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EMQ answers
Coeliac disease causes an enteropathy affecting
the small bowel. This can cause osteomalacia
from reduced ability to absorb vitamin D from
the duodenum. Inflammation in the small bowel
can also affect absorption of calcium and folate,
which are absorbed from the same site in the
duodenum.
3. G The vignette is suggestive of Paget disease.
The painful swollen leg would need to be
investigated further to rule out an underlying
fracture or osteosarcoma, which are more
common in association with Paget disease
4. A Paget disease is more commonly seen in
men of Anglo-Saxon descent and is in seen
increasingly with age. Typical features include
increasing size of the skull, which can cause
compression of cranial nerves II and VII giving
rise to poor vision and hearing, respectively.
Bone pain is a common feature. Other
complications include increased fracture risk,
osteoarthritis, risk of osteosarcoma and high
output cardiac failure.
5. D Renal failure can result in renal bone disease
related to either secondary or tertiary
hyperparathyroidism causing osteomalacia.
However, if the parathyroid hormone level is
suppressed too much (in the case with highdose activated vitamin D), this can lead to an
increased risk of fracture due to insufficient
bone turnover. This is termed ‘adynamic bone
disease’.
Hypoglycaemic medication and insulin
1. E This man has diabetic ketoacidosis. The first
treatment is fluid resuscitation, but following
this a fixed-rate intravenous insulin infusion
should be used to slowly lower the glucose
level and switch off further ketone production.
This intravenous insulin infusion should be
commenced until the patient has no ketones
and is eating and drinking normally.
2. D In an established diabetic patient using regular
insulin who is going to be nil by mouth for
potentially an extensive period and is clinically
unwell, a variable-rate intravenous insulin
infusion regimen is the treatment of choice.
You may well see in practice patients being nil
by mouth and not needing this variable-rate
intravenous insulin infusion regimen but just
being given their long-acting insulin and omitting
the short-acting insulin. This is common and
correct practice with elective surgery but not in
the unwell patient.
3. G In this patient with renal impairment, and already
taking gliclazide, the second-line agent would
be one of the dipeptidyl peptidase 4 inhibitors,
with linagliptin, for example, being safe with
renal impairment. Metformin is contraindicated
at an estimated glomerular filtration rate of less
than 30 mL/min per 1.73m2.
4. A Metformin is first-line treatment for diabetes and
has the advantage of not causing weight gain
5. I Exenatide is the only once-weekly injectable
treatment. It is an example of a glucagon-like
peptide 1 agonist and is third-line therapy
Emergency management
1. D Hypoglycaemia is managed with oral glucose
replacement (e.g., Lucozade) in the alert
patient. If consciousness is impaired, 100 mL
of 20% dextrose is administered intravenously
(IV). If there is no IV access, glucagon should
be given intramuscularly to release glucose
from glycogen stores until IV access can be
obtained.
2. I This is an Addisonian crises. The patient
has other features of autoimmune
disease. Hypotension, hypoglycaemia and
hyperkalaemia are all features of Addison
disease. Treatment involves intravenous (IV)
fluids and hydrocortisone. The hypoglycaemia
needs to be addressed as well as treatment
of the hyperkalaemia with IV insulin and
dextrose and calcium gluconate should there
be evidence of myocardial irritability (i.e., an
abnormal EKG).
3. G This is suggestive of a myxoedema (i.e.,
severe hypothyroidism). T3 is needed for
its rapid action. Intravenously administered
hydrocortisone is required particularly if
pituitary dysfunction is suspected. Underlying
precipitating factors (e.g., myocardial infarction
or sepsis) need to be ruled out.
4. C This is suggestive of a hyperosmolar
hyperglycaemic state. This is more common
in the elderly. It is often precipitated by
underlying sepsis, or myocardial infarction,
particularly if there has been nonadherence
to hypoglycaemic agents or in a patient with
undiagnosed diabetes. Treatment is with
intravenous fluid replacement. These patients
are often very dehydrated and hypernatraemic.
Ketone production is not a typical feature, and
low-dose insulin is required only if ketones are
present or if glucose level does not reduce with
fluid replacement alone. These patients are at
high risk of thromboembolism, and the mortality
rate is high.
5. A This woman with metastatic breast cancer and
symptoms of confusion and abdominal pain
438
EMQ answers
is likely to be hypercalcaemic. Treatment is
with intravenous fluids. Use of any contributing
medications (e.g., calcium or vitamin D
supplements) needs to be stopped. Only after
aggressive fluid resuscitation should intravenous
bisphosphonates be given if the calcium level
fails to reduce.
Chapter34 Musculoskeletal system
1. D Haemarthrosis. Spontaneous bleeding into a
joint is common with an elevated international
normalized ratio. Aspiration will reveal frank
blood. Lack of fever or raised levels of
inflammatory markers make septic arthritis
unlikely.
2. J Fibromyalgia. This is the characteristic
presentation of fibromyalgia in a middle-aged
woman with nonspecific symptoms including
muscle pain where the findings of investigations
are normal.
3. F Gout. This is the classic presentation of gout at
an MTP joint. Predisposing factors include male
sex, alcohol, impaired kidney function, diabetes
and diuretic use.
4. B PA. Asymmetrical distribution, dactylitis and
associated iritis and colitis are suggestive of PA.
5. A RA is likely given symmetrical involvement of
small joints in the hands. Morning stiffness
reducing on movement and the presence of
rheumatoid factor are also supportive. It is
important to consider psoriatic arthritis as a
differential diagnosis. This type of arthritis is,
however, often asymmetrical and associated
with skin disease.
Chapter35 Skin disease
Skin
1. H Sotos syndrome (also called ‘cerebral
gigantism’). It is a rare autosomal dominant
genetic condition. Birth length is often above
the 90th centile, and then continues to rapidly
increase. Macrocephaly, large hands and feet
are features. Children also commonly have
learning difficulties.
2. J Dermatitis herpetiformis. This is a characteristic
blistering, pruritic rash associated with coeliac
disease that is characteristically found on
elbows, shoulders, knees and buttocks. Despite
the name, the condition is neither caused by
nor related to herpes virus.
3. C Alopecia areata. This is a localized area of hair
loss that can be caused by ringworm infection.
Other risk factors include familial predisposition
and psychological stress. In some cases hair
loss can be extensive and permanent.
4. B. Koplik spots. These salt grain-like lesions seen
on buccal membranes are pathognomonic of
the measles described,
5. A T-cell lymphoma. Mycosis fungoides is the most
common form of cutaneous T-cell lymphoma. It
presents as patchy generalized dermatitis that
then develops into lesions or tumours.
Chapter36 Haematological disorders
Haematological disorders
1. I ALL. This is the most common form of
leukaemia in children, and the peak incidence
occurs at 2–5years. It commonly presents with
constitutional features and lymphadenopathy.
2. J AML. The incidence of AML increases with
age, and Down syndrome is one of the
predisposing diseases. In adults it takes a
more chronic course and commonly presents
with nonspecific features of malaise and
hepatosplenomegaly. It is usually not associated
with lymphadenopathy.
3. E NHL can present in various ways and is more
common in adults. Exceptions are highgrade lymphoblastic and small noncleaved
lymphomas, which are commonly found in
children. Risk factors for disease development
include viral illness, immunosuppression and
autoimmune disease. Treatment is symptomatic
or multiagent chemotherapy can be used.
4. C Multiple myeloma. The peak age of presentation
of multiple myeloma is 70years. It is more
common in Afro-Caribbean men and results
from results from neoplastic proliferation of
plasma cells. This leads to diffuse bone marrow
infiltration and failure. It shows increased
osteoclast activity and lytic bone lesions that
lead to the appearance of punched-out lesions
on radiographic investigations.
5. F CML is a myeloproliferative disorder of
pluripotent haemopoietic stem cells that can
affect any stem cell line. More than 90%
show cytogenetic abnormality of Philadelphia
chromosome. It can present with massive
splenomegaly and constitutional symptoms
of lethargy. Treatment is with tyrosine kinase
inhibitors.
Chapter37 Infectious diseases
Infectious disease
1. A The most probable diagnosis is TB. This is
the most common pathogen and it spreads
439
EMQ answers
through direct contact and air. It is likely the
19-year-old became infected in the new
environment of the university. Initially, TB may
be asymptomatic, but erythema nodosum,
pleural effusion and a persistent cough can
be troublesome. Chest X-ray characteristically
shows consolidation, air space or nodular
changes with loss of volume, and this is
typically in upper zones.
2. I Staphylococcus aureus is the most common
cause of infective endocarditis, which is
described in the vignette. The other causes
are streptococci and coagulase-negative
staphylococci. The management is with
intravenous antibiotics and supportive
treatment. Hypercoagulative state is also
a feature of the condition, and therefore
prevention of embolism should be considered
especially in patients with artificial heart valves.
3. J Giardia lamblia is a flagellated protozoa
common in eastern Europe and Russia. It
colonizes the small bowel, causing initial partial
villous atrophy and malabsorption. Then it
moves to the large bowel and causes watery
diarrhoea and flatus.
4. B This man presents with signs and symptoms
suggestive of Burkitt lymphoma. This is a
rapidly growing B-cell non-Hodgkin lymphoma
that is associated with Epstein–Barr virus and
immunosuppression. It is common in equatorial
Africa and in patients with HIV-related disease.
Most commonly it presents with swelling in
mandibular/maxillary and abdominal areas
fever and weight loss. Management is with
chemotherapy.
5. G This man has signs and symptoms of
pneumonia. He is at high risk of developing
the disease because of his l cirrhosis.
Streptococcus pneumoniae is the most
common causative organism. Other common
causes include Haemophilus influenzae and
Chlamydophila pneumoniae. The most common
signs and symptoms include fever, productive
cough and shortness of breath.
440
Index
Note: Page numbers followed by f
indicate figures, t indicate tables and
b indicate boxes.
A
abbreviated mental test score, 119
ABCDE approach
airway, 11
breathing, 11
circulation, 11
disability, 11
exposure, 11
stroke, 126–127
abdominal examination, 20–23
inspection, 21, 21t
abdominal mass, 22t
abdominal pain, 5
causes, 67–68
diagnosis, 68, 68f
differential diagnosis, 65t
examination, 66–68, 67f
history, 66
investigations, 68–69
abdominal swelling, 6
abducens nerve, 26
abscess
central nervous system, 298
cerebral, 102
liver, 251
absence attacks, 287
acarbose, 310
accessory nerve, 28
achalasia, 230
acidosis, 259, 261–262
acne rosacea, 155
acne vulgaris, 155, 351–352, 351f, 351t
acoustic neuroma, 142t
acquired factor inhibitors, 162
acromegaly
aetiology, 320
clinical features, 320–321, 321f
investigations, 321–322
medical therapies, 322
prognosis, 322
radiotherapy, 322
surgery, 322
actinic keratosis, 154, 352
action tremor, 14
activated partial thromboplastin time
(APTT), 160
acute cholecystitis, 242
acute coronary syndrome (ACS), 43b,
171–175
NSTEMI, 172–175
STEMI, 171–172
acute hepatitis, 246–248
acute kidney injury (AKI)
aetiology, 256, 257t
blood tests, 258
causes, 256, 257t
clinical features, 256–257
complications of, 256–257
investigations, 257–258
management
acidosis, 259
hyperkalaemia, 258–259
pulmonary oedema, 259
renal replacement therapies, 259
supportive management, 259
staging, 256, 256t
urine, 257–258
acute lymphoblastic leukaemia (ALL),
362–363, 363t
aetiology, 362
clinical features, 362–363
pathology, 362
treatment and prognosis, 363
acute myeloid leukaemia (AML), 363–364
aetiology, 363
clinical features, 363–364, 363t
pathology, 363, 364t
treatment and prognosis, 364
acute pancreatitis
clinical features, 243
investigations, 243
management, 244
modified Glasgow severity score, 244t
acute pyelonephritis, 267
acute respiratory distress syndrome
(ARDS), 224–225
definition, 225
management, 225
acute severe asthma, 204–205t
acute viral hepatitis, 246–248
adalimumab, 240
Addison disease
aetiology, 325–326
clinical features, 326, 326f
investigations, 326
management, 326–327
Addisonian crisis, 326
adenocarcinoma, 213
adenomatous polyps, 235
adenosine, 177
for supraventricular arrhythmias, 179
ADH. See antidiuretic hormone (ADH)
adrenal gland disorders, 323
Addison disease, 325–327
Conn syndrome, 327
cortisol production control, 323, 324f
Cushing syndrome, 324–325
phaeochromocytoma, 327–328
adrenocortical tumours, 325
adult polycystic kidney disease, 270–271,
271t
age, and hypertension, 183b
airway examination, 11
albumin-to-creatinine ratio (ACR),
253–254
chronic kidney disease, 260t
alcohol abuse, 388–391
health problems, 389
and hypertension, 183b
management, 389–390
alcoholic liver disease, 248–249
alcohol, units of, 3f
aldosterone antagonists, 182
ALL. See acute lymphoblastic leukaemia
(ALL)
allergies, 2
allopurinol, 340
alopecia, 152t
α-adrenergic receptor blockers, 187
α1-antitrypsin deficiency, 206, 251
alteplase, 127
amantadine, 293, 295
amaurosis fugax, 102
aminophylline, 204–205t
aminotransferase, 172
amiodarone, 180
AML. See acute myeloid leukaemia (AML)
amphetamines, 385, 387t
amyotrophic lateral sclerosis, 301
anaemia, 16, 76, 262, 357–362
aplastic, 362
causes of, 358–360
chronic disease, 358–359
chronic kidney disease, 262
diagnosis, 357
haemolytic, 359
hydroxycarbamide, 360
management, 357–358
blood transfusion, 357–358, 358t
erythropoietin, 358
folate replacement, 357
441
Index
anaemia (Continued)
iron replacement, 357
splenectomy, 358
vitamin B12 replacement, 357
paroxysmal nocturnal,
haemoglobinuria, 372, 373t
pernicious, 357
rheumatoid arthritis, 336–337, 337t
sickle cell, 359–360
sideroblastic, 369, 369t
thalassaemia, 360–362, 360–361t
anaplastic carcinoma, 110
angina pain, 43b
angiography, 104
angiotensin-converting enzyme inhibitors,
170, 173–174, 182, 186
angiotensin II receptor blockers, 186
ankle swelling, 4
ankylosing spondylitis, 147t
clinical features, 338–339, 339t
management, 339
pathology, 338
Ann Arbor system, staging of malignant
lymphomas, 367f, 368
anorexia, 3
anosmia, 6
antagonist drugs, 162
anterior horn cell lesions, 133–135t
antiarrhythmic drugs, 178–180
antibiotics. See also individual drugs
bronchiectasis, 209
pneumonia, 211, 212t
anticholinergics, 293
anticoagulant therapy, 127
anticoagulation, 176
antidiuretic hormone (ADH), 93, 93f,
275, 323
antiepileptic drugs, 286
antiglomerular basement membrane
disease, 265
antineutrophil cytoplasmic antibodies
(ANCA), 265
antiphospholipid antibodies, 341
antiphospholipid syndrome, 346
antiplatelet agents, 127, 170
antiplatelet therapy, 171, 173
antiretroviral therapy, 376–378
antithyroid drugs, 316–317
antoantibodies, neurological disease, 139t
anuria, 93
anxiety, palpitations, 58
aorta
coarctation, 197–198
regurgitation, 190–191
sclerosis, 190
stenosis, 190, 198
apex beat, 17
aplastic anaemia, 359, 362
causes of, 362, 362t
clinical features, 362
management, 362
appetite, 3
ARDS. See acute respiratory distress
syndrome (ARDS)
arginine vasopressin. See antidiuretic
hormone
Argyll Robertson pupil, 24
arms. See upper limb
arrhythmias, 175–180. See also specific
arrhythmias; palpitations
investigations, 175
myocardial infarction and, 175
supraventricular, 175–180
ventricular, 180
arrhythmogenic right ventricular
dysplasia, 194
arterial blood gas (ABG), 46, 201, 212
arthralgia, 148
arthritis, 148
mutilans, 348, 348f
ascites, 22t, 67
chronic liver disease, 245
Aspergillus spp., 223–224
aspiration pneumonia, 210
aspirin, 172–173, 386t
asterixis, 14
asthma, 203
aetiology, 203
clinical features, 203
differential diagnosis, 204b
investigations, 203–204
management, 204
emergency, 204–205, 204–205t
long-term, 205
pathophysiology, 203
astrocytomas, 289–290
atenolol, 170
atherosclerosis, 168. See also ischaemic
heart disease (IHD)
atonic/akinetic epilepsy, 287
atopic dermatitis/eczema, 153, 349–350,
350f
atrial fibrillation
aetiology and pathophysiology, 176
atrial flutter, 176
complications, 176
management, 176
atrial flutter, 176
atrial myxomata, 196
atrial septal defect (ASD), 197
atrioventricular (AV) block, 175
atrioventricular nodal reentry tachycardia,
177
at rophy, 152t
atypical facial pain, 285
auscultation, 17, 17f
dyspnoea, 50
Auspitz sign, 348, 348f
autoimmune haemolytic anaemia, 359
autoimmune hepatitis, 248
autoimmune polyendocrine syndrome,
329
autonomic neuropathies, 308
azathioprine, 240–241
B
Babinski response, 32f
back pain, 147t
causes, 148, 149t
differential diagnosis, 148
examination, 146–147
history, 145–146
investigations, 147–148
bacterial overgrowth, 233
Bamford classification, 124–125t
barium meal, heartburn, 73
Barrett oesophagus, 230
basal cell carcinoma, 156, 353–354
β-blockers, 170, 173–174
for heart failure, 182
for hypertension, 187
overdose, 385, 386t
for supraventricular and ventricular
arrhythmias, 180
Beau lines, 14
Becker muscular dystrophy, 300
beclomethasone, 206t
bedside manner, 1
Behçet disease, 345
bell palsy, 302, 302f
benign disease, 234–235
benign oesophageal stricture, 229
benign paroxysmal positional vertigo
(BPPV), 142t
benign proteinuria, 253
benign tumours, 251
benzhexol, 293
benzodiazepine overdose, 385, 386t
Berger disease. See IgA nephropathy
biguanides, 309
biliary colic
clinical features, 241
investigations, 241
management, 241–242
biliary tract cancer
cancer of ampulla of vater, 243
cholangiocarcinoma, 242
gallbladder cancer, 242
bilirubin, 89f. See also jaundice
biochemistry. See also specific conditions
acute kidney injury, 257–258
osteomalacia, 332
bisoprolol, 170, 175, 182
bisphosphonates, 330, 332
blackouts. See syncope
bleeding. See haemorrhage; and specific
conditions
bleeding disorders
clotting tests, 162t
coagulation abnormality, 162
coagulation studies, 160
differential diagnosis, 162–163
442
Index
bleeding disorders (Continued)
disseminated intravascular coagulation,
371–372
examination findings, 159–160
factor deficiency, 162
haemophilia A, 370–371
haemophilia B, 371
history, 159–160
immune thrombocytopaenia, 371
investigations, 160–161
platelet abnormality, 162
platelet dysfunction, 162
vessel wall abnormalities, 163
von Willebrand disease, 371
bleeding time, 161
blind spot, 23
blister/bulla, 152t
blood
blood film, 160, 359–360, 369–370, 374
culture, 126, 195, 251
thinning medication, 159
transfusion, 357–358, 358t
blood pressure (BP), 119. See also
hypertension
cardiovascular disease, 15, 167
respiratory disease, 18
blood tests, 162t
abdominal pain, 68
acute kidney injury, 258
acute pancreatitis, 243
back pain, 147
bowel habit changes, 82
chest pain, 46
confusion, 119
cough/haemoptysis, 54–55
focal neurological deficits, 138
glomerular disease, 264
haematemesis/melaena, 78
headache/facial pain, 104
heart failure, 181
hypothyroidism, 109
jaundice, 91
palpitations, 58
primary sclerosing cholangitis, 250
proteinuria, 254–255
PUO, 61
skin lesions, 152
stroke, 126
urinary symptoms, 96
weight loss, 86–87
bloody diarrhoea, causes of, 382, 382t
body habitus, 13
bone disease
osteomalacia, 330–331
osteoporosis, 330–331
Paget disease, 331–332
renal osteodystrophy, 261, 333–334
vitamin D metabolism, 329, 329f
bone marrow, failure, 159, 362–363, 363t,
366
bone mineral density (BMD), 319
bone pain, 8t
borreliosis. See Lyme disease
bouchard nodes, 14
bowel habits, 5 (see also constipation;
diarrhoea)
differential diagnosis, 81–82t
examination, 82, 83f
history, 81–82
investigations, 82–83
bowel sounds, 67
Bowen disease, 154, 354
brachial artery, 15
brachial plexus lesions, 133–135t
bradycardias, 178. See also specific types
bradykinesia, 291–292
breast examination, 34
breathing examination, 11
breathlessness. See dyspnoea
bronchiectasis
clinical features, 209
investigations, 209
bronchitis, 206
bronchodilators, 209
bronchoscopy, 56
pneumonia, 211
bronchospasm, clinical findings, 19t
Brudzinski sign, 104
bruising and bleeding
differential diagnosis, 162–163
examination findings, 159–160
history, 159–160
investigations, 160–161
pattern and extent, 159
B-type natriuretic peptide (BNP), 181
Budd–Chiari syndrome, 251–252
budesonide, 206t
bulbar palsy, 302
bullous lesions, 156
bullous pemphigoid, 156, 353
buttock pain, 4
C
cachexia, 67
CAGE questionnaire, 388–389, 389b
calcitonin, 332
calcium. See hypercalcaemia;
hypocalcaemia
calcium channel blockers, 170, 173–174,
186
calcium homeostasis, 279, 280f
calf
pain, 4
swelling, 4
cancer, of ampulla of vater, 243
candidiasis, 157
carbapenem-resistant Enterobacteriaceae
(CRE), 382
carbimazole, 316
carcinoid syndrome, 234
carcinoid tumours, 234
cardiac catheterization, 194, 197
cardiac failure, 174
cardiac markers, 46
cardiac resynchronization therapy (CRT),
183
cardiac rupture, 174
cardiac syndrome X, 167
cardiac transplantation, 183
cardiogenic shock, 174
cardiomyopathy, 193–194
causes of, 193t
dilated, 194
hypertrophic obstructive, 193–194
restrictive/infiltrative, 194
cardiovascular disease (CVD). See also
specific conditions
acute coronary syndrome, 171–175
arrhythmias, 175–180
arrhythmogenic right ventricular
dysplasia, 194
atrial myxomata, 196
cardiomyopathy, 193–194
congenital heart disease, 196–199
constrictive pericarditis, 193
coronary heart disease, 167
heart failure, 180–183
hypertension, 183–187
infective endocarditis, 194–196
pericarditis/pericardial effusion,
192–193
rheumatic fever, 196
symptoms, 4
valvular heart disease, 187–192
cardiovascular system
apex beat, 17
auscultation, 17
blood pressure, 15
brachial and carotid artery, 15
clinical examination, 15–17
face, 16
hands, 15
jugular venous pressure, 15–16
palpation, 17
position, 15
praecordium, 17
radial pulse, 15
visual survey, 15
carditis, 196
Carnett sign, 67
carotenaemia, 13
carotid artery, 15
carotid pulsation, jugular venous pressure
vs., 16t
carotid sinus massage, 177
carpal tunnel syndrome, 300
carvedilol, 170, 182
catamenial pneumothorax, 219
catechol O-methyltransferase inhibitors,
293
cellulitis, 157, 356
central cyanosis, 16
443
Index
central lesions, 142t
central nervous system
abscess, 298
cerebellar tremor, 293
cerebrovascular disease, 283–285
dementia, 286
epilepsy, 286–289
headache, 6, 284–285
infections, 296–298
encephalitis, 297–298
meningitis, 101, 296–297
spinal cord, 298
intracranial tumours, 289–290
movement disorders, 291–294
multiple sclerosis, 294–296
spinal cord disorders, 298–299
cerebellar lesions, 133–135t
cerebellar tremor, 293
cerebellopontine angle, 290
cerebellum
dysfunction, 138t
lesions, 295
signs, 295
tremor, 293
cerebral abscess, 102
cerebral angiography, 126
cerebral hemispheres, lesions of, 133–135t
cerebrospinal fluid
analysis, 138, 139t
in meningitis, 297, 297t
cerebrovascular accident/event. See stroke
cerebrovascular disease
extra-axial haemorrhage, 287
stroke, 283
Charcot joints, 308
chest pain, 4
central, 43
differential diagnosis, 43t
examination, 44–45, 45f
heartburn, 71
history, 44
associated symptoms, 44
nature of pain, 44
onset and progression, 44
site and radiation, 44
investigations, 45–46
pleuritic, 43
risk factors, 45
chest wall, tenderness, 43
chest X-ray (CXR), 181, 193
abdominal pain, 68
acute kidney injury, 258
acute respiratory distress syndrome,
225f
chest pain, 46
confusion, 119
dyspnoea, 50
glomerular disease, 264
interstitial lung disease, 222, 222t
lung cancer, 215
pericarditis, 193
chest X-ray (CXR) (Continued)
pleural effusion, 221
pneumonia, 211
pneumothorax, 219, 220f
pulmonary embolism, 213
stroke, 126
tuberculosis, 217–218
Cheyne-Stokes respiration, 49
Chlamydia trachomatis, 272
cholangiocarcinoma, 242
cholecystitis
acute, 242
recurrent, 242
cholesterol, 170b
Christmas disease. See haemophilia B
chronic asthma, 206t
chronic autoimmune thyroiditis, 108
chronic bronchitis
definition, 206
inflammation in, 207
chronic disease, anaemia of
clinical features, 358
management, 358–359
chronic heart failure, 182–183
chronic kidney disease (CKD)
aetiology, 260
albumin-to-creatine ratio categories
in, 260t
classification of, 259, 260t
clinical features, 260–261
investigations, 261
management, 261–262
chronic liver disease (CLD)
ascites, 245
clinical features, 244–245
hepatic encephalopathy, 245
hepatorenal syndrome, 245
signs of, 90b, 119
varices, 245
chronic lymphocytic leukaemia (CLL),
364–365
aetiology, 364
clinical features, 364–365
pathology, 364
treatment and prognosis, 365
chronic myeloid leukaemia (CML), 365
accelerated phase, 365
aetiology, 365
blastic phase, 365
chronic phase, 365
clinical features, 365
pathology, 365
treatment and prognosis, 365
chronic obstructive pulmonary disease
(COPD), 206–209
acute exacerbation, 207–208
aetiology, 206–207
α1-antitrypsin deficiency, 206
characteristic features of, 207, 208t
cigarette smoking, 206
clinical features, 207
chronic obstructive pulmonary disease
(COPD) (Continued)
investigations, 207, 208t
management, 207–208
long-term, 208–209
short-term, 208
occupation, 207
pathophysiology, 207
chronic pancreatitis, 244
chronic pyelonephritis, 267
Chvostek sign, 280
ciclosporin, 337, 338t
circulation examination, 11
clasp-knife phenomenon, 28
claudication, 4
clerking, 37–40
CLL. See chronic lymphocytic leukaemia
(CLL)
clopidogrel, 173
Clostridium difficile, 236
clotting tests, 162t
clubbing, 48, 76
abdominal pain, 67
cluster headache, 102, 285
CML. See chronic myeloid leukaemia (CML)
coagulation
abnormality, 162
cascade, 162
pathway, 160f
coagulopathies, 159
cocaine, 385, 387t
coeliac disease, 233
skin manifestations, 347
cognitive impairment, 295
Colicky pain, 66
collapsing pulse, 15t
colonic polyps, 234
colonoscopy, 82–83
colorectal cancer, 235–236
colorectal disorders
diverticulum, 236
neoplasia, 234–236
coma, 111
differential diagnosis, 112t
examination, 112–114, 113t
community-acquired pneumonia (CAP),
210–211, 212t
computed tomography (CT)
coronary angiography, 169
lung cancer, 215
pleural effusion, 221
pneumonia, 211
pulmonary angiogram, 213
confusion
causes, 118
examination, 118–119, 118f
history, 117–118
investigations, 119
pattern, 118
Confusion Assessment Method (CAM), 118
congenital adrenal hyperplasia, 329
444
Index
congenital heart disease, 196–199
acyanotic conditions, 197–198
cyanotic conditions, 198–199
congenital hypothyroidism, 108
congenital hypoventilation syndrome, 224
congestive cardiac failure, 181
connective tissue disorders
polymyositis/dermatomyositis, 342–343
Sjögren syndrome, 343–344
systemic lupus erythematosus, 341–342
systemic sclerosis, 342
Conn syndrome
clinical features, 327
investigation, 327
management, 327
consciousness, 119
loss of (see loss of consciousness)
constipation, 82t
constrictive pericarditis, 193
contact dermatitis, 349, 350t
continuous positive airway pressure
(CPAP), 202
COPD. See chronic obstructive pulmonary
disease (COPD)
coronary angiography, 169
coronary artery bypass graft (CABG),
170–171, 171b
coronary heart disease, 167
clinical features, 168
investigations, 168–169
pathophysiology, 168
risk factors, 167–168
treatment, 169–171
Corrigan sign, 15, 191
corticosteroids. See steroids
corticotrophin-releasing hormone
test, 328
cortisol
deficiency, 328
excess, 328
cough, 4, 47
differential diagnosis, 53b
examination, 54, 55f
history, 53–54
investigations, 54–56
coumarins, 162
crackles, 50
cranial diabetes insipidus, 323, 323t
cranial nerve. See also individual nerves
cranial nerve I, 23
cranial nerve II, 23–25
cranial nerve III, 25–26
cranial nerve IV, 25
cranial nerve V, 26, 26t
cranial nerve VI, 25–26
cranial nerve VII, 26–27
cranial nerve VIII, 27
cranial nerve IX, 27–28
cranial nerve X, 28
cranial nerve XI, 28
cranial nerve XII, 28
CRE. See carbapenem-resistant
Enterobacteriaceae (CRE)
crepitations, 50
Crohn disease
clinical presentation, 240
investigations, 240
management, 240–241
prognosis, 241
surgical intervention, 241
crust, 152t
cryptococcal meningitis, 378, 379t
crystal arthropathy
gout, 340
pseudogout, 341
CT. See computed tomography; computed
tomography (CT)
CT coronary angiography, 169
Cullen sign, 67
CURB65 score, 211, 212t
Curling ulcer, 230
Cushing syndrome
adrenocortical tumours, 325
clinical features, 324, 325f
disease, 324–325
ectopic adrenocorticotrophic hormone
syndrome, 325
investigations, 324
cyanosis, 12, 15
central, 48
cyst, 152t
cystic fibrosis
clinical features, 225–226
management, 226
cytomegalovirus, 378, 379t
D
DASHING mnemonic, 295
D-dimer, pulmonary embolism, 213
deafness, 6, 27t
decubitus ulcers, 157
delirium. See also confusion
differential diagnosis, 117t
history, 118
dementia, 286, 291t, 292, 301. See also
confusion
differential diagnosis, 117t
history, 118
de Musset sign, 16, 191
denosumab, 330
de Quervain thyroiditis, 108
dermatitis, 154
atopic, 153
exfoliative, 154
herpetiformis, 154
seborrhoeic, 153, 153f
dermatomes, 30f
dermatomyositis
clinical features, 343
management, 343
pathology, 343
destructive arthropathy, 14
detrusor instability, 94
dexamethasone suppression test, 324
diabetes insipidus, 94t
cranial, 323, 323t
management, 323
nephrogenic, 323, 323t
diabetes mellitus
aetiology and pathophysiology,
305–306
clinical features, 306–308
acute symptoms, 306–307, 306f
chronic complications, 306–308, 307f
diabetic feet, 308
infections, 308
macrovascular disease, 307
microvascular disease, 307–308
skin, 308
skin manifestations, 347
diagnosis, 305, 305t
emergencies
diabetic ketoacidosis, 312–313
hyperosmolar hyperglycaemic state,
313
hypoglycaemia, 311–312
and ischaemic heart disease, 168
management, 308–313
diet and lifestyle, 309
emergencies, 311–313
insulin, 310, 311f
oral hypoglycaemic agents, 309–310
surgery, 310–311
skin manifestations, 347
diabetic amyotrophy, 308
diabetic feet, 308
diabetic ketoacidosis (DKA), 312–313
diabetic nephropathy, 307–308
diabetic neuropathy, 308
diabetic retinopathy, 307
diarrhoea, 81t, 381–382, 381–382t
DIC. See disseminated intravascular
coagulation (DIC)
didanosine, 378, 378f
diet and lifestyle, 309
dietary sodium, and hypertension, 183b
digoxin, 175, 386t
for heart failure, 182
overdose, 385, 386t
for supraventricular arrhythmias, 180
dihydropyridines, 170
dilated cardiomyopathy, 194
diltiazem, 173–174
dipeptidyl peptidase 4 inhibitors, 310
diplopia, 294
direct current (DC) cardioversion, 175,
177
disability, 8
disability examination, 11
discoid lupus erythematosus, 154, 154f
disease-modifying antirheumatic drugs
(DMARDs), 337–338, 338t
445
Index
disseminated intravascular coagulation
(DIC), 371–372
aetiology, 371
clinical features, 372
pathology, 371–372
treatment and prognosis, 372
distal symmetrical polyneuropathy, 308
dithranol, 349
diuresis, 182
diuretics, 182
diverticular disease, 236
Dix-Hallpike manoeuvre, 143
dizziness, 6
differential diagnosis, 141, 141t
DMARDs. See disease-modifying
antirheumatic drugs (DMARDs)
dobutamine, 182
dopamine agonists, 292–293
dorsal column disease, 138t
Dressler syndrome, 174t
drug eruptions, 156
drug-induced lupus, 187
drug overdose/abuse
aetiology, 385
complications, 386–387, 387b
epidemiology, 385, 386–387t
examination, 385–387
history, 385
investigations, 387
management, 387–388
psychiatric and social assessment, 388
suicide risk, 385, 385b
drug-resistant bacteria, 382
carbapenem-resistant
Enterobacteriaceae, 382
methicillin-resistant Staphylococcus
aureus, 382
vancomycin-resistant enterococci, 382
drug therapy, 292–293
dual-energy X-ray absorptiometry (DXA),
330
Duchenne muscular dystrophy, 300
dupuytren contractures, 14
Duroziez sign, 191
dysarthria, 6, 7t
dyshidrotic eczema, 154
dyspepsia, 71
dysphagia, 5, 5t
dysphasia, 6, 7t
dysphonia, 6, 7t
dysplasia, arrhythmogenic right
ventricular, 194
dyspnoea, 4, 188, 212
aggravating/precipitating factors, 47
associated features, 47–48
clinical findings, 48t
examination, 48–50
history, 47–48
investigations, 50–51
onset of, 47
severity, 47
dysuria, 6, 94
E
echocardiography, 181
chest pain, 46
for ischaemic heart disease, 169
palpitations, 59
pulmonary embolism, 213
economy class syndrome, 212
ectopic adrenocorticotrophic hormone
syndrome, 325
eczema/dermatitis, 153–154, 349–351. see
also specific types
clinical features, 349–350
dyshidrotic, 154
management, 350–351
triggers of, 349, 350t
types of, 349, 350t
EEG. See electroencephalogram (EEG)
EGPA. See eosinophilic granulomatosis
with polyangiitis (EGPA)
Ehlers-Danlos syndrome, 159, 163
Eisenmenger syndrome, 197
electrocardiogram (EKG), 181, 193
acute kidney injury, 258
dyspnoea, 50
heartburn, 73
for ischaemic heart disease, 168
palpitations, 59
pericarditis, 193
pulmonary embolism, 213
electroencephalogram (EEG), 288
embolism, 194. See also thromboembolic
disorders
emphysema. See chronic obstructive
pulmonary disease
enalapril, 182
encephalitis, 297–298
encephalopathy, 90b
endocarditis, infective, 194–196
endocrine system, 7
disorders (see metabolic/endocrine
disorders)
endoscopy
haematemesis/melaena, 78
heartburn, 73
endothelial dysfunction, 168
end-stage renal failure (ESRF), 262
enoximone, 182
enteropathic arthritis, 340
enteropathic arthropathies, 340
entrapment/compression neuropathies,
299–300
eosinophilia, 61
eosinophilic granulomatosis with
polyangiitis (EGPA), 344
eosinophilic oesophagitis, 230
epigastric pain, 71
epilepsy
aetiology, 287–288
antiepileptic drugs, 286
classification, 286–287
driving and work, 289
epilepsy (Continued)
drug treatment, 288–289
focal onset seizures, 287
generalized onset seizures, 287
general overview, 286
investigations, 288
management, 288–289
pregnancy, 289
status epilepticus, 289
sudden unexpected death in
epilepsy, 289
treatment, 289
epilepsy syndromes, 286, 286t
eruption, 151, 155–156
erysipelas, 157
erythema, 152t
marginatum, 196
migrans, 156, 156f
multiforme, 155–156, 155f, 353
nodosum, 156, 156f, 353
erythematous lesions, 155–156, 347
erythrocyte sedimentation rate (ESR), 61
erythropoietin, 358
essential thrombocythaemia (ET), 370
essential tremor, 293
etanercept, 349, 349t
ethnicity, and ischaemic heart
disease, 167
evoked potentials, 139
examination. See also specific conditions
ABCDE approach, 11–12
abdomen, 20–23
breast examination, 34
cardiovascular system, 15–17
face and body habitus, 13
general principles, 12
hands, 13–14, 33
musculoskeletal examination, 33
neck examination, 34
nervous system, 23–33
respiratory system, 17–20
skin and lymphadenopathy, 33–34
visual survey, 12–13
excessive bruising and bleeding. See
bleeding disorders
exercise tolerance, 4, 168
exfoliative dermatitis, 154
exposure, to patients, 11
extradural haematoma, 284, 284f
extrapulmonary tuberculosis, 217–218
eyes. See also entries under visual
examination, in coma patients, 114t
ezetimibe, 315
F
face, 16
facial habitus, 13
facial nerve, 26–27
facial pain
chronic, 102–103
differential diagnosis, 101, 101t
446
Index
facial pain (Continued)
examination, 103–104, 103f
history, 101–103
investigations, 104, 105f
recurrent episodic, 102
facioscapulohumeral dystrophy, 300
factor deficiency, 160, 162
faecal occult blood test, 235
faeces, jaundice, 92t
familial adenomatous polyposis, 235
family history, 2
and ischaemic heart disease, 167
fatigue, 3
febuxostat, 340
fever. See pyrexia of unknown origin
fibrates, 315
fibrin degradation products, 160
fibrinogen levels, 161
fibromyalgia, 341
figurate erythema, 155–156
fine-needle aspiration cytology, 108
finger clubbing. See clubbing
fingolimod, 295–296
first-degree heart block, 178
fissure, 152t
flapping tremor. See asterixis
flecainide, 180
fluid balance and electrolyte disturbance
calcium balance, 279–281
intravenous fluid composition,
275, 275t
sodium and water balance, 275
fluid status, 13
fluticasone, 206t
focal neurological deficits, 103
autoantibodies, 139t
cause, 137–138
differential diagnosis, 133,
133–135t
disability, 138
examination, 137
history, 135–137
investigations, 138–139
onset, 135
pattern of, 135
precipitants, 135
progression, 135–137
symptoms and signs, 135, 136t
focal neurological signs, 143
focal onset seizures, 287–288
focal segmental glomerulosclerosis, 266
folate, 280–281
replacement, 357
follicular thyroid carcinoma, 110
folliculitis, 155, 155f
foot drop, 138t
forced expiratory volume, 203
forced vital capacity, 206
freckles/ephelides, 153
frontal lobe, 290
full blood count (FBC), 160
functional proteinuria, 253
G
gait, 32–33
abnormalities of, 138t
gallbladder cancer, 242
gallbladder disorders
acute cholecystitis, 242
gallstones and biliary colic, 241–242
gallstones
clinical features, 241
investigations, 241
management, 241–242
γ-hydroxybutyrate, 385, 387t
gastric carcinoma, 75t
gastrinoma, 234
gastritis, erosive, 75t
gastroduodenal disorders
gastric cancer, 232
gastroduodenitis, 230–231
gastrointestinal stromal tumour, 232
peptic ulcer disease, 230–231
upper gastrointestinal tract
haemorrhage, 231–232
gastroduodenitis, 230–231
gastrointestinal (GI) bleed
differential diagnosis, 75t
examination, 76, 76f
history, 75–76
investigations, 76–79, 77f
Rockall score, 78t
gastrointestinal disease, 5–6. See also
specific systems
gastric carcinoma, 75t
systemic sclerosis, 342, 343t
gastrointestinal haemorrhage
lower tract (see lower gastrointestinal
tract)
upper tract, 231–232
gastrointestinal stromal tumour (GIST),
232
gastrointestinal systems
lower gastrointestinal tract
bleeding, 236–237
Clostridium difficile, 236
colorectal disorders, 234–236
inflammatory bowel disease, 238–241
irritable bowel syndrome, 237
ischaemic colitis, 237
microscopic colitis, 237
nonulcer dyspepsia, 237–238
pseudomembranous colitis, 236
upper gastrointestinal tract, 229–234
oesophageal disorders, 229–230
small bowel disorders, 232–234
gastro-oesophageal reflux disease
clinical features, 229
complications, 229
investigations, 229
management, 229
GCA. See giant cell arteritis (GCA)
generalized lymphadenopathy, 130–131
generalized onset seizures, 287–288
generalized wasting, 14
genetics, and hypertension, 183b
genitourinary disease
acute kidney injury, 256–259
chronic kidney disease, 259–262
glomerular disease, 262–267
renal calculi, 268–269
urinary tract infections, 267–268
urinary tract malignancies, 269–270
genitourinary system, 6
giant cell arteritis, 346
GIST. See gastrointestinal stromal tumour
(GIST)
Glasgow coma scale, 113t, 119, 123
glaucoma, 102
Global Registry of Acute Cardiac Events
(GRACE) score, 173, 173b
glomerular disease
ANCA-positive vasculitis, 265
antiglomerular basement membrane
disease, 265
blood tests, 264
clinical features, 262–263, 263t
focal segmental glomerulosclerosis, 266
history, 263–264
IgA nephropathy, 265–266
investigations, 264
lupus nephritis, 266
management, 264–265
membranoproliferative
glomerulonephritis, 266–267
membranous glomerulonephritis, 266
minimal change nephropathy, 266
nephritic syndrome, 263
nephrotic syndrome, 263
poststreptococcal glomerulonephritis,
267
primary and secondary, 265–267
rapidly progressive glomerulonephritis,
265
urine, 264
glomerulonephritis
membranoproliferative, 266–267
membranous, 266
poststreptococcal, 267
rapidly progressive, 265
glomerulosclerosis, 266
glossopharyngeal nerve, 27–28
glucagon-like peptide 1agonists, 310
glucagonomas, 234
glucose-6-phosphate dehydrogenase
deficiency, 359
glyceryl trinitrate (GTN), 172
glycoprotein, 172
goitre
examination, 107–108
history, 107–108
investigations, 108
golimumab, 240
gonorrhoea, 272
Goodpasture disease, 265
GORD. See gastro-oesophageal reflux disease
447