Example SLEs

Here you can record a brief, anonymous description to allow the CBD to be contextualised:
Young, adult male presented to A&E with a 2 day history of headache on background of recurrent sinusitis. Vice-like headache started in the Philippines 2 days ago and then spread round to his left jaw and mastoid. On examination, there was facial swelling centred around the left ear with redness and tenderness within the left ear. A raised, red non-vesicular rash was also noted around the neck. Blood tests revealed an inflammatory process, with raised CRP and ESR, and normal WBC but raised neutrophils. He was given IV co-amoxiclav for ?parotitis. He was referred to ENT and also ID due to the recent history of travel.

Feedback on the case based discussion:
Excellent clinical assessment and discussion

Agreed action:
Review tropical infections from Philippines Review management of parotitis

Reflection:
I saw this patient in ambulatory majors, an acute setting, whilst on post-take ward round (FPC 1). I recognised the patient was acutely unwell, due to the combination of fever, acute pain and swelling (FPC 2) and the patient was subsequently handed over to the night registrar (FPC 5). I discussed the patient with the on-call infectious disease registrar, due to the concern regarding the patient’s recent travel history and covering any tropical diseases that may need to be covered (FPC 6).

Following this review, I researched mastoiditis as a presentation (FPC 12). I found it particularly interesting to learn that they frequently result from a spreading otitis media infection, most commonly caused by S. pneumoniae and S. aureus in adults and S. pyogenes in children due to vaccination schedules. The presence of swelling centred on the ear, fever, ear fullness and erythema in the ear all support a diagnosis of mastoiditis, however the classic boggy mastoid and tenderness were absent. Multidisciplinary team input from ENT surgery had also suggested parotitis as a cause. Whilst initially this didn’t seem to align with the clinical picture due to the ear-centred symptoms, on review of the CT scan, it did appear that the inflammatory changes were centred around the L parotid gland. I found this very intriguing that without seeing the patient and with a non-classical presentation, the ENT registrar was able to site the pathology accurately. This gave me a new insight into ENT as a specialty, and I researched the career further (FPC 13). Although I have previously not been interested in a surgical career, I find the ontological conditions interesting and the pathophysiology of head and neck cancers also lines up with my pre-existing interest in oncology.

Moving forwards, I have taken from this case that surgical issues often present to medical teams and as such, a basic understanding of these pathologies is required whilst awaiting more specialist input. With respect to my own practice, given that I am currently on respiratory placement, I will act on this by reviewing surgical complications that may present in respiratory, such as SVCO, ARDS, and operations for lung pathologies such as pneumonectomies.

By Dr Devon Ward

Here you can record a brief, anonymous description to allow the CBD to be contextualised:
5 weeks post partum + breastfeeding, left leg swelling, painful, cramping, red, reduced movements
GP had conducted US negative for DVT already
back pain, radiating into buttock
urinary incontinence, feels urge and finds difficult to make it to the bathroom
complicated obstetric history (cholestasis, GDM, pre-eclampsia etc.)
O/E left thigh extremely tender, red, marked unilateral swelling, reduced movements/power
Bloods included D-dimer (not specific during pregnancy), analgesia prescribed, arranged obstetric bed and booked MRI, which ended up showing large DVT in iliac vein, also excluded epidural abscess given raised CRP and epidural anaesthesia. US showed extended from CFV to vena cava. CTPA showed PE
1 week hospital admission and follow up with vascular surgeons due to post thrombotic syndrome. Treated with enoxaparin and leg elevation

Feedback on the case based discussion:
The documented history in the notes was excellent and Serena had realized that this was a complex/unwell patient who needed early F2F senior review. The investigation approach was challenging, highlighting that sometimes there aren’t ‘right and wrong’ answers in medicine and sensitivity and specificity of tests. We also talked about the utility of d-dimer in pregnancy and that it is less useful.

Agreed action:
No further action required as we discussed the case at length and pulled out lots of learning – clinical and organisational.

Reflection:
Comprehensive history taking and notation, appropriate handover in highlighting when worried
Improvement on neurovascular examination: always include pulses, also feel for lymph nodes
Timing of ED interventions – LMWH takes 4 hours to work, can start while await investigations, capability to do US on ED floor
Sensitivity of diagnostic tests – theory: previous ultrasound only showing up to femoral vein but clot building up in iliac vein, in this situation there was such high suspicion of DVT (pregnancy, obesity, clinical reasoning, reduced mobility)
Pregnant women are much more likely to get DVTs in the left leg
Role of ED in the medical pathway of patients and role of positive reflection in developing your own practice

By Dr Serena Cole

Here you can record a brief, anonymous description to allow the CBD to be contextualised:
35-year-old patient admitted with acute back pain and suspected cauda equina. Initial lumbar spine MRI excluded cauda equina. Neurology advised further imaging (head, cervical and thoracic spine). The head MRI was completed, but the patient abandoned the spinal MRI due to dizziness. I inherited the case and was tasked with re-booking the scan. Communication was complicated by a language barrier, initially managed with Google Translate before a Farsi-speaking colleague assisted.
Medical ward at the weekend, during handover of patient care. Attempted use of translation tools, with subsequent colleague support.

Feedback on the case based discussion:
Performed well:
• Recognised limitations of Google Translate for complex medical communication.
• Attempted to escalate and use formal interpretation services (Language Line).
• Persisted with re-booking MRI to ensure completion of investigation.
• Accepted support from a Farsi-speaking colleague to improve accuracy of history.
• Demonstrated awareness of safety issues (dizziness during scan) and need to clarify further before re-attempting.

Areas for development:
• Need clearer understanding of local procedures for accessing interpretation services out of hours.
• Reliance on bilingual staff, while helpful, does not replace professional interpreters — ensure this remains the exception rather than the norm.
• Could have documented the communication challenges and attempts to use interpretation services more robustly.
• Explore strategies for managing incomplete investigations and communicating this to the patient in a safe, comprehensible manner.

Agreed action:
• Familiarise self with hospital policy and contact details for interpretation services (including out-of-hours process).
• Practise concise documentation of communication difficulties and steps taken.
• Seek opportunities to use Language Line in future cases to gain fluency in the process.
• Read GMC guidance on working with interpreters and communicating across language barriers.

Reflection:
This case reinforced the importance of clear communication in patient safety and care planning. Relying on Google Translate was inefficient and risked inaccuracies, and although having a bilingual colleague helped, I recognised this is not the gold standard. I learnt that delays in arranging proper interpretation can hinder clinical assessment and decision-making. Going forward, I will make sure I know the formal process for contacting interpretation services and prioritise using them early. I also reflected on the importance of documenting these challenges transparently. This experience has encouraged me to develop confidence in working with interpreters and to ensure patients with language barriers receive equitable care.

By Anonymous (Your Friendly Neighbourhood F1!)

Here you can record a brief, anonymous description to allow the Mini-CEX to be contextualised:
A 70 year old lady had dropping oxygen saturations on the ward, 2 days post emergency femoral hernia repair. She had no respiratory conditions and was an ex-smoker who had recently stopped smoking. During this admission, her oxygen saturations had been maintained above 96% on small amounts of oxygen.
On my initial assessment, her oxygen saturations were 86% on 4L nasal cannula, and they came up to 94% on 15L oxygen via a non-rebreathe mask.
She was later weaned down to a 60% Venturi mask however on my reassessment a few hours later her saturations dropped to 87% again so she was stepped back up to 15L via a non-rebreathe mask.
She was then assessed by the ICU team and was transferred to ICU.

Feedback on behaviours observed during the mini-CEX:
• Good communication skills with other professionals and departments
• Maintained constant communication with the patient and used jargon-free language
• Took initiative when needed to expedite scans, for example taking patients down to radiology for scans
• Escalated to seniors appropriately
• Promptly acted on examination and investigation findings and communicated these to the wider MDT

Agreed action:
• Continue to utilise the CCOT team when managing unwell patients
• Use the SBAR format to discuss cases with other members of the MDT/other specialties to help them understand how unwell the patient is so they can act accordingly

Reflection:
When initially asked to see this patient, I carried out a full A-E assessment however she looked very well and the only clinical sign of any respiratory compromise was that she had a new oxygen requirement of 15L via a non-rebreathe mask. Due to being in the post-operative phase, my main differential diagnoses were a hospital acquired pneumonia, pulmonary embolism (PE) and a viral respiratory infection.

I requested the appropriate bloods and a chest x-ray initially to help narrow down my differentials, followed by a CTPA. During my initial assessment, I knew I needed the help of my senior however they were scrubbed into theatre at the time and were not available to help me. At this point, I asked the nurse looking after the patient to call the Critical Care Outreach (CCOT) team to provide further advice and guidance to ensure I was not missing anything. They provided me with invaluable advice which confirmed that my plan of action was correct and also meant the ICU team were aware of my patient in the event she deteriorated further.

This patient deteriorated during the day on the ward, when there were other ward tasks to be completed following the ward round and other unwell patients throughout the day with multiple emergency buzzers being pulled and one cardiac arrest. During this time with competing clinical commitments, I ensured I clearly communicated with my team and delegated tasks so that the most urgent time-sensitive tasks and unwell patients were prioritised. This meant that I spent most of my day managing one unwell patient which allowed all investigations to be promptly vetted and acted on, ICU could be kept informed of her clinical condition and by the end of my shift the patient had been handed over and transferred to ICU for high flow oxygen and closer monitoring.

Whilst trying to get a CTPA slot for my patient to rule out a PE in the radiology department, I was informed it would only be done later on in the evening. I was concerned by this as the patient’s saturations kept falling despite being on the maximal amount of oxygen we could deliver on the ward and I was running out of treatment options, so I escalated this to senior who advised I needed to inform the radiology department how unwell my patient is to help prioritise scans in the department and also find out if there is anything I can do to expedite the scan. When I called the department again, they helped me to expedite the scan with the clinical information which allowed us to get the patient to ICU sooner for further stabilisation and management.
By managing this unwell patient, I was able to develop my clinical communication skills when speaking to other members of the MDT and utilised the SBAR format to ensure the salient points were delivered in a timely manner and they knew what I wanted them to help me with. Additionally, at each step of the process I kept the patient informed of our medical opinion and plan so that she knew what to expect and when appropriate also communicated this to her family who were not available to visit her in hospital.

Managing this unwell patient was overall a daunting process, but with the help of my seniors, the CCOT team and the nursing team I was able to successfully escalate this patient to ICU and action initial management steps. The next time I manage an unwell patient during the day, I will always speak to the CCOT team as I learnt that they are an invaluable source of help and information who can help support until further senior help arrives. Additionally, I have learnt that when speaking to the radiology department about scan slots for unwell patients, it is important to inform them how unwell the patient is in order to help them prioritise scan slots and ask if there is anything we can do to help expedite the scan.

By Dr Sudiksha Devendra Kumar

Here you can record a brief, anonymous description to allow the Mini-CEX to be contextualised:
70F. Asked by staff nurse to review ECG/chest pain. Issues: CAP, T2RF. BG: COPD, Atrial flutter
Reviewed prev ECGs- atrial flutter previously noted. Took history and examination
ongoing right sided pleuritic chest pain – worse on breathing and movement determined timeline of associated n/v and leg swelling ruled out cardiac chest pain – no radiation to arms and jaw, worsening n&v or worsening SOB ruled out need for CXR ?PE – recent clear CTPA and checked VTE risk factors
A – E assessment

Feedback on behaviours observed during the mini-CEX:
Excellent focused history taking and examination as well as data gathering prior to review- not a patient under our team officially, so more time was spent looking at ward notes and current issues, previous ECGs to compare to, relevant investigations. Took patient concerns into consideration and involved family member (husband) in discussion so that his concerns could also be explored. Effective safety netting advice for patient to seek further advice including radiation to arms/jaw, worsening shortness of breath, worsening nausea, worsening chest pain. Considered review of analgesia to address main issue of pain. Considered relevant risk factors for differential diagnosis.

Agreed action:
Agree with reflective points- for stable patients consideration of various sources of information prior to review if not immediately unwell- potential sources include AMU clerking notes, ward round notes, primary care tab on nerve centre, previous investigations, previous ECGs for chest pain if available, CITO for specialty information if required.
Continue to have holistic approach to presenting complaint including uptitration of analgesia

Reflection:
A-E assessment useful approach when asked to see a patient
• include abdo, chest and resp
• check chest wall tenderness
• can ask pt to point to chest pain to check if generalised or localised (Less likely cardiac if localised -> MSK/pleuritic but caveat of pericarditis which can be well localised)
• Think about what would be critical in history e.g. MI, PE

Reviewed note taking

Discussed Plan
• safety net cardiac plan and document specifics
• review analgesia
• impression (pleuritic) and what you considered and ruled out

By Dr Serena Cole

What did I do well? What were my challenges? What was interesting or notable about this experience?
Along with Dr Gajraj I co-chaired a short oral presentation session at the Developing Excellence in Medical Education Conference. This involved timekeeping, fielding questions from the audience and managing technical issues with slides. This was a useful first chairing experience.
DEMEC is a 2 yearly UK wide medical education conference with approximately 1000 delegates including senior leaders in medical education.

How does this reflect my current abilities?
Direct feedback from trainer
Kaveeta was well prepared, having pre-read all the abstracts. Our pre-session meeting was straightforward with only a need to clarify rather than explain what was needed. Kaveeta had a clear idea of the requirements of chairing including timekeeping, a need to communicate with presenters and how to manage questions. Kaveeta had considered a question for each presenter in case none were forthcoming from the audience.

During the session Kaveeta chaired as if this was a regular process for her, despite it being the first. Her stated nervousness was in no way apparent and her management of time and speakers was first class. I was the unused parachute: well done!

After the event the debrief was reflective. Here preparation was clearly helpful and we discussed potential traps (eg the IT not working effectively). We discussed the need to ensure listening to the presentation to ensure pre-prepared questions were still relevant.

Reflection
This was a helpful experience and Dr Gajraj provided useful feedback about confidence and ways to signal limited remaining time in a subtle and polite way. It is important to consider transferable skills in medicine outside a typical clinical context and I will take this forward.

Where should I go next?
Seek out further opportunities to run sessions and seek feedback on performance. Remember that non-clinical experience is valuable and can and should be evidenced in the portfolio. Always consider in advance what the learning goals are from a planned exercise to maximise potential and optimise learning.

By Dr Kaveeta Malhi

Context:
Patient presenting in ED after fall while intoxicated CTH clear Frontal Scalp laceration required suturing. Patient did not immediately tolerate having the local anaesthetic injections. I administered local anaesthetic and completed 3 sutures.

Procedure:
Suturing

Feedback on the behaviours observed during the DOPS:
Excellent procedural skills, maintained appropriate sterile field and sutures well placed. Good advice given re post procedure care of sutures.

Agreed action:
Continue to perform practical skills to increase confidence – RCEM e learning has good section on suturing.

Reflection:
This experience helped me recognise that good procedural skills involve not only the technical task, but also preparing the patient, responding to discomfort and maintaining communication throughout. I was pleased that I undertook the procedure safely, but I also noticed that the patient’s initial difficulty tolerating the injections required me to pause, reassure them and adapt my approach. I can see that confidence in practical procedures develops through repeated supervised practice and by anticipating factors that may affect patient comfort. In future, I will continue to seek opportunities to practise suturing, review relevant learning resources and focus on explaining each step clearly before and during the procedure.

By Dr Serena Cole

Context:
The patient had failed a trial without catheter (TWOC) and was in urinary retention, requiring reinsertion of a urinary catheter to relieve symptoms and monitor urine output.

Feedback on behaviours observed:
• Good communication and professionalism.
• Aseptic technique maintained.
• Missed the step of thorough penile care before insertion, which increases infection risk.
• Required a prompt to ensure foreskin was retracted for cleaning and returned afterwards.

Agreed action:
• Practise catheterisation with specific focus on infection prevention measures.
• Always include foreskin retraction during cleaning and ensure replacement after insertion.
• Review local catheterisation and infection control guidelines.
• Aim to perform future catheterisations with reduced supervision as confidence increases.

Reflection:
I explained the procedure and gained consent, then confirmed patient identity and checked for allergies (particularly to latex or chlorhexidine). I prepared the sterile catheterisation pack and performed hand hygiene. Using aseptic technique, I cleaned the urethral meatus and surrounding area. A key teaching point highlighted by the more senior RD was the importance of performing full penile care, including retracting the foreskin to clean underneath, to reduce the risk of infection.

I lubricated the urethra and advanced the catheter gently until urine flowed. Once urine was seen, I advanced a further few centimetres before inflating the balloon with sterile water. I ensured the foreskin was replaced after insertion to prevent paraphimosis. The catheter was secured appropriately and connected to a closed drainage system. The patient tolerated the procedure well, with immediate relief of retention.

Reflection – What went well:
• I maintained aseptic technique throughout the procedure.
• I communicated clearly and reassured the patient, ensuring comfort.
• The catheter was inserted smoothly with immediate urine drainage.

Reflection – Areas for development:
• Need to be more thorough with penile care before catheterisation, including cleaning under the foreskin.
• Ensure heightened awareness of infection prevention measures in catheter care.
• Build confidence in anticipating potential complications (e.g. urethral trauma, paraphimosis).

By Anonymous – asked to be credited as ‘Your Friendly Neighbourhood F1’, if possible!

Here you can record a brief, anonymous description to allow the CBD to be contextualised:
A patient with metastatic ovarian cancer had a moderate pleural effusion on CT scan. A pleural US needed to be carried out to assess if it was appropriate for therapeutic and diagnostic aspiration.

Feedback on the behaviours observed during the DOPS:
Dr Ward applied her understanding of anatomy to pleural ultrasound and was able to interpret the scan correctly. She communicated well with the team and the patient throughout and respected the patient’s dignity

Agreed action:
Think about using your study budget on an ultrasound course like FAMUS – keep a logbook of scans performed

Reflection:
I carried out this procedure so we could assess the size of the pleural effusion and ability to aspirate (FPC1), as well as the patient’s comfort and ability to tolerate sitting in the position required for aspiration (FPC4). This was one of my favourite experiences throughout the respiratory block. I had used ultrasound machines before to assess potential sites for cannulation, but not for anything else. I was very keen to get involved in this procedure as I thought it would be an excellent opportunity to improve my knowledge of effusions and my competency using ultrasound machines (FPC12). I was unsure that I would be able to confidently identify any structures, given that this was my first time using the machine, but it was really exciting to be able to see clearly the liver, diaphragm and effusion. I couldn’t identify any lung tissue due to the size of the effusion, but did locate a dolphin’s tail sign in the fluid which was really interesting.

To continue to improve and develop as a clinician, I will see if there are any available courses nearby on ultrasounds so I can learn more about this skill to use in the future. In the meantime, my plan is to review other pathologies that can be assessed using ultrasound, particularly at pneumothoraces as I came across several patients with PTX during the placement. Based on my discussion with the registrar, I will also need to do some more consideration of careers in the future, looking at the skills and conditions that are managed by a senior registrar and consultant, rather than the day to day jobs of a foundation doctor (FPC13).

By Dr Devon Ward