Cardiology

12 January 2017 19:45

Bradycardia
What
Heart rate <60 bpm
Respiratory Sinus Arrhythmia - Heart rate decrease during respiration
Sinus Bradycardia - Higher stroke volume in athletes
Sick Sinus Syndrome - Sinus bradycardia, sinoatrial block, sinus arrest
Ventricular Bradycardia - <50 bpm - No atrial impulse
Atrioventricular Conduction Disturbances
Causes
Drug use
Hypothyroid
IHD
Valvular heart disease
Beta blockers - dangerous with calcium channel blockers
Symptoms
Fatigue
Weakness
Dizziness
Fainting
Treatment
Atropine

Vaso-Vagal Syncope
What
Enhanced vagal tone - Low heart rate, low cotnractility
Withdrawl of sympathetic tone - Low BP
Low heart rate -> Low BP -> Fainting
Symptoms
Lightheadedness
Nausea
Clammy and hot/cold
Tinnitus
Confusion
Chest discomfort
Fall down - Laying flat restores blood flow
Seizure if patient doesnt not land flat
Cause
Prolonged standing
Orthostatic Hypertension
Stress
Diagnosis
Tilt table test
Ambulatory Electocardiogram - Holter Monitor

1st Degree Heart Block

What
PR Interval normally 120-200ms
Heart block - PR interval >300ms
Cause
AV node disease
Myocarditis
MI
Electrolyte disturbances
Medication - Ca channel blockers, beta blockers, cardiac glycosides
These increase AV node refractory time
Complications
Atrial fibrillation
Progression to stage 3

2nd Degree Heart Block

What
One of more of the atrial impulses are not conducted to the ventricles
Mobitz 1/Wenckebach - AV node dysfunction
Progressive prolongation -> Blocked p wave -> dropped QRS
Mobitz 2 - His-Purkinje System dysfunction
P waves are intermittently not conduction
No PR prolongation or shortening
Symptoms
Light Headedness
Dizziness
Fainting
Treatment
Pacemaker

3rd Degree Heart Block

What
SA node does not conduct to ventricles
P wave and QRS unrelated
P waves sinus rhythm
QRS complex escape rhythm
Caused by ischaemic damage
Symptoms
Bradycardia
Hypotension
Haemodynamic Instability
Treatment
Pacemaker
Atropine

Bundle Branch Block

What
Bundle of His damage
Prolonged ventricular depolarisation
Symptoms
Palpitations
SoB
Lightheadness and fainting
Treatment
Pacemaker

Sinus Tachycardia
What
HR >100 bpm
Causes
Pain, Fever, Anxiety, Dehydration, Stimulants
Shock

Cardiology Page 1
 Shock
Anaemia
Heart Failure
Hyperthyroidism
Sepsis
PE
MI
Hypoxia

Atrial Fibrillation
What
Irregularly irregular heart rhythm
AF category Defining characteristics
Symptoms
Tachycardia First detected only one diagnosed episode
Palpitations Paroxysmal recurrent episodes that stop on their own in less than 7 days
Angina Persistent recurrent episodes that last more than 7 days
SoB
Permanent an ongoing long-term episode
Oedma
Risk
Age
High BP
Coronary Artery Disease
Mitral Stenosis
Mitral Regurgitation
Hypertrophic Cardiomyopathy
Obesity
Hyperthyroidism
Alcohol consumption
Endocarditis
Diagnosis
ECG
Echocardiogram - Valvular heart disease
TSH
Ambulatory Holter Monitering
Treatment
Warfarin/Heparin/Rivaroxiban/Dabigatran
Rate control
Beta blockers
Calcium channel blockers - Diltiazem/Verapamil
Digoxin
Cardioversion
Ablation
Complications
Stroke/TIA

Atrial Flutter
What
Electrical activity moves in circuit
Sawtooth ECG
Risk
Heart failure or MI
Valve abnormalities
High blood pressure
Symptoms
Palpitations
Tachycardia, steady pulse
SoB
Pain/tightness of chest
Dizziness/Fainting
Treatment
Verapamil
Ablation
Complications
Clots
Cardiomyopathy
Atrial fibrillation

Ventricular Tachycardia
Symptoms
Light-headedness
Palpitations
Chest pain
Cause
Coronary heart disease
Aortic stenosis
Cardiomyopathy
Electrolyte abnormalities
MI
Treatment
Cardioversion
Electrical
Amiodarone
Complications
Cardiac arrest
Ventricular Fibrillation

Supraventricular Tachycardia
What
Abnormal heart rhythm origination from upper heart chambers
Atrial fibrillation
PVST
Atrial flutter
Wolf-Parkinson-White Syndrome
Symptoms
Same as others
Diagnosis
Normally narrow QRS
Treatment
Adenosine

Ventricular Fibrillation
What
Ventricular quivering causing cardiac arrest, LoC, loss of pulse and
irreversible death
No p waves
Treatment
Defibrillation
Amiodarone
Adrenaline

Left Sided Heart Failure

Cardiology Page 2
Left Sided Heart Failure
What
Pulmonary congestion and oedema
Leads to RHF due to pulmonary hypertension
Preserved ejection fraction - diastolic HF - ventricles do not relax during
filling
Reduced ejection fraction - systolic - reduced contraction
Symptoms
Tachypnea
Dyspnoea
Pulmonary oedema
Cyanosis
Laterally displaced apex
Gallop rhythm
SoB on exertion
Paroxysmal nocturnal dyspnoea
Wheezing

Right Sided Heart Failure

What
Caused by cor pulmonale
Symptoms
Peripheral oedema
Ascites
Hepatomegaly
Raised JVP
Nocturia
Classification of HF
Heart Failure New York Heart Association [NYHA]
Causes Class 1 - no limitation of life activities
Congestive HF - overload situations, viral inflammation Class 2 - slight limitation of moderate exercise, comfortable in rest
Acute decompensation of chronic HF - Pneumonia, MI, hypertension, Class 3 - considerable limitation on exercise, only comfortable at rest
arrhythmia Class 4 - breathlessness and fatigue during res
Medication - NSAIDs
Diagnosis From <http://almostadoctor.co.uk/content/systems/ -cardiovascular-system/heart-failure>
B-naturetic peptide
Echocardiogram
CXR
Pulmonary oedema
Pleural effusions
Increased vascular lines
Kerley B lines
Cardiomegaly
ECG - Underlying cause
Blood tests
Anaemia
Hyponatremia
Hypo/Hyperkalaemia
LFT's - Liver damage
RFT's - severity
TFT's - Thyrotoxicosis
Angiography - IHD
Treatment
Exercise
Diet
Alcohol - causes af and hf
Smoking cessation
Ace inhibitors
Beta blockers
Calcium channel blockers
Diuretics and digoxin
Amiodarone for arrhythmias
CABG/Angioplasty
Valve replacement
Pacemaker
Complications
Thromboembolism and stroke
Arrhythmias
Infection risk

Angina
What
Chest pain due to poor perfusion of heart muscle
Because of obstruction or spasm of coronary arteries
Atherosclerosis
Stable angina
Pain on exertion
Relieved with rest and GTN
Unstable angina
At rest >10 minutes
Severe with new onset
Crescendo pattern
Worse with stress, cold weather and meals

Myocardial Infarction
What

Symptoms
Diagnosis
Treatment
Complications

Mitral Stenosis
What
Symptoms
Diagnosis
Treatment
Complications

Mitral Regurgitation
What
Infective endocarditis and rheumatic fever
Marfan's and Ehlers-Danos Syndrome
LV dilation and annular calcification
Symptoms
Pan systolic murmer
Mitral area
Radiates to axilla
Heave
Displaced apex beat
Pulmonary hypertension
AF
Fatigue

Cardiology Page 3
 Fatigue
Dyspnoea
Diagnosis
ECG - P mitrale
Transoesophageal ultrasound
Doppler echo

Aortic Stenosis
What
Senile calcification with corneal arcus
Biscuspid valve
Symptoms
Ejection Systolic murmur
2nd intercostal space on right
Radiates to carotids
Slow rising pulse
Heave - No displacement of apex
Pulmonary hypertension
Crackles at lung bases
Pink frothy sputum
Oedema
Atrial fibrillation
Angina
Syncope
Dyspnoea
Sudden death
Diagnosis
ECG - LBBB and LVH
Doppler echo
Treatment
Valve replacement

Aortic Regurgitation
What
Symptoms
Diagnosis
Treatment
Complications

Infective Endocarditis
What
Symptoms
Diagnosis
Treatment
Complications

Pulmonary Heart Disease

What
Symptoms
Diagnosis
Treatment
Complications

Hypertension
What
Symptoms
Diagnosis
Treatment
Complications

Peripheral Arterial Disease

What
Symptoms
Diagnosis
Treatment
Complications

Chronic Lower Limb Ischaemia

What
Symptoms
Diagnosis
Treatment
Complications

Acute Lower Limb Ischaemia

What
Blockage of peripheral artery
Thrombus - 40%
Emboli - 38%
Angioplasty occlusion - 15%
Trauma/Compartment syndrome
Symptoms - 6 P's
Pulseless
Parasthesia
Pain
Paralysis
Pallor
Perishing cold
Treatment
Thrombolysis - tPA
Angioplasty
Complications
Reperfusion injury - causes compartment syndrome

Aortic Abdominal Aneurysm

What
Abdominal aorta enlargement >3cm
Symptoms
Palpable pulsatile mass with bruit
Hypovolemic shock
Tearing back pain
Can go to groin/iliac fossa
May be intermittent

Aortic Dissection
What
Symptoms
Diagnosis
Treatment
Complications

Deep Vein Thrombosis

What
Symptoms
Diagnosis
Treatment

Cardiology Page 4
Treatment
Complications

Cardiology Page 5
Respiratory
12 January 2017 19:57

COPD
What
Chronic narrowing of airways, difficulty breathing out
Bronchitis - Inflamed and narrow airways
- Neutrophil involvement
Emphysema - Break down of alveoli
Symptoms
Sputum
Productive cough
Shortness of breath
Wheeze
Barrel chest
Pulmonary hypertension -> Cor Pulmonale
Oedema, raised JVP
Frequent infections
Cyanosis
Cause
Smoking
Air pollution
Occupational
Diagnosis
Spirometry
FEV/FVC <70
Gold grading <80 FEV1
MRC shortness of breath
Chest X-Ray
ABG - Low PaO2, high PaCO2
Treatment COPD Asthma
GP Age of onset >35 Age of onset <35
H. Influenza and pneumococcal vaccine No diurnal variation in FEV1 Diurnal variation in FEV1
Smoking cessation
SABA Non-reversible Reversible
LABA Chronic dyspnoea Acute episodes
LAMA Sputum produced No sputum produced
Inhaled Corticosteroid
History of many years of smoking (generally patients too young to have this)
Theophylline
Oral prednisolone Neutrophil infiltrate Eosinophil infiltrate
Antibiotics CD8 mediated CD4 mediated
Anti-Mucolytic >
Acute
24% O2, increase to 28% if decreased PaCO2
Doxapram if increased PaCO2 / Assisted ventillation
Nebulised Salbutamol + Ipratropium
Prednisolone
Antibiotics
Complications
Type 2 respiratory failure
Pneumonia

Bronchiectasis
What
Permanent enlargement of airways
Destruction of alveoli, fibrosis of parenchyma
Symptoms
Cough
Green mucus secretion
Haemoptysis
Halitosis
Recurrent RTI's and fever
Signs
Coarse crackles
Absent breath sounds
Nail clubbing
Cause
CF
TB/Pneumonia
Rheumatoid and IBD
Diagnosis
Sputum sample
CXR - Normal
CT - Signet ring appearance
CF genotyping
Treatment
Postural drainage
Antibiotics
Steroids
Complications
Pneumonia
Abscess
Empyema
Fibrosis
Cor pulmonale
Amyloidosis

Cystic Fibrosis
What
Symptoms
Diagnosis
Treatment
Complications

Respiratory Page 6
Asthma
What
Chronic airway inflammation and hypersensitivity
Non-atopic
Aspirin Induced
Occupational induced
Symptoms
Wheeze
SoB
Cough
Chest tightness
Worse at night and in cold
Eczema
Diagnosis
Obstruction reversible >15%
Extrinsic - skin prick test - T1 hypersensitivity reaction
PEF - 2 per day
Spirometry
Exercise test - 15% difference on PEF Features of acute severe asthma
CXR - Pneumothorax Inability to complete a sentence in one breath
Treatment RR>25
Long Term Tachycardia >110 bpm
SABA PEF <50% predicted (or <50% patients own best)
Inhaled corticosteroid Features of life-threatening attack
LABA Silent chest
Higher dose corticosteroid + Monteleukast/Theophylline Feeble respiratory effort
Prednisolone Cyanosis
Acute Exhaustion
ABG - CO2 >5, O2<8, low pH Bradycardia
100% O2, non-rebreathing mask Hypotenson
Salbutamol and ibatropium bromide nebuliser Exhaustion/confusion/coma
Prednisolone PEF <30% predicted normal or best this is approximately 150L/min in adults
>

Pneumonia
What
Inflammation of lung tissue - LRT infection
CAP - Strep p and Haemophilus
HAP - Staph and pseudomonas
Risk
Viral infection
Hospitalisation
Smoking
Alcohol
COPD
Bronchiectasis
Bronchial Carcinoma
Immunosuppression
IV Drug use
Symptoms
SoB
Fever
Tachycardia
Cough - Purulent sputum
Rigors
Vomiting, nausea, anorexia
Diarrhoea
Headache
Pleuritic chest pain - stabbing pain on inspiration
Tachypnea and Dyspnoea
Diagnosis
O2 sats <92%
CXR - Consolidation
WCC, CRP
Sepsis tests C Confusion use the abbreviated mental test (score 8)
Urine antigen - legionella U - Urea - >7mmol/L
Pleural fluid aspiration Respiratory rate - 30/min
CURB 65 Blood Pressure <90 systolic, or <60 diastolic
Treatment 65 age >65 years
CURB <2 - Oral antibiotics
>3 - IV antibiotics
O2
Fluids
Complications
Respiratory failure
Hypotension - Dehydration
Atrial Fibrillation - Resolves with pneumonia
Pleural effusion - inflamed pleura -> increased secretions
Empyema - infection effusion
Fluid aspiration
Chest drainage
Abscess
Septicaemia

Pulmonary Fibrosis
What
Scar tissue in lungs
Restrictive lung disease
Symptoms
Dry cough
Dyspnoea
Clubbing

Respiratory Page 7
 Restrictive lung disease
Symptoms
Dry cough
Dyspnoea
Clubbing
Diffuse inspiratory fine crackles
Cause
Idiopathic
Pneumoconiosis
Asbestosis
Mesothelioma risk
Allergic extrinsic alveolitis
Diagnosis
Raised ESR, Rheumatoid factor and antinuclear blood test positive
CXR - Reticulo-nodular shadows in lower zones
Reduced values for FEV and FVC, ratio is often normal
Treatment
Pirfenidone
Nintedanib
Complications

Lung Cancer
What
95% Bronchus carcinoma
2% alveolar
3% benign
Squamous cell carcinoma
Obstructive lesion of bronchus, sometimes cavitates
Jagged border, thick wall
Adenocarcinoma
Mucous cells in bronchial epithelium
Invades lymph nodes and pleura, brain and bones
Not smoking related
Large cell carcinoma
Less well differentiated carcinomas
Early mets, poor prognosis
Bronchoalveolar cell carcinoma
Huge amounts of white sputum
Small cell carcinoma
Endocrine cells
Untreatable
Pancoast's tumour
Apical cancer, effects brachial plexus - pain and weakness in arm
Horner's Syndrome
Sympathetic ganglion effected
Ptosis
Miosis
Lid lag
Anhydrosis
Risk
Smoking
Urban area
Asbestos
Arsenic
Oil
Coal mining
Radiation
Scarring post Tb
Symptoms
Haemoptysis
Cough
Pain
Stridor
Hoarseness - recurrent laryngeal nerve
Weight loss
Absent breath sounds
Dull percuss
Pleural rub
Axillary lymph node involvement
Diagnosis
CXR
Circular opacities
Hilar enlargement
Lung collapse
Consolidation
Pleural effusion
Bony mets
CT and PET for staging
Bronchoscopy - Cytology and biopsy
FBC - Anaemia
LFT - Mets
Hypercalcaemia - Bone mets
Hyponatreamia - Adrenal involvement
Sputum sample
Staging
TNM staging
Treatment
Surgery unlikely as late presentations
Chemotherapy
Complications

Pleural Effusion
What
Fluid in the pleural space

Respiratory Page 8
 Fluid in the pleural space
Transudate
Oncotic pressure disturbance
Low protein <25g/L
Mononuclear cells
Hypoalbuminaemia, hypothyroid, cardiac
Exudate
Inflammation, malignancy and infection cause
WBC, RBC, platelets and protein
Low glucose in infection
Symptoms
Reduced chest expansion on effusion side
Mediastinal shift away from effusion
Stony dull to percuss
Absent/Reduced breath sounds
Reduced vocal resonance
No additional sounds
Diagnosis
CXR
Blunting of costophrenic angle
Meniscus - if horizontal likely pneumothorax
If large enough whole lung may be opaque
pH <7.2 - empyema
Treatment
Treat cause first
Pleural tap - cytology, LDH, protein, pH, gram stain, AFB testing

Pneumothorax
What
Air in pleural space
Simple pneumothorax
Volume does not increase
No trachea deviation
Decreased lung markings
Tension pneumothorax
Volume continuously increases due to one way valve
Trachea deviated
Symptoms
Pleuritic chest pain
Breathlessness
Reduced breath sounds
Hyper-resonant purcussion
Decreased CO, increased HR, raised JVP - Compressed mediastinum
Diagnosis
Clinical
CXR
Treatment
Fine needle aspiration, 2nd intercostal space, midclavicular line

Respiratory Page 9
Gastrointestinal
12 January 2017 20:06

GORD
What
Stomach acid in oesophagus due to LOS dysfunction
Barrett's oesophagus - Columnar epithelium replaces squamous
Intestinal metaplasia
Risk of oesophageal adenocarcinoma
4 biopsies per 2cm squared
Risk
Hiatus hernia
Fatty foods, chocolate, caffeine
Smoking
Obesity
LOS dysfunction
Alcohol
Symptoms
Retrosternal chest pain
Worse on lying down
Diagnosis
Clinical
Endoscope
Barium swallow
Treatment
Weight loss
Quit smoking
Reduce alcohol
Reduce late night food
Sleep sitting upright
PPI's
Antacids
Nissen fundoplication - Stomach wrapped around LOS
Complications
Anaemia
LOS Stricture - fibrosis
Solid food dysphagia

Oesophageal Tumour
What
Adenocarcinoma, squamous cell, leiomyoma, squamous papilloma
Risk
Certain foods
Lack of vitamin A, C and iron
Achalasia
Chewing tobacco/smoking
HPV
Usually upper 2/3rds
Symptoms
Lump in throat - No change with eating
Dysphagia - Progressive
Regurgitation
Weight loss and anorexia
Palpable lymph nodes - Virchow's
Diagnosis
Endoscopy
Barium swallow if endoscopy cannot be tolerated
TNM staging - CT
Treatment
Surgery
Stenting and intubation - palliative
Complications
Bronchopneumonia due to aspiration
Oesophageal-Broncho fistula

Achalasia
What
Symptoms
Diagnosis
Treatment
Complications

Hiatus Hernia
What
Stomach protrudes into thoracic cavity through the diaphragm
Sliding hernia - Stomach at oesophageal-gastric junction pulled up
Contributes to reflux
Rolling - Fundus extends through diaphragm at a site separate to the junction

Peptic Ulcer Disease

What
Risk
H. pylori infection
Produces ammonia - neutralises stomach acid allowing colonisation
Lives in crypts next to acidic censors
Alters feedback loop causing excess acid production

GI Page 10
 Risk
H. pylori infection
Produces ammonia - neutralises stomach acid allowing colonisation
Lives in crypts next to acidic censors
Alters feedback loop causing excess acid production
Infection causes localised inflammation
Smoking
Alcohol
NSAIDs
Symptoms
Epigastric pain
Vomiting that relieves pain (rare)
Weight loss
Anaemia
Asymptomatic (50%)
Duodenal - Worse at night
Gastric - Worse on eating or before
Diagnosis
Stool test - 1st line - No PPI's 1 week before test
Urea breath test
Serum IgG
Endoscopy - Anyone >55 or with red flag symptoms, check again 6 weeks after
treatment
FBC - Anaemia
Treatment
Triple therapy
Omeprazole
Metronidazole
Clarithromycin
Complications
Perforation
Often duodenal
Sudden onset pain, poorly localised, may radiate to back
Peritonitis
Absent bowel sounds
Shock
Shallow breathing
Fever
Tachycardia
X-ray - Pneumoperitonitis
Haemorrhage
Anaemia
Cancer

Upper GI Bleed
Presentation
Haematemesis
Melena
Abdominal discomfort
Dizziness
Anaemia
Causes
Peptic ulcer
Gastroduodenal erosions
NSAIDS
Ulcer
Oesophagitis - GORD - Small volume
Oesophageal varices
Dark red blood - Large volume
Severe liver disease - Portal hypertension
Banding or Minnesota tube to treat
Mallory-Weiss tear - Large volume after retching/vomiting
Malignancy
Vascular malformation
Crohn's and Meckel's' diverticulum
Investigations
FBC
LFT's - varices
Clotting - Alcohol, bleeding disorders
OGD - Therapeutic measures can be taken at same time

Dysphagia
Pharyngeal/Oesophageal
MND
Myasthenia gravis
Achalasia
Polio
Botulism
Damage 9th/10th/12th cranial nerves
Oesophageal
Scleroderma
Achalasia
Oesophageal spasm
Luminal obstruction - Stricture, bolus or carcinoma
External
Goitre
Lung cancer

GI Page 11
Lower GI Bleed

Coeliac Disease
What
T-cell mediated autoimmune disease
Anti-endomysial antibody to TGG (tissue transglutaminase) - the enzyme for glutted
Hypertrophy of crypts and atrophy of villi - Reduced surface area for absorption
Symptoms
Fatigue - Iron deficiency anaemia
Diarrhoea - Malabsorption
Bloating
Angular stomatitis - Anaemia
Weight loss
Oral ulceration
Osteomalacia
Diagnosis
Anti-endomysial antibody and anti tTG
50% have no histological changes - 'latent Coeliac'
Endoscopy - Duodenal biopsy - Marsh Scale
Crypt hypertrophy
Villous atrophy
Inflammatory cells in lamina propria
Treatment
Stop eating gluten
Complications
Osteopenia, Osteoporosis, Osteomalacia
Cerebellar disorders - calcium
Neurological disorders - paraesthesia and muscle weakness
Other autoimmune disorders
Malignancy risk

Small Bowel Obstruction

Causes
Adhesions
Hernia
Tumours
Symptoms
Umbilical pain - colicky
Palpable bowel - Dilated loops
Vomiting
Abdominal distention
Absolute constipation
High pitched tinkling bowel sounds
Investigations
Abdominal X-ray - Supine
Bowel distended >5cm
Gas in biliary tree
Laparotomy
Treatment
Resuscitation
Laparotomy
Strangulation
Closed loop obstruction

Crohn's Disease
What
Causes skip lesions
70% effects terminal ileum
Effects anus, rarely rectum
Involves all layers of bowel wall

Symptoms
Diarrhoea
Abdominal pain
Weight loss
Fever, fatigue, anorexia
Constipation
Tender abdomen
Right iliac fossa mass - Abscess in terminal ileum
Anal/Rectal strictures
Fistulas from full thickness penetrating ulcers
Perianal disease - Skint tags, deep fissures, perianal fistulas, abscesses from anal canal
Clubbing
Large joint arthritis
Iritis
Fatty lvier
Renal stones
Pyoderma gangrenosum
B12 and iron deficiency
Diagnosis
Barium swallow - Strictures, gross mucuosal changes, fistulas
Colonoscopy
CT
Stool sample
Iron, B12, LFT, U+E, FBC, CRP, WCC, Hb, Albumin
Faecal calprotectin
Treatment

GI Page 12
 Treatment
Stop smoking
Vitamins plus Low residue or Elemental diet
Prednisolone
Azathioprine
Antibiotics - metronidazole
IM methotrexate - Not licenced
Infliximab
Bowel resection
Stricturoplasty

Ulcerative Colitis
What
Distal inflammation with rectal involvement
Confined to mucosa and submucosa
Excess production of mucous
Proctitis - Only the last 6 inches of the rectum
Symptoms
Bloody diarrhoea
With mucous and pus
Abdominal discomfort
Tenesmus and urgency
Fatigue and anorexia
Abdominal pain from stricture after eating
Clubbing
Extra-intestinal features
Oral ulcers
Arthritis of large joints
Iritis
Erythema nodosum - itchy raised lumps
Pyoderma gangrenosum - Black necrotic ulcerating mass
Cholangitis - causes liver failure
Acute
20X a day bloody diarrhoea
Fever
Tachycardia
ESR >30, Anaemia, low albumin
Diagnosis
PR exam
Rigid sigmoidoscopy
Inflamed bleeding mucosa
Blood tests - WCC, Platelets, anaemia, ESR, CRP
Stool sample - infective colitis
AXR and USS
CT
Colonoscopy - Crohn's
Barium enema
Rectal biopsy
Treatment
Corticosteroids - Induce remission
Prednisolone, hydrocortisone, dexamethasone
Oral/IV/Enema
Amino-salicylate - Remission - Not for Crohn's
Sulphasalazine - Safe in pregnancy
Immunosuppressants
Azathioprine
Ciclosporin
Methotrexate
Surgery
Restorative proctocolectomy
Smoking
Complications
Perforation
Bleeding
Toxic megacolon
Venous thrombosis
Colon cancer

Constipation
Causes
Lack of fluid/fibre
Lack of exercise
IBS
Drugs - Opiates, iron tablets
MS, Parkinson's
Metabolic - Pregnancy, diabetes, hypothyroidism, hypercalcaemia
Carcinoma
Diverticulitis
Obstruction
Crohn's
Fissures
Haemorrhoids

Diverticulitis
What
Diverticula - Small out-pouching of large intestine mucosa

GI Page 13
 Diverticula - Small out-pouching of large intestine mucosa
Diverticulosis - Presence of diverticula
Diverticular Disease - Symptomatic diverticulosis
Diverticulitis - Acute inflammation of diverticula
Often caused by lack of fibre
Symptoms
Constipation or Diarrhoea
Left iliac fossa pain
Fever
Palpable mass
Abdominal distension
Tachycardia
Diagnosis
Palpable sigmoid colon
Barium Enema
USS - for other differentials
Sigmoidoscopy - if Ba didnt work - Or colonoscopy if suspected carcinoma
Raised CRP
Treatment
Antibiotics - Metronidazole
Fluids
Analgesia - not opioids
Complications
Fistulation
Abscess
Peritonitis
Perforation
Haemorrhage

Haemorrhoids
What
Swelling and inflammation of veins in rectum and anus
Most common cause of rectal bleeding
Caused by constipation, pregnancy and congestion of venous plexuses
Primary - Cause bleeding, non-visible
Second degree - Bleed, pop out, can be pushed back
Third degree - Manual replacement after prolapse
Symptoms
Bright red blood
Discomfort
Pruritus ani - itchy skin
Mucus discharge
Treatment
Prevent constipation and straining
Sclerotherapy - Inject vein, make them shrink
Band ligation - restrict blood flow
Haemorrhoidectomy
Complications

Anal Fissure
What
Tear in skin below dentate line
Painful defication
Associated with Crohn's and UC
Occur in posterior midline most commonly
Often has oedematous skin tag - Sentinel pile
Pain and sphincter spasm make examination difficult if not externally visible
Anaesthetic cream, stool softener, nitric acid

Anal Fistula
What
Communication between epithelial surface of anal canal and perianal skin
Result from infection of anal glands or Crohn's
Present as abscesses - Excision treats
Skin maceration
Pus
Pruritus ani
Pain, swelling, tenderness, fever, odour
Laying open or cutting seton to treat

Colorectal Carcinoma
What
2nd most common cancer, 50% mortality rate
Benign - Adenoma - benign epethelia neoplasm - polyps
Often asymptomatic, may bleed
Endoscopic mucosal resection to treat
3-5 year follow up colonoscopy
Risk
FH
Age
Diet - Fat, meat, low fibre
IBD
Diabetes
Atherosclerotic disease
Symptoms
Iron deficiency anaemia
Weight loss

GI Page 14
 Weight loss
Fatigue
Altered bowel habit
Faecal incontinence
Abdominal pain
Faecal occult blood loss
Palpable mass
Obstruction
Tenesmus
Rectal bleeding
Anal/perianal pain
Recurrent UTI - bladder fistulation
Sister Mary Joseph Nodule
Ascites
Red Flag
Palpable rectal mass
Iron deficiency anaemia in men
Iron deficiency anaemia of non-menstruating women
Rectal bleeding and change in bowel habit for 6 week in over 40's
Bleeding for 6 week in anyone over 50
Diagnosis
Faecal occult blood
Routine bloods
Colonoscopy - IOC
Barium enema
USS/CT - Staging and mets
Staging
Dukes
TNM
Treatment
Resection in dukes A-C - 2cm either side of tumour, 5 in rectum
Radio/Chemotherapy in Dukes B-C
Pallative in Dukes D
Complications

Diarrhoea
Notes
Bloody diarrhoea - always pathological - normally colitis
Diarrhoea in morning, followed by normal stools at night is rarely pathological
In hospital often C. diff
Parasitic causes if foreign travel
Acute - often infective
Endocrine causes - Hyperthyroidism
Causes
Infective
Bacteria - E. coli, Salmonella, Shigella, Campylobacter Helicobacter
Viral - Rotavirus, Norovirus
Amoebic dysentery
Travel
Cholera
E. Coli
Giardiasis
Typhoid
Drugs
Antibiotics - Clindamycin, Erythromycin, Penicillins, Tetracycline,
Laxatives
Digoxin, Magnesium, PPI's, Cimetidine
Metabolic
Hyperthyroidism
Thyrotoxicosis
Anxiety
Small bowel disease
Crohn's
Coeliac
Large bowel disease
UC
Crohn's
IBS
Diverticulitis
Investigations
FBC
Anti tTG
Stool culture
Sigmoidoscopy
Small bowel enema

Irritable Bowel Syndrome

What
Abdominal pain and bowel habit changes with no underlying damage
Symptoms
Pain associated with diarrhoea/constipation
Urgency
Tenesmus
Bloating and distension
Depression and anxiety
Cause
Post infective

GI Page 15
 Post infective
Stress
Treatment
Diet
Laxatives/Anti-diarrhoeals
Antispasmodics
Discontinue PPI
Tricyclic antidepressants
SSRI's
Probiotics
Herbs

Appendicitis
What
Inflammation of appendix
Obstruction of lumen from lymphoid tissue hyperplasia, faeces, foreign bodies or
worms
Obstruction -> baterial overgrowth -> Distention -> Ischaemia -> Inflammation
Symptoms
Pain - Umbilical, moves to RIF
Peritonits pain - Washboard rigidity, worse with movement
Rebound tenderness at McBurney's point
Rovsing's sign - Pain in LRQ when LLQ palpated
Psoas sign - Pain on passive right hip extension
Obturator sign - pain on passive internal rotation of flexed hip
Nausea
Vomiting
Anorexia
Fever
Less frequent bowel movements
Diagnosis
Clinical
Contrast CT
USS
Laparotomy
Treatment
Appendectomy
Contraindicated in caecal IBD
Antibiotics
Complications
Peritonitis
Abscess formation

Ectopic Pregnancy
What
Symptoms
Diagnosis
Treatment
Complications

Peritonitis
What
Inflammation of peritoneum
Occurs with perforation, surgery/trauma, infection or autoimmune disorders
Symptoms
Sudden acute abdominal pain - worse with movement
Pain begins generalised then localises
Shock and fever
Washboard rigidity
Nausea and vomiting
Abdominal swelling
Absent bowel sounds
Diagnosis
CXR - Pneumoperitonitis
Serum amylase - Pancreatitis
USS/CT - Confirm diagnosis
Treatment
Fluid and electrolytes
IV antibiotics
Laparotomy

Large Bowel Obstruction

Symptoms
Pain
Loud borborygmi
Empty rectum
Non-tender abdomen
Distention
Absolute constipation
Vomit
Causes
Colon cancer
Benign strictures - Diverticular disease, IBD, ischaemic bowel
Sigmoid volvulus
Intussusception

GI Page 16
 Intussusception
Hernia

Jaundice
Pre-hepatic
Excessive RBC breakdown (Haemolytic) or Gilbert's
Dark stools and urine (not initially)
Anaemia and pallor
Splenomegaly
Normal LFT's, bilirubin 100umol/L
Causes
Sickle cell anaemia
Thalassaemia
Hereditary spherocytosis
G6PD deficiency
Pyruvate kinase deficiency
Hepatocellular Jaundice
Conjugated and unconjugated bilirubin levels raise
ALT and AST raised
Hepatitis
Hepatotoxicity
Cirrhosis
Alcoholic liver disease
LFT's deranged
Albumin low
Post-Hepatic
Obstruction of bile duct
ALP and Gamma GT raised
Primary biliary cirrhosis
Primary Sclerosing Cholangitis
Alcohol
CF
Gallstones
Cancer of head of pancreas
Liver flukes
Mirizzi's Syndrome

Hepatomegaly
Causes
Massive
Cancer
Right heart failure
ALD
Myeloproliferative disease
Moderate
Fatty liver
Amyloidosis
Haemachromatosis
Lymphoma
Leukaemia
Mild
All of the above
Biliary duct obstruction
Hepatitis
HIV
EBV
CMV
Autoimmune

Splenomegaly
Causes - CHICAGO
Cancer
Haematological malignancy
Infection and Inflammation - EBV, sarcoid, amyloid
Congestion - Portal hypertension
Autoimmune
Glycogen storage disorders
Other

Autoimmune Hepatitis
What
Cause of chronic hepatitis
Symptoms
Fatigue, anorexia, weight loss
Amenorrhoea
Behavioural changes
Abdominal pain
Epistaxis
Bruising
Jaundice
Hepato/Splenomegaly
Ascites
Cirrhosis
Diagnosis
IgG
Mononuclear liver infiltrates
Antibodies for liver proteins

GI Page 17
Non-Alcoholic Fatty Liver Disease
Causes
Insulin resistance
Metabolic syndrome - obesity, hyperlipidaemia, diabetes t2, high blood pressure
Medications - Amiodarone, antivirals, aspirin, corticosteroids, methotrexate,
tetracycline

Liver Cirrhosis
What
Irreversible liver damage due to fibrosis
Causes
Alcohol abuse
HBV/HCV
Haemachromatosis, Wilson's, alpha-antitrypsin deficiency
NASH
Budd Chiari
Autoimmune
Medication
Symptoms
Leukonychia
Clubbing
Palmar erythema
Dupuytren's contracture
Spider naevi
Xanthelasma
Gynaecomastia
Loss of body hair
Parotid enlargement
Hepatomegaly
Jaundice
Black stools
Haematemesis
Pruritus
Diagnosis
LFT - High bilirubin, AST, ALT, ALP, gGT
Low albumin, high PT/INR
Low WCC and platelets - Hypersplenism
Ferratin
Hepatic antibodies
Liver USS
MRI
Ascitic tap - neutrophils for peritonitis
Liver biopsy - Confirm diagnosis
Treatment
Liver transplant
Complications
Liver failure
Coagulopathy
Encephalopathy
Liver flap
Confusion
Hypoalbuminemia
Sepsis
Hypoglycaemia
Portal hypertension

Portal Hypertension
Symptoms
Ascites
Splenomegaly
Oesophageal varices
Caput medusae
Haemorrhoids

Ascites
Causes
Transudate
Cirrhosis
Heart failure
Budd-Chiari
Exudate
Cancer
TB
Pancreatitis
Nephrotic syndrome
Other
Vasculitis
Hypothyroidism

Primary Biliary Cirrhosis

What
Autoimmune destruction of small bile ducts, intralobular ducts and Canals of Herring
Symptoms
Pruritus
Fatigue
Jaundice

GI Page 18
 Jaundice
Xanthelasma
Liver cirrhosis
Causes
Sjorgrens
Systemic sclerosis
Rheumatoid arthritis
Hypothyroidism
Diagnosis
LFT, auto-antibodies

Wilson's Disease
What
Autosomal recessive disorder
Copper build up in hepatocytes and basal ganglia
Symptoms
Children - Liver failure and Jaundice
Adults - CNS signs - Ataxia, tremor, dysarthria
Kayser-Fleisher rings
Diagnosis
24 hour urinary copper excretion
Low serum copper
Liver biopsy
MRI
Treatment
Penicillamine

Hereditary Haemochromatosis
What
Autosomal recessive disorder of iron metabolism
Symptoms
Skin discolouration
Cirrhosis
Hepatocarcinoma
Diabetes - Pancreatic involvement
Arthritis - Joint involvement
Piuitary - Sexual dysfunction
Heart failure
Diagnosis
LFT
Serum transferrin and transferrin saturation
Serum ferratin
Liver biopsy
Treatment
Diet
Phlebotomoy
Complications

Alcohol and Alcoholic Liver Disease

What
14 units a week recommended
Alcohol causes - Trauma, vomiting, radial nerve palsy, risk taking behaviour,
vasodilation and hyperglycaemia
Withdrawal - Alcohol supresses brain activity (GABA), withdrawal causes over-activity
Hallucinations - Persecutory
Delirium tremens - Sweaty and shaking
Epilepsy
Cardiac arrhythmia
Hypertension and Tachycardia
Vomiting, diarrhoea and loss of appetite
Treat with benzodiazepines - Librium/Diazepam/Lorazepam
Stages
Fatty liver - Steatosis - accumulation of fat in liver cells, alcohol increases synthesis
Alcoholic hepatitis - Inflammation of hepatocytes
Cirrhosis

Wernicke's Encephalopathy
What
Vitamin B1 levels insufficient (Thiamine)
Alcohol addiction but may be malignant, eating disorder or Crohn's
Symptoms
Ataxia
Ophthalmalgia
Confusion
Short term memory loss
Diagnosis
Clinical
Treatment
IV thiamine
Hypoglycaemia risk
Complications
Korsakoff's Syndrome
Amnesia
Anterograde and retrograde
Loss of orientation in time and space
Apathy
Mild euphoria

GI Page 19
 Mild euphoria
Conflabbation
Irreversible

Liver Abscess
What
Pyogenic, amoebic or fungal
E. coli or Klebsiella pneumoniae
Staph aureus if spread from endocarditis
E. histolytica - Amoebic liver abscess
Candida albicans
Symptoms
Fever and chills
RUQ pain
Anorexia and malaise
Sometimes referred pain to right shoulder and coughs
Tender hepatomegaly
Treatment
Drainage
Antibiotic therapy
Complications
Sepsis
Empyema
Peritonitis

Liver Cancer
What
90% metastatic
Symptoms
Fever, fatigue, anorexia, weight loss
RUQ pain
Late jaundice
Hepatomegaly
Chronic liver disease signs
Bruit

Gallstones
What
Cholesterol or pigment stones
Common in women - higher cholesterol
Age. FH, Oestrogen and diet increases risk
Fair, fat, female, forty
Symptoms
No flatulence, dyspepsia, fat intolerance or vague upper GI symptoms
Biliary colic - Intermittent RUQ pain
Worse with fatty food
Pain to right shoulder tip
Nausea and vomiting
Chronic
Diagnosis
ALP and bilirubin raised higher than ALT
AXR - calcified stones
Ultrasound - IOC - 95% effective
Courvoisier's sign - Palpable gallbladder with painless jaundice is not gallstones
Treatment
Asymptomatic untreated
Cholecystectomy
Complications
Cholecystitis
Cholangitis
Pancreatitis
Fistulation
Obstructive jaundice
Stone in bile duct - Choledocholithiasis

Cholecystitis
What
Blockage in cystic duct or neck of gallbladder
Local inflammation rather than infection
Gallstone cause after gallbladder emptying, may be worms, tumour or mucus
Obstruction causes increase in gallbladder secretion which causes dilation of ducts
Reduces blood flow
Releases toxin
Leads to infection
Symptoms
Prolonged pain with fever and leucocytosis compared to biliary colic
Murphy's Sign - RUQ pain worse on inspiration - Only positive if negative in LUQ
Jaundice unlikely
Pain radiates to shoulder tip
Diagnosis
Raised WCC, CRP
Serum amylase - gallstones may cause acute pancreatitis
Raised bilirubin, ALP, ALT
Dilated bile duct >8mm
USS - Gallstones, thickening, dilated common bile duct
MRCP

GI Page 20
 MRCP
Treatment
Cefuroxime and Metronidazole
NSAID and pain relief
Fluid
Cholecystectomy
ERCP
Complications
Gangrene
Infection and empyema
Perforation

Ascending Cholangitis
What
Inflammation of bile duct due to bacterial infection secondary to gallstones
Symptoms
Rigors
Fever
Abdominal pain
Jaundice
Septic shock
Mental confusion
Diagnosis
WCC and CRP
Abnormal LFT's - Raised bilirubin, ALP and Gamma GT
Treatment
IV antibiotics - Cefotaxime
Biliary drainage
MRCP

Primary Sclerosing Cholangitis

What
Chronic inflammation of intra/extrahepatic bile ducts - causes fibrosis
Leads to cholestasis, hypertension and liver failure
Usually UC
Symptoms
Pruritus
Jaundice
Fatigue
RUQ pain
Weight loss
Acute cholangitis
Hepatosplenomegaly
Diagnosis
P-ANCA - antibody
LFT's - High ALP, Bilirubin
MRCP/ERCP - MRCP less sensitive but less invasive
Biopsy
IgM, IgG
Treatment
Liver transplant
Complications
Cholangiocarcinoma
Osteoporosis

Pancreatitis
What
Inflammation of pancrease
I GET SMASHED
Idiopathic
Gallstones
Ethanol - Alcohol
Trauma
Steroids
Mumps
Autoimmune
Scorpion bites
Hypercalcaemia, hypothermia, hyperlipidaemia
ERCP
Drugs
Symptoms
Epigastric pain with radiation to retroperitoneum
Tachycardia
Hypotension
Oligourea
Abdominal tenderness and guarding
Reduced bowel sounds
Cullen's sign - Periumbilical bruising
Grey Turner's sign - Flank bruising
Left sided pleural effusion
Diagnosis
Serum amylase and urinary amylase
Serum lipase
CXR - excludes gastroduodenal perforation
USS - gallstones or pancreatic calcification
MRI and CT - Stage damage
ERCP - look at pancreatic duct for inflammation and fibrosis

GI Page 21
 ERCP - look at pancreatic duct for inflammation and fibrosis
Staging - Glasgow Scoring - PANCREAS
PO2 <8kpa
Age >55
Neutrophils - WCC >15
Calcium <2
Renal Urea >16
Enzymes - LDH >600, AST >200
Albumin <32
Sugar - Glucose >10
Treatment
Fluids
Nasogastric suction - Reduce vomiting and abdominal distention <aspiration risk
Antibiotic prophylaxis
Tramadol and NSAIDs
Pancreatin
Complications
Sepsis

Carcinoma of Head of Pancreas

What
95% exocrine adenocarcinomas effecting duct
70% occur at head - causes painless jaundice
80% metastasised at diagnosis
Risk
Age
Smoking
Diabetes mellitus
FH
Symptoms
Pain that radiates to back
Anorexia and nausea
Diarrhoea
Cachexia
Jaundice + pale stool, dark urine
Pruritus
PE
Diabetes
Ascites
Diagnosis
Raised bilirubin and ALP - Obstructive jaundice
Hyperglycaemia
Anaemia
Hypokalaemia - vomiting/diarrhoea
Hypercalcaemia
CA19-9 tumour marker
USS
CT/PET staging
Treatment
Whipple's procedure

GI Page 22
Musculoskeletal
12 January 2017 21:06

Carpal Tunnel Syndrome

What
Compression of median nerve in flexor retinaculum
Gout
Pregnancy
OCP
Rheumatoid arthritis
Diabetes
Acromegaly
Obesity
Symptoms
Wasting of thenar eminence
Paraesthesia lateral 3.5 fingers
Pain/tingling in lateral 3 fingers
Diagnosis
Phalen's test - flexing
Tinel's test - tapping
Treatment
Splint
NSAIDs
Hydrocortisone injection
Surgical decompression
Complications

Mechanical Back Pain

What
Lower back pain, worse on twisting movements
Symptoms
Diagnosis
CRP - Ankylosing spondylitis
Treatment
Posture
Heat and swimming
Paracetamol, NSAIDs, opioids
Antidepressants
Red Flags
Previous malignancy
Age <16 or >50
Weight loss
Steroid use
Recent illness or infection
Saddle anaesthesia
Reduced anal tone
Hip or knee weakness
Neurological deficits
Progressive spinal deficit
Urinary retention

Disk Prolapse
What
Sciatica - Pain in lower back, buttocks, posterior and lower legs
Compression of L4-S3 nerve roots

Musculoskeletal Page 23
 Compression of L4-S3 nerve roots
Femoral nerve L2-L4 - Anterior compartment
Sciatic nerve L4-S3 - Posterior thigh, rest of leg and foot
Defect in annulus fibrosis - nucleus pulpous leaks out
Symptoms
Back and leg pain
Motor weakness
Altered reflexes
Altered sensation
Diagnosis
MRI - shows herniation location and size
Treatment
Analgesia
Local steroid injections
Microdiscectomy
Complications
Cauda Equina Syndrome
Impaired sphincter function
Altered perianal sensation
LMN signs

Osteoarthritis
What
Loss of cartilage in synovial joints
Risk
Genetic
Trauma
Obesity
Joint hypermobility
Osteoporosis - REDUCED risk
Occupation
Inflammatory arthritis
Symptoms
Joint pain and stiffness
Intermittent, aching
Better with rest
Worse in the morning, goes after a few minutes
Joint instability
Loss of joint function
Synovitis
Inflammation of joint capsule
Palpable lumps
Painful on movement
Tender joint line
Crepitus
Muscle wasting
Heberden's nodes - DIP joints
Bouchard's nodes - PIP joins
Diagnosis
X-Ray changes
Joint space narrowing
Subchondral sclerosis
Subchondral cyst
Osteophytes
Bloods - CRP, rheumatoid factor, antinuclear antibodies
MRI
Arthroscopy

Musculoskeletal Page 24
 Arthroscopy
Treatment
Physio and weight reduction
Paracetamol, codeine, NSAID's
Joint replacement

Rheumatoid Arthritis
What
Chronic symmetrical inflammatory polyarthritis with synovitis
Women more effected
HLA mediated
Smoking, stress and infection increase risk
Rheumatoid factor - IgG antibody
Activates compliment process - Inflammation
70% positive in RA
Symptoms
Symmetrical swollen distal joints
Warmth and tenderness
Mostly hand and feet
Rarely hips
Pain worse in morning, improves with activity
Nodules - pink/red and rubbery on elbows and hands
Osteoporosis
Swan neck deformity - Hyperextension PIP, flexed at DIP
Z-Thumb
Muscle wasting
Inflamed flexor tendon sheaths
Carpal tunnel syndrome
Ulnar deviation
Fixed flexion deformity
Worse in summer/heat
Systemic Signs
Anaemia
Lymphadenopathy
Splenomegaly
Sjogren's Syndrome
Vasculitis
Heart signs
Reynaud's
Eye changes
Dry eyes
Scleritis, cataracts, Uveitis, gluacoma
Pulmonary
Upper lobe fibrosis
Lung nodules
Pleural effusion
Diagnosis
Clinical
Morning stiffness >1 hour
>3 joints
Hands and wrists
Symmetrical
Nodules
RF positive
Blood - Anaemia, CRP
Rheumatoid factor, anti-nuclear antibodies, anti CCP

Musculoskeletal Page 25
 Rheumatoid factor, anti-nuclear antibodies, anti CCP
X-ray
Joint aspiration
Treatment
NSAIDs with omeprazole
Prednisolone for remission
Treat to prevent osteoporosis
DMARDs
Methotrexate
Sulfasalazine
IM gold
Cyclosporin
Myelosuppression risk
Anti-TNF-alpha
Entanercept
Infliximab
Adalimumab

Ankylosing Spondylitis
What
Seronegative inflammation of vertebral column and sacro-iliac joints
HLA-B27
Overlap with psoriasis
Spondylitis - Spinal inflammation
Spondylosis - Degenerative osteoarthritis changes
Ankylosis - Stiff joint
Symptoms
Episodic pain, worse in morning, relieved by exercise
Retention of lumbar lordosis in spinal flexion
Paraspinal muscle wasting
Spinal stiffness - Shoeber's test
Reduced chest expansion and anterior chest pain
Dactylitis
Diagnosis
Shoeber's test
CRP
HLA-B27
X-Ray in late disease
Joint fusion and loss of definition of margins
Treatment
Exercise
NSAIDs or steroid injections
TNF-alpha
Complications

Psoriatic Arthritis
What
Seronegative inflammation of skin and joints
Symptoms
Skin changes
Erythematous lesions with silver plaques
On knees and elbows most common
Psoriatic nail dystrophy with yellow/brown discolouration
Oncholysis and pitting
Subungal hyperkeratosis
Oligoarthritis
Dactylitis

Musculoskeletal Page 26
 Dactylitis
Osteolysis
Diagnosis
Synovial biopsy
Clinical
Treatment
Methotrexate
Leflunomide
Not hydrochlorequine - makes skin worse
Anti-TNF-alpha

Reactive Arthritis or Reiter's Syndrome

What
Spondyloathritis caused by STI's and diarrhoea
Chlamydia
Salmonella
1-4 weeks after infection
Symptoms
Conjunctivitis - Can't see
Urethritis - Can't pee
Arthritis - Can't bend the knee
Oligoarthritis - Large joints
Treatment
Rest/Splint
NSAIDs and steroids - symptomatic relief
Complications

Gout
What
Gout - Urate crystals - needle shaped
High levels of uric acid in blood
Pseudogout - calcium pyrophosphate crystals - rhomboid shaped
Risk
Genetic
Diet - Meat and alcohol, high purine diet
Weight
Diuretics
Chronic renal failure
Symptoms
Monoarthritis of MTP
Tophi - Chalky textured deposits under skin
Inflammatory arthritis and synovitis
Warm, tender, red and swollen joints
Pyrexia
Urolithiasis
Resolve after a few weeks
Diagnosis
Serum urate
WCC
CRP
Synovial fluid
X-Ray - Punched out erosions and flecked calcifications
Treatment
NSAIDs - 1st line
Colchicine
Allopurinol - After an attack

Musculoskeletal Page 27
 Allopurinol - After an attack
Complications
Renal failure

Septic Arthritis
Septic Arthritis
What
Monoarticular, high pain on movement of joint
Staphylococcal/streptococcal/gonorrhoea infections
Bacteraemia or direct inoculation, contagious spread (adjacent osteomyelitis)
>2 years old staphylococcus aureus
<2 years old gram negative bacteria
Young adults - gonorrhoea
Symptoms
Pain
Loss of joint function
Fever
Intolerance to passive ROM
Swelling, redness, temperature, tender, extreme pain
Joint extension decreased because swelling restricts movement - (extension
makes joint smaller)
Diagnosis
Blood test - High WCC, High ESR, CRP, High platelets
X-Ray (effusion elevates patella), US, MRI if needed
Joint aspiration - Gold standard
WCC, gram staining, culture, crystals (gout)
Alpha Defensin test - anti-microbial protein released by neutrophils
Treatment
Wash out joint with sterile wash
Flucloxacillin with fusidic acid

Systemic Lupus Erythematosus

What
Autoimmune connective tissue disorder
Inflammation, Fibrosis, Vasospasm and Vascular Thrombosis
Symptoms
Photosensitive rash
Weight loss, fatigue, alopecia, mouth ulcers
Splinter haemorrhages
Arthritis
Nephrosis
Discoid rash
Serositis
Cataracts
Pancytopenia
Seizures and psycosis

Scleroderma
What
Connective tissue disorder causing vascular damage and fibrosis
Symptoms - CREST
C - Calcinosis - Calcium deposits
R - Raynaud's disease
E - Esophageal dysmotility
S - Sclerodactyly - Skin thickening
T - Telangectasia

Musculoskeletal Page 28
Polymyalgia Rheumatica
What
Association with temporal arteritis
Women >50
Muscular pain and stiffness
Symptoms
Pain worse in morning - 45 minutes morning stiffness
In shoulders and thighs - Symmetrical
Appears over a week or two
Worse when resting
Unwell feeling with slight fever
Weight loss and fatigue
Anxiety and depression
No hand or feet swelling
No swollen joints
Diagnosis
CRP
Anaemia is common
Rule out rheumatoid - bloods
Treatment
Prednisolone
DMARDs and analgesia
Complications
Giant cell arteritis

Giant Cell Arteritis / Temporal Arteritis

What
Vasculitis of branches of external carotid artery
Complication with occlusion of ophthalmic artery
Symptoms
Bruits
Fever
Headache
Scalp tenderness
Jaw and tongue claudication
Reduced visual acuity - blurred vision
Acute visual loss - sudden blindness - arteritic anterior ischaemic optic neuropathy
Diplopia
Tinnitus
Polymyalgia rheumatica
Diagnosis
Tender and prominent temporal arteries
Fundoscopy - ischaemia
Decreased pulses
CRP
Biopsy - IOC - 1.5cm to 3cm - patchy pattern involved
Halo sign on ultrasound
Treatment
Prednisone

Osteoporosis
What
Reduction in bone mass and altered bone structure
Risk of fractures increased
Causes
Post-menopausal

Musculoskeletal Page 29
 Post-menopausal
Hyperparathyroidism
Coeliac
Osteomalacia
Myeloma
Hypopituitarism
Alcohol, smoking
Corticosteroids, anticonvulsants, heparin and thyroxine
Low vitamin D and calcium
Diagnosis
DEXA scan - Bone mineral density
TFT
Vitamin D levels
Myeloma screen
Treatment
Bisphosphonates - Alendronic acid
ADCAL-D3
HRT
Complications
Dowager's Hump - spinal fracture - height reduction
Nerve pain

Osteomalacia
Abnormal bone mineralisation - excess osteoid and cartilage, insufficient bone
Vitamin D deficiency
Muscle aches, weakness, bone pain, fractures
Kyphoscoliosis

Musculoskeletal Page 30
Renal
12 January 2017 21:14

Nephrotic Syndrome
What
Causes
Minimal change disease
Nephropathy - Hep B, SLE, diabetes, syphilis, sarcoidosis
Glomerulosclerosis - HIV, Diabetes, Obesity
Increases susceptibility to infection
Risk of thromboembolism and hyperlipidaemia
Symptoms
Proteinuria
Hypoalbuminaemia
Oedema
Hypertension may occur
Diagnosis
U+E, CRP
Urine - RBC, red cast cells, protein
Renal USS and biopsy

Glomerulonephritis
What
Symptoms
Diagnosis
Treatment
Complications

Cystitis
What
Symptoms
Diagnosis
Treatment
Complications

Pyelonephritis
What
Symptoms
Diagnosis
Treatment
Complications

Kidney Stone
What
Symptoms
Diagnosis
Treatment
Complications

UT Obstruction
What
Symptoms
Diagnosis
Treatment
Complications

Urology Page 31
 Complications

AKI
What
Symptoms
Diagnosis
Treatment
Complications

CKD
What
Symptoms
Diagnosis
Treatment
Complications

Autosomal-Dominant Polycystic Kidney Disease

What
Symptoms
Diagnosis
Treatment
Complications

Benign Prostate Enlargement

What
Symptoms
Diagnosis
Treatment
Complications

Prostate Carcinoma
What
Symptoms
Diagnosis
Treatment
Complications

Urology Page 32
Endocrinology
12 January 2017 21:21

Pituitary Adenoma
Symptoms
Bitemporal hemianopia
Unexpected bone growth and lactation
Headaches
Hypo/Hypopituitarism
Diagnosis
Hormone testing
CT/MRI
Treatment
Prolactinomas
Surgery
Complications
Acromegaly
Cushing's Syndrome
Diabetes insipidus

Acromegaly
What
Excess growth hormone from anterior pituitary
Caused by pituitary tumour
Symptoms
Gigantism
Sweating
Headache
Increased hand and feet size
Oligo/amenorrhoea
Infertility
Proximal muscle weakness
Signs
Prominent brow and jaw
Enlarged tongue
Carpel tunnel
Diagnosis
Random GH measurements
Serum IGF-1
OGTT - Glucose inhibits GH
Treatment
Surgical
Somatostatin analogues
Complications
Diabetes mellitus
Cardiomyopathy - heart failure
Osteoporosis
Obstructive sleep apnoea

Hypothyroidism
What
Due to autoimmune thyroid disease, radioiodine damage, post-partum or
iodine deficiency
Rarely secondary to pituitary or hypothalamic
Hashimoto's Thyroiditis

Endocrinology Page 33
 Hashimoto's Thyroiditis
Autoimmune
Goitre
Firm and rubbery thyroid
TPO antibody in blood
Associated with diabetes t1 and Addison's
Pernicious anaemia
Symptoms
Tiredness
Weight gain with appetite loss
Cold intolerance
Mental slowness
Depression
Loss of libido
Goitre without pain
Puffy eyes, dry brittle hair and skin
Constipation
Menorrhagia
Obesity
Hypertension
Hypothermia
Peripheral oedema
Deep voice
Carpal tunnel
Bradycardia
Myxoedema coma
Diagnosis
TFTs
High TSH, Low T4 - Hypothyroidism
Low TSH, Low T4 - Hypopituitarism
Hypercholesterolaemia and hyponatraemia
Treatment
Levothyroxine - gradual increase dose in CHD 50mg>
Complications
Addison's disease
Pernicious anaemia

Hyperthyroidism
What
Grave's disease
TSH receptor stimulating antibodies
Toxic Multinodular disease
Amiodarone
5% of nodules are cancerous
Iodine excess
Thyroid carcinoma
TSH secreting tumour
Thyroid hypertrophy and hyperplasia
Lymphocytic infiltrate
Symptoms
Acute
Fever, seizures, vomiting, diarrhoea, jaundice, death
Hyperactivity
Heat intolerance and sweating
Palpitations
Fatigue, weakness
Weight loss, increased appetite

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 Weight loss, increased appetite
Polyuria
Oligomenorrhoea and Menorrhagia
Tachycardia and atrial fibrillation
Tremor
Warm skin
Goitre
Pigmentation
Palmar erythema
Muscle weakness/wasting
Eyelid retraction
Gynecomastia
Psychosis
Exophthalmos
Splenomegaly
Pretibial myxoedema
Diagnosis
TFTs
TSH <0.05
High T4
TPO and Thyroglobulin antibodies in Grave's
TSH receptor antibodies in 60% Grave's detectable
Radioactive iodine uptake test - High uptake in Grave's, low in thyroiditis
Treatment
Prednisolone - Eye disease
Propranolol - Reduce tachycardia, af, tremor and anxiety
Radioiodine
Antithyroid drugs
Carbimazole
Propylthryouracil

Addison's Disease
What
Hypoadrenalism
Complete destruction of adrenal cortex
Reduced glucocorticoid, mineralocorticoid and sex steroids
Low Cortisol
Increased CRH and ACTH
Causes
Autoimmune
TB
Surgical
Haemorrhage
Symptoms
Weight loss and anorexia
Fatigue and weakness
Fever
Depression
Impotence/Amenorrhoea
Nausea and Vomiting
Diarrhoea or Constipation
Confusion
Syncope - Postural Hypertension
Abdominal pain
Myalgia and joint/back pain
Signs

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 Signs
Pigmentation - Scars and palmar creases
Postural hypertension
Diagnosis
ACTH stimulation test - >90 at 0900
Addisonian Crisis
Low BP, Na, Glu and dehydrated
High K
Plasma renin and aldosterone
Treatment
0.9% saline over 1 hour with 100mg IM hydrocortisone
Dextrose solution if hypoglycaemic
25mg hydrocortisone
Fludrocortisone

Cushing's Syndrome
What
Excess glucocorticoid, loss of circadian rhythm of cortisol secretion
Causes
Oral steroids
Cushing's Disease
Adrenal hyperplasia from ACTH secretion pituitary adenoma
Ectopic ACTH secretion from tumour
Adrenal carcinoma or nodular hyperplasia
Symptoms
Weight gain
Depression, irritability, psychosis
Proximal weakness
Impotence/Amenorrhea
Acne
Signs
Central obesity
Moon face and neck hump
Skin and muscle atrophy
Osteoporosis
Diagnosis
48 hour dexamethasone test
High glucose
Hyperkalaemia
Treatment
Surgery/Radiotherapy
Complications
Diabetes

Hypercalcaemia and Primary Hyperparathyroidism

What
Calcium >2.6
Causes
Parathyroid adenoma
Cancer
Vitamin D disorder
Hyperthyroidism
Kidney failure
Symptoms
Stones - Renal or kidney
Bones

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 Bones
Groans - Abdominal pain, nausea and vomiting
Thrones - Polyuria and dehydration
Psychiatric overtones - Depression, anxiety
Tachycardia
Diagnosis
ECG changes - Short QT interval, Osborn wave
Treatment
Fluids
Bisphosphonates
Calcitonin
Parathyroidectomy
Raised PTH and Ca

Hypoparathyroidism
What
Low PTH and Ca
Causes
Surgery
Autoimmune
Haemochromatosis
Symptoms
Paraesthesia
Muscle cramps and tetany
Seizures, arrhythmias, airway spasm

Conn's Disease
What
Hyperaldosteronism
High Na
Low K
Hypertension
Causes
Adrenal adenoma
Adrenal hyperplasia
Symptoms
Simple hypertension
Diagnosis
Discontinue beta blockers, ACE inhibitors and ARBs
Plasma aldosterone:renin ratio
Hypokalaemia and urinary potassium loss
Treatment
Remove adenoma

Diabetes Type 1
What
Adolescents
Autoimmune destruction of pancreas beta cells
Association with other autoimmune disease
Diabetic Ketoacidosis
Fatty acid metabolism due to lack of glucose uptake
Acetoacetic acid - causes ketone breath
Symptoms
Thirst - High glucose - High osmalarity
Weight loss
Polyuria
Polydipsia

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 Polydipsia
DKA Symptoms
Hyperglycaemia
Dehydration and electrolyte loss and hypotension
Hyperketonaemia
Metabolic acidosis
Abdominal pain
Leg cramping
Kussmaul breathing
Tachycardia
Hypothermia
Confusion -> Coma
Diagnosis
Urine analysis
Glycated haemoglobin HbA1C test
DKA
Ketones >6
Bicarb <5
pH <7
K <3.5
GCS <12
O2 <92% on air
BP <90
Hr >100 or <60
Treatment
Insulin
IV 0.9% NaCL - 500ml bolus
KCL may be needed

Diabetes Type 2
What
Risk
Age
Obesity
Ethnicity
Family History
Metabolic syndrome
Symptoms
Fatigue
Vision blurring
Polyuria
Polydipsia
Weight loss - less common
Complications
Skin infections
Retinopathy
Polyneuropathy
Erectile Dysfunction
Arterial disease - MI or peripheral gangrene
Acanthosis nigricans
Diagnosis
Glycosuria and High BM
Venous sample
Random blood glucose screening
<6.1 Not diabetes
>11.1 Diabetes
6.1-11.0 Unknown - Do a fasting glucose

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 6.1-11.0 Unknown - Do a fasting glucose
Fasting blood glucose
<6.1 Not Diabetes
>7 diagnosis of diabetes
6.1-8 Uncertain - OGTT - Oral glucose tolerance test
Normal fasting <6.1 and 2<7.8
Diabetes Fasting >7 and 2hr's >11
IFG (Impaired fasting glucose) Fasting >6.1 and 2hr's <7.8
IGT (Impaired glucose tolerance) Fasting <7 and 2 hr >7.8<11.1
Pre-Diabetes - IGT - Will lead to diabetes if no change - Risk of angina and MI
Treatment
Diet
Exercise
Medication
Metformin - Biguanide
Increase insulin sensitivity
No hypoglycaemia
Not in renal failure
Sulfonylureas
Gliclazide, Glimepiride
Increase insulin secretion
Hypoglycaemia risk
Weight gain
Glitazones
Thiazolidinediones
Reduce insulin resistance
Weight gain and Na retention
Gliptins
Increase insulin secretion
Insulin
Complications
Hypoglycaemia
Blood glucose <3.5
Sweating, trembling, palpitations, hunger and anxiety
Confusion, drowsiness, slurred speech, lack of coordination and
concentration
Nausea, tiredness and headache
Irreversible in insulin treated patients
Treat
Carbohydrate snack
IM glucagon or IM glucose
Hyperosmolar Hyperglycaemic State
Type 2
High glucose >600
High sodium
Hypovolaemia
Acidosis is absent or mild
Bicarbonate >15
Delirium common

Diabetic Retinopathy
What
Microvascular damage of retina
Symptoms
Non-proliferative diabetic retinopathy - Microaneurysms

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 Non-proliferative diabetic retinopathy - Microaneurysms
Proliferative - Neovascularisation - New blood vessels at back of eye
Vitreous haemorrhage of these blood vessels - Black spots
Diagnosis
Leaking blood vessels,
Macular oedema
Retinal exudates
Neuropathy
Changes in blood vessels
Treatment
Laser treatment

Endocrinology Page 40
Neurology
13 January 2017 18:07

Migraine
Symptoms
Visual aura
Unilateral throbbing headache within an hour
Often premenstrual
Nausea and vomiting
Photophobia
Phonophobia
Allodynia
Treatment
NSAIDs
Triptans
Propranolol
Amitriptyline
Complications

Subarachnoid Haemorrhage
What
Symptoms
Diagnosis
Treatment
Complications

Temporal Arteritis
What
Symptoms
Diagnosis
Treatment
Complications

Raised ICP
What
Symptoms
Diagnosis
Treatment
Complications

Trigeminal Neuralgia
What
Symptoms
Diagnosis
Treatment
Complications

Meningitis
What
Symptoms
Diagnosis
Treatment
Complications

Confusion

Neurology Page 41
Confusion
What
Symptoms
Diagnosis
Treatment
Complications

Dementia
What
Symptoms
Diagnosis
Treatment
Complications

Epilepsy
What
Symptoms
Diagnosis
Treatment
Complications

Ulnar Nerve Palsy

What
Symptoms
Diagnosis
Treatment
Complications

Median Nerve Palsy

What
Symptoms
Diagnosis
Treatment
Complications

Radial Nerve Palsy

What
Symptoms
Diagnosis
Treatment
Complications

Diabetic Neuropathy
What
Symptoms
Diagnosis
Treatment
Complications

B12 Deficiency
What
Symptoms
Diagnosis
Treatment
Complications

Guillain-Barr Syndrome
What

Neurology Page 42
 What
Symptoms
Diagnosis
Treatment
Complications

Sciatica
What
Symptoms
Diagnosis
Treatment
Complications

Stroke
What
Symptoms
Diagnosis
Treatment
Complications

Parkinson's Disease
What
Symptoms
Diagnosis
Treatment
Complications

Myasthenia Gravis
What
Symptoms
Diagnosis
Treatment
Complications

Neurology Page 43
Breast and Dermatology
13 January 2017 18:29

Fibroadenosis
What
Fibrocystic breast disease
Breast pain
Increase in breast size
Nodular lumps - before period
Related to menstrual cycle, disappear after periods

Fibroadenoma
What
Smooth, well-rounded, solid lumps
Easy to move around
Resolve after period, increase during pregnancy http://www.slideshare.net/shalaree/breast-surgery-for-medical-finals
Response to oestrogen
<30
Increased risk of breast cancer http://reference.medscape.com/features/slideshow/breastlumps#12

Breast Cyst
What
Fluid filled sac
Smooth, firm lumps

Breast Abscess
What
Painful collection of pus
Fever
Redness
Swelling
Often during breastfeeding

Other benign breast lumps

Mastitis - painful inflammation after smoking/nipple piercing
Fat necrosis - Hard irregular lump after trauma
Lipoma - fatty growth
Intraductal papilloma - wart-like growth in milk duct, discharges

Breast Cancer
What
Clear definition
Firm
Fixated
Persists after period/menopause
BRCA1/BRCA2 gene
Symptoms
New lump or area of thickened tissue
Change in breast size
Bloodstained discharge
Lump in armpits
Skin dimpling
Rash on nipple
Change in nipple appearance
Diagnosis
USS guided biopsy - fine needle aspiration
HER2+ receptor cancers are more aggresive
Treatment
Mastectomy - Whole breast
Quadrantectomy - one-quarter
Lumpectomy - lump only
Hormone blocking therapy
Tamoxifen
Aromatase inhibitor - Anastrazole
Chemotherapy
Cyclophosphamide
Doxorubicin
Monoclonal antibody
Trastuzumab - HER2 85% increased 5 year survival
Radiotherapy

Psoriasis
What
Keratinocyte hyperproliferation in 15-30 year olds
Symptoms
Erythematous plaque with silver scale
Clear border
On extensor surfaces - elbow, knee

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 Keratinocyte hyperproliferation in 15-30 year olds
Symptoms
Erythematous plaque with silver scale
Clear border
On extensor surfaces - elbow, knee
Or scalp/sacral
Painful and itchy but less so than eczema
Bleeds on scale removal - Auspitzs sign
Treatment
Topical corticosteroids
Vitamin D
Moisturiser and emollients
Phototherapy

Eczema
What
IgE mediated dermatitis, T-cell auto-immune response
Symptoms
Rash on flexor surfaces or around eyes and neck
Pruritus
Lichenification and staphylococcal infections from scratching
Cataracts
Treatment
Emollients
Steroid cream before emollients
Hydrocortisone -> betamethasone (Dermovate)
Pimecrolimus or tacrolimus
Phototherapy

Basal Cell Carcinoma

What
Small shiny pink/pearly white lump
Translucent or waxy
May be red and scaly with black pigment
Caused by sunlight

Squamous Cell Carcinoma

What
Firm pink lump
Rough and crusty surface
Sometimes has a spiky horn
Tender
Bleeds
Ulcerating

Malignant Melanoma
What
Common during pregnancy
Asymmetry
Border is irregular
Colour
Diameter - 7mm
Enlarging and evolving

Other Page 45