case study provided

Question 1

What are the aims of a GP consultation according to the Calgary Cambridge model

Answer 1

Initiating the Session
Gathering Information
Providing Structure
Building Relationship
Explanation and Planning
Closing the Session

Question 2

As part of your awareness of your learning opportunities, are there any issues in having done the majority of undergraduate training in hospital specialties when considering, for example, a child presenting with abdominal pain?

Answer 2

he hospital is the tip of the iceberg of care. You will see a narrow spectrum of presentations in hospital and may gain a distorted view of the presentation of illness.

Question 3

You did not find anything on brief examination and picked up on some verbal and body language cues from Lisa. In only 10 minutes you focused the consultation from a presentation of abdominal pain to one Lisa’s new pregnancy and associated concerns.

What form of problem solving does a GP use to rapidly narrow down the list of likely diagnoses?

Answer 3

Hypothetico-deductive reasoning

Question 4

Neighbour suggests Safety Netting in a consultation to minimise risk. Could you give three example of that?

Answer 4

They must know what to look out for and be told how exactly to seek help for given outcomes or clinical features.

It may be important to arrange follow-up face to face or by phone. They should know exactly how to seek help if needed.

They should know what to expect about time course. Where information about the likely time course of illness is known, safety-net advice should include this information. However, it should be made clear that if a patient (parent/carer) has concerns they should not delay seeking further medical advice.

Question 5

Lisa’s GP performs a 2nd pregnancy test which is also positive. She wonders whether she will keep the baby or not. List two ETHICAL, two PSYCHOLOGICAL and two SOCIAL issues that Lisa may be considering?

Answer 5

Ethical

Beliefs regarding termination
Any religious beliefs
Thoughts regarding bringing a child into the world that you do not feel able to care for
Psychological

Anxiety about being a parent
Anxiety about going through with a termination
Stress/anxiety about level of support she may have from family and friends
Social

Support network - does Lisa feel her friends would be supportive
Her social life will dramatically change after having a baby
Ability to find a job/work will be affected in the short or longer term
Following discussion with her GP and close family and friends, Lisa decides to keep the baby.

Question 6

Lisa knows that she doesn’t have the healthiest lifestyle and until now has not felt much need for change. What factors might increase the chance of someone changing their behaviour? (Give five factors)

Answer 6

You think the advantages of change outweigh the disadvantages
You anticipate a positive response from others to your behaviour change
There is social pressure for you to change
You perceive the new behaviour to be consistent with your self-image
You believe you are able to carry out the new behaviour in a range of circumstances

Question 7

Using Smoking or Alcohol as an example, how might these apply to Lisa’s current situation? (Give five factors)

Answer 7

The advantages of not drinking/smoking (healthy baby) outweigh the disadvantages
You anticipate a positive response from others to your behaviour change (e.g. your partner also wants the unborn child to be healthy)
There is social pressure for you to change (very socially unacceptable to drink/smoke when obviously pregnant!)
You perceive the new behaviour to be consistent with your self-image (a good mother)
You believe you are able to carry out the new behaviour in a range of circumstances (at home, celebrations, etc.)

Question 8

Lisa attends her GP to discuss actions she might take to keep her unborn baby healthy. Other than Smoking or Alcohol, what other factors affecting foetal wellbeing might her GP discuss with her? (Give five factors)

Answer 8

Illicit Drugs
Prescription drugs
OTC medication, Internet Remedies, Herbal Medication
X-Rays
Dietary Factors - Lack of Folic Acid, soft cheese, pate
Infectious Diseases e.g. TORCH (Toxoplasma, Rubella, Cytomegalovirus, Herpes)

Question 9

What kinds of actions might a government take to promote health in the population as a whole? (List five actions)

Answer 9

Legislation/policies on smoking/alcohol (e.g. minimum age to buy products, licensing laws, taxation)
Improvements in housing
Provision of health education
Health and safety laws
Traffic/transport legislation/policies

Question 10

A few weeks later, Lisa tells the GP that her partner Martin has left her, but he still turns up at her house late at night at the weekend after drinking with his friends. He is usually drunk, often upset and occasionally angry.

Are there any issues that the GP would note here? Which other health professional might the GP liaise with to get a better picture of the home situation? (Name one issue and one Health Professional)

Answer 10

Potential for gender based violence (domestic abuse)
Might be Child Protection issues at a later date?
The Health Visitor (regular contact with families of pre-school children)

Question 11

Despite the issues raised above, Lisa considers herself to be quite healthy and normal. What is the World Health Organisation (WHO) definition of Health?

Answer 11

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.

Question 12

According to this definition why might Lisa feel she is healthy? (List five reasons)

Answer 12

She has no illness / long term condition (chronic disease)
She exercises regularly
She is on no regular medication
She manages to work, socialise
'Healthy diet'
She managed to become pregnant

Question 13

Why might she feel that smoking is normal behaviour? (Give two reasons)

Answer 13

Might be normal for her peer or social group, but would be abnormal perhaps for the wider population.

Might watch TV programmes where smoking is normal behaviour.

Question 14

Lisa’s Mum Jill has arthritis. Her consultant is considering treating her with a new drug currently undergoing trials called CRX128, which is very expensive and only recently developed. It is not widely available for NHS use. He is considering using it for Jill as his early results have been promising.

What ethical principles would he have to consider and how would they apply to Jill’s case. (List four ethical principles and reasons)

Answer 14

Autonomy - Jill should be provided with all the facts about the treatment/trial and be able to decide if she wishes treated.
Justice - Jill should have treatment available to her as it would be available to others.
Beneficence - The medication might help.
Non-Maleficence - The medicine might harm in other ways.

Question 15

Jill’s arthritis has prevented her from working. She feels that she is unhealthy as a consequence of not being able to function and do what she could previously do. Functional ability is a lay view of health.

What other characteristics would lead a lay person to believe they are healthy? (Give two characteristics)

Answer 15

Absence of Disease

Physical Fitness

Question 16

Once Kayleigh is six months old, Lisa manages to obtain a part time job in a local hairdressers shop. She helps to set up the dyes and hair treatments. After a few weeks working there she notices a rash on her hands and attends her GP to ask her opinion.

The treatments she is in contact with could be defined as a chemical hazard.

Define Hazard and Risk.

Answer 16

Hazard: something with potential to cause harm

Risk: the likelihood of harm occurring

Question 17

What other kinds of Hazards are there? (List four hazards)

Answer 17

Physical
Mechanical
Biological
Psychosocial

Question 18

What questions might help the GP decide if the rash is linked to her occupation? (List three questions)

Answer 18

Does it happen at work?
Does it happen during holidays?
Did it ever occur before she started working there?
Is anyone else at work similarly affected?

Question 19

Lisa finds bringing up Baby Kayleigh increasingly difficult. She has little money and finds it difficult to organise childcare for Kayleigh when she is working. She suffers from stress.

What coping mechanisms might she employ to help her deal with stress? (List two coping mechanisms)

Answer 19

Problem focused e.g. enlist help of family and friends to help with Kayleigh’s care.
Emotion focused e.g. seek counselling/stress management (positive response), alcohol or drug misuse (negative response).
Combined problem and emotion focused.

Question 20

You allow time and ask some open ended questions. This allows Lisa to talk and she eventually discloses that she is worried that she might be pregnant. She has been having unprotected intercourse with her boyfriend Martin. She has had a positive pregnancy test but doesn’t yet know if she wishes to continue the pregnancy. She is also worried you will tell her Mum Jill.

You are also Jill’s GP and see her quite regularly. In fact she has an appointment with you booked for later in the week.

Can you disclose Lisa’s pregnancy to her mother?

What oath guides you about this?

Answer 20

no

hipoocratic oath

Question 21

You take a history and examine Lisa. You do not find anything on examination, but you feel that you are not getting the whole story from Lisa. What kind of questions might you use to elicit more information?

Answer 21

Open-ended question
Direct question
Closed question
Leading question
Reflected question

Question 22

Different factors can affect the consultation. One such factor may be Personal Factors. Can you think of another factor and give four examples of it?

Answer 22

Physical Factors

Site and environment
Adequacy of medical records
Time constraints
Patient status

Question 23

Lisa has been having some “stomach aches”. Jill advises her to go and see her GP. What three broad types of skill might you, as the GP, use during the consultation?

Answer 23

Content skills

Perceptual skills

Process skills