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(BQ) Part 2 book Essentials of Kumar and Clark''s clinical medicine presents the following contents: Cardiovascular disease, respiratory disease, intensive care medicine, drug therapy, poisoning, and alcohol misuse, endocrine disease, diabetes mellitus and other disorders of metabolism, the special senses, neurology, dermatology.
10 Cardiovascular disease COMMON PRESENTING SYMPTOMS OF HEART DISEASE The common symptoms of heart disease are chest pain, breathlessness, palpitations, syncope, fatigue and peripheral oedema, but none are specific for cardiovascular disease The severity of anginal pain, dyspnoea, palpitations or fatigue may be classified according to the New York Heart Association grading of ‘cardiac status’ (Table 10.1) Chest pain Chest pain or discomfort is a common presenting symptom of cardiovascular disease and must be differentiated from non-cardiac causes The site of pain, its character, radiation and associated symptoms will often point to the cause (Table 10.2) Dyspnoea Causes are discussed on page 407 Left heart failure is the most common cardiac cause of exertional dyspnoea and may also cause orthopnoea and paroxysmal nocturnal dyspnoea (p 407) Palpitations Palpitations are an awareness of the heartbeat The normal heartbeat is sensed when the patient is anxious, excited, exercising or lying on the left side In other circumstances it usually indicates a cardiac arrhythmia, commonly ectopic beats or a paroxysmal tachycardia (p 420) Syncope This is a temporary impairment of consciousness due to inadequate cerebral blood flow There are many causes and the most common is a simple faint © 2011 Elsevier Ltd, Inc, BV 10 408 • Cardiovascular disease Table 10.1 The New York Heart Association grading of ‘cardiac status’ (modified) Grade Uncompromised (no breathlessness) Grade Slightly compromised (on severe exertion) Grade Moderately compromised (on mild exertion) Grade Severely compromised (breathless at rest) Table 10.2 Common causes of chest pain Central Angina pectoris Crushing pain on exercise, relieved by rest May radiate to jaw or arms ACS Similar in character to angina but more severe, occurs at rest, lasts longer Pericarditis Sharp pain aggravated by movement, respiration and changes in posture Aortic dissection Severe tearing chest pain radiating through to the back Massive PE With dyspnoea, tachycardia and hypotension Musculoskeletal Tender to palpate over affected area GORD May be exacerbated by bending or lying down (at night) Pain may radiate into the neck Lateral/peripheral Pulmonary infarct Pneumonia Pneumothorax } Musculoskeletal Sharp, well-localized pain with a tender area on palpation Lung carcinoma Constant dull pain Herpes zoster Burning unilateral pain corresponding to a dermatome that appears to days before the typical rash Pleuritic pain, i.e sharp, well-localized, aggravated by inspiration, coughing and movement ACS, acute coronary syndrome; PE, pulmonary embolus; GORD, gastro-oesophageal reflux disease or vasovagal attack (p 717) The cardiac causes of syncope are the result of either very fast (e.g ventricular tachycardia) or very slow heart rates (e.g complete heart block) which are unable to maintain an adequate cardiac output Attacks occur suddenly and without warning They last only or minutes, with complete recovery in seconds (compare with epilepsy, where Cardiovascular disease • 409 Other symptoms Tiredness and lethargy occur with heart failure and result from poor perfusion of brain and skeletal muscle, poor sleep, side-effects of medication particularly β-blockers, and electrolyte imbalance due to diuretic therapy Heart failure also causes salt and water retention leading to oedema, which in ambulant patients is most prominent over the ankles In severe cases it may involve the genitalia and thighs INVESTIGATIONS IN CARDIAC DISEASE The chest X-ray This is usually taken in the postero-anterior (PA) direction at maximum inspiration (p 509) A PA chest film can aid the identification of cardiomegaly, pericardial effusions, dissection or dilatation of the aorta, and calcification of the pericardium or heart valves A cardiothoracic ratio (p 510) of greater than 50% on a PA film is abnormal and normally indicates cardiac dilatation or pericardial effusion Examination of the lung fields may show signs of left ventricular failure (Fig 10.1), valvular heart disease (e.g markedly enlarged left atrium in mitral valve disease) or pulmonary oligaemia (reduction of vascular markings) associated with pulmonary embolic disease The electrocardiogram The electrocardiogram (ECG) is a recording from the body surface of the electrical activity of the heart Each cardiac cell generates an action potential as it becomes depolarized and then repolarized during a normal cycle Normally, depolarization of cardiac cells proceeds in an orderly fashion beginning in the sinus node (lying in the junction between superior vena cava and right atrium) and spreading sequentially through the atria, AV node (lying beneath the right atrial endocardium within the lower inter-atrial septum), and the His bundle in the interventricular septum, which divides into right and left bundle branches (Fig 10.2) The right and left bundle branches continue down the right and left side of the interventricular septum and supply the Purkinje network which spreads through the subendocardial surface of the right ventricle and left ventricle respectively The main left bundle divides into an anterior superior division (the anterior hemi-bundle) and a posterior inferior division (the posterior hemi-bundle) Cardiovascular disease complete recovery may be delayed for some hours) Obstruction to ventricular outflow also causes syncope (e.g aortic stenosis, hypertrophic cardiomyo pathy), which typically occurs on exercise when the requirements for increased cardiac output cannot be met 10 410 • Cardiovascular disease Fig 10.1 The chest X-ray in acute left ventricular failure demonstrating cardiomegaly, hilar haziness, Kerley B lines, upper lobe venous blood engorgement and fluid in the right horizontal fissure Hilar haziness and Kerley B lines (thin linear horizontal pulmonary opacities at the base of the lung periphery) indicate interstitial pulmonary oedema The standard ECG has 12 leads: � Chest leads, V1–V6, look at the heart in a horizontal plane (Fig 10.3) � Limb leads look at the heart in a vertical plane (Fig 10.4) Limb leads are unipolar (AVR, AVL and AVF) or bipolar (I, II, III) The ECG machine is arranged so that when a depolarization wave spreads towards a lead the needle moves upwards on the trace (i.e a positive deflection), and when it spreads away from the lead the needle moves downwards Cardiovascular disease • 411 Cardiovascular disease Sinoatrial node Atrioventricular node His bundle Left posterior bundle Right bundle Purkinje fibres Fig 10.2 The conducting system of the heart In normal circumstances only the specialized conducting tissues of the heart undergo spontaneous depolarization (automaticity) which initiates an action potential The sinus (SA) node discharges more rapidly than the other cells and is the normal pacemaker of the heart The impulse generated by the sinus node spreads first through the atria, producing atrial systole, and then through the atrioventricular (AV) node to the His-Purkinje system, producing ventricular systole ECG waveform and definitions (Fig 10.5) Heart rate At normal paper speed (usually 25 mm/s) each ‘big square’ measures 5 mm wide and is equivalent to 0.2 s The heart rate (if the rhythm is regular) is calculated by counting the number of big squares between two consecutive R waves and dividing into 300 P wave is the first deflection and is caused by atrial depolarization When abnormal it may be: � Broad and notched (> 0.12 s, i.e small squares) in left atrial enlargement (‘P mitrale’, e.g mitral stenosis) � Tall and peaked (> 2.5 mm) in right atrial enlargement (‘P pulmonale’, e.g pulmonary hypertension) � Replaced by flutter or fibrillation waves (p 429) � Absent in sinoatrial block (p 421) The QRS complex represents ventricular activation or depolarization: � A negative (downward) deflection preceding an R wave is called a Q wave Normal Q waves are small and narrow; deep (> 2 mm), wide (> 1 mm) Q waves (except in AVR and V1) indicate myocardial infarction (p 453) 10 412 • Cardiovascular disease (A) V1 V V V4 V5 V6 (B) LA RA V1 V6 LV RV V5 V2 V3 V4 Fig 10.3 ECG chest leads (A) The V leads are attached to the chest wall overlying the intercostal spaces as shown: V4 in the mid-clavicular line, V5 in the anterior axillary line, V6 in the mid-axillary line (B) Leads V1 and V2 look at the right ventricle, V3 and V4 at the interventricular septum, and V5 and V6 at the left ventricle The normal QRS complex in each lead is shown The R wave in the chest (precordial) leads steadily increases in amplitude from lead V1 to V6 with a corresponding decrease in S wave depth, culminating in a predominantly positive complex in V6 Cardiovascular disease • 413 The augmented unipolar leads AVR I AVL III II AVF Fig 10.4 ECG limb leads Lead I is derived from electrodes on the right arm (negative pole) and left arm (positive pole), lead II is derived from electrodes on the right arm (negative pole) and left leg (positive pole), and lead III from electrodes on the left arm (negative pole) and the left leg (positive pole) � A deflection upwards is called an R wave whether or not it is preceded by a Q wave � A negative deflection following an R wave is termed an S wave Ventricular depolarization starts in the septum and spreads from left to right (Fig 10.2) Subsequently the main free walls of the ventricles are depolarized Thus, in the right ventricular leads (V1 and V2) the first deflection is upwards (R wave) as the septal depolarization wave spreads towards those leads The second deflection is downwards (S wave) as the bigger left ventricle (in which depolarization is spreading away) outweighs the effect of the right ventricle (see Fig 10.3) The opposite pattern is seen in the left ventricular leads (V5 and V6), with an initial downwards deflection (small Q wave reflecting septal depolarization) followed by a large R wave caused by left ventricular depolarization Cardiovascular disease The bipolar leads 10 414 • Cardiovascular disease R ST segment T P Voltage (mV) 10 mm = mV PR interval P U QS Isoelectric line QRS interval QT interval 0.04 s mm 0.2 0.4 0.6 Time (s) 0.8 Fig 10.5 The waves and elaboration of the normal ECG (From Goldman MJ (1976) Principles of Clinical Electrocardiography, 9th edn Los Altos: Lange.) Left ventricular hypertrophy with increased bulk of the left ventricular myocardium (e.g with systemic hypertension) increases the voltage-induced depolarization of the free wall of the left ventricle This gives rise to tall R waves (> 25 mm) in the left ventricular leads (V5, V6) and/or deep S waves (> 30 mm) in the right ventricular leads (V1, V2) The sum of the R wave in the left ventricular leads and the S wave in the right ventricular leads exceeds 40 mm In addition to these changes there may also be ST-segment depression and T wave flattening or inversion in the left ventricular leads Right ventricular hypertrophy (e.g in pulmonary hypertension) causes tall R waves in the right ventricular leads The QRS duration reflects the time that excitation takes to spread through the ventricle A wide QRS complex (> 0.10 s, 2.5 small squares) occurs if conduction is delayed, e.g with right or left bundle branch block, or if conduction is through a pathway other than the right and left bundle branches, e.g an impulse generated by an abnormal focus of activity in the ventricle (ventricular ectopic) T waves result from ventricular repolarization In general the direction of the T wave is the same as that of the QRS complex Inverted T waves occur in many conditions and, although usually abnormal, they are a non-specific finding The PR interval is measured from the start of the P wave to the start of the QRS complex whether this is a Q wave or an R wave It is the time taken Cardiovascular disease • 415 Exercise electrocardiography This assesses the cardiac response to exercise The 12-lead ECG and blood pressure is recorded whilst the patient walks or runs on a motorized treadmill The test is performed according to a standardized method (e.g the Bruce protocol) Myocardial ischaemia provoked by exertion results in ST segment depression (> 1 mm) in leads facing the affected area of ischaemic cardiac muscle Exercise normally causes an increase in heart rate and blood pressure A sustained fall in blood pressure usually indicates severe coronary artery disease A slow recovery of the heart rate to basal levels has also been reported to be a predictor of mortality Contraindications include unstable angina, severe hypertrophic cardiomyopathy, severe aortic stenosis and malignant hypertension A submaximal exercise test can be performed within days of a myocardial infarction A positive test and indications for stopping the test are: Cardiovascular disease for excitation to pass from the sinus node, through the atrium, atrioventricular node and His-Purkinje system to the ventricle A prolonged PR interval (> 0.22 s) indicates heart block (p 422) The ST segment is the period between the end of the QRS complex and the start of the T wave ST elevation (> 1 mm above the isoelectric line) occurs in the early stages of myocardial infarction (p 453) and with acute pericarditis (p 479) ST segment depression (> 0.5 mm below the isoelectric line) indicates myocardial ischaemia The QT interval extends from the start of the QRS complex to the end of the T wave It is primarily a measure of the time taken for repolarization of the ventricular myocardium, which is dependent on heart rate (shorter at faster heart rates) The QT interval, corrected for heart rate (QTc = QT/√2(R-R)), is normally ≤ 0.44 s in males and ≤ 0.46 s in females Long QT syndrome (p 432) is associated with an increased risk of torsades de pointes ventricular tachycardia and sudden death The cardiac axis refers to the overall direction of the wave of ventricular depolarization in the vertical plane measured from a zero reference point (Fig 10.6) The normal range for the cardiac axis is between –30° and +90° An axis more negative than –30° is termed left axis deviation and an axis more positive than +90° is termed right axis deviation A simple method to calculate the axis is by inspection of the QRS complex in leads I, II and III The axis is normal if leads I and II are positive; there is right axis deviation if lead I is negative and lead III positive, and left axis deviation if lead I is positive and leads II and III negative Left axis deviation occurs due to a block of the anterior bundle of the main left bundle conducting system (p 409), inferior myocardial infarction and the Wolff–Parkinson–White syndrome Right axis deviation may be normal and occurs in conditions in which there is right ventricular overload, dextrocardia, Wolff–Parkinson–White syndrome and left posterior hemiblock 10 416 • Cardiovascular disease (A) Left axis deviation AVR –150° AVL –30° I 0° Normal axis II +60° III +120° Right axis deviation (B) Normal axis AVF +90° Left axis deviation Right axis deviation Lead I Lead II Lead III Fig 10.6 Cardiac vectors (A) The hexaxial reference system, illustrating the six leads in the frontal plane, e.g lead I is 0°, lead II is +60°, lead III is 120° (B) ECG leads showing the predominant positive and negative deflection with axis deviation 858 • Index Plasma osmolality 332–337 Plasmapheresis 793 Plasmodium falciparum 26–29, 27t–28t chloroquine resistant 29 Plasmodium malariae 26 Plasmodium ovale 26 Plasmodium vivax 26–29 Platelets adherence 228 aggregation 228 concentrates 223 count, raised 220t disorders 230t, 231–233 Pleural aspiration/biopsy 511–512, 560–561 Pleural effusion 559–561, 559f, 560t Pleurisy 558–559 Pluripotential stem cells 221 Pneumocystis jiroveci 51–52, 540 Pneumonia 532–541 aetiology 534t clinical features 534–537 complications 537, 540–541 differential diagnosis 537 forms of 537–540 idiopathic interstitial 550–552 influenza and 515 investigations 535–536, 536f management 537, 538f–539f suppurative 515 Pneumothorax 561–563, 562f–563f Poliomyelitis 736 acute 12t Polyangiitis 308 Polyarteritis nodosa (PAN) 308 Polycystic ovary syndrome (PCOS) 635–637 Polycythaemia 217–219 absolute 217–218 causes 218f polycythaemia vera 218 relative/apparent (Gaisböck’s syndrome) 218 secondary 219 Polyethylene glycol 132 Polymyalgia (PMR) 307–308 Polymyositis (PM) 305 Polyneuropathy 787–788, 788t Polyposis syndromes 110, 111t Polystyrene sulphonate resins 352 Polyuria 355 Pontine lesions 724 Porphyrias 695–697, 696t acute intermittent 695–697 porphyria cutanea tarda (PCT) 697 types 697 Porphyrins 695, 696f Portal hypertension 162–164, 163t Portosystemic encephalopathy (PSE) 163t, 168–169, 168t Positron emission tomography (PET) scans 71, 511, 737, 773 Post-herpetic neuralgia (PHN) 20 Postural changes, Parkinson’s disease 760 Postural tremor 724 Potassium 323 regulation 338–341 removal 351 supplementation 351 Potassium-channel activators 502–503 Potassium-sparing diuretics 330t, 350 PR interval 414–415 Pramipexole 760 Pravastatin 693–694 Prednisolone acute glomerulonephritis 370 adrenal insufficiency 637 autoimmune bullous diseases 815–816 bone disease 266 eczema 811 endocrine disease 664 erythema nodosum 813 facial nerve 735 giant cell arteritis 777 hypersensitivity pneumonitis 552 idiopathic pulmonary fibrosis (IFP) 551 inflammatory bowel disease (IBD) 103 lung, carcinoma of 557–558 nephrotic syndrome 367–368 polymyalgia (PMR) 308 polymyositis 305 rhinitis 514 Pre-eclampsia 482 Pregabalin 268 Pregnancy diabetes mellitus 688 folate supplements 202 HIV 54 liver disease/disorders 179 pre-eclampsia 482 Index • 859 Pregnancy (Continued) pulmonary embolism (PE) 475–476 rubella 18 urinary tract infection (UTI) 373 varicella zoster virus 19 warfarin 247 Primary angioplasty, immediate 454–455 Primary biliary cirrhosis (PBC) 170–172 Primary gastric lymphoma 265 Primary gonadal disease 630t Primary hyperaldosteronism 657 Primary hyperlipidaemia 692–695 Primary hyperoxaluria 378 Primary hyperparathyroidism 649, 651 Primary hypoadrenalism 637–640, 640b Primary intracranial haemorrhage 750–753 Primary lateral sclerosis 783 Primary renal disease 377 Primary restrictive cardiomyopathy 478 Primary sclerosing cholangitis (PSC) 176–177 Prinzmetal’s angina 446 Procainamide 300 Prochlorperazine 135 Progressive bulbar palsy 783 Progressive muscular atrophy 783 Progressive organ failure 575 Progressive supranuclear palsy 761 Prokinetic agents 75 Prolactin 617 Promethazine 134 Propafenone 430 Propionibacterium acnes 807 Propranolol heart failure 495 migraine 776 phaeochromocytoma 658 variceal haemorrhage 165 Propylthiouracil 663 Prostate gland 401–403 benign enlargement (hypertrophy) 353–355, 401–402 carcinoma 402–403 Prosthetic heart valves 459–460 Protein 139 Protein C 229 Protein-losing enteropathy 97 Proteinuria 357–360, 358t asymptomatic 365 Proteus 378 Proteus mirabilis 371t Proton pump inhibitors (PPIs) 75, 87, 129, 244 Protozoal infections 52–53 Protozoan parasites 24 Pruritis (itching) 144–145, 171 pseudo-Cushing’s syndrome 641 Pseudobulbar palsy 736, 747, 783 Pseudogout 296 Pseudomonas 15, 378 Pseudomonas aeruginosa 56, 524, 526, 539–540 Psoriasis 807–809, 808f Psoriatic arthritis 292 Pulmonary alveolar proteinosis 552 Pulmonary artery catheters 581–582 Pulmonary embolism (PE) 472–476 clinical features 472 investigations 473–475, 473t management 245, 248, 474b pathology 472 Pulmonary function tests 548 Pulmonary heart disease 470–476 Pulmonary hypertension 470–472, 471t Pulmonary nodule, solitary 509–510, 511t Pulmonary regurgitation 467 Pulmonary valve disease 466–467 Pulse oximetry 583 Pulsed methylprednisolone 815–816 Pupils 729 bilateral fixed dilated 741 midpoint 741 pinpoint 741 pupillary light reflex 728f unilateral fixed dilated 741 Purpura Henoch–Schönlein 309 immune thrombocytopenic (ITP) 232, 232t post transfusion 226 thrombotic thrombocytopenic (TTP) 232t, 233 Pustular psoriasis 809 Pyelonephritis 370 acute 372 Pyoderma gangrenosum 814 Pyogenic abscess 179 Pyrazinamide 544, 545t Pyrexia of unknown origin (PUO) 13–14, 14t 860 • Index Pyridostigmine, myasthenia gravis (MG) 793 Pyridoxine (vitamin B6) 198, 544, 790 Pyrophosphate arthropathy 296 Q QRS complex 411 QRS duration 414 QT interval 415 long QT syndrome 432 Quinapril 440 Quinine 28–29 Quinolones 62 R Radiation 729 Radioactive iodine 625 Radioactive phosphorus 219 Radiolabelled octreotide 644 Radionuclide studies 382–383, 475 Radiotherapy 253–254, 617, 773 Raloxifene 313, 633–634 Ramipril 484, 498 Ramsay Hunt syndrome 735 Ranitidine 128 Ranolazine 448 Ranson’s criteria, acute pancreatitis 187 Raynaud’s disease/phenomenon 303, 487 Reactive arthritis 292–293 Recombinant human parathyroid peptide (teriparatide) 313–314 Record keeping Rectum 106–113 Red blood cells concentrates 223 disorders 213 haemolytic anaemia 205 transfusion complications 225–226 urine 361 Red eye 708–709, 710t–711t Refeeding syndrome 125 Reflux nephropathy 372 Regurgitation 73 Renal arteriography 362 Renal artery, imaging 376 Renal artery stenosis (RAS) 375, 376f Renal biopsy, transcutaneous 362 Renal calculi 377–381 aetiology 377–381 clinical features 378–379, 379t differential diagnosis 379 investigations 379, 380t management 379–381 Renal colic 379–381 Renal disease bilateral 375–376 cystic 398–399 glomerular 363–365 hypertension 374–377 investigations 356–362 osteodystrophy 390–391, 393f parenchymal 386–387, 386t presenting features 353–356 primary 377 prostate gland 401–403 renal cell carcinoma 399–400 secondary hypertension 481–482 tract 353–355 tubular acidosis 346–347 tubulointerstitial nephritis 374 tumours 399–401, 403–404 see also Kidneys; Renal calculi; entries under Urinary tract Renal failure acute see Acute kidney injury (AKI) intrinsic causes 385t Renal replacement therapy 395–398 Renin-angiotensin system 433–437, 436f drugs affecting 497–499 Renin-angiotensin-aldosterone system 655–657, 655t Renoprotection 394 Renovascular disease 375–376, 376f Repaglinide 673 Reproduction female 632–637 male 629–632 Research procedures, consent and Reserpine 761 Respiratory acidosis 344 Respiratory alkalosis 344 Respiratory disease 505–570 asthma see Asthma diffuse diseases of lung parenchyma (DPLD) 546–552, 546f investigations 508–512 lower tract 516–526 Index • 861 Respiratory disease (Continued) occupational lung disease 552–553 pneumonia see Pneumonia symptoms 506–508, 506t therapeutics 564–570 tuberculosis see Tuberculosis (TB) upper tract 513–515 Respiratory distress syndrome (ARDS), acute 586–587 Respiratory failure 582–586 causes 583t management 584–586, 585t monitoring 582–586 Respiratory system function 505–506 function tests 508–509 structure 505 Resting tremor 724 Resuscitation 594–595 Reticulocytes 193 Retinal artery occlusion 713t Retinal detachment, acute 713t Retinal vein occlusion 712f, 713t Retinoic acid derivatives 809 Retinopathy, diabetic 682–683, 682t Retrograde pyelography 362, 383 Revascularization 442 Rhesus (Rh) system 224 Rheumatic fever 458–459 Rheumatic heart disease, chronic 459 Rheumatoid arthritis 283–289 aetiology 283 clinical features 284–285, 284f, 286t differential diagnosis 285 epidemiology 283 investigations 285 management 285–288 pathology 283–284 prognosis 288–289 Rheumatology 271–322 therapeutics 316–322 see also Musculoskeletal disease Rhinitis 513–514 Rib fractures 558 Rifampicin 544, 545t, 768 Rifaximin 35–36 Right bundle branch block (RBBB) 423–425, 424f–425f Right ventricular hypertrophy 414 Right ventricular systolic dysfunction (RVSD) 437 Rigidity, Parkinson’s disease 759 Ringer’s lactate solution 327t Ringworm 805–806 Rinne test 703 Risedronate 313, 320 Rituximab (anti-CD20) autoimmune haemolytic anaemia 215–216 cancer treatment 254, 261 nephrotic syndrome 367–368 rheumatoid arthritis 288 thrombotic thrombocytopenic purpura (TTP) 233 Wegener’s granulomatosis 549 Rivastigmine 785–786 ‘Rockall’ Score 87, 90t Rodent ulcer 816, 817f Root compression syndromes 277–278, 278t Ropinirole 760 Rosiglitazone 673 Rotator cuff injury 275 Rotigotine 760 Roundworms (nematodes) 40t–41t Rubella (German measles) 17–18 congenital rubella syndrome 18 MMR vaccine 17 S S-P-I-K-E-S strategy 6–8 Salbutamol 521, 530, 565 Salicylate see Aspirin Salivary gland disorders 73 Salmeterol 530, 566 Salmonella 212, 292, 297 Salmonella choleraesuis 31 Salmonella enteritidis 31 Salmonella paratyphi 30 Salmonella typhi 30 Sando-K® 351 Sarcoidosis 546–547, 548t Schatzki ring 75–76 Schistosomiasis 30 Schumm’s test 205 Scintigraphy 274, 362, 511 Scleritis 711t Scleroderma (systemic sclerosis) 77, 303–304 diffuse cutaneous 304 limited cutaneous 303–304 Scoliosis of spine 558 Secondary biliary cirrhosis 172 862 • Index Secondary hyperlipidaemia 691–692, 692t Secondary hyperparathyroidism 649 Secondary hypertension 481–482 Secondary hypoadrenalism 641, 642t Secondary polycythaemia 219 Seizures akinetic 753 classification 754t generalized tonic-clonic 753, 757t grand mal 753 myoclonic 753 partial 754, 757t petit mal 753, 757t tonic 753 typical absence 753 Selective oestrogen receptor modulators (SERMS) 633–634 Selective serotonin reuptake inhibitors 761 Selegiline 760 Senna, constipation 131 Sensory system 721–724, 722f–723f innervation, arms and legs 723f Sepsis 577, 577t nephrotic syndrome 369 Septic arthritis 296–297, 298b Septic shock 581 Septicaemia 15–16 Seronegative spondyloarthropathies 289–293, 289t Serotonin 5-HT3 antagonists 253 Serum 193 Serum iron 196f Sexual problems female 632–637 male 629–632 Sexually transmitted infections (STIs) 39–44 Sheehan’s syndrome 614 Shigella 292 Shigellosis (bacillary dysentery) 33t, 37 Shingles 19–20 Shock 572–582 causes 574t clinical features 575–577 management 576b, 578–581, 578b, 580t mediator release 574–575 microcirculatory changes 575 monitoring 581–582 neuroendocrine response 574–575 pathophysiology 574–582 Short bowel syndrome 96 Short-acting selective β2-adrenoceptor stimulants 564 Shoulder pain 274–275 Shy–Drager syndrome 761 Sick sinus syndrome 421 Sickle cell anaemia 211 Sickle cell trait 213 Sickle syndromes 210–211, 211f, 213t, 214b Sideroblastic anaemia 198 Sigmoidoscopy 68 Sildenafil 632 Simvastatin 693–694, 701 Sinus arrhythmia 421 Sinus bradycardia 421–422 Sinus rhythm 421, 432f control 430 Sinus tachycardia 425–427 Sinusitis 707 Sjögren’s syndrome 305–306 Skin bullous disease 815–816 common conditions 594–595 diabetes mellitus complications 686–687 infections 803–806 malignant tumours 816–818 necrosis 246 structure/function 804f systemic disease, signs 812–815 testing 529, 544–545 Small intestine (bowel) 92–99, 93t examination 69 tumours 98–99 Smoking 219, 445, 512–513, 517, 520–521 Sodium 349 balance 323, 324t, 328 regulation 332–337 retention 329–330 Sodium chloride 325–326, 327t, 337–338 Sodium citrate 132 Sodium cromoglicate 530 Sodium (FENa), fractional excretion 385, 385t Sodium nitroprusside 486, 579 Sodium valproate 757t Soft tissue infections 803–806 Index • 863 Solvents 603 Somatic gene mutations 251 Somatostatin 165 analogues 617 Somatostatinoma 191t Sorafenib 254 Sotalol 428, 430, 496 Spectinomycin 42 Spectrin 206–207 Sperm banking 403–404 Spherocytosis, hereditary 206–207 Spinal abscess 769 epidural 770 Spinal cord 778f compression 779–780, 779t disease 777–782 lesions 721–724, 764 Spinal muscular atrophies 784 Spinal root lesions 721 Spinal stenosis 279 Spine, kyphosis/scoliosis 558 Spirometer 509 Spironolactone 330t, 350, 442, 637, 657 Spleen 221–222 Splenectomy 208, 215–216, 221–222, 233 Splenic sequestration 211 Splenomegaly 221, 222t Spondylolisthesis 279 Spontaneous bacterial peritonitis (SBP) 167–168 Sputum 508–512, 536, 543, 556–557 Squamous cell carcinomas (SCC) 54, 78, 555t, 816 Squint 732 ST segment 415 ST segment elevation myocardial infarction (STEMI) 452–458 clinical features 452 complications 456–458, 457t investigations 452–454, 453f management 451b, 454–456, 455b prognosis 458 Staging systems 252, 264t Stanozolol 810 Staphylococci 297, 769 Staphylococcus aureus 15 bronchiectasis 524 infective endocarditis 467 long-term dialysis 397 lung abscess 540 meticillin-resistant (MRSA) 11 pneumonia 515, 539 septic arthritis 296 skin infection 803 spinal epidural abscess 770 Staphylococcus epidermidis 371t, 396 Staphylococcus saprophyticus 371t Starling mechanism 433–437 Statins 456, 693–695, 700 Status epilepticus 755–756, 756b Steatorrheoa 67 Stem cell transplantation 255–261 STEMI see ST segment elevation myocardial infarction (STEMI) Sterculia 130 Steroids bronchiectasis 524 giant cell arteritis 777 headache 268 inflammatory bowel disease (IBD) 103 inhaled, asthma 530 multiple sclerosis (MS) 765 pyoderma gangrenosum 814 synthetic 637 uses/problems 639t, 640–641 Steroid-sparing agents 532, 549 Stevens–Johnson syndrome 813 Stokes–Adams attacks 422–423 Stomach 79–86 Strabismus 732 Streptococci 808 Streptococci anginosus 769 Streptococcus pneumoniae 54, 222, 467, 707 Streptococcus pyogenes 803 Streptokinase 237, 248 Streptomycin 544 Stress incontinence 404 Stress ulcer 84–85 Stridor 708 Stroke 743–753 ABCDE assessment 745, 745t definition 743–744 management 748–750, 748b–749b pathophysiology 743–744 prognosis 750 risk factors 744 Strontium ranelate 313 Subacute (bacterial) endocarditis (SBE) 467–470, 468t 864 • Index Subacute combined degeneration of cord 790 Subarachnoid haemorrhage (SAH) 750 Subconjunctival haemorrhage 710t Subdural haematoma (SDH) 752–753 Sucralfate 165 Suicidal intent 595 Sulfasalazine 287 Sulphonamides 61 Sulphonylureas 673, 699 Sunitinib 254 Superficial spreading malignant melanoma 817 Superior vena cava syndrome 255–256 Suppurative pneumonia 515 Supraventricular tachycardias 425–431 Surgery acute disc disease 278–279 acute pancreatitis 188 aortic regurgitation 466 brain tumour 773 bronchiectasis 524 chronic obstructive pulmonary disease (COPD) 520–521 Cushing’s syndrome 644 diabetes mellitus 687–688 diverticular disease 109 epilepsy 757–758 gastric cancer 86 gastro-oesophageal reflux disease (GORD) 75 Graves’ disease 627 inflammatory bowel disease (IBD) 104–106 lung 520–521, 540–541, 557 mitral regurgitation 463 osteoarthritis 282 parathyroid adenoma 651 phaeochromocytoma 658 pulmonary embolism (PE) 475 thyroidectomy 625 urinary tract obstruction 383 variceal haemorrhage 165 warfarin 247 Swan–Ganz catheters 581–582 Swan-neck deformity 284f Sympathetic nervous system, activation 433, 436f Syncope 407–409, 717–718, 717t Syndrome of inappropriate ADH secretion (SIADH) 647–648, 647t Syngeneic donor cells 255 Synovial fluid analysis 274 Syphilis 43–44 congenital 43 neurosyphilis 770–771, 770t tertiary 43 Syringobulbia 780–782 Syringomyelia 780–782, 781f Systemic hypertension 481–486 aetiology 481–486 clinical features 482 investigations 482–483 management 483–486, 483t, 485f Systemic inflammatory vasculitis 306–309, 307t Systemic lupus erythematosus (SLE) 299–302 aetiology 300 clinical features 300, 301t epidemiology 299 investigations 300–302 management 302 pathogenesis 300 prognosis 302 Systemic sclerosis see Scleroderma T T waves 414 Tachycardia 420 supraventricular 425–431, 427t Tacrolimus 811 Tadalafil 632 Takayasu’s arteritis 308 Tamoxifen 254 Tapeworms (cestodes) 40t–41t Task specific tremor 724 Tazarotene 809 Tazobactam 56–57 Teaching, consent and Temazepam 796 Temperature regulation disorders 659–662 Temporal arteritis 777 Tension headache 774 Terbinafine 806 Terbutaline 530, 565 Teriparatide (recombinant human parathyroid peptide) 313–314 Terlipressin 165 Tertiary hyperparathyroidism 649 Testicular tumour 403–404 Testosterone 314 Tetracosactide stimulation tests 642t Index • 865 Thalamic lesions 724 Thalassaemia 208–209 α-thalassaemia 210 β-thalassaemia 209 Thalidomide 266 Theophylline 521, 567 Thiamazole 625 Thiamin (vitamin B1) 790 Thiazide diuretics 330t, 348 chronic heart failure 442 diabetes insipidus 646–647 oedema 367–368 systemic hypertension 484–486 Thiazolidinediones (‘glitazones’) 673 Thiopurine drugs 103 Thiopurine methyltransferase (TPMT) 103 Thoracic aneurysms 486 Three-step analgesic ladder (WHO) 268f Throat 707–708 sore 708 Thrombin inhibitors 244 Thrombocythaemia, essential 219–220, 220t Thrombocytopenia 230–231, 232t thrombin inhibitors 245–246 Thrombolysis in Myocardial Infarction (TIMI) risk score 450, 452t Thrombophilia 229 Thrombophlebitis, superficial 487 Thrombosis 236–239 Thrombotic thrombocytopenic purpura (TTP) 232t, 233 Thymectomy 793 Thyroid crisis (’thyroid storm’) 626 Thyroid disease 618–629 enlargement see Goitre function tests 619, 619t malignancy 629, 629t Thyroid hormones 662 Thyroidectomy 625 Thyroid-stimulating hormone (TSH) 607 Thyrotrophin-releasing hormone (TRH) 609 Tic douloureux 733–734 Tick-borne encephalitis (TBE) 768 Tics 762 Tilt testing 417 Tinea capitis 806 Tinea corporis 805 Tinea cruris 806 Tinea faciei 805 Tinea manuum 806 Tinea pudis 806 Tinea unguium 806 Tinidazole 61 Tiotropium 566 Tiotropium bromide 566 TIPS (transjugular intrahepatic portosystemic shunting) 165–167 TNF (tumour necrosis factor)-blocking drugs 291–293 TNF-α (tumour necrosis factor) inhibitors 287–288 Tocilizumab 288 Todd’s paralysis 754 Tolbutamide 673, 699 Tolcapone 760 Tolvaptan 336 Tongue disorders of 66t geographical 72 Topiramate 757t Total iron binding capacity (TIBC) 196f, 197 Total parenteral nutrition (TPN) 124, 124t Toxic confusional state (delirium) 794–795, 795t Toxic multinodular goitre 623 Toxic nodule/adenoma, solitary 623 Toxic shock syndrome 15 Toxoplasma gondii 31, 52, 768 Tramadol 187–188 Transient ischaemic attacks (TIAs) 744–746 definition 743 features 744t investigations 745, 745t pathophysiology 744 Transjugular intrahepatic portosystemic shunting (TIPS) 165–167 Transmissible spongiform encephalopathy 771 Transoesophageal echo 419 Transphenoidal surgical resection 617 Transplantation bone marrow see Bone marrow transplantation cardiac 442 haemopoietic stem cell 255–261 heart-lung 524, 526 kidney 397–398 liver 170 lung 526 pancreas, whole/islet 676 stem cell 255–261 866 • Index Transthoracic echo 417–419 Traveller’s diarrhoea 35–36 Tremor benign essential 761–763 intention 724 Parkinson’s disease 759 postural 724 resting 724 task specific 724 Treponema pallidum 43 Tretinoin 807 Trichomonas vaginalis 39 Trichophyton 805–806 Tricuspid regurgitation 467 Tricuspid valve disease 466–467 Tricyclic antidepressants (TCA) 268 overdose 600t Trigeminal autonomic cephalgias 776–777 Trigeminal (fifth cranial) nerve 732–733, 733f cutaneous distribution 733f Trigeminal neuralgia (tic douloureux) 733–734 Trimethoprim 61, 807 Tropical infections 24t Tropical sprue 95 Troponin I 454 Troponin T 454 Trousseau’s sign 651–652 Tuberculin test 548 Tuberculosis (TB) 97 chemoprophylaxis 545–546 clinical features 541–543, 542f epidemiology 541–546 extrapulmonary 543 investigations 543–544 management 544–545, 545t pathology 541 prevention 545–546 urinary tract 373–374 Tuberculous arthritis 297 Tuberous sclerosis (epiloia) 814 Tubular necrosis, acute 386, 386t Tubulointerstitial nephritis (TIN) 374 acute 374 chronic 374 Tumour lysis syndrome, acute 255–256 Tumours adrenal 645 brain 771–773, 772t gastric 86 genitourinary/kidney 399–401, 403–404 liver 179–180 neuroendocrine 191t, 192 oesophageal 78–79 pituitary space-occupying 611–612, 612f serum markers 252–253, 252t skin 816–818 small intestine 98–99 see also Carcinomas Typhoid fever 30 Tyrosine kinase inhibitors 254 U Ulcers cornea dentritic 712f Curling’s 84–85 duodenal (DUs) 81, 83 gastric (GUs) 81, 83 genital 43 mouth 72 post-phlebitic syndrome 237 rodent 816, 817f stress 84–85 ulcerative colitis (UC) see Inflammatory bowel disease (IBD) see also Peptic ulcers (PUs) Ulnar deviation 284f Ultrasound endoanal/endorectal 69 endoscopic (EUS) 69 gastrointestinal disease 69 heart disease 417–419, 418f heart failure 417–419, 439–440 musculoskeletal disease 274 renal disease 361 transabdominal 69 see also Echocardiography Ultraviolet light 300 A radiation (UVA) 809 Umbilical cord blood 255 Unconsciousness see Coma Unstable angina 446 Uraemia acute 386–387 postrenal 385–386 prerenal 384, 385t symptoms 387 Uraemic acidosis 347 Uraemic emergencies 387–388, 390t Uraemic toxins 395–396 Index • 867 Ureaplasma urealyticum 42, 292 Ureteral stones (urolithiasis) 377 Urethral stones 378–379 Urethral syndrome 373 Urethritis 42 chlamydia 42–43 Urge incontinence 404–405 Uric acid 294–295, 294t stones 378, 380 Urinary alkalinization 595 Urinary incontinence 404–405 Urinary tract bleeding 359f calculi 379t obstruction 381–383, 382t tuberculosis (TB) 373–374 Urinary tract infection (UTI) 353–355, 370–374, 371t pregnancy 373 recurrent 372–373 Urine microscopy 360–361 osmolality 384, 385t sodium 384, 385t specific gravity 384, 385t volume 386–387 Urine tests coma 742 dipstick 357–360 pneumonia 536 Urolithiasis (ureteral stones) 377 Urothelial tumours 400–401 Ursodeoxycholic acid 171 Urticaria 809–810 Uteric stones 378–379 Uveitis acute 709–712 anterior (iritis) 711t V Vaginal discharge 39 Vagus (tenth cranial) nerve 736 Valaciclovir 19–20, 735 Valproate 799 Valsartan 440, 484–485, 498–499 Valve replacement, mitral regurgitation 463 Valvular heart disease 459–470 Vancomycin C difficile and 34 infective endocarditis 470 Vardenafil 632 Varenicline tablets 513 Variant (Prinzmetal’s) angina 446 Variceal haemorrhage 163t, 164–166, 164f Varicella zoster virus (chickenpox) 19 Vascular complication, diabetes mellitus 681 macrovascular 681 microvascular 681 Vascular dementia 786 Vasculitis granulomatous lung disease with 549 systemic inflammatory 306–309, 307t Vasodilator therapy 440, 579 Vaso-occlusion 211–212 Vasopressin see Antidiuretic hormone (ADH) Venous disease 487–488, 488t Venous thromboembolism 238 risk factors 238t Venous thrombosis 237–238 nephrotic syndrome 369 Ventricular arrhythmias 456–457 Ventricular dilatation 437 Ventricular ectopic premature beats (extrasystoles) 431–433, 431f Ventricular fibrillation (VF) 431–432, 432f, 434b–435b Ventricular remodelling 437 Ventricular repolarization see QT interval Ventricular tachyarrhythmias 431–433 Ventricular tachycardia (VT) non-sustained 431–432 sustained 427t, 431 Verapamil 428, 477, 501 Vertigo 704–706, 736 benign paroxysmal positional 704–706 Very-low-density lipoproteins (VLDLs) 691 disorders 692–693 Vessel wall, haemostasis and 228 Vestibular neuronitis 705 Vestibulocochlear (eighth cranial) nerve 735–736 Vibrio cholerae 37 Video capsule endoscopy 69 Video-assisted thoracoscopic (VATS) lung biopsy 512 VIPoma 191t Viral infections 16–21, 53 868 • Index Visual system 726–730 visual field defects 726–730, 727f visual loss 709–712, 713t, 714b Vitamins, deficiency neuropathies 790 Vitamin B1 (thiamin) 790 Vitamin B6 (pyridoxine) 198, 544, 790 Vitamin B12 (hydroxocobalamin) haematological disease 195t, 199, 200t, 201, 235, 241, 790 intestinal resection 96 treatment 241–242 Vitamin D endocrine disease 649t, 652t, 653–655 rheumatology 310–311, 310f, 315–316, 321 Vitamin K 242 Vitiligo 687 Vitreous haemorrhage 713t Vomiting 65–66 cancer treatment 253 palliation 268–269 therapeutics 134–137 von Recklinghausen’s disease 814 von Willebrand’s disease 228, 234 W Warfarin antiphospholipid syndrome 303 haemostasis 246 indications 246 pulmonary embolism (PE) 475–476 pulmonary hypertension 472 thromboembolism 239 Water body content regulation 333 distribution 326f requirements 323, 324t Waterhouse–Friderichsen syndrome 15 Weakness 718–721, 719f, 720t Weber test 703 Wegener’s granulomatosis 549 Weight gain 675 Wenckebach block phenomenon 422, 423f Wernicke’s encephalopathy (WE) 604–606 ‘Wet’ age-related macular degeneration 713t Wheezing 508 Whipple’s disease 96–97 White blood cells 226–227 urine 360–361 Wilson’s disease 174 Wiskott–Aldrich syndrome 231 Wolff–Parkinson–White syndrome arrhythmias 494 atrioventricular junctional tachycardia 426f atrioventricular reciprocating tachycardia (AVRT) 427 Worms parasitic 39, 40t–41t roundworms 40t–41t tapeworms 40t–41t X Xerostomia (dry mouth) 306 Ximelagatran 237–238 X-rays achalasia 76 asthma 529 chronic obstructive pulmonary disease (COPD) 519 gastrointestinal disease 69–71 heart disease 409, 410f heart failure 438–440 lung, carcinoma of 556–557 musculoskeletal disease 273–274 neurological disease 737 pleural effusion 559, 559f pneumonia 535, 536f pneumothorax 562, 562f pulmonary embolism (PE) 473–475 respiratory disease 509–510, 510f sarcoidosis 548 tuberculosis (TB) 543, 545 Y Yersinia 292 Z Zafirlukast 532 Zanamivir 515 Zoledronate 266, 313 Zollinger–Ellison syndrome 191t Zopiclone 796 Zoster-immune immunoglobulin (ZIG) 19 Medical emergencies SYMPTOM BASED Acute chest pain 407 Acute breathlessness 507-508 Coma 738-743 Delirium (toxic confusional state) 794-795 Fever in the returned traveller 22-24 Headache 715 Shock 578b SYSTEM BASED Infectious diseases and tropical medicine Septicaemia 15 Fever in the returned traveller 22-24 Malaria 24-29 Gastroenterology and nutrition Oesophageal perforation 78 Acute upper gastrointestinal bleeding 89b Lower gastrointestinal bleeding 91 Intestinal ischaemia 98 Acute severe colitis 105b The acute abdomen 118-121 Liver, biliary tract and pancreatic disease Fulminant hepatic failure 158 Bleeding oesophageal varices 164-166 Acute cholecystitis 182-183 Acute cholangitis 183-184 Acute pancreatitis 185-188 Diseases of the blood and haematological malignancies Fever in the neutropenic patient 205b Sickle cell crisis 214b Warfarin excess 246 Malignant disease Superior vena cava syndrome 255-256 Acute tumour lysis syndrome 255-256 Spinal cord compression 779-780 Fever in the neutropenic patient 205b Hypercalcaemia 651b Rheumatology Septic arthritis 296-297 Acute monoarthritis 298b Giant cell arteritis 777 Water and electrolytes Hyponatraemia 336b Hypernatraemia 337 Hypokalaemia 338 Hyperkalaemia 342b Hypomagnesaemia 342-343 Hypermagnesaemia 343 Disorders of acid–base balance 343-348 Renal disease Renal colic 379-381 Acute renal failure/kidney injury 389b Cardiovascular disease Acute chest pain 407 Cardiac arrhythmias 420 Cardiac arrest 434b-435b Acute heart failure 444b Acute coronary syndrome 451b ST elevation myocardial infarction 455b Pulmonary embolism 474b Pericardial tamponade 480 Severe hypertension 486 Ruptured abdominal aortic aneurysm 486-487 Aortic dissection 486-487 Deep venous thrombosis 487 Respiratory disease Acute breathlessness 507-508 Massive haemoptysis 508 Inhaled foreign body 515 Acute exacerbation of chronic obstructive airways disease 521-522 Acute severe asthma 533b Pneumonia 538f-539f Pneumothorax 563f Intensive care medicine Shock 578b Anaphylaxis 576b Sepsis 577 Respiratory failure 584-586 Poisoning, drug and alcohol abuse Drug overdose 598b, 594-595 Wernicke–Korsakoff syndrome 604-605 Alcohol withdrawal 606b Delirium tremens 605 Endocrinology Myxoedema coma 622b Thyroid crisis 626 Addisonian crisis 640b Syndrome of inappropriate ADH secretion 648 Hypercalcaemia 651b Hypocalcaemia 653 Hypophosphataemia 654-655 Hypothermia 661b Hyperthermia 661-662 Diabetes mellitus and other disorders of metabolism Hypoglycaemia 675 Diabetic ketoacidosis 679b Hyperosmolar hyperglycaemic state 678-680 The special senses Epistaxis 707 Stridor 708 The red eye 708-709 Sudden loss of vision 714b Neurology Headache 715 Coma 738-743 Transient ischaemic attack 744-746 Stroke 748b-749b Intracranial haemorrhage 750-753 Status epilepticus 756b Meningitis 767b Encephalitis 768 Giant cell arteritis (temporal arteritis) 777 Spinal cord compression 779-780 Guillain–Barré syndrome 788-789 Delirium (toxic confusional state) 794-795 Dermatology Necrotizing fasciitis 805 Gas gangrene 805 Angio-oedema 809-810 Bullous disease 815-816 This page intentionally left blank Normal values HAEMATOLOGY Haemoglobin Male Female Mean corpuscular haemoglobin (MCH) Mean corpuscular haemoglobin concentration (MCHC) Mean corpuscular volume (MCV) Packed cell volume (PCV) Male Female White blood count (WBC) Basophil granulocytes Eosinophil granulocytes Lymphocytes Monocytes Neutrophil granulocytes Platelet count Serum B12 Serum folate Red cell folate Red cell mass Male Female Reticulocyte count Erythrocyte sedimentation rate (ESR) COAGULATION Bleeding time (Ivy method) Activated partial thromboplastin time (APTT) Prothrombin time International normalized ratio (INR) D-dimer LIPIDS AND LIPOPROTEINS Cholesterol High-density lipoprotein (HDL) cholesterol Male Female Low-density lipoprotein (LDL) cholesterol Triglycerides Male Female BIOCHEMISTRY (SERUM/PLASMA) Alanine aminotransferase (ALT) Albumin Alkaline phosphatise 13.5–17.5 g/dL 11.5–16 g/dL 27–32 pg 32–36 g/dL 80–96 fL 0.40–0.54 L/L 0.37–0.47 L/L 4–11 × 109/L