Download Jolene Kertich

GPRA
practice case
scenarios
Jolene Kertich
32 years of age
Copyright 2015 GPRA
GPRA practice case scenarios
Disclaimer
All efforts have been made to ensure that the material presented in
this resource was correct at the time of publication and published in
good faith. GPRA does not accept liability for the use of information
within this publication.
General Practice Registrars Australia Ltd
Level 1, 517 Flinders Lane
Melbourne Victoria 3001
ABN 60 108 076 704
© 2015 GPRA. All rights reserved. Except as expressly provided in
the Copyright Act, no part of this publication may be reproduced,
distributed, stored in any retrieval system or transmitted by any
means (including electronic, mechanical, micropying, photocopying,
recording or otherwise) without prior written permission from the
publisher, General Practice Registrars Australia Ltd (GPRA).
This resource is for personal use only.
GPRA practice case scenarios – Jolene Kertich
Section A. Information for candidates
Instructions
•This is a 19-minute station. You will hear a bell after eight minutes and again after 11 minutes.
Ignore them
•This station involves an initial consultation followed by a review consultation
•Read the following scenario
•Take an appropriate history from the patient
•Request specific physical examination findings of any examination you deem is required
•Discuss the options and agree on a plan of management (which may include investigations) with
the patient
•Between the initial and review consultation, the observing examiner will provide you with
information about what has happened and the results of any investigations ordered
•In the second (review) consultation follow up the initial consultation, including discussing the
results of any investigations and management with the patient
•Discuss these issues with the patient and help them to explore the available options
Scenario
Jolene Kertich, aged 32 years, is seven weeks pregnant with her first child. You saw her last week
and all initial pregnancy related investigations were normal. Jolene is going to have midwife-led
care at the local public hospital, but they will not see her until she is 13 weeks pregnant. At the
appointment last week you ran out of time to discuss Down syndrome screening options. Jolene
presents today to discuss this.
A copy of the patient record summary sheet is attached.
Patient record summary
Name
DOB (age)
Allergies
Social history
Indigenous status
Occupation
Family history
Jolene Kertich
32 years
Nil known
Married to Reuben
Aboriginal origin
Accountant
Parents both alive and well
Current medications
Grandparents – both died from diabetes or heart disease
Pregnancy multivitamin containing folate and iodine
Immunisations
Salbutamol inhaler as needed
Influenza vaccine – 3 months ago
Routine childhood vaccinations
Past medical history
Drug and alcohol
MMR (measles/mumps/rubella) – 2 years ago
Asthma – currently mild intermittent, no admissions, had preventer until
about 3 years ago
Miscarriage – aged 31
Nil currently
When not pregnant, wine 1–2 glasses on 1–2 days/week
Never smoked
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GPRA practice case scenarios – Jolene Kertich
Section B. Information for the patient role-player/examiner
Background information for the role-player
First consultation
The following information is to be freely given:
• As discussed last week you are back to talk about Down syndrome screening
• Yes, everything else pregnancy related is still good and you have the appointment with the midwife
at about 13 weeks gestation
• The only thing that has been an issue this week is your asthma. You have been using your
salbumatol puffer most days. Is it okay to use it this much, or is it harmful?
Information only to be given with appropriate enquiry from the candidate:
Down syndrome screening related
• No one in your family or your husband’s family has Down syndrome or any genetic conditions that
you know of
• You know what Down syndrome is, your neighbours have a teenager who has Down syndrome
• You are confused about all the tests available: some friends have had blood tests, ultrasounds, a
really expensive blood test and others have had a ‘needle that gets near the baby’ to check. You
would like the doctor to explain these tests
• If needed, you will try to clarify what a test involves (prompt the candidate to explain tests) – does it
tell you if the baby has Down syndrome, what does it involve, are there any risks, does it cost much?
• You think you are interested in having some screening done
• You and your husband have talked about Down syndrome, and have decided that you want to know
if it is likely. You have both also commented that you would need to think hard about continuing with
the pregnancy if it is likely the baby has Down syndrome. You are not sure how to proceed if this is
the case
• You are open to having whatever procedure suits you best.
At the end of the first consult, you decide to have combined first trimester screening (blood test and
ultrasound).
Asthma related
• Mild asthma since childhood, usually worse this time of year or if you have a cold
• You have used a preventer on and off since childhood, but have not used it for the past 2–3 years
• The last couple of months you have been using your salbumatol inhaler more often – probably 2–3
times a week and last week, every day
• You have been coughing at night
• You want to check if using your inhaler is okay now that you are pregnant (prompt the candidate if
this has not been covered)
• You know how to use a salbumatol inhaler and when at home, you use a spacer
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GPRA practice case scenarios – Jolene Kertich
• Last time you were needing the salbumatol inhaler this much, you also needed a preventer
• Never been in hospital due to asthma
• Never been a smoker. Not exposed to smoke at home
• If a preventer is suggested, ask about pregnancy safety because you know you should check before
taking any medicines or over-the-counter medications when pregnant.
Second consultation
Down syndrome and pregnancy testing related
• Allow the candidate to explain the result
• If not explicit from the explanation, ask: “Does this mean the baby has Down syndrome?”
• Ask what are the options at this point
• Listen to these options and clarify as needed
• You are an accountant, so if numbers or probability or risk issues are explained to you clearly, you
will understand
• If the candidate says they will refer you to someone else (and if time allows), ask what the referral will
be for and what the person they are referring you to will offer them or be able to do for them. Ask
what they can tell you so you can be more prepared for this referral
• If given the choice, you would like to discuss what you have learned with your husband and come
back tomorrow.
Asthma related
• If prescribed a preventer in the initial consultation, yes, no more night symptoms and only using
salbutamol inhaler 1–2 times a week now
• If not prescribed a preventer in the initial consultation, still the same as before. You are wondering if it
is safe for the asthma to be playing up when you are pregnant.
Notes to examiners
Additional and specific patient concerns or specific patient inquiries may be used where candidates
require assistance.
Observing examiner
• If at 8–9 minutes into the station and not already requested, prompt the candidate to ask if there are
any physical exam findings they would like to have and provide whatever is requested
• If the consultation is at 11 minutes and there are no signs of the initial consultation ending, prompt
the candidate by stating: “You should consider ending this consultation in the next minute or two so
you can do the review consultation”
• Between the two consultations, the observing examiner can say: “Jolene had first trimester
combined screening – here is the result (and hand over the result). Begin the second consultation
when you are ready.”
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GPRA practice case scenarios – Jolene Kertich
Additional history
Past medical history
As above
Family history
No known genetic abnormalities in family
Cigarettes
As above
Alcohol
As above
Other drugs
Nil
Medications
As above
Allergies
As above
Immunisations
As above
Nutrition
Good diet – last week discussed
listeria, eats red meat, limited seafood –
understands eating requirements during
pregnancy
Systems review
Respiratory
Coughing at night, which she assumes is
the asthma
Occasional wheeze she can hear
Good response to salbutamol – needs it
most days
Gynaecological
Pregnancy going well – some morning
sickness, but this is not a problem
Other
Appetite okay
No change in weight
Sleep – slightly disrupted by the coughing
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GPRA practice case scenarios – Jolene Kertich
Physical examination
Candidates are to ask for specific examination findings.
All other physical findings are normal.
General appearance
Well looking, talking in sentences
BMI 22 kg/m2
Temp 36.5°C
BP 110/70 mmHg
Pulse 68 bpm
Cardiovascular
Normal
Respiratory
Trachea midline, lungs good air entry with no wheeze
(last had salbutamol two hours ago)
Ear, nose and throat
Normal
Respiratory rate 12 breaths/min
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GPRA practice case scenarios – Jolene Kertich
Investigations
First consultation
Nil relevant, apart from saying all initial pregnancy blood and urine tests are normal.
Second consultation
These results are available on a separate sheet that is to be handed to candidates prior to the second
consultation.
All other investigations are normal.
Surgery test results
PEFR
Unavailable
Investigation results
Investigation results are available at the second consultation.
Pathology
First trimester screening blood tests taken
Imaging
First trimester ultrasound – no abnormalities, consistent with
dates, information forwarded for first trimester combined
trisomy screening result
First trimester combined
screening – final result
Blood test and ultrasound – trisomy 21 result
The age related risk for this patient is 1 in 700
Based on the ultrasound and blood test for this patient the risk
of trisomy 21 is one in 180. This is an increased risk result
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GPRA practice case scenarios – Jolene Kertich
Section C. Information for examiners
Listed below are the key issues to be covered in this case. (The examiner can ‘tick’ these as covered
during the consult.)
Diagnosis
• Down syndrome testing options in pregnancy – exploration and management of result
• Asthma – poorly controlled in pregnancy, with indications for a preventer to be started.
Appropriate management and explanation
There are two distinct issues that need to be managed over these two consultations.
• Down syndrome (trisomy 21) testing in pregnancy
–– counselling of initial testing options, including whether screening or diagnostic, risks involved,
timing, some indication of costs
–– counselling after an increased risk result, including what options there are for further testing
–– the approach of the doctor to provide information to the patient, must demonstrate that there are
a range of options that a patient may prefer in the situation
• Asthma
–– poorly controlled with indication to increase treatment by the addition of a preventer
–– demonstrate an understanding that poorly controlled asthma is a greater risk to the mother
and foetus than any medications. Be able to reassure a pregnant woman with asthma of such.
Salbutamol is a category A drug and budesonide is also category A. In general, if a woman
has asthma and should be on a preventer for it, that should occur regardless of whether she is
pregnant
• Examiners will also be assessing the candidate’s communication with the patient as there is the
need for communication of complex information and supporting a patient in their decision making.
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GPRA practice case scenarios – Jolene Kertich
References and study notes
Australian Asthma Handbook. Available at asthmahandbook.org.au/ and pregnancy specific patient
information. Available at asthmaaustralia.org.au/uploadedFiles/Content/About_Asthma_2/Resources/
AA-Asthma-and-Pregnancy.pdf
Genetics in Family Medicine. Available at nhmrc.gov.au/health-topics/genetics-and-human-health/
health-practitioners/genetics-family-medicine-australian-han
RACGP resources for antenatal care/testing:
• Non-invasive prenatal testing: racgp.org.au/afp/2014/july/noninvasive-prenatal-testing/
• Genetic counselling and testing: racgp.org.au/your-practice/guidelines/redbook/genetic-counsellingand-testing/
• Specific antenatal care resources for the Indigenous health setting: racgp.org.au/your-practice/
guidelines/national-guide/antenatal-care/
RACGP resources for asthma:
• Asthma control in general practice: racgp.org.au/afp/2013/october/asthma-control/
Specific resources for the Indigenous health setting:
• National guide to a preventive health assessment for Aboriginal and Torres Strait people.
Asthma: racgp.org.au/your-practice/guidelines/national-guide/respiratory-health/asthma/
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General Practice Registrars Australia Ltd
Level 1, 517 Flinders Lane
Melbourne Victoria 3001
gpra.org.au
[email protected]
GPRA
practice case
scenarios
Victor Trantor
58 years of age
Copyright 2015 GPRA
GPRA practice case scenarios
Disclaimer
All efforts have been made to ensure that the material presented in
this resource was correct at the time of publication and published in
good faith. GPRA does not accept liability for the use of information
within this publication.
General Practice Registrars Australia Ltd
Level 1, 517 Flinders Lane
Melbourne Victoria 3001
ABN 60 108 076 704
© 2015 GPRA. All rights reserved. Except as expressly provided in
the Copyright Act, no part of this publication may be reproduced,
distributed, stored in any retrieval system or transmitted by any
means (including electronic, mechanical, micropying, photocopying,
recording or otherwise) without prior written permission from the
publisher, General Practice Registrars Australia Ltd (GPRA).
This resource is for personal use only.
GPRA practice case scenarios – Victor Trantor
Section A. Information for candidates
Instructions
•This is an eight minute station
•Read the following scenario
•If investigations are requested, this consultation may be conducted as if it were more than one
session
•Take a focused history from the patient
•When you are ready, request the details of an appropriate physical examination and the results
of appropriate surgery tests from the observing examiner
•Outline your diagnostic impressions to the patient and advise on the need for further
investigations if any
•Request the results of any investigations from the observing examiner
•Outline your conclusions and proposed management plan to the patient
Scenario
Victor Trantor, aged 58 years, is a patient you see about once a year. You last saw him three
months ago for a check-up. At this consult his overall cardiovascular risk was assessed as low
and his fasting glucose, renal function and liver function tests were normal. You do not know why
he is here today.
A copy of the patient record summary sheet is attached.
Patient record summary
Name
DOB (age)
Allergies
Social history
Victor Trantor
58 years
Nil known
Lives with wife
Indigenous status
Occupation
Family history
Current medications
Immunisations
Past medical history
Drug and alcohol
Three adult children
Unknown
Teacher
Adopted – unknown
Nil
Nil on record
Tonsillectomy aged 7 years
Never smoked
Alcohol: two drinks once weekly
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GPRA practice case scenarios – Victor Trantor
Section B. Information for the patient role-player/examiner
Background information for the role-player
The following information is to be freely given:
• You have come in today because of the “waterworks”.
Information only to be given with appropriate enquiry from the candidate:
• You have had to get up once at night to pass urine, but over the past year or so this has become
2–3 times a night. Things have just slowly been getting worse, not a sudden change
• It takes a while to get going and then the stream is nothing like it was and then a ‘bit dribbly’ at the
end
• Not painful, no burning, no discharge, no blood, bowels okay, no sexual problems (only partner has
ever been his wife)
• No incontinence. Passes urine approximately every three hours
• It is a bit annoying, but not something that is too much trouble
• You did not mention it last time, as it did not come to mind when you were with the doctor. You
came in today because when you were away on holiday you realised you were going more and
thought you should get it checked out – no specific concerns
• If directly asked, you are here today to make sure you are not being neglectful about “something
bad”. If there are things that may help you with these symptoms, you are interested in hearing about
them, but you are not sure that you would want them
• If asked, you are not worried about prostate cancer. You assume this is age related.
Notes to examiners
Additional and specific patient concerns or specific patient inquiries may be used where candidates
require assistance.
Suggested cues/prompts:
• During the management phase, the role-playing patient can ask the candidate: “What do you think
the problem is?”
• If the candidate only suggests referral or one option for management, the role-playing patient can
ask about other options, or whether they must do something, to encourage the candidate to provide
a range of options. You are happy to hear the big picture options, you do not need to know all the
details about everything in order to make a decision
• If the candidate has discussed a range of options that includes behavioural modifications and a wait
and see approach, you can indicate that these are your preference at this particular time.
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GPRA practice case scenarios – Victor Trantor
Additional history
Past medical history
Check-up three months ago – no issues
Tonsillectomy aged seven years
Family history
Unknown (adopted)
Cigarettes
Nil
Alcohol
Two drinks weekly
Other drugs
Nil
Medications
Nil
Allergies
Nil
Immunisations
Nil on record
Nutrition
Well-balanced diet
Systems review
Cardiovascular
No chest pain, no swelling of ankles,
sleeps on one pillow
Endocrine
Urination no bigger volumes, not thirsty
Respiratory
No snoring
Gastrointestinal
Bowels normal
Genitourinary
As previous history
Neurological
Legs normal
Psychological
No abnormality
Other
No weight loss
Energy reasonable given interrupted sleep
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GPRA practice case scenarios – Victor Trantor
Physical examination
Candidates are to ask for specific examination findings.
All other physical findings are normal.
General appearance
Looks well
Weight 74 kg
Height 178 cm
BMI 23 kg/m2
BP 128/78 mmHg
Pulse 68 bpm
Respiratory rate 12 breaths/min
Abdomen/per rectal
Soft abdomen, no tenderness or masses
Temp 36.5°C
Bladder not enlarged
Bowel sounds normal
Penis normal
Per rectal: empty rectum, prostate enlarged, symmetrical
prostate with no nodules
Nervous system
Lower limb neurological exam normal
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GPRA practice case scenarios – Victor Trantor
Investigations
These results are available on a separate sheet that is to be handed to candidates when they ask for
any investigations.
All other investigations are normal.
Candidates are to ask for specific investigations.
Surgery test results
Urinalysis
No abnormality
Random blood glucose
4.3 mmol/L
If the candidate asks for an American Urological Association score or International Prostate Symptom
Score – provide: IPSS score of 8 (moderately symptomatic) with bother score of 2 (mostly satisfied).
Investigation results
Pathology
Electrolytes (including calcium): normal
with eGFR 85 mL/min/1.73 m2
Prostate specific antigen: 2.8 ng/mL
Mid stream urine microscopy culture and
sensitivity: no abnormality
Imaging
Renal ultrasound: normal anatomy, with
residual volume 20 mL post-void
Other
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GPRA practice case scenarios – Victor Trantor
Section C. Information for examiners
Listed below are the key issues to be covered in this case.
Diagnosis
Most likely diagnosis: Benign prostatic hypertrophy (also known as benign prostatic enlargement or
benign prostatic hyperplasia).
Appropriate management and explanation
Management should include:
• Explain the condition (which may include clarifying that it is not prostate cancer)
• Explore the impact of the symptoms on the patient
• Explain the range of options for management:
–– watchful waiting – monitor symptoms
–– behavioural modification – limit caffeine, alcohol and fluid intake in the evening to minimise nocturia
–– mention that there are a range of medication options:
–– alpha blockers (and selective versions) – help symptoms on voiding
–– antimuscarinic drugs – help storage symptoms such as nocturia
–– 5-alpha reductase inhibitors – helps obstructive symptoms and reduce prostate size
–– combination medication with 5-alpha reductase inhibitors with alpha 1A selective blocker – more
effective
• Mention that there are a range of surgical options
• Share decision with the patient about which option to pursue at this particular time
• Arrange follow-up as appropriate, depending on decision about management.
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GPRA practice case scenarios – Victor Trantor
References and study notes
Andrology Australia. Clinical summary guide – prostate disease. 2012. Available at andrologyaustralia.
org/wp-content/uploads/clinical-summary-guide-07.pdf
Arianayagam M, Arianayagam R, Rashid P. Lower urinary tract symptoms: current management
in older men. Australian Family Physician 2011;40:758–767. Available at racgp.org.au/download/
documents/AFP/2011/October/201110arianayagam.pdf
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General Practice Registrars Australia Ltd
Level 1, 517 Flinders Lane
Melbourne Victoria 3001
gpra.org.au
[email protected]