Clinical Medicine (eBook)
John Wiley & Sons (Verlag)
978-1-118-49857-6 (ISBN)
Combining readability with high quality illustrations, this seventh edition has been thoroughly revised to reflect up to date practice in examination and clinical investigation, and advances in the evidence base supporting modern day clinical practice. Numerous figures and tables help distil the information for revision purposes, and there are new chapters on the medical interview and assessment.
Whether you need to develop your knowledge for clinical practice, or refresh that knowledge in the run up to examinations, Clinical Medicine Lecture Notes will help foster a systematic approach to the clinical situation for all medical students and hospital doctors.
John Bradley, Consultant Physician, Addenbrooke's Hospital and Cambridge Medical School, Cambridge, UK
Mark Gurnell, University Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
Diana Wood, Director of Medical Education, School of Clinical Medicine, University of Cambridge, UK
David Rubenstein, Consultant Physician, Addenbrooke's Hospital, Cambridge, UK
David Wayne, Consultant Physician, James Paget Hospital, Great Yarmouth, UK
Clinical Medicine Lecture Notes provides a comprehensive, accessible introduction to the management and treatment of medical conditions. A short manual of techniques on communication and physical examination in Part 1 is supported by the core knowledge required on diseases specific to each body system in Part 2. Combining readability with high quality illustrations, this seventh edition has been thoroughly revised to reflect up to date practice in examination and clinical investigation, and advances in the evidence base supporting modern day clinical practice. Numerous figures and tables help distil the information for revision purposes, and there are new chapters on the medical interview and assessment. Whether you need to develop your knowledge for clinical practice, or refresh that knowledge in the run up to examinations, Clinical Medicine Lecture Notes will help foster a systematic approach to the clinical situation for all medical students and hospital doctors.
John Bradley, Consultant Physician, Addenbrooke's Hospitaland Cambridge Medical School, Cambridge, UK Mark Gurnell, University Department of Medicine,Addenbrooke's Hospital, Cambridge, UK Diana Wood, Director of Medical Education, School ofClinical Medicine, University of Cambridge, UK David Rubenstein, Consultant Physician, Addenbrooke'sHospital, Cambridge, UK David Wayne, Consultant Physician, James Paget Hospital,Great Yarmouth, UK
CLINICAL MEDICINE: Lecture Notes 1
Contents 4
Preface to the Seventh Edition 5
Preface to the First Edition 6
Part 1: Clinical Examination 8
1 The medical interview 8
Effective consultation 8
Structure 8
Initiating the session 9
Gathering information 10
Explanation and planning 10
Closing the session 11
Special circumstances 11
Assessment of communication skills 12
REFERENCE 13
2 General examination 14
Introduction 14
Hands 14
Face 14
Neck 15
Axillae 16
Breasts 16
Legs 16
Notes 16
3 Cardiovascular system 17
Introduction 17
General inspection 17
Blood pressure 17
Hands 17
Arterial pulses 17
Jugular venous pressure and pulse 18
Heart 19
Complete the examination 20
Notes 20
Heart failure 20
Hypertension 21
The ECG 22
Peripheral vascular system 23
4 Respiratory system 26
History 26
Examination 26
Notes 27
Haemoptysis 27
Aetiology: common 27
Aetiology: uncommon 27
Investigation of haemoptysis 27
Clubbing 27
Respiratory causes 27
Cardiac causes 27
Gastrointestinal causes 29
Cyanosis 29
Investigation of the respiratory system 29
Chest radiology 29
Blood gases 29
Interpretation of blood gases 30
Arterial gas patterns 30
Causes of hypoxaemia 31
Type 1 respiratory failure (low PaO2, normal/low PaCO2) 31
Type 2 respiratory failure (low PaO2, high PaCO2) 32
Pulmonary function tests 32
Spirometry 32
Interpretation 32
Transfer factor 32
5 The abdomen 35
Examination of the abdomen 35
Liver 35
Spleen 36
Kidneys 36
Abnormal masses 36
Notes 37
Splenomegaly 37
Hepatomegaly 37
Hepatosplenomegaly 37
Palpable kidneys 37
Mass in right subcostal region 38
Suprapubic mass 38
Ascites 38
Dysphagia 38
Diarrhoea 40
Infectious diarrhoea 41
Non-infectious diarrhoea 41
Jaundice 42
Haematology 42
Liver function tests 42
Bilirubin 42
Alkaline phosphatase 42
Transaminases 43
Urinalysis 43
Serology 43
Abdominal radiology in jaundice 43
Needle liver biopsy 43
Other investigations 44
Congenital non-haemolytic hyperbilirubinaemias 44
Gilbert syndrome (autosomal dominant) 44
Dubin–Johnson syndrome (autosomal recessive) 44
Renal disease 44
6 Neurological system 46
History 46
Examination of the nervous system 46
Mental state and higher cerebral function 46
Cognitive function 46
Other tests of cognitive function 46
Concentration: serial sevens 46
Orientation 46
Mood 47
Speech disorders 47
Dysarthria 47
Expressive (motor) dysphasia and aphasia 47
Receptive (sensory) dysphasia 48
Tactile agnosia 48
Cranial nerves 48
Sense of smell 48
Eyes 48
Ptosis 48
Pupillary reflexes andaccommodation 49
External ocular movements (3rd, 4thand 6th nerve) 50
Nystagmus 50
Perform fundoscopy 50
Face 50
Facial expression (7th nerve, motor) 50
Facial sensation (5th nerve,sensory) 50
Mouth 50
Neck (11th nerve) 50
Hearing and vestibular function (8th nerve) 51
The limbs 51
Arms: motor system 51
Reflexes 53
Coordination 53
Sensation 53
Legs: motor system 55
Reflexes 55
Coordination 55
Sensation 55
Gait 56
Perform Romberg's test 56
Truncal ataxia 56
Notes 56
Visual field defects 56
Pupillary reflexes 56
Horner syndrome 57
Eye movements 58
Squint (strabismus) 58
Lateral rectus palsy (6th nerve) 58
Superior oblique palsy (4th nerve) 58
Third nerve palsy 58
Nystagmus 58
Horizontal nystagmus 58
Vertical nystagmus 58
Rotatory nystagmus 58
Facial palsy 58
Hearing 59
Rinne test 59
Weber test 59
Dizziness and giddiness 59
Vertigo 59
Dysarthria 60
Dysphasia and aphasia 60
Bulbar and pseudobulbar palsies 60
Patterns ofmotor loss in the limbs 60
Lower motor neuron lesions 60
Upper motor neuron lesion 60
Proximal myopathy 60
Patterns of sensory loss in the limbs 60
Peripheral neuropathy 60
Dorsal column loss without spinothalamic loss 61
Spinothalamic loss without dorsal column loss (dissociated anaesthesia) 61
Spinal cord lesions 61
Cerebral cortical lesions 61
Isolated peripheral nerve lesions 61
Radial nerve lesion 61
Lateral cutaneous nerve of the thigh 61
Lateral popliteal lesion 61
Abnormalities of coordination 61
Cerebellar incoordination 61
Proprioceptive incoordination (dorsal column loss) 61
Combined lower and upper motor neuron lesions 62
Abnormal gait 62
Hemiplegia 62
Paraplegia 62
Festinant gait: Parkinson's disease 62
Cerebellar gait 62
Sensory (dorsal column) ataxia 62
Steppage (drop-foot) gait 62
'Rolling' gait 62
Tremors 62
Physiological tremor 62
Exaggerated physiological tremor 62
Essential tremor 62
Resting tremor 63
Intention tremor 63
Asterixis 63
Chorea, athetosis and ballismus 63
7 Endocrinology and metabolism 64
History 64
Examination 64
Hands 64
Arterial pulse 65
Blood pressure 65
Skin 65
Face 66
Eyes 66
Neck 66
Breasts 66
External genitalia 66
Legs 66
Notes 66
The diabetic foot 66
Assessment of thyroid status 67
Examination of the thyroid gland 67
Assessment of thyroid status 68
Signs of hyperthyroidism 68
Signs of Graves' disease(hyperthyroidism plus) 68
Signs of hypothyroidism 68
8 Musculoskeletal system 69
History 69
Examination 69
Notes 70
Examination of the hands 70
9 Assessment 73
Standard setting 74
Assessment of clinical competence 78
Objective structured clinical examinations (OSCEs) 78
Mini-clinical examinations (mini-CEX) 79
Direct observation of procedural skills (DOPS) 79
Part 2 Clinical Medicine 80
10 Cardiovascular disease 80
Ischaemic heart disease 80
Coronary artery disease 80
Angina pectoris 80
Diagnosis 80
Investigation 81
Electrocardiogram 81
Management of stable and unstableangina 81
Coronary angiography and revascularisation 82
Myocardial infarction 82
Aetiology 83
Symptoms 83
Examination 83
Investigations 84
ECG 84
Cardiac biomarkers 84
Management 87
Reperfusion therapies 87
?-Blockade 88
Angiotensin-converting enzyme inhibitors 88
Anticoagulant and antiplatelet therapy 89
Complications 89
Late complications 89
Invasive and non-invasiveassessment post myocardialinfarction 89
Rehabilitation 89
Long-term pharmacologicaltreatments 91
Arrhythmias 91
Supraventricular tachycardias 91
Sinus tachycardia 91
Atrial fibrillation 91
Management 92
Medical therapy 92
Atrial flutter 92
Management 92
Atrial tachycardia 93
Management 93
Terminating an episode of atrialtachycardia 93
Preventing atrial tachycardia 93
Pre-excitation syndromes 93
Ventricular tachycardia 94
Management 94
Ventricular fibrillation 94
Heart block 94
Cardiorespiratory arrest 95
Clinical features 95
Aetiology 95
Management 95
Cardiovascular disorders and driving 95
Group 1 entitlement 95
Heart failure 95
New York Heart Association classification 95
Pathophysiology 95
Aetiology 96
Clinical features 98
Investigation 98
Echocardiography 98
Radionuclide studies 98
Coronary angiography 98
Treatment 98
Ventricular arrythmias and sudden death 99
Hypertension 99
Aetiology 99
Genetic factors 99
Renin–angiotensin–aldosterone system 99
Endothelins, prostacyclins and nitric oxide 99
Pharmacology of nitric oxide 100
Pathophysiology 100
Diagnosis of LVH 100
Symptoms 100
Examination 100
Investigation 101
Treatment 101
Severe hypertension 103
Hypertension in relation to other conditions 103
Diabetes 103
Treatment 103
Renal disease 103
Hypertension as a cause of renal disease 103
Renal disease as a cause of hypertension 103
Renovascular hypertension 103
Diagnosis 103
Treatment 103
Pregnancy 104
Treatment 104
Valvular heart disease 104
Aortic stenosis 104
Aetiology 104
Valvular stenosis 104
Congenital aortic stenosis (very rare) 104
Symptoms 104
Signs 105
Investigations 105
Complications 105
Management 105
Aortic regurgitation 105
Aetiology 105
Symptoms 105
Signs 105
Investigations 105
Management 105
Dominance of the lesion in combined rheumatic aortic stenosis/aortic regurgitation 105
Mitral stenosis 106
Aetiology 106
Symptoms 106
Signs 106
Auscultation 106
Assessment 106
Complications 106
Management 107
Mitral regurgitation 107
Aetiology 107
Symptoms 107
Signs 107
Investigations 107
Complications 107
Management 107
Other valve disease 107
Tricuspid regurgitation 107
Pulmonary stenosis 108
Atrial myxoma 108
Congenital heart disease 108
Maternal rubella 108
Down syndrome (usually 21-trisomy) 108
Turner syndrome (XO) 108
Marfan syndrome (arachnodactyly) 108
Working classification 108
Atrial septal defect (ASD) 109
Symptoms 109
Signs 109
Assessment 109
ECG 109
Chest X-ray 109
Cardiac catheterisation 109
Complications 109
Management 109
Patent ductus arteriosus 109
Symptoms 109
Signs 109
Assessment 109
Complications 110
Management 110
Ventricular septal defect 110
Symptoms 110
Signs 110
Assessment 110
Complications 110
Management 110
Fallot's tetralogy 110
Symptoms 110
Signs 110
Assessment 110
Complications 110
Management 111
Coarctation of the aorta 111
Signs 111
Assessment 111
Associations 111
Management 111
Eisenmenger syndrome 111
Infective endocarditis 111
Acute 111
Subacute 111
Predisposing abnormalities 111
Organisms 111
Diagnosis 111
Clinical features 112
Management 112
Prophylaxis 112
Chemotherapy 112
Indications for surgery 112
Culture-negative endocarditis 112
Constrictive pericarditis 112
Aetiology 112
Clinical features 113
Examination 113
Investigation 113
Management 113
Acute pericarditis 113
Aetiology 113
Clinical features 113
Assessment 113
Management 113
Syphilitic aortitis and carditis 114
Cardiomyopathy 114
Hypertrophic cardiomyopathy 114
Signs 114
Investigation 114
Management 114
Dilated (congestive) cardiomyopathy 114
Aetiology 114
Management 114
Restrictive cardiomyopathy 114
Peripheral arterial disease 115
Intermittent claudication 115
Diagnosis 115
Prognosis 115
Management 115
Acute obstruction 115
Diagnosis 115
Management 115
Ischaemic foot 115
Symptoms 115
Signs 115
Management 115
Raynaud's phenomenon 116
Definition 116
Aetiology 116
Management 116
REFERENCE 116
11 Respiratory disease 117
Chronic obstructive pulmonary disease (COPD) 117
Definitions 117
Pathogenesis 117
Aetiology 117
Clinical presentation 118
Investigation 118
Ventilatory function tests 118
Chest X-ray 118
Arterial blood gas estimations 118
Electrocardiogram (ECG) 118
Sputumfor bacterial culture and sensitivity 118
Haemoglobin 118
Management 118
Asthma 118
Clinical features 119
Acute attacks 119
Recurrent asthma 119
Management of chronic asthma 119
Acute severe asthma 119
Clinical 120
Laboratory 120
Clinical presentation 120
Investigation 120
Management 120
Respiratory failure 120
Acute 120
Chronic 121
Acuteonchronic respiratory failure 121
Clinical presentation 121
Management 121
Indications for respiratory support and mechanical ventilation 121
Acute anaphylaxis 122
Pneumonia 122
Clinical presentation 122
Investigations 122
Management 122
Lung abscess 124
Aetiology 124
Clinical features 124
Investigation 124
Treatment 124
Bronchiectasis 124
Aetiology 124
Clinical features 124
Management 124
Pneumothorax 124
Aetiology 124
Spontaneous pneumothorax 124
Management (of spontaneous pneumothorax) 125
Cystic fibrosis 125
Management 125
Lung cancer 126
Incidence 126
Aetiology 126
Clinical presentation 126
Blood and marrow 126
Neuromuscular 126
Skin, connective tissue, bone 126
Endocrine 126
Cardiovascular 127
Diagnosis 127
Treatment 127
Bronchial adenoma 127
Sarcoidosis 127
Clinical presentation 127
Pulmonary sarcoid 127
Non-pulmonary sarcoid 127
Investigation 128
Management 128
Prognosis (of pulmonary sarcoid) 129
Tuberculosis 129
Primary tuberculosis 129
Post-primary tuberculosis 129
Presenting features 129
Diagnosis 130
Management 130
Common antituberculosis drug doses and complications 131
Occupational lung diseases 131
Dust diseases 131
Clinical features 131
Asthma 131
Extrinsic allergic alveolitis 131
Aetiology 132
Clinical features 132
Acute (i.e. 4–6 h after exposure) 132
Chronic 132
Investigation 132
Treatment 132
Obstructive sleep apnoea 132
Pulmonary embolism 132
Clinical features 132
Clinical presentation (of pulmonary embolus) 133
Investigation 133
Chest X-ray 133
ECG 133
Arterial blood gases 133
Lung perfusion scan 133
Combined ventilation and perfusion scans 133
Pulmonary angiography 133
D-DIMER 133
Treatment 133
Hyperventilation syndrome 134
Fibrosing alveolitis 134
Clinical features 134
Investigation 134
Management 134
Adult respiratory distress syndrome 134
Treatment 134
12 Gastroenterology 135
Gastric and duodenal ulceration 135
Aetiology 135
Clinical presentation 135
Examination 135
Complications 135
Investigation 135
Management 136
Indications for surgery 136
Gastric carcinoma 136
Hiatus hernia and gastrooesophageal reflux 136
Symptoms 136
Investigations 136
Management 137
Inflammatory bowel disease (ulcerative colitis and Crohn's disease) 137
Aetiology 137
Ulcerative colitis 137
Clinical features 137
Diagnosis 137
Sigmoidoscopy 137
Histology 137
Imaging 138
Differential diagnosis 138
Treatment 138
Surgery 139
Crohn's disease 139
Aetiology 139
Clinical features 139
Imaging 139
Barium enema 139
Small-bowel enema 140
Histology 140
Complications 140
Treatment 140
Surgery 140
Extraintestinal manifestations of inflammatory bowel disease 141
Intestinal cancer in in.ammatory bowel disease 141
Endocrine tumours of the gut 141
Apudomas 141
Zollinger–Ellison syndrome 141
Vipoma 141
Endocrine tumours of the pancreas 141
Insulinoma 141
Glucagonoma 142
Gastrointestinal haemorrhage 142
Upper gut 142
Aetiology 142
Acute 142
Clinical presentation 142
Chronic 142
Management 142
Variceal bleeding 142
Investigation (for site and cause of bleeding) 142
Indications for surgery (in haemorrhage from peptic ulcer) 142
Lower gut 143
Steatorrhoea and malabsorption 143
Gluten-sensitive enteropathy (coeliac disease) 144
Aetiology 144
Clinical presentation 144
Examination 144
Diagnosis 144
Treatment 144
Other causes of malabsorption 144
Bile salt deficiency 144
Pancreatic enzyme deficiency 144
Imaging 145
Investigation 145
Tests of exocrine pancreatic function 145
Stimulation tests 145
Bentiromide test 145
Other intestinal disease 145
Postsurgical 145
Abnormal intestinal organisms 145
Crohn's disease 145
Rare causes 145
Investigation of malabsorption 146
Blood tests 146
Tests of absorption 146
Radiology 146
Diverticular disease 146
Clinical features 146
Management 146
Dietary fibre 146
Irritable bowel syndrome 147
Clinical presentation 147
Investigation 147
Treatment 147
Ischaemic colitis 147
Clinical features 147
Diagnosis 147
Prognosis 147
Pancreas 148
Carcinoma 148
Clinical presentation 148
Investigation 148
Management 148
Islet cell tumours 148
Acute pancreatitis 148
Aetiology 148
Clinical presentation 148
Differential diagnosis 148
Investigation 148
Management 148
Prognosis 149
Chronic pancreatitis 149
Aetiology 149
Clinical presentation 149
Investigation 149
Treatment 149
Gall bladder 149
Acute cholecystitis 149
Clinical features 149
Management 149
Chronic cholecystitis 149
Clinical presentation 149
Gallstones 150
Clinical features 150
Investigation 150
Management 150
13 Liver disease 151
Acute hepatitis 151
Viral hepatitis 151
Hepatitis A 151
Clinical presentation 151
Diagnosis 152
Differential diagnosis 152
Management 152
Prophylaxis 152
Hepatitis B 152
Clinical features 153
Diagnosis 153
Management 153
Immunisation 153
Hepatitis C 153
Clinical features 153
Diagnosis 153
Management 153
Hepatitis E 153
Clinical features 154
Hepatitis G 154
Autoimmune hepatitis 154
Management 154
Alcoholic hepatitis 154
Chronic liver disease 155
Chronic hepatitis 155
Cirrhosis 155
Classification of cirrhosis 155
Primary biliary cirrhosis 155
Histology 155
Management 155
Primary sclerosing cholangitis 155
Management 156
Other causes of cirrhosis 156
Clinical features 156
Hepatocellular failure 156
Acute liver failure 156
Management 156
Portal hypertension 157
Management of bleeding varices 157
Management of ascites 157
Budd–Chiari syndrome 158
Rare cirrhoses 158
Idiopathic haemochromatosis (bronzed diabetes) 158
Clinical presentation 158
Diagnosis 158
Treatment 158
Hepatolenticular degeneration (Wilson's disease, p. 205) 159
Drug jaundice 159
Hypersensitivity reactions 159
Cholestasis 159
Acute hepatitis 159
Direct hepatotoxicity 159
Haemolytic jaundice 159
14 Renal disease 160
Urinary tract infection 160
Management 160
Imaging the kidneys 160
Stones 161
Clinical features 161
Management 161
Measures to prevent stone formation 161
Chronic interstitial nephritis 161
Clinical features 161
Management 161
Reflux nephropathy 162
Management 162
Proteinuria 162
Causes 162
Clinical presentation 162
Assessment 162
Investigation 162
Nephrotic syndrome 162
Aetiology 163
Management 163
Haematuria 163
Aetiology 163
Common 163
Uncommon 163
Familial causes 163
Investigation 163
Acute kidney injury 164
Prerenal 164
Aetiology 164
Pathophysiology 164
Renal 164
Causes 164
Postrenal 165
Investigation 165
Management 165
Chronic kidney disease 166
Common causes 166
Clinical features 166
Investigations 166
Biochemical 166
Haematology 167
Urinalysis 167
Ultrasound 167
Management 168
Pathophysiology 168
Hypertension in chronic kidney disease 168
Dietary protein restriction 168
Complications 168
Bone disease 168
Cardiovascular disease 168
Anaemia 169
Sexual dysfunction 170
Renal replacement therapy 170
Assessment of dialysis adequacy 170
Glomerulonephritis 170
IgA-Nephropathy 171
Clinical features 171
Aetiology 171
Prognosis 171
Henoch-Schönlein purpura 171
Membranous nephropathy 171
Classification 172
Clinical manifestations 172
Aetiology 172
Prognosis 172
Membranoproliferative (mesangiocapillary) glomerulonephritis 172
Classification 172
Aetiology 172
Clinical features 172
Prognosis 172
Minimal-change nephropathy 172
Clinical features 172
Aetiology 172
Prognosis 172
Focal glomerulosclerosis 173
Aetiology 173
Clinical features 173
Prognosis 173
Systemic vasculitis 173
Renal lesion 173
Prognosis 173
Antiglomerular basement membrane disease (Goodpasture's disease) 173
Aetiology 173
Clinical features 174
Prognosis 174
Systemic lupus erythematosus 174
Clinical features 174
Prognosis 174
Post-streptococcal glomerulonephritis 174
Clinical features 174
Investigations 174
Prognosis 174
Fluid and electrolytes 174
Salt and Water 174
Serum sodium decreased (hyponatraemia) 174
Aetiology 174
Clinical features 175
Investigation 175
Management 175
Serum sodium increased (hypernatraemia) 175
Aetiology 175
Investigation 175
Management 175
Serum potassium 175
Serum potassium decreased (hypokalaemia) 175
Aetiology 175
Clinical features 176
Management 176
Serum potassium increased (hyperkalaemia) 176
Aetiology 176
Clinical features 176
Management 176
Metabolic acidosis 176
Aetiology 176
Management 176
Metabolic alkalosis 176
Aetiology 176
Management 176
Hypercalcaemia 176
Aetiology 176
Hyperparathyroidism 176
Malignancy 177
Sarcoid 177
Drugs 177
Endocrine (rare) 177
Hypocalcaemia 177
Aetiology 177
Hypoparathyroidism 177
Inadequate dietary intake of vitamin D or calcium (rarely, vitamin D resistance) 177
Hypomagnesaemia 177
Aetiology 177
Clinical features 177
Hyperphosphataemia 177
Aetiology 177
Hypophosphataemia 177
Aetiology 177
Uric acid 177
Serum uric acid increased 177
Causes 177
15 Neurology 178
Headache 178
Primary headache syndromes 178
Tension headache (chronic daily headache) 178
Migraine 178
Clinical presentation 178
Classical migraine with aura 178
Migraine without aura 179
Hemiplegic and ophthalmoplegic migraine 179
Investigation 179
Management 179
Acute attack 179
Prophylaxis 179
Cluster headache 180
Secondary causes of headache 180
Raised intracranial pressure 180
Idiopathic (‘benign’) intracranial hypertension (IIH Pseudotumour Cerebri)
Meningeal irritation 180
Post-concussion 180
Giant-cell arteritis 180
Neuralgias 180
Trigeminal neuralgia 180
Glossopharyngeal neuralgia 181
Postherpetic neuralgia . 181
Atypical facial pain 181
Epilepsy 181
Classification 181
Partial seizures 181
Generalised seizures 181
Aetiology 181
Provocation of seizures 181
Differential diagnosis 181
Clinical features 182
Epilepsy in childhood 182
Epilepsy in adulthood 182
Investigation 183
Management 183
Status epilepticus 183
Surgical treatment of epilepsy 183
Epilepsy and pregnancy 183
Epilepsy and driving 184
Epilepsy and employment 184
Epilepsy and lifestyle 184
Prognosis in epilepsy 184
Stroke 184
Aetiology and pathophysiology 184
Clinical features 185
Total anterior circulation infarct 185
Partial anterior circulation infarct 185
Lacunar infarct 185
Posterior circulation infarct 185
Spinal cord infarct 185
Diagnosis and initial investigation 185
Investigations to establish the aetiology 185
Early management 186
Prevention and treatment of complications 187
Venous infarction 187
Transient ischaemic attack (TIA) 187
Aetiology 187
Clinical features 187
Subclavian steal syndrome 188
Diagnosis and investigation 188
Assessment of those at highest risk of stroke following a TIA 188
Management 188
Acute management 188
Specialist management 188
Medical treatment 189
Surgical treatment 189
Extracerebral haemorrhage 189
Extradural haematoma 189
Subdural haematoma 189
Subarachnoid haemorrhage 189
Management 189
Dementia 190
Causes 190
Clinical assessment 190
Investigation 190
Alzheimer's disease 190
Aetiopathogenesis 191
Clinical features 191
Diagnostic criteria 191
Management 191
Multi-infarct dementia 192
Fronto-temporal dementia (Pick's disease) 192
Dementia with Lewy Bodies (DLB) 192
Parkinson's disease with dementia (PDD) 192
Prion diseases including Creutzfeldt–Jakob disease (CJD) 192
Huntington's disease 192
Management 193
Alcohol-related dementia 193
HIV-associated dementia 193
Normal-pressure hydrocephalus 193
Multiple sclerosis 193
Aetiology 193
Pathophysiology 193
Clinical presentation 193
Clinical features 194
Diagnosis/investigation 194
Differential diagnosis 194
Management 194
Acute relapse 194
Disease-modifying agents 194
Symptom control in chronic disease 195
Prognosis 195
Motor neurone disease 195
Classification 195
Clinical presentation 195
Diagnosis 195
Investigation 196
Management 196
Disease-modifying therapy 196
Nutritional support 196
Respiratory support 196
Other measures 196
Prognosis 196
Parkinson's disease and other extrapyramidal disorders 196
Parkinson's disease 196
Aetiology 196
Clinical presentation 197
Diagnosis 197
Management 197
Dopaminergic agents 198
Anticholinergic agents 198
Amantadine 198
Surgical treatment 198
Prognosis 198
Other idiopathic akinetic-rigid syndromes 198
Multiple system atrophy 198
Supranuclear palsy (Steele– Richardson–Olszewski syndrome) 198
Other movement disorders 199
Tremor 199
Chorea 199
Hemiballismus 199
Athetosis 199
Dystonia 199
Myoclonus 199
Tics 199
Disorders of the spinal cord 199
Spinal cord compression 199
Aetiology 199
Disorders of vertebrae (extradural 45% of cases)
Meningeal disorders (intradural 45%)
Disorders of the spinal cord (intramedullary 5–10%)
Clinical presentation 199
Investigations 200
Differential diagnosis 200
Cervical spondylosis 200
Clinical features 200
Brown–Séquard syndrome 200
Syringomyelia 200
Syringobulbia 201
Subacute combined degeneration of the cord 201
Clinical presentation 201
Investigation 201
Management 201
Prognosis 201
Spinal root disease (radiculopathy) 201
Peripheral nerve disorders 202
Mononeuropathies 202
Carpal tunnel syndrome 202
Ulnar neuropathy 202
Radial neuropathy 202
Others 202
Multifocal neuropathy/ mononeuritis multiplex 202
Peripheral polyneuropathy 202
Diabetic neuropathy (see metabolic disorders) 203
Carcinomatous neuropathy 203
Vitamin B Deficiency 203
Disorders of the neuromuscular junction 203
Myasthenia gravis 203
Clinical presentation 203
Diagnosis 204
Treatment 204
Differential diagnosis 204
Prognosis 204
Eaton–Lambert myasthenic syndrome 204
Disorders of muscles 204
Myotonia 204
Myotonic dystrophy (dystrophia myotonica) 204
Clinical presentation 204
Treatment 204
Muscular dystrophies 205
Pseudohypertrophic (Duchenne Becker)
Facio-scapulo-humeral (Landouzy–Déjérine) 205
Limb-girdle (Erb) 205
Acquired muscular disorders 205
Inflammatory myopathies 205
Neurological infections 205
Bacterial meningitis 205
Meningococcal meningitis 205
Clinical presentation 205
Investigations 205
Treatment 206
Prevention 206
Chemoprophylaxis 206
Vaccination 206
Pneumococcal meningitis 206
Haemophilus influenzae meningitis 206
Acute bacterial meningitis of unknown cause 206
Prognosis 206
Tuberculous meningitis 206
Intracranial abscess 207
Parameningeal infections 207
Lyme disease 207
Leprosy 207
Bacterial toxins 207
Botulism 207
Diphtheria 207
Tetanus 207
Viral meningitis 207
Viral encephalitis 207
HSV encephalitis 208
Retroviral infections 208
Protozoal infections 208
Metazoal infections 208
Rabies 208
Poliomyelitis 208
Clinical features 208
Diagnosis 208
Management 208
Prognosis 209
Syphilis of the nervous system 209
Investigation 209
Management 209
Miscellaneous neurological disorders 209
Cerebral tumours 209
Symptoms and signs 209
Caused by raised intracranial pressure 209
Epilepsy 209
Progressive focal neurological signs 209
Investigation 210
Management 210
Specific intracranial tumours 210
Acoustic neuroma (Schwannoma) 210
Meningioma 210
Pituitary adenomas 210
Guillain–Barré syndrome (GBS) 210
Aetiology 210
Clinical features 211
Differential diagnosis 211
Investigation 211
Management 211
Prognosis 211
Hereditary disorders 212
Hepatolenticular degeneration (Wilson's disease) 212
Management 212
Huntington's chorea 212
Hereditary ataxias 212
Friedreich's ataxia 212
Clinical presentation 212
Cerebellar degeneration 212
Hereditary spastic paraplegia 212
Leber's optic neuropathy (atrophy) 212
Hereditary motor and sensory neuropathy (Charcot–Marie–Tooth disease peroneal muscular atrophy)
Clinical presentation 213
Narcolepsy 213
Head injury and the Glasgow Coma Scale 213
Clinical presentation 213
Examination 213
Investigations 213
Management 214
Prognosis 214
Criteria for diagnosis of brainstem death 214
16 Endocrine disorders 215
Thyroid 215
Non-toxic goitre 215
Aetiology 215
Clinical presentation 215
Differential diagnosis 215
Investigation 215
Treatment 215
Thyrotoxicosis (hyperthyroidism) 216
Aetiology 216
Clinical presentation 216
Other presentations 216
Differential diagnosis 217
Investigation 217
Treatment 218
?-Thalassaemia minor (heterozygote) 218
Antithyroid drug (ATD) therapy 218
Radioactive iodine therapy (RAI 131I)
Surgery 218
Treatment of complications 218
Eyes 218
Atrial fibrillation 219
Thyrotoxic crisis/thyroid storm 219
Hypothyroidism 219
Aetiology 219
Clinical presentation 219
Other presentations 219
Investigation 220
Treatment 221
Thyroiditis 221
Acute thyroiditis 221
Post-partum thyroiditis 221
Thyroid cancer 221
Pituitary 221
Pituitary anatomy and physiology 221
Pituitary adenomas and hypopituitarism 224
Aetiology 225
Clinical presentation 225
Hormone hypersecretion 225
Hormone hyposecretion 227
Local mass effect(s) 227
Investigation 227
Hormone hypersecretion 228
Hormone hyposecretion 229
Local mass effect(s) 229
Treatment 229
Hormone hypersecretion 229
Correction of hormone hyposecretion 229
Local mass effect 230
Prognosis and treatment 230
Adrenal 230
Cushing syndrome 230
Primary hyperaldosteronism 230
Aetiology 230
Clinical presentation 230
Investigation 230
Management 231
Primary adrenal insufficiency 231
Aetiology 231
Clinical presentation 231
Investigation 231
Management 231
Congenital adrenal hyperplasia 232
Clinical presentation 232
Investigation 232
Management 232
Phaeochromocytoma 232
Clinical presentation 233
Investigations 233
Management 233
Multiple endocrine neoplasia (MEN) 233
Investigation and management 234
Autoimmune polyglandular endocrinopathies 234
Polycystic ovarian syndrome 234
Clinical presentation 234
17 Metabolic disorders 236
Diabetes mellitus 236
Diagnostic criteria 236
Classification 236
Type 1 diabetes mellitus 236
Type 2 diabetes mellitus 236
Gestational diabetes mellitus (GDM) 237
Other specific types of diabetes mellitus 237
Epidemiology 238
Aetiology 238
Genetics 238
Environmental/other factors 238
Clinical presentation 238
Management 239
General principles 239
Glycaemic control 241
Diabetic emergencies 245
Hypoglycaemia (‘hypo’) 245
Management 245
Hyperglycaemia 245
Diabetic ketoacidosis (DKA) 245
Management 246
Fluid replacement 246
Insulin replacement 247
Metabolic treatment targets 247
Additional measures 247
Hyperosmolar non-ketotic coma (HONK) 247
Long-term diabetic complications 248
Macrovascular complications 248
Attention to other cardiovascular risk factors in the patient with diabetes mellitus 248
Hypertension 248
Dyslipidaemia 248
Microvascular complications 248
Retinopathy 248
Management 248
Microalbuminuria and diabetic nephropathy 249
Management 250
Neuropathy 250
Distal symmetrical polyneuropathy (‘sensory peripheral neuropathy’) 250
Acute (painful) sensory neuropathy 250
Acute mononeuropathies 250
Diabetic amyotrophy (proximal motor neuropathy) 250
Autonomic neuropathy 250
Other complications 251
The diabetic foot 251
Diabetes-related skin conditions 251
Diabetes and pregnancy 251
Pregestational DM 251
Prepregnancy counselling 252
Antenatal care 252
Glycaemic control 252
Medication 252
Retinal assessment 252
Renal assessment 252
Fetal growth and well-being 252
Intrapartum care 253
Neonatal care 253
Preterm labour 253
Gestational diabetes mellitus 253
Other important information for patients with diabetes 253
Diabetes and intercurrent illness 253
‘Sick day rules’ 253
Diabetes and surgery 253
Diabetes and driving in the UK 254
Dyslipidaemia 254
Classification 254
Primary dyslipidaemias 254
Secondary dyslipidaemias 255
Associations between lipids and vascular disease 255
Clinical presentation 256
Investigation 256
Total cholesterol 256
LDL cholesterol 256
HDL cholesterol 256
Triglycerides 256
Other investigations 256
Management 256
Non-drug therapy 257
Drug therapy 257
Obesity 258
Aetiology 258
Clinical features 258
Investigation 259
Management 259
Prognosis 259
Under(mal)nutrition 259
Vitamin deficiencies 259
Fat-soluble vitamins 259
Water-soluble vitamins 260
Enteral feeding 260
Indications 260
Administration 260
Requirements 260
Complications 260
Parenteral nutrition 261
Administration 261
Requirements 261
Complications 261
Anorexia nervosa 261
Porphyria 261
Classification 261
Clinical presentation 261
Acute porphyrias 261
Non-acute porphyrias 263
Investigation 264
Management 264
Acute porphyrias 264
Non-acute porphyrias 264
Metabolic bone disease 264
Physiology 264
Osteoporosis 265
Aetiology 265
Clinical features 265
Investigations 265
Biochemistry 265
Radiology 265
Bone densitometry 265
Screening for secondary causes 266
Prevention and treatment 266
Exercise 266
Calcium 266
Vitamin D 266
Hormone replacement therapy (HRT) 266
Selective oestrogen receptor modulators (SERMs) 266
Bisphosphonates 266
Strontium ranelate 266
Teriparatide (recombinant parathyroid hormone) 266
Denosumab 266
Treatment of underlying cause 267
Osteomalacia 267
Causes 267
Clinical features 267
Adult osteomalacia 267
Childhood rickets 267
Investigation 267
Biochemistry 267
X-ray 267
Bone scan 268
Treatment 268
Vitamin D 268
Paget’s disease (osteitis deformans) 268
Aetiology 268
Clinical features 268
Complications 268
Investigations 268
Biochemistry 268
Radiology 268
Treatment 269
Hypercalcaemia 269
Aetiology 269
Clinical features 269
Investigation 269
Management 270
Mild hypercalcaemia (< 3.0mmol/l)
Moderate hypercalcaemia (3.0–3.5mmol/l) 270
Severe hypercalcaemia (> 3.5 mmol/l)
Principles of treatment 270
Hyperparathyroidism 271
Primary hyperparathyroidism 271
Secondary/tertiary hyperparathyroidism 271
Clinical presentation 271
Investigation 271
Biochemistry 271
Radiology 272
Management 272
Surgery 272
Medical management 273
Hypocalcaemia 273
Aetiology 273
Clinical features 273
Investigations 273
Management 274
Severe symptomatic hypocalcaemia 274
Chronic hypocalcaemia 274
Hypoparathyroidism 274
Aetiology 274
Clinical presentation 275
Investigation 275
Management 275
18 Rheumatology 276
Osteoarthritis (OA) 276
Clinical presentation 276
Investigation 276
Management 276
Prognosis 277
Rheumatoid arthritis (RA) 277
Clinical presentation 277
Musculoskeletal system 277
Skin and subcutaneous tissues 277
Ocular 277
Pulmonary 278
Cardiovascular 278
Neurological 279
Haematological 279
Reticuloendothelial system 279
Renal 279
Iatrogenic 279
Investigation 279
Serology 279
Radiology 280
Management 280
Drug therapy 280
Surgical management 281
Prognosis 281
Seronegative spondyloarthropathies 282
Psoriatic arthritis 282
Clinical presentation 282
Investigation 282
Management 282
Prognosis 282
Ankylosing spondylitis 282
Clinical presentation 283
Spinal symptoms 283
Systemic symptoms 283
Investigation 283
Blood tests 283
Radiography: plain X-ray findings 283
Management 283
Prognosis 283
Reactive arthritis (Reiter syndrome) 283
Clinical presentation 283
Investigation 284
Management 284
Acute phase 284
Chronic peripheral joint disease 284
Prognosis 284
Enteric arthropathy 284
Autoimmune rheumatic disorders (connective tissue diseases) 284
Systemic lupus erythematosus (SLE) 284
Clinical presentation 284
Musculoskeletal system (in 90% of cases) 284
Skin and mucous membranes (in 80% of cases) 285
Kidneys (in 100% of cases) 285
Neuropsychiatric manifestations (in 50–60% of cases) 285
Lungs (in 40–50% of cases) 286
Cardiovascular system (in 40% of cases) 286
Haematology 286
Investigation 286
Management 286
Prognosis 287
Antiphospholipid syndrome 287
Scleroderma (systemic sclerosis) 287
Clinical presentation 288
Investigation 288
Management 289
Prognosis 289
Sjögren syndrome 289
Clinical presentation 289
Investigation 289
Management 290
Prognosis 290
Inflammatory myopathies 290
Polymyositis and dermatomyositis 290
Clinical presentation 290
Muscle involvement 290
Skin involvement in dermatomyositis 290
Other systems 290
Investigation 290
Management 290
Prognosis 291
Mixed connective tissue disease (MCTD) 291
Vasculitides 291
Clinical features 291
Large-vessel vasculitis 291
Giant-cell arteritis (GCA temporal arteritis, cranial arteritis) and polymyalgia rheumatica (PMR)
Clinical presentation 291
Giant-cell arteritis (GCA) 291
Polymyalgia rheumatica (PMR) 292
Investigation 292
Management 293
Prognosis 293
Takayasu's arteritis ('pulseless disease') 293
Clinical presentation 293
Investigation 293
Management 293
Prognosis 293
Medium-sized vessel vasculitis 293
Polyarteritis nodosa (PAN) 293
Clinical presentation 293
Investigation 294
Management 294
Kawasaki disease 294
Small-vessel vasculitis 294
Wegener's granulomatosis 295
Clinical presentation 295
Investigation 295
Management 295
Prognosis 295
Microscopic polyangiitis 296
Clinical presentation 296
Investigation and management 296
Hypersensitivity (leucocytoclastic) vasculitis 296
Henoch–Schönlein purpura (HSP) 296
Churg–Strauss syndrome 296
Cryoglobulinaemic vasculitis 296
Clinical presentation 296
Investigation 296
Management 296
Prognosis 297
Behçet's disease 297
Clinical presentation 297
Differential diagnosis 297
Investigation 297
Management 297
Crystal arthropathies 297
Gout 297
Clinical presentation 298
Acute gout 298
Tophaceous gout 298
Nephrolithiasis and urate nephropathy 298
Investigation 298
Management 298
Acute episodes 298
Long-term control of gout and hyperuricaemia 299
Prognosis 299
Pseudogout (calcium pyrophosphate deposition disease chondrocalcinosis)
Clinical presentation 299
Investigation 299
Management 299
Acute episodes 299
Long-term control 300
Prognosis 300
Miscellaneous rheumatological disorders Carpal tunnel syndrome 300
Carpal tunnel syndrome 300
Clinical presentation 300
Investigation 300
Management 300
Prognosis 300
Septic arthritis 300
Clinical presentation 300
Investigation 300
Management 301
Prognosis 301
Shoulder pain 301
Frozen shoulder 301
Rotator cuff tendonitis 301
Rotator cuff degeneration 301
Back pain 301
Mechanical back pain 301
Vertebral disc prolapse 301
Vertebral crush fracture 301
Systemic Still's disease 302
Juvenile-onset (juvenile idiopathic arthritis) 302
Adult-onset 302
Acute rheumatic fever 302
Clinical presentation 302
Symptoms 302
Signs 302
Investigation 303
Management 303
Postinfectious arthralgia 303
Fibromyalgia 303
19 Dermatology 304
Psoriasis 304
Clinical presentation 304
Psoriatic arthropathy 304
Treatment 304
Topical agents 304
Phototherapy 307
Systemic therapy 307
Eczema/dermatitis 307
Clinical presentation 307
Treatment 307
Acne vulgaris 311
Clinical presentation 311
Investigation 311
Treatment 311
Rosacea 311
Hidradenitis suppurativa 312
Bacterial, viral, fungal and parasitic skin infections 312
Cutaneous drug reactions 312
Clinical features/causative agents 312
Exanthematous eruptions 312
Urticaria and anaphylaxis 312
Eczema 312
Exfoliative dermatitis (erythroderma) 312
Fixed drug eruptions 312
Vasculitis 320
Erythema multiforme 320
Erythema nodosum 320
Pigmentary changes 320
Bullous/blistering reactions 320
Photosensitivity 320
Acneiform eruptions 320
Lupus-erythematosus-like syndrome 320
Lichen planus-like eruptions 320
Purpura 320
Management 320
Skin manifestations of systemic disease 321
Infections 321
Diabetes mellitus 321
Endocrine disorders 321
Hyperlipidaemia 321
Rheumatological disorders 321
Sarcoidosis 321
Malignancy 323
Miscellaneous disorders 323
Bullous disorders 323
Epidermolysis bullosa 323
Pemphigus 323
Clinical presentation 323
Investigation 323
Management 323
Pemphigoid 324
Clinical presentation 324
Investigation 324
Management 324
Dermatitis herpetiformis 324
Clinical presentation 324
Investigation 324
Management 324
Benign and malignant skin tumours 324
Miscellaneous skin conditions 324
Skin pigmentation 324
Urticaria 324
Lichen planus 327
Pityriasis rosea 327
Disorders of the hair and nails 327
Hair abnormalities 327
Nail abnormalities 327
20 Haematology 328
Peripheral blood film features 328
Reticulocytes 328
Normocytic anaemia 328
Microcytic anaemia 329
Macrocytic anaemia 329
Anaemia secondary to chronic disease 330
Pancytopenia 330
Marrow suppression 330
Erythrocyte sedimentation rate (ESR) 330
Anaemia 330
Iron-deficiency anaemia 330
Diagnosis 330
Examination 330
Laboratory investigation 330
Management 331
Hazards of blood transfusion 331
Vitamin B12 deficiency (usually pernicious anaemia) 331
Clinical features 332
Diagnosis 332
Treatment 333
Folic acid deficiency 333
Haemolytic anaemia 334
Hereditary haemolytic anaemias 334
Hereditary spherocytosis 334
Hereditary elliptocytosis 334
Glucose-6-phosphate dehydrogenase deficiency 335
Paroxysmal nocturnal haemoglobinuria 335
Haemoglobinopathies 335
Clinical features 335
Genetic basis of haemoglobinopathies 335
Sickle-cell disease 335
Clinical features 335
Prognosis 336
Thalassaemia 336
?-Thalassaemia minor (heterozygote) 336
?-Thalassaemia major (homozygote) 336
Marrow disorders 336
Myeloproliferative disorders 336
Myelodysplastic syndromes 337
Complications 337
Marrow failure 337
Marrow aplasia 337
Bleeding disorders 338
Haemophilias 338
Treatment 338
Von Willebrand's disease 338
Skin haemorrhage 338
Thrombocytopenia 338
Idiopathic thrombocytopenic purpura 338
Thrombotic thrombocytopenic purpura 338
Henoch–Schönlein purpura 338
Osler's disease (Osler–Weber–Rendu) 338
Disseminated intravascular coagulation (DIC) 339
Leukaemia 339
Acute lymphatic leukaemia 339
Chronic lymphatic leukaemia 339
Acute myeloid leukaemia 339
Chronic myeloid leukaemia 339
Lymphoma 339
Clinical features 339
Myeloma 340
Clinical features 341
Investigation 341
Management of haematological malignancies 341
Alkylating agents 341
Antimetabolites 341
Vinca alkaloids 342
Cytotoxic antibiotics 342
Amyloidosis 342
21 Infectious diseases 343
Imported diseases 343
Malaria 343
Clinical features 343
Prophylaxis 343
Treatment 345
Acute attacks 345
Typhoid 345
Clinical features 345
Investigation 346
Treatment 346
Dysentery 346
Bacillary dysentery (shigellosis) 346
Amoebic dysentery 346
Giardiasis 346
Pyrexia of unknown origin 347
Special points in the history 347
Special points in examination 348
Basic screening tests already performed (check) 348
Further tests commonly required as determined by clinical leads 348
Invasive procedures as indicated 349
Other imported pathogens: nematodes, schistosomes 349
Septicaemia 349
Management 349
Antibiotics 349
Influenza 350
Human immunodeficiency virus infection 350
Clinical features 350
Opportunistic infections 350
Candidiasis 350
Pneumocystis jiroveci pneumonia 351
Mycobacterial infections 351
Cytomegalovirus 353
Cryptococcal infection 353
Toxoplasma 353
Diarrhoea 353
Herpes simplex 353
Herpes zoster 353
Progressive multifocal leukoencephalopathy 353
Malignancy 353
Primary treatment of HIV 354
Anti-retroviral therapy (ART) 354
Nucleoside reverse transcriptase inhibitors (NRTIs) 355
Non-nucleoside reverse transcriptase inhibitors (NNRTIs) 355
Protease inhibitors 355
Infectious mononucleosis (glandular fever) 355
Clinical presentation 356
Investigation 356
Complications 356
Differential diagnosis 356
Treatment 356
Tuberculosis 356
Chronic fatigue syndrome 356
Investigation 357
Management 357
22 Toxicology 358
Clinical presentation 358
Management 358
General measures 358
Cardiorespiratory dysfunction 359
Nausea/vomiting 359
Agitation 359
Seizures 359
Temperature dysregulation 359
Psychiatric assessment 359
Specific measures 359
UK National poisons information service and TOXBASE 359
Preventing absorption and enhancing elimination of ingested toxins 359
Gastric lavage 359
Activated charcoal 359
Alkaline diuresis and dialysis 360
Specific toxins 360
Carbon monoxide poisoning 367
SI Units conversion table 368
Index 369
Supplemental Images 394
"Overall, this is a very nice book for clinicians justlearning and a memory jogger for more experiencedclinicians." (Doody's, 19 July 2013)
| Erscheint lt. Verlag | 12.7.2012 |
|---|---|
| Reihe/Serie | Lecture Notes | Lecture Notes |
| Sprache | englisch |
| Themenwelt | Medizin / Pharmazie ► Medizinische Fachgebiete ► Innere Medizin |
| Schlagworte | Allgemeine u. Innere Medizin • clinical medical, clinical approach, OSCE exam, clinical examination, clinical essentials, clinical medicine essentials, evidence-based medicine, evidence-based clinical practice, OSCE exam study, doctor training, physician training, clinician guide, clinical medicine book • Community Nursing • Gemeindekrankenpflege • General & Internal Medicine • Klinische Medizin • Krankenpflege • Medical Science • Medizin • nursing |
| ISBN-10 | 1-118-49857-7 / 1118498577 |
| ISBN-13 | 978-1-118-49857-6 / 9781118498576 |
| Informationen gemäß Produktsicherheitsverordnung (GPSR) | |
| Haben Sie eine Frage zum Produkt? |
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