Escolar Documentos
Profissional Documentos
Cultura Documentos
peerassisted.org
Chan P, Katechia DT, Thant KZ, Adams C, Alanie O, Boyle A, Brookfield S, Connelly
L, Devine K, Dyer K, Hynd I, Kidd A, Little C, Low L, Lumsden A, Lynch L, Peiris D,
Sadler R, Syeda S, Tindell A.
Contents
Breast examination
Cerebellar examination
Cranial nerves III-VII
Fundoscopy
Intramuscular injection
Intravenous cannulation
Neck examination
Otoscopy and free-field voice test
Peripheral arterial examination
Suturing
Visual acuity testing
Digital rectal examination
History: Assessing suicide risk
History: Chest pain
History: Dysphagia
History: Falls and palpitations
History: Giving information Colonoscopy
History: Haematuria
History: Headache
History: Hyperthyroidism (thyrotoxicosis)
History: Jaundice
History: Rectal bleeding
History: Shortness of breath
rd
Breast examination
Instructions:
Time:
Task
Marks
1.
Introduces self and checks identity by asking full name and date of birth.
2.
3.
Offers chaperone.
4.
INSPECTION
5.
6.
7.
8.
9.
Inspects breasts with patient pushing down on bed or hips and comments on any
dimpling (tethering).
Comments on:
1.
2.
3.
4.
5.
6.
Symmetry.
Skin changes (e.g. peau dorange).
Lumps.
Scars.
Nipple changes (e.g. inversion, Pagets disease).
Nipple discharge.
mark for each.
PALPATION
10.
Positions patient lying flat with hands behind head and asks if tender anywhere.
11.
12.
13.
Up to 3 marks available.
14.
SUMMARY
15.
16.
rd
Breast examination
Written in April 2011 by Andrew Boyle and Alistair Tindell.
Site (e.g. mass in the upper inner quadrant of the left breast).
Overlying Skin (Colour? Punctum? Discharge?)
Size.
Shape.
Consistency.
Surface (craggy/smooth).
Temperature.
Tenderness.
Fluctuance.
Tethering to skin.
Transillumination.
Triple Assessment
(very likely to be asked this, good to know for OSCE and clinical attachments):
Under 35y:
1. History and examination.
2. Ultrasound (+ mammography if >35yrs).
3. Fine needle aspiration (faster, only shows cells) or core biopsy (shows structure).
For distant disease, further investigations are needed to detect metastases (e.g. LFTs, CT, skeletal survey).
Staging
Nottingham Prognostic Index (tumour size, tumour grade, lymph node status).
Sentinel node biopsy
Identifies draining lymph node during surgery. Injection of blue dye into tissue shows which lymph node drains the
area first by this lymph node turning blue first. This lymph node is then removed for pathological assessment for
cancerous cells during the surgery. If positive, axillary node clearance will be performed. If negative, no further
removal of lymph nodes is required.
Treatment
MDT, including breast care nurses, radiologists, oncologists, pathologists
Combination of:
Chemotherapy.
Radiotherapy.
rd
Cerebellar examination
Instructions:
Time:
Task
Marks
1.
2.
GENERAL
3.
4.
5.
Observes patients gait (including transfer from sitting to standing and vice-versa).
6.
EYES
7.
8.
9.
10.
11.
12.
13.
Asks patient to stretch out arms then observes for postural tremor. (Pronator drift in
stroke).
14.
LOWER LIMBS
15.
16.
17.
Tests for dysdiadochokinesis of feet by asking patient to tap on the floor quickly.
18.
SUMMARY
19.
20.
rd
Cerebellar examination
Written in April 2011 by Kristyn Dyer and Lauren Connelly.
Introduction
The cerebellum is the largest part of the hindbrain and is mainly responsible for functional movement. This means coordination of motor to effect precise and accurately timed movement. The cerebellum does this by integrating sensory
information from the cerebral cortex, basal ganglia, vestibular apparatus and spinal cord, to fine tune motor output.
Lesions can affect the cerebellum itself, input pathways from other parts of the brain and inner ear, or output
pathways from the cerebellum.
A patient with cerebellar dysfunction will typically present with difficulties with motor function, including weakness,
loss of power, and a new or worsening tremor. Other symptoms may include dizziness (exclude inner ear pathology),
and changes in speech.
Common Pathologies causing Cerebellar Dysfunction:
Cerebellar signs
Gait
Eyes
Speech
Upper limbs
Lower limbs
Body
Rombergs test
Rombergs test is positive in sensory ataxia and negative in cerebellar ataxia. It is not a test of
cerebellar function, as patients with cerebellar ataxia tend to have difficulty standing steady even with
their eyes open. It can be used to exclude sensory ataxia in a cerebellar examination.
To perform Rombergs test, ask the patient to stand with feet together and eyes closed, then observe
for 1 minute. Be prepared to catch them. The test is positive if the patient starts swaying.
D
A
S
H
I
N
G
nd
Essential Neurology, Wilkinson IMS, 1993, 2 edition, Blackwell Scientific Publications, p. 114.
Macleods Clinical Examination.
Oxford Handbook of Clinical Examination and Practical Skills.
rd
Task
Marks
1.
2.
Explains procedure, obtains consent and washes hands before and after examination.
CN III, IV, VI
3.
Inspects for ptosis, strabismus and pupillary size, shape & regularity.
Tests light reflex.
4.
i.
ii.
5.
6.
7.
8.
CN V SENSORY
i. Ophthalmic branch.
ii. Maxillary branch.
iii. Mandibular branch.
CN V MOTOR
10.
11.
12.
13.
CN VII MOTOR
14.
15.
16.
17.
18.
19.
20.
rd
Inspection
Inspection of the face can include looking for facial weakness, asymmetry and any involuntary movements.
Inspection of the eyes includes looking at the pupils, eyelids for ptosis and eyes for nystagmus.
Pupillary Responses
Pupil responses are afferent via CN II and efferent via CN III and are often considered part of CN II examination but
included here for completeness. Direct (same eye) and indirect (opposite eye) pupillary responses to light should be
assessed. When focusing from a distant to a close object pupils should converge and constrict.
Eye Movements
Start by asking the patient to look at your finger, asking if they have any double vision (diplopia) and looking for
nystagmus. If they do have diplopia, ask whether it is vertical or horizontal. Then trace out an H pattern, looking for
nystagmus or ophthalmoplegia and asking the patient to report any double vision. In identifying the lesion it helps to
remember which nerves supply which extra-ocular muscle.
Jaw Jerk
Not routinely tested. Place one finger in the centre of the jaw and gently strike your
finger with a tendon hammer. It is normally absent or a slight, brisk contraction of the
masseter may suggest an upper motor neurone lesion. The jaw jerk is both afferent and
efferent via the trigeminal nerve.
Corneal Reflex
Not routinely tested. Use a wisp of cotton wool to stimulate the lower outer quadrant of the cornea. This should cause
direct and consensual blinking. The corneal reflex is afferent via CN V and efferent via CN VII.
Facial Movements
Ask the patient to raise eyebrows/wrinkle forehead, and show their teeth. Test power by resisting screwing up eyelids
and puffing out cheeks. You can also test taste to the anterior tongue, lacrimation and hearing.
rd
Cranial Nerve
Normal function
CN III (oculomotor)
Ptosis.
CN IV (trochlear)
Cranial Nerve
Normal function
CN V (trigeminal)
Motor:
Supplies muscles of Mastication
(Masseter, & teMporal).
CN VI (abducens)
Tip: Think Ms
Sensory:
Afferent limb of corneal reflex.
rd
Cranial Nerve
Normal function
CN VII (facial)
Motor:
Facial asymmetry.
i. Frontalis
(receives bilateral UMN
innervation)
Sensory:
Chorda tympani, which receives
sensation from the anterior twothirds of tongue.
st
Chan P, Thant KZ, Katechia DT. PALI Clinical Years Companion, 1 Ed.
th
Douglas G, Nicol F, Robertson C. Macleods Clinical Examination, 11 Ed. Elsevier 2005, p249-259.
th
Talley NJ, OConnor S. Clinical Examination: A Systematic Guide to Physical Diagnosis, 6 Ed. Elsevier
2009.
rd
Fundoscopy
Instructions:
Time:
Task
Marks
1.
2.
3.
Explains procedure and gains consent. Warns about bright light, that it might be
uncomfortable and that you will turn off the lights.
4.
Explains that ideally, would have instilled dilating drops 10-15 minutes beforehand.
5.
6.
7.
8.
9.
Explains to patient to focus on a spot in the distance and warns about coming in close
to them.
10.
11.
12.
13.
Follows the four blood vessel arcades, and comments on appearance: tortuosity,
microaneurysms, A-V nipping.
Comments on appearance of periphery of fundus (nasal + temporal to disc):
haemorrhages, exudates, new vessels, photocoagulation scars, cotton wool spots.
14.
15.
16.
17.
Summarises findings.
18.
19.
20.
rd
Fundoscopy
Written in April 2011 by Andrew Lumsden and Sarah Syeda.
Tips on using the direct ophthalmoscope
Use the same eye as the patients eye youre examining and use the same hand, e.g. when examining the
patients right eye, use your right eye and hold the ophthalmoscope in your right hand.
Use the other hand to stabilise your head and lift the patients lid if needed.
Adjust the power of the lens to minus (myopic) direction until the fundus is in view.
Red reflex should appear red. Any opacities (they look like shadows) indicate e.g. cataracts.
Optic disc
1. Cup-disc ratio
0.3-0.5 = normal.
>0.5 = glaucoma.
No cup visible = papilloedema.
2. Colour
Pink = normal.
Pale = optic atrophy.
3. Margin
Non-proliferative
o Dot + blot haemorrhages.
o Hard exudates.
o Microaneurysms.
o Cotton wool spots (pre-proliferative).
Proliferative includes the above +
o New vessels, classified as:
a. NV at disc.
b. NV elsewhere.
Photocoagulation scars may be visible in the periphery (they look like black/white burns).
A-V nipping: arteries nip the veins where they cross. You may see the vein bulge adjacent to site of nipping.
Flame haemorrhages.
Cotton wool spots.
Exudates.
Optic disc swelling.
Microaneurysms.
3. Papilloedema
Optic disc swelling (disc margins indistinct). Most commonly due to ICP. May also be due to papillitis due to
optic neuritis.
4. Optic atrophy
Pale optic disc. May be due to optic neuritis, glaucoma, ischaemic/toxic optic neuropathy.
th
rd
Intramuscular injection
Instructions:
Time:
Draw up and administer medication via intramuscular injection to the mid-deltoid model.
You must choose an appropriate injection site, appropriate needle and use the Kardex.
5 minutes.
Task
Marks
1.
Introduces self and checks identity by asking full name and date of birth.
2.
3.
Washes hands before and after procedure and puts on appropriate protective
clothing.
4.
5.
6.
7.
8.
Gathers equipment: gloves, alcohol wipe, syringe, 21G needle, 23G needle, drug vial,
sharps box; and puts on gloves.
9.
Selects drug in the appropriate volume and dosage, and checks expiry date.
10.
11.
12.
Draws up the appropriate volume of drug required (1ml) with a 21G needle and then
disposes of needle safely.
Selects appropriate gauge (23G) and length of needle for the preferred site of
injection.
13.
14.
Warns the patient, and then pulls skin to one side (Z-track technique) and introduces
needle at 90 with a firm darting motion, penetrating with 2/3 of the needle.
15.
16.
17.
Aspirates (over 5-10 seconds) to ensure needle has not entered a blood vessel, and
injects slowly at a rate of 1ml/10s, if no blood is seen on aspiration.
Withdraws needle, immediately releases retracted skin and applies pressure with
cotton wool ball.
18.
Disposes of needle safely, and places other material in a clinical waste bin.
19.
20.
rd
Intramuscular injection
Written in April 2011 by Philip Chan and Kyaw Zayar Thant.
Intramuscular injections
IM injections are given into well-perfused muscles. The rate of absorption is faster than subcutaneous injection but
slower than intravenous administration. Indications for IM injection include delivering vaccines.
Five rights right patient, right drug, right dose, right route, right time.
Five sites
Mid-deltoid
Administer at hip.
Dorsogluteal
The site used is influenced by age, patient health, muscle bulk and type of medication being injected. Care must be
taken to avoid neurovascular structures.
Size of needle
The size (gauge and length) of needle used depends on the injection site, muscle mass, amount of subcutaneous fat
at the site and the weight of the patient. Needles commonly used are 21-23G and 2.5-5.0cm in length. Always consult
hospital local guidelines.
Z-track technique
The skin over the injection site is pulled to the side before the needle is introduced. When the needle is withdrawn,
the skin is released immediately afterwards. This technique ensures that the medication is trapped in the region that it
is required, reducing leakage. The online resource produced by the University of Nottingham gives a good visual
explanation of this (see link below). The Z-track technique is considered best practice.
After the procedure, do not massage the injection site as this causes leakage and local irritation. However, light
exercise or stretching of the muscle may help increase absorption of the medication.
Robb AJP. Intramuscular and subcutaneous injection techniques (presentation). Available from: Glasgow
University VALE clinical skills website.
Williams J, Harling M, Hardy C. Intramuscular injection by the Z-track technique (online resource). Available
from: http://www.nottingham.ac.uk/nmp/sonet/rlos/placs/nctl176_ztrack/index.html
Early D. Intramuscular injection technique. Video podcast. Available from: Glasgow University VALE clinical
skills website. (This is a really good video).
rd
Intravenous cannulation
Instructions:
Time:
Task
Marks
1.
2.
3.
4.
5.
6.
7.
Puts on gloves.
8.
9.
10.
11.
12.
Releases tourniquet.
13.
14.
15.
Flushes cannula.
16.
17.
18.
Comments on need to document insertion and ensure regular review of cannula sites.
19.
20.
rd
Intravenous cannulation
Written in April 2011 by Dilane Peiris and Lucy Lynch.
Introduction
Cannulation or intravenous (IV) access is the bread and butter of junior doctors clinical skills. Indications for a
patient to have IV access, includes:
However, patients are often left with cannulas in-situ for days, placing them at risk of local infection, thrombophlebitis
and sepsis. It is thus essential to have the skill to place a cannula, and review them frequently.
Equipment
Prepare a small tray with:
Gloves.
Cannula (appropriate size depending on indication).
Adhesive cannula dressing.
Alcohol skin wipe or chlorhexidine spray.
Gauze.
5 mL syringe.
5 mL normal saline (check expiry date).
Sharps bin.
Procedure
Clean up and dispose items in the appropriate receptacles (sharps bins and clinical waste bins).
Ensure that the patient is comfortable.
Thank the patient, wash your hands and document the insertion.
rd
Neck examination
Instructions:
Time:
Task
Marks
1.
2.
3.
4.
5.
6.
7.
8.
9.
Up to 3 marks available.
10.
11.
12.
Auscultates thyroid for bruits, after asking patient to hold their breath.
13.
Up to 2 marks available.
14.
15.
16.
17.
rd
Neck examination
Written in April 2011 by Caroline Little and Rebecca Sadler.
1. Submental.
2. Submandibular.
3. Parotid.
4.
5.
6.
7. Supraclavicular fossa.
8. Posterior triangle (also known as accessory chain).
(1)
http://www.droid.cuhk.edu.hk/web/specials/lymph_nodes/lymph_nodes.htm
http://www.firstinmedicine.com/summarysheets_files/ent.html
rd
Examine this patients right ear and assess his/her hearing using a free-field voice test.
5 minutes.
Task
1.
2.
3.
4.
5.
Marks
Washes hands at start and end, introduction, checks identity, explains procedure and
gains consent.
Examines external ear for scars, skin tags, tophi, sinuses, discharge, erythema,
swelling.
Selects otoscope and selects appropriate speculum.
Uses appropriate technique: Gently pulls pinna up and back, holds otoscope like a
pen, with right hand for right ear (or left hand for left ear).
Uses appropriate technique: Ulnar border of hand resting gently against patients
face.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Selects ear to test and reaches hand behind patients head to block other ear. Rubs
ear to create noise during test.
Begins with whisper at arms length, then moves to 6 inches beside patient if needed.
Then normal voice at arms length, then moves to 6 inches beside patient if needed.
Up to 2 marks available.
Repeats free-field voice test on other ear.
15.
Up to 2 marks available.
16.
17.
18.
rd
Alberti P. The anatomy and physiology of the ear and hearing. Available from:
http://www.who.int/occupational_health/publications/noise2.pdf
Hawke M, Keene M, Alberti PW. Clinical otoscopy: an introduction to ear disease. 2nd ed. Edinburgh:
Churchill Livingstone; 1990.
Swan, Ian R C. Examination of the Ear (video). Available from: Glasgow University VALE clinical skills
website.
rd
Examine this patients lower limb pulses, and suggest appropriate subsequent
investigations.
5 minutes.
Task
Marks
1.
Introduces self.
2.
3.
Explains examination.
4.
Gains consent.
5.
6.
Inspects legs, commenting on colour, scars, trophic skin changes and tissue loss
(ulceration/gangrene).
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
rd
General inspection
It is good practice in any examination to take a step back and make some general observations about the patient.
Abdominal Aortic Aneurysm
This is detected as a pulsatile and expansile mass found above the level of the umbilicus (the aorta bifurcates here).
To demonstrate this, place one hand on either side of the pulsation if it is expansile, your hands will be seen to
move apart in time with the pulse. A mass that is pulsatile but not expansile may only be transmitting a pulse
underneath it, and it is normal to palpate a pulse in thin subjects.
Anatomical Landmarks for Lower Limb Pulses
1.
2.
3.
4.
Dorsalis pedis lateral to extensor hallucis longus tendon on dorsum of foot. It is a common mistake to aim
too low on the foot, and be sure to palpate gently or you may occlude a weak pulse.
Posterior tibial in the groove between the Achilles tendon and medial malleolus.
Popliteal in popliteal fossa. Palpate bimanually with patients leg relaxed and slightly flexed at knee.
Difficult to feel! Consider a popliteal aneurysm if easily felt. Remember that if you have already managed to
feel the lower pulses, it should be in there!
Femoral the femoral pulse is located at the mid-inguinal point halfway between the anterior superior
iliac spine and the pubic symphysis. It is good exam practice to demonstrate locating these landmarks in
order to pinpoint the femoral pulse.
Ulcers
Remember to look between the patients toes for ulceration and necrosis, and lift their heels off the bed to perform a
thorough inspection.
A venous ulcer is typically in the gaiter area over the medial malleolus. There may also be other signs of high
venous pressure (usually due to varicose veins or previous DVT). These include haemosiderin deposition (a reddish
brown stain to the legs), oedema, lipodermatosclerosis, and varicose veins.
An arterial ulcer has typically a punched out appearance with some areas of necrosis and is more likely to be
painful.
A neuropathic ulcer is a painless ulcer occurring on pressure areas, e.g. the heel they are often surrounded by
callous. Diabetic patients can present with neuropathic ulcers, although in practice may be a mixed aetiology (arterial
and neuropathic).
Buergers Test
With patient lying supine, elevate both legs at the same time to approximately 45. Observe for onset of pallor in the
soles of the feet. The smaller the angle raised at which this occurs, the more severe the ischaemia (the angle at
which pallor occurs is termed Buergers angle). Then swing the patients legs round so they are hanging off the side
of the bed and observe for reactive hyperaemia (the foot turns purplish). Pallor on elevation followed by rubor on
dependency is a positive Buergers test.
Gilmour D. Peripheral Arterial Examination: Abdomen and Lower Limbs (video). Available from: Glasgow
University VALE clinical skills website.
ACE the OSCE (a good resource you can purchase online, helpful before finals).
MacLeods Clinical Examination.
rd
Suturing
Instructions:
Time:
Reappose the wound aseptically using the suturing equipment provided. Treat the model
as you would a real patient.
5 minutes.
Task
Marks
1.
2.
3.
4.
5.
6.
Uses the no touch technique to open the equipment. Check the expiry date of the
suture.
7.
8.
9.
10.
11.
2 marks awarded.
12.
13.
14.
15.
16.
17.
18.
States a desire to document procedure details into the patients medical notes.
19.
Total marks:______ / 20
rd
Suturing
Written in April 2011 by Devvrat T. Katechia and Omer Alanie
Suturing
The very first thing to mention about this station is that only 2 marks out of the 20 are actually awarded for the
suturing technique, so it is important not to get too disheartened if in the exam your suture is not exactly symmetrical.
The objective of suturing the skin is to approximate, oppose and evert the wound edges, thereby reducing the risk of
infection, promoting wound healing and providing a better cosmetic outcome.
Communicate with the patient very clearly what you are going to do and the fact that it should not be too painful.
It is important to maintain a sterile environment when suturing a wound and for the purposes of the exam I would
advise stating this out aloud.
Before suturing the wound it is best to prepare the trolley with the equipment that you require, namely: sterile gloves,
tooth forceps, sutures, needle holder, suture scissors, antiseptic for cleaning the wound, local anaesthetic and a
syringe. In the exam this may all be laid out for you.
With regard to the local anaesthetic, it is always best to check the details of the anaesthetic prior to injecting. State
the name of what youre injecting and the expiry date of it to the examiner. Allow sufficient time for the anaesthetic to
act and in the exam once you state this, the examiner may just ask you to proceed.
Suturing technique
Suture thread
Needle point
Needle body
Mounting the needle: Insert your thumb and ring finger inside the needle holder. Pick
up the suture 1/3 along the needle body from the suture thread attachment (known as
swage). If you hold the suture needle at the tip then this will damage the needle and
therefore it will not pierce the skin as effectively. If you need to manoeuvre the needle,
use the forceps and not your fingers!
Suture placement: Hold the skin edge using forceps and insert the needle
approximately 5mm from the wound edge. Penetrate the skin with the needle at a 90
angle. This will ensure symmetrical wound closure. Pull the needle through using
forceps and allow sufficient suture material to tie a knot.
Knot tying: Use the needle holder to hold the short piece of thread. The short end of
the suture is then grasped with the tip of the needle holder and pulled through the loops
of the long end by crossing the hands, such that the 2 ends of the suture material are
situated on opposite sides of the suture line. Repeat the process by rotating the long
end once and pulling through, then pulling the short end and again crossing your arms
This is a simple interrupted suture.
Do not pull the suture too hard as this will place tension on the suture and this will impair wound healing due to tissue
strangulation and wound oedema. Leave sufficient thread when cutting the suture to allow easier removal at a later
date
Finally it is essential to dispose of the sharps accordingly.
Document the site of the wound closure, date, suture material used and the type of knot used in the medical notes.
Aseptic skin closure. Clinical and communication skills OSCE assessment unit. Available from: Glasgow
University VALE clinical skills website.
Wiggan JM. Suturing techniques. Available from: http://emedicine.medscape.com.
Cyberwapx. Surgery simple interrupted suturing wound. Available from:
http://www.youtube.com/watch?v=PFQ5-tquFqY
rd
Task
Marks
1.
2.
3.
4.
Asks if patient wears corrective lenses for distance and if so, asks them to wear them.
5.
Asks patient to cover eye that is not being tested each time.
6.
7.
8.
Uses pinhole on left eye and indicates if improves (indicating a refractive error).
9.
10.
11.
12.
Asks if patient wears corrective lenses for reading and if so, asks them to wear them.
13.
Asks patient to cover eye that is not being tested each time.
14.
15.
16.
17.
18.
Summarises findings.
19.
20.
rd
A. Snellen chart
Snellen charts are used to test a patients distance vision.
Preparation
The patient should sit 6 metres away from the Snellen chart, however, often they will sit at 3 metres and look at a 3
metre chart through a mirror. The patient should be asked to wear spectacles or contact lenses for the test, if they
require them.
Assessing and recording vision
Each eye is tested individually by covering one eye at a time and getting the patient to read from the largest letter to
the smallest line they can read. This is repeated for the other eye, and the results are recorded as follows:
Distance from chart / Smallest line read (e.g. Left eye 6/18, Right eye 6/9.)
The number system on the Snellen chart (60, 36, 24, 18, 12, 9, 6, etc.) refers to the distance at which someone with
normal vision could read the line.
If a patient gets some of the letters on a line correct, this should be recorded as:
Distance from chart / Smallest line read with some mistakes MINUS the number of incorrect letters
or
Distance from chart / Smallest line with all letters correct PLUS the number of correct letters on the
smaller line.
For example, a patient correctly identifies four letters out of five on the 12 line could be recorded as:
6/12 1 or 6/18 + 4.
A pinhole should be used and each eye reassessed. If visual acuity improves, this suggests there is a refractive error.
If a patient is unable to read any of the letters, they should be moved closer to the chart (1 metre at a time until they
are 1 metre away from chart). If they are still unable to read any of the letters, the following should be attempted:
Normal vision is 6/6. Partially sighted is between 6/60 and 3/60. Blindness is below 3/60.
rd
Task
Marks
1.
Washes hands at start and end, introduction, checks identity, explains procedure and
gains consent.
2.
3.
4.
Wears gloves.
5.
6.
7.
8.
Tells the patient that they are now going to insert their finger and that they may feel
like their bowels are about to move.
9.
10.
11.
12.
13.
Palpates in sequence: the right lateral, posterior, and left lateral surfaces.
14.
15.
16.
Turns the hand so that the finger can examine the anterior surface and prostate
gland.
Notifies patient they are going to feel the prostate gland and that it may feel like they
are going to urinate but they will not.
Palpates lateral lobes and median sulcus of the prostate. Comments on the size,
shape, and consistency of the prostate.
17.
Withdraws finger and examines finger for faeces, blood and mucus.
18.
19.
20.
rd
Position
The patient should be positioned on the left hand side with his buttocks close to the edge of the examining table. Ask
the patient to draw their knees up to their chest.
Inspection
Comment on the presence of any lumps, ulcers, inflammation, rashes, excoriations and skin tags.
As the patient strains down, observe for the presence of any haemorrhoids.
Palpation
It is always best to warn the patient before you insert a finger up their anus.
As you insert your index finger, look at the patient for any signs of tenderness or pain. If the patient complains of
severe pain this may indicate the presence of an anal fissure.
Oxford Handbook of Clinical Examination and Practical Skills by James Thomas and Tanya Monaghan.
rd
Assess the suicide risk of this 25-year-old patient who has presented to A&E with an
overdose.
5 minutes.
Task
Marks
1.
2.
3.
4.
5.
6.
7.
Establishes whether final acts were taken (e.g. suicide note, leaving a will).
8.
Asks if it was the patients intention to die or asks if they sought help after the attempt.
9.
Asks whether the patient regrets being alive and if they still have suicidal ideations.
10.
11.
12.
Asks about major life events (e.g. being abused as a child, broken relationships) and
previous episodes of self-harm and/or suicide attempts).
13.
14.
15.
Family history.
16.
Social history.
17.
18.
Actors assessment. Marks are awarded for putting the patient at ease, employing an
empathic approach, using silences to give the patient space, having appropriate body
language, etc.
Up to 3 marks available.
rd
Male gender.
Age.
Previous suicide attempt or self-harm.
Psychiatric illness.
Hopelessness.
Social isolation.
Low socio-economic status.
Unemployment.
Alcoholism and drug abuse.
Major life events, e.g. difficult childhood.
Do not be put off if the actor does not respond to your questions. Allow enough silence for them to
reflect, but dont forget that you have a long list of questions to get through in five minutes, so just keep
asking. The examiner will give you the marks even if they dont answer.
The actor will often not make eye contact with you throughout the entire interview.
A lot of marks will be allocated for actors assessment, and so it is important that you use good
communication skills, e.g. showing empathy, using appropriate body language, leaning in to speak to the
patient, allowing silences, speaking at the appropriate volume.
It is unrealistic to expect you to take a full psychiatric history and perform a full mental state examination in a
five-minute OSCE station. However, this is what would be expected in a real life scenario.
Full psychiatric history taking and the mental state examination will be taught in more detail during your
psychiatry block in your clinical years.
Drug overdose is one of the most common A&E presentations and so suicide risk assessment is an
important skill that you must learn.
Suicide risk assessment and threats of suicide. Patient UK. Available from:
http://www.patient.co.uk/doctor/Suicide-Risk-Assessment-and-Threats-of-Suicide.htm
th
Harrison P, Geddes J, Sharpe M. Psychiatry (Lecture Notes series), 10 Ed. (The best and only book you
need for psychiatry for finals, in my humble opinion.)
rd
Take a focussed history of a 60-year-old patient who presented with chest pain.
5 minutes.
Task
Marks
1.
2.
Site of pain.
3.
Radiation of pain.
4.
Character of pain.
5.
6.
7.
8.
Severity of pain.
9.
10.
11.
12.
Asks about:
13.
14.
15.
16.
17.
18.
Total marks:______ / 20
rd
1.
2.
3.
4.
5.
6.
7.
8.
Cardiovascular
Acute coronary syndrome (STEMI, NSTEMI, unstable angina)
Middle aged/elderly patient with central, crushing/tight chest pain, radiating to either both arms neck/jaw.
Pain is sudden onset while patient is at rest, not relieved by GTN, antacids or resting and lasts more than
just a few mins. (cf. stable angina, which is pain on exertion, relieved by rest/GTN; lasting a few mins). May
have associated breathlessness, nausea/vomiting, sweating and sense of impending doom. Typically,
there is history of angina, MI, stroke, intermittent claudication and other cardiovascular risk factors (diabetes,
hypertension, hyperlipidaemia, smoking, alcohol excess, family history).
Aortic dissection
Severe, tearing chest pain, located centrally or to one side, radiating to the back. May have a difference in
blood pressure and radio-radial delay between the arms.
Pericarditis
Central, sharp chest pain which may radiate to the left shoulder or neck, exacerbated by lying down,
respiration or movement and relieved by leaning forward or use of NSAIDs. Mainly occur in patients post-MI.
Respiratory
Pulmonary embolism
Presentation of PE can be varied and difficult to diagnose. Typically, history of sudden onset shortness of
breath, pleuritic chest pain haemoptysis in someone with a hot, swollen, tender calves (DVT) or other
risk factors for blood clots (surgery, malignancy, pregnancy, period of immobility)
Pneumothorax
Sudden onset of pleuritic chest pain with breathlessness.
GI
Oesophagitis/GORD
Central, burning chest pain with no radiation, precipitated by heavy meals or bending down, e.g. to touch
his toes, relieved by antacids. May have associated waterbrash, acid brash.
Oesophageal spasm
Oesophageal spasm can mimic angina closely; i.e. central crushing chest pain, which may radiate to the
neck or upper arms, brought on by exercise and relieved by GTN. However, the pain may show relation to
meals and be accompanied by transient dysphagia and symptoms of GORD.
Musculoskeletal pain
Pain is variable. Pain which varies with posture and movement of upper body, local tenderness over
rib/cartilage are clues to musculoskeletal pain.
You must exclude the following diagnoses in all cases as they are potentially fatal and need immediate Rx:
1.
2.
3.
4.
Key investigations
1.
2.
3.
12 lead ECG.
Chest X-ray.
Blood tests: FBC, U&E, LFT, CRP, glucose, lipids, admission and 12 hour troponin.
st
Colledge NR et al. Davidsons principles and practice of medicine. 21 ed. Edinburgh; Elsevier: 2010.
Farne H, Norris-Cervetto E, Warbrick-Smith J. Oxford Cases in Medicine and Surgery. Oxford; Oxford
University Press: 2010.
rd
History: Dysphagia
Instructions:
Time:
Take a focussed history of a 65-year-old patient who presents with difficulty swallowing.
5 minutes.
Task
Marks
1.
Washes hands at start and end, introduction, checks identity, gains consent.
2.
Clarifies patients symptoms and position where patient feels things are sticking.
3.
4.
5.
6.
Pain on swallowing.
7.
8.
2 marks available.
9.
10.
3 marks available.
11.
Past medical history (must ask about GORD, peptic ulcer disease, previous
malignancy).
12.
Drug history (must ask about NSAIDs, indigestion tablets) and allergies.
13.
Family history.
14.
15.
16.
2 marks available.
Mark for excellence.
rd
History: Dysphagia
Written in April 2011 by Devvrat T. Katechia.
Dysphagia
Dysphagia is a difficulty in swallowing. It is important to clarify what a patient means when they say they have a
swallowing difficulty. Painful swallowing is known as odynophagia, which can be due to malignancy but more
commonly due to an infection such as candidiasis. Globus describes the sensation of having a lump in the throat and
this must be distinguished from dysphagia.
Dysphagia is caused by either:
Neurological pathology, which is commonly described as a functional problem. This can be further
subdivided into higher or lower dysphagia depending on which part of the nervous system is affected.
Structural pathology where there is pathology involving either the lumen, the oesophageal wall (mural) or
due to external compression of the oesophagus (extrinsic). Dysphagia due to luminal pathology is commonly
due to a foreign body. (See table below for specific conditions).
Functional causes
Structural causes
Higher dysphagia
Mural
Stroke
Parkinsons disease
Myasthenia gravis
Multiple Sclerosis
Oespophageal cancer
Pharyngeal pouch
Stricture: caustic or inflammatory
(hence we ask about previous GORD
and ulcers)
Lower dysphagia
Extrinsic
Achalasia
Diffuse oesophageal spasm
Bronchial carcinoma
Retrosternal goitre
Mediastinal mass
Radiological investigations
1.
2.
Endoscopy: useful in those with luminal or mural pathology. Tissue samples can also be obtained through
this method for biopsy.
3.
4.
Oesophageal manometry: used to measure the pressures in the lower oesophageal sphincter and
peristalsis. Manometry is used for diagnosing motility disorders.
Treatment of dysphagia will depend on the cause. It is important to obtain a very clear and thorough history from
patients presenting with swallowing difficulties to aid the process of making a diagnosis.
Oxford Cases in Medicine and Surgery by Hugo Farne, Edward Norris-Cervetto, James Warbrick-Smith.
History Taking in Medicine and Surgery by Jonathan Fishman, Laura Fishman.
rd
1.
2.
3.
4.
Take a history from this 65-year-old patient who has presented to A&E after a fall. The
patient has also been complaining of palpitations. Offer a differential diagnosis at the end.
5 minutes.
Task
Marks
Establishes that the patient lost consciousness prior to falling and regained
consciousness minutes after.
Establishes the circumstances of the patients fall, i.e. location, time, what they were
doing (e.g. exercising, getting out of bed, coughing or straining, extending their neck,
experiencing an intense emotion). In this case the patient was walking from their living
room to the kitchen in the afternoon.
Excludes mechanical cause of fall, i.e. tripping over something, and establishes that
the patient is mobile without walking aids and has normal vision.
5.
6.
Excludes seizure.
7.
8.
Excludes focal neurological symptoms after fall (e.g. loss of power, loss of sensation,
loss of vision, facial drooping, dysphagia, dysphasia).
9.
10.
11.
Establishes that by "palpitations" the patient means that they are aware of their heart
beating.
12.
13.
14.
15.
16.
Family history.
17.
Social history.
18.
19.
20.
rd
Causes of palpitations
Palpitations describe an intermittent awareness of your own heartbeat. The heartbeat can be normal, slow or fast in
rate, and regular or irregular in rhythm. It is useful to ask the patient to tap out the rate and rhythm of their palpitations
to help determine the underlying problem.
Anxiety disorder is a term used to describe a range of psychiatric problems. It is a non-cardiac cause of
palpitations that should be ruled out from the history.
Tachycardia includes supraventricular tachycardia and ventricular tachycardia. Paroxysmal tachycardia
can occur due to junctional re-entry phenomena.
Bradycardia requires an increased stroke volume to maintain cardiac output. This can cause palpitations.
Atrial fibrillation is experienced as an irregularly irregular rhythm that can be slow or fast. The three main
causes of AF are: 1. Ischaemic heart disease, 2. Rheumatic heart disease and 3. Thyrotoxicosis.
Extrasystoles (premature beats) are often benign. They are felt by patients as missed beats.
Cardiomyopathy can cause dysrhythmias.
rd
1.
Please explain to this patient what a colonoscopy entails and give enough accurate
information so that they will be capable of giving informed consent to the procedure.
5 minutes.
Task
Marks
2.
3.
Is it painful or uncomfortable?
4.
5.
6.
INFORMATION GIVING
7.
8.
Safe test, discomfort should be minimal, can use IV sedation but not GA.
9.
10.
ASSESSMENT OF UNDERSTANDING
11.
12.
SUMMARY
13.
14.
PATIENT/ACTOR ASSESSMENT
15.
Listen to concerns.
16.
Respond to concerns.
17.
18.
19.
Behaviour/manner appropriate.
20.
Total marks:______ / 20
rd
History: Haematuria
Instructions:
Time:
Take a focussed history of a 55-year-old patient who has presented with haematuria.
5 minutes.
Task
Marks
1.
2.
3.
4.
5.
6.
Associated pain.
7.
Loin mass.
8.
9.
10.
Trauma to loin.
11.
12.
13.
Asks about past medical history (must include: renal stones, UTIs).
14.
15.
16.
17.
18.
19.
20.
Total marks:______ / 20
rd
History: Haematuria
Written in April 2011 by Kyaw Zayar Thant.
!
Main differential diagnoses of frank haematuria and typical presenting histories
1.
2.
3.
4.
5.
Bladder cancer
Middle aged/elderly male, presenting with painless frank haematuria clots associated symptoms of
malignancy (weight loss, anorexia, fever etc). Risk factors of smoking, occupational exposure to chemical
carcinogens, e.g. rubber, textile, leather, paint industry.
Renal cell carcinoma
Middle aged/elderly male, presenting with triad of haematuria, loin pain and loin mass associated
symptoms of malignancy (weight loss, anorexia, fever, etc).
Renal stones
Male or female presenting with colicky loin pain radiating to groin haematuria (usually microscopic).
UTI
Female presenting with urinary frequency, dysuria, suprapubic pain and foul-smelling urine.
Bleeding from prostate
Elderly male with symptoms of LUTS and haematuria at end of stream with raised PSA.
Key investigations
1.
2.
3.
4.
5.
Urinalysis.
MSSU
a. Microscopy: confirms haematuria and help to distinguish medical and surgical causes.
b. Culture and sensitivity: confirms UTI.
CT urography: identifies lesions in the kidneys and ureters.
Cystoscopy: identifies lesions in the bladder.
Routine bloods: FBC, U&E, LFT, CRP, Coag.
th
Kumar P, Clark M. Kumar & Clarks Clinical medicine. 7 ed. Edinburgh: Saunders Elsevier, c2009.
nd
Feather A, Lumley JSP, Visvanathan R. OSCEs for medical students. Volume 2. 2 ed. Knutsford; Pastest;
2004.
rd
History: Headache
Instructions:
Time:
1.
2.
Take a focussed history of a 40-year-old patient who has presented with a headache and
suggest a diagnosis at the end.
5 minutes.
Task
Marks
Asks specific questions about pain site, onset, character, radiation, associated
symptoms, timing, exacerbating/relieving factors, severity.
Visual disturbances.
4.
Photophobia.
5.
6.
Neck stiffness.
7.
Rash.
8.
Fever.
9.
10.
11.
12.
13.
14.
15.
Family history.
16.
Social history.
17.
18.
rd
History: Headache
Written in April 2011 by Philip Chan.
!
A gradual onset of global, tightening pain, of mild-moderate severity. The pain is non-pulsatile, not made
worse by physical activity.
This is the most common cause of headache.
Most occur episodically but 3% of population have chronic TTH.
Migraine
A gradual onset of unilateral, pulsating, moderate-severe pain that is aggravated by exercise, typically
lasting hours or days.
Associated symptoms may include nausea, vomiting, photophobia and phonophobia.
May or may not occur following an aura. An aura is a prodromic sensory phenomenon that ranges from
visual disturbance (e.g. flickering lights or blind spots) to paraesthesia. Auras can occur hours or days before
a migraine and typically last 5-60 minutes.
Cluster headache
A rapid onset of unilateral, sharp, non-pulsatile pain, typically felt behind the eye, at the temple, or at the
forehead.
Pain is severe and can be described as the worst ever felt.
Each episode lasts 45-90 minutes and characteristically occurs at the same time every day.
Subarachnoid haemorrhage
Classically described as a thunderclap headache that comes on suddenly and lasting only a few seconds.
The pain is often the worst ever experienced.
After the initial event, a less severe headache lingers for 1-2 weeks.
Associated symptoms may include seizures, vomiting, stiff neck and photophobia.
Meningitis
A severe, throbbing, global headache with classical associated symptoms, such as fever, neck stiffness,
altered consciousness, shock, Kernigs sign (pain and resistance on passive extension of the knee, when
the hip is in a flexed position) Brudzinskis sign (hips flex when flexing the neck forward), focal neurological
deficits and seizures.
Meningococcal meningitis is associated with a non-blanching purpuric rash found anywhere on the body.
Temporal arteritis
Classically an elderly lady complaining of a severe, dull headache with scalp tenderness when she combs
her hair and jaw ache when she eats.
Associated with polymyalgia rheumatica.
Classically a young, obese woman complaining of a two-week history of headaches that are worse in the
morning and on lying down.
rd
Take a history from this 35-year-old woman who presents with weight loss and heat
intolerance.
5 minutes.
Task
Marks
1.
2.
Confirms weight loss, establishes amount of weight lost and over what period of time.
3.
Symptoms of hyperthyroidism:
4.
6.
7.
8.
Drug history.
9.
Family history.
10.
Social history.
11.
12.
13.
rd
History: Thyroid
Written in April 2011 by Philip Chan.
Hyperthyroidism
Causes
SYMPTOMS
Weight loss.
Increased appetite.
Heat intolerance.
Irritability.
Tremor.
SIGNS
Tremor.
Hyperkinesis.
Full pulse.
Warm peripheries.
Goitre.
Hypothyroidism
Causes
Primary hypothyroidism
Iodine deficiency is the most common cause of hypothyroidism worldwide, but is uncommon in the UK.
Autoimmune disease such as Hashimotos thyroiditis.
Iatrogenic due to treatment of hyperthyroidism with thyroidectomy or radioiodine therapy.
Secondary hypothyroidism
Impaired pituitary function causes reduced production of TSH (thyroid-stimulating hormone). This can
result from, e.g. tumour, surgical or radiological damage.
Tertiary hypothyroidism
SYMPTOMS
Lethargy.
Weight gain.
Cold intolerance.
Goitre.
SIGNS
Mental slowness.
Dry skin.
Slow-relaxing reflexes.
Bradycardia.
rd
History: Jaundice
Instructions:
Time:
Take a history from this 50-year-old patient who presents with jaundice.
5 minutes.
Task
Marks
1.
Washes hands at start and end, introduction, checks identity, gains consent.
2.
Was the onset of the jaundice acute or chronic and who noticed it?
3.
4.
Pale stools?
5.
Dark urine?
6.
Itch?
7.
8.
Weight loss?
9.
10.
Past medical history: gallstones, liver disease, inflammatory bowel disease, diabetes.
11.
2 marks available.
12.
13.
14.
Family history.
15.
2 marks available.
16.
17.
Summary.
18.
rd
History: Jaundice
Written in April 2011 by Devvrat T. Katechia
Bilirubin metabolism
1.
2.
3.
Production of unconjugated bilirubin: Red blood cells are broken down in the spleen. Haemoglobin is
degraded into iron and unconjugated (water insoluble) bilirubin. Unconjugated bilirubin binds to albumin and
travels to the liver.
Conjugation of bilirubin occurs in the liver. Hepatocytes conjugate water insoluble bilirubin to glucuronate
therefore making it water soluble conjugated bilirubin. Conjugated bilirubin is secreted into the bile canaliculi.
Excretion of bilirubin: Conjugated bilirubin flows into the duodenum. Conjugated bilirubin is metabolised by
gut bacteria into urobilinogen and stercobilinogen. The urobilinogen and stercobilinogen is oxidised to
urobilin and stercobilin and excreted in faeces.
Jaundice
The causes of jaundice can be divided into pre-hepatic, hepatic and post-hepatic.
Pre-hepatic jaundice is caused by the excessive production of bilirubin. This can be due to increased breakdown of
red blood cells known as haemolysis. Unconjugated bilirubin accumulates in pre-hepatic jaundice.
Hepatic jaundice refers to jaundice caused by pathology of the liver itself such as hepatitis and primary sclerosing
cholangitis.
Post-hepatic jaundice is caused by problems with biliary flow. Obstructive jaundice is a specific type of post-hepatic
jaundice and is caused by lack of bile flow into the gut and these patients have pale stools (lack of urobilin/stercobilin)
and dark urine (conjugated bilirubin). Cholestatic jaundice is caused by bilirubin not flowing out via the common bile
duct and this may be due to obstruction (gallstone) or ileus affecting common bile duct peristalsis (drug-induced).
Investigations
Bloods
Urine
Imaging
FBC and reticulocyte count Low RBCs but high reticulocyte count.
suggests increased RBC turnover. If this is so proceed with a blood film.
Serum bilirubin levels confirms if the jaundice is due to
hyperbilirubinaemia.
Liver enzymes ALT>AST viral hepatitis.
AST> ALT excess alcohol intake.
Raised ALP and raised GT Bile duct pathology such as obstruction.
Serum amylase or lipase elevated levels suggest pancreatic pathology.
Urinalysis bilirubin in the urine is pathological and is due to post-hepatic
obstruction.
Ultrasound of pancreas and biliary tree gallstones.
Liver ultrasound cirrhosis, cancer.
Liver biopsy used to establish diagnosis.
MRCP.
ERCP.
CT of the abdomen.
Viral serology hepatitis.
Liver autoimmune profile primary biliary cirrhosis, primary sclerosing
cholangitis.
Oxford Cases in Medicine and Surgery by Hugo Farne, Edward Norris-Cervetto, James Warbrick-Smith.
History Taking in Medicine and Surgery by Jonathan Fishman, Laura Fishman.
rd
Task
Marks
1.
Washes hands at start and end, introduction, checks identity, gains consent.
2.
3.
When did the symptoms start and how often does it occur?
4.
5.
Relationship of blood to the stool blood mixed with the stool, blood separate from
the stool, blood only on the toilet paper.
6.
7.
8.
9.
Abdominal pain.
10.
11.
12.
Past medical history: previous rectal bleeding, inflammatory bowel disease, recent
bowel surgery, bleeding tendency, previous haemorrhoids.
2 marks available.
13.
14.
15.
16.
17.
Summary.
18.
19.
rd
Upper GI bleeding peptic ulcer which leads to melaena. Patient would be acutely unwell.
Caecum caecal carcinoma, polyps.
Colonic diverticular disease, angiodysplasia, colonic tumour, inflammatory bowel disease.
Anorectal haemorrhoids, rectal tumour, anal tumour, anal fissure.
Investigations
Blood: FBC, clotting, ESR.
Biochemistry: U+Es, LFTs, CRP, tumour markers (CEA carcinoembryonic antigen).
Faecal occult blood.
Microbiology: blood cultures, stool culture infective colitis.
Imaging
Abdominal X-ray obstruction.
Barium enema polyps, carcinoma, diverticular disease, inflammatory bowel disease, ischaemic colitis.
Liver ultrasound metastases.
CT chest, abdomen, pelvis staging of carcinoma.
Sigmoidoscopy biopsy anorectal tumours.
Colonoscopy biopsy diverticular disease, polyps, colonic tumours, angiodysplasia.
Oxford Cases in Medicine and Surgery by Hugo Farne, Edward Norris-Cervetto, James Warbrick-Smith.
History Taking in Medicine and Surgery by Jonathan Fishman, Laura Fishman.
rd
Take a focussed history of a 60-year-old patient who has presented with breathlessness.
5 minutes.
Task
Marks
1.
2.
3.
4.
5.
Cough.
6.
Sputum.
7.
Chest pain.
8.
Haemoptysis.
9.
Wheeze.
10.
Fever.
11.
12.
13.
14.
15.
16.
1.
2.
3.
4.
5.
6.
Smoking.
Drinking.
Occupation and past exposure to asbestos, particulates.
Pets.
Recent travel.
Home circumstances.
mark for each.
17.
18.
Total marks:______ / 20
rd
3.
4.
Pneumonia
Cough and sputum pleuritic chest pain, breathlessness accompanied by fever/rigors, malaise.
Pleural effusion
History mainly of breathlessness. Diagnosis suspected on examination findings: reduced chest expansion,
stony dullness to percussion, reduced breath sounds and vocal resonance.
COPD
Chronic smoker presenting with progressive breathlessness, productive cough on most days of 3 months for
2 consecutive years wheeze.
8. Chronic asthma
Typically, younger patient with history of reversible cough, wheeze, shortness of breath, chest tightness
particularly worse at night, during exercise, exposure to allergens, cold or drugs such as NSAIDs. Past
medical history of other atopic illnesses: hay fever, atopic eczema and positive family history.
9. Heart failure
Breathlessness on exertion, orthopnoea, PND and ankle swelling. There is usually a history of
cardiovascular disease suggesting a cause for heart failure, e.g. previous MI, valvular disease, etc.
10. Pulmonary fibrosis
Typically, history of progressive breathlessness. May have history of risk factors/causes of pulmonary
fibrosis, e.g. exposure to asbestos and particulates, exposure to drugs, e.g. methotrexate.
Key investigations
1.
2.
3.
4.
CXR.
ECG.
Routine bloods: FBC, U&E, LFT, CRP, glucose.
Consider sputum/blood culture, PEFR, ABG, d-dimers, pulmonary function tests.
st
Colledge NR et al. Davidsons principles and practice of medicine. 21 ed. Edinburgh; Elsevier: 2010.
Farne H, Norris-Cervetto E, Warbrick-Smith J. Oxford Cases in Medicine and Surgery. Oxford; Oxford
University Press: 2010.