cmecde 5466
• Ask him if he has any questions or concerns.
• Thank him for his co-operation.
• Summarise your findings to the examiner and suggest a further course of action, e.g. physical
examination, referral to a self-help group, detox planning.
units, and one bottle of spirits to approximately 30 units.
122 Station 45 Alcohol history
Doctor: According to your blood tests, you appear to be drinking rather too much alcohol.
Patient: I suppose I do enjoy the odd drink.
drinking too much then you really need to stop.
Patient: You sound like my wife.
Doctor: Well, she’s right you know. Alcohol can cause liver and heart problems and many other things
besides. So you really need to stop drinking, OK?
Patient: Yes, doctor, thank you. (Patient never returns.)
Scenario B (using motivational interviewing)
Doctor: We all enjoy a drink now and then, but sometimes alcohol can do us a lot of harm. What do
you know about the harmful effects of alcohol?
months in hospital. I visited him often, but most of the time he wasn’t with it. Then he died from
Doctor: I’m sorry to hear that, alcohol can really do us a lot of damage.
Patient: It does a lot of damage to the liver, doesn’t it?
our finances, our relationships.
Patient: Funny you should say that. My wife’s been at my neck…
Doctor: So, you’ve told me that you’re currently drinking about 16 units of alcohol a day. This has
placed severe strain on your marriage and on your relationship with your daughter Emma, not to
mention that you haven’t been to work since last Tuesday and have started to fear for your job. But
Patient: Things are completely out of hand, aren’t they? If I don’t stop drinking now, I might lose
everything I’ve built over the past 20 years: my job, my marriage, even my daughter.
Doctor: I’m afraid you might be right.
Patient: I really need to quit drinking.
Doctor: You sound very motivated to stop drinking. Why don’t we make another appointment to talk
about the ways in which we might support you? (…)
Excerpted from Psychiatry 2e, by Neel Burton (Wiley-Blackwell, 2010)
• Introduce yourself to the patient.
• Confirm her name and date of birth.
• Ensure that she is comfortable.
Most patients with eating disorders are reluctant to seek help, so it is especially important
to be sensitive and non-judgmental. Here the patient is spoken of as female, but at least 1
in 10 patients with an eating disorder are male.
Screening for an eating disorder
Use the SCOFF questionnaire to screen for an eating disorder. A positive response to two or more
• “Have you ever felt so uncomfortably full that you have had to make yourself Sick?”
• “Do you worry that you have lost Control Over how much you eat?”
• “Do you believe yourself to be Fat when others say that you are too thin?”
• “Would you say that Food dominates your life?”
Weight and perception of weight
• Her current weight and height.
• The amount of weight that she has lost, and over what period. Was the weight loss intentional?
• Whether she still considers that she is overweight.
• How often she weighs herself/looks at herself in the mirror.
Diet and compensatory behaviours
• Amount and type of food eaten in an average day. What foods are avoided and why? Does she
engage in ritualised eating behaviours such as cutting food into little pieces and prolonged
chewing? Is she able to eat in front of other people? Beyond this, does she ever diet or fast?
• Binge eating: what, how much, how often. How does she feel after bingeing?
• Vomiting: how often, how induced. How does she feel after vomiting?
• Use of laxatives, diuretics, emetics, appetite suppressants, and stimulants.
Impact on health and quality of life
124 Station 46 Eating disorders history
– psychiatric complications, especially substance misuse, depression, and self harm
– physical complications, e.g. dizziness/syncope, peptic ulceration, constipation
• Past medical, drug, and family history (briefly and only if you have time left).
• Ask the patient if there is anything she might add that you have forgotten to ask about.
• Determine the patient’s level of insight into her problem.
• Suggest a further course of action:
– physical examination and investigations
– management, e.g. dietary advice, psychotherapy, antidepressants, day- or in-patient admission
Table 20. Anorexia nervosa vs. bulimia nervosa
• Restriction of energy intake leading to significantly low body weight for age, sex, developmental
trajectory, and physical health.
gain (even though significantly underweight).
• Recurrent episodes of binge eating together with a sense of lack of control.
• Recurrent inappropriate compensatory behaviour to prevent weight gain.
• Episodes of binge eating and compensatory behaviour both occur, on average, at least once a
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during periods of anorexia nervosa.
NB. Patients with an eating disorder may ‘migrate’ between anorexia, bulimia, and atypical eating
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain that you are going to ask him some questions to uncover the cause of his weight loss,
• Ensure that he is comfortable.
Presenting complaint and history of presenting complaint
• Establish how much weight he has lost. How did he discover the weight loss?
• Establish the time frame of the weight loss (i.e. acute or chronic).
• Did the patient intend to lose weight? If so, how much weight did he intend to lose and how did
• Enquire about the patient’s appetite and establish his dietary habits and intake, e.g. “What did
you have for breakfast this morning? What about for lunch?” “Did you enjoy your food?”
• Ask about any other associated symptoms. Specifically enquire about lethargy, weakness, fever
• Enquire about current and recent mood, and life events and stressors such as bereavement or
• If this seems appropriate, briefly assess mental state (see Station 40).
• Current, past, and childhood illnesses.
• Over-the-counter medication, including natural remedies.
• Recreational drugs, especially stimulant drugs.
• Parents, sibling, and children.
• Ask about e.g. diabetes, thyroid disease, TB, malignancy.
• Unprotected sexual intercourse.
126 Station 47 Weight loss history
• Employment, past and present.
• Housing and living arrangements.
• Ask the patient if there is anything that you have forgotten to ask about.
• Ask him if he has any questions or concerns.
• Summarise your findings and offer a differential diagnosis.
• State that you would like to obtain a collateral history, and carry out a physical examination and
some investigations to confirm your diagnosis.
Examiner’s questions: Principal differential of weight loss
With increased calorie consumption
• Malabsorption e.g. coeliac disease, IBD.
• Infection e.g. TB, HIV, parasitic infection.
Assessing capacity (the Mental Capacity Act)
The Mental Capacity Act 2005 (MCA) is a piece of legislation intended to protect people who lack the
Health Act 1983 and the Enduring Powers of Attorney Act 1985, and was introduced to clarify legal
uncertainties around decision-making on behalf of adults with mental incapacity, and to create new
1. Presumption of capacity: a person is presumed to have capacity to make a decision unless it
2. Maximising capacity: before a person is deemed to lack capacity, all practicable steps must
have been taken to help that person make his own decisions.
3. Right to make unwise decisions: a person must not be treated as unable to make a decision
merely because the decision appears unwise to others.
4. Best interests: decisions made on behalf of a person who lacks capacity must be made in their
and freedom must be considered first.
Section 2 of the MCA defines capacity as follows:
‘a person lacks capacity in relation to a matter if at the material time he is unable to make a
decision for himself in relation to the matter because of an impairment of, or a disturbance in the
functioning of, the mind or brain.’
in relation to a particular decision at a particular time.
• Competence is the legal right to have one’s decision regarding treatment respected. It is a binary
concept: a person is either ‘competent’ or not.
• Competence is informed by capacity: if capacity is beyond a certain threshold, the person is
deemed ‘competent’ to make a decision. This threshold varies according to the seriousness of the
Capacity is contextual and should not simply be inferred from the patient’s diagnosis or
from previous assessments of his capacity.
According to Section 3 of the MCA, a person has capacity to make a particular decision if he:
• Understands the information relevant to decision-making.
• Retains the information for long enough to make a decision.
• Weighs up the information and understands the consequences of a decision.
• Communicates this decision by whatever means necessary.
128 Station 48 Assessing capacity (the Mental Capacity Act)
Assessment of capacity in adults
lean on standardised criteria such as the ICD-10 or DSM-V diagnostic criteria.
person unable to make a decision about the matter in hand. Your assessment should be made on the
Efforts to optimise capacity might include:
• Making your explanations easier to understand, e.g. by using diagrams.
• Seeing the patient at his best time of day.
• Seeing him with one of his friends or relatives.
• Improving his environment, e.g. finding a quiet side-room.
• Adjusting his medication, e.g. decreasing the dose of sedative drugs.
Remember to document your assessment and to outline your reasoning.
Assessment of capacity in children and adolescents
• Decisions on behalf of a minor can be made by a person with parental responsibility or by a
• 16- and 17-year-olds are deemed competent by the same standards as adults (Family Law
Reform Act 1969). However, they cannot refuse treatment if it has been agreed by a person with
parental responsibility or the Court and it is in their best interests.
• Under-16s may be deemed competent to accept an intervention if they are mature enough
to fully understand what is proposed (‘Gillick competency’, after Gillick v. West Norfolk and
• Ideally, the consent of a person with parental responsibility should also be sought. However,
the decision of a competent minor to accept treatment cannot be overruled by a parent.
• A court order may be obtained to overrule the decision of a competent minor or parent if it is
considered in the best interests of the minor.
Deprivation of Liberty Safeguards
The Deprivation of Liberty Safeguards (DoLS) is an amendment to the MCA intended to protect
the right to legally challenge their detention.
authorisation from a DoLS supervisory authority, whether or not the patient (who lacks capacity) is
‘agreeing’ to the arrangements.
DoLS is not applicable to people detained under the Mental Health Act (MHA).
Station 48 Assessing capacity (the Mental Capacity Act) 129
The MHA applies to people with a mental disorder who need to be detained for assessment or
DoLS is used for people with mental disorders such as dementia and learning disabilities who do not
require assessment and for whom there is no medical treatment (for the mental disturbance), and who
wellbeing, including for the treatment of physical illness.
Section 2 Assessment is required in the interests of
the person’s own health and safety or the
Assessment has already been performed
and DoLS is called for in the interests of the
Section 3 Appropriate medical treatment for the
The purpose of DoLS is to provide general
care and treatment of physical illness, not
Detention is appropriate to the degree or severity of
DoLS is only appropriate after less restrictive
alternatives have been exhausted.
The person might have capacity to consent but refuses
the care or treatment required.
The person lacks capacity to consent to the
Does not include treatment of physical illnesses unless
they are a direct result or consequence of the mental
Allows for treatment of physical illnesses
Applies to people of all ages. Applies to people aged 18 and over.
Appeals are made to a Mental Health Tribunal. Appeals are made to the Court of Protection.
Formerly known as advance directives or living wills, advance decisions enable a person to make
decisions about their future care in the event that they come to lack the capacity to make these
applicable to the circumstances, and written without coercion at a time when the person had an
Lasting Power of Attorney (LPA)
An LPA is a legal document stating that one person has chosen another to make decisions about
his welfare on his behalf, should he lose capacity. There are two types of LPA, personal welfare and
The Court of Protection can rule upon whether a person has capacity, and, if not, appoint deputies
a dispute about the best interests of the person who lacks capacity.
The full text of the MCA is available at http://www.legislation.gov.uk/ukpga/2005/9/section/1
Common law and the Mental Health Act
Common law is the law that is based on previous court rulings (case law, such as Re. C), in
contradistinction to the law that is enacted by parliament (statute law, such as the Mental Health
Act). Under common law, adults have a right to refuse treatment, even when doing so may result
in permanent physical injury or death. If a competent adult refuses consent or lacks the capacity to
said, treatment without consent can be given under common law:
• If serious harm or death is likely to occur and there is doubt about the patient’s capacity at the
time and no advance directive (or ‘living will’) has been made; and the clinician is able to justify
• In an emergency to prevent serious harm to the patient or to others or to prevent a crime.
In England and Wales, the Mental Health Act 1983 (amended in 2007) is the principal Act governing
not only the compulsory admission and detention of people to a psychiatric hospital, but also their
treatment, discharge from hospital, and aftercare. People with a mental disorder as defined by the
dependence on alcohol or drugs. Note that Scotland is governed by the Mental Health (Care and
Treatment) (Scotland) Act 2003 and Northern Ireland by the Mental Health (Northern Ireland) Order
Two of the most common ‘Sections’ of the Mental Health Act used to admit people with a mental
disorder to a psychiatric hospital are the so-called Sections 2 and 3.
Section 2 allows for an admission for assessment and treatment that can last for up to 28 days. An
application for a Section 2 is usually made by an Approved Mental Health Professional (AMHP) with
special training in mental health, and recommended by two doctors, one of whom must have special
experience in the diagnosis and treatment of mental disorders. Under a Section 2, treatment can be
from the mental disorder (so, for example, treatment for an inflamed appendix cannot be given under
(Emergency admission to hospital) or Section 25 (Detention of patients already in Hospital).
Station 49 Common law and the Mental Health Act 131
A patient can be detained under a Section 3 after a conclusive period of assessment under a Section
been established by the care team and is not in reasonable doubt. Section 3 corresponds to an
AMHP with special training in mental health and approved by two doctors, one of whom must have
special experience in the diagnosis and treatment of mental disorders. Treatment can only be given
treated or the recommendation of a second doctor. A Section 3 can be discharged at any time by the
broadly similar to Section 18 of the Health (Care and Treatment) (Scotland) Act 2003.
If a patient has been detained under Section 3 of the Mental Health Act, he or she is automatically
placed under a ‘Section 117’ at the time of his or her discharge from the Section 3. Section 117
corresponds to ‘aftercare’ and places a duty on the local health authority and local social services
authority to provide the patient with a care package aimed at rehabilitation and relapse prevention.
Although the patient is under no obligation to accept aftercare, in some cases he or she may also be
placed under a ‘Supervised Community Treatment’ or ‘Guardianship’ to ensure that he or she receives
aftercare. Under Supervised Community Treatment, the patient is made subject to certain conditions
and if these conditions are not met, he or she can be recalled into hospital.
Commonly used civil Sections of the Mental Health Act are summarised in Table 22.
The principal criminal Sections are Sections 35 and 36, and Sections 37 and 41.
Sections 35 and 36 mirror Sections 2 and 3 (above), but are used for persons suffering from a mental
disorder and awaiting trial for a serious offence. Section 35 can be enacted by a Crown Court or
a Crown Court on the evidence of two doctors, one of whom must be Section 12 approved. In contrast
to Section 36, Section 35 does not enable treatment, and is used solely for the purpose of remanding
duration of 28 days, but can be extended for up to 28 days at a time for up to 12 weeks.
132 Station 49 Common law and the Mental Health Act
Table 22. Commonly used Sections of the Mental Health Act
Section Description Duration Treatment Application/
117 Automatically applies if a patient has been detained under Section 3. Under Section 117
it is the duty of the local health authority and the local social services authority to provide
aftercare. Unlike under Supervised Community Treatment, there is no obligation for the
Psychiatrists (MRCPsych) or having more than 3 years of relevant experience.
Station 49 Common law and the Mental Health Act 133
Section 37 is used for the detention and treatment of persons suffering from a mental disorder and
convicted of a serious offence which is punishable by imprisonment. It is enacted by a Crown Court
or Magistrates’ Court on the evidence of two Section 12 approved doctors. Section 37 has an initial
Examiner’s questions: Mental disorders and driving
and more severe forms of anxiety and depression.
The DVLA then sends the patient a medical questionnaire to fill in, and a form asking for permission
• their illness has been successfully treated with medication for a certain amount of time,
• the patient is conscientious about taking his medication.
• the side-effects of the medication are not likely to impair the patient’s driving.
• the patient is not misusing drugs.
People who suffer from substance misuse or dependence should also stop driving, as should some
people who suffer from other mental disorders such as dementia, learning disability, or personality
Further information can be obtained from the DVLA website at www.dvla.gov.uk. Note that the rules
for professional driving are different from and more strict than those described above.
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain that you are going to ask him some questions to uncover the nature of his eye problem,
• Ensure that he is comfortable.
With loss of vision, be ready to assist or guide the patient to his seat. Although body
language and non-verbal communication is bound to be less effective, avoid speaking too
loudly or otherwise patronising the patient.
Presenting complaint and history of presenting complaint
• Ask open questions to establish or confirm the problem, e.g. red eye, pain, and/or loss of vision
and to elicit the patient’s ideas, concerns, and expectations (ICE). Is the problem unilateral or
bilateral? If unilateral, have there been problems with the ‘good’ eye? If bilateral, which eye is
• For any problem, establish onset (sudden or gradual), duration, timing, progression, and any
aggravating or alleviating factors. For pain, use the SOCRATES mnemonic. Is the pain in or
around the eye? Is it associated with eye movement? For loss of vision, establish the extent
hemianopia suggests compression or lesion at the optic chiasm).
• If not already covered, ask specifically about:
– dry or gritty eye (often aggravated by e.g. reading or watching TV)
– sticky eye (e.g. bacterial conjunctivitis, blepharitis)
– eye discharge or watering (e.g. allergic conjunctivitis)
– glare in sunlight or difficulty driving at night due to glare from headlights (cataracts)
– floaters and flashing lights (associated with retinal tears and detachment)
– haloes (associated with an acute rise in intraocular pressure)
– double vision (not the same as blurred vision)
• Ask about the following systemic symptoms: headaches and scalp tenderness, migraine,
nausea and vomiting, fever, joint pain, rashes and other skin problems, urethral discharge.
Ophthalmology, ENT, and dermatology
Station 50 Ophthalmic history 135
• Previous problems with the eyes/vision.
– Does the patient wear glasses or contact lenses? How long since? Is he having any problems
– Has he ever seen an eye specialist?
– Has he ever had laser or other eye surgery?
– Has he ever suffered any eye trauma (blunt trauma, chemical trauma, foreign body)?
• Current, past, and childhood illnesses. Specifically ask about hypertension (retinopathy, retinal
vein occlusion), diabetes (retinopathy, maculopathy, retinal and vitreous haemorrhage), thyroid
• Over-the-counter medication, including herbal remedies.
• Allergies (may present as a red eye).
• Parents, siblings, and children. Among others, viral conjunctivitis is communicable.
• Employment, past and present: the eye problem might be caused by the work environment,
and may affect ability to work.
• Hobbies such as contact sports that might have led to the eye problem.
• Driving: how is the eye problem affecting ability to drive? Note that the DVLA issues guidelines
on visual requirements for driving.
• Housing and living arrangements: how is the eye problem impacting on living arrangements?
Is the patient at particular risk of falls or injuries?
• Unprotected sexual intercourse.
• Ask the patient if there is anything else that you have forgotten to ask about.
• Ask him if he has any questions.
• Summarise your findings and offer a differential diagnosis. State that the nextstep isto examine
Vision and the eye examination
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ensure that he is comfortable.
• Snellen chart. Assess each eye individually, either from a distance of 6 m or 3 m, correcting for
any refractive errors (glasses, pinhole). If the patient cannot read the Snellen chart, either move
him closer or ask him to count fingers. If he fails to count fingers, test whether he can see hand
movements and, if he cannot, test whether he can see light.
• Test types (or fine print). Assess each eye individually, correcting for any refractive errors.
• Ishihara plates. Indicate that you could use Ishihara plates to test colour vision specifically.
same level as him. Ask him to look straight at you and to cover his right eye with his right hand.
Cover your left eye with your left hand, and test the visual field of his left eye with your right
hand. Bring a wiggly finger into the upper left quadrant, asking the patient to say when he sees
the finger. Repeat for the lower left quadrant. Then swap hands and test the upper and lower
right quadrants. Now ask the patient to cover hisleft eye with hisleft hand. Cover your right eye
with your right hand and test the visual field of his right eye with your left hand. Bring a wiggly
finger into the upper right quadrant, asking the patient to say when he sees the finger. Repeat
for the lower right quadrant. Then swap hands and test the upper and lower left quadrants.
• Mapping of central visual field defects. Indicate that you could use a red pin to delineate the
patient’s blind spot and any central visual field defects.
• Visual inattention test. Ask the patient to fix his gaze upon you and simultaneously bring a
only the ipsilateral finger is perceived by the patient.
• Inspection. Inspect the eyes, paying particular attention to the size and symmetry of the pupils,
and excluding a visible ptosis or squint.
• Test the direct and consensual pupillary light reflexes. Explain that you are going to shine a
bright light into the patient’s eye and that this may feel uncomfortable. Bring the light in onto
his left eye and look for pupil constriction. Bring the light in onto his left eye once again, but
pupil) suggests a lesion of the optic nerve anterior to the optic chiasm.
• Test the accommodation reflex. Ask the patient to follow your finger in to his nose. As the eyes
converge, the pupils should constrict.
Ophthalmology, ENT, and dermatology
Station 51 Vision and the eye examination(including fundoscopy) 137
• Perform the cover test. Ask the patient to fixate on a point and cover one eye. Observe the
movement of the uncovered eye. Repeat the test for the other eye.
• Examine eye movements. Ask the patient to keep his head still and to follow your finger with
his eyes. Ask him to report any pain or double vision at any point. Draw an ‘H’ shape with your
• Nystagmus. Look out for nystagmus at the extremes of gaze. You can do this as part of eye
movements or separately by fixing the patient’s head and asking him to track your finger
Figure 30. Holding the ophthalmoscope.
Explain the procedure, mentioning that it may be uncomfortable. Darken the room and ask the patient
should have been dilated using a solution of 1% cyclopentolate or 0.5% tropicamide.
• Red reflex. Test the red reflex in each eye from a distance of about 10 cm. An absent red reflex
is usually caused by a cataract.
• Fundoscopy. Use your right eye to examine the patient’s right eye, and your left eye to examine
the patient’s left eye. If you use your left eye to examine the patient’s right eye, you may appear
more caring than the examiner might like to see. Look at the optic disc, the blood vessels, and
the macula. To find the macula, ask the patient to look directly into the light. Describe any
features according to protocol, e.g. “There are soft exudates at 3 o’clock, two disc diameters away
If the station is examining fundoscopy alone, the patient is likely to be replaced by a model
in which the retinas are very easy to visualise. Before the exam, it is a good idea to look at
as many retinas as you can, both in patients and in textbooks/on the internet.
138 Station 51 Vision and the eye examination(including fundoscopy)
Figure 31. Findings on fundoscopy of the right eye.
2. Senile macular degeneration.
4. Pre-proliferative diabetic retinopathy.
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