Barrows and Pickell model of problem solving
Barrows and Pickell model of problem solving
This is a case study concerning a patient presenting with low abdominal pain, frequent micturation and dysuria. I will discuss the consultation and show how I used the problem solving consultation style detailed by Alison Crumbie. This involves listening to the patients’ initial complaint and developing hypothetical diagnosis. Focused questioning and clinical examination and investigations will then be used to eliminate some of the initial hypotheses. The patients’ perspective of their problem will be addressed and the synthesis of gathered information will enable the practitioner to arrive at a differential diagnosis and to agree on a treatment plan with the patient so that they can manage their problem.
I currently work as a Nurse Practitioner in General Practice in East London. I provide first contact appointments for patients registered with the practice each morning on a walk-in basis. I am a non medical prescriber and generate prescriptions for patients. I work autonomously within my agreed scope of practice and am supported by the structure of a small organisation of professional clinical and administrative staff.
The patient , whom I will call Sue, presented in the walk-in Surgery and told me she had had three days of stinging pain on passing urine, increased frequency of passing water and intermittent low abdominal discomfort. She also said that she had a water infection three months previously and that she thought that she now had the same problem. She had tried over the counter (OTC) medications and had increased the amount of fluids she drank with little effect. She said that her abdominal pain reduced after taking paracetamol but reoccurred after a few hours. She requested a prescription of the same antibiotics she had last time she had this problem.
Forming the initial conceptMy first impression of Sue was that she was smartly dressed, of normal weight, looked physically well and did not appear to be distressed. She attended alone and I could see from her patient record that she was 25 years old. After introducing myself I asked her two opening questions – ‘how can I help you’ and ‘what brings you here today’. I find by combining open and closed questions in this manner it helps the patient be more focused on their presenting compliant than by using either of these opening questions alone. I try not to interrupt the patient as they respond and so give them the opportunity to relate what they think the problem is and what it is they think I can do to help them manage this problem.
Sue told me that she got a burning pain on passing urine and thought that she had cystitis. She told me that last time she had a similar problem she was given antibiotics tablets. Sue told me that she had tried to self manage with OTC medications for pain relief and for cystitis for the past 2 days but had had no lasting relief from symptoms. She said that a few hours after taking paracetamol her pain returned.
My initial concept was of an articulate, well dressed woman, who had decided that she was experiencing a urinary tract infection (UTI), who had tried unsuccessfully to manage her symptoms her self and was now requesting assistance from a health care professional. She appeared systemically well to me but possibly had cystitis.
Generating multiple hypothesesA provisional explanation for the patients’ problems could now be attempted. It is important to think as widely as possible about potential causes to generate broad hypotheses which can then be narrowed down with focused enquiry and investigations (Crumbie et all) The quality of hypotheses is dependent on the practitioners experience in eliciting information from the patient and in translating this information into a number of potential scenarios. It is important that the information offered by the patient is understood correctly and not translated badly by the practitioner. For example a patient may say they felt sick and the practitioner understands this as feeling nauseated whilst the patient meant they felt generally unwell.
I hypothesised that Sue could be suffering from Cystitis (uncomplicated UTI) , pylonephritis (ascending UTI), eptopic pregnancy, Pelvic Inflammatory Disease (PID), Sexually Transmitted Infection (STI) or constipation. On later reflection I realized I could have though about interstitial cystitis, appendicitis and renal calculi. My multiple hypotheses for this patient are presented in Table 1.
Formulating an Inquiry StrategySue had told me that she had pain on passing urine and as I focused my questioning she told me her urine appeared darker in colour than normal and smelled different than usual. She described the pain as stinging and said that it was provoked by micturating and relieved a minute or so after she stopped urinating. I asked her to point to where the pain was in her abdomen and she indicated the suprapubic region. She gauged the pain to be level 6 on a pain scale of 0-10 without analgesia but did say it was relieved by analgesia and resolved to a feeling of pressure rather than pain at that time.
Back/loin pain, nausea, vomiting, fever and frank haematuria are all more common with pylonephritis. Sue denied any of these symptoms which made it less likely as a diagnosis ultimately.
.On enquiry Sue told me that she used Depo- Provera injections for contraception and dysmenorrhoea and consequently did not menstruate. She also denied any spotting of blood. Her last injection was given in practice 40 days previously and by reviewing her notes I could see her history showed timely attendance for these injections. Although I knew that both dysuria and suprapubic pain can be experience in both normal early pregnancy and in eptopic pregnancy, and that cystitis is more common in pregnant women, I felt I could now discount pregnancy as a cause of her symptoms due to her contraceptive history.
I then asked her about her sexual history. Sue told me that she was currently celibate and had not had a sexual relationship for one year. I She told me she had never experienced genital herpes so I felt able to discount STI at this stage.
I enquired about her bowel habits and Sue told me that she had passed a soft stool that morning as was her normal routine and that there had been no recent change to bowel actions. This made a diagnosis of constipation less likely.
Whilst enquiring about her symptoms I used Mortens PQRST structured clinical questioning mnemonic. This enabled me to focus my questions and to analyse symptoms and Sues responses. It is especially useful when assessing symptoms of pain and enabled me to detail a focused history of her complaint. I have used this technique extensively since commencing Nurse Practitioner training and have found it easy to remember and that it adds a structure to my questioning that was previously lacking.
Incorporating the patients perspectiveFollowing the above questioning, I went on to discuss with Sue her own concept and concerns regarding her presenting complaint. I asked Sue what she thought was causing her problem, what she thought was required to rectify the problems and what could help prevent reoccurrence. She told me that she was sure that she had another episode of cystitis and that she needed antibiotics.
Applying appropriate clinical skillsI began with a general inspection of Sue’s external appearance ,her tone of voice and articulation. I recorded her vital signs. She was apyrexial @ 35.6 Celsius and normatensive @ 120/70. Respiratory rate was 12/min and pulse rate 80 bpm. These results are within normal limits for a person of her age. I performed near patient testing in the surgery with urine dip stick testing. This showed a positive response to nitrates and leukocytes. I did not have facilities for near patient pregnancy testing, and on reflection would not have performed one at this time in this case due to her contraceptive history. I chose not to send a test off to the laboratory for pregnancy testing for the same rational. Sue declined an internal exam at this time.
I noted from records that Sue had not had a smear test so I offered to do this at this time. After explanation Sue agreed to this. I asked Sue to undress from the waist down and to lie on the examination coach. I ensured that she was comfortable screened and relaxed before commencing the exam.
I examined her abdomen using the process taught in Nurse Practitioner training and described by ( Bickly 2005). I noted her abdomen was of normal appearance with what appeared to be an appendicectomy scar. Sue confirmed that she had had her appendix removed as a child. I auscilated for bowel sounds in the four quadrants and as these were heard and of normal tone I was able to rule out an acute abdominal problem. I then percussed her abdomen and found no change to expected tympani. This helped confirm the patient’s opinion that she was not constipated and after palpation of a soft abdomen I was able to discount this hypothesis at this stage. When I palpated her suprapubic region Sue complained of discomfort, this tenderness is indicative of bladder inflammation. Palpation of the costovertebral angles induced no pain response from Sue and as I recalled her vital signs and presenting history I felt able to exclude pylonephritis also.
I then began an exam of Sue’s external genitalia looking for swelling, ulcer, lacerations or discharge. Inflammation and discharge are common with Candida and other vaginal infections. Genital herpes causes ulcerated areas and scratching can cause minor skin lacerations. This external exam was normal. I continued with the vaginal examination. Using a bimanual technique I first felt for Sue’s cervix and palpated it from side to side looking for a positive chandelier sign. If there is infection in the uterus this test can elicit pain.
Sue did not have any pain on testing. I then inserted the speculum and examined the vaginal walls for signs of injury or discharge. This was also normal, inspection of the cervix and of the os showed no discharge and this combined with a negative chandelier sign now made the diagnosis of pelvic inflammatory disease less likely. I performed a smear test and took samples for HVS and Chlamydia testing.
My initial hypotheses of cystitis now seemed most likely as the cause of symptoms. During this examination sequence I was reminded to consider appendicitis as a hypothesis in the future with this set of presenting symptoms.
Developing the problem synthesisWhen I considered the presenting problem, my history and examination findings, and compared them with my original hypotheses I found that I was able to eliminate some at this stage.
As Sue had no fever, nausea, haematuria or costovertebral pain I discounted pylonephritis.
Bowel history and examinations were normal so constipation was also discounted.
As Sue had a record of in date contraceptive cover with an injectable contraceptive and denied sexual intercourse I discounted pregnancy.
Although I was aware that Pelvic inflammatory disease could account for her symptoms, examination findings had not supported these hypotheses and were all negative at this stage.
When I reviewed the consultation at this stage, recalling the positive urine dip test, the suprapubic tenderness and the patient’s history I was able to be confident that to proceed with the differential diagnosis of cystitis was most appropriate.
Diagnostic decision makingMy differential diagnosis was cystitis .I made a differential diagnosis of cystitis for the following reasons:Previous episodeDysuria – pain on micturation and frequencyLow abdominal pain – provoked by palpation of suprapubic areaNo systemic signs/ vital signs normalNo red flags – haematuria, pregnancy, recent change of sexual partnerPositive urine test for nitrates and leukocytesTherapeutic decision makingSue had come to surgery with the idea the she required antibiotics to treat her self diagnosed cystitis. She wanted her health care provider to facilitate this request. She had tried self management and used OTC preparations before presenting in surgery.
This showed me that she was motivated in trying to achieve resolution of her problem. As these measures had not been successful in this instance we could agree a short course of oral antibiotics would be an appropriate treatment plan. As I had access to Sues health record I could see that she had been prescribed trimethoprin previously. Sue confirmed that she had no side effects from this medication and that she was willing to take it. As there were no contraindications for prescribing trimethoprin for this patient I issued her with a prescription for 1 x 200mg tablet, twice a day for three days. This is in line with prodigy guidance and local prescribing policy.
As this was the treatment plan Sue had originally requested I was confident of concordance. I discussed with Sue some steps she could take to try and prevent reoccurrence of infection. These includes toilet hygiene (front to back wiping), post-coital micturation, regular voiding and reiterated early symptom self help measures with increased fluid intake and OTC cystitis remedies. I also provided Sue with a printed Patient Information Leaflet about self help measure for women with cystitis.
I advised Sue that she should find her symptoms improving within the next 24 hours and asked to return to either the practice or the NHS Walk in Centre (depending on hours of opening) if she had no improvement in 48 hours or if her symptoms changed and she became feverish or pain increased. I explained that these could be signs that the infection was moving up towards her kidneys and that this would require urgent review. I explained that I had given her an antibiotic which would work for the majority of infections but that on some occasions is not effective and a different antibiotic is necessary. I provided her with this information so that she could make sense of any change in symptoms and would be more likely to present earlier for a consultation with a health care professional if there was treatment failure.
Reflection in and on practiceI felt that this was a satisfactory consultation for both the patient and me.
It began with the patient stating that she thought she knew what was wrong with her and what action needed to be taken to resolve the problem. By listening to the patient’s story I was able to make an analysis of her responses and to think of a number of multiple hypotheses. Proceeding with focused inquiry and utilizing clinical examination skills enabled me to discount some of these hypotheses, and by using structure, reminded me of hypotheses I had originally forgotten to include. I was able to facilitate an unexpected health intervention when the patient and carry out opportunistic smear testing.
Following on from this I was able to reach a diagnostic decision and make therapeutic interventions. Throughout I was communicating with the patient, offering education and involving her in her care which should translate to better concordance with treatment plans and improved patient satisfaction with the consultation.
This consultation took me 18 minutes to conclude and although I feel that I covered a wide range of potential hypotheses concerning the initial complaint and responded effectively to the patients concerns, I did feel time pressured. On reflection I need to be able to balance the quality of the consultation with the quantity of patients requiring attention during a session. I could have asked Sue to book another appointment for a smear test which would have enabled me to manage my time better but at the expense of patient distress and an incomplete patient episode. It has been my experience to be critisised by my medical colleuges about the time taken for consultations and they are in fact able to move patients through the surgery quicker than I can.
Although this is a recurrent problem I believe that the most prevalent reason for this is that in using this model of consultation the practitioner addresses a wider range of potential hypotheses and that these can lead on to other health issues which then need addressing as demonstrated above. When I discussed this with my GP mentor he said that he would have probably tested her urine first and as it was positive for infection, prescribe an antibiotic after enquiring about her risk of pregnancy and not have addressed any other history at that stage. If he had wanted further testing, he would have asked her to make a nurse appointment. It would be interesting to see which approach is preferred by the patient and most satisfactory for the clinician.
ConclusionThis case study looked at a consultation where a patient presented with possible cystitis and requested antibiotics. After following a structured consultation and diagnostic style I was able to reach agreement with the patient and to provide a prescription for antibiotics. This was a satisfactory conclusion for both the patient and me. I was also able to address a secondary health enquiry and opportunistically provide a smear test which was of additional benefit for the patient and the practice, as auditing will show this patient to now have had a smear test which has positive financial implications for the practice.