3.1 Assessment of acute-phase response 121
3.1.1 Erythrocyte
sedimentation rate 121 3.1.2 C-reactive protein 121 3.2 Serological investigation of
autoimmune rheumatic disease 122
3.2.1 Antibodies to nuclear antigens 122
3.2.2 Antibodies to double-stranded DNA 123 3.2.3 Antibodies to extractable
nuclear antigens 124 3.2.4 Rheumatoid factor 125 3.2.5 Antineutrophil
cytoplasmic antibody 125 3.2.6 Serum complement
concentrations 125 3.3 Suspected immune deficiency
in adults 126
3.4 Imaging in rheumatological disease 129
3.4.1 Plain radiology 129 3.4.2 Bone densitometry 130 3.4.3 Magnetic resonance
imaging 131
3.4.4 Nuclear medicine 131 3.4.5 Ultrasound 132 3.5 Arthrocentesis 132 3.6 Corticosteroid injection
techniques 133
3.7 Immunoglobulin replacement 135
Self-assessment 138
A
Abbreviated Mental Test Score 22, 57 abdominal pain 54 – 6
examination 55 history 54 –5
investigation 55 – 6, 56 management 56 ACE inhibitors 18 N-acetylcysteine 101
acid-base disturbance, correction of 64 ACTH 73
activated charcoal 100, 100, 124, 130 acute coronary syndrome 15 –19
antiplatelet therapy 18 diagnosis 16
examination 16 history 16
hypotension in 20 –1 investigation 16 –18, 17 resuscitation 16
acute intermittent porphyria 56 acute scenarios
abdominal pain 54 – 6
acute spastic paraparesis 79 – 81 Addisonian crisis 71– 4
airways obstruction 42 – 4 anaphylaxis 90 –1 asthma 33 – 6 back pain 94 – 6 bloody diarrhoea 51– 4 bradyarrhythmia 27–30 cardiac arrest 8 –12
chest infection /pneumonia 39 – 42 chest pain and hypotension 12–15 collapse of unknown cause 30 –3 coma 86 – 9
diabetic ketoacidosis 62–5 fever in returning traveller 89 –90 hepatic encephalopathy/alcohol
withdrawal 56 –9 hypoglycaemia 65–7 hyponatraemia 69 –71 hypotension in acute coronary
syndrome 20 –1 join pain 91– 4 pleurisy 36 –9 pneumothorax 46 – 8
postoperative breathlessness 21–3 renal failure, fluid overload and
hyperkalaemia 59 – 62 self-harm 96 –7 severe headache 75 – 9
status epilepticus 81–3 stridor 44 – 6
stroke 83 – 6
tachyarrhythmia 23 –7 thrombolysis 15 –19 thyrotoxic crisis 74 –5
upper gastrointestinal haemorrhage 48–51
violence and aggression 97–9 acute spastic paresis 79 – 81
examination 80 nervous system 80 Guillain-Barré syndrome 80 history 79 – 80
investigation 80 –1, 80 management 81
Addisonian crisis 71– 4, 122, 129 examination 72
history 72
investigation 72–3, 83 management 73 – 4 adenosine 26 –7
adrenaline see epinephrine adrenal insufficiency 72 advanced life support 9, 10 airway/breathing 12 airway management 113 –17
basic 113 –16
adjuncts to airway control 114 head tilt/chin lift 113, 115 jaw thrust 113, 115 nasopharyngeal airway 115 oropharyngeal airway 114 removal of obstruction from oropharynx 114
tracheostomy 116 –17 airways obstruction 42– 4
cause of deterioration 43 examination 43
history 42–3 investigation 43 management 43 – 4 alcohol abuse 56 – 9, 82 alcohol withdrawal 57, 59 allergy 127, 132
amaurosis fugax 84 aminophylline 35 amoxicillin 44 amylase 55 analgesia 21, 77
anaphylactoid reactions 91 anaphylaxis 90 –1
examination, investigation and further
management 91 history 91
immediate management 91 animal bites 126 –7, 131–2 antiarrhythmics 11 antibiotics 15, 126 –7, 131–2
pneumonia 42 septic arthritis 94
anticoagulants, acute cardiac syndrome 18 antiplatelet therapy 18
aortic dissection 19, 19, 128, 132 artemether 90
arterial blood gases 23, 34, 37, 61 diabetic ketoacidosis 63 interpretation 113 measurement 112–13
preparation 112 technique 112, 113 normal values 113 pneumonia 40 aspirin 18, 86 asthma 33 – 6, 122, 129
examination 34, 34 history 33
investigation 34 – 5 management 35 – 6
atrial fibrillation 25, 26, 75, 125, 126, 131 treatment 27
atrial flutter 25, 26
atrioventricular block 120, 120 atropine 30
autoimmune diseases 72
B
back pain 94 – 6, 124 –5, 130 examination 94 –5, 95 history 94
investigation 95 management 95 – 6 red flags 94 basic life support 9, 9
Bence Jones proteinuria 68, 81 beta-blockers 18
overdose 30 binge drinking 57 bisphosphonates 69 blood pressure 22 bloody diarrhoea 51– 4
examination 52 history 51–2, 51
investigation 52–3, 52, 53 management 53 – 4 Note: page numbers in italics refer to figures, those in bold refer to tables.
Boerhaave’s syndrome 49 bradyarrhythmia 27–30, 108
examination 28 –9 history 28
investigation 29, 29 management 29 –30
and myocardial infarction 30 breaking bad news 3 – 4 breathlessness 13 –14, 36, 40
postoperative 21–3, 59 – 62
and spinal cord compression 79, 80 bronchodilators 35, 44
bronchoscopy 45 bronchospasm 45 Brudzinski’s sign 78 buffers 11
C
cachexia 68 calcitonin 69 calcium gluconate 60 Campylobacter jejuni 81 carbimazole 75 cardiac arrest 8 –12advanced life support 9, 10 antiarrhythmics 11 basic life support 9, 9 buffers 11
categories of 9 –10 communication 3 – 4 confirmation of 8 –9 outcome 11 pacing 11
post-resuscitation management 11 potentially reversible causes 10 –11 return of spontaneous circulation 11 stopping resuscitation 11
who to resuscitate 9 who should be notified 4 cardiac pacing 30, 107–9
indications 108 problems 109
technique 108 –9, 108, 109 cardiac syncope 32
cardioversion 109
cauda equina syndrome 95 central venous lines 13, 103 – 6
central venous pressure 106, 106 complications 103
consent for insertation 103 contraindications 103 indications 103
preparation for insertion 103 Seldinger technique 104 –5, 104
femoral vein 105, 106 internal jugular vein 104, 104 subclavian vein 105
central venous pressure 13, 106, 106 abnormal 106
cerebral oedema 64
cerebrospinal fluid 108 chest infection 22, 39 – 42 chest pain 13, 40 chest wall tenderness 37 chest X-ray
asthma 35
bloody diarrhoea 52 pleurisy 37
pneumonia 40 –1, 41 pneumothorax 47
postoperative breathlessness 22, 23 Cheyne-Stokes respiration 88 chloroquine 90
chlorpheniramine 91
chronic obstructive pulmonary disease 22, 42 – 4
circulation 12 clomthiazole 59 clopidogrel 18
Clostridium difficile 51, 52, 53, 123, 129–30 clubbing 45
coagulopathy 59 coiling 77 colchicine 93
collapse of unknown cause 30 –3 examination 32–3
history 31–2 investigation 33 management 33 colonic infection 51 coma 86 –9
differential diagnosis 88 examination 87– 8
Glasgow Coma Scale 4, 5, 20, 22, 76, 82, 84, 87
history 87
immediate maximum 87 investigation 88 management 88 –9 common law 97
communication skills and ethics acute pneumothorax 7– 8 cardiac arrest 3 – 4
community-acquired pneumonia 7 congestive cardiac failure 5 – 6 lumbar back pain 6 –7 stroke 4–5
community-acquired pneumonia 7 computed tomography, subarachnoid
haemorrhage 76
computed tomography angiography 38 concordance 25
confusion 40 alcohol-related 57 hypercalcaemia 68
congestive cardiac failure 5 – 6 consent to treatment 96, 97
insertion of central venous line 103 continuous positive airway pressure
117–18
controlled oxygen therapy 117
coroner 3 – 4 corticosteroids 93 – 4 cough 40
C-reactive protein 41, 52, 55 crystal synovitis 92
Cullen’s sign 55
CURB-65 Score 7, 41, 42
D
D-dimer 37 deathinforming relatives 3 – 4
reporting to coroner/procurator fiscal 3 – 4
death certificate 4
deep venous thrombosis 36 delirium tremens 59 dextrose 60
diabetic ketoacidosis 56, 62–5, 121–2, 129
examination 62–3 history 62 investigation 63 management 63 – 4 dialysis 2
diarrhoea, bloody 51– 4 diazepam 81
digital rectal examination 55 diuretics 44, 61
do not resuscitate orders 9 Dupuytren’s contractures 82 dysphagia 84
E
earache 78echocardiography 20 –1 transoesophageal 19 ventricular septal defect 24 elective DC cardioversion 109 electrocardiogram 22
acute coronary syndrome 16 –17, 17 heart block 29
hypothermia 31 pleurisy 37, 38
tachyarrhythmia 24 –5, 25, 26 electrolyte replacement 63 endocarditis 84
epiglottitis 45 epilepsy 32 epinephrine 10, 91 esmolol 75 exophthalmos 74
external cardiac pacemaker 30
F
familial Mediterranean fever 56 Fansidar 90femoral vein cannulation 105, 106
fever 39
in returning traveller 89 –90 fluid overload 59 – 62
management 61 fluid replacement 63, 64 fluid resuscitation 63 fluid therapy 21, 77 fosphenytoin 81
G
gallop rhythm 22, 37Glasgow Coma Scale 4, 5, 20, 22, 76, 82, 84, 87
glucocorticoids 69, 73 – 4 glucose test 88
goitre 74
Graves’ disease 74 Grey Turner’s sign 55
Guillain-Barré syndrome 79 – 81 symptoms 80
H
haematemesis 48 haemoptysis 36 headachewith fever 77–9 examination 78, 78 history 77– 8 investigation 78 –9 management 79 meningeal irritation 78 sudden onset 75 –7
examination 76 history 75 – 6
investigation 76 –7, 76 management 77 heart block 29 heart rate 14, 22 heart sounds 1
hepatic encephalopathy 56 –9 examination 57– 8, 58 grades of 57
history 57 investigation 58 management 58 –9 hepatomegaly 68
herpes simplex encephalitis 83 Horner’s syndrome 68, 88 hydrocephalus 77 hydrocortisone 44, 75, 91 hypercalcaemia 67–9, 72
causes 67 examination 67– 8 history 67
investigations 68, 68 management 68 –9 hypercapnia 10, 12, 34, 117 hyperglycaemia, correction of 64 hyperkalaemia 11, 59 – 62, 72
recognition of 59 – 60, 60 treatment 60
hyperosmolar non-ketotic diabetic coma 64 –5
hyperpyrexia 75 hyperthyroidism 75 hypoglycaemia 58, 65 –7, 87
causes 66 examination 66 history 65 – 6 investigations 66, 66 in malaria 90 management 66 –7 hypokalaemia 11, 58
hyponatraemia 41, 58, 69 –71, 72 causes 70
history and examination 70 investigation 70 –1
management 71 hypophosphataemia 58 hypotension 125, 131
orthostatic 32
hypotensive collapse 12–15 airway/breathing 12 circulation 12
differential diagnosis 12 examination 14 –15, 14 history 13 –14
investigation 15 management 15 resuscitation 12
hypothermia 11, 28, 30, 31, 87, 122, 123, 129
hypothyroidism 30
hypovolaemia 10 –11, 13, 58, 103 hypoxia 10, 12, 34, 117
I
infective colitis 53inflammatory bowel disease 53 inotropes 21
insulin 64, 64
intensive care unit 5 – 6, 89
intercostal chest drain insertion 109 –12 complications 112
indications 109 –10 post-procedure 111–12 preparation 110, 110 technique 110 –11, 111
large-bore chest drain 111 small-bore chest drain 111 internal jugular vein cannulation 104,
104
intestinal angina 54
intra-aortic balloon counterpulsation 21
intravenous fluids 35 – 6 ipratropium 35, 44 isoprenaline 30 isosorbide dinitrate 61
J
jaundice 58 joint pain 91– 4differential diagnosis 92 examination 93 history 92–3 investigation 93 management 93 – 4
jugular venous pressure 20, 22 jugular venous pulse 61
K
Kernig’s sign 78ketoconazole, hypoadrenalism 72 ketonuria 63
Klebsiella spp. 40 koilonychia 49
Korsakoff’s syndrome 58
L
laryngeal oedema 45 laryngitis 45Legionella pneumophila 128, 132–3 Legionnaire’s disease 40, 42 liver disease, physical signs 48 lorazepam 81
low-molecular-weight heparin 36, 39 Lugol’s iodine 75
lumbar back pain 6 –7 lumbar puncture 76 –7, 106 –7
contraindications 106 CSF findings 108 indications 106 preparation 107 technique 107, 107 lumefantrine 90 lung cancer 68 Lyme arthritis 92 lymphadenopathy 45, 68
M
magnesium sulphate 35 magnetic resonance imagingback pain 95
herpes simplex encephalitis 83 spinal cord compression 80 malaria 89 –90, 123, 129
diagnosis 89 examination 89 history 89
investigation 89, 90 management 90
malignancy, and hypercalcaemia 67–9 Medical Research Council dyspnoea scale
42–3 melaena 49, 57 meningeal irritation 78
meningococcal septicaemia 78, 78 meningoencephalitis 78
Mental Health Act (1983) 96, 97– 8 metabolic acidosis 114
metabolic alkalosis 114 methionine 101 metronidazole 53 migraine 75
Miller Fisher syndrome 80 mitral valve regurgitation 14 Mycoplasma pneumoniae 40, 42 myocardial infarction 125, 131
and bradyarrhythmia 30 ST-segment elevation 16
N
nasoendoscopy 45nasopharyngeal airway 115 neck stiffness 78, 84 necrotizing pancreatitis 56 Neisseria meningitidis 79 nephrotoxins 61 nerve root pain 94
neurological examination 95 nimodipine 77
non-invasive ventilation 118 NSAIDs 93
O
oesophageal pain 19, 54 oesphageal varices 50 –1 omeprazole 50opioids 94 toxicity 87
oropharyngeal airway 114 orthopnoea 43
orthostatic hypotension 32 Osler-Weber-Rendu syndrome 49 overdoses 100 –2, 127, 132
beta-blockers 30 management 100 –2, 101
paracetamol 100 –1, 101, 128, 132 prevention of absorption 100 salicylate 102, 124, 130 tricyclic antidepressants 101–2 Oxfordshire Community Stroke Study
Classification System 85 oxygen therapy 35, 44, 77
controlled 117
P
pacing 11 pancreatic pain 54 pancreatitis 122, 129paracetamol overdose 100 –1, 101, 128, 132
paraplegia 79
paroxysmal noctural dyspnoea 43
passive straight leg raise test 94 Pasteurella multocida 131–2 peak flow 34
peptic ulcer 49
perfusion isotope lung scanning 38, 39 pericarditis 19
peritonism 55 phenytoin 81 photophobia 76, 78 Plasmodium falciparum 89 Plasmodium malariae 89 Plasmodium ovale 89 Plasmodium vivax 89 pleural effusion 22 pleurisy 36 –9
differential diagnosis 36 –7 electrocardiogram 37, 38 examination 37
history 36 –7
investigation 37–9, 38, 39 management 39
pneumonia 22, 39 – 42, 121, 121, 129 community-acquired 7
examination 40 history 39 – 40
investigation 40 –1, 41, 42 management 41–2 Mycoplasma 40, 42
pneumothorax 43, 46 – 8, 120 –1, 121 acute 7– 8
examination 46 history 46 iatrogenic 13 investigation 47, 47 management 47– 8
tension 11, 15, 46, 110, 122–3, 129 postoperative breathlessness 21–3,
59 – 62
prednisolone 35, 44 pressure sores 28 presyncope 28 procurator fiscal 3 – 4 prophythiouracil 75 proton pump inhibitors 50 pseudomembranous colitis 53 psoriatic arthritis 92
pulmonary embolism 11, 36, 59, 123 – 4, 130
pulmonary oedema 22, 61 management 23 pulse oximetry 34 pneumonia 40 pulse rate 61 pulsus alternans 22 pulsus paradoxus 34
Q
QRS complex, wide 25 quadriplegia 79 quinine 90R
radiation colitis 51 ranitidine 58 rebleeding 77 rehydration 68 –9 Reiter’s syndrome 92 relativesbreaking bad news 3 – 4 watching resuscitation 12 renal failure 59 – 62
examination 61 history 61 investigation 61 management 61–2 reperfusion therapy 18 respiratory acidosis 114
respiratory alkalosis 114, 127, 132 respiratory rate 43, 61
resuscitation 12
acute coronary syndrome 16 fluids 13
relatives watching 12 stopping 11
successful 11 who to resuscitate 9 returning travellers 89 –90
return of spontaneous circulation 11 Riamet 90
rifampicin, hypoadrenalism 72 right ventricular gallop rhythm 37 right ventricular heave 37
S
salbutamol 35, 44, 60, 91 salicylate overdose 102, 124, 130 sciatica 94sedation 99
Seldinger technique 104 –5, 104 femoral vein 105, 106 internal jugular vein 104, 104 subclavian vein 105
self-harm 96 –7 examination 97 history 96 investigation 97
psychiatric and social background 96 suicide risk 96, 97
Sengstaken-Blakemore tube 50 sepsis 61
sepsis screen 63
serum mast cell tryptase 91 sickle cell crisis 56 sigmoidoscopy 52, 53 sinus tachycardia 22, 26, 34 small-bowel infection 51 sore throat 78
spider naevi 49, 82 spinal cord compression 79
symptoms 80
Staphylococcus spp. 40 Staphylococcus aureus 132 statins 18
status epilepticus 81–3 causes 82
examination 82 further management 83 history 82
immediate management 81 investigation 82–3, 83 steroids 35, 44
stiffness 92
stokes-Adams attack 28, 32 Streptococcus pneumoniae 40, 41 stridor 44 – 6, 122, 129
causes 44
exacerbating/triggering factors 45 history 44 –5
investigation 45 management 45 – 6 stroke 4 – 5, 83 – 6
classification 85 differential diagnosis 83 examination 84
functional/social history 84 history 83 – 4
investigation 84 –5 management 85 – 6 medical history 84
ST-segment elevation myocardial infarction 16
management 18
subarachnoid haemorrhage 75, 126, 127– 8, 131, 132
complications 77 features 76
subclavian vein cannulation 105 suicide risk 96, 97
sulfadoxine /pyramethamine 90 supraventricular tachycardia 22,
26 syncope 28
cardiac 32 causes 32
neurally mediated 31–2
syndrome of inappropriate antidiuretic hormone secretion 70
synovial fluid aspiration 93
T
tachyarrhythmia 23 –7, 108 broad-complex 24decision-making algorithm 28 treatment 27
examination 24 history 24
investigation 24 –5, 25, 26 management 25 –7 narrow-complex 24, 25, 26
irregular 25 tachycardia 75 tamponade 11
tension pneumothorax 11, 15, 110, 122–3, 129
thromboembolism, prophylaxis 64 thrombolysis 39, 85
Thrombolysis In Myocardial Infarction (TIMI) risk score 18
thrombophlebitis 127, 132 thyrotoxic crisis 74 –5
examination 74, 74 history 74
investigation 75 management 75 thyrotoxicosis 45
tissue plasminogen activator 86 toxins 11
tracheostomy 116 –17 changing 117 complications 116 formal 116 indication 116 management 116 mini-tracheostomy 116 percutaneous 116
transient ischaemic attacks 84 tricyclic antidepressant overdose
101–2
troponin 23, 61, 76
U
ulcerative colitis 52, 53upper gastrointestinal haemorrhage 48–51 examination 48 –9
history 48
investigation 49, 49 management 50 –1 risk scoring system 50 uraemia 41
urinary retention 61
V
vancomycin 53 vasospasm 77 venous pressure 37 ventilators 119ventilatory support 117–19
continuous positive airway pressure 117–18
controlled oxygen therapy 117 invasive ventilation 118 –19 non-invasive ventilation 118 ventricular fibrillation 10 ventricular septal defect 20
echocardiography 24
ventricular tachycardia, pulseless 10 violence and aggression 97–9, 125, 130 –1
common law 97
examination and investigation 98 history 98
management 98 – 9
Mental Health Act (1983) 97– 8 Virchow’s node 49
vitamin B 59 vitamin C 59 vitiligo 74
W
Wernicke’s encephalopathy 58, 66, 87, 128, 133wheezing 34
Wolff-Parkinson-White syndrome 27