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FOR THE FINAL YEAR MEDICAL STUDENT, FOUNDATION DOCTOR, AND GP TRAINEE

OXFORD CLINICAL GUIDELINES

NEWLY QUALIFIED DOCTOR

EDITED BY David Fisher Liora Wittner

AND CONSULTANT EDITOR Deborah Gill

Summarizes the clinical guidelines required by final year medical students and newly qualified doctors

Brings together over 115 guidelines for core conditions

Gives practical answers to the question 'what do I do now?'

OXFORD CLINICALGUIDELINES

Newly Qualified Doctor

EDITED BY

David Fisher

Specialist in Internal Medicine, Clalit Healthcare Services, Israel

Liora Wittner

Resident in Family Medicine, Clalit Healthcare Services, Israel

WITH CONSULTANT EDITOR

Deborah Gill

Vice-President (Education & Student Experience), University of Southampton, Southampton, UK

Great Clarendon Street, Oxford, OX2 6DP, United Kingdom

Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries

The moral rights of the authors have been asserted

First Edition published in 2023

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any formor by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above

You must not circulate this work in any other form and you must impose this same condition on any acquirer

Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY10016, United States of America

British Library Cataloguing in Publication Data

Data available

Library of Congress Control Number: 2021947301

ISBN 978–0–19–883450–2

eISBN 978–0–19–257143–4

DOI: 10.1093/med/9780198834502.001.0001

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 regulations. 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. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding

Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

Preface

Evidence-based guidelines have played an increasing role in medical practice in recent years. Healthcare professionals use guidelines to contend with the overwhelming wealth of available information and to translate scientific advances and new knowledge into safe clinical care.

The popularity of clinical guidelines has led to an exponential rise in guidelines being created since the 1980s and modern healthcare professionals are expected to be familiar with them. The General Medical Council’s (GMC) Good Medical Practice guidance, which records what is expected of every GMC-registered doctor, states: ‘You must be familiar with guidelines … that affect your work’. Such a directive is challenging to uphold. First, the range of available guidelines in every speciality is vast and constantly expanding. Furthermore, individual guidelines can be dense and lengthy, and are therefore impractical to comb through for a professional wishing to acquaint themselves quickly with current clinical approaches.

This publication seeks to address that challenge. Written by junior doctors, each chapter summarizes the key clinical evidence-based guidelines which shape UK practice and presents the information in an accessible and concise format. Where relevant, chapters provide brief additional contextual points in order to explain the guideline for those less familiar with the field. Junior doctors, in particular foundation doctors, will find this resource useful to rapidly familiarize themselves with the latest clinical guidelines for the commonest conditions that they encounter in both primary and secondary care. Students will find this book useful as a quick reference guide to better understand the patient journey. They can also use it as a revision aid, as knowledge of guidelines is increasingly tested in medical school examinations.

Reading and learning every clinical guideline that is relevant to junior doctors is an arduous and almost impossible task. We hope that this book helps to bridge the gap and makes clinical guidelines more accessible to junior doctors, both for their benefit and also for the benefit of the patients that they treat.

Introduction: how to use this book

This book contains 123 chapters, covering a wide range of topics within internal medicine, surgery, emergency medicine, paediatrics, obstetrics and gynaecology, and psychiatry. The book is designed to cover the breadth of knowledge expected of a foundation doctor and it is pitched at this level. However, we would expect it to also be useful for medical students, specialist nurses, and junior specialist trainees (ST/CT 1–3 level).

This book is intended to be concise. Content which is relevant to multiple chapters will usually be noted once and other chapters will signpost to the primary mention.

Multiple guidelines exist for some topics and occasionally they conflict with each other in terms of their conclusions. It can be challenging for non-specialists to know which guideline they should follow. Each specialty section in this book has been overseen by at least one senior specialist consultant who has provided direction in identifying the most relevant and widely used guideline (or guidelines) to base each chapter upon. Readers should be aware that institutions often have their own local protocols which supersede the guidelines used in this publication.

The information in each chapter refers to adult patients only, except for chapters in the Resuscitation section (Part 17) where paediatric content is highlighted and chapters in the Paediatric section (Part 10). Where a drug is suggested as a treatment option, any dosages mentioned assume an otherwise healthy, non-pregnant adult with normal hepatic and renal function, and of average height and weight. Exceptions include chapters dealing with obstetrics, paediatrics, elderly medicine, hepatology, and nephrology. In all cases, the most recent British National Formulary or local protocols should be consulted to verify the drug choice, dosage, and any contraindications.

This book includes some investigation and management options that should only be considered under the guidance of a senior or specialist clinician, and they are highlighted as such. It is vital that junior professionals should be aware of their own limitations and not do anything that they are not competent to do.

Finally, please note that the information contained within these pages is for educational purposes only and should not be solely relied upon to direct the management of patients. The full guidelines are referenced at the start of each chapter and can be accessed online.

Acknowledgements

First and foremost, this book would not have been possible without the hard work of each chapter contributor. We are also grateful for the dedication of the Senior Editorial Board and for all of the reviews and advice that they provided.

We are appreciative of Professor Deborah Gill for her thoughtful oversight and helpful suggestions over the course of writing this book.

We are of course indebted to the wonderful team at Oxford University Press. We are grateful to each of the project managers that we have been fortunate to work with including Sam Callard, Mark Knowles, Fiona Sutherland, and most recently Sylvia Warren.

Most of all we would like to thank our commissioning editors Elizabeth Reeve and Geraldine Jeffers, who have provided us with their wealth of expert experience and have guided every step of this project to fruition. They have been a pleasure to work with and we are grateful for their support. As a brand-new concept which took time to perfect, this book has been a long time in the making, so finally, we would like to acknowledge all the ‘OCG babies’born to the team since the start of this process, Tessa, Aurora, and Gidon!

Index of emergency topics

Section editors

Contributors

Symbols and abbreviations

Part 1 Cardiology

Acute coronary syndromes

Acute heart failure

Aortic stenosis and mitral regurgitation

Atrial fibrillation

Chronic heart failure

Hypertension

Pericardial diseases

Stable

Transient loss of consciousness

Part 2 Care of

Diabetic

Hypercalcaemia

Hyperglycaemia

Hyperglycaemic hyperosmolar syndrome

Hyperthyroidism

Hypocalcaemia

Hypoglycaemia

Hyponatraemia

Hypothyroidism

Osteoporosis

Part 4 Gastrointestinal

Acute

Coeliac

Part 6 Mental health

Bipolar disorder

Depression

Eating disorders

Generalized anxiety disorder

Panic disorder

Post-traumatic stress disorder

Psychosis and schizophrenia

Self-harm

Violence and aggression

Part 7 Nephrology

Acute kidney injury

Chronic

Hyperkalaemia

Part 8 Neurology

Acute encephalitis

Epilepsy

Headache Meningitis

Stroke

Part 9 Obstetrics and gynaecology

Antenatal care

Antepartum haemorrhage

Diabetes in pregnancy

Ectopic pregnancy and miscarriage

Hypertension in pregnancy

Intrapartum care

Nausea and vomiting in pregnancy

Pelvic organ prolapse in women

Postpartum haemorrhage

Sepsis in and following pregnancy

Thrombosis and embolism during pregnancy and the postnatal period

Urinary incontinence in women

Part 10 Paediatrics

Child

Fever

Neonatal

Paediatric

Paediatric bacterial meningitis and meningococcal septicaemia

Paediatric bronchiolitis

Paediatric

Paediatric type 1 diabetes

Paediatric urinary tract infections

Part 11 Respiratory

Acute oxygen therapy

Asthma

Chronic obstructive pulmonary disease

Pleural effusion

Pneumonia

Part 12 Rheumatology and musculoskeletal

Giant cell arteritis

Gout

Hot swollen joint

Low back pain and sciatica

Osteoarthritis

Polymyalgia rheumatica

Rheumatoid arthritis

Spondyloarthritis

Care of dying adults in the last days of life

Intravenous fluid therapy

Lower urinary tract symptoms in men

Malaria

Venous thromboembolic diseases

Part 15 Cancer guidelines

Brain and central nervous system cancers

Breast cancer

Childhood cancers

Gynaecological cancers

Haematological cancers

Head and neck cancers

Lower gastrointestinal cancers

Lung cancer Sarcomas

Skin cancers

Upper gastrointestinal cancers

Urological cancers

Part 16 Professional guidelines

17 Resuscitation

Advanced life support

Anaphylaxis and drug allergy

Bradycardia

Choking

Major trauma

Neutropenic sepsis

Sepsis

Tachycardia

Index

A-Zof all conditions

Acute coronary syndromes

Acute encephalitis

Acute heart failure

Acute kidney injury

Acute liver failure

Acute upper gastrointestinal bleeding and variceal bleeding

Adrenal insufficiency

Advanced life support

Alcohol-related liver disease

Alcohol use disorders

Anaphylaxis and drug allergy

Antenatal care

Antepartum haemorrhage

Aortic stenosis and mitral regurgitation

Asthma

Atrial fibrillation

Bipolar disorder

Bradycardia

Brain and central nervous system cancers

Breast cancer

Child maltreatment

Childhood cancers

Choking

Chronic heart failure

Chronic kidney disease

Chronic obstructive pulmonary disease

Coeliac disease

Delirium

Dementia

Depression

Diabetes in pregnancy

Diabetic ketoacidosis

Eating disorders

Ectopic pregnancy and miscarriage

Epilepsy

Falls

Fever in under 5s

Gastro-oesophageal reflux disease and dyspepsia

Generalized anxiety disorder

Giant cell arteritis

Gout

Gynaecological cancers

Haematological cancers

Head and neck cancers

Headache

Hip fractures

Hot swollen joint

Hypercalcaemia

Hyperglycaemia

Hyperglycaemic hyperosmolar syndrome

Hyperkalaemia

Hypertension

Hypertension in pregnancy

Hyperthyroidism

Hypocalcaemia

Hypoglycaemia

Hyponatraemia

Hypothyroidism

Intrapartum care

Irritable bowel syndrome

Liver cirrhosis

Low back pain and sciatica

Lower gastrointestinal cancers

Lower urinary tract symptoms in men

Lung cancer

Major trauma

Malaria

Meningitis

Metastatic spinal cord compression

Nausea and vomiting in pregnancy

Neonatal infections

Neuropathic pain

Neutropenic sepsis

Osteoarthritis

Osteoporosis

Paediatric asthma

Paediatric bacterial meningitis and meningococcal septicaemia

Paediatric bronchiolitis

Paediatric diabetic ketoacidosis

Paediatric gastroenteritis

Paediatric type 1 diabetes

Paediatric urinary tract infections

Panic disorder

Parkinson’s disease

Pelvic organ prolapse in women

Pericardial diseases

Pleural effusion

Pneumonia

Polymyalgia rheumatica

Post-traumatic stress disorder

Postpartum haemorrhage

Psychosis and schizophrenia

Rheumatoid arthritis

Sarcomas

Self-harm

Sepsis

Sepsis in and following pregnancy

Skin cancers

Spondyloarthritis

Stable angina

Stroke and transient ischaemic attack

Tachycardia

Thrombosis and embolism during pregnancy and the postnatal period

Transient loss of consciousness

Type 1 diabetes mellitus

Type 2 diabetes mellitus and diabetic foot problems

Ulcerative colitis

Upper gastrointestinal cancers

Urinary incontinence in women

Urological cancers

Venous thromboembolic diseases

Violence and aggression

Acute coronary syndromes

Acute heart failure

Atrial fibrillation

Adrenal insufficiency

Diabetic ketoacidosis

Hypercalcaemia

Hyperglycaemic hyperosmolar syndrome

Hypocalcaemia

Hypoglycaemia

Hyponatraemia

Acute upper gastrointestinal bleeding and variceal bleeding

Self-harm

Violence and aggression

Acute kidney injury

Hyperkalaemia

Acute encephalitis

Epilepsy

Meningitis Metastatic

Ectopic

Sepsis

Thrombosis and embolism during pregnancy and the postnatal period

Fever in under 5s

Neonatal infections

Paediatric asthma

Paediatric bacterial meningitis and meningococcal septicaemia

Paediatric diabetic ketoacidosis

Asthma

Chronic obstructive pulmonary disease

Hot swollen joint

Venous thromboembolic diseases

Advanced life support

Anaphylaxis and drug allergy

Bradycardia

Choking

Major trauma

Neutropenic sepsis

Sepsis

Tachycardia

Section editors

Rachel Ayers

2. Care of the elderly

Consultant in Geriatric Medicine, John Radcliffe Hospital, Oxford, UK

Andrew Baldwin

15. Cancer guidelines

GP Partner, East Sussex, UK

Robin Basu Roy

10. Paediatrics

Clinical Lecturer in Paediatric Infectious Disease, London School of Hygiene & Tropical Medicine, London, UK

Oliver Brain

4. Gastrointestinal

Consultant Gastroenterologist, Oxford University Hospitals NHS Trust, Oxford, UK

Laura Brown

2. Care of the elderly

Consultant in Geriatric Medicine, John Radcliffe Hospital, Oxford, UK

Chris Carson

Emergency editor

Accident and Emergency Registrar, University of Sheffield, Sheffield, UK

Jeremy Cobbold

5. Hepatobiliary

Consultant Hepatologist and Gastroenterologist, John Radcliffe Hospital, Oxford, UK

Ryan Devlin

6. Mental health

ST5 Doctor in General Adult Psychiatry, NHS Greater Glasgow and Clyde, Glasgow, UK

Andrew Greer

Emergency editor

Specialist in Intensive Care, Barnsley District General Hospital, UK

James Harrison

1. Cardiology

Consultant Cardiologist and Honorary Senior Lecturer, King’s College Hospital NHS Foundation Trust, London, UK

Abdullah Jibawi

13. Surgery

Consultant Vascular, Endovascular, and General Surgeon; Academic Instructor to the Royal College of Surgeons of England, Ashford, and St Peter’s Hospitals NHS Foundation Trust, UK

Nigel Lane

14. Miscellaneous

Consultant Physician, North Bristol NHS Trust, Bristol, UK

Suzanne Mason

Emergency editor

Professor of Emergency Medicine, University of Sheffield, Sheffield, UK

Kerry Munro

9. Obstetrics and gynaecology

Consultant Obstetrician, Queen Charlotte’s and Chelsea Hospital, London, UK

Eleana Ntatsaki

12. Rheumatology and musculoskeletal

Consultant Rheumatologist, Ipswich Hospital NHS Trust, Ipswich, and Honorary Senior Lecturer, University College London, London, UK

William Petchey

7. Nephrology

Consultant Nephrologist, West Sussex NHS Foundation Trust, Bury St Edmonds, and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Bernard Prendergast

1. Cardiology

Professor of Interventional Cardiology and Valvular Heart Disease, Department of Cardiology, St Thomas’Hospital, London, UK

Rustam Rea

3. Endocrinology

Consultant in Diabetes and Acute Medicine, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

David Semple

6. Mental health

Consultant Psychiatrist, University Hospital Hairmyres, East Kilbride, and Honorary Fellow, Division of Psychiatry, University of Edinburgh, UK

Manjeet Shehmar

9. Obstetrics and gynaecology

Consultant in Gynaecology and Deputy Medical Director, Walsall Healthcare NHS Trust, Birmingham, UK

Helen Turner

3. Endocrinology and 16. Professional guidelines

Consultant in Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK

Richard A. Watts

12. Rheumatology and musculoskeletal

Consultant Rheumatologist and Honorary Professor, Norwich Medical School, University of East Anglia, UK

Alastair Webb

8. Neurology

Consultant Neurologist and Wellcome Trust CRCD Fellow, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK

Stephanie Wittmann

10. Paediatrics

Paediatrician, St Mary’s Hospital, London, UK

Andrew Zurek

11. Respiratory

Consultant Respiratory Physician, Royal Berkshire Hospital, Reading, UK

Contributors

Sabrina Ahmed

GP trainee

General Practice, Barking, Havering

Redbridge University Hospitals NHS Trust

London, UK

Anna Maria Albert

Salaried GP

Manor surgery

Oxford, UK

Mohammed Al-Talib

NIHR Academic Clinical Fellow in Renal Medicine

North Bristol NHS Trust

James Andren

Anaesthetic Registrar

University Hospitals Sussex Brighton, UK

Gabriella Bathgate

North Central London CCG

London, UK

Darryl Ethan Bernstein

Core Surgical Trainee in Urology

East & North Hertfordshire NHS Trust

George Blanchard

Specialist Registrar in Adult and Old Age Psychiatry

Mental Health Services for Older People Barnet

Enfield and Haringey Mental Health NHS Trust

Harriet Blundell

General Medicine Registrar

St Bernard’s Hospital

Gibraltar

Laura Brodie

Registered Medical Practitioner

Centre for Health and Disability Assessments

Maximus, Newcastle Upon Tyne

Benjamin Bussmann

Cardiology Registrar

Royal Berkshire Hospital

Reading, UK

Stephanie Mei Yann Choo

Specialist Registrar in Renal Medicine

Hull Royal Infirmary

West Yorkshire, UK

Georgina Clark

Registrar

Obstetrics and Gynaecology

West Suffolk Hospital

Suffolk, UK

Ben Coombs

Specialty registrar in anaesthetics & intensive care medicine

Royal Air Force

Oxford, UK

John Creamer

Gastroenterology Registrar

Southmead Hospital

Bristol, UK

Angharad Everden

ST3 Haematology Registrar

Royal Cornwall Hospital

NHS Trust

David Fisher

Specialist in Internal Medicine

Clalit Healthcare Services

Israel

Harriet Gardner

ST3 in Obstetrics and Gynaecology

James Cook University Hospital

Middlesbrough, UK

Alison Hare

Core Trainee

Anaesthetics, Aneurin Bevan

University Health Board

Wales

Vanessa Jessop

Adam Maxwell Internal Medicine Trainee Year 3

University Hospitals Bristol and Weston NHS Foundation Trust

Georgios Karagiannis

Consultant Cardiologist

Department of Transplant

Harefield Hospital

London, UK

Thomas McCabe

NHS Ayrshire and Arran

Kilmarnock, UK

School of Medicine, Dentistry & Nursing

University of Glasgow

Glasgow, UK

Clemency Nye

Registrar in Infectious Diseases and Microbiology

University Hospital Wales

Cardiff, UK

Sarah Orr

Psychiatric Higher Trainee

South West Yorkshire Partnership

Tom Owens

ST4 in Emergency Medicine

Barts Health NHS Trust

London, UK

Bina Patel

Academic Clinical Fellow in Neurology

Addenbrookes Hospital

Cambridge, UK

Catharine Pearce

Speciality Training Registrar in Respiratory and General Internal Medicine

University Hospitals Plymouth NHS Trust Devon, UK

Shervin Poladi

Royal Brompton and Harefield

NHS UK

Emma Shephard

Specialist Registrar in Obstetrics and Gynaecology

Torbay Hospital

Devon, UK

Prabhsimran Singh

Specialist Registrar in Gastroenterology

Hull University Teaching Hospitals

Hull, UK

Yasmin Smith

Obstetrics & Gynaecology Registrar

South West Deanery

Matthew Sutton

Anaesthetic Registrar

James Cook University Hospital

Middlesbrough, UK

Elizabeth Tan

ST3 in Geriatric Medicine

North West London Deanery

Dinta Thakkar

General Practitioner and Health Tech Clinical Lead

Leicester, UK

Ashwini Virgincar

Anaesthetic Registrar

Chelsea and Westminster Hospital

London, UK

Rebecca Webb-Mitchell

Cardiology Registrar

South Tyneside and Sunderland

NHS Foundation Trust

Newcastle upon Tyne, UK

Nicola West

GP ST3

West Midlands Deanery

Samantha Williamson

Paediatric ST5 Doctor

North West Deanery

England

Liora Wittner

Resident in Family Medicine

Clalit Healthcare Services

Israel

Emily Yeung

Gateshead Health NHS Foundation Trust

QE Hospital

Symbols and abbreviations

> greater than

≥ greater than or equal to

< less than ≤ less than or equal to

decreased ↑ increased

↔ normal red flag

± with or without

2WW 2-week wait

4AT 4 ‘A’s Test

5-ASA 5-aminosalicyclic acid

ABCDE Airway, Breathing, Circulation, Disability, and Exposure

ABG arterial blood gas

ABPM ambulatory blood pressure monitoring

ACE angiotensin-converting enzyme

ACR albumin:creatinine ratio

ACS acute coronary syndrome

ACTH adrenocorticotropic hormone

AED antiepileptic drug

AF atrial fibrillation

AHT antihypertensive treatment

AKI acute kidney injury

ALF acute liver failure

ALP alkaline phosphatase

ALS advanced life support

ALT alanine aminotransferase

AMTS Abbreviated Mental Test Score

ANA antinuclear antibody

ANCA antineutrophil cytoplasmic antibody

AP anteroposterior

APH antepartum haemorrhage

APTT activated partial thromboplastin time

ARB angiotensin receptor blocker

ArLD alcohol-related liver disease

AS aortic stenosis

ASA American Society of Anesthesiologists

AST aspartate aminotransferase

AUDIT Alcohol Use Disorders Identification Test

AV atrioventricular

AVPU Alert, Voice, Pain, Unresponsive

BD twice daily (bis die)

βHCG beta-human chorionic gonadotropin

BMD bone mineral density

BMI body mass index

BNF British National Formulary

BNP B-type natriuretic peptide

BPE benign prostatic enlargement

BPPV benign paroxysmal positional vertigo

BSG British Society of Gastroenterology

CABG coronary artery bypass grafting

CAD coronary artery disease

CAM Confusion Assessment Method

CAMHS child and adolescent mental health services

CBG capillary blood glucose

CBT cognitive behavioural therapy

CCP cyclic citrullinated peptide

CD Crohn’s disease

CHF chronic heart failure

CJD Creutzfeldt–Jakob disease

CLD chronic liver disease

COPD chronic obstructive pulmonary disease