Kumar & Clark’s Clinical Medicine

1508 Pages·2020·112.722 MB·English

by  Adam Feather, David Randall, Mona Waterhouse

Kumar & Clark’s
Clinical
Medicine
Tenth Edition
Edited by Foreword by
Adam Feather MBBS, FRCP, FAcadMEd Professor Dame Parveen J Kumar CBE,
Consultant Physician and Clinical Director BSc, MD, DM(HC), FRCP (L&E), FRCPath
St Mary’s Hospital Professor of Medicine and Education
The Isle of Wight, UK Barts and The London School of Medicine and
Dentistry, QMUL;
David Randall MA, MRCP Honorary Consultant Physician and
Clinical Research Fellow Gastroenterologist
Barts and The London School of Medicine and Barts Health NHS Trust and Homerton University
Dentistry, QMUL; Hospital NHS Foundation Trust
Specialty Registrar in Renal Medicine London, UK
Barts Health NHS Trust
London, UK Michael L Clark MD, FRCP
Honorary Senior Lecturer
Mona Waterhouse MA (Oxon), MRCP Barts and The London School of Medicine and
Consultant Physician and Endocrinologist Dentistry, QMUL, and Princess Grace Hospital
St Bartholomew’s Hospital, Barts Health NHS Trust London, UK
London, UK
Use the PIN code on the inside front cover to access additional online content.
London New York Oxford Philadelphia St Louis Sydney 2021
© 2021, Elsevier Limited. All rights reserved.
First edition 1987
Second edition 1990
Third edition 1994
Fourth Edition 1998
Fifth Edition 2002
Sixth Edition 2005
Seventh Edition 2009
Eighth Edition 2012
Ninth Edition 2017
Tenth Edition 2021
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Foreword to the Tenth Edition
After 35 years and nine editions of Kumar and Clark’s Clinical Medi- We would like to give our warm thanks to all our readers and
cine, we felt it was time for the younger generation to continue friends across the world. They should take credit for the way that
with this 10th edition. The book has been described as the ‘gold this book has developed over the years, and no doubt will continue
standard, thorough guide to clinical medicine’, and is used by the to help over future editions.
majority of medical schools around the world. This would not have Lastly, on a personal note, we have both enormously enjoyed our
been possible without the dedication of our expert authors and spe- time as authors and editors of Clinical Medicine. It is hard to believe
cialists, who have written many chapters over the years. This 10th that, 35 years ago, a few of us sat down to think and design a new
edition certainly maintains the high standard of its predecessors. textbook of medicine. We endeavoured to produce a new book with
When we started those many years ago, our aim was to produce colour, tables and algorithms, changing the old, staid texts into a
a comprehensive book of medicine which had a sound grounding in lively, easy-t o- learn and user- friendly book. It has been very hard
the basic sciences for understanding the mechanisms of diseases. work but also a huge responsibility to assemble the correct medi-
This has proven to be a valuable concept for young students, doc- cal facts to inspire the next generation of young doctors. We would
tors and practising health professionals. It contains sufficient like to thank all those with whom we have had the pleasure to work
knowledge and detail to be of great value in the day- to- day care over the years, particularly the many dedicated staff at Elsevier, who
of patients in hospitals and clinics, and in the field. It is used not have worked tirelessly with us to come up with the final products.
only by the medical profession but also by all professions related
to medicine. Pharmacists and consultant nurses are now taking a Parveen Kumar and Michael Clark
bigger role in patient care, and Clinical Medicine is the book used by 2020
many of these professionals as a source of evidence-b ased medical
information.
Over the years, to keep up to date and advance with the times,
we have travelled widely across the world, visiting many countries
and developing lifelong friendships. This has enabled us to see dif-
ferent styles of education, along with different ways in which medi-
cine is practised. The result has been the production of a textbook
designed for a ‘doctor of the world’. This is essential, as with the
swiftness of travel, diseases spread with ease and rapidity, as seen
with the recent epidemics. Our International Advisory Board mem-
bers have provided much useful advice and written articles for the
online version to help us with this task.
We have taken much advice, as well as criticisms (!) and sugges-
tions, from our readers so that Clinical Medicine remains a compre-
hensive reference book, as well as being practical and user-f riendly.
We are delighted to welcome the new editors for this edition,
who are all in current clinical posts with research activities. They Dr Michael L Clark and Professor Dame Parveen J Kumar on the
have produced a book with a slightly different approach but still occasion of the publication of the first edition of Clinical Medicine
maintaining the high standards of previous editions. in 1987.
vii
Preface to the Tenth Edition
‘There must be a good reason to write a new textbook of medi- For this reason, we have introduced into this edition a number
cine when there are already a good number on the market.’ So of new chapters to equip readers to address these new challenges:
began the preface to the First Edition of Clinical Medicine, pub- Evidence-b ased practice (Ch. 4), Surgery (Ch. 11), Public health
lished 33 years ago this year. Edited by Professor Dame Parveen (Ch. 14), Geriatric medicine, frailty and multimorbidity (Ch. 15), Hae-
Kumar and Dr Michael Clark, ‘Kumar and Clark’ has become syn- matological oncology (Ch. 17) and Men’s health (Ch. 40). In some
onymous not just with a medical textbook, but with the combina- cases, we have divided up larger chapters to highlight conditions that
tion of excellence and accessibility they sought to provide. Their straddle traditional subspecialty boundaries but require a joined-u p
desire to empower clinical students and doctors has been the approach: Sepsis and the treatment of bacterial infection, (Ch. 8),
driving ambition behind the book ever since – ‘to strike a balance Venous thromboembolic disease (Ch. 29), Hypertension (Ch. 31) and
between exciting new developments in medical research and the Obstetric medicine (Ch. 38).
vast quantity of established fact that needs to be absorbed… so We have included new clinical skills content at the beginning of
that the management of disease can be based on sound physi- most of the chapters to try to fulfil the historic aims of this book:
ological concepts’. bringing the clinical sciences to bear on the problems experienced
The book they produced has become an international medi- by patients in day- to- day medical practice. We hope readers will
cal best- seller, and has played a crucial part in the education of learn not just to take generic histories and perform routine physical
a generation of doctors – among them a new team of editors, examinations, but to tailor their approach according to the presen-
humbled to be standing on the shoulders of these medical giants. tation of the individual patient in front of them. We offer our own take
Taking over is an honour and a great responsibility, and we are on the clinical method and the importance of building a therapeutic
grateful for the legacy they have left, as well as for their contin- relationship with patients in a new first chapter, describing what we
ued support and input as we have brought this current edition to believe remains key to the art of medicine: diagnosis (Ch. 1).
production. Online, readers will find a range of additional resources, includ-
Clinical Medicine has always attempted to bridge the gap ing self- assessment questions, bite- sized overview topic pages
between basic introductory texts and larger reference works: to be covering major conditions, clinical skills videos and expanded cov-
as comprehensible as it is comprehensive. The pace at which medi- erage of subjects with particular international or regional relevance.
cal science continues to develop is astounding. The present genera- We hope you will find this edition helpful in your efforts to learn
tion of junior doctors and undergraduates must provide high-q uality, and practise medicine. Any suggestions you may wish to make are
patient- centred care in the context of a burgeoning body of medical warmly welcomed and will help us to ensure that this book contin-
research, patients presenting with multimorbidity and resulting poly- ues to meet the needs of its readers.
pharmacy, continuing inequalities in society and across the world,
and a medical culture that expects doctors to work within teams, Adam Feather, David Randall and Mona Waterhouse
bridging traditional specialty and professional divides. 2020
viii
Preface to the Tenth Edition ix
HOW TO USE THIS BOOK E- Book extras
Clinical Overviews, Special Topics, Clinical Cases and more in the
There is a broad movement through the book from early chap-
Learning Resources, Videos and Assessments chapters online,
ters which focus on general principles of clinical practice, to later
chapters that deal with individual organ systems and clinical accessible via the PIN page in the front of this book. 
subspecialties.
These later chapters, based around individual subspecialties,
begin by offering a tailored approach to basic clinical skills such Prescribing
as history-taking and examination. We have tried to encourage
generic skills to be applied thoughtfully to the specialty in question: We have used the Recommended International Non- proprietary
to encourage learners to adopt the approach taken by experts in the Names (rINNs) for all drugs. In some diseases where a particular
field, so that relevant questions are asked and key physical signs formulation of a drug is required, the proprietary name is used.
are carefully sought. Drugs spellings follow international usage, e.g. bendroflumethiazide
Most chapters then cover basic sciences, including the anatomy and not bendrofluazide, and amfetamine and not amphetamine.
and physiology of the relevant organs in question, before dealing For adrenaline and noradrenaline, we have added epinephrine and
with individual conditions in order. Within the text: norepinephrine in brackets, as these names are often used in emer-
• Pink subheadings introduce individual conditions, gency guidelines across the world.
• Green subheadings introduce the scientific background to the Dosages have been given where appropriate but we recommend
condition (e.g. ‘Aetiology’ or ‘Clinical features’), and that all readers check with their national formularies for the exact
• Orange subheadings introduce clinical material, such as ‘In- dosages.  
vestigations’ or ‘Management’.
Boxes have been classified by the type of information they provide Units of measurement
and have the following symbols:
We have used the International System of Units (SI units) throughout
Emergency management the book. On occasion, if there is a possibility for confusion, we
have also used non- SI units and given a conversion factor.
Clinical information
Differential diagnosis Also in the Kumar & Clark family of books:
• Essentials of Kumar & Clark’s Clinical Medicine, 6e
Practical procedures • Kumar & Clark’s Cases in Clinical Medicine, 3e
• Clinical Surgery, 3e
‘Emergency’ boxes are in red.  • Essentials of Paediatrics, 2E
Online Clinical Overviews
Acid–base disorders Leukaemias: chronic
Anaemia: investigations Lung cancer
Arrhythmias: supraventricular tachycardia (SVT) and atrial Lymphoma
fibrillation (AF)
Malaria
Arrhythmias: bradycardia and heart block
Malnutrition
Asthma
Movement disorders
Blood transfusion
Multiple sclerosis (MS)
Breast cancer
Myeloma and other plasma cell disorders
Central nervous system infections
Myeloproliferative neoplasms
Chronic obstructive pulmonary disease (COPD)
Nephrotic syndrome, nephritic syndrome and
Cirrhosis glomerulonephritis
Colorectal carcinoma Obesity
Dementia Osteoarthritis
Diabetes: complications Pituitary disease
Diabetes: emergencies Pneumonia
Diabetes: management Potassium concentration: disorders
Eczema/dermatitis Prostate cancer
Epilepsy Renal disease: acute kidney injury (AKI)
Extracellular fluid volume: disorders Renal disease: chronic kidney disease (CKD)
Falls, instability, osteoporosis and fractures Renal replacement therapy
Frailty and ageing Rheumatoid arthritis
Gastrointestinal bleeding Sepsis
Heart disease: acute coronary syndrome (ACS) Sickle syndromes
Heart failure Skin: malignant disease
Hepatitis: B and C Sodium concentration: disorders
HIV: clinical approach to the patient Stroke
Hypertension Systemic lupus erythematosus (SLE)
Inflammatory bowel disease (IBD) Thyroid disorders: hypo- and hyperthyroidism
Leukaemias: acute Venous thromboembolic disease
x
Online Special Topics
From the International Advisory Board
Editors: Professor H Janaka de Silva and Professor Senaka Rajapakse
Arsenic poisoning Neurological manifestations of systemic disease
Arup Kumar Kundu Udaya K Ranawaka
Brucellosis Neurology of toxins and envenoming
Suliman S Fedail Udaya K Ranawaka
Cholera Non- communicable diseases in sub-S aharan Africa
K Neelakanthan Viswanathan Ntobeko A B Ntusi
Crimean–Congo haemorrhagic fever Pesticide and plant poisoning
Somia Iqtadar H Janaka de Silva
Dengue Pyogenic meningitis
Somia Iqtadar Saad Shafqat, Anita Zaidi
Diarrhoeas, including amoebiasis Rabies
Samy A Azer K Neelakanthan Viswanathan
Ebola virus disease Rheumatic fever
Somia Iqtadar K Neelakanthan Viswanathan
Fluorosis Rift Valley fever
F S Hough (deceased), Karen Barnard Suliman S Fedail
Heat stress and heat stroke Salt intake and cardiovascular disease
Samy A Azer Mary- Anne Land, Ntobeko A B Ntusi
HIV- associated immune reconstitution Severe acute respiratory syndrome (SARS)
inflammatory syndrome (IRIS) Kar Neng Lai
Graeme Meintjes
Snake bite
HIV in resource- limited settings Christeine Ariaranee Gnanathasan, Rezvi Sheriff,
Marc Mendelson, Gary Maartens Praveen Aggarwal
HIV nephropathy Soil- transmitted helminths
Nicola Wearne Nilanthi R de Silva
IgA nephropathy Thrombotic thrombocytopenic purpura (TTP)
Kar Neng Lai associated with HIV
Vernon J Louw
Immunology of leprosy
Sandhya Kamath Tropical neurological infections
Udaya K Ranawaka
Infections caused by Rickettsiae, Orientiae,
Anaplasma and Coxiella Tropical sprue
Ranjan Premaratna Samy A Azer
Leptospirosis Vaccination for adults
K Neelakanthan Viswanathan Richa Dewan
Liver transplantation Visceral leishmaniasis
Jennifer T Wells, Michael R Lucey K Neelakantan Viswanathan, Han Ni
Malaria Vitamin B and folic acid deficiency
12
Sandhya Kamath, Nilanthi R de Silva Vernon J Louw
Neurocysticercosis
K Neelakantan Viswanathan, Han Ni, Anita Devi K Ravindran
xi
Online Clinical Cases
Catatonia Gout
Nazish Imran Arup Kumar Kundu
Common child psychiatric disorders Infectious diseases
Nazish Imran Abdulla Saadeh
Congo–Crimean haemorrhagic fever Leptospirosis
Somia Iqtadar Neelakantan Viswanathan
Dengue virus infection Myocarditis
Somia Iqtadar Ntobeko AB Ntusi
Diabetic ketoacidosis Neurological disease
N A Abdella Abdullah Saadeh
Ebola virus disease Tropical sprue
Somia Iqtadar Samy A Azer
xii
List of Contributors
The editors would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new
edition would not have been possible.
Ajit Abraham MBBS, MS, MA(Med Ian Basnett MBBS, MSc, FFPHM Chloe Chin BSc (Hons), MSc,
Ethics & Law), FRCS, FRCS Public Health Director, Public Health Team, MBBS, MPhil (Cantab)
(General Surgery) Barts NHS Trust, London, UK Consultant in Palliative Medicine,
Consultant HPB, Trauma & General Public Health Department of Palliative Medicine,
Surgeon, Honorary Clinical Senior Lecturer, Cambridge University Hospitals NHS
QMUL, The Royal London Hospital, Barts Sara Booth MD, FRCP Foundation Trust, Cambridge, UK
Health NHS Trust, London, UK Macmillan Consultant in Palliative Medicine, Palliative care and symptom control
Surgery Clinical Director of Palliative Care, Palliative
Care Service, Addenbrooke’s Hospital, Francis Chinegwundoh MBE
Jane Anderson BSc, PhD, MBBS, Cambridge University Hospitals NHS MBBS, MS, MML FRCS(Eng),
FRCP Foundation Trust, UK FRCS(Ed), FRCS(Urol), FEBU
Consultant Physician and Director, Centre Palliative care and symptom control Consultant Urological Surgeon, Barts
for the Study of Sexual Health and HIV, Health NHS Trust, London, UK; Visiting
Homerton University Hospital NHS Julius Bourke MBBS, MRCPsych Professor, School of Health Sciences,
Foundation Trust; Professor, Institute of Consultant Liaison Psychiatrist and City University of London, UK; Honorary
Cell and Molecular Science, Barts and The Neuropsychiatrist; Honorary Clinical Senior Clinical Senior Lecturer, Wolfson Centre
London School of Medicine and Dentistry, Lecturer, Centre for Psychiatry, Wolfson of Preventative Medicine, Queen Mary
QMUL, UK Institute of Preventive Medicine, Barts College, University of London, London, UK
Sexually transmitted infections and human and The London School of Medicine and Men’s health
immunodeficiency virus Dentistry, QMUL, UK
Liaison psychiatry Michael L Clark
Neil Ashman PhD, FRCP Honorary Senior Lecturer, Barts and The
Consultant Nephrologist, Department of Deborah Bowman BA, MA (Oxon), London School of Medicine and Dentistry,
Renal Medicine and Transplantation, Barts PhD (London), FRSA QMUL, and Princess Grace Hospital,
Health NHS Trust, London, UK Professor of Bioethics, Clinical Ethics and London, UK
Kidney and urinary tract disease Medical Law and Deputy Principal, St Environmental medicine
George’s, University of London, UK
Simona Baracaia BSc (Hons), BM Ethical practice and clinical communication Richard Conway MD BCh, BAO,
BCh, MSc, MFPH PhD, MRCPI
Specialty Registrar in Public Health Sally M Bradberry BSc, MD, Consultant Rheumatologist, St James’s
Medicine, Public Health Team, Barts FRCP, FAACT, FEAPCCT Hospital, Dublin, Ireland
Health NHS Trust, London, UK Deputy Director, National Poisons Bone disease
Public Health Information Service (Birmingham Unit);
Director, West Midlands Poisons Unit, City Silvie Cooper PhD, FHEA
Gavin Barlow MBChB, DTM&H, Hospital, Birmingham, UK Teaching Fellow, NIHR ARC North Thames
MD, FRCP Prescribing, therapeutics and toxicology Academy, Department of Applied Health
Consultant Physician in Infectious Research, University College London,
Diseases/General Medicine, Hull and East Matthew Buckland MSc, PhD, London, UK
Yorkshire Hospitals NHS Trust; Clinical FRCP, FRCPath, FHEA Online content for Evidence-based practice
Associate, Centre for Immunology and Consultant in Clinical Immunology, Royal
Infection, University of York, UK London Hospital, Barts Health NHS Trust, UK Colette Coyle MBBS, BSc Hons
Infectious disease Immunity Physiotherapy, FFICM, MRCP
Consultant in Intensive Care Medicine,
Helen Barratt MBBS, PhD, MSc, Nicholas H Bunce BSc, MBBS, Adult Critical Care Unit, The Royal London
MA, BSc MD Hospital, London, UK
Senior Clinical Research Associate, Consultant Cardiologist, St George’s Critical care medicine
Honorary Consultant in Public Health, Healthcare NHS Trust, London, UK
Department of Applied Health Research, Cardiology
University College London, London, UK
Evidence- based practice
xiii