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					                                             P.D.S.

 A QUICK NO-NONSENSE GUIDE
                                         By Benjamin Spencer
                                       Email: b.spencer@ucl.ac.uk




©2003 PDS Textbook, Benjamin Spencer
                                                                    1
                             'If one will do it, it can be done'
                             Yamamoto Tsunetomo (Hagakure)




©2003 PDS Textbook, Benjamin Spencer
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                                           Contents

Skills of the trade                                                             4
          The basic rules of communication                                      5
          The interview                                                         7
          The history                                                           9
          Culture and the consultation                                         10
          The referral letter                                                  11
          Patients with hearing problems                                       12
          Patients with communication difficulties                             13
          Measuring the effects of chronic disease                             15
Health promotion                                                               16
          Primary and secondary medicine, and the health service               17
          Alcohol                                                              18
          Sexual health                                                        19
          Smoking                                                              20
          Diet                                                                 24
          Exercise                                                             25
          Injury                                                               26
          Diabetes                                                             27
Ethics and law                                                                 28
          The general medical council (GMC), law, and practical reasoning      29
          Rights and duties, confidence, and notification of serious illness   32
          Negligence and the duty of care                                      34
          Autonomy and consent                                                 35
          Human error                                                          36
          The declaration of helsinki and patients in teaching                 37
          Competence expounded                                                 38
          Parents and children                                                 39
Clinical examination                                                           40
          The introduction to the clinical examination                         41
          Examination of the mouth and throat, and the throat swab             42
          The respiratory exam                                                 43
          The cardiovascular exam                                              44
          Measuring blood pressure                                             46
          The abdominal exam                                                   47
          The GALS screen                                                      49
          The neurological exam                                                50
Evalutating evidence                                                           56
          Evaluating diagnostic tests                                          57
          Statistical analysis                                                 59
          Therapy trials                                                       62
          Paper appraisal                                                      63
          Assessing instruments                                                64
          Evidence based medicine                                              65
Exam case studies                                                              66




©2003 PDS Textbook, Benjamin Spencer
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                                   Skills Of The Trade




©2003 PDS Textbook, Benjamin Spencer
                                                         4
Section 1,
The Basic Rules of Comunication.
(1st Yr, FHD)


Communication is essential in the medical profession, not just doctor-patient but also doctor-doctor.
With good communication comes more information to the doctor and hence better diagnosis and
treatment, but also with good communication to the patient comes better patient compliance and a
faster patient recovery.
Good communication is essential between health professionals and certain rules and procedures have
been set up to enable this. In the modern medical climate one health professional cannot do everything
and as such has to work in a team of health professionals all involved with the care of one patient. It is
obvious that good communication is needed across this system.


Non-verbal Communication
Non-verbal communication is very important in the consultation, and apparently as much as 60% of our
communication is on a non-verbal level.
Non-verbal communication involves:

•Posture
•Hand movements/gestures
•Facial expressions

Generally one should act in a professional manner and hold a non-threatening posture, maintain eye
contact with the patient and look interested (do not just stare into your notes). Maintain neutral facial
expressions.



Open And Closed Questions
In questioning the patient it is important to understand what sort of questions to use for which situation.
Open questions are those for which there is no definite answer, “how do you feel about?; What do you
think about?” and so one. These questions give the patient the freedom to express anything that is
particularly on their mind, and gives them the feeling that you are listening to them and taking in their
needs and feelings.
Closed questions require a definite answer, “Where does it hurt?; How long ago did it start?” and so
one. These questions are used for when you, being the diagnostician, require some detail to help you
build up your profile of the patient. This gives an interrogation style feel to the conversation and
should be used reservedly.
It is best to start the conversation with the patient using open questions and then bridging the gaps in
your knowledge using closed questions.




Feedback
Feedback is an essential tool in helping the individual improve, through taking on comments and
criticisms given by others the individual can highlight the areas that are needed for improvement and
work on them, it must however be given in the correct way.



©2003 PDS Textbook, Benjamin Spencer
                                                                                                         5
Verbal feedback

In giving feedback there are a few rules to follow:

1.Positive comments about the performance of the individual should be made first, highlighting things
    they did particularly well.
2.Comments made should be related to the actions that the individual did, not the person themselves.
    (e.g. “that was not done well” as opposed to “you did not do that well”)
3.Comments made should be highly specific and not simply general feelings, general comments
    although appearing nice are in fact useless and do not help anyone improve.

In verbal feedback there is a recommended order of conversation that should be followed:

                                               Subject                             Observer

Positive Aspects                                  1                                    2
Areas For Improvement                             3                                    4


This is to allow a positive beginning to the conversation and to encourage the subject to learn to
scrutinise themselves.

Written feedback

Like verbal feedback there are also some rules to follow in written feedback:

1.Written comments given together with marking scales are the most effective.
2.Comments should be specific, quoting examples from the text where possible.
3.Comments made should highlight both strengths and weaknesses.
4.Comments for improvement should pertain to things that can realistically be changed.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        6
Section 2,
The Interview.
(1st Yr, FHD)


Early during the PDS course you will be asked to interview two patients, one in hospital, and one
related to a GP’s surgery. The method of interview differs to a normal history taking as the
information that is to be gleaned from the interview pertains more to the patient’s experience of health
care as opposed to the diagnostic tool that the patient history is. It is included here for two reasons, that
of completion, and it is useful to gain the full picture when taking a standard history and these
psychosocial aspects should be considered. Here follows the interview notes for each circumstance:

Guideline To The General Interview
An interview has three distinct parts:

1.The introduction.
2.Information gathering.
3.The closing statements.

The introduction

•Introduce yourself clearly using your full name.
•Greet the patient using their title and surname.
•Shake hands if appropriate.
•Explain that you are a medical student (doctor in training usually works better with difficult patients
     however).
•Make sure the patient is comfortable and that they understand that if they want to stop at any time they
     are free to do so.

Information gathering

•Use open-ended questions.
•Do not give medical advice or speculate about treatment/diagnosis.

Closing statements

•When enough information has been gathered or the patient seems tired stop the interview.
•Thank the patient.
•Say they have been very helpful.



The Hospital Patient

Background questions:
•Why are they in hospital.
•How long have they been there.
•Do they know when they will be allowed home.
•Have they been to hospital before.
•How they feel about being in hospital.

Before coming to hospital:
•The circumstances surrounding their admission to hospital.



©2003 PDS Textbook, Benjamin Spencer
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Being in hospital:
•Discuss what has happened since they came into hospital.
•What do they think makes a good doctor.

Going home:
•Discuss their plans for going home.
•Discuss their thoughts about returning home.
•Discuss how they think their hospital stay will have affected them.

The GP Patient

Personal Circumstances:
•Whether patient lives alone or with others.
•Whether employed, self employed, retired, caring for others, etc…
•If working, type of work.

Being ill:
•Patient’s main health problem(s).
•Duration of problem.
•Patient’s ideas on the cause(s) of their problem.
•How it started.

Becoming a patient:
•When and why they saw their doctor about it.

Being a patient:
•Type of care they have experienced.
•People involved in their care.
•Whether or not they had tried any remedies themselves.
•How the illness has affected their life, (physical problems, social life, family, work…).

Communication and the quality of care:
•Do they know as much as they want to about their condition and its treatment?
•Where has their information come from?
•Are they satisfied with their care?
•Is there anything they would like done differently?
•What do they think makes a good doctor?




©2003 PDS Textbook, Benjamin Spencer
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Section 3,
The History (Hx).
(Multi Yr, Multi Module)



Quite Simple Really:

•Presenting complaint.
•Hx of presenting complaint.
•Past medical Hx.
•Drug Hx.
•Family Hx.
•Social Hx. (this also involves a lifestyle history pertaining to smoking/alcohol/diet/exercise…)
•Systems review.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                    9
Section 4,
Culture And The Consultation.
(2nd Yr, MMB)


Communication Skills:
    Put patient at ease.
    Establish their understanding of English.
    If not interpreter is available, speak slowly and use diagrams.
    Use open questions.
    Establish their understanding of what you have said.
    Be aware of your own values so that you do not impose them on the patient.
    Learn about the cultural background of your community, particularly if they constitute a large
    portion.
    Learn which cultural differences might affect treatment.
    Explore their cultural practices only if necessary.
    If appropriate acknowledge a lack of knowledge of their culture.
    Show respect of their cultural differences.
    Do not make assumptions of their cultural practices.
    Do not be judgemental.
    Do not assume the cultural practices are related to their health problems.
    Be open minded about cultural practices that are unfamiliar to you.
    Accommodate cultural ideas without compromising treatment.

Do all this and you are guaranteed a full 20 marks in the MEQ question.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                     10
Section 5,
The Referral Letter.
(2nd Yr, MMB)


Referral Letters
This is what an anonymous UK hospital want, (no it's not a RUMS one):

Unless you need the patient to be seen by a particular consultant please address your letter to 'Dear Dr'
(ie, unnamed) rather than to a named consultant. This will help to expedite your referral by ensuring
that your patient receives the first available appointment with an appropriate consultant.

To help us deal with your referral, please ensure that your referral letter includes:

  * Full GP and practice details

  * Complete patient demographic data including correct name spelling and date of birth

   * Patient's contact telephone numbers etc (these are important in instances when we may be able to
offer a patient a late or cancelled appointment)

  * Patient's NHS number

  * All relevant clinical information

  * Information on any relevant pathology or X-ray tests carried out

  * Whether the patient needs transport on a medical basis (arranged by GP)

  * Whether an interpreter is required




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        11
Section 6,
Patients With Hearing Problems.
(2nd Yr, Neuro)


Deafness And Its Classification
Degree of Deafness

Mild               20-40 dBHL
Moderate           41-70 dBHL
Severe             71-95 dBHL
Profound           >95 dBHL
Total              No response at all

Types of Deafness

Age of onset of deafness defines it as being either Congenital pre-lingual, or if after spoken language
has been developed it is Acquire post-lingual.

The two forms of deafness are:

1.Peripheral, being either:
    Sensorineural (either cochlear or retrocochlear)
    Conductive (outer and middle ear)

2.Central (CNS involvement)


Skills

Communication with the deaf person

1.Gain the deaf person’s attention before speaking.
2.Speak clearly, but do not exaggerate or over-emphasise words.
3.Do not distort lip movements (it makes lip reading more difficult).
4.Use facial and body expression.
5.If the deaf person does not reply or seems to be having difficulty in comprehending rephrase the
     statement.
6.Look directly at the patient to ensure ease of lip reading.
7.Use paper and pencil.
8.Do not restrict topics of conversation.
9.Do not be in a hurry.
10.Ensure only one person speaks at a time

Interpreters

Make sure you have the right kind:
•Sign language interpreters.
•Lipspeakers. (they silently repeat what you have said in simple easily lipread gestures)
•Note takers (provide a written record of the conversation)
•Speech to text reporters (a computerised form of the note takers)
•Communicators or communication support workers (work with deaf students in educational settings)




©2003 PDS Textbook, Benjamin Spencer
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Section 7,
Patients With Communication Difficulties.
(2nd Yr, Neuro)


Conditions
Dysphasia, (aphasia)

This is a disorder of language processing, commonly caused by stroke, head injury, tumour, or
subarachnoid haemorrhage. It greatly varies from person to person but ranges from slight to totally
inability to understand language. This impairment can vary from recognising words to being able to
recall and speak them, or being able to understand grammar.
A large area of the brain is used in speech processing and damage to any part of it can cause some form
of aphasia, the extent of damage and site of the lesion is usually correlated with the aphasia presented.
Usually the patient will have other forms of brain damage which will make the communication even
more difficult.

Aphasia is distinguished from Alzheimer’s disease by being:
•Sudden
•Specific
•Usually not impairing intellect
•Aphasia can get better with time

Dyspraxia

This is a disorder of speech motor programming, the patient cannot voluntarily perform speech
movements but understand what is required, language comprehension is not affected. These speech
movements can be performed subconsciously however.

Dysarthria

This is a disorder of speech movement making it less intelligible and sometimes slurred. Damage is
usually to the pyramidal or cerebellar pathways.

Skills
The carer

If a carer/parent is involved with the patient or a spouse/friend and so on…

•Greet the patient and the carer.
•Be at their level.
•Begin interactions with the patient.
•Make it clear to the patient that they can involve the carer with the interaction if they want.
•Use eye contact with whoever is speaking.
•If the carer provides information, give the patient opportunity to agree/disagree.
•Acknowledge contributions from both the patient and the carer.

Strategies to understand the patient

1.Allow time to respond.
2.Encourage any form of response, the person may be able to draw, gesture, write, use another word
    which gives a clue.
3.Ask further questions to clarify the message.


©2003 PDS Textbook, Benjamin Spencer
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4.Structure questions carefully, yes/no questions, multiple choice questions, and open questions.
5.Feedback to ensure you have understood correctly.

Strategies to make the patient understand you

1.Find out which strategies help the person.
2.Make eye contact and listen carefully.
3.Slow down but use normal adult language and tone of voice.
4.Use plain english, avoid medical terms.
5.Say one thing at a time, pausing in between.
6.Make it clear when there is a change of topic.
7.Use non-verbal communication to support what is said. (writing key words, gestures, pointing)
8.Re-phrase if something is not understood.
9.Use examples.
10.Ask questions to ensure they understood




©2003 PDS Textbook, Benjamin Spencer
                                                                                                    14
Section 8,
Measuring The Effects Of Chronic Disease.
(2nd Yr, Neuro)


HAQ
Stanford's Health assessment questionnaire is used widely now as a measurement of chronic illness in a
patient and how it affects them, as such it is highly subjective but apparently it is quite accurate
(according to the makers). Patients rate their ability to perform a task on a scale of zero to three, 0
being no difficulty, 1 being with some difficulty, 2 with much difficulty, and 3 being unable to do.
At the end the results are summated and then divided by the number of questions to get the mean HAQ
score of disability for that patient.

Compared with GALS which is a clinical assessment the HAQ score is more to do with the patient's
experience of illness, hence whereas physiotherapy might improve the HAQ score greatly it is unlikely
to effect the GALS, as chronic disease by its very nature can only be treated palliatively.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                     15
                                       Health Promotion




©2003 PDS Textbook, Benjamin Spencer
                                                          16
Section 1,
Primary And Secondary Medicine, And The Health Service.
(!st Yr)

Primary, secondary, and tertiary care.
Primary care is the first port-of-call for the patient, being all health Services provided at the local
Medical Centre and within the community. This can involve practice nurses, physiotherapy, the local
pharmacy, to 24 hour emergency cover
Secondary care is from referral from primary care, this usually involves referral to a specific outpatient
department in a hospital, e.g. nephrology, cardiology…or can be inpatient care referred by the hospital
internally.
Tertiary care involves very specialised branches in the health service dedicated to rare conditions, a
yellow fever clinic for example.
Generally as the patient is referred up the care tree the treatment becomes more and more specialised,
hence primary care is all encompassing but not very powerful in specific cases, whereas tertiary care is
very focused at an expert level on one specific condition.

Health Service

Some general facilities that should be known about are gone through here:

The hospital

This is involved primary in secondary care of the patient, but accepts some primary care in the form of
accident and emergency admission. It has specialised departments and is deals with 24 hour care of
patients with serious conditions or simply detailed diagnosis (e.g. referral to specialist).

The GP Surgery

This is involved with the holistic care of the patient bringing in help from not just doctors but practice
nurses, dieticians… They sometimes run workshops for certain conditions, e.g. asthma, and can run
support meetings.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                         17
Section 2,
Alcohol.
(1st Yr FHD)


The health and social impact of alcohol abuse

Long term alcohol excess is associated with:
   Impaired mental capacity
   Liver damage
   Oesophageal cancer
   Heart disease

         Alcohol is implicated in most trauma cases
         Alcohol can lead to violence
         Drunk and disorderly behaviour is bad

Getting an Alcohol history

Key factors involved are:

        The frequency of alcohol consumption
        The amount consumed in one sitting
        The type of acohol consumed
        The Units of alcohol consumed per week
(One unit = 8mg of alcohol, i.e. One shot or half a pint or one glass of wine; the weekly advised alcohol
consumption limits are 21 units for a man and 14 for a woman)


The C.A.G.E. Questionnaire

The C.A.G.E. questionnaire is a diagnostic tool for the diagnosis of alcoholism, it has a high sensitivity
though a low specificity (the meaning of these terms are discussed in the evaluating evidence section).
It is a series of four questions as follows:

C – Do you ever feel the need to Cut down?
A – Do you ever get Annoyed when people comment on your drinking?
G – Do you ever feel Guilty about your drinking habits?
E – Do you ever need an Eye-opener of a morning?

A positive response in two or more questions implies the subject is an alcoholic, of course this is open
to much debate.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        18
Section 3,
Sexual Health,
(1st Yr, 2nd Yr RGD)


Facts
         There is an increase in condom use at 1st intercourse, and a decline in non-use of
         contraception.
         Circumstances of 1st intercourse more favourable as age at onset increases.
         School sex education is associated with lated onset of intercourse and increased contraceptive
         use.
         Outcomes are more strongly associated with education-related factors than family
         background.

Sex in the consultation: Who, Why, Where, When, How? (And malpractice
suites.)
When
         Always (when relevant).

In what context
        As part of differential diagnosis.
        Loss/abnormal funtion.
        As part of an emotional disturbance.

Where
         Comfortable surroundings.
         Unhurried.
         Privacy.
         Minimal/No interuptions.
         Assured Confidentiality.

Who
         Everyone (except the V young)


How:

Communication Tips

         Make no assumptions.
         Prepare and think ahead if you might have to discuss sex.
         Acknowledge with the patient that this might be a difficult/embarassing topic.
         Remind patient of confidentiality/non-judgemental/mutal respect.
         Remain neutral in body posture and tone of questioning.
         Use hypothetical questions.
         Go from general to specific and depersonalise the questioning.
         Use open questions for feelings...
         Use closed questions for specific symptoms...




©2003 PDS Textbook, Benjamin Spencer
                                                                                                      19
Section 4,
Smoking.
(1st Yr, CIRC/BREATH)


Problems caused by smoking

Smoking is a major problem to the health service, costing the NHS ₤1.7 billion a year (probably less
though than the amount of revenue through smoking taxation). It causes a whole variety of diseases:

•Coronary heart disease.
•Atherosclerosis.
•Cancer (just about everywhere)
•Emphysema.
•Thromboses.
•Bronchitis.

It causes 120,000 premature deaths each year, with 28% of the U.K. population smoking. Hence it is
still today a major concern.

Why start and why quit

People start smoking for a complex array of reasons, but they are mostly male and start in their ‘teens,
on average between twelve and thirteen years old.

Common reasons to start are given below:
•Curiosity and boredom.
•Rebellion and independence.
•Peer pressure (and social acceptability).
•Parental example.
•Tobacco advertising and promotion.
•Addiction and dependence (obviously this must happen after the first try).
•Habit formation (again as above).
•Weight control.
•Enjoyment.

It should be noted that smoking is far more prevalent in the lower social classes.

Most adult smokers want to give up, (70%), but most do not succeed before the age of sixty-five. In
fact even after serious medical complications like heart attack or lung cancer the patients still relapse
into smoking.

Common reasons for quitting are given below:
•Cost of the habit.
•Concerns over appearance and attractiveness.
•Social pressures.
•Sense of control.
•Health concerns.




©2003 PDS Textbook, Benjamin Spencer
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Helping the quitter, the 4 As
There is evidence that health professional help in trying to quit is effective in increasing the chance of a
quitter being successful. To this end the four As approach has been formulated.

1.Ask

The health professional should ask about the patient’s smoking status at every possible opportunity,
and record this in their clinical notes. (The details of taking a smoking history will be discussed later)

2.Advise

All smokers should be advised on the benefits of quitting the habit, with emphasis that past attempts to
quit which failed may actually improve their chances of quitting successfully. Practice staff should be
encouraged to reinforce this message and support patients to stop smoking. Nicotine replacement
therapy should be recommended and information regarding its use should be made available, (evidence
has found it to double the effectiveness of smoking cessation advice).

3.Assist

The health professional should help smokers who want to quit with quitting. This involves setting a
date for the patient to stop, review past attempts they may have made in quitting and evaluate why they
failed, discuss the value of nicotine replacement therapy, and plan a personalised strategy for the
patient in terms of their quitting.

4.Arrange

The health professional should arrange follow up sessions with the patient, perhaps referral to specialist
services like smoking cessation clinics and support groups. At these follow-up meetings the patient’s
progress in quitting should be re-evaluated.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                          21
The cycle of change

People will only succeed in quitting when they are ready to stop smoking, they have support from
family, and they understand fully how they will feel and adapt to the new social situation that they will
find themselves in.

In terms of quitting addiction patients usually follow a pattern of behaviour called the ‘cycle of
change’:




                                           CONTEMPLATION
                                       Part of the person wants to change




      PRE-CONTEMPLATION                                                        DECISION
          See no reason to change                                             Deciding change




                 RELAPSE                                             ACTIVE CHANGE
      Returning to pre-change behaviour                                        Changing behaviour




                                             MAINTENANCE
                                        Consciously keeping change going




                                   Change Carefully Adopted

Most patients will relapse and go through the cycle indefinitely, but hopefully some will breakout and
maintain their ‘quitter’ status. It is important to assess where the patient is in the cycle and use this
knowledge to tailor their treatment plan.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        22
Smoking history

The smoking history should include information gathering in the following areas:

•Whether or not the patient smokes.
•The type smoked, (cigar, pipe, cigarettes, filter or non-filter, roll-ups…)
•The amount smoked each day.
•Time after waking before smoking.

The ‘pack years’ can also be calculated and is a good comparative figure for the level of smoking
damage they have suffered, 1 pack year = 1 pack a day for a year. This is a cumulative figure, so 40
pack years could mean twenty packets of cigarettes a day for two years or 1 packet of cigarettes a day
for forty years.

An example for the usefulness of this is that the risk of chronic obstructive pulmonary disease develops
after twenty pack years on average.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                         23
Section 5,
Diet.
(1st Yr FNM)


(see Section 6, Exercise for factors affecting change, and how the clinician can help)

Health benefits of a healthy diet
         Less type II Diabetes
         Less CHD
         Less Obesity
         Less Cancer
         More Energy

Factors affecting food choices
          availability of foods
          cost of foods
          time for preparation and consumption
          disability and infirmity
          personal likes and dislikes
          intolerance or allergy
          eating alone or in company
          marketing pressure and advertising
          religious and ethical taboos
          perceived or real health benefits and risks
          modified diet for control of disease
          illness or medication.




©2003 PDS Textbook, Benjamin Spencer
                                                                                         24
Section 6,
Exercise.
(2nd Yr, MMB)


Health And Social Benefits
          Less CHD
          Less type II diabetes
          Less Obesity
          Longer life
          More energy
          Better Erg Scores

Problems in taking up an exercise regimen (factors affecting change)
1.Socioeconomic

          Lack of money
          Lack of time
          Lack of services
          Location of services

2.Personal

          Lack of information/knowledge
          Lack of skills
          Family preferences
          Want to rest/relax in spare time
          No wanting to partake on the lifestyle change suggested
          Family support

3.Cultural

          How their cultural beliefs affect/influence their lifestyle
          Goes against perceived social norms

How The Clinician Can Help

1.Medical
   Identify those at risk, via BMI.....
2.Behaviour change
   Persuade through one-on-one advice...
3.Educational
   Explore patient's attitudes and educate
4.Empowerment
   Work with communities to help their perceived needs, i.e. Fat women's groups...

          Refer : to physiotherapist, self-help groups, dieticians....
          Arrange follow ups.
          Take culture into account when making an action plan.
          Enlist the family.
          Realistic goals, realistic plans.




©2003 PDS Textbook, Benjamin Spencer
                                                                                     25
Section 7,
Injury.
(2nd Yr, Neuro)


Injury is a serious problem, claiming over 10,000 lives a year and costing the NHS £1.6 billion a year.

Causes
Injuries at home revolve around injuries to older people particularly from falls, for younger people they
revolve around fires, burns, poisoning, choking, and cuts.

Occupational injuries are due to:

•Environment (mining and quarrying).
•Exposure to hazardous substances.
•Work related illness (backache).
•Poor risk management (farming and construction industry)

Main target groups
The main groups to be targeted in an anti-injury strategy are:

•Children up to 15 years old. (especially those from manual and unskilled households)
•Young people between 16-24 involved in road traffic accidents (RTAs).
•Older people at risk of stumbling and falling.

Prevention

•Environmental change. The environment is the cause of most injury.

•Legislation and regulation.

•Reducing costs and improving access to safety equipment.

•Education and training.

•More effective emergency treatment.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                       26
Section 8,
Diabetes.
(2nd Yr, Endo)


Prevention and management of diabetes
This follows a five stage process:
1.Pevention
2.Initial diagnosis
3.Initial care
4.Continuing care

The management of a diabetic patient is multidisciplinary, and can involve:

          Diabetic Consultant
          Practice Nurse
          Dietician
          Day Centres
          Housing Services
          GP
          Occupational Therapists
          Physiotherapist
          Chiropodist
          Diabetic Specialist Nurse
          Carers Services
          Advocacy Services
          Other Hospital Specialists

The challenges to be tackled in the care of diabetes are:

          Person Centred Approach: Empowering the indiviual in self-care/lifestyle changes.
          Partnership Working: Allocate and clarify the role of everybody in the patient's care team.
          Equitable Care: Meet the needs of excluded/disadvantaged groups.
          Integrated Care: Work across diferent agencies and sectors.

Prevention of Diabetes

General Points
         Reduce Obesity Levels
         Increase Physical Activity
         Target Action On Most Vulnerable Groups
         Adopt Multi-Agency Health Promotion Action

Specific Programs
          Five-a-day Program
          National School fruit Scheme
          Physical Education and Sport Program
          Healthy Schools Program
          Food in Schools Program




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        27
                                       Ethics And Law




©2003 PDS Textbook, Benjamin Spencer
                                                        28
 Section 1,
 The General Medical Council (GMC), Law, and Practical Reasoning.
 (1st Yr, FHD)


 The GMC

 To practice medicine in the UK you must be registered with the GMC, this brings certain rights and
 privileges but these are balanced against the professional code of conduct you must follow as a GMC
 registered Doctor.

 The GMC has certain functions:

 1.It licences Doctors.
 2.It sets the standards.
 3.It is the disciplinary body.
 4.It controls the education of new doctors.

 To this end it is essentially a protective body, assuring the protection of the public from bad medical
 practice, it protects employers (ensuring any GMC registered Doctor is of a certain quality), and acts as
 a cerificate of ability for Doctors.

 The GMC can suspend the licence of a Doctor if it believes the Doctor unfit for practice, this could be
 for a variety of reasons ranging from professional misconduct to simply the Doctor being to ill to work
 properly, its powers end with suspension of licence and/or refferal to the courts.

 To help Doctors understand the duties they are expected to perform under the GMC a list of duties has
 been created and is displayed here:

Patients must be able to trust doctors with their lives and well-being. To justify that trust, we as a profession
have a duty to maintain a good standard of practice and care and to show respect for human life. In particular as
a doctor you must:

    •Make the care of your patient your first concern;
    •Treat every patient politely and considerately;
    •Respect patients' dignity and privacy;
    •Listen to patients and respect their views;
    •Give patients information in a way they can understand;
    •Respect the rights of patients to be fully involved in decisions about their care;
    •Keep your professional knowledge and skills up to date;
    •Recognise the limits of your professional competence;
    •Be honest and trustworthy;
    •Respect and protect confidential information;
    •Make sure that your personal beliefs do not prejudice your patients' care;
    •Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may
        not be fit to practise;
    •Avoid abusing your position as a doctor; and
    •Work with colleagues in the ways that best serve patients' interests.

In all these matters you must never discriminate unfairly against your patients or colleagues. And you must
always be prepared to justify your actions to them.




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The Law
English Law is split up into two areas: Civil Law and Criminal Law.

Civil Law is involved in compensating for a wrong between two civil parties,

For example, if I left my tricycle on your drive and you fell over it getting a paraplegic injury in the
process you could sue me for damages.

Criminal Law is involved in punishment of the perpertrator of a crime,

For example, if I went into your house and hacked you up with an axe the state could prosecute me and
send me to jail.

In medicine most aspects of law you will be dealing with is civil law as opposed to criminal law
(hopefully).

The rules of the Law come from two sources:

Statute Law, this consists of acts of parliament, the carte blanche of the legal system.

Case Law or Common Law, on the other hand is created from specific court cases that have arisen and
been decided on by a judge. Decisions in court cases are binding to all other courts, so if a judge
decides that it is illegal to eat herrings then it is applicable to other cases that arise unless it is
superceeded by a higher court in the court hierachy. Higher courts can also revoke lower court
decisions in specific cases.


The hierarchy of courts




                                            House of Lords

                                           Court of Appeal


                  High Courts                       |                     Crown Courts
                                                    |
                                                    |
                                                    |
                 County Courts                      |                  Magistrates Courts
                                                    |
                                                    |
                  (Civil Law)                       |                    (Criminal Law)




The GMC has a statute law that it is the governing body of the medical profession, maintaining the
professional standards. All legal issues arising however are dealt with in the legal system, hence the
GMC has no power but to revoke the licence of a Doctor and start the legal process going.


©2003 PDS Textbook, Benjamin Spencer
                                                                                                     30
Practical Reasoning

In medicine decisions must be made involving patient’s lives and courses of treatment, medical
knowledge and the GMC exist to provide guidelines on which course of action to take, but ultimately
the decision comes down to the Doctor. Practical reasoning is the process in which a decision can be
made which leads to a practical conclusion and can be used to justify to others that course of action,
hence it is at your discretion to decide what to do, but it might have to be defended in a court of law.

Practical reasoning revolves around the production of three items:

1.A Claim of Fact

    This is a statement which is factual. It can be general or particular (pertaining to the case in hand).

2.A Claim of Value

    This is a value statement, based on some ethical or society held belief.

3.A Conclusion

    The course of action to be taken.


An example of the practical reasoning process is worked through here:

John Smith has broken his arm, he comes to you, what do you do?


1.Claim of Particular Fact, John’s arm is broken

2.Claim of General Fact, Broken arms hurt

3.Claim of Value,           Doctors should alleviate pain


Conclusion: The doctor should give John painkillers.

Now this process can be used to justify anything and the claims of fact don’t necessarily have to be
true, hence the power of practical reasoning. In the above case one could equally have made a claim
that when a patient is dead they feel no pain so John should have been euthanised.

Remember: Any decision you make you will have to justify and make others believe it was the ‘right’
thing                                         to                                                do.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                         31
Section 2,
Rights and Duties, Confidence, and Notification of Serious
communicable Diseases.
(1st Yr, INF/DEF, 2nd Yr RGD)


Rights and Duties
A Right which is ascribed to someone implies a Duty of someone else. For example if I have the right
to live it means everyone else has the duty to not deprive me of my life

Rights can be morally or legally justified, in which case they are called either moral or legal rights
respectively.

Rights can come in various forms:

1.Human (natural) rights, these belong to everyone and consist of our basis human rights.
2.Absolute rights, these cannot be outweighed by anything else.
3.Prima Facie rights, similar to absolute rights but in very special circumstances they can be
     superceeded.

Pro-capital punishment campaigners would argue that the right to live is a prima facie right whereas
those against capital punishment would say it is an absolute right.


Confidence
The patient has the right to expect all their details to be kept in confidence, not to be shared with others,
during their treatment and after, even following their death. Their consent must be obtained before this
is done so. Any data about the patient for statistical/epidemological purposes must be anonymized.

There are exceptions to this rule, in which case the Doctor must inform other organisations:

1.The patient poses a serious risk to others.
2.The patient has been involved in criminal activity.
3.The patient has an informable serious communicable disease.
4.The patient is driving against medical advice.
5.A colleague is performing below the expected professional standards and is posing a risk to their
    patients.

Effectively confidence is only overiden if there is a serious risk of harm to others.

Of course when you bring framilies into the equation it opens up a whole can of worms.

Notification of Serious Communicable Diseases
Some diseases are deemed to be such a health risk that their spread must be prevented at the cost of
some of the individual patient‘s rights.

Diseases that fall under this category are hepatitis, tuberculosis, and meningitis for example, but not
HIV. If a patient if found to have a serious communicable disease the centre for disease control must
be informed whereupon they take over. Confidentiality of the patient is superceeded in this situation.




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                                                                                                          32
Patients can be restrained and remanded in hospital if it is believed that they will act in a way as to
spread the disease, and the Doctor can inform people they believe to be at risk about the patient‘s
disease status.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                     33
Section 3,
Negligence and the Duty of Care.
(1st Yr, CIRC/BREATH)


The Criteria of a successful negligence case
If a doctor is to be sued by a patient for negligence the following three critera must be met:

1.The Doctor owed a Duty of Care to the patient
2.This Duty of care was breached.
3.Harm was caused to the patient by the breach.

The duty of care


A duty of care is an obligation of the Doctor to prevent harm being suffered by their patient. GPs do
not owe a duty of care to everyone, only to the people on their books in their practice. Hospital
Doctors owe a duty of care to patients who turn up at the hospital, after they are dealt with it is their
GPs responsibility.

Breach of Duty of care


A duty of care is said to be breached if the Doctor does not perform to such a standard as would be
expected of the ‘ordinary skilled man‘ in their profession. Doctors are not expected to be superbeings,
just to perform as well as the average.

The proof


Finally it must be proved that harm was caused by this inaction, this is probably the most difficult and
the onus of proof is on the plaintiff (that who is doing the suing), not the Doctor defending.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                      34
Section 4,
Autonomy and Consent.
(1st Yr, FNM)


Autonomy
A mentally competent patient of adult age is free to decline any medical treatment providing the harm
that is done is only to themselves. If there is the potential of harm to others, i.e. the patient has
Tuberculosis or they are psychopathic and very likely to harm people then this can be overiden.

Consent
Consent can come from the patient in either verbal or written forms, the written form can be used as
evidence but it is not proof of valid consent.
Consent must entirely voluntary and the patient must be fully informed, consent must be given before
any proceedure is commenced.

For consent to be valid three critera must be met:

1.The patient is legally competent

         This means that they can:

         a) Understand and retain the information relevant to the case.
         b) They believe the information.
         c) They can come to a decision taking all factors into account.

2.There is no coercion from the medical practitioner

3.They have all the relevant information pertaining to the case




©2003 PDS Textbook, Benjamin Spencer
                                                                                                  35
Section 5,
Human Error.
(2nd Yr, MMB)


Human error is ever present in the medical profession, you and your colleagues will make mistakes,
and these can have multiple causes:

1.Errors, these arise from failing to cope with information, e.g. forgetting, inattention…, from this
    there are two groups:

a)Slips and Lapses, a failure of an execution of an action,

Slips are observable:                  Cutting too deep when operating.

Lapses are internal:                   Forgetting to anaethatise the patient first.

2.Violations, these are deviations from an agreed set of rules, there are three main groups:

a)Routine, (cutting corners)

e.g. Not checking the diagnosis for yourself before to cut out someones kidney

b)Optimising, (actions taken for personal reasons)

e.g. flamboyantly operating on your patient

c)Situational violations (course of action only apparent way to get job done)

e.g. emergency tracheotomy


Errors are minimised by better information, violations by improving morale and organisation.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                   36
Section 6,
The Declaration of Helsinki And Patients In Teaching.
(2nd Yr, MMB)


The declaration of Helsinki
This was set up in 1964, and amended later, to provide a set of rules to be followed for research on
humans, both therapeutically and non-therapeutically.

Essentially it boils down to:

1.The wellbeing of the patient always comes first.
2.The participants must be fully informed.
3.The participants must give consent.
4.The participants can back out at any time.
5.The research must be carried out by qualified professionals
6.The proposed research must be validated by an ethics committee independent of the party wanting to
    do the research.
7.All other forms of research must be exhausted first before reseach is done on humans.
8.The research must only be carried out if there is a reasonable likelyhood that the participants will
    stand to benefit from it.
9.The participants must be volunteers.

Patients in teaching
In teaching hospitals patients must be involved in the teaching of medical students, it is important to
note that:

1.Informed patient consent must be obtained.
2.There must be no coercion.
3.The patient must understand they can back out at any point and it will not affect their further care.
4.The patients are volunteers.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                          37
Section 7,
Competence Expounded.
(2nd Yr, Neuro)


    Minors under 16 -default assume non-competent
    Minors over 16 and adults -default assume competent

How to treat the non-competent patient
The problem with non-competent patients is, no treatment without consent, consent cannot be given by
proxy, but failing to treat is a breach of duty of care, so:
The defence of necessity is used, you can give treatment to a non-competent patient if it is in their best
interests.

Types of non-competent patients include:

          Temporarily non-competent: unconsious after accident.
          Permanent non-competant, but formerly: dementia, seriously damaged in accident.
          Never competent: Learning disabilities.

Advance Directives (living wills, refusal of treatment...)

These are valid providing:

          The patient was competent at the time.
          The decision was made without undue influence.
          The patient anticipated the full scope of the circumstances they are now in.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                       38
Section 7,
Parents and Children.
(2nd Yr, Endo)


The family Law Reform Act, 1969
          16 year olds can consent to treatment as if they were 18.

The Gillick Case, 1985
Basically a mother demanded that a health authority would not give her daughters contraception withou
her knowledge. The HA refused, so now after much litigation.

          Gillick competence consists of the child understanting, what the treatment is, why it is
          proposed, the benefits and risks, and the consequences of not proceeding with the treatment.
          Where contraceptives are concerned, the doctor prescribing must satisfy themself that: the girl
          has to understand the advice, the doctor cannot persuade her to tell her parents, she is very
          likely to continue or begin to have sexual intercourse with or without contraception, unless
          she recieves the advice her mental/physical health will suffer, her best interests are
          represented by giving advice/prescribing without parental consent.

The Children Act, 1989
          Child's welfare is paramount.
          The child is a person, and children of sufficient maturity should be listened to .
          Children should be raised by the family without intervention unless the child is at risk.
          Where conflicts arise the aim is negotiation and cooperation.
          With court actions, avoid delay.


Parents
         Consent on behalf of their children, but if the doctors disagree and it will harm the child
         through lack of consent: If there is time they can overrule the parents decision by going to the
         courts, or if there is not time they can ignore the parents views.
         Parental responsibility is held by: the mother, the father if married to the mother at time of
         insemination or birth, the father who has since: married the mother, made a written agreement
         with the mother, been given responsibility by a court order, has been appointed guardian after
         the mother's death.Also, guardians, and other court appointed people.

Consent for treatment of non-competent minors

         Urgent necessary treatment can be administered.
         For non-urgent treatment parental consent is needed.
         The consent of one person with parental responsibility is sufficient.

You can get specific issue orders from courts.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                      39
                                 Clinical Examination




©2003 PDS Textbook, Benjamin Spencer
                                                        40
Section 1,
The Introduction to Clinical Examination.
(1st Yr, INF/DEF)


Introducing yourself and general conduct
At the beginning of a clinical exam the usual general codes of practice must be followed:

1.Greet the patient and make them feel at ease.
2.Explain to the patient what you plan to do, ensure they understand and get their consent.
3.WASH YOUR HANDS.
4.Explain to the patient what to do in simple terms.
5.During the procedure do not keep a running commentary going, make jokes, speculate about
    diagnosis, make personal comments or ask personal questions.
6.Keep an air of professionalism throughout the procedure and be confident, do not hesitate.
7.Maintain a neutral facial expression, if the patient is anxious try to put them at ease, this is dealt with
    in the communication section.

This should be followed for every clinical examination.


Handwashing expanded
Handwashing should always be done before and after handling a patient, before handling food, going to
the toilet, when you come on and off duty… You should wash your hands even if you are going to use
sterile gloves.


The Procedure

•Remove watches and jewellery.
•Roll up long sleeves.
•Use properly designed hand basin if you can.
•Keep nails short and free of varnish.

•Apply disinfectant to the hands.
•Rub palms vigorously together, ensure all hand surfaces receive contact, washing fingertips, spaces
    between the fingers, the dorsal surface of the hand, and the wrist and upper forearm.
•Rinse off thoroughly.
•Don not recontaminate hands by touching the tap.
•Dry hands with paper towels.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                          41
Section 2,
Examination of the Mouth and Throat and The Throat Swab.
(1st Yr, INF/DEF)



Mouth and Throat Exam

•Inspect the patient’s face generally and note any swelling.
•Look at their lips for ulcers and/or fissures.
•Assess the gums and dentition for any bleeding, and to gain an impression of dental hygiene. Remove
    their dentures if you have to.
•Look at the hard palate and the floor of the mouth – ask the patient to rest their tongue to view the
    hard palate and then to lift it to view the floor.
•Use a torch and a tongue depressor to look at the throat.
•Ask the patient to say ‘aaaah’ and then inspect both tonsils, the posterior pharyngeal wall and the
    movement of the soft palate.
•Feel around the neck for swollen lymph nodes.




The Throat Swab

•Loosen the swab container.
•Ask the patient to say ‘aaaah’.
•Point the swab at the back of the patient’s throat and roll it around the fauces over the tonsils.
•Remove the swab an replace it in the culture medium of the container.
•Label the specimen.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                      42
Section 3,
The Respiratory Exam.
(1st Yr, CIRC/BREATH)


Set the patient reclining at 45 .

Hands and Arms

•Look and feel the hands for temperature and colour.
•Look at the fingers for clubbing of the nails and nicotine staining.
•Check for a CO2 retention flap and feel the radial pulse (rate, rhythm, and volume).

Face

•Look in the eyes for pallor.
•Look in the mouth for central cyanosis.

Neck

•Look for the jugular venous pulse.
•Feel for lymphadenopathy.
•Feel for the trachea (is it central or deviated).

Chest

Examine the front and back of chest using the following proceedure:

         Inspection

         •Look for asymmetry or deformity of the chest.
         •Look for scars.
         •Look at movement of the chest and note whether the patient is using accessory muscles.
         •Count the respiratory rate.

         Palpation

         •Feel for the apex beat – midclavicular line, 5th intercostal space.
         •Check chest expansion – upper and lower.
         •Tactile vocal fremitus.

         Percussion

         •Percuss the chest comparing chest from side to side and listening for changes in resonance.

         Auscultation

         •Auscultate all areas of the chest.
         •Listen for vesicular (normal) or bronchial breath sounds.
         •Listen for wheezes, crackles, or rubs.
         •Test for vocal resonance.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        43
Section 4,
The Cardiovascular Exam.
(1st Yr, CIRC/BREATH)


Set the patient reclining at 45 .

Hands

•Look at and feel the hands for temperature and colour.
•Look at the nails for clubbing and splinter haemorrhages.

Arms

•Feel for either the radial or brachial pulse.
•Note the rate, rhythm, and volume.
•Take the blood pressure.

Face

•Look in the eyes for pallor, arcus, and xanthelasma.
•Look in the mouth for central cyanosis.

Neck

•Feel for the carotid pulse - and its character.
•Look for the jugular venous pulse.

Chest

         Inspection

         •Look for asymmetry or deformity of chest.
         •Look for scars.

         Palpation

         •Feel for the apex beat – midclavicular line, 5th intercostal space.
         •Feel for heaves and thrills.

         Percussion

         •None in the cardiovascular exam.

         Auscultation

         Listen in the 4 areas:
         •Mitral (Apex)
         •Tricuspid         (Left lower sternal edge)
         •Aortic (2nd intercostal space at right sternal edge)
         •Pulmonary         (2nd intercostal space at left sternal edge)

         •Listen for heart sounds whilst feeling the carotid pulse.
         •Listen for murmors and added sounds.
         •Listen at lung bases.


©2003 PDS Textbook, Benjamin Spencer
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Finishing off

•Feel for sacral and ankle oedema.
•Feel for an abdominal aortic aneurysm.
•Feel for the peripheral pulses.




©2003 PDS Textbook, Benjamin Spencer
                                          45
Section 5,
Measuring Blood Pressure.
(1st Yr, CIRC/BREATH)


Set the patient sitting, ensuring the sphygmomanometer is at the same level as their heart and you have
the correct cuff size.

•Place the cuff around arm, (2.5cm above the antecubital fossa).
•Inflate cuff until radial pulse can no longer be felt. This will estimate the systolic pressure.
•Deflate cuff completely.
•Inflate cuff again to a pressure 30mmHg higher than estimated systolic pressure.
•Palpate the brachial artery.
•Place the stethoscope over the brachial artery.
•Deflate the cuff at 2-3mmHg/s.
•Note at what pressure the heart sounds start (systolic pressure) and when thy stop (diastolic pressure)

Usually, especially in patients unused to have their BP measured, their BP could be artificially high.
This is called “White Coat Syndrome” and is due to their anxiety, so take repeat measurements and try
to keep the patient calm.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                       46
Section 6,
The Abdominal Exam.
(1st Yr, FNM)


Set the patient reclining.

Hands

•Look and feel for Dupuytren’s contracture.
•Look at the nails for clubbing, leuconychia, and koilonychia.
•Check for a liver flap and feel the radial pulse.

Face

•Look in the eyes for pallor and jaundice.
•Look in the mouth for ulcers, candida, and signs of anaemia (angular stomatitis and glossitis).

Neck

•Look for the jugular venous pulse.
•Feel for lymphadenopathy, particulary Virchow’s node in the left supraclavicular fossa.

Chest

•Look for gynaecomastia and spider naevi.

Abdomen

         Inspection

         •Look for scars, stoma, distension, bruising, striae, and caput medusae.

         Palpation

         •Ask the patient if they have any tender areas and avoid these.
         •Perform a light palpation of all the four quadrants of the abdomen, whilst watching the
             patient’s face, feeling for tenderness, rigidity, and guarding.
         •Perform a deeper palpation for masses.
         •Palpate for the liver, co-ordinating the palpation with the patients breathing.
         •Palpate for the spleen, co-ordinating the palpation with the patients breathing.
         •Feel for an abdominal aortic aneurysm.

         Percussion

         •Percuss for the position of the liver and the spleen.
         •Percuss for shifting dullness.

         Auscultation

         •Listen for bowel sounds.
         •Listen for renal bruits.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                   47
Finishing off

•Examine the hernial orifices and the external genitalia.
•Do a rectal examination.
•Check for ankle oedema.




©2003 PDS Textbook, Benjamin Spencer
                                                            48
Section 7,
The GALS Screen.
(2nd Yr, MMB)


Initial questions

Ask patient’s level of difficulty in washing, dressing, and going up stairs.
Ask if patient has any pain, swelling, or stiffness.

Get the patient to copy you, do not move the patient, compare one side of the patient with the other.


Assess changes in Appearance and Movement in each section:

Gait

Look for:
•Smoothness and symmetry of movement.
•Gross abnormalities, e.g. kyphosis, scoliosis.
•Specific gait problems, e.g. antalgic gait.

Arms

•Look at dorsum of hands for swelling, deformity, muscle wasting.
•Patient turns hands over, look again.
•Check power and precision grips.
•Squeeze over metacarpophalangeal joints.
•Check full extension and flexion at elbow.
•Abduction and external rotation of shoulder.

Legs

•Look at legs for muscle wasting and asymmetry.
•Look at feet for deformities and swelling.
•Flexion and extension of knees, feel for crepitus.
•Check internal rotation of hips.
•Check ankle movements (dorsi/plantar flexion, inversion, eversion)
•Squeeze over metatarsophalangeal joints.

Spine

•Check lateral flexion of neck
•Place fingers on adjacent lumbar vertebrae to check movement as patient touches toes.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        49
Section 8,
The Neurological Exam.
(2nd Yr, Neuro)


Part One, The Locomotor System
Observation

           Bulk: The patient should be disrobed so you can view the limbs and trunk.
           Fasciculations: Visible twitches in a resting muscle; usually do not move the joint.
           Resting activity: Hypokinesia, Hyperkinesia, Abnormal spontaneous movements: tremor (at
           rest?, with sustained posture?, with action [intention]), chorea, .Dystonia: Sustained abnormal
           posture, but may fluctuate.

Tone

Test the neck, upper and lower extremities.
         Ask the patient to relax as you gently rotate the neck from side to side, and flex and extend it.
         Ask the patient to relax as you passively move the limb. Flex/extend at the elbows, wrists,
         knees, ankles, using smooth, gentle movements, feeling for resistance.
         Test for spasticity at the elbows, knees: Rapidly extend the elbow, or rapidly flex the knee. If
         the patient is supine, rapidly flex the knee by pulling it up from the bed, allowing it to move
         freely.

Strength

   The question to be answered when testing strength is not, "who is stronger, the patient or me?" but
rather, "is the patient's strength normal?" You must therefore adjust your expectations, depending upon
whether the patient is a child, elderly, male, female, fit, or out of shape. If you judge a patient's strength
to be abnormal, there must be a disorder affecting upper or lower motor neuron, neuromuscular
junction, or muscle.

Test strength

            Have the patient move the limb to a position where the muscle to be tested is maximally
           active.
           Have the patient attempt to maintain that position against your resistance. In order to detect
           mild weakness, you have to exert sufficient force. This will vary, depending upon the patient's
           age, sex, muscle bulk, and physical condition, but the common mistake is not to exert enough
           force, and thereby miss weakness.
           In the screening examination, sample proximal and distal muscles in upper and lower
           extremities (i.e., deltoid, wrist extensor, finger spreaders, hip flexors, knee flexors, ankle
           dorsiflexors).

The scale most neurologists use rates strength as follows:

Grade               Strength

zero                No muscle movement.
1                   Visible muscle movement, but no movement at the joint.
2                   Movement at the joint, but not against gravity.
3                   Movement against gravity, but not against added resistance.
4                   Movement against resistance, but does not attain normal strength.
5                   Normal strength.



©2003 PDS Textbook, Benjamin Spencer
                                                                                                           50
Tendon reflexes:

Position the patient so that left and right limbs are relaxed and in symmetric positions. If the patient is
seated, the hands should be resting on the thighs, and the legs should be dangling free. Instructions are
given for right-handers. Left handers should read "right" for "left."
  Biceps (C5,6)
          Position the arms so that the elbows are flexed 30-90 degrees, and relaxed
          Place your left thumb over the patient's biceps tendon, and strike your thumb with the reflex
hammer.
           Feel the response in the biceps tendon, look at the biceps muscle contract, and look for
flexion at the elbow.
          Triceps (C6,7)
          Option 1: Same position as biceps, strike the triceps tendon just above the elbow. Take care
not to strike the muscle, which ends very close the the elbow.
          Option 2: Support the abducted arm just proximal to the elbow, so the forearm is dangling,
and strike the tendon as above.
          Observe triceps muscle contraction and (if brisk) extension of the elbow.
          Knee (L2-4)
          Seated, legs dangling: Strike the patellar tendon between the patella and the tibia. Observe for
quadriceps contraction and knee extension.
          In bed: Support the patient's knee from below with one hand, be sure the quadriceps are
relaxed, and strike the patellar tendon with the hammer.
          Ankle ((L5,) S1)
          With the patient seated, place your left hand under the ball of the patient's foot and gently
dorsiflex the ankle so that the foot is at about 90 degrees to the leg. Strike the Achilles' tendon briskly
with the hammer. Observe for ankle plantarflexion.
o If the patient is in bed, cross the patient's legs, and support the foot as above, with the patient's ankle
resting on the opposite leg, and the knee flexed about 30 degrees from straight. Strike the Achilles'
tendon.

Reflexes are graded from zero (absent) to either 4 or 5 plus, as indicated in the following table.

Grade              Reflex

zero               absent
1                  hypoactive
2                  "normal"
3                  hyperactive without clonus
4u or 4            reduplicated reflex or unsustained clonus
4s or 5            sustained clonus




©2003 PDS Textbook, Benjamin Spencer
                                                                                                          51
Part Two, The Cranial Nerves
CN I (Olfactory)

         Use a non-volatile substance, such as soap. Do not use alcohol or ammonia, which will
         stimulate the fifth nerve as well.
         Have the patient occlude one nostril, close the eyes, sniff, and state whether or not they smell
         something.

CN II (Optic)

         Visual acuity
      Have patient wear glasses, or use pinhole, to correct refractive errors.
      Check with a Snellen chart at 20 feet, or a Rosenbaum chart at 14 inches.
      Test each eye separately
      Make sure the chart is well-illuminated
Give acuity as the smallest line the patient can read. For example, 20/40-2 OD, 20/20 OS means the
patient could read all but two letters on the 20/40 line with the right eye (OD), and all the letters on the
20/20 line with the left eye (OS).

          Visual fields to confrontation
  To determine the location and extent of visual field deficits from which one can infer localization of
lesions in the visual pathways [more]. Bilateral simultaneous stimulation tests for extinction as well as
for visual field deficits.
          Stand 2-3 feet in front of the patient, and hold your hands about two feet apart, exactly half-
way between you and the patient.
          Have the patient cover one eye and try to close your corresponding eye. Have the patient
fixate on your eye. Now your own visual field and that of the patient will overlap for stimuli half-way
between you.
          Be sure the patient maintains fixation on your eye. Patients who repeatedly fail to maintain
fixation may have motor impersistence.
          Make small movements with either or both fingers, and have the patient state or point to the
finger(s) you move.
Record: If the patient fails to report stimuli, map the area of visual loss by slowly moving your finger
until it becomes visible. If the patient reports stimuli in one field when the stimulus is single, but not
when another stimulus has been delivered simultaneously to the opposite visual field, record this as
extinction to double simultaneous stimulation.


Pupils (CN II and III)

         Pupil size and shape: You should note the size of the pupils (in millimeters) in room light, and
         dim light, as the patient fixes on a distant point. Note any asymmetry (anisocoria). Also note
         irregularities of pupil shape.
         Light reflex: shine a bright light obliquely into one pupil and observe the response of both
         pupils. Turn off the light to allow the pupils to recover, and then shine the light in the other
         eye. The direct and consensual responses should be equal.
         Accommodation: To test for accommodation have the patient shift gaze from a distant point to
         a point about 6 inches from the eye. The patient's own thumb is an excellent stimulus: hold it
         and move it towards the patient's eyes.

CN III (Oculomotor), IV (Trochlear), VI (Abducens)

         Pupils: (See above)
         Ptosis:
         Observe.



©2003 PDS Textbook, Benjamin Spencer
                                                                                                         52
         Interpretation: The ptosis seen with third nerve lesions can be complete, unlike the mild ptosis
seen in patients with Horner's syndrome, which rarely covers the pupil. Gradually progressive ptosis on
up-gaze suggests myasthenia gravis.
         Eye movements:
         Smooth pursuit: Hold the target (your finger) at least 2 feet from the patient's eyes, to
minimize convergence. Ask the patient to look at your finger as you move it smoothly. A + pattern of
movement assesses the extent of horizontal and lateral gaze. An "H" pattern of movement also tests
vertical movements in the four quadrants.
         Interpretation:
         Lateral movements should be full. Most patients will be able to "bury the sclera;" that is, at
extremes of horizontal gaze, one should see no sclera between the iris and the inner or outer canthi.
         Judge the extent of vertical gaze. Limited up-gaze is a normal finding in many elderly persons.
         Judge the smoothness of eye movements. Lesions affecting gaze pathways, but also lesions of
the basal ganglia and cerebellum, can result in loss of smooth pursuit. These patients make multiple
saccades or slow saccades to follow targets.



CN V (Trigeminal)

         Palpate the masseter muscles as the patient clenches the teeth, Ask the patient to open the
         mouth.
         Observe that the masseters are of equal bulk and that they both contract. Observe that the
         mandible travels vertically (normal) rather than to one side or the other (indicating pterygoid
         weakness on the side to which the jaw deviates).
         Sensory: Test light touch and pinprick in the first, second and third divisions of the trigeminal
         nerve, comparing sides.
         Corneal reflex (CN V and VII)
   Use a wisp of cotton, have the patient look to the opposite side, and gently touch the cornea with the
cotton (the sclera is not sensitive). Observe that the patient blinks both eyes (direct and consensual
response). Then test the other eye.

CN VII (Facial)

         Observe: at rest:
         Look for facial asymmetry (palpebral fissure, nasolabial fold...). Note that it is normal to have
some facial asymmetry.
         Observe spontaneous emotional expression, such as smiling or laughing or frowning.
         Test: Voluntary movement
         Compare sides, asking the patient to wrinkle the brow, squeeze the eyes shut, smile, purse the
lips.
         Assess strength on both sides by having the patient resist attempts to pry the eyes open, or to
open the lips against resistance. See if the patient can puff out the cheeks and hold air in them against
resistance.
         Interpretation:
         Unilateral weakness manifests most subtly as a lag in the movement of one side of the face as
compared with the other. With more severe weakness, there is a lag, plus diminished amplitude of
movement. Unilateral weakness can be either UMN or LMN. LMN weakness most often involves both
upper and lower facial muscles, while UMN weakness typically spares the upper face (frontalis
muscles). Emotional expression may be spared in UMN lesions. [more].
         Bilateral weakness is easily missed. A weak smile (that can look like a snarl) is a clue; eyelid
and lip closure strength must be assessed. Bilateral UMN weakness can be manifest also by
pseudobulbar palsy, and brisk jaw jerk.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                       53
CN VIII (Auditory/Vestibular)

        Exam for lateralized hearing loss If hearing is reduced on one side, do
  Weber test: Use a 512Hz or higher tuning fork applied to the forehead. Ask if the sound lateralizes,
and to which side.
        Rinne test: Use a 512Hz or higher tuning fork applied to the mastoid. When the patient can no
        longer hear the sound, hold the fork to the ear. Air conduction is better than bone conduction
        in normals, but the reverse is true with conductive (middle ear disease) hearing loss.

CN IX (Glossopharyngeal), X (Vagus)

         Observe palate movement: Look at palate with flashlight and have the patient say "Ah."
         Observe that the elevation of the two sides is symmetric. With unilateral weakness, one palatal
         arch fails to elevate as much as the other. The uvula will be pulled toward the stronger side.
         Note, however, that many people have uvula deviation at rest.
         Gag reflex: Touch the back of the throat lightly on each side and observe reflex symmetrical
         palate elevation. Both sides of the palate elevate with stimulation of either side (direct and
         consensual response). With afferent (CN IX) lesions, stimulation of one side produces less
         response than stimulation of the other side. With efferent (CN X) lesions, palate elevation is
         asymmetric.

CN XI (Accessory)

          Sternocleidomastoid (SCM) muscle
   Hold the palm of your hand against the patient's zygoma, and ask them to turn their head towards
that side against your resistance. Observe the opposite SCM muscle contract. Palpate it if it is not easily
visible. Repeat on the opposite side and compare. Test strength of neck flexion by having the patient
flex the neck against resistance (push against the patient's forehead).
          Trapezius
    Have the patient shrug the shoulders and palpate the trapezius muscles.

CN XII (Hypoglossal)

         Tongue movement: Ask the patient to protrude the tongue, Look for atrophy, fasciculations,
         and deviation. The tongue deviates toward the side of weakness. Supranuclear innervation of
         the tongue (corticobulbar pathways) is bilateral, but asymmetrical. Supranuclear lesions can
         cause mild tongue deviation, that recovers in days or weeks.
         Speech: Nerve, nuclear, or supranuclear corticobulbar lesions can cause dysarthria. In
         addition, cerebellar hemisphere lesions result in characteristic cerebellar dysarthria: an
         abnormality of speech rhythm that makes patients sound as if they are scanning poetry for the
         rhythm ("scanning speech").




©2003 PDS Textbook, Benjamin Spencer
                                                                                                        54
Part Three, Sensory Exams

Pin

        Ask if the stimulus feels sharp, and if it feels the same as a stimulus in another area (chosen
        for comparison according to your hypothesis). For example, you may be comparing right vs.
        left (brain or cord lesion), median vs. ulnar (peripheral nerve lesion), or distal vs. proximal
        (looking for polyneuropathy),
   Check reliability by occasionally using a blunt stimulus (your finger, for example). Do not waste
time checking sharp-dull discrimination at every site.

Temperature

This is not done routinely. It is reserved to situations in which it is likely to add useful information. For
example, looking for a dissociated sensory loss, a spinal level, or a Brown-Sequard syndrome.
There are several options for testing, listed in order of ease of use:

           Use your hand:
       "Does my hand feel warm or cold?"
      If the patient's skin feels cool to you, your hand should feel warm to the patient, and vice versa.

     Use two objects of different temperatures: for example, you can run one side of a tuning fork
under warm water, the other under cold water.
      Press each side to the patient's skin and ask which is warmer (or cooler).
     The patient should be able to discriminate the temperatures (if sufficiently different) in any area,
regardless of the patient's skin temperature.


Touch

         Ask the patient, "Show me where you feel your sensation is abnormal."
         Stroke the patient's skin with your finger or a piece of cotton, comparing involved and
uninvolved regions, and defining the limits of the deficit. "Tell me if this feels normal or not" is
preferable to "tell me where it is numb," since the abnormal area may feel more sensitive than normal.

         Light touch threshold:
         "Close your eyes"
         "Say 'yes' when you feel me touch you
         Touch the patient very lightly, and note areas where the patient fails to respond. Test different
regions depending upon your hypothesis.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                            55
                                  Evaluating Evidence




©2003 PDS Textbook, Benjamin Spencer
                                                        56
 Section 1,
 Evaluating Diagnostic Tests.
 (1st Yr, FHD)



 Sensitivity and Specificity


 No test is perfect, as such each test performed has an intrinsic level of error. A diagnostic test must be
 evaluated so that the practitioner can understand the likelihood that the test is giving good or bogus
 information. Tests are evaluated against a so called “Gold Standard”, a test which for the sake of the
 evaluation we assume is giving the correct information. This “gold standard” could simply be if the
 predictive results of a test manifest themselves (a patient tested for ‘flu going on to develop it), or a
 very detailed diagnostic agent (a patient tested for alcoholism then interview in depth by a
 psychoanalyst).

 The primary evaluation of a test is to measure its specificity and sensitivity, this is calculated by
 comparison with the gold standard as shown below:


                              Gold Standard +ve (PatientsGold Standard –ve            Total
                              who     actually have   the(Patients who don’t actually
                              condition)                 have the condition)
Test +ve
(Patients diagnosed for the                 36                               14                    50
condition)
Test –ve
(Patients    diagnosed      as              4                                46                    50
negative for the condition)
Total                                       40                               60                    100

 Here we are comparing a test with the “gold standard”, as can be seen the test diagnoses 36 people with
 the condition who actually have it, but 14 as having the condition who do not and so on.

                   N° of patients with the condition who have a postive test result
 Sensitivit y =                                                                     × 100
                            Total number of patients with the condition

 In this case that would be equal to:

                   36
 Sensitivit y =       ×100 = 90 %
                   40

 This equates to the chance that a patient having the condition will be diagnosed as having the condition.

                   N ° of patients without t he condition who have a negative test result
  Specificit y =                                                                          × 100
                           Total number of patients without have the condition




 ©2003 PDS Textbook, Benjamin Spencer
                                                                                                         57
Again in this case it would be equal to:

                 46
Specificit y =      ×100 = 77 %
                 60

This equates to the chance that a patient without the condition will be diagnosed as not having the
condition.


Positive and Negative predictive values


                                       N° of patients with the condition with a positive test result
Positive Predictive Value =
                                           Total number of subjects with a postive test result




This gives a value for the proportion of those tested and being found to have the condition who actually
have the condition.



                                       N ° of patients without t he condition with a negative test result
Negative Predictive Value =
                                             Total number of subjects with a negative test result




This gives a value for the proportion of those tested and being found to have the condition who actually
have the condition.

These are very easily confused with Sensitivity and Specificity but it is important to understand that
sensitivity/specificity are measures of the diagnostic ability of the test, whereas the positive and
negative predictive values are measures of proportion of true diagnoses in those diagnosed.


Pre and Post test odds


These are used to evaluate the odds of being diagnosed with a condition initially and then after a
diagnostic test the odds of being diagnosed of having said condition.
Odds are used in the gambling circuit to a large extent and are defined as:
            Probabilit y
Odds =
          1 - Probabilit y



Pre-test odds are the odds that a person prior to diagnosis will have a particular condition, this value is
usually taken from the prevalence in the community, or GP estimations.



©2003 PDS Textbook, Benjamin Spencer
                                                                                                          58
Section 2,
Statistical Analysis.
(1st Yr, FHD)


Confidence Intervals
Upon collection of data on a certain population we assume that the data we collect is representative of
the entire population, not just to our specific sample. We accept that there must be a certain degree of
inaccuracy here, it would be very unlikely that the mean values of our sample of data and that of the
whole population are the same. We assume that we took our data reliably and without bias so the
variances between the sample and the actual population should be similar. (variance is a measure of
spread of the data).

For the sample that we collect:        Mean = x
                                       Variance = s2
Hence:                                 Standard Deviation = s
For the actual population:             Mean = µ
                                       Variance = σ2
Hence:                                 Standard Deviation = σ

At this level these values will either be given or you will be shown how to calculate them in any exam
questions.

Confidence intervals are a measure of the range of values surrounding the sample mean with which we
can have a certain degree of confidence that the population mean lies within. Out of tradition the
confidence interval usually used is 95%, and as such only this will be shown how to calculate.




Confidence Interval of Mean (95%) = x ± 1.96 × S.E.

Where:

          s
S.E. =
           n

n = The sample size


This will produce two values which     µ , the population mean, is bounded by,

− 1.96 × S.E. ≤ µ ≤ 1.96 × S.E.

Effectively, this procedure is a method of making our data sample applicable to the entire population.

The two tailed t -Test
This is a test to compare the means of two different samples of data, effectively it checks to see if the
mean of one sample lies within the confidence interval of the other. The t-test is used to check if there
is a significant difference in the means of the two data sets, experimentally this is used to compare the
affect of variables, for example the incidence of lung cancer in a sample population that smokes, and a
sample population that does not.


©2003 PDS Textbook, Benjamin Spencer
                                                                                                         59
The t-test returns a t value which is compared with a data table, the level of accuracy required is chosen
(this is the p value) and hence the level of significance can be determined.

Requirements

The t-test requires that both the two sample groups‘ data is normal (it follows a normal distribution, as
in most the values are clustered around the mean), and that they also have similar variances (the spread
of the data).

The null hypothesis

For an effective t-test a null hypothesis must be proposed that we attempt to disproved by doing the
calculation. The null hypothesis is usually that the means of the two samples are the same:

x1 = x 2

Now we have this we use the t-test equation to calculate the t-value:


t=
                     (x1 − x2 )
        (n1 − 1)s1 + (n 2 − 1)s 2 2   n1 + n 2 
                    2

                                              
                                                  
              (n1 + n2 − 2)           n1 n2 

Where:

x1 = The mean of the first sample
x 2 = The mean of the second sample
s1 = The standard deviation of the first sample
s 2 = The standard deviation of the second sample
n1 = The number of records in the first sample
n 2 = The number of records in the second sample



And the degrees of freedom are equal to:

(n1 + n2 − 2)
(It is unlikely you will be asked to calculate a t-value, for most questions it will be given)


After putting the data through the above equation, the level of significance required is chosen. As
stated before for tradition a 95% confidence in the certainty of a significant difference is usually taken,
hence our p value = 0.05 (the probability the difference in the means could have arisen purely by
chance). Using the degrees of freedom and the p value chosen the t value is looked up on the t
distribution table, returning a result. If our t value from the above equation is less than the t value from
the table then the null hypothesis is rejected, and the difference in the means of the two samples is
significant.

The reason for this test being two-tailed is to allow the diffence between the two groups to go in either
direction (negative or positive), and this is the case for most clinical trials hence it is used here.


©2003 PDS Textbook, Benjamin Spencer
                                                                                                         60
The χ2-Test
This is used to compare catagorical variables that we observe against what we expect, and again gives a
measure of its significance, comparing eye colour to colon cancer incidence for example, we expect
equal over all catagories of eye colour.

Somewhat like the t-test a χ2 value is calculated and this is compared to a data table, the equation is:

          (O − E )2
χ =Σ
  2
              E
Where:

Σ = The sum of all category‘s calculations
O = The frequency observed
E = The frequency expected
Degrees of freedom = No of catagories – 1

(For each category the frequency expected from the frequency observed, then squared, then divided by
the frequency expect. All these values are then summated obtaining the 2 value)

Again p is usally equal to 0.05, and hence the significance of the difference of the expected to observed
frequencies can be found.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                           61
Section 3,
Therapy Trials.
(1st Yr, FHD)


Double-Blinded Randomised Controlled Trial
The double-blinded randomised controlled trial is seen as the gold standard for evaluation of therapies
and there effectiveness. All therapies must be put through a trial to ensure there are no ill-effects to the
patient and that the therapy actually represents a significant increase in the wellbeing of the patient over
and above either current therapies or natural progression of the disease.

(The ethics of clinical trials are dealt with in the ethics and law section)

The clinical trial firstly involves doing background scientific research, on the basis of which a
hypothesis or hypotheses are created. A study is designed, approval gained, carried out, the data
analysed, and finally a conclusion presented.

Some elements of a clinical trial are explained below:

Control groups

A control group is used such that those undergoing the therapy can be compared to the baseline of the
condition. The control group is chosen to be similar in all respects to the study group, except they are
either given no therapy and a placebo, or standard therapy and a placebo, depending on the condition
being studied.

Randomisation

This is to reduce confounding error from the clinical trial. Confounding error is caused by inequalities
and disimilarities between the makeup or environment of the control and strudy group. By
randomising which group participants in the clinical trial are entered into the chances of counfounding
error is reduced.

Double Blinding

This is a feature of a double-blinded randomised controlled trial meant to eliminate bias. Double
blinding means that the patient is blinded as to the type of treatment they are receiving (being placebo
or theraputic agent), the doctor is blinded as to what treatment the patient gets, and the doctors noting
the outcome of the therapy are also blinded to the treatment. (these last two can be and usually are the
same person) This blinding prevents subconcious human bias on behalf of any treatment group.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                         62
Section 4,
Paper Appraisal.
(1st Yr, Circ/Breath)


Key points to remember when reading a scientific paper:

         Is the methology sound and based on scientific theory/principles
         How have they tried to eliminate bias
         How have they dealt with confounding
         Could the affects observed be due to chance
         Have they done a sound statistical analysis
         If the exposure causal to the outcome
         Does the sample group studied apply to the general population




©2003 PDS Textbook, Benjamin Spencer
                                                                            63
Section 5,
Assessing Instruments.
(2nd Yr, MMB)


Instruments used in clinical practice have three desirable properties that purport to their usefulness:

1.Validity – “It measures what it purports to measure”

This can be assessed using specificity and sensitivity measurements of diagnostic equipment, of course
a gold standard is needed to compare the instrument to.

2.Reliability – “Yields the same results on repeated trials under the same conditions”

The variation in the results can be in two conditions, when the same observer gets different results on
different occasions (intra observer variation), or two different observers get different results on the
same occasion (inter observer variation).

The kappa (κ) statistic gives us a measure of reliability on a scale of 1 = totally reliable and 0 = totally
unreliable. It is simply a measure of correlation between different measuring conditions but when that
which is being measured is a categorical and correlation cannot be used.

3.Responsiveness – “Shows when true changes have occurred”

This is measured by taking a measurement off a patient before a change and then afterwards and
compare the results.




©2003 PDS Textbook, Benjamin Spencer
                                                                                                          64
Section 6,
Evidence Based Medicince.
(2nd Yr, Neuro)


Evidence based medicine is “the conscientious, explicit and judicious use of current best evidence in
making decisions about the care of individual patients.” Basically this means taking information about
treatments from up-to-date sources of information, usually in the form of systematic reviews.

Early attempts to resolve clinical questions involved searching journals and electronic databases for
relevant studies. These were hit by publication bias, in which usually only studies with highly
significant results are published, and errors crept in due to the varying methodological qualities of the
studies and heterogeneity of the results.

A systematic review involves collecting data on a certain therapy that exists among many similar trials
and merging it all together in an attempt to produce and overall strategy for a certain therapy with a
high degree of validity and significance. The systematic review resolves the earlier problems in
evidence based medicine by:

1.Finding the relevant evidence in an unbiased manner through searches through the newer electronic
    journal databases.
2.Appraising each paper for methodological quality, and hence rejecting those that do no come to a
    certain standard.
3.Merging the results from many papers together, (meta-analysis).

The “Cochrane collaboration” collects up all these reviews and organises them so that they are easily
available, as well as commissioning new reviews it also maintains a register of all randomised
controlled trials that are in the planning stages, are being worked on, and that have been completed.
This is to make sure that the databases are devoid of publication bias. These are all placed on the
Cochrane database.

As evidence goes, systematic reviews are the best, followed by a randomised controlled trial, a normal
trial, and so on…




©2003 PDS Textbook, Benjamin Spencer
                                                                                                      65
                                   Exam Case Studies




©2003 PDS Textbook, Benjamin Spencer
                                                       66
FHD

Mr James Burns is 42 and drives a London taxi. He was born and grew up in Scotland but now lives in
Hendon with his wife and two teenage children, Joanna and Cameron. He enjoys his job although he
admits that it is very stressful at times and he works long, irregular hours. He relaxes by watching
television and playing darts at his local pub where he usually has 7 or 8 pints of beer four times a week.
Mr Burns has smoked since he was 14 and now averages 25 cigarettes a day but often wishes that he
could give up.
He considers himself to be healthy and likes to keep away from doctors - in fact he last saw his GP, Dr
Rosemary Bell, three years ago when he had a bad bout of flu. Since then he has noticed that he has
become slower at walking uphill to the shops and the pub than his friends of the same age. For the past
few months he has had pain in his right knee. These symptoms have become so bad that he now finds
driving difficult and he decides to visit his GP who examines him, makes a provisional diagnosis of
osteoarthritis and arranges for him to have his knee X-rayed.

David is an 18 year old first year medical student. He was stabbed in the chest with a dirty knife late
one night on a secluded footpath on Hampstead Heath. He was found the next morning by an early
morning jogger, who immediately summoned an ambulance. He had suffered considerable loss of
blood, and was semi-conscious and hypothermic. He was brought by the ambulance crew to Accident
and Emergency at the Royal Free Hospital.


Justin Brown, aged 15, comes into the Accident and Emergency department of his local hospital one
Saturday evening in winter with an acute attack of asthma. He had become very breathless and wheezy
whilst playing football. His father tells the senior house officer (SHO) and the medical student who is
with her, that Justin has had asthma since he was six and that he usually took a salbutamol inhaler,
which controlled his asthma. However he had been to see his GP twice recently because he had had a
cold and had been coughing up green sputum.
The SHO asks Mr. Brown if there is anyone else in the family with chest problems. Mr Brown tells him
that he himself had a heart attack last year and has been a bit breathless since then. He's arranged to see
his GP next week because he occasionally has chest pain when he walks home from work. He's been a
bit worried about this particularly as he gave up smoking and expected to feel much better after that.
While Mr Brown is telling him all this, the medical student notices Justin quietly discarding a cigarette
packet into a nearby litter bin.
After the SHO has examined Justin, Mr Brown asks the SHO what can be done to stop Justin getting
asthma attacks.

MMB

Mrs Patel is a 65 year old Muslim Asian woman. She has been in the UK for 30 years and still speaks
little English. She is just about able to manage her job with her level of language. She lives with her
husband and three children above her husband’s newspaper and confectionery shop in Crouch End. She
has had a long history of back pain. This started several years after arriving in the UK and has
continued intermittently. It tends to get worse with stress, and she has seen her GP on a number of
occasions. She eats a normal vegetarian diet that includes milk. She has a tendency to be overweight
and takes no physical exercise except for standing for long periods in the shop.
Her three children are well integrated locally and have been to local schools. Her eldest daughter has a
European-Caucasian boyfriend and is being quite defiant. Mrs Patel and her husband had hoped that
she would marry a family friend back in Pakistan. This has caused considerable strife in the household.
More recently Mrs. Patel’s back pain has become worse, such that her children have been helping in
the shop. She has lower back pain with no involvement of the legs. She has taken to staying in bed until
lunchtime. Her family is very concerned about her and arrange an appointment for her to see her GP.

Neuro

Mr Rob Smith, a 19 year old civil servant was brought into casualty having been involved in a serious
road accident. It appeared that his bicycle spun out of control and went into the path of an oncoming


©2003 PDS Textbook, Benjamin Spencer
                                                                                                          67
lorry. He was conscious for a short time in the ambulance and was able to tell the paramedics hs name
and adress. He then lost consciousness and was deeply unconscious when seen in casualty. Physical
examination and investigations indicated that he had intra-cranial bleeding and he was taken to the
operating theatre. His parents were contacted by the police and taken to hospital.
He remained unconscious for several weeks during which it was established that he had suffered
considerable brain damage. When he regained consciousness, he was unable to move his right arm and
leg and had problems with his hearing, speech and vision. It was unclear how much he was capable of
understanding, and there were serious fears about how much normal functioning he would recover.
Eventually it was decided to move him to a centre specialising in the rehabilitation of people who had
suffered brain damage. His condition improved but it became obvious that he would never be able to
work and live independently again.




©2003 PDS Textbook, Benjamin Spencer
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