MRCGP: CSA practice case - Patient smells of alcohol

To be used individually or in a study group with someone playing the doctor, patient and assessor.

The clinical skills assessment (CSA) aims to test a candidate's ability to gather and assess medical information, make structured, evidence-based and flexible decisions and communicate with patients in a way that moves the consultation forward in an ethical and responsible manner.

The candidate will pass if they ask the patient the right questions, at the right time, in the right way, perform the right examinations correctly and communicate effectively, all within a 10-minute consultation.

Performing mock cases with your tutor or other trainees can provide valuable feedback and indicate how your skills are improving.

In this mock CSA case, patient and doctor roles are provided along with examiner feedback to see how you score across the CSA marking domains.

Do not read the marking guide and the debrief until after you have conducted the test. The marking guide and debrief also provide useful pointers towards the knowledge base needed for passing a CSA consultation such as this.

How to use this article

This article can help GP trainees prepare for CSA. It is ideally used in a study group consisting of three trainees.

The marking grid in this article models an ordered, step-wise approach to data gathering, management and communication and the group debrief is essential to review actual performance. The feedback as a whole informs the doctor about their current knowledge and communication skills and advises them on how to improve their performance for success in the CSA.

The 'patient'

The trainee playing the patient should read the 'brief to the patient' section so that they understand the expectations of the patient and can answer the doctor's questions.

If an examination is expected, the patient is briefed about the findings and may have to make up a card containing the relevant information prior to starting the consultation. If the patient brief does not contain this information, for example a BP reading, and the doctor wishes to examine the patient, the patient should allow the examination to occur.

Performing irrelevant or unjustified examinations eats into the consultation time. Intimate examinations are not permitted.

The 'doctor'

The trainee playing the doctor should read the 'patient medical record' section at the start of consultation because it contains a summary of the patient's relevant details. A recent test result may be provided. Sometimes, a copy of the last patient consultation is given.

The background information often provides a clue about the consultation or gives important data relevant to management decisions.

The 'examiner'

Ideally, the third trainee playing the examiner should enter the consulting room with the patient and sit unobtrusively where the 'doctor' cannot see them.

The examiner should mark the case using the marking guide by ticking against the positive or negative indicators as the consultation unfolds.

At the end of the consultation, the examiner should also make a global judgement of whether the 'doctor', based on this consultation, is fit for independent practice.
The 'examiner' times the case sounding an alarm when the 10 minutes are up.

Patient: Brief to patient

Download the brief to patient to print out.

You are Martin Rice, a 41-year-old unmarried municipal gardener.

  • You are brought in today by your work colleague Jim, who on visiting your flat, found you wrapped in a duvet and vomiting. You smell of alcohol.
  • You present as an emergency. Jim was concerned that you had not reported to work after a week of sick leave, which you were given by the consultant psychiatrist last week. The psychiatrist thought your feelings of panic were due to your medication (venlaflexine) being dropped from 75mg to 37.5mg, so he increased it back to 75mg once daily and also prescribed some diazepam. You took all the diazepam in the first two days, but because you continued to feel panicked you drank alcohol.
  • Jim confirms that you drank six litres of vodka over the week. He found the empty bottles in your room. Unless asked, Jim sits quietly in the room and lets you speak.
  • You are adamant that you usually hardly drink any alcohol. You binged over the last six days to self-medicate the anxiety. The medication changes did not help the anxiety and you 'want help'.
  • If asked, you admit to feeling very agitated and your legs feel restless. You have not been sweating excessively. You say you do not have a tremor; you have not had any hallucinations or periods of confusion. You have not been using recreational drugs.
  • If questioned about your past history, you have been on venlaflexine for two years to treat depression. About 12 months ago you were admitted to hospital for a brief period when you experienced a similar reaction when your medication was reduced. You barely remember the details, only that the nurses were very rude and you eventually self-discharged because they were not helping you.
  • You want further time off work to allow the venlaflexine to work. You want tablets stronger than the diazepam to help your anxiety. If you are advised that it is not safe for you to go home alone, you say you can go to your mother's house. You offer the GP your mother's mobile number. You prefer not to be hospitalised.
  • You appear very agitated with fidgety legs and hands throughout the consultation.

Doctor: Patient medical record

Download the patient medical record to print out.

Name: Martin Rice (41 years).

Past medical history: Depression (moderate to severe) 2009. Left scaphoid fracture 2005.

Current medication: Venlaflexine 37.5mg once daily.

Consultation by patient's usual GP (10 days ago): Two weeks ago reduced venlaflexine to 37.5mg and started to feel he is in a downward spiral, mood dropped, difficulty focusing at work. Started drinking two days ago and turned up to work drunk yesterday. No withdrawals or cravings. No thoughts of deliberate self-harm. Lives alone. He has nightmares and struggles to stay asleep.

Plan: Patient keen to get back to work. Will increase venlaflexine back to 75mg. Advised to throw alcohol away. I will write to psychiatrist to request that his review appointment is brought forward to this week.

Examiner: Marking guide

Generic indicators for targeted assessment domainsDescriptors - positive and negative

A. Data gathering, technical and assessment skills:

  • Gathering of data for clinical judgment, choice of examination, investigations and their interpretations.
  • Demonstrating proficiency in performing physical examinations and using diagnostic and therapeutic instruments.

Positive indicators:Positive indicators:

  • Asks selective questions, tailored to establishing what has triggered the patient's anxiety and restlessness.
  • Enquires about the medication, possible side-effects, dosing regime and compliance. Takes a comprehensive alcohol and drug history.
  • Enquires about red flags, such as delirium tremens, deliberate self harm and risk to others from the patient's driving and occupation.

Negative indicators:

  • Questioning and examination is not sufficiently selective. Most questions should address the alcohol issue in order to safely manage the patient's withdrawal symptoms.
  • The patient's use of diazepam or other drugs and the co-existence of physical or psychiatric illness are not explored.
  • Details of the patient's support network are not obtained.

B. Clinical management skills

  • Recognition and management of common medical conditions in primary care.
  • Demonstrates a flexible and structured approach to decision making.
  • Demonstrating ability to deal with multiple complaints and comorbidity and to promote a shared approach to managing problems.

Positive indicators:

  • Doctor discusses what they feel is the safest course of action and explain their reasoning.
  • Management options, including possible hospital admission or management in the community, are openly discussed.
  • Management is appropriate to the patient's level of risk, the doctor's experience, and the ability to enlist the help of support networks and agencies.
  • Doctor advises appropriately on work and driving.

Negative indicators:

  • Doctor fails to manage safely or in line with current best practice.
  • Follow-up arrangements are inadequate.

C. Interpersonal skills

  • Use of recognised communication techniques that enhances understanding of a patient's illness and promote a shared approach to managing problems.
  • Practising ethically with respect for equality and diversity in line with accepted codes of professional conduct.

Positive indicators:

  • Doctor displays a good mix of empathy and direction.
  • He or she communicates effectively with the patient, not his colleague.
  • Doctor obtains the patient's permission to discuss issues in front of the colleague or with his mother by telephone.
  • They develop a shared management plan, stressing what is safe management for the patient and others around him (work colleagues/road users) who could be harmed.

Negative indicators:

  • The doctor assumes the patient cannot provide a history and communicates with the work colleague.
  • The doctor's non-verbal communication and language is doctor-centred, potentially creating a parent-child dynamic.
  • The doctor appears judgmental about the use of alcohol.

Debrief

  • What questioning or examining enabled the doctor to differentiate between acute alcohol withdrawal, delirium tremens or serotonin discontinuation syndrome? Was the line of questioning methodical or erratic? Was the history taking tailored or did the doctor ask a battery of non-selective, rote psychiatric questions?
  • Did the doctor recognise significant findings: such as lack of support at home, co-existing depression and previous self-discharge possibly from in-patient detoxification? How did the doctor use this information to negotiate a safe management plan?
  • The most common reason for failure in the CSA is the doctor not developing a management plan - including prescribing and referral - reflecting knowledge of current best practice. Did the doctor manage this patient in line with current UK best practice?
  • Doctors with good interpersonal skills actively listen, appear to really want to know the patient's answers, and skilfully weave the patient's ideas, concerns and expectations into their management plan. Assess whether this consultation was doctoror patient-centred and suggest how it could safely be made more patient-centred.

Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP was published in January 2016.

Resources

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