Derek is a 50-year-old care worker who works with patients who have learning difficulties. He
was assaulted by one of his clients and was quite badly beaten up suffering multiple contusions
He first came to see me about two weeks after the incident for renewal of his fit note and was
really struggling with anxiety. He had been unable to sleep and had been suffering from panic
attacks, something that he had never experienced before. I explained that this was probably a
normal reaction to the incident and that hopeful y it would settle with time. I gave him a PILS
leaflet on dealing with anxiety and some advice on lifestyle measures which I felt would
probably help. I suggested that he might consider counsel ing but he was reluctant to consider
He came to see me two weeks later and his symptoms were if anything worse. We discussed the
options. He was not keen on medication but agreed that talking to someone may be helpful. I
referred him to the practice counsellor and we agreed to meet in a fortnight to assess progress,
as I felt it was important to maintain contact.
On review there was an entry in the notes from the counsellor suggesting that he may benefit
from having some medication to try and deal with his acute symptoms. She felt that this would
help him get the most benefit from her sessions.
We discussed possibly using a short course of diazepam or starting some citalopram with a view
to continuing this on for a longer period. He was worried about the addictive nature of
diazepam so we agreed to start the SSRI.
A month later he was much improved and we began a phased re-introduction to work.
I decided to bring this case as I found it chal enging and wondered whether I should have
This case can be used to explore Clinical Management
This competency is about the recognition and management of common medical conditions in
A Competent doctor formulates appropriate management plans in line with best practice and varies the
management options in response to changing circumstances. S/he refers appropriately, co-ordinates care
with other professionals and provides continuity of care for the patient rather than just the problem
Recognises the presentation Utilises the natural history of
common problems in developing identify quickly unexpected
Responds to the problem by Considers simple
Uses appropriate but limited Varies management options
Makes appropriate prescribing Routinely checks on drug
interactions and side effects and able to justify transgressions of
shows awareness of national and this principle
Performs up to, but does not Refers appropriately and co-
exceed, the limits of their own ordinates care with other
professionals in primary care and where these are needed
Ensures that continuity of care Provides continuity of care for the Contributes to an organisational
patient's problem e.g. through problem, reviewing care at
Responds rapidly and skil fully Appropriately fol ows-up patients Ensures that emergency care is co-
who have experienced a medical ordinated within the practice team
• When he first came to see you gave him a PILS leaflet and some lifestyle advice. Why did
• What other options did you consider?
• How did you decide on the initial management plan?
• How did you tailor this management plan to the patient?
• Why did you decide to refer when you did? What options did you consider? Why did
• Did you consider counselling him yourself? Explain your reasoning behind the referral?
• Did you consider any local or national guidance when making your decision?
• How do you justify your decision not to prescribe a short course of an anxiolytic?
• How did you ensure continuity of care?
• How did your note keeping help with continuity?
• Why did you choose to review him on a two weekly basis? What factors influenced this
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