Aids to Undergraduate Medicine (6th ed)

Other title in the Aids series

Burt on Aids to Postgrad uate Medicine 6E Burton Aids to Undergraduate MedIcine 6f Dixon A ids to Pathologv 4E Habel Aids to Paedi;:u r;C$ 3E Habel Aids to Paediatrics for U ndergraduates 2E Hayes and MacWaher Aids to Clinical Examination 2E Mead Aids to General Practice 3E Mowschen$On Aids to U ndcr ll r "du~w Su rgery.E Rogers and Spec:t or Aids 10 Clinical Pharmacology and Therapeuti

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8 . Po liomyel it is 9 . Sub-acute combined degeneration 10 . Gu illa in- Barre (acut e post·i nfect ive po lyneurit is)

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Cha racte rized by symmetrical f laccid weakness and sensory changes of 'g love and stocking' d ist ribut ion

S2

L1

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1. Many cas e s a re idiopathic 2 . Drugs and chemicals

" " MYOTOM ES WORTH REMEMBERING C6 C7 C8 l4 L5 51-

CAUSES OF POLYNEUROPATHY

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PERIPHERAL NEUROPATHY

Biceps, brachiorad ial is, radial extenso rs of wrist Triceps, u lnar extensors of wrist, f inger extenso rs Finge r flexors Quad riceps femor is Extenso r hallucis long us Planta r f lexors

REFLEXES An kle je rk Knee

5 1,2 L3, 4

Biceps

C5,6

Triceps C7, 8 (St art low and work up)

V incristine, am io d arone, mercu ry Lead causes mot o r neuropathy Ison iazid (via pyridox ine deficiency) Many organ ic ch em ica ls

3. M e t ab o lic Diabetes mellit us Amylo idosis Acut e i ntermittent porphy ria U raem ia Myxoede m a

4 . De fici e ncy states 8 12 d eficiency A lcoholism Be ri·be ri (thiam i ne deficiency) Pel lagra (nicotinamide deficiency)

5 . Infections Leprosy Diphtheria Tetanus Botu l ism

6. Misc ellaneous

CAUSES OF PARAPLEGIA 1. 2. 3. 4. 5. 6. 7.

Heredi tary spastic parapleg ia Cerebra l bi rth i nj ury (cerebra l pa lsy) Trauma Cord compression - int ra - or extramedu llary (p. 109) Mu ltiple sc le rosis Syri ngomyelia Motor neu rone d isease

'Acut e infective polyneuritis' of Gu i llain- Barre Collag en- vascu la r disease, esp. polya rt eritis and rheumatoid d isease Ma l ignancy Sarco idosis

7. Congenita l Rare hered ita ry ataxias and neuropat hies (e.g . Charcot- Ma rie- Tooth )

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Neurology

CAUSES OF PROXIMAL MYOPATHY CONG ENITA L

9. Endocrinology

Muscu lar dyst rop hy

RH EUMATIC Polymya lg ia r heumatica Po lymyositis o r der m atomyositis

THE PITUITARY META BOLIC

PITU ITARY HORMONES

Diabetes mell itus Glucocorticoids (Cushing's o r iatrogenic) Ost eoma lacia T hyrotoxicosis o r m yxoedema Carcinomat ous neuromyo pat hy

Anterio r FSH, L H, A CTH, T SH, G rowth hormone, P rolactin Mnemonic: FLAT GP Post e rior

AOH Oxytoc in

PITUITARY SPACE-OCC UPYING LESIONS 1. Secreting adenomas

2.

3. 4.

5.

(j) Prolactin oma Oil Cush ing's IACTH) (iii) Acromega ly IG H) Non-secreti ng adenomas Cran iopha ryng ioma Met ast ati c ca rcinoma or lymphoma G ran ulo m a, e.g. sarco id, T B

PRES ENTATIO N OF PIT UITA RY LES IONS ,. Sympt oms due to excess secretio n of ho r mones (i l Prolactin - amenorrhoea, galacto rr hoea, hi rsu tism Iii) ACTH - Cush ing's d isease (i ii) GH - acromega ly 2. Hypopitu ita ri sm d ue to d estruction o f nor mal p itui tary tissue 3. Headache 4. Visual field defect s, usua ll y bitempo ral hemianopia 5. Pituit ary apo plexy (rare)

CLI N ICA L FEATUR ES OF AC RO M EGALY Sympt o ms 1. Often insid io u s, w ith no sympt o m s 2. Headaches 3. Paraesthesiae (median nerve com pression) 4. Proximal weakness and jo int pains

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Endoc rin olo g v

5. 6. 7. 8.

Po lyu ria Im pot ence and loss o f li bido i n men Hirsutism and ameno rrhoea i n women Visual d et erio ration

Endocrino logy

3 . Gonado trophins (lH a nd FSH): (i ) Delayed pu berty i n ch ild ren (ii) Loss of bod y hai r, fine w rinkled skin, i mpotence, i nfe rti lity and am en o rr hoea in adu lts

9. Ga lactorrhoea

4 . Thyrotrophin (TSH) :

Signs 1. Characte ristic f acies, large hand s, f eet and t o ng ue 2. l eathe ry f u rrow ed skin. M ay be sebo rrho ea, hype rh idros is o r p ig ment ation

3. Hoa rs e de ep voice 4. No n-toxic go itre 5. Gynaecomastia 6. Bitem pora l hemianopia, o ptic atro phy, ocu lar palsies

Hypothyro id ism

5 . Corticotrophin (ACTH ): Hypoad renalism (asthenia, nausea, vom iting, hypog lycaem ia, collapse)

6 . M e la noc yte -stim u la t in g hormone (MSH): Skin pallo r

7. Ge nera lized o rgano megaly 8. Cardiac fa i lu re (hypertension and ischaem ia) 9. Signs of di abet es m ell itus o r it s co m p licat ions

10. Hypopit uit a rism

THE THYROID

11. Pro g ressive kyph os is

HYPOTHYROIDISM

12. Arth ro pat hy

CAUSES P rima ry (thyroid gla nd f a ilu re)

HYPOPITUITARISM CA USES

1. A uto i mmu ne thyroid itis (Hashi m oto's disea se a nd it s atro ph ic v ariant, m yxoed em a). In Hash im ot o 's the thy roid is larg e and may be tender, but in m YKoed ema it is i m pal pable. Ci rc ulating thyroid a ntibo d ies occu r in bo th 2. Iatrogen ic: (i) Su rge ry (ii) Irr ad iatio n (ii i) An t ithyro id d r ugs (iv) Lith ium 3. End em ic creti nism (maternal iodi ne deficiency ) 4. Absence o r ma ldevelo pme nt of thyroid g land (rare) 5. Dyshormonog enesis (rare co ngenital enlyme defects affecting hormone synthesis)

1. Tum o u rs: (i) Ch romoph o be adeno m a (ii) Eosi no phil adenoma (basophi l adeno ma is rarely large enough t o ca use hypo pitui t arism) (iii) Cranio p haryng io m a (iv) Met ast at ic can cer 2. Iat rogen ic - hypophysect o my o r irrad iation 3. Pitui t ary necrosis d ue to ante- o r p ost pa rtum haemorrhage (Sheehan's syndrome) 4. Gran u lomatous infi ltratio n, e.g . sarco idosis 5. Trauma 6. In fec tio n, e.g. T B, m eningitis

S e condary (TSH d e f icie ncy)

CLINICA L FEAT URES

1. Pitu it ary lesio n 2. Rarely hypothalamic lesio n (due to t hy rot ro p hin releasi ng ho rmone defi cie ncy)

Loss o f ant erio r pit u it ary hormones is usually part ia l, i n t he fo ll ow ing o rde r of f requency:

1 . Somatotrophin (GH) : (i) Dwarfism in c hild ren (iii Insuli n sensit iv ity i n adults

2 . Prola ctin: Failu re of lact atio n in postpartum patients

CLIN ICAL FEATURES ,. 2. 3. 4. 5. 6.

Ment al and physica l slug g ishness Co ld i ntole rance Constipation W eight gain Croaking voice, w ith slow speech Ro ugh, d ry yellowish skin

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Endoc rinology

Endoc rino logy

7. 'Myxoedema fa cies' w it h general ized thickening o f subcutaneous t issue, periorb ital puffiness, b rittle sparse hair and thin eyebrows 8. Bradyca rd ia 9. Delayed relaxation of tendon jerks

CLI NICA L FEATURES OF GRAVES' DISEAS E Thyroid gland 1. Goit re, usually diffuse (but may be nodular) 2. Increased thyroid vascu larity (th r ill, bru it)

Metabolic

l e ss commonly 10. A naemia (may be macrocytic) 11 . Cyanosis, Raynaud's phe nomenon or angi na 12. Carpal tu nnel syndrome

13. Perceptive deafness 14. Mya lg ia o r arthralgia 15. 'M yxoedema madness'

16. Coma

3. 4. 5. 6. 7. 8. 9. 10.

Increased heat pro d uct ion (warm moist skin, heat i nto lerance) We ight loss, increased appetit e, di arr hoea Tachycardia, exertiona l dyspnoea, hyperdynamic circu lat ion Ti redness, irritabil it y, nervousness Fine t remor, hyperkinesia Proxi m al muscle weakness with hyperactive refl exes Occasionally, bone pai n due t o osteoporosis In e lderly patie nts, alrial fibrillation or cardiac fai lure

Extra-thyroid m a nifest a t ions (possibly immunological)

ORGAN-SPECIFIC AUTO IMMUNE DISEASES 1. 2. 3. 4.

Hashimoto's t hyroid it is Adrenal it is (Add ison's) Pern ic ious anaem ia J uven ile-onset d iabetes me ll it us

5. Vitiligo 6. ? Alopecia areata

CAUSES OF 'NON-TOXIC' GOITRE 1. 'S imp le' colloid goit re (id io pathi c), common d u ring puberty and

pregnancy 2. 3. 4. 5.

Diffuse mu lti nodula r goitre (may become t oxic) Iodine def ic iency Goitrogens, e.g . antithyro id d r ugs, excess iodine Auto immune thyroid it is (Hash imoto's)

Possibility of mal ignanc y is sugge sted by : ,. 2. 3. 4.

Asymmet r ical enlargement wit h 'cold area' on scan Very hard t hyroid Pressure effects, e.g. ho arseness Cerv ical lym ph adenopathy

HYPERTHYROIDISM CAUSES 1. Graves' d isease 2. Toxic mu lt inod ular goitre. Resembles Graves' d isease but pat ients tend to be o lder, w ith fewe r eye signs 3. To xic adenoma 4. Iatrogenic (excess t hy roid hormone)

11. Eye signs: Eyel id oedema Conj unctivitis Exophthal mos Lid retract ion o r lag Opht ha lmopleg ia (usual ly superio r rect us) 12. Pretib ial myxoedem a 13. Thyroid acropachy (club bi ng) 14. Vit iligo 15. Splenomegaly

M ANAG EM ENT OF THYROTOX ICOS IS 1 . Indications for thyroid e ctomy (i) (ii ) (ii i) (iv)

Possib le mal ig nancy Pressure symptoms Retrosterna l go itre Large goitre (v) Ref usal o r failure o f med ica l t reatm ent (vi ) Hypersensit ivity to antith y roid drugs Patient m ust first be made eut hyroid to avoid t hyro id 'storm'

2. Indications for m e dical treatment (i) Young patie nts (ii) Pregnan cy (i ii) Mi ld hy pert hyro id ism w ith small goitre (iv) Pat ients unsuit able for su rg ery

3. Indications for radioiodine therapy (i) Relapse afte r thyro id ectomy (l j) Patients over age 45

(iii ) Toxic adenomas Su bsequent hypothyroidism is common (about 40% at 10 y ears)

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I En d oc r in o logy

Endocrino logy

THE PARATHYROIDS

CLINICA L FEATURE S

HYPERPARATHYROIDISM

1 . Due to hyp o cal caemia OJ Tetany (paraesthesiae, stridor, c ramps, hyperref lexia) Trousseau's and Chvost ek's signs are present {iiI Conv u lsions (especia ll y in ch i ldren ) (i ii) Cata racts

CA USES 1. Prima ry (i) A de noma (single or multi ple) (85%) ( ii ) Hyperplasia (i ii ) Carcino m a

2 . In idiopathic hypopar athyro idis m (i) M ental subno rmality Iii) Dry skin, sparse hair, poor teeth, na il dyst rophy o ften wit h ca ndid osis (i ii ) Papilloedema and calcif ied basal g angl ia (m imics brai n t umour) (iv) Ot her autoimmune d isorders, e .g . hypoadrenalism, pern icious anaem ia

2 . S econda ry Hy perplasia d ue t o chronic renal f ail ure. osteomalacia or rickets

3 . Te rtia ry A com p licat ion of secondary hyper pa rathyroidism in which autonomous hy perparathyroid ism develops

THE ADRENAlS

CLINICA L FEATURES

CUSHING'S SYNDROME

('Bones, st ones, abdom ina l groans and psychic moans')

CAU SES OF CU SHI NG'S SYNDROME

1 . Due t o hyperc a lca emia Ii) Anorexia, nausea and vom it ing

Constipa tion (iii) Po lydipsia a nd polyuria (iv) letharg y and depression, p rog ressing to coma and (ii)

convu lsio ns

2 . Me tas t a tic calc ification ( i) Re na l ca lculi (i i) Ne phrocalci nosis

1. Iat rogenic (prednisolo ne o r ACTH) 2. A lcohol ism (pseudo-Cushing 's) 3. Cush ing's d isease (pit uitary-dependent adrenal hyperp lasia) 4. Adrenal carcinoma o r adenoma 5. Ect o p ic ACTH (e.g. smal l cel l b ro nc h ia l cancer)

CLINICAL FEATUR ES 1. Obesity of t run k and face w ith ' buffa lo hu mp'

2. Hype rtension 3. Skin changes: (i) Striae

(ii i) Co nj unct iva l deposits and keratopathy

3 . Bo ne resorption (i) Pai n a nd def ormity (ii) Patholog ical f ractures

4 . Ra r e ly Peptic ulcer, pancreatitis, pseudo-gout

HYPOPARATHYROIDISM CAUSES 1. Postoperativ e (e.g. t hyroidectomy) 2. Idiopath ic (possib ly autoimmu ne) 3. Neonatal (transient. b ut dangero us)

(ii ) Bru isi ng

4.

5. 6. 7.

8.

(ii i) Hirsut ism (iv) Pig ment ation Ost eoporosis Proximal myopathy Menstrual d ist urba nces Neurosis or psych osis Facial plet ho ra due to polycythaemia

LA BORATORY FEATU RES 1. Increased plasma 11-hydroxyco rticost eroids ('cortisol') Norm al v alues: 9 a.m . 12 midnight 190-690 nmol/l 80- 190 nmolll (7- 25 IJgl100 ml) (3-7 IJg/ 100 mil

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I Endocri no log y Loss of d iurna l rh yth m occu rs early in Cushing 's syndrome (i.e. midnig ht sam ples give increased v al ue) 2. Po lycythaemia w it h leukocyto sis and eosino phi l d ecrease 3. Hypoka laemia, w it h sod i um in u pper norm al ran ge

4. 'Dia be tic' glucose tole ra nce test 5. 24 hou r u rinary 'free l 1-hydroxyco rticost ero id s' inc reased Low dos age d exame thason e (0.5 m g q .d .s. fo r 2 d ays) ca uses little suppressio n i n Cush ing's synd rom e High dosa g e dex amethasone (2 m g q .d .s. fo r 2 days) causes suppression in ad renal hy perp lasi a, b ut has little o r no effect in adrenal adeno m a o r carcinoma, o r ect o p ic ACTH secret io n d ue to

extra-adrenal ca rcinoma

Endocr inology

CAUSES OF HYPOADRENALISM ACUTE 1. Stress occur ring in patients w ith chro n ic hy poadrenalism 2. Septicaemia, especial ly m ening ococcal (Waterhouse-Fried r ic hsen) 3. Surg ical ad renalecto m y 4. A b rupt w it hdrawal o f stero id t herapy 5. Pit uitary necrosis (e.g . Sheehan's)

CHRONIC Primary

HAZARDS OF SYSTEM IC GLUCOCORTICOID

THERAPY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11.

12.

13. 14. 15. 16. 17.

Growth reta rd at io n in ch ild ren Cushi ngoid f acies, buffalo hump A drenal su ppress ion and atroph y Weig ht g ain , sod iu m and w at er retention, potassi um depleti o n Hype rt ensio n Hy perg lycaemia Hyperli p id aemia Infection s, especially v iral, TB and funga l Osteoporosis, aseptic bo ne necro sis, rupt ured Ach il les t end o n Gastroi ntes tina l Dyspepsia PePt ic u lcer and perfo ratio n Pancreat it is CNS Eu phoria Psyc hosis Increased i ntracrania l p ressure Increased tendency to epi lepsy Skin chan ges T hinni ng, stri ae and easy bruisi ng Poo r wo und heal ing, en largement of venous leg u lce rs A cne Hy pert richosis Myo pathy o r musc le atrophy Cataract s, and ra ised intra-ocu lar pressu re A m e no rr hoea or p remat u re menopa use Terat ogen icity (fet al cleft palate) 'RebOu nd' o f disease o n reduct ion of dosage

1. A uto immu ne adre nal it is (Ad d iso n's) 2. TB 3. Metastat ic cance r depo sit s occu r comm o n ly, b ut rarely cau se hypoad renal ism Sec ondary (ACTH deficiency) 1. Pit uita ry or hypothalam ic d isease 2. Pro longed corticosteroid therapy

CLI NICAL FEATURES OF CHRON IC HYPOADRENA LISM 1. Pigmentat io n, especially in exposed sk in, mout h, areolae, pal m ar creases, pressure areas and scars (except i n hy po p ituitarism ) 2. Deb ility and tiredn ess 3. Nausea, vom it ing, weig ht loss, abd omi nal pain, d iarrhoea 4. Hypotensio n, wi t h low-vol ume pulse 5. HYPoglycaemia, especially reactive after a meal 6. l oss o f bod y ha ir in wom en 7. Dep reSSi o n 8. May be associated aut o immu ne diso rder, e.g. v itil igo

LABORATORY FEATU RES OF HYPOA DREN A LI SM 1. Plas ma 11-hyd roxy cort icost eroids m ay be no rma l o r low b ut f ai l t o respon d adeq uately to 250 ~ g Sy nact hen i.m . ( s ho~ l d rise by m ore t ha n 193 nmolll (7 ~ g/ 1 00 m l) at 30 m in utes ) 2. l ow plasma sod ium and ch loride, w it h raised potaSSiu m and u rea 3. Low v o ltage ECG w ith f lat T waves 4. Low blo od sug ar, especiall y aft er fast ing

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I Endoc rin o log y

Endocrin o logy

D IABETES MELLITUS

CAUSES OF DIABETES MELLITUS 1. Id iopath ic ( i ) Insuli n·dependent ('juvenile') (i i ) Non-i nsu li n-dependent ('m at u r ity onset')

2 . Dr ug-i nduced

Glucocort icoids. thiazides, diazoxide

3. Panc reatic disease Panc reatit is, cancer, haemochromatosis, g lucagonoma, cystic fi b rosis

4. Other metabolic di sease Acromega ly, phaeoc hromocytoma, Cush ing's, thyrotoxicosis

5. Genetic syndromes Glycogen st o rage d isease, Down's syndro me, etc.

DIFFERENCES BETWE EN THE 2 M AIN TYPES OF DIABETES MELLITUS 'Juvenile' 1, Thin 2. Young

3. Tendency to ketosis 4. Low insu lin sec retion 5. Sensit ive to insul in 6 . Requi re treatment w ith insu lin 7 . HLA-associat ed (DR3 and 4)

8. Sib lings rarely affect ed

'Maturity onset' Obese Midd le-ag ed o r e lderly Resist ant to ketosis No rmal or i ncreased in su lin secret ion Insul in resis tant Respond to d iet, and o r al hypoglyca emic d ru gs No association Siblings often affected

DIFFE RENCES BETWEEN 'D IABETIC' AND HYPOG LYCAEM IC COMA Ketoacidaemic coma 1. Preceded by inf ection or insulin underdosage 2. Onset over hours or days 3. Deep rapid b reathing 4. Dehydration 5. Sweating ab sent 6. CNS changes unusua l

7. U rine - usua lly g lycosu ria and ketonuria

Hypoglycaemic coma Preceded by exercise, missed meal or insuli n overdosage Onset in m inutes Stertorous breath ing Norma l hydrat ion Sweating m arke d CNS changes common, especially Babins ki response U rine not hel pfu l

(ii) Cat aract s (iii) Retinopathy (see p. 94 ) (iv) Ru beosis ir id is (new blood vessels over i ris)- may cause g laucoma 2 . Neurologica l (i) Peri pheral neuropathy (early sign is loss of ankle jerks and malleolar v ib ration sense) (i i) Mononeu rit is mult ip lex (neu ro pat hy of several peri phera l or cranial ne rves; ohen asymmet ric al) (i ii) Autonomic neuropat hy: a. Diarrhoea b . Postura l hypoten sion c. Im pot ence d. A bnorma l sweating e. Dependent oedema

3 . Renal (i) Pyel o neph ri t is, sometimes w ith papilla ry necros is (ii) Glomerulonephrit is a. Kimme lstiel- W ilso n (eos inoph ilic nod ules in glomeru lar t uft) b. Prolife rative, with sc lerosed basement membrane (iii) At heroscl erosis and hypertensive vasc ular changes 4 . Va s cular Occlusion by atheroma (large vessels) o r endart erit is (smal l v essels) may cause ischaem ia of feet, myocardium, b rain or kid neys

5 . Dermatological (i) Fat atrophy o r hy pertrophy at i nsu lin injecti on sites (ii) U lcers due to neuropathy or isch aem ia

(i ii) (iv) (v) (vi)

Infect ions, especially f uruncles and cand id osis Pigmented scars over shi ns ('d iabet ic dermopat hy') Xanthomata Necro biosis tipo id ica

6 . Systemic infections Incide nce of TB and deep mycoses is i ncreased

CAUSES OF SHORT STATURE 1. 'C ON STITUTIONA L' Rac ial, fam ilial or sporadic

CO MPLI CATIONS OF DIABET ES MELLITUS 1 . Ocu la r (i) Blurred v isio n d ue to f luctu at ions in blood sugar

2. N UTRITIONAL (i) St arv atio n

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Endocrino logy

(ij) Malabso rption (i ii) Prote in loss

3. CHROMOSOMAL DEFECTS (i) Tri som ies, e .g . Down's (i i ) Turner's

4. SKE LETAL DEFECTS ( i ) Ricke ts (i i ) Achondroplas ia

(ii i) Ga rgoylism (Hurle r's)

5. CHRO NI C SYSTEMIC DISEASE (i) Cyanotic congen it al heart d isease I ii ) Rena l fai lu re (ii i ) Hepatic fai lure (iv) Pu lmonary d isease (v) Anaem ia

(vi) Infecti ons, e.g. TB (v ii ) Long-term st eroid therapy (e .g. for asthma )

6. ENDO CRINE DISEASE (i) (i i) /iii ) (iv )

Sex ual precocity

Hypopituitarism Hypothyroidism

End oc rin o logy

CAUSES OF GALACTORRHOEA 1. 2. J. 4.

Physiological (post partum o r neonat al) Prolactin-secreting pitu it ary t umour Ect opic prolactin, e.g . bronchial Ca Drugs (i) Phenothiazines (ii) Ora l contracept ives (i ii) Methyldopa

SIDE· EFFECTS OF ORAL CONTRACEPTIVES

1. SYMPTOMS DUE TO OESTROGENS Fluid retention, we ight ga in Nausea and vo mit i ng Headache Ti redness and i rritabi lity Venous hypertens ion in Jegs Inc reased menstru al loss

2. SYMPTOMS DU E TO PR OG ESTOG EN S Depression Acne Decreased libido, dry vagina Muscle cramps Breast d iscomfo rt Reduced menstrual loss

Congenital ad renal hyper plasia

3. GYNAECOLOGICAL 7. M ISCE LLANEOU S RARE DISEASES Diseases of unknown cause, e.g . progeria

CAUSES OF GYNAECOMASTIA 1. Neonat al, o r norma l pu berty 2. Ci rrhosis 3. Ma ligna ncy

4. Testicul ar or ad rena l tumours 5. Drugs (i) (i i)

Oestrogens Cyproterone acetate

(iii) Spirono lactone (iv) Cimetidine (v) M eth y ld opa (vi) Digoxi n 6. Klinefelter's syndrome (XXY)

Amenorrhoea on contraceptive withdra w al Cervical erosion Vag inal candidiasis Increase in size o f f ibroids

4. EN DOCRINE AND METABOLIC Abnormal ca rb o hyd rat e tolerance Increased plasma t riglycerides and choles tero l Abnorm al liver fun ct ion tes ts Plasma prote in chan ges, e.g . increased t ransfe rrin Increased th yrox ine and p lasma cortiso l Ra rely : Hy pertension Ch loasma Ga lactorr hoea Ga llstones

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I E n do c r ino lo gy 5. TH ROMBOEMBO LIC EFFECTS Increased ri sk of thrombosis (e.g. coronary, cerebral) o r embolism (e.g . pul monary) due t o increased clotting factors

and platelet st ickiness

CONTRA-INDICATIONS TO OESTROGENIC ORAL CONTRACEPTIVES 1. 2. 3. 4. 5.

Preg nancy Hepatic d isease Breast or cerv ica l ca rcinoma Histo ry of t hrombosis o r embolism Ca re is req uired in pat ients w ith a h isto ry of epilepsy, arter ia l disease, hypertension, va ricose ve ins, oedema, diabet es mell itus, p rolactinoma, ga llst ones, m igra ine or f i bro ids. Women over age 35 are at increa sed risk of t h ro mboembo lic d isease (esp. smokers)

OSTEOPOROSIS A reduct ion in bone mass below the norma l expected f or t he age and sex of t he patient. Histo log ically t he trabecu lar bone is redu ced, and the m i nera l- matrix ratio is ap proximately n orma l

COMMON CAUSES 1. 2. 3. 4.

Old age Immobilizat ion Gl ucocorticoid therapy (or Cushing's d isease) Sex hormone def iciency, e.g. prematu re menopause, Turner's synd rome 5. Cigarette smoking 6 . Rheuma toid arth rit is causes loca lized osteoporosis

OSTEOMALACIA A reduct ion i n t he m ineral- m atrix rat io, although t he t otal bone mass may be no rm al, decreased o r even increased

CAUSES , . Deficiency o f cho leca lcife ro l (vitam in OJ

Endocri no logy

(i) Inadequate diet, possi bly agg ravate d by preg nancy or lack of UV radiation (i i ) M alabsorption (i ii) Phenyto in 2. Chronic renal failu re 3. Hepat ic disease (d ist urbed v itamin 0 metabolism)

Causes o f hype r cal cae mia 1. Hyper pa ra t hyroidism 2. Mal ignancy wi t h o r wi t ho ut metastases 3. Myelomatosis (ra re ly lymphoma or leu kaemia) 4. Vit o 0 sensit ivi ty, especially sarcoidosis 5. Vit o 0 excess 6. M ilk-al kali synd rom e

Cau ses o f h y p ocalcaemia ' . Hypopa rathyroid ism (i) PosHhyro idectomy (i i) Id iopath ic (someti mes w it h hypoadrena lism and can d id osis) 2. Def iciency of choleca lcifero l 3. M a labsorption 4. Chronic ren al fa ilure or Fanconi syndrome 5. Hypoa lbum inaem ia

PAGET'S DISEASE

CLI NICAL FEATUR ES 1. Oft en asymptomat ic . Incidence increases wi t h age 2. Bone deform ity Ii) Enlarged sku ll (i i) Sa bre t ibia (ii i) l ong bone fractures 3. Nerve ent rapm ent (i) Deaf ness (ii) Basilar invag ination (ii i) Ce rvical spondy losis 4. Hig h o ut put card iac failure 5. Increased inci dence of bo ne sa rcoma

I

10. Renal disease

CLASS ICAL PRESENTATIONS OF REN A L DISEASE 1. Haematuria alone 2. Prote inuria alone 3. Nephrotic syndrome (severe proteinuria, hypoa lbuminaemia, peripheral oedema and often hyper li p idaem ia) 4. Ne ph rit ic syndrome (haematuria, hypertension and periphera l oedema ) 5. Acute rena l fa ilu re (ol iguria w ith acute uraem ia) 6. Ch ronic rena l fa il u re (po lyuria wi t h ins idi ous uraemia)

Renal disease which affects the glomeruli is called g lomerulonep hrit is, and t his is classif ied by the patholo gy shown on rena l biopsy (p. 132) . M any diseases can cause more than one of the above presen tat ions. T hus membranous g lomeru lo nep hritis usua l ly causes the neph rotic syndrome, but it can occasionally present as acute or chronic rena l fa il u re.

RENAL FAILURE CA USES OF ACUTE RENAL FAI LURE (A I Pre r e nal 1. loss of blood, plasma or wat er and elect ro lytes 2. Hypotensio n with normal b lood volume, e.g . myoca rdial i nfarct or septicaemic shock I BI Re nal 1. Acu te-on-ch ronic fa ilure, precipit ated by renal infect ion o r dehyd ration 2. Ac ute 'tubu lar necrosis' (or rarely cortica l necrosis) (i) Sustai ned hypotension (ii) Obstet ri c causes, e.g. abortion o r antepartum haemorrhage (ii i) Septi caemia (especia ll y Gram-negative) (iv) Free circu lating ha emog lob in (v) Ext ensive tissue damage (vi) Drugs and t oxi ns, e.g . heavy met als, carbon t et rach loride, NSAID 3. Pr imary renal d isease (i) Acute g lomeru lonephrit is

_

I Re na l dillle.a (i i ) Fu lm i nating py eloneph ritis (i ii) Acute 'collagen- vascular d isease'

4. Hep ata-rena ' syndro m es (includ ing We il's d isease) 5. Vascular 0) Arteria l - thro mbosis, em bo lism , trauma (ii) Venous - throm bosis

leI Pos tre na l Obstruction in urinary tract (p. 137)

Ren al disease

3. CARDIOVASCULAR (i) Pericarditis (may be t ampo nade) (ij) Ca rd iac f ailu re d ue to salt and wat er overlo ad (iii ) Hypertension wi t h retino pathy

(iv) Arrhythmia (d ue to hyperkalaem ia)

4. GAST RO INTESTINAL (i) Dry m outh, f oetor, m ay be paro t itis Iii) Anorexia, nausea and vom iti ng

CAUSE S OF CHR ON IC RENAL FAI LURE 1. 2. 3. 4.

Glo m erulo nep h rit is Pyeloneph ritis or T B Hypert ension Co ll agen- vascu lar disease, especially SLE and PA N

5. Meta bol ic ( i ) Diabetes me ll itus

(i i) Gout (iii) Chronic ana lgesic ingest ion

(ii i) Hiccups (iv) GI t ract ulcerat ion a nd b leed ing

5. GEN ITOURI NARY (i) In acu t e rena l f ailu re - ol igu ri a « 300 m ll24 h ) (ii) In ch ron ic ren al f ailu re - po ly u ria w it h fix ed u ri nary s pecif ic g rav it y (1.0 10)

(iv ) Amy lo idosis (v) Hyperca lcaem ia 6. O bstruct io n in rs nal l ra c! 7 . Myeloma 8. Sch istosom iasis (rare in UK)

6. RES PIRATORY

9 . Congen ital iii Po lycystic kid ney (ii) Tubular acidosi s

7. HAEM ATOLOG ICAL

( i ii) Fanconi syndrom e

CLINICAL FEATURES OF SEVERE CHRONIC RENAL FAILURE 1. DERMATOLOG ICAL (i) Pru ri tus

(iiI (ii i ) (iv) (v) (v i)

Pal lor Pigme nt at ion Pet echiae W hite na ils Ra rely ' urea f rost'

2. NE UR OLOG ICAL (i) I ii) (i ii) (iv) (v)

M ent al ch anges (co nf usio n, parano ia, et c.) A pat hy a nd wea kn ess Muscle tw itc hi ng and seizu res Coma in t erm inal cases Perip heral neu ropath y in chron ic und ialysed cases

(j) Hypervent ilat io n du e to ac idosis (ii) Pleu ral effusio n

(i) Anaem ia due to: GI b leed i ng Haemo lysis Diet ary rest r ictions Eryth ropoiet i n d eficiency (ii ) Bleed ing t endency due to platelet dysfu nct io n (iii) Suscept ib ility to secondary inf ectio n

8. DEFECTS IN BON E AND CALCIU M M ETABO LI SM (i) Osteo ma lac ia ('rena l rickets' in ch ild ren) (ii ) Second ary o r tertiary hy per pa rathy roid ism (ost eit is

f ib ro sa cyst ica ) (i ii) Pat chy ost eosclero sis (iv) Occasionally osteo po ros is (v) Occas ionally met ast at ic calcif icat ion of m uscles, blood v esse ls and con j unct iv ae

FACTORS W HICH M AY PREC IPITATE 'U RAEM IA' 1. Flu id and elect rolyte imba lance 2. Infect io n, sy st emic o r urinary

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Re n a l d isease

Ren a l disea s e

3. Increased protein ingestion 4. Obst ruction o f re nal t ra ct

5. Catabolic o r nephrotoxic drugs (e.g. tetracycline) 6 . Congest ive card iac fa il ure 7. Gastrointestina l haemor rhage o r su rgery

5 . M e sangioca pilla ry (type s I a nd II) C3 usually low Type II is associated wit h partial lipoat rophy and wit h C3 nephr itic factor

6 . Foca l Associat ed w ith WEgener's g ran ulomatosis, SlE, Endoca rd it is, Polyarter iti s nodosa, HEnoch- Schonlei n p urp ura Mnemonic: WE SLEEP HEre

GLOMERULONEPHRITIS T h is may be: Focal - some g lomeruli are affected o r Diffuse - all g lomeru li are affect ed

Segmental - part of a glomeru lus is affected or Global -

all of a g lomeru lus is affect ed

Th us, in fo cal segmenta l g lomeru lone ph r it is, parts o f some

glomeru li are affected

CLASS IFICATION OF GLOMERULONEPHRITIS 1 . M i nima l cha nge No change on l ight m icroscopy b ut EM show s loss of

7 . Ra pidly progressive (crescentic) Assoc iated wi t h W egener's gra nulomatosis, Henoch- Schon lein purpu ra, A ntig lomeru lar basement membrane (Goodpastu re's), M icroscopic polyangi it is, Imm une com plex disease Mnemonic: WHAM I

8 . Focal segme ntal glome rulo s c lero s is Somet i mes id io pathic, particu la rly in chi ldren, but in adu lts usually secon dary to other form s o f g lomeru lo nephrit is o r other rena l d isease such as pyelonephrit is o r seve re hypertension

pod ocytes Typica lly affects ch ildren b ut may be due to NSAIDs i n adults Produces acute nephrotic syndrome, but good prognosis

2 . IgA disease (Berger's disease) Si m ilar to Henoch- Scho n lein pu rpura,. w it h w hich it may overlap Typical ly causes haemat uria in young men 20% develop renal fa i lure over 15 years

3 . Pro l iferative Trad it ionally fo l lows Group A streptococcal infect io n, but now not usually associated in UK. Low C3 duri ng t he acut e attack. Good prognos is 4 . Me m bra nous Due to M ala ria M aligna ncy (e.g. b ronchia l ca nce r) Hepat it is B Rheumato id A rthritis (and penic illami ne o r gold the rapy fo r RAJ

S LE Mnemonic: MeMBRAnouS Prognos is: 1/3 i m prove, 1/3 st ay the same, 1/3 progress Commonest form of de novo glomeru lonephrit is in rena l al lografts

CAUSES OF NEPHROTIC SYNDROME 1. Glomeru lonephrit is accounts fo r 80% (usually membranous in ad ults, m inimal chan g e in ch ildren ) 2. Metabolic (i) Diabetes mell it us (ii) A m yloidosis (i iil Myelomat osis 3. SLE 4. Drugs - mercurials, pen ici llam i ne, trox idone 5. Renal vei n th rombosis

CAUSES OF LARGE KIDNEY lOR KIDNEYS) 1. 2. 3. 4. 5.

Cystic kidneys Hyd roneph ros is o r pyonephrosis Hypernephroma Hypert rophy followi ng contralat eral neph rect omy or fai l ure Neph roti c syndrom e A lso consider t he poss ibi lity of per irena l haematoma

TYPES OF RENAL TUBULAR DYSFUNCTION

1. RENAL DISEASE AFF ECTING MEDU LLA e.g . pyeloneph ritis. Impai rm ent of urinary co ncen t ration, ac idifi cation and e lectro lyte reabsorpt ion

I

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I Re n al d ise ase

Re n al disease

3. M ETABO LI C AC IDOSIS (low pH, low CO 2 con ten t)

2. RENAL GLYCOS URIA (ben ign)

Causes

3. 'VITAM IN D RESISTANT RICKETS'

til Ingestion of acidic compounds

Inabi lity to reabsor b phosphate

Amm o n ium chlor ide, salicylates, etc.

(iii Met abolic overproduction of a cids Ketosis, e.g. starvation, d iabetes mel litus l actic acidosis

4. IDIOPATHIC HYPE RCALCIU RIA Inabi lity to reabsorb calcium

5. RENAL T UBULAR AC IDOSIS (Type I -

(iii)

distal tubules)

Inabil ity t o acidify the uri ne causes meta bo lic acidos is. Less ca lci um is bou nd to protein and ca lcium filtratio n is increased, leading t o neph roca lcinosis and rena l stones

6. RENAL TU BU LA R AC IDOS IS (Type 2 tu bules)

prox ima l

Occu rs as part of Fanconi synd rome, wi th defective reabsorption of g lucose, am i no adds and phosphate (GAP) Hyperchloraem ic acidosis occu rs, but no nephrocalcinosis May also be due to t oxins (lead, mercu ry, out dated tetracyc line), kidney transp lant or cyst inosis

Intestinal loss of base Diarrhoea Fistu lae

(iv) Renal failu re: renal tubula r a c idos is 4. M ETABOLIC A LKALOSIS (h ig h pH, h igh CO 2 co nte n t )

Causes Ingestio n of alkali, e.g . NaHC0 3 • fo r indigestion Vomi t ing, or gastric aspirat ion Hypoka laem ia

CAUSES OF HYPOKALAEM IA 1 . Increased renal loss (i) Diuresis Drugs, e.g. thiazides Diabetes mellitus (i i) Minerolocorticoid excess, e.g. p r imary ald osteronism (Conn's t umour) and Cushi ng's d isease (ii i) Primary re nal d isease, e.g. chronic pyeloneph ritis

7. CYSTI N URIA Defect in reab sorption of cystine, ornithine, arg inine and lysine (COAL) Cystine stones fo r m

8. NEPH ROGEN IC DIABETES INSIPIDUS Impai red respon se t o ADH

ACID-BASE BALANCE

2 . Increased intestinal loss e.g. dia rrhoea, vom iting Consider pu rgative abuse

3. Decreased intake Dieta ry lack (especially in alcoholism, or d uri ng prot ei n ana bol ism in convalescence, o r f o ll owing p rolo nged i.v. fluids ) Ma labsorption

These headi ngs re fl ect changes in ext racell ular fluid on ly, e.g. in metabolic alka los is there is an assoc iat ed intracellu lar acidosis 1. RESPIRAT O RY ACI D OSIS (lo w p H, h igh CO 2 conte nt ) Any ca use of hypoventi lation (p. 43) 2. RESPIRATORY A L KALOS IS (hi g h pH , low CO 2 con t ent) Any cause o f hyperventi lat ion (e.g. asp irin overdose o r anxiety)

CLIN ICA L FEAT URES OF POTASS IUM DE PLETION 1. 2. 3. 4. 5.

Muscle wea kness Apathy, anorexia and confusion Ileus Inc reased cardiac excit abi lity and d igit alis toxicity Th i rst and polyuria

Re n a l disease

CAUSES OF HYPONATRAEM IA 1 . Excessiv e w at e r i nta ke Oral (po lyd ipsia) or intravenous

2 . Exce ss iv e w at e r r et ention

Re na l d isease

3. 4. 5. 6. 7.

Anticoagulant overd ose, bleeding diathesis Hypern ephroma Rena l infarct (incl uding polya rt eritis nodosa ) Po lycystic kidney Bacterial endocarditis

Inappropriate ADH secretion

3 . Inadequa t e sodium inta k e (rare)

(8) RENAL TRACT LES IONS

4 . I n adequ at e sodium re tention Ii) Vomiting, diarrhoea, ileus, fistu la, drainage of ascites Iii) Hypoad renalism (ii i) Rena l loss (iv) Skin loss a. Excessive sweating b. Cystic fi bros is c. Burns

1. Papillary tumour o f bladder 2. Acute cystitis (including cyclophosphamide toxicity) 3. Calcu li 4. Prost atic lesions: Hype rtro phy Cancer Prostatitis 5. Ureth ra l inflammation or trauma 6. T8 (now rare in UK) 7. Sch ist osomias is (rare i n UK)

CAUSES OF POLYURIA 1. 2. 3. 4. 5.

Chronic renal fa il ure Diabetes m ellitus Diuretic d rugs Compulsive wa ter drin king Diabetes insip id us Ii) Pitui tary (deficiency of ADH) (ii) Nephrogen ic (no re sponse to ADH ) 6. Potassium depletion 7. Hypercalcaemia

CAUSES OF PROTEINURIA 1. Conlamination (semen, prost atic or vaginal secretio n ) 2. Postural (orthosta tic) 3. Renal disease (i) Glomerulonep h ritis, especially neph rotic synd rome (ii) Pyelonephritis (ii i) Obst ruct ive ne phropathy (iv) M alignant hypertension (v) Tubercu losis 4. Disease of renal tract, e. g. cystitis 5. May be slight a lb umin u ria in fever or congestive heart fai l ure 6. Mu ltip le m yeloma (Bence Jones protei n)

CAUSES OF HAEMATURIA (A) KIDNEY LES IO NS 1. Glomeru loneph ri tis, pyelonephritis, TB 2. Trauma

CAUSES OF 'STERILE ' PYURIA 1. 2. 3. 4. 5.

Rena l TB Analgesic neph ropathy Rena l calculi U rinary infection treated w ith chemotherapy Non-specific urethritis

CAUSES OF ' DARK COLOURED' URINE 1. 2. 3. 4. 5. 6. 7. 8.

Concentration Bile Blood, haemoglob in u ria and myoglobinuria Methaemog lobinuri a Porphyria A lkapto nuria Melaninuria Beetroot, dyes in sweets, drugs (e.g. rifampicin), etc.

CAUSES OF URINARY TRACT OBSTRUCTION 1. 2. 3. 4. 5. 6. 7. 8.

Sto ne Strict ure (post-o p or i nfl ammatory) Ste nos is (congenita l) Neoplasm Clot Neuromuscular i ncoordinat ion Retroperitoneal fi b rosis Spread of cancer from pelvic o rg ans

occur t hroughout ) the u rinary tract

} u reter

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Rena l d i sease

Re n al disease

9. 10. 11. 12. 13.

Prost atic en largement or cancer Retroverted g ravid uterus Trau ma of labour Congen ital valves Phimosis o r paraphimosis

CYSTINE STONES } b ladder neck } u rethra

Common ca uses of acute reten tion in adults are:

Males 1. Post-operative retention 2. Prostatic lesio ns 3. Ureth ral str icture

Cysti nu ria Fancon i syndrome with cystinosis

Females 1. Trauma of labo ur 2. Pressu re fro m uterus (fetus o r fibroid l 3. Hysteria

Remember that retent ion m ay also be due to antichol inergic drugs Of a neuro log ica l lesion suc h as multi ple scle ro sis o r co rd co mpress ion

XANTHI NE STON ES Xanth in uri a

RENAL STONES Ra dio-op aque Calcium (80%) Mg a mmonium phosphate ( 10%) Cyst ine (2%)

N o n -o paq ue U ric acid (5%) Xa nth ine (1 %)

NEUROLOGICAL CONTROL OF BLADDER FUNCTION URINARY CALCULI FACTORS WH ICH PRED ISPOSE TO UR INARY CA LCU LI 1. 2. 3. 4. 5.

Metabol ic abnor ma lit ies (q.v.) Urinary tract infections, e.g . Proteus Urinary t ra ct stasis Fo reign bodies in u rinary t ract Geograph ica l fac t ors (e.g. hot, dry climat e, hard wa t er)

No rma l bladder capacity is 300-400 m l a nd larger vo lumes shou ld st im u late the des ire t o m ictu rate. A fferent fibres trave l via parasympathetic nerves t o sp ina l 'mict urition centre' (S 2, 3, 4) and b ladder contrac tion is in itiated by parasym pathetic efferents. The spina l 'm ict urition ce ntre' is no rm ally in hibited by higher motor centres, wh ich bomba rd it wi th faci lit atory impulses w hen m ictu r ition begins, so that the bladder empties completely

TYPES OF DYSFUNCTION M ETABOLIC CAUSES OF URINARY CALCULI CALCIUM STONES (composed of calciu m oxa late, phosphate o r bot h) 1. Hypercalciu r ia (on normal d iet, > 300 mg/2 4 h in m ale o r > 250 mg/24 h i n female) ( i) Id iopathic hypercalciuria ( ii) Hyperparathyroid ism (iii) Vita m in 0 excess (iv) Sarcoidosis (vi M ilk- alkali syndrome (vi) Rena l tubu lar acidosis (vii ) Ma lignancy (vi i i) Immob i lization (ix) Cush ing's syndrome 2. A lkaline u ri ne 3. Oxa luria

1. LACK OF NORMAL INHIBITION Frequency wi th sm all vol umes Occurs in anxiety, cold weather, etc.

2. ATON IC BLADDER Distended bladder w ith overflow, but no desire to m ictu rate Occu rs w ith sensory neu ro pathy, e.g. diabetes mell itus, tabes dorsal is

3. AUTOMATIC BLADDER Bladder empties p artially when vo lume of about 250 ml is reached, but w ithout d esi re to m icturate Occu rs with co rd section above S 2, 3, 4

4. AUTONOMO US BLADDER URIC ACID STON ES Primary o r seconda ry gout Uricosuric d ru gs

Large resid ua l ur ine vol ume, w ith wea k uncoord inated b ladde r contractions but no desire t o mict urate. Occ urs wi th LMN cord lesions at S 2, 3, 4 leve l

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I

Rena l disease

Unilat era l neu ro log ical lesicns may cause either frequ ency wi th smal l v o l umes o r a large hyp ot o nic b ladder w ith residual u rine after m ictu rit ion

11. Rheumatology

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RENAL CLEA RAN CE T he num ber o f m l of p lasma w h ich con tains t he am ount of a substance excreted in t he u rine i n one min ute is t he rena l clearance of that substance, i.e. C ", UV/pT m l w here U ", concent ration of subst ance in urine V = volume o f urine collected i n time T P = concentration of su bstance in plasma

Creatinine clearance gives a more accu rat e measu re o f renal function than th e plasma urea

PATTERNS OF POLYARTH ROPATHY PRIMARY OSTEOARTHROSIS Symmet rical, affecting many jo ints 1. Knees 2. Great t oes and th u mbs: MP joi nts 3. Fi ngers: t erm inal IP jo ints 4. Acrom ioclavicu lar joi nt s 5. Smal l joints of sp ine

SECONDARY OSTEOARTHROSIS Asymmet rica l, affecting weig ht-bea ring joi nt s 1. Knees 2. Hi p 3. Intervertebra l discs

RHEUMATOI D A RT HRITIS Usual ly symmetr ical, intermin ent and inflam ed 1. Hands: intercarpal jo i nts, M P joi nts and proxi m al IP joi nts 2. Feet: tarsal and lateral MP jo ints 3. Knees 4. Sma ll jo ints o f cervical spine and sub acro m ial bursae

ANKYLOS ING SPONDYLITI S 1. Spi ne and bot h sacro i liac joi nts 2. Knees, s hou lders, w rists

PSORIAS IS 1. 2. 3. 4. 5.

Hand s, te rm i na l IP j o ints (look fo r nai l pits) Sacroiliac jo i nt s 'R he umatoid' pattern Asymm etri ca l ol igoarthritis (e.g. knee) Arth rit is mut ilans

REITER'S DISEASE 1. Ankles and all joint s o f feet

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Rh eum atol ogy

Rheu mat olo 9V

2. Knees 3. Hi ps, sacroi liac jo ints and spine

6 . PERIP H ERA L N EU ROPAT HY (due t o vascu l iti s)

X-RAY CHANG ES OF OSTEOARTHROSIS

7. ENTRAPMENT N EUROPAT H Y, e.g . spi nal cor d at cervi cal level f rom atla nto-a xial subluxatio n, o r ca rpa l t u nnel syndrome

1, 2. 3. 4.

8. FELTY'S SYNDROME ( RA w ith leu ko p en ia and sp le n omega ly)

Joint space narrowi ng Subarticu la r sclerosis Osteo phytes Bone cyst s

JOINT COMPLICATIONS OF RHEUMATOIO ARTHRITIS ,. 2. 3. 4. 5. 6.

Deformity, su b luxation, m isa l ignment. swell ing Infection (sept ic a rth ritis) Tendon rupture Synovial sac p rot r usion and ru ptu re (e.g. Baker's cys t ) J uxta-articu lar osteoporosis Muscle atro phy secon dary t o d isuse

EXTRA-ARTICULAR MANIFESTATIONS OF RHEUMATOID DISEASE 1. ANAEM IA . (i) Fe defic iency (G I blood loss ca used by d rugs) I ii) Defect ive i ron ut i lization (a naem ia of ch ron ic d isorders) ( i i i) Marrow de press ion

2. PU LMONARY (i) Pleu ritis, effusions (ii) Nodu les in lung or p leu ra ( i i i) Fibrosi ng a lveol iti s

3. CARDIAC Ii) Pe ri ca rd it is ( ii ) Nodu les i n myoca rd i um

4. OC ULAR ( i) Scler it is, ep iscie ritis (i1) Scleroma lac ia perf orans

(iii) Sicca syndrome (Sjog ren's) 5. ARTE RI TIS 0 ) Digit a l isch aem ia (m ay be Rayn aud's ) (i i) Na il f o ld lesions (ii i) Leg u lcers (iv ) Mese nt e ric ischaem ia

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9. LYMPHADENOPATHY 10. A MYLOIDOS IS

SERONEGATIVE SPONDYLOARTHRITIS (HLA-B27 ASSOCIATION) A rth ritis invo lv i ng t he spine but wit h consistent absence of rheumato id f act o rs fr om serum 1. An ky losing s pondyl it is 2. Psoriatic arthrit is 3 . Ent eropat hic arthrit is (Crohn's, u lcerat ive colitis, Wh ipp le's, enteric inf ectio n, i ntest ina l bypass for o besity ) 4. Re ite r's d isease

FEATURES OF ANKY LOS ING SPONDYLITIS 1. Ankylosis/ arthr it is of sp ine (bam boo sp ine)

2. An t erior uveit is

3. A rrhythm ia 4. Aortic regurgitat ion 5. A pical p u lmona ry fibros is ( N.B. 5 A s)

CAUSES OF LUMBAR BACKACHE 1. MECHANI CA L (i) Muscu lotendino us and l igament strain (ii ) Prolapsed i nterve rteb ral d isc (i ii ) Sp ondylos is and spondylo l ist hesis (iv) Spinal f ractu re a. Ma jor trauma b. Cr ush fract ure in ost eopo rosis c. Stress fr actu re of t ransverse process due to muscu lar effort

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I Rh e u ma tology

Rhe umato lo gy

2. DE GENERATIVE OR M ETA BOLIC (i) Osteoa rt hrosis (ii ) Osteo porosis (ii i )

Osteoma la cia

(iv) Infectio us m o no nucleosis (v) Infect ive hepat it is (vi ) Mycoplasma pneum onia 6. Reit er's di sease 7. Occasionally, acu t e rh eumatoid arth rit is

3. INFLA MMATORY (i) Infe ction, e.g. T8, pyog e nic (i i) Seronegative spond y loarthriti s (q.v.)

CAUSES OF HVPERURICAEMIA 1. INCREA SED PUR INE SYNTHE SIS Pr imary gout (in 25% of cases)

4. NEOPLASM ( i) Usually metast atic mal ig nancy (i i) Primary ma lignancy - Oste os a rcoma

Myeloma Lymphoma

5. RE FERRED PA IN (i ) Posterior d uodena l ulcer

(iiI Cance r of pa ncreas (iii) Re na l colic (iv) Pelvic carcin o ma (v) Dysm enorrhoea. labo u r pai ns

CAUSES OF A SINGLE HOT RED JOINT 1. Traumat ic, e.g . sp rai ned ankle 2. Septic arthrit is May be seco ndary to penetrati ng in j ury, o steomy elitis, septicaemia, rheu matoid arthritis o r osteoarth ros is 3. Gout o r pseudo-gout (ch ondrocalci nosis o r periarticu lar ca lcif icat ion)

4. Haemoph ilia 5. Gonococcal arthritis

2. DECREA SED RE NAL EXCRETION (i) Primary g out (i n 75% of cases) (ii ) Ch ron ic ren al fai lu re (ii i) Drug s Sa licy lates (in low dosage) U ricosu rics (in low d osage) T hiazide d iuretics A lcohol

3. INCREA SED TUR NOVER OF PREFORMED PUR INES (i) M y elopro life rat ive disease and ly mpho m a (esp. afte r cytot o xic d rug s) (ii) Chro nic haem o lysis (ii i) Psoriasis

CLASSIFICATION OF VASCULITIS No cla ssificat ion is co mp letely satisfa ctory. since the c lin ic al sy ndromes m ay overl ap, and t hei r pat hogenesis is imperfect ly ,.nd erstood

6. Occasionally rheumatoid arthrit is

1. SYSTEMI C NECROTIZING VASCU LITI S

CAUSES OF A TRANSIENT ' FLITTING' ARTHRITIS , . Rheum atic feve r

2. Henoc h- Schon le in purpura 3. Serum sickn ess and drug re act io ns 4. SLE

5. Syste mic infecti ons (i) Go n ococca l o r m e ningococcal sept icaemia

(ii) Bact erial endoca rditis (iii) Ru bella

(i) Po lya rt erit is no dosa (ii ) Ch urg- St rauss synd ro me (wi th ast h ma and eosi no p hi l ia)

(ii i) W egener's g ranulom atosis (uppe r and lowe r res pi ratory t racts and kidneys) (iv) Behjunctiv itis, 158 COflso lidation rad iograph, 55 s ig ns, 54

Cor pu lmona le, 28, 40 Cord comp ressio n. 108 Cortica l loca li.at ion, 99 Cra n ia l n e , ves, 91 Cro hn's disease, 70 Cush ing 's syndrom e, 119 Cyanosis, 13

Dark u r in e, 137 Dead space, 42 Dea fness. 97 Dement ia. 104 Derm ato mes, 109 Dexamet hasone sup p ression, 120 Diabetes mell itus, 122 Diabet ic com a. 122 Diabetic retinopat hy, 94 Diffu se a irways obstruction, 45 Diff usio n defects. 42 Digita lis, 39 Dissem in ated coag u lat io n , 85 Dissem in ated sclerosis, 98 Diverticulitis, 68 Drug eru pt ion s, 157 Duodena l ul cer, 65 Dysarthria, 100 Dy sph ag ia, 63 Dysph asia, 100 Dysph onia, 100 Dyspn oea, 44 Ectop ic ven tricul ar bea ts, 17 Eczema, 149 Effu siorl pe r icard ia l, 62

p le ura l, 54, 57 Electr ocard iog r am IECG ) arrh yth mias, 35 COr pulmonale, 40 d igita lis e ffects, 39 heart b lock, 36 h yperkalaemi a, 39 h ypokalae m ia, 39 mi tra l ste n os is, 23 myocard ia l ischa emia, 38 , 39 n or m al,33 p e ricardit is, 40 p ulm on ary embo lism , 40 r eading, 40 ve rltricu lar hyp ertrop hy, 37, 38 Em p h ysema dcfin ition,44 rad iograph, 58 signs, 54 Em pyema, 48 Eos inop hi lia, 80 Epilepsy, 103, 104 Erythem a, 153 Erythema mu ltiforme, 154 Erythema nodosum, 154 Erythoder ma , 154 Essay question s, 2 Examinat ion, 6, 20 Epirator y f low rate, 42 E>