Table Of Content

OXFORD HANDBOOK OF CLINICAL SPECIALTIES TENTH EDITION ANDREW BALDWIN NINA HJELDE CHARLOTTE GOUMALATSOU GIL MYERS 3 Oxford University Press, Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States by Oxford University Press Inc., New York © Oxford University Press, 2016 The moral rights of the authors have been asserted First published 1987 Sixth edition 2003 Translations: Greek Second edition 1989 Seventh edition 2006 Spanish Romanian Third edition 1991 Eighth edition 2008 German Russian Polish Fourth edition 1995 Ninth edition 2013 Hungarian Portuguese Fifth edition 1999 Tenth edition 2016 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this book in any other form and you must impose the same condition on any acquirer. British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2015958817 Typeset by GreenGate Publishing Services, Tonbridge, UK; printed in China on acid-free paper through C&C Off set Printing Co. Ltd ISBN 9780198719021 Drugs Except where otherwise stated, recommendations are for the non-pregnant adult who is not breastfeeding. 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, safety regulations and latest BNF/BNFC. 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 oup.co.uk/academic/medicine/handbooks/updates. Contents Drugs ii Contents iii Preface to the tenth edition iv Preface to the fi rst edition v Confl icts of interest: none declared v Dedication vi Acknowledgements vii How to use this book viii A note on the use of pronouns viii Symbols and abbreviations ix 1 Obstetrics 1 2 Paediatrics 98 3 Gynaecology 240 4 Psychiatry 312 5 Ophthalmology 410 6 Primary care 466 7 Ear, nose, and throat 534 8 Dermatology 582 9 Anaesthesia 612 10 Eponymous syndromes 638 11 Orthopaedics 656 12 Trauma 714 13 Emergency medicine 762 14 Pre-hospital care 796 Index 817 The content of each chapter is detailed on each chapter’s fi rst page. Preface to the tenth edition This is the fi rst medical book to take the health of its readers seriously on the grounds that the health of one person (a patient) must not be bought at the expense of another (their doctor). It is an unsettling paradox that when we study medicine our own health may be forgotten, with long hours of hard work—often without joy or sustenance—as our health is shattered by the weight of an over-loaded curriculum (no doubt because we are over-stimu- lated by the too many receptors, organs, and systems, about which we know far too much). What can a book do about this dilemma? Whilst we strive to guide you through the realms of the specialties with a concise overview of exactly what you need to know, we also place prominence on developing your skills beyond just pure facts, since these may quickly be forgotten. We want to furnish your mind with anecdotes which will remind you of the value of your hard work to inspire and motivate you to learn more. It is the quirks of medicine which we remember best; the bits that make you smile and make you realize that the work we do can be truly inspiring. The spiral symbol [] throughout the book, and at the start of each chapter, is your reminder to connect with and enjoy your patients; to dis- cover what is important to them, and in so doing, make a real diff erence to their health and well-being. Few people receive such privileged insight into another’s life. Few other professions can refl ect on their day—and from the mundane, the routine, even the stressful—bring forth such engaging or thought-provoking episodes from their encounters at work. We also hope our writings inspire you that further work can be accomplished. Do not think that a student’s or junior doctor’s work goes unnoticed—you are in the ideal position to make astute and objective observations uncluttered by previous baggage. Two medical students were instrumental in the journey of discovery of insulin: in 1869, German student Paul Langerhans found clusters of cells within the pancreas whose function were unknown, but were later shown to be insulin producing -cells. Canadian student Charles Best’s work with Fred- erick Banting led to the discovery of insulin in 1921—a miracle treatment for a previously feared and deadly disease. You may think the world of discovery is exhausted, especially for such junior members of the team, but in 2014 a medical student was the lead author for research which revealed the extent of aspergil- losis in cystic fi brosis. Take heart! So in bringing these thoughts together, try to make a habit of treasuring those unique quirks that come your way, and regularly bring them to mind as a re- freshing antidote to the demands of our profession. And be aware of the possible line of enquiry that your studies or work may present, bearing in mind the dictum of Albert Szent-Gyorgyi, the physiologist who is credited with isolating vitamin C: ‘Discovery is to see what everybody else has seen, and to think what nobody else has thought’. ANDREW BALDWIN, NINA HJELDE, CHARLOTTE GOUMALATSOU, & GIL MYERS Preface to the tenth edition—2016 iv Preface to the fi rst edition When someone says that he is ‘doing obstetrics’—or whatever, this should not hide the fact that much more is being done besides, not just a little of each of medicine, psychiatry, gynaecology and paediatrics, but also a good deal of work to elicit and act upon the patient’s unspoken hopes and fears. At the operating table he must concentrate minutely on the problem in hand; but later he must operate on other planes too, in social and psychologi- cal dimensions so as to understand how the patient came to need to be on the operating table, and how this might have been prevented. All the best special- ists practise a holistic art, and our aim is to show how specialism and holism may be successfully interwoven, if not into a fully watertight garment, then at least into one which keeps out much of the criticism rained upon us by the proponents of alternative medicine. We hope that by compiling this little volume we may make the arduous task of learning medicine a little less exhausting, so allowing more energy to be spent at the bedside, and on the wards. For a medical student coming fresh to a specialty the great tomes which mark the road to knowledge can numb the mind after a while, and what started out fresh is in danger of becoming exhausted by its own too much. It is not that we are against the great tomes themselves—we are simply against reading them too much and too soon. One starts off strong on ‘care’ and weak on knowledge, and the danger is that this state of aff airs becomes reversed. It is easier to learn from books than from patients, yet what our patients teach us may be of more abiding signifi cance: the value of sympathy, the uses of compassion and the limits of our human world. It is at the bedside that we learn how to be of practical help to people who are numbed by the mysterious disasters of womb or tomb, for which they are totally unprepared. If this small book enables those starting to ex- plore the major specialties to learn all they can from their patients, it will have served its purpose—and can then be discarded. Because of the page-a-subject format, the balance of topics in the follow- ing pages may at fi rst strike the reader as being odd in places. However, it has been our intention to provide a maximally useful text rather than one which is perfectly balanced in apportioning space according to how common a particular topic is—just as the great Terrestrial Globes made by George Phil- lips in the 1960s may seem at fi rst to provide an odd balance of place names, with Alice Springs appearing more prominently than Amsterdam. To chart a whole continent, and omit to name a single central location out of respect for ‘balance’ is to miss a good opportunity to be useful. George Phillips did not miss this opportunity, and neither we hope, have we. It is inevitable that some readers will be disappointed that we have left out their favoured subjects (the Phillips’ Globe does not even mention Oxford!). To these readers we off er over 300 blank pages by way of apology. JABC & JML—Preface to the fi rst edition—Ferring, 1987 Confl icts of interest: none declared No pharmaceutical company employs us in any capacity and we have not re- ceived any fi nancial input or gifts bearing upon our research for this publication. We assert that the drugs recommended in this book have been selected on the basis of the best available evidence. v Dedication vi ‘He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.’ William Osler Canadian physician, 1849–1919 Acknowledgements This book was conceived and inspired by Judith Collier and Murray Longmore, who as lead authors presided over it for more than 25 years—from publication of the fi rst edition in 1987, until publication of the ninth edition in 2013. Their knowledge, wisdom, and creativity lives on in the pages of this edition and their work has been loved and trusted by generations of doctors. We thank all the authors who have contributed to previous editions: Judith Har- vey, Tim Hodgetts, Duncan Brown, Peter Scally, Mark Brinsden, Ahmad R. Mafi , Tom Turmezei, and Keith Amarakone. We thank those who have contributed their time and wisdom to previous editions: Dr Steven Emmet, Professor Tor Chiu, Natalie Langdown, and Professor Mark Lowenthal. Specialist Readers We are hugely indebted to our Specialist Readers for their advice, encouragement, and constructive criticism. Each chapter in this book has benefi tted from their trustworthy oversight. They are thanked individually at the beginning of each chapter. Junior Readers It was our great pleasure to welcome a new team of Junior Readers to the tenth edition of this book. Our Junior Readers showed commit- ment, intelligence, and ingenuity in their contributions to the referencing and cross-referencing of this edition. We have a better book for it. They are also thanked individually at the beginning of each chapter. Reader participation We have been very fortunate to receive so many well- considered suggestions and corrections to the book from readers all over the globe. Their contributions have enhanced the book and we are grateful. If you would like to give us feedback, correct a mistake, or make a suggestion, you can do so at www.oup.com/uk/academic/ohfeedback. vii How to use this book This book has some useful features to help you get the most out of the information inside. Quick chapter look-ups The index on the back cover refers to and aligns with the coloured tabs on the sides of the pages. References (1) Every reference has an individual identifi cation indicated by a pink superscript number. The full details of every reference are held online at www.oup.com/ohcs10refs. Further reading Throughout the book you will fi nd ‘Further reading’ sections which are intended to guide you to sources that will further your learning, un- derstanding, and clinical practice. Cross references There are cross references to other topics within the book, to the Oxford Handbook of Clinical Medicine (OHCM), and to other titles in the Oxford Medical Handbooks series. Reference intervals for common laboratory values are included inside the back cover. Conversion factors to and from SI units are given on the bookmark. Symbols and abbreviations See page ix. Corrections and suggestions Found a mistake? Have a suggestion for the next edition? Let us know at www.oup.com/uk/academic/ohfeedback. Major changes are announced online at www.oup.co.uk/academic/series/oxhmed/ updates. A note on the use of pronouns For brevity, the pronoun ‘he’ or ‘she’ has been used in places where ‘he or she’ would have been appropriate. Such circumlocutions do not aid the reader in forming a vivid visual impression, which is one of the leading aims of good au- thorship. Therefore, for balance and fairness, and where sense allows, we have tried alternating he with she. viii Symbols and abbreviations  ........don’t dawdle! Prompt action © ..........courtesy of the copyright holder saves lives C3 ..........complement ...........this phrase is important Ca .........carcinoma  ( † ) more (or less) vital topic; a rough CBRN ....chemical, biological, radiological, guide for 1st-time readers nuclear  .......an opportunity for holistic/non- CBT .......cognitive-behavioural therapy reductionist thinking CCDC ....consultant in communicable .......confl ict (controversial topic) disease control 1,2,3 .......references at oup.co.uk/ohcs10refs CCF .......combined (right- & left-sided) 1,2,3 ..........drug dose not in BNF, see cardiac failure oup.co.uk/ohcs10refs ChVS .....chorionic villus sampling # ...........fracture CI ..........contraindications  ............diagnosis CIN ........cervical intra-epithelial neoplasia  .........diff erential diagnosis CMV ......cytomegalovirus : ......male to female ratio CNS .......central nervous system  ............decreased CoC .......combined oral contraceptive  .........normal (eg plasma level) COM ......chronic otitis media  ............increased CPA .......care programme approach ~ ...........about CPAP .....continuous +ve airways pressure ≈ ............approximately equal CPR .......cardiopulmonary resuscitation –ve .......negative CRP .......C-reactive protein +ve ......positive CRPS .....complex regional pain syndrome ............on account of/because of CS ..........caesarean section ............therefore CSF .......cerebrospinal fl uid A2A .......angiotensin 2 receptor (blockers) CT ..........computed tomography ABC .......air, breathing, circulation CVP .......central venous pressure A(P)LS ..advanced (paediatric) life support CVS .......cardiovascular system manuals CXR .......chest x-ray ABR .......audiological brainstem responses D ............dimension (or dioptre) AC ..........ante cibum (before food) D&C.......dilatation (cervix) & curettage ACE(i) ...angiotensin-converting enzyme D&V ......diarrhoea and vomiting (inhibitor) dB ..........decibel ACTH .....adrenocorticotrophic hormone DHS .......dynamic hip screw ADD .......attention defi cit disorder DIC ........disseminated intravascular ADH ......antidiuretic hormone coagulation AED .......anti-epileptic drug DIP ........distal interphalangeal AFP .......-fetoprotein (=alpha) DKA ......diabetic ketoacidosis AIDS .....acquired immunodefi ciency syn. dL ..........decilitre AKI .......acute kidney injury DM ........diabetes mellitus Alk .......alkaline (phos=phosphatase) DMSA ...dimercaptosuccinic acid ALL .......acute lymphoblastic leukaemia DNA ......deoxyribonucleic acid ALS ........advanced life support DOH.......Department of Health (NHS) ALT........alanine aminotransferase DPL .......diagnostic peritoneal lavage ANA ......antinuclear antibody DRG .......dorsal root ganglion ANF .......antinuclear factor DSM-5 ..Diagnostic and Statistical Manual ANS.......autonomic nervous system of Mental Disorders, 5e AP .........anteroposterior DUB .......dysfunctional uterine bleeding APH.......antepartum haemorrhage DVT .......deep venous thrombosis APLS .....advanced paediatric life support EBM ......evidence-based medicine APM ......auto-premotor syndrome EBV .......Epstein–Barr virus ARM......artifi cial rupture of membranes ECG .......electrocardiogram ASD .......atrioseptal defect ECT .......electroconvulsive therapy ASO .......antistreptolysin O (titre) ED..........emergency department ASW .....approved social worker EDD .......expected delivery date ATLS∏ ..Advanced Trauma Life Support∏, EEG .......electroencephalogram see www.trauma.org EIA ........enzyme immunoassay ATN .......acute tubular necrosis ENT .......ear, nose and throat AV .........atrioventricular ERPC .....evacuation of retained products AVM ......arteriovenous malformation of conception HCG .....-human chorionic gonadotrophinESR .......erythrocyte sedimentation rate BJGP .....British Journal of General PracticeET ..........endotracheal BMI .......body mass index FB ..........foreign body BMJ ......British Medical Journal FBC .......full blood count BNF .......British National Formulary FCR .......fl exor carpi radialis BNFC......children’s BNF FDP .......fl exor digitorum profundus BP..........blood pressure FDS .......fl exor digitorum sublimis