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UCL MBBS (Fach) / Clinical conditions (Lektion)

Clinical conditions

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  • Prostatic hypertrophy DDx: Benign (→BPH), malignant (→prostate cancer), prostatitis Examination
  • z Renal replacement therapy Indication: Chronic kidney disease stage 6, eGFR<15ml/minObjective: Filter waste products (urea, phosphate) Electrolyte balance (potassium) Dialysis: pertoneal vs haemo Practicalities: time, travel, sterility Access: AV-fistula, central line: Complications: thrombosis, infection, aneurysm, stenosis, steal syndrome Medication: →erythropoietin, → phosphate binders, vit D antagonists (→calciferol) Renal transplant Types of graft: live/dead, related/unrelated; HLA-matching Immunosuppression: →mycophenolate/azathioprine, →ciclospron/tacrolimus; prednisolone; pre-OP anti-IL-2 (→basiliximab) → chronic kidney disease
  • Upper urinary tract obstruction, hydronephrosis --
  • Vesicoureteric reflux Glomerulonephritis leads to scarring and CKD Investigations: MCUG, DMSA-scan
  • z Anticoagulation Definition: Pharmacological reduction of the prospensity of the blood to form 'clots'Physiology: Intrinsic & extrinsic pathways, Virchow's triade, fibrinolysisIndications: Heparin: VTE prophylaxis & treatment → monitor Xa, APTT Warfarin: post-VTE, chronic AF, mechanical heart valve → monitor INR Mechanisms & drugs Warfarin: vitamin K peroxide reductase inhibitor: blocks factors I, VII, IX, X + protein C; initial thrombophilc effect → cover with heparin Heparin: anti-thrombin activator: LMWH lower half-life Dabigatran, bivalirudin: thrombin inhibitor Rivaroxaban, apixaban: factor Xa inhibitors Complications Bleeding: bruising, GI, haemorrhagic stroke Specific side effects, drug interactions Antidotes: Protamine sulphate; vit K + prothromboin complex concentrate
  • Thrombocytopenia Definition: Low platelet count (<100e9 / ml) Symptoms: Bleeding, bruising Causes: Production: aplastic / megaloblastic anaemia, marrow failure (drugs, radiation), infiltration (leukaemia, myeloma) consumption/destruction: DIC, microangiopathies (TTP, ITP). HUS, hypersplenism Pancytopenia Management: Treat underlying cause thrombopioetin (eltrombopag) plasma transfusion
  • DIC --
  • Haemophilia Inherited clotting factor deficiency Types A: X-linked recessive; factor VIII B: X-linked recessive: factor IX C: autosomal recessiv: factor XI acquired: factor VIII autoantobdies   Symptoms: Easy bruising, bleeding into joints → arthropathies
  • Blood transfusion --
  • Lymphoma Definition: Malignant proliferation of lymphocytesSymptoms: Malaise, lymphadenopathy (pain with alcohol), constitutional B symptoms (fever, night sweats, weight loss)Signs: rubbery lymph nodes, e.g. neck, groin, bihilar, cachexia, anaemia, spleno-  /hepatomegalyStaging (Ann-Arbor): single lymph node → two or more → both sides of diaphragm → organsClassification Hodgkin: Reed-Sternberg cells (mirror-image nuclei): Nodular sclerosing > follicular > lymphocute rich (best) > lymphocyte depleted (worst prognosis) non-Hodgkin Diagnosis: Biopsy Management Chemotherapy: Adriamycin, Bleomycin, Vinblastine, Dacarbazine Radiotherapy
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  • Leukaemia Definition: malignant proliferation of white cells Types: ALL: rare in adults AML: commonest acute leukaemia in adults; rapid progression; Auer rods CLL: progress slowly CML: Philadelphia chromosome (t9,22, bcr-abl on 22) Symptoms: Marrow failure: Infection, bleeding, anaemia Infiltration: Hepato-/splenomegaly; gum hypertrophy Complications: Bleeding, infection, hyperviscosity (→VTE), TLS, DIC Investigations: Peripheral WCC: blasts; → immunophenotyping → bone marrow aspirate Management: Conservative: walking exercise for fatigue, education, psych support Medical: treat complications; chemo Surgical: bone marrow transplant → lymphoma; myelodysplastic syndromes, myeloproliferative disorders (myelofibrosis, essential thrombocythaemia, polycythaemia rubra vera, CML)
  • Myeloma Definition: Malignant plasma cell proliferation w/ bone marrow infiltrationSymptoms: Marrow suppression → bleeding, infections, fatigue Light chain production → kidney failure, amyloidosis Hypercalcaemia →bone lesions & pain Diagnosis: Urine: nephrotoxic light chains in urine (Bence Jones cast nephropathy (BJCN); acellular; ATN, nonspecific tubulointerstitial nephritis) Bloods, blood film, bone marrow biopsy Treatment: Chemotherapy, Radiation → HGUS
  • z Haemolysis Definition: Excessive lysis of RBC → haemolytic anaemia; intra-/extravascularCauses: Aquired: AIHA (drugs: penicillin, warm: CLL, cold: mycoplsma; DAT+), MAHA (TTP, HUS),  mechanical (heart valve) Inherited: Membrane (sphero-, eliptocytosis), enzymes (G6PD, PK), Hb (thalassaemia, sickle) Symptoms: SoB, dizziness, headache, pre-/syncope, palpitations, jaundiceSigns: Blueish-yellow teint, tachypnoea; stools and urine normalInvestigations: Bloods (FBC, U&E, LFT, clotting), urine; ↑unconjugated bilirubin, reticulocytosisManagement: Treat underlying cause; maybe transfuse blood products → nutritional anaemia; haemoglobinopathies
  • Nutritional anaemia Iron B12/folate
  • Neutropenic sepsis Recognise Antibiotics according to local protocol Isolation in positive pressure environment
  • Polycythaemia Definition: Increased red cell mass (absolute) or decreased plasma volume (relative), e.g. due to dehydration Cause for absolute: 1ary: Polycythaemia Rubra Vera: JAK2-mutation, myeloproliferative disorder 2ary: high altitude, increased erythropoietin in renal Ca Risk: Thrombotic event Management: venesection, low-dose aspirin
  • Thrombophilia --
  • Myeloproliferative disorders Polycythaemia - RBC's CML - Leukocytes Myelofibrosis - Fibroblast Thrombocythaemia - Platelets Signs: Splenomegaly & according to cell type function  
  • Bone and joint infection Osteomyelitis Septic arthritis of joints → aspiration, washout, antibiotics TB Cellulitis
  • CNS infections Meningitis, encephalitis, abscess Infections in the immunocompromised → cerebral toxoplasmosis, cryptococcal meningitis, progressive multifocal leucoencephelpathy  Common pathogens: Meningitis: N. meningitidis, S. pneumonia, H. influenzae, L. monocytogenes; E. coli, TB Encephalitis: HSV, mycoplasma, measles, etc.; Symptoms Meningitis: neck stiffness, photophobia, headache Encephalitis: pesonality change, altered consciousness, seizures Management with ABx: Ceftriaxone +/- ampicillin +/- macrolide aciclovir i.v.
  • ENT infections Staph pneumoniae otitis media
  • Genitourinary infections Candida Bacterial vaginosis Trichomoniasis gonorrhoea chlamydia  Syphilis Herpes Warts Know: Pathogen, symptoms, diagnosis, ?STI, treatment
  • Hepatobiliary infections HBV a,b,c
  • Fever in the returning traveller including malaria!
  • Septic shock SIRS → Sepsis → Severe sepsis → septic shock Tx: Resuscitae + ABx; SEPSIS 6
  • TB Definition: Infection with mycobacterium tuberculosis, -bovis, etc. Classification: (also symptoms) pulmonary vs extrapulmonary latent vs active genitourinary, bone, skin, peritoneal, endocardial miliary, meningitis (in immunocompromised) Pathology: Gohn's focus, granulomatous inflammation (type IV hypersensitivity), caseous necrosis → pathognomonics Diagnosis: Mantoux → interferon γ; tuberculin test Culture: sputum (lavage, induction), pleura, pus, urine, bone marrow, CSF Histology: caeseating granulomata CXR: consolidation, cavitation, fibrosis, calcification Management Isoniazid → hepatitis, neuropathy, → pyridoxine deficit Rifampicin pyrazinamide hepatitis, arthralgia ethambutol → optic neuritis Vaccination BCG attenuated live: halth care workers, babies in high-prevalence districts
  • Urinary tract infection Definition: Symptomatic bacteruria (>10^5 /ml fresh MSU)Classification Upper/ascending (=pyelonephritis) vs lower (urethritis, prostatitis, cystitis) complicated vs uncomplicated: abnormal renal tract, impaired kidney function, virulent pathogen recurrent: new infection vs relapse: same pathogen Symptoms: Dysuria, frequency, urgency, haematuria, fever, loin painSigns: protein, nitrates on dipstick, loin tendernessInvestigations: Urine dipstick, bloods; imaging: CT, USCommon pathogens: E.coli, proteus, klebsiella; staph saprophyticus, enterococciManagement: Empirical ABx: Trimethoprim (not 1st trimester) → nitrofurantoin (not last trimester) Pregnancy: Cefadroxil → amoxicillin Pyelonephritis: Cefuroxime or ciprofloxacin   → sterile pyuria! Cancer etc
  • Immunisations Aim: Personal + herd immunity; give before peak incidence Schedule: 2m: DTaP(5), Polio, Hib, PCV, rotaV 3m: DTaP(5), Polio, Hib, MenB, rotaV 4m: DTaP(5), Polio, Hib, PCV 12-13m: MMR, Hib/MenB 3-4y: MMR, DTaP(3) 12-13y: HPV 16+18 +/- 6,11, e.g.gardasil Teenager: DTaP(3) booster Extra: Hep B, Men C, TB S/E: fever, headache, local discomfort; NOT autism C/I: high fever, immune suppression for live vaccines, e.g. Polio
  • Viral hepatitis --
  • Aortic stenosis Definition: Narrowing of the aortic valveCauses: Senile calcification, congenital: bicuspid valve; rheumatic heart diseaseSymptoms: Angina, pre-/syncope, heart failure; fatigue, SoB, dizziness, ↓exercise toleranceSigns: Slow-rising pulse, narrow pulse pressure (parvus & tardus) Ejection systolic murmer: 2nd right ICS, radiating to the carotids, loudest on expiration & leaning forwards; ±heaving apex beat (due to left ventricular hypertophy) Investigations: CXR (LVH, calcification), ECG (LVH, p mitrale, LAD), Echo to assess gradient and valve area (Mercedes sign)Management: Valvuloplasty if gradient > 50mmHg or symptomatic; TAVI, BAVI
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  • Aortic regurgitation Definition: Aortic valve incompetenceCauses: Degenerative, connective tissue disease (Marfan's), ankylosing spondylitisSymptoms: SoB, syncope, cough (left heart failure)Signs: Periphery: Wide pulse pressure, collapsing pulse, dancing carotids Precordium: Displaced apex beat, early diastolic murmur, loudes in expiration over tricuspid area Bibasal crackles; right heart failure (elevated JVP, pulsatile liver, pedal/sacral oedema) Investigations: ECG, CXR, echoManagement: Depends on symptoms; aortic valve repair / replacement
  • Mitral stenosis Rumbling mid-diastolic murmur, loudest over apex in expiration left-lateral with bell
  • Mitral regurgitation Definition: Incompetent mitral valveCauses: LV dilatation, anular calcification, IE, MV prolapse, rheumatic heart disease, connective tissue diseases (Marfahn, Ehlers-Danlos), post-MISymptoms: Fatigue, heart failure (→dyspnoea, oedema), palpitationsSigns: Pulse normal or AF Pansystolic murmur: loudest over mitral region (roll onto left), radiating to axilla; loudest in expiration Investigations: CXR (big LA, LVH, pulmonary oedema (=ABCDE)), ECG (AF, P-mitrale, LVH), echo, cardiac catheterizationManagement: AF → rate control, anticoagulation Diuretics for symptoms, ABx for IE surgical repair or replacement before irreversible damage → Mitral valve prolapse, mitral valve stenosis; aortic regurgitation, aortic stenosis, aortic sclerosis
  • Valvular disease --
  • Cardiomyopathies Hypertensive Hypertrophic ± obstructive Restrictive Dilated Arrhythmogenic Characteristic systolic / diastol heart failure pattern
  • TTP --
  • z HUS Definition: haemoltic uraemic syndrome = MAHA caused by E. coli O157 toxinSymptoms: Bleeding, thrombosis, palpitations, SoB, headache, jaundice; haematuriaSigns: Haemolyic aaemia (pallor-jaundice, hyperdynamic circulation)Investigations: Bloods (FBC - ↓Hb, clotting - ↓platelets, LFT - ↑unconjugated bilirubinaemia, other haem-metabolites, U&E - urea, K+); urine dipstick; blood filmManagement: Supportive, blood products / anticoagulation →TTP, DIC; haemolysis, MAHA/AIHA
  • Tangier's disease Lipid metabolism disorder Familial α-lipoprotein deficiency → low HDL
  • Ankylosing spondylitis Definition: Seronegative HLA B27 associated spondyloarthritis (chronic inflammatory disease) affecting the spine; unknown aetiology; often young menSymptoms: Lower back pain, stiffness - worse in the morning, relieved by exercise; M>F; Associations: Anterior uveitis/iritis, Amyloid, A/V block, Aortic regurgitation, Apical fibrosis, Achilles tendinopathySigns: ?-posture, sacroiliitis; X-ray: bamboo spine (~syndesmophytes), dagger (~spinous ligament); ↑ESR/CRPManagement: Lifestyle: Exercise (e.g. Badminton), Medical: NSAIDs (e.g. ibuprofen, celecoxib), TNF-α blockers (etanercept, adalimumab), steroid injections Surgery: hip replacement, osteotomy → reactive arthritis (Reiter's triade), psoriatic arthritis (different patterns), enteropathic arthritis
  • Thick heart Secondary to hypertension Primary Hypertrophic cardiomyopathy Fabry's disease Amyloid Sarcoid Complications: Obstruction  
  • Thin heart Dilated cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy   Complications: Mitral / aortic regurgitation
  • z Acute limb ischaemia Defintion: Tissue necrosis due to insufficient blood supplySigns & symptoms: Perishingly cold, Pallor, Pulseless, Parasthaesia & Pain, ParalysisCauses: peripheral vascular disease (e.g. diabetes), Buerger's disease, thromboembolismManagement: Refer to vascular surgeryDDx: DVT, cellulitis, varicose veins
  • Chronic limb ischaemia --
  • z Amputation Indication Rehabilitation
  • Aortic aneurysm History   Physical signs   Investigations   Management
  • Varicose veins History   Physical signs   Investigations   Management
  • Lymphoedema History   Physical signs   Investigations   Management
  • Diabetic foot --
  • Carotid stenosis Significant: symptomatic + 70% Stroke
  • Bronchiectasis Aetiology: Chronic infection of the lungs, dilatation of small bronchioles; pathogens: H. flu, Strep. pneumo, Staph. aureus, pseudomonasCauses: Congenital: CF, Young's, Kartagener's Post-infection: measles, pertussis, bronchiolitis; TB Other: ABPA, obstruction (e.g. malignancy), RA, UC Symptoms: Persistent cough, spurulent sputum, haemoptysisSigns: Clubbing, coarse insp crep's, +/- wheezeDiagnosis: Sputum culture, CXR (→ ring shadows), HRCT (→ signet ring sing), spirometry (→ obstructive pattern), bronchoscopy CF sweat test, aspergillus precipitins Management: Conervative: Postural drainage Antibiotics: ciprofloxacin or IV for pseudomonas Bronchodilators; inhaled ABx, e.g. gentamicin Steroids for ABPA Surgery: lung-transplant

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