Core Conditions Flashcards
Respiratory Malignancy
Definition:
Bronchial carcinoma, malignant tumour of the bronchial tree.
Most common malignancy and third most common cause of death in UK
Types:
Small Cell 20-30%
Non-small cell
Squamous 40%
Large Cell 25%
Adenocarcinoma 10%
Bronchoalveolar 1-2%
Aetiology:
Smoking (including passive) - squamous
Urban>rural
Occupational - adeno (asbestos, coal, chromium, aresenic, petroleum products and oils, radiation
Clinical Features:
Cough 41%
Chest Pain 22%
Cough & Pain 15%
Haemoptysis 7%
Chest Infection
Others (SoB, malaise)
Investigations:
CXR
Bloods - hyponatraemia, polycythaemia, anaemia
CT & PET for staging
Bronchoscopy biopsy
Management:
MDT
Surgery - 5-10% of cases suitable. Non-small cell only
Radiotherapy - squamous, symptom control, SVC obstr.
Chemotherapy - combination therapy
Prognosis:
55-67% 5-year survival with local disease
23-40% 5-year survival with locally advanced
1-3% 5-year survival with advanced disease
Hyperthyroidism
Definition:
Characterised by increased plasma concentration of free T4
Aetiology:
Grave’s Disease
Toxic multinodular goitre
Single toxic nodule
Gestational
Clinical Features:
Heat intolerance
Weight loss
Increased appetite
Diarrhoea
Irritability
Sleepleessness, tiredness
Exertional SoB
Goitre
Tachy / AF
Tremor
Hyperkinesia
Proximal muscle wasting
Cardiac failure
Pretibial myxedema
Eye Signs (Grave’s):
Exopthalmos
Lid lag
Lid retraction
Opthalmoplegia
Investigations:
T4 up
TSH down
Management:
Carbimazole
Propylthiouracil
Radioiodine
Surgical for:
Malignancy
Pressure symptoms
Failure of medical treatment
COPD
Definition:
Non-reversible progressive airflow limitation
Aetiology:
Smoking 90% of cases
Rarely alpha1-antitrypsin deficiency
Clinical Features:
Cough & sputum
Wheeze
SoB
Exacerbating factors - URTI, cold weather, pollution
Tachypnoea
Signs respiratory compromise or RHF
Investigations:
Spirometry
CXR - hyperinflation, flat diaphragm
ABG
ECG - P pulmonale, RBBB, RV hypertrophy
FBC -
Management:
Stop Smoking
Flu & pneumococcal vaccines
ß2 agonists
Antimuscarinics
Corticosteroids
Abx if required
Mitral Stenosis
Aetiology:
Rheumatic Fever
Clinical Features:
Secondary to Pulmonary HPT
Progressive SoB
PND
Orthopnoea
Haemoptosis
Recurrent Bronchitis
Others
Malar Flush
⇓Pulse Volume
AF
Heart Sounds
Tapping Apex Beat
Loud 1st Heart Sound
Opening Snap
Rumbling Mid-diastolic Murmur @ Apex
Signs of RVF
Investigations:
CXR – large L atrium, convex L heart border
ECG – bifid ‘P’ wave, AF, R ventricular hypertrophy, R axis deviation
Echocardiogram –
Management:
Medical:
Diruretics
Rate control for AF (β-blockers, Ca2+-blockers, Digoxin)
Anticoagulation
Endocarditis Prophylaxis
Surgical:
Balloon Valvotomy
Closed Valvotomy
Open Valvotomy
Replacement
Complications
AF
Emboli
Pulmonary HPT
Pulmonary Infarction
Chest Infections
Tricuspid Regurgitation
RVF
Dementia
Definition:
Progressive decline of cognitive function in the absence of clouded consciousness
Alzheimer’s - Neuronal loss, neurofibrillary tangles, senile plaques, amyloid deposition
Lewy Bodies shown on CT
Aetiology:
Alzheimer’s (65%) - may be familial
Lewy Body (25%)
CVD
Clinical Features:
Alzheimer’s - Inability to learn new or recall old information, decline in language (names), apraxia, impaired organizing / sequencing, behavioural change, paranoia & loss of insight
Lew Body - Fluctuating cognition with pronounced variation in attention / alertness, memory loss uncommon early on, sleep disorders, visual hallucinations, delusions & transient LOC
Vascular - Hx of stroke
Investigations:
Rule out delerium:
FBC, U&Es, ABG, BM, cultures, LFTs, TFTs, ECG, CXR
?CT / MRI, LP
MMSE
Management:
Alzheimer’s - cholinesterase inhibitors (eg rivastigmine, galantamine), NMDA (eg Memantine)
Lewy Body - avoid neuroleptics (antipsychotics)
Vascular - Stroke prevention
Anorexia
Definition:
Reduced nutritional intake and an irrational fear of gaining weight due to distorted fears of body image
Aetiology:
Genetic
Childhood sexual abuse
Dietary problems in early life
Social - higher class, ballet dancers, medical students
Clinical Features:
BMI
Intense wish to be thin & morbid fear of fattness
Amenorrhoea
F>>M with adolescent onset
Previously fat or chubby
Avoids carbs
Vomiting / excess exercise / purging
Loss of libido
Investigations:
Clinical diagnosis
Management:
CBT - goal setting with rewards
Psychotherapy
Family therapy
Pulmonary Embolism
Definition:
Embolus causing partial or total occulsion of the pulmonary artery or its tributaries.
Aetiology:
Usually arise from a venous thrombus in the pelvis or leg which gives of a clot whch travel through the right heart.
Risk Factors:
Recent surgery or prolonged bedrest
Recent stroke / MI
Disseminated malignancy
Thrombophillia / antiphospholipid syndrome
Pregnancy / post-partum / ?OCP/HRT
Clinical Features:
SoB, pleuritic chest pain, haemoptysis, dizziness, syncope COULD BE NO SYMPTOMS
Tachy, hypotension, cyanosis, tachypnoea, raised JVP, pleural rub, pleural effusion
Investigations:
FBC - infection (WCC), Anaemia (Hb), Platelets
U&Es – Electrolyte disturbances, renal function
Clotting Screen – baseline
*D-Dimer – only if no other explaination for clinical features
ABG – May show ¬⇓Pa02 and ⇓PaC02 (hyperventilation)
CXR – May be normal, or show oligaemia, dilated pulmonary artery, effusion, wedge-shaped opacities.
ECG – May be normal, or show tachy, RBBB, R vent. Strain (inverted T in V1 – V4). *(S1, Q3, T3 pattern is rare)*
Management:
WELLS SCORE FOR PE (gives probability)
Sit up and 15L O2
Analgesia
Fluids if low BP
Senior Help
CTPA +/- echo urgently
Consider thrombolysis
Enoxaparin 1.5mg/kg/24hr
Epilepsy
Definition:
A continuing tendency to suffer epileptic seizures, a seizure being an abnormal event resulting from paroxysmal discharge or cerebral neurons.
2% of the population has two or more seizures
Aetiology:
Genetic, Developmental, Trauma, Surgery, Pyrexia, Intracranial Mass, Infarction, Alcohol / Drug Withdrawal, Encephalitis, Metabolic Abnormalities (hyponatraemia/hypoglycaemia)
Clinical Features:
Classification
Generalised:
Absence (Petit Mal)
Myoclonic
Tonic-Clonic (Grand Mal)
Tonic
Akinetic
Partial:
Simple (Jacksonian - motor. No impairment of consciousness)
Complex (impairment of consciousness)
Investigations:
EEG – normal between seizures
CT/MRI Head
Serum Biochemistry
CXR - checking aspiration pneumonia
Management:
During Seizure:
ABCDEFG Approach
Maintain Airway & Physical Safety
Rectal or IV Diazepam 5-10mg if seizure doesn’t cease spontaneously
Prophylactic:
First-Line:
Generalised Tonic-Clonic – Phenytoin, Carbamazepine, Sodium Valproate
Generalized Absence – Sodium Valproate, Ethosuximide
Partial Seizures – Carbamazepine, Phenytoin, Sodium Valproate
Common SE:
Phenytoin – Rash, blood dyscasias, lymphadenopathy
Carbamazepine – Rash, leucopenia
Sodium Valproate – Anorexia, hair loss, liver damage
Ethosuximide – Rash, blood dyscrasias, night terrors
Other Drugs:
Felbamate
Gabaentin
Lamotragine
Levetiracetam
Oxcarbazapine
Tiagabine
Topiramate
Vigabatrin
Driving
It is illegal to drive for 12 months post any form of seizure or unexplained LoC. It is the responsibility of the doctor to inform the patient, but patient’s responsibility to inform DVLA.
Pleural Effusion
Definition:
Excessive liquid in the pleural space
Aetiology:
Transudates (
Exudates (>35g/l protein) - malignancy, infection, vasculitidies, rheumatoid.
If purulent and pH
Clinical Features:
SoB
Pleuritic Chest Pain
Investigations:
CXR - loss of costophrenic angle with a meniscus
Management:
o2
Investigate cause
? aspiration
Hyponatraemia
Definition:
Normal range 135-145 mmols/L
May be associated with normal extracellular volume and body Na+ content, salt deficiency or water excess.
Aetiology:
Abnormal ADH release - SIADH, Addison’s, Hypothyroid
Psychiatric Illness - psychogenic polydipsia, TCAs
Drugs - Oxytocin
GI Loss - D&V, haemorrhage
Renal Loss - hyperglycaemia, diuretics
Clinical Features:
Normovolaemia & signs of underlying disease
Hypovolaemia in GI / Renal losses
Investigations:
Determine cause if unknown
Management:
Replace lost fluids & electrolytes
Treat underlying cause
Ectopic Pregnancy
Definition:
The fertilised ovum implants outside the uterine cavity
Aetiology:
2° to salpingitis, tubal surgery, prev ectopic, endometriosis, older IUCD, PoP
Clinical Features:
Abdo pain
PV bleeding (prune juice)
~8 weeks amenorrhoea
Rupture - severe pain, shock, peritonism
Investigations:
Pregnancy test - +ve, ßHCG lower than normal
USS - TV probably better than abdo
Management:
Resus
x-match 6 units
Rhesus status - anti-D
Refer Gynae
Asthma
Definition:
Chronic inflammatory disease of the airways
Reversible airflow limitation
Hyperesponsiveness to stimuli
Inflammation of the bronchi
Aetiology and Precipitatin Factors:
Atopy & allergy
Increased airway responsiveness
Cold air, exercise, pollution
Occupational (paint sprayers)
Drugs eg NSAIDs, Beta-blockers
Clinical Features:
Cough
Wheeze
SoB
Chest tightness
Investigations:
CXR
Spirometry
Peak flow charts
Skin testing for allergies
Management:
BTS guidelines
GORD
Definition:
Decreased lower oesophageal sphincter; sustained or transient.
Aetiology:
Usually no obvious cause; secondary causes include smoking, pregnancy, scleroderma, drugs, trauma, alcohol, obesity
Helicobacter Pylori is not associated with GORD
Clinical Features:
Heartburn, regurgitation
Investigations:
OGD, 24hr pH monitoring in difficult cases
Management:
Conservative:
weight loss, avoidance of smoking and alcohol
Medical:
simple antacids, H2 blockers (Ranitadine), PPIs
Surgery:
Nissen fundoplication (fundus wrapped around distal oesophagus)
Complications
Reflux oesophagitis, peptic stricture, Barrett’s oesophagus
Guillian-Barre
Definition:
Acute inflammatory post-infective polyneuropathy
Aetiology:
Follows 1-3 weeks after infection (often trivial or campylobacter)
3 in 100 000 / year
Clinical Features:
Weakness of distal limbs +/- numbness
Weakness ascends over days for up to 3 weeks
Can affect respiratory and facial muscles in 30%
Investigations:
Clinical diagnosis
Nerve conduction studies
CSF - cell count normal, protein raised
Management:
Record respiratory function - ABG, vital capacity, FEV
Ventilate if required
High dose IV gamma-globulin
Plasmapharesis
SC heparin - prophylaxis
Prognosis:
Spontaneous gradual recovery
15% disability or death
IBS
Definition:
GI symptoms in the absence of structural pathology; abnormal autonomic reactivity, visceral hypersensitivity.
Aetiology:
Post-infective, stress, adverse life events, psychological problems: anxiety, depression.
Clinical Features:
Abdominal discomfort, relief with defaecation, alternating bowel habit, bloating
Investigations:
Patient
Patient >45, with short history or atypical symptoms – other pathologies should be ruled out
Management:
Supportive: explanation, reassurance, lifestyle advice
Medical: Aimed at specific symptoms – antispasmodics (Mebeverine), antidepressants, anti-diarrhoeals, constipation treatments
Dietary: Diary to discover causative foods & exclusion diet
Psychological: CBT
Bronchiectasis
Definition:
Abnormal & permanently dilated airways
Aetiology:
Congenital
Mechanical obstruction
Post-infective damage
Granuloma & fibrosis
Immunocological
Mucociliary clearence defects
Clinical Features:
Cough & excessive sputum
Recurrent chest infections
Halitosis
Haemoptysis
Clubbing
Coarse crackles
Hyperinflation
Investigations:
CXR - hyperinflation
CT
Sputum C&S
Immunoglobulins
Sweat electrolytes for CF
Mucociliary clearance
Management:
Postural drainage
Abx
Bronchodilators
Steroids
Tx
Peptic Ulcer Disease
Definition:
Break in the mucosal surface of the stomach or duodenum >5mm
Aetiology:
95% of duodenal ulcers & 70% of gastric ulcers are associated with H-pylori. Other associations are NSAIDs, smoking and alcohol.
Clinical Features:
Dyspepsia
Heartburn
Anorexia
Epigastric tenderness
Investigations:
OGD if >55 or red flag symptoms
Breath test if
Stool antigen test
Management:
PPI, amoxicillin, clarithromycin 500mg
or a PPI, metronidazole, clarithromycin 250 mg
Leukaemia
Definition:
Malignancy of the blood or bone marrow resulting in an abnormal increase of immature WBCs.
Acute - Rare (5 in 100 000) AML & ALL
Chronic - Usually older patients, changes to acute with a high 5-yr mortality CML & CLL
Aetiology:
Mostly unknown
Some genetic & environmental factors
Clinical Features:
Acute:
Bone marrow failure
Weakness and tiredness due to anaemia
Bruising due to thrombocytopenia
Repeated infections
Chronic Myeloid:
Anaemia
Night sweats & fever
Weight loss
Splenomegaly & pain
Chronic Lymphocytic:
Often incidental
Infections due to neutropenia
Anaemia
Lymphadenopathy
Hepatospenomegaly
Investigations:
Acute:
Blood count
Blood film - leukaemic blast cells
Bone marrow - blast cells
Chronic Myeloid:
Blood count - raised WCC
Multiple myeloid precursors
Bone marrow biopsy
Genetic testing for Philadelphia Chromosome 9:22 trans.
Chronic Lymphocytic:
Hb - low or normal
WCC - raised
40% lymphocytes
Plt - low or normal
Serum IG - low
Management:
Acute:
Correct anaemia & thrombocytopenia
Treat infections
Chemo to achieve remission
Bone marrow ablation
Chronic Myeloid:
Interferons - remission in 10%
Hydroxyurea reduced WCC
Myeloablation with BM Tx
Chronic Lymphocytic:
Nothing if asymptomatic
Steroids for haemolysis
Fludarabine or Chlorambucil
Delirium
Definition:
Impairment of consciousness associated with abnormalities of perception and mood
Aetiology:
Infection
Metabolic Disturbance
Hypoglycaemia
Intracranial - trauma, malig, abscess, haemorrhage
Drugs - anticonvulsants, anxiolytics, opiates, digoxin
Drug / alcohol withdrawal
Post-op
Vit Deficiency - Thiamine (wernicke-karsakoff), B12
Clinical Features:
Acute clears within days
Fluctuant with lucid periods
Worse at night
Visual hallucinations
Frightened, suspicious, restless & uncooperative
Investigations:
FBC, CRP, U&Es, LFTs, TFTs, B12
Cultures
ECG
CXR
CT Head
Management:
Treat underlying cause
Good nursing in well-lit environment
Good comms, include family
Hydration
Review drugs
Emergency Rx - Haloperidol 5mg IM, Lorazepam in withdrawal
Cor Pulmonale
Definition:
Right heart failure resulting from chronic pulmonary hypertension.
Aetiology:
COPD in most cases
Pulmonary Fibrosis
Recurrent PE
Clinical Features:
SoB
Wheeze
Chronic wet cough
Ascites
Peripheral oedema
Prominent neck and facial veins
Raised JVP
Hepatomegaly
Investigations:
Find cause
Management:
Treat cause
Neuropathy / Radiculopathy
Definition:
A pathological process that affects peripheral nerves (neuropathy) or roots (radiculopathy)
Pathology:
Demyelination
Axonal degeneration
Wallerian degeneration (after nerve section)
Compression
Infarction
Infiltration
Aetiology:
Mononeuropathies
Carpal tunnel syndrome
Ulnar nerve compression
Radial nerve compression (sat night palsy)
Mononeuritis multiplex
Polyneuropathies
Guillian-Barré syndrome
Wernicke-Korsakoff syndrome (Thiamin deficiency)
Vit B12 deficiency (subacute combined degeneration of the cord)
Peroneal Muscular Atrophy (Charcot - Marie - Tooth disease)
Autonomic Neuropathy
Caused by DM, G-B, Amyloidosis
Clinical Features:
Depends on cause
Investigations:
Depends on cause
Management:
Depends on cause
Nephrotic Syndrome
Definition:
A triad of:
- Proteinuria (>3g/24h)
- Hypoalbuminaemia (
- Oedema
Aetiology:
80% due to glomerulonephritis
membranous GN most common in adults
minimal change GN most common in children
Others:
DM, amyloidosis, SLE, drugs and allergies
Clinical Features:
Oedema - peri-orbital, face, arms
Frothy urine
Ascites
Normal JVP
Investigations:
Simple:
24hour urine, throat swab,
Bloods:
Albumin, U&Es (urea & Cr), Antibodies
Others:
CXR (pulmonary oedema)
Renal imaging (USS) +- biopsy
Management:
Sodium restriction
Diuretics
ACEi
Steroids
Cyclophosphamide
Complications:
DVT
Sepsis
Oliguric Renal Failure
Lipid Abnormalities
Glaucoma
Definition:
Raised intraoccular pressure
Disease of middle to late years and unioccular
Aetiology:
Blockage of drainage of aqueous from the anterior chamber via the canal of Schlemm
Clinical Features:
Pain
N&V
Corneal oedema
Fixed, dilated pupil
Investigations:
Opthalmoscopy
Management:
Refer to eye unit
Pilocarpine 2-4% drops hourly
Acetazolamide 500mg PO stat
Surgical - peripheral iridectomy
Red Eye
Definition:
Acute painful red eye
Aetiology:
Danger to vision - acute glaucoma, acute iritis, corneal ulcers)
Others - episcleritis, conjunctivitis, spontaneous conjunctival haemorrhage
Clinical Features:
Depends on location of irritation
Investigations:
Opthalmoscopy
Management:
Variable
Fibrosing Alviolitis
Definition:
Progressive idiopathic pulmonary fibrosis
Aetiology:
Idiopathic
Associations:
Autoimmune
Coeliac Disease
Ulcerative Colitis
Renal Tubular Acidosis
Clinical Features:
SoB
Cyanosis
Clubbing
Bilateral fine inspiratory crackles
Signs of respiratory failure, pulmonary HPT, RHF
Investigations:
CXR - reticulonodular shadowing
HiRes CT
Spirometry - restrictive pattern with reduced gas transfer
Bronchoalveolar lavage - hypercellular
Transbronchial biopsy
Management:
O2
Steroids
Immunosuppression
Single lung transplant
Complications:
Respiratory Failure
Median survival 5 years
Biliary Colic
Definition:
Pain caused by gallbladder contraction against a gallstone stuck in the neck or the cystic duct
Clinical Features:
Pain in the RUQ / Epigastrium - with radiation around costal margins to back
Sweaty
Pale
Tachycardia
Nausea / Vomiting
Patients often writhe around with pain, rather than sitting still
Attacks lasts < 6hrs
Examination is otherwise normal
Investigations:
FCB, U&Es, LFTs CRP, Urine Dipstix
USS gall bladder
Management:
Analgesia
Nil by mouth
Laprascopic Cholecystectomy
Psychosis
Definition:
Abnormal condition of the mind resulting in a loss of touch with reality
Aetiology:
Schizophrenia
Schizoaffective disorder
Bi-polar
PTSD
Drugs - alcohol, cannibis, meth
Clinical Features:
Schizophrenia:
First Rank Symptoms - auditory hallucinations, thought withdrawal, thought insertion, thought broadcasting, delusions, externally controlled emotions, somatic passivity and feelings
Investigations:
Clinical based on first rank symptoms
Management:
Neuroleptics - (SE)
Dopamine Antagonists (eg. Chlorpromazine, Haloperidol)
Atypical (eg. clozapine, risperidone, olanzaoine) less extrapyramidal SE
Psychosocial suppport and education
Melanoma
Incidence:
1 / 10000 per year
Median Age at Presentation 50
Risk Factors:
M:F = 1:2
FH
Acute Sunburn, esp. childhood
Number of pigmented moles
Previous Melanoma
Features:
Irregular pigment and edge
Increasing size in adult life
Occurs in young adults
Types:
Superficial Spreading
Nodular
Sites:
Males - back
Females - leg
Can occur anywhere on the body
Management:
Excise with wide margins - >1cm
Bundle Branch Block
Definition:
A disruption of conduction in the His / Purkinje system, either left or right. This causes the ‘blocked’ ventricle to receive the conduction impulse later.
Aetiology:
RBBB - congenital heart disease, cor pulmonale, PE, MI, cardiomyopathy, hyperkalaemia, normal
LBBB - AS, HPT, acute MI, severe coronary disease, cardiomyopathy
Clinical Features:
Investigations:
RBBB ECG - ‘RSR’ in v2 & slurred S in v5, v6
LBBB ECG - ‘RSR’ in I, AVL, v4-v6 & slurred S in v1, v2
Management:
Pacing in symptomatic patients
Tricuspid Regurgitation
Aetiology:
Infective Endocarditis in IV drug users
Chronic Lung Disease
Pulmonary HPT
Dilatation of Right Ventricle
Carcinoid Syndrome
Clinical Features:
Exersional SoB
GI upset due to congestion
Elevated JVP with giant V wave
Pulsatile Hepatomegaly
Peripheral Oedema
Ascites
Pleural effusions
Right Ventricular Impulse at Left Sternal Edge
Heart Sounds
Pansystolic Murmur at lower left sternal edge, louder in inspiration
Investigations:
Management:
Medical:
treat right ventricular failure
Surgical:
resection in infective EC
valve repair or replacement
Childhood UTI
Definition:
Commonest condition in childhood with E. Coli causing 95% of cases.
Clinical Features:
Fever
Poor Feeding
Irritability
Offensive Urine
Vomiting
Investigations:
Dipstix - leukocytes, blood, protein, nitrites
Clean Catch Sample - microscopy & culture
Management:
>3 months and not systemically unwell - treat at home with 3/7 Trimethoprim PO
Recurrent UTI - Trimethoprim low dose OD
Further Investigations:
Performed if UTI < 6months or recurrent >6months
USS - to detect structural abnormalities of kidneys or obstruction
DMSA - radio-isotope to give detailed anatomy of kidneys, shows renal scarring. Should be delayed by 2-3 months as recent infection affects validity.
Micturating Cysto-urethragram - detects reflux from bladder to ureters (vesico-ureteric reflux VUR)
Shock
Definition:
Circulatory failure resulting in inadequate organ perfusion. Generally systolic BP
Aetiology:
Pump Failure
Primary: Cardiogenic Shock
Secondary: PE, tension pneumothorax, cardiac tamponade
Peripheral Circulation Failure
Hypovolaemia
Bleeding: trauma, AAA, ruptured ectopic
Fluid Loss: Vomiting, diarrhoea, burns, ‘third spacing’
Anaphylaxis
Sepsis
Neurogenic
Endocrine Failure: Addison’s, Hypothyroidism
Iatrogenic: Drugs e.g. anaesthetics, antiHPT
Clinical Features:
Pallor
Inc. Pulse
Red. Capillary Return
Air Hunger
Oliguria
Investigations:
ABC approach
Simple: ECG, dipstix and culture, BM
Bloods: FBC, CRP, U&Es, TFTs, LFTs and clotting, Glucose, ABG + lactate, Cultures, X-Match
Radiology: CXR, ?echo, USS, abdo CT
Management:
ABC
Raise Foot of Bed
IV Access x2
Fluids Stat!
Identify Cause
Investigations as Above
Catheterise
Mitral Regurgitation
Aetiology:
Mitral Valve Prolapse
Rheumatic Fever
IHD
Dilated Cardiomyopathy
Infective Endocarditis
Clinical Features:
Palpitations
Exertional SoB
Fatigue
Cardiac Failure
Apex – laterally displaced, hyperdynamic, systolic thrill
Heart Sounds
Soft 1st heart sound
Loud pan-systolic @ apex with radiation to axilla
3rd heart sound
Investigations:
CXR
Echo
Cardiac Catheterisation
Management:
Medical:
Symptom management (ACEi, Diruretics) Endocarditis Prophylaxis
Surgical:
Valve replacement
Hernias
Definition:
The protrusion of a viscus through the walls of it’s containing cavity into an abnormal position
Aetiology:
Congenital hernias
Groin Hernias (most common 75%)
Inguinal - direct, enter inguinal canal through transversalis and emerge at superficial inguinal ring
- indirect, enter inguinal canal through deep ring and often protrude into scrotum
Arise SUPERIOR & MEDIAL to pubic tubercle
Femoral - emerge through femoral canal, normally contains only fat & lymph nodes.
More prone to strangulation due to sharp edge of lacunar ligament
Arise INFERIOR & LATERAL to pubic tubercle
AV Block
First Degree
Second Degree
Mobitz Type 1 - Wenckebach or
Mobitz Type 2
2:1 or 3:1 Block
Third Degree (Complete Heart Block)
Definition:
1st - Prolonged PR interval
Mobitz 1 - Progressive elongation of PR until missed
Mobitz 2- Missed QRS without PR elongation
2:1 or 3:1 - Every 2nd or 3rd P conducts
3rd - No association of P waves & QRS
Aetiology:
IHD
Cardiac Surgery
Dilated Cardiomyopathy
Drugs
Clinical Features:
1st - Usually asymptomatic
Mobitz 1 - Usually asymptomatic
Mobitz 2 - Usually asymptomatic
2:1 or 3:1 - Asymptomatic or syncope, dizziness, HF, fatigue, lethargy
3rd - Asymptomatic or syncope, dizziness, HF, fatigue, lethargy
Investigations:
Management:
1st - Surveillance and v.rarely pacing
Mobitz 1 - Pacing if symptomatic (v.rare)
Mobitz 2- Pacing if symptomatic (v.rare)
2:1 or 3:1 - Pacing if symptomatic and consider without symptoms as can progress to 3rd degree
3rd - Rule out reversible causes (K, Mg, Ca), sepsis, other illness and bradycardic drugs
Aoritc Regurgitation
Aetiology:
Rheumatic Fever
Marfan’s
Syphilis
Connective Tissue Disorders
Aortic Dissection
HPT
Clinical Features:
Can be asymptomatic
Palpitations
Angina
LVF
Collapsing Pulse
Pistol Shot Femorals
Wide Pulse Pressure
Heart Sounds
Apex – displaced, diffuse, hyperdynamic
Soft, high-pitched early diastolic
Left sternal edge
Possible systolic aortic flow murmur
Visible Carotid or Head Nodding
Investigations:
Management:
Medical:
Nifedipine may prolong time before replacement
Surgical:
Valve replacement at the onset of ventricular dysfunction
Acute Abdomen
Definition:
Someone who becomes acutely ill and in whom symptoms and signs are chiefly related to the abdomen.
Aetiology:
Clinical Syndromes That Usually Require Laparotomy:
Rupture of an organ – spleen, aorta, ectopic pregnancy
Peritonitis – perforation of ulcer, diverticulum, appendix, bowel or gall bladder
Syndromes That May Not Require Laparotomy:
Local Peritonitis – diverticulitis, cholecystitis, salpingitis or appendicitis
Colic -
Clinical Features:
Rupture of an organ – shock, swelling, trauma
Peritonitis – prostration, shock, lying still, +ve cough test, tenderness +- rebound/percussion, rigid abdomen, guarding, absent bowel sounds
Local Peritonitis –
Colic – waxing & waning pain, restlessness
Investigations:
FBC
U&Es
Amylase
LFTs
CRP
Urinalysis
ABG (mesenteric ischaemia)
CXR (gas under diaphragm)
AbdoCT / USS
Management:
ABC approach
Fluid Resus
Pain relief
Nil by mouth
Find & treat cause
Hypocalcaemia
Definition:
Normal Range 2.12-2.65 mmol/L
Always check corrected calcium as hypoalbuminaemia may give falsely low serum calcium.
Aetiology:
Vit D deficiency
Hypoparathyroid
Acute pancreatitis
Alkalosis
Alcoholism
Clinical Features:
spasm of hands and feet, twitching, tingling perioral, fatigue, depression, dry skin, coarse hair
Hyperreflexia, tetany, Trosseau’s, Chvosek’s
Worrying Features
Reduced GCS, chest pain, palpitations, low BP, abnormal ECG
Investigations:
ECG - prolonged QT, ST abnormalities, arrhythmias
Management:
Calcium Gluconate
?Vit D
Cholestasis
Definition:
Obstructive jaundice arising in the biliary tree
Aetiology:
Main
Gallstones
Pancreatic Cancer
Other
Cholangiocarcinoma
Chronic Pancreatitis
Enlarged lymph nodes in the porta-hepatitis
Clinical Features:
Yellow appearance of skin + mucous membranes (above 50 micromol/l)
Dark urine
Pale stools
Pruritis
Weight loss - due to inability to absorb fat
Investigations:
FBC
U&E
LFT - increased alk phos
Clotting
USS - gallbladder/biliary tree - is a stone or a tumour causing obstruction?
Chest X-ray
Management:
Gallstone
Laproscopic cholycystectomy + Laproscopic common bile duct exploration
or
ERCP with stone extraction + Laproscopic Cholycystectomy
Pancreatic Cancer
CT should be carried out too assess resectability
If it looks favourable then an endoscopic USS should be done:
Allow a closer look at head of pancreas
Allows cytology sample to be taken
If the endoscopic USS also suggests favourobility then Whipple’s should be done
If at surgery it’s decided the tumour is not removable, a biliary bypass should still be done
If the tumour is not treatable then a stent should be fitted via ERCP to provide symptomatic relief
Hepatic Failure
Definition:
Acute necrotizing hepatitis leading to cell destruction;
There are three types of acute liver failure:
- Hyperacute or fulminant liver failure – encephalopathy develops
- Acute liver failure – encephalopathy develops 2-4/52
- Subacute liver failure – encephalopathy develops 4-8/52
Aetiology:
viral hepatitis, infection, drugs, toxins, alcohol, ischaemia, complications of pregnancy, malignancy
Clinical Features:
Lethargy, weakness, nausea, anorexia, sleep disturbance, Jaundice, fever, fetor hepaticus, encephalopathy, cerebral oedema leading to bradycardia, hypertension, tachypnea
Investigations:
Liver Screen to identify cause
Poor prognostic indicators include: ⇑bilirubin, severe hyponatraemia, rising lactate, acidosis, rapid ⇓ transaminases, renal failure
Management:
Supportive in ITU, Liver Tx
Complications:
Renal failure, coagulopathy, respiratory failure, sepsis, circulatory failure, hypoglycaemia, pancreatitis
Migraine
Definition:
Recurrent headaches associated with visual and GI disturbance.
Aetiology:
Caused by the vasodilation and oedema of blood vessels and the release of vasoactive substances.
Clinical Features:
Prodrome:
Teichopsia (flashes)
Jagged Lines
Unilateral Patchy Scotoma
Lasts 15-60 mins
Headache (hemicranial or generalized)
N&V
Irritable
Preferance for the dark
Sleeping
Other Patterns:
Migraine without aura
Hemiplegic Migraine
Investigations:
Clinical
Management:
Avoid Precipitating Factors
During Attack:
Paracetamol
Antiemetics
Sumatripan (5HT agonist)
Ergotamine
Prophylaxis:
Pizotifen, Methylsergitide (5HT antagonist)
Propanolol
Amitriptyline (low-dose)
Orthostatic Hypotension
Definition:
A fall in systolic blood pressure of at least 20mm Hg and diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position.
Aetiology:
The symptom is caused by blood pooling in the lower extremities upon a change in body position and reduction in venous return causing reduced cardiac output.
Hypovolaemia
Addison’s
Atherosclerosis
Clinical Features:
Dizziness
Euphoria or dysphoria
Bodily dissociation
Distortions in hearing
Lightheadedness
Nausea
Headache
Blurred or dimmed vision
Seizures
Investigations:
Management:
BCC
Incidence:
1 / 1000 per year
M:F 1.3:1.0
Risk Factors:
Skin Types 1&2
Sunburn in childhood
Immunosuppression
Old Age
Site:
Upper 2/3 of face
Features:
Pearly papule with telangectasia
Eroded centre
Slowly increasing in size
Management:
Surgical Excision
Mohs
Curettage & Cautery
Cryotherapy
Photodynamic Therapy
Topical 5-fluouracil
Superficial Radiotherapy
Prognosis:
Excellent - rarely local recurrence
50% 2nd BCC at 5 years
Does not metastasize
Mania
Definition:
A state of abnormally elevated or agitated mood
Aetiology:
Physical - genetic, reduced 5HT, hormonal, CNS abnormalities
Psychological - maternal deprivation, learned helplessness
Social - stressful life events, sexual abuse in childhood
Clinical Features:
Elevated mood, fast, pressured speech, flight of ideas, grandiose ideation, insomnia, disinhibition, increased libido, excessive drinking / spending
Investigations:
Rule out intoxication
Management:
Acute - Lithium, Neuroleptics (eg Haloperidol)
Prophylaxis - Lithium (monitor closely U&Es, TFTs), Carbamazepine, Valproate
Psychotherapy / CBT
Social
Rheumatoid Arthritis
Definition:
Systematic disease with chronic, symmetrical polyarthritis, synovitis and non-articular features
1-3% of population
Presents at all ages
Commonly presents 30-50 years
F > M before menopause
Familial or sporadic
HLA-DR4 in 50-70%
Aetiology:
Unexplained
T Cell Activation
Presence of rheumatoid factors
Clinical Features:
Slow onset but progressive
Symmetrical peripheral polyarthritis
Joint pain & morning stiffness
Eased by gentle activity
Joints warm and tender
Limitation of movement and deformity
Joint effusion
Muscle-wasting
Lethargy, malaise
Non-articular features
Investigations:
Anaemia
⇑ inflammatory markers
Rh factors in 70%
Xray – erosions
Management:
Explain diagnosis and reassure
MDT approach
NSAIDs & Analgesics
DMARDs
Sulphasalazine
Methotrexate
Leflunomide
Anti-TNF Drugs:
Entanercept
Infliximab
Adalimumab
Corticosteroids
Less commonly used:
Gold
Penicillamine
Hydroxychloroquine
Azathioprine
Ciclosporin
Anikinra
Joint Replacment / other surgery
Non-articular Manifestations of RA:
Hands:
Nail fold lesions of vasculitis
Tenosynovitis
Tendon sheath swelling
Carpal tunnel syndrome
Arms:
Bursitis / nodules
Eyes:
Scleritis
Scleromalacia
Dry - Sjögren’s Syndrome
Mouth:
Dry – Sjögren’s Syndrome
Neck:
Lymphadenopathy
Atlanto-axial subluxation
Rarely causing cervical cord compression
Lungs:
Pleural Effusion
Fibrosing Alviolitis
Caplan’s Syndrome
Small Airway Disease
Nodules
Heart:
Pericarditis
Splenomegaly
Renal:
Amyloidosis
Lower Limb:
Ulcers
Oedema
Sensorimotor Polyneuropathy
Anaemia
Atrial Fibrillation
Definition:
Uncoordinated rapid continuous activation of atria from multiple foci. Fortunately only some of these are conducted to the ventricles due to the AV node.
Three Types
Paroxysmal
Persistent >48 hours
Permanent
Aetiology:
IHD, Rheumatic heart disease, Thyrotoxicosis, Cardiomyopathy, W-P-W Syndrome, Pneumonia, ASD, Pericarditis, PE
Clinical Features:
Spectrum - Asymptomatic > Palpitations > Dyspnoea > Chest Pain > Heart Failure > Syncope
Investigations:
ECG - irregularly irregular QRS, no P waves, irregular baseline
Rate may be fast, normal or slow
Management: (three principles)
Rate Control (if fast) - ß-blockers, Ca-blockers, Digoxin
Rhythm Control - ß-blockers, Flecanide (Na), Amioderone (K)
Stroke Prevention - Warfarin or Dabigatran/Rivaroxaban
CHA2Ds2VASc risk stratification for use of anti-coagulation
Consider DC Cardioversion
SVT
Definition:
Two abnormal circuits produce this arrythmia, both passing through the AV node.
AVNRT - atrio-ventricular node re-entrant tachycardia (passes through and near to AV node)
AVRT - atrio-ventricular re-entrant tachycardia (electrical ‘hole’ in AV septum. This conducts the signal more rapidly - pre-excitation and shows as a delta wave on ECG
Aetiology:
Exertion
Caffeine
Alcohol
ß2-agonists
Congenital - W-P-W
Clinical Features:
Palpitations
Chest Pain
SoB
Syncope
Polyuria
Rapid Regular Pulse 140-280bpm
Investigations:
ECG - narrow complex tachycardia, P waves may be within or after the QRS
Management:
Vagotonic Manoeuvres
Carotid Sinus Massage
Occular Pressure
Valsalva Manoeuvre
Adenoseine (avoid in asthma)
Prophylaxis
Accessory Pathway Ablation
Liver Cirrhosis
Definition:
Necrosis of hepatic parenchyma with connective tissue proliferation and nodular regeneration
Aetiology:
Alcoholism by far most common cause follwed by Hep c.
Others - Hep B, PSC, PBC, Drugs, NAFLD, AA hep, Wilson’s, Budd-Chiari
Clinical Features:
Related to underlying cause:
lethargy, splenomegaly, jaundice, leuconychia, telangiectasia, spider naevi, gynaecomastia, xanthelasma/xanthoma, Dupuytren’s, clubbing, dilated chest/abdo wall veins, excoriations, fetor hepaticus (breath of the dead), palmar erythema
Investigations:
Aimed at finding cause:
• LFTs
• FBC
• U&Es
• Albumin
• Coagulation
• Biopsy
Management:
Treat underlying cause
Complications of Cirrhosis:
Malnutrition
Hepatic Encephalopathy
Ascites / Oedema
Vitamin Deficiency
Coagulopathy
Impaired Immune System
Varices
Hepatorenal Syndrome
Hepatocellular Carcinoma
Anaemia
Definition:
Reduced Hb concentration (Normal Range 13M, 11.5F)
Aetiology:
Reduced production - aplastic, pernicious, iron deficiency
Increased destruction - congenital, sickle cell, AA, DIC
RBC loss - haemorrhage, menstruation
Clinical Features:
Fatigue
SoB
Exertional angina
Palpitations
Pallor
Tachy
Koilonychia
Angular stomatits / glossitis
Investigations:
WCC may be low in bone marrow failure
Reticulocytes - measures bone marrow activity
Blood film - shows erythrocyte morphology
Management:
Treat underlying cause eg iron supplements
