Cases and Concepts for the new MRCGP 2e
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About this ebook
This new edition of Cases and Concepts for the new MRCGP, now featuring over 200 “test yourself ” questions, is the ideal revision guide to use alongside the practical book Consultation Skills for the new MRCGP, second edition.
Featuring:
- for CSA, 42 typical exam cases with explanatory notes to help improve the assessment, management and interpersonal skills required for effective consulting
- for CbD, the models and concepts needed to demonstrate a thorough understanding of person-centred care, ethical issues, and professional codes of conduct
- new for the 2nd edition – over 200 questions, with explanatory answers, to test your theoretical knowledge.
This book is essential reading for all those preparing for the new MRCGP.
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Reviews for Cases and Concepts for the new MRCGP 2e
3 ratings2 reviews
- Rating: 3 out of 5 stars3/5pros: What to ask in presented cases and clinical management based on NICE.
Contras: Useless information reg CBD, and many other redundant info, those GP trainees who are using this book know already these info as such take all redundant pages and info the book will be half of what it is. - Rating: 5 out of 5 stars5/5GREAT BOOK FOR mrcgp.
Book preview
Cases and Concepts for the new MRCGP 2e - Prashini Naidoo
Cases and Concepts
for the new MRCGP
2nd Edition
Cases and Concepts
for the new MRCGP
2nd Edition
Clinical Skills Assessment
and Case-based Discussion
P. Naidoo
MBChB, MRCGP, DRCOG, DFFP, Dip Occ Med, MSc
GP in Oxfordshire
Includes contributions from
C. Monkley
MBBS, DRCOG, MSc (Sports Medicine), MRCGP, FFSEM (UK)
GP in the Defence Medical Services - for the CSA cases
A. Davy
MBBS, BSc, MRCGP, DRCOG
GP in the Defence Medical Services - for the CbD cases
Scion LogoSecond edition © Scion Publishing Ltd, 2009
First edition published 2008 (ISBN 978 1 904842 53 8); reprinted twice
All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission.
A CIP catalogue record for this book is available from the British Library.
ISBN 978 1 907904 15 8
Scion Publishing Limited
Bloxham Mill, Barford Road, Bloxham, Oxfordshire OX15 4FF
www.scionpublishing.com
Important Note from the Publisher
The information contained within this book was obtained by Scion Publishing Limited from sources believed by us to be reliable. However, while every effort has been made to ensure its accuracy, no responsibility for loss or injury 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.
The reader should remember that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications and practices are based on current indications, there may be specific practices which differ between communities. 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 practising.
Typeset by Phoenix Photosetting, Chatham, Kent, UK
Printed by Biddles Ltd, King’s Lynn, Norfolk
Contents
Preface
Acknowledgments
Abbreviations
An introduction to clinical skills assessment (CSA)
Clinical Skills Assessment
Case 1 – Back pain
Case 2 – Injectable contraception
Case 3 – Blacked out
Case 4 – Menorrhagia
Case 5 – Knee injury
Case 6 – Pins and needles in hand
Case 7 – Smoking cessation
Case 8 – Termination of pregnancy
Case 9 – Sore throat
Case 10 – Struggling to cope with a baby
Case 11 – Painful shoulder
Case 12 – Forearm in plaster cast
Case 13 – Haematuria
Case 14 – Erectile dysfunction
Case 15 – Hypothyroidism
Case 16 – Hyperthyroidism
Case 17 – Hypertension
Case 18 – Grief
Case 19 – Obsessive compulsive disorder
Case 20 – Tinea pedis
Case 21 – Migraine
Case 22 – Non-accidental overdose
Case 23 – Hernia
Case 24 – Osteoarthritis
Case 25 – Request for cosmetic surgery
Case 26 – Insomnia
Case 27 – Emergency contraception
Case 28 – Bariatric surgery
Case 29 – Multiple sclerosis
Case 30 – Balance problems
Case 31 – Tonsillitis
Case 32 – Menstrual problems
Case 33 – Irregular heart beats
Case 34 – Psoriasis
Case 35 – Onychomycosis
Case 36 – Transient ischaemic attack
Case 37 – Newly diagnosed diabetes mellitus
Case 38 – Cognitive impairment
Case 39 – Gout
Case 40 – Renal colic
Case 41 – Neck of femur fracture
Case 42 – Drug use
Case-based Discussion
An introduction to case-based discussion (CbD)
14 year old requests contraception
Earache and antibiotics
Request for a sick note
Patient worries about chest pain
Patient declines smear test
Patient requests an advance directive
Withholding life prolonging treatment
Euthanasia
Teenagers and confidentiality
Breast cancer reported for Significant Event Analysis
Concepts
Consultation models
Clinical governance
Patient safety
Evidence-based medicine
Giving feedback
Reflective learning and mentoring
Managing change
Ethical frameworks
Professionalism
Answers to ‘Test your knowledge’ questions
PREFACE to second edition
The aim of this book is to help candidates prepare for the Clinical Skills Assessment (CSA) and Case-based Discussion (CbD) components of the new MRCGP exam by making explicit ‘what’ to do and ‘how’ to do it to achieve success.
‘What’ is needed in CSA and CbD is the ability to:
gather and assess medical information
make structured, evidence-based and flexible decisions
communicate with patients in a way that moves the consultation forward in an ethical and responsible manner
‘How’ this is demonstrated to examiners is by:
asking the right questions, at the right time, in the right way
performing the right examination correctly
communicating the right things in the right way to patients and colleagues
This book tries to teach candidates how to demonstrate their competence in an exam by showing them how two general practitioners approached the presentations of their patients:
the questions they asked to get to the crux of the problem
the examinations they chose to conduct
the decisions they made
how they communicated with their patients
By breaking down each case in this way, this book provides a structured approach for candidates to aid them in their exam preparation.
Unlike its companion guide, ‘Consultation Skills for the new MRCGP’ , which primarily focuses on teaching consulting skills, our primary aim in this book is to mentally model for candidates an ordered, step-wise approach to data gathering, analysis, management and communication. In some cases, additional medical information is provided to clarify the management decisions. While the book does not aim to be completely comprehensive in its coverage of medicine or examination techniques, this second edition does include over 200 questions and answers to help candidates revise the background factual information. Candidates are also signposted to useful, usually internet-based, sources of information for aiding their medical revision.
We hope that this book is useful to you in developing a step-wise approach to CSA and CbD.
Dr P Naidoo and Dr C Monkley
November, 2008
acknowledgments
I would like to thank Dr Clive Monkley for his contribution to the Clinical Skills Assessment cases, and Dr Andrew Davy for his contribution to the Case-based Discussion cases.
Thank you to Dr Sarah Butterfield and Dr Samantha Wild for their helpful comments and critiques.
Thank you to my good friend Dr Dougie Wyper, for improving my social life. Life would be a lot less interesting without you.
Finally, a reminder to my husband Anton – you owe me a farm in Africa, at the foot of the Drakensberg Mountains.
Dedication
This book is dedicated to my father for his love and encouragement – thank you dad.
Abbreviations
BDD body dysmorphic disorder
BMA British Medical Association
BMJ British Medical Journal
CAM complementary and alternative medicine
CBT cognitive behavioural therapy
CG clinical governance
CHD coronary heart disease
CHI Commission for Health Improvement
CHRE Council for Healthcare Regulatory Excellence
CME continuing medical education
CPD Continuing Professional Development
CPP Committee on Professional Performance
DENs doctors’ educational needs
DVLA Driver and Vehicle Licensing Agency
EC emergency contraception
EBM evidence-based medicine
GMC General Medical Council
GP general practitioner
GPwSI GP with special interests
GUM genito-urinary medicine
HFEA Human Fertilization and Embryology Authority
IUD intra-uterine device
IVF in vitro fertilization
JC journal club
LCR ligase chain reaction
LMP last menstrual period
MAAG Medical Audit Advisory Group
MCA Medical Council on Alcohol
MDU medical defence union
MI myocardial infarction
MS multiple sclerosis
MUS medically unexplained symptoms
NAPCE National Association of Primary Care Educators
NCAA National Clinical Assessment Authority
NEJM New England Journal of Medicine
NHS National Health Service
NICE National Institute of Clinical Excellence
NNT number needed to treat
NPSA National Patient Safety Agency
NRT nicotine replacement therapy
OCD obsessive compulsive disorder
OM otitis media
OPD outpatients department
PCC Professional Conduct Committee
PCOS polycystic ovary syndrome
PCR polymerase chain reaction
PCT primary care trust
PDP personal development plan
PHCT Primary Health Care Trust
PID pelvic inflammatory disease
PM practice manager
PTSD post-traumatic stress disorder
PUNs patients’ unmet needs
RA rheumatoid arthritis
RCGP Royal College of General Practitioners
RCPCH Royal College of Paediatrics and Child Health
RCT randomized controlled trial
SEA significant event audit
STD sexually transmitted disease
TIA transient ischaemic attack
TOP termination of pregnancy
UTI urinary tract infection
An introduction to clinical skills assessment (CSA)
This introductory chapter discusses:
the structure of CSA
the marking of CSA
assessment within the nMRCGP:
curricular objectives: six domains and three essential features
assessment within CSA:
blueprints for writing cases
blueprints for selecting cases
preparing for the CSA
how best to use this book to prepare
The structure of CSA
The CSA is one of the three components of the nMRCGP assessment. The other two components are the applied knowledge test (AKT), and workplace based assessment (WPBA). The Royal College of General Practitioners (RCGP) will make CSA available from October 2007. Thereafter, the assessment will be available during a 3 or 4 week period in sessions in February, May and October each year. It will take place in one location, initially in Croydon, and in later years in a purpose-built centre in London.
The CSA is not primarily a test of knowledge or examination techniques. It is an assessment of a doctor’s ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice, ‘to produce a consultation that is meaningful to both patient and doctor and which moves the patient forward towards a justifiable management of their presenting problem’ (Hawthorne, 2007 – on the RCGP website).
What happens on exam day
On the day of the examination, at the examination venue, each candidiate will be given a consulting room.
The candidate will be briefed to treat the examination session as if he were a locum doctor.
The candidate is to interact with the patient and not the examiner, who will remain a silent observer.
The candidate’s surgery has thirteen booked patients who enter his consulting room when the buzzer sounds.
At the end of ten minutes, the buzzer sounds to signal the departure of the patient.
There will be a two minute gap between consultations.
Twelve patients are true examination cases on which the candidate is assessed. One is a ‘trial station’ in which new clinical scenarios are trialled. The candidiate will not know which is the trial case.
There will be a short break in the middle of surgery.
The marking of CSA
The patients, played by trained actors, will move from room to room, together with the examiner for that case. The examiners are all general practitioners who are selected and trained in assessment by the RCGP. Each examiner will mark the same case all day, thus providing standardized marking. Each case is marked in three domains, all have equal weighting:
data gathering, examination and clinical assessment skills
clinical management skills
interpersonal skills
The performance will be graded as Clear Pass, Marginal Pass, Marginal Fail or Clear Fail. The candidate is then given an overall grade.
In assessment speak, the four grades, from Clear Pass to Clear Fail, are called grid descriptors – they describe the standards, knowledge and skills found at each grade. The pass mark is set as the standard required to practice independently as a licensed GP. The marking sheet contains positive indicators and negative indicators of practice, which inform the examiner’s global judgement of the candidate’s performance.
The examiner does not tick boxes, as in the old MRCGP video marking sheet, and the pass is not determined by number of ticks the candidate scores in each case. This is what makes CSA a competency-based assessment – the candidate passes if he meets the criteria for competence, to the standard required to practice independently as a licensed GP. This is not a norm-referenced assessment in which a pre-determined number of the highest ranking candidates pass. Theoretically, if all the candidates meet the marking criteria to the pre-set standard required for passing, then all of them should pass.
Therefore, to prepare for CSA, it is useful to understand what is being assessed by the nMRCGP, and by the CSA in particular.
Assessment within the nMRCGP
Assessment is about making a judgement as to whether trainees have fulfilled the training objectives. The assessor should be able to say, ‘By the end of this training, the trainee should be able to…’.
To make this judgement, the assessor needs to measure the trainee’s progress against defined criteria.
Therefore, to understand assessment within the nMRCGP, we need to be familiar with its ‘training objectives’, and to understand the ‘criteria against which trainees are measured’.
The nMRCGP objectives
The nMRCGP objectives are described within the curriculum for speciality training for general practice. By the end of speciality training for general practice, trainees should have:
‘the wide-ranging knowledge, clinical skills and communication skills required by doctors who will specialise in general practice, to ensure the delivery of high quality standards of patient care in the NHS’ (RCGP, 2007).
Exactly what constitutes the knowledge, clinical skills and communication skills is described further in the GP curriculum, a rather large body of work. A summary of the GP curriculum is available as a core statement, within which six domains of core competencies and three essential features of patient-centred care are described. These constitute ‘criteria against which trainees are measured’.
The six domains (D1 – D6) and three essential features (EF1 – EF3)
D1. Primary care management – is about having the ability to recognize and manage common medical conditions in primary care. Trainees demonstrate the ability to deal with multiple complaints and co-morbidity.
D2. Person centred care – is about appreciating the patient as a unique person in a unique context, taking into account patient preferences and expectations at every step in the consultation. Trainees demonstrate the use of recognized communication techniques to gain understanding of the patient’s illness experience and develop a shared approach to managing problems.
D3. Specific problem solving skills – is about adopting a problem-based approach to practice in which uncertainty may have to be tolerated; time used as part of the diagnostic process; and incremental investigation undertaken. Trainees demonstrate proficiency in performing physical examination, and in using diagnostic and therapeutic instruments. The consultation itself is used as a diagnostic or therapeutic instrument; for example, the patient’s health beliefs are explored and later incorporated into the doctor’s explanation.
D4. A comprehensive approach – is about addressing multiple complaints and co-morbidity; using an evidence-based approach; and minimising the impact of the patient’s symptoms on his wellbeing by taking into account his personality, family, daily life, economic circumstances, and physical and social surroundings. Trainees demonstrate the ability to promote self-care and empower patients.
D5. Community orientation – is about understanding the potentials and limitations of the communities in which doctors’ work. Trainees demonstrate an ethical approach to rationing and a responsible approach to influencing health policy.
D6. A holistic approach – is about integrating the physical, psychological and social components of health problems in making diagnoses and planning management. Trainees demonstrate an understanding of the bio-psycho-social elements of illness and a willingness to use a wide range of interventions.
EF1. Contextual aspects – is about understanding the doctor’s context, the environment (community, culture, environment and regulatory frameworks) within which he works. Trainees demonstrate an understanding of the impact care given to an individual patient has on the practice’s resources (staff, equipment) and acts within financial and legal frameworks.
EF2. Attitudinal aspects – is about the doctor’s capabilities, values, feelings and ethics. Trainees demonstrate ethical practice with respect for equality and diversity issues and in line with the accepted codes of professional conduct.
EF3. Scientific aspects – is about adopting an evidence-based and critical approach to practice to continually improve quality. Trainees demonstrate familiarity with the concepts of scientific research, statistics, and critical appraisal, and apply their learning to improve the quality of their practice.
Assessment within CSA
The objective of the nMRCGP is to develop practitioners with wide-ranging knowledge, clinical skills and communication skills which, in assessment speak, are called the intended learning outcomes. The intended learning outcomes form the blueprint of the CSA. The RCGP published the blueprint for the CSA on its website. The table below is adapted from the RCGP web publication and shows the clinical, professional, communication and/or practical skills required of each criterion (A –F).
Each CSA case must be constructed to test criteria A to F. How is this done? Marks are awarded for:
Efficient and targeted data gathering – the ability to take a targeted history and perform a focussed physical examination. Candidates are expected to be knowledgeable and skillful in their examination techniques and in the appropriate use of medical instruments. Marks are awarded for the fluency with which procedures are performed.
Formulating clinical management in line with current accepted British general practice.
Interpersonal skills – the candidate shows an ability to engage patients in the consultation, using recognized interpersonal skills, such as enquiring about the patient’s health beliefs and incorporating these into the explanation given to the patient. Some cases also assess the candidate’s ability to value patients’ contributions, and to respect their autonomy and decision-making.
The overall mark given to the case will depend on the candidate’s ability to combine the two areas of clinical consulting with interpersonal skills.
In very simple terms, data gathering is about how you get to the ‘nub’ of the presenting problem; clinical management is about what you do to move the problem forward; and interpersonal skills is about how you go about doing it.
Each case is written to focus on a particular ‘nub’. The marking schedule, using positive and negative indicators, reflects this nub. For example, Case 30 in this book is written about a patient with multiple sclerosis who presents with balance problems. You may want to read this case before proceeding. The marking schedule is provided below:
Assessors also want to assess breadth of knowledge – they want cases to sample patients of different ages, and diseases of various systems. Hence, a case selection blueprint (see table below) is used so that the twelve examination cases in each CSA diet are sampled from across the grid.
CSA case selection blueprint.Preparing for CSA
Do the job
The CSA cases are all written by GPs active in the UK NHS and reflect real-life presentations. Therefore, candidates with some experience in NHS general practice should not have difficulty with the exam. The RCGP recommends that candidates first complete at least 6 months of UK NHS general practice before sitting the exam.
Read the website
Candidates are advised to read the Curriculum Statements from the RCGP website. Each curriculum statement has a section on common and important conditions and cases are quite likely to be based on one of these.
Analyse your video consultations
Candidates are advised to video their own consultations, watch them with a colleague, and analyse them for the clinical approach and interpersonal skills displayed.
Practise clinical examinations
Candidates are advised to practise the focussed examinations that are most likely to be tested, such as assessment of a limb, chest or abdomen. Some examinations, such as intimate examinations on a role player, or examinations that might cause discomfort if repeated are less likely to be tested. Candidates are advised to be familiar and confident with medical equipment, such as otoscopes.
Interpret data
Candidates are advised to practise to become familiar with the letters GPs receive from secondary care, and test results such as ECGs, spirometry, blood tests, urinalysis, skin scrapings, and swabs. Candidates need to ensure that they can interpret results correctly and explain them to a patient.
The CSA cases in this book include cases that require candidates to practise physical examination and interpret test results.
How best to use this book to prepare
This book is divided into three parts:
the clinical skills assessment section
the case-based discussion section
the concepts section
The CSA section will pose a typical CSA scenario.
If further information, such as blood results or a hospital discharge summary, is needed for the consultation, this will be indicated as ‘see Appendix at the end of the case.’
Under targeted history taking , will provide a list of questions that could be asked to the patient to gather relevant data.
Under data gathering , provides the information elicited from the patient if the relevant questions are asked. Question one from the targeted history gets answer one under data gathering.
Under targeted examination , will provide a list of focussed examinations that could be performed to gather relevant data.
Under clinical management , suggests ways in which a mutually agreed plan can be negotiated with the patient to produce a consultation that moves the patient forward towards a justifiable management of their presenting problem.
Under interpersonal skills , provides positive indicators, or negative indicators, or both, of communication skills, ethical practice and/or professional conduct. Indicators of positive practice are provided most often, in line with current educational norms. Examples of negative indicators are provided only to illustrate the concept.
Under additional information , provides some additional, usually theoretical information candidates may find useful to reach a deeper understanding of the issues dealt with in the case.
The case usually concludes with signposting to the primary sources of information. The literature changes at a rapid pace, and web sources are usually a good source of updated information. Where possible, useful websites are listed.
The case-based discussion section is discussed in detail under the chapter An introduction to case-based discussion – see page 179.
The concepts section:
explores the background knowledge and skills that are required for the interpersonal skills section of CSA in greater detail. The Consultation models chapter is particularly useful.
discusses common themes that run through most questions within case-based discussions. The concepts chapters provide generic background information that could be useful when preparing for CbD.
Additional information
Grand’Maison P (1993) Canadian experience with structured clinical examinations . Canadian Medical Association Journal , 148 : 1573–1576.
This article describes the development and use of the structured clinical examination to assess medical students and graduates in Quebec over the past 25 years. Also described is the input from Canadian medical educators. The review of the Canadian experience discusses simulated-standardized patients, objective-structured clinical examinations and the use of such examinations for licensure and certification.
Malik S (2006) An OSCE actress . BMJ Career Focus , 332 : 110.
Ms Malik describes her experience as an OCSE actress, how she was briefed to play the case, and what examiners asked of her regarding the candidates. She also gives her tips on how candidates should prepare:
‘I would suggest that if you can sense the acting patient is not happy with the situation then you should ask: "Is there anything I’ve said that is confusing or not clear or that you want explained again?’ Another tip is to have a mental checklist of questions prepared and if you find yourself in an awkward situation, go back to where you left off in the list.’
Relevant literature
Simpson RG (2007) Preparing for practice: nMRCGP and the Clinical Skills Assessment . Update, 75 : 36–37.
Royal College of General Practitioners nMRCGP website – http://www.rcgp.org.uk/nmrcgp_/nmrcgp.aspx, particularly:
http://www.rcgp.org.uk/nmrcgp_/nmrcgp/csa/csa_cases.aspx?theme=print for a document on CSA prepared by Hawthorne (May 2007)
for the GP curriculum – the core statement: http://www.rcgp-curriculum.org.uk/PDF/curr_1_Curriculum_Statement_Being_a_GP.pdf
for in-depth reading of learning outcomes for general practice: http://www.rcgp.org.uk/pdf/curriculum_Guide_for_Learners_and_Teachers.pdf
Case 1 – Back pain
Miss AT is a 25 year old woman who presents asking for a letter saying she needs a new chair at work. She gives an eight month history of intermittent back pain, but it has been worse in the last two months. In the last week, the back pain has been worse as the day progresses. She also complains of ‘dead legs’ which feel heavy and weak.
Targeted history taking
What job does she do?
Where is the pain? Elicit intensity, radiation, aggravating and relieving factors.
Enquire about what she means by ‘heavy and weak’ legs, taking care to exclude nerve compression symptoms.
Exclude cauda equine symptoms: perineal paraesthesia, bladder and bowel dysfunction.
Does the pain disturb her sleep?
What activities does the pain inhibit or limit?
What treatments has she tried already?
What are her expectations of this consultation: a note for the company, physiotherapy, a discussion on analgesia?
What is her general health like – does she have asthma or indigestion?
Data gathering
Listed below is the additional information elicited from the patient with appropriate questioning.
Allison works in telesales.
Further questioning on ‘heavy and weak legs’ elicits a history of pain extending into the buttocks only, with no actual loss of power or altered sensation in the legs.
The history sounds like mechanical back pain and there are no features to suggest more serious pathology.
She is in good health, systemically well and sleep is undisturbed. She does not have morning stiffness.
She lives alone in a 2nd floor flat and has to walk up the stairs with her shopping.
She is active and does weekly tai chi.
She has had one previous episode of back pain three years ago after back-packing. This improved with yoga and Pilates.
She does not like tablets and prefers alternative medicines.
Targeted examination
Expose the back – there is no scoliosis or kyphosis of the spine.
She points to pain ‘like a band’ around her lower back.
Palpation of spinous processes and paravertebral muscles does not elicit any tenderness.
She is able to reach her lower shins but not her ankles. Extension and lateral flexion are not reduced. Watch her face during movements and when she moves about the room.
Straight leg raising and femoral stretch tests are normal.
Clinical management
Discuss the natural history and aetiology of mechanical back pain.
Reassure the patient that the pain usually improves within six weeks. Unless her symptoms deteriorate within six weeks, further investigation such as imaging is not required.
Address the patient’s ideas: she may believe that her back is aggravated or provoked by her chair. You may be able to link this to a discussion on posture, and advise her on good posture.
Encourage Miss AT to continue with tai chi provided it does not make her symptoms worse; encourage activity and avoid long periods of prolonged sitting at work.
Address the patient’s concerns and expectations: the issue here may not be the incorrect chair; it may be prolonged periods of sitting at work. Therefore, instead of a letter, perhaps she could consult her Occupational Health department or her Health and Safety officer to have a work-place assessment. A new chair may not be the whole answer – she made need reconfiguration of her workstation.
Discuss whether she is happy to continue with posture exercises or whether she would like analgesia or a referral to physiotherapy.
Interpersonal skills
Good communication with the patient explores:
her agenda (to improve her back pain)
health beliefs (chair, posture, tai chi, etc.)
preferences (natural remedies and advice of avoiding prolonged periods of sitting at work)
Therefore, it results in an agreed management plan.
Additional information
From: Koes BW , et al . (2006) Diagnosis and treatment of low back pain. BMJ , 332 : 1430–1434.
‘Red flags’
Onset age < 20 or > 55 years
Non-mechanical pain (unrelated to time or activity)
Thoracic pain
Previous history of carcinoma, steroids, HIV
Feeling unwell
Weight loss
Widespread neurological symptoms
Structural spinal deformity
Indicators for nerve root problems
Unilateral leg pain > low back pain
Radiates to foot or toes
Numbness and paraesthesia in same distribution
Straight leg raising test induces more leg pain
Localized neurology (limited to one nerve root)
Treatment
Reassure patients (favourable prognosis)
Advise patients to stay active
Prescribe medication if necessary (preferably at fixed time intervals):
paracetamol
non-steroidal anti-inflammatory drugs
consider muscle relaxants or opioids
Discourage bed rest
Consider spinal manipulation for pain relief
Do not advise back-specific exercises
Test your knowledge
Answer true (T) or false (F) for each of the following statements.
Back pain is the second commonest cause of long-term sickness absence
Straight leg raising (SLR) is a sensitive (0.88–1) and specific (0.84–0.95) test for diagnosing nerve root compression
Bilateral neurological symptoms and signs, saddle paraesthesia and urinary frequency are features of cauda equina syndrome
In L3/4 compression, the knee reflex may be impaired
In a patient >50 years, severe unremitting night pain which gets worse on standing is suggestive of cancer
Case 2 – Injectable contraception
Mrs HW is a 23 year old woman who presents saying that the practice nurse whom she saw yesterday advised her to see the doctor for her depo-provera to be prescribed. See Appendix for summary details.
Targeted history taking
Why has the nurse referred her?
Why is she late for her depo?
Is she happy on the depo or is she experiencing side effects?
What are her expectations of this consultation: for the depo to be given or for contraception options to be discussed?
Does she have risk factors for osteoporosis such as a past history of eating disorders (anorexia or bulimia), does she smoke, does she drink alcohol, does she have a family history of osteoporosis, does she have a balanced, calcium-rich diet and does she undertake regular weight-bearing exercise?
If she smokes, has she considered stopping?
What is her general health like – is she on medication, including over-the-counter medication such as St John’s Wort, which could interact with hormonal contraception?
What is her occupation and does it affect her choice of contraception?
Data gathering
Listed below is the additional information elicited from the patient with appropriate questioning:
The nurse said she was too late for her (the nurse) to give the depo. It needed to