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National Practitioner Programme D ra ft D oc um en t Matrix specification of Core Clinical Conditions for the Physician Associate by category of level of competence 1 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Matrix specification of Core Clinical Conditions for the Physician Associate by category of level of competence D ra ft D oc um en t (WORKING DOCUMENT TO BE READ IN CONJUNCTION WITH THE COMPETENCE AND CURRICULUM FRAMEWORK FOR THE PHYSICIAN ASSOCIATE) 2 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Contents Specification of core clinical conditions Model for categorising clinical conditions on the basis of required competence Examples of core conditions matrices Matrix showing indicative conditions across the full range of system categories Example of a complete single system matrix: the cardiovascular system Example of core conditions related to a particular disease process: infection t Example of a condition matrix for a clinical presentation: chest pain um en Core Clinical Conditions Conditions in category 1A oc Conditions in category 1B D Conditions in category 2A ft Conditions in category 2B ra Symptom Based Competencies D ‘The Top 20’ – Common Medical Presentations Core clinical and procedural skills 3 D ra ft D oc um en t Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 4 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence ACKNOWLEGEMENTS um en t Consultant Endocrinologist Consultant Orthopaedic Surgeon Physician Associate Consultant Sexual Health Consultant Gastroenterologists Physician Associate Dermatology Registrar Consultant Respiratory Physician Consultant Haematologist Consultant in Emergency Medicine Consultant Physician Infectious Diseases Registrar Consultant Nephrologist Consultant medical Ophthalmologist Consultant Obstetrician Consultant Acute Physician Consultant Paediatrician D ra ft D oc Dr Prakash Abraham Mr George Ashcroft Ms Ria Agarwal Dr Steven Baguley Dr Gillian Bain Ms Kate Bascombe Dr Alexandra Bonsall Professor Graham Devereux Dr Karen Duncan Mr Fraser Gill Dr James McLay Dr Manjul Medhi Dr Colin Millar Dr John Olson Dr Ashaltha Shetty Dr Christopher Skinner Dr Angela Sun 5 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Specification of core clinical conditions The model on the following page describes a two-dimensional categorisation – the X axis referring to competence in undertaking the diagnostic process and the Y axis referring to competence in managing the condition. This model of conditions is then used in the systems-based lists on subsequent pages. um en t The categorisation of conditions relates to the expected competence on qualification. Depending on local arrangements and arrangement with the supervising practitioner, experience post-qualification within a particular field may draw conditions from a lower to a higher category (e.g. 2B to 1A) However, it is key to the Physician Associate role that, whatever their current field of practice, they maintain competence across the breadth of clinical conditions outlined in this section: i.e. conditions may not be allowed to ‘slip’ from category 1A to 2B. Following the explanation of the core condition matrix, this section gives four examples of matrices as follows: examples of indicative conditions across the full range of systems; • a complete example of the specification for one system; • an example of specification on the basis of a disease process; and • an example of specification of conditions on the basis of a clinical presentation. D ra ft D oc • 6 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Model for categorising clinical conditions on the basis of required competence X axis: Is the Physician Associate competent to take a significant role in the diagnostic process? YES: Category 1 The Physician Associate is able to identify a condition as a possibility within differential diagnoses and to take measures to confirm or refute the diagnosis. NO: Category 2 The Physician Associate is aware of the condition, but does not necessarily have the knowledge or resources to make the diagnosis. Y axis: Is the Physician Associate competent to take responsibility for management of the condition? The Physician Associate is able to manage the uncomplicated condition without routine referral to others. NO: Category B The Physician Associate participates in the management of the condition, but does not take a lead role in determining the management strategy. um en t YES: Category A oc X axis: Taking a significant role in the diagnostic process? ft NO – Category 2 2A Once the condition has been diagnosed, either by their supervising doctor or a clinical specialist, the Physician Associate is able to manage the condition without routine referral. The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately. The Physician Associate is able to undertake the day to day management of the patient and condition once the diagnosis and strategic management decisions have been made by another. ra The Physician Associate is able to diagnose the condition in a patient who is presenting with the problem for the first time and will normally be able to manage it without regular or routine referral. D YES – Category A NO – Category B Y axis: Taking responsibility for management of the condition? 1A D YES – Category 1 1B 2B 7 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence As with most models, this is something of an oversimplification of reality. Relatively simple conditions may be complicated by the personal circumstances of the patient, their reaction to the disease process or some other underlying health problem. Equally, a Physician Associate may already be familiar with a non-core condition because of prior experience. However, whilst the following diagram may be closer to the truth, we believe that the simplified model is a more appropriate basis for the development of curricula. X axis: Taking a significant role in the diagnostic process? Definitely not 1A Needs confirmation of diagnosis by supervising doctor Diagnosis requires knowledge beyond that of Physician Associate but Physician Associate responsible for management t Able to diagnose and treat 2A um en Y axis: Taking responsibility for management? Definitely Definitely oc Physician Associate differential diagnosis includes conditions that may need investigation in a specialist facility ft D Physician Associate differential diagnosis suggests referral is necessary Definitely not D ra Physician Associate diagnoses but recognises condition requires referral Physician Associate identifies that referral is necessary despite not having a differential diagnosis 1B Physician Associate may need advice on management if condition becomes exacerbated Condition may be diagnosed/managed by a Physician Associate with experience Peripheral to role, but may be part of patient history 2B 8 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Examples of core conditions matrices Matrix showing indicative conditions across the full range of system categories Taking a significant role in the diagnostic process? Yes No 1A 2A Mental health: depression Mental health: dysthymic disorder Cardiovascular: essential hypertension Cardiovascular: giant cell arteritis Respiratory: acute bronchitis Gastro-intestinal: gastroenteritis Musculoskeletal: gout Musculoskeletal: rheumatoid arthritis Eye: corneal abrasions Yes Ear, nose and throat: acute otitis media Neurological: partial/partial complex seizures Metabolic and endocrine: hyperkalaemia Metabolic and endocrine: hypertriglyceridaemia Renal and GU: cystitis Dermatological: atopic eczema Haematological: folate deficiency Sexual health: contraceptive advice Mental health: phobias oc Systemic infection: measles t Neurological: migraine um en Taking responsibility for management? Female reproductive: dysmenorrhoea Mental health: autistic disorder Cardiovascular: dilated cardiomyopathy Respiratory: acute epiglottitis Respiratory: tuberculosis Gastro-intestinal: pancreatic neoplasms Musculoskeletal: fracture of the hip Musculoskeletal: juvenile rheumatoid arthritis Eye: cataract Eye: hyphaema ft Gastro-intestinal: acute pancreatitis Ear, nose and throat: acoustic neuromas Female reproductive:placenta Female reproductive: carcinoma cervix praevia Neurological: Guillain-Barré syndrome ra Ear, nose and throat: mastoiditis Neurological: nerve entrapment, eg carpal tunnel Metabolic and endocrine: acromegaly Metabolic and endocrine: thyroiditis Renal and GU: renal vasculitis Renal and GU: testicular carcinoma Dermatological: lichen simplex chronicus Dermatological: basal cell carcinoma Haematological: G6PD deficiency D No D Cardiovascular: acute myocardial infarction Haematological: aplastic anaemia Sexual health: gonococcal infections Systemic infection: toxoplasmosis Systemic infection: malaria 1B 2B 9 Matrix specification of Core Clinical Conditions for the Physician Associate by category category ofof level level ofof competence competence Assistant by Example of a complete single system matrix: The Cardiovascular System Taking a significant role in the diagnostic process? Yes No 2A Vascular diseases Giant cell arteritis Ischaemic heart disease Angina pectoris • ab e Hypertension Secondary Malignant/accelerated Hypotension Cardiogenic shock Conduction disorders Bundle branch block Premature beats Atrioventricular block Paroxysmal supraventricular tachycardia Ventricular tachycardia Ventricular fibrillation/flutter Atrial fibrillation/flutter Vascular diseases Chronic/acute arterial occlusion Varicose veins Venous thrombosis Peripheral vascular disease Acute rheumatic fever Aortic aneurysm/dissection Arterial embolism/thrombosis Valvular disease Aortic stenosis/regurgitation Mitral stenosis/regurgitation Tricuspid stenosis/insufficiency Pulmonary stenosis/insufficiency Cardiac failure Ischaemic Valvular Hypertensive Ischaemic heart disease Acute myocardial infarction Angina pectoris • Unstable angina • Prinzmetals angina Other forms of heart disease Acute and subacute bacterial endocarditis Acute pericarditis Cardiac tamponade Pericardial effusion Cardiomyopathy Dilated Hypertrophic Restrictive Congenital heart disease Atrial septal defect Ventricular septal defect Coarctation of aorta Patent ductus arteriosus Tetralogy of Fallot Valvular disease Mitral valve prolapse ra ft D oc um en t Hypertension Essential Isolated systolic Iatrogenic Hypotension Orthostatic/postural Hypovolaemic shock Vascular diseases Phlebitis/thrombophlebitis D No Taking responsibility for management? Yes 1A 1B 2B 10 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Example of core conditions related to a particular disease process: Infection Taking a significant role in the diagnostic process? Yes No 1A 2A Taking responsibility for management? No Yes Respiratory system Bacterial pneumonia Neurological system Herpes zoster/shingles Eyes Acute bacterial conjunctivitis Renal and GU systems Orchitis Skin Cellulitis Skin Lyme disease um en t Cardiovascular system Acute bacterial endocarditis Respiratory system Acute epiglotitis Respiratory system HIVrelated pneumonia Bronchiectasis Digestive system Intra-abdominal abscess Neurological system Prion disease D Systemic infection disease Botulism ra 2B D 1B ft Musculoskeletal system Septic arthritis Ear, nose and throat Mastoiditis Peritonsillar abscess oc Digestive system Appendicitis 11 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Example of a condition matrix for a clinical presentation: Chest Pain Taking a significant role in the diagnostic process? Yes No 1A 2A Cardiovascular Angina pectoris: stable t um en Respiratory Fungal pneumonia HIV-related pneumonia 2B D 1B ra ft D oc Mental health Panic disorder Cardiovascular Acute myocardial infarction Angina pectoris: unstable Angina pectoris: Prinzmetal’s variant Respiratory Pulmonary embolism Pleurisy Gastro-intestinal Acute cholecystitis No Taking responsibility for management? Yes Respiratory Bacterial pneumonia Viral pneumonia Gastro-intestinal Oesophagitis Gastro-oesophageal reflux disease Dyspepsia Neurological Herpes zoster (of chest wall) 12 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Core Clinical Conditions Matrix of Core Clinical Conditions by system theme The conditions are broadly divided by the degree to which the PA plays a role in diagnosis and the level of responsibility the PA has in management of the process. Hence each condition falls into one of four categories: en t 1A-The PA plays a significant role in the diagnosis and takes significant responsibility in management 1B-The PA plays a significant role in the diagnosis but does not take significant responsibility in management 2A-The PA does not play a significant role in the diagnosis but does take a significant responsibility in management 2B-The PA does not play a significant role in the diagnosis and does not take a significant responsibility in management D ra ft D oc um By the end of the programme the student is expected to be able to demonstrate evidence of clinical experience in all conditions in category 1A, 1B and 2A and at a minimum a familiarity and a theoretical understanding of all conditions in category 2B. 13 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence CARDIOVASCULAR 1A 1A 1A 1B 1B Hypotension Orthostatic/ postural Hypovolaemic shock Cardiogenic shock 1B 1B 1B Vascular Diseases Phlebitis/ thrombophlebitis Deep venous thrombosis Pulmonary embolus Peripheral vascular disease Varicose veins Acute rheumatic fever Venous thrombosis Ruptured aortic aneurysm Aortic aneurysm dissection Arterial embolism/ thrombosis Acute cerebrovascular accident (stroke) Acute limb ischaemia Giant cell arteritis 1A 1A 1A 1B 1B 2B 1B 1B 1B 1B 1A 1A 2A ra ft D oc um en t Hypertension Primary Isolated systolic Iatrogenic Secondary Accelerated D Conduction Disorders Bundle branch block (left & right) Trifasicular block Premature beats Atrial fibrillation/ flutter Atrioventricular block Paroxysmal supraventricular tachycardia Ventricular tachycardia (emergency list) Ventricular fibrillation/ flutter (emergency list) Complete heart block (emergency list) 1A 1B 1B 1A 1B 1B 1A 1A 1A Cardiomyopathy Dilated Hypertrophic Restrictive 1B 2B 2B Congenital Heart Disease 14 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Atrial septal defect Ventricular septal defect Coarctation of the aorta Patent ductus arteriosus Tetralogy of Fallot 2B 2B 1B 2B 2B Ischaemic Heart Disease Acute coronary syndrome myocardial infarction Acute Coronary Syndrome e.g. myocardial infarction–unstable angina Angina pectoris: Prinzmetal’s / variant Angina pectoris: Stable en um Cardiac Failure 1B 1A 1B 1B 1B 1B 2B t Valvular Disease Aortic stenosis/ regurgitation Mitral stenosis/ regurgitation Tricuspid stenosis/ insufficiency Pulmonary stenosis/ insufficiency Mitral valve prolapse 1A 1A 1A 1A 1B 1A Other Cardiovascular Problems Acute bacterial endocarditis Subacute bacterial endocarditis Acute pericarditis Cardiac tamponade Pericardial effusion 1A 1B 1B 1B 1B D ra ft D oc Acute Left Ventricular Systolic dysfunction Chronic Left Ventricular Systolic Dysfunction Valvular Hypertensive Personal Notes 15 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence RESPIRATORY Infectious Respiratory Disorders Acute Bronchitis Influenza Croup Respiratory syncytial virus infection Bacterial pneumonia Viral pneumonia Acute bronchiolitis Acute epiglottitis Pertussis Empyema Fungal pneumonias HIV-related pneumonias Tuberculosis 1A 1A 1A 1A 1A 2B 1B 1B 1A 1B 2B 2B 1B ra ft D oc um Chronic Obstructive Pulmonary Disease Asthma Sleep apnoea Bronchiectasis Cystic fibrosis en t Obstructive Pulmonary Disease 1A 1A 1B 2B 2B 1B 2B 1B 2B 2B Restrictive Pulmonary Disease Idiopathic pulmonary fibrosis Extrinsic Allergic Alveolitis Asbestosis Pneumoconiosis Sarcoidosis 2B 2B 2B 2B 2B Pulmonary Circulation Pulmonary embolism (emergency list) Cor pulmonale Pulmonary hypertension – primary Pulmonary hypertension – secondary 1A 1B 2B 1B Pleural Diseases Pleural effusion Pleural Plaque Pneumothorax: Primary 1B 1B 1B D Neoplastic Pulmonary Disease Bronchogenic carcinoma Mesothelioma Metastatic tumours Carcinoid tumours Pulmonary nodules 16 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Pneumothorax: Traumatic Pneumothorax: Tension (emergency list) Pneumothorax: Secondary Pleurisy 1B 1A 1B 1B D ra ft D oc um en t Personal Notes 17 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence RENAL AND GENITO-URINARY 2A GU Infectious/ Inflammatory Conditions Cystitis Balanitis Prostatitis Epididymitis Orchitis Urethritis Pyelonephritis 1A 1A 2A 2A 2A 2A 1B Renal Diseases Acute kidney injury Glomerulonephritis Nephrotic syndrome Polycystic kidney disease Vasculitis Acute renal colic 1B 2B 1B 1B 2B 1A en um ra ft D oc Renal/ GU Neoplastic Diseases Bladder carcinoma Prostate carcinoma Renal cell carcinoma Testicular carcinoma Wilms tumour t Benign Conditions of the GU Tract Benign prostatic hyperplasia 1B 1B 1B 1B 2B 1B 1B 1B 1B 1B 1B Other Renal/ GU Problems Frank Haematuria Ureteric trauma Hyperkalaemia Acute urinary retention (emergency list) Chronic urinary retention 1B 2B 1A 1A 1B D Other GU Tract Problems Incontinence Cryptorchidism Hydrocoele/ variocoele Nephro/ urolithiasis Paraphimosis/ phimosis Testicular torsion (emergency list) 18 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 19 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence GASTRO-INTESTINAL Oesophagus Barrett's oesophagus Mallory-Weiss tear Neoplasms Strictures Varices Food bolus obstruction Motor Disorders ra ft D oc en Small Intestine Coeliac disease Small bowel bacterial overgrowth Bile acid malabsorption Short bowel syndrome um Stomach Gastro-oesophageal reflux disease Varices Gastritis and duodenitis (inc H.pylori) Peptic ulcer disease Gastric Neoplasms Pyloric stenosis t 2A 1B 1B 1B 1B 1B 2B 1A 1B 1A 1A 1B 1B 1B 2A 2B 2B 1A 1A 1A 1A 1B 1B 1B 1B 1B 1B 1B 1B 2B Rectum Haemorrhoids Anal fissure Anorectal abscess/ fistula Pilonidal disease Polyps Rectal neoplasms 1A 1A 1B 1B 1B 1B D Colon Constipation/ faecal impaction Irritable bowel syndrome Infectious diarrhoea Diverticular disease Diverticulitis Appendicitis Intussusception Ischaemic bowel disease Obstruction Toxic megacolon Polyps Colonic neoplasm Inflammatory bowel disease 20 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 1A 1B 1B 1B 2B Liver Viral hepatitis Cholestatic liver diseases (PBC, PSC) Metabolic liver disease (Haemochromatosis/Wilson's) Non alcoholic fatty liver disease Alcohol related liver disease Jaundice Ascites including SBP Hepatorenal syndrome Hepatic encephalopathy Acute liver failure including paracetamol overdose Liver transplantation Benign hepatic lesions Hepatic neoplasms (primary and secondary) 1B 2B 2B 1B 1B 1B 1B 2B 1B 2B 2B 1B 1B 1A 1B 1B D Hernia Hiatus Incisional Inguinal Umbilical Ventral ra ft D oc Pancreas Acute pancreatitis (emergency list) Chronic pancreatitis Pancreatic neoplasms um en t Gallbladder and Biliary Tree Acute cholecystitis Cholelithiasis Chronic cholecystitis Cholangiocarcinoma Sphinctor of Oddi dysfunction 1A 1B 1B 1B 1B Nutrition Nutritional assessment Refeeding syndrome 1A 1A Other Gastro-Intestinal Conditions Peritonitis-Acute Gastro-intestinal perforation (emergency list) Gastro-intestinal haemorrhage (emergency list) Iron deficiency anaemia Intra-abdominal abscess 1B 1A 1A 1A 1B 21 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 22 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence ENDOCRINE AND METABOLIC Diseases of the Thyroid and Parathyroid Hypothyroidism including Hashimoto’s Thyroiditis Hyperthyroidism: Graves’ disease 1A 1B Hyperthyroidism: Thyroid storm Thyroiditis Hyperparathyroidism Hypoparathyroidism Thyroid neoplastic disease 1B 1B 1B 1B 1B Diabetes Mellitus Type 2 diabetes mellitus Hypoglycaemia Type 1 diabetes mellitus 1A 1A 1B um en t Lipid Disorders Hypercholesterolaemia Hypertriglyceriadaemia 1A 1A 1A 1B 2B Electrolyte and Acid-Base Disorders Hypo/ Hypernatraemia Hypo/ Hyperkalaemia (emergency list) Hypo/ Hypercalcaemia Volume depletion (emeregency list) Hypomagnesaemia Metabolic alkalosis/ acidosis Respiratory alkalosis/ acidosis Volume excess 1B 1A 1B 1A 1B 1B 1B 1B Other Metabolic and Endocrine Gynaecomastia Galactorrhoea Lactose intolerance Phaeochromocytoma 1B 1B 2B 2B Diseases of the Pituitary Gland Acromegaly Diabetes insipidus 1B 2B D ra ft D oc Diseases of the Adrenal glands Corticoadrenal insufficiency. Addisons (emergency list) Cushing’s syndrome Cushings disease 23 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 24 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence MENTAL HEALTH Mood Disorders Depression: Mild/Moderate Depression Severe Bipolar/Affective Disorder 1A 1B 2B Organic Disorders Dementia 2A Disorders of Adult Personality Emotionally Unstable Personality Disorder Dissocial Personality Disorder en t 2B 2B 1A 1A 1B Neurotic, Stress and Somatiform Disorders Acute Reaction to Stress Adjustment Disorder Post-Traumatic Stress Disorder Generalised Anxiety Disorder Phobias Panic Disorder Obsessive Compulsive Disorder 1A 1A 1B 1A 1B 1B 2B D Psychosis Schizophrenia ra ft D oc um Disorders Due to Pyschoactive Substance Use Tobacco use Alcohol/Drug –Harmful Use Alcohol/Drug Dependence 2B Delusional disorder 2B Schizoaffective disorder 2B Behavioural Syndromes Associated with Physiological Disturbance Overeating Associated with Psychological Disturbance Anorexia nervosa Bulimia Nervosa 1B 1B 1B Disorders of Psychological Development Autism 2B 25 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Behavioural and Emotional Disorders with Onset Occurring in Childhood Hyperkinetic Disorder 2B Attention Deficit Hyperactivity Disorder 2B D ra ft D oc um en t Personal Notes 26 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence FEMALE REPRODUCTIVE 2A 2B 1B 2B 2B 1B Cervix Cervicitis Cervical dysplasia Benign Cervical Polyps Incompetent Cervix Carcinoma cervix 2A 2B 2A 2B 1B um ra ft D oc Vagina/ Vulva Vaginal Discharge Neoplasm Rectocoele Bartholin’s cyst Vaginal Septae en t Uterus Dysfunctional uterine bleeding Endometritis Prolapse Leimyoma Uterine Abnormality (Bicornuate uterus/uterus didelphys) Endometrial cancer 2A 1B 1B 1B 1B 1B 1A 1B 1B 2B Uncomplicated Pregnancy Prenatal diagnosis/ care 1A Uncomplicated Pregnancy Normal labour/ delivery Emergency Labour Complications 1B 1B Complicated Pregnancy Ectopic pregnancy (emergency list) Pre-eclampsia Complications of Pre-eclampsia Gestational diabetes Miscarriage Manual Vacuum Aspiration Fetal Abnormality Assessment of Fetal Wellbeing Abruptio placenta (emergency list) Placenta previa 2A 2A 1B 2A 2A 2B 2B 2B 1B 1B D Menstrual Disorders Dysmenorrhoea Premenstrual syndrome Amenorrhoea Polycystic ovarian syndrome Menopausal Symptoms 27 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 1B 2B 1B 1B 1B 2B 2B 2B 2B 1B 2B 1A 1B 1B 2B 1B um 1A 1B 2B 1A 2B 1B D Personal Notes ra ft D oc Breast Abscess Fibroadenoma Cystic change Milk mastitis Viral mastitis Breast cancer en t Postpartum haemorrhage Premature rupture of membranes Rh incompatibility Multiple gestation Fetal distress Gestational trophoblastic disease Cholestasis Epilepsy and Pregnancy Infections and Pregnancy (HIV,Hep B&C) Maternal Drug Abuse Perinatal Mental Health Postnatal Care (Perineal Care, Bladder care, pelvic Floor Exercises, Post C Section Care Puerperal Sepsis Thrombosis (DVT, PE) Dystocia Ovarian Neoplasms 28 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence SEXUAL HEALTH Contraception Contraceptive advice Contraceptive Methods Safe Sex Advice 1A 1A 1A Sexual Dysfunction Male sexual dysfunction Female sexual dysfunction 1B 1B Infertility en ra ft D oc Viral Disease Herpes Simplex Human papillomavirus infections HIV infection 1A 2A 1A 1A 1B 1A 1A 1B D Personal Notes um Sexual Assault Bacterial Disease Chlamydia Gonococcal infections Syphilis t Infertility advice and Overview Options Basic Infertility Workup 29 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence INFECTIONS (Not Covered Elsewhere) 1A 2B 2B 2B Viral Disease Epstein-Barr virus infections Herpes simplex-shingles Herpes simplex-oral Herpes simplex-labial Influenza Mumps Roseola (Sixth disease) Rubella Measles Varicella-zoster virus infections Erythema infectiosum Rabies Cytomegalovirus infections 1A 1A 1A 2A 1A 1A 1A 1A 1A 1A 1A 2B 2B D en um ra ft D oc Bacterial/ Mycobacterial Disease E.coli 0157 Salmonellosis Shigellosis Tetanus Cholera Diphtheria Botulism Atypical mycobacterial disease Cellulitis Osteomyelitis Acute bacterial endocarditis Sub-acute bacterial endocarditis Pneumonia bacterial t Fungal Disease Candidiasis Cryptococcosis Histoplasmosis Pneumocystis J Parasitic Disease Threadworms Hookworms Amoebiasis Malaria Toxoplasmosis 1A 1A 1A 2B 2B 2B 2B 2B 1A 1A 1A 1A 1A 1A 1A 2B 1B 2B 30 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 31 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence HAEMATOLOGICAL 1A 1A 1A 1B 1B Haematological Malignancies Acute/ chronic lymphocytic leukaemia Acute/ chronic myelogenous leukaemia Lymphoma Multiple myeloma Polycythaemia 1B 1B 1B 1B 1B en 1B 1B 2B 2B 2B 1B 1B 1B 1B 2B D ra ft D oc Other Haematological Disorders Aplastic anaemia Primary Polycythaemia Leucopenia Myelodysplastic Syndrome Thalassaemia um Coagulation Disorders Idiopathic thrombocytopenic purpura Thrombotic thrombocytopenic purpura Factor VIII disorders Factor IX disorders Thrombocytopenia t Anaemias Vitamin B12 deficiency Folate deficiency Iron deficiency Sickle cell anaemia Haemolytic anaemia 32 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 33 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence NEUROLOGICAL t 1A 1B 2B 2B 2B en Other Neurological Conditions Post-herpetic neuralgia 1A 1B 2B 2B um Diseases of Peripheral Nerves Bell’s Palsy Diabetic peripheral neuropathy Guillain-Barre syndrome (acute IDP) Chronic IDP Movement Disorders Essential tremor Parkinson’s disease Huntington’s disease Multi-system atrophy) Young onset movement disorders ?define Headaches Classic migraine Atypical migraine Tension headache Cluster headache 1A 2B 2A 2A 1A 1A 1A 1A Syncope - Vaso-vagal Spinal cord lesions 1A 1B Transient ischaemic Attack (emergency list) Multiple sclerosis Venous sinus thrombosis Cavernous sinus thrombosis Neoplasm – primary and secondary Metabolic Encephalopathy – acute and chronic Wernicke’s Encephalopathy Korsakoff’s Syndrome Peripheral nerve lesions – wrist or foot drop Nerve entrapment: e.g. carpal tunnel Myasthenia gravis Cerebral palsy Sarcoid 1A 2B 2B 2B 2B 2B 1A 2A 1B 1A 2B 2B 2B D ra ft D oc Neurological – seizures (emergency list) Syncope-Cardiac – arrhythmias and valvular Syncope Carotid sinus Seizure Disorders Status epilepticus (emergency list) Primary general Partial or partial complex seizures 1A 2B 2B 34 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Vascular Diseases 1A Subarachnoid Haemorrhage 1A Transient ischaemic attack Raised intracranial pressure Internal carotid dissection Temporal arteritis Cerebral Vasculitis ?define further 1A 1B 2B 2A 2B Infectious/ Inflammatory Disorders Viral Ecephalitis Acute bacterial meningitis (emergency list) HIV ?clarification Tuberculosis meningitis Neuro-Syphilis Lymes disease: Standard presentation Lymes disease: Non-standard presentation Prion Disease 2B 1A 2B 2B 2B 1A 2B 2B ra ft D oc um en t Cerebrovascular Accident Dementias Alzheimer’s disease D Personal Notes 1B 35 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 36 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence MUSCULOSKELETAL AND ORTHOPAEDICs Disorders of the Shoulder Sprains/ strains 1A 1A 1B 1B 1B 1B 2B 1B um en Disorders of the Elbow/Forearm/Wrist/Hand Sprains/ strains Trigger finger Dupytrens disease Fractures/ dislocations: Boxers’, Scaphoid, Colles Carpal tunnel syndrome de Quervain’s tenosynovitis Epicondylitis Fractures/Dislocations Elbow t Fractures/ (clavicle, humerus ,) Dislocations acromioclavicular joint, humerus Adhesive capsulitis/Frozen Shoulder Rotator cuff disorders Shoulder instability Osteoarthritis Shoulder 1A 1B 1B 1A 1B 1B 1A 1B 1A 1A 1B 1B 1B 2B 1B Disorders of the hip Fractures/ dislocations Osteoarthritis Avascular necrosis 1B 1B 1B Disorders of the Knee Sprains/ strains Bursitis Fractures/ dislocations Meniscal injuries Patello-femoral pain syndrome Osteoarthritis 1A 1B 1B 1B 1A 1B Musculoskeletal Neoplastic Disease Bone cysts/ tumours Osteosarcoma 2B 2B D ra ft D oc Disorders of the Back/ Spine Back/ neck pain Injury (differential diagnosis – musc./neuro.) Kyphosis/ scoliosis Herniated disk pulposis Back/ neck fractures Spinal stenosis Ankylosing spondylitis Disorders of the Ankle/ Foot 37 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Sprains/ strains Fractures/ dislocations Hallux Valgus/ Rigidus Morton’s Neuroma 1A 1B 1B 1B 1A 1A 1A 1B 1B 1A 1B 1B Rheumatological Conditions Fibromyalgia Gout Polymyalgia rhuematica Pseudogout Rheumatoid arthritis Reiter’s syndrome Polyarteritis nodosa Polymyositis Scleroderma Sjogren’s syndrome Juvenile rheumatoid arthritis Systemic lupus erythematosus 2B 1A 1B 1B 1B 1B 2B 2B 2B 2B 2B 2B ra ft D oc um en t Paediatric Flat foot Knock knees/bow legs Osgood-Schlatter disease Irritable/septic hip Developmental Dysplasia hip Pulled elbow Slipped upper femoral epiphysis Non-accidental injury 1B 1B 1B 1B Musculoskeletal Infection Cellulitis Septic arthritis Acute osteomyelitis Chronic osteomyelitis Infected joint arthroplasty 1A 1A 1A 1B 1B Orthopaedic Emergencies Compartment Syndrome Cauda equina syndrome 1B 2B D Other Musculoskeletal Problems Osteoporosis /Osteomalacia Paget’s disease Renal osteodystrophy Vascular sickle cell 38 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 39 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence SKIN 1A 1B 1B 1B 1B 1B 1B 1B Papulosquamous Diseases Tinea versicolor Tinea corporis/ pedis Drug eruptions Pityriasis rosea Psoriasis Dermatophyte infections Lichen planus 1A 1A 1A 1A 1B 1B 1B en um ra ft D oc Acneiform Lesions Acne vulgaris Rosacea Folliculitis t Eczematous Eruptions Atopic Contact Nappy Peri-oral Seborrhoeic Nummular Venous stasis Actinic keratosis 1A 1B 1A 1A Female baldness Onycomycosis Paronychia 1B 1A 1A D Hair and Nails Androgenic alopecia male Viral Diseases Exanthems Herpes simplex: Oral 2A 1A Herpes simplex: labial 2A Molluscum contagiosum Verrucae Varicella-zoster virus infectious Condyloma acuminatum 1A 1A 1A 1B Bacterial Infections Cellulitis Impetigo Erysipelas 1A 1A 1B Insects/ Parasites 40 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 1A 1A Bites Insect Animal Human 1A 1A 1A Skin Trauma Simple laceration Complex laceration Superficial burns Partial or full thickness burns Needlestick injuries 1A 1B 1A 1B 1A Other Dermatological Conditions Urticaria Vitiligo Hydradenitis suppurativa Melasma Lipomas Epithelia inclusion cysts Venous leg ulcers Bed sores Arterial leg ulcers Bullous conditions 1B 1B 1B 1B 1A 2B 1B 1B 1B 1B ra ft D oc um en t Lice Scabies 1B 1B 1B Dermal Neoplasia Basal cell carcinoma 1B Other Dermatological Conditions Dyshidrosis Lichen simplex chronicus 2B 2B D Desquamation Stevens-Johnson syndrome Erythema multiforme Toxic epidermal necrolysis 41 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 42 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc en um Eye Disorders Blepharitis Conjunctivitis Corneal abrasion Keratitis Foreign body Pterygium Chalazion Orbital cellulitis Dacrocytitis Strabismus Cataract Congenital cataract Macular degeneration Ectropion Entropion Chronic glaucoma Acute glaucoma (emergency list) Diabetic retinopathy Hypertensive retinopathy Retinal detachment Retinal vascular occlusion (emergency list) Retinoblastoma Raised intracranial pressure (signs of) Optic neuritis Optic atrophy Blow out fracture Acute visual loss Acute painful eye Thyroid eye disease Horner’s Hyphaema Neuromuscular – myasthenia gravis: LEMS Cranial nerve palsy (III, IV, VI) t OPHTHALMOLOGY 1A 1A 1A 1B 1B 1A 1A 1A 1A 1B 1B 2B 2B 1B 1B 2B 1B 2B 1B 1B 1B 2B 1B 1B 1B 1B 1B 1B 1B 1B 2B 2B 1B Personal Notes 43 D ra ft D oc um en t Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 44 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence EAR, NOSE AND THROAT 1A 1A 2B 1A 2B 1B 1B 1B 1B 1B 1A Nose/ Sinus Disorders Acute sinusitis Allergic rhinitis Epistaxis Chronic sinusitis Nasal polyps 1A 1A 1B 1B 1B en um ra ft D oc Mouth/ Throat Disorders Acute pharyngitis Acute tonsillitis Aphthous ulcers Laryngitis Oral candidiasis Oral herpes simplex Parotitis Quinsy (peritonsillar abcess) Epiglottits t Ear Disorders Acute otitis media Earwax impaction Acute labyrinthitis Otitis externa Vertigo Chronic otitis media Mastoiditis Meniere’s disease Barotrauma Hearing impairment Tympanic membrane perforation 1A 1A 1A 1A 1A 1A 1B 1B 1B 1A 1B 2B 1B ENT Neoplasm Acoustic neuromas Nasopharyngeal and oral cancers 1B 1B D Acute epiglottitis (emergency list) Oral leukoplakia Sialadenitis Dental abscess 45 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en t Personal Notes 46 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence D ra ft D oc um en CARDIOVASCULAR Accelerated Hypertension Orthostatic/ postural hypotension Hypovolaemic shock Cardiogenic shock Pulmonary embolus Deep venous thrombosis Ruptured Aortic aneurysm Dissecting Aortic aneurysm Arterial embolism/ thrombosis Acute cerebrovascular accident (stroke) Acute limb ischaemia Bundle branch block (left & right) Trifasicular block Atrial fibrillation/ flutter Atrioventricular block Paroxysmal supraventricular tachycardia Ventricular tachycardia (emergency list) Ventricular fibrillation/ flutter (emergency list) Complete heart block (emergency list) Acute coronary syndrome myocardial infarction Acute coronary syndrome –unstable angina Angina pectoris: Prinzmetal’s/ variant Angina pectoris: Stable Acute Left Ventricular systolic dysfunction Acute and subacute bacterial endocarditis Acute pericarditis Cardiac tamponade Pericardial effusion t Accident and Emergency Medicine RESPIRATORY Croup Acute bronchiolitis Acute epiglottitis Acute exacerbation of COPD Acute Asthma Pulmonary embolism Pneumothorax: Primary Pneumothorax: Traumatic Pneumothorax: Tension Pneumothorax: Secondary RENAL AND GENITOURINARY Acute kidney injury Paraphimosis/ phimosis Testicular torsion (emergency list) 1B 1B 1B 1B 1A 1A 1B 1B 1B 1A 1A 1A 1B 1A 1B 1B 1A 1A 1A 1A 1A 1B 1A 1A 1B 1B 1B 1B 1A 1B 1B 1A 1A 1A 1B 1B 1A 1B 1B 1B 1B 47 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Frank Haematuria Ureteric trauma Hyperkalaemia Acute urinary retention (emergency list) Acute priaprism 1B 2B 1A 1A 1B GASTRO-INTESTINAL Diverticulitis Acute Appendicitis Ischaemic bowel disease Intestinal Obstruction Acute cholecystitis Acute pancreatitis Acute peritonitis Gastro-intestinal perforation Gastro-intestinal haemorrhage en t 1B 1B 1B 1B 1A 1A 1B 1B 1B 1B 1A 1A 1B 1A 1B 1B 1B FEMALE REPRODUCTIVE Ectopic pregnancy Abruptio placenta 1B 1B SEXUAL HEALTH Contraceptive advice 1A HAEMATOLOGICAL Sickle cell crisis 1B D ra ft D oc um ENDOCRINE AND METABOLIC Hyperthyroidism: Thyroid storm Hypoglycaemia Corticoadrenal insufficiency. Addisons Syndrome Hypo/ Hypernatraemia Hypo/ Hyperkalaemia (emergency list) Metabolic alkalosis/ acidosis Respiratory alkalosis/ acidosis Volume excess NEUROLOGICAL Syncope - Cardiac – arrhythmias Syncope Vaso-vagal Cavernous sinus thrombosis Peripheral nerve lesions – wrist or foot drop Nerve entrapment: e.g. carpal tunnel Status epilepticus Primary general Partial or partial complex seizures Cerebrovascular accident Subarachnoid haemorrhage 1A 1A 2B 1B 1A 1A 2B 2B 1A 1A 48 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 1A 2B 1A D ra ft D oc um en MUSCULOSKELETAL AND ORTHOPAEDICS Sprains/ strains of the shoulder Fractures/ (clavicle, humerus) Dislocations acromioclavicular joint, humerus Sprains/ strains of the Elbow/Forearm/ Wrist/Hand Fractures/ dislocations: Boxers’, Scaphoid, Colles Fractures/Dislocations Elbow Back/ neck pain Spinal Injury (differential diagnosis – musc./neuro.) Back/ neck fractures Fractures/ dislocations of the hips Sprains/ strains of the knee Bursitis affecting the knee Fractures/ dislocations of the knee Meniscal injuries Sprains/ strains of the ankle and foot Fractures/ dislocations of the ankle and foot Osgood-Schlatter disease Irritable/septic hip Pulled elbow Slipped upper femoral epiphysis Non-accidental injury Cellulitis Septic arthritis Acute osteomyelitis Infected joint arthroplasty Compartment Syndrome Cauda equina syndrome t Transient ischaemic attack Internal carotid dissection Acute bacterial meningitis DERMATOLOGY Cellulitis Erysipelas Insect Animal Human Simple laceration Complex laceration Superficial burns Partial or full thickness burns Needlestick injuries Urticaria Stevens-Johnson syndrome Erythema multiforme Toxic epidermal necrolysis 1A 1B 1B 1A 1A 1B 1A 1A 1B 1B 1A 1B 1B 1B 1A 1B 1A 1B 1A 1B 1B 1A 1A 1A 1B 1B 2B 1A 1B 1A 1A 1A 1A 1B 1A 1B 1A 1B 1B 1B 1B 49 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence EYE Conjunctivitis Corneal abrasion Keratitis Foreign body Orbital cellulitis Acute glaucoma (emergency list) Retinal detachment Retinal vascular occlusion (emergency list) Blow out fracture of the orbit Hyphaema Acute visual loss 1A 1A 1A 1A 1A 1A 1B 1A 1B 2B 1B EAR NOSE AND THROAT 1B 1A 1B 1A um en t Epistaxis Quinsy (peritonsillar abcess) Epiglottits Acute epiglottitis (emergency list) D ra ft D oc Personal Notes 50 D ra ft D oc um en t Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 51 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence PAEDIATRICS Cardiovascular Measurement and Interpretation of blood pressure Secondary Hypertension Classification of heart murmur Innocent heart murmur Atrial Septal Defect Ventricular Septal Defect Coarctation of aorta Tetralogy of fallot Patent Ductus Arteriosus Hypovolaemic shock Heart failure Rheumatic Fever Bacterial endocarditis Supraventricular tachycardia D ra ft D oc um Respiratory Asthma Viral induced wheeze Bronchiolitis Viral Upper Respiratory Tract Infection Croup Viral pneumonia Bacterial pneumonia Pleural effusion Acute epiglottitis Bacterial tracheitis Pertussis Cystic fibrosis Pneumothorax Laryngomalacia Anaphylatic reaction Acute pharyngitis Acute tonsillitis Acute otitis media Otitis externa Acute sinusitis Allergic rhinitis Epistaxis en t 1A 2B 1A 1A 1B 1B 2B 2B 1B 1B 2B 2B 2B 1B Renal and Genito-Urinary Urinary tract infection Pyelonephritis Acute renal colic Nephrotic syndrome Acute nephritis Frank haematuria 1A 1A 1A 1A 1A 1B 1B 1B 2B 2B 1B 2B 1B 2B 1B 1A 1A 1A 1A 1A 1A 1B 1A 1B 1B 1B 1B 1B 52 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence en um ra ft D oc Dermatology Eczema Cradle cap Nappy rash Urticaria Erythema toxicum Erythema multiforme Steven Johnson Syndrome Toxic shock syndrome Kawasaki syndrome Haemangiomas Staph scalded skin Cellulitis Impetigo Lice Scabies 2B 1B 1B 1B 1B 1B 1B t Acute renal failure Balanitis Testicular torsion Hydrocoele Hypospadius Nocturnal eneuresis Haemolytic-uraemic syndrome 1A 1A 1A 1A 1A 1B 1B 1B 1B 1A 1B 1A 1A 1A 1A 1A 1B 1B 1A 1B 1B 1B 2B Electrolyte and Acid-based Disorders Hypo/Hypernatraemia Hypo/Hyperkalaemia Hypomagnesaemia Metabolic acidosis/alkalosis Respiratory acidosis/alkalosis Volume excess Syndrome of inappropriate anti-diuretic hormone secretion 1B 1B 1B 1B 1B 1B 1B Gastrointestinal Infectious diarrhoea +/- vomiting Appendicitis Intussusception 1A 1B 1B D Endocrinology Plotting growth chart Type 1 diabetes mellitus Diabetic ketoacidosis Hypoglycaemia Congenital hypothyroidism Autoimmune hypothyroidism Hyperthyroidism Corticosteroid insufficiency 53 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence ra ft D oc en um Haematology and Oncology Iron deficiency anaemia Vitamin B12 deficiency Folate deficiency Haemolytic anaemia Sickle cell anaemia Brain tumour Acute/ chronic lymphocytic leukaemia Acute/ chronic myelogenous leukaemia Lymphoma Bleeding disorders Febrile neutropenia Neutropenia Idiopathic thrombocytopenic purpura D Infection Septic shock Meningitis and encephalitis Fever of unknown origin Hand, foot and mouth Varicella-zoster virus infections Eczema herpeticum Molluscum contagiosum Epstein-Barr virus infections Mumps Roseola Rubella Measles Peri-orbital cellulitis Musculoskeletal Reactive arthritis Septic arthritis Osteomyelitis 1B 1A 2B 1A 1A 1A 1A 1A 1B 1B 1B 1B 1A 1A t Obstruction Constipation/ faecal impaction Inflammatory bowel disease Gastro-oesophageal reflux Cow’s milk protein intolerance Lactose intolerance secondary to infectious diarrhoea Coeliac disease Oesophagitis Mallory-Weiss tear Pyloric stenosis Neonatal jaundice Childhood jaundice Fluid requirement of neonate and children Dehydration 1B 2B 2B 2B 2B 2B 2B 2B 2B 2B 1B 1B 2B 1B 1B 2B 1A 1A 1B 1A 1A 1B 1A 1B 1B 1B 1B 1B 1B 54 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence en um ra ft D oc Neurology Developmental assessment Classic migraine Atypical migraine Tension headache Cluster headache Syncope Vaso-vagal Cerebral palsy Status epilepticus (emergency list) Primary general seizures Partial or partial complex seizures Febrile convulsion Raised intracranial pressure Bell’s Palsy Lymes disease Drug overdose Alcohol intoxication 1A 1A 1A 1A 1B 1B 1B 1B 1B 1B 1B 2B D Emergency Febrile convulsion Status Epilepticus Suspected Non Accidental Injury Aystole/ PEA SVT Apnoea/ respiratory depression Meningitis and encephalitis 1A 1B 2B 2B 2B 1A 2B 1B 1B 1B 1B 2B 2B 1B 1B 1B t Flat foot Knock knees/bow legs Hypermobile joints Osgood-Schlatter disease Irritable/septic hip Developmental Dysplasia hip Pulled elbow Slipped upper femoral epiphysis Perthes Non-accidental injury Juvenile idiopathic arthritis Systemic lupus erythematosus 1B 1B 1B 1B 1B 1B 1B Personal Notes 55 D ra ft D oc um en t Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence 56 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence EMERGENCY CONDITIONS The following table contains a list of acute presentations and conditions which a Physician Associate should be able to recognise, assess and initiate appropriate treatment and support prior to senior help arriving. DVT Ruptured aortic aneurysm Dissecting aortic aneurysm Acute limb ischaemia Accelerated hypertension with end organ damage Complete heart block VT VF SVT/AF (Haemodynamically Unstable) Acute pulmonary oedema ACS MI ACS unstable angina Syncope Bleeding Oesophageal Varices um en t Cardiovascular ra ft D oc Acute pancreatitis Gastrointestinal perforation Gastrointestinal haemorrhage Peritonitis Acute bowel ischaemia Intestinal obstruction Oesophageal food bolus obstruction Status epilepticus Subarachnoid haemorrhage GCA with visual symptoms Acute thromboembolic stroke Spinal Cord Compression Transient Ischaemic Attack Acute septicaemia Septic shock Acute meningitis Neutropenic sepsis Necrotising fasciitis Central Venous Line Sepsis Hypercalcaemia Acute hypoglycaemia Hypovolaemic shock Diabetic Keto-Acidosis Hyperglycaemic Hyperosmolar-State Alcoholic ketoacidosis D Gastrointestinal Neurological Infectious Disease Endocrine & Electrolytes 57 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Hyper/hypokaleamia Blood gas and acid base disruption Acute adrenal failure (Addisons/Iatrogenic) Myxoedema Coma Acute painful eye ra ft D oc Eye um Respiratory t ENT en Renal & GU Acute renal colic Testicular torsion Acute urinary retention Acute kidney injury Acute Epistaxis Acute peri-tonsillar abscess Acute epiglottitis adult and paediatric Near drowning Sea/Fresh water Pulmonary Embolus Tension pneumothorax Aspiration of Foreign Body Type 1 and 2 Respiratory failure Acute Severe Asthma Massive Haemoptysis Controlled Oxygen Therapy Foreign body/trauma Acute visual loss Female Health D Orthopaedics Miscellaneous Paediatrics Poisoning Pre-eclampsia Placental abruption Ectopic pregnancy Open fracture/dislocations Fracture dislocations with associated neurovascular compromise Alcohol Withdrawal/ Delirium Tremens Hypothermia/Hyperthermia Febrile convulsion Suspected Non Accidental Injury Opiate Toxicity Paracetamol Overdose Salicylate Toxicity Bezodiazepine Toxicity SSRI/SNRI and Tricyclic Antidepressant Toxicity Amphetamine /Cocaine/MDMA Toxicity 58 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Toxic Alcohol (ethanol, methanol, ethylene glycol) Ingestion Iron toxicity Beta blocker and calcium channel blocker toxicity D ra ft D oc um en t Personal Notes 59 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence The Content of Learning This section lists the specific knowledge, skills, attitudes and behaviours which should be attained following completion of a Physician Associate training programme. The competencies are presented in four parts: Part 1 - Symptom Competencies - define the knowledge, skills and attitudes required for each level of learning for different problems with which a patient may present. These symptoms are further broken down in to emergency presentations; top 20 presentations and other presentations. The top 20 presentations are listed together to emphasise the frequency with which these problems are encountered in clinical practice, and are based on medical admission unit audit data. en t Part 2 - System specific competencies - define competencies to be attained by the end of training for each body system, and also lists the conditions and basic science of which the physician associate must acquire knowledge. um Part 3 - Investigation competencies - lists investigations that a physician associate must be able to describe, order, and interpret by the end of training. D ra ft D oc Part 4 – Procedural competencies - lists procedures that a physician associate should be competent in by the end of training. 60 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Symptom Based Competencies Emergency Presentations Cardio-Respiratory Arrest The physician associate will have full competence in the assessment and resuscitation of the patient who has suffered a cardio-respiratory arrest, as defined by the UK Resuscitation Council Knowledge Skills Causes of cardiorespiratory arrest Attitudes and Behaviour Rapidly assess the collapsed patient in terms of ABC, airway, breathing and circulation um Maintain safety of environment for patient and health workers Participate in UK Resuscitation Council approved ILS and ALS course (MANDATORY REQUIREMENT) ra ft D oc Outline indication and safe delivery of drugs used in cardiac arrest scenarios: adrenaline, atropine, amiodarone, buffers Perform Basic Life Support competently as defined by Resuscitation Council (UK): effective chest compressions, airway manoeuvres, bag and mask ventilation en t Recall the ALS algorithm for adult cardiac arrest Recognise and intervene in critical illness promptly to prevent cardiac arrest such as peri-arrest arrhythmias, hypoxia D Competently perform further steps in advanced life support: IV drugs; safe DC shocks when indicated; identification and rectification of reversible causes of cardiac arrest Succinctly present clinical details of situation to senior doctor Consult senior and seek anaesthetic team support 61 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Shocked Patient The physician associate will be able to identify a shocked patient, assess their clinical state, produce a list of appropriate differential diagnoses and initiate immediate management Attitudes and Behaviour Identify physiological perturbations that define shock Recognise significance of major physiological perturbations Identify principle categories of shock (i.e. cardiogenic, circulatory) Perform immediate (physical) assessment (A,B,C) Define sepsis syndromes Adopt leadership role where appropriate um Involve senior and specialist (e.g. critical care outreach) services promptly Arrange simple monitoring of relevant indices (oximetry, arterial gas analysis) and vital signs (BP, pulse & respiratory rate, temp, urine output) ra ft D oc Elucidate main causes of shock in each category (e.g. MI, heart failure, PE, blood loss, sepsis) Institute immediate, simple resuscitation (oxygen, iv access, fluid resuscitation) Exhibit calm and methodical approach to assessing critically ill patient t Skills en Knowledge D Order, interpret and act on initial investigations appropriately: ECG, blood cultures, blood count, electrolytes 62 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Unconscious Patient The physician associate will be able to promptly assess the unconscious patient to produce a differential diagnosis, establish safe monitoring, investigate appropriately and formulate an initial management plan, including recognising situations in which emergency specialist investigation or referral is required Recognise need for immediate assessment and resuscitation Assume leadership role where appropriate Initiate appropriate immediate management (A,B,C, cervical collar, administer glucose) Involve senior staff promptly ra ft D oc Recognise the principal sub causes (drugs, hypoglycaemia, hypoxia; trauma, infection, vascular, epilepsy, raised intra-cranial pressure, reduced cerebral blood flow, endocrine) Make a rapid and immediate assessment including examination of coverings of nervous system (head, neck, spine) and Glasgow Coma Scale um Identify the principal causes of unconsciousness (metabolic, neurological) Attitudes and Behaviour t Skills en Knowledge Prioritise, order, interpret and act on simple investigations appropriately Involve appropriate specialists to facilitate immediate assessment and management (e.g. imaging, intensive care, neurosurgeons) D List appropriate investigations for each Take simple history from witnesses when patient has stabilised Outline immediate management options Initiate early (critical) management (e.g. control fits, manage poisoning) including requesting safe monitoring 63 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Anaphylaxis The physician associate will be able to identify patients with anaphylactic shock, assess their clinical state, produce a list of appropriate differential diagnoses, initiate immediate resuscitation and management and organise further investigations Identify physiological perturbations causing anaphylactic shock Recognise clinical consequences of acute anaphylaxis Elucidate causes of anaphylactic shock Perform immediate physical assessment (laryngeal oedema, bronchospasm, hypotension) Adopt leadership role where appropriate Involve senior and specialist allergy services promptly um Institute resuscitation (adrenaline, oxygen, IV access, fluids) Exhibit a calm and methodical approach ra ft D oc Define follow-up pathways after acute resuscitation Attitudes and Behaviour t Skills en Knowledge Arrange monitoring of relevant indices D Order, interpret and act on initial investigations (tryptase, C1 esterase inhibitor etc.) 64 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence ‘The Top 20’ – Common Medical Presentations Abdominal Pain The physician associate will be able to assess a patient presenting with abdominal pain to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Skills Attitudes and Behaviour Outline the different classes of abdominal pain and how the history and clinical findings differ between them Elicit signs of tenderness, guarding, and rebound tenderness and interpret appropriately Exhibit timely intervention when abdominal pain is the manifestation of critical illness or is lifethreatening, in conjunction with senior and appropriate specialists um Order, interpret and act on initial investigations appropriately: blood tests; radiographs; ECG; microbiology investigations Recognise the importance of a multi-disciplinary approach including early surgical assessment when appropriate ra ft D oc Identify the possible causes of abdominal pain, depending on site, details of history, acute or chronic en t Knowledge Define the situations in which urgent surgical, urological or gynaecological opinion should be sought D Determine which first line investigations are required, depending on the likely diagnoses following evaluation Initiate first line management: the diligent use of suitable analgesia; ‘nil by mouth’; IV fluids; resuscitation Display sympathy to physical and mental responses to pain Involve other specialties promptly when required 65 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Acute Back Pain The physician associate will be able to assess a patient presenting with back pain to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Skills Attitudes and Behaviour Recall the causes of acute back pain Perform examination and elicit signs of spinal cord / cauda equina compromise Involve neurosurgical unit promptly in event of neurological symptoms or signs Practise safe prescribing of analgesics / anxiolytics to provide symptomatic relief Ask for senior help when critical abdominal pathology is suspected Order, interpret and act on initial investigations appropriately: blood tests, myeloma screen, radiographs en Recognise the socioeconomic impact of chronic lower back pain ra ft D oc Outline the features that raise concerns as to a sinister cause (‘the red flags’) and lead to consideration of a chronic cause (‘the yellow flags’) um Specify abdominal pathology that may present with back pain t Knowledge Recall the indications of an urgent MRI of spine Participate in multidisciplinary approach: physio, OT D Outline indications for hospital admission 66 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Blackout / Collapse The physician associate will be able to assess a patient presenting with a collapse to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan (see also ‘Syncope’ and ‘Falls’) Recognise impact episodes can have on lifestyle particularly in the elderly Assess patient in terms of ABC and degree of consciousness and manage appropriately Recognise recommendations regarding fitness to drive in relation to undiagnosed blackouts Perform examination to elicit signs of cardiovascular or neurological disease and to distinguish epileptic disorder from other causes ra ft D oc Outline the indications for temporary and permanent pacing systems Elucidate history to establish whether event was LOC, fall without LOC, vertigo (with eye witness account if possible) t Differentiate the causes depending on the situation of collapse, associated symptoms and signs, and eye witness reports Attitudes and Behaviour um Recall the causes for sudden loss of consciousness (LOC) Skills en Knowledge Order, interpret and act on initial investigations appropriately: ECG, blood tests inc. glucose D Manage arrhythmias appropriately as per ALS guidelines Institute external pacing systems when appropriate 67 Matrix specification of Core Clinical Conditions for the Physician Assistant by category of level of competence Breathlessness The physician associate will be able to assess a patient presenting with breathlessness to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Order, interpret and act on initial investigations appropriately: routine blood tests, oxygen saturation, arterial blood gases, chest radiograph, ECG, PEFR, spirometry Initiate treatment in relation to diagnosis, including safe oxygen therapy, early antibiotics for pneumonia Perform chest aspiration and chest drain insertion ra ft D oc Define basic pathophysiology of breathlessness Differentiate between stridor and wheeze List the common and serious causes of wheeze and stridor Exhibit timely assessment and treatment in the acute phase Recognise the distress caused by breathlessness and discuss with patient and carers t Identify non cardiorespiratory factors that can contribute to or present with breathlessness Interpret history and clinical signs to list appropriate differential diagnoses: esp. pneumonia, asthma, COPD, PE, pulmonary oedema, pneumothorax Recognise the impact of long term illness en Explain orthopnoea and paroxysmal nocturnal dyspnoea Attitudes and Behaviour Consult senior when respiratory distress is evident um Specify the common cardio-respiratory conditions that present with breathlessness Skills Recognise disproportionate dyspnoea and hyperventilation Recognise other causes of dyspnoea in patients with wheeze (e.g. pneumothorax) and manage appropriately Involve Critical Care team promptly when indicated Exhibit non-judgemental attitudes to patients with a smoking history D Evaluate and advise on good inhaler technique 68 69 t en um ra ft D oc D 20 - Chest Pain Attitudes and Behaviour List respiratory causes of chest pain Define the pathophysiology of acute coronary syndrome and pulmonary embolus Recognise the contribution and expertise of specialist cardiology nurses and technicians Elect appropriate arena of care and degree of monitoring Formulate initial discharge plan D Outline emergency treatments for PTE Commence initial emergency treatment including coronary syndromes, pulmonary embolus and aortic dissection Involve senior when chest pain heralds critical illness or when cause of chest pain is unclear ra ft D oc Identify the indications and limitations of cardiac enzymes and d dimer analysis Order, interpret and act on initial investigations in the context of chest pain appropriately: such as ECG, blood gas analysis, blood tests, chest radiograph, cardiac enzymes Perform timely assessment and treatment of patients presenting with chest pain t List the common causes for each category of chest pain and associated features: cardiac, pleuritic, musculoskeletal, upper GI Interpret history and clinical signs to list appropriate differential diagnoses: esp. for cardiac pain & pleuritic pain um Characterise the different types of chest pain, and outline other symptoms that may be present en Skills 70 21 - Confusion, Acute The physician associate will be able to assess an acutely confused patient to formulate a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills Attitudes and Behaviour List the common and serious causes for acute confusion Examine to elicit cause of acute confusion Recognise that the cause of acute confusion is often multi-factorial en t Contribute to multidisciplinary team management Recognise effects of acutely confused patient on other patients and staff in the ward environment Recognise pre-disposing factors: cognitive impairment, psychiatric disease ra ft D oc Recognise the factors that can exacerbate acute confusion e.g. change in environment, infection Perform mental state examinations (abbreviated mental test and mini-mental test) to assess severity and progress of cognitive impairment um Outline important initial investigations, including electrolytes, cultures, full blood count, ECG, blood gases, thyroid D List the pre-existing factors that pre-dispose to acute confusion 71 22 - Cough The physician associate will be able to assess a patient presenting with cough to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills List the common and serious causes of cough Identify risk factors relevant to each aetiology including precipitating drugs Attitudes and Behaviour Order, interpret and act on initial investigations appropriately: blood tests, chest radiograph and PFT Contribute to patients understanding of their illness um Consult seniors promptly when indicated ra ft D oc Outline the different classes of cough and how the history and clinical findings differ between them en t Exhibit non-judgmental attitudes to patients with a history of smoking D State which first line investigations are required, depending on the likely diagnoses following evaluation Recognise the importance of a multi-disciplinary approach 72 23 - Diarrhoea The physician associate will be able to assess a patient presenting with diarrhoea to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Seek a surgical and senior opinion when required Assess whether patient requires hospital admission Exhibit sympathy and empathy when considering the distress associated with diarrhoea and incontinence Perform rectal examination as part of physical examination Demonstrate awareness of infection control procedures ra ft D oc Outline the pathophysiology of diarrhoea for each aetiology Evaluate nutritional and hydration status of the patient t Correlate presentation with other symptoms: such as abdominal pain, rectal bleeding, weight loss Attitudes and Behaviour en Specify the causes of diarrhoea (secretory, infective, etc) Skills um Knowledge Describe the investigations necessary to arrive at a diagnosis D Identify the indications for urgent surgical review in patients presenting with diarrhoea Initiate investigations: blood tests, stool examination, endoscopy and radiology as appropriate 73 24 - Falls The physician associate will be able to assess a patient presenting with a fall and produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan (see also ‘Syncope’ and ‘Blackout/Collapse’) Outline the assessment of a patient with a fall and give a differential diagnosis State conditions that may present as a fall Identify possible secondary complications of falls Recognise the psychological impact to an older person and their carer after a fall Contribute to the patients understanding as to the reason for their fall Discuss with seniors promptly and appropriately Commence appropriate treatment including pain relief and bone prophylaxis Relate the possible reasons for the fall and the management plan to patient and carers ra ft D oc Outline the relationship between falls risk and fractures Define the significance of a fall depending on circumstances, and whether recurrent, to distinguish when further investigation is necessary t Describe causes of falls and risk factors for falls, including drug and neurovascular causes Attitudes and Behaviour en Skills um Knowledge D Outline secondary risks of falls, such as loss of confidence, infection 74 25 - Fever The physician associate will be able assess a patient presenting with fever to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Define Pyrexia of Unknown Origin Order, interpret and act on initial investigations appropriately: blood tests, cultures, CXR Adhere to local antibiotic prescribing policies Highlight importance of nosocomial infection and principles for infection control Consult senior in event of septic syndrome Identify the risk factors in the history that may indicate an infectious disease e.g. travel, sexual history, IV drug use, animal contact, drug therapy Discuss with senior colleagues and follow local guidelines in the management of the immunosuppressed e.g. HIV, neutropenia ra ft D oc Recall the role of antipyretics Recognise the presence of septic shock in a patient, commence resuscitation and liaise with senior colleagues promptly t Recall the broad causes of fever: infection, malignancy, inflammation Attitudes and Behaviour en Outline the physiology of developing a fever Skills um Knowledge Differentiate features of viral and bacterial infection D Outline indications for LP in context of fever Commence appropriate empirical antibiotics when an infective source of fever is deemed likely in accordance with local prescribing policy Promote communicable disease prevention: e.g. immunisations, antimalarials, safe sexual practices 75 26 - Fits / Seizure The physician associate will be able to assess a patient presenting with a fit, stabilise promptly, investigate appropriately, formulate and implement a management plan Skills Recognise and manage a patient presenting with status epilepticus Recall the common epileptic syndromes Obtain collateral history from witness List the essential initial investigations following a ‘first fit’ ra ft D oc Recall the indications for a CT head Recognise the principles of safe discharge, after discussion with senior colleague um Promptly recognise and treat precipitating causes: metabolic, infective, malignancy Recognise need for urgent referral in case of uncontrolled recurrent loss of consciousness or seizures t Outline the causes for seizure Attitudes and Behaviour en Knowledge Describe the indications, contraindications and side effects of the commonly used anticonvulsants Recognise the psychological and social consequences of epilepsy D Differentiate seizure from other causes of collapse Recognise importance of Epilepsy Nurse Specialist 76 27 - Haematemesis & Melaena The physician associate will be able to succinctly assess the patient with an upper GI haemorrhage to determine significance; resuscitate appropriately; and liaise with endoscopist effectively Distinguish upper and lower GI bleeding Observe safe practices in the prescription of blood products Demonstrate ability to site large bore IV access Perform assessment to postulate cause of bleeding: in particular detect the presence of liver disease ra ft D oc Outline methods of assessing the significance and prognosis of an upper GI bleed and how this impacts on importance of urgent endoscopy e.g. Rockall score Seek senior help and endoscopy or surgical input in event of significant GI bleed Recognise shock or impending shock and resuscitate rapidly and appropriately t Specify the causes of upper GI bleeding, with associated risk factors Attitudes and Behaviour en Detail the anatomy of the upper GI tract Skills um Knowledge Outline the principles of choice of IV access, fluid choice and speed of fluid administration D Broadly outline endoscopic methods of haemostasis Safely prescribe drugs indicated in event of a likely upper GI variceal bleed: broad spectrum antibiotics, vasoconstrictor agents, acid suppression 77 28 - Headache The physician associate will be able to assess a patient presenting with headache to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Skills Understand the pathophysiology of headache Recognise the nature of headaches that may have a sinister cause and assess and treat urgently Liaise with senior doctor promptly when sinister cause is suspected t Perform a comprehensive neurological examination, including eliciting signs of papilloedema, temporal arteritis, meningism and head trauma Involve neurosurgical team promptly when appropriate Order, interpret and act on initial investigations ra ft D oc Define the indications for urgent CT/MRI scanning in the context of headache Recognise important diagnostic features in history um Recall the common and life-threatening causes of acute new headache, and how the nature of the presentation classically varies between them Attitudes and Behaviour en Knowledge Interpret basic CSF analysis: cell count, protein, gram stain and glucose D Define clinical features of raised intra-cranial pressure Perform a successful lumbar puncture when indicated with minimal discomfort to patient observing full aseptic technique Initiate prompt treatment when indicated: appropriate analgesia; antibiotics; anti-virals; steroids 78 29 - Jaundice The physician associate will be able to assess a patient presenting with jaundice to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Outline the pathophysiology of jaundice in terms of prehepatic, hepatic, and post-hepatic Skills Attitudes and Behaviour Exhibit non-judgmental attitudes to patients with a history of alcoholism or substance abuse List causes for each category of jaundice with associated risk factors Recognise the presence of chronic liver disease or fulminant liver failure Consult seniors and gastroenterologists promptly when indicated Describe the need for careful prescribing in a patient with jaundice Interpret basic investigations to establish aetiology: blood tests and abdominal ultrasound scanning Recognise complications of jaundice: sepsis and renal impairment en Recognise the importance of a multidisciplinary approach D Describe medical, surgical and radiological treatments Contribute to the patient’s understanding of their illness um ra ft D oc Outline basic investigations to establish aetiology t Take a thorough history and examination to arrive at a valid differential diagnosis 79 30 - Limb Pain & Swelling The physician associate will be able to assess a patient presenting with limb pain or swelling to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills t Recognise importance of thrombo-prophylaxis in high risk groups Recognise compartment syndrome and critical ischaemia and take appropriate timely action ra ft D oc Outline the pathophysiology for pitting oedema, nonpitting oedema and thrombosis Liaise promptly with surgical colleagues in event of circulatory compromise (eg compartment syndrome) en Summarise the different causes of limb pain in terms of leg, arm and hand Perform a full examination including assessment of viability and perfusion of limb and differentiate pitting oedema; cellulitis; venous thrombosis; compartment syndrome um Recall the causes of unilateral and bilateral limb swelling in terms of acute and chronic presentation Attitudes and Behaviour State the risk factors for the development of thrombosis Practise safe prescribing of initial treatment as appropriate (anticoagulation therapy, antibiotics etc) D Outline the indications, contraindications and side effects of diuretics and anti-coagulants Order, interpret and act on initial investigations appropriately: blood tests, Doppler studies, urine protein Differentiate the features of limb pain and/or swelling pain due to cellulitis and DVT Prescribe appropriate analgesia 80 31 - Palpitations The physician associate will be able to assess a patient presenting with palpitations to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills Attitudes and Behaviour Elucidate nature of patient’s complaint Consult senior colleague promptly when required Define the term palpitations Order, interpret and act on initial investigations appropriately: ECG, blood tests Advise on lifestyle measures to prevent palpitations/arrhythmias when appropriate en um Recognise and commence initial treatment of arrhythmias being poorly tolerated by patient (peri-arrest arrhythmias) as per UK Resuscitation Council Guidelines ra ft D oc Define common causes of palpitations e.g. anxiety, drugs, thyrotoxicosis) t Recall basic cardiac electrophysiology List the categories of arrhythmia Ensure appropriate monitoring of patient on ward D State common arrhythmogenic factors including drugs Outline the indications, contraindications and side effects of the commonly used antiarrhythmic medications 81 32 - Poisoning The physician associate will be able to assess promptly a patient presenting with deliberate or accidental poisoning, initiate urgent treatment, ensure appropriate monitoring and recognise the importance of psychiatric assessment in episodes of self harm Recall indications for gastric lavage, activated charcoal and whole bowel irrigation Recognise critically ill overdose patient and resuscitate as appropriate Define parameters used to give clues to type of poisoning: pupils, pulse and respiration, blood pressure, temperature, glucose, seizure, coma, renal function, osmolar and anion gap Take a full history of event, including collateral if possible D Recognise importance of accessing TOXBASE and National Poisons Information Service Contact senior promptly in event of critical illness or patient refusing treatment Recognise the details of poisoning event given by patient may be inaccurate Show compassion and patience in the assessment and management of those who have self-harmed um Commence poison-specific treatments ra ft D oc Outline presentation and management of poisoning with: paracetamol, aspirin, opiates, alcohol, benzodiazepines, beta blockers, digoxin, carbon monoxide, anti-coagulants, tricyclic anti-depressants, SSRIs, amphetamines and cocaine Examine to determine nature and effects of poisoning Attitudes and Behaviour t Skills en Knowledge Order, interpret and act on initial investigations appropriately: biochemistry, arterial blood gas, glucose, ECG, and drug concentrations Ensure appropriate monitoring in acute period of care 82 33 - Rash The physician associate will be able assess a patient presenting with an acute-onset skin rash and common skin problems to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Demonstrate sympathy and understanding of patients‘ concerns due to the cosmetic impact of skin disease Engage the patient in the management of their condition particularly with regard to topical treatments Recognise the importance of a detailed drug history Reassure the patient about the long term prognosis and lack of transmissibility of most skin diseases ra ft D oc Identify risk factors, particularly drugs, infectious agents and allergens Take a thorough focussed history & conduct a detailed examination, including the nails, scalp and mucosae to arrive at appropriate differential diagnoses t Outline basic investigations to establish aetiology Attitudes and Behaviour en Define the characteristic lesions found in the acute presentation of common skin diseases Skills um Knowledge D Describe possible medical treatments Recognise that anaphylaxis may be a cause of an acute skin rash Order, interpret and act on initial investigations appropriately to establish aetiology 83 34 - Vomiting and Nausea The physician associate will be able to assess a patient with vomiting and nausea to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan List commonly used antiemetics and differentiate the indications for each Recognise and treat suspected GI obstruction appropriately: nil by mouth, NG tube, IV fluids Involve surgical team promptly in event of GI obstruction Respect the impact of nausea and vomiting in the terminally ill and involve palliative care services appropriately Practise safe prescribing of anti-emetics ra ft D oc Outline alarm features that make a diagnosis of upper GI malignancy possible Elicit signs of dehydration and take steps to rectify um Recall the causes and pathophysiology of nausea and vomiting Attitudes and Behaviour t Skills en Knowledge D Order, interpret and act on initial investigations appropriately: blood tests, radiographs 84 35 - Weakness and Paralysis The physician associate will be able to assess a patient presenting with motor weakness to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan (see also ‘Speech Disturbance’ and ‘Abnormal Sensation (Paraesthesia and Numbness)’) Define the clinical features of upper and lower motor neurone, neuromuscular junction and muscle lesions Perform full examination to elicit signs of systemic disease and neurological dysfunction and identify associated deficits Describe likely site of lesion in motor system and produce differential diagnosis Order, interpret and act on initial investigations for acute motor weakness appropriately ra ft D oc Outline the common and important causes for lesions at the sites listened above Elucidate speed of onset and risk factors for neurological dysfunction Recall the Bamford classification of stroke, and its role in prognosis D Outline investigations for acute presentation, including indications for urgent head CT Recognise importance of timely assessment and treatment of patients presenting with acute motor weakness Consult senior and acute stroke service, if available, as appropriate t Recall the myotomal distribution of nerve roots, peripheral nerves, and tendon reflexes Attitudes and Behaviour en Broadly outline the physiology and neuroanatomy of the components of the motor system Skills Recognise patient and carers distress when presenting with acute motor weakness um Knowledge Recognise when swallowing may be unsafe and manage appropriately Detect spinal cord compromise and investigate promptly Perform tests on respiratory function and inform senior appropriate Consult senior when rapid progressive motor weakness or impaired consciousness is present Involve speech and language therapists appropriately Contribute to multidisciplinary approach 85 Other Important Presentations 36 - Abdominal Mass / Hepatosplenomegaly The physician associate will be able to assess a patient presenting with an abdominal mass to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Skills Attitudes and Behaviour Describe relevant investigations related to clinical findings: radiological, surgical, endoscopy Elicit and interpret important clinical findings of mass to establish its likely nature Recognise the anxiety that the finding of an abdominal mass may induce in a patient t Elicit associated symptoms and risk factors for the presence of diseases presenting with abdominal mass, hepatomegaly and splenomegaly Participate in multidisciplinary team approach ra ft D oc um Define the different types of abdominal mass in terms of aetiology, site, and clinical characteristics (e.g. mitotic, inflammatory) en Knowledge Order, interpret and act on initial investigations appropriately: blood tests, imaging D Identify the causes of hepatomegaly and splenomegaly 86 Abdominal Swelling & Constipation 37 - The physician associate will be able to undertake assessment of a patient presenting with abdominal swelling or distension to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Recognise the multifactorial nature of constipation, particularly in the elderly Recognise the importance of multi-disciplinary approach Identify risk factors for the development of ascites and constipation, including initial blood tests ra ft D oc Outline the pathophysiology of portal hypertension and bowel obstruction Examine to identify the nature of the swelling, including a rectal examination, and elicit co-existing signs that may accompany ascites t Outline the common causes of constipation, including drugs Attitudes and Behaviour en Define the causes of abdominal swelling and their associated clinical findings Skills um Knowledge Outline important steps in the diagnosis of the cause of ascites, including imaging and the diagnosis of spontaneous bacterial peritonitis and malignancy D Define alarm features that raise suspicion of colorectal malignancy Identify mode of action and side effects of the commonly used laxatives Order, interpret and act on initial investigations Perform a safe diagnostic and therapeutic ascitic tap with aseptic technique with minimal discomfort to the patient Interpret results of diagnostic ascitic tap Institute initial management as appropriate to the type of swelling 87 38 Abnormal Sensation (Paraesthesia and Numbness) The physician associate will be able to assess a patient with abnormal sensory symptoms to arrive at a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills Consult senior and acute stroke service, if available, as appropriate Describe likely site of lesion: central, root, mononeuropathy, or polyneuropathy t Perform full examination including all modalities of sensation to elicit signs of nervous system dysfunction Contribute to multidisciplinary approach ra ft D oc List common and important causes of abnormal sensation and likely site of lesion in nervous system (e.g. trauma, vascular) Recognise the distress chronic paraesthesia can cause en Recall the dermatomal distribution of nerve roots and peripheral nerves Take a full history, including drugs, lifestyle, trauma um Broadly outline the physiology and neuroanatomy of the sensory components of the nervous system Attitudes and Behaviour D Outline the symptomatic treatments for neuropathic pain Outline indications for an urgent head CT 88 Aggressive / Disturbed Behaviour 39 - The physician associate will be competent in predicting and preventing aggressive and disturbed behaviour; using safe physical intervention and tranquillisation; investigating appropriately and liasing with the mental health team Knowledge Skills Elucidate the factors that allow prediction of aggressive behaviour: personal history, alcohol and substance misuse, delirium Ensure appropriate arena for nursing patient with disturbed behaviour en Assess patient fully including mental state examination to produce a valid differential diagnosis t Ensure sufficient support is available Advocate practice outlined in national guidelines (e.g. NICE) on managing violence ra ft D oc Recall indications, contraindications and side effects of tranquillisers Involve senior colleague and mental health care team promptly um Define acute psychosis and list its predominant features and causes Attitudes and Behaviour D Outline the legal framework authorising interventions in the management of the disturbed or violent patient Order, interpret and act on initial investigations appropriately when possible Practise safe rapid tranquillisation if indicated as defined in national guidelines e.g. NICE Recognise warning signs of incipient violent behaviour Ensure close monitoring following tranquillisation 89 Alcohol and Substance Dependence 40 - The physician associate will be able to assess a patient seeking help for substance abuse, and formulate an appropriate management plan Describe the medical, psychiatric and socioeconomic consequences of alcohol and drug misuse Examine patient to elicit complications of alcohol and substance misuse Recognise the aggressive patient and manage appropriately Seek specialist advice when appropriate e.g. gastroenterology, intensive care, psychiatry Obtain collateral history if possible ra ft D oc Outline the measures taken to correct features of malnutrition, including vitamin and mineral supplementation Take a detailed medical and psychiatric history to identify physical or psychological dependence um Outline the pathophysiology of withdrawal syndromes Attitudes and Behaviour t Skills en Knowledge Practise safe prescribing of sedatives for withdrawal symptoms D Recall effects of alcohol and recreational drugs on cerebral function Investigate as appropriate Detect and address other health issues: liver disease, malnutrition, Wernicke’s encephalopathy 90 41 - Anxiety / Panic disorder The physician associate will be able to assess a patient presenting with features of an anxiety disorder and reach a differential diagnosis to guide investigation and management Skills Attitudes and Behaviour Be familiar with national guidelines (e.g. NICE) on management of anxiety Evaluate patient’s mental state to categorise cause of symptoms as per national guidelines (e.g. NICE) on Anxiety ra ft D oc Elucidate the main categories of anxiety disorder: panic, generalised anxiety, phobias Recognise the chronicity of anxiety syndromes and the distress and disability they cause t Assess a patient to detect organic illness um Recall the main features of anxiety disorder en Knowledge Recognise the role of depression in anxiety symptoms D Recall organic disorders and medications than can mimic some features of anxiety disorder Outline broad treatment strategies for anxiety disorders 91 42 - Bruising The physician associate will be able to assess a patient presenting with easy bruising to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Identify the possible causes of easy bruising, depending on the site, age of the patient and details of the history, particularly in relation to prescribed medication Order, interpret and act on initial investigations appropriately including blood tests, radiographs, microbiology investigations Initiate first line management in consultation with senior clinicians Acknowledge anxiety caused by possible diagnosis of a serious blood condition Consult senior if there is concern bruising is manifestation of critical illness ra ft D oc State which first line investigations are required, depending on the likely diagnosis Recognise the importance of a multidisciplinary approach um Outline the different types of easy bruising Attitudes and Behaviour t Skills en Knowledge D State the common clinical presentations of coagulation disorders Recognise that trauma is an important cause of bruising and that bruising is a common problem in the elderly 92 43 - Chance Findings The physician associate will be able to construct a management plan for patients referred by colleagues due to asymptomatic abnormal findings Decide whether immediate assessment of patient is required, after discussion with senior colleague if uncertain Refer non-urgent cases to either GP or appropriate specialist for out-patient review or investigation Recognise the nonspecific modes by which serious illness may present t Elucidate finding and place it in context of particular patient Formulate an appropriate management plan for each scenario Seek specialist advice when appropriate D ra ft D oc State asymptomatic findings that warrant immediate assessment, admission and management Attitudes and Behaviour en Recall asymptomatic abnormal findings that may precipitate discussion with medical team: abnormal radiograph; accelerated hypertension; deranged blood tests (anaemia, calcium, urea and electrolytes, full blood count, clotting); proteinuria; microscopic haematuria; abnormal ECG; drug interactions and reactions Skills um Knowledge Order, interpret and act on further initial investigations appropriately Manage common metabolic presentations appropriately (hyper/hypokalaemia, hyper/hyponatraemia) 93 44 - Dialysis The physician associate will be aware of the principles, indications, and complications of Renal Replacement Therapy (RRT) Knowledge Skills Order, interpret and act on initial investigations appropriately, recognising importance of full septic screen Recognise the valuable insight patients on long term RRT have into the nature of their symptoms um Recall the importance of sepsis in patients on RRT Recognise importance of prompt senior and Renal Unit input in the management of patients on RRT t Elucidate the common complications of long term haemodialysis Demonstrate ability to assess a patient on long term dialysis presenting to hospital to arrive at a valid differential diagnosis en Outline the methods of RRT Attitudes and Behaviour D ra ft D oc Commence initial management of patient if appropriate 94 45 - Dyspepsia The physician associate will be able to assess a patient presenting with heartburn to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Respect findings of previous endoscopy when patients have exacerbation of symptoms Investigate as appropriate: H pylori testing, endoscopy ra ft D oc State the indications for endoscopy as stated in national guidelines (e.g. NICE) Identify alarm symptoms indicating urgent endoscopy referral t Recall the lifestyle factors that contribute to dyspepsia Attitudes and Behaviour en Define dyspepsia and recall principle causes Skills um Knowledge Recall indications, contraindications and side effects of acid suppression and mucosal protective medications D Recall the role of H Pylori and its detection and treatment Define alarm symptoms of upper GI malignancy 95 46 - Dysuria The physician associate will be able to assess a patient presenting with dysuria to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills Initiate appropriate treatment if appropriate Participate in sexual health promotion Order, interpret and act on initial investigations Use microbiology resources in the management of patients with dysuria when appropriate ra ft D oc um Outline the pathophysiology of infective causes of urethritis Recognise the need for specialist genito-urinary input when appropriate t Elucidate the causes of dysuria in males and females Take a full history, including features pertaining to sexual heath en Recall anatomy of the genito-urinary tract Attitudes and Behaviour D Outline the principles of management 96 47 Genital Discharge and Ulceration The physician associate will be able to assess a patient presenting with genital discharge or ulceration to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Perform full examination including inguinal lymph nodes, scrotum, male urethra, rectal examination, speculum Recognise the reemergence of sexually transmitted diseases (STDs) Recognise the importance of contact tracing Promote safe sexual practices ra ft D oc Outline the investigations necessary: urinalysis; urethral smear and culture in men; high vaginal and endocervical swab in women, genital skin biopsy Take a full history that includes associated symptoms, sexual, menstrual and contraceptive history and details of previous STDs t List the disorders that can present with genital ulceration Attitudes and Behaviour en List the disorders that can present with genital discharge Skills um Knowledge Advocate the presence of a chaperone during assessment D Be able to pass a speculum competently and sensitively without discomfort to the patient 97 48 - Haematuria The physician associate will be able to assess a patient with haematuria to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Outline the causes of microscopic and macroscopic haematuria Involve renal unit when rapidly progressive glomerulonephritis is suspected Demonstrate when a patient needs urological assessment and investigation Order, interpret and act on initial investigations such as: urine culture, cytology and microscopy; blood tests D ra ft D oc Determine whether a glomerular cause is likely, and indications for a nephrology opinion Perform a focussed examination, including a rectal examination um Recall the anatomy of the urinary tract Attitudes and Behaviour t Skills en Knowledge 98 49 - Haemoptysis The physician associate will be able to assess a patient presenting with haemoptysis to produce valid differential diagnosis, investigate appropriately, formulate and implement a management plan Attitudes and Behaviour Perform a detailed history and physical examination to determine an appropriate differential diagnosis Describe initial treatment including fluids and oxygen management Order, interpret and act on initial investigations appropriately: routine bloods, clotting screen, chest radiograph and ECG, sputum tests Involve seniors and respiratory physicians as appropriate t Identify the common and life threatening causes of haemoptysis: bronchitis, pneumonia, PE and carcinoma en Skills um Knowledge D ra ft D oc Initiate treatment including indications for starting or withholding anticoagulants and antibiotics 99 50 - Head Injury The physician associate will able to assess a patient with traumatic head injury, stabilise, admit to hospital as necessary and liaise with appropriate colleagues, recognising local and national guidelines (e.g. NICE) Attitudes and Behaviour Instigate initial management: ABC, cervical spine protection Outline symptoms that may be present Assess and classify patient in terms of GCS and its derivative components (E,V,M) Ask for senior and anaesthetic support promptly in event of decreased consciousness Take a focused history and a full examination to elicit signs of head injury and focal neurological deficit Involve neurosurgical team promptly in event of CT scan showing structural lesion Manage short term complications, with senior assistance if required: seizures, airway compromise Recommend indications for repeat medical assessment in event of discharge of patient from hospital ra ft D oc Outline the indications for hospital admission following head injury Recognise advice provided by national guidelines on head injury (e.g. NICE) um Recall the pathophysiology of concussion t Skills en Knowledge Outline the indications for urgent head CT scan as per national guidelines (e.g. NICE) D Recall short term complications of head injury Advise nurses on appropriate frequency and nature of observations Participate in safe transfer procedures if referred too tertiary care 100 51 - Hoarseness and Stridor The physician associate will be able to assess a patient presenting with symptoms of upper airway pathology to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan (see also ‘wheeze’) Knowledge Skills Explain the mechanisms of hoarseness and stridor Differentiate hoarseness, stridor and wheeze Involve specialist team as appropriate: respiratory team, ENT or neurological team t Assess severity: cyanosis, respiratory rate and effort Involve senior and anaesthetic team promptly in event of significant airway compromise ra ft D oc um Perform full examination, eliciting signs that may co-exist with stridor or hoarseness e.g. bovine cough, Horner’s syndrome, other neurological signs, fever en List the common and serious causes for hoarseness and stridor Attitudes and Behaviour D Order, interpret and act on initial investigations appropriately: blood tests, blood gas analysis, chest radiograph, flow volume loops, FEV1/peak flow ratio 101 52 - Hypothermia The physician associate will be able to assess a patient presenting with hypothermia to establish the cause, investigate appropriately, formulate and implement a management plan Define hypothermia and its diagnosis Recognise seriousness of hypothermia and act promptly to re-warm Request appropriate monitoring of the patient Recognise that death can only usually be certified after re-warming D List complications of hypothermia Correct any predisposing factors leading to hypothermia Recognise the often multifactorial nature of hypothermia in the elderly and outline preventative approaches ra ft D oc List the causes of hypothermia Employ the emergency management of hypothermia as per ALS guidelines um Outline perturbations caused by hypothermia, including ECG and blood test interpretation Attitudes and Behaviour t Skills en Knowledge 102 53 - Immobility The physician associate will be able to assess a patient with immobility to produce a valid differential diagnosis, investigate appropriately, and produce a management plan Define the basic principles of rehabilitation Construct problem list following assessment Discuss the role of the multidisciplinary team in management of these patients Formulate appropriate management plan including medication, rehabilitation and goal setting. Recognise the importance of a multidisciplinary approach and specialist referral as appropriate Display ability to discuss plans with patients and or carers Recognise the anxiety and distress caused to patient and carers by underlying condition and admission to hospital ra ft D oc Describe the conditions causing immobility which may be improved by treatment and or rehabilitation Take appropriate and focussed collateral history from carers/family/GP t Explain the role of multidisciplinary team Attitudes and Behaviour en Describe the risk factors and causes of immobility Skills um Knowledge Identify conditions leading to acute presentation to hospital D Order, interpret and act on relevant initial investigations appropriately to elucidate a differential diagnosis 103 54 - Involuntary Movements The physician associate will be able to assess a patient presenting with involuntary movements to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills Attitudes and Behaviour Differentiate and outline the differential diagnoses of Parkinsonism and tremor: be aware of myoclonus, and other less common movement disorders Assess including a full neurological examination to produce a valid differential diagnosis Exhibit empathy when considering the impact on quality of life of patient and carers that movement disorders can have en t Recognise importance of multi-disciplinary approach to management um Outline the main drug groups used in the management of movement disorders D ra ft D oc Recognise the importance of specialist referral 104 55 - Joint Swelling The physician associate will be able to assess a patient presenting with joint pain or swelling to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Attitudes and Behaviour Outline the generic anatomy of the different types of joint Recognise the importance of history for clues as to diagnosis Recognise that monoarthritis calls for timely joint aspiration to rule out septic cause Differentiate mono-, oligo-, and polyarthritis and list principle causes for each Perform a competent physical examination of the musculo-skeletal system using both the GALS screening examination and the regional examination technique (REMS) D Outline treatment options for chronic arthritides: disease modifying drugs, analgesia, physiotherapy Recognise and facilitate the need for surgical intervention in septic arthritis en ra ft D oc Elucidate the importance of co-morbidities in the diagnosis of joint swelling t Skills um Knowledge Elicit and interpret extraarticular signs of joint disease Recognise importance of multi-disciplinary approach to joint disease: physio, OT, social services Order, interpret and act on initial investigations appropriately: blood tests, radiographs, joint aspiration, cultures Perform knee aspiration using aseptic technique causing minimal distress to patient Interpret plain radiographs of swollen joints Practise safe prescribing of analgesics for joint disease 105 56 - Lymphadenopathy The physician associate will be able to assess a patient presenting with lymphadenopathy to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Recall the causes of generalised and local lymphadenopathy in terms of infective, malignant, reactive and infiltrative Examine to elicit the signs of lymphadenopathy and associated diseases Recognise patient concerns regarding possible cause for lymphadenopathy Recognise the need for senior and specialist input Recognise the association of inguinal lymphadenopathy with STDs, assess and refer appropriately Order, interpret and act on initial investigations appropriately ra ft D oc Outline the investigations indicated when tuberculosis is considered Elicit associated symptoms and risk factors for the presence of diseases presenting with lymphadenopathy um Outline the anatomy and physiology of the lymphatic system Attitudes and Behaviour t Skills en Knowledge D Initiate treatment if appropriate 106 57 - Loin Pain The physician associate will be able to assess a patient presenting with loin pain to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Perform full examination to elicit signs of renal pathology Order, interpret and act on initial investigations appropriately: blood tests, urinalysis, urine culture and microscopy, radiographs, ultrasound Involve senior and renal team if there is associated renal impairment Involve urology team as appropriate Recognise local guidelines in prescribing antibiotics ra ft D oc Outline indications and contraindications for an urgent IVU Elucidate risk factors for causes of loin pain t Outline other symptoms that may classically accompany loin pain and renal colic Attitudes and Behaviour en List the common and serious causes of loin pain and renal colic Skills um Knowledge D Prescribe appropriate analgesia safely Commence appropriate antibiotics when infective cause is likely Recognise co-existing renal impairment promptly 107 58 Medical Complications During Acute Illness and Following Surgical Procedure The physician associate will be able to assess, investigate and treat medical problems arising post-operatively and during acute illness and recognise importance of preventative measures Assess patient with history and examination to form differential diagnosis Recognise importance of thrombo-embolic complications and prophylaxis during acute illness and in postoperative period Recognise the importance of measures to prevent complications: DVT prophylaxis, effective analgesia, nutrition, physiotherapy, gastric protection Initiate treatment when appropriate in consultation with the surgical team ra ft D oc Explain reasons for medical problems frequently presenting atypically postoperatively Recognise critically ill patient and instigate resuscitative measures um List common medical complications occurring in post-operative and unwell patients and how they present Attitudes and Behaviour t Skills en Knowledge Institute measures for thrombosis prophylaxis when appropriate, as per national or local guidelines Call for senior help when appropriate Respect opinion of referring surgical team D Recall investigations indicated in different scenarios: short of breath, chest pain, respiratory failure, drowsiness, febrile, collapse, GI bleed 108 59 - Medical Problems in Pregnancy The physician associate will be competent in the assessment, investigation and management of the common and serious medical complications of pregnancy Recognise the importance of thrombo-embolic complication of pregnancy Take a valid history from a pregnant patient Communicate with obstetric team throughout the diagnostic and management process Examine a pregnant patient competently Discuss case with senior promptly ra ft D oc Identify the unique challenges of diagnosing medical problems in pregnancy Recognise the critically ill pregnant patient, initiate resuscitation measures and liaise promptly with senior and obstetrician t List the common medical problems occurring in pregnancy Attitudes and Behaviour en Outline the normal physiological changes occurring during pregnancy Skills um Knowledge Recall safe prescribing practices in pregnancy Produce a valid list of differential diagnoses Seek timely gastroenterology opinion in cases of significant jaundice D Initiate treatment if appropriate 109 60 - Memory Loss (Progressive) The physician associate will be able to assess a patient with progressive memory loss to determine severity, differential diagnosis, investigate appropriately, and formulate management plan Skills Demonstrate a patient sensitive approach to interacting with a confused patient and their carers Perform a full examination looking for reversible causes of cognitive impairment and neurological disease Recognise that a change of environment in hospital can exacerbate symptoms and cause distress um List the principle causes of dementia Take an accurate collateral history wherever possible t Define the clinical features of dementia that differentiate from focal brain disease, reversible encephalopathies, and pseudo-dementia Attitudes and Behaviour en Knowledge Recommend support networks to carers ra ft D oc Demonstrate ability to use tools measuring cognitive impairment at the bedside Order, interpret and act on initial investigations appropriately to determine reversible cause such as: blood tests, cranial imaging, EEG D Recall factors that may exacerbate symptoms: drugs, infection, change of environment, biochemical abnormalities, constipation Detect and rectify exacerbating factors Participate in multidisciplinary approach to care: therapists, elderly care team, old age psychiatrists, social services Recognise need for specialist involvement and opportunities for treatment 110 61 - Micturition (Difficult) The physician associate will be able to assess a patient presenting with difficulty in micturition to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Skills Attitudes and Behaviour Outline causes of difficulty in micturating in terms of oliguria and urinary tract obstruction Examine to elicit signs of renal disease, bladder outflow obstruction and deduce volaemic status of patient Recognise the importance of recognising and preventing renal impairment in the context of bladder outflow obstruction en Liaise with senior in event of oliguria heralding incipient shock Order, interpret and act on initial investigations appropriately: urinalysis, abdominal ultrasound, bladder scanning, urine culture and microscopy Liaise promptly with appropriate team when oliguria from bladder outflow obstruction is suspected (urology, gynaecology) ra ft D oc Recall the investigation and management of prostatic cancer Differentiate oliguric prerenal failure; acute renal failure and post renal failure um Recall techniques that allow oliguria and bladder outflow obstruction to be differentiated t Knowledge D Initiate treatment when indicated Perform catheterisation using aseptic technique with minimal discomfort to patient Recognise incipient shock and commence initial treatment 111 62 - Neck Pain The physician associate will be able to assess a patient presenting with neck pain to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Outline the common and serious causes of neck pain in terms of meningism; tender mass; musculoskeletal; vascular Attitudes and Behaviour Take a full history, including recent trauma Consult senior colleague promptly in the event of focal neurological signs or critical illness Perform a full examination to elicit signs that may accompany neck pain ra ft D oc um Order, interpret and act on initial investigations appropriately: blood tests, plain radiographs, thyroid function t Skills en Knowledge D Recognise meningitis and promptly initiate appropriate investigations and treatment with consultation with senior Practise appropriate prescribing of analgesia 112 63 Physical Symptoms in Absence of Organic Disease The physician associate will be able to assess and appropriately investigate a patient to conclude that organic disease is unlikely, counsel sensitively, and formulate an appropriate management plan Knowledge Attitudes and Behaviour Adopt attitude that presentation has organic cause until otherwise proven, and assess and investigate as appropriate Perform full examination including mental state Consult senior promptly when appropriate en Strive to establish underlying precipitants to non-organic presentations: life stresses, hypochondriacal states ra ft D oc Recognise the hyperventilation syndrome t Take a full history, including associated symptoms of anxiety or depression and past medical assessments um List symptoms that commonly have a non-organic component Skills D Appreciate the implications of unnecessary tests in terms of cost and iatrogenic complications 113 64 - Polydipsia The physician associate will be able to assess a patient presenting with polydipsia to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Attitudes and Behaviour Understand mechanisms of thirst Identify other pertinent symptoms e.g. nocturia Identify common causes of polydipsia Order, interpret and act on initial investigations appropriately Use appropriate aseptic techniques for invasive procedures and to minimise healthcare acquired infection. D ra ft D oc um Initiate adequate initial therapy Sympathetically explain likely causes of polydipsia to patient t Skills en Knowledge 114 65 - Polyuria The physician associate will be able to assess a patient presenting with polyuria to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Consult senior colleague as appropriate Perform full examination to assess volaemic status, and elicit associated signs Order, interpret and act on initial investigations appropriately ra ft D oc Outline the pathophysiology of diabetes insipidus Identify other pertinent symptoms t Outline the causes of polyuria (in terms of osmotic, diabetes insipidus etc) Attitudes and Behaviour en Define true polyuria Skills um Knowledge Elucidate the principles of treating new onset diabetes mellitus, hypercalcaemia Calculate and interpret serum and urine osmolarity D Commence treatment as appropriate 115 66 - Pruritus The physician associate will be able to assess a patient presenting with itch to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills t Recognise the need for other specialists in pruritus heralding systemic disease Formulate a list of differential diagnoses Order, interpret and act on initial investigations appropriately ra ft D oc Outline the indications of and side effects of topical steroids and differentiate their different potencies Describe accurately any associated rash Recognise the need for specialist dermatological input en Outline the principles of treating skin conditions Examine to elicit signs of a cause for pruritus um Recall principle causes in terms of infestations, primary skin diseases, systemic diseases (e.g. lymphoma), liver disease, pregnancy Attitudes and Behaviour D Recognise the presentation of skin cancer 116 67 - Rectal Bleeding The physician associate will be able to assess a patient with rectal bleeding to identify significance differential diagnosis, investigate appropriately, formulate and implement a management plan Outline indications for surgical review Perform examination including rectal examination Liaise with senior and surgical team when appropriate Recognise and appropriately treat the shocked patient including consultation with surgical colleagues Recognise role of IBD nurse when patient with known IBD presents um Outline the treatments indicated in acute colitis Attitudes and Behaviour t Recall the causes of bleeding per rectum Skills en Knowledge ra ft D oc Order, interpret and act on initial investigations appropriately D Distinguish upper and lower GI bleeding 117 68 - Skin and Mouth Ulcers The physician associate will be able to assess a patient presenting with skin or mouth ulceration to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan (see also Dermatology in Section 2 for Skin Tumour competencies) Recognise life threatening skin rashes presenting with ulcers, commence treatment and involve senior Recognise the importance of prevention of pressure ulcers and diabetic ulcers Participate in multidisciplinary team: nurse specialists, podiatrist Assess and formulate immediate management plan for diabetic foot ulceration ra ft D oc Outline the pathophysiology, investigation and management principles of diabetic ulcers Recognise likely skin and oral malignancy t Outline the classification of skin ulcers by cause Attitudes and Behaviour en List the common and serious causes of skin (especially leg) or mouth ulceration Skills um Knowledge Order, interpret and act on initial investigations appropriately D Recognise association between mouth ulceration and immunobullous disease 118 69 - Speech Disturbance The physician associate will be able to assess a patient with speech disturbance to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Differentiate receptive and expressive dysphasia Recognise the role of speech and language therapy input Examine patient to define nature of speech disturbance and elicit other focal signs Recognise the relationship between dysarthria and swallowing difficulties and advise patients and carers accordingly List differential diagnoses following assessment Involve stroke team or neurology promptly as appropriate ra ft D oc List causes for dysphonia, dysarthria and dysphasia Take a history from a patient with speech disturbance t Recall the neuroanatomy relevant to speech and language Attitudes and Behaviour en Define dysphonia, dysarthria and dysphasia Skills um Knowledge D Order, interpret and act on initial investigations appropriately 119 70 - Suicidal Ideation The physician associate will be able to take a valid psychiatric history to elicit from a patient suicidal ideation and underlying psychiatric pathology; assess risk; and formulate appropriate management plan Attitudes and Behaviour Outline the risk factors for a suicidal attempt Take a competent psychiatric history Outline the common coexisting psychiatric pathologies that may precipitate suicidal ideation Be familiar with scoring tools to assess risk of further self harm (eg Beck’s score) um Elicit symptoms of major psychiatric disturbance Recognise the role of the Self Harm Team prior to discharge Ensure prompt communication is maintained with community care on discharge (GP, CPN) ra ft D oc Outline the indications, contraindications and side effects of the major groups of psychomotor medications Liaise promptly with psychiatric services if in doubt or when high risk of repeat self harm is suspected t Skills en Knowledge Recognise and manage appropriately anxiety and aggression D Outline the powers that enable assessment and treatment of patients following self harm or self harm ideation as defined in the Mental Health Act Obtain collateral history when possible 120 71 - Swallowing Difficulties The physician associate will be able to assess a patient with swallowing difficulties to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Differentiate between neurological and GI causes ra ft D oc Outline investigative options: contrast studies, endoscopy, manometry, CT Examine a patient to elicit signs of neurological disease, malignancy and connective tissue disease Recognise importance of multi-disciplinary approach to management t Recall the causes of swallowing problems Elicit valid history, detecting associations that indicate a cause: weight loss, aspiration, heartburn Attitudes and Behaviour en Outline the physiology of swallowing Skills um Knowledge Be able to evaluate whether patient is safe to eat or drink by mouth D Outline the pathophysiology, staging, and therapeutic options of oesophageal malignancy Define odynophagia and list causes 121 72 - Syncope & Pre-syncope The physician associate will be able to assess a patient presenting with syncope to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan (see also ‘ blackouts/collapse’) Take thorough history from patient and witness to elucidate episode Outline the pathophysiology of syncope depending on situation (vaso-vagal, cough, effort, micturition, carotid sinus hypersensitivity) Assess patient in terms of ABC and degree of consciousness and manage appropriately Recognise recommendations regarding fitness to drive in relation to syncope Recognise and act upon criteria for referral for carotid sinus hypersensitivity studies. ra ft D oc Differentiate from other causes of collapse in terms of associated symptoms and signs, and eye witness reports Differentiate pre-syncope from other causes of ‘dizziness’ Recognise impact episodes can have on lifestyle particularly in the elderly um Define syncope Attitudes and Behaviour t Skills en Knowledge Order, interpret and act on initial investigations appropriately: blood tests ECG D Outline the indications for cardiac monitoring Perform examination to elicit signs of cardiovascular disease 122 73 Unsteadiness / Balance Disturbance The physician associate will be able to assess a patient presenting with unsteadiness or a disturbance of balance to produce a valid list of differential diagnoses, investigate appropriately, formulate and implement a management plan Skills Attitudes and Behaviour Outline the neuroanatomy and physiology relevant to balance, coordination and movement Take history from patient and attempt to define complaint as either presyncope, vertigo or unsteadiness Recognise the importance of multi-disciplinary approach: physio, OT Define and differentiate types of vertigo and list causes Perform full physical examination to elicit signs of neurological, inner ear or cardiovascular disease including orthostatic hypotension en um Describe an abnormal gait accurately ra ft D oc Define and differentiate sensory and cerebellar ataxia and list causes t Knowledge D Recognise intoxication Initiate basic investigations and urgent treatment with vitamins when appropriate 123 74 Visual Disturbance (diplopia, visual field deficit, reduced acuity) The Physician Associate should be able to assess the patient presenting with a visual disturbance to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan Knowledge Skills Attitudes and Behaviour Broadly outline the basic anatomy and physiology of the eye and the visual pathways Perform full examination including acuity, eye movements, visual fields, fundoscopy, related cranial nerves and structures of head & neck In case of acute visual loss recognise early requirement for review by Ophthalmology team t en Formulate differential diagnosis Order, interpret and act on initial investigations appropriately Recognise anxiety acute visual symptoms invoke in patients ra ft D oc Define diplopia and list common causes Recognise rapidly progressive symptoms and consult senior promptly um Define the different types of visual field defect and list common causes D List common causes for reduced visual acuity 124 75 - Weight Loss The physician associate will be able to assess a patient presenting with unintentional weight loss to produce a valid differential diagnosis, investigate appropriately, formulate and implement a management plan List the common causes for weight loss (in terms of psychosocial, neoplasia, gastroenterological etc) Take a valid history highlighting any risk factors for specific disorders presenting with weight loss, and a thorough social history Examine fully to elucidate signs of disorders presenting with weight loss, and also assess degree of malnutrition Recognise multi-factorial aspect of weight loss, especially in the elderly Recognise prominence of psychosocial factors, with collateral history where possible Liaise with nutritional services appropriately um Outline the indications and complications for nutritional supplements, and enteral feeding including PEG/NG feeding Attitudes and Behaviour t Skills en Knowledge ra ft D oc Order, interpret and act on initial screening investigations D Initiate nutritional measures including enteral preparations when appropriate Pass a fine bore NG feeding tube and ensure correct positioning 125 126 ra D ft t um en oc D Core Clinical and Procedural Skills which the Newly Qualified Physician Associate should be able to undertake safely and competently. t Intermediate Life Support (ILS) Measure Blood Pressure- Adult Measure Blood Pressure-Child Venepuncture IV cannulation Arterial Blood Gas Sampling Urethral Catheterisation-Male Urethral Catheterisation-Female Perform and Interpret and Electrocardiogram (ECG) Perform and Interpret Peak Flow Complete a Paediatric Growth Chart Perform and Interpret Urine Dip-stick Analysis Principles of Manual Handling Blood cultures um en 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: Although Unable to Undertake the Following Procedures Within the NHS at the Present Time the Newly Qualified PA should also know how to perform the following: D ra ft D oc Injection –IV Injection- IM Injection –SC (Insulin, LMW Heparin) Prepare and administer IV medications and fluids Safely administer blood and blood products Oxygen Administration Airways Care including simple adjuncts (Guedal airway) 127 29
