sensitive to impairment. Disorientation is the hallmark of
the ‘organic mental state’ found in delirium and dementia.
Abnormalities may be evident during the interview but some
patients are adept at hiding them in social interactions. Check
the patient’s orientation to time, place and person by evaluating
their knowledge of the current time and date, recognition of
where they are, and identification of familiar people.
Memory function is divided into three elements:
• Registration is tested by asking the patient to repeat after
you the names of three unrelated objects (apple, table,
penny); any mistake is significant. Alternatively, in the digit
span test, ask the patient to repeat after you a sequence
of random single digit numbers. Make sure you speak
slowly and clearly. A person with normal function can
• Short-term memory (where short-term is defined as a
matter of minutes) is tested by giving the patient some
Delusions can sometimes be understood as the patient’s way
of trying to make sense of their experience, while the content of
the delusions often gives a clue that may help type the underlying
illness: for example, delusions of guilt suggest severe depression,
whereas grandiose delusions typify mania.
Some delusions are characteristic of schizophrenia. They
include a delusional perception (or primary delusion) and ‘passivity
phenomena’: namely, the belief that thoughts, feelings or acts
are no longer controlled by a person’s own free will.
People normally distinguish between their inner and outer worlds
with ease: we know what is real, what reality feels like, and what
resides in our ‘mind’s eye’ or ‘mind’s ear’. In mental illness this
distinction can become disrupted, so that normal perceptions
become unfamiliar, while abnormal perceptions seem real.
Abnormal perceptions are assessed via the history and specific
enquiries, backed up by observation. They fall into several
categories, defined in Box 16.9.
Perceptions may be altered (as in sensory distortions or illusions)
or false (as in hallucinations and pseudohallucinations). In a third
category, what is altered is not a perception in a specific sensory
modality but a general sense of disconnection and unreality
in oneself (depersonalisation), the world (derealisation) or both.
People find depersonalisation and derealisation intensely
unpleasant but hard to describe. They may occur in association
with severe tiredness or intense anxiety but can also arise in most
types of mental illness. Ask, for example, ‘Have you ever felt that
you were not real or that the world around you wasn’t real?’
With altered perceptions there is a real external object but its
subjective perception has been distorted. Sensory distortions,
such as unpleasant amplification of light (photophobia) or sound
(hyperacusis), can occur in physical diseases, but are also
common in anxiety states and drug intoxication or withdrawal.
Diminution of perceptions, including pain, can occur in depression
Illusions, in which, for example, a bedside locker is misperceived
as a threatening animal, commonly occur among people with
established impairment of vision or hearing. They are also found
in predisposed patients who are subjected to sensory deprivation,
notably after dark in a patient with clouding of consciousness.
They are suggestive of an organic illness such as delirium,
dementia or alcohol withdrawal.
True hallucinations arise without external stimuli. They usually
indicate severe mental illness, although they can occur naturally
Depersonalisation A subjective experience of feeling unreal
Derealisation A subjective experience that the surrounding
Hallucination A false perception arising without a valid
stimulus from the external world
Illusion A false perception that is an understandable
misinterpretation of a real stimulus in the
Pseudohallucination A false perception that is perceived as part
324 • The patient with mental disorder
be neither overstated nor ignored. Any others at risk are most
likely to be family or, less commonly, specific individuals (such
as celebrities in cases of stalking) or members of specific groups
(defined by age, ethnicity, occupation and so on). Sometimes the
risk applies non-specifically to strangers, or to anyone preventing
the patient from achieving their goals.
There may be direct risk to life and limb (as in suicide, self-harm
or violence to others), or it may be an indirect risk, either to health
(through refusal of treatment for physical or mental illness) or
welfare (through inability to provide basic care – food, warmth,
shelter, hygiene – for oneself or one’s dependents). The risk may
be imminent, as in a patient actively attempting self-harm, or
remote, as in a patient refusing prophylactic medical treatment.
Direct risks tend to be imminent and indirect risks remote, although
this is not always so. A patient declining renal dialysis because
their depression makes them feel unworthy is at imminent but
indirect risk of death. Finally, the likelihood of the risk may range
from near certainty to hypothetical possibility.
A risk assessment should readily distinguish between cases
where there is an imminent, direct and near-certain risk to the
patient’s life (such as a man actively trying to throw himself from
the window to escape delusional persecutors), and those where
any risks apply to the welfare of other people, at some point
in the future, and amount to possibilities (such as a depressed
woman who may be neglecting her frail elderly father). The former
case calls for urgent intervention, probably via mental health
legislation; the latter requires engagement over time, preferably
While all psychiatric evaluations require some assessment of
risk, it should be considered in depth whenever the presentation
includes acts or threats of self-harm or reports of command
hallucinations, the past history includes self-harm or violent
behaviour, the social circumstances show a recent, significant
loss, or the mental disorder is strongly associated with risk (as
Assessing suicidality is the element of risk assessment that is
most often needed. If a patient presents after an act of self-harm
or overdose, the questions arise naturally (‘What did you want
to happen when you took the tablets? Did you expect to die?
Is that what you wanted? How do you feel about that now? Do
you still feel you’d be better off dead? Have you had thoughts
about doing anything else to harm yourself?’).
In other circumstances the subject will need to be introduced,
but do not fear that you may be putting ideas in the patient’s
mind (‘You’ve told me how bad you have been feeling. Have
you ever felt life is not worth living? Have you had any thoughts
about ending your life? How close have you come? What has
stopped you acting on those thoughts so far?’).
Assessing capacity is a skill required of all doctors and should not
be delegated to psychiatrists. The legal elements vary between
jurisdictions but there are key clinical principles in common.
The first is the presumption of capacity: clinicians should treat
patients as retaining capacity until it is proven that they have lost
it. Secondly, capacity is decision-specific: patients may not be
able to understand the risks and benefits of complex medical
treatment options, while retaining the ability to decide whether
or not to enter a nursing home. Thirdly, residual capacity should
be maximised: if a patient’s ability to understand is impaired by
sensory deficits or language barriers, these should be corrected
new information; once this has registered, check retention
after 5 minutes, with a distracting task in between. Do the
same with the names of three objects; any error is
significant. Alternatively, use a six-item name and address
(in the format: Mr David Green, 25 Sharp Street, Durham).
More than one error indicates impairment.
• Long-term memory is assessed mainly from the personal
history. Gaps and mistakes are often obvious but some
patients may confabulate (that is, fill in the gaps with
plausible but unconsciously fabricated facts), so check the
account with a family member or other informant if
possible. Confabulation is a core feature of Korsakoff’s
syndrome, a complication of chronic alcoholism. Failing
long-term memory is characteristic of dementia, although
this store of knowledge can be remarkably intact in the
presence of severe impairment of other cognitive functions.
Impaired attention and concentration
These occur in many mental disorders and are not diagnostic.
Impaired attention is observed as increased distractibility, with
the patient responding inappropriately to intrusive internal events
(memories, obsessions, anxious ruminations) or to extraneous
stimuli, which may be either real (a noise outside the room) or
unreal (auditory hallucinations).
Concentration is the patient’s ability to persist with a mental
task. It is tested by using simple, repetitive sequences, such as
asking the patient to repeat the months of the year or days of
the week in reverse, or to do the ‘serial 7s’ test, in which 7 is
subtracted from 100, then from 93, then 86 and so on. Note
the finishing point, the number of errors and the time taken.
This is estimated clinically from a combination of the history
of educational attainment and occupations, and the evidence
provided at interview of vocabulary, general knowledge, abstract
thought, foresight and understanding. If in doubt as to whether
the patient has a learning disability, or if there is a discrepancy
between the history and presentation, a psychologist should
Insight is the degree to which a patient agrees that they are
ill. It can be broken down into the recognition that abnormal
mental experiences are in fact abnormal, agreement that these
abnormalities amount to a mental illness, and acceptance of the
need for treatment. Insight matters, since a lack of it often leads
to non-adherence, and sometimes to the need for compulsory
detention. You might ask ‘Do you think anything is wrong with
you’ or ‘If you are ill, what do you think needs to happen to
Risk assessment is a crucial part of every psychiatric assessment.
• What is the nature of the risk?
• What is the likelihood of the risk?
The person usually at risk, if anyone, is the patient themselves.
The risk posed to others by people with mental disorder must
Putting it all together: clinical vignettes • 325
The use of psychiatric rating scales as clinical tools in psychiatric
assessment is increasing. Most were developed in research
studies to make a confident diagnosis or to measure change in
severity of illness. Some require special training; all must be used
sensibly. In general, scales are too inflexible and limited in scope
to replace a well-conducted standard psychiatric interview but
they can be useful adjuncts for screening, measuring response
to treatment or focusing on particular areas.
In routine practice, scales are most widely used to assess
cognitive function when an organic brain disorder is suspected.
• Abbreviated Mental Test (AMT): takes less than 5 minutes
• Mini-Mental State Examination (MMSE) or Montreal
Cognitive Assessment (MoCA): takes 5–15 minutes.
Well-known instruments assessing areas other than cognition
• General Health Questionnaire (GHQ)
• Hospital Anxiety and Depression Scale (HADS)
• Beck Depression Inventory (BDI)
• CAGE questionnaire (Box 16.12)
• FAST questionnaire (Box 16.13).
Putting it all together: clinical vignettes
Examples in practice are provided in Boxes 16.14–16.17.
as far as possible by visual corrections, hearing aids and
The central matters to be assessed are essentially cognitive:
can the patient make, understand, remember and communicate
decisions about medical treatment or other options before them?
Determining that a patient lacks capacity for a particular
decision leads to the next stage: making that decision on their
behalf. The key principles here are to ensure that any treatment
proposed must benefit the patient and be the least restrictive
option available; it should take account of any wishes the patient
has previously expressed, as well as the views of family members
and any other relevant others (such as nursing home staff).
Physical and mental disorders are associated, so always consider
the physical dimension in any patient presenting with a psychiatric
disorder, and vice versa. The setting and the patient’s age, health
and mode of presentation will determine the extent of physical
In psychiatric settings, general physical observation, coupled
with basic cardiovascular and neurological examination, will usually
suffice. Bear in mind that some physical disorders can present
with psychiatric symptoms (such as thyrotoxicosis manifesting
as anxiety – look for exophthalmos, lid lag, goitre, tachycardia
and so on). For older patients with multiple medical problems, or
those with alcohol dependence and associated physical harm,
a more detailed examination is clearly needed.
In primary care and acute hospital settings, patients will
usually undergo physical examination tailored to the presenting
problem, but it is important to be aware that some psychiatric
disorders can present with physical symptoms, such as chest
pain and transient neurological symptoms as manifestations of
Collateral history is important whenever assessment is limited by:
• physical illness, acute confusional state or dementia
• severe learning disability or other mental disorder impairing
• disturbed, aggressive or otherwise uncooperative
Sources of third-party information will usually include family and
other carers, as well as past and present general practitioners
and other health professionals. Previous psychiatric assessments
are particularly valuable when a diagnosis of personality disorder
is being considered, as this depends more on information about
behaviour patterns over time than the details of the current
16.10 Personality disorder: definition
Patterns of experience and behaviour that are:
• pathological (i.e. outside social norms)
• problematic (for the patient and/or others)
• pervasive (affecting most or all areas of a patient’s life)
• persistent (adolescent onset, enduring throughout adult life and
From Hodkinson HM. Evaluation of a mental test score for assessment of mental
impairment in the elderly. Age and Ageing 1972; 1(4):233–238, by permission
16.11 The Abbreviated Mental Test
• Recognition of two people, e.g. doctor, nurse
• Dates of First World War (or other significant event)
• Name of the monarch (or prime minister/president as appropriate)
Each question scores 1 mark; a score of 8/10 or less indicates
• Cut down: Have you ever felt you should cut down on your drinking?
• Annoyed: Have people annoyed you by criticising your drinking?
• Guilty: Have you ever felt bad or guilty about your drinking?
• Ever: Do you ever have a drink first thing in the morning to steady
you or help a hangover (an ‘eye opener’)?
Positive answers to two or more questions suggest problem
drinking; confirm this by asking about the maximum taken.
326 • The patient with mental disorder
16.14 Clinical vignette: overdose
A 19-year-old woman attends the accident and emergency
department, having taken a medically minor overdose. She has
presented in this way three times in the last 2 years. She needs no
Your assessment should concentrate first on the circumstances of
the overdose and her intentions at the time. Collateral information
should include assessments after previous presentations and any
continuing psychiatric follow-up. Mental state examination should
screen for any new signs of mental disorder emerging since her last
assessment, and in particular any mood problems or new psychotic
symptoms. She will clearly have undergone a detailed physical
assessment, but even if the overdose appears medically trivial, you
need to undertake a risk assessment to judge the chances of further
self-harm or completed suicide in the near future. She probably does
not need a detailed cognitive assessment or psychiatric rating scales.
16.15 Clinical vignette: confusion, agitation and hostility
An 85-year-old man in a medical ward, where he is undergoing
intravenous antibiotic treatment for a chest infection, now appears
confused, agitated and hostile, in a way not previously evident to his
You need to approach him carefully to establish rapport and to
interview him as much as he will allow, while anticipating that you may
have to rely heavily on collateral information, and a mental state
examination limited to observation of appearance and behaviour. It will
be crucial to talk to his family to establish his normal level of cognition
and independence, and to the nursing staff to establish the diurnal
pattern of his problems. If there is any history of previous episodes,
acquire the results of previous assessments. He will need a
neurological examination and assessment of his cognition via a
standard scale. Risk assessment should focus on the indirect risks to
his health if he tries to leave hospital against advice, generating a view
about his detainability under mental health legislation. A capacity
assessment of his ability to consent to continuing antibiotic treatment
is required, and may result in the issue of an incapacity certificate.
16.13 The fast alcohol screening test (FAST) questionnaire
For the following questions please circle the answer that best applies
2 pint of beer or 1 glass of wine or 1 single measure of spirits
1. Men: How often do you have eight or more drinks on one occasion?
Women: How often do you have six or more drinks on one occasion?
• Yes, on more than one occasion (4)
• If the answer to question 1 is ‘Never’, then the patient is probably not misusing alcohol
• 50% of people are classified using this one question
• Only use questions 2–4 if the answer to question 1 is ‘Less than monthly’ or ‘Monthly’:
• Score questions 1–3: 0, 1, 2, 3, 4
• Score for hazardous drinking is 3 or more
Putting it all together: clinical vignettes • 327
16.16 Clinical vignette: fatigue
A 35-year-old woman attends her general practitioner, presenting with
Assessment of possible physical causes is required, via history,
examination and appropriate blood tests, but as these proceed, the
interview should also cover possible symptoms of depression, previous
episodes, family history and recent stressors. Mental state examination
should concentrate on objective evidence of lowered mood. Formal
assessment of cognition is probably not necessary, but a standard
rating scale for mood disorder may help establish a diagnosis and a
baseline against which to measure change. Risk assessment is not a
prominent requirement, unless a depressive illness is suspected and
she reports thoughts of self-harm, or is responsible for young children,
in which case the chance of direct or indirect harm to them needs to
16.17 Clinical vignette: paranoid thoughts
A 42-year-old man attends a psychiatric outpatient clinic for the first
time, having been referred by his general practitioner for longstanding
It will be particularly important to establish rapport with a patient
who is likely to be very wary. The interview needs to cover the
psychiatric history in some detail, considering substance misuse, family
history of mental illness and a full personal history in particular. Mental
state examination should explore the paranoid thoughts in detail, to
establish whether they are preoccupations or overvalued ideas
(suggesting a personality disorder), or delusions (suggesting a
psychotic illness). Risk assessment should concentrate on the risk to
others about whom the patient has paranoid fears. Neither detailed
cognitive assessment nor a specific rating scale is likely to add much
OSCE example 1: Assessing suicidal risk
Please assess her risk of self-harm and suicide
• Introduce yourself and clean your hands.
• Explain the purpose of your assessment; try to gain rapport.
• Tactfully introduce the subject of the overdose.
• Establish the number and type of tablets taken.
• Clarify how she was found and either came or was brought to hospital.
• Explore recent or chronic stressors.
• Establish her intent at the time of the overdose. Did she expect to die? Is that what she wanted?
• Establish who will be with her when she leaves hospital.
• Thank the patient and clean your hands.
The risk assessment should concentrate most on the short-term risk of suicide.
completed suicide in the first year after an act of self-harm (1–2%).
328 • The patient with mental disorder
OSCE example 2: Assessing delirium
agitated overnight, pulling out his intravenous line. He is now settled and cooperative.
Please assess the likely cause of this episode
• Introduce yourself and clean your hands.
• Explain the purpose of your assessment; try to establish rapport.
• Establish his awareness of where he is, why he is there and how long he has been in hospital.
• Enquire about any continuing hallucinations or fears.
• Ask about any previous similar episodes.
• Undertake a basic physical examination, assessing for tremor, ophthalmoplegia and nystagmus.
• Gain the patient’s permission to speak to his next of kin, general practitioner and others.
• Thank the patient and clean your hands.
the possibility of pre-existing cognitive impairment as a vulnerability factor.
Integrated examination sequence for the psychiatric assessment
• Review the relevant information to clarify the reason for referral or mode of self-presentation.
• Establish rapport to reduce distress and assist assessment.
misuse, family history, personal history).
• Make the extent, order and content of the assessment appropriate to the presentation and setting.
• Observe closely to gain objective evidence of mental state, especially non-verbal information.
perceptions, cognition and insight).
• Consider your own emotional response to your patient.
• Consider standardised rating scales as a screening tool (and sometimes to monitor progress).
• Undertake physical examination as appropriate to the setting and the presentation.
• As well as a diagnosis and management plan, be sure to consider:
• assessment of risk to self or others
• need to use mental health or incapacity legislation.
Assessment of the frail elderly patient 330
Factors influencing presentation and history 330
Common presenting symptoms 331
Social and functional history 332
Interpretation of the findings 337
OSCE example 1: History in a frail elderly patient with falls 337
OSCE example 2: Examination of an acutely confused frail
Integrated clinical examination for the frail elderly patient 338
330 • The frail elderly patient
Factors influencing presentation
Classical patterns of symptoms and signs still occur in the frail
elderly, but modified or non-specific presentations are common
due to comorbidity, drug treatment and ageing itself. As the
combination of these factors is unique for each individual, their
presentations will be different. The first sign of new illness may
be a change in functional status: typically, reduced mobility,
altered cognition or impairment of balance leading to falls.
Common precipitants are infections, changes in medication and
metabolic derangements but almost any acute medical insult can
produce these non-specific presentations (Fig. 17.1). Each of
these presentations should be explored through careful history
taking, physical examination and functional assessment.
Disorders of cognition, communication and mood are so
common that they should always be considered at the start of
the assessment of a frail older adult.
Communication can be challenging (Box 17.2). The history
can be incomplete, difficult to interpret or misleading, and the
whole assessment, including physical examination, may be
Whenever possible, assess the patient somewhere quiet with
few distractions. Make your patient comfortable and ensure they
understand the purpose of your contact. Provide any glasses,
hearing aids or dentures that they need and help them to switch
Assessment of the frail elderly patient
Comprehensive geriatric assessment is an evidence-based
process that improves outcomes. It involves taking the history
from the patient and, with the patient’s consent, from a carer
or relative, followed by a systematic assessment of:
The extent and focus of the assessment depend on the clinical
presentation. In non-acute settings such as the general practice
or outpatient clinic or day hospital, focus on establishing what
diseases are present, and also which functional impairments
and problems most affect the patient’s life.
In acute settings such as following acute hospital referral,
focus on what has changed or is new. Seek any new symptoms
or signs of illness and any changes from baseline physical or
The complexity of the problems presented, and the need for
comprehensive and systematic analysis, mean that assessment
is divided into components undertaken at different times, by
different members of the multiprofessional team (Box 17.1).
There is no specific age at which a patient becomes
‘elderly’; although age over 65 years is commonly used as the
definition, this has no biological basis, and many patients who
are chronologically ‘elderly’ appear biologically and functionally
Frailty becomes more common with advancing age and is
likely to be a response to chronic disease and ageing itself. A frail
elderly person typically suffers multimorbidity (multiple illnesses)
and has associated polypharmacy (multiple medications). They
often have cognitive impairment, visual and hearing loss, low
bodyweight and poor mobility due to muscular weakness, unstable
balance and poor exercise tolerance. Their general functional
reserve and the capacity of individual organs and physiological
systems are impaired, making the individual vulnerable to the
17.1 The multiprofessional team
Professional Key roles in assessment of
Physician Physical state, including diagnosis
Psychiatrist Cognition, mood and capacity
Physiotherapist Mobility, balance, gait and falls risk
Occupational therapist Practical functional activities
Nurse Skin health, nutrition and continence
Speech and language therapist Speech and swallowing
Social worker Social care needs
)XQFWLRQDOGHFRPSHQVDWLRQRIWKHIUDLOHOGHUO\DGXOW
Fig. 17.1 Functional decompensation in frail elderly people.
17.2 Communication difficulties: the seven Ds
Dysphasia Most commonly due to stroke disease but sometimes
Dysarthria Cerebrovascular disease, motor neurone disease,
Dementia Global impairment of cognitive function
Delirium Impaired attention, disturbance of arousal and
Depression May mimic dementia or delirium
Fractures, dislocations and trauma • 279
Establish the mechanism of injury. For example, a patient who
has fallen from a height on to their heels may have obvious
fractures of the calcaneal bones in their ankles but is also at
risk of fractures of the proximal femur, pelvis and vertebral
Use the ‘Look – feel – move’ approach. Observe patients
closely to see if they move the affected part and are able to
• See if the skin is intact. If there is a breach in the skin and
the wound communicates with the fracture, the fracture is
open or compound; otherwise it is closed.
• Look for associated bruising, deformity, swelling or wound
• Gently feel for local tenderness.
• Feel distal to the suspected fracture to establish if
sensation and pulses are present.
Fractures, dislocations and trauma
A fracture is a breach in the structural integrity of a bone. This
• normal bone from excessive force
• normal bone from repetitive load-bearing activity (stress
• bone of abnormal structure (pathological fracture, see Box
13.18) with minimal or no trauma.
The epidemiology of fractures varies geographically. There
is an epidemic of osteoporotic fractures because of increasing
elderly populations. Although any osteoporotic bone can fracture,
common sites are the distal radius (Fig. 13.47), neck of femur
(see Fig. 13.33), proximal humerus and spinal vertebrae.
Fractures resulting from road traffic accidents and falls are
decreasing because of legislative and preventive measures such
as seat belts, air bags and improved roads. A fracture may occur
in the context of severe trauma.
Fig. 13.46 Ruptured Achilles tendon. A Site of a palpable defect in the
Achilles tendon (arrow). B Thomson’s test. Failure of the foot to
plantar-flex when the calf is squeezed is pathognomonic of an acute
rupture of the Achilles tendon.
Fig. 13.47 Colles’ fracture. A Clinical appearance of a dinner-fork
deformity. B X-ray appearance.
280 • The musculoskeletal system
• Establish whether the patient can move joints distal and
• Do not move a fracture site to see if crepitus is present;
this causes additional pain and bleeding.
Describe the fracture according to Box 13.19. For each
suspected fracture, X-ray two views (at least) at perpendicular
planes of the affected bone, and include the joints above and
Fig. 13.48 Ankle deformity. A Clinical appearance. B Lateral X-ray
view showing tibiotalar fracture dislocation.
• What bone(s) is/are involved?
• Is the fracture open (compound) or closed?
• Is the fracture complete or incomplete?
• Where is the bone fractured (intra-articular/epiphysis/physis/
• What is the fracture’s configuration (transverse/oblique/spiral/
comminuted (multifragmentary)/butterfly fragment)?
• What components of deformity are present?
• Translation is the shift of the distal fragment in relation to the
proximal bone. The direction is defined by the movement of the
distal fragment, e.g. dorsal or volar, and is measured as a
• Angulation is defined by the movement of the distal fragment,
• Rotation is measured in degrees along the longitudinal axis of
the bone, e.g. for spiral fracture of the tibia or phalanges.
• Shortening: proximal migration of the distal fragment can cause
shortening in an oblique fracture. Shortening may also occur if
there has been impaction at the fracture site, e.g. a Colles’
fracture of the distal radius.
• Is there distal nerve or vascular deficit?
• What is the state of the tissues associated with the fracture (soft
tissues and joints, e.g. fracture blisters, dislocation)?
13.20 Common musculoskeletal investigations
Investigation Indication/comment
Protein Glomerular disease, e.g. SLE, vasculitis
Secondary amyloid in RA and other chronic arthropathies
Drug adverse effects, e.g. myocrisin, penicillamine
Blood Glomerular disease, e.g. SLE, vasculitis
Full blood count Anaemia in inflammatory arthritis, blood loss after trauma
Neutrophilia in sepsis and very acute inflammation, e.g. acute gout
Leucopenia in SLE, Felty’s syndrome and adverse effects of antirheumatic drug therapy
Erythrocyte sedimentation rate/plasma viscosity Non-specific indicator of inflammation or sepsis
C-reactive protein Acute-phase protein
Urea and creatinine ↑ in renal impairment, e.g. secondary amyloid in RA or adverse drug effect
Uric acid May be ↑ in gout. Levels may be normal during an acute attack
Calcium ↓ in osteomalacia; normal in osteoporosis
Alkaline phosphatase ↑ in Paget’s disease, metastases, osteomalacia and immediately after fractures
Angiotensin-converting enzyme ↑ in sarcoidosis
Urinary albumin : creatinine ratio Glomerular disease, e.g. vasculitis, SLE
in up to 15% of normal population. Superseded by anti-cyclic citrullinated peptide antibodies
RA. Occasionally found in Sjögren’s syndrome
Anti-Ro, Anti-La Sjögren’s syndrome
Common investigations in patients with musculoskeletal disease
13.20 Common musculoskeletal investigations – cont’d
Investigation Indication/comment
Anti-ribonucleoprotein Mixed connective tissue disease
Schirmer tear test, salivary flow test Keratoconjunctivitis sicca (dry eyes), Sjögren’s syndrome
bone changes in Paget’s disease, pseudofractures (Looser’s zones) in osteomalacia
Detection of bursae, tendon pathology and osteophytes
Magnetic resonance imaging Joint and bone structure; soft-tissue imaging
Computed tomography High-resolution scans of thorax for pulmonary fibrosis
vertebral assessment for fractures
Synovial fluid microscopy Inflammatory cells, e.g. ↑ neutrophils in bacterial infection
Negatively birefringent needle-shaped crystals – monosodium urate monohydrate (gout)
Bacteriological culture Organism may be isolated from synovial aspirates
Biopsy and histology Synovitis – RA and other inflammatory arthritides
RA, rheumatoid arthritis; SLE, systemic lupus erythematosus.
OSCE example 1: Right shoulder pain
Mr Hunt, 38 years old, has a 2-month history of right shoulder pain with no history of trauma.
• Introduce yourself and clean your hands.
• Expose both of the patient’s shoulders and arms.
• Comment on acromioclavicular deformity and muscle wasting; look for winging of the scapula.
• Compare the right shoulder to the normal left shoulder.
• Finally, examine the arm, looking for conditions such as biceps rupture.
• If all movements of the shoulder are normal, conduct a full examination of the neck.
• Thank the patient and clean your hands.
Suggest a differential diagnosis
post-traumatic), long head of biceps rupture and referred pain from the neck.
282 • The musculoskeletal system
• Introduce yourself and clean your hands.
• In this case there is swelling of two MCP joints on the right, and one PIP joint on the left.
• Normal nails and skin (therefore psoriatic arthropathy is unlikely).
• Ask first what is sore and seek permission to examine gently.
• Tender, soft swelling of the MCP and PIP joints in the hands and left elbow.
• In feet: tender across her MTP joints on squeeze test but no palpable swelling.
in limitation of hand function.
Suggest a differential diagnosis
Suggest initial investigations
Integrated examination sequence for the locomotor system
• Ask the patient to undress to their underwear.
• Ask the GALS (gait, arms, legs, spine) questions and perform the GALS screen.
• Identify which joints require more detailed examination:
• What is the pattern of joint involvement?
• Is it likely to be inflammatory or degenerative?
• Assess the general appearance:
• Look for pallor, rashes, skin tightness, evidence of weight or muscle loss, obvious deformities.
• Check the surroundings for a temperature chart, walking aids and splints, if appropriate.
• Examine the relevant joint, or all joints if systemic disease suspected:
• Ask about tenderness before examining the patient.
• Look at the skin, nails, subcutaneous tissues, muscles and bony outlines.
• Feel for warmth, swelling, tenderness, and reducibility of deformities.
• If systemic disease is suspected, go on to examine all other systems fully.
• Consider what investigations are required:
• Joint aspiration for synovial fluid analysis or culture.
Common presenting symptoms 285
Past medical and drug history 285
Supplementary examination techniques 291
OSCE example 2: Pigmented lesion 293
Integrated examination sequence for the skin 293
284 • The skin, hair and nails
Dermatological conditions are very common (10–15% of general
practice consultations) and present to doctors in all specialties.
In the UK, 50% are lesions (‘lumps and bumps’), including skin
cancers, and most of the remainder are acute and chronic
inflammatory disorders (‘rashes’), including infections, with genetic
conditions accounting for a small minority.
Dermatological diagnosis can be challenging: not only is there a
vast number of distinct skin diseases, but also each may present
with a great variety of morphologies and patterns determined by
intrinsic genetic factors, with the diagnostic waters muddied still
further by external influences such as rubbing and scratching,
infection, and well-meaning attempts at topical and systemic
treatment. Even in one individual, lesions with the same pathology
can have a very variable appearance (for example, melanocytic
naevi, seborrhoeic keratoses and basal cell carcinomas).
Many skin findings will have no medical significance, but it is
important to be able to examine the skin properly in order to
identify tumours and rashes, and also to recognise cutaneous
signs of underlying systemic conditions. The adage that the skin
is a window into the inner workings of the body is entirely true,
and an examination of the integument will often provide the
discerning clinician with important clues about internal disease
processes, as well as with information about the physical and
psychological wellbeing of an individual.
The skin is the largest of the human organs, with a complex
anatomy (Fig. 14.1) and a number of essential functions
(Box 14.1). It has three layers, the most superficial of which
is the epidermis, a stratified squamous epithelium, containing
melanocytes (pigment-producing cells) within its basal layer, and
Langerhans cells (antigen-presenting immune cells) throughout.
The dermis is the middle and most anatomically complex layer,
containing vascular channels, sensory nerve endings, numerous
cell types (including fibroblasts, macrophages, adipocytes and
smooth muscle), hair follicles and glandular structures (eccrine,
sebaceous and apocrine), all enmeshed in collagen and elastic
tissue within a matrix comprising glycosaminoglycan, proteoglycan
The deep subcutis contains adipose and connective tissue.
Dermatoses (diseases of the skin) may affect all three
layers and, to a greater or lesser extent, the various functions
Fig. 14.1 Structures of the skin.
Deep cutaneous vascular plexus
• Protection against physical injury and injurious substances, including
• Anatomical barrier against pathogens
• Appreciation of sensation (touch, temperature, pain)
• Absorption – particularly fetal and neonatal skin
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