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OXFORD ASSESS AND PROGRESS Series Editors Kathy 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 Clinical Specialties Second Edition Edited by Luci Etheridge Consultant Paediatrician and Senior Fellow in Clinical Leadership, Barking, Havering and Redbridge University Hospitals NHS Trust Alex Bonner Specialist Trainee in Anaesthesia and Critical Care, North West Deanery 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, 2013 The moral rights of the authors have been asserted First Edition published 2010 Second Edition published 2013 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 You must not circulate this work in any other form and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Library of Congress Control Number: 2012944655 ISBN 978–0–19–965758–2 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 breastfeeding Links 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 development 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 to be as much 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 only to test theoretical knowledge. These skills include: ● gathering and using data required for clinical judgement ● choosing the appropriate examination and investigations, and inter- pretation 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 in recognizing important symptoms and signs and suggesting the most appropriate investigations and management, and in so doing to aid the 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 Tomorrow’s Doctors and Good 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 referenced to the relevant sections of the accompanying Oxford Handbook and/or more widely to medical literature or guidelines. They are designed to guide and motivate the reader, being multi-purpose in nature and 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 being a more experienced junior doctor. We have suggested the following four degrees of diffi culty to refl ect the level of training, so that the reader can monitor their own progress over time: ● graduate should know(cid:144) ● graduate nice to know(cid:144)(cid:144) ● foundation doctor should know(cid:144)(cid:144)(cid:144) ● foundation doctor nice to know(cid:144)(cid:144)(cid:144)(cid:144) We advise the reader to attempt the questions in blocks as a way of testing their 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 clinical 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 appropriate investigations and management. Adopting such an approach can aid not only success in examinations, which really are designed to confi rm learning, but also—more import- antly—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. David Sales and Kathy Boursicot, 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 therefore 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. These consist of one correct answer and four incorrect options or ‘distractors’ from which the reader has to choose a response. Extended matching questions, also known as extended matching items, were introduced as a more reliable way of testing knowledge. They are still widely used in many undergraduate and postgraduate knowledge tests, and are therefore 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 are typically based on an evalu- ation of symptoms, signs, or results of investigations either as single entities or in combination, are designed to test reasoning skills rather than straight- forward recall of facts, and utilize 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 Good 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 they may appear correct to the less knowledgeable reader. When answering questions, the reader may wish to use the ‘cover’ test in which they read the scenario and the question but cover the options. Kathy Boursicot and David Sales, Series Editors This page intentionally left blank ix Preface to the Second Edition During the journey through medical school as a student, you experience medicine in a range of settings, from the rural general practice to the inner-city teaching hospital. You encounter doctors working in a wide range of specialties, many of which will be appealing future career choices and many of which will seem daunting. Specialty attachments may be the fi rst time that you encounter people with mental illness, or children, or pregnant women. Trying to absorb all of these new experiences while also continuing to work towards fi nal examinations can seem like a roller- coaster ride to some! In partnership with the well-established Oxford Handbook of Clinical Specialties, the Oxford Assess and Progress Clinical Specialties volume seeks to tie together the clinical specialties and to provide a grounding in knowledge that may get pushed to the back burner when medicine and surgery have to be revised. This second edition has been produced in line with the new edition of the Oxford Handbook of Clinical Specialties, and builds on the success of the fi rst book, bringing you questions on the latest hot topics, current issues, and core material. The questions in each chapter have been written by experienced doctors working within the specialty, who are familiar with the common presentations, pathologies, and dilem- mas that are encountered. Their knowledge of teaching medical students about their specialty, often within the confi nes of very short attachments, has been transferred to these pages. All of the questions map on to medical school curricula and are rooted in real-life clinical encounters. The grading system allows you to judge for yourself which knowledge is core and which might require some further reading. We have added many new guidelines and key websites to guide this reading, and we hope that you will fi nd these useful. The strong focus on clinical experiences also allows you to look forward to and prepare for your time as a foundation doctor. We hope that, as a result of working through these questions, your interest in and appreciation and understanding of the diff erent clinical specialties will grow, and you will have a useful tool for judging your own learning needs. Luci Etheridge and Alex Bonner