ITM Year 2
Role: Mrs. Rutten: Doctor, I am afraid I feel a lump in my breast.
Role number (for MaSP): 202
Information for the teacher
Learning goals:
-To be able to construct a complete consultation
-To ask in-depth questions about the reason for visit
-To take a specific history for the presented symptoms
-To indicate/perform physical examination (including undressing instructions) for the complaint ‘lump in breast’
-To decide on a treatment policy in consultation with the patient (negotiate)
-For some students with regard to attitude: when/how do I perform physical examination if I have not yet been trained to do so (what are my limits, how do I involve the patient in this decision), how does a breast examination affect me?
Additional information:
Furthermore, it should be noted that the patient in this SPC is currently on holiday abroad and therefore is not a native English speaker.
For more information see the NHGpractice guidelines for Dutch general practitioners: mammography/diagnostics of breast carcinomas.
Information for the SP
Patient record:
( ‘-’ = no specific instruction, fill in by yourself)
- name: Mrs. Rutten
- age:own age or adjusted after consultation with the sp
- gender: f
- social background:-
- appearance:-
- character:-
- mood:-
- level of education:-
- hobbies -
Situation:The basic situation is that all SPs come to consult the general practitioner (GP) while on holiday abroad with a question and/or health complaint.The cases were constructed in close connection to block 2.2. All SPs have a different question or complaint about something related to a breast lump.
The ages of the SPs have been chosen so that the students are offered a variety of epidemiology. The consent for a breast examination has been explicitly discussed with the SPs during the training. Please note if the student provides correct undressing instructions (e.g. only take off your shirt or sweater, but keep your bra on if the student has not explicitly asked you to take your bra off as well!).
Some SPs have a family history of breast cancer: a sister or mother or both. All SPs are worried and want a physical right now as well as X-ray or ultrasound examination.
Furthermore, it should be noted that the patient in this SPC is originally from abroad and and therefore English is not his / her mother tongue.
First sentence SP: Doctor, I am afraid I feel a lump in my breast.
Reason to consult doctor (to be filled in by the SP):
Expectations / questions to ask the doctor (to be filled in by the SP):
History-taking:
- Specific history:
No visible changes, nipple discharge, no blood excretion.
Menstrual cycle: to be filled in by the SP (related to age).
b. General history:
- allergy: none
- medical history: none
- use of medication:none
- family history : In some SPs, breast cancer occurs in the family:
either a sister or the mother or both.
- diet:normal
- smoking: To be filled in by the SP
- street drugs/alcohol: To be filled in by the SP
- job:To be filled in by the SP
- social situation:To be filled in by the SP
Physical examination: Each SP has the result of its own physical examination in an envelope (The SP receives the envelope with the results of physical examination of the breasts via SAS). After the physician has invited the patient for physical examination, the SP puts the envelope closed on the table. After the physician performed the physical examination, the SP instructs the physician to find the results of the physical examination of the breasts in the envelope on the table. Then the SP can dress calmly and the physician can read the results. (After the consultation, the SP returns the envelope again).
Medical history: uneventful
SP’s reaction to advice/ proposed course of action:
Final questions: (These are questions you, the SP, can ask at the end of the consultation).
Notes SP:
Information for the SPC-student –assistant (SAS)
Firsthand out theMASP
For the SAS:
Hand-out aan SAS: Geef alle vrouwen de uitslag in een aparte envelop mee.
Er zijn twee mogelijkheden: uitslag borstonderzoek is afhankelijk van de leeftijd van de SP.
1: SP 45 years and older:
Results of physical examination: (Text of the letter on the desk:)
Physical examination: 3-cm, elastic, oval, mobile, sharply defined swelling in the medial upper quadrant of the right breast, not attached to the layers above or below. Other breast tissue not abnormal, axillae NAD.
2: SP younger than 45 years old (according to the given birth date, can differ from the actual age!):
Results in these patient (Text of the letter on the desk:)
Physical examination: the swelling has a maximum diameter of 2cm, is sharply defined, elastic and ‘sensitive’. Not attached to the layers above or below. The breast tissue is generally slightly lumpy. Axillary lymph nodes show no abnormalities.
SAS shall ensure that approximately 40% -50% of the SP has an age under 45 years and 60-50% aged over 45 years. To ensure this, for some SP date of birth on the forms for the students have to be adjusted downwards.
Information for the student
Today you are doing an internship as a medical student in this general practice. The general practitioner has asked you to have a consultation with the next patient and /or to find out by talking with patient why (s)he is visiting the doctor today.
After the consultation you will discuss everything with this general practitioner.
You are about to see a patient you have never seen before: Mrs Rutten.
The patient record is on your desk. Read it carefully.
Patient Rutten is consulting you as (s)he has encountered a problem with her breast(s).
Perform a complete consultation, including physical examination. Before the physical examination starts, the simulation patient puts a card with the results of the breast examination on the table. After completing the physical examination, the simulation patient clogs and you have time to read the results of the breast examination on this card.
If you get stuck during a consultation, first ask the observer to help you. If you cannot solve it together, you may consult the SAS.
You have to ask the simulated patient (SP) for feedback (FB) after the consultation. First, ask the SP to step outside the room after the consultation while you prepare the FB. Make sure to ask specific questions (not: How did you like it?), so you will also receive specific answers.
You have 25 minutes in total, including time for the SP’s feedback. After 15 minutes, a bell will be rung 3x, indicating that you have 5 minutes left for the consultation. After 25 minutes, a bell will be rung 1x, this means the consultation and feedback should be rounded off.
Good luck!
Last version : maa 2018