Clinical Skills- Formative Assessment. Bridget McCarty. Tutor: Sharon Jones TASK ONE * D: So Stacey do you want to tell me why you came into the doctor today? P: Um, uh yesterday I sort of fell down my stairs, going to, going to work and I did something to my ankle, D: Mmhmm P: And it’s just it’s really really sore. Yeah. D: Cool, how did you fall down the stairs? I chose this segment because it is at the beginning of my consultation after initiating the session and it is very important.
I thought I started off well by asking a good open ended question and receiving a good reply from the patient as to what happened. I used encouraging nods and “ mmhmm” however, there were definitely multiple other questions I could have used instead of the second question I asked. I should have asked if there was any other reason that brought her into the doctor today and if not set the agenda for the session and then asked her more about her presenting problem which was falling down the stairs. P: It was quite icy yesterday and our stairs are pretty bad, I was rushing to get to work and I sort of slipped, and um and sort of rolled it, sort of rolled my ankle and then like it was really really sore but I had to keep going because I had to get to work D: Right, okay, so you walked on it yesterday? This was a good clarifying question to ask, but perhaps should have been used later on in the consultation when trying to find out more specific details.
This would have been a good time to acknowledge the amount of pain the patient was in and recognise the inconvenience for her as she still had to go to work even though she was in significant pain. After this, I could have maybe asked what kind of pain it was? Referring to dull, sharp etc but not mentioning the types, letting her describe it herself and if she didn’t understand asking her to explain what the pain feels like. * D: Um have you noticed that it is, um particularly sore at any points of the day between yesterday and today or is it just generally just…… P: Just generally when I am walking around and stuff
Good question at an appropriate time but I need to not trail off at the end of my sentences or lead onto any particular answer. I should have stopped after today? Didn’t need to even say or start saying the last part to get the response I was requiring. I chose this segment as I know this is something I need to work on as I do it quite a lot when I really don’t need too. TASK TWO 1. What was the reason for the patients presentation? Stacey had come to the doctor because she fell down the stairs the previous day and hurt her ankle. The stairs were very icy and she slipped.
She felt like she had rolled it and it was sore on the lateral side of the right foot and the pain was radiating down the sides towards the toes. She also mentioned she noticed bruising that morning. 2. Did you explore the problem from the biomedical perspective? From the patients perspective? I did explore the problem from a biomedical perspective and found out where the pain was and what movements it was affecting. I also partly explored it from the patients perspective by asking what she is concerned most about the injury, what her expectations were about coming to the doctor and how it is affecting her daily life.
However I could have asked what does she think may be causing this because it was only at the end after the summary that she told me this information when if I had of asked the question earlier I would have been able to gather this information earlier. 3. Which particular communication skills did you employ to gather this information? I used eye contact with the patient, and used non verbal encouragement quite a lot; and tried to use silence to allow her time to tell me more I sometimes used repetition in my own words of what they had said by summarising at the end and allowing her to correct me if I had anything wrong.
I used open questions at the start but didn’t continue to use them effectively in the cone, I kind of jumped back and forth between the two as I was trying to find out more about the information she gave me at that time, so this is something that I could work on. 4. Did you follow open to closed cones? As stated in the previous question, I think I did at points but it is definitely something that I need to work on as it definitely wasn’t clear throughout the whole consultation. I started off by saying “ Stacey do you ant to tell me why you came into the doctor today” which is an open question but then asked “ How did you fall down the stairs? ”, which is a closed question instead of continuing to ask open questions. I then continued to ask closed questions before going back to “ Can you tell me a bit about the pain in the ankle” which then encouraged her to tell me more information. 5. Identify 2 occasions on which you used a closed question where an open question would have been more appropriate. Rephrase them into appropriate open questions I said, “ So you walked on it yesterday? but could have rephrased it to, “ Can you tell me more about what happened after you rolled it. ” So then she could have told me other events that happened in the day, and also more reason as to why she walked on it all day which could have indicated more about her job situation. I said “ Is it quite tender to touch? ” but could have said, “ Can you describe to me what the pain feels like? ” Because she explained to me where the pain was but didn’t specifically say what kind of pain it was, asking this question instead could have led her to tell me more about the pain instead of just focussing on the tenderness. . Did your consultation have a discernible structure? For the most part, it did have an introduction, but I didn’t order the problems and set the scene for the consultation as she only had one problem. It then went onto the medical part where I learnt about her symptoms and then the patient’s perspective where I learnt about her concerns and how it was affecting her daily life. There was then other background information about past medical history, family history etc. I then summed up at the end and made sure I had all the right information.
At some points it didn’t follow exactly to the structure but it was quite close. 7. How did you demonstrate to the patient that you had heard and understood what was important to them? I used nodding and agreement, I could have maybe acknowledged more that it looked painful and it must be annoying and difficult for her, but it was kind of hard to do when the foot wasn’t actually swollen, and also acknowledged the serious concern it was for her as it was significantly impacting her work life particularly. . Give an example of when you demonstrated that you recognised and/or understood what the patient was feeling. That it was annoying her having to stand on her feet all day at work and it being distressing for her. I should have addressed this more though as stated earlier. 9. Give an example of when you think you might have missed or did not acknowledge what the patient was trying to tell you. At the point where she said she can’t take any time off work and if it was in a cast it would ruin her life.
I should have explored this further and asked why it would ruin her life etc as this was a big statement to make. There could have been underlying reasons for this statement but I didn’t find that out because I didn’t follow through with this remark from her. 10. What other information would it have been useful to gather with regard to the patients symptoms and the sequence of events related to those symptoms? Asked her the pain scale, to gauge how sore it was and find out the severity. If she had taken anything for the pain and if she had had trouble sleeping or lost her appetite.
She mentioned that her partner had dropped her off but I should have checked that someone was picking her up as it was her right foot so she wouldn’t have been able to drive. Also should have checked if she wanted a medical certificate as she had taken time off work to come and visit the doctor today. 11. What other information would it have been useful to gather about the patient’s context and why are these factors potentially important? If her parents were still alive and if she had any siblings for general background context but the sheet of paper did state at the start that she was a regular visitor of this G.
P however he was away today, that was her reason for seeing someone else so the regular G. P would already have all this information and seeing as it wasn’t particularly relevant to her case then might not have been so necessary to ask. Also what part of Dunedin she lived in to gather more information about her current living situation and ask if she has had any problem with the stairs before. Also possibly a bit more about her job as it sounded like she was working quite hard and felt pressured to not be able to take time off. 12.
If you were to physically examine this patient what things would you do/check for? Look at the ankle closely and check for erythema, look at the bruising that she mentioned, for swelling, deformity, feel the warmth of the skin, swelling again and tenderness. Then I would check the amount on movement in the ankle area, and see what movements were obstructed. Check for ability to invert, evert, dorsiflex and plantarflex. Maybe check the gait, if it wasn’t too much trouble and painful for her, but would refrain from doing this if it caused too much discomfort which it probably would. 3. What do you think might account for the patient’s symptoms? What mechanisms/processes might contribute to the presenting symptoms? What is on the list of possible diagnoses? A sprain of 1 or more of the 3 lateral collateral ligaments in the foot. Also could be a fracture of one of the tarsal bones in the foot but more unlikely. Stress from her job could be contributing to her feeling that a broken bone would “ ruin her life” as she felt a great deal of pressure she wouldn’t be able to take time off. 14. What has lead you to this conclusion?
The area that it is painful and the patients’ difficulty in walking. 15. Would you do anything differently if you had the chance to replay this scenario? Ask a few questions differently, and make sure that she knew I understood the hassle and trouble the pain was causing her. I would also ask her “ what do you think might have caused this? ” as I assumed that it was just from the icy stairs but only found out at the end she thought she had a weak ankle from a previous injury. I would also maybe ask her if she would like a chair to elevate her leg to maybe relieve some of the pain.
