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

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

produce at least five digits.

• 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.

Perceptions

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

and schizophrenia.

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

16.9 Perceptions: definitions

Term Definition

Depersonalisation A subjective experience of feeling unreal

Derealisation A subjective experience that the surrounding

environment is unreal

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

external world

Pseudohallucination A false perception that is perceived as part

of one’s internal experience

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

in a voluntary way.

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

in severe depression).

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?’).

Capacity

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.

Intelligence

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

formally test IQ.

Insight

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

make you better?’

Risk assessment

Risk assessment is a crucial part of every psychiatric assessment.

Consider:

• Who is at risk?

• 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

16

Psychiatric rating scales

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.

They include:

• Abbreviated Mental Test (AMT): takes less than 5 minutes

(Box 16.11)

• Mini-Mental State Examination (MMSE) or Montreal

Cognitive Assessment (MoCA): takes 5–15 minutes.

Well-known instruments assessing areas other than cognition

include:

• general morbidity:

• General Health Questionnaire (GHQ)

• mood disorder:

• Hospital Anxiety and Depression Scale (HADS)

• Beck Depression Inventory (BDI)

• alcohol:

• 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

interpreters.

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).

The physical examination

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

assessment required.

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

panic attacks.

Collateral history

Collateral history is important whenever assessment is limited by:

• physical illness, acute confusional state or dementia

• severe learning disability or other mental disorder impairing

communication

• disturbed, aggressive or otherwise uncooperative

behaviour.

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

presentation (Box 16.10).

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

resistant to treatment)

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

of Oxford University Press.

16.11 The Abbreviated Mental Test

• Age

• Date of birth

• Time (to the nearest hour)

• Year

• Hospital name

• Recognition of two people, e.g. doctor, nurse

• Recall address

• Dates of First World War (or other significant event)

• Name of the monarch (or prime minister/president as appropriate)

• Count backwards 20–1

Each question scores 1 mark; a score of 8/10 or less indicates

confusion.

16.12 The CAGE questionnaire

• 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

specific medical treatment.

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

family.

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

1 drink = 1

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?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

3. How often during the last year have you failed to do what was normally expected of you because of drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

4. In the last year, has a relative or friend, or a doctor or other health worker, been concerned about your drinking or suggested you cut down?

• Never (0)

• Yes, on one occasion (2)

• Yes, on more than one occasion (4)

Scoring FAST

First stage

• If the answer to question 1 is ‘Never’, then the patient is probably not misusing alcohol

• If the answer is ‘Weekly’ or ‘Daily or almost daily’, then the patient is a hazardous, harmful or dependent drinker

• 50% of people are classified using this one question

Second stage

• 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 question 4: 0, 2, 4

• Minimum score is 0

• Maximum score is 16

• Score for hazardous drinking is 3 or more

Putting it all together: clinical vignettes • 327

16

16.16 Clinical vignette: fatigue

A 35-year-old woman attends her general practitioner, presenting with

fatigue.

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

be considered.

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

paranoid thoughts.

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

to the initial assessment.

OSCE example 1: Assessing suicidal risk

Miss Gardiner, 27 years old, presented to the accident and emergency department the previous day after taking an overdose of paracetamol while

intoxicated with alcohol. She has undergone treatment with acetylcysteine overnight and is now medically fit for discharge.

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.

• Enquire how she is feeling physically (specifically asking about nausea, vomiting and abdominal pain).

• Tactfully introduce the subject of the overdose.

• Establish the number and type of tablets taken.

• Establish how much alcohol she drank, whether this was with the tablets (to ‘wash them down’) or whether she was already intoxicated at the time

of the overdose.

• Clarify the circumstances. Who else was present or expected? Did she write a note or otherwise communicate what she had done or was planning

to do?

• 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?

• Confirm her view now. Does she still wish to die? Does she have any thoughts about another overdose or other form of self-harm?

• Establish relevant past history. Are there any previous overdoses? Any previous or continuing psychiatric follow-up?

• Confirm whether she has parental or caring responsibilities for young children. Tactfully enquire about any thoughts of harming them.

• Establish who will be with her when she leaves hospital.

• Thank the patient and clean your hands.

Summarise your findings

The risk assessment should concentrate most on the short-term risk of suicide.

Advanced level comments

More advanced students would be expected to tabulate short- and long-term risk of both suicide and further self-harm, and to quote the risk of

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

Mr Duncan, 82 years old, is admitted to an orthopaedic ward after falling and breaking his hip. Forty-eight hours after surgery he became restless and

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.

• Enquire how he is feeling physically (specifically asking about pain, fever, constipation, and urinary and respiratory symptoms).

• Establish his awareness of where he is, why he is there and how long he has been in hospital.

• Ask how much he remembers of the night’s events and enquire specifically about any recollection of hallucinations or persecutory fears.

• Enquire about any continuing hallucinations or fears.

• Ask about any previous similar episodes.

• Clarify how active he was before his fall, and whether there is any awareness of memory impairment leading up to it.

• Ask about alcohol intake.

• Administer simple tests of cognitive function, especially of attention and memory (advanced performers should know the Abbreviated Mental Test

questions).

• 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.

Summarise your findings

The diagnosis is delirium, with further enquiries needed to establish the likely cause (which may be alcohol withdrawal, given the timing), as well as

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.

• Cover the key headings for the history (presenting symptoms, systematic review, past medical and psychiatric history, current medication, substance

misuse, family history, personal history).

• Cover the headings for the personal history (childhood development, losses and experiences, education, occupation, financial circumstances,

relationships, partner(s) and children, housing, leisure activities, hobbies and interests, forensic 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.

• Cover the headings for the mental state examination systematically (appearance and behaviour, speech, mood, thought form and content,

perceptions, cognition and insight).

• Use brief formal tests to assess cognitive function (Abbreviated Mental Test, Mini-Mental State Examination, Montreal Cognitive Assessment).

• 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.

• Gather further background information from other sources to the degree necessary (with permission).

• As well as a diagnosis and management plan, be sure to consider:

• assessment of risk to self or others

• capacity to take decisions

• need to use mental health or incapacity legislation.

17

The frail elderly patient

Andrew Elder

Elizabeth MacDonald

Assessment of the frail elderly patient 330

Factors influencing presentation and history 330

The history 331

The presenting symptoms 331

Common presenting symptoms 331

Past medical history 331

Drug history 331

Family history 332

Social and functional history 332

Systematic enquiry 332

The physical examination 333

General examination 333

Systems examination 334

Functional assessment 335

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

elderly patient 337

Integrated clinical examination for the frail elderly patient 338

330 • The frail elderly patient

Factors influencing presentation

and history

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 difficulties,

cognition and mood

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

time-consuming.

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:

• cognitive function and mood

• nutrition and hydration

• skin

• pain

• continence

• hearing and vision

• functional status.

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

cognitive function.

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

younger, and vice versa.

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

effects of minor illness.

17.1 The multiprofessional team

Professional Key roles in assessment of

Physician Physical state, including diagnosis

and therapeutic intervention

Psychiatrist Cognition, mood and capacity

Physiotherapist Mobility, balance, gait and falls risk

Occupational therapist Practical functional activities

(self-care and domestic)

Nurse Skin health, nutrition and continence

Dietician Nutrition

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

Problem Comment/causes

Deafness Nerve or conductive

Dysphasia Most commonly due to stroke disease but sometimes

a feature of dementia

Dysarthria Cerebrovascular disease, motor neurone disease,

Parkinson’s disease

Dysphonia Parkinson’s disease

Dementia Global impairment of cognitive function

Delirium Impaired attention, disturbance of arousal and

perceptual disturbances

Depression May mimic dementia or delirium

Fractures, dislocations and trauma • 279

13

The history

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

column.

The physical examination

Use the ‘Look – feel – move’ approach. Observe patients

closely to see if they move the affected part and are able to

weight-bear.

Examination sequence

Look

• 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

infection (Fig. 13.48).

Feel

• 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

may arise in:

• normal bone from excessive force

• normal bone from repetitive load-bearing activity (stress

fracture)

• 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.

A

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

Move

• Establish whether the patient can move joints distal and

proximal to the fracture.

• 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

below.

$ %

Fig. 13.48 Ankle deformity. A Clinical appearance. B Lateral X-ray

view showing tibiotalar fracture dislocation.

13.19 Describing a fracture

• 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/

metaphysis/diaphysis)?

• 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

percentage.

• Angulation is defined by the movement of the distal fragment,

measured in degrees.

• 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

Urinalysis

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

Haematological

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

Biochemical

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

Serological

Immunoglobulin M rheumatoid factor ↑ titres in 60–70% of cases of RA; occasionally, low titres in other connective diseases. Present

in up to 15% of normal population. Superseded by anti-cyclic citrullinated peptide antibodies

Anti-cyclic citrullinated peptide antibody (ACPA) Present in 60–70% of cases of RA and up to 10 years before onset of disease. Highly specific for

RA. Occasionally found in Sjögren’s syndrome

Antinuclear factors ↑ titres in most cases of SLE; low titres in other connective tissue diseases and RA

Anti-Ro, Anti-La Sjögren’s syndrome

Investigations

Common investigations in patients with musculoskeletal disease

are summarised in Box 13.20.

Investigations • 281

13

13.20 Common musculoskeletal investigations – cont’d

Investigation Indication/comment

Anti-double-stranded DNA SLE

Anti-Sm SLE

Anti-ribonucleoprotein Mixed connective tissue disease

Antineutrophil cytoplasmic antibodies Granulomatosis with polyangiitis, polyarteritis nodosa, Churg–Strauss vasculitis

Other

Schirmer tear test, salivary flow test Keratoconjunctivitis sicca (dry eyes), Sjögren’s syndrome

Imaging

Plain radiography (X-ray) Fractures, erosions in RA and psoriatic arthritis, osteophytes and joint-space loss in osteoarthritis,

bone changes in Paget’s disease, pseudofractures (Looser’s zones) in osteomalacia

Ultrasonography Detection of effusion, synovitis, cartilage breaks, enthesitis and erosions in inflammatory arthritis.

Double contour sign in gout

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

Dual-energy X-ray absorptiometry Gold standard for determining osteoporosis. Usual scans are of lumbar spine, hip and lateral

vertebral assessment for fractures

Isotope bone scan Increased uptake in Paget’s disease, bone tumour, infection, fracture. Infrequently used due to

high radiation dose.

Joint aspiration/biopsy

Synovial fluid microscopy Inflammatory cells, e.g. ↑ neutrophils in bacterial infection

Polarised light microscopy Positively birefringent rhomboidal crystals – calcium pyrophosphate (pseudogout)

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.

Please examine the shoulder

• 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.

• Perform active and passive movements. In particular, look for frozen shoulder, which is diagnosed by limitation of external rotation and flexion.

• 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.

Summarise your findings

The patient reports pain between 120 and 60 degrees of abduction when lowering the abducted shoulder. Pain is reproduced on abduction against

resistance.

Suggest a differential diagnosis

The most common cause of these symptoms is impingement syndrome, which can be confirmed by carrying out special tests (Neer and Hawkins–

Kennedy). Differentials include frozen shoulder, calcific tendonitis, acromioclavicular joint pain, arthritis (osteoarthritis, rheumatoid arthritis or

post-traumatic), long head of biceps rupture and referred pain from the neck.

Suggested investigations

X-ray will reveal degenerative changes in osteoarthritis or tendon calcification. Ultrasound may demonstrate effusions, calcific deposits and tendon

damage/rupture.

282 • The musculoskeletal system

OSCE example 2: Painful hands

Mrs Hill, 46 years old, presents with an 8-week history of insidious onset of pain, stiffness and swelling of her hands. She smokes 15 cigarettes per day.

Please examine her hands

• Introduce yourself and clean your hands.

• Look:

• 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).

• Feel:

• 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.

• Move:

• Painful MCP joints in right hand on active and passive flexion, reducing handgrip and fine movements.

Summarise your findings

The patient has tender, soft swelling of two MCP joints and one PIP joint. There is pain on active and passive movement of the affected joints, resulting

in limitation of hand function.

Suggest a differential diagnosis

The pattern of joint involvement, patient’s gender, duration of symptoms and history of smoking support a clinical diagnosis of rheumatoid arthritis. The

differential diagnosis of psoriatic arthropathy is less likely because of her normal nails and lack of the typical skin changes of psoriasis.

Suggest initial investigations

Full blood count, renal function tests, calcium, phosphate and liver function tests to assess for anaemia of chronic disease and to determine suitability

for disease-modifying antirheumatic drugs; C-reactive protein to assess the degree of systemic inflammation; anti-CCP antibody to confirm whether

seropositive rheumatoid arthritis is present; application of the 2010 American College of Rheumatology/European League Against Rheumatism criteria

(see Box 13.14) for classification of rheumatoid arthritis; hand and foot X-rays to detect any bony erosions; chest X-ray to look for rheumatoid lung

disease.

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?

• Examine gait and spine in more detail first, if appropriate, then position the patient on the couch for detailed joint examination.

• 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.

• Move:

– Active movements first: demonstrate to the patient then ask them to perform the movements. Is there pain or crepitus on movement?

– Passive movements second: determine the patient’s range of movement. Measure with a goniometer. What is the end-feel like? Describe the

deformities.

• If systemic disease is suspected, go on to examine all other systems fully.

• Consider what investigations are required:

• Basic blood tests.

• Inflammatory markers.

• Immunology.

• Ultrasound.

• X-rays.

• Special tests.

• Joint aspiration for synovial fluid analysis or culture.

14

The skin, hair and nails

Michael J Tidman

Anatomy and physiology 284

Skin 284

Hair 285

Nails 285

The history 285

Common presenting symptoms 285

Past medical and drug history 285

Family and social history 286

The physical examination 286

Distribution of a rash 286

Morphology of a rash 286

Morphology of lesions 290

Hair and nail signs 290

Supplementary examination techniques 291

Investigations 292

OSCE example 1: Pruritus 292

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.

Anatomy and physiology

Skin

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

and glycoprotein.

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

of the skin.

Fig. 14.1 Structures of the skin.

Epidermis

Dermis

Subcutis

Shaft of hair

Opening of sweat duct

Sweat duct

Subpapillary vascular plexus

Sebaceous gland

Arrector pili muscle

Sweat gland

Hair follicle

Subcutaneous adipose tissue

Deep cutaneous vascular plexus

Muscle layer

14.1 Functions of the skin

• Protection against physical injury and injurious substances, including

ultraviolet radiation

• Anatomical barrier against pathogens

• Immunological defence

• Retention of moisture

• Thermoregulation

• Calorie reserve

• Appreciation of sensation (touch, temperature, pain)

• Vitamin D production

• Absorption – particularly fetal and neonatal skin

• Psychosexual and social interaction

The history • 285