Proposed new FERRETS cases

The new simulation course will be, of course, based on the Foundation Programme curriculum and an appropriate curriculum for nursing participants. However, it may be useful to use the Joint Royal Colleges of Physicians list of common acute presentations of illness as a basis for selecting appropriate cases on which we can build scenarios. Here is a selection of the ‘Top 20 cases’ which could be suitable.  (You can see all of them in the GIM curriculum.)

It would be useful for members of the development group to try to find cases which would serve as exemplars for each of these categories. I will list who is doing what as you let me know.

Of course, if you think other presentations should be included, let me know as well.

Use the form at the bottom of this page to let me know if you have a suitable case or for any other comments.

Here is a list of the proposed cases (those in red are in development):

Abdominal Pain
Acute Back Pain
Blackout / Collapse
Breathlessness
Chest Pain
Confusion / Acute Delirium
Fits / Seizure
Haematemesis and Melaena
Headache
Limb pain and swelling
Palpitations
Poisoning
Vomiting and Nausea
Weakness and Paralysis 

Click here for the list of cases and their ‘sponsors’.

Knowledge Skills Behaviours
Abdominal Pain Outline the different classes of abdominal pain and how the history and clinical findings differ between them.  Elicit signs of tenderness, guarding, and rebound tenderness and interpret appropriately. Exhibit timely intervention when abdominal pain is the manifestation of critical illness or is life-threatening, in conjunction with senior and appropriate specialists.
 The trainee will be able to assess a patient presenting with abdominal pain to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan.
Identify the possible causes of abdominal pain, depending on site, details of history, acute or chronic. Order, interpret and act on initial investigations appropriately: blood tests; x-rays; ECG; microbiology investigations. Recognise the importance of a multi-disciplinary approach includingearly surgical assessment when appropriate.
Define the situations in which urgent surgical, urological or gynaecological opinion should be sought. Initiate first line management: the diligent use of suitable analgesia; ‘nil by mouth’; IV fluids; resuscitation. Display sympathy to physical and mental responses to pain.
Determine which first line investigations are required, depending on the likely diagnoses following evaluation. Interpret gross pathology on CT abdo scans, including liver metastases and obstructed ureters with hydronephrosis. Involve other specialties promptly when required.
Define the indications for specialist investigation: ultrasound, CT, MRI, endoscopy.
Knowledge Skills
Behaviours
Acute Back Pain Recall the causes of acute back pain. Perform examination and elicit signs of spinal cord / cauda equina compromise. Involve neurosurgical unit promptly in event of neurological symptoms or signs.
 The trainee will be able to assess a patient with a new presentation of back pain to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
Specify abdominal pathology that may present with back pain. Practise safe prescribing of analgesics / anxiolytics to provide symptomatic relief. Ask for senior help when critical abdominal pathology is suspected
Outline the features that raise concerns as to a sinister cause (‘the red flags’) and lead to consideration of a chronic cause (‘the yellow flags’). Order, interpret and act on initial investigations appropriately: blood tests and x-rays. Recognise the socio-economic impact of chronic lower back pain
Recall the indications of an urgent MRI of spine. Participate in multi-disciplinary approach: physio, OT.
Outline indications for hospital admission. Outline secondary prevention measures in osteoporosis.  Recognise impact of osteoporosis and encourage bone protection in all patients at risk
Knowledge
Skills  Behaviours
Blackout / Collapse Recall the causes for blackout and collapse. Elucidate history to establish whether event was LOC, fall without Recognise impact episodes can have on lifestyle particularly in the elderly
The trainee will be able to assess a patient presenting with a collapse to produce a validdifferential diagnosis, investigate appropriately, formulate and implement a management plan (see also ‘Syncope’ and ‘Falls’)
Differentiate the causes depending on the situation of blackout +/or collapse, associated symptoms and signs, and eye witness reports. Assess patient in terms of ABC and degree of consciousness and manage appropriately Recognise recommendations regarding fitness to drive in relation to undiagnosed blackouts
Outline the indications for temporary and permanent pacing systems Perform examination to elicit signs of cardiovascular or neurological disease and to distinguish epileptic disorder from other causes
Define indications for investigations: ECHO, ambulatory ECG monitoring, neuroimaging. Order, interpret and act on initial investigations appropriately: ECG, blood tests inc. glucose
Manage arrhythmias appropriately as per ALS guidelines.
Detect orthostatic hypotension
Institute external pacing systems when appropriate
Knowledge
 Skills  Behaviours
Breathlessness Recall the common and/or important cardio-respiratory conditions that present with breathlessness Interpret history and clinical signs to list appropriate differential diagnoses: Recognise the distress caused by breathlessness and discuss with patient and carers
The trainee will be able to assess a patient presenting with breathlessness to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
Differentiate orthopnoea and paroxysmal nocturnal dyspnoea Differentiate between stridor and wheeze Recognise the impact of long term illness
Identify non cardio-respiratory factors that can contribute to or present with breathlessness e.g. acidosis Order, interpret and act on initial investigations appropriately: routine blood tests, oxygen saturation, arterial blood gases, chest x-rays, ECG, Peak flow test, spirometry Consult senior when respiratory distress is evident
Define basic pathophysiology of breathlessness Initiate treatment in relation to diagnosis, including safe oxygen therapy, early antibiotics for pneumonia Involve Critical Care team promptly when indicated
List the causes of wheeze and stridor Perform chest aspiration and chest drain insertion Exhibit non-judgemental attitudes to patients with a smoking history
Outline indications for CT chest, CT pulmonary angiography, spirometry Recognise disproportionate dyspnoea and hyperventilation
Practice appropriate management of wheeze and stridor
Evaluate and advise on good inhaler technique
Recognise indications for ventilatory support, including intubation and non-invasive ventilation
Knowledge
 Skills  Behaviours
Chest Pain Characterise the different types of chest pain, and outline other symptoms that may be present Interpret history and clinical signs to list appropriate differential diagnoses: esp. for cardiac pain & pleuritic pain Perform timely assessment and treatment of patients presenting with chest pain
The trainee will be able to assess a patient with chest pain to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
List and distinguish between the common causes for each category of chest pain and associated features: cardiorespiratory, musculoskeletal, upper GI Order, interpret and act on initial investigations in the context of chest pain appropriately: such as ECG, blood gas analysis, blood tests, chest radiograph, cardiac biomarkers Involve senior when chest pain heralds critical illness or when cause of chest pain is unclear
Define the pathophysiology of acute coronary syndrome and pulmonary embolus Commence initial emergency treatment including coronary syndromes, pulmonary embolus and aortic dissection Recognise the contribution and expertise of specialist cardiology nurses and technicians
Identify the indications for PCI and thrombolysis in ACS Elect appropriate arena of care and degree of monitoring Recommend appropriate secondary prevention treatments and lifestyle changes on discharge
Identify the indications and limitations of cardiac biomarkers and dimer analysis Formulate initial discharge plan Communicate in a timely and thoughtful way with patients and relatives
Outline emergency and longer term treatments for PE
Outline the indications for further investigation in chest pain syndromes: CT angiography and tread mill
Knowledge
 Skills  Behaviours
Confusion / Acute Delirium List the common and serious causes for acute confusion / delirium. Examine to elicit cause of acute confusion / delirium ACAT, CbD, mini-CEX Recognise that the cause of acute confusion / delirium is often multifactorial
The trainee will be able to assess an acutely confused / delirious patient to formulate a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
Outline important initial investigations, including electrolytes, cultures, full blood count, ECG, blood gases, thyroid function tests Perform mental state examinations (abbreviated mental test and minimental test) to assess severity and progress of cognitive impairment Contribute to multi-disciplinary team management
Recognise the factors that can exacerbate acute confusion / delirium e.g. change in environment, infection Recognise pre-disposing factors: cognitive impairment, psychiatric disease Recognise effects of acutely confused / delirious patient on other patients and staff in the ward environment
List the pre-existing factors that pre-dispose to acute confusion / delirium Understand and act on the results of initial investigations e.g. CT head, LP
Outline indications for further investigation including head CT, lumbar puncture Interpret and recognise gross abnormalities of CT head/MRI Brain e.g. Mid line shift and intracerebral haematoma
Knowledge
Skills  Behaviours
Fits / Seizure Recall the causes for seizure (refer SSC) Recognise and commence initial management of a patient presenting with status epilepticus Recognise importance of Epilepsy Nurse Specialist
The trainee will be able to assess a patient presenting with a fit, stabilise promptly, investigate appropriately, formulate and implement a management plan
Recall the common epileptic syndromes Promptly recognise and treat precipitating causes: metabolic, infective, malignancy Recognise the psychological and social consequences of epilepsy
Recall the essential initial investigations following a ‘first fit’ Differentiate seizure from other causes of collapse using history and examination
Recall the indications for a CT head Recognise need for urgent referral in case of uncontrolled recurrent loss of consciousness or seizures
Describe the indications, contraindications and side effects of the commonly used anti-convulsants Recognise the principles of safe discharge, after discussion with senior colleague
Differentiate seizure from other causes of collapse
Knowledge
 Skills  Behaviours
Haematemesis and Melaena Specify the causes of upper GI bleeding, with associated risk factors including coagulopathy and use of NSAIDs/Aspirin /anticoagulants. Recognise shock or impending shock and resuscitate rapidly and assess need for higher level of care. Seek senior help and endoscopy or surgical input in event of significant GI bleed
 The trainee will be able to assess a patient with an upper GI haemorrhage to determine significance; resuscitate appropriately; and liaise with endoscopist effectively
Recall scoring systems used to assess the significance and prognosis of an upper GI bleed Distinguish upper and lower GI bleeding Observe safe practices in the prescription of blood products.
Recall the principles of choice of IV access including central line insertion, fluid choice and speed of fluid administration. Demonstrate ability to site large bore IV access
Recall common important measures to be carried out after endoscopy, including helicobacter eradication, acid suppression. Safely prescribe drugs indicated in event of an established upper GI
Knowledge
 Skills  Behaviours
Headache Recall the common and life-threatening causes of acute new headache, and how the nature of the presentation classically varies between them (see SSC) Recognise important diagnostic features in history Recognise the nature of headaches that may have a sinister cause and assess and treat urgently
The trainee will be able to assess a patient presenting with headache to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
Understand the pathophysiology of headache Perform a comprehensive neurological examination, including eliciting signs of papilloedema, temporal arteritis, meningism and head trauma Liaise with senior doctor promptly when sinister cause is suspected
Recall the indications for urgent CT/MRI scanning in the context of headache Order, interpret and act on initial investigations Involve neurosurgical team promptly when appropriate
Recall clinical features of raised intra-cranial pressure Perform a successful lumbar puncture when indicated with minimal discomfort to patient observing full aseptic technique
Demonstrate knowledge of different treatments for suspected migraine Interpret basic CSF analysis: cell count, protein, bilirubin, gram stain and glucose
Initiate prompt treatment when indicated: appropriate analgesia; antibiotics; antivirals; corticosteroids
Knowledge
 Skills  Behaviours
Limb pain and swelling Recall the causes of unilateral and bilateral limb swelling in terms of acute and chronic presentation Perform a full and relevant examination including assessment of viability and perfusion of limb and differentiate pitting oedema; cellulitis; venous thrombosis; compartment syndrome Prescribe appropriate analgesia
The trainee will be able to assess a patient presenting with limb pain or swelling to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
Recall the different causes of limb pain and the pathophysiology of pitting oedema, non-pitting oedema and thrombosis Recognise compartment syndrome and critical ischaemia and take appropriate timely action Liaise promptly with surgical colleagues in event of circulatory compromise (e.g. compartment syndrome)
Recall the risk factors for the development of thrombosis and recognised risk scoring systems Order, interpret and act on initial investigations appropriately: blood tests, doppler studies, urine protein
Recall the indications, contraindications and side effects of diuretics and anti-coagulants Practise safe prescribing of initial treatment as appropriate (anticoagulation therapy, antibiotics etc)
Demonstrate awareness of the longer term management of DVT Recognise importance of thrombo-prophylaxis in high risk groups
Differentiate the features of limb pain and/or swelling pain due to cellulitis, varicose eczema and DVT
Knowledge
 Skills  Behaviours
Palpitations Recall cardiac electrophysiology relevant to ECG interpretation Elucidate nature of patient’s complaint Consult senior colleagues promptly when required
 The trainee will be able to assess a patient presenting with palpitations to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
Recall common causes of palpitations Order, interpret and act on initial investigations appropriately: ECG, blood tests Advise on lifestyle measures to prevent palpitations when appropriate
Recall the categories of arrhythmia Recognise and commence initial treatment of arrhythmias being poorly tolerated by patient (peri-arrest arrhythmias)
Recall common arrhythmogenic factors including drugs Ensure appropriate monitoring of patient on ward ACAT, CbD, mini-CEX
Recall the indications, contraindications and side effects of the commonly used anti-arrhythmic medications Management of newly presented non compromised patients with arrhythmias
Demonstrate knowledge of the management of Atrial Fibrillation
Knowledge
 Skills  Behaviours
Poisoning Recall indications for activated charcoal and whole bowel irrigation Recognise critically ill overdose patient and resuscitate as appropriate Contact senior promptly in event of critical illness or patient refusing treatment
 The trainee will be able to assess promptly a patient presenting with deliberate or accidentalpoisoning, initiate urgent treatment, ensure appropriate monitoring and recognise the importance of psychiatric assessment in episodes of self harm
Recognise importance of accessing TOXBASE and National Poisons Information Service and the use of the information so obtained Take a full history of event, including a collateral history if possible Recognise the details of poisoning event given by patient may be inaccurate
Examine to determine nature and effects of poisoning Show compassion and patience in the assessment and management of those who have self-harmed
Commence poison-specific treatments in accordance with information from TOXBASE/NPIS
Order, interpret and act on initial investigations appropriately: biochemistry, arterial blood gas, glucose, ECG, and drug concentrations
Ensure appropriate monitoring in acute period of care (Toxbase)
Perform mental state examination
Knowledge
 Skills  Behaviours
Vomiting and Nausea Recall the causes and pathophysiology of nausea and vomiting Elicit signs of dehydration and take steps to rectify Involve surgical team promptly in event of GI obstruction
 The trainee will be able to assess a patient with vomiting and nausea to produce a validdifferential diagnosis, investigate appropriately, formulate and implement a management plan
Recall the use and adverse effects of commonly used anti-emetics and differentiate the indications for each Recognise and treat suspected GI obstruction appropriately: nil by mouth, NG tube, IV fluids Respect the impact of nausea and vomiting in the terminally ill and involve palliative care services appropriately
Recall alarm features that make a diagnosis of upper Gastro Intestinal malignancy possible Practise safe prescribing of anti-emetics
Order, interpret and act on initial investigations appropriately: blood tests, x-rays
Knowledge
 Skills  Behaviours
Weakness and Paralysis Broadly outline the physiology and neuroanatomy of the components of the motor system Elucidate speed of onset and risk factors for neurological dysfunction Recognise importance of timely assessment and treatment of patients presenting with acute motor weakness
The trainee will be able to assess a patient presenting with motor weakness to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan
Recall the myotomal distribution of nerve roots, peripheral nerves, and tendon reflexes Perform full examination to elicit signs of systemic disease and neurological dysfunction and identify associated deficits Consult senior and acute stroke service, if available, as appropriate
Recall the clinical features of upper and lower motor neurone, neuromuscular junction and muscle lesions Describe likely site of lesion in motor system and produce differential diagnosis Recognise patient and carers distress when presenting with acute motor weakness
Recall the common and important causes for lesions at the sites listed above Order, interpret and act on initial investigations for motor weakness appropriately Consult senior when rapid progressive motor weakness or impaired consciousness is present
Recall the Bamford classification of stroke, and its role in prognosis Recognise when swallowing may be unsafe and manage appropriately Involve speech and language therapists appropriately
Demonstrate knowledge of investigations for acute presentation, including indications for urgent head CT Detect spinal cord compromise and investigate promptly Contribute to multi-disciplinary approach
Perform tests on respiratory function and inform senior appropriate
Ensure appropriate care: thrombo-prophylaxis, pressure areas

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