HIV, Hep B

ETOH, THC

obese, male, >40yo

• Wernickes
• Parotidomegaly
• Proximal myopathy 
• Hypertension
• Dupuytren contracture
• Cardiomyopathy
• Exocrine pancreatic failure; steatorrhoea

obs (? infective delirium)

mental state; delerium, psychosis, mania, withdrawal states

gen med; anaemia, hypothyroid, B12; angular cheilitis

neuro; intracerebral mass, Parkinson, dementia

• Patient Health Questionnaire; a two question depression screening tool
• 1) mood 2) anhedonia over 2 weeks
• 0, 1 (some), 2 (half), 3 (most)
• 3 = +ve

Genetic; F>M, FHx

Biological; neurohormonal, peripartum, drugs (COCP, CS, B blocker), medical (psych, Parkinson, Dementia, thyroid, post infective states)

Environmental; stressors, seasonal

Outline the considerations with antidepressant use in

1. adolescents 
2. 18-25yo

1. generally not utilised unless depression is severe 
2. risk vs benefit ratio is equivocal as may experience a worsening of symptoms — in particular, suicidal ideation

• epilepsy; lowers seizure threshold 
• psychiatric; overdose carries high risk of fatality acute 
• cardiovascular; 
• proarrythmic (QT prolongation) 
• chornotropic (may precipitate angina) 
• orthostatic hypotension is likely to be exacerbated 
• prostatic hypertrophy; risk of precipitating urinary retention

1) agitation 2) temperature 3) diaphoesis 4) ocular clonus 5) tremor 6) peripheral clonus (spontaneous or inducible) 7) hypertonism 8) hyperreflexia

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• Early adulthood = genetic ("primary") 
• >40yo for first episode = more likely to be secondary to 
• drugs (CS, antiparkinsonian)
• medical (stroke, tumour, hyperthyroidism)

• Sleep; perceived lack of need for sleep 
• Goal directed activity; promiscuity, gambling, excessive spending 
• Risk taking activity 
• Enhanced perceptual experience; colours are more vivid, music more meaningful

Acute overdose rarely results in toxicity (even up to 25g) as it is readily excreted renally. Overdose is more commonly due to chronic use in the setting of decreased excretion (fluid status decreased or concomittant NSAID use)

Toxidrome = neuro (ataxia, tremor, dysarthria), GIT (vomiting), muscle twitches and AKI

> 6 months

OR

intense grief associated with impaired function

ABS always takes Jennys income 

• Appearance; dressed ^, groomed ^ 
• Behaviour; ^ppropriate, relaxed / agitated, cooperative 
• Speech; ^ rate, ^ volume, prosody is present (emotional inflection exists) 
• Affect; low/ euthymic/ elevated, congruent 
• Thought; ^ obsessions / delusions / hallucinations 
• Judgement; “if you went home and couldn’t find keys to get into house what would you do?” 
• Insight; ^ perception of disease process and need for treatment

First generation

- have higher rate of extrapyramidal side effects

- eg Haloperidol

Second generation

- have higher rate of cariac side effects ie QTc prolongation

- eg olanzapine, respiradone, quetiapine

Importance of distinction is diminishing as efficacy is generally the same between classes and it now primarily reflects the length of time the drugs have been available

bradykinesia

cogwheel rigidity

festinating gait

postural instability

akathesia

- average no more than 2 standard drinks per day on average to reduce the lifetime risk of ETOH related conditions

- no more than 4 standard drinks in one session to reduce the risk of alcohol related injury

- delay drinking age as late as possible

- no ETOH in pregnancy

- seroconversion refers to the immune control phase (ie Anti ABe +ve and Anti HBsAb +ve with low viral load)

- means that an individual is unlikely to transmit HBV

- it must be remembered that the HBV is never completely eradicated from the liver. In older age or if the patient is immune suppressed, the disease may flare again

at least 6 months, in more than one situation and before the age of 12 of one or more of

- inattention; easy distraction with frequent change of activity

- hyperactivity; excessive movement and restlessness that impairs social functioning

- impulsiveness; acting without reflection

• Early 
• cognitive; learning and retaining new information becomes difficult 
• function; progressive difficulty with tasks (eg finances) and mechanistic objects (eg phone, remote, CPU) 
• psychiatric; increasing mood swings, irritability and anhedonia 
• behaviour and physical are not effected 
• Intermittent 
• cognition; cannot learn new memories, worsening loss of sense of time and space 
• function; require help with basic ADLs 
• psychiatric; personality changes (often anger or flattened affect), altered perception may culminate in hallucinations / delusions 
• behaviour; problems begin (wandering, agitated, uncooperative) 
• physical; early loss of physical capacity may begin 
• Advanced 
• cognition; recent and remote memory is completely lost 
• function; cannot walk or perform any ADLs 
• psychiatric; perceptual disturbance can worsen 
• behaviour; previous problems start to settle as physical capacity declines 
• physical; progression to loss of swallow with death often via infection

1. non pharmacological is always first line given risk of use of antipsychotics
2. pharmacological
• second generation antipsychotics (given risk of lewy body dementia)
• start low, go slow
• at least 3 monthly review given natural progression of disease results in decreased behavioural dysfunction

• BRCA1 and 2 account for 5% of all breast cancers 
• A woman with BRCA 1 or 2 has a 
• 60% chance of getting breast cancer 
• 40% chance of ovarian cancer

Systemic

- conditions; renal, hepatic, thyroid, coagulopathy

- drugs; hormonal (HRT, contraception), anticoagulants

- physiological; perimenarche, obesity, PCOS, perimenopausal

Uterine

- IUD

- pregnancy 

- growth; myometrium (adenomyosis, fibroid), endometrium (hyperplasia, endometriosis, polyp, cancer)

- infection; endometrium

Cervical

- growth; ectropian, cancer

- infection; chlamydia

Duration of periods, earlier age of menarche

Smoking, obesity, ETOH,

Stressors, mental health

• tranexamic acid; good first line 
• NSAID; beware if pregnancy is possible 
• oestrogen; consider usual COCP contraindications (DVT, migraines with aura, smoker >40yo) 
• consider IUD; excellent efficacy 
• is there proven endometriosis; requires GnRH agonist 
• is there intermenstrual bleeding; NSAID / tranexamic alone will be ineffectual, need progersterone to atrophy endometrium 
• Advanced; hysterectomy, endometrial ablation

• Elevated serum oestrogen
• adipose tissue
• SERMs (eg Tamoxifen)
• unopposed oestrogen (eg HRT for >5yrs)
• Diabetes and hypertension
• debate as to whether is a cause or result of other RFs (eg obesity)
• Hereditary
• Lynch syndrome
• breast cancer

• Primary vs secondary 
• primary; life long, often psychological component 
• secondary; acquired condition 
• Superficial vs deep 
• superficial especially at time of insertion is commonly a learned response 
• deep is more likely to be associated with pathology

• Heterosexual 
• opportunistic 
• (interval unclear as per Redbook thus case by case determination of interval is appropriate) 
• women; self collected vaginal sample > endocervical sample > first pass urine (sensistivity) 
• men; first pass urine 
• MSM 
• annual urine, anorectal and throat testing
• 3 monthly if ongoing exposure to new partners

• cancer
• breast cancer
• MEC 3 with strong FHx 
• MEC4 if within last 5 years (only absolute contraindication)
• other sex steroid sensitive malignancies
• liver 
• tumours (benign or malignant)
• severe liver disease
• active thromboembolism 
• undiagnosed vaginal bleeding
• pregnancy

• Mental health; low mood, depression, anxiety, decreased concentration, irritability 
• Vasomotor; flushing and night sweats 
• Menstruation; perimenopausal variation in volume and frequency of periods 
• Vaginal dryness / dyspareunia 
• Decreased libido
• Joint pain
• Poor sleep 
• Fatigue 
• Formication (ants crawling over skin) 

• Best symptom relief comes from replacing the oestrogen deficit. This can be in oral or transdermal HRT preparations. 
• If main sxs are vaginal could consider just topical vaginal oestrogen cream
• If woman has a uterus needs progesterone to counterbalance the endometrial hyperplasia. If within 2 years of menopause this should be cyclical (eg two weeks on, two weeks off) to provide planned bleed and thus avoid irregular bleed
• If contraindications to HRT consider SSRI, SNRI, gabapentin or clonidine all of which have proven benefit for menopausal sxs

• Absolute
• cerebrovascular disease
• current breast or endometrial cancer
• active liver disease
• unexplained vaginal bleeding
• current VTE
• active SLE
• Relative
• focal migraine
• past history of breast, endometrial or ovarian cancer
• previous IHD
• increased VTE risk
• hyperlipidaemia

50 to 60 years old

- cardioprotective if no cardiac disease

- increased risk if already has cardiac disease

60+

- increases cardiac risk 

Breast cancer (with oestrogen+progesterone only)

VTE

Stroke

Cholecystitis

• usually preheadache 
• last for ~ 1/24 
• are 'positive' sxs (eg visual loss would be negative) 
• 90% are visual, commonly a fortification spectra 
• parasthesias are second most common

• severe, unilateral, retroorbital headache lasting 15 - 180 minutes associated with a sense of restlessness / agitation (do not lie down, unable to sit still) and at least one of 
• conjunctival injection and/or lacrimation
• nasal congestion and/or rhinorrhoea
• forehead and facial sweating / flushing
• miosis and/or ptosis 
• clusters result in attacks from every other day to up to 8 per day

• new-onset severe headaches 
• a change in character or pattern of pre-existing headaches 
• headache location is exclusively occipital 
• seizures 
• signs of neurological dysfunction 
• <6 years of age 
• a history of neurocutaneous syndrome (e.g. neurofibromatosis, tuberous sclerosis or Sturge–Weber sydrome)

• Identify triggers and avoid 
• hydration 
• sleep; same sleep / waking time and consistently 8 hours per day 
• caffiene; avoid regular use 
• diet; hunger can be a trigger, avoid high sugar and processed foods 
• CBT
• can be very effective

Paroxysmal attacks of pain lasting from seconds to minutes affecting one or more divisions of the trigeminal nerve and

- attacks are stereotyped in an individual patient

PLUS Either

- is either intense/sharp/stabbing 

OR

- reproducible by a trigger (shaving/cold air etc)

• Presents as relapsing and remitting upper motor neurone lesions separated in time and space
• Commonly
• optic neuritis; 20% as first presenting symptom, 40% at some stage of the disease process
• fatigue; 75%, is the major cause of unemployment
• cognitive dysfunction; 40-70%, not correlated to physical dysfunction
• pain; primary (due to demyelinating process), secondary (MSK due to posture, lack of use, spasticity)
• bladder dysfunction

• Clinical diagnosis with support from investigations 
• MRI 90% sensitivity 
• LP; oligoclonal IgG 90% sensitivity 
• visual evoked EEG potentials; 90% sensitivity

• RACGP Check article says
• Vitamin D decreases relapses and prevents people with FHx from developing MS 
• everyone at risk should be on at least 5000IU of vitamin D 
• UK MS Society
• summarises all evidence available up to 2016 
• Vitamin D seems to have a role to play studies have varied in it's effectiveness safe dose not yet established 
• more research needed 
• Vitamin D should be given at usual amounts to target Vitamin D deficiency and not MS (ie 1000IU daily if deficient)

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• Receptors 
• B1; responsible for cardiac inotropy and chronotropy 
• B2; responsible for relaxation of smooth muscle in lungs and vasculature 
• alpha 1; responsible for vascular smooth muscle constriction 
• Different classes 
• selective for B1; metoprolol 
• non selective B1/2; propanolol 
• non selective B1/2 + alpha1; carvedilol, labetalol

Can present acutely (eg overdose) or sub acutely (eg intercurrent illness, renal dysfunction)

Clinical

- early; GIT (N/V/D, abdo pain), hyperkalaemia

- progressing to; tachy or brady arrhythmias, hypotension, CNS depression

• Class I; 
• prolong depolarisation 
• flecainide 
• Class II 
• beta blocker 
• Class III
• prolong repolarisation 
• amiodarone, sotalol 
• Class IV 
• calcium channel blockers 
• diltiazem, verapamil 
• Class V 
• variable mechanism 
• digoxin, adenosine, magnesium

• Is a good first line drug if 
• no structural heart disease (as it predisposes to ventricular arrhythmia) 
• concomittant use of rate control drug (as it predisposes to conversion of atrial flutter into 1:1 conduction)

• Preinitiation 
• serum electrolytes, liver function and TFTs
• ECG 
• lung function 
• CXR 
• Monitoring 
• 6 monthly electrolytes, LFTs, TFTs 
• annual CXR and ECG

Lifestyle modification

Anticoagulate

- CT brain not required before starting as long as there is no ongoing neurological change (as bleed is unlikely to cause a TIA)

- if AF use warfarin / NOAC

- otherwise, start antiplatelet (Clopidogrel 1st line, Assassantin 2nd line but high SE profile or aspirin)

- Nb/ that aspirin has only mild decrease in efficacy so pretty good as first line (NNT 100 before benefit shown for others)

Statin

- even if normal lipids

Antihypertensive

- even if normal aim for asymptomatic decrease by 10mmHg

- harm if started in first 2 weeks so wait until after this

- ACEi good choice generally

Glycaemic control

• Pain; typically epigastric radiating to the back and accompanied by vomiting. May be exacerbated by food or alcohol 
• Exocrine insufficiency; hallmark = steatorrhoea due to defective secretion of lipase and bicarbonate, causing fat malabsorption. A 90% loss of exocrine function is needed before steatorrhoea develops 
• Weight loss; fat and protein malabsorption 
• Glucose intolerance; late and is usually insulin dependent

• Defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source 
• Primarily occurs in patients with 
• advanced cirrhosis 
• gross ascites 
• Mortality rate from a single episode has been estimated as 10 - 46% (if presentation is late with established sepsis survival is unlikely)

• Hepatic encephalopathy 
• Wernicke encephalopathy 
• Head trauma 
• Intracranial event 
• Electrolyte disturbance 
• Infection (including Spontaneous Bacterial Peritonitis)
• Alcohol withdrawal

• 80% have an organic cause 
• primarily vascular disease and medications  
• 20% are psychogenic 
• cluster around the begining of sexual experience

• Contraindications: 
• Asthma 
• 2nd / 3rd degree heart block 
• Symptomatic hypotension 
• Systolic blood pressure < 80 mm Hg 
• Heart rate < 50 bpm 
• Late pregnancy 
• B blockers should not be started until the heart failure has been stabilised. 
• Start at a low dose e.g., metoprolol CR 23.75 mg (½ tablet) once daily or carvedilol 3.125 to 6.25 mg twice daily 
• See patient fortnightly to slowly titrate the dose to avoid side-effects. 
• B blockers improve survival, but the patient's condition may worsen at first. If worsening heart failure on B blockers, either increase diuretics or halve the dose of the B blocker. 
• Titrate to the maximum dose unless limited by hypotension or bradycardia (resting heart rate < 60 bpm). Never stop a B blocker suddenly as there is a risk of rebound hypertension and arrhythmias. Gradual dose reduction over 1 to 2 weeks is recommended. 
• Target dose is metoprolol CR 190 mg daily, carvedilol 25 mg twice a day.

As an aldosterone receptor antagonist it inhibits the normal RAAS mediated Na and H20 retention for K excretion

This results in hyperkalaemia

• Triglycerides; account for 95% of dietary lipids, are converted to fatty acids and glycerol in adipose and muscle tissue to become and energy storage 
• Cholesterol; is primarily endogenous (body does not need endogenous as can synthesise from other materials) and functions in cell membrane formation, hormone synthesis and bile acid formation 
• Lipoprotiens; function to transport lipids and cholesterol around the body. 
• LDL deposits excesses into tissues (including arteries and is thus atherogenic)
• HDL transports it to where it is needed (including away from tissue / artery stores and is thus anti-atherogenic

• Gliaden = protein in gluten. Gluten is the principal storage protein in wheat 
• Transglutaminase is a tissue enzyme that binds gliadin in the intestine to form a complex that is recognised as being foreign by the immune system
• Gluten mediated immunological damage to the mucosa of the proximal small intestine causes atrophy of the villi and thus malabsorption

• TTG and DGP antibodies 
• after 3-6 months on a gluten-free diet, there is usually a fall in titres of either antibody type 
• TTG can take longer, as titres can be very high 
• DGP changes are usually more dynamic, with levels going up and down more quickly with changes

• more common in women >55
• common association with other autoimmune disease such and Coeliac and Type 1 Diabetes

• <18 years 
• unresponsive to therapy 
• pregnant 
• cardiac patients 
• presence of goitre, nodule, or other structural changes in the thyroid gland 
• presence of other endocrine disease

• Skeletal muscle fatiguability
• worse with activty and at end of day
• improves with rest
• Muscle bulk and reflexes are normal
• Can present as ptosis, bulbar weakness, proximal muscle weakness
• Test clinically via
• sustained upward eye gaze for 2 minutes
• count out loud to 30
• shoulder repetition of abduction x30