Conditions List Flashcards
Gives a brief overview (Epidemiology, Aetiology/Pathophysiology, Symptoms/History, Investigations/Screening, and Management) of, hopefully, every condition that we might come across.
T21 / Down’s
Epi: 1/700 births
Aet: Non-disjunction of Cr21, or the passage of a T(21, 14) to an offspring.
Hx/Sx: Upslanting palp fissures, epicanthal folds, single palm crease, bradycephaly, Cog delay. ±AVSD ±intestinal atresia ±Hirschsprung’s ±Alzheimer’s ±Hypothyroidism.
Ix: 11-13w USS, 15-22w Quad (+I, +B, -E, -A) ±Amniocentesis, 18-22 anatomy scan. Postnatal: Echo, resp tests.
Mx: Assessment with relevant specialties (Cardio, GI) + Parental genetic counselling +Physio +OT +SALT +Individual education plan.
T18 / Edward’s
Epi: 1/3,000 births (30x more pregnancies, most die before birth). ^^ with ^^mother age.
Aet: Non-disjunction of Cr18.
Sx/Hx: Rocker-bottom feet, Small jaw, low-set ears, Cog delay, Congen HD (ASD/VSD).
Ix: Antenatal: 11-13w USS, 15-22w Quad (I norm, -B, -E, -A) ±Amniocentesis, 18-22 anatomy scan. Postnatal: Echo, resp tests.
Mx: 10% 1y / 1% 10y survival. Symptom-focused management: Resp and cardio, mostly.
T13 / Pateau’s
Epi: ~1/15,000 births.
Aet: Non-disjunction of Cr13.
Sx/Hx: Small head, small eyes, Cleft lip/palate, Polydactyly. “PPP - Pateau’s, Palate, Polydactyly”.
Ix: Quad Screen is NOT substantial .
Mx: 19.8% 1y / 12.9% 10y survival. Surgery for cleft-lip/palate + cardiac abnormalities.
Turner’s Syndrome
Epi: 1/2500 female births.
Aet: 45XO, but they have to have had an X-Cr deletion, and not a Y, which is instead called: “disorders of differences of sex development”.
Sx/Hx: Bicusp Aortic Valve, Coarction of Aorta, Webbed neck, Long Torso, Short Stature, delayed puberty.
Ix: GSfDx: Karyotype. Bone age, echo, audiology, LFTs. Can sometimes be confirmed during pregnancy if heart defect is picked up on USS.
Mx: Screening; “Turner’s Hepatitis” / DM / Coeliac. Oestrogen/Cyclic Progesterone + GH for growth + puberty. ±Breast implants.
Noonan’s Syndrome
Epi: ~1/2000 births - Men:Women = 1:1
Aet: Many potential gain-in-function mutations.
Sx/Hx: Short stature, Dysmorphic face, Pulm stenosis (+Other CHDs), Delayed puberty, Bleeding disorder.
Ix: Clin Dx. Molecular testing, ECG + Echo + Coagulation for management.
Mx: Patient-specific (?Surgery) + GH for growth.
Fragile-X Syndrome
Epi: 1/4000 M, 1/8000 F.
Aet: CGG trinucleotide repeats, similar to HD, on one X chromosome; Thereby affecting males worse.
Sx/Hx: Large head, large testicles, Cog-delay, Low-set ears, Mitral-Valve prolapse.
Ix: Amniocentesis (CVS) - Generally done if a FHx is present.
Mx: SALT, OT, Specialist education, genetic counseling + Sx-based treatment.
Pierre-Robin Sequence/Syndrome
Epi: ~1/11,000 births.
Aet: 1st Trimester sequence of development errors in the head/chin development.
Sx/Hx: Small jaw, Cleft lip/palate, Posterior tongue displacement.
Ix: Clin Dx shortly after birth.
Mx: SALT, Surgery at 6m-2y. Breathing assistance.
Hereditary Spherocytosis
Epi: 1/2000
Aet: AD Inheritance AND 25% are AR. Membranoapthy. Cells do not pass splenic checks, leading to haemolysis + splenomegaly.
Sx/Hx: Neonatal Jaundice. Haemolytic crises (Parvo B19),
Ix: Check for other causes of haemolysis; Coombs test. Blood smear, USS spleen.
Mx: Splenectomy ±Cholecystectomy. Vaccines against Flu / Cov19 / Meningococcus / StrepPneumo. ±Transfusion in haemolytic crisis. Folate replacement.
Sickle-Cell Disease
Epi: 1/2000 - More common in African decent- 8% of black people have SS trait,
Aet: AR Inheritance. Sickle-trait protective against Malaria. Cells sickle in hypoxia due to HbS polymerisation.
Sx/Hx: Dactylitis, pneuomonia-like-syndrome, FTF, jaundice.
Ix: Newborn Blood-spot, Blood-smear:
“Howell-Jolly Bodies”.
DNA-Assays. FBC + Reticulocytes. ±Long-bone XR (infarct).
Mx: Hydroxycarbamide, Blood transfusions + Iron Chelation. ?Haematopoetic SS transplant. Acute: Analgesia, Abx, Fluid.
Congenital Hypothyroidism
Epi: 1/4000 births.
Aet: –Iodine (Developing Countries), Genetics. Lithium, ?Pesticides.
Sx/Hx: Jaundice, ++Sleeping, Abdo distention, –muscle tone, –Temperature.
Ix: TFT. Technetium-99m scan or Radioactive Iodine scan.
Mx: Daily levothyroxine > Develops normally.
Cystic Fibrosis
Epi: 1/3000 in white people.
Aet: CFTR allele, AR inheritance. Abnormal salt balance of cell membranes > Thick secretions.
Sx/Hx: –Meconium Passage, FTF, unsatiated, wet cough, recurrent infections.
Ix: Neonate blood-spot (Immunoreactive Trypsinogen), Sweat Test. ±Sinus XR ±Throat swab.
Mx: ±CFTR-Mod. MecIlleus: Osmotic agents ± surgery. Lungs: Physio, SABA, mucolytics ±28d inhaled abx (Tobramycin). ±Lung transplant. Gastro: Pancreatin (Enz replace) + ADEK replacement ±Ursodeoxycholic acid ±PPI/H2.
1-MCADD (Medium-Chain Acyl-CoA-Dehydrogenase Deficiency)
2-PKU (Phenylketouria)
3-MSUD (Maple Syrup Urine)
4-Homocystinurua
5-Isovalaric Aciduria
6-Glutaric Aciduria.
x6 Metabolic Diseases on Newborn Blood Spot: Epi, Inheritance, Complications, Mx.
1- ~1/10k, ARi, –Glucose –Ketones +Liver failure ~1/10 die in 10m, monitor diet well + illness rules.
2- 1/12k, ARi, Untreated: –CogDev +Musty Urine +Seizures, Diet low in Phe (No eggs/chicken etc) +Careful Phe replacement.
3- 1/250k, ARi, Subtle > 48h > Athetoid + Spasticity + coma + Sweet-urine/earwax, Transfusion > Diet control ±Liver transplant (Curative).
4- ~1/300k, ARi, Seizures +Marfan-Habitus
–CogDev +Eye issues, vB6 +Low Protein diet.
5- 1/250k, ARi, “Sweaty-feet” smell >3d: Seizures + vomiting + coma +~30% death, Diet: Leucine restriction.
6- 1/100k, ARi, ++Macrocephaly Spasms +more after encephalopathic crisis, Carnitine IV + Choline replacement.
Congenital Adrenal Hyperplasia
Epi: ~1/15,000 (Varies a lot between ethnicity)
Aet: Multiple alleles, 3 types: 21Hd, 17Hd, 11bHd > –Mineralocorticoids / –Androgens (See my mnemonics Section).
Sx/Hx: 11/21: Ambiguous genitelia in F. 17: Intersex boys. 17/11: Hypertension/–K. 21: Salt-losing crisis within 3w > Death.
Ix: Bloods: –Glucose. ±±Na, ±±K.
Mx: ++Glucocorticoids ±Androgens (Type-dependent) ±Salts.
Retinopathy of Prematurity
Epi: 5-8% Prems in developed countries.
Aet: Less growth of retinal vessels due to ++O2, followed by sudden growth when –O2, leading to retinal detachment.
Hx/Sx: Stages 1/2: Slight visual loss. 3/4/5: Blindness increasing in severity.
Ix: Screening for babies <30w + babies <1500g at 4-9w old.
Mx: Peripheral Retinal Ablation: Kill avascular part of retina so it doesn’t vascularise.
Prematurity (General)
Epi: 10% of Births. 85% = 32-37w gestation.
Aet: IUGR, genetics, PPROM, maternal chronic disease, Low/High BMI, smoking.
Hx/Sx: Neuromuscular + Physical maturity score, indicates how premature they are.
Ix: Bilirubin, O2 sats bilat, Fundoscopy, USS head.
Mx: Resus > NICU. +Heat +Surfactant +Caffeine +40% O2 +Breastmilk +Dextrose ±Empirical Abx (PPROM) ±Phototherapy ±NSAIDS/±Prostaglandins
Neonatal Jaundice
Epi: 50-70% term and >80% prems.
Aet: Conj or Unconj and time-related:
<24h: ABO/Rhesus, Sepsis, G6PDd/Spherocytosis. 2-14d (40%): Physiological/Milk. >14d: Billiary atresia +others.
Hx/Sx: Sclera yellow (All ethnicities) ±FamHx. More common in –Gestational age.
Ix: Transcut Billi. SBR. Coombs (?ABO). ±FBC ±Blood smear ±LFTs. ?Sepsis: Urine.
Mx: >95th Cent for Billi: Blue Phototherapy + Fluid Dilution. If above threshold on chart: Exchange Transfusion.
Congenital Heart Disease
Epi: 0.8% of live births
Aet: Risks; Down’s, Edward’s, Pateau’s. Turner’s. VSD = 20% of CHDs.
Hx/Sx: ?–Femorals, ?Cyanotic, FTF, ±Asymptomatic ±Murmur/Thrill. Soon after birth cyan: TGA likely. Cyan
Ix: Bilat O2 sats, Echo ±CXR. 10-13+6 USS may show +NuchalThickness.
Mx: ±Prostaglandins ±Diuretics ±Food fortification then Surgery; ToGA: ASAP, ToF: @3m, AVSD: @3-6m, VSD: @1-4m if bad, @6-9m otherwise.
Cerebral palsy
Epi: 1/500 live births. 70% spastic.
Aet: Brain damage before 2y of age: Causes: 80% antenatal, 10% intrapartum, 10% post natal; Hypox. Ataxic (Cerbellar) +Dyskinetic (Basal-Ganglia).
Hx/Sx: Developmental delay in motor + Speech. Clonus, scissoring, toe walking.
Ix: Mostly to rule out other causes: MRI head ±USS/CT, metabolic panel, genetics, coag.
Mx: OT/PT + Orthoses/Equipment ±Botox (Can cause atrophy+Fibrosis) ±Surgery.
Autism Spectrum Disorder
Epi: 1-2% (M:F = 4:1, but seems to be changing)
Aet: 50-80% heritable. Lots of environmental factors.
Hx/Sx: ±Delayed language dev ±Repetitive speech ±Non-verbal communication issues ±Repetitive behaviour ±Struggle with change ±ADHD.
Ix: Screening tests; e.g, CAST or CARS.
Mx: Behavioural + Parent-mediated interventions ±Early education service input ±Manage ADHD.
Attention Deficit Hyperactivity Disorder (ADHD)
Epi: 7-11%. Combined ADHD = 50-70%. M:F = 2:1.
Aet: Genetic + Environment; 76% in twin studies.
Hx/Sx: H/I/I: ±Hyperactivity ±Inattention ±Impulsivity: Fidgeting, daydreaming, blurting out answers, hyper-fixating, organisation difficulties
Ix: SNAP-IV Q: 26 items for H/Inattention. Observed classroom. Child Behavioural Checklist (CBCL-AP). +ECG/Weight/BP/HR (For meds).
Mx: All ages: Parental education. <6y: Only consider methylphenidate. >6y: Give methylphenidate (Ritalin) - Height /6m and Weight /3m (<10 +after starting) or /6m (>10).
±Behavioural Therapy >6y, ±Antidepressants (Last-line).
Biliary Atresia
Epi: ~1/15,000 of neonates.
Aet: Neonates, bile duct/hepatic duct destruction due to ?Viral ?Toxins ?Genetics ?Autoimmunity.
Hx/Sx: >2w Jaundice (2w = physiological). Dark urine. Appetite/Growth issues. ±Hepatomegaly ±Splenomegaly.
Ix: Total bilirubin may be normal. Check conjugated bilirubin specifically! LFTs + PTT. Differentials: Sepsis: FBC etc. USS: “Triangular Cord Sign”.
Mx: Surgery (Hepatoportoenterostomy) ±Ursodeoxycholic acid ±Liver transplant ±Abx coverage.
Developmental Dysplasia of Hip (DDH)
Epi: 1-3% of newborns.
Aet: A bit genetic, a bit hormonal, a lot of mechanical factors.
Hx/Sx: RF: Breech/Female/1st-Born/–Hydramnios/>5kgBW/FamHx.
Ix: Screen @birth and 6-8w for all infants: Barlow (Dislocate) & Ortalini’s (Relocate). USS @6w-4/6m (XR at 4-6m, depending on ossification) for all infants breech @36w gest, or other risk factors.
Mx: Observe > Splint (Pavlik Harness) > ?Failed splinting > Closed reduction surgery.
Non-Accidental Injury (NAI)
Epi: 4-16% children Physically abused in industrialised countries.
Aet: Risks: Children with –Intellect/Physical issues, twins. > Head trauma (Retinal/Subarach/Epidural Haemorrhage), rib fractures, other micro fractures.
Hx/Sx: Inconsistent Hx. Late presentation. Other (±Older) injuries. No trauma Hx. Symmetrical.
Ix: Skeletal Survey +CT head +Fundoscopy +Photo-survey of injuries +FBC +Calc/PTH/ALP/vitD +Clotting profile
Mx: ADMIT +Manage injuries +Talk to social services / coordinator.
Septic Arthritis
Epi: 1/20,000 children. (More in <4y)
Aet: Risks: Surgery, Join-injections, Trauma. Joint colonisation > Sepsis > Join destruction.
Hx/Sx: ±Non weight-bearing ±Hot/Swollen/Restricted ±Fever, <2w of sx.
Ix: Kocher’s: FBC (WCC > 12?), ESR (>40?), Temp (>38.5?) ±Weight bearing? Joint aspirate +Cultures. ±USS/XR.
Mx: 3-6w abx. Fluclox. Pen-allergic: Clindamycin. MRSA: Vanco. Meningococcus/G-?: Cefotaxime. +Joint aspiration +Analgesia.
Transient Synovitis
Epi: 3% children have an episode. 5-6y PkAg. 3-12y.
Aet: Mostly unknown. Link to viral URTI ~2w before. May be 1st sign of JIA/Chronic inflammation.
Hx/Sx: Limitation but freedom within limitaiton;
–Abduct, –InternalRot. +LogRollSign (Guarding on InternalRot). ±Limp +Pain.
Ix: FBC, ESR, Temp (3/4 Kocher’s for SA) +XR ±USS.
Mx: Ibuprofen + Paracetamol + Rest (Self-limiting). Make sure they are referred if <3y (SA), >9y -InternRot (SUFE), or other red flags.
(Legg-Calvé-)Perthes’ Disease
Epi: 10.8/100,000 white people. Varies massively between ethnicities (0.45/100,000 black people). Ages 4-8yo.
Aet: Idiopathic Avascular Necrosis of Femoral Head. RF: Low socioeconomic status +Passive smoke ±Hyper-coagulable state. 10% bilateral.
Hx/Sx: Limp + Pain + Limited ROM (Adduction, Flexion, Abdu+Exten due to impingement).
Ix: Bilateral Hip XR: AP + Frog. ±CRP/FBC/ESR.
Mx: <5y: good prog: Analgesia +Containment (FemHead-Acetab) + Checkup. 5-12y: ±Surgical containment ±Salvage (Dig into acetab). >12y: poor prog: Salvage ±Hip replacement once mature.
Slipped Upper-Femoral Epiphysis (SUFE/SCFE)
Epi: 5/100,000 /year in UK. ++Males, Age 10-15y, obese. Bilateral in 20%.
Aet: Growth + weight ±hormones + stress > Sheer force on joint.
Hx/Sx: EXTERNALLY rotated leg + Weight++ ±Trandelenburg’s gait.
Ix: AP + Frog bilateral XR hip.
Mx: Urgent surgical repair ±Prophylactic fixation of contralateral hip.
Juvenile Idiopathic Arthritis (JIA)
Epi: Prev: 1/11,000 of <16yo. ++in F, <6yo.
Aet: ??? - A bit genetic, and considered auto-immune. Systemic, Polyart (>4), Pauci/Oligoart (≤4), JuvRheumArt, JuvAnkyl, JuvPsoriatic.
Hx/Sx: Joint pain, joint swelling, >6w of sx, ?Fever. ±Morning stiffness ±Limp ±Rash ±Uveitis ±Nodules ±Salmon-pink rash.
Ix: FBC + ESR + CRP + ANA + RheumF. ±ACCP ±USS ±MRI.
Mx: All: ±NSAIDs ±IFa-inhibs.
>5 joints: Methotrex ±IA steroids ±Oral steroids.
<5 joints; IA steroids ±Methotrex.
Type 1 Diabetes Mellitus
Epi: 1/3000. 5-10% of diabetics. 10-14y most common age.
Aet: Autoimmune attack on pancreatic islets b-cells. HLA-DR/DQ. Coeliac also HLA-DQ.
Hx/Sx: Recent weight loss. Fatigue. Polyuria+dipsia. ±DKA. ±Abdo pain.
Ix: +Urine dip +Random/2h/Fasting Glucose +HbA1C ±C-Peptide (Distinguishing T1 from others).
Mx: Basal insulin (Long-Acting: Glargine/Detemir) + Pre-Meal: (Short: “LAG”: Lispo/Aspart/Glul) ±Metformin.
Preggo: Insulin ±Metformin +75mg Aspirin.
Henoch-Schonlein Purpura (IgA Vasculitis)
Epi: 1/4000 person-years. Ages 2-10.
Aet: Normally post-viral in children. IgA released and damages vessels.
Hx/Sx: Prev URTI. Non-blanching petechia on legs and bum. ±Arthralgia ±Abdo pain ±Haem/Proteinuria (Microscopic).
Ix: BP + Morning-Urinalysis + Cr/Urea levels (eGFR) ±IgA ±Coag studies ±USS abdo ±USS testicles (?Swelling).
Mx: Only in presence of nephritis:
Mild Steroids ±Azathioprine.
Severe: Cyclophosphamide ±Steroids etc.
Minimal Change Disease
Epi: 1/20,000 children per year
Aet: Typically idiopathic. Hodgkin’s, leukaemia, and Hep B/C can both cause it.
Hx/Sx: Facial + general oedema. >1y & <8y. No heamaturia. Normal BP. ±Recent viral illness.
Ix: Urinalysis. 24h Ur-protein. GFR, USS
Serum –albumin/++lipids, LFTs, compliment. ±Biopsy (“Minimal Change”).
Mx: Steroid every other day x 6w ±Low-salt diet ±Albumin ±Furosemide.
Ster resist: Cyclophosphamide/Tacrolimus.
Acute Lymphocytic Leukaemia (ALL)
Epi: 1/33,000. 75% in <6y.
Aet: Genetic (20% twins) + Radiation + Infection + T21 + Klinefelters + t(9,22) BCR/ABL. B + T cell proliferation.
Hx/Sx: Lymphad ±^^Hep/Splen ±Pallor ±Ecchymosis (bruising) ±Fever ±Fatigue ±Unilateral ^^Testicles ±Bone pain.
Ix: FBC + Smear + U&Es + LFTs + Coags + Marrow + Cytogenetics ±LP ±CT-head.
Mx: Induce: Pred + Cycloph + Vincr + Doxorub. + CNS prophlyaxis: Methotrex.
-CNS: Methotrex
-t(9,22)? > Tyrosine Kinase Inhib.
-Consolidation: Above + Stem-cell trans.
Necrotising Enterocolitis (NEC)
Epi: 7/100 VLBW infants on NICU.
Aet: Breastmilk + Steroids protective.
Hx/Sx: Mother: Drug use/HIV/Choranioamnitis. Child: 3w of life: Vague symptoms ±Abdo distension ±feeding difficulty.
Ix: Baseline bloods (May show ++CRP/WCC). Lying abdo XR: Dilated loops, gas in wall, gas in liver, bowel wall thickening.
Mx: Nill/Mouth. NG tube decompression. IV fluid + 3xAbx (Amox, Gent, Metro) + Analgesia (?Morphine). ±Antifungals with abx.
Intestinal Malrotation
Epi: Clinically evident: 1/6000 live births (Many many more are asymptomatic). 75% in <1yo.
Aet: 6w ges:Herniation > 10w: Return with 90 + 180 degrees = 270 total. Arrest may occur at any point.
Hx/Sx: Bilious vomiting + Abdo pain ±Normal examination ±^^HR ±vvBP ±^^BP.
Ix: Upper GI contrast series ±CT abdo (When no vomiting seen) ±WCC (Long-term Volvulus) ±ABG in severe cases.
Mx: Ladd’s Procedure. Either emergency if sign of ischaemia, urgent if just obstruction. +Cefo as an abx.
Duodenal Atresia
Epi: 1/10,000. T21 associated.
Aet: Presents a few hours after birth. FGF pathways? Mostly unknown. T21 more commonly presents with it.
Hx/Sx: Bilious/Non-Bilious vomit.
Ix: ±USS for antenatal detection. Postnatal: Abdo XR + NG-inflation: Double-bubble sign diagnostic.
Mx: NG tube fluid removal +IV fluids +Duodenoduodenostomy.
Hirschsprung’s Disease
Epi: 1/5000 births. T21 Associated.
Aet: 10q deletion common. 50% inherited RET and ~20% sporadic. Aganglionic submucosal plexus.
Hx/Sx: Vomiting + Explosive Leaky/Fowl stools +Abdo distension –Meconium (/delay >24-48h) ±Fever ±FTF. Can present over a month after birth.
Ix: GSfDx: Rectal Biop. Plan XR Abdo: Air-fluid level seen + dilation of colon. Contrast Enema (Dilated prox + contracted distal).
Mx: Typical: Bowel irrigation + Surgery in 1stW of life. Sometimes: 2-3m of life.
Short segment: Laxatives.
Total Colonic: Illiostomy + Surgery.
Pyloric Stenosis
Epi: 1/333 births. 3-6w old.
Aet: Not sure, less common in East-Asia.
Hx/Sx: ++Male, Non-bilious vomit, projectile vomit, 3-6w old ±Upper abdo mass.
Ix: Palpation can > dx “Olive”. USS. ±ABG (–Cl, ++pH, –K+)
Mx: Fluids + Pyloromyotomy.
Umbilical Hernia
Epi: Common: 75% of <1500g neonates.
Aet: Failure for umbilical ring to close.
Hx/Sx: Clear bulge. Mostly asymptomatic. Present from birth. Easily reducible. ±Sx of Small bowel obstruction.
Ix: Clinical Diagnosis.
Mx: Bowel in hernia (Incarcerated) > Milk + reduction > Surgery next day.
Non-reducible: Emergency Surgery.
Large/Symptomatic: Outpatient surgery @2-3y.
Small/Asymptomatic: Observe until 4/5y then ?Surgery if needed.
Intussusception
Epi: 1/1500. PkAg: 5-7m.
Aet: Lead point (Most common: Payer’s patch) leading to auto-peristalsis/telescoping.
Hx/Sx: Colicky pain ±Vomit (bilious/non-bili) ±Lethargy in waves ±Redcurrant-Jelly stool (late sign). ±Sausage-mass in abdo.
Ix: USS: Doughnut/Bullseye sign. Suspected obstruction/perf: XR. Only do enema if there is no perforation (Risk of Barium peritonitis).
Mx: 1st: Air enema. ±Saline/USS enema (Less experience but good results). ±Fluid Resus. Surgery if perforation/Shock or other CI to enema.
Cow’s Milk Protein Allergy (CMPA)
Epi: 2-8% infants. 0.5% in excl breast-fed.
Aet: Mostly IgE, some non-IgE.
Hx/Sx: Dermatitis, resp signs,
Ix: 2-4w Elimination diet > Challenge w/CMP; No: Egg, milk, peanuts, or soy ±fish ±wheat.
Mx: BrFee-mothers to avoid it in their diet. Excl Breast-feeding ideal. ±ExtenHydrolyFormula ±Amino-Acid-Formula. Severe: Assess whether IgE (?Atopy) > Allergy pathway.
Meckel’s Diverticulum
Epi: 0.3-3% prev. Probably higher, but asymptomatic. <2y = 50% of cases.
Aet: Failure for vitelline duct to close > Fistula/Div. 40-60% have Gastro (+some pancreatic) tissue releasing acid > Damage.
Hx/Sx: Often found incidentally. Bright-red Bleeding + Constipation ±pain ±vomit.
Ix: GSfDx: Tech-99m-Scan (Gastric mucosa). +FBC +USS to begin with. ±CT-Abdo.
Mx: Sx: Surgical removal of div + opposing bowel.
No Sx: Surgical-Incidental: Remove. Imaging-Incidental: Leave alone.
Appendicitis
Epi: 1/400 per year in 10-17y. 2/10,000 <4y.
Aet: Obstruction of appendix: Faecolith (poo stone), stool, ^^Lymphoid, idiopathic.
Hx/Sx: Pain (Gen>Local RIF), Anorexia, N/V ±tense abdomen ±mass ±reduced bowel sounds ±pyrexia.
Ix: FBC + CRP + USS (1st for children/pregnant) +Contrast CT abdo. ±bHCG ±Urinalysis.
Mx: Uncomplicated: Surgery in 24h. Complicated: Emergency appendectomy. +Fluid +Analgesia ±Abx if perforation.
Diarrhoea and Constipation
Epi: 3% of paediatric consultations. ~20% prevalence in US.
Aet: –Fibre, –Fluid, ++Hard stools, ±Motility delay. Vicious-Cycle: Slower transit through colon > ++water-absorption > harder stool.
Hx/Sx: RF + painful poo ± <3 poo/week ±Faecal incont ±Faecaloma +Otherwise healthy ±Anal fissure.
Ix: Clinical dx sufficient normally. ±USS ±XR ±Bloods (If complicated / other dx concerns).
Mx: Diet change ± Osmotic Lax (Movicol [pEG] / Lactulose).
No impaction: ±Stim Lax (Senna).
Impaction: Enema.
Severe + Chronic: ±Appendicostomy continuous flush.
Bronchiolitis
Epi: 3m - 3y. Almost all children show evidence of having been infected.
Aet: RSV infection of multiple smaller airways
Hx/Sx: Wheeze +Cough ±^^Resp Effort ±Poor feeding ±Low-fever ±Rhinitis ±Crackles.
Ix: Pulse ox ±Nose-swab (Enz-Link-Immunosorbent-Assay (ELISA) ±CXR.
Mx: ±Fluids ±O2 ±Ribavirin in SEVERE cases.
Palivizumab prophylaxis in high-risk patients.
Episodic Viral-Induced Wheeze
Epi: Common. Figures can’t be found.
Aet: Background smoke, Prematurity. Rhinovirus, RSV, Coronavirus, Parainfluenza, Adenovirus. Is a blend of bronchiolitis and asthma/MultTriggWheeze.
Hx/Sx: Multiple episodes (> 4/ year). Well between episodes. Coryza. Presents to hospital if >6 puffs Sal every 4h.
Ix: Dx clinical; Consider XR if sx asymmetrical or atypical.
Mx: 2-4x Salbutamol/Spacer every 4h ±Maintenance 3m-TRIAL with ICS then Montelukast ±Oral steroids ONLY if signs of atopy or previous severe (Req O2) wheeze.
Asthma
Epi: 8.5% of Children in USA.
Aet: Pretty much the same as “Multi-Trigger-Wheeze” in <5s. IgE mediated. Up to 75% genetic.
Hx/Sx: Wheeze w/Triggers. ±Atopy. ^^Work of Breathing ±Night Cough +Reversible ±Intermittent Sx ±Diurnal.
Ix: Spiro (FEV/FVC < 0.9). Reversible (>12% increase in FEV1). ±CXR ±Peak-Flow ±DDx Ix. ±Growth Monitoring (steroids).
Mx: 0-5y: -1: SABA -2: >3x/week: +Mod-ICS trial x8w. -3: Stop Mod-ICS
-4: Did sx go away then come back?
Yes: Start long-term Low-ICS.
No: Consider other dx. -5: Add LTRA. -6: Stop LTRA and refer.
>6y: SABA > Low-ICS > LTR > Med-ICS+SABA OR Low-ICS+LABA.
ACUTE: SABA x10 puffs (/30-60s) and switch to O2Nebs when possible + 3-5d PO Steroids. Worsening: “Oh Shit I Hate Asthma Mx”.
Croup
Epi: 15% all LRTI in kids. 6m-3y peak.
Aet: Parainfluenza. Inflammation of upper+lower airway. Previously: Diphtheria (Now vaccinated).
Hx/Sx: Barking cough ±Stridor ±Resp Effort. ±Sx worse at night. ±Late-autumn.
Ix: Clinical dx. Rarely would you XR neck, if complicated: Steeple Sign.
Mx: Single Dose Oral Steroids ±O2 ±Fluids. Severe: Nebulised adrenaline. Life-Threat: Intubation. Try best not to scare the child.
Whooping Cough (Pertussis)
Epi: <1/100,000 incidence.
Aet: G(-), Pertussis bacteria. Usually Vaccinated against (8,12,16w+3-5y). Highly contagious in unvaccinated. 4-21 incubation. Irritation of cilia.
Hx/Sx: 2-3d Flu-Like sx. Bouts of coughing followed by inspiratory whoop ±Post-cough vomit ±Apnoea ±Unvaccinated.
Ix: Nasopharynx swab +Culture +NAAT. +FBC (++WBC) ±CXR.
Mx: Macrolides (Clarythromycin) +Monitor for PyloricStenosis in <1m. >1m: Macrolides or Co-Trimoxazole if CI.
>21 since cough begins; No abx.
Epiglossitis
Epi: <1/100,000 /year. Decreased due to vaccination.
Aet: Usually due to Haem-Influ-B. Other pathogens (Strep Pneu. Staph. A) and trauma can precipitate.
Hx/Sx: Sore Throat +Stridor +Dysphagia +Fever +Toxic-appearance ±Tri-podding ±Drooling ±Non-vaccinated.
Ix: Laryngoscopy IN THEATRE ±Lateral-Neck Radiograph: Thumb sign. ±FBC ±Cultures.
Mx: Secure airway +Abx ±O2 ±Oral steroids every 6-12h.
Otitis Media
Epi: PkAg: 6-15m
Aet: 4d-1w infection. SrepPneumo. Can have chronic issues with Eustachian tube (T21/Cleft-Lip etc). >6w: Chronic?
Hx/Sx: Pain ±Coryza ±fever ±malaise +Inflamed TympMem ±Conductive Hearing loss. Mastoiditis: Swelling behind ear.
Ix: Swabs ± Tympanometry: Minimal movement (Flat curve).
Mx: Seriously/Systemically unwell / <2y: Abx (5-7d Amox or Claryth). Otherwise: Safety-netting ±Delayed abx. ?Mastoiditis: Hospital +IVAbx. ±Gromit if chronic.
Otitis Externa
Epi: Lifetime incidence of 10%.
Aet: PseudomonasAer (20-60%) +S.Aureus (10-70%). Abnormal pH, moisture, heat can cause it- Making it ++In swimmers.
Hx/Sx: Acute ear pain +Ear-canal swelling/redness/tenderness. Malignant: granulation tissue seen. ±Ottorhoea ±Itching.
Ix: PneumaticTests/Tympanometry (Normal if OtEx, abnormal w/OtMed) ±Culture ±ESR ±CT (?Temporal bone)
Mx: Ear drops (Abx or Afx). +PainMx.
Necrotising: IVAbx +Debridement.
Tonsilitis
Epi: Bacterial ~1/50-1/35. PkAg: 5-15y.
Aet: Bacterial: StrepPyogen (GAS). More commonly viral: Rhino/Adeno ±EBV.
Hx/Sx: Pain on swallowing ±Exudate(+1) ±Fever >38(+1). ±Headache ±Erythema/Swelling ±Anterior lymph-node swelling(+1) and NO COUGH(+1) =bacterial.
Ix: Clinical Dx (Centor Criteria) ±Throat cultures ±WBC (?EBV).
Mx: Analgesia.
Bacterial: 10d Phenoxymethylpenicillin ±1 dose steroid.
Recurrent bacterial: Tonsillectomy.
Congenital Diaphragmatic Hernia (CDH)
Epi: 1/2500 babies.
Aet: Bochdalek (90% - posterior) / Morgagni (Anterior). Mostly polygenetic, but still idiopathic.
Hx/Sx: Difficulty breathing ±Cyanosis ±Tachycardia ±Abnormal Chest development. Commonly associated with CHD.
Ix: 60% Diagnosed antenatally (Anomaly USS scan). +Echo (Ante/Post) ±MRI (Ante) ±CXR (Post) ±ABG.
Mx: AnteDx: Get to specialist hospital. Early ventilation +NG-tube +analgesia +arterial access. Stop Pulm hypertension then surgical repair.
Breast Cancer
Epi: 24% of female cancers. 40% of these are metastatic. 1/5000/year for In-Situ. Lifetime risk: 12%! PkAg 74y.
Aet: Often oestrogen-related. In situ (85/100 of these Lobular, 15/100 ductal) or metastatic.
Hx/Sx: RF: FHx, HeredDiffuseGastricCancer, Klienfelter’s, Nulliparity/^^MenopauseAge. DISCHARGE ±Lump ±NippleEczema ±Ulceration ±Pau d’Orang. Met: ±BonePain –Weight ±SOB.
Ix: 3x: Palpation +Mammography (?Calcifications)/USS(?Cystic/Solid) +Core-Bio: ?Necrosis ?Grade.±Hormone-tests ±Genetic-tests.
Screening: 1y (45-54y). 2y (>54y).
Mx: Ductal: LowRisk: Excision ±Further. HighRisk: Mastectomy ±AxLymph-Staging ±Radiotherapy ±EndoTherapy (Tamox/Aromat). Lobular: LowRisk: EndoTherapy. HighiRisk: Bilateral breast removal.
Metastatic: EndoTherapy. HER2+: Pertuzumab. Triple-Negative: Chemo.
Breast Abscess
Epi: 3-11% of women with mastitis (So 0.03%-1.1% of lactating women). 50% Infants with neonatal mastitis will develop a breast abscess.
Aet: ±Infective. Staph. Aureus most common. ±Poly-microbial. Lactational mastitis when breast-feeding.
Hx/Sx: ±Fever ±Reduced milk. ±Warmth ±Tenderness ±Firmness ±Fluctuant Mass.
Ix: GSfDx: Needle Bio w/USS: Purulent fluid. USS: Check underlying abscess. Discharge cytology. Refractory/Recurring: Biopsy.
Mx: Multiple needle aspiration +Milk-Removal (?Pump) + Pain-relief +Flucloxacillin (or Clinda) x10-14d.
Mastitis
Epi: 1-10% prev in lactating-women.
Aet: Staph. Aureus most common. ±Poly-microbial. Lactational mastitis when breast-feeding.
Hx/Sx: ±Fever ±Reduced milk. ±Warmth ±Tenderness ±Firmness ±Mass (Abscess = Fluctuant)
Ix: GSfDx: Needle Bio w/USS: Purulent fluid. USS: Check underlying abscess. Discharge cytology. Refractory/Recurring: Biopsy.
Mx: Milk-Removal (?Pump) + Pain-relief.
>24h / too painful after this: Flucloxacillin (or Clinda) x10-14d ±Topical Anti-fungal + Above.
Breast Ductal Ectasia
Epi: 5-9% non-lactating women
Aet: Ageing, smoking, nipple inversion; All leading to breast duct obstruction.
Hx/Sx: Green/Dirty-White discharge.
±Thickening/Lump ±Redness +Tenderness ±Inverted nipple.
Ix: Examination ±USS ±Mammogram.
Mx: May self-resolve. ±Abx (10-14d) ±Analgesia ±Surgery if not resolving.
Cervical Cancer
Epi: ~1/10-20,000 women die /year.
Aet: HPV 16/18 - 70% of cases - Infection usually resolved in 2y. E6/P53 + E7/Rb. Early sex, Multiple Partners, HIV, cigarettes, COCP. –SocialEcoStat.
Hx/Sx: Abnormal Vag Bleeding ±Post-coital bleeding. ±Backpain ±Mass ±MaligSigns.
Ix: GsFDx: Biop. ±Other imaging in atypical / staging. Screen: HPV(+)> Pap: ASCUS (AtypSquamCellUndetSig) (+)> Colposcopy.
Pap(-)> 1y > HPV(+)> 1y >HPV(+)> Colposc.
HPV(-)> 3y(<50) / 5y(>50).
HIV = Every year.
Mx: Staged (I)A-(IV)B. FertilityPrez: Cold-Cone biopsy / LETZ ±LymphNodes for (I)A1, (I)A2, (I)B1. FamFinished: Radical Hysterectomy >(I)A2 ±Lymphs ±ChemoRadio (Cisplatin).
Ectropion
Epi: 17-50% of women at some point.
Aet: Oestrogen > Cells from cervical canal are outside the opening. COCP / Pregnancy / Hormone change.
Hx/Sx: ±Non-purulent discharge ±Inter-menstrual bleeding ±Post-coital bleeding.
Ix: Clinical dx, picked up on specula or colposcopy.
Mx: Leave alone or if severe: ?Discontinue COCP
?Cryotherapy ?Ablation. Postpartum: Observe after 3m.
Ovarian Cancer
Epi: 1/10,000 women per year. PkAg: 63.
Aet: BRCA1/2. HNPCC. Spreads through peritoneal cavity >Liver/Omentum/Others.
Hx/Sx: Mass ±Ascites ±GI sx ±UrinaryFreq/Urg ±Pain. (Meig’s: Pleural effusion/Ascites/Benign).
Ix: GSfDx: Biop +TransVag Pelvic USS
+CA-125 ±PET/MRI/CT.
Mx: Surgical Removal + Debulking (from other organs, also stages the disease).
+Platinum-Chemo in stage 2+ or not-for-surgery.
Ovarian Cyst
Epi: 7% of women at some point. A lot self-resolve without symptoms.
Aet: Follicular, Corpus Luteum, or Lutein cysts. or Physiological, Infectious, BenignNeo, MaligNeo.
Hx/Sx: Pelvic pain ±early satiety ±bloating ±adnexal mass. ±Tamoxifen ±1st-Trim? ±^^LH/FSH?
Ix: TV-USS: Large ovary, may be cystic, solid, or mixed. ±CA-125 ±Pregnancy-test ±MRI/CT. “Risk of Malignancy Index /250)
Mx: Acute/HaemoUnstable: Laparotomy + Fluid resus ±Doxy+Cefoxitan.
<10cm and stable: USS in 3m, conservative ±COCP.
>5cm in PreMen: 6m USS.
>1cm in PostMen: 6m USS.
Malignancy suspect (All cases in post-menopausal): Laparotomy + Onc review.
Ovarian Torsion
Epi: ++Women of reproductive age. 56% have an ovarian mass.
Aet: Large ovaries (Cysts, pregnant (1/2000), OHSS (1/33) ±Long FallopianTube. More common on right (Rat = 3:2).
Hx/Sx:Pain(Acute/Chron/Intermittent) ±Radiation(Back,Groin,Flank). ±N/V/D ±Tender ±Mass ±Strenuous movement ±Fever.
Ix: Pregnancy Test (?Ectopic), Urine (?Renal), FBC (++WCC in torsion, –Hb: ?RuptEctop) CRP (++In torsion) TV-USS: ±Mass ±Whirpool sign.
Mx: Surgery: 1: Detorsion OR salpingo-oophorectomy if unviable ±2: Removal of cyst/tumour.
Polycystic Ovarian Syndrome (PCOS)
Epi: 6-13% of women of reproductive age. 90% of hyperandrogegism in women.
Aet: ?Hypothalamus issue ?Primary ovarian > ++LH. Insulin > +Androgen? > Insulin resistance?
Hx/Sx: Irregular Mens ±Infertility ±Hirsutism ±FHx. Sx typically start at puberty (Unless COCP) ±Acne ±Obesity ±HTN.
Ix: Ser-17HydroxyProg: R/O AdulOnset-21-Hydrox-Def (NCAH) +Ser-Prolactin: R/O hyperprolactinaemia +OGTT +Fasting lipids +TFTs ±Testosterone ±USS-Pelvis (After period): Polycystic; however not specific.
Mx: Weight-loss, metformin, COCP (FamFinished).
Letrozole/clomifene ±FSH/LH/GNRH therapy (WantKids).
Ovarian Hyperstimulation Syndrome
Epi: 0.5-5% of women on fertility Tx.
Aet: More common with gonadotrophin therapy, rarely seen with Clomifene. ++VEGF > ++Vascular permeability & ++Cytokines.
Hx/Sx: Mild: Abdo pain/bloating. Moderate: Mild N/V. Severe: Clinical ascites +Oliguria ++Haematocritt –Protein. Critical: VTE + ARDS + Anuria.
Ix: USS cysts/ascites +U&Es +Protein.
Mx: Hydration ±Paracentesis +Anti-emetics +Analgesia ±Electrolyte correction. +Delay pregnancy. AVOID NSAIDS / Teratogens.
Premature Ovarian Failure/Insufficiency
Epi: 1/100 females before age 40. 1/250 before age 35.
Aet: Def: ++Gonadotrophins (–Oestrogen) and sx of menopause before age 40. Idiopathic, bilat-Oophorectomy, mumps, chemo, radiotherapy.
Hx/Sx: ±FHx +Menstrual irregularities ±Hot flushes ±Poor sleep ±Vaginal Dryness ±Infertility.
Ix: BhCG test +Ser-FSH/LH/E2ol +TFTs +Ser-Prolactin +TVUSS (Ovarian dysgenesis?). +Others for rarer disease (Turner’s/FragX).
Mx: 1. Cyclic combined HRT for 1 year or if there are any “breakthrough bleeds” then 2. Continuous combined HRT. ±Testost (Libido + Bone-health) ±Donor oocyte (When on cyclic).
Endometrial Cancer
Epi: 1/4000 women. PkAg 63y.
Aet: Chronic oestrogen, unopposed > Endometrial Hyperplasia. (Obesity, PCOS, Tamoxifen, exogenous are all sources of this).
Hx/Sx: Uterine mass ±Abnormal PV bleed (inc post-menopausal) ±Pain ±Weight-loss ±Metastatic Signs/sx.
Ix: GSfDx: Biop ±Hysteroscopy (Adenocarc). TVUSS +FBC (bleed) +PapSmear + ±MRI/PET/CT
Mx: Standard: Surgery (Uterus, Ovaries, ±Nodes dependent on stage) ±Radiotherapy (Stage IB+) (External Radio or Vaginal Brachytherapy).
Preserve fertility/Frail (rare): Progesterone (Megestrol) + Aggressive Monitoring ±Careful surgery in young.
Pelvic Inflammatory Disease (PID)
Epi: 16-30% women have had an episode. PkAg: 20-24y.
Aet: 30% due to Chlamyd (G-Rod). Also NeisGonorr(G-Coc), Mycoplas, GardnerVag, H-Influ, StepAgal. Begins in cervix and ascends. +Iatrogenic (Dilat+Currit).
Hx/Sx: RF: ++UPSI. +VagTenderness +CervicalMotionTenderness ±Fever ±LowerAbdoPain ±Discharge. ±RUQ pain (Fitz-Hugh-Curtis Synd).
Ix: WCC (++) +NeutrophilSmear (Good PPV) +GeneticProbe/Culture for Neiss/Chlamyd +Nucleic-Acid-Amp for Mycoplasma. ±TVUSS/MRI.
Mx: Ceftriaxone x1d (Neiss Gonorr) +Doxy x14d (Chlamyd) +Metro x14d (Others). SexPartner Prophylax. Manage potential infertility. PROBABLY don’t remove IUD.
Endometriosis
Epi: ~1/10 women of reproductive age. PkAge: 18-29y.
Aet: Retrograde Menstruation (Endomet > Peritoneum) + –CellMediatedImmunity + Vascular/Lymphatic dissemination ±Mullerian abnormalities (poor outflow).
Hx/Sx: RF: +FHx. Dysmenorrhaea (±2d before “Secondary Dys”) ±ChronPelvPain ±Subfertility ±FrozenPevlis (Retrovert) ±Dysuria/FlankPain/Haematuria.
Ix: GSfDx: Laparoscopy + Biop. TVUSS: endometroma / UteroSacLig Nodularity. ±RectalUSS ±MRI.
Mx: 1. NSAIDs (E.g, Mefanamic Acid)/Analgesia.
FamFinished: 2.COCP / Mirena / OtherProgesterone. 3. GNRH antag 4. Hysterectomy.
WantKids: Controlled Ovarian HyperStim (Clomifene/Letrozole) ±IVF.
Adenomyosis
Epi: 1/4 women. PkAg: 35-50.
Aet: Endometrial Tissue in the myometrium. Breakdown of junction between endo + myometrium: C-Sec, Pregnancy, SurgicalTermination.
Hx/Sx: Dysmenorrhea, Menorrhagia, Large uterus, ChronPelvPain, Dyspareunia.
Ix: GSfDx: SurgicalBiop (Often not done). 1st: TVUSS/MRI.
Mx: NSAIDS + Hysterectomy or GnRH agonists / Mirena / Progesterone. Tranexamic acid if not wanting the above.
Uterine Fibroids (Uterine Leiomyomas)
Epi: 1/4 women >30y. ++In Black women.
Aet: A single mutated myometrial cell > Single fibroid. Multiple are all de novo (It is benign/in-situ). Oestrogen + Progesterone involved.
Hx/Sx: Asymptomatic ±HeavyMenBleed ±FirmPelvicMass ±PelvPain ±Dysmenorrhea ±Bloating ±Constip ±Infertility ±Dyspareunia. Red degeneration occurs in 1/2Trim (Temp, Pain, N/V).
Ix: TVUSS and AbdoUSS + EndoBiop (Look for carcinoma, instead of leiomyoma). ±Hysteroscopy ±MRI.
Mx: GnRH agonist ± Anti-Progesterone (Mifepristone) or Mirena. ±NSAIDs ±TranexamicAcid.
FamFinished: UterineArteryEmbolisation / Hysterectomy.
Uterine Prolapse
Epi: ~40% post-menopausal women.
Aet: ++Age, Multiparity (Vag delivery), Obesity, Spina Bifida - Weakness in PF-Muscles/Ligaments.
Hx/Sx: “Dragging”/”Coming Down” ±Dyspareunia ±Bleeding ±Urine Incontinence/Frequency/Urgency.
Ix: Clinical Dx.
Mx: LifeMod: –Smoking, –Weight. Cons: Kegels / Pessaries. Surg: Hysterectomy / Uterine-suspension surgery (Mesh from Sacrum>Uterus).
Menopause
Epi: 100% of women. PkAg: 51y.
Aet: –Ovarian production of Oes/Prog/Testosterone. –Fertility.
Hx/Sx: Amenorrhoea +Irregular MenCycle +HotFlush +NightSweats +MoodChange +Vaginal Dryness/Itching. ±Issues with Sleep/Memory. ±HeavyBleeding.
Ix: hCG-Test ±FSH (++ >30). (Only women <45y) ±E2ol (Extra testing not always needed beyond hCG).
Mx: Contraception for 12m if >50, 24m if <50.
–Weight, ++Exercise. Continuous E2 + 14d on/off progest (Sequential). ±SSRI ±Gabapentin.
Infertility
Epi: 6% of 15-44y women have difficulty after 1y of trying.
Aet: Issues with: 30% sperm. 25% ovulation, 15% tubal. 10% uterine. 20% idiopathic.
Hx/Sx: >35y fecundity. ±Hirsuitism ±Hx pelvic surgery ±IrregMenst ±dyspareunia.
Ix: Semen analysis, chlamydia screen, BMI (PCOS/AnOv), SerLH/FSH on d2-5 (?PCOS). SerProg on cycle-7d (Confirm Ovulation). TFTs, Prolactin, Rubella immunity ±TVUSS.
Mx: 400mcg folate acid. –Weight / Alcohol / Smoking + Sex every 2-3d. ±IVF ±Menotrophin/Lutropin (–Pit/Hypothal) ±Metformin (PCOS) ±Clomifene/Letrozole (if pit/hypothal are fine). ±Surrogacy (Damaged uterus).
Vulvo-Vaginal Candidiasis / Thrush
Epi: ~75% of women will have 1 infection in their life.
Aet: Albicans. Pregnancy / DM / Broad-Abx / Steroids / Hormone pills.
Hx/Sx: Thick, odourless, white discharge. Itching ±Discomfort ±Fissures ±Redness ±Dysparaunia ±Dysuria ±Excoriation.
Ix: pH with swab; <4.5. GSfDx: Charcoal swab + microscopy.
Mx: Antifungal: 1x Clotrimazole cream or 1x Clotrimazole pessary or 1x Fluconazole tablet. Recurrent (>4/y): 6m regime oral/vaginal antifungals. ++Alternate Contraception.
Bacterial Vaginosis
Epi: 30% 14-49y women in US.
Aet: Anaerobic bacteria. Loss of lactobacilli (Thereby ++pH >4.5). Can ++Risk of STIs. Gardnerella Vaginalis, Mycoplasma Hominis.
Hx/Sx: Fishy-smelling grey/white discharge. ±Hx of douching/Soap-washing. NOT TYPICALLY ITCHY. ±Complications in pregnancy (PPROM, LBW, Chorioamnionitis).
Ix: High-vaginal charcoal swab OR Low swab (Clue Cells). pH paper (>4.5). ±Other infections.
Mx: Normally no treatment needed. ±Metronidazole (anaerobic bacterial) + Avoid alcohol (Disulfiram-like-R) via oral/vaginal gel. ±Clindamycin.
Trichomoniasis
Epi: 3% general US population affected.
Aet: Protozoa (4 flagella front, 1 one back). Lives in urethra/Vagina. ++Risk of HIV + other infections.
Hx/Sx: 70% asymptomatic. ±Purulent/Yellow-green+Frothy ±Fish-smell ±Itching ±Balanitis (men). STRAWBERRY CERVIX.
Ix: GSfDx: Charcoal Swab from post fornix + Microscopy ±pH strip (>4.5). UrethralSwab / First-catch urine in men.
Mx: Metronidazole oral x1 +Tx sexual partners.
Chlamydia and Gonorrhoea.
Epi: In USA: 1/200/y Chlamyd. 1/500/y Gonorr. PkAg 15-24y.
Aet: 58% transmission M->F after one single UPSI (23% F->M) for Gonorr. Chlamyd Incubation: 7-21d (Gonorr: 3-4d).
Hx/Sx: ±Asymptomatic (++Chlamyd) ±PurrDischarge (Gonorr) / Yellow Discharge (Chlamyd). Epididymitis in Gonorr. ±Dysuria ±Pelvic pain ±Can’t pee/see/climb a tree (++In Chlamyd).
Ix: GSfDx: NAAT Swab (1st-Urine/Urethral/Vaginal) ±Oropharyngeal Swab. HIV+Syphilis bloods. Charcoal swab/1st-urine for MCS. ±TVUSS/MRI for PID.
Mx: Gonorr: Ceftriaxone IM x1 (Gent IM+ Azithromycin PO if allergic).
Chlamyd: Doxy PO BDx7 (Erythromycin in preg/breast-feeding).
Syphilis
Epi: 1/10,000/y primary + secondary.
Aet: Trep Pallidum. Can spread oro-genitally (So condoms may not prevent). 30-60% risk after UPSI. 10% of untreated get tertiary.
Hx/Sx: Prim: One painless ulcer (Chancre). Secon: Widespread vasculitis (MacPapRash) which resolves. Tertiary: Neuro/Gummatous/Cardio: Tabes Dorsalis (Ataxia, incontinence, –Proprio/vibration) +AorticRegurg.
Ix: GSfDx: Microscopy from lesion x3 (Often imposible). ±LP/Echo/CXR/HIV/FBC.
1: Trep-Test: Enzyme-ImmunoAssay (EIA) or TPPA/TPHA: Remains (+) for life.
2: Non-Trep-Test: Ser-Reagin (RPR) OR VDRL: Only (+) in active infection; Low sensitivity, though.
Mx: Empirical IM BenPen x1 (Or Doxy PO BDx14).
NeuroSyph: BenPen IM 1/week x1-3 (Or Doxy PO BDx28). ±Steroids.
HIV
Epi: 1/10,000/y new infections. 57.6% heterosexual. 10% MSM. 22% IVDU.
Aet: HIV1 (More progressive). HIV2 (Less progressive, more in West Africa). CD4+ T/Macrophages. 0.1%/contact Hetero transmission. ->Immunodeficiency.
Hx/Sx: Fever/Night Sweats, –Weight ±Rash ±Oral Ulcers ±Diarrhoea ±Kaposi’s Sarc ±Multi-dermal-Shingles ±CMV ±Lymphomas.
Ix: After window period of 12w: ±ELISA (EnzLinkedImmunoSorbAssay). ±RapidTest ±WesternBlot (Protein) ±CD4-Count (<200 = AIDS. >500 = Asymptomatic). Ser-ViralLoad. ±hCG (Before antiretrovirals). +HepC +Tuberculin ±CXR (PCP) ±LFTS ±IgG Toxoplasmosis/HepA.
Mx: ART: DoluTEGravir (InTEGrase Inhib) + Abacavir (Rev-Transcriptase Inhib [Goes BACk]) + Lamivudine (Rev-Transcriptase Inhib). +Prophylaxis of other infections (Vaccines).
Ectopic Pregnancy
Epi: 1/100 pregnancies. 1 death / 200,000 pregnancies.
Aet: 6-8w after LMP. RF: PriorEctopic, TubalSurgery, STIs, IVF, IUD, Smoking.
Hx/Sx: AbdoPain +Amenorrhea +VaginalBleed +AdnexalMass +Blood in VagVault. ±HaemodynInstability ±ShoulderPain ±NeedPoo.
Ix: hCG (Normally x2 in 48h) +TVUSS +AbdoUSS (Locate). ±Serial Ser-hCGs (Normal pregnancy = Large increase).
Mx: hCG <1500 (Ideally <1000) & FALLING & <35mm: Expectant.
Failed Expectant & hCG <5000 & <35mm : Methotrexate.
Ruptured/HeartBeat/Other: ±FluidResus +Surgery ±Metho ±Anti-D-Prophylaxis.
Gestational Trophoblastic Disease (GTD) / Hyatidiform Mole
Epi: 1/1000 pregnancies.
Aet: 46 XX/XY / 69 XXX/XXY. 2 copies of paternal DNA with 0/1 copies of maternal. Previous mole: 1-2% risk in future.
Hx/Sx: ^^Uterus for GestAge +MissedPeriod +1stTrimester +VagBleed ±Severe N/V ±Pre-Eclamptic ±Thyrotoxicotic.
Ix: Ser-hCG (Normal = x2/48h) +FBC +PT/PTT +LFTs/U&Es +ABO-Rh (?Haemorrhage) +USS (Snowstorm) +TFTs (?Thyrotox) +CXR (?Metastatic).
Mx: CervDilat +Oxytocin +Suction +LargeCannula (±Blood ±Abx) +STRICT Contraception x12m.
Thyrotox: b-Blocker.
Pre-Ecl: Labetolol/Nifedipine + MgSO4.
ViableTwin: Expectant +CloseMonitoring (Unless choriocarcinoma).
Miscarriage
Epi: Up to 30% of pregnancies.
Aet: 80% 1stTrimester. Majority: Embryonic Disease (Cr diseases). MaternalFactor: ++2ndTrimester, due to damage, infection, immunology (Anti-PhosLip), fibroids, etc.
Hx/Sx: Moderate-Severe bleeding = 18x risk than pts without these. ±Suprapubic/Back pain ±Post-coital bleed ±Trauma.
Ix: TVUSS ±Serial Ser-hCG: >50% fall in 48h = Failing. >50% rise = ?Ongoing. hCG test (+) upto 21d after miscarriage. ±FBC ±LupusAnticoag (AntiPhosLip) ±VagSwab ±ParentKaryotype.
Mx: All: Paractemol ±Anti-D-Prophy if >12w.
Threatened: Preservation attempt = Progesterone until 16w.
Inevitable: Seen in Cervix/Vag: Manual ±Misoprostol. >15mm: Suction +Abx ±Oxytoc.
Stillbirth
Epi: 1/200 pregnancies.
Aet: Dead foetus >24w since LMP. Idiopathic / Pre-Eclampsia / PlacAbruption / ObstetCholeo / Rubella/Parvo/Listeria / MultPreg.
Hx/Sx: ±Pain, +Reduced foetal movements, +VagBleed. RF: Smoking, Alcohol, sleeping on back.
Ix: USS (?Heartbeat). +Investigate RFs.
Mx Anti-D-Prophylaxis + Counsel + DopamineAgonist (Suppress lactation) +Mifepristone/Misoprostol (Stimulate Labour),
Termination of Pregnancy
Epi: 1 abortion /50 women /year recorded in the UK.
Aet: <24w legal if will cause woman or immediate family mental/physical health issues. >24w if substantial risk of baby abnormalities / Threat to mother’s life/Physical health.
Hx: Can cause: Bleeding / pain / infection. Abortion can fail. Can damage uterus/cervix.
Mx: <10w: Telephone + Home kits.
Rh-: >10w&medical OR Surgical: Anti-D.
Medical: Misoprostol (Anti-Prost) & Mifepristone (Anti-Proget - Not used in UK) Less preferred at later gestations.
Surgical: Dilation (Osmotic, Miso/Mife) + Suction (<14w) OR Forceps (14-24w).
Placental Accreta (+Increta +Percreta)
Epi: 1/300 deliveries.
Aet: Previous accreta / C-sec / surgery. ++Multigravida ++Maternal age. Acc: Superficial Myo, Inc: Deep Myo, Per: Perimetrium.
Hx/Sx: ±Antepartum Haemorrhage ±Significant PPH and difficulty delivering placenta at birth. Generally asymptomatic otherwise.
Ix: Antenatal dx w/ USS. ±MRI for extent of invasion.
Mx: Plan deliv for 35-36+6w +Steroids x7d before if <34w.
Found incidentally in C-sec: Close + Delay delivery so services can be put in place.
During C-Sec: Hysterectomy / Preserving Surgery.
Placental Praevia
Epi: 1/200 pregnancies.
Aet: Scarring, ++Age, ++Pregnancies, ++Tobacco. Placenta 100% covering cervical os. Haemorrhage at birth +Death x2 if untreated. Low-lying = <20mm from os.
Hx/Sx: Asymptomatic to 36w, >36w: ±Painless bleeding ±Low BP.
Ix: 18-22w Anomaly scan (+)THEN 32w (+)THEN 36w USS . ABO-Typing. FBC.
Mx: Steroids if <34w. Plan C-sec at 36-37w. ±Anti-D.
Bleeding ±Instability: Resus + Stabilise ±C-Sec if persistent.
Preterm: Prevent labour w/Tocolytics.
Term + Stable OR Pre-term + Labour: C-Sec.
Placental Abruption
Epi: 0.3-1% of births.
Aet: Direct/Indirect Trauma ±Cocaine (Vasospasm). Can be concealed / apparent.
Hx/Sx: ±Bleeding +Pain +Tenderness +Woody Uterus +High-Freq-Low-Amp contractions.
Ix: Foetal Monitoring +Hb/Hct +CoagStudies ±USS.
Mx: Monitor + Stabilise: Keep Hb >100 ±Tranexamic Acid ±Anti-D ±Post-delivery Oxytocin (Tonic).
<34w Reassuring: Vag delivery @37-38w + Steroids.
>34w Reassuring: Vag delivery (Membrane Sweep +Oxytocin).
Non-Reassuring: C-Sec.
Premature/Preterm Pre-labour Rupture of Membranes (PPROM)
Epi: 30% all preterm deliveries.
Aet: <37w rupture of amniotic sac.
Hx/Sx: ++Water breaking.
Ix: Speculum: Pooling of amniotic fluid in vagina. Monitor CRP/FoetalHR/WCC for chorioamneonitis.
Mx: ≤10d (or until labour) Erythromycin.
<34w: Steroids + Monitor ((±Tocolytics)).
<32w: Above + MgSO4 (Foetal Brain).
>34w: Deliver (Try to get to 37w).
Pre-Eclampsia
Epi: 2-8% of pregnancies worldwide.
Aet: Placental spiral arteries maladaptation > Systemic HTN > vascular dysregulation of liver/brain. Assoc with DM, GTD, and MultPreg.
RF:
Hx/Sx: >20w gestation. Prev Normotensive & BP >140 / 90. Headache ± Visual disturbances ±UpperAbdoPain ±FGR ±Oedema ±Breathlessness ±Oliguria ±Clonus/++Reflex.
Ix: Urinalysis (?Protein) +Foetal USS +UmbilicalArteryDoppler (?No End-Diastolic Flow)- Repeat 2x/w. +CTG +FBC (Platelets) +LFTs +Ser-Cr (RFT) ±Coag Screen.
Mx: Aspirin Prophylaxis from 12w gest: 1 mjr RF or 2 mnr RFs.
Hospital > Stabilise >
>37w = Deliver.
<34w = Don’t deliver ±Steroids @34-36 (Patient-based). Deliver if no improvement with other interventions.
HTN: 1. Labetolol, 2. Nifedipine, 3. Methyldopa, 4. Hydralazine (Severe) - Switch this to Enalapril/Nifedipine after birth.
+ MgSO4 (<32w for Baby +Seizure prevention).
HELLP Syndrome / Eclampsia
Epi: 10-20% women with severe pre-eclampsia develop HELLP.
Aet: HELLP: Haemolysis, Elevated Liver Enzymes, Low Platelets.
Hx/Sx: HELLP: N/V, RUQ-Pain, Lethargy. Eclampsia: Seizures
Ix: Ensure it is an eclamptic seizure and not epileptic, via hx + lab results seen in Pre-Eclampsia.
Mx: Seizures: MgSO4 to prevent AND treat- Continue for 48h after last seizure/delivery. too much MgSO4: Give CaGluconate. HELLP: Deliver baby.
Gestational Hypertension
Epi: 2-12% of pregnancies.
Aet: Unknown about precisely why. Belief it is related to insulin resistance in later pregnancy. SVR remains low, Cardiac output goes up.
Hx/Sx: >20w gest. Previously normotensive. Absence of pre-eclampsia symptoms. Normally asymptomatic. RF: Nulligravid, obesity, T1DM.
Ix: BP >140/90. Urinalysis. Baselines: FBC, LFTs, U&E/Cr, Uric acid, and Foetal size (USS).
Mx: Lifestyle mod. ±Antihypertensives: Labetolol, Nifedipine, Methyldopa, and (>160/110): Hydralazine.
Induction of labour if not controlled by 37w.
Gestational Diabetes
Epi: 16.7% of pregnancies.
Aet: HPL + TNFa lead to ++Insulin Resistance, mostly in 3rdTrim.
Hx/Sx: Polyuria, Polydipsia. RF: Previous, FHx DM, Previous macrosomia, ++BMI, Non-White, Old, PCOS.
Ix: OGTT @24-28w. (>5.6 fast, >7.8 2h). HbA1c (Assess whether they had T2DM).
Mx: Fasting <7mmol/L: 2w trial lifestyle then Metformin.
6-6.9mmol/L & ++Hydramnios / Macrosom: OR >7mmol/L alone:
Insulin ±Metformin +Monitoring +Exercise/Weight-loss +USS foetal monitoring (?Size).
Already diabetic before preggo: 5mg Folate.
Obstetric Cholestasis
Epi: 1-2% of pregnancies.
Aet: Most frequent in 3rd trimester; believed to be due to circulating reproductive hormones. FamHx/PrevCholestasis/HepC/Stones = RFs.
Hx/Sx: Itching + Excoriations without rash ±Mild jaundice.
Ix: Ser-Bile Acid + LFTs. ±Coag profile (Vit-K worry) ±USS ±FBC. Repeat some of these.
Mx: Labour induction at 37-38w. ±VitK. ±Antihistamines (for SLEEP, not itching). ±Emolients ±Ursodeoxycholic acid (Ser-Bile-Acid >40)
±Delivery at 35w (Severe: Ser-Bile-Acid >100).
Other Birth Complications:
1. Macrosomia
2. IUGR
3. Breech
4. Cord Prolapse.
5. Vasa Praevia
6. Amniotic Fluid Embolism
- Assoc with GestDiabetes. Shoulder Dystoica; Anterior shoulder on pubic synthesis. Mx: McRobert’s manoeuvre ±Wood-Screw (stuck shoulder down+distal, other up+proximal) ± Epis ±Symphysiotomy. Complications: BrachPlx ±Erb’sPals +FoetalDeath.
- “Small for gest age” = <10th cent. SevereSGA = <3rd. May be “Constitutionally small” which DOES NOT indicate IUGR. Caused: Infec / Anaemia / Malnutrition / Smoking / Alcohol / Pre-Ecl. Can cause stillbirth / NeoHypoglyc / NeoHypotherm.
- 33% <28w THEN 6% 37-40w. Frank (HipFlex, Knee Exten. 70%) OR Complete (HipFlex, Knee Flex). Mx: Tocolytics, ECV (When membranes intact). Failure = C-Sec / Breech Birth(++Complications: Mortality, Cord prolapse).
- 50% when PROM. CTG abnormal + Mass vaginally. RF: Abnormal lie. Mx: Minimal handling, wet, moist; Knee-Chest:All fours or LeftLatPos + Fill bladder. Tocolytics (Terbutaline) + Ideally Emerg-C-sec.
- Umbilical vessels go onto membrane before foetus. RuptureOfMembranes > Bleeding. Risk: Low-lying Placenta. Mx: Steroids <34w. Elective C-Sec 34-36w if found. Bleed = Cat-1-C-Section.
- 1/50,000 deliveries. No clear cause. ++MaternalAge +Induction. High Mortality. ++HR/RR ±Seizures ±MI. Mx: ABCDE- Nothing specific- Get help!
Post-Partum Haemorhage
Epi: Primary: 5-7% of deliveries.
Aet: Primary = >500ml (Vag) / >1000ml (C-Sec) blood-loss in <24h after delivery of baby+placenta. Secondary = >24h-12w. “Tone, Trauma, Tissue, Thrombin”.
Hx/Sx: Bleeding. RF: LongLabour / Prev / Pre-Ecl / Macrosomia / ++Age / Praevia/Accreta.
Ix: Clinical Dx. Clotting screen +FBC +Group/Save.
Mx: ABCDE, O2, WarmIV-Fluids ±FreFrozPlaz (If clotting abnormal).
Uterus: Rub, empty bladder.
Medical: Oxytocin ±Prostaglandin ±Ergometrine (++SmoothMuscle) ±Tranexamate.
Surgical: BalloonTamp > B-Lynch-Suture (Wrap around and tighten) > ArteryLigation > Hysterectomy.
Sheehan’s
Epi: Rare. More common in women giving birth at home.
Aet: PPH = Avasc necrosis of pituitary gland.
Hx/Sx: –Lactation, Amenorrhoea, Adrenal insufficiency/crisis, –Thyroid (All from Anterior Pituitary).
Ix: TFTs, Ser-prolactin, Ser-FSH/LH, Oestrogen. Ser Cortisol/ACTH. ±MRI pit.
Mx: Specialist endocrinologist; Lifelong hormone replacement.
Other Pregnancy Complications:
- Hyperemesis Gravidarum
>5% WL +ElectImbalance +Dehydration
Mx: Ginger > 1. Metoclopromide (D2 Ant) > 2, Odansetron (5-HT Ant) (+Risk Cleft-Palate) ±PPI ±Steroids ±IVFluid. - VZV Infection
1st check Abs if unsure
<20w: Anti-VZV-IVIG
>20w: <24h since rash: 7d Aciclovir. - Hypothyroid in pregnancy
-50% more thyroxine needed
-Thyroxine safe to take.
-Measure TSH every - Post-Partum Thyroiditis
-6-12m TSH tests for ++Risk women (T1DM, LevoThyrox Therapy, FHx), PP-Depression, –Lactation, or Hypo/Hyper-sx. Can go up-normal, down-normal, up-down-normal, or down forever. +Rule out Grave’s (TSH-R). - Anaemia
<110 1st trim, <105 2nd trim, <100 PP: Give iron supplement.
Other Post-Partum Complications
- Hypoglycaemia
- Poor-Feeding:
>10% Weight-loss in 1w since birth = Midwife-lead clinic. - Undescended Testes:
-Bilateral: Urgent Paeds Referral (?CAH).
-Unilateral: Re-Examine at 6-8w, Re-Examine 4-5m. Still there: Refer to surgery.
Enteric Fistulas
Epi: ++In Crohn’s and Diverticulitis.
Aet: EnteroCutaneous (To Skin), EnteroEntero (To other bowel), EnteroVaginal, EnteroVesicular (To bladder)
Hx/Sx: ±Fowl smelling vaginal discharge ±Gas
Ix: ±Barium Contrast ±MRI ±USS.
Mx: Will self-resolve if there is no obstruction. Prevent skin-damage (stoma bag) ±Abx ±Surgery (Especially in RectoVaginals).
Urinary Incontinence
Epi: 40-60% of women.
Aet: Stress: (Weakness Pelv-Floor +Weight): Laugh/Cough/Exercise.
Urge: (More Neurological- ++Detrusor). Or mixed.
Overflow: ++Post-void-Pressure.
Ves-VagFistula: Constant dribbling.
Hx/Sx: Leakage 1. with ++Abdo Pressure or 2. Followed by rapid urgency +Frequency points to UrgeIncont. Bladder Diary (Night+Freq = Urge?). Caffeine / Alcohol / Medicine / BMI.
Ix: Urine dip (?UTI) +BladderDiary +Urodynamics (Pressure + Cough/Running water) +ResidualBladderVolume.
Mx: Stress; –Caffeine –Weight ++Kegels ±Duloxetine ±Surgery (Retro-Pubic Suspension).
Urge: Bladder Retraining ±Oxybutynin ±Botox injections.
Mixed: A bit of both of the above.
Post-Partum Depression
Epi: 1/10 Women. Peaks 3m after birth.
Aet: Baby blues (Most women, Peaks 1w PP), PPPsychosis (1/1000; Peaks 3-4w PP. Less psychotic, more a mix of manic/psychotic ±depressive features - 25-50% chance of recurrence).
Hx/Sx: Low mood +Anhedonia +Low energy.
Ix: Edinburgh Postnatal Depression Scale (10Qs, Score /30).
Mx: Mild: followup. Moderate: SSRI (Sertraline or Parox for breastfeeding) DON’T USE St.JOHNS-W. Severe: ±Specialist input ±Mother/Baby unit.
PPPsych: Mother+Baby unit (25-50% chance reoccurrence).
PreMenstrual-Syndrome (PMS) and PreMenstrual Dysphoric Disorder (PMDD)
Epi: PMS: 3-8% of women. PMDD: 1.5% of women (w/ Strict dx criteria).
Aet: Luteal Phase (Last 14d cycle). Believed to be due to a drop in Oes/Prog; similar mechanism to post-natal depression.
Hx/Sx: –Mood ±Anxiety ±Mood-Swings ±Bloating ±Headaches/Fatigue ±Breast-Pain ±Low Libido.
Ix: Symptom diary x2 Cycles. ±TFTs ±FBC (?Anaemia) ±FSH ±Depression Screen.
Mx: LifeStyle: Exercise, –weight, Relaxation + High-Carb Diet. ±CBT ±NSAIDs ±COCP.
Moderate / Severe: COCP +Low-Dose-SSRI +Above.
Seasonal Affective Disorder (SAD)
Epi: 1-3% in UK, USA, Canada. PkAg 20-30y.
Aet: Depressive and Bipolar disorder associated with season of year. Common in bipolar II disorder. ?Melatonin rhythm?
Hx/Sx: >2y period of season-effected mood. Autumn/Winter depression + Spring/Summer remission. ±Spring/Summer mania/hypomania.
Ix: Clinical + Hx (As above) sufficient. ±Metabolic panel (Mostly TFTs).
Mx: Similar to depression. Psychological +2-WEEK FOLLOWUP. ±SSRIs. DO NOT GIVE SLEEPING TABLETS.
Bipolar sx: Valproate / Lithium.
Depression
Epi: 10.8% lifetime prevalence. F:M = 2:1.
Aet: Leading cause of disability and premature death in 18-44y. ±Genetic ±Gut-Flora. ++Stressful life events. ±Dysreg of Hypo-Pitu Axis ±Abnormal Neurotransmitters. RFs: Propanolol, Post-Natal, Steroids, Dementia, OCPs.
Hx/Sx: DEAD-SWAMP; DeprMood, EnergyLoss, Anhedonia, DeathThoughts, Sleep–, Worthless, Appetite–, Memory–, Psychomotor agitation.
Ix: PHQ-9 / HAD score / ICD10 = Clinical: >2-3/5 CoreSx= mild. 4/5Sx+FunctImpair = Mod. Severe = ??ReallyBad??. +Metabolic panel + FBC/TFTs ±B12/Folate/Cortisol.
Mx: 1. PsychoTherapy ±Antidepressant (<18y: Fluox. >18y: Sertraline); Treat for 9-12m after remission achieved or RELAPSE. Switch drugs with care.
CLASSIC Antidepressant Withdrawal: “BRAIN-ZAPS (±Akin to orgasm??)” ±Hyper-Arousal ±Anxiety ±Dysphoria.
Tx Resistant or Emergency: ECT.
Severe: Psychologist +Above ±Antipsychotic (Psychotic depression) ±Lithium (?Mood) ±ECT.
Suicide
Epi: 1/10,000 /year. M>F.
Aet: High / Med / Low Risk. Link to self-harm.
Hx/Sx: High Risk: Avoid-discovery, Left a Note, Final acts (Finances), Violence. SAD PERSONS: Sex(M), Age(<19/>45), Depres, PrevAttempt, EtOH, –Rational, –SocialSupp, Organised, NoSpouse, Sickness.
Ix: Clinical: Try to stratify risk and enquire what happened. Toxicology? Protective factors?
Mx: Ensure you’re safe. Assess pt safety. Document identifiable features of patient. Remove self-harm objects. Document bruises/marks. Mx underlying illness. Form safety plan.
Overdose:
1. Tri-Cyclic Antidepressants
2. Paracetamol
3. Benzodiazepines
4. Opioids
- 2w of doses enough. Metab –pH, arrhythmia (Long QT), seizures, coma. +AnticholinergicTox: Mydriasis etc. Mx: ECG +ABG. Hypervent, bicarb (++pH and QRS), fluids ±Benzos/Propofol with seizures.
- 50% of poisonings. ++NAPQI to LivFail. N/V, RUQpain, LivFailSigns. –Consciousness. Ix: Ser-Paracetemol, LFTs, INR, Glucose, ABG (?Lac–pH?), FBC. Mx: Activated charcoal <1h. Staggered dose or levels >line of 100@4h to 15@15h: Give Acetylcysteine (++Glutathione). pH <7.3 after 24h: Liver transplant.
- Impaired mental state +Drowsiness +Slurred Speech +Ataxia –Resp ±Coma –TendonReflex. Ix: O2%, ABG, FBC, U&Es, LFTs, ECG (+QT? Block?). CK (LongLie?) ±Ser-Paracetemol. Mx: ±Charcoal (<1h), ±Flumenazil (Benz Antag- ++Side-effects) +Support/ABCDE.
- Pinpoint pupils, –Resp. Ix: Can be dx’d by giving naloxone: RAPID response. +ECG.
Mx: Naloxone ±CPR ±Ventilation ±Bowel-Irrigation.
Bipolar Disorder
Epi: 1% Lifetime risk. PkAg 19-25.
Aet: Mania/Hypomania + Depression. A bit genetic +Some structural abnormality in frontal cortex on MRI.
T1: >1 Manic episode. (>7d, FuncImpair/Psy)
T2: >1 Hypomanic and >1 Depressive episode. (No Psy Sx, function intact).
Cyclothymia: Sub-threshold of T2.
Hx/Sx: –Need for sleep ±Talkative ±Distractible +No underlying Cause ±FlightIdeas +Not due to anti-depressants.
Ix: PHQ9 +MDQ (MoodDisorder) +TFTs (++Thyroid mimics) +FBCs +VitD +Toxicology ±Lipids (Baseline) +Glucose (Assoc w/ T2DM) ±MRI-Brain.
Mx: Agitated: Benzodiaz or Olanzapine (Rapid) -PO or, failing, IM. 1: Lithium / Valpro. 2: Switch or Combine 1sts. ±Benzos ±ECT and STOP antidepressants.
Schizo-Affective Disorder
Epi: 30% get sx <25y, 30% >35y, Epidemiology uncertain due to dx criteria.
Aet: Often clumped with either schizophrenia or bipolar disorder. Further sub-classified as manic-type (More common in younger) or depressive-type (older).
Hx/Sx: (+)Sx: Hallucinations +Delusions +Thought Disorder +Bizarre behaviour. (-)Sx: Anhedonia, Social Isolation, –Affect. +Major depressive & manic episodes. ++FamHx.
Ix: Drug Screen +STI Screen (HIV/Syph) +FBC +TFT (Mimics).
Mx: Acute: Start/Review antipsychotics. ±Tranquillisation (Benzo PO/IM) ±ECT
Long-Term: Lithium / Valproate and anti-depressants if depressive sx.
Schizophrenia
Epi: 1/150 affected. Onset <25 in M / <35 in F.
Aet: Heavily genetic. ?More common if born in Winter? Triggers: Loss + Trauma. ±Brain atrophy ±Large ventricles –Amygdala? ?Neurotransmitter imbalance.
Hx/Sx: DSM5 Criteria: ≥6m decline + ≥1m of ≥2 of: Delusions, Halluc, disordered speech, catatonia, or (-)Sx; ≥1 (+)Sx must be present.
No relation to substance misuse.
ICD10: ≥1m of ≥1 of 1st Rank: 3rdPAudHallu +ThoughtDisorder +DelPercep +Passivity.
Ix: Lipid profile (Baseline) ECG (For medication) ±bHCG (Pregnant?).
Mx: Benzodiazepines (PO/IM if quickly needed). Specialist +CBT +Antipsychotic (Aripip 1st). Monitor: Weight, AbdoCircum, BP 1w,12w,1y,2y; Lipid/>HbA1C/Fasting 12w,1y,2y; ±ECG/Prolactin if needed. Switch to other antipsychotics then Cloz after 2 others.
Most (but not Cloz) can be given as 1-monthly depot.
Extra-Pyramidal Side-Effects (EPS)
- NMS
-Few days onset. Rigidity +Temp +Autonomic. ++CK/WBCs/K. Tx: Dantrolene (Relax), Dopamine, Discontinue AntiPsychs. - Parkinsonism
- Acute Dystonia
-E.g., Torticolis & Oculogyric Crisis. Tx w/ Procyclidine (Anticholinergic). - Akathisia
- Tardive Dyskinesia
-May be irreversible. 40%
-Tx: Tetrabenazine (Depletes Dopamine).
Obsessive Compulsive Disorder (OCD)
Epi: 1-4% of children.
Aet: Genetic / Trauma / Paediatric AutImmune Neuropsycic disorder. Assoc with depression (30%), Schizop, Tourrettes, and AnorexiaNerv.
Hx/Sx: Obsessions (Unwanted, intrusive thoughts). Compulsions (Self-reinforcing actions that offer mild relief). Pt has INSIGHT into irrationality. NOT delusional. +Sensory phenomena.
Ix: Non-structured Clinical Interview is often sufficient. DSM-V criteria if needed; “SCID”
Mx: Mild: CBT (Ideally Exposure-Response Prevention [ERP]) > Fluox (>7y) > Both > Specialist.
Generalised Anxiety Disorder (GAD)
Epi: Lifetime Prev of 8%.
Aet: Genetic + Trauma + Stressors. “Excessive worry about multiple things”.
Hx/Sx: ++Worry for ≥6m. Not matching other disorder (PTSD/Panic/SocialPhobia). Not due to drugs. ±Sleep issues ±Fatigue ±Irritability ±PoorConcentration.
Ix: Clinical Dx: GAD-7 (5=Mild, 10=Mod, 15=Sev). ±TFTs ±Drug-Screen ±PulmonaryFTs (++RR?) ±ECG (Palpitations?).
Mx: Mindfulness ±Sleep-Hygeine Edu ±Exercise. 1. CBT ±Sert (or SNRI).
2. ±Benzodiazepine or Pregabalin or Quetiapine or Tri-Cyc.
NO DRUGS IN KIDS.
Panic Disorder
Epi: 2-3% adolescents and adults.
Aet: Now different from agoraphobia (Being surrounded by lots of people + Panic). Genetic, environment, and “temperamental” (Inhibition of self) factors contribute.
Hx/Sx: Unexpected Onset +Avoidance of situations / sensations (exercise). ++HR in anticipation of exposure. ±Palpitations ±Derealisation ±Muscle-Shaking ±Faint.
Ix: GAD-7: Clinical Dx; 5/10/15 Mild/Mod/Sev. ±ECG (Chest Pain) ±Glucose (–?) ±TFT ±Toxicology.
Mx: Reassurance + Benzos for acute attack. Disorder: CBT + SSRI/SNRI (Sert 1st). ±Combined Drug Therapy: SSRI + SNRI / Tri-Cyc / NaSSA (Mirtazapine),
Post-Traumatic Stress Disorder (PTSD)
Epi: 6.8% lifetime prevalence in USA.
Aet: Experience +1. IntrusiveThoughts +2. Avoidance +3. –Mood +4. ++Arousal / Reactivity. Acute-Stress Disorder for >4w,
Hx/Sx: 1. Exposure to threat/actual trauma to you or others. >1m of sx. As above: ±HyperVigilance(4) ±Feeling Detached(3) ±Avoiding people(2) ±Flashbacks(1). ±Depression ±Anxiety ±Substance Misuse.
Ix: Clinical: DSM-5-PTSD-Checklist +Others.
Mx: 1. Trauma-Focused CBT or EMDR (Eye-Movement Desensitisation & Reprocessing).
2. SSRI (+if CBT Contraindicated -Ongoing trauma).
3. SNRI or SSRI + Quetiapine. +Above.
Acute Stress Disorder
Epi: 6-33% of people who have experienced trauma. 33% of mass-shooting experiencers.
Aet: >3d of Sx. Same as PTSD but with Sx <4w.
Hx/Sx: DISSOCIATIVE (which partly differentiates it from PTSD). +IntrusiveThoughts +NegativeMood +SleepDisturbance +HyperVigilance.
Ix: Clinical dx.
Mx: Trauma-Focused CBT can prevent progression to PTSD. Reassure +Lie down. ±Benzodiazepines for sleeping. Delay any exposure therapy, as patient may show severe stress reaction. NO GOOD EVIDENCE THAT SSRIs HELP.
Phobias
1. Agoraphobia
2. Social Phobia / Social Anxiety Disorder.
3. Animal (Zoophobia)
4. Medical
5. Situational (Claustrophobia)
Treatment for all: CBT ±ExposureTherapy ±Tensing (Muscles to ++TPR) ±Benzos.
- 1.7% of adults. Fear of busy places, where there is no ease of escape. ±PanicAttack ±Fainting.
- 2-7% of adults. Fear of (-)evaluations from people. ++Conscious, Inaccurate Self-Defeating thoughts. Tx: SSRIs helpful +above.
- “Melissophobia” - Fear of bees. “Lepidopterophobia” - Fear of Moths/Butterflies. Tx: Medications used less; otherwise, as above.
- “White-Coat” is a very minor form of this. Rarely treated; Anaesthesia is often used as the “treatment” to allow procedures to go ahead.
- MRI machines = big issue. Related to amygdala function. B-Blockers or Anaesthesia can be used along with the above.
Anorexia Nervosa
Epi: 0.3% prevalence. 9:1 F:M diagnosed; it is believed the actual ratio is 7:3.
Aet: Environmental, Social, +Genetic. Weight-loss leading to abnormal function of EVERY organ system: Osteoporosis = long-term effect.
Hx/Sx: –EnergyIntake +FearOfWeightGain +DisturbanceOfBodyImage. Restricting OR Binge/Purging subtypes. ±Laxatives ±Diuretics ±Diet-Pills ±Amenorrhoea.
BMI: >17,16,15,”>” = Mild,Mod,Sev,Ext.
Ix: Low body-weight for height. FBC (NormCyt Anaemia) +Ser-Chem (Met++pH –K/–Na/–Pho/–Ca?) +TFTs +LFTs +Urinalysis ±ECG ±E2 (?Amenorrhea)
Mx: Structured eating plan +CBT (++Family Therapy in <18s) ±Potassium ±HospitalAdmission ±Parenteral/Enteral Feed ±Olanzapine+ECG (–Dysphoria and ++Weight)
Bulimia Nervosa
Epi: 2.6% lifetime prevalence in women by age 20.
Aet: Binging + Purging + “(+)”Feedback. Body-dissatisfaction ±Perfectionism ±SexualAbuse ±Depression. Purging = Vomit / Laxatives / Diuretics.
Hx/Sx: ±DentalErosion +Above ±Low-SelfEsteem ±ParotidHyper ±ScarringOnHandDorsum (Vomit-Induction) ±Arrhythmia.
Ix: Clinical: 1 episode Binge+Purge / week for >3m. ≤3,7,13,”≤” weekly = Mild,Mod,Sev,Extr. Ser: Electr + Cr + Mg. +BhCG +FBC +LFTs +Urine.
Mx: CBT + MealSupport ±SSRI/SNRIs (Children: Fluox). With Suicidality / DM / Physical Sx: Refer to specialist or A&E.
Delirium (General) / Acute Confusional State
Epi: 30% of elderly patients in hospital.
Aet: RFs: >65y, Dementia, Significant injury, Polypharmacy (++AntiCholinergics). Caused by: Infection, Urine/Bowel Retention, Electrolyte Imbalance. Many causes.
Hx/Sx: Inattention, ~~State of Consciousness, Disorganised Thinking. ±MoodChange ±Hallucinations ±DisturbedSleepCycle.
Ix: Ensure the changes have occurred acutely and are not related to dementia: CAM, MMSE, AMTs. ±Urine ±CXR ±ECG ±U&Es ±Drug-Levels ±LFTs ±Blood-Cultures ±OtherXRs. Check hydration.
Mx: Treat underlying cause, Modify Environment ±Haloperidol/Olanzapine.
In PD: Don’t give antipsychotics; perhaps slowly reduce Parkinson’s meds.
Delirium Tremens
Epi: 20% of admissions to hospital have “potentially-harmful” alcohol consumption.
Aet: Abrupt withdrawal of alcohol; Either “Cold-Turkey” attempts or >1d of hospital admission. DelTrem Peaks at 48-72h (2-3d) after stopping. Occurs due to –GABA-Receptors (Which are used to being stimulated by EtOH) which leads to low GABA action, –Inhibition.
Hx/Sx: 6-12h: Sweating, ++HR, Anxiety.
36h = ±Seizures
48-72h = Coarse Tremor, Confusion, Delusions, Aud/Visual Halluc, Fever, +Above.
Ix: AUDIT (AlcUseDisorderIdentifTest). Calculate units/week. +CollateralHx +AssessNutrition +U&Es +LFTs/Coag/Glucose +FBC +VBG.
Mx: Benzo (Chlordiazepoxide / Diaz preferred) +Pabrinex (B-Vits [Thiamine]) +Sort Electrolytes (Dehydration AND Anorexia common in ChronAlcUse) ±Airway Mx.
Psychotic: Halop/Olanz ±Ket/Propofol (Tranquil) ±Barbiturate.
Alcohol Use Disorder (Quitting, Symptoms, etc)
Epi: 7-10% Prev in Western Countries. M:F = 2:1.
Aet: Genetic (~50%)/Environmental/Social. Causes long-term down-reg of GABA-Rs, and up-reg of NMDA-Rs. Positive reinforcement through opioid/dopamin/serotonergic receptors.
Hx/Sx: ±Alcohol withdrawal (Tremor, ++HR, Delirium, Seizures etc). ±Wernicke’s (–Memory –Balance) ±LF-Sx (Ascites, RUQ-Pain etc). +Tolerance. –Nutrition –Hydration.
Ix: AUDIT / CAGE diagnostic interview. ±Blood-Alcohol ±LFTs ±FBC (Hb/MCV).
Mx: “CHoose To stop Drinking Alcohol”: CHlordiazepoxide +Thiamine initially then, to prevent relapse, Disulfiram +Acamprosate.
+PsychoSocialTherapy: “AA” good.
Wernicke’s and Korsakoff’s Syndrome
Epi: 0.8-2% total prevalence on autopsy.
Aet: –Thiamine. Higher prev in Chronic Alcoholism (12.5%), AIDS (10%), and Bone-Marrow-Transplant (6%) pts. +Other causes of malnutrition (E.g., Bypass surgery). 18d of storage in body. Def = KrebCyc Dysfunction.
Hx/Sx: MentalSlowing, Apathy, FrankConfusion ±Gaze-Palsy/Nystagmus ±VI CN Palsy ±Gait Dysfunction ±Delirium/Coma.
Korsakoff’s = ++MemoryLoss ++Confabulation.
Ix: Trial of Thiamine (B1) +FBC +Glucose +U&E/Cr +Ser-Ammonia (Mimics) +Ser-EtOH/B1 and Mg. ±LP (Exclu Meningitis)
Mx: Thiamine + Mg++ + Folate +Multivitamins +Fluids.
Opioid Use Disorder
Epi: 1.2% Prev in 15-64y. Rise in synthetic-opioid-related deaths.
Aet: 25% opioid-related deaths involved Benzos too. Kappa-Opioid receptors in CNS = Dysphoria. ±IV-Use.
Hx/Sx: –Ability to socialise (Work / School / Home). ±Use in hazardous environment (E.g., Heavy vehicle) +Blunting of euphoria (Tolerance) +Miosis (/Mydriasis in withdrawal) ±Needle-Marks –RR ±Coma ±Constipation (Diarr on withdrawal) ±N/V.
Ix: Urine/Saliva Levels +FBC +U&Es/Cr +LFTs +HepB/C-Ser +HIV-Screen +bHCG (?Preg) +Cultures (?InfEndo).
Mx: Induction: Buprenorphine/Methadone +Naloxone. ±NSAIDS/Parac (Pain) ±Odansetron (N/V) ±Bismuth (Diarr) ±Chlordiazepoxide (Benzo for Insomnia). ±Needle exchange.
Serotonin Syndrome
Epi: Data is terrible.
Aet: Overdose, SNRIs/SSRIs + MAO-Is, Opioids, some TCAs (Imipramine), St.JohnsWart.
Hx/Sx: SerotonergicAgent(1) ±SpontaneousClonus(2) ±InducedClonus(3) ±Agitation/Sweating(4) ±OccularClonus(5) ±Tremor(6) ±HyperReflexia(7) ±Hypertonia(8) ±Pyrexia(9).
Ix: Clinical Dx: Criteria: 1&2 OR 3&4 OR 5&4 OR 6&7 OR 8&9&(5/3) = Serotonin Toxicity.
±CK (?NMS) ±ECG (+QT) ±LP (CNS cause?).
Mx: ABCDE + Relevant. ±Activated Charcoal (<2h Ingestion). ±Cyproheptadine (Lots of low doses if fluoxetine, or one high dose if others) ±Consider stopping long-term serotonergic meds. Rhabdo: Paralyse muscle + Cool.
Neuroleptic Malignant Syndrome (NMS)
Epi: Incidence data limited. 8-9% Mortality.
Aet: Indistinguishable from a syndrome that occurs in Parkinson’s when dopamine agonists are suddenly stopped: Sudden hypostimulation of CNS. Speculation of genetic link.
Hx/Sx: Hx of Antipsychotic use. ++Thermia ++Rigidity ++Bp/HR. +Confusion +Delirium.
Ix: Ser-CK +U&Es (AKI/K+) +FBC (?WCC++) +ABG (Met–pH) +Glucose +LFTs (?Fail) +Repeated ECGs. Remember: KKK from “NMS Kidney Disease”.
Mx: DDD: +Dantrolene +Dopamine (Start/Continue agonists) +Discontinue Antipsychotics. ±Benzos ±ECT.
Eventually: Restart Antipsychotics.
Cluster A Personality Disorders
“Suspicious”: Mx: ±Low-Dose Antipsychotics ±Antidepressants.
ALL PDs: 11% Prevalence. Aet: Early psychological trauma +Genetics +TobaccoInPregnancy. Hx: Enduring problems in 2/4: Cogn/Percep / AffectRegulation / InterpersonalFunc / ImpulseControl. ++Risk of self-harm. Mx: Psychotherapy.
- Paranoid
+Suspects infidelity from partner +Suspects hidden intention from people’s actions +Reluctance to confide ±Conspiracy. - Schizotypal
++Odd thinking ±SocialAnxiety ±Ideas of Reference ±OddSpeech ±Eccentric. - Schizoid
+Lack of desire to socialise -Feels this is of no benefit. +May seem cold +Few interests.
Cluster B Personality Disorders
“Emotional”
ALL PDs: 11% Prevalence. Aet: Early psychological trauma +Genetics +TobaccoInPregnancy. Hx: Enduring problems in 2/4: Cogn/Percep / AffectRegulation / InterpersonalFunc / ImpulseControl. ++Risk of self-harm. Mx: Psychotherapy.
- Emotionally Unstable Personality Disorder
+Episodes of intense Anger ±Impulsive ±Self-Destructive (self-harm) ±Difficulty Maintaining Relationships. Mx: ±Lithium/Valproate. - Histrionic Personality Disorder
+Wanting to be the centre of attention ±Performing to maintain this. +”Impressionistic Speech” ±InappropriateSexualSeductivness. - Narcissistic Personality Disorder
++Grandiose sense of importance ±Fantasies of unlimited beauty+power+success. ±ChronicEnvy ±LackOfEmpathy. - Antisocial Personality Disorder
–Social Norms regarding law. +Lying +Conning +LackOfRemorse +Impulsive.
Cluster C Personality Disorder
“Anxious”
ALL PDs: 11% Prevalence. Aet: Early psychological trauma +Genetics +TobaccoInPregnancy. Hx: Enduring problems in 2/4: Cogn/Percep / AffectRegulation / InterpersonalFunc / ImpulseControl. ++Risk of self-harm. Mx: Psychotherapy.
- Avoidant Personality Disorder
+SevereAnxiety about rejection ±Needs to be certain they’ll be liked +Self-Inferiority.
Mx: ±Antidepressants. - Dependent Personality Disorder
±Difficulty making everyday decisions without others ±Lack of initiative +Fear of being alone. - Obsessive Compulsive Personality Disorder
+Occupied with rules/lists/order. Demonstrates perfectionism which slows the completing of tasks. +Ethics +Stingy
Alzheimers Disease
Epi: 5.5% of people >60y.
Aet: 60-70% of dementias. 5% ADi. RFs: T21 +White +FHx +SatFats +Smoking. b-Amyloid plaques (Tau) +NeurofibrilaryTangles. Moderate Alcohol consumption may be protective.
Hx/Sx: MemoryLoss ±Disorientation ±NominalDysphasia (Naming objects) ±GettingLost ±Apathy ±PersonalityChange.
Ix: MMSE FBC (?–Hb) +MetPanel (?–Ca –Na) +TSH +Drugs +CT/MRI (Atrophy, ++Ventricles)
Mx: Support ±Cholinesterase-Inhibitors (Rivastigmine / Donepezil) ±NMDA-Antagonists (Memantine).
±Manage Insomnia (Trazodone) +Depression (Sert) +Psychosis (Risperidone)
Vascular Dementia
Epi: 1.4% of people >60y.
Aet: 17% of all dementias Several diseases lead to it; Ischaemia ±Haemorrhage ±Leukoaraiosis. RFs: HTN +Choleterol +DM.
Hx/Sx: Stroke Hx. ±Apathy ±Difficulty Solving Problems ±Slow Information Processing ±Sustained-Glabellar/FrontalReflexes +Disinhibition.
Ix: FBC (?Anaemia) ±ESR ±B12/Folate ±TFTs ±MRI/CT ±ECG (?AF).
Mx: Aspirin ±Clopidogrel +LifestyleMod. CarotidSten >70 = Endarterectomy. ±BP-meds ±Statins ±GlycaemicControl (DM) ±AntiCoag (EmbolicDisease) ±SSRIs (Depression/Agitation).
Fronto-Temporal Lobe Degeneration
Epi: 3rd Most Common Dementia. 15 / 100,000 45-64y. Affects younger (~45y).
Aet: 30% have strong FHx ±Traumatic Brain Injury. ±Tau Protein (50% cases). Subclassified as Pick’s (Classical FTD), Coticobasal degeneration, & ProgSupranuclearPalsy. Sometimes includes Parkinsonism.
Hx/Sx: Key feature is a change in Personality / Behaviour / Taste / Movements / Language. +Must show deterioration/
Ix: GSfDx: Post-Mortem Biop. MMSE / MOCA +MRI(/CT) (?Frontal Atrophy) +FBC +CRP +TFTs +U&Es +LFTs +B12/Folate +Syphilis/HIV.
Mx: Irritability: Benzos or Risperidone. Compulsions: SSRIs. Poor Sleep: Mirtazapine. Distractibility: Amantadine (NMDA Antag, like Memantine). Mania etc: Valproate / Topiramate.
Lewy-Body Dementia
Epi: 10-15% of dementias.
Aet: a-Synuclein (Lewy Bodies) (Involved in synaptic vesicles). 40% of Alzheimer’s patients also have Lewy Bodies. Difference between PD: 1y of cognitive sx BEFORE motor sx.
Hx/Sx: Fluctuations ±VisualHallucinations ±ParkinsonianFeatures (85%) ±REM disturbance. ±AntipsychoticSensitivity ±Depression ±Anxiety ±OrthoStatHypotension ±Hyposmia ±Delusions.
Ix: TSH ±B12 ±MRI/CT (Often shows something). ±FBC ±Drug-Screen
Mx: Support +Rivastigmine/Donepezil (AcChoEst-I) / Memantine (NMDA-Ant) ±Risperidone (w/Psychosis - BE CAREFUL) ±Carbidopa/Levodopa (Motor sx).
Parkinson’s Disease
Epi: 1/333 person-years 80-99y. PkAg: 65.
Aet: Some genetic: Sporadic and AD. Death of dopaminergic neurones in SubsNig. +LewyBodies (a-Synuclein). Juvenile (<19y) + Young-Onset (21-40y) PD occurs rarely.
Hx/Sx: STARTS UNILATERAL. Bradykinesia (+Shuffle-Gait), Rigidity, “Pill-Rolling” Tremor, PostInstability ±Masked-Facies ±Micrographia ±Depression ±Dementia.
Ix: Trial dopamine (Upto 1200mg Levodopa). ±MRI ±Genetic ±24h-Urine-Copper (?Wilson’s) ±OlfactoryTests.
Mx: Drugs started as late as tolerated. Carba/Levodopa (together). if not: Dopamine agonist (Ropinirole) If not: MAO-Bs (Selegiline).
Tremor: Propanolol or Deep-Brain-Stimulation.
Normal-Pressure Hydrocephalus
Epi: 4/100,000 /year. PkAg: 70-80y.
Aet: Unknown. Theories: ±MalAbsorption of CSF. ±Toxic-Metabolites in CSF ±Compression of venous vasculature. NO structural abnormalities.
Hx/Sx: “Wet, Wacky, Wobbly”. Urinary Incontinence/Frequency, Cognitive fluctuations, Ataxic Gait (Cautious, unstable, falls). Symmetrical signs.
Ix: Levodopa Challenge (?PD or NPH). Non-Contrast CT/MRI head (Normal or mild/mod leukomalacia +Ventricular enlargement). ±LP (Pressure 7-25cm water ±Sx relief).
Mx: Surgery (Shunt) or, if not suitable: Repeated CSF taps.
Huntington’s Disease
Epi: 1/18,000 in UK. Can affect young.
Aet: >40xCAG nucleotide repeats = certain to get disease. Penetrance is affected by number of repeats. Autosomal Dominant, less likely to inherit it from mother (Sperm = Unstable).
Hx/Sx: ++FamHx. Impaired work/school performance. ±Impulsivity ±Irritability ±Chorea ±CoordinationLoss ±Depression ±Compulsions.
Ix: Clinical Dx. GSfDx: CAG repeat testing; Will condemn patient, and is often deferred. <28 = normal. ±MRI (?Atrophy of caudate)
Mx: Counselling. Depression: SSRIs then ECT if resistant.
Chorea: Tetrabenzine / Risperidone. Mood instability: Valproate / Carbamazepine.
Eye movements +Incoordination +Speech cannot be treated.
Haemorrhagic Stroke / Subarachnoid Haemorrhage.
Epi: 17% of strokes.
Aet: Primary (Idiopathic / AntiCoag) or Secondary (Malformation / Disease e.g. Cancer or Berry Aneurism). Burst artery > Growth ±Sheering more arteries ±Expanding for several hours. ±Mass-effect.
Hx/Sx: Unilateral weakness/Sensory-Loss ±Dysphasia/Dysarthria ±HomogHemiAnOp ±Headache (Insidious or Thunderclap in SubArach).
Ix: Non-Contrast CT. Glucose + U&Es (Mimics) +LFTs/FBC/Coag +ECG (?AF).
Mx: Neurosurgical referral ±RAPID BP reduction (If >150sys).
Warfarin: Reverse Vit K.
Dabigatran: Reverse with Idarucizumab
Xa-Inhib (Apixa): Prothrombin Complex.
+Pneumatic Leg Compression
Driving: 1m off.
Ischaemic Stroke
Epi: 1/650 strokes/year.
1/1900 deaths/year.
Aet: 10% external atherosclerotic. 25% cardioembolic. 4 Classes of infarct: Total Anter, Partial Anter, Poster, Lacunar. RF: Smoking, obesity, ++Lipids/Cholesterol, ++Age.
Hx/Sx: 1: Unilateral –Motor and/or –Sensation. 2: HomogHemAnOp. 3: Higher-Cog-Dysfunction (?Dysphasia). TotalAnter = 3/3. PartialAnter = 2/3. Lacunar = 1 OR PureSensory OR Ataxic Hemiparesis.
Post: 2 OR Weber’s (–Motor) OR Lateral-Medullary (–Sensory) OR Cerebellar (DANISH), OR Basilar (Locked-In).
Ix: Non-Contrast CT Head +
Non-Contrast CTangio + Contrast CTangio. ±CT-Perfusion if potential Thrombectomy after 6h.
Glucose, U&Es, Troponin/ECG, FBC + PTT (?Platelets).
Mx: Exclude Haemorr: Aspirin 300mg. <4.5h: Alteplase then <6h + CTA shows Proximal: Thrombectomy.
IF <24h & CT-Perfusion shows SALVAGEABLE brain +Proximal: Alteplase + Thrombectomy.
After 2d: Statin.
After 2w: Clopidogrel 75mg, not Aspirin.
Driving: 1m off.
Transient Ischaemic Attack (TIA)
Epi: 1/500 /year.
Aet: Cardioembolic (30%). Small-vessel occlusion (15%). Symptoms lasting <24h (Most resolve entirely in <1h).
Hx/Sx: (See Ischaemic Stroke). Total Anterior (3/3), Partial Anterior (2/3), Lacunar, Posterior, Webber’s Synd, Lat-Medullary Synd, Basilar.
Ix: Consider MRI (TIA Clinic Discretion). +CarotidDoppler +Glucose +FBC +Platelets +INR +Lipids +U&E +ECG. ±CT (Only if Haemorrhage suspected).
Mx Aspirin (300mg) / Clopidogrel (Long term- 75mg). +Statin. ±Anticoag for AF (CHADS2VASC).
Driving: 1m off. Multiple: 3m off + inform DVLA.
Subdural Haemorrhage
Epi: 1/800-2000 annually. 50-60% of intercranial haematomas.
Aet: Mostly trauma- SHEER force or other. Rarely due to rupture of aneurism. ++Age, ++Anti-Coagulation
Hx/Sx: ±Headache ±Trauma ±N/V ±AbnormalPupils, –GCS ±Seizures.
Ix: Non-Contrast CT (Banana/Crescent).
Mx: Correct any coagulopathy.
<10mm Size, <5mm Mid-Shift, no neuro signs, GCS >9: CT in 2-3w +1w Phenytoin/Keppra ±HypERtonicSaline (To lower ICP),
All else: ICP+EEG monitoring +Surgery
Epi / Extradural Haemorrhage
Epi: 2% of head injuries. 5-15% of fatal head injuries.
Aet: Usually a rupture of the Middle Meningeal artery. Between bone and dura mata. Limited by the suture lines of the skull.
Hx/Sx: Loses > Regains > Loses consciousness (Lucid Interval).
Ix: CT head: Biconcave (Lense/Lemon).
Mx: Craniotomy + Evacuation.
Driving: 1y off after craniotomy.
Sinusitis
Epi: 10% suffer chronic in the UK.
Aet: Acute (<12w) / Chronic. Endpoint of many diseases. RF: Smoking, CF or Primary Ciliary Dyskinesia, mid-septal deviations. S.Aureus (50%), Gram(-)Rod (20%), HFlu (4%), GAS (4%).
Hx/Sx: FacialPain ±NasalObstruction ±NasalDischarge/Drip ±Headache ±Purulence ±Fatigue ±Cough ±Fever.
Ix: Anterior Rhinoscopy +NasalEndoscopy (ENT, no anaesthesia- ?Polyps/Obstruction) ±Cultures ±Sinus-MRI (?Air-Fluid levels)
Mx: SalineSinusIrrigation +NasalSteroids ±Abx ±Decongestant (Phenylephrine).
Ongoing: Oral Steroids / Surgery.
Tension Headache
Epi: Chronic: 2-3% prevalence.
Aet: Psychological Stress ±Minimal tightening of pericranial muscles. Major nociceptor is within the pericranial muscles.
Hx/Sx: Non-throbbing, bilateral head pain. “Tight band around head”. ±Muscle tenderness ±Depression/Anxiety ±Medication-Overuse Headache (Transforms episodic headache to chronic).
Ix: Clinical dx. CT sinuses / MRI brain (If progressing / Refractory).
Mx: Paracetamol / Ibuprofen / Aspirin. >7-9 days/m: TCA / other antidepressant +Relaxation-training ±a2-Agonist (Tizanidine).
Idiopathic Intercranial Hypertension
Epi: 1/90,000 incidence.
Aet: Unknown; ++In obese women of childbearing age.
Hx/Sx: Risk factors +Some visual-field loss (Sometimes unnoticed -Due to papilloedema) ±Headache ±Tinnitus (with pulse) ±Photophobia
Ix: VIsualFields (Perimetry) +Dilated Fundoscopy +MRI (Transverse sinus stenosis) +L3/L4 LP (20-25cm H20).
Mx: –Weight –VitA –Sodium –Steroids. ±Acetazolamide (CarbonAnhydInhibitor) ±Furosemide / Topiramate.
Persistent: TCAs.
Migraine
Epi: 15% of the population (20% of women).
Aet: ++Genetics. Hyperexcitability to many stimuli. Neuronal inflammation > ++Blood supply > ++Sensitisation.
Hx/Sx: RF: F +Menstruation +Stress +Obesity. Long headache +Nausea –Function +Photophobia. Headache worse on activity. ±Phonophobia ±Aura (Zig-zags, flashing, numbness/tingling. dysphasia).
Ix: Clinical. ±ESR (?GCA) ±LP (?Xantho) ±MRI (Normal in migraine) ±
Mx: Acute: Metoclopromide (N/V) +Sumatriptan SC ±O2 ±Hydration
±IV Paracetamol ±Steroid.
Ongoing: Propanolol OR Topiramate (Terato) then TCAs.
Menses: Contraception (Not COCP if aura) ±Mg.
Trigeminal Neuralgia
Epi: 1/20,000 incidence.
Aet: Mostly due to demyelination after compression of CN V by vasculature. Compression is usually bilateral, but sx are not. 20x more common in MS.
Hx/Sx: Facial pain: >1 devision of CN-V +Intense/Sharp/Sudden/Superficial +Triggers +ASx between episodes +No neurological deficit ±Hx of trauma.
Ix: Clinical dx. May need oral XR or MRI if oral or other cause suspected.
Mx: Carbamazepine then Baclofen.
Unresponsive: MicrovascDecompression > Fails: AblativeSurgery > Fails: Neurostimulation (Frontal lobe).
Giant Cell Arteritis (GCA) / Temporal Arteritis
Epi: 1/3000-8000 >50y. PkAg: 80y
Aet: Associated with PolymyalgiaRheum. ++F +Genetics. Granulomatous inflammation >Intimal expansion +LumenCompression.
Hx/Sx: Headache +ScalpPain/Tender +Aching/Stiffness (All-over) ±Claudication (Jaw, tongue, shoulders) ±VisionLoss ±OpticDiscSwelling/Pallor.
Ix: Take blood then treat immediately: CRP/ESR +FBC +USS +Biop (If USS(-), be aware of skip lesions) +LFTs +U&Es/Cr. +Opthalmology review.
Mx: Oral Prednisolone 60mg Immediately.
Longterm: Pred PO OD ±Bisphosphonates ±CaVitD ±PPI ±Aspirin 75mg OD.
Cluster Headache
Epi: 1/500 prevalence.
Aet: Hx head trauma / Alcohol / Smoking. Associated with sleep apnoea +Genes. Key: CN-V distribution +Ipsilateral Cranial Autonomous Sx +Daily/Annual pattern of attacks.
Hx/Sx: +++Pain +One-sided +N/V +Lacrimation/Rhinorrhoea ±PartialHorner’s. Average 4 attacks/day lasting 1/4-3h.
Ix: MRI w/wo/contrast (Normal in cluster) +ESR (?GCA) +PituitaryFunc (Normal usually),
Mx: Triptan (CI in cardiovasc disease: Lidocaine instead here) + O2 (100%, >12L, >15m).
Chronic: Verapamil > Fail: Lithium / Topirimate / Gabapentin > Fail: Valproate > Fail: Occipital Nerve Stim / Deep Brain Stim.
Multiple Sclerosis
Epi: 1/300. M:F = 1:3. PkAg: 20-40. Can occur in young children.
Aet: Inflammatory +Degenerative disease of white matter in CNS. RelapsingRemit (90% initially), PrimProg (10%), SecProg (65% of Rel/Remit).
Hx/Sx: Optic Neuritis (Pain w/Movement, VisualLoss, Redness) +PeculiarSensations (Hot water, shooting down spine). ±Bowel/Bladder sx ±MSK ±Incoordination.
Ix: MRI brain/spine +Contrast (Lesions diff/ Time+Space). +FBC +B12/B9 +TFTs ±CSF (OliigoClonBands in 80%).
Mx: Ongoing: IFb. Pain: Gabapent / Pregab. Tremor: Propanolol. Physio.
ACUTE: MethylPred ODx3 ±Plasma Exchange.
Guillain-Barre Syndrome (GBS)
Epi: 1/50,000 incidence. Sometimes occurs in outbreaks (1976 Swine Flu).
Aet: Autoimmune attack on Schwann cells. 2/3 of patients have had an infection within 6w. Usually viral (CMV, EBV, HepE) sometimes Bacterial (Campylo).
Hx/Sx: Parasthesia, normally before Muscle weakness, both extending proximally to be worse at 2-4w. ±Leg pain ±RespIssues ±SlurredSpeech ±ReducedReflexes.
Ix: Nerve conduction +LP (++Protein) +Spirom (Aggressive monitoring- Every 6h) +LFTs (++) ±Serology (Virus+Bact+HIV) +CXR (?Resp).
Mx: IVIG (Can cause anaphylaxis if –IgA) OR PlasmaExchange (If –IgA. x2-5). +PainMx +VTEProph
Charcot-Marie Tooth (CMT)
Epi: 1/2500 people (Most common inherited neuro disorder). Can show at any age.
Aet: Some AD, Some AR, Some XLR inheritance. Mechanism different depending on gene. Primarily issues with Schwann cells or myelin > demyelination.
Hx/Sx: Walking difficulties ±High-Arch feet +FamHx ±SteppageGait –Reflexes –Vibration/Pinprick –Strength: Starts distally. +”Inverted-Wine-Bottle Legs”.
Ix: Nerve-conduction. ±GeneticTests (Commonly CMT1A- ADi).
Mx: No cure: PT +OT +Orthopaedic Surgery +Bracing +Prevention of osteoarthritis.
General Peripheral Neuropathy
Aet: Motor: GBS, CMT, LeadTox, Diphtheria, Porphyria.
Sensory: DM, Uraemia, Leprosy, Alcohol (B1/B12), B12. Vincristine, Phenytoin, other drugs.
Hx/Sx: Slow progression in many of the above. Mononeuropathies, nerve routes, or systemic demyelination (which gives more glove/stocking).
Ix: B12/Folate. Can be clinical (Hx deficiency, FHx, medication, infection) - Therefore FBC/HbA1C/Drug-Levels/Cultures/TFTs.
Mx: Remove stimuli, replace deficiency, treat infection, manage chronic disease.
Myasthenia Gravis
Epi: 1/100,000 incidence. F:M = 2:1.
Aet: 80-90% have Abs against post-synaptic nicotinic ACh receptor. Also: Muscle-specific-Tyrosine Kinase (MuSK)(3-7%). ±Thymus involvement (Thymoma in 10%). Strong genetic link.
Hx/Sx: Fatiguability. Ptosis +Diplopia +Dysphagia +Dysarthria +ProximalLimbWeakness ±SOB (if severe enough = Myasthenic Crisis).
Ix: Ser-AChR Abs and Ser-MuSK Abs. ?Crisis: Serial Spirometry. ±ElecMyoGram ±CT-Chest (Thymoma).
Mx: Crisis: Intubation +Ventilation ±Steroid +IVIG OR, with –IgA, Plasma Exchange.
Maintenance: Pyridostigmine (AChE-I) ±Steroids ±Rituximab ±Azathioprine ±Thymectomy.
Lambert Eaton Myasthenic Syndrome (LEMS)
Epi: 1/250,000 prevalence.
Aet: Depletion of pre-synaptic calcium channels. Associated with Small-Cell Lung Cancer. Non-Cancer LEMS is associated with other auto-immune conditions.
Hx/Sx: Proximal then distal limb weakness. Dry mouth “metal taste”. ±WaddlingGait. Later: Ptosis/Diplopia and others. Weakness improves w/ some exercise (Weakens w/Sustained).
Ix: ElecMyoGram (Post-Exercise Boost of conduction) +RepetNerveStim (DropInAmplitude) +Anti-Ca-Channel Abs +CT-Chest (?Cancer in >50-60%) +AChR-Abs (Found in 13%).
Mx: Resp Crisis: Intubation +Ventilation. +IVIG OR, in –IgA, PlasmaExchange.
Maintenance: Tx underlying cause +Amifampridine (–K efflux and longer action potentials) +Pyridostigmine (Some small improvements).
Chronic Fatigue Syndrome (Myalgic Encephalomyelitis)
Epi: 0.1-2% prevalence in the UK.
Aet: Dx after >4m of disabling fatigue unexplained by other causes 50% of the time. Past psychological Hx not shown to be a RF. Overlap with Post-Covid-Syndrome and other post-viral syndromes.
Hx/Sx: Post-exercise exhaustion. Short-term memory/cognitive impairment. Unrefreshing sleep, orthostatic Intolerance +Diffuse pain.
Ix: DePaul Syndrome Questionnaire. FBC, ESR/CRP, TSH, ANA, RF, HIV (Exclude differentials). ±HbA1c ±TTGA/Endomyseal for coeliac,
Mx: ±CBT ±Mindfulness +”Energy Envelope” ±SSRI/Benzos for sleep or depression.
Motor Neurone Disease
Epi: 1/25,000 incidence: ALS (50%).
Aet: AmyoLatSc: UMN (More in arms) +UMN (More in legs), Cr21/SOD1 implicated. PrimLatSc: UMN. PBP: Cranials: Worst prognosis. ProgMuscAtro: Isolated LMN.
Hx/Sx: Weakness. UMN: Hyperreflexia, rigidity, spasticity, LMN: Foot drop, dyspnoea, spasms/fasciculations, atrophy. NO sensory signs (Sometimes pain with cramping, though), NO cerebellar signs, external ocular signs, or changes in abdomen reflexes.
Ix: Clinical. ±NervCondStudies (Normal) ±EMG (Evidence of denervation) ±MRI (Exclude myelopathy, especially in PBP).
Mx: Rituzole (Na-Blocker- +3m of life) +BPAP (+7m of life) +PEG-Tube. 50% die in 3y. ±Carbocisteine (Mucolytic) ±Baclofen/Botox (Muscle relaxants).
Syringomyelia
Epi:
Aet: CSF within spinal cord. Similar to Syringobulbia (CSF in medulla). Caused by: Chiari Malformation (Around cerebellum), Trauma, tumours, or idiopathic.
Hx/Sx: Loss of mostly temperature sensation, bilaterally, on neck, shoulders, and arms. +LowerLimb UMN signs (Spastic, Weak, UpPlanters).
Ix: Spine MRI w/Contrast. Brain MRI (Exclude Chiari).
Mx: Treat cause of syrinx ±Shunt to drain CSF from syrinx.
Polio Myelitis
Epi: Wild-Type: eradicated. Still some very rare vaccine-associated types.
Aet: Faeco-oral spread. Spreads to CNS and lymph-nodes.
Hx/Sx: Unvaccinated (<36m), resident or travel to endemic area. –TendonReflex –Tone/Function +Atrophy of. ±Fever ±Malaise.
Ix: CSF/stool/Pharynx culture +Abs +CSF (+Lymphocytes) +MRI-Spine (AntHornCell Abnormalities).
Mx: Notify PHE +SupportiveCare +Ventilation (Bulbar Poliomyelitis) +PT.
Transverse Myelitis (TM)
Epi: 1/500,000 incidence. PkAg 10-19y + 30-39y (Bimodal).
Aet: Lesions, often 1-2 vertebrae in length, asymmetrical in PartialTM, longer and symmetrical in ExtensiveTM.
MS, post-vaccine, post-viral, SLE, Sjogren’s, Sarcoidosis, Para-Neoplastic. Aquaporin channels implicated leading to demyelination.
Hx/Sx: ±Bowel/Bladder Dysfunction (Differs from Gullian-Barre). Can present with Brown-Sequad. UMN signs below lesion ±LMN signs at lesion. ±SensoryLoss+Level. ±SOB (High lesion) +ElectricalSensation (L’Hermitte’s).
Ix: MRI Brain+Spine (+Gadolinium -Rule out compression/MS). Ser-AqPor4-Abs. LP (OligoClonal +Lymph= MS, Neuts ?= TM). +CSF Cultures/PCR/VDRL (EBV / CMV / Lyme / Syphilis / HSV).
Mx: 1. IV steroids for 3-5d. 2. Plasma Exchange. ±DVT-Proph ±RespSupport ±Catheterisation.
AqPor4(+): Azathioprine. MS: Treat MS.
Spinal Stenosis
Epi: 80% of women and 95% of men >65y = degenerative changes.
Aet: Thickening of surrounding bone > CaudaEquina and/or Radiculopathy
Hx/Sx: Slow onset, back pain. Leg pain ±LowerNumbness when walking. Absence of NeuroSigns. ±Pain radiating down leg (Radiculopathy) ±Bowl/Bladder Dys.
Ix: Plain XR (Degeneration +Spondylolisthesis) +T2-MRI (Guides treatment) ±CT ±EMG.
Mx: Significant: Surgical decompression. Otherwise: MxPain; NSAIDs ±Steroids ±SteroidEpidural.
Thoracic Outlet Syndrome (TOS)
Epi: 1/20ish.
Aet: ±CervicalRib ±Trauma ±Tennis ±Painters / Swimmers / Desk-Work. Neurological (Most common) ±Venous ±Arterial (Rare). E.g., CompleteSholAbduc = 180 degree bend in AxilArtery.
Hx/Sx: Pain (All-types), Fatiguability (art/venous), Parasthesia (Neuro), Numbness (Art), Raynauds (Neuro/Art), Weakness (Neuro),
Ix: C-Spine XR (?Rib, Frac, Other) ±CXR ±NerveConduct (Median: ?Carpel Tunnel or TOS) ±Angiogram (?Arterial TOS) ±USS (?Venous).
Mx: Objective signs of compression (True TOS): Surgical correction +PT.
Otherwise: PT (Core/posture) ±NSAIDs ±Surgery (If else is ineffective +Lower conduction velocity). ±Thrombolysis (If seen) ±Anticoag (art/ven).
Spinal Compression (+Cauda-Equina Syndrome)
Epi: ~7% of Cancer patients, ~1/25,000 Spinal Cord Injuries / year.
Aet: Car accidents, falls, GunSW, Sports, motorbike accidents, KnifeW. OlderPts; Osteoporosis, Cancer, Steroids. DiscHerniation, Discitis, TB (Pott’s), EpiduralAbscess.
Hx/Sx: Hx Trauma, malignancy, disc disease (C5/6, L4/5, L5/S1). ?Acute (Trauma/SlipDisc). ±Hypotension/–HR (NeurogenicShock) +UMNSigns ±Bladder/BowelDys ±CaudaEquina (SaddleAna, LegWeak, UrinReten) ±BrownSequad (Ipsi Motor/Vib, Contra Pain/Temp) ±TotalTransection.
Ix: MRI-Spine (Any Aet) +XR-Spine (SpinSten/SlipDisc) +CT (Surgical Planning) / CTMyelography (+Dye).
Mx: Surgery in all: Immobilising+Decompressive (Trauma). Laminectomy in <48h (CaudaEquina). Removal (Abscess[+Abx]/Cancer)
±Steroids (Be careful, CI in lots of aetiologies- Used in cancer) ±BP-maintenance (NeuroShock).
Carpal-Tunnel Syndrome
Epi: 3.7% Prevalence.
Aet: ++Weight +RepetitiveMovement +Genetics +Others = ++Pressure on median-nerve = Ischaemia (Symptoms) +Demyelination (Asymptomatic).
Hx/Sx: Intermittent Numbness +Weakness +Clumsiness. Worse at night. MedianNerveDistribution (Sparing ThenEminence- Superficial Branch).
Ix: EMG (Slowing conduction ±LowAmp) ±USS (?GangliCyst) ±MRI (Same as for USS).
Mx: 1. Wrist Splint ±Steroid Injection (Maximum 2x per year). 2. Relieving surgery.
Essential Tremor
Epi: 0.9% Prevalence. ++In Older.
Aet: Autosomal Dominant. Unknown Aetiology or gene. Issue with ?Cerebellum / Thalamus / Brainstem. Cerebellar strokes seem to cure pt of essential tremor.
Hx/Sx: Bilateral upper-limb tremor; Makes tasks of upper limb difficult +no other signs/sx. +Better with alcohol / Benzos / Gabapentin. ±Tremor of head, voice, and limbs. ±RestingTremor.
Ix: Clinical Dx. MRI only useful for ruling out other diseases (But no signs = no concern).
Mx: No dysfunction or embarrassment: No intervention. Otherwise: Propanolol or Primidone (>Barbiturate). 2. DeepBrainStim (Good outcome, risky). 3. Unilateral UltraSound Thalamotomy. 4. Gamma-Knife Thalamotomy (Older, Surgery CI).
Focal Seizures
Epi: >50% of seizures. Epilepsy = 1/2000 person-years incidence.
Aet: ±Idiopathic ±Trauma (+Skull fracture with >0.5h unconsciousness) ±CNS-Infection ±Tumour ±Stroke ±Dementias ±FHx ±Malformation ±PerinatalHypoxia.
Hx/Sx: One side of body or one body part. ±Pre-Seizure: Deja/Jamais ±Fear etc. ±Automatisms (E.g., Smacking lips- ?FIAS) ±PoorAwareness (FIAS) +Aphasia +Post-Ictal Period.
Ix: CT-Head (First episode) +MRI +Ser-Glucose +FBC (+WCC ?= Encephalitis) +U&Es ±Toxicology +EEG (50% Sensitivity, Perform within 72h ideally).
Mx: Acute Community: Rect/Buc Diaz. Hospital: IV Diaz +Phenytoin/Valpro.
Ongoing: 1&2: Mono: Lamotrigine / Keppra (Leve) then switch.
3&4: Mono: Carbamaz / Oxycarbaz / Zonisamide then switch.
5: Combine 2 drugs of different / agonistic mechanisms.
COCP: AVOID Carbamaz, Phenyt, Primidone, Phenobarbital.
Driving: 1st = 6m off. Established / Multiple unprovoked = 12m. No lorries for 5y. Withdrawal off drugs: 6m after last dose.
Generalised Seizures
Epi: Epilepsy: 1/2000 person-years incidence. GTonClon = 25%.
Aet: Provoked (–Glucose, Eclampsia)/ Unprovoked (Epilepsy). Primary generalised tend to be genetic. Secondary (to focal) are more lesion-associated.
Hx/Sx: ±NeurologicalDeficit before/after seizure. ±TemporaryHemiPlegia ±MeningSigns ±PreLimSx (Fear, Deja/Jamais).
Ix: EEG (–Sensitivity) +Glucose +FBC (?Encephalitis) +U&Es +CT
Mx: Ongoing: 1. Valproate, or F: Lamotrigine / Keppra (Levetiracetam).
2. Try other from above or: Topirimate, Carbamaz, Phenytoin.
3. Duel therapy from above.
Acute: Buc/Rect Midaz/Diaz, IV Loraz, IV Phenytoin, then anaesthetics.
Driving: 1st = 6m off. Established / Multiple unprovoked = 12m. No lorries for 5y. Withdrawal off drugs: 6m after last dose.
Status Epilepticus (SE)
Epi: 1/20,000 incidence.
Aet: Anti-Epileptic withdrawal / hypoxia / stroke / alcohol-withdrawal. Prolongued = ++Glutamate = Damage to Limbic System.
Hx/Sx: Prolonged tonic-clonic seizures w/ altered level of consciousness (Convulsive SE). Non-Convulsive SE (NeuroDeficits etc) may follow.
Ix: EMERGENCY: Glucose, ABG, urea, Cr, LFTs, U&Es, FBC (WCC), CRP, Coag. ++AntiConvulsant Drug Level (?Withdrawal due to PoorCompliance).
Mx: 1. Rule out non-epilepsy (NEA) and give Oxygen if needed.
2. Give Bucal/Rectal Midaz/Diaz.
OR 3. Give IV Lorazepam.
Maximum of 2x of 2 and/or 3 are given.
4. Phenytoin / Valproate / Levetiracetam (Keppra).
5. Get anaesthetist for GA or Phenobarbital.
“Oh My Lord, Call the Anaesthetist”.
Syncope
Epi: 0.8% of emergency department visits.
Aet: Cardiac (Dysarrhythmia, Tamponade etc), Reflex (Vasovagal, CarotidSinus, Situational), Orthostatic (Dyautonomia, Hypotension), Neuro (SAH, ?Migraine), Metabolic (–Glucose, –O2, –Co2), Psych (Anxiety, Convers).
Hx/Sx: DM Hx (?–Glucose), FHx sudden death (?Cardio), Posture+Prodrome+Provoking. +Before/after (?Neurological) +Other signs +LengthOfTime.
Ix: Clinical offers a lot. +ECG +L/S-BP (>20 drop=POTS) +NeuroExam +FBC (?Anaemia) +
Mx: Reverse any cause (Glucose), manage any long-term diseases better and encourage compliance.
(Psychogenic) Non-Epileptic (Seizures) Attack Disorder (NEAD)
Epi: ~1/5000 incidence. 5-20% of epilepsy outpatients.
Aet: Chronic stress or conflict ±Taboos against emotional expression ±Emotional Processing deficit. Subconscious and thought to be related to dissociation.
Hx/Sx: FamilyMember w/Epilepsy. Thrusting, ++F, Don’t occur when alone, +Crying +Falling down +LACK of severe tongue-biting, no rise in prolactin (as in epilepsy). Slightly longer duration that average seizures.
Ix: Lab-Tests + EEG (Both normal).
Mx: Explain +Manage consultation empathetically. Discontinue Epilepsy Meds. ±CBT ±SSRI (w/ Depression/Anxiety) ±Hypnosis ±Aripiprazole (If SSRIs fail).
Acute: Calm, get people to leave the room, no treatment.
Pneumonia
Epi: CAP: 1/1000 person-years.
Aet: Community (CAP)- S.Pneum, H.Flu, S.Aur, S.Pyo. 22% Atypical (E.g., Mycoplasma).
+Hospital (HAP) (>48h admission) +Ventilator (VAP) (>48h intubation).
Hx/Sx: Cough ++Sputum +SOB ±Confusion ±Fever ±Night-Sweats ±PleuriticChestPain ±AsculationFindings (Crackles, dullness, wheeze).
Ix: CURB65: Confusion +Urea >7 +RR >30 +BP <90/60 +Age >65y.
+CXR +O2% +ABG +FBC (WCC > 15 = bacterial) +CRP (>100) +LFTs (?Legionella) ±Cultures ±Sputum ±CT/USS (?Effusion).
Mx: CURB65:
1/2 = 5d PO Ammox / Claryth / Eryth (Preggo).
3/4/5 = Co-Amox PO / Claryth PO / BenPen IV.
Frailty
Aet: Older age +Osteoperosis +Polypharmacy (Opioids +Specific Anti-ACh Burden: TCAs, Furosemide, AntiHistamines, AntiEmetics, AntiACh) +Sarcopenia –ADLs. +Strokes
+Barthel Index (Strokes)
+Waterlow (Pressure sores)
+ORBIT (AF-Bleeding)
+AMT (CogImpair = <8/10).
+Clinical Frailty Score (/9):
1= Fit. 9= Terminally ill. 7= Dependent. 5= Need help with hard ADLs.
Hx/Sx: Weakness, tiredness, weight-loss, dementia/confusion, –ADLs, falls, fractures.
Ix: L/S BP ±ECG (?AF) ±AMT ±CT-Head ±DEXA (<-2.5) ±FBC (?Hb) ±U&Es (++Ca?) ±Cr/Ur/eGFR (?CKD) ±CXR (?Pneumo) ±UrineDip (Delirium).
Mx: DePrescribing (ACB), Fludrocortisone (Orthostatic –BP), Bisphosphonates+VitD+Ca. ±AntiCoag (?ORBIT). ±PT/OT.
Osteoporosis
Epi: 50% F & 20% M Fractures >50y.
Aet: Low bone mass, abnormal bone architecture, low bone mineral density, & a low peak-bone mass in earlier life. –Oestrogen, –VitD, –Ca. +RANK-L issue.
Hx/Sx: Back pain ±Kyphosis (VertFrac) ±Hx secondary amenorrhoea, smoking, steroids, –VitD, –Ca, ++Immobile, FamHx.
Ix: DEXA (May not be needed in women >75y w/Signs of LowBMD) (<-2.5 = Osteoporosis. <-1.0 = Osteopenia). +FRAX (10y frac-risk) +XR +PTH/Ca/Phos/ALP/VitD (Normal).
Mx: Bisphosphonates +Ca +VItD ±TestosteroneReplacement ±Teriparatide (PTH-Segment). Above CI: Denosumab (MonoClAb).
Hypoparathyroidism
Epi: 1/3333 prevalence.
Aet: 80% Post-surgical, Autoimmune, 22q11.2d, ++/–Mg. –Calcium ++Phos. Low PTH OR High-PTH +PTH-Resistance (?Receptor issue -Pseudohypopara).
Hx/Sx: ±SurgicalHx, Poor Diet, Alcoholism. Face-tap = Spazm. ±Convulsions.
Ix: Ca (Low), Albumin (Corrected Ca), Mg (–/++Mg?), VitD (Deficient), PTH (?Pseudo), ECG (?Long QT).
Mx: Acute: CaGluc. ±Mg (In –Mg) +Correct any alkalosis (++Albumin binding).
Ongoing: VitD +Ca ±PTH.
HyperCalciUria: Thiazide +Low salt diet.
Primary Hyperparathyroidism PHPT
Epi: 1/500 F, 1/2000 M >40y.
Aet: Adenomas (80%) / MEN1/MEN2 (AD) / Lithium > ++PTH > +BoneResorp +VitD +KidneyReabsorp > ++Ca/–Phos
Hx/Sx: ±Osteoporosis (++Resorp)
Moans (Depression), Groans (Myalgia), Thrones (++Urine/Const), Stones (CalcOxalate).
Ix: Ca (++), Phos (Low/Normal), PTH (++), VitD (If low, this could elevate the PTH levels), DEXA (Osteoporosis). ±CT/MRI neck for Mx planning.
Mx: Surgery ±VitD ±Bisphosphonates ±Cinacalcet (Calcium Mimetic- Think “Syn”acalcet -Suppresses PTH).
Secondary Hyperparathyroidism
Epi: CKD prevalence = 6.7% - 80% at risk of –VItD and ++PTH.
Aet: CKD (Starts around GFR=45 / Stage 3a) / VitD-Deff. PsudohypoPTH is also, technically, a secondary hyperPTH, as fewer receptors = ++PTH.
Hx/Sx: Bone pain (–Ca > ++PTH > Bone Resorption), Rickets / Osteomalacia, Face-Tap-Spaz Sign ±Hx CKD.
Ix: iPTH (++), Ca (–), Cr/Urea (eGFR), Phos (++ = CKD as cause, – = ?VitD / Other). High Ca+Phos = Calciphylaxis risk. VitD (– = Cause), Mg (Cause PTH resistance or –release), USS Neck.
Mx: +VitD: Sun exposure ±Supplement.
±Ca Supplement.
CKD: Less phosphorous consumption.
Persistant ++PTH: Cinacalcet (“Syn”acalcet - Mimetic) / Surgery.
Diabetes Insipidus (DI)
Epi: 1/20,000 prevalence. Central DI More common.
Aet: Anything damaging pituitary (Tumour, haemorrhage, Phenytoin) = Central. Nephrogenic: Lithium. Both: Genetic.
Hx/Sx: Polyuria/Nocturia +Polydipsia. FHx / PsychHx / AutoImmuneHx / Brain-SurgeryHx.
Ix: Water-Deprivation + synADH (Low UrinOsmol unchanged w/Deprivation
then ++w/synADH =Neurogenic.
then remains unchanged =Nephrogenic.
Increasing from start =PrimPolydipsia).
+UrineDip/Glucose (DM) +K (– in Nephrogenic) +Na (++)
Mx: Neurogenic: ADH + Fluids PO/IV.
Nephrogenic: ++Fluid intake, low sodium, Thiazide.
Primary (Psychogenic) Polydipsia (PPD)
Epi: 6-20% of psych patients.
Aet: Strongly associated with schizophrenia “Feels better” +Anorexia Nervosa (?Reduce hunger) +Smoking (Nicotine stimulates ADH release) +Alcohol-abuse. 3-6% develop –Na.
Hx/Sx: Water-seeking +Drinking, Agitation prior to water-loading. ±Polyuria ±Headache ±N/V.
Ix: Ser-Osmolality (<280) +Ur-Osmolality (<100) +Ser-Na (<135) +Ur-Na (<20). 24-Urine-V. Urea (?Renal Failure) +Urinalysis (?UTI) Water-Deprivation test (++Urine osmolality).
Mx: Severe –Na: 3% NaCl (Hypertonic).
Chronic: Fluid restriction ±Furosemide (Add salt specifically to get it to suck water into urine) ±AtypicalAntiPsychotic (Schizophrenia).
Type 2 Diabetes Mellitus (T2DM)
Epi: 8.3% prevalence.
Aet: ++Insulin resistance (And lower relative insulin) Due to: ++BMI ++Age.
Hx/Sx: Polydipsia +Polyuria. ±Candidiasis ±Cellulitis ±Fatigue ±BlurredVision ±Weight-loss ±AcanthosisNigricans (InsulinResist).
Ix: FastingGluc/>8h (>7) +RandomGluc/2h-75g (>11.1) +HbA1c >48 (Measure every 6m) ±FastingLipids ±UrineKetones ±C-Peptide (?T1)
Mx: Lifestyle if 42-48HbG
1: Metformin Max 2000mg/d. Aim for 48, Not in eGFR <30, PO.
±SGL2 (-Flozin) ++w/ HF. CI w/–eGFR, Risk of DKA (As not Insulin-related), PO
2: >58HbG: Dual therapy w/ aim of 53:
±DPP4 (-Gliptin), PO
±Thiazolid (-Glitazone), PO
±Sulfonylurea (Gliclazide), PO
3: >58HbG: Triple therapy w/ aim of 53:(Or Double wo/ Metformin)
- Insulin SC
&/Or GLP-Mimetic (-Tide), BMI >35, SC. - ±Bariatric Surgery.
Syndrome of Inappropriate ADH (SIADH)
Epi: 30% cases of hyponatraemia in cancer patients.
Aet: Small-Cell, Pancreas, Prostate Cancer. Also: Antidepressants, Carbamazepine, Amiodarone, Chemo. +Other pulmonary issues.
Hx/Sx: NO hypovoolaemia & NO hypervolaemia (So, Normovolaemic), –Na, N/V. NO signs of Addison’s/Hypothyroid. ±Seizures, coma.
Ix: Na (Low: <135) +Ser-Osmol (Low: <275) +Ser-Urea (Low) +Ur-Osmol (High: >100) +Ur-Na (High: >30). ±Sodium-Infusion Trial (Ser-Na will NOT improve in SIADH).
Mx: Acute: 3% NaCl. Treat underlying cause +FluidRestrict ±Furosemide (Add and flush sodium w/ water).
Chronic: ADH-RecepAntag: Conivaptan.
Primary Hypothyroidism
Epi: 0.2-5.3% prevalence. F>M.
Aet: IodineDef (Global), Hashimotos (Europe), Iatrogenic (RadioIodine, Lithium). Primary = Damage to thyroid gland.
Hx/Sx: Constipation +Weight gain + Lethargy +WeightGain +Bradycardia ±Cold-sensitivity.
Ix: TSH (>10) +Free-T4 (Normal = ?Subclinical) ±TPO (?Hashimoto’s) ±FBC (Mild normocytic anaemia?) ±FastingGlucose (?Tiredness).
Mx: Levothyroxine. Low dose with CVD or sub-clinical. Titrate up until TSH normalises.
Hashimoto’s Thyroiditis / Autoimmune Hypothyroidism / Chronic Lymphocytic Thyroiditis.
Epi: 1/3000 person-years incidence. F:M = 8:1.
Aet: HLA-DR3/DR5. Anti-TPO Abs. ±Lymphocytic invasion of thyroid. ±Initial hyPERthyroid phase. Leading to chronic HyPOthyroidism.
Hx/Sx: Painless ±Goitre. Cold Intolerance, weight gain +Fatigue +Constipation +Hypertension +Bradycardia.
Ix: TSH (+), T4 (-).
Mx: Levothyroxine. Low dose in CVD- Titrate up until TSH levels are normalised.
De Quervain’s / Subacute Thyroiditis / Subacute Granulomatous Thyroiditis.
Epi: 1/20,000 incidence.
Aet: ?Viral (Seasonal variation) on top of a genetically predisposed person. Returns to normal function in >90% pts. 4-6w ++Thyroid, 2-6m –Thyroid.
Hx/Sx: Pain, tender thyroid. +Fever ±Palpitations ±RecentVirus ±Tremor ±Heat-Intolerance.
Ix: ESR/CRP (++) +TSH (- at start, variable later) +T3/T4 (++) +I-123 Scan (Very low uptake in all phases, better in recovery) +TPO (Normal/Elevated).
Mx: Hyperthyroid: ±Iodine (Prevent T4 conversion to T3).
Symptoms: Propanolol / Verapamil. Pain: NSAIDS, Paracetemol, Codeine, or finally, prednisolone.
Hypothyroid (TSH >10): Levothyroxine.
Toxic Multinodular Goitre
Epi: 1/60,000 incidence in Iodine-Sufficient populations. ++Older.
Aet: Iodine deficiency = main risk factor. Therefore, this is the most common cause of hyperthyroidism in developing countries.
Hx/Sx: Lumpy, irregular goitre.
RF: Prior Iodine deficiency, Neck radiotherapy, or increasing age. +Tremor +Heat-Intolerance +Tachycardia +Weight-loss.
Ix: TSH (Needs to be low). T3/T4 (++), I-123 Scan (Multiple Hot+Cold areas). TPO/TSH ((-), but not specific).
Mx: 1. I-131 therapy (If not preggo). ±Carbimazole ±Propylthyrouracil.
2. Thyroid surgery (Risks of recurrent laryngeal damage or hypocalcaemia).
Pregnancy: Propylthyrouracil - Ideally not in 1st trimester.
Grave’s Disease
Epi: 1/3333. Larger proportion of hyperthyroidism in developed countries.
Aet: TSH-R-Abs (But also present with elevated TPO Abs, as it is a spectrum of disease). TSH receptors found in retro-orbital and dermal tissue.
Hx/Sx: Heat intolerance, ++HR, –Weight, Palpitations, PreTibial Myxoedema, Tremor, Goitre (Diffuse), Proptosis. ±CardiacFlowMurmur.
Ix: TSH (–), TSH-R-Abs (++), T3/T4 (++ Unless subclinical). ±I-123/Tc-99 scan (Diffuse uptake).
Mx: Symptoms: Propanolol.
Antithyroid Drugs (Carbimazole / Propylthyrouracil).
OR Thyroid Surgery
OR Radioactive Iodine +Steroids.
Thyroid Storm (CHF, Shock, N/V): High dose Carbimazole +Propanolol +Iodine +Steroids.
Urinary Tract Infection (UTI)
Epi: 50-60% lifetime incidence in F.
Aet: E.Coli = 70-90%. Proteus, Klebsiella. GBS. ±Decrease in urine flow > Ascending infection.
Hx/Sx: ±Dysuria ±Nocturia ±Urge Frequency ±Cloudy Urine. ±Fever ±Flank-Pain ±Haematuria (Ix if absence of other features) ±Incontinence.
Ix: Dipstick +Mic/Cult/Sens ±USS kidneys.
Mx: Complex: 7 Days. Simple: 3 Days.
Complex = Catheter, Male, Pregnant.
1. Trimethoprim (Not in 1st Trim) / Nitrofurantoin (Not in 3rd Trim or eGFR <45).
Pregnant: Cefalexin or Cefuroxime.
Pyelonephritis
Epi: 0.5-2% in pregnant women.
Aet: E.Coli (60-80%), Proteus (5%). Ascending (Cystitis first) or seeding from blood. Asymptomatic pyelo occurs in 30% of women with cystitis.
Hx/Sx: Flank Pain +Fever ±Myalgia +CostovVertebralAngle Tenderness +N/V
Ix: Urinalysis (Protein, Leuks, MicroHaem) +M/C/S +BoodCultures +U&Es +Cr (Kidney Function). ±USS/CTKUB (?Stones).
Mx: Complicated = Preg/Male/Catheter.
7-10d of Cefalexin / Co-Amox
14d Trimethoprim (Not in 1st Trim).
±Analgesia
Complicated: IV Co-Amox / Cefuroxime
Acute Kidney Injury (AKI)
Epi: Seen in 10-20% of hospital emergencies.
Aet: Pre (–Perfusion), IntaRenal (E.g., HaemolyticUraemicSynd), Post-Renal (E.g., Stones). 45% = Acute tubular necrosis- which is caused by sepsis in 19% of ICU patients.
Hx/Sx: RF: >65, CKD/CHD/LF/DM Hx, Myeloproliferative disease, Prev AKI ±DAMN drugs ±LowBP ±ReducedUrine ±Lower UT Sx ±Haematuria ±N/V ±Oedema ±Fever/Rash.
Ix: Stages 1-3: Cr (Rise by 50/100/200%) +6/12/(24)h Urine (<0.5(0.3)ml/kg/h).
+U&Es (eGFR) +K/ECG (++K) +FBC/CRP +Bicarb (Risk of acidosis) +Urinalysis +FluidChallange (Response = Pre-Renal) ±CXR/BloodCultures.
Mx: Fluid Resus (500ml NaCl bolus over 15m) - 250ml if HF, Hartmann’s if NOT ++K. +More boluses up to 2L.
+Stop Nephrotoxics (DAMN) +Treat Underlying Cause. ±Noradrenaline ±Vasopressin
±CalciumGluconate / Insulin / Dextrose (++K)
±Bicarb (Met Acidosis).
Chronic Kidney Disease (CKD)
Epi: 9-13% prevalence.
Aet: 1: DM: 1/3 patients will develop CKD. 2: HTN. 3: PKD/Nephritic syndromes etc. Stages 1-3b-5 (eGFR >90,60,45,30,15).
Hx/Sx: Fatigue ±Oedema ±N/±V ±Pruritus ±RestlessLeg (Uraemia) ±EnlargedProstate ±Orthopnoea ±Seizures. +RF (>65y, DM, HTN).
Ix: U&Es +Cr +Glucose +eGFR (Cr, <60. Uses CYSTATIN-C in people w/ high muscle-mass) +Urinalysis (Protein / Blood?) +USS-Kidney ±Biopsy.
Mx: 1: ACE/ARBs for BP ±SGLT2 (w/wo DM) +Statin.
Complications: ±EPO/Iron (Anaemia) ±Lower Phosphate/VitD (++Parathyroid) ±Bicarb (Acidosis) ±Glycaemic Control.
2: Verapamil / Diltiazem.
3: Stage-V: Transplant
or Dialysis: Peritoneal: Continuous at night. Haemo: 3x4h/7d.
Hypertension (HTN)
Epi: 1/7 prevalence. 31% of men in England.
Aet: Stage 1&2 BP >140/90 (ABPM >135/85) & >160/100.
Reflex+Increasing TPR to match CO. ++Na intake. +Renin & Na retention. +InsulinResistance.
Hx/Sx: ±Asymptomatic ±Retinopathy ±Headache ±ChestPain ±Dyspnoea.
Ix: ECG +eGFR +TSH +Hb +Lipids ±Renin/Aldosterone (?Conn’s) ±24h-Catecholamines (?Phaeo)
Mx: 1. Lifestyle +
Black/>55y: CCB / Thiaz-Like-Diur
DM/<55y: ACE-I/ARB (-Pril / -Sartan)
2. + ACE-I/ARB/Thiaz-Like or CCB.
3. All 3 of above options.
4. K>4.5: +a/b-Blocker. K<4.5: +Spiro.
5. Specialist.
Heart Failure (HF)
Epi: 1-2% prevalence.
Aet: CoronaryArteryDisease +HTN +Valvular Disease +Myocarditis +Other causes. Preserved/Reduced EjFrac (StrokeVolume <40% predicted). Also stages I-V (Mild-Discomfort@Rest).
Hx/Sx: Dyspnoea (++Orthoptic) ±NightCough +Neck-Vein distension ±S3 Gallop +CardioMegaly ±Hepatomegaly ±Rales ±AnkleOedema.
Ix: TTEcho (SysHF: Dilation –EjFrac. DiasHF: Hypertrophy ±Preserved EjFrac) +ECG (?QT++) +CXR (CardioMeg, KerlyB, AlveoOdema. DilatedUpperVessels, Effusion) +BNP (++) +FBC (?Anaemia) +U&E (–Na) +LFTs (?Congestion) +Other tests for cause.
Mx: Furosemide +ACE/ARB +b-Block ±SGLT2 (Start one drug at a time).
±Statin ±Aspirin/Clopidogrel +Vaccines ±Amiodarone/Digoxin. (AF).
Atrial Fibrillation (AF)
Epi: 0.5-1% prevalence.
Aet: Many: A/V dilation/hypertrophy ±Sick-Sinus ±Tumours ±Thyroid ±Alcohol/Caffeine ±Infections.
Paroxysmal = >1 x >30s self-resolves in 7d.
Persistent = >7d (Corrected by Cardioversion).
Permanent: Persistent +Failed Cardioversion.
Hx/Sx: Palpitations +Tachycardia +Irregular Pusle ±Stroke ±SOB ±ChestPain ±Murmur (Normally Mitral Stenosis ±RheumaticFever).
Ix: ECG (No Ps, irregularly irregular) +TFTs +Echo (Ideally trans-oesophageal to exclude thrombus BEFORE cardioversion) +U&Es.
Perform ORBIT and CHA2DS2VaSc.
Mx: Acute, HaemUnstable: DC Cardioversion.
Paroxysmal / Persistant:
Exclude Clots and/OR Start DOAC 3w before +Continue DOACs 4w after.
±Amiodarone 4w before DC +12m after.
Medical: Amiodarone (Struc Defect) or Flecainide (No Struc Defect).
Long-term: Apixaban (Reverse: Andexanet) / Dabigatran (Reverse: Idarucizumab)
+Atenolol / Diltiazem / Digoxin (–Rate).
Treatment resistant: Ablation (Needs to have detectable pathology).
Eczema
Epi: 15-20% Children. 1-3% Adults.
Aet: Genetic: Mostly Filaggrin gene. ++Environment: ++Cities, ++Lower SE-Status. Irritants +Infections +Allergens lead to breakdown of barrier.
Hx/Sx: Pruritus +DrySkin (Xeroxes) +TypicalSite (Flexor surfaces in teens/adults. May be on chin/scalp/forehead in children). +Scaling +Vesicles +Papules +Excoriations.
Ix: Clinical Diagnosis. ±IgE-test (+Food allergy test after initial mx). ±Patch-allergen testing.
Mx: 1. Barrier-Cream +Emollients. ±Intermittent topical Hydrocortisone.
?Infection (?Impetigo): Abx (Topical or oral).
2. Systemic steroids / cyclosporin / Tacrolimus.
Psoriasis
Epi: Prevalence variable.
Aet: Genetics (60-90%). External insult to susceptible individuals: Trauma, infection, lithium, b-Blockers. Guttate = 2nd to Strep-Throat or HIV. Hyperproliferative disease.
Hx/Sx: Scaly, red, circumscribed lesions. NailPitting +FHx ±JointSwelling ±Patches on extensors.
Ix: Clinical Dx. In doubt: Skin biopsy.
Mx: 1. Topical Hydrocortisone and/or Calcipotriol (VitD).
Moderate/Severe: Phototherapy +Methotrex / Ciclosporin ±Oral retinoid (Acitretin).
Psoriatic Arthritis
Epi: 1/10,000
Aet: 30-50% have psoriasis in 1st-degree relative. 15% have same disease in 1st degree relative. HLA-B27. CD8+ T-Cells.
Hx/Sx: “SPINEACHE”. FamHx +JointPain +Stiffness +PeripheralArthritis +Dactylitis +Scalp / Nail Problems.
Ix: XR hand+feet. RF (Can rule out RA in some) +ESR/CRP (Should be normal) +ACCP (Should be negative in most) +UricAcid (Normal/++) +Lipids (Risk of metabolic synd).
Mx. NSAIDs ±Physio ±Steroid-Injections (Up to 3x annually).
Progressive: DMARDs (Metho / Ciclo) ±TNF-a-I (Entanercept / Infliximab)
Rheumatoid Arthritis
Epi: 0.24-0.56% prevalence.
Aet: HLA-DR4 genetic factor. ±Infection in susceptible individuals? Inflamed synovium > ++Angiogenesis +T/B cells +TNF/IL1/IL6.
Hx/Sx: ±Age 50-55y. >6w active, symmetrical arthritis ±Female ±Joint pain / swelling / stiffness. +MorningStiffness >30m ±Nodules ±Scleritis ±Swan-Neck ±UlnarDeviation. Leads to Felty (+Splenomeg –WBCs) ±Interstitial Lung Disease ±
Ix: RF (Non-specific) +ACCP (Specific) +Radiographs (LESS - LossOfJointSpace +Erosions +Soft-Tissue +SoftBones).
Mx: 1. NSAIDs +Methotrexate / Sulfasalazine ±PO OD steroids / IM steroids every 1-4w as “Bridging” therapy.
Severe: ±TNFa-I (Infliximab / Entanercept).
Ankylosing Spondylitis
Epi: 1/500 prevalence. M > F.
Aet: HLA-B27. 97% inheritable. Inflammation > Erosion > Repair.
Hx/Sx: Inflammatory back pain (Worse in morning) +Uveitis +Enthesitis +FamilyHx ±Fatigue ±Dyspnoea ±Kyphosis ±Psoriasis (10% - THESE ARE NOT Psoriatic Spondylotic patients).
Ix: Pelvic XR (Sacroiliitis) ±MRI (Bone-Marrow Oedema) ±B27 (Not diagnostic).
Mx: Acute: 1. Naproxen +Paracetamol.
2. Hydrocortisone injections.
W/ Peripheral Joints: Methotrex / Sulfasalazine.
Long-Term: TNFa-I: Infliximab / Entanercept +NSAIDs +Physio.
Systemic Lupus Erythematosus
Epi: 1/5000 person-years incidence.
Aet: 43.9% heritable. Many gene loci. +DRUGS: Terbinafine, Sulfasalazine, Isoniazid, Phenytoin, Carbamazepine. High affinity of antibodies to dsDNA.
Hx/Sx: Butterfly, photosensitive Rash (30-40%).
Additive Criteria: Constitutional: FEVER. Haemo: –Leukos, –Thrombocytes, Autoimmune haemolysis. Neuro: Delirium, psychosis, seizure. Mucal: Alopecia, oral ulcers, cutaneous lesions. Serosal: Pericardial/Pleural Effusion. MSK: Joint involvement. Renal: ?Proteinuria.
Ix: ANA (Must be present) +FBC (Lymphopenia) +APT (?Long) +U&Es (+Urea/Cr) +ESR (++) +ANA/dsDNA (+) +CXR (?Effusion) +ECG (?Chest Pain).
Mx: Hydroxychloroquine ±NSAIDs.
Steroids: Useful to do pulses of IV steroids reduce SideEffects x3d.
±Methotrexate / Azathioprine ±Rituximab.
Clotting issues: Anti-platelet or Anticoag.
Haematological issues: TPO-Agonist or Splenectomy.
Anti-Phospholipid Syndrome (APS)
Epi: 1-5.6% have antibodies.
Aet: W/wo any autoimmune conditions underlying- But most commonly SLE associated (25% of SLE pts) and RA (6%). Abs bind to various blood-phospholipids and can cause thromboses.
Hx/Sx: Hx or dx of vascular thrombosis ±Hx of lost pregnancy or pregnancy morbidity. ±SLE ±PetichialRash ±GumBleeds ±Arthralgia ±Murmur (vegetations).
Ix: Serum Lupus-Anticoag +Anti-CardioLipin +anti-b2-glycoprotein +ANA +dsDNA +FBC (–Platelets?) +Cr/Urea (Nephopathy?).
Mx: Acute/Diagnosed: LMW (Preferred in pregnancy- Endoxaparin) or Unfractionated (Deltaparin) Heparin
Then: switch to Warfarin.
Pregnancies: LMWH +75mg/d Aspirin upto 6-8w postnatally.
Polymyalgia Rheumatica
Epi: 1/1700 incidence. PkAg >60y.
Aet: Acute onset. Link to infections, link to HLAs. IL6 +Link to GCA +Fewer B cells and ++T cells.
Hx/Sx: Shoulder +Hip stiffness +Pain +Rapid response to steroids. Acute ±Fever ±Weight-Loss ±Anorexia ±Malaise. ±GCA.
Ix: ESR/CRP +FBC ±TSH (Normal) ±ACCP/RF (Normal) ±CK/EMG (Normal).
Mx: Pred 12-25mg for 3-4w until ESR/CRP stabilise. Taper dose.
+Ca/VitD/Bisphosphonates
±NSAIDs.
2. Methotrex as a steroid-sparing mx (Check lungs with XR to exclude interstitial lung disease before) +Folate.
3. Tocilizumab (IL6-Antag).
Systemic Sclerosis
Epi: 1/4000 prevalence.
Aet: ANA +Genes assoc. 3 patterns:
Limiting Cutaneous (Distal Limbs +CREST - AC-abs).
Diffuse Cutaneous (Trunk+Proximal limbs, lung involvement - scl-70).
Scleroderma (No internals, just skin).
Hx/Sx: ±Raynauds ±DigitalPits/Ulcers ±SkinThickening ±ReducedHandFunc ±Dysphagia/Heartburn ±Telangiectasia ±Calcinosis ±Dyspnoea ±Fatigue ±DryCough.
Ix: Anti RNA/scl/NA +FBC (?MicroAnaemia- Bleeding) +Urea/Cr (?RenalFailure) +ESR/CRP (+ = Poor prognosis) ±ECG/Echo ±CXR (?Interstitial Lung disease) ±BariumSwallow (–Peristalsis?)
Mx: Renal: ACE ±CCBs etc (–BP)
CardiacTamp: Pericardial window surgery +Prednisolone.
Raynaud’s: CCB ±Aspirin +Lifestyle. Progression to ulcers: PDE5-Inhibitors +EndothelinInhibitor +Analgesia.
Gastric: Erythromycin then Octerotide.
Myopathy: Steroids then Methotrex (sparing- CHECK LUNGS).
Lungs: Steroids + O2 ±Lung Transplant.
Fibromyalgia
Epi: 0.5-5% prevalence. PkAg 30-50y.
Aet: CNS: Pain/Sensory amplification. One of multiple chronic-pain conditions (IBS, headache, etc.). Some stressors may incite it (Rheumatic disease, Lyme, EBV).
Hx/Sx: Chronic pain (>3m) +Diffuse tenderness on examination. ±Fatigue unresolved by rest ±SleepDisturbance ±Headache ±Stiffness.
Ix: Clinical Dx: 9 pairs of tender points; 11/18 makes Dx likely. All the following = normal: TFT/ESR/FBC//VitD and RF/ACCP/ANA (Not recommended due to high false(+))
Mx: Explanation ±AerobicExercise ±CBT ±Drugs: Amitryptaline, Pregabalin, Duloxetine.
Sjogren’s
Epi:
Aet:
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Ix:
Mx:
Rheumatic Fever
Epi:
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Tuberculosis
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