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UCL MBBS (Subject) / Clinical conditions (Lesson)

Clinical conditions

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  • Brugada syndrome ??
  • Carcinoid syndrome Definiton: diarrhoea, abdominal pain, flushing, dyspnoeaCauses: 5-HT secreting GI tumour (from neural crest cells?)Investigations: 24h 5-HIAA urine, plasmagrafin A, octreotide scanComplications: Carcinoid crisis, carcinoid heart disease (valves, CCF)Management: Conservative: Pharmacological: Octreotide + symptomatic (e.g. loperamide); targeted chemotherapy Surgery: resection + octreotide Prognosis: good
  • Meningitis Definition: Inflammation ± infection of the meningesSymptoms: Headache, fever, photophobia, neck stiffness, rashSigns: Meningism, sepsis, non-blanching rash (→glass test)Investigations: Bloods, CT head → LP, urine (?pneumococcal antigen)Management: DR ABCDE Empirical treatment: 1ary BenPen IM; 2ary Ceftriaxone 1g (or cefotaxime 2g) IV ± Ampicillin (if >50y/o) ± Aciclovir Close contact prevention: Ciprofloxacin or  Rifampicin Complications: Septicaemia→DIC→WhF→adrenal insufficiency→death
  • Cellulitis ???
  • Joint & bone infections Osteomyelitis: staph / strep; in sickle cell disease: salmonella ⇒ fluclox+clindamycin/fusidic acid + cipro
  • Surgical infections Types: Wound infectionsSigns: Fever, shock, erythema, tenderness / pain, swellingManagement: SEPSIS 6, drainage, wash-outProphylaxis: Antibiotics, e.g. co-amoxiclav or cefuroxime/gentamicin + metronidazole
  • Gastroenteritis Definition: --Symptoms: Diarrhoea, abdo. pain, vomitingSigns: Sepsis, tendernessInvestigations: Bloods, stool sampleManagement: Rehydration therapy ABx: clarithromycin or ciprofloxacin Returning traveller: Africa/middle east → ciprofloxacin; Asia → clarithromycin; Giardia → tinidazole →H. pylori eradication
  • H. pylori infection Definition:Symptoms: gastro pain, reflux, heart burnSigns: gastric ulcersInvestigations: urea breath test (no PPI's or ABx for ???), biopsyManagement: clarithromycin + metronidazole
  • z Alzheimer's Definition: dementia = continual decline in cognitive function < 24/30 + evidence on imagingPathology: Post-mortem diagnosis: amyloid plaques + intracellular τ-Neurofibrillary tanglesDDx: Frontal lobe, Lewy body, multi-infarctManagement: multidisciplinary Lifestyle + conversative treatment Pharmacological: AChE-I's (donapezil, rivastigmine, galantamine), memantine Future treatment: tramiprosate/CHHs. vaccination, NGF, etc
  • Anxiety Definition: Including generalised anxiety disorder, phobias, post traumatic stress disorder (PTSD) and obsessional-compulsive disorder (OCD) Psychological theory for phobias: classical + operant conditioning; cognitive dimension Behavioural theory: flooding, systematic desensitisation, modelling Cognitive theory (Beck) Treatment: Conservative: psycho-education, self-help, CBD Medical: Benzodiazepines - diazepam, lorazepam, oxazepam Barbiturates - phenobarbital β-blockers buspirone - 5-HT-1a agonist anti-depressants - TCA, SSRI, SNRI, MAO-I
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  • Bipolar disorder Lithium Anti-epileptics: gabapentin (Ca2+), valproate/lamotrogine (Na+) Anti-psychotics: olanzapine
  • Depression --
  • Insomnia Definition: Inability to sleep; types (falling asleep, continue sleep, wake-up phase) Causes: Physical, psychological (e.g. anxiety, depression)Pharmacological management: Benzo's - diazepam, tenazepam, lorazepam melatonin receptor agonist - ramelteon TCA's  - imipramine, amitryptilinedrowsy antihistamines - mepyramine, diphenhyramine Behavioural management: sleep hygiene no caffeine, alcohol, screen time etc exercise Complications: Hypertension
  • Nicotine dependence → Nicotine: replacement therapy → Bupropion → Varenicline
  • Schizophrenia Symptoms: positive, negative, cognitive Hypotheses (evidence?) Dopmaine glutamate 5-HT Antipsychotics Typical: D2-antagonists: halperidone, chlorpromazine Atypical:clozapine, risperidone, olanzapine, quetiapine → reduced side effects, efficacy at negative symptoms Side effects extrapyrimidal motor: acute dystonia, tardive dyskinesia hormonal: hyperprolactinaemia, sexual dysfunction non-specificity of drugs: other receptors weight gain (atypicals), agranulocytosis (clozapine)  
  • Schizophrenia Symptoms: positive: hallucinations, delusions, disorders of thought possession, passivity negative: catatonia, social withdrawal, emotional incongruence cognitive: lack of concentration Hypotheses (evidence?) Dopmaine glutamate 5-HT Antipsychotics Typical: D2-antagonists: halperidone, chlorpromazine Atypical: clozapine (efficacy at negative symptoms), risperidone, olanzapine, amisulpride, paripiprazole Side effects extrapyrimidal motor: acute dystonia, tardive dyskinesia → procyclidine hormonal: hyperprolactinaemia, sexual dysfunction non-specificity of drugs: other receptors metabolic (aypical, → monitor HR, BP, ECG), agranulocytosis (clozapine)  
  • Thrombosis Fibrinolytics Streptokinase anistreplase alteplase, duteplase: recombinant Anticoagulants heparin warfarin dabigatran Anti-platelets aspirin clopidogrel eptifibatide (cyclic), tirofiban abciximab
  • Prinzmetal's angina Definition: Cardiac ischaemia due to coronary artery vasospasm Management: Nitrates, Ca2+ channel blockers (type??); no β-blockers → ACS, stroke, IHD; cardiomyopathies
  • Breast cancer Definition: Mostly ductal (70%), also lobular (15%, medullary (5%)), rare in menRisk factors: Genetic (BRCA1-2, familiy hx, also ofovarian) Uninterrupted oestrogen exposure: OCP, HRT, early menarche / late menopause, nulliparity, 1st pregnancy > 30y/o, not breastfeeding Investigations: Triple assessment (clinical + imaging + biopsy) ⇒ MDT assessmentManagement: Widelocal excision + radiotherapy Mastectomy Neoadjuvant radio-/chemotherapy Hormone therapy Misc: Spreads to bones, lung, brain, chest wall; screening mammography 50-70y/o every 3yrs
  • Metastatic cancer Bone: Prostate, breast, lungLung: Breast, ProstateLiver: GIPeritoneum: GIAdrenal: LungBrain: Lung
  • Prostate cancer Definition: Adenocarcinoma of prostate; most common in peripheral zone; staging TNM; grading Gleason score (max 5+5, <4 indolent, 5-7 moderate, 8-10 aggressive) Epidemiology: 2nd most common cancer, 6th most common cause of cancer death Men over fifty, increasing with age Prognosis: 10% mortality in 6 months, 10% > 10yrs Symptoms: Prostatism: retention, nocturia, poor stream, dribbling B symptoms: weight loss, night sweat, lethargy Bone mets: Pain, wekness, numbness, sphincter disturbance Signs: enlarged, rough, hard, tethered prostate on DREInvestigations: Diagnosis: PSA, transrect USS + biopsy (→ Gleason score for grading), MRI, bone scan Staging: MRI Treatment:  Conservative: Watch & wait or active surveillance Medical: Symptomatic: α-blockers (e.g. tamsulosin), analgesia, radiotherapy Androgen-deprivation therapy: 5α-reductase inhibitors (e.g. finasteride), GnRH analogies ("chemical castration", e.g. goserelin), anti-androgens (e.g. flutamide). Resistance will develop Chemotherapy Radiotherapy: Brachytherapy or external beam Surgery: Radical prostatectomy
  • Congenital heart defects Cyanotic: Tetralogy of Fallot (VSD, PS, overriding aorta, RV hypertrophy), only at a few months of age Transposition of great arteries Tricuspid atresia Non-cyanotic: septal defects: AVSD (→ Downs), VSD (→ Eisenmenger's), ASD (machine murmur) PDA (close with PGI2 antagonists, keep open in duct dependent coarctation) Aortic coarctation (e.g. Turner's syndrome, pulses)
  • Developmental Dysplasia of the hip see also Perthes' disease (older preteen kids) Slipped upper femoral epiphysis (early teens)
  • Coeliac disease Definition: gluten-sensitive enteropathy Symptoms: diarrhoea, failing to thrive, dermatitis herpetiformis Investigations: Conservative: gluten-free trial + reintroduction Bloods: Total IgA, IgA tTG, IgA endomysial antibodies (EMA); if IgA-deficient:  IgG deamidated gliadin peptide (DGP), IgG-tTG, IgG-EMA Surgical:  duodenal biospy (→ villous atrophy) Management: gluten-free diet
  • Gastro-oesophageal reflux disease Overlap with: Dyspepsia (indigestion), peptic ulcer disease Aetiology: reduced sphinctertone, hiatus hernia, H. pylori, drugs, overweight, Epidemiology: very commonSymptoms: Epigastric / retrosternal pain, worse on lying down, and night Anaemia, weight Loss, Anorexia, Recent onset, Malaena, Swalloing difficulty Complications: perforation, bleeding, malignancyManagement (for dyspepsia) >55y/o or ALARM signs ⇒ upper GI endoscopy Else: lifestyle (diet, smoking), stop NSAIDs etc, OTC antacids, r/v in 4 weeks If no improvement: Test for H.pylori If negative: Treat with PPI (omeprazole 20mg OD) or H2-blocker (ranitidine 150mg BD; cimetidine → gynaecomastia) for 4 weeks; then stop or long-term low-dose +/- endoscopy if positive: Eradicate (PAC500 or PMC250: (omeprazole 20mg + metro 400mg + clari 250mg) BD for 7d) and r/v after 4 weeks; treat up to 2x, then endoscopy
  • Kawasaki disease Definition: Autoimmune medium-sized vessel vasculitisEpidemiology: rare, affects children <5, male > femaleSymptoms: Arthralgia, high feverSigns: conjunctivitis, lymphadenopathy, strawberry tongue, palmar rash, coronary aneurysms (→MI)Investigations: FBC, CRP, ESR, LFT, echocardiogramTreatment: IV Ig, aspirinPrognosis: good response to treatment, relapse possible
  • Wilm's tumour Nephroblastoma Symtoms: Abdominal mass, haematuria
  • Rickets Definition: Loss of mineral content in bones during childhood; common in Indian descent Causes: Vit D / Ca2+ deficiency Renal failure Vit D resistance (→vit D resistant rickets, high-dose calcitriol) Liver disease, oncogenic hypophosphataemia X-linked hypophosphataemic rickets Investigations: Plasma: ↓Ca2+, ↓PO43-, ↑ALP, ↑PTH (2°) X-ray: loss of cortical bone; partial fractures; deformities Biopsy: Incomplete mineralization Signs: Long-bone deformities; apathy; failure to thrive → osteomalacia, osteoporosis, Paget's disease of the bone
  • z Atrial flutter Definition: Cotinuous atrial depolarizationNotes: Saw-tooth baseline ±2:1 block; unmask with transient AV block (carotis sinus massage or adenosine) Anticoagulation + DC cardioversion if compromised Rate control (β-blockers) or pharm cardioversion (amiodarone) → atrial fibrillation, SVT, VT, ALS
  • z Supraventricular tachycardia Definition: regular narrow-complex tachycardia: Includes AVNT, AVRNT, MAT, JTCauses: Symptoms: palpitations, dizzinessSigns: tachycardiaInvestigations: Bloods (FBC, U&E, clotting, TSH, drugs), ECG (→150bpm +saw tooth baseline ≅ atrial flutter with 2:1 block)Management: Carotid sinus massage, valsava manoeuvers Adenosine (warn about chest tightness, dspnoea, headache, flushing; then 6mg→12mg→12mg) ⇒ verapamil ⇒ atenolol; beware asthma Magnesium sulphate DC cardioversion if CV compromise or drugs don't work
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  • Ventricular tachycardia Definition: HR > 100 bpm Causes: Hypovolaemia, sepsis, thyrotoxicosis Management: Fluid resuscitation, treat underlying cause
  • Ventricular fibrillation Definition: Irregular broad-complex tachycardia. Shockable rhythm Cause: Mycardial infarction, H4 & T4 Management: Defibrillation → BLS, ILS, ALS; pulseless VT
  • Ischaemic heart disease (IHD) Definition: Symptomatic narrowing of coronary arteriesCauses: Atheroma (hypertension, smoking, hypercholerolaemia, diabetes, age, male, family history)Symptoms: Anginal pain (exertion, emotional upset, cold), no pain at rest (→ACS)Signs: Narrowing on angiographyInvestigations: Nitrate trial, stress ECG, perfusion scan Management: Control modifiable riskfactors: lifestyle (smoking, diet, exercise); medical (diabetes, HTN, cholesterol) ⇒ statin 20mg PO ON, aspirin 75mg PO OD Prevention: Ca2+ channel blockers, β-blockers, ivabradine, nicorandil Symptom control: GTN spray Surgical: elective revascularization Complications: ACS
  • Pericarditis & tamponade Pericardial rub, pain worse on leaning fowards Post-MI = Dressler's dyndrome Reersible cause of cardiac arres (H4 + T4) ⇒ cardiocentesis
  • Lower respiratory tract infections Pneumonia etc
  • Metabolic syndrome Triade obesity, hypertension, diabetes Can be caused by typical antispsychotics
  • Acoustic neuroma Definition: Vestibular schwannomaSymptoms: Sudden unilateral hearing loss, balance, tinnitus, facial painCauses: idiopathic, NF-2Management: Watch&wait; surgery; radiation → cerebello-pontine angle syndrome; Merniere's syndrome; Bell's palsy, Ramsey-Hunt II
  • Merniere's syndrome Fullness + tinnitus + vertigo
  • Facial palsy Definition: Paresis of facial nerve) Causes: Idiopathic (Bell's), tumour (CPA, check V and VIII), herpes zoster (Ramsey-Hunt II) Signs: Facial drop, ?forehead sparing (→ UMN vs LMN lesion) Tx: Steroids +/- aciclovir; protect eye
  • Obstructive sleep apnoea Definition: Intermittend apnoea during sleep due to obstruction of the airway, resulting in impaired sleepEpidemiology: Risk factor obesity; Symptoms: tiredness, daytime somnolence, snoringSigns: HypertensionInvestigations:  Apnoea/Hypoxia index, Epworth sleepiness scale, sleep studyTreatment: nocturnal CPAP, tonsilectomy / adenoidectomy
  • Alcoholic liver disease Definiton: Steatohepatitis Investigations: USS, LFT (↑γ-GT), FBC (→macrocytic normoblastic anaemia) Pathological stages: Normal → alcoholic hepatitis → cirrhosis Complications: Liver failure (ascites, bleeding, infections etc), HCC
  • Perianal disease Haemorrhoids Abscesses Fistulae Fissures
  • Colon cancer Definition: Large bowel adenocarcinoma; left vs right sided; Duke classification A: within wall B: through the wall C: local spread to lymph nodes D: distant mets Symptoms: Unexpained anaemia, palpable mass 40-60yrs: rectal bleeding and change in bowel habits (diarrhoea, constipation, mucus) >60yrs: either Also: weight loss, lethargy Investigations: Bloods: FBC, CEA Imaging: colonoscopy (or CT contrast colonography >7mm) + biopsy MRI for locat staging CT CAP for distant staging Management: Chemotherapy, radiotherapy, resection
  • Gastric cancer Virchow's node MALT lymphoma Gastrectomy → pernicious anaemia, malabsorption etc
  • Liver cancer Definition: HCC, biomarker AFP; 1° vs mets Risk factors: Cirrhosis Signs: Liver faiilure (ascites, jaundice, encephelopathy)
  • Oesophageal cancer Definition: Squamous cell carcinoma; staging TNM; risk factor Barret's oesophagus Signs: Progressive dysphagia solids → fluids; B symptoms (weight loss, night sweat, lethargy) Investigations: Barium swallow, endoscopic USS, CT Treatment: Radiotherapy, surgery, palliative stenting (fizzy drinks if blocked)
  • Pancreatic cancer Definition: most commonly head of the pancreas; types: mucinous, adeno, etc.Risk factors: Alcohol, chronic pancreatitisSS: Painless jaundice, Lavoisier's sign (palpable, non-tender gallbladder)Investigations: Bloods: FBC, LFT, UnE, amylase, lipase, C19-9 Imaging: MRI, CT CAP DDx: cysts Management: Surgical resection → exo-/endocrine pacreatic insufficiency
  • Enteropathies & malabsorption → gluten-sensitive enteropathy (coeliac disease)
  • Functional disorders of the GI tract Irritable bowel syndrome Constipation
  • Gallstones Definition: Stones in gall bladder, cystic duct, common bile duct; composition:  bile salts, free fatty acids, pigmentsRisk factors: Fat, female, fertile, fortySymptoms: crampy right UQ pain, worse after eating, nausea, feverSigns: Murphy's sign in cholecystitisInvestigation: LFT, amylase / lipase, UnE; abdominal US; ERCP / MRCPManagement: Conservative: fat free diet Surgical: cholecystectomy (elective vs hot) → cholecystitis, biliary colic, cholangitis (Charcot's triad); pancreatitis; perforated duodenal ulcer

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