Abstract
This section of the journal has been developed to help GP trainees practice their consulting skills for the Simulated Consultation Assessment (SCA). The section includes a ‘Doctor’s sheet’ and a ‘Patient’s sheet’ to facilitate practising consultations with your trainer and colleagues. An ‘Examiner’s sheet’ describes the areas trainees need to display in each of the marking domains and finishes with key points and tips for the trainee.
Doctor’s sheet
Patient: Linda Brown Age: 58 years
Past medical history
Hypertension diagnosed 3 weeks ago
Total abdominal hysterectomy 10 years ago for fibroids
Medications
Amlodipine 5 mg daily (OD)
Oestradiol gel OD
Allergies: Nil
Recent investigations
Blood pressure (BP) 132/74 on amlodipine
Patient’s sheet
Patient: Linda Brown Age: 58 years
Background
Patient was commenced on amlodipine 3 weeks back for essential hypertension.
Opening line
‘I am getting redness on my cheeks since starting blood pressure treatment’.
Behaviour
Worried about the side effects of treatment.
Information given freely
Patient was diagnosed to have essential hypertension after 7-day BP monitoring. Her BP has improved with amlodipine, but she has noticed redness of her cheeks with a few thread veins appearing as well.
Information to be provided on appropriate exploration and a non-judgemental approach
Mrs Brown has tried to conceal the rash with makeup, but she is concerned whether it is a side effect of her medication or whether amlodipine is interfering her hormonal replacement therapy (HRT). She uses oestrogen gel regularly and there is no recurrence of hot flushes, sweats or low mood. She enjoys gardening and regularly attends to the vegetable patch in her garden.
If asked specifically, she will mention that she has had similar intermittent episodes for many years even before menopause. She has noticed that they can get worse when she has been out in the sun, and she has always put it down to having sensitive skin. Redness can get worse with spicy foods and alcohol. If asked, she will mention that she would like to stop amlodipine as her BP is now back to normal. A photo of the facial rash is available for the candidate for examination (Figure 1). Mrs Brown is happy to try another agent for hypertension and any other treatment offered.
Facial rash.
Examiner’s sheet
Data gathering
Candidate should explore the patient’s understanding of her presentation, her concerns and expectations. They should take a focused history to establish that the symptoms were intermittently present prior to commencing amlodipine, although they could be exacerbated by the latter as well as sun exposure.
Red flags
There are no red flags in the scenario.
Clinical management
Candidate should include rosacea as a part of the key differential diagnoses and develop a shared management plan with the patient, for example: Provide explanation about rosacea and its precipitating factors, advise lifestyle modifications, including regular use of sunscreens; pause amlodipine and monitor BP or swap amlodipine to a diuretic or an angiotensin converting enzyme inhibitor (ACEI). A candidate may either provide topical treatment for rosacea, such as ivermectin or metronidazole, during the consultation or provide information and arrange follow-up.
Interpersonal skills
Candidate should be able to explore patient’s concerns surrounding her symptoms and allow her an opportunity to discuss her expectations.
Treatment options should be offered in a way that does not overwhelm the patient with new information.
Discussion with trainee
Although the patient has classic symptoms of rosacea, there are issues that can muddy the picture. Consider the following questions:
What is the likely diagnosis in this scenario? (Rosacea exacerbated by dihydropyridine calcium channel blocker and sun exposure) What other conditions could mimic this rash? (Niacin deficiency, mitral stenosis, lupus, seborrheic dermatitis, etc.) What are the types of rosacea? How would you manage rosacea?
Top tips
Addressing patient’s concerns and expectations is key to satisfactory outcomes. It is important to allow the patient to familiarise themselves with a new diagnosis before providing treatment.
