Sunday 30 September 2012

Multiple Endocrine Neoplasia (MEN)

Simultaneous or metachronous occurrence of tumours in a number of endocrine glands with autosomal dominant inheritance

Type 1

  • Parathryoid - adenomas, hyperplasia
  • Pituitary - adenomas
  • Pancreas - islet cell tumours (e.g. insulinoma), gastrinoma
  • Adrenal adenoma
  • Thyroid adenoma


Type 2a

  • Adrenal - phaeochromocytoma
  • Thyroid - medullary carcinoma
  • Parathyroid - adenomas, adenocarcinoma


Type 2b

  • Type 2a PLUS
    • Marfanoid phenotype
    • Visceral ganglioneuromas

Saturday 29 September 2012

Chest radiograph - Revision boxes

Heart failure
  • A - Alveolar oedema (Bat's wings)
  • B - Interstitial oedema (Kerley B lines)
  • C - Cardiomegaly
  • D - Dilated prominent upper lobe vessels (Upper lobe diversion)
  • E - Effusion (Pleural)

Bronchiectasis
  • Tram-line shadowing

Miliary TB
  • Miliary shadowing

Pulmonary embolus
  • Wedge-shaped infarct

Fibrosis
  • 'Ground-glass' appearance (early)
  • 'Honeycomb' appearance (late)

Mesothelioma
  • Pleural mass with lobulated margin

Respiratory causes of clubbing - Revision boxes


  • Bronchial carcinoma
  • Bronchiectasis
  • Lung abscess
  • Empyema
  • Cystic fibrosis
  • Cryptogenic fibrosing alveolitis
  • Mesothelioma
  • TB
  • NOT: Asthma/COPD

Reminder:

GI causes
  • IBD
  • Cirrhosis
  • Lymphoma
  • Coeliac disease
  • Oesophageal cancer

CVS causes
  • Atrial myxoma
  • Subacute bacterial endocarditis
  • Congenital cyanotic heart disease
  • All causes of chronic hypoxia

On respiratory examination

Hyperexpanded chest

  • COPD
  • Chronic asthma

Postural flapping tremor
  • Acute CO2 retention

Stony dull percussion
  • Pleural effusion

Fine crepitations
  • Pulmonary oedema
  • Pulmonary fibrosis

Pleuritic chest pain
  • Pulmonary embolism, pneumonia, pneumothorax

Stridor
  • Upper airway obstruction, e.g. foreign body, croup

Side effects associated with cardiovascular drugs - Revision boxes

Beta-blockers, e.g. propranolol
  • Impotence
  • Shortness of breath
  • Cold peripheries

ACE (angiotensin-converting enzyme) inhibitor e.g. captopril
  • Persistent dry cough

Digoxin, spironolactone
  • Gynaecomastia

Amiodarone
  • Hyper/hypothyroidism
  • Corneal microdeposits
  • Lung/liver fibrosis

Verapamil
  • Constipation
  • Gynaecomastia

Nifedipine
  • Flushing
  • Headache
  • Ankle oedema

Thiazide diuretic e.g. bendrofluazide
  • Gout (hyperuricaemia)

Minoxidil
  • Increased hair growth

Hydralazine
  • Drug-induced systemic lupus erythematosus (SLE)

Myocardial infarction - locations

All MIs

  • Hyperacute T waves that invert later
  • ST elevation
  • Q wave formation
  • Localising infarct (leads with above ECG changes in that order)

Inferior infarct
  • II, III, aVF

Anterolateral infarct
  • I, aVL, V2-V6

Anterior infarct
  • V2-V5

Subendocardial infarct
  • ST and T wave changes but no Q waves

Posterior infarct
  • Reciprocal changes in V1 and V2
    • Tall R waves
    • ST depression
    • Tall upright T waves

ECG findings

'Saw-tooth' pattern with normal complexes
  • Atrial flutter

Absent 'p' wave
  • Atrial fibrillation
  • Sinoatrial block

Bifid 'p' wave
  • Left atrial hypertrophy, e.g. mitral stenosis

Peaked 'p' wave
  • Right atrial hypertrophy, e.g. pulmonary hypertension, tricuspid stenosis

ST depression
  • Myocardial ischaemia (MI)

ST elevation
  • Acute myocardial infarction (MI)
  • Left ventricular aneurysm

'Saddle'-shaped ST elevation
  • Acute constrictive pericarditis

Pulmonary embolus
  • SI,QIII,TIII pattern (Deep S waves in I, Q waves in III, inverted T waves in III)

Tall tented 't' waves, wide QRS complex (sine wave)
  • Hyperkalaemia

Flattened 't' waves, prominent 'U' waves (muscle weakness, cramps, tetany)
  • Hypokalaemia

Long 'Q-T' interval, tetany, perioral paraesthesia, carpopedal spasm
  • Hypocalcaemia

Congenital heart defects - Revision boxes

Atrial septal defect (ASD)
  • Wide, fixed split second heart sound
  • Ejection systolic murmur second, third intercostal space

Ventricular septal defect (VSD)
  • Harsh pansystolic murmur left sternal edge

Coarctation of aorta
  • Radiofemoral delay, hypertension

Persistent ductus arteriosus
  • Continuous 'machinery' murmur below left clavicle
    • Prostaglandins keep open
    • NSAIDS close

Transposition great vessels
  • Cyanosis first day of life
  • Chest radiograph: egg-shaped ventricles

Tetralogy of Fallot
  • Cyanosis first month of life
  • Chest radiograph: boot-shaped heart

Syndrome of inappropriate ADH secretion (SIADH)

  • Inappropriate ADH secretion leads to retention of water and hyponatraemia

Aetiology
  • Tumours
    • Prostate cancer
    • Small cell carcinoma of lung
    • Pancreatic cancer
  • Lungs
    • Pneumonia
    • TB
  • CNS
    • Meningitis
    • Tumours
    • Head injury
    • Chronic subdural haematoma
    • SLE vasculitis
  • Drugs
    • Chlorpropamide
    • Carbamezepine
    • Phenothiazines

Clinical features
  • Confusion
  • Nausea
  • Fits
  • Coma

Management
  • Underlying cause
  • Fluid restriction
  • Dimethylchlortetracycline

Friday 28 September 2012

EMQ revision - Chromosomal abnormalities

  • 14 year old, Male, Gynaecomastia, Low IQ, Eunuchoid habitus, Gynaecomastia, Testicular atrophy, 47 XXY
    • Klinefelter's syndrome
      • Seminiferous tubule dysgenesis and loss of Leydig cells
      • Underlying defects lead to androgen deficiency and cause testicular atrophy, gynaecomastia, and failure of secondary sexual characteristics
      • Androgen replacement as treatment but this cannot restore fertility
  • 15 year old, Female, Short stature, Webbed neck, Low hairline, Wide spacing of the nipples with a 'shield-shaped' chest, hearing impairment, 45 XO chromosomal analysis
    • Turner's syndrome
      • Phenotypically female
      • Associated with primary amenorrhoea and coarctation of the aorta
  • 2 year old, Male, Known chromosomal disorder, New cardiac murmur, Short stature, Epicanthal folds, Simian palmar creases, Auscultation of his heart reveals a harsh pansystolic murmur at the left sternal edge, Not cyanosed, No signs of cardiac failure
    • Down's syndrome
      • Trisomy 21
      • Commonest of chromosomal disorders
      • Atrioventricular endocardial cushion defect causes the cardiac disorders
      • Increased risk of ALL, Alzheimer's disease and hypothyroidism
      • 47 XX + 21 or 47 XY + 21
  • Neonate reviewed on labour ward, Hypotonic, Low-set ears, Micrognathia, 'Rocker bottom' feet, 47 XY +18
    • Edward's syndrome
      • Occipital prominence
      • Cleft lip and palate
      • Wide spacing of nipples
      • Cryptorchidism
      • Major cardiac and renal abnormalities
      • Death within 3 months of birth
      • If survives, there will be serious mental retardation
  • Neonate Special Care Baby Unit (SCBU), low set ears, cleft lip and palate, and six fingers on each hand, 47 XY + 13
    • Patau's syndrome
      • Same as Edward's syndrome
      • Death within 3 months of birth, with severe mental retardation even if they do survive past that
  • Cri-du-chat syndrome
    • Deletion of chromosome number 5
    • Cry that is high pitched and sounds like a cat
    • Downward slant to the eyes
    • Mental retardation
    • Microcephaly
    • Micrognathia
    • Partial webbing or fusing of fingers or toes
  • Double Y syndrome
    • Essential normal, with normal fertility and mental health
    • No increased aggression
    • No increased acne
    • Only quicker growth and increased final stature versus predicted
  • Fragile X syndrome
    • Change of X chromosome (FMR1)
    • FMR1 produces a protein that helps brain to develop and grow properly
    • More repeats, more likely there is to be a problem
    • Most common inherited form of mental retardation in boys
    • Both boys and girls affected but since girls have 2 X chromosomes they are less likely to take the full brunt
  • Prader-Willi syndrome
    • 7 genes on chromosome 15 not expressed on paternal chromosome (maternal normal)
    • Low muscle tone, short stature, incomplete sexual development, cognitive disabilities, problem behaviours, chronic feeling of hunger leading to life threatening obesity
    • Genetic imprinting
  • Angelman syndrome
    • 7 genes on chromosome 15 not expressed on maternal chromosome (paternal normal)
    • Intellectual and developmental disability, sleep disturbance, seizures, jerky movements (especially hand-flapping), frequent laughter or smiling, happy demeanour
    • Genetic imprinting
  • Triple X syndrome
    • Usually nothing, most are normal and many are never diagnosed
    • Increased risk of delayed language development, EEG abnormalities, motor-coordination problems, auditory-processing disorders and scoliosis
    • Accelerated growth until puberty
    • Premature ovarian failure
    • Personality and psychological problems

Acute lymphoblastic leukaemia (ALL) - Basis for logical management

ALL
  • ALL occurs mainly in >15s
  • 15-25 common
  • Older ages are far less common
  • Causes aplastic anaemia
  • High number of lymphoblasts cause increased viscosity in the blood, increasing risk of stroke

Management
  • Don't give transfusion first! Look at the child! Even with a very low Hb, the child may be well!
  • In fact, don't quickly give transfusion at all if necessary, since this will exacerbate the INCREASED VISCOSITY CAUSED BY THE LYMPHOBLASTS
  • IV fluids are better since it does two main things
    • Stimulates white cell lysis (also induced by dexamethasone given with bone marrow transplant)
      • This increases uric acid and increases potassium
        • Allopurinol (for uric acid)
        • Urate oxidase (for uric acid)
      • Hopefully IV fluid can flush all these through the kidneys
    • Treat hyperviscosity

SPIKES plus - extra personal notes

S - Setting
P - Perception
I - Invitation
K - Knowledge
E - Empathy
S - Strategy and summary


Pointers
  • Start off with "You look worried, do you mind telling me what's worrying you?" as opposed to asking concerns directly
  • Pick up more unspoken Qs even when there is clearly nothing - "You look very quiet, may I know what's going on in your mind?"
  • Say things like "I'm really sorry to say that, " or "Unfortunately, " or "I'm afraid that, "
  • ACKNOWLEDGE FEELINGS/CONCERNS
  • Don't BLOCK cues!
  • Be honest about uncertainties - "I'm sorry, but I can't guarantee that..."
  • It is possible to pause after every step, and the pause doesn't need to be right at the end
  • ASK FOR PERMISSION TO GO ON, EVEN BETWEEN STEPS! YOU CAN ASK FOR PERMISSION MORE THAN ONCE!
  • Don't forget to summarising
  • PAUSE PAUSE PAUSE! Just keep pausing as much as possible!

Breast cancer management

Breast cancer (Kills people, also most common cancer)
  • Types
    • Ductal Carcinoma In Situ (DCIS)
    • Lobular Carcinoma In Situ (LCIS)
    • Invasive Ductal Carcinoma (IDC)
    • Invasive Lobular Carcinoma (ILC)
    • Other types
      • Paget's disease of the nipple
      • Phyllodes tumours of the breast
  • Metastasis
    • Bone
    • Liver
    • Lung
  • Classify
    • Oestrogen receptor positive
      • Mainly older women
      • HORMONE
    • Oestrogen receptor negative
      • Mainly younger women
      • CHEMOTHERAPY
  • www.predict.nhs.uk


MANAGEMENT


SURGERY
  • WIDE LOCAL EXCISION (WLE)
    • Done mainly for focal disease
    • Followed by sentinel node biopsy (methylene blue)
    • If sentinel node is positive, then axillary lymph node excision can be done
      • Lymphoedema (20% risk)
      • Brachial plexus injury
      • Long thoracic nerve injury

  • MASTECTOMY
    • Done mainly for multifocal disease


MEDICAL (USUALLY ALWAYS USED AS AN ADJUNCT TO SURGERY) (HELPS PREVENT RECURRENCE)
  • Oestrogen receptor positive
    • Tamoxifen
      • Oestrogen receptor antagonist
      • Increases risk of endometrial cancer
    • Letrozole (node positive?), Anastrozole (node negative?), Exemestane (metastases?)
      • Aromatase inhibitor (stops production of oestrogen)
      • Follow up with bone scan, and give Ca2+/Vit D to counter the effects of osteoporosis (Decreasing what little oestrogen is left) 
    • Zoladex (Goserelin Acetate)
      • Gonadotropin releasing hormone superagonist (GnRH agonist)
      • Increases oestrogen and testosterone production in a non-pulsatile fashion such that production decrease
      • Eventual decrease in oestrogen and testosterone
      • Useful for prostate cancer, breast cancer, and precocious puberty
    • Chemotherapy

  • Oestrogen receptor negative
    • Chemotherapy (Bolded is a sample combination - FEC)
      • 5-fluorouracil
      • Epirubicin
      • Cyclophosphamide
      • Doxorubicin
      • Methotrexate
      • Docetaxel
    • Zoladex?

  • HER2/neu receptor positive
    • Trastuzumab
      • Monoclonal antibody
      • Arrest in cell stage G1 after treatment

RADIOTHERAPY (SOMETIMES USED AS AN ADJUNCT TO BOTH CHEMOTHERAPY and SURGERY) (HELPS PREVENT RECURRENCE)
  • Targeted versus not targeted - 'radiotherapy equivalent of mastectomy'
  • Has to be first simulated and planned
  • Treatment is then given after planning
  • HAS BEEN SHOWN TO IMPROVE ALL SUCCESS RATES
  • Not used so much after mastectomy, since even though there is still an improvement, because with mastectomy the % recurrence is so small anyway (given the chemotherapy that would inevitably be given)

OSCE revision - Examination of thyroid gland and status

General inspection
  • Look for signs of thyroid disease

Examine the neck
  • Look for a goitre
    • Ask the patient to take a sip of water and hold it in the mouth, then ask him or her to swallow while watching the neck - look for movement of goitre with swallowing
    • Stand behind the patient and feel the thyroid with both hands, standing in the centre below the thyroid cartilage over the trachea, and moving laterally to the two lobes which extend behind the sternomastoid muscle. Ask the patient to swallow while palpating. Assess the goitre for size, nodularity or diffuse enlargement, discrete nodules and firmness
    • Palpate for lymph nodes
    • Auscultate - listen over the thyroid for a bruit

Assess thyroid status
  • Pulse - count the rate and note the presence or absence of atrial fibrillation
  • Palms - warm and sweaty
  • Tremor of outstretched arms

Examine the eyes
  • Exophthalmos
  • Lid retraction
  • Lid lag

Examine the reflexes
  • Slow relaxation in hypothyroidism

Thursday 27 September 2012

Laboratory tests in Endocrinology

  • Hormones may be measured in blood/plasma or urine
  • Markers of function
    • Glucose in diabetes
    • Calcium in hyperparathyroidism


Basal levels

Blood or plasma levels
  • Useful measurements for hormones with long half-life, e.g. thyroxine (T4 and T3)
  • Also applied to certain conditions in which normal values are known, e.g.
    • Time of day - cortisol and adrenocorticotrophic hormone (ACTH)
    • Period of menstrual cycle - follicle stimulating hormone (FSH), oestrogen, progesterone
    • Posture - aldosterone

24-hour urine collections
  • Provide an average of a whole day's secretion of a hormone
  • Require normal renal function and accurately timed and complete urine collection

Dynamic tests
  • Test ability of a gland to respond appropriately to stimulation or suppression
  • Failure of normal negative fedback causing uncontrolled hormone secretion
    • From within the gland
    • From an ectopic source
  • Failure of a normal positive response to stimulation of a gland

Examples

Stimulation test - Synacthen test
  • Normal adrenal response to a dose of synthetic ACTH is an increase in plasma cortisol levels
  • Primary adrenal failure - a diminished or absent response
  • Adrenal failure secondary to lack of pituitary secretion of ACTH - normal or enhanced cortisol response
  • Long synacthen = if short is equivocal and Addison's disease suspected

Suppression test - Dexamethasone suppression test
  • Normal response to a dose of synthetic steroid is reduction in pituitary release of ACTH and subsequent fall in adrenal cortisol release and plasma levels
  • Uncontrolled endogenous production of ACTH from a pituitary tumour or ectopic source leads to inadequate suppression of plasma cortisol level

Wednesday 26 September 2012

Light's criteria for exudate being more likely than transudate


  • The ratio of pleural fluid protein to serum protein is greater than 0.5
  • The ratio of pleural fluid LDH and serum LDH is greater than 0.6
  • Pleural fluid LDH is greater than 0.6 or 2/3 the upper normal limit for serum (Different labs have different upper normal limit but examples include 200 and 300 IU/L

Drug causes of gynaecomastia

DISCO MTV


  • D - Digoxin
  • I - Isoniazid
  • S - Spironolactone
  • C - Cimetidine
  • O - Omeprazole/Oestrogens
  • M - Methyldopa
  • T - Tricyclic antidepressants
  • V - Verapamil

Causes of anaemia


  • 23 year old, male, recurrent nose-bleeds, infection after chemotherapy
    • Aplastic anaemia
      • Presentation of pancytopenia with hypoplastic marrow
      • Primary or secondary
      • Most common primary is idiopathic acquired aplastic anaemia
      • Congenital causes of primary aplastic anaemia are very rare (e.g. Fanconi's anaemia)
      • Secondary causes of aplastic anaemia include infection (especially viral, e.g. hepatitis, measles, parvovirus B19) and drugs
      • Cytotoxic drugs such as busulphan and doxorubicin are well-recognised causes of secondary aplastic anaemia via a type A (dose-related response)
      • Non-cytotoxic drugs such as chloramphenicol and gold have also been reported to cause aplastic via a type B (not dose-related) response
      • Rarely, pregnancy is associated with a secondary aplastic anaemia
  • 24 year old, Cypriot, male, worsening anaemia and jaundice, Heinz bodies
    • Glucose-6-phosphate dehydrogenase deficiency
      • G6PDH deficiency
      • Most common red blood cell enzyme defect
      • These individuals are susceptible to oxidative crises precipitated by fava beans and drugs such as ciprofloxacin and sulphonamides
      • G6PDH plays an important role in the hexose monophosphate shunt which provides NADPH (reduced nicotinamide adenine dinucleotide phosphate - the reducing agent)
      • NADPH is used to regenerate glutathione
      • In the absence of glutathione, red blood cells are exposed to oxidative stress
      • Heinz bodies represent oxidised haemoglobin
  • 50 year old, male, tiredness, dyspnoea and paraesthesia, on examination extensor plantars, brisk knee jerks, and absent ankle jerks, blood film shows macrocytic anaemia
    • Pernicious anaemia
      • Most common cause of vitamin B12 deficiency
      • Atrophy of gastric mucosa with subsequent failure of intrinsic factor production
      • Intrinsic factor is required for vitamin B12 absorption
      • Other causes are terminal ileum disease, gastrectomy, and low dietary intake (e.g. vegans)
      • Vitamin B12 can just be taken orally in those with lack in diet
      • It has to be given intramuscularly in those with pernicious anaemia (intramuscular hydroxocobalamin)
  • 23 year old, woman, trimethoprim for recurrent urinary tract infections (UTIs), macrocytic anaemia
    • Folate deficiency
      • Macrocytosis causes include vitamin B12/folate deficiency, alcohol, liver disease, hypothyroidism, and myelodysplasia
      • Trimethoprim is a bacterial dihydrofolate reductase inhibitor, but with prolonged therapy it can act in humans
      • It is avoided in pregnancy because interference with folate makes it teratogenic
      • Bone marrow biopsy is indicated if the cause of the macrocytosis is not established with blood tests
  • 25 year old, woman, SLE, acute anaemia, steroid treated, Direct Coomb's test was strongly positive, direct antiglobulin test was positive with IgG alone
    • Autoimmune haemolytic anaemia
      • Many causes of anaemia in patient with SLE
      • These include iron deficiency anaemia secondary to NSAID use, bone marrow suppression secondary to immunosuppressive drugs such as cyclophosphamide/azathioprine
      • AHA is the cause in this patient since the direct Coombs' test demonstrates and confirms the presence of antibody binding to red blood cells
      • Other causes of secondary AHA include lymphoma, infections (e.g. EBV, Mycoplasma spp.), carcinoma and other autoimmune conditions
      • Drugs may also cause immune haemolysis e.g. methyldopa treatment can induce the formation of red cell autoantibodies

EMQ practice - Treatment of respiratory infections

  • Standard therapy for community-acquired pneumococcal pnemonia not requiring hospital admission
    • Oral amoxicillin
      • Oral erythromycin if patient is allergic to penicillin
      • Can even combine with amoxicillin if an atypical organism is suspected
  • 35 year old, ward, pneumonia, HAI
    • Intravenous ceftazidime
      • Third generation cephalosporin for gram negative bacteria that causes HAI
  • 40 year old, builder, severe community acquired pneumonia, atypical pathogens
    • Intravenous cefuroxime and erythromycin
      • Standard therapy for community-acquired pneumonia
      • Rifampicin added empirically if high clinical suspicion of legionella infection
  • 22 year old, HIV positive, anti-retroviral therapy, Pneumocystic carinii pneumonia
    • Intravenous co-trimoxazole
      • Treatment of choice is high-dose co-trimoxazole delivered intravenously for 2-3 weeks
      • Intravenous pentamidine may be used if co-trimoxazole is contraindicated or not tolerated
      • Corticosteroids are used as an adjunct if there is hypoxaemia
      • Trimethoprim and sulfamethoxazole, folic acid synthesis inhibitors
  • 19 year old, male, pneumonia with symptoms of headache, fever and dry cough, chlamydia infection
    • Oral tetracycline
      • Chlamydial pneumonia often presents with a biphasic illness: upper respiratory tract symptoms precede pneumonia
      • Diagnosis is usually made retrospectively

Blood Transfusion - Part 1

Blood is liquid tissue. It is comprised of several types of blood cells suspended in plasma.

5 litres in circulation


Composition of blood
  • RBCs (erythrocytes)
  • WBCs (leukocytes)
    • Granulocytes
      • Neutrophils
      • Eosinophils
      • Basophils
    • Agranulocytes
      • Lymphocytes
      • Monocytes
  • Platelets (thrombocytes)


Haematocrit is usually 45%

Suspension in test tube:
  • Plasma above
  • White blood cells in the middle "Buffy coat"
  • Red blood cells below


Functions of blood
  • Transport
    • O2 and CO2
    • Food molecules (e.g. glucose/lipids/amino acids)
    • Ions (e.g. sodium, potassium, calcium)
    • Waste products (e.g. urea)
    • Hormones
    • Blood clotting factors (platelets and plasma)
    • Heat (blood also helps maintain its constant body temperature)
  • Immune system
    • Defence against infection and other foreign materials
    • Many different types of white blood cells participate in forming body's defence system against infections but most critical of these are neutrophils and lymphocytes


Anaemia
  • Drop in red blood cells
  • Drop in haemoglobin in red blood cells

Main causes
  • Nutritional deficiency
    • Such as iron, vitamin B12 or folate
      • Replace
  • Blood loss
    • Such as significant amount of surgical bleeding, trauma, internal bleeding from stomach or bowel
      • Treat cause
      • Salvage
      • Transfuse
  • Failure of production of red blood cells by bone marrow
    • Such as patients with leukaemia and those receiving chemotherapy
      • Transfuse
      • Erythropoietin to increase production


Platelets
  • 20-50 x 10^9/L
  • Drops in
    • Viral infections
    • Autoimmune thrombocytopenia (ITP)
    • Failure of production of platelets in the bone marrow
    • Platelets may be reduced following massive haemorrhage requiring replacement of 2 or more blood volumes


Plasma components
  • Water (90-93%)
  • Proteins (6-9%)
  • Salts (0.7%)
  • Lipids (0.6%)
  • Glucose (blood sugar) (0.1%)

OSCE practice - Endocrine Examination


  • Overall appearance
  • Height, weight, and nutritional status
  • Blood pressure (including postural measurements)
  • Neck - look for goitre
  • Thyroid status
  • Eyes - look for exophthalmos, Graves' eye disease
  • Visual fields - pituitary tumours
  • Secondary sexual characteristics and testicular examination
  • Skin and hair - pigmentation, bruising, telangiectasia, acne
  • Urine - check for glucose, protein, Beta-human chorionic gonadotrophin


Overall appearance (i.e. spot diagnosis), e.g. acromegaly, Graves' disease, should be assessed
All clinical 'systems' may be involved in endocrine disorders
Full examination of all systems is expected
Certain parts of the examination may be discriminatory in diagnosis

OSCE practice - Endocrine history taking

Past Medical History

  • Diabetes mellitus
  • Hypertension
  • Previous pregnancies/fertility
  • Previous surgery - thyroid/parathyroid, ovarian, testicular
  • Childhood milestones and development
  • Puberty
  • Previous radiation exposure - neck (thyroid), gonads

Family history
  • Autoimmune disorders
  • Endocrine disorders
  • Diabetes mellitus

Social history
  • Alcohol or drug abuse
  • Diet, e.g. salt/iodine intake

Drug history
  • Details of all drugs taken at present and previous regular medications
  • Corticosteroids
  • Sex hormones, e.g. HRT, oral contraceptive pill

Tuesday 25 September 2012

Carbon Monoxide Poisoning


  • Carbon monoxide combines readily with haemoglobin and prevents the formation of oxyhaemoglobin

Aetiology
  • Gas appliances with poor ventilation

Clinical features
  • Mental impairment
  • Nausea and vomiting
  • Headache
  • Hallucinations
  • Fit
  • Drowsiness and coma
  • Mild-moderate toxicity
    • Tachycardia
    • Tachypnoea
  • Severe toxicity
    • Hypotension
    • Bradycardia
    • Myocardial damage
    • Respiratory distress

Investigation
  • Blood carboxyhaemoglobin level

Management
  • Remove the sources
  • High-flow oxygen
  • Hyperbaric oxygen if
    • Coma
    • Carboxyhaemoglobin level >10%

Congenital heart disease


  • Affects 1% of live births

Disease associations
  • Maternal rubella infection
  • Maternal alcohol abuse

Chromosomal abnormal
  • Down's syndrome
  • Turner's syndrome

Monday 24 September 2012

Antibacterials - Grouped into mechanism of action

Inhibition of DNA synthesis
  • Quinolones (Gram-negative infections)
    • Ciprofloxacin
    • Moxifloxacin

Break bacterial DNA
  • Nitroimidazoles (Anaerobic infections)
    • Metronidazole

Folic acid synthesis inhibitors
  • Sulphonamides (Urinary tract and Pneumocystis carinii infection)
    • Sulfamethoxazole

Inhibit ribosomal function
  • Inhibit ribosomal function (Conjunctivitis - local therapy)
    • Chloramphenicol

Inhibit protein synthesis
  • Aminoglycosides (Gram negative infections)
    • Gentamicin
    • Neomycin
      • RENAL and OTOTOXICITY therefore serum levels need monitoring
  • Tetracyclines (Atypical pneumonias, acne)
    • Tetracycline, doxycycline
      • Contraindicated in children and during pregnancy as they cause permanently stained teeth
  • Macrolides (Atypical pneumonias)
    • Erythromycin, clarithromycin
  • Macrolides (Gram negative infection)
    • Clarithromycin, azithromycin
  • Fusidic acid (staphylococcus aureus osteomyelitis)

Block cell wall synthesis
  • Penicillins
    • 5 groups
      • Benzylpenicillin
      • Phenoxymethylpenicillin (Penicillin V)
      • Flucloxacillin
      • Amoxicillin/ampicillin
      • Temocillin
  • Cephalosporins
    • Better
    • First generation (Gram positive cocci and gram negative infections)
      • Cefalexin
      • Cefradrine
    • Second generation (Gram negative infection)
      • Cefuroxime
      • Cefaclor
    • Third generation (Gram negative infections)
      • Ceftazidime
      • Ceftriaxone
  • Monobactams
    • Aztreonam
  • Carbapenems
    • Imipenem, meropenem
  • Glycopeptides (Gram-positive bacteria)
    • Vancomycin

Fever of Unknown Origin

Infections (40%)
  • Abscess
  • Tuberculosis
  • Urinary infection
  • Biliary infection
  • Endocarditis
  • Epstein-Barr virus

Immune (20%)
  • Drugs
  • Connective tissue diseases
  • Sarcoidosis

Malignancy (30%)
  • Lymphomas
  • Leukaemia
  • Solid tumours

Other
  • Thyrotoxicosis
  • Ulcerative colitis
  • Crohn's disease
  • Factitious
  • 5-10% remain undiagnosed

Sunday 23 September 2012

OSCE practice - Respiratory

Introduction
  • Introduce yourself. Elicit name, age and occupation. Establish rapport

Consent
  • Explain the examination to the patient and seek consent

Position
  • Sit the patient at a 45 degree angle and exposure the patient appropriately

Inspection

General
  • Stand and observe the patient from the edge of the bed. Look for oxygen masks, nebulisers and sputum pots surrounding the patient
  • General observations in the Respiratory Examination
    • Breathing at rest - Comfortable, dyspnoea
    • Added sounds - Cough, wheeze, stridor
    • Presence of scars - Thoracotomy scar, operative scars
    • Chest shape - Barrel chest, pectus excavatum, pectus carinatum
    • Chest movements - Asymmetrical chest expansion, use of accessory muscles
    • Intercostal recession - Asthma, COPD (with pursed lips)
    • Respiratory rate - Count for 15 seconds and multiply by 4
      • Normal 16-25 breaths per minute
      • Tachypnoea >25 breaths per minute

Hands
  • Feel the hands for any temperature change. Look in the hands for:
    • Temperature - Warm and well perfused/poor perfusion
    • Tremor - Resting tremor (Beta agonist - Salbutamol)
    • Flapping Tremor - Asterixis - CO2 retention
    • Peripheral cyanosis - Blue nail beds
    • Nicotine stains - Evidence of smoking
    • Clubbing ABCDEF
      • Asbestosis/Abscess
      • Bronchiectasis/Bronchial carcinoma
      • Cystic fibrosis
      • Decreased O2
      • Empyema
      • Fibrosing alveolitis
    • CO2 retention
      • Examine for an irregular jerking of the hands after the wrists have been cocked back in wrist extension

Pulsus
  • Feek the raduak oykse abd asses tge rate and rhythm. Assess for the presence of a bounding pulse (CO2 retention)

Hypercalcaemia

Bones, Stones, Groans, Moans

Bones: Pain in bones
Stones: Kidney stones
Groans: Abdominal pain (pain)
Psychic Overtones (Moans): Confused state

CHADS2

Determining stroke risk


C - Congestive heart failure
H - Hypertension: blood pressure consistently above 140/90 mmHg (or treated on medication)
A - Age = or > 75 years
D - Diabetes mellitus
S2 - Stroke or TIA, or thromboembolism

Determines stroke risk - 1.9% - 18.2%

0 - None or aspirin
1 - Aspirin or Warfarin
2 - Warfarin

EMQ practice: Emergency management: respiratory distress

Respiratory distress
  • 65 year old male, long standing COPD, severe shortness of breath, Oxygen and nebulised bronchodilators, Hour later: PaO2 6.0 kPa (on max. O2), PaCO2 16.0 kPa, pH 7.2
    • Nasal intermittent positive pressure ventilation
      • Exacerbation of COPD and Type II respiratory failure
      • Responded poorly to medical therapy
      • Non-invasive intermittent positive pressure ventilation (NIPPV)
      • Reduce need for formal intubation
      • Anaesthesia and intubation can be difficult in a patient with respiratory failure
      • NIPPV should be tried unless patient is in extremis
      • It does need the patient to be conscious and cooperative though
  • 17 year old woman, wheeze and marked perioral swelling, Now: PaO2 7.0 kPa (on 28% O2), PaCO2 4.1 kPa
    • 100% O2, intramuscular adrenaline, nebulised salbutamol
      • Acute anaphylaxis
      • Type I IgE-mediated hypersensitivity reaction
      • Rash, oedema, tachycardia, hypotension, and wheeze
      • Laryngeal oedema giving rise to upper airway obstruction in particularly worrying because it may impede endotracheal intubation
      • Initial treatment of choice:
        • 0.5ml epinephrine 1:1000 solution (500 micrograms) delivered intramuscularly which can be repeated in the absence of clinical improvement or if deterioration occurs
        • Intravenous epinepherine is dangerous and should only be given in dilution of 1:10000 in an immediately life-threatening situation (e.g. frank cardiac arrest)
  • 14 year old asthma, acute severe asthma attack, PaO2 10.0 kPa (on 28% O2), PaCO2 8.0kPa
    • 100% O2, nebulised salbutamol, intravenous hydrocortisone
      • Severe asthma attack features
        • Peak expiratory flow rate PEFR < 50%
        • Respiratory rate more than or = 25 breaths/min
        • Pulse more than or equals to 110 beats/min
        • Inability to complete sentence in 1 breath
      • Life-threatening asthma attack
        • PEFR <33%
        • Silent chest
        • Cyanosis
        • Poor respiratory effort
        • Bradycardia
        • Arrhythmia
        • Hypotension
        • Exhaustion
        • Confusion
        • PaO2 <8kPa
        • Acidosis with pH<7.35
        • High PaCO2
      • Intubation and transfer to ICU if patient does not respond to drug therapy
      • 100% O2 should be given since there is no risk of respiratory depression resulting from a hypoxic ventilatory drive
      • Between attacks CO2 should be within normal range
      • Common mistake to restrict oxygen to patients with asthma dn a high CO2
  • 28 year old male, RTA, severe respiratory distress, Examination reveals decreased expansion on right side of chest with mediastinal shift to the left
    • Right-sided decompression
      • Tension pneumothorax is a medical emergency
      • Cannula inserted into second intercostal space in the mid-clavicular line in the affected side until a functioning intercostal tube can be positioned
  • Young man, acute onset shortness of breath, decreased expansion on the right, SaO2 95%
    • Chest radiograph
      • Indicated here to confirm diagnosis of pneumothorax and assess the degree of collapse
      • In healthy patients a small penumothorax will often heal without further intervention
      • Patient should be observed for 6 hours and, if there is no increase in the size of the pneumothorax, may be discharged with early follow-up and repeated chest radiograph
      • Spontaneous pneumothoraces are relatively common in young adults (especially tall thin men) and older patients with emphysema
      • In patients with thoracic disease/large pneumothoraces, simple aspiration is recommended
      • If not working, then chest drain is required

Pulmonary involvement in systemic diseases

Rheumatoid arthritis
  • Rheumatoid factor is always present
  • Lung features may precede arthropthy

Systemic lupid erythematosus
  • Pleurisy/ pleural effusion

Systemic sclerosis
  • Pulmonary fibrosis/ honeycomb lung

Wegener's granulomatosis
  • Granulomatous vasculitis of small arteries
  • Rhinorrhoea
  • Nasal ulceration
  • Nodular masses (+/- cavitation)
  • Migratory pulmonary infiltrates
  • Associated with antineutrophil cytoplasmic antibodies (c-ANCA)
  • Treated with cyclophosphamide

Churg-Strauss syndrome
  • Systemic vasculitis
  • Asthma
  • Rhinitis
  • Eosinophilia
  • Associated with ANCA (p-ANCA)
  • Treated with steroids

Goodpasture's syndrome
  • Disease associated with anti-glomerular basement membrane (GBM) antibodies which cross-react with the glomerulus and the lung
  • Cough
  • Haemoptysis (Can be massive)
  • Intrapulmonary haemorrhage
  • Glomerulonephritis
  • Treated with steroids

Pulmonary fibrosis and honeycomb lung
  • Localised
    • Systemic sclerosis
    • Sarcoidosis
    • Tuberculosis
    • Asbestosis
    • Berylliosis
  • Diffuse
    • Cryptogenic fibrosing alveolitis
    • Rheumatoid lung
    • Langerhans' cell histiocytosis
    • Tuberous sclerosis
    • Neurofibromatosis

Saturday 22 September 2012

Murmurs and heart sounds

Mitral stenosis

  • Tapping apex beat
  • Loud first heart sound
  • Rumbling mid-diastolic murmur at apex (louder in left lateral position on expiration)
  • Malar flush

Aortic regurgitation
  • Wide pulse pressure
  • Displaced, volume-overloaded apex beat
  • Early diastolic murmur at lower left sternal edge (best heard in expiration leaning forward)
  • Carotid pulsation (Corrigan's sign)
  • Head nodding (De Musset's sign)
  • Capillary pulsations in nail bed (Quincke's sign)
  • Pistol-shot heard over femorals (Traube's sign)

Mitral regurgitation
  • Displaced, volume overloaded apex beat
  • Soft first heart sound
  • Pansystolic murmur at apex radiating to the axilla (louder in expiration)

Tricuspid regurgitation
  • Large systolic 'v' waves
  • Pansystolic murmur lower left sternal edge (best heard in inspiration)
  • Pulsatile hepatomegaly

Aortic stenosis
  • Narrow pulse pressure
  • Heaving undisplaced apex beat
  • Soft second heart sound
  • Ejection systolic murmur heard in aortic area radiating to carotids and apex

Ventricular septal defect
  • Harsh pansystolic murmur  lower left sternal edge
  • Left parasternal heave


Conditions indicated by jugular venous pressure


  • Raised, fixed JVP - SVC obstruction
  • JVP rising on inspiration - Cardiac tamponade, constrictive pericarditis
  • Large 'v' waves - Tricuspid regurgitation
  • Absent 'a' waves - Atrial fibrillation
  • Cannon 'a' waves - Complete heart block, AV dissociation, Ventricular arrhythmias

Revision boxes - Cardiovascular

Conditions indicated by pulses

  • Irregularly irregular - Atrial fibrillating
  • Slow-rising pulse - Aortic stenosis
  • Collapsing pulse - Aortic regurgitation
  • Bounding pulse - Acute CO2 retention, hepatic failure, sepsis
  • Radiofemoral delay - Coarctation of aorta
  • Jerky pulse - Hypertrophic obstructive cardiomyopathy, Mitral regurgitation
  • Pulsus bisferiens - Mixed aortic valve disease, Hypertrophic obstructive cardiomyopathy
  • Pulsus paradoxus - Constrictive pericarditis, Cardiac tamponade

Calcium homeostasis - Once and for all.

Homeostasis: Blood Ca2+ level (10mg/100mL)

If there is too much Ca2+:

  • THYROID gland produces CALCITONIN
  • Calcitonin
    • Deposition into bone
    • Decreased absorption by kidneys

If there is too little Ca2+
  • PARATHYROID gland produces PARATHYROID HORMONE
  • Parathyroid hormone
    • Absorption from bone
    • Increased absorption from kidneys
    • Kidneys also activate Vitamin D
      • Vitamin D increases absorption from intestine


Sarcoidosis

Sarcoid

  • A multisystem granulomatous disorder presenting usually as
    • Bilateral hilar lymphadenopathy
    • Pulmonary infiltration
    • Skin/eye lesions

Epidemiology
  • 19 in 100000
  • Female > Male
  • More severe in Blacks than Whites

Aetiology
  • Unknown

Clinical features
  • Third or fourth decade

Extrapulmonary features
  • Skin
    • Erythema nodosum
    • Lupus pernio
  • Eye
    • Uveitis 
    • Conjunctivitis
    • Keratoconjunctivitis sicca
  • Face
    • Parotitis
    • Facial nerve palsy
  • Metabolic
    • Hypercalcaemia (10%)
  • CNS
    • Meningoencephalitis
    • Spinal cord disease
    • Myopathy
    • Polyneuropathy
  • Gastrointestinal
    • Hepatosplenomegaly
  • Cardiovascular
    • Cardiomyopathy

Investigations
  • Chest X-ray
  • CT chest
  • Blood tests
    • FBC (normocytic anaemia)
    • Increased ESR
    • Increased Ca++
    • Increased Serum angiotensin-converting enzyme (ACE)
  • Transbronchial biopsy
  • Spirometry
    • Restrictive defect
    • Decreased Gas transfer

Presentations
  • Respiratory symptoms / abnormal chest X-ray
    • 50%
  • Fatigue or weight loss
    • 5%
  • Peripheral lymphadenopathy
    • 5%
  • Fever
    • 4%
  • Normal chest X-ray
    • 20%

Asbestosis

Asbestosis

  • Ubiquitous use of asbestos put many at risk
  • Particular problems with roofers, shipyard workers, those making gas masks in World War II

Aetiology
  • Deposition of inhaled blue fibres in airways
  • Synergistic effect of smoking

Clinical features
  • Breathlessness
  • Cough
  • Chest pain

Investigations
  • Chest X-ray
    • Fine reticulonodular shadowing
    • Honeycomb lung
    • Pleural plaques/effusion
  • Spirometry - restrictive +/- decrease gas transfer

Diseases caused by asbestos
  • Pleural plaques
  • Pleural effusion
  • Bilateral diffuse pleural thickening
  • Mesothelioma occurs 20-40 years after exposure to asbestos dust
  • Asbestosis (restrictive fibrotic lung disease)
  • Carcinoma of the bronchus
    • Patients eligible for industrial injuries benefit

Friday 21 September 2012

EMQ practice - Treatment of asthma and COPD

Treatment of asthma and COPD
  • 7 year old girl, slight wheeze, SOB, already on inhaled salbutamol
    • Oral sodium chromoglycate
      • Inhaled salbutamol
      • Use spacer
      • In young patients, optimise bronchodilator therapy as early initiation of corticosteroids may lead to growth retardation
  • 22 year old student, mild asthma, treatment for occasional early morning wheeze
    • Inhaled salbutamol
      • Step 1 of management
  • 17 year old student, Male, salbutamol inhaler regularly to control wheezing
    • Inhaled beclomethasone
      • Step 2 of management
  • 32 year old patient, maximum dose-inhaled therapy and slow-release theophylline, persistently inadequate control of symptoms
    • Oral prednisolone
    • Step 5
    • Need specialise care too
  • 25 year old woman, add on therapy because inhaled beclomethasone and salbutamol not adequate
    • LABA
    • Alternatively, could increase steroid dose

EMQ practice - Chest radiograph pathology

Chest radiograph pathology

  • 28 year old, Male, African-Carribean, Dry cough, Progressive shortness of breath, Bilateral hilar lymphadenopathy
    • Sarcoidosis
      • Other causes of bilateral hilar lymphadenopathy
      • TB
      • Malignancy (more commonly unilateral)
      • Organic dust diseases
      • Extrinsic allergic alveolitis
  • 13 year old, male, cystic fibrosis, tramline and ring shadows
    • Bronchiectasis
      • Cough productive of large amounts of purulent sputum
      • Haemoptysis
      • Clubbed, coarse inspiratory crackles over infected areas of lung
      • Bronchiectasis - Kartagener's syndrome, pertussis, bronchial obstruction
  • 65 year old dockward worker, Male, Weight loss, Shortness of breath, Clubbed and Cachectic, Pleural calcification and lobulated pleural mass
    • Mesothelioma
      • Asbestos exposure
      • Mass with lobulated margin
      • Pleural calcification alone is actually benign
  • 40 year old, woman, clubbing and sortness of breath, fine end-inspiratory crackles, ground-glass appearance of lungs
    • Crytogenic fibrosing alveolitis
      • SOB + clubbing + fine end-inspiratory crackles suggests crytogenic fibrosing alveolitis
      • Middle age
      • Ground-glass shadowing, followed by 'honeycomb' lung
      • Fibrosing alveolitis is associated with RA, systemic sclerosis, and UC (in which case it is not cryptogenic)
  • 65 year old, smoker, eight ribs seen anteriorly above the diaphragm (in mid clavicular line)
    • COPD
      • Hyperexpansion

Coal-worker's pneumoconiosis

Coal-worker's pneumoconiosis
  • Patients may qualify for industrial injuries benefit

Aetiology
  • Deposition of dust particles in small airways

Clinical features
  • Breathlessness
  • Cough +/- black sputum

Investigations
  • Chest X-ray - Fine micronodular shadowing
  • Spirometry - Mixed restrictive and obstructive pattern with reduced gas transfer

Complications
  • Progressive massive fibrosis
    • Large round masses in upper lobes +/- necrotic centres
    • May be associated with rheumatoid factor and antinuclear factor
    • Respiratory failure

Occupational lung disease

Occupational lung disease
  • Exposure to dusts, gases, vapours and fumes at work can lead to:
    • Acute bronchitis and pulmonary oedema from irritants, e.g. SO2, chlorine
    • Pulmonary fibrosis due to mineral dust, e.g. coal
    • Occupational asthma
    • Extrinsic allergic bronchiolar alveolitis
    • Bronchial  carcinoma due to industrial agents, e.g. asbestos, radon

Thursday 20 September 2012

EMQ practice - Chest Radiograph Pathology

Chest radiograph pathology
  • Multiple bilateral nodules between 0.5 and 5cm in a former miner with rheumatoid arthritis
    • Caplan's syndrome
      • Pulmonary manifestation of rheumatoid arthritis (RA) characterised by the presence of pulmonary nodules
      • Patients have RA and are exposed to coal dust, or other dusts like silicosis and asbestos
      • Cough, shortness of breath, and haemoptysis
      • RA can also cause fibrosing alveolitis, pleural effusions, and obliterative bronchiolitis
      • RA can also affect the cricoarytenoid joints leading to upper respiratory tract infection
  • Kerley B lines, bat-wing shadowing, prominent upper lobe vessels, cardiomegaly
    • Left ventricular failure
      • Typical
  • Trachea deviated to the right, horizontal fissure and right hilum displaced upwards
    • Right lower lobe collapse
      • Left lower lobe there is no elevation of the horizontal fissure because there IS no horizontal fissure
      • Instead there is a hazy white appearance over a large part of the left lung field
  • Numerous calcified nodules sized less than 5mm located predominantly in the lower zones of the lungs
    • Previous varicella pneumonitis
      • Multiple small, calcified nodules may occur after varicella pneumonitis
      • Other causes include TB, histoplasmosis, and chronic renal failure
  • Double shadow right heart border, prominent left atrial appendage, left main bronchus elevation
    • Mitral stenosis
      • Calcification of mitral valve may also be seen, as may pulmonary oedema
      • Left ventricular enlargement absent despite pulmonary oedema

Cystic Fibrosis

Cystic Fibrosis
  • Autosomal recessive disorder of the cystic fibrosis transmembrane conductance regulator (CFTR) which induces low salt and chloride excretion into airways leading to increased viscosity of airway secretions

Clinical features
  • Respiratory
    • Recurrent chest infections
    • Clubbing
    • Sinusitis
    • Haemoptysis
    • Nasal polyps
    • Spontaneous pneumothorax
    • Respiratory failure
    • Right ventricular failure
  • Gastrointestinal
    • Steatorrhoea (pancreatic insufficiency)
    • Meconium ileus
    • Gallstones
    • Cirrhosis

Investigations
  • Sweat electrolyte test
  • DNA analysis for genotype

Management
  • Antibiotics
  • Pancreatic/nutritional supplements
  • Amiloride or adenosine to improve hydration of secretions
  • Inhaled antibiotics, corticosteroids and recombinant human DNase
  • CFTR gene therapy
  • Lung transplant

Prognosis
  • Median survival 40 years

Wednesday 19 September 2012

Portal hypertension - Basics

Portal Hypertension - Hypertension (high blood pressure) in the PORTAL VEIN and its TRIBUTARIES

Portal vein (splenic-mesenteric confluence) made up of tributaries

  • Splenic vein
    • Inferior mesenteric vein drains into this
  • Superior mesenteric vein

Portacaval (portosystemic) anastomosis
  • Portal circulation + Systemic circulation

Regions
  • Oesophageal
    • Oesophageal varices
      • Portal
        • Oesophageal branch of left gastric vein
      • Systemic
        • Oesophageal branches of the Azygos vein
  • Rectal
    • Rectal varices
      • Portal
        • Superior rectal vein
      • Systemic
        • Middle rectal veins and inferior rectal veins
  • Paraumbilical
    • Caput medusae
      • Portal
        • Paraumbilical veins
      • Systemic
        • Superficial epigastric vein
  • Retroperitoneal
    • Portal
      • Right, middle, left colic veins
    • Systemic
      • Renal, suprarenal, paravertebral and gonadal veins
  • Intrahepatic
    • Patent ductus venosus
      • Portal
        • Left branch of portal vein
      • Systemic
        • Inferior vena cava



Bronchiectasis

Bronchiectasis
  • Abnormal and permanently dilated airways

Aetiology
  • Congenital
    • Deficiency of bronchial wall elements
    • Pulmonary sequestration
  • Mechanical bronchial obstruction
    • Intrinsic
      • Foreign body
      • Inspissated mucous
      • Post-tuberculous stenosis
      • Tumour
    • Extrinsic
      • Lymph node
      • Tumour
  • Postinfective bronchial damage
    • Bacterial and viral pneumonia, including pertussis, measles and aspiration pneumonia
  • Granuloma and fibrosis
    • Tuberculosis, sarcoidosis, and fibrosing alveolitis
  • Immunological over-response
    • Allergic bronchopulmonary aspergillosis
    • Post-lung transplant
  • Immune deficiency
    • Primary
      • Panhypogammaglobulinaemia
      • Selective immunoglobulin deficiencies (IgA and IgG2)
    • Secondary
      • HIV and malignancy
  • Mucociliary clearance defects
    • Genetic
      • Primary ciliary dyskinesia (Kartagener's syndrome with dextrocardia and situs inversus)
      • Cystic fibrosis
    • Acquired
      • Young's syndrome - azospermia, sinusitis

Investigations
  • Chest X-ray
  • High-resolution CT of the lung
  • Sputum examination
  • Sinus X-rays
  • Immunoglobulins
  • Sweat electrolytes for cystic fibrosis
  • Mucociliary clearance

Management
  • Postural drainage
  • Antibiotics
  • Bronchodilators if airflow limitation
  • Steroids
  • Heart/lung transplant

Tuesday 18 September 2012

Chronic Obstructive Pulmonary Disease (COPD)

COPD
  • Progressive airflow limitation that is not fully reversible

Aetiology
  • Smoking accounts for 90% of cases
  • Rarely, alpha1-antitrypsin deficiency

Clinical features
  • Cough and sputum
  • Wheeze
  • Breathlessness
  • Exacerbating factors
    • Upper respiratory tract infection
    • Cold/foggy weather
    • Pollution
  • Tachypnoea with prolonged expiration
  • Use of accessory muscles
  • Intercostal muscle recession on inspiration
  • Pursed lips on expiration
  • Reduced chest expansion
  • Hyperinflation
  • Cyanosis
  • Signs of:
    • Right ventricular failure (oedema, hepatomegaly, increased JVP)
    • CO2 retention (bounding pulse, peripheral vasodilatation, tremor, confusion, coma)

Investigations
  • Spirometry
  • Chest X-ray
  • Blood gases
  • ECG (P pulmonale, right branch bundle block, right ventricular hypertrophy)
  • Haemoglobin and packed cell volume
  • White cell count
  • A1-antitrypsin level

Management
  • Stop smoking
  • Flu and pneumococcal vaccines
  • B2-agonists
  • Antimuscarinics e.g. tiotropium
  • Corticosteroids
  • Prompt antibiotics if infection present
  • Diuretics for right ventricular failure
  • Assisted ventilation with bilevel positive airway pressure ventilatory support - (BiPAP)
  • Home oxygen (if meets recognised criteria for benefit)

Surgery
  • Lung volume reduction in carefully selected patients

Prognosis
  • 50% of patients with severe breathlessness die within 5 years
  • Stopping smoking improves prognosis

Monday 17 September 2012

EMQ practice - Haemoptysis

Haemoptysis

  • 65 year old smoker, shortness of breath, gallop rhythm, production of pink frothy sputum
    • Pulmonary oedema
      • Increased JVP, gallop rhythm, pink frothy sputum
      • Could be underlying myocardial infarction
  • 24 year old male, cough and intermittent haemoptysis, few weeks later with haematuria, biopsy confirms crescentic glomerulonephritis, renal biopsy shows linear pattern deposition on immunofluorescence
    • Goodpasture's syndrome
      • Pulmonary renal syndrome (Wegener's granulomatosis, microscopic polyangiitis, and Goodpasture's disease (GD))
      • cANCA for Wegener's
      • Anti-GBM for GD (classic linear staining)
        • Binding to lung alveolar membrane and kidney glomerular membrane (type II hypersensitivity)
        • HLA-DR2 association
        • In smokers, and should avoid smoking
        • Treatment: plasmapheresis and corticosteroids
  • 34 year old woman, complaining of nasal obstruction develops cough, haemoptysis, and pleuritic chest pain, chest radiograph shows multiple nodular masses
    • Wegener's granulomatosis
      • Small artery vasculitis
      • Lesions in upper respiratory tract, lung and kidneys
      • Eye signs up to 50% (scleritis, uveitis, retinitis)
      • Vasculitis and granuloma deposition can affect any organ so less common associated symptoms and signs are legion
      • Treatment: high-dose corticosteroids with cyclophosphamide
  • 22 year old male, fever, nightsweats, weight loss and cough productive of cupfuls of blood. Ziehl-Neelsen stain positive for acid-fast bacilli
    • Tuberculosis (TB)
      • Miliary TB describes widespread TB through haematological dissemination
  • 35 year old businessman, returns from trip abroad, collapses at airport with haemoptysis and pleuritic chest pain, sinus tachycardia, ECG shows right axis deviation
    • Pulmonary embolus
      • Ventilation perfusion scanning and pulmonary angiography performed using spiral computed tomography
      • PE also increased by previous thromboembolic events, oral contraceptive pill and surgery (especially pelvic surgery immobility and associated thrombophilias)

Asthma

Asthma
  • Chronic inflammatory disease of the airways
  • Three components
    • Reversible airflow limitation
    • Airway hyper-responsiveness to stimuli
    • Inflammation of the bronchi

Epidemiology
  • Prevalence increasing

Aetiology and precipitating factors
  • Atopy and allergy
  • Increased airway responsiveness
  • Cold air, exercise, pollution
  • Occupational, e.g. isocyanates (paint-sprayers)
  • Drugs, e.g. NSAIDs, Beta-blockers

Clinical features
  • Cough
  • Wheeze
  • Breathlessness
  • Chest tightness

Investigations
  • Chest X-ray
  • Lung function tests
  • Peak flow charts
  • Skin testing of allergies

Management
  • Self-management plan
  • Avoid precipitants
  • Stepwise drug treatments
  • B2-agonists (short acting and long acting)
  • Antimuscarinics
  • Anti-inflammatories, e.g. sodium chromoglicate
  • Corticosteroids
  • Leukotriene antagonists

Stepwise treatment
  1. Inhaled short acting B2 agonist as required
  2. Add inhaled steroid 200-800 micrograms/day (400 normal)
  3. Add inhaled Long acting B2 agonists (LABA) and if it doesn't work stop and up dose of inhaled steroid to 800 micrograms/day, it if it works continue it, and if it works but isn't enough continue it but up dose of inhaled steroid to 800 micrograms'/day. If still inadequate try leukotriene receptor antagonists or SR (sustained release) theophylline
  4. Either increase inhaled steroid to 2000 micrograms/day or add a fourth drug such as leukotriene receptor antagonist, SR theophylline, or B2 agonist tablets
  5. Refer to specialist care, keep inhaled steroid dosage at 2000 micrograms/day, use LOWEST effective dose of ORAL steroid

Acute severe asthma
  • Clinical features
    • Inability to complete sentence in one breath
    • RR = 25/min
    • Tachycardia = 110 bpm
    • Peak flow = <50% of predicted normal or best
  • Life-threatening features
    • Silent chest, cyanosis or feeble respiratory effort
    • Exhaustion, confusion, or coma
    • Bradycardia or hypotension
    • Peak flow <30% of predicted normal or best
  • Very severe life-threatening features
    • A high PaCO2 > 6 kPa
    • A very low PaO2 < 8kPa despite oxygen
    • A low and falling arterial pH
  • Management
    • Reassure the patient and monitor pulse oximetry and arterial blood gases
    • Give oxygen 40-60%
    • Nebulised B2 agonist e.g. salbutamol 5mg and repeat if no improvement otherwise use 4 hourly
    • Add nebulised anti-muscarinics e.g. ipratropium bromide 0.5mg
    • Give IV steroids e.g. hydrocortisone 200mg IV every 4 hours
    • Exclude pneumothorax on CXR
    • If no improvement consider IV infusion of magnesium sulphate or salbutamol and ventilation

Sunday 16 September 2012

EMQ practice - Causes of pneumonia

Causes of pneumonia:

  • 80 year old male, bilateral cavitating bronchopneumonia after an influenza infection
    • Staphylococcus aureus
      • Not common pathogen in community acquired pneumonia
      • May cause secondary infection in elderly recovering from influenza
      • IV drug users
      • Flucloxacillin is the treatment of choice for staphylococcal infection
  • 24 year old student, severe headache, fever, dry cough and arthralgia. Recently bought several parrots and was previously fit and well
    • Chlamydia psittaci
      • Rare cause of community acquired pneumonia
      • Lower respiratory tract symptoms and signs with exposure to birds
      • No acute diagnostic tests are available and diagnosis is made in retrospect by demonstrating a rising titre of complement-fixing antibody (same as other atypical cases like Legionella pneumophila
      • Macrolide antibiotic
  • 40 year old male, HIV, fever, dry cough, weight loss, exertional dyspnoea
    • Pneumocystis carinii
      • Common complication of HIV infection (AIDS-defining illness)
      • Opportunistic infection in other immunocompromised patients such as  those receiving immunosuppressive drugs and cancer chemotherapy
  • 75 year old male, headache, dry cough, anaemia, skin rash, blood tests detect cold agglutinins
    • Mycoplasma pneumoniae
      • Most common atypical cause of community-acquired pneumonia
      • Cases usually occur during an epidemic, which may give a clue to diagnosis
      • Characteristic feature of is the autoimmune haemolytic anaemia caused by the presence of cold agglutinins
      • Erythema multiforme, myopericarditis, and meningoencephalitis
      • Diagnosis often made in retrospect via detection of a rising antibody titre
      • Macrolide should be commenced if suspected
  • 25 year old air conditioning technician, flu-like symptoms, dry cough, radiograph shows multilobar shadowing, blood tests show hyponatraemia and lymphopenia, urinalysis reveals haematuria
    • Legionella pneumophila
      • Rare cause of atypical community pneumonia
      • Hyponatraemia and lymphopenia may assist in diagnosis
      • This can be performed rapidly by testing for the presence of legionella antigen in the urine (high sensitivity and specificity)
      • Adequate chlorination of water supply

EMQ practice - Shortness of breath

Shortness of breath

  • 21 year old male, productive cough, wheeze, steatorrhoea. On examination, clubbed and cyanosed with bilateral coarse crackles
    • Cystic fibrosis
      • CFTR gene on chromosome 7
      • Bronchiectasis
      • Males infertile
      • Pancreatic insufficiency leads to malabsorption and steatorrhoea
      • High sweat concentration (>60 mmol/l)
  • 63 year old male, A&E, weight loss, cough, haemoptysis, shortness of breath. On examination he is anaemia, clubbed and apyrexial
    • Bronchogenic carcinoma
      • COPD and asthma are NOT causes of clubbing
      • Causes include: Carcinoma of the bronchus, mesothelioma bronchiectasis, abscess, empyema, cryptogenic fibrosing alveolitis, cystic fibrosis
  • 65 year old male, shortness of breath, cough productive of pink frothy sputum. On examination, cyanosed and tachycardic and has bibasal end-inspiratory crackles. His JVP is elevated
    • Pulmonary oedema
      • Sputum pink because of leakage of red blood cells into pulmonary alveoli
      • Heart failure (left ventricular)
  • 70 year old woman, fever, rigors, shortness of breath, right-sided pleuritic chest pain. On examination, right side of chest reduced expansion, dull percussion, and increased tactile vocal fremitus
    • Pneumonia
  • 30 year old farmer, repeated fever, rigors, dry cough, shortness of breath with onset several hours after starting work. On examination, pyrexial with coarse end-expiratory crackles. Chest radiograph shows mid-zone mottling
    • Extrinsic allergic alveolitis
      • Hypersensitivity reaction to inhaled antigens
      • In farmers it is due to mouldy hay or germinating barley
      • LFTs reveal a reversible restrictive defect
      • Honeycomb lung on chest radiograph

Tuberculosis

Tuberculosis

  • Caseating granulomatous infection due to mycobacterium tuberculosis in the lung
  • TB is a notifiable disease and contact tracing is important

Patients at risk
  • Those from developing countries (including contacts)
  • Immunosuppressed patients
  • HIV, steroids, malignancy
  • Alcoholics/homeless people/people living in overcrowded conditions

Clinical features
  • May be none
  • Malaise and lethargy
  • Anorexia/weight loss
  • Fever
  • Cough
  • Haemoptysis

Signs of
  • Pleural effusion
  • Pneumonia
  • Fibrosis

Investigations
  • Chest X-ray
  • Affects upper zones particularly
  • +/- calcification
  • +/- cavitation
  • Sputum microscopy (Ziehl-Nielsen stain) and culture
  • Lung tissue microscopy and culture: bronchoscopy and washings for lung/pleural biopsies

Management
  • 6 months of combination of antibiotics, usually
  • - Rifampicin and isoniazid
  • - + Pyrazinamide for first 2 months +
  • Add ethambutol if risk of drug resistance is increased
  • Compliance is vital
  • Multi-resistant TB does occur, particularly in HIV, and may require more antibiotics (according to sensitivities) over a longer period

Side-effects of anti-TB drugs
  • Rifampicin
    • Liver dysfunction
    • Discolouration of body fluids
    • Reduced effectiveness of oral contraceptives and other drugs
  • Isoniazid
    • High doses cause polyneuropathy
    • Pyridoxine is added to prevent this
  • Pyrazinamide
    • Liver dysfunction
  • Ethambutol
    • Retrobulbar neuritis (patients need ophthalmology monitoring)
  • Streptomycin
    • Vestibular nerve damage

Other mycobacteria
  • Mycobacterium kansasii
    • Less severe than Mycobacterium tuberculosis (normally)
    • Particularly middle-aged men
    • COPD and working in dusty conditions (e.g. miners)
  • Mycobacterium avium intracellulare (MAI)
    • Immunosuppressed patients (e.g. HIV)

Pulmonary infection

Pneumonia

  • Lung infections are classified by site (e.g. lobar pneumonia or bronchopneumonia) or by aetiology

Aetiology
  • Bacterial
  • Viral
  • Opportunistic organisms
  • Chemical (e.g. aspiration of vomit)
  • Radiotherapy
  • Allergic mechanisms

Clinical features
  • Cough
  • +/- Purulent sputum
  • Fever
  • Pleuritic chest pain
  • Breathlessness
  • CURB65
    • Confusion (MTS <9)
    • Urea (>7 mmol/l)
    • Respiratory rate (30/minute)
    • Blood pressure (SBP <90 mmHg or DBP = 60 mmHg)
    • Age (>65 years)

Specific features
  • Streptococcus pneumoniae
    • Rust-coloured sputum
    • Peri-oral HSV
  • Mycoplasma
    • White cell count normal, cold agglutinins occur in 50%
    • Extra-pulmonary complications (e.g. rash, myocarditis, pericarditis, haemolytic anaemia, myalgia, neurological abnormalities, abnormal liver function, diarrhoea)
  • Staphylococcus aureus
    • Abscesses - in lung and elsewhere
  • Coxiella burnetii
    • Multiple lesions on chest X-ray

Investigations
  • Chest X-ray
  • Arterial blood gases or oxygen saturation
  • Blood/sputum culture
  • Microbiological: urine for pneumococcal or legionella antigen, serology

Management
  • Antibiotics choice depends on severity
  • Mild: amoxicillin 500mg three times a day (or clarithromycin if allergic)
  • Moderate: IV amoxicillin 500mg three times a day and clarithromycin twice a day
  • Severe: IV cefuroxime 1.5g four times a day and clarithromycin 500mg twice a day
  • Adjust as appropriate if particular organism is suspected or known
  • Oxygen
  • Correct/prevent dehydration

Complications
  • Respiratory failure
    • Type 1 - Low PaO2, low/normal PaCO2
  • Lung abscess
    • Particularly aspiration pneumonia, staphylococcal or klebsiella infectio, bronchial obstruction (cancer or foreign body)
  • Empyema
    • Pus in the pleural space

Prognosis
  • Overall 5% mortality for hospital inpatients
  • >25% mortality for staphylococcus aureus pneumonia
  • 50% mortality for severe community acquired pneumonia

Saturday 15 September 2012

Coeliac disease

Coeliac disease
  • Hypersensitivity to gliadin in wheat, barley, rye
    • Small intestinal disease

Epidemiology
  • England 1:300; Ireland 1:100
  • Caucasians mainly
  • Positive family history

Pathology
  • Subtotal villous atrophy
    • Loss of villi
    • Crypt hyperplasia
  • Malabsorption

Clinical features
  • Abdominal pain
  • Diarrhoea
  • Steatorrhoea/malabsorption
  • Weight loss
  • Symptoms of anaemia
  • Mouth ulceration
  • Anaemia
    • Pale conjunctivae (50% iron deficiency)
  • Dermatitis herpetiformis (blistering rash on extensor surfaces)

Investigations
  • Anti-endomysial antibodies
    • Negative after gluten-free diet
  • Tissue transglutaminase
    • Negative after gluten-free diet
  • Antigliadin antibodies
  • Antireticulin antibodies
  • Endoscopy and duodenal biopsy
  • Full blood count
    • Anaemia (macrocytic or microcytic)
    • Hyposplenism, Howell-Jolly bodies

Disease associations
  • Thyroid disease/diabetes
  • Primary biliary cirrhosis
  • Autoimmune hepatitis

Complications
  • Ulcerative jejunitis
  • Small bowel lymphoma
  • Oesophageal carcinoma
  • Osteomalacia

Management
  • Gluten-free diet
  • Iron/folate supplementation

Friday 14 September 2012

Bronchial carcinoma

Bronchial carcinoma
  • Malignant tumour of bronchial tree

Epidemiology
  • Most common malignancy (32000 deaths/year in UK)
  • Third most common cause of death in UK

Cell types
  • Small cell (20-30%)
  • Non-small cell
    • Squamous (40%)
    • Large cell (25%)
    • Adenocarcinoma (10%)
    • Bronchoalveolar cell (1-2%)

Aetiology
  • Smoking (including passive)
    • Squamous
  • Urban > rural
  • Occupational
    • Adenocarcinoma
    • Asbestos, coal, chromium, arsenic, petroleum products and oils. radiation

Clinical features
  • Often no clinical signs
  • Clubbing
  • Supraventricular nodes (small cell)
  • Signs of:
    • Pleural effusion or collapse
    • Unresolved chest infection
    • Chronic lung disease (e.g. asbestosis)
  • Symptoms:
    • Cough
    • Chest pain
    • Haemoptysis
    • Chest infection
    • Others (malaise, breathlessness etc)

Spread of bronchial carcinoma
  • Direct
    • Pleura and ribs
    • Erosion of ribs and involvement of lower brachial plexus nerves in apical tumours (Pancoast's tumour)
    • Sympathetic ganglion (Horner's syndrome - small pupil and poptosis)
    • Recurrent laryngeal nerve palsy with unilateral vocal cord paralysis. (hoarseness, bovine cough)
    • Spinal cord compression
    • Oesophagus (dysphagia)
    • SVC obstruction (headache, facial congestion, fixed distended veins)

  • Metastatic
    • Bones (spinal cord compression can complicate)
    • Liver
    • Brain
    • Adrenal glands (usually asymptomatic)

Non-metastatic extrapulmonary manifestations
  • Ectopic hormone production, adrenocorticotrophic hormone (ACTH), e.g. (small cell)
  • Neurological, e.g. myasthenic syndrome
  • Hypertrophic pulmonary osteoarthropathy (HPOA)
  • Vascular/thrombotic/haematological
  • Cutaneous, e.g. dermatomyositis

Investigations
  • Chest X-ray
  • Blood tests
    • Hyponatraemia
    • Polycythaemia
    • Anaemia
  • CT scan and PET scanning for staging
  • Bronchoscopy biopsy (proximal lesions) or percutaneous biopsy (peripheral lesions)

Management
  • Multidisciplinary team approach
  • Surgery
    • Only 5-10% of cases suitable
    • For non-small cell
  • Radiotherapy
    • Particularly for squamous cell
    • Can be useful for symptom control
    • Used for SVC obstruction
  • Chemotherapy
    • Combination chemotherapy
      • Particularly useful for small cell
      • Also used for non-small cell

Prognosis
  • 55-67% 5-year survival for those with local disease only
  • 23-40% 5-year survival for those with locally adanced disease
  • 1-3% 5-year survival for those with advanced disease

Thursday 13 September 2012

Obstructive sleep apnoea

Obstructive sleep apnoea
  • Occurs in patients who are overweight
  • 30% have other correctable factors, e.g. ENT problems, drugs (sedatives), alcohol, acromegaly

Clinical features
  • Snoring/nocturnal choking
  • Daytime sleepiness
  • Unrefreshed or restless sleep
  • Morning headaches or 'drunkeness'
  • Reduced libido
  • Ankle swelling

Investigations
  • Sleep study (measure oximetry, abdominal/thoracic movement and EEG during sleep)

Management
  • Weight loss, ENT surgery, or correction of other factors listed above
  • CPAP ventilation at night

Wednesday 12 September 2012

Multiple sclerosis

Multiple sclerosis

  • Multiple plaques of demyelination in the brain and spinal cord disseminated in time and place
  • Clinical diagnosis: two neurological events separated in time and neurological location

Prevalence
  • Increases moving north from the Equator
  • 60-100 / 100000 in the UK

Aetiology
  • Increased concordance among monozygotic twins
  • HLA haplotype A3, B7, D2 and DR2 is more common
  • Environmental
    • ?Viral infection
    • ?Dietary antigens

Pathology
  • Plaques of demyelination particularly in
    • Optic nerves
    • Periventricular region
    • Brainstem and cerebellar connections
    • Cervical spinal cord
    • Corticospinal tracts
    • Posterior columns

Clinical patterns
  • Relapsing/remitting
  • Chronic progressive

Investigations
  • Imaging
    • MRI brain and spinal cord (visualises multiple plaques)
  • CSF
    • Oligoclonal bands in 80%
    • Raised mononuclear cell count 5-60 cells /mm^3
  • Visual evoked responses
    • Delayed following optic neuropathy

Management
  • No treatment has been shown to alter long-term outcome
  • Corticosteroids - i.v. methylprednisolone or ACTH may speed recovery in acute relapses
  • Beta-interferon - reduces relapse rate but not long-term outcome
  • Physiotherapy
  • Occupational therapy
    • Walking aids
    • Wheelchairs
    • Car/house conversions
  • Speech therapy
  • Counselling

Prognosis
  • Unpredictable course ranging from grave disability in mild and benign

Tuesday 11 September 2012

Diverticular disease

Diverticular disease

  • Presence of mucosal pouches protruding outside the bowel
  • Very common: 50% of those > 50 year old

Clinical features
  • 90% asymptomatic
  • Change in bowel habit
  • Left iliac fossa pain (diverticulitis)

Investigations
  • Barium enema
  • Colonoscopy
  • CT

Management
  • High-fibre diet
  • Antibiotics for diverticulitis

Complications
  • Diverticulitis - inflammation/infection
  • Diverticular abscess
  • Lower GI bleeding
  • Perforation

Monday 10 September 2012

Ulcerative colitis

Epidemiology

  • Prevalence = 80 to 120 / 100000
  • Uncommon in smokers


Pathology

  • Limited to colon
  • Inflammation spreads proximally from the rectum
  • Mucosal inflammation
  • Leads to erythema, oedema and ulceration
  • Inflammatory infiltrate
  • Crypt abscesses
  • Goblet cell depletion


Clinical features

  • Diarrhoea
  • Blood or mucous per rectum
  • Mouth ulcers


Disease associations

  • Uveitis/iritis/conjunctivitis
  • Erythema nodosum/pyoderma gangrenosum
  • Arthritis/sacroiliitis/ankylosing spondylitis
  • Sclerosing cholangitis


Investigations

  • Colonoscopy and biopsy
  • Indicators of acute severe colitis urgent treatment
    • > Six stools a day
    • Fever > 37.5 degrees celcius
    • Tachycardia >90 bpm
    • ESR >30 mm/hr
    • Haemoglobin <10 g/dL
    • Albumin <30 g/L


Management

  • 5-ASA, e.g. mesalazine
  • Steroids, e.g. prednisolone
  • Azathioprine
  • Surgery
  • Topical 5-ASA or steroids (enemas)


Complications

  • Toxic megacolon
  • Iron deficiency anaemia
  • Increased risk of colorectal cancer
  • Thromboembolism

Inflammatory Bowel Disease

Inflammatory Bowel Disease
  • Inflammatory diseases of the GI tract, of unknown aetiology. Both Crohn's disease and ulcerative colitis demonstrate uncontrolled inflammation.

Crohn's disease

Epidemiology
  • Prevalence = 50-60/100000
  • More common in Caucasian races
  • Familial association
  • Genetic predisposition

Pathology
  • Any part of the gut from mouth to anus
  • Skip lesions - patchy disease with normal mucosa in between
  • Commonly terminal ileum and ascending colon
  • -> Inflammation, ulceration, abscesses and fistulae
  • Full bowel wall thickness involved
  • Inflammatory infiltrates
  • Non-caseating granulomata

Clinical features
  • Depends on the area of bowel involved
  • Mouth ulcers
  • Diarrhoea
  • Abdominal pain - colicky
  • Nausea/vomiting
  • Low-grade pyrexia
  • Generally unwell, lethargy, weight loss
  • Cutaneous fistulae (often perianal)

Disease associations
  • Small joint arthritis
  • Sacroiliitis
  • Ankylosing spondylitis
  • Iritis/uveitis/conjunctivitis
  • Erythema nodosum - tender low leg lesions
  • Pyoderma gangrenosum - skin ulceration
  • Sclerosing cholangitis

Investigations
  • Barium follow-through may show strictures, ulceration and thickened small bowel wall
  • Colonoscopy and terminal ileal biopsy
  • Proctoscopy and rectal biopsy

Management
  • 5-aminosalicylic acid (5-ASA), e.g. mesalazine
  • Steroids, e.g. prednisolone
  • Azathioprine, methotrexate
  • Anti-TNF-a antibodies (infliximab)
  • Antibiotics for perianal disease
  • Surgery for resistant disease

Extra-gastrointestinal manifestations of Crohn's disease
  • Iritis, uveitis or conjunctivitis
  • Oral ulceration
  • Ankylosing spondylitis
  • Kidney stones
  • Sacroiliitis
  • Small joint arthritis
  • Erythema nodosum
  • Primary sclerosing cholangitis
  • Gall stones
  • Pyoderma gangrenosum

Complications
  • Vitamin B12 deficiency after surgery
  • Short bowel syndrome after surgery
  • Toxic megacolon in colitis
  • Kidney stones
  • Gallstones
  • Malnutrition
  • Colonic cancer
  • Venous and arterial thromboembolism

Sunday 9 September 2012

Dyspepsia

Dyspepsia
  • Symptoms referable to the upper gastrointestinal tract

Epidemiology
  • 75-90% of population get symptoms
  • 4% of all GP consultations

Aetiology
  • Non-ulcer (functional) dyspepsia
  • GORD
  • Gastritis (NSAIDs, H.pylori, bile)
  • Peptic ulcer disease
  • Gastric malignancy

Clinical features
  • Heartburn
  • Epigastric pain
  • Pain, discomfort or 'fullness' after eating
  • Nausea
  • Bloating

Alarm signals
  • Weight loss
  • Vomiting
  • Haematemesis, melaena or anaemia
  • Dysphagia
  • Previous gastric ulcer or gastric surgery
  • Non-steroidal anti-inflammatory drugs (NSAIDs)

Investigations
  • 13C urea breath test for H.pylori
  • H.pylori serology
  • Upper GI endoscopy if over 45 years old

Management
  • Depends on cause
  • Consider a trial of proton pump inhibitors if no alarm signals and age <50

Saturday 8 September 2012

Achalasia

Achalasia
  • Rare, 1/100000/year
  • Failure of relaxation of lower oesophageal sphincter
  • -> Dysphagia (intermittent to solids and liquids)

Investigations
  • Barium swallow - rat's tail appearance
  • Endoscopy - to exclude malignancy
  • Oesophageal manometry
    • Measurement of sphincter pressure (raised, non-relaxing)
    • Aperistalsis or non-propulsive contractions

Management
  • Endoscopic balloon dilataion of sphincter
  • Injection of Botulinum toxin in sphincter
  • Surgery (Heller's procedure: division of muscle)
    • Heller's myotomy followed by Dors fundoplication

Oesophageal carcinoma

Oesophageal carcinoma

  • 40% squamous cell carcinomas
  • 60% adenocarcinomas
  • Prevalence: 10-15 / 100000 and increasing

Clinical features
  • Dysphagia
  • Progressive: Solids then liquids
  • Weight loss
  • Anorexia
  • Virchow's node in supraclavicular fossa

Investigations
  • Upper GI endoscopy and biopsy
  • Endoscopic ultrasound
  • CT to stage tumour (+ - PET)

Management
  • 10% 5 year survival
  • Squamous cell cancer
    • Radiotherapy + - chemotherapy
    • Surgery
  • Adenocarcinoma
    • Surgery
    • Palliative neo-adjuvant chemotherapy
    • Palliation: oesophageal stents to reduce dysphagia
    • Thermal ablation (endoscopically)
    • Radiotherapy

Barrett's oesophagus

Barrett's oesophagus

  • Columnar epithelium with intestinal metaplasia replaces normal squamous mucosa
  • Increased risk of adenocarcinoma (Male > Female)
  • Associated with gastro-oesophageal reflux
  • Endoscopic screening of patients with Barrett's may reduce cancer mortality

Friday 7 September 2012

OSCE revision: Cardiovascular examination

Introduction
 
Introduction
  •  Introduce yourself. Elicit name, age and occupation. Establish rapport.
Consent
  •  Explain the examination to the patient and seek consent.
Position
  •  Sit the patient at a 45 degree angle and expose the patient appropriately.
 
 
Inspection

 
General
  • Stand and look at the patient from the edge of the bed. Observe for abnormal breathing, scars, added sounds or a pacemaker.
  • Breathing at rest: Comfortable, dyspnoeic, cough
  • Presence of scars: Midline sternotomy (CABG, valve replacement), Lateral thoracotomy (mitral valvotomy)
  • Malar flush: Dusky pink discolouration of cheeks (mitral stenosis)
  • Added sounds: Audible heart valves
Hands
  • Feel the hands.
  • Temperature: Warm and well perfused/poor perfusion
  • Peripheral cyanosis: Blue nail beds
  • Clubbing: Endocarditis, cyanotic congenital heart disease
  • Endocarditis (SBE): Osler nodes and Janeway lesions, Splinter haemorrhages
  • Nicotine stains: Peripheral vascular disease

Pulse
  • Feel the radial pulse medial to the radius with three fingers. Assess the rate, rhythm, volume and character of the pulse.
  • Rate
    • Count for 15 seconds and multiply by 4
    • Normal: 60-100 bpm
    • Tachycardia: >100 bpm
    • Bradycardia: <60 bpm
  • Rhythm
    • Establish the quality of the rhythm
    • Regular: Sinus arrhythmia
    • Regularly irregular: 2nd degree heart block
    • Irregularly irregular: AF or multiple ectopics
  • Volume
    • Establish the volume of the pulse
    • Low volume: Low cardiac output, heart failure, aortic stenosis
    • Large volume: Thyrotoxicosis, CO2 retention, aortic regurgitatio
  • Character
    • The carotid pulse is palpable in the neck and provides more accurate information of volume and character than the radial pulse
    • Normal pulse
    • Slow rising pulse (aortic stenosis)
    • Collapsing pulse (aortic regurgitation, patent ductus arteriosus)
    • Bisferien pulse (double peaks, both stenosis and regurgitation
  • Delay
    • Radio-radial delay (Aortic arch aneurysm
    • Radio-femoral delay (Co-arctation of the aorta)

Arms
  • Blood pressure

Face
  • Eyes for anaemia
  • Around eyes for hyperlipidaemia (xanthelesmata, corneal arcus)
  • Central cyanosis tongue
  • Dental hygiene (SBE)
  • High arched palate (Marfan's)

Carotid pulse
  • Never palpate both simultaneously

JVP
  • No more than 3cm above sternal angle
  • Causes of raised JVP -  PQRST
    • P - Pericardial effusion/ Pulmonary embolism/ Pericardial constriction
    • Q - Quantity of fluid increased (iatrogenic fluid overload)
    • R - Right heart failure or congestive heart failure
    • S - Superior vena caval obstruction
    • T - Tricuspid regurgitation/ Tricuspid stenosis/ Tamponade (cardiac)
  • Apply firm pressure over the abdomen for about 15 seconds and look for a rise of about 2cm in JVP (hepatojugular reflex
  • A persistent rise in JVP over 15 seconds of compression is a positive hepatojugular reflux sign (right ventricular failure)
Palpation
 
Apex beat
  • Palpate the apex beat by feeling the furthest pulsating point of the heart
  • It is normally located in the 5th intercostal space mid-clavicular line
  • Note
    • Character of apex beat
    • Whether it is displaced (Left ventricular hypertrophy)
  • Character
    • Tapping - Mitral stenosis
    • Thrusting - Aortic stenosis
    • Heaving - Mitral regurgitation or aortic regurgitation
    • Diffuse - Left ventricular failure, dilated cardiomyopathy
       
 
Heaves and thrills
  • Feel for the presence of thrills (palpable murmurs - AS, VSD) by using the flat of the hand to palpate over the precordium.
  • Use the flat of the hand to palpate over the left sternal edge, feeling for a parasternal heave (right ventricular hypertrophy)
 

Auscultation
Listen
  • Auscultate over the four areas of the heart with a stethoscope listening for heart sounds, additional sounds (extra heart sounds, clicks or snaps), murmurs, or pericardial rubs
  • Time the murmurs with carotid pulse to establish if its systolic or diastolic
 
Murmurs
  • Note
    • Timing
      • Systolic
        • Ejection (AS,PS,ASD)
        • Pansystolic (MR,TR,VSD)
      • Diastolic
        • Early diastolic (AR,PR)
        • Mid diastolic (MS, TS)
      • Continuous
        • Patient ductus arteriosus (PDA)
    • Intensity
      • Grade 1-3 - Thrill absent
      • Grade 4-6 - Thrill present
    • Site
      • Aortic, Pulmonary, Tricuspid, Mitral (Right to left)
    • Character
      • Note if the murmur is rumbling (MS), blowing (MR), or harsh (AS) in character
      • Assess if it is a crescendo-decrescendo, decrescendo, or crescendo or plateau type of murmur
    • Pitch
      • Assess the pitch of the murmur. High-pitch murmurs are best heard with the diaphragm (AS) while low pitch murmurs are best heard with the bell
    • Radiation
      • Check if the murmur radites to the carotids (AS), axilla (MR), left sternal edge (AR) or back (PDA)
    • Effect of respiration
      • Right sided murmurs heard with the greatest intensity on inspiration
      • Left sided murmurs heard with the greatest intensity on expiration
    • Position
      • Note
        • If heard best in supine
        • Leaning forward with breath held in exhalation (AR)
        • Or in left lateral position (MR)
 
Manoeuvre
  • The Valsalva manoeuvre (exert downward pressure on the patient's abdomen as they exert outward pressure) increases the intensity of hypertrophic cardiomyopthy and mitral valve prolapse while softening aortic stenosis
  • Squatting increases the intensity of aortic stenosis but softens hypertrophic cardiomyopathy

Lung bases
  • Keep the patient leaning forwards and auscultate the lung bases listening for crepitations and pleural effusion (left ventricular failure)

Additional points
 
Oedema
  • Sacral oedema by applying firm pressure on lower back and for pedal oedema by pressing down over the ankle
  • Pitting
    • Heart failure, nephrotic syndrome, cirrhosis, malnutrition, severe anaemia
  • Non-pitting
    • Lymphatic obstruction, deep vein thrombosis, myxoedema
Pulses
  • Palpate the peripheral pulses (femoral, popliteal, post tibial, dorsalis pedis)
  •  
Request
  • BP
  • ECG tracing
  • CXR
  • Dipstick
  • Fundoscopy (hypertension)
  • Oxygen sats and temperature chart