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 OXFORD
HANDBOOK
OF CLINICAL
SPECIALTIES
TENTH EDITION

ANDREW BALDWIN
NINA HJELDE
CHARLOTTE GOUMALATSOU
GIL MYERS

3
Oxford University Press, Great Clarendon Street, Oxford OX2 6DP
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education by
publishing worldwide. Oxford is a registered trade mark of Oxford University Press
in the UK and certain other countries.
Published in the United States by Oxford University Press Inc., New York
© Oxford University Press, 2016
The moral rights of the authors have been asserted
First published 1987 Sixth edition 2003 Translations: Greek
Second edition 1989 Seventh edition 2006 Spanish Romanian
Third edition 1991 Eighth edition 2008 German Russian Polish
Fourth edition 1995 Ninth edition 2013 Hungarian Portuguese
Fifth edition 1999 Tenth edition 2016
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, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this book in any other form and
you must impose the same condition on any acquirer.
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2015958817
Typeset by GreenGate Publishing Services, Tonbridge, UK; printed
in China on acid-free paper through C&C Offset Printing Co. Ltd
ISBN 9780198719021

Drugs
Except where otherwise stated, recommendations are for the non-pregnant
adult who is not breastfeeding.
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, safety regulations and latest BNF/BNFC. The
authors and the publishers do not accept responsibility or legal liability for any er-
rors in the text, or for the misuse or misapplication of material in this work.
For updates/corrections, see oup.co.uk/academic/medicine/handbooks/updates.
Contents

Drugs ii
Contents iii
Preface to the tenth edition iv
Preface to the first edition v
Conflicts of interest: none declared v
Dedication vi
Acknowledgements vii
How to use this book viii
A note on the use of pronouns viii
Symbols and abbreviations ix

1 Obstetrics 1
2 Paediatrics 98
3 Gynaecology 240
4 Psychiatry 312
5 Ophthalmology 410
6 Primary care 466
7 Ear, nose, and throat 534
8 Dermatology 582
9 Anaesthesia 612
10 Eponymous syndromes 638
11 Orthopaedics 656
12 Trauma 714
13 Emergency medicine 762
14 Pre-hospital care 796
Index 817
The content of each chapter is detailed on each chapter’s first page.
 Preface to the tenth edition
T his is the first medical book to take the health of its readers seriously on
the grounds that the health of one person (a patient) must not be bought
at the expense of another (their doctor). It is an unsettling paradox that when
we study medicine our own health may be forgotten, with long hours of hard
work—often without joy or sustenance—as our health is shattered by the
weight of an over-loaded curriculum (no doubt because we are over-stimu-
lated by the too many receptors, organs, and systems, about which we know
far too much).
What can a book do about this dilemma? Whilst we strive to guide you through
the realms of the specialties with a concise overview of exactly what you need
to know, we also place prominence on developing your skills beyond just pure
facts, since these may quickly be forgotten. We want to furnish your mind with
anecdotes which will remind you of the value of your hard work to inspire and
motivate you to learn more. It is the quirks of medicine which we remember
best; the bits that make you smile and make you realize that the work we do can
be truly inspiring. The spiral symbol [] throughout the book, and at the start of
each chapter, is your reminder to connect with and enjoy your patients; to dis-
cover what is important to them, and in so doing, make a real difference to their
health and well-being. Few people receive such privileged insight into another’s
life. Few other professions can reflect on their day—and from the mundane, the
routine, even the stressful—bring forth such engaging or thought-provoking
episodes from their encounters at work.
We also hope our writings inspire you that further work can be accomplished.
Do not think that a student’s or junior doctor’s work goes unnoticed—you are
in the ideal position to make astute and objective observations uncluttered by
previous baggage. Two medical students were instrumental in the journey of
discovery of insulin: in 1869, German student Paul Langerhans found clusters of
cells within the pancreas whose function were unknown, but were later shown
to be insulin producing -cells. Canadian student Charles Best’s work with Fred-
erick Banting led to the discovery of insulin in 1921—a miracle treatment for a
previously feared and deadly disease. You may think the world of discovery is
exhausted, especially for such junior members of the team, but in 2014 a medical
student was the lead author for research which revealed the extent of aspergil-
losis in cystic fibrosis. Take heart!
So in bringing these thoughts together, try to make a habit of treasuring those
unique quirks that come your way, and regularly bring them to mind as a re-
freshing antidote to the demands of our profession. And be aware of the pos-
sible line of enquiry that your studies or work may present, bearing in mind the
dictum of Albert Szent-Gyorgyi, the physiologist who is credited with isolating
vitamin C: ‘Discovery is to see what everybody else has seen, and to think what
nobody else has thought’.
ANDREW BALDWIN, NINA HJELDE, CHARLOTTE GOUMALATSOU, & GIL MYERS
Preface to the tenth edition—2016

iv
Preface to the first edition
W hen someone says that he is ‘doing obstetrics’—or whatever, this
should not hide the fact that much more is being done besides, not just
a little of each of medicine, psychiatry, gynaecology and paediatrics, but also
a good deal of work to elicit and act upon the patient’s unspoken hopes and
fears. At the operating table he must concentrate minutely on the problem in
hand; but later he must operate on other planes too, in social and psychologi-
cal dimensions so as to understand how the patient came to need to be on the
operating table, and how this might have been prevented. All the best special-
ists practise a holistic art, and our aim is to show how specialism and holism
may be successfully interwoven, if not into a fully watertight garment, then
at least into one which keeps out much of the criticism rained upon us by the
proponents of alternative medicine.
We hope that by compiling this little volume we may make the arduous task
of learning medicine a little less exhausting, so allowing more energy to be
spent at the bedside, and on the wards. For a medical student coming fresh
to a specialty the great tomes which mark the road to knowledge can numb
the mind after a while, and what started out fresh is in danger of becoming
exhausted by its own too much. It is not that we are against the great tomes
themselves—we are simply against reading them too much and too soon. One
starts off strong on ‘care’ and weak on knowledge, and the danger is that this
state of affairs becomes reversed. It is easier to learn from books than from
patients, yet what our patients teach us may be of more abiding significance:
the value of sympathy, the uses of compassion and the limits of our human
world. It is at the bedside that we learn how to be of practical help to peo-
ple who are numbed by the mysterious disasters of womb or tomb, for which
they are totally unprepared. If this small book enables those starting to ex-
plore the major specialties to learn all they can from their patients, it will have
served its purpose—and can then be discarded.
Because of the page-a-subject format, the balance of topics in the follow-
ing pages may at first strike the reader as being odd in places. However, it
has been our intention to provide a maximally useful text rather than one
which is perfectly balanced in apportioning space according to how common
a particular topic is—just as the great Terrestrial Globes made by George Phil-
lips in the 1960s may seem at first to provide an odd balance of place names,
with Alice Springs appearing more prominently than Amsterdam. To chart a
whole continent, and omit to name a single central location out of respect for
‘balance’ is to miss a good opportunity to be useful. George Phillips did not
miss this opportunity, and neither we hope, have we. It is inevitable that some
readers will be disappointed that we have left out their favoured subjects (the
Phillips’ Globe does not even mention Oxford!). To these readers we offer over
300 blank pages by way of apology.
JABC & JML—Preface to the first edition—Ferring, 1987

Conflicts of interest: none declared

No pharmaceutical company employs us in any capacity and we have not re-
ceived any financial input or gifts bearing upon our research for this publica-
tion. We assert that the drugs recommended in this book have been selected
on the basis of the best available evidence.

v
 Dedication

vi ‘He who studies medicine without books sails an uncharted sea,

but he who studies medicine without patients does not go to sea at all.’
William Osler
Canadian physician, 1849–1919
Acknowledgements
This book was conceived and inspired by Judith Collier and Murray Longmore,
who as lead authors presided over it for more than 25 years—from publication
of the first edition in 1987, until publication of the ninth edition in 2013. Their
knowledge, wisdom, and creativity lives on in the pages of this edition and their
work has been loved and trusted by generations of doctors.
We thank all the authors who have contributed to previous editions: Judith Har-
vey, Tim Hodgetts, Duncan Brown, Peter Scally, Mark Brinsden, Ahmad R. Mafi,
Tom Turmezei, and Keith Amarakone.
We thank those who have contributed their time and wisdom to previous edi-
tions: Dr Steven Emmet, Professor Tor Chiu, Natalie Langdown, and Professor
Mark Lowenthal.
Specialist Readers We are hugely indebted to our Specialist Readers for their
advice, encouragement, and constructive criticism. Each chapter in this book
has benefitted from their trustworthy oversight. They are thanked individually
at the beginning of each chapter.
Junior Readers It was our great pleasure to welcome a new team of Junior
Readers to the tenth edition of this book. Our Junior Readers showed commit-
ment, intelligence, and ingenuity in their contributions to the referencing and
cross-referencing of this edition. We have a better book for it. They are also
thanked individually at the beginning of each chapter.
Reader participation We have been very fortunate to receive so many well-
considered suggestions and corrections to the book from readers all over the
globe. Their contributions have enhanced the book and we are grateful.
If you would like to give us feedback, correct a mistake, or make a suggestion,
you can do so at www.oup.com/uk/academic/ohfeedback.

vii
 How to use this book
This book has some useful features to help you get the most out of the informa-
tion inside.
Quick chapter look-ups The index on the back cover refers to and aligns with
the coloured tabs on the sides of the pages.
References (1) Every reference has an individual identification indicated by a
pink superscript number. The full details of every reference are held online at
www.oup.com/ohcs10refs.
Further reading Throughout the book you will find ‘Further reading’ sections
which are intended to guide you to sources that will further your learning, un-
derstanding, and clinical practice.
Cross references There are cross references to other topics within the book,
to the Oxford Handbook of Clinical Medicine (OHCM), and to other titles in the
Oxford Medical Handbooks series.
Reference intervals for common laboratory values are included inside the
back cover. Conversion factors to and from SI units are given on the bookmark.
Symbols and abbreviations See page ix.
Corrections and suggestions Found a mistake? Have a suggestion for the
next edition? Let us know at www.oup.com/uk/academic/ohfeedback. Major
changes are announced online at www.oup.co.uk/academic/series/oxhmed/
updates.

A note on the use of pronouns

For brevity, the pronoun ‘he’ or ‘she’ has been used in places where ‘he or she’
would have been appropriate. Such circumlocutions do not aid the reader in
forming a vivid visual impression, which is one of the leading aims of good au-
thorship. Therefore, for balance and fairness, and where sense allows, we have
tried alternating he with she.

viii
Symbols and abbreviations
 ........don’t dawdle! Prompt action © ..........courtesy of the copyright holder
saves lives C3 ..........complement
...........this phrase is important Ca .........carcinoma
 (†) more (or less) vital topic; a rough CBRN ....chemical, biological, radiological,
guide for 1st-time readers nuclear
 .......an opportunity for holistic/non- CBT .......cognitive-behavioural therapy
reductionist thinking CCDC ....consultant in communicable
.......conflict (controversial topic) disease control
, ,
11,2,23 3 .......references at oup.co.uk/ohcs10refs CCF .......combined (right- & left-sided)
..........drug dose not in BNF, see cardiac failure
oup.co.uk/ohcs10refs ChVS .....chorionic villus sampling
# ...........fracture CI ..........contraindications
............diagnosis CIN........cervical intra-epithelial neoplasia
 .........differential diagnosis CMV ......cytomegalovirus
: ......male to female ratio CNS .......central nervous system
 ............decreased CoC .......combined oral contraceptive
 .........normal (eg plasma level) COM ......chronic otitis media
 ............increased CPA .......care programme approach
~ ...........about CPAP.....continuous +ve airways pressure
≈ ............approximately equal CPR .......cardiopulmonary resuscitation
–ve .......negative CRP .......C-reactive protein
+ve ......positive CRPS.....complex regional pain syndrome
............on account of/because of CS..........caesarean section
............therefore CSF .......cerebrospinal fluid
A2A .......angiotensin 2 receptor (blockers) CT..........computed tomography
ABC .......air, breathing, circulation CVP .......central venous pressure
A(P)LS ..advanced (paediatric) life support CVS .......cardiovascular system
manuals CXR .......chest x-ray
ABR .......audiological brainstem responses D ............dimension (or dioptre)
AC..........ante cibum (before food) D&C.......dilatation (cervix) & curettage
ACE(i) ...angiotensin-converting enzyme D&V ......diarrhoea and vomiting
(inhibitor) dB ..........decibel
ACTH .....adrenocorticotrophic hormone DHS .......dynamic hip screw
ADD .......attention deficit disorder DIC ........disseminated intravascular
ADH ......antidiuretic hormone coagulation
AED.......anti-epileptic drug DIP ........distal interphalangeal
AFP ....... -fetoprotein (=alpha) DKA ......diabetic ketoacidosis
AIDS .....acquired immunodeficiency syn. dL ..........decilitre
AKI .......acute kidney injury DM ........diabetes mellitus
Alk .......alkaline (phos=phosphatase) DMSA ...dimercaptosuccinic acid
ALL .......acute lymphoblastic leukaemia DNA ......deoxyribonucleic acid
ALS........advanced life support DOH.......Department of Health (NHS)
ALT........alanine aminotransferase DPL .......diagnostic peritoneal lavage
ANA ......antinuclear antibody DRG.......dorsal root ganglion
ANF .......antinuclear factor DSM-5 ..Diagnostic and Statistical Manual
ANS.......autonomic nervous system of Mental Disorders, 5e
AP .........anteroposterior DUB.......dysfunctional uterine bleeding
APH.......antepartum haemorrhage DVT .......deep venous thrombosis
APLS .....advanced paediatric life support EBM ......evidence-based medicine
APM......auto-premotor syndrome EBV .......Epstein–Barr virus
ARM......artificial rupture of membranes ECG .......electrocardiogram
ASD.......atrioseptal defect ECT .......electroconvulsive therapy
ASO.......antistreptolysin O (titre) ED..........emergency department
ASW .....approved social worker EDD .......expected delivery date
ATLS∏ ..Advanced Trauma Life Support∏, EEG .......electroencephalogram
see www.trauma.org EIA........enzyme immunoassay
ATN .......acute tubular necrosis ENT .......ear, nose and throat
AV .........atrioventricular ERPC.....evacuation of retained products
AVM......arteriovenous malformation of conception
HCG.....-human chorionic gonadotrophin ESR .......erythrocyte sedimentation rate
BJGP .....British Journal of General Practice ET ..........endotracheal
BMI.......body mass index FB..........foreign body
BMJ ......British Medical Journal FBC .......full blood count
BNF .......British National Formulary FCR .......flexor carpi radialis
BNF ......children’s BNF
C
FDP .......flexor digitorum profundus
BP..........blood pressure FDS .......flexor digitorum sublimis
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