bluuebunny/crossref_metadata_2025 huggingface dataset:
Ascites
Authors: Shmueli Ehoud
Published: August 2018

Ascites is the accumulation of fluid within the peritoneal cavity. Most patients with ascites usually have a known diagnosis of cirrhosis, malignancy, or heart failure. For patients newly presenting with ascites, the diagnostic problem is usually to differentiate between cirrhosis and malignancy. For patients with established liver disease, ascites represents a deterioration of their liver function, the development of a hepatocellular carcinoma, or another complication. Worsening of preexisting ascites may be due to spontaneous bacterial peritonitis. In malignancy, ascites denotes the development of peritoneal deposits or massive liver metastases. The diagnosis may be obvious from the context, but can be confirmed with imaging and a diagnostic paracentesis. The serum–ascites albumin gradient (SAAG) ([ascitic fluid albumin] − [serum albumin]) reflects portal pressure, and is the key diagnostic test. A SAAG >11 g/l indicates portal hypertension, and therefore probable cirrhosis. A SAAG <11 g/l excludes portal hypertension, and therefore the ascites is not caused by cirrhosis.
Chylous ascites
Authors: Shmueli Ehoud
Published: August 2018

Chylous ascites is ascites that has a cloudy or milky appearance due to a high level of triglycerides (>2.26 mmol/l).
Swelling in the neck
Authors: Newell-Price John , Munir Alia , Debono Miguel
Published: August 2018

A number of conditions may present with a swelling or lump in the neck. A detailed history and an examination defining the site of the swelling are paramount in reaching a diagnosis. The commonest cause is enlarged lymph nodes secondary to infection, of which non-specific infection is most common (followed by infectious mononucleosis, TB, syphilis, toxoplasmosis, and cat scratch fever). After infection, the next most common cause is secondary metastatic deposits, followed by lymphoproliferative diseases, and sarcoid.
Splenomegaly and other disorders of the spleen
Authors: Bunch Chris
Published: August 2018

The spleen is a predominantly lymphoid organ, normally about the size of a clenched fist located beneath the diaphragm in the left upper abdomen. It has a dual role as a filter for the circulation, and a primary lymphoid organ in its own right. About three-quarters of its volume is a matrix of capillaries and sinuses (the red pulp), through which blood is able to percolate slowly and come into contact with fixed macrophages, which are able to remove senescent or damaged red cells, or other particulate matter such as bacteria. The lymphoid tissue is organized into scattered follicles (the white pulp), which have a particularly important role in initiating primary humoral immune responses and antibody (IgM) synthesis. The spleen commonly enlarges when either its filtration function is increased—as in haemolysis—or it is stimulated by infection or inflammation. It may also be involved in myeloproliferative and lymphoproliferative neoplasias. This chapter covers hypersplenism, splenectomy, hyposplenism, overwhelming post-splenectomy infection (OPSI), and other infections in hyposplenic patients.
Lymphadenopathy
Authors: Bunch Chris
Published: August 2018

Lymph nodes are small, bean-shaped structures generally a few millimetres in size, distributed widely throughout the body and assuming a major role in the immune system. Peripheral lymph nodes are not normally palpable except in thin individuals. Enlargement of lymph nodes is called lymphadenopathy. It is important to distinguish between reactive lymphadenopathy, which is usually an appropriate response to infection or inflammation, and malignant or neoplastic lymphadenopathy.
Anaemia
Authors: Bunch Chris
Published: August 2018

Anaemia denotes a reduction in the circulating haemoglobin level or red-cell count below that which is normal for the individual’s age and sex. Anaemia is common and may be a primary problem or a feature of a wide variety of other conditions. This chapter covers the approach to diagnosis, diagnostic tests, therapies, prognosis, and dealing with uncertainty in the initial diagnosis.
Bruising and bleeding
Authors: Curry Nicola , Alikhan Raza
Published: August 2018

Bruising is extremely common and a normal response to injury. Perception of what is a normal level of bruising is subjective and it can be difficult to differentiate a patient with ‘normal’ bruising from a patient who has bruising due to a mild bleeding disorder. Patients with bruising/bleeding can be categorized into two clinical groups: those who have no other symptoms, in whom the cause is likely to be either a normal response to injury, or an isolated platelet disorder or clotting factor deficiency; and those who have additional symptoms, in whom haematological disease (e.g. thrombocytopenia due to bone marrow infiltration) or systemic disease (e.g. connective tissue disorder) is more likely.
Transient loss of consciousness
Authors: Timperley Jonathan , Hothi Sandeep
Published: August 2018

Transient loss of consciousness (TLoC) is characterized by a rapid, transient, and complete loss of consciousness of short duration with spontaneous, complete recovery. Syncope is a specific type of TLoC caused by transient, global, cerebral hypoperfusion. TLoC may be traumatic or non-traumatic. Causes of non-traumatic TLoC include syncope, epilepsy, psychogenic causes, and other, rarer causes. Syncope may be reflex (neurally mediated), due to orthostatic hypotension or to cardiovascular disease. This chapter describes the clinical approach to the patient with transient loss of consciousness.
Coma
Authors: Sprigings David
Published: August 2018

Coma is a pathological state of unconsciousness from which a patient cannot be roused to wakefulness by stimuli, and reflects dysfunction of the brainstem reticular system and its thalamic projections (the neuronal basis of wakefulness), or diffuse injury of both cerebral hemispheres. A unilateral lesion of a cerebral hemisphere (e.g. haemorrhagic stroke) will not cause coma unless there is secondary compression of the contralateral hemisphere or brainstem. Coma is a medical emergency, because a comatose patient is at high risk of permanent brain injury or death, caused either by the underlying disorder or the secondary effects of coma. Stabilization of the airway, breathing, and circulation, and exclusion of hypoglycaemia are the first priorities, before diagnosis is explored further. Clinical assessment together with neuroimaging will usually identify the likely cause or causes. The clinical approach to diagnosis and management of the comatose patient is described in this chapter.
Delirium (acute confusional state)
Authors: Sprigings David
Published: August 2018

Delirium is a functional brain disorder characterized by disturbances of consciousness, attention, and cognition. The term ‘acute confusional state’ is often used synonymously with ‘delirium’. Delirium may be associated with a range of associated clinical features including increased or decreased psychomotor activity (hyperactive and hypoactive variants), hallucinations and delusions, and efferent sympathetic hyperactivity. Delirium with pronounced psychomotor and sympathetic hyperactivity is more often seen in younger patients with alcohol or substance intoxication/withdrawal (delirium tremens), but no cause is specific to a clinical subtype. Delirium is distinguished from dementia (with which it may coexist, as dementia is a major risk factor for delirium) by its speed of onset (over hours or days) and reversibility with correction of the underlying cause. In some patients, however, delirium may be followed by long-term cognitive impairment, suggesting that the pathophysiology of delirium overlaps with that of dementia.
Seizures
Authors: Bäumer Dirk
Published: August 2018

Seizures are transient neurological events caused by abnormal excessive or synchronous neuronal activity in the brain. This can arise from a localized brain region, causing focal seizures, or simultaneously from both hemispheres, leading to generalized seizures. Epilepsy is the tendency to develop recurrent seizures and is usually diagnosed after two or more unprovoked seizures. This chapter covers simple partial seizures (sometimes called aura), complex partial seizures, and focal (or partial) seizures, their differential diagnosis, context, approach to diagnosis, key diagnostic tests, therapy, and prognosis, as well as dealing with uncertainty in a diagnosis.
Difficulty speaking (including dysphasia and dysarthria)
Authors: Bäumer Dirk , Lord Melanie
Published: August 2018

Difficulty speaking can arise from a problem with speech content, or the production of speech due to defective articulation or alteration of the voice. This topic covers the approach to diagnosis of the patient with difficulty speaking (whether the problem is one of articulation or of speech content), key diagnostic tests, therapies, and prognosis.
Weakness
Authors: Constantinescu Cris S. , Lim Su-Yin
Published: August 2018

Muscle weakness may reflect systemic disease (such as sepsis or severe hypokalaemia) or a neuromuscular disorder. The origin of neuromuscular weakness may be localized to upper motor neurons, lower motor neurons (including nerve roots, plexus, and peripheral nerves), anterior horn cells, neuromuscular junctions, or muscles. The mode of onset of weakness, its time course, and the findings on general and neurological examination will usually differentiate between the possible diagnoses. The approach to the patient with suspected neuromuscular weakness is described in this chapter.
Tremor and other abnormal movements
Authors: Schneider Susanne , Schmidt Alexander , Bhatia Kailash P. , Bain Peter G.
Published: August 2018

Tremor is a rhythmic involuntary oscillatory movement of a body part, most commonly affecting the hands and arms but other body parts can also be affected including the legs, head, jaw, chin, palate, voice, and trunk. This chapter covers the differential diagnosis of tremor, the approach to diagnosis (including key diagnostic tests), therapies, and prognosis.
Gait disorders
Authors: Abbott Richard
Published: August 2018

Gait problems can arise from a number of different causes ranging from primary neurological to locomotor conditions. Prevalence increases with age, and causation is often multifactorial. Falls are a frequent consequence. This chapter covers the diagnosis of gait disorders and therapies.
Sensory loss
Authors: Stoneley Sarah , Rinald Simon
Published: August 2018

Sensory disturbance can either be a complete loss (anaesthesia) or a reduction (hypoaesthesia) in the ability to perceive the sensory input. Dysaesthesia is an abnormal increase in the perception of normal sensory stimuli. Hyperalgesia is an increased sensitivity to normally painful stimuli, and allodynia is the perception of usually innocuous stimuli as painful. A complete loss of sensation is likely to be due to a central nervous system problem, while a tingling/paraesthesia (large fibre) or burning/temperature (small fibre) sensation is likely due to an acquired peripheral nervous system problem. Shooting, electric-shock-like pains suggest radicular pathology, a tight-band spinal cord dysfunction. Positive sensory symptoms are usually absent in inherited neuropathies, even in the context of significant deficits on examination. This chapter describes the clinical approach to patients with sensory symptoms. Common patterns of sensory loss and their causes are described.
Headache
Authors: Davies Paul
Published: August 2018

Headache is a pain in the head, with the pain being above the eyes or the ears, behind the head (occipital), or in the back of the upper neck. It may be secondary to numerous disorders such as meningitis (secondary headaches) or be a disorder in and of itself, such as migraine and cluster headache (primary headaches). Primary headaches are benign, diagnosed entirely on the history, and form the major morbidity in the problem of headache. They often exist in episodic and chronic forms. Secondary headaches may be acute or chronic, and benign or serious. Only some require investigation for their diagnosis. The clinical approach to the patient with headache is described in this chapter.
Loss of vision
Authors: Mollan Susan , Denniston Alastair
Published: August 2018

Loss of vision describes a reduction in vision that cannot be corrected by glasses or contact lenses. Patients who complain of changes in their vision may have loss of visual acuity, distorted vision, or visual field loss. The World Health Organization classifies visual impairment as blindness or low vision. Blindness is defined as visual acuity of less than 3/60 in the better eye. Low vision is present when the visual acuity is less than 6/18 but equal to or better than 3/60, in the better eye. The etiology of permanent visual loss is diverse and depends on the region studied. In the UK, the leading causes are age-related macular degeneration, glaucoma, diabetic retinopathy, optic atrophy, and cataract. This chapter describes the clinical approach to the patient with loss of vision.
The red eye
Authors: Mollan Susan , Denniston Alastair
Published: August 2018

‘Red eye’ is a term used to describe the colour of the conjunctiva when there is either dilation of the blood vessels (hyperaemia) or a ruptured blood vessel (subconjunctival haemorrhage). It can be characterized by its distribution as diffuse, focal, or circumcorneal. There are many causes of ‘red eye’, and it is seen and managed in all healthcare settings, including optometry services. This chapter presents an approach to the patient with a ‘red eye’, identifying those conditions that can usually be successfully managed in the primary care environment, and others that need immediate or elective management in more specialized services.
Facial pain
Authors: Davies Paul
Published: August 2018

Facial pain occupies the area below the orbitomeatal line, above the neck and anterior to the pinnae. It comes in many forms and may or may not be accompanied by other symptoms. It may be acute, subacute, or chronic, arise from local pathology (e.g. dentition, parotid gland, sinus), be referred from other structures (e.g. pain behind the eye may be due to cervical spondylosis or sphenoidal sinusitis) or be part of a neurological syndrome such as trigeminal neuralgia or persistent idiopathic facial pain (previously termed atypical facial pain). There is a wide differential diagnosis. As with headache, serious causes are rare. Some benign conditions are particularly painful (trigeminal neuralgia, cluster headache) but have effective treatment.
Dizziness
Authors: Luxon Linda , Murdin Louisa
Published: August 2018

Dizziness refers to a sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion. It can be distinguished from vertigo, which is the sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement. However, patients using this term may be referring to many different sensations, including vertigo. This chapter describes the clinical approach to the patient with dizziness, emphasizing the importance of the history and examination.
Disorders of sleep
Authors: West Sophie
Published: August 2018

Typically, disorders of sleep cause disturbance either to the sufferer or to their bed partner. If total sleep time is reduced, this may lead to problems with excessive daytime sleepiness, which can affect work, driving, concentration, and relationships. ‘Sleepiness’ implies an intrusive desire to fall asleep, caused by some form of sleep deprivation or sedative drugs; this is different from ‘tiredness’, which implies general fatigue, lethargy, and exhaustion and is caused by a range of conditions, including depression, chronic disease, or a busy lifestyle. Adults sleep on average for 8 hours a night. Normal sleep consists of periods of deep or slow-wave sleep, interspersed with shorter periods of dreaming or rapid-eye-movement (REM) sleep. Periods of REM sleep lengthen towards the morning and hence some people remember their dreams on waking. Different disorders of sleep can affect any of these sleep stages.
Haematuria
Authors: Chakera Aron , Herrington William G. , O’Callaghan Christopher A.
Published: August 2018

Haematuria is the presence of blood in the urine. Haematuria may be either macroscopic (frank haematuria) or detectable only on urine dipstick (microscopic haematuria). Frank haematuria can appear quite dramatic and usually leads patients in the community to seek medical attention. The high incidence of urinary tract infections as an underlying cause means that patients often have associated dysuria and frequency. Significant haematuria can lead to clot formation in the urinary tract and obstruction. The resulting symptoms are equivalent to those from obstruction due to stones. Microscopic haematuria is usually noted as an incidental finding. This chapter covers the approach to diagnosis, diagnostic tests, therapy, and prognosis.
Oliguria and anuria
Authors: Chakera Aron , Herrington William G. , O’Callaghan Christopher A.
Published: August 2018

Oliguria can be caused by any factor that affects renal function, or the free passage of urine down the urinary tract. Complete anuria most commonly occurs in men as a consequence of bladder outlet obstruction from an enlarged prostate. It can also arise in patients who have a single functioning kidney which then becomes obstructed or loses its vascular supply. Oliguria occurs commonly in hospitalized patients, is usually secondary to impaired renal perfusion, and is often predictable. The elderly and more unwell patients, for example, those in critical care settings, are most at risk. The presence of oliguria tends to reflect the severity of the underlying disease processes. The commonest cause of complete anuria is bladder outflow obstruction from an enlarged prostate. This may be precipitated by prostatitis or constipation in a patient with benign prostatic hypertrophy. In catheterized patients, a blocked catheter must be excluded.
Polyuria
Authors: Chakera Aron , Herrington William G. , O’Callaghan Christopher A.
Published: August 2018

Polyuria describes the passage of more than 3 l of urine a day. This is an arbitrary definition, and the term is commonly applied to patients who are complaining of passing larger than normal volumes of urine. As water excretion is tightly regulated by the body to maintain normal osmolality, water excretion varies greatly depending on intake. Polyuria may be physiological or pathological. A patient with polyuria often presents with nocturia, urination overnight that disturbs sleep. It is usually accompanied by polydipsia (to maintain normal fluid balance). In hospital the commonest causes of polyuria are diuretic therapy and recovery from an acute renal injury (e.g. acute tubular necrosis or obstruction). This polyuric phase can result in an impressive diuresis (8–10 l/day) before tubular cells recover their ability to concentrate urine. During this period, patients are vulnerable to dehydration and may require intravenous fluid replacement. Following pituitary surgery, the urine output should be closely monitored for evidence of new diabetes insipidus. This chapter covers the approach to diagnosis, diagnostic tests, therapy, and prognosis.
Dysuria
Authors: Sherrard Jackie , Luzzi Graz
Published: August 2018

The term dysuria denotes painful urination, or disturbance of urination.
Urinary incontinence
Authors: Jackson Simon , Price Natalia
Published: August 2018

Urinary incontinence is the complaint of any involuntary leakage of urine. Stress urinary incontinence is involuntary leakage of urine on effort. exertion, sneezing, or coughing. Urge urinary incontinence is involuntary leakage of urine accompanied by, or immediately preceded by, a strong desire to pass urine (void). Urgency with or without urge urinary incontinence and usually with frequency and nocturia is also termed overactive bladder syndrome. Mixed urinary incontinence is involuntary leakage of urine associated with both urgency and exertion, effort, sneezing, or coughing. Usually, one of these is predominant; that is, either the symptoms of urge incontinence or those of stress incontinence are most bothersome. Overflow incontinence occurs when the bladder becomes large and flaccid and has little or no detrusor tone or function. It is usually due to injury or insult, occurring post surgery or post-partum. The bladder simply leaks when it becomes full. Incontinence due to a fistula is incontinence resulting from a vesicovaginal, ureterovaginal, or urethrovaginal fistula. Congenital incontinence is incontinence due to congenital causes (e.g. an ectopic ureter).
Faecal incontinence
Authors: Shmueli Udi
Published: August 2018

Faecal incontinence is the recurrent uncontrolled passage of faecal material. It is important to subdivide it into passive leakage, when the patient is unaware of stool loss, and urge incontinence when there is insufficient time to reach the toilet. The inadvertent escape of flatus and partial soiling of undergarments with liquid stool is graded as minor incontinence, and the involuntary excretion of solid faeces as major incontinence.
Vaginal discharge
Authors: Sherrard Jackie , Luzzi Graz
Published: August 2018

Vaginal discharge may be a normal feature (physiological discharge). However, as a symptom, the term is used to denote vaginal discharge which is excessive in quantity or abnormal in appearance, consistency, or odour.
Joint pain
Authors: Watson Pippa
Published: August 2018

When a patient complains of pain confined to a joint or joints, they are said to have arthralgia. If, in addition, there is swelling of the joint, tenderness of the joint line to palpation, and limitation of movement, the patient is said to have an arthritis. It is important to establish if an arthritis is inflammatory or non-inflammatory, as this affects the differential diagnosis. Soft tissue swelling of the joint, the presence of a joint effusion, increased temperature of the joint, erythema of overlying skin, and early morning stiffness of at least 30 minutes duration are signs of an inflammatory arthritis.
Muscle pain
Authors: Das Parthajit , Jeffery Rachel
Published: August 2018

Muscle diseases constitute a large group of hereditary and acquired disorders, collectively referred to as myopathy. Symptoms of myopathy are muscle pain, muscle cramps or spasms, stiff or rigid muscles, and muscle weakness. Muscle pain, or myalgia, is by far the most common presentation. Although most myalgia will be benign and self-limiting, it can be a reflection of underlying serious illnesses which may lead to significant morbidity. It is important to differentiate myalgia from myopathy (muscle disease) and myositis (inflammation of muscle). A muscle is said to be in spasm when it contracts involuntarily. When the spasm is forceful and sustained, it becomes a cramp. Muscle cramps commonly occur with dehydration, with electrolyte abnormalities, and in neurological conditions. This chapter discusses muscle pain, including definitions, approach to diagnosis (time course, distribution, associated muscle weakness or stiffness, and clinical signs of specific etiologies of myopathy), key diagnostic tests, and further investigations.
Low back pain
Authors: Buchanan Elaine , Lavy Chris
Published: August 2018

Low back pain (LBP) is pain arising from the structures of the lumbar spine, including joints, discs, connective tissue, and nerves. Symptoms include pain and, muscle tightness or stiffness, with or without referral of pain to the legs. Most (95%) of LBP is managed in primary care; the rest is managed in secondary care. LBP affects nearly everyone at some point in their life and has an annual prevalence of around 40%. It is less common in children but from age 16 onwards the point prevalence for all age groups is around 25%. Many experience milder persisting symptoms interspersed with exacerbations, and 7% of adults have persisting LBP, which restricts function. This chapter discusses LBP, including definitions, differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom.
Painful leg
Authors: Bloch Benjamin , Sprigings David
Published: August 2018

This chapter discusses leg pain, including definitions, differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom.
Leg ulcers
Authors: Davies Emily , Cooper Susan
Published: August 2018

This chapter discusses leg ulcers, including definitions, differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom. Leg ulcers are defined as open wounds, usually below the knee, persisting for more than 6 weeks.
Rashes
Authors: Soon Christine
Published: August 2018

Rash is a generic term used to describe the appearance of discolouration of areas of the skin. It can be due to any factor and can be different colours. It is a generic term and by itself does not confer any true meaning without further elaboration.
Blistering rashes
Authors: Davies Emily
Published: August 2018

A blister is a fluid-filled, circumscribed elevation of the skin. By convention, blisters are divided by size; blisters less than 0.5 cm wide are called vesicles, and those greater than 0.5 cm wide are called bullae. A blistering rash is used to describe any skin condition which morphologically consists of vesicles or bullae. Vesicles more than 48 hours old may evolve into pustules (pus-filled lesions). Pustular eruptions have not been included in this chapter. Secondary lesions include erosions (partial loss of epidermis), which may occur when a superficial blister ruptures or is scratched, and ulcers (loss of epidermis and superficial papillary dermis), which may occur either as part of the blistering process or secondary to infection.
Photosensitive rashes
Authors: McGregor Jane
Published: August 2018

Clinical photosensitivity is an abnormal reaction of the skin to sun exposure. This can present in many ways, including sunburn, urticaria, itching, pain, and the development of skin rashes as diverse as skin necrosis and eczema.
Itching
Authors: Soon Christine
Published: August 2018

Itching, also known as pruritus, is an unpleasant sensation on the skin that leads to an urge to scratch the skin in order to obtain some relief from the symptom.
Lumps and bumps
Authors: Matin Rubeta , McGregor Jane , Harwood Catherine
Published: August 2018

A skin ‘lump or bump’ is taken here to refer to a lesion on the skin that an individual recognizes as something new or unusual. It comprises a heterogeneous group and presents in many guises, usually to primary care. Common causes of ‘lumps and bumps’ include warts, moles, skin tags, dermatofibromas, lipomas, epidermoid cysts, and, of course, melanoma and non-melanoma skin cancers. Distinguishing malignant from non-malignant is not always straightforward. Maintaining a low threshold for referral into secondary care is wise, especially for pigmented lesions, but also for those lesions where there is no obvious diagnosis. Occasionally, a lump in the skin may have arisen from an internal source, such as a metastasis or lymph node. This chapter describes only primary cutaneous lesions and classifies them according to their origin.
Falls
Authors: Darowski Adam
Published: August 2018

A fall is an involuntary event that results in coming to rest at a lower level. Most falls occur while standing or walking. Some people fall off a chair or out of bed, particularly in hospitals and care homes, when transferring is a time of particular risk.
Immobility (‘Off legs’)
Authors: Darowski Adam
Published: August 2018

Immobility (‘off legs’) is a progressive or a sudden deterioration in the ability to walk. This chapter discusses immobility, including differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom.
Suspected anaphylaxis
Authors: Misbah Siraj
Published: August 2018

A type I IgE-mediated systemic allergic reaction is characterized by a constellation of symptoms which are due to widespread histamine release and which comprise acute-onset urticaria, angioedema, bronchospasm, and hypotension. While a mild reaction may be limited to localized urticaria and/or angioedema, a full-blown allergic reaction associated with systemic features is best described as anaphylaxis. The term ‘anaphylactoid’, previously used to denote non-IgE-mediated systemic allergic reactions, is no longer recommended for use.
Fever
Authors: Wall Emma , Cooke Graham
Published: August 2018

Fever is a rise in core body temperature, which is measured at the tympanic membrane, of greater than 37.8°C and which is one standard deviation beyond the upper limit of the normal range. This chapter covers the common causes of fever, the approach to diagnosis, diagnostic tests, therapies, prognosis, and dealing with uncertainty.
Hyperthermia
Authors: Wise Matt , Frost Paul
Published: August 2018

An elevation in core body temperature due to thermoregulatory failure with a normal thermoregulatory set point is called hyperthermia. Globally, the most common heat illnesses are heat exhaustion and heat stroke, and these are major causes of morbidity and mortality. These illnesses represent a continuum of disease ranging from mild (heat exhaustion) to total (heat stroke) failure of thermoregulation. Heat exhaustion is characterized by sweating, muscle cramps, fatigue, vomiting, headaches, dizziness, and fainting. These symptoms may also occur in heat stroke but, in addition, neurological signs such as confusion, seizures, and coma predominate. While the diagnosis of these conditions may be straightforward, hyperthermia may complicate a variety of rarer illnesses, including neuroleptic malignant syndrome and drug-induced hyperthermia.
Unintentional weight loss
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Body weight is determined by the combination of metabolic rate, calorie intake, and activity levels. Natural weight loss is usually due to declining muscle mass, with the redistribution of muscle mass in the extremities, leading to greater truncal fat stores. Unintentional weight loss refers to weight loss that is not voluntary, and can reflect serious underlying pathology. It can be caused by inadequate nutritional intake, increased metabolism, malabsorption, or a combination of these factors. Weight loss of 5% of body weight over 6–12 months should be investigated. Cachexia is a complex syndrome in which loss of body mass (fat and protein) cannot be reversed nutritionally, that is, is due to underlying disease processes inducing catabolism, rather than to inadequate nutritional intake.
Obesity: differential diagnosis
Authors: Newell-Price John , Munir Alia , Debono Miguel
Published: August 2018

This topic addresses the causes and consequences of obesity, defined as a body mass index (BMI) of 30 or above. While BMI is the most commonly used measure of obesity, the waist-to-height ratio correlates better with visceral obesity. At least 1.1 billion adults are overweight worldwide, but a medical cause for obesity is found in less than 1 out of every 100 cases. The health consequences of obesity are diverse and serious. Approximately 50% of all hypertension is secondary to obesity, and the heart may also be harmed by obesity-induced chronic volume overload and ischaemic heart disease. Obesity contributes strongly to the pathophysiology of type II diabetes and its consequences. Obese patients have higher rates of stroke, osteoarthritis, obstructive sleep apnoea, gastro-oesophageal reflux, chronic liver disease, and infertility. In addition, obesity increases the incidence of some cancers (e.g. breast, prostate, and colorectal). The psychological and social effects of obesity include higher rates of depression and anxiety, and reduced employment.
Self-harm
Authors: Smyth Roger
Published: August 2018

Self-harm refers to self-poisoning or self-injury, regardless of the apparent purpose of the act. The term self-harm is preferred to the older terms parasuicide/attempted suicide (which suggests an intent to die which might not have been present) and deliberate self-harm (because self-harm may also occur without deliberate intent in dissociative states). Self-harm includes a wide range of behaviours, including poisoning with drugs, poisoning with toxic chemicals, cutting, mutilation, jumping from heights, jumping in front of moving vehicles, and attempted drowning, shooting, asphyxiation, and hanging.
Intravenous drug use
Authors: Timmins Bryan
Published: August 2018

Intravenous drug use (IVDU) is the unlawful self-administration of a psychopharmacologically active substance by the intravenous route. Opioids such as heroin (diamorphine), buprenorphine (especially in France), and morphine (usually medicinal morphine sulphate ground into powder and suspended in partial solution) are the drugs most commonly taken intravenously. Amphetamine sulphate, cocaine, and increasingly crack cocaine (especially in Latin America) and short-acting benzodiazepines such as temazepam and lorazepam are also frequently injected. Single drug use is rare and many users will experiment with different compounds and may have comorbid alcohol abuse or dependency and major psychiatric disorders such as depression and schizophrenia or schizoaffective disorder.
Risk factors for cardiovascular disease
Authors: Banerjee Amitava , Asrress Kaleab
Published: August 2018

The most prevalent cardiovascular diseases (CVDs) are atherosclerotic, affecting all arterial territories. Epidemiologic studies such as the Framingham and INTERHEART studies have firmly established the commonest or ‘traditional’ risk factors for CVD; namely, smoking, hypertension, diabetes mellitus, hypercholesterolaemia, and a family history of CVD. The ‘risk-factors approach’ to CVD looks at these factors, individually and in combination, in the causation of disease. The complex causation pathways involve interplay of individual factors, whether genetic or environmental. More recently, there has been increasing interest in ‘epigenetics’ or the way in which the environment interacts with genes in the process underlying CVD. This chapter presents an analysis of the traditional and novel risk factors for CVD.
Diagnosis and investigation in suspected heart disease
Authors: Forfar Colin
Published: August 2018

The past 20 years have seen significant changes in both the demographics and natural history of many cardiovascular diseases. Important reductions in case-fatality rates (such as in acute coronary syndromes) have resulted from improved diagnostics and treatment options and better understanding of natural history. For others (such as infective endocarditis), improvements have been limited and disappointing. While advances in therapy and the scientific evidence underpinning treatments have been crucial, the importance of accurate diagnosis has remained a key element for progress. Many of the principles needed for diagnosis are constant: the pre-eminence of a focused, accurate history, complete physical examination, and timely and relevant investigation endures. It is essential to have a secure knowledge of the strengths and limitations of interpretation of a frequently bewildering array of tests. Progress in this field has been rapid; advances in ultrasound, scintigraphy, and cardiac magnetic resonance stand out at the interface between structure and function central to good patient care.
Congenital heart disease in adults
Authors: Orchard Liz
Published: August 2018

Congenital heart disease is the most common congenital abnormality, affecting 0.8% of births. There have been major advances in both the surgical and interventional treatment of congenital heart disease, with about 85% of patients now surviving into adulthood. Congenital heart disease can be divided into simple and complex lesions. Simple lesions include atrial septal defect, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and left ventricular outflow tract lesions. Complex lesions include tetralogy of Fallot, complete transposition of great arteries, single ventricle/Fontan physiology, pulmonary atresia, and Ebstein’s anomaly of the tricuspid valve. This chapter reviews the clinical features and management of those congenital cardiac disorders seen in adolescents and adults.
Chronic stable angina
Authors: Shirodaria Cheerag , Dawkins Sam
Published: August 2018

Chronic stable angina is a condition where patients experience symptoms of chest pain of a particular character (e.g. angina pectoris) on effort only, due to atherosclerotic coronary artery disease. The hallmarks of stable angina are as follows. First, there must be stable atherosclerotic coronary artery disease, resulting in luminal narrowing(s) in one or more of the major epicardial coronary arteries. Atheroma can be detected by using appropriate technology. Not all angina chest discomfort is due to atherosclerotic coronary disease—some is due to aortic stenosis, and some to hypertrophic cardiomyopathy; rarely, pulmonary hypertension is the cause. Second, symptoms must have been present for some time, say, arbitrarily, 2–3 months, as opposed to the case for angina of acute coronary syndromes, where symptoms are present only for a few weeks at most (see Chapter 90). This time limit is important, as it allows the differentiation of symptoms from coronary obstruction due to coronary atheroma (generally a stable pathology, with a lower risk of infarction) from symptoms of coronary obstruction due to atheroma with superadded thrombus, which can be quite unstable and lead suddenly to total coronary obstruction with all its attendant risks. Third, symptoms must be stable, that is to say, from day to day, roughly similar levels of effort must be required for provocation. The pathological translation of this is that the degree of coronary obstruction is stable, as opposed to that of the rapidly changing coronary obstruction found in acute coronary syndromes.
Acute coronary syndromes
Authors: Shirodaria Cheerag , Dawkins Sam
Published: August 2018

The term ‘acute coronary syndrome’ includes unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST-elevation myocardial infarction (NSTEMI). The difference between these three syndromes is as follows. In STEMI and NSTEMI, there is evidence of myocardial necrosis, as evidenced by raised cardiac enzymes, specifically, the very sensitive cardiac biomarker troponin. STEMI is diagnosed when the ECG shows persisting ST elevation in an appropriate territory consistent with STEMI whereas, in NSTEMI, there can be any or no ECG changes, or very transient, self-limiting ST elevation. In unstable angina, there is no myocardial necrosis, and troponins are normal. The ECG is as for NSTEMI and often shows no change, ST depression, or T-wave inversion. The prognoses in STEMI and NSTEMI are identical; unstable angina has a better prognosis than either STEMI or NSTEMI.
Acute heart failure
Authors: Rahimi Kazem
Published: August 2018

Heart failure is a clinical syndrome characterized by an inadequate cardiac output for the needs of the body in the absence of low filling pressures, and reflects abnormal cardiac structure or function. Although various definitions for acute heart failure (AHF) exist, here AHF is defined as new-onset heart failure or an acute exacerbation of chronic heart failure, requiring urgent therapy. Patients with AHF typically have clinical features of organ hypoperfusion, with or without pulmonary and peripheral oedema.
Chronic heart failure
Authors: Rahimi Kazem
Published: August 2018

The European Society of Cardiology defines heart failure as a clinical syndrome in which patients have the following features: symptoms typical of heart failure (breathlessness, fatigue, ankle swelling); signs typical of heart failure (tachycardia, tachypnoea, pulmonary crackles, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly); and objective evidence of a structural or functional abnormality of the heart at rest (cardiomegaly, third heat sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuretic peptide concentration). Heart failure results in activation of the sympathetic nervous system and the renin–aldosterone–angiotensin system, and release of a number of hormones such as natriuretic peptides, and cytokines, including tumour necrosis factor amongst others. While neurohormone activation is initially compensatory and helps in the short term to maintain circulatory needs, ultimately it has detrimental effects on the myocardium and compromises its function further. These mechanisms are therefore therapeutic targets to improve symptoms and lessen the risk of death.
Aortic stenosis
Authors: Davey Patrick , Newton Jim
Published: August 2018

Aortic stenosis is characterized by thickening and reduced mobility of the aortic valve leaflets and results in restriction to the blood flow from the left ventricle to the aorta, and secondary left ventricular hypertrophy.
Aortic regurgitation
Authors: Rahimi Kazem
Published: August 2018

Aortic regurgitation is the diastolic reflux of blood from the aorta into the left ventricle, across the aortic valve.
Mitral regurgitation
Authors: Rahimi Kazem
Published: August 2018

Mitral regurgitation (MR) is the reflux of blood from the left ventricle into the left atrium as a result of dysfunction of the mitral valve. MR can result from abnormalities of any part of the mitral valve apparatus (valve leaflets, annulus, chordae tendineae, and papillary muscles), or dilatation/disease of the left ventricle.
Miscellaneous valvar pathology: Mitral stenosis, pulmonary stenosis, and tricuspid regurgitation
Authors: Rahimi Kazem
Published: August 2018

Mitral stenosis is obstruction to inflow of blood from left atrium to left ventricle at the level of the mitral valve. Non-valvar causes of left ventricular inflow obstruction include left atrial tumours and cor triatriatum.
Percutaneous coronary intervention
Authors: Shirodaria Cheerag , Dawkins Sam
Published: August 2018

Cardiac catheterization is a procedure by which information is obtained from the heart by passing fine plastic tubes (occasionally other instruments) either near to or within the heart, to introduce contrast to cardiac structures to understand their anatomy and function better, to measure pressures, and/or to measure oxygen saturations in different cardiac chambers. It is an extraordinarily useful diagnostic procedure. Percutaneous coronary intervention (PCI) is the modern term for an intervention on a coronary artery that relieves narrowing. It includes balloon angioplasty and stent insertion. PCI is a therapeutic procedure.
Heart surgery
Authors: Taggart David , Abu-Omar Yasir
Published: August 2018

Cardiac surgery is still a relatively young specialty, having been developed only in the latter half of the twentieth century with the introduction of extracorporeal circulation or ‘cardiopulmonary bypass’ (CPB). This initiated the era of open heart surgery, initially allowing the repair of congenital heart defects, then valve replacements, coronary artery bypass grafting (CABG), and, finally, heart transplantation. Over the last two decades, improvements in medical, anaesthetic, and surgical management of patients, allied to refinements in extracorporeal perfusion technology, have resulted in a decreasing mortality and morbidity from heart surgery despite the advanced age and significant comorbidity of many patients. Today, heart surgery continues to improve the prognosis and quality of lives of patients around the world. Surgical techniques and technologies continue to evolve and recent years have witnessed the emergence of, amongst others, the use of long-lasting conduits for CABG procedures, beating-heart (‘off-pump’) surgery, the use of minimally invasive and robotic techniques, and long-term mechanical circulatory support.
Circulatory support therapy
Authors: Rahimi Kazem
Published: August 2018

A broad range of acute and chronic conditions reaching from hypovolaemic shock to ventricular tachycardia can present with circulatory failure. Hence, the approach for management of circulatory failure can vary considerably. This chapter focuses on circulatory failure due to pump failure of the heart and builds on general treatment strategies discussed in Chapters 91 and 92. Three major circulatory support therapies are discussed further: pharmacological therapy, balloon pumping, and surgically inserted devices. Treatment of circulatory failure unrelated to pump failure, and general measures such as fluid resuscitation, are beyond the scope of this chapter.
Pulmonary hypertension
Authors: MacKenzie-Ross Robert , Sheares Karen K. K. , Pepke-Zaba Joanna
Published: August 2018

Pulmonary hypertension (PH) is a haemodynamic and pathophysiological condition defined as mean pulmonary artery pressure ≥25 mm Hg at rest, assessed by right-heart catheterization (8–20 mm Hg is considered normal). A pulmonary capillary wedge pressure measurement of >15 mm Hg indicates a significant pulmonary venous component. PH is associated with a variety of causes. The current PH classification is helpful in understanding the different etiological, pathological, and treatment approaches.
Venous thrombosis and pulmonary embolism
Authors: Sheares Karen , Pepke-Zaba Joanna
Published: August 2018

Venous thromboembolism (VTE) is a condition in which thrombus forms in a vein, commonly in the deep veins of the leg, termed deep-vein thrombosis (DVT). The thrombus may dislodge from the site of origin and be carried into the pulmonary vasculature, causing a pulmonary embolism (PE). Deep vein thrombosis and pulmonary embolism share similar predisposing factors; however, mortality is greater in those who present with PE than in those who present with DVT. Thrombi may form in other parts of the vasculature.
Aortic aneurysm
Authors: Chambers John
Published: August 2018

The epidemiology and natural history of thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA) are different. The thoracic aortic diameter is dependent on age and body habitus as well as the level at which it is measured. Average diameters are 2.1 cm/m2 for the ascending thoracic aorta, and 1.6 cm/m2 for the descending thoracic aorta, giving approximate thresholds for the diagnosis of a TAA of 40 mm and 35 mm, respectively. AAAs are defined by a diameter >30 mm and are mainly infrarenal, with only 2%–5% in a suprarenal position.
Aortic dissection
Authors: Chambers John
Published: August 2018

Aortic dissection is the separation of an endothelial flap from the underlying media. The natural history and management depend on the classification of dissection as either Type A, which involves the ascending thoracic aorta, or Type B, which involves only the descending thoracic aorta.
Peripheral arterial disease
Authors: Perkins Jeremy
Published: August 2018

Peripheral arterial disease is defined as an alteration to the blood supply to a limb, caused by an occlusion or stenosis in the arteries supplying that limb. The acuteness of the arterial compromise, and its severity and extent, will determine the symptoms experienced by the patient. Aneurysmal disease is defined as a localized dilatation of an artery and is most commonly seen in the infrarenal abdominal aorta. An infrarenal abdominal aorta is defined as being aneurysmal if its maximum anteroposterior diameter is 3 cm or greater.