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CLINICAL MEDICINE B r a d Lecture Notes 7th Edition le y , Reviews of the previous edition G u ‘...this book tackles the vast subject that is clinical medicine in a matter of fact, easy to learn way. It does r exactly what it says on the tin: a no-nonsense overview of clinical medicine, perfect in the run up to finals.’ ne CLINICAL MEDICINE Oxford Medical School Gazette ll & W ‘This book more than lives up to the other popular books in the same Lecture Notes series with its clear, o concise, no-nonsense format [...] ideal for revision.’ o Lecture Notes d North Wing, Sheffield Medics Magazine Clinical Medicine Lecture Notes provides a comprehensive, accessible introduction to the L management and treatment of medical conditions. A short manual of techniques on communication e c and physical examination in Part 1 is supported by the core knowledge required on diseases specific t u to each body system in Part 2. r e Combining readability with high quality illustrations, this seventh edition has been thoroughly revised N to reflect up-to-date practice in examination and clinical investigation, and advances in the evidence o base supporting modern day clinical practice. Numerous figures and tables help distil the information t e for revision purposes, and there are new chapters on the medical interview and assessment. s Whether you need to develop your knowledge for clinical practice, or refresh that knowledge in C LN the run up to examinations, Clinical Medicine Lecture Notes will help foster a systematic approach John Bradley L to the clinical situation for all medical students and hospital doctors. I N Mark Gurnell For information on all the titles in the Lecture Notes series, please visit: I C Diana Wood www.lecturenoteseries.com A L M 7th Edition Titles of related interest All content reviewed by students for students E Medicine at a Glance, Third Edition D Patrick Davey 2010 Wiley-Blackwell Medical Education books 9781405186162 are designed exactly for their intended IC Medicine at a Glance: Core Cases audience. All of our books are developed in I N Patrick Davey 2010 collaboration with students. This means that 9781444335118 our books are always published with you, E the student, in mind. The Hands-on Guide for Junior Doctors, Fourth Edition Anna Donald, Mike Stein and Ciaran Hill 2011 If you would like to be one 7 9781444334661 of our student reviewers, go to th www.reviewmedicalbooks.com E For more information on the complete range of Wiley-Blackwell to find out more. d medical student and junior doctor publishing, please visit: itio www.wileymedicaleducation.com n To receive automatic updates on Wiley-Blackwell books and journals, join our email list. Sign up today at www.wiley.com/email ISBN 978-1-4051-5714-8 9 781405 157148 www.wiley.com/go/medicine Clinical Medicine Lecture Notes John Bradley MA,DM,FRCP ConsultantPhysician Addenbrooke’sHospital Cambridge Mark Gurnell MA(MedEd),PhD,FRCP Associate Clinical Dean, University Lecturer and Honorary Consultant Physician UniversityofCambridge SchoolofClinicalMedicine Addenbrooke’sHospital Cambridge Diana Wood MA,MD,FRCP DirectorofMedicalEducation,ClinicalDeanandHonoraryConsultant Physician UniversityofCambridge SchoolofClinicalMedicine Addenbrooke’sHospital Cambridge Seventh Edition Thiseditionfirstpublished2012,(cid:1)2012byJohnBradley,MarkGurnell,DianaWood,DavidRubensteinandDavidWayne Previouseditions:1976,1980,1985,1991,1997,2003 BlackwellPublishingwasacquiredbyJohnWiley&SonsinFebruary2007.Blackwell’spublishingprogrammehasbeen mergedwithWiley’sglobalScientific,TechnicalandMedicalbusinesstoformWiley-Blackwell. Registeredoffice:JohnWiley&SonsLtd,TheAtrium,SouthernGate,Chichester,WestSussex,PO198SQ,UK Editorialoffices: 9600GarsingtonRoad,Oxford,OX42DQ,UK TheAtrium,SouthernGate,Chichester,WestSussex,PO198SQ,UK 111RiverStreet,Hoboken,NJ07030-5774,USA Fordetailsofourglobaleditorialoffices,forcustomerservicesandforinformationabouthowtoapplyforpermissionto reuse the copyrigh t material in this book please see our website at www.wil ey.com/wiley -blackwell TherightoftheauthortobeidentifiedastheauthorofthisworkhasbeenassertedinaccordancewiththeCopyright, DesignsandPatentsAct1988. Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,ortransmitted,inany formorbyanymeans,electronic,mechanical,photocopying,recordingorotherwise,exceptaspermittedbythe UKCopyright,DesignsandPatentsAct1988,withoutthepriorpermissionofthepublisher. Wileyalsopublishesitsbooksinavarietyofelectronicformats.Somecontentthatappearsinprintmaynotbe availableinelectronicbooks. Designationsusedbycompaniestodistinguishtheirproductsareoftenclaimedastrademarks.Allbrandnamesand productnamesusedinthisbookaretradenames,servicemarks,trademarksorregisteredtrademarksoftheirrespective owners.Thepublisherisnotassociatedwithanyproductorvendormentionedinthisbook.Thispublicationis designedtoprovideaccurateandauthoritativeinformationinregardtothesubjectmattercovered.Itissoldonthe understandingthatthepublisherisnotengagedinrenderingprofessionalservices.Ifprofessionaladviceorotherexpert assistanceisrequired,theservicesofacompetentprofessionalshouldbesought. LibraryofCongressCataloging-in-PublicationData Bradley,John,MRCP. Lecturenotes.Clinicalmedicine/JohnBradley,MarkGurnell,DianaWood.- -7thed. p.;cm. Clinicalmedicine Rev.ed.of:Lecturenotesonclinicalmedicine/DavidRubenstein,David Wayne,JohnBradley.6thed.2003. Includesindex. ISBN978-1-4051-5714-8(pbk.:alk.paper) I.Gurnell,M. II. Wood,Diana. III. Rubenstein,David.Lecturenoteson clinicalmedicine. IV. Title. V. Title:Clinicalmedicine. [DNLM: 1. ClinicalMedicine–Handbooks. WB39] 616–dc23 2011042644 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Coverimage:DanaNeely/Corbis Coverdesign:GroundedDesign Setin8/10ptUtopiabyThomsonDigital,Noida,India 1 2012 Contents PrefacetotheSeventhEdition iv Part 2 Clinical Medicine PrefacetotheFirstEdition v 10 Cardiovasculardisease 73 11 Respiratorydisease 110 Part 1 Clinical Examination 12 Gastroenterology 128 1 Themedicalinterview 1 13 Liverdisease 144 2 Generalexamination 7 14 Renaldisease 153 3 Cardiovascularsystem 10 15 Neurology 171 4 Respiratorysystem 19 16 Endocrinedisorders 208 5 Theabdomen 28 17 Metabolicdisorders 229 6 Neurologicalsystem 39 18 Rheumatology 269 7 Endocrinologyandmetabolism 57 19 Dermatology 297 8 Musculoskeletalsystem 62 20 Haematology 321 9 Assessment 66 21 Infectiousdiseases 336 22 Toxicology 351 SIUnitsconversiontable 361 Index 362 Theplatesectioncanbefoundfacingpage 314 Preface to the Seventh Edition History-takingandexaminationremaintheessential practiceofclinicalmedicine.Pleasecontinuetoletus toolsofclinicalmedicine.However,theenvironment haveyourviews. inwhichmedicineispractisedhaschangedsincethe firsteditionof LectureNotesinClinicalMedicinein JohnBradley 1975. The seventh edition follows the format of MarkGurnell previous editions of this book with two sections: DianaWood Clinical Examination and Clinical Medicine. Each section has been updated to reflect the increased Acknowledgements evidence upon which clinical practice is based and the more objective methods of assessment that are We would like to thank Dr Ellie Gurnell, Dr Mark nowused. LillicrapandDrNarayananKandasamyfortheircon- Itisrewardingtodiscoverhowmanyreadershave tributions,helpandadviceduringthepreparationof foundthetextusefulforstudy,forrevisionandforthe themanuscript. Preface to the First Edition Thisbookisintendedprimarilyforthejuniorhospital working knowledge in a clinical situation. It should doctor in the period between qualification and the notbeforgottenthatsomerarediseasesareofgreat examination for Membership of the Royal Colleges importanceinpracticebecausetheyaretreatableor ofPhysicians.Wethinkthatitwillalsobehelpfulto preventable,e.g.infectiveendocarditis,hepatolenti- final-yearmedicalstudentsandtocliniciansreading culardegeneration,attacksofacuteporphyria.Some for higher specialist qualifications in surgery and conditionsareimportanttoexaminationcandidates anaesthetics. becausepatientsareambulantandappearcommonly Thehospitaldoctormustnotonlyacquirealarge in examinations, e.g. neurosyphilis, syringomyelia, amountoffactualinformationbutalsouseiteffect- atrialandventricularseptaldefects. ivelyin the clinical situation. The experiencedphy- We have not attempted to cover the whole of sicianhasacquiredsomeclinicalperspectivethrough medicine,butbycross-referencingbetweenthetwo practice:wehopethatthisbookimpartssomeofthis sectionsofthebookandgivinginformationinsum- totherelativelyinexperienced.Theformatandcon- maryformwehavecompletelyomittedfewsubjects. tentsaredesignedfortheexaminationcandidatebut Somehighlyspecialisedfieldssuchasthetreatmentof thesameapproachtoproblemsshouldhelpthehos- leukaemiawerethoughtunsuitableforinclusion. pitaldoctorinhiseverydaywork. Ashortaccountofpsychiatryisgiveninthesection Thebookasawholeisnotsuitableasafirstreader onneurologysincemanypatientswithmentalillness fortheundergraduatebecauseitassumesmuchbasic attendgeneralclinicsanditishopedthatreadersmaybe knowledgeandconsiderabledetailedinformationhas warnedof gapsintheirknowledge of thisimportant hadtobeomitted.Itisnotintendedtobeacomplete field. The section on dermatology is incomplete but textbookofmedicineandtheinformationitcontains should serve for quick revision of common skin mustbesupplementedbyfurtherreading.Thecon- disorders. tentsareintendedonlyaslecturenotesandthemar- Wherever possible we have tried to indicate the gins of the pages are intentionally large so that the relativefrequencywithwhichvariousconditionsare readermayeasilyaddadditionalmaterialofhisown. likelytobeseeninhospitalpracticeinthiscountryand The book is divided into two parts: the clinical haveselectedthoseclinicalfeatureswhichinourview approach and essential background information. In are most commonly seen and where possible have thefirstpartwehaveconsideredthesituationwhicha listed them in order of importance. The frequency candidatemeetsintheclinicalpartofanexamination withwhichadiseaseisencounteredbyanyindividual oraphysicianintheclinic.Thispartofthebookthus physician will depend upon its prevalence in the resemblesamanualontechniquesofphysicalexam- districtfromwhichhiscasesaredrawnandalsoon ination,thoughitismorespecificallyintendedtohelp hisknownspecialinterests.Nevertheless,rarecondi- the candidate carry out an examiner’s request to tions are rarely seen; at least in the clinic. Examin- performaspecificexamination.Ithasbeenourex- ations,however,area‘specialcase’. perienceinlisteningtocandidates’performancesin Wehaveusedmanygenerallyacceptedabbrevi- examinationsandhearingtheexaminer’ssubsequent ations,e.g.ECG,ESR,andhaveincludedtheminthe assessment that it is the failure of a candidate to indexinsteadofsupplyingaglossary. examinecasessystematicallyandhisfailuretobehave Despiteourbestefforts,someerrorsoffactmay asifhewereusedtodoingthiseverydayofhisclinical havebeenincluded.Aswitheverybookandauthority, lifethatleadstoadversecomments. questionandcheckeverything–andpleasewritetous Inthesecondpartofthebookasummaryofbasic ifyouwish. clinicalfactsisgivenintheconventionalway.Wehave We should like to thank all those who helped includedmostcommondiseasesbutnotall,andwe us with producing this book and, in particular, have tried to emphasise points which are under- Sir Edward Wayne and Sir Graham Bull who have stressed in many textbooks. Accounts are given of kindly allowed us to benefit from their extensive manyconditionswhicharerelativelyrare.Itisneces- experience both in medicine and in examining for saryforthecliniciantoknowabouttheseandtobeon theCollegesofPhysicians. thelookoutforthembothintheclinicandinexam- inations. Supplementary reading is essential to un- derstandtheirbasicpathology,buttheinformationwe DavidRubenstein give is probably all that need be remembered by DavidWayne the non-specialist readerand willprovide adequate November1975 1 The medical interview Good communication between doctor and patient forms the basis for excellent patient care and the Effective consultation clinicalconsultationliesattheheartofmedicalprac- tice. Good communication skills encompass more Effective consultations are patient-centred and effi- thanthepersonalitytraitsofindividualdoctors–they cient,takingplacewithinthetimeandotherpractical formanessentialcorecompetenceformedicalpracti- constraints that exist in everyday medical practice. tioners.Inessence,goodcommunicationskillspro- Theuseofspecificcommunicationskillstogetherwith ducemoreeffectiveconsultationsand,togetherwith a structured approach to the medicalinterviewcan medicalknowledgeandphysicalexaminationskills, enhance this process. Important communication lead to better diagnostic reasoning and therapeutic skillscanbeconsideredinthreecategories:content, intervention.Theterm‘communicationskills’,when process and perceptual skills (see Table 1.1); these appliedtomedicalpractice,describesasetofspecific mirror the essential knowledge, skills and attitudes skillsthatcanbetaught,learnedandassessed.Alarge required for good medical practice. These skills are evidence-base shows that health outcomes for pa- closely interrelated so that, for example, effective tientsandbothpatientanddoctorsatisfactionwithin use of process skills can improve the accuracy of the therapeutic relationship are enhanced by good informationgatheredfromthepatient,thusenhan- communicationskills. cing the content skills used subsequently in the Inthischapterthemedicalinterviewasawhole consultation. willbeconsideredandthenthewayinwhichcom- municationskillsshouldbeapproachedindifferent Structure types of assessment encountered by students and traineesreviewed. Providingstructuretotheconsultationisoneofthe There are a number of different models for most important features of effective consultation. learning communication skills in use throughout Processskillsshouldbeusedtodevelopastructure the world. They are generally similar and all em- thatisresponsivetothepatientandflexiblefordif- phasise the importance of patient-centred inter- ferentconsultations.Sixgroupsofskillscanbeiden- view methods. This chapter is based on the tifiedandeachwillbeconsideredbelow. Calgary–Cambridgemodel(Fig.1.1)whichhasbeen Sequentialintheconsultation: widely adopted in Europe and the USA and with whichtheauthorsarefamiliarasameansofteaching . initiatingthesession and learning and as a framework for assessment . gathering information (including from physical (Silvermanetal.2005).Likeallclinicalskills,com- examination) municationskillscanonlybeacquiredbyexperien- . explanationandplanning tiallearning.Thismaytaketheformofsmallgroup . closingthesession learningwithroleplay,theuseofactorsinsimulated Throughouttheconsultation: learningenvironmentsor,formoreexperiencedlear- ners,inrecordedrealconsultationswithsubsequent . organisation feedback. . relationshipbuilding ClinicalMedicineLectureNotes,SeventhEdition.JohnBradley,MarkGurnellandDianaWood. (cid:1)2012JohnBradley,MarkGurnell,DianaWood,DavidRubensteinandDavidWayne.Published2012byBlackwellPublishingLtd. 2 Themedicalinterview Initiating the session (cid:129) Preparation Providing (cid:129) Establishing initial rapport Building the structure (cid:129) Identifying the reasons for the consultation relationship (cid:129) Make Gathering information (cid:129) Using organisation appropriate overt (cid:129) Exploration of the patient’s problems to discover the: non-verbal (cid:129) Attending behaviour to flow Biomedical perspective Patient’s perspective (cid:129) Developing rapport Background information – context (cid:129) Involving the patient Physical examination Explanation and planning (cid:129) Providing the correct type and amount of information (cid:129) Aiding accurate recall and understanding (cid:129) Achieving a shared understanding: incorporating the patient’s illness framework (cid:129) Planning: shared decision-making Closing the session (cid:129) Ensuring appropriate point of closure (cid:129) Forward planning Figure1.1 TheCalgary–CambridgeGuide.FromKurtz,S.,etal.(2005)TeachingandLearningCommunication SkillsinMedicine,2ndedn.RadcliffePublishing,Oxford. Table1.1 Categoriesofcommunicationskills Skill Examples Contentskills Whatthedoctorcommunicates Knowledge-based:appropriatequestionsandresponses;accurate informationgatheringandexplanationtopatient;cleardiscussionof investigationandtreatmentsbasedonknowledge Processskills Howthedoctorcommunicates Skills-based:verbalandnon-verbalcommunicationskills;relationship building;organisingandstructuringtheinterview Perceptualskills Whatthedoctoristhinking Attitude-based:clinicalreasoningandproblem-solvingskills;attitudes towardsthepatient;feelingsandthoughtsaboutthepatient;awarenessof internalbiases Initiating the session therestoftheinterview.Beforemeetingapatient,the doctor should prepare by focusing him- or herself, Theinitialpartofaconsultationisessentialtoformthe tryingtoavoiddistractionsandreviewinganyavailable basisforrelationshipbuildingandtosetobjectivesfor informationsuchaspreviousnotesorreferralletters. 3 Themedicalinterview Initiatingthesession Physicalexamination Establishrapport:greetthepatient,confirmtheir Askpermission:gainthepatient'sconsentfor name,introduceyourselfandexplainyourrole, examination. attendtothepatient'scomfort. Ensurethatthepatientiscomfortable:position Identifythereasonfortheconsultation:usean themadequatelyfortheexamination;ifdoingafull appropriateopeningquestion,listentothepatient, examination,coverpartsofthebodynotbeing confirmtheproblemandscreenforanyother examinedactively. issuesthatthepatientmaywishtodiscuss. Beclearandprecise:explainwhatyouaregoingto Confirmanagendafortheconsultation. doinadvance. Beaware:thepatientmaybeembarrassedorin pain. Gathering information Anaccurateclinicalhistoryprovidesabout80%ofthe Explanation and planning informationrequiredtomakeadiagnosis.Tradition- ally,history-takingfocusedonquestionsrelatedtothe Explanationandplanningiscruciallyimportanttothe biomedicalaspectsofthepatient’sproblems.Recent effective consultation. Establishment of a manage- evidencesuggeststhatbetteroutcomesareobtainedby mentplanjointlybetweenthedoctorandthepatient includingthepatient’sperspectiveoftheirillnessand hasimportantpositiveeffectsonpatientrecall,un- bytakingthisintoaccountinsubsequentpartsofthe derstanding of their condition, adherence to treat- consultation.Theobjectivesforgatheringinformation ment and overall satisfaction. Patient expectations should therefore include exploring the history from havechangedandmanywishtobemoreinvolvedin boththebiomedicalandpatientperspectives,checking decision-making about investigation and treatment thattheinformationgatherediscompleteandensuring options.Thegoalsofthispartoftheconsultationare thatthepatientfeelsthatthedoctorislisteningtothem. Explanationandplanning Gatheringinformation Avoidjargon:useclearconciselanguage;explain Askthepatienttotelltheirownstory. anymedicalterminology. Listenattentively:donotinterrupt;leavethepa- Findoutwhatthepatientknows:establishprior tienttimeandspacetothinkaboutwhattheyare knowledge;findouthowmuchtheywishtoknow saying. atthisstage. Useopenandclosedquestions:clarifyissuesin ‘Chunkandcheck’:provideinformationinsmall thehistory;useclear,conciseandeasilyunder- amountsandcheckunderstanding;usethisto stoodquestions;movefromopentoclosed assesshowtoproceed. questionsthenbackagain. Organiseexplanation:developalogicalsequence; Useverbalandnon-verbalfacilitation:silences, categoriseinformation;repeatandsummarise; repetition,paraphrasing. signpostwhatiscomingnext;usediagramsor Pickuponpatient'sverbalandnon-verbalclues: charts,writteninformationorinstructions. acknowledgethembychecking. Relatetheinformationtothepatient'sperspective. Summariseatintervals:verifyyourunderstanding; Respondtopatient'scues:verbalandnon-verbal; allowthepatienttocorrectoraddtothehistory. allowpatienttoaskquestionsorclarifyinformation. Encouragethepatienttoexpresstheirfeelings: Involvethepatient:sharethoughts;revealrationale activelyseektheirideas,concernsandexpectations. foropinions;offeryouropinionofwhatisgoingon andnameitwherepossible;exploremanagement options;takethepatient'slifestyleandcultural Furtherinformationisgatheredfromthephysical backgroundintoaccountinthediscussion. examination.Establishmentofagoodrapportduring thefirstpartoftheconsultationwillfacilitatecom- Negotiateamutuallyagreeableactionplan:check municationduringtheexamination.Anappropriate thatthismeetsthepatient'sexpectationsand chaperone should be present during the physical addressestheirconcerns. examination.