{"id":2686,"date":"2022-03-02T18:27:17","date_gmt":"2022-03-02T18:27:17","guid":{"rendered":"https:\/\/gp-training.hee.nhs.uk\/bolton\/?page_id=2686"},"modified":"2022-07-26T21:26:02","modified_gmt":"2022-07-26T20:26:02","slug":"case-4","status":"publish","type":"page","link":"https:\/\/gp-training.hee.nhs.uk\/bolton\/mrcgp-examinations\/rca-calibration-tool\/case-list\/case-4\/","title":{"rendered":"Case 4"},"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 concerns a triadic telephone consultation with a mother and her son regarding some urinary symptoms.<\/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 4 - Triadic Consult with teenager\" src=\"https:\/\/player.vimeo.com\/video\/672318441?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 could have been a great case, but a simple symptom led the doctor to fix on one diagnosis and to one dimensional management.<\/p>\n\n\n\n<h3 class=\"has-nhs-blue-color has-text-color wp-block-heading\">Timeline<\/h3>\n\n\n\n<p>Audio consult with mum and teenager doctor checks Andrew ok for him to talk to his mum<\/p>\n\n\n\n<p>0.45 Doctor asks what is going on? Mum says 2w stinging urine<\/p>\n\n\n\n<p>Week before mum spoke to a doctor who sent msu gave trimethoprim for suspected uti but no better mum volunteers thinks needs more antibiotics<\/p>\n\n\n\n<p>1.36 Doctor has listened, says could be a possibility but would like to check diagnosis right<\/p>\n\n\n\n<p>Then asks series closed questions<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Sounds like a typical teenager; Realistic consult. On the whole for RCA representation of the same problem doesn\u2019t 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\u2019t worked. That is well signposted by the Doctor<\/em><\/p>\n\n\n\n<p>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\u2019t follow that narrative and instead asks<\/p>\n\n\n\n<p>1.56 If any blood in urine -NO<\/p>\n\n\n\n<p>2.03 Tummy pain or temperatures -NO (note the double closed question)<\/p>\n\n\n\n<p>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<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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.<\/em><\/p>\n\n\n\n<p>2.30 Doctor asks for private chat which Andrew consents to<\/p>\n\n\n\n<p>3.10 Asks if penis looks normal he says bit red clarifies itchy and red<\/p>\n\n\n\n<p>3.30 No discharge<\/p>\n\n\n\n<p>3.40 Sensitively asks if sexually active<\/p>\n\n\n\n<p>3.52 Asks if anything else wants to say privately<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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\u2019t ask about the effect it\u2019s having on him day to day and we don\u2019t find out very much about Andrew as a person as a result<\/em><\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Once again whilst it could just be balanitis the possibility of a predisposing condition eg diabetes isn\u2019t explored. Nor is the possibility of an underlying phimosis or non-retractable foreskin<\/em><\/p>\n\n\n\n<p>4.10 Mum back in doctor thanks for stepping out<\/p>\n\n\n\n<p>4.26 Doctor starts explanation by acknowledging that mum thought water infection<\/p>\n\n\n\n<p>4.32 Explains rationale msu normal and no response antibiotics<\/p>\n\n\n\n<p>4.54 Doctor voices possibility of balanitis<\/p>\n\n\n\n<p>5.00 Mum asks what balanitis is and Doctor explains fungal and needs cream<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>The vocalisation of the doctor\u2019s ideas is well done<\/em>;<em> however the management is a bit one dimensional in that we don\u2019t get an idea of what might be used if that doesn\u2019t work is it severe enough that antibiotics might be needed now or if the cream didn\u2019t work. That would have been a better safety net (see later).<\/em><\/p>\n\n\n\n<p>5.32 Explains would like to examine as already seen once remotely<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>This is really a step back to data gathering If he was going to see Andrew then ideally the doctor could have said \u2018examination would help decide what to offer. If I\u2019m right when I see you then the choices for treatment of balanitis would be\u2026 \u2018 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<\/em><\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>However because the history was incomplete, examination could also have included urinalysis for sugar or a BM&nbsp;<\/em><\/p>\n\n\n\n<p>5.57 asks Andrew why reluctant to come in- says doesn\u2019t want female doctor<\/p>\n\n\n\n<p>6.10 Mum agrees this male doctor will do and other options for chaperone when comes Andrew grunts agreement<\/p>\n\n\n\n<p>6.47 Doctor explains cream should work in a week<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>As mentioned above the management is a bit one dimensional and it would have been difficult to negotiate this management<\/em><\/p>\n\n\n\n<p>7.10 Doctor arranges to see 3 days later<\/p>\n\n\n\n<p>7.28 Doctor says if gets temp vomiting abdo pain in meantime call practice or a and e if OOH<\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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<\/em><\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>Finally disaster safety nets don\u2019t work Safety netting has to be appropriate for the condition<\/em>. <em>Often outlining the prognosis will create your safety net \u2018with this treatment I expect you will be better in a few days if not we may need to use some antibiotics\u2019<\/em><\/p>\n\n\n\n<p class=\"has-nhs-light-blue-background-color has-background\"><em>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<\/em> <em>eg chest pain abdo pain where you may need help OOH if you aren\u2019t admitting them immediately<\/em><\/p>\n\n\n\n<p>7.47 End<\/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-white-color has-emergency-red-background-color has-text-color has-background\">RCA assessment Overall: <strong>Fail<\/strong><\/p>\n\n\n\n<p class=\"has-white-color has-emergency-red-background-color has-text-color has-background\">Data Gathering: <strong>Fail<\/strong><\/p>\n\n\n\n<p>Having highlighted that they wanted to consider other diagnoses the opportunity was missed&nbsp; limited exploration differentials Incomplete examination explained and tests. No family history No psychosocial<\/p>\n\n\n\n<p class=\"has-white-color has-nhs-grey-dark-background-color has-text-color has-background\">Management: <strong>Clear Fail<\/strong><\/p>\n\n\n\n<p>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\u2019t work. The potential of diabetes as a predisposing cause wasn\u2019t 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.<\/p>\n\n\n\n<p class=\"has-nhs-yellow-background-color has-background\">Interpersonal: <strong>Pass<\/strong><\/p>\n\n\n\n<p>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<\/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-4Triadic-with-teenager.pdf\" type=\"application\/pdf\" style=\"width:100%;height:600px\" aria-label=\"Embed of Embed of Case-4Triadic-with-teenager..\"><\/object><a id=\"wp-block-file--media-971e50ec-963f-486e-b07e-4ce07d44a4b3\" href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/Case-4Triadic-with-teenager.pdf\">Case-4Triadic-with-teenager<\/a><a href=\"https:\/\/gp-training.hee.nhs.uk\/bolton\/wp-content\/uploads\/sites\/52\/2022\/03\/Case-4Triadic-with-teenager.pdf\" class=\"wp-block-file__button\" download aria-describedby=\"wp-block-file--media-971e50ec-963f-486e-b07e-4ce07d44a4b3\">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-2686","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - 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