Davidson’s Principles and Practice of Medicine 22nd Edition Sir Stanley Davidson (1894–1981) This famous textbook was the brainchild of one of the great Professors of Medicine of the 20th century. Stanley Davidson was born in Sri Lanka and began his medical undergraduate training at Trinity College, Cambridge; this was interrupted by World War I and later resumed in Edinburgh. He was seriously wounded in battle, and the carnage and shocking waste of young life that he encountered at that time had a profound effect on his subsequent attitudes and values. In 1930 Stanley Davidson was appointed Professor of Medicine at the University of Aberdeen, one of the first full-time Chairs of Medicine anywhere and the first in Scotland. In 1938 he took up the Chair of Medicine at Edinburgh and was to remain in this post until retire- ment in 1959. He was a renowned educator and a par- ticularly gifted teacher at the bedside, where he taught that everything had to be questioned and explained. He himself gave most of the systematic lectures in Medicine, which were made available as typewritten notes that emphasised the essentials and far surpassed any text- book available at the time. Principles and Practice of Medicine was conceived in the late 1940s with its origins in those lecture notes. The first edition, published in 1952, was a masterpiece of clarity and uniformity of style. It was of modest size and price, but sufficiently comprehensive and up to date to provide students with the main elements of sound medical prac- tice. Although the format and presentation have seen many changes in 21 subsequent editions, Sir Stanley’s original vision and objectives remain. More than half a century after its first publication, his book continues to inform and educate students, doctors and health profes- sionals all over the world. Readers may be interested to listen to an interview with Sir Stanley Davidson, which can be found on the Royal College of Physicians of Edinburgh website at: www.rcpe. ac.uk/library-archives/sir-stanley-davidson-1894-1981. Content Strategist: Laurence Hunter Content Development Specialist: Wendy Lee Project Manager: Louisa Talbott Designer/Design Direction: Miles Hitchen Illustration Manager: Jennifer Rose Davidson’s M P 22nd Edition r Edited by i n Brian R. Walker BSc MD FRCPE FRSE c Professor of Endocrinology, i University of Edinburgh; ep Honorary Consultant Physician, l Royal Infirmary of Edinburgh, UK e s Nicki R. Colledge BSc FRCPdE Consultant Physician in Medicine for the Elderly, a Liberton Hospital, Edinburgh, n and Royal Infirmary of Edinburgh; Honorary Senior Lecturer, d i University of Edinburgh, UK cP Stuart H. Ralston MD FRCP FMedSci FRSE Arthritis Research UK Professor of Rheumatology, r University of Edinburgh; a Honorary Consultant Rheumatologisit, c Western General Hospital, nt Edinburgh, UK i c Ian D. Penman BSc MD FRCPE e Consultant Gastroenterologist, e Royal Infirmary of Edinburgh; o Honorary Senior Lecturer, f University of Edinburgh, UK Illustrations by Robert Britton Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2014 An imprint of Elsevier Limited © 2014, Elsevier Limited. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organisations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). First edition 1952 Twelfth edition 1977 Second edition 1954 Thirteenth edition 1981 Third edition 1956 Fourteenth edition 1984 Fourth edition 1958 Fifteenth edition 1987 Fifth edition 1960 Sixteenth edition 1991 Sixth edition 1962 Seventeenth edition 1995 Seventh edition 1964 Eighteenth edition 1999 Eighth edition 1966 Nineteenth edition 2002 Ninth edition 1968 Twentieth edition 2006 Tenth edition 1971 Twenty-first edition 2010 Eleventh edition 1974 Twenty-second edition 2014 Main Edition ISBN-13: 978-0-7020-5035-0 International Edition ISBN-13: 978-0-7020-5047-3 eBook ISBN-13: 978-0-7020-5103-6 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The publisher’s policy is to use paper manufactured from sustainable forests Printed in China Preface v Since Davidson’s Principles and Practice of Medicine was We are proud of Davidson’s international heritage. first published in 1952, over two million copies have As well as recruiting authors from around the globe, been sold and the book has acquired a large following particularly for topics such as Infectious Diseases and of medical students, doctors and other health profes- HIV, we have welcomed new members on to our sionals all over the world. It has been translated into International Advisory Board. These leading experts many languages, most recently Japanese, Russian, from 16 countries provide detailed comments that, Italian and Polish, and has won numerous prizes, the along with the feedback received from our global read- last edition being highly commended in the British ership, are crucial to our planning of every chapter in Medical Association Book Awards. Davidson’s has each new edition. We have also visited several medical endured because with each new edition it has evolved schools on the Indian subcontinent and received invalu- to provide comprehensive updated information in a able feedback from students and teachers. We have concise and easy-to-read format. addressed as many of these suggestions as possible in From its beginnings, Davidson’s has sought to explain this edition. the basis for medical practice. The integration of ‘pre- Education is achieved by assimilating information clinical’ science with clinical practice is now a feature of from many sources and readers of this book can enhance many undergraduate medical curricula, and many stu- their learning experience by using complementary dents use Davidson’s from the outset of their medical resources. The StudentConsult platform continues to course. In recognition of this, the first part of the book, provide online access to the text and illustrations of the ‘Principles of Medicine’, highlights the mechanisms of main edition. The book is also available in various eBook health and disease, along with the professional and formats. Davidson’s has had a long-standing association ethical principles underlying medical practice. Many with its sister books, Macleod’s Clinical Examination (now examples of clinical problems are included to bring the in its 13th Edition) and Principles and Practice of Surgery medical sciences to life for the new student and to reju- (now in its 6th Edition). The Davidson’s ‘family’ has venate the interest of the experienced clinician. The expanded with the publication of Davidson’s Essentials of second part of the book, ‘Practice of Medicine’, covers Medicine, a long-requested pocket-size version of the the major medical specialties. Every chapter has been main text; Davidson’s Foundations of Clinical Practice, a thoroughly revised for this edition to ensure that it guide to starting work as a junior doctor; Davidson’s 100 reflects the ‘cutting edge’ of medical knowledge and Clinical Cases, which contains cases directly based on the practice and is pitched at a level of detail to meet the ‘Presenting Problems’ in the main text; and Macleod’s needs of candidates preparing for examination for Clinical Diagnosis, which describes a systematic approach Membership of the Royal College of Physicians or its to differential diagnosis of symptoms and signs. We equivalents. In recognition of the emerging specialty of congratulate the editors and authors of these books for Stroke Medicine, this topic is now covered in a separate continuing the tradition of concise, easily read and beau- chapter from Neurological Disease. Surgical approaches tifully illustrated texts. to disease management are mentioned in Davidson’s, The regular introduction of new authors and editors but readers are encouraged to consult the sister book, to Davidson’s is important to maintain the freshness of Principles and Practice of Surgery, for more details. each new edition. On this occasion, Dr Ian Penman has Many of the innovations introduced in recent edi- joined the editorial team and 18 new authors have con- tions have been warmly received. We have retained both tributed material. We all take immense pride in produc- a patient-orientated approach, in the ever-popular ‘Clin- ing an outstanding book for the next generation of ical Examination’ overviews and ‘Presenting Problems’ doctors, and in continuing the great tradition first estab- sections, alongside practical content, in ‘Emergency’ and lished by Sir Stanley Davidson and passed on by all the ‘Practice Point’ boxes. Embedding horizontal themes previous editors and authors, for what remains one of within the book – for example, with the ‘In Old Age’ and the world’s leading textbooks of medicine. ‘In Pregnancy’ boxes – has been applauded, and we have extended this approach by adding ‘In Adolescence’ boxes in relevant chapters; these emphasise key points in managing the transition of patients between paed- BRW, NRC, SHR, IDP iatric and adult services. Edinburgh Contents vi List of presenting problems viii Contributors x International Advisory Board xiv Introduction xvi Acknowledgements xviii Figure acknowledgements xix PART 1 PRINCIPLES OF MEDICINE 1 Good medical practice 1 A.D. Cumming • S.I.R. Noble 2 Therapeutics and good prescribing 17 S. Maxwell 3 Molecular and genetic factors in disease 41 D.R. FitzPatrick • J.R. Seckl 4 Immunological factors in disease 71 S.E. Marshall 5 Environmental and nutritional factors in disease 97 P. Hanlon • M. Byers • J.P.H. Wilding • H.M. Macdonald 6 Principles of infectious disease 133 R.P. Hobson • D.H. Dockrell 7 Ageing and disease 165 M.D. Witham PART 2 PRACTICE OF MEDICINE 8 Critical illness 179 G.R. Nimmo • T. Walsh 9 Poisoning 205 S.H.L. Thomas • J. White 10 Medical psychiatry 231 M.C. Sharpe • S.M. Lawrie 11 Oncology 259 G.G. Dark • A.R. Abdul Razak Contents 12 Palliative care and pain 283 D. Oxenham 13 Infectious disease 293 D.H. Dockrell • S. Sundar • B.J. Angus • R.P. Hobson 14 HIV infection and AIDS 387 vii G. Maartens 15 Sexually transmitted infections 411 G.R. Scott 16 Clinical biochemistry and metabolism 427 M.J. Field • L. Burnett • D.R. Sullivan • P. Stewart 17 Kidney and urinary tract disease 461 J. Goddard • A.N. Turner 18 Cardiovascular disease 525 D.E. Newby • N.R. Grubb • A. Bradbury 19 Respiratory disease 643 P.T. Reid • J.A. Innes 20 Endocrine disease 733 M.W.J. Strachan • J. Newell-Price 21 Diabetes mellitus 797 E.R. Pearson • R.J. McCrimmon 22 Alimentary tract and pancreatic disease 837 I.D. Penman • C.W. Lees 23 Liver and biliary tract disease 921 Q.M. Anstee • D.E.J. Jones 24 Blood disease 989 H.G. Watson • J.I.O. Craig • L.M. Manson 25 Rheumatology and bone disease 1057 S.H. Ralston • I.B. McInnes 26 Neurological disease 1137 J.P. Leach • R.J. Davenport 27 Stroke disease 1231 P. Langhorne 28 Skin disease 1249 S.H. Ibbotson • R.S. Dawe 29 Laboratory reference ranges 1307 S.W. Walker Index 1313 List of presenting problems viii These presentations represent the most common also been employed in several of the chapters in the reasons for referral to each medical specialty and are ‘Principles of Medicine’ section, reinforcing the close described in the ‘Presenting Problems’ sections of connection between clinical problems and fundamental all system-based chapters. The same approach has mechanisms of disease. Abnormal investigation results Acid–base, 443 Erythrocyte sedimentation rate Lipids, 453 Metabolic acidosis, 445 Raised, 85 Hypercholesterolaemia, 453 Metabolic alkalosis, 446 Full blood count Hypertriglyceridaemia, 455 Mixed abnormalities, 447 Anaemia, 1001 Mixed hyperlipidaemia, 455 Respiratory acidosis, 447 Leucocytosis, 1005 Rare hyperlipidaemia, 455 Respiratory alkalosis, 447 Leucopenia, 1004 Liver function tests, 935 Blood culture Pancytopenia, 1008 Proteinuria, 476 Positive, 303 Polycythaemia, 1003 Radiology Electrolytes Thrombocytopenia, 1007 Adrenal mass, 779 Hypercalcaemia, 767 Thrombocytosis, 1008 Incidental pulmonary nodule, 660 Hypocalcaemia, 768 Glucose Pituitary tumour, 789 Hyperglycaemia, 808, 818 Hyperkalaemia, 442 Hypoglycaemia, 783, 814 Hypokalaemia, 440 Hormones Hypermagnesaemia, 448 Hyperprolactinaemia, 790 Hypomagnesaemia, 448 Hypogonadism, male, 760 Hypothyroidism, 743 Hypernatraemia, 439 Thyroid function tests Hyponatraemia, 437 Asymptomatic abnormalities, 745 Hyperphosphataemia, 449 Thyrotoxicosis, 740 Hypophosphataemia, 448 Symptoms and signs Amenorrhoea, 759 Fever, 296 Gynaecomastia, 762 Ascites, 938 In immunocompromised host, 301, 396 Haemoptysis, 658 Blackouts, 554, 1157 In injection drug user, 299 Hair and nail problems, 1264 Bleeding In neutropenic patient, 302 Heart murmurs and abnormal heart Gastrointestinal, 853, 942 With weight loss, 271 sounds, 560 Generalised, 201, 1006 Finger clubbing, 271 Heartburn, 852 Breathlessness, 289, 543, 655 Gait abnormalities, 1168 Hepatomegaly, 938 Chest pain, 539, 658 Galactorrhoea, 790 Hirsutism, 763 Coma, 198, 1159, 1237 Genital problems, 415, 417 Hypertension, 478 Constipation, 860 Itch/pain in women, 418 Incontinence Cough, 289, 654 Itch/rash in men, 415 Faecal, 1174 Deafness, 1173 Lumps in men, 416 Urinary, 175, 472, 1174 Diarrhoea, 306, 857 Lumps in women, 418 Infertility, 761 Dizziness, 173, 554, 1157, 1167 Ulceration in men, 415 Jaundice, 936 Dyspepsia, 852 Ulceration in women, 418 Lymphadenopathy, 395, 1005 Dysphagia, 851, 1173 Urethral discharge, 415 Memory loss, 1161 Erectile dysfunction, 474 Vaginal discharge, 417 Movement and coordination Falls, 172, 554, 1157 Goitre, 746 problems, 1165, 1237 List of presenting problems Nausea, 289, 306, 853 Psychological Sleep disturbance, 1175 Oedema, 478 Abnormal perception, 1167 Smell disturbance, 1169 Pain, 284 Anxiety, 234, 290 Speech disturbance, 1168, 1236 Abdominal, 418, 861 Confusion, agitation, delirium, 173, Splenomegaly, 1006 Ankle and foot, 1076 237, 238, 290, 1161, 1175 Syncope see Falls and Blackouts Back, 1072 Delusions, 236, 1175 Urinary symptoms, 471 Elbow, 1075 Depressed mood, 235, 290, 1175 Dysuria, 471 Generalised musculoskeletal, 1071, Elated mood, 235 Frequency, 472 1076 Hallucinations, 236, 1175 Haematuria, 474 ix Hand and wrist, 1075 Personality change, 1175 Incontinence, 175, 472, 1174 Headache, 1156, 1237 Puberty Nocturia, 472 Hip, 1075 Delayed, 758 Oliguria/anuria, 471 Knee, 1075 Seizures, 1159, 1237 Polyuria, 472 Loin, 471 Sensory disturbance, 1164 Visual disturbance, 1169, 1237 Multiple joints, 1069 Skin problems, 1256 Vomiting, 289, 306, 853 Neck, 1074 Blisters, 1258 Weakness, 290, 1076, 1162, 1236 Regional musculoskeletal, 1074 Colour change, 1263 Weight loss, 271, 290, 396, 859 Shoulder, 1074 Itch (pruritus), 415, 418, 1258 Single joint, 1069 Leg ulcers, 1262 Palpable mass, 270 Lumps and changing lesions, 1256 Palpitation, 556 Papulosquamous rashes, 1257 Pleural effusion, 661 Photosensitivity, 1260 Syndromes Adrenal insufficiency, 777 Gastrointestinal and liver abnormalities in Malabsorption, 857 Ageing problems, 176 critical illness, 198 Paraneoplastic syndromes, 271 Alcohol misuse, 240 Gastrointestinal obstruction in terminal Proctitis, 417 Allergy, 90 illness, 290 Psychological Anaphylaxis, 91, 190 Heart failure, 546 Medically unexplained symptoms, 236 Angioedema, 93 Hepatic encephalopathy, 941 Psychological factors affecting medical Cardiac arrest, 557 HIV/AIDS manifestations, 395 conditions, 240 Circulatory failure Cardiac, 405 Renal failure Anaphylaxis, 91, 190 Gastrointestinal, 399 Acute, 197, 478 Shock, 190, 544 Haematological, 404 Chronic, 483 Cushing’s syndrome, 773 Liver, 400 Respiratory failure, 191, 663 Diabetes mellitus, 808 Mucocutaneous, 396 Self-harm, 238 Complications, 820 Neoplasms, 405 Sepsis, 200, 304 Hyperosmolarity, 814 Nervous system, 402 Skin In pregnancy, 817 Ophthalmic, 402 Acute failure, 1264 In young patients, 818 Renal, 405 Skin manifestations of cancer, 272 Ketoacidosis, 811 Respiratory, 400 Sodium depletion, 432 Long-term supervision, 811 Rheumatological, 404 Sodium excess, 434 Newly discovered, 808 Hypopituitarism, 787 Substance misuse, 240 Peri-operative, 818 Infection manifestations Sudden death, 557 Disseminated intravascular In adolescence, 313 Venous thrombosis, 1008 coagulation, 201, 1007 In blood disease, 1008 Drug reactions In pregnancy, 313 Adverse reactions, 175 In the tropics, 308 Glucocorticoids/corticosteroids, 776 Recurrent, 79 Ectopic hormone production, 271 Liver failure Fracture, 1071 Acute, 932