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UCL MBBS (Fach) / Clinical conditions (Lektion)

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• GI bleeding Paeds: intussusception, IBD, gastroenteritis, NEC
• Dysphagia Sold vs fluid Acuity of onset Other symptoms? Cancer?
• Hepatitis Viral (A-E, acute vs chronic) vs autoimmune Jaundice, deranged LFTs New drugs, liver transplant
• Liver cirrhosis Definition: Scarring of the liver parenchyma: smooth or nodularCauses: Alcoholic liver disease Chronic viral hepatitis: →HBV, →HCV Autoimmune: AI hepatitis (α-LKM1-3, α-SLA), →PSC (UC; ANCA α-SM), →PBC (α-mitochondrial M2, ↑IgM) Non-alcoholic fatty liver disease Metabolic: →Wilson's disease, →haematochromatosis, →α1-atitrypsin deficiency →Budd-Chiari syndrome Drugs: methotrexate, amiodarone, methyldopa Complications: →HCC, →liver failure, →portal hypertension (varices, splenomegaly), encephelopathy, hepatorenal syndromeSympoms: Jaundice, itch, dark urine, pale stoolsSigns: ascites, jaundice, spider naevi, bleeding (vit K deficiency), clubbing, Dupuytren's, palmar erythema, gynacomastia, abnormal hair distribution, leukonychia, small testesInvestigations: Bloods (FBC, LFT's, U&E, clotting, AFP, antibodies), US, CT, biopsyManagement Good nutrition, alcohol abstinence, low salt, fluid restriction Ascitic tap Sprionolactone, then furosemide (for ascites / oedema), colestyramine (for itch) Treat underlyig cause; transplant
• GI infections & infestations Organisms Viral: Rota, noro, campylobacter Bacterial: Salmonella (thyphoid), shigella (dysentery), C. diff, E. coli (O157 → HUS) Parasitic: hook worms Immunocompromised: Cryptosporidium Symptoms: Diarrhoea, abdominal pain, vomiting, fever, dehydrationInvestigations: Vital signs, hydation status, stool culture +/- blood culture if septicManagement: Conservative: isolation, rehydration Medical: Antibiotics +/- VSL#3 probiotic, fluids
• Jaundice Prehapatic Intrahepatic Posthepatic Metabolites in blood und urine
• Oesophagitis PPI, H2 blockers: 4 weeks test + treat H. pylori: urea breath test, stool test ⇒ eradication + retest
• Barret's oesophagus Definition: Pre-malignant metaplasia squamous → columnar epithelium in the lower oesophagus; predisposes to adenocarcinoma of the oesophagusCauses: Reflux, oesophagitis, alcohol, smokingManagement: Screening, PPI, laser treatment if severe dysplasia →Mallory-Weiss tear, Boerhaave syndrome
• Pancreatitis Definiton: Inflammation of the pancreas; acute vs chronicCauses: I GET SMASHEDSymptoms: epigastric pain, nausea, vomiting, anorexia (DDx: Ruptured A3, cholecystitis, cholangitis, perforated DD ulcer)Score: Glasgow, Ranson , APACHE II Modified Glasgow criteria PaO2 < 7.9kPa Age > 55 years Neutrophils (WBC > 15) Calcium < 2 mmol/L Renal function: Urea > 16 mmol/L Enzymes LDH > 600iu/L, AST > 200iu/L Albumin < 32g/L (serum) Sugar BSL > 10 mmol/L Signs: Bruising, epigastric tendernessManagement: Supportive: analgesia+antiemetic, drip & suck, NBMComplications: Bleeding, rupture, sepsis; long-term: pancreatic cancerOutcome: 90% spontaneous resolution; 10% severe (necrotic, infected), 4% mortalitiy
• Pancreatic insufficiency Definition: Exocrine (digestive enzymes, e.g. amylase) vs endocrine (esp. insulin) insufficiency Symptoms: Steatorrhoea, weight loss, vit deficiciency (A,D,E,K; bleeding, infection etc.) Cause: Exocrine: CF, α1-antitrypsin deficiency, PCD, pancreatitis, tumour, resection Endocrine: autoimmune, pancreatitis, resection Management: enzyme supplement (→ Creon), insulin → acute / chronic pancreatitis, pancreatic cancer; Diabetes
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• Ulcers Peptic Duodenal Venous Arterial Neuropathic Mixed
• Tuberculosis Definition: Mycobacterium tuberculosis infection, causing caeseating granulomata. Lung (primary, latent, Ghon focus); miliary Epidemiology: Live BCG immunisation for high-risk children Symptoms: SoB, cough, fever, night sweats, lethargy, weight loss; erythema nodosum; may affect adrenals ⇒ Addisons with weight loss Investigations: Immunity: vaccination scar, tuberculin skin test, γ-interferon Bloods: FBC, CRP Investigations: CXR: apical cavitating lesions, hilar lymphadenopathy Management: (typical SEs) Rifampicin ⇒ orange man syndrome Ethambutol ⇒ optic neuritis Isoniazid + pyridoxine Misc: 1° pulmonary TB = AIDS; reactivation with immune supression
• Pyelonephritis Urosepsis (→gram-negative, Sepsis 6); flank pain, renal angle tenderness Ureteric stones Nephrostomy
• Bone cancers Ewing's tumour → sunburst appearance Osteasarcoma → onion sign Others: Osteoid osteoma, osteoclastoma, bone mets
• Common disorders and injuries of the hip, knee, ankle, foot, neck, back, shoulder, elbow, wrist and hand Osteoarthritis Seropositive/-negative arthritides Trauma, incl stress, avulsion fractures Bone cancers Frozen shoulder, tendinitis etc
• Common fractures of upper and lower limbs including principles of treatment Hx: Mechanism, functional baseline, neurovascular statusManagement: Analgesia → R4: Resuscitate → reduce → retain → rehabilitate Upper limb Humerus Radius Scaphoid, lunate Lower limb Neck of femur: intra- vs extracapsular; risk of necrosis Ankle Metatarsals
• Compartment syndrome Definiton: Compression to due to volume increase, e.g. bleeding, oedema; risks ischaemia (→ P6) and nerve damage Symptoms: Pain out of proportion to injury Management: Fasciotomy
• Connective tissue disorders Learn antibodies! Felty's syndrome (rheumatoid arthritis + splenomegaly) Systemic / drug-induced lupus erythematosis Polymyalgia Dermatomyositis Polymyositis Ehlers-Danlos Marfans
• Gout Definition: Crystallo-arthropathy due to deposition of urate oxalate crystal in joints; negatively birefringent spiked rods under polarized lightCauses: Idiopathic, drugs (loop & thiazide diuretics)Symptoms: mono-/oligoarticular joint pain, swelling, redness; 1st MTP, knee commonSigns: Asymmetric, deforming mono-arthropathy; ± gouteous tophi (elbow, ears, knee)Management: Diagnosis: Bloods (incl urate levels); joint aspirate; imaging (X-ray) Analgesia: NSAIDs / opiates Colchicine Allopurinol / febuxistat DDx: →pseudogout, septic arthritis, osteoarthritis
• Inflammatory arthropathies seronegative, other → Rheumatoid arthritis
• Spinal injuries Anatomy: Cauda equina sydrome Brown-Sequard syndrome Tabes dorsalis
• Metabolic bone diseases  Includes: →Paget's disease of the bone, →osteoporosis, →osteomalacia, →rickets Tests: Metabolic bone profile: (Ca2+, Phosphate, ALP, PTH, Vitamin D)
• Osteoarthritis Definition: Oligoarthropathy of big joints (knee, hip, shoulder) and hands; degenerativeRisk factors: High BMI, recurrent microtrauma, ageSymptoms: Pain, stiffness, swelling; better when restingSigns: Swelling, joint tenderness, esp. base of thumb, Heberden's nodules over DIPInvestigations: Imaging: X-ray (Loss of joint space, Osteophytes, Sclerosis, Subchondral cysts) Management: Conservative: Exercise, PT, weight loss Medical: Analgesia (e.g. paracetamol, naproxen/ibuprofen (beware CKD, gastric ulcer)) Surgical: hemi-/arthroplasty → RA, pseudo-/gout, septic arthritis
• Rehabilitation after joint replacement, fractures or severe injuries, especially spinal injuries MDT approach including PT, OT, social services
• Seronegative arthritis / spondyloarthritides Enteropathic arthritis → IBD Psoriatic arthritis → onycholysis Reactive arthritis → Reiter's (urethritis, conjunctivitis, arthritis) Ankylosing spondylitis → A6, young men, morning stiffness Features: Rh-factor negative HLA B 27 Axial, asymmetrical, oligo- or mono- distribution Dactylitis Extra-articular: Iritis, rashes, IBD → RA, crystallopathies (pseudo-/gout); septic arthritis
• z Alcohol and substance abuse Definition: Dependence: desire, lack of control, tolerance, withdrawal, social impact, continue despite adverse effects; need 4/6 Harmful use:  Notes:Screening: >6drinks? ⇒ Cut? Annoyed? Guilty? Eye opener? etc, detailed history
• Deliberate self harm good history, MSE, assessment of suicide risk attempted vs successful suicide vs parasuicide vs DSH
• Eating disorders Anorexia Psychological: body dismorphia, anxiety about getting fat, preoccupation with weight / eating / cooking Behavioural: exercise, laxative abuse, vomiting Physiological: low BMI, amenorrhoea, "everything low, except C" Bulimia nervosa: like AN, but with normal BMI Rule of 1/3's: mortality, improvement, recovery
• Depression Clinical classification: uni- vs bipolar; reactive vs endogenouspsychological theories: learned helplessness, dysfunctional beliefs, attribution theory Symptoms: (2+>2 - mild, 2+>4- moderate, 3+>8 severe; present for long enough) Major: Low mood, anhedonia, low energy Minor: sleep, appetite, concentration, memory Beck's triad: self, future, world Investigations: TFT, FBC, MMSE, suicide assessmenet Treatment: Conservative: Psychoeducation, self-help, CBD, Medical: TCA's - imipramine, amitryptiline SSRI - citalopram, fluoxetine - emotional SNRI - reboxetine - biological MAO-A-I - phenelzine, tranylcypromine, iproniazid RIMA - moclobemide Atypicals, St John's Wort Future treatment: neuropeptides, SP, CRH, ketamine Surgical: ECT Prognosis: tends to recur
• Personality disorders Don't diagnose before 18y; exclude, organic cause and mental illness Clusters: A (weird / odd): paranoid, schizoid, schizotypal B (dramatic / erratic): antisocial, borderline, histrionic, narcicistic C (dependent): avoidant, dependent, obsessive-compulsive
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• Post-partum mental health problems Baby blues Past-natal depression Puerperal psychosis → admit
• Psychosis Definition: Hallucinations + delusions; no insight Organic causes Delirium Intoxication / withdrawal Neurological disease, e.g. Lewby body dementia Functional Schizophrenia Delusional disorder Affective disorders: depression, mania
• Sexual dysfunction Causes psychogenic: e.g. performance anxiety, vaginisms physical: vascular (e.g. diabetic), pudendal nerve (post pelvic surgery - prostate, bowel) Management Conservative: Psychotherapy Medical: PDE-V inhibitors (sildenfafil, beware nitrates, nicorandil); prostaglandin (urethral tablets, intracavernous injections) Surgical: inflatable implants
• Somatoform disorders somatisation, somatoform pain disorder dissociation / conversion illness hypochondriacal disorder malingering factitious symptoms Munchausen /by proxy
• Intracranial and spinal tumours Glioma / -blastoma Meningioma Astrocytoma Intra- vs extra-axial 1° vs mets Management: conservative, chemo-/radiotheraoy, surgery
• Diabetes and the eye Diabetic retinopathy Background - Microaneurysms, <5 blot haemorrhages, hard exudates Pre-proliferative - >5 blot haemorrhages, cotton wool spots Proliferative - neovascularization, extensive bleeding Laser scars from treatment of retinal oedema Diabetic maculopathy Annual screening program → Diabetic nephropathy
• Red eye Conjunctivitis - allergic, viral, bacerial, fungal Subconjunctival haemorrhage → INR, BP Epi-/scleritis Acute angle-closure glaucoma
• Bowel obstruction Definition: Upper (gallstone ileus, adhesions, hernia, tumour) vs lower (tumour, volvulus, Hirschsprung's, toxic megacolon)Symptoms: Abdominal pain, bloating, constipation (w/o flatus), nausea, vomitingSigns: DistensionInvestigations: AXRManagement: Conservative: NBM Medical: drip and suck Surgical: defunctioning stoma, resection
• BPH Definition: Benign Prostatic HypertrophyEpidemiology: Common in elderly menSymptoms: Prostatism (retention, poor stream, dribbling, nocturia)Signs: Enlarged smooth prostate on DREInvestigations: PSA, +/- MR Treatment: acute: catheter long-term: α-blocker, e.g. tamsolusin; anti-androgens, e.g. finasteride
• Shock Definition: Global hypoperfusion; Types: hypovolaemic, cardiogenic, septic, neurogenic Signs: ↓BP, ↑HR, ↑RR, cold peripheries, long capillary refill; ↓GCS, confusion Management: ABCDE, including sepsis 6 (Fluids, oxygen, ABx; cultures, ABG, urine output) → SIRS cascade
• Post-OP pyrexia Atelectasis Infection Beware and treat SEPSIS
• Urinary calculi renal, ureteric, vesical
• Drug reactions EM → SJS → TEN EN Urticaria etc
• Medically unexplained symptoms BioPsychSocial approach Explore concerns, rule out pathologies, challenge and negotiate
• Pain Do SOCRATES Give analgesia, according to WHO ladder NSAIDs: Paracetamol (1g QDS), ibuprofen/naproxen; avoid diclofenac Opiates: weak (morphine 5-10mg QDS) --> intermediate --> strong Fentanyl patches Treat underlying cause
• Acute heart failure Definition: cardiogenic shock vs pulmonary oedema - fluid resuscitation vs fluid overloadSymptoms: SoB (orthopnea, paroxysmal, noctunal dyspnoea), wheeze, swelling, frothy sputumSigns: basal crackles, oedemaInvestigations: Bloods (FBC, U&E, LFT, BNP), CXR (ABCDE), ECGManagement: Dr. ABCDE Sit patient forward, 15l O2 non-rebreath-mask → target 94-98% Morphine 5mg every 4h + metoclopramide 10mg If haemodynamically stable: IV: diuretics, nitrates, ventilation, inotropes If haemodynamically unstable: inotropes, ventilation, intra-aortic balloon pump, VAD Review chronic management: Frusomide, ACE-I (or ARB), β-blocker → spironolactone → digoxin → assist device → heart transplant ? role of wedge pressure?
• z Acute asthma Definition: Exacerbation of symptoms in asthmaClassification: Mild-moderate-severe-life threatining: Ability to speak sentences, PEF, chest sounds, O2-satsSymptoms: SoB, Wheeze, chest pain, headacheSigns: Wheeze, ↓breath sounds, cough, dyspnoeaInvestigations: Bloods, PEF, CXR, ABGManagement: DR ABCDE High flow O2 non-rebreath mask, target 94%-98% Salbutamol nebulisers 2.5 - 5mg Steroids: prednisolone 30mg PO or hydrocortisone 200mg IV Aminophylline, magnesium sulphate, IV salbutamol If ↑pCO2 (>6.5kPa) ⇒ ventilatory support ⇒ Continue prednisolone 30mg for 5-7d, reassess medication
• COPD exacerbation Pneumonic non-pneumonic infective non-infective
• Angiooedema Types: Acute: Idiopathic, anaphylaxis Hereditary: C1 esterase deficiency x3 Treatment: Ecallatide, Icatabant
• Hyperaldosteronism Definiton: Aldosterone execess Primary: 2/3 Conn's (aldosterone-producing adenoma); 1/3 bilateral adrenal hyperplasia; rare: Glucocorticoid-Remediable Aldosteronism Secondary: ↑renin due to ↓renal perfusion (e.g. Renal Artery Stenosis, CCF, diuretics) Bartter's syndrome (autosomal recessive slt wasting, normal BP) Symptoms: Asymptomatic; ↓K+ → weakness, cramps, paresthaesia; hypertensionInvestigations: UnEs: ↑Na+, ↓K+ Specialized: Aldosterone/renin ratio, fludrocrotisone suppression test Imaging: CT or MRI of adrenals Surgical: Adrenal vein sampling Management: K+ replacement, tret underlying cause → Congentical Adrenal Hyperplasia, hypertension, phaeochromocytoma

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