th Concordance Script Test 25 June 2013 Script Concordance Test How to answer the script concordance test questions This test is made of 4 clinical vignettes (T1 to T4) one case per page. Each patient vignette contains 3 questions (a., b., c.). There are also vignettes with only one or two questions The vignette will give you partial information about a patient For each question you will find a hypothesis you have to adopt. This can be a diagnostic, investigational or therapeutical hypothesis. • Then additional information will be delivered. • You will have to decide how this new piece of information will influence the initial hypothesis. Mark only one field for each question on your answer sheet. • If there is more than one question per vignette, every question of a vignette has to be considered independently of the previous question (you start from scratch with the same vignette for each vignette. Don’t try to incorporate the information of the prior question in your reasoning). In the example beneath, when you are reasoning on the question b. don’t assume that the patient is suffering from esophagitis as suggested on question a. • • • • • Example (vignette with 2 questions) a. A 62-‐year-‐old male suffers from typical thoracic pain irradiating to the jaw when exercising. He smoked for 40 years. If you were thinking of asking urgently The advice of a cardiologist And you find out The new information makes your initial intention That he was suffering from esophagitis treated by 20 mg Omeprazol + 2: + 1: ± 0: - 1: - 2: essential more useful has no effect on the initial intention less useful, less relevant useless, not relevant b. (same as above) A 62-‐year-‐old male suffers from typical thoracic pain irradiating to the jaw when exercising. He smoked for 40 years. If you were thinking of asking Stress ECG And you find out The new information makes your initial intention The patient never was symptomatic at rest + 2: + 1: ± 0: - 1: - 2: essential more useful has no effect on the initial intention less useful, less relevant useless, not relevant 1 8192546645 Concordance Script Test - Pilot 2013 Answer sheet yes - correct way oﬃ lling outt he boxes no - don't cross the boxes T1 a. b. c. +2 T2 a. b. c. +2 T3 a. b. c. +2 T4 a. b. c. +2 +1 +1 +1 +1 ±0 -1 ±0 -1 ±0 -1 ±0 -1 -2 -2 -2 -2 Comments on the question Once ﬁlled out, please send this sheet back with the pre-paid envolpe. Thank you for your help and cooperation. Concordance Script Test T1 25 Juni 2013 a A 58-‐year-‐old man, known to have consumed alcohol in excessive amounts for many years and who has a 60 pack-‐year history of smoking, is admitted to the ER for weight gain of 1 2 k g in 4 weeks, w idespread oedema, and a distended abdomen. Liver function tests indicate: AST 132 UI/l; ALT: 93 UI/l; ALP: 87 UI/l; GGT: 243 UI/l, and creatine level of 180 µ mol/l. If the hypothesis is Decompensated alcoholic cirrhosis And laboratory results indicate Haemoglobin: 135g/l Leukocytes: 8.2x10⁹/l Platelets: 470,000/ml The new information makes your initial hypothesis + 2: + 1: ± 0: - 1: - 2: much more probable more probable has no effect on diagnostic hypothesis less likely much less likely b (same a s a bove) A 58-‐year-‐old man, known to have consumed alcohol in excessive a mounts for many y ears and who has a 60 pack-‐year h istory of smoking, is admitted to the ER for weight gain of 12 k g in 4 weeks, widespread oedema, and a distended abdomen. Liver function t ests indicate: AST 132 UI/l; A LT: 93 UI/l; ALP: 87 UI/l; GGT: 243 UI/l, and creatine level of 180 µmol/l. If the hypothesis is And a urine test reveals The new information makes your initial hypothesis Hepatorenal syndrome Sodium at 1 mmol/l + 2: + 1: ± 0: - 1: - 2: much more probable more probable has no effect on diagnostic hypothesis less likely much less likely c (same a s a bove) A 58-‐year-‐old man, known to have consumed alcohol in excessive a mounts for many y ears and who has a 60 pack-‐year h istory of smoking, is admitted to the ER for weight gain of 12 k g in 4 weeks, widespread oedema, and a distended abdomen. Liver function t ests indicate: AST 132 UI/l; A LT: 93 UI/l; ALP: 87 UI/l; GGT: 243 UI/l, and creatine level of 180 µmol/l. If the hypothesis is Congestive h eart failure And on clinical examination you observe A 3rd h eart s ound consistent with an S3 gallop The new information makes your initial hypothesis + 2: + 1: ± 0: - 1: - 2: much more probable more probable has no effect on diagnostic hypothesis less likely much less likely 1 Concordance Script Test 25 Juni 2013 T2 a A 62-‐year-‐old woman, midwife, w ith no significant prior medical or surgical history, presents with rotational vertigo that began the previous e vening and difficulty standing up. She complains of acute nausea. If you were considering performing An Epley or Sermont repositioning manoeuvre And you find out from the case h istory that The patient presents with occipital n euralgia Performing this manoeuvre becomes + 2: + 1: ± 0: - 1: - 2: essential more useful has no effect on the intended examination less useful, less relevant useless, not relevant b (same a s a bove) A 62-‐year-‐old woman, m idwife, with no significant p rior m edical or surgical h istory, p resents with rotational v ertigo that b egan the previous evening and difficulty standing up. She complains of acute nausea. If you were considering A h ead thrust (impulse) test And on clinical examination you observe that The patient presents with a spontaneous horizontal nystagmus observable with Frenzel glasses Performing this manoeuvre becomes + 2: + 1: ± 0: - 1: - 2: essential more useful has no effect on the intended examination less useful, less relevant useless, not relevant c (same a s a bove) A 62-‐year-‐old woman, m idwife, with no significant p rior m edical or surgical h istory, p resents with rotational v ertigo that b egan the previous evening and difficulty standing up. She complains of acute nausea. If you were thinking of asking The advice of a neurologist And you find out from the case h istory that The patient has experienced diminished hearing in h er left ear for several weeks The new information makes your initial intention + 2: + 1: ± 0: - 1: - 2: essential more useful has no effect on the intended examination less useful, less relevant useless, not relevant 2 Concordance Script Test 25 Juni 2013 T3 a A 33-‐year-‐old woman, w ho works as a night supervisor in an assisted-‐living facility and is asthmatic as well as allergic to dust and dust mites, consults you to help her stop smoking. If you were thinking of recommending Nicotine gum, 4 mg on demand And the patient tells you that She is very worried about gaining weight This n ew information makes your recommendation + 2: + 1: ± 0: - 1: - 2: crucial useful and desirable not influenced by the n ew information less useful, less relevant useless, irrelevant b (same a s a bove) A 33-‐year-‐old woman, who works as a night supervisor in an assisted-‐living facility and is asthmatic as well as a llergic to dust and dust m ites, consults you to h elp h er stop smoking. If you were thinking of recommending Treatment with bupropion And you find out from the case h istory that The patient suffered an epileptic s eizure two years ago as a result of s leep deprivation (long trip without rest) This n ew information makes your recommendation + 2: + 1: ± 0: - 1: - 2: crucial useful and desirable not influenced by the n ew information less useful, less relevant useless, irrelevant c (same a s a bove) A 33-‐year-‐old woman, who works as a night supervisor in an assisted-‐living facility and is asthmatic as well as a llergic to dust and dust mites, consults you to h elp h er stop smoking. If you were thinking of recommending Nicotine patches, 21mg/day And you find out from the case h istory that The patient sometimes gets up at n ight to s moke This n ew information makes your recommendation + 2: + 1: ± 0: - 1: - 2: crucial useful and desirable not influenced by the n ew information less useful, less relevant useless, irrelevant 3 Concordance Script Test 25 Juni 2013 T4 a A 25-‐year-‐old woman comes to see you complaining of episodes of palpitations with precordial distress and a suffocating sensation, occurring suddenly over the last month. Six weeks ago she suffered a miscarriage. Clinical examination is normal. If the hypothesis is Panic attacks And you find out from the case h istory That the miscarriage was complicated b y h eavy bleeding with continued spotting The new information makes your initial hypothesis + 2: + 1: ± 0: - 1: - 2: much more probable more probable has no effect on diagnostic hypothesis less likely much less likely b (same a s a bove) A 25-‐year-‐old woman comes to see you complaining of episodes of palpitations with precordial distress and a suffocating sensation, o ccurring suddenly over the last month. Six weeks a go she suffered a miscarriage. Clinical examination is normal. If the hypothesis is And on the ECG you notice Antiphospholipid antibodies Sinus tachycardia at 108 syndrome beats/min The new information makes your initial hypothesis + 2: + 1: ± 0: - 1: - 2: much more probable more probable has no effect on diagnostic hypothesis less likely much less likely c (same a s a bove) A 25-‐year-‐old woman comes to see you complaining of episodes of palpitations with precordial distress and a suffocating sensation, o ccurring suddenly over the last month. Six weeks a go she suffered a miscarriage. Clinical examination is normal. If the hypothesis is Psychological decompensation induced b y anxiety and depression And in the case h istory you find Lack of motivation at work, fatigue, trouble falling asleep and hyperphagia The new information makes your initial hypothesis + 2: + 1: ± 0: - 1: - 2: much more probable more probable has no effect on diagnostic hypothesis less likely much less likely 4