Case 2

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Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own assessment of the case.

This audio recording looks at a patient with Rectal Pain

Analysis

Summary

This is difficult as potentially two issues; so not a good case to submit. The doctor falls between the stools of not dealing with either fully (ie rectal pain vs mood).

Timeline

Doctor introduces himself and asks what is going on.

0.17 Patient says woke up with pain in bottom – finding it embarrassing and doesn’t know what going on.

0.55 Doctor acknowledges embarrassment and asks tell me more.

Good start puts patient at ease and open question

1.03 Patient says wasn’t sleeping well and 4am got needle like pain in bottom lasted for a short time. went to toilet and hasn’t happened since. Again says doesn’t know why happened.

Missed cues why wasn’t she sleeping well? Second time says doesn’t know what happening gives opportunity to ask if ‘anything had gone through mind?’

1.54 Doctor says “that’s what we’re going to try and figure out” and asks permission to ask more questions. He repeats “you say this happened last night” and asks some closed questions.

This doctor has the tendency to ask signpost going to ask questions and ask permission to do so. I think unless it’s a very sensitive area that’s a waste of time it breaks the narrative. Patients expect to be asked questions so get on with it. The doctor also has the tendency to repeat back to the patient what they have already said. Again my own view is this wastes time unless you are unclear in your own mind ‘Let me get this straight in my mind you said/think….?’ Or you want to make sure you haven’t missed something ‘so you said xyz have I missed anything?’

2.10 “Has it happened before?” Patient says no and normally well

Doctor says “you don’t come often do you?”. Patient says no and doesn’t take any medicines and keeps herself healthy and says very sharp and doesn’t know…. (she breaks off here).

2.40 Doctor says wanted to ask about that, repeats you said sharp and suggests that patient sounds concerned about pain. Patient repeats like a needle stabbing, similar level pain to childbirth, and again “so sharp”. Doctor says very intense pain did it wake you up Patient says not sure as wasn’t sleeping well at time.

Again the Doctor breaks the narrative and misses opportunities to get into the ICE as the doctor doesn’t follow the cues “doesn’t know…..” “not sleeping well” Rather than asking why she was concerned about the pain says you sound concerned

3.30 Doctor repeats you said went to toilet and asks a closed question was that to see if helped? Patient says because awake and needed to go and was restless and to calm her down as panicked.  Did it to calm herself down as got quite worried about the pain.

4.07 Doctor says you mentioned a couple of things that he would like to pick up on.  You said worried about it, and you weren’t sleeping well. Are you worried about things at moment?

The doctor finally asks about the worry and not sleeping well; it is four minutes since the first cue.

4.20 Patient says I don’t know if you can see it’s the anniversary of husband’s death which was traumatic.  Not really ok although better than a year ago.

4.50 Doctor says doesn’t know story asks if would be helpful for her to discuss. Patient says had been shopping pulled up in car he got chest pain and died and it was shocking. Ambulance came to no avail. Husband had been fit and well. Patient says has been thinking about it.

5.40 Doctor says oh my gosh sorry to have asked. Says harrowing story. Can’t imagine what must be like and suppose not been best of years. Patient concurs and says couldn’t have proper funeral and that family don’t live nearby although talks to them

Finally we get to the meat of what the problem is The patients true worries come tumbling out. The doctor tries to be empathic however rather than asking how she is feeling about things states how he thinks she must feel. The opportunity to ask open questions about mood and depression is missed and the opportunity to explore her social situation is missed. Work Home Family Alcohol Drugs?- Who is she talking to what have they said.? Is she depressed how depressed is she? Is she safe?

6.14 Doctor says wonders if relevance to pain bottom and Patient says did wonder. Doctor says more questions want to ask but whether something patient specifically worried about.

Good reflective question but rather than following narrative ie what did the patient worry about we get extra unnecessary words about needing more questions before them.

6.37 Patient says no as really well before and after. Because of what happened to husband wants to talk to someone and be told isn’t going to die.

7.03 Doctor says reasonable reason to talk to doctor, from what heard already reassured but wants to ask more questions to understand what going on and what to do next. Says wants to ask some questions around what can cause pain around bottom and goes back to closed questions:

  • Bleeding from bottom? No
  • Problems passing urine or opening bowels? No
  • Tingling around bottom or legs? No
  • Pain back? No
  • Weight loss? No
  • Eating well and probably gained
  • Any other symptoms? No completely fine year since lost Peter worried and not self last night says good to talk to him today

Again asking to ask questions is unnecessary and the closed questions are relevant.  The doctor tries to be reassuring re what he has heard so far.

8.50 Doctor says she is nothing said that increases her chance of sudden death and its awful what happened to Peter, can’t guarantee future for anyone but current symptom not overly concerned. Possible diagnoses muscle spasm from stress, Patient interjects  ‘I wondered that’ and doctor talks over her ‘and you wondered that yourself’ talks about examining for piles/cuts; unlikely as no associated symptoms and whether she would want examination for reassurance. Patient agrees.

I think the doctor is struggling to let go of a physical cause of the problem and manage the worry and stress. He does negotiate the examination ‘for reassurance’ so not a negative although I do wonder if really needed.

10.20 Doctor agrees to see later and then goes on to talk about what to do if examination normal professional help counselling. Patient says has bereavement number. Doctor says sometimes needs to be right time to do counselling and then goes back to physical if find pile manage that but has strong feeling all will be ok and that her gut feeling about cause is also right.

The management is very limited. If it’s a pile we will deal with it and how. The stress is managed with a suggestion of bereavement counselling which the patient already has the details of. As we have no idea of the severity of her symptoms the need for medication or not isn’t discussed nor whether she needs any more urgent psychological support That also means if it was needed safety netting for her psychological symptoms isn’t covered.

11.20 Doctor asks if that ok or whether wanted anything else. Patient says just wanted to talk to someone and thanks for listening doctor says will see later

RCA Assessment

RCA assessment Overall: Fail

Data Gathering: Fail

Good physical history and offer of examination but completely misses the psychological and psychosocial history.

Management: Clear Fail

Unfortunately the RCA needs you to do something and something that hasn’t already been suggested. So what did the doctor add here and the answer is nothing. Although a differential diagnosis was raised ie piles versus anxiety the potential management of each wasn’t discussed. Safety netting for depression risk wasn’t done because it wasn’t asked in the first place so a little double jeopardy from Data Gathering spills into Clinical Management.

Interpersonal: Pass

It took an age to get there but eventually cues were explored. Examination was negotiated. The doctor did try to relate explanations to the patient’s worries. He did try to be empathic.  However there was a lot of redundant language re summaries and permission to ask questions that wasted time and broke the narrative.

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