A Acute Internal Medicine (ST4) station on MedMock, start to finish

Thank you for joining us. We'll start with the scenario you've just read: a 32-year-old woman in same day emergency care with pleuritic chest pain and breathlessness, two months after starting the combined pill, with a heart rate of 104. How would you approach her?

I'd see her promptly and start with an A to E assessment. Apart from the tachycardia her observations are reassuring, but I'd recheck her blood pressure myself, look for signs of right heart strain and examine her legs for a DVT. Pulmonary embolism is my main concern, given pleuritic pain, breathlessness and tachycardia on the combined pill, but I'd also consider pneumonia, a pneumothorax, pericarditis and musculoskeletal pain. I'd ask about haemoptysis, previous clots, recent surgery, travel or immobility, family history, and whether she could be pregnant. Initial tests: an ECG, a chest X-ray, a pregnancy test, and bloods including a full blood count, renal and liver function and a clotting screen. I wouldn't use the PERC rule, because she's tachycardic and taking oestrogen, and my suspicion isn't low. On the two-level PE Wells score, if nothing else explains her symptoms, she scores 3 because PE is the most likely diagnosis and 1.5 for a heart rate over 100: 4.5, so PE is likely, and NICE says to go to a CTPA, immediately if possible, rather than a D-dimer. If the scan can't be done straight away, I'd start interim anticoagulation with apixaban or rivaroxaban, which can simply continue if the scan is positive, after sending the baseline bloods but without waiting for the results. If the scan can't happen today and she's well, she could go home on that and come back for it, which is what our ambulatory PE pathway is for. If she were hypotensive, it would be a different conversation about high-risk PE and thrombolysis, with senior and critical care input from the start.

Thank you. The CTPA shows a right lower lobe pulmonary embolism with no right ventricular strain, and her blood tests are normal. She tells you she has two young children at home and would like to leave. What would you do?

I'd see whether she's suitable for outpatient treatment, which NICE supports for low-risk PE, using a validated tool. Her simplified PESI score is zero: she's under 80, with no cancer, no chronic heart or lung disease, a heart rate under 110, a systolic pressure over 100 and saturations above 90%. With no right ventricular strain on the scan, normal bloods, pain controlled with simple analgesia, support at home and no bleeding risk factors, she's a good candidate. I'd start apixaban or rivaroxaban after checking her weight, renal function and other medicines, and ask whether she's breastfeeding, because neither should be used then. Before she leaves she needs written information on what to look out for, a direct number for our thrombosis or ambulatory team, and how to get help out of hours, as NICE sets out, plus a follow-up appointment. She should stop the combined pill today. Because the pill counts as a provoking factor, she'd have at least three months of anticoagulation and then a review; if she's recovered and is no longer taking it, stopping at that point is reasonable. Thrombophilia testing isn't indicated after a provoked PE. And I'd write to her GP the same day.

Thank you. She asks you: 'Was it the pill? And if I stop it, what do I do about contraception?' How would you answer her?

I'd sit down and use plain language, something like: 'It's very likely the pill played a part. The oestrogen in it makes clots more likely, so we'd advise you to stop it today and not to use it again in future. You do still need reliable contraception, because the blood thinner isn't recommended in pregnancy, as it may not be safe for a baby. There are good options without oestrogen that are safe for you: a copper or hormonal coil, the implant, or the progestogen-only pill. Your GP or a sexual health clinic can help you choose, and until then please use condoms. If you think you might be pregnant, contact us straight away, because we'd need to change your treatment. Some women find their periods get heavier on this medicine, so let us know if that happens.' Then I'd check what she's understood, ask what questions she has, and give her the same advice in writing.

Thank you, that is the end of the first question. I would like to move on to the second. This is a hypothetical situation, so just listen and then tell us how you would approach it. You are the medical registrar on a night shift. A healthcare assistant tells you that one of the ward's nurses has been entering observations and NEWS2 scores in the electronic record for patients she has not actually observed, because the ward is being audited on how many observations are done on time. How would you approach this?

My first concern is the patients, because if those scores are false, someone could be deteriorating and nobody would know. So straight away I'd ask the nurse in charge to arrange a fresh set of observations for every patient whose recent entries are in question, and I'd review anyone whose real observations are abnormal. I wouldn't act on a single second-hand report as if it were proven, though. Next I'd want to understand what happened. I'd speak to the nurse privately and without accusation: she may be overwhelmed, the ward may be short of staff, or there may be an explanation I haven't thought of. But entering observations that weren't taken is falsifying a clinical record. It breaks the honesty every professional is held to, and it puts patients at risk. Because it affects patient safety, I couldn't keep it between the two of us. I'd tell the nurse in charge that night and report it through the trust's incident system, and in the morning I'd make sure the ward manager or matron knew, so that it is looked into properly and she is supported; whether it goes any further is for them, not me. I'd also raise the staffing and the audit pressure, because a target that pushes people to do this is a problem with the system. And I'd document what I found and what I did.

Thank you. Which principles of Good Medical Practice are relevant here?

Patient safety comes first: Good Medical Practice says we must act promptly if we think patient safety is being compromised, and that includes raising a concern about a colleague, even when it's uncomfortable. Then honesty: records must be accurate and must not be false or misleading, and that applies to everyone who writes in them. It also expects us to support colleagues and help build a culture where people feel able to speak up, so I'd want the nurse treated fairly and the healthcare assistant who told me protected from any backlash. And it asks us to take part in improving care, which is why I'd raise the audit target and the staffing rather than treat this only as one person's failing.

Thank you. That's the end of this station.