CSA Revision Notes for the MRCGP, fourth edition

Jennifer Stannett, Sarah Osmond

• Publisher: Scion Publishing
• Year: 2020
• Print ISBN: 9781911510574
• eBook ISBN: 9781911510604
• Edition: 4
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

CSA Revision Notes for the MRCGP is the ideal book to help you to revise and prepare for the CSA part of the MRCGP exam.

The latest edition features new material on:

• Constipation in adults
• Cough
• Dupuytren's contracture
• Eating disorders
• Frailty assessment
• Gender dysphoria
• Gout
• Inguinal hernia
• Prediabetes
• Starting HRT
• Varicose veins
• Visual loss

A standardised format is used throughout to help you to improve your:

• data gathering – a broad range of appropriate questions to ask the patient are provided and red flags are highlighted where appropriate
• interpersonal skills – each clinical problem is described using terms that you can use in your explanations to patients
• clinical management – tells you which examinations to consider, which investigations to order, and how to manage each clinical problem based on the latest guidelines and current best practice
• consultations – to help you practise, every clinical case features a realistic role play scenario.

Appendix 1

Clinical examinations

Focused cardiovascular examination

• Expose the patient appropriately (ask permission first).

• Position the patient correctly (ideally at 45°).

• Inspection – pallor, cyanosis, scars, oedema, clubbing, JVP.

• Palpation – pulses (rate, rhythm), BP, apex beat, heaves, thrills.

• Auscultation – apex and carotid area (more detailed auscultation required if murmur heard). Listen to lung bases.

Focused respiratory examination

• Expose the patient appropriately (ask permission first).

• Position the patient at 45° ideally.

• Inspection – check hands for clubbing and peripheral cyanosis. Check tongue for pallor/cyanosis. Check respiratory rate and check chest for scars.

• Palpation – check for position of trachea and chest expansion. Check for cervical lymphadenopathy.

• Percussion – front and back of chest ideally.

• Auscultation – listen at front and back.

Focused gastrointestinal examination

• Expose the patient appropriately (ask permission first).

• Lie the patient flat if possible, with arms to the side.

• Inspection – check for jaundice, pallor, spider naevi or gynaecomastia. Check hands for clubbing, cyanosis, palmar erythema or Dupuytren’s contracture. Check abdomen for distended veins or masses.

• Palpation – check for cervical lymphadenopathy. Palpate each area of the abdomen then palpate liver, spleen, kidneys and bladder (or focus depending on history).

• Percussion – liver, spleen and for shifting dullness if relevant.

• Auscultation – check for presence and quality of bowel sounds.

Neurological examination

Cranial nerves

I	Olfactory	Have you noticed any change in your sense of smell or taste?
II	Optic	Any problems with your vision? If so, check visual acuity with Snellen chart. Also check visual fields. Fundoscopy.
III	Oculomotor	Accommodation, visual movements, direct/consensual light reflex.
IV	Trochlear	As for oculomotor tests.
V	Trigeminal	Check sensation on both sides of the face and compare (branches of trigeminal nerve).
VI	Abducens	Same as oculomotor and trochlear tests.
VII	Facial	Raise eyebrows, clench teeth, blow cheeks out, close eyes tightly and stop me from opening them.
VIII	Vestibulo-cochlear	Check gross hearing by whispering in each ear. If any concerns with hearing perform Rinne’s and Weber’s tests.
IX	Glosso-pharyngeal	Taste sensation as above.
X	Vagal	Say ‘aaaagghh’ (look for deviation of the uvula).
XI	Accessory	Please can you shrug your shoulders? Check power in sternocleidomastoid muscles by moving neck side to side against resistance.
XII	Hypoglossal	Can you stick your tongue out? (check for deviation, atrophy and fasciculations).

Whispered speech test

• To make a basic assessment of a patient’s hearing, you need to mask the non-test ear by blocking it with your finger, and then ask them to repeat random numbers that you speak into the test ear.

• You can start with a whisper, and if they are unable to hear this then increase the volume in incremental steps.

Rinne’s test

• Strike a 512 Hz tuning fork and place the fork behind the ear, firmly on the mastoid process.

• Then hold the vibrating fork a few inches away in front of the ear.

• In a normal ear, the patient should hear the tuning fork louder in front of the ear than behind.

• If a patient has a conductive hearing loss, they will hear the bone conduction behind the ear louder than the air conduction.

Weber’s test

• Strike a 512 Hz tuning fork and place the base of the fork on the patient’s forehead.

• A patient with normal hearing should hear the sound equally on both sides.

• If a patient has unilateral conductive hearing loss, the sound will localise to the affected ear.

• If a patient has unilateral sensorineural loss, the sound will localise to the opposite ear.

Thyroid examination

• Hands – check pulse, check for tremor.

• Eyes – check for exophthalmos and lid lag.

• Neck – inspect, check swallowing and tongue protrusion, palpate neck for mass, percuss neck swelling, auscultate for bruits.

• Check reflexes.

Shoulder examination

• Expose both shoulders (ask permission first).

• Look – from front, side and rear inspecting for scars, erythema, muscle wasting, asymmetry, swelling and any deformity of the shoulder joint.

• Feel – check temperature, palpate bony landmarks, joint line and surrounding muscles for any tenderness, crepitus or effusions.

• Move – check active/passive movements of abduction/adduction, flexion/ extension, internal/external rotation.

• Function – arms behind head and scratching back.

• Cross arm test – ask the patient to place their hand on their opposite shoulder. If gentle pressure on the joint elicits pain, this is indicative of acromioclavicular joint inflammation.

• Drop arm test – passively abduct the patient’s shoulder. Then ask the patient to lower the abducted arm slowly to the waist. A rotator cuff tear can be identified if the arm drops ...

Table of contents

• Front Cover
• Title Page
• Copyright Page
• Contents
• Preface to the fourth edition
• About the authors
• Acknowledgements
• Preface to the first edition
• Abbreviations
• Introduction to the CSA examination
• General practice consultation
• Healthy people: promoting health and preventing disease
• Genetics in primary care
• Care of acutely ill people
• Child health
• Care of older adults
• Women’s health
• Men’s health
• Sexual health and family planning
• Care and palliative care of people with cancer
• Mental health
• Cardiovascular
• Respiratory
• Gastrointestinal and renal
• ENT
• Ophthalmology
• Neurology
• Rheumatology and musculoskeletal
• Dermatology
• Endocrinology
• Drug and alcohol problems
• Appendix 1 – Clinical examinations
• Appendix 2 – Sexual history taking
• Appendix 3 – Mental state examination
• Appendix 4 – Driving and DVLA guidelines
• Appendix 5 – When to suspect child maltreatment
• Appendix 6 – Discussion following myocardial infarction
• Appendix 7 – Domestic violence
• Back Cover