810 e r a c e t a d e m m i i l a t i p s o h - e r P 1 SAPS = Simpli \201 ed Acute Physiology Score.60 Revised Trauma Score (RTS) 61 For each of GCS, SBP (systolic BP) and RR determine the attri buted value: Value 811 SBP (mmHg) >89 76 \200\22389 50 \200\22375 1 \200\22349 0 RR (bpm) 10 \200\22329 >29 6 \200\2239 1 \200\2235 0 GCS 13 \200\22315 9 \200\22312 6 \200\2238 4 \200\2235 3 e r a c 4 3 2 1 0 e t a i d e m m Then put into the equation: (0.9368 \211\210 GCS value) + (0.7326 \211\210 systolic BP va lue) + (0.2908 \211\210 RR value) = RTS i l a t i p s o h - e r P Blast injury Blast injury may be encountered in domestic (eg gas explosion) or industrial ( eg mining) accidents, or as the result of a terrorist bomb. Terrorism worldwide is responsi ble for at least 15,000 injured or killed in the last 20 years and most casualties are from bombs. Death may occur without any obvious external in- jury, often due to air emboli, the correct cause \201 rst being recognized by Pierre Jars in 1758 as a \200\230dilatation d \200\231air \200\231 (ie blast wave). Blast injury is split into 4 phases: \200 Primary : injury from the blast wave itself. \200 Secondary: injury from missiles & projectile de bris striking the victim. \200 Tertiary: the victim is thrown by the blast wind, striking surrounding objects. \200 Quaternary: other injuries caused by explosions \200\224eg bur ns, asphyxia, crush 812 \200 e r a c injuries and toxic inhalations. Explosions cause injury in seven ways: e t a d e m m 1 Blast wave A transient (milliseconds) wave of overpressure expands rap- idly away from th e point of explosion, its intensity inversely proportional to the distance cubed. It produc es: (a) cellular disruption at air \200\223tissue inter- face ( \200\230spalling \200\231), ie perforated ear-drum at 100kPa (deafness should prompt thoughts of signi \201 cant blas t injury), \200\230blast lung \200\231 at 175kPa; (b) shearing forces along tissue planes: submucosal/subserosal hemorrhage; (c) re-ex- pansion of compressed trapped gas: bowel perf oration, fatal air embolism (coronary artery or cerebral). i i l a t i p s o h - e r P 2 Blast lung may be delayed (up to 48h). Suspect it if there is a perforated drum, but this is not a prerequisite (as position of drum in relation to blast wave is critical). Intra-a lveolar hemorrhage causes acute respiratory dis- tress syndrome (OHCM p178). Most patients who survive lung blast injury regain good lung function within a year. 62 n=11 3 Blast wind Air displaced by the explosion will totally disrupt a body in the immediate vi cinity. Others may suff er avulsive amputations. Bodies can be carried by the wind with dec eleration injuries on landing (tertiary injury, as above). Glass, wood, stones, and other o bjects are also carried and act as secondary missiles. 63 4 Missiles Penetration or laceration from missiles are by far the commonest injuries. Missi les can arise from the bomb fragmentation: primary if from the casing or secondary if from preformed fragments (eg nails, nuts, bolts, ball- bearings) or from the environmental fabri c (eg glass and wood particularly). 5 Flash burns These are usually super \201 cial and oc cur on exposed skin (hands/face) in those close to explosion. Flame burns arise through ign ition of materials in the environment. 6 Crush injuries Can be the result of eg falling masonry or tertiary injury. 7 Psychologica l Acute fear and panic is the aim of the terrorist. Later, chron- ic intrusive thoughts, an xiety, and poor concentration may form the basis of a post-traumatic stress disorder (p347) . This may be augmented by re- peated watchings of the event on TV/Video. 64 Treatment \200\207Do not approach the scene until the possibility of a secondary device ha s been excluded and it has been declared safe to approach. \200\207Also remember that you are at a forensic scene, so do not disturb the envi- rons (or any dead bodies) unless neces sary to treat a patient. Approach the same as any major trauma with priority to airway and cervical spine, breathing , and circulation with hemorrhage control. Rest and observe any suspected of exposure to si gni \201 cant blast, but without other injury. Sudden death or renal failure may follow re lease of a limb after prolonged crush injury (hyperkalaemia and myoglobinuria): ensure cont inuous ECG and good hydration. Facial burns may compromise airway, which should be secured by intubation or surgical airway. Psychological support will be needed. 813 Diving accidents Thousands go diving every year for recreation. Because of speedy world tra vel, complications of diving may present to doctors miles from diving centers: for this rea son we all need to be familiar with the contraindications and complica- tions of diving, wh atever our specialty. Do not underestimate the stress of div- ing: a depth change of 7 met ers produces changes in ambient pressure equal to a trip from sea level to the top of Evere st.1 Contraindications to diving \200 Migraine + vomiting attacks \200 Otitis (media or externa) \200 Hypoglycaemia risk (eg DM) \200 Patent foramen ovale1 Complications of d iving \200 Drowning (p786) \200 Marine bites or stings (p782) \200 Surface accidents (boating) Acute decompression illness Nitrogen is more soluble in lipid than in water, so a s N2 tension increases, it accumulates in CNS, marrow, and fat. On ascent, N2 bubbles form in these tissues and in venous blood (arterial blood is pressure- equilibrated having just passed through the lungs). Symptoms appear from 1 to 36h after surfacing. Risk factors: Mul tiple dives, ignoring proper decompression stops, rapid ascent, obesity, increasing age, pr evious decompression sickness, alcohol ingestion, subsequent ascent to high altitude (p808) . Presentation: \200 Throbbing muscle/joint pains \200 Migrating skin mottling/rashes \200 Pruritus; paraesthesiae Management: Speed of response is vital. If recompression star ts \211 30min af- ter the onset of symptoms, 80% will respond; if 6h delay, only 50% respo nd. If air embolism is suspected, place on the left side and give 100% O2 (15L/min through tight- \201 tting facemask with reservoir). Seek expert help. Transfer to a hyperbaric fac ility.2 If airlift needed, maximally pressurize the cabin, if the route does not allow \202 ying at sea-level. Transportation the breathing apparatus and his diving partner (will give the history, but may himself also be at risk). If there is hypothermia, expect BP to drop after leaving the water, and be sure to transportation in the horizontal position, and keep cardiovascular instability to a minimum. Preventing diving accidents \200 Augment s wimming \201 tness. \200 Avoid dehydration (no alcohol or caff eine for >24h before the dive). \200 Do the deepest part of the dive \201 rst. Time your ascent. \200 Plan \200\230no-stop \200\231 dive pro \201 les (ie avoid decompression stops). \200 Make a s afety stop at 5m. Avoid remaining under water for longer than is e r a c e t a i d e m m Lung diseases \200 Epilepsy \200 M ni re \200\231s disease \200 Pregnancy Pneumothorax history \200 Angina; arrhythmias \200 Perforated ear drum \200 Bleeding disorders. i l a t i p s o h - e r P Barotrauma \200 Air embolism \200 Pulmonary oedema \200 Hypothermia Decompression illness Nitrogen narcosis. Vomiting Mood changes \200 Cough; chest pain \200 Cyanosis; shock \200 Osteonecrosis Deafness/nystagmus \200 Fits; CNS signs \200 Cognitive changes \200 Headache. recommended by decompression tables or dive computers. Rest before the dive, and keep warm during the dive. \200 After the dive avoid sitting st ill for long periods (decreases regional blood \202 ow and nitrogen removal). Avoid boarding aircraft for about 24h. No diving if pregnant: there is (uncertain) risk to the fetus as right-to-left shunting div erts blood from the lungs \200\224which are the best \201 lters of micro- bubbles. (The r ole of the placenta in this task is unknown.) 65 1 A careful MRI study in 160 asymptomatic scuba divers found many CNS lesions (?akin to mul ti-infarct dementia) associated with a patent foramen ovale (or other shunt, eg in the lung ) allowing paradoxical embolism of venous nitrogen bubbles (venous bubbles occur after asce nt from as little as 3m (these bubbles are normally \201 ltered by the lungs).66 2 Teleph one numbers: UK: Hyperbaric Medicine Unit, Aberdeen Royal In \201 rmary 0845 4086008; Roya l Navy: 07831 151523; Diving Diseases Research Center: 01752 209999; USA: Diver s Alert Net work (919 684 8111) or US Navy (904 234 4351) or Air Force (512 538 3281 or 512 536 3278) High-altitude illness WHO estimates that 140 million people live at altitudes >2500m and 40 million lowland dwellers travel to high altitude each year to ski, trek ( \201 g 1) or wo rk. 67 High-altitude illness refers to conditions affl icting individuals ascending to al- titudes faster than their bodies can acclimatize. It chie \202 y1 comprises: 1 Acute mount ain sickness (AMS) 2 High-altitude cerebral oedema (HACE) and 3 High-al- titude pulmonary o edema (HAPE). The latter 2 may be rapidly fatal if untreated. Acclimatizing to high altitud es During ascent, partial pressure of O2 in blood falls as barometric pressure drops. Carot id body and medullary chemo-recep- tors respond to this hypobaric hypoxia by \200\200 rate and depth of ventilation. The kidneys respond to the ensuing respiratory alkalosis over a period of days by excreting bicarbonate and reabsorbing hydrogen ions. A true \200\200 in the red cell count (RCC) resulting from renal erythropoietin secretion takes weeks to de- v elop. Acclimatization does not return the body to its sea level state. 68 814 e r a c e t a d e m m i There is considerable individual variation in the rate and extent of altitude ac- climatiza tion. Above 3000m, each night \200\231s sleeping altitude should be no higher than 300m abo ve the previous night, with a rest day every 2 \200\2233 days or 1000m ascended. High-altit ude mental and physical deterioration occurs during pro- longed stays at extreme altitude ( >5500m). Acute mountain sickness (AMS) Mild AMS is common at altitudes of >2500m. It may re sult from \200\200 cerebral blood \202 ow and mild cerebral oedema with an input from ox idative stress mediated by oxygen free radicals. Mild AMS is managed conservatively with re st, hydration, analgesia and antiemetics. For management of severe AMS (inability to walk, care for one- self, disturbed consciousness) see OPPOSITE. High-altitude cerebral oedema (H ACE) HACE is a potentially rapidly fatal encephalopathy with a change in mental status a taxia which is usually preceded by AMS. It may co-exist with HAPE. The exact incidence vari es between studies but may be as much as 0.5 \200\2231%. It arises from vasogenic cerebral oedema caused by disruption of the blood \200\223brain barrier cytotoxic oedema. HACE re quires a greater degree of descent than HAPE and recovery takes longer. High-altitude pulmo nary oedema (HAPE) HAPE is more common than HACE and may accompany AMS, typically 2 \200 \2234 days after ascent to altitudes of >3000m. Symptoms: Cough, dyspnoea at rest, haemopty sis, extreme lethargy. Signs: Tachycardia, tachypnoea, cyanosis crackles (often right mi ddle lobe; listen in the axilla). HAPE arises from patchy pulmonary vasoconstriction leadin g to stress failure of pulmonary capillaries and pulmonary oedema. People with a strong hyp oxic pulmonary vasoconstrictor response, concurrent respiratory infection or congenital abs ence of a pulmonary artery are most susceptible. Using acetazolamide Acetazolamide is a car bonic anhydrase inhibitor that causes \200\200bicarbonate excretion by the kidneys, thus a ccelerating acclimatization. \200 It does NOT hide symptoms of AMS. \200 It may be used as prophylaxis at a dose of 250mg/12h PO (until one day after the maximum altitude is reac hed) in those with past severe AMS, or those mak- ing a forced rapid ascent. \200 It can also aid sleep by \200\201periodic breathing (dose: 125mg PO 1h before bed). \200 Contra indication: sulfa allergy. Give a test dose prior to travel. \200 Side eff ects: paraesth esiae, carbonated beverages taste \202 at. i l a t i p s o h - e r P Risk factors for AMS: \200 Rate of ascent \200 Absolute altitude \200 Blunted ventila tory response to hypoxia (unreliable sign) 69 \200 Level of exertion (NB: physical \201 tness does not protect) \200 Permanent home at <900m \200 Previous AMS \200 Co ncurrent URTI \200 Neck irradiation or surgery 1 Other high-altitude illnesses: retinal hemorrhage (common; rarely problematic); chronic m ountain sickness (polycythaemia, headache, somnolence, depression); subacute mountain sickn ess. NB: harmless swelling of extremities, more common in females, does not predict AMS. 815 Golden rules at high altitude 4 \200 \200\230Climb high, sleep low \200\231 to promote acclimatization. e r a c Avoid undue exertion at high altitude. Avoid alcohol, sedating antihista- e t a i d e m m mines or sedative-hypnotics. Feeling unwell at altitude=altitude illness until proved otherwise. Never ascend with AMS symptoms \200 Never leave someone with AMS i Fig 1. Trekking on Mt. Elbrus on the North Iranian Plateau, where it unites Russia and Euro pe. At 5642m (18,442 ft) it is the highest peak in both land masses. Of the 7 continen- tal summits it is closest in height to Kiliman- jaro (5895m). alone. l a t i p s o h - e r P If you are worsening, or devel- oping HACE or HAPE \200 descend immediately. Lake Louise consensus criteria for the diagnosis of AMS AMS is de \201 ned as the presence of headache plus at least one of the following symptoms occurring several hours after reac hing a higher altitude: \200 Gastrointestinal upset \200 Fatigue or weakness \200 Diz ziness or light-headedness \200 Diffi culty sleeping. \200 Emergency management of sever e high-altitude illness Severe AMS (acute mountain sickness) DESCENT Acetazolamide Trekkers should NOT ascend on dexa- methasone Dexamethasone 4mg/6h PO 250mg/8h po HACE (high-altitude cerebral oedema) DESCENT Acetazolamide Dexamethasone 8mg IM then 4mg/6h PO Portable hyperbaric chamber ( \201 g 2) Consider O2 4L/min 250mg/8h PO HAPE (high-altitude pulmonary oedema) DESCENT Portable hyper- baric chamber Consider O2 at 4L/min Role unclear Inhaled salmeterol Sildena \201 l by mouth Acetazolamide 250mg/8h PO Dexamethasone 8mg IM then 4mg/6h PO Nifedipine SR 20mg/12h PO Fig 2. Portable hyperbaric chamber.66 We thank Dr Gerard Flaherty for supplying both images and compiling this page for us. 816 Cracks in the teacup, and chinks of darkness With our plummy accents and polite manners we have now served you 815 cups of tea in the \201 ne porcelain provided by OUP \200\231s typography. And would you like another cup? And do you take sugar? And can we tempt you with a morsel from our plateful of platitudes? Eve rything here seems clean, sweetly ordered, and well- mannered. But life at the bedside is r arely like this, and we now report that there is a crack in our teacup which OUP cannot men d. Somehow, we knew all the time it was there \200\224and it is through our narrow right-ha nd vertical columns that we can see chinks of darkness cast their shadow on the aOHCSbsurdl y sunny glades in our fool \200\231s paradise where no real patient ever trod or bled. So what is this vertical text, where are these right hand columns, and what do they mean \200\224p99, for example. Here the voice in the narrow right-hand column can subvert, be po litically incorrect, swear, and hint at other worlds. It is where a less-polished world int rudes with its skepticism, its cynicism, and its habit of subverting our best-laid plans. D o not fall into the trap of asking which world is true? Right or left? Yin or yang? Nor be fooled by the neat answer that each column represent two ends of a spectrum, and the truth lies somewhere in be- tween. The truth is the spectrum, and we cannot see it all. \201\201 The helix, the spiral, and a penultimate point Spirals and helices, beautiful (p534) and de adly (p99), are weaving their way through this book \200\224to what central point? Unlike t he circle, the spiral never returns us to our starting place, and recognizes that the perso n who set out reading this book is not the same as the person who, now exhausted and prob- ably \201 lled-to-bursting, has reached this penultimate point. So re \202 ect on your s piritual journey, and guess its direction \200\224in towards the center, concen t rating on ever \201 ner, but vital detail \200\224or away from the center, towards in \201 nity? The last word It is a pleasure to end this work with a chapter which is really a new beginn ing: the patient on his way to hospital. So far we have concentrated on what we can bring t o the patient. Now let us turn to what the patient brings to us. All too often, time and ci rcumstance lead us to the view that patients are tireless de- vourers of our energies, and that for all practical purposes, we must go on giving until we die, or give up the unequal struggle with Nature and her diseases. This is to negate the view of patients as food: not just in the sense of giving us our daily bread and butter, but also in the sense of nourish ing our personalities. They do this by telling us about ourselves. You may think that you a re kind and wise, or clumsy and inadequate, and it takes our patients to disabuse us of the se illusions, and to show us that some days we are good, and some days we are bad. Thanks t o our patients, we never stay the same. After practicing medicine for a few decades, our mi nds become populated by the ghosts of former patients, beckoning us, warning us, reminding us of the things we cannot control \200\224and the ideals to which we aspire. We are lucky to work in a profession in which experience counts for more than knowledge, an d it is to augment this thirst for experience that we urge our read- ers to turn away from learning by rote: let us read novels, cultivate our friends, travel far \200\224and try to keep forever curious, for then, if we are lucky, we stand to gain that priceless therapeuti c asset: a rich and compassionate personality, and we will be all the more inclined to refo rmulate this tiresome and inconven- ient patient who now confronts us into a lovable series of imperfections, which match and re \202 ect, and reveal our own foibles. 817 Index \200\207For drugs, consult the disease you want to treat, not the drug. Abbreviations: i refers to an image; t refers to a table; syn.=syndrome; dis.=disease. Agonist muscles 423 Agoraphobia 346 AIDS drugs and 613 EBM in 637 end 626 epidural 66, 634-635 extradural 634-635 failed 619 history 612 ideal agents 621 induction 624, 626 inhalational 618 IV agents 618 \200\223621 local 6 32 \200\223636, 730 maintenance 626 monitoring in 628 obstetric 66-67 patient-centered 637 patient-controlled Acquired A \200 -fetoprotein (AFP) 10, immunode \201 ciency syn. see AIDS Acromioclavicular arthritis 664 dislocation 740 12, 140 antenatal 34 childhood 145 ophthalmic 448 in pregnancy and labor 23, 34 \200 -galactosidase 183 A&E 656 \200\223657, 780, 781 ABC Acronyms 469 Acting out 383 Actinic keratosis 590 Activated protein C \201 rst aid 725, 794 neonatal 107 ABCDE 725, 798 skin 606 Air transfer 808 Air travel, and DVT prophylaxis 16 Airgun pellets 782 Airway in melanoma 587, 592i (APC) 15 Abdomen, obstetric palpation 40 Abdominal injury 726 \200\223727 Acuity, visual 412, 415i Acupuncture 515 Acute tubular necrosis control, GA 624 obstruction 567 in trauma 725 28 Abdominal masses, in children 170 Abdominal pain in children 170 in pregnancy 38 Abducens n erve 422 ABO incompatibility Adair \200\223Dighton syn. 700 ADD see attention Akathisia 360 Albinism 640 Albumin, in pregnancy 196, 636 de \201 cit disorder & hyperactivity pre-op assessment 613-615 Addictions 362 CBT 373 premedication 616 quality 637 rapid sequence induction 626 15 Alcohol Adenoidectomy 546 Adenoma 115, 116 abuse/addiction 363 and accidents 791 head injury 728 legal limit for driving Abortion pleiomorphic 578 sebaceum 184, incomplete 260 induced 258, 259 miscarriage 8, 260 \200\223261 missed 260 recurrent 2, 261 septic 260 Abortion Act 258 Abreaction 382 Abruption 56 Absence seizures 206 Abstinence vio lation eff ect 373 recovery 630 regional 632 spinal 634 triad of 612 638, 639 Adenomyosis 288 Adenoviruses 160 ADHD see attention 527, 791 lowering intake 513 in pregnancy 32, 138 Anal injury, birth 91 \200\22392 Analgesia see pain; pain Algodystrophy 739 Alkaline phosphatase 15 Allergic conjunctivitis 432, 460 \200\223461 Alle rgic eczema 596, 597 Allergic rhinitis 556 Allergy, hyperactivity de \201 cit disorder & hyperactivity Adhesive capsulitis 664 Admissions, avoiding relief Analgesia, pre-emptive 616 Anankastic types 348, 366 Anaphylaxis 237 Anderson \200\223Fabry dis. 183 Anencephaly 140 A neuploidy 152 Anger 383 Angio \201 broma 639 Angiography, pelvic trauma 751 Angiokeratoma 183 Angiolupoid sarcoid 589 Anhedonia 336, 358 Ankylosis 644 Ankle injury 756, 757i, 473 Adnexae 244 Adolescents anterior knee pain in 212 Allodynia 677, 679 Alma-Ata, WHO Abstinent contingent treatment 512 Abstract thought 153, 353 688 communicating on sexual issues 328 statement 470 criminality 390 does past sex abuse cause current problems? 323 eating disorders 348 gradua l loss of vision Alopecia 602 Alport \200\231s syn. 638 Alternative medicine 161, 377, 515 Altitude problems 814 Altruism 169, 481, 516 Alzheimer \200\231s dis. 352 Amaurosis fugax 434, Abuse, in childhood 146, 147, 323 Acanthamoeba 432, 433 Acanthosis nigricans 589 Accidents 438 domestic/industrial pregnancy 1, 99 suicide 338 Adoption 294 Adrenal cortex 134 Adrenal crisis 135 Adrenogenita l syn. 134 Advance directives 477 Advanced Trauma Life Support (ATLS) 721, 723, 725 792 440 778 and drug abuse 796 major 806 prevention 791 statistics 792 see also vehicle accidents Amblyopia 422, 438 Amenorrhoea 251 American Soc. of Anes- Annular lesions 586 Anogenital warts 268 Anophthalmos 138 Anorexia 348 Anovulation 294 Anta lgic gait 680 Antenatal care 8 Antenatal diagnosis 10 Antepartum thesiologists 615 Aminoaciduria 183 Amnesia 335, 350, 352 Amniocentesis 10 Amnion nodosum 14 Amniotic \202 uid, Acetabular fracture 750 Acetaminophen see paracetamol Acetazolamide 814, 815t Achalasia 572 Achilles tendon 712 Achrondroplasia 700 Acne 600 AED 795 Aerotitis 542 Aff ect, \202 at 358 Aff ective disorders embolism 89 hemorrhage (APH) 56 Amniotomy 62 Amsler grid 428 Amygdala 347 Amyloidosis 589 ANA +ve 589 Anemia Anterior cord syn. 769i Anterior cruciate tears 754 Anterior interosseus nerve 714 Anterior ischaemic depression 336, 340 mania 354 psychocutaneous disorders 583 Acoustic impedance Aff erent eye defects 424 AFP 10, 12, 140 After-pains in in children 196 in pregnancy 22 540, 547 puerperium 94 Agammaglobulinaemia optic neuropathy (AION) 434 Acoustic impedance audiometry 540 Anesthesia caudal 635 complications 628 198, 640 Anterior knee pain syn. Acoustic neuroma 553 Ageing, premature 655 688, 704 818 Anterior optic Art Ataxic diplegia 214 Athlete \200\231s foot 598 Athyreosis 182 Atlas vertebra 661i Atopic de rmatitis 596 Atopic eczema 596 Atopy 164, 584 Atrioseptal defect 136 Attachment 385 Attenda nce Allowance breastfed 181 colicky/crying 104 designer 293, 641 endotracheal ischaemia 434 insight into psychosis Anterior repair, 313 gynaeco logical 290, 308 and the mind 334, 335, 377 intubation 110 Anthocyanocides 441 Antiandrogens 252 Antibodies 116 see also OHCM 19 Art therapy 313, 377 Arteriolitis 588 Arteritis growth 53, 181 large 53 premature 52, 128 small for gestational age (SGA) 47, 52, 128 \200 \223129 de \201 ciency 198 Anti-centromere 589 Anticholinergics 456, 567 Anti-D 9, 56, 258-259 Ant idepressants indications 337 pregnancy 21, 408 swapping 369 types 340 \200\223341 withdrawa l 368 coronary 646 giant cell 434 522 Arthritis Attention de \201 cit disorder & hyperactivity (ADD/ ADHD) 211, 212 Audio-premotor syn. 21 5 Audiometry 540, 547, 548 Audit 506 Auricle pathology 538 Auriculo-temporal branch 579 Aus pitz sign 594 Authenticity, in weaning 126, 127 Baby battering see child juvenile idiopathic 654 mutilans 594 in pregnancy 30 rheumatoid see abuse Back examination 670 injuries 766 \200\223774, 795 OHCM 532 septic Back pain age-related 678t causes 674 \200\223675 chronic 679 common 671 EBM 671 intractable 679 mana gement 676 \200\223677 mechanical 674 in pregnancy 17 sinister 676, 678 triage 674, 679 of back 678 see also OHCM 412 Antihistamines, skin signs 588 Still \200\231s dis. 654 tuberculous 682, 696 see also OHCM Ch 13 Arthrocent esis (joint rhinosinusitis 556 Anti-Hu 589 Anti-IgE agents 165 Antilibidinal drugs 367 Antineutrophil consultations 481 Autism 394, 638 Autobiographical memory, retrograde 343 Autoeczematization 584 Autoeroticis m 210 Autoimmune cytoplasmic antibody- associated vasculitis (AAV) 432 aspiration) 708 Arthrodesis 668 Arthropathy, psoriatic 594 Arthroplasty elbow 742 lumbar disc 677 Arthroscopy 686 Arti \201 cial insemination Anti-oncogenes 421 Antioxidants 442 Antiphospholipid syn. 30 Antipsychiatry/post- Back slab 785i Bacteraemia, in childhood 106 Bacterial tracheitis 158 Bacteriuria thrombocytopenia 197 Autoimmunity psychiatry 356 Antipsychotics 360 Antipyretics 143 Antiretrovirals 33, 145 Antithrombin III 33 Anus, imperforate 130 Anxiety dermatomyositis 589 diabetes 186 pemphigus 602 SLE 603 Autometric in childhood 174 in pregnancy 28 294 Arti \201 cial rupture Bad news 499 Baker \200\231s cyst 690 Baldness 602 Ball and socket joints of membranes (ARM) 64 avoid if HIV +ve 23 Aryepiglottic folds 159i Arytenoid subluxation de \201 brillators 795 Automatic external compensation 738 counseling 380 symptoms 344 681 de \201 brillators 795 Barbiturate abuse 362 Bardet \200\223Biedl syn. 638 Barlow maneuver 684, 685i Barotrauma 54 2, 808 Barrier contraception 568 ASA classi \201 cation 614, 615i Aschoff bodies 167 Ascites 283 ASCOT (a severity Automutilation 648 Autonomic dysre \202 exia Anxiety state, acute 344 Anzieu hypothesis 611 AO classi \201 cation 756, 770 Autonomic nervous system 629i 757i AO screw 753 Aorta, coarctation 136 Apgar score 107 Aphakia 411, 442 Aphonia 568 Aplas tic crises 142 Apnoea 108 Autonomy 403, 471 Autosensitization 584 Autosomal dis. 154 Autosomal dominant nocturnal fro ntal lobe epilepsy (ADNLFE) 392 Autosomal recessive polycystic kidney dis. 132 characterization of trauma) 810 Asherman \200\231s syn. 251 Ashleaf macule 638 ASIA scale ( spinal cord injury) 767t Asian manners 492 AskMEDLINE 504 Asperger \200\231s syn. 384, 638 Asphyxia, birth 90, 107 Aspiration 296 Bartholin \200\231s cyst 268 Barton fracture 744i, 745 Basal cell carcinoma (BCC) 417, 590 Basic life support 238, 794 adult 721t Batten \200\231s syn. 638 Battery, ingestion 783 Bat tle \200\231s sign 728 Bayoneting 441 BCG see OHCM 558 Becker \200\231s syn. 638 Beckett, S . Waiting for suxamethonium 628 Apophysis 683i Apophysitis 704 Appendicitis, in Avascular necrosis 704 Aversion therapy 372, 376 pregnancy 38 Apple jelly nodules, in gastric 624 of joints 708 of meconium 120 Aspirin poisoning 192 Assault, medicolegal issues 759 Associate in training TB 598 Aviation medicine 808 AVPU scale 103, 720, 798 Awareness during Apprehension test 663 Apraxia, verbal 541 Arachnophobia 344, 372 Arc eye 452 Arches, foot 6 92i Area postrema 617 Argyll Robertson pupil Godot 498 Beckwith \200\223Wiedmann anesthesia 628 syn. 638 Axis vertebra 661i Axon injury 728 \200\223729, 760 Axonotmesis 760 Azoospermia 294 B B-Lyn ch brace suture 84 B-Lynch suture 85 Babies (AiS) 469 Bedside manners 492 Bedwetting 211 Bee sting 783i, 783t Behavior problems Asteatotic eczema 604 Asteroid hyalosis 462 Asthenopia 441 Asthma 164 424 Arm trauma 740 Aromatherapy 515 Arousal disorders 392 Arrhythmias, in 210 \200\223212 in pregnancy 52 Astigmatism 426 Asylum-seekers 150 Asystole 238 \200\223239 Behavioral therapy 372 \200\223373, 376 Belle indiff erence 335 Bell \200\231s palsy 574, 5 75i birth injury 90 pregnancy 20 Bends, the 813 Benign positional Blood Breast milk, expressing Candidiasis 284, 598 Cannabis 819 coagulation 88, 120 fetal sampling 44 loss, per rectum 168 normal values 220, 125 Breastfeeding 124 \200\223126, vertigo 555 Bennett \200\231s fracture 744 Bennett \200\231s paradox 643 Benzodiazepine, and attention de \201 cit disorder 212 and ENT tumors 180 Breathing, trauma 725 Breech presentation 66, 222 570 \200\223571 addiction/ withdrawal 368 68, 70 Bregma 42 Briquet syn. 640, 641 Bronchiolitis 160 Bronchopulmonary dysplasia 119 prenatal exposure 210 and psychosis 356 and schizophrenia see also bleeding; hemorrhage Bereavement 498 Best interests, legal aspects 403 Beta-blocker eyedrops Blood gasses 110 Blood pressure 356, 358 in children 156, 178 in pregnancy 48 Blue child 103, 238 Blueberries 441 Blushing 600 Body image 348 Body mass index (BMI) and sperm count| 295 use 317, 362 Cap, cervical 296 Capacity 402, 477 Capgras \200\231 syn. 640 Capillaritis 588 Capillary haemangioma Bronze area 807 Brow presentation 71 Brown lesions 586 Brown \200\223Sequard syn. 457 Bicarbonate 107 in pregnancy 15 Biceps 769i rupture 664 tendinopathy 664, Brudzinski \200\231s sign 202 Brunelli lesion 764 Bruner \200\231s rules 747 Bruton \200 \231s agammaglob- ulinaemia 198, 199 530 \200\223531 in children 226 602 Capnography 628 Capsulotomy 442 Caput succadaneum 90 Carbon monoxide, 710 Bier \200\231s block 744 Big babies 53 Biliary atresia 115, 117 Bilirubin, neonates 115 Binge eating 349 Bio \201 lms 558 Biopsychosocial models Body surface area 233 Body weight, ideal 621 Bohler \200\231s angle 756 Boils 598 Bonding 1 24 \200\223126, 150 Bone smoke injury 732 Bruxism 392 Buchanan \200\231s syn. 640 Bucket-handle tears 754 Buddha and Ananda 777 Bulim ia 349 Bullous myringitis 542, 602 Bullying 395 Bunion 692 Bupivicaine 632 Burnout 333 Burn s Carcinoma cervix 272 chorio 264 endometrium 274, 278 ENT 570 larynx 570 nasopharynx 570 eso phagus 572 ovary 282 \200\223283 parotid 576 pharynx 570 salivary 578 skin 590 tonsils 564 vagina 275 vulva 267-268 Carcinoma-in-situ cervical 267, 272 epithelial 590, 591 age 182 cement 707 contusion 755i dis.s 676 \201 brous dysplasia 699 healing 738 infectio ns 696 marrow contusion 471 Biparietal diameter 43i Bipolar disorder 354 Birmingham hip 707i Birth asphyxia 107 choice of location/ facilities 4 estimated date 8 injuries to baby 90 injuries to mother 91 normal 42, 58-59 Bi rth control 296 \200\223304, 755i scan 679i sclerotic lesions 665i, 699, 703i, 704, 709i depth 733 of the eye 452 \202 ash 812 mortality 733 pediatric 733 surface area 732 secondaries 698 tumors 698 \200\223699 types 701t 305 Birthweight Bursitis Bone-anchored hearing extremely low knee 687i, 690 olecranon 666 Byatt, A.S. 319, 377 C CA-125 282 \200\223283 Cacosmia 558 Ces arean section 78 \200\22379 Caff eine 442 Cahart \200\231s notch 550 Calcaneus fracture aid 549 (500 \200\223999g) 119 and prognosis 52-53 Bonhoeff er, Dietrich 315 Borderline personality disorder 366 Bottle feeding 124 \200\22312 6, Cardiac arrest adult see OHCM 766 child 238 \200\223239 Cardiac dis., in BIS monitoring 631 Bishop \200\231s score 62 Bites 782 Bit t \200\231s spots 450, 451i Bla ck report 523 Blackheads 600 Bladder pregnancy 20 Cardiac rehabilitation 127, 180 Bourneville \200\231s dis. 638 Boutonni \200\231ere deformity 527 Cardiac tamponade 722 Cardiopulmonary resuscitation (CPR), compression only 794 712 Bowen \200\231s dis. 587i 590 Brachial plexus injuries control 306 \200\223307 drainage, in spinal 712, 756 77, 764, 765i Brachycephaly 138 Bradycardia fetal 45 neonatal 107 BRAF gene 592 Brain Calcifying tendinopathy injury 772 extrophy 132 hyperactivity 306 665i Calcium Cardiotocography (CTG) 44, 45, 45i IV treatment 112 in pregnancy 15 Blast injury 812 Bleeding Care after major trauma, improving 809 Calipers 216, 774 Callus, in fractures 738i Calluses 694 Calorimetry 554 Calv \200\231s v ertebra 702 Camus, A. 640 Canal of Schlemm 430 \201 rst trimester 260 in the newborn 120 in pregnancy 88 wounds 730 Blepharitis 416 Blep harospasm 460 Blindness 454 concussion 728 \200\223729 in malformations 140 neonatal bleeds 108 sexually dimorphic continuity 475 eff ectiveness and quality 327 Care orders 399 Care plans 360, 405, 473 areas 134 tumors 200 community 405 diabetic 3 obstetric 2, 3 schizophenia 360 canal wall down (CWD) 545 up (CWU) 545 Canaliculus 419 Canaloliths 555 Cancer in children 216 Brainstem death 777 Branchial cyst 576, 577i Braxton \200\223Hicks Blindsight 428 Blisters 602 Blogs Carers contractions 58 dementia 353 ECT 343 panic attack 345 schizophrenia 357 advice and help BRCA1 gene 283 Breast for 351 and HPV 272 syn.s 649 engorgement 94, 136 neonatal swelling 121 for people with learning disability 365 820 Caries 580, 581 Certi \201 cation dyslexia 396 encopresis 211 enuresis 211 family therapy Chondromalacia of stillbirth 83 of termination of pregnancy 259 of time off work patellae 688, 689 Chondrosarcoma 698 Chordomas 698 Chorea, Sydenham \200\231s 564 Choriocar cinoma 264, 281 Carney syn. 638, 649, 699 Carotico-cavernous \201 stula 420 Carotid body, tumor 386-387 477, 522 Cerumen 538 Cerumenolytics 538 Cervantes: Don Quixote holistic assessment of health needs 100 \200\223101 576 Carpal bones 744 Carpal tunnel injection 710 syn. 714 Chorionic language disorders gonadotrophin 6, 264, 294 407 215 Cervical cancer, learning problems 216, 314, 364 parasomnias 392 play therapy 377 psychosis 391 school refus al 212 sexual abuse 323 sleep disorders 392 substance abuse 362 suicide 338 talking to youn g Chorionic villus biopsy classi \201 cation 272 Cervical carcinoma 272 Cervical disc, prolapse pregnancy 17 Cartilage, sclerosis 655i Caruncle, urethral 268 Carunculae 10, 152 Choroid 438 Choroiditis 438 Choroidoretinitis 438 Chromosome 660, 661i Cervical dystocia 74 Cervical dystonia 660 Cervical erosion (ectopy) 270 Cervical hostility 248, myrtiformes 244 Case management 329, 474 abnormalities 152, 642, 652 Casualties, major 724 Casualty/emergency department see A&E Philadelphia 194 Chronic fatigue syn. 528 Chronic granulomatous 302 Cervical incompetence people on sex 328 dis. 198 Chronic illness, in children 105 Chronic organic Cataplexy 392 Cataract 442 tics & Giles de la Tourette see OHCM 724 Child soldiers 150 Child-centered care 100, 214 260 Cervical os 244 Cervical polyps 270 Cervical rib 660, 661i Cervical smear 270 Cervical spine congenital 138 Catastrophizing 375 Catathrenia 392 Catatonia 358 Cates plots 517 Catharsis 4, 382, 478 Cauda equina 674, 675, 770 Cauli \202 ower ear 536 Causalgia 739 CBRN (chemica l, biological, radiological, nuclear) risk 796 reaction 350 \200\223351 Cigarettes see smoking Ciliary dyskineasia 546 Circadian rhythms 4 04 Circulation, trauma 725 Circumcision 247 Circumcorneal \202 ush 430 City life, and men tal health 391 Childbirth see labor Childhood see children ChildLine 146 Children lordotic curve reversed 159 pediatric 659 Cervical spondylosis/ at risk 147, 214 behavior disorder spondylolisthesis 660 Cervicitis 270 Cervix 270 Clairvoyance 323 Clarke \200\231s test 688 Claudication of spine 674 Clavicle 740 Clavicula r fractures 741i Claw toes 692 Clawing, ulnar 760 Cleft lip/palate 138 Cleidocranial dysost osis 210 bellyache 170 common happenings eff acement 58 in pregnancy 62 ripeness 62 see also cervical 104 Cebocephaly 139 Cebrebrospinal \202 uid (CSF), meningitis/ normal values 203 Cell cycle, and dis. 649 Cellulitis 598 orbital 420 deafness 548 disabled 214 global killers 169 growth 180 ill 103 overruling 100 rights 147, 150, 212, 214 screening 150 CFTR gene 162 Chalazion 416 Chaos, edge of 397 Charles Bonnet syn. 438 Check lists 615 Ched iak \200\223Higashi syn. 138 Cleidotomy 72 Clergyman \200\231s knee 690 Climacteric 256 Climbi report 146 Clinical ecology 515 Clinical governance 497 Clinical reasoning 532 Clinodactyly 114 Cloning Centile charts 181, 224 \200\223227 Chinese philosophy 753 Chiropractic 515 Chizukit 161 Chlamydia 640 Central cord syn. 769i Central retinal artery/ vein occlusion 435 \200\223436 Chemonucleolysis 677 Chemosis 411 Cherry red spot 435, 436i, 651, 655 eye 36, 450 one-stop health Cephalic presentation 74 Cephalopelvic Chest compressions 721 injury 722, 724 Chesty infants 161 Chickenpox 144 Chignon 90 Child abuse 1 46 \200\223147 Child development 150, care 285 ovine (from sheep) 35 salpingitis 286 screening 287 tests 285, 287 Chloasma 17, 586 Choana 561 Choanal atresia 138 Chocolate cysts 288 Choice, as quality human 293, 770 \200\223771 of personalities see Capgras syn. Clostridial infection 37 Club foot 684 Coagulation, in disproportion 74 Cerebellar tumors 200 Cerebral abscess 201 Cerebral atrophy 363 Cerebral c oncussion 728 \200\223729 Cerebral oedema 200, 814 pregnancy 88 218 \200\223221 Child guidance 211 Child minders 217 Child poverty 147, 217 Child psychiatr y 389-396 Coarctation 136 Cobb angle 672 Coblation 565 Cocaine 362, 560, 632 Cochlea 534i Cochlear im plant 535i, high-altitude (HACE) marker 327 814 Cerebral palsy 214 Cerebral tumors 200, 201 Choking 795 Cholecystitis, in abuse 146 anorexia/bulimia 348 Asperger \200\231s syn. pregnancy 38 Cerebral venous sinus Cholestasis, in 549, 550 210, 394 Codman \200\231s triangle 698 Coeliac dis. 171 Coff ee, polyphenolic thrombosis 200 Cerebrospinal fever 204 pregnancy 26 Cholesteatoma 539, 544 Chondomalacia patellae attention de \201 cit disorder 212 see also \202 avonoids 441 Cognitive and analytic therapy (CAT) 388 autism 394 bed wetting 211 bullying 395 drug addiction 362 meningococcus 689 Cerebrospinal \202 uid normal values 203 rhinorrhoea 560 Chondrodermatitis 538 Chondroma 576, 699 Cognitive behavioral therapy (CBT) 373, 374 \200\223375 physicians 474 psychiatric treatment for screening 486 to treatment 402 \200\223403 for web records 502 Consortia, in primary Cornelia De Lange syn. 640 821 Corns 694 Coronary arteritis 646 Coronary 329 Cognitive dissonance Community psychiatric nurse (CPN) 329 Compartment syn. 668, 738 care 474 494 Cognitive impairment, Constipation in children 210 pregnancy 17 microcirculation 595 mild 352 Cognitive therapy 374, 376 Cognitive \200\223genital Compensation neurosis Coronary risk 482 Coronary thrombosis, prevention 482 Corrigan \200\231s syn. 640 Corticotr ophin releasing factor (CRF) 348 Coryza see OHCM 572 Cosh, liquid 359 Cost containment 780 Cot death 148 Cotard \200\231s syn. 640 Cottage hospitals 472 Cotton wool spots 448 Council tax rebate 351 Counseling Consultant in 738 communicable diseases (CDC) 203 Complaints procedure, for NHS patients 497 Complex regional pain dissociation 773 Cohen syn. 180 Coil (intrauterine Consultation analysis 480i going wrong 479 inner 478 models 478 phone 477 premonitions 505 in primary ca re syn. 739 Compliance/ contraceptive device) 298 Coin, ingestion 586, 783 Coitus 296 Colic, in babies 104 Collabor ative self- management 472 \200\223473 concordance, with medication 519, 585