{"id":2676,"date":"2022-03-02T12:13:34","date_gmt":"2022-03-02T12:13:34","guid":{"rendered":"https:\/\/gp-training.hee.nhs.uk\/bolton\/?page_id=2676"},"modified":"2022-07-26T21:27:33","modified_gmt":"2022-07-26T20:27:33","slug":"case-2","status":"publish","type":"page","link":"https:\/\/gp-training.hee.nhs.uk\/bolton\/mrcgp-examinations\/rca-calibration-tool\/case-list\/case-2\/","title":{"rendered":"Case 2"},"content":{"rendered":"\n<a href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/mrcgp-examinations\/rca-calibration-tool\/case-list\/\" class=\"wp-block-nhsblocks-nhsbutton nhsuk-button\">Back to Case List<\/a>\n\n\n\n<p class=\"has-text-align-center has-white-color has-emergency-red-background-color has-text-color has-background\" style=\"font-style:normal;font-weight:700\">Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own assessment of the case.<\/p>\n\n\n\n<p>This audio recording looks at a patient with Rectal Pain<\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-vimeo wp-block-embed-vimeo wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Case 2 - Rectal Pain\" src=\"https:\/\/player.vimeo.com\/video\/672314866?dnt=1&amp;app_id=122963\" width=\"640\" height=\"360\" frameborder=\"0\" allow=\"autoplay; fullscreen; picture-in-picture; clipboard-write\"><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"has-white-color has-nhs-blue-background-color has-text-color has-background wp-block-heading\" style=\"font-style:normal;font-weight:700\">Analysis<\/h2>\n\n\n\n<p class=\"has-text-align-center has-white-color has-emergency-red-background-color has-text-color has-background\"><strong>It is important to note that the expert analysis is to be used as a guide only. These cases have not gone through the same rigorous approach used in the marking of the real RCA examination. However, the analyses provide an indication of how a typical assessor might review and grade a case.<\/strong><\/p>\n\n\n\n<h3 class=\"has-nhs-blue-color has-text-color wp-block-heading\">Summary<\/h3>\n\n\n\n<p>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).<\/p>\n\n\n\n<h3 class=\"has-nhs-blue-color has-text-color wp-block-heading\">Timeline<\/h3>\n\n\n\n<p>Doctor introduces himself and asks what is going on.<\/p>\n\n\n\n<p>0.17 Patient says woke up with pain in bottom &#8211; finding it embarrassing and doesn\u2019t know what going on.<\/p>\n\n\n\n<p>0.55 Doctor acknowledges embarrassment and asks tell me more.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Good start puts patient at ease and open question<\/em><\/p>\n\n\n\n<p>1.03 Patient says wasn\u2019t sleeping well and 4am got needle like pain in bottom lasted for a short time. went to toilet and hasn\u2019t happened since. Again says doesn\u2019t know why happened.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Missed cues why wasn\u2019t she sleeping well? Second time says doesn\u2019t know what happening gives opportunity to ask if \u2018anything had gone through mind?\u2019<\/em><\/p>\n\n\n\n<p>1.54 Doctor says &#8220;that\u2019s what we&#8217;re going to try and figure out&#8221; and asks permission to ask more questions. He repeats &#8220;you say this happened last night&#8221; and asks some closed questions.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>This doctor has the tendency to ask signpost going to ask questions and ask permission to do so. I think unless it\u2019s a very sensitive area that\u2019s a waste of time it breaks the narrative. Patients expect to be asked questions so get on with it<\/em>. <em>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 \u2018Let me get this straight in my mind you said\/think\u2026.?\u2019 Or you want to make sure you haven\u2019t missed something \u2018so you said xyz have I missed anything?\u2019<\/em><\/p>\n\n\n\n<p>2.10 &#8220;Has it happened before?&#8221; Patient says no and normally well<\/p>\n\n\n\n<p>Doctor says &#8220;you don\u2019t come often do you?&#8221;. Patient says no and doesn\u2019t take any medicines and keeps herself healthy and says very sharp and doesn\u2019t know\u2026. (she breaks off here).<\/p>\n\n\n\n<p>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 &#8220;so sharp&#8221;. Doctor says very intense pain did it wake you up Patient says not sure as wasn\u2019t sleeping well at time.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Again the Doctor breaks the narrative and misses opportunities to get into the ICE as the doctor doesn\u2019t follow the cues \u201cdoesn\u2019t know\u2026..\u201d \u201cnot sleeping well\u201d Rather than asking why she was concerned about the pain says you sound concerned<\/em><\/p>\n\n\n\n<p>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.&nbsp; Did it to calm herself down as got quite worried about the pain.<\/p>\n\n\n\n<p>4.07 Doctor says you mentioned a couple of things that he would like to pick up on.&nbsp; You said worried about it, and you weren\u2019t sleeping well. Are you worried about things at moment?<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>The doctor finally asks about the worry and not sleeping well; it is four minutes since the first cue<\/em>.<\/p>\n\n\n\n<p>4.20 Patient says I don\u2019t know if you can see it\u2019s the anniversary of husband\u2019s death which was traumatic.&nbsp; Not really ok although better than a year ago.<\/p>\n\n\n\n<p>4.50 Doctor says doesn\u2019t 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.<\/p>\n\n\n\n<p>5.40 Doctor says oh my gosh sorry to have asked. Says harrowing story. Can\u2019t imagine what must be like and suppose not been best of years. Patient concurs and says couldn\u2019t have proper funeral and that family don\u2019t live nearby although talks to them<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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?<\/em><\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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<\/em>.<\/p>\n\n\n\n<p>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\u2019t going to die.<\/p>\n\n\n\n<p>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:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Bleeding from bottom? No <\/li><li>Problems passing urine or opening bowels? No <\/li><li>Tingling around bottom or legs? No <\/li><li>Pain back? No <\/li><li>Weight loss? No <\/li><li>Eating well and probably gained<\/li><li>Any other symptoms? No completely fine year since lost Peter worried and not self last night says good to talk to him today<\/li><\/ul>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Again asking to ask questions is unnecessary and the closed questions are relevant.&nbsp; The doctor tries to be reassuring re what he has heard so far<\/em>.<\/p>\n\n\n\n<p>8.50 Doctor says she is nothing said that increases her chance of sudden death and its awful what happened to Peter, can\u2019t guarantee future for anyone but current symptom not overly concerned. Possible diagnoses muscle spasm from stress, Patient interjects&nbsp; \u2018I wondered that\u2019 and doctor talks over her \u2018and you wondered that yourself\u2019 talks about examining for piles\/cuts; unlikely as no associated symptoms and whether she would want examination for reassurance. Patient agrees.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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 \u2018for reassurance\u2019 so not a negative although I do wonder if really needed.<\/em><\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>The management is very limited. If it\u2019s 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\u2019t discussed nor whether she needs any more urgent psychological support That also means if it was needed safety netting for her psychological symptoms isn\u2019t covered<\/em>.<\/p>\n\n\n\n<p>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<\/p>\n\n\n\n<h2 class=\"has-white-color has-nhs-blue-background-color has-text-color has-background wp-block-heading\" style=\"font-style:normal;font-weight:600\">RCA Assessment <\/h2>\n\n\n\n<p class=\"has-text-align-center has-nhs-black-color has-nhs-warm-yellow-background-color has-text-color has-background\">RCA assessment Overall: <strong>Fail<\/strong><\/p>\n\n\n\n<p class=\"has-nhs-warm-yellow-background-color has-background\">Data Gathering: <strong>Fail<\/strong><\/p>\n\n\n\n<p>Good physical history and offer of examination but completely misses the psychological and psychosocial history.<\/p>\n\n\n\n<p class=\"has-white-color has-emergency-red-background-color has-text-color has-background\">Management: <strong>Clear Fail<\/strong><\/p>\n\n\n\n<p>Unfortunately the RCA needs you to do something and something that hasn\u2019t 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\u2019t discussed. Safety netting for depression risk wasn\u2019t done because it wasn\u2019t asked in the first place so a little double jeopardy from Data Gathering spills into Clinical Management.<\/p>\n\n\n\n<p class=\"has-nhs-yellow-background-color has-background\">Interpersonal: <strong>Pass<\/strong><\/p>\n\n\n\n<p>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\u2019s worries. He did try to be empathic.&nbsp; However there was a lot of redundant language re summaries and permission to ask questions that wasted time and broke the narrative.<\/p>\n\n\n\n<div data-wp-interactive=\"core\/file\" class=\"wp-block-file\"><object data-wp-bind--hidden=\"!state.hasPdfPreview\" hidden class=\"wp-block-file__embed\" data=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/Case-2-Rectal-Pain.pdf\" type=\"application\/pdf\" style=\"width:100%;height:600px\" aria-label=\"Embed of Embed of Case-2-Rectal-Pain..\"><\/object><a id=\"wp-block-file--media-34c7ceec-8bf1-4b1f-82b6-2f0fbdeceb90\" href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/Case-2-Rectal-Pain.pdf\">Case-2-Rectal-Pain<\/a><a href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/Case-2-Rectal-Pain.pdf\" class=\"wp-block-file__button\" download aria-describedby=\"wp-block-file--media-34c7ceec-8bf1-4b1f-82b6-2f0fbdeceb90\">Download PDF<\/a><\/div>\n\n\n\n<a href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/mrcgp-examinations\/rca-calibration-tool\/case-list\/\" class=\"wp-block-nhsblocks-nhsbutton nhsuk-button\">Back to Case List<\/a>\n","protected":false},"excerpt":{"rendered":"<p class=\"nhsuk-card__description\">Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own [&hellip;]<\/p>\n","protected":false},"author":107,"featured_media":0,"parent":2724,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2676","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - 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