Below is a scenario for you to read through. There are several questions for you to answer and anything you are not sure of you must look up. Embedded within the scenario are several facts, some are correct, but others clearly aren’t. You must find these errors and make suggestions for more correct alternatives. Even though some facts are correct, you may not be certain about them so, again, you need to look things up.

Pick a narrator to read out the scenario aloud and start from the beginning. Once you have found something you’re not 100% sure of, stop and look it up. The same thing goes when you come to a question. Once you are satisfied you can continue to read the scenario.

Blunder game for CD

Jessica and Tal, two 3rd year medical students, were sitting in the gastro clinic at UHSM when a 55 year-old man came in to see the consultant. He said he had been referred by his GP because he had recently been experiencing heartburn. The consultant asked Tal to take the history and he asked about the pain, the patient’s appetite and whether he had experienced symptoms like this before. The consultant then turned to Jessica and asked her if there were any other questions she needs to ask

  • What other questions should Tal have asked?

Having discovered there was no obvious cause for concern the consultant decided to order some investigations.

  • What investigations would you like to do and why?

He then consulted the NICE guidelines and decided to prescribe the H2 antagonist omeprazole 200mg daily. He suggested taking them at night as this was when most acid is produced in the stomach. He also suggested taking Gaviscon, which he could buy over the counter at a chemist, at the same time.

The patient then said he had read about something called Barratt’s oesophagus,and asked if the doctor could reassure him that he wasn’t suffering from this. The consultant the turned to Jessica and asked him if she was able to reassure the patient on this score.

  • Is Jessica in a position to do this?

After being partially reassured by Jessica’sexplanation the patient asked if it was ok to drink alcohol whilst taking these tablets. On closer question he admitted to drinking about 15 440ml cans of Stella Artois per week plus a bottle of red wine at the weekend. The consultant looked quite stern and said this amounted to about 35 units a week and he should really cut down.

  • What are the current safe drinking guidelines?

Following this discussion the consultant was trying to draw the consultation to a close when the patient disclosed that he was also taking St John’s Wort, which he had bought from his local health food shop. Was it ok to continue, he asked?

The next patient, in the clinic, was a 24 year old lady whose GP suspected had IBS. S was complaining of intermittent, lower abdominal, cramp-like pains that she said were 10/10 when they came on. She also had bleeding from the back passage and she had lost weight. She was partial to the odd bottle of lager (or 6) and often felt worse the day after a night out.

  • What are your differential diagnoses?

The consultant said it was quite clear from the history that she definitely had IBS and he was going to do a blood test to prove it. He explained that there was nothing he could do, it was probably psychological and she should just learn to live with it. She left looking rather dispirited, clutching a blood test (stool sample, colonoscopy) request form and headed for the venepuncture room.

Jessica was keen to learn how to take blood and asked if she could go with the patient to help. She looked at the request form which asked for

  • Which blood tests would you order?

Jessica took the blood sample herself and then asked the health care assistant to sign off her UPSA. The HCA declined saying she wasn’t qualified to do this. (Anyone qualified to teach or observe this procedure – not an FY1 doctor, FY2 or above and qualified healthcare professional)

On returning to the clinic Tal and the consultant were deep in conversation about their golf swings, despite the fact that Tal had never played golf in his life. When Jessica entered, the consultant called in the next patient who was an 84-year-old man who was with his daughter. His GP had found he had a microcytic anaemia which had improved with a course of B12 tablets, but had worsened once the course had finished.

  • What possible causes are going through your mind?
  • What other questions do you need to ask?

The consultant asked Jessica to examine the patient and she thought she could feel a mass in the LIF. She told the consultant this was most likely to be a burst appendix abscess. Tal agreed and the consultant looked to the heavens and sighed.

  • What are your top 3 differentials and why?
  • What else do you need to do on examination?
  • What further investigations are you going to order?

Finally, the clinic was over and Jessica and Tal’s nightmare was over, or so they thought. As they were leaving they heard one of the nurses whispering to a cleaner. They were gossiping about the consultant and you clearly heard them say that he had only finished half his bottle of whisky during the morning’s clinic and he must be cutting down.

  • Write your own SJT with 5 possible answers
  • Be ready to discuss the ethical and professional issues raised with your tutor