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دانلود کتاب Kumar and Clark's Clinical Medicine
دانلود کتاب داروی بالینی کومار و کلارک
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Kumar and Clark's Clinical Medicine
ویرایش: 10 نویسندگان: Adam Feather MBBS FRCP FAcadMEd (editor), David Randall MA MRCP (editor), Mona Waterhouse MA MRCP (editor) سری: ISBN (شابک) : 0702078689, 9780702078682 ناشر: Elsevier سال نشر: 2020 تعداد صفحات: 1508 زبان: English فرمت فایل : PDF (درصورت درخواست کاربر به PDF، EPUB یا AZW3 تبدیل می شود) حجم فایل: 113 مگابایت
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Kumar & Clark’s Clinical Medicine Copyright Foreword to the Tenth Edition PREFACE TO THE TENTH EDITION E-Book extras Prescribing Units of measurement Online Clinical Overviews Online Special Topics From the International Advisory Board Online Clinical Cases List of Contributors International Advisory Board Acknowledgements for the Tenth Edition 1 - Diagnosis: the art of being a doctor DIAGNOSIS IN THE CLINICAL CONSULTATION THE MEDICAL CONSULTATION The initial interaction – forming a rapport Information-gathering Discussion and negotiation around investigations CLINICAL DIAGNOSTIC REASONING Models of diagnosis Diagnostic error and patient safety Strategies for avoiding bias Levels of diagnostic depth The role of watchful waiting When not to investigate Diagnostic criteria Overdiagnosis COMMUNICATING A DIAGNOSIS Explaining diagnoses to patients Breaking bad news Team communication Shared decision-making Managing uncertainty DIAGNOSIS, ARTIFICIALINTELLIGENCE AND THE FUTURE OF MEDICINE AI systems in healthcare Future uses of AI The role and goals of medicine Further reading 2 -Human genetics CLINICAL SKILLS FOR GENETIC MEDICINE Taking a genetic family history Drawing a pedigree INTRODUCTION Gene editing CLINICAL GENETICS Approach to the patient with a suspected genetic disease Ethical considerations Testing for genetic disease THE CELLULAR BASIS OF GENETICS DNA and the genetic code Human chromosomes DNA transcription Control of gene expression Epigenetics The X chromosome and inactivation Protein synthesis and secretion Protein translation Protein structure Genetics and the cell Control of cell division G1 – S – G2 – synthesis phase: DNA replication The phases of mitosis (M) Prophase Metaphase Anaphase Telophase Cytokinesis When to divide? Control of the cell cycle and checkpoints Cyclin-dependent kinases G2/M checkpoint Met/Ana checkpoint Review of cellular genetics GENETIC DISORDERS Chromosomal disorders Abnormal chromosome numbers Abnormal chromosome structures Mitochondrial chromosome disorders Analysis of chromosomal disorders Point mutations, insertions and deletions Mutations Point mutation Insertion or deletion Splicing mutations Nonsense mutations Prenatal diagnosis of congenital anomalies Personal choice Investigations 7–11 weeks (vaginal ultrasound) 10–13 weeks and 6 days (combined test) 14–20 weeks (serum triple or quadruple test) 18–20 weeks Non-invasive prenatal testing Patterns of inheritance of single-gene diseases Autosomal dominant disorders Autosomal recessive disorders Sex-linked disorders X-linked recessive disorders X-linked dominant disorders Mitochondrial inheritance Special presentations of genetic disease Mosaicism Triplet repeat mutations and genetic anticipation Imprinting Different genes that cause the same disease Different diseases caused by the same gene CYLD STAT3 Complex traits: multifactorial and polygenic inheritance TECHNIQUES FOR STUDYING THE GENETIC CODE Polymerase chain reaction Sanger sequencing Next-generation sequencing Hybridization arrays Transcriptomics Epigenetic techniques Genome databases Research techniques Discovery of disease-causing genes Sequencing trios using whole-exome and whole-genome sequencing (WES/WGS) Genetic polymorphisms and linkage studies Genome-wide association studies (GWAS) Identification of gene function Animal models GENOMIC MEDICINE Gene therapy Haemophilia Cystic fibrosis Mitochondrial replacement therapy Stem cell therapy Pre-implantation genetic diagnosis THE GENETIC BASIS OF CANCER Inherited cancer syndromes Autosomal dominant inheritance of cancer syndromes Autosomal recessive inheritance of cancer syndromes Oncogenes Activation of oncogenes Mutation Chromosomal translocation Viral activation Tumour suppressor genes Genetic diagnostics for cancer Targeted treatments for cancer 3 - Immunity INTRODUCING THE TISSUES, CELLS AND MOLECULES OF THE IMMUNE SYSTEM The immune system Cytokines Chemokines INNATE IMMUNE SYSTEM Complement Neutrophils Eosinophils Mast cells and basophils Monocytes and macrophages Dendritic cells Natural killer cells Innate lymphoid cells ADAPTIVE IMMUNE SYSTEM Antigen receptors on T and B lymphocytes T lymphocyte development and activation Natural killer cells CELL MIGRATION HLA MOLECULES AND ANTIGEN PRESENTATION The human major histocompatibility complex Antigen presentation THE IMMUNE SYSTEM IN CONCERT Acute inflammation: events and symptoms Chronic inflammation: events and symptoms LABORATORY INVESTIGATIONS OF THE IMMUNE SYSTEM CLINICAL IMMUNODEFICIENCY Secondary (acquired) versus primary immunodeficiency Primary immunodeficiency ALLERGIC DISEASE (IMMEDIATE HYPERSENSITIVITY) AUTOIMMUNE DISEASE Mechanisms of tissue damage inautoimmune disease Common autoimmune diseases ORGAN REJECTION IN CLINICAL TRANSPLANTATION IMMUNE-BASEDTHERAPIES Monoclonal antibody therapy (targeted therapy) Chimeric antigen receptor T-celltherapy Immunosuppressive drugs 4 - Evidence-based practice INTRODUCTION The need for EBP Barriers to EBP A framework for applying evidence toclinical problems ASKING ANSWERABLE QUESTIONS SEARCHING FOR THE EVIDENCE How to conduct a search APPRAISING THE EVIDENCE The hierarchy of evidence Critical appraisal APPLYING THE EVIDENCE Challenges of implementing evidence Improving the uptake of evidence 5 - Ethical practice and clinical communication ETHICS AND THE LAW Ethics: what it includes and why it matters Ethical practice: sources, resources and approaches Professional guidance and codes of practice The law Respect for autonomy: capacity and consent Capacity Consent The basis of consent Consent in educational settings Advance decisions Format Ethical and practical rationale Advance statements Lasting power of attorney Best interests of patients who lack capacity Provision or cessation of life-sustaining treatment Assisted dying Mental health and consent Consent and children Confidentiality Respecting confidentiality in practice When confidentiality must or may be breached Resource allocation Fairness Global perspectives Professional competence and mistakes Standards and the law Conscientious objection Clinical negligence Professional bodies Policy COMMUNICATION IN MEDICINE What is patient-centred communication? What are the effects of communication? Barriers and difficulties in communication Teamwork Clinical records Culture, diversity and communication Beliefs Language Non-verbal communication Patients with impaired communication faculties Impaired hearing Impaired vision Patients with limited understanding or speech Technology The Internet Decision aids Training in communication skills 6 - Malignant disease CLINICAL SKILLS FOR MALIGNANT DISEASE Investigations Formulating a management plan INTRODUCTION THE BIOLOGY OF CANCER Evading growth suppression Inducing angiogenesis Invasion and metastasis AETIOLOGY AND EPIDEMIOLOGY SCREENING AND INVESTIGATIONS INVESTIGATIONSAsymptomatic detection through screening The symptomatic patient with cancer PRINCIPLES OF CANCER TREATMENT Aims of treatment Assessment before treatment Assessment of the benefits of treatment Principles of chemotherapy Principles of endocrine therapy Principles of biological and targeted therapy Principles of radiation therapy ACUTE ONCOLOGY COMMON SOLID TUMOUR TREATMENT LUNG CANCER BREAST CANCER UPPER GASTROINTESTINAL CANCERS LOWER GASTROINTESTINAL CANCERS HEPATOBILIARY AND PANCREATIC CANCERS Liver Biliary tract Pancreas UROLOGICAL CANCERS GYNAECOLOGICAL CANCERS BRAIN TUMOURS Brain metastases Primary brain tumours HEAD AND NECK CANCER METASTATIC CANCER OF UNKNOWN PRIMARY 7 - Palliative care and symptom control INTRODUCTION AND GENERAL ASPECTS Who provides palliative care? When should palliative care needs be assessed – problems rather than prognosis? What are the patient’s needs and what is the patient’s understanding? SYMPTOM CONTROL Pain The WHO analgesic ladder Strong opioid drugs Dose titration and route The opioid epidemic Side-effects Toxicity Adjuvants and alternatives Gastrointestinal symptoms Nausea and vomiting Constipation Bowel obstruction Anorexia, weight loss and malaise Respiratory symptoms Breathlessness Cough Secretions Other physical symptoms Fatigue Mouth symptoms Loss of function, disability and rehabilitation Poor sleep Psychosocial issues PALLIATIVE CARE IN NON-MALIGNANT DISEASE Heart failure Chronic respiratory disease Renal disease Withdrawal of dialysis Patients who are not on dialysis Neurological disease Motor neurone disease Multiple sclerosis Dementia Children and young people CARE OF THE DYING Do not attempt resuscitation orders and treatment escalation plans 8 - Sepsis and the treatment of bacterial infection CLINICAL SKILLS FOR INFECTION AND SEPSIS History Management of sepsis INTRODUCTION PATHOPHYSIOLOGY Organ dysfunction Consensus definition (Sepsis-3) Septic shock RECOGNITION OF SEPSIS At-risk groups In-hospital surveillance Origins of sepsis Clinical features Sepsis in special situations Returning travellers People who inject drugs Neutropenic patients Paralysed patients MANAGEMENT OF SEPSIS Surviving Sepsis Campaign guidelines Supporting a failing circulation: fluid resuscitation Aborting the microbial driver: antimicrobials and source control Useful diagnostic samples and laboratory processing Source control ANTIMICROBIAL STEWARDSHIP UK-based targets Considerations before starting empirical antibiotics Antimicrobial decision-making at 72 hours Outpatient parenteral antimicrobial treatment Conditions suitable for OPAT services Delivery of OPAT services Monitoring patients in OPAT services Assessment of allergy risk Antibiotic chemoprophylaxis ANTIBIOTIC THERAPIES Antibiotics commonly used in the treatment of sepsis Beta-lactams (penicillins, cephalosporins, monobactams) and carbapenems Penicillins Cephalosporins Monobactams Carbapenems β-lactam/β-lactamase inhibitor combinations Quinolones Aminoglycosides Glycopeptides Lipopeptides Oxazolidinones Tetracyclines Macrolides Polymyxins (polymyxin B, colistimethate sodium (polymyxin E)) Sodium fusidate Sulphonamides and trimethoprim Nitroimidazoles Other antibiotics Clindamycin Nitrofurantoin Mupirocin Fosfomycin Rifaximin Treatment of infection caused by multidrug-resistant organisms Meticillin-resistant Staphylococcus aureus Vancomycin-resistant enterococci Carbapenem-resistant Pseudomonas Extended-spectrum β-lactamase-producing Enterobacteriaceae Carbapenem-resistant Enterobacteriaceae 9 - Water balance, fluids and electrolytes CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR WATER BALANCE, FLUIDS AND ELECTROLYTES Assessing a patient’s fluid status Clues to volume status on clinical examination Assessing acid-base disturbance WATER AND ELECTROLYTES Osmotic pressure Distribution of different types of replacement fluid Regulation of extracellular volume Neurohumoral regulation of extracellular volume Volume regulation in oedematous conditions Mechanism of impaired escape from actions of aldosterone and resistance to ANP Regulation of water excretion Plasma osmolality Osmoregulation versus volume regulation Increased extracellular volume Clinical features Aetiology Heart failure Hepatic cirrhosis Nephrotic syndrome Sodium retention Other causes of oedema Idiopathic oedema Local increase in oedema Management Clinical use of diuretics Loop diuretics Thiazide diuretics Potassium-sparing diuretics Carbonic anhydrase inhibitors Aquaretics (vasopressin or ADH antagonists) Sodium–glucose co-transporter 2 (SGLT2) inhibitors Resistance to diuretics Effects on renal function Decreased extracellular volume Clinical features Symptoms Signs Aetiology Investigations Management Haemorrhage Loss of plasma Loss of water and electrolytes Intravenous fluids Loss of water alone DISORDERS OF SODIUM CONCENTRATION Hyponatraemia Hyponatraemia with hypovolaemia Clinical features Management Hyponatraemia with euvolaemia Syndrome of inappropriate ADH secretion Clinical features Hyponatraemic encephalopathy Risk factors for developing hyponatraemic encephalopathy Investigations Management Osmotic demyelination syndrome Avoiding osmotic demyelination syndrome Reversible hyponatraemia culminating in hypernatraemia Antidiuretic hormone antagonists (vasopressin antagonists) Hyponatraemia with hypervolaemia Hypernatraemia Clinical features Investigations Management DISORDERS OF POTASSIUM CONCENTRATION Hypokalaemia Aetiology Common causes Rare causes Bartter’s syndrome Gitelman’s syndrome Liddle’s syndrome Clinical features Management Hyperkalaemia Aetiology Common causes Rare causes Hyporeninaemic hypoaldosteronism Pseudohypoaldosteronism type 1 (autosomal recessive and dominant types) Hyperkalaemic periodic paralysis Gordon’s syndrome (familial hyperkalaemic hypertension, pseudohypoaldosteronism type 2) Suxamethonium and other depolarizing muscle relaxants Clinical features Management DISORDERS OF MAGNESIUM CONCENTRATION Control and renal handling of magnesium Cortical thick ascending limb of Henle Bartter’s syndrome Familial hypomagnesaemia, hypercalciuria and nephrocalcinosis Distal convoluted tubule Magnesiotropic proteins Hypomagnesaemia Clinical features Management Relationship between hypomagnesaemia and plasma calcium Relationship between hypomagnesaemia and plasma potassium Hypermagnesaemia Clinical features Management DISORDERS OF PHOSPHATE CONCENTRATION Hypophosphataemia Aetiology Vitamin D-dependent rickets type I Vitamin D-dependent rickets type II Decreased renal reabsorption of phosphate Excessive phosphatonins (FGF23) Reduced NPT2a/NHERF1 activity Dent’s disease Re-feeding syndrome Diagnosis Management Hyperphosphataemia ACID–BASE DISORDERS Normal acid–base physiology Renal reabsorption of bicarbonate Renal excretion of [H+] Buffer systems in acid excretion Titratable acid Ammonium (NH4+) Aetiology of acid–base disturbance Diagnosis Respiratory acidosis and alkalosis Respiratory acidosis Respiratory alkalosis Metabolic acidosis and alkalosis Metabolic acidosis Anion gap Metabolic acidosis with a normal anion gap Renal tubular acidosis Type 4 renal tubular acidosis Type 3 renal tubular acidosis Type 2 (‘proximal’) renal tubular acidosis Type 1 (‘distal’) renal tubular acidosis Urinary anion gap Metabolic acidosis with a high anion gap Chronic kidney disease Lactic acidosis Ketoacidosis Mixed metabolic acidosis Clinical features of acidosis General treatment of acidosis Metabolic alkalosis Classification and definitions Clinical features Management Chloride-responsive metabolic alkalosis Chloride-resistant metabolic alkalosis 10 -Critical care medicine INTRODUCTION CLINICAL APPROACH TO THE CRITICALLY ILL PATIENT Recognition and diagnosis of critical illness General aspects of managing the critically ill Intensive skilled nursing care Specialized physiotherapy Management of pain and distress Constant reassurance and support Gastric protection Deep vein thrombosis prevention Mouth care, tooth-brushing and oropharyngeal suction Prevention of constipation and pressure ulcers Organ support Nutritional support Insulin treatment Discharge from the ICU/HDU APPLIED CARDIORESPIRATORY PHYSIOLOGY Oxygen delivery and consumption Oxygenation of the blood Oxyhaemoglobin dissociation curve Alveolar oxygen tension (PAO2) Pulmonary gas exchange Oxygen cascade Mixed venous oxygen tension and saturation Adaptation to hypoxia Cardiac output Stroke volume Preload Myocardial contractility Afterload Cardiovascular assessment and monitoring of critically ill patients Assessment of tissue perfusion Blood pressure Central venous pressure Left atrial pressure Pulmonary artery pressures Cardiac output Less invasive techniques for assessing cardiac function and guiding volume replacement Arterial pressure variation as a guide to hypovolaemia Oesophageal Doppler Arterial waveform analysis Echocardiography Key points in monitoring cardiac function DISTURBANCES OF ACID–BASE BALANCE Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis SHOCK, SEPSIS AND ACUTE DISTURBANCES OF HAEMODYNAMIC FUNCTION Aetiology of shock Pathophysiology The sympatho-adrenal response to shock The neuroendocrine response Release of immune mediators Microorganisms and their toxic products Toxic products of tissue injury (surgery and trauma) Cytokines and other immune mediators Activation of the complement cascade Influence of genetic variation Haemodynamic and microcirculatory changes Activation of the coagulation system Clinical features of shock and sepsis Hypovolaemic shock Cardiogenic shock Obstructive shock Distributive shock: anaphylactic shock Distributive shock: sepsis and septic shock Sepsis and multiple organ failure (multiple organ dysfunction syndrome) Metabolic response to trauma, major surgery and severe infection Management of shock and sepsis Preload and volume replacement Myocardial contractility and inotropic agents Adrenaline (epinephrine) Noradrenaline (norepinephrine) Dopamine Dopexamine Dobutamine Phosphodiesterase inhibitors (e.g. milrinone, enoximone) Vasopressin Levosimendan Summary for use of inotropic and vasopressor agents Targeting haemodynamics and oxygen transport High-risk surgical patients Vasodilator therapy Mechanical support of the myocardium RESPIRATORY FAILURE Classification and aetiology Clinical features Investigations Monitoring Pulse oximetry Blood gas analysis PaO2/FiO2 ratio Capnography Management Oxygen therapy Methods of oxygen administration Oxygen toxicity Respiratory support Indications for mechanical ventilation Institution of invasive respiratory support Sedation, analgesia and muscle relaxation Tracheostomy Disconnection, failure of gas or power supply, and mechanical faults Cardiovascular complications Respiratory complications Ventilator-associated pneumonia Techniques for respiratory support Controlled mechanical ventilation Positive end-expiratory pressure Continuous positive airway pressure Pressure support ventilation Intermittent mandatory ventilation ‘Lung-protective’ ventilation High-frequency oscillation Extracorporeal gas exchange Non-invasive ventilation Weaning Neuromuscular weakness complicating critical illness Criteria for weaning patients from mechanical ventilation Techniques for weaning Extubation and tracheostomy decannulation ACUTE RESPIRATORY DISTRESS SYNDROME Definition and aetiology Pathogenesis and pathophysiology Non-cardiogenic pulmonary oedema Pulmonary hypertension Haemorrhagic intra-alveolar exudate Resolution, fibrosis and repair Physiological changes Clinical features Management Mechanical ventilation Pulmonary oedema limitation Prone position Inhaled nitric oxide Aerosolized prostacyclin Steroids Prognosis ACUTE KIDNEY INJURY NEUROCRITICAL CARE Physiology Clinical features and investigations Monitoring Management OUTCOMES Withholding and withdrawing treatment Brain death and organ donation Preconditions Exclusions Diagnostic tests for the confirmation of brainstem death 11 - Surgery CLINICAL SKILLS FOR SURGERY History Examination Investigations Surgical pathology and nomenclature INTRODUCTION Surgery in high-incomecountries Global provision of surgical care THE PATHOPHYSIOLOGY OF SURGERY The inflammatory and stress response Fluid balance in surgical conditions The metabolic response to surgery Wound healing MANAGEMENT OF THE PERIOPERATIVE PATIENT Fluid and electrolyte balance Nutrition Coagulation, bleeding and transfusion Trauma The critically ill surgical patient Cancer THE PATIENT JOURNEY IN SURGERY Preoperative phase Intraoperative phase Postoperative phase SURGICAL ETHICS, CONSENT AND THE LAW Consent in surgery Surgical audit and quality improvement 12 - Prescribing, therapeutics and toxicology PRESCRIBING INTRODUCTION WHY DO PATIENTS NEED DRUGS? THE CHOICE OF DRUG THE DOSE Pharmacokinetics Absorption Distribution Metabolism Excretion Pharmacodynamics PRESCRIBING IN SPECIAL POPULATIONS Pregnant women Breast-feeding women Prescribing in old age Patients with renal disease Patients with liver disease MONITORING DRUG THERAPY Measuring drug effects ADVERSE DRUG REACTIONS Classification Diagnosis Management DRUG INTERACTIONS INFORMATION SOURCES POISONING INTRODUCTION CLINICAL APPROACH TO THE POISONED PATIENT History Examination PRINCIPLES OF MANAGEMENT OF POISONING Care of the unconscious patient Cardiovascular support Other problems Hypothermia Hyperthermia Skin blisters Rhabdomyolysis Convulsions Stress ulceration and bleeding Body ‘packers’ and body ‘stuffers’ Management Specific management of the poisoned patient Antidotes Gut decontamination Increasing poison elimination Investigations ECG Radiology SPECIFIC POISONS The top ten Paracetamol (acetaminophen) Clinical features Management Non-steroidal anti-inflammatory drugs Clinical features and management Opiates and opioids Clinical features Management Antidepressants: tricyclics and selective serotonin reuptake inhibitors Clinical features Management Benzodiazepines Clinical features Management Stimulants Clinical features Management Ethanol Clinical features Management Neuroleptics and atypical neuroleptics Clinical features Management Cannabis (marijuana) and synthetic cannabinoids Clinical features Management Anticonvulsants Clinical features Management Other drugs of importance in poisoning Antidiabetic drugs Clinical features Management Severe insulin poisoning Sulphonylurea poisoning Antimalarials Chloroquine Quinine Primaquine Management Beta-adrenoceptor-blocking drugs Management Calcium-channel blockers Clinical features Management Digoxin Clinical features Management Iron salts Clinical features Management Lithium salts Clinical features Management Salicylates Clinical features Management Poisoning with chemicals Arsenic Clinical features Management Carbamate insecticides Clinical features Management Carbon monoxide Clinical features Management Copper sulphate Clinical features Management Corrosive agents Cyanide Clinical features Management Ethylene glycol Clinical features Management Household products Clinical features Hydrofluoric acid and hydrogen fluoride Clinical features Management Lead Clinical features Management Mercury Clinical features Management Methanol Clinical features Management Nerve agents Clinical features Management Organophosphorus insecticides Clinical features Management Phosphides Clinical features Management Poisons in the natural world Venomous snakes Clinical features Viperidae (Viperinae and Crotalinae) Elapidae Hydrophiidae Management POISONS IN THE NATURAL WORLD: ADDITIONAL ONLINE CONTENT Marine animals Clinical features and management Diarrhoeic shellfish (okadaic) poisoning Clinical features and management Neurotoxic shellfish (brevetoxin) poisoning Clinical features and management Paralytic shellfish (saxitoxin) poisoning Clinical features and management Ciguatera fish poisoning Clinical features and management Scombroid fish poisoning Clinical features and management Stings from marine animals Jellyfish stings Clinical features and management Venomous animals Scorpions Clinical features and management Spiders Clinical features and management Venomous snakes Clinical features Local effects Systemic effects Management First aid Hospital treatment Diagnosis Investigations Antivenom Supportive treatment and treatment of complications Prevention Plants Atropa belladonna Cicuta species Conium maculatum Datura stramonium Digitalis purpurea, Nerium oleander, Thevetia peruviana (yellow oleander) Mushrooms Cytotoxic mushrooms Clinical features and management Gyromitrin poisoning Clinical features and management Hallucinogenic mushroom poisoning Clinical features and management Isoxazole poisoning Clinical features and management Neurotoxic mushroom poisoning Clinical features and management Orellanin poisoning Clinical features and management 13 - Global health INTRODUCTION The scale of the problem worldwide MILLENNIUM AND SUSTAINABLE DEVELOPMENT GOALS GLOBAL BURDEN OF DISEASE POVERTY Poverty, hunger, agriculture and climate change WATER AND SANITATION ORGANIZATIONS AND THE GLOBAL HEALTH AGENDA EDUCATION MATERNAL AND CHILD HEALTH Maternal health Child health Vaccination Child labour Child nutrition MENTAL HEALTH ACCIDENTS AND TRAUMA CONFLICT AND CATASTROPHE ECONOMICS AND POLITICS IN GLOBAL HEALTH SOCIAL DETERMINANTS OF HEALTH HUMAN RIGHTS AND THE VALUE OF ENGAGEMENT IN GLOBAL HEALTH The healthcare workforce Medical electives 14 - Public health INTRODUCTION Public health and global health KEY CONCEPTS IN PUBLIC HEALTH Epidemiology and causality Health needs assessments Life expectancy and quality of life Health inequalities Politics and advocacy Smoking bans Reduction of daily salt intake PILLARS OF PUBLIC HEALTH Health improvement Wider determinants of health Behaviour change Individual interventions Structural interventions Fiscal interventions Legal interventions Health protection Prevention Hand hygiene Vaccination Control Control of infectious diseases Control of environmental hazards Monitoring (surveillance) Healthcare public health Screening Antimicrobial resistance Health economics Measuring outcomes Measuring cost-effectiveness The ethics of funding decisions Service delivery Centralization 15 - Geriatric medicine, frailty and multimorbidity INTRODUCTION AGEING Why do we age? Theories related to limited cell replication Telomere shortening Damage accumulation theory Free radical theory Theories related to evolution Disposable soma theory Mutation accumulation theory Antagonistic pleiotropy theory Calorie restriction Cell senescence Applied anatomy and physiology of ageing INVESTIGATIONS IN OLDER ADULTS TAKING A HISTORY MULTIMORBIDITY, SARCOPENIA AND FRAILTY Multimorbidity Sarcopenia Frailty Identifying frailty Frailty phenotype Frailty Index – accumulation of deficits The Clinical Frailty Scale (CFS) COMPREHENSIVE GERIATRIC ASSESSMENT Multidisciplinary team working ADVANCE CARE PLANNING THE MOST COMMON ISSUES IN OLDER PEOPLE Prescribing in older people Drug interactions Patient choice Evidence base Benefits of therapy Clinical decision-making Falls (instability) Consequences of falls Fear of falling Fragility fractures Neck of femur fractures Institutionalization Postural hypotension Aetiology Management Delirium Assessment and management Pharmacological management Prognosis Urinary tract infections Investigations Management Recurrent UTIs Urinary incontinence Stress incontinence Urge incontinence (overactive bladder) Overflow incontinence Functional incontinence Older adult abuse and safeguarding Management Rehabilitation Complex discharge planning Carer strain Loneliness AGEING WELL AND ADVANTAGES OF AGEING Health and wellbeing Societal and economic advantages 16 - Haematology CLINICAL SKILLS FOR HAEMATOLOGY History Examination Investigations Bone marrow biopsy INTRODUCTION The formation of blood cells (haemopoiesis) Haemopoietic growth factors Peripheral blood THE RED CELL Erythropoiesis Haemoglobin synthesis Haemoglobin function ANAEMIA: AN INTRODUCTION Clinical features Symptoms Signs Investigations Peripheral blood Bone marrow MICROCYTIC ANAEMIA Iron Dietary intake Absorption Transport in the blood Iron stores Requirements Iron deficiency Clinical features Investigations Differential diagnosis Management Anaemia of chronic disease Sideroblastic anaemia Management NORMOCYTIC ANAEMIA MACROCYTIC ANAEMIAS Megaloblastic anaemia Haematological findings Biochemical basis of megaloblastic anaemia Vitamin B12 (cobalamin) Absorption and transport Vitamin B12 deficiency Pernicious anaemia Pathogenesis Pathology Clinical features Investigations Absorption tests Gastrointestinal investigations Differential diagnosis Management Folic acid Dietary intake Folate deficiency Clinical features Investigations Blood measurements Further investigations Management and prevention of megaloblastic anaemia Management of vitamin B12 deficiency Management of folate deficiency Macrocytosis without megaloblastic changes ANAEMIA DUE TO MARROW FAILURE (APLASTIC ANAEMIA) Aetiology Clinical features Investigations Differential diagnosis Management and prognosis HAEMOLYTIC ANAEMIAS: AN INTRODUCTION Consequences of haemolysis Sites of haemolysis Extravascular haemolysis Intravascular haemolysis Evidence for haemolysis Demonstration of shortened red cell lifespan Intravascular haemolysis INHERITED HAEMOLYTIC ANAEMIA Red cell membrane defects Hereditary spherocytosis Clinical features Investigations Management Hereditary elliptocytosis Hereditary stomatocytosis Haemoglobin abnormalities The thalassaemias Beta-thalassaemia Genetics Clinical syndromes Thalassaemia trait (carrier) Non-transfusion-dependent thalassaemia (NTDT) Transfusion-dependent thalassaemia (TDT) Management of symptomatic thalassaemia Alpha-thalassaemia Genetics Sickle syndromes Pathogenesis Sickle cell anaemia Clinical features Vaso-occlusive crises Acute chest syndrome Pulmonary hypertension Anaemia Splenic sequestration Bone marrow aplasia Long-term problems Investigations Management Anaemia Counselling Prognosis Sickle cell trait Other structural globin chain defects Combined defects of globin chain production and structure Prenatal screening and diagnosis of severe haemoglobin abnormalities Metabolic disorders of the red cell Glucose-6-phosphate dehydrogenase deficiency Clinical syndromes Investigations Management Pyruvate kinase deficiency Investigations Management Pyrimidine 5′ nucleotidase deficiency ACQUIRED HAEMOLYTIC ANAEMIA Aetiology Causes of immune destruction of red cells Causes of non-immune destruction of red cells Miscellaneous causes Autoimmune haemolytic anaemias ‘Warm’ autoimmune haemolytic anaemias Clinical features Investigations Management and prognosis ‘Cold’ autoimmune haemolytic anaemias Chronic cold haemagglutinin disease Investigations Management Paroxysmal cold haemoglobinuria Drug-induced immune haemolytic anaemia Alloimmune haemolytic anaemia Haemolytic disease of the newborn Clinical features Investigations Routine antenatal serology Antenatal assessment and treatment Birth of an affected infant Postnatal management Prevention of RhD immunization in the mother Non-immune haemolytic anaemia Paroxysmal nocturnal haemoglobinuria Clinical features Investigations Management and prognosis Mechanical haemolytic anaemia POLYCYTHAEMIA Secondary polycythaemias Management ‘Relative’ or ‘apparent’ polycythaemia (Gaisböck’s syndrome) THE SPLEEN Function Sequestration and phagocytosis Extramedullary haemopoiesis Immunological function Blood pooling Splenomegaly Aetiology Hypersplenism Management Problems after splenectomy Prophylaxis against infection after splenectomy or splenic dysfunction Post-splenectomy haematological features Splenic atrophy BLOOD TRANSFUSION BLOOD GROUPS ABO system PROCEDURE FOR BLOOD TRANSFUSION IN HOSPITALS Pre-transfusion compatibility testing Blood grouping Antibody screening Selection of donor blood and compatibility testing Selection procedures Patients without atypical red cell antibodies Patients with atypical red cell antibodies Blood ordering Elective surgery Emergencies COMPLICATIONS OF BLOOD TRANSFUSION Prevention of wrong blood transfusions Immunological complications Alloimmunization Red cell complications: haemolytic transfusion reaction (immediate) Diagnosis Investigations Red cell complications: haemolytic transfusion reaction (delayed) Leucocyte complications: non-haemolytic (febrile) transfusion reactions Transfusion-related acute lung injury Transfusion-associated graft-versus-host disease Platelet complications: post-transfusion purpura Plasma protein complications: urticaria and anaphylaxis Immunosuppression Non-immunological complications Transmission of infection Viral transmission Bacterial transmission Variant Creutzfeldt–Jakob disease Transfusion-associated circulatory overload Iron overload STRATEGIES FOR THE AVOIDANCE OF UNNECESSARY TRANSFUSION BLOOD, BLOOD COMPONENTS AND BLOOD PRODUCTS Whole blood Red cell concentrates Washed red cell concentrates Platelet concentrates Granulocyte concentrates Fresh frozen plasma Prothrombin complex concentrates Cryoprecipitate Specific coagulation factor concentrates Albumin Normal immunoglobulin Specific immunoglobulins Therapeutic use of haemopoietic stem cell transplantation Autologous stem cell transplantation THE WHITE CELL Neutrophils Function Neutrophil leucocytosis Neutropenia and agranulocytosis Clinical features Investigations Management Eosinophils Basophils Monocytes Lymphocytes HAEMOSTASIS Vessel wall Platelets Platelet adhesion Platelet activation Platelet aggregation Coagulation Coagulation and fibrinolysis Coagulation pathway Factor VIII Von Willebrand factor Factor V Physiological limitation of coagulation Antithrombin Activated protein C Protein S Other inhibitors Fibrinolysis Plasmin Fibrinolytic system Tissue plasminogen activator Investigation of bleeding disorders Is there a generalized haemostatic defect? Is the defect inherited or acquired? Is the bleeding suggestive of a vascular/platelet defect or a coagulation defect? Vascular/platelet bleeding Coagulation disorders Laboratory investigations Blood count and film Coagulation tests VASCULAR DISORDERS Hereditary haemorrhagic telangiectasia Easy bruising syndrome Senile purpura and purpura due to steroids Purpura due to infections Henoch–Schönlein purpura Episodes of inexplicable bleeding or bruising PLATELET DISORDERS Thrombocytopenia Immune thrombocytopenic purpura ITP in children ITP in adults Clinical features Investigations Management Children Adults First-line therapy Second-line therapy Other immune thrombocytopenias Drugs Heparin-induced thrombocytopenia Neonatal alloimmune thrombocytopenia Post-transfusion purpura Thrombotic thrombocytopenic purpura Management Platelet function disorders Thrombocytosis INHERITED COAGULATION DISORDERS Haemophilia A Clinical features and investigations Management Complications Carrier detection and antenatal diagnosis Haemophilia B (Christmas disease) Von Willebrand’s disease Clinical features Management ACQUIRED COAGULATION DISORDERS Vitamin K deficiency Liver disease Disseminated intravascular coagulation Clinical features Investigations Management Excessive fibrinolysis Massive transfusion Inhibitors of coagulation 17 -Haematological oncology CLINICAL SKILLS FOR HAEMATOLOGICAL ONCOLOGY History Assessing suitability for treatment Examination Treatments Aims of treatment INTRODUCTION Aetiology Pathogenesis Early genetic changes Cellular phenotypes New mutational events Leukaemic and lymphomatous presentations Investigations Full blood count Morphology Blood films Bone marrow aspirate morphology Histology Biochemistry Immunophenotyping Cytogenetics Molecular genetics Minimal residual disease testing Tissue typing Radiological imaging Plain films Ultrasound scans Computed tomography scans Nuclear medicine scans Magnetic resonance imaging Multidisciplinary team and specialist integrated haematological malignancy diagnostic service LEUKAEMIAS Acute leukaemias Clinical features Investigations For confirming diagnosis For planning therapy Management Palliative therapy Curative therapy Active therapy Supportive care Specific treatment Refractory disease Stem cell transplant Acute myeloid leukaemia Prognosis Management Young patients: intensive therapy unless unfit Older patients: intensive versus non-intensive strategies Relapsed AML Acute promyelocytic leukaemia Acute lymphoblastic leukaemia Prognosis Management Chronic leukaemias Clinical features Symptoms Signs Investigations Management Chronic lymphocytic leukaemia Clinical features Investigations Prognosis Management General/supportive treatment Specific treatment Lymphomatous transformation Hairy cell leukaemia Clinical features Management MYELOPROLIFERATIVE NEOPLASMS Polycythaemia vera Clinical features Diagnosis Management Course and treatment General measures Prognosis Essential thrombocythaemia Clinical features Investigations Management Secondary thrombocytosis Myelofibrosis Clinical features Investigations Management Prognosis Other myeloproliferative neoplasms MYELODYSPLASIA Clinical features Investigations Management MDS/MPN overlap syndromes LYMPHOMAS Overall management strategy common to all lymphomas Investigations Hodgkin lymphoma Aetiology Diagnosis Clinical features Investigations Management Principles of management Treatment of early-stage disease Treatment of advanced-stage disease Management of resistant and relapsed disease Experimental approaches Long-term follow-up Non-Hodgkin lymphomas Aetiology Pathogenesis Genetic features Clinical features B-cell lymphomas Follicular lymphoma Clinical features and course Management General management Initial treatment: early disease Initial treatment: advanced disease (stages II–IV) Second therapy and beyond Prognosis Diffuse large B-cell lymphoma Clinical features Management Initial treatment Early-stage disease Advanced-stage disease Second (and subsequent) therapy Prognosis Burkitt lymphoma Management Prognosis Mantle cell lymphoma Management Prognosis Lymphoplasmacytic lymphoma Management Prognosis Primary central nervous system lymphoma Management Marginal zone lymphoma Management Peripheral T-cell lymphomas Management Mycosis fungoides and Sézary’s syndrome MYELOMA AND OTHER PLASMA CELL DISORDERS Myeloma Clinical features Diagnosis Investigations General Immunology Radiology Histology Staging and prognosis Management Supportive therapy Specific therapy Smouldering (asymptomatic) myeloma Monoclonal gammopathy of undetermined significance Solitary plasmacytoma Heavy chain diseases Monoclonal gammopathies of clinical significance 18 - Rheumatology CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR RHEUMATOLOGY Taking a musculoskeletal history Examination of the joints APPROACH TO THE PATIENT ANATOMY AND PHYSIOLOGY OF THE NORMAL JOINT Fibrous and fibrocartilaginous joints Synovial joints Juxta-articular bone Articular cartilage Synovium and synovial fluid Ligaments and tendons Blood vessels and nerves Skeletal muscle INVESTIGATION OF RHEUMATIC DISEASE Useful blood screening tests Other blood and urine tests Serum autoantibody studies Joint aspiration and examination of synovial fluid Diagnostic imaging and visualization Other tests to investigate rheumatological disease CLINICAL CONDITIONS IN RHEUMATOLOGY COMMON REGIONAL MUSCULOSKELETAL PROBLEMS Pain in the neck and shoulder Mechanical or muscular neck pain (shoulder girdle pain) Management Nerve root entrapment Management Whiplash injury Management Pain in the shoulder Rotator cuff (supraspinatus) tendonosis Management Torn rotator cuff Calcific tendonosis and bursitis Adhesive capsulitis (true ‘frozen’ shoulder) Pain in the elbow Epicondylitis Management Pain in the hand and wrist Tenosynovitis Management Carpal tunnel syndrome Management Other conditions causing pain Inflammatory arthritis Nodal osteoarthritis First carpometacarpal osteoarthritis Scaphoid fractures Ganglion Dupuytren’s contracture Pain in the lower back Investigations Mechanical low back pain Examination Lumbar spondylosis Facet joint syndrome Management of mechanical back pain Acute lumbar disc prolapse Examination Management Spinal and root canal stenosis Spondylolisthesis Diffuse idiopathic skeletal hyperostosis Osteoporotic crush fracture of the spine Management Septic discitis Ankylosing spondylitis Pain in the hip Osteoarthritis of the hip Lateral hip pain syndrome: trochanteric bursitis and gluteus medius tendonopathy Meralgia paraesthetica Fracture of the femoral neck Avascular necrosis (osteonecrosis) of the femoral head Inflammatory arthritis of the hip Polymyalgia rheumatica Pain in the knee Knee joint effusions Examination Investigations Pain arising from within the knee Osteoarthritis of the knee Inflammatory arthritis of the knee Haemarthrosis of the knee Torn meniscus Torn cruciate ligaments Chondromalacia patellae Osteochondritis dissecans Spontaneous osteonecrosis of the knee Pain from structures around the knee Medial knee pain Anterior knee pain Pre- and infrapatellar bursitis Osgood–Schlatter disease Enthesitis Posterior knee pain Popliteal cyst (Baker’s cyst) Ruptured popliteal cyst Pain in the shin, calf and ankle Sever’s disease Achilles tendonosis Achilles bursitis Compartment syndromes Pain in the foot Hallux valgus Hallux rigidus Metatarsalgia Morton’s neuroma Stress fractures of the metatarsals Tarsal tunnel syndrome Pain under the heel Plantar fasciitis Plantar spurs Calcaneal bursitis Clinical features and management of heel pain Pain in the chest Pain associated with sport and the performing arts CHRONIC PAIN SYNDROMES Chronic widespread pain Fibromyalgia Management Drugs Non-drug therapies Chronic regional pain Chronic (work-related) upper-limb pain syndrome Management Temporomandibular pain dysfunction syndrome Complex regional pain syndrome Management ANALGESIC AND ANTI-INFLAMMATORY DRUGS FOR MUSCULOSKELETAL PROBLEMS Simple and compound analgesic agents Non-steroidal anti-inflammatory drugs Effects and side-effects Uses DISORDERS OF COLLAGEN Hypermobile Ehlers–Danlos syndrome and hypermobility spectrum disorders Marfan’s syndrome Osteogenesis imperfecta Achondroplasia OSTEOARTHRITIS Epidemiology Aetiology and pathogenesis Clinical features Symptoms Signs Clinical subsets Nodal OA Hip OA Knee OA Primary generalized OA Erosive OA Crystal-associated OA Investigations Management Physical measures Medication Surgery INFLAMMATORY ARTHRITIS RHEUMATOID ARTHRITIS Epidemiology Aetiology and pathogenesis Immunology Pathology Rheumatoid factors and anti-citrullinated peptide antibodies (ACPA) Clinical features Typical presentation Symptoms and signs of early RA Other presentations Complications Septic arthritis Amyloidosis Joint involvement in RA Hands and wrists Shoulders Elbows Feet Knees Hips Cervical spine Other joints Non-articular manifestations Soft tissue surrounding joints Less common non-articular manifestations Lungs Vasculitis Heart and peripheral vessels Nervous system Eyes Kidneys Spleen, lymph nodes and blood Diagnosis and investigations Management Drug therapy Non-steroidal anti-inflammatory drugs and coxibs Corticosteroids Disease-modifying anti-rheumatic drugs Methotrexate Sulfasalazine Hydroxychloroquine Leflunomide Biological therapies TNF-α blockers Other biological agents Targeted synthetic DMARDS Switching between DMARDs and tapering therapy Physical measures Surgery Prognosis SPONDYLOARTHRITIS Aetiology Axial spondyloarthritis Ankylosing spondylitis Aetiology Clinical features Investigations Management Prognosis Psoriatic arthritis Clinical features Management and prognosis Reactive arthritis Aetiology Clinical features Management Enteropathic arthritis associated with inflammatory bowel disease Management Crystal arthritis Aetiology Gout and hyperuricaemia Epidemiology Pathogenesis of hyperuricaemia and gout Gout as an autoinflammatory disease Clinical features Investigations Management Dietary advice Treatment with agents that reduce serum uric acid levels Allopurinol Febuxostat Pegloticase Uricosuric agents Losartan Targeted therapies Chronic tophaceous gout Calcium pyrophosphate dihydrate deposition arthropathy (CPPD) Diagnosis Management Basic calcium phosphate deposition disease Diagnosis Management INFECTIONS OF JOINTS Septic arthritis Clinical features Investigations Management Empirical treatment in septic arthritis Management of infected prostheses Specific types of bacterial arthritis Gonococcal arthritis Tuberculous arthritis Meningococcal arthritis Infective endocarditis Lyme arthritis Brucellosis Leprosy Arthritis in viral disease Rubella Erythrovirus B19 Hepatitis Arbovirus Musculoskeletal aspects of infection with HIV and AIDS Fungal infections AUTOIMMUNE RHEUMATIC DISEASES Autoimmunity and autoantibodies Systemic lupus erythematosus Epidemiology Aetiology Pathogenesis Pathology Clinical features General features Joints and muscles Skin Lungs Heart and cardiovascular system Kidneys Nervous system Eyes Gastrointestinal system Investigations Blood Histology Diagnostic imaging Management General measures Symptomatic treatment Corticosteroids and immunosuppressive drugs Prognosis Pregnancy and SLE Antiphospholipid syndrome Pathogenesis Clinical features Management Systemic sclerosis (scleroderma) Pathology and pathogenesis Vascular features Fibrotic features Clinical features Raynaud’s phenomenon Limited cutaneous scleroderma (LcSSc): 70% of cases Diffuse cutaneous scleroderma (DcSSc): 30% of cases Investigations Management Prognosis Polymyositis and dermatomyositis Clinical features Adult polymyositis Adult dermatomyositis Antisynthetase syndrome Association with other ARDs Association with malignancies Childhood dermatomyositis Investigations Management Inclusion body myositis Sjögren’s syndrome Pathology and investigations Management ‘Overlap’ syndromes and undifferentiated autoimmune rheumatic disease SYSTEMIC INFLAMMATORY VASCULITIS Large-vessel vasculitis Polymyalgia rheumatica Investigation of PMR Giant cell arteritis Investigations in GCA Management of PMR or GCA Takayasu’s arteritis Medium-sized vessel vasculitis Clinical features Investigations and management Kawasaki’s disease Clinical features and management Small-vessel vasculitis Management of small-cell vasculitis Behçet’s disease Clinical features Management ARTHRITIS IN CHILDREN Juvenile idiopathic arthritis RHEUMATOLOGICAL PROBLEMS SEEN IN OTHER DISEASES Gastrointestinal and liver disease Respiratory disease Sarcoidosis Malignant disease Hypertrophic pulmonary osteoarthropathy Paraneoplastic polyarthritis Skin disease Psoriatic arthritis Erythema nodosum Neurological disease Neuropathic (Charcot’s) joints Blood disease Endocrine and metabolic disorders MISCELLANEOUS ARTHROPATHIES Familial Mediterranean fever SAPHO (synovitis, acne, palmoplantar pustulosis, hyperostosis, osteitis) Osteochondromatosis Pigmented villonodular synovitis Relapsing polychondritis 19 - Bone disease CLINICAL SKILLS FOR BONE DISEASE Clinical features Risk factors for osteoporosis Examination ANATOMY AND PHYSIOLOGY OF BONE Bone structure Matrix components Bone cells Osteoblasts Osteocytes Osteoclasts Bone growth and remodelling Calcium homeostasis and its regulation Calcium absorption and distribution Vitamin D metabolism Parathyroid hormone Calcitonin INVESTIGATION OF BONE AND CALCIUM DISORDERS Total plasma calcium Plasma phosphate Plasma PTH Serum 25-hydroxyvitamin D 24-hour urinary calcium Biochemical markers of bone formation and resorption Diagnostic imaging OSTEOPOROSIS Pathogenesis Risk factors Clinical features Investigations Bone density Associated disease and risk factors Selection of individuals for treatment: risk assessment Prevention and management Pharmacological intervention Bisphosphonates Denosumab Strontium ranelate Selective oestrogen-receptor modulators Recombinant human parathyroid hormone Hormone replacement therapy Calcitriol (1,25-dihydroxyvitamin D3) and calcitonin Combination therapies Surgery Treatment of specific conditions Glucocorticoid-induced osteoporosis Osteoporosis in men OSTEONECROSIS PAGET’S DISEASE OF BONE Aetiology and pathogenesis Clinical features Investigations Management Intravenous bisphosphonates Oral bisphosphonates Surgery RICKETS AND OSTEOMALACIA Aetiology Clinical features Investigations Management BONE INFECTIONS Acute and chronic osteomyelitis Diagnosis Management Tuberculous osteomyelitis NEOPLASTIC DISEASE OF BONE Investigations Management SCHEUERMANN’S DISEASE 20 - Infectious disease CORE SKILLS AND KNOWLEDGE CORE CONTENT History Examination INTRODUCTION Infectious agents CLINICAL APPROACH TO THE PATIENT WITH A SUSPECTED INFECTION Diagnostic assessment History Age Sex Occupational history Symptoms Human infection contact Animal contact Travel history Food and drink history Sexual activity Pregnancy Intravenous drug use and needle exposure Leisure activities Previous infections Co-morbidities Devices/prostheses/implants Vaccination history Medications Allergies/intolerances Immunosuppression Clinical examination Investigations General investigations General blood tests Radiological imaging Microbiological investigations Microscopy Culture Nucleic acid detection Immunodiagnostic tests Pyrexia of unknown origin Management Non-antimicrobial principles of infection care Multidisciplinary infection care Shared decision-making Confidentiality Re-evaluation EPIDEMIOLOGY AND PREVENTION OF INFECTIONS Increased population mobility Changing patterns of disease Factors limiting control of infectious diseases in LMICs Goals in international development Acquisition of infection Routes of transmission Endogenous infection Air-borne spread Faeco-oral spread Vector-borne disease Direct person-to-person spread Indirect person-to-person spread Direct inoculation Consumption of infected material Classification of outbreaks Infection prevention and control Healthcare-associated infections HAI prevention and control measures Care bundle approach Hand hygiene Personal protective equipment Aseptic technique Urinary catheters Vascular access devices Adequate hydration Communication Isolation Other infection prevention and control measures (non-HAI) Eradication of reservoir For arthropod- or vector-borne infections For food-borne infections For faeco-oral infections For blood-borne infections For infections spread by air-borne and direct contact Immunization, immunoprophylaxis and immunotherapy Protection for travellers to developing/tropical countries PRINCIPLES AND MECHANISMS OF INFECTION Host–organism interactions, including the human microbiome Specificity of microorganisms Pathogenesis Epithelial attachment Colonization and invasion Tissue dysfunction or damage Cell lysis Exotoxins and endotoxins Host response to infection Natural defences Immunological defences Metabolic and immunological consequences of infection Fever The inflammatory response VIRAL INFECTIONS OUTCOMES OF VIRUS INFECTION OF A CELL VIRUS INFECTIONS OF THE SKIN AND MUCOUS MEMBRANES Vesicular viral rashes HSV-1 HSV-2 Diagnosis and management Varicella (chickenpox) and herpes zoster (shingles) Clinical features of chickenpox Clinical features of shingles Diagnosis Prevention and management Picornavirus infections Herpangina Hand, foot and mouth disease Poxvirus infections Smallpox (variola) Monkeypox Cowpox Vaccinia virus Orf Molluscum contagiosum Human papillomavirus infections Maculopapular viral rashes Clinical features Typical measles Diagnosis and management Prevention Active immunization Rubella Clinical features Complications Diagnosis and management Prevention Erythrovirus infections Human herpesvirus types 6 and 7 infection Management VIRUS INFECTIONS OF THE RESPIRATORY TRACT Upper respiratory tract infections Parainfluenza Adenovirus infection Other viral causes of URTI Lower respiratory tract infections Influenza Respiratory syncytial virus infection Diagnosis and management Prevention Metapneumovirus Coronavirus infection – severe acute respiratory and Middle East respiratory syndromes SYSTEMIC VIRAL INFECTIONS Dengue Clinical features Classic dengue fever Severe dengue Diagnosis and management Prevention Zika virus infection Chikungunya Infectious mononucleosis: Epstein–Barr virus infection Clinical features Diagnosis Management Cytomegalovirus infection Clinical features Diagnosis Management Mumps Clinical features Complications Diagnosis and management Prevention HIV infections Human T-cell leukaemia/lymphotropic virus infection Myocarditis and skeletal muscle infection Postviral/chronic fatigue syndrome VIRUS INFECTIONS OF THE NERVOUS SYSTEM Acute flaccid paralysis, including poliomyelitis Clinical features Diagnosis Management Prevention and control of poliomyelitis Meningitis Encephalitis Japanese encephalitis West Nile encephalitis Tick-borne encephalitis Lymphocytic choriomeningitis Hendra and Nipah virus infection Rabies Clinical features Diagnosis Management Prevention and control Pre-exposure prophylaxis Post-exposure prophylaxis Control Progressive multifocal leucoencephalopathy VIRUS INFECTIONS OF THE GASTROINTESTINAL TRACT Rotavirus infection Clinical features Diagnosis and differential diagnosis Management and prevention Rotavirus vaccines Calicivirus infection VIRAL HEPATITIS VIRUSES AND MALIGNANT DISEASE Hepatitis viruses and primary hepatocellular carcinoma Human papillomaviruses and cancer of the uterine cervix Epstein–Barr virus and malignant disease Kaposi’s sarcoma and human herpesvirus type 8 Other rare malignancies due to virus infection VIRAL HAEMORRHAGIC FEVERS Yellow fever Clinical features Diagnosis and management Prevention and control Congo–Crimean haemorrhagic fever Hantavirus infection Rift Valley fever Lassa fever Clinical features Diagnosis Management Marburg virus disease and Ebola virus disease ANTIVIRAL DRUGS Anti-herpesvirus drugs Nucleoside analogues Nucleotide analogues Pyrophosphate analogues Novel anti-herpesvirus agents Anti-influenza drugs Adamantanes Neuraminidase inhibitors Novel anti-influenza drugs Anti-hepatitis B drugs Other drugs Interferons TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES (PRION DISEASES) UBIQUITOUS BACTERIAL INFECTIONS BACTERIAL INFECTIONS OF THE SKIN AND SOFT TISSUES Invasive staphylococcal infection Staphylococcal virulence factors Meticillin-resistant Staphylococcus aureus Pasteurellosis Cat-scratch disease Toxin-mediated skin disease Staphylococcal scalded skin syndrome Toxic shock syndrome BACTERIAL INFECTIONS OF THE RESPIRATORY TRACT Upper respiratory tract infections Scarlet fever Clinical features Diphtheria Clinical features Diagnosis Management Prevention Acute epiglottitis Lower respiratory tract infections BACTERIAL INFECTIONS OF THE GASTROINTESTINAL TRACT Gastroenteritis Mucosal adherence Mucosal invasion Toxin production Clinical syndromes Salmonella Campylobacter jejuni Shigella Enteroinvasive Escherichia coli Enterohaemorrhagic Escherichia coli Enterotoxigenic Escherichia coli Vibrio Yersiniosis Enterotoxin-producing Staphylococcus aureus Bacillus cereus Clostridial infections Clostridium difficile Pathogenesis Clinical features Diagnosis Management Prevention Clostridium perfringens Travellers’ diarrhoea Management of acute gastroenteritis Food poisoning Enteric fever, Helicobacter pylori, Whipple’s disease and bacterial peritonitis BACTERIAL INFECTIONS OF THE CARDIOVASCULAR SYSTEM Rheumatic fever Clinical features Management Prognosis BACTERIAL INFECTIONS OF THE NERVOUS SYSTEM Bacterial meningitis Meningococcal sepsis Clinical features Diagnosis Management Cerebral abscess Toxin-mediated infections Tetanus Clinical features Diagnosis Management Prevention BACTERIAL BONE AND JOINT INFECTIONS BACTERIAL INFECTIONS OF THE URINARY TRACT SYSTEMIC/MULTISYSTEM BACTERIAL INFECTIONS Leptospirosis Clinical features Diagnosis Management Brucellosis Clinical features Diagnosis Management and prevention Listeriosis Q fever Clinical features Management Lyme disease Clinical features Diagnosis Management Tularaemia BACTERIAL INFECTIONS SEEN IN DEVELOPING AND TROPICAL COUNTRIES Clinical features Diagnosis Management Prevention Anthrax Clinical features Diagnosis Management Control Mycobacterial ulcer (buruli ulcer) Tropical ulcer Endemic treponematoses Yaws Bejel (endemic syphilis) Pinta Trachoma Clinical features Diagnosis and management Prevention Gastrointestinal infections Clinical features Diagnosis Management Enteric fever Clinical features Diagnosis Management Prevention Systemic infections Non-tuberculous mycobacterial infections Plague Clinical features Diagnosis Management Prevention Relapsing fevers Louse-borne relapsing fever Tick-borne relapsing fever Diagnosis and management Prevention Rickettsiae and rickettsia-like infections Typhus group Epidemic typhus Endemic (murine) typhus Spotted fever group Scrub typhus Diagnosis Management and prevention Bartonellosis Carrion’s disease (Bartonella bacilliformis) Cat-scratch disease and bacillary angiomatosis (Bartonella henselae) Trench fever Ehrlichiosis Other bacterial infections Actinomycosis Nocardia infections ANTIBIOTIC THERAPIES FUNGAL INFECTIONS SYSTEMIC FUNGAL INFECTIONS Candidiasis Clinical features Diagnosis and management Candida auris Histoplasmosis Clinical features Diagnosis Management African histoplasmosis Aspergillosis Cryptococcosis Diagnosis and management Coccidioidomycosis Clinical features Diagnosis Management Blastomycosis Clinical features Diagnosis and management Paracoccidioidomycosis Mucormycosis SUBCUTANEOUS FUNGAL INFECTIONS Sporotrichosis Subcutaneous zygomycosis Chromoblastomycosis Mycetoma (Madura foot) Pneumocystis jirovecii infection SUPERFICIAL FUNGAL INFECTIONS Dermatophytosis Malassezia infection ANTIFUNGAL DRUGS Polyenes Azoles Imidazoles Triazoles Echinocandins Flucytosine Allylamines PROTOZOAL INFECTIONS BLOOD AND TISSUE PROTOZOA Malaria Epidemiology Parasitology Pathogenesis Clinical features Diagnosis Management Uncomplicated malaria Severe falciparum malaria Prevention and control Trypanosomiasis Epidemiology Parasitology Clinical features Diagnosis Management Control South American trypanosomiasis (Chagas’ disease) Clinical features Diagnosis Management and control Leishmaniasis Visceral leishmaniasis Clinical features Diagnosis Management HIV co-infection Cutaneous leishmaniasis Diagnosis and management Mucocutaneous leishmaniasis Diagnosis and management Other protozoal diseases of the blood and tissues Clinical features Diagnosis Management Babesiosis GASTROINTESTINAL PROTOZOA Amoebiasis Clinical features Diagnosis Management Prevention Giardiasis Clinical features Diagnosis Management Cryptosporidiosis Balantidiasis Blastocystis hominis infection Cyclospora cayetanensis infection Microsporidiosis HELMINTHIC INFECTIONS NEMATODES Lymphatic filariasis Clinical features Diagnosis Management Loiasis Onchocerciasis Pathogenesis Clinical features Diagnosis Management and prevention Mansonellosis Dracunculiasis Human intestinal nematodes Ascariasis (roundworm infection) Threadworm (Enterobius vermicularis) Whipworm (Trichuris trichiura) Hookworm Clinical features Diagnosis and management Strongyloidiasis Clinical features Diagnosis and management Zoonotic nematodes Trichinosis Toxocariasis (visceral larva migrans) Cutaneous larva migrans TREMATODES Water-borne flukes Parasitology and pathogenesis Clinical features S. haematobium infection (bilharzia) S. mansoni S. japonicum Diagnosis Management Prevention Food-borne flukes Paragonimiasis Liver flukes Other food-borne flukes Management of trematode infections CESTODES Taenia saginata Taenia solium and cysticercosis Management of cysticercosis Cerebral cysticercosis Diphyllobothrium latum Hydatid disease ARTHROPOD ECTOPARASITES LOCAL HYPERSENSITIVITY REACTIONS RESIDENT ECTOPARASITE INFECTIONS Scabies Jiggers Myiasis SYSTEMIC ENVENOMING VECTORS OF INFECTION 21 - Endocrinology Endocrinology History and examination Dynamic endocrine tests Introduction Hormonal activity Synthesis, storage and release of hormones Plasma transport Hormone action and receptors Mechanisms of hormone–receptor action Hormone release and binding to receptors Control and feedback Primary and secondary gland failure Hormone excess Hormone resistance Measurement of hormones Hormone-binding proteins Patterns of hormonal secretion Biological rhythms Other regulatory factors Aetiology and pathology Autoimmune disease Endocrine tumours Enzyme defects Receptor abnormalities Endocrine investigations Basal blood levels Stress-related hormones Urine collections Saliva Stimulation and suppression tests Radiological investigations The pituitary gland and hypothalamus Anatomy Physiology Hypothalamus Anterior pituitary Posterior pituitary Presentation of pituitary and hypothalamic disease Pituitary space-occupying lesions and tumours Approach for a possible or proven mass Is there a tumour Investigations Is there a hormonal excess Is there a deficiency of any hormone Management Removal/control of tumour Reduction of excess hormone secretion Replacement of hormone deficiencies Differential diagnosis of pituitary or hypothalamic masses Other tumours Hypophysitis and other inflammatory masses Other lesions Hypopituitarism Genetics Aetiology Clinical features Kallmann’s syndrome Septo-optic dysplasia Sheehan’s syndrome Pituitary apoplexy ‘Empty sella’ syndrome Investigations Management Hypothalamo–Pituitary–adrenal axis The adrenal cortex Glucocorticoids Mineralocorticoids Androgens Biochemistry Physiology Investigation of glucocorticoid abnormalities Basal levels Dexamethasone suppression tests ACTH stimulation tests Cushing’s syndrome Pathophysiology and aetiology History and examination Investigations Confirmation Differential diagnosis of the cause Management Cushing’s syndrome Cushing’s disease (pituitary-dependent hypercortisolism) Cushing’s syndrome due to other causes Nelson’s syndrome Addison’s disease History and examination Investigations Management Patient advice Secondary hypoadrenalism Congenital adrenal hyperplasia History and examination Investigations Management Prenatal diagnosis Problems of therapeutic steroid therapy Supervision of steroid therapy Steroids and surgery Incidental adrenal tumours (‘incidentalomas’) Primary hyperaldosteronism Pathophysiology Aetiology History and examination Investigations Management Glucocorticoid (or dexamethasone)-suppressible hyperaldosteronism Syndrome of apparent mineralocorticoid excess The adrenal medulla Phaeochromocytoma and paraganglioma Pathology History and examination Investigations Management The thyroid axis Anatomy and physiology Physiology Synthesis Control of the hypothalamic–pituitary–thyroid axis Physiological effects of thyroid hormones Dietary iodine requirement Investigations: thyroid function tests TSH measurement TRH test Problems in interpretation of thyroid function tests Serious acute or chronic illness Pregnancy and oral contraceptives Drugs Anti-thyroid antibodies Hypothyroidism Aetiology of primary hypothyroidism Autoimmune Atrophic (autoimmune) hypothyroidism Hashimoto’s thyroiditis Postpartum thyroiditis Dyshormonogenesis History and examination Investigation of primary hypothyroidism Management Replacement therapy Monitoring Borderline hypothyroidism or ‘compensated euthyroidism’ Myxoedema coma Myxoedema madness Screening for hypothyroidism Hyperthyroidism Graves’ disease Other causes of hyperthyroidism/thyrotoxicosis Solitary toxic adenoma/nodule Toxic multinodular goitre De Quervain’s thyroiditis Postpartum thyroiditis Amiodarone-induced thyrotoxicosis Immunotherapy-induced thyrotoxicosis History and examination Differential diagnosis Investigations Management Anti-thyroid drugs Relapse Toxicity Radioactive iodine Long-term surveillance Surgery Special situations in hyperthyroidism Thyroid crisis or ‘thyroid storm’ Hyperthyroidism in pregnancy and neonatal life The fetus and maternal Graves’ disease Thyroid hormone resistance Long-term consequences of hyperthyroidism Graves’ orbitopathy (ophthalmopathy) Clinical features Investigations Management Goitre (thyroid enlargement) Clinical features Diagnosis Diffuse goitre Simple goitre Autoimmune thyroid disease Thyroiditis Nodular goitres Multinodular goitre Solitary nodular goitre Fibrotic goitre (Riedel’s thyroiditis) Malignancy Investigations Management Euthyroid goitre Toxic nodule Thyroid carcinoma Papillary and follicular carcinomas Medullary carcinoma Anaplastic carcinomas and lymphoma Hypothalamo–pituitary–gonadal axis Anatomy and physiology Physiology The male The female Clinical features of disorders of sex and reproduction Investigation of gonadal function Disorders in the male Investigations Management Special instances of hypogonadism Cryptorchidism Klinefelter’s syndrome Kallmann’s syndrome Normosmic idiopathic hypogonadotropic hypogonadism Oligospermia and azoospermia Gynaecomastia Pubertal gynaecomastia Gynaecomastia in the older male The ageing male Disorders in the female Amenorrhoea Polycystic ovary syndrome Hypothalamic and weight-related amenorrhoea Premature ovarian insufficiency Investigation of oligo-amenorrhoea Management Hirsutism Normal hair versus hirsutism Aetiology Management Polycystic ovary syndrome History and examination Investigations and differential diagnosis Diagnosis Management Local therapy for hirsutism Systemic therapy for hirsutism Treatment of menstrual disturbance Treatment for fertility in PCOS Disorders of sex development Growth and puberty Normal growth and puberty Physiology Puberty Assessment of growth and puberty Growth Puberty Tanner staging Disorders of stature Investigations Management of short stature Tall stature Pubertal disorders Investigations Management Precocious puberty Gonadotrophin-dependent precocious puberty Gonadotrophin-independent precocious puberty Management Acromegaly and gigantism History and examination Investigations Management Surgery Pituitary radiotherapy Medical therapy Somatostatin receptor agonists Dopamine agonists Growth hormone antagonists Hyperprolactinaemia Aetiology History and examination Investigations Management Medical treatment Trans-sphenoidal surgery Radiotherapy The Thirst Axis Diabetes insipidus Aetiology Biochemistry Management Nephrogenic diabetes insipidus Other causes of polyuria and polydipsia Primary polydipsia Syndrome of inappropriate antidiuretic hormone secretion Investigations Management Disorders of Calcium Metabolism Parathyroid hormone Hypercalcaemia Primary hyperparathyroidism Secondary hyperparathyroidism Tertiary hyperparathyroidism Clinical features Mild hypercalcaemia Severe hypercalcaemia Investigations and differential diagnosis Imaging Management of hypercalcaemia Management of primary hyperparathyroidism Medical management Surgery Surgical technique and complications Postoperative care Familial hypocalciuric hypercalcaemia Hypocalcaemia Aetiology Clinical features Investigations Management Hypoglycaemia in the non-diabetic patient Insulinomas Management Hypoglycaemia with other tumours Postprandial hypoglycaemia Hepatic and renal causes of hypoglycaemia Endocrine causes of hypoglycaemia Drug-induced hypoglycaemia Alcohol-induced hypoglycaemia Factitious hypoglycaemia Other endocrine disorders Autoimmune polyendocrinopathy type 1 Multiple endocrine neoplasias MEN 1 MEN 2a and 2b Management Screening Screening for MEN 1 Screening for MEN 2 McCune–Albright syndrome Ectopic hormone secretion Endocrine treatment of other malignancies 22 - Dermatology CLINICAL SKILLS FOR DERMATOLOGY History and examination Epidermis Dermis Subcutis INVESTIGATION OF SKIN DISEASE PRINCIPLES OF DERMATOLOGICAL THERAPY Topical therapy Phototherapy Systemic therapy ERYTHRODERMA AND LOSS OF SKIN FUNCTION (‘SKIN FAILURE’) COMMON RASHES Acne and related disorders Rosacea Other rarer causes of facial rashes Eczema/dermatitis Psoriasis Other common papulosquamous rashes Urticaria and angio-oedema SKIN INFECTIONS Bacterial infections Viral infections Fungal infections Infestations Tropical dermatoses Tropical dermatoses HUMAN IMMUNODEFICIENCY VIRUS AND THE SKIN SKIN SIGNS OF SYSTEMIC DISEASE Endocrine disease Metabolic disease Pruritus Haematological disease Chronic liver disease Chronic renal disease Autoimmune rheumatic disease Disorders of blood vessels and lymphatics Leg ulcers Lymphatic disease Systemic malignant disease Genetic disease PHOTOSENSITIVITY BLISTERING AND BULLOUS SKIN DISEASE Immunobullous diseases Mechanobullous diseases (epidermolysis bullosa) SKIN TUMOURS Benign skin tumours Dysplastic/pre-malignantskin lesions Malignant skin tumours DISORDERS OF PIGMENTATION Hypopigmentation Hyperpigmentation NAIL DISORDERS HAIR DISORDERS Hair loss (alopecia) NAIL DISORDERS Increased hair growth BIRTH MARKS AND NEONATAL RASHES DRUG ERUPTIONS Maculopapular (morbilliform) exanthems Fixed drug eruptions Drug-inducedand drug-exacerbateddermatoses Severe cutaneous adverse drug reactions 23 - Diabetes mellitus CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR DIABETES MELLITUS Routine checks in people with diabetes INTRODUCTION PHYSIOLOGY OF INSULIN STRUCTURE, SECRETION AND ACTION Glucose metabolism Glucose production Glucose utilization Glucose transport Hormonal regulation CLASSIFICATION OF DIABETES Type 1 diabetes mellitus Epidemiology Aetiology Genetic susceptibility and inheritance Human leucocyte antigen system Other genes or gene regions Environmental factors Type 2 diabetes mellitus Epidemiology Aetiology Genetic susceptibility and inheritance Ageing Fetal origins of diabetes Obesity Diet Physical inactivity Other factors Pathogenesis Abnormalities of insulin action Abnormalities of insulin secretion Other hormonal abnormalities Glucose reabsorption in the kidney Monogenic diabetes mellitus CLINICAL APPROACH TO THE PATIENT WITH DIABETES Presentation Acute presentation Subacute presentation Complications as the presenting feature Asymptomatic diabetes Physical examination at diagnosis Diagnosis and investigations PREVENTION OF TYPE 2 DIABETES MANAGEMENT OF DIABETES Aims of diabetes care Role of self-management education Diet Physical activity Tobacco smoking Insulin Short-acting insulins Intermediate and longer-acting insulins Strengths of insulin Insulin regimens Basal-bolus regimen Twice-daily mixed insulin regimen Basal-only and basal-plus insulin regimens Insulin administration Lipohypertrophy and lipoatrophy Inhaled insulin Challenges of insulin therapy Hypoglycaemia Management of hypoglycaemia Weight gain Oral non-insulin treatments for type 2 diabetes Biguanides: metformin Mode of action Clinical use Adverse effects Sulphonylureas Mode of action Clinical use Adverse effects Meglitinides or post-prandial insulin releasers Mode of action Clinical use Adverse effects Thiazolidinediones or ‘glitazones’ Mode of action Clinical use Adverse effects Dipeptidyl peptidase-4 inhibitors or ‘gliptins’ Mode of action Clinical use Adverse effects Sodium-glucose transporter 2 inhibitors (‘flozins’) Mode of action Clinical use Adverse effects Alpha-glucosidase inhibitors Mode of action Clinical use Adverse effects Other oral therapies Quick-release bromocriptine Colesevelam Non-insulin injectable therapies for type 2 diabetes GLP-1 receptor agonists Mode of action Clinical use Adverse effects Amylin analogues Which drug and when? Measuring the metabolic control of diabetes Short-term measures of metabolic control Self-monitoring of capillary blood glucose Continuous glucose monitoring Long-term measures of metabolic control Glycated haemoglobin (HbA1c) Fructosamine Whole-pancreas and pancreatic islet transplantation Islet transplantation Whole-pancreas transplantation DIABETIC METABOLIC EMERGENCIES Diabetic ketoacidosis Pathogenesis Clinical features Diagnosis Management Replacement of the fluid losses Replacement of the electrolyte losses Restoration of the acid–base balance Insulin replacement Monitoring progress Seeking the underlying cause Other measures Complications of diabetic ketoacidosis On-going management Hyperosmolar hyperglycaemic state Clinical features Investigations and management Prognosis Lactic acidosis COMPLICATIONS OF DIABETES Microvascular complications Pathology of microvascular complications Formation of advanced glycation end products (AGE) Increased flux of glucose through the sorbitol–polyol pathway Abnormal microvascular blood flow Growth factors and cytokines Growth hormone–insulin-like growth factor axis Diabetic retinopathy Early changes without vision loss Transition to sight-threatening retinopathy Sight-threatening retinopathy Maculopathy Management of retinopathy Intravitreal injection Laser photocoagulation Vitreoretinal surgery Other ways in which diabetes can affect the eye Cataract Refractory defects External ocular palsies Glaucoma Blindness Clinical examination of the eye Eye screening Diabetic nephropathy Pathophysiology Albuminuria Other features of diabetic nephropathy Screening for diabetic nephropathy Investigation of microalbuminuria and proteinuria Management of nephropathy Management of end-stage renal disease Other ways that diabetes can damage the kidney Ischaemic lesions Diabetic neuropathy Symmetrical distal polyneuropathy Acute painful neuropathy Mononeuritis and mononeuritis multiplex (multiple mononeuropathy) Diabetic amyotrophy Autonomic neuropathy The cardiovascular system Gastrointestinal tract Bladder involvement Sexual dysfunction The diabetic foot Charcot neuroarthropathy Management of the diabetic foot Foot ulceration Ischaemia Infection Wound environment Multidisciplinary diabetic foot team Macrovascular complications Pathogenesis Management of atherosclerotic cardiovascular risk Heart failure OTHER COMPLICATIONS OF DIABETES Non-alcoholic liver disease and other gastrointestinal manifestations of diabetes Infections Cancer Skin and joints PSYCHOSOCIAL IMPLICATIONS OF DIABETES Psychological problems associated with diagnosis Diabetes-related distress Fear of hypoglycaemia Depression Eating disorders Consequences of psychological and psychiatric disorders of diabetes Management of psychological issues Social aspects of diabetes DIABETES IN SPECIAL SITUATIONS Diabetes in childhood, adolescence and early adulthood Diabetes in older people and at the end of life Inpatient diabetes Management of diabetes during an admission for surgery Diabetes in pregnancy Adverse effects of diabetes in pregnancy Management of diabetes during pregnancy Pre-conception care Antenatal management Birth Postnatal care Gestational diabetes Diagnosis of gestational diabetes Management of gestational diabetes ORGANIZATION OF DIABETES CARE 24 - Lipid and metabolic disorders INTRODUCTION Approach to the patient History Examination DISORDERS OF LIPID METABOLISM Chylomicrons Very-low-density lipoprotein particles Intermediate-density lipoprotein particles Low-density lipoprotein particles Lipoprotein(a) High-density lipoprotein particles Measurement of serum lipids Plasma lipids and cardiovascular risk Hyperlipidaemia Secondary hyperlipidaemia Primary hyperlipidaemia Disorders of VLDL and chylomicrons:moderate and severe hypertriglyceridaemia Lipoprotein lipase pathway deficiencies Disorders of LDL: hypercholesterolaemia alone Heterozygous familial hypercholesterolaemia Homozygous familial hypercholesterolaemia Mutations in the apoB and PCSK9 genes Polygenic hypercholesterolaemia Disorders of HDL Tangier disease Combined hyperlipidaemia (hypercholesterolaemia and hypertriglyceridaemia) Familial combined hyperlipidaemia (FCHL) Remnant hyperlipidaemia Management of hyperlipidaemia Lipid-lowering diet Exercise, weight loss and smoking Drugs Statins Gut-acting cholesterol-lowering drugs PCSK9 inhibitors Fibrates Omega-3 fatty acids Screening Management of hypertriglyceridaemia Management of hypercholesterolaemia (without hypertriglyceridaemia) Familial hypercholesterolaemia Primary prevention for people with type 2 diabetes Primary prevention for people without diabetes Secondary prevention Risk prediction tables Management of combined hyperlipidaemia Other lipid disorders Abetalipoproteinaemia INHERITED METABOLIC DISEASES Acute presentations of IMDs Management of acute presentations of inborn errors Known IMD Suspected IMD Encephalopathy Disorders of ammonia metabolism Rhabdomyolysis Stroke Hypoglycaemia Acidosis Mitochondrial diseases Diagnosis Management Disorders of protein metabolism Lysosomal storage disorders Disorders of carbohydrate metabolism Disorders of fatty acid oxidation defects Porphyrias Peroxisomal diseases Adult Refsum’s disease 25 - Liaison psychiatry INTRODUCTION Provision of psychiatric care in the general hospital Epidemiology and vulnerable patient groups CLINICAL APPROACH TO THE PATIENT WITH A PSYCHIATRIC DISORDER Psychiatric history Mental state examination Aspects of the MSE Appearance and general behaviour Speech Mood and affect Thoughts Abnormal perceptions Cognitive state Insight and illness beliefs Defence mechanisms Risk assessment Severe behavioural disturbance Management of the severely disturbed patient Relevant physical examination Summary or formulation CLASSIFICATION OF PSYCHIATRIC DISORDERS AETIOLOGY OF PSYCHIATRIC DISORDERS PSYCHIATRIC ASPECTS OF PHYSICAL DISEASES SICK ROLE AND ILLNESS BEHAVIOUR FUNCTIONAL SOMATIC SYNDROMES Chronic fatigue syndrome Clinical features Aetiology Management Prognosis Fibromyalgia (chronic widespread pain) Management Other chronic pain syndromes Aetiology Management Irritable bowel syndrome Management Multiple chemical sensitivity, Candida hypersensitivity and food allergies Aetiology Management Premenstrual syndrome Management Menopause SOMATOFORM DISORDERS Somatization disorder Hypochondriasis Management of somatoform disorders DISSOCIATIVE/CONVERSION DISORDERS Clinical features Differential diagnosis Aetiology Management Prognosis SLEEP DIFFICULTIES Insomnia Primary sleep disorders Delayed sleep phase syndrome Parasomnias Psychophysiological insomnia Clinical Features Hypersomnia Management of insomnia MOOD (AFFECTIVE) DISORDERS Unipolar affective disorders Depressive disorders Clinical features of depressive disorder Epidemiology Dysthymia Seasonal affective disorder Puerperal affective disorders Differential diagnosis of depressive disorders Investigation of depressive disorders Aetiology of unipolar depressive disorders Genetic factors Biochemical changes Monoamines Hypothalamo–pituitary–adrenal axis Brain-derived neurotrophic factor Neuroimaging changes Sleep Childhood traumas and personality Social factors An integrated model of aetiology Management of depressive illness Psychological treatments Cognitive behaviour therapy Interpersonal psychotherapy Other psychotherapies Physical treatments Exercise and other self-help Use of drugs in the treatment of clinical depression Drug choices in specific circumstances Selective serotonin reuptake inhibitors Tricyclic antidepressants Serotonergic and noradrenergic antidepressants Monoamine oxidase inhibitors Reversible inhibitors of monoamine oxidase A Selective irreversible inhibitors of monoamine oxidase B Melatonin receptor agonist and serotonin receptor antagonist Antidepressant augmentation Antidepressant use in general medicine Combining antidepressants with psychotherapy Electroconvulsive therapy Uncommonly used physical treatments Social treatments Prognosis Mania, hypomania and bipolar disorder Differential diagnosis Epidemiology Aetiology Genetic factors Biochemical changes Psychological factors Management Acute mania or hypomania Prevention of relapses Lithium Plasma levels Toxicity Pregnancy Other mood stabilizers Prognosis SUICIDE AND SELF-HARM ANXIETY DISORDERS Generalized anxiety disorder Clinical features Mixed anxiety and depressive disorder Panic disorder Aetiology Phobic (anxiety) disorders Aetiology Agoraphobia Social phobia Simple phobias Management of anxiety disorders Psychological management Drug treatments Acute stress reactions and adjustment disorders Acute stress reaction Adjustment disorder Normal grief Pathological (abnormal) grief Post-traumatic stress disorder Clinical features Management and prevention The adult consequences of childhood abuse Management Psychodynamic psychotherapy Cognitive analytical therapy Obsessive–compulsive disorder Clinical features Aetiology Genetic factors Biological model Cognitive behavioural model Management Psychological management Physical management Tricyclic antidepressants (TCAs) and serotonin reuptake inhibitors (SSRIs) Deep brain stimulation Psychosurgery Prognosis ALCOHOL MISUSE AND DEPENDENCE Epidemiology Diagnosis Guidelines Diagnostic markers of alcohol misuse Alcohol dependence syndrome Course Delirium tremens Aetiology of alcohol dependence Genetic factors Environmental factors Neurobiological factors Psychiatric illness Excess consumption in society Management Psychological management of problem drinking Drug treatments for problem drinking Alcohol withdrawal and delirium tremens Drugs for prevention of alcohol dependence Prognosis DRUG MISUSE AND DEPENDENCE Aetiology of drug misuse Drugs of misuse and their effects Inhaled substances Amfetamines and related substances Cocaine Hallucinogenic drugs Cannabis Tranquillizers Opiates Management of chronic misuse Drug-induced psychosis SCHIZOPHRENIA Aetiology Clinical features Differential diagnosis Management Antipsychotic drugs Neuroleptic malignant syndrome Pregnancy Typical or first-generation antipsychotics Atypical antipsychotics or serotonin dopamine antagonists Psychological management Social management Medical presentations related to treatment Prognosis ORGANIC MENTAL DISORDERS Delirium Management Prognosis EATING DISORDERS Obesity Anorexia nervosa Clinical features Aetiology Genetic Hormonal Psychological factors Individual Family Social and cultural factors Management Prognosis Bulimia nervosa Management Atypical eating disorders SEXUAL DISORDERS Sexual dysfunction Sexual deviation Gender role disorders PERSONALITY DISORDERS INVOLUNTARY DETENTION MENTAL CAPACITY ACT 26 - Neurology CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR NEUROLOGY History Examination Putting it all together INTRODUCTION CLINICAL APPROACH TO THE PATIENT WITH NEUROLOGICAL DISEASE Clinical features of neurological disease Difficulty walking and falls Spasticity and hemiparesis Parkinson’s disease: shuffling gait Cerebellar ataxia: broad-based gait Sensory ataxia: stamping gait Lower limb weakness: high-stepping and waddling gaits Gait apraxia Falls Dizziness, vertigo and blackouts Examination and formulation FUNCTIONAL NEUROANATOMY Neurone and synapse Neurotransmitters Clinical features of focal brain lesions: general mechanisms Localization within the cerebral cortex Dominant hemisphere (usually left) Aphasia Broca’s (expressive, anterior) aphasia Wernicke’s (receptive, posterior) aphasia Nominal (anomic) aphasia Global (central) aphasia Dysarthria Non-dominant hemisphere Memory and its disorders Essential elements of neuroanatomy CRANIAL NERVES I: Olfactory nerve II: Optic nerve and visual system Visual field defects Retinal and local eye lesions Optic nerve lesions Papilloedema Inflammatory optic neuropathy (optic neuritis) Anterior ischaemic optic neuropathy Optic atrophy Optic chiasm Optic tract and optic radiation Occipital cortex Pupils Horner’s syndrome Myotonic pupil (Holmes–Adie pupil) Argyll Robertson pupil III, IV, VI: Oculomotor, trochlear and abducens nerves Examination of eye movements Control of eye movements Abnormalities of conjugate lateral gaze Internuclear ophthalmoplegia One and a half syndrome Vestibulo-ocular (doll’s eye) reflexes Abnormalities of vertical gaze Nystagmus Jerk nystagmus Pendular nystagmus III: Oculomotor nerve lesions IV: Trochlear nerve lesions VI: Abducens nerve lesions Complete external ophthalmoplegia V: Trigeminal nerve Clinical features of a Vth nerve lesion Aetiology Trigeminal neuralgia Trigeminal sensory neuropathy VII: Facial nerve Unilateral facial weakness Causes of facial weakness Bell’s palsy Management and prognosis Ramsay Hunt syndrome Bilateral facial weakness Hemifacial spasm Management Other involuntary facial movements VIII: Vestibulocochlear nerve Basic investigations of cochlear lesions Causes of deafness Vertigo and the vestibular system Vertigo The dizzy patient Causes of vertigo Peripheral (vestibular) disorders Central causes of vertigo Basic investigations for vestibular problems Vestibular neuronitis Lower cranial nerves IX, X, XI, XII Glossopharyngeal (IX) Vagus (X) Accessory (XI) Hypoglossal (XII) IXth and Xth nerve lesions XIth nerve lesions XIIth nerve lesions Bulbar and pseudobulbar palsy Bulbar palsy Pseudobulbar palsy Dropped head syndrome MOTOR CONTROL SYSTEMS Corticospinal (pyramidal) system Characteristics of pyramidal lesions Pyramidal drift of an upper limb Weakness and loss of skilled movement Changes in tone and tendon reflexes Changes in superficial reflexes Patterns of UMN disorders Hemiparesis Spastic paraparesis Extrapyramidal system Essential anatomy Function and dysfunction Proposed model of principal pathways Cerebellum Cerebellar lesions Lateral cerebellar hemisphere lesions Midline cerebellar lesions Tremor Postural tremor Intention tremor Rest tremor Other tremors LOWER MOTOR NEURONE LESIONS Clinical features of lower motor neurone lesions Aetiology Spinal reflex arc SENSORY PATHWAYS AND PAIN Peripheral nerves and spinal roots Spinal cord Posterior columns Spinothalamic tracts Sensory cortex Lesions of the sensory pathways Peripheral nerve lesions Neuralgia Spinal root lesions Root pain Dorsal spinal root lesions Spinal cord lesions Posterior column lesions Lhermitte’s phenomenon Spinothalamic tract lesions Spinal cord compression Pontine lesions Thalamic lesions Parietal cortex lesions Pain Essential physiology of pain Gate theory of pain Peripheral and central sensitization Plasticity and receptor changes Neuropathic pain Neurotransmitters and receptors involved in pain Management of chronic pain Diagnostic Psychological Analgesics Co-analgesics Stimulation Nerve blocks Neurosurgery BLADDER CONTROL AND SEXUAL DYSFUNCTION Essential functions and anatomy Neurological disorders of micturition Male erectile dysfunction INVESTIGATION OF NEUROLOGICAL DISEASE Neuroimaging Skull and spinal X-rays Brain computed tomography CT angiography Spinal CT and CT myelography Magnetic resonance imaging Doppler studies Catheter angiography Positron emission tomography, single proton emission computed tomography, dopamine transporter imaging and functional MRI Isotope bone scanning Neurophysiological investigations Electroencephalography Epilepsy Diffuse brain disorders Brain death Electromyography and nerve conduction studies Electromyography Peripheral nerve conduction Cerebral-evoked potentials Lumbar puncture and cerebrospinal fluid examination Biopsy Brain and meninges Muscle Peripheral nerve Psychometric assessment Routine tests Specialized tests in specific diseases Genetic tests Immunological tests UNCONSCIOUSNESS AND COMA Disturbed consciousness: definitions The unconscious patient Immediate assessment and management General and neurological examination General examination Neurological examination Depth of coma Eye movements and position Other brainstem reflexes Lateralizing signs Coma ‘look-alikes’ Diagnosis and investigations in coma Blood and urine Brain imaging CSF examination Electroencephalography General management Prognosis in coma and the vegetative state STROKE Definitions Pathophysiology Ischaemic stroke Carotid and vertebral artery dissection Venous stroke Haemorrhagic stroke Transient ischaemic attacks Risk factors for stroke Other risk factors and rarer causes of stroke Vascular anatomy Clinical syndromes Transient ischaemic attack (TIA) Clinical features Amaurosis fugax Diagnosis Differential diagnosis Prognosis Cerebral infarction Clinical features Anterior circulation infarcts Posterior circulation infarcts Lacunar infarction Multi-infarct dementia (vascular dementia) Watershed (border-zone) infarction Investigations in stroke Neuroimaging Cardiac investigations Other investigations Acute stroke: immediate care and thrombolysis Thrombolysis Antiplatelet therapy and anticoagulation Decompressive craniectomy Stroke units Secondary prevention interventions Antihypertensive therapy Lipid-lowering therapy Lifestyle modification and education Surgery and stenting for carotid stenosis Stroke in the elderly Rehabilitation: multidisciplinary approach Prognosis INTRACRANIAL HAEMORRHAGE Intracerebral haemorrhage Aetiology Clinical features and investigations Management of haemorrhagic stroke Medical Surgical Subarachnoid haemorrhage Aetiology Saccular (berry) aneurysms Arteriovenous malformation Clinical features of subarachnoid haemorrhage Investigations Differential diagnosis Complications Management Subdural and extradural bleeding Subdural haematoma Extradural haemorrhage Management Cortical venous thrombosis and dural venous sinus thrombosis Cortical venous thrombosis Dural venous sinus thromboses Management HEADACHE, MIGRAINE AND FACIAL PAIN Mechanisms Clinical approach to the patient with headache Taking a history for ‘headaches’ Examination Investigations Primary headache disorders Mechanisms Clinical features Migraine without aura Migraine with aura Migraine-related dizziness Hemiplegic migraine Management Acute treatment of attacks Migraine suppression medication Tension-type headache Trigeminal autonomic cephalalgias Cluster headache Paroxysmal hemicrania and SUNCT Other primary headache disorders Chronic daily headache Secondary headache disorders Idiopathic intracranial hypertension Low-CSF-volume (low-pressure) headache Post-traumatic headache Facial pain Trigeminal neuralgia Clinical features Management Atypical facial pain Other causes of facial pain Giant cell arteritis (temporal arteritis) Clinical features Diagnosis and management EPILEPSY AND LOSS OF CONSCIOUSNESS Epilepsy Epidemiology Classification Generalized seizure types Typical absence seizures (petit mal) Generalized tonic–clonic seizures (grand mal seizures) Myoclonic, tonic and atonic seizures Focal seizure types Focal seizures with aura Focal motor seizures Focal seizures with altered awareness or responsiveness Epilepsy syndromes and aetiology of epilepsy Primary generalized epilepsies Focal epilepsy Hippocampal sclerosis Genetic and developmental disorders Trauma, hypoxia and neurosurgery Brain tumours and other mass lesions Vascular disorders Cortical venous thrombosis or venous sinus thrombosis Neurodegenerative disorders Infection Immunological disorders Alcohol and drugs Metabolic abnormalities Diagnosis of the first fit and investigations Which investigations are needed? Electroencephalography Brain imaging Recurrence risk after a first fit Management Emergency measures Status epilepticus Antiepileptic drugs Unwanted effects of drugs Epilepsy in women Epilepsy and driving Lifestyle and safety Drug withdrawal Refractory epilepsy Epilepsy surgery Other causes of blackouts Syncope or faints Other types of syncope Investigations Other conditions Sleep disorders Narcolepsy and cataplexy Diagnosis and management Parasomnias Obstructive sleep apnoea Restless leg syndrome (Willis–Ekbom disease) MOVEMENT DISORDERS Parkinsonian disorders Aetiology Age and gender Environmental factors Genetic factors Pathology Clinical features Prodromal pre-motor symptoms Motor symptoms Akinesia Tremor Rigidity Postural and gait changes Speech and swallowing Cognitive and psychiatric changes Clinical evolution of PD Diagnosis Management Levodopa Dopamine agonists Other drugs used in PD Long-term response to treatment Deep brain stimulation Levodopa intestinal gel infusion Tissue transplantation Physiotherapy, occupational therapy and physical aids Other akinetic–rigid syndromes Atypical parkinsonism Wilson’s disease Hyperkinetic movement disorders Essential tremor Chorea Huntington’s disease Hemiballismus Myoclonus Primary myoclonus Myoclonus in epilepsy Progressive myoclonic epilepsy–ataxia syndromes Secondary myoclonus Tics Tourette’s syndrome Dystonias Primary dystonias Torticollis Writer’s cramp and task-specific dystonias Blepharospasm and oromandibular dystonia Dopa-responsive dystonia Neuroleptics and movement disorders Management NEUROINFLAMMATORY DISORDERS Multiple sclerosis Epidemiology Aetiology and pathogenesis Genetic susceptibility Environmental factors Pathology Clinical features Types of MS Clinical presentations Optic neuritis Brainstem demyelination Spinal cord lesions Common symptoms in MS Unusual presentations Late-stage MS Diagnosis Investigations The clinically isolated syndrome Management General measures Acute relapses Disease-modifying drugs Oral DMDs Treatment of aggressive RRMS Other drugs and symptomatic therapies Prognosis Transverse myelitis Neuromyelitis optica Acute disseminated encephalomyelitis Other neuroinflammatory conditions Neurosarcoidosis Behçet’s disease NERVOUS SYSTEM INFECTION Meningitis Pathology Clinical features Meningitic syndrome Specific varieties of meningitis Acute bacterial meningitis Viral meningitis Chronic meningitis (see below) Differential diagnosis Management Prophylaxis Chronic meningitis Investigation and management of tuberculous meningitis Malignant meningitis Cells in a sterile CSF (pleocytosis) Encephalitis Viral encephalitis Investigations Management Autoimmune encephalitis HIV and neurology CNS and peripheral nerve disease in HIV Other infections and post-infectious inflammatory conditions Herpes zoster (shingles) Clinical patterns and complications Neurosyphilis Asymptomatic neurosyphilis Meningovascular syphilis Tabes dorsalis General paralysis of the insane Other forms of neurosyphilis Management Neurocysticercosis Subacute sclerosing panencephalitis Progressive rubella encephalitis Mollaret’s meningitis Whipple’s disease Brain and spinal abscesses Clinical features and management Brain tuberculoma Subdural empyema and intracranial epidural abscess Spinal epidural abscess BRAIN TUMOURS Gliomas Meningiomas Neurofibromas (schwannomas) Other neoplasms Clinical features Direct effects of mass lesions Raised intracranial pressure Seizures Investigations Imaging Routine tests Lumbar puncture Biopsy and tumour removal Management HYDROCEPHALUS Infantile hydrocephalus Hydrocephalus in adults Management Normal pressure hydrocephalus TRAUMATIC BRAIN INJURY Skull fractures Mechanisms of brain damage Clinical course Late sequelae Management Immediate management Rehabilitation SPINAL CORD DISEASE Spinal cord compression Aetiology Management Other spinal cord disorders Anterior spinal artery occlusion Arteriovenous malformations of the cord Genetic disorders – hereditary spastic paraparesis (HSP) Vitamin B12 deficiency Other causes of a spastic paraparesis Care of the patient with paraplegia Syringomyelia and syringobulbia Pathophysiology Clinical features Investigations and management NEURODEGENERATIVE DISEASES Dementia Epidemiology Clinical assessment Examination Bedside cognitive assessment Investigations Mild cognitive impairment Causes of dementia Alzheimer’s disease Investigations Molecular pathology and aetiology Genetics of AD Environmental risk factors Dementia with Lewy bodies and Parkinson’s disease dementia Vascular dementia Frontotemporal dementia Pathology Prion diseases, including Creutzfeldt–Jakob disease Creutzfeldt–Jakob disease Variant CJD Other dementias Management of dementia Motor neurone disease Pathogenesis Clinical features Diagnosis Prognosis and management CONGENITAL DISORDERS Cerebral palsy Clinical features Dysraphism NEUROGENETIC DISORDERS Neurocutaneous syndromes Neurofibromatosis type 2 Tuberous sclerosis (epiloia) Von Hippel–Lindau disease Spinocerebellar ataxias Early-onset ataxia Late-onset ataxia PARANEOPLASTIC SYNDROMES PERIPHERAL NERVE DISEASE Mechanisms of damage to peripheral nerves Demyelination Axonal degeneration Compression Infarction Infiltration Nerve regeneration Types of peripheral nerve disease Mononeuropathies Carpal tunnel syndrome Ulnar nerve compression Radial nerve compression Lateral cutaneous nerve of the thigh compression Common peroneal nerve palsy Hereditary neuropathy with pressure palsies Mononeuritis multiplex Polyneuropathies (peripheral neuropathy) Immune-mediated neuropathies Clinical features Diagnosis Course and management Chronic inflammatory demyelinating polyradiculoneuropathy Multifocal motor neuropathy with conduction block Paraproteinaemic neuropathies Chronic sensorimotor neuropathy: no cause found Metabolic, toxic and vitamin deficiency neuropathies Metabolic neuropathies Diabetes mellitus Uraemia Thyroid disease Porphyria Amyloidosis Toxic neuropathies Alcohol Drugs and industrial toxins Vitamin deficiency neuropathies Thiamine (vitamin B1) Pyridoxine (vitamin B6) Vitamin B12 (cobalamin) Genetic neuropathies Charcot–Marie–Tooth disease Hereditary motor and sensory neuropathy type III Other polyneuropathies Neuropathy in cancer Neuropathies in systemic diseases Autonomic neuropathy Neuromuscular weakness complicating critical illness Plexus and nerve root lesions Cervical and lumbar degeneration Lateral cervical disc protrusion Lateral lumbar disc protrusion Acute low back pain Cervical spondylotic myelopathy Central thoracic disc protrusion The cauda equina syndrome Spinal stenosis Neuralgic amyotrophy Thoracic outlet syndrome Malignant infiltration and radiation plexopathy MUSCLE DISEASES Definitions Pathophysiology Diagnosis Serum muscle enzymes Neurogenetic tests Electromyography Muscle biopsy Imaging Inflammatory myopathies Metabolic and endocrine myopathies Thyroid disease Disorders of calcium and vitamin D metabolism Hypokalaemia Alcohol and drugs Drugs Myophosphorylase deficiency (McArdle’s syndrome) Malignant hyperpyrexia Neuromuscular junction disorders Clinical features Investigations Course and management Drug treatment Oral anticholinesterases Immunosuppressant drugs Thymectomy Plasmapheresis and intravenous immunoglobulin Lambert–Eaton myasthenic–myopathic syndrome Muscular dystrophies Duchenne muscular dystrophy and Becker’s muscular dystrophy Clinical features Investigations Management Limb-girdle and facioscapulohumeral dystrophy Myotonias Myotonic dystrophy Myotonia congenita Channelopathies Hyperkalaemic periodic paralysis Stiff person syndrome Mitochondrial diseases 27 - Ear, nose and throat and eye disease CORE SKILLS AND KNOWLEDGE CLINICAL APPROACH TO THE PATIENT WITH AN ENT COMPLAINT Ear symptoms Hearing loss Vertigo Tinnitus Nose symptoms Nasal blockage Rhinorrhoea Dysosmia Throat symptoms Odynophagia/dysphagia Dyspnoea Dysphonia DISORDERS OF THE EAR ANATOMY AND PHYSIOLOGY CLINICAL APPROACH TO THE PATIENT WITH A DISORDER OF THE EAR Examination Rinne test Weber test Pure-tone audiometry COMMON DISORDERS OF THE EAR The painful ear (otalgia) Otitis externa Otitis media Referred otalgia The discharging ear (otorrhoea) Cholesteatoma Hearing loss Perforated tympanic membrane Otitis media and otitis externa Secretory otitis media with effusion (‘serous otitis media’ or ‘glue ear’) Otosclerosis Presbycusis Noise trauma Acoustic neuroma Dizziness/vertigo Benign paroxysmal positional vertigo Diagnosis Ménière’s disease Management Labyrinthine or central causes of vertigo Tinnitus Management DISORDERS OF THE NOSE ANATOMY AND PHYSIOLOGY CLINICAL APPROACH TO THE PATIENT WITH A DISORDER OF THE NOSE Examination COMMON DISORDERS OF THE NOSE Epistaxis Rhinitis Nasal obstruction Sinusitis Management Anosmia Fractured nose DISORDERS OF THE THROAT ANATOMY AND PHYSIOLOGY CLINICAL APPROACH TO THE PATIENT WITH A DISORDER OF THE THROAT Examination COMMON DISORDERS OF THE THROAT Hoarseness (dysphonia) Nodules Reinke’s oedema Acute-onset hoarseness Stridor Management Tracheostomy Tonsillitis and pharyngitis Tonsillitis Glandular fever Quinsy (peritonsillar abscess) Snoring Dysphagia Pharyngeal pouch Foreign bodies Globus pharyngeus DISORDERS OF THE EYE APPLIED ANATOMY AND PHYSIOLOGY CLINICAL APPROACH TO THE PATIENT WITH A DISORDER OF THE EYE History and examination COMMON DISORDERS OF THE EYE Refractive errors Management Disorders of the lids Entropion Ectropion Dacryocystitis Blepharitis Management Conjunctivitis Bacterial conjunctivitis Clinical features Management Chlamydial conjunctivitis Clinical features Management Trachoma Viral conjunctivitis Adenoviral conjunctivitis Herpes simplex conjunctivitis Molluscum contagiosum conjunctivitis Phthiriasis palpebrarum Management Allergic conjunctivitis Seasonal/perennial conjunctivitis Corneal disorders Corneal abrasions Corneal foreign body High-velocity trauma Keratitis Herpes simplex keratitis Contact lens-related keratitis Keratoconus Management Corneal dystrophy Cataracts Aetiology Clinical features Investigations Management Glaucoma Primary open-angle glaucoma Clinical features Management Acute angle-closure glaucoma Clinical features Management Uveitis Anterior uveitis (iritis) Management Intermediate uveitis Management Posterior uveitis Management Disorders of the retina Management Central retinal artery occlusion Management Retinal detachment Retinitis pigmentosa Age-related macular degeneration Management Visual loss 28 - Respiratory disease CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR RESPIRATORY MEDICINE FUNCTION OF THE RESPIRATORY SYSTEM Anatomy Nose, pharynx and larynx Trachea, bronchi and bronchioles Alveoli Lungs Pleura Diaphragm Pulmonary vasculature and lymphatics Nerve supply to the lung Physiology Nose Breathing Mechanical process Control of respiration Airways of the lungs Control of airway tone Airflow Flow–volume loops Ventilation and perfusion relationships Alveolar stability Defence mechanisms of the respiratory tract Particle removal Particle expulsion Respiratory tract secretions The respiratory microbiome Innate and adaptive immunity CLINICAL APPROACH TO THE PATIENT WITH RESPIRATORY DISEASE Cough Sputum Haemoptysis Breathlessness Wheezing Chest pain Examination of the respiratory system Nose Chest Inspection Palpation and percussion Auscultation Added sounds Cardiovascular system examination Additional bedside tests Investigation of respiratory disease Imaging Chest X-ray Collapse and consolidation Pleural effusion Fibrosis Round shadows Miliary mottling Computed tomography Magnetic resonance imaging Positron emission tomography–computed tomography Scintigraphic imaging Ultrasound Respiratory function tests Tests of ventilatory function Spirometry Peak expiratory flow rate Other ventilatory function tests Flow–volume loops Lung volumes Transfer factor Measurement of blood gases Exhaled nitric oxide Six-minute walk test Cardiopulmonary exercise testing Nocturnal polygraphy Haematological and biochemical tests Sputum Sputum cytology Pleural aspiration Pleural biopsy Intercostal drain placement Fibreoptic bronchoscopy Mediastinoscopy Video-assisted thoracoscopic lung biopsy Skin-prick tests Bronchial provocation testing DISEASES OF THE UPPER RESPIRATORY TRACT Rhinitis The common cold (acute coryza) Other forms of rhinitis Seasonal rhinitis (intermittent) Perennial rhinitis (persistent) Perennial allergic rhinitis Perennial non-allergic rhinitis with eosinophilia Vasomotor rhinitis Nasal polyps Investigations and diagnosis Management Allergen avoidance H1 antihistamines Decongestants Anti-inflammatory drugs Corticosteroids Leukotriene antagonists Immunotherapy Sinusitis Pharyngitis Acute laryngotracheobronchitis Acute epiglottitis Influenza Clinical features Complications Diagnosis and management Prophylaxis Inhalation of foreign bodies Acute and chronic cough Management of acute cough Management of chronic cough OBSTRUCTIVE RESPIRATORY DISEASE Asthma Prevalence Classification Other clinical phenotypes Aetiology Atopy and allergy Genetic factors Environmental factors Precipitating factors Occupational sensitizers Non-specific factors Cold air and exercise Atmospheric pollution and irritant dusts, vapours and fumes Diet Emotion Drugs Clinical features Investigations Lung function tests Histamine or methacholine bronchial provocation test Trial of corticosteroids Exhaled nitric oxide Blood and sputum tests Chest X-ray Skin tests Allergen provocation tests Management Control of extrinsic factors Drug treatment Beta2-adrenoceptor agonists Inhaled corticosteroids Oral corticosteroids and steroid-sparing agents Leukotriene receptor antagonists Antimuscarinic bronchodilators Anti-inflammatory drugs Monoclonal antibodies Antibiotics Bronchial thermoplasty Asthma attacks Acute severe asthma Acute bronchitis Chronic bronchitis Chronic obstructive pulmonary disease Definition Epidemiology and aetiology Pathophysiology Structural changes Emphysema Pathogenesis Cigarette smoking Infections Alpha1-antitrypsin deficiency Clinical features Symptoms Signs Diagnosis Investigations Management Smoking cessation Drug therapy Bronchodilators Phosphodiesterase type 4 inhibitors Corticosteroids Antibiotics Mucolytic agents Oxygen therapy Pulmonary rehabilitation Additional measures COPD exacerbation Type II respiratory failure in COPD Prognosis of COPD Obstructive sleep apnoea Pathophysiology Diagnosis Investigations Management Chronic ventilatory failure Domiciliary non-invasive ventilation SMOKING Prevalence Toxic effects Dangers Smoking cessation RESPIRATORY INFECTION Pneumonia Community-acquired pneumonia Clinical features Initial assessment Investigations Chest X-ray Blood tests Other tests General management Prevention Complications of pneumonia Parapneumonic effusion and empyema Lung abscess Pneumonia in other settings Ventilator-associated pneumonia Aspiration pneumonia Pneumonia in immunocompromised patients Pneumocystis jirovecii pneumonia Tuberculosis Pathogenesis Primary tuberculosis Reactivation tuberculosis Clinical features and diagnosis Pulmonary TB Lymph node TB Other forms of TB Gastrointestinal TB TB of bone and spine Miliary TB Central nervous system TB Pericardial TB Skin Microbiological diagnosis Stains Culture Nucleic acid amplification and polymerase chain reaction Management Unwanted effects of drug treatment Drug resistance TB in special situations Mycobacterium bovis infection HIV co-infection Latent TB infection BCG vaccination Non-tuberculous mycobacterial infection PLEURAL DISEASE Pleural effusion Diagnosis Transudates Exudates Management of malignant pleural effusions Chylothorax Empyema Pneumothorax Clinical features Investigations Management TUMOURS OF THE RESPIRATORY TRACT Pathophysiology Clinical features Local effects Metastatic spread Non-metastatic extrapulmonary manifestations of bronchial carcinoma Investigations Staging and diagnosis Chest X-ray Computed tomography PET-CT Other imaging modalities Obtaining histology and cytology Other investigations Assessing fitness for treatment Management Surgery Radiation therapy with curative intent Palliative radiation treatment Chemotherapy, targeted therapy and immunotherapy Laser therapy, cryotherapy and tracheobronchial stents Palliative care Mesothelioma Secondary tumours Solitary pulmonary nodules Screening for lung cancer Bronchial carcinoid tumours Benign tumours Bronchial adenoma Cylindroma, chondroma and lipoma Tracheal tumours BRONCHIECTASIS Aetiology Clinical features Investigations Management Airway clearance Anti-inflammatories Treatment of infection Treatment of complications Prognosis Cystic fibrosis Pathogenesis Clinical features and complications Diagnosis Management Pulmonary disease Respiratory infection Advanced disease Non-respiratory complications The future INTERSTITIAL LUNG DISEASES Sarcoidosis Epidemiology and aetiology Immunopathology Clinical features Pulmonary manifestations Bilateral hilar lymphadenopathy Pulmonary infiltration Extrapulmonary manifestations Skin lesions Eye lesions Metabolic manifestations Central nervous system Bone and joint involvement Hepatosplenomegaly Renal involvement Cardiac involvement Investigations Prognosis and management Idiopathic interstitial pneumonias Idiopathic pulmonary fibrosis Pathology Pathogenesis Clinical features Investigations Differential diagnosis Prognosis and management Other idiopathic interstitial pneumonias Hypersensitivity pneumonitis Pathogenesis Clinical features Investigations Differential diagnosis Management Rare interstitial lung diseases Pulmonary lymphangioleiomyomatosis Pulmonary alveolar proteinosis Small-vessel vasculitides Granulomatosis with polyangiitis Microscopic polyangiitis Eosinophilic granulomatosis with polyangiitis Anti-glomerular basement membrane disease (Goodpasture’s syndrome) Diffuse alveolar haemorrhage Pulmonary manifestations of autoimmune rheumatic diseases Systemic lupus erythematosus Systemic sclerosis Pulmonary infiltration with eosinophilia Diseases caused by Aspergillus fumigatus Allergic bronchopulmonary aspergillosis (asthmatic pulmonary eosinophilia) Aspergilloma and invasive aspergillosis Drug- and radiation-induced respiratory reactions LUNG AND HEART–LUNG TRANSPLANTATION Indications and donor selection Complications and their treatment Prognosis OCCUPATIONAL LUNG DISEASE Coal-worker’s pneumoconiosis Simple pneumoconiosis Progressive massive fibrosis Silicosis Diseases caused by asbestos Asbestosis Byssinosis Berylliosis MISCELLANEOUS RESPIRATORY DISORDERS Lung cysts Trauma Rib fractures Rupture of the trachea or a major bronchus Rupture of the oesophagus Lung contusion Kyphoscoliosis Ankylosing spondylitis Pectus excavatum and pectus carinatum Pleurisy DISORDERS OF THE DIAPHRAGM Diaphragmatic fatigue Unilateral diaphragmatic paralysis Bilateral diaphragmatic weakness or paralysis Complete eventration of the diaphragm Diaphragmatic hernias Hiccups MEDIASTINAL LESIONS Anterior mediastinum Thymic tumours (thymomas) Middle mediastinum Posterior mediastinum 29 - Venous thromboembolic disease CORE SKILLS AND KNOWLEDGE PATHOGENESIS OF THROMBOSIS Arterial and venous thrombosis DEFINITIONS EPIDEMIOLOGY AND RISK FACTORS CLINICAL FEATURES DIAGNOSIS Initial investigations Diagnosis of DVT and PE Risk scoring Measurement of D-dimer Imaging for DVT Imaging for PE Timescale of investigation Emergency presentations Upper limb DVT MANAGEMENT Initial treatment Traditional management Direct oral anticoagulants Ambulatory care Special circumstances Pregnant women Breast-feeding mothers Patients with cancer Role of thrombolysis Interventional approaches Surgical embolectomy Inferior vena cava filters Treatment duration Risk of recurrence COMPLICATIONS Mortality Associated cancer Post-thrombotic syndrome Pulmonary hypertension INVESTIGATION OF NEWLY DIAGNOSED VENOUS THROMBOSIS General investigations Thrombophilia testing Heritable thrombophilias Gain of function of procoagulants Loss of function of anticoagulants Management of heritable thrombophilias Acquired thrombophilia Antiphospholipid syndrome PREVENTION Mechanical prophylaxis Pharmacological prophylaxis ANTICOAGULANT AGENTS Parenteral anticoagulants Heparin Unfractionated (standard) heparin Low-molecular-weight heparin Heparin-induced thrombocytopenia Fondaparinux Oral anticoagulants Vitamin K antagonists Monitoring warfarin therapy Pregnancy and breast-feeding Risks of warfarin therapy Direct oral anticoagulants Special circumstances Management of bleeding on DOACs 30 - Cardiology CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR CARDIOLOGY History Examination ECG interpretation Examination ANATOMY, PHYSIOLOGY AND EMBRYOLOGY OF THE HEART Conduction system of the heart Sinus node (sinoatrial node) Atrial and ventricular myocyte action potentials Atrioventricular node, His bundle and Purkinje fibres Cellular basis of myocardial contraction–excitation–contraction coupling Starling’s law of the heart Nerve supply of the myocardium Adrenergic stimulation and cellular signalling Cardiac cycle Coronary circulation Blood vessel control and functions of the vascular endothelium Vasomotor control Anti- and prothrombotic mechanisms CLINICAL APPROACH TO THE PATIENT WITH HEART DISEASE Clinical features of heart disease Central chest pain Dyspnoea Palpitations Syncope Vascular Obstructive Arrhythmias Fatigue Peripheral oedema Examination of the cardiovascular system General examination Arterial pulse Rate Rhythm Character Blood pressure Jugular venous pressure Measurement of jugular venous pressure Jugular venous pressure wave Precordium Auscultation First heart sound (S1) Second heart sound (S2) Third and fourth heart sounds Heart murmurs Cardiac investigations Blood tests Chest X-ray Heart size Calcification Lung fields Electrocardiography ECG waveform Cardiac vectors Exercise electrocardiography Twenty-four-hour ambulatory taped electrocardiography Other tests Tilt testing Carotid sinus massage Echocardiography Physics Three-dimensional echocardiography Doppler echocardiography Transoesophageal echocardiography Wall motion stress echocardiography Myocardial perfusion echocardiography Contrast echo for left ventricular opacification Intravascular (coronary) ultrasound Nuclear imaging Image type Myocardial perfusion and viability Infarct imaging Cardiac computed tomography Coronary artery calcification CT coronary angiography Cardiovascular magnetic resonance Clinical use Congenital heart disease Cardiomyopathies, pericardial disease and cardiac masses Diseases of the aorta Valvular heart disease Coronary artery disease Pulmonary vessels Positron emission tomography Cardiac catheterization THERAPEUTIC PROCEDURES Cardiac resuscitation Basic life support Airway Circulation Breathing Advanced cardiac life support Defibrillation Post resuscitation – therapeutic hypothermia Direct current cardioversion Temporary pacing Permanent pacing Pericardiocentesis Right-heart bedside catheterization Intra-aortic balloon pumping CARDIAC ARRHYTHMIAS Sinus node function Sinus arrhythmia Sinus bradycardia Sinus tachycardia Mechanisms of arrhythmia production Accelerated automaticity Triggered activity Re-entry (or circus movements) BRADYCARDIAS AND HEART BLOCK Bradycardia Neurally mediated syndromes Management Heart block Atrioventricular block First-degree AV block Second-degree AV block Third-degree (complete) AV block Bundle branch block Bundle branch conduction delay Complete block of a bundle branch Hemiblock Bifascicular block Clinical features of heart blocks Aetiology SUPRAVENTRICULAR TACHYCARDIAS Atrioventricular junctional tachycardias Atrioventricular nodal re-entrant tachycardia Atrioventricular re-entrant tachycardia Clinical features of AVNRT and AVRT Management of AVNRT and AVRT Acute management Long-term management Atrial tachyarrhythmias Atrial fibrillation Clinical features Management Acute management Long-term management Rhythm control Rate control Anticoagulation Atrial flutter Management Atrial tachycardia Atrial ectopic beats VENTRICULAR TACHYARRHYTHMIAS Sustained ventricular tachycardia Management Ventricular fibrillation Brugada’s syndrome Long QT syndrome Congenital long QT syndrome Acquired long QT syndrome Clinical features Management Short QT syndrome Normal heart ventricular tachycardia Non-sustained ventricular tachycardia Ventricular premature beats (ectopics) Long-term management of cardiac tachyarrhythmias Antiarrhythmic drugs Class I drugs Class II drugs Class III drugs Class IV drugs Clinical use of antiarrhythmic drugs Catheter ablation Implantable cardioverter–defibrillator HEART FAILURE Pathophysiology Venous return (preload) Outflow resistance (afterload) Myocardial contractility (inotropic state) Neurohormonal and sympathetic system activation: salt and water retention Myocardial remodelling in heart failure Abnormal calcium homeostasis Natriuretic peptides (ANP, BNP and CNP) Endothelial function in heart failure Antidiuretic hormone (vasopressin) Clinical syndromes of heart failure Clinical features of heart failure Diagnosis of heart failure Investigations in heart failure Management of heart failure General lifestyle advice Monitoring Multidisciplinary team approach Drug management Diuretics Angiotensin-converting enzyme inhibitors Angiotensin II receptor antagonists Beta-blockers Aldosterone antagonists Angiotensin receptor neprilysin inhibitor Cardiac glycosides Vasodilators and nitrates Inotropic and vasopressor agents Other medications Non-pharmacological treatment Revascularization Hibernating myocardium and myocardial stunning Cardiac resynchronization therapy or implantable cardioverter–defibrillator Cardiac transplantation Acute heart failure Pathophysiology Diagnosis Management Mechanical assist devices Ventricular assist devices CORONARY ARTERY DISEASE Pathophysiology of coronary atherosclerosis Diagnosis Cardiovascular risk assessment for primary and secondary prevention of cardiovascular disease Lipids Lifestyle modifications Statin treatment ANGINA Epidemiology Diagnosis Examination Investigations Management of stable angina Revascularization Percutaneous coronary intervention Coronary artery bypass grafting PCI versus CABG Patients with intractable angina ACUTE CORONARY SYNDROMES Pathophysiology Clinical features Investigations Electrocardiogram Biochemical markers NSTEMI and unstable angina Investigations and management Antiplatelet drugs Antithrombin drugs Anti-ischaemia agents Plaque stabilization/remodelling Coronary angiography and intervention ST elevation myocardial infarction (STEMI) Pathophysiology Clinical features Investigations Electrocardiography Blood tests and other imaging Management Early medical management Primary percutaneous coronary intervention (PCI) Thrombolysis Coronary artery bypass surgery Complications of myocardial infarction Heart failure Myocardial rupture and aneurysmal dilation Ventricular septal defect Mitral regurgitation Cardiac arrhythmias Conduction disturbances Post-MI pericarditis and Dressler’s syndrome Post-ACS lifestyle modification Post-ACS drug therapy and assessment MITRAL VALVE Mitral stenosis Pathophysiology Clinical features Symptoms Signs Face Pulse Jugular veins Palpation Auscultation Investigations Chest X-ray ECG Echocardiogram Cardiac catheterization Management Trans-septal balloon valvotomy Closed valvotomy Open valvotomy Mitral valve replacement Mitral regurgitation Pathophysiology Clinical features Symptoms Signs Investigations Chest X-ray ECG Echocardiogram Cardiac catheterization Management Prolapsing (billowing) mitral valve AORTIC VALVE Aortic stenosis Pathophysiology Clinical features Symptoms Signs Pulse Precordial palpation Auscultation Investigations Chest X-ray ECG Echocardiogram Cardiac catheterization CMR and cardiac CT Management Percutaneous valve replacement Aortic regurgitation Pathophysiology Clinical features Symptoms Signs Investigations Chest X-ray ECG Echocardiogram Cardiac catheterization CMR and cardiac CT Management TRICUSPID VALVE Tricuspid stenosis Pathophysiology Clinical features Symptoms Signs Investigations Management Tricuspid regurgitation Clinical features Investigations Management PULMONARY VALVE Pulmonary stenosis Clinical features Investigations Management Pulmonary regurgitation PROSTHETIC VALVES Mechanical versus tissue valves Complications Interruption of anticoagulant therapy Pregnancy and prosthetic heart valves INFECTIVE ENDOCARDITIS Aetiology Organisms Rare causes Culture-negative endocarditis Clinical features High clinical suspicion Low clinical suspicion Diagnosis Investigations Management Persistent fever Surgery Prevention Fetal circulation Adult congenital heart disease Ventricular septal defect Clinical features Investigations and treatment Atrial septal defect Clinical features Investigations and treatment Patent ductus arteriosus Clinical features Investigations and treatment Coarctation of the aorta Clinical features Investigations and treatment Intervention/repair Tetralogy of Fallot Transposition of the great arteries Congenitally corrected transposition of the great arteries MARFAN’S SYNDROME Diagnosis Management Cardiovascular surveillance and management Medical therapy Lifestyle Pregnancy PULMONARY HEART DISEASE Pulmonary hypertension Pathophysiology Pulmonary artery hypertension Epidemiology Clinical features Investigations Management Other pulmonary hypertension groups CARDIAC TUMOURS MYOCARDIAL DISEASE Myocarditis Pathology Clinical features Investigations Management Giant cell myocarditis Chagas’ disease Cardiomyopathy Hypertrophic cardiomyopathy Clinical features Symptoms Signs Investigations Management Arrhythmogenic cardiomyopathy/arrhythmogenic right ventricular cardiomyopathy Clinical features Investigations and diagnosis Management Dilated cardiomyopathy Clinical features Investigations Management Left ventricular non-compaction Primary restrictive non-hypertrophic cardiomyopathy Clinical features Investigations Management Acquired cardiomyopathies Stress (Tako-tsubo/octopus pot/apical ballooning syndrome) cardiomyopathy Peripartum cardiomyopathy Tachycardia cardiomyopathy PERICARDIAL DISEASE Acute pericarditis Clinical features and investigations Management and treatment Incessant or chronic pericarditis Tuberculous pericarditis Post-cardiac injury syndromes Malignant pericarditis Pericardial effusion and cardiac tamponade Clinical features Investigations Management Constrictive pericarditis Clinical features Investigations Management PERIPHERAL ARTERIAL DISEASE Limb ischaemia Chronic lower limb ischaemia Clinical features Symptoms Signs Differential diagnosis Investigations Management Medical Surgical and radiological Acute lower limb ischaemia Clinical features Symptoms Signs Aetiology Investigations Management Medical Surgical and radiological Aneurysmal disease Abdominal aortic aneurysm Screening Clinical features Symptoms Signs Management Medical Surgical and endovascular intervention Prognosis Thoraco-abdominal aneurysm Clinical features Investigations Management Acute aortic syndromes Clinical features Symptoms Signs Investigations Management Other types of peripheral arterial disease Raynaud’s phenomenon or Raynaud’s disease Clinical features Diagnosis Management Takayasu’s disease Thromboangiitis obliterans (Buerger’s disease) Cardiovascular syphilis PERIPHERAL VENOUS DISEASE Varicose veins Superficial thrombophlebitis 31 - Hypertension CORE SKILLS AND KNOWLEDGE INTRODUCTION CLINICAL APPROACH TO THE PATIENT WITH HYPERTENSION History Examination and investigations MEASUREMENT OF BLOOD PRESSURE Office/surgery measurement Home measurement Ambulatory measurement PHENOTYPES OF HYPERTENSION Isolated systolic hypertension Orthostatic hypotension Variable blood pressure CAUSES OF RAISED BLOOD PRESSURE Lifestyle-related issues Diet Lack of exercise Population interventions Drugs Secondary hypertension THRESHOLDS AND TARGETS IN HYPERTENSION HYPERTENSIVE TARGET ORGAN DAMAGE Eyes Heart Kidney TREATMENT Lifestyle changes Drug treatment Future approaches MANAGING BLOOD PRESSURE IN HOSPITAL Preoperative Intraoperative Postoperative Blood pressure on the wards Hypertensive emergencies Referral to specialist care 32 - Gastroenterology CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR GASTROENTEROLOGY History and examination Visualizing the bowel INTRODUCTION ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL TRACT Mouth, oropharynx and oesophagus Stomach and duodenum Physiology Small intestine anatomy Enteric nervous system Gut motility Neuroendocrine peptide production Small intestine physiology General principles of absorption Simple diffusion Facilitated diffusion Active transport Absorption of nutrients in the small intestine Carbohydrate Protein Fat Water and electrolytes Water-soluble vitamins, essential metals and trace elements Calcium Iron Response of the small bowel to antigens and pathogens Innate chemical defence Innate immunological defence The gut microbiome Oral tolerance Colon and rectal anatomy Physiology of the colon Physiology of defecation INVESTIGATION OF GASTROINTESTINAL DISEASE Blood tests Stool tests Endoscopy Imaging Plain X-rays Ultrasound Computed tomography Magnetic resonance imaging Positron emission tomography Contrast studies Radioisotopes FUNCTIONAL GASTROINTESTINAL DISORDERS MOUTH Neoplasia (squamous cell carcinoma) Management Pigmented neoplastic lesions Non-neoplastic lesions Oral pigmented lesions Tongue Glossitis Geographic tongue Gums Teeth SALIVARY GLANDS PHARYNX AND OESOPHAGUS Clinical features Diagnosis and investigations Management Drugs Alginate-containing antacids Proton pump inhibitors H2-receptor antagonists Dopamine antagonist prokinetic agents Endoluminal gastroplication Surgery Complications of gastro-oesophageal reflux disease Barrett’s oesophagus Diagnosis and classification Motility disorders Clinical features Pathogenesis Differential diagnosis Investigations Management Complications Systemic sclerosis Diffuse oesophageal spasm Management Miscellaneous motility disorders Other oesophageal disorders Rings and webs Lower oesophageal rings Benign oesophageal stricture Oesophageal infections Management Mallory–Weiss syndrome Eosinophilic oesophagitis Management Oesophageal perforation Management Oesophageal rupture Oesophageal tumours Epidemiology and aetiology Squamous cell carcinoma Adenocarcinoma Clinical features Investigations Diagnosis Staging Management Other oesophageal tumours Functional oesophageal disorders Globus Functional chest pain of presumed oesophageal origin STOMACH AND DUODENUM Gastritis and gastropathy Gastritis Autoimmune gastritis Gastropathy Helicobacter pylori infection Epidemiology Pathogenesis Results of H. pylori infection Antral gastritis Duodenal ulcer Gastric ulcer Peptic ulcer disease Epidemiology of peptic ulcer disease Clinical features of peptic ulcer disease Diagnosis of Helicobacter pylori infection Non-invasive methods Invasive methods (endoscopy) Investigation of suspected peptic ulcer disease Management Eradication therapy Example regimens General measures Complications of peptic ulcer disease Haemorrhage Perforation Gastric outlet obstruction Surgical treatment and its long-term consequences Other H. pylori-associated diseases NSAIDs, Helicobacter and ulcers Management Gastroparesis Dyspepsia Cyclical vomiting syndrome Management Nausea and vomiting Gastric tumours Epidemiology and pathogenesis Screening Early gastric cancer Pathology Clinical features Symptoms Signs Diagnosis Staging Management Gastrointestinal stromal tumours Management Primary gastric lymphoma Aetiology Clinical features Management Gastric polyps ACUTE AND CHRONIC GASTROINTESTINAL BLEEDING Acute upper gastrointestinal bleeding Aetiology Drugs Clinical approach to the patient with acute upper GI bleeding Management Immediate management Blood volume Endoscopy Drug therapy Uncontrolled or repeat bleeding Discharge policy Specific conditions Oesophageal varices Mallory–Weiss tear Chronic peptic ulcer Gastric carcinoma Bleeding after percutaneous coronary intervention Prognosis Acute lower gastrointestinal bleeding Management Chronic gastrointestinal bleeding Diagnosis Management SMALL INTESTINE Diarrhoea Pathophysiology Osmotic diarrhoea Secretory diarrhoea Inflammatory diarrhoea (mucosal destruction) Abnormal motility Acute diarrhoea Chronic diarrhoea Irritable bowel syndrome Diagnosis Management Pain/gas/bloat syndrome/midgut dysmotility Functional diarrhoea Purgative abuse Malabsorption Coeliac disease (gluten-sensitive enteropathy) Aetiology Genetic factors Environmental factors Clinical features Diagnosis Histology Serology HLA typing Other investigations Management Complications Dermatitis herpetiformis Non-coeliac gluten intolerance Tropical sprue Aetiology Clinical features Diagnosis Management Prognosis Bacterial overgrowth Clinical features Management Bile acid malabsorption Lactose intolerance Small intestinal resection Ileal resection Investigations Jejunal resection Massive intestinal resection (short bowel syndrome) Shortened small intestine ending at a terminal small bowel stoma Shortened small intestine in continuity with colon Whipple’s disease Diagnosis Management Radiation enteritis Parasite infestation Other causes of malabsorption Miscellaneous intestinal diseases Meckel’s diverticulum Tuberculosis Clinical features Diagnosis Management Amyloidosis Autoimmune rheumatic diseases Intestinal ischaemia Acute small intestinal ischaemia Ischaemic colitis Chronic small intestinal ischaemia Eosinophilic gastroenteritis Intestinal lymphangiectasia Abetalipoproteinaemia Tumours of the small intestine Adenocarcinoma and lymphoma Predisposing factors for adenocarcinoma and lymphoma Coeliac disease Crohn’s disease Immunoproliferative small intestinal disease Management of small intestinal tumours Adenocarcinoma IPSID Lymphoma Carcinoid tumours Diagnosis of carcinoid syndrome Management of carcinoid syndrome Peutz–Jeghers syndrome Management Other tumours INFLAMMATORY BOWEL DISEASE Epidemiology Aetiology and pathogenesis Genetic factors Environmental and other factors Intestinal microbiota Intestinal immune system Pathology Macroscopic changes Microscopic changes Extraintestinal manifestations Differential diagnosis Crohn’s disease Clinical features Examination Investigations Blood tests Stool tests Endoscopy and radiological imaging Disease activity Medical management of Crohn’s disease General considerations Induction of remission Glucocorticosteroids Aminosalicylates Antibiotics Exclusive enteral nutrition Refractory or fulminant disease Maintenance of remission Conventional maintenance therapies Anti-TNF agents Novel biological therapies Surgical management of Crohn’s disease Prognosis Ulcerative colitis Clinical features Examination Investigations Blood tests Stool tests and C. difficile toxin Colonoscopy Imaging Medical management of ulcerative colitis Proctitis Left-sided colitis Extensive colitis Refractory/severe colitis of any extent Salvage therapy Novel therapies Surgical management of ulcerative colitis Course and prognosis Cancer in inflammatory bowel disease Mortality in inflammatory bowel disease Microscopic colitis COLON AND RECTUM Constipation Diagnosis Normal-transit constipation Defecatory disorders Slow-transit constipation Management Miscellaneous colonic conditions Treatment Megacolon Faecal incontinence Ischaemic disease of the colon (ischaemic colitis) Examination Differential diagnosis and investigations Management Diverticular disease Clinical features and investigations Management Acute diverticulitis Investigations Management Complications of diverticular disease Anorectal disorders Haemorrhoids Management Anal fissures Fistula in ano and anorectal abscesses Rectal prolapse, intussusception and solitary rectal ulcer syndrome Colonic tumours Classification of colorectal polyps Sporadic adenomas Sessile serrated adenomas Inherited polyposis syndromes Familial adenomatous polyposis MYH-associated polyposis Lynch syndrome Turcot’s syndrome Gardner’s syndrome Hamartomatous polyps Colorectal carcinoma Genetics Cancer families Pathology Clinical features Investigations Management Follow-up Screening for CRC THE ACUTE ABDOMEN Diagnosis History Pain Vomiting Other symptoms Physical examination The abdomen Vaginal and rectal examination Other observations Investigations Acute appendicitis Clinical features Differential diagnosis Management Gynaecological causes of an acute abdomen Ruptured ectopic pregnancy Ovarian causes Acute salpingitis Acute peritonitis Localized peritonitis Generalized peritonitis Clinical features Investigations Management Complications Intestinal obstruction Clinical features Management Acute colonic pseudo-obstruction PERITONEUM Disorders affecting the peritoneum Peritoneal adhesions Retroperitoneal fibrosis (peri-aortitis) Tuberculous peritonitis Management 33 - Nutrition CORE SKILLS AND KNOWLEDGE INTRODUCTION WATER AND ELECTROLYTE BALANCE Energy Energy balance Energy requirements Energy intake Energy expenditure Energy stores Body weight Protein Fat Trans fats (partly hydrogenated fatty acids) Polyunsaturated fatty acids Recommendations for fat intake Cholesterol Essential fatty acid deficiency Carbohydrate Health promotion Fortification of foods Nutrient goals and dietary guidelines Developed countries Pathophysiology of starvation Regulation of metabolism Insulin/glucagon ratios in the fed and fasted state Proportion of lean to fat tissue Role of cytokines Clinical features Management Developing countries Clinical features Investigations Management Resuscitation and stabilization Re-feeding Rehabilitation Care setting Prognosis Prevention VITAMINS FAT-SOLUBLE VITAMINS Vitamin A Function Vitamin A deficiency Diagnosis Management Prevention Other effects of vitamin A Vitamin D Vitamin K Function Vitamin K deficiency The newborn Cholestatic jaundice Concomitant vitamin K antagonists Vitamin E Function Vitamin E deficiency WATER-SOLUBLE VITAMINS Thiamine (vitamin B1) Thiamine deficiency Diagnosis Management Riboflavin Niacin Pellagra Clinical features Diagnosis and management Vitamin B6 Biotin and pantothenic acid Vitamin C Scurvy Diagnosis Management Prevention Vitamin B12 and folate DIETARY ANTIOXIDANTS Epidemiology Dietary intake HOMOCYSTEINE, CARDIOVASCULAR DISEASE AND B VITAMINS MINERALS Iron Copper Copper toxicity Zinc Zinc deficiency Iodine Iodine deficiency Fluoride Selenium Calcium Phosphate Other trace elements Early origins of health and disease in older adults Nutritional requirements in the elderly OBESITY Pathophysiology Genetic and environmental factors Food intake Control of appetite Peripheral signals (1st order in Fig. 33.14) Central pathways (2nd order in Fig. 33.14) Other factors Energy expenditure Basal metabolic rate Physical activity Thermogenesis Clinical features Morbidity and mortality Metabolic syndrome Management Dietary control Behavioural modification Drug therapy Surgical management (bariatric surgery, metabolic surgery) Prevention Support in the hospital patient Principles Nutritional requirements for adults Enteral nutrition Management of enteral nutrition Parenteral nutrition Peripheral parenteral nutrition Parenteral nutrition via a central venous catheter Nutrients Nitrogen source Energy source Electrolytes, vitamins and trace elements Management of parenteral nutrition Complications Support in the home patient Home enteral nutrition Home parenteral nutrition FOOD ALLERGY AND FOOD INTOLERANCE Food allergy Food intolerance Management ALCOHOL Effects of excess alcohol consumption Liver disease 34 - Liver disease CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR LIVER DISEASE Asking about alcohol Examination Investigations INTRODUCTION ANATOMY OF THE LIVER AND BILIARY SYSTEM Liver Biliary system FUNCTIONS OF THE LIVER Protein metabolism Synthesis and storage Degradation (nitrogen excretion) Carbohydrate metabolism Lipid metabolism Formation of bile Bile secretion and bile acid metabolism Bile acid receptors in liver disease Bilirubin metabolism Hormone and drug inactivation Immunological function INVESTIGATIONS IN THE PATIENT WITH LIVER DISEASE Blood tests Bilirubin Prothrombin time Alkaline phosphatase Gamma-glutamyl transpeptidase Total proteins and globulin fraction Viral markers Haematological tests Biochemical tests Serum autoantibodies Markers of liver fibrosis Genetic analysis Imaging techniques Ultrasound examination Colour Doppler ultrasound Hepatic stiffness (transient elastography) Computed tomography examination Magnetic resonance imaging Magnetic resonance cholangiopancreatography Radionuclide imaging – scintiscanning Endoscopy Endoscopic retrograde cholangiopancreatography Angiography Liver biopsy JAUNDICE Haemolytic jaundice Congenital hyperbilirubinaemias (non-haemolytic) Gilbert’s syndrome Crigler–Najjar syndrome Conjugated types Dubin–Johnson and Rotor’s syndromes Benign recurrent intrahepatic cholestasis Progressive familial intrahepatic cholestasis syndromes Cholestatic jaundice (acquired) Differential diagnosis of jaundice Clinical features Investigations Liver biochemistry Haematological tests Other blood tests HEPATITIS Acute hepatitis Pathology Chronic hepatitis Pathology Viral hepatitis Hepatitis A Epidemiology Hepatitis A virus Clinical features Investigations Liver biochemistry Haematological tests Viral markers: antibodies to HAV Other tests Differential diagnosis Prognosis Management Prevention Active immunization Passive immunization Hepatitis B Epidemiology Hepatitis B virus Hepatitis B mutants Pathogenesis Clinical features of acute hepatitis B infection Investigations Specific tests Prognosis Management of acute hepatitis Prevention Immunization Active immunization Dosage regimen Chronic hepatitis B virus infection Investigations Management of chronic hepatitis B Aim of therapy Antiviral agents Prognosis Hepatitis D Chronic hepatitis D Management Hepatitis C Epidemiology Hepatitis C virus (HCV) Clinical features Investigations Management Prognosis Chronic hepatitis C infection Pathogenesis Clinical features Investigations Management Antiviral agents Hepatitis E Hepatitis non-A–E Acute hepatitis due to other infectious agents Infectious mononucleosis Cytomegalovirus Herpes simplex Toxoplasmosis Yellow fever ACUTE HEPATIC FAILURE Clinical features Investigations Management Prognosis AUTOIMMUNE HEPATITIS Pathogenesis Clinical features Investigations Liver biochemistry Haematology Autoantibodies Liver biopsy Management Prognosis DRUG-INDUCED CHRONIC HEPATITIS CHRONIC HEPATITIS OF UNKNOWN CAUSE NON-ALCOHOLIC FATTY LIVER DISEASE Pathogenesis Investigations Management Hepatocellular carcinoma Liver transplantation New treatments for NASH CIRRHOSIS Aetiology Pathogenesis Pathology Investigations Severity Type Imaging Liver biopsy Management Prognosis Acute-on-chronic liver failure Liver assist devices Gut–liver axis Liver transplantation Indications Contraindications Preparation for surgery Rejection Prognosis Complications and effects of cirrhosis Portal hypertension Pathophysiology Aetiology Pre-hepatic causes Intrahepatic causes Post-hepatic causes Clinical features Variceal haemorrhage Management Initial management of acute variceal bleeding Resuscitation Urgent endoscopy Variceal banding or injection sclerotherapy Balloon tamponade Additional management of the acute episode Management of an acute rebleed Transjugular intrahepatic portocaval shunt Emergency surgery Prevention of recurrent variceal bleeding (secondary prophylaxis) Prophylactic long-term measures Non-selective beta-blockade Endoscopic treatment Surgery Prophylactic measures (primary prophylaxis) Ascites Clinical features Investigations Management Paracentesis Shunts Spontaneous bacterial peritonitis Portosystemic encephalopathy Pathogenesis Clinical features Investigations Additional investigations Management Prognosis Renal failure (hepatorenal syndrome) Hepatopulmonary syndrome Porto-pulmonary hypertension Primary hepatocellular carcinoma Types of cirrhosis Primary biliary cholangitis Aetiology Clinical features Associated disorders Investigations Differential diagnosis Management Complications Prognosis Primary sclerosing cholangitis Clinical features Diagnosis Pathology Management Secondary biliary cirrhosis Hereditary haemochromatosis Aetiology Mechanism of damage Pathology Clinical features Complications Investigations Homozygotes Heterozygotes Genetic testing Liver biopsy Magnetic resonance imaging Management Venesection Screening Wilson’s disease (progressive hepatolenticular degeneration) Aetiology Pathology Clinical features Investigations Management Prognosis Alpha1-antitrypsin deficiency Clinical features Investigations Management ALCOHOLIC LIVER DISEASE Pathology Fatty liver Alcoholic hepatitis Alcoholic cirrhosis Clinical features Fatty liver Alcoholic hepatitis Alcoholic cirrhosis Investigations Fatty liver Alcoholic hepatitis Alcoholic cirrhosis Management and prognosis General management Fatty liver Alcoholic hepatitis Discriminant function (DF) Alcoholic cirrhosis BUDD–CHIARI SYNDROME Clinical features Investigations Differential diagnosis Management Prognosis HEPATIC SINUSOIDAL OBSTRUCTION SYNDROME FIBROPOLYCYSTIC DISEASES Polycystic disease of the liver Solitary cysts Congenital hepatic fibrosis Congenital intrahepatic biliary dilation (Caroli’s disease) LIVER ABSCESS Pyogenic abscess Clinical features Investigations Imaging Management Prognosis Amoebic abscess Investigations Management Complications OTHER INFECTIONS OF THE LIVER Schistosomiasis Clinical features and investigations Management Hydatid disease Clinical features and investigations Management Complications and prognosis Acquired immunodeficiency syndrome LIVER DISEASE IN PREGNANCY LIVER TUMOURS Secondary liver tumours Clinical features Investigations Management Primary malignant tumours Hepatocellular carcinoma Aetiology Pathology Clinical features Investigations Management and prognosis Prevention Cholangiocarcinoma Benign tumours MISCELLANEOUS CONDITIONS OF THE LIVER Hepatic mitochondrial injury syndromes Idiopathic adult ductopenia Indian childhood cirrhosis Hepatic porphyrias Cystic fibrosis Coeliac disease DRUGS AND THE LIVER Drug metabolism Drug hepatotoxicity Hepatitic damage Individual drugs Paracetamol Steroid compounds Phenothiazines Anti-tuberculous chemotherapy Amiodarone Sodium valproate Drug prescribing for patients with liver disease 35 - Biliary tract and pancreatic disease INTRODUCTION GALL BLADDER AND BILIARY SYSTEM CORE SKILLS AND KNOWLEDGE BILIARY SYSTEM Gallstones Pathogenesis Types of gallstone Cholesterol gallstones Bile pigment stones Clinical features Biliary colic Acute cholecystitis Investigations Differential diagnosis Management Cholecystectomy Acute cholecystitis Specific complications of cholecystectomy Stone dissolution and shock wave lithotripsy Stone dissolution Extracorporeal shock wave lithotripsy Post-cholecystectomy syndrome Sphincter of Oddi dysfunction Biliary SOD Pancreatic SOD Common bile duct stones Examination Investigations Laboratory tests Imaging Differential diagnosis Management Complications of gallstones MISCELLANEOUS CONDITIONS OF THE BILIARY TRACT Gall bladder Acalculous cholecystitis Cholesterolosis of the gall bladder Adenomyomatosis of the gall bladder Chronic cholecystitis Extrahepatic biliary tract Autoimmune cholangitis Biliary cysts (choledochal malformation) Benign bile duct strictures Haemobilia Tumours of the biliary tract Carcinoma of the gall bladder Cholangiocarcinoma Secondary malignant involvement of the biliary tree Management Palliation of malignant bile duct obstruction Anatomy and function Structure Exocrine function Endocrine pancreas Investigations Assessment of exocrine function Direct tests of pancreatic function Non-invasive indirect tests of pancreatic function Faecal tests Oral pancreatic function tests Clinical application of pancreatic function tests Pancreatic imaging PANCREATITIS Classification Acute pancreatitis Pathogenesis Gallstone pancreatitis Alcohol-induced pancreatitis Clinical features Diagnosis Blood tests Radiology Assessment of disease severity Management Gallstone-related pancreatitis Complications Prognosis Chronic pancreatitis Aetiology Pathogenesis Genetic aspects of chronic pancreatitis Autoimmune chronic pancreatitis Clinical features Investigations Differential diagnosis Management Abdominal pain Malabsorption Diabetes Autoimmune pancreatitis Specific complications Cystic fibrosis PANCREATIC CANCER Pancreatic adenocarcinoma Aetiology Pathogenesis Clinical features Signs Diagnosis and investigations Differential diagnosis Management Pancreatic cystic neoplasms Pancreatic neuroendocrine tumours Clinical syndromes Investigations Management 36 - Kidney and urinary tract disease CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR NEPHROLOGY History A diagnostic approach to unexplained renal disease CORE SKILLS AND KNOWLEDGE Quantification of proteinuria Examination INTRODUCTION ANATOMY AND PHYSIOLOGY OF THE KIDNEY AND URINARY TRACT Functional anatomy Nephron Juxtaglomerular apparatus Physiology Absorption of solutes Absorption of water Glomerular filtration rate Measuring or estimating the GFR Drugs, toxins, proteins and the kidney Endocrine function Renin–angiotensin system Erythropoietin Vitamin D metabolism Autocrine function Prostaglandins Nitric oxide and the kidney INVESTIGATION OF RENAL AND URINARY TRACT DISEASE Examination of the urine Volume Dipsticks (chemical testing) and urine microscopy Specific gravity and osmolality Urinary pH Blood Protein Electrolytes Glucose Bacteria and pus cells Urine microscopy Blood and quantitative tests Serum biochemistry Haematology Immunology Imaging techniques Ultrasonography Computed tomography Magnetic resonance imaging Plain X-ray Antegrade pyelography Micturating cystourethrography Aortography or renal arteriography Renal scintigraphy Transcutaneous renal biopsy THE GLOMERULUS AND GLOMERULAR DISEASE Filtration barrier (slit diaphragm) Glomerular disease Nephrotic syndrome Pathophysiology Hypoalbuminaemia Proteinuria Hyperlipidaemia Oedema in hypoalbuminaemia Management General measures Specific measures Causes of nephrotic syndrome Clinical features Management Congenital nephrotic syndrome Focal segmental glomerulosclerosis Primary focal segmental glomerulosclerosis Aetiology of primary FSGS Pathology Management Secondary FSGS HIV-associated nephropathy Membranous glomerulopathy Pathogenesis Management Amyloidosis Pathophysiology AL amyloidosis (immunoglobulin light chain-associated) Reactive systemic (secondary AA) amyloidosis Familial amyloidoses Diagnosis Management Diabetic nephropathy Pathology Management Isolated proteinuria without haematuria Glomerulonephritis (asymptomatic, acute and rapidly progressive) Asymptomatic urinary abnormalities Acute nephritis (nephritic syndrome) Rapidly progressive glomerulonephritis Post-streptococcal glomerulonephritis Management Glomerulonephritis with infective endocarditis IgA nephropathy Histology Pathogenesis Clinical features Management Alport’s syndrome Management Thin GBM disease Anti-GBM glomerulonephritis ANCA-positive small-vessel vasculitis Pathogenesis Management Mixed nephritic and nephrotic syndrome Mesangiocapillary (membranoproliferative) glomerulonephritis Management IgM nephropathy C1q nephropathy Monoclonal gammopathy of renal significance Idiopathic fibrillary glomerulopathy Immunotactoid glomerulopathy Fibronectin glomerulopathy Systemic lupus erythematosus (lupus nephritis) Pathophysiology Management Prognosis Cryoglobulinaemic renal disease Immunoglobulin A vasculitis (Henoch-Schonlein syndrome) Other glomerular disorders Sickle nephropathy Glomerulopathy associated with pre-eclampsia Paraneoplastic glomerulonephritis KIDNEY INVOLVEMENT IN OTHER DISEASES Polyarteritis nodosa Systemic sclerosis (scleroderma) Haemolytic uraemic syndrome Diarrhoea-associated HUS Atypical HUS Management of aHUS Sporadic cases of aHUS Metabolism-associated HUS Thrombotic thrombocytopenic purpura Antiphospholipid syndrome Multiple myeloma HYPERTENSION AND THE KIDNEY Essential hypertension Management Renal hypertension Renovascular disease Atherosclerotic renovascular disease Management Prognosis Fibromuscular dysplasia of the renal arteries Screening for renovascular disease OTHER VASCULAR DISORDERS OF THE KIDNEY Renal artery occlusion Cholesterol embolization (atheroembolic renal disease) Renal vein thrombosis RENAL CALCULI AND NEPHROCALCINOSIS Renal and vesical calculi Aetiology Hypercalcaemia Hypercalciuria Hyperoxaluria Hyperuricaemia and hyperuricosuria Urinary tract infection Cystinuria Primary renal disease Drugs Clinical features Bladder stones Investigations Management Investigation of the cause of stone formation Prevention of recurrent stones Nephrocalcinosis URINARY TRACT OBSTRUCTION Aetiology Pathophysiology Clinical features Symptoms Signs Investigations Management Post-obstructive diuresis Specific causes of obstruction Pelviureteric junction obstruction Obstructive megaureter Retroperitoneal fibrosis (chronic peri-aortitis) Aetiology of RPF Clinical features and investigation of RPF Management of RPF Benign prostatic hypertrophy Prognosis of urinary tract obstruction DRUGS AND THE KIDNEY Drug-induced impairment of renal function Using drugs in patients with impaired renal function Absorption Metabolism Protein binding Volume of distribution End-organ sensitivity Renal elimination Drugs affecting protein anabolism and catabolism Problem patients URINARY TRACT INFECTION Aetiology and pathogenesis Bacterial virulence Innate host defence Risk factors Clinical features Diagnosis Natural history Acute pyelonephritis Reflux nephropathy Special investigations Management Management of a single isolated attack Management of recurrent infection Urinary infections in the presence of an indwelling catheter Bacteriuria in pregnancy Bacterial prostatitis Renal carbuncle Tuberculosis of the urinary tract Xanthogranulomatous pyelonephritis TUBULOINTERSTITIAL NEPHRITIS Acute tubulointerstitial nephritis Drug-induced acute TIN Infection causing acute TIN Acute TIN as part of multisystem inflammatory diseases TIN with uveitis syndrome Chronic tubulointerstitial nephritis Analgesic nephropathy Balkan nephropathy Chinese herb nephropathy Other forms of chronic TIN Hyperuricaemic nephropathy ACUTE KIDNEY INJURY Approaching AKI Management of pre-renal AKI Post-renal AKI Renal parenchymal AKI Acute tubular necrosis Emergency investigation of AKI Pre-renal, renal or post-renal AKI? Acute or chronic uraemia? Management of AKI General measures Hyperkalaemia Pulmonary oedema Sepsis Use of drugs Fluid and electrolyte balance Nutrition Renal replacement therapy – haemodialysis and haemofiltration Management of the recovery phase Other causes of AKI Acute cortical necrosis Contrast nephropathy Acute phosphate nephropathy Tumour lysis syndrome Hepatorenal syndrome CHRONIC KIDNEY DISEASE Staging and prevalence Complications of CKD Management CKD mineral and bone disorder Pathogenesis of CKD-MBD Management of CKD-MBD Reduction of phosphate and limiting of calcium load Control of PTH and achievement of normal calcium Calciphylaxis Cardiovascular disease Risk factors Coronary artery and generalized vascular calcification Other cardiovascular risk factors Pericarditis Skin disease Nephrogenic systemic fibrosis Gastrointestinal complications Metabolic abnormalities Gout Insulin Lipid metabolism Endocrine abnormalities Muscle dysfunction Nervous system abnormalities Management of CKD General measures Renoprotection Correction of specific complications Early referral Renal replacement therapy Initiation of dialysis An informed choice A difficult choice Haemodialysis Basic principles Access Aims Specific complications Haemofiltration Peritoneal dialysis Specific complications Adequacy Dialysis in the frail Renal transplantation Considerations in successful kidney transplantation Immunosuppression for transplantation Early complications Early (technical) failure Acute tubular necrosis Acute rejection Infection Late complications Renal transplantation in HIV patients CYSTIC RENAL DISEASE Autosomal dominant polycystic kidney disease Clinical features Complications and associations Diagnosis and screening Management Medullary cystic disease (‘juvenile nephronophthisis’) Medullary sponge kidney TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT Renal cell carcinoma Clinical features Diagnosis Management Nephroblastoma (Wilms’ tumour) Urothelial tumours Clinical features Investigations Management DISEASES OF THE PROSTATE GLAND Benign enlargement of the prostate gland Prostatic carcinoma THE URINARY TRACT IN THE ELDERLY Urinary tract infections Urinary incontinence 37 - Sexually transmitted infections and human immunodeficiency virus CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR STI AND HIV CARE History Examination in the sexual health clinic SEXUALLY TRANSMITTED INFECTIONS INTRODUCTION ASYMPTOMATIC STI SCREENING INVESTIGATION OF STIS Screening for hepatitis A and vaccination Screening for hepatitis B and vaccination Screening for hepatitis C Investigations for symptomatic patients MANAGEMENT, PREVENTION AND CONTROL SPECIFIC INFECTIONS HIV/AIDS Hepatitis B Chlamydia trachomatis Clinical features Diagnosis Management Gonorrhoea Clinical features Diagnosis Management Non-gonococcal urethritis and Mycoplasma genitalium Clinical features Diagnosis Management Recurrent/persistent NGU Pelvic inflammatory disease Clinical features Diagnosis Management Epididymo-orchitis Clinical features Diagnosis Investigations Management Bacterial vaginosis Clinical features Diagnosis Management Candidiasis Clinical features Diagnosis Management Trichomoniasis Clinical features Diagnosis Management Human papillomavirus – anogenital warts Clinical features Diagnosis Management Prevention and vaccination Molluscum contagiosum Diagnosis Management Herpes simplex Clinical features Diagnosis Management Initial episode Recurrence Episodic treatment Suppressive treatment HSV in pregnancy Syphilis Clinical features Primary syphilis Secondary syphilis Latent syphilis Tertiary syphilis Syphilis in pregnancy and congenital syphilis Diagnosis Treponemal tests Non-treponemal tests Management Early syphilis (primary, secondary and early latent) Late latent, cardiovascular and gummatous syphilis Neurosyphilis Pregnancy Syphilis and HIV Prognosis and follow-up Lymphogranuloma venereum Clinical features Diagnosis Management Chancroid Clinical features Diagnosis and management Donovanosis Clinical features Diagnosis and management Pediculosis pubis Diagnosis and management Scabies EPIDEMIOLOGY AND PATHOGENESIS Epidemiology HIV in sub-Saharan Africa HIV in high-income countries The changing face of the epidemic Pathology Routes of acquisition Sexual intercourse (vaginal and anal) Vertical transmission (transplacental, perinatal, breast-feeding) Contaminated blood, blood products and organ donations Contaminated needles (intravenous drug misuse, injections and needle-stick injuries) The virus Pathogenesis CLINICAL FEATURES OF UNTREATED HIV INFECTION Early HIV infection: incubation, seroconversion and acute illness Clinical latency Symptomatic HIV infection End-organ effects of HIV Eye disease Mucocutaneous manifestations Haematological complications Gastrointestinal effects Renal complications Respiratory complications Endocrine complications Cardiac complications Conditions associated with HIV immunodeficiency CLINICAL APPROACH TO THE PATIENT WITH HIV HIV testing Detection of anti-HIV antibodies Detection of viral p24 antigen Genome detection assays Isolation of virus in culture Initial assessment Monitoring Immunological monitoring Virological monitoring Monitoring other aspects of health MANAGEMENT OF HIV-POSITIVE PATIENTS Anti-retroviral drugs When to start ART Which drugs to start Nucleoside/nucleotide reverse transcriptase inhibitors Non-nucleoside analogues Protease inhibitors Integrase strand transfer inhibitors Co-receptor blockers Fusion inhibitors Post attachment inhibitors Monitoring therapy Drug resistance Drug interactions Adherence Treatment failure Changing therapy Stopping therapy Complications and long-term safety of ART Allergic reactions Lipodystrophy and metabolic syndrome Mitochondrial toxicity and lactic acidosis Bone metabolism Immune reconstitution inflammatory syndrome Specific therapeutic situations Acute HIV infection Pregnancy Post-exposure prophylaxis Towards cure SPECIFIC CONDITIONS ASSOCIATED WITH HIV INFECTION Prevention of opportunistic infection in patients with HIV Avoidance of infection Immunization strategies Chemoprophylaxis Fungal infections Cryptococcosis Candidiasis Aspergillosis Histoplasmosis, blastomycosis, coccidioidomycosis and Penicillium marneffei infection Protozoal infections Cryptosporidiosis Microsporidiosis Leishmaniasis Viral infections Hepatitis B infection Hepatitis C infection Cytomegalovirus infection CMV retinitis CMV gastrointestinal conditions CMV neurological conditions Herpesvirus infection Varicella zoster virus infection Epstein–Barr virus infection Human papillomavirus infection Polyomavirus infection Bacterial infections Mycobacterium tuberculosis infection Mycobacterium avium-intracellulare infection Infections due to other organisms Neoplasms Kaposi’s sarcoma Lymphoma Cervical carcinoma PREVENTION AND CONTROL OF HIV INFECTION Expanding HIV testing Strategies for reducing HIV transmission Pre-exposure prophylaxis Global strategies 38 - Obstetric medicine CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR OBSTETRIC MEDICINE History Examination Investigations Screening INTRODUCTION HYPERTENSIVE DISORDERS Chronic/pre-existing hypertension Management Gestational hypertension Investigations and management Pre-eclampsia Clinical features Investigations Management HELLP LIVER DISEASE Hyperemesis gravidarum Intrahepatic cholestasis of pregnancy Investigations Management and prognosis Acute fatty liver of pregnancy Investigations Management CARDIAC DISEASE THROMBOEMBOLIC DISEASE Diagnosis Management RESPIRATORY DISEASE Asthma Pneumonia Tuberculosis Sarcoidosis Cystic fibrosis Severe restrictive lung disease NEUROLOGICAL DISEASE Epilepsy Management Breast-feeding Contraception Migraine Multiple sclerosis Myasthenia gravis Stroke Depression ENDOCRINE DISEASE Diabetes mellitus Thyroid and parathyroid disease Thyrotoxicosis Hypothyroidism Hyperparathyroidism Pituitary disease Prolactinomas Diabetes insipidus Hypopituitarism Adrenal disease Conn’s syndrome and hyperaldosteronism Phaeochromocytoma and paraganglioma RENAL DISEASE Urinary tract infection Chronic kidney disease Management Renal transplantation Acute kidney injury SKIN DISORDERS RHEUMATIC DISEASE PRESCRIBING IN PREGNANCY 39 - Women’s health CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR WOMEN’S HEALTH History Examination INTRODUCTION THE LIFE COURSE APPROACH Sexual health education Pre-pregnancy counselling The physiological response to pregnancy The postnatal visit The normal menstrual cycle Menopause Clinical features Management Hormone replacement therapy Contraception Hormonal contraception The combined oral contraceptive pill The ‘mini-pill’ Long-acting reversible contraceptiion Barrier methods Intrauterine contraceptive devices Emergency contraception Permanent contraception MISCARRIAGE Management Recurrent miscarriage Stillbirths HEAVY MENSTRUAL BLEEDING Management First-line medical therapies Surgical treatments Uterine fibroids (leiomyomata) Management ABORTION/TERMINATION OF PREGNANCY URINARY INCONTINENCE DOMESTIC ABUSE AND VIOLENCE Female genital mutilation GYNAECOLOGICAL CANCERS 40 - Men’s health CORE SKILLS AND KNOWLEDGE CLINICAL SKILLS FOR MEN’S HEALTH History Examination Investigations: bladder scanning INTRODUCTION Disparities between men’s and women’s health Men are their own worst enemies SPECIFIC DISEASES OF MEN DISEASES OF THE PROSTATE GLAND Prostatitis Acute prostatitis Chronic prostatitis Benign enlargement of the prostate gland Clinical features Examination and investigations Management Prostate cancer Pathogenesis Clinical features and diagnosis Prognosis Management Localized disease Locally advanced and metastatic disease Screening DISEASES OF THE PENIS Malignant disease of the penis Penile cancer TESTICULAR AND SPERMATIC CORD DISEASE Epididymitis and orchitis Hydrocele and epididymal cyst Varicocele Undescended testes (cryptorchidism) Malignant disease of the testicle Clinical features Investigations and management Self-examination LACK OF LIBIDO AND ERECTILE DYSFUNCTION Management First-line therapies Second-line therapies Third-line therapies PRIAPISM THE AGEING MALE 41 - Environmental medicine CORE SKILLS AND KNOWLEDGE AIR POLLUTION Epidemiology Management HEAT INJURY Heat cramps Heat exhaustion Management Heat stroke Prevention Management COLD INJURY Hypothermia Clinical features Diagnosis Sequelae Management Severe hypothermia Prevention Peripheral cold injury Frostbite Management Chilblains Non-freezing cold injury HIGH ALTITUDE Acute mountain sickness High-altitude pulmonary oedema High-altitude cerebral oedema Management Retinal haemorrhage Deterioration Chronic mountain sickness DIVING Problems during descent Oxygen narcosis Nitrogen narcosis Problems during and following ascent Decompression sickness Management Lung rupture, pneumothorax and surgical emphysema DROWNING Management and prognosis Prevention IONIZING RADIATION Mild acute radiation sickness Acute radiation sickness Haemopoietic syndrome Gastrointestinal syndrome CNS syndrome Radiation dermatitis Late effects of radiation exposure Major nuclear power plant accidents Therapeutic radiation Management ELECTRIC SHOCK LIGHTNING STRIKE INHALED SMOKE Normal Values(These vary: please check with your local laboratory.) Haematology Biochemistry Lipids and lipoproteins Blood gases (arterial) Urine values Serum/urine values
