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ISTUDY
 Medicine for Finals
and Beyond

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 Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com

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 Medicine for Finals
and Beyond
THIRD EDITION

Edited by
John S. Axford
DSc MD FRCP FRCPCH
Emeritus Professor of Clinical Rheumatology
St George’s Hospital
University of London
London UK
Chris A. O’Callaghan
BM BCh MA DPhil DM FHEA FRCP
Professor of Medicine
Fellow of The Queen’s College
Nuffield Department of Medicine
University of Oxford
Hon Consultant Physician and Nephrologist
Oxford University Hospitals
Oxford, UK

ISTUDY
 First edition published 2023
by CRC Press
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
and by CRC Press
6000 Broken Sound Parkway NW, Suite 300,
Boca Raton, FL 33487-2742
© 2023 John Axford and Chris O’Callaghan
This title is a reworked and condensed version of Medicine published by Blackwell, 2004
CRC Press is an imprint of Informa UK Limited
The right of John Axford and Chris O’Callaghan to be identified as the authors of the editorial material, and of the authors for their
individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to
publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors
or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual
editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information
or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a
supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s
instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on
dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug
formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering
or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is
appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her
own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace
the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this
form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any
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All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other
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without permission in writing from the publishers.
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Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
ISBN: 978-1-032-04526-9 (hbk)
ISBN: 978-0-367-15059-4 (pbk)
ISBN: 978-1-003-19361-6 (ebk)
DOI: 10.1201/9781003193616
Typeset in Palatino LT Std
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ISTUDY BK-TandF-AXFORD_9781032045269-211289-FM.indd 4 13/05/22 10:08 AM

 The editors

John Axford is a Consultant in Adult and Paediatric Rheumatology and Emeritus Professor of Clinical Rheumatology
at St George’s Hospital, University of London.
After training at University College Hospital he worked at The National Hospital for Neurology, The Hammersmith
Hospital, The Royal Brompton Hospital, King’s College Hospital and the New England Medical Center, Boston,
Massachusetts, USA.
He has enjoyed teaching medicine throughout his career and pioneered video teaching to developing countries with the
Royal Society of Medicine.
He is an author and editor of the textbook UpToDate.

Chris O’Callaghan is Professor of Medicine at the University of Oxford and a Consultant Physician (in Acute General
Medicine) and Consultant Nephrologist in the Oxford University Hospitals.
He is Chief Examiner in Medicine for the University of Oxford, runs a research group, teaches medical students, and is
a Fellow and former Dean of The Queens’ College, Oxford.
After training and working in Oxford he worked at Guy’s, St Thomas’, Hammersmith, Brompton and Lewisham
Hospitals in London, Royal Stoke University Hospital, the University of California, San Francisco, and the California
Institute of Technology.
His other books include The Kidney at a Glance and The MRCP Part I: a System Based Tutorial.

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 Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com

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 Contents

Contributors ix
Acknowledgements xi
Introduction xiii

1 The Human Aspects of Medicine 1

Chris O’Callaghan & Alison Maycock

2 The Scientific Basis of Medicine 7

Chris O’Callaghan & Rachel Allen

3 Infectious Disease 21
Susanna J. Dunachie, Hanif Esmail, Ruth Corrigan & Maria Dudareva

4 Rheumatic Disease 83
John Axford

5 Metabolic Bone Disease 141

Jeffrey Lee

6 Respiratory Disease 155

Ian Pavord, Nayia Petousi & Nick Talbot

7 Cardiovascular Disease 203

Alexander Lyon

8 Renal Disease; Fluid and Electrolyte Disorders 277

Chris O’Callaghan

9 Liver, Biliary Tract and Pancreatic Disease 331

James Neuberger

10 Gastrointestinal Disease 359

Gareth Davies, Chris Black & Keeley Fairbrass

11 Diabetes Mellitus, Obesity, Lipoprotein Disorders and other Metabolic Diseases 429
Kevin Baynes

12 Endocrine Disease 471

Pierre-Marc Bouloux

13 Neurological Disease 511

Malcolm Macleod

14 Psychological Medicine 541

Harrison Howarth, Jim Bolton & Gary Bell

vii

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 CONTENTS

15 Haematological Disease 557

Thomas A. Fox & Emma C. Morris

16 Palliative Medicine 597

Adrian Tookman & Faye Gishen

17 Poisoning 607
Paul Dargan

18 Skin Disease 611

Christopher Bunker & Richard Watchorn

Index 657

viii

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 Contributors

Rachel L. Allen BSc (Hons) DPhil Ruth Corrigan BM BCh PhD

Professor & Director of the Institute of Medical and Academic Clinical Lecturer in Microbiology and Infectious
Biomedical Education Diseases
St George’s, University of London Nuffield Department of Clinical Laboratory Sciences
London, UK University of Oxford
Oxford, UK
John S. Axford DSc MD FRCP FRCPCH
Emeritus Professor of Clinical Rheumatology Paul I. Dargan MB BS FRCP FEAPCCT FAACT
St George’s Hospital Professor of Clinical Toxicology
University of London Guy’s & St Thomas’ NHS Foundation Trust
London, UK and King’s College Hospital
London, UK
Kevin C.R. Baynes BA (Oxon) MBBS PhD FRCP
Consultant in Diabetes & Endocrinology Gareth R. Davies BSc (Hons) MD FRCP
London North West University Healthcare NHS Trust Consultant Physician and Gastroenterologist
London, UK Harrogate District Hospital
Harrogate, UK
Gary Bell BA MB BS FRCPsych
Consultant Psychiatrist Maria Dudareva BM BCh PhD MRCP
Cognacity NIHR Doctoral Research Fellow
London, UK Bone Infection Unit
Oxford University Hospitals NHS Trust
Christopher J. Black MB BS(Hons) PhD MRCP Oxford, UK
Consultant Gastroenterologist
Leeds Teaching Hospitals NHS Trust Susanna Dunachie BM ChB PhD FRCP FRCPath
Leeds, UK Professor of Infectious Diseases
University of Oxford
Jim Bolton MB BS BSc(Hons) FRCPsych Oxford, UK
Consultant Psychiatrist
Department of Liaison Psychiatry Hanif Esmail MA MBBS MRCP PhD FRCPath
St Helier Hospital Associate Professor and Honorary Consultant in Infectious
London, UK Diseases
University College London and Hospital for Tropical
Pierre-Marc Bouloux BSc MB BS (Hons) MD FRCP Diseases
Director and Consultant Endocrinologist University College London Hospitals
Centre for Endocrinology London, UK
Royal Free Campus
UCL Keeley Fairbrass BSc(Hons) MBChB(Hons) MRCP
London, UK Gastroenterology Registrar and Clinical Research Fellow
Leeds Teaching Hospitals NHS Trust
Christopher B. Bunker MA MD FRCP Leeds, UK
Consultant Dermatologist
and Honorary Professor of Dermatology Thomas A. Fox BSc MB ChB MSc MRCP FRCPath
UCL and Chelsea & Westminster Hospitals, Department of Haematology
and University College Hospital
University College and Imperial College London, UK
London, UK

ix

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 CONTRIBUTORS

Faye Gishen MB BS BSc FRCP EdD PFHEA Chris A. O’Callaghan BM BCh MA DPhil
Professor of Medical Education & Palliative Medicine DM FHEA FRCP
UCL Medical School Professor of Medicine
London, UK Fellow of The Queen’s College
Harrison Howarth BSc (Hons) MB BS MRCPsych Nuffield Department of Medicine
Core Psychiatry Trainee University of Oxford
Camden and Islington NHS Foundation Trust Hon Consultant Physician and Nephrologist
London, UK Oxford University Hospitals
Oxford, UK
Jeffrey Lee MB BS (Hons) FRCP
Consultant Rheumatologist Ian Pavord MA MBBS DM FRCP FERS FMedSci
Royal Free Hospital Professor of Respiratory Medicine
London, UK Respiratory Medicine Unit and Oxford Respiratory NIHR BRC
Nuffield Department of Clinical Medicine
Alexander Lyon MA BM BCh PhD FRCP FHFA University of Oxford
Senior Lecturer and Honorary Consultant Cardiologist and John Radcliffe Hospital
Imperial College London and Royal Brompton Hospital Oxford, UK
London, UK
Nayia Petousi MA MB BChir MRCP DPhil
Malcolm R. Macleod BSc(Hons) MB ChB PhD FRCP Consultant Respiratory Physician
FRSB Oxford University Hospitals NHS Foundation Trust
Professor of Neurology and Translational Neurosciences Oxford, UK
(University of Edinburgh)
and Honorary Consultant Neurologist (NHS Forth Valley) Nick Talbot BM BCh MA DPhil MRCP
Edinburgh, UK Departmental Lecturer
Department of Physiology, Anatomy and Genetics
Alison J. Maycock MB BChir (Cantab) MA MRCGP University of Oxford
General Practitioner Partner, Trainer and Appraiser Consultant in Respiratory Medicine
Hollow Way Medical Centre Oxford University Hospitals NHS Foundation Trust
Oxford, UK Oxford, UK

Emma C. Morris BA MA MB BChir PhD FRCP Adrian Tookman MB BS FRCP

FRCPath FMedSci Consultant Palliative Medicine
Professor of Clinical Cell & Gene Therapy Former Medical Director Marie Curie Hospice
UCL Division of Infection and Immunity London, UK
Hon Consultant Haematologist
University College London Hospitals NHS Foundation Trust Richard E. Watchorn MB BCh BAO MD FRCP
and Royal Free London Hospitals NHS Foundation Trust Consultant Dermatologist
London, UK Beaumont Hospital, Dublin
and Honorary Consultant Dermatologist
James Neuberger DM FRCP University College London Hospitals NHS Foundation Trust
Hon Consultant Physician Honorary Clinical Senior Lecturer
The Liver and Hepatobiliary Unit Royal College of Surgeons of Ireland
Queen Elizabeth Hospital and Imperial College London
Birmingham, UK London, UK

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 Acknowledgements

All those who contributed to editions of this book’s predecessor, Medicine—this new book builds on their work especially:
Stephen H. Gillespie (Chapter 3), Chris Sonnex (Chapter 3), Christopher Carne (Chapter 3), Emma M. Clark (Chapter 5),
Jon Tobias (Chapter 5), M.J. Walshaw (Chapter 6), Charles Hind (Chapter 6), C.W. Pumphrey (Chapter 6), J.C. Kingswood
(Chapter 8), D.K. Packham (Chapter 8), D.S. Rampton (Chapter 10), D.J. Betteridge (Chapter 11), Felicity Kaplan (Chapter 12),
Gerard S. Conway (Chapter 12), C.J. Mumford (Chapter 13), D.H. Bevan (Chapter 15), A.C. Kurowska (Chapter 16),
A.K. Fletcher (Chapter 17) and F.P. Morris (Chapter 17). Peter Saugman was a key supporter from the start.
Jo Koster and Jordan Wearing for superb editorial support with this edition. Nora Naughton for her outstanding
and incredibly efficient project management of the production of this book. Becky Freeman and Susan Smyth for their
tireless efforts copy-editing and proof-reading respectively.
M. Ali Abbasi, Christine Heron and Andrew Hine for radiology advice. Julia Steed for keeping the text under control.
The following doctors for reviewing the text and providing helpful feedback: Nina Agarwal, Pat Woo Mark Cassar, Vijay
Hadela, Marcus Hughes, Simon Lambracos, Brian Lunn, Mike Mendall, Muthana Al Obaidi, Sanjeev Patel, Johnathan
Rogers, Malcolm Rustin, Paddy Stone and Malcolm Walker.
Our excellent colleagues for their valued expertise and discussions of medicine.

xi

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 Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com

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 Introduction

Our focus in this condensed third edition is on helping

you to pass your final assessments and examinations
HOW TO USE THIS BOOK
with ease and confidence.
Chapter 1 provides an overview of the human dimension
Medicine for Finals and Beyond contains all the informa-
to clinical medicine and Chapter 2 reviews the basic sci-
tion that you need to qualify as a doctor. The contributing
ence. Together, these help you to understand what under-
authors are experts in their respective fields, as well as expe-
pins modern medical practice. The chapters which follow
rienced writers and teachers. The book has been strongly
cover systems. Navigation is aided by the coloured page
influenced by input from many students and colleagues.
end-tabs that label each chapter. Drugs are referred to by
Much has changed since the second edition was published
their Recommended International Non-proprietary Name
and some chapters needed further refinement as the pan-
(rINN) although, in a few cases, older names are also pro-
demic unfolded.
vided if they are still in use.

DESIGNED FOR LEARNING

CHAPTER LAYOUT
To pass examinations and to practise medicine well, it is
The system chapters cover structure and function, approach
important to understand the basics. There are many text-
to the patient and diseases and their management. Aids to
books of medicine, but we believe that they are generally
learning within each chapter highlight important material:
not well designed for learning. Some have grown thicker
• At a Glance boxes summarize core topics for rapid
with each edition and include detail that is beyond the
revision.
needs of students and, indeed, of many qualified doctors.
• History and Examination boxes outline key features
This can make it difficult to see the ‘wood for the trees’ and
to elicit from the patient.
slows and complicates learning.
• Emergency boxes summarize essential information
Medicine for Finals and Beyond has been carefully crafted
about emergencies.
to avoid the overwhelming. Each system is presented in an
• Must-know checklists highlight key points.
integrated chapter, with sections on the basic structure,
The editors and authors have enjoyed creating this third
function and biology of the system, on clinical presenta-
edition and are confident that students will find it a useful
tions, on the approach to the patient and on the diseases
and enjoyable book as they learn medicine and particularly
affecting that system. There is a clear focus on evidence-
in the pressured run-up to final exams. The editors suggest
based medicine as well as consideration of the social, caring
that you remember:
and communicative aspects of practice and the impact of
‘the patient is always right…’
disease and treatment on the lives of patients.
and therefore……….
The material in this edition has been arranged to aid
‘if in doubt, ask the patient.’
learning and recall. The amount of information on each
Enjoy your career and REMEMBER to have fun outside
topic has been carefully regulated. Important topics are
medicine too.
readily identifiable and deliberately presented in detail if
they are very common or are often examined. Illustrations
John Axford and Chris O’ Callaghan
have been used extensively to aid learning.
The book is written for students but will also be of use
to doctors and other healthcare workers who are trying to
understand or revise medicine, so it will remain useful as
you advance beyond your student years.

xiii

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 Taylor & Francis
Taylor & Francis Group
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 The Human Aspects of Medicine

1 CHRIS O’CALLAGHAN & ALISON MAYCOCK

Introduction 1 Clinical reasoning or judgement 5

Communication with patients 1 Maintaining patient trust 5
Communication with relatives and carers 3 Reflective practice 6
Communication with colleagues 4 Providing leadership 6
Communication in challenging circumstances 4 Life as a clinician 6
Communication and confidentiality 5

⚬⚬ Support patients in their self-care.

INTRODUCTION
This chapter considers the context in which the clinical facts
and details discussed in the other chapters are gathered
and deployed. It is intended to help the student or clinician
reflect on how to make the most effective use of the infor-
mation contained in the other chapters.
The effectiveness of doctors rests not just on their knowl-
edge of clinical facts but also on good communication, clear
clinical reasoning and reflective practice. The General Medical
Council (GMC), which regulates medical practice in the
UK, captures these elements in its guidance ‘Good medical
practice’. This is divided into different domains and speci-
fies how doctors should act.
• Knowledge, skills and performance
⚬⚬ Have patient-centred care as their first concern.
⚬⚬ Be competent and up to date.
⚬⚬ Recognize and work within their competence.
• Safety and quality
⚬⚬ Act promptly if patient safety, dignity or comfort
is at risk.
⚬⚬ Protect and promote the health of patients and the
public.
• Communication partnership and teamwork
⚬⚬ Treat patients politely and considerately.
⚬⚬ Respect patients’ confidentiality.
⚬⚬ Listen to patients and respond to their concerns
and preferences.
⚬⚬ Give patients the information they want or need in
a form they can understand.
⚬⚬ Respect patients’ right to contribute to decisions
about their management.
DOI: 10.1201/9781003193616-1
⚬⚬ Work effectively with colleagues in the patients’
interest.
• Maintaining trust
⚬⚬ Be honest and open and act with integrity.
⚬⚬ Never discriminate unfairly against patients or
colleagues.
⚬⚬ Never abuse patient trust or public trust in the
profession of medicine.
These elements form the basis of doctors’ mandatory annual
appraisal and the 5-yearly revalidation of their licence to
practise in the UK.
A key element of medical practice is communication and
the clinician is involved in a complex communication net-
work (Figure 1.1).
COMMUNICATION WITH PATIENTS
Being a skilled listener is fundamental to the process of
understanding the problems that patients present and
their significance for the patient across all aspects of
their life. Consultations are usually face-to-face, but
increasingly occur via telephone, video, email or even
social media, and each medium presents different
challenges.
Patient-centredness and shared decision-making should
be the defining features of the consultation. The patient’s
values and goals should be established by the clinician and
incorporated into a negotiated plan of action. Agreeing a
plan is important, as the patient has to live with its conse-
quences. A negotiated and agreed plan is much more likely
1

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 THE HUMAN ASPECTS OF MEDICINE
Figure 1.1 The network of clinical communication.
to be effective than an instruction given by the doctor to the
patient. We all engage more fully in plans we have helped
devise.
Consider the structure of a consultation, its main phases
and tasks (Figure 1.2).
During these processes, the clinician provides a structure
to the consultation for the patient to understand, tackles their
problem and also builds a relationship with the patient. Let us
look in more detail at some of these elements.
OPENING THE CONSULTATION
Preparation
• Gather any data already available (e.g. test results,
letters from other clinicians).
• Manage your own feelings and needs (e.g. hunger,
tiredness, anxiety or stress).
• Be clear about your own agenda (e.g. you may wish
to achieve an audit target or reduce your clinic
numbers).
• Choose a comfortable setting.
Establishing rapport
• Make eye contact and smile.
• Identify yourself by name and role.
• Confirm that the patient is ready to talk.
• Ensure the patent is comfortable, appropriately
covered and positioned.
• Ensure any other people in the room are appropriate
and the patient consents to their presence.
• Put the patient at their ease with a kind and gentle
manner.
2
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• Explain any use of computers or other technology as
needed.
• Involve the patient and ask questions in a friendly
manner. Use non-verbal gestures such as smiling,
nodding and allowing silence.
• Acknowledge and respond to each point made by the
patient.
• Notice how the patient looks and behaves and draw
this into the consultation, if appropriate.
GATHERING INFORMATION
People generally consult doctors because they think that
they have a medical problem that should be diagnosed and
treated, or because something is adversely affecting them
and their coping mechanisms are failing.
Start by asking open and wide questions to capture all
the important information from your perspective and the
patient’s, such as:
• Why have you come to see me today?
• What outcome are you hoping we will achieve?
• What is it about this problem that worries you?
• What do you think the problem is?
• What next steps do you have in mind?
• Is there anything else that has been bothering you?
Follow each of these by an open prompt, such as:
• Can you tell me a bit more about that?
Clarify with open specific questions, such as:
• Do you have a cough?
Pin down your diagnosis by asking increasingly specific
closed questions, such as:
• Does anything bring the cough on?
• Does exercise bring the cough on?

Figure 1.2 The tasks and processes of the consultation.
Avoid negative leading questions, such as:
• You do not have the cough at night then?
• You don’t get any side effects from these medications?
PHYSICAL EXAMINATION
Tailor your examination according to the history and your
differential diagnosis.
EXPLANATION AND PLANNING
Achieve a shared understanding of the problem
• Clarify and summarize what has been said.
• Establish in your own mind your differential
diagnosis.
• Use non-specialist language to explain your
conclusions.
• Ask for the patient’s opinions, suggestions and
preferences.
• Relate explanations to the patient’s own terms or
concepts.
• Explicitly check the patient’s understanding.
Provide the correct type and amount
of information
• Deliver information in small chunks.
• Provide written material, such as patient information
leaflets or web links.
ISTUDY
COMMUNICATION WITH RELATIVES AND CARERS
Make a plan
• Agree the forward plan with the patient.
• Empower the patient to manage their own illness and
self-care.
• Document key points carefully.
CLOSING THE CONSULTATION
• Check for any outstanding patient concerns.
• Advise whom the patient may contact with further
questions.
• Advise what to do in situations that need action and
especially those which are a threat to patient safety.
COMMUNICATION WITH RELATIVES
AND CARERS
It is important to bear in mind the following, when talking
to relatives and/or carers.
• Obtain appropriate consent from the patient for the
discussion.
• Establish the identity and role of the carer or relative.
• Be sensitive to the impact of the patient’s illness on the
individual carer or relative.
• Establish what they already know and what more they
wish to know.
3
 THE HUMAN ASPECTS OF MEDICINE
• Use the skills of the patient consultation, such as
active listening, breaking information into small
chunks and providing written material, as appropriate.
COMMUNICATION WITH COLLEAGUES
Most doctors work in teams and this can be challenging,
rewarding and enjoyable. Good team working requires
showing respect and consideration for others. This includes
listening to the concerns and points of view of other peo-
ple and acknowledging and valuing their contributions.
Effective communication is needed to optimize efficiency
and patient safety.
• Keep accurate and concise records, which are signed
and dated or appropriately validated electronically.
• Formulate requests for help as clearly as possible, to
obtain the most useful response.
• Be sensitive to the roles and competencies of
colleagues.
• Promote a fair and supportive work environment.
• Be willing to help colleagues but realistic about what
can be done.
• Obtain patient consent for discussion with outside
teams or agencies.
COMMUNICATION IN CHALLENGING
CIRCUMSTANCES
Communication with patients or relatives or carers can be
especially challenging in certain situations, such as the
following:
• The patient and clinician do not speak the same
language. An interpreter should be used.
• The patient has impaired hearing. A hearing aid or
signing interpreter should be used as appropriate.
• The patient has impaired cognitive skills or lacks
capacity. The clinician must establish the level of
understanding and the capacity of the patient for each
specific decision. Mental capacity is always assumed
and is demonstrated for a specific decision when a
patient can:
⚬⚬ Understand the information given and the
decision required
⚬⚬ Retain the information
⚬⚬ Weigh up the information to make a decision
⚬⚬ Communicate that decision
• The patient displays strong emotions. The clinician
should remain calm, speak quietly, acknowledge the
emotion displayed and show a willingness to listen
further.
• The clinician must break bad news. The clinician should
choose a quiet, comfortable place, ask if the patient
wants someone else to be present and check what
4
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they already know. It can be helpful to offer a warning
along the lines of ‘I am sorry, but I have some difficult
information for you…’.
• The clinician is communicating a complex concept
such as risk. Advise the patient of absolute risk (not
relative). Give numbers not percentages. Use visual
decision-making aids if possible (e.g. Figure 1.3, a
patient decision-aid chart). Discuss the likelihood of a
problem both occuring and not occuring. For example,
in the hypothetical situation illustrated in Figure 1.3, if
discussing the option of taking a statin with a patient
who has a 10-year cardiovascular disease (CVD) risk
of 30%, you might say:
‘If there were 100 people like you in the room, over
the next 10 years, on average it is likely that 30 of them
would have heart pain, a heart attack or stroke and
70 of them would not. If they all take this medicine every
day for the next 10 years, then 20 of them would be likely
to have a problem and 80 would not. Therefore, 10 people
would be likely to avoid the problem.’
• There is uncertainty of diagnosis, prognosis or benefits
of intervention options. The doctor should be honest
with patients about the limitations of medical certainty
and predictability, but should offer reassurance
regarding what is known and can be done.
• There are medically unexplained symptoms. Medically
unexplained symptoms can be frustrating for both the
doctor and patient. The doctor should be explicit about
the limitations of current medicine to explain every
symptom. It is important to acknowledge that even
when no organic illness can be diagnosed, a patient
may be significantly affected by their symptoms and
Figure 1.3 Patient decision aid to communicate the benefit of a
statin on cardiovascular risk. This hypothetical decision aid could
be used to demonstrate how taking a statin might reduce the
likely number of cardiovascular events over a 10-year period from
30 to 20 per 100 people.

the doctor can still offer to support the patient in
•
managing their problem.
The patient is making a complaint. Clinicians have
a statutory duty of candour in the UK. This means
they must tell patients about any medical errors.
Complaints should be handled according to local
complaints procedures, which usually involve
providing the complainant with:
⚬⚬ A clear written description of what happened
⚬⚬ A clear description of how it was investigated
⚬⚬ An apology for any errors and acknowledgement
of the impact on the patient
⚬⚬ An indication of how future problems will be
avoided
⚬⚬ An invitation to meet to discuss the matter
• Obtaining informed consent. When obtaining consent
for a procedure, the emphasis is now on providing
the information which a reasonable patient can be
expected to want to know. This includes side effects
or consequences which are common and those which
are uncommon or rare but which are serious. In the
UK, this follows the High Court findings in the case of
Montgomery v Lanarkshire. In this situation, a mother
sued the hospital trust for not informing her of the
risks of a vaginal delivery to her unborn baby. The
mother was small and the baby was large. The baby
suffered injury during delivery and the court ruled
that she should have been informed of this small but
important risk.
• The patient has strong cultural or personal values
and beliefs which may affect the medical process. This
may be refusing certain treatments, such as blood
products in the case of some Jehovah’s Witnesses,
or gelatin-containing capsules for some Muslims.
Clinicians must be sensitive to diversity and avoid
making assumptions. They must be alert for cues
indicating embarrassment regarding being examined
or talking about intimate issues.
• The clinician is working outside their area of competence.
In this case, the doctor should explain to the patient
that this is so and further advice should be sought
from a colleague with appropriate expertise.
COMMUNICATION AND
CONFIDENTIALITY
Patients’ trust in doctors is, in part, founded on confidenti-
ality. The clinician should not disclose identifiable patient
details without consent. Implied consent can be assumed
for aspects of direct patient care and local audit as specified
in GMC guidance in the UK. All other disclosure requires
explicit consent except in the following circumstances:
• Disclosure is in the public interest if it is required
to prevent serious crime or communicable disease.
For example, clinicians have a duty to inform the
ISTUDY
MAINTAINING PATIENT TRUST
sexual contact of a patient who has HIV infection
if the patient is not prepared to prevent the risk of
transmitting the infection. A doctor also has a duty
1
in the UK to inform the police or Driver and Vehicle
Licensing Agency (DVLA) if a patient is not fit to drive
and is continuing to do so.
• The patient lacks capacity and disclosure is in the best
interest of the patient.
• A court orders disclosure of information.
In any case of disclosure without consent, the clinician must
carefully document the efforts they made to obtain consent
and inform the patient of their plans before disclosure or, if
this is not possible, as soon as possible thereafter.
Patient confidentiality must be safeguarded when patient
information is shared electronically, and any such commu-
nication must use systems which are compliant with the
appropriate security standards. In the UK, nhs.net accounts
currently fulfil these requirements. Outside this facility, clini-
cians should check the security of the system they are using
or remove all patient-identifying data from the communi-
cation. When emailing patients, the clinician should make
them aware of the potential limitations for security and docu-
ment the patient’s consent for this type of communication.
In the UK, the British Association of Dermatologists has
published GMC-approved guidance on how to take clinical
images and email these images for direct patient care. This
guidance states that securely configured devices and NHS
email or secure data transfer apps must be used. The images
must then be deleted immediately after transfer. In any other
circumstance, patient data must be completely anonymized.
CLINICAL REASONING
OR JUDGEMENT
Clinicians make sense of the information they gather by
a process of clinical reasoning, which aims at making a
working or differential diagnosis and management plan.
Clinical reasoning has several stages which may be reit-
erated until a best course of action is identified. We have
already identified some of the key components of this and
a framework for understanding clinical reasoning is sum-
marized in Figure 1.4.
MAINTAINING PATIENT TRUST
Patients often put enormous trust in the medical profession.
When interacting with doctors, patients may feel, and be,
very vulnerable. Their health and well-being may be under
serious threat. It is unlikely that they are familiar with the
concepts and information which form the basis for the
decisions they are being asked to make. There is therefore
a duty on clinicians to respect and safeguard patient trust
by acting honourably and in the patient’s best interests at
all times. These requirements are identified by the GMC
5
Another random document with
no related content on Scribd:
 ASSEMBLING THE GUN.
Reverse all the foregoing operations with the exception that the
recoiling portions must be replaced before the packing and packing
gland. In order to assemble the barrel and breech casings, they will
have to be turned upside-down—i.e., the filling hole down, and the
bottom plate of breech casing uppermost—they should be positioned
by the crosshead joint pin. Care must be taken that the ejector tube
spring is in position before joining the casings together. When
assembling the feed block the longer of the two bottom pawls must
always be placed at the front. When assembling the tangent sight, it
will be found convenient to place the slide on the stem before
attaching the milled head; in this position the pinion is prevented
from turning with the pawl when engaging the arms of the slide
spring outside the lugs in the pawl.
 REPLACEMENT OF DEFECTIVE PARTS OF
THE LOCK.
Should any of the components belonging to the lock become
defective they can be replaced from the spare parts, without
stripping the lock right down. Proceed as follows:—

(i) Sear.

Fully cock, lift the sear, and let the firing pin engage with the
tumbler and trigger; with the lock on the bench, left side up, drive
out the sear axis pin, and remove the sear with its spring.

(ii) Tumbler.

Fully cock, thus engaging the firing pin with the sear; drive out the
axis pin of tumbler, pull the trigger slightly, and lift out the tumbler.
Note.—Care should be taken not to allow the screwed head to lift
the sear when once the tumbler has been removed.

(iii) Trigger, Lock Spring or Extractor Levers.

Release the lock spring, drive out the lock spring axis pin, remove
the keeper bracket, extractor levers and lock spring; if the trigger is
defective, drive out the trigger axis pin and remove the trigger.

(iv) Firing Pin.

Proceed as for (iii), but do not remove the trigger. Remove the
tumbler axis pin and tumbler, raise the sear, push the screwed head
out of its way, and the firing pin will drop out.
(v) Gib, Gib Spring, or Extractor Spring.

This will necessitate the removal of the extractor from the face of
the lock casing. Release the lock spring, drive out the lock spring axis
pin, remove the keeper bracket and extractor levers; next drive out
the keeper pin of the extractor stop, remove the latter, and slide the
extractor off the lock casing: push out the gib spring cover, and
remove the spring or gib as the case may be. If the extractor spring
requires replacing, drive out its fixing pin and remove.
Note.—The serviceable components are replaced in the reverse
order.
 STOPPAGES.

1. Temporary.

Due to (a) Failure of some part of the gun of which a duplicate is

carried, or faulty ammunition; (b) neglect on the part of member or
members of the detachment. A high standard of training will avoid
this.

2. Prolonged.

Due to failure of some part of the gun which cannot, as a rule, be

put right under fire, or without skilled assistance.
In addition to the instructions in the “stoppage” table, the
following points should be observed:—
1. If, when the cover is opened to investigate cause of stoppage, it is
seen that extractor is not quite up, no attempt should be made to
raise it. It should be first pushed down before the crank handle is
turned over to the front, as by this means all risk of firing a cartridge
accidentally is avoided.
2. When a temporary stoppage necessitates the employment of the
spare lock, feed block, etc., the part which has been removed should
be repaired as soon as possible, making it again available as a
reserve.
3. Should it ever be necessary to release the lock spring, with the
lock out of gear, this should be done with the extractor fully up, and
firing pin hole opposite firing pin.
4. As the clearing of a stoppage often knocks the sights off the
aiming mark, care should be taken that the gun is immediately
relaid.
 TABLE OF STOPPAGES.
I. II. III. IV.
Position of Immediate action. Probable Prevention
crank cause. of
handle recurrence.
and its
indication.

FIRST (i) Turn the crank handle on to the The

buffer spring, pull the belt to the left extractor has
front, and let go the crank handle. not dropped.
This may be
due to:—
Indication. (a) Too
The lock is heavy fusee
unable to spring.
come back (ii) If failure recurs, lighten fusee (b) Excessive (b) Clean
far enough spring by three “turns.” friction, due and oil
to allow to want of working
the oil; grit or parts.
extractor tight pockets Examine
to drop. in the belt, the belt,
or excessive which
packing in should be
cannelure or dried if
packing damp; or if
gland. the
stoppage is
due to a
new or stiff
belt, the
pockets
(c) Partial should be
loss of the plugged. If
force of the due to
explosion excessive
due to— packing,
examine
and repack
(i) Worn cannelure
barrel. or packing
gland.
(ii) Defective (c) (i) The
ammunition. barrel
should be
 examined at
the first
opportunity,
and if much
worn in the
lead should
be changed.

SECOND. (i) Force the crank handle on to the (i) (a)

buffer spring. Open the cover and Damaged
examine the cartridge on the face of cartridge.
the extractor. If a damaged The
cartridge, or an undamaged cartridge is
cartridge with the front portion of a unable to
separated case adhering to it, clear enter the
the face of the extractor and re-load. chamber
completely,
although it
has
commenced
to do so.
Indication. (b)
The lock is Separated
unable to case with
go fully front portion
home after adhering to
recoil. undamaged
cartridge.
(ii) If an undamaged cartridge with (ii) (b) If a
no front portion of separated case Separated succession
adhering to it is found on the face of case. The of separated
the extractor, clear the face of the front portion cases occur
extractor and replace the lock, of the case the
keeping the crank handle on the causes an connecting
buffer spring. Take the clearing plug obstruction rod must be
(seeing that the centre pin is back) and prevents lengthened.
and insert it into the chamber. Push the next (See para.
the pin well home by allowing the cartridge 82.)
lock to go forward. Then keeping a from going
firm pressure on the crank handle, into the
give the clearing plug a rocking chamber.
motion; withdraw the lock; lever
back the handle of the clearing plug,
withdraw it (seeing that the front
 portion of the separated case is on
the clearing plug) and re-load.

THIRD.
Indication. (i) Strike the crank handle on to (i) (a) Too (i) (b) Clean
The check lever by a glancing blow with light fusee and oil
extractor the palm of the hand. If failure spring. working
is unable recurs, strengthen the fusee spring parts.
to rise to by three turns. (b) Excessive
its highest friction.
position.
If the feed
block slide
is jammed,
there is a
fault in
feed.
Note.—If the continued strengthening of the fusee spring results
in the crank handle stopping in the first position, change the lock,
putting the fusee spring back to normal; if failure recurs take
muzzle attachment into use. (See para. 44.)
(ii) If (i) fails, slightly raise the crank (ii) A (ii)
handle, pull the belt to the left front, cartridge is Carefully
let go the crank handle, and then fed up examine the
strike it down on the check lever. slightly belt.
crossways,
or a long
brass strip is
bent.
(iii) A. If (i) and (ii) fail, examine (iii) A. (1) (iii) A. (1)
feed block slide. If jammed, No. 1 Badly filled Carefully
holds up the crank handle and belt, or a examine the
opens the cover. No. 2, with the belt with new belt.
assistance of No. 1, removes the feed worn or
block, and replaces it by the spare loose
one. pockets. The
Meanwhile No. 1 forces down the cartridges
horns of the extractor, and places projecting
the crank handle on the buffer unevenly
spring. As soon as the spare feed from the belt
block is in position, No. 1 closes the prevent it
cover and pulls the top cartridge of a entering or
fresh belt into position and lets go passing
the crank handle. freely
 through the
feed block.
(iii) A. (2) (iii) A. (2)
Belt box not See that the
being in line new belt
with the feed box is in
block; the line.
belt does not
lead up
correctly to
the feed
block and
becomes
jammed.
Note.—The effect of a fault
in feed is that the top pawls,
being engaged behind a
cartridge in the belt, are
held fast when some
obstruction, such as above,
prevents the belt from
passing freely through the
feed block. The recoiling
portions, being connected
by the top and bottom
levers to the slide, are
arrested and prevented
from going home. The
distance they are held back
depends upon the point at
which the obstruction
asserts itself.
(iii) B. If free, No. 1 opens the cover. (iii) B. (1)
No. 2 forces down the horns of the Damaged
extractor. No. 1 clears the face of the cartridge
extractor, and changes the lock. He grooves.
removes the cartridge in positioning (2) Broken
the feed block and re-loads. gib spring.
(3) Broken
gib. In these
cases the
extractor is
prevented
from rising
 to its highest
position. It
may be
necessary
sometimes
to slide the
cartridge or
the empty
case
upwards,
when
clearing the
face of the
extractor.
(4) Thick-
rimmed
cartridge.
Note.—If it is apparent that
the stoppage is due to a
thick-rimmed cartridge, it
will not be necessary to
change the lock.

FOURTH. (a) Turn the crank handle on to the (a) (1) No

buffer spring, pull the belt to the left cartridge in
front, and let go the crank handle. the
chamber.
Indication. (2) Defective
That there ammunition.
has been
no
explosion, (b) If (a) fails, place the crank (b) (1)
or, if any, handle on to the buffer spring twice, Broken or
that there change the lock, and re-load. damaged
has been firing pin.
little or no
recoil, the
lock
remaining (2) Broken
in its lock spring.
forward
position.
 Note.—If the continued lightening of the fusee spring results in
the crank handle stopping in the third position, take muzzle
attachment into use, and put fusee spring back to normal weight (see
para. 44).

Note.—Worn or damaged side or extractor levers may result in the extractor

being unable to rise, or if the side levers are bent, there may either be a succession
of separated cases, or the lock may become jammed.

The causes of prolonged stoppages are so varied that they cannot

be set out in detail. The following are amongst the most probable,
and the detachment should be thoroughly trained to recognize them
and to apply such remedy as lies in their power pending a permanent
repair:—

(i) Broken Cover Springs.

The extractor may not drop when the lock is drawn back, and the
gun will stop with the crank handle in the first position. This may
possibly be overcome by liberal oiling of the lock, but in any case
single shots can be fired by holding the crank handle forward until
the extractor drops by its own weight.

(ii) Broken Ejector Tube Spring,

Causing either a block in the ejector tube or an accumulation of

empty cases in the breech casing. It may be found possible to keep
the gun in action if care is taken to prevent the latter.

(iii) Cotter working out,

Thus causing the screwed head and connecting rod to become

separated. To remedy proceed as follows:—
 (a) Take out the cotter. (This will be found either on the crank
or at the bottom of the breech casing.)
(b) Press down the screwed head with a large screwdriver to
lock the cock.
(c) Turn the screwdriver edgeways and insert it behind the
horns of the extractor and between the face of the barrel
and front of the lock flange, and force the lock to the rear.
(d) Turn crank handle on to the buffer spring, press down the
extractor, raise the lock and remove the live cartridge,
then lift out the lock.

(iv) Damaged Parts of the Lock, no Spare Part being

available.

The gun will fire without the sear, or if the bents of the sear or
firing pin are badly worn or broken off, but only single shots, and
only by pressing and releasing the double button quickly.
The gun will also fire if the nose of the trigger or bent of the
tumbler is badly worn or broken off, but only rapid firing. In this
case the gun will fire the instant the crank handle reaches the check
level, although the double button has not been pressed.
The gun can be worked as follows:—

(a) Group the cartridges in the belt, say 20 or 30 rounds each

group.
(b) Lay the gun before commencing to load, place crank handle
on buffer spring, pull belt to left and let handle go;
repeat, but before allowing the handle to reach check
lever and the gun to fire, grip the rear crosspiece with left
hand to control gun in the ordinary way.
If necessary firing can be stopped by throwing the filled end of the
belt over the breech casing to the left.
When the firing has been stopped as described above, hold the
crank handle with the right hand, open the cover, press down the
horns of the extractor, draw the lock back, and, if there is a live
cartridge on the face of the extractor, remove the feed block and belt,
close the cover, and allow the lock to fly forward, when the live
cartridge, which is on the face of the extractor, will be fired
automatically. The lock can then be changed with safety. On no
account should the lock be allowed to fly forward until the feed block
has been removed and the cover shut.
If, on drawing the lock back, it is found that there is no live
cartridge on its face, the lock may be changed at once, and the
necessity for removing the feed block and the subsequent
precautions will not arise.

(v) Gunmetal Valve Working Loose.

This will prevent the barrel from going home. It may be

temporarily remedied by tapping it round with a hammer and punch,
but it should be tightened at the earliest opportunity with the gib key,
the barrel being removed from the gun.
 ·303–inch Vickers Gun.

Explanation of Plates IV and V.

Similar numbers indicate corresponding parts in all the plates.

1. Casing, barrel.
2. Tube, steam.
3. Bracket, foresight.
4. Gland.
5. Casing, breech.
6. Cover, front.
7. Cover, rear.
8. Sight, tangent.
9. Bar, trigger.
10. Lock, rear cover.
11. Rear-crosspiece.
12. Lever, firing.
13. Lever, trigger bar.
14. Catch, safety.
15. }
16. } Plugs, screwed.
17. Protector, screwed, condenser boss.
18. Plug, cork.
19. Guide, front barrel bearing.
20. Crosshead.
21. Cams, right and left.
22. Steps of cams, right and left.
23. Catch, front cover.
24. Pin, screwed, joint cover.
25. Pin-T, fixing, rear-crosspiece.
26. Pin, screwed, fixing, crank handle.
27. Slides, right and left.
28. Roller.
29. Pin, screwed, joint, rear-crosspiece.
30. Bracket, check lever.
31. Lever, check.
32. Bracket, elevating joint.
33. Stop, mounting.
34. Plate, bottom, breech casing.
35. Shutter, sliding.
36. Hooks of front cover catch.
37. Hole for keeper pin, front cover catch.
38. Lever of catch, front cover.
39. Grooves in front cover catch to clear “36.”
40. Plunger, front cover catch.
41. Bridge, rear cover.
42. { Spring tangent sight.
{ Piston „ „
43. Grooves in rear cover for ribs on “5.”
44. Ramps, rear cover.
 45. Spring, rear cover lock.
46. Spring, trigger bar.
47. Lug on trigger bar for “46.”
48. Base of tangent sight stem.
49. Hooks of rear cover lock.
50. Lug on rear cover lock for “45.”
51. Slot in trigger bar for “86.”
52. Lug on trigger bar for “13.”
53. } Thumbpiece, sliding shutter catch.
54. }
55. Plunger, sliding shutter catch.
56. Arms of rear-crosspiece.
57. Grips, rear-crosspiece.
58. Pawl, firing lever.
59. Spring, safety catch, with piston.
60. Pin, screwed axis, safety catch.
60A. Finger grips, safety catch.
61. Pin, screwed, axis, firing lever.
62. } Thumbpiece, firing lever.
63. }
64. Pin, keeper, check lever.
65. { Piston, check lever.
{ Spring, „ „
66. Recess in check lever for “65.”
67. Barrel.
68. Casing, lock.
69. Plate, side, right.
70. Crank.
71. Handle, crank.
71A. Tail of crank handle.
71B. Knob of crank handle.
72. Rod, connecting.
72A. Stem of connecting rod.
73. Fusee.
73A. Chain, fusee.
74. Spring, fusee.
74A. Hook, fusee spring.
75. Box, fusee spring.
75A. Screw, adjusting, fusee spring.
76. Block, feed.
77. Cannelure in “67” for asbestos packing.
78. Trunnion block, barrel.
79. Lock.
80. Levers, side (pair).
81. Socket of side levers for “72A.”
82. Extractor.
83. Gib.
84. Spring, gib.
85. Cover, gib spring.
86. Trigger.
87. Lever, extractor, right.
88. Tumbler.
89. Spring, lock.
90. Pin, firing.
 91. Sear.
92. Spring, sear.
93. Flanges of lock casing.
94. Interruptions in flanges of lock casing.
95. Slots in lock casing for “99.”
96. Bearings on lock casing for “80.”
97. Upper extractor stop of lock casing.
98. Bent of extractor lever for “80.”
99. Lugs on side levers for “95.”
100. Bush, axis, side levers.
101. Pin, split, keeper, bush, axis, side levers.
102. Horns of extractor.
102A. Grooves in extractor for “79.”
103. Shoulders of extractor for “87.”
104. Grooves in extractor for side plate springs.
105. Hole in extractor for “90.”
106. Recess in extractor for “83.”
107. Pin, axis, trigger.
108. Pin, axis, tumbler.
109. Key of pin, axis, tumbler.
110. Projection on firing pin for “89.”
111. Lever, top, feed block.
112. Lever, bottom, feed block.
113. Pins, split, fixing, top and bottom levers, feed block.
114. Stud of top lever for feed block slide.
114A. Slide, feed block.
115. Pawl, top, feed block, rear.
115A. Thumb grips of “115” and “116.”
116. Pawl, top, feed block, front.
117. Spring, top pawls, feed block.
118. Pawls, bottom, feed block (pair).
119. Pin, axis, bottom pawl, feed block.
120. Finger plate of bottom pawls, feed block.
121. Spring, bottom pawls, feed block.
122. Cup, muzzle attachment.
123. Casing, outer, muzzle attachment.
124. Cone, front, muzzle attachment.
125. Gland, muzzle attachment.
126. Screw, clamping, cup, muzzle attachment.
127. Disc, muzzle attachment.
128. Vent, bullet, muzzle attachment.

Plate IV.

VICKERS GUN.
 Plate V.

VICKERS GUN.
 VICKERS LIGHT MACHINE GUN.
The principal features are as in Maxim with the following
exceptions:—
Total weight, ready for firing, is 38½ lbs. (Maxim, 67 lbs.).
Length, width and depth slightly less than Maxim.
Barrel casing is of corrugated steel (affording greater cooling
surface).
Rear end of barrel—i.e., chamber—goes back into barrel casing,
thus greatly assisting cooling of barrel where it is most essential.
Foresight is blade pattern, with protector.
No ejector tube or spring, there being an opening at bottom of
breech casing through which empty cases fall. (Shutter requires to be
opened before commencing firing.)
Tangent sight is 2½ in. nearer rear end of breech casing and is U
pattern.
There is no buffer spring or resistance piece.
An elevating stop on outside of left-hand plate, this preventing the
bracket head of the mounting damaging the fusee spring box.
No stud for the shoulder piece.
Connecting rod has an adjusting nut and washers.
Crank handle revolves in the opposite direction to Maxim.
Lock is inverted and joined to connecting rod by an interrupted
flange.
Lock has no extractor spring, as cases fall off extractor when clear
of barrel.
Lock can be easily stripped with the hand screw which forms the
axis pin of the trigger bar lever.
Top pawls are made with finger pieces, and can be pressed down
by hand to allow belt to be released, having only one spring, which is
removable.
Fusee spring can be adjusted without removing box, as the vice pin
of screw is loose.
Fusee has a clutch fixture, and is easily removable.