Oxford handbook of clinical medicine

923 Pages·2017·24.74 MB·English

by  Ian Boden

Index to emergency topics
‘Don’t go so fast: we’re in a hurry!’—Talleyrand to his coachman.
Abdominal aortic aneurysm 656 Intracranial pressure, raised 840
Acute abdomen 608 Ketoacidosis, diabetic 842
Acute kidney injury (acute renal failure) 848 Lassa fever 388
Addisonian crisis 846 Left ventricular failure 812
Anaphylaxis 806 Major disaster 862
Aneurysm, abdominal aortic 656 Malaria 394
Antidotes, poisoning 854 Malignant hyperpyrexia 574
Arrhythmias, broad complex 122, 816 Malignant hypertension 134
narrow complex 120, 818 Meningitis 832
see also back inside cover Meningococcaemia 832
Asthma 820 Myocardial infarction 808
Asystole back inside cover Needle pericardiocentesis 787
Bacterial shock 804 Neutropenic sepsis 346
Blast injury 862 Obstructive uropathy 645
Bleeding, aneurysm 656 Oncological emergencies 526
extradural/intracranial 482, 486 Opiate poisoning 854
gastrointestinal 252, 830 Overdose 850–7
rectal 631 Pacemaker, temporary 790
variceal 254, 830 Pericardiocentesis 787
Blood loss 804 Phaeochromocytoma 846
Blue patient 178–81 Pneumonia 826
Bradycardia 118 Pneumothorax 824
Burns 858 Poisoning 850–7
Cardiac arrest back inside cover Potassium, hyperkalaemia 688, 849
Cardiogenic shock/tamponade 814 hypokalaemia 688
Cardioversion, DC 784 Pulmonary embolism 828
Cauda equina compression 470, 545 Pulseless, altogether back inside cover
Central line insertion (CVP line) 788 in a leg 658
Cerebral malaria 397 Respiratory arrest back inside cover
Cerebral oedema 840 Respiratory failure 180
Chest drain 780 Resuscitation back inside cover
Coma 800 Rheumatological emergencies 540
Cord compression 470, 545 Shock 804
Cranial arteritis 558 Smoke inhalation 859
Cricothyrotomy 786 Sodium, hypernatraemia 686
Cyanosis 178–81 hyponatraemia 686
Cut-down 775 Spinal cord compression 470, 545
Defi brillation 784, back inside cover Status asthmaticus 820
Diabetes emergencies 842–4 Status epilepticus 836
Disseminated intravascular coagulopathy Superior vena cava obstruction 526
(DIC) 346 Supraventricular tachycardia (SVT) 818
Disaster, major 862 Tachycardia, ventricular 122, 816
Dissecting aneurysm 656 Thrombolysis, myocardial infarct 808
Embolism, leg 658 stroke 475
pulmonary 828 Thrombotic thrombocytopenic purpura
Encephalitis 834 (TTP) 308
Endotoxic shock 804 Thyroid storm 844
Epilepsy, status 836 Torted testis 654
Extradural haemorrhage 486 Transfusion reaction 343
Fits, unending 836 Varices, bleeding 254, 830
Fluids, IV 680, 804 Vasculitis, acute systemic 558
Haematemesis 252–5 Ventricular arrhythmias 122, 816
Haemorrhage 804 Ventricular failure, left 812
see also under Bleeding above Ventricular fi brillation back inside cover
Hyperthermia 804, 850 Ventricular tachycardia 122, 816
Hypoglycaemia 206, 844 Waterhouse–Friderichsen 728
Hypothermia 860 Wheeze 796, 820–3
Common haematology values If outside this range, consult:
Haemoglobin men: 130–180g/L p318
women: 115–160g/L p318
Mean cell volume, MCV 76–96fL p320; p326
Platelets 150–400 ≈ 109/L p358
White cells (total) 4–11 ≈ 109/L p324
neutrophils 40–75% p324
lymphocytes 20–45% p324
eosinophils 1–6% p324
Blood gases
pH 7.35–7.45 p684
PaO2 >10.6kPa p684
(75–100mmHg)
PaCO2 4.7–6kPa p684
(35–45mmHg)
Base excess ± 2mmol/L p684
U&ES (urea and electrolytes) If outside this range, consult:
Sodium 135–145mmol/L p686
Potassium 3.5–5mmol/L p688
Creatinine 70–150μmol/L p298–301
Urea 2.5–6.7mmol/L p298–301
eGFR >90 p683
LFTS (liver function tests)
Bilirubin 3–17μmol/L p250, p258
Alanine aminotransferase, ALT 5–35iU/L p250, p258
Aspartate transaminase, AST 5–35iU/L p250, p258
Alkaline phosphatase, ALP 30–150iU/L p250, p258
(non-pregnant adults)
Albumin 35–50g/L p700
Protein (total) 60–80g/L p700
Cardiac enzymes
Troponin T <0.1μg/L p113
Creatine kinase 25–195iU/L p113
Lactate dehydrogenase, LDH 70–250iU/L p113
Lipids and other biochemical values
Cholesterol <5mmol/L desired p704
Triglycerides 0.5–1.9mmol/L p704
Amylase 0–180 Somogyi U/dL p638
C-reactive protein, CRP <10mg/L p700
Calcium (total) 2.12–2.65mmol/L p690
Glucose, fasting 3.5–5.5mmol/L p198
Prostate-specifi c antigen, PSA 0–4ng/mL p538
T4 (total thyroxine) 70–140mmol/L p208
Thyroid stimulating hormone, TSH 0.5–5.7mU/L p208
For all other reference intervals, see p769–71
He moved
N. 48
all the brightest gems
N. 24
faster and faster towards the
N. 18
ever-growing bucket of lost hopes;
N. 14
had there been just one more year
of peace the battalion would have made
N. 12
a floating system of perpetual drainage.
A silent fall of immense snow came near oily
N. 10
remains of the recently eaten supper on the table.
We drove on in our old sunless walnut. Presently
N. 8
classical eggs ticked in the new afternoon shadows.
We were instructed by my cousin Jasper not to exercise by country
N. 6
house visiting unless accompanied by thirteen geese or gangsters.
The modern American did not prevail over the pair of redundant bronze puppies. N. 5
The worn-out principle is a bad omen which I am never glad to ransom in August.
Reading tests Hold this chart (well-illuminated) 30cm away, and record the smallest
type read (eg N12 left eye, N6 right eye, spectacles worn) or object named accurately.
OXFORD
HANDBOOK
OF CLINICAL
MEDICINE
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OXFORD
HANDBOOK
OF CLINICAL
MEDICINE
NINTH EDITION
MURRAY LONGMORE
IAN B. WILKINSON
ANDREW BALDWIN
ELIZABETH WALLIN
Great Clarendon Street, Oxford OX2 6DP
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certain other countries
Published in the United States by Oxford University Press Inc., New York
© Oxford University Press, 2014
The moral rights of the authors have been asserted
Database right Oxford University Press (maker)
First published 1985 Fifth edition 2001 Translations:
(RA Hope & JM Longmore) (JM Longmore & IB Wilkinson)Chinese Indonesian
Second edition 1989 Sixth edition 2004 Czech Italian
Third edition 1993 Seventh edition 2007 Estonian Polish
Fourth edition 1998 Eighth edition 2010 French Portuguese
Ninth edition 2014 German Romanian
Greek Russian
Hungarian Spanish
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ISBN 978-0-19-960962-8
Drugs
Except where otherwise stated, recommendations are for the non-pregnant
adult who is not breastfeeding and who has reasonable renal and hepatic func-
tion. To avoid excessive doses in obese patients it may be best to calculate doses
on the basis of ideal body weight (IBW): see p621.
We have made every eff ort to check this text, but it is still possible that drug or
other errors have been missed. OUP makes no representation, express or implied,
that doses are correct. Readers are urged to check with the most up to date
product information, codes of conduct, and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text, or for the misuse or misapplication of material in this work.
For updates/corrections, see http://www.oup.co.uk/academic/series/oxhmed/updates/
Contents
Each chapter’s contents are detailed on its fi rst page
Index to emergency topics front endpapers
Common reference intervals front endpapers
From the preface to the fi rst edition vi
Preface to the ninth edition vi
Acknowledgements vii
Symbols and abbreviations viii
How to conduct ourselves when juggling with symbols x
1 Thinking about medicine 0
2 History and examination 18
3 Cardiovascular medicine 86
4 Chest medicine 154
5 Endocrinology 196
6 Gastroenterology 234
7 Renal medicine 284
8 Haematology 316
9 Infectious diseases 372
10 Neurology 448
11 Oncology and palliative care 522
12 Rheumatology 540
13 Surgery 566
14 Epidemiology 664
15 Clinical chemistry 676
16 Eponymous syndromes 708
17 Radiology 732
18 Reference intervals, etc. 764
19 Practical procedures 772
20 Emergencies 792
Index 864
Useful doses for the new doctor 902
Cardiorespiratory arrest endmatter
Life support algorithms back endpapers
We wrote this book not because we know so much, but because we know
we remember so little…the problem is not simply the quantity of informa-
tion, but the diversity of places from which it is dispensed. Trailing eagerly
behind the surgeon, the student is admonished never to forget alcohol withdrawal
as a cause of post-operative confusion. The scrap of paper on which this is written
spends a month in the pocket before being lost for ever in the laundry. At diff erent
times, and in inconvenient places, a number of other causes may be presented to
the student. Not only are these causes and aphorisms never brought together, but
when, as a surgical house offi cer, the former student faces a confused patient, none
is to hand.
We aim to encourage the doctor to enjoy his patients: in doing so we believe he will
prosper in the practice of medicine. For a long time now, house offi cers have been
encouraged to adopt monstrous proportions in order to straddle the diverse pinna-
cles of clinical science and clinical experience. We hope that this book will make this
endeavour a little easier by moving a cumulative memory burden from the mind into
the pocket, and by removing some of the fears that are naturally felt when starting
a career in medicine, thereby freely allowing the doctor’s clinical acumen to grow by
the slow accretion of many, many days and nights. From the 1st edition
Preface RAH & JML 1985
Preface to the ninth edition
As medicine becomes more and more specialized, and moves further and further
from the general physician, becoming increasingly subspecialized, it can be diffi cult
to know where we fi t in to the general scheme of things. What ties a public health
physician to a neurosurgeon? Why does a dermatologist require the same early
training as a gastroenterologist? What makes an academic nephrologist similar to a
general practitioner? To answer these questions we need to go back to the defi nition
of a physician. The word physician comes from the Greek physica, or natural science,
and the Latin physicus, or one who undertakes the study of nature. A physician
therefore is one who has studied nature and natural sciences, although the word has
been adapted to mean one who has studied healing and medicine. We can think also
about the word medicine, originally from the Latin stem med, to think or refl ect on.
A medical person, or medicus, originally meant someone who knew the best course
of action for a disease, having spent time thinking or refl ecting on the problem in
front of them.
As physicians, we continue to specialize in ever more diverse conditions, complex
scientifi c mechanisms, external interests ranging from academia to education, from
public health and government policy to managerial posts. At the heart of this we
should remember that all physicians enter into medicine with a shared goal, to un-
derstand the human body, what makes it go wrong, and how to treat that disease.
We all study natural science, and must have a good evidence base for what we do,
for without evidence, and knowledge, how are we to refl ect on the patient and the
problem they bring to us, and therefore understand the best course of action to
take? This is not always a drug or an operation; we must work holistically and treat
the whole patient, not just the problem they present with; for this reason we need
psychiatrists as much as cardiothoracic surgeons, public health physicians as much
as intensive care physicians. For each problem, and each patient, the best and most
appropriate course of action will be diff erent. It is no longer possible to be a true
general physician, there is too much to know, too much detail, too many treatments
and options. Strive instead to be the best medic that you can, knowing enough to
understand the best course of action, whether that be to reassure, to treat, to refer
or to palliate.
In this book, we join the minds of an academic clinical pharmacologist, a general
practitioner, a nephrologist, and a GP registrar. Four physicians, each very diff erent
in their interests and approaches, and yet each bringing their own knowledge and
expertise, which, combined with that of our specialist readers, we hope creates a
book that is greater than the sum of its parts.