Medical Masterclass Clinical Skills.pdf

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MEDICAL MASTERCLASS
EDITOR-IN-CHIEF
JOHN D FIRTH
DM FRCP
Consultant Physician and Nephrologist
Addenbrooke’s Hospital
Cambridge
CLINICAL SKILLS
EDITORS
JOHN D FIRTH
DM FRCP
Consultant Physician and Nephrologist
Addenbrooke’s Hospital
Cambridge
CLAIRE G NICHOLL
FRCP
Consultant Physician and Clinical Director
Addenbrooke’s Hospital
Cambridge
DEE C TRAUE
MRCP
(UK )
Macmillan Consultant in Palliative Medicine
Addenbrooke’s Hospital
Cambridge
Second Edition
Disclaimer
Although every effort has been made to ensure that drug doses
and other information are presented accurately in this publication, the
ultimate responsibility rests with the prescribing physician. Neither the
publishers nor the authors can be held responsible for any consequences
arising from the use of information contained herein. Any product
mentioned in this publication should be used in accordance with the
prescribing information prepared by the manufacturers.
The information presented in this publication reflects the opinions of its
contributors and should not be taken to represent the policy and views of the
Royal College of Physicians of London, unless this is specifically stated.
Every effort has been made by the contributors to contact holders of
copyright to obtain permission to reproduce copyrighted material. However,
if any have been inadvertently overlooked, the publisher will be pleased to
make the necessary arrangements at the first opportunity.
LIST OF CONTRIBUTORS
Dr JD Firth
DM FRCP
Consultant Physician and Nephrologist
Addenbrooke’s Hospital
Cambridge
Dr R Morgan
BSc FRCP
Consultant Physician and Postgraduate Clinical Tutor
Medicine for the Elderly
Arrowe Park Hospital
Wirral
Dr CG Nicholl
FRCP
Consultant Physician and Clinical Director
Medicine for the Elderly
Addenbrooke’s Hospital
Cambridge
Dr JR Ross PhD
MRCP(UK)
Consultant in Palliative Medicine
St Joseph’s Hospice
London
Dr DC Traue
MRCP(UK)
Macmillan Consultant in Palliative Medicine
Palliative Care Team
Addenbrooke’s Hospital
Cambridge
Dr KJ Wilson
FRCP
Consultant Physician
Medicine for the Elderly
Addenbrooke’s Hospital
Cambridge
© 2008, 2010 Royal College of Physicians of London
Published by:
Royal College of Physicians of London
11 St. Andrews Place
Regent’s Park
London NW1 4LE
United Kingdom
Set and printed by Graphicraft Limited, Hong Kong
All rights reserved. No part of this publication may be reproduced, stored
in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, except as
permitted by the UK Copyright, Designs and Patents Act 1988, without the
prior permission of the copyright owner.
First edition published 2001
Reprinted 2004
Second edition published 2008
This module updated and reprinted 2010
ISBN: 978-1-86016-266-4 (this book)
ISBN: 978-1-86016-260-2 (set)
Distribution Information:
Jerwood Medical Education Resource Centre
Royal College of Physicians of London
11 St. Andrews Place
Regent’s Park
London NW1 4LE
United Kingdom
Tel:
+44
(0)207 935 1174 ext 422/490
Fax:
+44
(0)207 486 6653
Email: merc@rcplondon.ac.uk
Web: http://www.rcplondon.ac.uk/
CONTENTS
List of contributors iii
Foreword vii
Preface viii
Acknowledgements x
Key features xi
PAIN RELIEF AND
PALLIATIVE CARE
PACES Stations and Acute
Scenarios 61
MEDICINE FOR
THE ELDERLY
PACES Stations and Acute
Scenarios 107
1.1 History-taking 107
1.1.1
Frequent falls 107
1.1.2
Recent onset of confusion
110
1.1.3
Urinary incontinence and
immobility 114
1.1.4
Collapse 116
1.1.5
Vague aches and pains 119
1.1.6
Swollen legs and back
pain 121
1.1.7
Failure to thrive: gradual
decline and weight loss 127
1.2 Clinical examination 129
1.2.1
Confusion (respiratory)
129
1.2.2
Confusion (abdominal)
130
1.2.3
Failure to thrive
(abdominal) 131
1.2.4
Frequent falls
(cardiovascular) 131
1.2.5
Confusion
(cardiovascular) 132
1.2.6
Frequent falls
(neurological) 132
1.2.7
Confusion (neurological)
134
1.2.8
Impaired mobility
(neurological) 135
1.2.9
Confusion (skin) 135
1.2.10
Frequent falls
(locomotor) 136
1.2.11
Confusion (endocrine)
136
1.2.12
Confusion (eye) 136
CLINICAL SKILLS
FOR PACES
Introduction 3
History-taking for PACES
(Station 2) 6
Communication Skills and
Ethics for PACES (Station 4) 10
Examination for PACES
Stations 1, 3 and 5: General
Considerations 12
Station 1: Respiratory
System 15
Station 1: Abdominal
System 20
Station 3: Cardiovascular
System 26
Station 3: Central Nervous
System 35
Station 5: Brief Clinical
Consulations 53
1.1 History-taking 61
1.1.1
Pain 61
1.1.2
Constipation/bowel
obstruction 63
1.2 Communication skills and
ethics 65
1.2.1
Pain 65
1.2.2
Breathlessness 66
1.2.3
Nausea and vomiting 67
1.2.4
Bowel obstruction 69
1.2.5
End of life 70
1.3 Acute scenarios 71
1.3.1
Pain 71
1.3.2
Breathlessness 74
1.3.3
Nausea and vomiting 76
1.3.4
Bowel obstruction 79
Diseases and Treatments 82
Pain 82
Breathlessness 87
Nausea and vomiting 88
Constipation 89
Bowel obstruction 90
Anxiety and depression 91
Confusion 93
End-of-life care:
the dying patient 94
2.9 Specialist palliative care
services 96
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
Self-assessment 98
3.1 Self-assessment questions 98
3.2 Self-assessment answers 101
v

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