MRCGP - CSA practice case: UTI in a busy young man

To be used individually or in a study group with someone playing the doctor, patient and assessor. Dr Prashini Naidoo provides this clinical skills assessment practice case.

The patient is complaining of a burning feeling when he passes urine
The patient is complaining of a burning feeling when he passes urine

No amount of reading can replace the clinical experience and time spent with patients necessary for a winning performance in the clinical skills assessment (CSA).

However, mock cases with your tutor or fellow registrars are a valuable source of feedback to see how your skills are improving along the way.

The CSA tests the 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 passes if he or she is able to ask the patient the right questions, at the right time, in the right way, perform the right examination correctly and communicate effectively, all within 10 minutes.

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

Keep the next page folded over until you are ready to read the marking guide and the debrief.

How to use this article
This article is to help GP trainees prepare for CSA. It is written for use in a study group, ideally consisting of three trainees.

While the marking grid in this article models an ordered, step-wise approach to data gathering, management and communication, the group debrief, using the prompts at the end of the article, is essential to review the actual performance.

The feedback as a whole informs the doctor about his knowledge and communication skills and advises him on how he can improve his performance for success in the CSA.

The 'patient'
The trainee playing the patient should read the 'brief to the patient' section to enable him to understand the expectations of the patient so he can then 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 'doctor' should read the 'patient medical record' section at the start of the consultation because it contains a summary of the patient's relevant details. A recent test result, such as a fasting glucose 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 him. 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 judgment 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
  • Jake Gibson, a 29-year-old married man.
  • Jake has come to see the doctor today because for the past 24 hours he has been going to the toilet every one to two hours. He has a 'burning feeling' when he passes urine.
  • If questioned in detail, Jake denies feeling unwell or having a high fever. He does not have diarrhoea or vomiting but has had mild nausea. He hasn't had kidney stones, loin pain or frothy or blood-stained urine.
  • If asked, Jake has not been unfaithful to his wife. Both of them had negative STI screens before commencing their relationship.
  • Jake thinks he has a bladder infection. When his wife had similar symptoms, she was given a short course of antibiotics.
  • Jake has just been to the toilet while in the waiting room and definitely cannot produce a urine sample now. He also has an urgent appointment with his bank manager and will find it difficult to return to the surgery later the same day.
  • Jake is a snowboarding instructor for an events company and leaves in three days for a two-week snowboarding job in Austria. There is no information on what medical facilities are available at the resort.
  • Jake wants some antibiotics, just as his wife was given. Jake is not allergic to any antibiotics.
  • If the GP asks for a sample to be brought back, Jake becomes impatient because he was told the blood tests and kidney scans done in April last year ruled out any kidney problems.
Doctor: Patient medical record

Name: Jake Gibson (29 years)

Past medical history Isolated microscopic haematuria (April last year)

Letter from nephrologist (April last year):

"Dear GP, I do not feel that low level microscopic haematuria in the absence of proteinuria, abnormal renal function, hypertension or symptoms requires further investigation. You may consider arranging an ultrasound. I am sure this is likely to be normal but it is conceivable that you may pick up dysplastic, atrophic or polycystic kidneys. I do not think a renal appointment will add anything."

Investigations:

U&Es (April): No abnormality

US kidneys (April): Normal appearances. Both kidneys normal size. No PC dilatation. Normal bladder.

Debrief

  • Did the doctor elicit and address Jake's idea that there is no difference in the treatment of UTI in men and women?
  • Did the doctor adequately explain the need for an MSU?
  • Evaluate the doctor's response to Jake's reluctance to return later with an MSU. Was he sensitive to Jake's work commitments and personal deadlines?
  • Evaluate whether the doctor dealt adequately with the uncertainty created by not having an MSU.
  • The most common feedback statement in CSA failures is 'does not develop a management plan (including prescription and referral) that is appropriate and in line with current best practice or make arrangements for follow-up and safety netting'.
  • Evaluate whether the doctor formulated a safe management plan for a patient who perceives further investigation as repetitive and time-consuming.
  • The skill in this case is to shift the patient's ideas so that he wants to be investigated further.
  • Dr Naidoo is a GP trainer in Oxford. She has written two books on how to pass the CSA

This topic falls under section 10.2 of the RCGP curriculum 'Men's Health', www.healthcarerepublic.com/curriculum

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