Aid to the MRCP PACES, Volume 2

Dev Banerjee Department of Medicine, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust and City Hospital, BirminghamN. Sukumar Department of Medicine, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust and City Hospital, BirminghamRobert E.J. Ryder is Consultant Physician and Clinical IT Lead at City Hospital NHS Trust, Birmingham, and Honorary Senior Lecturer in Medicine at the University of Birmingham.Dr M. Afzal Mir is Senior Lecturer and Consultant Physician at University Hospital of Wales, CardiffDr Anne Freeman is Consultant Physician at Royal Gwent Hospital, Newport, and Clinical Adviser and Chairwoman of the Welsh Stroke Alliance

• Preface ixIntroduction xiiiSection D: History-Taking Skills 1Station 2, History-Taking Skills 71 Abdominal swelling 82 Ankle swelling 103 Asymptomatic hypertension 134 Back pain 165 Breathlessness 196 Burning of the feet 237 Chest pain 268 Cold and painful fingers 289 Collapse? cause 3010 Confusion 3211 Cough 3512 Diabetic feet 3713 Difficulty in walking 4014 Dizziness and feeling faint 4315 Double vision 4516 Dysphagia 4817 Epigastric pain and nausea 5018 Facial swelling 5219 Funny turns 5520 Haemoptysis 5821 Headache 6022 Hoarse voice 6323 Hypercalcaemia 6524 Hyperlipidaemia 6725 Jaundice 7026 Joint pains 7327 Loin pain 7628 Loss of weight 7829 Lower gastrointestinal haemorrhage 8030 Macrocytic anaemia 8231 Neck lump 8532 Painful shins 8733 Painful shoulders 8934 Palpitations 9135 Personality change 9336 Pins and needles 9637 Polyuria 9838 Pruritus 10039 Purpuric rash 10240 Pyrexia 10441 Renal colic and haematuria 10742 Tiredness 10943 Tremor 11244 Visual disturbances 11445 Vomiting 11746 Vomiting and forgetfulness 12047 Weakness of the right arm 12348 Weight gain 12649 Weight loss and chronic diarrhoea 12950 Wheeze 131Section E: Communication Skills and Ethics 135Station 4, Communication Skills and Ethics 145Category 1: Informed Consent1 Consent for a lumbar puncture 1472 Consent for oesophagogastroduodenoscopy (OGD) 1503 Emergency surgery under principles of ‘best interests’ 1544 A competent patient’s refusal of treatment 157Category 2: Diagnoses and Management Advice5 Obesity management 1606 Side-effects of cardiac medication 1637 Presentation of a first seizure 1668 Rheumatoid arthritis 1699 Valvular heart disease in a young woman 17210 Air travel with chronic obstructive pulmonary disease 17511 Polypharmacy 17812 Blood transfusion 18113 Hormone replacement therapy 18314 Lifestyle adjustments after a myocardial infarction 18615 Smoking cessation 18916 Starting insulin therapy 19217 Refusal of analgesia 194Category 3: General Clinical Issues18 Human immunodeficiency virus testing 19619 Communication of a human immunodeficiency virus-positive result 20020 New diagnosis of tuberculosis 20421 Non-compliance with anti-tuberculous treatment 20822 Multidrug-resistant tuberculosis 21123 ‘Hospital superbug’ 1 (Clostridium difficile) 21524 ‘Hospital superbug’ 2 (methicillin-resistant Staphylococcus aureus) 21925 Assessing suicide risk 22326 Genetic counselling 22627 Fitness for anaesthesia/surgery 23028 Screening for prostate cancer 232Category 4: Breaking Bad News29 Malignancy in a young patient 23530 A chronic illness 238Category 5: Ethical and Legal Issues31 A patient with a functional illness 24032 Brainstem death testing and organ transplantation 24333 Hospital postmortem 24834 Coroner’s postmortem 25335 Do not attempt resuscitation decisions 25736 Withholding information from patients 26237 Maintaining patient confidentiality 26638 Advance care decisions 27039 Healthcare decisions for a patient who lacks mental capacity 27440 Care of the vulnerable adult 27841 Blood transfusion for a Jehovah’s Witness 28242 Eligibility for major surgery 28543 Postponement of an investigation 28744 Clinical error in drug administration 28945 Fitness to drive 29246 Limits of treatment in end-stage disease 29547 Withdrawing treatment 29848 Enrolling a patient in a clinical trial 30149 Industrial Injuries Disablement Benefit 30450 Internet therapy 30651 Unrelated live donor transplant 309Category 6: Dealing with Difficult Patients/Relatives52 A patient desperate for a diagnosis 31153 A missed tumour 31554 An unhappy inpatient 31955 Delay in investigation 32256 A patient wanting to self-discharge 324Category 7: Professional Issues and Communication with Colleagues57 Major incident exercise 32758 A struggling team of doctors 33059 A colleague with hepatitis B infection 33460 A colleague with a needlestick injury 33761 The improper doctor 34062 The incompetent doctor 34363 The sick doctor 34564 Consent for medical examination 34765 Submitting an audit project 35066 Treating a prisoner 35367 A violent and abusive patient 35568 Withdrawing treatment in intensive care 357Section F: Experiences, Anecdotes, Tips, Quotations 359Full PACES experiences in the first person (since2009) 367Full PACES experiences in the first person (before2009) 389Additional Station 2 experiences 427Additional Station 4 experiences 431Invigilators’ diaries – Stations 2 and 4 435Some anecdotes from our most recent surveys 435Experiences 437The power and range of the candidate’s observations 439The candidate’s examination technique 441The clinical competence of the candidate 443Common errors 444Look first 444Double pathology 445Tell them of the expert that told you 445Apologies accepted 445‘Even though I didn’t mean to say it – I did’ 446Invigilator’s diaries 446Fly on the wall – complete accounts 448Ungentlemanly clinical methods 452Miscellaneous ‘pass’ experiences 452You never know you’ve failed until the list is published 464Survivors of the storm 466Some ‘fail’ experiences 470Downward spirals 475Anecdotes 477Some anecdotes in the first person 480Miscellaneous 483Useful tips 483Quotations 484Adopt good bedside manners 485Practise clinical examination and presentation 485Get it right 486Listen, obey and do not stray 486One wrong does not make one fail 487If you say less they want more 487Humility is more persuasive than self-righteousness 487Keep cool: agitation generates aggression 488Simple explanations raise simple questions 488Think straight, look smart and speak convincingly 488You have seen it all before 489Use your eyes first and most 489Doing and forgetting 489Examiners are different 489Additional comments and quotes from candidates 490Appendices 4911 Website links 4932 Abbreviations 495Index 497