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School of Medical Education
Year 4
Problem Based Learning
Study Guide: Student Version
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Resources for Year 4
In this study guide, you will find a list of Basic Resources. These resources are
helpful in reaching your learning objectives for all the modules this session. They
should not be considered as a compulsory reading list. For some of the disciplines,
more than one resource text is mentioned - use whichever one suits your style of
learning best. We recommend that you buy one textbook in each discipline.
As you will now be involved in clinical work, you should also consider a student
subscription to the Lancet, British Medical Journal or New England Journal of
Medicine if you have not already done so.
We have also included among the resources a list of core cases which are pertinent
to the module. This list is not exhaustive, not all the core cases are included in the
lists, neither should the core cases mentioned be considered any more important
than others. The core cases are merely included to remind you that one of the
greatest resources available to you in your learning is the patients you meet in the
wards or in the community.
For individual modules, additional resources are mentioned, which you may also find
helpful for your learning objectives. Again they should not be considered as
compulsory or a definition of the curriculum.
If you find any other
books/resources which are particularly helpful, please let the Year Directors know
at [email protected] and [email protected]
Year 4 PBL Study Guide 2007-2008 – Student Version
Basic Resources
Faculty website:
Structure and Function
Human Anatomy Resource Centre.
Clinical Anatomy for Medical Students. Snell RS, 7th ed., Lippincott, Williams
and Wilkins, 2004
Human Histology. Stevens A & Lowe J. 2nd Edition. Mosby-Wolfe, London
Barr’s The human nervous system: an anatomical viewpoint. Kiernan, John A
Lippincott-Raven 1998. 7th edition
Lecture notes on Human Physiology Bray JJ (et al), Blackwell Science, 1999.
4th edition
Principles of Physiology. Berne RM, Levy MN. 3rd edition. Mosby, St Louis.
Clinical Biochemistry for Medical Students. Laker MF. Saunders WB. London
Biochemistry. Zubay G. 4th edition. McGraw Hill. 1998.
Biochemistry. Stryer L. 4th edition. Freeman, New York. 1995.
Clinical Chemistry, 3rd Edition. Marshal W(ed.). Mosby-Wolfe. London 1995.
Color atlas of medical microbiology. Hart CT, 1996, Mosby-Wolfe, 1996 (also
known as Diagnosis in Colour Medical Microbiology)
General and systematic pathology. James C.E. Underwood, 4th ed., Churchill
Livingstone, 2004
Pathology. Stevens, A & Lowe, JS, 2nd ed., Mosby, 2000
Essential Clinical Pathology. Parums DV. Blackwells Scientific, Oxford. 1996.
Pharmacology. Winstanley, Peter & Walley, Tom, Churchill Livingstone, 1996
Human Nutrition - A Health Perspective. Barasi ME . Arnold London 1997.
Human Nutrition & Dietetics. Garrow JS, James WPT, Ralph A. 9th edition
Churchill Livingstone. Edinburgh 1993.
Hutchison’s Clinical Methods. Swash M. 21st edition, Saunders, 2002.
Clinical Examination. Epstein O, Solomons N, Robins A. 2nd Edition. Mosby,
The ECG made easy. Hampton JR. 6th edition. Churchill Livingstone. 2003.
Clinical Medicine: a textbook for medical students and doctors. Kumar,
Parveen J, 4th ed., W B Saunders 1998
Davidson’s Principles and Practice of Medicine. Davidson, Stanley, 18th ed.
Churchill Livingstone, 1999
Textbook of medicine. Souhami, R.L., 5th ed., Oxford University Press, 2001
Oxford Handbook of Clinical Medicine. Longmoor, JM, 5th edition. Oxford
University Press. 2001.
Year 4 PBL Study Guide 2007-2008 – Student Version
26. Oxford Textbook of Medicine Weatherall DJ, Ledingham JGG and Warrell
DA (eds) 3rd Edition , Oxford University Press, 1996.
27. Essential Surgery: problems, diagnosis and management. Burkitt HG, Quick
CRG. 3rd edition. Churchill Livingstone. 2002.
28. Essential Orthopaedics and Trauma. Dandy DJ, Edwards DJ. 4th edition
Churchill Livingstone 2003.
29. Lecture notes in Orthopaedics and Fractures. Duckworth T. 3rd edition
Blackwell Science 1995
30. ABC of Major Trauma. Driscol P, Skinner D, Earlam R., 3rd Edition, BMJ 1999.
31. Illustrated Textbook of Paediatrics. Lissauer T, Clayden G. 2nd Edition,
Mosby 2001.
32. Essential Paediatrics. Hull D, Johnson DI. 3rd edition. Churchill Livingstone
33. Essential Paediatrics. Hull David, 4th ed, Churchill Livingstone, 1999
34. Obstetrics by Ten Teachers. Clayton SG. 18th edition . Arnold, 2005.
35. Gynaecology by Ten Teachers. Clayton SG, Monga A, 18th edition. Arnold
36. The Handbook of Family Planning and Reproductive Health Care. Louden N,
Glasier A, Gebbie A. 3rd edition. Churchill Livingstone 1995.
37. ABC of Sexually Transmitted Diseases. Adler MW, 4th edition. BMJ, 1998.
38. Essential Reproduction. Johnson MH, Everitt, BJ. 5th edition. Blackwell
Science. Oxford 2000.
39. Clinical Dermatology. Hunter JAA, Savin JA, Dahl MV 2nd edition Blackwell
Science 1995
40. Clinical Dermatology. MacKie R M. 4th edition Oxford University Press 1997
41. Clinical Examination in Rheumatology. Doherty M, Doherty J. Wolfe London
42. Clinical ophthalmology: a systematic approach. Kanski, Jack L, 4th ed,
Butterworth-Heinemann, 1999
43. ABC of Eyes. Khaw, PT, 3rd ed, BMJ, 1999
44. Introducing Palliative Care. Twycross, Robert G, 3rd ed, Radcliffe Medical
Press, 1999
45. Psychiatry. Gelder M, Mayou R, and Geddes J. 2nd Edition Oxford University
Press 1999
46. ABC of Mental Health Davies T and Craig TKJ BMJ Books, 1998
Individuals, Groups and Society
47. The evidence based medicine workbook: critical appraisal for clinical problem
solving. Dixon, Robert A, Butterworth-Heinemann, 1997
48. An Introduction to Health Psychology. Gatchel RJ, Baum A, Krantz DS. 2nd
edition. McGraw-Hill. New York, 1989.
Year 4 PBL Study Guide 2007-2008 – Student Version
49. Sociology as applied to Medicine. Scrambler G. Edinburgh: Saunders, 5th
edition 2003
50. Outline of sociology as applied to Medicine. Armstrong D. London, Arnold, 5th
edition, 2003
51. Psychology in Medicine. IC McManus. Butterworth Heinemann. Oxford,
52. Inequalities in Health. Black D. 1980 DHSS.
54. An Introduction to the Sociology of Health and Illness. White K, London: Sage
55. Health and Illness. Senior M, Viveash B, UK: MackMillan Distribution Ltd,
Population Perspective
56. Website:
57. Essential Public Health Medicine. Donaldson RJ and Donaldson LJ Derdrecht:
Kluwer Academic Publisher. London 1993.
58. Medical Statistics: A Common Sense Approach. Campbell MJ, Machin D. 3rd
edition, Chichester Wiley,1999.
59. Statistics at Square One, Swinscow T.D.V, Campbell MJ. 10th edition. London
BMJ, 2002.
60. Philosophical medical ethics. Gillon, Raanan, Wiley, 1986 (new ed. Due in 2001)
Professional Values and Ethics
Medicine, Patients and the Law. Brazier M. 3rd edition. London Penguin,
Medical Ethics. Veatch R. 2nd edition. Jones and Bartlett. London 1997
Principles of Health Care Ethics. Gillon R & Lloyd A. Wiley, Chichester 1994.
GMC - Duties of a Doctor.
Principles of Biomedical Ethics. Beauchamp T.L, Childress J.F. 5th edition.
Oxford University Press, New York. 2001.
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Surgical Specialties and Palliative Care
Road Traffic Accident (RTA)
Convenors: Mr Peter Burdett-Smith
Dr Una Geary
Mr Tony Good
Dr Lawrence Jaffey
The paramedic team bring in three young men to Accident and Emergency, from a
serious road traffic accident in central Liverpool. The story is obtained from the
police that they had followed them after they were seen running from a drugs raid
in one of the clubs. After following them for some distance at high speed, their
car had collided with an articulated lorry and overturned. The driver and rear
passenger had been thrown out of the car. All three were agitated when the
paramedics arrived; the driver was semi-conscious and confused.
On initial assessment by the triage nurse in A & E, Dave, the driver, was quiet, pale
and confused. He had obvious injuries to both lower legs and was moaning about
pain in his left hip. John was very drunk, semi-conscious and combative. He was
bleeding heavily from scalp and facial wounds with an obvious boggy swelling on his
left scalp. He had obvious major trauma to his left arm and leg. Mark, the second
passenger, was abusive and smelt strongly of alcohol. He had multiple facial
abrasions and his left ankle was obviously deformed. He kept insisting, however,
that there was nothing wrong with him and he didn’t see why he should stay in
Year 4 PBL Study Guide 2007-2008 – Student Version
Core Reading
ABC of Major Trauma 1999, 3rd Ed. BMJ Publications.
Further Reading
American College of Surgeons Committee on Trauma.
Support for Doctors. Student Course Manual 1997.
Advanced Trauma Life
Anderson ID, Woodford M, de Dombal FT, Irving M. Retrospective study of 1000
deaths from injury in England and Wales. Br Med J 1988 296: 1305-1308
American College of Emergency Physicians: Trauma care systems development and
evaluation. Ann Emergency Med October 1998 32: 528-9
Oakley PA, Setting and living up to national standards for the care of the injured.
Injury 199425: 595-604
Laffoy M. Prevention of unintentional injury. J Irish Coll Phys Surg 1999 28(2):
Trunkey D. Initial treatment of patients with extensive trauma.
Concepts. New Eng J Med 1991 324(18): 1259-1262
Luke LC. ATLS: Has the means become the end? CPD Anaesthesia 1999 1(2):
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Surgical Specialties and Palliative Care
Lower Limb Ischaemia
Mr Geoffrey Gilling-Smith
I can’t walk properly
Mr Peterson is referred to the out-patient department by his General Practitioner.
He is a 54 year-old cabinet maker who has over the last few months experienced
increasing difficulty in walking. He suffers from a cramp like pain in his right calf
which comes on after walking 20-30 yards and which obliges him to stop and rest
after 50 yards. The pain is rapidly relieved if he stands still for a few minutes and
he can then walk a little further before the pain starts again. The pain is not a
problem when he is at home or work, but he finds that it interferes with his
leisure activities. Mr Peterson is married with two grown up children. He has
smoked at least 20 cigarettes a day for most of his adult life despite having been
advised on numerous occasions to give up and he is a diet-controlled diabetic.
Clinical examination revealed a full complement of peripheral pulses in his left leg,
but on the right only the femoral pulse is palpable. Non-invasive studies in the
Vascular Laboratory revealed an ankle brachial index of 0.7 on the right at rest
which fails to 0.4 after exercise. Duplex scanning reveals two localized stenoses
of the right superficial fermoral artery.
Year 4 PBL Study Guide 2007-2008 – Student Version
I can’t feel my leg
Mr Williams presents to the Accident and Emergency Department complaining that
he cannot feel or move his left leg. His symptoms had come on suddenly earlier
that day and had rapidly worsened. Mr Williams who is 68 years old has had
trouble with his leg for years. Six years previously, he had lost his right leg
because of circulation problems. He has a false leg, but he doesn’t use it and is
wheelchair bound. He lives in a ground floor flat with his wife who suffers from
Two years ago Mr Williams started to get pain in his left foot at night. This was
relieved by a bypass operation on his left leg and when he last came to clinic the
scan of the graft had revealed no problems.
Mr Williams is taken directly to the operating theatre. He undergoes graft
thrombectomy. On table angiography then reveals a localised stenosis of the
popliteal artery immediately beyond the distal anastomosis of the old graft. The
stenosis is treated by patch angioplasty. Mr Williams also undergoes bilateral
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Surgical Specialties and Palliative Care
Swelling in the Neck
Mr John Fenton
Mr Trevor Black, a 55 year-old man, presented with a three month history of a
progressively enlarging swelling in the left side of the neck. He also complained of
a recent onset of left side earache. He was otherwise asymptomatic. He smoked
20 cigarettes a day for 25 years and drank approximately 30 units of alcohol a
week. Examination of his oral cavity, pharynx and larynx revealed no abnormality.
He had a 3 cms hard mobile swelling anteromedial to the left sternomastoid muscle
in the mid cervical region. A fine needle aspiration cytology was performed which
revealed malignant squamous cell carcinoma cells.
He was admitted for
panendoscopy, biopsy of his postnasal space and left piriform fossa and left
tonsillectomy. Magnetic Resonance Imaging (MRI) of his neck confirmed the
presence of a malignant mass of lymph nodes but there was no evidence of a
primary malignancy. Computerised tomography (CT) of his chest revealed no
abnormality. Histology revealed a small primary focus of squamous cell carcinoma
in the left piriform fossa with no evidence of tumour in the other specimens.
After routine counselling, Trevor underwent a left radical neck dissection which
demonstrated metastases in three nodes with extra capsular tumour spread. He
had a full course of post operative radiotherapy to his neck and pharynx. Even
after treatment was completed, Trevor’s wife refused to sit on his left hand side.
Year 4 PBL Study Guide 2007-2008 – Student Version
Jill Czernikowsky, a 42 year old woman presented with an eight month history of a
swelling in front of her right ear. It was slowly progressing in size but she was
otherwise asymptomatic. She had had a right modified mastoidectomy for chronic
otitis media with cholesteatoma four years previously. She was found to have a
2cms smooth mobile ovoid swelling in the right preauricular region. The right
mastoid cavity was clean and dry. The remainder of the examination, including
assessment of facial nerve function, neck palpation and oropharynx was normal.
Fine needle aspiration cytology demonstrated cells consistent with a pleomorphic
adenoma. She had a right superficial parotidectomy performed and post-operation
facial nerve function was normal. Histology confirmed that the tumour was a
pleomorphic adenoma which was completely excised.
Jack Williams, a ten year old boy presented with a three week history of a tender
swelling under the angle of his left jaw. He had an episode of severe tonsillitis one
month previously which responded to oral antibiotics. He had suffered from
recurrent tonsillitis on approximately five to six occasions per year for the
previous three years. He also snored excessively and kept his brother awake. On
examination he was found to have a 2cms tender swelling in the left jugulodigastric
region which was non fluctuant in nature. An ultrasound of this swelling was
performed which revealed no evidence of abscess formation. He was admitted for
intravenous antibiotics which successfully treated the cervical infection. Six
weeks later he had a tonsillectomy and adenoidectomy performed.
Additional Resources
All available in the Royal Liverpool University Hospital Library
A new Short Textbook of ENT
McCormick, Primrose and Mackenzie
(Publisher: Edward Arnold)
Clinical ENT
O’Donoghue GM, Bates GJ, Marula AA
(Publisher: Oxford University Press)
Key Topics in Ear, Nose & Throat
Roland McRae and McCombe
(Publisher: Bios Scientific Publishers)
Year 4 PBL Study Guide 2007-2008 – Student Version
Logan Turner’s Disease of the Nose, Throat and Ear
J F Birrell
(Publisher: Wright PSG)
Head and Neck Surgery
Maran AGD, Gaze M, Wilson JA
(Publisher: Butterworth Heinemann Ltd)
Ear, Nose & Throat and Head and Neck Surgery
Dhillon RS, East CA
[An illustrated colour text]
(Publisher: Churchill Livingstone)
Diseases of the Head & Neck, Nose & Throat
Jones AS, Phillips DE, Hilgers FJM
(Publisher: Edward Arnold)
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Surgical Specialties and Palliative Care
A Worrying Lump
Professor Hilmar Warenius
It’s Anna’s 37th birthday. She is sitting in the surgical outpatients with her
husband, John. Three weeks ago she thought she could feel a lump in her right
breast and went straight to her GP who referred for an urgent appointment. Last
week she was seen by the consultant who detected a 3 cm lump in the left upper
outer quadrant and a firm mobile 1.5 cm node in the axilla. He performed a fine
needle aspiration (FNA). Anna has been convinced she had cancer from the
moment she discovered the lump and is anxious and tearful. John wants to know
why Anna wasn’t screened like her younger sister who had regular cervical smears
until she finally needed treatment. He refuses to talk with Anna about her fear of
cancer. His father died last year of a lung cancer which had spread to the liver
before it was diagnosed.
Anna and John are seen by the SHO who explains that the cells from the FNA
were not at all normal. Anna will need to be admitted to have the lump in the
breast removed and also the gland taken from under the arm so that both can be
looked at under the microscope.
Year 4 PBL Study Guide 2007-2008 – Student Version
Anna and John are sitting in the day room trying to understand a consent form for
a clinical trial comparing two different chemotherapy regimes with and without
hormone treatment. Anna really doesn’t want ‘chemo’ – she isn’t convinced it has
much chance of working and remembers how sick her aunt was when they gave her
platinum treatment after they took her ovaries out. She is more worried that her
daughters will get the same thing as her and wants to know at what age they should
start having the new molecular test. The houseman explains that in Anna’s case
although the scans and other tests are negative, there is still the chance that
some tumour cells may have spread to other parts of the body and chemotherapy is
definitely needed but doctors still need to find out what the best treatment is.
Anna wants to know how the houseman can be so certain she should go into the
trial and how long it would be before they could detect that the cells had
definitely spread on a scan or some other test. Why couldn’t they wait till then
before they gave her ‘chemo’? John wants to know why Anna isn’t having radiation
Further Reading
Dixon M, Sainsbury R ‘Handbook of Diseases of the Breast’ (2nd edition) Churchill
Livingstone 1998
Dixon JM (Ed) ‘ABC of Breast Diseases’ BMJPG 1997
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Surgical Specialties and Palliative Care
Palliative Care and Communication Skills
Dr John Ellershaw
A 46 year old woman of Chinese ethnic origin, Ming Wang, is complaining of pains in
the back and intermittent nausea. Although metastatic carcinoma has been
diagnosed, the primary cancer is unknown. She is married with two children aged 8
and 12. Both she and her husband are aware of the diagnosis but anxious the
children are not told.
Six months later, Ming’s condition has deteriorated. She has expressed a wish to
die at home. The patient has daily visits from her District Nurse who has started
a syringe driver to control her symptoms as she is too unwell to take oral
medication. The District Nurse visits and finds the patient is in pain and agitated.
The husband is finding it increasingly difficult to cope. The District Nurse phones
the GP to discuss hospice or hospital admission. The GP decides to visit the
patient and arrives 30 minutes later to find the patient has just died.
A 70 year old lady with longstanding rheumatoid arthritis had developed ulcers and
abscesses on her arms and legs, a rectal sore penetrating to the bone, fractured
vertebrae, deformed hands and feet and gangrene from steroid treatment. Her
weight was down to 42kg and it was agony for her to be touched. The pain was not
responsive to increasing doses of diamorphine.
Year 4 PBL Study Guide 2007-2008 – Student Version
Five days before her death she pleaded for tablets or an injection to end her life.
When this was refused she said that she wanted her treatment stopped and her
steroid therapy was discontinued. The consultant in charge of her case had known
the patient for 13 years and together with the patient’s family was convinced that
the patient’s requests to end her life were genuine.
A 26 year old man has been in a persistent vegetative state since he was crushed
in the Hillsborough Football Stadium Disaster several years ago. His family and
the health care professionals caring for him came to the conclusion that it would
be in his best interests if the naso-gastric feeding were to be withdrawn. Because
of the nature of the decision the courts become involved and finally the decision is
made by five Law Lords. The judges decide that the nourishment regime being
given to the patient by the nasal tube feeding is to be classed as medical
treatment. They are unanimous that it would be lawful to discontinue the
treatment that is keeping the patient alive, as it is in the patient’s best interests.
No advanced directives had been given.
Further Reading
Twycross R ‘Introducing Palliative Care’ (Second Edition) 1997 Radcliffe Medical
Randall F, Downie RS ‘Palliative Care Ethics: A Good Companion’ 1996 Oxford
Medical Publications, Oxford University Press.
Fallon M, O’Neill B (Eds) ‘ABC of Palliative Care’ 1998 BMJ Books.
British Medical Association ‘Medica; Ethics Today – The Practice and Philosophy’
London, Medical Journal Publishing Group, 1993.
British Medical Association ‘Advanced Statements about Medical Treatment’
London BMJPG, 1995
British Medical Association ‘Withholding and Withdrawing Life – Prolonging Medical
Treatment’ BMJPG 1999-08-23
Dyer C GMC Tempers Justice with Mercy (Cox Case) BMJ 1992;305:1311
Van Der Maas PJ, Van Delden JJM, Pijnenborg L, Looman CWN Euthanasia and
other Medical Decisions Concerning the end of Life The Lancet 1991;338:669-674
Year 4 PBL Study Guide 2007-2008 – Student Version
Drane G et al.
Withdrawal of Life Support from Patients in a persistant
vegetative state Lancet, 1991;337:96-98
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Medical Specialties and Geriatric Medicine
Endocrine Disorders
Dr Geoff Gill
Hamish Campbell, a 55 year old man has had diabetes for 6 years, managed by his
general practitioner. He is overweight with a body mass index (BMI) of 29.5, and
has a sedentary life style. He also smokes 10-15 cigarettes per day. For 2 years
after diagnosis he had been on dietary treatment only, but had then progressed to
tablets and was currently taking Gliclazide 160 mgs twice daily, and Metformin 850
mgs three times daily. Current glycosylated haemoglobin (HbA1c) is 8.9%, random
serum cholesterol 6.9 mmol/l, and blood pressure (BP) 160/95 mmHg. The GP was
concerned that he may need insulin treatment, and referred him to the local
hospital diabetic clinic. He was seen there some weeks later, and was surprised at
the unexpectedly detailed assessment he received before a decision was made on
insulin treatment.
You are a specialist registrar in public health medicine in a large northern
industrial town. Your supervising consultant, who is also the local Director of
Health, calls you into her office one day. The previous evening she was part of an
“expert panel” at a local branch meeting of the British Diabetic Association, and
received something of a “flea in her ear” from diabetic patients about the
inadequate district services. One of the local diabetologists was also on the panel,
and he gave her little support, basically agreeing with the patients and saying it
was all due to cash shortages and mistaken priorities of the public health doctors!
Your harassed boss wants you to critically evaluate whether money should be
provided for the following:-
Year 4 PBL Study Guide 2007-2008 – Student Version
a population screening programme for diabetes
a screening programme for retinopathy amongst diabetic patients
support services for GP-based care of Type 2 diabetes
an impotence clinic for diabetic patients, at the local hospital.
Maureen O’Callaghan, a 55 year old lady consults her general practitioner because
of weight gain and fatigue. She has no relevant past medical history and is on no
medication. The GP decides to check her thyroid function, and also wonders if her
symptoms are “menopausal”. She returns 2 weeks later for the results of her
blood tests. These show that her free thyroxine (FT4) level is 6.2 pmol/l
(reference range 10.5 – 25.5), and thyroid stimulating hormone (TSH) is 1.0 mU/I
(range 0.5 – 5.5). Serum thyroid antibodies are negative, and FSH and LH levels
are 1.0 mU/l (range 1.0 – 8.0) and 1.5 mU/I (range 1.0 – 6.0) respectively.
Uncertain of how to interpret these results, her GP refers her to hospital where
she is seen a few months later at an Endocrine Clinic. Over the next 2 or 3
months, the patient is surprised by the number and complexity of further tests
which she undergoes, but eventually she is put onto some treatment which makes
her feel considerably better.
Core cases
Diabetes mellitus in an adult
Complications of diabetes
Further Reading
Pickup JC & Williams G (Eds), Textbook of Diabetes, 2nd Edition (1997); Publ
Blackwell Science:Particularly chapters 2 (diagnosis), 33 (insulin treatment), 37 (diet), 38 (drug
treatment), 57 (cardiovascular disease), 59 (erectile dysfunction), and 80 (shared
Joint Working Party. Guidelines for good practice in the diagnosis and treatment
of non-insulin dependent diabetes mellitus. J Roy Coll Phys Lond 1993; 27: 259226.
Lazarus JH. Hyperthyroidism. Lancet 1997; 349: 339-343.
Weetman AP. Hypothyroidism: screening and subclinical disease. Brit Med J 1997;
314: 1175-1178.
Year 4 PBL Study Guide 2007-2008 – Student Version
Other Resources
The British Diabetic Association produce a number of patient information leaflets
which are of use and interest to health professionals (address: 10, Queen Anne
Street, London W1M 0BD; tel 0171 323 1531).
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Medical Specialties and Geriatric Medicine
Dr Jennie Hunter
A 30 year old woman is brought into A and E after being found unconscious in the
street. On admission, she is still breathing and has a palpable pulse. 30 minutes
later, the patient has died, before a diagnosis could be made.
A 25 year old single mother is found one morning on the kitchen floor, unconscious,
by her 7 year old son. He cannot rouse her so dials 999. The paramedics arrive
within 10 minutes. The patient is cold, groaning and restless, but not responding to
commands. An empty bottle of vodka, and two empty pill bottles (unlabelled) lie
beside her.
Core cases
Suicide and parasuicide
Stroke (CVA)
Alcohol misuse
Drug misuse
Further Reading
Brain-stem death and management of multiple-organ donor. Max Jonas In:
Textbook of Intensive Care. Eds. D Goldhill and Stuart Withington. 1997.
Chapman and Hall, London.
Year 4 PBL Study Guide 2007-2008 – Student Version
Coma. M. Bozza-Marrubini. Chapter 56. In: Care of the Critically Ill Patient. Eds.
J Tinker, WM Zapol, Springer-Verlag.
Neurology. Section 24, Vol 3. Oxford Textbook of Medicine. 3rd Edition. Eds DJ
Weatherall, JGG Ledingham, DA Warrell.
Poisoning. Section 8. Vol 1. Oxford Textbook of Medicine. 3rd Edition. Eds DJ
Weatherall, JGG Ledingham, DA Warrell.
Intensive Care. A concise textbook. CJ Hinds, D Watson. 2nd Edition. Saunders.
Chapters on Neurological disorders (14), Acute Renal Failure (12), Acute Liver
Failure (13) and Poisoning (18).
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Medical Specialties and Geriatric Medicine
Dr Patrick Chu
Sam is a successful 24 year old computer analyst. He is well educated. He was
born in England although his parents emigrated from Jamaica after the war. As a
child Sam found out he had sickle cell anaemia. Although he was troubled with
painful attacks from time to time, he was able to lead a fairly normal active life
and received full education. He is now happily employed.
However Sam’s brother Joseph, who is also affected by sickle cell anaemia, has
been in and out of hospital throughout his childhood, requiring transfusions and an
operation on his hip. Joseph’s mobility is now also severely restricted as a result
of partial blindness as well as his hip problem. As such Joseph needs a lot of
nursing and medical attention.
Sam has a stable relationship with his girlfriend Julie and they plan to get married
next year. Julie is also the British-born child of immigrants.
Sam and Julie are concerned that when they start a family their children will be as
seriously affected as Joseph.
They want to explore whether Julie also has a sickle cell condition and thus the
chance of their future children being affected.
Year 4 PBL Study Guide 2007-2008 – Student Version
Mrs Carter is a primary school teacher. She has always enjoyed good health and
been interested in health promotion matters. She swims regularly and attends
keep-fit classes. Mrs Carter is diet conscious and eats a lot of vegetables
although she is not keen on meat, particularly red meat. She does eat a lot of fish.
About 10 weeks ago Mrs Carter found that she was pregnant. Naturally she and
her husband are very excited about expecting their first child. However, when she
went to see her GP, a routine blood count revealed that she has anaemia with
haemoglobin of 8.0 g/dl. She is otherwise very well. Her GP advised her to go on
iron and folic acid tablets to increase her haemoglobin level.
Mrs Carter is reluctant to take any extra medications but is aware of the potential
hazards of a blood transfusion, the alternative the GP suggests.
Thus she is in a dilemma. She would prefer to receive the most appropriate
treatment other than blood transfusion but she is also aware that specific
treatment is only possible when the cause of her anaemia is established. She
therefore asks her GP to refer her to a Consultant Haematologist.
David is a 22 year old university student. About 2 months ago he appeared to
suffer from a viral illness with symptoms of headache, joint pain and muscle ache.
It took him 3 weeks to recover from this illness and he has now returned to his
university course.
However, in the last few days David has been feeling progressively tired. One day
on waking, he noticed his gums and his nose were bleeding. His room mate
remarked that he looked exceptionally pale and advised him to go to see his doctor.
The doctor carried out a thorough physical examination on David and could find
nothing wrong apart from the fact he looked very pale. David had a blood test and
this showed that he was severely anaemic with a haemoglobin of 6.0 g/dl, white cell
count 0.8 x 10 9/L and platelet count 15 x 10 9/L. The doctor told David that his
blood was grossly abnormal and because of the serious nature of this condition, the
doctor arranged for him to be immediately admitted to hospital for further
investigations which include a bone marrow aspiration and trephine biopsy.
Year 4 PBL Study Guide 2007-2008 – Student Version
David and his family, including his 3 brothers, now realise that he is very ill and are
very concerned about this and were told by the doctor that any treatment that
may be offered to David will depend on the results of the bone marrow biopsy,
available in a few days time.
Core cases
Iron deficiency anaemia
Bruising and bleeding
Sickle cell disease
Further Reading
The following books are available in the Medical Library, Royal Liverpool Hospital.
Protecting yourself and others against blood borne viruses
Blood transfusion in clinical medicine
Genetics of the human blood groups
Wintrobe’s clinical hematology
Essential haematology
Practical haematology
William’s hematology
Postgraduate haematology
Standard haematology practice 2
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Medical Specialties and Geriatric Medicine
Neurological Disorders
Dr Peter Moore
Stage 1: A 38 year old solicitor has returned from the Gambia 1 week ago, after a
holiday spoiled by traveller’s diarrhoea, now resolved. She attends her GP with
gradually progressive tingling sensations in the legs and difficulty walking. She
recalls tripping on the way down the plane steps but believes this was due to sitting
in a cramped position for several hours. She initially attended the A & E
department where her back was X-rayed because of a mild backache, and her right
foot splinted. She was then referred back to her GP. The GP found a mild bilateral
foot drop worse on the right, with subdued reflexes and no definite sensory loss.
She has been fit in the past but except for a period of vertigo, with nystagmus and
blurred vision lasting a month, 1 year earlier.
Stage 2: A week later when getting into the bath she burns her left foot without
feeling it, and only realises the water is too hot when she dips the right foot in.
On examination the right leg is weak with brisk reflexes, an extensor plantar
response, and altered touch, vibration and position senses. In the left leg there
were mild foot drop, slightly brisk reflexes and diminished pain and temperature
sensation. There was a sensory level at T8. Her bladder was distended and she had
difficulty initiating micturition.
After urgent investigation a diagnosis was confirmed and she was treated with a
course of steroids, and subsequently offered treatment in a double-blind trial of
Year 4 PBL Study Guide 2007-2008 – Student Version
Core cases
Motor neurone disease
Multiple sclerosis
Double vision
Further Reading
Brain’s diseases of the nervous system, Sir John Walton, published by Oxford
University Press.
Adams, Victor, Rapper. Principles of Neurology
Patten: Neurological Differential Diagnosis
Neurology and Neurosurgery Illustrated by Lindsay and Bone, published by
Churchill and Livingstone.
Other Resources
McMaster Website
Glaxo Neurological Centre – Neurological charities
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School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Adult Medical Specialties and Geriatric Medicine
Disorders of Older Life
On 14th April Amy Wilkinson, an 86 year old fell on her way to the Post Office to
collect her pension. She didn’t know how it had happened but did know that her
wrist and face were very painful. In Casualty she became tired of the endless
questions from the young doctor who shouted in her ear and insisted on calling her
“Amy” and “love”. Amy was anxious: “I have got to get home to see to my husband
and let the helper in.”
Her husband John is 96, incontinent and lives in the past. Amy normally washes
and dresses him, changes his pads and does the household chores. After putting
the plaster cast on her wrist the Casualty Officer was going to send her home, as
she was so keen to be discharged. However, the nurse in the Accident and
Emergency Department asked the doctor how Amy would do the cooking and
shopping with the plaster on. The SHO in Geriatric Medicine arranged for her to
be admitted to a ward. On examination, the SHO found that she had impaired
vision and several risk factors for recurrent falls.
When she can eventually get in, John’s carer is distraught to find the gas ring on,
John sitting in a pool of urine crying bitterly and no Amy. The Emergency Social
Worker went out to see John. She felt that his needs could not be met in the
community at such short notice. She was also very concerned to find that the
fridge was full of mouldy food and that she couldn’t even make a cup of tea for
John because the milk was sour. After several telephone calls a place at a Part III
home “Happy Valley” is found. John hates the home on first sight. The staff find
it difficult to give reassurance because he cannot hear them and he is also
convinced that he is at the railway station. The staff are worried that they don’t
know if he is on any drugs and little, if any, information has come with him.
Year 4 PBL Study Guide 2007-2008 – Student Version
Whilst on the ward, Amy’s pain was hard to control and she constantly asked for
painkillers. Amy found it difficult to get around the ward and couldn’t eat the meal
placed in front of her. Three days after admission Amy wandered confused into
the corridor with evidence that she was faecally incontinent.
When Amy’s GP received a letter saying that she was in hospital he was terribly
worried about John as he had repeatedly told Amy that she should put him in a
nursing home. However, Amy had also resisted because she worried about how she
would pay for this and also that the upheaval would make him more confused.
Amy’s GP rang the ward and was relieved to find that John had been placed in a
residential home.
During the night John wanders and the staff repeatedly give him cups of tea to try
and placate him. He is missing at 0400 hours and found by the Police wandering
down the road. The next morning the staff decide that it would help him if he
were to visit Amy. John finds it difficult to get into the taxi because of his
arthritis and the carer is worried that he will be wet by the time they arrive at
the hospital. Unfortunately this is the case and the nurses on the ward are forced
to change his trousers. On doing so they find that John has a pressure sore. Amy
is amazed that John has anything wrong with him as she thought they were
managing so well.
Core cases
Deafness in an adult
Dizziness/ vertigo
Visual impairment in an adult
Urinary incontinence
Faecal incontinence
Further Reading
Key Topics in Ear, Nose and Throat, Roland McRae and McCombe (Publisher: Bios
Scientific Publishers)
A new Short Textbook of ENT, McCormick, Primrose and Mackenzie (Publisher:
Edward Arnold)
Clinical ENT, O’Donoghue GM, Bates GJ, Marula AA (Publisher: Oxford Univeristy
Year 4 PBL Study Guide 2007-2008 – Student Version
Other Resources
Hearing loss
Contact with an audiology technician with regard to the following:
- use of hearing aid
- organisation of hearing aid for patient with hearing deficit
- assessment of common problems in the use of a hearing aid
- use of the tuning fork in both René and Weber test
- knowledge of the role of lip reading and interpreter for the deaf as well as
basic sign language
Visual loss
Clinical skills lab:
- use of the ophthalmoscope and Snellen chart
- testing visual function (acuity, quality of life measures)
- direct ophthalmoscopy
Ophthalmology OPD
- ABC of Eyes (Khaw and Elkington, BMJ)
- ICT Ophthalmology (Batterbury and Bowling, Churchill Livingstone)
Other literature:
- waiting list Prioritisation Scoring Systems (BMA Health Policy and Economics
Research Unit, 1998)
- The New Zealand Priority Criteria Project (BMJ 1997; 314:131-4 and 135-8)
- the abbreviated mental test and the mini mental state examinations
- knowledge of cut-off levels for confusion and normal
- knowledge of the problems of the use of these tests and their limitations
- Continence Adviser
- Nurse Practitioner with lead for continence
- Physiotherapist re. pelvic floor exercises
- Contact with Occupational Therapy and Physiotherapy Departments
- Session in an Elderly Health Unit or Day Hospital
- Exposure to out-patient physiotherapy
- Access to specific rehabilitation classes such as cardiac, respiratory or stroke
- Perform a falls assessment check on patients with recurrent falls either in the
community or hospital setting
Year 4 PBL Study Guide 2007-2008 – Student Version
Community-based assessment
- Contact with a Practice Nurse performing an over 75 years of age check
- Case conference discussing discharge planning of an elderly person both to the
community and to institutional care
- Visit to residential/nursing home
- Exposure to the various methods of funding of residential care and knowledge
around the nurse assessment of patients prior to acceptance for residential
- Dietician re. problems of nutrition in older people, specific to both hospital and
community (dentures that don’t fit, reduced appetite with ageing, problem of
vision and manual dexterity when eating)
- Occupational Therapist re. aids and appliances to assist with activities of daily
living and specifically with feeding
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Maternal & Child Health and Psychiatry
Dr Iwan Lewis-Jones
Jill and Peter Brown have been trying to have a baby for 6 months. Jill is very
upset that nothing has happened and is worried about her very irregular periods
which are very heavy and painful. They go and see Dr Jones, their General
Practitioner, who asks Peter to have his hormone levels checked and to have a
semen analysis at the local hospital. He also asks Jill to have hormone tests, the
first with her next period and another 21 days later.
When the couple return to the surgery 10 days later they are told that no sperm
were seen in the sample but that Peter’s hormone levels were normal. Jill’s
menstrual hormone levels were normal but her day 21 progesterone was very low.
The Doctor decided to refer the couple to the infertility clinic at their nearest
teaching hospital, which provided both an andrology service and an assisted
conception unit.
Rupinder and Assan Malik have been trying to have a family for 5 years and have
been fully investigated. Assan has been found to have testicular failure confirmed
by testicular biopsy. All Rupinder’s tests are normal and the couple have an
appointment at the assisted conception clinic to consider their options.
Year 4 PBL Study Guide 2007-2008 – Student Version
Simon and Susan Kent have just seen their local gynaecologist. They complained of
infertility of 4 years duration. Simon was investigated first and all his sperm and
hormone tests were normal but Susan was found to have an imbalance of her
gonadotrophins, a history of 3 miscarriages and something wrong with her
chromosomes. She was referred for genetic counselling and was told that she had
increased risk of miscarriage but that if she managed to continue a pregnancy to
term there was no significant risk to the child. She then was admitted for ovarian
diathermy after which she had Clomiphene for 3 months and succeeded in
becoming pregnant.
Core cases
Male infertility
Female infertility
Further Reading
‘Gynaecology’ by Ten Teachers
‘Obstetrics and Gynaecology’ Impey L p67-77 Blackwells 1999.
‘Infertility in Practice’, Balen AH, Jacobs HS Churchill Livingstone 1997
‘Assisted Conception: current technique and outcome’ Gazvani MR, Wood SJ &
Kingsland CR. British Journal of Hospital Medicine 58:6;268-270, 1997
‘Male Infertility: modern management and prognosis’ Lewis-Jones DI, Gazvani MR.
British Journal of Hospital Medicine 58:6;271-276, 1997
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Maternal & Child Health and Psychiatry
Abnormal Pregnancy
Mr Stephen Walkinshaw
Tracy, an 18 year old single woman presents to the delivery suite with a two hour
history of intermittent abdominal pains and vaginal bleeding. The pains have been
getting stronger and more frequent. She is 29 weeks into her pregnancy and had
one previous admission at 15 weeks with vaginal bleeding.
She lives with her mother and 3 younger brothers. She smokes 15 cigarettes per
day but stopped drinking when she became pregnant. Vaginal examination revealed
the cervix to be 2cm dilated and fully effaced.
Deborah, a 25 year old married teacher is referred by her community midwife at
34 weeks gestation after finding a blood pressure of 165/105. Urine testing at
the community clinic showed 1+ of protein in the urine. A few days earlier, she had
complained of swelling of her hands. Her blood pressure had been 135/88 at that
time. Clinical examination revealed a symphysis-fundal height of 30 cm.
Blood pressure remained elevated over 24 hours.
Ultrasound examination
demonstrated an estimated weight of 1.6kg with reduced liquor volume and
abnormal UA doppler.
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Sue, a 28 year old woman in her second pregnancy was seen at the clinic at 41
weeks. She requested induction of labour and was admitted 3 days later. Her
pregnancy had been uncomplicated (her previous baby weighed 4.2kg and was
delivered normally). The cervix had a modified Bishop score of 4 and PGE2 2mg gel
was inserted in the posterior fornix. Four hours later she was contracting every 3
minutes and the cervix was 2cm dilated and effaced. Her contractions eased, and
so an amniotomy was performed and an Oxytocin infusion commenced.
Her progress is charted on the partogram.
Continuous electronic fetal monitoring demonstrated a normal pattern for much of
labour. The final 40 minutes of fetal heart rate is shown.
Core cases
Antepartum haemorrhage
Pregnancy induced hypertension
Intra-uterine growth retardation
Dysfunctional labour
Delay in second stage of labour
Postpartum haemorrhage
Pregnancy with previous Caesarian section
Severe pre-eclampsia
Prenatal diagnosis
Deep vein thrombosis
Diabetes in pregnancy
Additional Resources
Access to Cochrane Library
ABC of Antenatal Care, ABC of intrapartum care (both BMJ publications)
Guide to medical disease in pregnancy. Catherine Nelson-Piercy
Year 4 PBL Study Guide 2007-2008 – Student Version
School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Maternal & Child Health and Psychiatry
Chronic Childhood Disease
Dr Heather McDowell
Brian is an 8 year-old boy who has recently undergone surgery for a
medulloblastoma. He is now being admitted for the insertion of a central venous
line before chemotherapy commences.
He still has the same symptoms of ataxia and diplopia that he had prior to surgery,
but his headaches are much better and he has stopped vomiting. His asthma is
under control.
His parents are separated and Brian has two other siblings aged 5 years and 10
years. They live with their mother who works part-time in a supermarket. Both
parents want to know what the outlook is, both for complications of treatment and
in the longer term.
Alice is 4 years old. She was referred to orthopaedics at the age of 3 because of
concerns raised at nursery about her poor mobility and awkward gait. She had not
walked independently until the age of 19 months and had never been able to run.
Multiple fixed deformities of her joints were noted in clinic but no diagnosis
She was referred for physiotherapy where swelling of her knees was noted. When
seen in the rheumatology clinic she had swelling of her knees, ankles, fingers and
wrists. A diagnosis of polyarticular juvenile idiopathic arthritis was made.
Year 4 PBL Study Guide 2007-2008 – Student Version
Investigations showed a positive antinuclear antibody.
She was referred to
Initial management with a non-steroidal anti-inflammatory drug plus physiotherapy
resulted in some improvement in the joint contractures. After 6 weeks, both
knees were injected with intra-articular steroids using sedation with intravenous
midazolam. In addition she was commenced on low dose oral methotrexate. Within
a further 3 months she had no evidence of disease activity and complete resolution
of her joint contractures. One year later she is able to walk and run normally and
remains well.
Lucy was born at 26 weeks gestation and admitted to Special Care Baby Unit and
ventilated. She had a stormy course. She had a large bilateral intraventricular
ventricoperitoneal shunt.
On review at 8 months of age, Lucy was just starting to smile, but she did not
consistently fix and follow. She was not yet reaching out for toys and was not
sitting. On examination she lay quietly on the bed and did not smile until she was
spoken to. Her tone was increased in her arms and legs, and reflexes were brisk.
Her head circumference was below the 3rd centile (it had been on the 25th centile
at birth).
Lucy’s mum was unhappy about her weight gain. Although she sucked well she was
slow to take feeds and occasionally seems to choke on her milk. Mum was also
worried about recurrent chestiness. Lucy’s Physiotherapist had noticed episodes
when Lucy rhythmically jerked her arms – Mum thought this was related to colic.
In view of her concerns, Lucy was admitted for further investigations
Core cases
Brain tumour
Developmental delay
Cerebral palsy
Rheumatoid arthritis
Double vision
Further Reading
Reporting on quality of life in randomised controlled trials: Bibliographic Study
Sanders C, Matthias E, Donovan J,, Tallon D, Frankel S
BMJ Volume 317 1191-1194
Year 4 PBL Study Guide 2007-2008 – Student Version
Neuropsychological Outcome of Children after Radiotherapy for Intracranial
Garcia-Perez A, Narbona-Garcia J, Sierrasesumaga L, Aguirre-Ventallo M, CalvoManuel F. Developmental Medicine and Child Neurology 1993, 35, 139-148.
Cognitive deficits in Long-Term Survivors of Childhood Brain Tumours
Glauser TA, Packer RJ
Child’s Nerv Syst (1991)
Late Mortality of Long-Term Survivors of Childhood Cancer
Hudson MM, Jones D, Boyett J, Sharp GB, Pui CH
Journal of Clinical Oncology, Vol 15, No. 6 (June), 1997: pp 2205-2213
High Risk of Leukemia after Short-Term Dose-Intensive Chemotherapy in Young
Patients with Solid Tumors.
Kushner BH, Heller G, Cheung NK, Wollner N et al
Journal of Clinical Oncology, Vol 16, No 9 (September), 1998: pp 3016-3120
Long-term Effects of Radiation for Medulloblastoma on Intellectual and Physical
Development. A Case Report of Monozygotic Twins.
Nishiyama K, Funakoshi S, Izumoto S, Ikeda T, Oku Y
Cancer 1994; 73:2450-5
Voute, Barrett, Lemerele
Cancer in Children, 1992
BMJ 1998 No. 7161
Archive Dis. Childhood 1998 79(2), 120-125, 161-164
Cassidy and Petty.
Textbook of Pediatric Rheumatology. (3rd edition) Saunders
Petty et al. Revision of the Proposed Classification Critria for Juvenile Idiopathic
Arthritis: Durban 1997. The Journal of Rheumatology 1998; 25: 1991-1994.
Giannini et al. Methotrexate in resistant juvenile rheumatoid arthritis. Results of
the USA-USSR double-blind, placebo-controlled trial. N Engl J Med 1992; 326:
Oxford Textbook of Rheumatology (2nd edition) Vol 2. Oxford Medical Publications
Year 4 PBL Study Guide 2007-2008 – Student Version
Diagnosis and Management of Cerebral Palsy
Rosenbloom l
Archives of Disease in Childhood 1995; 72: 350-354
The Child with a Disability
David Hall & Peter Hill
Blackwell Science Limited 1996 (2nd Edition) Chapter 13 Visual Impairment, Chapter
14 Cerebral Palsy.
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School of Medical Education
Year 4 2007-2008
PBL Study Guide – Student Version
Maternal & Child Health and Psychiatry
Convenors: Dr Megan Munro & Dr Pat Abbott
Dr Ahmed, general practitioner, was called to the home of Billy, a 20 year-old
single man by his parents. Billy’s parents had been concerned about him for some
time. A year earlier he had dropped out of his Business Studies course and had
done nothing to find himself an alternative occupation. In recent months he was
spending more and more time in his bedroom and had lost contact with his friends.
He was losing weight, and on several occasions his parents had been awoken by Billy
shouting at night. Billy’s parents were worried about his increasingly poor hygiene.
He became very irritable when they asked him what was wrong, and had been going
on about religion in a way that they found hard to understand. On several
occasions he complained of “clartens” getting inside his head but wouldn’t explain
what he meant by this.
Dr Ahmed felt it was likely that Billy was becoming mentally ill, but was unable to
persuade him to accept any kind of help. Dr Ahmed therefore visited several days
later accompanied by Charlotte, a social worker. Billy expressed no psychotic
symptoms, and there was then a heated debate as to whether he was making a
choice of an unusual lifestyle, and whether they should take action or not.
Year 4 PBL Study Guide 2007-2008 – Student Version
Mr Donaldson, a 55 year-old married man, attends Dr Ahmed accompanied by his
wife. He complains that his bowels have stopped working, and on further
questioning stated that he believed his bowels were rotting. Mr Donaldson is a
postman who has been increasingly worried for several months about a conflict
with his immediate superior at work. He has increasingly suffered from a feeling
that he may have delivered the wrong letters to various houses, and on a number of
occasions has called back over his delivery route to check whether this has
happened or not. He has increasingly felt that he is about to lose his job, and that
the people on his delivery route will lose their livelihoods because of his failures.
He expresses the feeling that his family would be better off if he were dead
because then at least they will be able to collect the insurance money.
Dr Ellington, a 23 year-old house officer, faints at work while she is on-call. She is
taken to A&E where nursing staff find that the copious white coat and jumper that
she is wearing conceal the fact that she is very thin. On examination by the
casualty officer she is noted to have eroded teeth and abrasions on her knuckles.
On recovery, Dr Ellington admits that such fainting has occurred on several
occasions recently but insists that she is now fine. The casualty officer wishes to
contact her parents and send her home, but she begs him not too. Faced with his
insistence, she becomes very tearful and explains that her parents have high
expectations and that she is finding it difficult to cope as a house officer
physically and emotionally. On direct questioning she admits to having taken an
overdose of sleeping tablets the previous weekend from which she recovered
without medical attention.
Extra-curricular activity at the Medical School
At 9.00 pm on a cold December evening, security cameras detected a young man
attempting to break into the Medical School. Police were quickly called to the
scene and arrested Leroy Jones, taking him to the City Accident and Emergency
Department under the auspices of Section 136 of the Mental Health Act 1983.
At interview, Mr Jones told the duty psychiatrist that the Professor of Surgery
had implanted a microchip in his brain whilst he was asleep. This discharged emails to the general population through his body, relaying Mr Jones’ thoughts and
feelings to all and sundry. He knew that the only way his situation could be
resolved was by ‘sorting that professor out’.
Year 4 PBL Study Guide 2007-2008 – Student Version
Mrs Jones, Leroy’s mother, arrived at the Accident and Emergency Department.
She explained that the family had moved from Jamaica to Britain 30 years
previously, 10 years before Leroy was born. He was the youngest of 5 siblings and
had been a happy go lucky boy until the last two years. However since then he had
become increasingly solitary and lazy and neglected himself. He had smoked
cannabis occasionally and showed little interest in trying to get a job. According to
his mother he was ‘a disgrace to the family’.
Crisis at the hostel
Jean Jeffers, the social worker, was surprised when she visited the hostel to find
Margaret Mitchell in her room, in an unkempt state, with the curtains closed. Miss
Mitchell was 46 years old and had been in the hostel for 3 years, attending a
sheltered workshop in the day time when the hostel was unstaffed.
Miss Mitchell had been a patient in Special Hospital since her early 20s after
setting fire to a local secondary school. From the Special Hospital she spent
several years in her Regional Secure Unit before being resettled into her current
hostel placement.
Jean Jeffers, on finding her at the hostel, asked her how she was feeling. Miss
Mitchell told her that she had no intention of allowing the flames of hell to engulf
her. She said that she intended to make sure that God delivered her from Satan’s
clutches before this could happen but she would not explain how she intended to do
this. Mrs Jeffers contacted Margaret Mitchell’s community psychiatric nurse, her
CPA key worker, to convene an urgent case conference. Immediately prior to the
case conference hostel staff found a large collection of Risperidone tablets in her
Core cases
Acute schizophrenia
Chronic schizophrenia
Phobic disorders
Further Reading
“Psychiatry”, 2nd Ed., Michael Gelder, Richard Mayhew and John Geddes. Oxford
University Press, ISBNO, 19, 262, 888, 7
“ABC of Mental Health”, Tefion Davies and TKJ Craig, BMJ books, ISBNO, 7279,
1220 – 8
Year 4 PBL Study Guide 2007-2008 – Student Version
“Problem Based Psychiatry”, Ben Green, Churchill Livingstone, ISBNO, 443 051 84
“Mental Health Services from Institutional Care to Community Care”, P Abbott
(available as handout)
“Making Care Programming Work”, by David Kingdom, “Advances in Psychiatric
Treatment”, 1994, vol 1, p 41-46, available as a reprint
“Schizophrenia and Substance Abuse”, Review Article, Jeanette Smith, Stephen
Hucker, British Journal of Psychiatry, 1994, 165, 13-21, available as a reprint
“Psychiatric Emergencies”, by Tom Brown, “Advances in Psychiatric Treatment”,
1998, Vol 4, p 270-276
“Models of Community Care”, Geoff Shepherd, Journal of Mental Health 1998,
7,2,165-177, also available as a reprint.
“Pocket Guide to the ICD10 Classification of Mental and Behavioural Disorders”,
Churchill Livingstone ISBNO – 443 – 04909 – 2
“A Carer’s Guide to Schizophrenia”, Greg Wilkinson, Tony Kendrick, Royal Society
of Medicine Press, ISBM1 – 853315 – 298 – 6
“Needs Assessment in Mental Health”, P Abbott, (available as handout)
Year 4 PBL Study Guide 2007-2008 – Student Version