Abstract
Welcome to the new Recorded Consultation Assessment (RCA) revision section of the journal developed to provide focus for GP trainees preparing for the RCA. This section includes a ‘Doctor’s sheet’ and a ‘Patient’s sheet’ to facilitate practicing consultations with your trainer and colleagues. An ‘Examiner’s sheet’ describes the areas trainees need to display in each of the marking domains and finishes with key points and tips for the trainee. It is important that trainees are familiar with the RCA pages on the RCGP website as this provides further highly relevant information and guidance.
Doctor’s sheet
Patient: Ellie Bates Age: 12 weeks
There is a comment in the 8-week check: ‘occasional vomiting after feeds, monitor weight.’
Patient’s sheet
Name: Ellie Bates Age: 12 weeks
Background
Telephone consultation with Ellie’s mother Nicola who is concerned about her weight and vomiting episodes.
Opening line
I am worried about Ellie. She is struggling to put on weight and is still vomiting more than normal.
Behaviour
Feels that it is time that Ellie is investigated and treatment offered.
Ideas: Is it severe reflux? Concerns: Weight has plateaued, could it be anything more serious? Expectations: Urgent referral to paediatrics.
Information given freely
Ellie’s sister Ava, who is 3 years old, had minimal sickness after feeds. Ellie is mainly breast fed with some bottle milk as a top up feed. Ellie followed the 75th centile on her growth chart until her 8-week check. After this her weight gain slowed down and she is currently between the 75th and 50th centile lines.
Information to be given if prompted
Ellie was born at term with no concerns at time of birth. She feeds well, but is sick after feeds about half the time. Vomiting is non-bilious, non-projectile and there is no history of an epigastric lump or visible peristalsis during or after a feed. Sickness has improved slightly with smaller feed volumes and being propped up for half an hour after a feed. Nicola changed the formula milk to an anti-reflux version last week and although this has helped, it makes Ellie quite constipated. Ellie will arch her back and cry if laid supine immediately after a feed. She is up to date with her milestones. Nicola herself has been exhausted since Ellie was born, but is not depressed and is coping with additional support from her mother. She is keen for an urgent referral to paediatrics:
Past medical history: Nil Current medication: Anti-reflux milk Social history: Lives with husband. Non-smoker and does not drink alcohol. Works as a non-clinical staff member at the local hospital and is currently on maternity leave. Examination: Trainee may offer for the mother and child to be brought to the surgery for an examination. At this stage, the role player should prompt, ‘What would you like to examine for?’ Examination would include a weight check, assessment of hydration status and an abdominal examination (checking for any olive-shaped masses and/or peristaltic movements in epigastrium during/after a feed.) Candidate should ask the patient’s mother to bring Ellie’s red book with her to review the growth chart.
Examiner’s sheet
Data gathering
Ask questions sensitively by signposting, understanding the timeline of vomiting and the impact of measures taken by Nicola to help with Ellie’s symptoms.
Explore ideas, concerns, and expectations and recognise the priority in this scenario without using formulaic phrases.
Must conduct data gathering related to the two main differential diagnoses, i.e., gastro-oesophageal reflux disease (GORD), and congenital hypertrophic pyloric stenosis (CHPS), the latter being less likely.
Red flags
Cover questions relating to CHPS (e.g. presence of epigastric lumps, visible peristalsis, etc.) and GORD. Ensure bilious vomiting has been excluded.
Clinical management
Candidate should be able to make a safe shared management plan with an appropriate follow up arrangement. It would be reasonable to suggest a face-to-face examination either within the next couple of days, or a week later - as long as an adequate explanation is provided for the rationale for either choice and with involvement of the mother in the decision.
Interpersonal skills
Talks sensitively to the mother and acknowledges the difference between Ellie’s and Ava’s feeding patterns.
Uses jargon-free language to explain the likely diagnosis (GORD) and involve Nicola in the management plan.
Candidate must address the parent’s expectations of an urgent referral to ensure a satisfactory outcome to the consultation.
Key points
Although this would start off as a telephone consultation, trainees should have a low threshold to see babies face to face, especially if there is a possibility of a serious diagnosis. This presentation leans towards GORD, but it would be important to ensure that the possibility of CHPS is considered.
Discussion with trainee
This is a classic example of being able to deal with uncertainty and manage patient concerns and expectations.
Although there is some improvement in symptoms with change to feeding regime, is this reflected in a steady weight gain?
What goes against CHPS? (Some points, other than the ones covered under red flags, include: CHPS has a four times male preponderance with increased prevalence in the first-born child, the typical presentation of vomiting is at about 2–8 weeks, although it can present late). An astute trainee may also inquire about neonatal exposure to erythromycin during data gathering.
Top tips
This case highlights the importance of acknowledging the mother’s experience with Ava and Ellie’s feeding and addressing the ensuing concerns and expectations Follow up plans may vary depending on the comfort level of the patient (or next-of-kin) in dealing with uncertainty and not just the medical need. A balanced approach is necessary in such situations
