Why is this type of case being chosen?

This case illustrates the co-morbidity often seen in general practice presentations.YOU are given the opportunity to demonstrate YOUR skill in identifying the constituents at play, prioritising them and dealing with the problem presented in the consultation.In this case, the woman’s diabetes is well controlled and she has no diabetic complications.

YOU simply have to establish this and then move on to diagnosing her presenting ‘problem’.

On the face of it, having two conditions in a consultation may seem complicated and challenging, but the task required is much more focusedand should be manageable in the 10 minutes allowed for the case.

 2. ‘Tired all the time’

Summary of the case presentation

This woman has just returned to work after the birth of her second child.She has seen the practice nurse recently for a contraception check up, and told her she was feeling tired all the time.(Tell me one patient who has not told ‘TATT’)

A series of blood tests, including full blood count, thyroid function tests, urea and electrolytes, creatinine, liver function tests and fasting blood sugar have all come back as normal.

She is hoping for a diagnosis and treatment, probably in the form of some sort of medication.

The task here is to take account of the normal blood results and, with a focussed history, ensure that all likely physical causes of tiredness have been excluded.At the same time YOU must obtain the patient’s view of her tiredness and ascertain her expectations.A social history should be taken.

Having decided that the patient’s tiredness does not appear to have a physical cause, and that she is not clinically depressed either, YOU need to explain this assessment sensitively, suggesting that there are important social factors from the history that could be causing the tiredness (back to work after maternity leave, a busy job and two small children at home).YOU, having helped the patient recognise this likely cause, should then discuss with her ways in which these factors could be manipulated to help her manage more easily (opportunities for time for herself, using parents to help out with child care, possible job share or job change etc).

This case is a good example of an undifferentiated presentation.YOU need to work through a diagnostic sieve to get to the decision that the cause of tiredness in this instance is likely to be due to social factors.In order to explain this properly to the patient,

YOU need to adopt a patient centred approach that both gathers all the necessary personal information as well as uses this information in the explanation back to the patient.

YOU need to explore the various ways in which the patient could adapt her lifestyle to help her cope and reduce her tiredness levels.

 

Summary of the case presentation

This is typical of the type of paediatric case that might appear.
Due to constraints with using child role players, some cases are written in such a way that a parent comes to talk about their child in that child’s absence.

In this case, the child is aged 2 and is troubled with constipation.Her diet is low in fibre and is similar to her mother’s. Mum has her ownstresses, being a single unemployed parent with low-income.She brought the child last week to the GP (another partner), who did notprescribe anything and advised a high-fibre diet and plenty of fluids.

Mum is not happy for this situation to carry on and wants something for the child to relieve the problem.

YOU would be expected to take a focussed history from the mother about the nature and duration of the constipation.The case notes from the previous consultation show that the mother appeared to want a prescription (which she did not get).YOU would need to confirm and explore the mother’s expectations in this respect.

If the candidate mentioned a growth chart to the mother, he/she would receive the chart from the assessor. This shows normal growth and development to date.

To be successful, YOU would be required to show their ability to negotiateand develop a shared plan with the patient, for example negotiating with the mother to work on the child’s diet while perhaps agreeing to the prescription of a laxative. (NICE GUIDELINES!!!)

Appropriate use of other members of the team, such as the Health Visitor in the first instance or perhaps a paediatric dietician could also be mentioned, demonstrating an understanding of team working.

Because this case is designed to test the ability to share understanding, giving the mother a leaflet on prevention of constipation in children wouldnot gain any marks unless its contents were also discussed and explained.

DO NOT OFFER LEAFLETS WITHOUT EXPLAINING FIRST!

Why is this type of case being chosen?

This type of case has been chosen to illustrate how problems affecting quite young children can be introduced into the CSA, so that ability to deal with a range of age groups can be demonstrated.

Summary of the case presentation

The patient is a businessman who has noticed intermittent but apparently severe palpitations while at a conference in Dublin recently.He noticed that they came on when he was eating, so much so that he was forced to sit down on a couple of occasions.
He was previously an infrequent attender at the practice.This is his second consultation – at the first one, another partner saw him and arranged some preliminary tests.
He has no pain or palpitations at the time he sees either doctor.

This case is an example of an acute presentation of a man with intermittent palpitations.It is designed to test YOUR approach to taking a focussed cardiovascular history, performing a suitable cardiovascular examination and from this constructing a rational investigation and management plan with the patient.

In order to give YOU time to do a cardiovascular examination if YOU think it necessary, much of the history has already been provided.Another task for the candidate is to confirm the history, interpret the results and explain them to the patient.

In this case, the assessor will expect YOU to examine the patient and some of the marks awarded will be for the nature of this examination, the technique and fluency with which it is carried out.The role player will not have any cardiac physical signs, but YOU could be asked to look at an ECG taken ‘earlier’, for example.A full cardiovascular examination is NOT expected here, as this is a case that should (and can) be performed in 10 minutes, but it should be focussed so that any significant cardiac pathology is unlikely to be missed.

This would include examination of the pulse, blood pressure, JVP and auscultation of the chest.

 

Summary of the case presentation

This is a case testing YOUR attitudes to patients and YOUR value judgementsin an ‘ethical’ issue.

I thank these GREAT PEOPLE on behalf of you all for offering us a wonderful insight into the csa case scenarios.

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In the words of Benjamin Disraeli,

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