1. Paul Baillie
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AKT revision
Paul’s Revision Notes (January 2014)
ONCOLOGY
NICE guidelines for Cancer Referrals (CG27 Modified April 2011)
http://publications.nice.org.uk/referral-guidelines-for-suspected-cancer-cg27/guidance#lung-cancer
Lung Cancer
Urgent referral for CXR (& take FBC):
1. Haemoptysis
2. Persistent (>3 weeks) …
Cough Shoulder tip pain Dyspnoea (SOB)
Weight loss Chest signs Hoarseness
Finger clubbing Cervical or supraclavicular lymphadenopathy
Features suggestive of mets from a lung cancer (Brain, bone, liver of skin)
* A report should be made back to the referring primary health care professional within 5
days of referral
Urgent referral for clinic:
1. Persistent haemoptysis in smokers aged 40+
2. CXR suggestive of lung cancer
3. CXR normal but lung ca still suspected
Immediate referral criteria (acute admission):
1. Signs of superior vena caval obstruction
2. Stridor
If the patient has a much increased risk of lung ca e.g. smoker, COPD, asbestos exposure, prev
lung ca → refer earlier than 3 weeks.
Upper GI Cancer
Urgent referral (at any age) if...
1. Dyspepsia +
Chronic GI bleeding Iron deficiency anaemia
Dysphagia Weight-loss
Vomiting (Persistent) Epigastric mass
Suspicious barium meal result
2. Patients 55+ with recent onset persistent dysphagia alone
3. Dysphagia that occurs within 5 seconds of swallowing
4. Unexplained abdo pain and weightloss
5. Upper abdo mass (without dyspepsia)
6. Obstructive jaundice
Consider urgent referral in
Weight-loss alone or Iron deficiency anaemia alone
Worsening dypepsia +
barrett’s oesophagus / known dysplasia / intestinal metaplasia / atrophic gastritis
Peptic ulcer surgery + 20 years ago
When going for endoscopy need to have stopped
PPIs for 2 weeks
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Antibiotics for 4 weeks
Lower GI Cancer
NICE recommend the following patients are referred urgently (i.e. within 2 weeks) to colorectal
services for investigation (+ take FBC and perform abdo exam and DRE):
● patients > 40 years old, reporting rectal bleeding and looser stools and/or increased
stool frequencypersisting for 6 weeks or more
● patients > 60 years old, with rectal bleeding persisting for 6 weeks or more without a
change in bowel habit and without anal symptoms
● patients > 60 years old, with a change in bowel habit to looser stools and/or more
frequent stools persisting for 6 weeks or more without rectal bleeding
● any patient presenting with a right lower abdominal mass consistent with involvement of
the large bowel
● any patient with a palpable intraluminal rectal mass
■ A mass outside the bow elwall→ refer to urologist or gynaecologist
● unexplained iron deficiency anaemia in men or non-menstruating women
■ (Hb < 11 g/dl in men, < 10 g/dl in w omen)
Breast Cancer
Urgent Referral
1. Lump -
a. Suspicious on examination -discrete, hard lump with fixation (+/- skin tethering)
b. Age > 30 years & lump persists after one period
c. Postmenopausal patient with lump
d. Lump enlarges
e. Family history of cancer
2. Eczematous nipple changes unresponsive to normal medication
3. Nipple distortion of recent onset
4. Spontaneous unilateral bloody nipple discharge
5. Male 50 years + with unilateral firm subareolar mass +/- nipple distortion or skin changes
NB. A Painful Breast alone is not an indication for referral unless it is persisting or resistant to
initial rx when a non-urgent referral could be made
Gynae Cancer
When any woman presents with alterations in the menstrual cycle, intermenstrual bleeding,
postcoital bleeding, postmenopausal bleeding or vaginal discharge a full pelvic exam +
speculum exam should be undertaken.
Urgent USS:
- palpable abdominal or pelvic mass not obviously uterine fibroid
Urgent referral
- Concerning features on speculum exam
- USS suggestive of gynae cancer
- Postmenopausal bleeding in women not on HRT
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- Postmenopausal bleeding which persists after 6 weeks off HRT
- Unexplained vulval lump
- Vulval ulcer + bleeding
- Vulval pruritis or pain resistant to treatment
- Consider in persistent intermenstrual bleeding despite normal speculum exam
NB. Tamoxifen can increase the risk of endometrial cancer
Urological Cancer
Prostate Cancer
Offer DRE and PSA (after counselling) for:
Erectile Dysfunction Haematuria
Lower back pain Bone Pain
Weightloss
NB. Postpone PSA for 1 month after a UTI
Urgent referral:
Hard Irregular Prostate on DRE (+ do PSA)
High PSA
NB. Borderline PSA → repeat in 1 to 3 months → if rising urgent referral
Bladder and Renal Cancer
Urgent referral:
Painless macroscopic haematuria (male or female)
40 years + recurrent UTIs associated with haematuria
Urinary tract mass (on USS or palpated clinically)
Non-Urgent Referral
<50 years + microscopic haematuria (normal creatinine and no proteinuria)
NB. Protein or raised creatinine → refer to renalphysician
Testicular cancer
Urgent referral:
Swelling or mass in body of testis
Urgent scan:
Scrotal mass which does not transilluminate &/or nondifferentiable from testis
Penile Cancer
Urgent referral:
Progressive Ulceration Mass in the glans or precupice
Mass of the skin of the penile shaft
Haematological Cancer
Urgent referral
Persistent unexplained splenomegaly
Blood film reported as acute leukaemia
Investigations of unexplained bruising, bleeding or purpura or symptoms of anaemia:
FBC Blood film
Clotting ESR CRP or Plasma Viscosity
Investigations of bone pain:
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FBC Xray
U&E LFTs
Bone profile PSA
ESR, Plasma Viscosity or CRP
Investigations of chronic fatigue or unexplained lymphadenopathy:
FBC Blood Film
ESR CRP or Plasma viscosity
NB. repeat at least once if chronic fatigue does not resolve
Worrying features of lymphadenopathy:
Persisting >6 weeks Increasing in size
Lymph nodes >2cm Widespread
Associated night sweats, splenomegaly or weight loss
Skin Cancer
For low- suspicion pigmented lesions close monitoring using the 7 point weighted checklist for 8
weeks should be undertaken. Measurement should be made with photographs using a marker
or ruler. Urgent referral if 3 points or more (or strong concerns about cancer & 1 point)
Major features (2 points each) Minor Features (1 point each)
Change in size 7mm or longer
Irregular shape Inflammation
Irregular colour Oozing
Change in sensation
Urgent referral:
Suspected Melanoma
Non healing lesions, >1cm, with induration on palpation, commonly on face, scalp or
back of hand with expansion over 8 weeks (?SCC)
Immunosuppression + new or growing cutaneous lesion
Non Urgent Referral
Suspicion of BCC
NB. All lesions not thought to be cancer w hich are excised should be done so w ith a margin of 2mm of normal skin and cut dow n to
subcutaneous fat
Head and Neck Cancer
Unexplained red and white patches of the oral mucosa (including suspected lichen planus) →
non-urgent referral. But if they are painful or bleeding or swollen → urgent referral to ENT
Urgent ENT referral
Oral ulceration or mass lasting >3 weeks
Hoarseness >3 weeks → urgent CXR → if negative refer to ENT
Unexplained neck lump that changes over 3-6 weeks
Persistent Parotid or Submandibular swelling
Persistent sore throat
Unilateral head/neck pain + earache but normal otoscopy for >4 weeks
Unexplained tooth mobility >3 weeks → urgent referral (dentist)
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Thyroid Cancer
Urgent referral… Thyroid swelling +:
Solitary nodule increasing in size Hx of neck irradiation
FHx of endocrine tumour Unexplained hoarseness or change in voice
Cervical lymphadenopathy Pre-pubertal patients
65 years & older
If none of these symptoms → TFTs
NB. Hypo- or hyper-thyroidismwith goitre is very unlikely to be cancer (non-urgent referral). Goitre without abnormalTFTs and none
of the above features should be referred non-urgently
Brain & CNS Cancer
This guideline tells you to refer everyone essentially.
Always refer when there is witnessed personality change
Useful bit of info: pulse synchronous tinnitus is a sign of raised ICS
Sarcoma
Urgent referral for soft tissue lump if:
>5cm
Painful
Deep to fascia
Increasing in size
A recurrence after a previous excision
Cancer in Children
Urgent referral
Presented 3 or more times with the same problem but no clear diagnosis
Persistent back pain → FBC and blood film
Persistent Parental Anxiety is a reason for referral even if you are happy it is likely to be benign
There is an association between
Down’s syndrome - Leukaemia
Neurofibromatosis - CNS cancer
Lymphoma (Non-Hogkins more rapidly growing cr. Hodgkin’s)
Refer urgently for lymphadenopathy if:
Non-tender and firm/hard >2cm
Progressively enlarging Other features of general ill health
Axillary nodes present Supraclavicular nodes present
Hepatosplenomegaly or mediastinal mass on CXR require immediate referral
Leukaemia
Childhood Leukaemia
Acute leukaemia (ALL or AML) is most common in children.
ALL is more common than AML.
Usually presents with a relatively short history (weeks rather than months). The presence of one
or more of the following symptoms or signs requires investigation with an FBC and blood film…
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● Pallor
● Fatigue
● unexplained fever
● Persistent or recurrent URTIs
● Generalised lymphadenopathy
● Persistent or unexplained bone pain
● Unexplained bruising
The presence of either of the following signs requires immediate referral …
● Unexplained petechiae
● Hepatosplenomegaly
Adult Leukaemia
About 90% of leukaemia is diagnosed in adults.
Chronic Leukaemias mostly occur in older patients
Most Lymphocytic leukaemias involve the B cell.
Four types of Leukaemia
Acute Lymphoblastic Leukaemia (ALL)→ most common form in children but can also occur in
adults >65 years old. Survival rates ~85% in children and 50% in adults.
Subtypes include precursor B acute ALL, precursor T ALL, Burkitt’s leukaemia and acute
biphenotypic leukaemia
Chronic Lymphocytic Leukaemia (CLL) - mostly affects adults >55years old. Essentially never
affects children. Men > Women 2:1. Incurable but 5 yr survival is 75%.
Acute Myeloid Leukaemia (AML) - Adults > children but can affect either. Men > Women. Rxed
c chemo. 5 year survival only 40%.
Chronic Myeloid Leukaemia - mainly in adults. Rx c Imatinib (Glivec). 5 yr survival is 90% but
this is less in chronic myelomonocytic leukaemia.
Other types include Hairy Cell Leukaemia, T-cell Prolymphocytic Leukaemia (Aggressive), Adult
T-Cell Leukaemia (caused by HTLV virus) and Large Granular Lymphocytic Leukaemia
Lymphomas
Hodgkin’s lymphoma presented typically with non-tender cervical and/or supraclavicular
lymphadenopathy. The history is long (months) and only a minority of patients have systemic
“B” symptoms (itching, night sweats, fever, weightloss).
Non-Hodgkin’s Lymphomas typically presented with a more rapid progression of symptoms and
can present with lymphadenopathy, breathlessness, SVC obstruction or abdominal distension.
Urgent referral is needed if one of the following is noted…
● Lymph nodes are non-tender, firm or hard
● Lymph nodes are >2cm
● LNs are progressively enlarging
● LNs and features of general ill health, fever or weight-loss
● Supraclavicular nodes are involved
● Hepatosplenomegaly
● Mediastinal or Hilar mass on CXR
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Gastroenterology
Diagnosis of Irritable Bowel Syndrome
● Do NOT diagnose if over 50 years old
● Need 6 months history of abdominal pain +/- bloating +/- diarrhoea
● Abdo pain relieved by defecation or abdominal pain + change in bowel habit + 2 of …
○ Altered stool passage (straining, urgency, incomplete evacuation)
○ Bloating, distension, tension or hardness
○ Symptoms worsened by eating
○ Passage of mucus
Need to exclude red flags: rectal bleeding, weight-loss, FHx bowel or ovarian ca
Advise:
● Insoluble sources of fibre such as bran and wholemeal should be avoided in IBS.
● for wind and bloating consider increasing intake of oats and linseeds.
● Avoid resistant starches (often found in processed foods)
● Have regular meals and take time to eat
● Drink at least 8 cups of fluid per day but avoid caffeine (Restrict to 3 cups coffee/tea)
● Reduce alcohol intake and fizzy drinks
● Limit fresh fruit to 3 portions per day
Rx:
Pain → antispasmodics.
Constipation → laxatives but avoid lactulose.
Diarrhoea → loperamide.
Second line rx: Tricyclic Antidepressants (Amitriptyline 5-10mg) or CBT. .
Gastroenteritis
E.Coli - common among travellers
Giardiasis - prolonged, no bloody stool
Cholera - profuse watery diarrhoea, severe dehydration → wt loss
Shigella - bloody diarrhoea, vomiting and abdo pain
Staph Aureus - Severe vomiting. Short incubation
Campylobacter - Flu-like prodrome → crampy abdo pains → fever and diarrhoea which can be
bloody. Complications include Guillain Barre Syndrome
Bacillus Cereus - Stereotypically due to rice.
Amoebiasis - Gradual onset of bloody diarrhoea, abdo pain and tenderness which can last
several weeks. Treated with diloxanide furoate
Peptic Ulcers
Classically duodenal ulcers cause most pain when you are hungry with an empty stomach or at
night.
Classically gastric ulcers cause most pain soon after eating.
Management of Proven Peptic Ulcer
Stop NSAID if possible
Advice against precipitants (alcohol, smoking)
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Test for Helicobacter & start a full dose PPI (e.g. 30mg Lansoprazole or 20mg Omeprazole)
If positive When associated with NSAID continue rx with full dose PPI for 2
months and THEN give eradication therapy.
When not associated with NSAID give eradication therapy for one week
4-8 weeks after eradication therapy → retest for H. Pylori.
If negative → continue rx with full dose PPI for 1-2 months depending on report
of severity
Arrange repeat endoscopy 6-8 weeks after treatment
If ulcer still present. If taking NSAID consider long term PPI but if this doesn’t
work consider H2 receptor antagonist. If not taking NSAID still consider other
cause e.g. malignancy, crohn’s, zollingher ellison syndrome (gastrin-producing
tumour)
If recurrent dyspepsia despite ulcer healed and eradication of H. Pylori and no
NSAID use offer lowest dose PPI to control symptoms.
PPIs adverse effects:
Hypomagnesaemia
Increased risk of bone fractures
Clostridium Difficile
Rebound acid hypersecretion
NB. They may help sugar levels in diabetes.
Helicobacter Pylori
Increases the risk of gastric ulcer, duodenal ulcer, gastric carcinoma and MALT lymphoma
(Gastric mucosa associated lymphoid tissue lymphoma. NB this regresses with triple therapy)
High rates in developing countries (100%)
In developed countries incidence increases with age (60% by 60)
C13
urea breath testing (or if not possible Stool antigen testing) is the recommended method.
Need to not use PPIs for 2 weeks before testing
Triple therapy is Double dose PPI (e.g. Omeprazole 40mg) + Clarithromycin + Metronidazole
or Amoxicillin (1 week) (PAC or PCM regimen)
It is only necessary to check eradication if symptoms return.
Inflammatory Bowel Disease
1. Ulcerative Colitis
Inflammation always starts at the rectum, is continuous and never goes past the
ileocecal valve but you can get backwash ileitis. There are two peaks in
incidence of UC (15-22 yrs and 55-65 yrs).
Features include bloody diarrhoea, urgency, tenesmus, abdo pain (esp. LLQ).
No inflammation beyond submucosa.
Neutrophils migrate through the wall to form Crypt Abscesses
Inflammatory cell infiltrate of lamina propria
Widespread ulceration → some preservation of mucosa (pseudopolys)
→ loss of haustrations (drainpipe colon)
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2. Crohn’s Disease
Commonly affects the terminal ileum but may be seen anywhere from the mouth
to the anus.
Strong genetic susceptibility
Inflammation occurs in all layers down to the serosa
→ prone to strictures, fistulas and adhesions
Presentation
- weight loss, lethargy
- Diarrhoea is the commonest symptom in adults (sometimes bloody)
- Abdo pain is the commonest symptom in children
- Perianal disease - skin tags or ulcers
Extraintestinal features which are common to both IBDs are arthritis (symmetrical, only
affecting a few joints), erythema nodosum (inflammation of subcut fat), episcleritis (more
common in Crohn’s) Uveitis (more common in UC), Primary Sclerosing Cholangitis
(much more common in UC), Pyoderma Gangrenosum, Clubbing and osteoporosis.
Coeliac Disease
Repeated exposure to gluten leads to villous atrophy which can lead to malabsorption.
Tissue transglutaminase (TTG) or Anti-endomysial antibodies
Associated with Dermatitis Herpetiformis (vesicular pruritic eruption) & autoimmune conditions
90% patients have HLA-DQ2
Common Symptoms (if anyone has any of these test them!):
Chronic or intermittent diarrhoea Failure to thrive / Faltering growth
Persistent unexplained N&V Sudden unexplained weight loss
Prolonged fatigue Recurrent abdo pain, cramping or
distension
Unexplained IDA or other unspecified anaemia
Tell them to avoid things which include gluten:
Wheat (Bread, pasta, pastry)
Barley (beer)
Rye
Oats (although some coeliacs tolerate oats)
They should be okay with these foods which do not contain gluten:
Potatoes
Rice
Corn (Maize)
Complications:
Anaemia (iron / folate / vitamin B12 deficiency) Hyposplenism
Osteoporosis or osteomalacia Lactose intolerance
Enteropathy-associated T cell lymphoma of small intestine
Subfertility / unfavourable pregnancy outcomes
Rare: oesophageal cancer, other malignancies
Associations:
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Dermatitis Herpetiformis:
- autoimmune blistering disorder caused by IgA deposition in the dermis which causes itchy
vesicular lesions on the elbows, knees and buttocks treated with dapsone and a gluten free diet.
Also associated with Type 1 diabetes and autoimmune thyroid disease and autoimmune
hepatitis. All those with the above conditions or IBS or first degree relative FHx should be
screened for coeliac dx.
Child Pugh Classification of Liver Cirrhosis
Score 1 2 3
Bilirubin (µmol/l) <34 34-50 >50
Albumin (g/l) >35 28-35 <28
Prothrombin time,
prolonged by (s)
<4 4-6 >6
Encephalopathy none mild marked
Ascites none mild marked
Grade A = <7 Grade B = 7-9 Grade C = >9
Hepatitis B
Double stranded DNA virus, spread through exposure to infected blood or body fluids, including
vertical transmission from mother to child. Incubation period 6-20 weeks.
Immunisation:
- Contained HBsAg using recombinant DNA.
- Most schedules give 3 doses and a booster at 5 years.
- At risk groups should be vaccinated: healthcare workers, IVDUs, sex workers, close
family, contacts of affected, regular transfusion receivers, people who may required
renal replacement therapy, prisoners and Chronic Liver Disease patients.
AntiHBs level response:
>100 = adequate response. Still booster at 5 years
10-100 = suboptimal → give one additional vaccine but no further testing required
<10 = Non-responder. Test for current or past infection. Give further 3 dose course and
test after. If still fails to respond HBIG would be required for protection if exposed to the
virus.
Testing for Hep B
● HBsAg - first marker to appear & normally implies acute dx (present 1-6 months)
● If HBsAg present > 6months → chronic disease
● Anti-HBs = immunity (either exposure or immunisation)
● Anti HBc = previous or current infection. IgM acute. IgG persists
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● HBeAg caused by breakdown of core antigen for infected liver cells & is therefore a
marker of infectivity
Complications from Hep B:
- Chronic Hepatitis 5-10% → Fulminant liver failure 1% - Cryoglobulinaemia
- Hepatocellular carcinoma - Glomerulonephritis - Polyarteritis Nodosa
Treatment of Hep B: pegylated interferon alpha, tenofovir and entecavir.
Achalasia
failure of smooth muscle fibres to relax.
Oesophageal achalasia is common; the lower oesophageal sphincter remains closed and
causes dysphagia of liquids and solids from the start. This typically presents between 25 and
40 years old. But these should always be referred for exclusion of cancer.
Rx: Medication: 1. Calcium channel blockers and nitrates. 2. Balloon dilitation. 3. Surgery →
Heller’s myotomy
Achalsia of the rectum is Hirshprung’s disease.
Primary Biliary Cirrhosis - the M rule
● IgM
● anti-Mitochondrial antibodies, M2 subtype
● Middle aged females
Classic presentation is itching in a middle aged female.
Associations:
Sjogren’s syndrome (in 80%)
Rheumatoid arthritis
Systemic Sclerosis
Thyroid disease
Diagnosis:
Anti-mitochondrial antibodies M2 subtype present in 98%
Raised serum IgM
Treatment:
Cholestyramine for itching
Fat soluble vitamin supplementation
Ursodeoxycholic Acid
Liver transplant e.g. if bilirubin >100. recurrence in graft is rare
Splenectomy
Following a splenectomy patients are particularly at risk from pneumococcus, haemophilus,
meningococcus and Capnocytophaga canimorsus (from dog bites) infections
Therefore you vaccinate before a splenectomy (ideally 2 weeks before) with
- Pneumococcus every 5 years
- Annual influenzae vaccine
- Meningitis A &C
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Antibiotic Prophylaxis
- Penicillin V normally for life but definitely at least for 2 years and at least until they are
16 years old
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Psoriatic Arthritis
● Can present before skin changes
● Tends to be like rheumatoid arthritis and is treated as if it were rheumatoid, although it
has a better prognosis
Drugs contraindicated in renal failure
● antibiotics: tetracycline, nitrofurantoin
● NSAIDs
● lithium
● metformin
Neck Lumps
● Lymphoma - rubbery lumps, occasionally pain drinking EtOH, nightsweats,
splenomegaly
● Thyroid Swellings move up on swallowing
● Thyroglossal cysts - seen in pts <20yrs and moves on tongue protrusion
● Pharyngeal Pouch - seen in older men, posteriomedial herniation between
thyropharyngeus and cricopharyngeus muscles, can occasionally gurgle, symtoms
include dyspahgia, regurge, aspiration and chronic cough
● Cystic Hygroma - Congenital lymphatic lesions, classically on the left side of the neck,
most are evident at birth and 90% present before 2 years of age.
● Branchial Cyst - oval, mobile mass between SCM and pharynx which usually presents in
early adulthood.
Weber’s test
If the left ear hears the noise better than the right, then either the
left ear has a conductive defect or right ear has a
sensorineural defect.
Rinne’s Test
Initially place on
mastoid process
(bone conduction)
until sound no longer
heard, then
immediately
placed outside the ear canal (air conduction)
Ask can you hear the vibration sound?
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Drug Induced Liver Disease
● Co-amoxiclav is a well recognised cause of jaundice (cholestasis)
● Hepatocellular damage can be caused by: paracetamol, sodium valproate, phenytoin,
MAOIs, Isoniazide, Rifampicin, Pyrizinamide, Statins, Alcohol, amiodarone, methyldopa
and nitrofurantoin
● Cholestasis (jaundice) is commonly caused by: the OCP, fluclox, co-amoxiclav,
erythromycin, anabolic steroids/testosterone, phenothiazones (e.g. chlorpromazine),
sulphonylureas, fibrates & nifedipine.
● Cirrhosis: methotrexate, methyldopa, amiodarone.
Nasal Polyps
● Affect men more than women
● Not common in children or elderly
● Associated with asthma and aspirin sensitivity (Samter’s Triad)
● Also associated with infective sinusitis, cystic fibrosis, kartagener’s syndrome and churg
strauss
● Symptoms: nasal obstruction, rhinnorhoea, sneezing, poor taste and poor smell
● If unilateral or bleeding needs further inx
● Refer all with nasal polyps to ENT
● Topical corticosteroids shrink them in 80%
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Pregnancy Visits
● 10 visits for primip; 7 for multips
● 8-12 weeks → booking visit (Info re: diet, smoking, folic acid, vitamin D), bloods (HIV,
Hepatitis B, Rubella, Syphilis, FBC, Blood Group, rhesus status, red cell alloantibodies,
haemoglobinopathies) Urine (to detect asymptomatic bacteriuria) blood pressure and
BMI chart.
Smoking Cessation: If says “ex-smoker” → carbon monoxide monitor + CBT or
motivational interviewing before Nicotine replacement therapy. All women who smoke or
have quit in the last 2 weeks or tested positive with CO reading 7ppm or more should be
referred to NHS stop smoking services. Rx: 1st line: CBT / self help. 2nd line: NRT.
● 10-14 weeks → Early scan (confirm dates and exclude multiple pregnancy)
● 11-14 weeks → Down’s syndrome screening inc. nuchal scan
● 16 weeks → Blood and scan results. If Hb <11 consider iron. BP and urine check
● 18-21 weeks → Anomaly Scan
● 25 weeks (only primip) → Routine Checks: BP, Urine, SFH
● 28 weeks - routine checks. second blood test (FBC & atypical red cell alloantibodies).
Consider iron if Hb <10.5 First dose of Anti-D for rhesus negative women.
● 31 weeks (Only primip) → routine checks
● 34 weeks - routine checks. Second dose of anti-D (NB. little evidence for second dose of
anti-D so some trusts do not give it). Info on birth plan / labour.
● 36 weeks - routine checks. Exam for presenting part - offer external cephalic version if
indicated. Info on breast feeding, vitamin K and ‘baby blues’
● 38 weeks- routine checks
● 40 weeks (only primip) - routine checks & discussion about prolonged pregnancy
● 41 weeks - Routine checks + Discuss labour plans and possibility of induction of labour
Polymorphic Eruption of Pregnancy
● very itch rash seen in the last trimester
● lesions often appear in abdominal striae
● Use emolients and mild steroids
Pemiphigoid Gestationis
● Pruritic blistering lesions seen in 2nd and 3rd trimester
● Often peri-umbillical initially, later spreading to back buttocks and arms
● Oral steroids are often required
Gestational Diabetes
Diagnosed by OGTT
Complicated 1 in 40 pregnancies
Risk factors:
- BMI >30
- Previous macrosomic baby (>4.5kg)
- First degree relative with diabetes
- South asian, black caribbean or middle eastern
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Treatment
- It responded to diet and exercise in 80% of women
- oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are
needed if poor control or complications e.g. macrosomia
- Stop hypoglycaemic medications following delivery
- a fasting glucose should be checked at the 6 week postnatal check
Maternal Complications:
- Polyhydramnios (25%) (?due to foetal polyuria)
- Preterm labour (15%)
Neonatal complications:
- Mascrosomia (but may also cause SGA)
- Hypoglycaemia (secondary to beta cell hyperplasia)
- Respiratory distress syndrome (surfactant production is delayed)
- Polycythaemia & jaundice
- Malformations e.g. sacral agenesis, hypertrophic cardiomyopathy
- Still birth
- Shoulder dystocia (may cause Erb’s palsy)
Pre-existing Diabetes
- Advise weight-loss if BMI>27
- Stop oral hypoglycaemic agents apart from metformin and commence insulin.
- Folic acid 5mg OD preconception to 12 weeks gestation
- Detailed anomaly scan at 18-20 weeks
Hyperemesis
Antihistamines e.g. Promethazine are first line
Natural remedies including ginger and acupuncture on the “p6” point (near the wrist) are
recommended
Advise against alcohol in the first trimester
Placenta Praevia vs Placental Abruption
Abruption = placenta separates from uterus lining
Shock out of keeping with visible blood loss
Constant pain & tender uterus
Normal lie and presentation
Foetal heart absent or distressed
CAn get coagulation problems e.g. DIC
Praevia = Placenta inserted in the lower uterine segment
Shock in keeping with visible blood loss
no pain & uterus non-tender
Lie may be abnormal
Foetal heart usually normal
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Ophthalmology
Primary open-Angle Glaucoma
Treatment:
Latanoprost - increase uveosacral outflow. Once daily drops. Adverse effects: brown
pigmentation of iris
Timolol: Reduces aqueous production. Avoid in asthmatics and heart failure.
Brimonidine: Sympathomimetics. Both effects. Avoid if taking MAOIs or TCAs. SE: hyperaemia
Dorzolamide: Carbonic anhydrase inhibitors. Reduces aqueous production.
Miotics e.g. pilocarpine, a muscarinic receptor agonist SEs: headache, blurred vision.
Surgery (Trabeculectomy) only in refractory cases
Causes of acute blindness
Ischaemic Optic Neuropathy - arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. diabetic)
of the short posterior ciliary arteries, causing damage to the optic nerve.
Central Retinal Vein Occlusion - incidence increases with age and more common than arterial
occlusion. Causes include glaucoma, polycythaemia and hypertension. Severe retinal
haemorrhages are normally seen.
Central Retinal Artery Occlusion - due to thromboembolism or arteritis. Feature: afferent
pupillary defect and cherry red spot on pale retina.
Vitreous Haemorrhage - Large bleeds → sudden visual loss. Moderate → large dark spots.
Small → floaters
Retinal Detachment - Dense shadows that start peripherally and move centrally e.g. veil /
curtain. Straight lines appear curved. Central visual loss.
Posterior Vitreous Detachment - Flashes of light (photopsia) in the peripheral field of vision.
Floaters, often on the temporal side of the central vision.
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Musculoskeletal
Non-specific Lower Back Pain
Do not perform lumbar x-rays
Proven therapies:
Manual therapy (physio)
Exercise programmes
Acupuncture
Paracetamol is first line
If >45 years co-prescribe PPI c NSAIDs
Consider TCAs
Strong opioids can be considered for short term use
Osteoporosis
Low bone mineral density. Secondary causes of osteoporosis include rheumatoid arthritis,
malabsorption, COPD, chronic liver disease, hypogonadism in men, diabetes &
hyperthyroidism. Drug causes include: anticonvulsants, PPIs, SSRIs and anti-retroviral drugs.
Treatment is indicated following osteoporotic fragility fractures in postmenopausal women who
have a T score of -2.5 or less. In women aged 75 years old a DEXA scan may not be required
if the responsible clinician feels it would be inappropriate or unfeasible.
Vitamin D & Calcium should be given to all patients, unless definite there intake/stores are
sufficient.
Qfracture score does not allow input of BMD (T score) whereas the FRAX tool does
High risk → treat empirically
- Women are high risk if 10 yr risk is >11.1%
- Men are high risk if 10 year risk is >2.6%
Intermediate Risk → get a DEXA scan
For women who have gone through premature menopause (before 40) offer HRT.
First line: Alendronate for 5 years (then rx holiday) unless high risk or DEXA still <-2.5
Second line: Risedronate or Etidronate (if can’t tolerate alendronate)
Third Line: Raloxifene (SERM)
NB. May worsen menopausal symptoms & ↑ DVTs. No evidence that it
reduces non-vertebral fractures. May decrease risk of breast cancer.
Note: Strontium Ranelate is no longer third line due to risk of myocardial
infarction; it is only used to treat severe osteoporosis with very high fracture risk
Teriparatide (Recombinant PTH) - good at increasing bone mineral density.
HRT is not generally recommended unless early menopause, due to the risk of
cardiovascular disease and breast cancer
Hip Protectors have good evidence but compliance is poor.
Patients who take the equivalent of 7.5mg Prednisolone for 3 months should be offered
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bisphosphonate bone prevention if they a) are over 65yrs b) have previously had a fragility
fracture or c) have a T score less than -1.5 SD
Pagets Disease
Excessive breakdown and formation of bone followed by disorganised bone remodelling. It can
be inherited or acquired through long exposure to certain viruses including RSV (bronchiolitis),
paramyxovirus (e.g. measles) and affects 1-2% of white adults >55 years. The UK has the
highest prevalence of Paget's disease in the world. There is a slight male preponderance.
There is a lytic phase and then a sclerotic phase. The first manifestation is a raised alk phos
(normal alk phos and calcium). Overall the most common symptom is bone pain and there are
characteristic x-ray features including the ‘blade of grass’ lesion of long bones and cotton wool
pattern in the skull. The pelvis, femur and lower lumbar vertebrae are the most commonly
affected bones. When it affects the skull one can get hearing loss. Nerve compression from
expanding bones can occur causing deafness or tinnitus. It can cause bowing of the tibia and
frontal bossing.
Rx with NSAIDs, bisphosphonates and calcitonin. But calcitonin is rarely used as it is linked with
causing cancer.
Osteopetrosis
Very rare inherited disorder. It means “stone bone”.
Pepperpot skull is classical of multiple myeloma
Vitamin D Supplementation
This is advised in all the following groups:
- All children between 6 months and 5 years. Babies fed with formula milk who are having
>500mls/day do not need to take extra supplements
- All pregnant and breastfeeding women should take 10µg Vitamin D daily
- Adults > 65 years
- People who are not exposed to much sun
- All patients with osteoporosis should be given Vitamin D / Calcium supplements (testing is not
necessary)
Not many people warrant a vitamin D test. People who do…
- people with bone disease that may be improved with rx e.g. osteomalacia or Paget’s disease
- People with bone disease prior to certain treatments e.g. Zoledronate or denosumab
- Patient with musculoskeletal problems that may be attributed to Vitamin D deficiency e.g. bone
pain, bowing of legs (genu valgum), knock knees (genu varum), swelling of the wrist, prominent
costochondral joints, deformable skull (Craniotabes), hypocalcemic seizures or tetany
Vitamin D deficiency can also be caused by certain drugs (Rifampicin, anticonvulsants,
Cholestyramine, HAART & glucocorticoids)
Assay of 25-OHD (25-hydroxyvitamin D) is the best way to measure vitamin D
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Insufficiency = 25-50nmol/L
Deficiency = <25nmol/L
Treatment
Insufficiency → Children <6 months 200-400iu/day
→ Children >6months 400-800iu/day
NB. Children w ith insufficiency we often advise a regular multivitamin tablet
→ Adults → 1000iu (2x AdcalD3/day) to 2000iu/day or 10000iu/week
NB. AdcalD3 chew able contains 400iu colecalciferol& calcium 600mg per tablet
Deficiency → Children <6 months 3000iu/day
→ Children >6months 6000iu/day
→ Children > 1 year 300000iu IM one off dose
→ Adults Treat with 3 months high dose calciferol (ergocalciferol or
cholecalciferol) 10000iu/day or 60000iu/week then maintenance dose or 2
injections of 300000iu IM spaced by 3 months
Osteomalacia
Soft bones due to low vitamin D
Signs: X-ray findings Loosers Zones (partial fractures)
Crush # of the vertebrae
Trefoil Pelvis
Spontaneous Fractures
Low calcium
Low phosphate
Raised ALP
Raised PTH
Ankylosing Spondylitis
● HLA-B27 associated spondyloarthropathy
● Male:female 5:1
● Tends to present in men in 20s to 30s
● Pain and stiffness worse in morning
● Schober’s test - draw a line on the back 10cm above and 5cm below the dimples of
venus and get the patient to bend as far forwards as possible → the distance should
increase by >5 cm
● “A” features
○ Apical fibrosis Anterior uveitis Aortic regurgitation
○ Achilles tendonitis AV node block Amyloidosis
○ Arthritis peripherally (more common in females)
De Quervain's tenosynovitis
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De Quervain's tenosynovitis is a common condition in which the sheath containing the extensor
pollicis brevis and abductor pollicis longus tendons is inflamed. It
typically affects females aged 30 - 50 years old
Features
● pain on the radial side of the wrist
● tenderness over the radial styloid process
● abduction of the thumb against resistance is painful
● Finkelstein's test: with the thumb is flexed across the palm of
the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
Management
● analgesia
● steroid injection
● immobilisation with a thumb splint (spica) may be effective
● surgical treatment is sometimes required
Trigger Finger
Caused by a disparity between tendon and pulley, so the tendon cannot pass smoothly through
the pulley; initially stiffness then snapping as digit extended. More common in women.
Normally idiopathic but can be associated with rheumatoid arthritis and diabetes.
Generally seen in thumb, middle or ring finger
A nodule may be felt at the base of the affected finger
Rx: Steroid injection is normally successful. Then apply a finger splint
Surgery is reserved for pts who did not respond to steroid injections
Morton’s Neuroma
Benign neuroma affecting the intermetatarsal plantar nerve, most commonly in the 3rd inter-
metatarsal space. Females > male 4:1
Feature: forefoot pain most commonly in the third inter-metatarsophalangeal space. Worse on
walking. Shooting or burning pain. Patient feel they have a pebble in their shoe. Mulder’s Click -
one hand holds the neuroma between finger and thumb whilst the other hand squeezes the
metatarsals together - a click can be heard as the neuroma moves between the two metatarsal
heads. May be loss of sensation distally in the toes. Can get USS to confirm.
Management: avoid high heels, metatarsal pad, refer if symptoms persist for >3 months, despite
normal footwear and pads. Orthotist may give a metatarsal dome. Surgeon could do a
neurectomy.
Growing Pains
This is a misnomer as most pains attributed to growing pains aren’t due to growing therefore are
often called “benign idiopathic nocturnal limb pains of childhood”.
Feature:
Never present at the start of the day once the child has woken
No limp
No limitation of physical activity
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Normal physical exam
Systemically well
Symptoms intermittent and worse after a strenuous day of activity.
Gout
Deposition of monosodium urate monohydrate in the synovium caused by chronic
hyperuricaemia (uric acid >450micromol/L)
Acute Rx: NSAIDs, intra-articular steroid injections, (colchicine has a slower onset and its main
side effect is diarrhoea. It also inhibits neutrophil mobility and activity. but is good for those with
CKD). If already taking allopurinol continue it.
Lifestyle Modifications
- Reduce alcohol and avoid completely during an acute attack
- Lose weight if obese
- Avoid foods high in purines
(Liver, kidney, seafood, oily fish (mackerel, sardines) and yeast products)
Allopurinol Prophylaxis - should not be started until 2 weeks after an acute attack has settled as
it may precipitate a further attack. Initial dose = 100mg OD titrated up each week until serum
uric acid <300 micromol/L). NSAIDS or colchicine should be used when allopurinol is started
Indications for allopurinol prophylaxis
- Recurrent attacks (2 within 1 year)
- Tophi
- Renal Disease
- Uric acid renal stones
- If on cytotoxics or diuretics
- Lesch-Nyhan Syndrome
Complex Regional Pain Syndrome
Umbrella term for a number of conditions which occur following surgery or minor trauma
including reflex sympathetic dystrophy and causalgia
3x more common in women
Type I - most common. there is no demonstrable lesions to a major nerve
Type II - there is damage to a major nerve
Features
● progressive, disproportionate symptoms to the original injury/surgery
● allodynia
● temperature and skin colour changes
● oedema and sweating
● motor dysfunction
● the Budapest Diagnostic Criteria are commonly used in the UK
Management
● early physiotherapy is important
● neuropathic analgesia in line with NICE guidelines
● specialist management (e.g. pain team) is required
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Rheumatoid Arthritis
Epidemiology:
● 2-4x more common in women
● Peak incidence is in 70s but any age can develop it
Clinical Features
Early Rheumatoid (best to start rx in first 12 weeks of dx):
● Typically bilateral symmetrical inflammation of small joints of hand & feet but can affect
essentially any joint → heat +/- redness, swelling, pain & stiffness (worse in morning)
Late rheumatoid:
● Joint destruction
● Loss of function
● Hand deformities
○ Ulnar subluxation 1st MCPs
○ Radial deviation of wrist
○ Swan neck and boutonniere's deformity
○ Z thumb
● Piano key sign - gently press down on the ulnar head → if it depresses and comes back
up like a piano key it means there is disruption of the distal radioulnar ligament (common
to RA)
Das28 scale - measure of disease activity - includes number of joints swollen and number
tender, CRP or ESR & “patient global health”
Referral:
- Refer people with persistent synovitis without a known cause to a rheumatologist urgently
(within 2 weeks) if there is…
A. small joints of hand or feet affected
B. More than one joint affected
C. Delay of 3 months or longer between onset and person seeking medical advice
Don’t delay referral if blood tests are normal or awaiting results
Rx for possible rheumatoid (whilst awaiting referral):
1. Paracetamol +/- codeine
2. NSAID PRN + PPI
a. If cardiac risk → Ibuprofen or Naproxen is first line NSAID (NOT DICLOFENAC)
*DO NOT PRESCRIBE A STEROID IN PRIMARY CARE BEFORE SPECIALIST
ASSESSMENT
Investigations:
● X-ray findings:
○ Narrowing of Joint space
○ Periarticular osteopenia
○ Juxta-articular bony erosions
○ Subluxation
○ Periarticular soft tissue swelling
● Rh Factor - positive in 5% of general population & 65% of rheumatoid arthritis
● Anti-CCP (cyclic citrullinated peptide) specific but not sensitive
Specialists with then tend to prescribe a DMARD + short course of oral steroids
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Rx of Rheumatoid Flare:
(Flare features: stiffness, pain, swelling or general fatigue
1. Exclude septic arthritis
2. NSAIDs + Paracetamol + Codeine
3. Intra-articular corticosteroid (Large joints → methypred + triamcinolone c lidocaine)
(Small joints → methylpred c lidocaine or hydrocortisone alone)
2nd line: IM steroid (if not possible to give intraarticular)
3rd line 2-4 week reducing course of PO steroids (if IM not possible)
Surgery in RA
People should receive a surgical opinion before damage or deformity becomes
irreversible
● Refer for joint replacement if
○ persistent pain due to joint damage
○ Worsening joint function
○ Progressive deformity
○ Persistent localised synovitis
● Refer if:
○ Imminent or actual tendon rupture
○ Nerve compression (e.g. carpal tunnel)
○ A stress fracture
Complications of RA:
● Anaemia (23% IDA 77% Anaemia of chronic dx)
● Misc
○ Vasculitis, Vasculitic ulcers
○ Pleurisy / pleural effusions, pulmonary fibrosis
○ Pericarditis
○ Dry eye syndrome (keratoconjunctivitis sicca)
○ Neuropathy
○ Felty’s Syndrome: RA + Enlarged Spleen + Neutropenia
○ Amyloidosis
● Orthopaedic Problems
○ Carpal Tunnel Syndrome
○ Tendon Rupture (esp. extensor tendons of fingers / thumbs)
○ Cervical Myelopathy (↓mobility, ↓upper limb function, parasthesia, hyperreflexia &
sphincter disturbance)
● Infections
○ RA = double risk of infection, chest infection and generalised sepsis are
particular risks.
Comorbidities
● RA is an individual risk factor for cardiovascular disease
○ Also NSAIDs can cause hypertension, corticosteroids can cause high blood
sugar & lipids and methotrexate (esp when used with sulfasalazine) is
thrombogenic
● Depression & Anxiety
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● Osteoporosis (lack of use & corticosteroids)
● Malignancy (leukaemia, lymphoma & multiple myeloma are more common in RA,
partially due to DMARDs)
Osteoarthritis
Definition: Disorder of synovial joint characterised by focal damage to articular cartilage,
remodelling of underlying bone and the formation of osteophytes & mild synovitis
Most commonly affected joints = knees, hips & small joints of hand
Working diagnosis:
● Age 45+ and clear signs (affected joints painful in use +/- rest pain, crepitus, RROM&
stiffness after rest) and no obvious signs of inflammation (no prolonged morning
stiffness, effusions or heat)
Clinical Features:
● Gelling - pain and stiffness caused by inactivity. When activity resumes the pain and
stiffness resolve quicker than with other arthritides (within 30 minutes).
● Bony swelling & joint deformity
● Crepitus
● Restricted ROM
● Joint tenderness
● Muscle wasting and weakness
X-ray changes
● Loss of joint space
● Osteophytes
● Subchondral cysts and/or bone thickening (subchondral sclerosis)
Hip problems in kids
DDH (Developmental dysplasia of the hip)
● often picked up on newborn examination (ortolani’s and barlows)
● unequal skin folds / leg lengths
Transient Synovitis (Irritable Hip)
● Typically 2-10 eyras
● acute hip pain associated with viral infection
● Commonest cause of hip pain in children
Perthes Disease
● Typically 4-8 years
● Avascular necrosis of femoral head
● 5x more common in boys
● 10% are bilateral
● Hip pain develops progressively over a few weeks
● limp
● stiffness and reduced ROM
● Xray: early changes include widening of joint space, later changes include decreased
femoral head size / flattening
Slipped Upper Femoral Epiphysis
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● 10-15 yeras
● more common in obese children and boys
● Displacement of the femoral head epiphysis postero-inferiorly
● Bilateral in 20%
● May present acutely following trauma but more often with chronic persistent symptoms
● Presents with knee or distal thigh pain & loss of internal rotation of the leg in flexion
Juvenile Idiopathic Arthritis
● Arthritis in someone <16 going on for >3 months.
● 60% Pauciarticular = 4 or less joints
ANA may be positively - associated with ant. uveitis
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Contraception
Mode of action
● COC inhibits ovulation, thins uterus lining and thickens cervical mucus
● POP & IUS Thickens cervical mucus and thins lining of uterus
● IUD (Copper coil) has pre-fertilization effects on the sperm and prevents implantation of
gametes
Contraceptives - time until effective (if not first day period):
● instant: IUD
● 2 days: POP
● 7 days: COC, injection, implant, IUS
Combined Contraceptive Pill
● Discontinue 4 weeks prior to major surgery
● Contraindications:
○ Breast feeding (for 6 months after birth) IHD
○ TIA without headache Liver disease
○ Undiagnosed PV bleeding BMI >39
○ Breast or genital tract cancer Age >50 years
○ Personal Hx of VTE Migraine with aura
or severe RFs for arterial dx i.e. 2 or more of…
○ FH of arterial dx in 1st relative <45 years Diabetes
○ BP >140/90 Smoking (avoid if >40/day)
○ Age >35 years Obesity (BMI >30)
● Interactions
○ Enzyme Inducers (For most e.g. carbamazepine, phenytoin) you can increase
the dose of oestrogen to 50mcg (max 70mcg) but not for rifampicin as the
contraceptive simply won’t work due to the degree of enzyme induction.
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○ NB. breakthrough bleeding may indicate low levels of oestrogen but check for
chlamydia before increasing the dose.
○ None-enzyme inducing abx do not need extra cover (condoms)
Missed pill
● One pill missed → missed pill taken ASAP even if it means taking 2 pills on one
day. The rest of the pack should be taken as usual. No additional contraception
is required.
● Two or more pills missed → last pill should be taken now (ignore the other
missed pills), even if it means taking 2 pills on one day. The rest of the pack
should be taken as usual and additional precautions should be used for 7 days.
If fewer than 7 pills are left of the pack then continue straight onto the next pack
and miss the pill-free break. Emergency contraception may be required if she has
had unprotected intercourse in the previous 7 days and they have missed 2 or
more pills in the first week of the pack.
Progesterone OnlyPill
- Starting the POP
● If commenced up to and including day 5 of the cycle it confers immediate protection,
otherwise additional barrier contraceptives should be used for the first 2 days.
● If switching from a COP if switched to at the end of a pill packet, it confers immediate
protection.
-It should be taken at the same time each day without a pill free break
-Missed Pill
● If less than 3 hours* late → continue as normal
● If more than 3 hours late→ take missed pill ASAP, continue with rest of the pack and
take extra precautions (condoms) until pill-taking has been re-established for 48 hours.
Consider need for emergency contraception if there was unprotected intercourse in the
2-3 days prior to the missed pill.
*Cerazette (Desogestrel only pill) give a 12 hours window
- Specific Circumstances
● Antibiotic use → do not need any extra protection unless the abx is a P450 inducer (e.g.
rifampicin)
● D&V → Continue taking the pill but assume pills have been missed
- Side Effects:
● Irregular vaginal bleeding is the most common problem
Implanon / Nexplanon
- Subdermal (more superficial than subcutaneous or IM)
- Contains Etonogestrel (no oestrogen so safe in PMHx of DVT, migraine etc.)
- Lasts 3 years
- Can be given immediately affect TOP
- Additional contraceptive required first 7 days if not inserted on days 1 to 5 of a menstrual
cycle.
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- Can cause irregular heavy bleeding and progesterone effects (headache, nausea, breast
pain).
- Contraindications: IHD / stroke, prev breast cancer, liver cirrhosis / liver cancer. positive
antiphospholipid antibodies
Ideal LARC for women <20 years
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices
(IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in
the management of menorrhagia
Effectiveness
● both the IUD and IUS are more than 99% effective
Mode of action
● IUD: primary mode of action is prevention of fertilisation by causing decreased sperm
motility and survival (possibly an effect of copper ions)
● IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous
thickening
Counselling
● IUD is effective immediately following insertion
● IUS can be relied upon after 7 days
Potential problems
● IUDs make periods heavier, longer and more painful
● the IUS is associated with initial frequent uterine bleeding and spotting. Later, women
typically have intermittent light menses with less dysmenorrhoea and some women
become amenorrhoeic
● uterine perforation: up to 2 per 1000 insertions (0.2%)
● the proportion of pregnancies that are ectopic is increased but the absolute number of
ectopic pregnancies is reduced, compared to a woman not using contraception
● infection: there is a small increased risk of pelvic inflammatory disease in the first 20
days after insertion but after this period the risk returns to that of a standard population
● expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Dysmenorrhoea
Excessive pain during the menstrual period
Primary (Appears within 1-2 years of menarche)
● Excessive endometrial prostaglandin is thought to be partially responsible
● Typically starts just before or within a few hours of the period starting
● Suprapubic cramping pains which can radiate to the neck or down the thigh
● Rx: NSAIDs e.g. mefenamic acid & ibuprofen (effective in 80% women) as they inhibit
prostaglandin syntesis
● Second line rx: Combined Oral Contraceptive Pill
Secondary (Usually develops many years after menarche)
● Pain usually starts 3-4 days prior to the onset of the period
● Causes include:
○ endometriosis (endometrial tissue outside of the uterus)
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○ adenomyosis (endometrial tissue in the wall of the uterus)
○ Pelvic Inflammatory Disease
○ Copper coil
○ Fibroids
● Refer all patients with secondary dysmenorrhoea to gynaecology for investigation
Menorrhagia
Previously defined as >80mls blood loss; now what the patient considers to be excessive.
Causes:
Dysfunctional uterine bleeding (idiopathic) = 50%
Anovulatory cycles - more common at extremes of reproductive life
Uterine fibroids
Hypothyroidism
Copper coil
PID
Bleeding disorders
Inx: FBC in all women
Rx: If requires contraception → Mirena (first line), COCs, long acting progesterones
Does require contraception → Mefanamic Acid 500mg TDS esp. if dysmenorrhoea or
tranexamic acid 1g TDS (both started on first day of period). If no improvement refer.
Norethisterone 5mg TDS can be used short-term to rapidly stop heavy menstrual
bleeding.
Amenorrhoea
Primary Amenorrheoa - failure to start menses by 16 years of age
● Turner’s syndrome
● Testicular feminisation
● Congenital Adrenal Hyperplasia
● Congenital Malformations o the genital tract
Secondary Amenorrheoa - cessation of regular menstruation for 6 months
● Pregnancy
● Hypothalamic amenorrhoea (e.g. stress, excessive exercise)
● PCOS
● Hyperprolactinaemia
● Premature ovarian failure
● Thyrotoxicosis or hypothyroidism
Initial Investigations
1. bHCG
2. gonadotrophins: low levels indicate a hypothalamic cause (e.g. stress); high levels
indicate an ovarian problem (e.g. premature ovarian failure)
3. Prolactin
4. Androgen levels (may be seen in PCOS)
5. Oestradiol
6. TFTs
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Premature Menopause = <40 years old
Early Menopause = <45 years old
Hormone Replacement Therapy
Benefits -
Reduces risk of osteoporosis in the spine and hip (if started <60 years old)
HRT is the first-line treatment for the prevention and management of osteoporosis in
women with menopausal symptoms who are under the age of 50 years
Reduces risk of colorectal ca.
If starting below 60 years old there is an overall favourable risk / benefit ratio.
If HRT is commenced within 10 years of the menopause it can reduce the risk of coronary heart
disease, but if started >60 years or > 10 years post menopause it can increase the risk of
coronary heart disease.
Risks -
Thromboembolism = 2-4x increased risk in DVT with oral HRT. Highest risk is in the
first year of use. Transdermal methods and implants are not associated with increased
risk of DVT. Stroke risk is increased and therefore use with caution in those with risk
factors
Breast Cancer - Increased risk with combined HRT. The increased risk is small (but
greatest in thin women). Unopposed oestrogen does not affect breast cancer risk
?Ovarian Ca (conflicting evidence)
If starting over 60 years lower doses should be used and preferably
Nb. Endometrial Ca (increased with unopposed oestrogen but reduced by continuous
combined oestrogen)
Relative Contraindications to HRT (these women should be referred for specialist assessment
if they want HRT)
Pregnancy and breastfeeding
Undiagnosed vaginal bleeding
VTE
Active Angina or Recent MI
Breast Ca
Endometrial or oestrogen dependent cancer
Liver disease with abnormal LFTs
Uncontrolled Hypertension
Combined HRT (Oestrogen and progesterone) for those with their uterus intact.
Unopposed oestrogen(Oestrogen Only) in those who have had a hysterectomy.
This is because if you just take oestrogen the lining of the uterus builds up which increases the
risk of endometrial cancer.
Cyclical combined HRT is given if you start HRT when still having or very recently finished (<1
year) periods. This is continuous oestrogen with progesterone added for 12-14 days of the
cycle.
→ gives a light 1 or 3 monthly withdrawal bleed. If cyclical is not given then these women often
experience abnormal bleeding. If bleeding is heavy or erratic double progesterone dose or
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increase to 21 days. If bleeding problems occur for >6 months → investigate.
Continuous Combined HRT is given if you start HRT more than a year after your last period or
you are over 54 years old. May get no bleeding but may get breakthrough bleeding. Can switch
back to cyclical is breakthrough bleeding occurs. Continuous can also increase the
progesterone SEs. Unopposed oestrogen with a mirena coil is a neat way to give HRT which
may reduce the side effects of the progesterone.
Side Effects / Effects of Progesterone:
Mineralocorticoid effects → Fluid retention
Androgenic Effects → Hirsutism & Acne.
If these are a problem you can reduce the dose of progesterone or try using mirena.
Nb. Tibilone is a man-made hormone with some oestrogen, progesterone and androgen.
Above 60 years old the risks (VTE) outweight the benefits.
HRT should only be used for the relief of vasomotor symptoms of the menopause. For other
symptoms there tends to be less risky options:
Vaginal Atrophy - Oestrogen creams are now liscenced for indefinite use and Estring (the
vaginal ring) is liscenced for 2 years.
1. Panay N, Hamoda H et al. The 2013 British Menopause Societyand Women's Health Concern
recommendations on hormone replacementtherapy.Menopause Int 2013;19
Herbal HRT
Phytoestrogens in the diet (e.g. soy, legumes) can reduce menopausal symptoms by 60% but
will not take them away completely.
Black Cohosh
Herbal medicine from a North American plant Actaea racemosa. The
MHRA has given a preparation of Black Cohosh called Menoherb a
Traditional Herbal Registration for the relief of menopausal symptoms.
The most important adverse effect to inform women about is the risk of
liver toxicity. The results of randomised controlled trials have been
mixed
Evening primrose
oil
May potentiate seizures
Ginseng May cause sleep problems and nausea
Red clover Contains a type of phytoestrogens. Theoretical risk of endometrial
hyperplasia and stimulating hormone-sensitive cancers.
Dong Quai Type of Chinese medicine
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Bacterial Vaginosis
Predominantly caused by overgrowth of anaerobic bacteria; mostly Gardnerella Vaginalis.
Consequently this reduces the amount of lactic acid producing aerobic lactobacilli resulting in a
raised pH (alkaline).
Not sexually transmitted but essentially exclusively seen in sexually active women.
Amsel’s criteria: 3 of 4 of…
Thin, white homogenous discharge
pH >4.5
Clue cells on microscopy
Positive Whiff Test (add potassium hydroxide to smear → fishy smell)
Rx: Oral Metronidazole 5-7days → 75% cure but 50% relapse in 3/12
In Pregnancy→ risk of late miscarriage, preterm labour, low birth weight and chorioamnionitis.
Oral metronidazole should still be used in pregnancy.
Baby Blues
- Affects 70% women
- Typically 3-7 days post delivery
- More common in primips
- Mothers are anxious tearful and irritible
- Reassure them
PND
Affects 10% women
Most cases start within 1 month and peaks at 3 months
Features similar to depression. Use the Edinburgh Postnatal Depression Scale - score >13/30
indicates depression
Reassure and support. Also CBT may be helpful and SSRIs such as sertraline and paroxetine
may be useful if severe and can be used in breastfeeding.
Puerperal Psychosis
Affects 0.2% women
Onset usually first 2-3 weeks post birth
Features: severe mood swings, disordered perception e.g. auditory hallucinations
Admit to hospital (normally)
20% risk of recurrence with further child
Breastfeeding
The following drugs can be given to mothers who are breastfeeding
● Penicillins, Cephalosporins (e.g. cefalexin), Trimethoprim
● Endocrine: glucocorticoids, levothyroxine
● Epilepsy: Sodium Valproate, Carbamazepine
● Asthma: salbutamol, theophyllines
● Psychiatric drugs: TCAs, antipsychotics (apart from Clozapine)
● Hypertension: beta-blockers, hydralazine, methyldopa
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● Anticoagulants: warfarin, heraprin
● Digoxin
The following drugs cannot be given to mothers who are breastfeeding
● ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
● psychiatric drugs: lithium, clozapine, benzodiazepines
● aspirin
● carbimazole
● sulphonylureas
● cytotoxic drugs
● amiodarone
Infertility
80% of couples will conceive if the woman is less than 40 years old and they have regular
(every 2 to 3 days) unprotected intercourse. Of those who do not conceive in the first year 50%
will conceive in the second
For the baby prior to conception the woman should take 0.4mg Folic Acid daily and until 12
weeks gestation. (Previous neural tube defect or anti-epileptic meds or diabetes → 5mg per
day). Also offer testing for rubella status - so if susceptible to rubella can be vaccinated
Lifestyle advice to help conception
Stop smoking
Normalise your BMI (20-25)
Alcohol Don’t drink more than the advised units
Regular sex (2-3x / week)
Nb. Caffeine does not reduce fertility but can reduce effectiveness of IVF
Main causes:
Idiopathic 25%
Ovulatory 25%
Tubal Damage 20%
Male infertility 30%
Uterine or Peritoneal disorders 10%
Nb. in 40% cases causes are found both in the man and woman
Criteria for Investigation
Regular (every 2 to 3 days) unprotected intercourse for >1 year
Earlier if 36 years old (or over) or known predisposing factors or known cause of
infertility or there is treatment planned which may result in infertility (e.g. cancer
treatment)
A woman who is using artificial insemination (privately) either with her partner or a sperm
donor should be offered further clinical assessment if unable to conceive after 6 cycles.
Investigations:
Basic (First investigations) prior to referral:
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● Semen analysis
● Serum progesterone 7 days before expected next period
Semen Analysis
● Should be performed between 3 to 5 days of abstinence
● Needs to be delivered to the lab within one hour
● Normal Semen Results:
○ Volume >1.5ml
○ Concentration >15 million sperm /ml
○ Total number of sperm >39 million / ejaculate
○ pH 7.2 or more
○ Morphology >4% normal forms
○ Total Motility >40%
○ Vitality: >58% live spermatazoa
● If the first sample is abnormal a repeat test confirmatory should be offered 3 months
later or ASAP if gross abnormality found e.g. Azoospermia (this can sometimes be
solved by epididymal un-blockage. An alternative is surgical sperm retrieval and IVF)
Progesterone Level
Interpreting the progesterone level result:
<16nmol/L Repeat, if consistently low → Refer to a specialist
16 - 30nmol/L Repeat
>30nmol/l Indicates Ovulation
Ovarian Reserve Testing
1) + one of 2a), 2b) or 2c)
1) Mid luteal (day 21 to 28 of cycle) progesterone to confirm ovulation
2a) TV USS on day 3 of cycle - Total antral follicle count (normal = 4 to 16)
2b) Anti-mullerian hormone (normal = 5.4 to 25 pmol/l)
2c)FSH (normal = 8.9 to 4)
If irregular cycles test FSH and LH
Hysterosalpingogram
This is offered to those with PID, prev ectopic or endometriosis to look for tubal occlusion
Hysterosalpingo-contrast-ultrasonography
Where available this is offer to women who do not have the above conditions
Treatment
In Vitro Fertilisation (IVF)
Criteria
<40 years who have had 2 years of unprotected sex or 12 cycles of artificial insemination
where 6 or more have been intrauterine → offer 3 full IVF cycles (ovarian stimulation
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with gonadotrophins or clomiphene + transfer of fresh or frozen embryos + luteal phase
support with progesterone up to 8 weeks gestation)
Nb. Any previous IVF cycle (private or NHS) counts towards the 3 cycles
40-42 years who have had 2 years of unprotected sex or 12 cycles of artificial
insemination where 6 or more have been intrauterine, never had IVF before, → offer 1
cycle of IVF
People having IVF should be offered testing for HIV, Hep B and Hep C
No more than 2 embryos should be transfers (only one if there is a top quality blastocyst)
The older the patient generally you tend to transferring 2 embryos
Oocyte Donation
Ovarian failure (Premature or following chemo- / radio-therapy)
Gonadal Dysgenesis inc. Turner’s syndrome
Bilateral oophorectomy
High risk of transmitting genetic disease to offspring
Intracytoplasmic SpermInjection
Severe deficits in semen quality
Obstructive azoospermia
Non-obstructive azoospermia
Donor Insemination (minimum of 6 cycles)
Obstructive azoospermia (although surgery can sometimes work)
Non-obstructive azoospermia
High risk of transmitting genetic disease
Ovulation Induction (e.g. Clomiphene or Gonoadotropins)
Irregular ovulation...
WHO group I anovulatory infertility (Hypothalamic Pituitary failure)
If BMI<19 gain weight and do less exercise
Pulsatile GnRH (or gonadotrophins) & LH
WHO group II infertility (Predominantly PCOS)
BMI >30 → exercise & lose weight
1st line Clomiphene
2nd line Metformin (Clomiphene is superior to metformin)
3rd line (where Clomiphene Failed) options include
Clomiphene and Metformin if not previously tried
Laparoscopic ovarian drilling
Gonadotrophins - this also has the risk of ovarian hyperstimulation,
multiple pregnancies and needs to be monitored by USS
Nb. WHO Group III infertility is ovarian failure
Council re: ovulation induction e.g Clomiphene
Long term health outcomes for mum and children is not known
Ovarian hyperstimulation (abdominal discomfort, N&V, SOB and can be life-
threatening.
Headaches, breast tenderness, blurred vision
Increased miscarriage risk
High chance of multiple pregnancy (5-8%)
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Nb. Need to do USS in first cycle of rx to ensure risk of multiple pregnancy is not too high
Cannot continue more that 6 months
Do not offer stimulation agents( e.g. clomiphene) in Unexplained Infertility or Mild endometriosis
or Mild Male Factor Infertility. Offer IVF after 2 years of regular intercourse
Intrauterine Insemination
Unable to have sex (physical disability)
HIV positive man → Sperm washing + Intrauterine Insemination
Tubal Disease
Surgery or tubal catheterisation
Hydrosalpinx → salpingectomy (this increases likelihood of live birth with IVF)
Intrauterine Adhesions
Hysteroscopic adhesiolysis
Hyperprolactinemia
Bromocriptine. Nb. Hyperprolactinaemia is not routinely tested for.
Urinary Incontinence in Women
Work Up
● Vaginal Exam
○ Ask the patient to squeeze finger to assess strength and endurance and muscle
tone
○ Look for prolapse (central = vault, ant = cystocele, post.=rectocele)
○ Look for atrophic vaginitis
○ Look for a pelvic mass
● Urine Dip +/- M,C&S
● Bladder diary for 3 days - amount & type of fluid drank, individual voided volume,
frequency of micturition, episodes of incontinence, pad and clothing changes
○ Normal volume of urine passed is 200-400ml 4-8x / day including once at night
Stress incontinence
● occurs when sneezing, cough, straining
● over 50% of women with stress incontinence have a cystourethrocoele
● Weight-loss in BMI>30 kg/m2
● First line rx: Supervised pelvic floor muscle training (PFMT) for 3 months - minimum 8
pelvic floor exercises 3x/day. Digital assessment of strength before and after.
● Second line rx: Duloxetine or refer to urologist for surgery (tape/sling/colposuspension)
Urge Incontinence (overactive bladder)
● Feels that needs the toilet urgently but could not reach the toilet quick enough
● Formal urodynamic testing is not recommended prior to conservative rx
● Weight-loss in BMI >30kg/M2
● Look for UTI & neurological conditions e.g. Parkinsons, MS
● First line: bladder training 8 weeks
● Second line: add in immediate release oxybutinin (Antimuscarinic)
● Consider
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○ Propiverine for overactive bladder without incontinence
○ Intravaginal oestrogen if atrophy or dysuria or urethral pain
○ Desmopressin if <65, nocturia and no CVD risk
● Refer for sacral nerve stimulation or augmentation cystoplasty (but these later women
will ned t self catheterise)
Chronic Urinary Retention (overflow incontinence)
● voiding difficulty (hesitancy, straining to void, dribbling,)
● examine for a palpable bladder
● Need to get a residual urine measurement for diagnosis
Fistula
● Constant passive leakage of urine
Urethral Diverticulum
● post void dribbling, dyspareunia, dysuria
● feel fora soft vaginal mass on anterior vaginal wall which is tender
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Pharmacology / Therapeutics
BNF Symbols http://w ww.evidence.nhs.uk/formulary/bnf/current/general-information-and-changes/how-to-use-the-bnf/figure-1
black triangle ( ) symbol = newly licensed medication → report all adverse reactions
= Drug less suitable for prescribing
= prescription only medicine
= not prescribable on the nhs
= preparation in schedule 1 of controlled drug regulations 2001
Reaction most commonly associated with each antibiotic:
Amoxicillin - rash with infectious mononucleosis
Doxycycline - Photosensitivity
Metronidazole - reaction following alcohol ingestion
Co-amoxiclav - cholestasis
Flucloxacillin - Cholestasis
Erythromycin - Gastrointestinal upset
Ciprofloxacin - Tendonitis & Lowers seizure threshold
Trimethoprim - Rashes inc. photosensitivity, Pruritus & suppression of hematopoiesis
Do not prescribe >20mg Simvastatin with Amlodipine or Diltiazem due to increased risk
of myopathy
Drug interactions associated with increased risk of
myopathy/rhabdomyolysis
Interacting agents Prescribing recommendations
Itraconazole
Ketoconazole
Posaconazole
Erythromycin
Clarithromycin
Telithromycin
HIV protease inhibitors (eg, nelfinavir)
Nefazodone
Ciclosporin
Danazol
Gemfibrozil
Contraindicated with simvastatin
Other fibrates (except fenofibrate) Do not exceed 10 mg simvastatin
daily
Amiodarone
Amlodipine
Verapamil
Diltiazem
Do not exceed 20 mg simvastatin
daily
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Fusidic acid Patients should be closely
monitored.Temporarysuspension of
simvastatin treatment may be
considered.
Grapefruit juice Avoid grapefruit juice when taking
simvastatin
Common drug interactions:
● Amiodarone & Quinolones (e.g. lefofloxacin) prolong QT interval
● Macrolides (e.g. erythromycin) can increase Carbamazepine levels risking toxicity
● Macrolides (e.g. erythromycin) can increase Digoxin levels risking toxicity
● Azole antifungals(e.g. itraconazole) can increase Digoxin levels risking toxicity
● Omeprazole & clopidogrel - increased risk of bleeding
● Simvastatin and Amiodarone increases risk of myopathy - only give 20mg Simva -
CYP3A4
● Avoid Azole antifungals with statins due to risk of myopathy - consider other antifungals
e.g. terbinafine CYP3A4
● Many antidepressants can reduce the efficacy of tamoxifen (not venlafaxine and
less so citalopram) - CYP2D6
● Amiodarone can increase the concentration of warfarin (bleeding risk) - CYP2CP
● Azole antifungals can increase the concentration of warfarin (bleeding risk) - CYP2CP
Warfarin
Drugs which potentiate warfarin include:
- Cranberry juice
- NSAIDs
Levothyroxine
-P450 inhibitor e.g. amiodarone, ciprofloxacin, azole antifungals, fibrates, statins,
trimethoprim, metronidazole
Drugs which reduce the effect of warfarin include:
- P450 Inducers e.g. St Johns Wart, Rifampicin (most potent), Carbimazole,
griseofulvin, carbamazepines, OCP/HRT
Side effects
- Hemorrhage
- Teratogenic but can be used in breast feeding
- Skin necrosis & purple toes due to temporary procoagulant phase when starting
warfarin therefore warfarin is started with concurrent heparin
Morphine → diamorphine = divide dose by 3 (not 2 as you would expect from the name)
Breakthrough dose of morphine is ⅙th daily dose
When increasing the daily dose increase by 30-50%
Codeine or Tramadol→ Morphine divide by 10
Morphine → oxycodone divide by 1.5-2
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A 12mcg fentanyl patch equates to 30mg oral morphine daily
A 10mcg buprenorphine patch is equivalent to 24mg oral morphine daily
All patients on strong opioids should have laxatives
In CKD Alfentanil, Buprenorphine and Fentanyl are preferred
Controlled Drugs
Misuse of drugs regulations 2001 divides controlled drugs into 5 schedules
Schedule 1 - controlled drug license have no recognised medicinal usage including cannabis.
production, possession and supply is limited to research
Schedule 2 - (controlled drugs). Includes diamorphine (heroin), morphine, remifentanil,
pethidine, secobarbital and cocaine. A license is required to keep them and they need to be
kept in a locked receptacle. A register (bound; not loose leaved) must also be kept. Destruction
must be authorised and witnessed.
Schedule 3 - (controlled drugs no register). Includes barbiturates, buprenorphine, midazolam
and temazepam.
Schedule 4- Part 1 = benzodiazepines (Except temazepam and midazolam) & zolpidem.
Posession is an offence without a prescription. Part 2 - Androgenic and anabolic steroids e.g.
testosterone.
Schedule 5- codeine, oramorph, tramadol. Invoices must be kept for 2 years. NIl else.
Prescription for schedule 2,3 or 4 drugs is only valid for 28 days
FP10s now have a box at the back where patients picking up a CD prescription must put their
signature
Oramorph oral solution ,morphine sulphate 10 mg/5 mL does NOTlegallyneed to be treated like CD.
Oramorph concentrated oral solution ,sugar-free,morphine sulphate 100 mg/5 mL MUST be treated like a CD.
Health act 2006 says every healthcare organisation needs to appoint an Accountable Officer
responsible for the safe and effective use of controlled drugs as well as producing a SOP
(Standard Operating Procedure) describing the responsibilities and procedures necessary to
manage CDs safely and accountably, validated by the PCT and review period.
Prescribing Controlled Drugs
THe prescription needs to contain:
● patients full name, address and where appropriate age
● Name and form of the drug (Even if only one form exists)
● The strength of the preparation, where appropriate
● Dose to be taken
● Either the total quantity of the preparation or number of doses to be supplied in
both words and figures
Form FP10MDA-S is used to prescribe to addict. NB. you needs a special liscence to prescribe
diamorphine, dipipanone or cocaine for treatment of addiction.
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A special form (FP10PCD) has been introduced for private prescriptions of controlled drugs
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Metoclopramide is D2 (dopamine) receptor antagonist and can cause worsening of parkinson’s
and oligogyric crises and other extrapyramidal side effects, especially in children and young
people. It is a prokinetic so often used in gastroparesis in diabetes and to help the absopriont of
analgesics in migraine as migraine causes a transient gastroparesis
Sodium Valproate is the antiepileptic most associated with weight gain. Other adverse effects
include nausea, alopecia (regrowth may be curly), ataxia, tremor, hepatitis and pancreatitis. It is
used first line in tonic clonic epilepsy (generalised).
Carbamazepine is first line in focal epilepsy. It is also used to treat neuropathic pain, trigeminal
neuralgia, mania and manic depression.
Cranberry juice interacts with warfarin
Grapefruit juice interactions with statins
Emergency Protocols
IM Benzylpenicillin in suspected Meningitis
<1 year 300mg IM
1-10years 600mg IM
>10years 1.2g IM
Anaphylaxis
Adrenaline Hydrocortisone Chlorphenamine
< 6 months 150 mcg (0.15ml 1 in
1,000)
25 mg 250 mcg/kg
6 months - 6 years 150 mcg (0.15ml 1 in
1,000)
50 mg 2.5 mg
6-12 years 300 mcg (0.3ml 1 in
1,000)
100 mg 5 mg
Adult and child > 12
years
500 mcg (0.5ml 1 in
1,000)
200 mg 10 mg
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Endocrinology
Hypothyroidism
Symptoms:
Constipation Hoarse voice Weaker muscles
Feeling colder Puffy eyes Hairloss
Infertility Thyroid Pain (de quervain's thyroiditis)
Signs:
Deep voice / hoarseness Slowed movements Slow relaxing reflexes
Dry coarse skin Sparse coarse hair Periorbital oedema
Proptosis Myxoedema (non-pitting) Hypothermia
Galactorrhoea (due to increased prolactin levels) Bradycardia
Goitre (Hashimoto’s, Thyroiditis, infiltration or pendred’s syndrome)
Investigations:
TSH & T4
Indications to check TPO (Thyroid Peroxidase antibody) include:
Subclinical hypothyroidism where the TSH is <10mU/L
Previous amiodarone*, lithium* or interferon alfa
*Drug induced hypothyroidism is still rxed with thyroxine but specialistcare is needed
Overt Hypothyroidism
↑TSH ↓T4
Subclinical Hypothyroidism →only offer rx if symptomatic, goitre, TSH rising or >10 or
↑TSH + Normal T4 pregnant (if on rx when gets pregnant increase rx by
25-50mcg & aim TSH in low normal range e.g. 0.4-2)
Secondary Hypothyroidism
↓or normal TSH + ↓T4
*In pregnancy you need to apply special trimester-related ranges for TSH and Free and Total T4
* In the early months of treatment for hyperthyroidism TSH may remain suppressed and if this
occurs T4 is a better marker, however TSH should be used to guide Rx when the hypothalamic
pituitary axis has recovered
*Sick euthyroid syndrome - People with a wide range of chronic or acute non-thyroidal illness
may have abnormal TFTs despite being clinically euthyroid. In hospitalised people an increased
TSH is as likely to be due to recovery from an illness as to be due to hypothyroidism.
De Quervain's Thyroiditis may present with thyroid pain, systemic upset with fever, a small
tender goitre which may be diffuse or asymmetrical & a history or prodromal viral infection
several weeks earlier.
Postpartum (Silent) thyroiditis may present within 2-6 months after delivery with non-specific
symptoms such as tiredness, anxiety or depression. The thyroid does not tend to be painful and
no goitre and no systemic upset. This often doesn’t require treatment.
Suspect secondary hypothyroidism if
The blood test indicate secondary hypothyroidism (low T4 & low or normal TSH)
Features of hypopituitarism (e.g. hypogonadism or adrenal failure)
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The patient is taking bexarotene
Screening for Thyroid Disorders is indicated in:
Goitre (especially if pregnant - also 6- 8 weeks postpartum)
Type 1 DM at presentation & annually & if planning pregnancy & 6-8/52 postpartum
Type 2 DM at presentation Atrial Fibrillation
Osteoporosis Dyslipidaemia
4-8 weeks post radioactive iodine rx, then 3 monthly until 1 year then annually
Previous neck irradiation or surgery on thyroid - annually
FHx of thyroid dx is planning to get pregnant
Addison’s Down’s Syndrome & Turner’s syndrome
Subfertility, abnormal menstrual cycle, miscarriage or preterm birth
Treatment of overt hypothyroidism:
If > 50 or CVD → start with 25 micrograms OD
If <50 & no CVD → start on 50 micrograms OD
Treatment target is a TSH within the normal range (0.4-4.5)
Adjust the dose according to TSH each 2-3 months
Most require a dose of 75-150 micrograms OD
If patient gets pregnant increase dose by 25-50mcg, check TFTs 4 weekly and aim for
0.4-2 (low normal range). Reduce the dose to pre-pregnancy dose post-partum.
NB. if a patient feels worse during their rx they may have undiagnosed Addison’s disease (in
these you need to start corticosteroids before thyroxine
Hyperthyroidism
Symptoms:
Dyspnoea Palpitations Heat intolerance / sweating
Hyperactivity Insomnia
Irritability, emotional lability Anxiety / nervousness
Exercise intolerance, fatigue, muscle weakness
Diarrhoea Increased appetite and weight loss or gain
Infertility, oligomenorrhoea, amenorrhoea Polyuria, thirst
Signs:
Agitation Sinus tachycardia Atrial Fibrillation Heart Failure
Thyroid enlargement Tremor Warm, moist skin; palmar erythema
Onycholysis Pruritis, urticaria Diffuse pigmentation
Diffuse alopecia Muscle wasting / weakness / proximal myopathy
Gynaecomastia in men Chorea (rare)
Hypokalemic Periodic Paralysis (in asian men following a large carbohydrate meal or
vigorous exercise) A bruit over the tyroid in Graves
Investigations
If TSH is normal Thyrotoxicosis is essentially excluded
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If TSH is low or High check the free T4 & free T3
Low TSH & High T4
Most commonly caused by Grave’s Disease or less commonly a multinodular
goitre, a toxic thyroid nodule or amiodarone.
Grave’s Disease is confirmed in secondary care with Anti TSH receptor
antibodies.
Low TSH, High T3 and normal T4 “T3 toxicosis”
Can be seen in early or relapsing graves disease or mild toxic nodular goitre
Persistently Low TSH + normal T4&T3
This is subclinical hyperthyroidism
Distinguishing the cause:
1. Graves Disease
Thyroid gland - diffusely enlarged, pyramidal lobe is often palpable
and often a bruit. Additional signs which are not seen in other forms of
thyrotoxicosis include
Ophthalmopathy (reduction in eye movement)
Pretibial myxoedema
Acropachy (clubbing)
Vitiligo
Thyroid Eye Disease - gritty, excessive tears, retrobulbar pain,
double vision when looking up and out. Oedema, Proptosis,
Exposure keratopatitis,
2. Toxic Multinodular Goitre
Dysphagia, Dyspnoea & neck pressure
Non-tender nodules of the thyroid
Nb. In amiodarone induced hyperthyroidism a toxic multinodular goitre is often present
3. Toxic Adenoma
Unilateral non tender mass usually easily palpable and reaches at least 3cm in size
before hyperthyroidism occurs
4. De Quervains Thyroiditis
Rapid onset fever, malaise & thyroid pain which can extend to the jaw, ears or down the
anterior chest wall.
Extremely tender enlarged firm & irregular palpable thyroid gland
5. Thyroid Storm (thyrotoxic crisis)
Rare. May occur after trauma, childbirth, infection, stroke, DKA or surgery in people with
untreated or poorly treated hyperthyroidism.
Severe tachycardia Atrial FIbrillation Congestive Heart Failure
Fever Dehydration, D&V Jaundice
Agitatation, delerium, psychosis and coma.
Management of hyperthyroidism
Signs of a thyroid storm → Admit
Overt Hyperthyroidism → Refer everybody for specialist assessment
While awaiting specialist review consider beta blocker (symptomatic relief)
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Subclinical Hyperthyroidism → Consider other causes e.g drugs. Recheck in6 months
Peristent Subclinical Hyperthyroidism → refer
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Scotums…
1. Epipidymal Cysts - most common cause of scrotal swellings. Swelling is separate from
body of testicle and posterior to testicle. Associated with Polycystic Kidney Disease,
Cystic Fibrosis and Von-Hippel-Lindau Syndrome. RX is conservative unless v. big.
2. Hydrocoele - Fluid in tunica vaginalis. Can develop secondary to epididymo-orchitis,
testicular torsion and testicular tumours. Soft, non-tender transilluminable swelling of
hemiscrotum, usually anterior and you can get above it. Ultrasound is warranted to
exclude an underlying cause but management is usually conservative. Seen in 3% of
neonates where it is likely to be communicating hydrocele (caused by defect in
processus vaginalis allowing peritoneal fluid to drain down) and tend to resolve in first
few months of life but they are repaired if still there by age 1-2 years.
3. Varicocoele - enlargement of testicular veins, much more common on left side. USS is
used for diagnosis. Associated with infertility but there is debate as to whether surgery
helps this or not. Therefore, unless the patient is trouble by pain rx is usually
conservative.
Hirsutism
Hirsutism is androgen dependent excess hair growth
Grading: Ferriman-Galloway Scoring System
Most common cause: PCOS
Other causes:
Cushings, Congenital Adrenal Hypoplasia, Obesity, Adrenal Tumour, Androgen
Secreting Ovarian Tumour, Phenytoin
Management:
Weight-loss if overweight
Cosmetic: Waxing / Bleeching
Consider Combined Oral Contraceptive Pills (Dianette or Yasmin). NB. Dianette
shouldn’t be used long term due to risk of DVT
Topical Eflornithine for facial hirsutism (contraindicated in pregnancy and
breastfeeding)
Hypertrichosis
Hypertrichosis is androgen-independent excess hair growth
Causes include
Drugs (Minoxidil, Cyclosporin, Diazoxide)
Congential hypertrichosis (lanuginosa or terminalis)
Porphyria Cutanea Tarda
Anorexia Nervosa
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Lipid Management Trials:
The 4S Trial: 1994 Scandinavian Simvastatin Survival Study. Demonstrated a 30% reduction in
all cause mortality in patients who had a history of ischaemic heart disease who were given
simvastatin
WOSCOPS Trial: 1995 West of Scotland Coronary Prevention Study. Men who had high
cholesterol >6.5mmol/L (but no previous IHD) had a 22% reduction in mortality when given
pravastatin cf. placebo.
Heart Protection Study: Anti-oxidants did not affect clinical outcome in those with IHD
Target Cholesterol is <4mmol/L
Metabolic Syndrome
Unfortunately there are a number of competing definitions.
Key pathology: insulin resistance
Most guidelines tend to use
● central obesity (elevated waist circumference)
● elevated triglycerides >1.7
● reduced HDL <1.03 in males <1.29 in females
● Raised blood pressure >130/85 (or on rx)
● raised fasting plasma glucose >5.6mmol/L (or T2DM)
WHO also include microalbuminaemia
Other features include:
● raised uric acid levels
● NAFLD
● PCOS
Type II Diabetes Mellitus
Diagnosis: HbA1c >=48 (6.5%) is diagnostic but is not appropriate in children/ in pregnancy /
symptoms <2 months / Patients on steroids or antipsychotics.
HbA1c less than 48 does not exclude the diagnosis as it is not as sensitive as fasting samples
Previous (and still accepted) diagnosis:
Random Blood serum glucose ≧11.1
Children tend to present with severe symptoms and diagnosis often should be
made on a single raised blood glucose result
Fasting plasma glucose ≧ 7.0 (> 6.1 mmol/l but < 7.0 mmol/l is IFG=pre-diabetes
→ offer OGTT)
All with IFG should have an OGTT
Two hour plasma glucose post OGTT ≧11.1 (> 7.8mmol/l but < 11.1 mmol/l is IGT →
lifestyle change +/- metformin)
If asymptomatic … the above criteria must be demonstrated on two separate occasions
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If HbA1c 42-47 (6-6.4%) or IGT or IFG → lifestyle advice & monitor HbA1c annually.
HbA1c should be checked every 2-6 months until stable, then 6 monthly
HbA1c target = 48mmol/mol (6.5%)
Trial lifestyle intervention first
- high fibre, low glycaemic index sources of carbohydrates
- include low-fat dairy products and oily fish
- discourage use of foods marketed specifically at people with diabetes
- initial target weight loss in an overweight person is 5-10%
First line rx = Metformin
Stop metformin if Creat >150 or GFR <30 (stage 4 CKD)
Metformin is good for overweight people
Second Line = Add sulfonylurea (e.g. Gliclazide or Glimepiride) if HbA1c remains >48 unless
patient at risk of hypoglycaemia. Sulphonylureas put on weight and risk of hypos.
NB.Consider Acarbose if unable to use other oral glucose lowering agents. NB. SEs diarrhoea
and flatulence. It is a starch blocker: blocks the breakdown of larger carbohydrates into glucose.
Inhibits glycoside hydrolases.
If HbA1c remains >48 (6.5%) consider dual therapy (see below in order of preference)
Metformin + Sulphonylurea (Gliclazide)
or
Metformin + DPP-4 Inhibitor (sitagliptin or vitagliptin)
NB. Only continue DDP-4 inhibitor if there is a reduction of HbA1c by 0.5 or more at 6
months. They do not cause hypoglycaemia
or
Metformin + Thiazolidinedione aka Glitazones (Pioglitazone)
NB. Only continue DDP-4 inhibitor if there is a reduction of HbA1c by 0.5 or more in 6/12
or
Metformin + Dapaglifozin
or
Metformin + Liraglutide
or
Metformin + Prolonged release Exanetide
-NB. works via the incretin effect of its GLP1 (Glucagon-like peptide1) mimicking action.
GLP1 is a hormone release in the small intestine in response to oral glucose. This
causes an increase in insulin secretion and inhibits glucagon secretion. It is a SC
injection given before meals. Should only be used when BMI>35 and only continued if
HbA1c dropped >1.0 and 3% wt loss at 6 months. Risks: Pancreatitis & renal impairment
or
Consider a rapid acting secretogogue for people with erratic lifestyles
If HbA1c >58 (7.5%) consider either triple therapy or human insulin (and continue Metformin)
Triple therapy - Metformin + sulphonyurea (Gliclazide) + Sitagliptin or Pioglitazone
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Drug side Effects:
Metformin - metabolic acidosis
- Gastrointestinal SEs
Sulphonylureas - Hypoglycaemic episodes
- Increased appetite and weight gain
- Inappropriate secretion of ADH
- Cholestasis
Gltazones - Weight gain
- Fluid retention
- Liver Dysfunction
- Fractures
- NB Rosiglitazone has been removed due to increased MIs and Heart
failure
Other important Treatment:
Aspirin should be given to all type 2 diabetic patients > 50 years and to younger patients with
other significant risk factors
BP target is < 140/80 mmHg (or < 130/80 mmHg if end-organ damage is present)
Patients > 40-years-old who have no obvious cardiovascular risk (e.g. Non-smoker, not obese,
normotensive etc) and have a cardiovascular risk < 20%/10 years do not need to be given a
statin.
Target total cholesterol is < 4.0 mmol/l.
If serum cholesterol target not reach consider increasing simvastatin to 80mg
If serum Triglycerides are >4.5mmol/L prescribe fenofibrate
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Cardiology
Angina
Diagnosis:
2 out of 3 = atypical 3 out of 3 = typical angina
1. constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
2. precipitated by physical exertion
3. relieved by rest or GTN in about 5 minutes
Further inx:
If typical pain and CAD risk >90% (e.g. typical symptoms + >70 years old) → no need for
further inx
61-90% CAD risk → Cornary angiography
30-60% Functional Imaging e.g. SPECT, stress echo, first pass contrast enhanced MR
perfusion, MR imaging for stress motion abnormalities.
10-29% CT calcium scoring
Stable Angina
● Give all patients Aspirin and Statin
● sublingual GTN PRN
○ NB many patients develop tolerance to nitrates
● Either use calcium channel blocker or beta blocker depending on comorbidities
○ If calcium channel blocker is used as monotherapy use a rate limiting one
(verapamil or diltiazem)
○ If calcium channel blocker is used in combo with a beta blocker use a long acting
dihydropyridine e.g. modified release nifedipine
● If there is poor response initially then treatment should be titrated to the maximum
tolerated dose (e.g. atenalol 100mg OD)
● If a patient is stills ymptomatic after monotherapy add the other (beta blocker or calcium
channel blocker but remember beta blockers should not be prescribed concurrently with
verapamil due to risk of heart block
● If a patient cannot tolerate dual therapy consider a long acting nitrate, ivabridine,
nicorandil or ranolazine
○ Ivabradine - works on If “funny” ion current at the sinoatrial node to slow HR by
reducing the pacemaker activity. SEs include luminous visual effects &
bradycardia
○ Nicorandil - this has nitrate properties (vasodilation) and calcium channel
blocking effects. SEs include flushing, palpitations, weakness, headaches and
mouth & GI tract ulceration.
● If a patient is on dual therapy only add in a third drug whilst awaiting assessment for PCI
or CABG
Heart Failure
Trials proving use of…
ACEi = SOLVD, SAVE & CONSENSUS
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Beta Blockers = CIBIS
Spironolactone = RALES
Hydralazine with Nitrates = VHEFT-1
When you suspect heart failure on the basis of the history (Orthopneoa, Lethargy, Palpitations
etc.) and examination (bibasal crepitations, ankle oedema etc.) those who have had a previous
heart attack should be urgently referred (2 weeks) to a cardiology clinic with access to
echocardiography. THose who have not had a heart attack should have a B type Natriuretic
Peptide level taken. If they are high (> 400 pg/ml (116 pmol/litre)) → urgent referral to
cardiology clinic (with echo). If they are raised (100–400 pg/ml (29–116 pmol/litre)) the patient
needs to be given a routine cardiology appointment (within 6 weeks with echo).
Treating heart failures due to left ventricular systolic dysfunction
First line → ACEi & Beta blocker.
If intolerant of ACEi and ARBs use nitrate & hydralazine instead especially in people of
african or caribbean origin.
Second line → Spironolactone or ARB or Hydralazine & nitrate
Third line → Cardiac Resynchronisation Therapy (pacing +/- defil) or digoxin
Treating Heart Failure with preserved Ejection Fraction
→ Manage comorbid conditions e.g. IHD / diabets
Give flu jab and one off pneumococcal vaccine
Hyperlipidaemia
Primary Prevention
One of the following risk models should be used to detect people 40-74 who have a 10 year
CVD risk of 20% or greater…
Framingham , Joint British Society 2 (JBS2), QRISK, ASSIGN (scotland only)
If using the Framingham equation, adjustments need to be made…
1st degree relatives c premature coronary heart disease (<55yrs in men, <65yrs
in women) increase risk by 1.5x (if one relative affected or 2x if >1 affected
South Asian Ethnicity increase risk by 1.4x
Advise lifestyle changes plus Simvastatin 40mg. There is no target level for total or LDL
cholesterol for primary prevention. LFTs should be checked at baseline, 3 months and 12
months but then not again.
Secondary Prevention
All patients with CVD should be taking a statin in the absence of contraindications
NICE recommend increasing Simvastatin to 80mg unless
total cholesterol <4mmol/l and LDL cholesterol <2mmol/l
Familial Hypercholestrolaemia
Autosomal dominant and affects ~1 in 500 people. Causes high levels of LDL cholesterol. It is
caused by defects in the gene which encodes the LDL receptor protein.
Diagnosis of Familial Hypercholesterolaemia is absed on the Simon Broome Criteria:
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Adults with Total cholesterol (TC) >7.5mmol/ L + LDL >4.9mmol/L or children with TC
>6.7 & LDL >4.0, plus,
For definite FH: tendon xanthomata or DNA evidence of FH in 1st or 2nd degree relative
For possible FH: FHx of MI <50yrs in 2nd degree relative or <60 yrs in 1st degree
relative.
Management:
The use of CVD risk estimation tables is not appropriate
Refer to a specialist lipid clinic
Maximum dose of potent statins is usually required
Screen relatives including children
Discontinue statins 3 months prior to conception due to risk of congenital defects
Atrial Fibrillation
Rate Control
- First choice = beta blockers
- Second choice (e.g. in asthmatics) = Rate limiting calcium channel blockers
- Digoxin only if patient has coexistent heart failure. Otherwise not considered first line
any more as less effective at controlling the heart rate during exercise
Rhythm Control
- sotalol
- amiodarone
- flecainide
Rhythm control could be considered for those…
Under 65 years
Symptomatic
First presentation
Lone AF (or secondary to corrected precipitant e.g. alcohol)
Congestive heart failure
Rhythm control is not considered for those with IHD or older than 65 years
DVT
Two level DVT well’s score
→ score >1 (DVT likely) → proximal leg uss within 4 hours* → if negative do a D-Dimer
→ score 1 or less (DVT unlikely) → D-dimer → if positive USS within 4 hours*
*If a proximal leg USS cannot be done in 4 hours LMWH should be administered whilst awaiting
for USS (within 24hrs)
Management
-LMWH or fondaparinux should be given initially after a DVT is diagnosed and continued for 5
weeks or until the INR is >2 for 24 hours, whichever is longer.
- A vitamin K antagonist should be given within 24 hours of the diagnosis and continued for at
least 3 months; if there are no obvious precipitating factors consider longer rx
- for patients with active cancer NICE advice LMWH for 6 months
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Bendroflumethiazide is a thiazide diuretic which works by inhibiting sodium absorption at the
beginning of the DCT. Potassium is lost (hypokalaemia) as a result of more sodium reaching the
collecting ducts. it used to be used for hypertension but now Indapamide and chlortalidone are
the recommended thiazides for hypertension. it still has a role in the treatment of mild heart
failure although loop diuretics (e.g. furosemide) are better. Common adverse affects include
dehydration, postural hypotension, hyponatraemia, hypokalaemia and hypercalcaemia (gout),
Impaired glucose tolerance and impotence. Occasionally thrombocytopaenia, agranulocytosis,
photosensitivity rash and pancreatitis.
Statins inhibit the action of HMG Co-A Reductase (rate limiting step in hepatic cholesterol
synthesis). Side effects include myopathy, myositis, myalgia and rhabdomyolysis as well as liver
impairment (NICE recommend checking LFTs at baseline, 3 months and 12 months and
discontineud if transaminase is >3x normal limit). Avoid in those with a previous intracerebral
bleed (as may cause another). Recommended in…
- All established Cardiovascular dx (Stroke/TIA, PVD, IHD)
- 10 year CV risk >20%
Antiphospholipid Syndrome
Classical features:Paradoxically prolonged APTT + low platelets
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to venous
and arterial thromboses, recurrent foetal loss and thrombocytopaenia. It is also associated with
livedoreticularis, pre-eclampsia and pulmonary hypertension.
It may occur as a primary disorder or secondary to other conditions, most commonly SLE. It can
cause a paradoxical rise in APTT.
Management:
Initial venous thrombosis → Warfarin for 6 monhts (target INR 2.5)
Recurrent venous thromboses → Lifelong warfarin
Arterial Thrombosis → life long warfarin (target 2.5)
If events occur whilst on warfarin increase target to 3.5
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Venous Ulcers
Venous ulceration is typically seen above the medial malleolus (gaiter area).
Varicose eczema and varicose veins can proceed to ulceration
Investigations
● ABPI - to check for any arterial component
○ Normal ABPI = 0.9 -1.2
○ Very high readings may be due to calcification
○ ABPI 0.5-0.9 = PVD
○ ABPI<0.5 = critical ischaemia
Management of venous ulcers
● Compression bandaging (four layer)
● Oral Pentoxifylline (peripheral vasodilator)
● ?flavioids
Peripheral Vascular Disease (SIGN guidance)
● History
○ All those with intermittent claudication - feel their foot pulses and feel for aortic
aneurysm
○ Cold, numb toes
○ Arterial ulcers
○ Loss of hair from feet, legs or toes
● ABPI should be measured in all those suspected
○ <0.9 = abnormal
○ Critical limb ischaemia <0.5
○ Values above 1.5 suspect calcinosis
● Fontaine Classification
○ Grade 1 Assymptomatic
○ Grade 2 intermittent claudication
○ Grade 3 rest pain/ nocturnal pain
○ Grade 4 Necrosis / gangrene
● Referral Criteria:
○ Uncertainty over diagnosis
○ risk factors unable to be managed to recommended targets
○ Symptoms limit lifestyle
○ Young otherwise healthy adults should be referred to exclude entrapment
syndromes
● Management
○ Risk factor modification
■ Encourage exercise - builds up vasculature
■ Statin recommended if cholesterol >3.5
■ Antiplatelet therapy is recommended for those with symptomatic PVD
(Aspirin 75mg OD)
