MRCP PACES Communication Skills and History Taking Notes

Session One
MRCP-PACES
ETHICS & COMMUNICATION SKILLS
MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/201
Copyright: KM-426122-613404
1. Ethical issues:
Respect for Patient Autonomy
Consent
Confidentiality/Disclosure/Public interest
Justice
2. Public protection:
a- Driving;
Epilepsy
Diabetes Mellitus
and TIA
and eart disease
b- GU infeci!n"#C!$$%nicab&e 'i"ea"e"(
I!
T"
"!
3. Breaking Bad News
4. Medico legal issues:
Resuscitation/D#R
Ad$ance directi$es
"rain deat% & persistent $e'etati$e state
Coroner referral
Eut%anasia
Postmortem e(amination
Or'ans donation
Reli'ious bioet%ics
5. ounseling:
Multiple Sclerosis
ID & Cardiac re%abilitation
Cystic )ibrosis
untin'ton*s Disease
R%eumatoid Art%ritis
+ncontrolled DM
"ronc%ial Ast%ma/COPD
!. Procedures:
eart,-un' Transplant.
CA"/
Pacema0ers
"ronc%oscopy
Endoscopy
)* U+'ae' NICE G%i'e&ine"(
"eta,Interferon in MS
Infli(imab 1anti,T#)2 in RA & CD
La,$an Eng&i"-(
.ee& e'g, /an e'ge0( #er$ous
Inva&i'( Terminally ill
L!1( Depressed
Give 1a,( Collapse
Hea' +iece( "rain
.aining( Syncope
Gi''ine""( !erti'o
.i"#S-a2e"( Epilepsy/Con$ulsions
Ringing in ear"( Tinnitus
3ac2 +a""age( Anus
3!!$( "uttoc0s
P-&eg$( Sputum
T%be"( -un's
P%ffe'#P%ff,( "reat%less
Hear aac2( MI
T-e 4e&fare( Social ser$ices
Ge -e "ac2( -ose 3ob
P%ffe' %+( S4ollen
T%$$,#be&&,( Stomac%/bo4el
G%&&e( Oesop%a'us
.ee&" "ic2( #auseated
3een "ic2( !omited
4in'( )latulence
- T! be&c-( Send 4ind from stomac%
- T! +ar( 55 55 anus
T!i&e"( Motions/stools
4aer( +rine
Kee+ 1aning ! g!( )re6uency
T! ge %+ a nig-( #octuria
A gr!1-( A mass5 cancer 1also7 t%e big C2
L!"e( Menses
Pic%re"#I$aging( 8,Rays
Te$+era%re( )e$er
Ge bac2#.&are( Relapses
T! be &!!2ing#! %rn -e c!rner( Impro$es
T! be &ai' %+( Confined to bed
T! fin' !ne5" &eg"( Start 4al0s after illness
T! -ave a ba' %rn( "ecomes suddenly ill
T! -ave a b%g( To catc% a $irus/infection
T! &!"e !ne5" na%re( "ecomes impotent
T! g! "ea',( To %a$e a re'ular partner
(Ref: English for Overseas Doctors)
T-e 3rii"- Hea&- S,"e$
/uidelines & Policies7
T%e /eneral Medical Council 1/MC2
T%e #ational Institute of Clinical E(cellence 1#ICE2
T%e Scottis% Intercolle'iate /uidelines #et4or0 1SI/#2
T%e Royal Colle'es
ospitals 1#S27 SO5 SpR5 Consultants
T%e /Ps
T%e Social Ser$ices System
T%e ome ealt% Care
Pre$enti$e Section5 CICD
T%e -e'al Ad$isor5 t%e Coroner system5 etc
Occupational %ealt% ser$ices & re%abilitation
T%e #ursin' teams7
, Specialist nurses 1diabetes5 Ast%ma52
, District nurses
, Teams 1e.'. McMillan team2
, #ursin' %omes
!oluntary a'encies
Support 'roups & Societies 1MS2
Station 97 ETICS and COMM+#ICATIO#
Can'i'ae5" In"r%ci!n"(
o You will be given 5 minutes before entering the examination room to read a
scenario & to mae !our "lan of action# On hearing the bell$ enter the room
& begin the consultation#
o You will have %& minutes to interview the "atient'actor & one minute after
he'she leaves the room to organi(e !our thoughts and to "re"are !ourself for
the discussion with the examiners#
o Don)t re*tae histor! from the "atient and don)t examine him'her#
In t%is section some scenarios 4ill be presented & 4ill be follo4ed by a su''estion on %o4
to approac% similar situations 4%en you5 %opefully face t%em in your actual e(amination.
T%is 4ill be preceded by s%ort tal0s emp%asi:in' essential et%ical & le'al issues and some
important 'uidelines e.'. D!-A5 I#) in MS5 End of life decisions etc.
A compre%ensi$e 0no4led'e of +; la4 is not re6uired from o$erseas candidates< %o4e$er5
t%ey are e(pected to 0no4 in broad terms rele$ant et%ical & le'al principles.
Many candidates fail t%is section of t%e PACES e(amination not as a result of its difficulty5
but because t%ey fail to prepare to it ade6uately. On t%e ot%er %and5 many of t%e successful
ones feel t%at 4it% 'ood preparation5 success in t%is section is probably more predictable
t%an in any ot%er section of t%is e(am.
666T-e 2e, "enence ! "%cce"" i" 7Pracice & +racice i&& $a"ering8

Station 97 ETICS and COMM+#ICATIO#
USE.UL HINTS
=%en 'i$en t%e scenario outside t%e e(amination rooms ST+D> it carefully &
decide at first 4%ic% et%ical/communication principle is bein' tested.
T%en on t%e pro$ided paper 4rite do4n t%e points t%at you 4ould li0e to discuss
4it% t%e patient/actor & t%e plan of action needed to mana'e t%e 'i$en problem.
On enterin' t%e e(am. room5 start by 'reetin' t%e e(aminers t%en sit facin' t%e
patient5 'reet %er/%im & inr!'%ce "e&f an' e9+&ain r!&e e.'. ? ello Mrs. 8. I*m
doctor >5 t%e medical SO 4%o is loo0in' after your %usband@. T%en agree -e
+%r+!"e !f -e inervie1 ?=e are %ere today to discuss t%e result of %is bone
ima'in'. Is t%at ri'%tA =ould you li0e to discuss any ot%er issueA@
Maintain 'ood eye,to,eye contact 4it% t%e patient & put %im/%er at ease.
Start t%e inter$ie4 4it% open,ended 6uestions ?e.'. 4%at do you 0no4 about your
%usband*s conditionA@ or ?I learned from your /P*s letter t%at you %a$e %ad a
sei:ure last 4ee0end5 can you tell me more about t%atA@
+se close,ended 6uestions as t%e inter$ie4 pro'resses.
Pro$ide clear & understandable e(planations
Av!i' %"ing :arg!n"
"t the end o# the inter$iew:
, Agree" a clear course of action 4it% t%e patient
, S%$$ari;e"
, C-ec2 %n'er"an'ing 1e.'. ?4%at messa'e you 4ill ta0e
%ome 4it%
youA@ or ?4%at are you 'oin' to tell t%e ot%er members of t%e
familyA@2
, S%a0e %ands & say 'oodbye.
PRINCIPLES O. MEDICAL ETHICS
T-e < Princi+&e" !f Me'ica& E-ic"
=* Re"+ec f!r Paien A%!n!$,
>* 3eneficence
?* N!n-$a&eficence
<* @%"ice
1. %especting the patient&s "utono'(: 14is%es & self,rule2
Autonomy7 means self rule i.e.1t%e capacity to t%in05 decide & act freely and
independently2. It is t%e patient*s ri'%t to be in$ol$ed in any decision about %is %ealt%.
T%is re6uires t%at t%e %ealt% professionals %elp patients in ma0in' t%eir o4n decisions and
respect & follo4 t%ese decisions. Respect of autonomy implies t%at doctors treat competent
patients in accordance 4it% t%eir informed c%oices5 e$en if t%ese conflict 4it% t%e doctor*s
beliefs.
2. Bene#icence: 1doin' 'ood to & promotin' of 4%at is best for t%e patient.2
T%is entails doin' 4%at is best for t%e patient.
In most situations B&C lead to t%e same conclusions5 %o4e$er5 t%e t4o principles conflict
4%en a competent pt. c%ose a course of action t%at is not in %is/%er best interests.
D If suc% a conflict arises 1Autonomy $s. "eneficence27
B. Ma0e sure t%at t%e patient is competent
C. E(plain t%e possible conse6uences of %is c%oice 1e.'. refusal of treatment2
E. Su''est discussin' ot%ers 1a friend5 family member5 etc2 & a senior collea'ue
9. Respect t%e patientFs autonomy
3. Non)'ale#icence: 1do no %arm5 need to a$oid %arm2
=it% re'ard to treatment & procedures5 t%e potential 'oods & %arms and t%eir possibilities
must be 4ei'%ed up to decide 4%at5 o$erall5 is in t%e patient s best interest.
D DT%ese t4o last principles imply t%at7
B. Treatment must be t%ou'%t li0ely to be successful OR t%at5
C. Potential benefits o$er4ei'%t potential ris0s.
4. *ustice: 1fairness in pro$ision of %ealt% care2
Refers to t%e duty of t%e doctor to t%e 4%ole society.
A. Patients 4it% similar situation s%ould 'et accessibility to similar %ealt% care.
". =%en determinin' 4%at le$el of care s%ould be a$ailable to one set of patients5 4e
s%ould ta0e into account t%e effect of suc% use of resources on ot%er patients 1i.e. 4e
must try to distribute limited resources fairly2. +sin' t%ese resources to a''ressi$ely
treat a terminally ill patient is potentially depri$in' ot%ers of t%e treatment.
DSometimes t%e patientFs autonomy conflicts 4it% t%e GPublic InterestG. In suc% a
case t%e latter must be respected< as your role for t%e 4%ole society is more superior
to respectin' t%e patientFs autonomy.
CONSENTING PATIENTS
T,+e" !f C!n"en(
=* E+pressed: =ritten or $erbal a'reement for t%e procedure
>* ,'plied: e.'. t%e patient*s action in response to a re6uest for e(am.
?* -tatuar(: =%en t%e la4 re6uites a particular consent e.'. I!)
E&e$en" !f va&i' c!n"en(
AALID CONSENT B
Un'er"an'ing 1+om"etent "atient , -""ro"riate .nformation2
C A!&%nar, 'eci"i!n 1i#e# without coercion2
True informed consent re6uires t%at t%e patient does not merely passi$ely assents to t%e
doctor*s decision5 but specifically aut%ori:es t%e doctor to initiate t%e medical plan.
Inf!r$ai!n ! be +r!vi'e' ! -e +aien(
Diagnosis'/rognosis
0ncertaint! about the diagnosis'need for further investigations
/ur"ose$ details & ex"ected outcome of "rocedures
1iel! benefits & "robabilit! of success
/ossible side*effects & com"lications
Tec-niD%e"(
, +se illustrations5 4ritten or $isual aids for e(planation
, Allo4 a relati$e/a friend to attend if t%e patient a'rees
, In$ol$e ot%er staff e.'. a nurse
, /i$e a balanced $ie4
, Allo4 sufficient time for reflection & decision,ma0in'
C!n"en in Eng&i"- &a1(
4-a i" C!$+eence /Ca+aci,0E
A competent patient must fulfill t%e follo4in' re6uirements & demonstrate t%em repeatedly
and consistently7
.nderstands a sim"le ex"lanation of his'her medical condition$ treatment and
ex"ected outcome#
.s able to reason about s"ecific goals of treatment & choose to act on the best of
such reasoning#
o''unicates his'her choice & the reason for this choice#
0nderstands the conse/uences of such choice#
N*3* , A patient s%ould not be re'arded as incompetent merely because %e ma0es
a decision t%at is a'ainst %is best interest.
, Competence is ?function specific@
Consent cont*dH
011 o'petent patient:
A. A competent patient may refuse any5 e$en life,sa$in' treatment.
Anyt%in' done 4it%out t%e patient*s consent5 e$en touc%in'5 is batter( 1for 4%ic%
dama'e may be a4arded2. In contrast to ne'li'ence5 t%e patient doesn*t need to
pro$e t%at %e/s%e %as suffered %arm as a result of t%e battery for dama'es to be
a4arded.
". T%e patient s%ould be 'i$en information about t%e nature of t%e procedure or ot%er
medical inter$entions 1ot%er4ise battery25 common & rare side,effects5 benefits &
reasonable alternati$es 1ot%er4ise negligence: failure to 'i$e appropriate
information to t%e patient before c%oosin' to accept/refuse a treatment or a
dia'nostic test.
021 ,nco'petent patient:
P!""ib&e a++r!ac-e"(
A. Doctors s%ould act in -e be" inere"" !f +aien"*
Relati$es & friends may be approac%ed as a source of information to 3ud'e t%e
patient*s best interests5 but can*t 'i$e or 4it%%old consent 1i.e. t%ere is n! +r!9,
c!n"en for an incompetent adult patient2.
#"7 T%!r 'aive 1Partners%ip 'i$in'2
". S%b"i%e' :%'g$en( =%at treatment option 4ould t%e patient c%oose if %e
become competentA
To ans4er t%is 6uestion5 Consider7
, T%e patient*s pre$iously e(pressed preference
, is 'eneral $alues & bac0'rounds
, T%e doctor*s e(perience 4it% ot%er patients
C. A'vance Direcive"(
S%ould be respected after ensurin' t%at t%e patient 4as competent & %ad all t%e
rele$ant information and t%at %e %ad considered t%e clinical situation t%at %as arisen.
D. Inv!&ve -!"+ia&5" &ega& a'vi"er#a++&, ! -e C!%r if(
T%ere are differences of opinions/contro$ersy in t%erapy.
E9a$inai!n#e"ing & rea$en 1i-!% c!n"en(
%# 2or life*saving "rocedures when the "atient is unconscious'incom"etent to indicate
his'her wishes#
3# 4here a "atient is inca"able of giving consent as a result of a mental illness$ the
treatment should be based on the "atient)s 5best interest6 "rinci"le#
7# 4here a minor (8%9 !ears of age) is a ward of +ourt & the +ourt decides that a
s"ecific treatment should be given in the child)s 5best interest:#

SESSIO# T=O
U"ef%& S2i&&" in 3rea2ing 3a' Ne1"
33N Se+-b,-"e+(
/=0Pre+arai!n(
"efore tal0in' to t%e patient / relati$e7
, a$e all t%e facts a$ailable< ensure pri$acy5 uninterrupted inter$ie45 etc
, Ma0e sure t%at support is a$ailable from an e(perienced nurse5 a relati$e / friend
or an appropriate reli'ious support
, )ind out 4it% 4%om you are 'oin' to spea0/Any relati$es aroundA
/>0 C-ec2 a1arene""(
Establis% t%e patient/relati$e*s current 0no4led'e e.'. ?a$e you any t%ou'%ts of 4%at
mi'%t be causin' your / %er pain or problemA ,,, =%at you understand from all t%e tests
t%at 4ere carried outA ,,, a$e you any idea of 4%at*s 'oin' 4ron' 4it% youA@
T%is 4ill %elp to 3ud'e t%e 'ap bet4een t%e person*s perception & t%e reality.
I" $!re inf!r$ai!n 1ane' & -!1 $%c-E
?=ould you li0e me to e(plain a bit moreA Do you li0e to 0no4 e$eryt%in'A
Don*t force information into t%e patient.
/?0 Give a 71arning "-!8(
?I am afraid t%at it loo0s rat%er more serious@
T%en pause to allo4 t%e pt to prepare for t%e ne4s. T%e pt 4ill t%en as0 for clarification
or re,maintain an eye contact 4%en ready to listen to more.
T-en give f%r-er 'eai&"F to narro4 t%e 'ap step,by,step. A$oid information o$erload
& t%e use of 3ar'ons. Spea0 out slo4ly & clearly.
/?0Pa%"ing & ac2n!1&e'ging 'i"re""(
Don*t be afraid of silence.
Allo4 time for t%e bad ne4s to be absorbed & t%e response to occur.
=ait for a si'nal t%at t%e pt. is ready to re,en'a'e in t%e con$ersation.
Acti$ely ac0no4led'e distress ?I can see t%at 4%at you %a$e %eard %as made you
$ery upset@
/<0 Enc!%rage veni&ai!n !f fee&ing"(
T%is is t%e 0ey p%ase in items of pt satisfaction 4it% t%e inter$ie4. It also 'i$es you t%e
c%ance to s%o4 empat%y.
/G0 Reaci!n" ! -e ba' ne1"(
r(ing:
A$oid loo0in' embarrassed & let t%e pt 0no4 t%at t%is is understandable & normal
be%a$ior5 also a$oid spea0in' 4%ilst t%e patient is reco$erin' %is composure.
a$e tissues a$ailable
"nger:
An'er is from t%e bad ne4s & is not a'ainst you.
Remain ob3ecti$e5 stay calm & don*t 'et defensi$e.

2enial3disbelie#:
A useful copin' mec%anism. e.'. ?Are you sure t%at %e is deadA
Could t%ere %a$e been some mista0e e.'. identificationA
Are you sure t%at t%ese reports are mineAG
)irmly5 but 'ently5 reassure t%e person.
4uilt: e.'. ?I s%ould %a$e made %im come to t%e %ospital earlierI@
/H0 Di"c%""ing +r!gn!"i"(
1;ey ad$ice7 "e %onest & realistic, A$oid 'i$in' specific time frames.2
66C!$$!n&, a"2e' I5" ab!% 'ea- & ',ing(
5"' , going to die67
?I am afraid t%at your cancer is so ad$anced5 t%at it is li0ely to s%orten your life@
58ow long ha$e , got67
A useful frame4or0 is ?I can not tell e(actly. It may be mont%s rat%er t%an years5 but it is
unli0ely to be a fe4 4ee0s@
A better approac% mi'%t be7 ?Different cancers be%a$e differently in different people & it
isn*t possible to predict e(actly %o4 t%ey be%a$e in eac% indi$idual@
J Encoura'e %ope7 ?-et us loo0 fore4ord e.'. symptom control5 a birt%day5 8,mas etc@
C!&&%"i!n 1i- re&aive"(
52on&t tell hi' doctor9 the news will kill hi'.:
=%en re6uested by relati$es not to tell t%e patient7
B2 Ac0no4led'e t%eir concerns & stress. E(plain t%at you 4ill %andle t%e matter
sensiti$ely.
C2 Outline t%e et%ical position often %elps. e.'. ? >our %usband1t%e pt.2 %as t%e ri'%t to
0no4 if %e 4ants5 but I 4ill not force t%e information on %im.@
E2 Stress t%at it is best to be open no4 about t%e situation rat%er t%an ris0in' t%e
distrust of t%e patient if %e found out at a later sta'e.
T%en e(plain t%at tellin' %im about t%e bad ne4s is not all bad ?e mi'%t %a$e t%in's to
do5 specific people to be around5 some 4ills to tell5 plannin' for t%e 3ourney5 etc@
/H0 I'enif,ing !-er c!ncern"(
, Elicit all t%e pt*s main concerns 1e.'. pain relief c%emot%erapy5 sur'ery etc.2
before 'i$in' ad$ice or furt%er information.
, Reassurance can be 'i$en t%at e$ery effort 4ill be made to %elp t%e patient
e.'. 'i$in' t%e best possible care5 %elpin' pain relief etc.
, Don*t 'i$e a false reassurance about t%e future.
, )oster %ope but don*t allo4 misunderstandin' treatment for cure.

/)0 S%$$ari;e"F
& C-ec2 %n'er"an'ing freD%en&,(
e.'. ?=%at messa'e you are ta0in' %ome 4it% youA@
?=%at you are 'oin' to tell t%e ot%er members of t%e familyA@

1K2 En"%re c!nin%i, !f care#"%++!r(
Support7 e.'. ? =e 4ill do our best to ma0e you/%im as comfortable as possible@
E(plain t%e potential treatment a$ailable & s%are 4it% %im/%er t%e mana'ement
plan e.'. radiot%erapy for bone metastasis5 feedin' etc
Offer a$ailability
12ocu'ent in the patient&s 'edical records1
U"ef%& Sraegie" in 33N(
A&1a," re"+ec -e +aien a%!n!$,. Don*t discuss %is condition 4it% relati$es
4it%out %is consent.
H!ne", is t%e best policy.
D!n5 e&& -e + $!re -an -e#"-e 1an" ! 2n!1
Never give a "+ecific i$e +eri!'
D!n5 a2e a&& -e -!+e a1a,< find some reason to be optimistic e.'. encoura'es
t%e pt to loo0 fore4ord to a particular e$ent suc% as a birt%day5 a period of
remission or pain,free deat%. o4e$er5 you s%ould never give a fa&"e -!+e*
Pifa&&" in 3rea2ing 3a' Ne1"(
""# 4it%out e(plorin' t%e patientFs 4illin'ness to 0no4 t%em
"ein' unsure of t%e information to 'i$e to t%e patient
""# too early 4it%out preparin' t%e patient by a reasonable G4arnin' s%otG
Delayin' t%e bad ne4s in a fear of t%e patient reactions
/ettin' s%a0y or %esitant 4%en as0ed direct Ls by t%e patient li0e GIs it cancerAG Or
GIs s%e 'oin' to dieAG
Remember to brea0 t%e "# at an appropriate time & to lea$e ade6uate amount of
time to deal 4it% t%e patientFs reactions5 ot%er concerns5 or discussin' ot%er rele$ant
issues e.'. D#R5 Postmortem5 etc
Session T%ree

C!%n"e&ing f!r an HIA e"ing
Ob:ecive" !f Pree" 'i"c%""i!n(
%# ;o clarif! wh! the "atient have to be tested & what are his ex"ectations
3# ;o "rovide information on technical as"ects of the test
7# ;o "rovide information on "ossible im"lications of the test
&# ;o educate about riss of transmission & ris reduction
C!n"ening f!r HIA e"ing(
, In most cases informed consent is sou'%t. =ritten consent is only re6uired from
blood donors and for life insurance.
, Implied consent can be assumed 4%en an indi$idual is re6uestin' to be tested.
, =%en testin' a seriously ill patient in order to ma0e a dia'nosis5 t%e doctor s%ould
act in ?t%e patient*s best interest@. Informed consent s%ould normally be obtained.
Pree" C!%n"e&ing(

Tec-nica& a"+ec" !f -e HIA e"(
A simple5 clear & 3ar'on,free e(planation of t%e test s%ould be 'i$en to t%e patient. =ritten
materials s%ould be a$ailable as some indi$iduals may li0e to defer t%e test.
E(amples of information t%at patients need to be told7
, It is a simple blood test & its result 4ill be a$ailable t%e same day.
, It reflects t%e I! status in t%e pre$ious t%ree mont%s 1e(plain in a simple lan'ua'e
Pretest discussion checklist
.ntroduce !ourself & clearl! identif! !our role
-ssess ris factors & ex"lore <.='-.D>
Ex"lain the test "rocedures
Discuss "otential advantages'disadvantages
Discuss co"ing with the test results
.dentif! "ersonal$ social & medical su""ort s!stems
Discuss how to "rotect sexual "artner(s) in the meantime (safer sex and'or
safer drug use)
.f a female$ discuss "regnanc! & fertilit!
+hec who the "atient lie to tell & who has alread! been told
t%e 4indo4 period2. A sin'le test at E mont%s 4ill dia'nose t%e ma3ority of patients.
, E(plain t%at if t%e test is positi$e5 a confirmatory test 4ill be re6uired on anot%er
blood sample in t%e same day.
, If someone is labeled as I! positi$e5 t%is means %e is confirmed positi$e.
A'vanage" an' Di"a'vanage" !f HIA e"ing
3enefi" /A'vanage"0 !f HIA e"ing
011 ,ndi$idual health bene#its:
B. Early dia'nosis & institution of anti,retro$iral t%erapy
C. Prop%yla(is a'ainst opportunistic infections e.'. PCP
E. Screenin'/prop%yla(is a'ainst T"5 STD5 etc
9. Appropriate $accinations
M. Institution of ot%er %ealt% measures
N. "etter moti$ation for safer se( and dru's use
O.
021 Public Bene#its:
B. Reduction of %i'% ris0 be%a$iors & attitudes
C. Monitorin' of I! epidemiolo'y
E. Impro$ement of t%e 'eneral a4areness of I!
9. O$erall reduction of t%e pre$alence of I!/AIDS
Ri"2" /'i"a'vanage"0 !f HIA e"ing
B. )alse positi$e/ne'ati$e results
C. Psyc%olo'ical reactions
E. Possible loss of 3obs
9. Conse6uent problems 4it% mort'a'e
M. Difficulties in 'ettin' life insurance
N. Social relations%ip prospects
O. "reac% of confidentiality
HIA( Inr!'%ci!n ! 'i"c%""i!n
, A discussion of dia'nostic possibilities & results of in$esti'ations to date may %elp.
, C%ec0 a4areness of7 , #ature of t%e test
, Difference bet4een I! and AIDS
, Ris0 factors/ris0 reduction met%ods
, If t%ere is e$idence of I!5 t%e patient s%ould be told of t%is.
, As0 %im/%er if t%ere are any t%ou'%ts as to 4%at t%e illness mi'%t beA
, En6uire about ris0 factors in an indirect 4ay e.'. marital status5 se(ual acti$ities5
partner1s2/5 e(posure to %i'% ris0 be%a$iors5 P/ STD5 tra$el abroad5
dru' use5 blood transfusion etc
, As0 about any pre$ious test or recent blood donation.
, As0 if %e 4ould li0e to %a$e an I! test performedA

E'%cae(
, Met%ods of transmission5 ris0 factors & %o4 to reduce t%em.
, T%at e$ery day social & domestic acti$ities are safe.
, T%at t%e patient 4ill %a$e continued medical care re'ardless of t%e test result.
, Discuss ad$anta'es & disad$anta'es of testin' and %o4 %e/s%e 4ill cope 4it% result.
, Inform of t%e a$ailability of social & psyc%olo'ical support.
C!nfi'enia&i,(
, Patients can be reassured t%at t%eir I! results 4ill only be seen for ?Medical@ reasons
by doctors& nurses in$ol$ed in t%eir care.
, Samples may be labeled ?i'% Ris0@ & p%rases li0e ?-o4 T9 Count@ or ?Retro$iral
Illness@ may be used.
, Reassure t%e patient t%at t%e front of t%e notes 4ill not be c%an'ed to identify t%e
infection. 1See section Cof #S !enereal Disease Re'ulation BPO92
, It is important to discuss 4it% patient 4%o t%ey 4ant to made a4are of t%eir illness
e.'. a partner5 family doctor etc
, As a 'eneral rule5 information is best disclosed on ?A #eed to ;no4@ only.
HIA( Giving -e re"%&
,# the result is P;-,<,=E:
o ""#7 ,,, S%oc05 an'er denial etc ,,,,, EMPAT>
o IS IT I! OR AIDSA
o P&an !f aci!n(
o Q =%at is t%e ne(t stepA
o Q =%o 4ill be loo0in' after t%e patientA
o Q =%at furt%er tests need to be doneA
o Q Any t%erapeutic measures/inter$entionsA
o Q =it% 4%om t%e patient 4is%es to s%are t%e informationA
o Q Educate7 safer se(5 in3ectin' practices etc
o Q "e ready to ans4er t%e patient*s 6uestions & 6ueries5
e.'. ?o4 lon' %a$e I been infectedA@ In t%is case t%e patient
4anted to discuss 4%o else mi'%t %a$e been infected
o Q /i$e 4ritten information
o Q Pro$ide t%e patient 4it% a list of $oluntary a'encies5 support 'roups5
and social 4or0 facilities.
,# the result is NE>"<,=E:
o Ad$ice to repeat t%e test after E mont%s 1;he 4indow /eriod2
o Assertin' safer se(ual or in3ectin' practices 1Ris Reduction2
o Clearly emp%asi:es to t%e patient t%at a ne'ati$e test does not mean t%at %e/s%e is
immune a'ainst I! infection unless t%e present practice is modified.
Nee'&e-"ic2 in:%rie"( 1See attac%ment2
Session )our
En' !f Life Deci"i!n" & Ter$ina& Care
Di"c%""ing Re"%"ciai!n Sa%" & DNR 1i- +aien" an' re&aive"
*usti#ications #or 'aking 2o) Not) %esuscitate 02N%1 decisions:
=* =%en a fully,informed competent patient as0s not to be resuscitated
>* A poor 6uality of life follo4in' a successful CPR is anticipated
?* )utility7 t%e c%ances of t%e patient sur$i$in' CPR are so lo4 t%at it can be re'arded
futile. T%is is a clinical decision5 4%ic% doesn*t need in$ol$ement of t%e patient5 &
t%ere is no obli'ation to attempt CPR in suc% cases. E(amples7 disseminatin'
mali'nancies5 septicaemia5 se$ere ) etc
" 2N% decision isn&t necessar( to discuss with patients:
B. If t%e patient is incompetent
C. If t%e decision 4as made on 'rounds of futility
E. If a competent patient indicates t%at %e/s%e doesn*t 4is% to discuss it
9. T%is may also be 3ustified in competent patients5 4it%out obtainin' consent5 if
decision is based on basis of ?poor 6uality of life@.
Di"c%""ing DNR 'eci"i!n 1i- +aien" & re&aive"(
1. o'petent patients:
, T%e discussion s%ould aim at determinin' t%e patient*s $ie4s of %is/%er 6uality
of life.
, Relati$es s%ould only be in$ol$ed in discussion 4it% t%e patient*s consent.
, Relati$es may be discussed if t%e decision is made on ?Poor 6uality of life@
"asis & t%e patient donFt li0e to discuss t%e issue.

2. ,nco'petent patients:
, T%e doctor s%ould decide on t%e ?"est interest@ of t%e patient.
, Relati$es & friends can be discussed for t%e purpose of 'ettin' a better idea of
t%e patient*s 4is%es and also to determine 4%et%er t%ere is an Ad$ance Directi$e
1-i$in' 4ill2
4-a fac" nee' ! be !&' ! -e +aienE
- T%e patient s%ould be fully informed about t%e dia'nosis & pro'nosis
, T%at CPR is usually unsuccessful.
, About BR Q CRS sur$i$e to lea$e t%e %ospital & for one year after4ards
, T%e possibility of sur$i$al 4it% a neurolo'ical dama'e s%ould be pointed out.
o4e$er5 t%ese are relati$ely uncommon< B QCS sur$i$es in a Permanent
!e'etati$e State 1P!S2
, Elderly patients 4it% c%ronic illnesses %a$e T MS c%ance of sur$i$al to
disc%ar'e.
- Ascertain t%at t%e patient understand t%at if t%ey %a$e a cardio,respiratory arrest &
t%ey don*t %a$e CPR5 t%ey 4ill almost certainly die.
, T%at a D#R is a Consultant decision.
Session )i$e
S%''en Dea- !f a fa$i&, $e$ber
/A "+ecia& f!r$ !f brea2ing ba' ne1" -a reD%ire" grea e$+a-,0
/A0 T-e inervie1 1i- -e re&aive; 3rea2ing -e ba' ne1"(
Preparation:
, C%ec0 your facts about t%e deceased per son5 %is illness5 etc.
, Put %im at ease.
, Ma0e sure t%at support is a$ailable 1an e(perienced nurse/ot%er %ealt%
professional5 a relati$e/friend5 reli'ious support5 etc2.
(%) ,ntroduce !our self$ ex"lain role & identif! the relative#
Also c%ec0 4%et%er ot%er relati$es are around / need to attend t%e inter$ie4.
(3) Establish his current in#or'ation3 nowledge of the situation:
(7) ?ive a warning shot :
(&) 4ait for his res"onse$ then BBN:
, Don*t 4ait too lon' as t%is 4ill a''ra$ate t%e a'ony.
, "e ready to confirm direct 6uestions e.'. ?Is %e deadA@
, If t%ere is no direct 6uestion7 +se a clear & simple lan'ua'e to 'i$e
a brief description of t%e illness and e(plain t%at treatment/resuscitation
%asn*t been successful & t%e patient %as died.
(5) ?ive relatives the chance to $entilate #
E+press e'path( & give more details when needed#
, Insure & s%o4 continued care and support to t%e family.
E.'. Q Offer transport to %ome5 'i$e details of contact 4it% t%e
department for more e(planation etc.
, Allo4 accessability to t%e deceased body5 it is important for some people
to see and %old t%eir dead lo$es ones & to 0eep a loc0 of t%eir %air.
, Pro$ide clear e(planation of any $isible in3uries
/J0 "lwa(s -u''ari?e @ check understanding.
/30 A ReD%e" f!r Organ D!nai!n(
A* Many relati$es as0 about or'an donation.
3. Ot%er4ise you can sensiti$ely & at t%e suitable time5
brin' t%e issue for discussion. T%is can be addressed in
many 4ays< one approac% is to as0 4%et%er t%e deceased
%ad e(pressed any 4is%es/ad$anced directi$e in t%is
re'ard 1c%ec0 also if %e %as a donor card2. >ou can also
in$ite t%e discussion by tellin' ot%er people*s
e(periences e.'. ?Some people in a situation similar to
yours li0e to ma0e 'ood to t%eir lo$ed ones by donatin'
t%eir or'ans to some patient 4%o are in desperate need
of t%em.@ ?is internal or'ans can be used for ot%er
patients 4%o need t%em to maintain t%eir li$es@
Re* C!rnea& D!nai!n(
T%e e,e" must be remo$ed 4it%in H -!%r" if t%e corneas are to be donated.
Contact t%e eye %ospital.
If deat% %as to be reported to Coroner5 %is/%er permission must be obtained
before or'ans are donated.

/C0 ReD%e"ing +er$i""i!n f!r a P!"$!re$ E9a$inai!n(
,Approac% in a sensiti$e & understandin' manner t%at allo4s relati$es to ma0e
4ell, informed decisions.
, E(plain t%e specific reason for t%e PM re6uest & t%e benefits of PM e(am.
, T%e re6uest s%ould be made in a 4ay t%at doesn*t put pressure on relati$es.
, Relati$es s%ould be 'i$en enou'% time to t%in0 about t%e issue & to discuss
4it% ot%er members of t%e family if t%ey 4is% to do so.
, Try to e(plore relati$e*s misconceptions re'ardin' PM & to find out t%e
reasons for refusal and t%en to clarify t%em1refer to information bo( 2.
, Relati$es s%ould be informed of t%e PM results as soon as possible.

- linicians should be:
, Able to anticipate & cope 4it% t%e concerns and reactions of relati$es at
t%e time of berea$ement.
, A4are of t%e possible cultural/reli'ious impacts related to deat%5 funeral
arran'ements & attitude to4ards PM.
, A4are of t%e administrati$e procedures.
, Able to e(plain t%e difference bet4een medico le'al & academic PM.
1#". In non,medico le'al PM consent is re6uired from t%e ne(t of 0in2.
, Able to consider possible alternati$es in case of PM refusal
E.'. limited PM5 laproscopic/endoscopic e(am. etc
, 3e a1are !f 'ea-" re+!rab&e ! -e C!r!nerK

%easons #or consent #or a Post'orte' e+a'ination:
B, To establis% t%e precise cause of deat%
C, To confirm t%e dia'nosis
E, To %elp ot%ers / medical researc%es etc
9, To respect t%e 4is%es of t%e deceased / family
M, Or'an donation
%easons #or re#usal o# Post'orte':
1) Concerns about dis#igure'ent of t%e deceased
2) Interference 4it% #uneral arrange'ents
3) Aack o# in#or'ation about t%e reason for PM
4) %eligious 3 ultural 1e.'. Muslims5 Je4s5 Afro,
Caribbean*s5 C%ristian Scientists2
5) Respect for t%e deceased & t%eir 4is%es
!) Too upset to consider it
B) A desire to finis% t%in's as soon as possible
C) Ob3ection from ot%er family members
2eaths reportable to the oroner:
B, T%e deceased 4asn*t seen by a doctor 4it%in B9 days prior to deat%
C, If t%e deat%7
A. Is of suspicious circumstances5 t%ere is a %istory of $iolence or may be
lin0ed 4it% an accident
". May be lin0ed 4it% an abortion
C. Is related to a medical procedure or treatment
D. ad occurred durin' an operation or before full reco$ery from anest%esia 1or
in any 4ay related to anest%esia2
E. Is due to lac0 of medical care
). Is due to industrial disease or in any 4ay related to t%e deceased
employment.
/. Occurred durin' or s%ortly after detention in police or prison custody.
E. T%e actions of t%e deceased may %a$e contributed to %is deat%.
COUNSELING RELATIAES .OR A POSTMORTEM ELAMINATION
,# a relati$e is concerned about PM e+a'ination:
-peak to the relati$e ai'ing at: e+ploring their 'ain concerns about PM9 i'pro$ing
their understanding @ gi$e Dusti#ications and bene#its o# PM e+a'. e.g.
) ;he /@ ma! "rovide useful information that was not available when the deceased was
alive#
) ;he /@ results ma! assist relatives overcoming their grieving reaction# .t ma! lead to
"eace of mind b! nowing the cause of death & that the a""ro"riate care was given#
) ;he /@ can be beneficial$ not onl! to medical "rofession$ but also to the famil! & the
societ! in general (give exam"les)
) @edical "rofession can gain vital feedbac about accurac! of diagnosis$ effects
of treatments$ etc#
011 %eassurance re. dis#igure'ent:
T%e PM e(am. is similar to a sur'ical operation & is carried out by
medically,6ualified pat%olo'ists.
T%e out4ard appearance of t%e deceased 4ould not be altered in ant 4ay
& no e(ternal mar0ers 4ould be $isible apart from incision scar.
021 %eassurance re. possible inter#erence with #uneral arrange'ents:
PM e(am. 4ill only need a s%ort time to perform.
In ur'ent cases5 t%e PM can be e(pedited.
T%e mortuary staff can liaise 4it% t%e funeral director to release t%e body
in a reasonable time.

<8E BENEE,<- ;E PM
". Eor the relati$es:
;no4led'e of t%e precise cause of deat% / Confirmation of t%e dia'nosis.
Reassurance & peace of mind. Alle$iation of 'uilt by reassurance t%at deat%
4as ine$itable & t%at all t%e needed care 4as pro$ided.
Identification of possible %ereditary conditions.
elpin' ot%ers e.'. or'an donation.
Assistance in ad$ances in medical 0no4led'e.
Insurance & compensation claims.
B. Eor the 'edical pro#ession:
To establis% t%e precise cause of deat%.
/i$es a feedbac0 about t%e accuracy of t%e clinical dia'nosis.
Aids in medical audit & ris0 mana'ement.
Enables researc%es & ad$ancement in 0no4led'e.
Impro$es accuracy of epidemiolo'ical statistics.
. Eor the societ(:
Impro$ement of accuracy of epidemiolo'ical statistics.
Or'an donation.
Identification & pre$ention of en$ironmental and occupational %a:ards /
infectious diseases & epidemics.
Impro$ement of medical 0no4led'e.
Session Si(
COUNSELLING
/uidelines for /i$in' Information to a Patient

/=0 C-ec2 -!1 $%c- inf!r$ai!n ! give*
E.'. test result5 dia'nosis5 mana'ement plan5 ad$ice on life style5 etc
54ould !ou lie to now the result of !our bone scanA Do !ou want
to discuss an! thing elseA: T%en e(plain accordin'ly.
/>0 S%$$ari;e" -e +aien5" +r!b&e$"*
E.'. 5 You have told me that !our -sthma isn)t as well controlled as it
used to be# .s that)s rightA:
/?0 C-ec2 -e +aien5" Un'er"an'ing !f -i" c!n'ii!n*
E.'. 5<ave an! thoughts of what might be the cause of this "roblemA:
/<0 O%&ine -e Sr%c%re !f -e inervie1*
E.'. 5Bow we are going to discuss several things: %
st
: what . thin is
wrong with !ou# 3
nd:
what further tests we need to do$ and lastl!: what
treatment .)m going to give !ou# .s that)s oA:
/G0 U"e a++r!+riae &ang%age(
, Describe and e(plain eac% piece of information
, /i$e t%e most important information first.
, +se s%ort sentences.
, "e specific.
, A$oid medical 3ar'ons
/H0 U"e 'ra1ing" 1-en a++r!+riae*
/)0 E9+&!re -e +aien5" vie1"(
E.'. 5/erha"s !ou could tell me what !ou thin about that:
/M0 Neg!iae $anage$en*
If necessary5 %elp t%e patient in ma0in' %is decision
/J0 C-ec2 %n'er"an'ing(
E.'. 54ell$ @r# Cames$ . seem to have given !ou lots of information#
4ould !ou lie to Dust go over what we have saidA:
/=N0 S%$$ari;e"*
MULTIPLE SCLEROSIS
Fhat should the patient be told6
, As0 t%e patient if %e/s%e %a$e 5-n! thoughts about what might be wrong with !ouA:
5-n! "articular condition worries !ouA:
, ""# step,by,step
, Educate7 4%at is MS
, C%ec0 understandin' ?4hat are !ou going to tell !our famil!A:
- C!n"eD%ence"(
Difficult to 'et life insurance or promotion at 4or0
Alteration of life style
Psyc%olo'ical & emotional burden
- P!"iive a"+ec" !f 'iagn!"i"(
#OT a brain tumour & #OT a mental disease
"enefits of early dia'nosis & treatment 4it% Interferon beta & copolymer
- Ear&, f!&&!1-%+ a++!in$en(
To 'i$e t%e patient t%e c%ance of as0in' 6uestions in a calmer state of mind.
- Pr!vi'e "%++!r & inf!r$ai!n(
=ritten information5 $ideos
Specialist nurse
Social 4or0er
Occupational t%erapist for self,support measures
-ocal MS society, s%ouldn*t be rus%ed as an early $isit may be depressin' for a
ne4ly,dia'nosed patient
Fhat in#or'ation to gi$e6
MS is a c%ronic disease affectin' B7BRRR of +; population
Cause is #OT 0no4n
At present #O medical cure5 but t%ere are treatments 4%ic% can %elp many
symptoms
C!%r"e( ,!ariable & is $ery difficult to predict.
, Different in eac% indi$idual
, Initially may be relapsin' & remittin' 4it% full reco$ery bet4een t%e
attac0s. -en't% of relapses 1flares2 is C9 %rs.,BC mont%s. Rate of relapses
is around B7BRR/year. Relapses are more common in t%e first M years &
particularly t%e first year.
, May become pro'ressi$e at any time5 secondary pro'ression affects 9RS
patients by BR years & NRS by BM years. Pro'ression is not ine$itable.
, Primary pro'ression from t%e onset occurs in BR,CRS cases.
, T%ere is a clear relations%ip bet4een pro'ression & late a'e of onset
, )oster %ope by 'i$in' e(amples of 'ood predicti$e features applicable to
t%e patient.
E'plo('ent:
Different studies7
, In t%e first M years7 up to MRS 4ere in full 4or0 & ORS capable of some 4or0
, "y BM years7 BR,CMS 4ere in full 4or0 & 9RS of lon',term sur$i$als are capable of
some useful acti$ity. Spastic paraparesis is t%e ma3or cause of loss of 4or0. More
patients could 4or0 from %ome.
Ai#e e+pectanc(:
, Is stron'ly predicted by t%e de'ree of t%e disability.
, Deat% isn*t directly caused by MS but results from infecti$e complications
, -ife e(pectancy 4as found to be only N,O years less t%an population 4it%out MS for t%e
a'es CR,MR & t%is is e$en less after t%e a'e of MR.
, Many indi$iduals %a$e normal life e(pectancy.
Pregnanc(:
, )ertility isn*t reduced
, #o increased ris0 of abortion or stillbirt%
, #o specific complications of labour
, #o contra,indications to breast feedin'
, T%ere is sli'%t ris0 of relapse durin' t%e first E mont%s after deli$ery.
>enetics:
MS doesn*t occur more common in relati$es t%an in 'eneral population. T%e ris0 of a c%ild
bein' affected is B,9S.
-el#)help 'easures:
, #o specific diet alters t%e course of MS.
, Symptoms may be a''ra$ated or induced 4it% e(ertion. Ad$ice to a$oid e(cessi$e
fati'ue5 but ot%er4ise to continue normal acti$ities.
HUNTINGTON5S DISEASE

, Pro'ressi$e c%orea & dementia in middle life are t%e %allmar0
, Onset7 ER,MR years. Pre$alence is B7CRRRR . AD 4it% full penetrance.
, Mutation in t%e s%ort arm of C% 9 4it% $ariable e(pression of CA/, repeat in e(onB. T%is
results in translation of an e(tended 'lutamine se6uence in %untin'tin< t%e protein product
of t%e 'ene.
Pa-!&!g,(
, Cerebral atrop%y 4it% mar0ed loss of neurons in t%e C#&P.
, C%an'es in neurotransmitters
C!%r"e(
, Pro'ressi$e illness & deat% occurs bet4een BR,CR years of onset.
, #OT a cancer & #OT a psyc%iatric disorder
, Initial symptoms7 personality or be%a$ioral c%an'es5 uncontrolled a''ression or se(ual
be%a$ior. Serious depression is common & suicide is a ris0.
-ater, ri'idity & a0inesia , bed ridden & emaciated , deat%
, #O cure.
, #O treatment to arrest t%e disease alt%ou'% p%enot%ia:ines1e.'. sulpiride2 may reduce
c%orea. Tetraben:ine %elps to control mo$ements.
, C%ronicity & disability , psyc%olo'ical impact on family7 Consider residential care
, Supportin' t%e family is essential.
.a$i&, Screening(
, C%ildren of patients %a$e B7C c%ance of %a$in' t%e disease & t%eir c%ildren %a$e B79 ris0
, +sin' molecular 'enetics. "lood D#A samples are re6uired from as muc% family
members as possible.
, Mutation analysis 1accurate &specific2 is a$ailable for pre,symptomatic testin' of family
members.
Centers performin' t%ese tests %a$e a common nationally a'reed protocol for counselin'.
, Pre,natal dia'nosis is possible.

MRCP-PACES
Station 2: HISTORY TAKING
(SHOULD BE PROBLEM-FOCUSED & ELL STRUCTURED ITH
SPECIAL CONSIDERATION TO SOCIAL CIRCUMSTANCES!
THE " MAIN TASKS:
#$ OPENING THE ENCOUNTER:
, G%&&t '( na)&
, Int%o*+,&- &./0ain %o0&
, A1%&&2 t3& a1&n*a
, E./0ain not&-ta4in1
2$ MAIN DISCUSSION
, Gat3&%in1 in5o%)ation
, T3& )ain 24i005+0 ta24 to /%o)ot& *i2,0o2+%&
, ICE (I*&a2- Con,&%n2 & E./&,tation2!
"$ CLOSURE:
, En,o+%a1& t3& /ati&nt to a24 6+&2tion2 & &./%&22 I*&a2-
Con,&%n2 & E./&,tation2 (ICE!
, Co+n2&0 on 3&a0t3 /%o)otion
, A1%&& a )+t+a00( 2ati25a,to%( /0an an* 5o00o7 +/$
, C3&,4 +n*&%2tan*in1 & Co%%&,t 73&n n&,&22a%($
, Goo*'(& & O55&% a8ai0a'i0it($
MRCP-PACES
A$ O/&nin1 t3& &n,o+nt&%:
En1a1&)&nt (Sta%tin1 t3& int&%8i&7!:
, G%&at '( na)&
, Int%o*+,& (o+%2&05 & E./0ain (o+% %o0&
, B+i0* 1oo* %a//o%t
, A1%&&2 t3& a1&n*a
, E./0ain not&-ta4in1
B$ Gat3&%in1 t3& in5o%)ation:
P%&2&ntin1 Co)/0aint (PC!:
, E0i,it t3& )ain /%&2&ntin1 /%o'0&)(2!$
, An( ot3&% /%o'0&)9
HPC:
- F+00 *&tai0&* 3:o &a,3 ,o)/0aint 5%o) on2&t to *at&$
, C0a%i5( &a,3 /%o'0&) '&5o%& )o8in1 to t3& n&.t$
, A//%o/%iat&0( +2& o/&n & ,0o2&-&n*&* 6+&2tion2$
, Nat+%&: &$1$; o+0* (o+ t&00 )& )o%& a'o+t t3& /%o'0&):2()/to);
, On2&t: ;3&n it 2ta%t&*9;
, D+%ation: ;Ho7 0on1 it 0a2t&*9;
, Patt&%n: - Contin+o+2:Int&%)itt&nt
, E/i2o*i, (5%&6+&n,(- 2&8&%it( & *+%ation o5 &a,3 &/i2o*&!
, Co+%2& to *at&:(2tati,- /%o1%&22i8&- o% i)/%o8in1!
, P%&,i/itatin1:R&0i&8in1 5a,to%2$
, A22o,iat&* 2()/to)2$
, Pati&nt<2 8i&7:/&%,&/tion o5 3i2:3&% /%o'0&): ;An( t3o+13t2 o5 73at
)i13t '& ,a+2in1 t3i2 /%o'0&)9;
, ;Do (o+ 7ant to a** an(t3in1 73i,3 I )i13t 5o%1&t to a24 a'o+t9;
, E55&,t o5 2()/to):/%o'0&) on 6+a0it( o5 0i5&9
, S+))a%i=&$
PMH:
, O/&n >: ;3at a'o+t (o+% 3&a0t3 ot3&%7i2&9;
, Si)i0a% /%o'0&)9
, S/&,i5i,: DM- HTN- HD- BA- &t,
, Ho2/ita0i=ation2 & O/&%ation2
FH:
, O/&n >: ;3at a'o+t t3& 3&a0t3 o5 (o+% 5a)i0(9;
, A00 #
2t
*&1%&& 3&a0t3 (/a%&nt2- 2i'0in12- ,3i0*%&n!
, I5 an( *&at3: A1& & ,a+2& o5 *&at3$
, S/&,i5i,: DM- HTN- HD- BA- &t,

DH:
, A24 a'o+t t3& *%+1<2 0i2t$
, En6+i%& a'o+t &a,3 *%+1:
, Do2&- 5%&6+&n,(- *+%ation
, Do&2 it 3&0/9
, Co)/0ian,&$
, SE: ;Ha8& (o+ &./&%i&n,&* an( /%o'0&) 7it3 t3i2 *%+19;
, An( %&,&nt ,3an1& in )&*i,ation29
ROS (R&8i&7 o5 2(2t&)2!:
, A07a(2 a24 a'o+t: 1&n&%a0 7&00'&in1- 5&8&%- a//&tit&- 7t
0o22:1ain- %a23&2-
, B%i&50( &n6+i%& a'o+t &a,3 'o*( 2(2t&)$
, T3&n a24 in )o%& *&/t3 a'o+t a55&,t&* 2(2t&)$
SOCIAL Hi2t$ (SH!:
#$ O,,+/ation: P%&2&nt & /%&8io+2; 3at *o (o+ *o 5o% 0i8in19; I5 +n&)/0o(&*-
a24 a'o+t /&n2ion2$
2$ Ma%ita0 2tat+2: 9/a%tn&%(2!- 2&.+a0 0i5&:o%i&ntation
"$ S)o4in1$
?$ ALCOHOL: D&tai0&*: 6+antit(- t(/&- an* 5%&6+&n,($ CAGE
@$ Finan,&: in,o)& 2+//o%t- in8a0i*it( '&n&5it2- ot3&% a00o7an,&2 & a*&6+a,(
o5 t3&2&$
A$ A8ai0a'i0it( o5 S+//o%t: P%a,ti,a0 & &)otiona0: Ho)& 3&0/- *i2t%i,t n+%2&-
2o,ia0 7o%4&%- o,,+/ationa0 t3&%a/(- &t,
B$ I)/a,t o5 /%o'0&): A'i0it( to 7o%4- ,o/in1 7it3 *ai0( a,ti8iti&2- )oo*-
/&%2ona0 %&0ation2- &t,
C$ Ho+2&: 50at2- 2t&/2- )o*i5i,ation2
D$ A,ti8iti&2 o5 *ai0( 0i8in1: 9Co/in1- 3&0/
#E$ Ho''i&29 ani)a02- 2/o%t2
##$ T%a8&0:
#2$ Di&t$
#"$ I))+ni=ation & /%o/3(0a.i2$
A0,o3o0 3i2to%(:
, D%in4in1 3a'it2: 3at t(/&9 Ho7 )+,39 Ho7 5%&6+&nt9
Fo% 3o7 0on19
, >+antit(:
# UNIT a0,o3o0 F #:2 Pint o5 '&&% F # 10a22 o5 7in& F # )&a2+%& o5 2/i%it
, CAGE test:
C: Ha8& (o+ &8&% 5&0t t3& n&&* to C +t *o7n on *%in4in19
A: -- -- -- -- A nno(&* '( ,%iti,i2) on *%in4in19
G: -- -- -- 3a* G +i0t( 5&&0in1 a'o+t *%in4in19
E: -- -- -- ta4&n a0,o3o0 t3& 5i%2t t3in1 in t3& )o%nin19
(E (& o/&n&%!
D%+12:
, 3at a'o+t %&,%&ationa0 *%+129
, Ha8& (o+ &8&% inG&,t&* *%+129 S3a%&* n&&*0&*9
, Ma%iG+ana ;/ot;
, Co,ain& ;,o4&;
, H&%oin- ot3&%2
, A%& (o+ +2in1 t3&) no79 Ho7 o5t&n9
S)o4in1:
, Do (o+ 2)o4&9 Ha8& (o+ &8&% 2)o4&*9
, T(/&- a)o+nt- 5o% 3o7 0on19
, Di* (o+ &8&% t%( to 6+it9
"$ C0o2+%&:
C3&,4 Un*&%2tan*in1:
;It 2&&)2 7& *i2,+22&* )an( i22+&2- an* I n&&* to )a4& 2+%& t3at 7& 3a8&
t3& 2a)& +n*&%2tan*in1- 2o:
, 3at )&22a1& (o+ ta4& 3o)& 7it3 (o+9
, 3at (o+ 7i00 t&00 to a 5a)i0( )&)'&%(2! i5 t3&( a24&*9;
A1%&&2 a ,0&a% ;P0an o5 a,tion;:
In8&2ti1ation2- )ana1&)&nt- 3o2/ita0i=ation- &t,
Di2/o2& A//%o/%iat&0(:
In t3& ,0o2in1 /o%tion o5 t3& int&%8i&7- (o+ )a(:
, In5o%) t3& /ati&nt o5 (o+% o/inion a'o+t t3& i00n&22
(*ia1no2i2- )ana1&)&nt- /%o1no2i2!
, En,o+%a1& t3& /ati&nt to a24 >2 & to &./%&22 ,on,&%n2
, N&1otiat& a )+t+a00( 2ati25a,to%( /0an
, Co+n2&0 a'o+t 3&a0t3 /%o)otion
, O55&% a*8i,& in,0+*in1 5o00o7-+/
, An( >29
, O55&% a8ai0a'i0it(
, T3an4 & 2a( 1oo*'(&
COMMUNICATION SKILLS
U2&5+0 S4i002 to /%o)ot& *i2,0o2+%&
Eye contact:
E2ta'0i23&* at t3& on2&t o5 t3& int&%8i&7 & )aintain&* at %&a2ona'0& int&%8a02 t3%o+13o+t
t3& ,on2+0tation$ R&-&2ta'0i23 73&n t3& /ati&nt )&ntion i)/o%tant /i&,& o5 in5o%)ation$
Acknowledin ! e"#lo$in %e$&al c'e(:
B( t3at (o+ %&50&,t t3at (o+ a%& int&%&2t&* in t3& /ati&nt /%o'0&)$
Non)%e$&al c'e(:
Pi,4- a**%&22- &./0o%& & a,4no70&*1& t3&)$
&$1$ ;Yo+ 0oo42 an.io+2- ,an + '&a% to 2a( 73(9;
O#en)di$ecti%e *(:
Yo+ ,an 1at3&% 0ot o5 in5o%)ation '( +2in1 o/&n-&n*&* >2$
T3&2& a%& t3& t(/& o5 >2 t3&i% an27&%2 a%& not (&2 & no$
&$1$; Can + t&00 )& )o%& a'o+t (o+% 'o7&0 /%o'0&)9;
Clo(ed)ended *(:
T3&2& a%& +2&* 73&n a 2/&,i5i, /i&,& o5 in5o%)ation i2 n&&*&*$
&$1$ ;Do&2 t3& /ain 1o an(73&%& &02&9;
Cont$ol ! Sen(iti%e $edi$ection:
G&nt0( ,ont%o0 t3& int&%8i&7$ I5 t3& /ati&nt %ai2&* a %&0&8ant i22+& 73i0& (o+ a%& *i2,+22in1
anot3&% i)/o%tant on&- (o+ ,an 2+11&2t /o2t/onin1 t3& i22+& ti00 + 5ini23 7it3 t3& 5i%2t on&$
Ho7&8&%- i5 t3& i22+& %ai2&* i2 not i)/o%tant o% i%%&0&8ant- (o+ ,an 2+11&2t 0&a8in1 it 5o%
anot3&% 2&22ion$
Neotiation:
A07a(2 n&1otiat& (o+% /0an2 7it3 t3& /ati&nt & t%( to %&a,3 an a1%&&)&nt$ Ho7&8&%- i5 (o+
5ai0&* to *o 2o- t3& /%io%it( i2 5o% t3& /ati&nt<2 a1&n*a$
+$eci(ion:
&$1$ ; Yo+ 2a( + 3a8& '&&n 2+55&%in1 *i==in&22$ Can + *&2,%i'& &.a,t0( 73at 3a//&n2
73&n + &./&%i&n,& t3i29;
E,#at-y:
U2& I & (o+$
&$1$; I ,o+0* i)a1in& 3o7 t3at &./&%i&n,& 3a* a55&,t&* yo';
;I +n*&%2tan* yo'$ ,on,&%n2 a'o+t (o+% Go';
;I ,an 2&& t3at it i2 3a%* 5o% yo' to ,a%& 5o% (o+% *a* & t3& 2 4i*2;
Ed'cational 'e((e(:
S3a%& t3&) 7it3 t3& /ati&nt$
&$1$ ;3&n 7& a%& ta04in1 I 1ot t3& 5&&0in1 t3at (o+% *ia'&t&2 3a* a55&,t&* (o+% Go' & t3at +
0oo42 %at3&% 7o%%i&* o5 0oo2in1 it;
.acilitation ! Silence:
Fa,i0itation: '( no**in1 o% '( 2a(in1; (&2- I 2&&- 1o on- +3-3+3- o% 73at &02&; & '( 0oo4in1
att&nti8&0( to t3& /ati&nt$
N&8&% 1&t /ani, '&,a+2& o5 2i0&n,&$ T3i2 i)/o%tant 5o% 'ot3 o5 (o+ & t3& /ati&nt to
o%1ani=& t3o+13t2 an* to t3in4 o5 ;73at i2 n&.t9;
Re#etition:
U2&* to 5o2t&% &0a'o%ation$
Yo+ ,an %&/&at t3& /ati&nt<2 0a2t 2&nt&n,& &$1$; ,3&2t /ain9;
Cla$i/ication:
Yo+ 3a8& to ,0a%i5( an( in5o%)ation (o+ a%& not ,0&a% a'o+t$
&$1$; I<) not 2+%& I +n*&%2tan*$ o+0* + &./0ain it a1ain9;
;Do + )&anH9;
;Co+0* (o+ &./0ain to )& 73at (o+ + )&an '( 0i13t-3&a*&*9;
Enco'$ae,ent ! S'##o$t:
- Fin&$ T3at<2 1%&at$ Yo+<%& *oin1 5in&- ,a%%( on$
- Yo+ 3a8& /+t 1%&at &55o%t to 3&0/ (o+% 2i,4 )+)$
- I<) 3a//( t3at (o+<%& 7o%4in1 3a%* to ,ont%o0 (o+% BP$
MRCP-PACES
SUGGESTED STRATIGY
In t3& @ )in2 '&5o%& &nt&%in1 t3& &.a)ination %oo)- )a4& (o+% /0an in t3&
/%o8i*&* 23&&t o5 /a/&%:
#$ OPENING
, Int%o*+,& (o+%2&05- Ro0&
, P%i8a,(
, A1&n*a
, An( %&0ati8& to att&n*
, E./0ain not& ta4in1
2$ MAIN DISCUSSION
, PC
, HPC
, ROS
, PMH
, FH
, DH
, SH
"$ CLOSUING
, A1%&&in1 a /0an o5 a,tion
, C3&,4in1 +n*&%2tan*in1
, Di2/o2a0
+AIN: SOCRATES
Sit&
On2&t
C3a%a,t&%
Ra*iation
A22o,iation
Ti)& (*+%ation!
E.a,&%'atin1:R&0i&8in1
S&8&%it(
MRCP-PACES
T3& Mo2t Co))on Ca2& Hi2to%i&2
o A'*o)ina0 /ain
o (IBD!
o Ia+n*i,&:CLD:PBC
o Ma0a'2o%/tion: Dia%%o3&a - Co&0ia,
o H&a*a,3&
o E/i0&/2(
o TIA (5+nn( t+%n2!:CJA
o IHD:CAD:CHF
o SOB:Pa0/itation2(PAF!
o BA:COPD
o P+0)ona%( 5i'%o2i2
o B%on,3i&,ta2i2:CF
o DM
o Goit%&:t3(%oi* *i2&a2&
o P(%&.ia:Diaao3&a 5o00o7in1 5o%&i1n t%a8&0
o A%t3%iti2:RA- SLE
o HBJ:HIJ
o L&+4&)ia:L()/3o)a

MRCP PACES Communication Skills and History Taking Notes

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Session One

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