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
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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,
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