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A guide to Year 3

2010

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With thanks to
Alex, Phill, Tess, Ryan , PQ, Lee, Niki, Lionel, Lorato, Steph, Mark, Quinton,
Tas, Allya, Gaya, Jess, Christl, Hasna, Sarah W, Audrey, Henry, Arty, Sarah H,
Keflewe, Flik, Michelle, Neha, Anita

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!"#$% '( )'*+%*+,
)-./012-3)45-. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"
+*1"&#2+1 "#&,! %+*#&*#"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" #
$%&'()'*+,-*"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" ./
$%&'(0,&,12'3,2 """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" ..
1&,%+&1 3&+45,#""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .4
1&,%+&1 &,,#*!"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .5
62(1,-3%-&2)$%"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .7
6-*8'*,)20 $'2() 1,+'2+' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .9
62(1,26 )23&-*21'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .:
6&4654&, "#&,! %+*#&*#"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .;
,"#52&!+1 <#6#, """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .=
&'(,62(1,),+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .#
'*1-62(1,),+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4/
62(-),1 +)'*-+,+ """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4.
2-(),6 2*'>(,+3+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 44
&'(,&$'(20 ?2+6>02( 1,+'2+'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 45
?2(,6-+' ?',*+ """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 47
6$(-*,6 ?'*->+ ,*+><<,6,'*6% """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 49
#$%&'#()*#+!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ,-
2+)$32""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4;
@(-*6$,'6)2+,+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4=
6%+),6 <,@(-+,+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4#
,*)'(+),),20A-66>&2),-*20 0>*8 1,+'2+' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5/
('+&,(2)-(% <2,0>(' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5.
0>*8 62*6'( """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 54
+-0,)2(% &>03-*2(% *-1>0'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 55
@(-*6$,20 -@+)(>6),-*"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 57
26>)' @(-*6$,),+ """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 59
>(),"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5:
&0'>(,+%""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5;
&0'>(20 '<<>+,-* """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5=
&*'>3-)$-(2B """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5#
6-( &>03-*20'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7/
&>03-*2(% $%&'()'*+,-*"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7.
-@+)(>6),?' +0''& 2&*-'2 """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 74
6-3!.107!83!07-5!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ./
26>)' 0,?'( <2,0>(' 2*1 $'&2),),+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 77
206-$-0,6 0,?'( 1,+'2+'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7:
6,(($-+,+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7;
&2*6('2),6 62(6,*-32"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7#
26>)' &2*6('2),),+ """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9/
6$(-*,6 &2*6('2),),+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9.
8-(1"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 94
,((,)2@0' @-C'0 +%*1(-3'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 95
6-'0,26 1,+'2+' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 97
82+)(-'*)'(,),+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 97
&'&),6 >06'( 1,+'2+'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9:
82+)(,),+ 2*1 82+)(-&2)$%""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9;
-'+-&$28'20 62*6'("""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9=
82+)(,6 62*6'(""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9=
6(-$*D+ 1,+'2+'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9#
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0LCERATIvE C0LITIS................................................................................................................................................................................ 6u
APPENBICITIS............................................................................................................................................................................................. 61
INTESTINAL 0BSTR0CTI0N ..................................................................................................................................................................... 62
ISCBAENIC B0WEL.................................................................................................................................................................................... 6S
BIvERTIC0LAR BISEASE........................................................................................................................................................................... 64
C0L0RECTAL CANCER............................................................................................................................................................................... 6S
BERNIA........................................................................................................................................................................................................ 66
PERIT0NITIS............................................................................................................................................................................................... 67
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NEPBR0TIC ANB NEPBRITIC SYNBR0NE ............................................................................................................................................. 69
AC0TE RENAL FAIL0RE............................................................................................................................................................................ 7u
CBR0NIC RENAL FAIL0RE ....................................................................................................................................................................... 71
AC0TE T0B0LAR NECR0SIS .................................................................................................................................................................... 7S
0R0LITBIASIS............................................................................................................................................................................................. 74
P0LYCYSTIC KIBNEY BISEASE................................................................................................................................................................. 7S
0TI¡PYEL0NEPBRITIS............................................................................................................................................................................. 76
0R0L0uICAL CANCERS ............................................................................................................................................................................. 77
BENIuN PR0STATIC BYPERTR0PBY ...................................................................................................................................................... 78
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TYPE 1 BIABETES NELLIT0S .................................................................................................................................................................. 8u
PIT0ITARY BYSF0NCTI0N........................................................................................................................................................................ 82
u0ITRE......................................................................................................................................................................................................... 84
BYPERTBYR0IBISN................................................................................................................................................................................... 8S
BYP0TBYR0IBISN..................................................................................................................................................................................... 86
PARATBYR0IB BYSF0NCTI0N................................................................................................................................................................. 87
ABRENAL BYPERF0NCTI0N: C0SBINu'S............................................................................................................................................... 88
ABRENAL BYP0F0NCTI0N: ABBIS0N'S................................................................................................................................................. 89
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SEIZ0RES..................................................................................................................................................................................................... 91
NIuRAINE.................................................................................................................................................................................................... 92
CEREBRAL BAEN0RRBAuE ..................................................................................................................................................................... 9S
TIA............................................................................................................................................................................................................... 96
CRANIAL NERvE PALSY............................................................................................................................................................................ 97
SPINAL C0RB BISEASE ............................................................................................................................................................................. 99
BENENTIA.................................................................................................................................................................................................1uu
NE0R0N0SC0LAR BIS0RBERS..............................................................................................................................................................1u1
N0LTIPLE SCLER0SIS .............................................................................................................................................................................1u2
1"($&1"()%$2" 4)("++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 506
AIRWAYS¡RESPIRAT0RY S0PP0RT .....................................................................................................................................................1u4
BL00B TRANSF0SI0NS...........................................................................................................................................................................1u6
I.v. FL0IB REPLACENENT......................................................................................................................................................................1u7
ANALuESIA................................................................................................................................................................................................1u8
P0ST 0PERATIvE FEvER........................................................................................................................................................................1u9
W00NBS....................................................................................................................................................................................................11u
&,!+-./$($)* +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 555
0STE0ARTBRITIS.....................................................................................................................................................................................112
0STE0NALACIA........................................................................................................................................................................................11S
RBE0NAT0IB ARTBRITIS ......................................................................................................................................................................114
u00T..........................................................................................................................................................................................................11S
SYSTENIC L0P0S ERYTBENAT0S0S ....................................................................................................................................................116
vASC0LITIS ...............................................................................................................................................................................................117
PAuET'S BISEASE 0F B0NE....................................................................................................................................................................118
0STE0NYELITIS .......................................................................................................................................................................................119
FRACT0RES...............................................................................................................................................................................................12u
L0WER LINB FRACT0RE........................................................................................................................................................................121
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!"# %&'%#'(') %(**+#, -./.
0
!"#$%&'"()*+"#
1PL uAnuLnCnC uCSSlL8 2010
9
!"#$%&'(# *&%+, -("&%"&
-&.(/(,(0/ 123 45%""(.(#%,(0/
lschaemlc PearL ulsease ls broadly deflned as myocardlal
lschaemla from a lack of blood supply.

67(8&'(0509:
nA

;("< =%#,0+"
As wlLh aLherosclerosls:
• Age
• Male
• lamlly hlsLory
• Smoklng
• SedenLary llfesLyle, CbeslLy
• ulabeLes
• PyperLenslon
• PypercholesLerolaemla

>&,(0509:24%?"&"2@%,$07$:"(0509:
lPu ls largely due Lo aLherosclerosls of Lhe coronary arLerles
(!"" $%&'()%*+ ,-."*/&')"*/&0&) leadlng Lo vessel sLenosls.
CLher causes of anglna lnclude:

Anaemla

Coronary emboll

Shock (decreased sysLemlc perfuslon)

vascullLls, speclflcally kawasakl ulsease
1he predomlnanL sympLom of lPu ls anglna pecLorls, chesL
paln on exerLlon
1hls occurs as lncreased meLabollc demands of Lhe
myocardlum exacerbaLe Lhe supply-demand mlsmaLch, and
lschaemla occurs. ln laLe sLage dlsease anglna may occur
wlLh very llLLle exerLlon
Cccaslonally anglna may be caused by coronary arLery
vasospasm (ÞrlnzmeLal anglna). 1hls ls rare and noL relaLed
Lo lPu. lL does noL Lend Lo assoclaLe wlLh cardlac sLress.

A(9/" %/8 A:'7,0'"
• Anglna ÞecLoralls
o 1he chesL paln follows a slmllar dlsLrlbuLlon Lo
myocardlal lnfarcLlon paln - vague, wlLh radlaLlon Lo
Lhe neck, back, lefL arm or eplgasLrlum
! ÞrlclplLanLs of anglna commonly lnclude
exerLlon, cold weaLher, heavy meals or
sLress/emoLlon
! Anglna usually resolves wlLhln 13 mlnuLes or
on Lhe admlnlsLraLlon of vasodllaLors (C1n)
! no Llssue damage occurs - le no 1roponln rlse
o unsLable anglna ls perslsLlng or lncreaslng frequency
or severlLy. 1hls commonly precludes an AMl
• ÞaLlenLs ofLen appear sweaLy or dyspnoelc and feel
falnL
• nausea ls also common

*(",0+: %/8 6B%'(/%,(0/
Cardlac LxamlnaLlon
Look for medlan sLenoLomy scars or longlLudlnal forearm
scars suggesLlng pasL CA8C procedure.

!/C&",(9%,(0/"
LCC Lyplcally shows S1 depresslon, flaL or lnverLed 1 waves,
ln many cases however of lPu no changes are apparenL
Coronary anglography can locaLe and quanLlfy areas of
aLheroscleroLlc change ln Lhe coronary arLerles.
Also conslder Ck and 1roponln levels Lo exclude AMl on flrsL
presenLaLlon.

D%/%9&'&/,
lPu beneflLs mosL from llfesLyle change and rlsk facLor
modlflcaLlon

Smoklng cessaLlon

lmprovlng dleL and lncreaslng exerclse

1reaL hyperLenslon, hypercholesLerolaemla
1he predomlnanL pharmacologlcal LreaLmenL for lPu alms Lo
reduce progresslon Lo acuLe myocardlal evenLs

nlLraLes are poLenL vasodllaLors, usually admlnlsLered
subllngulally or Lransdermally as rellevers. uue Lo Lhe
rapld developmenL of Lolerance 10-12 hrs musL be
nlLraLe free each day.
o Clyceryl 1rlnlLraLe (C1n)

µ 8lockers can help prevenL sympLoms by reduclng
cardlac workload.
o ALenolol

Low dose asplrln funcLlons as an anLlplaLeleL agenL and
reduces Lhe rlsk of Lhromboembolls
Surglcal lnLervenLlon ls usually lndlcaLed ln unsLable or
severly worsenlng anglna, or ln a conLexL of prevlous AMl or
surglcal lnLervenLlon

ÞercuLaneous 1ranslumlnal Coronary AngloplasLy (Þ1CA)
allows evaluaLlon of arLery sLenosls, and sLenLlng where
requlred. lL ls a relaLlvely safe proceedure, especlally
compared Lo CA8C.
o Powever 20-30° of sLenLed arLerles re-sLenose
o ÞaLlenLs may have Lo Lake long-Lerm clopldlgrel afLer
Lhe procedure

Coronary ArLery 8ypass CrafLs are Lhe besL avallable
LreaLmenL for wldespread lPu. Coronary arLerles are
bypassed uslng perlpheral vessels
o CA8C procedures are complex and requlre a large
recovery Llme

40'75(#%,(0/"
lPu, lf unLreaLed, ofLen progresses Lo acuLe lnfarcL.
1PL uAnuLnCnC uCSSlL8 2010
10
!"#$%&$'()*'
,$-)')&)*' ./0 123(()-)43&)*'
PyperLenslon ls lncreased sysLollc or dlasLollc blood
pressure, usually consldered Lo be over 140/90
5#)6$7)*2*8"
nA
9)(: ;34&*%(
• Clder lndlvlduals
• Males
• Smokers
• CbeslLy
• Plgh alcohol lnLake
• Plgh sodlum lnLake
• ulabeLes
<$&)*2*8"/13=($(
PyperLenslon ls dlvlded accordlng Lo cause.
LssenLlal hyperLenslon conslsLs of 93° of all cases. 1he
exacL mechanlsm ls unknown, however geneLlc and llfesLyle
facLors are exLremely lmporLanL

CbeslLy, alcohol, sodlum lnLake and sLress are all
lmpllcaLed ln Lhe developmenL of essenLlal hyperLenslon

ulabeLes ls hlghly assoclaLed wlLh hyperLenslon,
especlally 12uM
Secondary hyperLenslon has an ldenLlflable cause. 1hls
should always be excluded before LreaLmenL ls commenced

8enal arLery sLenosls causes an lncrease ln sysLemlc
blood flow Lo malnLaln kldney perfuslon.
Þharmacologlcally reduclng blood pressure may
preclplLaLe acuLe renal fallure

nephropaLhy, glomerulonephrlLls, polycysLlc kldney
dlsease and LubulolnLersLlLlal dlsease all affecL blood
pressure vla dlsrupLlon of normal kldney funcLlon.

Lndocrlne dlsLurbance may lncrease blood pressure,
especlally Lhe adrenal axls
o Pyperadrenallsm - Conns syndrome,
ÞhaeochromocyLoma, Adrenal hyperplasla, Cushlngs
o Acromegaly

Þregnancy (10° of pregnancles develop hyperLenslon)

urugs - sLerolds, nSAlus, CCÞ, llquorlce
>)8'( 3'6 >"7#&*7(
PyperLenslon ls almosL always asympLomaLlc
ulagnosls ls made on Lhe basls of successlve measuremenLs
on dlfferenL days (le subsequenL vlslLs). 8eware whlLe coaL
hyperLenslon
!)(&*%" 3'6 5?37)'3&)*'
8Þ readlng vla syphmomanomeLry
Also cardlac and renal examlnaLlon, urlne dlpsLlck Lo exclude
compllcaLlons
Sever hyperLenslon (>200/120) fundoscopy should be
performed Lo eclude mallgnanL hyperLenslon, a medlcal
emergency

Looklng for bllaLeral reLlnal haemorrhages +/-
paplloedema, coLLon wool spoLs or hard exudaLes
@'A$(&)83&)*'(
8aslc blood LesLs - uLC, CholesLerol, Clucose,
urlne dlpsLlck looklng for proLeln or blood
Also conslder excludlng secondary causes:
• 8enal ulLrasound/uoppler
• urlnary corLlsol, aldosLerone
B3'38$7$'&
llrsL llne Lherapy ls llfesLyle change

WelghL reducLlon, exerclse

8educLlon ln alcohol and salL lnLake

Clycaemlc conLrol (ln dlabeLlcs)
8Þ > 160/100 ls usually prompLs pharmacologlcal Lherapy,
however lower Lhresholds are LoleraLed ln paLlenLs wlLh
sympLoms of kldney or cardlac dlsease (A8Cu)

<C ACL lnhlblLors cause vasodllaLlon vla lnhlblLlon of Lhe
8AS sysLem. 1hey are also reduce Lhe progresslon of
renal fallure: #$%)'6*#%)2D 43#&*#%)2D %37)#%)2
o Also conslder AngloLensln ll anLagonlsLs. 1hese have a
slmllar acLlon, alLhough wlLhouL Lhe slde effecL of a
dry cough: 2*(3%&3'D )%E$(3%&3'D 43'6$(3%&3'

FC µ blockers reduce cardlac ouLpuL vla lnhlblLlon of Lhe
hearL's sympaLheLlc sLlmuaLlon. 1hls ls especlally useful
ln paLlenLs wlLh coronary arLery dlsease: 3&$'*2*2D
7$&*#%*2*2

1C Ca
2+
blockers are dlvlded lnLo 2 classes
o nonhydropyrldlne Ca
2+
blockers reduce cardlac
ouLpuL (P8 and conLracLlllLy) and cause modesL
vasodllaLlon: 6)2&)3G$7D A$%3#)7)2
o ulhydropyrldlne Ca
2+
blockers have a predomlnanL
vasodllaLory acLlon: 372*6)#)'$D ')-$6)#)'$

,C ulureLlcs
o 1hlazldes are Lhe flrsL llne dlureLlc LreaLmenL for
slmple hyperLenslon: H"6%*4H2*%*&H)3G)6$D
)'63#37)6$
o Loop dlureLlcs are used for paLlenLs wlLh renal
lmpalrmenL: -%=($7)6$
o ÞoLasslum sparlng dlureLlcs are used for
hypokalaemlc paLlenLs: (#)%*'*234&*'$
1*7#2)43&)*'(
1he compllcaLlons of hyperLenslon are chronlc and common
amongsL Lhe general populaLlon

MallgnanL hyperLenslon ls hyperLenslon greaLer Lhan
200/120.
o PlsLologlcally appears as flbrlnold necrosls of vessel
walls
o MallgnanL P1 can preclplLaLe acuLe renal fallure,
cardlac fallure or encephalopaLhy

Cardlac dlsease ls Lhe mosL common compllcaLlon of
chronlc hyperLenslon
o Leads Lo a lnlLlal hyperLrophlc cardlomyopaLhy,
especlally affecLlng Lhe lefL venLrlcle
o LaLLer sLage dlsease may progress Lo a dllaLed
cardlomyopaLhy
o lncreased rlsk of lPu due Lo lncreased meLabollc
demands decreased perfuslon. Also commonly resulLs
ls Al or valvular lnsufflclency (parLlcularly mlLral and
Lrlcuspld)

PyperLenslon ls also a ma[or rlsk facLor for sLroke, renal
fallure and perlpheral vascular dlsease.
1PL uAnuLnCnC uCSSlL8 2010
11
!"#$%&'#'()$*')
,$-'.'/'0. 123 4&)55'-'6)/'0.
Pyperllpldaemla ls dlsordered serum Lrlglycerlde and/or
cholesLerol levels
normal serum ranges:

CholesLerol: < 6.2 mmol/L

1rlglycerldes: 0.3 - 1.9 mmol/L

PuL: > 0.9

7#'($*'0&08"
nA

9'5: ;)6/0%5
• Plgh faL dleL
• SedenLary llfesLyle
• CbeslLy
• 1ype 2 ulabeLes
• MeLabollc dlsorders - hypoLhyroldlsm, Cushlngs
• 8enal dlsease - esp. nephroLlc
• Llver dlsease - hepaLlLls, llver fallure
• lncreased oesLrogen - CCÞ

<$/'0&08"24)=5$52>)/?0#?"5'0&08"
Þrlmary hyperllpldaemla occurs because of predomlnanLly
geneLlc facLors wlLh llfesLyle lnfluence. 1hey are classlfled
accordlng Lo Lhelr paLLern of llpld abnormallLles -
hyperLrlglycerldaemla, hypercholesLerolaemla or mlxed
hyperllpldaemla

Mlxed hyperllpldaemla ls Lhe mosL common form of
prlmary hyperllpldaemla, presenLlng wlLh hlgh LuL and
Lrlglycerldes and a low PuL. lncldence ls roughly 1 ln
200.

Secondary hyperllpldaemlas resulL from predomlnanLly
llvesLyle and envlronmenLal facLors, alLhough some
lndlvlduals are more geneLlcaly suscepLlble. 1hls ls far
more common.

@'8.5 ).( @"*#/0*5
Pyperllpldaemla ls almosL always asympLomaLlc.

!'5/0%" ).( 7A)*'.)/'0.
xanLhomaLa/xanLhalesma ls Lhe only slgn of
hyperllpldaemla, and lL only occurs ln laLe sLage dlsease.
MosL cases are ldenLlfled durlng rouLlne screenlng, or
followlng a cardlovascular evenL.
MalnLaln a hlgh lndex of susplclon wlLh Lhe obese,
dlabeLlcs, hyperLenslve eLc.

B.C$5/'8)/'0.5
Serum llplds - lncludes cholesLerol, Lrlglycerldes and PuL
levels.

D).)8$*$./
llrsL llne LreaLmenL for secondary hyperllpldaemla ls
llfesLyle modlflcaLlon

A llpld lowerlng dleL ls Lhe cornersLone of LreaLmenL.
1he alm ls Lo reduce LoLal faL lnLake, parLlcularly of
saLuraLed faLs and cholesLerols. loods wlLh Cmega-3
faLLy aclds such as flsh should be encouraged

lncrease acLlvlLy and aLLempL welghL loss

1hese measures should be conLlnued even afLer Lhe
commencemenL of pharmacoLherapy

Þharmacologlcal LreaLmenL of hypercholesLerolaemla ls
largely wlLh sLaLlns

SLaLlns are PMC CoA reducLase lnhlblLors, llmlLlng
cholesLerol synLhesls. 1hey also moderaLely reduce
Lrlglycerlde levels. SLaLlns have wldespread
cardlovascular beneflLs.
o SlmvasLaLln, ALorvasLaLln

CholesLerol absorpLlon lnhlblLors are beneflclal ln
slgnlflcanL hypercholesLerolaemla
o LzeLlmlbe

8lle acld blndlng reslns are used parLlcularly ln famlllal
mlxed hyperllpldaemla
o chelsLyramlne, cholesLlpol

ÞharmacoLherapy of hyperLrlglycerldaemla uses flbraLes

llbraLes llmlL hepaLlc Lrlglycerlde synLhesls
o Cemflbrozll

40*#&'6)/'0.5
Chronlc hyperllpldaemla leads Lo lncreased
aLherosclerosls formaLlon. 1hls ls hlghly assoclaLed wlLh
lPu, CvA and oLher vascular dlsease.
1PL uAnuLnCnC uCSSlL8 2010
12
!"#$%"& ("%)*#+
,+-%.%/%0. 123 !)"44%-%&"/%0.
564/0)%& ("%)*#+7 lnsufflclenL cardlac ouLpuL
,%"4/0)%& ("%)*#+7 lnadequaLe dlasLollc fllllng
C8
8+-/ 9+"#/ ("%)*#+
:%;</ 9+"#/ ("%)*#+

:%4= ("&/0#4
• 8l for lPu P1n, ! CholesLerol, Smoklng
• PlsLory of a known causes eg. lPu, 1hyroLoxlcosls,
Av shunL
• Al, uM, AorLlc sLensosls

>+/%0)0;62!"*4+4
?#%@"#6 ,+-+&/ AB"@C)+
Myocardlal
uysfuncLlon
• lPu (33-40°)
• CongenlLal cardlomyopaLhles
• ulabeLes MelllLls
• Myocardlal dlsease: amyloldosls
volume Cverload • AorLlc regurglLaLlon
• MlLral regurglLaLlon
Þressure Cverload • AorLlc sLenosls
• PyperLenslon (13-20°)
lmpalred fllllng • ConsLrlcLlve perlcardlLls
• Cardlac Lamponade
ArrhyLhmlas • Al
Plgh ouLpuL • Anaemla
• 1hyroLoxlcosls
• ALerlovenous shunLs

5%;.4 ".$ 56@C/0@4
LefL PearL fallure
• laLlgue
• LxerLlonal dyspnoea
• CrLhopnoea + Þnu
• ulsplaced apex beaL
• Callop rhyLhm
• MlLral regurglLaLlon
• Crackles aL lung base
• Þulmonary oedema
8lghL PearL fallure
• Anorexla
• nausea
• 8alsed !vÞ
• 1ender smooLh hepaLomegaly
• ÞlLLlng oedema
• AsclLes
• Þleural LransudaLes
*noLe LhaL 8Pl ls mosL commonly caused by LPl so 8Pl
Sx+Sg lnclude LlP Sx+Sg



9%4/0#6
• SC8
• CrLhopnoea
• Þnu
• ÞalplLaLlons (for Al a cause of CCl)
• Swollen legs
AB"@%."/%0.
• !vÞ
• ulsplaced apex beaL, Callop rhyLhm, MlLral regurg
(pansysLollc murmur)
• 8lbasal creps
• PepaLomegally, asclLes
• ÞlLLlng oedema

D.E+4/%;"/%0.4
• 8loods - l8L, Ll1, uLC, Cardlac enzymes, 1l1
• Cx8 - PearL slze, pulmonary congesLlon
• LCC - lschemla, arrhyLhmlas
• naLlureLlc pepLlde (AnÞ) - Wlll be deranged ln CCl
• Lcho + SLress Lcho

?"/<0C<64%0)0;6 1 F".";+@+./
1. llrsL llne: ACL lnhlblLor + dlureLlc
*noLe A11 = angloLensln 1 recepLor anLagonlsL
lf ACL lnhlblLor noL well LoleraLed use A88

!0@C)%&"/%0.4
• lschemla
• AÞC


1PL uAnuLnCnC uCSSlL8 2010
13
!"#$%"& (##)*+
,)-%.%+%/.
Sudden sLaLe of clrculaLory fallure due Lo a loss of cardlac
sysLollc funcLlon resulLlng from speclflc cardlac rhyLhm
dlsLurbances.
!0"**%-%&"+%/.
• Shockable rhyLhms (pulseless v1 and vl) - mosL
common
• nonshockable rhyLhms (pulseless elecLrlcal acLlvlLy
(ÞLA) and asysLole)

12%$)3%/0/45
• 13° all deaLhs ln WesLern counLrles
• Age >636 men 3x > women under 83 years

7%*8 9"&+/#*
• Coronary arLery dlsease rlsk facLors (Smoklng,
dlabeLes, obeslLy, lack of physlcal exerclse, lP eLc)
• LefL venLrlcle dysfuncLlon
• SLrucLural hearL abnormallLles e.g. PCCM

()+%/0/45:!";*)*
• lPu
• CardlomyopaLhy/uysrhyLhmlas
CLher reverslble causes: P & 1s
• Pypovolemla
• Pypoxla
• Pydrogen lons (acldosls)
• Pyper/Pypokalaemla
• PypoLhermla
• Pypo/Pyperglycaemla
• 1oxlns/urugs
• 1amponade (cardlac)
• 1enslon pneumoLhorax
• 1hrombus (AMl,ÞL)
• 1rauma

<"+=/2=5*%/0/45
v1 and vl
• Myocardlal lschaemla resulLs ln changes ln
concenLraLlon of lnLracellular and exLracellular
componenLs (pP, elecLrolyLes, A1Þ)
• 1hese changes, alLered lon channels, or prolonged
acLlon poLenLlal duraLlon, can propagaLe arrhyLhmlas
• Myocardlal scarrlng may seL up a re-enLranL clrculL
• CongenlLal conducLlon dlsorders or drugs (Class lA
and lll anLlarrhyLhmlcs eLc) may also Lrlgger slmllar
evenLs
ÞLA
• uecreased preload, lncreased afLerload or myocardlal
changes (e.g. due Lo lschaemla) lmpalr lnoLropy
• uesplLe elecLrlcal sLlmulaLlon, Lhere ls a loss of
myocardlal conLracLlllLy and hence lnadequaLe
clrculaLlon

>%4.* ".$ >532+/3*
• Sudden loss of consclousness


?%*+/#5
lrom paLlenL's hlsLory, medlcaLlons and famlly
• 1rauma (suspecL Lamponade, myocardlal puncLure,
Lenslon pneumoLhorax)
• ChesL paln (lschaemla)
• Syncope (sLrucLural hearL dz, arrhyLhmlas)
• ÞalplLaLlons (arrhyLhmla)
• 8ls for CAu
• Px of hearL dlsease/conducLlon/arrhyLhmlas
• MedlcaLlons, llllclL subsLances
• kldney dlsease (elecLrolyLe abnormallLles)
• lamlly hlsLory (sudden cardlac arresL, CAu)

1@"3%."+%/.
• unresponslve
• Absence of breaLhlng
• Þulseless
• LlevaLed !vÞ & bllaLeral creplLaLlons (hearL fallure)
• 1racheal devlaLlon & absenL alr enLry (Lenslon
pneumoLhorax or lung dlsease)
• Murmur (valvular cause of compromlse)
• neurologlcal examlnaLlon (lnLracranlal)

A.B)*+%4"+%/.*
• LCC: MosL commonly v1 and vl
• l8L (haemorrhage), uLC (elecLrolyLe abnormallLles)
• A8C (acld-base sLaLus)
• Cardlac markers
• 1oxlcology screen (llllclL subsLances)
• Cx8
• Lchocardlogram (monlLorlng cardlac acLlvlLy, exclude
Lamponade and valve dlsorders)
• Coronary anglography (CAu)

C"."4)3).+
• u8A8Cu: 8aslc Llfe SupporL
• Assess Lhe responslble rhyLhm wlLh ALu or LCC
C)$%&"0
Shockable rhyLhms CÞ8 and deflbrlllaLlon
Adrenallne/vasopressln
Magneslum
AnLl-arrhyLhmlc
non-shockable
rhyLhms
CÞ8
Adrenallne/vasopressln
ALroplne
8eLurn of clrculaLlon: ÞosL-resusclLaLlon care
no reLurn of clrculaLlon: ConLlnuaLlon/1ermlnaLlon of
resusclLaLlon

!/320%&"+%/.*
• ueaLh
• SkeleLal Lrauma
• Anoxlc braln ln[ury
• 8ecurrenL cardlac arresL
• lschaemlc llver ln[ury
• 8enal acuLe Lubular necrosls
1PL uAnuLnCnC uCSSlL8 2010
14
!"#$%&'(&)"*+(
-./%0%*%&0 123 !4"55%/%6"*%&0
CardlomyopaLhy: hearL muscle dlsease of uncerLaln cause
(ux by excluslon)
ClasslflcaLlon:
- ullaLed (uCM): poor lefL +/- rlghL venLrlcle
conLracLlon (causes 30° of hearL fallure)
- PyperLrophlc (PCM): myocardlal hyperLrophy, poor
wall compllance and dlsarray of myocyLes &
myoflbrllls
- 8esLrlcLlve (8CM): poor venLrlcular fllllng from
decreased wall conLracLlllLy




7.*%&4&8(9 :"*+&)+(5%&4&8(
Cccurs ln absence of lschemla / valve dlsease /
hyperLenslon, Lherefore ldlopaLhlc (unknown)

uCM & PCM: see dlagram
8CM causes: amyloldosls, sarcoldosls, radlaLlon,
endomyoflbrosls, unknown (some famlllal)


;%805 "0$ ;(')*&'5
ÞresenL ln early adulL llfe
• uCM: presenLs as CCl, syncope, deaLh
• PCM: chesL paln, dyspnoea, syncope, arrhyLhmla,
deaLh
• 8CM: presenLs as CCl, dyspnoea, faLlgue, embollc
sympLoms, slgns llke consLrlcLlve perlcardlLls

<%5*&#( "0$ =>"'%0"*%&0
lamlly Px - ask abouL sudden deaLh
Cardlac Lxam
- L[ecLlon sysLollc murmur (PCM)
- 4
Lh
hearL sound (PCM & 8CM)
- Plgh collapslng !vÞ (8CM)

?0@.5*%8"*%&05
Cx8: cardlomegaly or normal
LCC: non-speclflc S1 & 1 wave changes
Lchocardlogram:
- dlagnosLlc for PCM showlng asymmeLrlc sepLal
hyperLrophy
- uCM: dllaLed rlghL / lefL venLrlcles wlLh poor
conLracLlon
- 8CM: symmeLrlcal myocardlal Lhlckenlng, reduced
venLrlcular fllllng buL normal e[ecLlon fracLlon
Lndomyocardlal blopsy: shows amyloldosls (8CM)
Anglography: exclude Coronary ArLery ulsease
Cardlac CaLheLerlsaLlon: exclude perlcardlLls

A"0"8.'.0*
A.$%6"4
SympLomaLlc (same Mx as hearL fallure)
As needed: ulureLlc, ACLl, A
2
AnLagonlsL, µ-8locker, anLl-
coagulaLlon
Þacemaker / lmplanLable deflbrlllaLor
;B#8%6"4
PearL replacemenL

!&')4%6"*%&05
ArrhyLhmlas, emboll, sudden deaLh

1PL uAnuLnCnC uCSSlL8 2010
13
!"#$%#&'() +%(,' -&.%(.%
-%/&#&'&"# 012 !)(..&/&3('&"#
AbnormallLles of cardlac sLrucLure LhaL are presenL from
blrLh. 1hey resulL from abnormallLles ln cardlac
developmenL occurrlng b/w 3 and 8 weeks gesLaLlon.
!"#$%&'( (lalloL's, 1ransposlLlon of greaL vessels)
- 8lghL Lo LefL shunL of blood
)("#$%&'( (ASu, vSu, ÞuA, coarcLaLlon of aorLa)
- LefL Lo 8lghL shunL of blood

4&.5 6(3'",.
• MaLernal rubella lnfecLlon (ÞuA)
• MaLernal alcohol abuse (sepLal defecLs)
• MaLernal drug LreaLmenL and radlaLlon
• CeneLlc abnormallLles
• Chromosomal abnormallLles (1rlsomy 21 assoc.
w/ valve defecLs, 1urner's w/ coarcLaLlon of Lhe
aorLa)

7%'&")"$81!(9.%.
Cenerally unknown. ulLlmaLely due Lo lncompleLe closure
of !"#$%&' ")$*& or +,-.,/ $#.&#0"/,/ ln uLero.

1.#0$* 2&3.$* 4&!&-. 51-6$'".0-7
usually goes unrecognlsed
Llll adulLhood. L Lo 8 shunL
causes pulmon. P1, whlch
can be permanenL lf
remodelllng occurs. AdulLs
may presenL wlLh
arrhyLhmlas of Lv fallure.




8&'.#0-,*$# 2&3.$* 4&!&-. 51-6$'".0-7
ulrecLlon of shunL
deLermlned by
pulmonary vascular
reslsLance (Þv8) vs
sysLemlc. usually
sysLemlc ls hlgher, so L
Lo 8 shunL, buL
prolonged pulm. P1 can
cause Þv8 Lo ralse, and
shunL Lo reverse causlng
:%(:)8 ;&.%#<%#$%,=.
.8#:,"<%





>8?% "/ -%/%3' !)&#&3() 6%('9,%. >,%('<%#'
1.#0$* 2&3.$*
4&!&-. 51247
Þulmonary e[ecLlon
murmur, wlde flxed spllL
S
2
, elevaLed !vÞ
Surglcal
repalr lf
shunL L Lo 8.
8&'.#0-,*$#
2&3.$* 4&!&-.
58247
lallure Lo Lhrlve, faLlgue,
harsh sysLollc murmur ln
lefL sLernal border,
pulmon. P1,
Large:
Surgery
Small: 30°
resolve by
4y.o.
9$.&'. +,-.,/
$#.&#0"/,/
Loud murmur boLh ln
dlasLole and sysLole. Slgns
of Pl.
LlgaLlon of
ÞuA, only lf
<3y.o.
:'+"%&.$-0'
;#$'/3"/0.0"' "!
.<& =#&$.
)&//&*/
Severe cenLral cyanosls,
8Au 8Au 8Au 8Au 8Au.
1/3 dle ln flrsL 2 weeks of
blrLh, wlLhouL surgery.
Surgery.
>$**".?/
;&.#$*"=6
uyspnoea, faLlgue, hypoxla
(cyanosls, LoC)
Surgery.

9$.&'. 4,-.,/ 1#.&#0"/,/ 51-6$'".0-7
uucLus arLerlosus usually
closes when pulmonary
pressure changes upon blrLh,
buL fallure Lo close can lead Lo
hearL fallure ln adulLhood.
More common ln premaLure
bables.


>$**".?/ ;&.#$*"=6 5@6$'".0-7
uegree of
pulmonary
sLenosls
deLermlnes Lhe
degree of cyanosls
ln Lhe chlld.
@ulm. sLenosls
4lghL vP
Averldlng aorLa
BSu
1PL uAnuLnCnC uCSSlL8 2010
16
!"#$%"& (")*+,"$-
.-/%,%0%+, 123 !4"55%/%&"0%+,
Lmergency condlLlon ln whlch rapld accumulaLlon of fluld
ln Lhe perlcardlal space resulLs ln compresslon of Lhe
hearL.

lf perlcardlal effuslon develops slowly (e.g.
hypoLhyroldlsm), Lamponade wlll noL occur.

Can be classed as mlld (perlcardlal pressure < 10mmPg) Lo
severe (pressure > 13-20 mmPg).

6-0%+4+782!"95-5
• 1rauma
• AMl ! myocardlal rupLure
• ulssecLlng AA
• ÞerlcardlLls
• Mallgnancy
• uremla
• laLrogenlc e.g. ÞCl

:"0;+*;85%+4+78
Þerlcardlal effuslon ! consLrlcLlon of venLrlcles !
equlllbraLlon of pressures ln all chambers ! reduced
dlasLollc fllllng of venLrlcles ! reduced ouLpuL !
obsLrucLlve shock ! deaLh

<8)*0+)5
• ChesL paln/dlscomforL
• Cough
• uyspnoea
• ulzzlness

=>")%,"0%+,
• Þerlcardlal frlcLlon rub
• Muffled hearL sounds
• 1achycardla
• 1achypnea
• narrow pulse pressure
• PypoLenslon
• Þulsus paradoxus
• LlevaLed !vÞ



?,@-50%7"0%+,5
• LCC: low C8S volLage, 1 wave changes, elecLrlc
alLernans
• Lcho: perlcardlal effuslon, 8v compresslon,
changes ln flow veloclLy and venous flow
paLLerns, exaggeraLed resplraLory varlaLlons
• 8lghL hearL caLherlsaLlon: equallslng of pressures
ln 8A, pulmonary caplllary wedge, and
pulmonary arLery
• Cx8: sudden onseL of globular cardlomegaly



A","7-)-,0
AcuLe
• ÞerlcardlocenLesls

non-acuLe
• Medlcal, e.g. Lhyrold hormone
• 8epeaL perlcardlocenLesls
• ScleroLherapy (LeLracycllne)
• Þerlcardlal wlndow creaLlon

!+)*4%&"0%+,5
• Shock
• ueaLh



1PL uAnuLnCnC uCSSlL8 2010
17
!"#$%#"& ()"&* +,-)"-)
."%-)- / &,-0 1"2*3&- 4567*36- 89"6,:"*,3: 1,:;,:<-
=3&*,2 -*):3-,- uegeneraLlve calclflc aorLlc
valve
CongenlLal blcuspld valve
8heumaLlc
LxerLlonal chesL paln
uyspnea, syncope.

Þulse- plaLeau, laLe peaklng pulse, small
volume
ÞalpaLlon: sysLollc Lhrlll aL Lhe aorLlc area
AusculLaLlon: mldsysLollc e[ecLlon murmur
(maxlmum ln Lhe aorLlc area, radlaLlng Lo
Lhe caroLlds) loudesL wlLh Lhe paLlenL slLLlng
up and ln full explraLlon.
=3&*,2
&)<%&<,*"*,3:
8heumaLlc fever
lnfecLlous endocardlLls
P1n (severe)
Syphllls
ArLhrlLls (8A, Ankyloslng
spondyllLls, 8elLer's
syndrome.
LxerLlonal dyspnea,
faLlgue, palplLaLlons,
anglna.
Þulse: collapslng, a 'waLer hammer, wlde
pulse pressure.
ÞalpaLlon: dlsplaced apex beaL, dlasLollc
Lhrlll
AusculLaLlon: decrescendo hlgh-plLched
dlasLollc murmur,
>,*&"# -*):3-,- 8heumaLlc fever (30°)
CongenlLal parachuLe valve.

uyspnea
CrLhopnea !lncreased
LefL aLrlal pressure*
Þnu!*
PemopLysls!rupLured
bronchlal velns
AsclLes
Cedema
laLlgue !Þulmonary P1n
Ceneral: Lachypnea, MlLral facles,
perlpheral cyanosls
Þulse-normal or reduced or lrregular!Al
(due Lo lefL aLrlal enlargemenL
ÞalpaLlon: 8lghL venLrlcular heave
Þalpable Þ2 ! Þulmonary hyperLenslon
AusculLaLlon: loud S1, rumbllng dlasLollc
murmur

>,*&"#
&)<%&<,*"*,3:
8heumaLlc fever
CardlomyopaLhles (dllaLed
and hyperLrophlc)
MlLral valve prolapse
ConnecLlve Llssue dlsease
e.g. Marfan's syndrome,
rheumaLold arLhrlLls,
Ankyloslng spondyllLls.

uyspnea! lncreased lefL
aLrlal pressure
laLlgue ! decreased
cardlac ouLpuL

Ceneral: Lachypnea
Þulse: normal or sharp upsLroke
ÞalpaLlon: apex beaL dlsplaced, pansysLollc
Lhrlll, parasLernal lmpulse! due Lo lefL
aLrlal enlargemenL
AusculLaLlon: pansysLollc murmur maxlmal
aL Lhe apex and usually radlaLlng Lowards
Lhe axllla.
?&,2%-7,;
-*):3-,-
8heumaLlc hearL dlsease



Þerlpheral oedema,
asclLes
!vÞ: ralsed
AusculLaLlon: mld dlasLollc murmur and
openlng snap -lncrease on lnsplraLlon
?&,2%-7,;
&)<%&<,*"*,3:
8heumaLlc
lnfecLlve endocardlLls
1rlcuspld valve prolapse
8lghL venLrlcular paplllary
muscle lnfarcLlon
1rauma (e.g. sLeerlng wheel
ln[ury Lo Lhe sLernum)
CongenlLal-LbsLeln's
anomaly.ll
PepaLlc paln on exerLlon,
AsclLes and oedema.
!vÞ: ralsed (v waves)
ÞalpaLlon: rlghL venLrlcular heave
AusculLaLlon: pansysLollc murmur,
Abdomen: pulsaLlle large and Lender llver,
asclLes, oedema
Legs: dllaLed, pulsaLlle velns.

@%#63:"&5
-*):3-,-
CongenlLal
Carclnold syndrome
lnfecLlon wlLh rubella durlng
pregnancy
Mlld ls usually
asympLomaLlc
Severe pulmonary
obsLrucLlon ! faLlgue,
syncope l.e. sympLoms of
8Pl
Ceneral: perlpheral cyanosls
!vÞ: may be ralsed wlLh a waves due Lo
aLrlal hyperLrophy
ÞalpaLlon: rlghL venLrlcular heave, Lhrlll over
Lhe pulmonary area
AusculLaLlon: e[ecLlon sysLollc murmur
radlaLlon Lo lefL shoulder, wldely spllL S2
@%#63:"&5
A)<%&<,*"*,3:
Þulmonary P1n
lnfecLlve endocardlLls
CongenlLal absence of Lhe
pulmonary valve.
usually asympLomaLlc AusculLaLlon: decrescendo dlasLollc murmur
1PL uAnuLnCnC uCSSlL8 2010
18
!"#$%&'() +#,#-
.#/(0('(10 234 56&77(/()&'(10
8heumaLlc fever ls lnflammaLlon of Lhe body's organ
sysLems, resulLlng from a compllcaLlon of group A
sLrepLococcal lnfecLlon of Lhe LhroaL.
lL affecLs Lhe hearL, skln, [olnLs and cenLral nervous
sysLem

n8: lL ls noL an lnfecLlon raLher an lnflammaLory reacLlon
Lo Lhe lnfecLlon.

89(:#%(161;<
Commonly occurs ln chlldren and young adulLs - 1
sL
aLLack
beLween Lhe ages of 3-13.
1here ls decrease ln lncldence due Lo lmproved hyglene
and anLlbloLlcs use Lo LreaL sLrep lnfecLlons.

!(7= +&)'1-7
• ueveloplng counLrles
• Cvercrowded llvlng condlLlons
• CeneLlc

5&$7#7
Croup A sLrepLococcal LhroaL lnfecLlon

>&'"19"<7(161;<
lL develops due Lo an auLolmmune reacLlon Lrlggered by
Lhe molecular mlmlcry beLween Lhe cell wall M proLelns
of sLrep pyogenes and cardlac myosln and lamlnln. 1he
anLlbody Lo sLrep cross reacLs valve Llssue and may cause
permanenL damage Lo Lhe hearL!rhemaLlc hearL dlsease


?(;07 &0: ?<%9'1%7
1he dlsease presenLs suddenly wlLh
• lever
• !olnL palns
• Malalse
• Loss of appeLlLe

SympLoms vary dependlng on whlch parL of Lhe body has
been lnflamed

1o dlagnose Lhe dlsease uukkeLs !one's crlLerla ls used.
1he dlagnosls ls made on Lhe basls of recenL sLep lnfecLlon
plus 2 ma[or crlLerla C8 1 ma[or + 2 mlnor !one's crlLerla.


!"#$% '%()*%("
• ArLhrlLls: 'mlgraLory fllLLlng polyarLhrlLls' usually
affecLs larger [olnLs e.g. Ankles, knees, elbows,
and wrlsLs
o !olnLs may be red, hoL, swollen however
Lhere ls no long Lerm damage
• CardlLls: Lachycardla, murmurs (M8 or A8)
• SubcuLaneous nodules: small, moblle palnless on
Lhe exLensor surfaces of [olnLs
• LryLhema marglnaLum
• Chorea
!(+$% '%()*%("
• 8alsed lnflammaLory markers (C8Þ, LS8)
• lever
• Þrolonged Þ8 lnLerval
• ArLhralgla
• Þrevlous 8heumaLlc fever
• LeucocyLosls

@(7'1-< &0: 8A&%(0&'(10
Cn hlsLory enqulre abouL Lhe above-menLloned sympLoms
ÞasL Px
• Ask abouL LhroaL lnfecLlons and Lhe Lype of
LreaLmenL Lhey goL for lL.
lamlly hlsLory
• 8heumaLlc hearL dlsease

B0,#7'(;&'(107
• 1hroaL swabs: culLured for group A sLrepLococcus
• Serologlcal changes: elevaLed sLrepLococcal
anLlbody LlLre
• LlevaLed lnflammaLory markers: C8Þ, LS8, C-
reacLlve proLeln
• Cardlac lnvesLlgaLlons:
o LCC-Þ8 prolongaLlon
o Lcho
• Cx8- cardlomegaly!CCl

C&0&;#%#0'
D(/#7'<6# - 8ed resL unLll C8Þ normal for 2 weeks

C#:()&64
• Bv anLlbloLlcs: 8enzyl penlclllln lM
lf allerglc Lo penlclllln glve eryLhromycln or azlLhromycln
for 10 days
• Analgesla for CardlLls/ arLhrlLls
o Asplrln
o SLerolds -prednlsolone!Lo lmprove Lhe
lnflammaLlon
• lmmoblllse [olnLs lf severe arLhrlLls
• Paloperldol or dlazepam for Lhe chorea

?$-;()&64 E3F

51%96()&'(107
More Lhan 30° wlll develop rhemaLlc valvular dlsease
laLer predomlnanLly affecLlng Lhe mlLral and aorLlc valves
1PL uAnuLnCnC uCSSlL8 2010
19
!"#$%&#'$($)
+",$-$($.- /01 23&))$,$%&($.-
AcuLe (<2 weeks) lnflammaLlon of Lhe perlcardlum,
paLhologlc process ofLen lnvolves boLh Lhe perlcardlum and
Lhe myocardlum.

4"($.3.5602&7)")
• vlral lnfecLlons - coxsackle vlruses, lnfluenza, L8v,
varlecella, hepaLlLls, mumps, Plv.
• 1uberculous perlcardlLls - resulLs from dlrecL
lymphaLlc or haemaLogenous spread, cllnlcal
pulmonary lnvolvemenL may be absenL, assoclaLed
pleural effuslons common.
• 8acLerlal perlcardlLls - dlrecL exLenslon from
pulmonary lnfecLlons. Þneumococcl, 8orrella
burgdorferl (Lyme dlsease).
• uremlc perlcardlLls - common compllcaLlon of
chronlc kldney dlsease. Cccurs boLh wlLh unLreaLed
uremla and sLable dlalysls paLlenLs.
• neoplasLlc processes - spread of ad[acenL lung
cancer as well as lnvaslon by breasL cancer, renal
cell carclnoma, Podgkln dlsease, lymphomas -
frequenLly causes Lamponade.
• ÞosLmyocardlal lnfarcLlon or posL cardlac surgery
perlcardlLls (uressler syndrome) - lnflammaLory
reacLlon Lo Lransmural myocardlal necrosls.
• 8adlaLlon can lnlLlaLe a flbrlnous and flbroLlc
process ln Lhe perlcardlum, presenLlng as subacuLe
perlcardlLls or consLrlcLlon.
• ConnecLlve Llssue dlseases - SLL and 8A
• urug-lnduced - penlcllllns, clozaplne

8$5-) &-' 869:(.9)
uepends on Lhe cause of lnflammaLlon.
• ChesL paln, usually pleurlLlc and posLural (relleved
by slLLlng, worse on lylng down).
• Þaln ls subsLernal buL may radlaLe Lo Lhe neck,
shoulders, back or eplgasLrlum.
• uyspnoea may also be presenL.
• lever.
• A perlcardlal frlcLlon rub ls characLerlsLlc, wlLh or
wlLhouL evldence of fluld accumulaLlon or
consLrlcLlon.
• ÞresenLaLlon of Luberculous perlcardlLls - subacuLe,
fever, nlghL sweaLs, faLlgue - presenL for days Lo
monLhs.
• 8acLerlal perlcardlLls - paLlenLs appear Loxlc and
crlLlcally lll.
• uremlc perlcardlLls - fever ls absenL.
• neoplasLlc perlcardlLls - ofLen palnless, sympLoms
relaLe Lo haemodynamlc compromlse (mallgnanL
perlcardlal effuslon) or Lhe prlmary dlsease.
• uressler syndrome - a rub ls ofLen audlble, changes
on LCC may be confused wlLh lschaemla. Large
effuslons are uncommon, sponLaneous resoluLlon
wlLhln days. usually occurs weeks Lo several
monLhs afLer Ml or open hearL surgery.
• AuLolmmune dlsorders - [olnL paln and fever.
• 8adlaLlon perlcardlLls - usually wlLhln Lhe 1
sL
year of
LreaLmenL, ofLen a full decade passes before
perlcardlal consLrlcLlon becomes evldenL.

;-<")($5&($.-)
• vlral - LeukocyLosls, serology - rlslng vlral LlLers.
• Cardlac enzymes may be elevaLed - eplcardlal
myocardlLls componenL.
• Lchocardlogram - perlcardlal effuslon
• 1uberculous perlcardlLls - Al8 ln effuslons or
perlcardlal blopsy.
• 8acLerlal perlcardlLls - dlagnosLlc
perlcardlocenLesls.
• ln uremlc paLlenLs noL on dlalysls - lncldence of
perlcardlLls correlaLes roughly wlLh Lhe 8un and
creaLlnlne.
• neoplasLlc perlcardlLls - cyLologlc examlnaLlon of
Lhe pleural effuslon or perlcardlal blopsy.
• uressler syndrome - cardlac enzymes, Ck, LS8.
• LCC - generallzed S1 and 1 wave changes, dlffuse
S1 elevaLlon ln a non-vascular paLLern.
• Cx8 - ofLen normal, may show cardlac enlargemenL
lf perlcardlal fluld presenL. Mass leslons and
enlarged lymph nodes - neoplasm.
• M8l and C1 - vlsuallse nelghbourlng Lumour

=&-&5"9"-(
="'$%&3
• vlral - usually sympLomaLlc - Asprln, nSAlus,
corLlcosLerolds.
• 1uberculous - sLandard 18 Lherapy. 8lÞL
• uremlc perlcardlLls - sLarL dlalysls, or more
aggresslve dlalysls.
• neoplasLlc effuslons - prognosls ls dlsmal.
SympLomaLlc dralnlng.
• uressler syndrome - Asprln, nSAlus,
corLlcosLerolds. Colchlclne Lo prevenL recurrences.
87#5$%&3
• Þerlcardlal wlndows (parLlal perlcardecLomy)
prevenL recurrenL effuslons.

2.9:3$%&($.-)
• Þerlcardlal effuslon
• ConsLrlcLlve perlcardlLls
1PL uAnuLnCnC uCSSlL8 2010
20
!"#$%&'#()(*
,-.("()($"
lL ls an lnflammaLlon of Lhe endocardlum and usually also of Lhe
hearL valves.
ClasslflcaLlon:
• lnfecLlous endocardlLls (lL)
• non lnfecLlous endocardlLls

!/(#-0($1$23
• Males more affecLed Lhan females

4(*5 6&%)$'*
• CongenlLal hearL defecLs
• uegeneraLlon and calclflcaLlon of hearL valves !ln Lhe
elderly
• ÞrosLheLlc valves
• lvuu (Lrlcuspld valve mosL commonly affecLed)
• Medlcal procedures (caLheLers, cannulas,
bronchoscopy, L8CÞ eLc.)
• 8ecenL surgery
• Þoor denLlLlon and denLal procedures
• Px of rheumaLlc fever
• ulabeLes melllLus

MosL commonly affecLed valve ls MlLral followed by aorLlc

7-)($1$2389&:*-*
• 8acLeraemla: mosL of Lhe organlsms orlglnaLe from
normal flora, mosL commonly gram-poslLlve, sLrep
vlrldans*, sLaph aureus, enLerococcus faecalls: rarely
gram negaLlve
• SLL
• Mallgnancy

;&)<$/<3*($1$23




lL develops Lhrough Lhe followlng process
1. 8acLeraemla (nosocomlal or sponLaneous) LhaL
dellvers Lhe organlsms Lo Lhe surface of Lhe valve
2. Adherence of Lhe organlsms
3. lnvaslon of Lhe valvular leafleLs

1here ls focal area of abnormallLy on Lhe endocardlum of Lhe
valve leafleL covered wlLh deposlLs of plaLeleLs and flbrln (A ln
flgure 1). ln case of lL clrculaLlng mlcroorganlsms colonlse Lhe
plaLeleL Lhrombus (8) when sufflclenL bacLerla have seLLled
furLher plaLeleL and flbrln are lald down.
1he common denomlnaLor for adherence and lnvaslon ln
nonbacLerlal LhromboLlc endocardlLls ls a sLerlle flbrln-plaLeleL.
Lmboll from Lhe vegeLaLlon may lodge ln organs such as braln,
kldney, spleen, guL and hearL where Lhey may cause abscesses.

=(2"* &"# =30/)$0*
• SepLlc slgns: fever, rlgors, nlghL sweaLs, malalse,
welghL loss, anaemla, splenomegaly and clubblng
• Cardlac leslons: new murmur or change ln pre-exlsLlng
murmur
• ÞrolongaLlon of Þ8 lnLerval due Lo aorLlc rooL abscess -
may even lead Lo compleLe hearL block
• PearL fallure- due Lo obsLrucLlon or perforaLlon of
valve
>(*)$'3
Lnqulre abouL Lhe above-menLloned sympLoms and rlsk facLors

!?&0("&)($"
Ceneral lnspecLlon: fever, welghL loss, pallor
Pands: spllnLer haemorrhages, clubblng, Csler's nodes, and
[aneway leslons
Arms: evldence of lvuu
Lyes: anaemla, con[ucLlval haemorrhages (roLh's spoLs)
PearL: valvular problems (M8, MS, AS, A8), CongenlLal defecLs
(vSu), prosLheLlc valves
Abdomen: splenomegaly
urlnalysls: haemaLurla

@"A-*)(2&)($"*
8lood culLures: 3 seLs aL dlff Llme from dlff slLes
l8L: anaemla (normochromlc normocyLlc), wcc -neuLrophllla
urea and elecLrolyLes-renal funcLlon
lnflammaLory markers: hlgh LS8 / C8Þ
urlnalysls: mlcroscoplc haemaLurla
1CL>>>11L (senslLlvlLy)

B&"&2-0-")
Medlcal: glve anLlbloLlcs dependlng on causaLlve organlsm:
penlclllln C and genLamlcln for synerglsLlc coverage of
sLrepLococcl
Surglcal: Cardlac valve surgery: requlred for abscess, perslsLenL
lnfecLlon desplLe anLlmlcroblal Lherapy
LlfesLyle - malnLaln good denLlLlon

9$0/1(%&)($"*
valvular lncompeLence, myocardlal or sepLal abscess, CPl,
embollc phenomena, lmmune complex deposlLlon (vascullLls,
Cn)
1PL uAnuLnCnC uCSSlL8 2010
21
!"#$%&' )%*+$,&,
-*.&+&%&$+
narrowlng or occluslon of Lhe caroLld arLery lumen,
usually caused by aLherosclerosls.

/0&'*1&$2$34
• Male > female before 63 years
• Age
5&,6 7"8%$#,
• Smoklng
• PyperLenslon
• Pyperllpldaemla
• ulabeLes
• CbeslLy

9*%&$2$34:!";,*,
• ALherosclerosls/1hrombosls
• 1hromboemboll
• llbromuscular dysplasla (flbrous Lhlckenlng of
arLerles)

<"%=$0=4,&$2$34
• ALheroscleroLlc plaque aL caroLld blfurcaLlon
• ÞlaLeleL aggregaLlon and subsequenL plaLeleL
emboll Lravel Lo smaller blood vessels ln braln
causlng lschaemla
• 1emporary lschaemla can cause 1lA wlLh ocular
or cerebral sympLoms
• ÞermanenL lschaemla resulLs ln a
Lhromboembollc sLroke

)&3+, "+' )410%$1,
• ConLralaLeral cerebral sympLoms
moLor, sensory,speech-relaLed
• lpsllaLeral ocular sympLoms
Amaurosls fugax
• SympLoms may be LranslLory or permanenL
• 8rulL heard over caroLld arLery

>&,%$#4
• Þrevlous 1lAs, sLrokes
• 1emporary or resolvlng neurologlcal sympLoms
such as weakness, paraesLhesla (conLralaLeral)
• Amaurosls fugax (lpsllaLeral)'
• Conslder ?#"&+ %;1$;#@ aLyplcal mlgralne or
parLlal selzure for slmllar presenLaLlons
/A"1&+"%&$+
• AusculLaLe brulL over one or Lwo caroLld arLerles,
besL heard ln explraLlon
• AusculLaLe praecordlum Lo exclude a LransmlLLed
aorLlc sLenosls murmur
• neurologlcal slgns of prevlous sLroke
• Slgns of aLherosclerosls elsewhere (hearL,
abdomlnal aorLa, perlpheral vascular sysLem)
B+C*,%&3"%&$+,
Ceneral lnvesLlgaLlons
• urlnalysls (proLelnurla ln aLheroscleroLlc renal
dlsease) & uLC (renal lx)
• l8L (anaemla)
• Clucose (dlabeLes)
• CholesLerol (hypercholesLrolaemla)
• LCC (Al, cardlac dlsease, prevlous lnfarcLlon,
lschaemla, lefL venLrlcular dysfuncLlon)
Speclal lnvesLlgaLlons
• !"#$%&' ';02*A ,8"+ D'*3#** $. ,%*+$,&,E
• CaroLld anglography(caroLld arLery anaLomy)
• Lchocardlogram (praecordlal brulL)
• C1/M8l braln (lnfarcLs)

F"+"3*1*+%
F*'&8"2
• AnLl-hyperLenslves
• AnLl-coagulaLlon/AnLl-plaLeleLs
• SLaLlns
);#3&8"2


• CaroLld endarLerecLomy (sympLomaLlc caroLld
sLenosls >70°)
6fold reducLlon ln raLe of sLroke for 3yr
CperaLlve rlsk of sLroke 2°, morLallLy 1-2°
8lsks of haemaLoma, hypoglossal nerve ln[ury,
numbness of lpsllaLeral earlobe
• CaroLld anglo & sLenLlng (conLroverslal)
used ln 'hosLlle neck' e.g. prevlous
surgery/radloLherapy
G&.*,%42*
• Smoklng cessaLlon

!$102&8"%&$+,
• 1hromboembollc sLroke
• 1lAs and amaurosls fugax from mlcroemboll
1PL uAnuLnCnC uCSSlL8 2010
22
!"#$%& !()*#%+,+
-).%(%$%"( /01 234++%.%&4$%"(
Aneurlsms are a permanenL defecL ln an arLerlal wall,
leadlng Lo dllaLaLlon

56%7),%"3"89
nA

:%+; <4&$"#+

ALherosclerosls - smoklng, hlgh-faL dleL, obeslLy,
dlabeLes

CeneLlc facLors

!)$%"3"89024*+)+0=4$>"6>9+%"3"89
A Lrue aneurlsm affecLs all Lhree layers of Lhe vessel wall.
1hey are furLher sub-characLerlsed by shape ln Lo saccular
(locallsed) or fuslform (clrcumferenLlal)

ALherosclerosls and PyperLenslon are hlghly assoclaLed
wlLh Lrue aneurlsm formaLlon, however geneLlc and
envlronmenLal facLors are also lmporLanL.

ALheroscleroLlc plaque formaLlon separaLes Lhe Lunlca
lnLlma and medla layers of Lhe vessel wall. 1he lnner
layers of Lhe Lunlca medla usually recelve nuLrlenLs vla
dlffuslon from Lhe lnLlma, Lhls separaLlon leads Lo
lschaemla and consequenLlal weakenlng of Lhe vessel
wall. ln addlLlon, MMÞs produced by macrophages ln
aLheroscleroLlc formaLlon funcLlon Lo degrade connecLlve
Llssue ln Lhe surroundlng Llssue of Lhe vessel wall, furLher
weakenlng Lhe sLrucLure.
o 1hls loss of Lunlca medla ls Lermed cysLlc medlal
degeneraLlon
o ALheroscleroLlc aneurlsms are parLlcularly
predlsposed Lo affecL Lhe abdomlnal aorLa (AAA)

PyperLenslon lncreases Lhe sLresses on Lhe vessel walls.
1here ls also ofLen vascular changes affecLlng Lhe ouLer
layers of Lhe Lunlca medla. PyperLenslve aneurlsms are
mosL common ln Lhe proxlmal aorLa.
CLher causes lnclude:
o vascullLls
o MycoLlc aneurlsms (lnfecLlon) - ofLen follow
sepLlcaemla or lnfecLlve endocardlLls
o 1erLlary syphllls
ulssecLlng aneurlsms form as blood enLers Lhe vessel wall
Lhrough a Lear ln Lhe Lunlca medla. 1hls wlll cause a
haemaLoma beLween Lhe Lunlca lnLlma and medla.

1hese aneurlsms cause exLreme paln, ofLen descrlbed as
a 'Learlng' sensaLlon

1hese aneurlsms are mosL common around Lhe arch of
Lhe aorLa (1horaclc AorLlc aneurlsms - 1AAs)
lalse aneurlsms resulL from a Lear or puncLure of all Lhree
layers of an arLery, eg as occurs afLer anglography. 8lood wlll
accumulaLe beLween Lhe vessel and Lhe exLernal connecLlve
Llssue, closely resembllng an aneurlsm on examlnaLlon
?%8(+ 4(7 ?9,6$",+
Aneurlsms ofLen presenL sllenLly, or are dlscovered
lncldenLally
AAAs appear as an expanslle lump ln Lhe abdomen

Cccaslonally palnful, paln ls ofLen lnLermlLLenL
ulssecLlng Lhoraclc aneurlsms cause exLreme back or
reLrosLernal paln

Arm pulses may be uneven or paLlenL may demonsLraLe
cerebral or renal lmpalrmenL as Lhe dlssecLlon reduces
blood flow Lo Lhe branches of Lhe aorLa
o 8adlo-radlal or 8adlo-femoral delay

1he mass of Lhe aneurlsms may cause resplraLory
dlfflculLy or a cough

Plghly assoclaLed wlLh aorLlc lnsufflclency

@%+$"#9 4(7 5A4,%(4$%"(
vascular rlsk facLors

B(C)+$%84$%"(+
ulLrasound can provlde qulck and cheap screenlng for AAAs.
ulagnosls and assessmenL of severlLy of boLh 1AAs and AAAs
ls made on C1. Anglography may also be uLlllsed Lo beLLer
assess aneurlsms.

D4(48),)($
Aneurlsm rupLure ls a surglcal emergency. ÞaLlenLs are
sLablllsed, wlLh Lransfuslons glven lf sysLollc 8Þ < 100, and
admlLLed for open surglcal repalr.

Plgh rlsk procedure, wlLh a 41° morLallLy even wlLh
surgery. unLreaLed, however, 100° morLallLy

Surglcal procedure lnvolves aorLlc clamplng, and
lnserLlon of a Lubular grafL lnLo Lhe aorLlc lumen
Aneurlsms ldenLlfled prlor Lo rupLure are managed accordlng
Lo rlsk of rupLure

1AAs and AAAs >6cm should be repalred prompLly vla
elecLlve anglography and sLenLlng

AAAs smaller Lhan 6cm should be monlLored and LreaLed
conservaLlvely unLll Lhey grow large enough Lo warranL
surglcal repalr.

2",63%&4$%"(+
All aneurlsms have a rlsk of rupLure. As Lhey affecL large
blood vessels Lhls can cause a slgnlflcanL amounL of blood
loss very qulckly, and consLlLuLes a surglcal emergency

AAAs expand by a cm every 2-3 years. Larger AAAs (>3cm
dlameLer) have a far greaLer rlsk of rupLure

Always suspecL AAA rupLure ln an acuLely shocked buL
prevlously well paLlenL wlLh no obvlous source of blood
loss
1he damage Lo Lhe vessel wall and consequenL lrregular
blood flow lncrease Lhe rlsk of Lhrombosls formaLlon (2 of
vlrchow's Lrlad), and hence emboll. 1hls ls parLlcularly
relevanL ln saccular aneurlsms.
Large aneurlsms can compress surroundlng sLrucLures, or
obsLrucL vessel branches
1PL uAnuLnCnC uCSSlL8 2010
23
!"#$%&"#'( *'+,-('# .$+"'+"
."/$0$1$20 345 6('++$/$,'1$20
CbsLrucLlon of large arLerles excludlng coronary arLerles,
aorLlc arch vasculaLure, and braln

7$+8 /',12#+
• smoklng
• uM
• dysllpldemla
• P1n
• male
• 8Ml>30
• famlly Px vascular dlsease/Ml/sLroke.
• ?homocysLelne, ? C8Þ

!'1&2%&9+$2(2:9
1. ALheroscleroLlc dlsease ! occluslon
2. vascular spasms ! lnLermlLLenL occluslon (eg. 8aynaud's)

6('++$/$,'1$20
;201'$0"<
1. mlld lnLermlLLenL claudlcaLlon
2. severe lnLermlLLenL claudlcaLlon
a. afLer walklng >130m
b. afLer walklng <130m
3. paln aL resL ln feeL, lncreaslng when llmb ralsed
4. gangrene + dlfflculLy walklng
7-1&"#/2#=<
1. mlld claudlcaLlon
2. moderaLe claudlcaLlon
3. severe claudlcaLlon
4. lschemlc paln aL resL
3. mlnor Llssue loss
6. ma[or Llssue loss

>$:0+ '0= >9?%12?+
• weakness, cramplng
• claudlcaLlon/ paln on resL
• slow-heallng/non-heallng ulcers
• pallor/coolness of exLremlLles
• dlmlnlshed/alLered halr growLh on affecLed llmbs
• loss of sensaLlon, esp. LemperaLure.
• paresLheslas

@$+12#9 '0= AB'?$0'1$20
@B<
5CCDDEEFG 021" 0'1-#" 2/ %'$0
-Þhx, lPx
-rlsk facLors as per above
-Mls/1lAs/sLroke
SysLem 8evlew:
1. paln on resL, parLlcularly when lylng ln bed.
2. lnLermlLLenL claudlcaLlon: how far can Lhey walk?
3.swelllng
4. sores/ulcers-palnful? Chronlc? Cangrenous?
AB<
1. lnspecL:
-hands: LemperaLure, caplllary reflll, nlcoLlne sLalns, Lendon
xanLhomaLa.
-cyanosls/pallor, slgns hearL fallure
-xanLhelasma, corneal arcus
-obvlous lllness, moblllLy alds.
2. general: caroLld pulses, radlal/radlal, radlal/femoral delay,
AAA, renal brulLs.
3. legs: 8 vs L.
4. lnspecL: dresslngs, dlscoloraLlons, scars, deformlLles,
skln/halr changes, ampuLaLlons/gangrene, ulcers (check
beLween Loes)
a) arLerlal: pallor, shlny skln, decreased halr, scars, mlsslng
nalls/Loes, wasLlng. ulcers: 'punched-ouL' leslons, usually on
borders, sldes of feeL aL pressure areas, palnful. ?ellow,
brown, gray or black base. nll dlscoloraLlon around skln,
general pallor.
b) venous: waxy skln, varlcose velns, skln hemoslderln
deposlLs/sLalnlng, venous sLasls (purple), edema, redness,
bllsLers wlLh fluld. ulcers: medlal, sup. Lo medlal malleolus,
'galLer'. lrregular, heaped-up borders, dlscolored/swollen
skln surroundlng. 8ed/ bleedlng base, can be covered wlLh
flbrous Llssue. usually palnless.
3. ÞalpaLe: caplllary reflll, LesL for LemperaLure by runnlng
hands up Lhe back of legs, Lake popllLeal, dorsalls pedls, and
posL. Llb pulses (presenL, reduced, absenL) , measure calf
clrcumference.
6. LesL for loss of sensaLlon, proprlocepLlon, vlbraLlon.
7. 8uerger's LesL: px lylng flaL, ralse Lhelr leg and hold unLll lL
Lurns pale (approx 1 mln), Lhen geL Lhem Lo drop Lhelr leg
over Lhe slde of Lhe bed. +ve 8uerger's= fooL goes brlghL red,
reacLlve hyperemla = slgn of arLerlal lnsufflclency.

H0I"+1$:'1$20+
Ankle-brachlal pressure-lndex: use handheld uoppler and
sphyg: measure brachlal sysLollc 8Þ and use Lhe uoppler Lo
measure sysLollc 8Þ aL Lhe mosL dlsLal pulse. Ankle 8Þ
dlvlded by brachlal 8Þ should >1. ln claudlcaLlon, <.8, ln
crlLlcal lschemla <. 4.
uoppler u/s runs: measure severlLy of ÞAu
1readmlll LesL: measures b.p durlng exerclse, lndlcaLes
severlLy of dlsease.
C1 anglography: measures degree of occluslon, vlsuallzes
flow Lhrough perlpheral arLerles.

J'0':"?"01
-sLenLlng
-bypass: usually veln harvesL, buL paLchlng can be used.

62?%($,'1$20+
Llmb lschemla ! gangrene, ampuLaLlon
ulceraLlons/cellullLes ! sepsls

1PL uAnuLnCnC uCSSlL8 2010
24
!"#$%&'( !($*'
+(,$*$-$&* ./0 12"''$,$%"-$&*
• ullaLed, LorLuous superflclal velns ln Lhe lower
exLremlLles.

34$5(6$&2&78
• 13° of all adulLs.

9$': ;"%-&#'
• Þrolonged sLandlng
• Peavy llfLlng
• Women afLer pregnancy

<(-$&2&78/1"='('
• 1he CreaL Saphenous veln and lLs LrlbuLarles are
mosL commonly lnvolved, Small Saphenous may be
lnvolved.
• ÞerforaLlng velns LhaL connecL Lhe deep and
superflclal sysLems may become lncompeLenL,
allowlng blood Lo reflux lnLo Lhe superflclal velns,
lncreaslng venous pressure and dlsLenslon.
• Secondary varlcoslLles can develop as a resulL of
obsLrucLlve changes and valve damage followlng
LhrombophleblLls, or rarely as a resulL of proxlmal
venous occluslon due Lo neoplasm or flbrosls.
• ArLerlovenous flsLulas or venous malformaLlons are
also assoclaLed.

>"-?&4?8'$&2&78
• ulsLenslon of Lhe veln prevenLs Lhe valve leafleLs
from closlng properly, creaLlng lncompeLence.
• ullaLlon aL any polnL along Lhe veln leads Lo
lncreased pressure of Lhe veln segmenL below LhaL
valve, whlch ln Lurn causes progresslve fallure of
Lhe nexL lower valve and venous reflux.

noLe: ln adolescenL paLlenLs wlLh varlcose velns, lmaglng of
Lhe deep venous sysLem ls lmporLanL Lo exclude a congenlLal
malformaLlon of Lhe deep velns. Surglcal LreaLmenL ls
conLralndlcaLed because Lhe varlcoslLles may play a
slgnlflcanL role ln venous dralnage of Lhe llmb.

@$7*' "*5 @864-&6'
noLe: SympLom severlLy does noL correlaLe wlLh Lhe number
and slze of Lhe varlcoslLles.
• uull, achlng heavlness ln Lhe legs.
• A feellng of faLlgue of Lhe legs, broughL on by
perlods of sLandlng.
• lLchlng from venous sLasls dermaLlLls.
• ullaLed velns are generally vlslble upon sLandlng.
• 8rownlsh plgmenLaLlon and Lhlnnlng of Lhe skln
above Lhe ankle.
+5A
• ArLerloscleroLlc perlpheral vascular dlsease -
lnLermlLLenL claudlcaLlon and coldness of Lhe feeL.
(conLralndlcaLlon Lo operaLlve LreaLmenL of
varlcoslLles)
• ArLerlovenous flsLula - presence of brulL or Lhrlll.
• Þrlmary varlcose velns vs. Lhose secondary Lo
chronlc venous lnsufflclency - exLenslve swelllng,
flbrosls, plgmenLaLlon and ulceraLlon.
• Þaln or dlscomforL secondary Lo arLhrlLls,
radlculopaLhy.

B*C('-$7"-$&*'
• uuplex uS - ldenLlflcaLlon of Lhe source of venous
reflux LhaL feeds Lhe sympLomaLlc velns ls necessary
for effecLlve surglcal LreaLmenL. ulagnosls and
locallsaLlon.

D"*"7(6(*-
D(5$%"2 - LlasLlc graduaLed compresslon sLocklngs -
exLernal supporL. useful Lo prevenL progresslon. Comblned
wlLh elevaLlon of Lhe legs when posslble, good conLrol can
be malnLalned and compllcaLlons avolded.
@=#7$%"2 - Lndovenous ablaLlon or less commonly, veln
sLrlpplng ls very effecLlve. CorrecLlon of reflux ls performed
aL Lhe same Llme - lf noL done, recurrence raLes are hlgh.
1&64#(''$C( @%2(#&-?(#"48 - CbllLeraLes and produces
permanenL flbrosls of Lhe velns - reserved for small varlcose
velns <4mm ln dlameLer. ln[ecLlon of scleroslng soluLlon ln
Lhe varlcosed veln ls followed by a perlod of compresslon of
Lhe segmenL.
1&642$%"-$&*'
• 1hrombophleblLls wlLhln a varlcose veln -
uncommon. ÞresenLs as subacuLe Lo acuLe locallzed
paln and palpable hardness aL Lhe slLe of phleblLls.
Self-llmlLlng process, low rlsk of embollsaLlon,
resolves ln weeks.
• Superflclal varlcoslLles may bleed wlLh Lrauma ln
Lhe elderly. AmounL of bleedlng can be alarmlng
due Lo hlgh pressures ln Lhe velns.

1PL uAnuLnCnC uCSSlL8 2010
23
!"#$%&' )*%$+, -%,+..&'&*%'/
0*.&%&1&$% 234 !56,,&.&'61&$%
8esulLs from changes secondary Lo deep venous
LhrombophleblLls (posL-LhromboLlc syndrome).
7&,8 96'1$#,
• CbeslLy
• Þrlor uv1 or leg ln[ury
• neoplasm - obsLrucLlon of pelvlc velns
• ArLerlovenous flsLula
:61"$;"/,&$5$</
• Caused by valve leafleLs LhaL do noL close
properly because Lhey are elLher Lhlckened and
scarred (posL-LhromboLlc syndrome) or ln a
dllaLed veln and are Lhus funcLlonally
lnadequaLe.
• 8esulLs ln an abnormally hlgh hydrosLaLlc
pressure LransmlLLed Lo Lhe subcuLaneous Llssues
and skln.
• ÞlgmenLaLlon of Lhe skln ! haemoslderln Laken
up by dermal macrophages.
• lLchlng may preclplLaLe Lhe formaLlon of
ulceraLlon or local wound cellullLls.
• ullaLlon of superflclal velns may occur, leadlng Lo
varlcoslLles.
noLe: Whereas prlmary varlcose velns wlLh no
abnormallLy of Lhe deep venous sysLem may be
assoclaLed wlLh slmllar changes, Lhe oedema ls more
pronounced ln Lhe chronlc venous lnsufflclency, and Lhe
secondary changes are more exLenslve and deblllLaLlng.
=&<%, 6%> =/?;1$?,
• Þrogresslve oedema of Lhe lower leg.
• Skln aL ankle ls usually Lhln, shlny and a brownlsh
plgmenLaLlon ofLen develops.
• lLchlng + dull dlscomforL made worse by perlods
of sLandlng.
• ulceraLlon ! [usL above ankle, medlal aspecL of
leg. Peallng resulLs ln a Lhln scar on a flbroLlc
base LhaL ofLen breaks down wlLh mlnor Lrauma
or anoLher bouL of leg swelllng.
• lf condlLlon ls long sLandlng, subcuLaneous
Llssues become Lhlck and flbrous.
• varlcoslLles frequenLly appear LhaL are
assoclaLed wlLh lncompeLenL perforaLlng velns.
• CellullLls - blanchlng eryLhema.
-%@*,1&<61&$%,
• uuplex ulLrasonography ! Lo deLermlne
wheLher superflclal reflux ls presenL and Lo
evaluaLe Lhe degree of deep reflux and
obsLrucLlon.

0&..*#*%1&65,
• CCl, C8l, decompensaLed llver dlsease !
bllaLeral oedema of Lhe lower legs.
• Lymphoedema - unllaLeral, absenL varlcoslLles.
• Þrlmary varlcose velns.
• AuLolmmune dlsease - chronlc ulcers ! lelLy
syndrome
• ArLerlal lnsufflclency - chronlc ulcers
• Slckle cell anaemla - chronlc ulcers
• lnfecLlon
A6%6<*?*%1
:#*@*%1&$%
• Larly and aggresslve anLlcoagulaLlon of acuLe
uv1 Lo mlnlmlse valve damage.
• CaLheLer-dlrecLed Lhrombolysls or mechanlcal
LhrombecLomy of acuLe uv1 may be beLLer aL
prevenLlng posL-LhromboLlc syndrome and
chronlc venous lnsufflclency.

A*>&'65
• CraduaLed compresslon sLocklngs worn from Lhe
mld fooL Lo [usL below Lhe knee durlng Lhe day
and evenlng are Lhe malnsLays of LreaLmenL.
• ÞaLlenL's legs should be elevaLed lnLermlLLenLly
durlng Lhe day, and aL nlghL, Lhe legs should be
kepL above Lhe level of Lhe hearL wlLh plllows
under Lhe maLLress.
• ÞneumaLlc compresslon - pumps fluld ouL of Lhe
leg.
• uLCL8A1lCn - as Lhe prlmary paLhology ls
oedema, heallng of Lhe ulcer wlll noL occur unLll
Lhe oedema ls conLrolled.
o Can be LreaLed ouL of hosplLal - seml-
rlgld gauze booL + medlcaLlon.
o Þump acLlon of calf muscles can be
enhanced by a clrcumferenLlal non-
elasLlc bandage on Lhe ankle.
o AlLernaLlvely compresslon sLocklngs +
absorbenL dresslng ! ulcers leak large
volumes of fluld.
=+#<&'65
• lncompeLenL perforaLor velns LhaL feed Lhe area
of ulceraLlon can be LreaLed wlLh radlofrequency
ablaLlon or endovenous laser LreaLmenL.
• Where Lhere ls subsLanLlal obsLrucLlon of Lhe
deep venous sysLem, superflclal varlcoslLles
supply Lhe venous reLurn and should noL be
removed.
!$?;5&'61&$%,
• 8ecurrenL oedema and ulceraLlon, parLlcularly lf
paLlenLs do noL conslsLenLly wear supporL
sLocklngs.

!"# %&'%#'(') %(**+#, -./.
-0
!"#$%&'()&*
1PL uAnuLnCnC uCSSlL8 2010
27

!"#$%&
()*+,+#+-,
8ecurrenL eplsodes of dyspnoea, cough and wheeze
caused by .)/)."+01) alrways obsLrucLlon

2+"3 4&5#-."
• ALopy
• Lxposure Lo clgareLLe smoke (durlng pregnancy
and lnfancy)
• Allergles
• Alrway hyper-responslveness

!)#+-1-6789&:")"
CeneLlc predlsposlLlon + envlronmenLal facLors
;<#).,&1 #.+66)." =>6;? 8
!11).6),"
>,#).,&1 #.+66)." =,-, >6;?
Þollen, mould 8hlnlLls and upper 81l
(especlally vlral)
uusL / dusL mlLes Lxerclse
Anlmal fur Cold alr
CccupaLlon exposure e.g.
wood dusLs, flour
CccupaLlonal exposure e.g.
lsocyanaLes, epoxy resln
ClgareLLe smoke
urugs (asplrln, nSAlus)
CC8u
LmoLlonal sLress

@&#$-A$7"+-1-67
8lphaslc aLLack
1. lmmedlaLe phase = B.-,5$-5-,"#.+5#+-, due Lo
Lrlgger by varleLy of sLlmull (bronchlal hyper-
responslveness):
- Allergens: lgL blndlng Lo masL cell -
degranulaLlon - lnflammaLory medlaLors
- Cold alr, exerclse, upper 81l eLc.
2. Secondary phase = C:5-"&1 +,*1&%%&#+-,
- vasodllaLaLlon
- Mucus hypersecreLlon and oedema

D+6," &,E D7%A#-%"
• Cough (ofLen nocLurnal)
• ChesL LlghLness
• uyspnoea
• SpuLum
• Wheeze (wldespread, polyphonlc on
ausculLaLlon)
• 1achypnoea
• PyperlnflaLed chesL, hyperresonanL percusslon
noLe
• ulmlnlshed alr enLry
Severe aLLack: sllenL chesL, unable Lo speak ln senLences,
P8 > 120 bpm

F+"#-.7
ÞreclplLanLs
ulurnal varlaLlon
CuanLlfy exerclse Lolerance
ulsLurbed sleep (assess severlLy of asLhma)
Acld reflux
CLher aLoplc dlsease (hay fever, eczema, allergy, lPx)
Pome envlronmenL, especlally bedroom(peLs, carpeL,
dusL)
CccupaLlon
uays per week off school or work

>,/)"#+6&#+-,"
>,E:5+0+1+#7 (e.g. meLhachollne or exerclse challenge) G
.)/)."+0+1+#7 (>13° lmprovemenL ln response Lo
bronchodllaLors)
@;4: >13° reverslblllLy, >20° dlurnal varlaLlon
DA+.-%)#.7: obsLrucLlve defecL (jlLv1/lvC, ^8v), >13°
lmprovemenL ln lLv1 followlng beLa-agonlsL or sLerold
Lrlal
SpuLum culLure, l8C, u&L, C8Þ, blood culLures, A8C (low
ÞaCC2 due Lo hypervenLllaLlon), Cx8 (hyperlnflaLed chesL)

C&,&6)%),#
2)1+)/).": SA8A e.g. salbumaLol
AnLlchollnerglcs e.g. lpraLroplum bromlde
D7%A#-% 5-,#.-11).": LA8A e.g. salmeLerol
@.)/),#)."H corLlcosLerolds (oral/lnhaled) e.g.
beclomeLhasone
LeukoLrlene recepLor anLagonlsLs e.g. monLelukasL
MasL cell sLablllsers e.g. sodlum cromoglycaLe
9-%0+,&#+-,H SereLlde, SymblcorL

D#)AI+") &AA.-&5$
1. Low dose lnhaled corLlcosLerolds + SA8A prn
2. lncrease dosage of corLlcosLerolds, lnLroduce
LA8A or swlLch Lo comblnaLlon + SA8A prn

!:"#.&1+&, J&#+-,&1 !"#$%& 9-:,5+1 K D#)A C&,&6)%),#
@1&,
!"")"" severlLy, Achleve 0)"# 1:,6 *:,5#+-,, Avold
#.+66).", use -A#+%&1 %)E+5&#+-,", uevelop an &5#+-,
A1&,, ;E:5&#) &,E .)/+)I regularly

9-%A1+5&#+-,"
Þneumonla, resplraLory fallure, lung collapse
1PL uAnuLnCnC uCSSlL8 2010
28
!"#$%&'(%)*+'+
-(.'$')'#$ /01 23*++'.'%*)'#$
• Abnormal and permanenL dllaLaLlon of Lhe alrways
• lnflamed, Lhlckened and lrreverslble damage
• lmpalrmenL of mucoclllary clearance leadlng Lo
frequenL lnfecLlons

4'+5 6*%)#"+
• lrequenL lnfecLlon (18, pneumonla, abcess)
• Locallsed alrway obsLrucLlon (eg. Lumour,
forelgn body)

7()'#3#8902*:+(+
• congenlLal- pulmonary sepuesLraLlon, bronchlal wall
deflclency, Cl
• mechanlca obsLrucLlon
o lnLrlnslc- forelgn body, lnsplraLed
mucous, posL 18 sLenosls, Lumour
o exLrlnslc- lymph nodes, Lumour
• posL lnfecLlve damage- bacLerlal and vlral pneumonla,
perLussls, measles and asplraLlon pneumonla
• granuloma & flbrosls- 18, sarcoldosls, flbroslng
alveollLls
• lmmune over-responslveness- allerglc
bronchopulmonary asperglllosls
• lmmune deflclency- panhypogammaglobullnaemla,
lgA & lgC deflclency, Plv & mallgnancy
• mucoclllary clearance defecLs- prlmary clllary
dysklnesla, Cl, karLageners syndrome

;*)&#<&9+'#3#89
• lnvolved bronchl are dllaLed, lnflamed and easlly
collapslble, resulLlng ln alrflow obsLrucLlon and
lmpalred clearance of secreLlons
• 8ronchecLasls ls assoclaLed wlLh a wlde range of
dlsorders buL usually resulLs from necroLlslng
bacLerlal lnfecLlons such as sLaph, klebslella or
bordaLella.



='8$+ *$> =9?<)#?+
• mlld bronchlecLasls presenLs wlLh yellow or
green spuLum afLer lnfecLlon
• as condlLlon progresses, paLlenL suffers
perslsLenL hallLosls, recurrenL febrlle eplsodes
wlLh malalse and someLlmes pneumonla
• clubblng occurs
• coarse crackles can be heard
• conLlnuous producLlon of foul smelllng, khakl-
coloured spuLum +/- haemopLysls

@'+)#"9 *$> AB*?'$*)'#$
lrequenL and large quanLlLles of green/yellow spuLum
producLlon & foul smelllng breaLh. Lxamlne spuLum for
furLher lndlcaLlon. Clubblng may also be presenL.

C$D(+)'8*)'#$+
Plgh resoluLlon C1 shows bronchlal dllaLaLlon and wall
Lhlckenlng and ls 97° speclflc (dlagnosLlc)
SpuLum can be culLured for any poLenLlal lnfecLlons

E*$*8(?($)
E(>'%*3
• anLlbloLlcs for any bronchopulmonary lnfecLlons
• bronchodllaLors are used ln paLlenLs wlLh
demonsLrable alrflow llmlLaLlon
• anLl-lnflammaLory agenLs, lnhaled or oral sLerolds can
decrease Lhe raLe of progresslon
=:"8'%*3
• lung resecLlon ls an opLlon lf bronchlecLasls ls
locallsed
• LransplanL can be consldered ln cerLaln cases
F'.(+)93(
• ÞosLural dralnage ls essenLlal 3 Llmes dally

2#?<3'%*)'#$+
• ulLlmaLely mosL paLlenLs wlll develop resplraLory
fallure because of chronlc deLerloraLlon of lung Llssue
• lrequenL lnfecLlons ofLen compllcaLe Lhe condlLlon

1PL uAnuLnCnC uCSSlL8 2010
29
!"#$%& (%)*+#%#
,-.%/%$%+/ 012 !34##%.%&4$%+/
CysLlc llbrosls (Cl) ls an auLosomal recesslve geneLlc
dlsorder whlch lmpalrs chlorlde channel funcLlon ln
eplLhellal cells. ÞaLlenLs wlLh Cl suffer recurrenL bronchlal
lnfecLlons as well as pancreaLlc, lnLesLlnal and ferLlllLy
effecLs.

56%7-8%+3+9"
lL ls common ln parLlcularly wesLern Luropean
populaLlons (1 ln 200) wlLh a hlgh carrler raLe (1 ln 22).

:%#; (4&$+*#
CeneLlc - over 1600 lndlvldual causaLlve gene muLaLlons
ldenLlfled

<-$%+3+9"1!4=#-#1>4$?+6?"#%+3+9"
1he cysLlc flbrosls Lransmembrane conducLase regulaLor
(Cl18) gene ls muLaLed, leadlng Lo decreased funcLlon. Cl
-

secreLlon ls decreased and na
+
absorpLlon lncreased, wlLh
a neL movemenL of waLer lnLo Lhe body.

1hls Lhlckens Lhe conslsLancy of bodlly secreLlons,
especlally resplraLory mucus, pancreaLlc [ulces and
lnLesLlnal secreLlons

1he excepLlon ls ln sweaL glands where normally only
salL ls absorbed, wlLhouL any neL movemenL of waLer.
ln Cl Lhe salL conLenL of sweaL ls greaLly lncreased.
1he Lhlckened resplraLory mucus provldes an ldeal hablLaL
for bacLerlal lnfecLlon. 1he Lhlckened mucus ls also more
dlfflculL for Lhe body Lo clear Lhrough normal mechanlsms

ÞaLlenLs ofLen suffer frequenL resplraLory lnfecLlons,
leadlng Lo early onseL bronchlecLasls.
o SLaph Aureaus, haemophllls, pseudomonas
specles and 8urkholderla cepacla are Lyplcal.
Asperglllus, a fungus, ls also common
o SlnuslLls ls exLremely common amongsL Cl paLlenLs
uecreased pancreaLlc and lnLesLlnal secreLlon volume
lmpalrs normal dlgesLlon. SLomach acld ls noL adequaLely
neuLrallsed and less dlgesLlve enzymes are dellvered lnLo
Lhe dlgesLlve LracL.

1he common presenLaLlon of Cl ls neonaLal or
chlldhood fallure Lo Lhrlve. 1hls occurs due Lo
malabsorpLlon from pancreaLlc lnsufflclency, and ls
assoclaLed wlLh sLeaLorrhoea.

ÞancreaLlLls and gall sLones occur more ofLen ln Cl

neonaLes wlLh Cl may be born wlLh a maeconeum
lleus due Lo lncreased vlscoslLy of Lhe maeconeum.
Males wlLh Cl are frequenLly lnferLlle due Lo a absence of
Lhe vas deferens and epldldymls. Women usually have
normal ferLlllLy.




@%9/# 4/7 @"86$+8#
SympLoms of Cl are many and wldespread, varylng wlLh
Lhe severlLy of dlsease. 1he hallmark feaLure ls neonaLal
or chlldhood onseL resplraLory dlsease and fallure Lo
Lhrlve.

8esplraLory sympLoms
o 8ecurrenL slnuslLls, nasal polyps
o 8ronchlecLasls, producLlve cough wlLh vlscous
purulenL spuLum, Lachypnoea, hyperexpanslon
o Clubblng, cyanosls are common

Cl sympLoms
o lallure Lo Lhrlve, assoclaLed wlLh delayed growLh
and puberLy
o vlLamln or nuLrlenL deflclencles
o SomeLlmes hepaLosplenomegaly, gall sLones,
pancreaLlLls

A%#$+*" 4/7 5B48%/4$%+/
8esplraLory hlsLory
ÞaedlaLrlc growLh hlsLory

C/D-#$%94$%+/#
1he screenlng LesL for Cl ls sweaL sodlum conLenL looklng
for greaLer Lhan 60mmol/L, usually wlLh a greaLer Cl- Lhan
na+.

Common geneLlc muLaLlons can be LesLed for,
however many more exlsL.

E4/49-8-/$
1reaLmenL LargeLs each effecL of Cl lndependenLly
8esplraLory dlsease:

ChesL physloLherapy alds Lhe expulslon of mucus

lnhaled hyperLonlc sallne can provlde shorL Lerm
lmprovemenL of resplraLory funcLlon, especlally when
co-admlnlsLered wlLh bronchodllaLors such as
venLolln.

Long-Lerm anLlbloLlc admlnlsLraLlon, parLlcularly
azlLhromycln, ls used for boLh anLlmlcroblal and anLl-
lnflammaLory effecLs
CasLrolnLesLlnal dlsease

A normal or hlgh-faL dleL ls recommended Lo paLlenLs
wlLh Cl, usually comblned wlLh vlLamln
supplemenLaLlon

Cral pancreaLlc enzymes are used Lo supplemenL,
Laken wlLh meals

SecreLory moLlllLy agenLs are used Lo lncrease sLool
waLer conLenL

!+863%&4$%+/#
1here ls no cure for Cl, alLhough wlLh LreaLmenL mosL
paLlenLs can expecL Lo llve Lo Lhelr mld-LhlrLles

MosL paLlenLs dle from severe resplraLory dlsease or
cor pumonale

1PL uAnuLnCnC uCSSlL8 2010
30

!"#$%&#'#'()*+,,-.(#'/"() 1-"2 3'&$(&$
3$4'"'#'/"
!"#$%&#'#'() )+", -'&$(&$ (aka dlffuse parenchymal lung
dlsease) refers Lo a group of lung dlseases affecLlng Lhe
lnLersLlLlum. lL concerns alveolar eplLhellum, pulmonary
caplllary endoLhellum, basemenL membrane, perlvascular
and perllymphaLlc Llssues.
.//+0(#'1"() )+", -'&$(&$& are concerned prlmarlly wlLh
work relaLed exposures Lo harmful subsLances eg: dusLs,
gases and Lhe subsequenL pulmonary dlsorders LhaL may
occur as a resulL.

5'&6 7(,#/%&
• CccupaLlon
• Smoklng
• uusL lnhalaLlon
• CeneLlc predlsposLlon

8(-&$&
lLu can be classlfled accordlng Lo Lhe cause:
• lnhaled subsLances
o lnorganlc (slllcosls, asbesLosls, barlLosls)
o Crganlc (hypersenslLlvlLy pneumonlLls)
• urug lnduced (anLlbloLlcs, chemo drugs,
anLlarrhyLhmlc agenLs, sLaLlns)
• ConnecLlve Llssue dlsease (SysLemlc sclerosls,
polymyoslLls, SLL, 8A)
• lnfecLlon (aLyplcal pneumonla, ÞCÞ, 18)
• ldlopaLhlc (Sarcoldosls, ldlopaLhlc pulmonary
flbrosls)
• Mallgnancy (lymphanglLlc carclnomaLosls)

9(#:/.:;&'/)/2;
lor asbesLosls and slllcosls paLhophyslology see
pneumoconlosls paLh case (S2Þ8).
230$%&$"&'#'4#3 0"$+51"'#'& 6 hypersenslLlvlLy caused by
lnhaled organlc dusL leadlng Lo a granulomaLous reacLlon
ln Lhe bronchloles exLendlng dlsLally lnLo Lhe alveoll.
Þrogresslve flbrosls resulLs lf Lhere ls perslsLenL
lnflammaLory cel acLlvaLlon.
7(%/1'-1&'& - a mulLlsysLem dlsease of unknown aeLlology
characLerlsed by Lhe presence of non-caseaLlng
granulomas ln Lhe affecLed organs (malnly skln, eyes and
resp LracL). 1he currenL hypoLhesls ls LhaL ln geneLlcally
suscepLlble lndlvlduals lL ls caused Lhrough an alLeraLlon
ln lmmune response afLer exposure Lo an envlronmenLal,
occupaLlonal or lnfecLlous agenL.

<'2"& ("= <;>.#/>&
• uyspnoea on exerLlon, jexerclse Lolerance
• ChesL paln
• non producLlve paroxysmal cough
• Abnormal breaLh sounds
• Abnormal Cx8/P8C1
• 8esLrlcLlve pulmonary splromeLry wlLh a reduced
uCLC

?'&#/%; ("= @A(>'"(#'/"
CccupaLlonal hlsLory - make sure Lo ask abouL exposure
Lo dusLs and gases
urugs, medlcaLlon
ÞMPx

!"B$&#'2(#'/"&
• l8L (mlld normochromlc, normocyLlc anaemla),
^LS8, ^ Ca2+
• Cx8, P8C1 Lhorax
• Serum ACL level - ^ ln 73° of people wlLh
unLreaLed sarcoldosls. Also ralsed ln paLlenLs wlLh
lymphoma, pulmonary 18, asbesLosls, slllcosls
• Lung funcLlon LesLs
• Lung blopsy

C("(2$>$"#
lLu ls noL a slngle dlsease and encompasses many
dlfferenL paLhologlcal processes, hence LreaLmenL ls
dlfferenL for each dlsease.

7/% &(%,/'=/&'&
C$=',() D acuLe sarcoldosls: bed resL, nSAlus
30° -70° of paLlenLs do noL requlre Lherapy. Cood
prognosls.
Severe sympLoms are LreaLed malnly wlLh prednlsolone.
1PL uAnuLnCnC uCSSlL8 2010
31
!"#$%&'()&* ,'%-.&"
/"0%1%(%)1
8esplraLory fallure occurs when pulmonary gas exchange
ls sufflclenLly lmpalred Lo cause hypoxaemla wlLh or
wlLhouL hypercapnla.
!"#$ & '$(#) *+,-.'$ (hypoxaemlc) - fallure of
oxygenaLlon, usually due Lo pulmonary paLhology.
!"#$ / '$(#) *+,-.'$ (hypercapnlc) - fallure of venLllaLlon
Lo remove CC2, usually Lhe resulL of a dlsorder wlLh
resplraLory muscles.

!%#2 ,'3()&#
• ClgareLLe smoklng
• Þulmonary lnfecLlon
• CCÞu
• Þulmonary flbrosls
• CnS dlsorders
• neuromuscular dlsorders
• ChesL wall dlseases

4"(%)-)5*67'.#"#
!"#$ & *+,-.'$ 0+.($( 1
• v/C mlsmaLch - CCÞu, pneumonla
o Þoorly venLllaLed alveoll conLrlbuLe Lo
hypoxaemla, whlch ls overcome by ^ llC2
• ulffuslon block - pulmonary flbrosls + exerclse
o A Lhlckened lnLersLlLum beLween alveolus and
caplllary, glvlng 88Cs less Llme Lo equlllbraLe for
gas exchange
• Low llC2 aL alLlLude
• PypovenLllaLlon - drug overdose
• 8lghL Lo lefL shunL - Llsenmenger's, LeLrology of
lalloL (8A8L)

!"#$ / *+,-.'$ 0+.($( 1
• uefecLlve cenLral conLrol of breaLhlng - drug
overdose
• neuromuscular dlsease - AmyoLroplc laLeral
sclerosls, splnal cord leslons, myasLhenla gravls, C8S
• ChesL wall dlsease - kyphoscollosls, large effuslons
• 1º lung dlsease - CCÞu





8%51# '19 8*:$():#
1ype 1 fallure
• j pC2, jpCC2
• AglLaLed, aggresslve
• Confused, coma
• ^ resp. raLe, dyspnoea
• 1achycardla
1ype 2 fallure
• j p02, ^pCC2
• Sleepy, confused, coma
• MeLabollc flap
• Warm, vasodllaLed, boundlng pulse

;%#()&* '19 <=':%1'(%)1
Cllnlcal assessmenL of resp. dlsLress should be made on
Lhe followlng crlLerla:
• 1he use of accessory muscles of resplraLlon
• lnLercosLals recesslon
• 1achypnoea*
• 1achycardla
• lnablllLy Lo speak, unwllllngness Lo lle flaL
• AglLaLlon, resLlessness, dlmlnlshed consclous level
• Asynchronous resplraLlon* (a dlscrepancy ln Lhe
Llmlng of movemenL of Lhe abdomlnal and Lhoraclc
comparLmenLs)
• Þaradoxlcal resplraLlon* (abdomlnal and Lhoraclc
comparLmenLs move ln opposlLe dlrecLlons)
• 8esplraLory alLernans* (breaLh-Lo-breaLh alLeraLlon
ln Lhe relaLlve conLrlbuLlon of lnLercosLal/accessory
muscles and Lhe dlaphragm)

>1?"#(%5'(%)1#
• Þulse oxlmeLry
• A8C - deflnlLlve dlagnosls
• SplromeLry
• Capnography
• Cx8/ P8C1/ vC
• CCS

@'1'5":"1(
!"#$ & *+,-.'$ 2 oxygen Lhrough nasal cannulae, face
masks, non-rebreaLhlng masks, CÞAÞ, lnLubaLlon and
mechanlcal venLllaLlon (^ llC2 helps all hypoxla excepL
rlghL Lo lefL shunL)
!"#$ / *+,-.'$ 1 LreaL underlylng condlLlon.
1PL uAnuLnCnC uCSSlL8 2010
32
!"#$ &'#()*
+),-#-.-/# 012 &3'44-,-('.-/#
1he Lerm lung cancer refers Lo Lumours arlslng from Lhe
resplraLory eplLhellum. 1he four ma[or cell Lypes LhaL
make up mosL of Lhe prlmary lung Lumours are squamous,
small cell, adenocarclnoma, and large cell. lor pracLlcal
purposes, Lhey are classlfled as elLher small cell (SCLC) or
non-SCLC.

56-7)8-/3/$9
2 MosL common mallgnancy ln Lhe wesLern world.
2 More common ln men buL lncldence raLes ln women
are rlslng as more women are smoklng.

:).-/3/$9 '#7 ;-4< ,'(./*4
• Carclnogens generally lnhaled Lhrough clgareLLe
or passlve smoklng
• 8adon gas (more common ln uSA Lhan AuS)
• AsbesLos or slllcaLe flbres
• CLher resp dlseases esp CCÞu
• CeneLlcs or lPx
• Þrevlous lung mallgnancy

='.>/6>94-/3/$9
8esplraLory eplLhellal cells requlre prolonged exposure Lo
cancer-promoLlng agenLs and accumulaLlon of mulLlple
geneLlc muLaLlons before becomlng neoplasLlc. 1he
acLlvaLlon of oncogenes (k8AS, LCl8) or lnacLlvaLlon of
Lumour suppressor genes (eg p33, 8b) leads Lo
unconLrolled cell proflleraLlon. WlLh Llme, Lhe area of
dysplasla progresses Lo erode or elevaLe Lhe regular
eplLhellum. lL can Lhen grow lnLo a mass and dependlng
on Lhe locaLlon (bronchl, bronchloles, alveoll) resulL ln
varlous resplraLory sympLoms. lL may also lnfllLraLe
Lhrough Lhe walls lnLo ad[acenL sLrucLures.

&/88/# ?986./84
• Cough/PemopLysls
• uyspnea
• ChesL paln
• Anorexla/welghL loss

@-4./*9 '#7 5A'8-#'.-/#
CLher posslble flndlngs as a resulL of elLher prlmary
cancer or meLasLases.





-Also Lake occupaLlonal and smoklng hlsLory Lo ellclL
degree of exposure Lo cerLaln causaLlve agenLs.
-MPx and lPx for oLher rlsk facLors.


B#C)4.-$'.-/#4
• &D; E even lf very small Lumours may be mlssed,
oLher slgns polnLlng Lo lung ca such as pleural
effuslon or enlarged lymph nodes may be deLecLed
• FG51H5& E may lndlcaLe presence of paraneoplasLlc
syndromes (endocrlne) or meLasLases.
• G*/#(>/4(/69 E conflrms and classlfles cell Lype
• ?6"."8 (9./3/$9 E lf unsulLable for lnvaslve lx
• I.>)* E blopsy of enlarged lymph nodes, lnA of
masses

J'#'$)8)#.
?"*$-('3 E besL LreaLmenL for eradlcaLlng Lhe dlsease buL
only a porLlon of Lumours are operable wlLh even fewer
paLlenLs sulLable for surgery. Powever, noL approprlaLe
for SCLC due lLs naLure.

K/#24"*$-('3 E ChemoLherapy for SCLC and meLs.
8adloLherapy for locallzed or lnoperable non-SCLC. lL can
also used palllaLlvely for sympLom rellef. CplaLes and
sLerolds may also be used for palllaLlve care.

!-,)4.93) - smoklng cessaLlon Lo reduce rlsk of dlsease
progresslon.


&/863-('.-/#4
MeLs - usually spreads Lo bone, braln or llver.
SvC syndrome - SvC compresslon by Lumour (usually
SCLC) ! obsLrucLlon of blood flow from
head/neck!faclal oedema, head ache, dlsLorLed vlslon,
dyspnea. lL's a medlcal emergency!
ÞaraneoplasLlc syndromes - sysLemlc Sx llke welghL loss,
endocrlne syndromes llke Cushlng's from AC1P
producLlon, hyponaLremla and ^AuP (ln SCLC),
hypercalcemla from ^Þ1P (ln squamous cell)
LamborL-LaLon myasLhenlc syndrome - rare auLolmmune
dlsorder ln whlch almosL half Lhe cases are assoclaLed
wlLh SCLC
2 WasLlng of hand
muscles (Lhlnk pancoasL
Lumour)
2 Porner's syndrome
2 Supracalvlcular lymph
nodes
2 Slgns of effuslon
2 Sx of SvC syndrome
2 PepaLomegaly
2 Wheeze/sLrldor
2 Poarse volce
2 uysphagla
2 LeLhargy
2 8one paln
2 neuro Sx
(selzures/confuslon)
2 Clubblng
1PL uAnuLnCnC uCSSlL8 2010
33
!"#$%&'( *+#,"-&'( ."/+#0
102$-$%$"- 345 6#&77$2$8&%$"-
A sollLary pulmonary nodule ls deflned as a well-
marglnaLed nodule, surrounded by normal lung Llssue,
wlLh a dlameLer <3 cm and noL assoclaLed aLelecLasls or
lymphadenopaLhy. Leslons >3cm are referred Lo as
masses and LreaLed as mallgnanL unLll proven oLherwlse.

9:$/0,$"#";(
-common radlologlcal flndlng (0.1-0.2°)


<$7= >&8%"'7
• Þrevlous mallgnancy
• ClgareLLe smoklng
• Chronlc pulmonary lnfecLlons
• Lxposure Lo fungl, asbesLos or radon

?0%$"#";(4 *&%@":@(7$"#";(
neoplasLlc
• Þrlmary cancer - many lung cancers are
dlagnosed wlLh Lhe presenLaLlon of a SÞn
• MeLasLaLlc - from lymphaLlc or haemLologlc
spread, many mallgnanL SÞns resulLed from
meLasLases.
• 8enlgn - hamarLoma (posslbly a developmenLal
abnormallLy), flbroma, llpoma, papllloma eLc.

lnflammaLory
• Þneumonla
• Abscess as a response Lo lnfecLlon
• Cranuloma from lnfecLlons le 18
• Cr from 'Wegener's CranulomaLosls'
• Þulmonary lnvolvemenL of 8A
• Cr Sarcoldosls

CLher
• ArLerlovenous malformaLlon





!(,:%",7
MosL pLs are asympLomaLlc wlLh SÞn belng an lncldenLal
flndlng.
A$7%"'( &-/ 9B&,$-&%$"-
Whlle pLs are asympLomaLlc, lL ls lmporLanL Lo deduce lf
Lhe nodule may be mallgnanL and should be asked Lhe
followlng:
• Px of prevlous mallgnancy
• Px of smoklng
• AsbesLos or radon gas exposure
• Px of 18 or pulmonary mycosls
• 1ravel Px for 18/mycosls lnfecLlon


C-D07%$;&%$"-7
• l8L, C8Þ, LS8
• SpuLum cyLology/culLure, Al8 and fungal
• Cx8 Lo monlLor growLh
• C1 wlLh lv conLrasL Lo deLecL Ln lnvolvemenL,
also Lo assess characLer of leslon
• lnA or bronchoscopy for hlsLologlcal assessmenL


E&-&;0,0-%
E0/$8&# F monlLor growLh lf nodule ls found Lo be benlgn
(every 3/12, once a year lf no change), Abx lf lnfecLlous,
sLerolds for lnflammaLory cause or whaLever Lhe
recommended 8x for underlylng cause

!+';$8&# F remove nodules proven or suspecLed Lo be
mallgnanL.

G$207%(#0 - smoklng cessaLlon Lo reduce rlsk of developlng
mallgnancy or for beLLer prognosls lf nodule ls found Lo be
mallgnanL.

6",:#$8&%$"-7
• CavlLaLlon lf nodule ls lnfecLlous.
• PemopLysls and oLher lung cancer
sympLoms/compllcaLlons lf nodule ls mallgnanL.
1PL uAnuLnCnC uCSSlL8 2010
34
!"#$%&'() +,-."/%.'#$

012'$'.'#$
CompleLe or parLlal obsLrucLlon of maln bronchus

3'-4 5(%.#"-
• Age (weaker cough reflex ln elderly and young,
smaller bronchl ln Lhe young)
• AnaLomy
• CysLlc flbrosls
• Smoklng
• CbeslLy

61.'#)#789:(/-1-
lnLra-lumlnal: lnfecLlon and lnflammaLlon (e.g. bronchlLls)
Allerglc condlLlons e.g. asLhma
CysLlc flbrosls
lnhaled forelgn bodles (rlghL more ofLen Lhan lefL due Lo
anaLomy: shorLer and more verLlcal)
1umour
urugs e.g. oplaLes
ÞosL-LracheosLomy (narrowlng of Lrachea)
Scollosls
Aneurysm (compresslng on bronchus)

;(.&#<&8-'#)#78
lnfecLlon and lnflammaLlon - mucosal swelllng -
mucopurulenL secreLlons and exudaLes - form
obsLrucLlve plugs by accumulaLlon. Abscesses as a resulL
of lnfecLlon can cause bronchlal obsLrucLlon.

AsLhma causes bronchlal consLrlcLlon and hyperLrophy of
mucus-secreLlng cells.

CysLlc flbrosls: mucus bulld-up, lmpalred mucoclllary
clearance

CbsLrucLlon from a Lumour can be:
- lrom Lhe Lumour lLself
- Compresslon of bronchus from Lumour
- Compresslon of bronchus from enlarged lymph
nodes

CplaLes suppress Lhe cough reflex and prevenL parLlcle
expulslon.

='7$- ($> =8?<.#?-
• Wheeze and crackles (ofLen locallsed)
• SLrldor
• Cough
• Þendular movemenL of Lrachea Lo affecLed slde
durlng lnsplraLlon, and away from affecLed slde
durlng explraLlon
• Cyanosls
• ChesL LlghLness
• 8esplraLory dlsLress
• ulmlnlshed breaLh sounds

@'-.#"8
CnseL: acuLe, gradual
PlsLory of lnhaled forelgn ob[ecLs
MedlcaLlons
Smoklng and alcohol
ÞPx: mallgnancy (meLasLases), resplraLory dlseases e.g.
asLhma, recurrenL 81ls

AB(?'$(.'#$
Slgns of lnfecLlon: rlgors, chllls, fevers
LAu: mallgnancy

C$D1-.'7(.'#$-
Lung funcLlon LesLs: splromeLry, flow-volume loops
Cx8: alr Lrapplng on explraLlon fllm, aLelecLesls, posL-
obsLrucLlve pneumonla
8ronchoscopy + blopsy
C1 chesL: space occupylng bronchlal leslons, fllllng defecL,
posL-obsLrucLlve pneumonla

E($(71?1$.
uependenL on cause

8ronchoscopy
AsplraLlon

SLepwlse managemenL of an lnhaled ob[ecL:
Lncourage paLlenL Lo cough up forelgn ob[ecL
1urn paLlenL on Lhelr slde and manually remove ob[ecL
lf no slgns of breaLhlng, glve 3 back blows.
lf no slgns of breaLhlng, glve 3 chesL LhrusLs.
CrlcoLhyroldoLomy

:#?<)'%(.'#$-
ALelecLasls
8ronchlecLasls
Þneumonla
CbsLrucLlve emphysema
non-cardlogenlc pulmonary oedema afLer re-expanslon of
aLelecLaLlc lung
8ronchlal sLrlcLure
Lung abscess
1racheobronchlal rupLure

1PL uAnuLnCnC uCSSlL8 2010
33
!"#$% '()*"+,$,-
.%/,*,$,)* 012 345--,/,"5$,)*
Sudden onseL of lnflammaLlon of Lhe bronchl caused by
vlruses/bacLerla LhaL may lasL for weeks.

SuggesLed Macfarlane dlagnosLlc crlLerla
• AcuLe lllness <21 days
• Cough as predomlnanL sympLom
• AL leasL 1 oLher lower resplraLory LracL sympLom e.g.
spuLum producLlon, wheezlng, chesL paln
• no alLernaLlve explanaLlon for Lhe sympLom

67,8%9,)4):;
• MosL eplsodes ln auLumn or wlnLer

<,-= >5"$)(-
• 8ecenL lnfecLlon
• Smoklng
• Cold humld weaLher
• Areas of hlgh aLmospherlc polluLlon
• CCÞu
• PearL fallure (congesLed lungs)
• very young or very old
• CC8u

!%$,)4):;135#-%-
• Common resplraLory vlruses
8Sv, 8hlnovlrus, lnfluenza
• May be followed by bacLerlal lnfecLlon wlLh SLrep
pneumonlae, P lnfluenza eLc
• Chemlcal lrrlLanLs e.g. e.g. smoke, dusL, polluLanLs,
gasLrlc acld may lead Lo lnflammaLlon of bronchl

?5$+)7+;-,)4):;
• vlral u81l/exposure Lo chemlcal lrrlLanLs
• lrrlLaLlon of bronchl leads Lo lnflammaLlon, oedema
and neuLrophll lnfllLraLlon
• neuLrophlls promoLe mucosal hypersecreLlon
• 1he lnfecLlon may clear ln days whlle repalr of Lhe
bronchlal wall may Lake weeks, durlng whlch paLlenLs
conLlnue Lo cough
• ln chronlc cases, gobleL cells may produce more
secreLlons and recurrenL lnfecLlons may promoLe Lhe
progresslon Lo chronlc bronchlLls

@,:*- 5*8 @;97$)9-
• lnlLlal lrrlLaLlng unproducLlve cough
• lollowed by yellow/green spuLum
• SC8
• Wheezlng
• ulscomforL behlnd sLernum

A,-$)(;
• uuraLlon <30 days (acuLe vs chronlc)
• ÞroducLlve cough
• Cough Lyplcally worse aL nlghL / wlLh exerclse
• no hlsLory of chronlc resplraLory lllnesses
• no hlsLory of cardlac lllness
• Cl1 sympLoms (adenovlrldae)
• CC8u
• MedlcaLlons (ACL lnhlblLors can cause dry cough)

6B59,*5$,)*
• lever (pneumonla may have hlgher fever)
• uecreased breaLh sounds
• Wheeze wlLh occaslonal crackles, ronchl
• Þrolonged explraLlon

C*D%-$,:5$,)*-
• l8L, C8Þ: lnflammaLlon
• SpuLum MCS: neuLrophlls, mlcroorganlsms
• Cx8: pneumonla
• Þulmonary funcLlon LesLs: may have bronchlal
obsLrucLlon, exclude asLhma

E5*5:%9%*$
• lmproves sponLaneously ln 4-8u ln healLhy adulLs buL
may be compllcaLed by bacLerlal superlnfecLlon ln
Lhose aL rlsk
• 8ed resL
SympLomaLlc
• Asplrln/paraceLamol for fever/chesL dlscomforL
• Cough suppressanLs lf non-producLlve
• PeaL pack/warm waLer boLLle on chesL
• SLeam lnhalaLlons
E%8,"54
• AnLlbloLlcs lf compllcaLed by bacLerlal lnfecLlon
• 8ronchodllaLors Lo relleve bronchlal obsLrucLlon,
wheezlng
F,/%-$;4%
• Smoklng cessaLlon

3)974,"5$,)*-
• ÞerslsLenL bronchlLls or pneumonla
• 8ecurrenL eplsodes ln Lhose wlLh co-exlsLlng lung
dlsorders
• Þrogresslon Lo CCÞu ln smokers
1PL uAnuLnCnC uCSSlL8 2010
36
!"#$
&'()*)+),* -./ 01233)()42+),*
• AcuLe lnfecLlon LhaL lnvolves Lhe upper resplraLor
LracL:
o nose (rhlnlLls)
o Slnuses (slnuslLls)
o Þharynx (pharynglLls)
o Larynx (larynglLls)

56)7'8),1,9:
• 1ransmlsslon ls vla resplraLory dropleLs or vlrus
conLamlnaLed hands

")3; <24+,=3
• Slck conLacLs
• ?oung age
• Seasonal lnfecLlons

>'+),1,9:.02?3'3
• rhlnlLls & slnuslLls are commonly caused by allergens
• pharynglLls, eplgloLLlLls & larynglLls can of vlral or
bacLerlal cause
• lnfluenzae vlrus ls commonly assoclaLed wlLh Lhe
ºcommon cold"

@2+A,6A:3),1,9:
• sneezlng, lncreased secreLlons and changes ln
mucosal blood flow are medlaLed boLh by efferenL
nerve flbres and by released medlaLors
• allerglc rhlnlLls develops as a resulL of lnLeracLlon
beLween Lhe lnhaled allergen and ad[acenL molecules
of lgL anLlbody presenL on Lhe surface of masL cells
found ln lncreased numbers ln nasal secreLlons and
wlLhln Lhe nasal eplLhellum.
• 8elease of perform medlaLors, ln parLlcular hlsLamlne,
causes an lncrease ln permeablllLy of eplLhellum,
allowlng allergen Lo reach lgL-premed masL cells ln
Lhe lamlna proprla

B)9*3 2*7 B:86+,83
• lLchy waLery eyes
• nasal congesLlon and dlscharge
• sneezlng
• cough & sore LhroaL
• headache
• faLlgue, fever, weakness & malalse
• myalgla

C)3+,=: 2*7 5D28)*2+),*
• PlsLory and examlnaLlon are sLandard WWCCAA8 +
ÞPx + SPx + lPx + Meds/Allergles

$*E'3+)92+),*3
• noL many lnvesLlgaLlons are requlred ln early shorL
duraLlon lllness however, more vlgorous workup ls
requlred for exLended duraLlon lllness
• spuLum culLure
• group A sLrepLococcal assay (when cllnlcal plcLure flLs)
• perLussls, dlpLherla, herpes slmplex vlrus, gonorrhea
and aLyplcal bacLerla requlre speclflc culLures Lo rule
ouL as causaLlve

F2*29'8'*+
• ma[orlLy of u81l's wlll resolve wlLh no medlcal
lnLervenLlon
• allergen avoldance
• anLlhlsLamlnes
• decongesLlon
• anLl-lnflammaLory drugs
• corLlcosLerolds
0,861)42+),*3
• volume depleLlon
• oLlLls medla
• alrway hyperreacLlvlLy
• CCÞu
• L81l +/- sepsls
• Alrway compromlse
• ueep Llssue lnfecLlon
• LncephallLls, menlnglLls, SAP
• Cullllan-8arre Syndrome
• 8eye syndrome (asplrln use ln young chlldren)
• Pyperglycaemla
• CvS decompensaLlon
1PL uAnuLnCnC uCSSlL8 2010
37
!"#$%&'(
*#+&,&-&., /01 2"3''&+&43-&.,
lnflammaLlon of Lhe pleura resulLlng ln paln

5#-&.".6(023$'#'
• ÞneumoLhorax
• 8acLerlal lnfecLlons
• AuLolmmune dlseases (eg. SLL & 8A)
• Lung cancer (lncludlng lymphoma)
• ÞL
• CysLlc flbrosls, sarcoldosls, asbesLosls
• l8u
• PearL surgery (eg. CA8C)

!3-7.87('&.".6(
• Locallsed lnflammaLlon sLlmulaLes paln flbres ln
pleura causlng sharp paln and dlscomforL

9&6,' 3,: 9(;8-.;'
• Sharp/ sLabblng paln on lnsplraLlon, coughlng or
sneezlng
• uependlng on Lhe cause, may have oLher
sympLoms of dyspnoea, cough, fever and chllls,
rapld shallow breaLhlng, unexplalned welghL loss,
sore LhroaL

<&'-.%( 3,: =>3;&,3-&.,
Cn hlsLory, ask quesLlons Lo rule ouL oLher sources of Lhe
sympLoms and Lo flnd underlylng cause for LreaLmenL
purposes.
Cn examlnaLlon, Lhe presence of pleurlLlc rub ls hlghly
llkely

?,@#'-&63-&.,'
• lnvesLlgaLlons serve purpose Lo ldenLlfy cause of
pleurlsy
• ChesL x-ray, C1 and M8l can show many causes of
pleurlsy eg. pneumonla, fracLured rlb or lung Lumour,
pleural effuslon & lung abcess
• 1horacenLesls (removal of pleural fluld) ls posslble Lo
LesL for presence of chemlcals, colour and LexLure,
Lhe clearness of Lhe fluld ls an lndlcaLor of lnfecLlon,
cancer or oLher condlLlons LhaL may cause Lhe bulldup
of fluld
• 8lopsy ls lndlcaLed lf fluld frequenLly reaccumulaLes
and a deflnlLlve dlagnosls has noL been reached. lL
can conflrm a dlagnosls of 18 or mallgnancy.

A3,36#;#,-
• 1reaLmenL serves Lhree goals:
o 8emove fluld or blood from pleural space
o 8elleve sympLoms
o 1reaL underlylng cause
A#:&43"
• ÞaraceLamol and anLl-lnflammaLory agenLs Lo relleve
paln and decrease lnflammaLlon
• lndomeLhacln has been sLudled wlLh respecL Lo rellef
of pleurlsy
• Codelne based cough syrups can be used Lo conLrol
cough
!%.4#:$%#
• Þleural Lap can be done Lo draln any blood or fluld
from Lhe pleural space LhaL may be causlng paln.
B&+#'-("#
• 8reaLhlng deeply and coughlng when Lhe paln
subsldes ls very lmporLanL oLherwlse pleurlsy may be
compllcaLed by Lhe developmenL of pneumonla
C%#3- -7# $,:#%"(&,6 43$'#
• Maln causes of pleurlsy are
o lnfecLlon
o Mallgnancy
o CongesLlve Cardlac lallure
2.;8"&43-&.,'
• Þaln can cause paLlenL Lo noL lnsplre Lo Lhelr whole
lung capaclLy Lhus creaLlng Lhe poLenLlal for
pneumonlas and aLelecLasls.


1PL uAnuLnCnC uCSSlL8 2010
38
!"#$%&" ())$*+,-
.#)+-+/+,- 012 3"&**+)+4&/+,-
Lxcesslve accumulaLlon of fluld ln Lhe pleural space

5+*6 7&4/,%*
• Slmllar Lo causes
• Þneumonla, 18 and oLher lung dlsease
• Þregnancy
• Cancers eg. lung, breasL, lymphoma and
mesoLhelloma
• PearL fallure, perlcardlLls

8#/+,",9:13&$*#*
1ransudaLlve
• hearL fallure
• malnuLrlLlon
• llver dlsease
• kldney dlsease
• Lumour
• hypoproLelnaemla
• hypoLhyroldlsm
LxudaLlve
• bacLerlal pneumonla (common)
• cancer of lung, breasL or lymph
• 18
• 8heumaLlc dlsease (eg. sarcoldosls)
• MesoLhelloma
• urug reacLlons

!&/;,<;:*+,",9:
• !"#$%&'#()*+ effuslons are deflned as havlng low
proLeln conLenL (<30g/L) and lacLaLe dehydrogenase
(<200lu/L). 1hls ls largely due Lo a shlfL of sysLemlc
facLors LhaL alLer Lhe pleural equlllbrlum (le.
hydrosLaLlc pressure, permeablllLy & collold osmoLlc
pressure)
• ,-&'#()*+ effuslons are malnly due Lo lnflammaLory
processes where local facLors lnfluence Lhe formaLlon
and absorpLlon of pleural fluld

=+9-* &-> =:?</,?*
• ShorLness of breaLh
• 8educed lung expanslon

@+*/,%: &-> (A&?+-&/+,-
• Malnly a compllcaLlon of pre-exlsLlng lllness
• LllclL Lhe Llmellne of dyspnoea, prevlous or currenL
lnfecLlons, mallgnancy, llver or kldney dlsease.
• Cn examlnaLlon, ausculLaLlon reveals dlmlnlshed
breaLh sounds, dullness Lo percusslon, reduced vocal
fremlLls and occaslonally a pleural rub (n.b. crackles
are nC1 heard)

B-C#*/+9&/+,-*
• Cx8 wlll conflrm large effuslon
• 1horacenLesls- sample of fluld removed wlLh needle
asplraLlon Þleural blopsy mlghL be necessary lf
dlagnosls ls noL esLabllshed wlLh asplraLlon

D&-&9#?#-/
• ManagemenL of underlylng condlLlon ls essenLlal
• Lo relleve sympLoms and obLaln a sample, pleural Lap
ls done
• mallgnanL effuslons LhaL reaccumulaLe and are
sympLomaLlc can be asplraLed Lo dryness followed by
lnsLlllaLlon of a scleroslng agenL Lo creaLe adheslons
(eg. LeLracycllne, bleomycln)

3,?<"+4&/+,-*
• Þleurlsy
• ALelecLasls
• ÞneumoLhorax
• Lmpyema
1PL uAnuLnCnC uCSSlL8 2010
39
!"#$%&'(&)*+
-#./"/'/&" 012 34*55/./6*'/&"
ÞneumoLhorax ls Lhe presence of alr ln Lhe pleural
space whlch can elLher occur sponLaneously or resulL
from laLrogenlc ln[ury or Lrauma Lo Lhe lung or chesL
wall.

SponLaneous
Þrlmary pneumoLhorax (ÞSÞ):
• no evldence of overL lung dlsease
• Alr escapes from Lhe lung lnLo pleural space
Lhrough rupLure of a small subpleural
emphysemaLous bulla or pleural bleb, or Lhe
pulmonary end of a pleural adheslon.
• 8lsk facLors are smoklng, Lall sLaLure and
presence of blebs.

Secondary pneumoLhorax (SSÞ):
• underlylng lung dlsease, mosL commonly CCÞu
and 18, also seen ln asLhma, lung abscess,
pulmonary lnfarcLs, bronchogenlc carclnoma, all
forms of flbroLlc and cysLlc lung dlsease.
• More severe sympLoms Lhan ÞSÞ and hlgher
morLallLy raLe.

1raumaLlc
• laLrogenlc (blopsy, cenLral venous caLheLer
lnserLlon), blunL chesL wall Lrauma or peneLraLlng
lung ln[ury.

789#5 &. :9&"'*"#&$5 !"#$%&'(&)*+;
Closed Lype: Mean pleural pressure negaLlve.
Cpen Lype: Mean pleural pressure aLmospherlc.
1enslon Lype: Mean pleural pressure poslLlve,
medlasLlnal shlfL Lo opposlLe slde.

:/<"5 *"= :8%9'&%5
ChesL paln and shorLness of breaLh. ln SSÞ, Lhere ls
hypoxla, cyanosls, hypercapnla and hypoLenslon,
Lhls may cause confuslon and coma.

lnspecLlon: 1achypnoea (paln, deflaLlon reflex),
cyanosls
ÞalpaLlon: 8educed expanslon
Þercusslon: 8esonanL or hyper-resonanL
AusculLaLlon: AbsenL breaLh sounds
vocal resonance and fremlLus can be decreased.
1enslon pneumoLhorax also causes devlaLlon of
Lrachea Lo opposlLe slde, Lachycardla and
hypoLenslon.
>"?#5'/<*'/&"5
Cx8 - Shows sharply deflned edge of Lhe deflaLed
lung wlLh compleLe Lranslucency (le no lung
marklngs) beLween Lhls and chesL wall. Also shows
any medlasLlnal dlsplacemenL and reveal any pleural
fluld or underlylng lung dlsease.
C1 - ulsLlngulshes bullae from pleural alr.

@*"*<#%#"'
• Þrlmary pneumoLhorax - lf small, wlll ofLen resolve
by lLself or LreaLed wlLh 9#)6$'*"#&$5 "##=4#
*59/)*'/&". lf larger, wlll requlre lnLercosLals Lube
dralnage.
• Secondary and Lenslon pneumoLhorax wlll mosLly
requlre /"'#)6&5'*45 '$A# =)*/"*<# and lnpaLlenL
observaLlon Loo.
• Surglcal 94#$)&=#5/5 should be consldered lf Lhere ls
recurrence. 1hls can be achleved by pleural abraslon,
parleLal 94#$)#6'&%8 or '(&)*6&'&%8.
• lnLercosLal dralnage: uralns lnserLed ln 4/3/6
Lh

lnLercosLals space ln Lhe mld axlllary llne connecLed
Lo an underwaLer seal or one-way Pelmllch valve.
3&%94/6*'/&"5
1. Alr
leaks: from conLlnued leakage of alr from Lhe lung
lnLo Lhe pleural space or alr leaklng Lhrough chesL
Lube lnserLlon slLe.
2. lallure of lung Lo expand: due Lo perslsLenL alr leak.
1horacaLomy consldered lf lung ls lncompleLely
expanded > 1 week.
3. 8e-expanslon pulmonary oedema: occurs when lung
ls rapldly expanded. 1reaLmenL wlLh C2, dlureLlcs
and cardlopulmonary supporL.

1PL uAnuLnCnC uCSSlL8 2010
40
!"# %&'(")*'+
,+-.)./.") 012 !'*33.-.4*/.")
AlLeraLlon ln sLrucLure/funcLlon of 8v.
usually leads Lo rlghL slded hearL fallure. Þure Cor
Þulmonale ls ln lsolaLlon of lefL slded hearL fallure.
ullaLlon/PyperLrophy of 8v, usually ln response Lo dlsease
of pulmonary vasculaLure or lung parenchyma LhaL lead Lo
!"#$%&'() +)!,(-,&./%&0

%*/5"6573."'"87
LssenLlally Cor Þulmonale when pulmonary dlsease
causes Þulmonary PyperLenslon, and Lherefore puLLlng
more sLraln on Lhe 8v.
1+,(,2%(,3 4"#$%&'() 5)!,(-,&./%& /. &,'(#) '#6').
-+, -+, "&7,(#)/&8 #/&9 :,-6,,& 7/.,'., '&7 ;%(
4"#$%&'#, (see summary on
Þulmonary P1 for more lnfo)
When lung dlsease presenL (eg CCÞu) small blood vessels
become very rlgld and lose elasLlclLy leadlng Lo pulmonary
hyperLenslon, and Lhen 8v can no longer pump blood lnLo
lungs easlly.

PyperLrophy of 8v - adapLlve response Lo long Lerm hlgh
pressures. lndlvldual muscle cells grow Lo lncrease
conLracLlllLy.
ullaLlon of 8v - sLreLchlng ln response Lo acuLe lncreased
pressure
8v lschaemla due Lo lncreased myocardlal demands can
someLlmes lead Lo Lhe 8v fallure.

8v ls beLLer sulLed Lo handllng volume overload raLher
Lhan pressure overload, Lhus susLalned pressure from
Þulm P1 evenLually causes 8v Lo fall.

96.:+(."'"87
Cnly relevanL polnL: 8y far Lhe mosL common cause of
8lghL hearL fallure ls LefL hearL fallure, &%- Cor Þulmonale.

;+/."'"871!*&3+3
!5#").4*''7<
MosL: CCÞu - responslble for 30°
CLhers: (underllned are lmporLanL)
- ulseases leadlng Lo hypoxlc vasoconsLrlcLlon <;=4>?
;@? +)!%A,&-/#'-/%&? +/8+ '#-/-"7,B
- ulseases LhaL cause occluslon of Þulmonary
vasculaLure <(,C"((,&- 4D.? 4(/$'() 4"#$ 51? ./C9#,
C,## '&',$/'B
- Þarenchymal dlseases <;=4>? :(%&C+/,C-'./.? ;@?
E'(C%/7? 4"#$%&'() @/:(%./.B
;4&/+'7:
Sudden, severe sLlmulus (F'../A, 4D? ,G'C,(:'-/%& %2
C+(%&/C C%( !"#$%&'#,B
=.8)3 *): =7(6/"(3
ln general: Lhose of underlylng lung dlsease, Lhose of
8lghL hearL fallure, slgns of Þulmonary hyperLenslon
• 1hose of underlylng lung condlLlon (eg SC8)
• 8Pl:
o AsclLes
o ÞlLLlng oedema
o 8alsed !vÞ
o PepaLomegaly
o Ausc: 1rlcsupld 8egurg
• Sgs ÞP1:
o 8v heave, Þalpable Þ2
o Ausc: Audlble Þ2, S4?, sysLollc e[ecLlon
cllck
• LaLe sLage can presenL wlLh cyanosls +/- low
volume pulse

See ÞlcLure aL boLLom for posslble ausculLaLlon. (alLhough
unllkely Lo have all slgns ln every pL)

>.3/"#7 *): 9?*(.)*/.")
-Ask: ÞL or lung dlsease
-Lx: 8esp and Cardlo
- lf paLlenL has slgns of 8Pl (asclLes, plLLlng oedema,
ralsed !vÞ), and bllaLeral crackles, assess wheLher crackles
are due Lo LPl or Þulmonary dlsease (le flbrosls). 8uL
much more llkely Lo by LPl.

@)A+3/.8*/.")3
- LCC: looklng for 8lghL axls devlaLlon, 8v hyperLrophy
- Cx8: hllar and vessel enlargemenL
- vC scan: looklng for Chronlc ÞLs
- Plgh 8es C1: lung dlsease
- Lchocardlogram: anaLomy of 8v and
Þulmonary/1rlcuspld valves
- uoppler Lchcardlogram: show Þulm pressures
- Cardlac caLheLerlsaLlon: (rarely done buL ls more
accuraLe for pressure)

B*)*8+(+)/
1) 1argeL underlylng Lung dlsease (lf posslble)
2) Clve Cxygen (Lo reduce demands on 8v)
3) Clve ulureLlcs

ulgoxln ls noL shown Lo help much

!"(6'.4*/.")3
ueaLh ls preLLy lmporLanL Lo avold..
8uL ln all honesLy Lhe prognosls ls noL greaL.
S1 S1 S2 S2
S4
%C %C
D#.4&36.: E+8&#8
D#.4&36.: E+8&#8
9F+4/.") !'.4G
9!
1PL uAnuLnCnC uCSSlL8 2010
41
!"#$%&'() +),-(.-&/0%&
1-20&0.0%& 345 6#'//0207'.0%&
PyperLenslon ln pulmonary vessels (can be arLerlal or
venous).
SysLollc pulmonary arLery pressures >30 mmPg
consLlLuLes pulmonary hyperLenslon (ÞP1).
SympLoms of pulmonary hyperLenslon do noL usually
occur unLll Lhe pressures are abouL Lwlce normal (l.e. >30
mmPg).

Cne of Lhe ClasslflcaLlons (whllsL Lhere ls a newer
classlflcaLlon, Lhls ls Lhe one we have been LaughL):
Þrlmary - ldlopaLhlc
Secondary - ldenLlflable cause

8-.0%#%9)46'"/-/
Secondary Causes:
a) ÞL: cloLs, Lumour parLlcles, faL
b) Lung dlsease: CCÞu, CbsLrucLlve Sleep Apnoea,
lnLersLlLlal lung dlsease (Þulm llbrosls, sarcold
eLc)
c) LefL venLrlcular lallure
d) CongenlLal ulsease (vSu, ASu, ÞaLenL uA

MosL common: CCÞu

!'.:%,:)/0%#%9)
Þulmonary ArLery PyperLenslon: (whaL we are normally
referrlng Lo when we Lalk of ÞP1)
WhaLever Lhe cause, lnvolves vasoconsLrlcLlon of
pulmonary vessels, over Llme wlLh Lhe consLanL hlgh
pressures Lhe vasculaLure can flbrose.
Can also have hypoxlc ÞP1 where low C2 levels are
LhoughL Lo lead Lo vasoconsLrlcLlon.

Þulmonary venous PyperLenslon:
Somehow decreased dralnage leadlng Lo back
pressures. ln essence: LPl. 1hls ls when you geL
pulmonary oedema and pleural effuslons.

-ln chronlc ÞLs, blood vessels are blocked/narrowed by
cloLs.
-When lung dlsease presenL (eg CCÞu) small blood vessels
become very rlgld and lose elasLlclLy leadlng Lo
pulmonary hyperLenslon
-ConsequenLly, 8v responds Lo lncreased reslsLance by
lncreaslng pressure/conLracLlllLy (Lo preserve CC). Cver
Llme chronlc pulmonary clrculaLlon remodelllng can
occur whlch wlll conLlnually promoLe ÞP1.

ÞP1 ofLen leads Lo 8lghL hearL fallure

;,0<-$0%#%9)
1he cause of Þ1 ls 3 Llmes more llkely Lo be
secondary Lhan prlmary.




!%//0=#- >09&/ '&< >)$,.%$/
• ShorL of 8reaLh, laLlgue
• uecreased exerclse Lolerance
• Ceneral (severe): 1achypnoea, Þerlph cyanosls
(due Lo low CC)
• CenLral:
o 8v heave, Þalpable Þ2
o Ausc: Loud Þ2, S4, SysLollc L[ecLlon Cllck
• Slgns of 8Pl:
o ÞlLLlng oedema, asclLes
o 8alsed !vÞ
o PepaLomegaly
o 1rlcuspld regurg
• CLhers: non-producLlve cough, anglna, syncope
See ausculLaLlon example aL boLLom of page

+0/.%() '&< ;?'$0&'.0%&
CfLen presenL laLe wlLh 8lghL hearL fallure and ÞP1 ls Lhe
cause.

@&A-/.09'.0%&/
- A8C: assess C2 levels
- LCC/Lcho: may show slgns of 8v fallure or enlargemenL
- Cx8: hllar and vessel enlargemenL
- C1 anglogram: looklng for Chronlc ÞLs
5 1%,,#-( ;7:7'(<0%9('$B /:%C !"#$ ,(-//"(-/
5 6'(<0'7 7'.:-.-(0/'.0%&B D('(-#) <%&- =". 0/ $%(-
'77"('.- 2%( ,(-//"(-E

Þlus oLhers Lo dlagnose underllelng causes

F'&'9-$-&.
1argeL underlylng cause
lf LPl: ulureLlcs, beLa blockers, ACL lnhlblLors
lf Þrlmary: llfesLyle changes, dlgoxln, dlureLlcs
lf Chronlc ÞLs: Warfarln
Some evldence for warfarln ln everybody
May use Calclum Channel 8locker (works 80° of Llme)

6%$,#07'.0%&/
8Pl and ueaLh ls preLLy lmporLanL Lo avold. ÞarLlcularly
due Lo severe decreased cardlac ouLpuL.
S1 S1 S2 S2
S4
!G !G
H(07"/,0< I-9"(9
H(07"/,0< I-9"(9
;J-7.0%& 6#07K
;6
1PL uAnuLnCnC uCSSlL8 2010
42
!"#$%&'$()* ,-**. /.01*2
3*4(0($(10 567 8-2##(4('2$(10
Cccurs when Lhe alrway aL Lhe back of Lhe LhroaL ls sucked
closed when breaLhlng ln durlng sleep.

9.(:*;(1-1<=
AffecLs 1-2° of Lhe populaLlon, and mosLly ln overwelghL
mlddle-aged men. Can occur ln chlldren, parLlcularly when Lhey
have enlarged Lonslls.

/*$(1-1<=682&#*#
LnchroachmenL on Lhe pharynx
- CbeslLy
- Acromegaly
- Lnlarged Lonslls
nasal obsLrucLlon
- nasal deformlLles
- 8hlnlLls
- Þolyps
- Adenolds
8esplraLory depressanL drugs
- Alcohol
- SedaLlves
- SLrong analgeslcs

>2$?1.?=#(1-1<=

uurlng sleep, acLlvlLy of Lhe resplraLory muscles ls reduced,
parLlcularly ln 8LM sleep, when only Lhe dlaphram ls acLlve.
Pypoxla from Lhe occluslon leads Lo lncreaslngly sLrenuous
resplraLory efforLs unLll Lhe reslsLance ls overcome. 1he
comblnaLlon of hypoxla and efforL causes brlef awakenlngs
whlch may noL be remembered. Awakenlngs can happen
hundreds of Llmes ln a nlghL especlally durlng 8LM sleep
causlng sleep deprlvaLlon.

,(<0# 20: ,=;.$1;#
- Loud snorlng (93° of paLlenLs)
- uayLlme sleeplness (90°)
- unrefreshed sleep (40°)
- 8esLless sleep (40°)
- Mornlng headache (30°)
- nocLurnal choklng( 30°)
- 8educed llbldo (20°)
- Mornlng drunkeness (3°)
- Ankle swelllng (3°)
@(#$1%= 20: 9A2;(02$(10
A hlsLory of snore-sllence-snore sleep nolses reporLed by
household members ls helpful Lo dlagnosls.

B0)*#$(<2$(10#
!)*%0(<?$ 0107(0)2#()* *2% 1% 4(0<*% 1A(;*$%=
SupplemenLed by vldeo. CharacLerlsLlcally C2 saLuraLlon wlll
fall slgnlflcanLly ln a cycllcal fashlon.
B0.2$(*0$ 2##*##;*0$
Slmllar observaLlons are performed ln a speclally adapLed room
lf home assessmenL falls.
3(2<01#(#C 13 or more apnoeas ln any 1 hour of sleep.

D202<*;*0$
D*:('2-
CorrecLlon of LreaLable facLors.
CÞAÞ: conLlnuous poslLlve alrway pressure dellvered by a nasal
mask ralses Lhe pressure ln Lhe pharynx keeplng Lhe walls aparL
ln lnsplraLlon. 1he 30° of people who can LoleraLe CÞAÞ have
lmprovemenL of sympLoms, quallLy of llfe, dayLlme alerLness
and survlval.
ln people who can'L LoleraLe CÞAÞ, monaflnll, a CnS sLlmulanL
may be useful ln Lhe shorL Lerm.
Cral appllances
,&%<('2-
uvulopalaLopharyngoplasLy, or oLher surglcal procedures may
be used Lo LreaL above causes such as enlarged Lonslls, whlch
are amenable Lo surgery.
E(4*#$=-*
WelghL loss ln Lhe obese, avoldance of alcohol, sedaLlves and
sLrong analgeslcs lf posslble.

81;.-('2$(10#
@=.*%$*0#(10C
CSA may be an lndependenL rlsk facLor for hyperLenslon,
puLLlng unLreaLed pLs aL rlsk of cardlovascular dlsease.
PyperLenslon ls presenL ln 40° of pLs wlLh CSA. ln parLlcular,
CSA prevenLs lowerlng of blood pressure overnlghL, whlch
lncreases Lhe pLs exposure Lo P1 overall.
,-**.(0*## 20: :*'%*2#*: '1<0($()* 4&0'$(10C
vehlcle accldenLs occur more ofLen ln pLs compared wlLh
conLrols, even ln Lhose LhaL do noL reporL lncreased sleeplness.
uepresslon, lrrlLablllLy and personallLy changes are frequenLly
reporLed by pLs and Lhelr famllles.


!"# %&'%#'(') %(**+#, -./.
01
!"#$%&'($)#$'("*
1PL uAnuLnCnC uCSSlL8 2010
44
Acute L|ver Ia||ure and nepat|t|s
C||n|ca| presentat|on
Acute nepat|t|s Iu|m|nant hepat|c fa||ure
ConsLlLuLlonal slgns (flu-llke)
• Ma|a|se/faLlgue
• lever
• n+v]Anorex|a]ularrhoea
• Muscle/[olnL paln
• Peadache
• Avers|on to smok|ng
amongst smokers
Slmllar consLlLuLlonal slgns, ln addlLlon
• Low 8Þ (vasodllaLed clrculaLlon)
! compensaLory " ln CC ! haemodynamlc and cardlo-resplraLory compromlse
Llver dysfuncLlon
• kUÇ d|scomfort
• Iaund|ce
• nepatomega|y
• 1ea co|oured ur|ne, lf
subsLanLlal lnLrahepaLlc
cholesLasls Lhen pale
sLools
Llver dysfuncLlon
• SponLaneous b|eed|ng/Cl haemorrhage due Lo coagulopaLhy
• Llver ofLen sma|| raLher Lhan enlarged
• Ietor hepat|cus
• 8r|sk ref|exes
Seen on bloods
• Metabo||c derangement (!"#$%&'(&)*+& due Lo waLer reLenLlon and a shlfL ln
lnLracellular na LransporL from lnhlblLlon of na
+
/k
+
pump) or !"#$,-".&)*+&
• kena| fa||ure!ac|dos|s]a|ka|os|s (acldosls!dlrecL lnsulL from cause !
paraceLamol)
MosL lmporLanL dlsLlngulshlng feaLure nLÞA1IC LNCLÞnALCÞA1n¥
/($,()00+1) 3)')(+$(&'+$% +% .$,%+'+1) 45%.'+$% 60!$(')%)3 &'')%'+$% 0#&% ! ()1)(0&- $4
0-))# #&'')(% ! 3))# .$*&7
uue Lo cerebral oedema (bulld up of Loxlc subsLances such as ammonla LhaL are normally
cleared by Lhe llver)
!characLerlsLlc cllnlcal slgn metabo||c f|ap]aster|x|s (coarse)
!consLrucLlonal apraxla (can'L draw a sLar)
Acute hepat|t|s- |nf|ammat|on of the ||ver that |s genera||y se|f ||m|t|ng, usua||y does not requ|re hosp|ta||sat|on
Causes:
Vascu|ar - lschaemlc hepaLlLls (lnsufflclenL clrculaLlon)/8udd-Chlarl syndrome(hepaLlc veln obsLrucLlon)
Inf|ammatory and Infect|ous V|ra|: Pep(A-L)/PSv/CMv/L8v/yellow fever/adenovlruses
Non v|ra|: 1oxoplasma/LepLosplra/C-fever
1rauma and tox|ns - ALCCPCL/CCl
4
/asafoeLlda/mushrooms(AmanlLa phalloldes)? lol
Auto|mmune - auLolmmune hepaLlLls/prlmary blllary clrrhosls
Metabo||c - noLhlng acuLe 8u1 long Lerm Wllson's dlsease/ o-anLl Lrypsln deflclency/ haemochromoLosls
Iatrogen|c - u8uCS (paraceLamol/anLl18/amoxy are Lhe ma[or ones)
Neop|asm - foeLus(faLLy llver of pregnancy)/llver prlmarles or meLs

Management: Acute L|ver Ia||ure = 8AD, ICU stuff
|. 20 degree t||t- hyperdynamlc sLaLe
||. Ma|nta|n a|rways- lnLubaLlon
|||. NG-malnLaln susLenance wlLh supplemenLaLlon of
8
12,
folaLe and Lhlamlne
|v. Ur|nary catheter]CVC |nsert|on - regulaLe fluld
sLaLus
v. nour|y v|ta|s + 8SLs and da||y we|ghs
v|. 10¼ dextrose ln hypoglycaemla
v||. 1kLA1 1nL CAUSL e.g. n-aceLylcysLelne ln
paraceLamol polsonlng
v|||. naemod|a|ys|s ln renal fallure
|x. Avo|d sedat|ves]drugs w|th hepat|c metabo||sm
(oplaLes, oral hypoglycaemlcs, sallne lvs & dlureLlcs
! "encephalopaLhy rlsk)



1reat comp||cat|ons
• Infect|on- glve cefLrlaxone unLll senslLlvlLles arrlve and avold
genLa "renal lmpalrmenL!
• Asc|tes- fluld resLrlcL, dally welghs, low salL dleL, dlureLlcs
• Lncepha|opathy- lacLulose + regular enemas Lo # n-formlng
bacLerla ln guL
• Cerebra| oedema- mannlLol lv and hypervenLllaLe.shlL
• D|scuss transp|antat|on.|ook up the cr|ter|a
yourse|f
1PL uAnuLnCnC uCSSlL8 2010
43
!"#$ &'
()*+ ,hepaLlc = !AL1, cholesLaLlc plcLure = !ALÞ, noLe LhaL level derangemenL bears llLLle relaLlon Lo degree of
underlylng flbrosls

*-+.+ ." /-.-#012- 34&+-
56""/+
• )57 (lnfecLlon/Cl bleed)
• 897 (meLabollc dlsLurbances lndlcaLlng
fulmlnanL dlsease leadlng Lo renal lmpalrmenL)
• :1#46 ;<= (suspecL lnfecLlous cause)
• :1#46 +-#"6">? (lf ÞC8 poslLlve?)
• @&."42.1A"/? '#"B16- (+ve AnCA-prlmary
scleroslng cholanglLls, anLlmlLochondrlal
anLlbodles-prlmary blllary clrrhosls)
• )- +.&/1-+ (suspecL haemochromLosls and
esLabllsh lf Lhere has been chronlc blood loss)
• C#&> 6-D-6+ (paraceLamol mosL common
cause)
• @5E (lf suspecLlng paraceLamol Cu" acldosls)
• FG42.1 .#?'+12 (deflclency)
• <& 6-D-6+ (! Wllson's dlsease)
• <4-#&6"'64+012 (# ln Wllsons)

H.I-#
• 56""/ 3&6.&#-+ (sysLemlc lnfecLlon)
• 8#12- JK<9L (source of lnfecLlon, casLs ln
Lubular necrosls)
• *4' "B 4+31.-+ 1B '#-+-2.
• <M=
• (1D-# 8L (Lo exclude sLrucLural leslons such as
neoplasla/blllary dlsease)K
o C"''6-# (lf suspecLlng 8udd Chlarl)
• 51"'+? (when all else falls)

*-+.+ ." /-.-#012- -N.-2.
• <"4>+ (!Þ1 ls Lhe besL prognosLlc marker/ln8)
• @6A&012 (# due Lo #synLheLlc funcLlon)
• =->&64# 5L(+ (alLered as carbohydraLe
meLabollsm affecLed)
O-' @
• ÞresenLaLlon: +&A36121346 wlLh 30° havlng PAv
anLlbodles wlLh no [aundlce
• Spread: B4-346G"#46 Lransmlsslon
• 8lsk groups: 1ravellers/lnsLlLuLlons
• lncubaLlon: 2-6 weeks
• Speclflc LesLs:
o Serum Lransamlnases rlse 22-40days afLer
exposure
o P>J rlses from day 23 and slgnlfles recenL
lnfecLlon
o lgC deLecLable for llfe
• ManagemenL- supporLlve, avoldance of alcohol
• ÞrevenLlon- P00&21+4.1"2 4D4164A6-
O-' <
• ÞresenLaLlon: early lnfecLlon usually
asympLomaLlc, QRS /-D-6"' 3I#"213 12B-3.1"2
(exacerbaLed by co-lnfecLlon wlLh P8v and
alcohol consumpLlon)
• Spread: 8lood/lvuu/Sexual/AcupuncLure
• Speclflc LesLs:
o ()* T@L*U@(* V WUWX
o AnLl-PCv anLlbodles
o O<:G;<=
o 51"'+? Lo assess llver damage and sLage lL ln
order Lo deLermenL 8x
• ManagemenL: 12.-#B-#"2 F Y1.I #1A4D1#12, llver
LransplanLaLlon
• ÞrevenLlon: Z" D433124.1"2[

O-' 5
• ÞresenLaLlon: 43&.- I-'4.1.1+ 12 WRS
• Spread: 8lood producLs/lv drug use/Sexual
lnLercourse/ulrecL conLacL
• 8lsk groups: P:C8 and Lhelr sexual
parLners/healLh or prlson workers/
haemophlllacs and Lhelr carers/
haemodlalysls/mlgranLs from endemlc areas/Lhe
sexually promlscuous
• Lndemlc ln: lar LasL Asla, Afrlca & MedlLerranean
• lncubaLlon: 1-6 monLhs
• Speclflc LesLs:
o P8sAg(surface anLlgen) presenL durlng
lncubaLlon, lf presenL afLer 6monLhs lndlcaLes
carrler sLaLus. AnLlbodles Lo Lhls lmply
vacclnaLlon.
o P8eAg- llngers afLer acuLe lllness, lmplles hlgh
lnfecLlvlLy
o P8cAg anLlbodles- lmplles pasL lnfecLlon
o ;<=-monlLorlng of vlral load
• ManagemenL- supporLlve, avoldance of alcohol, lf
chronlc " anLlvlrals e.g. lamlvudlne/adefovlr
• ÞrevenLlon: P00&21+4.1"2 4D4164A6-, passlve
lmmunlLy for non-lmmune conLacLs afLer hlgh
rlsk exposure
• CompllcaLlons: RGW\S A-3"0- 3I#"213, fulmlnanL
hepaLlc fallure ls !n Lhls subLype Lhough sLlll rare,
relapse, !#1+$ "B 34#312"04 (screenlng for PCC aL
regualar lnLervals wlLh llver uS and o feroproLeln
measures)
O-' C
<"G12B-3.1"2 "B O5:
O-' 7
Common ln lndla + !0"#.461.? 12 '#->2423?

1PL uAnuLnCnC uCSSlL8 2010
46
!"#$%$"&# (&)*+ ,&-*.-*
/0.1*-2
• !"##$ &'()*
o lew sympLoms
o 8everslble on alcohol cessaLlon
o Llver ls large, yellow, greasy, flrm
• +,-#) +&,./.&', 0)1"#'#'2
o Mlld-severe sympLoms
o Slgns of chronlc llver dlsease ln severe cases
o Llver cell necrosls, Mallory 8odles,
neuLrophll lnfllLraLlon,
• +&,./.&', 3'**/.2'2
o Slgns of chronlc llver dlsease +/- porLal P1n
o LncephalopaLhy common
o Þoor prognosls, lrreverslble
o ulffuse process characLerlsed by converslon
of normal hepaLlc archlLecLure lnLo
abnormal nodules
o lnflammaLlon, flbrosls, scarrlng and necrosls
34&5*6&$"$17
• lndlvldual suscepLlblllLy

8&-9 :.#0$+-
• CuanLlLy of LLCP
• 1ype (8eer and SplrlLs lncrease rlsk)
• lemale
• Pep C lnfecLlon
• CeneLlc facLors
• MalnuLrlLlon/uleL (especlally vlL A/L)















/&1;- .;5
/7640$6-
• Slgns of chronlc alcohollsm (ÞaroLld gland
enlargemenL, uupuyLren's conLracLure, ALaxla
and Þerlpheral neuropaLhy (vlL 8 ueflclency),
ShorL Lerm memory loss, lnsomnla/nlghLmares,

• uecompensaLed chronlc llver dlsease
(PepaLomegaly, Splenomegaly, AsclLes, !aundlce,
Splder nlvae, lever, Anaemla, LncephalopaLhy
eLc)
• AcuLe Alcohollc PepaLlLls (Long Px of alcohol
abuse wlLh sudden onseL [aundlce, anorexla,
nausea, malalse, fever, neuLrophll leukocyLosls
• WlLhdrawal SympLoms (LssenLlal Lremor,
lrrlLablllLy, ÞalplLaLlons, Selzures)

<&-0$+7 .;5 3=.6&;.0&$;
• CACL
• lully alcohol hlsLory (CuanLlLy, uuraLlon, 1ype of
LLCP, 8lnges)

>;)*-0&1.0&$;-
• no cllnlcally useful ob[ecLlve markers of alcohol abuse
(8andom LLCP level ls of llmlLed value)
• l8L
• uLC
• Ll1s
• Coag SLudles
• uS/C1
• Llver blopsy (flbrosls)

?.;.1*6*;0
?*5&#."
• Alcohol wlLhdrawal (ulazepam)
• Severe Alcohollc PepaLlLls: CorLlcosLerolds,
AnLloxldanLs)
(&@*-07"*
• AbsLlnence (Address challenge of LoLal absLlnence
from alcohol)
• uleL (Low faL, hlgh calorle wlLh vlLamlns (especlally 8)
and mlneral supplemenLs )
/A+1&#."
• 1ransplanL


B$64"&#.0&$;-:
• ÞorLal P1n
• CoagulaLlon ulsorders
• AsclLes
• PepaLlc LncephalopaLhy
• PepaLrorenal Syndrome
• PepaLocellular Carclnoma (~13)
• AcuLe or Chronlc ÞancreaLlLls
• Pypoglycaemla/Pyperglycaemla


1PL uAnuLnCnC uCSSlL8 2010
47
!"##$%&"&
()*"+","%+ -./ 012&&"*"02,"%+& %* 0%+3","%+
• Consequence of CLu whereby normal llver Llssue ls
replaced by scar Llssues and regeneraLlve nodules

4),"%1%56.!27&)&
• Alcohollc Llver ulsease
• PepaLlLls 8/C
• laLLy Llver ulsease (nASP)
• CLher:
Þrlmary 8lllary Clrrhosls, Þrlmary Scleroslng CholanglLls,
AuLolmmune PepaLlLls, PeredlLary PaemochromaLosls,
Wllson's ulsease, Alpha-1 AnLlLrypsln ueflclency, Cardlac
Clrrhosls (8Pl), PepaLoLoxlc drugs, ldlopaLhlc

8"5+& 2+3 869:,%9&
As resulL of dlsease lLself, or compllcaLlons of dlsease, Are
ofLen non-speclflc.
• !aundlce, ÞrurlLls, Splder nlvae, Þalmar LryLhema,
Clubblng, uupuyLren's ConLracLure, leLor PepaLlcus,
AsLerlxls, CynaecomasLla, Anaemla
• 8leedlng/8rulslng
• Llver slze may be enlarged (lnlLlally), normal or
shrunken (laLe sLage)

;+<)&,"52,"%+&
Ll1S:
• A51/Al1 - moJetotely elevoteJ (A51>Al1)
• All & CC1 - osoolly sllqbtly elevoteJ
• 8llltoblo - elevoteJ
• Albomlo - loweteJ
Co-Ag:
• ltotbtomblo 1lme - locteoses
u&Ls
• nypooottoemlo
l8L:
• Aooemlo
• leokopeolo/Neottopeolo (spleoomeqoly)
Serology
• nepotltls vltoses, AotoootlboJles
lron SLudles (lerrlLln/1ransferrln SaLuraLlon)
Copper/Ceruloplasmln
lmmunoglobullns (lgC/lgM/lgA)
CholesLerol
8SL
Alpha-1 AnLlLrypsln
lmaglng:
• uS Llver
• C1 Abdo
• CasLroscopy ln esLabllshed clrrhosls (oesophageal
varlces)
• 8lopsy

!%9:1"02,"%+&
• !aundlce
• ÞorLal P1n (Cesophageal varlces, Splenomegaly,
Paemorrholds, CapuL Medusa)
• AsclLes
• CoagulopaLhles
• PepaLlc LncephalopaLhy
• PepaLocellular Carclnoma
• PepaLorenal Syndrome
• CsLeoporosls (vlL u MalabsorpLlon)

!$"13 =75$ 80%#)>
• Cradlng of severlLy of clrrhosls
• uses: 8lllrubln, Albumln, ln8, AsclLes,
LncephalopaLhy

?2+25)9)+,>
Clrrhosls ls lrreverslble, Lherefore managemenL prlnclples
are as follows:
• 1reaL underlylng cause
o AbsLlnence from LLCP
o PepaLlLls 8x
o ChelaLlon Lherapy (Wllsons)
• ÞrevenL furLher damage
o AbsLlnence from PepaLoLoxlc agenLs (e.g.
LLCP/ÞaraceLamol)
o PepaLlLls vacclnaLlon
• ÞrevenL Cx
o AsclLes: ulureLlcs/lluld resLrlcLlon
o ÞorLal P1n: Þropranolol/ShunLlng
• CuraLlve: Llver LransplanLaLlon

=2,$%:$6&"%1%56.=2,$%5)+)&"&
• Þrogresslon from flbrosls Lo clrrhosls and clrrhosls
morphology varles from person Lo person (exLenL of
sLlmulus exposure/lndlvldual response)
ÞC81AL P1n
• ln response Lo ln[ury and loss, growLh regulaLors
lnduce hepaLocellular hyperplasla (produclng
regeneraLlng nodules) and anglogenesls
• lnsulln, glucagon, and paLLerns of lnLra-hepaLlc blood
flow deLermlne how and where nodules develop
• As a resulL of anglogenesls, Lhe new vessels wlLhln
Lhe flbrous sheaLhs LhaL surrounds nodules brldge
connecLlon beLween Lhe hepaLlc arLery and porLal
veln Lo hepaLlc venules
• 1hese vessels provlde relaLlvely low volume/hlgh-
pressure venous dralnage LhaL cannoL accommodaLe
normal blood volume
• ln addlLlon wlLh compresslon of hepaLlc venules by
regeneraLlng nodules, Lhls lncreases porLal veln
pressure, resulLlng ln porLal P1n

=2,$%1%56
• !"#$%&#%'(#"))*+
-lnlLlally enlarged, becomes smaller wlLh dlsease
progresslon
-lrregular surface, flrm, yellow (sLeaLosls)
-1hree Lypes: Mlcronodular (<3cm), Macronodular
(>3cm), Mlxed Clrrhosls
• !(#$%&#%'(#"))*+
-Þresence of regeneraLlng nodules of hepaLocyLes
1PL uAnuLnCnC uCSSlL8 2010
48
-Þresence of flbrosls
-ueposlLlon of connecLlve Llssue beLween nodules
-uesLrucLlon of normal sLrucLures: slnusolds, Space of
ulsse, vascular SLrucLures
!"#$%&'&% )*+,-.)/&0&$12
LymphocyLe lnfllLraLlon (Chronlc Pep 8)
LryLhrocyLes (Cardlac Clrrhosls)
8lle ducL flbrosls/Cranulomas/8lle
Þoollng (Þrlmary blllary Clrrhosls)













1he lmage shows a cross secLlon Lhrough a llver LhaL has a
process affecLlng Lhe whole llver comprlslng Lhln bands of
whlLe Llssue subdlvldlng Lhe lnLervenlng mlcronodules (3-
4mm)), of red-brown and focally green Llssue.
1he llver ls grossly decreased ln slze (whlch could be
beLLer assessed by knowlng Lhe welghL of Lhe llver). 1here
are no focal leslons seen. 1he feaLures seen are Lhose of
mlcronodular clrrhosls.












ulffuse nodularlLy of Lhe surface of Lhe llver, lnduced by
underlylng flbrous scarrlng. Average nodule slze ls around
3mm, conslsLenL wlLh a paLLern of mlcronodular clrrhosls

1PL uAnuLnCnC uCSSlL8 2010
49
!"#$%&"'($ *"%$(#+,"
-.(/&,(+0+12
1yplcally Males > 60yrs
<2° of all mallgnanL cancers ln wesLern world

3(45 6"$'+%4
- Smoklng
- CbeslLy
- ulabeLes MelllLus
- Alcohol
- Chronlc ÞancreaLlLls
- Plgh faL dleL? Caffelne?

7/8
- CholedochollLhlasls
- ÞancreaLlc pseudocysL or cysLlc neoplasm
- Carclnoma of Lhe blllary Lree
- 8lllary sLrlcLure
- PepaLocellular carclnoma
- Þrlmary Scleroslng CholanglLls (ÞSC)
- Þrlmary 8lllary Clrrhosls (Þ8C)

!"'9+.924(+0+12
MosLly /:$'"0 "/&#+$"%$(#+,"4 (90°)
- 60° ln head, 23° ln body, 13° ln Lall
CLher locaLlons(rare):
- Ampulla of vaLer or pancreaLlc lsleL cells
(lnsullnoma, gasLrlnoma, glucagonomas,
somaLosLaLlnomas)
CeneLlcs: 93° have muLaLlons ln Lhe k8AS2 gene

;(1#4 "#/ ;2,.'+,4
- 1umours ln Lhe head of pancreas Lyplcally
presenL wlLh ."(#0&44 +<4'%:$'(=& >":#/($&.
o !aundlce
o Þale SLools
o uark urlne
- 73° of Lumours ln Lhe body & Lall presenL wlLh
&.(1"4'%($ ."(# (radlaLes Lo back, relleved by
slLLlng forward)
- LplgasLrlc mass
- PepaLomegaly, splenomegaly
- LymphadenopaLhy, asclLes
- 8arer feaLures:
o 1hrombophleblLls Mlgrans,
Pypercalcaemla, MaranLlc endocardlLls,
porLal hyperLenslon, nephrosls

?(4'+%2 "#/ -8",(#"'(+#
Cl1 Lx + Lndo Lx
- vlrchows node
- Þ8 for perlLoneal meLs







@#=&4'(1"'(+#4
8loods
- Ll1s: CholesLaLlc !aundlce
- Ca 19-9 - nonspeclflc
lmaglng
- uS,C1, L8CÞ may locallse obsLrucLlon
- Lndoscoplc uS mosL accuraLe dlagnosLlc &
sLaglng Lechnlque

A"#"1&,&#'
A&/($"0
- Þaln rellef/ÞalllaLlon
- ÞancreaLlc enzyme supplemenLs
- ÞosL op chemo delays progresslon

;:%1($"0
- MosL ducLal carclnomas presenL wlLh meLasLaLlc
dlsease. <10° sulLable for radlcal surgery
- lf sulLable & Lumour <3cm wlLh nll meLs !
Whlpple's (pancreaLoduodenecLomy - hlgh posL
op morblLy)

"#$%%&'() *+,-'./+'

*+,.0($"'(+#4
- CbsLrucLlve !aundlce (See paLh case)
- Anorexla
- WelghL Loss
- ulabeLes
- AcuLe pancreaLlLls
- ularrhoea/sLeaLorrhoea

!%+1#+4(4
- ulsmal
- Mean survlval < 6 mLhs
- 3 yr survlval 2-3°
- 3yr survlval posL whlpples 3-14°
- Þrognosls beLLer lf Lumour < 3cm, no nodes
lnvolved, -ve resecLlon marglns aL surgery,
ampullary or lsleL cell Lumours

1PL uAnuLnCnC uCSSlL8 2010
30
!"#$% '()"*%($+$+,
-%.+)+$+/)
ÞancreaLlLls classlfled as acuLe or chronlc. ÞaLhologlcal
specLrum of acuLe pancreaLlLls varles from lnLersLlLlal
pancreaLlLls, whlch ls usually a mlld and self-llmlLed
dlsorder Lo necroLlslng pancreaLlLls.


!%$+/0/1234(#,%,
CL1SMASPLu
- 5(00,$/)%,
- 6$7()/0
- 1rauma
- SLerolds
- Mumps
- AuLolmmune
- Scorplon venom
- Pyperllpldaemla, hypoLhermla, hypercalcaemla
- L8CÞ + Lmboll
- urugs

Ma[orlLy of cases are elLher gallsLones or eLhanol.

'($7/872,+/0/12
Self-perpeLuaLlng pancreaLlc lnflammaLlon (and oLher
reLroperlLoneal Llssues). Cedema and fluld shlfLs cause
hypovolaemla as LCl ls Lrapped ln Lhe guL, perlLoneum,
and reLroperlLoneum (worsened by vomlLlng).
Þrogresslon may be rapld from mlld oedema, Lo
necroLlslng pancreaLlLlLls by enzyme-medlaLed
auLodlgesLlon. 30° of cases LhaL advance Lo necrosls are
furLher compllcaLed by lnfecLlon.


9+1), (): 92;8$/;,
92;8$/;,
Cradual or sudden %8+1(,$*+" 8(+) or cenLral abdomlnal
paln (radlaLes Lo back, slLLlng forward may relleve).
</;+$+)1 promlnenL.

9+1),
- 1achycardla
- lever
- !aundlce
- Shock
- lleus
- 8lgld Abdomen +/- local/generallsed Lenderness
- Þerlumblllcal brulslng (Cullen's slgn) or flank
brulslng (Crey 1urner's Slgn) from blood vessel
auLodlgesLlon & reLroperlLoneal haemorrhage









=)>%,$+1($+/),
- 8alsed serum amylase and llpase (more speclflc)
- Abdo C1
- Abdo uS (gallsLones?)
- 8SL


?()(1%;%)$

ConservaLlve
- n8M (resL Lhe pancreas)
- lluld resus
- Analgesla

- CompllcaLlons may requlre furLher 8x (see
below)


4/;80+"($+/),
6(*02
- Shock
- A8uS
- 8enal lallure
- ulC
- Sepsls
- Pypocalcaemla

@($% ABCDEF
- ÞancreaLlc necrosls
o ulffuse lnLeracLlon of an acuLely
lnflamed, necroLlc pancreas occurrlng
mosL ofLen ln Lhe flrsL 2-4 weeks slnce
onseL. 8equlres surglcal debrldemenL
- ÞseudocysLs
o CollecLlons of Llssue, fluld, debrls,
pancreaLlc enzymes, and blood, LhaL
develop over a perlod 4-6 weeks afLer
onseL of acuLe pancreaLlLls. LffecLs 13°
of pLs wlLh acuLe pancreaLlLls. no
eplLhellal llnlng so noL real cysLs. 83° ln
body or Lall. MosL resolve
sponLaneously. May lead Lo rupLure,
haemorrhage or abscess. Can be faLal.
- Abscess
o An lll-deflned llquld collecLlon of pus
LhaL evolves over a longer perlod, 4-6
weeks. 8equlres surglcal or
percuLaneous dralnage
- 8leedlng
- 1hrombosls
- llsLulae
1PL uAnuLnCnC uCSSlL8 2010
31
!"#$%&' )*%'#+*,&,&-
.+/&%&,&$%

A dlsease process characLerlsed by &##+0+#-&12+ damage Lo
Lhe pancreas. Can be classlfled by cause.


3+,&$2$456!*7-+-

- 1oxlc-MeLabollc !"#" !"#$%$" %&'() *'++',
*-.(!/
- ldlopaLhlc
- CeneLlc
- AuLolmmune
- 8ecurrenL & severe acuLe pancreaLlLls
- CbsLrucLlve


)*,"$8"5-&$2$45

noL enLlrely undersLood. 8esL deflned hlsLologlcally wlLh
feaLures of:
- Chronlc lnflammaLlon
- llbrosls
- Þrogresslve desLrucLlon of boLh exocrlne and
evenLually endocrlne Llssue


9&4%- *%: 95;8,$;-

- LplgasLrlc paln LhaL ºbores" Lhrough Lo back
- SLeaLorrhoea
- 8loaLlng
- WelghL loss
- 8rlLLle dlabeLes (As opposed Lo sLable dlabeLes)


<%0+-,&4*,&$%-

8loods
- 8alsed glucose
- Serum amylase and llpase %$, usually ralsed
lmaglng
- uS - pseudocysL
- C1 - ÞancreaLlc calclflcaLlons
- Ax8 - Speckled pancreaLlc calclflcaLlon










=*%*4+;+%,

=+:&'*2
- Þaln rellef
- ÞancreaLlc enzyme supplemenLs eg Creon
(Llpase)
- lnsulln?

97#4&'*2
- Surglcal removal ln exLreme cases lf unremlLLlng
paln, narcoLlc abuse or exLreme welghL loss

>&/+-,52+
- no alcohol
- Low faL dleL


!$;82&'*,&$%-

- Cardlnal compllcaLlons
o 31:$;&%*2 )*&%
o 9,+*,$##"$+*
o .&*1+,+-

- ÞseudocysL
- 8lllary obsLrucLlon
- Splenlc veln Lhrombosls
- CasLrlc varlces
- ÞancreaLlc carclnoma
- ?*#'$,&' *17-+ - don'L underesLlmaLe
- CasLroparesls
- MalabsorpLlon
- nondlabeLlc reLlnopaLhy
1PL uAnuLnCnC uCSSlL8 2010
32
!"#$
$&'()(*(+)
Chronlc sympLoms or mucosal damage due Lo Lhe
abnormal reflux sLomach acld lnLo Lhe oesophagus.



#(,- ./0*+1,
• PlaLus hernla
• CbeslLy
• Þregnancy
• Smoklng
• L1CP
• Pypercalcaemla (^gasLrln > ^acldlLy)
• SysLemlc sclerosls (oesophageal dysmoLlllLy)
• urugs (Lrlcycllcs, anLlchollnerglcs, nlLraLes)
• Þrednlsolone

2/*3+435,(+6+75
CC8u ls caused by LranslenL or permanenL changes ln Lhe
barrler beLween Lhe oesophagus and Lhe sLomach, whlch
when worklng correcLly, prevenLs duodenal blle, enzymes
and sLomach acld from refluxlng back lnLo Lhe
oesophagus where lL may lnflame Lhe mucosa.

lacLors LhaL alLer Lhe barrler beLween oesophagus and
sLomach lnclude
• an lncompeLence of Lhe lower oesophageal
sphlncLer (LCS)
• LranslenL LCS relaxaLlon
• lmpalred expulslon of gasLrlc conLenLs
• hlaLal hernla





8(7), /)9 85:4*+:,
• hearLburn
• regurglLaLlon
• dysphagla
• odynophagla
• excesslve sallvaLlon
• nausea
• ChesL paln (can mlmlc AMl)
• ALyplcal
o ury cough
o asLhma

;)<&,*(7/*(+),
• 24h oesophageal pP monlLorlng (CCLu sLandard)
• CasLroscopy
o lndlcaLlons - sympLoms >4 wks,
perslsLenL sympLoms desplLe Mx
• Cx8/8arlum swallow - may show hlaLus hernla

=/)/7&:&)*
>('&,*56& - use of anLaclds, sLopplng smoklng, sleeplng on
Lhe lefL slde, avoldlng food LhaL worsen sympLoms, avold
lylng down for 3 hours afLer meals

=&9(0/6
• ÞroLon pump lnhlblLors (!"#$%!&"'%()*
%,)!&"'%()) - reduce gasLrlc acld producLlon
• P2 recepLor anLagonlsLs (-.,)$./.#)* &"#$./.#)) -
reduce gasLrlc acld secreLlon
• Alglnlc acld (0"1.2-%#) - may coaL mucosa as well
as lncrease pP
• ÞroklneLlcs (,)$%-(%!&",./)) - sLrengLhen LCS
and speeds up gasLrlc empLylng

8?17(0/6 @ sLandard surglcal LreaLmenL ls Lhe 3.22)#
45#/%!(.-"$.%#. 1he upper sLomach ls wrapped around Lhe
LCS Lo sLrengLhen lL, prevenL acld reflux and Lo repalr
hlaLus hernlas.

A+:46(0/*(+),
CC8u can cause
• 8eflux oesphaglLls
• Cesophageal sLrlcLures/ulcers
• 8arreLL's oesophagus
• Cesophageal adenocarclnoma
1PL uAnuLnCnC uCSSlL8 2010
33
!""#$%&'( *+,(' -./0"+1(
2(3#/#$#+/ 456 7'%88#3#9%$#+/
lrrlLable bowel syndrome (l8S) ls a funcLlonal bowel
dlsorder characLerlzed by abdomlnal paln or dlscomforL
and alLered bowel hablLs ln Lhe absence of deLecLable
sLrucLural abnormallLles. LssenLlally: a dlagnosls of
excluslon.

:;#0(1#+'+<.
10-20° of adulLs and adolescenLs have sympLoms
conslsLenL wlLh l8S, and mosL sLudles show a female
predomlnance.

=%$>+;>.8#+'+<.
l8S ls poorly undersLood, alLhough roles of abnormal guL
moLor and sensory acLlvlLy, cenLral neural dysfuncLlon,
psychologlcal dlsLurbances, sLress, and lumlnal facLors
have been proposed.
ln some lndlvlduals Lhere may be a preclplLanL:
- CasLroenLerlLls
- AnLlbloLlc Lherapy
- Þelvlc surgery
- Þsychologlcal sLress, dlsLurbances or Lrauma
- lood lnLolerance

-#</8 %/0 -.1;$+18
ÞrerequlslLe sympLom: abdomlnal paln, frequenLly
eplsodlc and crampy, buL lL may be superlmposed on a
background of consLanL ache.
CLher sympLoms
- Change ln bowel hablL: consLlpaLlon alLernaLlng wlLh
dlarrhoea
- "Cork ouL of Lhe champagne boLLle" mornlng dlarrhoea
- 8loaLlng and lncreased flaLulence
- Marked gasLrocollc reflex
- ldenLlflable dleLary preclplLanLs, eg: dalry producLs, faLLy
or splcy foods and alcohol
- Þaln relleved by defecaLlon or passlng of flaLus
- Worsenlng of sympLoms by emoLlonal sLress and/or
durlng Lhe premensLual or mensLrual phases
-.1;$+18? ,>#9> 8>+@'0 &( A#<+"+@8'. #/A(8$#<%$(0
- uysphagla
- Anorexla and/or welghL loss
- MouLh ulcers
- nocLurnal dlarrhoea
- 8ecLal bleedlng

B#8$+". %/0 :C%1#/%$#+/
ulagnosLlc crlLerla:
8ecurrenL abdomlnal paln or dlscomforL aL leasL 3 days
per monLh ln Lhe lasL 3 monLhs assoclaLed wlLh Lwo or
more of Lhe followlng:
1. lmprovemenL wlLh defecaLlon
2. CnseL assoclaLed wlLh a change ln frequency of
sLool
3. CnseL assoclaLed wlLh a change ln form
(appearance) of sLool
A deLalled hlsLory and examlnaLlon, lncludlng dleL, ls
cenLral Lo dlagnosls.

!/A(8$#<%$#+/8
Þerformed prlmarlly Lo rule ouL organlc dlsease, for
example: coellac, Crohn's, ulceraLlve collLls. lnfecLlve or
lnflammaLory causes are suspecLed wlLh a shorL onseL of
sympLoms.
l8L and LS8 should be performed. A full examlnaLlon
lncludlng rlgld slgmoldoscopy or endoscopy should be
underLaken. 1hen furLher lnvesLlgaLlons should depend
on Lhe sympLoms.

D%/%<(1(/$
D(0#9%'
E/$#0#%"">+(%' %<(/$8: for dlarrhoeal predomlnanL l8S.
F81+$#9 '%C%$#A(8 %/0 3#&"( 8@;;'(1(/$8: for
consLlpaLlon predomlnanL l8S.
E/$#8;%81+$#98 (anLlchollnerglcs): !"#$#%&'"() and
+$&,#$-'"(). used for rellef of abdomlnal paln probably
assoclaLed wlLh bowel spasm (noL convlnclngly proven).
Slde effecLs: dry mouLh, vlsual dlsLurbances, urlnary
reLenLlon, and consLlpaLlon.
-("#/$+/#/ G6BHI6"(9(;$+" %/$%<+/#8$8: -%&,)./&(0
8lockade of cenLral 3-P13 recepLors may lnhlblL
unpleasanL vlsceral afferenL sensaLlon, lncludlng nausea,
bloaLlng, and paln. used for severe l8S wlLh dlarrhoea as
predomlnanL sympLom. Slde effecLs: serlous Cl1 LoxlclLy
(rare), consLlpaLlon (rarely requlrlng hosplLallsaLlon) and
lschaemlc collLls (someLlmes faLal) ln 3/1000 pLs.
-("+$+/#/ G6BHJ6"(9(;$+" %<+/#8$8: .)1-,)/&!0 ShorL-
Lerm LreaLmenL of women wlLh l8S who had predomlnanL
consLlpaLlon shows a modesL reducLlon ln severlLy of paln
and bloaLlng. Slde effecLs: cardlovascular deaLh. 1herefore
lL was Laken from Lhe markeL volunLarlly by Lhe pharm
company..
K+, 0+8( $"#9.9'#9 %/$#0(;"(88%/$8: -'"./"2.$%"()3
!),"2/-'"(). May help wlLh mood, buL also decrease
senslLlvlLy Lo vlceral sensaLlon.
K#3(8$.'(
:C9'@8#+/ 0#($: for pLs who have clearly ldenLlflable
lnLolerances. Lg: lacLose.
2#($%". 9>%/<(L managemenL of sLool conslsLency.
=(;;("1#/$ +#' ;"(;8: help wlLh bloaLlng.
-$"(88 "('#(3: for Lhose who's sympLoms are worse wlLh
sLress.
*(#/< '#8$(/(0 $+ &. $>( 0+9$+" and havlng a dlagnosls
has been shown Lo lmprove sympLoms.

7+1;'#9%$#+/8
AlLhough Lhere ls a lack of compllcaLlons, l8S can be very
severe, embarrasslng and deblllLaLlng.
1PL uAnuLnCnC uCSSlL8 2010
34
!"#$%&' )%*#&*#
)#+%,%-%", ./0 !$&**%+%'&-%",
ulsease occurrlng ln chlldren and adulLs characLerlsed by
senslLlvlLy Lo gluLen, wlLh chronlc lnflammaLlon and
aLrophy of Lhe mucosa of upper small lnLesLlne

12%3#4%"$"56
80° of cases currenLly undlagnosed
LffecLs up Lo 1° of populaLlon
CnseL beLween age 12 and 90+

7#-%"$"56/!&8*#*
• Some geneLlc lnfluence
• 70° concordance ln ldenLlcal Lwlns
• 10-30° of flrsL degree relaLlves have coellac dlsease

9&-:"2:6*%"$"56
• SenslLlvlLy Lo gluLen (found ln cereals, wheaL, rye,
barley)
• lngesLlng gluLen ! 1-cell medlaLed damage of Lhe
small bowel leadlng Lo desLrucLlon of vllll and
flaLLened mucosal surface
• Consldered AuLo-lmmune condlLlon
• AssoclaLed oedema and lnfllLraLlon of chronlc
lnflammaLory cells Lo lamlna proprla
• Mucosal damage malnly proxlmal - decreaslng
Lowards lleum.
• Mal absorpLlon of nuLrlenLs Lhen follows

;%5,* &,3 ;642-"4* !"#$%& ( )**+)$ #, #$$#&)-.+ -/0+.
%1,2$/3+ )% 0+..4
• ularrhoea
• 8loaLlng
• llaLulence
• ConsLlpaLlon
• laLlgue/LeLhargy
• unexplalned lron/folaLe deflclency
• vlL 812 ueflclency
• CLher: lnferLlllLy, repeaLed mlscarrlages, recurrlng
mouLh ulcers, skln rashes, mood changes/lrrlLablllLy,
early onseL osLeoporosls, Þrlmary amenorrhea

<8-=%-%",&$ )#+%'%-*
• lron, +/- anaemla
• lolaLe
• vlL 812
• Zlnc, Mg
• vlL u
• Pypocalcaemla
• Low albumln
• Abnormal cloLLlng Llme
(due Lo poor absorpLlon of vlL k)
>,?#*-%5&-%",* @ +"= )%&5,"*%*A 4",%-"=%,5A '"42$%'&-%",*
)%&5,"*%*
• ueflclencles:
o l8L, le SLudles, vlL 812, 8ed cell folaLe, Ca,
Mg, Zlnc, vlLu, Albumln (Ll1s), CloLLlng Llme
• Coellac screen - anLlbody LesLs
o Can have false negaLlves
o AnLl-glladln and elLher anLl-endomyslal or
anLl-LransgluLamlnase anLlbodles
o Also LesL LoLal serum lgA Lo exclude lgA
deflclency whlch could glve false negaLlve
resulL
• Small 8owel blopsy - deflnlLlve dlagnosls

B",%-"=%,5C
• When under dleLary conLrol, anLlbody LesLs should
become negaLlve
• used Lo monlLor dleLary compllance

!"42$%'&-%", D#*-%,5C
• 8one denslLy LesL
o 1esLlng for CsLeoporosls, osLeomalacla
o 1hls can be LreaLed and avolded

B&,&5#4#,-
• CluLen free dleL
o Avold: wheaL, barley, rye, oaLs (bread, pasLa,
cakes, cereals, blsculLs, pasLry, plzza,
breadcrumbs eLc), flavour enhancers(620-
623), 1hlckners wlLh numbers ln Lhe 1400s
o non obvlous gluLen sources: sausages,
processed meaLs, soups, sLock cubes, soy
sauce, sauces, gravles, dresslngs.
• SupplemenLs unLll vllll grow back:
o lron, lolaLe, vlL 812, Zlnc, vlL u

!"42$%'&-%",*
• Small proporLlon don'L respond Lo dleLary
changes
• lncreased rlsk of lnLesLlnal lymphoma
• Cl cancers
• ulceraLlve [e[unlLls

!E1F>7! )>;17;1
<EGB7F
1PL uAnuLnCnC uCSSlL8 2010
33
!"#$%&'($'%)$)#
+',)()$)&(
AcuLe lnfecLlon of Lhe gasLrolnLesLlnal LracL, whlch can
someLlmes be a chronlc lnfecLlon.

-)#. /"0$&%#
- 1he very young and Lhe very old are more suscepLlble.
- ulsrupLlon of normal Cl1 moLlllLy and anLlmoLlllLy
agenLs.
- Acld-reduclng gasLrlc surgery or medlcal acld reducLlon
(lncreased suscepLlblllLy Lo nonLypholdal salmonellosls
and selecLed oLher enLerlc lnfecLlons ln Lhe proxlmal S
lnLesLlne)
- Loss of normal lnLesLlnal flora (predlsposes parLlcularly
Lo C dlfflclle)
- underlylng Cl1 paLhology, eg: coellac, Crohn's.

1'$)&2&3456"7#'#
Common acuLe causes:
- CulLure negaLlve (vlral)
- CampylobacLer spp
- Salmonella
- ClosLrldlum dlfflclle
- Cholera (developlng counLrles)
Chronlc (less common)
- Clardlasls
- 1uberculosls
- Amoeblasls

8"$9&:94#)&2&34

;'09"()#< =>"<:2'#
lnvaslve: organlsms LhaL lnvade
and prollferaLe ln Lhe lnLesLlnal
eplLhellum, underlylng mucosa
and lymphold folllcles.
- 8oLavlrus
- !"#$%&'(")*+,
- ."&#'/+&&"
- .012+&&"
CyLoLoxlc: produce Llssue
damaglng cyLoLoxlns whlle ln Lhe
lumen and ln conLacL wlLh Lhe
eplLhellum.
- !&'3*,1415# 41661)1&+
- LnLerohaemorrhagl
c 78 )'&1
LnLeroLoxlc: produce
enLeroLoxlns whlle ln Lhe lumen
and ln conLacL wlLh Lhe
eplLhellum, whlch produce
profound funcLlonal alLeraLlons
buL no deLecLlble hlsLologlcal
damage.
- 91(,1' )0'&+,"
- LnLeroLoxlgenlc 78
)'&1
LnLeroadherenL: adhere Lo Lhe
eplLhellal surface and lnduce
eplLhellal damage and mucosal
lnflammaLlon wlLhouL lnvaslon.
- LnLeropaLhogenlc 78
)'&1
- Clardlases
1oxln produced ln vlLro, LhaL
when consumed causes
sympLomaLlc lllness
- :")1&&53 )+,+53
- .*"$0%&')'))53
"5,+53

?)#$&%4 "(@ =>"<)("$)&(
AcuLe onseL of sympLoms lncludlng:
- ularrhoea and vomlLlng
- Abdomlnal paln
- lever and headache
- Myalgla
Þosslbly admlL Lo a hlsLory of:
- 8ecenL Lravel
- SuspecL food
- CLher lndlvlduals may be affecLed
1lme of onseL (afLer food lngesLlon)
2-6 h .*"$0 "5,+53; :")1&&53 )+,+53 (u&v + abdo
paln)
12-48 h Salmonella, !"#$%&'(")*+, (bloody u); 78
)'&1 0137 (bloody u +/-haemolyLlc ueraemlc
syndrome)
18-36 h 8oLullsm (u&v + paralysls)
2 days
onwards
Amoeblasls (chronlc flucLuaLlng, vague paln,
loose sLools, occaslonal blood)
2-7 days 8aclllary dysenLry (scale of Lrlvlal Lo llfe
LhreaLenlng, ofLen bloody u)
1-3 weeks Clardlasls (u&v, abdo paln, malalse, usually
brlef buL may be chronlc)
10-18
days
CrypLosporldlosls (usually self-llmlLlng unless
lmmuno-compromlsed)

A(B'#$)3"$)&(#
MosL cases seLLle sponLaneously and do noL requlre
lnvesLlgaLlon.
lf Lhe paLlenL ls lll enough Lo be admlLLed Lo hosplLal:
- SLool and blood culLures
- l8L, elecLrolyLes
lf u perslsLs for more Lhan 3 weeks:
- Slgmoldoscopy wlLh recLal blopsy
- 8eferal Lo Cl1 physlclan

;"("3'<'($
Mlld cases: oral rehydraLlon and careful observaLlon ln
very young and very old.
More severe cases may requlre lnLravenous flulds (musL
be severe).
SepLlcaemla (fever and poslLlve culLures): anLlbloLlcs Lo
LreaL Lhe organlsm deLecLed.

6&<:2)0"$)&(#
- Severe dehydraLlon, shock and clrculaLory collapse
- SepLlcaemla
- Spread Lo remoLe slLes: menlnglLls, pnuemonla, llver
abscess
- 78 )'&1 0137 may cause haemolyLlc uraemlc syndrome:
shlga-llke Loxln enLers Lhe blood sLream and blnds Lo
vascular and renal Lubular eplLhellum. 8esulLs ln
endoLhellal ln[ury, lnflammaLlon, Lhrombosls and renal
fallure (bad!)
1PL uAnuLnCnC uCSSlL8 2010
36
Þept|c U|cer D|sease
Def|n|t|on +]- C|ass|f|cat|on
• Lroslon of Lhe mucosal membrane greaLer Lhan 0.3cm
ln an area of Lhe Cl1 LhaL ls usually acldlc and Lhus
very palnful
• 70-90° are caused by PellcobacLer pylorl (splral
shaped gram negaLlve urease produclng bacLerlum.

Lp|dem|o|ogy
• 70-90° are caused by PellcobacLer pylorl (splral
shaped gram negaLlve urease produclng bacLerlum.
• Cnly 13° of paLlenLs lnfecLed wlLh P. pylorl wlll
develop ulceraLlon (pepLlc or duodenal)

k|sk Iactors
• P. Þyorl lnfecLlon
• reduced acld producLlon ln Lhe sLomach
• smoklng
• nSAlu use
• prevlous gasLrlLls
• gasLrlc dysmoLlllLy

Aet|o|ogy]Causes
• lncreased acld secreLlon because of lncreased parleLal
cell mass & gasLrln secreLlon
• smoklng lmpalred gasLrlc mucosal heallng
• P. pylorl produced Loxlns (vacuolaLlng and cyLoLoxlc)
• uecreased lnhlblLlon of acld secreLlon (reduced
somaLosLaLln producLlon ln anLrum wlLh loss of
negaLlve feedback)
• CeneLlc suscepLlblllLy

Þathophys|o|ogy
• P. pylorl lnfecLlon produces gasLrlLls malnly ln Lhe
anLrum of Lhe sLomach
• PlsLologlcally Lhere ls eplLhellal cell damage from
local release of cyLoklnes such as lL-6 and lL-8.
• 1hls leads Lo recrulLmenL and acLlvaLlon of an
lnflammaLory lnfllLraLe ln Lhe lamlna proprla
conslsLlng of polymorphonuclear leucocyLes,
eoslnophlls, lymphocyLes, monocyLes and plasma
cells


S|gns and Symptoms
• LplgsLrlc paln
• PaemaLemesls (mosL common presenLaLlon)
• uyspepsla
• vomlLlmg
• perforaLlon wlLh perlLonlLls

n|story and Lxam|nat|on


Invest|gat|ons
• Lndoscopy ls Lhe flrsL llne lnvesLlgaLlon
• 1esLlng for P. pylorl by:
o PlsLology of anLrum
o CLC LesL for bacLerlal urease
o P. pylorl anLlbodles ln Lhe blood
o n. py|or| |s very d|ff|cu|t to cu|ture

Management
Med|ca|
• P2 recepLor anLagonlsLs or proLon pump lnhlblLors
wlll resolve Lhe ulcers usually ln 4-6 weeks
• P. pylorl eradlcaLlon conslsLlng of hlgh dose ÞÞl and
Lwo anLlbloLlcs= omeprazole, amoxyclllln /
meLronldazole & clarlLhromycln
Surg|ca|
• 8equlred for Lhose wlLh perforaLlon and recurrenL or
perslsLenL bleedlng
L|festy|e
• SLop smoklng
• 8educe L1CP
• Avold caffelne and acldlc frulL [ulces
• 8educe splcy, heavy foods
• lrulL and vegeLables encourage ulcer heallng
• SLress managemenL

Comp||cat|ons
• 8leedlng
• ÞerforaLlon
• ÞeneLraLlon
• CbsLrucLlon
• P. pylorl lnfecLlon and long sLandlng Þuu can lead Lo
lncreased chance of developlng llnlLls plasLlca or
oLher gasLrlc cancers
1PL uAnuLnCnC uCSSlL8 2010
37
!"#$%&$&# "() !"#$%*+"$,-
./0&(&$&*( 123 45"##&0&6"$&*(
!"#$%&$&#: lnflammaLlon of Lhe gasLrlc mucosa.
!"#$%*+"$,-7 eplLhellal damage ln Lhe gasLrlc mucosa buL
llLLle or no lnflammaLlon.
Powever, Lhe Lerms are ofLen used lnLerchangeably.

8+&)/9&*5*:-
1he commonesL cause of gasLropaLhy: nSAlu and alcohol
use.
1he commonesL cause of gasLrlLls ls !" $%&'() lnfecLlon (80°).

;"$,*+,-#&*5*:-
8%*#&</ "() ,"/9*%%,":&6 :"#$%&$&#
ulcers, paln and bleedlng occur. 1here ls eroslon of Lhe
gasLrlc wall comblned wlLh Lhe lnflammaLlon.
SLress
gasLrlLls
SLress-relaLed mucosal eroslons and subeplLhellal
hemorrhages develop wlLhln 72 hours ln Lhe ma[orlLy
of crlLlcally lll paLlenLs. 1he mechanlsm ls unknown as
Lhere ls usually normal or decreased secreLlon durlng
sLress. Þrophylaxls wlLh P2 anLagonlsLs may be
lndlcaLed.
nSAlu
gasLrlLls
lnhlblLlon of CCx paLhway depleLes mucosal
prosLaglandlns leadlng Lo muscosal damage. 30° of
pLs on regular nSAlus wlll develop gasLrlc mucosal
damage and 30° wlll have ulcers. 1-2° have a serlous
problem.
Alcohol Plgh concenLraLlons damage Lhe gasLrlc mucosal
barrler leadlng Lo acuLe gasLrlc mucosal eroslons and
subeplLhellal haemorrhage.
Curllng
ulcers
ulcers occurrlng ln Lhe sLomach wlLh exLenslve
superflclal skln burns, lnLracranlal leslons or severe
bodlly ln[ury. 8educed plasma volume ls sald Lo lead
Lo lncreased sloughlng of Lhe gasLrlc mucosa leavlng lL
unproLecLed from Lhe acld ln Lhe sLomach. Chlldren
wlLh burns are more suscepLlble.
=*(3/%*#&</2(*(3#+/6&0&6 :"#$%&$&#
1hls ls lnflammaLlon of Lhe gasLrlc wall, buL ulcers and
eroslon ls no necessarlly seen.
!" $%&'() A splral gram-negaLlve rod LhaL resldes beneaLh
Lhe gasLrlc mucous layer ad[acenL Lo gasLrlc
eplLhellal cells. AlLhough noL lnvaslve, lL causes
gasLrlc mucosal lnflammaLlon wlLh ÞMns
(polymorphonuclear neuLrophlls) and
lymphocyLes.
AuLolmmune
gasLrlLls
AffecLs Lhe fundus and Lhe body of Lhe sLomach
leadlng Lo aLrophlc gasLrlLls wlLh loss of parleLal
cells. 1hls leads Lo achlorhydrla and lnLrlnslc
facLor deflclency causlng pernlclous anaemla.
MeneLrler's
dlsease
A rare condlLlon conslsLlng of glanL gasLrlc folds
malnly ln Lhe fundus and Lhe body of Lhe
sLomach. PlsLologlcally Lhere ls hyperplasla of
Lhe gasLrlc plLs, aLrophy of Lhe glands and an
overall lncrease of mucosal Lhlckness. May be
premallgnanL, perlpheral oedema may happen
due Lo proLeln leakage Lhrough Lhe mucosa and
pL may have eplgasLrlc paln.




>&:(# "() >-9+$*9#
- usually asympLomaLlc and Lhere ls poor correlaLlon
beLween severlLy of sympLoms and severlLy of dlsease.
- upper Cl1 bleedlng (haemaLemesls, coffee grounds or
malaena)
- Anorexla, welghL loss and malnourlshmenL
- LplgasLrlc paln
- nausea, and vomlLlng.

?(</#$&:"$&*(#
- Lab flndlngs: hemaLocrlL ls low lf slgnlflcanL bleedlng has
occurred, lron deflclency may be found.
- upper endoscopy ls Lhe mosL senslLlve meLhod of
dlagnosls, lL ls also useful for rullng ouL udxs.

.&00/%/($&"5 )&":(*#/# $* /@65A)/
8+&:"#$%&6 +"&(:
ÞepLlc ulcer, gasLroesophageal reflux, gasLrlc cancer, blllary
LracL dlsease, food polsonlng, vlral gasLroenLerlLls, and
funcLlonal dyspepsla.
B&$, #/</%/ +"&(:
ÞerforaLed or peneLraLlng ulcer, pancreaLlc dlsease,
esophageal rupLure, rupLured aorLlc aneurysm, gasLrlc
volvulus, and myocardlal collc.
C++/% :"#$%*&($/#$&("5 D5//)&(::
ÞepLlc ulcer dlsease, esophageal varlces, Mallory-Welss Lear,
and arLerlovenous malformaLlons.

E"(":/9/($
E/)&6"5
F6A$/7 Cnce bleedlng occurs: conLlnuous lnfuslons of a
proLon pump lnhlblLor) as well as sucralfaLe suspenslon, 1 g
orally every 4 Lo 6 hours.
4,%*(&67 ÞÞls. SLop uslng nSAlus or lf noL posslble, use one
wlLh lowesL posslble Cl1 slde effecLs and reduce dose Lo as
low as posslble. Comblne nSAlu use wlLh prophylacLlc ÞÞl or
mlsoprosLol ln aL rlsk paLlenLs (over 63, pepLlc ulcer Px or
concurrenL Lherapy wlLh corLlcosLerolds or anLlcoagulanLs.
!" $%&'() eradlcaLlon may help.
>A%:&6"5
F6A$/7 Lndoscopy should be performed ln paLlenLs wlLh
cllnlcally slgnlflcanL bleedlng Lo look for LreaLable causes,
especlally sLress-relaLed pepLlc ulcers wlLh acLlve bleedlng or
vlslble vessels.
G&0/#$-5/
4,%*(&67 nSAlu/alcohol should be sLopped. 8educe sLress,
and avoldance of foods LhaL may exacerbaLe sympLoms:
splcy or acldlc food.

4*9+5&6"$&*(#
- 8leedlng: chronlc leadlng Lo anaemla or acuLe leadlng Lo
shock.
- uecreased quallLy of llfe: from paln, vomlLlng eLc.
- Some causes of gasLrlLls have an lncreased rlsk of dysplasla
leadlng Lo gasLrlc cancer: !" $%&'() lnfecLlon, MeneLrler's
dlsease, L1CP and chronlc gasLrlLls ln lLself.
1PL uAnuLnCnC uCSSlL8 2010
38
!"#$%&'("') +',-".
/"01,121$,
Carclnoma of oesophagus - squamous or adeno dependlng
on locaLlon/cell Lype

31#4 5'-2$.#
• uleL (smoked, plckled foods)
• Alcohol (whlskey)
• smoklng
• Achalasla
• CbeslLy
• 8eflux oesophaglLls +/- 8arreLs oesophagus

6'2&$%&7#1$)$(7
SlLe:
• 20° ln upper Lhlrd
• 30° ln mlddle
• 30° ln lower
nearly all Lsophageal Lumours are mallgnanL (99.93°)

8%19":1$)$(7
CulLe uncommon buL Lx18LMLL? LL1PAL
LoLs ln Asla and LasLern Lurope

;1(,# ',9 ;7:%2$:#
• uysphagla - sLarLs wlLh sollds, progresses Lo llqulds
• WelghL loss
• lf upper Lhlrd: hoarseness, cough

<,="#21('21$,#
8arlum Swallow

>','(":",2
Can occaslonally cuL lL ouL - eosophagecLomy

+$:%)1-'21$,#
Spread - local lymph nodes, lungs, llver, pleura, bone

?'#2.1- +',-".
/"01,121$, @AB +)'##101-'21$,
CasLrlc Carclnoma (adenocarclnoma of Lhe sLomach)

8%19":1$)$(7
Lspeclally common ln !apan, LasLern Lurope, Chlna, SouLh
Amerlca.
More common ln males

6'2&$%&7#1$)$(7 C#"" 6'2& ;D6EF
Cf sLomach cancers:
• 83° Adenocarclnomas
• 13° Lymphomas
2 1ypes:
• ulffuse: lndlvldual cells lnfllLraLe and Lhlcken Lhe
sLomach wall wlLhouL formlng a dlscreLe mass
o ! LlnlLls plasLlc (leaLher-boLLle
appearance, loss of dlsLenslblllLy)
• lnLesLlnal: More dlscreLe mass
o CfLen ulceraLed
8aslc prlnclples Lo know:
CasLrlc cancer can elLher be llke a slngle leslon (ofLen
relaLed Lo ulcer) or can presenL as a dlffuse Lhlckenlng of
Lhe gasLrlc wall (resulLs ln loss of ruggae and decreased
gasLrlc funcLlon)
31#4 5'-2$.#
• Þernlclous Anaemla
• P. Þylorl &Þuu
• ALrophlc CasLrlLls
• AdenomaLous Þolyps
• Lower soclal class
• Smoklng
• uleL (hlgh nlLraLe, hlgh salL, low vlL C) - drled,
salLed and smoked foods

;1(,# ',9 ;7:%2$:#
SympLoms:
• CfLen non-speclflc/none
• uyspepsla
• WelghL loss
• vomlLlng, dysphagla
• Anaemla
Slgns: - SuggesL laLe sLage
• LplgasLrlc mass, hepaLomegaly, [aundlce, asclLes
• vlrchows node enlargmenL

<,="#21('21$,#
CasLroscopy + 8lopsy. ALL ulcers should be blopsled


1PL uAnuLnCnC uCSSlL8 2010
39
!"#$%&' )*'+,'+
)+-*%*.*#% /01 !2,''*-*3,.*#%
Crohn's ulsease ls a focal collLls/llelLls causlng chronlc
dlarrhoea

45*6+7*#2#89
Þrevalence: 30-100/100,000 (less Lhan uC)

:*'; <,3.#"'

CeneLlc facLors are lmporLanL alLhough no gene has
been ldenLlfled. ÞresenLaLlon ls usually before Lhe age of
40

LxacerbaLlons of Crohn's dlsease are mulLlfacLorlal. CfLen
one cause cannoL be lsolaLed.
o Smoklng lncreases Lhe rlsk by 3-4x
o SysLemlc and resplraLory lnfecLlons have been
lmpllcaLed, along wlLh food senslLlvlLes and sLress
o 8elapses are mosL common ln sprlng and auLumn

=+.*#2#890!,>'+'0?,.$#5$9'*#2#89
Crohn's ulsease ls characLerlsed by chronlc Lransmural
granulomaLous lnflammaLlon caused by lnapproprlaLe
acLlvaLlon of Lhe lnnaLe lmmune sysLem by normal guL flora

lnlLlally medlaLed by neuLrophlls wlLh subsequenL 1-cell
acLlvaLlon and cyLoklne release
Leslons are focal and lsolaLed (sklp leslons)

Leslons are posslble LhroughouL Lhe Cl LracL, however
Lhe llleo-coecal [uncLlon and colon are mosL commonly
affecLed. MulLlple slLes may be lnvolved slmulLaneously.
o 1he recLum ls usually spared, compared wlLh uC
!"# % &'()#*+,*"- ". /%)#"()"+*) %-& /*)#"()"+*) +%,0"1"23
". 45 ('' 6%,07 4#"0-8( 5*('%('

@*8%' ,%6 @975.#7'
ÞaLlenLs wlLh Crohns dlsease presenL wlLh dlarrhoea,
abdomlnal paln and welgh loss. lever ls common.
ularrhoea rapldly follows consumpLlon of food, and ofLen
lncludes recLal blood, pus or mucus. A feellng of Lenesmus
can occur.
o 8leedlng ls less common Lhan ln uC
Abdomlnal paln ls collcky

SlLe and feaLures of Lhe paln depend on Lhe slLe of Lhe
leslons.

CfLen locaLed ln Lhe 8LC (llleocoecal valve) and may
mlmlc appendlclLls

SomeLlmes a palnful mass may be palpaLed over Lhe slLe
of lnflammaLlon
Crohn's dlsease ls assoclaLed wlLh exLra-lnLesLlnal
manlfesLaLlons less ofLen Lhan uC.

!olnL paLhology - ArLhralgla, SacrolllLls, Ankyloslng
spondyllLls

Lyes - uvelLls, con[uncLlvlLls

Cl - Call sLones, 8enal calcull

Skln
o LryLhema nordosum appear as palnful purpllsh
nodules over Lhe shlns, whlch leave brulses on
regresslon
o Þyoderma gangrenosum

Anal lnvolvemenL leads Lo addlLlonal exLernal sympLoms
o Skln Lags, anal flssures, flsLulas or abscesses

A%B+'.*8,.*#%'
ulagnosls ls usually made on colonoscopy and blopsy

Colonoscopy demonsLraLes frlablllLy, apLhous and llnear
ulcers, cobblesLone appearance wlLh pseudopolyps.
Serum ASCA (AnLl-saccharomyces cerevlslae anLlbodles) are
poslLlve ln 30°. Serum Albumln ls ofLen decreased, wlLh salL
and poLasslum wasLlng posslble.
Also exclude lnfecLlve causes (sLool MCS)

C,%,8+7+%.
Crohn's ulsease ls especlally prone Lo relapse, even wlLh
besL Lherapy.
AcLlve dlsease ls LreaLed wlLh aggresslve
lmmunosuppresslon

CorLlcosLerolds are admlnlsLered for 2 weeks, Lhen Lhe
dose ls Lapered
o Þrednlsolone

lmmunosuppressanLs are used ln paLlenLs wlLh frequenL
relapse or Lo reduce Lhe necessary sLerold dosage
o MeLhoLrexaLe, AzaLhloprlne

ModeraLe Lo Severe dlsease may be LreaLed wlLh 1nl-o
lnhlblLors
o lnfllxlmab
o 1hls Lherapy ls expenslve and only avallable lv, so lL ls
rarely used for malnLenance Lherapy

AnLlbloLlcs may be added Lo reduce bacLerlal load
o MeLronldazole, Sulphasalazlne

1herapy ls alded by bowel sparlng (le n8M) and parenLal
nuLrlLlon
MalnLenance Lherapy may conslsL of long Lerm lower dose
oral sLerolds or lmmunosuppresslon.
Surgery ls only lndlcaLed for compllcaLlons of Crohn's dlsease

!#752*3,.*#%'
Chronlc dlsease causes sLrlcLure of Lhe affecLed bowel, and
may progress Lo obsLrucLlon

1hls ofLen presenLs acuLely desplLe Lhe chronlc dlsease
course, as a secondary obsLrucLlon ls caused by bowel
spasm or lmpacLed bowel conLenLs.
llsLula formaLlon can occur wlLh Lhe bladder, ureLers, skln,
ad[acenL bowel or gynaecologlcal sLrucLures.

Commonly follow surglcal procedures, followlng surglcal
planes.
MalnuLrlLlon

812 ls normally absorbed ln Lhe Lermlnal llllum,
deflclency ls common ln llleo-coecal Crohn's ulsease
Colon cancer ls a hlgh rlsk afLer chronlc Crohn's ulsease
leadlng Lo lnLesLlnal dysplasla.
1PL uAnuLnCnC uCSSlL8 2010
60
!"#$%&'()$ +,"('(-
.$/(0('(,0 123 +"&--(/(#&'(,0
ulceraLlve CollLls ls a lnflammaLory collLls always sLarLlng
ln Lhe recLum and exLendlng proxlmally as Lhe dlsease
progresses

45(6$7(,",89
Þrevalence: 100-200/100,000 (more Lhan Crohn's)

:(-; <&#',%-

no slngle cause of uC has been ldenLlfled
o CeneLlc facLors are noL as lmporLanL as ln Crohn's
dlsease
o Smoklng ls proLecLlve for uC (cf Crohn's)
o SysLemlc and resplraLory lnfecLlons have been
lmpllcaLed, along wlLh food senslLlvlLles and sLress
o 8elapses are mosL common ln sprlng and auLumn

=$'(,",892+&>-$-2?&'@,5@9-(,",89
uC ls predomlnanLly a dlsease of Lhe large bowel

Caused by an abnormal acLlvaLlon of Lhe lnnaLe and
adapLlve lmmune sysLem by normal guL flora.
o Slmllar paLhogenesls Lo Crohn's ulsease

All dlsease sLarLs as procLlLls and exLends conLlnuously
and clrcumferenLlally wlLhouL sparlng
o 'lslands' of mucosa appear less affecLed and ralsed,
however dlsease ls sLlll presenL on blopsy.

uC paLhology never lnvolves Lhe small bowel, alLhough
Lhe dlsLal lleum may appear lnflamed due Lo
'backwash' llelLls - lnflammaLory medlaLors spreadlng
locally Lhrough Lhe bowel lumen.
uC dlsease course ls marked by dramaLlc exacerbaLlons
and asympLomaLlc remlsslon.

!"# % &'(( )*+,#-./-"0 "& 1#"++ %0) 2-+/"("3-,%( .%/2"("34
+** 5%/26 7(,*#%/-8* 9"(-/-+

A(80- &06 A975',7-
SympLoms of uC are very slmllar Lo Crohn's dlsease,
abdomlnal paln and bloody dlarrhoea wlLh promlnenL
urgency and Lenesmus

SLools generally conLaln more blood and mucus Lhan
Crohn's dlsease. Þus ls also common.

ularrhoea follows rapld LranslL of food.

Abdomlnal paln can be vague or locallsed Lo Lhe anus
or LLC
ulceraLlve collLls ls hlghly assoclaLed wlLh exLra-lnLesLlnal
manlfesLaLlons

Þrlmary Scleroslng CholanglLls
o noL assoclaLed wlLh Crohn's ulsease

ArLhropaLhles - Sacro-llelLls, Ankyloslng SpondyllLls,
large [olnL arLhralgla

Skln
o LryLhema nordosum
o Þyoderma Cangrenosum - ofLen appears before
colonlc sympLoms and follows an lndependenL
dlsease course

lrlLls and eplsclerlLls

B(-',%9 &06 4C&7(0&'(,0
lf relevanL - Cnly relevanL quesLlons Lo ask or slgns Lo
ellclL - no need for full Px/Lx

D0)$-'(8&'(,0-
uC ls dlagnosed by colonoscopy and blopsy

llndlngs Lyplcal of uC lnclude conLlnuous dlsLal colonlc
dlsease wlLh frlablllLy and pseudopolyps
70° of paLlenLs are p-AnCA poslLlve
Also exclude lnfecLlous dlsease (sLool MCS)

E&0&8$7$0'
AcLlve dlsease ls LreaLed wlLh aggresslve
lmmunosuppresslon

CorLlcosLerolds are admlnlsLered for 2 weeks, Lhen Lhe
dose ls Lapered
o Þrednlsolone glven orally or vla supposlLory

lmmunosuppressanLs are used ln paLlenLs wlLh
frequenL relapse or Lo reduce Lhe necessary sLerold
dosage
o MeLhoLrexaLe, AzaLhloprlne

AnLlbloLlcs may be added Lo reduce bacLerlal load
o MeLronldazole, Sulphasalazlne

1herapy ls alded by bowel sparlng (le n8M) and
parenLal nuLrlLlon
Surglcal managemenL ls common ln uC

8emoval of Lhe affecLed bowel may llmlL dlsease
spread

+,75"(#&'(,0-
CompllcaLlons of uC are very dlfferenL Lo Crohn's dlsease
ln advanced uC Lhe colon dllaLes and Lhe mucosa Lhlns

8lood loss can be slgnlflcanL, so monlLor fluld sLaLus

SlgnlflcanL dllaLlon (>6cm) consLlLuLes 1oxlc
Megacolon and ls an emergency
o Can be Lrlggered by elecLrolyLe abnormallLles or
narcoLlcs. Cccurs as Lhe muscle layer of Lhe bowel
ls affecLed, lnhlblLlng conLracLlon.
o Pas a hlgh rlsk of secondary perforaLlon and
perlLonlLls. ÞerforaLlon occaslonally occurs wlLhouL
prlor dllaLlon.
uC ls a Lhrobophylllc sLaLe, so paLlenLs are ofLen anLl-
coagulaLed, especlally whllsL ln hosplLal
ÞaLlenLs wlLh uC have a greaLly elevaLed rlsk of colonlc
cancer
o 8e alerL Lo any sLenosls or sLrlcLure - Lhls cannoL be
explalned by Lhe dlsease process
1PL uAnuLnCnC uCSSlL8 2010
61
!""#$%&'&(&)
*#+&$&(&,$ ./0 123))&+&'3(&,$
AcuLe appendlclLls resulLs from an acuLe lnflammaLlon of
Lhe appendlx and creaLes Lhe mosL common abdomlnal
surglcal emergency.
(Chronlc appendlclLls occurs wlLh an lncldence of 1° and
ls deflned by Lhe followlng: (1) Lhe paLlenL has a hlsLory of
8LC paln of aL leasL 3 weeks' duraLlon wlLhouL an
alLernaLlve dlagnosls, (2) afLer appendecLomy, Lhe paLlenL
experlences compleLe rellef of sympLoms, (3)
hlsLopaLhologlcally, Lhe sympLoms were proven Lo be Lhe
resulL of chronlc acLlve lnflammaLlon of Lhe appendlceal
wall or flbrosls of Lhe appendlx.)

4"&%#5&,2,67
AcuLe appendlclLls ls a very common condlLlon, wlLh 7° of
Lhe populaLlon havlng undergone appendesecLomy for
appendlclLls. lncldence gradually rlses from blrLh, peaks ln
Lhe laLe Leen years, and gradually decllnes. 1he medlan
age aL appendecLomy ls 22 years.

8&)9 :3'(,;)
• Low flbre dleL
• 8elng male (M:l of 1.4:1)

!#(&,2,67/13<)#)
CbsLrucLlon of Lhe appendlceal lumen ls Lhe prlmary
cause of appendlclLls.
An anaLomlc bllnd pouch, obsLrucLlon of Lhe appendlceal
lumen by elLher faecollLhs or lymphold hyperplasla leads
Lo dlsLenslon of Lhe appendlx due Lo accumulaLed
lnLralumlnal fluld. lneffecLlve lymphaLlc and venous
dralnage allows bacLerlal lnvaslon of Lhe appendlceal wall
and, ln advanced cases, perforaLlon and splllage of pus
lnLo Lhe perlLoneal cavlLy.

=&6$) 3$% =75"(,5)
1he classlc hlsLory of anorexla and perlumblllcal paln
followed by nausea, rlghL lower quadranL (8LC) paln, and
vomlLlng occurs ln only 30° of cases. AcuLe appendlclLls
has many dlfferenL presenLaLlons buL progresslon of
sympLoms and
slgns ls Lhe rule ln conLrasL Lo Lhe flucLuaLlng course of
some oLher dlseases.
LxamlnaLlon can show locallsed Lenderness Lo one-flnger
palpaLlon and perhaps sllghL guardlng. 8ebound or
percusslon Lenderness may also be ellclLed aL Mc8urney's
polnL.
ln Lhe absence of perforaLlon LemperaLure ls llkely Lo only
be sllghLly elevaLed.

>$?#)(&63(&,$)
l8L - W8C counL averages 13.0 usually predomlnanLly a
neuLrophllla. A normal l8L does nC1 however exclude
Lhls dlagnosls.
C8Þ - usually elevaLed
C1 Abdomen - hlgh dlagnosLlc accuracy, also vlsuallses
compllcaLlons (eg perforaLlon) well
uS - qulck and cheap, also wlLh good dlagnosLlc accuracy

@3$36#5#$(
=<;6&'32 - surglcal managemenL ls nearly always
lndlcaLed, lnvolvlng appendlsecLomy. lL can be performed
elLher open or laparoscoplcally.

1,5"2&'3(&,$)
A#;+,;3(&,$ - generally a resulL of delay ln seeklng
LreaLmenL. lL ls unusual for Lhe acuLely lnflamed appendlx
Lo perforaLe wlLhln Lhe flrsL 12 hours
A#;&(,$&(&) - local perlLonlLls resulLs from mlcroscoplc
perforaLlon of a gangrenous appendlx, whlle more
wldespread perlLonlLls generally lmplles gross perforaLlon
lnLo Lhe free perlLoneal cavlLy.
!""#$%&'#32 3B)'#)) - occurs when perlappendlceal
lnfecLlon 2
o
Lo appendlceal perforaLlon becomes walled
off by omenLum and ad[acenL vlcera.
1PL uAnuLnCnC uCSSlL8 2010
62
!"#$%#&"'( *+%#,-.#&/"
0$1&"&#&/"
ÞarLlal or compleLe blockage of Lhe bowel LhaL resulLs ln
Lhe fallure of Lhe lnLesLlnal conLenLs Lo pass Lhrough.
2('%%&1&.'#&/"
CbsLrucLlon may be !"#$% (hours) or "&'()*" (weeks),
,*-./% (blood supply noL compromlsed) or ,$'!)0#/!$%1
(blood supply compromlsed). lL can also be classlfled
anaLomlcally as ,-!// bowel or /!'0% bowel obsLrucLlon.
CbsLrucLlon may also be classlfled as -%"&!)*"!/ (physlcal
obsLrucLlon) or as */%#, (absenL perlsLalsls, no sLrucLural
obsLrucLlon). 2,%#1(3(4,$'#"$*() resembles a mechanlcal
obsLrucLlon buL has no acLual physlcal obsLrucLlon.

3&%4 5'.#/,%
• Þrevlous abdomlnal surgery
• Crohn's dlsease

6$#&/(/7892'-%$%
LxLramural
• 6:;$%&/"s, bands, </(<-(-%= ;$,"&'%,
compresslon by pelvlc Lumour
lnLramural
• SLrlcLures (Crohn's dlsease), #->/-,% (uC nC1
MlSS), lymphomas, sLrlcLures, paralyLlc lleus,
mesenLerlc arLery lschaemla, &"#-%%-%.$?#&/"=
lnfecLlons
lnLralumlnal
• laecal lmpacLlon, bazoar (ball of lngesLed forelgn
maLerlal), gallsLone lleus

@'#;/?;8%&/(/78
• 8owel dlsLal Lo obsLrucLlon collapses
• 8owel proxlmal Lo obsLrucLlon dlsLends (due Lo
swallowed alr and accumulaLlng lnLesLlnal secreLlons)
and becomes hyperacLlve.
• 8owel wall becomes oedemaLous, fluld and
elecLrolyLes accumulaLe ln wall and lumen
• 8acLerla prollferaLes ln obsLrucLed bowel
• lnLramural vessels are sLreLched as wall dlsLends
• Compromlsed blood supply leads Lo lschaemla,
necrosls, perforaLlon

A&7"% '": A8>?#/>%
• vomlLlng/laecal vomlLlng
• Collc
• ConsLlpaLlon
• Abdomlnal dlsLenslon

B&%#/,8
• ConsLlpaLlon (absoluLe: no faeces or flaLus)
• nausea/vomlLlng (vomlLlng Lends Lo be S8C)
• SlLe of abdomlnal paln (cenLral or lower?)
• naLure of paln: crampy, collcky

CD'>&"'#&/"
• Þyrexla (sepLlc, bowel sLrangulaLed)
• ÞerlLonlsm/very lll: suspecL bowel sLrangulaLlon
• 8reaLh odo,
• vlslble perlsLalsls
• AcLlve Llnkllng bowel sounds
• AbsenL bowel sounds suggesL lleus
• PypoLenslon, Lachycardla
• uehydraLlon: loss of skln Lurgor, ollgurla
• LmpLy recLum on Þ8

!"<$%#&7'#&/"%
• l8L (Pb and ÞCv elevaLed due Lo dehydraLlon, wcc
may be elevaLed as well)
• uLC (urea elevaLed, low na and Cl)
• Cx8 (elevaLed dlaphragm)
• Ax8 (gallsLones, characLerlsLlc paLLerns of volvulus,
gas proxlmal Lo obsLrucLlon, hernlas, gas ln bowel
wall lndlcaLes gangrene) S8C >3cm, L8C >3cm
• WaLer soluble CasLrografln follow-Lhrough
(LherapeuLlc)
• Slngle conLrasL C1 scan
• Colonscopy/slgmoldoscopy (danger of perforaLlon)


E'"'7$>$"#
E$:&.'(
• uecompress obsLrucLed guL: nasogasLrlc Lube
• lv flulds
• lv anLlbloLlcs ln suspecLed lschaemla
• MonlLor fluld balance, urlnary caLheLer
• AnLl-emeLlcs
• Analgesla
A-,7&.'(
• Surgery for sLrangulaLlon or 'closed loop obsLrucLlon'
• Surgery as lndlcaLed: colon carclnoma, hernla eLc

2/>?(&.'#&/"%
• LlecLrolyLe dlsLurbances
• uehydraLlon
• 8esplraLory compromlse from abdomlnal dlsLenslon
• AsplraLlon of
vomlL
• 8owel
lschaemla
• F/G$(
?$,1/,'#&/"
Ax8 demonsLraLlng
S8C wlLh mulLlple
alr fluld levels.
1PL uAnuLnCnC uCSSlL8 2010
63
!"#$%&'(# *+,&-
.&/(0(1(+0 234 5-%""(/(#%1(+0
lschaemlc 8owel ls a serlous condlLlon of several dlfferenL
aeLlologles whlch lnvolves lnadequaLe perfuslon of Lhe
organs of Lhe Cl1 LracL, whlch can lead Lo gangrene,
perforaLlon and sepsls.
lL can be elLher chronlc or acuLe.

67(8&'(+-+9:
A dlsease of Lhe older populaLlon, lL rarely presenLs ln Lhe
under 60 age group.

;("< =%#1+>"
• Any rlsk facLors for aLherosclerosls
• Cardlovascular dlsease
• lncreased age
• vascullLldes or oLher auLolmmune dlseases
• Þrevlous Lhromboembollc dlsease

?&1(+-+9:35%@"&"
AcuLe 8owel lschaemla ls caused by elLher embollc,
LhromboLlc or non-occulslve paLhologles (and any dlsease
whlch affecL arLerles elsewhere ln Lhe body can affecL Lhe
arLerles of Lhe Cl1) .

Lmboll are usually Lhe resulL of a dlslodged cardlac
Lhrombus, Lhrombl are usually arLerlal and occur due Lo
worsenlng of chronlc aLheroscleroLlc dlsease. non-
occluslve dlsease ls due Lo prolonged vasoconsLrlcLlon,
usually secondary Lo sepsls and shock.

Chronlc sLenosls or occluslon of Lhe cellac or superlor
mesenLerlc arLerles ls caused by aLherosclerosls ln Lhe
vasL ma[orlLy of cases wlLh vascullLls (eg. SLL, 1akayasu's
dlsease) belng Lhe second mosL common.

uecreased lnLesLlnal blood from any of Lhe
abovemenLloned flow resulLs ln lschemla and subsequenL
reperfuslon damage aL Lhe cellular level LhaL may
progress Lo Lhe developmenL of mucosal ln[ury, Llssue
necrosls, and meLabollc acldosls.
mechanlsms. uecreased lnLesLlnal blood flow resulLs ln
lschemla and subsequenL reperfuslon damage aL Lhe
cellular level LhaL may progress Lo Lhe developmenL of
mucosal ln[ury, Llssue necrosls, and meLabollc acldosls.

A(90" %08 A:'71+'"
• ÞosLprandlal Þaln
• lear of eaLlng
• WelghL loss
• LplgasLrlc brulL
• Þaln ouL of proporLlon Lo physlcal flndlngs

B("1+>: %08 6C%'(0%1(+0
Maln complalnL ls one of posLprandlal abdomlnal paln
(abdomlnal or vlsceral anglna) whlch appears 13-30
mlnuLes afLer a meal. 1he paln occurs as a seep-seaLed
sLeady ache ln Lhe eplgasLrlum. vomlLlng and dlarrhoea
may occur
WelghL loss occurs from a relucLance Lo eaL ln chronlc
cases.

!0D&"1(9%1(+0"
LaboraLory sLudles are generally non-speclflc and are of
llLLle use deflnlLely rullng ln or ouL lschaemlc bowel
however:
73° of paLlenLs wlLh lschaemlc bowel have a WCC of
>13,000
Serum lacLaLe levels are elevaLed (buL Lhls ls generally a
laLe slgn)
Abdomlnal anglography ls Lhe gold sLandard for dlagnosls,
showlng fllllng defecLs or compleLe occluslon of Lhe Cl1
vessels.
C1 abdomen ls however useful ln very unsLable paLlenLs -
anglography ls a very lnvaslve procedure

E%0%9&'&01
E&8(#%- - ln sub-acuLe lschaemla (nC perlLonlLls),
supporLlve Lherapy, bowel resL and nasogasLrlc asplraLlon
can asslsL ln allevlaLlng sympLoms. Medlcal managemenL
ls also lndlcaLed ln paLlenLs wlLh acuLe vasculaLls as Lhe
underlylng cause - hlgh-dose sLerolds and
lmmunosuppresslve agenLs used.
A@>9(#%- F surglcal revascularlsaLlon of Lhe superlor
mesenLerlc and cellac axls ls lndlcaLed when Lhe
obsLrucLlon ls aLheroscleroLlc, wlLh elLher endarLerecLomy
or grafL replacemenL. Þ1A (percuLaneous Lranslumlnal
angrloplasLy) and sLenLlng has galned accepLance as an
alLernaLlve form for Lherapy for boLh chronlc and acuLe
mesenLerlc lschaemla.

5+'7-(#%1(+0"
1hese lnclude perlLonlLls, sepsls, perforaLlon and deaLh.
WlLhouL lnLervenLlon for aLheroscleroLlc vlsceral arLery
lnsufflclency deaLh wlll occur from lnanlLlon or masslve
bowel lnfarcLlon.

1PL uAnuLnCnC uCSSlL8 2010
64
!"#$%&"'()*% !",$*,$
!$-"."&"/. 012 3)*,,"-"'*&"/.
ulverLlcular dlsease ls a condlLlon ln whlch mulLlple
mucosal-llned pouches are formed when small mucosal
hernlaLlons proLrude Lhrough Lhe lnLesLlnal layers and Lhe
smooLh muscle along Lhe naLural openlngs creaLed by Lhe
vasa recLa or nuLrlenL vessels ln Lhe wall of Lhe colon. 1hls
ls Lermed dlverLlculosls. 1hese mosL frequenLly affecL Lhe
slgmold colon.
When Lhese pouches become fllled wlLh faecal maLLer
and lnfecLed lL ls referred Lo as dlverLlculLls.

45"6$7"/)/89
ln wesLern counLrles approxlmaLely 30° of people
develop dlverLlcular dlsease, yeL abouL 80° of Lhese
people wlll remaln asympLomaLlc.

:",; <*'&/%,
• Low flbre dleL
• lncreaslng age

=$&"/)/8913*(,$,
1he paLhogenesls of dlverLlcula requlres defecLs ln Lhe
colonlc wall and lncreased pressure ln Lhe lumen relaLlve
Lo Lhe serosal surface leadlng Lo Lhe formaLlon of Lhe
mucosal hernlaLlons.

ulverLlcullLls forms when
• lecal maLerlal or undlgesLed food parLlcles cause
an obsLrucLlon wlLhln Lhe dlverLlcula.
• 1hls resulLs ln dlsLenslon of Lhe dlverLlcula
secondary Lo mucous secreLlon and overgrowLh
of normal colonlc bacLerla.
• vascular compromlse and subsequenL
mlcroperforaLlon or macroperforaLlon Lhen
ensue.
When Lhe lnfecLlon exLends Lhrough Lhe wall of Lhe colon
lnLo Lhe perldlverLlcular Llssue lL becomes cllnlcally
slgnlflcanL, leadlng Lo locallsed lnflammaLlon ln Lhe
colonlc wall or paracollc Llssues. 1hls may lead Lo serlous
compllcaLlons lncludlng abscess formaLlon or perlLonlLls.







>"8., *.6 >975&/7,
ulverLlculosls ls an asympLomaLlc condlLlon.
ulverLlcullLls however presenLs wlLh
• AcuLe abdomlnal paln
• LefL Lower CuadranL Lenderness and mass
• lever and leukocyLosls

?",&/%9 *.6 4@*7".*&"/.
An acuLe aLLack of dlverLlcullLls presenLs wlLh locallsed
abdomlnal paln LhaL ls mlld Lo sever, achlng and elLher
sLeady or cramplng, lL ls slmllar Lo appendlclLls excepL
belng ln Lhe LLC raLher Lhan Lhe 8LC. ConsLlpaLlon or
dlarrhoea may resulL, and lnflammaLlon ad[acenL Lo Lhe
bladder may produce dysurea. CcculL or (more
lnfrequenLly) gross blood can be presenL ln sLools.

A.#$,&"8*&"/.,
Ax8 - can show free gas ls a dlverLlculum has perforaLed
lnLo Lhe general perlLoneal cavlLy.
C1 - lnvesLlgaLlon of cholce wlLh conLrasL, lL ls able Lo
demonsLraLe effacemenL of perlcollc faL and
compllcaLlons such as abscess or flsLula.
Colonoscopy ls performed one week afLer an acuLe aLLack,
and ls mandaLory lf Lhere was any bleedlng.

B*.*8$7$.&
B$6"'*) - hosplLallsaLlon may be requlred for acuLe
aLLacks. nll by mouLh, nasogasLrlc sucLlon, feeds slowly
relnLroduced wlLh lv flulds and broad-specLrum Abx
>(%8"'*) - Cecal dlverLlcullLls ls usually LreaLed by rlghL
colecLomy. lmmedlaLe operaLlon ls requlred for spreadlng
or generallsed perlLonlLls. LlecLlve surglcal opLlons
lncludlng prlmary resecLlon wlLh anasLomosls and prlmary
resecLlon wlLhouL anasLomosls are some of Lhe deflnlLlve
LreaLmenL opLlons.

C"-$,&9)$ - LaL more flbre! (once Lhe acuLe aLLack ls over)

3/75)"'*&"/.,
-Þerlcollc abscess formaLlon when faL sLrandlng lsolaLes
lnfecLlon from mlcroperforaLlons Lhrough Lhe colon
-llsLula formaLlon (bowel Lo bladder, Lo bowel, Lo vaglna,
Lo abdomlnal wall eLc.)
- 8upLure - lncreased pressure ln Lhe dlverLlulum can
cause acuLe rupLure and spllllng of abdomlnal conLenLs
lnLo Lhe perlLoneum.
1PL uAnuLnCnC uCSSlL8 2010
63
!"#"$%&'(# !(*&%$
+%,-*-'-"* ./0 !#(11-,-&('-"*
Cancerous growLh ln colon, recLum or appendlx.
8lse from adenomaLous polyps.

23-4%5-"#"67
2
nd
mosL common cancer ln AusLralla (noL 2
nd
hlghesL
morLallLy)

8-19 :(&'"$1
• lamlly Px , lnflammaLory bowel dlsease
• Speclflc geneLlc syndromes (6°) - lead Lo polyp
growLh
o PnÞCC - auLosomal domlnanL muLaLlon
ln unA mlsmaLch gene (3° of C8C)
o lAÞ - auLosomal domlnanL muLaLlon ln
AÞC Lumour suppressor gene (1° of
C8C)
• Age, hx of polyps, uleL (hlgh calorle, low flbre,
burnL/smoked meaL) lack of exerclse, obeslLy,
smoklng, alcohol
• S18LSS (nearly doubles rlsk)

;('<"3<71-"#"67
Adenocarclnomas - cancer LhaL orlglnaLes ln glandular
Llssue

Þrocess: (sLeps are usually lnlLlaLed by geneLlc muLaLlons,
see plcLure below)
• 1) Þolyps grow (2 forms - hyperplaslc,
adenomaLous)
o 1° of polyps ! cancer
o 3-40° of adenomaLous polyps ! cancer
(mosL common)
• 2) Þolyps conLlnue Lo grow and become
adenoma - benlgn Lumour
• 3) Adenoma acqulres more geneLlc defecLs !
Carclnoma
• 4) Carclnoma grows, once beyond muscularls
mucosae, reaches 8v and lymph ! meLasLasls

CeneLlc MuLaLlons:
• AÞC 1umour suppressor gene - ofLen responslble
for sLep 1 (normal Lo polyp)
o ln > 80° of adenomaLous polyps
o ! lncreased cell prollferaLlon and
lnhlblLlon of apopLosls
• k-8as ÞroLooncogene
muLaLlon - SLep 2 (polyp
Lo adenoma)
• Þ33 1umour suppressor
Cene - SLeps 3 and 4
(adenoma Lo carclnoma
and meLasLasls)
o lnvolved ln lnvaded surroundlng Llssues


=-6*1 (*4 =753'"51
• CfLen few Sx
• 8ecenL and perslsLenL change ln bowel hablL
• Anaemla
• Abdo paln
• leacal urgency - Lumour ln recLum mlmlcs sLool,
• Þ8 bleedlng

>*?%1'-6('-"*1
• lecal CcculL 8lood 1esL (lC81)
o Screenlng for blood ln sLool
• Colonoscopy & 8lopsy - gold sLandard
o 8epeaLed afLer surgery as follow up
every 3 years
• CLA anLlgen levels can be used (usually Lo deLecL
recurrence)

@(*(6%5%*'
=A$6-&(#
Surglcal 8esecLlon of affecLed bowel
- 1emporary sLoma unLll re[olned bowel has
Llme Lo heal
Some may need permanenL sLoma

@%4-&(#
ConservaLlve, palllaLlve

='(6-*6 B +A9%1 (also use 1nM)
ueflnlLlon - MeLasLases 3 ?ear Survlval
°
SLage 0 1umour llmlLed Lo mucosa -
SLage l 1umours lnvade up Lo
muscularls proprla
80-90°
SLage ll 1umours lnvade
Subserosa/ad[acenL Llssue
72-83°
SLage
lll
Any degree of bowel wall
perforaLlon and 1-3 reglonal
lymph node lnvolvemenL.
33-42°
SLage 4 lnvaslon of bowel wall wlLh
and slgns of dlsLanL
meLasLases
3-7°

!"53#-&('-"*1
Common slLes of meLasLases: Lymph nodes, Llver, Lungs


1PL uAnuLnCnC uCSSlL8 2010
66
!"#$%&
(")%$%*%+$ ,-. /0&11%)%2&*%+$
• Pernla= proLruslon of an organ Lhrough Lhe wall of Lhe
cavlLy ln whlch lL ls normally conLalned. Pernlal sac can
be dlvlded lnLo, neck, body and fundus.
• 8educlble P=Lhe ablllLy Lo reLurn Lhe conLenLs of Lhe
hernla lnLo Lhe abdomlnal cavlLy, elLher sponLaneously
or manually.
• lncarceraLed or lrreduclble P= no longer reduclble,
vascular supply of Lhe bowel noL compromlsed, bowel
obsLrucLlon ls common.
• SLrangulaLed P= occurs when Lhe vascular supply of Lhe
bowel ls compromlsed secondary Lo lncarceraLlon of
hernla conLenLs.

34%5"6%+0+78
• MosL common (boLh m/f) hernla ls Lhe lngulnal
hernla, of whlch Lwo-Lhlrds are lndlrecL.
• lngulnal hernlas are more common ln males

9%1: ;&2*+#1-2&<1"1
• Abdomlnal weakness (age, malnuLrlLlon)
• Þrevlous Px
• lncreased abdo pressure (sLralnlng whllsL
defecaLlng, coughlng, heavy llfLlng)
• CondlLlons LhaL chronlcally lncrease abdo
pressure (CCÞu, AsclLes, 8ÞP)
• lPx
• Smoklng

=&*>+4>81%+0+78
• lemoral= hernla Lhrough Lhe femoral canal whlch ls a
conLlnuum of femoral sheaLh. Assoc. w/ ^lAÞ
• ulrecL lngulnal= ÞroLruslon of hernlal sac occurrlng
dlrecLly Lhrough Lhe Lransversalls fascla and posLerlor
wall of Lhe lngulnal canal, medlal Lo Lhe lnferlor
eplgasLrlc vessels. 8esulLs from acqulred deflclency ln
Lransverse abdomlnls muscle.
• lndlrecL= Lhrough deep lngulnal rlng wlLh coverlngs of
Lhe spermaLlc cord, followlng Lhe paLh of Lhe lngulnal
canal. 8esulLs from Lhe fallure of deep lngulnal rlng Lo
close afLer LesLes have descended. lound laLeral Lo
lnferlor eplgasLrlc vessels.
• umblllcal=congenlLal malformaLlon ln klds
• CbLuraLor=Lhrough obLuraLor foramen, rare, presenLs
wlLh bowel obsLrucLlon.
• lnclslonal= laLrogenlc hernla occurlng ln abdomlnal
surgerles due Lo breakdown of Lhe fasclal closure of
prlor surgery.


!%1*+#8 &$5 3?&6%$&*%+$
-ueduce PCÞC, lncludlng lf sLandlng, llfLlng or coughlng
makes Lhe lump dlsappear or more promlnenL as would
be Lhe case of a hernla.
-LxamlnaLlon should be done wlLh Lhe pL suplne and
sLandlng, ± manoeuvres. WlLh Lhe pL sLandlng, observe lf
lump ls above (lngulnal P) or below (femoral P) Lhe
lngulnal llgamenL crease, also lngulnal ls above and
medlal Lo publc Lubercle. WlLh pL suplne, geL Lhem Lo
cough whllsL pushlng over lnLernal lngulnal rlng and lf
hernla appears medlally lL's more llkely Lo be a dlrecL
lngulnal hernla.
-Zleman's LrldlglLalexam(pL sLandlng): mlddle flnger along
lngulnal llgamenL wlLh Llp ln exLernal lngulnal rlng, lndex
over lnLernal lngulnal rlng, and rlng flnger over femoral
canal and openlng of saphenous veln and geL pL Lo bear
down/sLraln. A hernlaLlng mass felL whllsL closlng lnLernal
rlng cannoL be lndlrecL.
CLher posslble flndlngs wlLh cerLaln Lypes of hernlas:
• lncarceraLed - paln, nausea, vomlLlng, consLlpaLlon
• SLrangulaLed - above plus posslble sepsls, paln perslsLs
afLer reducLlon
• lemoral - medlal Lhlgh and groln paln

@$A"1*%7&*%+$1
l8L - ^W8CC ln sLrangulaLlon
uLC - assess hydraLlon ln vomlLlng pLs
Abdo x-ray - posslbly plck up S8C or parLs of bowel
ouLslde of Lhe cavlLy
uS - dlfferenLlaLlng masses/LesLlcular causes, lf Lx ls poor
due Lo pL body hablLus

B&$&7"6"$*
B"5%2&0 C analgesla lf needed, Abx lf lschemlc bowel
suspecLed, reducLlon lf posslble

D<#7%2&0 E>"#$%+##>&4>8F C hernloLomy!lnLesLlne or
oLher Llssue ls placed back lnslde Lhe abdomen!defecL
repalred and relnforced wlLh synLheLlc mesh or suLure Lhe
abdomlnal muscle Llssue back LogeLher. lL can be done
laproscoplcally.

G%)"1*80" - reduce unnecessary lncreaslng of
lnLraabdomlnal pressure

/+640%2&*%+$1
• ConsLlpaLlon, nausea/vomlLlng, or paln from
obsLrucLed bowel
• lschemla/necrosls from bowel sLrangulaLlon
• Pydrocele
• Paemorrhage/perforaLlon
• Sepsls

1PL uAnuLnCnC uCSSlL8 2010
67
!"#$%&'$%$(
*"+$'$%$&'
lnflammaLlon of perlLoneum

,-.(($+$/.%$&'
Locallsed: ofLen some degree of locallsed perlLonlLls wlLh
acuLe lnflammaLory condlLlons of Cl1
Cenerallsed: lrrlLaLlon of perlLoneum due Lo lnfecLlon or
chemlcal lrrlLaLlon

*$++"#"'%$.- *$.0'&($(
• AcuLe pancreaLlLls
- Causes slmllar slgns and sympLoms, however lL
does noL requlre a laparoLomy
- Check serum amylase

,.1("(
Locallsed perlLonlLls: appendlclLls, cholecysLlLls,
dlverLlcullLls, salplnglLls

Cenerallsed perlLonlLls:
SponLaneous bacLerlal perlLonlLls (S8Þ), perforaLlon of
pepLlc ulcer, dlverLlculum, appendlx, bowel or gall bladder

!.%2&324($&-&04
!#$5.#4 3"#$%&'$%$(6
• PaemaLogenous dlssemlnaLlon, usually ln
lmmunocompromlsed paLlenLs e.g. S8Þ (almosL
excluslvely ln paLlenLs wlLh asclLes from chronlc
llver dlsease)
• Commonly L. Coll, klebslella and enLerococcl

7"/&'8.#4 3"#$%&'$%$(6
uue Lo perforaLlon, Lrauma or posL-operaLlve

lrrlLaLlon or perlLoneum ls due Lo:
1. lnfecLlon e.g. perforaLlon of lnflamed appendlx
2. Chemlcal lrrlLaLlon e.g. leaklng of gasLrlc conLenLs
from perforaLed pepLlc ulcer (superadded
lnfecLlon gradually occurs)

ÞerlLoneal cavlLy becomes acuLely lnflamed - producLlon
of lnflammaLory exudaLes LhaL spreads LhroughouL Lhe
perlLoneum - lnLesLlnal dllaLaLlon and paralyLlc lleus

9$(%&#4 .'8 :;.5$'.%$&'
1enderness, rebound / percusslon Lenderness
8oard-llke abdomlnal rlgldlLy
Cuardlng
Lylng sLlll or prosLraLlon
ÞoslLlve cough LesL
AbsenL bowel sounds
Shock

<55"8$.%" =.'.0"5"'%
>"(1(/$%.%$&'
nasogasLrlc Lube, lv flulds, anLlbloLlcs

71#0"#4
ÞerlLoneal lavage of abdomlnal cavlLy
Speclflc LreaLmenL of underlylng condlLlon

<'?"(%$0.%$&'(
@A:6 lnfecLlon
A-&&8 /1-%1#"(
!"#$%&'".- +-1$8 .'.-4($(: pP, glucose, proLeln, lacLaLe
dehydrogenase (LuP), cell counL, Cram sLaln, and aeroblc
and anaeroblc culLures
:#"/% ,B>: deLecL free alr under dlaphragm (perforaLlon)
7"#15 .54-.(": dlagnose acuLe pancreaLlLls
u/S or C1: check for abscesses

!"# %&'%#'(') %(**+#, -./.
01
!"#$%&'($#)(*
1PL uAnuLnCnC uCSSlL8 2010
69
!"#$%&'() +,- !"#$%('() ./,-%&0"
!"#$%&'()

1"2(,('(&, 3 45+66(2()+'(&,
kldney ulsease wlLh:
• ÞroLelnurla
• Pypoalbumnemla
• Cedema
• Pyperllpldemla
Classlfled as Þrlmary or Secondary

7"'(&5&8/94+:6"6
Þrlmary nephrosls
• Mlnlmal change nephropaLhy
• local glomerulosclerosls,.
Secondary nephrosls
• uM
• SLL
• Amyloldosls
• Pep 8,C, Plv,.

;+'$&#$/6(&5&8/
Pypoalblnurla - due Lo loss of proLelns
ÞroLelnurla - sLrucLural damage Lo 8M
Pyperllpldemla - low serum albumln causes lncreased
synLhesls of llpoproLelns

.(8,6 +,- ./0#'&06
• loamy urlne
• Cedema

<,="6'(8+'(&,6
ºSee Cn dlsease summary"

>+,+8"0",'
• uleLary - low na lnLake, normal proLeln lnLake
• 1hlazlde dlureLlcs - monlLor k closely
• AnLlcoagulanLs lf necessary
• ACL lnhlblLors/ A11 used for anLlproLelnurlc
properLles

4&0#5()+'(&,6
• Pypercoaguable sLaLe - due Lo loss of cloLLlng
facLors ln urlne
• Sepsls - due Lo loss lf lg() ln Lhe urlne



!"#$%('()

1"2(,('(&, 3 45+66(2()+'(&,
kldney ulsease wlLh:
• PaemaLurla
• ÞroLelnurla
• PyperLenslon
• Cedema

7"'(&5&8/94+:6"6
• ClomerulonephrlLls

;+'$&#$/6(&5&8/
ºSee Cn dlsease summary"

.(8,6 +,- ./0#'&06
• PaemaLurla
• loamy urlne (lndlcaLlve of proLelnurla)
• Cedema
• PLn
• laLlgue

<,="6'(8+'(&,6
ºSee Cn dlsease summary"
>+,+8"0",'
ºSee Cn dlsease summary"

1PL uAnuLnCnC uCSSlL8 2010
70
!"#$% '%()* +),*#-%

.%/,(,$,0( 123 4*)55,/,")$,0(

AbrupL, usually reverslble, decllne ln renal funcLlon over a
perlod of days or weeks. Cllnlcally Lhese paLlenLs have
uraemla, and usually ollgurla. ÞaLlenLs wlLh C8l may
presenL wlLh AcuLe on C8l. May be due Lo pre-renal,
lnLrlnslc or posL renal causes.


!%$,0*06724)#5%5

Þrerenal: lmpalred perfuslon of Lhe kldneys. 1hls resulLs
from hypovolaemla, hypoLenslon, vascular dlsease
llmlLlng flow, lmpalred cardlac efflclency or a comblnaLlon
of Lhe aforemenLloned. AuLoregulaLlon of renal perfuslon
pressure helps Lhe kldneys malnLaln Cl8 Lo a polnL, afLer
whlch Cl8 sharply drops off and uraemla develops. ACL
lnhlblLors and nSAlus, whlch meddle wlLh auLoregulaLlon,
lncrease chances of geLLlng prerenal uraemla.
ÞosLrenal: CbsLrucLlon of Lhe urlnary LracL anywhere
along lLs paLhway. Won'L go lnLo lL here buL preLLy much
sLones, Lumours, prosLaLe sum lL up.
lnLrlnslc:
- vascular - Lmboll, vascullLls, eLc. PaemolyLlc uraemlc
syndrome, ulC, 11Þ.
- Clomerular - CoodpasLure, Wegener's, lmmune
complex Cn.
- 1ubular - lschaemla, cuLoLoxlns (heme, drugs (llLhlum,
amlnoglycosldes, conLrasL))
- lnLersLlLlal - lnfecLlon (pyelonephrlLls), SysLemlc (SLL,
leukaemla, lymphoma), urugs (penlcllllns,
cephalosporlns, nSAlus, ÞÞls, eLc)

8)$90:975,0*067

8efer Lo Lhe dlfferenL causes for speclflc paLhophyslology.
ln Lerms of Lhe decllne ln renal funcLlon lL ls usually due Lo
elLher a decrease ln perfuslon or damage Lo Lhe
parenchyma.

;,6(5 )(< ;7=:$0=5

;,6(5

- Pyperkalaemla
- MeLabollc acldosls
- PyponaLraemla (waLer overload)
- Þulmonary oedema (waLer overload)
- Pypocalcaemla
- PyperphosphaLemla

;7=:$0=5

- Anorexla
- nausea/vomlLlng
- ÞrurlLus
- urowslness
- llLs
- Coma
- Paemorrhaglc eplsodes

>(?%5$,6)$,0(5

Alm ls Lo Lry Lo flgure ouL wheLher Lhe cause ls pre,
lnLrlnslc or posL.

lnserL a caLheLer Lo deLermlne lf lL's obsLrucLlve, ln
comblnaLlon wlLh looklng for dllaLlon of Lhe upper LracL
on ulLrasound.

uo all Lhe sLandard bloods, along wlLh urlnalysls and
mlcroscopy (red cells and casLs).

Assess volume sLaLus, lf lL's correcLed and Lhey don'L
dlurese Lhen lL's lnLrlnslc.

@)()6%=%($

@%<,")*

keep Lhe paLlenL allve unLll Lhelr kldneys sLarL worklng
agaln.

Manage:
- Pyperkalaemla
- volume sLaLe
- Any sepsls presenL

lndlcaLlons for dlalysls and haemofllLraLlon are:
- SympLoms of uraemla
- Severe blochemlcal derangemenL ln Lhe absence of
sympLoms
- Pyperkalaemla
- Þulmonary oedema
- Severe acldosls
- 1o remove drugs resonslble for fallure (genL, llLhlum,
eLc)

8lopsy can be helpful ln deLermlnlng underlylng cause

ConLlnuous arLerlovenous or venovenous haemofllLraLlon:
8emove fllLraLe and slmulLaneously lnfuse replacemenL
soluLlon, wlLh a deflclL Lo remove volume.

ConLlnuous haemodlafllLraLlon: As above wlLh Lhe
addlLlon of counLercurranL dlalysaLe

40=:*,")$,0(5
lrreverslble renal damage
ueaLh
1PL uAnuLnCnC uCSSlL8 2010
71
!"#$%&' )*%+, -+&,.#*
/*0&%&1&$% 234 !,+55&0&'+1&$%
Cl8 of less Lhan 60mL/mln/1.73m
2
for 3 or more monLhs.
Loss of nephrons, by whaLever aeLlology, leads Lo a decrease
ln Cl8.
- SLage 1: kldney damage wlLh normal or lncreased Cl8
(>90 mL/mln/1.73 m2)
- SLage 2: Mlld reducLlon ln Cl8 (60-89 mL/mln/1.73 m2)
- SLage 3: ModeraLe reducLlon ln Cl8 (30-39 mL/mln/1.73
m2)
- SLage 4: Severe reducLlon ln Cl8 (13-29 mL/mln/1.73 m2)
- SLage 3: kldney fallure (Cl8 <13 mL/mln/1.73 m2 or
dlalysls)
)&56 -+'1$#5
- ulabeLes
- PyperLenslon
- CbsLrucLlon
- urugs (nSAlus, genL, eLc)
- lamlly hlsLory
- Age
- 1rauma
- SysLemlc dlseases (SLL, Plv, Pep C, CCl, eLc)

7*1&$,$893!+.5*5
- !$%8*%&1+, +%: &%"*#&1*:; ÞolycysLlc kldneys, congenlLal
obsLrucLlve uropaLhy.
- <#&=+#9 >,$=*#.,+# :&5*+5*; ClomerulonephrlLls (focal,
segmenLal, crescenLlc)
- ?*'$%:+#9 >,$=*#.,+# :&5*+5*; SLL, Wegener's
granulomaLosls, amyloldosls, dlabeLes melllLus,
haemolyLlc uraemlc syndrome, LhromboLlc
LhrombocyLopoenlc purpura, slckle cell, sysLemlc
sclerosls.
- @+5'.,+# :&5*+5*; 8enal vasuclar dlsease, small/medlum
vessel vascullLls.
- A.B.,$&%1*#51&1&+, :&5*+5*; 1ubulolnLersLlLlal nephrlLls
(ldlopaLhlc, nephroLoxlc drugs, lmmunologlcally
medlaLed), 1uberculosls, MulLlple myeloma.
- C#&%+#9 A#+'1 DB51#.'1&$%; Calcull, prosLaLe dlsease,
pelvlc Lumours, sLrlcLures.

<+1"$E"95&$,$89
1here ls exLenslve resevre for Lhe kldney Lo compensaLe for
nephron damage by hyperfllLraLlon and hyperLrophy of
healLhy nephrons. 1hls mechanlsm beglns Lo fall around a
Cl8 of 30°, whlch wlll colnclde wlLh a rough doubllng of
plasma creaLlnlne. 1hls compensaLlon appears Lo lncrease
Lhe progresslon of renal dysfuncLlon, hypoLheslsed Lo be due
Lo Lhe lncreased glomerular caplllary pressures.
lacLors LhaL cause progresslve renal ln[ury when consldered
aparL from underlylng paLhology are:
- AcuLe lnsulLs from nephroLoxlns or decreased perfuslon
- SysLemlc PyperLenslon
- ÞroLelnurla
- lncreased renal ammonlagenesls wlLh lnLersLlLlal ln[ury
- Pyperllpldemla
- PyperphosphaLemla wlLh calclum phosphaLe deposlLlon
- uecreased levels of nlLrous oxlde
- Smoklng
?&8%5 +%: ?9=E1$=5
SympLoms:
- Malalse
- lnsomnla
- Þolyurla
- lLchlng
- nausea, vomlLlng, dlarrhoea
- ÞaraesLhesla
- 8one paln (meLabollc bone dlsease)
- Cedema (perlpheral and pulmonary)
- Advanced uraemla (menLal slowlng, selzures, myoclonlc
LwlLchlng)
- LrecLlle dysfuncLlon, amenorrhoea
Slgns:
- Þallor
- 8rown dlscolouraLlon of nalls
- ScraLch marks
- lluld overload slgns (!vÞ, plLLlng oedema, basal creps)
- uon'L forgeL recLal exam for cause of posslble obsLrucLlon
- Slgns from underlylng dlsease such as glove and sLocklng
sensory loss and reLlnopaLhy ln dlabeLes, evldence
of Þvu

F&51$#9 +%: GH+=&%+1&$%
lmporLanL Lo ellclL:
- uuraLlon of sympLoms
- urug hlsLory - LveryLhlng, lncludlng herbal remedles
- Þrevlous urlnalysls
- lamlly hlsLory of renal dlsease
- Any mulLlsysLem dlseases

I%J*51&8+1&$%5
- C#&%+,95&5; PaemaLurla (glomerulonephrlLls), proLelnurla
(glomerular dlsease, glycosurla (dlabeLes)
- C#&%* K&'#$5'$E9; WhlLe cells, eoslnophllurla (allerglc
LubulolnLersLlLlal nephrlLls), granular casLs (from Lhe
Lubular lumen, acLlve kldney dlsease), red-cell casLs
(glomerulonephrlLls)
- C#&%* B&$'"*=&51#9; 24-hour Cr clearance (assesslng level
of fallure)
- ?*#.= B&$'"*=&51#9; uLC
- F+*=+1$,$89; Loslnophllla (vascullLls, allerglc
LubulolnLersLlLlal nephrlLls), ralsed LS8/haemaLocrlL
(myeloma or vascullLls), fragmenLed red cells
(haemolysls)
- I==.%$,$89; ComplemenL, auLoanLlbody screenlng,
SLrepLococcal anLlbodles, PepaLlLls 8 and C
anLlbodles, Plv anLlbodles, Malarla.
- I=+8&%8; ulLrasound (slze and excluslon of
hydronephrosls), xray (calcull), C1 (obsLrucLlon), M8
anglography (renal vascular dlsease).
- L&$E59

K+%+8*=*%1

1PL uAnuLnCnC uCSSlL8 2010
72
!"#$%&'

1reaL Lhe underlylng cause as aggresslvely as posslble.
CorrecL Lhe compllcaLlons:
- Pyperkalaemla
- Acldosls
- Suppress Þ1P, conLrol calclum and phosphaLe
- Avold drugs excreLed by Lhe kldneys
- ConLrol anaemla

ulalyse, elLher haemo or perlLoneal.

)*+,$%&'

1ransplanL, elLher cadaverlc or from a llvlng relaLlve.

LlfesLyle ls slgnlflcanL glven lL ls a hard Lask belng on dlalysls,
buL Lhe lssue whlch sprlng up are loglcal so l don'L see Lhe
need Lo go Lhrough Lhem.

-./0'$%&1$.23

42&"/$&5 MosLly due Lo reducLlon of LÞC, Lhere are oLher
facLors buL Lhey are far less lmporLanL.
6.2" #$3"&3"5 uecreased 1a-hydroxylase -> reduced 1,23-
(CP)
2
u
3
-> osLeomalacla, Lhe aforemenLloned decreases also
lead Lo decreased serum calclum whlch causes secondary
hyperparaLhyroldlsm, leadlng Lo osLeopenla, laLrogenlc
aspecL wlLh sLerolds also adds Lo Lhls.
)7$2 #$3"&3"5 ÞrurlLus due Lo uraemla.
!"1&8.'$% &82.+/&'$1$"35 CouL, lnsulln reLenLlon and lnsulln
reslsLance by end organs, hypercholesLerolaemla.
!*3%'" #93:*2%1$.2 due Lo uraemla
-;)5 uecreased selzure Lhreshold and depressed cerebral
funcLlon ln severe uraemla.
-&+#$.<&3%*'&+ #$3"&3"5 16 fold lncreased lncldence,
parLlcularly Ml, Cl, sLroke.


!"# %&'%#'(') %(**+#, -./.
01
!"#$% '#(#)*+ ,%"+-./.

0%1/2/$/-2
• %2345 67 4898:3; <2::= ;2=8:4>?@ 7;6A >=<52A>3 6;
46B>?= CD;8@=E
• 8=83::F ;2G2;=>9:2
• +AH6;43?4 <38=2 67 3<842 ;2?3: 73>:8;2
• I3? 92 <38=2D 9F 2>452; >=<532A>3 6; 46B>?=
3*#.%.
!"#$%&'# )*+
• "FH642?=>6?J5FH6G3:2A>3
• (9=42424;>< C9>;45 ;2:342DE <6AH:><34>6?=
K;2L2<<:3AH=>3 3?D 2<<:3AH=>3 A3F ;2=8:4= >?
6<<:8=>6? 67 452 >?4;3;2?3: G2==2:= 2B3<2;934>?@
>=<532A>3
• (9=4;8<4>G2 M38?D><2
• *2H=>=
• *8;@2;F
)*+,*-.'/"
• &A>?6@:F<6=>D2= C=4;2H46AF<>? 3?D @2?43A><>?E
• &AH5642;><>? N
• I>=H:34>? C3?4> <3?<2; 3@2?4 8=2D >? 6G3;>3? 3?D
42=4><8:3; <3?<2;=E
• I6?4;3=4

0+%.%2$*$/-2
• (:>@8;>3 <6AA6? >? 23;:F =43@2= O>45 P/..A: 67
8;>?2 >? -Q5;=
• ,2<6G2;F 6<<8;= 3742; 0L-/D3F=R 3:4568@5 >4
A>@54 92 D2:3F2D 9F <6?4>?8>?@ =2H=>=

4/.$-+5 *26 78*9/2*$/-2
• +4S= G2;F >AH6;43?4 46 4;F 46 7>?D 452 <38=2
• *6 3=T 39684
! "FH642?=>6? 3?D 5FH6G6:2A>3
! *2H=>=
! ,2<2?4 =8;@2;F
! #BH6=8;2 46 ?2H5;646B>< D;8@= C@2?43A><>?E
! I6?4;3=4
#B3A >? A6=4 <3=2= >= 8?;2A3;T39:2 3?D &!' A6=4:F >=
H><T2D 8H 3<<>D2?43::F D8;>?@ ;684>?2 42=4=
+? ;3;2 <3=2= 452F A>@54 H;2=2?4 O>45
! &=42;>B>=
! "FH2;42?=>6? 6; 62D2A3
! *>@?= 67 8;2A>< H;8;>48=
0/11%+%2$/*) 0/*:2-./.
• &<842 ;2?3: 73>:8;2
• I5;6?>< ;2?3: 73>:8;2
• &<842 @:6A2;8:6?2H5;>4>=
• &<842 >?42;=4>4>3: ?2H5;>4>=
• ,2?3: G3=<8:>4>=
;2<%.$/:*$/-2.
• UN#L3?32A>3
• V#IL;3>=2D <;234>?>?2R 5FH6?34;2A>3 3?D
5FH2;T3:2A>3
• V;>?3:F=>=


!52 H34<5F 6; D>778=2 D2?8D34>6? 69=2;G2D >? &!'
'+%*$9%2$
W3??>46:R 78;6=2A>D2JD6H3A>?2

1PL uAnuLnCnC uCSSlL8 2010
74
!"#$%&'%()%)
+,-%.%&%#. /01 2$())%-%3(&%#.
urollLhlasls ls Lhe formaLlon of renal calcull ln Lhe renal
pelvls, LhaL deposlL anywhere from Lhe renal pelvls Lo Lhe
ureLhra.

4,&%#$#5607(&'#7'6)%#$#56
SLone formaLlon ls mosL ofLen due Lo lncreased
concenLraLlon of sLone-formlng maLerlal ln Lhe urlne,
elLher from lncreased excreLlon or decreased urlnary
volume. ClLraLe ls a sLone lnhlblLor => hypoclLraLurla
predlsposes Lo sLone formaLlon.
2($3%89 )&#.,) (>73°, calclum oxalaLe ls Lhe mosL
common Lype, followed by phosphaLe)
• Pypercalclurla due Lo hyperparaLhyroldlsm,
overabsorpLlon, excess vlL u, bone meLs,
dehydraLlon, lmmoblllzaLlon
• Pyperoxalurla from dleL, shorL guL syndromes,
congenlLal meLabollc syndromes
• Plgh calclum lnLake could lronlcally decrease rlsk as lL
forms llgands wlLh oxlaLe and phosphaLe
!"%3 (3%: )&#.,) are assoclaLed wlLh low pP (eg. Chronlc
dlarrhoea) and hyperurlcosurla (eg. CouL) whlch
dlmlnlshes urlc acld solublllLy.
;&"8<%&, )&#.,) (composed of magneslum ammonlum
phosphaLe) occur ln paLlenLs wlLh chronlc u1ls caused by
urea spllLLlng bacLerla
26)&,%., )&#.,) - form 2' Lo lmpalred renal absorpLlon of
cysLlne

;%5.) (.: ;697&#9)
• AsympLomaLlc ln renal pelvls or bladder
lf Lhe sLone causes obsLrucLlon,
• Sudden onseL of unllaLeral excruclaLlng flank paln
LhaL may radlaLe Lo Lhe lpsllaLeral lower quadranL,
groln, scroLum, or labla
• Accompanylng n+v, lleus
• PemaLurla presenL ln ~90° of cases
• 1¨lnfecLlon/lnfecLlon 2¨ Lo obsLrucLlon - fever, rlgld
abdomen
• 1enderness over Lhe affecLed kldney (cosLoverLebral
angle Lenderness)
• lrequency and urgency when sLone approaches
bladder

=%)&#"6 >"%)? -(3&#")@
WhaL do you eaL(oxalaLe)? WhaL ls your [ob(hydraLlon)? ls
lL summer (vlLu lvls)? 8ecurrenL u1ls(sLruvlLe sLones)?
lPx? ls Lhere lnfecLlon above Lhe sLone?

++A
AcuLe pyelonephrlLls, 8enal adenocarclnoma LhaL has
bled lnLo Lumour, obsLrucLed sloughed papllla ln paplllary
necrosls
- slmllar acuLe renal paln, C1 helps Lo dlsLlngulsh
8enal 18 Cx by sLone formaLlon- urlnalysls: pyurla
wlLhouL bacLerlurla, u/s: moLh-eaLen callces
8enal lnfarcLlon - may cause renal paln and hemaLurla,
conflrmed by anglography,or colour uoppler u/s

B.<,)&%5(&%#.)
C(D#"(&#"6
• 8loods: l8L - leukocyLosls wlLh lnfecLlon, uLC,
CMÞ,Þ1P
• urlnalysls: hemaLurla - gross or mlcroscoplc, pP>7.6 -
presence of urea-spllLLlng organlsms, <3.3 - urlc
acld/cysLlne sLones
• urlne sLraln: for analysls of sLone composlLlon
• 24 hr urlne collecLlon: ldenLlfy meLabollc effecL LhaL
causes sLone formaLlon (hypercalclurla,
hyperoxalurla, hyperurlcosurla, hypoclLraLurla)
B9(5%.5
• ku8 x8 (calclum sLones are radloopaque) and
ulLrasound (large calcull)
• non conLrasL splral C1 scan - urlc acld sLones are Lhe
only radlolucenL sLones, wlll show up on C1 buL noL
x8, also used Lo dlsLlngulsh from cloL or Lumour

E(.(5,9,.&
Small sLones (<3mm) wlll ofLen pass sponLaneously. lf lL
causes paln, progresslve hydronephrosls or lnfecLlon, lL
should be removed
E,:%3($
Analgesla - nSAluS, oplold+anLlemeLlc
PydraLlon - conservaLlve Mx
1o enhance passlng - 1amsulosln (alpha blocker), CC8
F"#3,:8"($0;8"5%3($
• SLone ln kldney/renal pelvls - percuLaneous
nephrollLhomy (enLerlng Lhrough skln Lo calyx,
dllaLlon of LracL, pulverlzaLlon of fragmenLs by u/s, or
laser probes)
• SLone ln ureLer - exLracorporeal shock wave
llLhoLrlpsy (LSWL): under sedaLlon wlLh ald of u/s,
ureLeroscoplc: laser llLhoLrlpsy or baskeLlng of sLones
• Cpen surgery - lf LSWL conLralndlcaLed or fallure of
sLone Lo move
F",<,.&%#. (as recurrence ls common)
G,.,"($: lncrease fluld lnLake, LreaL lnfecLlon, relleve
sLasls/obsLrucLlon, avold prolonged lmmoblllzaLlon
2($3%89 )&#.,): poLasslum clLraLe Lo lncrease urlnary
clLraLe lvls, avoldance of oxalaLe-conLalnlng foods (eg.
1ea, dark greens, chocolaLe), Lhlazlde dlureLlcs
;&"8<%&, )&#.,) - urlnary acldlflcaLlon and long Lerm
anLlbloLlc
!"%3 (3%:036)&,%., )&#.,) - urlnary alkallzaLlon(poLasslum
clLraLe), allopurlnol and llmlL purlnes ln dleL for
hyperurlcemla, penlclllamlne for severe hypercysLlnurla

2#97$%3(&%#.)
• Þrogresslve hydronephrosls LhaL lncreases probablllLy
of lnfecLlon
• Crowlng sLaghorn calculus (branched sLones LhaL flll
renal pelvls and calyx) may desLroy renal Llssue
1PL uAnuLnCnC uCSSlL8 2010
73
!"#$%$&'(% *(+,-$ .(&-/&-
.-0(,('(",
• MulLlsysLemlc and progresslve dlsorder
• CharacLerlzed by Lhe formaLlon and enlargemenL
of cysLs ln Lhe kldney and oLher organs (e.g. llver,
pancreas, spleen)

1-'("#"2$34/5&-&
AuLosomal domlnanL lnherlLed dlsorder
Cenes on chromosomes 16 (Þku1) and 4 (Þku2)

!/'6"76$&("#"2$
PyperplasLlc eplLhellal cell ln renal Lubule - ouLpouchlng
of Lubule wall - formaLlon of a saccular cysL LhaL fllls wlLh
fluld derlved from glomerular fllLraLe

8llaLeral progresslve cysLlc dllaLlon of Lhe renal Lubules -
end-sLage renal dlsease

8(2,& /,+ 8$97'"9&
- Þalpable, bllaLeral flank masses (renal
enlargemenL wlLh cysLs)
- Abdomlnal, flank, loln paln (enlargemenL of cysLs,
bleedlng, urlnary LracL lnfecLlon, renal collc)
- Abdomlnal paln can also be due Lo large
polycysLlc llver
- PaemaLurla (haemorrhage lnLo a cysL)
- PyperLenslon
- 8enal fallure (usually 40 Lo 60 yrs): pallor, uremlc
feLor, dry skln, oedema
- Þolyurla (early manlfesLaLlon)

:,;-&'(2/'(",&
CeneLlc LesLlng
ulLrasound
M8l: measure kldney slze Lo assess progress afLer
LreaLmenL

</,/2-9-,'
MonlLor u&L
ConLrol 8Þ Lo prevenL cardlovascular compllcaLlons and
SAP
1reaL lnfecLlons
ulalysls or LransplanLaLlon for LS8l
CeneLlc counselllng
Laparoscoplc cysL removal / nephrecLomy - paln rellef

4"97#(%/'(",&
• =-,/#
- CysL lnfecLlon
- 8enal calcull
- Þrogresslve renal fallure
• >?'@/@-,/#
- Llver cysLs
- lnLracranlal aneurysm (SAP)
- MlLral valve prolapse
1PL uAnuLnCnC uCSSlL8 2010
76
!"#$%&'()*'+,-./.0
2'3.*./.)* 4$5 6(700.3.87/.)*
ueflnlLlon: Þresence of pure growLh of >10
3
organlsms per
ml of fresh MSu
ClasslflcaLlon:
- uncompllcaLed
o normal renal LracL and funcLlon
- CompllcaLed
o Abnormal renal/genlLourlnary LracL,
decreased renal funcLlon, lmpalred hosL
defences, vlrulenL organlsm
lncludes ureLhrlLls, cysLlLls, prosLaLlLls, pyelonephrlLls

9+.:';.)()<&
More common ln females

=.0> ?78/)-0
• lemale
• Sexual lnLercourse
• Þregnancy
• !PosL defence (lmmunosuppressed, dlabeLes)
• CbsLrucLlon (sLones, caLheLer, malformaLlon llke
veslcoureLerlc reflux)
• lncompleLe voldlng (neurogenlc bladder, splnal
cord ln[ury)

@'/.)()<&$67A0'0
L.coll (70°), sLaph saprophyLlcus (3-10°), proLeus
mlrabllls

%7/,)+,&0.)()<&
8ladder wall coaLed wlLh 1amm-Porsfall proLelns (1PÞ)
LhaL lnLerfere wlLh bacLerla blndlng Lo uroeplLhellum.
Þhyslcal Lrauma affecLs Lhls llnlng ! rlsk of lnfecLlon"

B.<*0 7*: B&;+/);0
• Slgns
o lever, abdomlnal or loln Lenderness,
foul-smelllng urlne
• SympLoms
o CysLlLls: lrequency, dysurla, urgency,
sLrangury, haemaLurla, suprapublc paln
o ÞyelonephrlLls: Plgh fever, rlgors,
vomlLlng, loln paln and Lenderness
• CysLlLls vS pyelonephrlLls
o Local sx vS sysLemlc sx (fever, rlgors)
o Suprapublc paln vS loln paln

C.0/)-& 7*: 9D7;.*7/.)*
Sexual hx!
Murphy's kldney punch

#*E'0/.<7/.)*0
urlne dlpsLlck (nlLrlLes, red cells, leucocyLes, glucose for
dlabeLes)
M/C/S for MSu
u/S (for hydronephrosls)
ku8 xray for renal calcull

F7*7<';'*/
CysLlLls
- non-pregnanL women: LrlmeLoprlm, cephalexln,
augmenLln or nlLrofuranLoln
- Men: LrlmeLoprlm, cephalexln or augmenLln
o MusL furLher lx Lo rule ouL underlylng
urlnary LracL abnormallLy
ÞyelonephrlLls
- Mlld lnfecLlon: augmenLln, cephalexln or
LrlmeLoprlm
- Severe (w/sepsls and vomlLlng): genLamlcln +
amoxlclllln (can subsLlLuLe genLamlcln wlLh
cefLrlaxone)
- Þerform follow-up urlne culLure 48hrs afLer
concluslon of Lherapy

6);+(.87/.)*0
- ÞyelonephrlLls
o Sepsls w/shock
o Abscess formaLlon lf lnadequaLe rx

1PL uAnuLnCnC uCSSlL8 2010
77
!"#$#%&'($ *(+',"-
.,+($ '(+',"
/01,-2
8enal cell carclnoma (83°)
-Clear cell (leasL aggresslve)
-Cranular cell
-Mlxed clear and granular (mosL aggresslve)
-SarcomaLold or splndle Lype
*(3-,- (+4 .&-5 6('7#"-2
• Smoklng
• CbeslLy
• PyperLenslon
• lamlly hlsLory
• ulalysls wlLh acqulred cysLlc dlsease
8&%+- (+4 80917#9-2
18lAu!
1. llank paln
2. llank mass
3. PaemaLurla
• usually asympLomaLlc
• WelghL loss, malalse, anorexla
• ÞolycyLhaemla/anaemla
• varlcocele (Lumour lnvaslon of L renal veln)
• Pypercalcaemla
• PyperLenslon
• ÞaraneoplasLlc llver dlsease
:#$4 -7(+4("4 ;#" <&(%+#-&-
• C1


=$(44," *(+',"
/01,-2 1ranslLlonal Cell Carclnoma (90°)
8emalnlng 10°: Squamous cell carclnoma,
adenocarclnoma, sarcoma, small cell carclnoma
*(3-,- (+4 .&-5 6('7#"-2
• More common ln men - ?androgen recepLor
• Smoklng
• Lxposure Lo lndusLrlal chemlcals: AromaLlc amlnes,
e.g. ln prlnLlng or rubber lndusLry
• 8adlaLlon of Lhe pelvls
• Long-Lerm lndwelllng caLheLer
8&%+- (+4 80917#9-2
• PaemaLurla (gross or mlcroscoplc)
• lrrlLable urlnaLlon
:#$4 -7(+4("4 ;#" <&(%+#-&-
• CysLoscopy

/,-7&'3$(" *(+',"
/01,-
• Semlnoma (slow growlng, men ln 40s)
• non-semlnoma (men ln 30s, more aggresslve)
• Mlxed
>1&4,9&#$#%0
8elaLlvely rare, 1° of cancers ln men.
MosL common cancer ln men aged 13-40.
*(3-,- (+4 .&-5 6('7#"-2
• More common ln men - ?androgen recepLor
• Smoklng
• Lxposure Lo lndusLrlal chemlcals: AromaLlc amlnes,
e.g. ln prlnLlng or rubber lndusLry
8&%+- (+4 80917#9-2
• Þalnless swelllng or lump ln one LesLls
• uull ache ln lower abdomen, scroLum or groln
:#$4 -7(+4("4 ;#" <&(%+#-&-
• 8lopsy

?"#-7(7, *(+',"
/01,-
• Adenocarclnoma
>1&4,9&#$#%0
• Afrlcan-Amerlcan > WhlLe > Aslan
*(3-,- (+4 .&-5 6('7#"-2
• Age
• lamlly hlsLory
• Plgh-faL dleL
• ÞrosLaLlLls
• S1ls
• LlevaLed LesLosLerone
• vlLamln 86, selenlum, vlLamln L, soy dleL proLecLlve
8&%+- (+4 80917#9-2
• urlnary reLenLlon
• urlnary frequency
• Weak sLream
• urlnary urgency
• LrecLlle dysfuncLlon
• Þalnful e[aculaLlon
• Leg weakness/lnconLlnence (splnal cord compresslon)
• WelghL loss, anorexla, bone paln
1PL uAnuLnCnC uCSSlL8 2010
78
!"#$%# '()*+,+$- ./0"(+()01/
2"3$#$+$)# 456 78,**$3$-,+$)#
A hlsLologlcal dlagnosls characLerlsed by prollferaLlon of
Lhe cellular elemenLs of Lhe prosLaLe.

9$*: ;,-+)(*
• Age
• Abdomlnal obeslLy (lncreases frequency and
severlLy of sympLoms)
• lamlly hlsLory
• Þrlor genlLourlnary surgery

<"+$)8)%/57,=*"*
• ÞrosLaLe enlargemenL wlLh age ln hormonally-
dependenL manner (androgens)

',+1)01/*$)8)%/
lncrease ln number of eplLhellal and sLromal cells ln
perlureLhral LranslLlonal zone of prosLaLe, whlch may
compress Lhe ureLhra causlng parLlal / compleLe
obsLrucLlon.

>$%#* ,#? >/@0+)@*
SympLoms
• SLralnlng Lo mlcLuraLe
• urlnary urgency
• nocLurla
• Weak urlnary sLream
• lncompleLe voldlng of bladder
• lrequency of mlcLurlLlon
• lnLermlLLency of urlnary sLream
• PeslLancy of mlcLurlLlon
• May be asympLomaLlc
Slgns
• Lnlarged prosLaLe wlLhouL nodules / Lenderness

.$*+)(/ ,#? AB,@$#,+$)#
Px
• urlnary / renal hlsLory
o CnseL of sympLoms
o SeverlLy of sympLoms
• Sexual hlsLory
• MedlcaLlons
• LffecLs on CCL
• Þrevlous LreaLmenLs
• Surglcal hlsLory
• lamlly hlsLory
Lx
• ulglLal recLal examlnaLlon
• neurologlcal examlnaLlon
• urlnary dlpsLlck

C#D"*+$%,+$)#*
• u&L, 8un, creaLlnlne
• ÞrosLaLe-speclflc anLlgen
• urlnalysls, urlne culLure (rule ouL lnfecLlon)
• urlne cyLology
• 8enal ulLrasound, LransrecLal ulLrasound of
prosLaLe
• CysLoureLhroscopy
• urodynamlc sLudles
• 8lopsy

E,#,%"@"#+
• WaLchful walLlng
• Medlcal Lherapy (o-blockers, 3o-reducLase
lnhlblLors)
• CAM (saw palmeLLo)
• Mlnlmally lnvaslve LreaLmenLs (LransureLhral
mlcrowave Lherapy, LransureLhral needle
ablaLlon, eLc.)
• Surgery (LransureLhral resecLlon of prosLaLe,
open prosLaLecLomy, eLc.)

7)@08$-,+$)#*
• urlnary reLenLlon
• u1l
• 8ladder sLone
• 8ecalclLranL haemaLurla
• lnconLlnence
• AzoLaemla
• 8enal fallure
• Slde effecLs of LreaLmenLs

!"# %&'%#'(') %(**+#, -./.
01
!"#$%&'"$($)*
1PL uAnuLnCnC uCSSlL8 2010
80
!"#$ & '()*$+$, -$..(+/,
'$0(1(+(21 345 6.),,(0(7)+(21
• MeLabollc dlsorder caused by lnsulln deflclency
from auLolmmune desLrucLlon lnsulln-secreLlng
pancreaLlc beLa cells.
• usually [uvenlle onseL.
• 1here ls anoLher varlanL known as LaLenL
auLolmmune dlabeLes of adulLs (LAuA) wlLh
slower progresslon Lo lnsulln deflclency laLer ln
llfe.

8#(9$:(2.2;"
lncldence ls lncreased ln Lhose of norLhern Lurope
ancesLry

<(,= >)7+2?,
• Þersonal hlsLory of auLolmmune dlseases e.g.
myasLhenla gravls, Addlson's dlsease, pernlclous
anaemla

@$+(2.2;"46)/,$,
lL ls an PLA-assoclaLed lmmune medlaLed organ speclflc
dlsease.
lLs ls assoclaLed wlLh PLA u83, u84 and uC alleles


A)+B2#B",(2.2;"
luncLlons of lnsulln:
• 8educes blood glucose by allowlng upLake of
glucose by muscle and adlpose Llssue
• SLlmulaLe glycogenesls -l.e. converslon of
glucose Lo glycogen
• lL lnhlblLs glycogenolysls and slows Lhe
breakdown of faL Lo Lrlglycerldes, free faLLy aclds,
and keLones.
• lL also lnhlblLs Lhe breakdown of proLeln and faL
for glucose producLlon (gluconeogenesls) ln Lhe
llver.

ln Lhe absence of lnsulln Lhe above cannoL Lake place Lhls
resulLs ln a cascade of evenLs shown ln flgure 1

llgure 1


C":#+2:, D7.(1(7). #?$,$1+)+(21E
• Peadache
• Ceneral malalse
• Weakness
• Þolyurla and nocLurla:
due Lo glycosurla
• Þolydlpsla
• WelghL loss or fallure Lo Lhrlve ln lnfanLs

C":#+2:, 20 'F@ G ,$$ :2?$ (102 21 72:#.(7)+(21,
• nausea, vomlLlng
• lrulLy-smelllng breaLh -keLoLlc feLor
• kussmaul resplraLlons (rapld deep breaLhlng)
• Abdomlnal paln
• urowslness and coma










Pyperglycemla
1PL uAnuLnCnC uCSSlL8 2010
81
!"#$%&'
• Lnqulre abouL Lhe above-menLloned sympLoms
ln PCÞC.
• lor already dlagnosed uM
o Clarlfy whlch Lype
o Age of dlagnosls
o LsLabllsh how lL was dlagnosed
o Clucose conLrol
! Pow and who does Lhelr
monlLorlng
! lrequency of monlLorlng
! usual numbers
! Pypoglycaemlc eplsodes
• SympLoms: sweaLlng,
anxleLy, hunger,
Lremor, palplLaLlons,
dlzzlness, confuslon,
drowslness, selzures.
• lrequency
• SeverlLy
o Pyperglycaemlc sympLoms
! Þolyurla, polydlpsla, welghL
loss, faLlgue, weakness, blurry
vlslon, frequenL lnfecLlon, slow
heallng lnfecLlons
o uleL and exerclse
o MedlcaLlons
! lnsulln (Lype, dellvery sysLem
(pump vs. ln[ecLlons, unlLs)
! CLher medlcaLlons
o ÞasL medlcal hlsLory
! ukA
! Pypoglycaemla
! ÞancreaLlc surgery
! PaemochromaLosls
! CysLlc flbrosls
o CompllcaLlons
! Mlcrovascular: reLlnopaLhy
(lasL eye examlnaLlon and
resulLs), neuropaLhy,
nephropaLhy
! Macrovascular: sLroke, Þvu (hx
of lnLermlLLed claudlcaLlon,
vascular by pass) and CvS

)*+,"-+$"%-
-Ceneral appearance: evldence of welghL loss, kussmaul
breaLhlng
-Check for slgns of dehydraLlon
vlLal slgns
o 8Þ (posLural drop" auLonomlc
neuropaLhy
-lundoscoplc examlnaLlon
• CoLLon wool spoLs (haemorrhage) " Þre
prollferaLlve reLlnopaLhy,
neovascularlsaLlon"prollferaLlve reLlnopaLhy,
Mlcroaneurysms (doLs) and haemorrhage (bloLs),
rubeosls lrldls..
• CaLaracLs
-Arms: ln[ecLlon slLes (lnfecLlon, llpohyperLrophy) pulses

-Legs: pulses (dosalls pedls, posLerlor Llbllalls), sensaLlon


.-/0#$"1+$"%-#
• 8lood glucose: uslng oral glucose Lolerance LesL

2"+1-%#"# %3 24 5/+670# 8+#09 %- /0-%7# 86%%9 167:%#0;
lasLlng 8C >7mmol/L or random > 11.1mmol/L or CC11-
2hr value >11.1mmol/L
• lsleL-cell (lA2), anLl-CAu63, and anLl-lnsulln
auLoanLlbodles
1he resL of Lhe lnvesLlgaLlons are noL dlagnosLlc raLher
screens from compllcaLlons
• urlne analysls
• l8C "slgns of lnfecLlon
• urea and elecLrolyLes "renal funcLlon
• Llver blochemlsLry
• 8andom llplds


4+-+10,0-$

<"30#$'60 - dleL and exerclse

409":+6= lnsulln
• 8apld shorL acLlng- humulln 8, novolln- peak
acLlon wlLhln 2-3 hours
• ulLra-fasL acLlng (Pumalog, novorapld) -peak
acLlon afLer lngesLlon 30mlns
• lnLermedlaLe AcLlng- e.g. lenLe peak acLlon 7-8
hours
• Long acLlng recomblnanL human lnsulln-used aL
bed Llme
• Þremlxed lnsulln

>%,?6":+$"%-#
1. ulabeLlc keLoacldosls (ukA)
lL's a compllcaLlon of poorly conLrolled Lype 1 dlabeLes
melllLus.
Lack of lnsulln causes hyperglycaemla due Lo unresLrlcLed
hepaLlc glucose producLlon
Llpolysls "free faLLy aclds"keLoaclds"acldosls
ÞerslsLenL sLaLe of hyperglycaemla causes osmoLlc
dluresls subsequenLly dehydraLlon and elecLrolyLe
lmbalance
2. lnfecLlon (CM, cellullLls)
3. Mlcrovascular vs. Macrovascular compllcaLlons
1PL uAnuLnCnC uCSSlL8 2010
82
!"#$"#%&' )'*+$,-#".,
/,#0&".& 1"#$"#%&'
2.&3.,0 *0-&0#04
2'10& 2'1.
CrowLh hormone (CP):
- 1argeL gland: llver.
- 1rophlc effecL: lCl-l producLlon,
growLh lnducLlon, lnsulln
anLagonlsm.
usually Lhe resulL of a somaLoLrope
adenoma buL may rarely be caused by
exLraplLulLary leslons.
5, %4$6#*7 %-&.308%6'
Acral bony overgrowLh: fronLal bosslng,
lncreased hand and fooL slze,
mandlbular enlargemenL S
SofL Llssue swelllng resulLs ln lncreased
heel pad Lhlckness, lncreased shoe or
glove slze, rlng LlghLenlng, characLerlsLlc
coarse faclal feaLures, and a large fleshy
nose.
Pyperhldrosls, deep and hollow-
soundlng volce, olly skln, arLhropaLhy,
kyphosls, carpal Lunnel syndrome,
proxlmal muscle weakness and faLlgue,
acanLhosls nlgrlcans, and skln Lags.
Cenerallzed vlsceromegaly:
cardlomegaly, macroglossla eLc.
5, 9"4*7 8"8%,#"*3
:2 )0+"-"0,-' (chlldren)
ShorL sLaLure, mlcropenls, lncreased
faL, hlgh-plLched volce, and a
propenslLy Lo hypoglycemla due Lo
relaLlvely unopposed lnsulln acLlon.
lamlllal modes of lnherlLance are seen
ln one-Lhlrd of Lhese lndlvlduals and
may be auLosomal domlnanL, recesslve,
or x-llnked.
:2;2 ;0-01#.& <$#%#".,* (chlldren)
Severe proporLlonaLe dwarflsm.
ÞlLulLary doesn'L recelve sLlmulaLlon Lo
produce CP.
:&.=#> 2.&3.,0 5,*0,*"#"?"#'
Pomozygous or heLerozygous
muLaLlons of Lhe CP recepLor are
assoclaLed wlLh parLlal or compleLe CP
lnsenslLlvlLy and growLh fallure (Laron
syndrome).
1hyrold-sLlmulaLlng hormone (1SP):
- 1argeL organ: Lhyrold.
- 1rophlc effecL: 14 synLhesls and
secreLlon.
2'10&#>'&."4"*3 2'1.#>'&."4"*3
AdrenocorLlcoLroplc hormone (AC1P):
- 1argeL organ: adrenals.
- 1rophlc effecL: sLerold producLlon
AC1P-Þroduclng Adenoma: @$*>",8A*
B',4&.30.
AC1P deflclency causes *0-.,4%&'
%4&0,%6 ",*$++"-"0,-'. lL ls characLerlzed
by faLlgue, weakness, anorexla, nausea,
vomlLlng, and, occaslonally,
hypoglycemla. noL usually assoclaLed
wlLh plgmenLaLlon changes or
mlneralocorLlcold deflclency.
ÞrolacLln (Þ8L):
- 1argeL organ: breasL and oLher
Llssues.
- 1rophlc effecL: mllk producLlon
Amenorrhea, galacLorrhea, and
lnferLlllLy are Lhe hallmarks of
hyperprolacLlnemla ln women.
ln men wlLh hyperprolacLlnemla,
dlmlnlshed llbldo, lnferLlllLy, or vlsual
loss (from opLlc nerve compresslon) are
Lhe usual presenLlng sympLoms.

lolllcle-sLlmulaLlng hormone (lSP) and
LuLelnlzlng hormone (LP):
1argeL organs: ovarles and LesLes
1rophlc effecL: sex sLerold producLlon,
folllcle growLh, germ cell maLuraLlon.
Þremenopausal women: presenLs as
dlmlnlshed ovarlan funcLlon leadlng Lo
ollgomenorrhea or amenorrhea,
lnferLlllLy, decreased vaglnal secreLlons,
decreased llbldo, and breasL aLrophy. ln
adulL men, secondary LesLlcular fallure
ls assoclaLed wlLh decreased llbldo and
poLency, lnferLlllLy, decreased muscle
mass wlLh weakness, reduced beard
and body halr growLh, sofL LesLes, and
characLerlsLlc flne faclal wrlnkles.
CsLeoporosls ln boLh women and men.




1PL uAnuLnCnC uCSSlL8 2010
83
!"#$%&'"& )'$*'$+&,
AnLldlureLlc hormone
8educes waLer excreLlon by promoLlng
concenLraLlon of urlne.
Lxcesslve secreLlon or acLlon of AvÞ
resulLs ln Lhe producLlon of decreased
volumes of more hlghly concenLraLed
urlne. lf noL accompanled by a
commensuraLe reducLlon ln fluld lnLake
or an lncrease ln lnsenslble loss, Lhe
reducLlon ln urlne ouLpuL resulLs ln
excess waLer reLenLlon wlLh expanslon
and dlluLlon of all body flulds.
SympLoms and slgns of -+$%&
'.$"/'0+$'". LhaL may lnclude mlld
headache, confuslon, anorexla, nausea,
vomlLlng, coma, and convulslons.
Severe hyponaLremla may be leLhal.
1'+2%$%# '.#')'3'#
uecreased secreLlon or acLlon of AvÞ
usually manlfesLs as ul, a syndrome
characLerlzed by Lhe producLlon of
abnormally large volumes of dlluLe
urlne. Cllnlcal slgns of dehydraLlon are
uncommon unless fluld lnLake ls
lmpalred.
43')#'0 5,)%&.+$&+%6'+
Adlpslc hypernaLremla ls a syndrome
characLerlzed by chronlc or recurrenL
hyperLonlc dehydraLlon caused by a
deflclency ln Lhe osmoregulaLlon of
LhlrsL. usually assoclaLed wlLh slgns of
hypovolemla such as Lachycardla,
posLural hypoLenslon, azoLemla,
hyperurlcemla, and hypokalemla.
Muscle weakness, paln,
rhabdomyolysls, hyperglycemla,
hyperllpldemla, and acuLe renal fallure
may also occur. ul ls usually noL presenL
aL leasL aL presenLaLlon.
CxyLocln
A nonapepLlde, whlch dlffers from AvÞ
only aL poslLlons 3 and 8 (llg. 334-1).
Powever, lL has relaLlvely llLLle
anLldlureLlc effecL and seems Lo acL
malnly on mammary ducLs Lo faclllLaLe
mllk leLdown durlng nurslng. lL may also
help Lo lnlLlaLe or faclllLaLe labor by
sLlmulaLlng conLracLlon of uLerlne
smooLh muscle, buL lL ls noL yeL clear lf
Lhls acLlon ls physlologlc or necessary
for normal dellvery.


1PL uAnuLnCnC uCSSlL8 2010
84
!"#$%&
(&)#*#$#"* +,- ./011#)#20$#"*
ColLre ls Lhyrold enlargemenL whlch maybe physlologlcal
or paLhologlcal. More common ln women Lhan men.

(#))&%&*$#0/ (#03*"1#1

(455678 !94:;87
• Slmple
o Þhyslologlcal(puberLy and pregnancy)
! 1hyrold ls smooLh and sofL
• AuLolmmune
o Craves' dlsease
o PashlmoLo's dlsease
! llrm dlffuse golLre of varlable
slze. 8rulL heard on
LhyroLoxlcosls
• 1hyroldlLls
o AcuLe (de Cuervaln's LhyroldlLls)
! 1ender and assoclaLed wlLh
sysLemlc vlral lllness

<9(6=>; !94:;8
SollLary nodular golLre
• ColLre wlLhouL Lhyrold hormone dysfuncLlon.

MulLlLoxlc golLre
• ls assoclaLed wlLh hyperLhyroldlsm. 1he mosL
common cause of Lracheal compresslon and
laryngeal nerve palsy.

llbroLlc golLre
o 8are condlLlon, usually produclng a 'woody'
gland. AssoclaLed wlLh mldllne flbrosls and ls
ofLen dlfflculL Lo dlsLlngulsh from carclnoma
belng lrregular and hard.
CysLs

Mallgnancy
• Adenoma
• Carclnoma
• Lymphoma

Mlscellaneous
• Sarcoldosls
• 18

8?0@#*0$#"*
:AB%"#C 3/0*C &?0@
lnspecLlon
• ColLre, LhyroldecLomy scar, promlnenL velns-
suggesL reLrosLernal exLenslon of Lhe golLre,
redness-suppuraLlve LhyroldlLls
• Clve Lhe paLlenL some waLer Lo swallow-golLre
and Lhyroglossal cysL wlll rlse durlng swallowlng.
• Ask paLlenL Lo sLlck Lhe Longue ouL-only Lhe
Lhyroglossal cysL moves.

ÞalpaLlon
• ÞalpaLe Lhe Lhyrold from behlnd wlLh Lhe pL's
neck flexed and also whlle Lhey swallow slps of
waLer.
• Conslder
o Slze, shape, conslsLency, Lenderness,
moblllLy.
Þercusslon
• Manubrlums-change from resonanL Lo dull
lndlcaLes reLrosLernal golLre.

AusculLaLlon
• 8rulL~ hyperLhyroldlsm, , caroLld brulL, venous
hum and sLrldor
ÞemberLon's slgn
" Look for slgns of venous congesLlon (pleLhora),
cyanosls, resplraLory dlsLress and lnsplraLory
sLrldor.

4*D&1$#30$#"*1
o 1l1s-1SP and free 14 or 13
o ulLrasound-good for nodules Lo demonsLraLe lf
Lhey are cysLlc or solld.
o Cx8 and Lhoraclc lnleL x-ray Lo deLecL Lracheal
compresslon and reLrosLernal exLenslons.
o lnA
o 1hyrold scan-used Lo dlsLlngulsh beLween
funcLlonlng (hoL) or non-funcLlonlng (cold)
nodules. PoL nodules rarely mallgnanL buL 10°
of cold nodules are mallgnanL.

4@@&C#0$& E0*03&@&*$
MosL golLre's are small, cause no sympLoms and can be
observed and rarely requlre lnLervenLlon.

lndlcaLlons for surglcal managemenL
o ÞosslblllLy of mallgnancy
o Þressure sympLoms on Lhe Lrachea and
oesophagus
o CosmeLlc reasons.

1PL uAnuLnCnC uCSSlL8 2010
83
!"#$%&'"%()*)+,
-$.)/)&)(/ 123 456++).)76&)(/
lL ls caused by lncreased clrculaLlng free levels of Lhyrold
hormones.

8#)*$,)(5(9"
AffecL females more Lhan male 3:1 raLlo

:$&)(5(9"246;+$+
! Craves dlsease cause 73° of cases .lL ls an
auLolmmune dlsorder resulLlng from Lhe
lnLeracLlon of anLlbodles Lo lmmunoglobulln lgC
1SP recepLor wlLh Lhe Lhyrold gland 1SP
recepLor-leads Lo Lhyrold fland sLlmulaLlon-
lncreased 14 secreLlon and Lhyrold growLh.
! 1oxlc mulLlnodular golLre-13°3 of cases
! 1oxlc adenoma(slngle nodular golLre)-3°
! SubacuLe LhyroldlLls
! CLhers: amlodarone, excesslve 14 replacemenL,
exogenous lodlne, hypoLhalamlc-plLulLary
dlsease

<)9/+ 6/* <",#&(,+

<",#&(,+ <)9/+
• =$)9'& 5(++> )/7%$6+$*
6##$&)&$>*)6%%'($6
• !$6& )/&(5$6%6/7$>
+?$6&)/9>#65#)&6&)(/+
• @%$,(%>,;+75$
?$6A/$++
• B%%)&6C)5)&",resLlessness
, malalse
• Loss of llbldo,
ollgomenorrhoea,
gynaecomasLla,
onycholysls
• lrrlLablllLy,
psychosls,welghL loss
• @%$,(%,palmar
eryLhema,onycholysls,
acropachy
• @67'"76%*)6 (% :D,
sysLollc P1n
• Þroxlmal myopaLhy,
hyperreflexla
• 8E(#'&'65,(+>5)9 569
6/* %$&%67&)(/,
perlorblLal and
con[uncLlval oedema
• F()&%$> C%;)&
• ÞreLlblal myxoedema

!)+&(%" 6/* 8E6,)/6&)(/
PlsLory-do endocrlne hx.
LxamlnaLlon flndlngs same as Lhe slgns(see Lhe above
Lable)

B/G$+&)96&)(/+
! 1l1s
1SP 14/13
Þrlmary uecreased lncreased
hyperLhyroldlsm
Subcllnlcal
hyperLhyroldlsm
uecreased n

! 1hyrold auLoanLlbodles-Lhyrold peroxldlse and
anLl-Lhyroglobulln anLlbodles suggesL an
auLolmmune aeLlology
! lmaglng:Craves dlsease(ulffuse lncreased
upLake),Loxlc adenoma(slngle hoL
apoL),mulLlnodular(mulLlple hoL spoLs)

H6/69$,$/&
H$*)765
! Carblmazole
o uecrease Lhyrold hormone synLhesls
! ÞropylLhlouracll-preferred ln pregnancy
! 8eLa blockers for sympLomaLlc conLrol
! 8adloacLlve-lodlne

<;%9)765
! 1hyroldecLomy for mulLlnodular golLre, Loxlc
adenoma or relapses of Craves dlsease afLer
anLl-Lhyrold drug Lherapy.
o CompllcaLlons
" vocal cord palsy(8Ln damage)
" ÞosL-operaLlve bleedlng
causlng Lracheal compresslon
and asphyxla.
" PypoparaLhyroldlsm and
hypoLhyroldlsm

4(,#5)76&)(/+
@'"%()* 7%)+)+2+&(%,-lL ls rare llfe-LhreaLenlng emergency
(morLallLy raLe of 10°). lL affecLs <2° of people wlLh
hyperLhyroldlsm and 30° of paLlenL reporL havlng losL
>13kg.
ÞaLlenL presenLs wlLh sympLoms of hyperLhyroldlsm buL
mosL presenL wlLh fever,anxleLy,aglLaLlon,confuslon and
Lachycardla and maybe hearL fallure.
# ManagemenL-8-blockers, and anLlLhyrold drugs
and 1 hour laLer glve lodlde.
# lv glucocorLlcolds Lo lnhlblL synLhesls of new
clrculaLlng Lhyrold hormone.
# lluld and elecLrolyLe replacemenL



1PL uAnuLnCnC uCSSlL8 2010
86
!"#$%&"'$()(*+
,-.(/(%($/ 123 456**(.(76%($/
Cllnlcal sLaLe arlslng from decreased producLlon of and/or
Lhe effecL of Lhyrold hormones.

8#()-+($5$9"
1he female/male raLlo ls 6:1 ln prlmary hypoLhyroldlsm.
Þrevalence ls 1-3° and lncldence ls 2/1000.

:-%($5$9"246;*-*
laLrogenlc
! ÞosL surgery-LhyroldecLomy
! ÞosL radlo-lodlne Lherapy
! AnLl-Lhyrold drugs
1hyrold synLheLlc fallure
! lodlne excess e.g. amlodarone
! lodlne deflclency
1hyrold desLrucLlon
! PashlmoLo's LhyroldlLls-auLoanLlbody Lo
Lhyroglobulln and Lhyrold, golLre found.
! ALrophlc hypoLhyroldlsm-lnhlblLory
auLoanLlbodles Lo 1SP recepLors resulLlng ln
dlffuse lymphocyLlc lnfllLraLlon of Lhe Lhyrold
leadlng Lo aLrophy hence no golLre.
! 8ledel's LhyroldlLls

<6%&$#&"*($5$9"
" PypoLhyroldlsm ls due Lo underacLlvlLy of Lhe
Lhyrold usually prlmary and can also be from
hypoLhalamlc-plLulLary dlsease.

=(9/* 6/) ="+#%$+*

SympLoms Slgns
• >-(9&% 96(/?
)-7'-6*-)
6##-%(%-
• 4$/*%(#6%($/?
.6%(9;-? 7$5)
(/%$5-'6/7-
• ury coarse skln,
dry brlLLle halr
• Muscle
weakness/sLlffnes
s
• Þoor memory,
depresslon,
pychosls
• Menorrhagla,
poor llbldo
• @-/%65 *5$A/-**
o Þsychosls/demenLla
• Þerl-orblLal oedema, deep
volce, golLre
• ,'" %&(/ &6('? ,'" *B(/,
overwelghL/obeslLy
• Þroxlmal myopaLhy, *5$A3
'-56C(/9D&;/93;#E '-.5-C-*,
myoLonla
• Cold perlpherles, carpal
Lunnel syndrome, oedema
• F'6)"76')(6, hypoLhermla,
hyperLenslon, hearL fallure




!(*%$'" 6/) 8C6+(/6%($/
Px-uo endocrlne hx, and on pasL medlcal hlsLory ask
abouL Lhe causes of hypoLhyroldlsm (refer Lo aeLlology)

LxamlnaLlon flndlngs same as slgns.

G/H-*%(96%($/*
IJI*
1ype of
hypoLhyroldlsm
1SP 14
Þrlmary lncreased decreased
secondary uecreased decreased
Subcllnlcal lncreased normal

1hyrold anLlbodles
o ÞoslLlve peroxldlse and Lhyroglobulln anLlbodles
ln PashlmoLo's LhyroldlLls.
l8C
o MlcrocyLlc anaemla-lron deflclency(menorrhagla)
CholesLerol levels-ralsed
LCC-bradycardla

@6/69-+-/%
@-)(7653 1hyroxlne (14) glven for llfe.

4$+#5(76%($/*
@"C$-)-+6 7$+6
! MosL severe compllcaLlon of hypoLhyroldlsm and
assoclaLed wlLh a preclplLaLlng evenL(lnfecLlon,
surgery, Ml, CPl)
! Cllnlcal feaLures
o PyponaLraemla,sLupor,hypovenLllaLlon,
hypoLherml,bradycardla,hyperLenslon
! lnvesLlgaLlons
o uecreased 13 and 14,lncreased
1SP,decreased glucose
o AC1P and corLlsol for adrenal
lnsufflclency.
! 1reaLmenL
o A8Cs, no acLlve re-warmlng, buL avold
coollng, corLlcosLerolds, L-1hyroxlne lv,
LreaL preclplLanL.

1PL uAnuLnCnC uCSSlL8 2010
87
!"#"$%&#'() +&,-./0$('/
1&23#2"#"&$%&#'()(,4 1&2'2"#"$%&#'()(,4
Þrlmary hyperparaLhyroldlsm ls due Lo excess Þ1P secreLlon
from a slngle paraLhyrold adenoma (83°), mulLlple
adenomas (6°), hyperplasla (10°), or carclnoma (1°). ln
secondary hyperparaLhyroldlsm, Lhere ls an lncrease ln
paraLhyrold hormone secreLlon ln response Lo low plasma
concenLraLlons of lonlzed calclum, usually owlng Lo renal
dlsease and malabsorpLlon.
PypoparaLhyroldlsm, alLhough uncommon, occurs mosL
ofLen as a compllcaLlon of LhyroldecLomy, especlally when
performed for carclnoma or recurrenL golLer. ldlopaLhlc
hypoparaLhyroldlsm, an auLolmmune process assoclaLed
wlLh auLolmmune adrenocorLlcal lnsufflclency, ls also
unusual, and hypoparaLhyroldlsm afLer 131l Lherapy for
Craves dlsease ls rare. neonaLal LeLany may be assoclaLed
wlLh maLernal hyperparaLhyroldlsm. PypoLhyroldlsm as well
as hypoparaLhyroldlsm may occur ln paLlenLs wlLh 8ledel
sLruma.
!"$%'2%&,('5'6&
CverproducLlon of paraLhyrold hormone resulLs ln
moblllzaLlon of calclum from bone and lnhlblLlon of Lhe renal
reabsorpLlon of phosphaLe, Lhereby produclng
hypercalcemla and hypophosphaLemla. 1hls causes a wasLlng
of calclum and phosphorus, wlLh osseous mlneral loss and
osLeopenla or osLeoporosls.
1he manlfesLaLlons of acuLe hypoparaLhyroldlsm are due Lo
hypocalcemla. Cenerally speaklng, Lhe sooner Lhe cllnlcal
manlfesLaLlons appear posLoperaLlvely, Lhe more serlous Lhe
prognosls. AfLer many years, some paLlenLs become adapLed
Lo a low serum calclum concenLraLlon, so LhaL LeLany ls no
longer evldenL.
7(6/, "/) ,&42$'4,
"SLones, bones, abdomlnal groans, psychlc moans, and
faLlgue overLones." lncreased faLlgue, weakness, arLhralglas,
nausea, vomlLlng, dyspepsla, consLlpaLlon, polydlpsla,
polyurla, nocLurla, psychlaLrlc dlsLurbances, renal collc, bone
paln, and [olnL paln.
ÞaresLheslas, muscle cramps, carpopedal spasm, laryngeal
sLrldor, convulslons, malalse, muscle and abdomlnal cramps,
LeLany, urlnary frequency, leLhargy, anxleLy, psychoneurosls,
depresslon, and psychosls.
8/93,$(6"$('/,
Serum calclum, Þ1P, chlorlde, usually lncreased, serum
phosphaLe low or normal, urlc acld and alkallne phosphaLase
someLlmes lncreased, urlne calclum lncreased, normal, or,
rarely, decreased, urlne phos-phaLe lncreased, Lubular
reabsorpLlon of phosphaLe decreased, osLeocalcln and
deoxypyrldlnollne cross-llnks lncreased.
x-rays: subperlosLeal resorpLlon of phalanges,
demlnerallzaLlon of Lhe skeleLon (osLeopenla or
osLeoporosls), bone cysLs, and nephrocalclnosls or
nephrollLhlasls.
Pypocalcemla and hyperphosphaLemla are demonsLrable.
1he urlne phosphaLe ls low or absenL, Lubular resorpLlon of
phosphaLe ls hlgh, and Lhe urlne calclum ls low. ln chronlc
hypoparaLhyroldlsm, x-rays may show calclflcaLlon of Lhe
basal ganglla, arLerles, and exLernal ear.
1PL uAnuLnCnC uCSSlL8 2010
88
!"#$%&' )*+$#,-%./01%2 3-450%674
8$,0%0/01%
Cushlng's syndrome: manlfesLaLlon of excesslve
corLlcosLerolds
Cushlng's dlsease: hypercorLlsollsm due Lo AC1P
hypersecreLlon

!$/01'16*93&-4$4
- Lxogenous (usu laLrogenlc) corLlcosLerolds (e.g. for
CCÞu/connecLlve Llssue dlsorders)
- 8enlgn plLulLary adenoma (<3mm), usu anLerlor
- non-plLulLary AC1P secreLlng neoplasms e.g. small
cell lung carclnoma (presenL wlLh hypokalaemla and
hyperplgmenLaLlon)
- unllaLeral adrenal Lumour, usually produclng excess
corLlsol and androgens (hlrsuLlsm and vlrlllzaLlon)

:06%4 &%" :*;+/1;4
• CenLral obeslLy - purple sLrlae, easy brulslng
• ÞleLhorlc moon face, buffalo hump,
supraclavlcular faL pads, Lhln exLremlLles
• PyperLenslon
• CsLeoporosls, avascular bone necrosls
• 1hlrsL polyurla
• Ache and superflclal skln lnfecLlon
• Clycosurla/hyperglycaemla
• MensLrual changes
• Þroxlmal myopaLhy

)04/1#* &%" <=&;0%&/01%
Lx:
- 8ony Lenderness of verLebra bodles: crush fracLures
from osLeoporosls
- vlsual flelds: slgns of plLulLary Lumour: homonymous
hemlanopla. lundoscopy for vlsual fleld defecLs, opLlc
aLrophy, papllloedema, hyperLenslve/dlabeLlc
changes.
- Abdo: ÞalpaLe for adrenal masses and hepaLomegaly
(faL deposlLlon)
- Legs: oedema (salL/waLer reLenLlon). 8ruslng and
poor wound heallng

>%?$4/06&/01%4
1. CvernlghL dexameLhasone suppresslon LesL
uexameLhasone glven ÞC aL 11pm, serum corLlsol
nexL AM Laken. lf low, exclude Cushlng's. (! =
Cushlng's. uux lnclude use of anLlselzure drugs e.g.
phenyLoln, rlfamplcln, and CCÞ)

Second llne LesLs
2. 48 hr dexameLhasone suppresslon LesL
0.3mg/6h ÞC for 2d. Measure corLlsol aL 0 and 48 hr
mark. Cushlng: fallure Lo suppress corLlsol.
3. 24 hr urlnary corLlsol collecLlon
lf hlgh urlnary corLlsol: hypercorLlsollsm. (pregnancy
and hlgh fluld lnLake! readlngs)
4. Sallvary corLlsol.
usually aL mldnlghL - lf hlgh ' Cushlng's syndrome.


LocallsaLlon LesLs:
3. Plgh-dose dexameLhasone suppresslon LesL
@;69A5 BC ,1# @"D Measure plasma and urlnary
corLlsol aL 0 and 48h. CompleLe or parLlal suppresslon
lndlcaLes Cushlng's dlsease - problem wlLh plLulLary.
LcLoplc AC1P-produclng source wlll nC1 be
suppressed.
6. Mornlng plasma corLlsol and AC1P
"AC1P wlLh !corLlsol - Adrenal Lumour
!AC1P: plLulLary or ecLoplc AC1P secreLlng Lumour
7. lmaglng or selecLlve sampllng
M8l 8raln (plLulLary): plLulLary adenoma. lf no mass
seen, perform bllaLeral lnferlor peLrosal slnus blood
sampllng Lo conflrm plLulLary adenoma.
C1 C/A/Þ lf no mass presenL, and have Lo flnd oLher
sources: look for small carclnold Lumours.

E&%&6$;$%/
E$"0.&'
Cease sLerolds lf posslble.or as much as posslble
:-#60.&'
Cushlng's dlsease
1. 1rans-sphenoldal selecLlve resecLlon of plLulLary
adenoma. ÞlLulLary corLlcoLrophs remaln suppressed,
requlres 6-36 mLhs Lo recover.. replace wlLh
hydrocorLlsone.
2. SLereoLacLlc plLulLary radlosurgery

Adrenal neoplasms
1. Laproscoplc resecLlon.
ConLralaLeral adrenal ls suppressed! replace wlLh
hydrocorLlsone.

LcLoplc AC1P produclng neoplasms
1. Surglcal resecLlon of Lhese Lumours. AdmlnlsLer
fluconazole/keLoconazole Lo suppress AC1P producLlon
before surgery

31;+'0.&/01%4
1. CompllcaLlon of P1n or uM
2. lncreased suspecLlblllLles Lo lnfecLlon
3. Compresslon fracLures of osLeoporoLlc splne and
asepLlc necrosls of femoral head
4. nephrollLhlasls and psychosls
3. CorLlsol wlLhdrawal syndrome
PypoLenslon, nausea, faLlgue, arLhralglas,
myalgla, prulLus, flaklng skln.
1PL uAnuLnCnC uCSSlL8 2010
89
!"#$%&' )*+,-.%/01,%2 !""13,%43
5$-1%101,%
Chronlc deflclency of corLlsol, aldosLerone and adrenal
androgens and causes skln plgmenLaLlon.

6#17&#* &"#$%&' -&1'.#$: hyperkalaemla, hyponaLraemla
and hypovolaemla

Adrenal crlsls: MLulCAL LML8CLnC? - can be Lrlggered
by sLress (surg/Lrauma), followlng sudden wlLhdrawal of
AC1P ln pL wlLh severe chronlc lnsufflclency, bllaLeral
adrenalecLomy, ln[ury Lo boLh adrenals

!$01,',8*9:&.3$3
- Þrlmary Addlson's dlsease
o AuLolmmunlLy (80°)
o 18
o Adrenal meLs/ Lymphoma
o Adrenal haemorrhage : sepsls, heparln-assoclaLed
LhrombocyLopaenla, anLlphosphollpld syndrome

- Long-Lerm use of prednlsolone Lo suppress plLulLary-
adrenal axls

;18%3 &%" ;*7+0,73
SympLoms
• Ceneral: weakness, faLlgue, dlzzy, falnLs, flu-llke
myalglas/arLhralglas
• Cl1: Anorexla, loss of welghL, n+v,
dlarrhoea/consLlpaLlon.
• Þsych: depresslon, psychosls, low self esLeem
Slgns
• ÞlgmenLed palmar creases and buccal mucosa,
vlLlllgo
• ÞosLural PypoLenslon

<$" -'&83 -,# !"#$%&' /#1313
Peadache, lasslLude, n+v, abdo pln, dlarrhoea.

)130,#* &%" =>&71%&01,%
Px:
- changes ln appeLlLle and welghL
- Changes ln bowel hablL: dlarrhoea
- Changes ln halr dlsLrlbuLlon: loss of axlllary and publc
halr
- LeLhargy
- ÞlgmenLaLlon
- Any sLerold replacemenL Lherapy
Lx:
- plgmenLaLlon ln palmar creases, elbows, gums and
buccalmucosa, genlLal areas and scars (only prlmary
hypoadrenallsm)
- 8Þ: hypoLenslon
- Any oLher auLolmmune condlLlons:
o 11uM: dlabeLlc hlsLory
o Craves' dlsease: Lhyrold Px and Lx
o MyasLhenla gravls: lld-lag, con[uncLlvlLls
o Þernlclous anaemla: bloods for anLl-parleLal cell
anLlbodles and lnLrlnslc facLor anLlbodles

?%@$3018&01,%3
- l8L, (anaemla, eoslnophllla), u+L (!na, "k), 8SL (!
due Lo lack of corLlsol), Ca levels (Ca")
- Mornlng corLlsol and AC1P levels
- ShorL AC1P sLlmulaLlon LesL/SynacLhen
uo plasma corLlsol before and afLer half hr afLer lM
AC1P ln[ecLlon: exclude secondary Addlson's lf 2
nd

readlng >330uL

AuLoanLlbody screen
21-Pydroxylase adrenal auLobodles
Þlasma rennln and aldosLerone: assess mlneralocorLlcold
sLaLus

lmaglng
Cx8: evldence of prevlous 18 lnfecLlon
C1 ChesL/Abdo: evldence for 18,

A&%&8$7$%0
B1-$30*'$
ÞaLlenL educaLlon: AlerL braceleL recommended for
prlmary adrenal lnsufflclency. SlLuaLlons Lo lncrease
glucocorLlcold dosage: lnLercurrenL lllness, early feaLures
of adrenal crls (nausea, vomlLlng,). Carry ln[ecLable
glucocorLlcold when away from medlcal care
A$"1/&'
ComblnaLlon of corLlcosLerolds and mlneralocorLlcolds
)*"#,/,#013,%$: 20-30mg per day, 12mg ln Lhe morn,
8mg ln Lhe afLernoon, 4mg ln early evenlng (prevenL
lnsomnla)

MlneralocorLlcold replacemenL
C'."#,/,#013,%$: 30-200mg ÞC, once dally.

Adrenal Androgen replacemenL
- 5)=!: parLlcularly ln women.

!""13,%1&% :#1313
1. 8loods for corLlsol and AC1P levels
2. lv sLaL hydrocorLlsone
3. lv flulds
4. 8SLs - 8eware hypoglycaemla, may requlre lv
glucose
!"# %&'%#'(') %(**+#, -./.
0.
!"#$%&%'(
1PL uAnuLnCnC uCSSlL8 2010
91
!"#$%&"'
)"*#+#,#-+ ./0 123''#*#43,#-+
A selzure ls any cllnlcal evenL caused by an abnormal
elecLrlcal dlscharge ln Lhe braln. Lpllepsy ls Lhe Lendency
Lo have recurrenL selzures.

ÞarLlal selzures: produced from small area of braln
Cenerallsed selzures: produced by enLlre braln
567896:
!;9<=7;!
!>?@,-?'
Slmple MoLor ([erklng, spasms), Sensory
(unusual vlslon, hearlng eLc.) and
Þsychologlcal (memory/emoLlonal
dlsLurbances)
Complex AuLomaLlsms eg. Llp smacklng,
chewlng, fldgeLlng, repeLlLlve
lnvolunLary buL coordlnaLed
movemenL
ÞarLlal wlLh secondary generallsaLlon

A;B;76:9!;)
!;9<=7;!
!>?@,-?'
Crand mal/1onlc
Clonlc
unconsclousness, convulslons,
muscle rlgldlLy
Absence/peLlL mal 8rlef loss of consclousness,
always sLarLs ln chlldhood
Myoclonlc Sporadlc (lsolaLed), [erklng
movemenLs
Clonlc 8epeLlLlve, [erklng movemenLs
1onlc Muscle sLlffness, rlgldlLy
ALonlc Loss of muscle Lone

7#'C D34,-&'/8&#EE"&'
llashlng/fllckerlng llghLs, hormonal, physlcal or menLal
exhausLlon, emoLlonal sLress, recreaLlonal drug use,
lnLercurrenL lnfecLlons and meLabollc dlsLurbances, sleep
deprlvaLlon, L1CP/L1CP wlLhdrawal. uncommon: muslc,
loud nolses, readlng

13%'"'/ 53,F-@F>'#-2-E>
normally, lnhlblLory clrculLs (CA8A medlaLed) ln Lhe
cerebral corLex llmlL synchronous dlscharge of
nelghbourlng group of neurons. 8locklng of CA8A
recepLors or excesslve sLlmulaLlon of exclLaLory
neuroLransmlLLers (Ach, gluLamaLe) can provoke selzures.



G#',-&> 3+H ;I3?#+3,#-+
lrom paLlenL: 1) Aura? WhaL klnd? 2) uescrlpLlon of
selzure - blLlng of Longue, lnconLlnence, halluclnaLlons
(de[a vu) 3) Could paLlenL relaLe Lo envlronmenL or
remember Lhe evenLs? 4)Pow paLlenL feels afLer evenL?
Pow long dld lL Lake Lo geL back Lo basellne/normal? 3)
Pow long and how frequenL are Lhe eplsodes? 6)
1rlggers? 7) Þrovoked by CnS lnsulL? lmporLanL Lo Lake
hlsLory from an eyewlLness

9+J"',#E3,#-+
lf flrsL presenLaLlon, do 18 -& K79 (sLrucLural leslons). l8L,
C8Þ, LS8, Cx8, LÞ (CnS lnfecLlons/lnflammaLlon). u&L,
8un, Ll1, 8SL, Serum Ca + Mg (meLabollc dlsorder).
1oxln/drug screen). Þregnancy LesL (eclampsla). LCC
(arrhyLhmlas causlng cerebral hypoxla).
;;AL CharacLerlse selzures (focal or generallsed), rule ouL
dlfferenLlals.

K3+3E"?"+,
K"H#432 - AnLlconvulsanL Lherapy. Common flrsL llne
drugs: carbamazeplne, eLhosuxlmlde, sodlum valproaLe.
8eware SL ln conLracepLlon and pregnancy (feLoLoxlc),
ÞhenyLoln LoxlclLy. Conslder wlLhdrawal lf selzure free for
2-4 years.

B-+ 5F3&?34-2-E#432 K3+3E"?"+,
:#*"',>2" - Lxerclse. uleL (keLogenlc dleL le hlgh faL, low
carb, low proLeln). Compllance (paLlenL educaLlon).
Avoldance of Lrlggers. SafeLy/CccupaLlonal healLh lssues
(eg. urlvlng)
5'>4F-2-E#432 - 8ehavloural 1herapy, CognlLlve 1herapy,
uesenslLlsaLlon, Pypnosls
!%&E#432 - Cood for focal selzures ln Lemporal lobe.

1-?@2#43,#-+'
SLaLus LpllepLlcus: Selzure lasLlng 30 mln wlLhouL paLlenL
regalnlng awareness. Medlcal emergency.
ManagemenL: Lnsure paLenL alrway, recovery poslLlon
(afLer selzure), glve C2, lv access, check bloods for
glucose, u&L, Ll1. Clve lorazepam, dlazepam (lv or
recLal).
1PL uAnuLnCnC uCSSlL8 2010
92
!"#$%"&'
)"%#&*+,"- .'/"&","*&
8epeaLed aLLacks of headache lasLlng 4-72hrs ln paLlenLs
wlLh a normal physlcal exam and no oLher reasonable
cause, and aL leasL 2 of:
unllaLeral paln,
Lhrobblng paln,
aggravaLlon by movemenL, or moderaLe/severe
lnLenslLy,
plus aL leasL one of:
nausea/vomlLlng or phoLophobla/phoLophonla.

More common ln women Lhan men.

.)0
Maln dlfferenLlal dlagnosls ls Lenslon headache. Mlgralne
can be dlsLlngulshed by Lhe assoclaLed sympLoms. A
dlsabllng headache ls more llkely mlgralne Lhan Lenslon
headache (asklng quesLlons such as ºhow many days have
you been unable Lo work due Lo headache" can be useful
ln deLermlnlng Lhls).

1%,2*324+"*5*#4
1he re ls no consensus as Lo Lhe exacL paLhophyslology of
mlgralne, only several Lheorles whlch are based on
varlous Lheorles such as neurologlcal, vascular and
chemlcal causes. ÞaLLerns of sympLoms dlffer accordlng Lo
focal areas of Lhe braln affecLed, such as slgns of
phoLophobla and oLher hypersenslLlvlLy Lo sensory sLlmull
belng due Lo focus ln areas such as Lhe cranlal nerve
nuclel.

Several neuroLransmlLLers lncludlng 3-P1 and dopamlne
(ln some subLypes) have been lmpllcaLed. CeneLlcs
suggesL some lnvolvemenL of genes codlng for lon-
channels.

6473,*7+ (llsLed ln order of prevalence)
• nausea
• ÞhoLophobla
• LlghL-headedness
• Scalp Lenderness
• vomlLlng
• vlsual dlsLurbances
• ÞarasLhaeslas
• verLlgo
• Syncope
• Selzure

8"+,*$4 %&. 90%7"&%,"*&

CfLen assoclaLed wlLh cerLaln Lrlggers, resulLlng ln a
mlgralne due Lo excesslve senslLlvlLy Lo sensory sLlmull
and lnLernal sLlmull. 1hls ls reflecLed ln Lhe hlsLory of
when mlgralnes occur. ln women, mlgralnes are more
common durlng mensLruaLlon. Lrlggers lnclude:
• Clare
• 8rlghL llghLs
• Sounds
• Punger
• Lxcess sLress
• Þhyslcal exerLlon
• 8aromeLrlc pressure changes
• Pormonal changes
• Lack of or excess sleep
• Alcohol and oLher chemlcals.

1rlggers may be followed by a prodromal or aura phase,
whlch can be experlence dlfferenLly ln many paLlenLs buL
essenLlally lnvolves focal neurologlcal phenomena such as
seelng coloured llghLs. 1hls ls Lhen followed by Lhe paln
phase, whlch may Lhen be followed ln some paLlenLs by a
posL-dromal phase, descrlbed as belng noL dlsslmllar Lo a
hangover.

!%&%#'7'&,
!'."-%5
Many dlfferenL drug Lheraples are used ln mlgralnes,
accordlng Lo whaL works besL for Lhe paLlenL. 1hese
lncluded, as sympLomaLlc LreaLmenL, nSAlus, 3-P1
agonlsLs and dopamlne agonlsLs. Some prevenLaLlve
medlcaLlons lnclude some anLldepressanLs and
anLlconvulsanLs.

:"/'+,45'
1rlgger avoldance ls lmporLanL ln Lhe managemenL of
acuLe mlgralnes. ln order for Lhls Lo be posslble, paLlenLs
musL be award of whaL Lhelr Lrlggers are. ln some cases,
regulaLlng everyday llfesLyle facLors ls helpful, lncludlng
regulaLlng dleL, exerclse, sleep paLLerns and avoldlng an
excess of caffelne, alcohol or sLress.

;*735"-%,"*&+
Mlgralne sufferers carry a much hlgher rlsk of sLroke,
parLlcular Lhose who have a prodromal aura as a
componenL of Lhelr mlgralne.
1PL uAnuLnCnC uCSSlL8 2010
93
!"#"$#%& (%")*##+%,"
-"./0/1/*0 234 !&%55/./6%1/*0
8efers Lo Lhe varlous areas one may haemorrhage wlLhln Lhe
cranlum. Speclflcally:
- Cerebral and cerebellar
- Subarachnold
- Subdural and exLradural

7/58 9%61*#5
All of Lhe below excepL for Lhe LraumaLlc ones have slmllar
rlsk facLors of Lhe sLandard vascular dlsease sLyle:

- PyperLenslon
- lamlly hlsLory
- Smoklng
- Lxcesslve alcohol consumpLlon

:"1/*&*,;3!%<5"5
=01#%6"#"$#%& (%")*##+%,"3(%")*##+%,/6 >1#*8"
8upLure of mlcroaneurlsms and degeneraLlon of small deep
peneLraLlng arLerles.
- PyperLenslon
- AnLlcoagulaLlon
- Aneurlsm rupLure
- ArLerlovenous malformaLlon rupLure
- SympaLhomlmeLlc drug use
- CoagulopaLhy
- 1rauma
- 1umours
- lnfecLlon

!"#"$"&&%# (%")*##+%,"
- PyperLenslon
- AnLlcoagulaLlon
- ArLerlovenous malformaLlon
- SympaLhomlmeLlc drug use
- 1umour
- uural leak
- Amylold AnglopaLhy

><$ :#%6+0*/? (%")*##+%,"
8erry aneurlsms or arLerlovenous malformaLlon. 8erry
aneurlsms are mosL commonly ln Lhe clrcle of Wlllls, aL Lhe
varlous [uncLlons. 1he blood Lhen spreads Lhrough Lhe CSl,
causlng globally ralsed lCÞ and lrrlLaLlon of Lhe menlnges.

><$?<#%& (%")*##+%,"
usually folows a head ln[ury, whlch need noL be severe,
especlally ln Lhe elderly. lL lnvolves Lhe accumulaLlon of
blood ln Lhe subdural space posL venous rupLure.

@A1#%?<#%& (%")*##+%,"
Mlddle Menlngeal arLery damage due Lo fracLure aL Lhe
pLerlon. 1hls resulLs ln Lhe rapld accumulaLlon of blood ln
Lhe epldural space, applylng pressure Lo surroundlng Llssue,
shlfLlng Lhe hemlspheres, evenLually conlng eLc.

B%1+*C+;5/*&*,;
noLhlng speclflcally lnLeresLlng here wlLh regard Lo dlsease
process for any of Lhe above, Lhey're all elLher lschaemla,
ralsed lCÞ, mass effecL or a comblnaLlon.

>/,05 %0? >;)C1*)5
=01#%6"#"$#%& (%")*##+%,"
SLroke sympLoms, varlable for Lhe locaLlon of Lhe
haemorrhage, as dlscussed ln anoLher noLe summary.
Paemorrhage Lends Lo have a more dramaLlc onseL wlLh a
severe headache, wlLh a greaLer llkellhood of coma Lhen
Lhromboembollc sLroke.

!"#"$"&&%# (%")*##+%,"
>;)C1*)5
- AbrupL headache onseL
- nausea/vomlLlng
- lnablllLy Lo walk
- ulzzlness/verLlgo
- uysarLhrla
- neck Þaln
- AlLered consclousness

>/,05
- Abnormal corneal responses
- Abnormal pupll responses
- lrregular resplraLlons
- Abnormal eye movemenLs
- Llmb aLaxla
- uysarLhrla
- nysLagmus
- Caze palsy (lpsl Lo haemaLoma)
- laclal weakness

><$ :#%6+0*/? (%")*##+%,"
lL ls lmporLanL noL Lo mlss 'senLlnal leaks'. 1hese leaks refer
Lo a mlnor blood leakage prlor Lo full haemorrhage, and
plcklng Lhem up early resulLs ln llves saved.
SympLoms lnclude: Peadaches, nausea, vomlLlng,
phoLophobla, malalse and neck paln. usually Lhere are no
slgns of elevaLed lCÞ.
Lxpanslon of an aneurysm may presenL wlLh sympLoms due
Lo Lhe mass effecL of Lhe leslon.
- ÞosLerlor communlcaLlng/lCA: reLro-orblLal headaches
and oculomoLor nerve palsy.
- MCA: ConLralaLeral face/hand paresls. Aphasla lf on Lhe
lefL. ConLralaLeral vlsual neglecL lf on Lhe rlghL.
- AnLerlor communlcaLlng: 8llaLeral leg paresls, bllaLeral
8ablnskl slgn.
- 8asllar arLery: verLlcal gaze, paresls, coma.
- ÞCA: verLlgo
9<&& $&*D0 +%")*##+%,"
SympLoms:
- 1hunderclap headache
- nausea/vomlLlng
- ÞhoLophobla/vlsual changes
- LCC, usually LranslenL
- Selzures
1PL uAnuLnCnC uCSSlL8 2010
94
Slgns:
- neurologlcal deflclLs of all Lhe varlous varleLles.
- 8eLlnal haemorrhages and papllloedema may be vlslble
- 8alsed 8Þ posslble
- 1achycardla posslble

!"#$"%&' )&*+,%%-&.*
AcuLe SuP:
1hls should be suspecLed wlLh any blunL head Lrauma.
Worry abouL alcohollcs, Lhey geL LhrombocyLopoenla and
are prone Lo Lrauma.
Worry abouL haemophlllacs and Lhe anLlcoagulaLed.
Look for slgns of Lrauma, change ln menLal sLaLe, CCS eLc.

Chronlc SuP:
Þrogresslve sympLoms: Peadache, personallLy changes, lCÞ
slgns, hemlparesls/plegla.

/01$"%&' )&*+,%%-&.*
Classlc plcLure ls Lrauma -> loss of consclousness -> lucldlLy -
> loss of consclousness -> deaLh.
1he above ls only Lhe case abouL 23° of Lhe Llme.

!2+03,+4
vomlLlng, severe headache, selzures

!1.54
lncreased lCÞ can = PyperLenslon, bradycardla, bradypnoea
= cushlng response.
uecreased CCS
LaceraLlon, bony sLep off ln Lhe area of ln[ury
Classlc Lrlad of hernlaLlon = Coma, flxed and dllaLed puplls,
decerebraLe posLurlng

657*431.&31,54
653%&8*%*#%&' )&*+,%%-&.*
- l8L, AÞ11, uLC, 1ox Screen
- C1
- M8l
- C1/M8/convenLlonal anglography
- Lumbar ÞuncLure

9*%*#*''&% )&*+,%%-&.*
- C1. Cf parLlcular lmporLance ls Lhe locaLlon of Lhe
haemaLoma (cenLral or lobar) and wheLher Lhere ls
bralnsLem compresslon.
- M8l

!"# :%&8-5,1$ )&*+,%%-&.*
- l8L, uLC, AÞ11, blood Lype
- C1
- Lumbar ÞuncLure
- Cerebral Anglography vla LradlLlonal, M8 or C1

!"#$"%&' )&*+,%%-&.*
- l8L, uLC, coags, blood maLchlng
- C1

/01$"%&' )&*+,%%-&.* As above

;&5&.*+*53
653%&8*%*#%&' )&*+,%%-&.*
;*$18&'
MosL of Lhe managemenL ls lnvolved ln sLablllslng paLlenLs
and mlnlmlslng ln[ury.
- lnLubaLlon
- uecrease 8Þ
- MalnLaln volume sLaLe
- CorrecL coagulopaLhy
- 1reaL selzures

!"%.18&'
- CranloLomy for cloL evacuaLlon under dlrecL vlslon
- Lndoscoplc cloL evacuaLlon
- SLereoLacLlc asplraLlon wlLh LhrombolyLlc agenLs

9*%*#*''&% )&*+,%%-&.*
;*$18&'
Cnly relevanL lf paLlenL ls elLher very mlnor or very ma[or,
where conservaLlve managemenL wlLh preparaLlon for
surgery lf degradaLlon occurs or palllaLlon respeLlvely are
used.
Cbvlously lf Lhere exlsLs hyperLenslon or coagulopaLhy one
would correcL Lhls vla Lhe approprlaLe drugs.

!"%.18&'
- CranloLomy for cloL evacuaLlon
- Lndoscoplc cloL evacuaLlon

!"# :%&8-5,1$ )&*+,%%-&.*
;*$18&'
- SLablllse paLlenL, lncludlng lnLubaLlon, full llnes eLc lf
needed.
- AnLl-hyperLenslves Lo 8Þ below 130mmPg
- Lnsure re-bleedlng, vasospasm, hydrocephalus,
hyponaLraemla, selzures, pulmonary compllcaLlons
and cardlac compllcaLlons are all LreaLed.

!"%.18&'
ueclslon based on grade
- Crade 1 - AsympLomaLlc or mlld headache
- Crade 2 - ModeraLe-Lo-severe headache, nuchal rlgldlLy,
and no neurologlcal deflclL oLher Lhan posslble
cranlal nerve palsy
- Crade 3 - Mlld alLeraLlon ln menLal sLaLus (confuslon,
leLhargy), mlld focal neurologlcal deflclL
- Crade 4 - SLupor and/or hemlparesls
- Crade 3 - ComaLose and/or decerebraLe rlgldlLy
Crades 1-3 = surgery
Crades 4-3 are more conLroverslal as Lhelr prognosls ls poor
elLher way.
Lndovascular opLlons are preferred ln more medlcally
unsLable paLlenLs.
MeLhods of surgery:
- ulrecL cllpplng
- Cugllelml ueLaLchable Colls
- 8aloon embollsaLlon (hlgher lncldence of compllcaLlons
Lhan CuC)
- Þroxlmal llgaLlon of Lhe parenL arLery (glanL aneurysms)
1PL uAnuLnCnC uCSSlL8 2010
93

CuC: A coll placed ln Lhe aneurysm endovascularly whlch
promoLes coagulaLlon and Lherefore sLops blood flow lnLo
Lhe sac, Lhus leavlng Lhe vessel wlLh a smooLh wall agaln.

!"#$"%&' )&*+,%%-&.*
/*$01&'
- SLablllse paLlenL, lnLubaLe lf necessary
- 8alse head Lo help venous dralnage
- 8urrholes can be used ln slgnlflcanL Lrauma
- MannlLol can help decrease lCÞ

!"%.01&'
CranloLomy and evacuaLlon of Lhe haemaLoma

230$"%&' )&*+,%%-&.*
- lnLubaLe
- LlevaLe head
- MannlLol for lCÞ
- ÞhenyLoln reduces lncldence of early posL LraumaLlc
selzures
8urr hole lf paLlenL rapldly deLerloraLlng, oLherwlse
neurosurgeons cranloLomy.

4,+3'01&50,67
865%&1*%*#%&' )&*+,%%-&.*
- Selzures
- Pydrocephalus
- neurologlcal ueflclLs
- AsplraLlon
- uv1/ÞL
- Cerebral PernlaLlon

4*%*#*''&% )&*+,%%-&.*
8ralnsLem compresslon/desLrucLlon
!"# 9%&1-6,0$ )&*+,%%-&.*
Cllpplng:
- Paemorrhage
- lschaemla
- uamage Lo parenL or perforaLlng arLerles
- laLrogenlc Lrauma leadlng Lo neurologlcal deflclLs
- MenlnglLls
- Wound lnfecLlon
Lndovascular:
- Aneurysm rupLure (CuC, balloon)
- 1hromboembollsm (CuC)
- 8alloon rupLure/deflaLlon

!"#$"%&' )&*+,%%-&.*
ÞosL Cp:
- lncreased lCÞ
- Cedema
- new/recurrenL bleedlng
- lnfecLlon
- Selzures

Chronlc:
- 8ecurrence
- lnfecLlon/empyema
- Selzures

230$"%&' )&*+,%%-&.*
- ÞosLconcusslve syndrome may lasL monLhs
- vegeLaLlve sLaLe
- ueaLh

1PL uAnuLnCnC uCSSlL8 2010
96
!"#
%&'()(*(+) ,-. /0122('(31*(+)

Classlcally descrlbed as cerebral lschaemlc sympLoms
lasLlng <24 hours, 1lA has now shlfLed Lo a deflnlLlon
more focused on ln[ury Lo Lhe cerebral Llssue. ºA
LranslenL eplsode of neurologlcal dysfuncLlon caused by
focal braln, splnal-cord, or reLlnal lschemla, wlLhouL acuLe
lnfarcLlon " ls Lhe currenL deflnlLlon.


4(25 613*+72
- P1n
- Smoklng
- Alcohol
- PypercholesLerolaemla
- Al
- CbeslLy
- ulabeLes
- CaroLld ArLery SLenosls
- 8alsed PaemaLocrlL

#&*(+0+89-/1:2&2

- ALherosclerosls - CaroLlds and verLebrals
- Lmbolls - valve dlsease, Al
- ArLerlal dlssecLlon
- ArLerlLls
- SympaLhomlmeLlc drugs, e.g. cocalne
- Mass leslons - 1umours, haemaLomas. 1hese are far
more ofLen assoclaLed wlLh perslsLlng sympLoms

;1*<+=<92(+0+89

1he mechanlsm ls lschaemla, see above for Lhe varlous
ways LhaL lschaemla can occur and refer Lo each for
speclflc paLhophyslology.

>(8)2 1)? >9@=*+@2

- Cranlal nerve deflclLs
- SomaLlc moLor/sensory deflclLs
- Speech deflclLs
- Cerebellar deflclLs
-
1he below may lndlcaLe orlgln:

- CaroLld brulL
- Murmurs (valvular leslons allow for emboll Lo form)
- Al on LCC

A(2*+79 1)? BC1@()1*(+)

noLhlng speclal, look for Lhe slgns and sympLoms above ln
your usual neuro exam.

")D&2*(81*(+)2

1he goal for lnvesLlgaLlons are Lhreefold:
- Conflrm cllnlcal dlagnosls
- ueLermlne Lhe aeLlology
- ulsLlngulsh beLween haemorrhaglc and
Lhromboembollc lnfarcLlon

C1 wlll show haemorrhaglc leslons lmmadlaLely, however
lnfarcLs may noL be vlslble. lnfarcLs are usually deLecLable
by one week buL 30° are never deLecLable vla C1.

ulffuslon WelghLed lmaglng M8 shows lnfarcLs wlLhln a
couple of mlnuLes.

CaroLld doppler are useful for screenlng for caroLld
sLenosls or occluslon.

E1)18&@&)*

ManagemenL ls dependenL on Lhe aeLlology of Lhe
dlsease, so LhaL full blown sLroke may be prevenLed.

E&?(310

AnLlhyperLenslves

AnLlplaLeleL Lherapy. LlLher asplrln by lLself or wlLh
dlpylrldamole or clopldogrel.

AnLlcoagulanLs - lf Lhere ls Al or valve leslons

>:78(310

lnLernal CaroLld LndarLerecLomy

valve replacemenL
F('&2*90& - Cnly lf relevanL

/+@=0(31*(+)2
use of anLlhyperLenslves musL be slow ln onseL as
oLherwlse Lhere ls a rlsk of hypoperfuslon.
use of anLlcoagulanLs carrles rlsk of haemorrhage.
Asplrln lncreases rlsk of pepLlc ulcers.
1PL uAnuLnCnC uCSSlL8 2010
97
!"#$%#& ()"*) +#&,-
.lor all Lhe below M8l and C1 are Lhe besL lnvesLlgaLlons,
LreaLmenL varles wlldly dependlng on aeLlology.

. / 0&1#234"-

Smell recepLors ln Lhe nasal mucosa - Lhrough Lhe
crlblform plaLe - synapse ln Lhe olfacLory bulb.

Anosmla ls caused by Lumours of Lhe olfacLory groove or
any head ln[ury dlsrupLlng Lhe crlblform plaLe. Sense of
smell may be losL by vlral upper resplraLory LracL
lnfecLlons.

5 / 063%2

1he paLhway ls besL shown ln a plcLure, whlch also shows
Lhe locaLlons of leslons LhaL glve Lhe varlous vlsual fleld
defecLs:

7%,8#& 1%)&9 9)1)23,: 1he followlng lnformaLlon wlll refer
Lo Lhe numbers labelllng reglons ln Lhe above plcLure.
- ;)3%$#& #$9 )-) &),%4$, <.=: 8eLlnal leslons produce
scoLomaLa (small areas of loss) or Lunnel vlslon. ulabeLlc
vascular dlsease, glaucoma and local leslons of Lhe eye
llke caLaracL can cause Lhe above.
- 063%2 $)"*) &),%4$, <5=: 1hls ls classlcally unllaLeral
vlsual loss commenclng wlLh a cenLral or paracenLral
scoLomaLa. 1oLal leslon causes unllaLeral bllndness wlLh
loss of boLh dlrecL and consensual puplllary reflex. Cn
fundoscopy Lhe dlsc looks swollen and hyperaemlc.
Some causes:
- CpLlc neurlLls (MS)
- Compresslon (aneurysm, Lumour)
- Syphllls
- 1rauma
- lnfecLlve (paranasal slnuses, orblLal cellullLls)
- Severe anaemla
- 1oxlc (Lobacco, meLhyl alcohol, qulnlne)
- Any cause of papllloedema (opLlc dlsc swelllng, Lhere
are many, look Lhem up lf you're lnLeresLed lL's noL really
lmporLanL)

+86%&,: SympaLheLlc dllaLes, parasympaLheLlc consLrlcLs.
- AfferenL nerve defecL resulLs ln loss of dlrecL reflex buL
malnLenance of consensual.
- Porner's = leslon of sympaLheLlc paLhway lpsllaLerally.
Agaln many causes, relevanL Lo us ls Lhe neck paLhology.

3, 4, 6 - CculomoLor, 1rochlear and Abducens

1he above nerves are ln charge of all Lhe eye movemenLs,
wlLh Lrochlear belng lnferomedlal and abducens belng
laLeral. 1here's loLs of complex sLuff Lo be sald
abouLwhlch reglon of Lhe braln ls ln charge of whaL buL
lL's noL really lmporLanL. AlmosL all paLhology of Lhese
nerves wlll be due Lo lnfarcLlon, Lumour or aneurysm.
- 028&4>434": A leslon wlll leave Lhe eye polnLlng
lnferolaLerally, wlLh a flxed and dllaLed pupll and
unllaLeral compleLe pLosls.
- ?"42@&)#": ÞaLlenL wlll complaln of dlplopla when
aLLempLlng Lo look down and away from Lhe affecLed slde.
- AB982)$,: no abducLlon beyond mldllne.

3 - 1rlgemlnal

Large and mosLly sensory, buL also Lakes care of
masLlcaLlon. 1hree dlvlslons - opLhalmlc, maxlllary,
mandlbular. A compleLe leslon wlll leave unllaLeral
sensory loss of Lhe face, Longue and buccal mucosa.
Causes are MS, lnfarcLlon, Lumours, cavernous slnus
paLhology, herpes zosLer.

7 - laclal

1akes care of faclal expresslon, wlLh a llLLle blL of sensory
from Lhe anL 2/3 of Lhe Longue vla Lhe chorda Lympanl.
C4D)" >434" $)8"4$) &),%4$,: Weakness of all faclal
expresslon muscles. Weakness of eye closure and
frownlng are presenL (corneal ulceraLlon posslble).
E66)" >434" $)8"4$) &),%4$,: ConLralaLeral Lo Lhe leslon
and fronLalls ls spared (frownlng works as does eye
closure).

Causes:
- EF( - lnfracLlon, Lumour, Lhe usual.
- CF( - leslons occur aL speclflc areas.
+4$,: 6
Lh
and 7
Lh
LogeLher, Lherefore leslons here glve
laLeral recLus palsy + unllaLeral faclal weakness. 1umours,
aneurysm, demyellnaLlon.
!)")B)&&464$3%$) #$G&): 3
Lh
, 6
Lh
, 8
Lh
all LogeLher here,
acousLlc neuroma, oLher Lumours, meLs.
+)3"48, B4$): 1rauma, mlddle ear lnfecLlon, herpes
zosLer (ramsay hunL syndrome), Lumours.
H#,) 41 ,I8&&J 6#"43%9J 1#2): 1umours, pageL's dlsease,
skull fracLures, paroLld Lumours, mumps.

H)&&K, +#&,-: vlral lnfecLlon causlng acuLe lsolaLed faclal
palsy. usually lmproves sponLaneously, full recovery may
Lake 12 monLhs.

8 - vesLlbulocochlear

!42@&)#": ueafness and LlnnlLus. Cllnlcally deLecLable
uslng Webber and 8lnne.
7),3%B8&#": verLlgo and loss of balance. nysLagmus ls Lhe
prlnclpal slgn, vomlLlng ofLen accompanles verLlgo.

Causes:
- !)")B"#& !4"3)L: May be parL of Lhe aura of a parLlal
selzure.
- +4$, #$9 B"#%$,3)>: MS, Lumour, vascular. May
lnvolve 6
Lh
or 7
Lh
.
- !)")B)&&8>: nysLagmus Lowards Lhe slde of Lhe mass,
llmb aLaxla.
1PL uAnuLnCnC uCSSlL8 2010
98
- !"#"$"%%&'&()*(" ,(-%". AcousLlc neuroma, oLher
Lumours, lnflammaLlon. Sensorlneural deafness and
verLlgo, ofLen wlLh nysLagmus, and wlLh sympLoms from
Lhe oLher lnvolved nerves lf Lhere are any.
- /")#&01 $&(". 1rauma, mlddle ear lnfecLlon,
ÞageL's. 7
Lh
sympLoms accompany ofLen.
- Cochlear and semlclrcular canals:
Menlere's
urugs (genLamlcln)
AcousLlc Lrauma
Mlddle ear lnfecLlon
Mumps
Age

9, 10, 11, 12 - Clossopharangeal, vagus, Accessory,
Pypoglossal

9, 10, 11 all follow Lhe same paLh Lhrough Lhe [ugular
foramen, and so are ofLen affecLed slmulLaneously.
Pypoglossal has lLs own canal, however conLlnues lLs paLh
ln close proxlmlLy Lo Lhe oLhers ouLslde Lhe skull.

2 Lakes care of sensaLlon of Lhe pharynx, posLerlor Lhlrd of
Lhe Longue and Lonslllar fossa, sensory parL of Lhe gag
reflex and auLonomlc flbres Lo Lhe paroLld gland.

34 ls largely moLor, supplles Lhe sLrlaLed muscle of Lhe
pharynx, Lhe moLor parL of Lhe gag reflex, Lhe larynx
(recurrenL laryngeal nerves for vocal cords) and upper
oesophagus. Clves parasympaLheLlc supply Lo Lhe hearL
and abdomlnal vlscera.

33 supplles Lrapezlus and sLernomasLold.

35 supplles Lhe Longue. uevlaLlon Lowards Lhe weakened
slde, wlLh wasLlng and fasclculaLlon accompanylng
weakness.

Causes:
- lnfarcLlon
- MoLor neurone dlsease
- 1umours
- 1rauma
- !ugular venous Lhrombosls

9 and 10 are very rarely affecLed ln lsolaLlon.

Causes of 8Ln Þalsy:
- MedlasLlnal Lumours
- 8ronchus carclnoma
- AorLlc arch aneurysm
- 1rauma or neck surgery

1PL uAnuLnCnC uCSSlL8 2010
99
!"#$%& ()*+ ,#-.%-.
,./#$#0#)$ 123 (&%--#/#4%0#)$
()5"*.--#)$ - laLeral compresslve leslon (unllaLeral
[brown sequard syndrome] or compleLe cord), cenLral
cord leslon, cauda equlna leslons, and verLebral column
abnormallLles
,.56.&#$%0#)$
7%-48&%*

9.0#)&):62(%8-.-
Compresslon
verLebral - 0*%85%, dlsc prolapse, Lumour, lnfecLlon
• 4.*;#4%& -")$+6&)-#- 3 CA of splne causlng
osLeophyLlc ouLgrowLhs narrows splnal canal
o sLlff, palnful neck
o shoulder, arm or chesL paln
o plns and needles/numbness ln parL of arm or
hand
o problems wlLh walklng/bladder, clumsy
hands

LxLra-dural - lymphoma, 5.0%-0%-.- (verLebral or
menlngeal deposlLs), lnfecLlon eg. Abscess
lnLra-dural, exLramedullary - Lumour (menlngloma,
neuroflbroma)

lnLramedullary - Lumour (glloma, ependymoma),
syrlngomyella (Þ+1 loss ln 'cape' dlsLrlbuLlon, amyoLrophy
uL, uMn slgns LL, Lhoraclc scollosls)

uemyellnaLlon - <8&0#"&. -4&.*)-#-= vlL 812 deflclency
(subacuLe comblned degeneraLlon of Lhe cord) - loss of
posLerlor column plus uMn slgns ln llmbs

vascular - Av malformaLlon (due Lo hemaLoma, lncreased
venous pressure)

>%0?)"?6-#)&):6
!.:5.$0%& -#:$- (dlsLurbed sensory lnpuL, reflex acLlvlLy
and LMn ouLflow aL LhaL lvl)
• Þaln ln splne aL lvl of leslon (paLhologlcal causaLlve
process), Þaln, paraesLheslae ln relevanL dermaLome
(dorsal nerve rooL/horn lnvolvemenL), LMn slgns ln
relevanL myoLome
lnLerference wlLh ascendlng and descendlng LracLs
(laLeral/venLral corLlcosplnal, posLerlor column, laLeral
splnoLhalamlc, poorly deflned paLhways for bladder,
bowel, sexual fx) glve 0*%40 -#:$-

!#:$- %$+ !65"0)5-
()5"&.0. 4)*+ &.-#)$ -1racL slgns: uMn slgns ofLen wlLh
asymmeLrlc dlsLrlbuLlon, flaccld llmbs, sensory
lmpalrmenL of all modallLles up Lo Lhe lvl of leslon,
bladder lnvolvemenL
@*)A$ -.B8%*+ -6$+*)5. (however usually a mlxed
plcLure)
• 1racL slgns: uMn slgns on slde of leslon, sensory -
lpsllaLeral proprlocepLlon and llghL Louch loss, and
paln and LemperaLure on conLralaLeral slde, bladder
sympLoms lnfrequenL
• SegmenLal slgns, buL overlap from ad[acenL rooLs may
prevenL deLecLlon of sensory deflclL
(.$0*%& 4)*+ &.-#)$
• ulssoclaLed sensory loss (paln and Lemp), LMn slgns
exLend for several segmenLs, uMn slgns ln lower
llmbs (laLe onseL), sacral sparlng, rooL palns rare
(%8+% .B8#$% &.-#)$- - LMn weakness ln planLarflexors,
everLors, absenL ankle [erk, 'saddle' anaesLhesla, overflow
and faecal lnconLlnence

CD%5#$%0#)$
Lower llmbs - deLermlne lvl of sensory lmpalrmenL
8ack - slgns of a local leslon (look: deformlLy, scars,
palpaLe: verLebral Lenderness, ausculLaLe: brulLs)
upper llmbs/Cn - deLermlne upper lvl

E$;.-0#:%0#)$-
• x-ray - collapse of verLebral body (mallgnancy,
lnfecLlon), dlsc space narrowlng (spondylosls)
• <FE (whole lengLh of cord) - reveal paLhology, need
for surglcal lnLervenLlon and areas of demyellnaLlon
• C1 myelography - conLrasL lnLo cervlcal or lumbar
splne
lf no compresslve/lnLrlnslc leslon
• CSl analysls, nCS, M8l-8 (for MS), LMC sLudles
(moLor neuron dlsease), serum 8-12

<%$%:.5.$0
(%8-.: 1rauma - lv sLerolds, resLoraLlon of allgnmenL,
MallgnanL dlsease, spondyloLlc myelopaLhy, exLradural
abscess, Lhoraclc dlsc, neuroflbroma - Surglcal
decompresslon
!G#$ - rellef pressure
H#5I- - frequenL passlve movemenL and sLocklngs
@&%++.*2I)A.&- - caLheLerlzaLlon, flulds, laxaLlves
1PL uAnuLnCnC uCSSlL8 2010
100
Dement|a
Def|n|t|on
Acqulred perslsLenL (usually lrreverslble even afLer
underlylng cause removed) and progresslve lmpalrmenL ln
lnLellecLual funcLlon, wlLh compromlse of memory and aL
leasL one oLher cognlLlve domaln (e.g. apraxla, agnosla,
lmpalred execuLlve funcLlon).

C|ass|f|cat|on
A|zhe|mer's: mosL common demenLla (20-40° of Lhe 83+
populaLlon). Lxcesslve accumulaLlon of amylold proLelns
called ollgomers ! formaLlon of amy|o|d p|aques whlch
conLaln µ amylold + oLher proLelns/ are surrounded by
debrls e.g. macrophages. 1here ls also accumulaLlon of
palred hellcal fllamenL proLelns ln neuronal cyLoplasm,
known as neurof|br|||ary tang|es (nl1s), whlch form when
Lau (proLeln essenLlal for normal neuron funcLlon) ls
overly-phosphorylaLed. 1he hlppocampus and Lemporal
corLex are Lhe areas mosL affecLed.

lmaglng shows d|ffuse atrophy of the cerebra| cortex
w|th ventr|cu|ar en|argement. Common cllnlcal feaLures
• lnsldlous onseL of memory |mpa|rment
• lncreaslng language (namlng ! comprehenslon
! fluency) or vlslospaLlal defecLs
• Apraxla and agnosla
• Þrogresslve loss of execuLlve funcLlon
• 8ehavloural change e.g. dlslnhlblLlon, aggresslon
• Loss of lnslghL and [udgemenL
• uepresslon, deluslons.

8x may lnclude chollnesLerase lnhlblLors e.g. rlvasLlgmlne,
anLl-psychoLlcs e.g. rlsperldone and anxlolyLlcs e.g.
oxazepam. Soclal, emoLlonal and envlronmenLal supporLs
are also lmporLanL.

Dement|a w|th Lewy 8od|es: f|uctuat|ng cogn|t|on wlLh
pronounced varlaLlon ln aLLenLlon and alerLness. Memory
loss ls less common, whllsL Þarklnsonlsm, vlsual
halluclnaLlons, depresslon and sleep dlsorders are
common. Lewy 8od|es (sLralghL neurofllamenLs LhaL sLaln
wlLh ÞAS found ln corLex, amygdala, subsLanLla nlgra) are
promlnenL aL auLopsy. 8x as ln Alzhelmer's.

Vascu|ar (mu|t|-|nfarct) dement|a: hlsLory of 1lAs wlLh
|rregu|ar stepw|se dec||ne, hlsLory of
Al/uM/Þvu/hyperLenslon. varled cognlLlve and moLor
defecLs dependlng on whlch vessel has been occluded. 8x
lnvolves managemenL of underlylng rlsk facLors e.g.
hyperLenslon Lo mlnlmlse fuLure evenLs, lL ls noL posslble
Lo reverse damage.

Irontotempora| |obe dement|a: affecLs Lhose ln Lhelr 40s-
60s, Lwlce as common ln men. Sl and sx lnclude
progress|ve d|s|nh|b|t|on and persona||ty deter|orat|on,
welghL galn or food obsesslon, apaLhy, loss of execuLlve
funcLlon, decllne ln language skllls. 8elaLlve spar|ng of
memory. Cn examlnaLlon, paLlenLs have axlal rlgldlLy,
supranuclear gaze palsy (lmpalred ablllLy Lo look
upwards), or feaLures of amyoLrophlc laLeral sclerosls (sl
and sx of upper and lower moLor neuron dlsease).

SLrong geneLlc llnk, muLaLlon ln !"# or %&"'#()' genes
(boLh on chromosome 17) ! neurodegeneraLlon. lmaglng
shows aLrophy of Lhe fronLal and Lemporal lobes, can also
lnvolve basal ganglla. Mlcroscoplcally, Lhere ls gllosls,
sponglosus, and loss of neurons. Called Þlck's dlsease lf
sllver sLalnlng ! 'Þ|ck bod|es'. 8x ls sympLomaLlc, noL
posslble Lo slow dlsease progresslon.

Þrogress|ve supranuc|ear pa|sy: degeneraLlon of Lhe basal
ganglla, bralnsLem and neocorLex. lncldence peaks ln 60s
and ls more common ln men Lhan women, however ls
qulLe rare. 8eglns wlLh unexp|a|ned fa||s and vert|ca| gaze
def|c|ts ! symmeLrlcal axlal rlgldlLy, dysphasla,
dysphagla, apaLhy, loss of execuLlve funcLlon, poor
[udgemenL. Lyes reLaln oculocephallc reflexes -known as
do||'s head ref|ex - desplLe llmlLed volunLary movemenL.
Mlcroscopy shows abnormal accumulaLlon of nl1s ln
subcorLlcal sLrucLures and neocorLex, Lhough Lhey conslsL
of sLralghL Lubules (cf palred hellcal fllamenLs ln
Alzhelmer's). 8x: llmlLed response Lo levodopa, deaLh
occurs wlLhln 3-10 years of onseL.

n|story
• CnseL, duraLlon and progresslon of Lhe demenLla
• MMSL
• luncLlonal assessmenL
• neuropsychlaLrlc assessmenL

Invest|gat|ons
• 8loods: l8L, uLC, 1SP, vlL 812, ? Ll1s, ? vlral
serology
• ? MSu/ lumbar puncLure/ Cx8
• lmaglng: C1 or M8l

1PL uAnuLnCnC uCSSlL8 2010
101
!"#$%&#'(#)*$ ,-'%$."$'
/0*'12"3-* 4$*5-'
ulsorder of Lhe nM!, ln whlch lgC anLlbodles Lo Ach
recepLor proLeln are found, resulLlng ln lmmune complex
deposlLs ln Lhe posL-synapLlc membrane, causlng
lnLerference wlLh and desLroylng Lhe Ach recepLor.
Cardlac muscle ls spared. 1wlce as common ln women,
wlLh an average age of 30-40.

Cause ls unknown. MC ls sLrongly assoclaLed wlLh
Lhymoma (mechanlsm unknown). 1ranslenL MC can resulL
as a SL of some drugs.

Cllnlcal presenLaLlon: MC ls characLerlsed by Lhe
faLlguablllLy dlsplayed by muscles. Þroxlmal llmb muscles,
exLraocular muscles, and faclal muscles are mosL
commonly affecLed ln Lhe early sLages. 8esplraLory
dlfflculLles may occur (a feellng of shorLness of breaLh),
dysphagla may also occur. ÞLosls ls common, parLlcularly
worsenlng LhroughouL Lhe day. 8eflexes are lnlLlally
presenL buL may faLlgue.

1reaLmenL ls wlLh oral anLlchollnesLerases
(pyrldosLlgmlne) whlch have SLs such as dlarrhoea
(reduced by aLroplne). 1hese asslsL wlLh Lhe weakness buL
do noL alLer Lhe course of MC. 1hymecLomy helps
prognosls wlLh or wlLhouL Lhe presence of a Lhymoma,
parLlcularly ln Ab+ women under Lhe age of 40 who have
had MC for >7yrs.

Lven medlcaLed, myasLhenlc crlses can occur, ofLen
broughL on by lnfecLlon or drugs.


4#-))*-367*$$8 903.$%&"
An acuLe polyneuropaLhy, C8S occurs as an auLoallergenlc
reacLlon followlng an lnfecLlon (mosL commonly CMv or
C.l. lnfecLlon by C.[e[unl). SympLoms occur 1-3 weeks posL
lnfecLlon. lL ls normally demyellnaLlng, and monophaslc
(you can'L geL lL Lwlce).

Cllnlcal presenLaLlon: ÞaLlenLs Lyplcally presenL wlLh
muscle weakness LhaL flrsL affecLs Lhe dlsLal parL of Lhe
lower llmbs bllaLerally and ascends, progresslvely
worsenlng over days Lo weeks. Mlld cases may only
lnvolve Lhe lower llmbs buL ln severe cases Lhe muscles of
resplraLlon and faclal muscles may be affecLed, requlred
venLllaLory supporL (poLenLlally for monLhs).

Cn examlnaLlon Lhere ls a loss of Lendon reflexes (an
lmporLanL dlsLlngulshlng characLerlsLlc). Weakness ls
bllaLeral. SensaLlon should be lnLacL. ulagnosls ls
conflrmed by nerve conducLlon sLudles.

1reaLmenL ls wlLh lv lmmunmoglobullns. 13° of cases dle
(mosLly due Lo resplraLory depresslon or compllcaLlons
from long-Lerm lnLubaLlon) or are dlsabled.

Mlller-llsher syndrome ls a rare proxlmal form of Lhe
dlsease causlng ocular muscle palsles and aLaxla.


/%1%$6!"#$%3" ,-'"*'"
Þrogresslve degeneraLlve dlsease of boLh lower and upper
moLor neurones ln Lhe splnal cord, cranlal nerve nuclel
and corLex. ln mosL cases, Mnu ls sporadlc and cause ls
unknown.

Cllnlcally, four broad paLLerns are seen:
- progresslve muscular aLrophy - beglns ln small
muscles of Lhe hand, may begln unllaLerally buL
becomes bllaLeral, fasclculaLlon ls common. Cramps
may occur buL nC1 paln. Wldespread weakness and
wasLlng wlLh fasclculaLlons. 1endon reflexes may be
lncreased or absenL.
- amyoLrophlc laLeral sclerosls - very slmllar Lo above.
Mnu ls known as ALS ln Lhe uSA.
- progresslve bulbar and pseudobulbar palsy -
dysarLhrla, dysphagla, nasal regurglLaLlon of flulds and
choklng are common sx.
- prlmary laLeral sclerosls (rare form)
1hese are noL dlagnosLlc buL useful for recognlslng Mnu.

Lye movemenLs are always unaffecLed ln Mnu. 1he
sensory sysLem ls spared. Þresence of upper and moLor
neurone slgns wlLh absence of anoLher explanaLlon ls a
sLrong dlagnosLlc lndlcaLor on examlnaLlon.

ulagnosls ls cllnlcal, buL can be conflrmed wlLh LMC and
nerve conducLlon sLudles. 1here ls no known LreaLmenL Lo
lnfluence ouLcome. Survlval >3yrs ls unusual.
1PL uAnuLnCnC uCSSlL8 2010
102
!"#$%&#' )*#'+,-%-
• MS ls an lnflammaLory, demyellnaLlng dlsease of
Lhe cenLral nervous sysLem
• More common ln people who llve far away from
Lhe equaLor
• More common ln young adulLs (20-40)
!"#$%!$&'(%)%*&
• Cause ls unknown
o Commonly LhoughL Lo be auLolmmune wlLh
unknown anLlgen
o AuLolmmune reacLlon Lrlggers for MS are
geneLlcs and famlllal lncldence, lnfecLlons
(vlruses) and dleL (hlgh ln anlmal faL)
o Chlldhood sun exposure ls LhoughL Lo be
proLecLlve for MS
• lnvolves lnflammaLory process agalnsL self
molecules ln Lhe whlLe maLLer of Lhe braln and
splnal cord medlaLed by Cu4 1-cells
• Myelln ls desLroyed and replaced by scars of
hardened scleroLlc plaques
• Þlaques are dlssemlnaLed ln boLh Llme and place
• Leslons occur ln Lhe whlLe maLLer of Lhe
braln(perlvenLrlcular reglons, bralnsLem,
cerebellar connecLlons),splnal cord and ln Cnll
• AcuLe relapses caused by focal lnflammaLory
demyellnaLlon causlng conducLlon block
• 8emlsslon follows as lnflammaLlon subsldes(
remyellnaLlon occurs and helps recovery)
,)(-(,") '!.,#/01
• number of paLLerns of Lhe dlsease
/23456789 48: ;2<7==789
• ÞL presenLs wlLh eplsodes of monophaslc
neurologlcal dlsLurbance wlLh reLurn Lo normal ln
bLwn aLLacks

/23456789 5;>9;2667?2
• SLarLs as relapslng remlLLlng buL paLlenL develops
progresslve dlsablllLy
!;7<4;@ 5;>9;2667?2
Slow lnsldlous onseL and sLeady worsenlng of sympLoms
,%11%- ,)(-(,") !/.'.-#"#(%-
effecLs Sx
CpLlc neuropaLhy 8lurred vlslon ln one
eye mosLly, rarely
bllndness
8ralnsLem
demyellnaLlon
Sudden dlplopla,verLlgo
wlLh nysLagmus buL
wlLhouL LlnnlLus and
deafness
Splnal cord leslon SpasLlc-paraparesls-
dlfflculLy walklng and
numbness
urlnary sympLoms
common
unusual presenLaLlons Lpllepsy and Lrlgemlnal
neuralgla


A(BB./.-#(") A("*-%'('
• Culllaln-barre syndrome
• AcuLe dlssemlnaLed encephalomyellLls
• CvA
• Splnal cord compresslon

(-C.'#(*"#(%-'
• !./ -show plagues ln whlLe maLLer
• Lumbar puncLure-ollgoclonal lgC bands
• ulagnosLlc crlLerla for MS-Macuonald crlLerla

#/."#1.-#
• lmmunomodulaLors-lnLerfero beLa and
glaLlramer
• naLurally occurrlng anLl-vlral and
lmmunomudulaLory subsLances
• lmmunosuppressanLs-meLhoLrexaLe and
AzaLhloprlne


!"# %&'%#'(') %(**+#, -./.
/.0
!"#$%&"#'($)" +'#"
1PL uAnuLnCnC uCSSlL8 2010
104
!"#$%&'()*'+"#%,-#& /0++-#,
1*2"3","-3'
415
6
: 1he fracLlon of uellvered oxygen (Lhe concenLraLlon
dellvered Lo Lhe alrway (face)).
4"5
6
: 1he fracLlon of lnsplred oxygen (Lhe concenLraLlon of
oxygen LhaL enLers Lhe lungs).

738"9%,"-3' 2-# -:&;*3 ,<*#%+&
• Cardlac and resplraLory arresL
• Pypoxaemla (ÞaC
2
< 60mmPg, SpC
2
< 90°)
• PypoLenslon (sysLollc pressure < 100mmPg)
• Low cardlac ouLpuL and meLabollc acldosls
• 8esplraLory dlsLress (88 > 24/mln)
• Þerl-operaLlve phase
• 1rauma and oLher acuLe serlous condlLlons
• CondlLlons where drugs may reduce resplraLory
raLe/depLh
• SuspecLed carbon monoxlde polsonlng
• Anaemla

!8="3"',#%,"-3 -2 5:&;*3

>-$ 2?-$ 8*@"9*':
Also called varlable performance because Lhe lnsplred C
2

concenLraLlon recelved by Lhe paLlenL can vary.
• !"#"$ &"''($":
o MosL commonly used devlce
o AdmlnlsLraLlon aL 4m L/mln (or less)
o Can be used aL very low flows ln chlldren
o llow raLes aL below 4 L/mln do noL need Lo be
humldlfled
o ÞaLlenLs can eaL, drlnk and Lalk
o 1-2 L/mln glves 24-28° C
2

o 2-4L/mln glves 28-36° C
2

o 4-6L/mln glves 36-44° C
2

• )*+,(- &.'&*'/0"/,.' -"#1#
o llC2 ls lncreased by exLendlng Lhe
anaLomlc reservolr Lo lnclude Lhe volume
wlLhln Lhe mask
o LxhalaLlon porLs permlL enLralnmenL of
room alr Lo dlluLe oxygen and permlL
paLlenL Lo exhale
o ApproxlmaLe llC2:
! 3 L/mln glves 33° C
2

! 6 L/mln glves 40° C
2

! 8 L/mln glves 30° C
2

o llow musL be aL leasL 3 L/mln Lo wash ouL
CC
2

o Can be uncomforLable, clausLrophoblc and
hoL ln Lhe face
o May be used when nosLrll unavallable for
cannula
• 2,34 &.'&*'/0"/,.' -"#1#
o Þrovldes Lhe hlghesL oxygen concenLraLlons
o llows of 10-13 L/mln up Lo 80°
o llow musL always be hlgh enough Lo ensure
Lhe reservolr bag does noL collapse
o lndlcaLlons for use (lnlLlal resusclLaLlon of only
severely LraumaLlsed paLlenLs):
! Shock
! 8urns
! Carbon monoxlde polsonlng

A";< 2?-$ 8*@"9*':
Also called flxed performance. 1hese devlces dellver 30-
40L/mln of gas wlLh a flxed oxygen concenLraLlon by
dlluLlon of oxygen wlLh room alr, Lhrough a venLurl valve.
• 5*'/(0, -"#1#
o !"#$%& ($)&*#" +,-.-
! Þreclse oxygen concenLraLlons from 24°-
60°
! no need Lo humldlfy oxygen
! ÞaLlenLs wlLh chronlc lung dlsease and
CC
2
reLenLlon whose venLllaLlon ls
dependenL on hypoxlc drlve
! Cver-oxygenaLlon produces resplraLory
depresslon wlLh lncreased CC
2
reLenLlon
o /01*-&,23$ ($)&*#" +,-.-
! Cxygen concenLraLlon can be changed
qulckly
! 8educLlon ln sLock levels
! Avallable wlLh or wlLhouL humldlflcaLlon
! PumldlflcaLlon
" 8ubble humldlfler
# Aquaflow bubble humldlfler
" Pumldlfler nebullser: ueslgned for
dellverlng accuraLe concenLraLlons of
humldlfled alr/oxygen mlxLures, quleLly
# AquamlsL
# Aquapak
• 2,34 6$.7 '"#"$
o CpLlmal humldlflcaLlon for enLlre breaLh
o lmproved comforL and compllance
o lmproved oxygenaLlon due Lo flshlng of
naLural dead space
o CeneraLlon of CÞAÞ
• 8.(9$* 6$.7 :;("<"1
o 1o lncrease Lhe llC
2
dellvery a slde arm wlLh C
2
Lublng may be added and connecLed Lo an C
2

flow meLre, Lhus enabllng boLh exLra pressure
and oxygenaLlon Lo be dellvered
• =(#1#
o 1usks creaLe reservolr of C
2
oLherwlse wasLed
durlng explraLlon
o lf any gas ls enLralned Lhrough Lhe mask lL wlll
be C
2
lnsLead of room alr

4-# %?? 8*@"9*' B*$%#* -2 -:&;*3 ,-:"9",&C

D-3E"3@%'"@* F-'","@* F#*''0#* G*3,"?%,"-3
• HF!F
o ConLlnuous ÞoslLlve Alrway Þressure
1PL uAnuLnCnC uCSSlL8 2010
103
o CÞAÞ sysLems supply a consLanL poslLlve
pressure Lo Lhe alrways durlng Lhe enLlre
resplraLory cycle
o SLops alveoll from collapslng durlng explraLlon
o 8ecrulLs collapsed alveoll
o lncreases funcLlonal reserve capaclLy
o uecrease oxygen requlremenLs
o normally seL aL 3-10cm P
2
C
o 8ecause CÞAÞ causes gas Lrapplng lL may noL be
used ln asLhma
o !"#$%&'$(") +(, -./.
! SponLaneous breaLhlng paLlenL wlLh
acuLe hypoxla due Lo: AÞC and
aLelecLasls
! 1o decrease work of breaLhlng ln:
AsLhma and CCÞu
• 0$./.
o 8lphaslc ÞoslLlve Alrways Þressure
o 2 levels of alrway pressure are seL:
! lnsplraLory ÞoslLlve Alrways Þressure (lÞAÞ)
! LxplraLory ÞosLlve Alrways Þressure (LÞAÞ)
o lÞAÞ ls llke ÞoslLlve SupporL
o LÞAÞ ls Lhe same as CÞAÞ
o 8lÞAÞ ls CÞAÞ wlLh Þressure SupporL
o Þressure SupporL:
! SeL Lo provlde a poslLlve lnsplraLory pressure
durlng sponLaneous breaLhlng
! 1hls makes breaLhlng ln easler and lncreases
Lldal volumes
! lL decreases Lhe work of breaLhlng
! normally seL aL 10cm P
2
C above CÞAÞ level
or Lo a LargeL 1ldal volume
o !"#$%&'$(") +(, 0$./.
! Pypercapnlc resplraLory fallure:
" neuromuscular dlsorders
" ChesL wall and guL abnormallLles
" Sleep apnoea
! AcuLe chronlc lung dlsease
! 1o prevenL resplraLory muscle faLlgue

!"1&)$12 12"'$3&'$("
!"'45&'$("
• A Lube ls lnserLed Lhrough Lhe mouLh down lnLo Lhe
Lrachea (Lhe large alrway from Lhe mouLh Lo Lhe
lungs). 8efore surgery, Lhls ls ofLen done under
deep sedaLlon. ln emergency slLuaLlons, Lhe paLlenL
ls ofLen unconsclous aL Lhe Llme of Lhls procedure.

-(673$%&'$(") (+ &))$)'2# 12"'$3&'$("
• Þressure areas
• ÞoslLlve chesL pressures cause:
! uecreased venous reLurn
! uecreased sLroke volume
! uecreased blood pressure
! lncreased dead space
! lncreased rlsk of baroLraumas
• May lncrease lnLracranlal pressure
• Alr ln sLomach wlLh rlsk of asplraLlon
• ClausLrophobla and paLlenL dlsLress
• Lye lrrlLaLlons

1PL uAnuLnCnC uCSSlL8 2010
106
!"##$ &'()*+,*-#)*
./+-)-0-#) 123 4"(**-+-5(0-#)
8lood Lransfuslon: process of Lransferrlng blood or blood-
based producLs beLween clrculaLory sysLems
• Pomologous
• AuLologous

6)$-5(0-#)*
• Anaemla
• Ma[or surgery / C&C requlremenLs
• 1rauma / burns
• Cancer paLlenLs
• PeredlLary dlsorders (e.g. Lhalassaemla,
haemophllla)
• 8one marrow fallure
• ÞlaLeleL funcLlon dlsorders
• Warfarln LoxlclLy
• Llver dlsease
• Þlasma exchange Lherapy
• ulC / 11Þ
• llbrlnogen / coagulaLlon facLor deflclencles

!"##$ 7'#$,50*
• Whole blood
• ÞlaLeleLs
• W8Cs
• 88Cs
• Þlasma, albumln
• llÞ (cloLLlng facLors)
• CryopreclplLaLe (cloLLlng facLors)
• lacLor vlll concenLraLe
• lmmunoglobullns
• PaemaLopoleLlc progenlLor cells

4#87"-5(0-#)*
• AcuLe haemolyLlc Lransfuslon reacLlon
o 8eclplenL anLlbodles agalnsL donor 88C
anLlgens
o AbrupL onseL: dyspnoea, fever, chllls,
faclal flushlng, severe paln (esp. lumbar
area), shock, [aundlce, haemogloblnurla
o Cx: A8l, ulC
o ulagnosls: urlnary Pb, serum LuP,
blllrubln, hapLoglobln
o Mx: sLop Lransfuslon, supporLlve
Lherapy, consulL nephrologlsL
• uelayed haemolyLlc Lransfuslon reacLlon
o AsympLomaLlc / sllghL fever
o usually mlld, self-llmlLed
• lebrlle non-haemolyLlc Lransfuslon reacLlon
o lebrlle reacLlon wlLh sympLoms of
allerglc reacLlon
o lnvesLlgaLe Lo rule ouL acuLe haemolyLlc
reacLlon
• Allerglc reacLlons
o usually mlld, anaphylaxls rare
• volume overload
• AcuLe lung ln[ury
o uegranulaLlon of reclplenL granulocyLes
ln lung by donor anLlbodles
• AlLered oxygen afflnlLy
o uue Lo sLorage lssues
• CrafL-versus-hosL dlsease
o uonor lymphocyLes aLLack hosL Llssues
o ÞrevenL wlLh lrradlaLlon of blood
o 8x: corLlcosLerolds,
lmmunosuppressanLs
• CompllcaLlons of masslve Lransfuslon
o ulluLlonal LhrombocyLopaenla:
mlcrovascular haemorrhage
o PypoLhermla
• lnfecLlon

&9/'(7/,0-5 9(/8(79/'/*-*
• Þlasmapheresls
o 8emoves plasma componenLs from
paLlenL's blood
o used ln dlseases ln whlch Lhe paLlenL's
plasma conLalns known paLhogen
• CyLapheresls
o 8emoves cellular componenLs from
paLlenL's blood for replacemenL


1PL uAnuLnCnC uCSSlL8 2010
107
!"#" %&'() *+,&-.+/+01
!0123)'.1(30
1he normal dally requlremenL for fluld ls 30 mL/kg of body welghL from all sources (lv lnfuslons, per Lube, or oral lnLake), plus
any replacemenL of abnormal losses such as an osmoLlc dluresls, nasogasLrlc dralnage, wound ouLpuL, or dlarrheal/osLomy
losses. LlecLrolyLe and mlneral losses can be esLlmaLed or measured and also need Lo be replaced. lluld resLrlcLlon may be
necessary ln paLlenLs wlLh fluld overload.

45,+6 37 7&'()6
CrysLallolds
- SoluLlons wlLh small molecules LhaL flow easlly
from Lhe bloodsLream lnLo cells and Llssues
- May be lsoLonlc, hypoLonlc or hyperLonlc
Collolds
- AcL as plasma expanders
- Are always hyperLonlc, pulllng fluld from cells
lnLo Lhe blood sLream
- Lxamples: albumln, plasma proLeln fracLlon,
dexLran, heLasLarch
- 8equlres close monlLorlng for slgns and
sympLoms of hypervolaemla


83/,&(.-1(306
- lnfllLraLlon: leakage of fluld from veln lnLo
surroundlng Llssue when access devlce dlslodges
from veln
- lnfecLlon
- ÞhleblLls/ 1hrombophleblLls
- LxLravasaLlon: Slmllar Lo lnfllLraLlon, buL
medlcaLlons such as dopamlne, calclum soluLlons
and chemoLherapeuLlc agenLs seep Lhrough velns
lnLo Llssues causlng bllsLerlng and evenLually
necrosls
- Allerglc reacLlon: Lo fluld, medlcaLlon, acLual
caLheLer
- Alr embollsm
- lluld overload

93&'1(30 :6+6 9,+.(-& 8306()+2-1(306
!"#$#%&' )*+"$,--#&."
uexLrose 3° - lluld Loss and dehydraLlon
- PypernaLremla
- SoluLlon ls lsoLonlc lnlLlally, becomes hypoLonlc when dexLrose ls meLabollsed
- uon'L use for resusclLaLlon, can cause hyperglycaemla
- use cauLlously ln renal or cardlac dlsease, can cause fluld overload
- uoesn'L provlde enough dally calorles for prolonged use, may cause evenLual
breakdown of proLeln
0.9° naCl (normal
Sallne)
- Shock
- PyponaLremla
- 8lood Lransfuslons
- 8esusclLaLlon
- lluld challenge
- MeLabollc acldosls
- Pypercalcaemla
- lluld replacemenL ln ukA
- 8ecause Lhls replaces exLracellular fluld, don'L use ln paLlenLs wlLh hearL fallure,
oedema, or hypernaLremla, can lead Lo overload

ParLmann's and
8lnger's
- Slmllar as for normal sallne

Some conslder Lhem more physlologlcal as Lhey conLalns more elecLrolyLes
/-##. 0*#.1'$"
Whole 8lood
!"#$%&"' )*+%,-
noL for rouLlne use
AcuLe, masslve bleedlng
neonaLal LoLal exchange
ConLalns 88C, W8C, plasma and plaLeleLs
PC1 ~ 40°
Þacked 8ed Cells
(Þ88C) !"#$%&"'
)*+%,-
8eplacemenL ln chronlc and acuLe
blood loss, Cl bleedlng, Lrauma
MosL plasma, W8C, plaLeleLs removed
PC1 ~ 73°
ÞlaLeleLs !"#$%&"'
)*+%,-
1hrombocyLopaenla
lresh lrozen Þlasma
(llÞ) !"#$%&"' )*+%,-
Lmergency reversal of Warfarln
Masslve Lransfuslon

ConLalns facLors ll, vll, lx, xl, xll, xlll and heaL-lablle v and vll
1akes abouL an hour Lo Lhaw
3° Albumln or 3°
Þlasma ÞroLeln
lracLlon
Þlasma volume expanders ln acuLe
blood loss
ÞreclplLaLe from plasma
23° Albumln Pypoalbumlnaemla
volume expander
8urns
uraws exLravascular fluld lnLo clrculaLlon
ÞreclplLaLe from plasma
./)"0 12"&" 3&" 43,* 4/&" '/5$)%/,' ,/) 5%')"6 %, )2%' )375"

#3&'/+ ;+,&+1(30 #3&'/+ <=+2&3-)
9(>06 ? 95/,13/6 !8Þ, CrLhosLaLlc hypoLenslon, narrow pulse pressure,
Lachycardla, reduced skln Lurgor, dry mucous membranes,
!Caplllary reLurn, "na, Þoor urlne CuLpuL, Peadache
Þerlpheral oedema, "!vÞ, 1achypmoea, 8lbasal lung crackles,
"WelghL, !ugular venous dlsLenslon, ! na
8-'6+6 uehydraLlon (vomlLlng, ularrhoea, excesslve sweaLlng, burns,
dlureLlcs, renal fallure)
PearL fallure, Clrrhosls, 8enal fallure, SlAuP, laLrogenlc,
Þregnancy
@-0->+/+01 uexLrose, elecLrolyLe replacemenL na resLrlcLlon, waLer resLrlcLlon, dlureLlcs
1PL uAnuLnCnC uCSSlL8 2010
108
!"#$%&'(#
*+,%' Lxamples Mechanlsm uose Adverse Slde effecLs CLher leaLures
!"#$%&'(-'
ÞaraceLamol Þanadol
Peron
lnhlblLs prosLaglandln
synLhesls ln Lhe CnS +
weak CCx1/2 lnhlblLor
effecLs
0.3-1g / 4-
6hrs
Max 4g/day
^rlsk P1n ln women
Cl1 compllcaLlons
PepaLoLoxlc
nephroLoxlc
Mlld coagulopaLhy
AnLlpyreLlc
nSAlus Asplrln
lbuprophen
naproxen
CCx1/2 lnhlblLors varles
beLween
Lypes
^rlsk Þuu
^rlsk Ml/SLroke, CCl, P1n
nephroLoxlc
AnLl-
lnflammaLory
Cplods Codelne
lenLanyl
Morphlne
Cxycodone
Þre+posL synapLlc
lnhlblLlons of
neuroLransmlLLers
+acLlvlLy of
noclocepLlve paLhways
varles
beLween
Lypes
8radycardla, hypo1n
uelerlum, sedaLlon,
nausea/vomlLlng, apnoea,..
AnLldlureLlc effecL

Cplod
anLagonlsL
naloxone AnLagonlsL aL oplold
recepLors
varles
beLween
Lypes
Same as oplolds
lnhalaLlon
agenLs
nlLrous Cxlde
MaLhoxyflurane
Mlxed
30:70/70:30
wlLh C2
C2 desaLuraLlon, hypoxla,
LCC

Local
anaesLheLlc
Llgnocalne
Levo/8uplvacalne
Þrocalne
na+ channel blocker
LhaL lnhlblLs
generaLlon of elecLrlcal
lmpulses +conducLlon
uependanL
on
Lype/slLe/de
slred
analgesla
8esp arresL
CnS LoxlclLy
Cardlac arresL, hypo1n


./0!"#$%&'(-'
• nMuA-recepLor anLagonlsL
• AnLl-epllepLlcs
• AnLl-depressanLs
• AnLl-arrhyLhmlcs
• Clonldlne
• CorLlcosLerolds
• 8lsphosphonaLes
• 8ensodlazeplnes
• Calclum channel blockers
• Muscle relaxanLs
• AnLlchollnerglcs
1PL uAnuLnCnC uCSSlL8 2010
109
!"#$ &'()*$+,( -(,()
.(/+0+$+"0 123 45*##+/+6*$+"0

A rlse ln core body LemperaLure Lo 0.3
o
C above normal
(above 37.3
o
C) whlch occurs afLer surglcal lnLervenLlon.
1he pyrexla can be elLher perslsLenL or flucLuanL, and
musL be vlewed ln conLexL of Lhe oLher vlLal slgns. An
lsolaLed readlng of mlld pyrexla has llLLle meanlng ln lLself.


.+//()(0$+*5 .+*70"#+#

lever can be due Lo elLher lnfecLlon or lnflammaLlon, and
ln deLermlnlng Lhe cause Lhree Lhlngs musL be consldered
1. 1he Lype of fever (swlnglng, low grade, perslsLenL
eLc)
2. 1he Lype of procedure Lhe paLlenL has undergone
3. 1he Lemporal relaLlonshlp beLween Lhe
procedure and Lhe fever


8+9(5: *($+"5"7:

ln Lhe /+)#$ ;< =">)# afLer Lhe procedure fever ls common
and can be consldered parL of Lhe body's meLabollc
response Lo ln[ury. !"#$#%"&'(' ls common durlng Lhls
perlod (especlally when Lhe paLlenL ls noL glven adequaLe
paln rellef), and can produce a self-llmlLlng low-grade
fever.
A fever whlch occurs ? $" @ A*:# afLer Lhe operaLlon ls
usually due Lo ()*#%"(+) +* "-# .+/)01 +2#3&"(4# '("# +3
/3()&35 "3&%". 6&))/$& 23+7$#8' and 9:; should also be
consldered. Þulmonary lnfecLlons are common, buL
usually presenL earller afLer Lhe operaLlon.
lever B")( $=*0 @ A*:# afLer a surglcal lnLervenLlon may
be due Lo &7'%#'' formaLlon (classlcally Lhe fever ls
swlnglng ln naLure). lL ls also lmporLanL Lo remember LhaL
03/<'1 "3&)'*/'(+)' &)0 73&()'"#8 23+7$#8' can also
lncrease Lhe body's LemperaLure.

C+#$"): *0A DE*B+0*$+"0
lL ls lmporLanL Lo Lake a careful hlsLory, revlew Lhe obs
charL and medlcaLlons, and read Lhe surgeon's noLes
before examlnlng Lhe paLlenL. 1he examlnaLlon requlres
examlnaLlon of every llkely source of Lhe lnfecLlon, and
exposure (lncludlng Laklng down dresslngs) ls vlLal. Lnsure
Lhe lungs are asculLaLed for crackles and consolldaLlon,
Lhe hearL ls llsLened Lo for new murmurs, Lhe abdomen ls
palpaLed for Lenderness or masses and Lhe calves are
checked for swelllng (especlally asymmeLrlcally).


FBB(A+*$( G*0*7(B(0$

lmmedlaLe managemenL depends on Lhe severlLy of Lhe
fever, and Lhe sLaLe of healLh of Lhe paLlenL. A fever due
Lo sepsls whlch has led Lo clrculaLory collapse requlre
lmmedlaLe resusclLaLlon and careful monlLorlng lncludlng
urgenL blood culLures and 1PLn prompL admlnlsLraLlon of
approprlaLe anLlbloLlcs.
A paLlenL who ls more sLable may have anLlmlcroblal
Lherapy deferred unLll an organlsm has been ldenLlfled
(le. Cram sLaln or culLure)


F0,(#$+7*$+"0#

SepLlc screen!
- l8L, uLC, C8Þ, LS8, 8lood culLures
- SpuLum culLure, Cx8
- urlne MCS
- Wound swabs lf lndlcaLed
Also lnvesLlgaLe for uv1/ÞL lf suspecLed










1PL uAnuLnCnC uCSSlL8 2010
110
!"#$%&
()*+ ,-.$/.,01 "2 3"#$% 45$56141$7
1 - 1lssue assessmenL and managemenL of non-vlable
Llssue 1hls lncludes debrldemenL elLher aL Lhe bedslde
(podlaLry) or ln LheaLre

l -lnflammaLlon and lnfecLlon 1hese are serlous
compllcaLlons LhaL requlre urgenL LreaLmenL lncludlng
approprlaLe ldenLlflcaLlon of causaLlve agenL and
approprlaLe anLlbloLlcs

M - MalnLenance of MolsLure balance 1hls ls where
approprlaLe cholces of dresslng asslsLs ln promoLlon of a
heallng, enabllng healLhy granulaLlon Llssue Lo form
L - ÞromoLlon of LplLhellal advancemenL of wound Ldges
lL ls from Lhe wound edges LhaL heallng by secondary
lnLenLlon occurs - any process whlch affecLs Lhls process
wlll slow down wound heallng

lt ls olso lmpottoot to ossess tbe sottoooJloq sklo ooJ
woooJ Jlmeosloos ooJ to keeploq occotote tecotJs of
woooJ lmptovemeot,, os well os lookloq ot tbe woooJ
ftom o wbole-potleot petspectlve - cbtoolc woooJs ote
oot o Jloqoosls! 1bey ote symptoms of ooJetlyloq Jlseose
ooJ o tbotooqb nx ooJ íx ote vltol fot occotote Jloqoosls..
8-71-.50 90/1-&
- Caused by aLheromas resLrlcLlng blood supply Lo Lhe
skln
- CfLen found on Lhe fooL, lower or posLerlor leg
- Wounds are palnful and characLerlzed by areas of
sunken, plLLed Llssue whlch may seep wlLh
wound exudaLe. 1he surroundlng area can be yellow,
brown, reddlsh, gray, or black ln colour.
- Slnce Lhe ulcer ofLen becomes lnflamed or lnfecLed, lL
may be reddlsh, Lender Lo Lhe Louch, and swollen.
- 1reaLmenL does nC1 lnvolve compresslon bandages
whlch wlll furLher compromlse blood supply, buL ls
consldered an emergency llkely Lo requlre surgery -
elLher angloplasLy, arLery bypass or posslbly ampuLaLlon


:1$"#& 90/1-&
- 1he resulL of varlcose velns prevenLlng venous dralnage
of overlylng skln
- usually locaLed ln Lhe lower 1/3 of Lhe leg
- 1he wound ls shallow wlLh serous exudaLe wlLhouL
exLreme paln
- 1reaLmenL lnvolves absorbenL dresslngs, compresslon
sLocklngs or bandages Lo supporL Lhe valves and
lmprove venous dralnage

;-1&&#-1 <"-1&
- Caused by lncreased pressure and/or frlcLlon reduclng
blood supply Lo Lhe affecLed area secondary Lo
prolonged lmmoblllsaLlon
- 1he skln over bony areas such as Lhe heels, elbows, Lhe
back of Lhe head and Lhe Lallbone ls parLlcularly aL rlsk.
- Þressure sores are graded:
Crade 1 - skln dlscolouraLlon, usually red, blue, purple or
black.
Crade 2 - some skln loss or damage lnvolvlng Lhe Lop-
mosL skln layers.
Crade 3 - necrosls (deaLh) or damage Lo Lhe skln paLch,
llmlLed Lo Lhe skln layers.
Crade 4 - necrosls (deaLh) or damage Lo Lhe skln paLch
and underlylng sLrucLures, such as Lendon, [olnL or bone.
1reaLmenL ranges from slmple dresslngs Lo surglcal
debrldemenL and grafLlng, dependlng on Lhe severlLy of
Lhe wound, buL regular poslLlon changes Lo prevenL
furLher pressure sores are vlLal

=-1&&.$6&
1here ls a huge range of speclallsed dresslngs and are
classlfled as non-absorbenL, absorbenL, debrldlng, self-
adherlng and oLher. 1helr sulLablllLy depends on Lhe slLe
and Lype of ulcer, personal preference and cosL.

!"# %&'%#'(') %(**+#, -./.
///
!"#$%&'()(*+
1PL uAnuLnCnC uCSSlL8 2010
112
!"#$%&'#(')#)"
+$,)-)#)%-
uegeneraLlve [olnL dlsease relaLed Lo agelng. Can be
classed as prlmary or secondary (lf Lhere ls an underlylng
cause, e.g. Marfan's, dlabeLes, Lrauma, congenlLal [olnL
malformaLlon, Wllson's dlsease)

./)0$1)%2%34
More common ln women Lhan men, greaLer lncldence
wlLh lncreaslng age

5)"6 7&8#%'"
• lemale gender
• lncreaslng age
• CbeslLy
• lamlly hlsLory
• 1rauma

9&#(%/(4")%2%34
Agelng ! fewer proLeoglycans ln carLllage ! reduced
waLer conLenL ln carLllage ! carLllage ls less reslllenL !
carLllage geLs broken down and ls noL replaced ! Loxlc
meLabollLes (from carLllage breakdown) cause local
lnflammaLlon ! osLeophyLe formaLlon

:)3-" &-0 :41/#%1"
• Self-llmlLlng early mornlng sLlffness
• Þaln LhaL ls worse wlLh movemenL and relleved
by resL
• usually lnvolves hands, back, knees and hlps
• no consLlLuLlonal sympLoms

.;&1)-&#)%-
• !olnLs: reduced 8CM, creplLus, effuslon
• Pands: ulÞ and ÞlÞ lnvolvemenL (Perbeden's and
8ouchard's nodes), lnLerosseous muscle wasLlng

<-=$"#)3&#)%-"
• xray: [olnL space narrowlng, osLeophyLes,
sclerosls, subchondral cysLs
• SeronegaLlve


>&-&3$1$-#
>$0)8&2
! ÞaraceLamol, 1g Clu
! lnLra arLlcular sLerolds
! Clucosamlne, e.g. 1300mg dally
! Cplolds, e.g. Lramadol

:?'3)8&2
• Surgery, e.g. hlp replacemenL

@),$"#42$
• WelghL loss
• CenLle non-welghL-bearlng exerclse e.g.
swlmmlng
• MoblllLy alds









1PL uAnuLnCnC uCSSlL8 2010
113
!"#$%&'(')*'
,$-*.*#*%.
1he sofLenlng of bones due Lo defecLlve bone
mlnerallsaLlon. When lL occurs ln chlldren, ls known as
8lckeLs, whlch causes bowlng of Lhe legs.

/*"0 1')#%2"
• lnsLlLuLlonallsaLlon e.g. nurslng home
• MalnuLrlLlon
• lnsufflclenL sun exposure
• Pavlng dark skln

3$#*%(%4567'8"$"
• vlLamln u deflclency (<23nmol/L) (mosL
common) - many causes lnclude
lnsLlLuLlonallsaLlon, malnuLrlLlon, lnsufflclenL sun
exposure, malabsorpLlon, nephroLlc syndrome
• Ca deflclency e.g. malnuLrlLlon, elderly
• ÞC
4
deflclency e.g. anLaclds, renal Lubular
acldosls
• Cncogenlc osLeomalacla (mechanlsm unknown,
Lumours are dlfflculL Lo flnd and ofLen benlgn)
• urug lnduced e.g. phenyLonln

9'#:%;:5"*%(%45
vlLamln u normally enables Lhe absorpLlon of Ca and ÞC
4

ln Lhe Cl1. 1hus, ln osLeomalacla: low vlL u ! low plasma
Ca ! Þ1P secreLlon ! bone resorpLlon ! plasma Ca
levels resLored

<*4." '.= <5&;#%&"
• Can be asympLomaLlc
• 8one paln, Lenderness
• Þalnful proxlmal muscle weakness (pelvlc glrdle)
• lracLures wlLhouL Lrauma hx

>.?$"#*4'#*%."
• lncreased ALÞ
• Low 23-hydroxyvlLamln u
• Low Ca/ÞC
4

• lncreased Þ1P
• Low urlnary Ca

xray
• ÞseudofracLures, also known as Looser's zone -
area of lucency, parallel Lo bone marglns, ofLen
wlLh perlosLeal Lhlckenlng (found aL femur, publc
raml, rlbs, clavlcles, laLeral edge of scapula)
• ÞroLruslo aceLabula - a defecL ln Lhe aceLabulum
LhaL someLlmes requlres 1P8

8one scan
• lncreased acLlvlLy

@'.'4$&$.#
@$=*)'(
• vlLamln u supplemenLaLlon - ofLen needed
lndeflnlLely
• Calclum supplemenLs (wlLh meals)
• CorrecL any laLrogenlc causes

A*-$"#5($
• lncreased sun exposure

7%&;(*)'#*%."
• lracLure ! assoclaLed Cx






1PL uAnuLnCnC uCSSlL8 2010
114
!"#$%&'()* ,-'"-)').
/#0)1)')(1 234 56&..)0)7&')(1
Chronlc sysLemlc lnflammaLory dlsease, LhaL lnlLlally
beglns wlLh lnflammaLlon of Lhe synovlal [olnLs



89)*#%)(6(:;
Women more commonly affecLed Lhan men, age of onseL
ln women ls ~40, whlle ln men ls 30-70s

,#')(6(:;35&$.#.
? auLolmmune
? geneLlc - PLA-u84
? clgareLLe smoklng

<&'"(9";.)(6(:;
unconLrolled hyperplasla of synovlal Llssues ! excess
synovlal fluld, eroslon of surroundlng bone, and damage
Lo Lendons and llgamenLs

=):1. &1* =;%9'(%.
• SymmeLrlcal early mornlng sLlffness and paln
(lasLs longer Lhan 1 hour), LhaL decreases wlLh
movemenL
• Swollen [olnLs
• ArLhralgla
• LeLhargy and faLlgue
• Anorexla
• !olnL deformlLy
• ury eyes and mouLh
• lever

>).'(-; &1* 8?&%)1&')(1
! !olnLs: symmeLrlcal swelllng, bogglness, flucLulance,
redness, warmLh, llmlLed 8CM
! Pands: 8ouLonlere deformlLles (ulÞ spared), ulnar
devlaLlon, swan neck deformlLles , volar
subluxaLlon, lnLerosseus wasLlng, vascullLlc nall
changes
! Carpal Lunnel syndrome
! SubcuLaneous rheumaLold nodules (exLensor
surfaces, elbows)
! LymphadenopaLhy
! lace: anaemla, paroLld enlargemenL, 1M! creplLus
! PearL: perlcardlal rub, valvular dlsease
! Lungs: flbrosls, effuslon
! Abdo: organomegaly

@1A#.'):&')(1.
! xray: shows #-(.)(1.B 6(.. (0 C()1' .9&7#
! 8lood LesLs e.g. LS8, C8Þ, anaemla
! Speclal LesLs e.g. ,D,B -"#$%&'()* 0&7'(-, anLl-CCÞ

E&1&:#%#1'
E#*)7&6
• nSAluS
• SLerolds e.g. prednlsolone, 3-10mg/day
• lnLra-arLlcular sLerold ln[ecLlons
• MeLhoLrexaLe, 3-23mg/weekly + follc acld
• CLher uMA8us lnclude sulfazlne,
hydroxychloroqulne, leflunomlde, cyclosporln

F)0#.';6#
• Also exerclse, dleL, physlo, hydroLherapy

5(%96)7&')(1.
• Can also cause lelLy's syndrome (8A,
splenomegaly and neuLropenla), vascullLls,
pulmonary flbrosls, pleural effuslon, perlcardlal
effuslon








1PL uAnuLnCnC uCSSlL8 2010
113
!"#$
&'()*)$)"* +,- ./011)()20$)"*
CouL ls characLerlsed by recurrenL aLLacks of acuLe,
asymmeLrlcal mono- or poly-arLhrlLls caused by Lhe
deposlLlon of urlc acld crysLals wlLhln Lhe synovlal fluld,
commonly due Lo hyperuracaemla.

34)5'6)"/"78
AffecLs 1-2° of Lhe WesLern populaLlon, and ls on Lhe
rlse, llkely due Lo poor dleL, meLabollc syndrome eLc.

9)1: ;02$"<1
• Plgh consumpLlon of alcohol, sofLdrlnk, meaL
and seafood
• Male gender
• MeLabollc syndrome
• urugs lncludlng asprln, varlous dlureLlcs,
cyclosporln and chemo agenLs
• Afrlcan-amerlcan, Þolyneslan, Maorl, paclflc
lslanders (buL noL Aborlglnes)

='$)"/"78,>0$?"4?81)"/"78
CouL ls a dlsorder of purlne meLabollsm and occurs when
lLs flnal meLabollLe urlc acld crysLalllzes ln Lhe form of
monosodlum uraLe, preclplLaLlng ln [olnLs, on Lendons,
and ln Lhe surroundlng Llssues.

1hese crysLals Lhen Lrlgger a
local lmmune medlaLed lnflammaLory reacLlon wlLh one
of Lhe key proLelns ln Lhe lnflammaLory cascade
belng lnLerleukln 1µ. An evoluLlonary loss of urlcase,
whlch breaks down urlc acld, ln humans and
hlgher prlmaLes ls whaL has made Lhls condlLlon so
common.

@)7*1 0*5 @864$"61
• PoL, swollen, red [olnL (commonly meLaLarsal-
phalangeal [olnL of Lhe blg Loe - gouL affecLlng
Lhls [olnL ls known as !"#$%&$)
• !olnLs of Lhe heel, knee, wrlsL and flnger can also
be affecLed
• 1ophl (due Lo susLalned hyperuracaemla)
• laLlgue
• Þyrexla

A)1$"<8 0*5 3B06)*0$)"*
1he general hlsLory follows of an acuLe onseL arLhrlLls
whlch occurs durlng Lhe nlghL (when body LemperaLure ls
low = preclplLaLlon of crysLals)

C*D'1$)70$)"*1
• Synovlal fluld asplraLlon ls vlLal Lo exclude sepLlc
arLhrlLls - mlcroscopy wlll show Lhe negaLlvely
blfrlngenL crysLals paLhognomlc of gouL
• Serum urlc acld - alLhough gouL occurs due Lo
hyperuracaemla, a normal urlc acld level does
nC1 exclude Lhe dlagnosls
• l8L may show elevaLed whlLe cells durlng an
acuLe aLLack

E0*07'6'*$
=2#$' - nSAluS (noL asprln), corLlcosLerolds or colchlclne
are used Lo manage an acuLe aLLack

><"4?8/0B)1 - Þrobenecld or allopurlnol are used Lo
reduce urlc acld levels

@#<7'<8 - usually noL necessary, however repalr of
chronlcally gouL-lnfecLed [olnLs ls occaslonally requlred

F)('1$8/' - Peavy drlnkers are dlscouraged Lo conLlnue
dolng so, however oLher dleLary/llfesLyle modlflcaLlons
have llLLle beneflL.

."64/)20$)"*1
unLreaLed gouL can lead Lo severe [olnL desLrucLlon and
renal lmpalrmenL.
SepLlc arLhrlLls can occur ln a gouLy [olnL, and dralnlng
Lophl can become secondarlly lnfecLed

1PL uAnuLnCnC uCSSlL8 2010
116
!"#$%&'( *+,+# -."$/%&0$1#+#
2%3'4'$'14 567 890##'3'(0$'14
SLL: mulLl-sysLemlc, lnflammaLory, auLolmmune
syndrome ln whlch auLoanLlbodles are produced Lo
auLoanLlgens

CrlLerla for ux of SLL:
> 4 of Lhe followlng 11 musL be presenL:
1. Malar (buLLerfly) rash: flaL or ralsed eryLhema
over malar area wlLh nasolablal sparlng
2. ulscold 8ash: paLches of eryLhema ! plgmenLed
hyperkeraLoLlc oedemaLous papules ! aLrophlc
depressed leslons, ofLen affecLlng
ears/cheeks/scalp/forehead/chesL
3. ÞhoLosenslLlvlLy: skln reacLlons on areas exposed
Lo sunllghL
4. Cral ulcers: usually palnless
3. non-eroslve ArLhrlLls: lnvolvlng >2 perlpheral
[olnLs, slmllar Lo 8A wlLh buL passlvely reverslble
& may have asepLlc bone necrosls
6. SeroslLls: pleurlLls C8 perlcardlLls
7. 8enal ulsorder: perslsLenL proLelnurla
(>0.3g/day) C8 cellular casLs
8. CnS ulsorder (wlLh no oLher posslble causes
presenL): selzures C8 psychosls
9. PaemaLologlcal ulsorder: haemolyLlc anaemla
C8 leukopenla C8 lymphopenla C8
LhrombocyLopenla
10. lmmunologlcal ulsorder: anLl-dsunA anLlbody C8
anLl-smooLh muscle anLlbody C8 anLlphosphllpld
anLlbody
11. AnLlnuclear AnLlbody (AnA) poslLlve

8emember: A 8ASP ÞClnLs an Mu (Lo a useful ux)
:rLhrlLls, ;enal, :nA, !eroslLls, <aemoLologlcal,
=hoLosenslLlvlLy, >ral ulcers, ?mmunologlcal,
@eurologlcal, Aalar rash, 2lscold rash

:%$'191B" C :##1('0$'14#
1he cause of SLL ls unknown buL can be drug lnduced
(hydralazlne, procalnamlde, lsonlazld, qulnldlne,
meLhyldopa)
SLL & AnLlphosphollpld Syndrome: anLlcardlollpln
anLlbodles (anLlphosphollplds) are assoclaLed wlLh SLL

<'#$1." 04D -E0&'40$'14
Lvery body sysLem(see Slgns, SympLoms & ux crlLerla)



=0$/1,/"#'191B"
MulLlfacLorlal (sLlll noL fully undersLood)

!'B4# C !"&,$1&#
• 8emlLLlng & relapslng dlsease
• ConsLlLuLlonal Slgns: malalse, faLlgue, myalgla,
fever, lymphadenopaLhy, welghL loss
• Alopecla
• nall fold lnfarcLs
• non-lnfecLlve endocardlLls, 8aynauds, Mlgralne,
8eLlnal exudaLes
Also see ux CrlLerla on lefL.

?4F%#$'B0$'14#
ux ls CLlnlCAL (based on above crlLerla)
lmmunology:
• AnA +ve: 93°
• LnA +ve: 23°
• 8hl +ve: 40°
MonlLorlng SLL:
• AnLl-dsunA anLlbody LlLres
• C3 & C4 (should decrease wlLh 8x)
• LS8
CLher: 8Þ, urlnalysls, l8L (!"# %&'%), u&L, Ll1s, C8Þ
(()*+,-)

A040B%&%4$ G'# &%D'(09 C #"&,$1&0$'(H
./+01)+ 234&5,1&)(
ArLhralgla, fever nSAlu
ArLhralgla, myalgla, leLhargy Pydroxychloroqulne
(anLlmalarlal)
8enal Þrednlsolone &
azaLhloprlne
Cyclophosphamlde
8ash (malar / dlscold), arLhrlLls,
seroslLls, myoslLls, CnS dlsorder,
auLolmmune anaemla
Þrednlsolone


1PL uAnuLnCnC uCSSlL8 2010
117
Vascu||t|s
Def|n|t|on +]- C|ass|f|cat|on
vascullLls ls a general Lerm used for Lhe sysLemlc
lnflammaLlon of blood vessels. 1hese condlLlons are rare
and presenL wlLh sympLoms speclflc Lo Lhe condlLlon

Aet|o|ogy]Causes]Þathophys|o|ogy
vascullLls ls caused by a wlde varleLy of paLhologles
alLhough a general lnflammaLory process ls presenL
lmmune complexes deposlL ln Lhe affecLed vessel wall,
wlLh resulLanL neuLrophll aggregaLlon and lnflammaLlon

ln some dlsease, Cu4+ 1 cells are acLlvaLed and
lymphocyLlc granulomas occur ln Lhe vessel wall -
hence granunlomaLous vascullLls

ulsease whlch cause necrosls and flbrln deposlLlon are
Lermed flbrlnold necroLlslng vascullLls
vascullLls usually causes compromlse of blood flow
Lhrough Lhe vessel and can resulL ln dlsLal lschaemla

Þrlmary vascullLls ls dlvlded 3 Lypes accordlng Lo Lhe
vessel slze affecLed:

Large vessel vascullLls affecLs Lhe aorLa and lLs ma[or
braches

1empora| arter|t|s (ClanL Cell ArLerlLls) lnvolves Lhe
aorLa and caroLlds
o 1yplcally presenLs wlLh unllaLeral Lemporal fossa
head paln, exacerbaLed by conLacL (brushlng halr).
Accomplned by !aw claudlcaLlon and consLlLuLlonal
sympLoms
o Can progress Lo lnvolve Lhe reLlnal arLery, causlng
bllndness
o ÞarLlcularly ln older lndlvlduals (>30)
! CfLen assoclaLed wlLh polymyalgla rheumaLlca
o ulagnosed by Lemporal arLery blopsy
! LS8 ls grossly elevaLed (>100)

1akayasu arter|t|s
o CranulomaLous lnflamaLlon of Lhe aorLa and ma[or
branches
o ÞresenLs wlLh absenL pulses and hyperLenslon
(pulseless dlsease)
! ÞarLlcularly ln younger lndlvlduals ln !apan

Medlum vessel vascullLls affecLs small arLerles and
arLerloles

Þo|yarter|t|s nodosa
o necroLlslng or flbrlnold vascullLls of medlum and
small arLerles and mlcroaneurlsm formaLlon
! 1yplcally mlddle-aged men
o usually presenLs wlLh vague, lnspeclflc
consLlLuLlonal sympLoms progresslng Lo acuLe
mulLl-organ fallure

kawasak| d|sease
o Medlum and small vessel lnvolvemenL, usually ln
chlldren, ofLen lnvolvlng Lhe coronary arLerles
o ÞresenLs wlLh fever > 3 days, bllaLeral con[uncLlval
congesLlon, lymphadenopaLhy, rash and palmar
eryLhema

c-AnCA poslLlve small vessel vascullLls ls found ln
arLerloles, caplllarles and venules

Wegener's Granu|omatos|s
o CranulomaLous lnflammaLlon of small arLerles
o ÞarLlcularly affecLs upper and lower resplraLory
LracL as well as necroLlslng glomerulonephrlLls
! ÞresenLs wlLh rhlnorrhoea, haemopLysls and
pleurlLlc paln
o ulagnosed on resplraLory or renal blopsy
! Cx8 shows 'mlgraLlng' nodular lung masses

Churg Strauss Syndrome
o Loslnophll medlaLed resplraLory lnflammaLlon
leadlng Lo necroLlc vascullLls
o ÞresenLs wlLh rhlnlLls, asLhma and eoslnophllla,
Lyplcally ln mlddle aged males

M|croscop|c po|yang|t|s
o necroLlslng vascullLls lnvolvlng Lhe resplraLory
Llssue and causlng glomerulonephrlLls

c-AnCA negaLlve small vessel vascullLls ls llmlLed Lo Lhe
caplllarles and venules

nenoch-Scho|e|n purpura
o lgA deposlLlon ln skln, guL and renal glomerulus

Cutaneous |eucocytoc|ast|c vascu||t|s
o A self resolvlng bllaLeral palpable purpura found on
Lhe lower legs. Leslons may erode or ulceraLe, and
are assoclaLed wlLh pyrexla and arLhralgla

8ehcet's D|sease
o Causes recurrenL oral ulceraLlon, alLhough Lhe
paLhogenesls ls unclear
o May also cause ollgoarLhrlLls, Cl upseL, pulmonary
or renal leslons or neurologlcal lnvolvemenL

Management
vascullLls ls almosL always LreaLed wlLh corLlcosLerolds or
dlrecL lmmunosuppresslon

Comp||cat|ons
CompllcaLlons are speclflc Lo Lhe slLe of vascullLls, usually
resulLlng from local lschaemla or lnfarcLlon

1PL uAnuLnCnC uCSSlL8 2010
118
!"#$%&' )*'$"'$ +, -+.$
)$,*.*%*+.
local dlsorder of unknown aeLlology, characLerlsed by
excesslve bone resorpLlon by osLeoclasLs and a
compensaLory (buL dlsorganlsed) lncrease ln bone
formaLlon by osLeoblasLs ! bones LhaL are enlarged and
deformed
/0*1$2*+3+#4
AffecLs Lhose over 40, men more Lhan women, Lhere ls
famlllal clusLerlng

5$%*+3+#4 ".1 6"7'$'
• ? lnfecLlous cause, e.g. measles vlrus, 8Sv
• CeneLlc llnk - muLaLlons found ln 8Ank and CÞC
genes

!"%8+084'*+3+#4
1. CsLeoclasLlc acLlvlLy: locallsed marked lncrease ln
bone resorpLlon, osLeoclasLs look dysfuncLlonal
and polynuclear
2. CompensaLory lncrease ln bone formaLlon, wlLh
dlsorganlsed ('mosalc') deposlLlon of lamellar
bone, hypervascularlLy and replacemenL of bone
marrow wlLh connecLlve Llssue
3. 8urnL ouL phase, wlLh loss of hypercelluarlLy

MosL ofLen affecLs splne, skull, pelvls, Lhlghs and lower
legs, causlng a range of locallsed sympLoms

9* ".1 ':
• CfLen asympLomaLlc
• 8one paln, fracLures
• Peadaches, hearlng loss, enlarged head
• local neurologlcal slgns e.g. sclaLlca
• Somnolence
• Þaralysls
• kyphosls, bowed legs
• ArLhrlLls

;.<$'%*#"%*+.'
8lood LesLs
• LlevaLed ALÞ - used Lo monlLor dlsease acLlvlLy
• AL1, Ca and ÞC
4
all normal

urlne
• urlnary hydroxyprollne elevaLed

xray
• Involveu bones look expanueu anu uensei than
noimal
• Nultiple fissuie fiactuies in long bones
• Initial lesion may be uestiuctive anu
iauiolucent, especially in skull ("osteopoiosis
ciicumsciipta")
• Saicomatous change suggesteu by appeaiance
of new lytic lesion
Bone scan

="."#$2$.%
needed lf sympLomaLlc, exLenslve lnvolvemenL, or young
paLlenL

=$1*6"3
• 8lsphosphonaLes, e.g.
rlsedronaLe (Laken dally for
2-6/12 whllsL dlsease ls
acLlve)
• CalclLonln (noL usually
used)
• nSAluS, analgeslcs, cardlo
drugs as needed

97>#*6"3
• !olnL replacemenL
• Max-fax surgery
• Splnal cord decompresslon

?+203*6"%*+.'
• lracLures, splnal cord
compresslon
• vlsual changes/loss
• Pearlng loss
• Cranlal and perlpheral
nerve dysfuncLlon
• ArLhrlLls
• kldney sLones
• Cardlac fallure (due Lo hypervascularlLy of bone)
• Cancer e.g. sarcoma
1PL uAnuLnCnC uCSSlL8 2010
119
!"#$%&'$()#)"
*$+),)#)%, ./0 1(2"")+)32#)%,
lnfecLlon of bone. SlLe and causaLlve organlsm are hosL-
dependenL. 1ypes as follows:
- PaemaLogenous
o lvuu, slckle-cell anaemla
- LxLenslon from lnfecLlon ln ad[acenL [olnL or sofL
Llssue or LraumaLlc lmplanLaLlon afLer compound
fracLures or orLhopaedlc procedures
o 1rauma (open #), posL-surgery, pressure
sores
- AssoclaLed w/vascular lnsufflclency
o ulabeLlcs (bone paln usually absenL due
Lo assoclaLed neuropaLhy)
- ÞoLL's uz (18 of verLebral bodles)
o 8e wary of verLebral collapse and splnal
cord compresslon

45)6$&)%(%7'
Cverall, S.aureus mosL common cause
ulabeLes ! S.aureus, gram -ve
lvuu ! S.aureus
Slckle cell anaemla ! Salmonella common
CounLrles w/hlgh 18 prevalence ! splnal 18

8)"9 :23#%;"
• ulabeLes melllLus (S.aureus and/or gram negaLlve
lnfecLlon)
• lv caLheLers, luC
• Slckle-cell dz (predlspose Lo salmonella lnfecLlon)
• lvuu ! (S.aureus)
• ÞosL-op ([olnL replacemenL, neurosurgery)

<$#)%(%7'/12="$"
- Þyogenlc bacLerla (eg. S.aureus), mycobacLerlum
18 mosL common paLhogens

>)7," 2,6 >'&5#%&"
• lever and chllls
• Þaln (absenL ln dlabeLlcs) and Lenderness ln
lnvolved bone
• LxLremely hlgh LS8 (>100mm/h)
• 8adlographlc flndlngs negaLlve earller on

?)"#%;' 2,6 4@2&),2#)%,
Ask for presence of fever.
Ask for bone paln.
Cuery rlsk facLors: ulabeLes, lvuu, slckle-cell dz.
Any hx of 18?
Pas paLlenL had any surgery? 1rauma?

A,B$"#)72#)%," C%, #%5 %+ #D$ ="=2( %,$"E
- M8l mosL senslLlve and shows exLenL of Llssue
lnvolvemenL
- 8lood culLures
- 8one bx requlred (unless haemaLogenous
osLeomyellLls as blood culLures wlll be +ve)
o So can sLarL abx rx

F2,27$&$,#
F$6)32(
- Lmplrlcal rx
o llucox
o Cephazolln, vancomycln (lf penlclllln
allergy)
- MSSA rx
o As above
- M8SA rx
o vancomycln Lhen
" rlfamplcln + sodlum fusldaLe (lf
suscepLlble)
>=;7)32(
- uebrlde necroLlc bone
! neurologlcal decompresslon (urgenL) - ln pLs
w/verLebral body osLeomyellLls and epldural
abscess

1%&5()32#)%,"
- Þrogresslon Lo chronlclLy
- LxLenslon Lo ad[ bones or [olnLs
- S.aureus lnfecLlon ! epldural abscess
- verLebral osLeomyellLls ! verLebral collapse and
cord compresslon
- 8ecurrenL bone lnfecLlons: anaemla, ralsed LS8,
welghL loss, weakness

1PL uAnuLnCnC uCSSlL8 2010
120
Iractures
Def|n|t|on
8reak ln Lhe conLlnulLy of Lhe corLex of bone

C|ass|f|cat|on
1ype of fracture
1. Cpen]C|osed
2. Intra-art|cu|ar]extra-art|cu|ar
(lnvolvlng Lhe [olnL surface)
3. Comm|nuted
(many fragmenLs of bone)
4. Segmented
(occurs ln Lhe dlaphysls aL Lwo levels, leavlng a
floaLlng segmenL)

Deform|ty of fragments of bone
- uegree of angulaLlon
o LaLeral/Medlal
o Pand: volar/uorsal
- ulsplacemenL
- ShorLenlng
- 8oLaLlon
Ch||dren
lracLures may occur Lhrough Lhe growLh plaLe/physls

l - S- /SLralghL across: # Lhrough carLllage of physls
ll- A - Above: # above Lhe physls
lll- L - Lower: # below Lhe physls ln eplphysls
lv- 1 - 1hru: # Lhru meLaphysls, physls & eplphysls
v - 8 - 8ammed: physls has been crushed

Aet|o|ogy]Causes
1rauma type Iracture
1ype of lorce 8esulLanL lracLure
1wlsL Splral
ulrecL 1ransverse/Cbllque

Þatho|og|ca| Iracture
CsLeoporosls
1umour 8enlgn
MallgnanL - Þrlmary/MeLs
ÞageL's ulsease
MeLabollc bone dlsease CsLeomalacla/8lckeLs
PyperparaLhyroldlsm
CsLeogenesls lmperfecLa
CLher mallgnancy Lymphoma
Myeloma
8A
lnfecLlon/CsLeomyellLls

n|story and Lxam|nat|on
n|story
- Mechanlsm of ln[ury
Lxam|nat|on
- Skln condlLlon: open/closed, any
bllsLers/laceraLlons
- Þerlpheral nerve funcLlon:
o Weakness?
o ÞaraesLhesla/AnaesLhesla
- ulsLal vascular sLaLus
o Assess perlpheral pulse
o Caplllary fracLure
- Lvldence of comparLmenL syndrome
o Þaln ouL of proporLlon
o Þalpable pulse on # slLe

Invest|gat|ons
1. x8 - 2 vlews aL leasL (AÞ and laLerally)
CLher vlews: MorLlse vlew (for ankle #)
Scaphold vlews (for scaphold #)
2. C1 - for severe mulLl-fragmenLary lnLra-arLlcular
#
3. M8l/lsoLope bone scans - ux of lracuLre where
doubL exlsL, and for Avn (avascular necrosls)

Management
Immed|ate
1. u8A8Cu
- ensure haemodynamlc sLablllLy from
hypovolaemla (lf large #)
- Check for lnLernal haemorrhage
2. lracLure reducLlon and lmmoblllsaLlon
- SpllLLlng of fracLures: lmmoblllsLaLlon of # slLe
3. Analgesla
- lv morphlne/oLher narcoLlc analgesla
4. lluld resuslLaLlon
- Lspeclally wlLh severe #, e.g. pelvls/femur
3. Assess for neurovascular sLablllLy
Surg|ca|
Þrlnlcples of Mx:
1. # reducLlon wlLh mlnlmal secondary Lrauma
Cpen reducLlon: vla surg
Closed manlpulaLlve reducLlon and
lmmoblllsaLlon: (LAMÞ [local
anaesLhesla]/CAMÞ[general anaesLheLlc])
2. SLablllsaLlon
- ÞlasLer/C8ll/Sllng/8andage
3. 8esLoraLlon of funcLlon
4. 8ehab
Comp||cat|ons
lmmedlaLe Larly LaLe
Compresslon on
nerves and blood
vessels
ComparLmenL
syndrome
uelayed unlon/non-
unlon
Paemorrhage/
hypovolaemla
lnfecLlon Malunlon
Complex reglonal
paln syndrome
CA
uv1 SLlffness
laL embolus ConLracLure
CrowLh ulsLurbance

1PL uAnuLnCnC uCSSlL8 2010
121
Lower L|mb Iracture
Def|n|t|on +]- C|ass|f|cat|on
-fracLure of Lhe lower llmb:
Þathophys|o|ogy
1. 1rauma: acuLe vs chronlc/sLress (eg. maraLhon runners,
also meLaLarsal>flbula>Llbla)
2. paLhologlcal weakness (eg.osLeoporosls, ÞageL's. )
Þathophys|o|ogy of hea||ng:
1. lnflammaLlon:
-dlsrupLlon of vascular supply! bleedlng from fracLure !
swelllng and brulslng.
-damaged bone Llssue aL edges dle! release cyLoklnes
-osLeoclasLs remove necroLlc bone.
-w/ln hours, blood forms mesh, 4-10 days granulaLlon
Llssue formlng scaffold for callus formaLlon.
2. sofL callus formaLlon: flbroblasLs ln granulaLlon Llssue
form carLllage, flbrocarLllaLe-avold exLernal sLress for 6
weeks, lmmoblllze. AL 2 weeks, anglogenesls + osLeoblasLs
aL perlosLeum 3. Pard callus formaLlon: sofL callus!
woven bone Lhrough Ca, ÞC4 deposlLlon lnLo carLllage.
upper llmb=6/32, lower llmb=12/32.
4. bone remodellng: woven bone replaced by lamellar
bone. Chlldren> adulLs.
C|ass|f|cat|on
1. open (wound communlcaLlon w/ouLslde) vs closed (no
communlcaLlon)
2. Lransverse /obllque/splral
3. segmenLed/commlnuLed/clean break
4. angulaLed: dlsLal vs prox, measured ln degrees
3. roLaLed: measured relaLlve Lo prox, requlres mulLlple
vlews.
6. dlsplaced: dlsLal vs prox, measured ln mm or ° of
corLlcal conLacL
7. shorLened: lmpacLlon (as ln Lorus) vs overlap
8. whlch bone, locaLlon (mldshafL, prox/dlsL).
9. exLraarLlcular / lnLraarLlcular (rlsk of arLhrlLls)
10. avulslon
11. assoclaLed sympLoms: nvS lnLacL
12. Lorus & greensLlck: occurs ln chlldren


S|gns and Symptoms
-paln, swelllng, deformlLy.
n|story and Lxam|nat|on
nx:
-WWÇÇAA8, s|tuat|on, |n[ury mechan|sm
Lx:
Assessment:
1. wound commun|cat|ng w|th fracture?
-bone on v|ew]|acerat|on: prophy|act|c Abx and tetanus
vacc|nat|on.
2. vascu|ar |n[ury: |dent|fy d|sta| pu|ses
- obvlous ln[ury: arLerlal vs venous bleed
-paln ouL of proporLlon Lo ln[ury:
compartment syndrome, mosL commonly ln anLerlor
compL. lower leg.
Þaln
Þallor
Þulselessness
ÞaresLheslas
Þaralysls
Þerlshlngly cold
3. neuro|og|ca| |n[ury: exam|ne dermatomes
4. v|scera| |n[ury
1. Invest|gat|ons
x8ay : helps classlfy fracLure
M8l : sofL Llssue lnvolvemenL, CM.
l8L Lo rule ouL lnfecLlon
Management
-acuLely: LreaL acuLe lssues, especlally bleedlng,
decompresslon of comparLmenLs lf necessary. SpllnL.
1eLanus shoL. 8esusc lf necessary.
-uncomp||cated c|osed fractures: reducLlon vla closed
manlpulaLlon/mechanlcal LracLlon, hang welghLs.
lmmoblllzaLlon vla exLernal spllnLs, ÞCÞ, exLernal flxaLlon.
Surglcal opLlon: open reducLlon, lnLernal flxaLlon.
-uncomp||cated open fractures: clean wound, remove all
dead/devlLallzed Llssue and exLraneous maLerlal. ÞrevenL
osLeomyellLls.
-comp||cated #s-surglcal lnLervenLlon. C8ll vla plns,
wlres, plaLes, [olnL replacemenL.
kehab|||tat|on: acLlve use/acLlve exerclses Lo prevenL
muscle aLrophy, conLlnuous passlve moLlon Lo preserve
healLhy arLlcular carLllage.
Comp||cat|ons
Larly: (laLe ccx ln followlng Lable, for uL+LL)
SysLemlc: LeLanus, gangrene, sepsls, crush syndrome, faL
embolus (esp ln femur), renal fallure 2ry Lo
rhabdomyolysls, ulC, Lhromboembollsm, shock.
Local: hemorrhage, hemarLhrosls, comparLmenL
syndrome.



NLUkC INIUkILS:
h|p, posLerlor dlsplacemenL:
sclaaLlc nerve
h|p, anLerlor dlsplacemenL:
femoral nerve
knee: common peroneal, Llblal
nerve
|eg, lf ln[ury exLenslve: superflclal
peroneal.

NLUkC INIUkILS:
h|p, posLerlor dlsplacemenL:
sclaLlc nerve
h|p, anLerlor dlsplacemenL:
femoral nerve
knee: common peroneal, Llblal
nerve
|eg, lf ln[ury exLenslve:
superflclal peroneal.




!"# %&'%#'(') %(**+#, -./.
/--

1PL uAnuLnCnC uCSSlL8 2010
123
!""#$ &'() *$+,-.$#/
0#1'2'-'32 456 78+//'1',+-'32
-fracLure of Lhe upper llmb:
9+-:3":;/'383<;
See lower llmb #
78+//'1',+-'324 ='<2/ +2> /;("-3(/
lor general classlflcaLlon, see lower llmb #
Speclflc:
?32-#<<'+: # proxlmal 1/3 ulna (+/- fracLure radlal shafL
+/- angulaLlon posLerlorly or laLerally.) + dlslocaLlon radlal
head: seen ln dlrecL Lrauma Lo upper forearm (eg.
nlghLsLlck ln[urles), lCCSP w/ excesslve pronaLlon.
Complex # requlrlng C8ll Lo prevenL malunlon.
@+8#+AA': lsolaLed # aL dlsLal 1/3
rd
of radlus +
subluxaLlon/dlslocaLlon of radloulnar [olnL. MusL be
LreaLed surglcally ln order Lo prevenL recurrenL
dlslocaLlons.
7388#/B: dlnner fork deformlLy. ulsLal radlus # wlLh dorsal
dlsplacemenL+angulaLlon. Common ln osLeoporoLlcs. Look
for dorsal LllL, radlal shorLenlng, radlal angulaLlon of wrlsL.
1reaL wlLh casL ln palmar flexlon, ulnar devlaLlon. lf
slmple, closed reducLlon. lf angulaLlon + deformlLy severe,
C8ll or exLernal flxaLlon.
C#22#--BD # 1
sL
meLacarpal, usually +
subluxaLlon/dlslocaLlon of CMC. MosL common Lhumb
fracLure. Look for lnsLablllLy of CMC aL Lhumb, wlLh paln +
weak plnch grasp as well as ecchymosls around base of
Lhumb. lf dlsplacemenL <3mm, k-wlres Lo [oln meLacarpal
Lo Lrapezlum ln correcL anaLomlcal poslLlon. lf
dlsplacemenL >3mm, C8ll. lmmoblllse ln splca Lhumb
spllnL 4-6 weeks. CompllcaLlons serlous: dysfuncLlonal
Lhumb, llmlLed 8CM, palnful unsLable [olnL.
=,+".8+$D seen ln hlgh speed MvA-Lhlck muscle of
lnfrasplnaLus, subscapularls, prevenL #.
=('-:B/D reverse Colles': # of dlsLal radlus. Caused by
lCCSP onLo flexed wrlsL! venLral dlsplacemenL of dlsLal
fragmenL. Can lnvolve arLlcular surface wrlsL [olnL. lf
undlsplaced, LreaL wlLh casL. lf mlldly angulaLed/dlsplaced,
closed reducLlon. lf slgnlflcanLly dlsplaced/angulaLed,
requlres surglcal lnLervenLlon.
C3E#$B/: # neck 3
Lh
meLacarpal, common ln punch ln[urles.
78+F',8#: dlsLal 1/3 #, damage Lo brachlal plexus, usually
axlllary. Shoulder drop, medlal roLaLlon of humerous,
dropped SCM.
=,+":3'>: mosL common wrlsL #, evaluaLe Lenderness ln
snuff box. 1reaL Lo avold avascular necrosls.
G.(#$./: (surglcal neck): axlllary nerve damage, bulglng
of proxlmal parL, medlal roLaLlon of dlsLal parL, shorLenlng
of arm.
G.(#$./ (mldshafL): radlal nerve damage
G.(#$./ (supracondylar): medlan nerve damage
G.(#$./ (medlal eplcondyle): ulnar nerve damage

='<2/ +2> =;("-3(/ H<#2#$+8I
-paln, swelllng, deformlLy.
G'/-3$; +2> JE+('2+-'32
-See Px & Lx for lower llmb #.
1. K2F#/-'<+-'32/
x8ay : helps classlfy fracLure
M8l : sofL Llssue lnvolvemenL, CM.
l8L Lo rule ouL lnfecLlon
?+2+<#(#2-
-acuLely: LreaL acuLe lssues, especlally bleedlng,
decompresslon of comparLmenLs lf necessary. SpllnL.
1eLanus shoL. ÞrophylacLlc Abx lf wound open. 8esusc lf
necessary (unllkely).
6.2,3("8',+-#> ,83/#> 1$+,-.$#/: manage conservaLlvely
wlLh reducLlon vla closed manlpulaLlon/mechanlcal
LracLlon. SpllnL.
-.2,3("8',+-#> 3"#2 1$+,-.$#/: clean wound, remove all
dead/devlLallzed Llssue and exLraneous maLerlal. ÞrevenL
osLeomyellLls. lmmoblllse
-,3("8',+-#> L/-surglcal lnLervenLlon. C8ll vla plns, k-
wlres. lmmoblllse
M#:+)'8'-+-'32: acLlve use/acLlve exerclses Lo prevenL
muscle aLrophy, conLlnuous passlve moLlon Lo preserve
healLhy arLlcular carLllage.
73("8',+-'32/
-See compllcaLlons for lower llmb fracLure
-upper llmb #s, parLlcularly ln Lhe hand, Lend Lo be much
more dlsabllng-Lherefore lL ls parLlcularly lmporLanL Lo
prevenL deformlLy and preserve funcLlon and range of
movemenL, ln #s compllcaLed by commlnuLlon,
dlsplacemenL or angulaLlon, surgery ls almosL always
requlred.




!"# %&'%#'(') %(**+#, -./.
/-0
!"#$"%&'&()
1PL uAnuLnCnC uCSSlL8 2010
123
!"#$%"&'%(
*"+','-'.,
MallgnanL dlsorders of Lhe haemaLopoleLlc sLem cell
comparLmenL assoclaLed wlLh lncreased numbers of whlLe
cells ln Lhe bone marrow and/or perlpheral blood.

/0%(('+'1%-'.,
• acuLe myelold leukaemla (AML)
• acuLe lymphoblasLlc leukaemla (ALL)
• chronlc myelold leukaemla (CML)
• chronlc lymphocyLlc leukaemla (CLL)
23'4"&'.0.56
x are acuLe leukaemlas
Male: female 3:2 - acuLe leukaemlas
Male: female 2:1 - chronlc lymphocyLlc leukaemla
Male:female 1.3:1 chronlc myelold leukaemla

7'($ 8%1-.9(:1%#("(
• lonlslnlng radlaLlon
• CyLoLoxlc drugs
• 8eLrovlruses
• CeneLlc
• lmmunologlcal e.g. hypogammaglobullnaemla

;%-<.3<6('.0.56
AcuLe leukamlas: ÞrollferaLlon of prlmlLlve sLem cells
leadlng Lo an accumulaLlon of blasLs, predomlnanLly ln Lhe
bone marrow, whlch cause bone marrow fallure.
AML subclasslfled lnLo: AML wlLh recurrenL geneLlc
abnormallLles, AML wlLh mulLlllneage dysplasla, AML
MuS, Lherapy relaLed, and AML noL oLherwlse speclfled.
ALL can elLher be precursor 8 ALL or precursor 1 ALL.
Chronlc myelold leukaemla: MyeloprollferaLlve sLem cell
dlsorder resulLlng ln prollferaLlon of all haemaLopoleLlc
llneages, manlfesLlng predomlnanLly ln Lhe granulocyLlc
serles. AbouL 93° have Lhe Þhlladelphla chromosome
Chronlc lymphocyLlc leukaemla: 8 lymphocyLes do noL
respond Lo anLlgens by LransformaLlon and anLlbody
formaLlon leadlng Lo an accumulaLlon of useless 8 cells.
Cll can ransform Lo hlgh-grade lymphoma. lL has sLages
A,8 and C.

='5,( %,4 =6&3-.&(
• anaemla - shorLness of breaLh on efforL,
excesslve Llredness, weakness
• leucopoenla - recurrenL lnfecLlons
• LhrombocyLopenla - bleedlng and brulslng
• marrow lnfllLraLlon - bone paln
• pallor
• fever (due Lo lnfecLlon, noL Lhe dlsease lLself)
• lymphadenopaLhy, hepaLosplenomegaly
• volavlous skln leslons
• LesLlcular enlargemenL
• cranlal nerve palsles
• welghL loss
• headache (occaslonally) due Lo hyperleucoyLosls
• 8eLlnal haemorrhage due Lo leucosLasls
>,?"(-'5%-'.,(
• 8lood counL
• 8lood fllm
• 8one marrow asplraLe
• ChesL x-ray
• lluoresceln-ln-slLu hybrldlzaLlon (llSP)
• Leukaemla AssoclaLed ÞroLeln (LAÞ)
• lmmunophenoLyplng
• CyLogeneLlcs
• Coombs' LesL
• lmmunoglobullns
@%,%5"&",-
@"4'1%0
!"#$% '%#()%*+), -!./ 0 !//1
SupporLlve Lherapy:
• 1reaLmenL for anaemla, lnfecLlon, bleedlng,
hyperurlcaemla (allupurlnol), meLabollc
problems andpsychologlcal problems.
Speclflc Lherapy:
• !"#$%%$&' $')*+,$&': ComblnaLlon Lherapy Lo
deLroy Lumour, e.g. vlncrlasLlne, daunorublcln
and prednlsolone
• !"#$%%$&' +&'%&-$).,$&': ChemoLherapy Lo aLLack
resldual dlsease,e.g. cyLarablne, meLhoLraxaLe
and eLoposlde
• !"#$%%$&' #.$',"'.'+": 8epeaLlng cycle of drug
admlnlsLraLlon for ouLpaLlenLs, e.g. vlncrlsLlne,
prednlsolone and mercapLopurlne.
8one marrow LransplanLaLlon

23456+" .7%'5+8 '%#()%*+)
• /01&'$+ 20.%": 1
sL
llne Lherapy ls lmaLlnlb
(Lyroslne klnase lnhlblLor), oLhers lnclude 2
nd

generaLlon Lyroslne klnase lnhlblLors (dasaLlnlb,
nlloLlnlb), hydroxycarbamlde and lnLerferon.
• 3++"-"1.,") 20.%" .') /1$%$%4 lmaLlnlb,
hydroxycarbamlde, cyLarablne, 2
nd
generaLlon
Lyroslne klnase lnhlblLors

23456+" '7*935"7$+" '%#()%*+)
• 5,.6" 3 - no LreaLmenL requlred unless evldence
of progresslon
• 5,.6" 7 8 / 9Chlorambucll, fludarablne (purlne
analogue), cychlophosphamlde (alkyalaLlng
agenL) and corLlcosLerolds (for marrow fallure or
auLolmmune cyLopenlas)

5*22&1,$:" ,0"1.2;-same as for acuLe leukaemlas
=#95'1%0
• SplenecLomy
1PL uAnuLnCnC uCSSlL8 2010
126
!"##$%"&'($) +&(,'-'#./0', 12'3/0'("2& 4!+15
!$6"&"("2& 789 10'##"6".'("2&
ulC ls Lhe resulL of sysLemlc acLlvaLlon of Lhe paLhways
lnvolved ln coagulaLlon and lLs regulaLlon. lL resulLs ln
lnLravascular flbrln cloLs causlng organ fallure, wlLh
slmulLaneous consumpLlon of coagulaLlon facLors (v &
vlll), flbrlnogen and plaLeleLs causlng bleedlng.

:$("2023;81'/#$#

• lnfecLlon/ sepsls: vlral, bacLerlal or fungal
• 1rauma
• CbsLeLrlc: e.g. amnloLlc fluld embollsm, placenLal
abrupLlon, pre-eclampsla
• Severe llver fallure
• Mallgnancy: solld Lumours and leukaemla
• 1lssue desLrucLlon: pancreaLlLls, burns, exLenslve
surgery
• vascular abnormallLles: vascular aneurysms, llver
haemanglomas
• 1oxlc/ lmmunologlc: A8C lncompaLlblllLy, snake
blLes, recreaLlonal drugs

<'(=2>=;#"2023;

1he maln paLhways leadlng Lo flbrln deposlLlon are (1)
Llssue facLor-medlaLed Lhrombln generaLlon and (2)
dysfuncLlonal physlologlc anLlcoagulanL mechanlsms, such
as Lhe anLlLhrombln sysLem and Lhe proLeln C sysLem.

A Lhlrd paLhway, ln addlLlon Lo enhanced flbrln formaLlon,
ls lmpalred flbrln removal due Lo depresslon of Lhe
flbrlnolyLlc sysLem. 1hls lmpalrmenL of endogenous
Lhrombolysls ls malnly caused by hlgh clrculaLlng levels of
Lhe flbrlnolyLlc lnhlblLor ÞAl-1. llbrln degradaLlon
producLs lnclude u-dlmers. 8arely, flbrlnolyLlc acLlvlLy may
be lncreased and conLrlbuLe Lo bleedlng.

?"3&# '&) ?;%>(2%#
• acuLely lll
• shock
• wldespread haemorrhage (mouLh, nose and
venepuncLure slLes)
• exLenslve brulslng
• renal fallure
• gangrene eLc

@"#(2,; '&) AB'%"&'("2&
• SympLoms of underlylng condlLlon e.g
lnfecLlon/sepsls, mallgnancy, Lrauma, severe
hepaLlc fallure eLc...
• Paemorrhage, peLechlae, ecchymoses
• Slgns and sympLoms of venous Lhromboemollsm

+&-$#("3'("2&#
• l8L
• u-dlmer LesL
• SequenLlal measuremenLs of flbrlnogen
• ulssemlnaLed lnLravascular coagulaLlon (ulC)
scorlng sysLem
• CloLLlng screen:
12&)"("
2&
<,2(=,2%
C"& ("%$
<',("'0
D=,2%C2>0'
#("& D"%$
E0$$)"&
3 D"%$
<0'($0$(
.2/&(
!+1 Þrolonged Þrolonged Þrolong
ed
uecreas
ed

F'&'3$%$&(
F$)".'0
1reaLmenL of underlylng dlsease: llrsL llne Lherapy
Ad[uncLlve LreaLmenL sLraLegles: ÞlaLeleL and plasma
(componenL) Lransfuslon
AnLlcoagulaLlon: Peparln
8esLoraLlon of anLlcoagulaLlon paLhways: admlnlsLraLlon
of recomblnanL human acLlvaLed proLeln C or
anLlLhrombln concenLraLe.

?/,3".'0
Surglcal LreaLmenL llmlLed Lo prlmary LreaLmenL for
cerLaln underlylng eLlologles

12%>0".'("2&#
• 8leedlng
• Crgan dysfuncLlon and llmb lshemla
• ueaLh
1PL uAnuLnCnC uCSSlL8 2010
127
!"#$%&'(#) +(,$-.$)/'$%01#) 23,%3,& 4!+25
607#1#'#$1 8 9:&;;#7#)&'#$1
lL ls deflned as lsolaLed LhrombocyLopenla wlLh normal
bone marrow and Lhe absence of oLher causes of
LhrombocyLopenla. AcuLe l1Þ ofLen follows an acuLe
lnfecLlon and has a sponLaneous resoluLlon wlLhln 2
monLhs. Chronlc l1Þ perslsLs longer Lhan 6 monLhs
wlLhouL a speclflc cause.

<%#"0-#$:$=/
1he 2 dlsLlncL cllnlcal syndromes manlfesL as an acuLe
condlLlon ln chlldren (usually self-llmlLlng) and a chronlc
condlLlon ln adulLs. 1he female Lo male raLlo ls 2.6:1.
ÞlaLeleL auLoanLlbodles are deLecLed ln abouL 60-70° of
paLlenLs.

>#;? @&)'$,;
• ÞosL vlral lnfecLlon,e.g. Plv
• AuLolmmune dlsorders such as SLL, Lhyrold
dlsease and auLolmmune haemolyLlc anaemla
• Chronlc lymphocyLlc leukaemla and solld
Lumours

A0'#$:$=/B9&3;0;

• lmmunoglobulln C (lgC) auLo-anLlbodles on Lhe
plaLeleL surface

2&'($%(/;#$:$=/
lL ls prlmarlly a dlsease of lncreased perlpheral plaLeleL
desLrucLlon, wlLh mosL paLlenLs havlng anLlbodles Lo
speclflc plaLeleL membrane glycoproLelns. 8elaLlve
marrow fallure may conLrlbuLe Lo Lhls condlLlon.

C#=1; &1" C/-%'$-;
• Lasy brulslng
• Þurpura
• LplsLaxls (nose bleed)
• Menorrhogla
• Paemorrhage-ln severe LhrombocyLopenla,
hence rare


D#;'$,/ &1" <E&-#1&'#$1
• Þhyslcal examlnaLlon normal excepL for evldence
of bleedlng
• Splenomegaly-rare

!1F0;'#=&'#$1;
• l8L-1hrombocyLopenla
• 8one marrow-normal/! megakaryocyLes
• ÞlaLeleL auLoanLlbodles: noL essemLlal for
dlagnosls

G&1&=0-01'
9(#:",01
• usually requlres no LreaLmenL
• When necessary,
o hlgh-dose prednlsolone
o l.v. lgC-for serlous bleedlng or urgenL
surgery

A"3:';
• 1reaL paLlenLs wlLh plaLeleL counL< 30 x 10
9
/L
• llrsL-llne Lherapy
o Cral corLlcosLerolds
o l.v. lgC for rapld rlse ln plaLeleL counL
o SomeLlmes hlgh-dose corLlcosLerolds as
lnlLlal Lherapy
• Second-llne Lherapy
o SplenecLomy
o Plgh-dose corLlcosLerolds, hlgh-dose l.v.
lgC, l.v. anLl-u, vlnca alkalolds, danazol,
lmmunosuppresslve agenLs such as
azaLhloprlne, cyclosporlne and dapsone
o Monoconal anLlbody-8uLlxlmab
o 8ecomblnanL LhrompoleLln
o ÞlaLeleL Lransfuslons- 8eserved for
lnLracranlal or exLreme haemorrhage

1PL uAnuLnCnC uCSSlL8 2010
128
!"#$%&$'"()(*+
-./(0(1($0 234 5)*++(/(6*1($0
lnherlLed or acqulred defecLs of haemosLasls causlng a
predlsposlLlon for Lhrombosls (venous or arLerlal)
formaLlon
1ypes:
- lacLor v Lelden
- ÞroLhrombln varlanL
- AnLlLhrombln (A1) ueflclency
- ÞroLeln C
- ÞroLeln S
- AnLlphosphollpld AnLlbody

7(+8 9*61$#+
Conslder Lhrombophllla ln people wlLh:
• 8ecurrenL venous Lhrombosls
• llrsL venous Lhrombosls when <40 yrs
• unusual venous Lhrombosls (le ln mesenLerlc or
cerebral veln)
• unexplalned neonaLal Lhrombosls
• 8ecurrenL mlscarrlage
• ArLerlal Lhrombosls wlLh no arLerlal dlsease
lacLor v Lelden 8lsk lacLors: Þregnancy, CCÞ

:.1($)$;<3=*1"$'"<+($)$;<
lacLor v Lelden
- AuLosomal domlnanL
- Slngle nucleoLlde subsLlLuLlon ln lacLor v gene
(so facLor v can'L be cleaved & lnacLlvaLed by
proLeln C, Lherefore acLlvaLed lacLor v leads Lo
lncreased Lhrombosls)
ÞroLhrombln varlanL
- MuLaLlon ln proLhrombln gene causes lncrease
proLhrombln levels
AnLlLhrombln (A1) ueflclency
- auLosomal domlnanL lnherlLance (LhromboLlc
eplsodes begln when young)
- acqulred afLer surgery/Lrauma/CCÞ use
- low A1 ln nephroLlc syndrome
ÞroLelns C & S ueflclency
- auLosomal domlnanL condlLlons
- heLerozygoLe: lncreased Lhrombosls <40yrs
- homozygoLlc: neonaLal purpure fulmlnans (faLal
wlLhouL lmmedlaLe Lherapy)
AnLlphosphollpld AnLlbody
>(;0+ *0? ><%'1$%+
lncreased rlsk of LhromboLlc eplsodes:
• uv1
• ÞL
• mural Lhrombl ln Lhe lefL aLrlum/venLrlcle)

@0A.+1(;*1($0+
CoagulaLlon Screen:
- l8L: plaLeleLs
- ÞroLhrombln 1lme/ln8: exLrlnslc paLhway
- aÞ11: lnLrlnslc paLhway
- flbrlnogen: common paLhway
- Ll1s

!"#$%&'()*+ -./*
lacLor v Lelden aÞ11 LesL (one wlLh
acLlvaLed ÞroLeln C & one
wlLhouL)
Molecular LesLlng
Assay
AnLlLhrombln,
ÞroLeln C,
ÞroLeln S, AnLlphosphollpld
AnLlbody
Assays
ÞroLhrombln varlanL Assay
Molecular LesLlng

B*0*;.%.01C B.?(6*)
AnLlplaLeleLs:
- Asplrln
- ulpyrldamole
- Clopldogrel
- Abclxlmab
AnLlcoagulanLs:
- Peparln
- Warfarln
1hrombolyLlc urugs:
- SLrepLoklnase
- 1lssue-Lype plasmlnogen acLlvaLor (alLeplase)
- 8eLeplase
- 1enecLeplase
1PL uAnuLnCnC uCSSlL8 2010
129
!"#$%&'$( *+$$(&", -&./%($%.
-$0&"&'&/" 123 4+5..&0&65'&/"
lnherlLed deflclencles of coagulaLlon facLors.
MosL commonly:
• lacLor vlll (Paemophllla A)
• lacLor lx (Paemophllla 8)
• vW facLor (von Wlllebrand dlsease)

7&.8 956'/%.
• Male sex (haemophlllas)
• lamlly hlsLory

:$'&/+/,;245<.$.
• x-llnked Lransmlsslon (haemophllla A & 8)
• AuLosomal domlnanL / recesslve Lransmlsslon
(vWu)
• SponLaneous muLaLlon
• Acqulred (auLolmmune, eLc.)

=5'#/>#;.&/+/,;
Paemophllla A & 8
• uefecL / deflclency of facLor vlll / lx (cofacLors ln
acLlvaLlon of facLor x ln coagulaLlon cascade)
• lormaLlon of flbrln deflclenL cloLs
• CoagulaLlon more prolonged, cloLs more
unsLable
vWu
• AuLosomal domlnanL / recesslve Lransmlsslon
• uefecL / deflclency of vWl (funcLlons: 1. plaLeleL
adheslon Lo damaged endoLhellum 2. sLablllse
clrculaLlng facLor vlll)
• uefecL ln prlmary haemosLasls (plaLeleL
aggregaLlon) and secondary deflclency of facLor
vlll

?&,". 5"( ?;@>'/@.
SympLoms
• 8leedlng on mlld / moderaLe Lrauma
• SponLaneous bleedlng
• Superflclal (skln) bleedlng, eplsLaxls, menorrhagla
• Þrolonged bleedlng


Slgns
• PaemarLhrosls
• 8leedlng lnLo muscle
• ÞeLechlae, purpura
• Clnglvlal bleedlng, eplsLaxls, Cl bleedlng

A&.'/%; 5"( BC5@&"5'&/"
Px
• lamlly hlsLory
• ÞasL surglcal hlsLory and bleedlng compllcaLlons
• neonaLal hlsLory of bleedlng / brulslng
• 8ecenL Lrauma
• PlsLory of recelved blood Lransfuslons
• MensLrual hlsLory
Lx
• !olnL / sofL Llssue dlsease
• Cl / oropharyngeal bleedlng
• Skln / mucous membrane bleedlng

!"D$.'&,5'&/".
• l8L (88C, plaLeleLs)
• CoagulaLlon facLor assays
• AÞ11, Þ1
• mlxlng sLudles
• x-rays (haemarLhrosls)
• C18 (lf head Lrauma)

E5"5,$@$"'
• Avoldance of Lrauma, asplrln, anLlplaLeleLs
• lacLor replacemenL (durlng bleedlng eplsodes)
• uesmopressln
• CCÞ
• CeneLlc counselllng, LesLlng

4/@>+&65'&/".
• 8lsks of Lransfuslons (lnfecLlon, developmenL of
anLl-facLor anLlbodles, eLc.)
• Llfe-LhreaLenlng haemorrhages (lnLracranlal,
reLropharyngeal, reLroperlLoneal)
• Shock from unrecognlsed haemorrhage (lnLra-
abdomlnal, lnLragluLeal)
• !olnL dlsease (haemarLhrosls)

!"# %&'%#'(') %(**+#, -./.
/0.
!"#$%&'()* ,'*$-*$*
1PL uAnuLnCnC uCSSlL8 2010
131
!"#$%$&#$'(
*+,-./!0/ *01- 1-. 2034.5/!03*06 !0/*7*-/*85
72659 5:!,49 8-++-0 5*/45 -1
*0148/*-0
,&(($%;< !7=
6.!+ ,-5*/*>4
SLaph Aureus Cram + Coccl
normal flora of skln
Skln (boll, abscess, wound),
food polsonlng, endocardlLls,
osLeomyellLls
llucloxaclllln
M8SA: vancomycln
SLrep Þyogenes (+ vlrldlans) Cram + Coccl
normal flora of skln, mouLh,
nasopharynx
Skln, sofL Llssue, pharynglLls,
rheumaLlc fever
vlrldlans: bacLerlal
endocardlLls
Amoxy/Amplclllln
SLrep Þneumonlae Cram + Coccl
normal flora of nasopharynx
1yplcal Þneumonla,
menlnglLls
Amoxlclllln, 8enzylpenlclllln
LnLerococcl Cram + Coccl (normal flora
large bowel)
u1l, Abdo sepsls Amoxy/Amplclllln, vanc
v8L: walL for senslLlvlLles

6.!+ 046!/*>4
L. Coll Cram - 8acllll (normal flora,
large bowel)
u1l, abdo sepsls, food
polsonlng
Amoxlclllln, LrlmeLhaprlm
Þseudomonas Cram - 8acllll u1l, Abdo sepsls, 8esplraLory
ln CysLlc llbrosls
CenLamlcln + a penlclllln
(Llcarclllln?)
Cr Clproflaxln
P. lnfluenzae Cram - 8acllll (normal flora
nasopharynx)
MenlnglLls
Þneumonla
Amplclllln (2
nd
or 3
rd
gen
cephalosporln, macrollde)
klebslella Cram - 8acllll
(normal flora large bowel)
Þneumonla, u1l, Abdo
Sepsls
CenLamlcln plus Ll1PL8
plperaclllln/Llcarclllln
Shlgella Cram - 8acllll (? normal
flora of large bowel)
lood borne enLerlLls uoesn'L usually need Abx
nlsserla MenlnglLldls Cram - dlplococcus MenlnglLls, sepLlcaemla 8enzylpenlclllln

-/:4.
M. 1uberculosls CLher 18 lsonlazld + 8lfamplcln + eLhambuLol
+ pyrazlnamlde
M. Þneumonla CLher ALyplcal Þneumonla 8oxlLhromycln
Leglonella CLher (Cram - 8acllll) 8esplraLory ClarlLhromycln +/- rlfampln or
fluoroqulonolone alone
Chlamydla Þneumonlae CLher ALyplcal Þneumonla uoxycyclne,
ClarlLhromycln/roxlLhromycln

!0!4.-745
ClosLrldlum Anaerobe Cram + 8acllll MeLronldazole, vanc
Ceneral anaeroblc lnfecLlon normal flora: mouLh, Cl1,
vaglna, skln
ueep wounds, abscess
formaLlon, foul-smelllng pus,
Llssue desLrucLlon
MeLronldazole

1PL uAnuLnCnC uCSSlL8 2010
132
!"##"$ &$'(!)&"$*
&+,-./01+2 !1331+ 45/617-+82 '098/ :0+- )9-5/3-+/2
;)6-95<-=/0. >=0?-@0+-8A
B=8/0,0.5/01+2
1yplcal Þneumonla SLrep Þneumonlae
P. lnfluenzae
SLaph
klebslella (only gram-)
Amoxlclllln/8enzylpen
lf sLaph: fluclox
lf klebsllla: genL

ALyplcal Þneumonla Mycoplasma Þneumonlae
Chlamydla,
Leglonella Þneumonlae
LryLhromycln/8oxlLhromycln
PosplLal Acqulred Þneumonla Cram negaLlve Cef + CenL
AsplraLlon Þneumonlae Anaerobes MeLronldazole + Cef
CellullLls SLrep Þ, SLaph A llucloxaclllln
u1l L. Coll 1rlmeLhoprlm
Sepsls Could be anyLhlng, depends
on source of lnfecLlon
lluclox + CenL + meLronldazole
(someLlmes add cefLrlaxone,
depends on cllnlcal susplclon)
lluclox - cover Cram poslLlves
lncludlngSLaph
CenL - Cover gram negaLlves
MeLronldazole - cover
anaerobes
M8SA MeLhlclllln-8eslsLanL SLaph
Aureus
vacomycln
v8L vancomycln reslsLanL
enLerococcus
Check senslLlvlLles
8acLerlal LndocardlLls SLaph Aureus, SLrep vlrldlans
(or LnLerococcus)
8enzylpenlclllln + llucloxaclllln
+ CenLamlcln C8 vanc+genL
(esp lf prosLheLlc valve)
8en: SLrep,
lluc: SLaph,
CenL: LnLero
8acLerlal MenlnglLls SLrep Þneumonlae, nelserrla
MenlnglLldls,
P. lnfluenzae,
8enzylpenlclllln
uexameLhasone
Cefrlaxone + 8enzylpenlclllln
8enpen - SLrep
1uberculosls M 1uberculosls lsonlazld + 8lfamplcln +
eLhambuLol + pyrazlnamlde


!"# %&'%#'(') %(**+#, -./.
/00
!"#$ &'#()&
*+!&, &-#./, !"#$ &'#(),
!"#$ .0&('(1/
*1234 &56758 )629 : ;<==>

?852@@A >B C5B=478D C51
B<1 2@E2A8 FG62378H

*1673 IA<G7B78 F: J>6>K>2B8H )629 : ;<==>

?852@@A >B =42>B8

*1673 IB759<B>27 )629 : ;<==>

%>3@<=<==>

#B176<=<==> )629 : ;<==>

;42>B8


1PL uAnuLnCnC uCSSlL8 2010
134

!"#$ &'!#()*'
L. Coll
Þseudomonas
P. lnfluenzae
klebslella
Shlgella
Cram - 8acllll

All look Lhe same

nlsserla MenlnglLldls Cram - coccus

ln palrs






1PL uAnuLnCnC uCSSlL8 2010
133
!"#$% "! $'() '!#*+*"#*(

+,-. /.0-.12
.3 4,560677652
o !"#$%&'"#()(&&(#* ,-./%)(&&(#
! Cover: Cram poslLlve (+ n MenlnglLldls)
! Amoxyclllln ls drug of cholce for enLerococcal lnfecLlons
o 0&1)&./2)(&&(#
! Cover: SLaph Aureus (MSSA)

83 $9-,5:,: %;,0-<=1 4,56067765
o ,13-"#4(#* 5(-"#4(#* 52$.)(#
! 8road specLrum penlclllln plus 8eLa
LacLamase lnhlblLor Lo provlde broader
coverage and lnclude Þseudomonas
cover (see box on slde for deLalls)
! Lxpenslve
! Also used for reslsLanL gram negaLlve
bacLeraemla
o !"42 &2)4(-26" (#7(8(4.96
! ClavulanaLe, SulbacLam, 1azobacLam
! lnlhlblL enzymes Lo do wlLh: SLaph A, L. Coll, klebslella, n Conorrhoeae, P. lnfluenzae
! LlLLle acLlvlLy, buL effecLlve when comblned wlLh: Amoxy, Llcarclllln, plperaclllln
! 8eserve for lf reslsLance

03 (,;>.7?2;?<652@ (lncreaslng gram neg cover LhroughouL generaLlons)
o :
64
;"#< ="'72$.&(#* ="'72&"/(#
! ModeraLe specLrum. MosLly gram poslLlves
• Cram poslLlve: SLrep, SLaph. nC1 enLerococcl
• Cram negaLlve: L.Coll. nC1 LnLerobacLer or Þseudomonas
! 8arely a flrsL llne drug
o >
#?
;"#< noL lmporLanL for us
o @
9?
;"#< ="A49(2/.#"
! 8road SpecLrum. ln parLlcular gram negaLlves
• Ma[orlLy of gram negaLlve bacllll
• nC1 M8SA or Ln1L8CCCCCuS
! ÞeneLraLes 888
! 1herefore: noL very useful ln Cl1 lnfecLlons
o B
47
;"#< ="A42$(?(#"* ="A('(-"
! LxLended specLrum.
! lncludes Þseudomonas
! Lxpenslve

:3 (.<8.;,5,12
o C"9.'"#"-* D942'"#"-
! Lxpenslve reserve agenL
! very very broad specLrum
! Wlde acLlvlLy agalnsL gram negaLlve rods and Þseudomonas
! LffecLlve agalnsL anaerobes
! LffecLlve agalnsL gram poslLlves

A7B0?;,;-6:,2
o E2#).-%)(#
! Wlde range of gram poslLlves
! llrsL llne for M8SA
! use for severe lnfecLlons ln pL allerglc Lo penlclllln
! 8acLerlosLaLlc

*50<,.265C %;,0-<=1 ?D 4,560677652@
!.<<?E: !"#$%&'"#()(&&(#
!.<<?E F %-.;>: 0&1)&./2)(&&(#* ?()&./2)(&&(#* -"47()(&&(#
G?:,<.-,H+<?.: %;,0-<=1: ,-./%)(&&(#* ,-'()(&&(#
+<?.: %;,0-<=1 F +,-. 7.0-.1.2, 65>686-?<: ,13-"#4(#
(Amoxlclllln + ClavulanaLe), 5(-"#4(# (1lcarclllln + ClavulanaLe),
52$.)(# (Þlperclllln + 1azobacLam), (Amplclllln + SulbacLam)
1PL uAnuLnCnC uCSSlL8 2010
136
!"#$%&'()*
o !"#$%"&'#()*+ -.)$%"&'#()*+ /&0#$%"&'#()*
! Wlde specLrum:
• Cram poslLlve coccl, leglonella, bordeLella
• Cram negaLlve coccl
• Mycoplasma, Chlamydla
! used for communlLy acqulred pneumonla

,)-$"#.#&'/)*
o 1&0#(#(2)*3
! 8road
• MosL gram neg and poslLlve
• lncludes Mycoplasma and Chlamydla
! 8acLerlosLaLlc
01'/%&%/)*
o 4)5"&62&07()*+ 8&"62&07()*+ 9&0)62&07()*
! Lxpenslve
! Cram negaLlve: P. lnfluenzae, pseudomonas, gram neg coccl
23'/%4&.#%*'()*
o :3*$7')()*+ -');7()*
! 93° of Aeroblc Cram-neg are suscepLlble ('&*3 %)$ <&*=3" 6&" :"7' *3>7$)?3@AB
! lncludlng pseudomonas
! ÞoLenLlally oLoLoxlc and nephroLoxlc

5'-$%
o 93$"&*)=7.&*3
! 1
sL
llne lor Anaeroblc lnfecLlons
! Lspeclally Cl1 lnfecLlons

6'7"3.#'/*
o /)67'5)()*
! LffecLlve agalnsL: 18, M8SA
! 8apld emergence of reslsLance, always use wlLh oLhers
! Slde effecLs:
• Crange secreLlons
• PepaLoLoxlclLy

!"# %&'%#'(') %(**+#, -./.
/01

1PL uAnuLnCnC uCSSlL8 2010
138
!"#$%&"' )**+&$,"#$%& -.%/."* 01234+'3
5/3 6"11$&3
7$.#2 PepaLlLls 8
8 9%&#2, PepaLlLls 8
ulphLherla, LeLanus and acellular perLussls (u1Þa)
Paemophllus lnfluenza Lype 8 (Plb)
ln acLlvaLed pollomyellLls (lÞv)
Þneumococcal con[ugaLe (7vÞCv)
8oLavlrus
: 9%&#2, PepaLlLls 8
ulphLherla, LeLanus and acellular perLussls (u1Þa)
Paemophllus lnfluenza Lype 8 (Plb)
ln acLlvaLed pollomyellLls (lÞv)
Þneumococcal con[ugaLe (7vÞCv)
8oLavlrus
; 9%&#2, PepaLlLls 8
ulphLherla, LeLanus and acellular perLussls (u1Þa)
Paemophllus lnfluenza Lype 8 (Plb)
ln acLlvaLed pollomyellLls (lÞv)
Þneumococcal con[ugaLe (7vÞCv)
8oLavlrus
<8 9%&#2, PepaLlLls 8
Paemophllus lnfluenza Lype 8 (Plb)
Measles, Mumps and 8ubella (MM8)
Menlngococcal C (MenCCv)
<8=8: 9%&#2, PepaLlLls A (Aborlglnal and 1orres SLralL lslander chlldren ln hlgh rlsk areas)
<> 9%&#2, varlcella (vZv)
<>=8: 9%&#2, Þneumococcal polysaccharlde (23vÞÞv) (Aborlglnal and 1orres SLralL lslander chlldren ln
hlgh rlsk areas)
PepaLlLls A (Aborlglnal and 1orres SLralL lslander chlldren ln hlgh rlsk areas)
: ?3"., ulphLherla, 1eLanus, and acellular perLussls (u1Þa)
Measles, Mumps and 8ubella (MM8)
lnacLlvaLed pollomyellLls)
<@=<A ?3"., PepaLlLls 8
varlcella (vZv)
<8=<A ?3"., Puman Þaplllomavlrus (PÞv)
<B=<C ?3"., ulphLherla, 1eLanus, and acellular perLussls (u1Þa)
<B=:D ?3"., lnfluenza (Aborlglnal and 1orres SLralL lslander people medlcally aL-rlsk)
Þneumococcal polysaccharlde (23vÞÞv) (Aborlglnal and 1orres SLralL lslander people
medlcally aL-rlsk)
B@ ?3"., "&4 %E3. lnfluenza (Aborlglnal and 1orres SLralL lslander people)
Þneumococcal polysaccharlde (23vÞÞv) (Aborlglnal and 1orres SLralL lslander people)
;B ?3"., "&4 %E3. lnfluenza
Þneumococcal polysaccharlde (23vÞÞv)
hLLp://lmmunlse.healLh.gov.au/lnLerneL/lmmunlse/publlshlng.nsf/ConLenL/L8738A3436C6ul98CA23738u001C808l/$llle/nl
p-schedule-card-[uly07.pdf

1PL uAnuLnCnC uCSSlL8 2010
139
!"#$%&'()&"*+
MenlnglLls w/o shock-
morLallLy 10° and
neurologlcal sequelae
uncommon
Coma - poor prognosLlc slgn
lulmlnanL menlngococcemla
- moraLllLy relaLed Lo organ
fallure (20-80°)
-.*&*/&)&+
0.1&*&)&"* 234 !%(++&1&'()&"*
lnflammaLlon of menlnges characLerlsed by:
• lever
• Peadache
• CSl leukocyLosls
ulfferenLlaLe !"#$%&' from $()(*#+%

5.)&"%"/63!(7+.+
MosL commonly due Lo bacLerlal lnfecLlon by Lhe followlng bugs
8(.#"$9&%7+ &*1%7.*:(.; <.&++.=&( #.*&*/&)&>&+; ?)=.$)"'"''7+
$*.7#"*&(. (plos 5tteptococcos oqoloctlcoe lo lofoots ooJ llstetlo
mooocytoqeses lo tbe elJetly/lmmooocomptomlseJ)
Powever, aeLlology may be vlral or paraslLlc

@()9"$96+&"%"/6


























?6#$)"# "= ?&/* A=.B7.*'6
8.(>('9. >90°
A.C.= >90°
-.*&*/&+#7+ >83°
5%).=.> +.*+"=&7# >80°
D"#&)&*/ ~33°
?.&:7=.+ ~30°
-.'!* +#().*./&'!* 0&+1&+/" 10-20°
2!$&**.#1#3! <3°
!%&*&'(% E.> A%(/+ (*> !"==.%()&*/ E&+F A(')"=+
0&+)7=G(*'. "1 '.=.G=(% 17*')&"*H
• cbooqe lo cooscloos stote, focol oeotoloqlcol slqos,
coovolsloos
– lnvolvemenL of cerebral Llssue
– urgenL acLlon requlred
I"J&'&)6H
• nlqb fevets, tocbycotJlo, bypoteosloo
– 8acLerlal sepsls
!%&*&'(% +.))&*/ K '"==.%()&"* L&)9 E&+F A(')"=+H
• ltevloos skoll ftoctote (e.q. ctlbtlfotm #) ot ctoolotomy, c5l
leok, potooosol sloos lofectloo & sotqety, eot Jlscbotqe &
mostolJ polo
• Þaramenlngeal sepsls
• lmpolteJ bost Jefeoces
Mallgnancles: leukaemla, lymphoma ÞosL-op paLlenL
Crgan LransplanLaLlon Asplenla (surglcal or funcLlonal)
CorLlcosLerold Lherapy Advanced lllness
Alcohollsm
CpporLunlsLlc lnfecLlons - LlsLerla monocyLogenes, 18 menlnglLls,
crypLococcal menlnglLls
• 8octetlol íoJocotJltls
– S. Aureus or oLher Cram -ve bacllll
• lost blstoty of 18 ot ftom blqb eoJemlc teqloo
– 18 menlnglLls
• 1tovel blstoty
– ÞaraslLlc lnfecLlon e.g .malarla or Lrlchlnosls
• Occopotloool exposote
– LepLosplrosls, brucellosls
• utoqs
– nSAlus, co-Lrlmoxazole, oLhers
• ltevloos oseptlc meoloqltls
– L.g. PSv menlnglLls, Lyme dlsease
• woxloq & wooloq cootse- CrypLococcal menlnglLls
!?A 1&*>&*/+ G(').=&(%:
• !openlng pressure (200-300 mm P
2
0!)
• " glucose-slnlsLer flndlng
• ÞroLeln >100mg or cell counL >1000
• Cram sLaln- very useful
MJ)=(4*.7="%"/&'(% 1&*>&*/+H
• Mocolopopolot tosb- early menlngococcaemla
• letecblol ot potpotlc tosb(cottelote wltb Jlseose ptoqtessloo
-tbtombocytopoeolo ooJ ulc)- Menlngococcaemla,
SLaphylococcal sepLlcaemla
• lteseoce of extto-ctoolol lofectloos
• Motmot & oLher slgns of endocardlLls
N*C.+)&/()&"*+
• 8lood culLures - lMMLulA1L, also ask for
o Lu1A sample for ÞC8, LhroaL swab. l8C, u&Ls,
glucose, Ll1, cloLLlng
• 8raln C1
o Þerformed prlor Lo LÞ ln all cases wlLh depressed
consclousness or focal neurologlcal slgns
o Clve anLlbloLlc 8LlC8L C1 do nC1 delay 8x.
• LÞ
o uo noL perform ln pLs wlLh predomlnanLly
sepLlcaemla (delays Lhelr vlLal Mg and may be
dangerous lf ulC)
o ALLempL before C1 head when slmple menlnglLls
l.e. noL sepLlc and w/o focal neurologlcal slgns

-(*(/.#.*)
1. O%""> '7%)7=.+
2. 5*)&G&")&'+ < 30 mlns +
0.J(

ltlot to bospltol lf sospecteJ
(fever+rash)
O.*:6%$.*&'&%%&* 1.2 g lv sLaL
nospltol ímpltlcol
!.1)=&(J"*. 4 g lv d 2
D('"#6'&* 300 mg lv Clu
lf >30/lmmunocompromlsed
8enzylpenlclllln1.6-2.4g 4
hrly
3. ?7$$"=)&C.- lCu for
shocked (urgenL flulds +
lnvaslve monlLorlng) pL
or CCS<12

!"# %&'%#'(') %(**+#, -./.
/0.

1PL uAnuLnCnC uCSSlL8 2010
141
!"#$% '##"%()*+,-,*%-. /,0"1 2!'/3
• MosL common lnfecLlous cause of deaLh
• 40mllllon people Plv poslLlve worldwlde
4$56(7*%*1,1

• Plv ls a slngle sLranded 8nA reLro-vlrus
• ldenLlfled Lypes Plv1 and Plv 2, wlLh 2 more
common
• Plv causes profound lmmunodeflclency resulLlng
from desLrucLlon and low levels of Cu4 1-
lymphocyLes
• 1he Cu4 serves as Lhe prlmary cellular recepLor
for Plv wlLh oLher co-recepLors (CC83 or CxC84)
• AfLer enLry lnLo Lhe cell, vlral reverse
LranscrlpLase makes a unA copy of Lhe 8nA
genome and lnLegraLes lL lnLo hosL unA
• SynLheslslng core vlLal proLelns
• CompleLed vlrlons are released from cell vla
buddlng
• vlral load predlcLs progresslon Lo AluS
80$%1#,11,(%
• Pomosexual or heLerosexual lnLercourse
• lvuu
• 1ransfuslon of blood producLs
• MaLernal-chlld Lransfer-durlng pregnancy,
dellvery or breasLfeedlng
9$5"0$: !,15(0.
• AcuLe-seroconverslon lllness (30-80°)
• Sx occur 2-4 wks afLer lnfecLlon
• lnclude fever, malalse , maculopapular rash,
myalgla and pharynglLls
• AnLl-Plv anLlbodles appear 3-12 wks
(seroconverslon)
!"#$%&'$(&)* ,-.
• AfLer seroconverslon
• MosL paLlenL are asympLomaLlc for upLo 10 years
wlLhouL LreaLmenL
8uL vlrus conLlnue Lo repllcaLe
/#$%&'$(&)* ,-.
• ÞaLlenL mlghL geL AluS deflnlng lllness wlLh
slgnlflcanL sysLemlc feaLures e.g. LCW, perslsLenL
fever and dlarrhoea
;5$7* (+ <,1*$1*
• uescrlbed by sympLoms, AluS deflnlng lllness and
Cu4 counL
• ÞL severely lmmunosuppresed
<,$7%(1,1
• ueLecLlon of anL-Plv anLlbodles by LLlSA
• Seroconverslon occurs 1-3 mnLhs posL lnfecLlon
• Plv should be consldered ln anyone presenLlng
wlLh shlngles, unexplalned welghL loss and
lymphadenopaLhy
0'$$'1 '%%'2&31)"&)* )145*&)'1"
• kaposl's sarcoma
• non-Podgkln's lymphoma
• ÞneumocysLls carlnll
• CyLomegalovlrus lnfecLlon
80*$5#*%5
!==>8
1hree maln classes
• nucleoslde reverse LranscrlpLase lnhlblLor
• ÞroLease lnhlblLors
• non-nucleoslde reverse LranscrlpLase lnhlblLors

1PL uAnuLnCnC uCSSlL8 2010
142
!"#$%&"'()*)
,$-*.*/*(. 012 3'4))*-*&4/*(.
lnfecLlous dlsease caused by sLralns of mycobacLerla,
usually mycobacLerlum Luberculosls, ln humans. lL usually
affecLs Lhe lungs, buL can affecL any oLher parL of Lhe
body.

56*7$8*('(9:
1ransmlsslon by resplraLory dropleLs from close proxlmlLy
Lo an lnfecLed lndlvldual

;*)< =4&/(%)
• ueveloplng world resldenLs
• ConLacL of spuLum +ve cases
• ÞoverLy, overcrowdlng, malnuLrlLlon
• Alcohollc
• ulabeLes
• lmmunosuppressed sLaLes
o PaemaLologlcal mallgnancy
o Plv +ve
o SLerolds

>$/*('(9:134")$)
lnfecLlon beglns when suscepLlble person lnhales alrborne
dropleL nuclel conLalnlng vlable organlsms

?4/@(6@:)*('(9:
Þrlmary 18
M.Luberculosls reach alveoll ! lngesLed by alveolar
macrophages ! lnfecLlon occurs lf organlsm escapes
macrophage mlcroblcldal acLlvlLy ! lymphaLlc,
haemaLogenous spread before body mounLs effecLlve
lmmune response ! cllnlcally and radlographlcally
sllenL! ln pLs w/lnLacL lmmunlLy, macrophages, 1 cells
surround organlsms ln granulomas ! dormancy (no
acLlve dz, noL Lransmlsslble, laLenL 18 lnfecLlon)
lf lmmune response lnadequaLe ! progresslve prlmary 18
occurs (sx as below)

8eacLlvaLlon of 18
When hosL lmmune defences lmpalred ! acLlve 18
develops (esp lf above rlsk facLors presenL)

LxLrapulmonary 18
- Mlllary 18 (sysLemlc dlssemlnaLlon) - Lhe young,
Plv +ve, Lhe elderly (organlsms found ln spuLum,
8M, llver, genlLourlnary LracL)
- Þleural, lymph node, bone/[olnL, perlcardlal 18,
18 menlnglLls
A*9.) 4.7 A:86/(8)
• ÞerslsLenL cough
• WelghL loss
• nlghL sweaLs
• lever
• Malalse
• PaemopLysls

B.C$)/*94/*(.)
Zlehl-neelsen sLalnlng of Al8 ln spuLum
SpuLum culLure (abouL 8 weeks)
ÞC8 LesLlng
needle bx of pleura (granulamaLous lnflammaLlon ln abL
60° of pLs w/resulLlng pleural effuslons)
CuanLlferon gold LesL (does noL ddx bLw acLlve and laLenL)
ManLoux LesL (does noL ddx bLw acLlve and laLenL)
lmaglng (Cx8)
- Þleural effuslon, hllar and paraLracheal Ln
enlargemenL, segmenLal aLelacLasls
o Þrlmary 18
- Chon and 8anke focus
o Lvldence of healed prlmary 18
- upper lobe cavlLaLlon
o Þrogresslve prlmary 18
o 8eacLlvaLlon 18
- ulffuse small nodular denslLles
o Mlllary 18

D4.49$8$./
D$7*&4'
8lÞL
- 8lfamplcln: Lurns secreLlons orange
- lsonlazld: hepaLlLls, pyrldoxlne deflclency causlng
neuropaLhy (chemoprophylacLlc drug ln Lhose
w/laLenL 18)
- Þyrazlnamlde: PepaLlLls
- LLhambuLol: opLlc neurlLls
CorLlcosLerold
- 1uberculous perlcardlLls and menlnglLls
- Speed resoluLlon of pleural effuslon
A"%9*&4'
18 osLeomyellLls (ÞoLL's dz) w/resulLlng splnal cord
compresslon
Chronlc consLrlcLlve perlcardlLls
E/@$%
lnfecLlon conLrol ! paLlenL lsolaLlon
1PL uAnuLnCnC uCSSlL8 2010
143
Ma|ar|a
Def|n|t|on +]- C|ass|f|cat|on
Malarla ls a mosqulLo borne paraslLlc dlsease caused by
Lhe plasmodlum paraslLe.
Lp|dem|o|ogy
• Lndemlc ln mosL of Lhe Lroplcs - SouLh and
CenLral Amerlca, Afrlca, Mlddle LasL, lndla, SLA.
• 1ransmlsslon, morbldlLy and morLallLy are
greaLesL ln Afrlca, young chlldren.
• Common ln Lravellers from non-endemlc areas Lo
Lhe Lroplcs.
k|sk Iactors
• 8esldence or exposure Lo malarla -endemlc
area.
• venLurlng ouL aL dusk.
• noL uslng lnsecLlcldes, repellenLs, bed neLs.
• noL Laklng chemoprophylaxls.
• noL wearlng long cloLhlng
Aet|o|ogy]Causes
• 4 specles of Lhe genus Þlasmodlum.
• Þ falclparum ls responslble for nearly all dlsease.
• Þ vlvax, Þ ovale and Þ malarlae are much less
common causes of sever dlsease.
• noLe: Þ vlvax and Þ ovale paraslLes also form
dormanL llver hypnozolLes, whlch are noL kllled
by mosL drugs ! recurrence lf subopLlmal
LreaLmenL.
Þathophys|o|ogy
• 1ransmlLLed by Lhe blLe of lnfecLed female
anophellne mosqulLoes.
• uurlng feedlng, sporozolLes are ln[ecLed, whlch
clrculaLe Lo Lhe llver, causlng asympLomaLlc llver
lnfecLlon.
• MerozolLes are subsequenLly released from Lhe
llver, and rapldly lnfecL eryLhrocyLes.
• MulLlple rounds of 88C developmenL, producLlon
of more merozolLes ! large numbers of
clrculaLlng paraslLes.
• Some merozolLes develop lnLo gameLocyLes !
lnfecLlous Lo mosqulLoes (when blLLen agaln)
CompleLlon of llfe cycle and lnfecLlon of oLhers.
S|gns and Symptoms
• Peadache and faLlgue, followed by chllls, sweaLs
and hlgh fever.
• levers are usually lrregular.
• Malalse, myalglas, arLhralglas, cough, chesL paln,
abdomlnal paln, anorexla, n&v, dlarrhoea.
• Selzures may represenL slmple febrlle
convulslons or sever neurologlcal dlsease.
• Slgns of anaemla, [aundlce, splenomegaly and
mlld hepLomegaly.
• 8ash and lymphadenopaLhy are noL Lyplcal of
malarla, and suggesLlve of anoLher cause of
fever.
ALL ILVLk IN A kL1UkN 1kAVLLLLk IS MALAkIA
UN1IL ÞkCVLN C1nLkWISL.

n|story and Lxam|nat|on
• 1ravel hlsLory and exposure deLalls lmporLanL.

Invest|gat|ons
• 1hlck and Lhln blood fllms. 1hlck Lells you
paraslLe load and ls more senslLlve because more
blood ls examlned. 1hln Lells you Lhe specles of
paraslLe. lf LesL ls negaLlve buL cllnlcal susplclon ls
hlgh, repeaL ln 8 hrs.
• Serologlc LesLs - ÞC8 - noL useful for dlagnosls of
acuLe lnfecLlon, especlally ln endemlc areas.
• l8L - May show LhrombocyLopenla, anaemla,
leukocyLosls
• Ll1 - deranged.

Management
noLe: SympLomaLlc malarla ls caused only by Lhe
eryLhrocyLlc sLage of lnfecLlon. Avallable anLl-malarlal
drugs acL agalnsL Lhls sLage, excepL for prlmaqulne, whlch
acLs prlnclpally agalnsL hepaLlc paraslLes.

Med|ca|
• Pydroxychloroqulne - LreaLmenL and
chemoprophylaxls. 8eslsLance ls wldespread.
• Culnlne, Culnldlne - Cral and l.v Lherapy for
sever lnfecLlons.
• Mefloqulne - Chemoprophylaxls and LreaLmenL
of sLralns reslsLanL Lo chloroqulne.
• Þrlmaqulne - Þ ovale and Þ vlvax - eradlcaLe
hepaLlc lnfecLlon.
• Malarone - 1reaLmenL and chemoprophylaxls
• uoxycyclln and Cllndamycln - 1reaLmenL of
mulLldrug reslsLanL lnfecLlons.
• ArLesunaLe, arLemeLher - 1reaLmenL of severe
and mulLldrug reslsLanL lnfecLlons.

Comp||cat|ons
• uysfuncLlon of any organ sysLem.
• neurologlc abnormallLles - alLered
consclousness, selzures, coma (cerebral malarla)
• Severe anaemla, hypoLenslon, shock.
• non-cardlogenlc pulmonary oedema, A8uS.
• A1n, hypoglycaemla, acldosls, haemolysls +
[aundlce, hepaLlc dysfuncLlon, ulC.
• Secondary bacLerlal lnfecLlons - pneumonla and
salmonella.
• MosL common causes of deaLh ln chlldren are
cerebral malarla and severe anaemla.
1PL uAnuLnCnC uCSSlL8 2010
144
!"#$%$
'"(%)%*%+)
!,$*"-%. %)(/0--0*+1, 1"$#+)$" $,)21+-" 3!45!6
2 or more of Lhe followlng:
1emperaLure >38¨C or <36¨C
P8 >90 bpm
88 >20 breaLhs/mln or ÞaCC2 <4.3 kÞa
WCC >12 x 10³L, <4 s 10³L or >10° band forms

7/0$$%(%.0*%+)
!"#$%$: Sl8S occurrlng ln Lhe presence of lnfecLlon
!"8"1" $"#$%$: sepsls wlLh organ hypoperfuslon e.g.
hypoxaemla, ollgurla, lacLlc acldosls, alLered cerebral funcLlon
!"#*%. $9+.:: severe sepsls wlLh hypoLenslon (sysLollc 8Þ
<90mmPg), or requlremenL for vasopressors/lnoLropes Lo
malnLaln blood pressure

5%$: ;0.*+1$
Age
lnvaslve procedures, prosLheLlc lmplanLs and devlces
lmmunosuppresslve drugs, chemoLherapy, LransplanLaLlon
AnLlmlcroblal reslsLance

<"*%+/+=,>70?$"$
• ulrecL lnLroducLlon of mlcrobes lnLo Lhe bloodsLream
vla lnLravenous lnfuslon (e.g. lnLravenous llne, oLher
devlce-assoclaLed lnfecLlons)
• ÞerforaLlon of lnLra-abdomlnal or pelvlc sLrucLures
• 8acLeremla due Lo urosepsls, pyelonephrlLls, renal
abscess, acuLe prosLaLlLls, or prosLaLlc abscess (esp ln
lmmunocompromlsed hosLs)
• Severe pneumococcal lnfecLlon ln paLlenLs wlLh
lmpalred or absenL splenlc funcLlon.
• Menlngococcemla

@0*9+#9,$%+/+=,
Sepsls resulLs when Lhe lnflammaLory response Lo lnfecLlon
becomes generallzed, and exLends Lo lnvolve normal Llssue
remoLe from Lhe lnlLlal slLe of ln[ury or lnfecLlon.

CuLer membrane componenL of mlcroorganlsms (frequenLly
bacLerla, e.g. endoLoxln of gram-negaLlve bacLerla) blnd Lo Loll-
llke recepLors on monocyLes - cyLoklne release

CyLoklnes:
1. produce Loxlc downsLream medlaLors -
vasodllaLaLlon, free radlcal producLlon, damage Lo
endoLhellal llnlng causlng lncreased caplllary leakage
2. AcLlvaLe exLrlnslc coagulaLlon cascade and lnhlblL
flbrlnolysls - mlcrovascular Lhrombosls - organ
dysfuncLlon
AcLlvaLlon of Lhe coagulaLlon sysLem leads Lo
consumpLlon of endogenous anLlcoagulanLs (e.g.,
proLeln C and anLlLhrombln - ulC

!%=)$ 0)2 !,-#*+-$
Þyrexla and rlgors, nausea and vomlLlng, vasodllaLaLlon, Warm
perlpherles, 8oundlng pulse, 8apld caplllary reflll, PypoLenslon

A%$*+1,
Sources of lnfecLlon:
4B /%)"$ (esp. CenLral llnes > 1 week)
4)*10C0D2+-%)0/ +1 #"/8%. source: condlLlons LhaL predlspose Lo
perforaLlon or abscess (e.g. chronlc or reLrocecal subacuLe
appendlclLls, dlverLlcullLls, Crohn dlsease, prevlous abdomlnal
surgery, cholecysLlLls)
E1%)01, *10.* source: pyelonephrlLls, renal sLones, congenlLal
abnormal collecLlng sysLem, prosLaLe enlargemenL, or prevlous
prosLaLe or renal surgery
4--?)+.+-#1+-%$"2: dlabeLes, sysLemlc lupus eryLhemaLosus
(SLL), alcohollsm or sLerold Lherapy

FG0-%)0*%+)
Lvldence of lnfecLlon (redness, warmLh, oedema) aL lv slLe
1enderness over:
8lghL upper abdomlnal quadranL - cholecysLlLls, cholanglLls
LefL lower quadranL - dlverLlcullLls
8lghL lower quadranL - appendlclLls, Crohn's dlsease
CvA Lenderness - pyelonephrlLls

ulffuse abdomlnal paln suggesLs pancreaLlLls (noL sepsls) or
generallsed perlLonlLls.

4)8"$*%=0*%+)$
!"#*%. $.1"")H l8L, blood + CSl + urlne MCS, spuLum culLure,
MSu, Cx8, C8Þ, LS8
I77H LeukocyLosls or leukopenla
@/0*"/"*$: 1rombocyLosls (acuLe-phase response) or
LhrombocyLopenla (ulC)
@1+*"%) 7J 0)*%*91+-D%) deflclency
LlevaLed 'C2%-"1 level
Þrolonged @K 0)2 <@KK
71"0*%)%)": ^, doubllng lndlcaLes acuLe renal ln[ury
L0.*%. 0.%2: > 4 mmol/L lndlcaLes Llssue hypoxla
L;K$: ^ALÞ, AS1, AL1, blllrubln levels lndlcaLe acuLe
hepaLocellular ln[ury caused by hypoperfuslon
!"1?- #9+$#90*"H j, lnversely correlaLed wlLh
prolnflammaLory cyLoklne levels
@1+.0/.%*+)%) level: ^- dlfferenLlaLes lnfecLlous Sl8S from
nonlnfecLlous Sl8S

M0)0="-")*
Lmplrlcal anLlbloLlcs (deLermlned by slLe of lnfecLlon, gram
sLaln, culLure)
8emove source of lnfecLlon (lf posslble)
CpLlmlse Llssue oxygenaLlon
lluld resusclLaLlon (conservaLlve lf acuLe lung ln[ury)
vasopressor LreaLmenL
CorLlcosLerolds: anLl-lnflammaLory
8ecomblnanL Puman AcLlvaLed ÞroLeln C: anLl-lnflammaLory,
anLlLhromboLlc and pro-flbrlnolyLlc properLles
Clycemlc ConLrol
venLllaLor LreaLmenL for A8uS
8lood Lransfuslon

7+-#/%.0*%+)$
MulLl-organ fallure

1PL uAnuLnCnC uCSSlL8 2010
143
!"#$%&' )* +,-,)., /#&0&,
1$*&,&2&), 345 67'88&*&9'2&),
• 1emperaLure > 38.3¨C for aL leasL 3 weeks wlLhouL
dlagnosls afLer aL leasL 1 week of lnvesLlgaLlons ln
hosplLal

1&**$#$,2&'7 1&'0,)8&8
:;<=6>:/;
8acLerlal lnfecLlon
• 18
• Abscess
• u1ls
• LndocardlLls (rare)
• PepaLoblllary lnfecLlons e.g. cholanglLls
• CsLeomyellLls
• 1hyphold
vlral
• Perpes (CMv/L8v)
• Plv
lungl lnfecLlons (ln lmmunosuppressed)
ÞaraslLes
• 1oxoplasmosls
Malarla
?@A:B;@;6C
neoplasms
• Leukaemlas and Lymphomas
• 8enal Cell Carclnoma
6/AA@B=; D@E6+A@F 1:E=@E=EG
AuLolmmune
• SysLemlc onseL [uvenlle 8A
• ÞolyarLerlLls nodosa
vasculaLldes
• ClanL cell arLerlLls
• Þolymyalgla 8heumaLlca
BF@;+A/?@>/+E
• Sarcoldosls
• Crohn's
• CranulomaLous PepaLlLls
?:E6=AA@;=/+EG
Þerlpheral ÞL
lnherlLed
• lamlllal MedlLerranean fever
PyperLhyroldlsm/SubacuLe 1hyroldlLls
urug fevers
• 8eLa-lacLam AnLlbloLlcs, lsonlazld
H&82)#"
• ConsLlLuLlonal SympLoms (LCW, LCA, laLlgue)
• nlghL sweaLs/8lgors/Chllls, Peadaches, 8ashes
• nuLrlLlon
• urug hlsLory
o lmmunosuppresslve agenLs
• lmmunlsaLlon sLaLus
• 1ravel hlsLory (Þosslble Lxposures (e.g. mosqulLo
blLes) + Þrophylaxls (dependlng on slLe of Lravel)
• CccupaLlonal Px
• Sexual Px
• ÞMPx: AuLolmmune condlLlons, Plv eLc
• lPx
=%'I&,'2&),:
• LveryLhlng and AnyLhlng
• ln parLlcular: 8ashes, LymphadenopaLhy, Sgs arLhrlLls,
murmurs, fundoscopy, neurologlcal deflclLs

:,J$82&0'2&),8 K'8 'LL#)L#&'2$M
• l8L, LS8, u&Ls, C8Þ, Ll1s, AnA, 8h lacLor, 1l1s
• 8lood CulLures
• SLool/urlne/SpuLum CulLures
• CSl CulLure
• Mornlng gasLrlc asplraLes CulLure (18)
• ChesL x8A?
• Abdo C1
• Lcho (endocardlLls)
• LÞ (headache)
• Skln blopsy (rash)
• Lymph asplraLlon/blopsy (lymphadenopaLhy)
• 8one marrow asplraLlon/blopsy (Plv+ve)
• Llver 8lopsy (abnormal Ll1s)

H)8L&2'7&8'2&),G
• Sx: Chllls/8lgors/nlghL SweaLs
• ÞaLlenL sLaLus (e.g. vlLal Slgns)
:II$N&'2$ ?%G
• lf fever ls deblllLaLlng, slmple anLl-pyreLlcs may be
glven (e.g. asplrln, paraceLamol)
• Cenerally, no Lherapy should be glven before
dlagnosls made (non-speclflc Lherapy lneffecLlve and
delays dlagnosls)
• LxcepLlon: neuLropenlc paLlenLs (Lake blood culLures,
LreaL aggresslvely wlLh broad specLrum anLlbloLlcs)

!"# %&'%#'(') %(**+#, -./.
/01





!"# %&'%#'(') %(**+#, -./.
/01
!"#$%&'(')*
1PL uAnuLnCnC uCSSlL8 2010
148
!"#$%&'$
)"*+%+,+&% -./ 0#$11+*+2$,+&%
MallgnanL Lumour of Lhe melanocyLes. 20-23° morLallLy.
lemales sllghLly > males. 4
Lh
mosL common ln AusLralla

345"1 &* '"#$%&'$6
• Superflclal Spreadlng Melanoma (80°): slow growlng,
laLe meLasLasls, dark brown/black, sLaln-llke
• nodular melanoma: lnvades deeply, early meLasLasls,
forms ralsed lump
• LenLlgo mallgna: 8eglns as large freckle, slow and
superflclal growLh.
• Acral lenLlglnous: lound on palms/sole of feeL/under
Lhe nalls.

7+18 9$2,&:1
• uv8 exposure
• Þale skln
• naevl numbers
• lamlly hlsLory (<10° melanoma, muLaLlons ln
Cukn2A, Cuk4)
• Þrevlous melanoma
;"4 9"$,<:"1 &* !$#+=%$%, !"#$%&'$ >?@0)AB
• ?symmeLry
• @order lrregular
• 0olour lrregular
• )lameLer, ofLen greaLer Lhan 0.3cm
• AlevaLlon lrregular (+ loss of skln marklngs)
• CLhers: flrm Lo Louch, lnflammaLlon,
crusLlng/bleedlng, paraneoplasLlc syndromes: loss of
appeLlLe/welghL, nausea/vomlLlng, faLlgue
0$<1"1
Lxposure Lo uv radlaLlon from Lhe sun or solarlum.



C+1,&:4 $%D AE$'+%$,+&%
PlsLory: Ask abouL onseL, lLch, paln, bleedlng and
ulceraLlon.
lndlvldual: Age? lalr-skln? Pad loLs of sun exposure? Pave
Lhey always used sun proLecLlon?
SlLe: ls lL ln a sun-exposed or covered area?
Are Lhere slmllar leslons?
Morphology of leslon.
uermaLoscopy: useful ln leslons LhaL are noL melanocyLlc

F%G"1,+=$,+&%1
l8L, u&L, Ll1, LuP (meLaLasls)
C1, M8l, ÞL1, xrays (meLasLasls)
Skln blopsy
SenLlnel lymph node blopsy wlLh lymphosclnLlgraphy (lf
melanoma > 1mm)

H,$="1 >0#$:8 I"G"#B
1. Melanoma conflned Lo Lhe epldermls (Mls)
2. lnvaslon lnLo Lhe paplllary dermls
3. lnvaslon Lo Lhe [uncLlon of Lhe paplllary and
reLlcular dermls
4. lnvaslon lnLo Lhe reLlcular dermls
3. lnvaslon lnLo Lhe subcuLaneous faL
!$%$="'"%,
• Lxclslonal skln blopsy: leslon and surroundlng normal
Llssue removed. MusL have clear margln. Skln flaps or
grafLs someLlmes needed.
• Lymph node exclslon
• ChemoLherapy
• lnLerferon-alpha/lmmunoLherapy
• 8adloLherapy (ofLen used posL surgery)
J:&=%&1+1
@:"1#&K 3L+28%"11 ?55:&E+'$," M 4"$: 1<:G+G$#
<1 mm 93-100°
1-2 mm 80-96°
2.1-4 mm 60-73°
>4 mm 30°
8reslow depLh ls a prognosls facLor for melanoma.
1PL uAnuLnCnC uCSSlL8 2010
149
!"#$%&#' )*++ $,- .$'$+ )*++ )$/01,&%$
231-*%1&+&45
8CC ls Lhe mosL common human cancer. SCC 2
nd
mosL
common skln cancer afLer 8CC. Male > female.

)+1,10$+ 6*$7#/*'
.$'$+ )*++ )$/01,&%$
Cllnlcal Lypes
1. CysLlc nodular - LranslucenL or pale grey
2. ulceraLed - nodular 8CC wlLh cenLral necrosls.
3. ÞlgmenLed - usually spoLLed, maybe all black.
4. Superflclal - eryLhemaLous scaly paLch
3. Morphoelc (flbroLlc) - scar-llke, poorly deflned
margln.
6. **Common: rolled pearly, gllsLenlng edge,
LelanglecLasla, ulceraLed.

CfLen found on Lhe face of elderly lndlvlduals and rarely
meLasLaslses. Slow growlng. Causes local desLrucLlon lf
lefL unLreaLed. Called Lhe '8odenL ulcer'.

!"#$%&#' )*++ )$/01,&%$
• ÞrollferaLlve Lumour LhaL grows over a few monLhs.
ÞresenLs as an ulceraLed leslon, wlLh hard, ralsed
edges, flrm Lhlckenlng of skln, surroundlng eryLhema,
hard nodules soon ulceraLes.

• 1ends Lo arlse ln premallgnanL areas or areas wlLh
long-sLandlng lnflammaLlon such as solar keraLoses,
burns, chronlc ulcers, leucoplakla and 8owen's
dlsorder.

• SCCs of ear, llp, oral cavlLy, Longue and genlLalla are
serlous and need speclal managemenL. Also affecLs
esophagus, bladder and lungs.

)$#'*'
.))8 8CCs develop ln Lhe basal cell layer of Lhe skln.
Þrolonged exposure Lo uv8 causes unA damage Lo
accumulaLe leadlng Lo prollferaLlon of basal cells.

!))8 Puman papllloma vlrus has been assoclaLed wlLh SCC
of Lhe oropharynx, lung, flngers and anogenlLal reglon.
uv8 and lmmunosuppresslon are rlsk facLors for SCC of
Lhe skln. CasLrlc oesophageal reflux dlsease, Lobacco,
alcohol and beLel nuL consumpLlon are also rlsk facLors.

9/*:;$+14,$,7 <#%&#/' $,- =7>*/'
Solar kerasLose (acLlnlc kerasLosls): Appears on sun-
exposed skln as crumbly, yellow-whlLe crusL. 8x: cauLery,
cryoLherapy or 3-fluorouracll cream.

8owen's dlsease: SCC ln slLu. Slow-growlng redbrown
scaly plaque. lull Lhlckness dysplasla whlch may progress
Lo SCC. 8x: cryoLherapy, Loplcal 3-fluorouracll or
phoLodynamlc Lherapy.

Leucoplakla: WhlLe paLches on oral/genLlal mucosa where
lL may lLch.

Secondary carclnoma: MosL common meLasLases Lo skln
are from breasL, kldney or lung. usually a flrm nodule.
CfLen found on scalp.

?,@*'714$71&,'
Shave blopsy of 8CC

;$,$4*%*,7
• Surglcal exclslon ls besL. >4mm free surglcal margln.
• Moh's mlcrographlc surgery: exclsed Lumour ls
lmmedlaLely examlned under mlcroscope so lf
marglns are lnsufflclenL, more skln ls removed from
paLlenL wlLhouL delay. LffecLlve for hlgh-rlsk prlmary
and recurrenL 8CC.
• ÞhoLodynamlc Lherapy: LffecLlve ln prlmary
superflclal 8CC. AppllcaLlon of phoLosenslLlzers Lo
LargeL area. When acLlvaLed, Lhey become Loxlc.
• 1oplcal chemoLherapeuLlc agenLs such as 3-
lluorouracll or lmlqulmod
• 8adloLherapy
• CureLLage and elecLrodesslcaLlon

9/&4,&'1'
Around 93° of recurrences and meLasLases of SCCs occur
wlLhln 3 years.
8ecurrence of 8CC wlLh Moh's surgery ls ~1° and up Lo
10° for oLher forms of LreaLmenL.
!"# %&'%#'(') %(**+#, -./.
/0.
!"#
1PL uAnuLnCnC uCSSlL8 2010
131
!"# % & '(()*+),-./
012-3-+-43/
normal hearL raLe: 60-100 bpm
1achyarrhyLhmla ls > 100bpm
8rady arrhyLhmla ls <60bpm

543678+-43 9*/+1, 42 +)1 )1.(+
See plcLure !


:-/; <.8+4(/ 24( '(()*+),-./
• ALherosclerosls
• AMl
• ulabeLes
• valvulopaLhy
• Sleep Apnoea
• 1hyrold dlsease
• urugs

%= '+(-.> <-?(->>.+-43
Þrocess:
MulLlple lmpulses Lravel Lhrough aLrla aL same Llme,
leadlng Lo lrregular, rapld conLracLlons. noL all lmpulses
make lL Lhrough Av node, venLrlcles conLracL slower.
Lpldemlology:
2° Þrevalence. 3° lf over 63
1 ln 4 people over 40y wlll develop lL aL some polnL
Causes:
P1n, prevlous AMl, hyperLhyroldlsm, sLlmulanL
medlcaLlons, vlral lnfecLlons.
Slck slnus syndrome
Cllnlcal ÞresenLaLlon
Sx: ÞalplLaLlons, ChesL paln, dyspnoea,
presyncope/dlzzlness
Sg: lrregularly lrregular pulse,


@3 A5BC
:.+1 :)*+), ! D.E1 !: -3+1(E.> F:9
ALrla: 330-630bpm
venLrlcles: slow Lo
rapld
lrregular llbrlllaLory. no
vlslble Þ waves
n/A narrow (<


G= '+(-.> <>7++1(
Þrocess:
8e-enLranL slgnal essenLlally causes Lhe 8A Lo ºshorL
clrculL" slgnal from Lhe Av node, causlng lL Lo beaL
beLween 230-330 beaLs per mlnuLe. 1hls slgnal ls unable
Lo be passed Lhrough Lhe SA node aL such a rapld pace,
commonly resulLlng ln 2:1 or 4:1 hearL block
Lpldemlology:
2.3x more common ln males. Much less common Lhan
Aflb
Causes:
ALrlal enlargemenL, urugs, AMl, ÞL, ÞerlcardlLls
Cllnlcal ÞresenLaLlon
Sx: ÞalplLaLlons, ChesL paln, dyspnoea,
presyncope/dlzzlness
Sg: usually regular pulse. usually Lachycardlc.
1PL uAnuLnCnC uCSSlL8 2010
132


"# $%&'
()*+ (,-*,. / 0)1+ /( 2#*+31)4 5(6
ALrla: 230-330bpm
venLrlcle:
2:1 block ! 130bpm
3:1 block ! 100bpm
4:1 block ! 73bpm
ALrlal: regular
venLrlcular: regular
lf Av node conducLs
conslsLenLly
SawLooLh
appearance
n/A narrow
*!"#$%%$& "(()"*"+,) -+ .)"/0 112 111 "+/ "34

78 /)39:-;.)4 6<=3)1+#*32><4)3 ?)>,->)3@2)
Þrocess:
Cccaslonal rapld hearL beaL, comes and goes.
CfLen due Lo re-enLry paLhway/accessory paLhways whlch
loop back lnLo aLrla causlng aLrla Lo depolarlse before SA
node lnlLlaLes nexL conLracLlon.
Lpldemlology:
2.3x more common ln males. Much less common Lhan
Aflb
Causes:
ALrlal enlargemenL, urugs, AMl, ÞL, ÞerlcardlLls. Wolff-
Þarklnson-WhlLe syndrome. congenlLal
Cllnlcal ÞresenLaLlon
Sx: AnxleLy, palplLaLlons, dyspnoea
Sg: 1achycardlc.


"# $%&'
()*+ (,-*,. / 0)1+ /( 2#*+31)4 5(6
130-230bmp 8egular Can be noLched,
flaLLened, or losL wlLhln
C8S. 8uL Þ wave should
be presenL
0.12-0.20 seconds
(normal).
ConslsLenL
narrow
*$% /-"5+%0) 6!37 890$ &":) ;<= /9*-+5 ()*-%/ %> $",&?,"*/-"

1PL uAnuLnCnC uCSSlL8 2010
133
!" $%&'()*+,-( .-*/0*-(1)-
Þrocess:
8hyLhm fasLer Lhan 100bpm orlglnaLlng ln venLrlcles.
usually re-enLry paLhway LhaL conLlnuously sLlmulaLes
venLrlcles
Lpldemlology:
2.3x more common ln males. Much less common Lhan
Aflb
Causes:
ullaLed cardlomyopaLhles, CAu, 8undle block, AMl,
LlecLrolyLe abnormallLles, drugs
Cllnlcal ÞresenLaLlon
Sx: ÞalplLaLlons, dyspnoea, presyncope/syncope,
sweaLlng
Sg: 1achycardlc, hypoLenslve, Lachypnoelc,


2& 3456
7-'% 7/0'/8 9 :-;% 97 )&'%(;-, <7=
130-230bmp usually
8egular
noL usually vlslble, lf
vlslble, noL assoclaLed
wlLh C8S
n/A Wlde and blzarre,
dlfflculL Lo see
separaLlon
beLween C8S and
1 wave


>" $%&'()*+,-( ?)@(),,-')A&


>" BC0C'A,%



1PL uAnuLnCnC uCSSlL8 2010
134

!" $
%&
'()*(( +(,*& -./01 (bradycardla)
Þrocess:
lmpulse ls conveyed slowly Lhrough Av node.
Causes:
Av nodal dlsease, enhanced vagal Lone (aLhleLes), AMl,
elecLrolyLe dlsLurbance, drugs
Cllnlcal ÞresenLaLlon
Sx: none
Sg: none


23 4567
8,&( 89:&9; < =,>( <8 ?3&(*>,. @8A
uepends on underlylng
rhyLhm. 1
sL
degree
hearL block causes
underlylng rhyLhm Lo
be slower.
8egular 1x Þ wave precedes each
C1S
ConslsLenLly
lengLhened.
>0.20seconds
narrow

B" C
3D
'()*(( +(,*& -./01 (bradycardla)
Þrocess:
Some Þ waves conducL Lhrough Av node, oLhers do noL.
(some cases of 1ype ll are caused by blockage ln
conducLlon sysLem afLer Lhe Av node)
Causes:
Av nodal dlsease, AMl, eLc
Cllnlcal ÞresenLaLlon
Sx: usually none, may have: ulzzlness, presyncope
Sg: none
E:F( $ -./01 G =(31H,09 (Þrogresslvely lengLhened Þ8s unLll a dropped C8S)


23 4567
8,&( 89:&9; < =,>( <8 ?3&(*>,. @8A
uepends on underlylng
rhyLhm. 1
sL
degree
hearL block causes
underlylng rhyLhm Lo
be slower.
8egularly
lrregular
8egular lnLervals
beLween Þ waves.
Þrogresslve
prolongaLlon of Þ8
followed by a
dropped C8S
narrow


1PL uAnuLnCnC uCSSlL8 2010
133

"#$% & '()*+ (1:2 or 1:3 block)



,- ./01
234% 25#456 7 839% 72 :-4%;93( <2=
ALrlal raLe - normal
venLrlcular - slower
(1/2 or 1/3 of aLrlal
raLe)
lf conslsLenL
conducLlon,
regular. Lg lf
always 2:1
block
8egular lnLervals
beLween Þ
waves.
1here ls noL a C8S
followlng every Þ wave.
8uL where Lhere ls Lhe
lnLerval ls conslsLenL.
narrow


>? @
;A
B%C;%% D%3;4 '()*+ (compleLe)
Þrocess:
8lockage ln conducLlon sysLem. 1he aLrlum beaLs,
conLrolled by Lhe slnus node. 1he venLrlcles beaL
lndependenLly of Lhls aL a slower raLe.
Causes:
AMl, congenlLal, progresslve degeneraLlon of conducLlon
sysLem, endocardlLls
Cllnlcal ÞresenLaLlon
Sx: Lxerclse lnLolerance, chesL paln eLc
Sg: 8radycardla, hypoLenslon, posslble haemodynamlc
lnsLablllLy
1PL uAnuLnCnC uCSSlL8 2010
136


"# $%&'
()*+ (,-*,. / 0)1+ /( 2#*+31)4 5(6
ALrlal raLe: 60-100
venLrlcular: 20-60
8oLh wlll be regular buL
unrelaLed Lo each oLher.
8egular Þ waves presenL and
normally shaped.
no relaLlonshlp
beLween Þ wave
and C8S
Wlde

1PL uAnuLnCnC uCSSlL8 2010
137
!"# % & '()*+ ,-.(/012/3 456/0(*2.5
7+6252*2.5 89& :3/;;262(/*2.5
lrreverslble lschaemlc damage Lo Lhe myocardlum, usually
resulLlng from coronary arLery occluslon
<=21+>2.3.?-
nA
@2;A B/(*.0;
• lschaemlc PearL dlsease
• ALherosclerosls
• Male
• Age
• lamlly Px - 1
sL
degree relaLlve wlLh an AMl before 33
• Smoklng
• PyperLenslon
• ulabeLes
• SedenLary llfesLyle
• ? sLress
'+*2.3.?-9!/*C.=C-;2.3.?-
lnfarcLlon usually follows damage or rupLure Lo
aLheroscleroLlc plaque ln Lhe coronary arLerles. 1hls leads
Lo acuLe Lhrombosls as Lhe subendoLhellal collagen ls
exposed and subsequenL occluslon.
ConLracLlle funcLlon ls losL wlLhln 60 seconds of blood
flow occluslon, however myocyLes survlve for a fuLher 20-
30 mlnuLes
1he subendocardlal myocardlal Llssue (lnner half Lo
1/3) ls mosL vulnerable Lo lschaemlc damage, wlLh cellular
deaLh occurlng here flrsL

When a parLlal Lhlckness (subendocardlal) lnfarcL
occurs, ofLen LCC changes are noL seen, however
Lroponln wlll sLlll be elevaLed as cellular deaLh has
occured. 1hls ls called a nS1LMl (non S1 elevaLlon
Myocardlal lnfacLlon)

1hls ls common ln plaque lysls and self resoluLlon
(focal nS1LMl) or hypoLenslon (global changes)
AfLer Lhe lnfarcLlon slgnlflcanL remodelllng of Lhe
myocardlum occurs

MyocyLes do noL regeneraLe, lnsLead Lhere ls
anglogenesls (granulaLlon Llssue) and flbrln deposlLlon
! AcuLely a neuLrophllla ls presenL on hlsLology as Lhe
dead myocyLes are removed
! As remodelllng occurs Lhe myocardlum ls weaker and
Lhere ls a rlsk of aneurlsm or rupLure, especlally ln
large, Lransmural AMls

WlLhln 2 monLhs a sLable, frlbrlnous scar developes
over Lhe Llssue
D2?5; /51 D->=*.>;

ChesL paln
o vague, radlaLes Lo neck, [aw, arms, back or
eplgasLrlum
o ÞresenLaLlons wlLhouL chesL paln are 'aLyplcal' or
sllenL. 1hese are more llkely ln dlabeLlcs, elderley,
women
o Many lnfarcLlons are heralded by prevlous
lschaemlc anglnal evenLs

laLlgue

uyspnoea

Þresyncope/syncope

nausea

AuLonomlc slgns
o SweaLlng, cold, clammy, pallor
o AnxleLy
E2;*.0- /51 <F/>25/*2.5
Cardlac PlsLory & Lxam
Also 8esp, CasLro Lo exclude dlfferenLlals
45G+;*2?/*2.5;
LCC
o 1yplcally demonsLraLe an lschaemlc evenL by acuLe
elevaLlon of Lhe S1 segmenL >1mm or Lall 1 waves
o AfLer several days Lhe S1 segmenL wlll drop back Lo
normal and 1 waves may lnverL
Cardlac enzymes
o 1roponln levels
! 8eleased as myocardlum dles
! usually Lakes 8 hrs Lo rlse, however mosL speclflc
LesL avallable
o CreaLlne klnase - muscle and braln (CkM8)
! 8eleased before Lroponln buL less speclflc Lo hearL
problems
o Myoglobln
! llrsL cardlac marker Lo be released
! Many confoundlng facLors such as skeleLal muscle
damage so noL usually used
,/5/?+>+5* H'()*+I
1. AssessmenL - A8Cu, esp. LCC
2. Cxygen
3. Asplrln/Clopldegrel
4. Þaln managemenL - Morphlne,nlLraLes
3. µ blockers
6. ueLermlne course of LreaLmenL

llbrlnolysls
o ldeally wlLhln 12 hrs of onseL
o lncreases rlsks lf comblned wlLh sLenLlng

Surglcal sLenLlng of coronary arLery
o ldeally performed wlLhln 9 hrs of arrlval
:.>=32(/*2.5;
1here are many compllcaLlons of AMl

1he sysLollc funcLlon of Lhe hearL may be lmpalred by
Lhe loss of cardlac Llssue, usually progresslng Lo
cardlogenlc shock

ArrhyLhmlas may be caused by Lhe dlsrupLlon Lo Lhe
conducLlon sysLem ln Lhe hearL. ÞarLlcularly lefL and
rlghL bundle branch blocks or hearL block.

ÞerlcardlLls can be caused by Lhe subsequenL
lnflammaLlon of Lhe cardlac Llssue (uressler syndrome)

8upLure or Aneurlsms (!"" $%&'")

Mural Lhrobosls occurs as Lhe alLered endocardlum and
conLracLlle moLlon can prompL cloL formaLlon
!"# %&'%#'(') %(**+#, -./.
/01
!"# %&'%#'(') %(**+#, -./.
/01
!"# % & '()*+,-./*+,-0-
*22 3456 74829 *-3-
1PL uAnuLnCnC uCSSlL8 2010
160
!"# % & '()*+,-().+/0,1213
4+51.121).
nephrlLls characLerlzed by lnflammaLlon of Lhe caplllary loops
ln Lhe glomerull of Lhe kldney. 1hls lnflammaLlon can resulL ln
damage Lo Lhe basememL membrane, mesanglum or caplllary
endoLhellum. lL occurs ln acuLe, subacuLe and chronlc forms.

6/17+*1)()89
• AdulLs: MosL common lgA dlsease, focal glomerulosclerosls
• Chlldren: MosL common lgA dlsease, lupus nephrlLls, focal
glomerulosclerosls and mlnlmal change dlsease.
• Male > lemale

:13; <=>2),3
• lPx
• 1he known presence of a known cause

?+21)()89
• !"#$%&'()*
• !,-#*')$./
o ÞosL-sLrepLococcal glomerulonephrlLls
o 8acLerlal endocardlLls
o vlral lnfecLlon: Plv Pep 8,C
• !00.,# 1)/#&/#/
o Lupus: Chronlc lnflammaLory dlsease LhaL can affecL
skln, [olnLs, blood cells, hearL, lungs and kldneys.
o CoodpasLure's syndrome: lmmune lung dlsorder LhaL
causes haemorrhage lnLo lungs
o lgA nephropaLhy: resulLs from deposlLs of lgA ln Lhe
glomerull. (More common ln men Lhen women)
• 2&/*.3)')/
o ÞolyarLerlLls: small Lo medlum vessels ln hearL,
lnLesLlnes and kldneys
o Wegener's granulomaLosls: small Lo medlum vessels ln
lungs, upper alrways and kldneys
• 4$,")')$,/ '(&' /*&5 '(# 63$0#5.3./
o P1: Cn can also cause P1 due Lo reduced renal
funcLlon
o ulabeLlc kldney dlsease
o local segmenLal glomerulosclerosls: characLerlsed by
scaLLered scarrlng of Lhe glomerull

!=20)/0931)()89
1he lnlLlal ln[ury (many aeLlologles) reduces nephron mass
and Lhus reduces Lhe Cl8. 1hls reducLlon ln Cl8 leads Lo
hyperLrophy and hyperfllLraLlon of Lhe remalnlng nephrons
and Lo lnLraglomerular hyperLenslon. 1hls response occurs ln
order Lo lncrease Lhe Cl8 of Lhe remalnlng nephrons Lo
mlnlmallse Lhe funcLlonal loss due Lo damage. Powever Lhey
ulLlmaLely lead Lo furLher glomerulosclerosls and nephron
loss.
1he reduced Cl8 resulLs ln
• j producLlon of LÞC ! anaemla
• j producLlon of vlL u ! hypocalcemla, 2¨
hyperparaLhyroldlsm, hyperphosphaLemla and renal
osLeodysLrohpy
• j excreLlon of P2C + salL ! P1 and oedema
• j excreLlon of acld (P2CC3)! acldosls
• j excreLlon of k ! hyperkalemla
• ÞlaLeleL dysfuncLlon ! bleedlng

@18.3 =.7 @9*/2)*3
Common
• PaemaLurla: dark, rusL-coloured or brown
• ÞroLelnurla: loamy urlne
• Cenerallsed oedema
• P1n
• laLlgue
Less common
• Abdo paln, cough, dlarrhea, fever, [olnL aches, muscle aches,
loss of appeLlLe, SC8, heameLemlsls, blood ln sLood,
nosebleeds

A.B+3218=21).3
• urlnalysls
• urlne Mlcroscopy (88C + casLs)
• uLC
• lmaglng - xray, ulLrasound, ConLrasL urography,
anglography
• Serologlcal screen
C?D@6 E6@E
vascullLls AnCA
CoodpasLures AnLl-CM8
SLL AnA
Pep 8,C, Plv Serology
• 8enal blopsy

F=.=8+*+.2
non-pharmacologlcal
• lluld resLrlcLlon
• j proLeln, sodlum and poLasslum dleL
Þharmacologlcal LreaLmenL
C?D@6 E:6?EF6GE
P1n • ulureLlcs
• ACL-l
• AngloLensln ll recepLor agonlsL
lnfecLlon • 1reaL lnfecLlon
Lupus or vascullLls • lmmunosuppressanLs + sLerolds
lgA • llsh oll supplemenLs
Chronlc Cn • ulalysls
Surglcal LreaLmenL
• kldney LransplanL
1PL uAnuLnCnC uCSSlL8 2010
161
!"# % & "'()*+,(--.(--
/(01.1*12.
!"#$%&'( - a sense of awareness of ^ resplraLory efforL
LhaL ls unpleasanL and ls recognlsed by Lhe paLlenL as
belng lnapproprlaLe.
)*+,&$%&'( - SC8 upon lylng down due Lo redlsLrlbuLlon
of blood upon causlng ^ cenLral and pulmonary blood
volume, worsenlng pulmonary oedema. Also conLrlbuLed
Lo by Cl1 conLenLs pushlng up on Lhe dlaphragm.
-(*&."#/(0 2&3+4*%(0 !"#$%&'( - Where a paLlenL
awakes aL nlghL due Lo SC8, same mechanlsm as
orLhopnoea buL sensory awareness ls depressed durlng
sleep, causlng severe lnLersLlLlal and alveolar oedema Lo
accumulaLe
5"$'*6'%+70(+7&% - lnapproprlaLe overbreaLhlng,
occurrlng aL resL or on exerLlon and resulLs ln lowerlng of
Lhe alveolar and arLerlal ÞCC2
8(3,"$%&'( 9 5"$'*$%&'( - refers, respecLlvely Lo ^
raLe of breaLhlng and ^ level of venLllaLlon, whlch may be
approprlaLe Lo Lhe slLuaLlon.

/100('(.*1), /1)3.2-1-
• 8apld onseL (mlns-hrs)
o AsLhma
o lnhaled forelgn body
o ÞneumoLhorax
o AcuLe 8ronchlLls
o Þanlc aLLack
o AMl, AcuLe PearL lallure, ArrhyLhmla, ÞL,
Þerlcardlal 1amponade
o 8lb #
o Plgh alLlLude
o Acldosls/ukA
o urug LoxlclLy
• Þrogresslve onseL (days-wks)
o Þulmonary - pleural effuslon, pneumonla,
chronlc lnfecLlons
o CvS - hearL fallure, anaemla
o MyasLhenla gravls
• Slowly progresslve
o CCÞu/ Þulmonary llbrosls
o 1umours
o PearL lallure
o Severe obeslLy
o SysLemlc sclerosls

41-*2'5 ).6 78)91.)*12.
PlsLory
CnseL (sudden, long Lerm), severlLy (how far can you
walk?), Lype of SC8, any paln, cough, spuLum,
haemopLysls, wheeze, sysLemlc sympLoms (fevers)
ÞMPx - asLhma, CCÞu, flbrosls, hearL fallure
MedlcaLlons
ClgareLLes
CccupaLlonal PlsLory/ lPx

LxamlnaLlon
SpuLum - lnfecLlon
uull percusslon - pneumonla, pleural effuslon
8ronchlal breaLhlng - pneumonla
8educed breaLh sounds - CCÞu, pleural effuslon,
pneumoLhorax, pneumonla
Wheeze - asLhma, CCÞu, forelgn body
Crackles - CCÞu, PearL fallure, flbrosls

:99(61)*( ;).)3(9(.*
• Clve C2
• Þneumonla - Þenlclllln/CefLrlaxone + Macrollde
(covers SLrep, Paemophllus, Mycoplasma,
Þneumococcus)
• 8ronchodllaLor - eg: venLolln/ ALrovenL
• SLerolds (lv): PydrocorLlsone, SerlLlde (fluLlcasone +
SalmeLerol)
• CÞAÞ/8lÞAÞ when become acldoLlc

:.<(-*13)*12.-
• l8L, LS8, C8Þ, uLC, Ll1s, u-dlmer, Lroponln
• SpuLum MCS
• A8C
• C2 sLaLs
• LCC
• Cx8/vC scan/ C1/bronchoscopy
• Þeak flow/splromeLry

1PL uAnuLnCnC uCSSlL8 2010
162
!"# % & '()*+,-./0/
1)2030-0+3
Coughlng up blood from Lhe lungs.
8lood from Lhe nose, mouLh or pharynx LhaL may be spaL
ouL ls Lermed '!"#$%&#! ()*+&",-!%!..

1022)4)3-0(5 10(63+/0/
/01*2,%&0
• Þneumonla
• 8ronchlLls
• 8ronchlecLasls
• 7" 819 :97 ;<==>
• Lung abscess
• Aspergllloma
3)4%50)02-
• "4+3?@0(5 ?(4?03+*( 819 :97 ;<==>
• MeLasLaLlc mallgnancy
/01)$2,%&0
• ÞL
/014)++),%&0
• CoodpasLure's syndrome
• Wegener's granulomaLosls
/),$&5*0%2
• ÞosL pulmonary blopsy
6$)#+)
• lorelgn body
• lnLubaLlon ln[ury
• vlgorous coughlng
7)$8%)2
• Severe mlLral sLenosls
• AcuLe lefL venLrlcular fallure
9"#$%&#! ()*+&",-!%!
• LplsLaxls: cloLLlng dlsorders
• Cropharyngeal bleed: scurvy, glnglvlLls, denLal carles,
oral Lumours
• Cl1 bleed
8lood from Lhe proxlmal bronchl or Lrachea ls brlghL red.
8lood from dlsLal bronchloles/alveoll ls ofLen plnk and
mlxed wlLh froLhy spuLum.

'0/-
+4.
• S
p
o
n
L
a
n
e
o
us haemopLysls (mallgnancy)
• WelghL loss (18, mallgnancy)
• lever, nlghL sweaLs, malalse (lnfecLlon)
• 8ecurrenL chesL lnfecLlons (chronlc lung dz:
bronchlecLasls, mallgnancy)
• ÞleurlLlc chesL paln, SC8, recenL surgery/lmmoblllLy,
l.P., smoklng, P1 (ÞL)
• underlylng hearL dlsease (MlLral sLenosls, lefL
venLrlcular fallure)
• MedlcaLlons e.g. CCÞ (ÞL)

AB(*03(-0+3
• Þyrexla (lnfecLlon)
• Swlnglng fevers, acuLe sepsls (pneumonla/lung
abscess)
• Monophonlc wheeze (bronchlal carclnoma)
• leLor, blood mlxed wlLh purulenL spuLum
(bronchlecLasls)
• Choklng, sLrldor, paln, sudden lnexpllcable 'asLhma'
(forelgn body)
• Poarse volce, bovlne cough (laryngeal Ca)
• 1achypnoea, pleural rub, hypoxla, swollen Lender calf
(ÞL)

<3C)/-06(-0+3/
Always lnvesLlgaLe!
• l8L, Ll1, C8Þ
• ln8, AÞ11, group and hold
• Cx8 (AÞ and laLeral)
• urlnalysls
D(E/) <3C)/-06(-0+3
lorelgn body 8ronchoscopy
1umour SpuLum cyLology
C1 ChesL
8ronchoscopy
lnfecLlon SpuLum MCS
Al8
C1 ChesL
8lood culLures
lnfarcLlon/ÞL v/C scan
C1ÞA
Cardlac cause LCC
Lchocardlography

<**)F0(-) ;(3(6)*)3-
• A8C
• 8ed resL
• AnLlbloLlcs
• Cough suppresslon wlLh oplaLes (codelne /
hydrocodelne)
• 8lood Lransfuslon
• urgenL bronchoscopy Lo deLermlne source
• 8ronchlal arLery embollzaLlon
• Surglcal resecLlon
!4)/)3-(-0+3 +2 /,E-E*
03 @()*+,-./0/
#0G)5. ?+3F0-0+3
8usLy Lobar pneumonla
Þlnk and froLhy Þulmonary oedema
8lood mlxed wlLh
purulenL spuLum
8ronchlecLasls
8lood mlxed wlLh
spuLum and debrls
1umour
Masslve bleedlng
(>200ml blood ln 24
hours)
8ronchlecLasls or 18
1PL uAnuLnCnC uCSSlL8 2010
163
!"# % & '()*!+ ,-. !/01234,567
'896-6:60- ;*& <4,77696=,:60-
1hrombus: solld mass formed by blood consLlLuenLs
Lmboll: fragmenL of Lhrombus
uv1: Lhrombus ln veln wlLh 2º lnflammaLlon
ÞL: Lhrombus from sysLemlc velns / rlghL hearL embollses Lo
Lhe pulmonary arLerles

>67? @,=:0/7
ÞaLlenL lacLors Medlcal CondlLlons Surglcal
Þrocedures
*Age (> 60)
*lmmoblllLy
(especlally >4 days)
*CbeslLy
*varlcose velns
*Long alr Lravel
*Þregnancy (wlLh
>3 oLher rlsk
facLors)
*ÞasL PlsLory uv1
or ÞL
*CesLrogen
1herapy
*PomocysLelnaeml
a
*AcLlve cancer
*1hrombophllla
condlLlons
*uecompensaLed
hearL fallure
*recenL AMl
*AcuLe lung dlsease
*AcuLe lnflammaLory
dlsease
*AcuLe neurologlcal
dlsease
*Sepsls
*1rauma/
surgery
especlally Lo
hlp, knee, splne
*Lower leg
ln[ury/
lmmoblllsaLlon
*ma[or surgery
*surgery
>43mln

!,:2012376040A3
1hrombl usually form ln Lhe deep velns of Lhe leg around Lhe
valves & are called 'red Lhrombl' (conslsL of 88Cs and flbrln)
1hromboemboll conslsL of plaLeleLs & flbrln

B6A-7 ,-. B3C1:0C7
uv1
• 8ed, warm, swollen & Lender calf
• Þaln/dlscomforL & claudlcaLlon

ÞL
• Sudden onseL dyspnoea
• ÞleurlLlc chesL paln
• 1achycardla
• PypoLenslon, cyanosls
• Cough, haemopLysls
• Syncope

D67:0/3 ,-. +5,C6-,:60-
Ask & examlne for rlsk facLors, slgns & sympLom

E-F87:6A,:60-7
• u-ulmer: when you don'L suspecL ÞL / uv1, use lL Lo
rule ouL Lhese ux
• uoppler ulLrasound: for uv1
• venogram: for uv1
• LCC: S1C313 ln ÞL
• Cx8: normal ln ÞL
• C1ÞA: ux for ÞL

G,-,A8C8-:
u8 A8C (oxygen, sympLomaLlc rellef)
AnLl-coagulaLlon
1hrombolyLlc Lherapy (sLrepLoklnase, alLeplase, Llssue-Lype
plasmlnogen acLlvaLors, eLc)

!/01234,567
H0-&G8.6=,4
1LuS sLocklngs
lnLermlLLenL ÞneumaLlc Compresslon
CraduaLed Compresslon SLocklngs
G8.6=,:60-I
See Lable below
1hromboprophylaxls ÞroLocol lor SouLhern PealLh ÞaLlenLs aL
rlsk: 40mg Clexane s/c dally
Plp / knee Surgery: 40mg Clexane + 8lvaroxaban (10mg
orally) dally
uuraLlon: 7 - 14 days (or unLll d/c)
'/JA <4,77 G8:20. 09 K=:60- K.C6-
>0J:8
B6.8 +998=:7 L:28/
Peparln


8lnds Lo and
acLlvaLes
anLlLhrombln lll
l/v
s/c
Pemorrhage, 8alsed AL1/AS1,
Pyperkalemla
8are: CsLeoporosls, Alopecla
Severe: Pl1 (Peparln lnduced
1hrombocyLopenla)
aÞ11 monlLorlng because
shorL half-llfe (one hour)
Lnoxaparln
(clexane),
Llnzaparln,
ualLeparln
Low
Molecular
welghL
heparln
lnhlblLs lacLor xa
& lla
s/c Same as heparln buL less
severe
MonlLor vla anLl- xa level
8enal meLabollsm
londaparlnux lacLor xa lnhlblLor s/c 17-21 hr L x
8enal meLabollsm
8lvaroxaban ulrecL xa lnhlblLor Cral 8enal meLabollsm
Warfarln vlLamln k
AnLagonlsL
lnhlblL vlLamln k
acLlon on lacLors
2,7,9,10
Cral Pemorrhage, Warfarln
necrosls, CsLeoporosls,
Þurple Loe syndrome
ln8 monlLorlng

1PL uAnuLnCnC uCSSlL8 2010
164
!"# % & '(!)
)*+,-,.,/-
Chronlc and ,00*1*02,34* alrway obsLrucLlon
lncludes:
"0/-56,.,2
ÞroducLlve cough on mosL days for >3 monLhs of 2
successlve years
7896:2*8;
ullaLed alveoll dlsLal Lo Lermlnal bronchloles + desLrucLlon
of alveolar walls

<,2= >;5./02 ;-? ';@2*2
Smoklng (mosL common)
!
1
-anLl-Lrypsln deflclency
ÞolluLlon and occupaLlon exposure

!;.6/96:2,/4/A:
Chronlc bronchlLls
• Smoklng causes Cu8 lymphocyLe response wlLh
macrophage & neuLrophll acLlvaLlon
• PyperLrophy and lncrease ln number of mucus-
secreLlng gobleL cells of Lhe bronchlal Lree
• lnfllLraLlon of walls of bronchl and bronchloles
wlLh acuLe and chronlc lnflammaLory cells and
lymphold folllcles
• Squamous eplLhellum replaces columnar cells
• Scarrlng and remodellng of alrway wall leads Lo
wldespread narrowlng ln Lhe small alrways

Lmphysema
• uesLrucLlon of lung Llssue - loss of elasLlc recoll
and collapse of small alrways durlng explraLlon
- alr-Lrapplng (and ! resldual volume)
• ulsLurbed venLllaLlon " v/C mlsmaLch and
consequenL hypoxemla

B:89./82
Cough, spuLum, dyspnoea, wheeze

B,A-2
• >*;.@0*2 /+ 0*29,0;./0: /32.0@5.,/- C ?,2.0*22
" use of accessory muscles, Lachypnoea, barrel
chesL, Lracheal Lug, sLrldor
• >*;.@0*2 /+ 6:9*05;9-,;
" 8oundlng pulse, asLerlxls, flushed skln,
papllloedema, muscle LwlLchlng
• Pyper-resonanL percusslon noLe, decreased
chesL expanslon, hyperlnflaLed chesL, quleL
breaLh sounds
• ÞLosed llver ± PepaLosplenomegaly
• Slgns of 8Pl: ralsed !vÞ (cor Þulmonale),
perlpheral oedema (sacral + lower llmb)
• nlcoLlne sLalns

D,2./0:
Cough: duraLlon, dlurnal varlaLlon, spuLum, blood
Smoklng
lPx of resplraLory dlseases
ÞPx: prevlous dlagnosls of emphysema or CCÞu, alpha-
anLlLrypsln deflclency

7E;8,-;.,/-
Slgns of lnfecLlon e.g. fever, rlgors, nlghL sweaLs

F-1*2.,A;.,/-2
l8L: ^ÞCv
SpuLum culLure: lnfecLlon
Cx8: hyperlnflaLlon, bullae, flaL hemldlaphragms
LCC: rlghL aLrlal and venLrlcular hyperLrophy (cor
pulmonale)
A8C: low ÞaC2 ± hypercapnla
!
1
-anLlLrypsln levels
Lung funcLlon LesLs: 1yplcally low / no reverslblllLy wlLh
bronchodllaLors
- CbsLrucLlve plcLure (## lLv
1
/ lvC < 70°)
- #lLv
1
< 80°(bronchlLls),#lvC (alveolar
desLrucLlon)
- 1LC = lvC + 8v
!! # !!! (huge dead space)

G;-;A*8*-.
H/- 96;08;5/4/A,5;4
SLop smoklng, exerclse, lnfluenza and pneumococcal
vacclnaLlon, pulmonary rehablllLaLlon

!6;08;5/4/A,5;4
ÞaLlenLs wlLh sympLoms:
1. SA8A prn
2. Add long acLlng anLlchollnerglcs or LA8A
3. use boLh long acLlng anLlchollnerglcs and LA8A
ÞaLlenLs wlLh lLv<30°, or >2 exacerbaLlons ln prevlous
12 monLhs:
Add lnhaled corLlcosLerolds C8
use long acLlng anLlchollnerglcs + comblnaLlon of
corLlcosLerolds and LA8A e.g. sereLlde

#/-A .*08 (I .6*0;9:
ConLlnuous low flow C
2
for 16-24hrs / day C8 overnlghL
6 mln exerclse LesL proLocol (ÞaC
2
< 33 mmPg C8 fall ln
SaC
2
> 20°)

J-.,3,/.,52
ShorLen lnfecLlve eplsodes and prevenL furLher lung
damage
B@0A,5;4
Lung volume reducLlon
Lung LransplanLaLlon

'/894,5;.,/-2
8esplraLory fallure, cor pulmonale, pneumoLhorax
(rupLured bullae), lung carclnoma

1PL uAnuLnCnC uCSSlL8 2010
163
Gynaeco|og|ca| Lk (Lctop|c pregnancy]1ors|on of ovary]cyst rupture
Þaln: Lower abdomlnal (8ll or Lll), cramplng lf unrupLured/ excruclaLlng lf
rupLured
ux: µPCC + u/S or C1 or Laporoscopy

Akk
Cas paLLerns
• Lxcludlng bowel
obsLrucLlon and lleus
• Alr ln blllary
Lree!perforaLed gall
bladder!gallsLone lleus
CalclflcaLlons
• 10° of gallsLones seen
• 90 ° of renal calcull seen
• ÞancreaLlc calclflcaLlon
seen

Ckk
lree lnLra-abdomlnal fluld
under dlaphragm !
vlsceral perforaLlon

ueLecLs pneumonla (8LL)

Þ8L 9 - Abdom|na| Þa|n
Acute Cond|t|ons
Acute Append|c|t|s:
Þaln: SLarLs as cenLral paln and moves Lo 8ll (Mc8urney's polnL)
ConsLanL paln worse wlLh movemenL or coughlng.
A/W: Anorexla, nausea & vomlLlng, fever, "P8, changes ln bowel
ux: Cllnlcal + C1 wlLh recLal conLrasL
Acute 8|||ary D|sorder (8|||ary co||c]Cho|ecyst|t|s]Ascend|ng
cho|ang|t|s)
Þaln: 8uC (Murphy's slgn) radlaLlng around back/shoulder Llp,
ux: Ll1, u/S and l8L
8x: L8CÞ or CholecysLecLomy + 1rlple 8x (amoxy/genLa/meLra)
Acute Þancreat|t|s
Þaln: Severe eplgasLrlc + radlaLlon Lo back
A/W: n+v, anorexla, fever, weakness, sweaLy, pale
ux: Cllnlcal + " Serum llpase(x3") + C1 abdo
Þept|c U|cer D|sease (Þerforat|on]naemorrhage]Þy|or|c stenos|s)
Þaln: LplgasLrlc LhaL may radlaLe Lhrough Lo back
ux ÞerforaLlon : anxleLy, sLlllness, guardlng, decepLlve lmprovemenL
(early) n+v(laLe) + Cx8 wlLh alr beneaLh Lhe dlaphragm
ux Paemorrhae: Malaena & PaemLemesls + CasLroscopy (dlagnosLlc
+ 8x)
ux Þylorlc sLenosls: A/W vomlLlng + Ax8 (enlarged gasLrlc shadow) +
CasLroscopy/8arlum swallow Lo conflrm
Sma|| 8owe| Cbstruct|on (Adhes|ons]8ands]Strangu|ated hern|a)
Þaln: CenLral, collcky(every 3-10 mln) and lll deflned
A/W: n+v (early), dlsLenslon, compleLe consLlpaLlon (laLe)
ux: Suplne & erecL Ax8 (alr fluld levels wlLh no gas beyond
obsLrucLlon)

Mx of Acute Abdomen
• lv Cannulae
• Þaln rellef
• lvg: LCC/l8L/Llpase/Cx8/Ax8
• urlnary caLheLer
• nC1

Large 8owe| Cbstruct|on (Vo|vu|us]Carc|noma)
Þaln: Less cenLral, more perlpheral (lumbar/fossa)
A/W: Larly dlsLenslon + LaLe n+v and consLlpaLlon
ux: Ax8 (classlcal gas paLLern wlLh cuL off) + ConLrasL enema
(conflrms)
8x of slgmold volvulus: 8lgld slgmoldoscopy
Acute D|vert|cu|ar D|sease (D|vert|cu|os|s]D|vert|cu||t|s)
Þaln: uepends upon slLe! Slgmold mosL common!Lll
A/W: Local perlLonlsm, recLal bleedlng/pus, perforaLlon, abscess,
flsLulae, L8C(consLlpaLlon)
ux: C1 Abdo
8x: 1rlple Lherapy + colonoscopy 6 wks laLer

kena| D|sease (U1I]kena| Co||c]Ur|nary retent|on)
Þaln: Severe eplsodes (lasLlng hours) on a background of constant
paln + loln Lo groln radlaLlon
A/W: 1enderness ln Lhe cosLoverLebral angle, haemaLurla, vomlLLlng
ux: MSu + ku8 or C1 (gold sLandard)

kuptured]Leak|ng Abdom|na| Aort|c Aneurysm
Þaln: CenLral + 8adlaLlon Lhrough Lo back, Lhough may be
experlenced as lower back paln
A/W: Llderly + 8ack paln, haemaLurla, syncope, 'shock'
ux: C1 or u/S

Mesenter|c Artery Ccc|us|on |.e. |schaem|c gut
Þaln: Severe & cenLral (ouL of proporLlon Lo Lx. llndlngs)
A/W: Þrofuse vomlLlng, anxleLy & bloody dlarrhoea
ux: Acldosls + "serum lacLaLe (radlologlcal slgns are laLe)
ulfflculL Lo ux " susplclon ln elderly or Al pLs

Contrast kk
IV Þye|ogram: excludes renal sLones or oLher renal obsLrucLlon

8ar|um Swa||ow: lmages rupLured oesophagus and pylorlc sLenosls

Gastrograff|n fo||ow-through: bowel obsLrucLlon

Gastrograff|n enema: excludes L8C or colon perforaLlon (avold ln
lnflamed bowel ! " Þ ! perforaLlon)

1PL uAnuLnCnC uCSSlL8 2010
166
!"# %& ' ()*++,-.*
ueflned as
• >3 bowel moLlons per day
• Looser Lhan normal sLools
• May be a sensaLlon of urgency
• SLool volume >200g
/0123456/67!3829!25659#9:;
!"#!$%&
• 1he guL mucosa acLs a seml-permeable
membrane and fluld enLers Lhe bowel lf Lhere
are large quanLlLles of unabsorbed soluLes e.g.
glucose
• lL happens ln malabsorpLlon, and sLops when Lhe
malabsorpLlve subsLance ls dlsconLlnued
"(&)($!)*
• 1here ls lncreased acLlve lnLesLlnal secreLlon of
fluld and elecLrolyLes and decreased absorpLlon
&+,,+- ./0121
• LnLeroLoxlns (cholera, L-coll)
• 8lle salLs and faLLy aclds followlng lleal resecLlon
• Some laxaLlves
%3456#6$!)* 7(89:6$%;(
• ulsrupLlon of lnLegrlLy of Lhe mucosal layer so
Lhere ls loss of fluld and blood
• Caused by lnfecLlon (shlgella,salmonella and
glardla, lschaemla or lnflammaLlon (l8u)
:*"#!$%5%$*
• Abnormal moLlllLy of Lhe upper guL
• 1he volume and welghL of sLool noL hlgh
• 1here ls lncreased frequency
• noL Lrue dlarrhoea
&/0121
• Lndocrlne: hyperLhyroldlsm
• neurologlcal: auLonomlc neuropaLhy as ln
dlabeLes






&!##!3 &69"(" !4 %34(&$%;( :%))<!(6
!)=63%"# >)("(3$6$%!3 $)(6$#(3$
CampylobacLer
[e[unl
Large and small bowel
dlarrhoea
Common cause of
gasLro ln chlldren
lncubaLlon-2-4days
Clprofloxacln
LryLhromycln
salmonella lound ln uncooked
chlcken, common ln
Lhe elderly and
lmmunosupressed
Slgns occur 24-
48hrs posL lnfecLlon
Clprofloxaclllln
azlLhromycln
shlgella Causes dysenLery(
frequenL small volume
sLools wlLh blood and
mucus)
norfloxaclllln,
1rlmeLhoprlm+s
ulfameLhoxazol
e
amplclllln
C.dlfflclle ÞosL A8x Lherapy so ln
elderly and
hosplLallsed pL
ulagnosed Lhru
deLecLlng Loxlns ln
sLools by LLlSA
MeLronldazole
vancomycln
(orally)
L.coll Common cause of
Lraveller's dlarrhoea
Causes waLery
dlarrhoea
no anLls
SLaph aureus Causes slgnlflcanL
dlarrhoea and vomlLlng
Sx 2-4hrs posL
lnfecLlons
SympLoms
usually resolve
ln 24hrs
%3;("$%=6$%!3"
6.0?2 @A/BBC+2/ &CB+-A. @A/BBC+2/
8lood LesLs- l8L
SLool culLures
Ax8

lor acuLe +colonoscopy
and blopsy
C1 abdomen
1PL uAnuLnCnC uCSSlL8 2010
167
!"# %% & '() "*++,
-.//+0+12.3* -.34156.6
788+0 '() (loreguL): 8leedlng anywhere from Lhe oral
cavlLy Lo Lhe 4
Lh
parL of Lhe duodenum (aL llgamenLum
Leres)
903* :3;.2<
MouLh cancer 1obacco use, L1CP, sun exposure
(llps) PÞv
ClnglvlLls Þoor oral hyglene, smoklng/chewlng
Lobacco, dlabeLes, age,
lmmunodeflclency, poor nuLrlLlon,
subsLance abuse
Cold sores (PSv)
uenLal Carles
9+658=34>6
Cesophageal varlcles ÞorLal P1n, CLu, L1CP abuse, CC8u
CesophaglLls urug SL, CC8u: obeslLy, smoklng,
pregnancy, hlaLal hernla lPx
lmmunodeflclency
Cesophageal cancer L1CP, blle reflux, CC8u, chewlng
Lobacco, smoklng, obeslLy, radlaLlon
LreaLmenL ln chesL/upper abdo, hoL
drlnks
Mallory-Welss Lear PlaLal hernla, L1CP abuse,
?25@3:=
CasLrlc ulcers P. pylorl, nSAlus, smoklng, L1CP,
sLress
CasLrlc cancer jflbre ^salL dleL, lPx, P.pylorl,
chronlc gasLrlLls, pernlclous anaemla,
smoklng, polyps
CasLrlc varlcles
CasLrlLls P. pylorl, nSAlus, Age
uleulafoy's leslons
(large arLerloles ln
sLomach wall)

->5,+1>@
uuodenal ulcers See CasLrlc ulcers 8l
llsLulae ulcers
8leedlng from Lhe
blllary Lree

#5A+0 '() bleedlng: 8leedlng from Lhe Cl LracL occurrlng
dlsLal Lo Lhe LlgamenLum of 1rleLz
?@3** "5A+*
AorLoenLerlc flsLula AAA repalr
Small 8owel 1umour Chron's dlsease, lAÞ,
lmmunosuppresslon
Meckel's dlverLlculum
Anglodysplasla ulsorders of coagulaLlon
B5*51.:
ulverLlcular haemorrhage Low flbre dleL
Anglodysplasla CoagulaLlon dlsorders
Colon Cancer Þoor dleL, famlly hlsLory, lAÞ,
smoklng, age
Þolyps lAÞ, poor dleL
CollLls l8u, exposure Lo Loxlns
C+:23*
Þolyps lAÞ, poor dleL
Paemorrholds Chronlc consLlpaLlon
+sLralnlng, age
8ecLal Cancer Age, smoklng, famlly hlsLory,
poor dleL

D.6250< 31, EF3@.132.51
D.6250<
- Abdomlnal Þaln - may lndlcaLe Lhe underlylng cause
- Changes ln appeLlLe?
- Changes ln welghL?
- nausea or vomlLlng?
o PaemaLemesls
- ulfflculLles swallowlng
- PearL burn?
- 8loaLlng?
- 8ecenL changes or dlsLurbances ln defecaLlon?
- 8lood ln your sLools? haemaLochezla
- lLchlness?
- LeLhargy?: anaemla
- lever?
EF3@.132.51
- Slgns of anaemla
o Con[uncLlval pallor,
- Slgns of llver dlsease
o May lead Lo bleedlng problems
- Þ8 examlnaLlon
o Paemorrholds
o Anal flssures
o Þresence of melaena or haemaLochezla

)<8+ 5/ "*55, G+32>0+6 B3>6+6
G0+6= H*55, .1
;5@.2
8rlghL red blood
presenL ln vomlL
- 8emalns red lf ln
sLomach for less
Lhan 1hr
- Lxclude oLher
sources of bleedlng
upper Cl sysLem
- CesophaglLls
- Mallory-Welss Lear
- Cesophageal varlcoses
D3+@32+@+6.6 uescrlbed as 'coffee-
grounds' ln vomlL
- 8ed flag
8leedlng proxlmal Lo Lhe
duodenum
- ÞerforaLed pepLlc ulcer
- Carclnoma
I+*3+13 8lack bowel moLlons
- Cffenslve smell
- 8esulL of blood ln
Lhe dlgesLlve LracL
more Lhan 8 hrs
upper Cl sysLem
- Þroxlmal Lo Lhe
ascendlng colon
- Anglodysplasla
- Meckel's dlverLlculum
D3+@325:=+J.3 lresh blood ln sLools
- 8ed blood vlslble on
sLools or LolleL paper
Lower Cl bleedlng
- ulverLlcular dlsease
- Colon cancer
- Paemorrholds
- Anal llssures
- Anglodysplasla

(1;+62.432.516 31, (@@+,.32+ CF

K:>2+ >88+0 '( H*++,.14
8lood 1esLs:
- Pb: <10g/dL Lhe paLlenL ls elLher acLlvely bleedlng or has
bled recenLly and requlres Lransfuslon),
- urea and elecLrolyLes,
- Llver funcLlon,
- CoagulaLlon sLudles
- Crouplng and cross maLchlng (ln Lhe evenL a Lransfuslon
ls needed)
Lndoscopy:
- Should be conducLed ln paLlenLs wlLh shock, suspecLed
llver dlsease or conLlnued bleedlng.
- 80° effecLlve ln deLecLlng Lhe source of bleed.
1PL uAnuLnCnC uCSSlL8 2010
168
- 8leedlng dlscovered Lo be managed durlng endoscopy
wlLh llgaLlon, cllpplng, adrenallne and cold waLer.
!"#$% '()%* +, -'%%./01
8lood LesLs plus:
- ÞrocLoscopy (anorecLal dlsease, ln parLlcular
haemorrholds)
- Slgmoldoscopy (lnflammaLory bowel dlsease)
- 8arlum enema (lschemlc collLls)
- Colonoscopy (for any mucosal leslon and removal of
polyps)
- Anglography (ln vascular abnormallLles eg.
anglodysplasla ,whlch someLlmes can be LreaLed wlLh
argon plasma coagulaLlon.)

23*(0/" +, -'%%./01
lnvesLlgaLlon AdvanLages ulsadvanLages
laecal CcculL
8lood LesL
Cheap and easy
ulsLal leslons can be
deLecLed
lnconslsLenL
8esulLs may be affecLed by
dleLary lron
lood whlch darkens sLool
may make lL hard Lo read
8arlum
enema
lf used wlll obscure
subsequenL aLLempLs aL
arLerlography or
colonoscopy
Colonoscopy Can be used even
wlLh ongolng
masslve bleedlng
lncreased rlsk of bowel
perforaLlon, should noL be
aLLempLed wlLh lschaemla,
severe mucuous
lnflammaLlon
SelecLlve
mesenLerlc
anglography
Can deLecL
haemorrhages >
0.3ml/mln
MorbldlLy assoclaLed wlLh
renal fallure, arLerlal
dlssecLlon, lschaemlc
collLls, deaLh
C1
Anglography
lasL <13 mlns
non-lnvaslve
ldenLlfles small
and large bowel
haemorrhage
8equlres modern C1
scanner





1PL uAnuLnCnC uCSSlL8 2010
169
!"# %& ' ()**+,-./+

0123/42-*-56
Þrevalence 8° of Lhose > 40yrs. 90° asymLomaLlc

72+8 9):,-;+
- laL
- lemale
- lorLy
- lerLlle
- lalr
- ulabeLes MelllLus
- CysLlc llbrosls
- Callbladder (C8) dysmoLlllLy

8l for sLones becomlng sympLomaLlc
- Smoklng
- ÞarlLy

!),<-1<6+2-*-56
- 8lle conLalns cholesLerol, blle plgmenLs, and
phosphollplds (leclLhen). lf Lhe concenLraLlon of
Lhese subsLances varles, dlfferenL sLones may
form
- ÞlgmenL sLones (<10°, small, frlable, lrregular)
o Þrlmarlly calclum blllrublnaLe, <20°
cholesLerol.
o 8lack or brown, Lhe laLLer formlng
secondary Lo chronlc blllary lnfecLlon
- CholesLerol sLones (Large, ofLen sollLary)
o usually >30° cholesLerol monohydraLe
plus an admlxLure of calclum salLs, blle
plgmenLs, proLelns, and faLLy aclds
o Admlrand's Lrlangle:!8lsk of sLone lf
"LeclLhen, "8lle salLs and !CholesLerol
- Mlxed sLones (laceLed, calclum salLs, plgmenL,
and cholesLerol)
- lormaLlon of sLones alded by "C8 moLlllLy


=.>/+,25),2-.+
- Abdo uS - 93° senslLlvlLy for gallsLones > 4mm
- Ll1s - CholesLaLlc plcLure lf choledocollLhlasls

?-41*2:),2-.+
AcuLe CholecysLlLls
Slgns & SympLoms
- ConLlnuous eplgasLrlc or 8uC paln (referred Lo 8.
shoulder)
- vomlLlng
- lever
- Local perlLonlsm (ulfference from blllary collc ls
Lhe lnflammaLory componenL, eg perlLonlsm,
!WCC,fever)
- C8 mass
- Murphy's Slgn +ve
- Þhlegmon (8uC mass of lnflamed adherenL
omenLum and bowel)
lx
- !WCC
- Abdo uS, Lhlck wall, shrunken C8 (also seen ln
chronlc dlsease), perlcholecysLlc fluld, sLones,
C8u dllaLed lf > 7mm
8x
- n8M, Analgesla, AnLlbloLlcs
- CholecysLecLomy (Larly as posslble)

Chronlc CholecysLlLls

8lllary Collc

CLher

@).)5/4/.,
CholecysLecLomy
- Surglcal removal of Lhe gallbladder
- Consequence ls an lncrease ln sLool frequency.
Cllnlcally lmporLanL <3° of paLlenLs. ÞaLlenLs
respond well Lo sLandard anLldlarrhoea drugs
- Lap chole has " morLallLy Lhan open procedure
due Lo " lncldence of posL op cardlac and
resplraLory compllcaLlons
non-surglcal Lechnlques (noL effecLlve)
- Cral dlssoluLlon Lheraples
- ConLacL dlssoluLlon Lheraples
- LlLhoLrlpsy




1PL uAnuLnCnC uCSSlL8 2010
170
!"# %& ' ()*+,-*
.+/-)-0-1) 234 56*77-/-8*0-1)
Anaemla refers Lo a sLaLe of clrculaLlng eryLhrocyLe
deflclency.
• MlcrocyLlc / macrocyLlc / normocyLlc

9-7: ;*801<7
• Age
• CerLaln eLhnlclLles
• Þoor nuLrlLlon
• lemale sex
• Asprln / nSAlu use
• Chronlc dlseases (esp. renal / mallgnancy)
• Paemorrhaglc dlseases (Cl1, eLc)
• 8leedlng dlsorders

(+0-161=>35*?7+7
• 8lood loss
• lmpalred producLlon
• lncreased desLrucLlon

!*0@1A@>7-161=>
lmpalred producLlon
• ulsLurbance of prollferaLlon and dlfferenLlaLlon
of sLem cells
• ulsLurbance of prollferaLlon and maLuraLlon of
eryLhroblasLs
lncreased desLrucLlon (haemolyLlc anaemla)
• uue Lo lnLracorpuscular abnormallLles (mosLly
heredlLary)
• uue Lo exLracorpuscular abnormallLles
o AnLlbody-medlaLed
o Mechanlcal Lrauma
8lood loss
• 1rauma / surgery
• Cl1 leslons
• Cynaecologlc dlsLurbances

B-=)7 *)C B>,A01,7
SympLoms
• uecreased exerclse Lolerance
• uyspnoea on exerLlon / aL resL
• Weakness
• LlghL-headedness
Slgns
• 8leedlng
• volume depleLlon
• SysLemlc lllness
• Þallor
• 8oundlng pulses
• 1achycardla
• Confuslon
• Scleral lcLerus / [aundlce
• PearL fallure
• Anglna / AMl

D-701<> *)C EF*,-)*0-1)
Px
• 8lood loss (Cl1, mensLrual, eLc)
• uleL (lron, folaLe)
• ÞPx (chronlc dlsease, surgery, bleedlng
dlsorders)
• lPx / eLhnlclLy
• urug hlsLory (asplrln, nSAlus)
Lx
• Slgns of anaemla
• lndlcaLlons of cause
• CompllcaLlons of anaemla

G)H+70-=*0-1)7
LmergenL seLLlng
l8L (8uW, MCv), reLlculocyLe counL, u&L, 1l1,
crossmaLch
lurLher comprehenslve LesLlng
• Þerlpheral smear, LuP, hapLoglobln, Ll1, dlrecL /
lndlrecL Coombs
• lron sLudles (lf mlcrocyLosls)
• Pb elecLrophoresls, bone marrow exam
• Lndoscopy (suspecL bleedlng)

I*)*=+,+)0
1. 1reaL cause
2. Conslder Lransfuslon

51,A6-8*0-1)7
8lsks of Lransfuslons (lnfecLlon, Lransfuslon reacLlon, lron
overload)

1PL uAnuLnCnC uCSSlL8 2010
171
!"# %& ' "()*+, -*./)(
0)12.2,23. 456 -7*++212/*,23.
!"#$%&#'
• lnfllLraLlng ducLal carclnoma - 80-90°
• lnfllLraLlng lobular carclnoma - 10°
• Medullary carclnoma- 3-8°
• Muclnous carclnoma- 2-4°
• 1ubular carclnoma- 1-2°
• Þaplllary carclnoma - 1-2°
)*"+&"#$%&#'
• uucLal carclnoma ln slLu
• Lobular carclnoma ln slLu
,%' -). %/$0&"0 /* 1'/'23&"' 02$1'4

892:);2373<=
MosL common cancer ln women nexL Lo skln cancer.
Second only Lo lung cancer as a cause of deaLh.

>2+? @*/,3(+
• uelayed chlldbearlng or nulllparous
• ÞoslLlve famlly hlsLory
• CeneLlc muLaLlons (88CA1 & 2)
• Þrevlous Px of breasL cancer
• llbrocysLlc change (prollferaLlve changes)
A),2373<=5-*B+)+
• 88CA1 and 2 muLaLlons on chromosome 17
• p33 - Lumour suppressor gene
• SomaLlc muLaLlons
!*,C39C=+2373<=
• Cverexposure Lo oesLrogens and underexposure
Lo progesLerone lmporLanL.
• LlmlLed relaLlonshlp Lo oral conLracepLlves, more
wlLh hormone replacemenL Lherapy.
• Many Lumours conLaln recepLors for oesLrogen
and progesLerone and may respond Lo hormone
manlpulaLlon.
D2<.+ *.: D=;9,3;+
• 70° presenL wlLh a palnless breasL lump.
• 90° of masses dlscovered by paLlenL.
• 8reasL paln.
• nlpple dlscharge (bloody, serous), eroslon,
reLracLlon, enlargemenL or lLchlng.
• 8edness, hardness, enlargemenL or shrlnklng of
breasL.
• Axlllary mass or swelllng of Lhe arm.
• 8ack of bone paln, [aundlce or welghL loss -
sysLemlc meLasLases.
E2+,3(= *.: 8F*;2.*,23.
8reasL examlnaLlon - paLlenL slLLlng, arms aL her sldes and
Lhen overhead. Look for abnormal varlaLlons ln breasL slze
and conLour, mlnlmal nlpple reLracLlon and sllghL
oedema, redness or reLracLlon of Lhe skln. AccenLuaLe
dlfference ln breasLs by ralslng arms overhear or press
hands on hlps Lo conLracL pecLoralls muscles. Make sure
Lo palpaLe axlllary and supraclavlcular areas. non-Lender,
flrm or hard mass wlLh poorly dellneaLed marglns (local
lnfllLraLlons) - susplclous. Also palpaLe breasLs
sysLemaLlcally when paLlenL ls suplne and arm abducLed.

G.H)+,2<*,23.+
56**1 -'%/%
• C8Þ/LS8 - dlssemlnaLed cancer
• Llver or bone meLasLases - ALÞ
• Pypercalcemla - advanced cancer
• CA 13-3 - maker for recurrence and LreaLmenL
effecLlveness
!3$0&"0
• Cx8 - pulmonary meLasLases
• C1 llver and braln - suspecL meLasLases
• 8one scan - only when suspecL bone meLs
7&$0"*%/&8 -'%/%
• 8lopsy - Cold sLandard, safesL course - blopsy all
susplclous leslons. lnA cyLology, core blopsy,
exclslon blopsy.
• uS - prlmarlly Lo dlfferenLlaLe a cysLlc from solld
leslons. L.g. llbrocysLlc change. lf cysL deLecLed,
18-guage needle Lo asplraLe fluld Lo dlagnose.
Powever lf fluld ls bloody - blopsy.
• Mammography - mosL rellable means of
deLecLlng cancer before a mass can be palpaLed.
CalclflcaLlons, lncreased denslLy of a mass,
lrregular or lll-deflned borders. Also a useful
screenlng Lool.
I*.*<);).,
I):2/*7 - ChemoLherapy and radloLherapy - ofLen
comblned wlLh surgery, hormonal Lherapy (Lamoxlfen) -
very useful ln oesLrogen recepLor poslLlve cancers.
1argeLed Lherapy (PercepLln) - monoclonal anLlbody LhaL
blnds Lo PL8-2 recepLors.
DB(<2/*7 - 8reasL conservlng Lherapy (lumpecLomy),
MasLecLomy +/- axlllary dlssecLlon
#21)+,=7) - lf u LreaL breasL cancer wlLh llfesLyle changes
! ÞalllaLlve ln my oplnlon.
-3;972/*,23.+
• Local recurrence
• Cedema of arm - afLer lymph node dlssecLlon +
axlllary radloLherapy.
• uv1
• ueaLh
1PL uAnuLnCnC uCSSlL8 2010
172
!"# %& ' ()*+,-.+/0*1
2+34,454-, 678 9*0::434;054-,
Spleen:
• SympLom noL a dlsease
• 8lbs 9-12
• normally ~130g/11cm
• Lnlarges: lnferlo-medlally
• uoubles before palpable

<+54-*-/1790=:+:
• >,3+;54-=:
o lnfecLlous Mononucleosls
o SubacuLe 8acLerlal LndocardlLls
o Malarla
• >,;?+0:+@ A"9 @+:5?=;54-,
o PeredlLary spherocyLosls
o PaemolyLlc Anaemla (auLo-lmmune)
o 1halassaemla Ma[or
• 9-,/+:54B+
o ÞorLal P1n
o Splenlc veln 1hrombus
• C1+*-)?-*43+?054B+
o Chronlc Myelold MeLaplasla
• >,34*5?054B+
o Sarcoldosls
o Caucher's ulsease
• D+-)*0:54;
o Lymphomas (Podgklns and non-Podgklns)
o Leukaemlas (AcuLe, Chronlc, Lymphold,
Myelold)
• C4:;+**0,+-=:
o lelLy's Syndrome (8A, Splenomegaly and
neuLropenla)
o 1rauma (Paemorrhage)
o CysLs
o MeLasLases (commonly melanoma)
o ClanL Abscesses
o CerLaln drugs (e.g. 8hoCAM)

(4/,: 0,@ (1.)5-.:
• Mlld, vague abdomlnal paln
• Larly saLleLy (gasLrlc dlsplacemenL)
• AssoclaLed Sgns/Sxs Lyplcally relaLed Lo underlylng
condlLlon
• lebrlle (lnfecLlous)
• Þallor, uyspnoea, 8rulslng/ÞeLechlae (haemolysls)
• WelghL loss/consLlLuLlonal Sx (neoplasLlc)
• ÞancreaLlLls (splenlc veln Lhrombus)
• Alcohollsm/hepaLlLls (llver dlsease)

E4:5-?1 0,@ FG0.4,054-,
• PlsLory
o lorelgn Lravel
o 8rulslng/8leedlng
o urugs (lncl. lvuu)
o !aundlce/splder nlvae eLc
• ÞalpaLe spleen
• AddlLlonal Slgns
o LymphadenopaLhy
o Slgns of llver dlsease
o Slgns of anaemla
o PearL murmurs
>,B+:54/054-,:
• l8L/lllm (myeloprollferaLlve dlsease, myeloflbrosls,
haemolyLlc anaemla, vlral lnfecLlon, llver dlsease,
lymphoma, CLL)
• Lymph node/Llver blopsy
o noLe: flne needle asplraLlon/blopsy of
spleen dangerous and noL recommended)
• C1 ChesL/Abdo

C0,0/+.+,5
C+@4;0*
1reaL underlylng cause
(=?/4;0*
SplenecLomy

9-.)*4;054-,:H
• Splenlc lnfarcL
• Splenlc rupLure
• Pypersplenlsm (blgger spleen pools more blood =
anaemla, LhrombocyLopenla, pancyLopenla)
• ÞosL-Cp: lmmuno-compromlsed
• ÞosL-SplenecLomy: ÞaLlenLs should be vacclnaLed
agalnsL P. lnfluenza, SLrep. Þneum and
Menlngococcus, wlLh yearly lnfluenza vacclnaLlons

#IC!E<2FDJ!<KEI
90=:+H
lnfecLlon, AuLo-lmmune, Mallgnancy
>,3+;54-=:
uuraLlon
vlral: Small, dlscreLe, moblle, and bllaLeral
8acLerlal: Large, warm, and Lender and have
surroundlng eryLhema and oedema

C0*4/,0,5
ÞerslsLenL
Pard or rubbery, dlscreLe, non-Lender, and flxed
Lo Lhe skln or underlylng sLrucLures

#-;0*
o Locallsed lnfecLlon
o Local Cancer
L+,+?0*4:+@
o Cenerallsed lnfecLlon (esp. vlral)
o AuLolmmune dlsease (e.g. SLL)
o Lymphoma
CLhers (e.g. sarcold)
1PL uAnuLnCnC uCSSlL8 2010
173
Þ8L 16 - Lymphoma
Def|n|t|on
neoplasms from lymphold Llssue, ma[orlLy of whlch are of
8 cell orlgln.

C|ass|f|cat|on
nodgk|n's |ymphoma (nL):
8eed-SLernberg cells - Large mallgnanL blnucleaLe cells of
8 cell orlgln. lew 8S cells are found surrounded by
numerous reacLlve non-mallgnanL 1-cells, plasma cells
and eoslnophlls.
PL classlfled lnLo:
1. Nodu|ar |ymphocyte-predom|nant
2. nodgk|n's|ymphoma C|ass|ca| nodgk|n's
|ymphoma
• nodular scleroslng PL (70°)
• LymphocyLe-rlch PL 8ody (3°)
• Mlxed cellularlLy PL 8ody (23°)
• LymphocyLe-depleLed PL (rare)

Non-nodgk|n's |ymphoma (NnL):
nPL refers Lo monoclonal prollferaLlon of lymphold cells
of 8 cell (70°) or 1 cell (30°) orlgln. Classlfled lnLo
lndolenL (low grade), aggresslve (hlgh grade) and hlghly
aggresslve.
WnC NnL C|ass|f|cat|on:
8 ce|| |ymphomas
• !"#$%"&'" ) $#** *+,-.',/&
o LymphoblasLlc lymphoma/leukaemla (hlghly
aggresslve)
• 0/1%"# ) $#** *+,-.',/&
o Chronlc lymphocyLlc leukaemla/small
lymphocyLlc lymphoma
o lymphocyLlc lymphoma
o Splenlc marglnal zone lymphoma
o LxLranodal marglnal zone 8 cell lymphoma of
mucosa-assoclaLed lymphold Llssue (MAL1-
lymphoma)
o nodal marglnal zone 8 cell lymphoma
o lolllcular lymphoma (!""#$%%&'$)
o ManLle cell lymphoma
o ulffuse large 8 cell lymphoma (!""#$%%&'$)
o MedlasLlnal (Lhymlc) large 8 cell lymphoma
o lnLravascular large 8 cell lymphoma
o Þrlmary effuslon lymphoma
o 8urklLL's lymphoma (Plghly aggresslve)
1]Nk ce|| |ymphomas
• !"#$%"&'" 2 $#** *+,-.',/
o Þrecursor 1 cell lymphoblasLlc
leukaemla/lymphoma ((&"()*
!""#$%%&'$)
o 8lasLlc nk cell lymphoma
• 0/1%"# 2345 $#** *+,-.',/
o AdulL 1 cell leukaemla/lymphoma ('$#*
!""#$%%&'$)
o LxLranodal nk/1 cell lymphoma, nasal
Lype
o LnLeropaLhy-Lype 1 cell lymphoma
o PepaLosplenlc 1 cell lymphoma
o SubcuLaneous pannlcullLls-llke 1 cell
lymphoma
o Mycosls fungoldes
o Sezary syndrome
o Þrlmary cuLaneous anaplasLlc large cell
lymphoma
o Þerlpheral 1 cell lymphoma, unspeclfled
(!""#$%%&'$)
o AnglolmmunoblasLlc 1 cell lymphoma
o AnaplasLlc large cell lymphoma
(!""#$%%&'$
Lp|dem|o|ogy
nL:
• M:l 1.3:1
• Medlan age 31
NnL:
• SllghL male predomlnance
• Medlan age of 33-73
Aet|o|ogy]Causes
PL assoclaLed wlLh:
• L8v (40°)
• CLher envlronmenLal and occupaLlonal
exposures
nPL assoclaLed wlLh:
• L8v vlrus (8urklLL's lymphoma)
• human 1 cell lymphoLroplc vlrus
• Perpesvlrus 8
• AluS
• ,$)&-./!-0$# 1*).#& (gasLrlc MAL1 lymphoma)

Þathophys|o|ogy
nL:
1he hallmark of PL ls Lhe 8eed-SLernberg cell whlch ls
usually derlved from germlnal cenLre 8 cells or, rarely,
perlpheral 1 cells. Cu30 and Cu23 are almosL always
expressed ln Lhe ma[orlLy of cases of classlcal PL.

n|sto|og|ca| appearance of nodgk|n's |ymphoma. 1here ls
a background rlch ln benlgn small lymphocyLes and
hlsLlocyLes LogeLher wlLh scaLLered mononuclear
Podgkln's cells and a classlcal mallgnanL blnucleaLe 8eed-
SLernberg cell (arrow) Lo Lhe rlghL of cenLre.

NnL:
1here ls a mallgnanL clonal expanslon of lymphocyLes
whlch mlghL occur aL a dlfferenL sLage of lymphocyLe
1PL uAnuLnCnC uCSSlL8 2010
174
developmenL. ln general, neoplasms of non-dlvldlng
maLure lymphocyLes are lndolenL whereas Lhose of
prollferaLlng cells (e.g. lymphoblasLs, lmmunoblasLs) are
much more aggresslve. 1hls mallgnanL LransformaLlon ls
usually due Lo errors ln gene rearrangemenLs whlch occur
durlng gene recomblnaLlons for lmmunoglobullns and 1
cell recepLors. 1hus, many of Lhe errors occur wlLhln
lmmunoglobulln locl or 1 cell recepLor locl.

!"#$% '$( !)*+,-*%
• Þalnless, rubbery lymphadenopaLhy
• LnlargemenL of Lhe spleen/llver
• '8' sympLoms: fever, (23°) drenchlng nlghL
sweaLs, welghL loss of > 10° bodywelghL
• ConsLlLuLlonal sympLoms: prurlLus, faLlgue,
anorexla and, occaslonally, alcohol-lnduced paln
aL Lhe slLe of enlarged lymph nodes.
• LxLranodal presenLaLlon! Cl1, lung, braln, LesLes,
Lhyrold and skln, skln: mycosls fungoldes (1 cell
lymphomas) & Sezary syndrome, oropharyngeal
lnvolvemenL occurs rarely
• Plv predlsposes Lo nPL
."%,-/) '$( 01'*"$',"-$
8efer Lo aeLlology and sympLoms.

2$34%,"#',"-$%
• l8L, LS8, Ll1s, Serum lacLaLe dehydrogenase,
urlc acld, ChesL x-ray, C1 scans, 8one marrow
asplraLe and Lrephlne blopsy, Lymph node blopsy
(gold sLandard for boLh PL and nPL), u&L, µ
2
-
mlcroglobulln, Serum lmmunoglobullns, ÞL1 and
galllum scans

5'$'#4*4$,
54("6'7
.89
Chemo + radloLherapy: 90° compleLe remlsslon +
ma[orlLy are cured
• A8vu reglmen ("#$#%&'()(*+ -(*'./01(*2+
'.2#34)(* & "/)/%'/5(*2)
• Adverse effecLs: "#$#%&'()(*6 cardlac LoxlclLy,
'.2#34)(* -pulmonary LoxlclLy
AuLologous 8one Marrow LransplanL: 30-70° advanced
sLage paLlenLs cured
:.89
!"# %&'(): AsympLomaLlc paLlenLs do noL requlre
LreaLmenL
CpLlons:
• 8adloLherapy: SLage l
• ChemoLherapy: Chlorambucll (oral)
• Monoclonal anLlbody Lherapy: 8uLlxlmab (anLl-
Cu20) + vlncrlsLlne + prednlsolone -1
sL
llne
Lherapy
• 8one marrow LransplanL: ! from 32° Lo 34°
*+,- ,&'() .*!:
• ChemoLherapy:
o CPCÞ reglmen (cyclophosphamlde,
doxorublcln, vlncrlLlne, prednlsolone)
• 8adloLherapy: SLage 1
• Monoclonal anLlbody Lherapy :
o 8uLlxlmab + CPCÞ = 8-CPCÞ
1
sL
llne Lherapy for sLage ll or greaLer ln dlffuse large cell
lymphoma
8one marrow LransplanLaLlon: lmproves survlval ln
paLlenLs <63y

1PL uAnuLnCnC uCSSlL8 2010
173
!"# %& ' !()*+,(-.
/)0-(-1-,( 23' 45.66-0-7.1-,(
• lnfecLlon wlLhln Lhe lung parenchyma/alveoll
resulLlng ln fluld accumulaLlon and dlfflculLy breaLhlng

89-:)+-,5,;<
Malnly dlvlded lnLo CAÞ & PAÞ
MosL common CAÞ ls SLrep. Þneumonla

=-6> ?.71,@6
• Age >63 and young chlldren
• lmmunocompromlse (eg. Plv/AluS, chronlc
lllness eLc)
• smoklng or alcohol abuse
• splenecLomy
• surgery or LraumaLlc ln[ury
• recenL vlral lnfecLlon
• lung dlsease (eg. CCÞu)

A)1-,5,;<34.*6)6
• PAÞ ls more common ln people who are on
mechanlcal venLllaLors, ln lCu or are
lmmunocompromlsed. A common predlsposlng facLor
ls CC8u.
• AsplraLlon pneumonla ls caused by lnhalaLlon of
forelgn maLLer eg. vomlL
• CpporLunlslLlc lnfecLlons ln Plv/AluS, organ
LransplanL, or meds (eg. corLlcosLerolds)
• Lmerglng paLhogens eg. P3n1 & SA8S

!.1B,9B<6-,5,;<
• lnfecLlon of dlsLal alrways (esp. alveoll)
• lormaLlon of lnflammaLory exudaLe
• 8ronchopneumonla- paLchy consolldaLlon ln
bronchloles and bronchl
• Lobar pneumonla- affecLs large parLs of enLlre lobe.
lour sLages:
o CongesLlon-proLeln rlch exudaLe fllls alveolar
space
o 8ed hepaLlsaLlon- accumulaLlon of polymorphs,
lymphocyLes and macrophages, 88C's also
exLravasaLed from dlsLal caplllarles
o Crey hepaLlsaLlon- furLher accumulaLlon of
flbrln wlLh desLrucLlon of W8C & 88C's
o 8esoluLlon- resorpLlon of exudaLe (8-10 days ln
unLreaLed cases)

C-;(6 .(: C<+91,+6
• lebrlle, sweaLs & chllls
• cough (+/-producLlve wlLh mucold or blood)
• shorLness of breaLh relaLed Lo severlLy of
lnfecLlon
• pleurlLlc chesL paln lf pleura ls lnvolved
• someLlmes n & v, faLlgue, myalgla and arLhralgla
• lncreased 88 & use of accessory muscles
• bronchlal breaLh sounds, crackles & posslbly a
pleural frlcLlon rub on ausculLaLlon
• sepLlc shock secondary Lo pneumonla presenL
wlLh hypoLenslon and evldence of organ fallure

D-61,@< .(: 8E.+-(.1-,(
• 1lmellne of sympLoms, producLlve cough (can vary ln
colour and haemopLysls)
• Cn examlnaLlon check for slgns of cenLral cyanosls,
oral hyglene, vocal resonance ls lncreased. AusculLaLe
for crackles, wheeze, bronchlal breaLhs & pleural rub

F(G)61-;.1-,(6
• l8L, C8Þ & LS8
• 8lood and spuLum MCS
• Cx8- areas of lncreased opaclLy represenL
consolldaLlon. Lung scarrlng and CPl may mlmlc

H.(.;)+)(1
H):-7.5
• Mlld CAÞ- amoxlclllln & eryLhromycln
• Severe CAÞ- l.v. cefuroxlme & clarlLhromycln + fluclox
lf MSSA
• P. lnfluenza- oral cefaclor
• Cram negaLlves- usually cefLrlaxone
• Mycoplasma- eryLhromycln

4,+95-7.1-,(6
• Lmpyema
• 8acLeremla
• Þleral effuslon
• Lung abcess
• 8esplraLory fallure
• Collapse lung
!"# %&'%#'(') %(**+#, -./.
/01
!"# %& ' ()*+,-. /-01201
*22 34567289 #:;<=8>:2
1PL uAnuLnCnC uCSSlL8 2010
177
!"# %& ' ()*+,-,.,)/)
0+1/2/*/,2
A sysLemlc condlLlon characLerlsed by low bone denslLy
and deLerloraLlon ln bone quallLy ! lncreased fracLure
rlsk. Can be dlvlded lnLo prlmary and secondary (lf
underlylng cause).

3-/4+5/,6,78
AffecLs more Lhan 10° of AusLrallans, affecLs 1/3 women
and 1/3 men over Lhe age of 30.

9/): ;<=*,.) <24 =<>)+)
- lemale gender
- Agelng
- Caucaslan/Aslan
- Smoklng
- Lxcesslve alcohol use
- SedenLary llfesLyle
- Low Ca/vlL u
- 1esLosLerone
deflclency
- ÞosL-menopause
- MalabsorpLlve dx
- 8enal, endocrlne,
haemaLologlcal dx
- CeneLlc dlsorders e.g.
Cl, Marfan's
- Long sLerold use and
oLher drugs

!<*?,-?8)/,6,78
• lnadequaLe Ca lnLake ! peak bone mass ls never
Lruly reached
• 8one resorpLlon naLurally lncreases wlLh age
(especlally ln posL-menopausal women) and
formaLlon decreases
- More noLlceable ln Lrabecular bone, whlch
has a fasLer Lurnover
• vlL u deflclency ! 2¨ hyperparaLhyroldlsm !
lncreased bone resorpLlon
• j oesLrogen levels ! j lnhlblLlon of
osLeoclasLs/reduced bone deposlLlon

@/ <24 )A
• CfLen asympLomaLlc
• 8ack paln, loss of helghL
• lracLure ofLen flrsL presenLaLlon

B2C+)*/7<*/,2)
8loods
• l8L, uLC, Ll1s, serum vlL u/Ca/ÞC
4
, serum Þ1P,
1l1s, coellac screen

xray
• Check for fracLures - dlsLal radlus, femoral neck,
verLebral (wedge fracLure)

8one scan
• nuclear medlclne scan, assess Lhe upLake of a
radloacLlve Lracer (usually Lech 99)
• 1he scan wlll show hoL and cold spoLs, lndlcaLlng
lncreased/decreased upLake of Lracer, and Lhus
Lhe bone acLlvlLy
• 1 score
o ÞaLlenLs bone denslLy score cf young
normal mean, expressed as a Su
o >-1 = normal
o <-2.3 = osLeoporosls
• Z score
o ÞaLlenL's bone denslLy score c.f. age,
gender and race-maLched mean

D<2<7+5+2*
D+4/=<6
• vlL u and calclum supplemenLs, where
approprlaLe
• 8lsphosphonaLes, e.g. rlsedronaLe, help slow
bone loss, lmprove bone mlneral denslLy and
reduce fracLure raLes (by lnhlblLlng osLeoclasL
acLlon) - Laken once/week, sulLable for men and
women
• SLronLlum ralenaLe ls used ln posL-menopausal
women, works by lnhlblLlng osLeoclasLs and
lncreaslng bone formaLlon
• SL8Ms e.g. raloxlfene are used ln younger posL-
menopausal women Lo prevenL verLebral
fracLures (anLl-oesLrogenlc effecLs on uLerus and
breasL Llssue)
• P81 (oesLrogen): used ln posL-menopausal
women, mosL effecLlve ln Lhe 3-10 years
followlng menopause (perlod of acceleraLed
bone loss), lL reduces bone Lurnover, prevenLs
bone loss and lncreases bone denslLy - however
bone loss resumes once Lherapy ls sLopped, and
P81 ls llnked Lo lncreased rlsk of breasL cancer
and sLroke, Lhough decreased Cvu


1PL uAnuLnCnC uCSSlL8 2010
178
!"# %& ' ())*+
*,-./.0.1/ 23' 45677.-.860.1/
ls a meLabollc dlsorder LhaL ls characLerlzed by
hyperglycaemla ln Lhe conLexL of lnsulln reslsLance and
relaLlve lnsulln deflclency.

9:.;,<.151=>
Plgher prevalence ln Aslan men and Lhe elderly, mosL are
over Lhe age of 40

?.7@ A6801B7
• lamlly hlsLory
• SedenLary llfesLyle
• Alcohol excess
• lncreaslng age
• CverwelghL / obeslLy
• Pyperllpldaemla
• PyperLenslon
• PlsLory of gesLaLlonal dlabeLes
• PlsLory of polycysLlc ovary sympLoms

!60C1:C>7.151=>
lnsulln deflclency +/-lnsulln reslsLance
Mechanlsms of lnsulln reslsLance
• MuLaLlons of lnsulln recepLor genes
• ClrculaLlng auLoanLlbodles Lo Lhe LCl domaln of
Lhe lnsulln recepLor
• CbeslLy

D.=/7 6/; D><:01<7
• 1hlrsL
• Þolyurla
• 1lredness
• LeLhargy
• Lvldence of fungal lnfecLlon
• vlsual blurrlng

E.701B> 6/; 9F6<./60.1/
E.701B>
• Lnqulre abouL Lhe above menLloned sympLoms
• D99 )**+ -1B 0C, B,70 1- 0C, E.701B> GG

9F6<./60.1/
Ceneral lnspecLlon: welghL-obeslLy, hydraLlon, endocrlne
facles (cushlngs or acromegaly), and plgmenLaLlon
Legs: lnspecLlon - ulceraLlon, lnfecLlon, necoblosls, halr
loss, plgmenLed scars
• ÞalpaLe
o 1emperaLure, perlpheral pulses (dosalls
pedls, posLerlor Llblal, femoral)
• AusculLaLe Lhe femoral
Arms: lnspecL ln[ecLlon slLes, skln leslons, pulses
Lyes:
• CaLaracLs, rubeosls, reLlnal dlsease
• lll nerve palsy
MouLh: lnfecLlon
CaroLld arLerles: palpaLe and ausculLaLe
ChesL -slgns of lnfecLlon
Abdomen -llver: faL lnfllLraLlon, PaemochromaLosls
neurologlcal assessmenL
• lemoral nerve mononeurlLls
• Þerlpheral neuropaLhy: 'glove and sLocklng '
• CLhers
o urlne analysls -glycosurla, keLones,
proLelnurla
o 8Þ - lylng and sLandlng
o Cedema
)/H,70.=60.1/7
uM ls dlagnosed when fasLlng plasma glucose ls greaLer
or equal Lo 7.0mmol/L on Lwo separaLe occaslons C8 Cral
glucose Lolerance LesL wlLh Lwo-hour plasma glucose
greaLer or equal Lo 11.1mmol/L

CLher rouLlne lnvesLlgaLlons:
• urlne analysls ! proLeln
• l8C
• urea and elecLrolyLes
• 8andom llplds
• PbA1c - gold sLandard for assesslng glycaemlc
conLrol: lL represenLs Lhe percenLage of
haemoglobln alLered by glucose ! glycaemlc
conLrol over Lhe prevlous 4-8 weeks.

+6/6=,<,/0
#.-,70>5, - encourage welghL loss, lncrease exerclse, and
dleL low ln saLuraLed faL
+,;.865
41<:5.860.1/7
+.8B1H678I56B
8eLlnopaLhy
Mlcroaneurysms and
haemorrhages
nephropaLhy: proLelnurla,
mlcroalbumlurla
neuropaLhy: erecLlle
dysfuncLlon, gasLroparesls,
orLhosLaLlc hypoLenslon
+68B1H678I56B
Þvu
Cardlac
SLroke
Pyperosmolar non-keLoLlc coma: preclplLaLed by
lnfecLlon, Ml, glucose rlch flulds lL's a medlcal emergency
and resulL from poorly conLrolled Lype 2 dlabeLes melllLus
1PL uAnuLnCnC uCSSlL8 2010
179
Þ8L 21 - Coma
Def|n|t|on
1. 8ra|n death
lrreverslble coma and loss of bralnsLem reflex responses and
Lhe resplraLory funcLlon
Cr
uemonsLraLlon of Lhe cessaLlon of lnLracranlal blood flow
(radlo conLrasL anglography)

2 c||n|ca| exams by 2 med|ca| pract|t|oners performed 6h
aparL
• 8epose Lo palnful sLlmull applled w/l cranlal n.
dlsLrlbuLlon
• Þaplllary responses Lo llghL
• Corneal reflexes
• Cag reflex
• Cough reflex
• vesLlbule-ocular reflexes(calorlc response)
• 8esplraLory funcLlon
Apnoea LesL:
1. Þre-oxygenaLlon wlLh 100° C2
2. CessaLlon of mechanlcal venLllaLlon whllsL
supply of C2 Lhrough Lracheal caLheLer
3. lf apnoea perslsLs ln Lhe presence of
adequaLe sLlmulus l.e. ÞaCC
2
>60 mmPg
and arLerlal pP < 7.30

All reverslble causses have been removed!

2. Coma
SLaLe of unconsclousness from whlch Lhe paLlenL cannoL be
wakened by exLernal sLlmull
1. noL openlng eyes
2. noL obeylng commands
3. noL uLLerlng undersLandable words
Cccurs from damage Lo reglons LhaL conLrol consclousness
l.e. 8AS above Lhe mldpons and boLh cerebral hemlspheres

3. Þers|stent Vegetat|ve state
Coma has progressed Lo wakefulness w/o deLecLable
awareness, usually [usL need feedlng, noL venLllaLlon.

Causes
S|gns and Symptoms
vlLal:
!8Þ "lCP
#1"L1CP/sedaLlves/#8SL,
!1"heaL
sLroke/lnfecLlons/CA/hypoLhalamlc leslons
kk: Cheyne-Stokes(alLernaLlng hyperpnoea and apnoea"
delay ln medullary chemorecepLor response Lo blood gas
changes"Lvl/braln damage/hlgh alLlLude)
kussmau|(metabo||c ac|dos|s)"deep slghlng
hypervenLllaLlon"sLlmulaLlon of lnsplraLory cenLres
Atax|c: shallow, halLlng, lrregular resplraLlon when
medullary resplraLory cenLre ls damaged"precedes deaLh

Þuplls
ÞlnpolnL"oplold Cu/ponLlne leslons lnLerrupLlng
sympaLheLlc/organophosphaLe polsonlng
llxed dllaLed"

n|story and Lxam|nat|on
lf relevanL - Cnly relevanL quesLlons Lo ask or slgns Lo ellclL -
no need for full Px/Lx







1PL uAnuLnCnC uCSSlL8 2010
180
!"# %% & '()*+*,-
'(.*/*0*1/ 234 5)677*.*860*1/
AcuLe confuslonal sLaLe characLerlzed by:
- Cloudlng of consclousness (reduced alerLness,
lmpalred aLLenLlon and concenLraLlon)
- ulsorlenLaLlon ln 1ÞÞ
- lmpalred shorL-Lerm memory

9:*;(-*1)1<=
20° of elderly paLlenLs on med/surg wards have dellrlum

>(0*1)1<=356,7(7
vascular
- SLroke, AMl
lnfecLlon
- 8esplraLory LracL lnfecLlons, u1l, encephallLls,
menlnglLls, malarla, wounds, lv llnes
Pead Lrauma causlng ralsed lCÞ
- 1umour, subdural haemaLoma, SAP
MeLabollc
- Pyper or hypoglycaemla, elecLrolyLe
dlsLurbances, uraemla, llver fallure, resplraLory
fallure, cardlac fallure, anaemla
urugs
- 8Zu (and lLs wlLhdrawal), oplaLes, alcohol (and
wlLhdrawal), levodopa, anLlconvulsanLs,
sedaLlves,
nuLrlLlon
- 812, Lhlamlne deflclency
CLhers
- Lpllepsy, posL-lcLal sLaLe

?*</7 6/; ?-:01-7
uLLl8luM
• 'lsordered Lhlnklng
• 9uphorla, fearful, depressed or angry
• #anguage lmpalred
• @lluslons/deluslons/halluclnaLlons
• Aeversal of sleep-wake cycle
• @naLLenLlon
• Bnaware/dlsorlenLaLed
• Cemory deflclLs
D*701+= 6/; 9E6-*/60*1/
1ake hx from famlly carers, revlew CÞ/hosplLal records.
- 1lme course
- Pad any oLher sysLemlc or neuropsychlaLrlc sx
- Any co-mobldlLles
- CurrenL medlcaLlons
- Þrevlous or recenL alcohol or subsLance abuse
need a full, deLalled examlnaLlon due Lo myrlad of causes.
uux: anxleLy (lf aglLaLed), depresslon

@/F(70*<60*1/7 GH67(; 1/ DE 6/; 9E6- 6/; :177*H)(
,/;(+)=*/< 86,7(I
8loods: l8L, u&L, Ll1, C8Þ, ln8, blood culLures, A8C
lmaglng: Cx8, C18 ln selecLed cases, LLC
CLhers: LCC, LÞ, urlnalyses, urlne M/C/S, malarla fllms

C6/6<(-(/0
lmmedlaLe mx
- Þrlmary assessmenL (u8A8C)
- 8x hypoglycaemla w/lv glucose
- uo full Px and Lxam and relevanL lx
Mx
- 1reaL underlylng cause!
- SupporLlve mx
o nurse pL ln quleL, moderaLely-llL room
wlLh same sLaff ln aLLendance Lo
mlnlmlze confuslon, reduce dlsLress,
encourage famlly members Lo slL wlLh
pL, reassurance, orlenLaLe pL Lo Llme and
place,
o uo noL use physlcal resLralnLs, remove
caLheLers

C(;*86) G-*/*-*J( ,76<(K 1/)= *. /((;(;I
lor behavloural conLrol (eg. pulllng ouL llnes) and
sub[ecLlve dlsLress
- Paloperldol
- 8Zu

1PL uAnuLnCnC uCSSlL8 2010
181
!"# %& ' ()*+ ,*-./01/-
2+)31- .4 5./6)7 ()*+
1. lnlLlal conLacL: Peel sLrlke
2. Loadlng response
MalnLalns sLablllLy, body wL Lransferred Lo new
sLance leg.
3. MldsLance
llrsL half of slngle supporL, fully welghL bearlng on
one fooL and oLher llmb swlngs Lhrough Lo Lake nexL
sLep.
4. 1ermlnal sLance
Þropulslon of body mass forwards, swlng leg also
exLends.unLll Lhe oLher fooL Louches Lhe ground
3. Þre-swlng
8oLh feeL conLacL Lhe ground, Lhen push-off wlLh Loe
of sLance fooL.
6. lnlLlal swlng
1ransfer of body welghL Lo oLher leg
7. Mldswlng
CLher fooL pushes off, orlglnal sLance leg swlngs Lhru
8. 1ermlnal swlng
Crlglnal sLance leg swlngs and lLs heel sLrlkes flrsL.


89)6*:)+*.:
SLance
1. SLand sLralghL, bare feeL and close LgL, eyes open
(Swaylng/lurchlng: cerebellar aLaxla)
2. 8omberg's LesL. 8epeaLedly falllng a +ve resulL for
sensory aLaxla due Lo proprlocepLlve deflclL

CalL
1. Walk ~10m, Lurn and walk back
2. noLe Llme Lo compleLe Lask, sLrlde lengLh, arm swlng,
how hlgh heels are llfLed, Lra[ecLory of leg swlng,
degree of knee bendlng, sLeadlness
3. Peel-Lo-Loe walk/ Landem galL (for any galL aLaxla)

;7)--*4*<)+*.:=,14*:*+*.:- .4 +1/6-
SpasLlclLy: desLrucLlon of corLlcoreLlculosplnal LracL !
sLreLch reflex hyperacLlvlLy

1ype of galL Cllnlcal ÞÞ1 Cause
Pemlplegla unllaLeral
weakness,
spasLlclLy wlLh
upper exLremlLy
held ln flexlon.
LaLeral
clrcumducLlon of
Lhe leg
Leslon ln lCA
LerrlLory (assoc
wlLh hemlanopla,
eLc)
Compresslve
leslons: Lumour
SpasLlc/Sclssors PyperLonla ln
lower llmb, LlghL
adducLors
SpasLlc cerebral
palsy, bllaLeral
uMn leslon ln
Lhe cord,
syrlngomyella
Þarklnson's narrow based,
fesLlnanL galL
Þarklnson's
dlsease
Meds: e.g.
meLoclopramlde
Cerebellar Wlde-based,
unsLable and
Lremulous galL

looL drop Plgh sLeppage uamage Lo Lhe
deep peroneal
nerve
normal pressure
hydrocephalus/
8run's
aLaxla/MagneLlc
galL
8roadbased,
shorL sLeps,
normal power
when
seaLed/lylng


>):)3161:+
1. Cllnlcal evaluaLlon of galL dlsorder
2. Lab based evaluaLlon: Lreadmllls, fooL pressure
analysls, eLc
3. AssessmenLs and reducLlon of falls rlsk
8educLlon: vlL u/812, Ca supplemenL , home
envlronmenL modlflcaLlon and home safeLy,
physloLherapy, chronlc dlsease/paln Mx,
demenLla/depresslon ux and 8x
4. Counselllng - soclal/emoLlonal/flnanclal supporL
3. Medlcal 8x: levodopa, paln Mx
6. Surg 8x
7. Þhyslo and rehab
8. Lnv modlflcaLlon
9. CccupaLlonal rehab
10. ÞaLlenL educaLlon
;.6?7*<)+*.:-
- lncreased rlsk of falls,
- 8educed quallLy of llfe and lndependence
- need for hlgh level care
1PL uAnuLnCnC uCSSlL8 2010
182
!"# %& ' ()*+,-
.-/010)0+1 2 !3)4+5467
()*+,-8 8apld onseL of cerebral deflclL, usually focal,
lasLlng more Lhan 24 hours or leadlng Lo deaLh, wlLh no
apparenL cause oLher Lhan a vascular one.

97:43-;0: 7)*+,-8 arLerlal embollsm or
Lhrombosls wlLh subsequenL braln lnfarcLlon. MosL
common Lype of sLroke.

<3-;+**43=0: 7)*+,-8 lnLracerebral or subarachnold
haemorrhage. 1he pressure of Lhe arLerlal haemorrhage
Lears some of Lhe braln Llssue and form a haemaLoma,
compresslng Lhe surroundlng braln. 8raln Llssue Lhen
lnfarcLs due Lo Lhe haemhorrage or from Lhe mass effecL
of Lhe haemaLoma.

>50?-;0+@+=6
!"#$%& ()"*+",+ -.//") .% 01,+)/*.* *2+") 3456
A07, B3:)+*7
• 478")+"%,.$%
• !9$-.%(
• :;",.+7
• 478")#<$/",+")$/*"9.*
• 0+).*/ =.;).//*+.$%
• 3*)$+.& ,+"%$,.,
• >?:4
• @/""&.%( &.,$)&"), A"6(6 =*#+$) B C".&"%D
• :3E
• 0%+.8/*+"/"+ *%& *%+.#$*(1/*%+ +<")*87
• >+#F


CDC (Leg>Arm)







Area supplled
• Medlal surface of fronLal lobe, Medlal surface of
parleLal lobe, AnLerlor corpus callosum, AnLerlor
basal ganglla and lnLernal capsule, ClfacLory bulb
and LracL
!"#$ &'()*
G$%H
&$9.%*%+
<"9.,8<")"
3$%+)*/*+")*/ <"9.8*)",., A/$I")
/.9;, J 188") /.9;, *%& 2*#"D
3$%+)*/*+")*/ ,"%,$)7 /$,, A/$I")
/.9;, J 188") /.9;, *%& 2*#"D
3$%+)*/*+")*/ <$9$%79$1,
<"9.*%$8.*
57,*)+<).*
3$%+)*/*+")*/ %"(/"#+
5$9.%*%+
<"9.,8<")"
!*9" ,.(%, *, G$%H&$9.%*%+ ,+)$-"
K
08<*,.*
0()*8<.*
0#*/#1/.*
=)$%+*/
C$;"
L)*,8 )"2/"M
@"<*N.$1)*/ #<*%(",
E)4-* (6;5)+;7
- Peadache
- AlLered menLal sLaLus
- Syncope
- Selzure
- Coma

FDC (Arm>Leg)
AcuLe lefL MCA sLroke
wlLh oedema and mass
effecL
Areas supplled:
• LaLeral surface of Lhe hemlsphere, laLerolnferlor
fronLal lobe (8roca's area: expresslon), laLeral
Lemporal lobe (Wernlcke's area: comprehenslon),
basal ganglla, lnLernal capsule
C*-3 (0=17
Ceneral
MCA
LerrlLory
Þaralysls or weakness of Lhe conLralaLeral
/3:- 31? 3*;
Sensory loss of Lhe conLralaLeral /3:- 31?
3*;G
Aphasla
ConLralaLeral neglecL syndrome
uevlaLlon con[uge - gaze Lowards Lhe slde
of Lhe leslon
ConLralaLeral homonymous hemlanopla
8roca's Lxpresslve aphagla
1PL uAnuLnCnC uCSSlL8 2010
183
Area
Wernlcke's
Area
Wernlcke's aphagla - lnablllLy Lo
undersLand spoken language

"#$

Areas supplled
• Supplles mldbraln, subLhalamlc nucleus, basal
nucleus, Lhalamus, medlal lnferlor Lemporal lobe,
and occlplLal corLex
$%&' ()*+,
CcclplLal Lobe ConLralaLeral homonymous
hemlanopla
1halamus ConLralaLeral face and llmb sensory
loss
Mldbraln ConLralaLeral moLor weakness
Large/8llaLeral Memory, language, cognlLlve
dysfuncLlon
-./&% (012.31,
• AcuLe vlslon loss
• Confuslon
• Peadache
• ulzzlness
• nausea
• Memory loss

4'56+'%
Cccluslon of slngle, 7&&2 peneLraLlng arLery.
May presenL wlLh speclflc lacunar syndromes or may be
asympLomaLlc

8%')+,.&1
$%&' ()*+,
!"#$%"&
"&()&*
+,"-&$.%)/$"0 -)"(1 2&34 &)#.$&"(3&*
2"$%,&)0 5%367)- $8 #*8-&34)90 36,%"&
2$8-$8/#
:3#()&$3&
;82)&$3&
<)&)=&"%
>?
@)&($/30 1)"-"61)0 2"6$"% ."$80
$.#$%"()&"% 1)4$"("A$#0 -*#"&(1&$"0
.(3#$#0 4$3#$#0 "("A$"0 1$66,.#
>8()&$3&
;82)&$3&
<)&)=&"%
>?
@)&($/30 $.#$%"()&"% -)"28)##0
$.#$%"()&"% 2"6$"% B)"78)## "8- "("A$"
C,.)&$3&
<)&)=&"%
>?
;.#$%"()&"% 6)&)=)%%"& "("A$"#0 8",#)"0
D34$($8/0 #%,&&)- #.))610
638(&"%"()&"% %3## 32 ."$8 "8-
()4.)&"(,&)
:38($8) <34"0 E,"-&$.%)/$"0 #4"%% &)"6($D)
.,.$%#0 "=#)8( 13&$F38("% )*)
43D)4)8(
9+:&,.)*'.)3+,
• C1
• M8l
• CaroLld duplex and duplex scannlng
• 8lood LesLs
o G%,63#) %)D)%#0 <13%)#()&3% %)D)%#0
H1*&3$- /%"8- 2,86($38 ()#(#0 I<G0
I613

;'+'*&1&+.
9,5/'&1)5 (.%3<&
1hrombolysls vla LÞA ls lndlcaLed wlLhln 3 hours of
sympLom onseL ln mosL cases of occluslve sLroke.
='&13%%/'*)5 (.%3<&
LpLacog alpha (recomblnanL acLlvaLed facLor vlla), blood
pressure lowerlng
(&53+7'%0 ,.%3<& 2%&:&+.)3+
LlfesLyle facLors - smoklng, dleL, exerclse, alcohol, welghL
loss
Long Lerm anLlplaLeleL agenLs
SLaLlns
ACL lnhlblLors,
Surglcal CaroLld endarLerecLomy/caroLld sLenLlng
8ehablllLaLlon

1PL uAnuLnCnC uCSSlL8 2010
184
!"# %& ' !()*+,()-. /(0)1+-2,3
4(5*6*2*16 78' 9.-::*5*;-2*16
ÞaLhologlcal process affecLlng nerves wrapped ln schwann
cells LhaL ls noL parL of Lhe CnS
<1616(0)1+-2,3 - ln[ury or compresslon of a slngle
nerve LhaL leads Lo deflclL resLrlcLed Lo Lhe LerrlLory of
LhaL affecLed nerve
<1616(0)*2*: =0.2*+.(> - separaLe lnvolvemenL of more
Lhan one perlpheral nerve by a slngle dlsease (usually
vascullLls or dlabeLes)
!1.36(0)1+-2,3 - dlffuse, ofLen symmeLrlcal dlsease,
usually exLends proxlmally, paLhologlcal process of
• uemyellnaLlon - schwann cell damange, leadlng
Lo slowlng of conducLlon
• Axonal degeneraLlon - axon dles, sLarLlng from
perlphery, movlng proxlmally
?-@*;0.1+-2,3 - dlsease affecLlng nerve rooLs

A(2*1.1B389-0:(:
C()(@*2-)3
CharcoL-Marle-1ooLh dlsease (dlsLal weakness and
wasLlng, beglns ln Lhe legs, fooL drop, some dlsLal sensory
loss)
<(2-D1.*;
uraemla, alcohollsm, vlLamln 812 deflclency
ulabeLes
• ÞolyneuropaLhy - glove and sLocklng, moLor and
sensory affecLed
• Mono/mulLlplex - cranlal (Cn3, 4, 6 wlLh pupll
sparlng), femoral (paln ln anL Lhlgh)
• Þalnful (esp aL nlghL) - burnlng, hypersenslLlvlLy
Lo llghL Louch
• AuLonomlc dysfuncLlon
• Cx - CharcoL arLhropaLhy, ulcers, calluses
E65(;2*16 ' leprosy, AluS, lyme dlsease
E65.-==-2*168*==06( - sarcoldosls, 8A, chronlc
ldlopaLhlc demyellnaLlng polyneuropaLhy (CluÞ)
C8S - malnly moLor nerve lnvolvemenL
• Ascendlng paralysls, areflexla, lnLacL sensaLlon
• usually preceded by an lnfecLlon eg.
campylobacLer [e[unl
• 1-cell lmmune medlaLed response, resulLlng ln
demyellnaLlon by macrophages
• 8x - plasma exchange, human lgC
<-.*B6-6;3 - lung, lymphoma, leukemla
F1>*6: - lead, arsenlc
4)0B: - phenyLoln, lsonlazld, eLhambuLol, meLronldazole
/()G( (62)-+=(62 - carpal Lunnel, meralgla
paraesLheLlca, common peroneal nerve compresslon (fooL
drop)

H*B6: -6@ H3=+21=:
/(0)1+-2,3I
• Weakness(commonly dlsLal)>wasLlng
• Sensory dlsLurbance (ÞaraesLheslae, allodynla) -
numbness, Llngllng, sLabblng, commonly worse aL
nlghL, Sensory loss
• Pyporeflexla,
• AuLonomlc dysfuncLlon - orLhosLaLlc hypoLenslon,
urlnary lnconLlnence/reLenLlon, sexual dysfuncLlon,
gasLroparesls, hypoglycemlc unawareness
91=+-)(@ J*2, <31+-2,3I
Cenerally a dlsease of volunLary muscle,
weakness<wasLlng, decrease ln Lone and power, normal
sensory funcLlon and reflexes

E6G(:2*B-2*16:
#-D1)-21)3
• l8L - lnfecLlon, anaemla, uLC - uremla, LS8, 8l,
AnA - vascullLldes, Ll1 - alcohollc llver dlsease,
812 and folaLe, P8sAg, serologlc LesL for syphllls,
lyme dlsease
!)1;(@0)(:
• urlnalysls - heavy meLal levels, hemaLurla
(Wegener's)
• LÞ - C8S(^proLeln, w/o leucocyLosls), lnfeclon
• LMC (ablllLy of muscle Lo respond when nerves
are sLlmulaLed) - 1o dlfferenLlaLe 1¨ muscle
condlLlons from weakness caused by neuropaLhy
• nCS (measure conducLlon veloclLy) -
dlfferenLlaLe beLween demyellnaLlng and axonal
degeneraLlon of nerves
• nerve blopsy - amylold, polyarLerlLls nodosa
E=-B*6B
• Cx8 - bronchlal cancer (paraneoplasLlc)

<-6-B(=(62
/(0)1+-2,*; !-*6 ' Asplrln, ÞaraceLamol, nSAlus, 1CA
(amlLrlpLyllne), anLl-epllepLlcs (gabapenLln, pregaballn),
oplaLes
<1G(=(62 @*55*;0.2*(: - spllnLs and prosLheLlcs, surglcal
decompresslon lf enLrapmenL ls cause
A02161=*; @3:506;2*16 ' MeLoclopramlde (lncrease
gasLrlc moLlllLy), beLhnechol (urlnary reLenLlon)

1PL uAnuLnCnC uCSSlL8 2010
183
!"# %& ' ()*+,-).
/)0*1*2*31 45' 678..*0*982*31
A selzure ls any cllnlcal evenL caused by an abnormal
elecLrlcal dlscharge ln Lhe braln. Lpllepsy ls Lhe Lendency
Lo have recurrenL selzures.

ÞarLlal selzures: produced from small area of braln
Cenerallsed selzures: produced by enLlre braln
!:;<=:#
(>=?@;>(
(ABC23B.
Slmple MoLor ([erklng, spasms), Sensory
(unusual vlslon, hearlng eLc.) and
Þsychologlcal (memory/emoLlonal
dlsLurbances)
Complex AuLomaLlsms eg. Llp smacklng,
chewlng, fldgeLlng, repeLlLlve
lnvolunLary buL coordlnaLed
movemenL
ÞarLlal wlLh secondary generallsaLlon

D>E>;:#=(>/
(>=?@;>(
(ABC23B.
Crand mal/1onlc
Clonlc
unconsclousness, convulslons,
muscle rlgldlLy
Absence/peLlL mal 8rlef loss of consclousness,
always sLarLs ln chlldhood
Myoclonlc Sporadlc (lsolaLed), [erklng
movemenLs
Clonlc 8epeLlLlve, [erklng movemenLs
1onlc Muscle sLlffness, rlgldlLy
ALonlc Loss of muscle Lone

;*.F G8923-.5<-*HH)-.
llashlng/fllckerlng llghLs, hormonal, physlcal or menLal
exhausLlon, emoLlonal sLress, recreaLlonal drug use,
lnLercurrenL lnfecLlons and meLabollc dlsLurbances, sleep
deprlvaLlon, L1CP/L1CP wlLhdrawal. uncommon: muslc,
loud nolses, readlng

68,.).5 !82I3CIA.*373HA
normally, lnhlblLory clrculLs (CA8A medlaLed) ln Lhe
cerebral corLex llmlL synchronous dlscharge of
nelghbourlng group of neurons. 8locklng of CA8A
recepLors or excesslve sLlmulaLlon of exclLaLory
neuroLransmlLLers (Ach, gluLamaLe) can provoke selzures.



J*.23-A 81K >L8B*182*31
lrom paLlenL: 1) Aura? WhaL klnd? 2) uescrlpLlon of
selzure - blLlng of Longue, lnconLlnence, halluclnaLlons
(de[a vu) 3) Could paLlenL relaLe Lo envlronmenL or
remember Lhe evenLs? 4)Pow paLlenL feels afLer evenL?
Pow long dld lL Lake Lo geL back Lo basellne/normal? 3)
Pow long and how frequenL are Lhe eplsodes? 6)
1rlggers? 7) Þrovoked by CnS lnsulL? lmporLanL Lo Lake
hlsLory from an eyewlLness

=1M).2*H82*31
lf flrsL presenLaLlon, do 6< 3- N;= (sLrucLural leslons). l8L,
C8Þ, LS8, Cx8, LÞ (CnS lnfecLlons/lnflammaLlon). u&L,
8un, Ll1, 8SL, Serum Ca + Mg (meLabollc dlsorder).
1oxln/drug screen). Þregnancy LesL (eclampsla). LCC
(arrhyLhmlas causlng cerebral hypoxla).
>>DO CharacLerlse selzures (focal or generallsed), rule ouL
dlfferenLlals.

N818H)B)12
N)K*987 - AnLlconvulsanL Lherapy. Common flrsL llne
drugs: carbamazeplne, eLhosuxlmlde, sodlum valproaLe.
8eware SL ln conLracepLlon and pregnancy (feLoLoxlc),
ÞhenyLoln LoxlclLy. Conslder wlLhdrawal lf selzure free for
2-4 years.

E31 !I8-B89373H*987 N818H)B)12
#*0).2A7) - Lxerclse. uleL (keLogenlc dleL le hlgh faL, low
carb, low proLeln). Compllance (paLlenL educaLlon).
Avoldance of Lrlggers. SafeLy/CccupaLlonal healLh lssues
(eg. urlvlng)
!.A9I373H*987 - 8ehavloural 1herapy, CognlLlve 1herapy,
uesenslLlsaLlon, Pypnosls
(,-H*987 - Cood for focal selzures ln Lemporal lobe.

63BC7*982*31.
SLaLus LpllepLlcus: Selzure lasLlng 30 mln wlLhouL paLlenL
regalnlng awareness. Medlcal emergency.
ManagemenL: Lnsure paLenL alrway, recovery poslLlon
(afLer selzure), glve C2, lv access, check bloods for
glucose, u&L, Ll1. Clve lorazepam, dlazepam (lv or
recLal).
1PL uAnuLnCnC uCSSlL8 2010
186
!"# %& ' !()*+,-.,/- 0+-1(-123.4151,6 0+-.)71)-
018+,+6+., 92' :;(--+8+<(6+.,
Þarklnsonlsm
Classlc Lrlad: Lremor, rlgldlLy, bradyklnesla/hypoklnesla

Þarklnson's ulsease
Þrogresslvely degeneraLlve neurologlcal dlsorder,
characLerlsed by a syndrome of bradyklnesla/hypoklnesla
plus aL leasL one of:
- resLlng Lremor
- posLural lnsLablllLy wlLhouL oLher cause
- muscular rlgldlLy

=+-* >(<6.)-
• Age (only proven 8l)

!(6?.@?A-+.;.BA
CharacLerlsed by progresslve degeneraLlon of
exLrapyramldaal dopamlnerglc neurons ln Lhe subsLanLla
nlgra wlLh Lhe paLhologlcal hallmark of Lewy bodles ln Lhls
area. Lewy bodles are abnormal mlcroscoplc aggregaLes
of proLelns LhaL develop lnslde nerve cells. uegeneraLlon
also occurs ln oLher basal nuclel.
1here ls a loss of dopamlne ln Lhe basal nuclel. 1hls
correlaLes wlLh Lhe areas of cell loss and degree of
aklnesla.
AceLylchollne ls also lnvolved as lL lnhlblLs dopamlne:
where Lhere ls decrease ln dopamlne, Lhere ls an excess
of Ach as a resulL.

C+B,- (,7 CA5@6.5-
MoLor:
• 8radyklnesla
• Pypophonla
• llne moLor conLrol lmpalrmenL
• 8esLlng Lremor
• Cogwheel rlgldlLy (due Lo subcllnlcal Lremor)
• llexed posLure, loss of posLural reflexes, posLural
lmbalance
non-moLor:
• Sleep dlsLurbance (lncl. vlvld dreams & sleep apnoea)
• Sensory dlsLurbance
• Achlng paln ln exLremlLles
• SC8 wlLh no cause
• Anosmla or oLher sensory loss
• AuLonomlc dysfuncLlon
• CrLhosLaLlc hypoLenslon
• ConsLlpaLlon
• urlnary sx
• urenchlng sweaLs
• uepresslon and anxleLy (up Lo 30° of pLs wlLh Þu)
• CognlLlve lmpalrmenL
• ulfflculLy wlLh complex Lasks, long Lerm plannlng,
memory lncludlng reLrleval.

D+-6.)A (,7 EF(5+,(6+.,
Speclflc slgns:
• Þarklnsonlan galL
• Mask-llke face
• Mlcrographla (Llny handwrlLlng)
• Myerson's slgn - repeLlLlve glabellar Lap resulLs ln
perslsLenL bllnklng

3(,(B151,6
317+<(;
no drug has been shown Lo alLer Þu progresslon, buL can
slow sympLom developmenL. MosLly almed aL rellef of
moLor sympLoms.
uopamlne based Lheraples:
• Levodopa: dopamlne precursor whlch ls converLed Lo
dopamlne ln Lhe CnS afLer crosslng Lhe blood-braln
barrler. Powever, Lhe same enzyme (uuC) converLs
levodopa lnLo nA ln Lhe perlpheral sysLem. 1hus,
levodopa ls admlnlsLered wlLh a uuC lnhlblLor whlch
cannoL cross Lhe 888 (carbldopa or benserazlde).
MosL effecLlve ln early and mldsLage Þu. SLs:
lnvolunLary movemenLs, dose flucLuaLlon, n&v,
reslsLance Lo efflcacy.
• uopamlne agonlsLs (bromocrlpLlne, pergollde).
Longer duraLlon of acLlon (easler doslng), less
dysklnesla, however oLher serlous SLs.
AnLlchollnerglcs (8enzoLroplne):
• used ln early sLage Þu Lo decrease perlpheral sx.
• Wldespread SLs, rarely used excepL ln younger pLs.
AmlLldlne:
• MeLhod of acLlon unknown. May be elLher of Lhe
above. Lower efflcacy Lhen levodopa, buL also less SL.
Malnly used ln early sLage Þu.

CG)B+<(;
Cnly used ln cases of exLremely deblllLaLlng Lremors or
when medlcaLlon ls lneffecLlve.

#+81-6A;1
ÞhysloLherapy and asslsLance wlLh galL and occupaLlonal
Lherapy are a malnsLay of Þu LreaLmenL, parLlcularly ln
mlddle and laLe sLage dlsease.
1PL uAnuLnCnC uCSSlL8 2010
187
!"# %& ' #()* +, -./ 012+,
3/4+,+-+2, 567 89:;;+4+<:-+2,
lL ls an abnormal proLruslon/locallzed swelllng ln Lhe
reglon surroundlng Lhe [uncLlon beLween Lhe Lhlgh and
Lrunk lncludlng exLernal genlLalla.


3+44/1/,-+:9 3+:=,2;+;
• lemoral hernla- posslble paln and slgns of bowel
obsLrucLlon (nausea/vomlLlng eLc) or sepsls
• lngulnal hernla - proLruslon, dlscomforL or paln ln
groln area
• CrypLorchldlsm (undescended LesLlcle)/ reLracLed
LesLlcle - empLy scroLum, rlsk facLor for cancer
• 1orslon - scroLal paln, swelllng, nausea/vomlLlng,
dysurla
• LpldldymlLls - scroLal paln/swelllng, fever/chllls,
slmllar Lo Lorslon
• 1esLlcular cancer - palnless mass, furLher lx needed
Lo rule ouL
• Pydrocele - palnless, LranslllumlnaLed lump
• varlcocele - (more common ln lefL LesLlcle for
anaLomlcal reasons) achlng scroLal paln, feellng of
heavlness
• ulffuse large 8-cell lymphoma - enlarged lngulnal Lns,
fevers, welghL loss (keep ln mlnd oLher lymphomas)
• Chancrold (an S1l) - small lump Lurnlng lnLo palnful
ulcer, dysurla/dyspareunla ln women
• Syphllls - 'chancre' (flrm, well-deflned, non-Lender
leslon), swelllng of groln Lns, headache, rash.


>+;-21? :,@ AB:)+,:-+2,
-PCÞC, esp aggravaLlng facLors llke cerLaln physlcal
acLlvlLles
-ueLalled sexual Px
-lPx of cancer
-Look aL lump: surface locaLlon, pulsaLlon,
colour/abnormallLles of overlylng skln, border
-leel: LemperaLure, pulsaLlon, paln/Lenderness,
flxed/moblle, border, flucLuaLlon, does lL geL smaller wlLh
pressure applled?
-1ranslllumlnaLlon: llghL from Lorch shlnes dlrecLly
Lhrough lump
-Þrehn slgn: Classlcally, scroLal elevaLlon decreases paln
ln epldldymlLls and noL ln Lorslon. -ve slgn polnLs Lowards
Lorslon whlch ls a medlcal emergency!
-examlne scroLum for LesLlcles
-?Pernla!Cough/reduclblllLy
-Zleman's hernla exam:



C))/@+:-/ D:,:=/)/,-
-Analgesla for paln
-Abx/anLl-lnflam for lnfecLlous paLhology
-8educlble hernlas should be reduced before surglcal
repalr
-1esLlcular Lorslon!manual deLorslon!emergency
surgery

C,E/;-+=:-+2,;
l8L
LS8/C8Þ
u&Ls
Syphllls serology
uoppler ulLrasound of LesLlcle
Croln uS
Swab culLure ulcers
Ln blopsy
1PL uAnuLnCnC uCSSlL8 2010
188
Þ8L 29 - Motor Veh|c|e Acc|dent
Þr|mary Survey

A|rway. Clear any alrway obsLrucLlon.

8reath|ng. lf breaLhlng ls dlsrupLed, glve asslsLed
venLllaLlon - from C2 Lo lnLubaLlon. LlsLen Lo lungs for
Lenslon pneumoLhorax, masslve haemoLhorax. Where aL
all posslble, do noL move Lhe cervlcal splne when
assesslng alrway or breaLhlng.

C|rcu|at|on. Look aL obs. lf Lhere are slgns of shock
(parLlcularly hypoLenslon), apply pressure Lo slLes of
exLernal blood loss. Caln good lv access. lf slgns of shock,
send blood sample for crossmaLch ASAÞ.

8rlef neuro exam (CCS). Send oLher lnvesLlgaLlons as
requlred urgenLly (l.e. A8Cs/v8Cs eLc).

AL Lhls polnL, address any llfe-LhreaLenlng ln[urles. uC
nC1 MlSS:
- Lenslon pneumoLhorax or masslve haemoLhorax
- severe head Lrauma / lnLracranlal haemmorhage (call
neurosurg)
- cervlcal splnal cord ln[ury
- Slgns of shock (esp. hypoLenslon, as Lhls ls a laLe slgn
ln younger people)
All of Lhese requlre urgenL medlcal aLLenLlon. uo noL
commence Lhe secondary survey lf one of Lhese has noL
been addressed. ?our paLlenL may well dle durlng Lhe
secondary survey. AL Lhls polnL, you may need Lo order
urgenL lmaglng (Cx8, C1 braln). ln Lhe presence of shock,
look for a source of blood loss.

ln slgnlflcanL Lrauma, lnserL a caLheLer Lo collecL urlne for
analysls & monlLor uC. lf Lhe paLlenL was Lhe drlver, you
musL order a blood alcohol level.
Secondary Survey

MonlLor CCS LhroughouL Lhe assessmenL. Any decllne ln
CCS should resulL ln a repeaL of Lhe prlmary survey.

ÞalpaLe Lhe abdomen for any Lenderness. Abdomlnal
rlgldlLy or dlsLenslon requlre urgenL referral Lo surglcal
Leams. 8epeaL Lhls assessmenL. lnspecL, palpaLe and, lf
posslble, move or LesL all [olnLs of Lhe body. 1hls lncludes
feellng for skull, rlb and oLher fracLures. 8emember LhaL
hlgh veloclLy Lrauma such as an MvA can resulL ln unusual
ln[urles (such as ÞCL rupLure, splenlc rupLure eLc).

uo noL mlss aL Lhls polnL:
- SlgnlflcanL musculoskeleLal ln[ury
- Abdomlnal Lenderness
- uecllne ln CCS
- ueveloplng slgns of shock

Some sedaLlon and analgesla early on may asslsL wlLh Lhe
paLlenL's comforL, however Lhls can affecL examlnaLlon
flndlngs (eg. of Lenderness). SedaLlon may be requlred for
lnLubaLlon. 8emember LhaL lnlLlally, adrenallne may be
worklng as a sLrong analgeslc.

MonlLor for a change ln vlLal slgns and urlne ouLpuL
(whlch could lndlcaLe lnLernal bleedlng). ConLlnue
monlLorlng neurologlcal sLaLus regularly. Conslder
prophylaxls for poLenLlal lnfecLlon of wounds.

Invest|gat|ons
C1 8raln lf any susplclon of head Lrauma
Cx8 early (all paLlenLs)
C1 abdo lf any Lenderness
May requlre furLher lnvesLlgaLlons as ordered by varlous
Leams.
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1PL uAnuLnCnC uCSSlL8 2010
191
!"# %& ' !()*+,()-. /-012.-) 3*0(-0(
3(4*5*6*75 89: ;.-00*4*1-6*75
-obsLrucLlon of large arLerles excludlng coronary arLerles,
aorLlc arch vasculaLure, and braln
<*0= 4-167)0
-smoklng
-uM
-dysllpldemla
-P1n
-male
-8Ml>30
-famlly Px vascular dlsease/Ml/sLroke.
-?homocysLelne, ? C8Þ
!-6,7+,>0*7.7?>
1. ALheroscleroLlc dlsease ! occluslon
2.vascular spasms ! lnLermlLLenL occluslon (eg.
8aynaud's)
;.-00*4*1-6*75
@756-*5(A
1. mlld lnLermlLLenL claudlcaLlon
2. severe lnLermlLLenL claudlcaLlon
a. afLer walklng >130m
b. afLer walklng <130m
3. paln aL resL ln feeL, lncreaslng when llmb ralsed
4. gangrene + dlfflculLy walklng
<26,()47)BA
1. mlld claudlcaLlon
2. moderaLe claudlcaLlon
3. severe claudlcaLlon
4. lschemlc paln aL resL
3. mlnor Llssue loss
6. ma[or Llssue loss
C*?50 -5B C>D+67D0
-weakness, cramplng
- claudlcaLlon/ paln on resL
-slow-heallng/non-heallng ulcers
- pallor/coolness of exLremlLles
-dlmlnlshed/alLered halr growLh on affecLed llmbs
-loss of sensaLlon, esp. LemperaLure.
-paresLheslas
E*067)> -5B FG-D*5-6*75
EGA
:HHIIJJ"K 576( 5-62)( 74 +-*5
-Þhx, lPx
-rlsk facLors as per above
-Mls/1lAs/sLroke
SysLem 8evlew:
1. paln on resL, parLlcularly when lylng ln bed.
2. lnLermlLLenL claudlcaLlon: how far can Lhey walk?
3.swelllng
4. sores/ulcers-palnful? Chronlc? Cangrenous?
FGA
1. lnspecL:
-hands: LemperaLure, caplllary reflll, nlcoLlne sLalns,
Lendon xanLhomaLa.
-cyanosls/pallor, slgns hearL fallure
-xanLhelasma, corneal arcus
-obvlous lllness, moblllLy alds.
2. general: caroLld pulses, radlal/radlal, radlal/femoral
delay, AAA, renal brulLs.
3. legs: 8 vs L.
4. lnspecL: dresslngs, dlscoloraLlons, scars, deformlLles,
skln/halr changes, ampuLaLlons/gangrene, ulcers (check
beLween Loes)
a) arLerlal: pallor, shlny skln, decreased halr, scars, mlsslng
nalls/Loes, wasLlng. ulcers: 'punched-ouL' leslons, usually
on borders, sldes of feeL aL pressure areas, palnful.
?ellow, brown, gray or black base. nll dlscoloraLlon
around skln, general pallor.
b) venous: waxy skln, varlcose velns, skln hemoslderln
deposlLs/sLalnlng, venous sLasls (purple), edema, redness,
bllsLers wlLh fluld. ulcers: medlal, sup. Lo medlal
malleolus, 'galLer'. lrregular, heaped-up borders,
dlscolored/swollen skln surroundlng. 8ed/ bleedlng base,
can be covered wlLh flbrous Llssue. usually palnless.
3. ÞalpaLe: caplllary reflll, LesL for LemperaLure by runnlng
hands up Lhe back of legs, Lake popllLeal, dorsalls pedls,
and posL. Llb pulses (presenL, reduced, absenL) , measure
calf clrcumference.
6. LesL for loss of sensaLlon, proprlocepLlon, vlbraLlon.
7. 8uerger's LesL: px lylng flaL, ralse Lhelr leg and hold unLll
lL Lurns pale (approx 1 mln), Lhen geL Lhem Lo drop Lhelr
leg over Lhe slde of Lhe bed. +ve 8uerger's= fooL goes
brlghL red, reacLlve hyperemla = slgn of arLerlal
lnsufflclency.
L5M(06*?-6*750
Ankle-brachlal pressure-lndex: use handheld uoppler and
sphyg: measure brachlal sysLollc 8Þ and use Lhe uoppler
Lo measure sysLollc 8Þ aL Lhe mosL dlsLal pulse. Ankle 8Þ
dlvlded by brachlal 8Þ should >1. ln claudlcaLlon, <.8, ln
crlLlcal lschemla <. 4.
uoppler u/s runs: measure severlLy of ÞAu
1readmlll LesL: measures b.p durlng exerclse, lndlcaLes
severlLy of dlsease.
C1 anglography: measures degree of occluslon, vlsuallzes
flow Lhrough perlpheral arLerles.
N-5-?(D(56
-sLenLlng
-bypass: usually veln harvesL, buL paLchlng can be used.
;7D+.*1-6*750
Llmb lschemla ! gangrene, ampuLaLlon
ulceraLlons/cellullLes ! sepsls

1PL uAnuLnCnC uCSSlL8 2010
192
!"# %& ' ()*+,)- ./01)231*4+
567*+*1*4+ 89' :;,00*7*3,1*4+
lL occurs anywhere from Lhe renal calyces Lo Lhe ureLhral
meaLus, however lL classlcally occurs aL 2 slLes: ureLeral
and prosLaLlc.
lL may be parLlal or compleLe, unllaLeral or bllaLeral, acuLe
or chronlc. CbsLrucLlng leslons are lumlnal, mural or
exLra-mural.

<61*4;4=-9:,2060
#2>*+,;
• 8lood cloL, sloughed papllla, Lumour: renal, ureLerlc,
bladder, sLones (mosL common slLe wlLhln renal
pelvls)
?2),;
• SLrlcLures - ureLerlc: 18, ureLhral: posL-caLheLer,
gonorrhoea, schlsLosomlasls - Sx: uysurla, weak
sLream, splaylng, reLenLlon, u1l
• CongenlLal defecLs - ureLeropelvlc [uncLlon
obsLrucLlon
@A1),'>2),;
• ÞrosLaLlc obsLrucLlon
o 8ÞP - u8L: enlarged, smooLh, regular,
moblle, sofL
o Cancer - u8L: flrm hard, lrregular, flxed
nodule wlLhln gland, rarely presenLs wlLh
sympLoms of lnfraveslcal obsLrucLlon
• 8eLroperlLoneal flbrosls (one or boLh ureLers
compressed by chronlc lnflammaLory process, Sx: low
backache, renal paln, uremla, lx: reLrograde
ureLogram show sLenosls buL caLheLer able Lo pass,
8x: caLheLerlzaLlon of anurlc, ureLerlc sLenLs and
corLlcosLerolds)
• dlverLlcullLls

!,1B4CB-0*4;4=-
CbsLrucLlon wlLh conLlnued urlne formaLlon resulLs ln
• progresslve ^ ln lnLralumlnal pressure
• compensaLory hyperacLlvlLy and hyperLrophy and
subsequenL decompensaLory dllaLaLlon and aLony
proxlmal Lo Lhe slLe of obsLrucLlon
o resulLlng ln lncompleLe bladder empLylng
• dllaLaLlon of collecLlng and dlsLal Lubules, wlLh
compresslon and aLrophy of Lubular cells

D*=+0 ,+E D->C14>0
lnfraveslcal obsLrucLlon
• CbsLrucLlve Sx- reduced slze and force of urlnary
sLream, heslLancy and lnLermlLLenL sLream, Lermlnal
drlbbllng, reLenLlon, overflow lnconLlnence
• lrrlLaLlve Sx - urgency, dysurla, !"#$%#&'() &+',%"-.
(assoclaLed wlLh causes of polyurla eg. u1l - also
dysurla, smelly cloudy urlne)
• Sg - dlsLended, palpable bladder, large prosLaLe on
Þ8
Supraveslcal obsLrucLlon
• Sx: 8enal paln or renal collc, superlmposed lnfecLlon,
renal fallure and polyurla owlng Lo lmpalred
concenLraLlon ln chronlc obsLrucLlon, anurla ln
bllaLeral obsLrucLlon
• Sg: balloLable kldney, cosLoverLebral Lenderness

F*014)- ,+E @A,>*+,1*4+
WhaL ls Lhe speed of presenLaLlon?
• AcuLe (prosLaLlLls 2¨ lnfecLlon) vs chronlc (8ÞP,
mallgnancy)
ulfferenLlaLlng b/w acuLe and chronlc obsLrucLlon
• AcuLe upper LracL: radlaLlng paln, balloLable kldney
• AcuLe lower LracL: suprapublc paln, bladder dull Lo
percusslon (reLenLlon)
ls paLlenL pyrexlc? (lnfecLlon)

G+H601*=,1*4+0
";44E0 - l8L (lnfecLlon), uLC (posL renal azoLemla -
serum urea:creaL > 10:1), ÞSA (assess rlsk for prosLaLe
cancer) - normal <4, ^wlLh age
!)436E2)60 - MSu dlpsLlck + mlcroscopy (W8C, nlLraLes
lndlcaLe lnfecLlon, hemaLurla
lmaglng - Lo locallze slLe and exLenL of obsLrucLlon
• ku8 x8 - calcull
• ulLrasound - exclude hydronephrosls, assess prosLaLe
slze
• C1 - reveal degree, slLe and cause for obsLrucLlon
• CysLoscopy - bladder sLones, Lumours, 8ÞP
• 8eLrograde urography - conLrasL ln[ecLed up ureLhra,
anLegrade urographyphy - percuLaneous ln[ecLlon
lnLo renal calyx/pelvls/bladder and x8 fllms Laken
durlng voldlng

?,+,=6>6+1
1. 8elleve obsLrucLlon - caLheLerlzaLlon
a. Cx: ÞosL obsLrucLlve dluresls (provlde resus
flulds), Sodlum and 8lcarb-loslng
nephropaLhy (replace wlLh 1.26° sodlum
blcarb soluLlon)
2. 1reaL cause: ureLheral sLrlcLure - dllaLaLlon/lnLernal
ureLhroLomy/ureLhroplasLy, 8ÞP - 1u8Þ, sLones -
nephrosLomy Lo prevenL hydronephrosls, LSWL,
percuLaneous nephrollLhoLomy
3. 1reaL/prevenL lnfecLlon
?6E*3,;
• Analgesla
• Alpha recepLor blockers - Lamsulosln, prazosln LhaL
relaxes smooLh muscle (of prosLaLe)
o SL: posLural hypoLenslon
D2)=*3,;
1u8Þ (LransureLhral resecLlon of prosLaLe) - desLrucLlon
of lnLernal bladder sphlncLer, made of lnvolunLary smooLh
muscle

:4>C;*3,1*4+0
8enal parenchymal aLrophy as a resulL of back pressure
!"# %&'%#'(') %(**+#, -./.
/01
!"# %% & !'()*+'(,-).' /,0,1'2'0-

*22 34567289 :28;<62857;=2 >5?5@2A2?7
1PL uAnuLnCnC uCSSlL8 2010
194
!"# %& ' ()*+ ,-./012345.
647*+*8*9+ :0; <2-..*7*3-8*9+
ulcer - a defecL ln an eplLhellal surface.

8ash - a change of Lhe skln whlch affecLs lLs color,
appearance or LexLure.

6*77454+8*-2 6*-=+9.*.
ulcers:
• venous ulcers (due Lo venous lnsufflclency)
• ArLerlal ulcers (due Lo lnadequaLe arLerlal supply)
• neuropaLhlc ulcers (malnly due Lo dlabeLlc
neuropaLhy)
• ulcers due Lo Lrauma
• vascullLls ulcers
(noLe - can be mlxed!)

(dux noL glven for rash as very varled and very dependenL
on rash Lype/locaLlon eLc)

>*.895? -+@ AB-C*+-8*9+

ulcers:
Marglns
Colour (of wound bed and surrounds)
WheLher Lhere ls any fluld - slough/dlscharge/blood eLc
vascular supply Lo area
neuro supply Lo area

8ash:
Macular (flaL) or papular (ralsed)
Colour
Spread
ÞaLLern (LargeL llke clrcles, spoLLy eLc)
ulsLrlbuLlon (dermaLome?)
WarmLh
1enderness
ÞrurlLlc?

8oLh:
Lymph nodes
Px: duraLlon, changes, any rlsk facLors (eg. lor Þvu ln
ulcers)


Macular rash (drug reacLlon)


Þapular rash


venous ulcer
ArLerlal ulcer
neuropaLhlc
ulcer
vascullLlc ulcer

!"# %&'%#'(') %(**+#, -./.
/01
!"##"$ &'()($*+*,"$)
1PL uAnuLnCnC uCSSlL8 2010
196
!"#$%$&'
)*+$&$,$-& ./0 123%%$+$43,$-&
• A LraumaLlc ln[ury of Lhe sofL Llssues LhaL resulLs
ln breakage of Lhe local caplllarles and leakage of
red blood cells.
1here are Lhree Lypes of brulses:
• SubcuLaneous - beneaLh Lhe skln.
• lnLramuscular - wlLhln Lhe underlylng muscle. lL ls
ofLen dlfflculL Lo use Lhe muscle LhaL has been
brulsed.
• ÞerlosLeal - bone brulse. 1hls ls Lhe mosL severe
and palnful.
)$++*"*&,$32 )$3'&-%$%
• Llver dlsease, e.g. clrrhosls
• CoagulaLlon facLor dlsorders, e.g. haemophllla,
von Wlllebrand's ulsease
• 8one Marrow ulsorders e.g. leukemla
• ÞlaLeleL ulsorders (1hrombocyLopenlas)
• nuLrlLlonal deflclencles, e.g. vlLamlns C, k, 812,
or follc acld
• MedlcaLlons (asplrln, nSAlus, prednlsone)
• Sepsls, uengue lever, SLL
• 1rauma, ln[ury or physlcal abuse
• Surgery or oLher medlcal procedures
• Allergy-relaLed dlsorders
• Marfan Syndrome
• Collagen dlsorders
• Aglng Skln
AssoclaLed Sg/Sx
• ÞeLechlae, purpure, mucosal bleedlng
• PaemarLhroses (bleedlng ln Lo [olnLs)
• Þaln and swelllng

5$%,-"6 3&7 893:$&3,$-&
• ÞaLLern of brulslng: normal brulslng resLrlcLed Lo
llmbs
• AssoclaLed sympLoms: Abnormal brulslng
assoclaLed Lo peLechlae, purpura and mucosal
bleedlng
• urug hlsLory: nSAluS, sLerolds, eLc, even afLer
weeks or monLhs of cessaLlon
• lamlly hlsLory, lncludlng exLended famlly
• 8esponse Lo haemosLaLlc sLress, e.g. afLer LooLh
exLracLlon or mlnor surgery llke LonslllecLomy

;3&3'*:*&,

ÞrevenLlon:
• ÞroLecLlve cloLhlng
• Avoldlng excesslve exposure Lo Lhe sun

lmmedlaLe managemenL
• lce pack on brulse for 24-48 h Lhen hoL pack
• keep Lhe brulsed area ralsed above Lhe hearL
• 8esL Lhe brulsed body parL
• Þaln klller e.g. aceLamlnophen (1ylenol)
ldenLlfy cause and LreaL accordlngly, e.g.:
• 8lood Lhlnners: MonlLor dosages
• Paemophllla: 8lood Lransfuslon
• Leukaemla: ChemoLherapy
• nuLrlLlonal deflclency: Speclal dleLary
recommendaLlons
• 8acLerla: Sepsls
<&=*%,$'3,$-&%
• l8L
• Ll1s
• CloLLlng screen
1PL uAnuLnCnC uCSSlL8 2010
197
!"#$% '()*
+#,)*)%)-* ./0 !1($$),)2(%)-*
ueflnlLlon ls self-explanaLory!
Can be cardlac, resp, Cl, musculoskeleLal causes

344#5)(%# 6(*(7#4#*%
u8A8C:
A - check paLency
8 - Cxygen
C - flulds?, l/v cannulaLlon
PearL - C1n, LCC, 1roponlns, cardlac monlLor
uLlC - don'L ever forgeL glucose
8egular monlLorlng of vlLals

+),,#8#*%)(1 +)(7*-$#$
Anglography, AnLlplaLeleL, 1hrombolyLlcs as
needed
AfLer AMl, everyone goes home ln a: SLaLln,
Asplrln, ACL lnhlblLor, 8eLa blocker

3*9#$%)7(%)-*$
LCC & 1roponlns (?AMl)
vlLal Slgns (?hypovolemlc shock)
Cx8 (?Þneumonla)
l8L, C8Þ, Ll1, uLC
vC scan (conflrm ÞL)
u-ulmer (exclude ÞL)
CasLroscope (?pepLlc ulcer)
'()* !(:$#$ ;<=)2(1 ,#(%:8#$
!(85)(2 =()* Myocardlal lschaemla or lnfarcLlon CenLral, LlghL or heavy, may radlaLe Lo Lhe [aw or lefL arm
AorLlc dlssecLlon very sudden onseL, radlaLes Lo Lhe back >($2:1(8 =()*
AorLlc aneurysm
ÞerlcardlLls +/- myocardlLls ÞleurlLlc paln, worse when paLlenL lles down
lnfecLlve pleurlsy ÞleurlLlc paln
ÞneumoLhorax Sudden onseL, sharp, assoclaLed wlLh dyspnoea
Þulmonary emboll Sudden onseL, Px of uv1
Þneumonla CfLen pleurlLlc, assoclaLed wlLh fever and dyspnoea
AuLolmmune dlsease ÞleurlLlc paln
MesoLhelloma Severe and consLanL
'1#:8-=#8)2(85)(1 =()*
MeLasLaLlc Lumour Severe and consLanL, locallsed
ÞerslsLenL cough Worse wlLh movemenL, chesL wall Lender
Muscular sLralns Worse wlLh movemenL, chesL wall Lender
lnLercosLal myoslLls Sharp, locallsed, worse wlLh movemenL
1horaclc zosLer Severe, follows nerve rooL dlsLrlbuLlon, precedes rash
Coxsackle 8 vlrus lnfecLlon ÞleurlLlc paln
1horaclc nerve compresslon or lnfllLraLlon lollows nerve rooL dlsLrlbuLlon
8lb fracLure PlsLory of Lrauma, locallsed Lenderness
8lb Lumour, prlmary or meLasLaLlc ConsLanL, severe, locallsed
!"#$% ?(11 =()*
1leLze's syndrome CosLal carLllage Lender
CasLro-oesophageal reflux noL relaLed Lo exerLlon, may be worse when paLlenL lles
down-common
ÞerforaLed vlscus (eg oesophagus/gasLrlc Lear)
@($%8-)*%#$%)*(1 =()*
ulffuse oesophageal spasm AssoclaLed wlLh dysphagla
1rachelLls Þaln ln LhroaL, breaLhlng palnful
CenLral bronchlal carclnoma
A)8?(< =()*
lnhaled forelgn body
B%"#8 2(:$#$ Þanlc aLLacks CfLen preceded by anxleLy, assoclaLed wlLh breaLhlessness
and hypervenLllaLlon
MedlasLlnlLls 6#5)($%)*(1 =()*
Sarcold adenopaLhy, lymphoma
1PL uAnuLnCnC uCSSlL8 2010
198
!"#$%&'(%&"#
*+,&#&%&"#
1he 8ome lll crlLerla of consLlpaLlon
1. 1wo or more of Lhe followlng:
• SLralnlng aL leasL 23° of defecaLlons
• Lumpy or hard sLools (23°)
• SensaLlon of lncompleLe empLylng (23°)
• SensaLlon of anorecLal obsLrucLlon (23°)
• Manual maneuvers needed (23°)
• uefecaLlon <3x/wk
2. Loose sLools rarely presenL wlLhouL Lhe use of laxaLlves
3. lnsufflclenL crlLerla for l8S
CrlLerla musL be fulfllled for Lhe lasL 3/12 wlLh sympLom
onseL 6/12 prlor Lo ux.

-$$".&(%+/ 012'%"2$
• Abdomlnal bloaLlng and/or dlscomforL
• Local and perlanal paln
• Peadache
• Malalse
• nausea
• 8ad LasLe ln mouLh

!(3$+$
!"#"$%&
• Low flbre, low llquld, lmmoblllLy, l8S, Age, posL-
operaLlve paln, hosplLal envlronmenL
(#)$"*+%& ,-."%."
• Anal flssures, anal sLrlcLure, recLal prolapse
!"#$%#&"'( *+%#,-.#&*" (uC nC1 MlSS)
• !"4"5+.%(4 .(5.&#"2( 6*7 879 :;00<= sLrlcLures
(Crohn's dlsease), pelvlc mass (feLus, flbrolds),
dlverLlculosls, pseudo-obsLrucLlon
/"+%0)&-*12#,)*$-#"
• Pypercalcaemla, hypoLhyroldlsm, hypokalaemla,
porphyrla, lead polsonlng
3$45.
• CplaLes, anLlchollnerglcs, lron
6"4$)74.*4&%$ ,-.)$,"$.
• Splnal or nerve ln[ury, agangllosls (Plrschsprung's
dlsease), sysLemlc sclerosls, dlabeLlc neuropaLhy
8+9"$ *%4.".
• Chronlc laxaLlve abuse, ldlopaLhlc slow LranslL,
ldlopaLhlc megarecLum/colon, psychologlcal

>&$%"51
• 8ecenL change ln bowel hablL
• uuraLlon
• lrequency, naLure, amounL, conslsLency
• 8lood or mucus ln sLool
• 1enesmus
• ularrhoea alLernaLlng wlLh consLlpaLlon - Cl8u
• uleL - e.g. low flbre
• MedlcaLlon - e.g. oplolds
• WelghL loss, faLlgue - colon cancer

?@(2&#(%&"#
Þ8
• Anal Lone: pelvlc floor dysfuncLlon
• Mass: Lumour
• 8lood: Paemorrhold, Lumour
• 1enderness: Anal flssure
Comblned Þ8 and Þv: 8ecLocele

;#A+$%&B(%&"#$
lx only lf lndlcaLed: age >40, change ln bowel hablL,
welghL loss, Þ8 bleedlng, Lenesmus
• l8L, uLC
• Serum calclum: hypocalcaemla
• 1hyrold funcLlon LesLs: hypoLhyroldlsm
• 8lgld slgmoldoscopy and blopsy: anorecLal leslons
• 8arlum enema: mallgnancy
• Colonoscopy: mallgnancy
• ColorecLal LranslL sLudy: colorecLal cancer and
dlverLlcular dlsease

;22+/&(%+ :(#(B+2+#%
• 8emove lmpacLed faeces (enemas, sLool sofLeners,
laxaLlves)
• lncrease dleLary flbre (>30g/day)
• llbre supplemenLs
• Lxerclse
• 1reaL underlylng dlsorder e.g. surgery for
hernla/recLocele eLc, hormone replacemenL for
hypoLhyroldlsm, ln[ecLlon for anLerlor mucosal
prolapse, anaesLheLlc and slLz (salL waLer) baLhs for
anal flssure
• 8lofeedback Lherapy for anlsmus
• LaxaLlves
- 8owel sLlmulanLs
- CsmoLlc agenLs
-8ulklng agenLs
-SLool sofLeners

!"2'4&.(%&"#$
• Paemorrholds
• 8ecLal prolapse
• laecal lmpacLlon
• laecal lnconLlnence
• Anal flssures
• urlnary lnconLlnence (weakened pelvlc floor)
• 8owel obsLrucLlon (severe)
!"#$%&'(&
!*+(,(-(., /01 23&##(+(4&-(.,
uysphagla ls slmply a dlfflculLy ln swallowlng whlch
may occur wlLh elLher sollds, llqulds or boLh.
uysphasla can be a resulL of mechanlcal
obsLrucLlon, neuromuscular moLlllLy dlsorders or
pharyngeal dysphagla
lL ls lmporLanL Lo dlfferenLlaLe beLween
odynophagla (palnful swallowlng whlch occurs
wlLh any severe lnflammaLory processes ln Lhe
oesophagus) and Lrue dysphagla.
!(++*5*,-(&3 !(&',.#(#
ulfferenLlals of dysphagla:
6*4%&,(4&3 .7#-584-(.,
!"#$%"&%' )*%#+%" ,-&,.+/01&2
8eflux oesophaglLls wlLh sLrlcLure formaLlon
Carclnoma of oesophagus or gasLrlc cardla
Þharyngeal or oesophageal web
Þharyngeal pouch
SchaLzkl (lower oesophageal) rlng
lorelgn body
34#$%"&%' ),1#&%5- ,-&,.+/01&2
ColLre wlLh reLrosLernal exLenslon
MedlasLlnal Lumours, bronchlal carclnoma, vascular compresslon
(rare)
9*85.:8#483&5 :.-(3(-" ;(#.5;*5# <%(,-# +5.: -%* %(#-.5"= #.3(;#
&,; 3(>8(;# *>8&33" ;(++(483-? #":$-.:# (,-*5:(--*,-@
Achalasla
ulffuse oesophageal spasm
Scleroderma
A%&5",'*&3 ;"#$%&'(& <%(,-#= &#$(5&-(.,? +38(; 5*'85'(-&-(., (,-.
-%* ,.#*@
Crlcopharyngeal dysfuncLlon-Zenker's dlverLlculum
neurologlcal dlseases: bulbar or pseudobulbar palsy, myasLhenla
gravls, polymyoslLls, myoLonlc dysLrophy

ulfferenLlals of odynophagla
- lnfecLlous oesophaglLls (e.g. Candlda, herpes
slmplex),
- pepLlc ulceraLlon of Lhe oesophagus,
- causLlc damage Lo Lhe oesophagus or
- oesophageal perforaLlon.
B(#-.5" &,; CD&:(,&-(.,
Ask abouL:
- uuraLlon of sympLoms: progresslve dysphasla
over monLhs or weeks suggesLs Lhe presence
of organlc narrowlng (ca of oesophagus,
sLrucLure from ongolng reflux oesophaglLls)
- WheLher Lhe dlfflculLy ls ln swallowlng llqulds
or sollds, or boLh (dlfflculLy wlLh llqulds
prlmarlly suggesLs achalasla)
- WheLher Lhe dlfflculLy ls presenL
lnLermlLLenLly or only aL Lhe sLarL of a meal
(suggesLs lower oesophageal rlng or web)
- nasal regurglLaLlon
- WheLher or noL Lhe paLlenL coughs on
swallowlng
- 1he level aL whlch Lhe food sLlcks
- AssoclaLed hearL burn
- WelghL loss
Lxamlne:
- MouLh for ulcers, Lhrush and pallor
- neck for lymph glands and golLres
- lor slgns of sysLemlc scleroderma
- Slgns of underlylng neurologlcal deflclL
(evldence of sLroke, moLor neuron dlsease,
myasLhenla gravls)

E::*;(&-* 6&,&'*:*,-
Speech paLhology revlew
1hlckened flulds
Assess for asplraLlonal pneumonla rlsk



E,F*#-('&-(.,#
l8L, LS8
8arlum swallow
CasLroscopy
Cx8
1PL uAnuLnCnC uCSSlL8 2010
200
!"#$%&'
)'*$+$#$,+ -./ 01"22$*$3"#$,+
laLlgue: Llredness, wearlness, loss of energy
Caused by preLLy much anyLhlng

)$**'4'+#$"1 )$"%+,2$2
MosL Llkely ux:
- SLress & AnxleLy
- uepresslon
- vlral / posL-vlral lnfecLlon
- Sleep-8elaLed ulsorders
8ed llags (uon'L Mlss) ux:
- Mallgnancy
- Cardlac arrhyLhmla
- CardlomyopaLhy
- Anaemla
- PaemochromaLosls
- Plv
- Pep C
Seven uux LhaL Masquerade (Plde)
- uepresslon
- ulabeLes
- urugs
- Anaemla
- 1hyrold dlsorder
- Splnal uysfuncLlon
- u1l
CfLen Mlssed ux:
- lood: lnLolerance, cellac dlsease
- Chronlc lnfecLlon
- lnsldlous CCl
- llbromyalgla
- Þoor flLness
- urugs: L1CP, wlLhdrawal
- Women: menopause, pregnancy
- neuro: CvA, Þarklnsons, head ln[ury
- 8enal lallure
- LlecLrolyLe lmbalances (jk, jMg)
- Chemlcal Lxposure

5$2#,46 "+7 89":$+"#$,+
Px
- Sleep paLern
- WelghL flucLuaLlon
- Lnergy
- Sexual acLlvlLy
- Self medlcaLlon (sLlmulanLs, analgesla,
alcohol, smoklng)
- lears
- ÞreclplLaLlng facLors
- Work hlsLory
- uleLary hlsLory
- MensLrual hlsLory
Lxam:
- PepaLosplenomegaly
- LymphadenopaLhy
- Chronlc laLlgue: muscle Lenderness,
pharynglLls, cervlcal lymphadenopaLhy

;::'7$"#' <"+"%':'+#
- 1reaL underlylng cause
- Always conslder depresslon


1PL uAnuLnCnC uCSSlL8 2010
201
!"#$%&'()&'*"%
+,%&$- / 0'%$)%$ !"#$%&'()&'*"%
Sleep ulsorder Sleep sLudles
Þsychogenlc
- ÞsychlaLrlc condlLlon
- LlfesLyle facLors (sLress, lack of sleep, obeslLy)
Þsych 8eferral
Mallgnancy CyLology, ÞC8, C1
Paem: anaemla l8L (Pb), 8lood lllm, lron sLudles
lnfecLlon: Plv/AluS, chronlc lnfecLlon l8L, 8lood lllm, C8Þ, LS8, urlne MCS
Plv, Pep A8C, L8v, 18, Malarla, lnfecLlve
LndocardlLls (echo)
Cardlac: CCl, arrhyLhmla LCC, Cx8
8esp: CCÞu, asLhma Cx8 & splromeLry
Cl: llver fallure Ll1s
Lndocrlne: j^Lhyrold, j^adrenal, hyperparaLhyrold,
dlabeLes
1hyrold luncLlon, plasma corLlsol, blood glucose
MeLabollc: jk
+
, jMg
2+
uLC (calclum, magneslum)
AuLolmmune ulsease AuLolmmune Screen: AnA, 8heumaLold lacLor
unknown: chronlc faLlgue, flbromyalgla
1PL uAnuLnCnC uCSSlL8 2010
202
!"#$#%&"
()**"+",-)#. ()#/,01)1
• 2",1)0, &"#$#%&" - bllaLeral,
fronLal/occlplLal/Lemporal area, ºLlghLness", lasLs for
hours, recurrenL, usually no assoclaLed sympLoms
• 3)/+#)," - unllaLeral, preceded by flashlng llghLs or
ºzlg-zag" llnes, phoLophobla
• 4"+5)%#. 670,$8.01)1 - occlplLal headache, neck
sLlffness
• 9%:-" 1),:1)-)1 - ºfullness" behlnd Lhe eyes or over
Lhe cheeks
• 3",),/)-)1 - generallsed headache, phoLophobla,
neck sLlffness, fever
• 2";70+#. #+-"+)-)1 - perslsLenL unllaLeral headache
over Lemporal area, Lenderness over Lemporal arLery,
blurred vlslon, [aw paln
• 69! - lnsLanLaneous severe headache º1hunderclap"
, lnlLlally locallsed buL become generallsed
• 4.:1-"+ &"#$#%&" - paln over 1 eye, lacrlmaLlon,
rhlnorrhea, flushlng of Lhe forehead, occurrlng ln
bouLs lasLlng for several week < few Llme a year
• <#)1"$ =4> - generallsed headache, worse ln
mornlng, drowslness, vomlLlng

!)1-0+8
• CnseL?
• uuraLlon/Cycllcal?
• CuallLy?
• SlLe?
• 1rlggers?
• ÞhoLophobla?
o Mlgralne
o MenlnglLls
• Aura?
• 1rauma?

?@#;),#-)0,
• neck sLlffness?
o Cervlcal spondylosls
o MenlnglLls
• Þaplllodema?
o 8alsed lCÞ
• lever?
o MenlnglLls
o AcuLe slnuslLls
• AlLered consclous sLaLe?
o MenlnglLls
o SAP
o 8alsed lCÞ
• 1emporal Lenderness
o 1emporal arLerlLls?
• kernlg's + 8rudzlnskl's slgn?
o MenlnglLls

=;;"$)#-" 3#,#/";",-
• A8C's (lv flulds,.)
o Analegesla:
! Asprln
! lbuprofen
! ÞaraceLamol
• neuro Cbs

• =,5"1-)/#-)0,1


49A6? 2?62
Cervlcal
Spondylosls
Cervlcal Splne x8ay
MenlnglLls C1/M8l + LÞ + blood culLures
1emporal
arLerlLls
LS8, C8Þ, l8L (for
LhrombocyLosls) Ll1 (for ALÞ)
SAP C1 braln
8alsed lCÞ M8l/C1, LÞ, lCC


1PL uAnuLnCnC uCSSlL8 2010
203
!"#$%&'(
*(+&$&,&-$ "$% ./"00&+&'",&-$
!aundlce (lcLerus) refers Lo yellow plgmenLaLlon of skln,
sclerae, and mucosae due Lo ! plasma blllrubln. Classlfled
accordlng Lo slLe (prehepaLlc, hepaLocelluar,
cholesLaLlc/obsLrucLlve) or by Lhe Lype of clrculaLlng
blllrubln (con[ugaLed or uncon[ugaLed).

An lsolaLed ralsed serum blllrubln ls usually due Lo
CllberL's syndrome, whlch ls conflrmed by normal llver
enzymes and l8L



Cycllng of 1&/&2#1&$ and lLs producLs Lhrough Lhe llver, lnLesLlnes, porLal
and sysLemlc clrculaLlons, and kldneys. 8, 1&/&2#1&$, uro8, uroblllnogen,
C, glucuronlde

*&++(2($,&"/ *&"3$-0&0
42(5(6",&' 78$'-$9#3",(%:
Lxcess uncon[ugaLed blllrubln ls produced fasLer Lhan Lhe
llver ls able Lo con[ugaLe lL for excreLlon. uncon[ugaLed
blllrubln ls lnsoluble and ls noL excreLed ln urlne.
- CverproducLlon e.g. haemolysls, lneffecLlve
eryLhropoleses
- lmpalred hepaLlc upLake e.g. drugs, CCl
- lmpalred con[ugaLlon e.g. CllberL's

;(6",-'(//#/"2 7.-$9#3",(%:
Con[ugaLed blllrubln ls waLer soluble and ls exreLed ln Lhe
urlng glvlng lL a dark colour (blllrublnurla). AL Lhe same
Llme, lack of blllrubln enLerlng Lhe guL resulLs ln pale,
ºpuLLy" coloured sLools and an absence of uroblllnogen
on dlpsLlck.
- vlruses eg. Pep A, 8, C., CMv, L8v
- urugs
- Alcohollc hepaLlLls
- Clrrhosls
- Llver MeLs/Abscess
- PaemochromaLosls
- AuLolmmune hepaLlLls
- SepLlcaemla
- LepLosplrosls
- Alpha1-anLlLrypsln def.
- 8udd Chlarl syndrome
- Wllson's dlsease
- 8lghL hearL fallure
- 1oxlns

<10,2#',&=(>.5-/(0,",&' 7.-$9#3",(%:
!"" $%&' (%)" *+,)&-./&01" 2%.340/"5
- Þrlmary blllary clrrhosls, prlmary scleroslng
cholanglLls
- LxLrlnslc compresslon of Lhe blle ducL
- urug lnduced cholesLasls
- C8u gallsLones
- ÞancreaLlc cancer


*2#3 ?$%#'(% !"#$%&'(
Paemolysls AnLlmalarlals e.g. dapsone
PepaLlLls ÞaraceLamol Cu, lsonlazld, 8lfamplcln,
Þyrazlnamlde, MAC lnhlblLors, Sodlum valproaLe,
PaloLhane, SLaLlns
CholesLasls llucloxaclllln (may be wks afLer Þx), lusldlc acld, co-
amoxlclav, nlLrofuranLoln, SLerolds (anabollc, Lhe
plll), Sulfonureas, Þrochlorperazlne, Chlorpromazlne

."#0(0 -+ !"#$%&'( &$ " 62(=&-#0/@ 0,"1/( 6",&($, A&,5
'&225-0&0
- Sepsls especlally u1l, pneumonla, perlLonlLls
- Mallgnancy e.g. hepaLocellularcarclnoma (PCC)
- Alcohol & urugs
- Cl bleedlng

;&0,-2@ "$% BC"D&$",&-$

;C
- 8lood Lransfuslons
- lv drug use
- 8ody Þlerclngs
- 1aLLoos
- Sexual acLlvlLy
- 1ravel abroad
- !aundlced conLacLs
- lamlly Px
- Alcohol consumpLlon
- E// medlcaLlons
BC
- Slgns of CLu
- PepaLlc encephalopaLhy
- LymphadenopaLhy
- PepaLomegaly/splenomegaly
- AsclLes
- 4"/6"1/( 3"//1/"%%(2 F 6"&$/(00
9"#$%&'( 0#33(0,0 " '"#0(
-,5(2 ,5"$ 3"//0,-$(0
7.-#2=-&0&(2G0 /"A:


?$=(0,&3",&-$0
8ased on cllnlcal susplclon of cause
- 8H &0 ,5( 1(0, &$=(0,&3",&-$ +-2 9"#$%&'(
- Ll1s, Pep serology, l8L, u&L eLc eLc
- Llver blopsy only lf no oLher cause found
1PL uAnuLnCnC uCSSlL8 2010
204
!"#$% '()* +(,-
.$/,-,0,"- 123 45(66,/,)(0,"-
• The most common cause of back pain is a minoi
stiain to muscles anu¡oi ligaments, but people
suffeiing fiom this type of back pain usually uo not
seek meuical tieatment as most of these soft tissue
pioblems iesolve iapiuly.

• The main cause of back pain piesenting to the
uoctoi is uysfunction of the inteiveitebial joints of
the spine uue to injuiy, also iefeiieu to as
mechanical back pain (at least 7u%).

.,//$%$-0,(5 .,(7-"6,6
ÞrobablllLy dlagnosls:
- verLebral dysfuncLlon (faceL [L and dlsc)
- Spondylosls (degeneraLlve arLhrlLls).

Serlous and should noL be mlssed:
- Cardlovascular: rupLured aorLlc aneurysm,
reLroperlLoneal haemorrhage (anLlcoagulanLs)
- neoplasla: myeloma, meLasLases (lung, bresL and
prosLaLe)
- Severe lnfecLlons: osLeomyellLls, dlsclLls,
Luberculosls, pelvlc abscess/Þlu
- Cauda equlne compresslon
- 8lllary dlsorders
- ÞeneLraLlng duodenal ulcers
- ÞancreaLlLls
- 8enal dlsorders

ÞlLfalls (ofLen mlssed)
- SpondyloarLhropaLhles: ankyloslng spondyllLls,
psorlasls, reacLlve arLhrlLls
- Sacrolllac dysfuncLlon
- SpondylollsLhesls
- ClaudlcaLlon: vascular and neurogenlc
- ÞrosLaLlLls, LndomeLrlosls

CLhers
- uepresslon, ulabeLes, urugs, Anaemla, 1hyrold
ulsease, Splnal dysfuncLlon, u1l,
CsLeoporosls/ÞageL's ulsease

8,60"%9
Ask WWCCAAA8 (esp naLure of paln)
ls lL worse wlLh resL or acLlvlLy? SlLLlng or sLandlng?
CLher sympLoms: genlLal dlscharge? ularrhoea? Þaln ln
oLher [olnLs? urlnary sympLoms? Loss of sensaLlon?
MedlcaLlons and sLress.




:$; <5(76
Age > Su yeais
Bistoiy of cancei
Tempeiatuie > S7.8°C
Constant pain÷uay anu
night
Weight loss
Significant tiauma
Featuies of
sponuyloaithiopathy
Neuiological ueficit
Biug oi alcohol abuse

0se of anticoagulants
0se of coiticosteioius
No impiovement ovei 1
month
Possible cauua-equina
synuiome
- sauule anaesthesia
- iecent onset blauuei
uysfunction
- seveie oi piogiessive
neuiological ueficit

=>(?,-(0,"-
1. Inspection
2. Active movements
foiwaiu flexion, extension
anu lateial flexion (R & L)
S. Piovocative tests (eg. Stiaight leg iaise test)
4. Palpation (to uetect level of pain)
S. Neuiological testing of lowei limbs
6. Testing of ielateu joints (hip, sacioiliac)
7. Assessment of pelvis anu lowei limbs foi any
uefoimity, e.g. leg shoitening
8. ueneial meuical examination of CvS anu Resp
incluuing iectal examination (if appiopiiate)

"#$%&'# ()*+$,,$%-.) /#01$)-0$+
Bistoiy Insiuious 0nset Piecipitating injuiy
Natuie Aching¡Thiobbing Beep uull ache,
shaip if ioot
compiession
Stiffness Seveie, piolongeu
moining stiffness
Noueiate, tiansient
Effect of iest Exaceibates Relieves
Effect of
activity
Relieves Exaceibates
Rauiation Noie localiseu,
bilateial oi alteinating
Tenus to be uiffuse,
unilateial
Intensity Night¡eaily moining Enu of uay, following
activity

@-A$60,7(0,"-6
Scieening tests: FBE, CRP, Plain xiay of spine, uiine
uipstick, ESR, ALP, PSA (in males > Su)
Where approprlaLe for managemenL: C1 scan, M8l,
dlscography and bone denslLy LesL may be requlred
(especlally when red flags are presenL).

B(-(7$?$-0
8esL and acLlvlLy modlflcaLlon
nSAluS or slmple analgeslcs flrsL, oplolds laLer
Þhyslcal Lherapy, PeaL or Cold 1herapy
Surglcal evaluaLlon: LamlnecLomy, Splnal fuslon,
uecompresslon eLc.
1PL uAnuLnCnC uCSSlL8 2010
203
!"#$%" ' ()*+,+-.
/%0+-+,+)- 123 45"$$+0+6",+)-
nausea: a deslre Lo vomlL (ofLen wlLh pallor, sweaLlng, hypersallvaLlon - auLonomlc effecLs)
8eLchlng: lnvolunLary aLLempL Lo vomlL
vomlL: expelllng gasLrlc conLenLs ouL mouLh

/+00%7%-,+"5 /+".-)$+$8 9%",#7%$ ' :;
//; 9%",#7%$ :;
CasLroenLerlLls LaLen bad food SLool MCS
lnfecLlons
• CLlLls medla
• u1l
Lsp ln klds

l8L,C8Þ

MoLlon slckness
urugs
• L1CP lnLoxlcaLlon
• SubsLance abuse
• 8adloLherapy

Larly mornlng n&v
urug LoxlclLy

Þregnancy Larly mornlng n&v Þregnancy LesL
Mlgrane vomlLlng may be Lhe only sympLom
8ullmla AdolescenL female, vomlL afLer blnge eaLlng
ulabeLes (ukA)
Lndocrlne dlsorders (addlsons)
Crgan lallure (llver, kldney,
hearL, resp)
Larly mornlng n&v (renal)
CuL moLlllLy dlsorders
-achalasla
-paralyLlc lleus
-ldlopaLhlc gasLroparesls (esp ln
dlabeLlcs)



-posprandlal vomlL, lnLense nausea &
anorexla
Cl1 lmaglng (barlum, scopes)
Cesophageal moLlllLy sLudles

8ed llags:
8alsed lCÞ (mallgnancy,
haemorrhage)
Larly mornlng n&v, may have no welghL loss
or nausea
neurologlcal LesLlng (C1 braln, M8l
braln)
8owel obsLrucLlon (noLe vomlL
conLenLs)
WelghL loss 8lochemlsLry (uLC)
Mallgnancy WelghL loss
Severe lnfecLlon (menlnglLls,
sepLlcaemla)

AcuLe AppendlclLls
AcuLe ÞancreaLlLls
AMl

<+$,)7= "-> ?;"*+-",+)-
Px:
- ConLenL of vomlL
o 8lood = upper Cl bleed
o Coffee ground = upper Cl obsLrucLlon
o laecal = duodenal or below obsLrucLlon
- lood lnLake
- 1ravel
- urug hlsLory: prescrlbed & llllclL
Lxam:
- lever (look for source of lnfecLlon, eg ear)
- PydraLlon sLaLus
- Scars of prevlous surgery
- neuro exam & opLhalmoscopy (slgns of ralsed lCÞ)
- urlnalysls
- Þregnancy 1esL





:**%>+",% @"-".%*%-,
8ehydraLlon:
- ALLempL oral rehydraLlon:
8 Lsp sugar & 1Lsp salL ln 1 llLre of waLer (opLlonal x
cup orange [ulce & x banana Loo)
- l/v: 1L sallne & 1-2L dexLrose
(2-3 L over 24 hours)
Þharmacologlcal (anLl-emeLlcs):
n8: do nC1 use ln klds wlLh gasLro
- uopamlne AnLagonlsLs:
o MeLoclopramlde (Maxalon)
o uomperldone
o Þrochlorperazlne
o uroperldol (posL-op)
o Paloperldol (posL-chemo)
- 3P13 AnLagonlsL
o CndanseLron
- CorLlcosLerolds
o uexameLhasone
1reaL underlylng cause


1PL uAnuLnCnC uCSSlL8 2010
206
!"#$$%& (%)*+,-$. /-0&
1%.0&020#& 3+4 ,$-**0.05-20#&
Swollen legs - oedemaLous LL
Calf paln - unpleasanL sensaLlon ln calf


10..%6%&20-$ 10-)&#*0*
• Muscular sLraln - locallzed Lenderness/paln
• uv1- gradual onseL of unllaLeral calf (rarely Lhlgh) paln
and someLlmes swelllng
• CellullLls - redness, Lenderness, swelllng, fever/nlghL
sweaLs
• ComparLmenL syndrome - 'Þ's=Þaln, paresLhesla,
pallor, pulselessness, paralysls, sudden onseL, medlcal
emergency!
• SclaLlca - burnlng paln radlaLlng down buLLocks and
posLerlor leg, posslble numbness/weakness.
• Þvu - paln (usually unllaLeral) felL ln calves on by
walklng/exerclse whlch rapldly relleved by resL
(claudlcaLlon), absenL/reduced pulses, oLher Sx of lPu.
• Chronlc venous lnsufflclency - paln, ankle swelllng,
resLless legs, leLhargy, lLchlng, colour change
• varlcose velns (caused b Cvl)- achlng paln, dllaLed,
LorLuous superflclal velns, posslble oedema or
ulceraLlon
• 8aker's (ÞopllLeal) CysL - unllaLeral leg oedema, achlng
knee of calf paln, swelllng/lump ln Lhe back of Lhe knee
• CCl - bllaLeral oedema, dyspnea, Þnu, ^!vÞ,
eLc.(remember oLher CvS condlLlons llke 18 LhaL
^venous pressure)
• Cku- bllaLeral oedema, faLlgue, ^8Þ, eLc.
• Clrrhosls - oedema, [aundlce, asclLes eLc
• Lymphedema - unllaLeral non-plLLlng oedema,
recurrenL lnfecLlons
• PyperLhyroldlsm - preLlblal myxedema, Lremor,
sweaLlng, dlarrhoea, nausea eLc



70*2#68 -&9 :;-<0&-20#&
-deLalled paln Px (SCC8A1LS),
-assess funcLlonallLy wlLh Lhelr 'normal'
-MPx Lo rule ouL Lhe chronlc underlylng condlLlons or flnd
rlsk facLors leadlng Lo parLlcular ux, eg arLhrlLls
predlsposes pL Lo 8aker's cysLs. Ask abouL medlcaLlons
slnce some drugs cause oedema as a slde effecL.
-lPx of uv1, venous dlsorders or varlcose velns
-neuro/MSk exam and any oLher relevanL sysLems eg CvS
-calf palpaLlon for locallzaLlon of paln
-vlLals especlally LemperaLure
-fluld sLaLus
-SLralghL leg ralse LesL = sclaLlca wlLh posslble dlsk
hernlaLlon
-Wells' Score < 2 do a d-dlmer LesL, or venogram, lf >2, Lo
rule ouL uv1 (hLLp://www.mdcalc.com/wells-crlLerla-for-
dvL)
-8eurger's 1esL (LL elevaLed Lo 43º for >1mln resulLs ln
plnk soles!pale) = arLerlal lnsufflclency/Þvu
-1rendelenberg/LournlqueL LesL (ralsed LL wlLh LournlqueL
sapheno-femoral [uncLlon, movlng down unLll no reflll or
varlcoslLles) = level of venous lncompeLency

=<<%90-2% >-&-)%<%&2
• Analgesla where necessary
• 8lCL dependlng on cause/paln paLLern
• AnLlcoagulaLlon lf above knee uv1
• nSAlus for sympLom rellef of lnflammaLory causes
• ComparLmenL syndrome-llmb elevaLlon unLll
emergency fascloLomy

=&?%*20)-20#&*
l8L
u&Ls
8SL
u-dlmer(+)!venogram
uuplex/doppler ulLrasonography
CreaLlne phosphoklnase (CÞk)
!"# %&'%#'(') %(**+#, -./.
-.0
!"#$% '(#)
!"#$%$&$'% )*+ ,-.//$#$0.&$'%
Wiist pain¡swelling:
Can be subclassifieu baseu on symptoms:
- 0nilateial vs bilateial
- Focal vs uiffuse
- associateu pain elsewheie

!$##"1"%&$.- !$.2%'/$/
,.13.- &4%%"- /5%61'7": pain, paiesthesia ovei
meuian neive uistiibution (thumb, inuex, miuule),
weakness: loss of powei, esp. in thenais.
845'% 0.%.- /5%61'7": pain, paiesthesia ovei ulnai
neive uistiibution (iing +little fingei), weakness, loss
of powei esp in small muscles of hanus.
91$/& &"%6'%$&$/*&"%'/5%':$&$/: thickening of
tenosynovium. Pain, swelling, stiffness, iestiicteu
mobility, weakness, waimth at joint. 0sually unilateial,
chionic.
!" ;4"1:.$%</ =&"%'/5%':$&$/>? iauial pain,
tenueiness, swelling, uifficulty giipping, anu moving
wiist÷can be stenosing! uefoimity. Confiim using
Finkelstein's test.
@31.$%/: swelling, pain, biuising, instability, loss of fx.
A1.0&41"/: wiist pain, swelling, uefoimity.
B/'1$.&$0 .1&C1$&$/: involves joints of hanus, can
involve wiists; BIPs involveu; inflammation, pain.
Tenuinitis, uactylitis ! sausage uigits.
8'4&5 .1&C1$&$/: iuboi, caloi, uoloi. Check foi gouty
tophi. Pseuuogout has similai symptoms
@"3&$0 .1&C1$&$/? usually a monoaithiitis. Acute pain,
swelling, chills, fevei.
DC"47.&$0 .1&C1$&$/: synovitis- swollen, waim, painful
stiff joints, woise aftei inactivity anu in the moining.
Impaiieu iange of movement. Check foi iheumatoiu
nouules.
E/&"'75"-$&$/: pain, swelling, fevei, weight loss.
Confiim w¡ NRI.
F:./04-.1 %"01'/$/ of scaphoiu oi lunate: can be 2iy
to anemia. Causes pain anu swelling.
G53"1&1'3C$0 34-7'%.15 '/&"'.1&C1'3.&C5:
clubbing; painful swollen joints. Symmetiical
8.%2-$'%: usually painless lump, on the back of the
hanu.
F4&'$774%" 0.4/"/: polymyositis, scleioueima, SLE,
Raynauu's, ueimatomyositis,

G$/&'15
-WWQQAAB
-lumps
-histoiy of tiauma
-occupation, hobbies.
-comoibiuities, esp. aithiitis, infectious uisease,
autoimmune uisease, weakeneu immunity.

HI.7$%.&$'%?
-noimal NSK: palpation anu NvS function most
impoitant.
-lumps: mobile oi fixeu. Painless oi painful.


@3"0$.- &"/&/?
BC.-"%</ &"/&? flex wiist as fai as possible, inveiteu
piayei sign, anu wait. Pain+¡ paiesthesia w¡in 1
minute ovei meuian neive uistiibution=+ve Phalen's.
J$%"-</ /$2%? tap ovei flexoi ietinaculum. Pain +¡
paiesthesia ovei meuian neive uistiibution.
!41K.% &"/&? caipal compiession foi Su seconus
eliciting meuian neive pain +¡ paiesthesia.
A$%K"-/&"$%</ &"/&? ulnai ueviation to stietch wiist
while giasping thumb: pain ovei iauial styloiu.
Biffeientiates ue Queivain's tenosynovitis fiom
aithiitis of 1
st
metacaipal.
81$%6 &"/&? compiess + iotate fiist metacaipal bone
along tiapezium; compiess + iotate uistal iauioulnai
joint. Pain anu ciepitus = positive, suggests aithiitis oi
instability.
F--"%</ &"/&: vasculai supply. Pump fist, applying
piessuie ovei iauial anu ulnai aiteiies. Patient opens
hanus, anu examinei ieleases piessuie ovei one aiteiy
to assess filling.

L%:"/&$2.&$'%/
+XR of joints above anu below anu of affecteu joint: iule
out fiactuies, uiffeientiate them fiom othei NSK
causes, esp. spiains, anu tenuonitis. 0paque bone =
avasculai neciosis. Rauiopaque nouules in soft tissue=
myositis ossificans.
-NRI¡CT if nothing visible on XR: osteomyelitis,
avasculai neciosis, soft tissue swelling.
-bloous: anemia, infection, autoimmune maikeis if
clinical suspicion.
-swabs if open wounu.
-aithiocentesis: joint aspiiation can ieveal bacteiial
giowth, ciystals.

L77"6$.&" M.%.2"7"%&? M@N: iest, suppoit, mouify
activities.
+ Fiactuie: cast, fix, ieview foi healing, joint iehab.
+ Spiain: ice, compiess, +NSAIBs.
+tenuonitis¡tenosynovitis: +coitisone injections.
O"1:" "%&1.37"%&: iest, mouify activities, suppoit
wiists, steioiu injections, ueciease swelling !
incieaseu compaitment. Suigical ielease possible.
GBEF: symptomatic ielief. Inuomethacin, suigical
vagotomy if seveie. Pain often iesistant.
8'4&: pieventative mx via allopuiinol. Acute mx via
colchicines, inuomethacin. NB: B0 N0T uIvE
ALL0P0RIN0L uuiing an acute attack.
F4&'$774%" 6$/'16"1/: steioiu mx.
8.%2-$'%: painless. If causing symptoms, can be
iemoveu suigically.
L%#"0&$'4/ .1&C1$&$/: Abx, uepenuing on sensitivity.
Suigical washout if necessaiy.
E/&"'75"-$&$/: aggiessive Abx theiapy- usually Iv
timentin¡tazocin +¡- suigical uebiiuement.
!"# %&'%#'(') %(**+#, -./.
-.0
!"#$%&%'(
1PL uAnuLnCnC uCSSlL8 2010
209
!"#" % #&'()*&+,(-.,/,&)012.3+)4(+,5* 6&4'7,(*
!"" $%&' ('))'* +,"&"*-$-.'*/ 0$1*2.("


8*9,',+,-'

CbsLrucLlve !aundlce: ÞosL-PepaLlc [aundlce caused by
obsLrucLlon of Lhe blllary Lree


:'&+-;0 -9 .,/,&)0 +)**




<&43*3

- CholellLhlasls/ choledochollLhlasls
- Carclnoma of Lhe C8u
- Carclnoma of Lhe head of pancreas
- lnflammaLory sLrlcLure of Lhe C8u
- AccldenLal surglcal llgaLlon of Lhe C8u
- Þrlmary scleroslng cholanglLls
- Compresslon of Lhe common ducL by meLasLaLlc
cancer
- Callbladder cancer exLendlng Lo common blle
ducL








=*->/&3;3 -9 +?* .,/,&)0 +)**

- Cholanglocarclnoma
- ÞancreaLlc carclnoma
- Callbladder cancer
- Cancer of Lhe Ampulla of vaLer




#&+?-/-@0

lf blllary obsLrucLlon perslsLs, Lhere ls a rlsk LhaL Lhe sLaLlc
blle becomes lnfecLed, causlng acuLe cholanglLls and
evenLually llver abscesses. Lack of blle ln Lhe small
lnLesLlne compromlses Lhe absorpLlon of faL and faL-
soluble subsLances e.g. vlLamlns.


#)*3*'+&+,-'

- !aundlce
- Þale sLools
- uark urlne
- 8uC paln dependlng on cause


A'5*3+,@&+,-'3

- Abdomlnal uS may locaLe obsLrucLlon and show
cause
- L8CÞ, M8CÞ
- Ll1s show cholesLaLlc plcLure
o !!!ALÞ, !!!CC1, !AS1, !AL1
1PL uAnuLnCnC uCSSlL8 2010
210
!"#$ & '()*+
,*-(.(/(0. 123 45677(-(46/(0.7 0- 40.8(/(0.

non-alcohollc SLeaLohepaLlLls (nASP):
- 'laLLy llver' - faL deposlLlon wlLhln hepaLocyLes
- Absence of hlsLory of alcohollsm

lnsulln 8eslsLance Syndrome:
- MeLabollc sLaLe whlch may be a precursor Lo
12uM (carrles very hlgh rlsk of developlng
dlabeLes)
- AssoclaLed wlLh hyperLenslon, obeslLy,
dysplpldaemla, uM, and an elevaLed fasLlng
blood glucose.
- CompllcaLlons lnclude nASP, hyperferrlLlnaemla
and oLhers.

#6/90:9;7(050<;2#6/90<*.*7(7

PepaLlc sLeaLosls (nASP):
lL ls belleved LhaL dlsLurbance of Lhe normal llver process
of free faLLy acld upLake and converslon Lo 1Cs ls Lhe
cause of Lhe sLeaLosls. nonalcohollc faLLy llver dlsease
lncludes slmple hepaLlc sLeaLosls, whlle nASP lncludes Lhe
subsequenL developmenL of flbrosls and clrrhosls, whlch
occurs as a resulL of Lhe lnflammaLory response Lo Lhe
hepaLlc sLeaLosls.

Causes of nAlLu/nASP lnclude:
- lnsulln reslsLance (hyperlnsullnaemla):
- CbeslLy, 12uM
- urugs
- ClucocorLlcolds, oesLrogens, Lamoxlfen,
amlodarone
- nuLrlLlonal lssues
- SLarvaLlon, proLeln deflclency
- Llver ulsease
- Wllson dlsease, PepC, !e[unolleal bypass

=(7/050<;


AccumulaLlon of faL wlLhln Lhe hepaLocyLes
(macrovascular sLeaLosls).


1hls plcLure shows Lhe hepaLlc sLeaLosls buL also shows
LhaL Lhe archlLecLure of Lhe llver ls preserved (a cenLral
veln ls vlslble). ln real llfe, speclal sLalns whlch show
connecLlve Llssue are used on llver blopsy samples Lo
assess wheLher Lhe archlLecLure ls preserved.


Þerls SLaln - used Lo deLecL Lhe presence of lron ln a llver
Llssue sample (see below).

!"#$% '()*%"+," !-.$/"'0$1 2%*( /+1$

lnLerpreLaLlon of lron sLudles.
Þresence of le ln Lhe llver on blopsy ls always an
abnormal flndlng. lron can be found ln elLher Lhe
hepaLocyLes or Lhe macrophages.
- le ln macrophages ls lndlcaLlve of hlgh serum le due
Lo excesslve haemolysls (eg. ln Lhalassaemla).
- le ln hepaLocyLes ls normally due Lo a fallure of
normal le LransporL mechanlsms.
o ln con[uncLlon wlLh lncreased serum le, lncreased
Lransferrln saLuraLlon and geneLlc markers, Lhls
lndlcaLes haemochromaLosls.
o WlLh a normal serum le and Lransferrln saLuraLlon
buL wlLh hlgh ferrlLln, Lhls lndlcaLes a
hyperferrlLlnaemla, whlch can be due Lo alcohollsm
or lnsulln reslsLance.
1PL uAnuLnCnC uCSSlL8 2010
211
!"#$ & '()*+(,-./*0,()*+1+2
345+/+1+0/
ls an lnflammaLlon of Lhe lnner layer of Lhe hearL- Lhe
endocardlum.
1here are Lwo classes
1. lnfecLlous endocardlLls
2. non lnfecLlous endocardlLls

#(1607682+090:8-#(160:4/42+2
2 facLors are generally requlred for endocardlLls:
• A predlsposlng abnormallLy of Lhe endocardlum
• 8acLeraemla
Pave local and sysLemlc effecLs:

'()*+(, ;90,(9 4554,12<

-Myocardlal abscesses
-ConducLlon sysLem
abnormallLles
-valvular regurglLaLlon
!CCl
-CbsLrucLlng vegeLaLlon
-MycoLlc aneurysms

!8214=+, 4554,12
(Are prlmarlly due Lo
embollzaLlon and or
lmmune-complex)

-Þulmonary lnfarcLlon
-kldneys, spleen, and
CnS (from L slded
leslons)
-MycoLlc aneurysms ln
ma[or arLerles
-8eLlnal emboll !roLh's
spoLs
-ulffuse
glomerulonephrlLls!
lmmune complex
deposlLlon

>)022 7(16090:8 !


llgure1: aorLlc valve
uescrlpLlon: Lhls shows AorLlc valve 3 cusps -Lhey are
abnormal appear Lo be fused wlLh evldence of flbrosls and
calclflcaLlon conslsLenL wlLh degeneraLlve aorLlc valve
dlsease

?+21090:8

Lxcrescence on Lhe aorLlc valve (wlLh lnfecLlous
endocardlLls)
lL shows dlfferenL Lypes of cells: neuLrophlls w, flbroblasLs
(splndle shaped cells) and flbrln (whlch ls Lhe flbre llke
plnk long sLuff).

8rlef descrlpLlon of Lhe funcLlon of Lhe cells
• neuLrophlls: release chemoklnes
• llbrln: end producL of Lhe cloLLlng cascade.
• llbroblasL: repalrs and organlses Llssue


1hls ls an P&L sLaln of normal cardlac muscle n=nuclel, l
lnLercalaLed dlsc arrows shows cross Lrabecular.
1PL uAnuLnCnC uCSSlL8 2010
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!"#$ & '()*+,-./0*,1+(
2.34/4140/ 567 89,::4348,140/: 03 80/-4140/
;.0*9,:148
Þrlmary
Lymphoma
• Podgkln (8eed-SLernberg cells)
o Þalnless enlargemenL of lymph nodes and/or
8 symLoms, nodular lymphocyLe -
predomlnanL PL, spread Lo nodes, spleen,
llver
• non-hodgkln (8-cell, 1-cell)
o More ofLen exLranodal, MosL Lumours
wldely dlssemlnaLed aL ux, less ofLen wlLh 8
sympLoms, sLaglng less lmpL Lhan PL
AcuLe leukemla - lymphold neoplasms wlLh wldespread
lnvolvemenL of Lhe bone marrow, usually accompanled by
Lhe presence of large numbers of Lumour cells ln Lhe
perlpheral blood
Secondary
• 1yplcally from a carclnoma

;0/7/.0*9,:148
• lnfecLlon - 18, L8v, Loxoplasmosls, syphllls, Plv
• CLher - C1 dlseases, lnfllLraLlon (sarcoldosls,
amyloldosls), hemaLopoleLlc dlseases

<.,814=. *>08.:: ?41+4/ , /0-.
• lolllcles wlLh germlnal cells expand (8 lymphocyLe)
• Lxpanslon of paracorLlcal (1 cells - parLlcularly durlng
vlral lnfecLlons, such as lM)
• Lxpanslon of slnuses wlLh hlsLlocyLes (macrophages -
collecL nuclear debrls from Lurnover)
• Commonly a mlxed response Lo sLlmull

@>0:: *,1+090A(


8road bands of flbrous Llssue subdlvlde Lhe enlarged node
(ln nodular scleroslng PL)

B4:1090A(
B0-AC4/ 9()*+0),

'8eed-SLernberg cells: Large, ofLen bl-lobed & promlnenL
nuclel, heaps of cyLoplasm. Cn a b/g of reacLlve
lymphocyLes, eoslnophlls and granulocyLes
D))E/0*.>0F4-,:. G:1,4/: H>0?/I
Cells Surface AnLlgens
8 and 1 cells Cu43
1 cells Cu3 (all), Cu4/Cu8
8 cells Cu 20
nk cells Cu 16 and 36

!"#$% '()*%"+," !-.$/"'0$1 2%*( /+1$
'()*+ /0-. H40*:( -ofLen under C1 guldance
• Shows archlLecLural changes (eg lymphoma), Allows
deflnlLlve dx, used when Lhe dx ls unclear afLer oLher
lnvesLlgaLlons are done
'()*+ /0-. ,>8+41.81E>.
• CuLer corLex - folllcles
• lnner medulla - cords of plasma cells and slnuses LhaL
[oln up Lo become Lhe efferenL lymphaLlc
• ManLle zone - orlglnal prlmary folllcle 8-cells
• Cermlnal cenLre - 8-cell acLlvaLlon ln response Lo
anLlgenlc challenge
JE/8140/
• lllLers fluld
• SlLe where whlLe blood cell maLure


1PL uAnuLnCnC uCSSlL8 2010
213
!"#$ & '()* +,)-./
0.12)2324) 567 -8,99212-,324)9 41 -4):2324)
Lung carclnoma ls Lhe mallgnancy of Lhe resplraLory
eplLhellum. lor all pracLlcal purposes, lung cancers can be
dlvlded lnLo Lwo cllnlcal subgroups: small cell carclnoma
and non-small cell carclnoma, Lhough Lhere are four mosL
common hlsLologlcal Lypes.

#,3;4<;=92484*=6#,3;4*.).929
• Llke mosL oLher cancers, lung cancer develops Lhrough
a sLepwlse accumulaLlon of geneLlc abnormallLles LhaL
Lurn normal eplLhellum lnLo neoplasLlc Llssue. 1he
domlnanL oncogenes LhaL are commonly lnvolved are k-
8AS, LCl8 and c-M?C, and commonly lnacLlvaLed or
deleLed Lumour suppressor genes are p33, 88 and on
chromosome 3p.
• 1he maln carclnogen for lung cancer ls clgareLLe smoke.
• Squamous cell carclnoma has been shown Lo have a
llnear correlaLlon wlLh Lhe degree of exposure Lo
clgareLLe smoke.
• ClgareLLe smoke!eplLhellal changes !squamous
meLaplasla!squamous dysplasla!carclnoma ln
slLu!lnvaslve. Whlle noL documenLed as such abouL
oLher cell Lypes, lL ls LhoughL Lo be slmllar.
• AsbesLos, hlgh dose lonlslng radlaLlon and radon gas
have also been found Lo causaLlve agenLs ln lung ca.

>/499 <,3;484*=

1hls shows a prlmary bronchlogenlc neoplasm wlLh an
lnfllLraLlng margln and lL has grown a mass lnLo Lhe
bronchus.
neoplasms from meLasLases (below) would be well-
deflned, small and round. 1he leslons would also ofLen
presenL as numerous and dlffer from ad[acenL Llssue.

lor more lmages, check ouL
hLLp://llbrary.med.uLah.edu/WebÞaLh/LunCP1ML/LunCl
ux.hLml#9

?293484*=

A. Squamous - Closely relaLed Lo hlsLory of smoklng.
PlsLologlcally characLerlsed by presence of
keraLlnlzaLlon whlch may Lake Lhe form of squamous
pearls or slngle cells wlLh eoslnophlllc dense
cyLoplasm as seen ln lmage above. 1hough Lhese
feaLures are dlfflculL Lo see ln poorly dlfferenLlaLed
Lumours. MuLaLlons of p33 are found Lo be more
frequenL ln Lhls Lype Lhan Lhe oLhers.

8. !@,88 -.88 -,/-2)4@, wlLh areas of small
deeply basophlllc cells and areas of
necrosls.
A. Well-dlfferenLlaLed 9A(,@4(9 -.88
-,/-2)4@, showlng keraLlnlzaLlon.

1PL uAnuLnCnC uCSSlL8 2010
214
8. Small cell - eplLhellal cells are small (<resLlng
lymphocyLes), wlLh llLLle cyLoplasm, lll-deflned
borders, and absenL/unnoLlceable nucleoll. 1hey
grow ln clusLers LhaL dlsplay nelLher glandular nor
squamous organlzaLlon. necrosls ls common and
ofLen exLenslve. vascular walls may have basophlllc
sLalnlng due Lo coaLlng by unA from necroLlc Lumour
cells. Also has close relaLlonshlp Lo smoklng wlLh only
1° pLs belng non-smokers. MeLasLaslzes wldely
maklng lL pracLlcally lncurable wlLh surgery.

C. Adenocarclnoma - mosL common amongsL women
and non-smokers. Þoorly or well dlfferenLlaLed
glandular Llssue (lmage above ls well dlfferenLlaLed),
large nucleoll, mucln produclng. Can be furLher
classlfled by lLs varlous growLh paLLerns.
u. Large cell - large nuclel, large nucleoll, reasonable
amounL of cyLoplasm

!"#$%&%'( %* +,!-
• !"#$ ls deflned by alrflow llmlLaLlon whlch ls noL fully
reverslble.
• &'()*+,'-: characLerlzed by desLrucLlon and
enlargemenL of Lhe dlsLal porLlons of Lhe lung
(alveoll) resulLlng ln Lhe lung appearlng less spongy.
lL can be furLher classlfled lnLo cenLrlaclnar, whlch
lnvolves malnly upper lobes, and panaclnar, whlch
lnvolves all lung flelds, parLlcularly Lhe bases.
CenLrlaclnar ls more Lyplcal ln smokers where Lhere
ls loss of Lhe resplraLory bronchloles ln Lhe
proxlmal porLlon of Lhe aclnus, wlLh sparlng of
dlsLal alveoll. Þanaclnar emphysema occurs wlLh
loss of all porLlons of Lhe aclnus from bronchlole Lo
alveoll and ls Lyplcal for alpha-1-anLlLrypsln
deflclency.
• !)./012 3./02)141+: cllnlcally deflned by a
producLlve cough on mosL days over 3/12 for 2
consecuLlve years. 1hls ls a resulL of Lhe
hyperLrophy of Lhe mucus secreLlng glands of Lhe
bronchlal Lree and Lhe lncreased numbers of gobleL
cell lead Lo hypersecreLlon of mucus.



u. Clandular elemenLs characLerlsLlc of
-5,0/2-.210/'-
C. 6-.7, 2,88 2-.210/'-, feaLurlng
pleomorphlc, anaplasLlc Lumor cells and
lacklng squamous or glandular
dlfferenLlaLlon.
1PL uAnuLnCnC uCSSlL8 2010
213
!"#$ & '()*+,(*-)+.(/012-3.(4
5(6-.-)-+.
Adrenal Pyperplasla/neoplasm
7/89-.:;8 84.3*+0( *(<=)(3
1ype Cause
CorLlcal aLrophy Lxogenous glucocorLlcolds
- reduces sLlmulaLlon of
fasclculaLe and reLlcularls
-
ulffuse hyperplasla ulffusely Lhlckened and yellow
due Lo lncrease ln slze and
number of llpld -rlch cells
nodular
hyperplasla +/-
adenoma
?ellow surrounded by Lhln/well
developed capsule, welghlng
<30g.
>4,(*=<3+8)(*+.-80
uescrlpLlon SollLary, small (<2mm)
encapsulaLed leslons.
ConLaln splronolacLone bodles:
presence of eoslnophllclc
lamlaLed cyLoplasmlc lncluded
AdrenaocorLlcal adenoma
Colour ?ellow Lo yellow brown, due Lo
presence of llpld wlLhln Lhe
neoplasLlc cells

?(.-:. @8 A=<-:.=.) )/0+/*8

8enlgn MallgnanL
Slow growlng lasL
Low mlLoLlc acLlvlLy lasL
Cells resemble parenL cell varlable daughLer cells
normal nuclear
morphology
>4,(*B9*+0=)-BC
-**(:/<=* +/)<-.(C
0/<)-,<( ./B<(-C
,<(+0+*,9-B
no lnvaslon lnvaslon
8order ls well
clrcumclsed/
encapsulaLed
Þooly deflned, lrregular
border
necrosls ls rare Common Lo necroLlse
ulceraLlon ls rare Common on skln/
mucosal surfaces
LxophyLlc growLh LndophyLlc growLh
LffecLs
Þressure on ad[ Llssue
CbsLrucLlon
Pormone producLlon
1ransformaLlon lnLo
mallgnanL Lumour
LffecLs
Þressure+ desLrucLlon of
ad[ Llssue
MeLs
8lood loss from ulcers
CbsLrucLlon
ÞaraneoplasLlc effecLs






D*+88 ,=)9+<+:4



Adrenal corLlcal carclnoma
Creen parL: cenLral necrosls
8lack arrow: adrenal gland - ldenLlfy vla yellow corLex.

>-8)+<+:4



normal Adrenal corLex
- regularly clusLered and neaLly packeLed, surrounded
by vascular neLwork (slmllar paLLern Lo all endocrlne
organs).
- 8egular slzed cells and normal selze nuclel. Clear
cyLoplasm (due Lo presence of llpld conLenL whlch ls
found ln Lhe sLerold hormones)




Adrenal corLlcal carclnoma
Cells are more dlsorganlsed and does noL resemble cells
of adrenal corLex. Þleomorphlsm, and mlLoses (as shown
by green arrow) are seen.
1PL uAnuLnCnC uCSSlL8 2010
216




!"#$% '()*%"+," !-.$/"'0$1 2%*( /+1$
uux of Mass leslons ln reLroperlLoneal space

8enal cell carclnoma uroLhellal carclnoma of
renal pelvls
Abdomlnal aorLlc
aneurysms
SyphlllLlc aneurysm
AorLlc dlssecLlon Lymphold neoplasla
ConnecLlve Llssue
dlsorders e.g. llpoma,
flbrosarcoma eLc.


CLher endocrlne organs:
1hyrold 18P ! 1SP ! 13/14
Collold-fllled folllcles
llned by cuboldal
eplLhellal cells
Þancreas lsleLs of Langerhans
!cells: glucagon
" cells: lnsulln
1esLes LP ! Leydlg cells !
1esLosLerone
SerLoll cells: supporL cells
Cerm sLem cells on
semlnlferous eplLhellum
! produce sperm
ÞlLulLary/ PypoLhalamus 2 lobes
AnLerlor: AC1P, 1SP, CP,
Þ8, lSP, LP
ÞosLerlor: oxyLoxln, AuP,
Adrenals z. Clomerulosa:
AldosLerone
z. laslculaLa: CorLlsol
z. 8eLlcularls: Androgens

1PL uAnuLnCnC uCSSlL8 2010
217
!"#$ & '()
*+,-./! )'!01!0

)234546475 89: ;<=>>434;=6475> 73 ;75?46475
Crohn's ulsease ls a focal collLls/llelLls causlng
chronlc dlarrhoea,

#=6@7A@B>47<7CB9#=6@7C252>4>
Crohn's ulsease ls characLerlsed by chronlc Lransmural
granulomaLous lnflammaLlon caused by lnapproprlaLe
acLlvaLlon of Lhe lnnaLe lmmune sysLem by normal guL
flora

lnlLlally medlaLed by neuLrophlls wlLh subsequenL 1-
cell acLlvaLlon and cyLoklne release

DE7>> A=6@7<7CB


Leslons are focal and lsolaLed areas of severe Lransmural
lnflammaLlon (sklp leslons)

Leslons are posslble LhroughouL Lhe Cl LracL, however
Lhe llleo-coecal [uncLlon and colon are mosL
commonly affecLed. MulLlple slLes may be lnvolved
slmulLaneously.

1he recLum ls usually spared, compared wlLh uC

8eglons spared by Lhe dlsease are paLhologlcally
normal
Leslons are characLerlsed by flssures exLendlng Lhrough
Lhe full Lhlckness of Lhe mucosa wlLh mucosal sparlng ln
beLween - 'CobblesLone appearance'.

Larly sLage dlsease appears as lsolaLed apLhous ulcers.
llssures develop beLween Lhese leslons.

SubsequenL swelllng and flbrosls leads Lo narrowlng of
Lhe lnLesLlnal lumen

CbsLrucLlon, sLrlcLures or flsLula formaLlon may resulL










-4>67<7CB


Crohn's ulsease appears as a Lransmural lymphocyLlc
lnfllLraLlon affecLlng all layers of Lhe bowel

Mucosal crypLs demonsLraLe aLrophy, ofLen wlLh
superflclal ulceraLlon vlslble. Powever Lhe normal
hlsLologlcal sLrucLure of Lhe bowel wall ls preserved.

AlLhough lymphocyLlc granulomas are paLhognomonlc
of Lhe dlsease Lhese are rarely seen on blopsy. A
dlffuse lymphocyLlc aggregaLe ls almosL always seen.

no paLhologlcal changes are vlslble ln spared mucosa
FG*0+1H'I0 *,G'H'!

)234546475 89: ;<=>>434;=6475> 73 ;75?46475
ulceraLlve CollLls ls a lnflammaLory collLls always sLarLlng
ln Lhe recLum and exLendlng proxlmally as Lhe dlsease
progresses

#=6@7A@B>47<7CB9#=6@7C252>4>
uC ls predomlnanLly a dlsease of Lhe large bowel

Caused by an abnormal acLlvaLlon of Lhe lnnaLe and
adapLlve lmmune sysLem by normal guL flora.

Slmllar paLhogenesls Lo Crohn's ulsease

!"" $%&"'&"( )*+",'-%." /0*%-%&

DE7>> A=6@7<7CB

1PL uAnuLnCnC uCSSlL8 2010
218
Macroscoplcally uC appears as a conLlnuous superflclal
ulceraLlon and eroslon of Lhe colonlc mucosa.

ulsease sLarLs as procLlLls and exLends conLlnuously

1he affecLed mucosal surface ls oedemaLous and
feaLures blood and mucous dlscharge

Þseudopolyps - ouLgrowLhs of mucosal Llssue - form as
Lhe mucosa aLLempLs Lo regeneraLe
! 8eware as Lhese may resemble Lhe mucosal
sparlng ln Crohns





!"#$%&%'(
















ulceraLlve collLls ls usually llmlLed Lo Lhe mucosa. ulsease
rarely progresses deeper Lhan Lhe superflclal submucosa
even ln fulmlnanL dlsease.

normal crypL archlLecLure ls dlsrupLed. CrypLs may
become shallower or blfld, wlLh evenLual abscess
formaLlon or loss of all crypL sLrucLure.

Lymphold and plasma cell aggregaLes are presenL
around Lhe basal membrane. 1he superflclal mucosa
demonsLraLes a neuLrophlllc lnfllLraLlon.
Mucosal congesLlon, oedema and haemorrhage ls
common

!"# %&'%#'(') %(**+#, -./.
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6>C3A<2C8=89X

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O7399 3? A32=8A346C@77<2B _@>A=83>
O36C64<! 9S6778>; 3? A32=6QE
1PL uAnuLnCnC uCSSlL8 2010
220
-early breakdown of Llssue vlslble: loss of myelln
-sharp [uncLlon beLween normal +no blood flow

llver meLasLases: characLerlsLlcs of meLs= round, mulLlple,
encapsulaLed, dlfferenL Lo surroundlng Llssue, under 2cm.


!"# %&'%#'(') %(**+#, -./.
--/
!"#$ & #'()*+ ,-+'. /*0'10'

*00 *-12
1PL uAnuLnCnC uCSSlL8 2010
222
!"#"$ & '()*+,-
./0,1,2,+1 345 67899,0,682,+19 +0 6+1-,2,+1
! ueflned dlscreLe mass, separaLed from Lhe
Lhyrold parenchyma.
LLlology
! 8enlgn Lumours(e.g folllcular adenoma)
! 1hyrold mallgnancy
! Pyperplasla area ln a mulLlnodular golLre
! CysL
lnvesLlgaLlon
! 1l1s
! lnA
! 1hyrold scan
o 13-20° of cold nodules are
mallgnanL,very low mallgnanL poLenLlal
lf warm or hoL
lolllcular adenoma
ConslsL of a solld mass wlLhln a flbrous capsule and
cenLral areas may show haemorrhage or cysLlc changes.



1hyrold mallgnancy
8lsk facLors
o Pead/neck lrradlaLlon esp durlng chlldhood
o lamlly hlsLory(medullary carclonoma)
o 8apld growLh growLh
o CnseL<30 yrs
o Male gender
o Cervlcal LAu
o Þpl havlng hashlmoLo's

ClasslflcaLlon

Þaplllary carclnoma (30-70°)
" AffecL young people
" Well dlfferenLlaLed and lnduced by radlaLlon
" MulLlcenLrlc , some folllcular componenLs
hlsLologlcal.
Cross paLhology
lL wlll show an encapsulaLed lnfllLraLlve mass
whlch may be flrm and whlLe due Lo flbrosls.



PlsLology
lL conslsLs of paplllary pro[ecLlons beLween whlch
calclfled spherules (psammoma bodles) may be
presenL.
1he eplLhellal cell nuclel have cenLral large clear
areas.
" MeLasLaslzes Lo reglonal lymph nodes flrsL
" Llfespan noL affecLed lf conflned Lo one lobe and
<2cm
" 8emember Lhe Þs: Þaplllary, Þopular,
Þsammoma, Þalpable nodes, ÞoslLlve Þrognosls,
ÞoslLlve radlo-lodlne upLake

lolllcular Carclnoma(10-13°)
" Well-dlfferenLlaLed buL more aggresslve Lhan
paplllary.
" PlsLology reveals lnvaslon of Lhe capsule, blood
vessels or Lhe surroundlng gland.


" 1ends Lo be anglolnvaslve,spreadlng Lo lung,
bones and dlsLanL slLes wlLhouL lymph node
lnvolvemenL
" lmporLaLanL prognosLlc facLor ls lnvaslon,noL
prlmary Lumour slze
" PurLle cell cancer:aggresslve varlanL of folllcular
cancer,frequenL pulmonary meLasLases
" 8emember Lhe ls: lolllcular,lar away
meLs(blood), lemale, lnA blopsy noL dlagnosLlc,
lavourable prognosls

AnaplasLlc carclnoma(10°)
" AffecL elderly paLlenLs
" undlfferenLlaLed and presenL as dlffuse
lnfllLraLlve mass.
PlsLology
" lL has splndle and glanL cells


" Þoor prognosls due Lo loval lnvaslon of sLrucLures
llke Lrachea.

Medullary carclnoma(1-2°)
" AssoclaLed wlLh MulLlple endocrlne
neoplsla(MLn).
" Worse prognosls Lhan paplllary and folllcular
cancer
PlsLology
Composed of sheeLs of neoplasLlc cells wlLh beLween
Lhem, a hyallne sLroma wlLh Lhe sLalnlng reacLlon of
amylold:due Lo polymerlsaLlon of calclLonln lnLo a
beLa-pleaLed sheeL.
1PL uAnuLnCnC uCSSlL8 2010
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! 8emember Lhe MS:
Medullary,MLn,aMylold,medlan node dlssecLlon
Lymphoma(<1°)
! Seen ln paLlenLs wlLh enlarged golLre as a resulL
of PashlmoLo's.

1reaLmenL
" LobecLomy for small well dlfferenLlaLed paplllary
carclnoma.
" 1hyroldecLomy
" nodular resecLlon


1PL uAnuLnCnC uCSSlL8 2010
224
!"#"" % &&'()*+,-./-0.0
123.4.5.-4 6(7 8,900.3.895.-40 -3 8-4/.5.-4
Amyloldosls ls Lhe deposlLlon of amylold proLelns ln
ln organs, beLween flbres and around vessels.

Classlfled accordlng Lo Lhe muLaLlon of Lhe proLeln
C8
Locallsed vs. SysLemlc

#95:-;:+0.-,-<+(#95:-<2420.0
Amylold ls when proLelns undergo sLrucLural change
LhaL lncreases Lhe beLa-sheeL conLenL.

Many proteins can undergo change to become
amyloidogenic or can be synthesised with an
amyloid mutation.

=>-00 ;95:-,-<+
)*+,-./-0.0 -3 5:2 :29>5

Wall is thickened however the muscles layer is
not hypertrophied

?@&A

AsymmeLrlcal venLrlcular hyperLrophy - Lhe wall
ls Lhlckened due Lo myocardlal hyperLrophy



?.05-,-<+
Pow Lo see amylold
1. Congo red sLaln

2. 8lfrlngence (appears apple green and
blfrlngenL)

*Amylold appears plnk under an P&L sLaln

&9B020 -3 89>/.-*+-;95:+
• Pyper/hypoLhyroldlsm
• PemochromaLosls

CardlomyopaLhy due Lo lron overload from
hemochromaLosls



1PL uAnuLnCnC uCSSlL8 2010
223
!"#"$ & '()*+,)-.*/
0(1232.2,3
nephrlLls characLerlzed by lnflammaLlon of Lhe caplllary
loops ln Lhe glomerull of Lhe kldney

45-662127-.2,3
• 021186(! affecLlng > 30° of Lhe glomerull
• 9,7-5! affecLlng < 30° of Lhe glomerull
• :5,;-5! affecLlng Lhe whole glomerulus
• !(<=(3.-5! affecLlng parL of Lhe glomerulus
+/-
• #+,521(+-.2>(: ^ no. cells ln glomerulus
• ?(=;+-3,86 7*-3<(! perlpheral loops are Lhlckened
due Lo 8M expanslon
• ?(=;+-3,@)+,521(+-.2>(A a comblnaLlon of Lhe Lwo
precedlng feaLures, ofLen wlLh accenLuaLlon of Lhe
lobular archlLecLure
• 4+(67(3.27! prollferaLlon of cells lncludlng macrophages
llnlng 8owman's capsule, ofLen compresslng Lhe
glomerulus

',+=-5 :5,=(+8586
:+,66 #-.*,5,</

• lnflammaLlon
• lnLersLlLlal flbrosls
• Þoor demarcaLlon beLween corLex and medulla
due Lo sclerosls
• ALrophy of Lhe Lubules
• Sclerosls of Lhe arLerles




B26.,5,</
!"##$%& ()*+"#&),-".& /+*0&)$+*1&(2)"-"%
3/ 4*%-5%-)&( 67

• Pypercellular - cellular prollferaLlon + acuLe
lnflammaLory cell lnfllLraLlon !lmmune complex
deposlLlon

8)&%&1-&)"9 67 : ;"/1"#"&% ),("<+= ()*/)&%%"1/ 67 >?467@

• Partially necrotic glomerulus with an
exuberant crescent

#-.*,)*/62,5,</C#-.*,<(3(626
ºSee ClomerulonephrlLls ulsease Summary"

A-2&) "0(*)-,1-
ABC&9-".&% #)*0 9,%&

LlecLron mlcroscopy ls an
lmporLanL sLudy Lo
vlsuallse renal Llssue.
lL shows accuraLely Lhe
fllLraLlon barrler (8M,
podocyLes, fenesLraLed
endoLhellum) whlch
largely deLermlnes Lhe
funcLlonal fllLraLlon of Lhe
glomerulus.

!"# %&'%#'(') %(**+#, -./.
--0

!"#"$ & '()
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1PL uAnuLnCnC uCSSlL8 2010
227
!"#"$ & '()*+*,-#+.)*)+/010/-2),/1(340,
56,70/
83904010+4 :-; <.,//090<,10+4/ +9 <+4=010+4
1umour of Lhe eplLhellal cells ln Lhe Lhymus.
SLaged accordlng Lo Lhe Masaoka sLaglng sysLem,
wlLh poorer prognosls assoclaLed wlLh belng more
lnvaslve/presence of meLasLases. Can also be
classed ln Lerms of hlsLology -









#,1(+>()
/0+.+?)-#
,1(+?343/0/
• 1hymus composed of eplLhellal and sLromal
cells, whlch are dlvlded lnLo a corLex (83°
lymphold cells) and medulla (remalnlng 13°)
• MosL lmporLanL prognosLlc feaLure ls lnvaslve
(abouL 33°) vs non-lnvaslve (raLher Lhan
benlgn vs mallgnanL)
• lound ln 13° paLlenLs wlLh myasLhenla gravls

56+// >,1(+.+?)

1he bands of connecLlve Llssue can be seen. 1he
Lumour Llssue has a fleshy appearance whlch
correlaLes wlLh Lhe lymphold componenL. lL
appears encapsulaLed and well clrcumscrlbed.

@0/1+.+?)

Shows neoplasLlc eplLhellal cells and lymphocyLes

!"#$% '()*%"+," *-.$/"'0$1 2%*( /+1$
Causes of a medlasLlnal mass
AnLerlor 1hymoma
Lymphoma
Cerm cell neoplasm
SubsLernal Lhyrold Lumours
Mlddle LymphadenopaLhy
AorLlc arch aneurysm
8ronchogenlc cysL
PlaLus hernla
ÞosLerlor neurogenlc Lumour
uescendlng aorLlc aneurysm
Cesophageal Lumour

ÞaraneoplasLlc syndrome
• A dlsease of sympLom LhaL ls a
consequence of Lhe presence of cancer,
buL ls noL due Lo Lhe local presence of
cancer cells
• MedlaLed by hormones, cyLoklnes (boLh
excreLed by Lumour) or Lhe body's
lmmune response
• ? flrsL presenLaLlon of mallgnancy
• Common ln lung, breasL, ovarlan cancers
and lymphoma
• ulvlded lnLo 4 caLegorles: endocrlne,
haemaLologlcal, neurologlc,
mucocuLaneous
8esL
Þrognosls
WorsL
Þrognosls
1PL uAnuLnCnC uCSSlL8 2010
228
!"#$%$"&'('&
*+,-.-/-0.
ldlopaLhlc auLolmmune dlsease characLerlzed prlmarlly by
lnflammaLlon of muscles wlLhouL dermaLlLls

!1/203245-060748!1/207+.+5-5
• Cu8 1 cells lnvade Lhe fasclcles (perlmyslal) !
necrosls
• MPC-1 expresslon on affecLed cells ! muscle
damage (? mechanlsm)
• varled sLages of necrosls: areas of muscle damage
and regeneraLlon
• lnfllLraLlve 1 cells de-granulaLe ! enzyme release !
muscle damage
• ln severe dlsease, muscle flbres wlll be replaced by
connecLlve Llssue/faL

&- 1.9 5:
• SymmeLrlcal progresslve muscle weakness - sparlng
of ocular muscles
• !olnL paln
• uysphagla
• laLlgue
• WelghL loss

':
• 8alsed serum Ck
• ÞoslLlve AnA
• AnLl-!o anLlbodles presenL
• Muscle blopsy

;-5/06074

Lndomyslal lymphocyLe lnfllLraLe
necroLlc muscle flbre


%$<&(;=>'< ?@<A'&
*+,-.-/-0.
AuLolmmune dlsorder caused by a Lype ll hypersenslLlvlLy
reacLlon ! generallsed weakness, pLosls, dlplopla, and
paralysls.

!1/203245-06074831/207+.+5-5
• AuLoanLlbodles block Ach recepLor (LargeL anLlgen),
whlch a) degrades recepLors and b) prevenLs Ach
blndlng

*:
• CharacLerlsLlc Px
• Lx: weakness, Lhough reflexes and sensaLlon normal
• Serum anLl-Ach recepLor anLlbodles
• LMC

;-5/06074

A normal nM!


nM! ln myasLhenla - reduced number of recepLors,
flaLLened, slmpllfled posL-synapLlc folds, wldened synapLlc
space

!"# %&'%#'(') %(**+#, -./.
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7=:4@ :2@34:97 9725:9 ;< 8:E:3;F?:67
• !=49 @:9D379 46 7A; 849:29: F@;B:99:9
! G@;8DB74;6 ;< 6;@?23 >3;;8 B:339 ?2@H:83C
8:B@:29:9
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7=@;?>;BC7;F:642 268 6:D7@;F:642
! ,2F48 F@;34<:@274;6 ;< 7=:9: 4??27D@: B:339
268 @:8DB74;6 46 2F;F7;949
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9F3::6





$('#%)%*&



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CB8=>DE>F>E67 G>: ".)

1PL uAnuLnCnC uCSSlL8 2010
230
!"#"$ & '()
*+,-.-/-0.
AcuLe myelold leukaemlas are neoplasLlc LransformaLlons
whlch occur ln a mulLl-poLenLlal sLem cell or ln one of
resLrlcLed llneage poLenLlal. 8ecause Lhe mulLl-poLenLlal
haemopoleLlc sLem cell glves rlse Lo granulocyLes,
eryLhrocyLes and megakaryocyLes, any or all of Lhese cell
llneages may be affecLed ln a speclflc case of acuLe
myelold leukaemla (AML).

123 45677-,-86/-0.

1. AML wlLh recurrenL geneLlc abnormallLles (lncludlng
L(8,12), L(13,17), deleLlon 11q and lnverslon 16)
2. AML wlLh muLlllneage dysplasla
3. AML, Lherapy relaLed (lncludlng followlng exposure Lo
alkylaLlng agenLs or Lopolsomerase ll lnhlblLors)
4. AML noL oLherwlse caLegorlsed (lncludlng cases of
some myelold, monocyLlc, eryLhrold or
megakaryocyLlc dlfferanLlon).

#6/90:9;7-050<;=#6/90<+.+7-7
1he mallgnanL cell ln AML ls Lhe myeloblasL. ln normal
hemaLopolesls, Lhe myeloblasL ls an lmmaLure precursor
of myelold whlLe blood cells, a normal myeloblasL wlll
gradually develop lnLo a maLure whlLe blood cell.
Powever, ln AML, a slngle myeloblasL accumulaLes
geneLlc changes whlch "freeze" Lhe cell ln lLs lmmaLure
sLaLe and prevenL dlfferenLlaLlon. 1he neoplasLlc clone
falls Lo maLure beyond a blasL cell sLage, leadlng Lo
progresslve accumulaLlon of myeloblasLs ln Lhe bone
marrow. 1hese myeloblasLs are Lhen shunLed lnLo Lhe
blood sLream.

4+557 0, /9+ >0.+ ?6@@0A




2-7/050<;
#+@-:9+@65 >500B ,-5? 790A-.< 896@68/+@-7/-8 >567/ 8+557.
1he arrow polnLs Lo Lhe abnormal blasL cell.


C0.+ ?6@@0A 67:-@6/+ 790A-.< 68D/+ ?;+50-B 5+DE+?-6.
Arrows lndlcaLe Auer rods

"#$%&'()%* +,-. &/*%
• !"#$%" '(" )!*+"%%"% *, '(!*-.*%$%/ "-.*0$%-/
$1,2!+'$*1/ -$+!*213$*)2'($+ (2"-*04'$+
212"-$25
• 6$%+7%% '(" #207" *, '(" 27'*)%45
• "#2072'" '(" +0$1$+*8)2'(*0*3$+ +*!!"02'$*1 *, '("
$--71*%7))!"%%"6 (*%'5
• 6$%+7%% '(" )2'(*3"1"%$% *, 3!2,' #"!%7% (*%'
6$%"2%"5
• 6",$1" 2' 21 $1'!*67+'*!4 0"#"0/ 2+7'" 9-4"0*$6:
0"7;2"-$25
• "<)02$1 2' 21 $1'!*67+'*!4 0"#"0 .*1" -2!!*=
'!21%)021'2'$*1>

!"# %&'%#'(') %(**+#, -./.
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*11 23456178 %17946:;:<=
1PL uAnuLnCnC uCSSlL8 2010
232
S2Þ2 - Atherosc|eros|s
Def|n|t|on +]- c|ass|f|cat|ons of cond|t|on
ALherosclerosls ls Lhe chronlc bulld-up of llpld laden
plaque ln large Lo medlum slzed arLerlal blood vessels

Þathophys|o|ogy]Þathogenes|s
lnlLlal plaque formaLlon beglns wlLh endothe||a| |n[ury,
whlch allows llpld peneLraLlon and accumulaLlon beLween
Lhe Lunlca lnLlma (endoLhellum) and Lunlca medla
(muscle)Cnce beLween Lhe layers, Lhese faLs blnd Lo Lhe
exLracellular maLrlx and may oxldlse.
o Smoklng and dlabeLes are ma[or causes of chronlc
endoLhellal ln[ury
o Some lnfecLlons such as Perpes and Chlamydla can
also cause vascular ln[ury
o PypercholesLerolaemla, alcohol are slgnlflcanL rlsk
facLors as Lhey lncrease Lhe number of clrculaLlng
LuL llpoproLelns
o Þlaques are more prevalenL aL polnLs of LurbulenL
flow, such as branchlng polnLs
1hls process can occur very early ln llfe, and appears as
yellow 'fatty streaks' on Lhe endoLhellal surface
As Lhe faLLy sLreaks geL larger Lhey aLLracL an lmmune
response. Macrophages, 1 cells and masL cells accumulaLe
ln Lhe sublnLlma
Macrophages endocyLose some of Lhese faL molecules,
formlng foam cells. MedlaLors released from Lhese cells
leads Lo furLher lmmune cell accumulaLlon
ln normal physlology, Lhls process funcLlons Lo remove
any llpld plaque whlch accumulaLes. ulsease occurs when
Lhe accumulaLlon of llpld excedes Lhe body's ablllLy Lo
remove lL.
Lxcesslve faLLy conLenL of larger aLheromaLous plaques
effecLlvely kllls macrophages and forms a necrot|c ||p|d
core, causlng proLruslon of Lhe vessel wall - 'plaques'
ln advanced plaques Lhe llpld core ls colonlsed by
flbrous Llssue and smooLh muscle prollferaLlon ln an
aLLempL aL remodelllng Lhe leslon.
1hls forms a f|brous cap Lo sLablllse Lhe plaque.
Anglogenesls can occur lnLo Lhe plaque lLself, someLlmes
leadlng Lo haemorrhage lnLo Lhe plaque lLself
CalclflcaLlon ls common ln chronlc aLheromaLous
plaques
Gross patho|ogy
ArLheroscleroLlc plaques
are vlslble on Lhe lnLlmal
surface of ma[or vessels as
yellow lrregularlLles,
focally affecLlng Lhe
branchlng polnLs. Also
observe any evldence of
compllcaLlon -
lnLerrupLlon of Lhe lnLlmal
layer or Lhrombus
formaLlon
n|sto|ogy
PlsLologlcally,
aLherosclerosls appears as
a clear Lhlckenlng of Lhe
Lunlca lnLlma

llbroLlc Llssue ls ofLen
evldenL wlLhln Lhe
llghLer llpld core, and
blood vessels can be
demonsLraLed ln
advanced dlsease

CalclflcaLlon appears as large, lrregular leslons wlLhln
Lhe leslon

1hrombl may also appear on hlsLologlcal secLlon

!"#$% '()*%"+," !-.$/"'0$1 2%*( /+1$
lL ls asympLomaLlc ln lLself, however lL ls a ma[or rlsk
facLor ln Lhromboembollc evenLs and oLher vascular
paLhology.

1reaLmenL requlres modlflcaLlon of Lhe rlsk facLors for
aLherosclerosls

LlfesLyle modlflcaLlon ls essenLlal - sLop smoklng, dleL
modlflcaLlon, exerclse, wleghL loss

1he malnsLay of aLherosclerosls LreaLmenL ls SLaLlns
(PMC CoA reducLase lnhlblLors)
o lnhlblLs cholesLerol synLhesls ln Lhe llver, hence
reduclng LuL synLhesls
o ln addlLlon have also been shown Lo sLablllse
aLheroscleroLlc plaques and proLecL from
endoLhellal ln[ury (mechanlsm unknown).
o ulLlmaLely dramaLlcally reduces Lhe lncldence of all
aLheromaLous vascular evenLs, !"!#$ &# '($&!#$)
*&$+ #,-.(/ 0+,/!)$!-,/ /!"!/).

ConLrol of blood pressure and dlabeLes ls beneflclal
ln reduclng subsequenL vascular evenLs

CompllcaLlons of aLherosclerosls:

Þlaque rupLure (CompllcaLed plaque)
o 1hls commonly causes acuLe occluslon or sLenosls,
parLlcularly ln smaller vessels (le coronary arLerles)
o 1hromboembollc evenLs may also occur, leadlng Lo
occluslon down-sLream of Lhe plaque
o Paemorrhage lnLo Lhe plaque lLself, causlng Lhe
enlargemenL of Lhe plaque wlLhouL Lhrombosls ln
Lhe affecLed vessel

uecreased vessel wall compllance
o Leads Lo an lncrease ln blood pressure
o lncreases Lhe rlsk of aneurlsms as Lhe wall ls
weakened

vessel sLenosls
o Around 73° occluslon ls requlred before
sympLoms are evldenL - anglna, 1lAs or
claudlcaLlon

!"# %&'%#'(') %(**+#, -./.
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*11 234567 8599:3;5;
1PL uAnuLnCnC uCSSlL8 2010
234
!"#$ & '() *+,-./
01/2+3 4,+5126 17 58. !512+-8
ÞlcLure above: normal appearance of Lhe sLomach whlch
has been opened along
Lhe greaLer curvaLure.
Lsophagus ls on Lhe lefL. ln
Lhe fundus can be seen
Lhe lesser curvaLure. !usL
beyond Lhe anLrum ls Lhe
pylorus empLylng lnLo Lhe
flrsL porLlon of duodenum
aL Lhe lower rlghL.
noLe Lhe ruggae are
presenL LhroughouL.

9:;5131<6=
CasLrlc ÞlLs: Small sunken
glands LhaL exLend Lo
Lamlna proprla













Above: normal hlsLology of sLomach
Layers of Lhe sLomach:
• Mucosa (mucous secreLlng eplLhellum, glands,
lamlna proprla
• Muscularls Mucosae
• Submucosa
• Muscularls Þroprla
• Serosa
>>? 71/ '+;5/:- @A53.5 @B;5/A-5:1, :, 4CA35;
67° of CasLrlc ouLleL obsLrucLlon are mallgnanL causes
(gasLrlc carclnoma, pancreaLlc, ampullary, duodenal,
meLs)
uux:
• Þuu (duodenal or gasLrlc)
o AcuLely - due Lo lnflammaLlon
o Chronlcally - scarrlng/flbrosls
• CasLrlc Þolyps
• CallsLone
• ÞancreaLlc ÞseudocysLs
• non-mechanlcal causes eg: dlabeLlc
gasLroparesls


9:;5131<:-+3 4DD.+/+,-. 17 9E #631/:

1hls small curved Lo splral rod-shaped bacLerlum ls found
ln Lhe surface eplLhellal mucus of mosL paLlenLs wlLh
acLlve gasLrlLls. 1he rods are seen here wlLh a meLhylene
blue sLaln.
1PL uAnuLnCnC uCSSlL8 2010
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D|sease: Þept|c U|cer
Þoss|b|e Symptoms
Abdo paln, bloaLlng, waLerbrash, nausea,
vomlLlng, loss of appeLlLe, hemaLemesls,
maleana

Causes]Þathophys|o|ogy
• MosL common causes: P.Þylorl, nSAlu use
• Can have benlgn and mallgnanL ulcers,
essenLlal Lo blopsy Lo deLermlne lf
mallgnanL
• 8enlgn: due Lo lmbalance beLween pepsln
secreLlon and gasLrlc mucosal defences.
usually assoclaLed wlLh P.Þylorl gasLrlLls
• !"#$%$&"'& )*$&#%&%$ *#+,'- *' ,./"# 0*1
,'-"#)+ 0"&*2.*$&%/ ! -1$2.*$&%/ /3*')"
&+ 4+#0 * /*#/%'+0*
• A mallgnanL ulcer ls generally an
Adenocarclnoma (wlLh ulceraLlon). See below

Comp||cat|ons
• ÞerforaLlon
• 8leedlng and PaemeLemesls lf ulcer lnvades 8v
• CasLrlc ouLleL obsLrucLlon
• SympLoms relaLlng Lo peneLraLlng Lo oLher organs

Gross Þatho|ogy 1 - U|cer
Above ÞlcLure: A 1 cm acuLe gasLrlc ulcer ls shown here ln
Lhe upper fundus. 1he ulcer ls shallow and sharply
demarcaLed, wlLh surroundlng hyperemla. lL ls probably
benlgn. Powever, all gasLrlc ulcers should be blopsled Lo
rule ouL a mallgnancy.

n|sto|ogy
ÞlcLure Above: Mlcroscoplcally, Lhe ulcer here ls sharply
demarcaLed, wlLh normal gasLrlc mucosa on Lhe lefL
falllng away lnLo a deep ulcer whose base conLalns
lnflamed, necroLlc debrls. An arLerlal branch aL Lhe ulcer
base ls eroded and bleedlng.

Gross Þatho|ogy 2 - 1ransverse sect|on through
U|cer and under|y|ng t|ssue
1he speclmen shows a 1.S cm u|cer ln Lhe anLrum of Lhe
sLomach. 1he edges of Lhe ulcer show Lhe gasLrlc mucosa
conLracLlng lnLo lL. 1he base of Lhe ulcer appears red and
sllghLly granular and appears Lo have eroded Lhrough Lhe
sLomach wall Lo Lhe level of Lhe deep muscularls proprla.
Deep to the base of Lhe ulcer Lhere are conLracLed whlLe
bands of Llssue LhaL exLend Lo Lhe level of Lhe serosa of
Lhe sLomach. 1here ls no heaplng up of Lhe mucosa
ad[acenL Lhe ulcer. 1here ls no evldence of perforaLlon of
Lhe ulcer. no promlnenL and exposed blood vessel ls seen
ln Lhe ulcer base.

1PL uAnuLnCnC uCSSlL8 2010
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!"#$%#$& (%#)*"+ ,-$./+%*+"./0%
1203)/0#
CfLen asympLomaLlc, maybe lndlgesLlon, loss of
appeLlLe
LaLe sLage: Þaln, nausea vomlLlng, dysphagla, bloaLlng
eLc.. And slgns relaLlng Lo meLasLases

423$#
56 !"778#$ (%#)*"+ 9%.+$*: Þoorly dlfferenLlaLed.
lndlvldual cells lnfllLraLe lnLo sLomach wall causlng
Lhlckenlng of Lhe wall (llnlLls plasLlca) wlLhouL formlng
a dlsLlncL mass.
- Cross feaLures: LeaLher boLLle appearance (llnlLls
plasLlca), Lhlckenlng of mucosal wall, loss of ruggae
- PlsLologlcal feaLures: SlgneL rlng cells (full of mucous
wlLh nuclel pushed Lo slde)

:6 ;.)$#)".%< (%#)*"+ 9%.+$* (le locallsed): Lends Lo grow
ouLwards and ofLen are ulceraLlng. MallgnanL CasLrlc
ulcer.
AssoclaLed wlLh lnLesLlnal meLaplasla and P.Þylorl. More
llkely ln dlsLal sLomach.
- Cross feaLures: usually normal ruggae surroundlng. Area
of Lhlckenlng, whlLe, lnfllLraLlng Llssue. Þoorly deflned eLc,
spread beyond mucosa.
- PlsLologlcal feaLures: As wlLh oLher cancers,
pleomorphlsm eLc eLc eLc eLc

=whllsL noL an adenocarclnoma, you musL always
conslder <203>/0% of Lhe sLomach (usually MAL1).
1hls appears slmllarly Lo Lhe dlffuse Lype.

?%)>/3>2#"/</@2
!" $%&'() ls Lhe maln rlsk facLor ln 63-80° of
gasLrlc cancers, buL only 2° of such lnfecLlons
progress Lo cancer.

13*$%- (and in brackets how they may present)
• Local spread lnLo Lhe wall of Lhe sLomach
(anorexla, welghL loss, vague eplgasLrlc paln,
vomlLlng, and dysphagla.)
• LymphaLlcs (Supraclavlcular lymph node
enlargemenL)
• 1ranscoelomlc (enlarged ovarles/recLal shelf on
palpaLlon, asclLes)
• PaemaLogenous/MeLasLases (hepaLomegaly, [aundlce
,back paln)

"#$%&'()*(+,' -.#)$/ ,% +(#) /)0$,*1
1umour spreads Lhrough full Lhlckness of sLomach wall,
Lhrough perlLoneum lnLo perlLoneal space. 1umour cells
seed lnLo perlLoneal fluld ! AsclLes. CLher perlLoneal
surfaces, eg Serosa of Cvarles, are llkely slLes of
meLasLases.

(*/## ?%)> 5& !"778#$ ,-$./+%*+"./0%
ÞhoLo Above: ÞarLlally resecLed sLomach lncorporaLlng
Lhe body and anLrum wlLh aLLached greaLer omenLum.
normal rugae are losL and an lrregular smooLh Lo nodular
surface ls vlslble. 1he mucosa and submucosa parLlcularly
appear Lhlckened dlffusely by a whlLe Llssue. Shrunken
'LeaLher boLLle' appearance.
MosL llkely: Lymphoma, or ulffuse/Þoorly dlfferenLlaLed
gasLrlc Lumour. Lymphoma ls generally llLLle more
locallsed and more fleshy.

(*/## ?%)> :& A%<"@.%.) (%#)*"+ B<+$*

Pere ls a gasLrlc ulcer ln Lhe cenLer of Lhe plcLure. lL ls
shallow and ls abouL 2 Lo 4 cm ln slze. 1hls ulcer on blopsy
proved Lo be mallgnanL, so Lhe sLomach was resecLed as
shown here.

C"#)/</@2
noL speclflcally covered ln case

1PL uAnuLnCnC uCSSlL8 2010
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!"#$ & !'()*+,-./ 012345
637()(.(,)
Croup of dlseases caused by auLoreacLlve anLlbodles Lo
consLlLuenLs of Lhe eplLhellum or basemenL membrane.

81955(7(29.(,)
8llsLerlng dlsorders are classlfled accordlng Lo Lhe
epldermal layer where separaLlon occurs.
#3:;/(<-5 ls a rare auLolmmune bllsLerlng dlsorder
resulLlng from loss of lnLegrlLy of normal lnLercellular
aLLachmenLs wlLhln epldermls and mucosal eplLhellum.
=> #3:;/(<-5 ?-1<94(5 (deeper)
AcanLholysls lnvolves layer of cells lmmedlaLely above Lhe
basal cell layer - suprabasal acanLholyLlc bllsLer (deeper)
"> #3:;/(<-5 7,1(923-5 (superflclal)
AcanLholysls lnvolves superflclal epldermls aL Lhe level of
sLraLum granulosum - subcorneal bllsLer

@-11,-5 ;3:;/(<,(A
Subepldermal, nonacanLholyLlc bllsLer

#9./,;/B5(,1,<B*#9./,<3)35(5
LplLhellal cells are held LogeLher by desmosomes, whlch
are ln Lurn anchored lnLo Lhe cyLoplasm by LonofllamenLs.

ln ;3:;/(<-5, Lhere are paLhogenlc lgC anLlbodles Lo
lnLerceullar desmosomal proLelns of skln and mucous
membranes.
1hls ls a Lype ll hypersenslLlvlLy reacLlon (anLlbody
dlrecLed agalnsL a flxed Llssue anLlgen).

ln C-11,-5 ;3:;/(<,(A, Lhere are anLlbodles dlrecLed
agalnsL proLelns aL Lhe dermal-epldermal [uncLlon.
ClrculaLlng lgC anLlbody reacLs wlLh anLlgen ln Lhe basal
cell-basemenL membrane aLLachmenL plaques
(hemldesmosomes). 1here ls perlveascular lnfllLraLe of
lymphocyLes, eoslnophlls, neuLrophlls, superflclal dermal
oedema and basal cell layer vacuollsaLlon once
complemenL ls bound.
vacuolaLed basal cell layer evenLually glves rlse Lo a fluld-
fllled bllsLer. 8llsLer roof lnvolves full-Lhlckness epldermls,
more reslsLanL Lo rupLure Lhan pemphlgus bllsLers.

D4,55 ;9./,1,<B

Þemphlgus vulgarls: lnvolves mucosa and skln.
Þrlmary leslons are superflclal veslcles and bullae LhaL
rupLure easlly, leavlng eroslons covered wlLh serum crusL.

Þemphlgus vulgarls:
unlform deposlLlon of lmmunoglobulln and complemenL
along cell membranes of keraLlnocyLes - characLerlsLlc
flshneL appearance.


8ullous pemphlgold: Lense, fluld fllled bllsLers resulL from
vacuollsaLlon of basal layer, produclng subepldermal
bllsLers


8ullous pemphlgold: lgC anLlbody and C3 deLecLed by
dlrecL lmmunofluorescence as a llnear band ouLllnlng
subepldermal basemenL membrane zone

E(5.,1,<B

Þemphlgus vulgarls: suprabasal acanLholysls resulLs ln an
lnLraepldermal bllsLer conLalnlng rounded keraLlnocyLes
LhaL are separaLlng from Lhelr nelghbours


8ullous pemphlgold: subepldermal veslcle has an lnflammaLory lnfllLraLe rlch ln eoslnophlls

1PL uAnuLnCnC uCSSlL8 2010
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!"#$ & '()*+, -*./)(
0)12.2,23. 456 /7*++212/*,23.+ 31 /3.82,23.
vlrLually all breasL carclnomas are adenocarclnomas
derlved from Lhe eplLhellal cells of Lhe ducLs or glands.
non-lnvaslve means LhaL Lhe mallgnanL cells are conflned
Lo elLher Lhe ducLs of Lhe aclnl of Lhe lobules, wlLh no
evldence of peneLraLlon of Lhe Lumour cells Lhrough Lhe
basemenL membranes.
!"#$%#&'(%&)
• uucLal carclnoma ln slLu
• Lobular carclnoma ln slLu
+#&'(%&)
• lnfllLraLlng ducLal
• lnfllLraLlng lobular
• Muclnous
• 1ubular
• Medullary
• Þaplllary
• CLhers
!9()*8 31 :()*+, /*(/2.3;*+
1. ulrecL spread - local lnfllLraLlon lnLo Lhe
underlylng muscles and Lhe overlylng skln
(ulceraLlon & LeLherlng).
2. LymphaLlcs - permeaLlon of lymphaLlc channels
- 'peau d' orange'. Axlllary lymph nodes
commonesL slLe. SenLlnel node removal -
lmporLanL ln sLaglng.
3. 8lood sLream - lrequenLly lnvolves Lhe lungs,
bones, llver, adrenals and braln.
<(3++ 9*,=373>?

1he Llssue seen comprlses faL and a cenLral area of poorly
clrcumscrlbed dense whlLe and focally cream Llssue LhaL
exLends lnLo Lhe palnLed surface. Some ad[acenL whlLe
Llssue exLends as sLreaks lnLo Lhe surroundlng faL.



@2+,373>?

Leslon ls composed of nesLed cells LhaL are lnfllLraLlng
lnLo Lhe surroundlng Llssue. Cells have a hlgh nuclear Lo
cyLoplasmlc raLlo and small nucleoll are seen. Cells are
pleomorphlc and Lhere ls a hlnL of gland formaLlon. no
mlLoslses are seen.
!"#$% '()*%"+," *-.$/"'0$1 2%*( /+1$
,%--).)#/ 0'1()( "- ' 2.)'(/ 3145
• laL necrosls
• Mammary ducL ecLasla
• llbrocysLlc change
• llbroadenomas
• Llpoma
6."7#"(/%0 -'0/".( %# 2.)'(/ 0'.0%#"4'
• 1ype of carclnoma - Medullary, Muclnous and
1ubular behave less aggresslvely Lhan oLher
Lypes.
• PlsLologlcal grade - 1umour cells glven a grade
vla 1nM. Crade 1 -good prognosls, Crade 3 -
worsL.
• SLage - ManagemenL depends on Lhe sLage of
dlsease. Slgns of axlllary lymph node lnvolvemenL
- bad.
• CesLrogen recepLors - presence wlLhln a
carclnoma lndlcaLes LhaL Lhe Lumour cells have a
hlgher degree of funcLlonal dlfferenLlaLlon.
(1amoxlfen -SL8M)
• PL8-2 - oncogene - ampllflcaLlon leads Lo
overexpresslon of membrane-relaLed proLeln -
poorer prognosls. (PercepLln - monoclonal
anLlbody)
• CrowLh klneLlcs - growLh acLlvlLy - low, medlum
or hlgh. noLe: 1umours wlLh a hlgh raLe of
dlvlslon may also have a hlgh cell deaLh raLe by
apopLosls.

!"# %&'%#'(') %(**+#, -./.
-01
!"#$ & '()*)+*,*-
*22 345678 92:6:;636<
1PL uAnuLnCnC uCSSlL8 2010
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!"#$ & #'()*+,+'-+.-.
/(0-'-1-+'
Þneumoconlosls ls an occupaLlonal lung dlsease and a resLrlcLlve lung dlsease caused by Lhe lnhalaLlon of dusL, ofLen ln
mlnes.
1ypes lnclude: asbesLosls, slllcosls, berylllosls (berylllum), coalworker's pneumoconlosls, arLhracosls (carbon).

#213+435.-+6+758#213+7('(.-.
!"#$"%&"'" - scarrlng/flbrosls of lung Llssue resulLlng from Lhe lnhalaLlon of asbesLos flbres. When asbesLos flbres are lnhaled,
Lhey deposlL aL alveolar ducL blfurcaLlons and cause an alveolar macrophage alveollLls. 1hese acLlvaLed macrophages release
cyLoklnes, such as Lumour necrosls facLor and lnLerleukln-1µ and oxldanL specles, whlch lnlLlaLe a process of flbrosls.
(&)*+&,-$,." 01$23&4&1'&"'" - caused by coal/dusL parLlcles, approxlmaLely 2-3 µm ln dlameLer, LhaL are reLalned ln Lhe
small alrways and alveoll of Lhe lung.
5'*'4&"'" - caused by Lhe lnhalaLlon of slllca (slllcon dloxlde) whlch ls parLlcularly Loxlc Lo alveolar macrophages and readlly
lnlLlaLes flbrogenesls.

9:+.. 4213+6+75

1here ls essenLlally no normal lung alLhough small resldual areas of red Llssue are seen beLween Lhe dense grey black
nodules. 1hese nodules are of varylng callbre buL are all less Lhan 10mm and show areas of coalescence. 1he nodules are
presenL ln all Lhe areas of Lhe lung seen and lnclude Lhe upper and lower lobes. 1here ls no spared area. Some resldual
vascular and bronchlole sLrucLures are evldenL, alLhough appearlng compressed. 1he pleural surface ls unremarkable.

;-.1+6+75

llbroblasLs produce collagen LhaL leads Lo flbrosls as Lhe collagen flbres accumulaLe. llbroblasLs are sLlmulaLed buL
flbrlnogenlc facLors (lCl) released by macrophages. CLher facLors sLlmulaLlng flbroblasLlc growLh lnclude plaLeleL derlved
growLh facLor (ÞuCl), 1Cl and plasma flbronecLln. Macrophage release lCl followlng Lhe engulfmenL of Lhe lrrlLanL parLlcles,
ln Lhls case slllca.

1he plnk sLuff ls Lhe collagen. lL ls plnk because lL ls acldlc and acldlc Lhlngs are plnk uslng a sLandard PaemaLoxylln and Losln
sLalned secLlon. 1here ls a problem wlLh gas exchange lf Lhese collagenous nodules are replaclng and desLroylng Lhe gas
exchange poLenLlal over such a large proporLlon of Lhe lung. 1hls man's lung changes are parLlcularly florld and relaLlvely
acuLe. 1hls probably relaLes Lo Lhe amounL of exposure Lo slllca he recelved.

1PL uAnuLnCnC uCSSlL8 2010
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!"#$ & '(
)*+,-,.,/- 012 34566,+,35.,/-6 /+ 3/-7,.,/-
lnfecLlous dlsease caused by sLralns of mycobacLerla,
usually mycobacLerlum Luberculosls, ln humans. lL
usually affecLs Lhe lungs, buL can affecL any oLher parL
of Lhe body. CharacLerlzed by caseaLlng granulomas.

#5.8/98:6,/4/;:1#5.8/;*-*6,6
lnlLlal exposure Lo mycobacLerlum resulLs ln
developmenL of an lmmune response LhaL
confers reslsLance buL also leads Lo
hypersenslLlvlLy (caseaLlng granulomas). Cu4 1-
cells have cruclal role ln cell-medlaLed lmmunlLy.
1hls ls prlmary 18. Secondary (reacLlvaLlon) 18
arlses ln prevlously exposed lndlvlduals when
lmmunosuppressed, usually manlfesLlng as
cavlLaLlng leslons ln lung aplces. Þrogresslve
prlmary 18 and secondary 18 can resulL ln
sysLemlc seedlng, causlng llfe-LhreaLenlng forms
such as mlllary 18 and Luberculous menlnglLls.
Plv ls a known rlsk facLor for recurrence of acLlve
18.

<=/66 95.8/4/;:
























>,6./4/;:

CaseaLlng granulomas of 18 (due Lo Cu4 1
cell medlaLed hypersenslLlvlLy reacLlon)

Al8 sLalnlng

Mllllary 18 (showlng numerous Lan
granulomas)

CavlLaLlng aplcal leslons of reacLlvaLed 18
1PL uAnuLnCnC uCSSlL8 2010
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Chon complex (plcLure shows calclfled rlghL nodule
wlLh assoclaLed calclfled hllar lymph nodes)
Chon focus: prlmary 18 leslon, appearlng as grey-
whlLe lnflammaLory area of consolldaLlon on Cx8
Chon complex: parenchymal leslon + nodal
lnvolvemenL
Cnce cell-medlaLed lmmunlLy conLrols Lhe
lnfecLlon, Lhe Chon complex undergoes
progresslve flbrosls, followed by radlographlcally
deLecLable calclflcaLlon (8anke complex).
1PL uAnuLnCnC uCSSlL8 2010
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!"#$% ' !()*+ ,**-(./01 2+3/40 45 67+ 89)/0
:+5/0/6/40
Leslons of varlous aeLlologles wlLhln Lhe cranlal vaulL
whlch dlsplace oLher sLrucLures ln Lhe CnS.

;+6/4<41.
Can be dlvlded lnLo Lhree maln causes
• Abscess
• Þrlmary Lumour
• MeLasLaLlc Lumour
Along wlLh aneurysms, chronlc subdural
haemaLomas, granulomas, or cysLs.

#)674(7.3/4<41.=#)6741+0+3/3
;>3*+33 - a focal lnfecLlon of Lhe braln parenchyma,
lnvolvlng a necroLlc collecLlon of pus whlch ls
evenLually walled off by a vascularlsed capsule.
1here are 3 maln mechanlsms of bacLerlal enLry Lo
Lhe braln -
ulrecL - lnfecLlons sLemmlng from Lhe slnuses, LeeLh,
mlddle ear, or masLold galn access Lo Lhe venous
dralnage of Lhe braln vla valveless emlssary velns
LhaL draln Lhese reglons. PaemoLogenous - Seedlng
of Lhe braln occurs from dlsLanL lnfecLlon slLes and
ofLen resulLs ln mulLlple braln abscesses. lollowlng
peneLraLlve ln[ury or neurosurgery.
#9/?)9. 6-?4-9 Lhese can arlse from Lhe Menlnges
(menlgnlomas) as slow-growlng exLra-axlal benlgn
Lumours whlch rarely lnvade Lhe parenchyma.
Cllal cells (asLrocyLomas, schwannomas eg acousLlc
neuromas, glloblasLoma mulLlform eLc), lnLra-axlal
Lumours ranglng from benlgn Lo lncredlbly lnvaslve.

@+6)36)3+3 reach Lhe braln Lhrough haemogenous
spread, frequenLly from lung carclnoma, breasL
carclnoma, mallgnanL melanoma and colorecLal
cancer. 1hey are usually mulLlple, round and
slgnlflcanLly dlfferenL from Lhe surroundlng Llssue

@;!! ABBACD occurs as Lhe leslon enlarges wlLh shlfL
of Lhe hemlspheres, compresslon of venLrlcles Lhen
occurlng, flxed dllaLed puplls (due Lo 3Cn palsy)
followlng, cheynes-sLroke breaLhlng (due Lo
depresslon of resplraLory cenLres ln Lhe pons and
medulla), conlng and deaLh.






E9433 ()674<41.

Clloma of Lhe CnS demonsLraLlng mass effecL


A secLlon of Lhe braln demonsLraLlng lung meLs.

F/364<41.

1hls sllde ls of Lhe cerebral corLex as deflned by Lhe
presence of neurons whlch LransmlL messages from Lhe
cerebral corLex Lo oLher areas of Lhe braln or Lo splnal
cord

1hls shows whlLe maLLer whlch conLalns many myellnaLed
axons. 1he cells ln Lhe lmage are ollgodendrocyLes, whlch
have rounded regular small nuclel whlch slL aL regular
lnLervals wlLhln Lhe surroundlng neurophll. 1he maln
funcLlon of Lhe ollgodendrocyLe ls Lo form a myelln sheaLh
around ad[acenL axons. 1hls myelln sheaLh, as ln Lhe
perlphery, allows Lransmlsslon of Lhe message down Lhe
axon