Terms 2 & 3 - Mededcoventry.com · 2017-04-04 · 2016 Cohort Delivering ‘Tomorrow’s Doctors...

Clinical Skills Course (CSc)

2016 Cohort

Delivering ‘Tomorrow’s Doctors’

Terms 2 & 3

Clinical Skills 2016/17 2

Table of Contents

Clinical Skills Course 2: Introduction to Clinical Skills

•4Clinical and Administration Staff

•7Aims and Objectives of CSc

•9CSc: Teaching Timetable

•13Learning Resources

•15Learning Outcomes for CSc

•17Organisation of CSc

•22Clinical Skills Course Certification

•23CSc Assessment

•28Session 11: History and Examination of the Nervous System 1: Limbs and

Gait

•36Session 12: History and Examination of the Nervous System 2: Cranial

Nerves

•43Session 13: Communications Skills 3

•44Session 14: Psychiatric Aspects of the General Medical History and

Examination


•54Session 15: The Musculoskeletal System 1: Shoulder and Hands

•61Session 16: The Musculoskeletal System 2: Knee and Hip

•67Session 17: Palpable Masses and Dermatology

•75Session 18: The Musculoskeletal System 3: Spine and GALS

•81Session 19: Communication Skills 4

•82Sessions 20-22: Clinical Skills Revision

•83Session 23: Breast Examination

•87Session 24: Communication Skills 5

•88Session 25: Clinical Skills Revision

•89Appendicies


Theme Lead: Dr. Vinod Patel

BSc (Hons.) MD FRCP FHEA MRCGP DRCOG

Principal Clinical Teaching Fellow Theme Lead in in Clinical Skills

Education & Development, Warwick Medical School The University of Warwick, Coventry, CV4 7AL, UK

Room 017, Medical Teaching Centre

Hon. Consultant in Endocrinology and Diabetes

George Eliot Hospital NHS Trust College Street Nuneaton, CV10 7DJ, UK

Contact: Tel: +44 (0)2476 865212 Email: [email protected]

Administrative Lead: Mrs. Lorraine Brown MB ChB Operations Manager Room 013, Medical Teaching Centre Warwick Medical School Contact: Tel: +44 (0)2476 573813 Email: [email protected]

Administrative Assistant: Mrs. Anjula Kang Phase I Administrative Assistant Room 012, Medical Teaching Centre Warwick Medical School Contact: Tel: +44 (0)2476 573815 Email: [email protected]

Clinical and Administration Staff

mailto:[email protected]




Lead Tutors (based at hospital trusts)

Dr Andrew Ilchyshyn Consultant Dermatologist UHCW

Email: [email protected]

Dr Jane Hill Clinical Skills Lead Warwick Hospital


Dr Rajiv Nair Consultant Physician /Clinical Skills Lead George Eliot Hospital


Associate Directors (based at hospital trusts)

Dr Sailesh Sankaranarayanan

Deputy Medical Director (Education)

UHCW


Dr Asok Venkataraman

Consultant Cardiologist

George Eliot Hospital


Dr Chris Marguerie

Consultant Rheumatologist

Warwick Hospital










Undergraduate Co-ordinators (based at hospital trusts)

Rowena Ahmed

Undergraduate Programme Manager

UHCW

Tel: 024 7696 8793


Sam Cook

Undergraduate Co-ordinator


Tel: 024 7686 5024


Jenny Oriel

Undergraduate Co-ordinator

Warwick Hospital

Tel: 01926 495321 Ext 8190

Email: [email protected] Jo Williams

Head of Undergraduate Medical Education

Tel: 01926 495321 Ext 4411


Shaheen Shaikh

Undergraduate Medical Education Secretary


Tel: 024 7686 5024


Clinical Education Fellows Dr. David Tweedie Email: [email protected] Dr. Aimee Palace Email: [email protected] Mr Patrick Henry Email: [email protected] Dr. Laura Reeves Email: [email protected] Dr. James Gill Email: [email protected] Room 113, 1st Floor, MTC. Tel: 024 7657 4497 / 4495










Building on the teaching in the first term, Clinical Skills terms 2 & 3 aims to continue to provide an

introduction to the knowledge, skills and attitudes necessary to perform clinical history-taking and

physical examination and develop a foundation for the skills required for diagnosis, reassurance

and management. Key objectives introduced in this block are:

Nervous System Clinical Examination:

The ability to recognise common presentations in relation to the nervous system. Other skills

would include:

Conducting clinical histories in relation to common presentations.

Demonstrating the skills of neurological examination by demonstrating examination

techniques in relation to assess of tone, power, co-ordination, reflexes, gait and cranial

nerve examination.

Presenting findings.

Musculo-skeletal Clinical Examination:

The ability to recognise common Musculo-Skeletal (MSK) clinical conditions. Other skills would

include:


Demonstrating the skills of examination of the hip, knee, spine, hands.

GALS Assessment: Gait, Arms, Legs, Spine.


Mental Health Clinical Examination:

The ability to recognise common Mental Health presentations. Other skills would include:

Conducting clinical histories in relation to common presentations

Demonstrating the skills of MMSE assessment and basic aspects of psychiatric

assessment.


Surgical Clinical Examination:

Aims and Objectives of CSc


The ability to recognise common presentations in relation to surgical presentations. Other skills

would include:


Demonstrating the skills of examination of a mass such as breast examination, hernia

examination or lymph-nodes examination.


Health Promotion and Behavioural Change:

The ability to recognise the main modifiable behavioural risk factors for that lead to significant

clinical conditions such as cardiovascular disease, respiratory disease, diabetes, cancer, arthritis

and mental health problems. Other skills would include:

Presenting the risk to health to individual patients.

Eliciting a comprehensive history of risk factors affecting future health.

Role play and the use of behavioural change strategies with patients.

Attitudes

A student should realise that clinical history-taking and physical examination are essential

components of interaction with patients and their carers. These should always be performed in a

way which recognises the needs, sensitivity, and rights of the patient.


CSc Term 2 & 3: Learning Clinical Skills with Hospital Patients

This module continues the clinical skills teaching in a non-clinical setting but now

introduces contact with real patients in the hospital setting.

The clinical teaching continues to be taught at the CSB on Fridays and on the wards

on Mondays and Tuesdays (dependent on assigned group).

For the ward based teaching you will be assigned to one of the three hospital trusts

that are detailed below.

University Hospitals Coventry & Warwickshire (UHCW)

Lectures

Clinical Science Building (CSB) Lecture Theatre 8.00 - 9.00

Clinical Skills Lab (Hospital & CSB)

AM Group: 9.15-12.30

PM Group: 13.15-16.30

Clinical Anatomy Labs

AM Group: 9.15-12.30

PM Group: 13.15-16.30

Clinical Skills 2 - Teaching Timetable


Warwick Hospital

South Warwickshire NHS Foundation Trust

Lakin Road

Warwick

CV34 5BW


George Eliot Hospital NHS Trust

Eliot Way

Nuneaton

CV10 7DJ

Clinical Skills Session Date Topic

11

Friday 13 January History and Examination of the Nervous System 1: Limbs and Gait

12

Friday 20 January History and Examination of the Nervous System 2: Cranial Nerves

13

Friday 27 January Communication Skills 3

14

Friday 3 February Psychiatric aspects of the General Medical History and examination

15 Friday 10 February

The Musculoskeletal System 1: Shoulder and Hands

16

Friday 17 February The Musculoskeletal System 2: Knee and Hip

17

Friday 24 February Palpable Masses and Dermatology

18 Friday 3 March

The Musculoskeletal System 3: Spine & GALS

19

Friday 10 March Communication Skills 4

20

Friday 17 March Clinical Skills Revision

21

Friday 28 April Clinical Skills Revision

22

Friday 5 May Clinical Skills Revision

23

Friday 12 May Breast Examination

24

Friday 19 May Communication Skills 5

25

Friday 26 May Clinical Skills Revision

UHCW Friday Teaching Timetable 2017


Clinical Skills Session Date

Additional Information

T1

9 January / 10 January

T2

16 January / 17 January

T3

6 February / 7 February

T4


T5


T6

24 April / 25 April

T7

8 May / 9 May

T8

15 May / 16 May

T9

22 May / 23 May

OSCE Examination

12 to 15 June 2017 (provisional dates)

Hospital Trust Teaching Timetable 2017

Clinical Skills 2 – 2016 13

Reading “To study the phenomena of disease without books is to sail an uncharted sea. Whilst to study books without patients is not to go to sea at all”.

William Osler (1840-1919)

Recommended Core Textbook(s) 1. Practical and Professional Clinical Skills (CSc textbook).

Edited by Vinod Patel and John Morrissey. Oxford University Press 2011. ISBN: 019958561X

2. Macleod’s Clinical Examination: Latest Edition 13th 2013.

Edited by Graham Douglas, Fiona Nicol and Colin Robertson. Churchill Livingstone 2013. ISBN: 0702047287

Other Useful Textbooks 3. Introduction to Clinical Examination.

M J Ford, I Hennessy, A Japp, Elsevier 2005.

4. Clinical Medicine (not a clinical skills text but very useful). Praveen Kumar and Michael Clark. Latest Edition, W B Saunders.

Clinical Equipment You will need to purchase a pen torch and a stethoscope.

Learning Resources

http://www.amazon.co.uk/Practical-Professional-Clinical-Skills-Vinod/dp/019958561X/ref=sr_1_1?ie=UTF8&qid=1410509782&sr=8-1&keywords=clinical+skills+patel

http://www.amazon.co.uk/Macleods-Clinical-Examination-STUDENT-CONSULT/dp/0702047287/ref=sr_1_1?ie=UTF8&qid=1410509930&sr=8-1&keywords=macleods+clinical


Warwick Medical School Videos Clinical skills videos and the answers to the pre-session work are available on Moodle. Macleod’s Clinical Examination Videos Via the internet site for the book (latest edition 13th). Other sites: There are several internet sites. The one below has been found to tie in well with this course. www.osceskills.com

Learning Resources - Clinical Videos

http://www.osceskills.com/

http://moodle.warwick.ac.uk/course/view.php?id=2907


Curriculum

The following list illustrates how the Clinical Skills theme learning outcomes map to Tomorrow’s Doctors (GMC 2009) curriculum learning outcomes and the Warwick MB ChB outcomes. The “P” and bracketed letter, refer to the paragraph sections of the Tomorrow’s Doctors document. These learning outcomes will apply throughout the whole course. Block Learning Outcomes P9: Apply psychological principles, method and knowledge to medical practice. The graduate will be able to: (e) Discuss psychological aspects of behavioural change and treatment compliance Summarise key influences on long-term physical illness including effects of diet, exercise, weight and, smoking and alcohol on cardiovascular disease

P9

P13: The graduate will be able to carry out a consultation with a patient. The graduate will be able to: (a) Take and record a patient's medical history, including family and social history, talking to relatives or other carers where appropriate

List the elements of a standard medical history that allows the details of a patient's presenting issue and background to be elicited

List basic abbreviations and their meanings commonly used when recording medical histories

Recognise and ensure accurate documentation of patient's level of functioning in activities of daily living and requirements for social support by informal or professional carers

Identify attitudes commensurate with patient-centred interviewing

List skills associated with effective patient-centred interviewing. List the tasks and functions in the Calgary Cambridge Model. Explain the use of structured communication assessments (Such as the Leicester Assessment Package or LAP) in clinical practice.

Define a patient-centred interview; explain reasons for adopting a patient-centred approach and contrast this with alternatives

(b) Elicit patient's questions, their understanding of their condition and treatment options, and their views, concerns, values and preferences Demonstrate accepted methods of allowing patients to ask questions and discuss their views, concerns and preferences (c) Perform a full physical examination State the elements of a full clinical examination including the overall structure and steps involved in examining each system Demonstrate ability to communicate appropriately with patient while performing a physical examination; to explain what is going to be done; reassure during performance; continual observance of patient's non-verbal and verbal cues during examination

P13

Learning Outcomes for CSc


P14 Diagnose and manage clinical presentations. The graduate will be able to: (c) Formulate a plan of investigation in partnership with the patient, obtaining informed consent as an essential part of this process Outlines the process of formulating a plan of investigation/care and how to discuss this with a patient (and carers/family if appropriate). Demonstrates how to check understanding by the patient (and carers/family if appropriate)

P14

P15 Communicate effectively with patients and colleagues in a medical context (a) Communicate clearly, sensitively and effectively with patients, their relatives or other carers, and colleagues from the medical and other professions, by listening, sharing and responding. Identify and reflect on the communication practices of and amongst different groups of health professionals (d) Communicate appropriately in difficult circumstances, such as when breaking bad news, and when discussing sensitive issues, such as alcohol consumption, smoking or obesity. List reasons why people do not adhere to behaviour change options. Identify the domains to be considered when promoting behaviour change. Identify the stages in the trans-theoretical Model of Behaviour Change. Identify patient’s thoughts and feelings at each stage of the model. Show how to assess motivation and self-efficacy in changing (e) Communicate appropriately with violent patients. Explain the operation of the zero tolerance policies for violence against NHS staff

P15

P16: Provide immediate care in medical emergencies. The graduate will be able to: (d) Provide immediate life support Demonstrate in-hospital resuscitation skills including chest compressions, ventilation, recovery position, use of pocket mask

P16

Tomorrow’s Doctors Appendix 1: Practical Procedures for Graduates Diagnostic procedures Measuring pulse rate and blood pressure Venepuncture Therapeutic procedures Correct techniques for ‘moving and handling including patients General aspects of practical procedures Giving information about the procedure, obtaining and recording consent, and ensuring appropriate aftercare Hand washing Use of personal protective equipment (gloves, gowns, masks) Safe disposal of clinical waste needles and other ‘sharps


Clinical Teaching with patients: There are 9 sessions in total (T1 to T9 on the timetable). Groups of students will attend one of the hospitals for clinical teaching, either on a Monday morning or a Tuesday afternoon. Each group will be allocated to a teaching team of clinical staff who will see them throughout the course. You will receiving a mandatory Trust induction at the first session. You will be informed as to where to turn up on the first day from your Trust Undergraduate Co-ordinator.

Organisation of CSc Terms 2 & 3

• The most important component of the course is the clinical learningthat will take place with patients in the hospital trusts. The tutorials andlectures are an adjunct to better prepare you to get the most out ofyour time at the hospitals trust with patients and experienced clinicians.

Aims


Outline Plan for Clinical Session in Hospital Trusts

Initial gathering and briefing:• Tutors and Students

meet in designated area and outline teaching session and allocate students to each tutor.

Clinical Teaching with Patients:• The bulk of the

teaching time should be observation of the student taking a clinical history, conducting a clinical examination and then presenting the clinical findings. This should be followed by feedback to the student.

Ensuring broad coverage of clinical cases:• Students should be

invited to state, to the tutors, which areas of clinical skills they feel they have not covered. These areas should be targeted for teaching by the tutors.

De-brief at the end of teaching:• The students and

tutors should summarise what they have learnt at the end of the session. It is always important to address any concerns especially in relation to specific techniques or any clinical aspect that arose in the teaching.

Clinical Cases logbook:• Use the template

(end of handbook) to record 2 or 3 cases each week. This will allow you to vividly recall cases you have been taught on or seen on your own.


It is important that the following main areas of clinical history and examination have been covered in these clinical sessions:

Clinical History:

General examination

Abdominal examination

Cardiovascular examination

Respiratory examination

Nervous system examination: Limbs and Gait

Nervous system examination: Cranial Nerves

Assessment of Mental Function (MMSE)

Musculoskeletal Examination: Knee, Hip, Spine, Hands, GALS

Examination of a lump eg breast, hernia, lymph-node


Teaching Format

The format of the teaching sessions may vary from Trust to Trust. You may be allocated to patients so that you can attempt history-taking and physical examination, initially under supervision. Once you are familiar with the basic principles it is up to you to spend time on the wards developing your skills as far as possible in the student-directed clinical history and examination sessions (as advised by your undergraduate co-ordinator). Try to ensure that you have been observed taking at least two full clinical histories and an examination of the cardiovascular, respiratory, gastrointestinal, neurological and musculoskeletal system by a tutor and given feedback in these or the Friday Clinical Skills sessions.

Review and meet the tutors initially (5 – 30

minutes)

Ward and meet patients

(up to 90 minutes)

Debrief (up to 30 minutes)


Student-directed Clinical History and Examination in Hospital Trusts

Clinical Skills Lectures External lecturers will lecture, on several occasions, during the Friday morning 8 to 9am lecture slots. Approximately half the lectures will be Clinical and Communication skills and others Clinical anatomy. The lecturers will be sent an e-version of this guide and advised that the content of the 60 minute lecture should be as follows:

All external lecturers will be given a written reminder to put their talk into a folder on the desktop on the day of the lecture. This will be undertaken by a student ideally and this student will then leave a message with the school office for the lecture to be transferred to the intranet.

Although students will be encouraged to see patients on their own, in their own time, (in pairs or threes), this will be under strict conditions.

• Access to patients on wards or other clinical areas will be directed and advised by the Undergraduate Co-ordinators at each hospital site.

• Please ensure that high standards of professionalism are maintained at all times-especially infection control, explanation to and consent from the patient, appropriate use of chaperones and not getting in the way of clinical care of the patient.

• Consent will also be needed from the nursing staff and clinical team looking after the patient. Students should aim to attend a minimum of 3 sessions, each 2.5 to 3.5 hours long. This time will be needed for you to complete your portfolio cases and clinical

logbook.

Initial summary/recap of the topic

This should take no more than 10 minutes as the topic has been covered in some detail previous.

There should then be an invitation to ask questions.

Sharing clinical experience

The lecturer can then focus on the more detailed aspects of the topic.

This may vary according to what the experienced clinician would want medical students to know more about.

The lecture slides

Should be left behind and saved into the folder on the lecture theatre Desktop

NB: this remains the prerogative of the lecturer.


Clinical Skills Course 2 Certification - IMPORTANT

• There is a form at the back of this workbook which you MUST ask your clinical skillstutor(s) to sign at the end of the course.

• This form certifies your attendance, your workbook and your student case reports.

It MUST be returned to the School Office by 4pm on Thursday 25th May 2017.


Please read carefully. All the taught material in Terms 1, 2 and 3 can be examined in any of the formats used for assessment at the end of Term 2 and 3. Therefore the material covered will be assessed in both the written and OSCE elements of the assessment at the end of Phase 1. The practical assessment consists of a number of stations in an Objective Structured Clinical Examination (OSCE). The stations will be chosen to reflect the range of objectives in the whole of the Phase 1 course and can include:

Assessment of clinical history and communication skills.

Assessment of physical examination skills.

Assessment of practical procedures (for example, blood pressure taking, venepuncture on model arm, basic electrocardiogram interpretation).

In-hospital resuscitation.

Clinical Anatomy stations: relating to anatomy, histology and embryology.

Data interpretation exercises (for example, epidemiological data, ECGs).

Skills of information retrieval (such as Medline exercises).

Presentation skills – eg clinical history, clinical examination, written clinical record.

Other tasks as appropriate to the curriculum objectives.

CSc Assessment


Overall the Clinical Skills course has 5 main requirements for progression: 1: Attendance and Participation in the Monday or Tuesday Clinical Skills Teaching Sessions at the Hospital Trusts The workbook has a certificate to be signed by your Hospital Clinical Skills Tutor to indicate attendance and active participation in the course. As with all aspects of the course that are compulsory, 100% attendance is expected. If a student cannot attend a session for any reason, they must submit an absence request form to the medical school office. 2: Attendance and Participation in the UHCW Friday Clinical Skills Teaching Sessions The workbook has a certificate to be signed by your UHCW Friday Clinical Skills Teaching clinical tutor to indicate attendance. Again, 100% attendance is expected. 3: Clinical Skills workbook entries Periodically, the clinical tutors will examine the entries in your workbook to ensure that you have completed the work specified. There is a certificate at the end of the workbook for your UHCW Friday Clinical Skills Teaching clinical tutor to indicate this. It is not expected that every session's work will be examined in detail. Provided you have made a serious attempt at the preparatory questions and can demonstrate that you satisfactorily completed the clinical work specified, then the relevant section of your workbook will be signed. 4: Student Case Reports Your Hospital Clinical Skills Tutor must sign the certificate at the end of this workbook to confirm that you have completed TWO student case reports. One case should be marked according to the standardised marking scheme and graded at least ‘Pass’. 5: OSCE Examination: The June OSCE examination will cover all the clinical material in Clinical Skills Course across terms 1, 2 and 3 and some Clinical Anatomy. Some stations may also integrate material taught in any of the five Phase I Blocks. There will be a number of stations that specifically test clinical history and examination. There will be further stations on clinical anatomy and basic procedures.


Medical Students in Hospitals

This section has been prepared from guidance from the representatives of Health Authorities, the General Medical Council, the Joint Consultants Committee and the Committee of Vice-Chancellors and Principals. Scope

The guidance applies to bona fide medical students who are either:

'on attachment': students who have access to patients and assist in clinical work while attending in hospitals under agreed arrangements (including periods of elective study) in fulfilment of the curricular arrangements of their medical schools; or

'assistants': students in the final stages of their training who voluntarily assist those practitioners who are undertaking the duties of Foundation Year 1 doctors.

For these purposes a 'bona fide student' is a medical student who is registered for and attending a course of study leading to a degree or diploma from:

a licensing body in the United Kingdom; or

an overseas university, provided that either the qualifications of that university are registerable for full or limited registration with the General Medical Council; or

the student is temporarily registered with a medical school in the United Kingdom for the purpose of pursuing a period of clinical training in the United Kingdom

Consent - Patients' Rights

Any hospital where clinical teaching takes place should include advice to patients which includes an explanation of the importance of clinical teaching and an outline of what it might involve. In addition, patients should be reminded on admission, or as soon as possible thereafter, that they are entitled to decline to be observed or attended by students without affecting in any way the treatment they receive. Wherever practicable, the student's status and the reason for his/her presence must be obtained before the first occasion on which a medical student is present during the examination or treatment of a patient and always before interviewing or examining a patient. The explanation should be given by the supervising registered medical practitioner or by a member of the nursing or midwifery staff but not by the student unless specifically authorised in advance by the supervising registered medical practitioner. The Medical Act 1983

By virtue of section 47 of the Medical Act 1983, an appointment as a physician, surgeon or other medical officer can only be held by a person fully registered with the General Medical Council. Persons with provisional or limited registration may be deemed to be fully registered to the extent permitted by sub-sections 15(3) and 22(7) of that Act. Students are excluded from these provisions and cannot perform any clinical service that is not directly supervised by a registered medical practitioner. Authorities are liable at law for the acts and omissions of students they admit to their premises.


Conditions governing students' clinical work

To ensure that the interests of patients, Authorities and Trusts are safeguarded the Department and the profession have agreed on the conditions under which students may undertake clinical work. All medical, nursing, midwifery, pharmacy and radiography staff, and in particular staff responsible for patient care in units where students will be present, should be familiar with these conditions which must also be fully understood by the students themselves. Dress Code and Basic Equipment

In relation to the following, students should:

Dress Code: when in the presence of patients adopt a dress code, which projects a professional image and allows patients to feel comfortable in your presence. Medical students should also introduce themselves in an appropriate manner. Dress should be formal and it is your responsibly to contact your consultant/General Practice Manager/Undergraduate Co-ordinator to find out appropriate standard of dress for the local environment. Currently the code is: no ties (or tucked in) and bare from elbows to fingertips. One ring is allowed but not watches.

University ID Badge: wear their University ID badges at all times for identification purposes. Most Hospital Trusts will also require you to wear your Trust identity badge as well. The latter will also be needed for access to certain clinical areas of the hospital.

Stethoscope: purchase a stethoscope of reasonable quality and use this in the clinical environment when needed. Other devices such as ophthalmoscopes will usually be available on wards and clinics and do not need to be purchased

With Regards to the Health of the Patient, Staff, General Public and Medical students themselves

Students should:

Protect the health of patients and themselves by meticulous attention to infection control. The most important single act is to wash/cleanse your hands immediately before and after each patient encounter. Alcohol gel hand wash will suffice in many instances but not all. Clostridium difficile and MRSA infections can be reduced by >90% by meticulous hygiene.

After encountering a patient with possible or suspected or actual Clostridium difficile infection, you will need to wash your hands with soap and water. The spores of Clostridium difficile are resistant to alcohol gel.

Bring the appropriate health declaration information on the first day of each new attachment

Take responsibility for their own health in the interests of public safety. If a student knows that they have a serious condition that could be passed onto patients or performance could be significantly affected by a condition illness (or its treatment) they must take and follow advice from a consultant or occupational health staff or from another suitably qualified doctor on whether and in what ways their clinical contact with patients should be altered

Ensure that all your immunisation records are up to date for the safety of your patients and yourself. You should ensure you provide the required immunisation evidence to the Phase I Office in good time and inform us and occupational health if you test positive for the Hep B.


Conditions for all medical students

The admission of a medical student to the premises of a Health Authority or a Trust is subject to the prior written approval of that body. Only 'bona fide medical students' may have access to patients and take part in any clinical procedure involving patients, including all forms of clinical examination, even under supervision. Students must be readily identifiable as such, e.g. wear a suitable lapel badge, University ID, Trust ID. Never breach patient confidentiality. Never use names and other identifiers in writing about or discussing patients in teaching. Before admitting a medical student:

Health Authorities and Trusts should make any necessary inquiries into the health of students, and may request and arrange for them to undergo a medical examination as a condition of their attendance in hospital if they are satisfied that the interests of patients require it

Health Authorities and Trusts must ensure that any clinical assistance by a student, whether or not on their premises, is given under the close supervision of a registered medical practitioner; save that, where a student assists with a maternity case, the supervision of a registered midwife is acceptable.

Students must in no circumstances:

Initiate, alter or stop the treatment of a patient on their own diagnosis; both diagnosis and treatment must be confirmed by the registered medical practitioner supervising them.

Prescribe, request radiological examinations or other diagnostic investigations, or order blood to be cross-matched. If students complete an order form for any of these purposes it must then be signed by the registered medical practitioner supervising them before it is executed.

Take any part in obtaining or witnessing the signature by or on behalf of a patient on a form of consent to treatment.

Take a history from, examine or undertake a procedure on a patient unless his/her prior informed consent has been obtained. If it is practicable to obtain specific consent, the student must seek authorisation in advance from the supervising registered practitioner. This will apply in the case of those patients unable, for whatever reason, to make a decision on consent. Exceptionally, this may include some anaesthetised patients, though normally such consent should have been sought from the patient in advance.

Emergency Situations A student acting in an emergency e.g. a cardiac arrest, has the same rights and responsibilities as any other citizen. In general always call for urgent help and help to the limit of your competence. Conditions for medical students on attachment

The consultant to whom the student is attached will determine the degree of supervision required, will provide such supervision personally, or will arrange for its provision by one or more identified registered medical practitioners.

Clinical Skills 2 - 2016 28

Session 11: History and Examination of the Nervous System 1: Limbs and Gait

• The aim of these sessions (11 and 12) is that you should understandthe common symptoms of neurological disease and be able to examinethe cranial nerves and peripheral nervous system.

• You should also practice clinical history-taking in relation to your CBLcases if time permits.

Aims

• By the end of this session(s) you should:

• Recognise the common symptoms of neurological disease includingheadache, impairment of consciousness, dizziness and vertigo.

• Be able to examine the cranial nerves in a normal subject and beginto appreciate how abnormalities may present.

• To be able to visualise the fundus with the ophthalmoscope (later inrevision sessions).

• Examine motor power in the limbs.

• Examine muscular tone.

• Elicit the biceps, triceps, supinator, knee, ankle and plantar reflexes.

• Elicit light touch, pain, joint position sense and vibration sense.

• Examine co-ordination of the limbs.

• Differentiate an upper motor from a lower motor neurone lesion.

Objectives


Clinical Context Background Stroke is by far the commonest major neurological disease and the one most frequently requiring urgent hospital admission. However, the non-specialist will frequently be required to manage patients with Parkinson’s disease, multiple sclerosis or motor neurone disease when they develop concurrent problems, such as chest or urinary tract infection. The cause of stroke in about 80% of cases is thromboembolic. Haemorrhagic stroke is less common because of more effective treatment of its main risk factor, hypertension. Common presentations The patient with a neurological problem affecting one or more limbs will usually present with: • Pain • Paraesthaesia • Numbness • Muscle weakness Anatomical & physiological principles When testing power in the upper limbs many muscle groups can be assessed but a minimum set, since each root level is tested at least once, is:

Upper Limb Lower Limb

shoulder abduction (C5, C6)

shoulder adduction (C5, 6, 7)

elbow flexion (C5, 6)

elbow extension (C7, C8)

wrist dorsiflexion (C5, C6, C7)

wrist palmar flexion (C6, C7,8)

grip (C8, T1) and finger abduction (T1)

hip flexion (L1, 2)

hip extension (L5, S1)

knee flexion (S1)

knee extension (L3, 4)

ankle dorsiflexion (L4, L5)

ankle plantar flexion (S1, 2).

A quick screening assessment of sensation in the upper limbs is to test for light touch on the upper arm medially and laterally, on the lower arm medially and laterally, on each digit, followed by vibration and position sense on a finger. In the lower limbs test light touch on the thigh medially and laterally, on the calf medially and laterally, on the dorsum of the foot, the tip of the big toe, the lateral border of the foot, then vibration sense at the medial malleolus and position sense on the big toe.


Pre-session work

1. How can the headache of migraine, tension headache and a cerebral tumour be distinguished on

the history?

2. How would an observant bystander describe a grand mal epileptic fit?

3. Distinguish between 'vertigo' and 'dizziness'

4. At what level do a) pyramidal motor fibres, b) pain fibres, c) position sense fibres cross over in the spinal cord?

5. What is the MRC grading system for loss of muscle power?


6. What is the sequence of neurophysiological events in a tendon reflex?

7. How can an upper motor neurone lesion of the limbs be distinguished from a lower motor neurone

lesion?

8. Write down three tests of cerebellar function

9. Revise these tables: books will differ- defer to Dr Richard Tunstall’s teaching notes!

Reflex

Nerve Root

Biceps

Triceps

Supinator

Knee

Ankle

Plantar

Point

Dermatome

Tip of shoulder

Middle finger

Axilla

Umbilicus

Supra-pubic area

Knee

1st Toe

5th Toe

How will you remember these? Any tips or mnemonics?


Neurological Examination of the Arms Sequence Objective: Neurological deficits

Introduction, Explanation, Consent, Position

Wash hands, Ask patient to uncover and remove all clothes covering arms and shoulders. Offer to cover chest with a sheet, towel or item of clothing

General Inspection and Examination

? distress, ? pain ? unsteady ? wasting ? walking aids ? splints, ? hemiplegia ? Parkinsonism ?

Inspection

?wasting,?fasciculations ?movements ?arthritis ? scars Tone

Wrist, elbow and shoulder (? Normal, increased, decreased, cog-wheel, clasp knife, lead pipe)

Power

Shoulder Abduction (C5, C6) and Adduction (C6, C7, C8)

Elbow Flexion (C5, C6) and Extension (C7, C8)

Wrist Extension (dorsiflexion, C5, C6, C7) and Flexion (palmar flexion, C6, C7, C8)

Grip: use your index and middle finger (C8, T1)

Fingers out straight, “stop me bending them” C7 Radial N.

Spread fingers “ stop me pushing them together (Dorsal interossei, ulnar N)

“Hold this paper between your fingers, stop me pulling it out” (palmar interossei, ulnar N)

“Point your thumb to the ceiling stop me pushing it down” abductor. pollicus brevis, median N)

“Put your thumb and little finger together and stop me pulling them apart” opponens pollicus, median N)

Use MRC Scale: o 0= nil o 1= flicker/fasciculation o 2= movement if gravity eliminated o 3= versus gravity but not resistance o 4= versus gravity but weaker than normal o 5= normal.

Reflexes

Test biceps (C5, C6) ? Jendrassik Manoeuvre to re-inforce

Supinator (C5,6)

Triceps (C7,8) also finger jerk (C8,T1)

Use scale: 0=absent, +reduced, ++ normal, +++increased, ++++increased with clonus Co-ordination

Finger-nose test

Alternating hand movements (dysdiadochokinesia).


Sensation

Light touch: o C4 = shoulder tip o C5 = deltoid o C7 = middle finger o C8 = little finger o T1 = elbow

Pin-prick, Proprioception, Vibration sense, temperature. Essential Extras:

Assessment of function: undoing buttons, writing, holding a cup, reach out for object

In many cases examination for Carpal Tunnel syndrome: Median nerve muscles (abductor pollicis brevis and opponens pollicis, thenar eminence, senation loss lateral half of palm and lateral 3.5 digits (palmar surface)

Professionalism: Maintains dignity of patient, communicates sensitively with patient, thanks patient, washes hands, writes appropriate record Presentation of findings: General ► Important positive findings ►important “negative” findings including extended examination ► Clinical Conclusion


Neurological Examination of the Legs Sequence Objective: Neurological defecits


Wash hands, Ask patient to uncover and remove all clothes covering legs. Cover groin and upper thighs with a sheet, towel or item of clothing


? distress, ? pain ? unsteady ? wasting ? walking aids ? splints, ? hemiplegia ? Parkinsonism ? shortening of leg

Inspection

?wasting, ?fasciculations ?movements ?arthritis ? scars ? Charcot joint ? ulcer ?bowing of tibia

Tone

Knee and Hip (? Normal, increased, decreased) Power

Hip Flexion (L1, L2) and Extension (L5, S1)

Hip Adduction (L2, L3, L4) and Abduction (L4, L5, S1)

Knee Extension (L3, L4) and Flexion (S1)

Dorsiflexion of Foot (L4, L5), Plantarflexion (S1, S2)

Inversion of foot (L4, L5) and Eversion (L5, S1)

Toe Extension (L5) and Flexion (S1)

Use MRC Scale: 0= nil, 1= flicker/fasciculation, 2= movement if gravity eliminated, 3= versus gravity but not resistance, 4= versus gravity but weaker than normal, 5= normal.

Reflexes

Knee (L3, L4) ? Jendrassik Manoeuvre to re-inforce

Ankle (L5, S1)

Plantar Reflex (S1) if positive = Babinski response of UMN)

Use scale: 0=absent, +reduced, ++ normal, +++increased, ++++increased with clonus Co-ordination

Heel-shin test

Foot tapping movements Sensation

Light touch: Outer thigh = L2, inner thigh = L3, outer calf = L5, ;lateral foot = S1,

Pin-prick

Proprioception

Vibration sense

Temperature

Romberg’s Test (Proprioception)


Essential Extras:

Assessment of function: gait (ordinary, heel to toe for ataxia, on toes for foot drop)

Romberg’s test

Putting on clothes Professionalism: Maintains dignity of patient, communicates sensitively with patient, thanks patient, washes hands, writes appropriate record Presentation of findings: General ► Important positive findings ►important “negative” findings including extended examination ► Clinical Conclusion

Babinski reflex: plantar extension indicates Upper Motor Neurone Lesion

Co-ordination: Checking for dysdiadochokinesia

Reflexes: note tendon hammer is held at the very end, correct swinging action essential to deliver short sharp knocks (2 or 3 usually)


Session 12: History and Examination of the Nervous System 2: Cranial Nerves

• The aim of these sessions (11 and 12) is that you should understandthe common symptoms of neurological disease and be able to examinethe cranial nerves and peripheral nervous system.

• You should also practice clinical history-taking in relation to your CBLcases if time permits.

Aims

• By the end of this session(s) you should:

• Recognise the common symptoms of neurological disease includingheadache, impairment of consciousness, dizziness and vertigo.

• Be able to examine the cranial nerves in a normal subject and beginto appreciate how abnormalities may present.

• To be able to visualise the fundus with the ophthalmoscope (later inrevision sessions).

• Examine motor power in the limbs.

• Examine muscular tone.

• Elicit the biceps, triceps, supinator, knee, ankle and plantar reflexes.

• Elicit light touch, pain, joint position sense and vibration sense.

• Examine co-ordination of the limbs.

• Differentiate an upper motor from a lower motor neurone lesion.

Objectives


Clinical Context Background Most non-specialists find neurological assessment daunting. However, neurological symptoms are common and it essential to master the history and a basic examination. Headaches are a near-universal phenomenon: most are benign but it is important to identify accurately the small proportion of patients who need further investigation, sometimes urgently. Cranial nerve disorders are not unusual: Bell’s palsy is frequently seen in primary care and others may be encountered especially in patients with diabetes. Common presentations A general principle in neurology is that whereas the examination locates the lesion in the nervous system it is the history - especially the timing of symptoms, for example whether of sudden onset or slowly progressive - which gives the best clue to the nature of the pathology. Vascular pathologies usually have a sudden onset of symptoms, space-occupying or inflammatory pathologies a more insidious onset. Common symptoms in the head with which patients present are:

All of these symptoms may also arise from non-neurological causes. Anatomical & physiological principles The cranial nerves are twelve pairs of nerves which originate from the brain and innervate the head and neck. Some provide the same motor and sensory functions as the spinal nerves do to the trunk and limbs but others are responsible for the special senses; smell, vision, taste and hearing. The olfactory and optic nerves are not actually nerves at all but forward protrusions of the central nervous system. The 12 pairs of cranial nerves are numbered according to the location of their nuclei in the brain stem. For instance, Oculomotor nerve (CN III) leaves the brainstem at a higher position than Hypoglossal nerve (CN XII), whose origin is situated more caudally.

Visual loss Hearling lossDisturbance of smell or

tasteHeadache

Blackouts and syncope

Dizziness and vertigo

Muscle weakness


Left Facial Nerve lesion Left facial muscle wekness and loss of tone

Left Vagus Palsy: On phonation, uvula deviates to the right

Left Hypoglossal N lesion Tongue deviates to the left

Papilloedema: Blurred optic disc margin- raised ICP


Pre-session work

1. Draw a diagram of the visual fields of a patient with right homonymous hemianopia. Where is the structural deficit? 2. List the features of a complete 3rd nerve palsy. 3. In a patient with nystagmus, the cause is likely to be lie in one of three structures. What are these? 4. What are the features distinguishing an upper from a lower motor neurone lesion of the 7th nerve? 5. What findings would you expect in a left lower motor neurone lesion of the 12th nerve? 6. Draw a diagram of the pathways for the perception of light from the retina to the visual cortex.


7. What are the actions of the parasympathetic and sympathetic systems in the eye? 8. Draw a diagram to show in which direction each of the extraocular muscles has its main action 9. What broad muscle groups are supplied by (a) 5th and (b) 7th cranial nerve?

a.

b.


Cranial Nerves Sequence

Objective: Neurological defecits


? Facial asymmetry ?Horner’s ?Bell’s palsy ?Parkinsonism ?Squint ?Myotonic facies. Olfactory Nerve (I)

Ask “has there has been any difficulty or change in your sense of smell?. Rarely need to formally examine with easily available “smells” such as coffee or orange.

Check nose not blocked. Optic Nerve (II)

Check visual acuity with Snellen chart: consider pinhole to eliminate refraction problems (record as: Right VA 6/x, Left VA 6/y)

Assess visual fields: by direct confrontation

Consider checking colour vision with Ishihara plates

Pupillary light and accommodation reflexes: check pupil size (state in mm, right and left), check axis, distant object then near, light reflex with pen torch

Direct ophthalmoscopy: light reflex for cataract, optic disc, macular area, general retina and peripheries

Oculomotor (III), Trochlear (IV) and Abducens (VI) Nerves

Inspect for ptosis, squint and check for diplopia. ? divergent or convergent squint

Move eyes through the 9 positions of gaze, returning to the centre point (primary position) at each test whilst following a slow target. Ask the patient to tell you if they have double vision (see appendices for further explanation).

When checking for diplopia, observe for nystagmus at same time: jerky, pendular, rotational

Oculomotor (III) all extraocular muscles except those supplied by Trochlear (IV) and

Abducens (VI) Nerves

Trochlear (IV) Nerve supplies superior oblique (SO4)

Abducens (VI) Nerve supplies lateral rectus (6LR)

Trigeminal Nerve (V)

Facial Sensation: ophthalmic, maxillary, mandibular

Muscles of mastication: masseters and temporalis

Corneal reflex: light wisp of cotton wool applied over the cornea on the lateral part of iris (motor efferent component is facial). This test rarely done (useful for pituitary examination)

Jaw Jerk: positive in bilateral UMN lesions above the pons Facial Nerve (VII)

Facial movement muscles: frontalis, orbicularis oculi, buccinator, orbicularis oris, naso-labial.

(Greater superficial petrosal N supplies lachrymal and salivary glands).

(Stapedius nerves: dampens loud noises).

(Chorda tympani : taste to anterior 2/3 of tongue).


Vestibulo-cochlear Nerve (VIII)

Assess hearing

Weber’s: lateralizing test, use 512 or 256 Hz tuning fork, place on middle of forehead and ask patient to lateralize the sound. ? equal or lateralized

Rinné’s test: in healthy air conduction better than bone conduction. Use mastoid process

Glossopharyngeal (IX) and Vagus (X) Nerves

Assess movement of the soft palate. Look at position of uvula. Check phonation.

Assess sensation of the soft palate with a gag reflex (rarely done, mention only)

Glossopharyngeal is taste to the posterior third of the tongue and afferent limb of the gag reflex

Vagus is efferent in the gag reflex and motor supply to pharynx, soft palate and larynx Accessory Nerve (XI)

Assess trapezius and sternocleidomastoid muscles Hypoglossal Nerve (XII)

Assess the tongue and its movements: wasted, fasiculating, ? reduced power

Assess power by asking patient to poke tongue into one cheek and you trying to push tongue towards the midline with your first two fingers on the cheek.

Professionalism: Maintains dignity of patient, communicates sensitively with patient, thanks patient, washes hands, writes appropriate record


Session 13: Communication Skills 3

• To focus on the skills of providing explanations to patients

• To explore skills that may change damaging behaviour

• To practise using skills that may change damaging behaviour

Aims

• By the end of the session you should be able to:

• Revise: the skills related to the task of providing information to patients

• Revise: the domains to be considered when promoting behaviour change

• Revise: the stages in the Transtheoretical Model of Behaviour Change

• Identify patient’s thoughts and feelings at each stage of the model

• Know how to assess motivation and self-efficacy in changing behaviour

• Outline the doctor’s tasks at each stage

• Practise skills that enhance behaviour change

• Utilise reflective statements to enhance behaviour change

Objectives


Session 14: Psychiatric Aspects of the General Medical History and Examination

• The aims of this session are to get you in to the habit of asking aboutpsychiatric aspects of the past medical history, family history andsystems enquiry and looking for psychiatric signs and symptoms in yourclinical examination. It will also include topics such as emotional literacy,being comfortable talking about mental health issues, thinking of yourown values and possible prejudices, co-morbidity of physical/psychiatricdisorders and psychiatric signs/symptoms of physical illness and viceversa.

Aims


• Know how to integrate taking a psychiatric history into taking a generalmedical history, including the systems/systemic review, past medicalhistory and family history.

• Have reflected on your own attitudes to patients with mental healthproblems and how these might influence your approach to suchpatients.

• Conduct a mental state examination

Objectives


Pre-session work Write your answers to the following questions in the spaces provided before the lecture. 1. Name five types of disorder that ‘run in families’? 2. Have you ever discussed their past medical history with your parents or siblings? 3. Have you ever discussed their past psychiatric history with your parents or siblings? 4. Think of a film or television programme you have watched where any of the protagonists had a

mental health problem. Were they portrayed in a positive or negative light? 5. How would you ask someone about their past psychiatric history?


Clinical Context The history is probably the most important aspect of the psychiatric assessment and it is the bedrock of making a diagnosis, explaining aetiology and deciding on prognosis. Whenever possible, the history from the patient should be supplemented by information from another person who knows him/her well, but the collateral history should not be taken as a substitute for getting and describing a first-hand account of the patient’s experiences, memories and views. A psychiatric history should follow the format given below. The text below is an extract from the Psychiatry Module Handbook. You will therefore return to this structure and content later in the course in order to build on the initial clinical skills you gain in this introduction within Clinical Skills 2. Self-Directed Learning Questions 1. Name one neurological disorder that might present with hallucinations. 2. Name one endocrine disorder that might present with low mood. 3. Name one psychiatric disorder associated with muscle atrophy. 4. Should doctors be involved in tackling the stigma associated with mental illness?


Psychiatric History Sequence

Objective: Obtain a satisfactory psychiatric history.

Presenting Complaint

Name, age, address, type of accommodation, marital status, religion, occupation

Name of any informants present and their relationship to the patient

Chief (presenting) complaints with duration [reasons for referral]

History of present illness Onset & course of presenting problems, and any precipitating and/or exacerbating factors

Description of the time relations between symptoms and physical disorders and psychological or social problems

Current treatment, and any treatment since the onset of this episode

Important negative history Past Psychiatric history

Similar or different episodes and duration

Pharmacological and psychological treatments and effectiveness of these. Hospital admissions

Response to the treatment/outcome

Any residual deficits

History of deliberate self harm.

Has the patient been previously told a diagnosis. Past Medical history

Illness, operations, accidents and any time spent in hospital

Drug history and allergies

Illness, operations, accidents and any time spent in hospital

Family History

Parents: age now or at death (cause of death), health, occupation, personality, quality of relationship with patient

Siblings: names, ages, marital status, occupation, personality and psychiatric illness, relationships with patient

Family history of mental illness or relevant neurological or disorder Include family history of common medical conditions such as diabetes or cardiovascular disease.


Personal and Social History

Mother’s pregnancy and the birth

Early development and milestones. Any delays

Childhood

separations

Illnesses

Description of family environment

Any emotional and behavioural problems, truanting, special schooling, drug use

Bullying

Education and higher qualifications – remember to ask about peer relationships.

Occupations (chronologically, and including reasons for leaving jobs)

Menstrual history

Relationship. Functioning within, how many, how long did they last, any violence.

Sexual history

Children

Housing, composition of household, financial state, and social network

Drug and alcohol history

By substance: age of first use, amounts consumed (and/or amount of money spent per day or week), problems associated with use. Lifetime periods of heavy use.

Circumstances in which substance consumed (eg drinking with friends in the pub, with other drinkers on the park bench or at home alone?)

What time of day do they use given substance? Do they need drugs or alcohol to get up in the morning, or to be able to leave the house?

Attempts to discontinue or reduce consumption, including detoxification or rehabilitation history. Ask about duration of periods of abstinence. Symptoms of dependence syndrome, if indicated.

Forensic History

Arrests

Convictions and imprisonment

Nature of the offences

Personality

Relationships: friends few or many, superficial or close? How did they get on with peers at school and colleagues at work? How would others describe them?

Leisure activities, hobbies and interests

Prevailing mood

Character

Attitudes and standards: towards health, morals and religion


Clinical Context The mental state examination (MSE) is a systematic enquiry into symptoms and signs at the time of the interview. For example, just as when you examine the abdomen, you ask the patient whether the pressure exerted by your palpation results in pain (now), when you do a mental state examination you ask about the patient’s mood (at the moment). Whilst once you have mastered a psychiatric history and MSE you may ask about previous and contemporaneous symptoms and signs consecutively, when in examination circumstances or when presenting to clinicians, you will need to elicit/present the MSE separately.


Mental State Examination Sequence

Objective: Ascertain the patient’s current mental state. Appearance and Behaviour Appearance, especially self-care Facial expression Posture Movements (including abnormal movements) Eye contact Rapport with the interviewer Speech Reaction time and spontaneous speech Rate and amount Volume: normal, quiet or loud? Tone: reactive or monotonous? Affect Your objective opinion of the patients mood during the course of the interview Changes in the variability of mood Lability Incontinence Blunting, flattening Mood Subjective mood Changes in the nature of mood Depressed Elated Anxious Angry and irritable Inconsistency between mood and thinking (“incongruent mood”), for example speaking of a recent bereavement while simultaneously laughing and smiling. Thoughts about the future, including hopelessness, thoughts of death or dying, and ideas (and any plans) about self-harm Thought Form of thought (how thoughts are organized and expressed), which can be abnormal in (a) the amount or volume of thoughts expressed Pressure of thought Poverty of thought Thought blocking Perseveration (persistent and inappropriate repetition) (b) The way in which thoughts are connected to one another Flight of ideas Rhyming, clang associations Punning Loosening of associations (including tangential thinking) Content of thought (what the person is thinking about) Delusions Delusional mood


Delusional memory Overvalued ideas Thoughts of self-harm, self-esteem, hopelessness, worthlessness and guilt Obsessional and compulsive symptoms Possession of thought Thought insertion Thought broadcast Thought withdrawal Passivity Experiences Perception Illusions: a misperception of an external stimulus Hallucinations: a perception experienced in the absence of an external stimulus in any modality Depersonalisation Derealisation Cognition Tests of cognition* Insight Does the patient believe they are ill? Do they think the illness is mental or physical? Does he or she see him/herself as needing treatment?


Cognition

It is important that all patients (not just those with mental health problems) have some form of cognitive assessment undertaken and documented. The degree to which this is performed will vary depending on the patient’s presentation and whether any deficits are detected. Areas of cognition The areas of cognitive functioning are memory, attention / concentration, language, executive functioning, reading, writing, calculation, praxis and visuospatial ability. In an assessment of cognition, it may not be necessary to cover all areas unless specifically indicated. However memory, attention / concentration and language should be the minimum assessed in any patient. Many areas of cognition can be assessed through observation during the interview and bedside tests may only be required if indicated. Memory Memory can be divided into working memory (this is the immediate recall of small amounts of material), anterograde memory (the ability to learn new information) and retrograde memory (the ability to recall previously learnt information). Please note that ‘short-term memory’ has no agreed meaning, and therefore the term should be avoided. Memory can be observed during the interview – Is the patient able to give a coherent account (supported by relatives or carers)? Are they repetitive? These will indicate whether there are any deficits. Bedside tests of memory could include –

Working memory – digit span forwards / backwards, immediate recall of a 10 item list / name and address.

Anterograde memory – delayed recall of a 10 item list / name and address / 3 items.

Retrograde memory – dates of wars, recall of Prime Ministers / Presidents / Monarchs. Attention / Concentration Attention can be observed during the interview- is the patient able to maintain the conversation or do they tend to lose focus? Bedside tests of attention / concentration could include orientation in time / place, digit span forwards / backwards, serial subtraction eg 100-7 or 20-3, spelling of familiar words backwards eg WORLD, days of week or months of year backwards. Language Language can be readily assessed during the interview – is the patient able to express themselves correctly and fluently? Do they use the correct words? Do they appear to understand your questions? Bedside tests of language could include -

Naming of objects / parts of objects eg watch, strap, winder.

Comprehension of instructions - 3 stage command, pen-watch-keys test.

Repetition of a sentence eg “No ifs, ands or buts”.

Executive Functioning


This is not so readily assessed at interview and may require specific bedside testing, which could include:

Verbal fluency e.g. Word fluency (letters F,A and S), Supermarket fluency, Animal fluency

Abstraction e.g. proverb interpretation (“people in glass houses shouldn’t throw stones”), similarities test, cognitive estimates (“how fast does a horse gallop?”)

Response inhibition / set shifting - Alternating sequence test, Luria 3 step test, Go-no-go test

Reading Ask the patient to read aloud a sentence. Reading comprehension can be tested by asking the patient to follow written instructions e.g. “close your eyes”. Writing Ask the patient to write a simple sentence. Calculation Ask the patient to undertake addition, subtraction, multiplication and division. Praxis Ask the patient to mime a common action eg cleaning their teeth. Visuospatial ability Bedside tests could include copying drawings (overlapping pentagons or cube) and clock drawing test Formal assessment schedules There are many assessment schedules that attempt to cover most areas of cognition in one test. They vary how comprehensive they are and how long they take to administer. The most common ones are GP-COG, Folstein’s MMSE, ACE-R / ACE-III, MoCA, Camcog, DemTect and 6-CIT (see appendices). The advantages of using an assessment schedule are that they have been validated for sensitivity, specificity and reliability, and that they are readily understood by others who use the same schedule. However, most do not cover all areas fully, and therefore if you chose to use a schedule, you should be aware that further testing of areas not fully covered may be required.


Session 15: The Musculoskeletal System 2: Shoulder and Hands

• To aim of this session is that you shoulde learn how to take a historyfrom and perform a physical examination upon a patient presenting withmusculskeletal problems.

Aims


• Recognise the common symptoms of joint disease in terms of pain,swelling, deformity and disability and describe the ways in which apatient may refer to each of these symptoms

• Perform an examination of the hands and shoulders by techniques ofinspection, palpation, active movement, passive movement andfunction.

Objectives


The shoulder

1. Which joints are involved in movements of the upper arm? 2. Describe the joints and the muscles involved in abduction of the shoulder

a. up to 90°

b. beyond 90° 3. Describe the joints and muscles involved in adduction at the shoulder. 4. Describe the muscles involved in flexion, extension and lateral rotation at the shoulder and give

their nerve supply.


The elbow

1. How many joints are there at the elbow? 2. Which joint is involved in pronation and supination? 3. Which muscle is involved in flexion? Give their nerve supply.

a. when the arm is supinated?

b. when the arm is pronated?


Musculoskeletal: Hand Examination Clinical Context The small joints of the hands are commonly affected at an early stage in both the common polyarthritides: osteoarthritis and rheumatoid arthritis. However, the pattern of joint involvement is different in the two conditions. The appearance of advanced rheumatoid changes in the hands is characteristic and can often be recognised immediately. The hands may also be affected by rarer rheumatological conditions, including psoriatic arthropathy, scleroderma and SLE. Anatomical & physiological principles The distal and proximal interphalangeal (DIP and PIP) and metacarpophalangeal (MCP) joints can all be assessed individually. However, it is easy to forget the thumb. Carpometacarpal joint tenderness here can be detected by palpation in the anatomical snuffbox. It is also necessary to examine the wrists and look at the elbows. Muscle groups which require attention are the interossei and those of the thenar and hypothenar eminences. The nerve supply to the hand is via the radial, ulnar and median nerves. Common presentations Patients with arthritis in the hands typically present with pain, swelling and stiffness in the joints, and deformity may follow. • Osteoarthritis typically presents with pain in the joints aggravated by movement and worse as

the day proceeds: the joints most commonly affected are the DIP and the first MCP. • Rheumatoid arthritis most commonly presents with pain, stiffness and swelling of the hands and

feet, especially in the morning. The MCP joints are typically involved first and other joints follow. Patient safety tip Generalised wasting of the muscles of the hands may occur in any chronic arthritis consequent upon disuse. However, specific wasting due to a mononeuropathy may also occur. A median nerve palsy in particular may complicate rheumatoid arthritis: the outward sign of this may be wasting of the thenar eminence. A lesion of the ulnar nerve causes wasting of the interossei and the hypothenar eminence with sparing of the thenar. The diagnoses can be confirmed by the findings of muscle weakness and characteristic areas of sensory loss. Examination of the joints of the hands should therefore always include a neurological assessment.


Prayer sign

Positive in diabetic cheiroarthropathy: associated with Carpal Tunnel syndrome.

Osteoarthritis Hands:

With Heberden’s and Bouchard’s nodes.


Examination of the Hand Sequence Objective: Musculoskeletal pathology.


Wash hands, Ask patient to uncover and be bare below the elbows.

Ask about any particularly painful or tender areas. General Look: although you are examining part of the musculoskeletal system always remember to take a general look at the patient. Do they look well? Do they appear to have lost weight? Do a general examination if you are not sure. Their hand symptoms may be part of a bigger picture. First place your patient’s hands on a pillow palm down

Initially feel for any heat in the joints using the back of my hands.

Now look at the back of the hands for joint swelling (? Heberden’s nodes, Bouchard’s nodes), deformities, muscle wasting, scars, splinter haemorrhages, nail fold infarcts, psoriatic nail changes, ? RA changes (check up to elbow for RA nodules).

Now look at the palms for any nodules, Dupuytren’s contracture. Now assess movement in the small joints of the hand

Ask the patient to try making a fist and bury their fingernails. Make a note of any fingers that do not have full movement, assess these individual joints in more detail.

Ask the patient to turn their fists over. Are there gutters between the heads of the metacarpals? (Lost if swelling of the metacarpophalangeal joints or muscle wasting).

Now palpate the small joints of the hand to feel for the nature of any swelling (is it bony, soft tissue or fluid?) and any tenderness

Use your thumb and index finger of each hand, in opposing “C”s, to palpate the distal and proximal interphalangeal joints. If you gently squeeze with one hand you will detect the fluctuation of an effusion with the other hand.

Use your thumbs to palpate the metacarpophalangeal joints.

Palpate in the anatomical snuffbox for thumb carpometacarpal joint tenderness as this is a common place for osteoarthritis.

Trigger fingers (and thumbs) are a common problem screen for this by asking the patient to open their closed fists quickly and observing whether the fingers move freely. Assess function in the hands by

Checking pincer grip and Opposition of the thumbs. Screen for nerve problems by

Assessing thumb abduction (median nerve).

Assessing little finger abduction (ulna nerve).

Assess light touch and pin prick sensation. The wrist is usually assessed as part of the hand examination

You should already have noticed any swelling or deformities etc. earlier but if not look again now. Then palpate both wrists.

Now ask the patient to put their hands together as if praying and then reverse this to assess first dorsiflexion and then palmar flexion.

Tinel’s test (percussion of Median Nerve at wrist → tingling in digits (lat 3 ½).

Phalen’s test (forced flexion at the wrist to trigger paraesthesia in fingers (lat 3 ½).


Examination of the Shoulder Sequence Objective: Musculoskeletal pathology.


Wash hands, Ask patient to uncover and remove all clothes covering neck and chest apart from underclothes.

Ask about any particularly painful or tender areas. General Look: although you are examining part of the musculoskeletal system always remember to take a general look at the patient. Do they look well? Do they appear to have lost weight? Consider a general examination. Shoulder pain could be ?septic arthritis ? humerus secondary. First, with your patient standing comfortably with arms at their sides.

Look from the front, the side and behind the patient to assess muscle bulk, deformities, scars, etc. Then palpate the joints, bones and muscles: of shoulder complex to assess for tenderness and the nature of any swelling (bony, soft tissue or fluid).

Sternoclavicular joint, Clavicle, Acromioclavicular joint

Acromion, Coracoid, Deltoid, Supraspinatus, Infraspinatus

Finally using the back of your hand feel for heat over the anterior joint line. Now assess movement. Stand behind the patient to observe the movement of the scapulae. They should move smoothly. If they don’t this should alert you to a potential problem.

Ask the patient to lift their arms up in front of them to assess flexion

Then lift them up sideways to assess abduction

Now ask them to reach up behind their back with a thumb and then the other. Note to which vertebral level they can reach and any difference.

With the patient’s arms at their sides and elbows flexed to 90 degrees, ask them to turn their hands outwards to assess external rotation. (This is the first movement to be restricted in a frozen shoulder)

Now assess passive movement while palpating the joint with your other hand to feel for crepitus and any ligamentous clicks or sudden jumping movements of the humeral head. If you suspect impingement and the patient has a painful arc of abduction a further test for impingement is the Kennedy-Hawkins test.

Flex the patient’s elbow to 90 degrees.

Abduct the shoulder to 90 degrees.

Rotate the shoulder. As the tendon of supraspinatus is caught under the acromion the patient will experience discomfort.

Finally you test the integrity and strength of the rotator cuff muscles

With the patient’s arm straight and abducted to 90 degrees and about 30 degrees anterior to the coronal plane, gently push down on the arm while asking the patient to resist you. This tests supraspinatus. If there is a complete tear the patient will not be able to maintain this position.

With the patient’s arm at their side and their elbow flexed to 90 degrees, ask the patient to resist you pushing their hand towards the midline. This tests resisted external rotation and infraspinatus.

With the patient in the same position, ask them to resist you pushing their hand out. This tests resisted internal rotation and subscapularis.


Session 16: The Musculoskeletal System 1: Knee and Hip

• The aim of this session is that you should learn how to take a historyfrom and perform a physical examination upon a patient presenting withmusculoskeletal problems.

Aims

• By the end of this session you should be able to:

• Recognise the common symptoms of joint disease in terms of pain,swelling, deformity and disability and describe the ways in which apatient may refer to each of these symptoms

• Perform an examination of the following by techniques of inspection,palpation, active movement, passive movement and function

• Knee

• Hip

Objectives


Pre-session work Questions to be completed before the session begins

1. List the different types of joints occurring in the human body. You may wish to construct more than one list depending on the system of classification you use. You will need to remind yourselves of the basic structure of the musculoskeletal system. Make sure that you know the basic structure of each joint, and the main groups of muscles responsible for movements at that joint.


Musculoskeletal: Knee Examination Clinical Context A painful swollen knee is a problem commonly encountered, especially in the Accident and Emergency Department. Acute pain and swelling in a fit young person is usually due to trauma. However, the knee can be affected by all the common arthritides including osteoarthritis, rheumatoid arthritis, septic arthritis and gout. Common presentations The patient with a knee problem will typically present with: • Pain: trauma to the knee or a mechanical problem cause localised pain whereas in arthritis it is

usually more diffuse. • Swelling: depending on its aetiology this may be acute or chronic. • Functional impairment: walking, climbing stairs and getting in and out of chairs may be difficult. Other symptoms which patients may report are: • Locking and unlocking: these are due to a loose body in the joint, often a torn meniscus. • “Giving way”: this may be due to ruptured ligaments or patellar instability. Anatomical & physiological principles The knee is a hinge joint with a rather complex structure consequent on the need to maintain its stability. The anterior cruciate ligament prevents the tibia slipping forwards on the femur and the posterior cruciate prevents it slipping backwards. The medial and lateral collateral ligaments prevent sideways movement. The medial and lateral menisci are unfortunately susceptible to degeneration and tearing. Patient safety tip An acutely painful swollen knee is not necessarily due to trauma: the differential diagnosis includes septic arthritis and gout. The former must be considered especially if the patient is feverish or systemically unwell. The most important investigation is joint aspiration. If doubt remains then the patient should be treated for septic arthritis. Untreated sepsis can result in irrevocable damage to the joint within days.


Examination of the Knee Sequence Objective: Musculoskeletal pathology.


Wash hands, Ask patient to uncover and remove all clothes covering legs apart from underclothes. Cover groin and upper thighs with a sheet, towel or item of clothing.

Ask about any particularly painful or tender areas. General Look: although you are examining part of the musculoskeletal system always remember to take a general look at the patient. Do they look well? Do they appear to have lost weight? Do a general examination if you are not sure. Their knee pain could be due to septic arthritis or a secondary in the femur. First ask your patient to stand straight with their arms at their sides.

Look from the front. Are there any obvious deformities, muscle wasting, etc.

Look for varus (bow legged, genu varum) or valgus (knock knees, genu valgum).

Look from behind to observe any popliteal swellings e.g. Baker’s Cyst. Now ask the patient to walk

Observe gait. Ask the patient to lie down on the couch on their back

Look for symmetry, redness, muscle wasting, scars, rashes, fixed flexion deformities. Next palpate the joint.

Check temperature using the backs of your hands and compare with other parts of the leg.

Palpate for tenderness along the border of the patella, behind the knee, along the joint lines.

Perform a patella tap and bulge test. Next check movements

Examine active movements first.

Then passive flexion and extension feeling for crepitus. Now assess the ligaments.

Anterior and posterior cruciate ligaments flex the knee to 90o and sit on the patient’s foot (check that it is OK to do this first).

Pull the tibia anteriorly; there should be no movement. Excessive movement suggests damage of ACL. Push the tibia posteriorly excessive movement suggests damage of the PCL.

Look for any posterior lag.

Collaterals. Hold the knee at 15o and place a lateral then medical stress on the knee. Any excessive movement suggests collateral ligament damage.

Final aspects of examination

Finally assess for muscle strength and offer to test for a torn meniscus.

For example McMurray’s test.


Musculoskeletal: Hip Examination Clinical Context The hip is frequently affected by osteoarthritis, the commonest disease of the joints. Symptomatic osteoarthritis is three times commoner in women than in men and the mean age of onset is 50 years. However, other disorders may also cause pain in the hip and/or limping. Hip replacement is one of the most frequently performed orthopaedic procedures. Common presentations The patent with a hip problem will typically present with: • Pain: this is usually felt in the groin but may radiate to the knee. • A limp: in association with pain a limp is a compensatory mechanism to take weight off the joint.

A painless limp may be due to instability of the hip or to differing leg lengths. • Functional impairment: sitting down, standing up, walking and climbing stairs may all be

uncomfortable and difficult because of stiffness and pain. Anatomical & physiological principles The hips are ball and socket joints and carry the weight of the upper body. The joint lies deep beneath layers of muscle, consequently disease of the hip produces less in the way of visible external signs than disorders of most other joints. Similarly it is not really possible to palpate the hip joint but disease may result in tenderness around the mid-point of the inguinal ligament. With aging the neck of the femur becomes osteoporotic and is there the commonest site of a hip fracture. Patient safety tip Do not assume that pain in the hip is always due to osteoarthritis. Serious or even life-threatening disease may be responsible, for example septic arthritis or a secondary deposit in the pelvis or femur. It is important not to focus on examination of the joint immediately but to make a general assessment of the patient first. If necessary perform a full physical examination and investigate appropriately.

Inspect the pelvis from in front and behind for

deformity, muscle wasting and pelvic tilt.

Trendelenberg’s sign – the pelvis on the

unaffected side drops when the patient stands

on the affected leg – indicates chronic hip

disease.


Examination of the Hip Sequence Objective: Musculoskeletal pathology.


Wash hands, Ask patient to uncover and remove all clothes covering legs apart from underclothes. Cover groin and upper thighs with a sheet, towel or item of clothing

Ask about any particularly painful or tender areas. General Look: although you are examining part of the musculoskeletal system always remember to take a general look at the patient. Do they look well? Do they appear to have lost weight? Their hip pain could be due to septic arthritis or a secondary in the femur or pelvis. First ask your patient to stand straight with their arms at their sides

Look from the front. Are there any obvious deformities, muscle wasting, etc. and is the pelvis level?

Look from behind. Again assessing muscle bulk, etc.

Perform the Trendelenburg Test

Identify the anterior superior iliac spines (ASIS).

Ask the patient to stand on one leg and observe the ASIS. (The ASIS on the side of the leg that has been lifted should rise above the imaginary horizontal line between the two ASISs).

Repeat for the other side.

You may find it helpful to keep a finger on each ASIS while the patient lifts their leg.

Ask the patient to lie down on the couch on their back

Assess leg length by measuring the true leg length from the ASIS to the tip of the medial malleolus. Any discrepancy will be due to differences in the lengths of the femur or tibia/fibula.

Assess apparent leg length by measuring from the umbilicus to the tip of the medial malleolus on each side. A discrepancy is due to pelvic tilt from spinal problems.

Hip joint is very deep and not possible to palpate. But with the patient lying supine

Palpate the area around the mid point of the inguinal ligament as the patient may be tender here if there is significant pathology.

Ask the patient to first lie on one side and then the other and

Palpate over the greater trochanter (many patients complaining of “hip pain” have trochanteric bursitis).

Palpate over the ischial tuberosities (again in more athletic patients “hip pain” may be due to a bursitis here or hamstring origin, enthesitis).

Now assess active movement. With the patient supine

Ask them to bring their knee up to their chest and compare with the other side.

Place your hand under their lumbar spine and repeat. This is Thomas’ test and you will detect any spinal movement trying to compensate for a fixed flexion deformity of either hip.

Then ask them to flex the hip to 90degrees and the knee to 90degrees and move their foot out (internal rotation) and in (external rotation)

With your hand on the ASIS to detect when pelvic movement occurs, ask them to abduct the leg and then adduct the leg. Compare with the other side

Now ask the patient to lie prone.

Assess hip extension Finally if you think there may be a muscle strain or tendon problem you may wish to test resisted movements to see if these cause discomfort.


Session 17: Palpable Masses and Dermatology

• To be able to examine and assess various masses and skin lesions andrelate them to the anatomy and pathological processes most relevant.

Aims


• Take a history from a patient presenting with a lump, and determineany associated symptoms.

• Assess by inspection, palpation, and if appropriate percussion,auscultation and transillumination lumps and bumps in the followingstructures:

• Salivary glands; thyroid lumps; other neck lumps; groin lumps; skinlumps; scrotal swellings.

• Describe a lump clinically.

Objectives


Questions to be completed before the session begins. 1. List the boundaries of the triangles of the neck. Indicate in which triangles the following are

located: the submandibular gland, the thyroid gland, the jugulo-digastric node. 1. From an anatomical point of view, what would be the serious consequences of a rapidly

expanding swelling of the thyroid gland occurring at the level of the thoracic inlet? 3. An otherwise fit 40 year old woman develops a nodule in the thyroid gland that produces an

abnormally large quantity of thyroxine. Apart from noticing a lump in her neck, what else might she become aware of?

4. What do we mean by the term 'hernia'? What are the common hernial orifices of the peritoneal

cavity? 5. What is the difference between a direct and indirect inguinal hernia? 6. List the structures which make up human skin and asterisk those that commonly give rise to

lumps or swellings.


Clinical Context The general aim of this session is that you should learn how to assess lumps and bumps appearing in a wide variety of anatomical sites, and relate them to the relevant anatomical structures and possible pathologies producing them. Lecture

The taking of a history and examination of patients presenting with 'lumps and bumps'. Objectives

The specific objectives are that by the end of the session you should be able to:

Take a history from a patient presenting with a lump, and determine any associated symptoms.

Assess by inspection, palpation, and if appropriate percussion, auscultation and transillumination lumps and bumps in the following structures: - salivary glands; thyroid lumps; other neck lumps; groin lumps; skin lumps; scrotal swellings.

Note breast lumps will be covered in a separate session on Breast Examination.

Describe a lump in the following terms: S P A S E C T I T Size and Shape: use diagram Position: anatomical size and related structures, ? lymphnodes involved Attachment to skin: ? fixed, ? mobile Surface characteristics: smooth, lobulated, regular Edge characteristics: sharp, blunt, diffuse Consistency: soft (lip), firm (tip of nose), hard (forehead) Thrills or pulsations: ? vascular bruit, cough impulse? Inflammation: redress, heat, pain, tenderness, oozing, crusting Transillumination: ? solid cystic (use pen torch)


Size and Shape

Position

Attachment

Surface

EdgeConsistency

Thrills

Inflammation

Trans-illumination

Palpable Mass


Dermatology: History and Examination Objectives By the end of this session you will have • Developed an approach to history-taking in a patient with a skin condition. • Learnt how to distinguish between the primary lesions and how to describe them. The Principles of Diagnosis As in every branch of medicine, diagnosis is based on history and examination. However, skin diseases can often be recognized at a glance, so brief, preliminary look at the skin can save time in history taking. The History • When and where did the trouble start? • How did it spread? • Has its subsequent course been phasic or continuous? • Does it itch? • Does it ‘weep’? • Have the mouth, scalp or nails been involved? • If chronic over years is it seasonal? • What makes it better or worse? Any treatment, either internal or external, that could possibly be related to the disorder must be documented. What drugs was the patient taking, for any reason, prior to, subsequent to or at the time of onset? What local treatments have been applied to the affected skin, both prescribed and otherwise? Have any of the applications patently aggravated the rash? Often it is necessary to make specific enquiries about steroids, antibiotics, antiseptics, etc. The patient’s environment must be investigated. What is his occupation? What are his hobbies? What chemical exposures are known at work or at leisure? Does the rash improve at the weekends? Has it cleared up during annual holidays or periods off work? What is the effect of sunlight? Previous illnesses, family history and any symptoms in sexual or social contacts A good light is essential for the examination, and natural light is ideal. Look at the overall distribution of the rash as this can point strongly to the diagnosis even before its morphology has been considered. Is distribution symmetrical or asymmetrical? Is it centrifugal or centripetal? Does it have a predilection for extensor or flexor surfaces? Is it confined to light-exposed areas? A rapid inspection will determine if the eruption is monomorphic or polymorphic. In polymorphic eruptions each of the different types of lesions must be carefully studied in turn. Finally, never neglect to look carefully at the nails, the hair and the mouth, or to make any obvious relevant further examinations, e.g. palpation of the lymph glands in the differential diagnosis of a neoplasm or palpation of peripheral arterial pulses where ischaemia is suspected. It should also be mentioned that palpation of skin lesions themselves is vital.


Primary Lesions

Macules

• areas of discolouration of the skin.

• visible but not palpable.

Papules

• palpable elevations of the skin varying from about 1 – 5mm in diameter.

• surfaces maybe pointed, rounded or flat.

Nodules

• larger than papules and may be more deeply seated in the skin

• lesions in the subcutaneous tissues may form nodules, e.g. the nodules of rheumatoid arthritis.

Vesicles

• small blisters formed by the accumulation of the fluid in the skin and associated with the disintegration of the cells of the affected area.

• usually filled with serous fluid.

Bullae

• large blisters.

• intra-epidermal or sub-epidermal. Bullae may contain serum, sero-purulent or haemorrhagic fluid.

Pustules

• a vesicle containing pus, i.e. it is packed with polymorphonuclear leucocytes and serum.

• may be non-infective, as in acne vulgaris or pustular psoriasis.

Erythema

• redness of the skin caused by vascular dilation.

• may be transient or chronic. Erythema can be blanched.

Pupura

• extravasation of blood into the skin.

• purpura does not blanch. The blood in the tissue is degraded within phagocytes to haemosiderin which is a brown pigment.


Ecchymosis

• subcutaneous purpura larger than 1cm in diameter.

Haematoma (or bruise)

• palpable and detectable by touch alone.

Weals

• elevations of the skin caused by oedema of the dermis.

• sometimes linear in shape and are usually erythematous. Weals are caused by an increased permeability of the walls of the blood capillaries.

Scales

• an abnormality of the process of keratinisation of the epidermal cells.

• found when imperfectly keratinized cells of the horny layer (which maybe nucleated), adhere together. They may be small, as in dandruff, or large, as in psoriasis.

Burrows

• irregular, short, linear elevations of the horny layer and are usually dark or speckled black.

• characteristic lesions of scabies.

Blackheads

• small plugs of laminated horny cells and sebum blocking the pilo-sebaceous orifices.

• they are the primary lesions of acne vulgaris.

Plaques

• circumscribed flat areas of abnormal skin or mucous membrane, which may be raised above or sunk below the level of the surrounding skin.

• examples are the plaques of scleroderma or leucoplakia.


Secondary Lesions

Fissures

• small cracks extending through the epidermis so that the dermis is exposed.

Ulcers

• lesions formed by destruction of the whole skin, e.g. by ischaemia, infection or neoplasia.

• the base of an ulcer may be granulation tissue, tendon, etc. but cannot be any layer of the skin.

Erosion

• a more superficial loss of tissue whose base is in the skin.

Atrophy

• shrinkage of skin.

• the epidermis may be atrophic, as in ischaemic skin, or the dermis may become atrophic due to loss of collagen, e.g. from life-long exposure to sunlight.

Scars

• develop as part of a healing process and consist of avascular connective tissue in the dermis and often sub-cutis.

• the epidermis over a dermal scar is usually atrophic.

Crusts

• three main varieties; red-black blood crusts; yellow-green pus crusts, and honey-coloured serum crusts.


Session 18: The Musculoskeletal System 3: Spine and GALS

• The aim of this session is that you should learn how to take a historyfrom and perform a physical examination upon a patient presenting withmusculoskeletal problems.

Aims


• Recognise the common symptoms of joint disease in terms of pain,swelling, deformity and disability and describe the ways in which apatient may refer to each of these symptoms.

• Perform an examination of the following by techniques of inspection,palpation, active movement, passive movement and function.

• Spine

• GALS

Objectives


Musculoskeletal: Spine Examination

Clinical Context Back pain is extremely common. It is usually due to trauma, such as twisting injury or injudicious heavy lifting, or to degenerative or mechanical causes. However, on occasions it may be the first manifestation of serious or even life-threatening disease. The vast majority of cases are managed in primary care but patients with a new severe episode sometimes refer themselves to the Accident and Emergency Department. Common presentations Patients will usually present with: • Back pain: radiation to a limb may occur and may be significant.

Inquiry must also be made about: • Neurological symptoms: in particular weakness or sensory disturbance in the limbs. Anatomical & physiological principles The vertebral column is divided into the cervical, thoracic and lumbar spines: the neck and the upper and lower back respectively. It is a complex structure which protects the spinal cord and provides scaffolding for the limbs, and the intervertebral discs are shock absorbers which dampen vibration on walking. The cervical spine can move in all directions. The main movement of the thoracic spine is rotation and that of the lumbar spine is flexion and extension. In the adult the spinal cord extends to the upper part of the second lumbar vertebra – lower in children – and is drawn upwards when the spine is flexed. Patient safety tip It is easy to jump to the conclusion that back pain is due to a traumatic, mechanical or degenerative cause: serious pathology can therefore be missed. Warning symptoms and signs in a patient with back pain include fever, unexplained weight loss, abnormal gait, progressive neurological deficit, bladder or bowel dysfunction and saddle anaesthesia. Such patients require full physical and neurological examination and usually urgent investigation.

Cervical Spine (C1 and C2, Atlas and Axis)

Cervical Spine (C1-C7)

Thoracic Spine (T1-T12)

Lumbar Spine (L1-L5)

Sacrum (S1-S5, fused)

Coccyx (3 to 5 rudimentary vertebrae)

Schober’s test measures flexion of the lumbar

spine: increase of less than 5cm indicates limitation.

This is often seen in ankylosing spondylitis.


Examination of the Spine Sequence Introduction, Explanation, Consent, Position

Wash hands, Ask patient to remove all clothes covering legs and spine apart from underclothes.

Ask about any particularly painful or tender areas.

General Look: Do they look well? Do they appear to have lost weight? Do a general examination if you are not sure. Their back pain could be due to disciitis or secondaries.

With the patient standing look at them from behind

Is the spine straight? Is there a scoliosis or lateral shift?

Is there any obvious muscle wasting around the shoulders and buttocks?

Are there any scars, bruises, rashes, areas of erythema, etc.?

Is the pelvis level? If not you should measure leg length. Then look at them from the side

Do they have the normal cervical lordosis, thoracic kyphosis and lumbar lordosis? Next check active cervical spine movements.

Flexion and extension: Put their chin on their chest and then put their head as far back as possible.

Lateral flexion: Put each ear onto the shoulder (1st movement affected by degenerative changes).

Rotation: Chin over each shoulder. Now assess lumbar and thoracic spine movements.

Ask them to try and touch their toes while keeping their legs straight (lumbar flexion).

Ask them to bend backwards (lumbar extension).

Ask them to run one of their hands down the outside to the leg and then do the same on the other side (lumbar lateral flexion, should reach knee joint line).

Ask them to turn their shoulders from side to side while holding their hips steady to assess rotation (thoracic spine).

Modified Schober’s test With the patient standing identify the two dimples that occur at the top of the sacroiliac joints and mark a spot 10cm above and 5cm below an imaginary line between the two dimples. Ask the patient to bend as far forwards as they can. Measure the distance between the two marks. It should be more than 20cm. Now ask the patient to sit on a chair or the couch.

Palpate the cervical vertebral spines and the muscles alongside, including the lateral trapeziae. Ask the patient to lie prone on the couch

Palpate the thoracic and lumbar vertebral spines and paraspinal muscles.

Palpate over the sacroiliac joints and upper buttock muscles.

Femoral nerve stretch test: Ask the patient to tell you if they get any pain down the anterior thigh as you flex their leg at the knee and then extend it at the hip. Repeat with their other leg.

Then ask the patient to turn over and lie on their back.

Ask them to lift each leg in turn keeping them straight (measure how far in degrees).

Sciatic stretch test: Ask patient to say if they feel any pain down the back of the thigh and lateral leg as you lift the leg as far as you can, keeping it straight, and finally dorsiflex the foot.

Finally assess the sacroiliac joints

Apply pressure to both anterior superior iliac spines simultaneously, asking if the patient experiences any discomfort in the sacroiliac area.

Another way of checking is to flex the hip and pull the knee across the midline.


Musculoskeletal: GALS Screen

Clinical Context

Rheumatological conditions are extremely common and account for about 10% of consultations in primary care. After mental health problems they are the second commonest cause of time lost from work in the United Kingdom. Since prevalence rises with age it can be predicted that the burden of arthritis and other rheumatological conditions will increase with a progressively ageing population.

Common presentations

The main symptoms referable to the joints with which patients present are:

• Pain.

• Stiffness.

• Swelling.

• Deformity.

• Loss of function.

However, since many rheumatological conditions are multisystem disorders patients may also present with extra-articular problems, such as rashes or Raynaud’s syndrome.

Examination of the joints mostly follows the sequence look - feel - move but it is sometimes necessary to deviate slightly from this. GALS – Gait Arms Legs Spine – is a quick screening assessment for musculoskeletal disorders.

Anatomical & physiological principles

Most of the joints of the limbs exhibit a wide range of movement and are synovial joints. Such joints are surrounded by a fibrous capsule lined on the inside by a synovial membrane. The latter secretes synovial fluid which occupies the joint cavity. The ends of the bones are covered in cartilage which facilitates their movement relative to each other. The joints of the vertebral column are cartilaginous joints: they have no cavity and move only slightly. Fibrous joints, such as those between the bones of the skull, do not move at all.

Patient safety tip

The GALS assessment is not a comprehensive rheumatological examination: its purpose is screening. If the patient experiences no symptoms from a joint, it looks normal and its range of movement is satisfactory it is reasonable to conclude that it is a normal joint. However, if any of these conditions do not apply, the joint must be formally examined in detail.


Rheumatoid Hands often with distinct changes such

as swan-neck and boutonnière’s deformity

and rheumatoid nodules.

Typical gait and

demeanour of patient with Parkinson’s Disease.

Psoriasis: note classical

skin changes, often

associated with arthritis.


GALS (Gait, Arms, Legs, Spine) Sequence Objective: Musculoskeletal pathology.


Wash hands, Ask patient to uncover and remove all clothes legs apart from underclothes. Cover groin and upper thighs with a sheet, towel or item of clothing when possible.

Ask about any particularly painful or tender areas. General inspection

Assesses patient’s appearance and posture, commenting on any relevant findings.

Inspects patient’s surroundings for ‘clues’.

General examination

Comments on whether a general examination is required.

GALS examination Gait

Observes patient’s gait: ? Trendelenberg’s gait due to hip pain, ? Parkinsonian, ? painful

Arms

With patient sitting, “Arms straight”: tests active elbow extension, supination and pronation.

“Put hands behind head”: tests active shoulder external rotation.

Inspects hands.

Palpates metacarpophalangeal joints.

“Put index finger on thumb”: tests pincer grip.

Assesses function in hands.

Legs

With patient supine, inspects legs.

If any knee swelling tests for effusion.

Tests passive knee flexion and extension.

Tests passive hip flexion and internal rotation.

Inspects feet.

Palpates metatarsophalangeal joints.

Spine

With patient standing, inspects spine from behind and from the sides.

Palpates over mid-supraspinatus.

“Tilt head towards shoulder”: tests cervical spine lateral flexion.

“Touch your toes”: tests hip and lumbar spine flexion.

Additional examination

Comments on whether detailed examination of any joint(s) is necessary in view of findings.

Professionalism

Assists patient to dress, thanks patient, washes hands.



• To explore what it means to share bad news

• To identify skills, knowledge and attitudes that can make sharing bad news less difficult.

Aims


• Definitions of ‘bad news’

• Know why breaking bad news effectively is important

• Identify breaking bad news contexts for different health professionals

• Identify why doctors sometimes have difficulty sharing bad news

• Identify core skills to use in sharing bad news

• Practise the skills to make the process of sharing bad news less difficult

Objectives


Sessions 20-23: Clinical Skills Revision

• This sessions will revisit the skills taught so far and give students the opportunity to revise and practice them.

Aims


• Conduct the various clinical examinations.

• Be able to describe masses clinically.

• Be more confident with clinical histories.

Objectives


Session 23: Breast examination

• To perform a competent clinical breast examination (CBE).

Aims


• Take a history from a patient presenting with a breast complaint.

• Assess by inspection and palpation the breast and nearby lymph nodes.

• Report your findings using appropriate descriptions.

Objectives


Breast Examination Background Breast cancer is the second most common cancer in women after lung. Detection of a lump understandably causes fear and apprehension. Meticulous examination of the breast can both increase the likelihood of correct diagnosis and help to allay some of the patient's fears. Common presentations The usual indications for breast examination are:

A new breast lump

Change in the appearance of the nipple

Nipple discharge

Changes in the breast contour or skin dimpling

Pain in the breast Anatomical & physiological principles The base of the female breast extends from the 2nd to the 6th rib vertically and from the sternum to the mid-axillary line horizontally. Most of the breast rests on the pectoralis muscles. Breast tissue may extend into the axilla to form the axillary tail (Tail of Spence). It is important to remember this during examination. The majority of the lymphatic drainage of the breast is to the axillary nodes: involvement of these is an important prognostic feature in breast cancer.

Patient safety tip

Clinical examination of the breast will often yield a clear indication whether the problem is cancer or not. However, it is not totally reliable and overconfidence must be avoided. Many breast lumps will require further investigation with imaging and fine needle aspiration. If in doubt, refer. Most trusts have fast-track clinics for the urgent assessment of breast lumps.


Examination sequence Clinical context

Explanation and consent.

Informed consent is especially important for intimate examinations and documentation in the notes is advisable. Obtain a chaperone if necessary. Wash hands before contact with the patient.

Correct position and adequate exposure.

The patient should be sitting on the edge of the examination couch and exposed to the waist.

Inspection

Do not be in too much of a hurry to palpate the breast: much useful information can be gained from inspection. Check for supernumerary nipples along the mammary milk line.

Asymmetry, abnormal contour and skin dimpling may suggest the presence of cancer.

Palpation

Reposition the patient at 45o with her hands behind her head.

The two methods of palpation commonly used are “concentric circles” and the “lawnmower”. Remember to examine the whole breast including nipple and the axillary tail (tail of Spence).

If a lump is detected note its position, size, shape, surface, consistency, mobility, tenderness, temperature, any skin changes, and its relations to overlying skin and underlying muscle.

Cancers are typically hard with an irregular shape and surface, and may be tethered or fixed to skin or muscle.

Professionalism.

Maintain patient dignity, communicate sensitively, thank the patient, wash hands, explain conclusions to the patient, document fully and accurately, communicate appropriately with colleagues


Breast Examination Sequence Objective: Assessment of breast for abnormal pathology.


Expains procedure to patient, obtains verbal consent, asks for chaperone.

Washes hands. Correct position and adequate exposure

Positions patient appropriately.

Exposes neck, breasts, chest wall and arms. General inspection

Assesses symmetry and comments on any skin or nipple changes.

Asks patient to slowly elevate hands above head and repeats inspection.

Asks patient to press hands against hips and repeats inspection.

Examination Sequence Summary

1: Inspection: Ensure adequate exposure, maintain comfort and dignity.

3: Ask the patient to push her hands into hips to contract pectoral muscles

1

2

3

4

2: Ask the patient to lift her hands above her head and hold head from behind.

4: Palpation: With the patient lying down at 45 degrees, and arm resting on her forehead or hand behind the head. Palpate all 4 quadrants in a stepwise fashion using the pulps of three fingers, not the tips.

Palpation

Lies patient back at 45 degrees with hands behind head.

Starts palpation on asymptomatic side.

Systematically palpates whole breast including areola and nipple.

Palpates axillary tail.

Palpates axilla for lymphadenopathy.

Repeats palpation for symptomatic side.

Palpates supraclavicular fossae for lymphadenopathy.

Checks for nipple discharge.

Professionalism

Assists patient to dress, thanks patient, washes hands.



• To explore the issues involved in triadic consultations with children andadolescents and their parents

• To identify skills, knowledge and attitudes that can enhance the effectiveness of triadic consultations.

Aims


• Consider the evidence base and guidance for a child-centredapproach to a triadic consultation – historical perspectives and morerecent guidance

• List the key points for effective communication identified in GMC Guidance for ages 0-18 (2007)

• Identify core skills to use in consulting with children and parents

• Practise the skills in a simulated consultation with an adolescent and parent

Objectives


Sessions 25: Clinical Skills Revision

• This sessions will revisit the skills taught so far and give students the opportunity to revise and practice them.

Aims


• Conduct the various clinical examinations.

• Be able to describe masses clinically.

• Be more confident with clinical histories.

Objectives


Appendices


Appendix 1: Good Medical Practice

Good Medical Practice: Duties of a doctor registered with the General Medical Council

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and make sure your practice meets the standards expected of you in four domains. Knowledge, skills and performance Make the care of your patient your first concern. Provide a good standard of practice and care.

Keep your professional knowledge and skills up to date.

Recognise and work within the limits of your competence. Safety and quality Take prompt action if you think that patient safety, dignity or comfort is being compromised. Protect and promote the health of patients and the public. Communication, partnership and teamwork Treat patients as individuals and respect their dignity.

Treat patients politely and considerately.

Respect patients’ right to confidentiality.

Work in partnership with patients.

Listen to, and respond to, their concerns and preferences.

Give patients the information they want or need in a way they can understand.

Respect patients’ right to reach decisions with you about their treatment and care.

Support patients in caring for themselves to improve and maintain their health.

Work with colleagues in the ways that best serve patients’ interests. Maintaining trust Be honest and open and act with integrity. Never discriminate unfairly against patients or colleagues. Never abuse your patients’ trust in you or the public’s trust in the profession. You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

GMC 2013


Appendix 2: History and Examination Proformas

Clinical History: Quick Template Clinical History and Examination Proforma & Teaching Clinical History and Examination Proforma.


Clinical history: Quick template

PC

HPC

► “open”

► “closed” ? SQITAS ► specific system ► ?red flags

► systems review

CVS, RS, GIT UT, CNS Locomotor/Skin Endo (Red flags)

SH

• Smoking, Alcohol,

• Other Lifestyle Factors

• Occupation

• Home Circs

• Effect of condition on life and

ADL

Family Hx

PMH, Drugs, Allergies

• Ops, Serious illnesses, Past and current

• Drugs: POM, OTC, Recreational

• Allergies: drugs, penicillin, foods

ICE ??

Ideas, Concerns,

Expectations

Do you have any other

information for me?

Do you have any questions

for me?

Summary:

General overview, Main positive findings, Main “Negative” finding. Clinical Conclusion


Clinical History and Examination Proforma Medical Admission Proforma

Patient Details

NHS No: Hospital No:

Name: (First Name, Surname) Address: Post Code:

Telephone: Gender: Male Female Age

Next of Kin: Name Relationship Address Telephone:

GP

Episode Details

Date patient Seen: Time Patient seen

Patient’s Location Source of Referral: GP A&E OPD Other

Clerking Doctor Grade Bleep

Date of Clerking Time of Clerking

Responsible Consultant Other Consulting:

Presenting Complaint (s)

Reason for Admission & Presenting Complaints (include age)

Source of History (patient, relative, interpreter etc):


History of Presenting Complaint (s)

History of each Presenting Complaint:

Relevant Risk Factors:

Past Medical, Surgical and Mental Health History

Significant Co-morbidities: circle and add details ► CVD: Acute Myocardial Infarction, Congestive Failure Respiratory: Pulmonary Disease Neurological: Stroke (CVA), Dementia, Paraplegia Metabolic/Endocrine: Renal Disease, Diabetes, Diabetes Complications Gastro Intestinal: Liver Disease, Peptic Ulcer, Severe Liver Disease Others: PVD, Cancer, Metastatic Cancer, HIV

Details of Operations/Procedures

Mental Health N/Y

Other

Medication Record - Current Medications (including self-medication) in CAPITALS


APPROVED NAME DOSE FREQUENCY INDICATION

1

2

3

4

5

6

7

8

9

10

11

12

Continue here if needed

Relevant Previous Medications

Name: Dose, Frequency, Relevant details

Allergies & Adverse Reactions (including details of reaction)

Relevant Legal Information

Advance decisions to refuse treatment, lasting power of attorney or deputy, organ donation, (mental capacity)

Social History

Lifestyle Functional Status

Current Smoker: _____ per day for _____ years, = ____ pack years

Ex-smoker : _____ per day for ______ years

Never smoked


Alcohol consumption: Units per week = ? binge (6 U women, 8 U men)

Physical Activity: Minimal Active Regular Exercise/Very Active

Diet: Driving Status:

WHO Functional Status: 0 Asymptomatic

1 Symptomatic but completely ambulatory

2 Symptomatic, <50% in bed during day

3 Symptomatic, >50% in bed, not bedbound

4 Bedbound

Social and Personal Circumstances

Occupation: Current Previous (where relevant)

Marital Status: Single Married Widowed Divorced Partner

Housing: House Flat Bungalow Sheltered flat Residential home Nursing home Other Lives alone? Y/N

Communication Language and Communication Difficulties

Services and Carers:

Main Carer Home care (frequency) District nurse Meals on wheels Other Needs and Services

Other relevant social history (eg. recent travel):

Family History

Systems enquiry

CVS RS GIT UT CNS MS ENDO OTHER ?RED FLAGS

Patient’s Ideas, Concerns, Expectations

Clinical Observations and Examination

Vital Signs:

Date & Time:

BP HR Temp.

B Glucose Resp. R O2 Sats % on

Weight Height BMI


General Appearance:

Jaundice N/Y= Pallor N/Y=

Cyanosis N/Y= Lymphadenopathy N/Y=

Oedema N/Y= Clubbing N/Y=

Unwell N/Y= Other

Cardiovascular System:

Rate Apex Beat Rhythm Pulse character Heart sounds JVP Other: eg oedema, lung bases

Peripheral Pulses R Femoral Popliteal Dorsalis pedis Post tibial

L Femoral Popliteal Dorsalis pedis Post tibial

Respiratory System:

Resp Rate /min Breath sounds ? Peak flow:

Abdomen:

Notes: PR: Normal Abnormal Not done


Nervous System:

Fundi R L

Pupils Tone: UL

Cranials Nerves:

LL

Power: UL

LL

Co-ordination Reflexes: Biceps

Sensation Supinator

Gait Triceps

Other: Knee

Ankle

Plantars

Structured scales:

Glasgow Coma Scale (GCS)

Eyes opening Motor response Verbal

1: None 2: To pain 3: To speech 4: Spontaneous

1: None 2: Decerebrate extension 3: Decerebrate flexion 4: Flexion withdrawal 5: Localises to pain 6: Obeys commands

1: Silent 2: Incomprehensible sounds 3: Inappropriate words 4: Confused 5: Orientated

Coma < 8 GCS Total = Max 15

Mini Mental Score (MMS)

1: Age 1: Date of Birth

1: Recall 42 West Street, Salford 1: Dates of World War II (recall at end)

1: Present Monarch 1: Name of Hospital

1: Count down from 20 1: Year

1: Time to nearest hour 1: Recognises 2 people or objects

MMS Score = Max 10

Physical Function eg Barthel Cognitive Function (eg AMT, MMSE)

Genito-Urinary:

Musculo-skeletal:

Skin:

Other Observations


Problem list , Working Diagnosis, Differential Diagnosis

Discharge Planning

Investigations & Initial Procedures : Tick if requested, insert results (abnormal results underlined or in red):

FBC U&Es LFTs Calcium

Group & Save Amylase INR ABG

Urine Dip MSU βHCG

ECG CXR Abdo Film CT Head

Other Ix requested:

Results

Hb Na ABG 2 on: ABG 1 on:

WCC K H+ H+

Plts Urea pH pH

HCT Creatinine pCO2 pCO2

MVC eGFR pO2 pO2

Neutrophils Glucose Bicarb. Bicarb.

Lymphocytes Calcium Base Excess Base Excess

Eosinophils LFT: Normal or Abnormal

O2 Sats %

O2 Sats %

Basophils Total Protein Other Investigations

Monocytes Albumin

Blood Film Bilirubin

Alk Phos

CRP ALT

GTT LDH

Amylase

Urine Analysis

Leucocytes Protein: Blood: Ketone: Glucose: HCG:

ECG ECG Normal/Abnormal:

Rate Rhythm Axis/BBB ? old MI ? ischaemic ?MI

Conclusion:

Other Imaging/Investigation CXR


Management Plan

Summary and interpretation of findings: Initial Plan

Information given to the patient and/or authorised representative:

Next steps:

Monitoring required:

Specialist Registrar/Senior Review

Person Completing Clerking: (Doctors name, grade and signature) GMC No:

Post Take Ward Round


In Charge Person Conducting Post-Take Ward Round: (Doctors name, grade and signature) GMC No: Discharge Plan:

Resuscitation status


Teaching Clinical History and Examination Proforma





Appendix 3: Systems Review: Cardinal Symptoms “Click into one system in detail for any history” Cardiovascular Chest Pain/Angina - SQITAS for pain Shortness of Breath (+ exercise tolerance) Palpitations Pre-syncope/Syncope Peripheral Oedema Orthopnoea Paroxsymal Noctural Dyspnoea Intermittent Claudication

Respiratory Shortness of Breath (+ exercise tolerance) Cough/Sputum/Haemoptysis Wheeze/Stridor Chest Pain (pleuritic)

Central Nervous System Headaches Fits/faints/loss of consciousness Dizziness Vision – loss of vision, diplopia Speech – dysphasia, slurred speech Hearing Weakness Numbness/Tingling Loss of Memory/Personality Change Depression/Anxiety Hallucinations: Auditory/Visual

Gastrointestinal Appetite/Weight Loss Nausea/Vomiting/Haematemesis Dysphagia/Difficulty chewing Heartburn/Indigestion Abdominal pain Bloating Jaundice (Skin/Urine/Stool) Bowels: description of stool Change in bowels/ Constipation/ Diarrhoea/ Blood/ Mucous/ Flatus/ Tenesmus / Incontinence

Genito-urinary

Frequency/Polyuria/Dysuria/Nocturia/ Oliguria Haematuria Incontinence/Urgency Menstrual Cycle Menorrhagia/Dysmenorrhoea Post Menopausal/Post Coital Bleeding Vaginal Discharge Dyspareuina Penile Discharge Genital lumps/ulcers Sexual History (if appropriate)

Musculoskeletal Pain/Swelling/Stiffness: Muscles/Joints/Back Power Restriction of Movement/Function

Endocrine Polydipsia/Polyuria Hair quality Hirsutism/alopecia Skin Pigmentation Fatigue Intolerance to cold/heat Sweating/Palpitations/Headaches Weight loss/gain Menstrual Changes (if appropriate)

Skin Dry Skin Rash Pruritis Acne Skin Lesion – change in: Colour/Shape/Size/Itching/Bleeding


Appendix 4: Student Cases Lecture

A lecture will introduce the Student Case Reports

Student Case Reports As part of the assessment of the clinical skills course, you will be asked to write up TWO cases that you have seen, and submit these your clinical skills tutor who will mark them and provide feedback. You should also save this work as evidence of your clinical development to your private portfolio. Our intention in CSc is to give you some practice in case writing in preparation for your future clinical practice.

The Student Case Report format

The Student Case Report format is derived from the case record completed for patients on admission to hospital. However, it is not intended to be an exact copy of the patient’s clinical record. You will include sections that demonstrate your ability to understand and interpret the significance of your findings. You will need to utilise the knowledge, skills and attitudes developed so far in the course to satisfactorily complete this exercise. You should also demonstrate your awareness of the social and psychological effects upon patients of physical illness. Your learning from earlier blocks will assist you in showing how knowledge of basic clinical and behavioural sciences together with your clinical experience in clinical placements is essential in clinical practice. Student Guidelines for writing your Student Case Reports

This part is intended to help you get started on the process of recording your clinical experience in written form. Aim

To enable you to demonstrate and enhance your understanding of how attainment of selected course objectives contributes to the knowledge, skills and attitudes required by competent doctors.

Objectives

Your Student Case Reports provide an opportunity to assess directly your attainment of some over-arching objectives of the MB ChB curriculum.

Acquire from the individual patient the information necessary to formulate and test diagnostic hypotheses by: - taking a history, considering appropriate physical, social and psychological aspects of the

patient’s presentation - selectively eliciting normal and abnormal signs - using investigations selectively

Formulate appropriate diagnostic hypotheses for the particular patient, based on sound, scientific understanding of normal and abnormal structure and function, disease processes, appreciation of the social and psychological context of illness, and understanding of environmental, occupational and social factors in disease causation


Formulate management plans, if necessary using information sources and appraisal of evidence, and apply the conclusions for the care of patients with both common, and uncommon but serious, conditions

Appreciate the role of other health care professionals, and communicate effectively (in writing)

Recognise the economic and practical constraints of organisations concerned with the delivery of health care

Selection of Cases

Patients do not usually present with a discrete diagnosis, but rather with one or more symptoms. Diagnostic reasoning consists of the formulation of hypotheses, which are then tested and refined by the history, physical examination and investigations. The Student Case Reports will form a record of this process and will enable the assessment of your achievements with the patients you have actually seen, rather than the cases you might have been expected to see. Therefore, it is important that the Student Case Reports are defined in terms of presentations, rather than disease or disease processes. By the time you see a patient a diagnosis will often have been made and you will discover what this is, if only from the patient! Therefore teachers and students should regard each patient as an exemplar of a certain presentation; 'this is a patient with chest pain' not 'this is a case of angina'. What is important is your demonstration of your understanding and critique of the process by which the diagnosis was made and the patient managed. The Warwick MB ChB programme has a list of clinical presentations that most effectively cover the overall objectives of the course (see shortened list below).

Note that most of these have 'qualifiers' - 'acute', 'recurrent' etc. which limit the possibilities, but which do not lead to a single diagnosis. Teachers will be able to make other suggestions, which are likely to be a selection from the problems general practitioners refer. Many cases you see in hospital, particularly in general medicine, are not completed episodes of disease and your Student Case Reports must represent this continuum of care. It is important you include within your submission a selection of cases, which demonstrate the challenges to health professionals of the continuing care of incurable disease. The list of possible cases is given in a table at the end of this section. Attempt to choose one case from a different major sub-heading for your 2 cases.


Constructing your Student Case Reports

Before deciding to write up a patient you encounter during your CSC 2 placement, ideally you must check that your clinical teacher thinks it is a suitable case. Each case report be word-processed using the standard template which follows. It is suggested that you write short notes rather than an essay or a series of abbreviated phrases. The length will depend on the complexity of the case but should not normally exceed a maximum of 1500 words or 5 A4 pages. Many students find it helpful to make additional notes on their cases to help in future revision; these need not be incorporated into the report. A Student Case Report is not a copy of the clerking notes, with some added features. It should summarise the experience of the episode of illness experienced by the patient, and in writing it you should demonstrate your ability to elicit and interpret information required to define and manage the patient’s problem(s). Confidentiality

Patients must be referred to by fictitious initials, not name or even actual initials. You should keep a separate hand-written note of the hospital number to enable you to access the records at a later date. You should inform the patients that you would like to make a special study of their problem and obtain their permission. You must record this in the hospital record and date it. You must maintain the confidentiality of their records at all times. Confidential material should not be recorded, therefore ensure anonymity at all times. Memory sticks even for anonymised notes should be encrypted. Use the password function of Word to further protect confidentiality. Referral information

You should summarise key information from the referral letter and indicate who referred the patient. Comment on the usefulness of the information provided and notable omissions. This demonstrates the importance of good communication within the health care team.

History

You should include all relevant information gathered from the patient about this illness, co-existing problems, current drug treatment, significant past history and the social and family background. Indicate what are the patients (or parent/guardian's) ideas, concerns and expectations about the problem and its management. Do not include a long list of irrelevant negative findings. Remember to start with an open question. Use of direct quotes from the patient is often illuminating. Physical examination

To improve your skills of physical examination you should conduct a complete examination of the four major systems in all cases. In presenting your findings you should highlight those most relevant to your clinical problem solving by underlining them. Formulation of the patient’s problem

Encapsulate the patient's problem in physical, psychological and social terms in a short statement (triple diagnosis). If the patient's problem is largely physical, psychological or social this should be stated and your reasoning explained. For example: ‘A healthy 28 year old manual worker with a physically demanding job has been admitted for elective repair of his right indirect inguinal hernia. He is anxious about the procedure as he has a phobia about needles' neatly encapsulates a triple diagnosis which provides much important information about his problem.


Management

You could use the mnemonic RAPRIOP to help you consider all the elements that might be included within a management plan for the patient.

Reassurance and explanation

Advice

Prescription/other medical intervention

Referral and team working

Investigation

Observation

Prevention

The order in which the elements are presented in your report will vary according to the circumstances of the case and the setting in which you encounter the patient. The above order is most logical for patients encountered in outpatients or a general practice surgery. For patients seen as hospital in-patients the order proposed in the template will be more appropriate. Each aspect may not be relevant in every case, but should be considered. Various options and treatment modalities may be required under a single heading. Investigation

Relevant investigations (i.e. those that will influence the diagnosis and/or management) and their results should be listed. If possible include illustrations of any microscopic pathology and imaging. Then describe how the result of each listed investigation contributes to either solving or managing the patient's problem. This section should include any planned investigations after the patient has had their immediate care. Reassurance and explanation

You should write down in brief the actual words you would use to:

appropriately reassure the patient.

explain the nature of the disease.

describe the management plan. Prescription/medical intervention

Drugs and the rationale for their use. Include those actually used, and any alternatives. Choices should be justified. For all drugs: generic name, mechanism of action, indication in your patient, main side-effects and interactions. Operations

Details of surgical technique are not essential but could be included with particular attention to the anatomy demonstrated. Referral and team working

You should discuss referrals made to other agencies and future referrals that may be required, particularly community services on discharge from hospital.


Advice

Those measures that the patient can take to alleviate the problem. This may include life-style advice (e.g. dietary changes after a myocardial infarction) or self-help (e.g. exercises for a ligament sprain). You can include in this section: Prevention. These are opportunities for health promotion which are not directly linked to the management of the problem. For example, a patient admitted with a leg fracture might be encouraged to use the reduced opportunities for smoking during admission as a stimulus to give up smoking permanently. Addressing risk factors for future problems such as diabetes and cardiovascular disease, by addressing obesity and lack of exercise are particularly important. Some Student Case Reports will provide opportunities to discuss in more depth particular issues in management. For example; critical care/management of emergencies, disability, long term management, continuing management in the community, shared care between community services or organisational and financial aspects of health care delivery. The completed two case reports should contain a balance of such opportunities and discussion. Outcome

You should follow the progress of the patient as far as possible and consider what further issues remain to be resolved. In some cases you may be able to arrange to see the patient when they return to the outpatient clinic for review. In many cases it would be appropriate to contact by telephone patients who have been discharged home to discover whether their disease/problem is following the predicted course. For this reason you should seek the consent of the patient, and the consultant responsible for their care, to make a telephone contact after their discharge home. Evidence based care and issues for research

You should indicate the evidence base for decisions about diagnosis and management, including the source. You are encouraged to use library resources, including the Cochrane Library database of systematic reviews, the NHS CRD database of systematic reviews and evidence-based guidelines including Clinical Evidence. Where appropriate you should include a commentary indicating that you have critically appraised the evidence. In some cases the patient’s problem might highlight an unresolved research question. You are not expected to copy sections from textbooks or review articles but to use sources critically and appropriately. Commentary

In this section you should comment on important issues raised by the patient’s problem(s). These will vary considerably with the case. The matters that you may need to cover will include:

Issues of health care delivery To include important aspects of trans-cultural medicine, public health and the financial consequences of different decisions and issues in the organisation and management of services.

Ethical issues

Disability You should show awareness of the problems that any disability may cause and the methods available to overcome or minimise it.


Impact on your learning

Describe here briefly what you have learnt from this case.

Time-tabling

Students and teachers may want to develop their own methods, but one that seems to work well is as follows:

1. The teacher selects a suitable patient. 2. The student clerks the patient making clinical notes as contemporaneously as possible. 3. Discussion with your tutor may take place around the case including findings hypothesis

generation, the appropriate use of investigations and issues of management. 4. The student then writes up the case on their own in the agreed format, incorporating any issues

discussed with the teacher and the results of their own reading. Presentation of case reports

This is an extremely important skill. Clear and accurate communication is central to good clinical practice.

The following pages reproduce the template for the presentation of your Student Case Reports. Copies of this template will be available for you to word process your written presentation of the cases you have chosen. Assessment of the Student Case reports

Your clinical teacher is required to assess the degree to which you have attained the objectives for each case report. The following descriptors of performance will be used to assist in making judgements. The necessary documentation must be completed and forwarded to the Medical School Office. One case should be marked according to the standardised marking scheme and graded at least ‘borderline’.

The Warwick 4 Point Presentation

Important “Negative” Findings“However, there was no ascites”

Clinical Conclusion“These findings would be consistent with malignancy.

Further tests would include urine examination and

an ultrasound scan of the liver.

General Findings“On Examination the patient was comfortable”

Important Positive Findings“My main findings were jaundice and

an enlarged liver that was hard and nodular”


Criteria for the award of grades:

Excellent: All significant issues have been considered. Consistent excellence is shown across most or all of the nine areas of the Student Case Report. The student demonstrates an awareness of matters beyond those that must be addressed. To obtain an “Excellent” grade you must demonstrate an ability to integrate or synthesise the information you present under the different headings. Good: The student demonstrates standards above those expected for this stage of the course in several areas, including patient management. There are no significant omissions. Pass: All the important issues are considered. Any omissions are minor and unlikely to be of clinical significance for the diagnosis and management of a patient with this presentation. Borderline: There are significant omissions of detail, or there are errors of fact or interpretation. These have the potential to lead to mistakes in diagnosis and/or management of a patient with this presentation. Fail: There are important omissions, or significant errors of fact and/or interpretation, which are likely to jeopardise the diagnosis, management or solution of the problem of a patient with this presentation. You will be unable to count this case against your total unless it is amended satisfactorily


Short List for CSc Student Case Reports

History, Examination and Final Diagnosis

Blood and Lymph

Anaemia

Lymphadenopathy

Haematological malignancy

Purpura

Bleeding tendency

Hypercoagulability

Cardiovascular

Central chest pain (Acute)

Central chest pain (chronic)

Limb claudication

Palpitations

Blood pressure problems

Cardiorespiratory arrest

Breathlessness due to heart failure

Shock

Anaphylaxis

Swollen painful leg

Heart murmurs

Collapse

GI

Abdominal pain (Acute)

Abdominal pain (General)

Bleeding from the GI tract

Change in bowel habit

Dysphagia

Jaundice

Chronic abdominal pain

Diarrhoea

Enlarged liver

Lump in the groin

Abdominal distension

Vomiting

Inadequate nutrition

Weight loss

Homeostatic

Fluid and electrolyte abnormalities

Abnormal blood sugar



Homeostatic cont.

Hypercalcaemia

Acid-base abnormalities

Abnormal weight

Oedema

Lump in the neck

Infectious Disease

Fever

Infection and international travel or residence

HIV

Mental Health

Depression

Substance abuse (Drugs)

Substance abuse (Alcohol)

Memory loss

Dementia

Psychological aspects of physical illness

Deliberate self-harm

Musculoskeletal

Acute joint pain and swelling

Back pain and sciatica

Chronic joint pain

Fractures/osteoporosis

Hip Fracture

Pathological fracture

Soft tissue injury/other trauma

Musculoskeletal deformities

Neurological

Dizziness and vertigo

Fits (adult)

Headache

Acute severe headache

Chronic headache

Loss of consciousness

Disturbance of consciousness

Falls



Neurological cont,

Mobility difficulties [Elderly]

Falls (General)

Numbness and tingling

Confusion/delirium

Confusion (General)

Chronic movement disorder

Facial pain

Weakness

Stroke

Renal

Dysuria

Haematuria

Urinary retention

Renal failure

Proteinuria

Scrotal swellings/pain

Respiratory

Pleuritic chest pain

Haemoptysis

Cough

Recurrent wheezy breathlessness

Breathlessness (non-cardiac)

Acute upper respiratory symptoms

Increased Sputum

General

The patient needing pain control

Pain (General)

The patient needing palliative care

The preoperative and postoperative patient

Other Cases


Clinical History, Examination and Management Template

Clinical History

Patients Details: followed by specifics of the clinical encounter.

Presenting Complaint: reason, source of history, details, risk factors.


Medication Record: Prescribed, Self-prescribed, recreational, indication, dose, relevant previous medications.

Allergies and Adverse Reactions (details of reaction)

Relevant Legal Information: Advance decisions e.g. to refuse treatment, lasting Power of Attorney, organ donation, mental capacity.

Social History: smoking, alcohol, driving status, occupation and associated health risk, marital status, housing, language, support services. Other relevant history: travel, physical activity, diet, weight issues, companion animals, mental health (e.g. stresses).

Family History

Systems inquiry: consideration of all main systems.

Patient Values: exploration of Ideas, Concerns and Expectations.

Clinical Examination

General Observations and Vital Signs

Systems examination: Cardiovascular, Respiratory, Abdomen, Nervous System, Genito-urinary, Musculo-skeletal, Skin.

Problem List and Differential Diagnosis

List of all main problems/concerns and working diagnoses. Important diagnoses to exclude can also be stated.

Discharge Planning

Even at admission it is important to consider the discharge to promote early safe discharge.

Management Plan

Summary of findings and interpretation of findings.

Information given to patient/carers.

Next steps.

Special monitoring.

Resuscitation status. Investigation and Initial Procedures

Details of results, highlighting abnormal results (some trusts do not allow red ink) Specialist Registrar/Senior Review Post Take Ward Round


Clinical History and Examination Proforma for Student Case Record

Patient Details : Fictitious only- ensure complete confidentiality

NHS No: Hospital No:

Name: (First Name, Surname) Address: Post Code:

Telephone: Gender: Male Female Age

Next of Kin: Name Relationship Address Telephone:

GP

Episode Details

Date patient Seen: Time Patient seen

Patient’s Location Source of Referral: GP A&E OPD Other

Clerking Doctor Grade Bleep

Date of Clerking Time of Clerking

Responsible Consultant Other Consulting:

Presenting Complaint (s)

Reason for Admission & Presenting Complaints (include age)

Source of History (patient, relative, interpreter etc):


History of Presenting Complaint (s)

History of each Presenting Complaint:

Relevant Risk Factors:


Significant Co-morbidities: circle and add details ► CVD: Acute Myocardial Infarction, Congestive Failure Respiratory: Pulmonary Disease Neurological: Stroke (CVA), Dementia, Paraplegia Metabolic/Endocrine: Renal Disease, Diabetes, Diabetes Complications Gastro Intestinal: Liver Disease, Peptic Ulcer, Severe Liver Disease Others: PVD, Cancer, Metastatic Cancer, HIV

Details of Operations/Procedures

Mental Health N/Y

Other


Medication Record - Current Medications (including self-medication) in CAPITALS

APPROVED NAME DOSE FREQUENCY INDICATION

1

2

3

4

5

6

7

8

9

10

11

12

Continue here if needed

Relevant Previous Medications

Name: Dose, Frequency, Relevant details

Allergies & Adverse Reactions (including details of reaction)

Relevant Legal Information

Advance decisions to refuse treatment, lasting power of attorney or deputy, organ donation, (mental capacity)


Social History

Lifestyle Functional Status

Current Smoker: _____ per day for _____ years, = ____ pack years

Ex-smoker : _____ per day for ______ years

Never smoked

Alcohol consumption: Units per week = ? binge (6 U women, 8 U men)

Physical Activity: Minimal Active Regular Exercise/Very Active

Diet: Driving Status:

WHO Functional Status: 0 Asymptomatic

1 Symptomatic but completely ambulatory

2 Symptomatic, <50% in bed during day

3 Symptomatic, >50% in bed, not bedbound

4 Bedbound

Social and Personal Circumstances

Occupation: Current Previous (where relevant)

Marital Status: Single Married Widowed Divorced Partner

Housing: House Flat Bungalow Sheltered flat Residential home Nursing home Other Lives alone? Y/N

Communication Language and Communication Difficulties

Services and Carers:

Main Carer Home care (frequency) District nurse Meals on wheels Other Needs and Services

Other relevant social history (eg. recent travel):

Family History

Systems enquiry

CVS RS GIT UT CNS MS ENDO OTHER ?RED FLAGS

Patient’s Ideas, Concerns, Expectations


Clinical Observations and Examination

Vital Signs:

Date & Time:

BP HR Temp.

B Glucose Resp. R O2 Sats % on

Weight Height BMI

General Appearance:

Jaundice N/Y= Pallor N/Y=

Cyanosis N/Y= Lymphadenopathy N/Y=

Oedema N/Y= Clubbing N/Y=

Unwell N/Y= Other

Cardiovascular System:

Rate Apex Beat Rhythm Pulse character Heart sounds JVP Other: eg oedema, lung bases

Peripheral Pulses R Femoral Popliteal Dorsalis pedis Post tibial

L Femoral Popliteal Dorsalis pedis Post tibial

Respiratory System:

Resp Rate /min Breath sounds ? Peak flow:

Abdomen:

Notes: PR: Normal Abnormal Not done

Nervous System:

Fundi R L

Pupils Tone: UL

Cranials Nerves:

LL

Power: UL

LL

Co-ordination Reflexes: Biceps

Sensation Supinator

Gait Triceps

Other: Knee

Ankle

Plantars


Structured scales:

Glasgow Coma Scale (GCS)

Eyes opening Motor response Verbal

1: None 2: To pain 3: To speech 4: Spontaneous

1: None 2: Decerebrate extension 3: Decerebrate flexion 4: Flexion withdrawal 5: Localises to pain 6: Obeys commands

1: Silent 2: Incomprehensible sounds 3: Inappropriate words 4: Confused 5: Orientated

Coma < 8 GCS Total = Max 15

Mini Mental Score (MMS)

1: Age 1: Date of Birth

1: Recall 42 West Street, Salford 1: Dates of World War II (recall at end)

1: Present Monarch 1: Name of Hospital

1: Count down from 20 1: Year

1: Time to nearest hour 1: Recognises 2 people or objects

MMS Score = Max 10

Physical Function eg Barthel Cognitive Function (eg AMT, MMSE)

Genito-Urinary:

Musculo-skeletal:

Skin:

Other Observations

Formulation of the Patient’s Problem 1: Problem list 2: Main and then Differential Diagnoses with factors for and against each differential 3: Psychological factors 4: Social factors


Investigations & Initial Procedures : Tick if requested, insert results (Urgent and abnormal results underlined or in red):

Here list investigations that will help in establishing a diagnosis, assessing severity, assessing prognosis etc. Identify which you would need to do urgently.

Common Investigations:

FBC U&Es LFTs Calcium

Group & Save Amylase INR ABG

Urine Dip MSU βHCG

ECG CXR Abdo Film CT Head

Other Ix requested:

Results

Hb Na ABG 2 on: ABG 1 on:

WCC K H+ H+

Plts Urea pH pH

HCT Creatinine pCO2 pCO2

MVC eGFR pO2 pO2

Neutrophils Glucose Bicarb. Bicarb.

Lymphocytes Calcium Base Excess Base Excess

Eosinophils LFT: Normal or Abnormal

O2 Sats %

O2 Sats %

Basophils Total Protein Other Investigations

Monocytes Albumin

Blood Film Bilirubin

Alk Phos

CRP ALT

GTT LDH

Amylase

Urine Analysis

Leucocytes Protein: Blood: Ketone: Glucose: HCG:

ECG ECG Normal/Abnormal:

Rate Rhythm Axis/BBB ? old MI ? ischaemic ?MI

Conclusion:

Other Imaging/Investigation CXR


Final Diagnoses: Post Investigations

Management Plan

This should include all relevant management steps including medical (symptomatic and “curative”), surgical, referrals, team working, lifestyle factors. List up to 10 drugs on the prescription chart Initial Plan

Information given to the patient and/or authorised representative: Please write here verbatim what you say to the patient in terms of diagnosis and management.

Next steps:

Monitoring required:


Outcome and Discharge Planning 1: A description of the progress of the patient as far as soon. 2: Consider further issues to be resolved. 3: Include details on discharge planning.

Evidence-based Care and issues for research A consider of a question in relation to this case: presentation, examination findings, investigation or management (eg evidence for the use of a specific drug). Use a different aspect of these in each portfolio. State an Evidence-based question to start this section: Total 500 to 1000 words. Add key references: key papers, NICE, Cochrane

Impact on your learning (Commentary) Brief notes on what you have learnt from this case: 150 to 300 words

Feedback from Clinical Skills Supervisor detailing Student Learning Needs and Learning Plan Brief notes: List under

Learning Needs Learning Plan


Prescription Chart 1:

Fictitious name, address DOB

Allergies Diagnoses:

times Indications Class of drug and action

Side-effects, Interactions

Approved Drug Name:

Dose

Route

Special Instructions

Approved Drug Name:

Dose

Route


Approved Drug Name:

Dose

Route


Approved Drug Name:

Dose

Route


Notes:

All prescriptions must be clearly legible using black ink ideally in block capitals

Use approved, generic names and metric doses ie not as 2 tabs but as 500mg

Only use common and accepted abbreviations: eg. od, bd, tds, qds,

Special instructions often very important eg. nocte only, pre-meals, fasting,


WHO Functional Status

The ECOG score (published by Eastern Cooperative Cancer Group, Oken et al. in 1982), also called the WHO or Zubrod score, with 0 denoting perfect health and 5 death. Its advantage over other systems such as the Karnofsky scale is its simplicity. The scale would also highlight those patients that may be more difficulty to discharge due to social needs or extra services. This would patients in Class 4, 3 or 2).

WHO Functional Status Class

Criteria

0 Asymptomatic: Fully active, able to carry on all pre-disease activities without restriction

1 Symptomatic but completely ambulatory: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example: light housework, office work

2 Symptomatic, <50% in bed during the day: Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours

3 Symptomatic, >50% in bed, but not bedbound: Capable of only limited self-care, confined to bed or chair 50% or more of waking hours

4 Bedbound: Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

5 Death: Patient has died. Duties remain to the patient (providing dignity), family (providing explanation, legal forms and bereavement services) and society (reporting death accurately and involving Coroner if indicated)


CSc - STUDENT CASE REPORT FEEDBACK Student Name:

Block

No: 1

Brief description of case (student to complete):

Complexity of case in relation to stage in the course (please circle):

High Average Low

Excellent Good Pass Borderline Fail Unable to

comment

Medical record

keeping

Clinical

assessment

Investigations

& reasoning

Management

plan

Prescription

Evidence base

Commentary

Anything especially good

Suggestions for development

Agreed action Case needs re-presenting Yes / No

I confirm that this case report was presented to me If the case is not personally known to the supervisor this should be checked (via notes, booking system, results systems etc. If you cannot confirm this or believe the case may be fully or partly plagiarised contact the Year 1 Administration Lead (Lorraine Brown), Warwick Medical School

Supervisor name

Signature Date


CSc - STUDENT CASE REPORT FEEDBACK Student Name:

Block

No: 2

Brief description of case (student to complete):

Complexity of case in relation to stage in the course (please circle):

High Average Low

Excellent Good Pass Borderline Fail Unable to

comment

Medical record

keeping

Clinical

assessment

Investigations

& reasoning

Management

plan

Prescription

Evidence base

Commentary

Anything especially good

Suggestions for development

Agreed action Case needs re-presenting Yes / No

I confirm that this case report was presented to me If the case is not personally known to the supervisor this should be checked (via notes, booking system, results systems etc. If you cannot confirm this or believe the case may be fully or partly plagiarised contact the Year 1 Administration Lead (Lorraine Brown), Warwick Medical School

Supervisor name

Signature Date


Appendix 5: Supplementary Eye Examination for Cranial Nerves




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Appendix 6:

Making Every Contact Count: 4 As Approach Brief Intervention

Brief interventions with respect to life-style changes have been proven to be the most cost-effective

method in persuading people to adopt healthier lifestyle choices. A Cochrane review (Kaner et al CD

004148, 2009) showed that in 7000 participants randomised to brief-intervention or control intervention

with respect to safer alcohol consumption, the brief-intervention group drank 4 to 6 units less (per week)

at the end of the 12 month study. Longer counselling was actually found to confer little additional

benefit. With respect to smoking the quit rate was 69% higher with Brief Intervention.

The 5 minute brief intervention can usefully be structured using the 4 As Approach below.

Throughout: try to ascertain and work out the stage that the patient is terms of readiness to change

using the stages of change or similar model.

Prochaska and DiClemente model is: Pre-contemplation, Contemplation, Preparation, Action

and Maintenance.

Actively engage in Clinical Conversation with these ideas and reflections from the patient during the

consultation.

Positively reinforce maintenance of beneficial behaviours- do this initially

4 As Approach

Ask “Can I explore lifestyle factors that may apply to your current

problem .?”

Do general lifestyle history of the “Big 4” at least *Smoking,

Physical activity, Diet and weight)

Moving onto your social history, can I ask whether you smoke?

Drink alcohol?...how active are you do you think? Have you had

difficulty with weight control? Or diet?

Focus on one specific important issue

Assess Determine the cigarettes smoked…pack years?

Alcohol units per week, ? safe, ? binge drinking

Physical activity: ? 30 mins x 5 per wek, ? SOB , hot

Weight ? normal BMI… ? 5 fruit and veg per day?

Assess stage of change, as above: “ How do you feel about

smoking…?

Advise Cover harms and benefits of lifestyle factor- use facts from

MECC cards or HEALTH Passport, for example.

Assist whatever stage the patient is at

Clear, personalised, supportive, evidence-based, non-

confrontational messages. “ the most importance factor…. etc

5 Rs. Clear basic advice on how to address the problem:

relevance, risk, rewards, roadblocks, repetition

MECC Conversation cards, Quitlines, Information, Change for

Life Websites etc

Arrange Arranging follow-up: ? visit, ? email, ? questionnaire , ? signpost

to community support, friends /family etc

Throughout and again at the end: Opportunity to ask questions or offer further

information. Person-centred consultation/interview style.

At end: Ask patient what changes they think they can make. Finish on a positive.


4 As Approach Role Play Scenario Notes on the Clinical Scenario

Clinical Environment:

The “Patient”:

The “Clinician”:

The Main lifestyle issue:

Clinical Background:

4 As Approach

Ask

Assess

Advise

Arrange

Throughout and again at the end: Opportunity to ask questions or offer further

information. Person-centred consultation/interview style.

At end: Ask patient what changes they think they can make. Finish on a positive.


Appendix 7: Tests of Cognitive Function: GPCOG & MMSE





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Appendix 8: CSc Course Certificate (Terms 2 & 3)

Clinical Skills Course Certificate - 2016 Cohort

Full Name and WMS Number

Please print your name clearly in block capitals.

You are required to obtain signatures from your clinical tutor(s) as detailed below. You must return this completed form only to the Phase I Post Box by 4.00pm 25th May 2017

Hospital Clinical Skills: Attendance Certification

This student has satisfactory attendance (T 1-9). 100% attendance is expected. Number of Sessions Attended …………… (out of 9) Hospital Tutor Signature ……………………………………… Date ………………… Hospital Tutor Name (Please print clearly) ………………………………………………

Workbook Certification

I have examined entries for at least 4 sessions and found them to be of a satisfactory standard. On questioning the student demonstrated adequate knowledge and understanding of the topics concerned. Friday Clinical Skills Tutor Signature…………………………… Date ………………… Friday Clinical Skills Tutor Name (Please print clearly) ..…… …………………………

Student Cases Certification

This student has completed 2 Student Case Reports, at least one of which is graded as Satisfactory. Hospital Tutor Signature ……………………………………… Date ………………… Tutor Name (Please print clearly) ..………………………………………………………

Please retain the workbook for revision rather than submitting it for inspection.


Appendix 9: In-Hospital Resuscitation

In Hospital Resuscitation: 2015 UK Resuscitation Council Algorithm

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