Not their normal — multimorbidity and diagnostic overshadowing structured encounter

Station status

This is one MedVellum formative structured clinical encounter. Scoring and prompts are educational feedback tools, not an official college station or pass standard. The encounter assesses multimorbidity framing, anti-overshadowing reasoning, baseline-aware examination, polypharmacy safety, communication and residual-risk handover. [1] [14] [20]

Candidate instructions

You are the paediatric registrar in acute assessment. Reframe the triage label “behavioural — known disability.” Establish Noor’s personal baseline. Perform a dignified, adapted examination with a structured search for medical drivers of behaviour. Reconcile medicines. Speak directly to Noor and her mother. Finish with a problem representation, plan and residual-risk safety-net. Do not perform painful manoeuvres on the actor; say what you would assess. [10] [13] [17]

Room setup and observable starting state

The encounter. Noor is 11. She uses a few single words, gestures and a simple picture board. She sits with her mother. The triage card reads “behavioural — known disability.” Mother opens with “They’re not themselves.” [1] [17]

What is visible before touch. Noor looks less interactive than the baseline card. She rocks and bites the left side of her hand. She is not in respiratory distress. There is no rash or fever at first look. The candidate should refuse premature closure and open a medical differential. [13] [14]

Simulation safety. Noor uses the board and gestures. No forced examination. Cards supply abdominal, dental and medicine findings when asked. Portray disability through documented baseline, never caricature. [10]

Actor cues

Child actor

• Engage when spoken to by name with short phrases and time to respond.
• Select “hurt” and “tummy” if offered those board options after gentle rapport.
• If ignored and spoken about only in the third person, look to mother and withdraw. [10] [13]

Caregiver actor

• Start with “They’re not themselves.”
• If asked what changed: “Noor usually greets me with eye contact and a smile. For two nights she is quiet, biting her hand, sleeping poorly. Her bowels have not opened. We missed two laxative doses because the bottle ran out.”
• Offer the medicine list and emergency plan if asked.
• If the candidate dismisses concern because of disability, repeat once: “This is not normal for her.” [17] [18]

Assessor cues and clinical data

Release findings only when requested or when the candidate reaches that step. [11] [13]

Reassessment cue

After the candidate names constipation and dental pain as leading drivers and starts treatment planning, say: “Noor is a little calmer after explanation and a toilet plan, but she is not back to her usual smile. Mother remains worried.” The candidate should call this partial response, keep residual risks open and set review criteria. [14] [17]

Expected candidate sequence

1. Reject the closed label. Name diagnostic overshadowing risk in the triage note. Reframe as multimorbidity with a new change. [1] [3]
2. Baseline and concern. Ask what is different. Document caregiver words. Treat concern as data. [17]
3. Problem list and medicines. Rank active conditions. Reconcile full medicine list and missed doses. Flag prescribing cascade risk from the new sedative. [11] [19]
4. Adapted examination. Search for pain and medical drivers: mouth, abdomen, constipation/retention clues, ears, skin, hips, neurology versus baseline. [13] [24]
5. Working synthesis. Lead with constipation and dental pain while keeping infection, medicine effect and seizure change open. [13] [14]
6. Plan. Analgesia and dental pathway, constipation management, medicine review with usual prescribers, observation or timed review as residual risk requires. [11] [13]
7. Communication and handover. Speak to Noor and mother. Name residual risks and return precautions. Hand over more than “stable complex.” [18] [20]

MedVellum formative marking domains

10 domains scored 0–3 (formative total 30). Score 0 omitted/unsafe, 1 named but incomplete, 2 clear and safe, 3 integrated and prioritised. [1] [14]

Critical fails

• Accepts “behavioural — known disability” as the final diagnosis without medical search.
• Ignores caregiver concern because of disability or complexity.
• Adds another sedating medicine without reconciliation or examination.
• Hands over only “stable complex child” with no residual risks.
• Speaks only about Noor, never to her, and dismisses adapted communication. [1] [11] [17] [18]

Examiner prompts

1. “What is unsafe about the triage label?”
2. “How will you use baseline and caregiver concern?”
3. “Talk me through a medical search for this behaviour change.”
4. “What will you do with the medicine list?”
5. “Give me your problem representation and residual risks.”
6. “Hand over to night staff in one structured paragraph.” [14] [20]