A concerned mother

Brief to patient

You are Mrs Perret, a 29-year-old mother. You present today without your children to
obtain a prescription for two-year-old Anne, and for advice about five-year-old Olivia's
night terrors.
When you consulted with Anne 10 days ago, the doctor agreed that Anne's persistent
night-time cough and her occasional wheeze may be due to asthma. She advised you to try
a blue salbutamol inhaler. Anne used the inhaler and facemask without difficulty. It has
made some difference but she is not completely better.
Anne has used the inhaler two to three times a day; 30 minutes after using it, her
cough recurs. You are not sure if the blue inhaler alone is adequate medication. You have
had asthma since childhood and based on your experience, you feel Anne needs a brown
steroid inhaler.
You are concerned about the night-time cough. It still disturbs Olivia, who has to
wake up for school the next morning. You are also worried about Olivia's night terrors. Is
the poor sleep making these worse? Is there anything you could do to help Olivia with her
night terrors?
Olivia has had night terrors from the age of three. The health visitor advised a good
night-time routine for her, but despite this Olivia tends to have at least one episode every
week. If questioned, it usually happens two hours after she falls asleep. She sits bolts
upright in bed, screams, looks ashen, cries inconsolably and never remembers it in the
morning. It is difficult to rouse her from a terror.
You would like a prescription for a brown steroid inhaler for Anne and advice for
Olivia. You did not think Anne needed to be re-examined today. She is usually fine during
the day and, at the last consultation, the doctor did not detect anything untoward on
examination. You do not think it is worth coming back with the children for medication to
be issued. If you are asked to return before a prescription is issued, you want to know what
the examination will add to the consultation.

Patient medical record

Name: Anne Perret (two years)

Consultation notes by GP (10 days ago):

Mum had asthma from age of five years. Anne occasionally has cough at night (after
9pm) and over past few nights, mum noticed wheeze. Kept sister (school age) awake.

Tried steam inhalation/propping up head of bed, but did not help. Frustrated as
presented many times with cough and told it is a self-limiting viral illness.

On examination: chest sounds normal; no wheeze. Healthy looking.

Plan: try salbutamol inhaler and review if needed.

Accessor: Marking guide

Generic indicators for targeted

assessment domains

Descriptors - positive and negative

Positive indicators:

A. Data gathering, technical and

assessment skills:

Reads the previous consultation notes prior

to the patients presentation.
Asks open questions to clarify the nature
of the problem followed by closed questions to
understand exactly what mum is requesting
today.
The doctor systematically excludes red
flags (intercurrent illness; severe asthma) that
may signal the need for in-person review.
Comes to an understanding of how Annes
night-time cough exacerbates Olivias night
terrors and the impact on the family.
Elicits mums concerns about Annes
partially treated asthma and her expectations
of a prescription.

Gathering of data for clinical

judgment, choice of examination,
investigations and their interpretations.

Demonstrating proficiency in
performing physical examinations and
using diagnostic and therapeutic
instruments.
Negative indicators:

B. Clinical management skills

Recognition and management of

common medical conditions in
primary care.
Demonstrates flexible and
structured approach to decision
making.

The doctor fails to respond to mums cues

about disturbed sleep. By not establishing the
link between disturbed sleep and Olivias
worsening night terrors, the doctor does not
provide holistic family care.

Positive indicators:

Demonstrating ability to deal with

multiple complaints and comorbidity
and to promote a shared approach to
managing problems.

Makes a clinically sound working

diagnosis on the basis of probability. Either
offers a test for asthma or initiates step two
asthma treatment on a trial basis.
The explanation about interrupted sleep
aggravating night terrors is logical and
incorporates the patients beliefs.
Advises about the treatment of night
terrors.
Outlines when follow-up or review is
needed (safety nettings). If referral to the
asthma nurse is offered, mum is given

sufficient information to make a decision.

Negative indicators:

Fails to prescribe safely, or in line with

current best practice, or fails to justify why a
prescription is given or withheld.
Fails to check patients understanding of
the medication and/or her ability to use the
medication appropriately.
Fails to formulate a management plan for
night terrors or fails to advise why this needs to
be addressed in a separate consultation.

Positive indicators:

C. Interpersonal skills

Use of recognised communication

techniques that enhance understanding
of a patients illness and promote a
shared approach to managing
problems.

Practising ethically with respect

for equality and diversity in line with
accepted codes of professional
conduct.

Listens attentively and empathises with the

adverse effect of Annes nocturnal cough on
the family.
Is non-judgmental about mums ideas.
Encourages mums opinions and autonomy
but maintains primary duty of care to the
children.

Negative indicators:

The doctor interrupts unnecessarily and

breaks the flow of conversation.
The doctors manner discourages
questioning or the sharing of opinions.
The patient is not offered options
regarding treatment or follow-up.

Debrief

Discuss how the doctor could improve his or her performance.

Assess whether the doctor showed poor time management.

How long did the doctor take to obtain the history? Was questioning appropriately
selective or needlessly repetitive?
Was the second half of the consultation rushed?
Were the relevant psychosocial factors covered?
In the group, discuss whether the doctor developed an adequate management plan,
and whether it was appropriate to the risk level.
Were the risks and benefits of different management approaches, including
prescribing, clearly identified and discussed?

Dr Naidoo is a GP trainer in Oxford

Resources

van Dorp F. Consultations with children. InnovAiT 2008; 1(1): 54-61.

Driver HS, Shapiro CM. ABC of sleep disorders. Parasomnias. BMJ 1993; 306: 9214.