Additional Information
Book Details
Abstract
The 3rd edition of PACES for the MRCP has been fully revised and updated throughout to retain its pole position as the textbook to accompany core medical training (CMT) and prepare candidates for success in the Practical Assessment of Clinical Examination Skills and a future specialty career.
Features
Fully revised for the new Station 5 and completely updated throughout.
Promotes understanding and deeper learning of modern medicine applicable to PACES and the specialist registrar.
Emphasis on clinical assessment – history-taking, examination and communication skills – equipping candidates with appropriate differential diagnoses from which to develop the right diagnosis.
Encourages candidates to question why a diagnosis has arisen and consider its consequences. For example, ‘Heat failure’ is a not a diagnosis until a candidate has considered the differential diagnoses of breathlessness and decided why heart failure is most likely, and then considered its cause (not always ischaemic heart disease), its presentation (acute, chronic, left or right ventricular or both) and, most importantly, the effects of it and its treatments on a patient’s life.
This 3rd edition of PACES for the MRCP continues to provide fully revised, up-to-date, evidence-based coverage of investigations and treatments. Whilst the emphasis of PACES is on clinical skills, candidates who understand when, for example, a patient with rheumatoid arthritis might benefit from a biologic agent and how this will influence inflammatory disease, is better equipped for success.
- A one-volume text giving candidates complete preparation for the PACES exam within one portable volume
- 250 cases organised into the 5 stations of the PACES exam – respiratory and abdominal system, history taking, cardiovascular and nervous system, communication and ethics and skin, locomotion, eyes and endocrine systems
- Engaging question-and-answer approach at the end of each case – excellent preparation for the exam
- Boxed tips highlight vital information – helps identify what is most important to remember
- Produced in full colour throughout
- Colour coding for each station
- Many more illustrations added - now over 300 clinical photographs and line drawings in colour
- Many more cases added, bringing the number up to 250 - 50 per station
- History-taking and communication skills stations now revised so that they exactly mimic the requirements of the exam
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | cover | ||
| PACES for the MRCP | i | ||
| Copyright page | iv | ||
| Table of Contents | v | ||
| Acknowledgements | xi | ||
| Preface | xiii | ||
| Introduction | 1 | ||
| The Practical Assessment of Clinical Examination Skills (Paces) | 1 | ||
| Structure | 1 | ||
| Stations 1 and 3: the clinical examination stations | 1 | ||
| Stations 2 and 4: history-taking skills and communication skills and ethics | 1 | ||
| Documents for Station 2 | 2 | ||
| Documents for Station 4 | 3 | ||
| Station 5: integrated clinical assessment | 3 | ||
| Documents for Station 5 | 4 | ||
| Marking system | 4 | ||
| PACES for the MRCP | 5 | ||
| Stations 1 and 3: the clinical examination stations | 5 | ||
| Instruction | 5 | ||
| Recognition | 5 | ||
| Interpretation | 5 | ||
| Confirm the diagnosis | 5 | ||
| What to do next – consider causes or assess other systems | 5 | ||
| Consider severity/decompensation complications | 6 | ||
| Consider function | 6 | ||
| Discussion | 6 | ||
| Station 2: history-taking skills | 6 | ||
| Candidate information | 6 | ||
| Role | 6 | ||
| Scenario | 6 | ||
| Patient information | 7 | ||
| Station 1 Respiratory and abdominal system | 9 | ||
| Contents | 9 | ||
| Respiratory system | 10 | ||
| Examination of the respiratory system | 10 | ||
| Inspection | 10 | ||
| General | 10 | ||
| Listen | 10 | ||
| Hands | 10 | ||
| Face | 10 | ||
| Station 2 History-taking skills | 141 | ||
| Contents | 141 | ||
| Introduction to history-taking skills | 142 | ||
| Clinical reasoning | 142 | ||
| Clinical reasoning – what it is | 142 | ||
| Clinical reasoning strategies | 142 | ||
| Hypothetico-deductive reasoning | 142 | ||
| Scheme-inductive reasoning | 142 | ||
| Pattern recognition | 143 | ||
| The traditional medical history model | 143 | ||
| The traditional model | 143 | ||
| Limitations of the traditional model | 143 | ||
| Incorporating the patient’s perspective – ideas, concerns and expectations | 143 | ||
| Understanding what patients are thinking | 143 | ||
| Scenario | 143 | ||
| The patient’s perspective – ideas, concerns and expectations (ICE) | 143 | ||
| But do not just assume! | 144 | ||
| ICE in practice | 144 | ||
| How it all affects the patient | 144 | ||
| History-taking skills – the communication skills that make history taking effective | 144 | ||
| Listening skills | 145 | ||
| Active listening | 145 | ||
| Use of appropriate questions | 145 | ||
| Open questions | 145 | ||
| Closed questions | 145 | ||
| Eliciting or facilitating skills | 145 | ||
| Encouragement | 146 | ||
| Interpretation | 146 | ||
| Clarification | 146 | ||
| ‘Questions in disguise’ | 146 | ||
| Legitimising | 146 | ||
| Recognising and responding to cues | 146 | ||
| Verbal cues | 146 | ||
| Non-verbal cues | 146 | ||
| Use of appropriate language | 147 | ||
| Summarising | 147 | ||
| Summarising periodically | 147 | ||
| Summarising at the end | 147 | ||
| The traditional model and communication skills – putting these together | 147 | ||
| Content versus process | 147 | ||
| Content plus process | 147 | ||
| Cases | 149 | ||
| Respiratory problems | 149 | ||
| Case 2.1 Breathlessness and other respiratory symptoms | 149 | ||
| Candidate information | 149 | ||
| Role | 149 | ||
| Scenario | 149 | ||
| Patient information | 149 | ||
| How to approach the case | 149 | ||
| Data gathering in the interview and interpretation and use of information gathered | 149 | ||
| Presenting problem(s) and symptom exploration | 149 | ||
| Elicit details of breathlessness. | 149 | ||
| Ask about trigger factors. | 149 | ||
| Explore associated symptoms. | 149 | ||
| Patient perspective | 149 | ||
| Past medical history | 149 | ||
| Drug and allergy history | 150 | ||
| Family history | 150 | ||
| Social history | 150 | ||
| Discussion | 150 | ||
| What is silicosis? | 150 | ||
| What is meant by the terms total lung capacity (TLC), vital capacity (VC) and residual volume (RV)? | 150 | ||
| Which dynamic volumes are helpful in pulmonary function testing? | 150 | ||
| What happens to flow rates and flow rate curves in obstructive and restrictive lung diseases? | 151 | ||
| What do you understand by compliance and elastic recoil? | 152 | ||
| What are flow–volume loops? | 152 | ||
| What do you understand by the term transfer factor and which diseases affect it? | 152 | ||
| What is respiratory failure? | 153 | ||
| Case 2.2 Asthma | 153 | ||
| Candidate information | 153 | ||
| Role | 153 | ||
| Scenario | 153 | ||
| Patient information | 153 | ||
| How to approach the case | 154 | ||
| Data gathering in the interview and interpretation and use of information gathered | 154 | ||
| Presenting problem(s) and symptom exploration | 154 | ||
| Explore precipitating factors. | 154 | ||
| Patient perspective | 154 | ||
| Past medical history | 154 | ||
| Drug and allergy history | 154 | ||
| Family history | 154 | ||
| Social history | 154 | ||
| Discussion | 154 | ||
| What is asthma? | 154 | ||
| What do you know about the pathophysiology of asthma? | 155 | ||
| Atopy and allergy | 155 | ||
| Allergens in asthma | 155 | ||
| Are there different types of asthma? | 155 | ||
| How is asthma diagnosed? | 155 | ||
| What do you know about the British Thoracic Society and Scottish Intercollegiate Guideline Network (BTS / SIGN) guidelines for the management of chronic asthma in adults? | 156 | ||
| Standard therapies | 156 | ||
| Omalizumab and emerging therapies | 156 | ||
| How would you explain to a patient how to use an MDI? | 156 | ||
| How should patients with asthma be monitored? | 157 | ||
| How would you recognise acute severe asthma (ASA) and life-threatening asthma? | 157 | ||
| How would you manage acute asthma? | 157 | ||
| Does asthma management differ in pregnancy? | 157 | ||
| When would you consider it safe to discharge a patient from hospital after ASA? | 157 | ||
| What might you consider when a patient has chronic asthma that is difficult to control? | 157 | ||
| Alternative diagnosis | 158 | ||
| Coexisting conditions | 158 | ||
| Persistence of aggravating factors | 158 | ||
| Concordance | 158 | ||
| Is asthma preventable? | 158 | ||
| Are inhaled medications dangerous? | 158 | ||
| Abdominal problems | 158 | ||
| Case 2.3 Dyspepsia and upper gastrointestinal bleeding | 158 | ||
| Candidate information | 158 | ||
| Role | 158 | ||
| Scenario | 158 | ||
| Patient information | 159 | ||
| How to approach the case | 159 | ||
| Data gathering in the interview and interpretation and use of information gathered | 159 | ||
| Presenting problem(s) and symptom exploration | 159 | ||
| Consider the causes of dyspepsia. | 159 | ||
| Consider the differential diagnoses of dyspepsia. | 159 | ||
| Patient perspective | 159 | ||
| Past medical history | 159 | ||
| Drug and allergy history | 160 | ||
| Family history | 160 | ||
| Social history | 160 | ||
| Discussion | 160 | ||
| What do you know about the types of gastro-oesophageal reflux disease (GORD)? | 160 | ||
| Non-erosive reflux disease (NERD) | 160 | ||
| Functional heartburn | 160 | ||
| Reflux oesophagitis | 160 | ||
| What is the pathophysiology of GORD? | 160 | ||
| What are the complications of GORD? | 160 | ||
| What is the relationship between a hiatus hernia and GORD? | 161 | ||
| How may GORD be investigated? | 161 | ||
| Oesophagogastroduodenoscopy (OGD) | 161 | ||
| Oesophageal ambulatory pH studies | 161 | ||
| Oesophageal manometry | 161 | ||
| Multichannel intraluminal impedance | 161 | ||
| Why is Barrett’s oesophagus important and how is it managed? | 161 | ||
| Other than GORD, what other causes of oesophageal pain are there? | 161 | ||
| List some causes of duodenal and gastric ulceration | 161 | ||
| What do you know about Helicobacter pylori? | 161 | ||
| What do you know about the pathophysiology of peptic ulceration and gastric cancer, and their links with H. pylori? | 162 | ||
| Normal gastric secretion | 162 | ||
| How peptic ulceration develops | 162 | ||
| How gastric cancer develops | 162 | ||
| Is the location of H. pylori important in determining clinical outcome? | 162 | ||
| Are there any implications from the presence of H. pylori for the use of PPIs? | 162 | ||
| What is Zollinger–Ellison syndrome? | 163 | ||
| How is H. pylori infection diagnosed? | 163 | ||
| Invasive tests | 163 | ||
| Non-invasive tests | 163 | ||
| When is OGD indicated in patients with dyspepsia? | 163 | ||
| People under 55 years | 163 | ||
| People 55 years or over or those with alarm symptoms | 163 | ||
| What empirical treatments are useful in dyspepsia? | 163 | ||
| Predominant epigastric pain or discomfort | 163 | ||
| Heartburn or regurgitation (GORD) | 163 | ||
| How are patients managed following OGD investigation? | 164 | ||
| Oesophagitis or peptic ulceration | 164 | ||
| No structural lesion and GORD symptoms | 164 | ||
| No structural lesion and functional dyspepsia | 164 | ||
| For which conditions should H. pylori infection definitely be treated? | 164 | ||
| How can H. pylori eradication be confirmed? | 164 | ||
| List some causes of upper gastrointestinal bleeding | 164 | ||
| How should peptic ulcer bleeding be managed? | 165 | ||
| How might you assess risk in a patient who presents with upper gastrointestinal bleeding? | 165 | ||
| Can bradycardia be a sign of acute haemorrhage? | 165 | ||
| Case 2.4 Dysphagia | 166 | ||
| Candidate information | 166 | ||
| Role | 166 | ||
| Scenario | 166 | ||
| Patient information | 166 | ||
| How to approach the case | 166 | ||
| Data gathering in the interview and interpretation and use of information gathered | 166 | ||
| Presenting problem / s and symptom exploration | 166 | ||
| Swallowing assessment | 166 | ||
| Patient perspective | 166 | ||
| Past medical history | 166 | ||
| Drug and allergy history | 166 | ||
| Family history | 166 | ||
| Social history | 166 | ||
| Discussion | 166 | ||
| What are the phases of swallowing? | 166 | ||
| Oral phase | 167 | ||
| Pharyngeal phase | 167 | ||
| Oesophageal phase | 167 | ||
| Outline your approach to managing dysphagia | 167 | ||
| What is the role of speech and language therapists in a swallow assessment? | 167 | ||
| Case 2.5 Abdominal pain | 168 | ||
| Candidate information | 168 | ||
| Role | 168 | ||
| Scenario | 168 | ||
| Patient information | 168 | ||
| How to approach the case | 169 | ||
| Data gathering in the interview and interpretation and use of information gathered | 169 | ||
| Presenting problem(s) and symptom exploration | 169 | ||
| Determine the type of abdominal pain. | 169 | ||
| Determine the site of abdominal pain. | 169 | ||
| Integrate the above two pieces of information to form likely diagnoses. | 169 | ||
| Be alert to typical patterns of common conditions. | 169 | ||
| Patient perspective | 170 | ||
| Past medical history | 170 | ||
| Drug and allergy history | 170 | ||
| Family history | 170 | ||
| Social history | 170 | ||
| Discussion | 170 | ||
| What are the major arteries supplying the small intestine and colon? | 170 | ||
| What is meant by the term acute mesenteric ischaemia? | 170 | ||
| How does acute mesenteric ischaemia present? | 170 | ||
| How does chronic mesenteric ischaemia present? | 170 | ||
| What do you know about ischaemic colitis? | 170 | ||
| Which investigations may aid diagnosis of intestinal ischaemic disorders? | 171 | ||
| What treatments are available? | 171 | ||
| How should biliary sepsis be managed? | 171 | ||
| Case 2.6 Altered bowel habit and lower gastrointestinal bleeding | 171 | ||
| Candidate information | 171 | ||
| Role | 171 | ||
| Scenario | 171 | ||
| Patient information | 171 | ||
| How to approach the case | 171 | ||
| Data gathering in the interview and interpretation and use of information gathered | 171 | ||
| Presenting problem(s) and symptom exploration | 171 | ||
| Determine the type of diarrhoea. | 171 | ||
| If symptoms suggest a small bowel cause. | 171 | ||
| If symptoms suggest a large bowel cause. | 172 | ||
| Patient perspective | 172 | ||
| Past medical history | 172 | ||
| Drug and allergy history | 172 | ||
| Family history | 172 | ||
| Social history | 172 | ||
| Discussion | 172 | ||
| List some investigations for diarrhoea with a suspected small bowel cause | 172 | ||
| Where are the major nutrients absorbed, including iron, vitamin B12 and folate? | 172 | ||
| What do you know about coeliac disease? | 172 | ||
| What are the infectious causes of acute watery diarrhoea? | 173 | ||
| What are the infectious causes of chronic watery diarrhoea? | 173 | ||
| What are the infectious causes of acute bloody diarrhoea? | 173 | ||
| What are the infectious causes of chronic bloody diarrhoea? | 173 | ||
| Are there any advances in antimicrobial treatment of diarrhoea? | 173 | ||
| Why is norovirus important? | 173 | ||
| Why is Shiga-toxin-producing E. coli (STEC) important? | 173 | ||
| What is C. difficile? | 173 | ||
| Why is C. difficile important? | 173 | ||
| When is C. difficile likely to become more pathogenic? | 174 | ||
| What are the symptoms of CDAD? | 174 | ||
| How is CDAD diagnosed? | 174 | ||
| Which haematobiochemical disturbances are common with CDAD? | 174 | ||
| What are the markers of CDAD severity? | 174 | ||
| How is CDAD treated? | 174 | ||
| How is C. difficule controlled, especially in severe outbreaks? | 174 | ||
| How is constipation managed? | 175 | ||
| How is acute lower gastrointestinal bleeding (ALGIB) defined? | 175 | ||
| What are the causes of LGIB? | 175 | ||
| Which factors predict ongoing bleeding or death in ALGIB? | 175 | ||
| How is ALGIB initially managed? | 175 | ||
| How is ALGIB investigated? | 175 | ||
| Radiological | 175 | ||
| Endoscopic | 175 | ||
| How is ALGIB treated? | 176 | ||
| What do you know about the molecular basis and genetics of CRC risk? | 176 | ||
| Which factors determine a higher risk of malignant transformation within a polyp? | 176 | ||
| How is CRC staged? | 176 | ||
| How is CRC managed? | 176 | ||
| What do you know about CRC screening? | 176 | ||
| Cardiovascular problems | 177 | ||
| Case 2.7 Weight gain, obesity, and prevention of cardiovascular disease | 177 | ||
| Candidate information | 177 | ||
| Role | 177 | ||
| Scenario | 177 | ||
| Patient information | 177 | ||
| How to approach the case | 177 | ||
| Data gathering in the interview and interpretation and use of information gathered | 177 | ||
| Presenting problem(s) and symptom exploration | 177 | ||
| Consider causes. | 177 | ||
| Consider consequences. | 178 | ||
| Patient perspective | 178 | ||
| Past medical history | 179 | ||
| Drug and allergy history | 179 | ||
| Family history | 179 | ||
| Social history | 179 | ||
| Discussion | 179 | ||
| What do you know about abdominal obesity and the hypertriglyceridaemic phenotype and the metabolic syndrome? | 179 | ||
| How is obesity managed? | 180 | ||
| What do you understand by total cardiovascular risk assessment? | 180 | ||
| Total CVD risk versus single risk factors | 180 | ||
| CVD risk assessment systems | 180 | ||
| Those who should have CVD risk assessment | 180 | ||
| Risk assessment | 181 | ||
| Risk assessment for those already on treatment for blood pressure or lipids | 181 | ||
| Groups prioritised for CVD prevention | 181 | ||
| National Institute for Health and Clinical Excellence (NICE) guidance | 181 | ||
| What are the lifestyle interventions and targets in people with high CVD risk? | 181 | ||
| Is unaccustomed exercise risky? | 182 | ||
| What are the blood pressure targets in people with high CVD risk? | 182 | ||
| What are the lipid targets in people with high CVD risk? | 182 | ||
| What are the blood glucose targets in people with high CVD risk? | 182 | ||
| Can type 2 diabetes be prevented? | 182 | ||
| Why might older patients be at increased risk of CVD? | 182 | ||
| Outline the place of angiotensin-converting enzyme (ACE) inhibitors in CVD | 182 | ||
| Can these benefits of ACE inhibitors in CVD be extrapolated to angiotensin receptor blockers (ARBs)? | 183 | ||
| Have you heard of the ‘polypill’ and mass population preventive strategies? | 183 | ||
| Case 2.8 Chest pain and stable angina | 183 | ||
| Candidate instructions | 183 | ||
| Role | 183 | ||
| Scenario | 183 | ||
| Patient information | 184 | ||
| How to approach the case | 184 | ||
| Data gathering in the interview and interpretation and use of data gathered | 184 | ||
| Presenting problem(s) and symptom exploration | 184 | ||
| Elicit details of chest pain. | 184 | ||
| Ask about associated symptoms. | 184 | ||
| Explore risk factors. | 184 | ||
| Consider the severity of angina. | 184 | ||
| Consider the differential diagnosis of chest pain. | 184 | ||
| Patient perspective | 184 | ||
| Past medical history | 184 | ||
| Drug and allergy history | 184 | ||
| Family history | 184 | ||
| Social history | 185 | ||
| Discussion | 185 | ||
| What is atherosclerosis? | 185 | ||
| Is atherosclerosis an inflammatory disease? | 185 | ||
| How do atherosclerotic lesions evolve? | 185 | ||
| Endothelial activation | 185 | ||
| Chemokines and adhesion molecules | 185 | ||
| Macrophages in the developing plaque | 185 | ||
| T-cell activation and vascular inflammation | 185 | ||
| Types of atherosclerotic lesion | 185 | ||
| Treatment implications | 185 | ||
| How do atherosclerotic plaques rupture? | 186 | ||
| How do acute coronary syndromes arise? | 186 | ||
| How is stable angina diagnosed? | 186 | ||
| Clinical assessment and typicality of angina pain | 186 | ||
| Diagnostic testing | 186 | ||
| Making the diagnosis | 187 | ||
| Some important rules of judgement | 188 | ||
| Which angiographic lesions tend to pose a higher risk? | 188 | ||
| How is stable angina managed? | 188 | ||
| How important is reducing heart rate in coronary heart disease and what agents may be used to effect this? | 188 | ||
| Case 2.9 Acute coronary syndrome | 189 | ||
| Candidate instructions | 189 | ||
| Role | 189 | ||
| Scenario | 189 | ||
| Patient instructions | 190 | ||
| How to approach the case | 190 | ||
| Data gathering in the interview and interpretation and use of data gathered | 190 | ||
| Presenting problem(s) and symptom exploration | 190 | ||
| Ask about the chest pain. | 190 | ||
| Ask about associated symptoms. | 190 | ||
| Ask about progress. | 190 | ||
| Consider the differential diagnosis of acute chest pain. | 190 | ||
| Patient perspective | 190 | ||
| Past medical history | 190 | ||
| Drug and allergy history | 191 | ||
| Family history | 191 | ||
| Social history | 191 | ||
| Discussion | 191 | ||
| What are the causes of a raised cardiac troponin level and how do you interpret results? | 191 | ||
| Are other markers of myocardial damage on the horizon? | 191 | ||
| Which electrocardiogram leads are affected in each type of myocardial infarction? | 191 | ||
| What systems are there for stratifying ACS risk? | 191 | ||
| Summarise antiplatelet therapy in non-ST elevation acute coronary syndrome (NSTE-ACS) | 191 | ||
| 1. Aspirin | 192 | ||
| 2. ADP pathway antagonists – P2Y12 receptor inhibitors | 192 | ||
| 3. Emerging platelet receptor antagonists | 193 | ||
| 4. GPIIbIIIa inhibitors | 193 | ||
| Summarise antithrombin therapy in NSTE-ACS | 193 | ||
| Summarise the use of anti-ischaemic drugs in NSTE-ACS | 193 | ||
| Beta blockers | 194 | ||
| Nitrates | 194 | ||
| Calcium channel blockers | 194 | ||
| Other anti-anginal drugs | 194 | ||
| Summarise revascularisation strategies in NSTE-ACS | 194 | ||
| Invasive versus conservative approach | 194 | ||
| PCI versus CABG | 194 | ||
| What do you understand by the term drug-eluting stent (DES)? | 195 | ||
| Is bleeding risk from antithrombotic treatment a concern? | 195 | ||
| What special patient group or comorbidity considerations are there in ACS? | 195 | ||
| Older people | 195 | ||
| Women | 195 | ||
| Diabetes | 195 | ||
| Renal disease | 195 | ||
| Heart failure | 196 | ||
| Extreme body weight | 196 | ||
| Non-obstructed coronary arteries | 196 | ||
| Anaemia | 196 | ||
| Bleeding | 196 | ||
| Thrombocytopenia | 196 | ||
| What is Takotsubo cardiomyopathy? | 196 | ||
| Why are patients with diabetes at higher risk of an ACS? | 196 | ||
| What are the immediate management principles in a STEMI? | 196 | ||
| Are there other causes of ST elevation? | 196 | ||
| What do you know about right ventricular infarction (RVI)? | 196 | ||
| Which complications may follow myocardial infarction? | 197 | ||
| What are the important secondary preventive measures after an ACS? | 197 | ||
| How might you investigate acute severe interscapular pain? | 197 | ||
| Serial electrocardiogram and 12-hour troponin testing | 198 | ||
| Echocardiography | 198 | ||
| Electrocardiogram gated multidetector CT | 198 | ||
| What do you know about aortic dissection? | 198 | ||
| Causes | 198 | ||
| Presentation | 198 | ||
| Management | 198 | ||
| Case 2.10 Heart failure | 199 | ||
| Candidate information | 199 | ||
| Role | 199 | ||
| Scenario | 199 | ||
| Patient information | 199 | ||
| How to approach the case | 199 | ||
| Data gathering in the interview and interpretation and use of data gathered | 199 | ||
| Presenting problem(s) and symptom exploration | 199 | ||
| Elicit details of symptoms. | 199 | ||
| Establish symptom severity. | 199 | ||
| Consider causes. | 199 | ||
| Patient perspective | 200 | ||
| Past medical history | 200 | ||
| Drug and allergy history | 200 | ||
| Family history | 200 | ||
| Social history | 200 | ||
| Discussion | 201 | ||
| What is heart failure? | 201 | ||
| What is the pathophysiology of heart failure? | 201 | ||
| What are the two main types of heart failure? | 201 | ||
| Which pharmacological treatments improve the prognosis in heart failure? | 201 | ||
| How do angiotensin-converting enzyme (ACE) inhibitors work? | 201 | ||
| Why are ACE inhibitors relatively contraindicated in aortic stenosis? | 201 | ||
| Why are ACE inhibitors relatively contraindicated in renal artery stenosis? | 201 | ||
| When might you suspect renal artery stenosis clinically? | 203 | ||
| How do ARBs work? | 203 | ||
| Should ACE inhibitors and ARBs be used in combination? | 203 | ||
| How do beta blockers work in heart failure? | 203 | ||
| How does spironolactone work in heart failure? | 204 | ||
| List some non-pharmacological interventions you might consider for a patient with heart failure | 204 | ||
| What do you know about devices in heart failure? | 204 | ||
| Cardiac resynchronisation therapy (CRT) | 204 | ||
| How CRT works | 204 | ||
| Patient selection | 204 | ||
| Implantable cardioverter defibrillator (ICD) | 205 | ||
| Secondary prevention | 205 | ||
| Primary prevention | 205 | ||
| What do you know about surgery in heart failure? | 205 | ||
| Surgery to vessels, valves and ventricle | 205 | ||
| Transplantation and left ventricular assist devices (LVADs) | 205 | ||
| How might you differentiate between heart failure and cor pulmonale in a patient with significant peripheral oedema? | 206 | ||
| How would you define ‘acute’ heart failure and what are its causes? | 206 | ||
| What is the pathophysiology of ACPOE? | 206 | ||
| How is ‘acute heart failure’ diagnosed? | 207 | ||
| How is ACPOE treated and what is the evidence for treatments? | 207 | ||
| Case 2.11 Palpitations | 207 | ||
| Candidate information | 207 | ||
| Role | 207 | ||
| Scenario | 207 | ||
| Patient information | 207 | ||
| How to approach the case | 208 | ||
| Data gathering in the interview and interpretation and use of information gathered | 208 | ||
| Presenting problem(s) and symptom exploration | 208 | ||
| Consider possible causes. | 208 | ||
| Elicit details of the palpitations. | 208 | ||
| Ask about associated symptoms. | 208 | ||
| Ask about risk factors for AF. | 208 | ||
| Patient perspective | 208 | ||
| Past medical history | 208 | ||
| Drug and allergy history | 208 | ||
| Family history | 208 | ||
| Social history | 208 | ||
| Discussion | 208 | ||
| List some types of tachyarrhythmia | 208 | ||
| How may SVT arise in WPW syndrome? | 209 | ||
| How may SVT be treated? | 209 | ||
| Why is digoxin contraindicated in WPW syndrome? | 209 | ||
| What other types of SVT are there? | 209 | ||
| Which clinical or electrocardiographic features can help to determine whether a broad complex tachycardia is the result of VT or SVT with aberrant conduction? | 209 | ||
| How might you manage VT? | 209 | ||
| What may cause bradycardia? | 209 | ||
| What is meant by the term sudden cardiac death (SCD)? | 209 | ||
| How might patients be evaluated? | 209 | ||
| What are the indications for an electrophysiological study? | 210 | ||
| Which treatments may be considered for patients at risk of SCD? | 210 | ||
| What is the role of genetic mutation analysis? | 210 | ||
| What is the value of tracing relatives? | 210 | ||
| Case 2.12 Atrial fibrillation | 211 | ||
| Candidate information | 211 | ||
| Role | 211 | ||
| Scenario | 211 | ||
| Patient information | 211 | ||
| How to approach the case | 211 | ||
| Data gathering in the interview and interpretation and use of information gathered | 211 | ||
| Presenting problem(s) and exploration of symptoms | 211 | ||
| Explore symptoms. | 212 | ||
| Consider potential complications. | 212 | ||
| Patient perspective | 212 | ||
| Past medical history | 212 | ||
| Drug and allergy history | 212 | ||
| Family history | 212 | ||
| Social history | 212 | ||
| Discussion | 212 | ||
| How common is AF? | 212 | ||
| Why is AF important? | 213 | ||
| What is the pathophysiology of AF? | 213 | ||
| How AF is sustained | 213 | ||
| Sequelae | 213 | ||
| Atrial factors | 213 | ||
| Electrophysiological mechanisms | 213 | ||
| Genetic predisposition | 213 | ||
| How is AF defined? | 213 | ||
| What types of AF are there? | 213 | ||
| What are the acute management priorities in AF? | 213 | ||
| Determination of symptoms | 214 | ||
| Estimation of stroke risk and consideration of other complications | 214 | ||
| Search for causes | 214 | ||
| What do you know about antithrombotic therapy in AF? | 214 | ||
| Risk stratification for stroke and thromboembolism | 214 | ||
| Antithrombotic therapy | 214 | ||
| Evidence for antithrombotic agents | 214 | ||
| Risk of bleeding | 215 | ||
| Optimal INR | 215 | ||
| AF in special situations | 215 | ||
| Paroxysmal AF | 215 | ||
| Perioperative anticoagulation | 215 | ||
| Stable vascular disease | 216 | ||
| Acute coronary syndrome and / or percutaneous coronary intervention (PCI) | 216 | ||
| Elective PCI | 216 | ||
| Acute stroke | 216 | ||
| Cardioversion | 216 | ||
| Atrial flutter | 216 | ||
| What do you know about acute rate and rhythm management in AF? | 216 | ||
| Acute rate control | 216 | ||
| Pharmacological cardioversion | 216 | ||
| Direct current cardioversion (DCCV) | 217 | ||
| When might you consider long-term rate control in AF and what might you use? | 217 | ||
| How might long-term rhythm control be achieved? | 217 | ||
| What non-pharmacological therapies are you aware of for AF? | 218 | ||
| How might you manage atrial flutter? | 218 | ||
| Case 2.13 Dyslipidaemia | 218 | ||
| Candidate information | 218 | ||
| Role | 218 | ||
| Scenario | 218 | ||
| Patient information | 218 | ||
| How to approach the case | 218 | ||
| Data gathering in the interview and interpretation and use of information gathered | 218 | ||
| Presenting problem(s) and symptom exploration | 218 | ||
| Patient perspective | 220 | ||
| Past medical history | 220 | ||
| Drug and allergy history | 220 | ||
| Family history | 220 | ||
| Social history | 220 | ||
| Discussion | 220 | ||
| Why is cholesterol important? | 220 | ||
| What are lipoproteins? | 221 | ||
| What types of apolipoprotein are there? | 221 | ||
| What happens to dietary (exogenous) lipids? (Fig. 2.6A) | 221 | ||
| What is endogenous lipid transport and metabolism? | 221 | ||
| How is lipid transported from the liver to peripheral tissues? (Fig. 2.6B) | 221 | ||
| What influences LDL levels as well as diet? | 221 | ||
| Why are increased LDL levels dangerous? | 223 | ||
| How is lipid transported from peripheral tissues to the liver? (Fig. 2.6C) | 223 | ||
| What is the association between CVD and cholesterol? | 223 | ||
| What is the average plasma TC concentration in the UK? | 223 | ||
| How would you investigate hypercholesterolaemia? | 223 | ||
| Are there other ways of assessing dyslipidaemia as well as serum lipid profiles? | 223 | ||
| What are the common dyslipidaemias? | 223 | ||
| What do you know about risk levels and treatment targets? | 223 | ||
| Risk levels and assessment | 223 | ||
| Treatment targets | 223 | ||
| How strong is the evidence for lipid-lowering therapy in reducing CVD risk? | 224 | ||
| What lipid-lowering therapies are there? | 224 | ||
| Might statins work in ways other than lipid lowering? | 224 | ||
| What is the clinical spectrum of statin-induced myopathy? | 224 | ||
| What are the risk factors for statin-induced myopathy? | 224 | ||
| Should creatine kinase be measured before starting statin therapy and monitored during statin therapy? | 226 | ||
| Should liver enzymes be checked in people on statin therapy? | 226 | ||
| How should we react to HDL levels on current evidence? | 226 | ||
| Is HDL cholesterol always good? | 226 | ||
| Is hypolipidaemia a problem? | 226 | ||
| Does management differ in familial hypercholesterolaemia compared with common hypercholesterolaemia? | 227 | ||
| Is the benefit of statin therapy as clear for stroke as for coronary heart disease? | 227 | ||
| Case 2.14 Hypertension | 227 | ||
| Candidate information | 227 | ||
| Role | 227 | ||
| Scenario | 227 | ||
| Patient information | 227 | ||
| How to approach the case | 227 | ||
| Data gathering in the interview and interpretation and use of information gathered | 227 | ||
| Presenting problem(s) and symptom exploration | 227 | ||
| Consider causes. | 227 | ||
| Patient perspective | 227 | ||
| Past medical history | 227 | ||
| Consider target organs. | 227 | ||
| Consider risk factors for cardiovascular disease. | 228 | ||
| Drug and allergy history | 228 | ||
| Family history | 228 | ||
| Social history | 228 | ||
| Discussion | 228 | ||
| How would you investigate hypertension in a young person? | 228 | ||
| Urinalysis, creatinine and electrolytes | 229 | ||
| Electrocardiography, chest radiography and renal ultrasonography | 229 | ||
| Measurement of plasma aldosterone and renin | 229 | ||
| 24-hour urinary-free catecholamines or plasma-free metanephrines | 229 | ||
| Renal imaging | 229 | ||
| How may the RAAS contribute to the pathophysiology of hypertension? | 229 | ||
| How is phaeochromocytoma managed? | 229 | ||
| Why is hypertension important? | 229 | ||
| How is hypertension defined? | 229 | ||
| How should blood pressure be measured? | 230 | ||
| Postural hypotension | 230 | ||
| How is hypertension diagnosed? | 231 | ||
| Clinic blood pressure | 231 | ||
| Confirming the diagnosis | 231 | ||
| Severe hypertension | 231 | ||
| Specialist investigations | 231 | ||
| Using ambulatory or home blood pressure monitoring | 231 | ||
| If hypertension is not diagnosed | 231 | ||
| How are cardiovascular risk and target organ damage assessed? | 231 | ||
| What lifestyle interventions should be considered for hypertension? | 231 | ||
| How should antihypertensive drug treatment be initiated and titrated? | 231 | ||
| How is treatment monitored? | 231 | ||
| What are the blood pressure targets? | 232 | ||
| What is the evidence for choice of antihypertensive therapy? | 232 | ||
| Prescribing steps if no compelling indications or contraindications | 232 | ||
| Compelling and potential indications and contraindications | 233 | ||
| What is the concern about ACE inhibitors and ARBs being used in combination? | 233 | ||
| Is isolated systolic hypertension (ISH) important in older people? | 234 | ||
| Neurological problems | 234 | ||
| Case 2.15 Headache | 234 | ||
| Candidate information | 234 | ||
| Role | 234 | ||
| Scenario | 235 | ||
| Patient information | 235 | ||
| How to approach the case | 235 | ||
| Data gathering in the interview and interpretation and use of information gathered | 235 | ||
| Presenting problem(s) and symptom exploration | 235 | ||
| Elicit details of the headaches. | 235 | ||
| Consider causes. | 235 | ||
| Patient perspective | 237 | ||
| Past medical history | 237 | ||
| Migraine | 237 | ||
| Tension-type headache (TTH) | 238 | ||
| Cluster headache | 238 | ||
| Medication overuse headache (MOH) | 238 | ||
| Drug and allergy history | 238 | ||
| Family history | 238 | ||
| Social history | 238 | ||
| Discussion | 238 | ||
| How are migraine attacks prevented and treated? | 238 | ||
| Is migraine linked with adverse vascular events? | 239 | ||
| How are cluster headaches and other trigeminal autonomic cephalgias treated? | 239 | ||
| How is a SAH diagnosed? | 239 | ||
| What is xanthochromia? | 239 | ||
| How is SAH managed? | 240 | ||
| List some causes of headache and fever | 240 | ||
| List some warning signs in meningococcal disease | 240 | ||
| What are the findings of a normal CSF examination? | 240 | ||
| Should patients with suspected bacterial meningitis be scanned before lumbar puncture? | 240 | ||
| What is the treatment of choice for bacterial meningitis? | 240 | ||
| When might you scan a patient with a headache? | 240 | ||
| Case 2.16 Transient ischaemic attack | 241 | ||
| Candidate information | 241 | ||
| Role | 241 | ||
| Scenario | 241 | ||
| Patient information | 241 | ||
| How to approach the case | 241 | ||
| Data gathering in the interview and interpretation and use of information gathered | 241 | ||
| Presenting problem(s) and symptom exploration | 241 | ||
| Elicit details of symptoms. | 241 | ||
| Consider other conditions that can produce focal neurological symptoms: | 241 | ||
| Patient perspective | 242 | ||
| Past medical history | 242 | ||
| Drug and allergy history | 242 | ||
| Family history | 242 | ||
| Social history | 242 | ||
| Discussion | 242 | ||
| Which investigations would you recommend for a patient following a suspected TIA? | 242 | ||
| How does carotid stenosis cause TIAs? | 242 | ||
| Why do recurrent TIAs often give rise to identical symptoms? | 243 | ||
| Why does carotid or vertebral dissection cause TIAs and strokes? | 243 | ||
| Why might a patent foramen ovale lead to stroke? | 243 | ||
| How may aortic arch disease or subclavian artery disease cause TIAs or strokes? | 243 | ||
| What are crescendo TIAs? | 244 | ||
| Which patients with a TIA are at highest risk of subsequent stroke? | 244 | ||
| How should patients with TIAs be managed following risk stratification? | 244 | ||
| High risk | 244 | ||
| Lower risk | 244 | ||
| Late presentation | 245 | ||
| What are the indications for brain imaging in those with a suspected TIA or non-disabling stroke? | 245 | ||
| High risk | 245 | ||
| Lower risk | 245 | ||
| What are the contraindications to MRI? | 245 | ||
| What are the indications for carotid imaging in those with a suspected TIA or non-disabling stroke? | 245 | ||
| How should carotid imaging results be interpreted and managed? | 245 | ||
| Would you consider referral for consideration of endarterectomy in a patient with asymptomatic carotid stenosis? | 245 | ||
| Do carotid stenoses merit treatment with warfarin? | 245 | ||
| Would you anticoagulate a patient with recurrent TIAs despite antiplatelet therapy? | 246 | ||
| How is carotid dissection managed? | 246 | ||
| What secondary prevention measures would you recommend for a patient after a suspected TIA? | 246 | ||
| Would you consider statin therapy in an 89-year-old following a TIA? | 246 | ||
| Case 2.17 Weakness and wasting | 246 | ||
| Candidate information | 246 | ||
| Role | 246 | ||
| Scenario | 246 | ||
| Patient information | 246 | ||
| How to approach the case | 247 | ||
| Data gathering in the interview and interpretation and use of information gathered | 247 | ||
| Presenting problem(s) and symptom exploration | 247 | ||
| Patient perspective | 247 | ||
| Past medical history | 247 | ||
| Drug and allergy history | 247 | ||
| Family history | 247 | ||
| Social history | 247 | ||
| Discussion | 247 | ||
| How might malignancy affect the nervous system? | 247 | ||
| What are the characteristic features of paraneoplastic syndromes? | 247 | ||
| What types of paraneoplastic syndrome do you know of? | 248 | ||
| Case 2.18 Multiple sclerosis | 248 | ||
| Candidate information | 248 | ||
| Role | 248 | ||
| Scenario | 248 | ||
| Patient information | 248 | ||
| How to approach the case | 249 | ||
| Data gathering in the interview and interpretation and use of information gathered | 249 | ||
| Presenting problem(s) and symptom exploration | 249 | ||
| Elicit the range of symptoms. | 249 | ||
| Consider the types of MS. | 249 | ||
| Consider differential diagnoses. | 249 | ||
| Patient perspective | 249 | ||
| Past medical history | 249 | ||
| Drug and allergy history | 249 | ||
| Family history | 249 | ||
| Social history | 249 | ||
| Discussion | 250 | ||
| What is MS? | 250 | ||
| What do you know about the epidemiology of MS? | 250 | ||
| What is the pathogenesis of MS? | 250 | ||
| Is MS one disease or many? | 250 | ||
| Do you know of any diagnostic criteria for MS? | 251 | ||
| How would you investigate a patient with possible MS? | 251 | ||
| What symptomatic treatments are used in MS? | 251 | ||
| How are acute relapses treated? | 251 | ||
| What disease-modifying treatments (DMTs) are used in MS? | 252 | ||
| Relapsing–remitting MS | 252 | ||
| Primary and secondary progressive MS | 252 | ||
| Novel potential treatments | 252 | ||
| What do you know about the course and prognosis of MS? | 252 | ||
| Case 2.19 Tremor | 252 | ||
| Candidate information | 252 | ||
| Role | 252 | ||
| Scenario | 252 | ||
| Patient information | 253 | ||
| How to approach the case | 253 | ||
| Data gathering in the interview and interpretation and use of information gathered | 253 | ||
| Presenting problem / s and symptom exploration | 253 | ||
| Patient perspective | 253 | ||
| Past medical history | 253 | ||
| Drug and alcohol history | 253 | ||
| Family history | 253 | ||
| Social history | 253 | ||
| Discussion | 253 | ||
| Are the any tests that can help distinguish the tremor in essential tremor from that in Parkinson’s disease? | 253 | ||
| What is restless leg syndrome (RLS)? | 253 | ||
| Rheumatological problems | 254 | ||
| Case 2.20 Back pain and osteoporosis | 254 | ||
| Candidate information | 254 | ||
| Role | 254 | ||
| Scenario | 255 | ||
| Patient information | 255 | ||
| How to approach the case | 255 | ||
| Data gathering in the interview and interpretation and use of information gathered | 255 | ||
| Presenting problem(s) and symptom exploration | 255 | ||
| Determine more about the back pain. | 255 | ||
| Consider osteoporosis symptoms. | 255 | ||
| Consider falls risk. | 255 | ||
| Patient perspective | 255 | ||
| Past medical history | 256 | ||
| Explore factors for risk of osteoporosis and fractures. | 256 | ||
| Drug and allergy history | 256 | ||
| Family history | 256 | ||
| Social history | 256 | ||
| Discussion | 256 | ||
| What is the scale of the osteoporosis problem? | 256 | ||
| What do you understand by bone remodelling? | 256 | ||
| Bone resorption | 257 | ||
| Bone formation | 257 | ||
| What regulates bone remodelling? | 257 | ||
| How do problems with bone remodelling lead to disease? | 257 | ||
| What is the pathophysiology of osteoporosis? | 257 | ||
| Bone mineral density (BMD) | 257 | ||
| Acquisition of peak bone mass | 258 | ||
| Bone loss | 258 | ||
| Fractures | 258 | ||
| How is osteoporosis defined? | 258 | ||
| How would you measure BMD? | 258 | ||
| Are there any other investigations you might consider in osteoporosis? | 258 | ||
| Do biochemical markers of bone turnover have an investigative place? | 258 | ||
| What treatments are there for osteoporosis? | 258 | ||
| How might you in practice approach the use of BMD measurement and primary and secondary prevention of osteoporosis fragility fractures? | 259 | ||
| NICE guidelines | 260 | ||
| Primary prevention (opportunistic) | 260 | ||
| Secondary prevention | 260 | ||
| NOGG guidelines | 260 | ||
| Is monitoring of BMD during treatment sensible? | 261 | ||
| When does glucocorticoid-induced osteoporosis begin? | 261 | ||
| Case 2.21 Joint pain | 261 | ||
| Candidate information | 261 | ||
| Role | 261 | ||
| Scenario | 261 | ||
| Patient information | 261 | ||
| How to approach the case | 262 | ||
| Data gathering in the interview and interpretation and use of information gathered | 262 | ||
| Presenting problem / s and symptom exploration | 262 | ||
| Determine if symptoms are localised to joints and the pattern and features of joint involvement. | 262 | ||
| Consider the differential diagnoses. | 262 | ||
| Patient perspective | 262 | ||
| Past medical history | 263 | ||
| Drug and allergy history | 263 | ||
| Family history | 263 | ||
| Social history | 263 | ||
| Discussion | 263 | ||
| Patients, especially older patients, often present with non-specific aches and decreased mobility. Do you have an approach to the differential diagnosis? | 263 | ||
| What do you know about septic arthritis? | 263 | ||
| Endocrine problems | 263 | ||
| Case 2.22 Type 1 diabetes mellitus | 263 | ||
| Candidate information | 263 | ||
| Role | 263 | ||
| Scenario | 263 | ||
| Patient information | 263 | ||
| How to approach the case | 263 | ||
| Data gathering in the interview and interpretation and use of information gathered | 263 | ||
| Presenting problem(s) and symptom exploration | 263 | ||
| Initial priorities in assessing a patient with newly diagnosed diabetes. | 263 | ||
| Presentation of type 1 diabetes. | 263 | ||
| Consider if admission to hospital is warranted. | 263 | ||
| Patient perspective | 264 | ||
| Past medical history | 264 | ||
| Drug and allergy history | 264 | ||
| Family history | 264 | ||
| Social history | 264 | ||
| Discussion | 264 | ||
| What is diabetes? | 264 | ||
| How is diabetes defined? | 264 | ||
| How is diabetes classified? | 264 | ||
| What do you know about maturity onset diabetes of the young (MODY) and how to recognise when other types of diabetes than types 1 or 2 may be the present? | 264 | ||
| Genetic mutations | 265 | ||
| Clinical features | 265 | ||
| Diagnosis | 265 | ||
| Patients diagnosed with type 1 diabetes who should be referred for genetic testing. | 265 | ||
| Patients diagnosed with type 2 diabetes who should be referred for genetic testing. | 265 | ||
| Treatment | 266 | ||
| What is diabetic ketoacidosis (DKA) and how is it treated? | 266 | ||
| How is type 1 diabetes managed? | 268 | ||
| What are the principles of nutrition in diabetes? | 268 | ||
| Does glycaemic control in type 1 diabetes reduce vascular complications? | 268 | ||
| Why does glycaemic control in diabetes tend to destabilise in hospital? | 268 | ||
| Why is hypoglycaemia dangerous? | 269 | ||
| How is hypoglycaemia normally detected? | 269 | ||
| What is the normal response to hypoglycaemia? | 270 | ||
| How problematic is hypoglycaemia in diabetes? | 270 | ||
| What are hypoglycaemia-associated autonomic failure (HAAF) and hypoglycaemic unawareness? | 270 | ||
| How is hypoglycaemia treated? | 270 | ||
| Can hypoglycaemia be predicted and prevented? | 270 | ||
| How would you tackle nocturnal hypoglycaemia? | 270 | ||
| Other than overly tight glucose control in diabetes, what other causes of hypoglycaemia are there? | 271 | ||
| What is hyperosmolar non-ketotic coma? | 271 | ||
| Case 2.23 Type 2 diabetes mellitus | 271 | ||
| Candidate information | 271 | ||
| Role | 271 | ||
| Scenario | 271 | ||
| Patient information | 271 | ||
| How to approach the case | 271 | ||
| Data gathering in the interview and interpretation and use of information gathered | 271 | ||
| Presenting problem(s) and symptom exploration | 271 | ||
| Elicit the range of symptoms and complications. | 271 | ||
| Patient perspective | 271 | ||
| Past medical history | 272 | ||
| Drug and allergy history | 272 | ||
| Family history | 272 | ||
| Social history | 272 | ||
| Discussion | 272 | ||
| What is the scale of the problem of type 2 diabetes? | 272 | ||
| What causes type 2 diabetes? | 272 | ||
| Insulin resistance | 272 | ||
| Beta-cell failure | 272 | ||
| How is diabetes care best coordinated? | 272 | ||
| Why is glycaemic control in type 2 diabetes important? | 273 | ||
| Acute glycaemic management | 273 | ||
| The UK Prospective Diabetes Study (UKPDS) and long-term gylcaemic control | 273 | ||
| Which groups of hypoglycaemic agent are used in type 2 diabetes? | 274 | ||
| How would you approach using glycaemic control agents in type 2 diabetes in practice? | 275 | ||
| First-line therapy – metformin | 275 | ||
| Second-line therapy – sulphonylureas, DPP-4 inhibitors, thiazolidinediones | 275 | ||
| Sulphonylureas | 275 | ||
| DPP-4 inhibitors and thiazolidinediones | 275 | ||
| Third-line therapy – sitagliptin, GLP-1 mimetics | 275 | ||
| The role of insulin | 275 | ||
| What other measures are important in reducing complications in type 2 diabetes? | 275 | ||
| Blood pressure | 276 | ||
| Lipid lowering | 277 | ||
| What do you know about diabetic nephropathy? | 277 | ||
| What do you know about diabetic neuropathy? | 278 | ||
| What do you know about the diabetic foot? | 278 | ||
| What do you know about sexual dysfunction in diabetes? | 278 | ||
| Eye problems | 278 | ||
| Case 2.24 Visual loss | 278 | ||
| Candidate information | 278 | ||
| Role | 278 | ||
| Scenario | 278 | ||
| Patient information | 279 | ||
| How to approach the case | 279 | ||
| Data gathering in the interview and interpretation and use of information gathered | 279 | ||
| Presenting problem / s and symptom exploration | 279 | ||
| Explore visual loss. | 279 | ||
| Ask about colours or shapes. | 279 | ||
| Patient perspective | 279 | ||
| Past medical history | 279 | ||
| Drug and allergy history | 279 | ||
| Family history | 279 | ||
| Social history | 279 | ||
| Discussion | 279 | ||
| What is glaucoma? | 279 | ||
| What are the visual requirements for driving? | 279 | ||
| Renal and metabolic problems | 279 | ||
| Case 2.25 Acute kidney injury | 279 | ||
| Candidate information | 279 | ||
| Role | 279 | ||
| Scenario | 280 | ||
| Patient information | 280 | ||
| How to approach the case | 280 | ||
| Data gathering in the interview and interpretation and use of information gathered | 280 | ||
| Presenting problem(s) and symptom exploration | 280 | ||
| Ensure safety. | 280 | ||
| Consider risk factors and possible causes. | 280 | ||
| Consider effects. | 280 | ||
| Symptoms. | 280 | ||
| Fluid status. | 281 | ||
| Metabolic status. | 282 | ||
| Patient perspective | 282 | ||
| Past medical history | 283 | ||
| Drug and allergy history | 283 | ||
| Family history | 283 | ||
| Social history | 283 | ||
| Discussion | 283 | ||
| What investigations are important in newly detected renal failure? | 283 | ||
| Urinalysis | 283 | ||
| Blood tests | 284 | ||
| Electrocardiogram and chest X-ray | 284 | ||
| Renal tract ultrasound | 284 | ||
| Renal biopsy | 284 | ||
| What do you understand by the term acute tubular necrosis or injury (ATN or ATI)? | 284 | ||
| How may pre-kidney AKI be distinguished from established ATN or oliguric AKI? | 284 | ||
| What are the management principles in an acute uraemic emergency? | 284 | ||
| Treat the effects | 284 | ||
| Establish and treat the cause | 284 | ||
| Establish reversibility | 286 | ||
| How would you manage a patient with renal and heart failure who has pulmonary oedema but is hypotensive? | 286 | ||
| What are the indications for urgent haemodialysis? | 287 | ||
| How is serum potassium concentration regulated and what are the causes of hypokalaemia and hyperkalaemia? (Table 2.56) | 287 | ||
| How would you treat hypokalaemia? | 287 | ||
| Case 2.26 Chronic kidney disease | 287 | ||
| Candidate information | 287 | ||
| Role | 287 | ||
| Scenario | 287 | ||
| Patient information | 287 | ||
| How to approach the case | 287 | ||
| Data gathering in the interview and interpretation and use of information gathered | 287 | ||
| Presenting problem(s) and symptom exploration | 287 | ||
| Patient perspective | 287 | ||
| Past medical history | 288 | ||
| Drug and allergy history | 288 | ||
| Family history | 288 | ||
| Social history | 288 | ||
| Discussion | 288 | ||
| Why is CKD important? | 288 | ||
| What causes CKD? | 288 | ||
| How is CKD defined and classified and how does this aid management? | 288 | ||
| What do you understand by the term glomerular filtration rate (GFR)? | 288 | ||
| What do the renal tubules do? | 288 | ||
| How is GFR derived? | 288 | ||
| Why is GFR a better marker of renal function than serum creatinine? | 288 | ||
| Why is proteinuria important? | 290 | ||
| Types of proteinuria | 290 | ||
| Quantification of proteinuria | 290 | ||
| Why is early detection of CKD important? | 290 | ||
| Which people should be targeted for early detection of CKD? | 290 | ||
| How may acute kidney injury be distinguished from CKD? | 291 | ||
| What strategies can slow the rate of progression of CKD? | 291 | ||
| How should hypertension be managed in CKD? | 291 | ||
| What is the rationale for using ACE inhibitors or angiotensin II receptor blockers (ARBs) in diabetic nephropathy? | 291 | ||
| What is the rationale for using ACE inhibitors or ARBs in non-diabetic nephropathy? | 291 | ||
| How do ACE inhibitors and ARBs delay progression of CKD? | 292 | ||
| Should ACE inhibitors or ARBs be stopped if serum creatinine rises? | 292 | ||
| Why might ACE inhibitors or ARBs be dangerous in renal artery stenosis (RAS)? (Fig. 2.9) | 292 | ||
| What do you know about renal metabolic bone disease or osteodystrophy in CKD? | 292 | ||
| Why is CKD associated with accelerated CVD? | 292 | ||
| What do you know about anaemia in CKD? | 292 | ||
| What forms of renal replacement therapy (RRT) are there? | 292 | ||
| Haemodialysis (Fig. 2.10) | 292 | ||
| Peritoneal dialysis | 295 | ||
| Renal transplantation | 295 | ||
| Why is dialysis use increasing? | 295 | ||
| When should dialysis be started? | 295 | ||
| When might dialysis be considered inappropriate and ‘maximal conservative treatment’ appropriate? | 295 | ||
| Case 2.27 Glomerulonephritis | 296 | ||
| Candidate information | 296 | ||
| Role | 296 | ||
| Scenario | 296 | ||
| Patient information | 296 | ||
| How to approach the case | 296 | ||
| Data gathering in the interview and interpretation and use of information gathered | 296 | ||
| Presenting problem(s) and symptom exploration | 296 | ||
| Establish the range of symptoms. | 296 | ||
| Consider possible causes of haematuria and the significance of haematuria and proteinuria. | 296 | ||
| Patient perspective | 296 | ||
| Past medical history | 297 | ||
| Drug and allergy history | 297 | ||
| Family history | 297 | ||
| Social history | 297 | ||
| Discussion | 298 | ||
| To whom should patients with haematuria be referred? | 298 | ||
| Urology referral | 298 | ||
| Nephrology referral | 298 | ||
| Surveillance | 298 | ||
| What is glomerular disease? | 298 | ||
| How may GN be classified? | 298 | ||
| How prevalent is GN? | 298 | ||
| What are the common types of GN? | 298 | ||
| Which types of GN tend to progress to stage 5 chronic kidney disease (CKD)? | 298 | ||
| What treatments are there for GN? | 298 | ||
| What is anti-GBM disease or Goodpasture’s disease? | 298 | ||
| What is Alport’s syndrome? | 301 | ||
| What is thin basement membrane nephropathy? | 301 | ||
| Case 2.28 Systemic vasculitis | 301 | ||
| Candidate information | 301 | ||
| Role | 301 | ||
| Scenario | 301 | ||
| Patient information | 301 | ||
| How to approach the case | 301 | ||
| Data gathering in the interview and interpretation and use of information gathered | 301 | ||
| Presenting problem(s) and symptom exploration | 301 | ||
| Patient perspective | 301 | ||
| Past medical history | 301 | ||
| Drug and allergy history | 303 | ||
| Family history | 303 | ||
| Social history | 303 | ||
| Discussion | 303 | ||
| What is vasculitis? | 303 | ||
| What types of vasculitis are there? | 303 | ||
| Why are vasculitides important to recognise? | 303 | ||
| What do you know about the epidemiology of ANCA-associated vasculitis? | 304 | ||
| What causes ANCA-asscociated vasculitis? | 304 | ||
| What is the role of ANCA in the pathogenesis of ANCA-associated vasculitis? | 304 | ||
| ANCA correlation with disease | 305 | ||
| How is ANCA-associated vasculitis diagnosed? | 305 | ||
| How is ANCA-associated vasculitis treated? | 305 | ||
| Standard treatment to induce remission | 306 | ||
| Maintenance treatment | 306 | ||
| Longer term and risk of relapse | 307 | ||
| Newer therapeutic agents | 307 | ||
| Specialist otolaryngological management of patients with granulomatosis with polyangiitis | 307 | ||
| Monitoring | 307 | ||
| Disease flares | 307 | ||
| What is the prognosis in ANCA-associated vasculitis? | 308 | ||
| What is Henoch–Schönlein purpura? | 308 | ||
| What is polyarteritis nodosa? | 308 | ||
| What is Takayasu’s arteritis? | 308 | ||
| What is Behçet’s diease? | 308 | ||
| Case 2.29 Hypercalcaemia | 308 | ||
| Candidate information | 308 | ||
| Role | 308 | ||
| Scenario | 308 | ||
| Patient information | 308 | ||
| How to approach the case | 309 | ||
| Data gathering in the interview and interpretation and use of information gathered | 309 | ||
| Presenting problem(s) and symptom exploration | 309 | ||
| Explore symptoms of hypercalcaemia. | 309 | ||
| Explore the worrying symptoms. | 309 | ||
| Patient perspective | 309 | ||
| Past medical history | 309 | ||
| Drug and allergy history | 309 | ||
| Family history | 309 | ||
| Social history | 309 | ||
| Discussion | 309 | ||
| What are the causes of hypercalcaemia? | 309 | ||
| What is familial hypocalciuric hypercalcaemia (FHH)? | 309 | ||
| How does PHPT present? | 310 | ||
| How is PHPT managed? | 310 | ||
| What are the pros and cons of treating mild PHPT conservatively? | 310 | ||
| Cardiovascular risk with mild PHPT | 310 | ||
| Cancer with mild PHPT | 311 | ||
| What medical treatments are possible in mild asymptomatic PHPT? | 311 | ||
| Bisphosphonates | 311 | ||
| Cinacalcet | 311 | ||
| What are the possible endocrine manifestations of malignancy? | 311 | ||
| What are secondary and tertiary hyperparathyroidism? | 311 | ||
| What happens to serum levels of alkaline phosphatase in hyperparathyroidism? | 311 | ||
| How is serum calcium normally regulated? | 311 | ||
| Parathyroid hormone (PTH) | 311 | ||
| Vitamin D | 312 | ||
| What are the causes of hypocalcaemia? | 312 | ||
| How may hypocalcaemia present? | 312 | ||
| What is ‘simple’ vitamin D deficiency and how does it differ from vitamin D deficiency with secondary hyperparathyroidism? | 312 | ||
| What are the clinical manifestations of vitamin D deficiency? | 313 | ||
| What is pseudohypoparathyroidism? | 313 | ||
| What is pseudopseudohypoparathyroidism? | 313 | ||
| How might you approach assessing for causes of hypocalcaemia? | 314 | ||
| What levels of calcium are worrying? | 314 | ||
| How should hypocalcaemia be treated? | 314 | ||
| Acute hypocalcaemia | 314 | ||
| Persistent control – vitamin D deficiency | 314 | ||
| Persistent control – hypoparathyroidism | 314 | ||
| Is hypophosphataemia a problem? | 314 | ||
| Case 2.30 Hyponatraemia | 315 | ||
| Candidate information | 315 | ||
| Role | 315 | ||
| Scenario | 315 | ||
| Patient information | 315 | ||
| How to approach the case | 315 | ||
| Data gathering in the interview and interpretation and use of information gathered | 315 | ||
| Presenting problem(s) and symptom exploration | 315 | ||
| Patient perspective | 315 | ||
| Past medical history | 315 | ||
| Drug and allergy history | 315 | ||
| Family history | 315 | ||
| Social history | 315 | ||
| Discussion | 315 | ||
| How is fluid distributed throughout the body? | 315 | ||
| How are the ICF and ECF compartments maintained? | 316 | ||
| How is intravascular plasma volume and ISF balance maintained? | 316 | ||
| How does oedema arise? | 316 | ||
| What are the normal intake and urine fluid volumes and sodium concentrations? | 316 | ||
| What is osmolality? | 316 | ||
| How is sodium regulated? | 316 | ||
| What happens to serum osmolality in dehydration? | 317 | ||
| What happens to salt and water in stress? | 317 | ||
| What are the causes of hyponatraemia? | 317 | ||
| Pseudohyponatraemia | 317 | ||
| True hyponatraemia | 317 | ||
| What are the consequences of hyponatraemia? | 318 | ||
| Clinical features and rate of change | 318 | ||
| Brain adaptation | 318 | ||
| What is central pontine myelinosis? | 318 | ||
| How should hyponatraemia be treated? | 318 | ||
| Treatment principles | 318 | ||
| Correction rates | 318 | ||
| What are the causes of hypernatraemia? | 320 | ||
| What are the consequences of hypernatraemia? | 320 | ||
| How is hypernatraemia treated? | 320 | ||
| What are the causes of polyuria? | 320 | ||
| What is the water deprivation test? | 320 | ||
| 1. Dehydration step: 8-hour water deprivation | 321 | ||
| 2. Desmopressin step | 321 | ||
| What are the principles of fluid management on a medical ward? | 321 | ||
| Assessing fluid balance | 321 | ||
| Fluid choice and administration | 321 | ||
| Case 2.31 Poisoning and metabolic disturbance | 322 | ||
| Candidate information | 322 | ||
| Role | 322 | ||
| Scenario | 322 | ||
| Patient information | 323 | ||
| How to approach the case | 323 | ||
| Data gathering in the interview and interpretation and use of information gathered | 323 | ||
| Presenting problem(s) and symptom exploration | 323 | ||
| Establish facts about the overdose. | 323 | ||
| Establish events around the overdose. | 323 | ||
| Assess suicide risk. | 323 | ||
| Patient perspective | 323 | ||
| Past medical history | 323 | ||
| Drug and allergy history | 323 | ||
| Family history | 323 | ||
| Social history | 323 | ||
| Discussion | 323 | ||
| How is acid–base balance regulated? | 323 | ||
| What acid–base balance disturbances do you know of? | 323 | ||
| What are the causes of metabolic acidosis? | 324 | ||
| Increased anion gap metabolic acidosis | 324 | ||
| Normal anion gap metabolic acidosis | 324 | ||
| What are the causes of metabolic alkalosis? | 324 | ||
| What are the causes of respiratory acidosis? | 324 | ||
| What are the causes of respiratory alkalosis? | 324 | ||
| Do you know anything about ethylene glycol and methanol poisoning? | 324 | ||
| What is the role of the proximal tubule and what disorders can occur here? | 325 | ||
| What is the role of the loop of Henle, and how do loop diuretics work? | 325 | ||
| What is Bartter’s syndrome? | 325 | ||
| How do thiazide diuretics work? | 325 | ||
| What is Gitelman’s syndrome? | 325 | ||
| What is the role of the terminal distal tubule and what is the effect of aldosterone here? | 325 | ||
| What is the role of the collecting duct and antidiuretic hormone (ADH)? | 325 | ||
| What is RTA? | 325 | ||
| Type 1 or distal RTA | 325 | ||
| Type 2 or proximal RTA | 326 | ||
| Type 4 RTA (associated aldosterone deficiency or resistance) | 326 | ||
| What is the current profile of drug addiction? | 326 | ||
| Traditional drugs of misuse | 326 | ||
| Novel recreational drugs | 326 | ||
| Treatment | 327 | ||
| Haematological problems | 327 | ||
| Case 2.32 Anaemia | 327 | ||
| Candidate information | 327 | ||
| Role | 327 | ||
| Scenario | 328 | ||
| Patient information | 328 | ||
| How to approach the case | 328 | ||
| Presenting problem / s and symptom exploration | 328 | ||
| Consider possible causes. | 328 | ||
| Ask about symptoms. | 328 | ||
| Patient perspective | 328 | ||
| Past medical history | 328 | ||
| Drug and allergy history | 328 | ||
| Family history | 328 | ||
| Social history | 328 | ||
| Discussion | 328 | ||
| What is anaemia? | 328 | ||
| What are the general signs of anaemia? | 328 | ||
| What do you know about iron uptake, transport and storage? | 329 | ||
| What are the causes of microcytic anaemia and how would you differentiate iron deficiency anaemia from other causes of microcytic anaemia and other anaemais with altered iron status? | 329 | ||
| How is sideroblastic anaemia treated? | 329 | ||
| What is anaemia of chronic disease? | 329 | ||
| List some causes of normochromic–normocytic anaemia | 329 | ||
| What is megaloblastic anaemia? | 329 | ||
| List some conditions that can cause macrocytosis | 329 | ||
| List some causes of vitamin B12 or folate deficiency | 330 | ||
| What abnormalities may appear on a megaloblastic peripheral blood film? | 330 | ||
| What is ‘pernicious’ anaemia? | 330 | ||
| What are the complications of B12 deficiency? | 331 | ||
| How would you treat B12 deficiency? | 331 | ||
| Is there a risk in administering a blood transfusion in the setting of B12 deficiency? | 331 | ||
| Are there risks in giving folate in the setting of B12 deficiency? | 331 | ||
| Is red cell folate a better marker of tissue folate status than serum folate? | 331 | ||
| If both folate and iron levels are low, what condition would you screen for? | 331 | ||
| What is haemolytic anaemia? | 331 | ||
| What are the laboratory findings in haemolytic anaemia? | 331 | ||
| What is reticulocytosis? | 331 | ||
| When might you suspect a haemolysed blood sample? | 331 | ||
| What are the causes of haemolytic anaemia? | 331 | ||
| How is autoimmune haemolytic anaemia (AIHA) detected? | 332 | ||
| What types of AIHA are there? | 332 | ||
| How would you treat AIHA? | 332 | ||
| List some other autoimmune cytopenias | 332 | ||
| What is schistocytosis? | 332 | ||
| What is paroxysmal nocturnal haemoglobinuria? | 332 | ||
| What are Howell–Jolly bodies? | 332 | ||
| What is aplastic anaemia? | 332 | ||
| What is myelodysplasia? | 333 | ||
| How might you manage pancytopenia of any cause? | 333 | ||
| Case 2.33 Sickle cell disease and thalassaemia | 333 | ||
| Candidate information | 333 | ||
| Role | 333 | ||
| Scenario | 333 | ||
| Patient information | 333 | ||
| How to approach the case | 333 | ||
| Presenting problem(s) and symptom exploration | 333 | ||
| Evaluate symptoms. | 333 | ||
| Patient perspective | 333 | ||
| Past medical history | 333 | ||
| Drug and allergy history | 333 | ||
| Family history | 333 | ||
| Social history | 333 | ||
| Discussion | 334 | ||
| How might abnormalities in red cell components give rise to inherited anaemia? | 334 | ||
| Hereditary spherocytosis and abnormalities of the red cell membrane | 334 | ||
| Enzymopathies | 334 | ||
| Haemoglobinopathies – SCD and thalassaemias | 334 | ||
| What is the underlying abnormality in SCD? | 334 | ||
| What types of SCD are there? | 335 | ||
| How is SCD diagnosed? | 335 | ||
| How can complications of SCD be prevented and treated? | 335 | ||
| Pain | 335 | ||
| Preventing infection | 335 | ||
| Acute chest syndrome | 335 | ||
| Pulmonary hypertension | 335 | ||
| Stroke | 335 | ||
| Priapism | 335 | ||
| What are the risks of general anaesthesia in SCD? | 335 | ||
| What are the risks in pregnancy in SCD? | 336 | ||
| What are the thalassaemias and how do they arise? | 336 | ||
| What types of α-thalassaemia are there and how are they diagnosed? | 336 | ||
| What types of β-thalassaemia are there? | 336 | ||
| How are patients with thalassaemia treated? | 336 | ||
| Asymptomatic carriers | 336 | ||
| Thalassaemia intermedia | 336 | ||
| Thalassaemia major | 337 | ||
| Alternative therapeutic options | 337 | ||
| Potential cure | 337 | ||
| Case 2.34 Purpura | 338 | ||
| Candidate information | 338 | ||
| Role | 338 | ||
| Scenario | 338 | ||
| Patient information | 338 | ||
| How to approach the case | 338 | ||
| Data gathering in the interview and interpretation and use of information gathered | 338 | ||
| Presenting problem(s) and symptom exploration | 338 | ||
| Establish purpura details. | 338 | ||
| Ask specific questions. | 338 | ||
| Patient perspective | 338 | ||
| Past medical history | 338 | ||
| Drug and allergy history | 338 | ||
| Family history | 339 | ||
| Social history | 339 | ||
| Discussion | 339 | ||
| How is haemostasis regulated? | 339 | ||
| How does the endothelium contribute to haemostatic homeostasis? (Fig. 2.11A) | 339 | ||
| List some vascular disorders that cause purpura | 339 | ||
| How do platelets contribute to thrombus formation? (Fig. 2.11B) | 339 | ||
| Platelet adhesion | 339 | ||
| Platelet activation | 340 | ||
| Platelet aggregation | 340 | ||
| How do antiplatelet agents work? | 340 | ||
| List some platelet disorders that cause a bleeding tendency | 340 | ||
| What is idiopathic thrombocytopenic purpura? | 340 | ||
| What are the thrombotic microangiopathies? | 341 | ||
| At what level of thrombocytopenia does purpura start to appear? | 341 | ||
| Do you know of any recent advances in the understanding of blood coagulation (Fig. 2.11C)? | 341 | ||
| The coagulation ‘jigsaw’ | 341 | ||
| The central role of TF and factor VIIa | 341 | ||
| Why factor Xa is so important | 341 | ||
| Not forgetting factor Va and the prothrombinase complex | 342 | ||
| And finally, the importance of thrombin | 342 | ||
| Natural anticoagulation mechanisms | 342 | ||
| List some coagulation disorders that cause a bleeding tendency | 342 | ||
| Case 2.35 Haemophilia | 342 | ||
| Station 3 Cardiovascular and nervous system | 451 | ||
| Contents | 451 | ||
| Cardiovascular system | 452 | ||
| Examination of the cardiovascular system | 452 | ||
| Inspection | 452 | ||
| Hands and arms | 452 | ||
| Face and neck | 452 | ||
| Jugular venous pulse (JVP) | 452 | ||
| Chest wall | 453 | ||
| Palpation | 453 | ||
| Arterial pulse | 453 | ||
| Blood pressure | 453 | ||
| Apex | 455 | ||
| Right ventricular parasternal lift | 455 | ||
| Palpable heart sounds and murmurs (‘thrills’) | 456 | ||
| Predicting valve abnormalities before auscultation | 456 | ||
| Percussion | 456 | ||
| Auscultation | 456 | ||
| Auscultation sites | 456 | ||
| Heart sounds | 456 | ||
| First heart sound (S1). | 457 | ||
| Second heart sound (S2). | 457 | ||
| Third heart sound (S3). | 457 | ||
| Fourth heart sound (S4). | 457 | ||
| Added sounds | 457 | ||
| Murmurs | 457 | ||
| Murmurs and physiological manoeuvres | 459 | ||
| Murmurs and respiration. | 459 | ||
| Murmurs and dynamic auscultation. | 459 | ||
| Additional examination | 459 | ||
| Summary | 460 | ||
| Cases | 462 | ||
| Case 3.1 Mitral stenosis | 462 | ||
| Instruction | 462 | ||
| Recognition | 462 | ||
| Interpretation | 462 | ||
| Confirm the diagnosis | 462 | ||
| What to do next – consider causes | 463 | ||
| Consider severity / decompensation / complications | 463 | ||
| Consider function | 463 | ||
| Discussion | 464 | ||
| What happens to the valve pathologically? | 464 | ||
| What is the most common presenting symptom of mitral stenosis? | 464 | ||
| Why should patients experience exertional dyspnoea? | 464 | ||
| What other symptoms may occur in mitral stenosis? | 464 | ||
| How does pulmonary hypertension arise? | 464 | ||
| What are the diagnostic criteria for rheumatic fever? | 464 | ||
| List some features the electrocardiogram (ECG) might show in mitral stenosis | 464 | ||
| List some features the chest X-ray might show in mitral stenosis | 464 | ||
| What might echocardiography be used to assess in mitral stenosis? | 464 | ||
| What is the place of cardiac catheterisation? | 465 | ||
| How might you clinically detect if there is significant concomitant mitral regurgitation? | 465 | ||
| Which treatments may be considered for mitral stenosis? | 465 | ||
| Case 3.2 Mitral regurgitation | 465 | ||
| Instruction | 465 | ||
| Recognition | 465 | ||
| Interpretation | 466 | ||
| Confirm the diagnosis | 466 | ||
| What to do next – consider causes | 466 | ||
| Primary (valve problem) | 466 | ||
| Secondary (left ventricular problem) | 466 | ||
| Consider severity / decompensation / complications | 466 | ||
| Consider function | 466 | ||
| Discussion | 466 | ||
| What is the pathophysiology of mitral regurgitation and does it tend to progress? | 466 | ||
| List some features the electrocardiogram (ECG) might show in mitral regurgitation | 466 | ||
| List some features the chest X-ray might show in mitral regurgitation | 466 | ||
| What other investigations are available in VHD? | 466 | ||
| What treatments may be considered for mitral regurgitation? | 466 | ||
| Case 3.3 Aortic stenosis | 467 | ||
| Instruction | 467 | ||
| Recognition | 467 | ||
| Interpretation | 467 | ||
| Confirm the diagnosis | 467 | ||
| What to do next – consider causes | 467 | ||
| Consider severity / decompensation / complications | 467 | ||
| Consider function | 467 | ||
| Discussion | 468 | ||
| How does the pathophysiology of aortic stenosis correlate with the pulse, pulse pressure and murmur? | 468 | ||
| Why might patients with aortic stenosis develop angina? | 468 | ||
| Is there a difference between aortic sclerosis and aortic stenosis? | 468 | ||
| How does calcific aortic stenosis arise? | 468 | ||
| Do you know of any unusual anaemia associations with aortic stenosis? | 468 | ||
| List some other forms of left ventricular outflow obstruction | 468 | ||
| List some features the electrocardiogram (ECG) might show in aortic stenosis | 468 | ||
| What might the chest X-ray show in aortic stenosis? | 468 | ||
| How is aortic stenosis severity determined by echocardiography? | 468 | ||
| What is the rate of progression of aortic stenosis? | 469 | ||
| Which drugs should be used with caution or avoided? | 469 | ||
| What treatments may be considered for aortic stenosis? | 469 | ||
| Case 3.4 Aortic regurgitation | 469 | ||
| Instruction | 469 | ||
| Recognition | 469 | ||
| Interpretation | 469 | ||
| Confirm the diagnosis | 469 | ||
| What to do next – consider causes | 469 | ||
| Consider severity / decompensation / complications | 470 | ||
| Consider function | 470 | ||
| Discussion | 471 | ||
| How does the pathophysiology of aortic regurgitation correlate with the pulse, pulse pressure and murmur? | 471 | ||
| What might the electrocardiogram (ECG) show in aortic regurgitation? | 471 | ||
| List some features the chest X-ray might show in aortic regurgitation | 471 | ||
| What treatments may be considered for aortic regurgitation? | 471 | ||
| Case 3.5 Tricuspid regurgitation and Ebstein’s anomaly | 471 | ||
| Instruction | 471 | ||
| Recognition | 471 | ||
| Interpretation | 471 | ||
| Confirm the diagnosis | 471 | ||
| What to do next – consider causes | 471 | ||
| Consider severity / decompensation / complications | 472 | ||
| Consider function | 472 | ||
| Discussion | 472 | ||
| What other right-sided valve abnormalities do you know of? | 472 | ||
| What are the indications for surgery in tricuspid regurgitation? | 472 | ||
| What do you know about Ebstein’s anomaly? | 472 | ||
| Case 3.6 Other right-sided heart murmurs | 472 | ||
| Instruction | 472 | ||
| Recognition | 472 | ||
| Interpretation | 472 | ||
| Confirm the diagnosis | 472 | ||
| What to do next – consider causes | 472 | ||
| Station 4 Communication skills and ethics | 615 | ||
| Contents | 615 | ||
| Introduction to communication skills and ethics | 616 | ||
| Communication skills | 616 | ||
| Effective communication | 616 | ||
| Doctor- and patient-centred communication | 616 | ||
| Ethics | 617 | ||
| The importance of ethical decision making | 617 | ||
| Ethical principles | 617 | ||
| Applying ethical principles | 617 | ||
| A word on dignity | 617 | ||
| Cases | 618 | ||
| Discussing clinical management | 618 | ||
| Case 4.1 Explaining a diagnosis | 618 | ||
| Candidate information | 618 | ||
| Role | 618 | ||
| Scenario | 618 | ||
| Patient / subject information | 618 | ||
| How to approach the case | 618 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 618 | ||
| 1. Introduction | 618 | ||
| 2. Clarify the task | 619 | ||
| 3. Establish previous experience | 619 | ||
| 4. Be alert to ideas, concerns and expectations | 619 | ||
| 5. Frame the explanation | 619 | ||
| 6. Keep it clear | 619 | ||
| 7. Repeat important information | 619 | ||
| 8. Confirm understanding | 619 | ||
| 9. Encourage feedback and invite questions | 619 | ||
| 10. Agree a way forward | 619 | ||
| Discussion | 619 | ||
| Would you tell her that her condition is incurable, if she asked? | 619 | ||
| Case 4.2 Explaining an investigation | 619 | ||
| Candidate information | 619 | ||
| Role | 619 | ||
| Scenario | 620 | ||
| Patient / subject information | 620 | ||
| How to approach the case | 620 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 620 | ||
| 1. Introduction | 620 | ||
| 2. Clarify the task | 620 | ||
| 3. Establish previous experience | 620 | ||
| 4. Be alert to ideas, concerns and expectations | 620 | ||
| 5. Frame the explanation | 620 | ||
| 6. Keep it clear | 620 | ||
| 7. Repeat important information | 620 | ||
| 8. Confirm understanding | 620 | ||
| 9. Encourage feedback and invite questions | 621 | ||
| 10. Seek consent | 621 | ||
| Discussion | 621 | ||
| An 86-year-old woman with moderately severe dementia has a suspicious lesion on chest X-ray. Would you recommend bronchoscopy? | 621 | ||
| What do you understand by the terms sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)? | 621 | ||
| Sensitivity | 621 | ||
| Specificity | 621 | ||
| Positive predictive value (PPV) | 621 | ||
| Negative predictive value (NPV) | 621 | ||
| Explain the terms pre-test probability and post-test probability | 621 | ||
| What criteria are important in determining whether or not to implement a screening test for a disease? | 622 | ||
| What is meant by a valid and reliable test? | 622 | ||
| Which factors may influence a decision to investigate older people? | 622 | ||
| Case 4.3 Discussing treatment | 622 | ||
| Candidate information | 622 | ||
| Role | 622 | ||
| Scenario | 622 | ||
| Patient / subject information | 622 | ||
| How to approach the case | 622 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 622 | ||
| 1. Introduction | 622 | ||
| 2. Explain the reasons for considering treatment | 623 | ||
| 3. Give the patient a chance to react to the need for treatment | 623 | ||
| 4. Be alert to ideas, concerns and expectations | 623 | ||
| 5. Explain the likely benefits of treatment | 623 | ||
| 6. Explain what the treatment involves | 623 | ||
| 7. Explain likely side effects of treatment | 623 | ||
| 8. Encourage feedback and invite questions | 623 | ||
| 9. Seek consent | 623 | ||
| 10. Respect autonomy | 623 | ||
| Discussion | 623 | ||
| Are you more reluctant to prescribe medications for older people? | 623 | ||
| Is drug treatment for coronary syndromes the same for older as younger patients? | 623 | ||
| Is treatment for hypertension the same for older as younger patients? | 623 | ||
| Is treatment for hyperlipidaemia the same for older as younger patients? | 623 | ||
| Is warfarin justified in patients aged over 75 years with atrial fibrillation? | 624 | ||
| What do you know about drug-induced disease? | 624 | ||
| What do you know about adverse drug reactions (ADRs)? | 624 | ||
| Are pharmaceutical companies and pharmaceutical representatives to be considered favourably by doctors? | 624 | ||
| What do you know about drug licensing? | 625 | ||
| Case 4.4 Discussing management, prognosis and possible complications in a patient with multiple problems | 625 | ||
| Candidate information | 625 | ||
| Role | 625 | ||
| Scenario | 625 | ||
| Patient / subject information | 625 | ||
| How to approach the case | 625 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 625 | ||
| 1. Introduction | 625 | ||
| 2. Know how to deal with multiple problems | 625 | ||
| 3. Take one step at a time | 625 | ||
| 4. Obtain the facts | 626 | ||
| 5. Explore concerns | 626 | ||
| 6. Discuss management options with a clear framework | 626 | ||
| 7. Discuss potential prognoses and possible complications of any diagnoses (with and without treatment) or treatments | 626 | ||
| 8. Prioritise … but do not forget unturned stones | 626 | ||
| 9. Encourage feedback and invite questions | 626 | ||
| 10. Agree a way forward and ensure follow-up arrangements are in place | 626 | ||
| Discussion | 626 | ||
| What issues should you be generally aware of when managing older people? | 626 | ||
| Case 4.5 Discussing diagnostic uncertainty | 626 | ||
| Candidate information | 626 | ||
| Role | 626 | ||
| Scenario | 626 | ||
| Patient / subject information | 627 | ||
| How to approach the case | 627 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 627 | ||
| 1. Introduction | 627 | ||
| 2. Clarify the task | 627 | ||
| 3. Obtain the necessary facts | 627 | ||
| 4. Be alert to ideas, concerns and expectations | 627 | ||
| 5. Outline the possibilities | 627 | ||
| 6. Share the probability and potential seriousness of a diagnosis | 627 | ||
| 7. Give an honest professional opinion | 627 | ||
| 8. Confirm understanding | 627 | ||
| 9. Encourage feedback and invite questions | 627 | ||
| 10. Cast a ‘safety net’ | 627 | ||
| Discussion | 627 | ||
| An 85-year-old man has had a large cortical stroke causing dysphasia and dense hemiplegia. Routine tests reveal a haemoglobin of 9 g / dl with a low ferritin. Would you investigate this further or accept diagnostic uncertainty? | 627 | ||
| A 70-year-old woman has new onset exertional chest pain. She has severe osteoarthritis, walking only a limited distance, and Parkinson’s disease. Would you attempt to further the diagnosis of angina with a stress test? | 628 | ||
| A 48-year-old non-smoker is being discharged from your ward today following investigation for chronic diarrhoea. No cause has been found. He tells you that a few weeks ago he had a single episode of ‘coughing up a teaspoonful of blood’ that he’d forgotten to mention until now. His chest X-ray was normal. What are the important issues? | 628 | ||
| Case 4.6 Discussing risk and treatment effect | 628 | ||
| Candidate information | 628 | ||
| Role | 628 | ||
| Scenario | 628 | ||
| Patient / subject information | 628 | ||
| How to approach the case | 629 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 629 | ||
| 1. Introduction | 629 | ||
| 2. Review the history | 629 | ||
| 3. Clarify the task | 629 | ||
| 4. Be alert to ideas, concerns and expectations | 629 | ||
| 5. Clarify risk | 629 | ||
| 6. Risk communication | 629 | ||
| 7. Optimise the likelihood of concordance | 629 | ||
| 8. Confirm understanding | 629 | ||
| 9. Encourage feedback and invite questions | 629 | ||
| 10. Agree a way forward and ensure follow-up arrangements are in place | 629 | ||
| Discussion | 630 | ||
| What is meant by the term prevalence? | 630 | ||
| What is meant by the term incidence? | 630 | ||
| What is meant by the term risk? | 630 | ||
| What is meant by the term odds? | 630 | ||
| What is meant by the term rate? | 630 | ||
| What is meant by the term risk ratio? | 630 | ||
| What is meant by the term odds ratio? | 630 | ||
| What is meant by the term rate ratio? | 630 | ||
| How does relative risk (RR) differ from absolute risk (AR)? | 630 | ||
| What is meant by the term relative risk reduction (RRR)? | 630 | ||
| What is meant by the term absolute risk reduction (ARR)? | 631 | ||
| What is meant by the term number needed to treat (NNT)? | 631 | ||
| What is meant by the term number needed to harm (NNH)? | 631 | ||
| Case 4.7 Negotiating a management plan for a chronic disease / long-term condition | 631 | ||
| Candidate information | 631 | ||
| Role | 631 | ||
| Scenario | 631 | ||
| Patient / subject information | 631 | ||
| How to approach the case | 631 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 631 | ||
| 1. Introduction | 631 | ||
| 2. Clarify the task | 631 | ||
| 3. Establish the facts | 631 | ||
| 4. Explore concerns | 631 | ||
| 5. Share management options | 632 | ||
| 6. Frame your suggested management plan | 632 | ||
| 7. Respond to patient cues | 632 | ||
| 8. Confirm understanding | 632 | ||
| 9. Encourage feedback and invite questions | 632 | ||
| 10. Agree a way forward and ensure follow-up arrangements are in place | 632 | ||
| Discussion | 632 | ||
| What do you understand by the term chronic disease or long-term condition (LTC)? | 632 | ||
| Should LTCs be managed by primary or secondary care? | 632 | ||
| Is there a role for community geriatricians? | 632 | ||
| Are domiciliary visits still important? | 633 | ||
| Case 4.8 Encouraging concordance with treatment and prevention | 633 | ||
| Candidate information | 633 | ||
| Role | 633 | ||
| Scenario | 633 | ||
| Patient / subject information | 633 | ||
| How to approach the case | 633 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 633 | ||
| 1. Introduction | 633 | ||
| 2. Clarify the task | 633 | ||
| 3. Explore whether poor concordance could be a problem | 633 | ||
| 4. Be alert to ideas, concerns and expectations | 634 | ||
| 5. Counter misunderstandings | 634 | ||
| 6. Discuss management options within a clear framework | 634 | ||
| 7. Repeat important information | 634 | ||
| 8. Confirm understanding | 634 | ||
| 9. Encourage feedback and invite questions | 634 | ||
| 10. Agree a way forward and ensure follow-up arrangements are in place | 634 | ||
| Discussion | 634 | ||
| A 34-year-old man being treated for a high-grade non-Hodgkin’s lymphoma on your haematology ward is 3 days into a chemotherapy regimen involving high-dose steroids. This morning, according to your house officer, he was in a strange mood, tearful but also declaring he believed himself cured. He left the ward in pyjamas and overcoat and has not returned. What should be done? | 634 | ||
| How might you help persuade a patient to stop smoking? | 634 | ||
| Communication in special circumstances | 635 | ||
| Case 4.9 Cross-cultural communication | 635 | ||
| Candidate information | 635 | ||
| Role | 635 | ||
| Scenario | 635 | ||
| Patient / subject information | 635 | ||
| How to approach the case | 635 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 635 | ||
| 1. Introduction | 635 | ||
| 2. Remember to treat patients equally and do not do very much differently! | 635 | ||
| 3. Establish as far as possible the patient’s concerns and give non-verbal reassurance | 636 | ||
| 4. Frame your suggested management plan | 636 | ||
| 5. Keep explanations clear and simple, avoiding jargon | 636 | ||
| 6. Repeat important information | 636 | ||
| 7. Respond to patient cues | 636 | ||
| 8. Confirm understanding and acceptance | 636 | ||
| 9. Encourage feedback and invite questions | 636 | ||
| 10. Agree a way forward and ensure follow-up arrangements are in place | 636 | ||
| Discussion | 636 | ||
| What do understand by the term culture? | 636 | ||
| What potential problems may arise when using interpreters? | 636 | ||
| Case 4.10 Communicating with angry patients or relatives | 636 | ||
| Candidate information | 636 | ||
| Role | 636 | ||
| Scenario | 636 | ||
| Patient / subject information | 637 | ||
| How to approach the case | 637 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 637 | ||
| 1. Introduce yourself | 637 | ||
| 2. Make it clear that you want to help | 637 | ||
| 3. Remember to deal with emotions before facts and that anger is not usually anger | 637 | ||
| 4. Acknowledge the concerns | 637 | ||
| 5. Explore the emotions and concerns | 637 | ||
| 6. Work towards resolution, weaving in the facts | 637 | ||
| 7. Try to ameliorate concerns that can honestly be ameliorated | 637 | ||
| 8. Never criticise colleagues | 637 | ||
| 9. Encourage feedback and invite questions | 637 | ||
| 10. Agree a way forward | 637 | ||
| Discussion | 638 | ||
| Would you encourage him to make a formal complaint? | 638 | ||
| What do you do if a patient is threatening, abusive or violent? | 638 | ||
| Case 4.11 Communicating with upset or distressed relatives | 638 | ||
| Candidate information | 638 | ||
| Role | 638 | ||
| Scenario | 638 | ||
| Patient / subject information | 638 | ||
| How to approach the case | 638 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 638 | ||
| 1. Preparation and scene setting | 638 | ||
| 2. Give vital information early | 639 | ||
| 3. Deal with emotions before facts | 639 | ||
| 4. Acknowledge distress and support ventilation of feelings | 639 | ||
| 5. Respond to patient cues | 639 | ||
| 6. Gently explain what happened | 639 | ||
| 7. Do not raise personal concerns | 639 | ||
| 8. Identify patient support systems | 639 | ||
| 9. Check present information needs | 639 | ||
| 10. Make clear what support is available | 639 | ||
| Discussion | 639 | ||
| How might you detach yourself from distressed relatives? | 639 | ||
| Case 4.12 Discharge against medical advice | 639 | ||
| Candidate information | 639 | ||
| Role | 639 | ||
| Scenario | 639 | ||
| Patient / subject information | 640 | ||
| How to approach the case | 640 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 640 | ||
| 1. Introduction | 640 | ||
| 2. Make it clear you want to help | 640 | ||
| 3. Explore concerns and reasons for wanting to self-discharge | 640 | ||
| 4. Explain the medical reasons for wanting the patient to stay | 640 | ||
| 5. Aim to address the patient’s concerns | 640 | ||
| 6. Accept that the patient may self-discharge | 640 | ||
| 7. If self-discharge seems inevitable, try to reach the best compromise | 640 | ||
| 8. Confirm understanding and acceptance | 640 | ||
| 9. Encourage feedback and invite questions | 640 | ||
| 10. Agree a way forward and ensure follow-up arrangements are in place | 640 | ||
| Discussion | 641 | ||
| Is a discharge against medical advice form a legal necessity? | 641 | ||
| Case 4.13 Delayed discharge | 641 | ||
| Candidate information | 641 | ||
| Role | 641 | ||
| Scenario | 641 | ||
| Patient / subject information | 641 | ||
| How to approach the case | 641 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 641 | ||
| 1. Introduction | 641 | ||
| 2. Make it clear that you want to help | 641 | ||
| 3. Start by listening and agreeing | 641 | ||
| 4. Explore ideas, concerns and expectations | 641 | ||
| 5. State a suggested management plan | 641 | ||
| 6. Be alert to cues | 642 | ||
| 7. Do not criticise hospital managers | 642 | ||
| 8. Encourage feedback and invite questions | 642 | ||
| 9. Confirm understanding and acceptance | 642 | ||
| 10. Agree a way forward | 642 | ||
| Discussion | 642 | ||
| What is an integrated care pathway (ICP)? | 642 | ||
| Hospital trust managers are very keen on discharge planning. Do you think you should be as concerned as your hospital managers? | 642 | ||
| What is early supported discharge? | 642 | ||
| Is there a role for discharge teams? | 642 | ||
| Home | 642 | ||
| Rehabilitation or other interim settings | 643 | ||
| Care home (residential or nursing, but the term care home has been adopted since 2003) | 643 | ||
| What is meant by delayed transfer of care (DTOC)? | 643 | ||
| What is meant by the term intermediate care? | 643 | ||
| How is a patient assessed for entry into long-term care? | 643 | ||
| What is meant by the term continuing care? | 643 | ||
| Breaking bad news | 643 | ||
| Case 4.14 Cancer – potentially curable | 643 | ||
| Candidate information | 643 | ||
| Role | 643 | ||
| Scenario | 643 | ||
| Patient / subject information | 643 | ||
| How to approach the case | 644 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 644 | ||
| 1. Preparation and scene setting | 644 | ||
| 2. Establish what the patient knows already | 644 | ||
| 3. Establish what the patient wants to know | 644 | ||
| 4. Give a warning shot | 644 | ||
| 5. Break bad news gently | 645 | ||
| 6. Acknowledge distress and support ventilation of feelings | 645 | ||
| 7. Identify and prioritise concerns | 645 | ||
| 8. Check present information needs | 645 | ||
| 9. Identify patient support systems | 645 | ||
| 10. Make clear what support is available and what is going to happen | 645 | ||
| Discussion | 645 | ||
| How should bad news be broken? | 645 | ||
| Can you think of some common mistakes when breaking bad news? | 646 | ||
| Case 4.15 Cancer – probably incurable | 646 | ||
| Candidate information | 646 | ||
| Role | 646 | ||
| Scenario | 646 | ||
| Patient / subject information | 646 | ||
| How to approach the case | 646 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 646 | ||
| 1. Preparation and scene setting | 646 | ||
| 2. Establish what the patient knows already | 646 | ||
| 3. Establish what the patient wants to know | 646 | ||
| 4. Give a warning shot | 646 | ||
| 5. Break bad news gently | 647 | ||
| 6. Acknowledge distress and support ventilation of feelings | 647 | ||
| 7. Identify and prioritise concerns | 647 | ||
| 8. Check present information needs | 647 | ||
| 9. Identify patient support systems | 647 | ||
| 10. Make clear what support is available and what is going to happen | 647 | ||
| Discussion | 647 | ||
| What information would you need before seeing her again? | 647 | ||
| The radiologist, at a second view, thinks the pelvic masses could be simple cysts and are likely to be unrelated to the gastric malignancy. The histopathology of the latter, surprisingly, reports a high-grade non-Hodgkin’s B-cell lymphoma rather than carcinoma. When you see her again, will you attempt to persuade her to have treatment? | 647 | ||
| She asks if she will die without treatment. How might you respond? | 647 | ||
| She says that she does not wish more hospital tests or treatments. She says ‘When my time has come, my time has come; I’d rather take my chances than have any more tests or treatment.’ Would you accept this? | 648 | ||
| Case 4.16 Cancer – patient not fit for active treatment | 648 | ||
| Candidate information | 648 | ||
| Role | 648 | ||
| Scenario | 648 | ||
| Patient / subject information | 648 | ||
| How to approach the case | 648 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 648 | ||
| 1. Preparation and scene setting | 648 | ||
| 2. Establish what the patient knows already | 648 | ||
| 3. Establish what the patient wants to know | 648 | ||
| 4. Give a warning shot | 648 | ||
| 5. Break bad news gently | 649 | ||
| 6. Acknowledge distress and support ventilation of feelings | 649 | ||
| 7. Identify and prioritise concerns | 649 | ||
| 8. Check present information needs | 649 | ||
| 9. Identify patient support systems | 649 | ||
| 10. Make clear what support is available and what is going to happen | 649 | ||
| Discussion | 649 | ||
| An elderly woman has liver metastases from an unknown primary site. She is frail, deemed medically unfit to undergo more than palliative treatment, and wishes to know ‘just what I need to know, doctor, but no more’. You judge her mental capacity to be borderline. What might you tell her? | 649 | ||
| An 88-year-old man has been losing weight. He smokes and has a recent Horner’s syndrome and a Pancoast’s tumour clinically. He was informed that this is worrying. The chest X-ray now confirms it. What would you tell him? | 650 | ||
| Case 4.17 Chronic disease | 650 | ||
| Candidate information | 650 | ||
| Role | 650 | ||
| Scenario | 650 | ||
| Patient / subject information | 650 | ||
| How to approach the case | 650 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 650 | ||
| 1. Preparation and scene setting | 650 | ||
| 2. Establish what the patient knows already | 650 | ||
| 3. Establish what the patient wants to know | 650 | ||
| 4. Give a warning shot | 650 | ||
| 5. Break bad news gently | 650 | ||
| 6. Acknowledge distress and support ventilation of feelings | 650 | ||
| 7. Identify and prioritise concerns | 650 | ||
| 8. Check present information needs | 651 | ||
| 9. Identify patient support systems | 651 | ||
| 10. Make clear what support is available and what is going to happen | 651 | ||
| Discussion | 651 | ||
| Would you allow a patient in denial of their illness to continue in such denial, or attempt to change this? | 651 | ||
| Case 4.18 Discussing an acutely terminal situation with relatives | 651 | ||
| Candidate information | 651 | ||
| Role | 651 | ||
| Scenario | 651 | ||
| Patient / subject information | 651 | ||
| How to approach the case | 651 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 651 | ||
| 1. Preparation and scene setting | 651 | ||
| 2. Establish what the relative knows already | 652 | ||
| 3. Establish what the relative wants to know | 652 | ||
| 4. Give a warning shot | 652 | ||
| 5. Break bad news gently | 652 | ||
| 6. Acknowledge distress and support ventilation of feelings | 652 | ||
| 7. Identify and prioritise concerns | 652 | ||
| 8. Check present information needs | 652 | ||
| 9. Identify support systems | 652 | ||
| 10. Make clear what support is available and what is going to happen | 652 | ||
| Discussion | 652 | ||
| Patients with incurable but more chronic conditions often ask about how much time is left. How might you respond? | 652 | ||
| Why is it important to respond to questions about prognosis? | 652 | ||
| Confidentiality, consent and capacity | 653 | ||
| Case 4.19 Legal points in confidentiality | 653 | ||
| Candidate information | 653 | ||
| Role | 653 | ||
| Scenario | 653 | ||
| Patient / subject information | 653 | ||
| How to approach the case | 653 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 653 | ||
| 1. Introduction | 653 | ||
| 2. Establish rapport | 653 | ||
| 3. Explore patient understanding and concerns | 653 | ||
| 4. Attempt to discover the patient’s reasons for not wanting to disclose | 653 | ||
| 5. Share your concerns and desired management plan | 653 | ||
| 6. Respond to patient cues | 653 | ||
| 7. Discuss possible consequences of refusal | 653 | ||
| 8. Confirm understanding | 653 | ||
| 9. Allow time to think about what has been discussed and invite questions | 654 | ||
| 10. Agree a way forward | 654 | ||
| Discussion | 654 | ||
| Why is confidentiality important? | 654 | ||
| What is your legal commitment to respect confidentiality? | 654 | ||
| Under what circumstances might confidential information be disclosed? | 654 | ||
| What are the possible consequences of breach of confidentiality? | 654 | ||
| Does information remain confidential after death? | 654 | ||
| Case 4.20 Breaching confidentiality when a third party may be at risk | 654 | ||
| Candidate information | 654 | ||
| Role | 654 | ||
| Scenario | 655 | ||
| Patient / subject information | 655 | ||
| How to approach the case | 655 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 655 | ||
| 1. Introduction | 655 | ||
| 2. Establish rapport | 655 | ||
| 3. Explore patient understanding and concerns | 655 | ||
| 4. Attempt to discover the patient’s reasons for not wanting to disclose | 655 | ||
| 5. Share your concerns and desired management plan | 655 | ||
| 6. Respond to patient cues | 655 | ||
| 7. Discuss possible consequences of refusal | 655 | ||
| 8. Confirm understanding | 655 | ||
| 9. Allow time to think about what has been discussed and invite questions | 655 | ||
| 10. Agree a way forward | 655 | ||
| Discussion | 656 | ||
| Does his girlfriend have a right to know? | 656 | ||
| A 32-year-old man has presented to your general medical clinic with weight loss and admits to a history of intravenous drug misuse and having multiple sexual partners. He is now living with his girlfriend, who is pregnant. You mention the possibility of HIV infection and he admits to having suspected this but adds ‘if I had AIDS I would want to kill myself, doctor’. He also says that he feels angry. How might you respond? | 656 | ||
| Case 4.21 Breaching confidentiality in the public interest | 656 | ||
| Candidate information | 656 | ||
| Role | 656 | ||
| Scenario | 656 | ||
| Patient / subject information | 656 | ||
| How to approach the case | 656 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 656 | ||
| 1. Introduction | 656 | ||
| 2. Establish rapport | 657 | ||
| 3. Explain the results | 657 | ||
| 4. Explore patient understanding and concerns | 657 | ||
| 5. Attempt to discover the patient’s reasons for not wanting to adhere to advice | 657 | ||
| 6. Explain the risks and consider alternatives | 657 | ||
| 7. Respond to patient cues | 657 | ||
| 8. Discuss possible consequences of refusal | 657 | ||
| 9. Allow time to think about what has been discussed and invite questions | 657 | ||
| 10. Agree a way forward | 657 | ||
| Discussion | 657 | ||
| When may disclosure of confidential information be made in the public interest? | 657 | ||
| What is the driving advice in medical conditions? | 657 | ||
| Seizures | 657 | ||
| Syncope | 657 | ||
| Cardiac conditions | 657 | ||
| Stroke / transient ischaemic attacks | 657 | ||
| Dementia | 658 | ||
| Other | 658 | ||
| When should you disclose confidential information to the DVLA? | 658 | ||
| Case 4.22 Confidentiality when talking with relatives and other third parties | 658 | ||
| Candidate information | 658 | ||
| Role | 658 | ||
| Scenario | 658 | ||
| Patient / subject information | 658 | ||
| How to approach the case | 658 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 658 | ||
| 1. Introduction | 658 | ||
| 2. Acknowledge a valued contribution | 658 | ||
| 3. Explain a little | 658 | ||
| 4. Ask a little | 659 | ||
| 5. Explain in more depth, directed by responses | 659 | ||
| 6. Involve the carer in the desired management plan | 659 | ||
| 7. Respond to cues | 659 | ||
| 8. Consider other issues | 659 | ||
| 9. Allow time to think about what has been discussed and invite questions | 659 | ||
| 10. Agree a way forward | 659 | ||
| Discussion | 659 | ||
| Under which circumstances may implied consent be sufficient for disclosure of confidential information to third parties? | 659 | ||
| Under what circumstances must express consent be sought to disclose information to third parties? | 659 | ||
| What type of consent is needed when disclosing information to third parties such as employers, police, lawyers and insurance companies? | 659 | ||
| Can information about a patient be disclosed for education and research without consent? | 659 | ||
| An 80-year-old man has just recovered from a stroke. He lives independently and is to be discharged from your ward later this week. One of the nurses on your ward asks if you will speak to his daughter. You are asked by a woman over the phone, ‘What has happened to my father?’ Would you tell her? | 659 | ||
| The daughter now requests that you not tell him anything more about his condition without her prior permission – ‘he is a worrier’. Would you agree to this? | 660 | ||
| What are Caldicott Guardians? | 660 | ||
| Case 4.23 Consent for investigation or treatment | 660 | ||
| Candidate information | 660 | ||
| Role | 660 | ||
| Scenario | 660 | ||
| Patient / subject information | 660 | ||
| How to approach the case | 660 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 660 | ||
| 1. Introduction | 660 | ||
| 2. Explain the situation so far | 660 | ||
| 3. Explain the best way forward | 660 | ||
| 4. Establish previous experience and be alert to ideas and concerns | 661 | ||
| 5. Explain the nature of the investigation or treatment | 661 | ||
| 6. Explain the risks and benefits of the investigation or treatment | 661 | ||
| 7. Explain any possible alternatives | 661 | ||
| 8. Show respect for autonomy | 661 | ||
| 9. Confirm understanding and invite questions | 661 | ||
| 10. Seek permission to proceed | 661 | ||
| Discussion | 661 | ||
| What is consent? | 661 | ||
| What are the necessary requirements for valid consent? | 661 | ||
| What is battery? | 661 | ||
| What is meant by implied and express consent? | 661 | ||
| What information should be shared with a patient in order to obtain consent? | 662 | ||
| How should information be shared? | 662 | ||
| What would you do if a patient asks for decisions to be made on their behalf? | 662 | ||
| Can a patient demand a treatment? | 663 | ||
| What exceptions are there to informed consent? | 663 | ||
| How might doctors be at risk of committing battery when obtaining consent from a competent patient? | 663 | ||
| How might doctors be at risk of negligence when obtaining consent from a competent patient? | 663 | ||
| A 65-year-old man has diabetic nephropathy as evidenced by microalbuminuria. You wish to start an angiotensin-converting enzyme (ACE) inhibitor. What type of consent would you obtain? | 663 | ||
| Case 4.24 Consent and capacity | 663 | ||
| Candidate information | 663 | ||
| Role | 663 | ||
| Scenario | 663 | ||
| Patient / subject information | 663 | ||
| How to approach the case | 663 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 663 | ||
| 1. Introduce yourself and establish the relative’s identity | 663 | ||
| 2. Establish background knowledge | 664 | ||
| 3. Explain the problem | 664 | ||
| 4. Explain possible solutions | 664 | ||
| 5. Be alert to cues | 664 | ||
| 6. Ask how the relative feels, and how she thinks the patient would feel about this | 664 | ||
| 7. Attempt to address concerns | 664 | ||
| 8. Relative agrees or relative disagrees with what you see as in patient’s best interests | 664 | ||
| 9. Confirm understanding and invite questions | 664 | ||
| 10. Agree a way forward | 664 | ||
| Discussion | 664 | ||
| What are the key aspects, based on case law, of capacity to give or withhold consent? | 664 | ||
| Can any doctor (or health-care professional) judge a patient’s capacity? | 665 | ||
| What do you know of the legal necessity to treat incapacitated patients? | 665 | ||
| How may doctors be guided when making decisions for a patient without capacity? | 665 | ||
| What are the key principles and innovations of the English Mental Capacity Act 2005? | 665 | ||
| Does the Mental Capacity Act aid determination of best interests? | 665 | ||
| Can incapacity be inferred from a particular medical illness or diagnosis? | 665 | ||
| What do you know about legal representation for incapacitated adults? | 665 | ||
| Power of attorney (PA) | 665 | ||
| Court of Protection / Court Appointed Deputies | 665 | ||
| Does the Mental Capacity Act allow detention of patients? | 668 | ||
| What do you know about safeguarding vulnerable adults in hospital? | 668 | ||
| Case 4.25 Refusal of consent | 668 | ||
| Candidate information | 668 | ||
| Role | 668 | ||
| Scenario | 668 | ||
| Patient / subject information | 668 | ||
| How to approach the case | 668 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 668 | ||
| 1. Introduction | 668 | ||
| 2. Explain the situation so far | 669 | ||
| 3. Explain the best way forward | 669 | ||
| 4. Establish previous experience and be alert to beliefs and concerns | 669 | ||
| 5. Explain the nature of the investigation or treatment | 669 | ||
| 6. Explain the risks and benefits of the investigation or treatment and the consequences of not pursuing matters | 669 | ||
| 7. Explain any possible alternatives | 669 | ||
| 8. Show respect for autonomy | 669 | ||
| 9. Confirm understanding and invite questions | 669 | ||
| 10. Keep the door open | 669 | ||
| Discussion | 670 | ||
| If a young woman with Graves’ thyrotoxicosis wanted to pursue homeopathic treatment, even when the endocrinologist has recommended carbimazole, would you agree? | 670 | ||
| You have been seeing a 50-year-old man with tuberculosis in the respiratory clinic. He wishes to pursue homeopathic treatment rather than continue with antibiotics. Would you agree? | 670 | ||
| Can a patient refuse treatment, even to the point of death? | 670 | ||
| Case 4.26 Deliberate self-harm | 670 | ||
| Candidate information | 670 | ||
| Role | 670 | ||
| Scenario | 670 | ||
| Patient / subject information | 671 | ||
| How to approach the case | 671 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 671 | ||
| 1. Introduction | 671 | ||
| 2. Show empathy | 671 | ||
| 3. Establish ideas and concerns | 671 | ||
| 4. Assess patient following a suicide attempt | 671 | ||
| 5. Explain what should be done next | 671 | ||
| 6. Reassure that information given is confidential | 671 | ||
| 7. Reassure that the psychiatrist will help to identify problems | 671 | ||
| 8. Explain possible alternatives | 671 | ||
| 9. Invite further questions | 672 | ||
| 10. Agree a way forward | 672 | ||
| Discussion | 672 | ||
| What would you do if a patient wants to leave hospital before being assessed by a mental health professional? | 672 | ||
| What does common law allow in the matter of detention or treatment of patients? | 672 | ||
| Can you detain or treat against a patient’s will if they have capacity? | 672 | ||
| Which aspects of the Mental Health Act are relevant to general medicine? | 672 | ||
| An elderly woman takes a lethal ingestion with the intention of suicide. She declines intervention. She is assessed by the psychiatric team who feel that she has capacity to make this decision. Would you accept this? | 673 | ||
| End-of-life issues | 673 | ||
| Case 4.27 End of life and palliative care | 673 | ||
| Candidate information | 673 | ||
| Role | 673 | ||
| Scenario | 673 | ||
| Patient / subject information | 673 | ||
| How to approach the case | 673 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 673 | ||
| 1. Introduction | 673 | ||
| 2. Establish what the relative knows | 673 | ||
| 3. Give a warning shot | 673 | ||
| 4. Explain the situation | 673 | ||
| 5. Acknowledge distress and allow ventilation of feelings | 673 | ||
| 6. Identify and prioritise concerns | 673 | ||
| 7. Explain what is likely to happen | 674 | ||
| 8. Identify support networks | 674 | ||
| 9. Invite questions | 674 | ||
| 10. Conclude with assurances | 674 | ||
| Discussion | 674 | ||
| What is meant by end of life (EoL)? | 674 | ||
| What is meant by EoL care? | 674 | ||
| What do you understand by the term ‘palliative care’? | 674 | ||
| What principles govern EoL care? | 675 | ||
| Equalities and human rights | 675 | ||
| Presumption in favour of prolonging life | 675 | ||
| Presumption of capacity | 675 | ||
| Maximising capacity to make decisions | 675 | ||
| Overall benefit | 675 | ||
| What sorts of ethical and legal issues arise in EoL decision making? | 675 | ||
| Do you know of any decision-making models in relation to EoL care? | 676 | ||
| What measures in the acute hospital setting help ensure good EoL care? | 676 | ||
| Recognising and diagnosing EoL | 676 | ||
| Advance care planning (ACP) | 676 | ||
| TEP and resuscitation decision patient-held record | 676 | ||
| Preferred priorities of care (PPC) document | 676 | ||
| Advance decision to refuse treatment (ADRT) | 676 | ||
| Lasting power of attorney (LPA) – health | 676 | ||
| The EoL register | 676 | ||
| Liverpool Care Pathway (LCP) for the dying person | 678 | ||
| Which drugs may be used to alleviate pain in modern palliative care? | 678 | ||
| What is the doctrine of double effect (DDE)? | 678 | ||
| Consider a patient dying from a malignant brain tumour who develops pneumonia and respiratory failure. A ventilator may prolong life but may also delay an inevitable death. What courses of action are there? | 680 | ||
| Is allowing a person to die different from killing that person? | 680 | ||
| Have you heard of the Assisted Dying for the Terminally Ill Bill and, if so, what ethical issues does it raise? | 680 | ||
| One of your patients, a dying man with end-stage renal failure, diabetes and peripheral gangrene, has a hypoglycaemic attack. Would you treat him? | 680 | ||
| A woman has breast cancer with cerebral metastases. She asks you how many of her anticonvulsant pills she would need to take to end her life. How might you respond? | 680 | ||
| Case 4.28 Advance decision making | 681 | ||
| Candidate information | 681 | ||
| Role | 681 | ||
| Scenario | 681 | ||
| Patient / subject information | 681 | ||
| How to approach the case | 681 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 681 | ||
| 1. Introduction | 681 | ||
| 2. Establish rapport and be alert to cues | 681 | ||
| 3. Seek further information about the patient | 681 | ||
| 4. Be sure that you understand the legal principles of advance decision making | 681 | ||
| 5. Explain the situation | 681 | ||
| 6. Have a plan | 681 | ||
| 7. Ensure that your suggestions do not conflict with any ideas, concerns and expectations | 681 | ||
| 8. Seek acceptance of this plan | 682 | ||
| 9. Invite questions | 682 | ||
| 10. Conclude with assurances | 682 | ||
| Discussion | 682 | ||
| What is an advance statement? | 682 | ||
| What is an advance decision or advance directive? | 682 | ||
| How might you act on advance requests for treatment? | 682 | ||
| How might you act on advance refusals of treatment? | 682 | ||
| Binding advance refusals | 682 | ||
| Non-binding advance refusals | 682 | ||
| How might you assess the validity and applicability of advance refusals? | 682 | ||
| An elderly woman with dementia, living alone but with carers, fractures the neck of her femur. She is admitted to hospital with an abbreviated mental test score (AMTS) of 4 / 10. Her son says she would not wish any treatment. Would you agree to his request? | 682 | ||
| A young woman with a history of asthma, necessitating multiple admissions to ITU, and depression is admitted with a further exacerbation of asthma requiring immediate ITU support. A handwritten letter in her notes addressed to her chest physician states that she wishes no treatment in the event of future collapse. Should she be admitted to ITU? | 683 | ||
| Case 4.29 Resuscitation status decision making – discussion with patient | 683 | ||
| Candidate information | 683 | ||
| Role | 683 | ||
| Scenario | 683 | ||
| Patient / subject information | 684 | ||
| How to approach the case | 684 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 684 | ||
| 1. Introduction, setting and rapport | 684 | ||
| 2. Ensure the patient has enough information about their condition | 684 | ||
| 3. Then come directly to the reason for the discussion | 684 | ||
| 4. Pace the explanation slowly and carefully, and in words the patient will understand, allowing him to assimilate what you are saying | 684 | ||
| 5. Many patients immediately understand all of this, and pre-empt further discussion by declaring clearly pre-considered wishes. Some patients wish to go further and may ask about resuscitation | 684 | ||
| 6. Be prepared to deal with emotions before facts if you sense the discussion is causing distress | 684 | ||
| 7. Many patients prefer to leave the decision to their doctors | 684 | ||
| 8. Some patients might ask what you think | 684 | ||
| 9. Confirm patient understanding and explore any other concerns | 684 | ||
| 10. Conclude with assurances | 684 | ||
| Discussion | 685 | ||
| Why is it important to consider cardiopulmonary resuscitation (CPR) decision making in advance care planning? | 685 | ||
| Do not attempt CPR (DNACPR) decisions | 685 | ||
| Do you know of any CPR decision-making frameworks? | 685 | ||
| What is the ‘presumption in favour of CPR’ when there is no DNACPR decision? | 685 | ||
| Emergencies | 685 | ||
| If further information comes to light | 685 | ||
| Certainty of sufficient information to judge that CPR will not be successful | 685 | ||
| What is the approach to decision making when CPR will not be successful? | 685 | ||
| CPR will not be successful | 686 | ||
| CPR unlikely to be successful and likely to prolong or increase suffering | 686 | ||
| Communication | 686 | ||
| What is the way forward if a patient requests CPR in situations where it will not be successful? | 687 | ||
| What is the approach to decision making when CPR may be successful? | 687 | ||
| Patients who have capacity | 687 | ||
| Patients who lack capacity | 688 | ||
| What is the ethical and legal stance on refusal of CPR by adults with capacity? | 688 | ||
| Advance decisions refusing CPR | 688 | ||
| When might it be appropriate to temporarily suspend a DNACPR decision? | 688 | ||
| Case 4.30 Resuscitation status decision making – discussion with relative | 688 | ||
| Candidate information | 688 | ||
| Role | 688 | ||
| Scenario | 688 | ||
| Patient / subject information | 688 | ||
| How to approach the case | 688 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 688 | ||
| 1. Introduction | 688 | ||
| 2. Establish what the relative knows | 688 | ||
| 3. Seek further information about the patient | 689 | ||
| 4. Do not forget empathy | 689 | ||
| 5. Explain the situation | 689 | ||
| 6. Approach the issue of more invasive interventions | 689 | ||
| 7. Ensure that your explanation does not conflict with any ideas, concerns and expectations | 689 | ||
| 8. Many relatives worry that the decision is theirs and theirs alone | 689 | ||
| 9. Confirm understanding and invite questions | 689 | ||
| 10. Conclude with assurances | 690 | ||
| Discussion | 690 | ||
| What do you know about cardiopulmonary resuscitation decision making for adults who lack capacity? | 690 | ||
| Case 4.31 Appropriateness of intensive therapy unit transfer | 690 | ||
| Candidate information | 690 | ||
| Role | 690 | ||
| Scenario | 690 | ||
| Patient / subject information | 690 | ||
| How to approach the case | 690 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 690 | ||
| 1. Introduction, setting and rapport | 690 | ||
| 2. Acknowledge how unwell the patient has been | 690 | ||
| 3. Explore the patient’s concerns | 690 | ||
| 4. Address the patient’s concerns | 690 | ||
| 5. Discuss resuscitation status | 691 | ||
| 6. Ensure that the patient is fully informed | 691 | ||
| 7. Agree a plan | 691 | ||
| 8. Confirm understanding | 691 | ||
| 9. Invite questions | 691 | ||
| 10. Conclude with assurances | 691 | ||
| Discussion | 691 | ||
| Which patients fare better in ITU, and which worse? | 691 | ||
| Is invasive ventilation contraindicated in COPD? | 691 | ||
| How does age affect ITU outcome? | 691 | ||
| What complications can follow a spell in ITU? | 691 | ||
| Case 4.32 Withholding and withdrawing life-prolonging treatments – antibiotics and drugs | 692 | ||
| Candidate information | 692 | ||
| Role | 692 | ||
| Scenario | 692 | ||
| Patient / subject information | 692 | ||
| How to approach the case | 692 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 692 | ||
| 1. Introduction | 692 | ||
| 2. Acknowledge the value of the relative | 692 | ||
| 3. Reassure the relative that any decisions will be carefully considered and that the ‘burden of responsibility’ for difficult decisions will not rest with him | 692 | ||
| 4. Explain the problem | 692 | ||
| 5. Explain your view | 692 | ||
| 6. Explore what the relative feels the patient would have wanted | 693 | ||
| 7. Explore any concerns the relative may have | 693 | ||
| 8. Consider and justify, or plan to change, any apparent discrepancies such as delivering some medications but not others | 693 | ||
| 9. Confirm understanding and invite questions | 693 | ||
| 10. Give strong reassurance about continuing with care | 693 | ||
| Discussion | 693 | ||
| Do you know of any guidance on withholding and withdrawing life-prolonging treatments? | 693 | ||
| Must you provide treatment to a patient who demands it but which you do not think is in that patient’s best interests? | 693 | ||
| How might you be guided in making decisions about limitation of treatment for patients without capacity? | 693 | ||
| Case 4.33 Withholding and withdrawing life-prolonging treatments – clinically assisted nutrition and hydration | 693 | ||
| Candidate information | 693 | ||
| Role | 693 | ||
| Scenario | 694 | ||
| Patient / subject information | 694 | ||
| How to approach the case | 694 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 694 | ||
| 1. Introduction | 694 | ||
| 2. Acknowledge the value of the relative | 694 | ||
| 3. Reassure the relative that any decisions will be carefully considered and that the ‘burden of responsibility’ for difficult decisions will not rest with her | 694 | ||
| 4. Explain the reasons for and against clinically assisted nutrition and hydration | 694 | ||
| 5. Explain your view | 694 | ||
| 6. Explore what the relative feels the patient would have wanted | 694 | ||
| 7. Explore any concerns the relative may have | 694 | ||
| 8. Consider and justify or plan to change any apparent discrepancies such as delivering hydration but withholding nutrition | 694 | ||
| 9. Confirm understanding and invite questions | 695 | ||
| 10. Give strong reassurance about continuing with care | 695 | ||
| Discussion | 695 | ||
| When might the question of clinically assisted nutrition or hydration be considered? | 695 | ||
| What is meant by clinically assisted nutrition or hydration? | 695 | ||
| How might you decide if clinically assisted nutrition or hydration should be provided? | 695 | ||
| Should clinically assisted nutrition or hydration should be provided in advanced dementia? | 695 | ||
| A 68-year-old man with advanced Lewy body dementia is admitted with an unsafe swallow and multiple failed nasogastric feeding attempts because he pulls out the tubes. He is receiving intravenous fluid. His essential medical therapy is warfarin for a metallic heart valve. What are the options? | 695 | ||
| He shows signs of improvement with comfort feeding but has choking episodes with comfort feeding. What would you do now? | 696 | ||
| Case 4.34 Percutaneous endoscopic gastrostomy feeding | 697 | ||
| Candidate information | 697 | ||
| Role | 697 | ||
| Scenario | 697 | ||
| Patient / subject information | 697 | ||
| How to approach the case | 697 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 697 | ||
| 1. Introduction | 697 | ||
| 2. Explain the current situation as you see it | 697 | ||
| 3. Explain the main issues relating to PEG tubes | 697 | ||
| 4. Try to establish the patient’s wishes | 697 | ||
| 5. Explain alternatives | 698 | ||
| 6. Be alert to cues | 698 | ||
| 7. Explore her concerns | 698 | ||
| 8. Respond to questions | 698 | ||
| 9. Confirm understanding and agree a way forward | 698 | ||
| 10. Reassure that decisions are not irreversible | 698 | ||
| Discussion | 698 | ||
| A 68-year-old man has a left total anterior circulation stroke with right hemiparesis and dysphagia. His swallow is deemed unsafe by the speech and language therapy (SLT) team. His family want to know if you will be feeding him to keep his strength up. When is enteral feeding recommended and what methods are there? | 698 | ||
| At day 2 the SLT team feel his swallow is still unsafe and NGT feeding is suggested. What are the complications of NGT insertion? | 698 | ||
| At day 10 the SLT team feel his swallow has shown little sign of improvement. A gastrostomy tube is recommended. What do you know about gastrostomy feeding? | 698 | ||
| What are the benefits of gastrostomy feeding? | 698 | ||
| Which patients may be considered for gastrostomy feeding? | 698 | ||
| What are the contraindications to gastrostomy? | 699 | ||
| What are the complications of gastrostomy feeding? | 699 | ||
| What is the role of gastrostomy feeding in dementia? | 699 | ||
| What is re-feeding syndrome? | 699 | ||
| Normal glucose metabolism | 699 | ||
| Starvation | 699 | ||
| Diabetic ketoacidosis (DKA) similarities to starvation | 700 | ||
| Re-feeding | 701 | ||
| Clinical manifestations of re-feeding syndrome | 701 | ||
| How may re-feeding syndrome be prevented and managed? | 701 | ||
| Case 4.35 Vegetative state | 701 | ||
| Candidate information | 701 | ||
| Role | 701 | ||
| Scenario | 701 | ||
| Patient / subject information | 701 | ||
| How to approach the case | 702 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 702 | ||
| 1. Introduction | 702 | ||
| 2. Establish what the relative knows | 702 | ||
| 3. Elicit ideas, concerns and expectations | 702 | ||
| 4. Address ideas, concerns and expectations | 702 | ||
| 5. Be alert to cues | 702 | ||
| 6. Elaborate on the meaning of the term persistent vegetative state | 702 | ||
| 7. Be honest about the prognosis as it appears now | 702 | ||
| 8. Concede uncertainty | 702 | ||
| 9. Invite questions | 702 | ||
| 10. Conclude with assurances | 702 | ||
| Discussion | 702 | ||
| What is the vegetative state? | 702 | ||
| How does the vegetative state differ from other disorders of consciousness such as coma? | 703 | ||
| What is coma? | 703 | ||
| How is coma measured? | 703 | ||
| What is the minimally conscious state? | 703 | ||
| What is locked-in syndrome? | 703 | ||
| Why are coma and the vegetative state not the same as brain death? | 704 | ||
| What affects prognosis in patients with a vegetative state? | 704 | ||
| How is the vegetative state diagnosed? | 704 | ||
| Why do we provide life-sustaining treatments to patients in a vegetative state? | 704 | ||
| Does misdiagnosis of the vegetative state occur? | 704 | ||
| Is there a place for brain imaging as a diagnostic tool? | 704 | ||
| Case 4.36 Brainstem death | 705 | ||
| Candidate information | 705 | ||
| Role | 705 | ||
| Scenario | 705 | ||
| Patient / subject information | 705 | ||
| How to approach the case | 705 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 705 | ||
| 1. Introduction | 705 | ||
| 2. Establish what the relative knows | 705 | ||
| 3. Explain the situation | 705 | ||
| 4. Explain brainstem death | 705 | ||
| 5. Acknowledge distress and allow ventilation of feelings | 705 | ||
| 6. Explain what will happen now | 705 | ||
| 7. Discuss organ donation | 705 | ||
| 8. Identify support networks | 705 | ||
| 9. Invite questions | 705 | ||
| 10. Ensure that the relative has a point of contact | 705 | ||
| Discussion | 706 | ||
| How might brainstem function be assessed? | 706 | ||
| What are oculocephalic and oculovestibular responses? | 706 | ||
| Which brainstem syndromes arise from brain shift? | 706 | ||
| How is brain death determined? | 707 | ||
| Is there a legal definition of death? | 707 | ||
| Case 4.37 Discussing live organ donation | 707 | ||
| Candidate information | 707 | ||
| Role | 707 | ||
| Scenario | 707 | ||
| Patient / subject information | 707 | ||
| How to approach the case | 707 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 707 | ||
| 1. Introduction | 707 | ||
| 2. Establish background knowledge | 707 | ||
| 3. Explore ideas, concerns and expectations | 707 | ||
| 4. Explain the principles of live organ donation | 707 | ||
| 5. Respond to ideas, concerns and expectations | 707 | ||
| 6. Explain potential benefits to recipient and donor | 707 | ||
| 7. Explain potential risks to recipient and donor | 708 | ||
| 8. Other matters | 708 | ||
| 9. Invite questions | 708 | ||
| 10. Explain what would happen next | 708 | ||
| Discussion | 708 | ||
| How is organ transplantation governed in the UK? | 708 | ||
| Is there a shortage of organ donors? | 708 | ||
| How might the supply of organ donors be increased? | 708 | ||
| Does the Human Tissue Act improve the number of organ donors? | 708 | ||
| Can dying patients who are potential donors be ‘kept alive’ in intensive care while consent is being sought for organ donation? | 708 | ||
| Are there advantages of live organ donation? | 708 | ||
| What ethical criteria should be met by live organ donors? | 708 | ||
| Is there a place for unrelated live transplants? | 708 | ||
| Case 4.38 Requesting an autopsy (post mortem) | 709 | ||
| Candidate information | 709 | ||
| Role | 709 | ||
| Scenario | 709 | ||
| Patient / subject information | 709 | ||
| How to approach the case | 709 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 709 | ||
| 1. Introduction | 709 | ||
| 2. Acknowledge that it is a difficult time | 709 | ||
| 3. Retrace the relevant background | 709 | ||
| 4. Explain the reasons for requesting an autopsy | 709 | ||
| 5. Explain the autopsy consent form | 709 | ||
| 6. Explore concerns | 710 | ||
| 7. Be prepared to discuss arrangements about the body | 710 | ||
| 8. Invite questions | 710 | ||
| 9. Explain what would happen next | 710 | ||
| 10. Seek consent or accept refusal | 710 | ||
| Discussion | 710 | ||
| What changes have occurred in recent years in the law regarding retention of human tissue and organs? | 710 | ||
| What is the role of the Human Tissue Authority? | 710 | ||
| What are the implications for hospital autopsies? | 710 | ||
| In which circumstances might the coroner (in Scotland Procurator Fiscal) wish to perform an autopsy? | 710 | ||
| Does a coroner’s autopsy need consent? | 711 | ||
| Clinical governance | 711 | ||
| Case 4.39 Critical incident | 711 | ||
| Candidate information | 711 | ||
| Role | 711 | ||
| Scenario | 711 | ||
| Patient / subject information | 711 | ||
| How to approach the case | 711 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 711 | ||
| 1. Introduction and setting | 711 | ||
| 2. Listen to concerns | 711 | ||
| 3. Acknowledge concerns | 711 | ||
| 4. Apologise, if appropriate | 712 | ||
| 5. Do not criticise colleagues but give your view | 712 | ||
| 6. Explain how the incident occurred | 712 | ||
| 7. Work with facts – do not speculate! | 712 | ||
| 8. Give an assurance of further action | 712 | ||
| 9. Invite questions and provide further information if needed | 712 | ||
| 10. Document everything fully and carefully | 712 | ||
| Discussion | 712 | ||
| What do you understand by the term clinical governance (CG)? | 712 | ||
| What is a critical incident? | 712 | ||
| Should you report all incidents? | 712 | ||
| What do you understand by the term system error? | 713 | ||
| What is the National Patient Safety Agency (NPSA)? | 713 | ||
| How is a hospital managed? | 713 | ||
| What do you know about the Access to Health Records Act? | 714 | ||
| Case 4.40 Managing a complaint and the question of negligence | 714 | ||
| Candidate information | 714 | ||
| Role | 714 | ||
| Scenario | 714 | ||
| Patient / subject information | 714 | ||
| How to approach the case | 714 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 714 | ||
| 1. Introduction and setting | 714 | ||
| 2. Listen to concerns / complaint | 714 | ||
| 3. Acknowledge concerns | 714 | ||
| 4. Apologise, if appropriate | 714 | ||
| 5. Do not criticise colleagues but give your view | 715 | ||
| 6. Explain how the incident occurred | 715 | ||
| 7. Work with facts – do not speculate! | 715 | ||
| 8. Give an assurance of further action about the complaint | 715 | ||
| 9. Invite questions and provide further information if needed | 715 | ||
| 10. Document everything fully and carefully | 715 | ||
| Discussion | 715 | ||
| Why do people make a complaint? | 715 | ||
| How might complaints be avoided or minimised? | 715 | ||
| Must you cooperate with a complaint, even if you disagree with the person making the complaint? | 715 | ||
| What are the purposes of NHS complaints procedures? | 715 | ||
| What are the general levels of complaints procedures? | 715 | ||
| Can an NHS complaints procedure be used to discipline a doctor or award compensation? | 715 | ||
| What sorts of medical error occur? | 716 | ||
| What are the conditions for negligence? | 716 | ||
| Is there a time limit for suing for an act of alleged negligence? | 716 | ||
| Are individual doctors or trusts sued? | 716 | ||
| Are damages awarded in cases of negligence punitive? | 716 | ||
| What are vicarious liabilities? | 716 | ||
| What is an inquest? | 717 | ||
| Case 4.41 Fitness to practise – poor performance in a colleague | 717 | ||
| Candidate information | 717 | ||
| Role | 717 | ||
| Scenario | 717 | ||
| Patient / subject information | 717 | ||
| How to approach the case | 717 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 717 | ||
| 1. Introduction and setting | 717 | ||
| 2. Open diplomatically | 717 | ||
| 3. Make it clear you are there to offer constructive help | 717 | ||
| 4. Listen to the experiences of the poorly performing doctor | 717 | ||
| 5. Share the good points | 718 | ||
| 6. Be honest about where you think performance falters | 718 | ||
| 7. Identify problems and possible solutions | 718 | ||
| 8. Invite further questions | 718 | ||
| 9. Agree a plan | 718 | ||
| 10. Offer ongoing help | 718 | ||
| Discussion | 718 | ||
| Do you have a duty to identify poorly performing doctors? | 718 | ||
| What types of problem doctor can you identify? | 718 | ||
| Is the problem usually of a doctor in difficulty or a difficult doctor? | 718 | ||
| Is the problem usually clinical or behavioural? | 718 | ||
| What are the causes of poor performance? | 718 | ||
| What should be done when a doctor in difficulty is identified? | 719 | ||
| List some duties of a doctor | 719 | ||
| List some key components of good medical practice | 719 | ||
| A colleague is making small clinical errors. Who should be made aware? | 720 | ||
| Case 4.42 Fitness to practise – misconduct in a colleague | 720 | ||
| Candidate information | 720 | ||
| Role | 720 | ||
| Scenario | 720 | ||
| Patient / subject information | 720 | ||
| How to approach the case | 720 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 720 | ||
| 1. Introduction and setting | 720 | ||
| 2. Open diplomatically | 720 | ||
| 3. Make it clear you are there to offer constructive help | 720 | ||
| 4. Listen to the experiences of the doctor with poor conduct | 721 | ||
| 5. Share any good points | 721 | ||
| 6. Be honest about where you think performance falters | 721 | ||
| 7. Identify problems and possible solutions | 721 | ||
| 8. Invite further questions | 721 | ||
| 9. Agree a plan | 721 | ||
| 10. Offer ongoing help | 721 | ||
| Discussion | 721 | ||
| What types of professional misconduct do we sometimes hear about in doctors? | 721 | ||
| What are the possible outcomes of challenges to a doctor’s actions? | 721 | ||
| Should you accept a gift from a patient? | 722 | ||
| Should you always see a patient if a junior asks you to? | 722 | ||
| Case 4.43 Fitness to practise – health problems in a colleague | 722 | ||
| Candidate information | 722 | ||
| Role | 722 | ||
| Scenario | 722 | ||
| Patient / subject information | 722 | ||
| How to approach the case | 722 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 722 | ||
| 1. Introduction and setting | 722 | ||
| 2. Ask if the sick doctor recognises the problem | 722 | ||
| 3. Make it clear you are there to offer constructive help | 722 | ||
| 4. Listen to the experiences of the doctor | 722 | ||
| 5. Ask specific questions | 723 | ||
| 6. Be specific about your concerns | 723 | ||
| 7. Explore any other concerns | 723 | ||
| 8. Discuss possible solutions | 723 | ||
| 9. Agree a plan | 723 | ||
| 10. Offer ongoing confidential help | 723 | ||
| Discussion | 723 | ||
| If you suspect a colleague’s sickness is putting patients at risk, how do you decide when ‘whistleblowing’ overrides the confidentiality of the colleague? | 723 | ||
| Case 4.44 Recruitment to a randomised controlled trial | 723 | ||
| Candidate information | 723 | ||
| Role | 723 | ||
| Scenario | 723 | ||
| Patient / subject information | 723 | ||
| How to approach the case | 724 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 724 | ||
| 1. Introduce yourself and the topic for discussion | 724 | ||
| 2. Explain the nature of the study | 724 | ||
| 3. Discuss ethics approval | 724 | ||
| 4. Explain potential benefits and risks | 724 | ||
| 5. Explain data handling | 724 | ||
| 6. Discuss confidentiality | 724 | ||
| 7. Discuss consent | 724 | ||
| 8. Consider conflict of interest | 724 | ||
| 9. Confirm understanding and invite questions | 724 | ||
| 10. Seek consent or refusal | 724 | ||
| Discussion | 724 | ||
| What do you understand by the term evidence-based medicine (EBM)? | 724 | ||
| What do you understand by the term critical reading or critical appraisal? | 724 | ||
| What broad types of research are there? | 724 | ||
| Quantitative research | 724 | ||
| Qualitative research | 725 | ||
| What types of study design are there? | 725 | ||
| Case report | 725 | ||
| Cross-sectional (descriptive) study | 725 | ||
| Case–control (retrospective) study | 725 | ||
| Cohort (prospective) study | 725 | ||
| Clinical trial | 725 | ||
| Systematic review and meta-analysis | 725 | ||
| What is a clinical practice guideline? | 725 | ||
| Are there guidelines for critically appraising papers? | 725 | ||
| What is bias? | 726 | ||
| What information might you need to determine the sample size necessary for a study? | 726 | ||
| What is the null hypothesis? | 726 | ||
| What is a ‘P’ value? | 726 | ||
| What do you understand by the term confidence interval (CI)? | 726 | ||
| What is a type 1 error? | 727 | ||
| What is a type 2 error? | 727 | ||
| What do you understand by the term generalisation? | 727 | ||
| What do you understand by the term confounding factors? | 727 | ||
| What do you know about intention to treat (ITT) analysis? | 727 | ||
| Other communication, ethical and legal scenarios | 727 | ||
| Case 4.45 Genetic testing | 727 | ||
| Candidate information | 727 | ||
| Role | 727 | ||
| Scenario | 727 | ||
| Patient / subject information | 727 | ||
| How to approach the case | 727 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 727 | ||
| 1. Introduction | 727 | ||
| 2. Establish area for discussion and background knowledge | 727 | ||
| 3. Establish any family history | 727 | ||
| 4. Explore ideas, concerns and expectations | 727 | ||
| 5. Respond to ideas, concerns and expectations | 727 | ||
| 6. Advise about genetic testing | 728 | ||
| 7. Advise about counselling for genetic testing | 728 | ||
| 8. Consider legal aspects | 728 | ||
| 9. Invite questions | 728 | ||
| 10. Agree a way forward | 728 | ||
| Discussion | 728 | ||
| What is Huntington’s disease? | 728 | ||
| What are the clinical features of Huntington’s disease? | 728 | ||
| What is the genetic basis of Huntington’s disease? | 728 | ||
| How is genetic testing undertaken? | 729 | ||
| What ethical considerations surround genetic testing? | 729 | ||
| Confidentiality and consent | 729 | ||
| Having children | 729 | ||
| What are the implications of a positive gene test? | 729 | ||
| How is Huntington’s disease managed? | 729 | ||
| Case 4.46 HIV testing | 729 | ||
| Candidate information | 729 | ||
| Role | 729 | ||
| Scenario | 729 | ||
| Patient / subject information | 729 | ||
| How to approach the case | 730 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 730 | ||
| 1. Introduction | 730 | ||
| 2. Explain the results of tests | 730 | ||
| 3. Explore risk factors, suggesting possible implications of the results | 730 | ||
| 4. Explore ideas, concerns and expectations | 730 | ||
| 5. Respond to ideas, concerns and expectations | 730 | ||
| 6. Counsel with respect to HIV testing | 730 | ||
| 7. Give an assurance of confidentiality | 730 | ||
| 8. Invite questions | 730 | ||
| 9. Seek consent to proceed with the HIV test | 730 | ||
| 10. Discuss what would happen after the test | 730 | ||
| Discussion | 730 | ||
| Does a negative test exclude HIV infection? | 730 | ||
| Case 4.47 Needlestick injury | 730 | ||
| Candidate information | 730 | ||
| Role | 730 | ||
| Scenario | 730 | ||
| Patient / subject information | 731 | ||
| How to approach the case | 731 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 731 | ||
| 1. Introduction | 731 | ||
| 2. Advise on immediate management | 731 | ||
| 3. Establish details of the incident | 731 | ||
| 4. Establish details about the patient and the staff member | 731 | ||
| 5. Remain calm | 731 | ||
| 6. Explain what you will do next | 731 | ||
| 7. Respect confidentiality and consent | 731 | ||
| 8. Explore outstanding concerns | 731 | ||
| 9. Invite questions | 731 | ||
| 10. Consider the remainder of the shift | 731 | ||
| Discussion | 731 | ||
| What is the risk of HIV transmission from a positive patient following needlestick injury? | 731 | ||
| What action is indicated in the setting of needlestick injury if a patient is known to be positive for HIV? | 731 | ||
| What factors increase the risk of occupationally acquired HIV transmission? | 731 | ||
| Would your management be any different if your house officer were pregnant? | 732 | ||
| Case 4.48 Medical opinion on fitness for anaesthesia | 732 | ||
| Candidate information | 732 | ||
| Role | 732 | ||
| Scenario | 732 | ||
| Patient / subject information | 732 | ||
| How to approach the case | 732 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 732 | ||
| 1. Introduction | 732 | ||
| 2. Clarify the task | 732 | ||
| 3. Explore symptoms | 732 | ||
| 4. Explore the past medical history | 732 | ||
| 5. Explore ideas, concerns and expectations | 733 | ||
| 6. Explain and advise as clearly as possible | 733 | ||
| 7. Repeat important information | 733 | ||
| 8. Confirm understanding | 733 | ||
| 9. Encourage feedback and invite questions | 733 | ||
| 10. Agree a way forward | 733 | ||
| Discussion | 733 | ||
| List some risk factors for anaesthesia | 733 | ||
| Why are surgery and anaesthesia such a threat? | 733 | ||
| What cardiovascular problems are provoked by anaesthesia? | 733 | ||
| Is hypertension a risk factor for anaesthesia? | 734 | ||
| What medical problems are relevant to anaesthesia? | 734 | ||
| Case 4.49 Fitness to drive | 734 | ||
| Candidate information | 734 | ||
| Role | 734 | ||
| Scenario | 734 | ||
| Patient / subject information | 734 | ||
| How to approach the case | 734 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 734 | ||
| 1. Introduction | 734 | ||
| 2. Provide initial reassurance | 734 | ||
| 3. Review her diabetes treatment and any complications to date | 734 | ||
| 4. Be alert to ideas, concerns and expectations | 734 | ||
| 5. Reframe her ideas | 734 | ||
| 6. Keep it clear | 734 | ||
| 7. Repeat important information | 735 | ||
| 8. Confirm understanding | 735 | ||
| 9. Encourage feedback and invite questions | 735 | ||
| 10. Agree a way forward | 735 | ||
| Discussion | 735 | ||
| Who is legally responsible for deciding whether a patient is unfit to drive? | 735 | ||
| When might it be a doctor’s responsibility to inform the DVLA? | 735 | ||
| Do you know the differences between a prescribed disability, a relevant disability and a prospective disability? | 735 | ||
| May a patient with a prospective disability drive? | 735 | ||
| What are the visual requirements for driving? | 735 | ||
| What are the rules on driving after a seizure? | 735 | ||
| Case 4.50 Industrial injury benefits | 735 | ||
| Candidate information | 735 | ||
| Role | 735 | ||
| Scenario | 735 | ||
| Patient / subject information | 736 | ||
| How to approach the case | 736 | ||
| Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law | 736 | ||
| 1. Introduction | 736 | ||
| 2. Explain the results of tests | 736 | ||
| 3. Explore occupational history | 736 | ||
| 4. Explain the implications of the results | 736 | ||
| 5. Establish knowledge of eligibility for compensation | 736 | ||
| 6. Explain the legal position | 736 | ||
| 7. Explain what to do in practice | 736 | ||
| 8. Explore any outstanding concerns | 736 | ||
| 9. Invite questions | 736 | ||
| 10. Agree a way forward | 736 | ||
| Discussion | 736 | ||
| What types of asbestos lung disease make a patient eligible for compensation? | 736 | ||
| Can compensation be considered for any other lung diseases? | 736 | ||
| Can patients sue previous employers? | 736 | ||
| Further reading | 737 | ||
| Communication skills and ethics | 737 | ||
| Discussing clinical management | 737 | ||
| Discussing treatment | 737 | ||
| Communication in special circumstances | 737 | ||
| Breaking bad news | 737 | ||
| Confidentiality, consent and capacity | 737 | ||
| End-of-life issues | 737 | ||
| End of life and palliative care | 737 | ||
| Resuscitation status decision-making | 738 | ||
| Withholding and withdrawing life-prolonging treatments | 738 | ||
| Percutaneous endoscopic gastrostomy feeding | 738 | ||
| Vegetative state | 738 | ||
| Requesting an autopsy | 738 | ||
| Clinical governance | 738 | ||
| Other communication, ethical and legal scenarios | 738 | ||
| Fitness to drive | 738 | ||
| Station 5 Integrated clinical assessment | 739 | ||
| Contents | 739 | ||
| Skin problems | 740 | ||
| Examination of the skin | 740 | ||
| Introduction | 740 | ||
| History | 740 | ||
| Examination | 740 | ||
| Distribution of skin lesions | 740 | ||
| Description of skin lesions | 740 | ||
| Summary | 740 | ||
| Cases | 742 | ||
| Case 5.1 Psoriasis | 742 | ||
| Candidate information | 742 | ||
| Role | 742 | ||
| Scenario | 742 | ||
| Patient information | 742 | ||
| Focused history and examination | 742 | ||
| Initial history | 742 | ||
| Initial examination | 742 | ||
| Chronic plaque psoriasis | 742 | ||
| Hands and nails | 743 | ||
| Further assessment | 743 | ||
| Feedback to patient | 744 | ||
| Feedback to examiners | 744 | ||
| Summarise the key history and examination findings | 744 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 744 | ||
| Outline an investigation and management plan | 744 | ||
| Case 5.2 Dermatitis | 746 | ||
| Candidate information | 746 | ||
| Role | 746 | ||
| Scenario | 746 | ||
| Patient information | 746 | ||
| Focused history and examination | 746 | ||
| Initial history | 746 | ||
| Initial examination | 747 | ||
| Further assessment | 747 | ||
| Feedback to patient | 747 | ||
| Feedback to examiners | 749 | ||
| Summarise the key history and examination findings | 749 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 749 | ||
| Outline an investigation and management plan | 749 | ||
| Case 5.3 Lichen planus | 749 | ||
| Candidate information | 749 | ||
| Role | 749 | ||
| Scenario | 749 | ||
| Patient information | 749 | ||
| Focused history and examination | 750 | ||
| Initial history | 750 | ||
| Initial examination | 750 | ||
| Further assessment | 750 | ||
| Feedback to patient | 750 | ||
| Feedback to examiners | 751 | ||
| Summarise the key history and examination findings | 751 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 751 | ||
| Outline an investigation and management plan | 751 | ||
| Case 5.4 Blistering skin disorders | 751 | ||
| Candidate information | 751 | ||
| Role | 751 | ||
| Scenario | 751 | ||
| Patient information | 751 | ||
| Focused history and examination | 751 | ||
| Initial history | 751 | ||
| Initial examination | 751 | ||
| Bullous pemphigoid | 751 | ||
| Pemphigus | 751 | ||
| Further assessment | 751 | ||
| Feedback to patient | 752 | ||
| Feedback to examiners | 753 | ||
| Summarise the key history and examination findings | 753 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 754 | ||
| Outline an investigation and management plan | 754 | ||
| Case 5.5 Facial rash | 756 | ||
| Candidate information | 756 | ||
| Role | 756 | ||
| Scenario | 756 | ||
| Patient information | 756 | ||
| Focused history and examination | 756 | ||
| Initial history | 756 | ||
| Initial examination | 756 | ||
| Systemic lupus erythematosus (SLE) | 756 | ||
| Discoid lupus erythematosus (DLE) | 756 | ||
| Rosacea | 756 | ||
| Seborrhoeic dermatitis | 757 | ||
| Dermatomyositis | 757 | ||
| Lupus pernio | 757 | ||
| Lupus vulgaris | 757 | ||
| Pulmonary hypertension | 758 | ||
| Xanthelasmata | 758 | ||
| Further assessment | 758 | ||
| Feedback to patient | 758 | ||
| Feedback to examiners | 758 | ||
| Summarise the key history and examination findings | 758 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 759 | ||
| Outline an investigation and management plan | 759 | ||
| Case 5.6 Scleroderma, vitiligo and autoimmune skin disease | 759 | ||
| Candidate information | 759 | ||
| Role | 759 | ||
| Scenario | 760 | ||
| Patient information | 760 | ||
| Focused history and examination | 760 | ||
| Initial history | 760 | ||
| Initial examination | 760 | ||
| Scleroderma – face | 760 | ||
| Scleroderma – hands | 760 | ||
| Further assessment | 760 | ||
| Feedback to patient | 761 | ||
| Feedback to examiners | 761 | ||
| Summarise the key history and examination findings | 761 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 761 | ||
| Outline an investigation and management plan | 761 | ||
| Case 5.7 Oral lesions and nail lesions | 761 | ||
| Candidate information | 761 | ||
| Role | 761 | ||
| Scenario | 761 | ||
| Patient information | 761 | ||
| Focused history and examination | 762 | ||
| Initial history | 762 | ||
| Initial examination | 762 | ||
| Hereditary haemorrhagic telangiectasia (HHT) | 762 | ||
| Peutz–Jeghers syndrome | 762 | ||
| Mouth ulcers and intraoral lesions | 762 | ||
| Other | 762 | ||
| Further assessment | 762 | ||
| Feedback to patient | 762 | ||
| Feedback to examiners | 762 | ||
| Summarise the key history and examination findings | 762 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 763 | ||
| Outline an investigation and management plan | 763 | ||
| Case 5.8 Shin lesions | 764 | ||
| Candidate information | 764 | ||
| Role | 764 | ||
| Scenario | 764 | ||
| Patient information | 764 | ||
| Focused history and examination | 764 | ||
| Initial history | 764 | ||
| Initial examination | 764 | ||
| Erythema nodosum | 764 | ||
| Pyoderma gangrenosum | 765 | ||
| Necrobiosis lipoidica (diabeticorum) | 765 | ||
| Pretibial myxoedema | 765 | ||
| Further assessment | 765 | ||
| Feedback to patient | 766 | ||
| Feedback to examiners | 767 | ||
| Summarise the key history and examination findings | 767 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 767 | ||
| Outline an investigation and management plan | 767 | ||
| Case 5.9 Neurofibromatosis and tuberose sclerosis | 767 | ||
| Candidate information | 767 | ||
| Role | 767 | ||
| Scenario | 767 | ||
| Patient information | 767 | ||
| Focused history and examination | 768 | ||
| Initial history | 768 | ||
| Initial examination | 768 | ||
| Further assessment | 768 | ||
| Epidemiology | 768 | ||
| Genetic basis | 768 | ||
| Diagnostic criteria and clinical features | 768 | ||
| Differential diagnosis | 770 | ||
| Feedback to patient | 771 | ||
| Feedback to examiners | 771 | ||
| Summarise the key history and examination findings | 771 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 771 | ||
| Outline an investigation and management plan | 771 | ||
| Case 5.10 Neoplastic skin lesions | 771 | ||
| Candidate information | 771 | ||
| Role | 771 | ||
| Scenario | 771 | ||
| Patient information | 771 | ||
| Focused history and examination | 772 | ||
| Initial history | 772 | ||
| Initial examination | 772 | ||
| Further assessment | 773 | ||
| Feedback to patient | 773 | ||
| Feedback to examiners | 773 | ||
| Summarise the key history and examination findings | 773 | ||
| Provide a diagnosis or differential diagnosis with supporting evidence | 774 | ||
| Outline an investigation and management plan | 774 | ||
| Rheumatological problems | 774 | ||
| Examination of the joints | 774 | ||
| Examination of the joints – overview | 774 | ||
| The GALS screen | 774 | ||
| Regional examination | 774 | ||
| Further assessment | 776 | ||
| Symptoms | 776 | ||
| Autoimmune tests | 776 | ||
| Examination of the hands and arms | 777 | ||
| The hands and wrists | 777 | ||
| The elbow | 777 | ||
| The shoulder | 777 | ||
| Subacromial disease – rotator cuff disease | 779 | ||
| Glenohumeral disease – adhesive capsulitis (‘frozen shoulder’) and osteoarthritis | 780 | ||
| Summary | 780 | ||
| Examination of the legs | 782 | ||
| The hip | 782 | ||
| Thomas’s test | 782 | ||
| Trendelenberg’s test | 782 | ||
| The knee | 782 | ||
| The ankles and feet | 784 | ||
| Appendix – 100 tips for passing PACES | 895 | ||
| Before paces | 895 | ||
| Timing | 895 | ||
| What the examiners are looking for | 895 | ||
| It’s in your hands! | 895 | ||
| Practice | 895 | ||
| On the day of paces | 896 | ||
| Some formalities | 896 | ||
| At the start | 896 | ||
| The patients are more important than the examiners! | 896 | ||
| Examiners | 896 | ||
| Examining patients | 896 | ||
| Examining and presenting | 896 | ||
| When the diagnosis is not clear | 897 | ||
| History-taking skills | 898 | ||
| Communication skills | 898 | ||
| Answering examiners’ questions | 898 | ||
| Answering examiners’ questions at the communication skills and ethics station | 898 | ||
| When you think things are going badly | 898 | ||
| After paces | 899 | ||
| Index | 901 | ||
| A | 901 | ||
| B | 906 | ||
| C | 908 | ||
| D | 913 | ||
| E | 916 | ||
| F | 917 | ||
| G | 918 | ||
| H | 919 | ||
| I | 923 | ||
| J | 925 | ||
| K | 925 | ||
| L | 925 | ||
| M | 927 | ||
| N | 929 | ||
| O | 930 | ||
| P | 932 | ||
| Q | 936 | ||
| R | 936 | ||
| S | 937 | ||
| T | 940 | ||
| U | 942 | ||
| V | 943 | ||
| W | 944 | ||
| X | 944 | ||
| Z | 944 |