OXFORD ASSESS AND PROGRESS Series Editors Katharine Boursicot Reader in Medical Education and Deputy Head of the Centre for Medical and Healthcare Education, St George’s, University of London David Sales Consultant in Medical Assessment OXFORD ASSESS AND PROGRESS YOUR PRESCRIPTION FOR EXAM SUCCESS Written by clinicians and educational experts, these unique guides present complete coverage for your exam revision, with illustrative material and tips to help you succeed in your medical exams. www.oup.com www.oxfordtextbooks.co.uk/oap OXFORD ASSESS AND PROGRESS Clinical Medicine Second Edition Alex Liakos MBBS , MRCP(UK), BA and Martin Hill MRCGP, MBBS, BpharmS 3 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2014 The moral rights of the authors have been asserted First Edition published in 2010 Second Edition published in 2014 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above Y ou must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2013937062 ISBN 978–0–19–967404–6 Printed in China by C&C Off set Printing Co. Ltd Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding. L inks to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work. v Series Editor Preface The Oxford Assess and Progress Series is a groundbreaking develop- ment in the extensive area of self-assessment texts available for medical students. The questions were specifi cally commissioned for the series, written by practising clinicians, extensively peer reviewed by students and their teachers, and quality assured to ensure that the material is up to date, accurate, and in line with modern testing formats. The series has a number of unique features and is designed as much as a formative learning resource as a self-assessment one. The questions are constructed to test the same clinical problem-solving skills that we use as practising clinicians, rather than just testing theoretical knowledge, namely: ● Gathering and using data required for clinical judgement ● Choosing examination, investigations, and interpretation of the fi ndings ● Applying knowledge ● Demonstrating diagnostic skills ● Ability to evaluate undiff erentiated material ● Ability to prioritize ● Making decisions and demonstrating a structured approach to decision making. Each question is bedded in reality and is typically presented as a clinical scenario, the content of which has been chosen to refl ect the common and important conditions that most doctors are likely to encounter both during their training and in exams! The aim of the series is to build the reader’s confi dence around recognizing important symptoms and signs and suggesting the most appropriate investigations and management, and in so doing aid development of a clear approach to patient management which can be transferred to the wards. The content of the series has deliberately been pinned to the relevant Oxford Handbook but in addition has been guided by a blueprint which refl ects the themes identifi ed in T omorrow’s Doctor s and G ood Medical Practice to include novel areas such as history taking, recognition of signs including red fl ags, and professionalism. Particular attention has been paid to giving learning points and con- structive feedback on each question, using clear fact or evidence-based explanations as to why the correct response is right and why the incorrect responses are less appropriate. The question editorials are clearly refer- enced to the relevant sections of the accompanying O xford Handbook and/or more widely to medical literature or guidelines. They are designed to guide and motivate the reader, being multipurpose in nature, covering, for example, exam technique, approaches to diffi cult subjects, and links between subjects. vi SERIES EDITOR PREFACE Another unique aspect of the Series is the element of competency pro- gression from being a relatively inexperienced student to a more expe- rienced junior doctor. We have suggested the following four degrees of diffi culty to refl ect the level of training so the reader can monitor their own progress over time, namely: (cid:144) Graduate should know (cid:144)(cid:144) Graduate nice to know (cid:144)(cid:144)(cid:144) Foundation should know (cid:144)(cid:144)(cid:144)(cid:144) Foundation nice to know. We advise the reader to attempt the questions in blocks as a way of testing knowledge in a clinical context. The Series can be treated as a dress-rehearsal for life on the ward by using the material to hone clini- cal acumen and build confi dence by encouraging a clear, consistent, and rational approach, profi ciency in recognizing and evaluating symptoms and signs, making a rational diff erential diagnosis, and suggesting appro- priate investigations and management. Adopting such an approach can aid not only being successful in exami- nations, which really are designed to confi rm learning, but also, more importantly, being a good doctor. In this way we can deliver high quality and safe patient care by recognizing, understanding, and treating common problems, but at the same time remaining alert to the possibility of less likely but potentially catastrophic conditions. Katharine Boursicot and David Sales, Series Editors vii A Note on Single Best Answer and Extended Matching Questions Single best answer questions are currently the format of choice being widely used by most undergraduate and postgraduate knowledge tests, and hence most of the assessment questions in this book follow this format. Briefl y, the single best answer question presents a problem, usually a clinical scenario, before presenting the question itself and a list of fi ve options. Of these fi ve, there is one correct answer and four incorrect options or ‘distractors’ from which the reader chooses a response. Extended matching questions are also known as extended match- ing items and were introduced as a more reliable way of testing knowl- edge. They are still currently widely used in many undergraduate and postgraduate knowledge tests, and hence are included in this book. An extended matching question is organized as one list of possible options followed by a set of items, usually clinical scenarios. The correct response to each item must be chosen from the list of options. All of the questions in this book, which typically are based on an evalu- ation of symptoms, signs, or results of investigations either as single enti- ties or in combination, are designed to test reasoning skills rather than straightforward recall of facts, and use cognitive processes similar to those used in clinical practice. The peer-reviewed questions are written and edited in accordance with contemporary best assessment practice and their content has been guided by a blueprint pinned to all areas of G ood Medical Practice , which ensures comprehensive coverage. The answers and their rationales are evidence-based and have been reviewed to ensure that they are absolutely correct. Incorrect options are selected as being plausible and indeed may look correct to the less knowledgeable reader. When answering questions, readers may wish to use the ‘cover’ test in which they read the scenario and the question but cover the options. Katharine Boursicot and David Sales, Series Editors ix Preface to the First Edition As undergraduate fi nals approach, students drift from the safety of their bible, the O xford Handbook of Clinical Medicine (OHCM), towards a range of disparate self-test resources in a bid to assess their progress. Meanwhile, senior colleagues attempt to reassure, saying, ‘Know the OHCM and you’ll be fi ne …’. So rich in detail and broad in its range, the challenge of knowing the OHCM is a daunting one. We wrote this book after our own fi nals to help students meet that challenge. The vehicles for this are two types of self-assessment question: the single best answer and extended matching question, increasingly the favoured formats in written medical exams. Gone (or going) are the reams of true or false questions that quiz the student on abstract details of clinical specifi cs. The questions here are all based on clinical scenarios with the student generally required to play the role of the junior doctor. Each question is accompanied by an explanation behind the answer (Why A?), as well as, crucially, an explanation as to why the answer is none of the other options (Why not B, C, D, or E?). These explanations are linked both to the relevant page in the OHCM and, where appropri- ate, to illuminating papers or supporting guidelines. It would be impossible for the questions to cover every topic featured in the OHCM. Whilst some niche topics are addressed, the majority of scenarios are built around either very common clinical areas (‘regulars’) or situations that could have catastrophic consequences (‘unmissables’). Although this book is a self-assessment aid, it is not exam-centric. It acknowledges the fact that the transition from student to junior doctor is a silent one and that preparations for fi nals must also include practical preparations for working. There is much in these questions that does this. As is the case for a junior doctor, the focus is often not on diagnosis but on ensuring a safe and systematic approach to acute and chronic man- agement, examination fi ndings and techniques, communication, patient safety, ethical dilemmas, and professional practice. The principle of this book is not simply to reinforce the encyclopaedic knowledge of the OHCM in order to pass exams. It is to hone the stu- dent’s ability to apply this knowledge confi dently in the varying and chal- lenging range of rotations and scenarios that they face post-graduation. In this way, we hope that this book becomes an invaluable reference text and a worthy junior companion to the OHCM. Alex Liakos and Martin Hill