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| Patient identifiers: Confirm Margo Stone's full name and age | | | You asked for the patient's name and age but did not confirm the surname “Stone” or full name. Always confirm full name to avoid identity issues. |
| Confirm the reason for the visit: Concerns about her son Mason's nocturnal episodes | | | You appropriately confirmed the reason for consultation early on. Well done. |
| History of present illness: Frequency, timing, and nature of Mason's nocturnal episodes | | | You covered the timing (middle of the night), frequency (almost daily for 4 months), and nature (screaming). Great detailed exploration here. |
| Ask if Mason remembers the episodes in the morning | | | You asked this directly and noted that Mason doesn’t remember. Good inclusion. |
| Rule out external triggers: Scary movies, recent stressors or changes in Mason's routine | | | You explored routine changes and stressors but missed asking about media exposure or any frightening content. This would help rule out nightmares. |
| Discuss family history of similar episodes, noting Mason's father's history | | | You did not ask about family history or if similar episodes have occurred in any relatives, including the father. A quick question like “Any family history of similar issues?” would’ve sufficed. |
| Ask about current health: Any fever, infections, or other illnesses | | | You asked if he has medical conditions (03:08), but didn’t specifically ask about recent infections or illnesses which are important in ruling out organic causes. |
| Vaccination: Confirm Mason is up to date with all vaccinations | | | You asked directly and got confirmation. Good. |
| Take birth and early history: Pregnancy, delivery, feeding and development | | | You asked about developmental milestones (02:55), but not about birth history, delivery, or early feeding. This is essential for a full paediatric history. |
| Differential Diagnosis: Rule out nightmares and infections | | | You ruled out stressors and mentioned a diagnosis of night terrors, but did not sufficiently rule out nightmares or infections like URTI, especially given the screaming. |
| ICE (Ideas, Concerns, Expectations): Explore Margo's ideas, concerns, and expectations | | | You asked about her thoughts, concerns and expectations explicitly. Strong point. |
| Effects of Symptoms: Discuss how Mason's episodes affect Margo's sleep and peace of mind | | | You explored how this has affected her work, and she expressed emotional distress multiple times. |
| Examination: Conduct head-to-toe examination and assess developmental milestones | | | You said you'd examine Mason “head-to-toe” but did not clearly mention developmental milestone assessment though you asked about them in history. It’s better to explicitly mention both. |
| Conduct thorough physical and developmental examination of Mason along with vitals | | | You mentioned vitals and head-to-toe check, but there’s no evidence you assessed developmentally or said what you were looking for. A line like "I’d like to assess his motor and speech milestones" would help. |
| Reassurance and Education: Explain the provisional diagnosis as night terrors and the difference between nightmares and night terrors | | | You explained night terrors well, but missed clearly contrasting them with nightmares. This would help reduce confusion for the parent. |
| Provide reassurance that these episodes are common and typically outgrown | | | You reassured that the condition would subside with time and management. Well done. |
| Treatment Plan for Nightmares: Discuss stressors, ensure a relaxing bedtime routine, avoid scary media | | | You focused on night terrors, but missed discussing nightmare management, which should always be considered differentially. |
| Treatment Plan for Night Terrors: Advise staying calm, avoid waking Mason, maintain a safe environment | | | You didn't advise on practical home management like keeping Mason safe, not waking him, or staying calm during episodes. These are vital. |
| Follow-Up: Schedule a follow-up appointment in 2 months to review progress | | | You didn’t mention any follow-up plan. Always offer a timeframe for review—2 months is reasonable. |
| Provide a leaflet with information about managing nightmares and night terrors | | | You mentioned giving a leaflet. Great job. |
| Safety Netting: Advise to seek help if new symptoms develop (e.g., daytime changes, injury, breathing problems) | | | You did not mention red flags or when to return. Include signs like daytime confusion, injury during episode, etc. |
| Effective Communication: Use empathetic and clear language to explain the condition | | | You were warm and clear but used some rehearsed lines. To score higher, avoid repetitive stock phrases like “we will find a solution”. |
| Validate Margo’s concerns and provide supportive advice | | | You frequently acknowledged her distress. Very compassionate approach. |
| Patient-Centered Approach: Encourage Margo to share her observations and feelings | | | You created a space for her to express herself, and you responded appropriately. |
| Involve Margo in the management plan and discuss any concerns she might have | | | You mentioned referring to seniors and support groups, but did not explore what she'd prefer in the plan or if she was happy with it. |
| Summarize and Clarify: Summarize the discussion, ensuring Margo understands the management plan | | | You didn’t summarise the discussion or check her understanding. This would’ve been a strong close. |
| Invite any further questions and provide comprehensive answers | | | You answered her questions when she asked, but you didn’t actively invite them or ask “any other concerns?” which is standard good practice. |
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