Oxford Handbook of Clinical and Laboratory Investigation pdf

Oxford Handbook of Clinical and Laboratory Investigation Drew Provan Andrew Krentz OXFORD UNIVERSITY PRESS OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Clinical and Laboratory Investigation 01OHCI-PRE(i-xxiv) 8/10/02 10:04 AM Page i Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up- to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regula- tions. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. i Except where otherwise stated, drug doses and recommendations are for the non-pregnant adult who is not breast-feeding. 01OHCI-PRE(i-xxiv) 8/10/02 10:04 AM Page ii Oxford Handbook of Clinical and Laboratory Investigation Drew Provan Senior Lecturer in Haematology, St Bartholomew’s and The Royal London Hospital School of Medicine & Dentistry, London, UK Andrew Krentz Honorary Senior Lecturer in Medicine, Southampton University Hospitals NHS Trust, Southampton, UK 1 01OHCI-PRE(i-xxiv) 8/10/02 10:05 AM Page iii 1 Great Clarendon Street, Oxford OX2 6DP Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Paris São Paolo Singapore Taipei Tokyo Toronto Oxford is a trade mark of Oxford University Press Published in the United States by Oxford University Press, Inc., New York © Oxford University Press 2002 The moral rights of the author have been asserted First published 2002 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. Within the UK, exceptions are allowed in respect of any fair dealing for the purpose of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms and in other countries should be sent to the Rights Department, Oxford University Press, at the address above. This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, re-sold, hired out, or otherwise circulated without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser. British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data 1 3 5 7 9 10 8 6 4 2 ISBN 0 19 263283 3 Typeset by Drew Provan and EXPO Holdings, Malaysia Printed in Great Britain on acid free paper by The Bath Press, Avon, UK 01OHCI-PRE(i-xxiv) 8/10/02 10:05 AM Page iv Contents 3 99 165 241 257 303 325 355 383 423 459 487 495 539 583 Contributors vi Foreword by Professor Sir George Alberti viii Preface ix Acknowledgements x Symbols & abbreviations xi Introduction: Approach to investigations xix Part 1 The patient 1 Symptoms and signs Part 2 Investigations 2 Endocrinology and metabolism 3 Haematology 4 Immunology 5 Infectious & tropical diseases 6 Cardiology 7 Gastroenterology 8 Respiratory medicine 9 Neurology 10 Renal medicine 11 Poisoning and overdose 12 Rheumatology 13 Radiology 14 Nuclear medicine 15 Normal ranges Index 585 01OHCI-PRE(i-xxiv) 8/10/02 10:06 AM Page v vi Contributors John Axford Reader in Medicine, Academic Unit for Musculoskeletal Disease, Department of Immunology, St George’s Hospital Medical School, London SW17 0RE Immunology & rheumatology Martyn Bracewell Lecturer in Neurology, Department of Neurology, The Queen Elizabeth Hospital, Birmingham B15 2TH Neurology Joanna Brown Clinical Research Fellow, University of Southampton, School of Medicine, RCMB Division, Southampton SO16 6YD Respiratory medicine Tanya Chawla Specialist Registrar in Radiology, Department of Radiology, Southampton University Hospitals NHS Trust, Southampton SO16 6YD Radiology Keith Dawkins Consultant Cardiologist, Wessex Cardiology Unit, Southampton University Hospitals NHS Trust, Southampton SO16 6YD Cardiology Colin Dayan Consultant Senior Lecturer in Medicine, Division of Medicine Laboratories, Bristol Royal Infirmary, Bristol BS2 8BX Endocrinology & metabolism Tony Frew Professor of Medicine, University of Southampton, School of Medicine, RCMB Division, Southampton SO16 6YD Respiratory medicine Stephen T. Green Consultant Physician and Honorary Senior Clinical Lecturer, Department of Infection & Tropical Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF Infectious & tropical diseases Alison Jones Consultant Physician and Clinical Toxicologist, Medical Toxicology Unit, Guy’s & St Thomas’ Hospital, London SE14 5ER. Poisoning & overdose Andrew Krentz Consultant in Diabetes & Endocrinology and Honorary Senior Lecturer in Medicine, Department of Medicine, Southampton University Hospitals NHS Trust, Southampton SO16 6YD Endocrinology & metabolism Val Lewington Consultant in Nuclear Medicine, Department of Nuclear Medicine, Southampton University Hospitals NHS Trust, Southampton SO16 6YD Nuclear medicine 01OHCI-PRE(i-xxiv) 8/10/02 10:08 AM Page vi vii Praful Patel Consultant Gastroenterologist, Department of Gastroenterology, Southampton University Hospitals NHS Trust, Southampton SO16 6YD Gastroenterology Drew Provan Senior Lecturer, Department of Haematology, St Bartholomew’s & The Royal London School of Medicine & Dentistry, London E1 1BB Haematology, transfusion & cyto- genetics Rommel Ravanan Specialist Registrar, The Richard Bright Renal Unit, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB Renal medicine Charlie Tomson Consultant Nephrologist, The Richard Bright Renal Unit, Southmead Hospital, Westbury- on-Trym, Bristol BS10 5NB Renal medicine Ken Tung Consultant Radiologist, Department of Radiology, Southampton University Hospitals NHS Trust, Southampton SO16 6YD Radiology Adrian Williams Professor of Neurology, Department of Neurology, The Queen Elizabeth Hospital, Birmingham B15 2TH Neurology Lorraine Wilson Senior Registrar, Department of Nuclear Medicine, Southampton University Hospitals NHS Trust, Southampton SO16 6YD Nuclear medicine Dr Tanay Sheth Specialist Registrar in Gastroenterology, Southampton University Hospitals NHS Trust, UK Our registrars We are indebted to our juniors for writing and checking various sections, in particular Symptoms & signs. Southampton University Hospitals: Martin Taylor, Michael Masding, Mayank Patel, Ruth Poole and Catherine Talbot. St Bartholomew’s & The Royal London School of Medicine & Dentistry: Simon Stanworth, Jude Gaffan, Leon Clark and Nikki Curry. Contributors 01OHCI-PRE(i-xxiv) 8/10/02 10:10 AM Page vii viii This book fills an obvious gap in the Handbook series and indeed a major lacuna in the medical literature. Too often investigations of a particular condition are lost in the welter of other text. Alternatively, they appear as specialist books in pathology and radiology. One unique feature of this book is the inclusion of all clinical investigative techniques, i.e. both truly clinical tests in the shape of symptoms and signs and then laboratory- based investigations. This stops what is often an artificial separation. Each section is clearly put together with the intent of easing rapid reference. This is essential if the book is to have (and I believe it does have) real use- fulness for bedside medicine. There are many other useful aspects of the text. These include a comprehensive list of abbreviations—the bugbear of medicine, as well as reference ranges which some laboratories still do not append to results. Overall, the Handbook should be of benefit to not just clinical students and junior doctors in training, but all who have patient contact. With this in one pocket, and Longmore in the other, there should be little excuse for errors in diagnosis and investigation, with the added benefit that the balance between the two will allow the upright posture to be maintained. Professor Sir George Alberti President of The Royal College of Physicians of London July 2002 Foreword 01OHCI-PRE(i-xxiv) 8/10/02 10:10 AM Page viii ix Preface With the increasing complexity of modern medicine, we now have literally thousands of possible investigative techniques at our disposal. We are able to examine our patient’s serum and every other body fluid down to the level of individual nucleotides, as well as being able to perform precise imaging through CT, MRI and other imaging technologies. The problem we have all faced, especially as senior medical students or junior doctors is: which test should we use in a given setting? What hazards are associated with the tests? Are there any situations where specific tests should not be used or are likely to produce erroneous results? As medical complexity increases so too does cost; many assays available today are highly expen- sive and wherever possible we would ideally like to use a test which is cheap, reliable, reproducible and right for a given situation. Such knowledge takes many years to acquire and it is a fact of life that senior doctors (who have attained such knowledge) are not usually those who request the investigations. In this small volume, we have attempted to distil all that is known about modern tests, from blood, urine and other body fluids, along with imaging and molecular tests. The book is divided into two principal parts: the first deals with symptoms and signs in The patient section, because that is how patients present. We have tried to cover as many topics as possible, discussing these in some detail and have provided differential diagnoses where possible. We also try to suggest tests that might be of value in determining the cause of the patient’s symptom or sign. The second part of the book, Investigations, is spe- cialty-specific, and is more relevant once you know roughly what type of disease the patient might have. For example, if the symptom section sug- gests a likely respiratory cause for the patient’s symptoms, then the reader should look to the Respiratory investigations chapter in order to determine which tests to carry out, or how to interpret the results. The entire book is written by active clinicians, rather than scientists, since we wanted to provide a strong clinical approach to investigation. We have tried, wherever possible, to cross-refer to the Oxford Handbook of Clinical Medicine, 5th edition, Oxford University Press, which provides the clinical detail omitted from this handbook. The symbol  is used to highlight a cross-reference to OHCM , in addition to cross-referencing within this book. We would value feedback from readers since there will doubtless be tests omitted, errors in the text and many other improvements we could, and will, make in future editions. All contributors will be acknowledged individually in the next edition. We would suggest you e-mail us directly: a.provan@virgin.net. Drew Provan Andrew Krentz 2002 01OHCI-PRE(i-xxiv) 8/10/02 10:11 AM Page ix [...]... neutrophil alkaline phosphatase New England Journal of Medicine ammonia non-Hodgkin’s lymphoma nucleated red blood cells non-steroidal anti-inflammatory drugs non-ST-elevation myocardial infarction osteoarthritis oral contraceptive pill omni die (once daily) oesophagogastroduodenoscopy oral glucose tolerance test Oxford Handbook of Clinical Haematology Oxford Handbook of Clinical Medicine posteroanterior... them then we have today, and their diagnoses were often made solely from the history and examination Of course, they would claim that their clinical acumen and skills were greater than ours and that we rely too heavily on the huge armoury of laboratory and other investigations available today This, in part, is probably true, but we cannot ignore the fact that advances in science and technology have spawned... Storage and age of sample Container used, e.g for blood sample, as well as anticoagulant Method of analysis Reference ranges (normal values) These are published for most measurable components of blood and other tissue and we have included the normal ranges for most blood and CSF analytes at the end of the book What makes a test useful? A really good test, and one which would make us appear to be outstanding... or without using tourniquet) Storage and age of sample Container used, e.g for blood sample, as well as anticoagulant Method of analysis Reference ranges (normal values) These are published for most measurable components of blood and other tissue and we have included the normal ranges for most blood and CSF analytes at the end of the book Introduction Approach to investigation Why do tests? Patients... challenge of medicine is being able to talk to the patient and obtain a history and then carry out a physical examination looking for pointers to their likely underlying problem Our elders and, some would argue, betters in medicine had less tests available to them then we have today, and their diagnoses were often made solely from the history and examination Of course, they would claim that their clinical. .. Of course, they would claim that their clinical acumen and skills were greater than ours and that we rely too heavily on the huge armoury of laboratory and other investigations available today This, in part, is probably true, but we cannot ignore the fact that advances in science and technology have spawned a bewildering array xxi of very useful and sophisticated tests that help us to confirm our diagnostic... sections and we thank the London registrars: Simon Stanworth, Jude Gaffan, Leon Clark and Nikki Curry, and the Southampton registrars: Fiona Clark, Michael Masding, Mayank Patel, Ruth Poole and Catherine Talbot Dr Murray Longmore, the undisputed Oxford Handbook king, has prox vided invaluable wisdom and has very kindly allowed us to use his specially designed OHCM typeface (OUP) for many of the symbols... make the diagnosis: request these and review the diagnosis in the light of the test results Review the patient and arrange further investigations as necessary The downside of tests It is important to remember that tests may often give ‘normal’ results even in the presence of disease For example, a normal ECG in the presence of chest pain does not exclude the occurrence of myocardial infarction with 100%... provided page proofs of the OHCM, 5th edition, which was invaluable for cross-referencing this handbook Warm thanks are also extended to Oxford University Press, and in particular Esther (Browning) who first commissioned the book Very special thanks must go to Catherine (Barnes), commissioning editor for medicine, who has stuck with the project, and most likely has aged 10 years as a result of it! She has... the input of many people, besides the main editors and we are indebted to many of our colleagues for providing helpful suggestions and for proofreading the text Dr Barbara Bain, St Mary’s Hospital, London, kindly allowed us to peruse the proofs of Practical Haematology, 9th edition (Churchill Livingstone) to help make sure the haematology section was up to date Dr Debbie Lillington, Department of Cytogenetics, . Oxford Handbook of Clinical and Laboratory Investigation Drew Provan Andrew Krentz OXFORD UNIVERSITY PRESS OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Clinical and Laboratory Investigation 01OHCI-PRE(i-xxiv). 10:04 AM Page ii Oxford Handbook of Clinical and Laboratory Investigation Drew Provan Senior Lecturer in Haematology, St Bartholomew’s and The Royal London Hospital School of Medicine &. daily) OGD oesophagogastroduodenoscopy OGTT oral glucose tolerance test OHCH Oxford Handbook of Clinical Haematology OHCM Oxford Handbook of Clinical Medicine PA posteroanterior or pernicious anaemia or pulmonary artery 01OHCI-PRE(i-xxiv)