FACTS ON FINGER TIPS( ref.MIMS)-  List

 1.  Constipation                                                                                                                   2.  Ulcerative Colitis                                                                                                           3.  Crohn's Disease                                                                                                              4.  Primary Biliary Cirhosis                                                                                                5.  Rheumatic Fever                                                                                                            6. Congestive Heart Failure                                                                                                7. Migraine                                                                                                                            8. Rheumatoid Arthiritis                                                                                                  9. Ankylosing Spondylitis                                                                                            10. Osteoarthirotis                                                                                                          11. Gout                                                                                                                           12. Hydatidiform Mole                                                                                                   13. Menorrhagia                                                                                                             14. Polycystic Ovary Syndrome                                                               15.Endometriosis

FACTS ON FINGER TIPS (ref. MIMS)

1.CONSTIPATION

Definition   

o Straining of stools more than 25percent of bowel movements                                          o Two or fewer bowel movements in a week

Clinical features                                                                                                                 

   o Straining                                                                                                                             o Abdominal features                                                                                                           o Bloating                                                                                                                             o A loaded  colon may be palpable on abdominal examination                                           o Increased bowel sounds

Aetiology                                                                                                                             

 o Largely related to reduced intake of dietary fibre                                                              o May be secondary to other disorders eg.g-i obstruction, irritable bowel syndrome,             hypothyroidism                                                                                                                  o Pregnancy

Epidemiology                                                                                                                   

 o About 10 percent of population regularly constipated

Investigations                                                                                                                     

  o Usually none, diagnosis is made on clinical grounds.                                                        o Lower  g-i endoscopy or baruim enema if there are features suggesting a colorectal      carcininoma

Management                                                                                                                       

 o Exclude organic illness                                                                                                      o Oral laxatives                                                                                                                     o Review  medication to rule out drugs as cause                                                               o Treat mild cases by encouraging mobilation, intake of fluids and fibres                         o Suppositories or enemas in more persistent cases. 

Key Points                                                                                                                         

 o Constipation may be presenting symptom of coorectal cancer                                         o Chronic constipation will often require prolonged treatment

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2.ULCERATIVE COLITIS

Definition-                                                                                                                           o Idiopathic, recurent infalammatory disease of the large bowel                                       o The rectum is invariably affected

Presentation

o One of the commonet causes of prolonged bloody diarrhea

Clinical features

 o Commonly blood and mucous are passed with the stools                                               o Blood loss can lead to anemia                                                                                         o Diarrhea is common and in some cases farcal incontinence occurs                                 o Fever                                                                                                                               o Abdominal pain                                                                                                               o Weight loss

Differential diagnosis     

 o Cancer of the bowel                                                                                                         o Crrohn's disease                                                                                                               o Infective gastroenteritis

Investigations

o Full Blood Count- reduced haemoglobin and increased platelets indicate active                  disease                                                                                                                           o  ESR and C-Reactive protein (CRP)                                                                               o  Liver Function tests                                                                                                         o Stool cultures                                                                                                                   o Colonoscopy and biopsy

Management

 o Acute attacks generally require hospitilasation                                                               o  Conservative treatment of acute attacks -supportive therapy with rehydration, nil by       mouth and a course of steroids                                                                                        o Surgery may be needed in cases of toxic megacolon o Long term aminosalicylate             maintenance therapy reduces the likelihood of relapse

Key Points

o Considerable psychological mordbidity                                                                            o Increased risks of bowl cancer o Severe chronic disease may require total     protocolectomy with permanent ileostomy

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3.CROHN'S DISEASE

Definition

o A chronic, recurrent inflammatory disorder affecting any part of the g-i tract

Pathophysiology

o Idiopathic condition affecting the whole body thickness of the bowel wall                         o Normal bowel between affected areas are known as skip lesions                                   o  Smoking is a risk factor

Clinical features

o Aphthous ulcers                                                                                                                 o Fever                                                                                                                               o Diarrhea that may be bloody                                                                                             o Cramping abdominal pain                                                                                                o Weight loss and slowing of growth in children                                                                  o Failure to thrive in infanta                                                                                               o  Anal and perianal lesions are characterstic                                                                     o  Other organs systems may be involved, including the skin,joints,epiglotottis and vocal    cords

Differential  diagnosis

o Barium studies  may inclide features such as ' rose thorn' ulcers and strictures

Management

o Corticosteroids (systemic ,parentral or both) can be used for acute excaberations        o Azathioprine for maintaing remission                                                                                o  Codeine phosphate for controlling Diarrhoea 

Key Points                                                                                                                          o Surgery is likelyy to be needed in most patients, but is not curative                                  o There is no good evidence for an association with the MMR vaccine                                o  There is an increased risk of small and large bowel carcinoma

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4.PRIMARY BILLIARY CIRRHOSIS

Epidemiology

 o About 90 percent of cases occur in women                                                                       o Peak age of onset is between 30 and 60 years                                                               o  Condition is probably due to autoimuune disease                                                       o   Can be associated with thyroid diease, Sjogrens syndrome, coeliac disease,                   CREST  syndrome, hepatic and extra-hepatic malignancy and pancreatic                        hyposecretion

Clinical featutes

o The earliest stage is chronic nonsuppurative  destructive cholangitis                            o  Tiredness and pruritus                                                                                                    o Jaundice                                                                                                                           o Enlargement of liver and spleen                                                                                       o Half of the patients asymtomatic at presentation                                                            o  Dry eyes and mouth                                                                                                         o  Steatorrhoea  o  Easy brusing due to Vitamin  K deficiency

Investigations

o  Liver  finction tests , Liver enzymes are deranged                                                         o  Clotting screen: anabnormal clotting profile is indicative of advanced disease             o  Increased levels of aAlkaline Phosphotase                                                                     o   Autoimmune screen: affected have positiveanti-microchondrial anibodies                  o  Liver biopsy cinfirms diagnosis

Management                                                                                                                      o   Symptomatic treatment of pruritus                                                                                 o   Patient should be supervised by a  gastroerloogist or hepatologist                              o   Supplementation with fat soluble vitamins                                                                  o   Patients with advanced disease or intractable symptoms may have a liver transplant

Key Points

 o   Without  a transplant, most patients do not survive more than 10 years                       o   Patients  are at increased risk of hepatacellular carcinoma                                          o   Deficiencies in the fat souble  Vitamin A ,D and K may occur, resulting in                           osteomalacia and coagulation defects                                                                        o    Jaundice may be a late feature

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5. RHEUMATIC FEVER

 Aetiology       

 o Cardiac valvular damage resulting from cross reactivity with group A beta-haemolytic         streptococci                                                            

Epidemiology     

o  Peak incidence in childhood                                                                                              o Most common in developing countries like India

Clinical features                                       

o Follows recent streptococci infection of the throat                                                            o  Carditis is common and may manifest as changing  cardiac murmurs, relative                     tachycardia or pericardial rub                                                                                           o  Fitting polyarthiritis                                                                                                         o  Chorea                                                                                                                           o Erythema marginatum ( marginal erythema and central pallor)                                         o Subcutaneous nodules 

Investigations

o Throat swab                                                                                                                         o Blood tests: ASO tires, C-reactive protein                                                                         o ECG, Echocardiogram and X-Ray of the joints                                                                                                                                                     

Management

o  Penicillin antibiotics during active illness                                                                          o  Analgesia for joint pain and haloperidol for chorea                                                        o  Bed-rest during acute illness                                                                                                                                                                     

Key Points

o Patients are at increased risk of endocarditis                                                                    o Valvular disease is an important long-term complication                                                 o The oral contraceptives pill may precipitate relapse

6.CONGESTIVE HEART FAILURE

Definition

o  Pulmonary and peripheral congestion from insufficient cardiac output   

Epidemiology                                                                                                                      o More common in older people    

Risk Factors     

 o  Ischemic heart disease, hypertension, valvular heart disease  and arrhythmias             o  High output states, such as pregnancy, anaemias, thytotoxicosis                                   o  Latrogenic -for examples, beta-blockers

Clinical features- 

 o  Shortness of breath                                                                                                           o Paroxysmal nocturnal dyspepsia and orthopnoea                                                             o Signs suggesting left ventricular failure include tachycardia, dyspnoea, basal crackles       and gallop rhythm                                                                                                             o Signs suggesting right ventricular failure include raised  jugular venous pressure,               hepatomegaly and pitting oedema of the ankles                                                                                                                            

Investigations

o  Consider blood test- FBC, TFTs and U & Es                                                                  o  Chest X-ray may show signs of pulmonary oedema                                                      o  Echocardiogram and ECG

Key Points

o Echocardiography greatly improves diagnostic accuracy

7. MIGRAINE

Epidemiology

o Onset of migraine may  be at any age, but symptoms most commonly begin between        the ages of  10 and 40                                                                                                     o Women are commonly affected than men.  o About half of migraine sufferers have a         positive family history                                                                                                                                         

Pathogenesis                                                                                                                      o  Incompletely understood,but dysregulation of cerebral blood flow appears to be important  

Triggers   

o Combined oral contraceptives                                                                                            o Insomina                                                                                                                            o Tiredness                                                                                                                        o Lack of food                                                                                                                        o Food such as chocolate  

 Clinical features

o Classically there is aura- usually visual -followed by throbbing,unilateral headache        o Associated nausea,vllomiting,or both                                                                              o  Hypersensitivity to light,sound or smell

Investigation

 o Not  normally needed              

  Management

o Advise patients to avoid trigger factors                                                                              o Patients should rest in  quiet place during an attack                                                       o  Simple analgesics(preferably aspirin or  paracetamol ) and ani-emetics are often               effective                                                                                                                            o  For resistant headaches, suggest a 5HT,agonist such as sumatriptan, naratriptan,            rizatriptan.                                                                                                                        o Ergotamine is helpful in some patients, but its side effects limit its use

Key Points

o Consider the possibility of an underlying space-occupying lesion in patients with onset     of symptoms over age of 40.                                                                                              o Recommend prophylaxis for patients who have frequent attacks. The most commonly        used drugs are Beta-blockers and tricyclic antidepressants.                                          o When starting prophylaxis assess each drug by prescribing for at least two months

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 8. RHEUMATOID ARTHIRITIS

 Aetiology

• An auto-immune condition

Epidemiology

• Peak onset is in the third or fourth decade
• Women are commonly affected (female: male ratio of approximately 3:1)

Clinical Features

• Commonly affects metacarpo-phalangeal joints and proximal inter-phalangeal joints in a symmetrical way with pain and swelling
• Any joint may be affected
• Relapse and remission with progressive disruption of joint architecture
• Extra -articular manifestations include anaemia, vasculitis, scleritis. Pericarditis and pulmonary fibrosis         

Investigations

• Full blood count
• Inflammatory markers-CRP or ESR
• Rheumatoid factor and auto-antibody screen
• Liver function tests
• X-ray shows loss of joints space, peri-articular bony erosions and soft tissue swelling

Management

• Analgesics
• Disease Modifying Drugs
• Intra-articular corticosteroids may help control exacerbations
• Consider physiotherapy, occupational therapy

Key Points

• Early referral to rheumatologist for Disease Modifying Drugs
• This is systemic disease with potentially serious manifestations
• Surgery may have a role in patients with severe joint deformity

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9. ANKYLOSING SPONDYLITIS

 Aetiology

• Familial disorder
• Occurs in those with HLA-B27 tissue type

Epidemiology

• Prevalence is estimated at 1 in 1000
• Males are more commonly affected ( male: female ratio of approximately 10:1)
• Usual age of onset is 15-25 years

Pathogenesis

• Chronic inflammatory disorder of the spine and sacro-iliac joints

Clinical features

• Back and stiffness
• Symptoms are usually worse in the morning
• Peripheral joint involvement occurs in a minority of patients
• Spinal extension may be severely limited.
• Chest expansion may be reduced in advanced disease

Investigations

• X-ray evidence of erosion of the sacro-iliac joints is a tell-tale feature
• Bamboo spine on X-ray and erosion of apophyseal joints
• ESR and CRP may be raised during active phases of the disease
• Consider physiotherapy, occupational therapy

 Management

• Largely symptomatic management
• Analgesia for pain
• Physiotherapy may help reduce stiffness
• Patients with advanced disease may need orthopaedic surgery

Key Points

• ‘Question mark ‘ posture is characteristic
• Patients should exercise regularly to minimise stiffness
• Increased risk of atlanto-axial subluxation
• Ocular involvement, aortic valve disease and pulmonary fibrosis are rare but important recognised features

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10. OSTEOARTHRITIS

 Aetiology

• Most cases are primary or idiopathic
• May complicate any joint disease

Epidemiology

• Mean age of onset is the fifth decade
• Women are more commonly affected (female: male ratio of approximately 3:1)

Pathophysiology

• Degenerative joint disorder resulting in increasing loss of articular cartilage accompanied by new bone formation and capsular fibrosis

Clinical features

• Insidious onset with symptoms of joint pain and swelling
• Most commonly affects the distal interphalangeal joints (Heberden’s nodes)
• The first metatarso- phalangeal joint is often affected
• Weight bearing joints (lumber spine, hip and knee joints) are also commonly affected
• Progressive loss of mobility may occur if weight bearing joints are affected
• Joint effusions may occur

Investigations

• X-ray shows loss of joint apace, bone cysts, subchondral sclerosis and osteophytes

 Management

• Simple analgesics
• NSAIDs
• Rest during exacerbations of symptoms
• Waking aids may help.
• Physiotherapy may improve mobility and muscle strength.
• Patients with severe impairment in mobility may need joint replacement

Key Points

• May occur in younger people after joint injury or a history of joint disorders
• X-ray may be normal in early disease. Conversely, osteoarthritic changes on an X-ray may be coincidental finding and should not presumed the cause of symptoms
• Weight reduction may reduce the rate of progression of the disease
• Chiropodists , occupational therapists and family members may need to be involved

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11. GOUT

 Definition

• A disorder of purine metabolism characterised by hyperuricemia and recurrent attacks of synovitis due to urate crystal deposition

Epidemiology

• Male preponderance (male: female ratio 8:1) rare in menopausal women

Acute Gout

• Sudden severe joint pain lasts for one to two weeks if untreated
• Most commonly affects the first metatarsophalangeal joint, ankle and finger joints, although other joints may also be involved
• Affected joints are inflamed and exquisitely tender
• Triggers include alcohol, thiazide diuretics, trauma and surgery

Chronic gout

• Soft tissue deposits of urate (tophi) in the pinna, tendons, and bursae, leading to joint disruption and progressive disability

Investigations

• ESR, CRP and serum uric acid may be raised
• Synovial fluid microscopy reveals negativity birefringent crystals under polarised light
• X-ray show peri-articular ‘punched-out cysts’ in chronic gout

Management

• Acute episodes should be treated with a combination of rest and high dose NSAIDs
• Systemic corticosteroids and colchicine are suitable alternatives
• Allopurinol can be used for prophylaxis in those with recurrent attacks, but never for treatment of acute exacerbations

Management

• Acute episodes should be treated with a combination of rest and high dose NSAIDs
• Systemic corticosteroids and colchicine are suitable alternatives
• Allopurinol can be used for prophylaxis in those recurrent attacks, but never for acute treatment of acute exacerbations

Differential diagnosis

• Septic arthritis is an important differential diagnosis. If in doubt admit for further investigations
• Myeloproliferative disorders and renal failure both result in hyperuricaemia. Gout may be presenting feature of these conditions

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12. HYDATIDIFORM MOLE

 Definition

• Benign tumor consisting of degenerated chronic villi

Epidemiology

• Relatively uncommon, affecting about one in 500 pregnancies

Risk Factors

• History of hydantoin moles
• Extremes of maternal age

Clinical features

• Pre-eclampsia during first trimester
• Hyperemesis
• Vaginal bleeding with or without abdominal pain.                                      Uterus is large and bulky
• Absent foetal heart sounds

Investigations

• Characteristic snowstorm appearance on unsound scan
• Abnormally raised B-HCG hormone

Management

• Surgical therapeutic termination of pregnancy
• Monitor serum B-HCG levels until normal
• Advise not to conceive until B-HCG level has been normal for six months
• Rarely may develop into invasive chloriocarcinoma – hence the need to monitor serum B-HCG

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13. MENORRHAGIA

 Definition

• Excessive menstrual blood loss, objectively defined as more than 80ml per cycle
• A more practical definition for use in family practice is ‘disproportionate menstrual losses occurring over several consecutive cycles’.

Epidemiology

• A very common problem
• But about 25 per cent of women who complain of heavy periods have ‘normal’ blood loss.

Clinical features

• History of bleeding that cannot be controlled with a single tampon or sanitary towel.
• Waking at night to change tampon or towel.
• Regularly passing ‘clots’ or ‘flooding’.
• Crampy uterine pain may be a feature

Investigations

• Patients should keep a menstrual diary of symptoms
• Full blood counts and thyroid function tests.
• Ultrasound scan if fibroids suspected

Management

• Refer over -40s for further investigations
• Combined oral contraceptive should be prescribed if contraception is also required
• NSAIDs such as mefenamic acid reduce loss by 20-50 per cent if taken during menstruation
• Tranexamic acid reduces blood loss by up to 70 per cent, but has side effects
• Surgical options are mainly reserved for those who fail to respond to medical treatment

Key Points

• Consider the possibility of endometrial cancer
• Women taking danazol must avoid becoming pregnant

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14. POLYCYSTIC OVARY SYNDROME

 Definition

• A sex hormone disorder in which ovarian follicles fail to rupture, resulting in cystic ovarian enlargement
• Also called Stein- Leventhal syndrome

Epidemiology

• A common disorder
• More common among women in Asia

Clinical features

• Irregular menstrual cycles
• Obesity
• Hirsutism
• Male pattern baldness
• Subfertility or infertility

Investigations

• Diagnosis is made usually on symptoms
• Pelvic ultrasound scan typically shows large cystic ovaries
• Blood tests: raised luteinising hormone and testosterone are characteristic

Management

• Treatment depends on symptoms and whether or not the patient wants to conceive.
• Spironolactone may help hirsutism
• Oral contraceptive pill to help regulate menstrual cycles.
• Clomiphene may be used to induce ovulation in women wishing to conceive
• Surgical treatment involving wedge resection of the ovary may rarely be indicated

Key Points

• Patients are at increased risk of endometrial cancer
• Weight loss may be beneficial

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15. ENDOMETRIOSIS                                                                                                                                             

  Definition

• Presence and proliferation of endometrial tissue outside the uterine cavity

  Pathophysiology

• Poorly understood; retrograde menstruation is considered as a possible mechanism     

  Epidemiology

• Affects up to 10 per cent of menstruating women.
• More common in women with a family history
• An early first pregnancy is protective

  Clinical features

• May be asymptomatic
• Typically cyclical pelvic and abdominal pain
• Dysmenorrhoea and menorrhagia
• Pain during intercourse
• Subfertility or infertility
• Fixed retrograde uterus
• Differential diagnosis are irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID)

Investigations

• Multiple tender nodules palpable along the utero-sacral ligament on rectal/vaginal examination.
• Laparoscopy is the investigation of choice

Management

• Asymptomatic women do not need treatment
• Medical treatment: drugs that suppress ovarian function such as oral contraceptives, danazol, gonadotrophin releasing hormones, progestogens.
• Surgical treatment: aim is to remove the maximum ectopic endometrial tissue

Key Points

• Endometriosis is a chronic relapsing disorder
• Frequency and severity of symptoms do not necessarily correlate with the extent of ectopic endometrial tissue.
• Treatment may not improve fertility

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