Case 4

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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 concerns a triadic telephone consultation with a mother and her son regarding some urinary symptoms.

Analysis

Summary

This could have been a great case, but a simple symptom led the doctor to fix on one diagnosis and to one dimensional management.

Timeline

Audio consult with mum and teenager doctor checks Andrew ok for him to talk to his mum

0.45 Doctor asks what is going on? Mum says 2w stinging urine

Week before mum spoke to a doctor who sent msu gave trimethoprim for suspected uti but no better mum volunteers thinks needs more antibiotics

1.36 Doctor has listened, says could be a possibility but would like to check diagnosis right

Then asks series closed questions

Sounds like a typical teenager; Realistic consult. On the whole for RCA representation of the same problem doesn’t lead to good cases. (Better single issue not seen before ie undifferentiated symptom) However here there is the potential to revisit the data gathering as it sounds like only one diagnosis was considered and treated and it hasn’t worked. That is well signposted by the Doctor

1.41 ?Urinary frequency Mum asks Andrew who grunts and she says going more and also drinking more to flush it out. The doctor doesn’t follow that narrative and instead asks

1.56 If any blood in urine -NO

2.03 Tummy pain or temperatures -NO (note the double closed question)

2.12 How been in self (Open question) immediately followed by three linked closed questions (?going to school eating and drinking normally):Luckily mum answers all three separately

The opportunity to widen the differential is missed What about diabetes? The drinking more is ignored is it flush out or because he is thirsty and questions about weight vision etc are missed. No family history.

2.30 Doctor asks for private chat which Andrew consents to

3.10 Asks if penis looks normal he says bit red clarifies itchy and red

3.30 No discharge

3.40 Sensitively asks if sexually active

3.52 Asks if anything else wants to say privately

The doctor handles this well including asking mum to step outside. Andrew does open up a little more and the doctor signposts the awkward questions He doesn’t ask about the effect it’s having on him day to day and we don’t find out very much about Andrew as a person as a result

Once again whilst it could just be balanitis the possibility of a predisposing condition eg diabetes isn’t explored. Nor is the possibility of an underlying phimosis or non-retractable foreskin

4.10 Mum back in doctor thanks for stepping out

4.26 Doctor starts explanation by acknowledging that mum thought water infection

4.32 Explains rationale msu normal and no response antibiotics

4.54 Doctor voices possibility of balanitis

5.00 Mum asks what balanitis is and Doctor explains fungal and needs cream

The vocalisation of the doctor’s ideas is well done; however the management is a bit one dimensional in that we don’t get an idea of what might be used if that doesn’t work is it severe enough that antibiotics might be needed now or if the cream didn’t work. That would have been a better safety net (see later).

5.32 Explains would like to examine as already seen once remotely

This is really a step back to data gathering If he was going to see Andrew then ideally the doctor could have said ‘examination would help decide what to offer. If I’m right when I see you then the choices for treatment of balanitis would be… ‘ If really balanitis and that alone then remote treatment would be reasonable with review in person if not settling (Use of resources) Management could have included advice on personal hygiene had that history been taken above. If a phimosis was a possibility exploring attitude to surgery for it could have shown negotiation skills

However because the history was incomplete, examination could also have included urinalysis for sugar or a BM 

5.57 asks Andrew why reluctant to come in- says doesn’t want female doctor

6.10 Mum agrees this male doctor will do and other options for chaperone when comes Andrew grunts agreement

6.47 Doctor explains cream should work in a week

As mentioned above the management is a bit one dimensional and it would have been difficult to negotiate this management

7.10 Doctor arranges to see 3 days later

7.28 Doctor says if gets temp vomiting abdo pain in meantime call practice or a and e if OOH

Things go from bad to worse here No treatment for 3 more days He could have given the cream in the meantime to see if helping when actually seen. Worse still if this was the presenting symptoms of Type 1 diabetes then the opportunity to diagnose early has been missed

Finally disaster safety nets don’t work Safety netting has to be appropriate for the condition. Often outlining the prognosis will create your safety net ‘with this treatment I expect you will be better in a few days if not we may need to use some antibiotics’

Telling people to go to A and E or call OOH whatever happens or for unlikely complications is considered a poor use of resources and unsettling for patients There are exceptions eg chest pain abdo pain where you may need help OOH if you aren’t admitting them immediately

7.47 End

RCA Assessment

RCA assessment Overall: Fail

Data Gathering: Fail

Having highlighted that they wanted to consider other diagnoses the opportunity was missed  limited exploration differentials Incomplete examination explained and tests. No family history No psychosocial

Management: Clear Fail

A diagnosis was made and treatment was offered. However there was a three day delay before prescribing the cream until after examination no other options discussed if that didn’t work. The potential of diabetes as a predisposing cause wasn’t managed. The safety net for the condition diagnosed was inappropriate especially in context of the delay in seeing them. The Clear Fail is because I felt this management was unsafe.

Interpersonal: Pass

The doctor did listen and gave good vocalisation of his ideas and rationale. He explained well. He tried to engage with a reluctant teenager and he did manage in a good manner to get him on his own. He got a grunted consent to talk to mum at the start. There was some negotiation around the examination but not the management plan

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