Ebook Essentials of Kumar and Clark''s clinical medicine (5th edition): Part 1

Medical emergencies
Numbers refer to pages in text
SYMPTOM BASED
Acute chest pain  395
Acute breathlessness  488
Coma  720
Delirium (toxic confusional state)  779
Fever in the returned traveller  22
Headache  695
Shock  552
SYSTEM BASED
Infectious diseases and tropical medicine
Septicaemia  12
Fever in the returned traveller  22
Malaria  24
Gastroenterology and nutrition
Oesophageal perforation  000
Acute upper gastrointestinal bleeding  82
Lower gastrointestinal bleeding  000
Intestinal ischaemia  000
Acute severe colitis  101
The acute abdomen  115
Liver, biliary tract and pancreatic disease
Fulminant hepatic failure  144
Bleeding oesophageal varices  150
Acute cholecystitis  000
Acute cholangitis  000
Acute pancreatitis  175
Diseases of the blood and haematological
malignancies

Fever in the neutropenic patient  196
Sickle cell crisis  204
Warfarin excess  000
Malignant disease  000
Superior vena cava syndrome  000
Acute tumour lysis syndrome  000
Spinal cord compression  764
Fever in the neutropenic patient  196
Hypercalcaemia  633
Rheumatology
Septic arthritis  277
Acute monoarthritis  278
Giant cell arteritis  762
Water and electrolytes
Hyponatraemia  317
Hypernatraemia  321
Hypokalaemia  322
Hyperkalaemia  324
Hypomagnesaemia  000
Hypermagnesaemia  000
Disorders of acid–base balance  327
Renal disease  000
Renal colic  364
Acute renal failure/kidney injury  369
Cardiovascular disease
Acute chest pain  395
Cardiac arrhythmias  408
Cardiac arrest  421
Acute heart failure  432
Acute coronary syndrome  439

ST elevation myocardial infarction  442
Pulmonary embolism  466
Pericardial tamponade  474

Severe hypertension  482
Ruptured abdominal aortic aneurysm  482
Aortic dissection  483
Deep venous thrombosis  000
Respiratory disease
Acute breathlessness  000
Massive haemoptysis  489
Inhaled foreign body  496
Acute exacerbation of chronic obstructive
airways disease  501
Acute severe asthma  514
Pneumonia  515
Pneumothorax  546
Intensive care medicine
Shock  552
Anaphylaxis  552
Sepsis  000
Respiratory failure  563
Poisoning, drug and alcohol abuse
Drug overdose  569
Wernicke–Korsakoff syndrome  584
Alcohol withdrawal  585
Delirium tremens  586
Endocrinology
Myxoedema coma  612
Thyroid crisis  613

Addisonian crisis  622
Syndrome of inappropriate ADH
secretion  629
Hypercalcaemia  633
Hypocalcaemia  636
Hypophosphataemia  000
Hypothermia  644
Hyperthermia  646
Diabetes mellitus and other disorders of
metabolism
Hypoglycaemia  657
Diabetic ketoacidosis  658
Hyperosmolar hyperglycaemic state  660
The special senses
Epistaxis  000
Stridor  687
The red eye  687
Sudden loss of vision  690
Neurology
Headache  695
Coma  720
Transient ischaemic attack  000
Stroke  725
Intracranial haemorrhage  733
Status epilepticus  740
Meningitis  750
Encephalitis  000
Giant cell arteritis (temporal arteritis)  762
Spinal cord compression  764
Guillain–Barré syndrome  000

Delirium (toxic confusional state)  779
Dermatology
Necrotizing fasciitis  000
Gas gangrene  000
Angio-oedema  000
Bullous disease  000


Essentials of Kumar & Clark’s Clinical Medicine


ESSENTIALS
Series Editors

Professor Parveen Kumar
Professor of Clinical Medicine and Education
Barts and The London School of Medicine and Dentistry
Queen Mary University of London, and
Honorary Consultant Physician and Gastroenterologist
Barts and the London NHS Trust and Homerton University Hospital
NHS Foundation Trust, London, UK
and

Dr Michael Clark
Honorary Senior Lecturer, Barts and
The London School of Medicine and Dentistry
Queen Mary University of London
London, UK

Commissioning Editor: Pauline Graham

Development Editor: Helen Leng
Project Manager: Gopika Sasidharan
Designer/Design Direction: Stewart Larking
Illustration Manager: Gillian Richards


ESSENTIALS OF

Kumar & Clark’s

CLINICAL
Medicine
Fifth edition

ANNE BALLINGER MD FRCP
Consultant Gastroenterologist and General Physician
Queen Elizabeth The Queen Mother Hospital
East Kent Hospitals University NHS Foundation Trust
Kent, UK

Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto  2011


© 2011 Elsevier Ltd/B.V. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the Publisher. Details on how to seek permission, further information about
the Publisher’s permissions policies and our arrangements with organizations such as the Copyright
Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
First edition 1995
Second edition 2000
Third edition 2003
Fourth edition 2007
Fifth edition 2011
ISBN 9780702035234
International ISBN 9780702035241
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas

contained in the material herein.
 
Printed in China

Working together to grow
libraries in developing countries
www.elsevier.com | www.bookaid.org | www.sabre.org

The
publisher’s
policy is to use
paper manufactured
from sustainable forests


Contents
Medical emergencies
Series preface
Preface
Abbreviations
Significant websites

Inside front cover
vii
ix
xi
xv

1 Ethics and communication



2 Infectious diseases

11



3 Gastroenterology and nutrition

65

1



4 Liver, biliary tract and pancreatic disease

139



5 Haematological disease

193

6 Malignant disease

251



7 Rheumatology

271



8 Water, electrolytes and acid–base balance

323



9 Renal disease

353



10 Cardiovascular disease

407

11 Respiratory disease

505



12 Intensive care medicine

571



13 Drug therapy, poisoning and alcohol misuse

589



14 Endocrine disease

607



15 Diabetes mellitus and other disorders of metabolism

667

16 The special senses

703



17 Neurology

715



18 Dermatology

803

Dictionary of terms
Index
Normal values

819
831
Inside back cover


This page intentionally left blank


Series Preface
Medical students and doctors in training are expected to travel to different

hospitals and community health centres as part of their education. Many
books are too large to carry around, but the information they contain is often
vital for the basic understanding of disease processes.
The Essentials series is designed to provide portable, pocket-sized companions for students and junior doctors. They are most useful for clinical
practice, whether in hospital or the community, and for exam revision.
The notable success of Essentials of Clinical Medicine over many editions is
shown by its presence in the pockets of all healthcare professionals – nurses,
pharmacists, physical and occupational therapists, to name a few – not
simply medical students and doctors.
All the books in the series have the same helpful features:
�
�
�
�
�
�

Succinct text
Simple line drawings
Emergency and other boxes
Tables that summarize causes and clinical features of disease
Exam questions and explanatory answers – now online
Dictionary of terms

They contain core material for quick revision, easy reference and practical
management. The modern format makes them easy to read, providing an
indispensable ‘pocket essential’.

Parveen Kumar and Michael Clark
Series Editors

This page intentionally left blank


Preface
This is the fifth edition of ‘Pocket’ Essentials of Clinical Medicine and we
continue to strive to produce a small medical textbook with anatomy, physiology and pathophysiology as a key part to understanding clinical features and
treatment for each disease process. The book is based on its parent textbook,
Kumar and Clark’s Clinical Medicine, from which we have taken these core
principles. The ‘Pocket’ has been dropped from the title in recognition that
white coats, and with it the pocket, have been largely discarded in clinical
areas. However, the book has remained small so that it is easy to carry
around and use as a portable reference source. The revised title, Essentials
of Kumar and Clark’s Clinical Medicine reflects the close association with its
parent text.
The fifth edition has been extensively revised and updated, in line with
changes in clinical medicine and with its parent text. Since the publication
of the fourth edition there have been huge changes in many areas of medicine. Stroke medicine is now a specialty of its own with thrombolysis a routine
treatment for ischaemic stroke, and emergency triage and assessment of
transient ischaemic attack. The biological agents are used earlier and with
expanded indications in both rheumatology and gastroenterology. Advances
in imaging have seen PET scanning in routine staging of malignancy, CT and
MRI used in the assessment of cardiovascular disease and CT colonography
competing with and complementing conventional colonoscopy. These name
a small percentage of the advances in clinical medicine that have been
incorporated into this edition.
Malignant disease is a new chapter in the fifth edition, in which we have
described specific and symptomatic treatment of cancer, discussed oncological emergencies and also dealt with care of the dying patient. ‘Practical
procedures’ was introduced in the third edition but we have now removed

this chapter. In this era of internet videos, animated procedures and simulation teaching this topic is far better dealt with outside of a textbook. We have
also removed ‘Therapeutics’ as an individual chapter and instead have put a
section at the end of each chapter specifically dedicated to a description of
common drugs relevant to that system. It is beyond the scope of this book
to provide an exhaustive drug list that covers prescribing in all patient groups.
We have also removed the examination questions that have appeared in
previous editions. These will appear in a different format as a stand-alone
text. The changes to the chapters have allowed us to expand the text dedicated to the description and management of diseases in clinical medicine.
In previous editions we have extensively cross-referenced to the current
edition of the parent textbook Clinical Medicine. This formatting has been
removed from the fifth edition of Essentials of Clinical Medicine because we
no longer assume that a single edition of Clinical Medicine is in widespread


x  •  Preface
use and because the page headings in Clinical Medicine mean that topic
navigation is rapid and straightforward.
The fifth edition of Essentials of Clinical Medicine has seen many changes
from previous editions. However one constant feature throughout is the
support and assistance of Mike Clark and Parveen Kumar, the editors of
Clinical Medicine and this series of small textbooks.
Anne Ballinger


Abbreviations
ACE angiotensin-converting enzyme
ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone
AF atrial fibrillation
AIDS acquired immunodeficiency syndrome

ALS advanced life support
ANA antinuclear antibodies
ANCA antineutrophil cytoplasmic antibodies
ANF antinuclear factor
APACHE acute physiology and chronic health evaluation
ARDS adult respiratory distress syndrome
AST aspartate aminotransferase
AV atrioventricular
AXR abdominal X-ray
BCG bacille Calmette–Guérin
BMD bone mineral density
BMI body mass index
BP blood pressure
COPD chronic obstructive pulmonary disease
CAPD continuous ambulatory peritoneal dialysis
CCF congestive cardiac failure
CCU coronary care unit
CLL chronic lymphatic leukaemia
CML chronic myeloid leukaemia
CNS central nervous system
CPR cardiopulmonary resuscitation
CRP C-reactive protein
CSF cerebrospinal fluid
CT computed tomography


xii  •  Abbreviations
CVP central venous pressure
CXR chest X-ray
DIC disseminated intravascular coagulation

DMARDs disease-modifying antirheumatic drugs
DNA deoxyribonucleic acid
DVT deep venous thrombosis
DXT dual energy X-ray absorptiometry
ECG electrocardiogram
EEG electroencephalogram
ELISA enzyme-linked immunosorbent assay
ERCP endoscopic retrograde cholangiopancreatography
ESR erythrocyte sedimentation rate
EUS endoscopic ultrasound
FBC full blood count
GABA γ-aminobutyric acid
γ-GT γ-glutamyltranspeptidase
GFR glomerular filtration rate
GORD gastro-oesophageal reflux disease
Hb haemoglobin
HDU high-dependency unit
5-HIAA 5-hydroxyindoleacetic acid
HIV human immunodeficiency virus
HLA human leucocyte antigen
ICD International Classification of Diseases – the classification used to
code and classify mortality data from death certificates
ICD-9-CM ICD, Clinical Modification – used to code and classify morbidity
data from the inpatient and outpatient records, general practices
and Health Statistic surveys
ICU intensive care unit
Ig immunoglobulin (e.g. IgM = immunoglobulin the M class)
i.m. intramuscular
INR international normalized ratio

Abbreviations  •  xiii
iu/IU international unit
i.v. intravenous
IVP intravenous pyelogram
JVP jugular venous pressure
LP lumbar puncture
LVF left ventricular failure
MCV mean corpuscular volume
ME myalgic encephalomyelitis
MRI magnetic resonance imaging
MRSA meticillin-resistant Staphylococcus aureus
MSU mid-stream urine
Na+ concentration of sodium ions
nd notifiable disease
NICE National Institute for Health and Clinical Excellence
NSAIDs non-steroidal anti-inflammatory drugs
OGD oesophagogastroduodenoscopy
Paco2 partial pressure of carbon dioxide in arterial blood
Pao2 partial pressure of oxygen in arterial blood
PCR polymerase chain reaction
PCV packed cell volume
PEG percutaneous endoscopic gastrostomy
PET positron emission tomography
PPI proton pump inhibitor
PR per rectum (rectal instillation)
PT prothrombin time
PTC percutaneous transhepatic cholangiography
PTCA percutaneous transluminal coronary angioplasty
PTTK partial thromboplastin time with kaolin

RAST radioallergosorbent test
RCC red cell count
RhF rheumatoid factor


xiv  •  Abbreviations
RIA radioimmunoassay
RNA ribonucleic acid
s.c. subcutaneous
SLE systemic lupus erythematosus
STI sexually transmitted infection
SVC superior vena cava
SVT supraventricular tachycardia
TIA transient ischaemic attack
TNM tumour, node, metastasis classification
TPN total parenteral nutrition
TRH thyrotrophin-releasing hormone
TSH thyroid-stimulating hormone
UTI urinary tract infection
VDRL Venereal Disease Research Laboratory (test for syphilis)
VF ventricular fibrillation
VIP vasoactive intestinal polypeptide
VT ventricular tachycardia
WBC white blood (cell) count
WCC white cell count
WE Wernicke’s encephalopathy


Significant websites
GENERAL WEBSITES

Medical dictionaries
/> />
Guidelines and evidence based medicine
/>The National Library of Guidelines is a collection of guidelines for the NHS.
It is based on guidelines produced by NICE and other national agencies

UK National Institute for Health and Clinical Excellence
/>US National Institutes of Health

Scottish Intercollegiate Guidelines Network

NHS Evidence – evidence-based clinical and non-clinical information to
help make decisions about treatment and use of resources
/>National Guideline Clearing House
/>Driver and Vehicle Licensing Agency – guide to the current medical
standards of fitness to drive and exclusions
/>Cochrane Reviews are part of the Cochrane Library and provide systematic
reviews of primary research in human healthcare and health policy. They
investigate the effects of interventions for prevention, treatment and
rehabilitation. They also assess the accuracy of a diagnostic test for a given
condition in a specific patient group and setting
/>Monthly journal on evidence-based healthcare

eMedicine features up-to-date, searchable, peer-reviewed medical journals,
on-line physician reference textbooks, and a full-text article database. Also
patient information leaflets


xvi  •  Significant websites

British Medical Association. A library, excellent ethics section and
healthcare information. More sections for members

Medical calculators
/> />Clinical calculators and formulas for many conditions, e.g. sodium
correction rate in hyponatraemia, APACHE II score and anion gap

Healthcare journals and magazines
/>BMJ (British Medical Journal)
/>Chief Medical Officer’s publications

Medical societies and organizations
/>UK General Medical Council

Others
/>Search for the definitions of ICD9/ICD-9-CM codes
/>PubMed: Medline on the Web


Information for patients on diseases, operations and investigations

Charity providing a life-saving identification system for individuals with
hidden medical conditions and allergies

CHAPTER-SPECIFIC WEBSITES
1  Ethics and communication
/>British Medical Association ethics site

UK Clinical Skills Network

Significant websites  •  xvii

UK Clinical Ethics Network
/>General Medical Council
/>National Institutes of Health website – bioethics pages
/>European Association for Communication in Healthcare
/>World Medical Association policy

2  Infectious diseases

US Department of Health and Human Services, Centers for Disease Control
and Prevention (CDC). The CDC has a major role in public health efforts to
prevent and control infectious and chronic diseases, injuries, workplace
hazards, disabilities, and environmental health threats
/>Department of Health Expert Advisory Group on AIDS: information about
post-exposure prophylaxis, guidelines for pre-test discussion on HIV testing
and risks of transmission
/>Centers for Disease Control and Prevention: HIV/AIDS treatment/information
service

The communication centre for infectious diseases

National Foundation for Infectious Disease, USA

Health Protection Agency website. Provides up-to-date information for
medical practitioners on some infectious diseases and their prevention,
particularly those that are new or where an epidemic is expected
/>UK Public Health Laboratory Service: UK regional information on infections
/>The World Health Organization is the United Nations specialized agency for

health. The website provides information and fact sheets on many
infectious diseases, and much more

3  Gastroenterology and nutrition
/>Nutrient analysis tool. Free analysis of the nutrient content of food


xviii  •  Significant websites

British Society of Gastroenterology. Regularly updated clinical practice
guidelines for many common conditions
/>American Gastroenterology Association medical position statements provide
preferred approaches to specific medical problems or issues

Information for patients and relatives
– Coeliac UK
– Core
– National Digestive
Diseases information clearing house
/>Association Patient Centre

–

American

Gastroenterology

– National Association for Crohn’s and Colitis

4  Liver, biliary tract and pancreatic disease

/>American Association for the Study of Liver Disease practice guidelines

European Association for the Study of the Liver
/>British Association for the Study of the Liver

Information for patients and relatives
– British Liver Trust
– American Liver Foundation
– The National Pancreas Foundation

5  Haematological disease

The British Committee for Standards in Haematology. Guidelines for medical
practitioners on diagnosis and treatment of haematological diseases

American Society of Haematology. Clinical guidelines, self-assessment
program, teaching cases and video library


Significant websites  •  xix

Information for patients and relatives
– UK National Blood Service
– The Haemophilia Society for patients
affected by bleeding disorders
– Leukaemia Foundation
www.sicklecellsociety.org – Sickle Cell Society

6  Malignant disease

US National Cancer Institute provides cancer statistics, patient information
and clinical trials
/>NHS National End of Life Care Programme

Information for patients and relatives
– Macmillan Cancer Support
– Cancer Research UK

7  Rheumatology

The British Society for Rheumatology. Clinical guidelines for medical
practitioners

Arthritis Research UK. Publications on musculoskeletal conditions

National Osteoporosis Society. Guidance on investigation and management
of osteoporosis
/>American College of Rheumatology clinical practice guidelines

Information for patients and relatives
– British Society for Rheumatology
– Arthritis Research UK
– National Osteoporosis Society
– National Rheumatoid Arthritis Society


xx  •  Significant websites

8/9  Water, electrolytes and acid–base balance/
Renal disease

/>ARUP Consult; the physician’s guide to life-threatening electrolyte
abnormalities

British Renal Society, guidance on clinical management
/>National Kidney Foundation clinical practice guidelines

The Renal Association guidelines

Nephronline management and guidance section for health professionals

Information for patients and relatives
– UK National Kidney Federation
– Nephronline

10  Cardiovascular disease

European Resuscitation Council (ERC). Latest guidelines on resuscitation, as
well as a full overview of the ERC educational tools such as manuals,
posters and slides

Resuscitation Council (UK). Resuscitation guidelines

European Society of Cardiology clinical practice guidelines

American College of Cardiology

ECG tracings library to help improve ECG skills

Information for patients and relatives
– British Heart Foundation

– American Heart Association

11  Respiratory disease

British Thoracic Society. Clinical practice guidelines and clinical information


Significant websites  •  xxi

The WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD).
Clinical guidelines on diagnosis, treatment and prevention of COPD

American Thoracic Society, clinical practice guidelines

Information for patients and relatives
– British Thoracic Society
– Asthma UK
– The WHO Global Initiative for COPD
– American Thoracic Society
– The Quit Smoking Company
– NHS Quit Smoking Service

12  Intensive care medicine

European Society for Intensive Care guidelines and recommendations for
medical practitioners

UK Intensive Care Society standards and guidelines for medical
practitioners

Surviving Sepsis Campaign clinical guidelines

Information for patients and relatives
– UK Intensive Care Society
– Surviving Sepsis Campaign

13  Drug therapy, poisoning and alcohol misuse

Medicines and Healthcare Products Regulatory Agency includes http://
yellowcard.mhra.gov.uk to report suspected side-effects to any medication

Toxbase. Database of UK National Poisons Information Service

US National Library of Medicine Toxicology and Environmental Health
Information Program. Toxicology, environmental health, chemical databases
and other information resources


xxii  •  Significant websites
/>International Programme on Chemical Safety contact details of all poisons
– centres world-wide.
/>Department of Health. Detailed information on carbon monoxide poisoning

Information for patients and relatives
www.patient.co.uk/dils.asp – Patient UK. Information leaflets on specific
medicines and drugs
helps people assess their drinking patterns. o – useful information about harmful
effects of alcohol and guidelines for safe drinking

14  Endocrine disease

US National Endocrine and Metabolic Diseases Information Service

Society for Endocrinology. Clinical updates, clinical cases and publications
related to endocrinology

Information for patients and relatives
– website for diabetes, osteoporosis,
thyroid, parathyroid and other endocrine disorders
– The Pituitary Foundation (UK). Information
and support for those living with pituitary disorders

15  Diabetes mellitus and other disorders of
metabolism

International Diabetes Federation

Information for patients and relatives
– Diabetes UK
– American Diabetes Association.
– Juvenile Diabetes Research Foundation (UK)

16  The special senses

National Eye Institute with a professional section of statistics and pathology
collection


Significant websites  •  xxiii
/>Online atlas of ophthalmology

British Association of Otorhinolaryngologists, guidelines and position papers

Information for patients and relatives
– Deafness Research UK
– National Eye Institute
– British Association of Otorhinolaryngologists

17  Neurology

Documents relating to evidence-based neurology

Information for patients and relatives
– Epilepsy Action
– Guillain–Barré Syndrome Support Group
– UK Multiple Sclerosis Society
– Parkinson’s Disease Society
– The Stroke Association (UK)

18  Dermatology
www.dermatlas.com
A collection of 11 750 images in dermatology and skin disease

British Association of Dermatologists clinical guidelines and other
professional information.

Information for patients and relatives
– UK National Eczema Society
– Psoriatic Arthropathy Alliance (psoriasis)

Therapeutics
– British National Formulary. Authoritative and practical
information on the selection and clinical use of drugs
– Drug and Therapeutics Bulletin. Independent
reviews of medical treatment.
Registration is necessary for these websites.