Odds and Odds ratio

Odds = Number : total - number

Odds ratio = ratio of odds.

Haemorrhoids

Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the 3,7,11 positions. Haemorrhoids are said to exist when they become large, congested, and symptomatic.

Clinical features:

Painless rectal bleeding is the most common symptom
Pruritus
Pain: usually not significant unless piles are thrombosed
Soiling may occur with third or fourth degree piles


Types of haemorrhoids (EXTERNAL and INTERNAL)

External: Originate below the dentate line, prone to thrombosis, and may be painful

Internal: Originate above the dentate line, do not generally cause pain

Grading: 1 - does not prolapse. 2 - prolapses but reduces. 3 - remains out but manually replaceable. 4 - can't even manually put it back

Management: Soften stools - increase dietary fibre and increase fluid intake. Topical local anaesthetics and steroids may be used to help symptoms. Outpatient treatments: rubber band ligation superior to injection sclerotherapy. Surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments. Newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Acutely thrombosed external haemorrhoids: typically present with significant pain, examination reveals purplish, oedematous, tender subcutaneous perianal mass. If patient presents within 72 hours then referral should be considered for excision. Otherwise, patients can be managed with stool softeners, ice packs, and analgesia. Symptoms usually settle within 10 days.

Gastric Adenocarcinoma

Epigastric pain is non-specific symptoms of upper-gastrointestinal pathology, but weight loss and anorexia are more sinister, with anaemia implying chronic gastrointestinal bleeding. The endoscopic appearance of a thickened rigid gastric wall suggests 'linitis plastica' (leather bottle stomach), a term used for gastric adenocarcinoma that diffusely infiltrates all layers of the gastric wall. The findings of numerous signet ring cells on biopsy confirms poorly differentiated (or diffuse) adenocarcinoma.

Patent ductus arteriosus

Overview

Acyanotic congenital heart defect, with a connection between the pulmonary trunk and descending aorta. More common in premature babies, born at high altitude or maternal rubella infection in the first trimester.

Features

Left subclavicular thrill
Continuous 'machinery' murmur
Large volume, bounding, collapsing pulse
Wide pulse pressure
Heaving apex beat

Management

Indomethacin closes the connection in the majority of cases. If associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful in keeping the duct open until after surgical repair.

Ankylosing spondylitis

Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 5:1) aged 20-30 years old.

Features:

Young man with lower back pain and stiffness of insidious onset
Stiffness usually worse in the morning and improves with exercise
The patient may experience pain at night which improves on getting up

Clinical examination

Reduced lateral flexion
Reduced forward flexion - Schober's test - a line drawn 10cm above and 5cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5cm when the patient bends as far forward as possible
Reduced chest expansion


Other features

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Cauda equina syndrome
Peripheral arthritis (25%, more common if female)

Drugs - taking a drug history

Ask about each individual substance

• Quantity
• Frequency
• Pattern of usage
• Age of onset when taking drugs
• When was the most recent use
• Method of administration
• Money spent on drugs
• Risky behaviours
• TOLERANCE
• DEPENDANCE
• WITHDRAWAL
• Motivation to quit
• Physical problems: cellulitis, hepatitis, aneurysms, abscesses, infection, other drug related medical issues
• Trigger factors to use drugs
• Understanding and insight

Clinical features of drug use:
Opiates - pinpoint pupils, low BP, venepuncture marks
Benzodiazepines - disinhibited or gives the impression of intoxicated, but is not drunk
Psychostimulants - rapid speech, large pupils, agitation, restlessness, high BP

Subarachnoid Haemorrhage - SAH

Sudden onset headache at back of head

Due to:
Rupture of aneurysm, AV malformation, maybe trauma but not true

8/100000

Atherosclerotic risk factors

Signs and symptoms

Headache
Neck stiffness - Kernig's sign - chemical meningitis
Impaired consciousness
Cranial nerve signs
Hemiplegia
Sentinel headache - before actual headache


Grade 1-5
5 = 100% (prolonged coma)
1 = 0% (no signs)

Prognosis
Overall mortality 35-50%, most die within 1 month
Worse with aneurysm better with AV malformation
Rebleeding very common


Investigations

CT
Lumbar puncture for blood and xanthochromia (yellow CSF)


Treatment - Coiling > clipping