the DVLA is notifi ed (B) (A). The hospital has no role to
play in confi scating Tom’s driving licence (G).
38
Q
- A staff nurse approaches you with concerns about Mark, a
young man with a recently repaired femoral fracture. He insists
on wearing his own clothes and will not change into a hospital gown.
Friends also bring food in for him (e.g. take-away curries), which upsets
other patients.
Choose the THREE most appropriate actions to take in this situation
A Ask Mark to change into a gown because otherwise he is diffi cult to
examine.
B Tell the nurse that there is no good reason why Mark shouldn’t wear
his own clothes.
C Explain to the nurse that Mark should be able to eat food from outside
if he prefers.
D Tell Mark that if he is well enough to eat curry then he is well enough
to be discharged.
E Tell the nurse that the other patients should ask their friends/relatives
to bring in food if that’s what they want.
F Ask Mark to consider other patients having to eat hospital food
before choosing food for his friends to bring.
G Suggest that Mark be swapped with another patient who is currently
in a side room with diarrhoea and vomiting.
H Tell the nurse that Sister controls the ward and that she should speak
to Mark if there is a problem.
A
- B, C, F
There is no obvious reason why Mark should wear a hospital gown
(B) (A) and he certainly cannot be forced to wear one. Similarly, there
is no clinical reason why Mark should be confi ned to hospital food (C).
However, if this is having a negative impact on other patients, it may be
worth bringing this to Mark’s attention (F). Although the Ward Sister
might want to talk to Mark, there is no reason why you shouldn’t do
so (H).
It cannot be assumed that all patients have people willing to bring them
food (E) and neither does it follow that Mark must be fi t enough for discharge
(D). Moving Mark to a side room is a possibility, but only if one is
available. He should certainly not be swapped for a patient isolated for
clinical reasons (e.g. diarrhoea and vomiting) (G).
39
Q
- You are asked to site a cannula in John, a patient with traumatic
brain injury and a permanent GCS of 8. He is dehydrated and
requires intravenous fl uid.
Choose the THREE most appropriate actions to take in this situation
A Explain to the patient what you are going to do.
B Aim blind if you can’t see a target vein as multiple attempts are
unlikely to cause pain.
C Ask a medical student to insert the cannula as he can try a few times
and it will be good practice.
D Defer the job until later as it is uncomfortable being in the room with
someone who is unresponsive.
E Omit washing your hands and cleaning the area as the patient is
unlikely to comment.
F Warn the patient about a ‘sharp scratch’ as you would for any other.
G Explain to the patient why a cannula is necessary.
H Try to give oral fl uid instead to see if this is tolerated.
A
- A, F, G
Although the patient has a GCS of 8, it is impossible to know to what
extent he is aware of his surroundings. Therefore you should assume
that he can hear and understand. You should explain the procedure fully
(A) (G) and give warnings when appropriate (F).
You should not treat John diff erently because he is unresponsive, for
example by careless attempts at cannulation (B), omission of important
steps (E), or delegating the task inappropriately (C). John is a vulnerable
patient as he cannot advocate for himself and so his care should not be
deferred until later (D). Giving oral fl uid to an unresponsive patient is
likely to result in aspiration (H).
40
Q
- You are on your way to the blood gas analyser with a sample
which shouldn’t be left out for more than ten minutes.
You hear a patient shouting and put your head around the curtain. An
elderly patient of the opposite sex you haven’t met before says they
have been sitting on the commode for half an hour and shouting to be
helped into bed.
Choose the THREE most appropriate actions to take in this situation
A Tell the patient you are in a hurry.
B Tell the patient you are in a hurry but will come back in ten minutes.
C Off er to help if you can without compromising the sample.
D Say you will let a nurse know that they need help.
E Reassure the patient that someone will probably come to their
assistance soon.
F Suggest that the patient pulls the emergency bell to attract the nurses’
attention.
G Say you are sorry that they have been there for so long.
H Tell the patient that they shouldn’t shout unless there is an emergency
as they may alarm other patients.
A
- C, D, G
In this scenario you must balance the dignity and comfort of one patient
against the need to take a second blood sample from another. You
should certainly help the patient on the commode if you are able (C) or
ask a nurse to do so (D). Clearly, it is not appropriate for a patient to
be left on the commode shouting and it is likely the nurses are occupied
elsewhere. You could apologize for this without the need to assign blame
(G). Clearly, reprimanding the patient for shouting is not helpful (H).
Letting the patient know that you are in a hurry is only helpful if it
precedes your assurance that someone else will help shortly (A) (B).
A vague reassurance that ‘someone’ will ‘probably’ help soon is unhelpful
(E). The patient should not be encouraged to abuse their emergency
bell (F).
