An Aid to the MRCP PACES, Volume 2

Preface ix Introduction xiii Section D: History-Taking Skills 1 Station 2, History-Taking Skills 7 1 Abdominal swelling 8 2 Ankle swelling 10 3 Asymptomatic hypertension 13 4 Back pain 16 5 Breathlessness 19 6 Burning of the feet 23 7 Chest pain 26 8 Cold and painful fingers 28 9 Collapse? cause 30 10 Confusion 32 11 Cough 35 12 Diabetic feet 37 13 Difficulty in walking 40 14 Dizziness and feeling faint 43 15 Double vision 45 16 Dysphagia 48 17 Epigastric pain and nausea 50 18 Facial swelling 52 19 Funny turns 55 20 Haemoptysis 58 21 Headache 60 22 Hoarse voice 63 23 Hypercalcaemia 65 24 Hyperlipidaemia 67 25 Jaundice 70 26 Joint pains 73 27 Loin pain 76 28 Loss of weight 78 29 Lower gastrointestinal haemorrhage 80 30 Macrocytic anaemia 82 31 Neck lump 85 32 Painful shins 87 33 Painful shoulders 89 34 Palpitations 91 35 Personality change 93 36 Pins and needles 96 37 Polyuria 98 38 Pruritus 100 39 Purpuric rash 102 40 Pyrexia 104 41 Renal colic and haematuria 107 42 Tiredness 109 43 Tremor 112 44 Visual disturbances 114 45 Vomiting 117 46 Vomiting and forgetfulness 120 47 Weakness of the right arm 123 48 Weight gain 126 49 Weight loss and chronic diarrhoea 129 50 Wheeze 131 Section E: Communication Skills and Ethics 135 Station 4, Communication Skills and Ethics 145 Category 1: Informed Consent 1 Consent for a lumbar puncture 147 2 Consent for oesophagogastroduodenoscopy (OGD) 150 3 Emergency surgery under principles of ‘best interests’ 154 4 A competent patient’s refusal of treatment 157 Category 2: Diagnoses and Management Advice 5 Obesity management 160 6 Side-effects of cardiac medication 163 7 Presentation of a first seizure 166 8 Rheumatoid arthritis 169 9 Valvular heart disease in a young woman 172 10 Air travel with chronic obstructive pulmonary disease 175 11 Polypharmacy 178 12 Blood transfusion 181 13 Hormone replacement therapy 183 14 Lifestyle adjustments after a myocardial infarction 186 15 Smoking cessation 189 16 Starting insulin therapy 192 17 Refusal of analgesia 194 Category 3: General Clinical Issues 18 Human immunodeficiency virus testing 196 19 Communication of a human immunodeficiency virus-positive result 200 20 New diagnosis of tuberculosis 204 21 Non-compliance with anti-tuberculous treatment 208 22 Multidrug-resistant tuberculosis 211 23 ‘Hospital superbug’ 1 (Clostridium difficile) 215 24 ‘Hospital superbug’ 2 (methicillin-resistant Staphylococcus aureus) 219 25 Assessing suicide risk 223 26 Genetic counselling 226 27 Fitness for anaesthesia/surgery 230 28 Screening for prostate cancer 232 Category 4: Breaking Bad News 29 Malignancy in a young patient 235 30 A chronic illness 238 Category 5: Ethical and Legal Issues 31 A patient with a functional illness 240 32 Brainstem death testing and organ transplantation 243 33 Hospital postmortem 248 34 Coroner’s postmortem 253 35 Do not attempt resuscitation decisions 257 36 Withholding information from patients 262 37 Maintaining patient confidentiality 266 38 Advance care decisions 270 39 Healthcare decisions for a patient who lacks mental capacity 274 40 Care of the vulnerable adult 278 41 Blood transfusion for a Jehovah’s Witness 282 42 Eligibility for major surgery 285 43 Postponement of an investigation 287 44 Clinical error in drug administration 289 45 Fitness to drive 292 46 Limits of treatment in end-stage disease 295 47 Withdrawing treatment 298 48 Enrolling a patient in a clinical trial 301 49 Industrial Injuries Disablement Benefit 304 50 Internet therapy 306 51 Unrelated live donor transplant 309 Category 6: Dealing with Difficult Patients/Relatives 52 A patient desperate for a diagnosis 311 53 A missed tumour 315 54 An unhappy inpatient 319 55 Delay in investigation 322 56 A patient wanting to self-discharge 324 Category 7: Professional Issues and Communication with Colleagues 57 Major incident exercise 327 58 A struggling team of doctors 330 59 A colleague with hepatitis B infection 334 60 A colleague with a needlestick injury 337 61 The improper doctor 340 62 The incompetent doctor 343 63 The sick doctor 345 64 Consent for medical examination 347 65 Submitting an audit project 350 66 Treating a prisoner 353 67 A violent and abusive patient 355 68 Withdrawing treatment in intensive care 357 Section F: Experiences, Anecdotes, Tips, Quotations 359 Full PACES experiences in the first person (since2009) 367 Full PACES experiences in the first person (before2009) 389 Additional Station 2 experiences 427 Additional Station 4 experiences 431 Invigilators’ diaries – Stations 2 and 4 435 Some anecdotes from our most recent surveys 435 Experiences 437 The power and range of the candidate’s observations 439 The candidate’s examination technique 441 The clinical competence of the candidate 443 Common errors 444 Look first 444 Double pathology 445 Tell them of the expert that told you 445 Apologies accepted 445 ‘Even though I didn’t mean to say it – I did’ 446 Invigilator’s diaries 446 Fly on the wall – complete accounts 448 Ungentlemanly clinical methods 452 Miscellaneous ‘pass’ experiences 452 You never know you’ve failed until the list is published 464 Survivors of the storm 466 Some ‘fail’ experiences 470 Downward spirals 475 Anecdotes 477 Some anecdotes in the first person 480 Miscellaneous 483 Useful tips 483 Quotations 484 Adopt good bedside manners 485 Practise clinical examination and presentation 485 Get it right 486 Listen, obey and do not stray 486 One wrong does not make one fail 487 If you say less they want more 487 Humility is more persuasive than self-righteousness 487 Keep cool: agitation generates aggression 488 Simple explanations raise simple questions 488 Think straight, look smart and speak convincingly 488 You have seen it all before 489 Use your eyes first and most 489 Doing and forgetting 489 Examiners are different 489 Additional comments and quotes from candidates 490 Appendices 491 1 Website links 493 2 Abbreviations 495 Index 497