GENERAL SYMPTOMS SEEN IN GP LAND

*HAIR LOSS* - androgenetic alopecia - alopecia areata - tinea capitis - secondary syphilis - trichotillomania - chemotherapy

*ANDROGENETIC ALOPECIA* - the most common type of alopecia affecting 30% of men by age 30 and 50-70% by age 50 - loss of hair from the scalp: thinning of the hairline at the temples and vertex baldness - associated with genetics, cardiovascular disease, prostate cancer, diabetes/obesity (insulin resistance), PCOS; all associated with androgens. - manage with oral finasteride (5-a reductase inhibitor) or topical minoxidil. *ALOPECIA AREATA* - autoimmune disease causing smooth, rounded patches of hair loss. - associated with other autoimmune diseases e.g Hashimoto's, type 1 diabetes, coeliac disease, pernicious anaemia, SLE or RA. - spontaneous recovery within 6-12 months - initial treatment is *intradermal triamcinolone* steroid injections however; in <10yrs; minoxidil is used. *TINEA CAPITIS*: - similar bald spots to alopecia areata but they're *thickened, scaly and pruritic* - mostly seen in pre-pubertal children - treatment: oral griseofulvin *SECONDARY SYPHILIS* - patchy hair loss - Warthin-Starry stain confirms diagnosis of spirochaetes. - A positive FTA-ABS test confirms the diagnosis of secondary syphilis - penicillin G is treatment but note warning of Jarisch-Herxheimer reaction; manage this with NSAIDs. *TRICHOTILLOMANIA* - patchy hair loss due to hair pulling - patches of hair loss are ill-defined and the hair shafts may be of different lengths. The scalp, eyebrows, and eyelashes are common sites of hair pulling. - puberty is a common age of onset, F>M, follows an emotional event.

*LOWER GI BLEEDING* - the most common cause for bright rectal bleeding in <50yrs is anorectal disease ==> melaena: consider an upper GI bleed or caecum ==> maroon stool: right side of colon ==> bright red: left side of colon or massive upper GI bleed ==> bloody diarrhoea: infectious most likely

*ANGIODYSPLASIA* - 75% on the right colon - presents with black, tarry stool (melaena) - associated with advanced age (>60yrs), ESRD, von Willebrand disease and aortic stenosis. - colonoscopy or angiography required for confirmation *DIVERTICULOSIS* - advanced age, LLQ pain, fever (if diverticulitis) rectal bleed, diarrhoea/constipation *ULCERATIVE COLITIS* - bright red bleeding *INFECTIOUS DIARRHOEA* *HAEMORRHOIDS* and *ANAL FISSURES* - see anorectal diseases - anal fissures produce sharp pain on defecation like thrombosed hemorrhoids only that a lump is seen. *MESENTERIC ISCHAEMIA* *COLORECTAL CANCER* *COLORECTAL POLYPS* bright red bleeding: UC (in young patients), colorectal cancer, diverticular disease, haemorrhoids, anal fissures, angiodysplasia, management 1) ABCDEs: first aim is to stabilise 2) *colonoscopy* (can offer therapeutic interventions to stop the bleeding) or *CT angiogram* (good for active bleed). Otherwise a *radionuclide scan*. If melaena; perform an *endoscopy* 4) immediate laparotomy only if patient is unstable, bleeding in large amount and the source cannot be found.

🚑 *CHEST PAIN EMERGENCIES* - aortic dissection - NSTEMI - STEMI - acute pancreatitis - pulmonary embolism sign and symptoms for: acute MI: sudden retrosternal chest pain described as tight/pressing/squeezing, radiating to left arm/jaw, lasting 20 mins, associated with diaphoresis and dyspnoea and does NOT alleviate with nitroglycerin. It is severe enough to wake patient up at night - most commonly it occurs in the early hours of the morning. Silent in diabetics, elderly, post-op and women 💡 can I fly doctor? (caa.co.uk) - unstable angina: should not fly - complicated MI: 4-6 weeks - uncomplicated: 7 days - Well's score for PE: *DA* *HIP* *H*urts *M*e - 3 points each: *D*VT s/s, *A*lternative diagnosis unlikely - 1.5 points each: *H*R>100, *I*mmobilization >3 days or surgery in the last 4 weeks, *P*revious DVT/PE - 1 point: *H*aemoptysis, *M*alignancy

*AORTIC DISSECTION*: - similar presentation to acute MI however; the pain is more sharp/tearing and there will be nil ECG changes - causes: chronic HTN, coarctation, Marfan's syndrome, Ehler's-Danlos syndrome. - examination: *BP difference between both arms*, *weak pulses in lower limbs* - CXR: widened aorta, transoesphoageal U/S, CT. - worst complications: hypovolaemic shock, pericardial tamponade. - management: type A (1st 10cm): surgical intervention, type B (descending aorta): beta blockers and nitroprusside. *NSTEMI* - ECG: ST depression without new pathological Q waves. Differentiated from ST unstable angina by subsequent high enzyme level - initial management with GP: *MONA*: IV morphine (e.g. diamorphine), oxygen PRN if sats <94%, nitrate (GTN spray) and aspirin 300mg (or clopidogrel stat if allergic) + metoclopramide. Aspirin is continued for life afterwards. - if GRACE mortality risk is >1.5%: ===> add on *clopidogrel* 300mg loading dose - if GRACE mortality risk is <3%: ===> add *fondaparinux or LMWH* e.g. enoxaparin 1mg/kg bd SC which will help PREVENT further clot formation. - if GRACE mortality is >3%: ===> *coronary angiography +/- PCI* required within 96 hours or immediately if unstable and consider administering IV eptifibatide or tirofiban beforehand (NICE guidelines). *STEMI* - ECG: ST elevation later forming pathological Q waves or new LBBB - initial management: MONA - if within 2 hours, don't wait for troponin levels; discuss with cardiology for immediate primary PCI - If between 2 and 12 hours of symptom onset: give fibrinolytic therapy - if beyond 12 hours: PCI - if beyond 12 hours and there is still evidence of ischaemia give PCI *ACUTE PANCREATITIS* - can mask an inferior MI; acute epigastric pain that radiates to the back - nil ECG changes. *PULMONARY EMBOLISM* - acute SOB (80%), tachypnoea (55%), pleuritic chest pain (40%), tachycardia (25%), haemoptysis and fever (<5%) - ECG: acute RV overload in 40% - ABG: ↑PH,↓O2,↓pCO2 (respiratory alkalosis) - assess with Well's score (see left side) - management - start warfarin AND a LMWH or fondaparinux on the same day together for at least 5 days and until INR ≥ 2 for at least 24 hours). Continue warfarin for at least 3 months. Continue for 6 months if PE unprovoked and >12 months if recurrent PE/DVT and long term if AF present. - IVC for when anticoagulants are contraindicated

Foot Problems - Athlete's foot - Ingrown toenails - Plantar fasciitis - Bunions. ... - Corns - Blisters - Heel spur - Diabetic neuropathy. ... - gout -

*ATHLETE'S FOOT* - exposure to fungus in a gym, shower, or pool where people walk around barefoot - itching, cracking, blistering, and peeling of the feet. The condition usually starts between the fourth and fifth toes, then spreads. - advise to keep feet dry. To also try daktacort cream *INGROWN TOENAILS* - advise on wide fitting shoes, avoid cutting nails too short and keep them straight - soak the nail in warm water for 15 minutes then apply cotton wool underneath the nail. Do this approx 3-4x/day. - if all else fails: podiatrist referral - redness, swelling, pain, or even drainage from the toenail suggests infection: manage with either fusidic acid or flucloxacillin depending on patient choice/preference. *PLANTAR FASCIITIS* - pain in the heel; worse in the mornings after taking first steps. Generally worse with rest - options: paracetamol, NSAIDs, ice compresses, steroid injection *GOUT* - naproxen: initially 750 mg, then 250 mg every 8 hours until attack has passed. Alternatively, colchicine or tapered down prednisolone 20 mg - follow up in 4-6 weeks: allopurinol can be used for prophylaxis

*BODY ITCHING* - atopic dermatitis - psoriasis - scabies - polycythaemia vera - primary biliary cholangitis

*ATOPIC DERMATITIS*: - history of hay fever and asthma; usually present with dry, itching, bleeding, oozing, cracking, thickening of the skin - In patients < 2 years of age: it affects the face and extensor surfaces of the extremities but infants >2yrs: the flexures - Hanifin and Rajka criteria - consider infectious eczema: weeping lesions: manage with flucloxacillin or erythromycin. *CONTACT DERMATITIS*: - irritant or allergic - allergic: type IV hypersensitivity: 12-48 hours after exposure; papules, oedema, vesicles, itching. Patch test for confirmation. *PSORIASIS*: see dermatology *SCABIES*: see dermatology *POLYCYTHAEMIA VERA*: - myeloproliferative neoplasm - malignant clonal proliferation of haematopoietic stem cells leading to excessive erythrocyte production INDEPENDENT of erythropoietin - s/s: due to *hyperviscosity* - *pruritus/itching* (distinguishes it from other MPDs), headaches, dizziness, visual impairment, *thrombotic phenomena* - DVT, MI, unusual thrombosis e.g. portal vein thrombosis, *bleeding* - GI, ecchymoses, epistaxis, splenomegaly, hepatomegaly: - important to rule out secondary polycythaemia (e.g. CO poisoning, hypoxaemia from sleep apnoea, lung disease, long standing COPD. Also EPO producing tumours) - bloods: FBC (↑PCV - packed cell volume, ↑Hb>160, *↑Hct>50%*, ↑PLT, ↑leukocytes, ↓EPO, hyperuricaemia (may lead to gout). BM biopsy is confirmation. JAK2, KALR mutation screening tests with 90% genetic testing. - management: - repeated phlebotomies (lowers haematocrit, aspirin, chemo (lowers blood cell count), IFN-a - reduces rate of blood cells formation, allopurinol (prevent gout), BM transplant (for younger patients). *PRIMARY BILIARY CHOLANGITIS*: - F>M, autoimmune disorder - s/s: fatigue, *pruritus worse with bathing* and hyperpigmentation, *hepatosplenomegaly*. - as the bile ductules become destroyed; cholestasis develops leading to steatorrhoea (fatty stool) with deficiencies of fat soluble vitamin (A, D, E and K) - appears to be associated with Sjogren's syndrome: dry eyes and dry mouth. - bloods show ↑ALP, ↑direct bilirubin & ↑GGT + *↑antimitochondrial antibodies*. - *ursodeoxycholic acid* helps slow down the progression of disease - in advanced cirrhosis: liver transplant - antipruritic treatment includes: antihistamines, cholestyramine, rifampin and plasmapheresis

*HAEMATURIA* "bisto mnemonic" *B*PH *I*NFECTIONS: UTI, pyelonephritis, prostatitis *S*TONES *T*RAUMA: from catheterisations or surgery *O*THERS: bladder or renal cell cancer, glomerulonephritis, polycystic kidney disease, Alport's, sickle cell disease, coagulopathies note: if patient presents with erythrocytes of urine dip: follow up in 1-2 weeks for repeat urine dip: if microscopic haematuria still present and patient is >60; they need urgent referral for rigid cystoscopy + biopsy

*BENIGN PROSTATIC HYPERPLASIA - 1st line: tamsulosin 400 micrograms OD (α1-blocker); 1-2 week response. - alternative: finasteride: 5α-reductase inhibitors. Indicated when symptoms more severe, prostate is >30g or PSA >1.4. - TURP if medical treatment fails *INFECTIONS* - see "urinary frequency" section" *PROSTATITIS* - dysuria, fever/chills - treat with ciprofloxacin for 14 days *KIDNEY STONES* / *RENAL COLIC* - *calcium oxalate* (80%): most common and radio-opaque - *uric acid* (5-10%): stones are radiolucent (not visible on KUB); commonly caused by ingestion of purine rich foods. Advised to drink approx 3L/day otherwise IVI with potassium citrate. - *struvite stones* (5-10%) are potentiated by bacterial infection and can cause staghorn calculi located in the renal pelvis. Antibiotics required for 6 weeks. *Acetohydroxamic acid* helps with prevention. - suspected stones in the renal tract require CT scan as first line for review. - <5mm in diameter pass spontaneously in 75%: hydration and analgesia all that's needed - if <2cm: shockwave lithotripsy but not if febrile; refer to septic guidelines. - if >2cm: percutaneous nephrolithotomy - refer to hospital if: intractable pain and/or vomiting, fever (suggests infection), compromised renal function (including single kidney, bilateral obstructing stone) and pregnancy. CT abdomen primarily done to rule out hydronephrosis but also helps identify location of stone. - if septic; CT to rule out hydronephrosis, empirical ceftriaxone or ampicillin/gentamycin before an urgent decompression via ureteric stent (1st line) or perform percutaneous nephrostomy - prevention: hydration + *thiazides* (for calcium oxalate stones) or *potassium citrate* (uric acid/cystine stones), *acetohydroxamic acid* (struvite stones). *POLYCYSTIC KIDNEY DISEASE* - autosomal dominant - cysts arise from tubules throughout the nephrons but can occur also in other organs - both kidneys are always affected - typically ESRD by 5th-6th decade of life - s/s: abdominal/flank pain, gross haematuria, palpable bilateral flank masses in advanced cases - increased risk of mitral valve prolapse, intracranial berry aneurysms, colonic diverticula and nephrogenic diabetes insipidus. *BLADDER CELL CANCER* - majority are TCC - risks: M>F, >60yrs, smoking, carcinogen exposure, TZD anti-diabetic medication - s/s: painless haematuria (80-90%), urinary s/s (20%) +/- pelvic pain - investigate: rigid cystoscopy + biopsy - management: TURBT: for non-invasive ca followed with intravesical chemo/BCG or repeat resection in recurrent cases *RENAL CELL CANCER* - 10% present with classic triad of flank pain (40%), haematuria and a unilateral palpable flank mass - risk factors: smoking, M>F, Blacks, 50-70yrs, family history, analgesia overuse, HTN, long term dialysis *GLOMERULONEPHRITIS* ➖ *IgA nephropathy* (Berger disease) most common GN worldwide; young teen/adult with gross haematuria during or immediately after an URTI or GI infection ➖ *post-strep GN*: nephritic syndrome with haematuria ("cola coloured") 2-3 weeks after GAS tonsillopharyngitis or other infections, ↑antistreptolysin O titres. Generally resolves within a month. Rarely progresses to CKD. ➖ *Alport's*: x-linked dominant/boys with haematuria in infancy + sensorineural hearing loss and ocular signs ➖ *Goodpasture syndrome*: haemoptysis and haematuria; unlike Wegener's; isn't a vasculitis. Look for serum anti-GBM ➖ *Wegener's*: URTI + LRTI (haemoptysis) and haematuria (RPGN), c-ANCA in blood, granulomas on biopsy ➖ *microscopic polyangiitis*: like Wegener's but no granulomas or nasopharynx involvement ➖ *Churg-Strauss*: palpable purpura (skin involvement) differentiates it from the above vasculitis syndromes. Bloods: eosinophilia note: if patient presents with erythrocytes of urine dip: follow up in 1-2 weeks for repeat urine dip: if microscopic haematuria still present and patient is >60; they need urgent referral for rigid cystoscopy + biopsy

*WEIGHT LOSS* - ⚠️ be aware of superior mesenteric artery syndrome in anyone displaying rapid weight loss. This is when the AAA compresses on the duodenum and SMA leading to duodenal obstruction and thus epigastric pain (sharp, especially postprandial), nausea, vomiting and early satiety. AXR may show gastric distension but CT is modality of choice.

*CANCER*: history of unexplained weight loss in the last 6 months *HIV* *SUPERIOR MESENTERIC ARTERY SYNDROME* *HYPERTHYROIDISM* *ANOREXIA NERVOSA* *DEPRESSION* *MALNOURISHMENT* *MEDICATIONS*: metformin

*SHORTNESS OF BREATH (CHRONIC)

*CHRONIC ASTHMA* - episodic dyspnoea with wheezing and chest tightness; precipitated by environmental factors and improved with beta-2-agonists. - reduced FEV1/FVC for spirometry - differential is *VOCAL CORD DYSFUNCTION*: seen in young adults and managed with speech therapy. *COPD* - consider in older patients with history of smoking. - reduced air entry of examination - CXR shows hyper-inflation. *PNEUMONIA* - fever, productive cough, unilateral crackles - CXR: consolidation (if typical pneumonia) improvement with antibiotics. *BRONCHIECTASIS* (see haemoptysis) - s/s: productive cough, chronic dyspnoea, bibasal coarse crackles and clubbing. *IDIOPATHIC PULMONARY FIBROSIS* - chronic dyspnoea, fine bibasal crackles and clubbing in advanced cases *SARCOIDOSIS* - chronic dyspnoea, FINE bibasal crackles and clubbing in advanced cases *ATELECTASIS* - alveoli are deflated down to little or no volume leading to dyspnoea, chest pain, reduced air entry, dullness on percussion and increased vocal fremitus - most commonly after abdominal surgery. - manage: early ambulation, incentive spirometry, encourage to cough, vigorous physiotherapy to help expand the collapsed lung. If no success after 24 hours; flexible fibreoptic bronchoscopy. *ANGINA* - SOB and chest pain on exertion relieved with rest and/or GTN spray *CONGESTIVE HEART FAILURE* - raised JVP, peripheral oedema, bilateral crackles, history of ischaemic heart disease. *AORTIC STENOSIS* - systolic ejection murmur heard best @ 2nd ICS radiating to the carotids with pulsus parvus et tardus. - in older patients >70yrs: calcified valves. Younger patients <70yrs; most common cause is a *bicuspid valve*. Others: *rheumatic fever*. - exertional dyspnoea (due to LVH), chest discomfort, palpitations, fatigue, weakness, dizziness, syncope - if symptomatic: refer for aortic valve repair. or TAVR (transcatheter aortic valve replacement) if severe and patient has an increased risk of stroke. In children: balloon valvuloplasty due to the increased recurrency of stenosis in adults.

*BREAST PAIN* - cyclic - non-cyclic - extra-mammary

*CYCLICAL* - causes: fibrocystic breast changes, fibroadenoma, period related hormonal changes, HRT - most common in 2/3 cases of breast pain - usually bilateral (but can be unilateral) - in those actively menstruating (2 weeks prior menses) or using HRT - management: better fitting bra, soft-support bra during the night, paracetamol +/- NSAID gel. If first-line management fails: refer for consideration of tamoxifen or danazol. - note: the use of vitamin E, primrose, OCPs are useless according to studies. *NON CYCLICAL* - pregnancy - breast lumps: cysts, mastitis (fevers/chills, breast warmth, redness, swelling, and pain) - breast cancer: although doesn't typically cause pain. Always ask about about associated lumps, nipple discharge (bloody), retraction - mastitis: mostly in breast-feeding women - medication (contraceptives, antidepressants, antipsychotic drugs) - post-breast surgery *CHEST WALL* - costochondritis: can occur with arthritis. Arthritis in the neck or upper back can also lead to pain or numbness in the chest *OTHERS* - GORD, angina, rib fracture - chest/arm/back injury: ask about hobbies (e.g. rowing) and/or occupation

*HALLUCINATIONS* - delirium - substance abuse and medications - psychotic disorders e.g. schizophrenia, schizophreniform disorder and schizoaffective disorder - brain tumours or metastasis

*DELIRIUM* - moreso visual than auditory - suspect in older aged patients with risk factors: M>F, ↑age, nursing home residents (moreso than hospital), cognitive impairment/dementia, undergone surgery (anaesthetic effect, trauma, dehydration, opioids), anticholinergics *SUBSTANCE ABUSE* - hallucinogens e.g. LSD, ketamine, PCP - cocaine - chronic amphetamine use - ecstasy (but to a lower extent than hallucinogens) 💡 note: marijuana does not cause hallucinations *SCHIZOPHRENIA* - major depressive episode swings with mania or hypomania: occurring for >12 months (if less; considered schizophreniform disorder). - if combined with characteristics of bipolar disease: schizoaffective disorder.

*HIP PAIN* - developmental dysplasia of the hip - transient synovitis of the hip - Perthes' disease - slipped upper femoral epiphysis - avascular necrosis - femoroacetabular impingement - trochanteric bursitis

*DEVELOPMENTAL DYSPLASIA OF THE HIP* - *presents @ birth* - risks: *F*rank breech (most important), *F*emale (8x more!!) *F*amily history, *F*irst born, left hip, oligohydramnios - painless limp when starting to walk (9-12 months). Parents may notice leg length discrepancy, limp, trouble crawling/walking, waddling, and restricted ROM. - s/s: assessment of child at 6 weeks; affected leg shortened (results in asymmetry in skin folds), limited abduction angle of the flexed hip - examination: *Barlow's test*: checks if hips are dislocatable. *Ortolani test*: checks if hips are dislocated aiming to relocate hip back into position: palpable clunk will be felt if hip successfully reduced - if suspected, U/S to confirm. - management depends on the age => @ <6 months: pavlik harness in abduction and flexion => @ >6 months: closed reduction with GA, hip spica cast => @ > 2 years: open reduction *TRANSIENT SYNOVITIS OF THE HIP* - *2-10 years* of age with M>F commonly occurring after a viral infection. - hip +/- knee pain, refusal to weight bear, more common on the right side. There is full ROM and patient looks well. - x-ray: normal, bloods may show mildly elevated inflammatory markers, U/S may show effusion. - typically resolves in 7-10 days *PERTHES' DISEASE* - peaks *4-7 years* with M>F - pain in the hip/knee later forming limited ROM, bilateral in 10% cases; *due to idiopathic avascular necrosis of the femoral head* - XR: flattened head of femur, osteonecrosis*. If negative but clinical suspected; request MRI - all cases to be referred to orthopaedics. Manage with rest, bracing (and surgery ensuring the femoral head remains well seated in socket. - usually heals in 2-3 years *SLIPPED UPPER FEMORAL EPIPHYSIS* - peaks in puberty *teenage years*: M>F, typically obese, tall and underdeveloped children - chronic pain in the the *groin* and anterior thigh +/- knee pain progressing to a *limp*. Bilateral in 20% with L>R - examination: *positive Trendelenburg sign*. tenderness over joint capsule with reduced ROM . - XR shows "frog leg", posterior inferior displacement of the femoral head in relation to the neck. - management: surgery - complications: avascular necrosis, premature OA *AVASCULAR NECROSIS* - common complication with *sickle cell disease* typically manifesting in *pubertal/teenage* years of life. - always suspect in an African-American child presenting with groin pain and bone tenderness with no systemic symptoms. - s/s: subacute hip pain with lack of systemic symptoms are signs for avascular osteonecrosis, which occurs due to trabecular bone infarction from RBC sickling and vaso-occlusion. The femoral head is commonly affected as a result of poor collateral blood supply. *FEMOROACETABULAR IMPINGEMENT* - extra bone grows (bone spurs) along the hip joint causing friction eventually leading to pain and limited activity. S/S: gradual *anterolateral hip joint pain* exacerbated by pivoting laterally and sitting from standing. ==> physical exam: "FADIR test": flex, adduct then internally rotating the hip will reproduce the pain. *TROCHANTERIC BURSITIS* - lateral thigh pain and tenderness with no radiation down the leg. Worse when standing up and with abducting the hip against resistance.

*LOSS OF CONSCIOUSNESS* - epidural haematoma - subarachnoid haemorrhage - seizures - vasovagal syncope - orthostatic hypotension - cardiac syncope - severe hypoglycaemia - heat stroke

*EPIDURAL HAEMATOMA* - caused by trauma (e.g. contact sports) leading to middle meningeal artery laceration - consciousness lost transiently with CN palsy (eye "down and out") - CT shows lenticular (convex) deformity - management: emergency craniotomy for evacuation of clot but if patient is stable with GCS>8, no focal deficit and small clot/midline shift: admit for observations and serial CT scans. *SUBARACHNOID HAEMORRHAGE* - can be due to trauma, ruptured aneurysms, idiopathic or AVMs. - commonly occurs at older age though 20% cases @ <45yrs (think Emilia Clark whom has brain aneurysms and is at risk of SAH) - severe "thunderclap" headache, n/v, meningism, confusion, reducing consciousness - CT: *effacement of sulci and cisterns by hyperdense fluid.*. If result negative but high suspicion: LP, CTA (for aneurysms) - management: ICU, oxygen/ventilation, NBM, bed rest, elevate head at 30 degrees. Nimodipine is a calcium channel blocker helps narrow the blood vessels to slow bleeding. - complications: cerebral vasospasm, ischaemia, disability, death *PARTIAL SEIZURES* *simple* - aura/warning symptoms, - NO loss of consciousness or awareness and it usually lasts <1 minute. Can develop into complex. - sensory: numbing/tingling, motor: limb jerk, facial twitch, autonomic: blushing, nausea or psychic: deja vu, hallucinations (visual, sound, taste, smell) *complex* - consciousness and awareness altered unlike simple partial seizures GENERALISED SEIZURES *- absence/petit mal*: usually start in childhood; mistaken for daydreaming with no postictal period. The patient will resumes normal activity with no memory of the event. *- myoclonic*: v.brief <1 second muscle jerks often in the upper body. Consciousness unaffected *- tonic*: "drop attack": sudden brief stiffening of the muscles and falls rapidly *- atonic*: same as above but whole body flaccid *- tonic-clonic (*grand mal*): characteristic sudden loss of consciousness and stiffness --> fall then jerking (clonic). Often followed by a postictal period (confusion, drowsiness, nausea, etc). *reflex anoxic seizure* in children; they will often open their mouth as if they're going to cry, but make no sound before turning pale grey and losing consciousness. There may be jerking before regain of consciousness after 1 minute. Usually disappears by 4-5yrs - first line treatment for generalised seizures is lamotrigine - note: epilepsy is defined as at least 2 unprovoked seizure attacks *VASOVAGAL SYNCOPE*/NEUROCARDIOGENIC SYNCOPE: faint after the body overreacts to certain triggers; such as the sight of blood, prolonged standing, sitting/standing up suddenly or extreme emotional distress. - sudden drop in HR and BP resulting in temporal loss of blood supply to the brain. - pre-syncope symptoms are common: sweating, lightheadedness. This is later followed by syncope (collapse) +/- brief duration of jerking before a prompt recovery (note: seizures last much longer). - it is the most common cause of syncope in 50% of syncopal attacks. *ORTHOSTATIC HYPOTENSION*: - tends to affect *older people*, particularly >65yrs secondary to dehydration, medications, diabetes or neurological conditions - dizziness/collapse usually *occurs within minutes of standing* from a sitting position. - sustained drop of >20 systolic or >10 diastolic mmHg BP within 3 minutes of standing upright. *CARDIAC SYNCOPE*: - repeated episodes of fainting that come on *suddenly without warning or on exertion*. Patient *recovers instantly* and there is no post-ictal period. - common in older patients with ischaemic heart disease, arrhythmias and valve disease e.g. aortic stenosis. - consider also young patients with cardiomyopathy, arrhythmias or valve disease. *SEVERE HYPOGLYCAEMIA*: - prodromal symptoms (tachycardia, palpitations, sweating, tremors, agitation, confusion; all present before LOC; Immediate sugary beverage needs to be given for symptom reversal *HEAT STROKE* - vulnerable: children and elderly - mechanism: dehydrated enough to fail the sweating mechanism that helps cool the body. If they cannot sweat, their body temperature rises further - early s/s include lightheadedness, dizziness (hypotension), confusion (perhaps due to lost salt), *impaired sweating*, throbbing headache, etc - management: cool down methods and call 999 💡 note the difference with *heat exhaustion*: s/s: heavy sweating, rapid breathing, lightheadedness, fatigue, nausea, etc. Aim to get out the sun, cool down in a shower and rehydrate. *DELIRIUM TREMENS* - prodromal symptoms just like hypoglycaemia present before collapse if left untreated - occurs *within 24-72 hours of untreated alcohol withdrawal* in those with dependence. On examination; usually there's no sniff of alcohol. - manage with lorazepam stat then chlordiazepoxide detox regime.

*SMALL JOINT PAIN*

*GOUT* - typically rapid onset <24hrs with exquisite tenderness. 1st attack 1st MTPJ in 50-70%. - risks: previous attacks, male, >30, diet: ETOH, meats or seafood, obesity, thiazide diuretics and renal impairment. - joint aspiration is gold standard: *urate crystals: needle-shaped and negatively birefringent* (yellow under parallel light) - manage with rest, elevation, ice packs, NSAIDs (naproxen: initially 750 mg, then 250 mg every 8 hours until attack has passed.) +/- PPI cover or colchicine 500mcg 2-4x daily or taper down prednisolone 20 mg OD. - advise to return if symptoms worsen/do not resolve in 1-2 days for gout/pseudogout. Follow up with GP in 4-6 weeks after acute attack has resolved with review of starting allopurinol. Do not stop allopurinol if already on it. Do not start allopurinol if not on it. *PSORIATIC ARTHRITIS* - seronegative spondyloarthropathy seen in up to ⅓ of patients with psoriasis - primarily on hands, feet, spine (40%) - oligoarthritis (70% cases) - may also present with psoriasis, dactylitis, nail dystrophy and negative RF - manage: NSAIDs, DMARDs, physiotherapy *RHEUMATOID ARTHRITIS* - F>M, peak 50-70yrs, associated with specific HLA types (HLA-DR4, HLA-DR1) and triggered by environmental factors e.g. smoking, infection - DIP joints not typically affected - synovial hypertrophy leads to symmetrical pain, swelling, morning stiffness >30 min that improves with activity - joint deformities in advanced cases - other systemic s/s: low-grade fever, myalgia, malaise, night sweats, rheumatoid nodules, pleuritis, lung fibrosis, myocarditis, conjunctivitis, scleritis or episcleritis, anaemia, tenosynovitis, Raynaud's phenomenon - diagnostics: *anti-CCP* - management: NSAIDs, methotrexate (1st line for moderate cases), DMARDs, TNF-α *OSTEOARTHRITIS* - gradually progressive joint pain (dull/sharp) + stiffness worse with movement and in the evenings but improves with rest - *morning stiffness* is present, is of short duration (<30 minutes) - commonly *knees, hips and hands* are affected - risk factors:↑age, genetics (50-60%), obesity (for knee OA), female, previous trauma of the joint - management: appropriate footwear, exercise, paracetamol +/- NSAIDs +/- codeine, physiotherapy (improve mobility and ADLs) - topical therapies: diclofenac/ibuprofen gel, rosehip (anti-inflammatory oil), capsaicin cream (particularly useful for knee and hand osteoarthritis but it is expensive) - if severe osteoarthritis: intra-articular steroid injections. - surgery: e.g. total hip/knee replacement only if 〰️ severe pain, swelling and stiffness in the joint with reduced mobility 〰️ pain is so severe that it interferes with quality of life and sleep - everyday tasks, such as shopping or getting out of the bath, are difficult or impossible - feeling depressed because of the pain and lack of mobility - impairment on work/social life

*THYROID AND PARATHYROID ISSUES* - Hashimoto's disease - postpartum thyroiditis - hyperthyroidism - primary hyperparathyroidism

*HASHIMOTO'S DISEASE* - hypothyroidism: ↑TSH ↓T3/T4 - goitre, F>M, mid-age, autoimmune disease family history), iatrogenic (from radioiodine therapy, thyroidectomy, lithium), pituitary disease (secondary ↓TSH) or hypothalamic disease (tertiary ↓TRH) - anti-TPO in 90% - manage with levothyroxine 25mcg (if age>50 or cardiac disease) or 50-100mcg OD in healthy patients. Effect within 2-4 weeks, monitor TSH (if primary hypothyroidism) every 6-8 weeks and adjusting dose accordingly until stable. Once stable; measure blood levels every 6-12 months - complications: cardiovascular disease in the long term. Recurrence of symptoms that could worsen to confusion, drowsiness and hypothermia. *POSTPARTUM THYROIDITIS* - similar pathogenesis to Hashimotos. - affects 5% within a year of birth. - 1st its hyperthyroidism --> then hypo --> finally euthyroid. *HYPERTHYROIDISM* - ↓TSH, ↑T3/T4 caused commonly by Grave's disease (TSH receptor Ab, thyrotropin receptor autoantibodies (TRAbs), anti-TPO in 75% & ↑TPI) - specific symptoms for Grave's: goitre +/- bruit, exophthalmos and rarely pretibial myxoedema. - other causes: Plummers, toxic adenoma, subacute thyroiditis (painful, viral, rare), carcinoma, amiodarone/radiation induced. - secondary causes: gestational thyrotoxicosis (falling TSH in first trimester), TSH secreting pituitary adenoma, hCG secreting tumour, levothyroxine intake, ovarian tumour (extra-thyroid tissue) - if normal T3/T4: consider subclinical hyperthyroidism. - manage s/s with propanolol or Ca2+ blockers then carbimazole (or PTU if pregnant) till patient is euthyroid (4-8 weeks). Once euthyroid; give radio-iodine (3-6 months for effect). If they're pregnant or breastfeeding; thyroidectomy. - complications: thyroid storm (precipitating factor from infection, DNA or physical stress). - differential diagnosis: hypoglycaemia, panic/anxiety attacks, mania, stress, acute MI, Addison's disease (hypoglycaemia, mental s/s, hyperpigmentation), factitious disorder (ingesting thyroid medications to deliberate s/s). *PRIMARY HYPERPARATHYROIDISM* - ↑/normal PTH, ↑Ca2+, ↓PO4, ↑/normal ALP - 80% due to *adenoma* otherwise found in postmenopausal women and MEN1 syndrome - *most common cause for hypercalcaemia* - s/s: bones, stones, groans and psychological moans however, most patients are either just asymptomatic or have general weakness/fatigue 💡 secondary hyperparathyroidism is seen with CKD associated with excessive PTH secretion in response to hypocalcaemia - normal/↑Ca2+ and ↓PO4 💡 tertiary hyperparathyroidism (often in CKD), lithium, renal cell ca. - ↑Ca2+ and ↑PO4

*PAINFUL PERIODS/DYSMENORRHOEA* CHRONIC PELVIC PAIN *primary dysmenorrhea* - recurrent cramps lower abdominal pain *during menses* in the absence of demonstrable disease - normal due to wound muscle contraction *secondary dysmenorrhea*: - pain attributed to an underlying disorder e.g. PID, endometriosis, adenomyosis or fibroids *ask about* - ascertain age - acute/chronic pain? all the time or cyclic? - periods: last period? regular/irregular? heavy? - associated bleeding? is it breakthrough? taking any contraception or IUD within the first 3 months? - sex: sexually active? any pain? or bleeding after sex (post-coital) - thick/foul smelling vaginal discharge? fever? - vitals, abdominal +/- pelvic exam - urine dip, c&s + hcG test - vaginal swabs + culture if necessary - pelvic U/S, hysteroscopy note: *ACUTE PELVIC PAIN* - *acute appendicitis*: abdominal pain, fever, nausea, vomiting, etc - *ovarian torsion*: excruciating unilateral pain +/- adnexal mass on palpation. Usual associated symptoms; nausea, vomiting, low grade fever. Occurs in reproductive age. Other risk factors include: previous episode, ovulation induction, ovarian mass and pregnancy. - *ectopic pregnancy*: period of amenorrhoea followed by severe unilateral pelvic pain + shock (if rupture) . Rule out with hCG and transvaginal U/S. - *ruptured ovarian cyst*: can cause peritoneal signs + hypovolaemic shock - *tubo-ovarian abscess* - *vulvovaginitis* - *pelvic girdle ligament relaxation* in late pregnancy can cause pelvic + lower back pain worsening and lasting weeks

*IMPERFORATE HYMEN* - 💡think! an *adolescent/teenage* woman who presents with *cyclic period pain without having yet achieved menarche* should raise the suspicion of an imperforate hymen (without opening) - secondary sexual characteristics present - vaginal examination: *bulging, bluish tissue* approx 1cm inside the vaginal introitus *PRIMARY* - *normal period pain due to wound muscle contraction* (mediated by prostaglandin) that encourages the endometrial lining to shed away - usually diagnosed early in women who start their periods and is generally relieved with NSAIDs. - advise to reduce pain with exercise, warm bathes/showers, massage, NSAIDs (before onset of pain). If no response; offer the combined OCP. - you could also offer pyridoxine 50-100 mg daily for PMS (symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes.) *MITTELSCHMERZ/OVULATION PAIN* - physical examination normal - one sided iliac fossa mild pain sharp/cramping that *occurs @ time of ovulation*. *ENDOMETRIOSIS and ADENOMYOSIS* - already discussed above *FIBROIDS* - already discussed above; benign tumours - usually asymptomatic otherwise menorrhagia (heavy bleed >7 days), dysmenorrheaa (painful cramps), irregular periods, abnormal uterine bleeding +/- dyspareunia, frequency/urgency (if compressing on bladder); enlarged irregular uterus, *symptoms correlate just before a period* - pelvic U/S for diagnosis - management: NSAIDs, oral contraception are first line options; see above for more *PELVIC INFLAMMATORY DISEASE* - fever, dyspareunia, lower abdominal pain and abnormal foul smelling discharge - most commonly due to chlamydia or gonorrhoea; see above *VAGINAL CANCER* - more common in women >50yrs - pelvic discomfort and vaginal discharge *ENTEROCELE* - pelvic pain and/or pressure, which *worsens on standing or walking*, in the presence of posterior vaginal wall protrusion and lax sphincter tone on pelvic examination - posterior vaginal wall prolapse can either be an enterocele (upper 1/3rd of the posterior vaginal wall) or rectocele (middle 1/3rd of the posterior vaginal wall). Both can occur concurrently - common amongst the elderly, postmenopausal women, multiparity, prior pelvic surgery, and diabetes mellitus.

*CHRONIC DIARRHOEA* (>4 weeks) history: rule out red flags - unexplained weight loss - unexplained rectal bleed - persistent >2 weeks bloody diarrhoea - mass in the rectum, abdomen - severe abdominal pain investigations - check drug history: e.g. laxatives - *FBC (including B12, ferritin, folate), U&E, CRP/ESR and albumin, LFTs, HbA1c, TFTs - coeliac panel: *tTg-IgA*: especially if fatty diarrhoea - *stool ova, cysts and parasites*, if an infectious cause is suspected or there is a history of exotic foreign travel: 3 specimens @ 2 days apart from each other - *c.diff stool testing*: if recent hospitalization - *foecal calprotectin*: helps differentiates between IBS and IBD in people <40yrs. It should not be done when ruling out cancer or those with bloody diarrhoea - consider HIV testing - 2WW referral for colonoscopy (see below) ➖ aged >40 with unexplained weight loss and abdominal pain ➖ aged >50 with unexplained rectal bleeding ➖ aged >60 with iron deficiency anaemia or changes in bowel habit, or tests show occult blood in faeces.

*INFECTION* - clostridium difficile: suspect in previous hospitalized patients - raised inflammatory markers - treat with metronidazole (1st line in UK) or vancomycin (1st line in Canada) or fidaxomycin. - parasites, ova, cysts: amoebae, giardia, or cryptosporidium are suspected, particularly if persistent diarrhoea or travel to an at-risk area. *MEDICATIONS* - laxatives, antibiotics, antihypertensives (ACE-i), NSAIDs, metformin, gliptins, PPI therapy, SSRI, furosemide, etc *CYSTIC FIBROSIS* - bulky greasy stool *COELIAC DISEASE* - fatty/greasy stool, excessive wind, abdominal cramping/bloating, family history. - usually early childhood/young adulthood. - HLA-DQ2 serotype predisposition - dermatitis herpetiformis may present - serum IgA antibodies (anti-tTG) *LACTOSE INTOLERANCE* - s/s worse with dairy product intake *HYPERTHYROIDISM* *INFLAMMATORY BOWEL DISEASE* - young age, family history, bleeding, alternating bowel movements, abdominal pain, urgency with nocturnal diarrhoea *IBS*: diagnosis of exclusion: - recurrent central/LLQ abdominal pain/discomfort for >3 days/month for the last 3 months - symptoms *relieved by defecation* or associated with *altered bowel movements/frequency* + >2 of the following: bloating, straining, postprandial urgency and mucorrhoea *COLORECTAL CANCER* - advanced age, unintentional weight loss, alternating bowel movements and rectal bleeding - ask about family history - colonoscopy referral (see left) *DIVERTICULAR DISEASE* - advanced age, LLQ pain, fever (if diverticulitis) rectal bleeding, diarrhoea/constipation *CHRONIC PANCREATITIS* - fatty/greasy stool - elderly patient with alcoholism history *DIABETIC NEUROPATHY* - may present with nocturnal diarrhoea *OTHERS* - faecal incontinence - vitamin D deficiency - carcinoid syndrome

*ACUTE DIARRHOEA* definitions - acute (<2 weeks) - persistent (>2 weeks) - chronic (>4 weeks) when to send a faecal specimen for routine microbiology investigation? - systemically unwell - blood or pus in the stool. - immunocompromised. - recently received antibiotics, PPI or been in hospital: request specific testing for Clostridium difficile. - occurs after foreign travel — also request tests for ova, cysts, and parasites and state the countries visited on the form. - amoeba, giardia, or cryptosporidium are suspected, particularly if diarrhoea is persistent (2 weeks or more) - need to exclude infectious diarrhoea (for example severe abdominal pain, exacerbation of inflammatory bowel disease, or irritable bowel syndrome). - a public health indication: suspected food poisoning, in food handlers, healthcare workers, elderly residents in care homes general management - advise "SADE" habit control - loperamide is first line (unless bloated). Alternatively; codeine or co-phenotrope - specialised management for those who suffer despite initial management: refer to specialist continence service for pelvic floor muscle training, etc. "Mrs X presents to me today with a 3 day history of ongoing diarrhoea. She has about 4 episodes/day with no associated unintentional weight loss, nocturnal symptoms or blood. She however does have abdominal cramping. She has not started any new medications. There is no history of any recent hospitalizations or exotic travel however, her symptoms arose soon after a bbq at a friends house. Her boyfriend who also attended experienced similar symptoms. She denies any family history of bowel problems." taking history 1) how long? frequency? 2) blood? unintentional weight loss and/or nocturnal s/s 3) associated abdominal cramps, n/v, fevers/chills 4) recent exotic travel? ingestion of untreated water? 5) recent hospitalizations? 6) recent trips to restaurants, bbqs, etc 7) any close contacts with similar s/s 8) family hx of bowel problems 9) occupation: for public health purposes

*INFECTION* - norovirus is one of the most common organisms isolated, as well as sapovirus and rotavirus. Viral diarrhoea lasts approx 2-3 days. - *campylobacter*: most common secondary to undercooked poultry: foul smelling watery diarrhoea followed by bloody diarrhoea, abdominal cramps and high fever - *clostridium* (antibiotic overuse) - protozoan e.g. cryptosporidium (no blood/leukocytes), giardia (lakes/streams), entamoeba histolytica may cause persistent diarrhoea (>2 weeks) - taenia solium (pork) and taenia saginata (beef) cause cysticerosis - Diphyllobothrium latum found in Scandinavia and the Great Lakes can also cause vitamin B12 deficiency with megaloblastic anaemia. Ingestion of raw/uncooked fish. *DRUGS* - laxatives, allopurinol, angiotensin-II receptor blockers, antibiotics *FACTITIOUS DIARRHOEA* - psychological disorder whereby patients try to replicate symptoms (in this case taking laxatives) in order to gain sympathy and attention. - usually occurs in healthcare professionals. *FOOD ALLERGY* - *s.aureus* (exotoxin causes s/s quickly within hours of ingestion and resolve within 24-48 hours; vomiting major symptom after several hours of ingestion of improperly stored or heated foods containing high salt and or sugar) - *shigella*: bloody diarrhoea; can cause haemolytic uraemic syndrome - *salmonella* (eggs, poultry, affects the large bowel with watery diarrhoea, stool PH>5.5, leukocytes>10) - *e.coli*: improperly cooked hamburger meat - diarrhoea starts 3-4 days after ingestion and progresses to bloody diarrhoea. Lasts for a week. Can cause haemolytic uraemia syndrome - *bacillus cereus* (rice) - *clostridium* (antibiotic overuse) - *vibrio cholera* (contaminated water) - *vibrio vulnificus*: uncooked seafood: similar presentation to cholera with watery diarrhoea and abdominal pain. Pre-existing liver disease is a vulnerability; Treat with ciprofloxacin or doxycycline. - *rotavirus* (children), *norwalk virus* (travel) - *yersinia*: undercooked pork, RIF pain amoebae, cryptosporidium, protozoa should be suspected if diarrhoea persists >2 weeks or recent travel to an at-risk area. - *protozoa e.g. giardia* (campers drinking from lake/stream, etc: watery/secretory, malodorous, mushy, greasy stool, significant abdominal cramping, flatulence, faecal leukocytes<5, PH<5.5, treat with metronidazole. Advise to boil water before drinking. - *amoebae*: e.g. entamoeba histolytica: predominant in central and south America, Africa and Asia; cramping, watery/bloody diarrhoea and weight loss presenting for between 1-2 weeks. - *cryptosporidium*: no blood or leukocytes in stool. - *tapeworms*: taenia solium (pork) and taenia saginata (beef) cause cysticerosis. Fish tapeworm e.g. Diphyllobrothium latum found in Scandinavia and the Great Lakes can also cause vitamin B12 deficiency with megaloblastic anaemia. Ingestion of raw/uncooked fish. 🔷 *CLOSTRIDIUM DIFFICILE COLITIS* - recent course of antibiotics? Manage with metronidazole (1st line in UK) or vancomycin (1st line in Canada) or fidaxomycin. general management: - if history of exotic travel abroad or recurrent/ prolonged: request stool ova, cysts, and parasites and give details of travel. Send three specimens a minimum of 2 days apart. These tests are not part of the normal stool culture.

*SLEEP PROBLEMS* - insomnia - excessive daytime sleepiness: sleep apnoea, narcolepsy, poor sleep hygiene, sedatives, hypothyroidism, depression, alcohol, GORD, seizure disorder, restless leg syndrome

*INSOMNIA* - primary cases are psychological e.g. from recent divorce, anxiety - other causes: caffeine intake, antidepressants, steroids - talk about sleep hygiene: ⇢ comfortable sleeping environment ⇢ relaxation beforehand e.g. warm/hot bath ⇢ fixed times going to bed/waking up ⇢ avoid caffeine, nicotine, and alcohol within 6hrs of going to bed ⇢ avoid exercise within 4hrs of going to bed ⇢ avoid heavy meals late at night ⇢ avoid daytime napping. - CBT effective for primary cases (70% effective) - zopiclone: consider for short term use; but warn that it may reduce sleep quality - amitriptyline increases certain neurotransmitters like serotonin and norepinephrine to help improve mood, sleep, pain, and anxiety *NARCOLEPSY* *SLEEP APNOEA* - *complete apnoea:* 10 sec pause in breathing activity during sleep - *partial/hypopnoea:* 10 seconds in which there is continued breathing but ventilation is reduced by at least 50% from the previous baseline during sleep - identify a few s/s (tired/sleepy while driving, inability to work effectively may damage interpersonal relationships and social interactions) - risk factors: obesity, sedatives, alcohol, family history, diabetes, hypothyroidism and acromegaly. - use the Epworth Sleepworth scale to decide on whether to refer for sleep studies - investigate causes: TFTs, HbA1c, lipid profile. Also request FBC, U&E. - polysomnography* - measures no. of apnoeas/hypopnoea episodes/hr. Mild (5-14/hr), mod (15-30/hr), severe (>30/hr) - manage: nasal CPAP, dental appliances, surgery (e.g. uvulopalatopharyngoplasty) + lifestyle changes: weight reduction, avoidance of alcohol and caffeine. - if daytime sleepiness persists despite CPAP; offer modafinil. - differential: fragmented/sleep deprivation, depression, alcohol, drugs (sedatives, beta-blockers, SSRIs), hypothyroidism, narcolepsy (v.rare) and usually evident from childhood, idiopathic (with long sleep duration), anaemia *POOR SLEEP HYGIENE* - stress/anxiety, caffeine intake, blue light, primary insomnia

*ABDOMINAL PAIN* *RUQ* (right hypochondriac) ⇥ GI: acute cholangitis/cholecystitis, gallstones, hepatitis, liver abscess, hepatic porphyria, atypical acute appendicitis ⇥ renal: renal colic, pyelonephritis, trauma, ⇥ lung: right lower lobe pneumonia *EPIGASTRIC* ⇥ heart: *angina, ⚠️acute MI, aortic dissection/rupture, AAA* - see chest pain ⇥ gastrointestinal ⚠️ *acute pancreatitis*: severe onset; (commonly history of gallstones more commonly or alcohol use, pain relief leaning forward but worse after a meal, bruised umbilicus and flank, raised amylase and lipase). - *GORD, oesophagitis, gastritis* (tightness/burning central/epigastric pain exacerbated after meals, bending or lying down, +/- melaena, anaemia. Discuss lifestyle changes, reviewing precipitating medications, 24 hour PH monitoring and/or upper GI endoscopy (if suspected oesophagitis/gastritis). Generally, GORD is a clinical diagnosis and requires 1 month of PPI therapy. Always rule out *pregnancy* in young women because of the increased intra-abdominal pressure - *PUD*: dyspepsia s/s, main causes: H.pylori, NSAIDs, smoking, alcohol, stress. If suspected Zollinger Ellison syndrome; measure fasting gastrin levels to rule out gastrinoma. Formal diagnosis with endoscopy. - *pancreatic cancer*: African elderly smoker with unintentional weight loss, jaundice and severe pruritus, palpable gallbladder (30%), CA-19-9, CEA levels up. *HYPOGASTRIC* ⇥ urinary: UTI (positive urine dip), interstitial cystitis (ulcers), ⚠️ testicular torsion (acute, severe testicular swelling), urinary retention (distended) ⇥ gynaecology: ovarian cancer, endometriosis, PID, adenomyosis, fibroids (all associated with menorrhagia), period pain (primary dysmenorrhea) ⇥ obstretics: ⚠️placental abruption, miscarriage *RLQ/RIF* ⇥ if loin pain in a man >55yrs: ⚠️always rule out *AAA* or consider *renal colic, pyelonephritis, perinephric abscess or renal cell ca* ⇥ GI: ⚠️acute appendicitis, caecal obstruction, Crohns disease, mesenteric adenitis (common in children after viral/bacterial infection; CT shows enlarged mesenteric LN and ileocaecal wall thickening), hernias, IBS ⇥ gynaecology: ⚠️ectopic pregnancy, PID, miscarriage, ovarian torsion, ovarian cyst ⇥ urology: ⚠️testicular torsion, epididymitis, ureteric colic, UTI

*LUQ* (left hypochondriac) ⇥ spleen: *acute splenomegaly* (blood cancers), ⚠️*splenic rupture* (trauma), *splenic abscess*, ⇥ renal: renal colic, pyelonephritis ⇥ lung: left lower lobe pneumonia *EPIGASTRIC/CENTRAL* ⚠️*ischaemic colitis* (left moreso, consider age and history of AF), *bowel obstruction*. More commonly and milder pain includes ⚠️*bowel obstruction*: could be secondary to adhesions or gallstones ileus - *IBS, IBD, lactose intolerance, coeliac disease or gastroenteritis*: usually associated with diarrhoea +/- fever. Rule out with stool c&s, tTG (coeliac) and/or colonoscopy. - *chronic mesenteric ischaemia*: consider in age>60, W>M: postprandial abdominal pain associated with significant weight loss, food fear, nausea, vomiting, or diarrhoea - *sick cell anaemia* ⇥ gynaecology: *ovarian cancer, ectopic pregnancy, period pain* *LLQ/LIF* ⚠️ if loin pain in a man >55yrs: always rule out *AAA* or consider *renal colic, pyelonephritis, perinephric abscess or renal cell ca* ⇥ GI: *constipation, gastroenteritis, diverticulitis, UC, hernias, IBS, ⚠️sigmoid colon obstruction* (colorectal cancer or sigmoid volvulus; colon twists around mesentery; look for hx of chronic constipation, abdominal pain + distension and tympany without guarding or rebound; patient would need decompression via insertion of a rectal tube or colonoscopy followed by elective sigmoid colon surgery. Laxatives would be contraindicated), *proctitis* (inflammation of rectum leading to tenesmus and diarrhoea/rectal bleed. Due to STDs, IBD or radiation therapy). ⇥ gynaecology: *PID, ectopic pregnancy, miscarriage, ovarian cyst* ⇥ urology: *ureteric colic, ⚠️testicular torsion, epididymitis, UTI*

*NECK LESIONS/MASSES* (NICE CKS) history taking 1) site, onset, growth, and any changes 2) ⚠️ local malignancy red flags: *weight loss, dysphagia/odynophagia, persistent hoarseness, earache, sore throat, or haemoptysis*) and ask about smoking history considering age>40 3) ⚠️ haematological malignancy red flags: *fever, night sweats, weight loss, fatigue, generalized itching, breathlessness, bruising or bleeding, recurrent infections, bone pain*) 4) recent infections (particularly URTI), travel, pet exposure 5) history trauma 6) family history of endocrine tumours (MEN2) examination - observation and palpation of the neck - ears, nose and throat examination - skin in general: pallor, petechiae, or bruising (leukaemia); excoriation (lymphoma); generalized rash (adenovirus, CMV, EBV); or jaundice (CMV, EBV) - chest: lung cancer - abdomen for hepatosplenomegaly, and the axillae and groin for lymphadenopathy (if haematological malignancy is suspected). facts - likelihood of malignancy increases with age>40 years - children most likely to have reactive lymphadenopathy of cervical nodes - midline — thyroid swellings (isthmus), thyroglossal cyst, laryngeal swellings, submental lymph nodes, dermoid cysts - lateral (anterior triangle) — thyroid swellings (lobe), pharyngeal pouch, submandibular gland swelling, branchial cyst, lymph nodes (reactive, infective, or malignant), parotid swelling - lateral (posterior triangle) — lymph nodes (reactive or malignant), carotid artery aneurysm, carotid body tumour, cervical rib, lipoma

*MALIGNANCY* - consider in children: lymphomas (rubbery painless) and soft tissue sarcomas most likely - thyroid ca: papillary type most commonly (mid-age/female) solid irregular cystic mass with cervical lymphadenopathy. Slow growing and rarely metastasise. Other types: follicular (25%), lymphoma (5%), anaplastic and medullary (<5%) - nasopharyngeal cancer: consider in smokers; male 3:1, Asians with epistaxis, nasal obstruction, sensation of ear fullness and tinnitus, CN palsies (particularly V, VI) and multiple metastatic LNs. Diagnose with endoscopic biopsy - salivary gland cancers are more common in older people than in children. Most of these occur in the parotid gland but 80% are benign. Consider malignancy if pain, paraesthesia and/or facial nerve involvement. If there is a parotid or submandibular gland swelling that is persistent and unexplained, refer urgently within 2 weeks. Other causes: mumps. *SALIVARY GLAND LUMPS* - 80% benign but malignancy should be considered (see above) - infection of the salivary glands (sialadenitis) can result from stones causing swelling and tenderness particularly whilst eating. Other causes include bacterial (s.aureus), viral (mumps), TB, autoimmune (e.g. Sjogren's syndrome). *LYMPHADENOPATHY* - reactive LN most commonly secondary to an URTI: and are *tender to touch* - consider also glandular fever, HIV and bacterial causes: e.g. tonsillitis, strep pharyngitis - safetynet: seek medical advice if swelling persists or has grown >7 days (may be indicative of non-infective swelling or abscess formation). - if not resolved >2 weeks; refer to ENT - in people >40yrs with supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, consider urgent chest X-ray (within 2 weeks) - in people >45yrs with lymphadenopathy and unexplained hoarseness; consider laryngeal cancer; especially if a smoker *THYROID NODULE*: - if >1cm: perform thyroid function tests then refer to endocrinologist within 2 weeks for further investigations. Do not perform any other investigations in general practice. Re-assure that >95% of cases are benign. → If TSH low; thyroid ca is rare but refer to an endocrinologist as to perform thyroid scan. If hot nodule; closely observe but cold nodules (20% risk of malignancy) require FNA and biopsy. → if TSH normal; FNA +/- biopsy *GOITRE* - diffuse swelling in midline that moves upward with swallowing - associated with either Grave's disease or Hashimoto's *PHARYNGEAL POUCH* - in older men - large midline lump gurgles with swallowing - associated with dysphagia and bad breath *BENIGN LUMP* - lipoma (does not illuminate) - sebaceous cyst - reassure otherwise referral if surgical excision considered (for example for a sebaceous cyst that becomes recurrently infected) *CONGENITAL AND DEVELOPMENTAL LUMPS* - *thyroglossal cyst*: children, midline mass moving upward when tongue protruded - *branchial cyst*: present in early adult life as compressible painless, slow-growing, smooth, fluctuant swellings in the lateral neck but can become inflamed - *laryngocele*: intermittent neck swelling, which becomes palpable when the person performs the valsalva manoeuvre - *dermoid cyst*: midline @ suprasternal notch. Typically however in the upper outer corner of the orbit - *haemangioma* - *cystic hygroma*: in newborns, side of neck, transilluminates due to fluid - *cervical rib*: adult females *CAROTID ANEURYSM* - pulsatile lateral neck mass *TRAUMA* - haematoma, surgical emphysema, fibrosis *NECK ULCER* - if non-healing; rule out SCC with a punch biopsy. If confirmed; perform surgical excision with 6mm margin

*BREAST LUMPS / MASSES* *RED FLAGS* 🚩Hard, irregularly shaped lump 🚩Fixity of lump to skin or chest wall +/skin tethering 🚩Fixed axillary lymphadenopathy 🚩Bloody nipple discharge breast cancer screening (mammogram) is offered every 3 years for women age 50-70 1) age of patient + assess for red flags and if meets the criteria for referrals. 2) if no red flags: ask if any history of breast/ovarian ca, HRT, if breast feeding, when did they notice it? if they feel the mass more prior to menstruation; has it changed size? Topics - invasive ductal ca (painless lump, fixed) - inflammatory breast ca (everything associated) - Paget's disease (erythematous eczematous lesion of the nipple) - intraductal papilloma (blood stained nipple discharge) - fibroadenoma (painful, rubbery, mobile) - Phyllodes tumour (rapidly growing variant of fibroadenoma) - fibrocystic changes (tender, rubbery, irregular) - mastitis (fever, tender, swelling, redness, etc) - breast abscess (always lactating breast) - fat necrosis (minor trauma history) - others: sebaceous cyst, lipoma, galactocele referral dictation example "thank you for seeing this 31 year old lady who presents with a painless non-tender hard solitary lump in her right breast. I'd be grateful for further investigations to ascertain the cause"

*MALIGNANCY*: - invasive ductal carcinoma (80%) - more likely to occur after menopause - possible s/s: bloody nipple discharge, inverted nipple, skin changes (dimpling, rashes, ulceration), hard, irregularly shaped lumps with fixity - initial investigate for mammogram - U/S guided core needle biopsy required for diagnosis *2-week referral* 🔥 aged >30 with unexplained lump: refer for mammogram and/or U/S 🔥 aged >50 with any of the following in one nipple only: discharge, retraction or other changes of concern *consider (with risk factors) 2-week referral for*: 🕯️ age >30yrs with skin changes or an unexplained lump in the axilla *non-urgent referral* 🕯️ age <30yrs with an unexplained breast lump with or without pain (chances are it's just fibroadenoma). *INFLAMMATORY BREAST CANCER* - rare form of *advanced invasive breast ca* - breast tenderness, erythema and oedematous skin plaques overlying a rapidly growing breast mass, + axillary lymphadenopathy. There may be tenderness + blood tinged nipple discharge. - obstruction of the lymphatic vessels causes these symptoms resulting in localised lymphoedema. - requires chemotherapy + radiotherapy + radical mastectomy - differential: mastitis, Paget's disease, breast abscess *PAGET'S DISEASE OF THE BREAST* - rare adenocarcinoma usually infiltrating the nipple and areola - *erythematous, scaly, vesicular pruritic rash* affecting the nipple and areola - the lesion eventually ulcerates leading to a *blood-tinged nipple discharge* - differential: mammillary eczema *INTRADUCTAL PAPILLOMA* - solitary or multiple benign lesions that arise from the epithelium of breast ducts - peak incidence 40-50yrs - *most common cause of bloody nipple discharge* - if lesion palpable; requires core needle biopsy *FIBROADENOMA*: - *most common benign breast tumour in young women <35 years old*. - *painful, firm, round, smooth, highly mobile rubbery lumps* that may feel *tender especially prior to menstruation*. - mammogram: large and coarse popcorn calcifications. - biopsy: fibrous and glandular tissue overgrowth - may need referral for U/S guided FNA *FIBROCYSTIC CHANGES*: - most common benign lesion of the breast - occurs more commonly in *premenopausal women*. characterised by *tender, rubbery, irregularly shaped immobile lumps* - premenstrual bilateral breast pain - refer for U/S *MASTITIS*: (see obstetrics) - tender, firm, red, swollen, warm (inflamed area) of the breast, fever >38°C, flu-like symptoms, painful lump caused by a blocked duct - most common in lactating women *occurring within the first 6-12 weeks after giving birth* - management for lactating women: *warm compresses*, *warm water bathes*, to relieve pain and help milk to flow, rest, avoid wearing a bra at night, advise to *continue breastfeeding if possible* - treat: *flucloxacillin* 500 mg QDS for 10-14 days or *erythromycin/clarithromycin*; safe to use during pregnancy - warn patient to seek medical advice is s/s do not improve within 48 hours of antibiotics - if treatment fails, *consider breast abscess or cancer.* - management for NON-LACTATING women: as above except all women should receive *co-amoxiclav* 500/125 mg TDS for 10-14 days. Alternatively clarithromycin/erythromycin or metronidazole. *GALACTOCELE* - most common benign breast lesion in lactating women - painless, firm mass - mainly a clinical diagnosis otherwise refer for U/S *FAT NECROSIS* - associated with trauma (e.g. seatbelt injury) - rare, peaks @ 50yrs - irregularly defined mass with skin erythema - requires U/S for further evaluation *OTHERS* - *lipoma* (soft mass); non-infective mastitis Ask patient their age, history of breast/ovarian ca, HRT, if breast feeding, when did they notice it? if they feel the mass more prior to menstruation; has it changed size? - diagnostic mammography is usually preferred, but ultrasonography is more sensitive in women younger than 30 years

*DEMENTIA DIFFERENTIAL AND CONFUSIONAL STATES* - mild cognitive impairment - Alzheimer's disease - vascular dementia - dementia with lewy bodies - fronto-temporal dementia - Parkinson's dementia - normal pressure hydrocephalus - CJD prion disease - neurosyphilis - pseudo-dementia of depression others: - delirium - hepatic encephalopathy - encephalitis - brain tumour/mets - TTP - vitamin B3 (niacin) deficiency

*MILD COGNITIVE IMPAIRMENT* - deficits in memory that do not significantly impact daily functioning. Memory problems may be minimal/mild and hardly noticeable to the individual. *ALZHEIMERS DISEASE*: - most common: *age>65* due to deposition of *beta amyloid* plaques between neurons and tangles within them - follows course: - undetectable => short term memory loss => motor skills/language loss => long term memory loss --> disorientated => late stages: bed ridden => common causes of death are chest infections - CT/MRI head not conclusive (only biopsy is) will show *widening of the sulci*, *narrowing of gyri* and *larger ventricles* may be seen - only 4 qualified drugs in use => donepezil, galantamine, rivastigmine if mild/moderate => memantine if severe (≤18/30 MMSE) *VASCULAR DEMENTIA* - occurring *within 3 months* of a stroke. - relapse/remitting dementia. *DEMENTIA WITH LEWY BODIES*: (1) fluctuating attention/cognitive impairment (2) recurrent visual hallucinations (3) spontaneous Parkinsonian motor signs. Unlike Parkinson's disease; neurocognitive function comes earlier than motor problems. *FRONTOTEMPORAL DEMENTIA* (PICK'S) - more common in *mid-age* rather than elderly associated with *tau gene mutations*. - unlike Alzheimer's; you *first lose your sociableness*/altered personality... then you lose your memory. Insidious onset and slow progression. - identify in those with *personality changes, inappropriate behaviour (e.g. kissing strangers on the street) and overeating (particularly of sweet foods)*. They have an *intact cognitive function*. - faster progression compared to other dementias with patients surviving an average of 6-8yrs after symptom onset. - in later stages, parkinsonism is also common. *PARKINSONS DEMENTIA*: - dementia is a very late onset. In comparison to lewy body dementia; neurocognitive dysfunction comes 12 months after muscular problems. *NORMAL PRESSURE HYDROCEPHALUS*: - idiopathic impaired CSF absorption leading triad of *wet, wobbly, wacky* - *urinary incontinence, ataxia and dementia* develop over the course of weeks/months. - absence of papilloedema confirms CSF pressure is normal - CT: ventricular enlargement (like Alzheimer's). - management: *ventriculoperitoneal shunt drain* to remove CSF fluid to relieve symptoms. *CREUTZFELDT-JAKOB DISEASE*: - *rapid progressive mental deterioration*, aggressive *ataxia* and *myoclonic jerks*. - sporadic cases (95%) mostly in those aged >50. - MRI shows increased T2 and flair signal intensity in the *putamen and head of caudate*. *NEUROSYPHILIS*: - part of tertiary syphilis: may cause numbness/paraesthesia, meningitis, strokes, dementia, loss of coordination, numbness and vision problems years after onset of disease. *PSEUDODEMENTIA OF DEPRESSION* - a person may seem like they have dementia i.e. forgetting events but actually they just have poor attention due to depression over an event that has psychologically affected them. Other differentials: *DELIRIUM*: - acute confusional state fluctuating throughout the day. - attention is more a problem than memory*. - accompanied by irritability/aggression with delusions or paranoia - most commonly due to vision/hearing impairment, dehydration, drugs (anticholinergics), immobility, cognitive impairment, sleep deprivation and infections e.g. UTI, chest, neuro - ways to prevent delirium in hospitalised patients: repeated reorientation in those with cognitive impairment, early mobilisation, minimising unnecessary noise and sufficient hydration. *WERNICKE-KORSAKOFF SYNDROME*: - 2-3 weeks of vitamin B1/thiamine deficiency most commonly from chronic alcoholism leads to classic triad of *confusion, cerebellar ataxia and nystagmus*. Other symptoms include: ↓attention/concentration, ↓memory and peripheral oedema. - treat with pabrinex IV. - other causes: malnutrition, starvation (anorexia nervosa, schizophrenia), gastric malignancy, AIDS). *DELIRIUM TREMENS* - usually occurs 24-72 hours after last drink in those suffering with alcohol withdrawal. - if left untreated; rapid onset of confusion, tonic-clonic seizures, diaphoresis, agitation, tachycardia, hypertension. - manage acutely with oral lorazepam then maintainenance with diazepam/chlordiazepoxide (regime length depends on dependency). *HEPATIC ENCEPHALOPATHY* - delirium, confusion can progress to stupor or coma. - ammonia buildup *ENCEPHALITIS* - most commonly infectious; viral mainly e.g. HSV, VZV, MMR. Others include tick-borne, Japanese encephalitis or rabies - parenchymal involvement may lead to *low grade fever, seizures, altered mental status and focal neurological signs* (e.g. hemiparesis, ataxia, aphasia), memory loss, bizarre behaviour and weird hallucinations (PCR confirmation with CSF). - cerebral function is altered and there are no meningeal signs: very much unlike meningitis - always suspect this if a young person has symptoms suggestive of a stroke... but it can occur in any age. *BRAIN TUMOUR OR METS*: see headaches - the most common origins of brain metastasis in adult are lung cancer (50%) > breast cancer (15-20%) > melanoma (10%). *TTP (Thrombotic Thrombocytopenic Purpura)* - rare non-immune disorder in small vessels characterised by the pentad: mnemonic "Nasty Fever Ruined My Tubes": - N: fluctuating neurological s/s: e.g. confusion, headache, seizures - F - Fever - R - Renal involvement (↑creatinine, proteinuria, haematuria) - M - Microangiopathic haemolytic anaemia (e.g., ↓ Hb, ↑LDH, indirect hyperbilirubinemia, schistocytes) - T - Thrombocytopenia with bleeding manifestations (petechiae, bleeding gums, occult GI bleeding. Pregnancy is a known risk factor for TTP. - treat with plasmapheresis/plasma exchange. *PELLAGRA* - caused by VITAMIN B3/niacin deficiency: *pellagra*: - remember with the 4D's: 4 D's: diarrhoea, dermatitis, dementia, and/or death. - dermatitis in these patients usually presents as a symmetric rash with hyperpigmented skin lesions in the sun-exposed areas of skin - common causes include chronic alcohol use and carcinoid syndrome.

*GYNECOMASTIA* - idiopathic (approx 58%) - normal @ puberty - testicular cancer - hepatic cirrhosis - CKD - lung cancer - Klinefelter's syndrome - drugs: ketoconazole, anabolic steroids, tamoxifen

*NON-SEMINOMATOUS TESTICULAR CA*: - if male patient comes in with complaints about gynecomastia; the first thing is to ask + examine for lumps in the testicles or evidence of hypogonadism. Consider also an U/S - ↑alpha-fetoprotein, ↑hCG - orchiectomy most effective treatment followed by platinum based chemotherapy. - good prognosis

*SORE THROAT* - pharyngitis - acute tonsillitis - infectious mononucleosis (glandular fever) - peritonsillar abscess - epiglottitis - Kawasaki disease - drugs that cause neutropenia: carbimazole, clozapine, sulfasalazine, phenytoin or methotrexate. rarer causes of sore throat - diphtheria pharyngitis - herpangina - hand, foot and mouth disease - oropharyngeal cancer - Steven Johnson syndrome - Behcet's disease notes: 💡 Difflam™ Spray (fast acting sore throat relief) 💡 be wary of those on those DMARDs, carbimazole, antipsychotics, immunosuppressive drugs (following a transplant) which can cause neutropenia withhold the drug and perform immediate FBC. Discuss with specialist for further plan 💡 SAFETYNET! advise follow up if: - symptoms not improving or worsening after 3 days - if swallowing liquids become difficult - breathing difficulties - one sided neck/throat swelling ask 1) history of complaint: sore throat: for how long? any associated fever/chills, dysphagia, odynophagia, cough (for centor score). Determine severity: impact of ADLs, occupation, social activities. 2) past medical hx: medications: are they taking carbimazole, clozapine, sulfasalazine, phenytoin or methotrexate? 3) social hx: smoking hx (especially if persistent), alcohol 4) physical exam: check temperature, palpate for cervical LN, throat examination (ulcers, enlarged tonsils or erythema), ears & nose 5) determine management 6) safetynetting

*PHARYNGITIS and ACUTE TONSILLITIS*: ➖ viral is most common cause (rhinovirus, parainfluenza, influenza, coxsackie A, etc) - acute herpetic pharyngitis secondary to HSV-1 presenting with vesicles on the palate - glandular fever due to EBV (see below) ➖ bacterial: GABHS is the most common bacterial cause of pharyngitis, tonsillitis and scarlet fever and is bacterial causes are most common during winter and autumn - use the centor score: *C*ough absent, *E*xudate on tonsils, *N*odes: cervical lymphadenopathy, *T*emperature (>38). Score between 2-3 indicates likelihood of having to prescribe antibiotics (in Canada; you'd do the streptococcal antigen test). - if viral: re-assure self limiting; resolves within 2 weeks. Advise on simple paracetamol, NSAIDs and warm salt water gargling for sore throat relief - if bacterial: → phenoxymethylpenicillin 500mg QDS 10 days → macrolides: clarithromycin 250-500mg BD or erythromycin (if pregnant) 250-500mg QDS 5 days* are alternatives. - complications of streptococcal pharyngitis ➖ otitis media (most common) ➖ acute sinusitis ➖ peritonsillar abscess (quinsy) ➖ scarlet fever (skin rash from s.pyogenes) ➖ acute rheumatic fever (main concern) ➖ post-strep glomerulonephritis. *INFECTIOUS MONONUCLEOSIS* - also known as the kissing disease secondary to EBV: s/s: *sore throat >7 days*, pain with swallowing, severe fatigue that can persist for months, enlarged tonsils, cervical lymphadenopathy, splenomegaly, raised WBC, abnormal LFTs (liver function affected in 80%), jaundice (<10%), lethargy (months) - 80% have positive monospot test - do not give amoxicillin: it precipitates a maculopapular rash - treatment is conservative. Advise to refrain from contact sports for 4 weeks after onset of illness due to risk of splenic rupture. ⚠️ *PERITONSILLAR ABSCESS* - medical emergency occurring in adults more commonly: *sudden onset of severe, worsening sore throat, unilateral swelling behind the tonsil, dysphagia, trismus, "hot potato voice"* (muffled voice due to sore throat). Referral is same day; not within the week. If present, patient needs admission for incision and drainage + IV clindamycin and steroids. ⚠️ *RETROPHARYNGEAL ABSCESS* - severe sore throat not resolving after a few days. - trismus or visible neck swelling. ⚠️*EPIGLOTTITIS* - febrile patient with sore throat, muffled voice, and stridor with a background of incomplete vaccinations. - aim to keep patient calm and call an ambulance immediately. *HERPANGINA* - coxsackie A infection - acute onset of fever, sore throat, and dysphagia, vomiting and abdominal symptoms - small vesicles may be seen on the soft palate, fauces, palate, uvula, and tonsils, which rupture to become small white ulcers. - usually affects any child/teenager from 2yrs - most commonly occurs in the late summer and autumn. *HAND FOOT AND MOUTH* - high grade fever, malaise, loss of appetite, cough, abdominal pain and sore mouth that precede tender lesions in the mouth and/or vesicles on the palms of the hands and soles of the feet. - risks: children <4yrs, late summer and autumn *OROPHARYNGEAL CANCER* - hoarseness, dysphonia, sore throat, dysphagia, and neck mass or adenopathy. - ask about smoking history *BEHCET'S SYNDROME* - vesicles on pharynx, genital ulcers, skin and eye lesions STEVEN JOHNSON SYNDROME - vesicles on pharynx, along with more pronounced mucosal changes in a person with recent infections, seizures, or new medications.

*VAGINAL DISCHARGE* - physiological leucorrhoea - vulvovaginal candidiasis - bacterial vaginosis - chlamydia - gonorrhoea - trichomonas - if pregnant: onset of labour/PROM *VAGINAL DISCOMFORT* - Bartholin's cyst/abscess - vaginal prolapse - vaginal atrophy - lichen sclerosus - vaginal cancer - infections: vulvovaginal candidiasis, bacterial vaginosis, etc.

*PHYSIOLOGICAL LEUKORRHOEA* - non-purulent, no strong odour, not irritating - typically seen at the onset of puberty (due to a surge in the levels of oestrogen), around the time of ovulation (due to a peak in oestrogen levels), prior to menstruation (due to pelvic congestion), and during pregnancy. - occasionally, physiologic leukorrhea can occur during the early neonatal period (due to the influence of maternal hormones) *VULVOVAGINAL CANDIDIASIS* - s/s: *white cottage cheese discharge*, intense *pruritus*, stinging/soreness/burning during sex/peeing - risks: diabetes (most important), pregnancy, obesity, immunocompromised, OCP, antibiotics - investigate: usually clinical but wet mount test can be done: *pseudohyphae and spores* - management: ⚠️ *if pregnant: avoid ORAL antifungal therapies*. ↪ try *topical clotrimazole* 1% or 2% applied 2-3 times a day for 7-14 days and advise to come back if s/s persist. - if non-pregnant: you can give one-off dose of fluconazole 150mg ↪ *conservative management* - avoid soaps, cleanse with water only - dry the affected area after washing - wear cotton underwear, loose fit clothes - take showers instead of baths ↻ IF RECURRENT vulvovaginal candidiasis - be sure to obtain swabs; could the cause be bacterial instead? - urine dip +/- culture and sensitivity - an immune deficiency? diabetes/antibacterial therapy/pregnancy/OCP; be sure to check bloods - differential: vulvar lichen planus, chronic candidiasis, contact dermatitis, atrophic vaginitis, vaginal adenosis *BACTERIAL VAGINOSIS* - painless vaginal discharge: *thin watery white/grey discharge with a strong fish odour*. Rarely itching involved. - most commonly due to Gardnerella vaginalis (a gram-variable rod) - risks factors: vaginal douching (vaginal irrigation), soaps/shampoos in bath, improper drying of area, tight/occlusive clothing, IUD, multiple sexual partners, not using condoms - diagnosis: vaginal PH>4.5, *whiff test* (positive with fishy odour after addition of KOH), wet mount test (clue cells) - complications if pregnant: preterm labour, low birth weight, chorioamnionitis, late miscarriage - treatment ↪ oral *metronidazole* is first line: can also be used in pregnancy: 400mg BD for 5 to 7 days ↪ intravaginal *metronidazole gel 0.75%* once a day for 5 days (off-label for women aged less than 18 years), or intravaginal clindamycin cream 2%* once a day for 7 days. - complications: 2nd/3rd premature labour and birth, postpartum endometritis, PID (rarely) - differential diagnosis ➟ *bacterial*: grey, thin, watery discharge with fishy smell particularly after intercourse. Itching is rare. Whiff test positive, clue cells on microscopy. *CHLAMYDIA*: <refer to GUM clinic> - obligate intracellular organism - vaginal PH acidic, nucleic acid amplification (PCR) from vaginal swabs required for diagnosis - treatment options (🇬🇧 NICE guidelines) 💊 1st line: *doxycycline* 100mg BD for 7 days ⚠️ contraindicated in pregnancy and children 💊 2nd line: *azithromycin* 1g stat for 1 day, then 500mg OD for two days 💊 OR *erythromycin* 500mg BD for 10-14 days *GONORRHOEA* <refer to GUM clinic> - gram negative intracellular diplococci - *purulent creamy discharge* - can be detected by PCR but also gram stain - treatment (🇬🇧 NICE guidelines) 💊 1st line: IM ceftriaxone 1g single dose 💊 if pregnant: ceftriaxone 500mg IM + azithromycin 1g PO (like in Canada) 💊 2nd line: oral cefixime + azithromycin 🇨🇦 note in Canada - gonorrhoea and chlamydia treated with: => ceftriaxone 250mg IM + azithromycin 1g PO stat => OR doxycycline 100 mg PO bid x 7 d *TRICHOMONIASIS* (parasitic infection) - *foul smelling green/yellow discharge* - *itching*, soreness - dysuria, dyspareunia and abdominal pain. - vaginal PH>4.5, Whiff test positive, *strawberry cervix*, wet mount preparation shows flagellated protozoa - treat with metronidazole *PREGNANCY* RUPTURE OF THE MEMBRANES +/- LABOUR* - risk factors: prior PROM (most important), family history, infection: UTI, STD, smoking, illicit drugs e.g. cocaine, multiple gestation, low BMI, invasive procedure like amniocentesis - s/s: distinct "gush" or a steady flow of small amounts of watery fluid in the absence of steady uterine contractions (PROM) or in the presence of uterine contractions (labour). - pooling of fluid on speculum exam - PROM requires administration of ampicillin (risk of listeria) and betamethasone (if preterm). Monitor vitals and consider inducing labour; ideally @ term (>37 weeks). - if preterm: (24-33 weeks): consider tocolytic therapy (delays labour for up to 48 hours), betamethasone (accelerate prematurity) and ampicillin (GBS infection). *BARTHOLIN'S CYST/ABSCESS* - Bartholin's glands are found on the labia majora and secrete fluid that acts as a lubricant during sex. The fluid travels down ducts, into the vagina. If the ducts become blocked, they can fill with fluid and expand to form a cyst - usually affects sexually active women aged between 20 and 30yrs - s/s: soft pea-sized painless lump that may grow causing pain in the vulva when walking, sitting down or having sex. - management: soaking in warm water QDS + analgesia, warm compresses. If abscess: incision and insertion of a word catheter for drainage; helps cure problem permanently *VAGINAL PROLAPSE* - different types: cystocele, rectocele, enterocele and vault prolapse. - involves herniation of the peritoneal sac between the vagina and the surrounding organ. When the muscles and tissues supporting the pelvic organs (the uterus, bladder, or rectum) become weak or loose. This allows one or more of the pelvic organs to drop or press into or out of the vagina - risk factors: previous pelvic surgeries, multiparity, increasing age, obesity - s/s: *pulling sensation in the pelvis or low back pain that worsens in the evening but eases up when lying down*. A sensation of a mass bulging into the vagina. - caused by increased pressure on the pelvic floor e.g. pregnancy, childbirth, chronic constipation. - if asymptomatic; try pelvic floor muscles, vaginal pessaries, exercise, avoid smoking otherwise surgical repair. Other options: *VAGINAL ATROPHY* - common in peri/post-menopausal women complaining of *dyspareunia*. - manage with topical oestrogen cream - those with menopausal symptoms should be offered HRT. *LICHEN SCLEROSUS* - dyspareunia and *vaginal pruritus* in a postmenopausal woman with a *white vulvar plaque* on pelvic examination after vaginal cancer has been ruled out - after ruling out SCC (that lichen sclerosus increases the risk of) and confirming the diagnosis via biopsy; emollients, topical steroids (e.g. betamethasone or clobetasol), should be applied to help reduce the inflammation and itching. - differential: candida infection

*SECONDARY AMENORRHOEA* *no menses for >6 months OR 3 cycles after documented menarche* - pregnancy (most common cause of secondary amenorrhoea) - polycystic ovarian syndrome (40%) - hypothalamic dysfunction (35%) - pituitary disease (19%) - hypothyroidism - intrauterine system - Asherman's disease - menopause WORKUP 1) ascertain age, their LMP and differentiate primary from secondary amenorrhoea 2) ask: sexually active? any chance of pregnancy? taking contraception? 3) ask about lifestyle: athletic, stressful, diet 4) previous surgeries 5) calculate BMI 6) bloods: hCG, TSH, FSH/LH levels, prolactin, oestrogen, free testosterone, DHEA - ↓LH/↓FSH indicates a central cause. Consider lifestyle (stress, excessive exercise), anorexia nervosa, lactation, pituitary adenoma - ↑LH, ↑FSH*: peripheral (ovarian failure) or premature menopause. - ↑LH+FSH: in a 3:1 ratio: suggests PCOS: - workup: s/s indicating high androgens. Assess bloods (free testosterone, DHEA) and request pelvis U/S 7) pelvic U/S especially if suspecting polycystic ovarian syndrome or any other female reproductive pathology.

*PREGNANCY* - rule out with LMP question. If >3 weeks; hCG pregnancy test *POLYCYSTIC OVARIAN SYNDROME* - ↑LH/FSH: in a 3:1 ratio - usually detected in *late teenage* years - *oligomenorrhoea* (long >35 days periods) or *amenorrhoea* (no cycles for >6 months) - *high androgen levels* - testosterone (clinical symptoms of infertility, obesity, acne, hirsutism, male patterned baldness, *acanthosis nigricans*). Total testosterone levels should be repeated if initial test is negative; ideally done in the morning - *polycystic ovaries on USS* - *LH>FSH 3:1* - ↑risk of cardiovascular disease and endometrial cancer - management: 💎 *encourage weight loss/exercise* 💎 *OCP* (regulates menstruation and are first line) progestogens (induce a withdrawal bleed if oligomenorrhoea) 💎 *co-cyprindiol*: (reduces acne and hirsutism), 💎 *clomiphene* (induces ovulation and is 1st line for those who want to conceive 💎 *metformin*: (insulin sensitivity and infertility) *LIFESTYLE AND PSYCHIATRIC*: - *↓FSH, ↓LH levels suggest central cause* - stress, lactation, malabsorption, low BMI (e.g. excessive exercise weight loss, anorexia nervosa) are more likely causes - energy deficit suppresses the hypothalamic-pituitary-ovarian axis - if headache, visual field defects, diplopia present; obtain prolactin levels. If raised; refer to endocrinology. A hypothalamic or pituitary tumour must be ruled out. - those with suspected anorexia nervosa should be referred to a psychiatrist. - counselling on diet and exercise required for those with a low BMI. Leuprolide (GnRH agonist) injections can be given to trigger ovulation. - a DEXA scan should be ordered for those excessive athletic women or anorexia nervosa with amenorrhoea of >6 weeks due to risk of osteoporosis *PITUITARY ADENOMA* - see headaches - raised prolactin, galactorrhea, diplopia *HYPOTHYROIDISM* - bloods: ↑TSH, ↓T3, ↓T4 *INTRAUTERINE SYSTEM (IUS) e.g. Mirena coil* - makes *periods lighter, shorter or stop altogether/amenorrhoea (20% risk of amenorrhoea)* - indicated for heavy or painful periods. - spotting may occur for 6 months and periods may be erratic but gradually the menstrual flow should become lighter... approximately 20% of women experience complete amenorrhoea. *ASHERMAN'S DISEASE* - amenorrhoea secondary to *uterine adhesions* due to previous operations on the uterus - *oestrogen + progesterone response challenge shows no withdrawal bleed* indicating some form of outflow obstruction - direct treatment involves with *lysis with hysteroscopy* - recurrence risk is reduced by placing a *foley balloon catheter* and applying *hyaluronic acid gel* to keep the walls of the uterus separated. *HYPERPROLACTINAEMIA* - secondary to pituitary adenoma. - remember associated s/s of *headaches, bitemporal hemianopsia and galactorrhea* (excessive milk production) *PREMATURE OVARIAN FAILURE* - ovaries produce insufficient levels of oestrogen: 1/3 as a result from autoimmune disorders like Addison's disease, type 1 diabetes, Hashimoto's thyroiditis. - due to low oestrogen and thus higher risk of osteoporosis: these patients should be advised to have an adequate calcium (1,500mg/day) and vitamin D (400IU/day) intake. - classic triad of 💎 amenorrhoea 💎 ↑FSH, ↑LH 💎 ↓oestrogen *MENOPAUSE* - s/s: usually milder in obese patients - usually between 45-55yrs with confirmed >12 months of amenorrhoea - irregular periods (longer), hot flushes, headaches, insomnia, night sweats, anxiety, palpitations, vaginal tract atrophy, hair thinning, osteoporosis, weight gain - ovarian failure leads to reduced oestrogen and progesterone release; thus resulting in a decrease in negative feedback to the hypothalamus. This results in an increase in GnRH levels and subsequent *increase in FSH*. ❕hyperthyroidism may manifest similarly to some of these s/s: so add on TSH level as well as ↓oestrogen and ↓progesterone to confirm diagnosis of peri-menopause. - treatment 🔅 for atrophic vaginal symptoms: vaginal oestrogen creams, rings, or tablets 🔅 *hormonal replacement therapy* - if <50 years - HRT should be offered since the benefits far outweigh the risks ❕note: if between 50 and 60 years - the benefits of HRT outweigh the risks whilst >60 years: HRT risks tend to outweigh the benefits - oestrogen only therapy for those who've had a hysterectomy otherwise include progestin - risks: breast cancer, endometrial cancer, cardiovascular disease 🔅 *non-hormonal therapy*: alternative - to treat menopausal vasomotor symptoms when hormonal medications have been refused or contraindications exist with HRT. SERMs e.g. tamoxifen are good alternatives. Raloxifene is beneficial in those with an increased risk of breast cancer. The benefits include prevention of osteoporosis. Major risk if thromboembolism; of which they are contraindicated if there is a history. 🔅 *prevent osteoporosis*: smoking cessation, adequate vitamin D intake and regular weight-bearing exercise.

*POLYURIA* >2.5L-3L urine passed in 24 hours - UTI: urine dip: ↑nitrites, ↑leukocytes - diabetes mellitus: urine dip: ↑glucose - DKA: urine dip: ↑ketones - diabetes insipidus: ↓specific gravity 💡note: SIADH would present with oliguria and a urine dip showing ↑specific gravity - diuretics: urine dip: ↑Na+ - chronic kidney disease

*PRIMARY POLYDIPSIA*: - s/s: excessive thirst, intake of unusual amounts of water, polyuria - normovolaemic hyponatraemia - often have *underlying psychiatric disorder* - *water deprivation test* allows primary polydipsia to be differentiated from diabetes insipidus. Normal values of serum and urine osmolality after the water deprivation test indicate that both the release and effect of ADH are intact, ruling out diabetes insipidus and confirming the diagnosis of primary polydipsia. Urine osmolality increases after water deprivation unlike diabetes inspires *DIABETES INSIPIDUS* - polyuria, polydipsia, due to poor re-absorption of water from the collecting duct and distal tubules. *Hypernatraemia* will be present also. 🔹*CENTRAL*: damage to hypothalamus due to idiopathic, head injury, tumours, infections or sarcoidosis: ↓ADH - urine osmolality <300 (after fluid deprivation) increases to >800 after desmopressin test - treatment: *desmopressin* 🔹*NEPHROGENIC*: kidney doesn't respond to ADH; due to lithium or polycystic kidney disease - urine osmolality will show no change after desmopressin because the drug simply cannot act on the kidney receptors. - management: *thiazide* diuretics 🔹*GESTATIONAL*: placenta releases vasopressinase which breaks down ADH. Usually starts in week 8 getting worse throughout pregnancy. *CKD* ⚇ ↓GFR stimulates RAA causing volume overload ⚇ ↓electrolyte clearance causing ↑K+, ↑H+, ↑Mg2+ and ↑phosphate ⚇ uraemia: GI s/s, reduced immunity, CNS s/s ⚇ normocytic normochromic anaemia - management: correct and avoid risks of complications e.g. calcium and vitamin D to prevent secondary hyperparathyroidism. Dialysis and transplant if necessary

*ANORECTAL DISEASE* - proctitis - internal haemorrhoids - external haemorrhoids - anal fissures - anorectal abscess - anal fistula - pilonidal disease - rectal prolapse - the most common cause for bright rectal bleeding in <50yrs is anorectal disease - note: if a CT angio fails to identify source of bleeding; colonoscopy is required.

*PROCTITIS* - inflammation of the anus; - s/s: anal pain while defecating, rectal bleed, tenesmus and constipation. Physical: extreme tenderness with PR. Diagnosis made with colonoscopy and management includes: sitz baths, stool softeners, antispasmodics and antibiotics. *INTERNAL HAEMORRHOIDS*: painless rectal bleeding, mucus discharge, pruritus, ◆ 1st degree: bleed but *do not prolapse* => treatment: *high fibre/bulk diet/fluid intake, sitz baths, steroid cream, parmoxine* (Anusol®) ◆ 2nd degree: bleed, *prolapse with straining but spontaneously reduce*. Can cause perianal itching and irritation => treatment: *rubber band ligation*, and photocoagulation ◆ 3rd degree: bleed, prolapse, *requires manual reduction*. Can cause perianal itching and irritation => treatment: same as 2nd degree, but may require *closed haemorrhoidectomy* ◆ 4th degree: bleed, *permanently prolapsed, and cannot be manually reduced*. Can cause perianal itching and irritation => treatment: refer for urgent surgical review <be cautious over the rubber band ligation procedure: its most feared complication is necrotising pelvic sepsis occurring 1-2 weeks after surgery and is characterised by severe pain, urinary retention and fever> *EXTERNAL HAEMORRHOIDS* - pain after bowel movement. Associated with poor hygiene. Unlike internal haemorrhoids; they can present with acute thrombosis with severe sharp pain peaking at 72 hours. => conservative management: ↑fluids, ↑fibre/bulk diet, sitz baths, stool softeners (e.g. docusate), steroid cream, parmoxine (Anusol®). Try Xyloproct rectal ointment (contains hydrocortisone and lidocaine). => prevention: avoid straining/sitting too long in the toilet, avoid strenuous weight lifting exercises => refer to colorectal surgeon if change in bowel habit, tenesmus symptoms, abdominal pain or other lower gastrointestinal tract symptoms. Refer also if unable to assess with proctoscope. => if thromboses (very painful): they should resolve within 2 weeks leaving a perianal skin tag, Consider surgery within 48 hours of presentation. *ANAL FISSURES* - acute fissure: very painful bright red bleeding especially after bowel movement - causes: tear of anal canal secondary to irritant diarrhoea stools, large hard stools, nervousness. Others: IBD. - initial treatment is conservative: ↑fibre, ↑fluids, analgesia, shallow warm baths, stool softeners, sitz baths* (heals 90%). If pain extreme: *lidocaine 5% ointment. If ongoing for >1 week; try rectal *GTN 0.4% ointment* BD for 6-8 weeks - usually anal fissures resolve within 6-8 weeks - if unhealed/chronic (>6 weeks): same as above + try 2nd course of GTN or refer for lateral internal anal sphinterectomy. If symptomatic: try *diltiazem 2%* or refer. *ANORECTAL ABSCESS* - throbbing pain, worse with straining, tender mass - manage with *incision and drainage* +/- antibiotics - if recurrent; associated with Crohn's disease *ANAL FISTULA* - manage with fistulotomy: Post op: sitz baths, irrigation, and packing to ensure healing proceeds from inside to outside *PILONIDAL DISEASE* - cyst or abscess near or on the intergluteal cleft of the sacrococcygeal area containing hair and skin debris - commonly young men @ 15-35 yr age associated with occupations that require prolonged sitting, obesity, and high amounts of body hair - s/s: asymptomatic otherwise chronic itch - I&D for acute abscess otherwise pilonidal cystotomy *RECTAL PROLAPSE* - hernia of the rectum through the floor of the pelvis - risk factors: elderly women, prior pelvic surgery, neurological damage, psychiatric disorder affecting motility - s/s: persistent dull perianal pain, difficulty with bowel regulation: (tenesmus, constipation, faecal incontinence) - management ==> if just protrusion of mucosa (type 1) only (most common in children: gentle manual reduction of prolapsed area. Adults would need mucosectomy ==> if just type 2: surgery

🚑 *SHORTNESS OF BREATH (ACUTE)* management in GP practice 1) sit up 2) oxygen: aim sats >94% usually or 88-92% if T2RF COPD (only use 28% venturi mask at 4L/min for COPD patients, neuromuscular disorder at risk of T2RF. If sats<88%; use simple face mask >5L) 3) initial treatment of suspected disease (see above) whilst calling an ambulance

*PULMONARY EMBOLISM* - SOB (in 80%), sharp pleuritic pain, tachypnoea, tachycardia +/- haemoptysis *ACUTE PULMONARY OEDEMA* - give oxygen, IV furosemide, diamorphine, metoclopramide, GTN spray initially and monitor *ACUTE MI/ACS: see chest pain - retrosternal radiating to jaw and left arm; worse with exertion - stat dose of MONA: morphine, oxygen, nitrate and aspirin 300mg. If confirmed ACS; add clopidogrel/prasugrel or ticagrelor and s/c LMWH e.g. enoxaparin. - call for blue light ambulance *ANAPHYLAXIS*: - acute SOB, wheezing, chest pain, urticarial rash, flushing: responsive to epinephrine, hydrocortisone and chlorpheniramine . *ASTHMA/COPD EXACERBATION*: - wheezing responsive to beta2-agonist inhalation. - if infection involved; fever, productive cough and unilateral crackles. *PNEUMOTHORAX*: - identify with reduced air entry in one lung on auscultation *PANIC ATTACKS* - intense fear, chest pain, palpitations, tachycardia. - tests are all normal

*ABDOMINAL FLANK PAIN* - renal colic - pyelonephritis

*RENAL COLIC* - peak incidence @ 35-45yrs - sudden, colicky pain radiating from the flank to the lumbar region, vomiting, low grade fever. - often seen constantly moving unable to find comfortable position - risk factors: M>F, family history, mid-age - modifiable risks: dehydration, ↑protein, ↑salt, ↑sugar diet, ↑oxalates (tea, coffee, beer, chocolate, green leafy vegetable), obesity, digestive disease and surgeries, taking furosemide, etc - initial investigation: *urine dip*: microscopic haematuria - *spiral CT scan* required as first line for review in A&E: identifies location and helps rule out hydronephrosis. ➖ <5mm in diameter pass spontaneously in 75%: hydration and analgesia all that's needed ➖ <2cm: *shockwave lithotripsy* unless febrile; refer to septic guidelines. If shockwave lithotripsy fails; use percutaneous nephrolithotomy. ➖ >2cm: *percutaneous nephrolithotomy* - other methods of investigation: retrograde pyelogram: definite diagnosis - refer to hospital if: intractable pain and/or vomiting, fever (suggests infection), compromised renal function (including single kidney, bilateral obstructing stone) and pregnancy. - ⚠️ if septic: empirical ceftriaxone or ampicillin/gentamycin before an urgent decompression via ureteric stent (1st line) or perform percutaneous nephrostomy - prevention: hydration + *thiazides* (for calcium oxalate stones) or *potassium citrate* (uric acid/cystine stones), *acetohydroxamic acid* (struvite stones). *PYELONEPHRITIS*: - fever/chills, n/v, unilateral *mild/dull* flank pain, costovertebral angle tenderness. - *tend to lie very still as opposed to colic* - treat in outpatient if not septic; empirically with ciprofloxacin 500mg BD for 7 days or co-amoxiclav 625mg TDS for 7 days until MSU c&s result come back. - if pregnant; manage with cephalexin. - safetynetting: if s/s do not improve or become worse within 24 hours; attend A&E *HERPES ZOSTER* - burning band like pain across the dermatome - characteristic vesicular rash - manage with acyclovir *MUSCLE STRAIN* - dull/aching thoracolumbar pain with history of heavy lifting or repetitive bending

*TREMORS*: ripe mnemonic - rest - intentional - postural - essential

*REST TREMOR*: - often seen in Parkinson's disease - moving the limb makes the tremor vanish/disappear but stress/anxiety makes it worse - other symptoms include: rigidity, slowness, cogwheel movements, shuffling gait. - note dementia is only a late sign *INTENTION TREMOR* - shaking when approaching the target e.g. stretching hand out then reaching for nose; tremor is more pronounced when attempting to reach the target. - commonly seen in multiple sclerosis or cerebellar disease *POSTURAL TREMOR* - tremor noticeable when holding arms stretched against gravity - indicative of cerebellar pathology *ESSENTIAL TREMOR*: - tremor that's more pronounced with activity improving with rest - e.g. tremor when reaching for a glass of water, difficulty writing - causes: family history - manage with primidone (older patients) or propanolol (younger patients).

*APPROACHING A PATIENT WITH BACK PAIN* referral when: **** they have neurological features of cauda equina syndrome or cord compression *** they develop progressive neurological deficit (weakness, anaesthesia) *** nerve root pain not resolving after 6 weeks: perform routine bloods including U&E, haematinics and Mg2+. ** suspected underlying inflammatory disorder such as ankylosing spondylitis ** simple back pain and have not resumed their normal activities in 3 months. The effects of pain will vary and could include reduced quality of life, functional capacity, independence or psychological well-being. Where possible, referral should be to a multidisciplinary back pain team + they develop a serious unwanted effect from drug therapy

*SOCRATES*: - cervical: rule out recent trauma and in particular; spinal fracture. With whiplash; there is not much you can do aside from physiotherapy. - thoracic: rule out acute pancreatitis, acute MI, AAA rupture, aortic dissection, PUD as well as cord compression especially in older patients - lumbar pain: red flags: cord compression, cauda equina, abscess/infection, cancer. Others to consider: herniation (positive SLR and dorsiflexion), stenosis (relief bending forward, worse with walking), compression fracture (sudden onset, elderly) optional to ask: occupation/hobbies ❗️*history of *trauma*: - if yes and major; call ambulance, send to A&E with immobilisation and x-ray. - If minor; refer to A&E to rule out fracture if (history of trauma, osteoporosis, aged>55, c-spine midline tenderness) --> send to A&E for x-ray. Otherwise; whiplash injury. - rule out cord compression/cauda equina: with bilateral limb weakness/bladder or bowel dysfunction/difficulty walking. ❗️*inflammatory* cause? - pain that is severe/unrelenting worse at night and with rest. Improves with exercise. Accompanies by fever/chills and night sweats. - usually no hx of trauma; though for an abscess, may have had previous spinal surgery, IVDU, hx of inflammatory arthritis etc. - positive Lhermitte's sign; consider myelopathy such as MS. ❗️rule out *cancer* - unintentional weight loss, hx of cancer: if so; consider lung (CXR), prostate, (PSA), thyroid (TFTs), breast (hx and physical) and myeloma (bloods). if all above negative; most likely mechanical especially if aged 20-55, pain easing with bed rest and worsening with exercise and occupation involves repetitive stress. If physical identifies radiculopathy; mechanical compression of the nerve root secondary to: (1) disc herniation (90%) (2) spinal stenosis (3) spondylolisthesis examination includes (A) spurling test: cervical (B) straight leg raise and foot dorsiflexion for lumbar management: re-assure mechanical pain resolves within 1-2 weeks. Avoid heavy lifting, remain active, exercise, analgesia. Sciatica symptoms should settle within 4-6 weeks.

*CHRONIC BACK PAIN* see "GP: musculoskeletal/ortho/neuro section"

*SPINAL STENOSIS*: pain that is worse with walking (neurogenic claudication) with improvement bending forward: these are hallmarks of the disease. *PAGET'S DISEASE* - 2nd most common metabolic bone disorder after osteoporosis with a *peak age of >55*. - excessive bone resorption followed by quick ↑bone formation which is less organised and weak leading to fractures - elderly, bone pain, ↑↑ALP - normal Ca2+, PTH and phosphate - conductive hearing loss (due to skull enlargement), long bone bowing, high cardiac output. - XR shows *coarsened trabeculae with increased bone density, bone lucency, osteolytic lesions, "blade of grass" lesions* - bone scan essential for further evaluation. - all patients require *biphosphonates* *METASTATIC DISEASE*: - most commonly from prostate or renal cancer. Can also be due to lymphoma. - consider in those presenting with thoracic/lumbar pain, bone tenderness with history of weight loss, pain worse at night - ALP is important for evaluating bone disease. If a patient with a history of breast cancer has elevated ALP and back pain, vertebral bone metastasis must be considered. - request MRI whole spine - manage pain with external beam RTx + zolendronic acid to reduce risk of fractures and spinal cord compression *MULTIPLE MYELOMA*: always suspect in an elderly patient with a history of constipation, weight loss, lower back pain with tenderness, anaemia and raised ESR. The back pain is due to hypercalcaemia. Remember mnemonic: iCRAB: *i*nfections (most common cause of death), hyper*c*alcaemia, *r*enal failure, *a*naemia, *b*one lytic lesions.

*CHEST PAIN OTHER DIFFERENTIAL* 1) does the pain have an angina pattern? --> yes: perform ECG --> if positive --> hospital, if negative; perform troponin --> if positive --> hospital, if negative, evaluate with exercise stress tests 2) if not typical for angina pain.. is there a clinical suspicion for PE? --> yes: calculate Well's score and order d-dimers and/or CTPA 3) if not typical for angina or PE; is there fever/chills and/or productive cough? --> evaluate for pneumonia --> perform CXR and/or treat if fully obvious suspicion 4) if no clinical signs of angina, PE or pneumonia; ask has patient felt anxious, had palpitations, SOB in the last 6 months? --> if yes --> consider panic disorder --> if no; ask if the pain reproduced with palpation --> if yes; costochondritis or musculoskeletal pain is likely - angina - pneumothorax - atelectasis - pneumonia - asthma/COPD - pleural effusion - pericarditis - lung cancer - acute pancreatitis - peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis - oesophageal rupture - musculoskeletal: costochondritis, rib fracture - psychogenic - shingles - coxsackie B infection: unilateral, knife-like chest or upper abdominal pain, following an URTI - precordial catch: brief, episodic left-sided chest pain commonly associated with bending or posture, relieved by a single deep depth or straight posture

*STABLE ANGINA*: - retrosternal pain occurs after exertion/stress with relief on rest and GTN - ECG and troponin negative *UNSTABLE ANGINA* - pain typically occurs for >15 minutes and occurs @ rest. - cardiac enzymes normal PRINZMETAL ANGINA - coronary artery spasm without obstructive lesion occurs @ rest. Consider cocaine use in young adults. - decubitus: pain occurs when lying down; more fluid redistribution therefore heart works harder. angina investigations: (NICE) - firstly; perform a baseline ECG before referring to cardiology for: first line is *CT coronary angiogram* (venous contrast). 2nd line is non-invasive tests e.g. *stress ECHO* or *MIBI/MPS scan* (myocardial perfusion scintigraphy technetium scan with CT) helps localise area of ischaemia; performed both at rest and after exercise. Useful for those with baseline normal ECGs. 💊- medical treatment includes the use of beta-blockers, nitrates and/or calcium channel blockers. Be sure patient is on low dose aspirin and statin. *PNEUMONIA* - fever, productive cough +/- wheeze, dyspnoea, or pleuritic chest pain - unilateral crackles, dull percussion note, increased vocal fremitus *COSTOCHONDRITIS*: - unilateral, sharp, anterior chest-wall pain, exaggerated by inspiration, activity, or a particular posture - usually preceded by exercise or an URTI and can last for months. - tenderness over the costochondral junction and pain in the affected area when palpating the chest wall. - inflammation of the costochondral joints - diagnosis of exclusion; ECG, CXR, etc. *PERICARDITIS*: - viral cause: sharp pleuritic chest pain improved when leaning forward. - ST-T elevation seen in ALL ECG leads except aVR, VI and III. - pericardial rub heard continuing even with brief breath hold (unlike a pleural friction rub which would stop). - manage with NSAIDs *EXERCISE INDUCED ASTHMA* - cough, SOB, wheeze, chest tightness - reduced exercise tolerance - diagnose with reversible spirometry *ANXIETY* - chest tightness, palpitations, etc - anxiety disorders are common, especially panic disorders. *SHINGLES AND POST-HERPETIC NEURALGIA* - painful vesicular rash; managed with acyclovir 800 mg 5x/day for 7 days. For post-herpetic neuralgia (>3 months of pain); manage with nortriptyline or amitriptyline.

NEUROLOGICAL DEFICIT: *PARAESTHESIA/NUMBNESS/PERIPHERAL WEAKNESS/ABNORMAL GAIT* - stroke unilateral neurological deficit - TIA - subdural haematoma - simple partial seizure - myasthaenia gravis: bilateral worse as the days goes on - Bell's palsy: unilateral facial weakness - Guillain Barre syndrome: after URTI, unilateral —> bilateral, distal - chronic inflammatory demyelinating polyneuropathy - long version of GBS - botulism - bilateral and descending paralysis - myotonic dystrophy - 20-30yrs, AD, face and distal muscles - Duchenne muscular dystrophy- X-R, <6yrs, motor milestone delay - Becker muscular dystrophy - amyotrophic lateral sclerosis - Friedrich's ataxia - primary adrenal insufficiency - Charcot Marie Tooth - multiple sclerosis - vitamin B12 deficiency - Wernicke's encephalopathy - Korsakoff psychosis - electrolyte imbalances - neurosyphilis - claudication

*STROKE* - *anterior cerebral*: aphasia (speech problem), urinary incontinence, contralateral leg weakness and sensory loss - *posterior cerebral*: contralateral homonymous hemianopsia, agnosia, alexia, back headaches, dizziness - *middle cerebral*: lacunar strokes consist of arteries that supply the basal ganglia: contralateral hemiparesis of the face and arm + sensory loss. Note the lower limbs are spared. 💡 in dominant area: Broca's and Wernicke's area" on left hemisphere causing motor and sensory aphasia respectively 💡 in non-dominant area: contralateral neglect syndrome (on right hemisphere) 💡 lacunar strokes can present in 5 ways: (1) pure motor hemiparesis (most common), (2) pure sensory loss (3) dysarthria/clumsy hand, (4) ataxic hemiparesis (2nd most common), (5) mixed sensorimotor: hemiparesis/hemiplegia (weakness) with sensory impairment on the same side - management: urgent CT head to rule out haemorrhagic stroke. Once ruled out (an ischaemic ruled in); alteplase within 4.5hrs of presentation and antiplatelet treatment (aspirin 300mg OD for 2 weeks or clopidogrel with maintenance dose for life. If patient already was on aspirin, then include dipyridamole MR 200mg BD in their regime. Also add statin and an ACE-i *TIA* - unilateral temporary facial weakness, arm/leg weakness or slurred speech - suspected TIA in the last 7 days: give stat aspirin 300mg with review from stroke physician (for carotid doppler or CTA/MRA) within 24hrs. - suspected TIA over 7 days ago: ensure seen by stroke physician within 1 week (NICE) general TIA management involves - aspirin 300mg stat (or clopidogrel if allergic or already on aspirin) for 2 weeks aiming to include dipyridamole afterward - if >50% stenosis with symptoms: for carotid endarterectomy. - *amaurosis fugax*: associated with TIAs where sudden one eye blindness develops. Associated with *Hollenhorst plaques*: cholesterol bodies on the retinal arterioles. - determining risk of subsequent stroke: ➖ AF: refer within 24 hours ➖ TIA episode whilst on an anticoagulant: refer within 24 hours ➖ >1 TIA episode in a week: refer within 24 hours ➖ ABCD2 score of >4: refer within 24 hours ===> *A*ge>60 (1) ===> *B*P>140/90 (1) ===> *C*linically: unilateral weakness, speech (1 point for each ===> *D*uration: <10 minutes = 0, 10-60 mins = 1, and >60 minutes = 2 ===> *D*iabetes (1) *DVLA RULES* after any TIA or stroke, the minimum driving ban is 1 month regardless of severity. If there is residual neurological deficit after 1 month; i.e. visual, cognitive, limb impairment, then the DVLA should be informed but if its minor limb weakness alone; no need to be. *CAN I FLY* - 3 day wait before flying for TIA or stroke (caa.co.uk) *SIMPLE PARTIAL SEIZURE*: aura/warning symptoms but there is NO loss of consciousness or awareness - s/s usually lasts <1 minute. - may include sensory: numbing/tingling or motor: limb jerk, facial twitch or autonomic: blushing, nausea or psychic s/s: deja vu, hallucinations (visual, sound, taste, smell) *MYASTHAENIA GRAVIS*: - most common NMJ disorder; acquired disease (not genetic) involving destruction of AcH post-synaptic receptors causing *weakness* primarily of the facial muscles (but can occur in the peripheries). The s/s become worse as the day goes on - typically women<40 or men>60 - *early symptoms affects the facial muscles*: ptosis, diplopia and slurred speech. It can also cause dysphagia and dyspnoea. ==> good test: ask patient to look up for 30 seconds; if diplopia is present; may be an indication for the disease - late symptoms include limb weakness - diagnosis: positive anti-acetylcholine receptor (AChR) antibodies in 80-90% or anti-MuSK. Others: edrophonium tests, CT (thymoma). - thymoma present in 15% - management: thymectomy if <60yrs, cholinesterase inhibitors (effective early), steroids, immune therapy *BELL'S PALSY* - post-infectious unilateral facial muscle weakness secondary to CN VII dysfunction. Other risk factors: diabetes and pregnancy. Manage with steroids and antivirals. Resolution in 2 weeks. *GUILLAIN BARRE SYNDROME*: - usually precedes an infection (1-3 weeks after); typically an URTI or GI infection - ascending sensory and motor s/s: 70% develop paraethesias distally: in their hands and feet followed by symmetrical weakness after a few days. Motor symptoms predominate. LMN signs (absent reflexes, flaccid weakness). - most common CN palsy is bilateral facial weakness while spinal nerve palsy (70%) present with bilateral feet paraesthesia - can cause life-threatening respiratory paralysis: therefore FVC should be monitored daily - EMG: tpical demyelination findings - CSF: high protein - treat with *IV immunoglobulin and plasmapheresis* within first 2 weeks of onset - 85% of patients make a complete recovery with a mortality of only 10% :-) *CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY (CIDP) - considered a chronic equivalent form of Guillain Barre syndrome: s/s that return after treatment for GBS syndrome. *Weakness* of the limbs, *paraesthesias and numbness* of the hands and feet. Consider underlying cause; i.e. immunodeficiency syndromes e.g. HIV, Hodgkin's lymphoma, MM, MS, SLE, IBD. *BOTULISM* - characterised by *descending paralysis*: CN-->upper limbs-->lungs--> lower limbs *LAMBERT-EATON MYASTHENIC SYNDROME* - 2nd most common neuromuscular disorder targeting CALCIUM channels on the pre-synaptic membrane inhibiting entry of calcium into the membrane required for acetylcholine to be released. - it is NOT inherited, 2/3 cases are *associated with paraneoplastic disorder* like small cell lung cancer (90% of cases). - middle/older aged males most at risk; its earliest symptom is *fluctuating proximal limb weakness (legs usually affected first), decreased reflexes and and autonomic symptoms* (including dry mouth and constipation). - patients may have symptoms revolving around CN nerve pathology like MG but these are mild *MYOTONIC DYSTROPHY*: - autosomal dominant disorder - onset @ 20-30yrs typically - slowly progressive muscle wasting and weakness in the lower legs, hands, neck and face getting worse over time. - characteristic facial muscle *wasting and weakness* of the jaw, neck muscles, ocular (bilateral ptosis). - associated with cataracts (80%), hypogonadism, frontal balding, cardiac disorders *DUCHENNE MUSCULAR DYSTROPHY* dystrophy (DMD) - X-linked recessive: boys>girls - most common of the muscular dystrophies. - s/s: usually <6yrs but may appear as early as infancy. Typically wheelchair bound by adolescence - progressive difficulty in walking and performing everyday activities. - typically, the first noticeable symptom is a *delay of motor milestones*, including sitting and standing independently *BECKER MUSCULAR DYSTROPHY* - considered to be a *milder form of DMD*, as both are caused by mutations in the same gene and have similar symptoms. - calves are often enlarged. - has a *later onset and slower progression*. *ALS (MOTOR NEURON DISEASE*): - *both upper and lower motor neuron disease*: (UMN: weakness, spasticity, brisk reflexes, clonus, LMN: weakness/wasting, reduced tone, reduced reflexes, fasciculation) - distal --> proximal MOTOR ONLY function lost...everything else intact. - manage with *riluzole*: reduces destruction of motor neurons - death commonly due to respiratory muscle dysfunction and lung infections with average survival approximately 2-4 years. - common in middle age M>W - note: syringomyelia and syringobulbia can also cause both UMN and LMN lesions. *FRIEDREICH ATAXIA* - autosomal recessive disorder - *bilateral lower limb weakness, progressive ataxia and UMN lesions* - age of onset in pubertal years - UMN lesions (Babinski's sign), loss of lower limb deep tendon reflexes and ataxia. Most end up in wheelchair by teenage years. - GAA unstable expansion on chromosome 9 - 5 hydroxytryphotan may help with ataxia symptoms *SUBDURAL HAEMATOMA*: - e.g. infants, alcoholics and elderly patient with history of head trauma presenting with *unsteady gait and multiple falls* - haemorrhage results from torn bridging veins - CT: hyperdense concave/crescent fluid on CT that does not cross the suture lines - always suspect child or elderly abuse in these patients. *PRIMARY ADRENAL INSUFFICIENCY OR ADDISON'S DISEASE - commonly autoimmune - weakness, fatigue, GI symptoms, hypotension, hyperpigmentation, characteristic ↓Na+ and ↑K+. - evaluate initially with cosyntropin (ACTH) stimulation test measuring cortisol levels 30-60 minutes later; if low; indicates disease is present. *SIMPLE PARTIAL SEIZURE*: often known as an aura; warning before onset of a tonic-clonic seizure. Usually last <1 minute; sensory s/s include numbing, paraesthesia and burning. Motor: limb jerk or facial twitch. There may be autonomic s/s and psychic (deja vu, hallucinations, panic, anxiety, etc); patient is fully conscious. *CHARCOT MARIE TOOTH* - hereditary polyneuropathy/autosomal dominant - gradual progressive bilateral distal muscle weakness and atrophy (hands/feet) + paraesthesia - associated with foot deformities (e.g. high arches and hammer toes) foot drop, balance problems and paraethesias *MULTIPLE SCLEROSIS*: F>M, caucasian, mid-age presenting with *isolated limb paraesthesia* and/or Lhermitte's sign. - early s/s: *urinary incontinence, sexual dysfunction* before onset of visual disturbances (*retrobulbar neuritis*, pain with eye movement and *internuclear opthalmoplegia*). Late signs are motor: gait ataxia and tremor worse with movement. - dietary linoleic acid has been proven to reduce the severity of relapse. Steroids and ACTH bring forward remission after relapse but do not modify the overall course of the disease *VITAMIN 12 DEFICIENCY*: mainly ↓vibration and fine touch but can also produce bilateral numbness/paraesthesia in peripheries, megaloblastic anaemia, reduced serum levels of B12 and methylmalonic acid. Occurs secondary to pernicious anaemia, post-gastrectomy or intestinal organisms. *WERNICKE'S ENCEPHALOPATHY*: due to >12 weeks of *THIAMINE DEFICIENCY* leading to: *confusion, cerebellar ataxia and nystagmus and opthalmoplegia*. Symptoms can also include *diffuse polyneuropathy* and *Korsakoff psychosis (neurological sequelae)*. - Wernicke encephalopathy results from severe acute deficiency of thiamine (vitamin B1), whilst Korsakoff's psychosis is a chronic neurologic sequela of Wernicke encephalopathy. *WERNICKE-KORSAKOFF SYNDROME*: 2-3 weeks of vitamin B1/thiamine deficiency most commonly from chronic alcoholism leads to classic triad of *confusion, cerebellar ataxia and nystagmus*. Other symptoms include: ↓attention/concentration, ↓memory and peripheral oedema. Treat with pabrinex IV. - other causes: malnutrition, starvation (anorexia nervosa, schizophrenia), gastric malignancy, AIDS). *ELECTROLYTE IMBALANCES*: see below for further details *NEUROSYPHILIS*: part of tertiary syphilis: may cause - *numbness/paraesthesia*, meningitis, strokes, dementia, loss coordination, numbness and vision problems - Argyll Robertson pupil: highly specific to neurosyphilis (although may be found with diabetic neuropathy, MS and stroke). Usually bilateral and presents as bilaterally miotic and irregular pupils, which constrict briskly with accommodation but do not react to bright light

*URINARY FREQUENCY* - urinary tract infection* (UTI) - prostatitis* (acute and chronic) - BPH - bladder tumours - diabetes - interstitial cystitis - fibroids

*URINARY TRACT INFECTION* - asymptomatic bacteriuria is only treated in pregnant women because it is a risk factor for pyelonephritis and premature delivery (in the UK: first line is nitrofurantoin but avoid 3rd trimester, amoxicillin or cephalexin for 7 days) and repeat culture. This is to reduce any chances of developing premature labour and risk of maternal pyelonephritis. - non-pregnant women aged >16 years: 1st line is trimethoprim 200mg BD for 3 days or nitrofurantoin (GFR>45) 100mg MR for 3 days. Note that it's better to use trimethoprim if febrile and nitrofurantoin if afebrile. Nitrofurantoin concentrates well in the bladder but doesn't penetrate the kidneys as well. - if pregnant >12yrs: nitrofurantoin MR is first line: 100mg BD for 7 days (but avoid in last few weeks) otherwise amoxicillin or cephalexin for 7 days - in men: trimethoprim 200mg BD for 7 days or nitrofurantoin 💡 always consider prostatitis in men presenting with symptoms that improved then relapsed *ACUTE PROSTATITIS* - s/s: acute fever/chills, UTI symptoms and perineal or lower back pain, tender/boggy prostate on PR examination. - most commonly from ascending UTI (E.coli in most cases) or less commonly: STDs 💡 be sure to obtain MSU in suspected cases - management: *ciprofloxacin or ofloxacin for 14 days* is first line (NICE) for acute prostatitis; review after this time. Alternative includes TMP-SMX (co-trimoxazole) for 14 days. - advise to seek medical help if s/s don't improve within 48hrs of starting antibiotics and review patient after 14 days of therapy. - following recovery refer for investigation to exclude structural abnormality of the urinary tract. *CHRONIC PROSTATITIS* - recurrent exacerbations of acute prostatitis-like s/s, recurrent UTI with same organism - s/s: pelvic pain, ejaculation pain - for men with suspected chronic bacterial prostatitis (a history of urinary tract infection, or an episode of acute prostatitis within the last 12 months): refer to a urologist and whilst awaiting referral prescribe a single course of antibiotic treatment. Options include: - (NICE guidelines) *trimethoprim for 4-6 weeks or azithromycin for 3 weeks*. Note: fluoroquinolones no longer recommended in the UK for this. *INTERSTITIAL CYSTITIS*: - suprapubic/pelvic pain with *urinary frequency up to 60x a day*!! - due to ulcer formation in the bladder with potassium entering in. - risk factors: *citrus, chocolate, tomatoes, coffee, tobacco, alcohol, spicy foods worsen symptoms. - urinalysis and culture will be normal - definite diagnosis is cystoscopy however; can be negative. Biopsy should be done to rule out cancer. - treatment includes lifestyle modification with low potassium foods. Medication: pentosa polysulfate sodium or oxybutynin. *FIBROIDS* - if large enough can compress on the bladder causing frequency, urgency or incontinence - suspect in reproductive aged women, particularly if Asian/Black, obese and have other risk factors for high oestrogen exposure - mostly asymptomatic otherwise may also complain of menorrhagia, dysmenorrhoea and bloating - investigate with U/S - control bleeding with NSAIDs, contraception/IUS or tranexamic acid other GnRH agonists, ulipristal acetate (to shrink tumours), myomectomy (if child bearing) or hysterectomy if >40yrs and no plans to childbear

*PALPITATIONS* *CAUSES* - alcohol, caffeine (e.g. coffee/sodas), nicotine, cocaine, heroin, amphetamines, ecstasy, and cannabis - hypoglycaemia - hypovolaemia (dehydration) - anaemia - thyrotoxicosis - premature ventricular contractions (PVCs): very common - arrhythmias (induced by structural heart disease, CAD, valve disease, HTN or electrolyte abnormalities e.g. supraventricular tachycardias e.g. AF (especially if irregular), Wolff-Parkinson White syndrome - stress, anxiety, panic attacks, somatization disorder - medications: beta-2 agonists, antimuscarinics (e.g. ipratropium), vasodilators (e.g. hydralazine), recent beta blocker withdrawal, QT prolongers (antihistamines, macrolides, antipsychotics, SSRIs, TCAs, antifungals) - pheochromocytoma *INVESTIGATE* - determine if any associated chest pain, SOB, lightheadedness or fainting spells - history of: stress, anxiety, panic attacks, caffeine/tea intake, smoking, medication use include illicit drugs - assess vital signs; particularly BP for hydration status - ECG (resting and 24 hour tape). - bloods: FBC, U&E, TFTs, glucose REFER TO CARDIOLOGY IF: - emergency if current palpitations with VT on ECG or s/s present (chest pain, SOB, dizziness) - history of syncope or near syncope. - palpitations precipitated by exercise. - pre-existing heart disease: - family history of sudden cardiac death under <40yrs - resting ECG abnormality: e.g. WPW, LBBB, pathological Q waves, prolonged QT interval - suspected paroxysmal atrial fibrillation - ventricular extrasystoles (ectopics) with suspected underlying heart disease

*WOLFF PARKINSON WHITE SYNDROME - short PR, delta wave with broad QRS *SICK SINUS SYNDROME* - most commonly from degeneration and fibrosis of the SA node and surrounding myocardium, leading to abnormal automaticity (generation of electrical impulse) and/or abnormal conduction. - may also be caused or exacerbated by medications, including β-blockers (e.g., metoprolol). - referred to as tachycardia-bradycardia syndrome - s/s vary: palpitations, SOB, chest pain, etc - Holter monitor: detects bradycardia episodes and sinus pauses - if unstable: give IV atropine or temporary cardiac pacing - long-term therapy & symptomatic: pacemaker - if in AF: consider anticoagulation *ATRIAL FIBRILLATION* - SOB, lightheadedness, palpitations - ECG: no P waves, irregularly irregular - first line is rhythm control (cardioversion or pharmacology) in certain situations: new onset, reversible cause, heart failure, atrial flutter, clinical judgement - for rate control: manage if in fast AF

*COUGH* in children think of the mnemonic acute: "BBB" - acute *b*ronchitis - foreign *b*ody - pertussis *b*ordetella chronic "ABCDE" - *a*sthma - *b*ronchiectasis - *c*ystic fibrosis - *d*rip (post-nasal drip) - *e*xposure to smoke and allergens ACUTE (<3 weeks) - *foreign body* (in children: stridor, reduced chest wall movement on the affected side, bronchial breathing, and reduced or diminished breath sounds) - *PE*: chest pain, SOB, tachycardia, tachypnoea - *pneumothorax*: chest pain, SOB, reduced sounds - *acute bronchitis* (chest cold 90% due to viruses) - *pneumonia* - *acute exacerbations of asthma, COPD or bronchiectasis*: worsening breathlessness and wheeze, and increased and/or purulent sputum SUBACUTE (3-8 weeks) - *whooping cough*: paroxysms of cough - a mix of chronic causes - see below CHRONIC (>8 weeks) - *lung cancer* (s/s in 40%): rule out with history taking (unintentional weight loss, fever, night sweats, persistent hoarseness: request a CXR) - *laryngeal or thyroid ca* - *cigarette smoke* (passive/active) - *ACE-i usage* - *asthma*: wheeze, breathlessness, worse @ night, with exercise and exposure to allergens. PEFR reduced - *COPD*: wheezing, chest tightness, hyperinflated chest, possible RHF signs e.g. ankle oedema and increased jugular venous pressure - *bronchiectasis*: coarse crackles in early inspiration in the lower lung fields - *GORD*: cough worse during/after eating, talking, and with bending - *post-nasal drip*: frequent throat clearing +/- chronic sinusitis (nasal blockage or discharge with facial pain or pressure over the affected sinus) or allergic rhinitis (nasal itching, sneezing, discharge, and blockage). - *ILD* (dry *c*ough, fine-end inspiratory *c*rackles and *c*lubbing). Request spirometry and CXR - *sarcoidosis* - *pulmonary oedema*: orthopnoea and/or paroxysmal nocturnal dyspnoea, peripheral oedema and raised jugular venous pressure - *CF* (lung involved @ childhood onset)

*history* - duration, dry/wet (if wet colour? green/bloody?) anything that precipitates it? any associated chest pain/SOB, hoarseness, dysphagia, acid reflux s/s - recent URTI - any fevers, night sweats or weight loss - smoking history (active/passive) - occupational history - history of allergies (e.g. pets), asthma, eczema - medications: on ACE-i? investigate - feel for enlarged cervical LNs - for smokers, initial investigations are *CXR* and *spirometry*, with *advice to stop smoking*. If smoking is the cause, cough should improve within eight weeks of smoking cessation. management: - GORD? - trial of high-dose proton pump inhibitors (may require up to 12 weeks for improvement). - postnasal drip syndrome? - trial of antihistamines or nasal steroids (8 weeks). for symptomatic relief - simple linctus have the advantage of being harmless and inexpensive. 5ml; 3-4 times a day.

*HOARSENESS*

- causes: laryngeal cancer, occupational/lifestyle (public speaking, karaoke), reflux red flags ⚠️ for 2WW especially with smokers >40yrs - >45yr old with persistent (rather than intermittent) hoarseness >3 weeks - odynophagia - dysphagia - haemoptysis - otalgia - unexplained neck lump normal referral - intermittent hoarseness >12 weeks not responding to lifestyle measures alone

*HAEMOPTYSIS* - bronchitis - pneumonia - bronchiectasis - TB - PE - lung cancer e.g. SCC, NSCLC and mesothelioma - aspergillosis - small vessel vasculitis - mitral stenosis and CCF - anticoagulation/bleeding disorders STEPS 1) consider/rule out *PE* if acutely SOB +/- calf swelling/tenderness and *pulmonary oedema* if chronically SOB, ankle oedema, orthopnoea, PND. 2) rule out from history possible *TB* - if high, send off 3x AFB smear & culture, normal sputum c&s, refer for urgent CXR and consider isolation. Discuss risk with microbiologist 3) consider *lung cancer*: know the 2WW urgent (within 2 weeks) CXR for aged>40 if they have (A) >2 of the following unexplained symptoms: (cough, chest pain, SOB, fatigue, weight loss, appetite loss) OR (B) they have ever smoked 🚬 and have 1 or more of above unexplained symptoms: 4) consider *occupational exposure*: bird faeces, STEPS (if child presentation) 1) rule out *TB* 2) consider *foreign body aspiration*: mostly presents as acute emergency with cough, choking and dyspnoea. CXR and flexible fibre-optic bronchoscopy would be required. 3) consider *bronchiectasis* associated with *CF*, *dyskinetic cilia syndrome* 4) ask about haematuria: rule out *vascular diseases* and any *bleeding disorders* 5) once all ruled out: most likely just *bronchitis* 💡 in any case of haemoptysis: request sputum c&s, CXR +/- coagulation and FBC. 💡 if massive haemoptysis (coughing >100ml of blood within 24hrs (equivalent to a third of a can of drink): hospital admission necessary

- most commonly *bronchitis, pneumonia and bronchiectasis and TB* (worldwide). Note: cavitation lesion tends to damage both vascular supplies. Ask about fever, chills, night sweats and obtain sputum c&s and acid fast stain (3x) and urgent CXR. - *PE*: acute SOB, hypoxia, Well's score risk factors - *lung cancer* (in 7%); ask about unintentional weight loss, chronic cough and smoking history. Assess with CXR, HRCT and if either negative bronchoscopy. *BRONCHIECTASIS* - airways abnormally widened, leading to a build-up of excess mucus leading to infection vulnerability - causes: most commonly idiopathic but thought to contribute are: previous infections e.g. (pneumonia, TB, measles whooping cough), immunodeficiency, allergic bronchopulmonary aspergillosis and cilia disorders - s/s: productive cough, chronic dyspnoea, bibasal coarse crackles and clubbing - HRCT gold standard for diagnosis - there is no treatment: only tertiary prevention: stop smoking (if applicable), hydration, good diet, chest physiotherapy (e.g. and pneumococcal + yearly flu vaccine, nebulizers (beta 2-adrenergic agonist, anticholinergics, theophylline but particularly dornase alpha), antibiotics if infective exacerbation 💡 long term antibiotics may be required if patient has had >3 infective exacerbations/year *TUBERCULOSIS* - no symptoms, positive PPD/TST (>10mm if healthy, >5mm immunocompromised) but negative IGRA: think other cause e.g. vaccination - no symptoms but positive PPD/TST and IGRA: treat as latent (dormant) infection (isoniazid and pyridoxine for 9 months). - has symptoms + positive sputum acid fast bacilli (AFB smear & culture) + CXR => isolate and treat as active infection rarer causes: - *mitral stenosis and CCF*: present with SOB worse when lying down - orthopnea and PND. obtain pro-BNP and ECHO. Mitral stenosis would present as diastolic murmur heard best in the apex and severe cases; associated with RHF. In a young patient; consider rheumatic fever as the cause. An older person: atrial myxoma. - *granulomatosis with polyangiitis* (also presents with haematuria): check bloods : ANA, ANCA, anti-GBM and renal function - *inhalation of irritants, aspergillosis*: ask about occupational history and any pets e.g. birds - *anticoagulation, bleeding disorders, post-BM transplant*: check drug history, coagulation profile and renal function - other sources: *rule out upper GI bleed and epistaxis*

*MENOPAUSE AND HORMONE REPLACEMENT THERAPY/HRT) - menopausal s/s: irregular periods (longer), amenorrhoea (if >12 months: true menopause), hot flushes, headaches, insomnia, night sweats, anxiety, palpitations, vaginal tract atrophy, hair thinning, osteoporosis, weight gain - HRT aims to replace lost oestrogen and help relieve troublesome vasomotor symptoms and improve quality of life

1) discuss their menopause s/s, ask if they've had 12 months of amenorrhoea: if not, in perimenopausal state otherwise postmenopause 2) consider differential i.e. hyperthyroidism and request further investigations if necessary 3) type of HRT will depend on: ➯ *hysterectomy* - require oestrogen only therapy note: if a uterus is present, a progestogen must be included to avert the consequences of prolonged exposure to unopposed oestrogen. ➯ the *menopausal status* - *peri*menopausal women should be offered sequential therapy using *DAILY* oestrogen and *CYCLICAL* progestogen (if uterus present). - *post*menopausal women can be offered continuous combined therapy using DAILY oestrogen and DAILY progestogen ➯ preference for type of treatment: oral or not ➯ past medical history ➯ current medication ➯ age of menopause. Generally for women with menopausal symptom who are: - <50 years - HRT should be offered since the benefits far outweigh the risks - between 50 and 60 years - the benefits of HRT outweigh the risks - >60 years - risks tend to outweigh the benefits absolute contraindications - liver disease - undiagnosed vaginal bleeding - venous thrombosis - known/suspected breast or endometrial cancer

*DOCTOR, I FEEL DIZZY!* DIZZINESS

1) establish what they mean by dizziness ➖ vertigo: "room is spinning" ➖ lightheaded (feel lightheaded?) ➖presyncope (feeling like you're going to faint?") ➖ off-balance (failing to keep your balance?): think subdural haematoma, peripheral neuropathy, Parkinson's, strokes/TIAs (secondary to vertebrobasilar insufficiency or carotid stenosis). Ensure you perform full neurological and cerebellar examination. - if acute: think trauma, intoxication, migraine, cerebellar infarction or haemorrhage - if subacute (days/weeks): MS, hydrocephalus, viral cerebellitis, Guillain-Barre syndrome, posterior fossa tumour or abscess - if chronic (months-years): alcoholic cerebellar degeneration (most common), foramen magnum compression, chronic infection, vitamin E deficiency, hereditary ataxia direct questions based on the above 2) ask for how long and how frequently (i.e. how many episodes or is all the time? 3) what are you doing usually before the episodes occur? 4) any loss of consciousness? or collapses? 5) any associated palpitations, SOB, chest pain, nausea/vomiting EXAMINE - observations/vitals including LSBP - physical: any murmurs? irregular pulse? ears (?wax) - bloods: FBC, U&E, CRP, TFTs, LFTs, HbA1c - ECG +/- ECHO -

*ATAXIA* - acute (hours/days): trauma, intoxication, migraine, cerebellar infarction or haemorrhage - subacute (days/weeks): MS, hydrocephalus, viral cerebellitis, Guillain-Barre syndrome, posterior fossa tumour or abscess - chronic (months-years): alcoholic cerebellar degeneration (most common), foramen magnum compression, chronic infection, vitamin E deficiency, hereditary ataxia

see "dementia differential and confusional states" for hydrocephalus, CJD prion disease, encephalitis and Wernicke's disease. see "paraesthesia, numbness and weakness" section for MS, Guillain-Barre syndrome and Friedrich's ataxia. *ALCOHOLIC CEREBELLAR DEGENERATION*: - gradual onset (months/years); most common chronic acquired cause for ataxia; usually secondary to moderate (rather than excessive) alcohol consumption therefore not a dose dependent cause - genetics may also be playing a factor.

*HEARING, BALANCE AND TINNITUS* *conduction hearing loss*: sound waves unable to pass from the middle to inner ear - Rinne test (bone>air) with Weber test showing localisation/pathology to the quiet ear - impacted wax, glue ear, foreign body/debris, otosclerosis, cholesteatoma *sensorineural hearing loss*: damage to the specialised nerves VIII and hair cells of the inner ear - Rinne test (air>bone) with Weber test localising the pathology in the louder ear - most commonly ongoing exposure to loud noises an ageing (presbyacusis which is bilateral). Others: Meniere's disease (unilateral) *HEARING REFERRAL TO ENT* - 2WW if persistent foul smelling otorrhoea: rule out cholesteatoma - associated with developmental delay - hearing loss severe (>61 dB) and requires urgent referral within 2 weeks to exclude additional sensorineural deafness - TM structurally abnormal (or there are other features suggesting an alternative diagnosis). - child has Down's syndrome or has a cleft palate. *TINNITUS REFERRAL TO ENT* - referral to ENT if acoustic neuroma, Meniere's disease, carotid AV fistula or cholesteatoma suspected ⚠️ red flag 2WW referrals for tinnitus to rule out cerebrovascular disease or neoplasm - secondary to head trauma - associated with severe vertigo. - associated with unexplained sudden hearing loss. - sudden onset pulsatile tinnitus - association with significant neurological symptoms and/or signs (e.g. facial weakness) refer to ENT urgently if tinnitus - pulsatile tinnitus (not sudden) - unilateral tinnitus (consider acoustic neuroma, cerebellopontine angle tumour or Meniere's disease. An MRI scan may be needed - tinnitus + unilateral hearing loss (rule out acoustic neuroma) - persistent otalgia or otorrhoea that does not resolve with routine treatment: rule out cholesteatoma - tinnitus with vertigo/dizziness: acoustic neuroma or Meniere's disease refer all people with tinnitus for an audiological assessment, particularly if it is persistent (lasting 6 months or more).

⚠️ *PULSATILE TINNITUS* - audible by the physician - dural AV fistula or a carotid artery aneurysm. - AV fistula treatment: embolisation of external carotids to reduce shunt flow. ⚠️ *CHOLESTEATOMA* - keratinising squamous epithelium grows from the tympanic membrane or the auditory canal into the middle ear mucosa - congenital or more commonly acquired - *painless otorrhoea (scant, foul-smelling)* +/- conductive hearing loss - otoscope: *deep retraction pocket in TM* or *yellow crust like lesion* on TM or rarely and if congenital: a *white or pearly mass behind the TM* - image with CT to show extent of bone destruction - emergency ENT referral if facial nerve palsy, vertigo or other neurological symptoms (including pain) or signs that could be associated with the development of an intracranial abscess or meningitis otherwise 2WW referral required. - surgery always indicated - complications: erosion of temporal bone → extradural abscess, meningitis, sigmoid sinus thrombosis ⚠️ *ACOUSTIC NEUROMA* - rare tumour presenting 90% with unilateral hearing loss - 70% with tinnitus but *rarely with vertigo* - CN V, VII, VIII can be affected. *CERUMEN IMPACTION* - the most common cause of conductive hearing loss for those 15-50yrs - risks: hairy, narrow ear canals, in-the ear hearing aids - s/s: conductive hearing loss, ± tinnitus, vertigo, otalgia, aural fullness - manage with water or drops (bicarbonate solution, olive oil, glycerine, Cerumenol®, Cerumenex®) or with manual debridement - syringing indicated for total occlusive cerumen with earache or associated decreased hearing, tinnitus or vertigo. It is contraindicated if there's an active infection, previous ear surgery, only hearing ear or if there's TM perforation. Aim to make sure patient uses 3-5 days of cerumenlytic drops before undergoing syringing. - advise not to insert anything else into the ear e.g. fingers, cotton buds to avoid the risk of further impaction and TM perforation. - arrange for audiogram if hearing loss still present after ear wax removal. *OTOSCLEROSIS* - 2nd most common cause of conductive hearing loss (progressive) in 15-50 yr old (after cerumen impaction) - TM normal ±pink blush (*Schwartz's sign*) associated with the neovascularization of otosclerotic bone - characteristic dip at 2000Hz (Carhart's notch) on audiogram - definite treatment: stapedectomy or stapedotomy (with laser or drill) with prosthesis *PRESBYCUSIS* - most common cause of sensorineural hearing loss; occurs in elder patients - hair cell and basilar membrane degeneration - progressive bilateral hearing loss *initially at high frequencies*, then middle frequencies - refer for hearing aidGF

*TESTICLE PATHOLOGY* *PAIN RELATED* - testicular torsion: puberty age, Preh's sign negative - hydatid of Morgani: earlier age approx 10, small blue point of discolouration - epididymitis: post-pubertal/teenagers, Preh's sign relief, fever/discharge - orchitis: acute inflammatory painful testicle due to mumps or chronically from trauma or syphilis - fournier's gangrene: immunocompromised *MASS RELATED* - cryptorchidism (undescended testicle) - testicular cancer: seminoma, teratoma or yolk sac tumour - hydrocele - varicocele - spermatocele

⚠️ *TESTICULAR TORSION* (TT) - most common *before or during puberty* - severe acute onset of unilateral testicular pain +/- n/v, testicle tenderness, high riding and swelling *- lifting of the testicle (Preh's sign) does not provide relief (unlike epididymitis where it does)*. - cremasteric reflex is absent (elevation of the testicle by stroking the inner thigh). - urgent urology review. U/S can be done but this would only add to delay. - treat manually or surgically <6hrs for 90% chance of preservation. At 12 hours the rate drops to 50% and 24 hours it drops to 10%. - if testis not viable: manage with orchiectomy😞 otherwise gold standard is *orchiopexy*😊 *HYDATID OF MORGAGNI*: torsion of testicular appendage presents similarly to TT; but - occurs earlier: more commonly *approximate age of 10* - has a *small blue point* of discoloured and extreme point of tenderness in the upper pole (rather than diffuse pain) - reflexes are positive. it would be still safe to refer to urology *EPIDIDYMITIS*: - sudden, constant testicular pain with scrotal swelling, tenderness of the posterior region of the testis, - *fever and discharge* - more common in post-pubertal age - cremasteric reflex and Prehn's sign are present unlike TT. - management with *ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg BD for 10 days* (CDC guidelines). If gonorrhoea suspected; consider adding on azithromycin. Alternative antibiotics include levofloxacin 500mg for 10 days. - advise scrotal elevation (supportive underwear), analgesia until signs of local inflammation or fever have resolved. - advise testing for both patient and partners in GUM clinic particularly for gonorrhoea and chlamydia - can co-exist with orchitis *ORCHITIS* - acute: due to viral e.g. mumps commonly presenting 3-7 days after parotid enlargement or co-exist with epididymitis. - request anti-mumps antibodies; if negative, consider same day referral to the sexual health specialist - chronic causes: trauma or tertiary syphilis. *FOURNIER'S GANGRENE*: - immunocompromised e.g. HIV, diabetics - necrotising fasciitis of the external genitalia and/or perineum It's a urological emergency requiring IV antibiotics and debridement *CRYPTORCHIDISM* - 1 in every 25 boys - normally, the testicles form inside the abdomen before slowly moving down into the scrotum about 1-2 months before birth - s/s: abdominal mass felt in inguinal region with no palpable mass felt in the associated hemiscrotum - management: *watchful waiting till 6 months of life* - *if >6 months; orchidopexy* required to move the testicles into the correct position inside the scrotum. This should be carried out before 12 months of age to avoid the risk of infertility and preserve spermatogenesis. - note: a pelvic U/S is appropriate only if testicles are bilaterally absent - complications; infertility, testicular cancer *TESTICULAR CANCER* - *seminoma*: solid slow growing painless irregular body in the testis. Age usually 30-40 years. Refer for scrotal U/S. Orchidectomy is main treatment. - *teratoma*: @ 20-30yrs "troops" - *yolk sac tumour* - *leydig cell tumour*: excess androgen leads to precocious pseudopuberty in boys >4yrs with prominent external genitalia *HYDROCELE*: - soft non-tender cystic swelling in the scrotum which *transilluminates*; can be found as young as 6 months of age - resolves usually by 1yr as the patent processus vaginalis closes - closely monitor; if still present @ 1yr or excessive discomfort; refer for surgery (excision of the hydrocele sac). *VARICOCELE*: - palpable "bag of worms" or *squishy tubes* in the upper pole especially with standing after valsalva. - may be dull/aching dragging pain - *L>R* moreso affected - presents during *teenage years* - U/S confirms dilated pampiniform vessels - most common reversible cause for infertility in men - varicocele embolisation or surgery *SPERMATOCELE*: - cyst that contains sperm common in the head of the epididymitis occurs commonly after a vasectomy.

FATIGUE / EXHAUSTION causes - malignancy: ask unintentional weight loss, fevers, sweats - infections: e.g. TB, tropical infections, HIV, hepatitis, EBV - depression - poor sleep hygiene: e.g. taking care of young children, illicit drug use, restless leg, obstructive sleep apnoea - lifestyle: alcohol, poor diet, work/family stress - low vitamin D: housebound, darker skin, gut absorption problem - medications: sedatives/hypnotics, antidepressants, muscle relaxants, opioids, antihypertensives, and antihistamines. - chronic conditions: diabetes, hypothyroidism, hypercalcaemia, anaemia, allergies, asthma, COPD, heart/liver failure, arthritis - chronic fatigue syndrome (CFS): W>M, common in mid-age, red flags - 5% unintentional weight loss in the last 6 months, lymphadenopathy, haemoptysis, dysphagia, rectal bleeding, breast lump, post-menopausal bleeding, neurological deficit, CO poisoning remember to always ask about impact on driving

➖ S/S: how long for? timing? - rule out red flags: unintentional weight loss, fevers, sweats - associated s/s: headaches, nausea, sore throat, weakness, snoring/sleep pauses, daytime sleepiness - sleep hygiene: insomnia? - low mood/irritable? interest/pleasure to do things? - severity: on driving, family/work life ➖ Event: ask ICE: children? stress? ➖ Medications ➖ Allergies ➖ Social: smoking, alcohol, diet, exercise, occupation (driving/operating heavy machinery, indoor work, hours, are they self-employed?) ➖ history of chronic conditions and infections ➖ family history of chronic conditions Physical Examination - vitals: including temperature, BP, HR, RR and - lymph node examination - Epworth questionnaire (if relevant) Bloods - FBC, ESR/CRP, LFTs, U&E, TFTs, HbA1c, tTG-IgA - consider: bone profile (if >60yrs), vitamin D (if housebound, darker skin, HIV, hepatitis serology, monospot test (if <40yrs), CXR (if TB suspected) - if s/s persisted for >3 months: urinalysis (for protein/blood), bone biochemistry, creatinine kinase Management - lifestyle advice: particularly alcohol, diet and exercise promotion - sleep hygiene: fixed times for going to bed and waking up, comfortable environment, avoid caffeine, nicotine, alcohol or exercise within 4 hours of going to bed, avoid heavy meals late at night, avoid napping during the day. Consider short term hypnotic in insomnia only if daytime impairment is severe. - manage underlying disorder - refer to appropriate

*VERTIGO* - 4 types of dizziness: vertigo (54% cases in primary care: false sense of motion), lightheadedness, pre-syncope and disequilibrium - 93% of primary care patients with vertigo have BPPV, acute vestibular neuronitis, or Ménière's disease. topics - BPPV - Meniere's disease - vestibular neuritis - labyrinthitis - acoustic neuroma (rarely vertigo) - postural hypotension PERIPHERAL VERTIGO - self-limiting and brief e.g. BPPV - s/s worse with head movement and nausea/vomiting is usually severe - the effects of head posturing to provoke attack becomes fatigued - nystagmus is unidirectional and oscillopsia (visual illusion of moving back/forward) are always present with attacks - the Hallpike manoeuvre vertigo occurs SHORTLY AFTER the change in position and does fatigue when repetitively done (unlike central). *CENTRAL VERTIGO* - vertigo is constant and probably severe enough for patient to have difficulty even standing - nausea/vomiting usually absent/mild - tinnitus or hearing loss are absent - *nystagmus in all directions* with oscillopsia rarer in central causes. - brain stem signs e.g. *diplopia* (always a sign) usually present and the best way to distinguish between central and peripheral - Hallpike manoeuvre vertigo occurs DURING the change in position and does not fatigue if repetitively done (unlike peripheral). - common causes: brainstem stroke which would require an MRA to assess atheroma and occlusion. Other causes include cerebellopontine angle tumour, migraine and MS. - referral to a neurologist is necessary management of vertigo - to rapidly relieve severe n/v associated with vertigo, consider giving *buccal prochlorperazine* or IM prochlorperazine or cyclizine. - to alleviate less severe n/v and vertigo: short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine).

*BPPV*: - peripheral vertigo and the most common cause of vertigo in the elderly. - W>M, 40-70yrs - brief recurrent <1 minute vertigo episodes *worse with head movement and when lying down* - caused by otoliths (calcium carbonate) in the posterior semicircle canal. - diagnosis: with Dix-Hallpike manoeuvre which induces rotational vertigo and positional nystagmus - Epley maneuver is used to treat. - 30% however re-occur after a year therefore; consider ENT referral for surgery: posterior canal occlusion. *MENIERE'S DISEASE* - fluctuating vertigo *lasts for minutes-hours + unilateral or bilateral sensorineural hearing loss + fullness and tinnitus*. - risk factors: family history, allergies, autoimmune disorder and trauma. - refer all cases to a neurologist. Audiometry helps establish diagnosis - treat with antiemetics and antihistamines. *VESTIBULAR NEURITIS* - post-infectious (URTI): fever followed by severe peripheral vertigo (n/v worse with head movement): initially 2-3 days before easing off over weeks with full recovery by 6 weeks - mean age of onset is mid-age - examination may show *rotational nystagmus* especially with head movement - ensure patient informs the DVLA regarding their dizziness episodes. *LABYRINTHITIS* - vestibular neuritis + *hearing loss* *ACOUSTIC NEUROMA* - 90% have unilateral hearing loss - 70% have tinnitus - *rarely presents with vertigo*. - CN V, VII, VIII can be affected. *PERILYMPHATIC FISTULA* - breach between the inner ear and middle ear - may be caused by trauma from a direct blow, or from activities such as scuba diving (from barotrauma) and heavy weight bearing or excessive straining with bowel movements - sneezing or movements that place the affected ear downward also can provoke vertigo in patients with perilymphatic fistulas *OTOSCLEROSIS* - abnormal growth of bone in the middle ear, leading to immobilisation of the bones of conduction and a conductive hearing loss; this process also may affect the cochlea, leading to tinnitus, vertigo, and rarely sensorineural type hearing loss *OTHER CAUSES OF VERTIGO* - drug induced, psychological - central causes: brainstem stroke, cerebellopontine angle tumour, migraine or MS. differential diagnosis - postural hypotension: symptoms worse when standing up. Measure LSBP for confirmation and eliminate any antihypertensives that may be the cause. - hypoglycaemia - ataxia: cerebellar, Friedrich's

*HEADACHES* - meningitis - brain tumour (worse in morning/exertion) - pseudotumour cerebri (always consider also SAH) - subarachnoid haemorrhage - giant cell arteritis (>50yrs with eye s/s) - pre-eclampsia (think in 3rd trimester) - cervicogenic headache (v.common) - tension headache (bilateral, band-like) - migraine (unilateral + n/v, photophobia) - cluster (mid-age, unilateral + eye s/s) - trigeminal neuralgia (sharp, brief) - acute angle closure glaucoma - hypertensive crisis - acromegaly red flags - following head trauma (haemorrhage) - thunderclap/explosive, scalp tenderness, jaw claudication (SA haemorrhage, GCA) - new onset headache: particularly if >50yrs - neck stiffness, fever, photophobia, seizures, focal neurological deficit (meningitis) - cough worse with cough, sneezing, sexual activity, valsava manoeuvre, papilloedema (↑ICP) - pregnancy (pre-eclampsia) consultation 1) SOCRATES, look for red flags: any other similar episodes in the past. Ask about associated n/v, visual problems, neck stiffness, fevers, photophobia. - ask ICE where relevant 2) Event: hx of trauma, pregnant (3rd trimester), stress/anxiety - ask ICE where relevant 3) Medications: e.g. nitrates 4) Allergies: rhinitis/sinusitis symptoms 5) Social: smoking, alcohol, (diet/exercise). Occupation (?sitting on the computer all the time ?stress), hobbies 6) History or family history of anxiety/depression, polymyalgia rheumatica 7) physical: vitals: temp, BP (especially for pulsating headache), ask them to move their neck, CN exam (including ophthalmoscope), cerebellar exam (if posterior headache), meningeal signs

*BRAIN TUMOUR* - progressive throbbing/aching *worse in the morning, on exertion and when lying down* - disturbs sleep +/- nausea and vomiting - look for papilloedema on ophthalmoscopy ➖ meningioma: - slow-growing tumours - neck pain (early) worse with neck flexion and manoeuvres that ↑ICP (e.g., coughing, sneezing). - long tract signs; sensory and motor deficits typically start in one extremity and spread to the others. - late presentation: spastic quadriparesis (hyperreflexia, positive Babinski's sign), gait disturbances, and lower cranial nerve palsies (CN IX-XII) *PITUITARY ADENOMA* - risk factors: MEN1, - prolactinoma can present with headaches, bitemporal hemianopsia and amenorrhoea and galactorrhoea (bilateral white nipple discharge) - ↓FSH, ↓LH, ↑prolactin - pituitary macroadenomas (>1cm) - manage initially with dopamine agonists e.g. cabergoline, bromocriptine which can shrink the tumour - surgery if failure to tolerate medical therapy or wishes to have children. *PSEUDOTUMOR CEREBRI* a.k.a. idiopathic intracranial HTN - *severe headaches with papilloedema +/- horizontal diplopia (due to VI palsy) on examination. - risk factors include obese women who take oestrogen containing contraception. - MRI normal. Often it takes CSF analysis to confirm an elevated opening pressure. - 💊 use medications to reduce the ICP e.g. acetazolamide, mannitol, furosemide or hyperventilation); otherwise craniotomy - if left untreated; long-standing macular oedema will lead to irreversible optic neuropathy with visual field and colour vision loss. *CERVICOGENIC HEADACHE* - caused by cervical spondylosis - patients often describe a headache that's more global, can be worse when lying down, with neck movement + neck stiffness. - often, there is history of neck trauma - CN exam should be normal - management consists of: analgesia (e.g. naproxen) and physiotherapy. A short course of diazepam may also help in the short term especially if co-current anxiety, affecting ADLs or disturbing sleep. *EYE STRAIN* - occupational mainly: those staring at computer screens - advise eye hygiene: frequent blinking, eye breaks, adjust monitor brightness, artificial tears and perhaps book an appt with the optician for a full assessment *TENSION* - *bilateral dull* band-like frontal pain associated with stress. - risk factors include: white, female, higher education, history of depression/anxiety and history of trauma - caffeine withdrawal can present also with waves of hot/cold sensations. *MIGRAINE* - W>M, *unilateral, pulsating*, moderate/severe pain accompanied by *nausea and/or vomiting and photophobia*. - symptoms *worse with physical exercise, loud noises and bright lights*. - triggers include: stress/anxiety, fatigue/sleep deprivation, food, (especially red wine, chocolate, cheese, caffeine withdrawal) and hormonal changes (1-2 days before menstruation). => 💊 acute treatment: *paracetamol/NSAID +/- sumatriptan* 50-100 mg PO (max 300 mg/day) => prophylaxis: advise patient to avoid triggers + offer pharmacology if there's >4 attacks/month: (A) propranolol* 80/160 mg OD/BD or *topiramate* (B) *gabapentin/acupuncture* (C) *botulinum A toxin*. *CLUSTER* - sharp excruciating brief 5-10 minute attacks of pain *unilaterally*, often *felt around the eye and/or the temple*, *associated with autonomic symptoms* (e.g. drooping eyelid, constricted pupil, red eye). Occurs at the *same time every day*. NOT associated with nausea/vomiting or photophobia. Patient is usually restless and agitated during an attack; similar to trigeminal neuralgia. - risks: M>W, mid-age, smokers, family history. - triggers include alcohol/strong smells (e.g. perfume, paint or petrol), extreme temps, allergic rhinitis, sex, etc - 💊 acute treatment: sumatriptan s/c or intranasally (if >18yrs) 2nd line: 100% O2 >12L facemask for 10-15mins - refer for neurologist follow up *TRIGEMINAL NEURALGIA*: - *brief recurrent* 'electric shock' episodes lasting minutes/seconds - *worse with cold weather* and touch. R>L side and often unilateral. - W>M, peaking age 50. - if it presents <50yrs; *suspect underlying multiple sclerosis*. Other causes: neurosyphilis and tumours of the posterior fossa - 💊 first line: carbamazepine (gradually increase dose to avoid drowsiness). If not tolerated; try phenytoin or gabapentin - surgical intervention if all else has failed *GIANT CELL ARTERITIS*: - v.severe abrupt *thunderclap headache*, low grade fever, scalp tenderness, diplopia, blindness/amaurosis fugax (25-50%), jaw claudication, fatigue and night sweats. - risk factors: W>M, age>50, ESR>50 - monitor with ESR (best inflammatory marker). - definite diagnosis: temporal artery biopsy. - strongly linked with polymyalgia rheumatica, aortic aneurysm and dissection. - 💊 treat with high dose prednisolone 40-60 mg OD (to reduce risk of permanent vision loss), aspirin and PPI + refer immediately same day to a neuro-ophthalmologist. *SUBARACHNOID HAEMORRHAGE* due to *trauma* or cerebral artery *aneurysm rupture*. The most common cause of non-traumatic SAH is an intracranial aneurysm rupture (80%). - sudden severe "thunderclap" headache +/- photophobia or meningism. - risk factors: HTN, smoking, alcohol, cocaine - other risk factors: Ehlers-Danlos syndrome, Marfan syndrome, adult polycystic kidney disease, and neurofibromatosis type I - CT: hyperdensity in the area of the Circle of Willis (e.g. suprasellar cistern) - CT angio if suspected aneurysm rupture - management: stabilise (ABCDs), ITU admission, calcium channel blocker, prophylactic anticonvulsants, neurosurgical intervention for surgical clipping or endovascular coil embolisation *ACUTE ANGLE CLOSURE GLAUCOMA* severe unilateral headache, periorbital eye pain, photophobia, halos around lights, profuse tearing hazy cornea and blurred vision*. - on examination: cornea looks hazy, pupil fixed and dilated with circumcorneal redness. - risk factors: increasing age, Asians, hyperopia, shallow anterior chamber, genetic - refer urgently: treatment includes latanoprost, betamethasone and laser peripheral iridotomy. *MENINGITIS* (see paediatrics for more info) - in older children and adults: fever, headache, neck stiffness, confusion, lethargy, altered level of consciousness, seizures, focal neurological signs, N/V, photophobia, papilloedema - *nuchal rigidity* - *Brudzinski's sign*: passive neck flexion causes involuntary flexion of hips and knees - *Kernig's sign*: resistance to knee extension when hip is flexed to 90 degrees - risk factors: unvaccinated from H.influenzae, s.pneumoniae or N.meningitidis in children, penetrating head trauma, haematogenous spread from nasopharynx, immunosuppression. - if suspected in the community: administer stat dose of IM penicillin and call an urgent ambulance ➖ for <1yr child: 300mg IM benzylpenicillin ➖ for 1-10yr child: 600mg IM benzylpenicillin ➖ for >10yr child: 1200mg IM benzylpenicillin *HYPERTENSIVE CRISIS* - pain tends to pulsate and often gets worse with physical activity - check for organ damage (papilloedema, renal failure, heart failure, or encephalopathy). In order to check for papilloedema properly (with a slit lamp), you may need to refer to ophthalmology for review. *ACROMEGALY* - *broadening of the skeleton, organs and soft tissue; which results from excess secretion of pituitary GH *AFTER* epiphyseal closure - most commonly from a *pituitary adenoma* <note: if it happened before epiphyseal closure - we call it gigantism (excessive height) - which is not acromegaly> - most often diagnosed in middle aged adults with an insidious onset and slow progression - symptoms as below *1. GROWTH PROMOTION*: soft tissue and skeleton overgrowth, enlarged jaw, frontal bossing, abnormally large hand and foot size, ↑glove/ring size), carpal tunnel syndrome, arthralgia, organomegaly, hypertrophic cardiomyopathy (leads to low cardiac output: - accounts for most deaths) *2. METABOLIC DISTURBANCES*: glucose intolerance and DM in 10-25% of patients, ↑triglycerides, ↑phosphate, ↑prolactin, ↑GH, hypertension, sleep apnoea *3. PARASELLAR DISTURBANCES*: headache, bitemporal hemianopsia (superior growth leads to compression of the optic chiasm, cavernous sinus compression (lateral growth), sphenoid sinus invasion (inferior growth) - investigate: initially with *IGF-1*. This is usually enough to make the diagnosis if there are also symptoms present. - gold standard diagnosis: *OGTT with serum GH level* measured between 30 mins and 2 hours afterward - MRI: rule out pituitary adenoma - screening test: IGF-1 - treatment: transsphenoidal resection of pituitary adenoma, radiation, medications to lower GH (octreotide, cabergoline or pegvisomant).

*COMMONLY USED MEDICATION SIDE EFFECTS

*ASPIRIN* - bleeding, peptic ulcers, abdominal pain, tinnitus *WARFARIN* - ↓vitamin K: bleeding with purpura - ↓protein C: warfarin induced skin necrosis *BETA BLOCKERS* - contraindicated in asthma, COPD: a cardioselective beta-blocker should be be prescribed in these patients under specialist opinion - other contraindications: acute HF, Prinzmetal angina, sinus bradycardia, hypotension SBP<100, 2nd-3rd degree block, sick sinus syndrome, cardiogenic shock, severe peripheral arterial disease - side effects: bronchospasm, SOB, arrhythmias, bradycardia, hypotension, dizziness, peripheral vasoconstriction (Raynaud's exacerbation), fatigue, paraethesias, sexual dysfunction, purpura, thrombocytopaenia. *ALPHA-1 BLOCKERS* - e.g. tamsulosin, duloxetine are used primarily 1st line for overflow incontinence caused by BPH *PPI THERAPY* - headache, diarrhoea, nausea, vomiting, abdominal pain, constipation, and dizziness. - long term: hypomagnesaemia, increased risk of fractures, c.diff infection, - can enhance the effects of warfarin, digoxin, methotrexate and reduce efficacy of clopidogrel. *ACE INHIBITORS* - side effects: dry cough (15%), angioedema (because of ↑bradykinin), hypotension, dizziness, headaches, hyperkalaemia, rash, abdominal discomfort, etc. - contraindications: bilateral renal artery stenosis, history of angioedema, pregnancy or those planning pregnancy, breastfeeding women, diabetics with GFR<60 taking aliskiren. - ensure electrolytes and GFR/creatinine are measured at baseline and after 1-2 weeks of initiating treatment - check BP 4 weeks after each dose titration *CALCIUM CHANNEL BLOCKERS* - *rate limiting* (verapamil/diltiazem) or *dihydropyridine* (e.g. amlodipine, nifedipine) - adverse effects (dihydropyridines): dizziness, drowsiness, ankle swelling, abdominal pain/discomfort, constipation, gingival hyperplasia (rarely). - adverse effects (rate limiting): AV block, bradycardia, palpitations, vertigo, rash, vomiting, diarrhoea - BP should be measured 4 weeks after each dose change. - contraindications: unstable CCF, cardiac outflow obstruction, 2nd degree AV block *THIAZIDE TYPE DIURETICS* - e.g. indapamide (2.5mg daily, to be taken in the morning) or chlortalidone - side effects: headaches, dizziness, hypotension, mild gastro disturbance, ↑Ca2+, ↑glucose, ↓Na+, ↓K+, ↓Mg2+ *SPIRONOLACTONE* - contraindications: Addison's disease, AKI, hyperkalaemia *VALPROIC ACID*: - nausea, headache, ↑bleeding time, ↓PLT, insomnia, rash, diarrhoea, hepatic necrosis, pancreatitis, drug interactions due to CYP450 inhibition, weight gain, and GI distress. *LAMOTRIGINE* - Steven Johnson Syndrome (fever, blistering rash, positive Nikolsky sign within 2-8 weeks) - all patients should be advised to discontinue lamotrigine therapy at the first sign of a rash *FERROUS SULPHATE/FUMARATE* - abdominal pain, nausea, constipation - take with food to ↓risk of GI symptoms - for better absorption; best to take with vitamin C especially if taking medication that reduces acidity i.e. antacids, PPIs, H2 blockers). - once Hb levels are within range; supplements should be continued for several months after. *METFORMIN* - adverse effects: weight loss, nausea, abdominal pain - contraindicated with renal failure (creatinine>132). moderate liver dysfunction and CCF *COMBINED ORAL CONTRACEPTIVE* - initial headaches, nausea, breast tenderness and mood swings (should resolve) - breakthrough bleeding (BTB) and spotting (mid-cycle bleed) is common in for the first few cycles - HTN: risk of DVT, PE, stroke, heart attack. - small risk of breast and cervical cancer - porphyria cutanea tarda - contraindicated in aged>35 who smoke 🚬, BMI>35, family history of clots, family history of breast cancer, hypertension (BP>140/90 consecutively), diabetes, IHD, severe migraines (especially with aura), postpartum (6 weeks), pregnancy (as it won't do anything) *MACROLIDES* - nausea, vomiting, abdominal discomfort, and diarrhoea are most common side effects - *prolong QT interval* so avoid in those taking other certain drugs and those with hypokalaemia - avoid erythromycin in those with porphyria - severe hepatic with renal impairment *INSULIN* - must inform the DVLA - can drive a car as long as they have hypoglycaemic awareness and not had more than one episode of hypoglycaemia within the preceding 12 months - group 2 drivers can still drive but must adhere to the strict rules of hypoglycaemia *RHEUMATOLOGICAL DRUGS* - methotrexate: bone marrow suppression - infliximab: septicaemia - hydroxychloroquine: retinopathy. Those on long term therapy should have annual eye screening

*PENILE PROBLEMS* topics ➖ *impotence/erectile dysfunction* => organic (90%): no morning erection => psychogenic (10%): morning erection ➖ *priapism* >4 hours prolonged painful erection ➖ *paraphimosis* foreskin not retracting causing inflammation ➖ *balanitis* penile inflammation ➖ *condyloma acuminata* penile/anal/vulva warts

*IMPOTENCE / ERECTILE DYSFUNCTION* - diagnosis requires >3 months duration. - causes: vascular (90%) e.g. atherosclerosis; smoking (just 2 cigarettes/day can reduce blood flow to the penis by 30%), alcohol and obesity. Others: endocrine (poorly controlled type 2 diabetes, ↓testosterone), neurological (post-op, DM), medications (e.g. antihypertensives, antidepressants), psychogenic (10%). - good way to differentiate between organic and psychogenic cause is the question of a *morning erection*; this is absent in organic cause and present in psychogenic cases. - investigate: HbA1c, lipid profile, TSH, urinalysis, testosterone, prolactin - management: lifestyle changes, sildenafil (viagra), sex counselling (if psychogenic suspicion) - sildenafil: warn about flushing, headaches and indigestion. Do not prescribe with nitrates. *PRIAPRISM*: - prolonged painful penile erection persisting for >4 hours not associated with sexual arousal but rather; a failure of blood to drain from the penis. - aim to drain blood with needle into the side *PARAPHISMOSIS*: - uncircumcised males develop inflammation of the foreskin. When foreskin retracts and cannot be returned to normal position - blood trapping causes glans to swell leading to tissue death and gangrene. - common in adolescence and elderly needing frequent catheterisations *BALANITIS*: - inflammation (redness, irritation and soreness) at the end of the penis +/- pain when passing urine, penile discharge. - risk factors: poor hygiene, STDs, immunosuppression, phimosis - can occur at any age; more commonly boys aged under 4 years and also men who have not been circumcised. - treatment: daktacort cream or mupirocin cream *CONDYLOMA ACUMINATA*: - warts (pruritic cauliflower-shaped papules): clusters of non-painful raised, rough-textured lesions found on the penis, vulva and/or anus - due to *HPV 6,11* from unprotected sex - *acetic acid turns lesions white* - biopsy if diagnosis uncertain, doesn't respond to therapy, atypical, warts are pigmented/indurated, fixed, bleeding or ulcerated - usually 50% resolve within 4 months without treatment and 75% disappear within 2 years - home remedies include: imiquimod 5% cream (best as recurrency rate is lower), podofilox and sinecatechins ointment; continue for a maximum of 16 weeks until lesions disappear. - if in the case of numerous warts: *cryotherapy*, curettage, laser surgery, or electrocoagulation are useful. Cryotherapy (best initial treatment with good clearance rate at 3 months), excision, or electrocautery are better suited to keratinised warts

*PELVIC PAIN / LEFT ILIAC FOSSA PAIN* ⚠️ rule out AAA in a man >55yrs presenting with loin pain and consider *renal colic, pyelonephritis, perinephric abscess or renal cell ca* ⇥ GI: *constipation, gastroenteritis, diverticulitis, UC, hernias, IBS, proctitis ⇥ gynaecology: *PID, ectopic pregnancy, miscarriage, ovarian cyst* ⇥ urology: *ureteric colic, ⚠️testicular torsion, epididymitis, UTI*

*URETERIC COLIC* - M>F, mid-age - intense, colicky in waves radiating down groin - urine dip: microscopic haematuria - XR: radio-opaque stones :calcium oxalate and phosphate - U/S: to exclude hydronephrosis - CT non-contrast is gold standard *ACUTE DIVERTICULITIS* - consider in >40yrs with acute LIF pain worse with walking/change in position associated with chronic constipation, fever, tenderness, guarding or rigidity - gold standard: CT abdomen + pelvis *LARGE BOWEL OBSTRUCTION* - 75% cases due to colon ca - most commonly sigmoid volvulus - hypogastric/LIF colicky pain +/- vomiting, abdominal distension, rigid/hard, not opened bowels or passed wind, PR empty - XR: haustral markings - manage: NBM, NG tube decompression, IV fluids, analgesia, antiemetics. Surgery if failed. *SIGMOID VOLVULUS* - risk factors: age and use of psychotropic drugs - colon twists around mesentery; look for hx of chronic constipation, abdominal pain + distention and tympany *without guarding or rebound* - would require decompression via insertion of a rectal tube or colonoscopy followed by elective sigmoid colon surgery. - laxatives contraindicated *PROCTITIS* - inflammation of rectum leading to tenesmus and diarrhoea/rectal bleed - due to STDs, IBD or radiation therapy *ULCERATIVE COLITIS* - 💬 suspect in teenage years, family history, rectal bleeding, alternating bowel movements with diarrhoea >4 weeks, urgency to defecate, abdominal pain, weight loss, fever - sigmoidoscopy +/- colonoscopy - gold standard!! with *diffuse inflammation, erythema and pseudocysts seen. - treatment in mild cases: 5-aminosalicylic acid derivatives e.g. *mesalazine suppositories or oral sulphasalazine + loperamide*. 2nd line: steroids. Azathioprine and infliximab only in refractory cases. - surgery: if no response to medical treatment or complications present:: total colectomy + reversible ileostomy - complications: malignancy (>10yrs), toxic megacolon, obstruction, haemorrhage, perforation, abscess - extra-intestinal: - mouth ulcers, arthritis (most common), pyoderma gangrenosum (especially in UC when tissue becomes necrotic, causing deep ulcers that usually occur on the legs), ITP, anterior uveitis and episcleritis, *sclerosing cholangitis*, clubbing. *CROHNS DISEASE* - colonoscopy: skipped lesions, aphthous ulcers, cobblestoning - complications: SBO (40%), anorectal disease (30% with fissures, abscesses, perianal fistulae), colorectal cancer (but more common in UC) - extra-intestinal manifestations particularly for crohns; gallstones (cholelithiasis) due to malabsorption of vitamin B12 and bile acids (both occur in terminal ileum) *IRRITABLE BOWEL SYNDROME* - see chronic diseases section

*INFERTILITY* causes: *infections, age>35, lifestyle and diseases* - 85% conceive within 1 year of regular unprotected sex, 95% within 1 year - If history/examination, age>36, day 21 bloods (progesterone) abnormal; refer to fertility clinic.

1) counselling ➖ aim for unprotected sex 2-3x/week for at least 12 months especially just before ovulation. ➖ discuss lifestyle factors: smoking, alcohol, cocaine, marijuana, improper diet, medications (contraceptives, NSAIDs, antipsychotics, spironolactone, chemotherapy), lack of exercise. Others: stress, anxiety. *WOMAN HISTORY, EXAM AND TESTS* ➖ determine age ➖ length of time trying to conceive ➖ previous healthy children: ?miscarriages ?ectopic pregnancies ➖ LMP, any irregular periods and/or bleeding, current use of contraception, menorrhagia, dysmenorrhoea ➖ *galactosemia* ➖ *smoking/alcohol, stress, drugs* ➖ *occupational hazards* ➖ *previous/current pelvic inflammatory disease*, pelvic surgeries, cervical smear history ➖ examination: BMI (anorexia), hirsutism, acne (PCOS), galactorrhoea (prolactinoma), pelvic masses (ovarian cyst, fibroids) ➖ investigate: day 21 progesterone, chlamydia testing, gonadotropins, TFTs, prolactin - with progesterone @ 3-5 days of their period (levels should be high). ➖ U/S or hysterosalpingogram to rule out for tubal, uterus or cervix *anatomical abnormalities*, *fibroids*, *PCOS* or *adhesions* (e.g. from surgery, Asherman's syndrome), reversal of vasectomy. 💡 if *ovulatory dysfunction*: clomiphene can be used to trigger ovulation *MALE HISTORY, EXAM AND TESTS* ➖ length of time trying to conceive ➖ previous children ➖ ejaculation or problems with erectile dysfunction ➖ history of genital problems in the past: i.e. previous surgeries/procedures (orchidopexy, hernia repairs, vasectomy) history of testicular trauma (e.g. testicular torsion), pelvic infections (STDs, mumps) ➖ occupation: carcinogen exposure e.g. pesticides, solvents, etc ➖ smoking/alcohol history ➖ systemic disease: CCF, CKD, liver cirrhosis, uncontrolled diabetes, thyrotoxicosis ➖ examine: urethral meatus position, testicular lumps (cancer, varicocele, hernias), testis (undescended? small - think hypogonadism), breasts (gynecomastia: think hypogonadism) - *Kallman syndrome*: characterised by delayed onset of puberty and hyposmia/anosmia. Often associated with structural/developmental abnormalities: cryptorchidism, cleft palate, scoliosis, renal agenesis ➖ request *sperm analysis* (35% cause), chlamydia screening +/- systemic disease workup - if sperm abnormal; work up for chromosomal karyotyping e.g. Klinefelter's or Turner's

*ACUTE BACK PAIN* see "GP: musculoskeletal/ortho/neuro section" - acute: aortic dissection/rupture, acute MI, acute pancreatitis, PUD, pyelonephritis, vertebral fracture/compression, adrenal crisis, musculoskeletal, spinal mets to be ruled out, ankylosing spondylitis (young with back/buttock pain worsens with rest)

*ACUTE MI*: see chest pain *AORTIC DISSECTION*: see chest pain: knifelike/tearing pain *AAA*: smoking, HTN, age>50, diabetes are all risk factors. *AAA RUPTURE*: triad of back pain, hypotension and pulsatile abdominal mass. Endovascular aneurysm repair required. *ANTERIOR SPINAL ARTERY SYNDROME* - loss of function of the part of the spinal cord supplied by the anterior spinal artery affecting: => descending corticospinal tract fibres resulting in bilateral flaccid paralysis and loss of DTRs in the acute phase), => ascending spinothalamic tracts: bilateral pain/temperature sensation loss, and autonomic fibres (resulting in hypotension). - anterior spinal cord is at increased risk for infarction because it is supplied by the single anterior spinal artery, which has few collaterals. - risk factors: vascular disease, arteriosclerosis, diabetes, trauma and hypovolaemia, - acute back/chest pain within hours with s/s (as above) occurring below the level of lesion - MRI whole spine required <note: vibration and proprioception are typically spared because of an intact dorsal column!> *ACUTE PANCREATITIS*: epigastric pain radiating to the back; improves when leaning forward. - causes: gallstones > chronic alcoholism. Others: autoimmune disease, infections, trauma, metabolic disorders, and surgery *VERTEBRAL COMPRESSION FRACTURE*: associated with osteoporosis, trauma or spinal metastases. Consider percutaneous vertebroplasty, and balloon kyphoplasty for osteoporotic fractures *DISC HERNIATION*: think in a young person with history of an awkward lift or other strain. Nerve roots affected causing to sciatica. Straight leg raise with foot dorsiflexion confirms diagnosis. Advise <48 hours of bed rest to calm severe pain otherwise continue to keep active without exacerbating the pain. Give analgesia and consider epidural, physiotherapy, chiropractice or discectomy. 90% resolve within 6 weeks. *CAUDA EQUINA SYNDROME*: compression of lumbosacral nerve roots below L2 causing lumbar back pain, lower motor neuron signs, perianal anaesthesia and reduced anal sphincter tone (urinary retention and faecal incontinence). - commonly due to herniated disc, vertebral fracture or tumour. *CONUS MEDULLARIS SYNDROME*: similar to cauda equina but is higher up, is mild, sudden and bilateral. Impotence is seen more regularly. *SPINAL EPIDURAL ABSCESS*: fever, neurological deficits, bladder/bowel dysfunction. Consider in IV drug abusers.

*FACIAL PAIN* - acute sinusitis: see below - trigeminal neuralgia - TMJ syndrome - herpes zoster ophthalmicus - sialadenitis - trauma

*ACUTE SINUSITIS* - see below *TRIGEMINAL NEURALGIA*: - brief recurrent 'electric shock' episodes lasting minutes/seconds worse with cold weather and touch. - W>M, peaking age 50. - if it presents <50yrs; suspect underlying MS. - first line: carbamazepine *TMJ SYNDROME*: - temple headaches, jaw and ear pain, jaw locking/clicking when opening. Pain is worse with chewing and stress - early adulthood, M>W, overuse of jaw muscles (teeth grinding/clenching, chewing gum, etc). - manage with self-care (e.g. eating soft foods, paracetamol/ibuprofen, ice/heat packs, massage the muscles) and avoidance of risk factors. If s/s persist: refer for physiotherapy before referring to the maxfax team - if teeth grinding an issue or suspicion of dental infection: advise to see a dentist - differential: ear infection/wax, dental abscess/infection, temporal arteritis ⚠️ *HERPES ZOSTER OPHTHALMICUS* - pain/altered sensation on unilateral forehead before an eruption of painful vesicles 1 week after on the upper eyelid + headaches. - ocular complications e.g. conjunctivitis, keratitis, episcleritis, anterior uveitis, secondary glaucoma etc can occur months after acute phase. - systemic antivirals + *referral to the ophthalmologist* to evaluate for corneal disease and iritis as vision can be compromised. - early treatment with acyclovir (within 72 hours after rash onset) reduces the percentage of eye disorders in ophthalmic zoster patients from 50% to 20-30%. This early treatment also lessens acute pain *SIALADENITIS*: - causes: viruses (commonly mumps), bacteria (s.aureus: limited almost entirely to elderly, dehydrated, debilitated, and malnourished patients with poor oral hygiene. It appears in the second postoperative week and is associated with prolonged NG intubation, use of dry mouth causing medications such as antihistamines, antidepressants, or anticholinergic agents, things that reduce salivary output e.g. stones, autoimmune diseases e.g. Sjogren's syndrome. - infection of the salivary glands; parotid or submandibular - tenderness just anterior to the ear + painful lump in the gland with foul smelling pus draining into the mouth. - always examine cranial nerves VII (facial), IX (glossopharyngeal), and XII (hypoglossal) as deficit may occur if swelling is significant: may need surgical intervention. - antibiotics are mainstay of the treatment: flucloxacillin, co-amoxiclav. Antibiotic treatment is continued for 10 to 14 days note: if there is a parotid or submandibular gland swelling that is persistent and unexplained, refer urgently (for an appointment within 2 weeks). - if a salivary gland calculus is suspected, refer to a maxillofacial surgeon or ENT depending on local service provision. *FACIAL TRAUMA and FRACTURES* - zygomatic arch: trismus/difficulty chewing - inferior orbital: cheek numbness +/- limited upward gaze - medial orbit: limited abduction of eye - basal skull: "racoon eyes", bilateral periorbital bruising - nasal fracture: septal haematoma

*LOSS OF VISION / BLINDNESS*

*AGE RELATED MACULAR DEGENERATION* - most common cause of blindness in elderly - risk factors: smoking>HTN, alcohol abuse - central vision loss with peripheral blurry. Sometimes, a patient may seen visual hallucinations within the central vision (commonly gargoyles and at night when the light is low). This is is probably because the brain wants to process fake information for the loss of information received by the dying photoreceptors. - referral within the week preferably next day to avoid permanent vision loss ⚠️ *CENTRAL RETINAL VEIN OCCLUSION* - sudden painless loss of vision - incidence increases with age - more common than arterial occlusion - causes: glaucoma, polycythaemia, hypertension - severe retinal haemorrhages are usually seen on fundoscopy/slit lamp view - multiple flame shaped and blot haemorrhages on fundoscopy/slit lamp view ⚠️ *CENTRAL RETINAL ARTERY OCCLUSION* - sudden and painless loss of vision - due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) - features include afferent pupillary defect, 'cherry red' spot on a pale retina - treatment: ocular massage and carbogen therapy. ⚠️ *AMAUROSIS FUGAX*: (see TIA below) - cholesterol emboli secondary to AF or from giant cell arteritis. - patients describe it as "curtain coming down one eye" and it's painless. - if GCA is suspected; administer IV methylprednisolone or prednisolone 60 mg immediately to avoid risk of permanent vision loss. ⚠️ *OPTIC NEURITIS* - 50% cases due to MS; others include HZ and autoimmune disease. *VITREOUS HAEMORRHAGE* - causes: diabetes (90% due to bleeding from abnormal new blood vessels forming in advanced diabetic eye disease), trauma (in young people), bleeding disorders, anticoagulants - varies in degree from mild, with 'floaters' and haziness in the vision, to complete loss of vision or dark spots. - usually painless but comes on suddenly. *RETINITIS PIGMENTOSA* - autosomal recessive disorder - gradual peripheral to central vision loss, night blindness and tunnel vision - fundoscopy reveals bony spicule-shaped pigment deposits in the periphery with preservation of the macula - genetic counseling and an ophthalmology assessment required

*OTHER URINARY/KIDNEY ISSUES* - *urge incontinence*: (involuntary detrusor contractions): leakage associated with sudden urgent desire to void due to involuntary detrusor contractions - *stress incontinence*: (weakened pelvic floor muscles): leakage with pressure - *overflow incontinence*: (impaired detrusor contractility or obstruction): bladder doesn't empty properly: sensation of bladder fullness, weak stream, dribbling due to over-distention of the bladder from impaired detrusor contractility (e.g. from autonomic neuropathy, anaesthesia, etc) or from bladder outlet obstruction - *urinary retention* - *SIADH* - *focal segmented glomerulosclerosis* - *membranous nephropathy* - *membranoproliferative glomerulonephritis* - *diabetic nephropathy* - *amyloidosis related nephrotic syndrome*

*OAB/URGE URINARY INCONTINENCE*: - clinical syndrome with sudden urgency that can't be controlled, frequency and nocturia; due to *involuntary detrusor contractions*. - secondary to stroke, MS, BM; neurological issue. - investigate with urodynamic studies - management: *bladder training with behavioural therapy* (minimum for 6 weeks has a 75% success rate), *anticholinergics* (e.g. oxybutynin has a direct relaxant effect on urinary smooth muscle thus reducing involuntary detrusor contractions and increasing bladder capacity), e.g. oxybutynin or duloxetine. - when to refer to urology? - patients fail to respond to drug treatment after three months or who do not wish for drug treatment. they may be offered *botulinum toxin A injection* into the bladder wall, nerve stimulation or surgical treatment. *STRESS INCONTINENCE*: - urine leakage with increased abdominal pressure e.g. laughing or coughing - risk factors: obesity, increasing age, previous childbirths, post-menopausal (oestrogen loss), vaginal prolapse are all factors that weaken the pelvic floor muscles - *urethral hypermobility* is one of the most common causes and is due to impaired support from the pelvic floor. At times of increased intra-abdominal pressure (e.g., laughing, coughing, sneezing), the proximal urethra and the bladder neck descend out of the pelvis and transit more pressure to the bladder. During this process, intraurethral pressure falls below bladder pressure, resulting in urine leakage. - NICE guidelines advise a trial of *supervised pelvic floor/Kegel muscle training* of at least 3 months duration as first line. Others: lifestyle changes (e.g. alcohol cessation) and use of continence pessaries. 2nd line: duloxetine or anticholinergics. 3rd line: urethral sling surgical procedure *OVERFLOW INCONTINENCE* - bladder doesn't open fully causing *weak stream and post-void dribbling*. Feeling sensation of a bladder that doesn't feel empty. - commonly seen in alcoholics, B12 deficiency, diabetics (due to autonomic neuropathy causing detrusor hypotonia), post-pregnancy, BPH (obstruction). - rarely it occurs in women but if it does: consider fibroids or ovarian cancer - for BPH: management includes: tamsulosin 400 micrograms OD (α1-blocker); 1-2 week response. Alternative is are 5α-reductase inhibitors e.g. finasteride if symptoms more severe. TURP if medical treatment fails. - for autonomic neuropathy causes: cholinergic drugs e.g. bethanechol. *URINARY RETENTION* - causes: opioids: (especially early post-op, anticholinergics (eg, antipsychotic drugs, antidepressant agents particularly TCAs, anticholinergic respiratory agents, detrusor relaxants), general anaesthetics, BDZ, NSAIDs (e.g. ibuprofen), calcium-channel blockers, antihistamines, alcohol, BPH (see above). - manage: catheterisation and manage underlying cause. *SIADH* - ADH continues to released, water is reabsorbed leading to *dilutional euvolaemic hyponatraemia*. - the extra fluid reduces aldosterone level causing Na+ to shift into the urine thus normalising the fluid volume 💡 s/s of hyponatremia: headaches, nausea, vomiting, tremors, muscle cramps, confusion, mood swings, hallucinations, cerebral oedema, seizures, coma, death. - causes: stroke (haemorrhage or ischaemic), surgery, drugs (anti-epileptics, mood stabilisers), ectopic ADH release (e.g. SCC of the lung) - management: restrict daily intake of fluid, increase salt and protein diet, hypertonic IV if severe. *FOCAL SEGMENTED GLOMERULOSCLEROSIS* - most common cause of *nephrotic syndrome* in BLACK populations - can be associated with heroin abuse, HIV infection, obesity, and sickle cell disease - EM: *effacement of the foot processes* - requires immunosuppressants *MEMBRANOUS NEPHROPATHY* - most common cause of *nephrotic syndrome* in WHITE populations (oedema, proteinuria and fatty casts, and hyperlipidaemia). - secondary causes can be associated with lupus, infections (hepatitis B and C), tumours, and medications - EM: subepithelial deposits of immune complexes with a characteristic spike and dome appearance - renal biopsy shows *thickened capillary loops* - manage with steroids *MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS* - can manifest as either nephrotic or nephritic syndrome - associated with SLE, hepatitis C, monoclonal gammopathy - no single effective treatment *DIABETIC NEPHROPATHY* - light microscope: thickening of the GBM - treat underlying cause *AMYLOIDOSIS RELATED NEPHROTIC SYNDROME* - can be associated with multiple myeloma or chronic inflammatory disease (e.g., rheumatoid arthritis) - LM: Congo red stain shows apple green birefringence under polarised light - steroid treatment *MINIMAL CHANGE DISEASE* - 90% of cases of nephrotic syndrome in <5yrs - usually normal BP and renal function - minimal or absent haematuria - EM: foot processes - steroid responsive

*EAR DISCHARGE AND INFECTIONS* - otitis externa - acute otitis media - glue ear (otitis media with effusion) - otitis media chronic suppurative - mastoiditis - malignant otitis externa - cholesteatoma (see above) ear discharge differential - otitis externa - acute otitis media - otitis media chronic suppurative - cholesteatoma - trauma - liquefying ear wax - rarely but dangerously: mastoiditis and CSF otorrhea

*OTITIS EXTERNA* 👨 >> 👶 - more common in older people than children. - causes: 90% cause due to bacterial (most commonly pseudomonas), seborrheic dermatitis, psoriasis, eczema or allergy induced by hot weather, moisture (e.g. swimming), cosmetics, etc. - s/s: ear pain/*itch*, yellow discharge and debris, possible reduced hearing, posterior auricular LN, 🕵️‍♀️ signs: *pulling on the pinna is extremely painful* in otitis externa but not so much in otitis media - *otomize ear drops/spray* one into each affected ear TDS. It contains: dexamethasone, neomycin and acetic acid - only consider systemic antibiotics in those whom are immunocompromised e.g. flucloxacillin or a macrolide. *ACUTE OTITIS MEDIA* 👶 >> 👨 - inflammation of the middle ear in which there is fluid in the middle ear + inflammation ☑️ *bulging/inflamed eardrum* usually accompanied by pain ☑️ in young children: pulling, tugging, or rubbing of the ear, or non-specific symptoms such as fever, irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoea. ☑️ can be complicated by a perforated eardrum, often with drainage of purulent material (pus) - when to give antibiotics? if symptoms (a) lasted >3 days (as most tend to improve after 3 days by themselves) (b) bilateral AOM <2yrs (c) associated with perforation and/or discharge - antibiotics: amoxicillin for 5-7 days or a macrolide (erythromycin, clarithromycin or azithromycin). - warn parent that ear discharge may occur afterward and that this only normal (with TM perforation). This should heal within several weeks. If painful; advise on warm compresses and paracetamol to help. If not healed within several weeks; refer for myringoplasty (closure of the perforation). Advise that they can fly but to limit activities like swimming, smoking, sports, strenuous exercises. - if no response to antibiotics and TM still bulging/red; *tympanocentesis* is indicated (to puncture the eardrum with a needle) - *tympanostomy tubes* are indicated in children with recurrent treatment-refractory acute otitis media (3 episodes in 6 months or 4 episodes in 1 year) *OTITIS MEDIA CHRONIC SUPPURATIVE* - chronic inflammation of the middle ear and mastoid cavity, which presents with (often foul smelling) recurrent ear discharges through a tympanic perforation - AOM is considered to be CSOM after at least 2 weeks of discharge - pseudomonas aeruginosa most common - children <5yrs most common with atopy - complications: hearing loss can lead to language development delay. Others include: meningitis, mastoiditis - s/s: ear discharge >2 weeks without ear pain or fever, unilateral hearing loss +/- tinnitus - otoscopy: TM perforation with painless examination - ensure there is no postauricular swelling (tenderness), facial paralysis, or vertigo and signs or symptoms of intracranial infection as this would require admission. - *refer all suspected cases to ENT*: explain this will probably involve examination, an audiometry, topical steroid/antibiotics and intensive cleaning of the affected ear so they can visualise the TM better. *GLUE EAR/OTITIS MEDIA WITH EFFUSION* - collection of fluid within the middle ear space without signs of acute inflammation: like acute otitis media just without any infection/inflammation. - 50% of cases follow an episode of acute otitis media, especially in children <3yrs particularly those with cleft palate (e.g. those with Down's syndrome), allergic rhinitis, passive smoking - most common in children 2-5yrs and during the winter months - s/s: mild conductive hearing loss can develop to problems with speech, language and communication if not properly treated - otoscope: *retracted, concave, indrawn drum, loss of light reflex*, abnormal colour but TM can be normal. - active observation over 6-12 weeks is appropriate for most children, as spontaneous resolution is common - refer to an ENT specialist if s/s for >12 weeks, Down's syndrome patient, confirmed hearing loss (on audiometry) or suspicion of a delay in the child reaching developmental milestones: tympanometry (test of middle ear function: gold standard diagnosis) - management: myringotomy, and insertion of grommets ⚠️ *MASTOIDITIS* - severe complication of acute otitis media presenting 2 weeks after onset of untreated or inadequately treated acute suppurative otitis media - profuse ear discharge, *tender and oedematous mastoid*, and anterolateral protrusion of the auricle. - perform otoscopy first to evaluate the tympanic membrane for inflammatory signs then confirm mastoiditis diagnosis with *CT of the temporal bone*. - *IV antibiotics* (e.g. with vancomycin) as well as *tympanostomy* and subsequent *tympanostomy tube insertion* in mild cases or *mastoidectomy* in more severe cases. ⚠️ *MALIGNANT OTITIS EXTERNA* (SKULL BASE OSTEOMYELITIS) - rare complication of otitis externa - pseudomonas 95% aetiology causing temporal bone osteomyelitis - risks: elderly with poorly controlled diabetes or immunosuppressed - s/s: severe ear pain, red & swollen periauricular soft tissue, otorrhoea, conductive hearing loss - otoscopic findings: granulation tissue at the transition between the cartilaginous and the osseous part of the ear canal - complications: facial nerve palsy, osteomyelitis - CT temporal bone: bone destruction - IV broad spectrum antibiotics (e.g. ciprofloxacin, piperacillin-tazobactam, cefepime) for 6-8 weeks

*LEG PAIN* - *claudication*: pain, discomfort, numbness/paraethesias, cramping in the leg that *occurs during walking or standing* and is relieved by rest: *relief bending forward* helps differentiate neurogenic from vascular causes. - *peripheral ARTERIAL disease*: also known as peripheral VASCULAR disease involves chronic arterial insufficiency (affects the arteries causing angina of the extremities), critical limb ischaemia - *peripheral VENOUS disease*: DVT, varicose veins, chronic venous insufficiency, lymphedema - muscle cramping after surgery, with trauma, electrolyte deficiencies or simply idiopathic.

*PERIPHERAL ARTERIAL DISEASE - caused by atherosclerosis: smoking 🚬 , diabetes, HTN, obesity,↑age, ↑cholesterol, family history - intermittent claudication - ABI<0.9, peripheral pulses weak, duplex U/S of the lower limbs. - diagnose with angiography (CTA/MRA) - once confirmed; commence on aspirin/clopidogrel (mortality/morbidity benefit) , statin and cilostazol (for claudication relief), stent (severe cases) and advise regular exercise as pain tolerates. - femoropopliteal site is the most common affected area causing diminished pedal pulses but normal femoral pulse leading to paraesthesia of the foot upon elevation above heart level. *NEUROGENIC CLAUDICATION*: - caused by nerve root compression (e.g. lumbar disc L4-5), or spinal stenosis (consider in elderly). - *symptom relief with flexion (e.g. sitting down) or bending forward helps differentiate from vascular causes* as pain relief occurs when the spinal canal opens up more *CHRONIC ARTERIAL INSUFFICIENCY*: - caused by atherosclerosis - aetiology: smoking, diabetes, HTN, obesity,↑age, hypercholesterolaemia, family history - intermittent claudication: aching/cramping pain felt in legs during exercise improving with rest. Diminished pulses on examination. - diagnosis: ankle-brachial index <0.9, doppler U/S, CTA or MRA (excellent for large arteries). - treatment: lifestyle changes, exercise if capable, aspirin or clopidogrel, cilostazol (for claudication relief). stent (in severe cases) *CRITICAL LIMB ISCHAEMIA*: - severe occlusion of the arteries. - s/s: rest pain, night pain, tissue loss (ulceration or gangrene); pain most commonly over the forefoot, waking person from sleep, often relieved by hanging foot off bed. There may also be hair loss, hypertrophic nails, atrophic muscle, ulcerations and infections and a slow capillary refill - diagnosis: ABI <0.40, pulses may be absent, bruits may be present - management: if limb salvageable: angioplasty +/- stenting, endarterectomy or bypass. If non-salvageable; amputation. *DEEP VEIN THROMBOSIS* - calf pain and tenderness - risk factors: ↑age, previous cancer, surgery, immobilisation <4 weeks, etc. oestrogen contraception, thrombophilia disorder - *phlegmasia alba dolens*: DVT progressing to full occlusion leading to oedema, pain and a white appearance. - *phlegmasia curulea dolens*: potentially life-threatening complication of acute DVT characterised by marked swelling of the extremities with pain and cyanosis, which in turn may lead to arterial ischaemia and ultimately cause gangrene with high amputation and mortality rates. Thrombolysis is mainstay of treatment otherwise surgical thrombectomy. - consider in young patients if they have a hereditary thrombophilia disorder e.g. factor V leiden being the most common. - treatment: LMWH for 5 days + warfarin for 6 months at least; discontinue LMWH when INR is between 2-3. *CHRONIC VENOUS INSUFFICIENCY* - increased venous pressure due to malfunctioning valves in the veins - lower limb discomfort, superficial tortuous veins, oedema, hyperpigmentation (yellow-brown or red-brown skin pigmentation), stasis dermatitis (scaly, pruritic rash) and ulcer formation - can lead to *lipodermatosclerosis* a localised chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg: painful, indurated, and hardening: requires regular emollient use and v.potent topical steroid. - risks: F>M, higher age, family history, sedentary lifestyle, prolonged standing, obesity, smoking, pregnancy - diagnosis established based on duplex ultrasonography - general advise: avoid heat and prolonged standing. Walk as much as possible, raise legs when sitting down, compression stockings, *POST-THROMBOTIC SYNDROME*: - symptomatic chronic venous insufficiency after deep venous thrombosis - pain, cramps, calf/ankle oedema (relief with elevation), pruritus, hyperpigmentation, lipodermatosclerosis, shallow painless irregular ulcers above the medial malleolus, thrombophlebitis s/s. - conservative management: compression stockings, ambulation, avoid prolonged standing and elevate limbs when sitting/sleeping. - ulcers require district nurse r/v with compression bandaging and antibiotics if infective. Surgery if all else fails. - if fluid leaking: apply dressings: 1-2x/day, compression therapy, elevation (when resting), exercise, diuretics, potassium permanganate (in supervision of a dermatologist). If all else fails; refer to dermatologist (in non-healing ulcers present) or vascular surgeon (if ABPI<0.8). *VENOUS ULCERS* - most frequently just above the ankle - shallow, irregular borders, mild pain - management: district nurses review/tissue viability nurse for debridement, skin care, wound dressings. Systemic antibiotics in signs of infection. Skin graft in large or refractory ulcers ❗the presence of a non-healing ulcer in chronic venous insufficiency should raise suspicion of cutaneous squamous cell carcinoma; a punch biopsy would therefore be necessary. *ARTERIAL ULCERS* - seen in peripheral arterial disease - severe pain, punched-out ulcer, well-defined borders, usually involving the foot, particularly pressure points (e.g., lateral malleolus, tips of the toes) OTHERS: MUSCLE CRAMPS - manage with muscle stretching, *massaging*, *heating pads* - *treat any underlying causes* such as dehydration, electrolyte deficit, calcium levels etc. Review medications. - *quinine* ONLY if cramps have no cause, are nocturnal and affecting one's ability to sleep. It is a drug that carries many adverse effects and to be used with caution. It can take 4 weeks to work; if no effect; then stop the treatment. The licensed dose for the treatment and prevention of nocturnal leg cramps in adults is 200-300 mg at night for quinine sulphate (recommended starting dose 200 mg).

*PELVIC PAIN* AND *RIGHT ILIAC FOSSA PAIN* cases in a women only - ectopic pregnancy (1st trimester, hcG+) - miscarriage (<20 weeks, hCG+) - acute appendicitis (psoas, Rovsing's) - pelvic inflammatory disease (temp>38, dyspareunia +/- discharge and bleeding) - ovarian torsion (adnexal mass) - ruptured ovarian cyst (peritoneal signs) - period pain (cyclic, vitals normal) - fibroids (+/- cyclic menorrhagia) - endometriosis (cyclic menorrhagia) - adenomyosis (age >40, cyclic menorrhagia) - ovarian cancer (similar presentation to IBS in >50yrs woman) - vaginal dryness (post-menopausal) cases in men only - testicular torsion - epididymitis cases in both men and women - UTI (urine dip+) - ureteric colic (microscopic haematuria) - urinary retention (risk factors) - bowel obstruction (not opened bowels or passed flatus), distension, low bowel sounds +/- vomiting - IBD: young teenagers - IBS: diagnosis of exclusion

*ACUTE APPENDICITIS* - periumbilical/RIF pain, nausea, vomiting - psoas sign (pain with resisted hip flexion), rovsing's sign (RIF pain with palpation of the left side). - differential would be mesenteric adenitis *ECTOPIC PREGNANCY* - period of amenorrhoea followed by severe pelvic pain. Rule out with hCG - risks: previous ectopic pregnancy (15% chance of recurrence), history of surgery; tubal surgery, history of PID, multiple sex partners, smoking, current IUD, IVF pregnancy, uterine fibroids/adhesions - salpingostomy: removal of mass from fallopian tube; helps preserve fertility. Salpingectomy: fallopian tube removal: indicated if unstable and bleeding present in pelvis; fertility will be affected *OVARIAN TORSION* - excruciating unilateral pain +/- *adnexal mass on palpation*. Usual associated symptoms; nausea, vomiting, low grade fever. - risks: reproductive age, previous episode, ovulation induction, ovarian mass and pregnancy *RUPTURED OVARIAN CYST* - peritoneal signs *TESTICULAR TORSION* *PELVIC INFLAMMATORY DISEASE* - fever >38, dyspareunia, vaginal discharge post-coital bleeding, pelvic tenderness - history of multiple partners - 14 day outpatient antibiotics (ceftriaxone IM single dose + doxycycline) with aim to follow up after treatment. Advise to seek medical attention if no response to antibiotics within 48hrs. - complications: infertility, ectopic pregnancy *PERIOD PAIN* - primary dysmenorrhoea that's cyclic *IBS, IBD, LACTOSE INTOLERANCE, COELIAC DISEASE AND GASTROENTERITIS* - usually associated with diarrhoea +/- fever. - rule out with stool c&s, tTG (coeliac) and/or colonoscopy. *URINARY TRACT INFECTION *URINARY RETENTION* *VAGINAL DRYNESS* - common in post-menopausal women complaining of dyspareunia. Manage with topical oestrogen cream.

*OTHER VISION PROBLEMS*

⚠️ *ORBITAL CELLULITIS*: - ocular emergency - proptosis, pain with eye movement, severe fever, reduced vision - usually diagnosed at age 7 but adults with history of trauma, surgery, dental infections, etc may get it too. - manage: admit, IV antibiotics (with review 48 hours later if surgical intervention required). *DIABETIC RETINOPATHY* - prevalence approximately 75% after 20 years of diabetes. ==> *nonproliferative* accounts for the majority: fundoscopy shows haemorrhages, exudates, microaneurysms and venous dilatation. Usually asymptomatic unless retinal oedema or ischaemia - involves the central macula which causes vision loss. HTN and fluid retention exacerbate this condition. ==> *proliferative retinopathy*: new vessel formation (neovascularization) and scarring. Two serious complications are vitreous haemorrhage and retinal detachment. - laser photocoagulation is the treatment of choice + ranibizumab for those with non-proliferative retinopathy with macular oedema and proliferative causes. Aim to also keep HbA1c between 6-7%. *STRABISMUS* - strabismus/squint (esotropia when the eye points inward, exotropia when eye points outward). Parents will describe it as "turning eye". - if left untreated, can become permanent, cause amblyopia, binocular vision, reduced perception of depth and of psychosocial complications - amblyopia: most common cause of monocular *vision impairment* in children and young adults and its caused by strabismus - exam: eye symmetry, ptosis, corneal light reflex (light reflected back from the corneas should be symmetric), cover test, look for red reflex. If appropriate/possible: fundoscopy and visual acuity. - any child with a suspected or confirmed squint should be referred to the paediatric eye service for management (urgently if a serious cause is suspected). Glasses to correct refractive error or surgery may be required. *VITAMIN A DEFICIENCY* - causes *night blindness, dry and hyperkeratotic skin*. This can progress to conjunctival dryness and corneal ulceration - risk factors: alcoholics, liver disease, proteinuria, TPN. *INTERNUCLEAR OPHTHALMOPLEGIA* - blurred vision and horizontal diplopia due to lesion in the mid-pons. - 1/3 cases caused by vascular ischaemia - other causes include MS, neurological damage from encephalitis, hepatic and Wernicke's encephalopathy, glioma tumour in the 4th ventricle, head trauma, neurosyphilis, intoxications

*OSTEOPOROSIS MANAGEMENT*

1) *smoking and alcohol cessation* 2) *diet*: daily calcitonin (1200mg/day), vitamin D 3) *weight bearing exercise* 3x/week to stimulate bone formation 4) medication 💊 *biphosphonates* (oral alendronate or risedronate) reduce osteoclastic activity and thus the risks of fractures. A/E - reflux, oesophageal irritation, ulceration. Include PPI cover. Advise to taken one tablet in the morning; 30 minutes before breakfast and sitting upright. Alternatively: IV zolendronic yearly or denosumab 💊 2nd line - PTH therapy (*teriparatide s/c)* if 1st line failed or severe spinal osteoporosis - max 24 months course. 💊 *raloxifene* (Evista) is a SERM indicated for the treatment and prevention of osteoporosis in postmenopausal women who are at an increased risk of breast cancer. - good alternative for biphosphonate - contraindicated in women with a history of venous thromboembolism.

*VOMITING* investigate: - observations determines stability of patient and if needing admission - bloods: FBC, U&E, (hcG if young) - if coffee ground; acute gastritis: stop NSAIDs. Chronic gastritis: investigate for H.pylori (blood/saliva), pernicious anaemia, - upper endoscopy + biopsy - if persistent vomiting/coffee ground vomit or if "SWIPE CV" indicated.

COFFEE GROUND ⚠️ *gastric cancer* (coffee ground): suspect strongly in aged>60 patients who smoke, heavy drink use, poor diet (smoked foods, high salt) and present with unintentional weight loss 🔷 *chronic PUD or acute/chronic gastritis*: coffee ground vomit with melaena. Duodenal ulceration is the most common cause for upper GI bleed. Rule out NSAIDs/steroids and H.pylori cause BRIGHT RED BLOOD ⚠️*oesophageal varices*: often caused by portal hypertension from CIRRHOSIS secondary to *alcoholic liver disease* (ALP>ALT 2:1 is highly specific and sensitive). But can be other causes e.g. *Budd Chiari syndrome, hepatocellular carcinoma, haemochromatosis, Wilson's disease, etc. Look for other complications of portal HTN: splenomegaly (80%), ascites, spider angioma, palmar erythema, haemorrhoids. Signs of cirrhosis include: hepatic encephalopathy, hepatorenal syndrome, hepatocellular carcinoma, bacterial peritonitis, hyperestrinism, coagulopathy. ⚠️*Mallory Weiss tear*: laceration of the GE junction; occurs with excessive vomiting. ⚠️*severe gastritis or gastric cancer* BILOUS/DARK GREEN ⚠️*bowel obstruction*: when did they last open their bowels? pass wind? previous abdominal surgeries, distended abdomen? WATERY/NORMAL 🔷 *gastroenteritis*: any associated diarrhoea or recent travel? 🔷 *pregnancy*: young patient associated with nausea 🔷 *alcohol 🍺 and/or medications* e.g. opioids more pain associated 🔷 *gastroparesis*: an autonomic neuropathy: moreso associated with nausea, early satiety and and feeling bloated rapidly after meals. Manage with smaller frequent meals, improved glycaemic control and metoclopramide. ⚠️ *ischaemic bowel*: severe generalised abdominal pain with CVD risk factors particularly AF. ⚠️*acute appendicitis, cholangitis and/or cholecystitis*: associated more with abdominal pain ❣️*acute MI*: chest or epigastric pain. Consider risk factors treat: - hydration - general "SADE" advice for those with PUD, gastritis. Administer PPIs +/- H2 blockers +/- amoxicillin & clarithromycin if H.pylori results are positive. - antiemetics if persistent

*NASAL AND SINUS PROBLEMS* causes - rhinorrhoea - allergic rhinitis (sneezing, itching, history of atopy) - rhinitis medicamentosa (iatrogenic rhinitis due to prolonged use of decongestants for >1 week) - sinusitis (facial pain, tenderness) - nasal polyps - foreign body - enlarged adenoids - nasal septal deviation - neoplastic (persistent unilateral) urgent immediate referral if: - unilateral clear nasal discharge (?CSF leak) with history of head injury, facial trauma or sino-nasal surgery - neurological symptoms (severe frontal headache, signs of symptoms of meningism, neurological signs) 2WW ENT referral if: - unilateral findings raising suspicion of neoplasia, blood-stained nasal discharge, recurrent epistaxis or nasal pain note: dose of fexofenadine for hayfever - child >12yrs: 120mg once a day - child 6-12yrs: 30mg BD note: dose of fexofenadine for hives - child >12yrs: 180mg once a day note: side effects of fexofenadine: headache, nausea, dry mouth, fatigue, dizziness

COMMON COLD (NICE CKS) - explain this is a self-limiting condition that resolves within a week (adults) or 2 weeks for children and that antibiotics are not only unnecessary but puts them at increased risk of side effects like diarrhoea and abdominal pains. - advise to continue normal activity (no evidence that rest improves symptoms any quicker), fluids, healthy diet and an antipyretic if co-existing headache, muscle pain, or fever. Avoid over the counter medication for children <6yrs as risks outweigh benefits. - follow up if s/s are worsening after 5 days. - for nasal congestion: steam inhalation, gargling with salt water, sucking menthol sweets or nasal saline drops, decongestants (oral: found in over the counter meds: effect does not extend past a few days, and the benefit is relatively small). - for watery rhinorrhoea: add in intranasal ipratropium bromide (Atrovent Nasal Spray 0.06%): fast acting (within 1st dose) but don't use for >4 days in a cold and >3 weeks for allergic rhinitis. 2 sprays in each nostril 3-4x/day. - for sore throat: as above - for cough: warm drink of honey and lemon complications (for children mainly) *=> sinusitis* (0.5-2% of cases). *=> otitis media* (as many as 20% of young children with the common cold): see "hearing problems". *=> croup* in very young children and babies. *=> chest infections*: bronchiolitis in the very young, acute bronchitis, pneumonia, and exacerbations of COPD or asthma. *ALLERGIC RHINITIS/HAY FEVER* - sneezing, itchy watery eyes, runny nose, and nasal congestion: can be seasonal (depends on high pollen counts) or all year round (consider house dust mites or pets) or occupational. - *tree pollen* occurs first (25% of hay-fever sufferers particularly to birch pollen with myself being one of them) occurs first in Spring (from March-May). It is noted that those who develop an oral allergy to apples/pears are most likely to be birch tree pollen sufferers. - most people however are allergic to *grass pollen* which peaks in the *first 2 weeks of June* with a 2nd lower peak in the *first 2 weeks of July* - precautions/advise to give when pollen count is high ⇨ avoid walking in grassy, open spaces, particularly during the early morning, early evening, and during mowing ⇨ avoid drying washing outdoors ⇨ keep windows shut in cars and building. ⇨ shower or wash hair following high pollen exposures. - if mild persistent s/s: *intranasal antihistamine* (more superior) e.g. azelastine (Optivar®) however, they're expensive. Alternatively, use a non-sedating oral antihistamine e.g. fexofenadine (least sedating of all 2nd gen antihistamines). Alternatively: *intranasal sodium cromoglicate* but doesn't work as well as intranasal steroids. - if mod/severe: *regular intranasal steroid* during expected periods of allergen exposure (e.g. *Avamys®* i.e fluticasone 1-2 sprays each nostril/day: warn that it takes 2 weeks to show effect). They help reduce congestion, sneezing, itchy, watery eyes and a drippy nose - what if treatment fails? → check for compliance failure → if nasal congestion a problem: use a short-term intranasal decongestant e.g. ephedrine or xylometazoline for up to 5-7 days only → if persistent watery rhinorrhoea: add in intranasal ipratropium bromide (Atrovent Nasal Spray 0.06%): fast acting (within 1st dose) but don't use for >4 days in a cold and >3 weeks for allergic rhinitis. 2 sprays in each nostril 3-4x/day. → if persistent nasal itching or sneezing: regular oral antihistamine or *Dymista® spray* (combined intranasal antihistamine and steroid) - if severe with impact on quality of life: continue intranasal steroid with inclusion of *oral steroid*. → prednisolone 0.5 mg/kg for 5-10 days (adults) → prednisolone 10-15 mg for 3-7 days (children) - if steroids not working, refer for consideration of immunotherapy - allergy testing: *skin prick* or *RAST* which involves measuring levels of serum-specific immunoglobulin IgE to allergens such as house dust mites, pollen, and animal dander. - refer to ENT for 2WW if unilateral blood-stained nasal discharge, recurrent epistaxis or nasal pain. *NASAL POLYPS* - mid age peak 40yr old males - caused by "AAA CCC K": *a*spirin, *a*sthma, *a*llergic rhinitis, *c*hronic sinusitis, *C*F, *C*hurg-Strauss, *K*artagener's syndrome. - examine nasal cavity with otoscope: polyps are often bilateral - manage with steroid nasal drops OD for 1 month until polyps shrink then steroid nasal spray e.g mometasone to reduce recurrence otherwise polypectomy. *ACUTE RHINOSINUSITIS* - s/s: pain/tenderness around cheeks, eyes or forehead, blocked nose, sinus discharge, fever, bad breath. - diagnosis: presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain/pressure (or headache) and/or reduction (or loss) of the sense of smell. Other s/s: cheekbone/periorbital tenderness, swelling, or redness and cough. - manage: re-assure 98% cases are viral: manage as you would with rhinitis (over-the counter meds/sprays). Return in 10 days if symptoms persist. - manage: if >10 days: try steroid nasal spray: mometasone (Nasonex) 200 micrograms twice a day or Avamys 1-2 sprays/day. - consider bacterial cause if several of the following criteria present:: s/s>10 days, unilateral purulent nasal discharge, severe local pain, unilateral maxillary sinus tenderness and worsening s/s after initial improvement: manage with: back up antibiotic prescription: first line treatment treatment in the UK is 💊 *phenoxymethylpenicillin* 500mg four times a day for 5 days (*amoxicillin* 10 days/*macrolide* in Canada) or *doxycycline* and if symptoms severe: 💊*co-amoxiclav* 625mg TDS for 5 days if severe. Alternatively, a fluoroquinolone. *CHRONIC SINUSITIS*: - >3 months of symptoms - advise to avoid allergens, stop smoking/avoid passive smokers, dental hygiene, avoid underwater diving (due to risk of sinus barotrauma). Consider saline irrigation, and a course of intranasal steroids e.g. Avamys: for up to 3 months - if no response after 3 months of intranasal steroids, check compliance before referring for nasal endoscopy. - refer if red flags (CT imaging to rule out complications or neoplasia), no response to medical therapy for >3 months (nasal endoscopy to look for polyps +/- allergy and immune function testing) and if the patient considers surgery (functional endoscopic sinus surgery).

*RED EYE* *emergencies* => anterior chamber pathology - angle closure glaucoma, hyphema (blood in anterior chamber), hypopyon (pus within) => cornea pathology - infectious keratitis (bacterial affecting the cornea) *urgent* => anterior chamber pathology: anterior uveitis => cornea: infectious keratitis (viral) => conjunctiva/sclera: scleritis *benign*: lids/orbit/lacrimal system => hordeolum, chalazion, blepharitis => conjunctivitis, dry eyes, episcleritis => corneal abrasion, foreign body, contact lens overwear (urgent follow up if no improvement within 24-48 hours).

PRIMARY ANGLE CLOSURE GLAUCOMA - a leading cause of blindness for >60yrs patients which can often be prevented with early treatment. - open-angle glaucoma (2% of people in the UK) - aqueous humour ends up having difficulty draining into the trabecular network (like a sink drain) at the drainage angle leading to increased eye pressure causing optic nerve damage - acute painful red eye, rainbow coloured halos around lights, blind spots in vision, semi-dilated and fixed pupil, - risk factors: increasing age, family hx, Blacks (2x), steroid use, myopia, diabetes (2x), hypertension - treatment: positioning (lie flat with face up and head not supported by pillow), pilocarpine drops, acetazolamide orally, laser iridotomy. - treatments: topical prostaglandin analog, beta blockers, alpha agonists, carbonic anhydrase inhibitors eye drops. Laser and PRIMARY OPEN ANGLE GLAUCOMA - closed angle glaucoma (0.4% of people in the UK) occurs suddenly and occurs when one's iris is very close to the drainage angle in the eye - risk factors: age>40, W>M (3x), Asian, hyperopic eyes, family history - s/s: progressive peripheral vision loss leading to tunnel vision (consider if driving), central vision affected later. Eventually: blind spots in vision, coloured halos around lights. In 5-10% of patients irreversible blindness develops. - suspect chronic glaucoma in a person with a visual field defect without other eye symptoms - treatments: topical prostaglandin analog (e.g. latanoprost), beta blockers (timolol), alpha agonists, carbonic anhydrase inhibitors (acetazolamide) eye drops. Laser and surgical treatments. - opportunistic testing for glaucoma? >60yr olds every 2 years, >70yrs annually, age >40 Black or first degree relative with glaucoma every year. HYPHEMA (blood in anterior chamber) HYPOMA (pus within) => cornea pathology *KERATITIS* - usually bacteria affecting the cornea - eye pain, redness and tearing - advise removal of the contact lens and seek urgent ophthalmology review *CONJUNCTIVITIS* (viral, bacterial, allergic) *EPISCLERITIS* - episcleritis is usually self-limiting. *DRY EYES* - *CORNEAL ABRASION* - abrasion (secondary to trauma or contact lens use: pain, redness, tearing, photophobia and foreign body sensation) - risks: foreign body, contact lens overwear (urgent follow up if no improvement within 24-48 hours). ECTROPION, ENTROPION, TRICHIASIS - ectropion can cause exposure keratopathy - entropion and trichiasis can cause corneal irritation and abrasion *BEHCET'S DISEASE*: - 3x episodes of mouth ulcers in the last 12 months PLUS (a) genital ulcers (b) relapsing uveitis/iritis which can progress to blindness (c) pathergy/cutaneous hypersensitivity (d) erythema nodosum. - this is more common in young Eastern Asians and involves inflammation of blood vessels. *REITER'S SYNDROME*: U2CAT mnemonic: - *U*rethritis (chlamydia, campylobacter, shigella, salmonella) - *U*lcers (oral+/-genital) - *C*onjunctivitis/anterior uveitis - *A*rthritis (commonly lower limbs) - *T*endon insertion site tenderness/enethesitis

*KNEE PAIN* remember - inflammatory: pain worse with rest, better with exercise. Furthermore: associated fever, chills - non-inflammatory: pain better with rest, worse with exercise - medial knee pain: OA, MCL injury, medial meniscus tear and fractures of the tibial plateau - lateral knee pain: iliotibial band syndrome, lateral meniscus injury - anterior knee pain: ACL injury, pre-patellar bursitis, chondromalacia patellae, patella instability, osgood-schlatter disease. OTTAWA RULES FOR X-RAY: only applies to those with an acute knee injury + >1 of: - >55 years or older - Tenderness at head of fibula - Isolated tenderness of patella - Inability to flex the knee greater than 90° - Inability to bear weight both immediately and in the emergency department (4 steps) TOPICS - septic arthritis (in emergency) - pseudogout - reactive arthritis - juvenile idiopathic arthritis: Still's disease, oligoarticular arthritis, polyarticular JIA, enthesitis related arthritis - osteoarthritis (see small joint pain) - ligament damage: ACL (sports), PCL (motor vehicle accident) - meniscal tears: MCL (blow laterally), LCL (blow inside) - anterior knee pain: chondromalacia patellae, patella instability, osgood-schlatter disease *HOW TO DICTATE A REFERRAL* e.g. 1) thankyou for seeing this young gentleman who presents today left anterior knee pain 2) the pain is localised in the anteromedial area and has been ongoing for the last 4 months. It is particularly worse when sitting for prolonged periods or going up and down the stairs 3) examination is unremarkable 4) I suspect Mr X has chondromalacia patellae and would therefore benefit from your guidance in regards to muscle strengthening exercises (to physio)

for acute pains: septic arthritis, etc: please see "emergency" quizlet section. *PSEUDOGOUT* - calcium pyrophosphate: positively birefringent (blue under parallel light) rods and *rhomboid crystals* in synovial fluid - knee most common site of attack. *REACTIVE ARTHRITIS* acute asymmetrical *lower limb arthritis*; a few days to weeks after GI/GU infection. - triad of *conjunctivitis, arthritis and urethritis*. - other possible s/s include skin changes. It has an association with HLAB27. Can present with arthritis anywhere including the back but the lower limbs are most common. *STILL'S DISEASE*: - joint pain, swelling, muscle pain, and a salmon-pink maculopapular rash. Inflammatory markers raised *OLIGOARTICULAR ARTHRITIS* - the most common type of JIA. It affects up to 4 joints in the body - most commonly in the knees, ankles and wrists. Usually *girls>boys (80%), age <4 years*, affects *large joints* and can be associated with *uveitis in 20%* *POLYARTICULAR JIA*: - second most common type of JIA and affects 5 or more joints; s/s similar to RA. *ENTHESITIS RELATED ARTHRITIS* - type of juvenile arthritis that often affects weight bearing joints with inflammation at the site where tendons or ligaments attach to the bone. Stiffness can occur in the neck and lower back in the teenage years. It's also linked to acute uveitis *ACL INJURY* - sudden deceleration, twisting, pivoting, turning causing audible pop, immediate swelling, "giving way" with inability to continue activity - diagnosis: positive anterior drawer test, pivot shift sign and Lachmann test (more accurate) *PCL INJURY* - secondary to a motor vehicle crash - sudden posterior displacement of tibia when knee is flexed or hyperextended*. Symptoms as above. Diagnosis: positive posterior drawer test, reverse pivot shift sign - management for ACL or PCL 1) immobilise with knee brace for 2-4 weeks with early ROM and strengthening 2) if complete tear/very active individual: ligament reconstruction *MENISCAL TEARS* - MCL more common with direct blow to outside of knee causes valgus deformity: pain, instability, difficulty weight-bearing, locking. LCL is due to a blow from the inside (rare). Diagnose with MRI or arthroscopy. Management: surgical repair if there is locking or non-operative management failed *PATELLOFEMORAL SYNDROME - CHONDROMALACIA PATELLAE* - risks: young athlete females, excessive knee strain causing articular cartilage damage *predominantly in the medial aspect of the patella* - s/s: deep aching anterior knee pain *worse with squatting, stair climbing or strenuous athletic activity*, "popping", catching, stiffness may also accompany clinically features - physical examination: ==> pain with firm compression of the patella into the medial femoral groove. ==> *J sign*: ask patient to sit with legs hanging; then extend knee from baseline 90 to 180 degrees. Observe for patellar deviation laterally in the shape of the letter "J" . - *MRI is best to assess cartilage*. X-ray may be non-conclusive - management: exercise and strengthening via physio is the mainstay of treatment, surgery if all else fails <note: there should be NO swelling or locking as this indicates an intra-articular pathology> *OSGOOD-SCHLATTER DISEASE* - inflammation of the patellar ligament at the insertion point on the tibial tuberosity due to repetitive stress - puberty, athletic boys>girls - s/s: *tender lump over tibial tuberosity, pain on resisted leg extension*. There are no effusions, instability or loss of ROM. - x-ray: lateral: shows fragmentation of tibial tubercle - management: restrict high intensity exercises, pain relief, physiotherapy. - most cases completely resolve in 18-24 months. *GROWING PAINS* - diagnosis of exclusion with physical findings normal - intermittent, non-articular pain night pain, often bilateral limited the calf or shin, relief with heat/massage - child is well, asymptomatic during the day with no loss of function *ILIOTIBIAL BAND SYNDROME*: lateral thigh pain radiating down to the lateral knee: the most common overuse injuries among runners. Climbing stairs or running downstairs makes the pain worse. Can be tender in this area and s/s worse with knee flexed to 30 degrees. *ANSERINE BURSITIS* - medial knee, night pain. 2-3cm below medial joint line; can be bilateral with localised tenderness.

*MOUTH ULCERS* if recurrent ulcers, consider the following tests - FBC (+iron, B12 and folate), tTg-IgA, foecal calprotectin (for suspected Crohns disease) - if inflammatory cause suspected: request also ESR, CRP consultation 1) SOCRATES, first time? recurrent? associated fevers, bowel problems?general fatigue/exhaustion, eye pain/redness or floaters, rash on the face of legs. Impact on quality of life: eating/drinking ok? 2) ICE 3) Event? e.g. trauma from brushing teeth 4) Medications e.g. nicorandil, captopril, methotrexate, penicillamine 5) Social: smoking, alcohol in particular 6) History of coeliac disease, IBD, lupus, rheumatoid arthritis, skin diseases e.g. lichen planus 7) family history of the above 8) physical: site(s), size 9) consider bloods: see above 10) management depends on suspected cause

rule out cancer: any solitary ulcer persisting for >3 weeks warrants urgent referral for incisional biopsy. - early lesions may present with erythroplakia (red patch) or leukoplakia (white patch). - risk factors: heavy smoking, heavy alcohol drinking, age over 45 years, and male sex. canker sores/aphthous ulcers (see pic) - usually inner lips and buccal mucosa: painful recurrent round/oval light grey/yellow elevated spot surrounded by a red halo. - common in non-smokers, genetic in 40%, iron/folic acid or B12 deficiency, hormonal factors, local trauma and triggered by certain foods (typically chocolate, coffee, peanuts, and/or gluten products). - to relieve the pain, try warm saline mouthwash, hydrocortisone buccal tablets applied directly onto the ulcer (up to 4x a day for 5 days). Alternatively, topical benzydamine or chlorhexidine mouthwash. In severe recurrent cases: oral prednisolone. Specialist referral if no response. - re-assure, should resolve within 1-2 weeks but advise to return if persistent for >3 weeks. cold sores/herpes labialis - secondary to HSV (usually on the outer lips). - re-assure self-limiting and should heal in 10-14 days without scarring. If painful, suggest basic analgesia. - do not routinely prescribe topical anaesthetics, mouthwash and lip barrier preparations: evidence suggests there is no good-quality evidence on the effectiveness of these products. If the patients insists, they can be purchased over the counter. - the sores can become infected causing impetigo: manage with fusidic acid. systemic diseases - coeliac disease, inflammatory bowel disease, SLE, Behcet's syndrome, Reiter's syndrome, HIV lichen planus - painful white patches on the gums, tongue or the insides of the cheeks - can of course also present with polygonal purple pruritic rash particularly on the wrists. medications - nicorandil, captopril, methotrexate, penicillamine

*RAYNAUD'S PHENOMENON*

s/s: finger colour changes, numbness or paraesthesias; precipitated by cold, anxiety and stress causes: idiopathic, autoimmune disorders (SLE, scleroderma, RA, mixed connective tissue disease), hypothyroidism, trauma, beta blockers, oestrogen tablets (without progesterone), treatments for cancer symptomatic treatment with calcium channel blockers e.g. nifedipine

*VAGINAL BLEEDING* / *MENORRHAGIA* - ask when? after periods, within periods, after sex - how much? - associated with fever? - consider age: is it post-menopausal? ➟ *neonatal bleed* tinge of blood @ 2-3 days of age ➟ *vulvovaginitis* ➟ *pelvic inflammatory disease* fever, dyspareunia, lower abdominal pain and abnormal foul smelling discharge ➟ *fibroids/leiomyomas* menorrhagia, dyspareunia, and dysmenorrhea in an obese nulliparous woman with an asymmetrically enlarged nodular uterus on examination is suggestive of uterine fibroids, ➟ *endometriosis* in a woman of childbearing age, chronic dysmenorrhea and dyspareunia with no evidence of pelvic pathology on examination (e.g. enlarged irregular uterus, adnexal mass, cervical discharge, cervical motion tenderness) is highly suggestive of endometriosis ➟ *adenomyosis* similar to endometriosis but older age ➟ *miscarriage* pregnancy loss <20 weeks ➟ *hydatidiform mole* vaginal bleed in 1st trimester ➟ *endometrial hyperplasia* ➟ *endometrial cancer* ➟ *vaginal cancer* ➟ *dysfunctional uterine bleeding*

♣️ neonatal - tinge of blood can be normal between 2 or 3 days of age due to withdrawal of oestrogen the child was exposed to in the womb ♣️ infant - consider foreign object; which can precipitate them to *VULVOVAGINITIS* with blood tinged, foul smelling discharge. Gentle irrigation of the vagina with saline solution or water in the outpatient setting is usually sufficient to dislodge any foreign body. If this is a recurrent problem; consider child abuse (see community medicine section). ♣️ adolescents *ANOVULATORY CYCLES* - most common cause of menorrhagia in postmenarchal adolescents within the first 2 years post-menarche due to an immature hypothalamic-pituitary-ovarian axis. - bleeding heavy and irregular with a negative urine screen, absence of fever and abnormal discharge. - manage with NSAIDs or OCP ♣️ contraception *BREAKTHROUGH BLEEDING (BTB)* - bleeding/spotting within periods - associated with initial 3 months of COC use or if having missed the pill - if >3 months; start NSAIDs and/or supplemental oestrogen for 1-2 weeks then follow up. If still no improvement, change pill formation to either higher oestrogen or different progestin. If still no improvement, try another form of contraception. *IUD* - a T shaped device that releases COPPER producing a spermicidal environment; works immediately for 5-10 days. Can be taken out anytime without effect on fertility (unlike IUS). - periods may become heavier, longer or more painful initially after initial use. This is usually the most common reason for wishing to discontinue. - it's use: first-line for emergency contraception; can be used <5 days of unprotected sex (↑efficacy). - *risk of ectopic pregnancy is higher* and it doesn't protect against infections. ♣️ abnormal e.g. post-coital *PELVIC INFLAMMATORY DISEASE*: - fever, dyspareunia, lower abdominal pain and abnormal foul smelling discharge ♣️ pregnancy *MISCARRIAGE* - loss of pregnancy before 20 weeks' gestation - causes: chromosomal abnormality (50%), reproductive organ anatomical issue, systemic disease (e.g. diabetes, thyroid issues, etc), trauma, maternal smoking/toxins, iatrogenic (e.g. amniocentesis or CVS) *HYDATIDIFORM PREGNANCY* (MOLAR PREGNANCY) - vaginal bleeding during 1st trimester with *uterus greater in size than normal for gestational age* - associated with hyperemesis gravidarum - gestational trophoblastic disease with a mass of abnormal tissue originating in the placenta - complete: abnormal placenta tissue, no foetus, diploid - 90% are 46XX both a paternal X chromosomes, ⇈β-hCG levels - partial: contains some foetal tissue with placenta growing abnormally, triploid - 69XXX or 69XXY, β-hCG are lower than in complete. - transvaginal U/S: may reveal a complex intrauterine mass containing many small theca lutein cysts, - initially: try *vaginal pessary of misoprostol* in the posterior fornix every 4 hours to cause cervical dilation and expulsion of the non-viable products of conception. If this fails uterine evacuation by dilation and suction curettage with monitoring of β-hCG every few months. Give methotrexate if unresolved. ♣️ getting older *FIBROIDS* / *LEIOMYOMAS* - benign smooth muscle tumors of the uterus with oestrogen receptors therefore grow with higher exposure and shrink after menopause. Various types: ➟ subserous: (most common) associated with calcification which can be seen on x-ray ➟ intramural (2nd most common): usually asymptomatic ➟ submucosal: (3rd most common) are more likely to symptomatic - typically premenopausal >35yrs with 70% presenting by 45yrs - risk factors: obesity, *nulliparity*, family history, early puberty (long exposure to oestrogen), African-American - s/s: usually asymptomatic otherwise menorrhagia (heavy bleed >7 days), dysmennorhoea (painful cramps), irregular periods, abnormal uterine bleeding +/- dyspareunia, urinary frequency/urgency (if compressing on bladder) - can cause spontaneous abortions - bimanual exam: firm irregularly enlarged uterus - request *pelvic U/S* (transvaginal or transabdominal) if larger fibroids suspected, the woman is too obese to examine or the uterus is easily palpable: hypoechoic mass seen on endometrial wall. - request *hysteroscopy* in those with submucosal fibroids, polyps, or endometrial pathology. It allows for confirmation of fibroids. - management: only if symptomatic 1) watchful waiting: they tend to regress after menopause due to lower oestrogen levels. 2) control pain and bleeding symptoms with - consider *levonorgestrel IUS* first line if fibroids are <3cm in size - *NSAIDs, transexamic acid*: use regularly only doing periods of heavy bleeding - *OCP/Depo-Provera®* 3) to shrink fibroids: - *GnRH agonist* e.g. leuprolide which decreases oestrogen production - *ulipristal acetate* - *uterine artery embolisation* (helps shrink fibroids and improve bleeding) 4) surgery - *myomectomy* (ideal choice for those who would like to preserve fertility), - *hysterectomy* if beyond age and do not want children. *ENDOMETRIOSIS* - presence of endometrial tissue outside the uterine cavity; most commonly ovaries - young women 25-30yrs old, family history, early menarche, late menopause, nulliparity - resolves only with menopause - s/s: mostly asymptomatic otherwise: sacral backache, dysmennorhoea (painful cramps prior to menses), menorrhagia (heavy bleeding), deep dyspareunia (painful sex), bladder/bowel issues. May complain of infertility (30-40% of those with endometriosis will be infertile) *- pain worsens prior and during menses and regressing after menopause* - diagnosis: CA125 may be raised but not used due to low specificity. Definite: hysteroscopy + biopsy - U/S pelvis commonly shows *chocolate cysts* of the ovaries - 1st line: symptom control with NSAIDs. OCP, progestin* (Depo-Provera® or Visanne®) or the *Mirena IUD* - 2nd line: GnRH analog e.g. leuprolide or weak androgen e.g. danazol - 3rd line: laparoscopy with *laser and electrocautery for ablation* or *hysterectomy + bilateral salpingo-oophorectomy*: if children not desired. <in a woman of childbearing age, chronic dysmenorrhea and dyspareunia with *NO evidence of pelvic pathology on examination* is highly suggestive of endometriosis> *ADENOMYOSIS* - ectopic endometrial tissue within the uterine wall (myometrium) - similar to endometriosis except → *older age: typically 40-50 years* → *more common with multiparous women* than nulliparous - investigate with *transvaginal U/S* in suspected cases (menorrhagia, significant dysmenorrhoea that worsens during menstruation or a bulky, diffusely enlarged tender uterus in a multiparous woman - if patient refuses a transvaginal U/S; then offer a transabdominal U/S or MRI but explain that they would be less accurate on detection. - first line treatment: *levonorgestrel IUS*. If declined: NSAIDs, tranexamic acid, otherwise oral contraception. *ENDOMETRIAL HYPERPLASIA* - risk factors; obese, >35yrs, nulliparity, early menarche, late menopause, - endometrial biopsy required: confirms proliferation of endometrial glands - treatment: progestin therapy. - follow-up with ultrasound after 3-6 months of conservative treatment is recommended to rule out progression to endometrial hyperplasia with aplasia or endometrial carcinoma. *ENDOMETRIAL CANCER* - referral for >55yrs with post‑menopausal bleeding - risk factors: PCOS (most common), obesity (increases endogenous oestrogen), prolonged exposure to oestrogen (nulliparity, late age of menopause, early menarche, white race, breast cancer, tamoxifen use, systemic disease (diabetes, HTN, gallbladder disease) - management: radical hysterectomy, bilateral salpingo-oopherectomy and radiotherapy *VAGINAL CANCER* - post-menopausal bleeding with mass/plaque on vaginal wall +/- urinary frequency - biopsy is required and if positive, clinical staging with cystoscopy, proctoscopy, and chest and skeletal radiography will be required. - treatment requires surgical excision with or without radiation and chemotherapy, depending on the stage of the cancer. ♣️ unexplained *DYSFUNCTIONAL UTERINE BLEEDING* - 40-60% with no pathology - *first line treatment is IUS* (Cochrane studies suggest this is more effective than oral treatment). Alternatives include oral contraceptives, transexamic acid, NSAIDs, endometrial ablation or hysterectomy.

*DYSPHAGIA* - obstructive causes: angioedema, cancer, AAA/aortic dissection, GORD/peptic strictures, schatzki rings, pharyngeal pouch/Zenker's diverticulum, oesophageal candidiasis, radiotherapy, scleroderma - neurological causes: stroke, MS, dementia, myasthenia gravis, achalasia ask 1) how long for? 2) any associated s/s: odynophagia 3) does the food feel "stuck in the chest" (oesophageal dysphagia requires upper GI endoscopy) or is there difficulty initiating the swallow when you had food in the mouth (oropharyngeal dysphagia: requires barium swallow) 4) do they have difficulty swallowing solids, liquids or both? - if both suspect achalasia: manometry required 5) any history of smoking, reflux, cancer, stroke, known neurological disease like MS *SENSATION OF SOMETHING IN THROAT* - a.k.a. *globus pharyngeus* - tickling, lump or constriction feeling often exacerbated by stress and may have reflux - *red flags must be ruled out: pain, dysphagia, persistent hoarseness and lateralising symptoms*. - consider treating as reflux but main aim is to re-assure

⚠️ *ANGIOEDEMA* - acute drug reactions or anaphylaxis - ask bugs, drugs and food history ⚠️ *PERITONSILLAR ABSCESS* - consider strongly in children with a history of sore throat, dysphagia, dysphonia, drooling, unable to open their mouth, unilateral neck pain, mass or tenderness ⚠️ *CANCER* - feel for neck lumps and ask about unintentional weight loss, fever, night sweats, bone pain, dysphagia, odynophagia, persistent hoarseness, earache, sore throat, or haemoptysis - oesophageal/laryngeal ca: consider in heavy smokers - thyroid cancer: previous ionising radiation exposure - lymphoma: night sweats, weight loss, fever ⚠️ *AAA or AORTIC DISSECTION* - consider in men >60yrs particularly those who smoke - compression on adjacent areas *PHARYNGEAL POUCH/ ZENKER DIVERTICULUM* - large midline lump most common in older men; gurgles on palpation. - associated with bad breath - abnormal oesophageal motor function *GORD AND PEPTIC STRICTURES* - peptic strictures are an end stage result of chronic reflux oesophagitis *SCHATZKI RINGS* - intermittent dysphagia with solid foods or sensation of food stuck in the throat - unknown cause but thought to be linked to acid reflux - diagnose with endoscopy or barium swallow: will show narrowing of the lower oesophagus - manage with balloon dilatation - complication: "steakhouse syndrome": when food not thoroughly chewed is stuck causing severe chest pain. Requires manual removal. *OESOPHAGEAL CANDIDIASIS* - rule out immunodeficiency e.g. HIV *RADIOTHERAPY* *SCLERODERMA* - African American, 30-50yrs, fibrotic disease and vascular alternations: limited form "CREST": *c*alcinosis, *r*aynaud's phenomenon, *e*sophageal dysfunction, *s*clerodactyly and *t*elangiectasia. - systemic form affects the organs. - raynaud's phenomenon in 70%. *NEUROLOGICAL* - *stroke, MS, dementia, myasthenia gravis* - *oesophageal achalasia*: impaired relaxation (related to nerve issue) of the LES leads to dysphagia of *BOTH solid and liquid foods simultaneously*. Diagnosed with manometry. investigations - if oropharyngeal dysphagia: videofluoroscopy (modified barium swallow) - if oesophageal dysphagia: OGD or barium swallow (which helps rule out strictures, narrowing or tumours) Management - change consistency of food and liquids, SALT review, ?NG/PEG/oesophageal stent - if achalasia: medications and botox

*ACUTE EPIGASTRIC PAIN* - ruptured AAA - aortic dissection - acute pancreatitis - ischaemic colitis - chronic mesenteric ischaemia - perforated PUD - acute inferior MI - acute cholangitis *CHRONIC EPIGASTRIC PAIN* - GORD/PUD/oesophagitis/gastritis - medications e.g. antidiabetics, antidepressants what to request (essential) - FBC, U&E + creatinine, CRP, crossmatch pRBC - amylase, troponin - ABG/VBG - ECG - CXR and AXR - U/S abdomen - upper GI endoscopy (if relevant)

⚠️ *RUPTURED AAA* - epigastric pain radiating to the back - hypotension/tachycardia - *palpable pulsatile mass* in the epigastric area. note: distal pulses may be intact. For thoracic aorta ruptures: look for decrease in femoral pulses - management: IV fluids, NBM, crossmatch RBC, transfer to operating theatre - risk factors for AAA: smoking, HTN, vascular disease, age>65, family history with 75% are asymptomatic - ultrasound is best but for a ruptured aorta: aortography is gold standard (in Canada) because it provides exact location and severity of injury - if not ruptured: watchful waiting. Indications for surgery (EVAR): rupture, symptomatic, size>5cm ⚠️ *ACUTE PANCREATITIS* - severe onset radiating to the back - *pain relief leaning forward but worse after a meal* - commonly history of gallstones more commonly or alcohol use - bruised umbilicus and flank - raised amylase and lipase ⚠️ *ISCHAEMIC COLITIS* - severe cramping left sided pain moreso, rectal bleeding* (dark red) +/- diarrhoea, fever >38 - risk factors: typically age>60 with cardiovascular disease e.g. AF (acute mesenteric ischaemia), HTN, diabetes - if ischaemia continues: abdominal pain becomes more widespread, tenderness, reduced/absent bowel sounds with no further bloody stools, shock with altered mental status, unstable observations - VBG (initial test): *metabolic acidosis + raised lactate*. - AXR may reveal air in the bowel wall - CT scan although cases are officially diagnosed with endoscopy. If patient is unstable: they require emergency exploratory laparotomy. - management: IV fluids, analgesia, antiemetics, NBM, NG tube (if evidence of ileus), immediate surgical intervention - if worsening symptoms and signs such as high WBC, fever, worsened abdominal pain, or increased bleeding, then they may require surgical intervention; laparotomy and bowel resection. ⚠️ *PERFORATED PEPTIC ULCER* - sudden onset of severe epigastric pain that lessens after a few hours before becoming more generalised. Nausea/vomiting is delayed. - abdominal distension - abdominal tenderness/guarding and rigidity, haematemesis, bloody stools, diminished bowel sounds after 6 hours - may follow a heavy meal - maximal incidence 45-55yrs - CXR: free air under the diaphragm (75%) - manage: NBM, fluids, analgesia, antiemetics, NG suction, broad spectrum antibiotics, immediate laparotomy - complications: shock (after 3 hours), peritonitis (after 6 hours) ⚠️ *ACUTE INFERIOR MI*: see "chest pain" - chest pain radiating to the back. Rule out with ECG and troponin. - inferior MI: look for changes in II, II and aVF ⚠️ *ACUTE CHOLANGITIS* - infection of the biliary secondary to bile stasis from obstruction. 80% due to choledocholithiasis. - RUQ pain, fever, jaundice +/- mental status changes and hypotension. - definite diagnosis via ERCP (also therapeutic) or PTC. - manage: IV fluids, antibiotics and urgent decompression with ERCP/PTC *GORD, PUD, oesophagitis, gastritis* - burning pain exacerbated after meals, bending or lying down, +/- melaena, anaemia - risk factors: smoking, alcohol, NSAIDs, aspirin, SSRIs, biphosphonates, history of H.pylori infection - lifestyle changes, reviewing NSAID use, urea breath/stool H.pylori tests, 24 hour PH monitoring and/or upper GI endoscopy. - if suspected Zollinger Ellison syndrome; measure fasting gastrin levels to rule out gastrinoma. - administer PPI therapy. *CHRONIC MESENTERIC ISCHAEMIA* - consider in age>60, W>M: postprandial abdominal pain associated with significant weight loss, food fear, nausea, vomiting, or diarrhoea