Csa Book Mrcgp Csa Cases Mrcgp Course

March 25, 2018 | Author: Eshtiag | Category: Pregnancy, Public Health, Health Care, Medicine, Wellness
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Practice CSA Cases & Communication Skills for the MRCGP CSA Exam...

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Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

MRCGP  CSA  CASES     Practice  CSA  Cases  &  Communication  Skills   for  the  MRCGP  CSA  Exam  

    Muhammed  Akunjee     GP  Principal  

  Nazmul  Akunjee     GP  Principal                 Clinical  Prep  Publishing   London  

MRCGP  CSA  Cases                 Clinical  Prep  (Publishing),  2013   339/341  West  Green  Road   London  N15  3PB     www.csaprep.co.uk           First  published  in  2013       ©  2013  Muhammed  Akunjee,  Nazmul  Akunjee     Muhammed  Akunjee  and  Nazmul  Akunjee  have  asserted  their  right  under  the  Copyright,  Designs   and  Patents  Act  1998  to  be  identified  as  the  authors  of  this  work.     All  rights  reserved.  No  part  of  this  publication  may  be  reproduced,  stored  in  a  retrieval  system  or   transmitted,   in   any   form   or   by   any   means,   electronic,   mechanical,   photocopying,   recording   or   otherwise,  without  the  prior  permission  of  the  copyright  owner.     Important  Note  from  the  Publisher   The  information  contained  within  this  book  was  obtained  by  Clinical  Prep  from  sources  believed  to   be  reliable.  Whilst  every  effort  has  been  made  to  ensure  the  accuracy  of  the  material  contained   herewith,  no  responsibility  for  loss,  injury  or  failure  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.       Although  every  effort  has  been  made  to  ensure  that  all  owners  of  copyright  material  have  been   acknowledged  where  relevant  in  this  publication,  we  would  naturally  be  pleased  to  acknowledge   in  subsequent  reprints  or  editions  any  omissions  brought  to  our  attention.       All   readers  should  beware   that   medical   sciences   are   constantly   evolving   and   whilst   the   publishers   and  authors  have  checked  all  dosages  and  guidance  are  based  upon  current  indications,  there  may   be  specific  practices  and  procedures  that  differ  between  countries  and  nations.  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  residing  and/or  practicing.       ISBN-­‐13:  978-­‐0-­‐99276610-­‐8       Typeset  and  designed  by  Clinical  Prep,  UK   Printed  and  bound  by  Action  Press,  West  Sussex,  UK  

 

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

Preface       Since   the   introduction   of   the   Clinical   Skills   Assessment   (CSA)   as   part   of   the   requirements   to   qualify   as   a   GP   in   2007,   some   registrars   have   struggled   to   understand  what  is  needed  of  them  to  pass  these  examinations.  The  CSA  was  set   up   to   assess   registrars   using   specifically   trained   actors   recreating   situations   and   scenarios  that  a  competent  GP  would  be  expected  to  face  or  meet  in  the  course  of   their  clinical  practice.       A   General   Practitioner,   as   the   name   suggests,   is   a   physician   that   has   a   wide   knowledge  base  about  a  whole  range  of  different  conditions  and  problems.  As  in   real   life,   almost   any   type   of   condition   can   present   at   the   surgery   and   the   same   rings   true   for   the   CSA.   This   does   not   mean   you   must   know   every   minute   detail   about   all   conditions,   as   we   know   that   this   will   be   impossible,   but   rather,   means   that   one   must   be   prepared   to   face   a   wide   range   of   presenting   complaints   and   know  how  to  deal  with  them  in  a  competent  manner. Unfortunately,   a   cohort   of   registrars   have   been   found   to   repeatedly   fail   the   examinations   irrespective   of   the   length   of   their   clinical   experience   nor   their   success   in   previous   clinical   examinations.   Having   worked   with   a   large   number   of   such   registrars   and   helped   many   of   them   to   pass   the   CSA   examination,   we   felt   the   need   to   write   a   textbook   of   MRCGP   CSA   Cases   that   would   help   candidates   appreciate   the   subtleties   of   the   communication   skills   being   assessed   which   has   previously  tripped  up  a  number  of  these  registrars.        

MRCGP  CSA  Cases  

This  Book   The   MRCGP   CSA   Cases   book   has   been   divided   into   two   sections;   an   introductory   section   that   goes   into   detail   about   the   key   communication   and   interpersonal   skills   needed  for  the  exams,  as  well  as  a  section  that  contains  challenging  MRCGP  CSA   cases.  We  have  written  the  cases  to  reflect  the  standard  of  the  harder  end  of  the   examination   spectrum   and   have   tried   to   combine   medical   knowledge,   with   cues,   and  concerns  that  so  often  throw  and  confuse  registrars.  For  each  case  we  have  a   candidate  brief,  a  comprehensive  actors  brief  and  a  case  walk-­‐through,  which  we   would  consider  to  be  the  best-­‐practice  approach  for  that  scenario.  We  have  tried   our   best   to   make   the   cases   as   realistic   as   possible   but   to   a   level   of   complexity   that   can  be  completed  in  a  10  minute  consultation.     When  using  the  book  we  advise  you  to  practice  with  at  least  2  fellow  GP  registrars,   one  acting  as  the  examiner  and  the  other  as  the  actor.  In  this  way,  all  registrars  will   be  able  to  appreciate  the  different  nuances  of  the  cases  from  the  perspectives  of   the  examiner  and  the  actor.  We  hope  that  this  would  give  you  some  insight  into   what  is  required  to  pass  the  CSA  exam.     Muhammed  &  Nazmul  Akunjee   November  2013  

 

 

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

About  the  Authors       Muhammed  Akunjee  MBBS  MRCGP  PgCert  (Diabetes)  PgCert  (MedEd)   Muhammed  Akunjee  has  been  a  GP  Principal  in  North  London  since  2007.  He  also   works   closely   with   the   local   PCT   being   both   a   board   member   as   well   as   mental   health   lead.   He   qualified   from   Guy’s,   Kings   and   St.   Thomas’s   Medical   School   in   2002  and  completed  his  MRCGP  gaining  a  distinction  in  2006.  During  this  time  he   was  also  awarded  first  prize  for  the  Roche  /  RCGP  Registrar  award  for  a  work  on   miscommunication  between  secondary  and  primary  care.  He  is  a  GP  Appraiser  for   the  NCL  cluster  as  well  as  a  BMA  Book  Award  Appraiser.     He  completed  a  Postgraduate  Certificate  in  Medical  Education  at  the  University  of   Dundee   and   more   recently,   a   Certificate   in   Diabetes   at   Warwick   University.   He   has   attended   the   London   Deanery's,   Introduction   to   Teaching   in   Primary   care   course   and   has   taught   and   examined   clinical   skills   at   a   London   University.   He   is   an   avid   medical   book   writer   and   has   a   number   of   articles   published   in   peer   review   journals.       Nazmul  Akunjee    MBBS  MRCGP   Nazmul   Akunjee   has   recently   completed   his   GP   vocational   training   and   is   currently   a   GP   Principal   in   a   large   North   London   practice.   He   qualified   from   GKT   medical   school  in  2005  and  is  currently  actively  engaged  in  teaching  medical  students  and   preparing  them  for  their  exams.  He  has  published  a  number  of  articles  related  to   examination   skills   in   peer-­‐reviewed   journals   and   more   recently   has   been   appointed  as  a  GP  Appraiser  by  NHS  England  (London).      

MRCGP  CSA  Cases  

Nazmul  Akunjee  passed  and  excelled  at  his  CSA  exam  in  February  2011  passing  all   13   stations   at   the   first   attempt.   Since   that   time   he   has   been   involved   in   1-­‐2-­‐1   private   CSA   coaching   as   well   as   group   tuition   with   GP   registrars.   He   completed   the   London   Deanery's,   Introduction   to   Teaching   in   Primary   care   course   in   June   2011   and  has  taught  and  examined  medical  students  at  a  London  Medical  School.       Nazmul  is  currently  a  GP  lead  for  the  Primary  Care  Strategy  of  Haringey  CCG  and  is   the   Medical   Director   for   Tottenham   Primary   Care   Services   LTD.   He   is   also   the   clinical  lead  for  both  the  Haringey  Primary  Care  Intelligence  Group  and  CCG  Access   and   Productivity   Task   Force   looking   to   help   improve   quality   in   general   practice   across  the  borough.     Nazmul  Akunjee  and  Muhammed  Akunjee  are  both  authors  of  ‘The  Easy  Guide  to   OSCEs'  series  published  by  Radcliffe.  In  2008  their  book  the  'Easy  Guide  to  OSCEs   for  Final  Year  medical  students'  was  Commended  in  the  BMA  book  awards.  Their   second   publication,   ‘The   Easy   Guide   to   OSCEs   for   Specialties’   was   Highly   Commended   in   the   BMA   book   awards   the   following   year   in   2009.   Their   most   recent   work   'Clinical   Skills   Explained'   was   Highly   Commended   at   the   BMA   book   awards,   2013.   Radcliffe   Publishing   nominated   the   authors   for   the   BMA   Young   Author  of  the  Year  in  2010.  

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

The  CSAPrep  Course       The  CSA  Prep  course  was  started  in  the  winter  of  2011  providing  an  intense  one-­‐ day  coaching  experience  for  GP  registrars  to  help  pass  the  RCGP  CSA  exit  exams.  It   was  the  brainchild  of  Dr  Nazmul  Akunjee  who  sat  and  successfully  passed  the  CSA   examination  at  his  first  attempt.  However,  after  he  attended  a  number  of  courses,   he   felt   that   there   was   no   course   that   actually   reflected   accurately   the   examination   experience.   Hence,   he   went   about   devising   and   creating   a   course   that  was,  ‘as  close  to  the  exam  as  possible.’       The  course  is  unique  in  that  it  solely  utilizes  MRCGP  trained  actors  who  have  all   acted  out  in  the  MRCGP  CSA  exams  and  appreciate  the  nuances  of  how  to  act  out   medical  cases  and  when  to  drop  cues.  The  full  day  course  uses  four  different  CSA   actors  who  act  out  18  different  cases  in  total.       The   course   employs   2   course   facilitators,   both   of   whom   are   GP   partners,   with   each   in   charge   of   a   group   of   3   registrars   so   that   each   candidate   gets   at   least   6   goes   on   the   day   and   sees   12   further   cases.   The   facilitators   give   honest   and   personalized   feedback   with   a   view   to   helping   you   through   the   CSA   examination   hurdle.     The  cases  used  on  the  day  have  been  written  to  be  equivalent  to  the  harder  end   of   the   CSA   exam   spectrum   and   focus   on   difficult   consultations   such   as   dealing   with  angry  patients,  breaking  bad  news,  underage  consent  and  negotiating  shared   management  plan,  typically  areas  when  GP  registrars  usually  find  challenging.      

MRCGP  CSA  Cases  

We  pride  ourselves  in  trying  to  give  you  an  experience,  ‘as  close  to  the  exam  as   possible’  and  in  this  vein  we  have  created  our  own  MRCGP  CSA  Prep  course  app   that  allows  you  to  practice  with  the  Ipad  during  the  course  as  you  will  have  to  do   so  in  the  real  examination.     For   those   who   have   completed   the   full-­‐day   CSA   course   and   wanting   further   personalised   feedback   and   more   challenging   cases   covering   other   areas   of   the   RCGP  curriculum,  is  a  half-­‐day  mini-­‐CSA  exam.  This  course  uses  2  CSA  actors,  but   has   10   further   challenging   cases   and   each   candidate   is   allocated   a   single   GP   facilitator  to  coach  them  on  their  communication  and  consulting  skills.       The   CSAPrep   experience   does   not   end   there,   but   through   the   website,   www.csaprep.co.uk   you   can   gain   access   to   free   CSA   cases   as   well   as   free   communication  skills  material  with  quick  reference  tools  on  how  to  succeed  in  the   examination.   You   can   also   download   an   exam-­‐like   free   app   that   can   be   downloaded   onto   your   iOS   device   and   practice   cases   in   a   similar   format   to   that   of   the   examination.   The   website   also   contains   numerous   articles   on   top-­‐tips   on   how   to   pass   the   CSA   exam   and   how   to   understand   the   RCGP   feedback   following   the   examination.  

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

CIRCUIT  1   Case  10:  Margaret  Kennie Candidate’s  brief     Patient  medical  records     Name:           Past  medical  history:       Drug  history:        

Margaret  Kennie  (31  years)   Asthma  (2000)   Folic  acid  400  mcg  

Letter  from  Genetic  clinic  (1  week  ago)   Letter  from  Genetic  Screening  to  GP:  I  am  writing  to  summarise  the  results  of  the   genetic  screening  tests.  The  couple  had  performed  the  initial  tests  but   unfortunately  they  did  not  attend  the  follow-­‐up  appointment  for  the  explanation   of  the  results.  Of  note,  the  partner  was  tested  previously  and  had  been  told  he   was  a  carrier.     Cystic  Fibrosis  occurs  when  a  child  inherits  a  defective  copy  of  the  CF  gene  from   both  parents.  A  defect  in  the  gene  is  not  the  same  in  all  cases.  However,  in  the   couples’  case  both  partners  have  inherited  the  commonest  type  of  defect  called   delta  F508  gene  and  they  are  therefore  both  carriers.  This  means  that  there  is  a  1   in  4  risk  of  any  child  being  born  from  the  two  partners  being  affected  with  CF.     Dr  Michael  Shumer  -­‐  Consultant  Geneticist       Consultation  (4  weeks  ago)   Dr  Andrews:  Patient  reports  she  is  pregnant.  LMP  1  week  late  -­‐  approximately  5   weeks  gestation.  Commenced  on  folic  acid.  Advice  given  in  pregnancy  regarding   healthy  eating,  diet  and  alcohol  -­‐  Emma’s  diary  given.  Non-­‐smoker  but  drinks  a   glass  of  wine  on  occasions.  Has  agreed  to  stop  for  pregnancy.  No  cats  in  the   house.  Family  history  of  CF.  Organised  referral  to  genetic  clinic  due  to  anxieties.  

MRCGP  CSA  Cases  

Actor’s  brief     Background:  You  are  Margaret  Kennie,  a  31  year  old,  IT  columnist  for  an  online   technology  magazine.     Approach:  You  are  well  dressed  and  are  softly  spoken.  You  are  a  confident   middle-­‐class  lady.     Opening  statement:  “Doctor,  I  guess  you  know  I’m  pregnant,  but  I  am  a  little   worried.”     History   Open  history  



You  have  been  trying  for  a  baby  for  a  while  with  your  partner  and  have   just  got  pregnant.  You  are  obviously  very  happy  but  also  very  anxious  to   make  sure  your  baby  is  born  healthy  (verbal  cue).  



Verbal  cue:  You  know  you  missed  your  appointment  as  you  had  been   ‘overwhelmed  with  everything’.  

  Reveal  history  if  asked   DNA  



You  have  been  quite  anxious  about  whether  your  child  will  be  born   health.  After  your  partner  and  you  had  the  blood  test  you  were   ‘overcome  by  nerves’  and  could  not  face  hearing  the  results.  You  already   know  that  your  partner  is  a  carrier  of  the  CF  gene.  



You  missed  the  appointment  but  now  having  done  some  research  on  the   web  are  more  confused  than  ever.  You  managed  to  pluck  the  courage   and  book  the  appointment  today  with  the  doctor  to  know,  ‘once  and  for   all’.  

  Cystic  Fibrosis  



You  have  a  nephew  called,  Daniel,  who  was  diagnosed  with  cystic   fibrosis.  He  is  the  son  of  your  aunt  (Martha)  on  your  dad’s  side.    

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  



Your  aunt  and  her  partner,  Tom,  had  a  very  difficult  time  bringing  up   Daniel.  They  were  told  that  he  would  die  before  he  passed  his  teenage   years  but  instead  he  is  still  alive  and  is  currently  22  years  old.    



When  he  was  younger  he  had  lots  of  chest  infections  and  was  quite   unwell  needing  constant  one-­‐to-­‐one  lung  physiotherapy.  He  was  ‘always   in  and  out  of  hospital’  and  had  a  few  close  brushes  with  death  due  to   pneumonia.  However,  he  is  more  stable  now  and  he  is  keen  to  be  a   physiotherapist  and  help  others  with  the  same  condition.    



After  seeing  how  Daniel  grew  up,  you  know  enough  about  CF  and  its   treatment.  However,  now  that  you  are  pregnant  -­‐  ‘It’s  hitting  home,  I   need  to  know  if  my  child  has  it  or  not!’  



You  do  not  want  an  explanation  about  the  condition.  



Ideas:  You  want  to  know  the  blood  results:  whether  your  child  has  cystic   fibrosis  or  not.  

● ●

Concerns:  You  are  worried  that  your  child  has  cystic  fibrosis.  

 

Expectations:  You  want  the  results  of  the  genetic  tests  as  you  want  to   know  with  certainty  whether  your  baby  has  Cystic  Fibrosis  or  not.    

  Past  medical  history  



You  have  suffered  with  Asthma  for  over  10  years  but  are  well  controlled   with  inhalers.  For  the  last  1-­‐year  you  have  not  needed  to  use  your   inhalers  at  all.  

  Past  obstetric  history  

● ●

You  have  no  previous  pregnancies,  children  or  terminations.  



You  are  really  excited  with  your  pregnancy  but  you  are  finding  it  hard  to   celebrate  with  this  hanging  over  you.  

You  have  been  previously  reluctant  to  get  pregnant  with  your  knowledge   that  something  was  wrong  with  the  genes  in  your  family.  However,  you   are  overtly  aware  that  ‘time  is  running  out  and  nature  does  not  wait  for   anyone’.  

  Family  history  



As  above  regarding  CF.  

MRCGP  CSA  Cases  



You  have  no  other  medical  problems  in  your  family.  

  Drug  history  



You  no  longer  need  your  inhalers.  You  take  folic  acid  400mcg  as   prescribed.  



You  have  no  drug  allergies.  

  Social  history  



You  do  not  smoke  but  drink  the  occasional  glass  of  wine  at  least  3  times   a  week;  usually  at  social  events.    

● ●

Your  mood  is  stable  and  you  sleep  and  eat  well.  



Occupation:  You  live  in  a  2  bedroom  flat  with  a  minimal  mortgage.  You   have  no  financial  worries  and  have  a  good  job  in  the  city  as  an  IT   journalist  with  a  regular  column  for  an  online  magazine.  



Diet:  You  are  conscious  of  what  you  eat  after  Dr  Andrews  informed  you   what  diet  is  good  for  your  baby.  You  have  read  all  the  books  and  avoid  all   the  foods  that  you  are  meant  to.  You  do  not  want  either  antenatal  or   booking  advice  today.  

 

Relationship:  You  have  been  with  your  partner  for  3  years  and  decided  to   try  for  a  child  this  year  as  things  between  yourselves  have  never  been   better.  You  are  happy  with  him  and  he  is  very  supportive.  He  will  support   any  decision  you  make  about  the  baby.  

 

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam    

Nub  of  the  case   -­‐  You  are  a  middle  class,  softly  spoken  lady  who  is  pregnant  and  worried  about   her  baby  having  cystic  fibrosis.   -­‐  You  missed  your  genetic  clinic  appointment  as  you  were  too  nervous  of  the   results.  Both  you  and  your  partner  have  already  had  your  DNA/swab  taken.   -­‐  You  have  a  cousin  who  has  CF  and  has  struggled  with  his  health  from  it   (recurrent  chest  infections).   -­‐  You  believe  that  the  doctor  is  going  to  inform  you  whether  your  baby  has  CF  or   not.  You  are  surprised  it  is  only  a  probability  score.   -­‐  You  want  to  know  how  to  test  for  sure  whether  your  baby  has  CF  or  not.      

  How  to  respond  



Results:  If  the  doctor  informs  that  you  and  your  partners  are  carriers  of   CF  gene  act  surprised  and  worried.  Ask  to  clarify  what  that  means  for   your  baby:  ‘Does  that  mean  my  baby  has  it?’  

○ If  the  doctor  informs  you  that  there  is  a  1  in  4  chance  that   your  baby  has  CF  appear  surprised  and  confused  and  suggest,   ‘I  thought  I  will  be  finding  out  today  definitely  whether  my   child  had  it  or  not.  What  does  1  in  4  mean?”  

■ Accept  an  explanation  of  the  chance  of  inheriting  CF  if   explained  accurately.  

■ Remain  puzzled  if  performed  poorly.   ○

If  the  doctor  says  that  the  test  will  not  inform  you  100%  that   your  baby  has  CF  or  not  act  surprised  that  it  is  not  conclusive.   Request  for  a  test  that  would  give  you  a  100%  answer  as  the   stress  is  killing  you.  

 



Investigations:  If  the  doctor  suggests  that  there  are  tests  that  can  be   done  in  the  womb,  seek  clarification  what  test  and  when  it  is  done.  Also   ask  how  it  is  performed.  

○ If  the  doctor  suggests  the  test  is  performed  with  a  needle,  act   alarmed  (non-­‐verbal  cue).    

■ Your  concern,  if  asked,  is  whether  the  needle  will  hit   your  baby  and  cause  bleeding  to  your  child  inside  your  

MRCGP  CSA  Cases  

womb:  ‘What  if  you  insert  the  needle  and  hit  my  baby?’   Be  reassured  if  they  explain  that  it  is  ultrasound   guided.  

○ Enquire  about  the  risks  of  the  test  i.e.  miscarriage,  harm  to   the  fetus.  

○ If  the  doctor  suggests  that  you  can  wait  until  your  child  is  born   and  then  perform  a  sweat  test  reply  that  you  must  know  now   ‘to  put  your  mind  at  ease’.    

■ You  believe  that  you  will  have  an  ‘awful  7  months’  of   pregnancy  if  you  did  not  know.      



Implications:  If  the  doctor  asks  you  the  question  about  what  you  would   do  if  you  learnt  that  your  baby  had  CF  then  reply,  ‘I  really  want  this  baby   and  I  will  do  everything  to  keep  it.’    

○ Explain  further  that  you  want  to  be  fully  prepared  for  any   eventuality  and  you  learnt  lessons  from  Daniel’s  experience   and  believe  that  there  are  good  treatments  and  support  for   children  with  CF.  

○ Already  you  have  seen  Daniel  live  longer  than  expected  with   current  treatments.  You  have  been  reading  alot  about  viral   gene  technology  and  believe  that  by  the  time  your  baby  is   older,  medical  advancements  will  mean  your  baby  will  be   almost  cured  of  CF.      

Examination  findings        

  Examination       Declines  as  has  appointment  in  3  days  time   with  own  midwife  

Vitals     BP       Pulse   BMI     Temp        

110  /  68     81  bpm   29   37.1oC  

 

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

CSA  Case  points     This  scenario  is  testing  your  ability  to  discuss  genetics  testing  with  a  pregnant   mother.  The  mother  is  already  well  informed  about  Cystic  Fibrosis,  and  is  keen  to   find  out  definitively  as  to  whether  her  current  pregnancy  may  be  suffering  with   the  condition.  The  case  centers  on  taking  a  good  history  as  well  as  the   concurrent  pyscho-­‐social  stressors  surrounding  the  mother  and  ultimately   exploring  how  exactly  she  wants  to  proceed  if  she  were  to  learn  the  definitive   results  from  further  testing.       CANDIDATE  BRIEF   The  candidate’s  brief  offers  a  key  insight  into  the  possibility  that  this  case  will   focus  on  a  genetic  topic.  It  is  revealed  that  the  mother  is  currently  pregnant  and   that  she  has  a  family  history  of  cystic  fibrosis.  As  a  result  she  has  been  referred  to   speak  to  the  geneticist.  However,  as  per  the  Consultant’s  letter,  she  missed  the   follow-­‐up  appointment  to  discuss  the  results  in  detail.  The  geneticist  has   informed  you  that  both  partners  were  found  to  be  carriers.  Prior  to  the  patient   entering  the  room,  you  should  plot  out  a  genetic  tree  and  calculate  the  risks  of   the  baby  being  a  carrier  as  well  the  risk  of  suffering  the  full-­‐blown  disease.   Consider  ways  of  how  to  communicate  the  different  risks  to  the  mother  if  she  is   attending  today  to  discuss  these.     Given  the  mother’s  anxiety  about  cystic  fibrosis  warranting  a  genetics  referral,   and  the  clear  family  history,  it  would  be  prudent  to  consider  exploring  these  two   issues  further  in  the  consultation.  It  is  likely  that  she  is  attending  today  due  to   missing  her  appointment  and  perhaps,  given  that  you  are  her  GP,  she  is  more   likely  to  trust  your  explanation  and  be  comfortable  to  ask  questions.     The  patient  is  currently  only  on  folic  acid  that  was  commenced  a  few  weeks   prior.  However,  there  is  a  note  that  they  have  suffered  from  asthma.  It  may  be   useful  during  the  consultation  to  establish  how  well  controlled  the  patient’s   asthma  is  and  whether  they  are  currently  taking  any  treatment  for  this.  It  is  a   well-­‐known  fact  that  in  about  a  third  of  pregnancies  patients  with  asthma  may   develop  worsening  of  symptoms.     Given  that  she  is  pregnant,  and  there  is  little  antenatal  history,  it  may  well  be   worth  asking  more  history  surrounding  the  mother’s  obstetric  background.  Has  

MRCGP  CSA  Cases  

she  been  pregnant  before?  Had  she  had  any  terminations  (if  so,  particularly  was   it  due  to  a  possible  congenital  deformity)?  Does  she  have  any  children  now?  If   so,  are  they  healthy?     INTERPERSONAL  SKILLS   Genetic  cases  are  quite  sensitive  consultations  since  they  broach  subjects  that   may  affect  whether  a  pregnancy  will  be  continued  or  not.  The  advice  given   during  the  consultation  may  alter  the  plans  a  mother,  or  the  parents  have  for   their  child.  Hence,  one  has  to  be  quite  conscious  of  the  issues  and  broach  the   topic  with  the  delicateness  it  deserves.       As  the  patient  begins,  she  starts  with  an  opening  statement  that  expresses  her   anxieties  surrounding  the  pregnancy.  It  is  important  to  use  open  questions  to   help  allow  the  patient  to  offer  her  true  feelings  and  the  surrounding  history  as   freely  as  possible  without  interruption.  Ensure  that  you  always  act  empathically   if  the  patient  reveals  any  anxieties  or  any  concerns.  Make  sure  that  you  do  not   over  complicate  any  explanation  or  use  excessive  medical  jargon  particularly   when  speaking  about  genes  and  inheritance.  This  will  only  serve  to  confuse  and   confound  the  patient  and  is  likely  to  make  them  feel  even  more  anxious  than   they  already  are.     Negative  indicators:  



Fails  to  listen  to  the  patient  and  obtain  a  detailed  understanding  of  the   issues.  

● ● ●

Fails  to  identify  or  respond  to  cues.   Fails  to  use  open  questions  and  appears  abruptive.  

Uses  excessive  medical  jargon  when  communicating  the  risk.     DATA  GATHERING   Although  the  patient  describes  her  anxieties  about  the  pregnancy  and  the   possibility  of  cystic  fibrosis  it  is  important  to  try  and  establish  what  she  already   knows.  It  may  be  an  idea  to  quickly  summarise  the  previous  consultation  back  to   her,  to  check  she  agrees  with  what  was  said  and  then  to  request  whether  she   received  a  copy  of  the  letter  from  the  genetics  clinic.  It  would  be  relevant  as  well   to  establish  why  she  missed  the  follow-­‐up  appointment  with  the  hospital.    

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

DNA  



Try  and  find  out  why  the  patient  missed  the  follow-­‐up  appointment?  Did   she  do  this  willingly  or  was  the  appointment  forgotten?  If  she  missed  it   intentionally,  what  was  the  reason?  What  was  she  afraid  of  finding  out?   Does  she  want  you  to  communicate  the  risk  of  CF  today  to  her?  

  Cystic  Fibrosis  



Why  is  the  patient  so  worried  about  the  risk  of  Cystic  Fibrosis?  Has  she  or   her  partner  been  tested  before?  Does  she  know  anyone  with  CF  and   what  was  their  experience  with  it?  What  does  she  understand  about  CF?  



Does  she  want  you  to  explain  the  condition  today?  Or  was  she  expecting   something  else  from  the  consultation.  

  Psycho-­‐social  context  



Establish  the  impact  the  symptoms  have  had  on  the  patient’s  cousin  i.e.   attendance  to  numerous  hospital  appointments,  number  of  admissions   and  near-­‐death  experiences  (ITU  admissions).  



Determine  the  patient’s  current  living  arrangements  and  who  they  live   with.  What  does  their  partner  know  about  CF?  What  would  the  partner   want  to  do  if  the  child  had  CF?  



Check  if  they  smoke  or  drink  and  signpost  to  health  promotion  initiatives   as  appropriate.  

  Negative  indicators:  



Takes  only  a  superficial  history  about  the  presenting  complaint  and  fails   to  elicit  subtle  signs  of  anxiety  about  the  pregnancy.    



Makes  superficial  assumptions  about  the  patient’s  health  and  does  not   elicit  relevant  psycho-­‐social  context  i.e.  impact  on  life-­‐expectancy.  

  CLINICAL  MANAGEMENT  SKILLS   When  a  patient  attends  for  their  first  appointment  after  finding  out  they  are   pregnant,  it  is  important  to  ascertain  their  intentions  with  regards  to  keeping  the   baby  or  having  a  termination  (TOP).  This  becomes  more  so  when  dealing  with   sensitive  topics  especially  with  genetic  cases.  If  one  were  to  assume  that  the   patient  intended  to  have  a  TOP,  this  may  be  taken  as  being  judgmental  and   dramatically  change  the  tone  of  the  consultation.  Often  a  good  question  to  ask  

MRCGP  CSA  Cases  

early  on  would  be:  ‘If  you  found  out  that  your  baby  had  this  condition,  how   would  it  change  things?  Would  it  change  whether  you  wanted  to  keep  this   pregnancy  or  not?’’     Inheritance  



Explain  to  the  patient  the  mode  of  inheritance:  ‘Genes  come  in  pairs  with   one  from  each  pair  coming  from  both  parents.  A  person  suffering  from  CF   inherits  one  copy  of  the  sleeping  defective  gene  from  each  parent  who   are  the  recessive  carrier.’  



Explain  other  possible  outcomes:  ‘If  a  person  inherits  a  single  defective   gene  than  this  means  that  they  do  not  have  the  disease  but  are  a  carrier.   This  means  they  can  pass  on  the  gene  to  their  children,  but  will  not  be   affected  with  the  disease  themselves.’      



Explain  to  the  patient  the  risk  to  their  child:  ‘In  your  case,  since  both  your   partner  and  yourself  are  carriers  there  is  a  1  in  4  (25%)  chance  that  your   baby  will  have  Cystic  Fibrosis.  In  other  words  if  you  were  to  have  4   children  with  your  partner  we  would  expect  1  child  completely  well   without  any  defective  gene,  2  children  who  are  well  and  healthy  but  are   carriers  of  the  defective  gene,  and  1  child  who  will  have  CF.’    

  Definitive  tests  



Discuss  with  the  patient  options  to  conduct  more  accurate  tests  in-­‐utero   to  determine  whether  the  fetus  has  CF:    ‘Chorionic  villus  sampling  or   amniocentesis  are  techniques  that  allow  us  to  take  a  sample  from  the   womb  of  the  baby’s  cells.  We  will  pass  a  fine  needle  through  the  wall  of   your  tummy.  It  is  performed  in  early  pregnancy  (11-­‐14wk  -­‐  CVS,  16wk  -­‐   amniocentesis)  and  we  will  use  ultrasound  to  guide  us  to  ensure  the  baby   is  safe.    



Explain  the  risks  associated  with  Chorionic  villus  sampling  or   amniocentesis:  ‘However,  the  test  is  not  100  percent  accurate  and  there   is  a  slight  risk  of  causing  a  miscarriage  (1/100).’  

  Post  delivery/diagnosis  



Offer  the  patient  alternative  methods  to  diagnose  Cystic  Fibrosis   including  the  heel  prick  test  or  sweat  test.  Emphasise  that  these  tests  can   only  be  conducted  once  the  baby  has  been  delivered    

Practice  CSA  Cases  &  Communication  Skills  for  the  MRCGP  Exam  

 



Referral:  Support  the  mother  in  her  decision  to  keep  the  baby.  Suggest   that  you  can  organise  an  early  obstetric  and  paediatric  referral.  Offer   patient  group  details  of  charity  information  for  patients  with  CF.    



Follow  up:  Consider  reviewing  the  patient  in  a  few  weeks  after  they  have   had  time  to  discuss  with  their  partner  or  the  midwife.  Consider  seeing   the  patient  with  their  partner  to  further  explore  the  issues.  

  Negative  indicators:  

● ●

Uses  inappropriate  (e.g.  technical)  language.  



Fails  to  incorporate  patient’s  ideas  and  expectations  into  the   management  plan  i.e.  patient  wants  to  keep  the  child  regardless  of   diagnosis  and  would  like  in-­‐utero  testing  to  be  prepared.  

Fails  to  offer  suitable  options  for  investigating  CF  i.e.  CVS  or   amniocentesis.  

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