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Ryad Chebbout
The Peer Teaching Society is not liable for false or misleading information…
CVS
Atherosclerosis
Atherosclerosis
RF
(modifiable)
• Smoking
• HTN
• Hyperlipidaemia
• DM
• Obesity
(non-modifiable)
• Age
• Sex (male)
• FH
Angina Pectoris (stable)
Statins Primary Prevention
INDICATIONS
• Hx CVD
• Familial lipid disorder
• QRISK2>-10% (<84yrs)
• T1DM + >40yrs OR
DM>10yrs OR
Nephropathy OR CV RF
• CKD
SE
• Fatigue
• Headache
• Nausea
• Indigestion
• Myopathy (myalgia,
myositis,
rhabdomyolysis)
Measure CK!!!!
Angina
PATH
• Atherosclerosis in coronary artery
caused stenosis and then ischaemia.
• Rarely: Anaemia, AF,
Tachyarrhythmia, Vasculitis
Stable
SYM
• Central Chest Tightness/Heaviness
(exacerbated by exercise, relieved by
rest, radiate to arms/neck/jaw/teeth)
PREC
• Emotion, Cold, Heavy Meals
INV
• ECG (possibly ST depression, old
infarct)
• Exercise ECG (horizontal ST
depression of 2mm)
• Stress Echo, Coronary Angiography,
Cardiac CT
Types
• Stable (stable at rest)
• Unstable (unstable at rest or on
minimal exertion)
• Decubitus (exacerbated by lying
down)
• Variant/Prinzmetal (coronary artery
spasm during rest, transient ST
elevation on ECG during pain, CCB +/Long-Acting Nitrates)
Angina Mx
RF Mx!
Pharma:
1. BB (atenolol)/CCB (verapamil/diltiazem)
2. BB + CCB (nifedipine), OR monotherapy + long-acting
nitrate/ivabradine/nicorandil/ranolazine
3. Can use BB + CCB + 3rd Drug whilst waiting for
PCI/CABG
• Adjuvant Mx: Aspirin, Statin, Glyceryl Trinitrate (SL)
• PCI/Surgery (CABG)
Heart Failure
RF
• IHD, Smoking, HTN, Valvular
Disease, Obesity, Cardiomyopathy
Left-Sided Sym/Sig:
• SOB
• PND/Orthopnoea
• Nocturnal Cough (pink frothy
sputum) / Wheeze
• Poor Exercise Tolerance/Fatigue
• Cold Peripheries
• Weight Loss
• Muscle Wasting
Right Sided AE:
• Left Sided HF
• Cor Pulmonale
• Pulmonary Stenosis
Right Sided Sym/Sig:
• Peripheral Oedema/Ascites
• Hepatomegaly
• Raised JVP
• Nausea
• Anorexia
• Facial Engorgement
Framingham Criteria for CCF
New York Classification of Heart
Failure
I: No Limitation, no sym on usual activity
II: Mild Limitation, sym on ordinary activity
III: Moderate Limitation, comfortable only at
rest
IV: Severe Limitation, sym at rest
INV
INV
• Bloods (FBC, U&E, BNP)
• CXR (ABCDE)
• ECG
(ischaemia/MI/ventricular
hypertrophy)
• Echo (MI, valvular, LV
dysfunction)
HF CXR = ABCDE:
• Alveolar Oedema (bats
wings)
• Kerley B lines (interstitial
oedema, short white lines
run perpendicular to
pleura)
• Cardiomegaly
• Upper lobe Diversion
(prominent upper lobe
vessels)
• Effusion (pleural)
Diagnosis
• Previous myocardial infarction
arrange echocardiogram within 2 weeks
OR
• No previous myocardial infarction
measure serum natriuretic peptides (BNP)
If levels are 'high‘ (>400) arrange echocardiogram
within 2 weeks
If levels are 'raised‘ (100-400) arrange
echocardiogram within 6 weeks
Mx
• Annual Influenza Vaccine
• One-Off Pneumococcal
Vaccine
• RF Mx +/- Cardiac
Rehabilitation
• Treat Cause (valvular, IHD)
• Cardiac Resynchronisation
Therapy
Drugs that improve mortality:
• ACEi (A)
• Spironolactone (S)
• Beta-Blockers (B)
• Hydralazine + Nitrates (HN)
1. A + B
2. + ARB/S/HN
3. Cardiac Resynchronisation
Therapy OR Digoxin
Hypertension
AE
• Essential (95%, primary, cause
unknown) and Secondary (5%)
Secondary Causes:
• Renal Parenchymal Disease
(glomerulonephritis, vasculitis)
• Renovascular Disease (renal
artery stenosis)
• Endocrine (Cushings, Conns,
Phaeochromocytoma,
Acromegaly, Thyrotoxicosis)
• Coarctation of Aorta
End-Organ Damage:
• Eyes: Retinopathy
• Cardiac: LVH
• Kidney: Proteinuria
• Neuro: Headache, Nausea,
Vomiting
Stage
Criteria
Stage 1 hypertension
Clinic BP >= 140/90 mmHg and
subsequent ABPM daytime average or
HBPM average BP >= 135/85 mmHg
Stage 2 hypertension
Clinic BP >= 160/100 mmHg and
subsequent ABPM daytime average or
HBPM average BP >= 150/95 mmHg
Severe hypertension
Clinic systolic BP >= 180 mmHg, or clinic
diastolic BP >= 110 mmHg
HTN
INV
• Other RF: Blood Glucose,
Cholesterol
• End-Organ: ECG, Urine
Analysis, Eye
Examination
• Exclude Secondary
Causes: U&E’s, Calcium,
Cortisol, Aldosterone,
Renal USS
Mx
• RF Mx (smoking, diet,
alcohol, exercise)
• Pharma
• Adjuvant treatment
(>55yrs = Aspirin,
Statin)
Atrial Fibrillation
AF
PATH
• AVN bombarded with depolarisation
waves of varying strength
• No P waves, irregularly irregular RR
duration, QRS normal (rate: 75190bpm), depressed ST V5-6
• First Detected Episode, Paroxysmal
(episodes terminate spontaneously),
Persistent (not self-terminating, last
>7d), Permanent (rhythm control
failed)
AE
•
•
•
•
•
•
•
IHD
HF
HTN
Post-MI
PE
Hyperthyroidism
Mitral Valve Disease
SYM
• Asymptomatic
• Chest Pain, Palpitations, SOB
SIG
• Irregularly Irregular Pulse
AF
Mx
(acute)
• Cardioversion (electrical or
Amiodarone IV),
Diltiazem/Verapamil/Metoprolol PO
(Chronic)
• Rate Control (older, hx IHD):
1. Beta-Bloker (Metoprolol) OR CCB
(Diltiazem)
2. Dual therapy: Beta-blocker,
Diltiazem, Digoxin
•
COMP
• Embolic Stroke/TIA
Rhythm Control (younger, SYM, 1st
presentation, CHF):
1. Onset < 48hrs = Heparin +
Immediate DC Cardioversion OR
Amiodarone (OR flecainide if no
structural heart disease)
2. Onset > 48hrs = Heparin + 3wk later
DC Cardioversion
•
Anticoagulation: Warfarin (postTIA/Stroke)
RESP
Asthma
PATH:
1. Bronchial smooth muscle contraction
(bronchospasm)
2. Mucosal swelling/inflammation (SM
hypertrophy)
3. Increased (glands) mucus production
Atopic:
IgE-mediated (type 1 hypersensitivity), eosinophils
Associated: Eczema/Hayfever/Allgery, GORD
Asthma
SYM:
1. SOB
2. Wheeze
3. Cough
4. Decreased exercise tolerance and sleep
Pattern: intermittent, nocturnal (diurnal variation), worse
at home/work (allergens)
Precipitants: cold air, exercise, emotion, allergens,
infection (URTI), smoking
Asthma
SIG
• Wheeze (expiratory,
polyphonic)
• Sputum
• Hyperinflated chest
• Hyperresonant
percussion
INV
• Clinical
• PEF (diurnal variation),
Spirometry (FEV1/FVC),
CXR (hyperinflation)
COPD
PATH:
• Irreversible airway obstruction
• Chronic bronchitis (cough/sputum on most
days for 3m of 2 consecutive years)
+
• Emphysema (enlarged or destroyed alveoli
walls)
RF: SMOKING!
COPD
SYM
• SOB (exertional)
• Cough (chronic)
• Sputum (regular)
• Wheeze
SIG
• Use of accessory breathing
muscles
• Hyperinflated chest
• Hyperresonant chest
INV
• Spirometry (FEV1/FVC, TLC,
bronchodilator response)
• FBC
• Chest X-ray
• ECG
COMP
• Acute exacerbation (infection)
• Polycythaemia
• RF
• Cor pulmonale
• Pneumothorax (bullae burst)
COPD Mx
•
•
•
-
Smoking cessation
Vaccination (pneumococcal, influenza)
Pulmonary Rehab
Exercise
Diet
Nutrition
• Mucolytic (e.g. n-acetylcystine)
• Depression Mx
COPD Mx
• Home nebs
• Steroids PO
• LT O2 therapy
Endo
Diabetes Mellitus (DM)
DEF
• Deficiency or diminished
effectiveness of endogenous
insulin
AE
• Type 2 DM
• Type 1 DM
• Gestational DM
• Secondary AE
- Pancreatic disease (CF, chronic
pancreatitis)
- Endocrine (Cushing’s,
acromegaly, thyrotoxicosis,
phaeochromocytoma)
- Drug-induced (thiazides,
corticosteroids)
- Genetic (haemochromatosis)
DM
DIAG
• SYM + Abnormal
Random/Fasting
• Abnormal Random + 2x
Abnormal Fasting
• Abnormal OGTT
• Abnormal HbA1c
Abnormal Random/OGTT
>=11.1mmol/L
Abnormal Fasting
>=7mmol/L
HbA1c >= 48mmol/mol
(65%)
T1 DM
PATH
• Any age (mainly paed)
• AUI destruction of beta-cells =
No insulin
AE
• Genetic predisposition (HLA
DR3/4) + AUI process (islet cell
Ab’s)
RF
• Caucasian
• Northern Europe
ASSOC
• Other AUI
PRES
[acute]
• Polyuria, Polydipsia
• Weight Loss
• Lethargy
• Recurrent/Prolonged
infections, Pruritus vulvae,
Boils
• Acute COMP (DKA, hypo)
Type 1 DM
INV
• HbA1c
• U+E, TFT, Lipid profile
• Urine albumin excretion,
Albumin:creatinine ratio
• C-peptide
• Coeliac serology
Mx
• Insulin
Self-Mx
1. Dose Adjustment for Normal
Eating (DAFNE)
2. X-PERT Programme
• Lifestyle Advice (diet, physical
activity, smoking cessation,
identification bracelet, DVLA)
• HbA1c goal
• Self-monitoring (fingerprick)
• Advice on Mx during illness,
and hypoglycaemia Mx
Type 1 DM
Mx Insulin
• Vary sites (lipodystrophy)
• Short (novorapid, humalog),
Intermediate (isophane,
aspart, lispro) and Long Acting
(glargine, detemir, degludec)
• Regimens:
- Twice-daily (long BD, prebreakfast + pre-evening)
- Basal-bolus (intermediate/late
+ short to cover meals)
- Continuous subcutaneous
insulin infusion (hypo’s OR
persistent HbA1c>8.5%)
Adult T1DM
1. Basal-bolus
(BD Insulin Detemir + Before
Meal Rapid-Acting Insulin)
2. Twice-Daily (mixed insulin)
Overweight = Metformin
Paeds/Young Adult T1DM
1. Basal-Bolus
2. CSII
T2 DM
PATH
• Adolescent and older (usually
>30yrs)
• Genetic predisposition + Lifestyle
• Impaired insulin resistance +
secretion
RF
• Obesity
• Lack of exercise
• Ethnicity (South Asia, Polynesian,
Afro-Caribbean)
• Hx Gestational DM
• FH
• Metabolic Syndrome
PRES
[subacute]
• Polyuria, Polydipsia
• Lethargy
• Recurrent/Prolonged infections,
Pruritus vulvae, Boils
T2 DM
Mx
• Lifestyle Advice (diet,
physical activity, smoking
cessation)
1. DESMOND
2. X-PERT
• Self-monitoring
• HbA1c monitoring (Aim for
6.5%)
• Pharma
1. Standard-Release
Metformin
2. + DPP-4 Inhibitor
(sitagliptin) / Pioglitazone /
Sulfonylurea
3. Triple therapy (e.g.
metformin + DPP-4i +
sulfonylurea)
4. Insulin (isophane
intermediate OD/BD +/short acting) + Metformin
T2 DM
Mx (cont.)
• Monitor BP
• Mx BP
1. A
2. Dual Therapy (A + C/D)
3. Triple (A + C + D)
[Afro-Carib 1st = dual
therapy]
•
•
•
•
•
Renal monitoring
Serum Lipids
Eye monitoring
Neuropathic pain
Feet monitoring
HbA1c
• Normal: 20-42 mmol/mol (4-6%)
• 3-6m monitoring until stable
• Aim 48 mmol/mol (6.5%) OR if
struggling 53 (7%)
CI = Interference by reducing lifespan of
RBC:
• Blood loss
• Haemolysis
• Haemogolbulinopathies
• Red cell disorders
• Myelodysplastic disease
DM Chronic Complications
Macrovascular
• CV Ischaemia (ACS, CVE,
peripheral vascular
disease)
Microvascular
• Nephropathy
• Retinopathy
• Neuropathy
• Diabetic Foot
Hyperthyroidism
AE
• Grave’s Disease (female,
middle-aged)
• Toxic nodular goitre
(>60yrs)
• Solitary thyroid nodule
• De Quervain’s thyroiditis
• Drugs (amiodarone, lithium,
exogenous thyroxine)
• Thyroid follicular Ca
• Ovarian teratoma
• Phaeochromocytoma
RF
• FH
• High iodine intake
• Smoking (thyroid eye
disease)
• Trauma/Surgery
• Childbirth
• AUI hx
Hyperthyroidism
SYM
• Weight Loss + Increased
Appetite
• Diarrhoea
• Sweating, Tremor
• Irritability
• Heat Intolerance
• Labile Emotions
• Oligo/amenorrhoea
• Proximal myopathy
SIG
• Palmar erythema
• Sweaty/warm hands
• Fine tremor
• Tachycardia (+/- AF)
• Hair thinning
• Lid lag
• Hypereflexia
• Goitre
• Thyroid eye disease
Thyroid Eye Disease
PATH
• Usually hyperthyroid,
Sometimes euthyroid,
hypothyroid
• Usually bilateral, can be
unilateral
SYM
• Ocular irritation
• Ache behind eye (morning)
• Red eyes
• Diplopia (restricted eye
movement in socket)
RF
• Smoking
SIG
• Proptosis (exophthalmos)
• Lid lag
• Conjunctival injection
• Chemosis
AE
• Grave’s
Grave’s Disease
PATH
• IgG TSH Ab’s:
1. Smooth thyroid
enlargement (diffuse
goitre)
2. Thyroxine production
• AUI personal/family hx
PRES
• SYM/SIG
Hyperthyroidism
• Thyroid eye disease
• Goitre
• Pretibial myxoedema
• Thyroid acropachy
(clubbing)
• Splenomegaly
Toxic Nodular Goitre
• Multinodular goitre +
Grave’s Disease PRES,
elderly
Solitary Thyroid Nodule
• Palpable, toxic
adenoma
De Quervain’s Thyroiditis
• Transient
hyperthyroidism,
hyperthyroidism PRES +
fever + neck pain
Hyperthyroidism
INV
• TFT (low TSH + high
T3/4 = Grave’s)
• Antibodies (Anti-TPO
Ab’s, Antithyroglobulin
Ab’s)
• CRP/ESR
• Thyroid USS
Mx
• Beta-blocker/CCB
1. Carbimazole (preg =
propylthiouracil) +/Thyroxine
2. Radio-iodine
3. Surgery
(thyroidectomy)
Hypothyroidism
AE
(primary)
• Iodine deficiency
• Autoimmune (Hashimoto’s,
atrophic)
• Drugs (amiodarone, lithium,
carbimazole)
• Iatrogenic (radio-iodine,
surgery)
• Postpartum thyroiditis
(secondary)
• Hypopituitarism
• Hypothalamic disorders
Hashimoto’s
• Painless goitre with rubbery
consistency and irregular
surface
• 60-70yrs
• Female
• AUI (Addison’s, pernicious
anaemia, T1DM)
PRES
[insidious onset, subtle,
nonspecific]
Hypothyroidism
SYM
• Lethargy
• Weight gain + Decreased
appetite
• Intolerance to cold
• Dry skin, hair loss
• Slowing of intellectual
ability
• Constipation
• Menorrhagia
SIG
• Dry coarse skin
• Cold peripheries
• Myxoedema (puffy face,
hands, feet)
• Reflexes relax slowly
• Bradycardia
Hypothyroidism
INV
• TFT (high TSH, low T3/4
= primary, low TSH +
low T3/4 = secondary)
• Antibodies (anti-TPO
ab’s, anti-thyroglobulin)
• Raised CK, cholesterol
• USS
Mx
• Levothyroxine (T4)
(lower dose = >50yrs,
cardiac disease, severe
hypothyroidism)
Hypothyroidism
COMP
• Myxoedema Coma
• Carpal tunnel syndrome
• Serositis (pleural,
pericardial, ascites)
• AKI
• Cardiomyopathy
• Intestinal obstruction
• Psychosis
Myxoedema Coma
• Elderly, high mortality!
• PREC: infection, stopping
thyroxine, MI, sedatives
• PRES: low GCS, seizure,
hypothermia
• Hypoventilation =
respiratory failure
• Mx = IV Levothyroxine +
Hydrocortisone
GI
Gastro-Oesophageal Reflux Disease
DEF
2 x dyspepsia episodes pw
RF
• Obesity
• Smoking/Alcohol
AE
• Hiatus Hernia
• LOS Hypotension
• Loss of Oesophageal Peristalsis
• Increased Gastric Acid
• Decreased Gastric Emptying
SYM
Dyspepsia
• Burning
• Retrosternal
• Increased by meals/lying
down/bending over/straining
• Decreased by antacids
Other SYM:
Acid Brash/Waterbrash
(regurgitation), Odynophagia,
Chronic Cough, Nocturnal Asthma
Gastro-Oesophageal Reflux Disease
M
• PPI (ST, then LT, switch individual drug if
necessary)
• H2 Antagonist (Ranitidine)
• Endoscopy (Barretts)
• Surgery (e.g. Lap Fundoplication)
COMP
Oesophagitis, Peptic Ulcer Disease, Benign
Oesophageal Stricture, Barretts Oesophagus
Helicobacter pylori
PATH
G-ve, curved spiral, produces urease, oral-oral, faecal-oral
Enters epithelial lining, ammonia from urease damaged epithelium
INV
1. C-13 Urea Breath Test OR Stool Antigen Tests
2. (retest for eradication) C-13 Urea Breath Test
M
PPI + Amoxicillin + Clarithromycin/Metronidazole (7d PO)
(repeat if unsuccessful)
COMP
Chronic Gastritis, Peptic Ulcer Disease, Upper GI Carcinoma
Coeliac Disease
PATH
• Immune-mediated, inflammatory,
systemic
• Genetic susceptibility (HLA
DQ2/DQ8)
• Gluten (prolamines) = wheat, rye,
barley
• Villous Atrophy = Malabsorption
RF
• FH
• Northern European
PRES (NICE, require serological
testing)
• Persistent unexplained GI SYM
• Faltering growth
• Prolonged fatigue
• Unexplained weight loss
• Severe/persistent mouth ulcers
• Unexplained Fe/B12/folate
deficiency
• T1DM
• AUI Thyroid disease
• IBS (adults only)
• 1st Degree FH
Coeliac Disease
SYM
• Diarrhoea
• Weight Loss
• Steatorrhea
• Abdominal Pain
• Bloating
• N+V
SIG
• Anaemia (Fe/B12)
• Aphthous ulcers
• Dermatitis Herpetiformis
COMP
• Metabolic Bone Disease
(OP, OM)
• Neurological (cerebellar
ataxia, peripheral
neuropathy, epilepsy)
• Hyposplenism
• Infertility
• T-cell Lymphoma
Coeliac Disease
INV
(test on gluten-containing diet,
retest serology if SYM persist)
1. Total IgA + IgA Tissue
Transglutaminase (tTG)
2. (if tTG weakly +ve) IgA
Endomysial Antibodies (EMA)
3. Endoscopy (biopsy =
histology: subtotal villous
atrophy)
Also:
• FBC (anaemia), B12, Ferritin,
Folate, LFT’s
M
• Lifelong strict gluten-free diet
(GFR)
Irritable Bowel Syndrome
PATH
• Relapsing functional bowel disorder
characterised by abdominal
pain/discomfort associated with
bowel habit.
• Possibly disturbed gastrointestinal
motility and enhanced pain
perception involved.
• Female. 20-30yrs.
• Can be grouped according to
predominant bowel habit: IBS-C
(constipation), IBS-D (diarrhoea), IBSM (mixed)
• IBS-D usually triggered after bout of
gastroenteritis
CRITERIA
>6m of one of:
• Abdominal pain/discomfort
• Bloating
• Change in bowel habit
OR
Abdominal pain relieved by defecation
OR associated with altered bowel
frequency OR stool form, AND >=2 of:
• Altered passage of stool (straining,
urgency, incomplete evacuation)
• Bloating, distension
• Symptoms aggravated by eating
• Rectal mucus
IBS
INV (do all if satisfy clinical
criteria)
• FBC
• ESR
• CRP
• Coeliac Screen
• CA 125 (women)
• Faecal Calprotectin
Mx
• Lifestyle (increase exercise,
regular meals, increase
fluids, decrease
fibre/alcohol/caffeine, low
FODMAP diet, probiotics)
• Symptomatic Pharma
- Diarrhoea = Loperamide
- Pain = Peppermint Oil,
Hyoscine
- Constipation = Laxative (not
lactulose)
- Amitriptyline
Crohn’s Disease
PATH
• Chronic relapsing and
remitting IBD
• Transmural granulomatous
inflammation with skip
lesions
• Any GI (ileum>colon)
• Extra-intestinal
manifestations
• Two Age Peaks: 15-30yrs >
50-70yrs
RF
• Family Hx
• Smoking
• URTI/Enteric Infection
• NSAID’s
PRES (relapsing remitting,
young)
• Diarrhoea (chronic, +/blood)
• Abdominal Pain
• Weight Loss
• Malaise, Anorexia, Fever
Crohn’s Disease
SIG
(acute): Hypotension,
Tachycardia, Pyrexia
(chronic):
• Fe Deficiency Anaemia
• Abdominal Distension,
Abdominal Mass
• Anal/Perianal Fistulae,
Abscess, Skin Tags
• Mouth Ulcers
Cutaneous:
• Clubbing
• Erythema Nodosum
• Pyoderma Gangrenosum
Ophthalmology:
• Conjunctivitis
• Episcleritis
• Iritis
Rheum:
• Large Joint Arthritis
• Sacroiliitis
Other:
• Fatty Liver
• Granulomata (skin, ENT,
abdomen)
Crohn’s Disease
INV
• Blood (FBC, U&E, LFT, CRP) CRP =
risk of remission/infection
• Serology (ASCA)
• Stool M+C
• Faecal Calprotectin
• Ileocolonoscopy + Biopsy
• Small Bowel Enema, CT OR MRI
Perianal = Pelvic MRI, EUA
Mx
(relapse)
1. Glucocorticoid (PO, topical, IV)
2. Mesalazine
+/- Azathioprine OR Mercaptopurine,
Methotrexate
(maintenance)
• Smoking cessation
• Azathioprine / Mercaptopurine
• Methotrexate
Surgery (if restricted to distal ileum)
Crohn’s Disease
Mx (cont.)
• Osteopenia monitoring
• Fistula’s = Metronidazole
• Loperamide (not during relapse)
• Elemental/Polymeric Diet
COMP
Bowel
• Strictures (-> obstruction)
• Fistulae
• Perforation, Acute Dilatation
• Colorectal Ca
Other
• OP
• Renal Disease (right ureter
obstruction)
• Fe/B12/Folate Def
• Gallstones, Renal Calculi
• Failure to Thrive (paed)
Ulcerative Colitis
PATH
• Idiopathic chronic relapsing and
remitting inflammatory disease of the
colon.
• +/- Extra-intestinal features
• Two age peaks: 15-25yrs > 55-65yrs
1. Proctitis
2. Proctosigmoiditis
3. Left-sided colitis (up to splenic
flexure = 40%)
4. Extensive Colitis (up to hepatic
flexure)
5. Pancolitis (whole colon = 20%, +/terminal ileum from incompetent
ileocaecal valve)
6. Backwash Ileitis
RF
• FH
• Crohn’s
[decreased risk in smokers!]
SYM
• Bloody Diarrhoea
• Abdominal Pain (colicky)
• Urgency/Tenesmus
• Constipation
(active) Malaise, Fever, W.loss
Ulcerative Colitis
SIG
• Pale, Fever, Dehydrated
• Tachycardia, Hypotension
• Abdominal Tenderness,
Distension, Mass
Cutaneous
• Erythema Nodosum
• Aphthous ulcers
• Pyoderma Gangrenosum
Ophthalmology
• Episcleritis
• Anterior Uveitis
Rheum
• Large Joint Arthritis
• Sacroiliitis
• Ankylosing Spondylitis
Other
• PSC
Ulcerative Colitis
INV
• Blood (FBC, U&E, LFT, ESR,
CRP, Folate, B12, Fe)
• Serology (pANCA)
• Faecal Calprotectin
• Stool Micro (C.difficile, CMV,
ova, parasite)
• Sigmoidoscopy (+ rectal
biopsy)
• AXR (exclude dilatation,
perforation) +/- USS/CT/MRI
• Colonoscopy (2x biopsies,
from 5 sites, incl. rectum and
distal ileum)
(flare) INV
• Bloods
• AXR (excl toxic megacolon)
Severity
• MILD: <4 stools/day (+/blood)
• MODERA TE: 4-6 stools/day,
more blood
• SEVERE: >=6 stools/day, visible
blood, 1x systemic feature
(fever, tachycardia, anaemia,
ESR>30)
Ulcerative Colitis
Mx
(relapse – mild/mod)
1. Mesalazine (suppository > both
> PO)
2. Corticosteroid (suppository >
PO)
(Prednisolone/Beclometasone)
(relapse-severe)
1. Ciclosporin IV OR Corticosteroid
IV OR Surgery
(maintenance)
1. Mesalazine PO
2. Azathioprine OR
Mercaptopurine
3. Surgery
Surgery (up to 30%)
• Colectomy = Curative
(restorative protocolectomy with
ileal pouch-anal anastomosis)
COMP
• Colorectal Ca (screening)
• Toxic Megacolon
• OP (optimise 5-ASA and
thiopurine Mx)
• Perforation
Renal
Chronic Kidney Disease
PATH
• Kidney damage (albuminuria) or
decreased function (GFR <
60ml/min per 1.73m2) for >3m
• Kidney failure = GFR < 15ml/min
OR need for dialysis/transplant
RF
•
•
•
•
•
•
•
Increasing age
CVD
DM
Obesity
Smoking
AKI
Proteinuria
AE
• Arteriopathic renal disease
• HTN
• Glomerulonephritis
• DM
• Infective, obstruction, reflux
nephropathies
• FH ESRF/CKD
• Hypercalcaemia
• Vasculitis (SLE)
• Myeloma
• Malignancy
CKD
PRES
• Asymptomatic
• Severe CKD -> anorexia, N+V,
peripheral neuropathy,
pruritus, peripheral oedema,
SOB, muscle cramps, sexual
dysfunction
• Very severe CKD: pericarditis,
seizures, coma
INV
• FBC (normocytic
normochromic anaemia)
• GFR, creatinine, urea
• U+E (hyperkalaemia, low
bicarbonate, high PO4,
secondary hyperPTH, high alk
phos = bone disease,
dyslipidaemia)
• Serology (Ab’s, hepatitis, HIV)
• Urine (dipstick, 24hr ACR,
electrophoresis)
• ECG/Echo (LVH)
• USS, XR, IV pyelogram, CT
Other evidence:
• Persistent microalbuminuria/proteinuria
• Persistent haematuria (after exclusion of other AE)
• Structural abnormalities on USS/XR (PKD, reflux nephropathy)
• Biopsy-proven chronic glomerulonephritis
CKD
Mx
• Mx AE
• Avoid nephrotoxic drugs, exercise,
stop smoking, weight loss
• GFR + ACR monitoring
• CVD prevention (conservative,
statins, folic acid, B12)
• BP control
• Stage 4 = monitor calcium, PTH, PO4,
vit D
• Hyperphosphataemia (diet, calcium
acetate (PO4 binder))
• Anaemia (EPO)
• Acidosis (oral sodium bicarbonate)
• Fluid overload (diet, loop diuretic)
• Renal replacement therapy
COMP
• Anaemia (LVH, anaemia)
• Coagulopathy
• HTN (LVH, HF, stroke)
• Renal osteodystrophy (osteitis fibrosa
cystica)
• Calcium phosphate loading (CVD,
CVE, arthropathy)
• Neuro (peripheral neuropathy,
uraemic encephalopathy)
• Dialysis amyloid (bone pain,
arthropathy)
• Fluid overload
• Malnutrition
MSK
Osteoarthritis
PATH
• Decreased proteoglycans
= decreased collagen
protection = cartilage
degeneration =
inflammation + bony
growth/remodelling
• Knees, Hips, Hand (DIP,
thumb CMC)
AE
• Primary
• Secondary
(haemochromatosis)
RF
• FH
• Increasing Age
• Female
• Obesity
• Joint injury, joint laxity,
joint malalignment,
occupational/recreational
joint stresses, reduced
muscle strength
OA
SYM
• Joint pain (exacerbated by
exercise, relieved by rest,
+/- rest/night pain, knee
is often bilateral, hip felt
in groin/thigh)
• Joint stiffness (morning,
after rest)
• Reduced function
SIG
• Periarticular tenderness
• Joint swelling/synovitis
(warmth, effusion)
• Bony swelling/deformity
(Heberdens and
Bouchards nodes)
• Reduced ROM
• Pain on movement
• Crepitus
• Joint instability
Osteoarthritis
=>45yrs + Activity-Related Joint
Pain + No/<30mins Morning
Stiffness = OA (no INV needed)
INV
• X-ray
1. Joint space narrowing
2. Subchondral cysts
3. Subchondral sclerosis
4. Osteophytes
• INV of exclusion (joint
aspiration, MRI)
Mx
• Education, advice, access
• Exercise +/- Physio +/- OT,
assistive devices (stick), insoles
• Weight loss advice
• Thermotherapy (local
cold/heat)
1. Paracetamol and/or Topical
NSAIDs
2. Oral NSAID
3. Opioid analgesic
• Corticosteroid Injection
• Surgery (joint replacement)
Rheumatoid Arthritis
PATH
• Chronic, systemic, inflammatory,
AUI, synovial joints, bilateral +
symmetrical, peripheral joints
• 1/3rd = seronegative
• Hands (MCP, PIP), Wrist, Feet
(MTP), Ankle, Knee, Cervical
Spine
Clinical Patterns
• Insidious symmetrical small joint
arthritis + systemic SYM
• Sudden onset, widespread
• Systemic, minimal joint
involvement
• Palindromic: moving, recurring
• Persistent monoarthritis
RF
• Female
• Smoking
• HLA DR4/DR1
SYM
• Arthritis (pain, red, warm,
morning stiffness > 1hr, reduced
ROM)
• Systemic (fatigue, fever, sweats)
Rheumatoid Arthritis
SIG
• Hand: Ulnar Deviation,
Swan Neck deformity,
Boutonnieres deformity, Z
deformity, MCP
subluxation, Wrist
Subluxation, Finger
flexion deformity
• Tenosynovitis, Bursitis
• Muscle wasting
• Tendon Rupture
Extra-articular
• Rheumatoid nodules
• Eyes (Sjogrens, scleritis)
• Skin (ulcers = Feltys
Syndrome)
• Resp (pleurisy, fibrosis)
• Neur (peripheral nerve
entrapment)
• CV (pericarditis,
pericardial effusion)
• Increased atherosclerosis
Rheumatoid Arthritis
INV
• Blood (raised ESR/CRP, anaemia,
thrombocytosis, mild AlkPhos/GGT
raise)
• Abs (ANA = 30% vs 10%, RhF = 70% vs
5%, Anti-CCP = 98%)
• X-ray
1. Soft tissue swelling
2. Periarticular osteopenia
3. Joint space narrowing
4. Bony erosions
5. Subluxation
Monitoring
• DAS28 (joint involvement, ESR,
patient satisfaction)
Mx
• Physio, OT, Podiatry, Psychological
• Analgesia (paracetamol, codeine)
• NSAID/COX-2 (ibuprofen, celecoxib) +
PPi
• Corticosteroid PO, intra-articular, IM
(start of Mx, flare)
1.
2.
3.
4.
•
Methotrexate + DMARD +
Corticosteroid (ST)
TNF inhibitor
Methotrexate + Rituximab
Methotrexate + TNFi
Surgery (SA/cervical myelopathy =
immediate, tendon rupture/carpal
tunnel = refer, deterioration/poor Mx
= refer)
Rheumatoid Arthritis
COMP
• Work/social life
impairment
• Depression
• Vasculitis
• Pleurisy, pleural
effusion, fibrosis
• Pericarditis, pericardial
effusion
• Felty’s Syndrome (leg
ulcers, splenomegaly,
low WCC)
• Carpal Tunnel
• Cervical Myelopathy
• Tendon Rupture
• OP
Osteoporosis
PATH
• Progressive systemic
skeletal disease
• Reduced bone mass +
Micro-architectural
deterioration of bone =
Low bone mineral
density (BMD)
• Susceptibility to
osteoporotic #
RF (OP #’s)
• Increasing age
• Female
• FH
• Hx OP #
• Corticosteroid Therapy
• Cushing’s Syndrome
• Alcohol
• Smoking
Osteoporosis
AE (OP)
• Inflammatory
arthropathy (RA)
• Prolonged
immobilisation
• Primary hypogonadism
• Primary
hyperparathryoidism
• Hyperthyroidism
• CKD
PRES
• Asymptomatic
• OP #
- Spine (vertebrae)
- Hip (proximal femur)
- Wrist (distal radius)
Osteoporosis
INV
• Blood Screen (FBC, ESR/CRP,
U+E, LFT, TFT, Ca, sex
hormones, immunoglobulins,
paraproteins)
• Dual-energy X-ray
absorptiometry (DEXA)
# Risk
• QFracture score (DEXA +
clinical factors)
OR
• FRAX
Mx
• Lifestyle (smoking cessation,
alcohol intake, weight-bearing
exercise)
• Calcium and/or Vitamin D
supplementation
• PHARMA (primary)
1. Bisphosphonates
(Alendronate)
2. Risedronate/Etidronate
3. Strontium Ranelate /
Raloxifene
Premature menopause = HRT