1 Inspection 69

Introduction, consent, position patient sitting on a chair (with space behind), ad-
equately expose neck. Inspect from front and sides for any obvious goitres or swell-
ings, scars, signs of hypo-/hyperthyroidism.

History and examination

2 Swallow test
Standing in front of the patient ask them to “sip water…hold in your mouth …and
swallow” to see if any midline swelling moves up on swallowing.

3 Tongue protrusion test

Ask patient to "stick out your tongue". Does the lump move up?

If evidence favours lump not arising

from thyroid, examine lump like any
other (p596)

4 Palpation
Stand behind the patient.
• Proptosis: (p211) whilst standing behind the patient ask them to tilt their head
back slightly; this will give you a better view to assess any proptosis than when
assessing the other aspects of eye pathology from front on, as in 8)
• The thyroid gland: ask the patient “any pain?” Place middle 3 fingers of either
hand along midline below chin and ‘walk down’ to thyroid. Assess any enlarge-
ment/ nodules
• Swallow test: repeat as before, now palpating; attempt to ‘get under’ the lump
• Lymph nodes: examine lymph nodes of head and neck (p60). Stand in front of
the patient
• Trachea: palpate for tracheal deviation from the midline.

5 Percussion
Percuss the sternum for dullness of retrosternal extension of a goitre.

6 Auscultation
Listen over the goitre for a bruit.

7 Hands
• Inspect: for thyroid acropachy (clubbing) and palmar erythema
• Temperature
• Pulse: rate and rhythm
• Fine tremor: ask patient to “hold hands out”, place sheet of paper over out-
stretched hands to help.

8 Eyes
• Exophthalmos: inspect for lid retraction and proptosis (p211)
• Lid lag: ask patient to “look down following finger” as you move your finger from
a point above the eye to below
• Eye movements: Ask patient to follow your finger, keeping their head still, as you
make an ‘H’ shape. Any double vision?

9 Completion
Ask patient to stand up from the chair to assess for proximal myopathy, look for
pretibial myxoedema, test ankle reflexes (ask patient to face away from you with
knee resting on chair). Thank patient and wash hands.
Common haematology values If outside this range, consult:
Haemoglobin men: 130–180g/L p318
women: 115–160g/L p318
Mean cell volume, MCV 76–96fL p320; p326
Platelets 150–400 ≈ 109/L p358
White cells (total) 4–11 ≈ 109/L p324
neutrophils 40–75% p324
lymphocytes 20–45% p324
eosinophils 1–6% p324

Blood gases
pH 7.35–7.45 p684
PaO2 >10.6kPa p684
(75–100mmHg)
PaCO2 4.7–6kPa p684
(35–45mmHg)
Base excess ± 2mmol/L p684

U&E S (urea and electrolytes) If outside this range, consult:

Sodium 135–145mmol/L p686
Potassium 3.5–5mmol/L p688
Creatinine 70–150μmol/L p298–301
Urea 2.5–6.7mmol/L p298–301
eGFR >90 p683

LFTS (liver function tests)

Bilirubin 3–17μmol/L p250, p258
Alanine aminotransferase, ALT 5–35iU/L p250, p258
Aspartate transaminase, AST 5–35iU/L p250, p258
Alkaline phosphatase, ALP 30–150iU/L p250, p258
(non-pregnant adults)
Albumin 35–50g/L p700
Protein (total) 60–80g/L p700

Cardiac enzymes
Troponin T <0.1μg/L p113
Creatine kinase 25–195iU/L p113
Lactate dehydrogenase, LDH 70–250iU/L p113

Lipids and other biochemical values

Cholesterol <5mmol/L desired p704
Triglycerides 0.5–1.9mmol/L p704
Amylase 0–180 Somogyi U/dL p638
C-reactive protein, CRP <10mg/L p700
Calcium (total) 2.12–2.65mmol/L p690
Glucose, fasting 3.5–5.5mmol/L p198
Prostate-specific antigen, PSA 0–4ng/mL p538
T4 (total thyroxine) 70–140mmol/L p208
Thyroid stimulating hormone, TSH 0.5–5.7mU/L p208
For all other reference intervals, see p769–71
He moved N. 48

all the brightest gems N. 24

faster and faster towards the N. 18

ever-growing bucket of lost hopes; N. 14
had there been just one more year
of peace the battalion would have made N. 12
a floating system of perpetual drainage.
A silent fall of immense snow came near oily
N. 10
remains of the recently eaten supper on the table.
We drove on in our old sunless walnut. Presently
classical eggs ticked in the new afternoon shadows. N. 8

We were instructed by my cousin Jasper not to exercise by country

house visiting unless accompanied by thirteen geese or gangsters. N. 6

The modern American did not prevail over the pair of redundant bronze puppies.
The worn-out principle is a bad omen which I am never glad to ransom in August. N. 5

Reading tests Hold this chart (well-illuminated) 30cm away, and record the smallest
type read (eg N12 left eye, N6 right eye, spectacles worn) or object named accurately.
 OXFORD
HANDBOOK
OF CLINICAL
MEDICINE
This page intentionally left blank
 OXFORD
HANDBOOK
OF CLINICAL
MEDICINE
NINTH EDITION

MURRAY LONGMORE
IAN B. WILKINSON
ANDREW BALDWIN
ELIZABETH WALLIN
Great Clarendon Street, Oxford OX2 6DP
Oxford University Press is a department of the University of Oxford. It furthers
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Oxford is a registered trade mark of Oxford University Press in the UK and in
certain other countries
Published in the United States by Oxford University Press Inc., New York
© Oxford University Press, 2014
The moral rights of the authors have been asserted
Database right Oxford University Press (maker)
First published 1985 Fifth edition 2001 Translations:
(RA Hope & JM Longmore) (JM Longmore & IB Wilkinson) Chinese Indonesian
Second edition 1989 Sixth edition 2004 Czech Italian
Third edition 1993 Seventh edition 2007 Estonian Polish
Fourth edition 1998 Eighth edition 2010 French Portuguese
Ninth edition 2014 German Romanian
Greek Russian
Hungarian Spanish
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,
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to the Rights Department, Oxford University Press, at the address above.
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and you must impose the same condition on any acquirer.
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Typeset by GreenGate Publishing Services, Tonbridge, UK; printed in China by
C&C Offset Printing Co. Ltd.
ISBN 978-0-19-960962-8

Drugs
Except where otherwise stated, recommendations are for the non-pregnant
adult who is not breastfeeding and who has reasonable renal and hepatic func-
tion. To avoid excessive doses in obese patients it may be best to calculate doses
on the basis of ideal body weight (IBW): see p621.
We have made every effort to check this text, but it is still possible that drug or
other errors have been missed. OUP makes no representation, express or implied,
that doses are correct. Readers are urged to check with the most up to date
product information, codes of conduct, and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text, or for the misuse or misapplication of material in this work.
For updates/corrections, see http://www.oup.co.uk/academic/series/oxhmed/updates/
Contents

Each chapter’s contents are detailed on its first page

Index to emergency topics front endpapers

Common reference intervals front endpapers

From the preface to the first edition vi

Preface to the ninth edition vi
Acknowledgements vii
Symbols and abbreviations viii
How to conduct ourselves when juggling with symbols x

1 Thinking about medicine 0

2 History and examination 18
3 Cardiovascular medicine 86
4 Chest medicine 154
5 Endocrinology 196
6 Gastroenterology 234
7 Renal medicine 284
8 Haematology 316
9 Infectious diseases 372
10 Neurology 448
11 Oncology and palliative care 522
12 Rheumatology 540
13 Surgery 566
14 Epidemiology 664
15 Clinical chemistry 676
16 Eponymous syndromes 708
17 Radiology 732
18 Reference intervals, etc. 764
19 Practical procedures 772
20 Emergencies 792
Index 864
Useful doses for the new doctor 902
Cardiorespiratory arrest endmatter
Life support algorithms back endpapers
W
e wrote this book not because we know so much, but because we know
we remember so little…the problem is not simply the quantity of informa-
tion, but the diversity of places from which it is dispensed. Trailing eagerly
behind the surgeon, the student is admonished never to forget alcohol withdrawal
as a cause of post-operative confusion. The scrap of paper on which this is written
spends a month in the pocket before being lost for ever in the laundry. At different
times, and in inconvenient places, a number of other causes may be presented to
the student. Not only are these causes and aphorisms never brought together, but
when, as a surgical house officer, the former student faces a confused patient, none
is to hand.
We aim to encourage the doctor to enjoy his patients: in doing so we believe he will
prosper in the practice of medicine. For a long time now, house officers have been
encouraged to adopt monstrous proportions in order to straddle the diverse pinna-
cles of clinical science and clinical experience. We hope that this book will make this
endeavour a little easier by moving a cumulative memory burden from the mind into
the pocket, and by removing some of the fears that are naturally felt when starting
a career in medicine, thereby freely allowing the doctor’s clinical acumen to grow by st
From the 1 edition
the slow accretion of many, many days and nights. Preface RAH & JML 1985

Preface to the ninth edition

As medicine becomes more and more specialized, and moves further and further
from the general physician, becoming increasingly subspecialized, it can be difficult
to know where we fit in to the general scheme of things. What ties a public health
physician to a neurosurgeon? Why does a dermatologist require the same early
training as a gastroenterologist? What makes an academic nephrologist similar to a
general practitioner? To answer these questions we need to go back to the definition
of a physician. The word physician comes from the Greek physica, or natural science,
and the Latin physicus, or one who undertakes the study of nature. A physician
therefore is one who has studied nature and natural sciences, although the word has
been adapted to mean one who has studied healing and medicine. We can think also
about the word medicine, originally from the Latin stem med, to think or reflect on.
A medical person, or medicus, originally meant someone who knew the best course
of action for a disease, having spent time thinking or reflecting on the problem in
front of them.
As physicians, we continue to specialize in ever more diverse conditions, complex
scientific mechanisms, external interests ranging from academia to education, from
public health and government policy to managerial posts. At the heart of this we
should remember that all physicians enter into medicine with a shared goal, to un-
derstand the human body, what makes it go wrong, and how to treat that disease.
We all study natural science, and must have a good evidence base for what we do,
for without evidence, and knowledge, how are we to reflect on the patient and the
problem they bring to us, and therefore understand the best course of action to
take? This is not always a drug or an operation; we must work holistically and treat
the whole patient, not just the problem they present with; for this reason we need
psychiatrists as much as cardiothoracic surgeons, public health physicians as much
as intensive care physicians. For each problem, and each patient, the best and most
appropriate course of action will be different. It is no longer possible to be a true
general physician, there is too much to know, too much detail, too many treatments
and options. Strive instead to be the best medic that you can, knowing enough to
understand the best course of action, whether that be to reassure, to treat, to refer
or to palliate.
In this book, we join the minds of an academic clinical pharmacologist, a general
practitioner, a nephrologist, and a GP registrar. Four physicians, each very different
in their interests and approaches, and yet each bringing their own knowledge and
expertise, which, combined with that of our specialist readers, we hope creates a
book that is greater than the sum of its parts.
 Acknowledgements
Heart-felt thanks to our advisers on specific sections—each is acknowledged on
the chapter’s first page. We especially thank Dr Judith Collier and Dr Ahmad Mafi
for reading the entire text, and also Rev. Gary Bevans for his kind permission to
use the image on p225, from his beautiful Sistine Chapel sequences reproduced on
the ceiling of the Church of the English Martyrs, Goring-by-Sea. IBW would like to
acknowledge his clinical mentors Jim Holt and John Cockcroft and EFW her clini-
cal and literary mentor Dr John Firth. We thank the Department of Radiology at
both the Leeds Teaching Hospitals NHS Trust and the Norfolk and Norwich Univer-
sity Hospital for their kind help in providing many images, particularly Dr Edmund
Godfrey, whose tireless hunt for perfect images has improved so many chapters.
Readers’ comments These have formed a vital part of our endeavour to provide
an accurate, comprehensive, and up-to-date text. We sincerely thank the many
students, doctors and other health professionals who have found the time and
the generosity to write to us on our Reader’s Comments Cards, in editions past,
or, in more recent times, via the web. These have now become so numerous for
past editions that they cannot all be listed. See www.oup.com/uk/academic/series/
oxhmed/links for a full list, and our very heart-felt tokens of thanks.
3rd-party web addresses We disclaim any responsibility for 3rd-party content.
Symbols and abbreviations
..........this fact or idea is important
 .......don’t dawdle!—prompt action saves lives
.....incendiary (controversial) topic
[ ] .......non-BNF drug dose
1 ...........reference available on our website www.oup.com/ CPAP ....continuous positive airways pressure
uk/ohcm9refs
:......male-to-female ratio. :=2:1 means twice as
common in males
@12 ....search Medline (pubmed.gov) with ’12…’ to get an CSF ......cerebrospinal fluid
abstract (omit ‘@’)
 .........on account of
 .........therefore
~ ..........approximately
–ve ......negative (+ve is positive)
 ........increased or decreased (eg serum level)
 .......normal (eg serum level)
 ..........diagnosis
........differential diagnosis (list of possibilities)
 ..........deprecated term
A2 ........aortic component of the 2nd heart sound
A2A .....angiotensin-2 receptor antagonist (p309; = AT-2,
A2R, and AIIR)
Ab ......antibody
ABC ......airway, breathing, and circulation: basic life
support (see inside back cover)
ABG .....arterial blood gas: PaO2, PaCO2, pH, HCO3
ABPA ....allergic bronchopulmonary aspergillosis
ac ........ante cibum (before food)
ACE-i .....angiotensin-converting enzyme inhibitor
ACS .......acute coronary syndrome
ACTH ....adrenocorticotrophic hormone
ADH .....antidiuretic hormone
ad lib ..as much/as often as wanted
AF ........atrial fibrillation
AFB ......acid-fast bacillus
AFP ......(or -FP) alpha-fetoprotein
Ag .......antigen
AIDS ....acquired immunodeficiency syndrome
AKI ........acute kidney injury
alk phos
.......alkaline phosphatase (also ALP)
ALL ......acute lymphoblastic leukaemia
AMA ....antimitochondrial antibody
AMP .....adenosine monophosphate
ANA .....antinuclear antibody
ANCA ...antineutrophil cytoplasmic antibody
APTT ....activated partial thromboplastin time
AR ........aortic regurgitation
ARA(b)
........angiotensin receptor antagonist (p309;
also AT-2, A2R, and AIIR)
ARDS ...acute respiratory distress syndrome
ARF .......acute renal failure = AKI
AS ........aortic stenosis
ASD .....atrial septal defect
ASO .....antistreptolysin O (titre)
AST ......aspartate transaminase
AT-2 .....angiotensin-2 receptor blocker (p309;
also AT-2, A2R, and AIIR)
ATN ......acute tubular necrosis
ATP ......adenosine triphosphate
AV ........atrioventricular
AVM .....arteriovenous malformation(s)
AXR .....abdominal X-ray (plain)
Ba ........barium
BAL ......bronchoalveolar lavage
bd .......bis die (Latin for twice a day)
BKA .....below-knee amputation
BMA .....British Medical Association
BMJ .....British Medical Journal
BNF ......British National Formulary
BP ........blood pressure
BPH ......benign prostatic hyperplasia
bpm ....beats per minute (eg pulse)
ca ........cancer
CABG ...coronary artery bypass graft
CAD .....coronary heart disease
cAMP ...cyclic adenosine monophosphate (AMP)
CAPD ...continuous ambulatory peritoneal dialysis
CBD ......common bile duct, cortico-basal degeneration
CC ........creatinine clearance (also CrCl )
CCF ......congestive cardiac failure (ie left and right heart HIV ......human immunodeficiency virus
failure)
CCU ......coronary care unit
CHB ......complete heart block
CHD ......coronary heart disease (related to ischaemia and IBD ......inflammatory bowel disease
atheroma)
CI .........contraindications
CK ........creatine (phospho)kinase (also CPK)
CKD ......chronic kidney disease
CLL ......chronic lymphocytic leukaemia
CML .....chronic myeloid leukaemia
CMV .....cytomegalovirus
CNS ......central nervous system
COC ......combined oral contraceptive pill
COPD ....chronic obstructive pulmonary disease
CPR ......cardiopulmonary resuscitation
CRD ......chronic renal disease
CRP ......c-reactive protein
CT ........computer tomography
CVA ......cerebrovascular accident
CVP ......central venous pressure
CVS ......cardiovascular system
CXR ......chest x-ray
d ..........day(s); also expressed as /7; months are /12
DC ........direct current
DIC ......disseminated intravascular coagulation
DIP ......distal interphalangeal
dL .......decilitre
DoH .....(or DH) Department of Health (UK)
DM .......diabetes mellitus
DU ........duodenal ulcer
D&V .....diarrhoea and vomiting
DVT ......deep venous thrombosis
DXT ......deep radiotherapy
EBM .....evidence-based medicine and its journal published
by the BMA
EBV ......Epstein–Barr virus
ECG ......electrocardiogram
Echo ...echocardiogram
ED ........emergency department
EDTA ....ethylene diamine tetra-acetic acid (anticoagulant
coating, eg in FBC bottles)
EEG ......electroencephalogram
eGFR ....estimated glomerular filtration rate (GFR; mL/
min/1.73m2—see p683)
ELISA ...enzyme-linked immunosorbent assay
EM .......electron microscope
EMG .....electromyogram
ENT ......ear, nose, and throat
ERCP ....endoscopic retrograde
cholangiopancreatography; see also MRCP
ESR ......erythrocyte sedimentation rate
ESRF ....end-stage renal failure
EUA ......examination under anaesthesia
FB ........foreign body
FBC ......full blood count
FDP ......fibrin degradation products
FEV1 .....forced expiratory volume in 1st sec
FiO2 ....partial pressure of O2 in inspired air
FFP ......fresh frozen plasma
FSH ......follicle-stimulating hormone
FVC ......forced vital capacity
g ..........gram
GA .......general anaesthetic
GAT ......Sanford Guide to Antimicrobial Therapy 43ed
GB ........gallbladder
GC ........gonococcus
GCS ......Glasgow coma scale
GFR ......glomerular filtration rate eGFR, p683
GGT ......gamma-glutamyl transferase
GH ........growth hormone
GI ........gastrointestinal
GP ........general practitioner
G6PD ....glucose-6-phosphate dehydrogenase
GTN ......glyceryl trinitrate
GTT ......glucose tolerance test (OGTT: oral GTT)
GU(M) ..genitourinary (medicine)
h ..........hour
HAV .....hepatitis A virus
Hb .......haemoglobin
HBSAg ..hepatitis B surface antigen
HBV .....hepatitis B virus
HCC ......hepatocellular cancer
HCM .....hypertrophic obstructive cardiomyopathy
Hct ......haematocrit
HCV ......hepatitis C virus
HDV .....hepatitis D virus
HDL ......high-density lipoprotein, p704
HHT ......hereditary haemorrhagic telangiectasia
HIDA ....hepatic immunodiacetic acid
HONK ...hyperosmolar non-ketotic (diabetic coma)
HRT ......hormone replacement therapy
HSV ......herpes simplex virus
IBW .....ideal body weight, p446
ICD ......implantable cardiac defibrillator
ICP .......intracranial pressure
ICU ......intensive care unit
IDA ......iron-deficiency anaemia
IDDM ...insulin-dependent diabetes mellitus
IFN- ..interferon alpha
IE .........infective endocarditis
Ig ........immunoglobulin
IHD ......ischaemic heart disease
IM ........intramuscular
INR ......international normalized ratio (prothrombin)
IP .........interphalangeal
IPPV ....intermittent positive pressure ventilation
ITP .......idiopathic thrombocytopenic purpura
iU/U .....international unit
IVC ......inferior vena cava
IV(I) ....intravenous (infusion)
IVU ......intravenous urography
JAMA ...Journal of the American Medical Association
JVP ......jugular venous pressure
K ..........potassium
KCCT ....kaolin cephalin clotting time
kg .......kilogram
KPa ......kiloPascal
L ..........litre
LAD ........left axis deviation on the ECG; also left anterior
descending coronary artery; left anterior hemiblock
LBBB ....left bundle branch block
LDH ......lactate dehydrogenase
LDL ......low-density lipoprotein, p704
LBW .....lean body weight, p434
LFT ......liver function test
LH ........luteinizing hormone
LIF .......left iliac fossa
LKKS ....liver, kidney (R), kidney (L), spleen
LMN .....lower motor neuron
LOC ......loss of consciousness
LP ........lumbar puncture
LUQ ......left upper quadrant
LV ........left ventricle of the heart
LVF .......left ventricular failure
LVH ......left ventricular hypertrophy
μg ........microgram
MAI .....Mycobacterium avium intracellulare
mane ..morning (from Latin)
MAOI ...monoamine oxidase inhibitor
MAP .....mean arterial pressure
MC&S ...microscopy, culture and sensitivity
MCP .....metacarpo-phalangeal
MCV .....mean cell volume
MDMA ..3,4-methylenedioxymethamphetamine
ME .......myalgic encephalomyelitis
MET .....meta-analysis
mg ......milligram
MI ........myocardial infarction
min(s) minute(s)
mL .......millilitre
mmHg millimetres of mercury
MND .....motor neuron disease
MRCP ...magnetic resonance cholangiopancreatography/
member of Royal College of Physicians
MRI ......magnetic resonance imaging
MRSA ...methicillin-resistant Staph. aureus
MS .......multiple sclerosis (mitral stenosis)
MSU .....midstream urine
NAD .....nothing abnormal detected
NBM .....nil by mouth
ND ........notifiable disease
NEJM ...New England Journal of Medicine
ng .......nanogram
NG(T) ...nasogastric (tube)
NHS .....National Health Service (UK)
NICE ....National Institute for Health and Clinical
Excellence, www.nice.org.uk
NIDDM ..non-insulin-dependent diabetes mellitus
NMDA .. N-methyl-D-aspartate
NNT .....number needed to treat, for 1 extra satisfactory TPR ......temperature, pulse and respirations count
result (p671)
Nocte ..at night
NR ........normal range (=reference interval)
NSAID ..non-steroidal anti-inflammatory drug
N&V .....nausea and/or vomiting
od .......omni die (Latin for once daily)
OD ........overdose
OGD .....oesophagogastroduodenoscopy
OGS ......oxogenic steroids
OGTT ....oral glucose tolerance test
OHCS ....Oxford Handbook of Clinical Specialties 9e
om ......omni mane (in the morning)
on .......omni nocte (at night)
OPD ......outpatients department
ORh– ....blood group O, Rh negative
OT ........occupational therapist
OTM .....Oxford Textbook of Medicine 5e (OUP)
P2 ........pulmonary component of 2nd heart sound
PaCO2 ...partial pressure of CO2 in arterial blood
PAN ......polyarteritis nodosa
PaO2 .....partial pressure of O2 in arterial blood
PBC ......primary biliary cirrhosis
PCP ......Pneumocystis carinii (jiroveci) pneumonia
PCR ......polymerase chain reaction (DNA diagnosis)
PCV ......packed cell volume
PE ........pulmonary embolism
PEEP ....positive end-expiratory pressure
PEF(R) ..peak expiratory flow (rate)
PERLA ..pupils equal and reactive to light and
accommodation
PET ......positron emission tomography
PID ......pelvic inflammatory disease
PIP .......proximal interphalangeal (joint)
PMH .....past medical history
PND .....paroxysmal nocturnal dyspnoea
PO ........per os (by mouth)
PPF ......purified plasma fraction (albumin)
PPI .......proton pump inhibitor, eg omeprazole
PR ........per rectum (by the rectum)
PRL ......prolactin
PRN ......pro re nata (Latin for as required)
PRV ......polycythaemia rubra vera
PSA ......prostate-specific antigen
PTH ......parathyroid hormone
PTT ......prothrombin time
PUO ......pyrexia of unknown origin
PV ........per vaginam (by the vagina, eg pessary)
PVD ......peripheral vascular disease
qds .....quater die sumendus; take 4 times daily
qqh .....quarta quaque hora: take every 4h
R ..........right
RA ........rheumatoid arthritis
RAD .....right axis deviation on the ECG
RBBB ...right bundle branch block
RBC ......red blood cell
RCT ......randomized control trial
RFT ......respiratory function tests
Rh ........Rh; a contraction, not an abbreviation: derived
from the rhesus monkey
RIF .......right iliac fossa
RUQ .....right upper quadrant
RV ........right ventricle of heart
RVF ......right ventricular failure
RVH ......right ventricular hypertrophy
 .........recipe (Latin for treat with)
s/sec ...second(s)
S1, S2 ...first and second heart sounds
SBE ......subacute bacterial endocarditis (IE is any infective
endocarditis)
SC ........subcutaneous
SD ........standard deviation
SE ........side-effect(s)
SL ........sublingual
SLE ......systemic lupus erythematosus
SOB ......short of breath
SOBE ....short of breath on exercise
SPC ......summary of product characteristics,
www.medicines.org.uk
SpO2 ....peripheral oxygen saturation (%)
SR ........slow-release (also MR, modified-release)
Stat ....statim (immediately; as initial dose)
STD/I ...sexually transmitted disease/infection
SVC ......superior vena cava
SVT ......supraventricular tachycardia
Sy(n) ...syndrome
T° .........temperature
T½ .......biological half-life
T3; T4 ...tri-iodothyronine; T4 is thyroxine
TB ........tuberculosis
tds ......ter die sumendus (take 3 times a day)
TFT ......thyroid function test (eg TSH)
TIA ......transient ischaemic attack
TIBC ....total iron-binding capacity
tid .......ter in die (Latin for 3 times a day)
TRH ......thyroid-releasing hormone
TSH ......thyroid-stimulating hormone
U ..........units
UC ........ulcerative colitis
U&E .....urea and electrolytes and creatinine—in plasma,
unless stated otherwise
UMN .....upper motor neuron
URT(I) ..upper respiratory tract (infection)
US(S) ....ultrasound (scan)
UTI ......urinary tract infection
VDRL ....Venereal Diseases Research Laboratory
VE ........ventricular extrasystole
VF ........ventricular fibrillation
VMA ....vanillyl mandelic acid (HMMA)
V/Q .......ventilation/perfusion ratio
VSD ......ventriculo-septal defect
VT ........ventricular tachycardia
WBC ....white blood cell
WCC ....white blood cell count
wk(s) ..week(s)
WR ......Wassermann reaction (syphilis serology)
yr(s) ...year(s)
ZN ........Ziehl–Neelsen stain, eg for mycobacteria
Index to emergency topics
‘Don’t go so fast: we’re in a hurry!’—Talleyrand to his coachman.
Abdominal aortic aneurysm 656 Intracranial pressure, raised 840
Acute abdomen 608 Ketoacidosis, diabetic 842
Acute kidney injury (acute renal failure) 848 Lassa fever 388
Addisonian crisis 846 Left ventricular failure 812
Anaphylaxis 806 Major disaster 862
Aneurysm, abdominal aortic 656 Malaria 394
Antidotes, poisoning 854 Malignant hyperpyrexia 574
Arrhythmias, broad complex 122, 816 Malignant hypertension 134
narrow complex 120, 818 Meningitis 832
see also back inside cover Meningococcaemia 832
Asthma 820 Myocardial infarction 808
Asystole back inside cover Needle pericardiocentesis 787
Bacterial shock 804 Neutropenic sepsis 346
Blast injury 862 Obstructive uropathy 645
Bleeding, aneurysm 656 Oncological emergencies 526
extradural/intracranial 482, 486 Opiate poisoning 854
gastrointestinal 252, 830 Overdose 850–7
rectal 631 Pacemaker, temporary 790
variceal 254, 830 Pericardiocentesis 787
Blood loss 804 Phaeochromocytoma 846
Blue patient 178–81 Pneumonia 826
Bradycardia 118 Pneumothorax 824
Burns 858 Poisoning 850–7
Cardiac arrest back inside cover Potassium, hyperkalaemia 688, 849
Cardiogenic shock/tamponade 814 hypokalaemia 688
Cardioversion, DC 784 Pulmonary embolism 828
Cauda equina compression 470, 545 Pulseless, altogether back inside cover
Central line insertion (CVP line) 788 in a leg 658
Cerebral malaria 397 Respiratory arrest back inside cover
Cerebral oedema 840 Respiratory failure 180
Chest drain 780 Resuscitation back inside cover
Coma 800 Rheumatological emergencies 540
Cord compression 470, 545 Shock 804
Cranial arteritis 558 Smoke inhalation 859
Cricothyrotomy 786 Sodium, hypernatraemia 686
Cyanosis 178–81 hyponatraemia 686
Cut-down 775 Spinal cord compression 470, 545
Defibrillation 784, back inside cover Status asthmaticus 820
Diabetes emergencies 842–4 Status epilepticus 836
Disseminated intravascular coagulopathy Superior vena cava obstruction 526
(DIC) 346 Supraventricular tachycardia (SVT) 818
Disaster, major 862 Tachycardia, ventricular 122, 816
Dissecting aneurysm 656 Thrombolysis, myocardial infarct 808
Embolism, leg 658 stroke 475
pulmonary 828 Thrombotic thrombocytopenic purpura
Encephalitis 834 (TTP) 308
Endotoxic shock 804 Thyroid storm 844
Epilepsy, status 836 Torted testis 654
Extradural haemorrhage 486 Transfusion reaction 343
Fits, unending 836 Varices, bleeding 254, 830
Fluids, IV 680, 804 Vasculitis, acute systemic 558
Haematemesis 252–5 Ventricular arrhythmias 122, 816
Haemorrhage 804 Ventricular failure, left 812
see also under Bleeding above Ventricular fibrillation back inside cover
Hyperthermia 804, 850 Ventricular tachycardia 122, 816
Hypoglycaemia 206, 844 Waterhouse–Friderichsen 728
Hypothermia 860 Wheeze 796, 820–3
 1 Inspection 69
Introduction, consent, position patient sitting on a chair (with space behind), ad-
equately expose neck. Inspect from front and sides for any obvious goitres or swell-
ings, scars, signs of hypo-/hyperthyroidism.

History and examination

2 Swallow test
Standing in front of the patient ask them to “sip water…hold in your mouth …and
swallow” to see if any midline swelling moves up on swallowing.

3 Tongue protrusion test

Ask patient to "stick out your tongue". Does the lump move up?

If evidence favours lump not arising

from thyroid, examine lump like any
other (p596)

4 Palpation
Stand behind the patient.
• Proptosis: (p211) whilst standing behind the patient ask them to tilt their head
back slightly; this will give you a better view to assess any proptosis than when
assessing the other aspects of eye pathology from front on, as in 8)
• The thyroid gland: ask the patient “any pain?” Place middle 3 fingers of either
hand along midline below chin and ‘walk down’ to thyroid. Assess any enlarge-
ment/ nodules
• Swallow test: repeat as before, now palpating; attempt to ‘get under’ the lump
• Lymph nodes: examine lymph nodes of head and neck (p60). Stand in front of
the patient
• Trachea: palpate for tracheal deviation from the midline.

5 Percussion
Percuss the sternum for dullness of retrosternal extension of a goitre.

6 Auscultation
Listen over the goitre for a bruit.

7 Hands
• Inspect: for thyroid acropachy (clubbing) and palmar erythema
• Temperature
• Pulse: rate and rhythm
• Fine tremor: ask patient to “hold hands out”, place sheet of paper over out-
stretched hands to help.

8 Eyes
• Exophthalmos: inspect for lid retraction and proptosis (p211)
• Lid lag: ask patient to “look down following finger” as you move your finger from
a point above the eye to below
• Eye movements: Ask patient to follow your finger, keeping their head still, as you
make an ‘H’ shape. Any double vision?

9 Completion
Ask patient to stand up from the chair to assess for proximal myopathy, look for
pretibial myxoedema, test ankle reflexes (ask patient to face away from you with
knee resting on chair). Thank patient and wash hands.