Cases and Concepts for the new MRCGP 2e

Cases and Concepts

for the new MRCGP

2nd Edition

Cases and Concepts

for the new MRCGP

2nd Edition

Clinical Skills Assessment

and Case-based Discussion

P. Naidoo

MBChB, MRCGP, DRCOG, DFFP, Dip Occ Med, MSc

GP in Oxfordshire

Includes contributions from

C. Monkley

MBBS, DRCOG, MSc (Sports Medicine), MRCGP, FFSEM (UK)

GP in the Defence Medical Services - for the CSA cases

A. Davy

MBBS, BSc, MRCGP, DRCOG

GP in the Defence Medical Services - for the CbD cases

Second edition © Scion Publishing Ltd, 2009

First edition published 2008 (ISBN 978 1 904842 53 8); reprinted twice

All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission.

A CIP catalogue record for this book is available from the British Library.

ISBN 978 1 907904 15 8

Scion Publishing Limited

Bloxham Mill, Barford Road, Bloxham, Oxfordshire OX15 4FF

www.scionpublishing.com

Important Note from the Publisher

The information contained within this book was obtained by Scion Publishing Limited from sources believed by us to be reliable. However, while every effort has been made to ensure its accuracy, no responsibility for loss or injury whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the authors or publishers.

The reader should remember that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications and practices are based on current indications, there may be specific practices which differ between communities. You should always follow the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which you are practising.

Typeset by Phoenix Photosetting, Chatham, Kent, UK

Printed by Biddles Ltd, King’s Lynn, Norfolk

Contents

Preface

Acknowledgments

Abbreviations

An introduction to clinical skills assessment (CSA)

Clinical Skills Assessment

Case 1 – Back pain

Case 2 – Injectable contraception

Case 3 – Blacked out

Case 4 – Menorrhagia

Case 5 – Knee injury

Case 6 – Pins and needles in hand

Case 7 – Smoking cessation

Case 8 – Termination of pregnancy

Case 9 – Sore throat

Case 10 – Struggling to cope with a baby

Case 11 – Painful shoulder

Case 12 – Forearm in plaster cast

Case 13 – Haematuria

Case 14 – Erectile dysfunction

Case 15 – Hypothyroidism

Case 16 – Hyperthyroidism

Case 17 – Hypertension

Case 18 – Grief

Case 19 – Obsessive compulsive disorder

Case 20 – Tinea pedis

Case 21 – Migraine

Case 22 – Non-accidental overdose

Case 23 – Hernia

Case 24 – Osteoarthritis

Case 25 – Request for cosmetic surgery

Case 26 – Insomnia

Case 27 – Emergency contraception

Case 28 – Bariatric surgery

Case 29 – Multiple sclerosis

Case 30 – Balance problems

Case 31 – Tonsillitis

Case 32 – Menstrual problems

Case 33 – Irregular heart beats

Case 34 – Psoriasis

Case 35 – Onychomycosis

Case 36 – Transient ischaemic attack

Case 37 – Newly diagnosed diabetes mellitus

Case 38 – Cognitive impairment

Case 39 – Gout

Case 40 – Renal colic

Case 41 – Neck of femur fracture

Case 42 – Drug use

Case-based Discussion

An introduction to case-based discussion (CbD)

14 year old requests contraception

Earache and antibiotics

Request for a sick note

Patient worries about chest pain

Patient declines smear test

Patient requests an advance directive

Withholding life prolonging treatment

Euthanasia

Teenagers and confidentiality

Breast cancer reported for Significant Event Analysis

Concepts

Consultation models

Clinical governance

Patient safety

Evidence-based medicine

Giving feedback

Reflective learning and mentoring

Managing change

Ethical frameworks

Professionalism

Answers to ‘Test your knowledge’ questions

PREFACE to second edition

The aim of this book is to help candidates prepare for the Clinical Skills Assessment (CSA) and Case-based Discussion (CbD) components of the new MRCGP exam by making explicit ‘what’ to do and ‘how’ to do it to achieve success.

‘What’ is needed in CSA and CbD is the ability to:

gather and assess medical information

make structured, evidence-based and flexible decisions

communicate with patients in a way that moves the consultation forward in an ethical and responsible manner

‘How’ this is demonstrated to examiners is by:

asking the right questions, at the right time, in the right way

performing the right examination correctly

communicating the right things in the right way to patients and colleagues

This book tries to teach candidates how to demonstrate their competence in an exam by showing them how two general practitioners approached the presentations of their patients:

the questions they asked to get to the crux of the problem

the examinations they chose to conduct

the decisions they made

how they communicated with their patients

By breaking down each case in this way, this book provides a structured approach for candidates to aid them in their exam preparation.

Unlike its companion guide, ‘Consultation Skills for the new MRCGP’ , which primarily focuses on teaching consulting skills, our primary aim in this book is to mentally model for candidates an ordered, step-wise approach to data gathering, analysis, management and communication. In some cases, additional medical information is provided to clarify the management decisions. While the book does not aim to be completely comprehensive in its coverage of medicine or examination techniques, this second edition does include over 200 questions and answers to help candidates revise the background factual information. Candidates are also signposted to useful, usually internet-based, sources of information for aiding their medical revision.

We hope that this book is useful to you in developing a step-wise approach to CSA and CbD.

Dr P Naidoo and Dr C Monkley

November, 2008

acknowledgments

I would like to thank Dr Clive Monkley for his contribution to the Clinical Skills Assessment cases, and Dr Andrew Davy for his contribution to the Case-based Discussion cases.

Thank you to Dr Sarah Butterfield and Dr Samantha Wild for their helpful comments and critiques.

Thank you to my good friend Dr Dougie Wyper, for improving my social life. Life would be a lot less interesting without you.

Finally, a reminder to my husband Anton – you owe me a farm in Africa, at the foot of the Drakensberg Mountains.

Dedication

This book is dedicated to my father for his love and encouragement – thank you dad.

Abbreviations

BDD body dysmorphic disorder

BMA British Medical Association

BMJ British Medical Journal

CAM complementary and alternative medicine

CBT cognitive behavioural therapy

CG clinical governance

CHD coronary heart disease

CHI Commission for Health Improvement

CHRE Council for Healthcare Regulatory Excellence

CME continuing medical education

CPD Continuing Professional Development

CPP Committee on Professional Performance

DENs doctors’ educational needs

DVLA Driver and Vehicle Licensing Agency

EC emergency contraception

EBM evidence-based medicine

GMC General Medical Council

GP general practitioner

GPwSI GP with special interests

GUM genito-urinary medicine

HFEA Human Fertilization and Embryology Authority

IUD intra-uterine device

IVF in vitro fertilization

JC journal club

LCR ligase chain reaction

LMP last menstrual period

MAAG Medical Audit Advisory Group

MCA Medical Council on Alcohol

MDU medical defence union

MI myocardial infarction

MS multiple sclerosis

MUS medically unexplained symptoms

NAPCE National Association of Primary Care Educators

NCAA National Clinical Assessment Authority

NEJM New England Journal of Medicine

NHS National Health Service

NICE National Institute of Clinical Excellence

NNT number needed to treat

NPSA National Patient Safety Agency

NRT nicotine replacement therapy

OCD obsessive compulsive disorder

OM otitis media

OPD outpatients department

PCC Professional Conduct Committee

PCOS polycystic ovary syndrome

PCR polymerase chain reaction

PCT primary care trust

PDP personal development plan

PHCT Primary Health Care Trust

PID pelvic inflammatory disease

PM practice manager

PTSD post-traumatic stress disorder

PUNs patients’ unmet needs

RA rheumatoid arthritis

RCGP Royal College of General Practitioners

RCPCH Royal College of Paediatrics and Child Health

RCT randomized controlled trial

SEA significant event audit

STD sexually transmitted disease

TIA transient ischaemic attack

TOP termination of pregnancy

UTI urinary tract infection

An introduction to clinical skills assessment (CSA)

This introductory chapter discusses:

the structure of CSA

the marking of CSA

assessment within the nMRCGP:

curricular objectives: six domains and three essential features

assessment within CSA:

blueprints for writing cases

blueprints for selecting cases

preparing for the CSA

how best to use this book to prepare

The structure of CSA

The CSA is one of the three components of the nMRCGP assessment. The other two components are the applied knowledge test (AKT), and workplace based assessment (WPBA). The Royal College of General Practitioners (RCGP) will make CSA available from October 2007. Thereafter, the assessment will be available during a 3 or 4 week period in sessions in February, May and October each year. It will take place in one location, initially in Croydon, and in later years in a purpose-built centre in London.

The CSA is not primarily a test of knowledge or examination techniques. It is an assessment of a doctor’s ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice, ‘to produce a consultation that is meaningful to both patient and doctor and which moves the patient forward towards a justifiable management of their presenting problem’ (Hawthorne, 2007 – on the RCGP website).

What happens on exam day

On the day of the examination, at the examination venue, each candidiate will be given a consulting room.

The candidate will be briefed to treat the examination session as if he were a locum doctor.

The candidate is to interact with the patient and not the examiner, who will remain a silent observer.

The candidate’s surgery has thirteen booked patients who enter his consulting room when the buzzer sounds.

At the end of ten minutes, the buzzer sounds to signal the departure of the patient.

There will be a two minute gap between consultations.

Twelve patients are true examination cases on which the candidate is assessed. One is a ‘trial station’ in which new clinical scenarios are trialled. The candidiate will not know which is the trial case.

There will be a short break in the middle of surgery.

The marking of CSA

The patients, played by trained actors, will move from room to room, together with the examiner for that case. The examiners are all general practitioners who are selected and trained in assessment by the RCGP. Each examiner will mark the same case all day, thus providing standardized marking. Each case is marked in three domains, all have equal weighting:

data gathering, examination and clinical assessment skills

clinical management skills

interpersonal skills

The performance will be graded as Clear Pass, Marginal Pass, Marginal Fail or Clear Fail. The candidate is then given an overall grade.

In assessment speak, the four grades, from Clear Pass to Clear Fail, are called grid descriptors – they describe the standards, knowledge and skills found at each grade. The pass mark is set as the standard required to practice independently as a licensed GP. The marking sheet contains positive indicators and negative indicators of practice, which inform the examiner’s global judgement of the candidate’s performance.

The examiner does not tick boxes, as in the old MRCGP video marking sheet, and the pass is not determined by number of ticks the candidate scores in each case. This is what makes CSA a competency-based assessment – the candidate passes if he meets the criteria for competence, to the standard required to practice independently as a licensed GP. This is not a norm-referenced assessment in which a pre-determined number of the highest ranking candidates pass. Theoretically, if all the candidates meet the marking criteria to the pre-set standard required for passing, then all of them should pass.

Therefore, to prepare for CSA, it is useful to understand what is being assessed by the nMRCGP, and by the CSA in particular.

Assessment within the nMRCGP

Assessment is about making a judgement as to whether trainees have fulfilled the training objectives. The assessor should be able to say, ‘By the end of this training, the trainee should be able to…’.

To make this judgement, the assessor needs to measure the trainee’s progress against defined criteria.

Therefore, to understand assessment within the nMRCGP, we need to be familiar with its ‘training objectives’, and to understand the ‘criteria against which trainees are measured’.

The nMRCGP objectives

The nMRCGP objectives are described within the curriculum for speciality training for general practice. By the end of speciality training for general practice, trainees should have:

‘the wide-ranging knowledge, clinical skills and communication skills required by doctors who will specialise in general practice, to ensure the delivery of high quality standards of patient care in the NHS’ (RCGP, 2007).

Exactly what constitutes the knowledge, clinical skills and communication skills is described further in the GP curriculum, a rather large body of work. A summary of the GP curriculum is available as a core statement, within which six domains of core competencies and three essential features of patient-centred care are described. These constitute ‘criteria against which trainees are measured’.

The six domains (D1 – D6) and three essential features (EF1 – EF3)

D1. Primary care management – is about having the ability to recognize and manage common medical conditions in primary care. Trainees demonstrate the ability to deal with multiple complaints and co-morbidity.

D2. Person centred care – is about appreciating the patient as a unique person in a unique context, taking into account patient preferences and expectations at every step in the consultation. Trainees demonstrate the use of recognized communication techniques to gain understanding of the patient’s illness experience and develop a shared approach to managing problems.

D3. Specific problem solving skills – is about adopting a problem-based approach to practice in which uncertainty may have to be tolerated; time used as part of the diagnostic process; and incremental investigation undertaken. Trainees demonstrate proficiency in performing physical examination, and in using diagnostic and therapeutic instruments. The consultation itself is used as a diagnostic or therapeutic instrument; for example, the patient’s health beliefs are explored and later incorporated into the doctor’s explanation.

D4. A comprehensive approach – is about addressing multiple complaints and co-morbidity; using an evidence-based approach; and minimising the impact of the patient’s symptoms on his wellbeing by taking into account his personality, family, daily life, economic circumstances, and physical and social surroundings. Trainees demonstrate the ability to promote self-care and empower patients.

D5. Community orientation – is about understanding the potentials and limitations of the communities in which doctors’ work. Trainees demonstrate an ethical approach to rationing and a responsible approach to influencing health policy.

D6. A holistic approach – is about integrating the physical, psychological and social components of health problems in making diagnoses and planning management. Trainees demonstrate an understanding of the bio-psycho-social elements of illness and a willingness to use a wide range of interventions.

EF1. Contextual aspects – is about understanding the doctor’s context, the environment (community, culture, environment and regulatory frameworks) within which he works. Trainees demonstrate an understanding of the impact care given to an individual patient has on the practice’s resources (staff, equipment) and acts within financial and legal frameworks.

EF2. Attitudinal aspects – is about the doctor’s capabilities, values, feelings and ethics. Trainees demonstrate ethical practice with respect for equality and diversity issues and in line with the accepted codes of professional conduct.

EF3. Scientific aspects – is about adopting an evidence-based and critical approach to practice to continually improve quality. Trainees demonstrate familiarity with the concepts of scientific research, statistics, and critical appraisal, and apply their learning to improve the quality of their practice.

Assessment within CSA

The objective of the nMRCGP is to develop practitioners with wide-ranging knowledge, clinical skills and communication skills which, in assessment speak, are called the intended learning outcomes. The intended learning outcomes form the blueprint of the CSA. The RCGP published the blueprint for the CSA on its website. The table below is adapted from the RCGP web publication and shows the clinical, professional, communication and/or practical skills required of each criterion (A –F).

Each CSA case must be constructed to test criteria A to F. How is this done? Marks are awarded for:

Efficient and targeted data gathering – the ability to take a targeted history and perform a focussed physical examination. Candidates are expected to be knowledgeable and skillful in their examination techniques and in the appropriate use of medical instruments. Marks are awarded for the fluency with which procedures are performed.

Formulating clinical management in line with current accepted British general practice.

Interpersonal skills – the candidate shows an ability to engage patients in the consultation, using recognized interpersonal skills, such as enquiring about the patient’s health beliefs and incorporating these into the explanation given to the patient. Some cases also assess the candidate’s ability to value patients’ contributions, and to respect their autonomy and decision-making.

The overall mark given to the case will depend on the candidate’s ability to combine the two areas of clinical consulting with interpersonal skills.

In very simple terms, data gathering is about how you get to the ‘nub’ of the presenting problem; clinical management is about what you do to move the problem forward; and interpersonal skills is about how you go about doing it.

Each case is written to focus on a particular ‘nub’. The marking schedule, using positive and negative indicators, reflects this nub. For example, Case 30 in this book is written about a patient with multiple sclerosis who presents with balance problems. You may want to read this case before proceeding. The marking schedule is provided below:

Assessors also want to assess breadth of knowledge – they want cases to sample patients of different ages, and diseases of various systems. Hence, a case selection blueprint (see table below) is used so that the twelve examination cases in each CSA diet are sampled from across the grid.

Preparing for CSA

Do the job

The CSA cases are all written by GPs active in the UK NHS and reflect real-life presentations. Therefore, candidates with some experience in NHS general practice should not have difficulty with the exam. The RCGP recommends that candidates first complete at least 6 months of UK NHS general practice before sitting the exam.

Read the website

Candidates are advised to read the Curriculum Statements from the RCGP website. Each curriculum statement has a section on common and important conditions and cases are quite likely to be based on one of these.

Analyse your video consultations

Candidates are advised to video their own consultations, watch them with a colleague, and analyse them for the clinical approach and interpersonal skills displayed.

Practise clinical examinations

Candidates are advised to practise the focussed examinations that are most likely to be tested, such as assessment of a limb, chest or abdomen. Some examinations, such as intimate examinations on a role player, or examinations that might cause discomfort if repeated are less likely to be tested. Candidates are advised to be familiar and confident with medical equipment, such as otoscopes.

Interpret data

Candidates are advised to practise to become familiar with the letters GPs receive from secondary care, and test results such as ECGs, spirometry, blood tests, urinalysis, skin scrapings, and swabs. Candidates need to ensure that they can interpret results correctly and explain them to a patient.

The CSA cases in this book include cases that require candidates to practise physical examination and interpret test results.

How best to use this book to prepare

This book is divided into three parts:

the clinical skills assessment section

the case-based discussion section

the concepts section

The CSA section will pose a typical CSA scenario.

If further information, such as blood results or a hospital discharge summary, is needed for the consultation, this will be indicated as ‘see Appendix at the end of the case.’

Under targeted history taking , will provide a list of questions that could be asked to the patient to gather relevant data.

Under data gathering , provides the information elicited from the patient if the relevant questions are asked. Question one from the targeted history gets answer one under data gathering.

Under targeted examination , will provide a list of focussed examinations that could be performed to gather relevant data.

Under clinical management , suggests ways in which a mutually agreed plan can be negotiated with the patient to produce a consultation that moves the patient forward towards a justifiable management of their presenting problem.

Under interpersonal skills , provides positive indicators, or negative indicators, or both, of communication skills, ethical practice and/or professional conduct. Indicators of positive practice are provided most often, in line with current educational norms. Examples of negative indicators are provided only to illustrate the concept.

Under additional information , provides some additional, usually theoretical information candidates may find useful to reach a deeper understanding of the issues dealt with in the case.

The case usually concludes with signposting to the primary sources of information. The literature changes at a rapid pace, and web sources are usually a good source of updated information. Where possible, useful websites are listed.

The case-based discussion section is discussed in detail under the chapter An introduction to case-based discussion – see page 179.

The concepts section:

explores the background knowledge and skills that are required for the interpersonal skills section of CSA in greater detail. The Consultation models chapter is particularly useful.

discusses common themes that run through most questions within case-based discussions. The concepts chapters provide generic background information that could be useful when preparing for CbD.

Additional information

Grand’Maison P (1993) Canadian experience with structured clinical examinations . Canadian Medical Association Journal , 148 : 1573–1576.

This article describes the development and use of the structured clinical examination to assess medical students and graduates in Quebec over the past 25 years. Also described is the input from Canadian medical educators. The review of the Canadian experience discusses simulated-standardized patients, objective-structured clinical examinations and the use of such examinations for licensure and certification.

Malik S (2006) An OSCE actress . BMJ Career Focus , 332 : 110.

Ms Malik describes her experience as an OCSE actress, how she was briefed to play the case, and what examiners asked of her regarding the candidates. She also gives her tips on how candidates should prepare:

‘I would suggest that if you can sense the acting patient is not happy with the situation then you should ask: "Is there anything I’ve said that is confusing or not clear or that you want explained again?’ Another tip is to have a mental checklist of questions prepared and if you find yourself in an awkward situation, go back to where you left off in the list.’

Relevant literature

Simpson RG (2007) Preparing for practice: nMRCGP and the Clinical Skills Assessment . Update, 75 : 36–37.

Royal College of General Practitioners nMRCGP website – http://www.rcgp.org.uk/nmrcgp_/nmrcgp.aspx, particularly:

http://www.rcgp.org.uk/nmrcgp_/nmrcgp/csa/csa_cases.aspx?theme=print for a document on CSA prepared by Hawthorne (May 2007)

for the GP curriculum – the core statement: http://www.rcgp-curriculum.org.uk/PDF/curr_1_Curriculum_Statement_Being_a_GP.pdf

for in-depth reading of learning outcomes for general practice: http://www.rcgp.org.uk/pdf/curriculum_Guide_for_Learners_and_Teachers.pdf

Case 1 – Back pain

Miss AT is a 25 year old woman who presents asking for a letter saying she needs a new chair at work. She gives an eight month history of intermittent back pain, but it has been worse in the last two months. In the last week, the back pain has been worse as the day progresses. She also complains of ‘dead legs’ which feel heavy and weak.

Targeted history taking

What job does she do?

Where is the pain? Elicit intensity, radiation, aggravating and relieving factors.

Enquire about what she means by ‘heavy and weak’ legs, taking care to exclude nerve compression symptoms.

Exclude cauda equine symptoms: perineal paraesthesia, bladder and bowel dysfunction.

Does the pain disturb her sleep?

What activities does the pain inhibit or limit?

What treatments has she tried already?

What are her expectations of this consultation: a note for the company, physiotherapy, a discussion on analgesia?

What is her general health like – does she have asthma or indigestion?

Data gathering

Listed below is the additional information elicited from the patient with appropriate questioning.

Allison works in telesales.

Further questioning on ‘heavy and weak legs’ elicits a history of pain extending into the buttocks only, with no actual loss of power or altered sensation in the legs.

The history sounds like mechanical back pain and there are no features to suggest more serious pathology.

She is in good health, systemically well and sleep is undisturbed. She does not have morning stiffness.

She lives alone in a 2nd floor flat and has to walk up the stairs with her shopping.

She is active and does weekly tai chi.

She has had one previous episode of back pain three years ago after back-packing. This improved with yoga and Pilates.

She does not like tablets and prefers alternative medicines.

Targeted examination

Expose the back – there is no scoliosis or kyphosis of the spine.

She points to pain ‘like a band’ around her lower back.

Palpation of spinous processes and paravertebral muscles does not elicit any tenderness.

She is able to reach her lower shins but not her ankles. Extension and lateral flexion are not reduced. Watch her face during movements and when she moves about the room.

Straight leg raising and femoral stretch tests are normal.

Clinical management

Discuss the natural history and aetiology of mechanical back pain.

Reassure the patient that the pain usually improves within six weeks. Unless her symptoms deteriorate within six weeks, further investigation such as imaging is not required.

Address the patient’s ideas: she may believe that her back is aggravated or provoked by her chair. You may be able to link this to a discussion on posture, and advise her on good posture.

Encourage Miss AT to continue with tai chi provided it does not make her symptoms worse; encourage activity and avoid long periods of prolonged sitting at work.

Address the patient’s concerns and expectations: the issue here may not be the incorrect chair; it may be prolonged periods of sitting at work. Therefore, instead of a letter, perhaps she could consult her Occupational Health department or her Health and Safety officer to have a work-place assessment. A new chair may not be the whole answer – she made need reconfiguration of her workstation.

Discuss whether she is happy to continue with posture exercises or whether she would like analgesia or a referral to physiotherapy.

Interpersonal skills

Good communication with the patient explores:

her agenda (to improve her back pain)

health beliefs (chair, posture, tai chi, etc.)

preferences (natural remedies and advice of avoiding prolonged periods of sitting at work)

Therefore, it results in an agreed management plan.

Additional information

From: Koes BW , et al . (2006) Diagnosis and treatment of low back pain. BMJ , 332 : 1430–1434.

‘Red flags’

Onset age < 20 or > 55 years

Non-mechanical pain (unrelated to time or activity)

Thoracic pain

Previous history of carcinoma, steroids, HIV

Feeling unwell

Weight loss

Widespread neurological symptoms

Structural spinal deformity

Indicators for nerve root problems

Unilateral leg pain > low back pain

Radiates to foot or toes

Numbness and paraesthesia in same distribution

Straight leg raising test induces more leg pain

Localized neurology (limited to one nerve root)

Treatment

Reassure patients (favourable prognosis)

Advise patients to stay active

Prescribe medication if necessary (preferably at fixed time intervals):

paracetamol

non-steroidal anti-inflammatory drugs

consider muscle relaxants or opioids

Discourage bed rest

Consider spinal manipulation for pain relief

Do not advise back-specific exercises

Test your knowledge

Answer true (T) or false (F) for each of the following statements.

Back pain is the second commonest cause of long-term sickness absence

Straight leg raising (SLR) is a sensitive (0.88–1) and specific (0.84–0.95) test for diagnosing nerve root compression

Bilateral neurological symptoms and signs, saddle paraesthesia and urinary frequency are features of cauda equina syndrome

In L3/4 compression, the knee reflex may be impaired

In a patient >50 years, severe unremitting night pain which gets worse on standing is suggestive of cancer

Case 2 – Injectable contraception

Mrs HW is a 23 year old woman who presents saying that the practice nurse whom she saw yesterday advised her to see the doctor for her depo-provera to be prescribed. See Appendix for summary details.

Targeted history taking

Why has the nurse referred her?

Why is she late for her depo?

Is she happy on the depo or is she experiencing side effects?

What are her expectations of this consultation: for the depo to be given or for contraception options to be discussed?

Does she have risk factors for osteoporosis such as a past history of eating disorders (anorexia or bulimia), does she smoke, does she drink alcohol, does she have a family history of osteoporosis, does she have a balanced, calcium-rich diet and does she undertake regular weight-bearing exercise?

If she smokes, has she considered stopping?

What is her general health like – is she on medication, including over-the-counter medication such as St John’s Wort, which could interact with hormonal contraception?

What is her occupation and does it affect her choice of contraception?

Data gathering

Listed below is the additional information elicited from the patient with appropriate questioning:

The nurse said she was too late for her (the nurse) to give the depo. It needed to