From SSC handbook: Guidance for students and tutors 

This SSC gives you choice in respect of a patient in which to apply your understanding of clinical methods and sciences to the central goal of good medical practice; as laid out by the GMC in Tomorrow’s Doctors; Outcome 2 (the doctor as a practitioner) and Outcome 3 (the doctor as scholar and a scientist).

All patients that you see while on placement could be suitable for your SSC. Find a clinician to watch you for about 10 minutes worth of eliciting a patient’s history and then they will give you feedback on how you communicate with the patient to establish rapport and gain a good history.  You do not have to use the history obtained during this session for your SSC but it can help you improve for future sessions.  The feedback is aligned to MiniCEx but shorter and relates just to eliciting the history.

For this SSC you will submit a report on a patient whom you have interviewed and examined. It will incorporate and integrate subject matter and information covered in Phase 1, the Clinical Skills Courses and the Clinical rotation.

The SSC tutor is normally your clinical supervisor but can be another doctor on the team, as long as they are at a level above Foundation Year 2 (this includes education fellows for London students).

In summary, therefore, the key point of this SSC is to draw upon and integrate a range of previously learned skills and knowledge and apply them to a patient case.

The report will include the following sections:

Section 1:     The Medical History (Content)

Section 2:     The Examination Findings, Investigations & Tests, and Initial Assessment

Section 3:     The Inter-Professional Care (1250 words max)

Section 4:     Reflection (1000 word min – 1500 words max)

Tutor and student should meet at the beginning of the rotation to devise a project/programme of work and the student should complete the SSC3a Supervisor Details Form (onQMPLUS) by 12pm Friday 16th February 2024. The tutor should then plan to meet the student at regular agreed intervals during the rotation.  Appropriate deadlines should be set by the tutor for written work with the final deadline for SSC3a being 12pm Monday 18th March 2024, and subsequent to this, the tutor should complete the assessment form sent by email by the School.

Results and feedback should be available by April/May 2024.

Patients should be over 18 years of age and should be able to speak to the student without the need for an interpreter (histories should be taken in English). Students should not use the same patient as another student, if possible. 

Lack of appropriate engagement with your Tutor could affect your grade, it is therefore essential that you make full use of this resource. Failure to contact and interact with your tutor will constitute unprofessional behaviour and will be flagged.

Initial Assessment - Problem Orientated Medical Records

The purpose of Problem Orientated Medical Records (POMR) is to structure the medical case history to make it easier to interpret the relevant clinical information and to provide a framework for planning diagnostic tests and therapeutic procedures. It will also help to remind the clinician what is troubling a patient and how such problems may be resolved. The emphasis of POMR is the compilation of a list of problems on the basis of clinical findings (history and examination). The diagnosis or diagnoses will only be made if all problems are considered. If used appropriately, POMR will help you to make decisions about patient care: it will also provide a structure which is very helpful for medical audit.

How to problem orientate a medical record:

1.      Problem listing. Review your patient’s history and examination findings and list all of the apparent problems (including social/domestic ones). You should list the problems in what you consider to be an order of priority with the presenting medical problem(s) at the top – P1, P2, P3 etc. Problems may be categorised into ‘active’ or current problems and ‘inactive’ or past problems – it is important when you do this to recognise possible associations between past problems and current ones. For example, rheumatic fever as a child may be the explanation for the development of cardiac failure as an adult. In this circumstance, the presenting problem of breathlessness (P1) should be listed as follows: P1 Breathlessness – past history of rheumatic heart disease. All the problems should be listed irrespective of whether they are currently active or inactive if you consider they may have a bearing on the patient’s well-being. For example, if your patient with breathlessness and a past history of rheumatic heart disease has also been treated for peptic ulcer, this should be listed as a problem i.e. P2. The significance of this will be if the patient needs anticoagulation for mitral valve disease – endoscopy before starting warfarin to confirm inactivity of the ulcer will be prudent.

2.      Structuring each problem. Having listed the problems, you should start to formulate an initial plan of investigation and possible treatment. This requires you to think about a possible diagnosis or diagnoses which best fit the clinical findings. It is useful at this stage to analyse each of the patient’s main problems in more detail by using the principle of SOAPI. This stands for Subjective, Objective Assessment, Plan and (patient) Information – in other words, all the factors you will be considering for making a diagnosis. If we take our patient with breathlessness and apply SOAPI:

P1 Breathlessness – past history of rheumatic fever

S -            Breathlessness

O -             History and clinical signs suggest cardiac failure. Raised JVP, bilateral ankle oedema and basal crepitations. In addition, there is a pansystolic murmur at the apex and atrial fibrillation.

A -           Biventricular failure possibly secondary to rheumatic valvular disease.

P -            ECG, CXR (if not already done) blood cultures and an echocardiogram.

I -                  ‘Your breathlessness results from congestion on the lungs due to some heart failure’.

P2 Past history of peptic ulcer disease

S -            No complaints

O -                No symptoms or signs

A -           Probably now resolved

P -                   Needs endoscopy in view of anticoagulation.

I -             Informed about endoscopic procedure.

3. Progress notes. It is useful to follow the patient’s progress during admission by keeping progress notes in a similar structured fashion, addressing each of the patient’s active problems in turn. Although POMR appears unwieldy at first sight, you will find not only a useful way of structuring your case histories but also a practical method to enable  you to use all the important clinical information which you have gathered.