Crammer’s Corner

Abstract

This is third in the series of practice scenarios for the Recorded Consultation Assessment (RCA), looking at backpain, a common presentation in primary care. The scenario in this article was written by Dr Anish Kotecha in collaboration with Dr Kunal Chawathey. It covers important aspects of the ‘back pain’ consultation.

The majority of primary care consultations have been conducted remotely to reduce transmission risk during the COVID-19 pandemic. GPs tend to invite patients for face-to-face consultations when an examination is necessary (for example, if a patient-assisted examination or a video call will not provide adequate information), or when there are barriers to communication. More face-to-face appointments are now being offered according to patient preference. Bearing this in mind, let us look at the following practice scenario.

Practice case scenario

Doctor’s sheet

Name: Jenna Jones

Age: 28

Past medical history: Horse riding injury (ankle sprain 3 years ago)

Drug history: Combined oral contraceptive pill

Last consulted the surgery 6 months ago for a pill check

Patient information sheet

Name: Jenna Jones

Age: 28

Background: Back pain for 2 weeks

Opening line: I’ve had constant back pain for the past 2 weeks, and I need something to be done now.

Behaviour: Very insistent for a scan and tramadol

Ideas: A scan will help with a diagnosis and tramadol will help the pain

Concerns: If back pain continues, it will affect her professionally. She may also struggle to look after her children

Expectations: A referral for a magnetic resonance imaging (MRI) scan and a prescription for tramadol

Information given easily: Sprained her back 2 weeks ago while riding a horse. The pain is no better with paracetamol or ibuprofen. It is causing her more pain when trying to pick up her two young children. Pain score is 5–6/10

Information given if prompted: No sciatica type symptoms. No urinary or bowel symptoms. No perianal paraesthesia. No weight loss. Works as a horse rider – worried about losing her job, which is prompting her to ask for a scan to find the cause of the problem

Past medical history: Ankle injury after a fall during horse-riding. Took 2 months to be able to resume work

Medication: Nil

Family history: Nil

Social history: Lives with husband and two children. Worried about losing her job and being able to compete at equestrian vaulting. Pain is causing difficulty with picking up her two young children

Examination: Full range of movement of her back – some pain at extremes of movement. No spinal tenderness. Power and sensation both lower limbs intact

Examiner’s sheet

Data gathering: Allows the patient time to explain why they have consulted. Covers red flag symptoms. Asks if and how the problem is affecting her at home and at work. Reasonable examination offered and done (may well be virtual in the context of the pandemic). Shows empathy with her situation at home and at work, and opportunistically explores her ankle injury, which may have a bearing on her insistence for an early scan. Covers ideas, concerns and expectations and deals with them well.

Red flags: Ask about symptoms like sciatica, urinary and bowel symptoms and perianal paraesthesia to rule out cauda equina syndrome. Ask about the mechanism of injury. Is there a possibility of a wedge fracture? (How reliable would spinal tenderness be in a patient-assisted examination during a telephone/video consultation?)

Clinical management: Explain that this is likely to be musculoskeletal pain. Suggest naproxen (if no contraindications) for the pain as per the WHO (World Health Organization) ladder. Explain the reasons for avoiding tramadol. Reassure that there are no red flags, and her pain should improve with time. Offer a physiotherapy referral if keen. Currently no evidence for a scan but can certainly continue to monitor actively over a couple of weeks. This patient will need good explanations as she is very keen on certain medication and a referral for a scan. Discuss requirement for a fit note. Do safety netting appropriately.

Interpersonal skills: Build a good rapport. Show empathy as the symptoms are affecting the patient’s home and work life. Offer a good explanation of the likely diagnosis, explain why a scan isn’t warranted and explain why different medication should be tried. Check understanding with the patient and ask if they have any questions.

Key points

The trainee needs to be very inquisitive and try to understand why the patient is consulting. They must cover the red flag symptoms. Having a supportive nature and building a good rapport is important here to make sure the patient is happy with the endpoint. Explore the impact of previous injury on work and home. Focused examination and explanation of the likely cause should be jargon-free. Reasonable follow-up should be specified.

Further discussion with trainee

Depending on the level of performance of the trainee, trainers could probe further into the scenario using the following domains.

Wider clinical issues: Did the trainee explore the mechanism of injury and exclude red flags in acute onset back pain? Psychosocial: Did the trainee explore details of Jenna’s profession, for example, is she involved in competitive riding? If so, what would be the impact on her career? Advanced learning: There are differences in the incidence of back pain in the different horse-riding disciplines (for example, dressage, show jumping and vaulting), but is this relevant in this case? Not surprisingly, vaulters, compared with riders of other disciplines, seem to suffer from recurrent back pain to a greater extent. Could Jenna’s insistence for an MRI scan stem from this piece of information, well known to competitive horse riders? Need for a face-to-face examination: Would it be useful to examine this patient in person from the perspective of diagnosis or reassurance?

Top tips

Consultations about mechanical back pain can be challenging

Always probe when faced with patient expectations incongruent to the presentation

Arrange face-to-face review whenever necessary, as this can aid not only diagnosis but also patient reassurance

If you would like to contribute to Crammer’s Corner please contact us at editorialoffice@innovaitjournal.co.uk

Footnotes

ORCID iDs

Dr Kunal Chawathey

Dr Anish Kotecha

References

NICE (2020) Clinical knowledge summary. Back pain – low (without radiculopathy). Available at: https://cks.nice.org.uk/topics/back-pain-low-without-radiculopathy/ (accessed 10 June 2021).

RCGP (2021) MRCGP Examination. The Recorded Consultations Assessment frequently asked questions. Available at: www.rcgp.org.uk/-/media/Files/GP-training-and-exams/CSA-page/CSA-RCA/FAQs-Recorded-Consultation-Assessment.ashx?la=en (accessed 10 June 2021).