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March 28th, 2023
 
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Overview

Left bundle branch block occurs due to failure of conduction down the left bundle branch, resulting in depolarisation of the left ventricle after the right ventricle.
Sinus arrest is the temporary interruption of sinoatrial node automaticity, that may occur due to intrinsic or extrinsic factors affecting the sinoatrial node.
Alpha thalassaemia is an inherited condition affecting the alpha chains of haemoglobin, resulting in defective haemoglobin synthesis.
  • Classification

    Hypertension is defined as persistently elevated blood pressure, based on at least two readings over at least two visits.
  • Normal <120 / 80
  • Pre-hypertension 120 / 80 - 139 / 89
  • Stage I hypertension 140 / 90 - 159 / 99
  • Stage II hypertension >160 / 100
Heart failure can be functionally debilitating, though proper management can have a significant positive effect on a patient's mortality risk and quality of life.
Atrial fibrillation is an often insidious condition involving irregular contraction of the ventricles due to fibrillation of the atria. If not properly managed this condition can result in significant complications including cardioembolic stroke.
Hypercalcaemia, or an increased serum calcium concentration >2.60 mmol/L, shortens action potentials which primarily results in early ventricular repolarisation (shortened QT) on ECG.

Pathogenesis

  • Causes of Tricuspid Regurgitation

  • Rheumatic heart disease
  • Infective endocarditis (particularly associated with IV drug use)
  • Ebstein's anomaly
  • Carcinoid syndrome
  • Trauma
  • Causes of Mitral Regurgitation

  • Acute

  • Acute myocardial infarction
  • Infective endocarditis
  • Trauma
  • Chronic

  • Mitral annular calcification
  • Mitral valve prolapse
  • Rheumatic heart disease
  • Papillary muscle dysfunction
  • Connective tissue disease - systemic lupus erythematosus, rheumatoid arthritis

Overview

Left heart failure typically manifests with interstitial and pulmonary oedema, and is most commonly caused by pathology affecting the left ventricular myocardium.
Patients with renal or urological disease may present with a wide variety of symptoms, from alterations in their urine to severe pain or systemic symptoms. Patients with chronic kidney disease pose a wide variety of diagnostic and management issues, which may be further complicated by a history of dialysis or renal transplantation.
Careful history-taking can be used to identify and localise a patient's neurological pathology. By understanding the circumstances and natural history of a neurologic event, it is possible to narrow down the list of likely causes for a patient's presentation.
Haematologic conditions such as leukaemia, lymphoma and the anaemias can be difficult to diagnose. The history is an important first step in this diagnosis, and provides information about the patient's baseline level of function prior to presentation.
A thorough history is valuable in the diagnosis of symptoms such as cough, dyspnoea and chest pain, and can be used to understand a patient's baseline respiratory function.
A thorough history is vital for the diagnosis of patients with issues such as chest pain, heart failure symptoms, palpitations or syncope. The cardiovascular history may also provide important insight into patients' cardiac status, and their risk of future cardiovascular disease in the future.
Gastrointestinal disease can present with a wide variety of symptoms affecting oral intake, the abdomen, bowel motions and the patient's constitution. By taking a thorough history it is possible to narrow down the differential diagnosis and guide clinical examination.
The cranial nerve examination is a complex mix of examination techniques designed to localise pathology to one or more of the twelve cranial nerves. 
Examination of the cardiovascular system is easy to learn but difficult to master. Careful inspection and palpation for peripheral findings, coupled with attentive auscultation of the praecordium, may allow for clinical diagnosis of a patient's cardiac pathology prior to any further investigations.
The urine dipstick is used to assess for a wide variety of renal, urinary tract and systemic pathologies. Using a paper strip containing several reagent-containing squares corresponding to blood, glucose, protein and other analytes, it is possible to gain a significant amount of insight into the cause of a patient's presentation.
The full blood count provides information about a patient's red cells, white cells and platelets. This may be used for several purposing including diagnosing anaemia, monitoring infection or uncovering haematologic disorders.
The arterial blood gas is useful for assessing a patient's oxygenation, and identify acid-base disorders. This section outlines an approach to interpreting ABGs.
X-rays are commonly used in clinical practice to diagnose fractures. Characteristics of the fracture such as the type, deformity and soft tissue / joint involvement are used to guide management.
Haemolysis is the destruction of red blood cells prior to the end of their normal 120-day lifespan, and should be considered in anaemic patients with risk factors or no obvious cause of anaemia. Serum markers may be used to diagnose haemolysis and suggest a cause.
Iron is an important mineral that is involved in red blood cell metabolism and oxygen transport. Iron studies are used to identify iron deficiency or overload states, and are a common test performed as part of the anaemia screen.
The acute phase response is a facet of the innate immune system that occurs in response to infection, trauma or other insults. Certain mediators, known as acute phase reactants, are increased or decreased in the context of acute inflammation. These markers are commonly measured in clinical practice as indicators of acute illness.
Examining urine under the microscopy reveals the presence of cells, crystals, casts and other findings that can suggest the cause of a patient's renal or urinary complaint.
Venipuncture, or phlebotomy, is the process of collecting blood for testing. This section outlines the process for taking blood, with pitfalls and clinical pearls.
Supplemental oxygen is a drug and should be used rationally for specific indications, at the lowest concentration and for the shortest time possible.
The arterial blood gas is useful in acutely unwell patients for assessing acid-base balance and oxygen status. This section outlines the approach for collecting an ABG.
Urinary catheters are used for a wide variety of indications including to relieve urinary retention, measure urine output and collect urine samples.
Intravenous cannulas are inserted every day into hospitalised patients in order to provide IV fluids and medications. IVCs should be inserted using a no-touch technique and assessed regularly in order to avoid complications.
Several manoeuvres and devices can be used to restore patency in patients with a threatened airway. This page outlines the basic interventions that can be provided in these patients.
  •  
    Oral
    Artemether + Lumefantrine
    Riamet 
     
    Uncomplicated malarial infection
  •  
    Oral
    Atovaquone + Proguanil
    Malarone 
  •  
    Oral
    Chloroquine

  •  
    Oral / IV / IM
    Quinine
    Quinate 
  •  
    Oral / IV / PR
    Metronidazole
    Flagyl 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV
    Actinomycin D / Dactinomycin

  •  
    Oral / IV
    Cyclophosphamide
    Cyclonex, Endoxan 
  •  
    IV
    Cladribine
    Leustatin 
  •  
    IV
    Mitoxantrone

  •  
    IV
    Cytarabine / Cytosine Arabinoside

  •  
    IV
    5-Fluorouracil (5-FU)

  •  
    Oral
    Procarbazine

  •  
    IV
    Carboplatin
    Paraplatin 
  •  
    IV
    Vincristine
    Oncovin 
  •  
    IV
    Irinotecan
    Camptosar 
  •  
    IV
    Dacarbazine

  •  
    IV
    Docetaxel
    Inhibits the cell cycle primarily in S phase
  •  
    IV
    Doxorubicin
    Adriamycin 
  •  
    IV
    Etoposide

  • Equipment Required for Intercostal Catheter Insertion

The Safe Triangle

  • How to Perform

    Using the pen, mark the area bound by the:
  • Superiorly - base of the axilla
  • Anteriorly - lateral edge of pectoralis major
  • Inferiorly - 5th intercostal space
  • Posteriorly - lateral edge of latissimus dorsi

Blockage

  • Clinical Features

  • Catheter is not draining
  • Fluid in the drainage system is not swinging with respiration
  • Pain

Overview

  • Timing

  • Glucose / glucose tolerance testing - fast for 8-10 hours
  • Triglycerides (fasting lipids) - fast for 10-12 hours
  • Equipment Required for Phlebotomy

Troubleshooting

No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally

Positioning

Changing from a supine to an upright position can increase haematocrit, red blood cells, white cell count, calcium, thyroxine, AST, ALP, immunoglobulins, total protein, albumin, lipids, adrenaline, noradrenaline and renin levels.

Overview

Find out when the patient took the last dose of the drug in question, and determine the best time to take the blood level.
  • Significance

  • Taking blood from the same limb that a heparin infusion is running into will falsely elevate the APTT.
Apply the tourniquet and feel for a straight, firm, round, elastic, non-pulsatile vein.
  • Clinical Features

  • Red / purple discolouration
  • Swelling
  • Tenderness

Sample Clotting

  • Causes of Sample Clotting

  • Leaving blood sitting for too long before placing them in the correct tubes
  • Inadequate mixing of blood in tube

Overview

Tourniquets are a very useful tool for identifying veins when taking blood or inserting a cannula. However, leaving a tourniquet on for too long can affect the interpretation of blood test results.
  • Effects of Late Testing

  • Ongoing cellular metabolism will occur as specimens are left without being tested.
  • Decreased pO2 and increased pCO2 - due to ongoing metabolism
  • Decreased pH - due to increase in pCO2
  • Decreased calcium - due to increased binding to protein at a lower pH
  • Increased glucose - due to glycolysis
  • Increased lactate - due to glycolysis

Sample Haemolysis

  • Causes of Sample Haemolysis

  • Vigorous mixing of sample
  • Drawing blood from a haematoma
  • Drawing too quickly
  • Using a needle that is too small
  • Forcing the blood into a collection tube using a syringe

Phlebotomy Collection Tubes

  • Order of Draw

  • Blood culture tubes
  • Citrate tube - coags
  • SST tube - chemistry, immunology, serology, blood bank
  • Heparinised tube - lithium level, ammonia level
  • EDTA - haematology, blood bank
  • Acid-citrate-dextrose - HLA typing, paternity testing, DNA studies
  • Glucose inhibitor tube

Stress

  • Effects on Blood Results

  • Transiently elevated white cell count, cortisol and catecholamines
  • Hypocapnia - due to hyperventilation

Overview

Low flow oxygen devices deliver an amount of gas that is less than the patient's total minute ventilation.
Non-invasive ventilation should occur in an appropriate venue with sufficiently trained staff, such as a respiratory ward, HDU or ICU.
Reservoir systems include a reservoir bag, which allows for oxygen to accumulate between breaths. This allows for a higher concentration of oxygen to be inspired.
Invasive ventilation is performed following either intubation or tracheostomy.
High flow devices deliver an amount of gas that is sufficient to meet the patient's total minute ventilation, allowing for delivery of a precise amount of oxygen.
Supplemental oxygen is a drug and should be used rationally for specific indications, at the lowest concentration and for the shortest time possible.

Troubleshooting

No flashback - insert the needle slightly deeper or withdraw slightly and reattempt at a slightly different angle
  • No flashback - insert the needle slightly deeper or withdraw slightly and reattempt at a slightly different angle

Overview

  • Clinical Features

  • Pain
  • Pallor
  • Pulselessness
  • Paralysis
  • Paraesthesia
  • Poikilothermia
  • Clinical Features

  • Numbness
  • Paraesthesia
  • Equipment Required for Arterial Line Insertion

  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Clinical Features

  • Blood pressure not reading properly
  • Clot in the line
  • Kinking of the line
  • Pain
  • Clinical Features

  • Bruising
  • Active bleeding from the site
When identifying an artery for insertion of an arterial line, place the index and middle fingers over the desired artery and palpate for the area of maximal impulse.
Raise the bed to waist level to allow for comfortable collection.

Indications for Arterial Lines

  • Indications

  • Fluctuant blood pressure
  • Titration of vasoactive infusions
  • Frequent blood testing

Overview

Raise the bed to waist level to allow for comfortable collection.
  • Clinical Features

  • Bruising
  • Active bleeding from the site

Troubleshooting

No flashback - insert the needle slightly deeper or withdraw slightly and reattempt at a slightly different angle

Overview

  • Clinical Features

  • Numbness
  • Paraesthesia
  • Equipment Required for Arterial Blood Gas Collection

  • Clinical Features

  • Pain
  • Pallor
  • Pulselessness
  • Paralysis
  • Paraesthesia
  • Poikilothermia
When looking for an artery, place the index and middle fingers over the desired artery and feel for the area of maximal impulse.
  • Equipment Required for Catheter Insertion

Use of Catheters

  • Indications

  • Bladder drainage - for relief of acute urinary retention or bladder outlet obstruction
  • Prevention of urinary retention due to clots
  • Measurement of urine output
  • Perioperative use - urologic surgery, prolonged surgery, large volumes of intraoperative infusion or diuretics, intraoperative urine output measurement
  • Urine specimen collection in patients who are unable to voluntarily void
  • To assist in the healing of perineal wounds in incontinent patients
  • Instillation of medications into the bladder
  • Indications

  • Bladder drainage - for relief of acute urinary retention or bladder outlet obstruction
  • Prevention of urinary retention due to clots
  • Measurement of urine output
  • Perioperative use - urologic surgery, prolonged surgery, large volumes of intraoperative infusion or diuretics, intraoperative urine output measurement
  • Urine specimen collection in patients who are unable to voluntarily void
  • To assist in the healing of perineal wounds in incontinent patients
  • Instillation of medications into the bladder

Catheter-Associated UTI

  • Clinical Features of Cystitis

  • Burning around the catheter
  • Urge to urinate despite passing urine
  • Lower abdominal pain
  • Cloudy urine
  • Haematuria
  • Foul smelling urine
  • Low grade fevers

Overview

Right internal jugular: 16 - 18cmHeight / 10
Internal jugular vein - identify the vein using ultrasound. Place the probe between the two heads of the sternocleidomastoid and look for a large-bore, non-pulsating, collapsible vessel lateral to the carotid artery.
  • Equipment Required for Central Venous Catheter Insertion

Confirming Venous Placement

Flashback - the flashback from a needle in a vein should be dark red with slow flow. Bright red blood that pulsates indicates arterial catheterisation; the needle should be removed and pressure placed for at least five minutes.

Overview

  • Clinical Features

  • Bruising
  • Active bleeding from the site
  • Clinical Features

  • Pain, swelling, erythema of the upper arm (subclavian line) or leg (femoral line)
  • Symptoms / signs of pulmonary embolism
Internal jugular vein - identify the vein using ultrasound. Place the probe between the two heads of the sternocleidomastoid and look for a large-bore, non-pulsating, collapsible vessel lateral to the carotid artery.
  • Do

  • Think about the future plan for this patient, and whether this site will be needed for any other access
No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally
  • Clinical Features

  • Bright red, pulsating blood from the needle
  • Haematoma formation
  • Needle or guidewire in the artery on ultrasound
  • Indications for CVCs

  • Administration of certain medications - high-dose potassium, vasopressors, TPN, certain chemotherapy
  • Haemodynamic monitoring - central venous pressure
  • Difficult peripheral venous access - with need for frequent blood samples
  • Ongoing large transfusion requirement
The Trendelenburg or supine position is best for central venous catheter insertion, in order to avoid air embolisation.

Inserting the Guidewire

Do not forcefully insert the guidewire, as this may damage the guidewire or surrounding structures.

Overview

  • Look For

  • Placement of the CVC in the right atrium or beyond.
  • Clinical Features

  • Unable to flush the line
  • Kinking of the line
  • Pain
  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Fevers / systemic features
  • Equipment Required for Nasogastric Tube Insertion

Confirming NG Placement

Instil air - use a syringe to inject air into the NG while auscultating over the epigastrium, listening for a gurgling sound. This should not be used as the sole method of checking placement.

Avoiding Incorrect NG Placement

Oesophageal (i.e. not far enough) - measure the intended insertion length (nose to earlobe to xiphoid process) prior to insertion, and check NG position via pH of aspirate or chest x-ray prior to using the NG.

Difficult NG Insertion

Provide the patient with a cup of water and ask them to take small sips and swallow as you advance the tube

Identifying the Right Site

With the patient in the lateral or sitting position, use the index and middle fingers on either side to palpate the tops of the iliac crests. Once identified, bring the thumbs together into the midline and feel for the intervertebral space - this is L4/L5.

Overview

Lateral position - patient lying in lateral decubitus with lumbar spine flush with edge of the bed and knees drawn upward toward the chest
  • Clinical Features

  • May occur hours or days after LP
  • Headache
  • Nausea / vomiting
  • Dizziness
  • Equipment Required for Lumbar Punctures

CSF collection for lab analysis
  • Prevention

  • Do not perform an LP on a patient with raised intracranial pressure, as this can result in the severe complication of cerebral herniation.
  • Absolute

  • Papilloedema
  • Signs of raised ICP on CT - mass lesion, ventricular compression, midline shift, obstructive hydrocephalus
  • Don't insert a needle through infected tissue
Lateral position - patient lying on one side with the back at the edge of the bed and knees upward toward the chest

Identifying the Right Site

With the patient in the lateral or sitting position, use the index and middle fingers on either side to palpate the tops of the iliac crests. Once identified, bring the thumbs together into the midline and feel for the intervertebral space - this is L4/L5.

Measuring Opening Pressure

  • How to Measure

  • Attach the manometer with three way tap directly onto the needle.

Troubleshooting

Do not forcefully insert the guidewire, as this may damage the guidewire or surrounding structures.

Overview

  • Equipment Required for PICC Line Insertion

Jugular Placement

  • Look For

  • Placement of the PICC line in the jugular vein on chest xray.

Overview

  • Clinical Features

  • Pain, swelling, erythema of the upper arm
  • Symptoms / signs of pulmonary embolism

Troubleshooting

No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally

Overview

  • Clinical Features

  • Inability to flush the line
  • Kinking of the line
  • Pain
The most common sites for PICC line insertion are the cephalic vein (laterally) or basilic vein (medially) within the antecubital fossa or just above.
  • Clinical Features

  • Bruising
  • Active bleeding from the site
  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Symptoms / signs of sepsis
  • Clinical Features

  • Erythema
  • Pain / tenderness
  • Warmth
  • Swelling
  • Pus from the site
  • Clinical Features

  • Red / purple discolouration
  • Swelling
  • Tenderness
  • IVC visibly out of the vein
  • Clinical Features

  • Swelling around the site
  • Coolness
  • Pain / tightness
  • Infusion no longer working
  • Clinical Features

  • Infusion not running due to pressure in the line
  • Blood / clot in the line
  • Kinking of the line
  • Pain
  • Clinical Features

  • Erythema
  • Oedema
  • Pain
  • Swelling
  • Tracking along the course of the vein

Troubleshooting

No flashback (not in the vein) - try advancing further or pulling back and inserting slightly medially or laterally

Overview

24 - paediatrics, fragile veins
  • Equipment Required for Inserting IV Cannulas

Potential Cannula Sites

Dorsum of the hand - small veins, and more likely to clot

Overview

  • Equipment Required for Intramuscular Injection

  • Potential Sites for IM Injection

  • Deltoid (1-2mL) - 2-3 finger breadths below the acromian in the mid-axillary lineThe small size of this muscle limits the volume injectable
  • Ventrogluteal (2-3mL) - with the palm over the greater trochanter of the femur, make a V shape with the index and middle finger along the iliac crest then inject within the VThis area has good muscle bulk and a lack of nerves / vessels
  • Dorsogluteal (3-4mL) - in the upper quadrant of the buttock, above and lateral to the imaginary line between the greater trochanter and PSISIt is possible to inject a large volume here, but this has the slowest absorption rate
  • Vastus lateralis (2-3mL) - within the lateral middle third of the thigh

Injection of Incorrect Site

  • Prevention of Subcutaneous Injection

  • Don't bunch up the skin prior to injection
  • Avoid the dorsogluteal region in obese patients

Pain Associated with Local

  • Strategies for Reducing Pain

  • Warm the solution to 37 degrees prior to injection
  • Buffer the solution with sodium bicarbonate, to increase the pH
  • If injecting a laceration, inject directly into the wound rather than through intact skin
  • Use the finest needle possible
  • Inject slowly - use a small syringe to have greater control over the rate and volume injected

Overview

  • Equipment Required for Local Anaesthetic Injection

Pain Associated with Local

  • Strategies for Reducing Pain

  • Warm the solution to 37 degrees prior to injection
  • Buffer the solution with sodium bicarbonate, to increase the pH
  • If injecting a laceration, inject directly into the wound rather than through intact skin
  • Use the finest needle possible
  • Inject slowly - use a small syringe to have greater control over the rate and volume injected

Overview

  • Equipment Required for Ascitic Taps

Indications for Ascitic Tap

Diagnostic tap - for investigation of new-onset ascites, or for investigation of suspected spontaneous bacterial peritonitis (SBP)

Overview

  • How to Assess

  • If the patient is talking then this suggests that their airway is patent (however, this is not always the case)
  • Look, listen and feel for movement of air
  • Stridor (musical, high-pitched sounds) suggests upper airway obstruction
  • Snoring is a sign of airway compromise
  • Paradoxical abdominal movement is a sign

Bag-Valve-Mask

The bag-valve-mask system is a self-inflating device that is able to deliver high-flow oxygen, expiratory pressure and inspiratory pressure.

Overview

Airway manoeuvres are used to relieve upper airway obstruction, and maintain a patent airway.
Airway adjuncts are used to relieve upper airway obstruction.

Injection of Incorrect Site

  • Prevention of Intramuscular Injection

  • Bunch up the skin prior to injection

Overview

  • Equipment Required for Subcutaneous Injection

Avoid burns, infections, oedema or moles when assessing for a site to inject.
Left anterior fascicular block occurs due to failure of conduction down the left anterior fascicle.
Myelodysplasia refers to the presence of morphologically and functionally abnormal blood cells. 

Manifestations

  • Clinical Signs

  • Calcinosis cutis: hard masses beneath the skin, due to calcium deposition
  • Raynaud's phenomenon: areas of white, blue or red change in the hands
  • Sclerodactyly: thickening of the fingers / toes
  • Telangiectasia: visible dilated blood vessels
  • Reduced oral aperture
  • Nailfold abnormalities
  • Tendon friction rubs (severe disease)

Overview

Digoxin is a cardiac glycoside which can be associated with significant toxicity. Certain ECG findings are characteristic.
Nonthyroidal illness (also known as sick euthyroid syndrome) is an adaptive response of the thyroid to acute of chronic illness.
Metabolic acidosis is a process in which an external agent or internal process is causing excessive acidity in a way that is metabolic (i.e. non-respiratory).

Pathogenesis

  • Causes of Hypomagnesaemia

  • Reduced intake - malnutrition, TPN
  • Urinary loss - acute tubular necrosis (polyuric phase), postobstructive diuresis, loop / thiazide diuretics, ACE inhibitors, renal tubular acidosis, aminoglycoside toxicity, hypercalcaemia, genetic tubular defects
  • GI loss - diarrhoea, laxative abuse, malabsorption, vomiting, NG aspirates, GI fistula, short bowel syndrome, long-term PPI use
  • Compartmental shift - refeeding syndrome, hyperparathyroidism, hyperthyroidism, acute pancreatitis, hungry bone syndrome

Diagnosis

  • Signs of Psoriatic Arthritis

  • General Signs

  • Symmetric polyarthritis affecting digits as a whole (rather than in rays of digits)
  • Nail changes - onycholysis, pitting, crumbling of the nail plate
  • Psoriatic plaques - particularly on the extensor surfaces of joints, scalp, periumbilicus, skin folds
  • Dactylitis: 'sausage-like' digits due to synovitis of each joint
  • Enthesitis: inflammation of a tendon insertion; affecting the Achilles tendon or the plantar fascia
  • Evidence of sacroiliitis - tender sacroiliac joints
  • Signs of Complications

  • Evidence of iritis - painful, erythematous eye

Overview

Atelectasis refers to alveolar volume loss resulting in collapse of a portion of the lung.
When the right bundle branch and the left bundle branch (or both left-sided fascicles) are blocked, complete heart block occurs. However, several patterns suggest 'incomplete' or 'impending' trifascicular block.

Diagnosis

  • Signs of Osteoarthritis

  • Muscle wasting
  • Evidence of active arthritis - swelling, erythema, tenderness
  • Reduced joint range of motion
  • Heberden's nodes: firm swelling over the distal interphalangeal joints
  • Bouchard's nodes: firm swelling over the proximal interphalangeal joints
  • Varus knee deformity

Overview

Hypertrophic Cardiomyopathy (HCM) is a disorder that  causes left ventricular hypertrophy (particularly of the interventricular septum), which may be obstructive or non-obstructive.
Ventricular fibrillation is a chaotic ventricular rhythm that is not compatible with haemodynamic stability.
Focal atrial tachycardia is a rapid atrial rhythm originating from a single atrial focus.
Marfan syndrome occurs due to one of many mutations in the gene encoding the extracellular matrix protein fibrillin 1.
Vitamin B12, also known as cobalamin, is an important cofactor in the homocysteine metabolism, haemoglobin synthesis and myelination.

Pathogenesis

  • Causes of Pleural Effusion

  • Exudative

  • Malignancy
  • Infection - parapneumonic effusion, empyema, viral, fungal, TB, ruptured abscess / cyst
  • Pulmonary embolism (90% exudative)
  • Autoimmune disease - rheumatoid pleuritis, SLE
  • Pancreatitis
  • Haemothorax
  • Chylothorax
  • Asbestosis
  • Uraemia
  • Oesophageal rupture
  • Transudative

  • Heart failure
  • Cirrhosis
  • Hypoalbuminaemia
  • Nephrotic syndrome
  • Pulmonary embolism (10% transudative)
  • Myxoedema
  • Meig's syndrome
  • Constrictive pericarditis
  • SVC obstruction
  • Urinothorax

Overview

Most hepatitis A assays measure both IgM and IgG levels.
Respiratory acidosis is a process by which reduced effective ventilation results in carbon dioxide retention.
Vitamin B12, also known as cobalamin, is an important cofactor in the homocysteine metabolism, haemoglobin synthesis and myelination.
Hypernatraemia is a serum sodium concentration >145mmol/L. This may be caused by losing water, gaining salt or by redistribution of water within the body.

Pathogenesis

  • Causes of Hyperphosphataemia

  • Excessive Phosphate Intake / Production

  • Phosphate replacement
  • Rhabdomyolysis
  • Tumour lysis syndrome
  • Reduced Excretion

  • Renal failure - acute or chronic
  • Hypoparathyroidism
  • Vitamin D deficiency
  • Bisphosphonates
  • Osteoblastic metastases

Overview

Down syndrome occurs as a result of trisomy 21, or three copies of chromosome 21.
AV reentrant tachycardias occur when an atrial impulse is conducted through an accessory pathway - either retrogradely following AV conduction (orthodromic) or anterogradely (antidromic).
Atrioventricular (AV) block occurs due to delayed conduction of an impulse between the atria or ventricles, due to intrinsic or extrinsic causes.
Peptic ulcer disease is a common condition where ulcers may form in the stomach or duodenum. This may be as a result of Helicobacter pylori infection, medications, stress or dietary factors.
Hypokalaemia, or a reduced serum potassium concentration of <3.5mmol/L, is associated with hyperpolarisation of cardiac myocytes. If severe, hypokalaemia causes abnormal ventricular automaticity which may result in ventricular arrhythmias.
Multiple myeloma is a plasma cell neoplasm: a condition involving clonal expansion of plasma cells that secrete paraprotein or free light chains.
Hypothyroidism refers to underactivity of the thyroid, with reduced circulating thyroid hormones. This is usually accompanied by typical signs and symptoms of hypothyroidism.

Pathogenesis

  • Causes of Pneumothorax

  • Primary Spontaneous Pneumothorax

  • Idiopathic (ruptured pleural bleb / bulla)
  • Secondary Spontaneous Pneumothorax

  • Connective tissue disease - Marfan syndrome, Ehlers-Danlos syndrome, rheumatoid arthritis, scleroderma, ankylosing spondylitis, dermatopolymyositis
  • Airway disease - emphysema (bullous rupture), cystic fibrosis, severe asthma
  • Infections - PJP pneumonia, tuberculosis, necrotising pneumonia
  • Interstitial lung disease
  • Lung cancer
  • Thoracic endometriosis
  • Non-Spontaneous

  • Traumatic - blunt, penetrating
  • Iatrogenic - CVC placement, transthoracic procedures, mechanical ventilation
  • Causes of Ventricular Septal Defect

  • Congenital - associated with Down syndrome
  • Acquired - septal myocardial infarction, iatrogenic

Overview

Left posterior fascicular block occurs due to failure of conduction down the left posterior fascicle.
A patent ductus arteriosus is the persistence post birth of a blood vessel connecting the pulmonary artery and the aorta.
Pulmonary embolism is the complete or partial obstruction of the pulmonary arterial system due to an embolus, most commonly as a complication of lower limb deep venous thrombosis.
Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited disorder in which there is fibro-fatty replacement of the right ventricular myocardium. The condition is the second most common of sudden cardiac death in young people.
Right heart failure typically manifests with peripheral overload - resulting in findings such as a raised JVP, peripheral oedema, pleural effusions and ascites.

Pathogenesis

  • Causes of Pulmonary Oedema

  • Cardiogenic

  • Heart failure
  • Fluid overload
  • Renal failure
  • Transfusion-associated circulatory overload (TACO)
  • Non-Cardiogenic

  • Acute respiratory distress syndrome
  • Pulmonary embolism
  • Re-expansion pulmonary oedema (e.g. with drainage of a pleural effusion or pneumothorax)
  • Neurogenic pulmonary oedema
  • Transfusion-related acute lung injury (TRALI)
  • High altitude pulmonary oedema (HAPE)

Overview

Atrial flutter is most commonly due to a right atrial macro-reentrant circuit, and has significant crossover with atrial fibrillation in its pathogenesis.
Gastroesophageal reflux disease is a condition in which there is incompetence of the lower oesophageal sphincter, resulting in reflux of gastric acid.

Pathogenesis

  • Risk Factors for Ischaemic Heart Disease

  • Family history of ischaemic heart disease
  • Advanced age
  • Smoking
  • Hypertension
  • Hyperlipidaemia
  • Diabetes mellitus
  • Physical inactivity
  • Obesity

Overview

Tuberculosis is the disease caused by the bacteria Mycobacterium tuberculosis, and may affect almost any organ in the body resulting in a wide range of clinical presentations.
Several hereditary conditions are associated with a prolonged QT interval, which increases the risk of life-threatening arrhythmia.
Brugada syndrome is an inherited condition that strongly predisposes to sudden cardiac death. The condition is autosomal dominant in inheritance and involves a loss of function mutation in sodium channels, predominantly affecting the right ventricle.
  • Types of Lung Cancer

  • Non-Small Cell Lung Cancer - adenocarcinoma, squamous cell carcinoma, large cell carcinoma
  • Small Cell Lung Cancer
Pulmonary hypertension refers to a heterogeneous and functionally limiting group of disorders that result in increased pressure within the pulmonary arteries.
Monomorphic VT is a focal or reentrant ventricular rhythm that requires rapid assessment and management, due to its risk of haemodynamic instability and collapse.
Turner syndrome occurs secondary to monosomy X, where all or part of an X chromosome is missing, or due to duplication of the long arm of one X chromosome.
Sinus tachycardia originates from the sinus node and is a physiologic response that occurs due to changes in autonomic regulation - either sympathetic activation or reduction in parasympathetic tone.

Pathogenesis

  • Causes of Mitral Stenosis

  • Rheumatic heart disease
  • Congenital mitral stenosis
  • Mitral annular calcification

Overview

Thyrotoxicosis refers to hyperactivity of the thyroid gland, with increased circulating thyroid hormones. This tends to be accompanied by typical signs and symptoms of thyrotoxicosis such as those listed below.

Pathogenesis

  • Causes of Aortic Regurgitation

  • Acute

  • Infective endocarditis
  • Dissecting aneurysm
  • Hypertension
  • Trauma
  • Chronic

  • Rheumatic heart disease
  • Congenital bicuspid aortic valve
  • Ankylosing spondylitis
  • Marfan syndrome / Ehlers-Danlos syndrome
  • Aortitis

Overview

Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac pre-excitation syndrome that occurs due to the presence of an accessory conduction pathway.
Multifocal atrial tachycardia is an irregular rhythm that occurs due to multiple atrial ectopic foci.
Bifascicular block occurs when there is failure of conduction down the right bundle branch as well as either the left anterior or left posterior fascicle.
  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, lichen planus, cryoglobulinaemia, glomerulonephropathy
  • Management - direct acting antivirals, surveillance
  • Classification

    Based on body mass index (BMI)
  • Underweight - <18.5
  • Normal - 18.5 - 24.9
  • Overweight - 25 - 29.9
  • Obese - 30 - 34.9
  • Severely obese - 35 - 39.9
  • Morbidly obese - 40+
AV nodal reentrant tachcardia (AVNRT) is the most common type of paroxysmal supraventricular tachycardia (pSVT), and occurs due to a reentrant loop within the AV node.
Chronic obstructive pulmonary disease is a severely functionally limiting condition primarily affecting previous tobacco smokers. Management is targeted to the severity of the disease, and underpinned by smoking cessation.
Beta thalassaemia is an inherited defect in beta globin chains of haemoglobin, resulting in defective haemoglobin synthesis.

Diagnosis

  • Signs of Chronic Inflammatory Demyelinating Polyneuropathy

  • Foot drop
  • Symmetrical lower motor neuron weakness - distal predominance affecting the upper limb more than the lower limb
  • Sensory loss distally (glove and stocking distribution)

Overview

Chronic liver disease is a common condition most often caused by alcohol, fatty liver disease or viral hepatitis. This condition can be difficult to diagnose, and the examination is crucial for identifying evidence of portal hypertension, oestrogen excess encephalopathy and other complications of cirrhosis.

Pathogenesis

  • Risk Factors for Rheumatoid Arthritis

  • Female sex
  • Family history of rheumatoid arthritis
  • Infections - EBV, CMV, E coli, periodontal disease (Porphyromonas gingivalis)
  • Smoking

Overview

Hypophosphataemia refers to a reduced serum phosphate concentration of <0.8 mmol/L. This may occur in the context of reduced intake, compartmental shift or increased excretion of phosphate.
Sinus bradycardia is initiated by the sinus node, and occurs in the setting of reduced automaticity due to either intrinsic or extrinsic causes.

Pathogenesis

  • Risk Factors

  • Male gender
  • Obesity
  • Chronic kidney disease
  • Drugs - diuretics, ethambutol, certain chemotherapeutic agents
  • Excess purine-rich foods - beer, shellfish, liver, marmite
  • Excess sucrose / fructose intake
  • Alcohol excess

Overview

Sinoatrial exit block is a delay in conduction between the sinoatrial node and atrial myocardium.
Hyponatraemia is an imbalance between sodium and water balance in the body, producing a reduced serum sodium concentration of <135 mmol/L.
Sickle cell anaemia is an inherited disorder affecting haemoglobin synthesis, resulting in 'sickling' of red blood cells and resultant complications.
Iron deficiency may occur due to poor intake, poor absorption or loss of iron. The most common complication of iron deficiency is anaemia, which presents as a microcytic, hypochromic anaemia.

Pathogenesis

  • Causes of Myotonia

  • Myotonic Dystrophy

  • Dystrophia myotonia
  • Myotonia congenita
  • Non-Dystrophic Myotonia

  • Paramyotonia congenita
  • Acid maltase deficiency

Overview

  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, polyarteritis nodosa, membranous glomerulonephropathy
  • Management - antivirals, surveillance
Right bundle branch block occurs due to failure of conduction down the right bundle, resulting in slowed right ventricular depolarisation.
Folate, also known as vitamin B9, is an important coenzyme in DNA and amino acid metabolism pathways.
  • Ask About

  • Diagnosis - when the diagnosis was made
  • Manifestations - tremor, bradykinesia, rigidity, postural instability
  • Management - dopamine replacement, MAO-B inhibitors, COMT inhibitors
Hypocalcaemia, or a reduced serum calcium concentration >2.15 mmol/L, prolongs action potentials which primarily results in delayed ventricular repolarisation (prolonged QT) on ECG.
  • Chest X-Ray Signs of Pneumonia

  • Pulmonary consolidation without volume loss - may be lobar (lobar pneumonia) or multifocal
  • Air bronchograms - tubular outlines of the smaller airways
  • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
Catacholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited disorder that occurs due to mutations in the ryanodine receptor, affecting calcium release from the sarcoplasmic reticulum.
The anaemia of chronic disease is a common condition that is associated with chronic infection, inflammation or malignancy where patients develop a non-specific anaemia.

Pathogenesis

  • Causes of Aortic Stenosis

  • Calcific degeneration
  • Rheumatic heart disease
  • Congenital bicuspid aortic valve
  • Infective endocarditis

Overview

Sick sinus syndrome (SSS) occurs when the sinus node is not functioning correctly, due to either intrinsic or extrinsic causes.
  •  
    Oral
    Cephalexin
    Keflex 
     
    Alternative to fluclox / diclox in patients hypersensitive to penicillins
  •  
    IV / IM
    Gentamicin

  •  
    IV infusion / IM
    Oxytocin
    Syntocinon 
  •  
    Oral
    Nifedipine
    Adalat 
  •  
    IM
    Ergometrine + Oxytocin
    Syntometrine 
  •  
    MDI / Nebule
    Salbutamol
    Ventolin, Asmol 
  •  
    IV / IM
    Ergometrine

  •  
    IV
    Apheresis Platelets
    Blood is removed, platelets collected and blood returned to patient
  •  
    IV
    Recombinant Factor VIII
    Advate, Kogenate, Xyntha 
  •  
    IV
    Whole Blood Plasma
    Plasma separated from whole blood collection
  •  
    IV
    Recombinant Factor IX
    BeneFIX 
  •  
    IV
    Whole Blood Cryoprecipitate
    Plasma separated from whole blood collection and then cryoprecipitate isolated from plasma
Transfusion of blood products is often a life-saving intervention, however blood products are associated with multiple infective and non-infective complications that patients should be monitored for.
  •  
    IV
    Prothrombinex

  •  
    IV
    Antithrombin-III
    Thrombotrol, Thrombate III 
  •  
    IV
    Factor VIII + Von Willebrand Factor
    Biostate 
  •  
    MDI
    Salmeterol
    Serevent 
  •  
    MDI
    Budesonide / Formoterol
    Symbicort, DuoResp 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Subcut
    Omalizumab
    Xolair 
  •  
    MDI / Nebule
    Ipratropium Bromide
    Atrovent 
     
    Short-acting - best for acute COPD / asthma
  •  
    Inhaler
    Beclomethasone
    Qvar 
  •  
    MDI / Nebule
    Salbutamol
    Ventolin, Asmol 
  •  
    MDI
    Tiotropium
    Spiriva 
     
    Long-acting - best for COPD maintenance
  •  
    MDI
    Fluticasone / Umeclidinium / Vilanterol
    Trelegy Ellipta 
  •  
    Oral
    Montelukast
    Singulair 
  •  
    Subcut
    Mepolizumab
    Nucala 
  •  
    MDI
    Tiotropium / Olodaterol
    Spiolto Respimat 
  •  
    MDI / Nebule
    Salbutamol
    Ventolin, Asmol 
  •  
    Oral
    Donepezil
    Aricept 
  •  
    Oral / IV
    Sodium Valproate
    Epilim, Valpro 
  •  
    Oral
    Eletriptan
    Relpax 
  •  
    Oral
    Pizotifen
    Sandomigran 
  •  
    IV
    Alemtuzumab
    MabCampath (CLL), LemTrada (MS) 
  •  
    Oral / IV
    Sodium Valproate
    Epilim, Valpro 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral
    Topiramate
    Topamax 
  •  
    Oral
    Propranolol
    Deralin / Inderal 
  •  
    IM / Subcut
    Interferon Beta-1a
    Avonex 
  •  
    Oral
    Amitriptyline
    Endep 
  •  
    Oral
    Ethosuxamide
    Zarontin 
  •  
    Oral
    Fingolimod
    Gilenya 
  •  
    IV
    Natalizumab
    Tysabri 
  •  
    Oral
    Topiramate
    Topamax 
  •  
    Oral / IV / IM
    Diazepam
    Valium 
     
    [Peak] 1-2 hours
    Half-life 20-48 hours
  •  
    Oral / IV
    Phenytoin
    Dilantin 
  •  
    Oral
    Carbamazepine
    Tegretol 
  •  
    Oral
    Pramipexole
    Sifrol 
  •  
    Oral
    Levodopa + Carbidopa
    Sinemet 
  •  
    Oral / IV
    Levetiracetam
    Keppra 
  •  
    Oral / IV
    Paracetamol / Acetaminophen
    Panadol, Tylenol, Dymadon, Panadol Osteo (SR) 
  •  
    Oral / Topical
    Ibuprofen
    Advil / Brufen / Nurofen 
  •  
    Oral / IM
    Promethazine
    Phenergan 
  •  
    IM / Subcut / Nebule
    Adrenaline / Epinephrine
    Used for anaphylaxis
  •  
    Oral
    Cetirizine
    Zyrtec 
There are many varied means for achieving contraception, each of which is associated with a risk of unintended pregnancy. This section lists the efficacy of possible contraceptive methods, both for correct and consistent use as well as the use typically seen.
  •  
    Oral
    Levonorgestrel Emergency Contraceptive
    Levonelle, Postinor, Plan B 
  •  
    IUS
    Levonorgestrel Intra-Uterine Device
    Mirena 
     
    Inserted into the uterus for five years of contraception
    May cause pelvic inflammatory disease and uterine perforation
  •  
    IM
    Methoxyprogesterone Acetate
    Depo-Provera 
     
    Depot injection for 12 weeks of contraception
    Should be given within the first five days of the menstrual cycle
    Causes decreased bone mineral density
  •  
    Subdermal
    Etonogestrel
    Implanon NXT 
     
    Implanted into the upper arm for 3 years of contraception
  •  
    Vaginal
    Ethinyloestradiol + Etonogestrel
    NuvaRing 
  •  
    Oral
    Ethinyloestradiol + Levonorgestrel
    Levlen, Eleanor 
     
    Lower risk of DVT
  •  
    Oral
    Clomiphene Citrate
    Clomhexal, Serophene 
  •  
    Oral
    Levonorgestrel
    Microlut 
  •  
    Oral
    Mifepristone (RU486)
    Given initially to prepare the genitourinary tract
  •  
    IM
    Hydroxocobalamin

  •  
    IV
    5% Dextrose

  •  
    IV / IM
    Physostigmine

  •  
    IV
    N-Acetylcysteine
    Acetadote 
  •  
    IV
    Protamine Sulfate

  •  
    IM
    Desferrioxamine

  •  
    IV
    Fomepizole
    Antizol 
  •  
    IV
    Flumazenil

  •  
    IV / IM
    Glucagon

  •  
    IV
    Naloxone
    Narcan 
  •  
    Oral
    Succimer

  •  
    IV
    Sodium Calcium Edetate

  •  
    Oral / IV
    Phytomenadione
    Konakion 
  •  
    Oral
    Penicillamine

  •  
    IV / IM / Subcut
    Atropine

  •  
    IV / NG
    Ethanol 10%

  •  
    IV
    Sodium Thiosulfate

  •  
    IV
    50% Dextrose

  •  
    Subcut / IV
    Ustekinumab
    Stelara 
  •  
    Oral
    Baricitinib
    Olumiant 
     
    Selective inhibitor of JAK1 and JAK2
  •  
    IV
    Infliximab
    Remicade 
     
    Chimaeric monoclonal antibody to TNF
  •  
    IV
    Basiliximab
    Simulect 
  •  
    IV / Subcut
    Abatacept
    Orencia 
  •  
    IV
    Eculizumab
    Soliris 
  •  
    IV / Subcut
    Rituximab
    Mabthera 
Monoclonal antibodies are named based on standard nomenclature that describes the target and species of origin of the antibody.
  •  
    IV / Subcut
    Tocilizumab
    Actemra 
  •  
    Subcut
    Canakinumab
    Ilaris 
  •  
    IV
    Belimumab
    Benlysta 
  •  
    Subcut
    Anakinra
    Kineret 
  •  
    Subcut
    Secukinumab
    Cosentyx 
  •  
    Subcut
    Omalizumab
    Xolair 
  •  
    Subcut
    Mepolizumab
    Nucala 
  •  
    IV
    Alemtuzumab
    MabCampath (CLL), LemTrada (MS) 
  •  
    Oral / IV
    Cyclophosphamide
    Cyclonex, Endoxan 
  •  
    Oral
    Everolimus
    Certican 
     
    Half-life ~30 hours
  •  
    Oral / IV
    Azathioprine
    Imuran 
  •  
    IV
    Anti-Thymocyte Globulin
    Thymoglobuline 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral / IV
    Mycophenolate Mofetil
    CellCept, Myfortic 
  •  
    Oral
    Leflunomide
    Arava 
  •  
    Oral / IV
    Cyclosporin
    Sandimmun, Neoral 
  •  
    IV
    Intravenous Immunoglobulin (IVIg)
    Intragam, Octagam, Privigen, Flebogamma 
  •  
    IV
    3% Sodium Chloride (Hypertonic Saline)

  •  
    IV
    5% Dextrose

  •  
    Oral
    Spironolactone
    Aldactone, Spiractin 
  •  
    Oral
    Oral Potassium Chloride
    Chlorvescent, Slow K, Span K, Duro K 
  •  
    IV
    0.9% Sodium Chloride

  •  
    IV
    20% Albumin

  •  
    Oral
    Calcium Polystyrene Sulfonate
    Resonium 
  •  
    IV
    Compound Sodium Lactate (Hartmanns)

  •  
    Subcut / IV
    Insulin Aspart
    Novorapid 
  •  
    Oral / IV
    Magnesium Sulfate

  •  
    IV
    4% Albumin

Opioids are a group of natural, semi-synthetic and synthetic medications that are used for pain relief. Though opioids can be useful in certain situations, they are associated with adverse effects and a significant risk of dependence.
  •  
    Oral / IV / IM / Subcut / Topical / Epidural
    Fentanyl
    Durogesic patch 
     
    Strong μ receptor selectivity
    Short duration of action, though patches create a reservoir in the skin
  •  
    IV / Oral
    Tramadol
    Tramal 
  •  
    Oral
    Pregabalin
    Lyrica 
  •  
    Oral / IV
    Paracetamol / Acetaminophen
    Panadol, Tylenol, Dymadon, Panadol Osteo (SR) 
  •  
    Oral / Intrathecal
    Baclofen

  •  
    Oral
    Oxycodone
    Endone, Oxycontin (SR) 
     
    Better tolerated than morphine / codeine
  •  
    Oral / Rectal / IV / IM / Subcut
    Morphine
    Kapanol, MS Contin (SR) 
     
    Predominant μ receptor selectivity
    Good absorption but significant first-pass metabolism - bioavailability of 30%
  •  
    Oral
    Gabapentin
    Neurontin 
  •  
    Local / Regional / Epidural
    Bupivacaine
    Marcain 
  •  
    Oral
    Celecoxib
    Celebrex 
  •  
    Oral / Topical
    Ibuprofen
    Advil / Brufen / Nurofen 
  •  
    IV / Subcut
    Abatacept
    Orencia 
  •  
    IV
    Infliximab
    Remicade 
     
    Chimaeric monoclonal antibody to TNF
  •  
    Oral / IV
    Azathioprine
    Imuran 
  •  
    Oral
    Apremilast
    Otezla 
  •  
    Oral / IV
    Cyclosporin
    Sandimmun, Neoral 
  •  
    Oral
    Leflunomide
    Arava 
  •  
    Subcut / IV
    Ustekinumab
    Stelara 
  •  
    IV / Subcut
    Tocilizumab
    Actemra 
  •  
    Oral
    Colchicine
    Colgout 
  •  
    Subcut
    Anakinra
    Kineret 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV / Subcut
    Rituximab
    Mabthera 
  •  
    Oral
    Baricitinib
    Olumiant 
     
    Selective inhibitor of JAK1 and JAK2
  •  
    Oral
    Hydroxychloroquine
    Plaquenil 
  •  
    Oral
    Allopurinol
    Zyloprim, Progout 
     
    May be associated with increased cardiovascular risk
  •  
    Oral
    Sulfasalazine
    Salazopyrin 
     
    Not absorbed well - therefore most effective within the gut
  •  
    Oral
    Imatinib
    Glivec 
  •  
    Oral
    Crizotinib
    Xalkori 
  •  
    Oral
    Erlotinib
    Tarceva 
     
    Acneiform rash can be a major concern
  •  
    Oral
    Dabrafenib + Trametinib
    Tafinlar + Mekinist 
  •  
    Oral
    Sorafenib
    Nexavar 
  •  
    Oral
    Vemurafenib
    Zelboraf 
     
    Given as monotherapy or in combination with cobimetinib (MEK inhibitor)
  •  
    Oral
    Olaparib
    Lynparza 
  •  
    Oral
    Ribociclib
    Kisqala 
  •  
    Oral / IM / PR
    Prochlorperazine
    Stemetil 
  •  
    Oral / IV
    Omeprazole
    Losec 
  •  
    Oral / Rectal
    Mesalazine
    Salofalk 
  •  
    Oral / Subling / IM / IV
    Ondansetron
    Zofran 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral
    Magnesium Sulphate
    Epsom Salt 
  •  
    Oral / IV
    Azathioprine
    Imuran 
  •  
    Oral
    Docusate Sodium
    Coloxyl 
     
    Generally combined with Senna
  •  
    Oral
    Psyllium
    Metamucil 
  •  
    Oral / IV
    Methotrexate
    Weekly dosing
  •  
    IV
    Infliximab
    Remicade 
     
    Chimaeric monoclonal antibody to TNF
  •  
    Oral / IM / IV
    Metoclopramide
    Maxolon, Pramin 
     
    Selectively binds D2 receptors
  •  
    Oral
    Sennosides
    Senna 
     
    Generally combined with docusate (coloxyl)
  •  
    Subcut / IV
    Ustekinumab
    Stelara 
  •  
    Oral / IV
    Ranitidine
    Zantac 
  •  
    Oral
    Doxycycline

  •  
    Oral
    Primaquine
    Primacin 
  •  
    Oral
    Mefloquine
    Lariam 
  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
  • Ask About

  • Travel to other countries - especially developing countries
  • Prophylaxis before travelling - vaccines, malaria prophylaxis
  • Exposure to animals - especially bites or scratches
  • Food intake - especially raw meat, fish, unpasteurised dairy products
  • Contact with fresh water
  • Contact with sick people
  • Insect bites
  • Sexual contacts
  • Needle exposures
  • Ask About

  • Any past surgeries the patient has had.
The patient's past medical history provides the medical context that underpins their current presentation. By understanding the natural history and course of their existing medical conditions, it is possible to predict their risk of complications and narrow down the differential diagnosis of their presenting complaint.
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
  • Ask About

  • Whether the patient takes any recreational drugs
  • How long they have been taking the drug for
  • How often they take the drug
  • Whether they have injected drugs
  • Past attempts to quit
  • Willingness to cut down or stop
  • Ask About

    The patient's ability to perform important tasks around the house and outside, and whether they have any assistance from family, friends or home services.
  • Shopping
  • Cooking
  • Cleaning
  • Laundry
  • Toiletting
  • Showering
  • Administering medications
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
These questions are incredibly valuable for elderly patients who are poorly mobile, though are likely to be inappropriate in younger patients who are fit and active.
  • Ask About

    Any allergies that the patient may have.
  • Known or potential allergens - pollen, dust, pets, certain foods, latex, medications
  • Symptoms of allergy - itch, rash, wheeze, rhinorrhoea, red eyes, swelling, vomiting, diarrhoea, anaphylaxis
  • How long after exposure the symptoms begin
  • Timing - age that the allergy first started, frequency of reactions, whether the reaction is seasonal
  • Severity of the reaction - hospital / ICU admissions
  • Treatment - medications given and response, epipen
  • Family history of allergy (atopy) - asthma, eczema, hay fever, food allergies
  • Ask About

  • Any conditions in the family
  • If passed, what their family members passed away due to
The patient's medication history is a very important aspect of their medical history. Documenting a comprehensive list of a patient's medications allows for correct charting of medications as well of the identification of potential drug interactions or adverse effects.
  • Ask About

    Any reactions to medications.
  • What specific drug they have had a reaction to
  • What happens when they take the drug in question
  • How long after exposure to the drug the reaction began
  • How severe the reaction was
  • Whether the reaction resolved after cessation or dose-reduction of the drug
  • When this reaction first / last happened
Alcohol abuse, binging and dependence is very common in the community, and can result in significant acute and chronic complications. A tactful history will aid in understanding the patient's pattern of alcohol intake and their attitude toward alcohol.
  • Ask About

  • Diagnosis - cause of chronic kidney disease, stage
  • Complications - acidosis, fluid overload, electrolyte derangements, cardiovascular disease, anaemia, mineral bone disease, malnutrition
  • Management - management of complications, dialysis, renal transplant
  • Dialysis - commencement, modality, access, timing, fluid removal
  • Ask About

  • Commencement - when they started dialysis; indication
  • Modality - haemodialysis / peritoneal dialysis
  • Access - vascath / fistula / graft (HD), Tenckhoff catheter (PD)
  • Timing - frequency and duration
  • Fluid removal - dry/ideal weight, amount of fluid removed
  • Complications
Renal transplantation is a complex field and requires a detailed understanding of the patient's physical, psychological and social factors. This page contains basic questions to ask in order to better understand the history of a patient who has had a renal transplant.
  • Ask About

  • Diagnosis - when diagnosed, clinical phenotype
  • Family history of multiple sclerosis
  • Relapses - symptoms, frequency, duration, partial / complete resolution of symptoms
  • Management - lifestyle changes, immunomodulators
  • Ask About

  • Diagnosis - when the diagnosis was made
  • Manifestations - tremor, bradykinesia, rigidity, postural instability
  • Management - dopamine replacement, MAO-B inhibitors, COMT inhibitors
  • Ask About

  • Diagnosis - when diagnosed, EEG changes, MRI changes
  • Family history of seizures / epilepsy
  • Manifestations - type of seizures, prodrome, postictal period
  • Severity - frequency of seizures, last seizure
  • Management - avoidance of precipitants, medications
  • Ask About

  • Diagnosis - type of MND, when diagnosed, disease course
  • Manifestations - dysphagia, dysarthria, spasticity, weakness
  • Management - physiotherapy, respiratory support, optimisation of nutrition, psychological support, pharmacologic agents
  • Prognosis - expected trajectory of disease
  • Ask About

  • Diagnosis - when diagnosis was made, symptoms on presentation
  • Manifestations - past myaesthenic crisis / issues with anaesthetics in the past
  • Management - anticholinesterase agents, immunosuppression, thymectomy, past IVIg / plasmapheresis for crisis
  • Drugs that Can Cause Megaloblastic Anaemia

  • Interference with DNA Synthesis

  • Folate antagonists - methotrexate, trimethoprim
  • Purine analogues - azathioprine, 6-mercaptopurine, allopurinol, cladribine, fludarabine
  • Pyramidine antagonists - 5-fluorouracil, cytarabine, gemcitabine, capecitabine
  • Anticonvulsants - valproate, phenytoin
  • Reverse transcriptase inhibitors - abacavir, emtricitabine, entacavir, lamivudine, zidovudine, tenofovir, efavirenz
  • Malabsorption of B12 / Folate

  • Colchicine
  • Isoniazid
  • Metformin
  • Cholestyramine
  • Proton pump inhibitors
  • Histamine 2 receptor antagonists
  • Other

  • Ethanol
  • Sulfasalazine
  • Nitrous oxide
  • Medications Associated with Neutrophilia

  • Glucocorticoids
  • Adrenaline
  • Lithium
  • Granulocyte colony stimulating factor (G-CSF)
  • Medications Associated with Immune Haemolysis

  • Methyldopa
  • Quinine / quinidine
  • IV immunoglobulin
  • Penicillins - especially piperacillin
  • Cephalosporins - especially cefotetan and ceftriaxone
  • NSAIDs - especially diclofenac
  • Medications Associated with Bleeding

  • NSAIDs - ibuprofen, diclofenac, meloxicam, naproxen, ketorolac, indomethacin, celecoxib
  • Antiplatelets - aspirin, clopidogrel, prasugrel, ticagrelor, abciximab, eptifabitide, tirofiban, dipyridamole
  • Anticoagulation - heparin, enoxaparin, dalteparin, warfarin, dabigatran, rivaroxaban, apixaban,
  • SSRIs - citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
  • Medications Associated with Thrombosis

  • Hormonal therapies - oral contraceptives, hormone replacement therapy, SERMs
  • COX-2 inhibitors - celecoxib
  • Erythropoietin
  • Warfarin (initially)
  • Medications Associated with Pure Red Cell Aplasia

  • Recombinant human erythropoietin
  • Antibacterials - linezolid, chloramphenicol, sulfamethoxazole
  • Antimycobacterials - isoniazid, rifampicin, dapsone
  • Antivirals - interferon alpha, lamivudine, zidovudine
  • Anticonvulsants - valproate, carbamazepine
  • Immunosuppressants - azathioprine, mycophenolate
  • Medications Associated with Eosinophilia

  • Antibiotics - penicillins, cephalosporins, glycopeptides, sulfamethoxazole
  • Anticonvulsants - phenytoin, carbamazepine, phenobarbitone
  • Antipsychotics - chlorpromazine
  • H2 receptor antagonists - ranitidine
  • Proton pump inhibitors - omeprazole, lansoprazole
  • Sulfonylureas
  • ACE inhibitors
  • NSAIDs
  • Medications Associated with Sideroblastic Anaemia

  • Isoniazid
  • Pyrazinamide
  • Chloramphenicol
  • Cycloserine
  • Ethanol
  • Causes of Drug-Induced Thrombotic Microangiopathic Anaemias

  • Acute Immune Reactions

  • Antiplatelets - clopidogrel, ticlodipine
  • Quinine
  • Cocaine
  • Toxic

  • Chemotherapy - mitomycin, cisplatin, oxaliplatin, gemcitabine, vincristine
  • Immunotherapy - interferons, bevacizumab
  • Immunosuppressants - cyclosporine, tacrolimus, sirolimus
  • Medications Associated with Immune Thrombocytopaenia

  • Glycoprotein IIb/IIIa inhibitors - abciximab, eptifibatide, tirofiban
  • Heparins - heparin sodium, low molecular weight heparins
  • Anticonvulsants - carbamazepine, phenytoin, valproate
  • Antibacterials - rifampicin, linezolid, vancomycin, sulfamethoxazole
  • Antimalarials - quinine, quinidine
  • NSAIDs - diclofenac, naproxen
  • Paracetamol
  • Hydrochlorothiazide
  • Medications Associated with Heparin-Induced Thrombocytopaenia

  • Unfractionated heparin - heparin sodium
  • Low molecular weight heparin - enoxaparin, dalteparin
  • Causes of Drug-Induced Thrombotic Microangiopathic Anaemias

  • Acute Immune Reactions

  • Antiplatelets - clopidogrel, ticlodipine
  • Quinine
  • Cocaine
  • Toxic

  • Chemotherapy - mitomycin, cisplatin, oxaliplatin, gemcitabine, vincristine
  • Immunotherapy - interferons, bevacizumab
  • Immunosuppressants - cyclosporine, tacrolimus, sirolimus
  • Medications Associated with Aplastic Anaemia

  • NSAIDs - ibuprofen, indomethacin, diclofenac, aspirin
  • Antirheumatic drugs - sulfasalazine, penicillamine, gold
  • Antithyroid drugs - propylthiouracil, carbimazole, methimazole
  • Anticonvulsants - carbamazepine, phenytoin
  • Antibacterials - chloramphenicol, sulfamethoxazole
  • Chloroquine
  • Medications Associated with Neutropaenia

  • NSAIDs - ibuprofen, indomethacin, diclofenac, aspirin
  • Antirheumatic drugs - sulfasalazine, penicillamine, gold
  • Antithyroid drugs - propylthiouracil, carbimazole, methimazole
  • Anticonvulsants - carbamazepine, valproate, phenytoin
  • Antipsychotics - clozapine, risperidone, haloperidol
  • Antibiotics - penicillins, cephalosporins, vancomycin, gentamicin, ciprofloxacin, metronidazole, sulfamethoxazole, chloramphenicol
  • Antimalarials - quinine, chloroquine
  • Antihistamines - ranitidine, cimetidine
  • Cardiovascular drugs - procainamide, digoxin, nifedipine, beta blockers
  • Chemotherapy agents
  • Rituximab
  • Medications that can Trigger Haemolysis in G6PD Deficiency

  • Flutamide
  • Dapsone
  • Methylene blue
  • Naphthalene
  • Nitrofurantoin
  • Primaquine
  • Sulfamethoxazole
An allogeneic stem cell transplant involves depleting a patient's bone marrow using chemotherapy, and then transfusing another (matched) patient's stem cells. This serves purposes of both replacing their haematopoietic cells with normal cells, and providing some degree of graft-vs-disease effect.
  • Medications Associated with Erythrocytosis

  • Anabolic steroids
  • Erythropoietin (EPO)
An autologous stem cell transplant refers to the process of mobilising and collecting a patient's stem cells, providing chemotherapy to deplete the bone marrow, and then retransfusing their stem cells. This process is less complex and has less potential side effects than an allogeneic stem cell transplant.
Learning clinical medicine can be a daunting task - whether you're just starting out in medical school or getting onto the wards. However, there is now a wide range of clinical medicine apps that can help you to nail down core concepts efficiently and effectively. Apps focused on clinical medicine may offer a variety of features such as guides to history and examination, diagnostic support, interactive clinical cases, and point-of-care tools. With so many options available, it can be difficult to know which apps are most useful.
Flashcards have long been a popular and effective study tool for medical students. Using flashcards as part of your study routine improves retention of medical concepts, particularly if you use spaced repetition to maximise your recall.
Note-taking is a key part of the study process. We use notes to collect, categorise, synthesize and review the large amount of information that we learn in medical school. 
The medical sciences - anatomy, physiology, pathology, pharmacology and many more - are core aspects of medical education that you’ll jump right into when starting medical school. These topics provide a foundation for understanding how the human body works, how diseases affect it and how drugs can interact with human physiology.
Clinical medicine refers to the aspects of medicine that deal directly with the patient - history, examination, investigations, management and prognosis. Clinical medicine is a vital aspect of your medical education, and requires a deep theoretical understanding as well as practical experience. As medical education moves more and more online, a large number of video resources and platforms have become available that focus on clinical medicine. Such videos allow us the opportunity to learn from expert clinicians and educators, and can fast-track learning - particularly if you identify as a ‘visual’ learner.
Let’s be honest - medical school is a busy, challenging and stressful time. Long study sessions are required to cram a massive amount of information into your brain. You’ll have exams and clinical placements to deal with, not to mention the need to find your niche and work toward a residency program. You will likely be expected to perform research during this time as well. It can be difficult to remain calm and maintain a social life - it’s no surprise that medical medical students struggle with burnout and mental health issues.
Navigating the medical world requires not just knowledge, but also the ability to make informed decisions based on complex medical data. There is a vast array of evidence-based formulae, clinical checklists and tools that have been developed and validated to assist us in medical decision-making, to facilitate the best possibleoutcomes for our patients.
Medical school is a busy time with a demanding workload, and it's often challenging to stay organised, manage your time effectively and maintain productivity. Fortunately, there is a massive number of productivity apps that you can leverage to optimise your study time, boost your efficiency, pass exams and keep up with extracurricular activities! 
ECG interpretation is an essential skill for medical students and doctors - these seeminly simple traces are crucial for diagnosing and managing a wide range of cardiac condition. However, ECG interpretation can be challenging - particularly if you’re looking at ECG traces for the first time. It is important to develop a consistent method for approaching ECGs so you don’t miss anything.
Learning is a constant process during medical school, and we will take in a massive amount of information over a few short years. Before diving in and trying to absorb everything, it is useful to have an understanding of how we learn. This can then guide your note-taking, studying and overall approach to university.
We learn a plethora of information during our time at medical school, and we need to make it stick - both for exams, and for our clinical practice in the future. There are several methods for improving your memory and ensuring that you recall information when required.
Studying is a key part of the medical school experience - whether it is alone or in a group. You'll be spending plenty of long days or nights in the books, on your laptop or with a plethora of study tools.
During your time in medical school, you will learn many practical skills that will complement your medical knowledge. Skills such as blood-taking, cannulation, urinary catheterisation and suturing are vital to your everyday job as a junior doctor, and as such it is important to have experience with these procedures before you are unleashed on the wards. 
The amount that you’ll learn in your years of medical school is staggering. Anatomy, physiology, histology, pathology, pharmacology - and that’s before even starting on clinical medicine! You are likely under pressure to master complex concepts in a short amount of time, and it can be challenging to retain everything you’ve learned. Luckily, there are a variety of study tools available to help you remember everything. A key tool for medical students is the humble flashcard.
  • How to Assess

  • Ask the patient to relax and allow you to move their upper limbs. Move the shoulder, elbow, wrist and fingers passively through their range of motion, looking for rigidity. Repeat to assess the lower limbs.
The patient's body habitus provides insight into a patient's diet and metabolic status as well as their overall risk of cardiovascular and non-cardiovascular complications in the future. While static measures such as body habitus and waist-hip ratio can estimate future risk, unexpected change in weight may suggest active disease.

Cheyne-Stokes Respiration

  • Look For

  • Periods of hyperventilation interspersed with periods of apnoea or bradypnoea.

Overview

Power assessment is a key part of the motor examination, and can be used to identify focal or global weakness.

Oral Candidiasis

  • Look For

  • Creamy white lesions present on the tongue or inner cheeks, which may be associated with angular cheilitis or glossitis.

Dehydration

  • Look For

  • Abnormal obs - tachycardia, hypotension
  • Fluid balance chart - negative fluid balance, oliguria
  • Weight loss - an acute decrease in weight may indicate short-term change in fluid status
  • Dry mucous membranes - especially the tongue
  • Sunken eyes
  • Increased capillary refill time (>2 seconds)
  • Weak radial pulse
  • Decreased skin turgor - pinch a fold of skin on the patient's arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.

Overview

Capillary refill time is a marker of perfusion, and prolonged refill time suggests poor perfusion of the area being examined.
  • How to Elicit

  • Biceps - ask the patient to relax their arms in their lap and strike the biceps tendon with a tendon hammer.
  • Supinator - ask the patient to relax their arms in their lap and strike the brachioradialis tendon, proximal to the wrist on the lateral aspect of the forearm.
  • Triceps - lift the patient's shoulder into abduction and internal rotation, with the arm flexed to 90°. Strike the triceps tendon with a tendon hammer.
  • Patellar - with the patient supine, support the knee from underneath providing slight flexion and strike the patellar tendon below the patella.
  • Achilles - flex the knee, externally rotate the hip and dorsiflex the foot. Strike the Achilles tendon of the heel.
Diabetics often exhibit onycholysis of the nails, and poor diabetic control can lead to increased infection risk and paronychias.
  • How to Assess

  • Ask the patient to cover one eye, look at a Snellen chart (wall-mounted at 6m or handheld at arm's length) and identify the smallest line that they can read.
  • How to Perform

  • Auscultate within the triangle bound by the mandible, sternocleidomastoid and thyroid cartilage. Ask the patient to hold their breath.
  • Look For

  • Fixed flexion deformity of one or more fingers, associated with a nodule or cord over the palm proximal to the deformity.
Ulcers, or non-healing open wounds, may occur in the lower limb in the context of arterial disease, venous disease or peripheral neuropathy.
  • How to Assess

  • Light touch - Ask the patient to close their eyes. Using a cotton ball or microfilament, gently touch each dermatome / nerve distribution and ask the patient if they can feel the stimulus. Compare sides and proximally / distally.Spinothalamic tract & dorsal column - medial lemniscus pathway
  • Pain - demonstrate a sharp stimulus by touching the patient lightly on the chest with a neurotip. Ask the patient to close their eyes, and test each dermatome / nerve distribution alternating between the sharp and dull sides of the neurotip at random. Ask the patient if they percieve the stimulus as sharp or dull.Spinothalamic tract
  • Vibration - with the patient's eyes closed, place a vibrating 128hz tuning fork over the interphalangeal joint of the great toe. Ask the patient to describe the sensation. If they can feel it vibrating, progressively diminish the vibration until they cannot feel it. If they cannot feel it vibrating, test on the medial / lateral malleolus and then the tibial tuberosity.Dorsal column - medial lemniscus pathway
  • Proprioception - ask the patient to observe as you demonstrate upward and downward movement of the great toe. With their eyes closed, slowly move the joint over one to two seconds to the upward or downward position. Ask the patient to report whether the toe has been moved up or down. Repeat several times, and then repeat on the other side.Dorsal colun - medial lemniscus pathway
  • How to Assess

  • With the back of the hand, feel from the top of the calf to the dorsum of the foot. Note if there is any change in temperature distally.

Comprehension

Written comprehension - show a written instruction, e.g.

Overview

  • How to Assess

  • Gestures - ask the patient to mirror both meaningful (waving) and non-meaningful (hand positioning) movement.
  • Fist-palm-edge - ask the patient to place a fist onto the table (or onto their knee), and then their palm, and then the edge of their hand. Begin by performing these tasks with the patient and then watch as they attempt them alone.
  • Ask the patient to demonstrate  how they would use a hammer, comb or scissors.
The patient's level of consciousness is an assessment of their wakefulness and responsiveness to external stimuli.
  • Overlapping pentagons - ask the patient to copy a diagram of overlapping pentagons.
  • Overlapping pentagons - ask the patient to copy a diagram of overlapping pentagons.
  • Look For

  • Rhythmic, involuntary vibration of one or more body parts. Note whether the tremor is worse with movement and whether it increases with target-directed movement (increases on approaching a target).
  • Signs of Myotonic Dystrophy

  • Myopathic facies - temporalis wasting, mandibular wasting, frontal baldness
  • Flaccid dysarthria - nasal speech, breathiness, monotony, impaired articulation
  • Warm-up phenomenon - grip myotonia, repeated eye closure
  • Percussion myotonia - muscle contraction with percussion of the thenar eminence
  • Wasting of the forearm and small muscles of the hand
  • Distal muscle weakness
  • Hyporeflexia
The patient's ability to perform fine motor tasks is an indicator of their ability to perform functional tasks such as writing and cooking.
The biceps, triceps and supinator reflexes are the major motor reflexes of the upper limb. The strength of the reflex, elicited by tapping on the appropriate tendon, can aid in localising a patient's weakness to the upper motor neuron or lower motor neuron.
Segmental syndrome - sensory loss and upper motor neuron weakness below the affected level, with bladder and bowel dysfunctionComplete transection of the cord
  • Signs of Radiculopathy

  • Lower motor neuron weakness affecting a myotomal distribution
  • Sensory loss affecting a dermatomal distribution
Assessment of tone is the first part of the motor assessment, and is a good starting point and screening tool in that abnormal tone can immediately suggest an upper motor neuron lesion or Parkinsonism.

Cutaneous Manifestations of Neurologic Disease

  • Signs of Neurofibromatosis Type 1 (NF1)

  • Neurofibromata: non-painful rubbery skin tumours
  • Cafe au Lait spots: flat (macular) patches of hyperpigmentation

Overview

  • Signs of Brachial Plexopathy

  • Lower motor neurone weakness affecting multiple myotomes / peripheral nerve distributions
  • Sensory loss affecting multiple dermatomes / peripheral nerve distributions
  • Horner's syndrome - miosis, partial ptosis, anhydrosis
  • Test For

  • Carpal tunnel syndrome (median nerve compression)
Peripheral polyneuropathy presents with motor, sensory or mixed deficits affecting multiple (usually symmetrical) nerve distributions, without a clear pattern of involvement affecting a nerve root or peripheral nerve distribution.
Neurological causes of weakness may be delineated into upper motor neuron (brain, brainstem or spinal cord) or lower motor neuron (nerve root, plexus or peripheral nerve) causes. These two broad groups manifest with specific findings elicitable on examination.
Power assessment is a key part of the motor examination, and can be used to identify focal or global weakness.
Patients with myaesthenic syndromes exhibit muscle fatigability, or the inability to maintain contraction of muscles over time.
  • Signs of Multiple Sclerosis

  • Signs of optic neuritis - reduced visual acuity, central visual loss, optic disc atrophy
  • Internuclear ophthalmoplegia - inability to adduct one eye, with nystagmus in the other eye
  • Lhermitte's sign - electric sensation in the limbs on neck flexion
  • Upper motor neuron weakness - increased tone, reduced power, hyperreflexia
  • Dorsal column (vibration / proprioception) sensory loss
  • Signs of cerebellar involvement - ataxia, dysarthria, dysmetria, dysdiadochokinesis, nystagmus
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Peripheral mononeuropathy is a type of peripheral neuropathy affecting a single peripheral nerve.
Mononeuritis multiplex (also known as mononeuropathy multiplex and multiple mononeuropathy) is a peripheral neuropathy that affects two or more peripheral nerves.
Sensation is a key aspect of the nervous system, and includes many different modalities. By thoroughly assessing the pattern of sensory loss it is possible to characterise and localise a central or peripheral nervous lesion.
  • Signs of Motor Neurone Disease

  • Bulbar palsy (LMN) - nasal speech, absent gag reflex, tongue wasting and fasciculations, absent palate rise, absent (i.e. normal) jaw jerk
  • Pseudobulbar palsy (UMN) - dysarthria, increased / normal gag reflex, tongue spasticity, absent palate rise, increased jaw jerk
  • Upper motor neuron signs - increased tone, clonus, reduced power, hyperreflexia, upgoing plantar reflex
  • Lower motor neuron signs - muscle wasting, fasciculations, reduced tone, reduced power, hyporeflexia, downgoing plantar reflex
  • Signs of Chronic Inflammatory Demyelinating Polyneuropathy

  • Foot drop
  • Symmetrical lower motor neuron weakness - distal predominance affecting the upper limb more than the lower limb
  • Sensory loss distally (glove and stocking distribution)
  • Clinical Features

  • Resting tremor
  • Rigidity - leadpipe, cogwheel
  • Akinesia - hypokinesia (small movements), bradykinesia (slow movements)
  • Postural instability - reduced postural reflexes
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.

Abnormal Posturing

  • Look For

  • Abnormal flexion and / or extension of limbs, in an uncomfortable position.

Overview

Proximal weakness is most commonly a manifestation of muscular pathology, though may also occur in certain neurologic conditions.
Asterixis, also known as hepatic flap or uraemic flap, is an important sign of metabolic encephalopathy that occurs due to dysregulation of the diencephalic motor centers in the brain that regulate innervation of muscles responsible for maintaining position.
In the context of the gastrointestinal examination, it is important to inspect for jaundice as well as bronzing of the skin, as these signs may suggest the presence of liver disease or haemochromatosis.
The patient's body habitus provides insight into a patient's diet and metabolic status as well as their overall risk of cardiovascular and non-cardiovascular complications in the future. While static measures such as body habitus and waist-hip ratio can estimate future risk, unexpected change in weight may suggest active disease.

Candidiasis

  • Look For

  • Creamy white lesions present on the tongue or inner cheeks, which may be associated with angular cheilitis or glossitis.

Overview

Examination of the supraclavicular lymph nodes is of particular importance in the gastrointestinal exam, as enlargement of Virchow's node (the left supraclavicular node) may occur due to embolisation of a GI tumour.
Examination of the lips may provide valuable insights into a patient's nutritional and immune status. Localised pathology may also be picked up by examining the lips.
During the gastrointestinal examination, inspection of the hands is important as it may reveal signs of chronic liver disease or anaemia.
Examination of the skin of the abdomen can reveal significant clues regarding the presence of portal hypertension, previous abdominal distension and previous abdominal procedures.
Palpation of the liver can be used to assess the liver span and consistency, as well as for tenderness over the liver or gallbladder.

Digital Clubbing

  • Look For

  • Enlargement of the distal segments of the fingers and / or toes, due to proliferation of connective tissue.

Overview

During the gastrointestinal examination, inspection of the skin can reveal skin changes that can point toward a specific GI or hepatobiliary pathology.

Rectal Masses

  • Feel For

  • A mass within the rectum.

Renal Bruits

  • How to Elicit

  • Listen over the upper abdomen, approximately 2cm superior and lateral to the umbilicus on either side.

Common Signs on the Tongue

Dry TongueDehydration

Overview

During the gastrointestinal examination the flanks are often ignored in favour of the abdomen, however there is valuable information to be gained from inspecting and palpating the flanks routinely.
  • How to Assess

  • Use the palpating finger to assess the resting tone of the anus. Ask the patient to squeeze down against the finger.

Poor Dentition

  • Look For

  • The number and overall health of the teeth, and the presence of any carious or erosive lesions.

Overview

Peritonism refers to inflammation of the peritoneum, which suggests acute abdominal pathology that should be rapidly diagnosed and treated.
There are several pathognomonic and diagnostic signs to be found on inspection of the eyes.

Dehydration

  • Look For

  • Abnormal obs - tachycardia, hypotension
  • Fluid balance chart - negative fluid balance, oliguria
  • Weight loss - an acute decrease in weight may indicate short-term change in fluid status
  • Dry mucous membranes - especially the tongue
  • Sunken eyes
  • Increased capillary refill time (>2 seconds)
  • Weak radial pulse
  • Decreased skin turgor - pinch a fold of skin on the patient's arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.

Overview

Patients with hepatic encephalopathy in the setting of acute or chronic liver disease may be confused or have a reduced level of consciousness.
Auscultation for the character of the bowel sounds may reveal evidence of hyperactive or underactive bowels.
Consent - ask for the patient's consent to perform a digital rectal examination. Explain what to expect.
Lymphadenopathy refers to enlargement of the lymph nodes, which is often painful. It is important to carefully assess for lymph node enlargement, this suggests infective, inflammatory or malignant pathology.
Nail signs such as leukonychia and koilonychia are useful external signs of gastrointestinal or hepatobiliary pathology.
The patient's breath may reveal information about their oral hygiene, or suggest the presence of metabolic disease.
Ask the patient to indicate where on the abdomen is painful. Superficially palpate the nine segments of the abdomen to elicit tenderness and assess for masses. If no tenderness is present, palpate more deeply.
Ascites (fluid within the peritoneal cavity) may be caused by many conditions - particularly cirrhosis, heart failure and hypoalbuminaemia. Ascites can be difficult to diagnose on examination, however shifting dullness and the fluid wave can assist in assessing for abdominal fluid.
Appendicitis is an emergency that should be rapidly diagnosed and treated, however this is often difficult clinically - especially in female patients. Signs such as tenderness in McBurney's point as well as the Rosving sign can suggest acute appendicitis.
It is possible to identify an abdominal aortic aneurysm by clinical examination; the aneurysm may be visible on inspection or become apparent on palpation.
The arms can provide a lot of information regarding a patient's liver disease; spider naevi and Bier spots are signs of chronic liver disease, purpura may suggest an underlying coagulopathy and scratch marks suggest an obstructive cause of liver disease.
Inspection of the chest during the gastrointestinal exam can reveal disease specific rashes, as well as signs of cirrhosis such as spider naevi and loss of normal chest hair distribution.

Gingival Inflammation

Gingivitis - generalised swelling and erythema.Viral / bacterial / fungal infection, trauma, lichen planus, pemphigoid, erythema multiforme, SLE, drugs, malnutrition

Overview

The kidneys are often missed during examination of the abdomen, though the presence of ballotable or tender kidneys can provide a significant amount of information about the cause of their presentation.

First Steps

Consent - ask for the patient's consent to perform a digital rectal examination. Explain what to expect.

Overview

Chronic liver disease is a common condition most often caused by alcohol, fatty liver disease or viral hepatitis. This condition can be difficult to diagnose, and the examination is crucial for identifying evidence of portal hypertension, oestrogen excess encephalopathy and other complications of cirrhosis.
  • Look for

  • The patient's current weight
  • Change in weight - compare to past weights
  • Time course of weight change - sudden or over time

Joint Swelling

  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.

Focal Abdominal Tenderness

Right hypochondrium - liver, gallbladder, stomach, hepatic flexure of colon, lungGallstones, peptic ulcer

Overview

Inspecting the patient's skin for evidence of pallor, plethora or jaundice provide information regarding the presence of anaemia, polycythaemia or haemolysis.
The nails can reveal signs suggestive of haematologic disease. While pallor of the nail bed is a sign of anaemia, koilonychia suggests potential iron deficiency.

Chest Wall Tenderness

  • How to Elicit

  • Gently palpate the chest wall, checking for tenderness. Ask the patient where is tender, and watch their face for nonverbal cues.

Palmar Crease Pallor

  • Look For

  • Loss of colour in the creases of the palm.

Overview

The axillary lymph nodes drain from the neck, chest wall, breast and upper limbs. Enlargement of these lymph nodes can suggest pathology affecting these regions or a systemic process that is infective, inflammatory or malignant.
Splenomegaly is present if the spleen is palpable. This may be a sign of portal hypertension due to liver, vascular or pulmonary disease; splenomegaly also occurs with certain infections and haematologic malignancies.

Bony Tenderness

  • How to Elicit

  • Gently press over the bony prominences of the lower limb, asking the patient if this elicits pain.

Hepatomegaly

  • Feel For

  • The size of the  liver, by estimating the location of the upper and lower liver edges.

Joint Swelling

  • Look For

  • Generalised swelling over one or both upper limbs. May be associated with redness, tenderness or warmth.

Purpura

  • Look For

  • Red / purple lesions that do not blanch with pressure. May be present over the head, arms, legs, chest or abdomen.

Overview

Lymphadenopathy refers to enlargement of the lymph nodes, which is often painful. It is important to carefully assess for lymph node enlargement, as this suggests infective, inflammatory or malignant pathology.

Oropharyngeal Inspection

  • How to Perform

  • Ask the patient to open their mouth and make an 'ahh' sound, in order to contract the palate and uvula. Depress the tongue if required in order to visualise the posterior pharynx.

Overview

  • Feel For

    A palpable mass within the abdomen, noting its:
  • Location
  • Size
  • Shape
  • Consistency
  • Mobility
  • How to Perform

  • Using the pulps of the fingers, gently palpate the lymph nodes along the inguinal ligament and down the medial aspect of the thigh.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
The term nystagmus is used mainly to refer to jerk nystagmus, abnormal rhythmic eye movements that may be a sign of cerebellar disease.
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
  • Interpretation

  • Ask the patient to walk with the heel of the front foot making direct contact with the first toe of the back foot.

Testing for Station

  • How to Assess

  • Ask the patient to stand still with their heels together.

Overview

The finger-nose test is used to assess coordinated, target-driven movement of the upper limb; this is lost in the context of cerebellar pathology.
Dysdiadochokinesis is the inability to perform rapidly alternating contractions of agonist and antagonist muscles.
  • How to Perform

  • With the patient supine, ask them to place their left heel onto their right shin just below the knee. Ask them to slowly and accurately run their heel down the length of the shin to the top of the foot. Ask the patient to repeat this several times, and then perform the same test on the other side.
  • How to Elicit

  • Ask the patient to rapidly tap your hand with the dorsum of their foot (dorsiflexion and plantar flexion).
  • Interpretation

  • Ask the patient to walk on their toes.
  • How to Assess

  • Ask the patient to walk on their heels.
  • Signs of Conductive Dysphasia

  • Inability to repeat phrases
  • Recognition of errors (unlike in receptive dysphasia)
  • Paraphasias: switching of a word in a sentence for another incorrect word
  • Neologisms: new words created by the patient
Ataxic dysarthria is also know as 'scanning speech' or 'drunken speech'.

Facial Asymmetry

  • Look For

  • Drooping of one side of the face. Compare the angles of the mouth on both sides. Determine whether the eyebrow is spared on the affected side or not.

Overview

  • Signs of Flaccid Dysarthria

  • Hypernasal speech
  • Breathiness of voice
  • Monotone speech - single pitch, single loudness
  • Impaired articulation - imprecise consonants
  • Shortened phrases
  • Drooling
  • How to Perform

    Ask the patient to repeat back words or sentences of increasing complexity.
  • Orange
  • Watch
  • Hippopotamus
  • Aubergine
  • Emerald
  • Perimeter
  • No ifs, ands or buts
  • British constitution
  • The orchestra played and the audience applauded
  • How to Perform

  • Ask the patient to read a paragraph aloud, or count to twenty.
  • Ask About

  • Time - day, date, month, year, season
  • Place - floor, building, city, state, country
  • Person - full name, date of birth, address
Agrammatism is the incorrect use of grammar.
Repetition of simple sounds is useful for identifying weakness of the muscles involved in articulation

Dysphonia

  • Signs of Dysphonia

  • Hoarse voice
  • Bovine cough

Overview

  • Aspects of Fluency

  • Rate of speech - words or syllables per minute
  • Continuity of speech - lack of hesitation or pauses
  • Effort of speech - due to muscular, word-finding or sentence structure difficulty
  • Interjections - added sounds such as um, ah
  • Repetition - word or syllable repetition, e.g. stuttering
  • Paraphasias: switching of a word in a sentence for another incorrect word
  • Neologisms: new words created by the patient
Also known as Wernicke's dysphasia.
  • Signs of Hyperkinetic Dysarthria

  • Involuntary movements - single or repetitive
  • Harsh voice - strained-strangled quality
  • Signs of Spastic Dysarthria

  • Slow speech
  • Harsh voice - strained-strangled quality
  • Impaired articulation - imprecise consonants
  • Signs of Hypokinetic Dysarthria

  • Hypophonia: quiet speech
  • Monotonous speech
  • Reduced mouth opening
  • Short runs of speech with inappropriate silences
Also known as Broca's dysphasia.
  • Signs of Nominal Dysphasia

  • Anomia: the inability to name objects
  • Circumlocution: talking around a specific word, rather than saying it directly. E.g. 'a tool that I use to write with' rather than 'pen'
  • Look For

  • The pulsation of the jugular vein, between the sternal and clavicular heads of the sternocleidomastoid.
Listen to each of the cardiac areas for normal / pathologic heart sounds, a pericardial rub and for the presence of a murmur.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.
Human body temperature is a balance of heat production and heat dissipation, and tends to vary very little within an individual. Temperature is regulated by the hypothalamus, which drives thermoregulatory processes that include vasoconstriction / vasodilation, sweating and shivering.
Decreased skin turgor is a sign of dehydration.
  • Assessing for Airway Patency

  • If the patient is talking then this suggests that their airway is patent (however, this is not always the case)
  • Look, listen and feel for movement of air
  • Stridor (musical, high-pitched sounds) suggests upper airway obstruction
  • Snoring is a sign of airway compromise
  • Paradoxical abdominal movement is a sign
The respiratory rate is an important vital sign that is an early marker of deterioration.
Auscultate the abdomen for bowel sounds. First listen in one quadrant and if an abnormality is discovered then listen in each of the three other quadrants.
Palpate the radial pulse for at least thirty seconds and determine whether the beats fall in time or are irregular.
Look for swelling of the lower limbs; apply pressure to the anterior aspect of the tibia for fifteen seconds and then release to assess for pitting oedema.
The oxygen saturation is a reflection of the percentage of haemoglobin that is bound to oxygen.
The Glasgow Coma Scale (GCS) is a 15-point scale indicating level of consciousness.

Breath Sounds

  • Interpretation

  • Vesicular breath sounds: soft, non-musical, heard in inspiration and early expiration
  • Bronchial breath sounds - hollow sounds similar to those normally heard over the trachea

Abdominal Tenderness

Ask the patient to indicate where on the abdomen is painful. Superficially palpate the nine segments of the abdomen to elicit tenderness. If none is present, palpate more deeply.

Overview

The heart rate is an invaluable vital sign that is commonly used as part of the assessment of a patient's haemodynamic state.

Assessing the Calves

Look at and feel the patient's calves, looking for signs of deep venous thrombosis.

Overview

The blood sugar should be tested in every acutely unwell person, mainly because hypoglycaemia is an underdiagnosed cause of reduced consciousness, and can mimic stroke symptoms.
There are multiple clinical signs that suggest hypoperfusion, or shock.

Inspection of Pupils

  • Look For

  • The size of the pupils (dilated, normal, constricted) and equality of size bilaterally.

Overview

The presence of respiratory distress indicates that the patient has significant pathology (respiratory or otherwise) that requires immediate assessment and management.
Human body temperature is a balance of heat production and heat dissipation, and tends to vary very little within an individual. Temperature is regulated by the hypothalamus, which drives thermoregulatory processes that include vasoconstriction / vasodilation, sweating and shivering.
The oxygen saturation is a reflection of the percentage of haemoglobin that is bound to oxygen.

  • The respiratory rate is an important vital sign that is an early marker of deterioration.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.
The heart rate is an invaluable vital sign that is commonly used as part of the assessment of a patient's haemodynamic state.
The residual volume is the volume left in the lungs after a maximal expiration.
While spirometric values such as FEV₁ and FVC can be suggestive of restrictive lung disease,  a reduced total lung capacity (TLC) of 80% predicted is diagnostic.
Lung volumes are measures of the amount of gas present within the lungs during each phase of the respiratory cycle. These volumes can be used clinically to diagnose respiratory disease.
The volume-time graph is a graphical representation of spirometry results.
Flow-volume loops are produced by asking the patient to breath out then in as forcefully as possible, and may reveal a characteristic pattern suggestive of restrictive, obstructive or other pulmonary disease.
Diffusing Capacity of Lung for Carbon Monoxide (DLCO) is a measure of the efficiency of lung gas transfer. This test is used to further characterise a respiratory defect following spirometry and lung volume testing, to provide evidence supporting a specific respiratory pathology.
The total lung capacity refers to the volume of air within the lungs after a maximal inspiration.
The functional residual capacity (FRC) is the volume left in the lungs after passive expiration, i.e. without use of accessory muscles.
Correct spirometry technique is vital for collecting an accurate sample, and poor compliance with the test may result in a false positive or false negative result.
    • Normal Range

    • 25 - 40 sec
  • Important Lab Points

  • Measures the level of anti-Xa activity in a sample.
  • Performed by adding a known amount of factor Xa to a plasma sample and then measuring the residual Xa level; this is inversely proportional to the amount of anti-Xa activity.
  • The result is measured against a curve specific to the medication being monitored - e.g. low molecular weight heparin, rivaroxaban, dabigatran, fondaparinux or danaparoid.
Coagulation testing is useful for assessing patients' ability to clot; for investigating the cause of a patient's coagulopathy; and for therapeutic monitoring of certain anticoagulant medications. The classical coagulation profile includes the prothrombin time and activated partial thromboplastin time, though other tests may be performed as required.
The thrombin time (TT) is not routinely performed as part of a coagulation screen.
    • Normal Range

    • 1.5 - 4.5 g/L
Fibrin D-dimer is a measurement of cross-linked fibrin degradation products, generally indicative of clot formation with active clot breakdown.
The prothrombin time (PT) and international normalised ratio (INR) are measures of the extrinsic coagulation pathway. 
Mixing studies are used to determine the cause of prolonged PT/INR and/or APTT.
    • Normal Range

    • 5 - 20 cmH₂O
    • Normal Range

    • <5 x 10⁶
    • Normal Range

    • <10 x 10⁶
    • Normal Range

    • 15 - 45 mg/dL
Analysis of cerebrospinal fluid is used to identify infections affecting the central nervous system. CSF testing (particularly of proteins) also be used in the diagnosis of demyelinating diseases such as Guillain-Barre syndrome and multiple sclerosis.
The colour and consistency of a patient's urine can provide significant information regarding the cause of their urinary complaint. 
The urine specific gravity is a measure of the amount of solute compared to water. Pure water has a specific gravity of 1.000.
Urine pH is a measure of the acid content in urine. This often reflects the acidity of serum, however there are certain cases (e.g. renal tubular acidosis) in which the urine pH does not match the serum pH.
There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.
Leukocyte esterase (LE) is an enzyme produced by white blood cells. If leukocyte esterase is present in urine then this is indicative of an increase in leukocytes in urine, also known as pyuria. 
First degree sinoatrial exit block is due to delayed transmission of an impulse from the sinoatrial node, and is not detectable on ECG.
Type II second degree AV block occurs when there is an intermittently missed QRS complex due to failure of conduction through the AV node.
Also known as Wenkebach SA exit block.
Type I second degree AV block occurs when there is progressively delayed AV transmission eventually resulting in a missed QRS complex.
Sinoatrial exit block is a delay in conduction between the sinoatrial node and atrial myocardium.
Atrioventricular (AV) block occurs due to delayed conduction of an impulse between the atria or ventricles, due to intrinsic or extrinsic causes.
In advanced or 'high-grade' second degree heart block, multiple beats are blocked and it is difficult to distinguish between Mobitz type I and II.
Complete atrioventricular block represents complete failure of conduction between the atria and ventricles.
First degree AV block indicates delayed conduction between the atria and the ventricles.
In third degree sinoatrial exit block, there is complete failure of transmission to the atria - this is indistinguishable from sinus arrest on ECG.
Type II second degree sinoatrial exit block occurs when there is an intermittently missed P wave due to failure of conduction to the atrial myocardium.
Reticulocytes are non-nucleated immature red blood cells. They are not normally present in the circulation in high numbers, though may be seen if the bone marrow is producing large numbers of red cells.
Neutrophils are the most prevalent white blood cells in circulation. They are a type of polymorphonuclear (PMN) leukocyte, with 3-5 nuclear lobes and fine granules within the cytoplasm.
Eosinophils are granulocytes with a bilobed nucleus, blue cytoplasm and orange-red cytoplasmic granules
Anaemia is a very common condition that may occur in the context of reduced red blood cell production, increased red blood cell destruction, or red blood cell loss.
Beta thalassaemia is an inherited defect in beta globin chains of haemoglobin, resulting in defective haemoglobin synthesis.
The mean cell volume (MCV) is a measure of the average volume of a red blood cell.
Lymphocytes are small leukocytes with a large nucleus, though they may be larger with a low nuclear : cytoplasmic ratio if they are reactive.
  • The mean corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin concentration (MCHC) are red blood cell indices which confer whether a cell is normochromic, hyperchromic or hypochromic.
  • Mean corpuscular haemoglobin (MCH) - the average amount of haemoglobin per red blood cell
  • mean corpuscular haemoglobin concentration (MCHC) - the average concentration of haemoglobin within red blood cells
Red cell distribution width (RDW) is the amount of variation in red blood cell size. Cells may be relatively uniform in size and have a low RDW, or have a wide range of sizes and have a high RDW.
Platelets are very small non-nucleated cells that derive from fragmentation of megakaryocytes. They play an important role in clot formation and haemostasis.
Reflects the number of circulating red blood cells.
Alpha thalassaemia is an inherited condition affecting the alpha chains of haemoglobin, resulting in defective haemoglobin synthesis.
Leukocytes represent a variety of cells derived from myeloid and lymphoid lineages that perform a variety of immune functions.
Basophils are relatively uncommon white blood cells. Morphologically they are granulocytes with large bluish (basophilic) granules. 
Haemoglobin is a tetrameric protein found within red blood cells, composed of a haem (iron-containing) molecule, two alpha and two beta globin subunits.
Monocytes are large leukocytes of myeloid origin with blue-grey ground glass cytoplasm and horseshoe-shaped nucleus.
The haematocrit, also known as the packed cell volume (PCV), is the volume of red blood cells as a percentage of total blood volume.
The anaemia of chronic disease is a common condition that is associated with chronic infection, inflammation or malignancy where patients develop a non-specific anaemia.
Sickle cell anaemia is an inherited disorder affecting haemoglobin synthesis, resulting in 'sickling' of red blood cells and resultant complications.
The PaO₂ on an arterial blood is only relevant for assessing for hypoxia when the patient is on room air.  If they are receiving supplemental oxygen this will artificially increase the PaO₂ which may appear normal.
Respiratory acidosis is a process by which reduced effective ventilation results in carbon dioxide retention.
The bicarbonate level is significantly influenced by acid-base buffering system, and can by affected by the presence of a respiratory process. The base excess is an indicator of a metabolic process that is independent of this buffering system.
The serum pH is a measure of the acidity of alkalinity of the blood, based on an inverse log of the hydrogen ion concentration. This can be used in conjunction with the HCO₃ and PaCO₂ to determine whether there is an acid-base disorder present.
Serum lactate is an important marker of prognosis and resolution in many critical illnesses.
  • Look For

  • Alkalaemia with raised bicarbonate.
Metabolic acidosis is a process in which an external agent or internal process is causing excessive acidity in a way that is metabolic (i.e. non-respiratory).
Left heart failure typically manifests with interstitial and pulmonary oedema, and is most commonly caused by pathology affecting the left ventricular myocardium.
When auscultating the heart, systematically listen to each of the cardiac regions for a heart sounds, murmurs or a rub. If added heart sounds or a murmur are noted, determine which area the extra sound is loudest in, and then perform manoeuvres to further isolate the added sound.
In the context of the cardiovascular examination, inspecting the mouth can reveal information about the patient's dentition, reveal evidence of hypoxia or suggest the presence of a hereditary or congenital disorder.

Pacemakers

  • Look For

  • A mass in the left subclavicular area.

Overview

Skin changes and overall poor skin condition of the lower limb may occur due to soft tissue disease; arterial, venous or lymphatic insufficiency; loss of afferent nerve supply or simply poor self-care.
  • How to Assess

  • Auscultate while palpating the pulse (preferably the carotid). Identify whether the murmur is systolic (between S1 and S2), diastolic (between S2 and S1 of the next cardiac cycle) or continuous.
Palpating the praecordium for palpable heaves and thrills may provide valuable clues regarding the patient's cardiac pathology.
The main priorities in auscultating the lung fields during the cardiovascular examination are to assess for evidence of pulmonary oedema or a pleural effusion.
Listening for cardiac murmurs in different positions as well as in inspiration and expiration can be used to narrow down the potential cause for the murmur.
Right heart failure typically manifests with peripheral overload - resulting in findings such as a raised JVP, peripheral oedema, pleural effusions and ascites.
  • How to Assess

  • With the back of the hand, feel from the top of the calf to the dorsum of the foot. Note if there is any change in temperature distally.
Aortic stenosis manifests as an ejection (mid) systolic murmur best heard over the base of the heart, associated with narrowed pulse pressure and reduced intensity of S2.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.
  • How to Assess

  • With the tips of the fingers, palpate for the most inferior and lateral point at which the cardiac impulse is clearly palpable.
Oedema or swelling of the lower limb occurs due to fluid accumulation, and may be either pitting or non-pitting.
In the context of the cardiovascular examination, inspection of the skin can provide important information about the patient's peripheral perfusion and oxygenation.
Aortic regurgitation manifests as a descrescendo diastolic murmur, heard loudest on sitting forward on expiration.
Mitral regurgitation examines as a pan-systolic murmur best heard over the apex with a volume-loaded heart, soft S1 and present S3 with or without evidence of left ventricular failure.
Right ventricular failure may manifest as hepatomegaly, splenomegaly and ascites; demonstrating these findings can help to clinch the clinical diagnosis. An important target for palpation in the cardiovascular examination is also the abdominal aorta, as an undiagnosed aneurysm may be fatal in the future.
Scars on the chest can suggest past surgery, trauma, burns or healed skin conditions.
There are several pathognomonic and diagnostic signs to be found on inspection of the eyes.
Whether a delay occurs between two radial arteries or between the radial artery and femoral artery depends on whether the lesion is proximal or distal to the branching of the left subclavian.
Palpation of the rate and rhythm of the radial pulse is a useful screening tool for the presence of cardiac arrhythmias.
Down syndrome occurs as a result of trisomy 21, or three copies of chromosome 21.
Hypertrophic Cardiomyopathy (HCM) is a disorder that  causes left ventricular hypertrophy (particularly of the interventricular septum), which may be obstructive or non-obstructive.
Pulmonary hypertension refers to a heterogeneous and functionally limiting group of disorders that result in increased pressure within the pulmonary arteries.
Mitral stenosis manifests as a low-pitched, mid-diastolic murmur best heard in the apex in the left lateral position.
Turner syndrome occurs secondary to monosomy X, where all or part of an X chromosome is missing, or due to duplication of the long arm of one X chromosome.
When performing a cardiovascular examination, always ask to perform fundoscopy. This may reveal signs of diabetic or hypertensive nephropathy.
Pulmonary stenosis manifests as an ejection systolic murmur heard loudest over the pulmonary area on inspiration, and may be associated with a split S2 and S4.
The second heart sound (S2) indicates closure of the aortic (A2) and pulmonary (P2) valves.
A patent ductus arteriosus is the persistence post birth of a blood vessel connecting the pulmonary artery and the aorta.
Tricuspid regurgitation manifests as a pan-systolic murmur best heard at the left lower sternal edge on inspiration.
Dynamic manoeuvres are useful for distinguishing between hypertrophic cardiomyopathy and aortic stenosis in the presence of a systolic murmur.
The waist circumference and waist-hip ratio are markers of central obesity, with evidence to support their use in estimating cardiovascular risk.

Resting Tremor

  • Look For

  • Tremor while at rest, that decreases with target-directed movement.

Anosmia

Loss of sense of smell is a classic early finding in Parkinson's disease.

Overview

Postural hypotension may be present in a patient with Parkinson's disease, as they may develop autonomic neuropathy.
  • How to Assess

  • Ask the patient to relax and allow you to move their arms. Move the shoulder, elbow, wrist and fingers passively through their range of motion, looking for rigidity.
The mask-like facies seen in Parkinsonism is also referred to as hypomimia, and occurs as a manifestation of bradykinesia and hypokinesia.
  • Ask About

  • Time - day, date, month, year, season
  • Place - floor, building, city, state, country
  • Person - full name, date of birth, address
  • Situation - why the patient is in hospital, who the prime minister is
  • Clinical Features

  • Resting tremor
  • Rigidity - leadpipe, cogwheel
  • Akinesia - hypokinesia (small movements), bradykinesia (slow movements)
  • Postural instability - reduced postural reflexes
  • How to Elicit

  • Percuss repeatedly between the eyebrows, looking for reactive blinking.
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Patients with myaesthenic syndromes exhibit muscle fatigability, or the inability to maintain contraction of muscles over time.
The patellar and ankle reflexes are the major motor reflexes of the lower limb. The strength of the reflex, elicited by tapping on the appropriate tendon, can aid in localising a patient's weakness to the upper motor neuron or lower motor neuron.

Abnormal Posturing

  • Look For

  • Abnormal flexion and / or extension of limbs, in an uncomfortable position.

Cutaneous Manifestations of Neurologic Disease

  • Signs of Neurofibromatosis Type 1 (NF1)

  • Neurofibromata: non-painful rubbery skin tumours
  • Cafe au Lait spots: flat (macular) patches of hyperpigmentation

Overview

Peripheral mononeuropathy is a type of peripheral neuropathy affecting a single peripheral nerve.
Pain sensation is conveyed via the spinothalamic pathway, and mapping of this can be used to determine the distribution of a patient's sensory loss.
Power assessment is a key part of the motor examination, and can be used to identify focal or global weakness.
  • Sensory Modalities

  • Dorsal column pathway - proprioception and vibration sensation; soft touch
  • Spinothalamic pathway - pain and temperature sensation; soft touch
Assessment of tone is the first part of the motor assessment, and is a good starting point and screening tool in that abnormal tone can immediately suggest an upper motor neuron lesion or Parkinsonism.
  • Look For

  • Intermittent shock-like jerks.
  • Look For

  • Spontaneous, abrupt, irregular movements. May manifest in the face, neck, torso, arms or legs.
  • Look For

  • Intermittent stereotyped movements or vocalisations that are suppressible and preceded by an urge.
  • How to Perform

  • Ask the patient to stand still with their heels together, and look for loss of balance.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • Signs of Chronic Inflammatory Demyelinating Polyneuropathy

  • Foot drop
  • Symmetrical lower motor neuron weakness - distal predominance affecting the upper limb more than the lower limb
  • Sensory loss distally (glove and stocking distribution)
  • Signs of Lower Motor Neuron Weakness

  • Muscle wasting
  • Fasciculations
  • Reduced tone
  • Reduced power
  • Hyporeflexia
  • Downgoing plantar reflex

Muscle Wasting

  • Feel For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle, muscle group, limb, or is generalised.

Overview

Mononeuritis multiplex (also known as mononeuropathy multiplex and multiple mononeuropathy) is a peripheral neuropathy that affects two or more peripheral nerves.
  • Look For

  • Sustained or intermittent muscle contractions resulting in abnormal movements or abnormal posturing.
  • Signs of Motor Neurone Disease

  • Bulbar palsy (LMN) - nasal speech, absent gag reflex, tongue wasting and fasciculations, absent palate rise, absent (i.e. normal) jaw jerk
  • Pseudobulbar palsy (UMN) - dysarthria, increased / normal gag reflex, tongue spasticity, absent palate rise, increased jaw jerk
  • Upper motor neuron signs - increased tone, clonus, reduced power, hyperreflexia, upgoing plantar reflex
  • Lower motor neuron signs - muscle wasting, fasciculations, reduced tone, reduced power, hyporeflexia, downgoing plantar reflex
Proprioception is the sense of position and movement of the body in the absence of vision.
  • Look For

  • Rhythmic, involuntary vibration of one or more body parts. Note whether the tremor is worse with movement and whether it increases with target-directed movement (increases on approaching a target).
Soft touch is transmitted via multiple sensory pathways, and can be used as a screening tool to assess for sensory loss.
Also known as pallesthesia
Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Mixed upper and motor neuron signs can occur rarely, and there are few conditions which are able to cause both. The major differential would be the presence of two separate pathologies.
Segmental syndrome - sensory loss and upper motor neuron weakness below the affected level, with bladder and bowel dysfunctionComplete transection of the cord
  • Signs of Upper Motor Neuron Weakness

  • Minimal muscle wasting
  • Spasticity (clasp-knife rigidity) - velocity-dependent increase in tone
  • Clonus - rhythmic contractions in response to a sudden stimulus, e.g. sudden ankle dorsiflexion
  • Reduced power
  • Hyperreflexia
  • Upgoing plantar reflex
Proximal weakness is most commonly a manifestation of muscular pathology, though may also occur in certain neurologic conditions.
  • Signs of Multiple Sclerosis

  • Signs of optic neuritis - reduced visual acuity, central visual loss, optic disc atrophy
  • Internuclear ophthalmoplegia - inability to adduct one eye, with nystagmus in the other eye
  • Lhermitte's sign - electric sensation in the limbs on neck flexion
  • Upper motor neuron weakness - increased tone, reduced power, hyperreflexia
  • Dorsal column (vibration / proprioception) sensory loss
  • Signs of cerebellar involvement - ataxia, dysarthria, dysmetria, dysdiadochokinesis, nystagmus
  • Clinical Features

  • Resting tremor
  • Rigidity - leadpipe, cogwheel
  • Akinesia - hypokinesia (small movements), bradykinesia (slow movements)
  • Postural instability - reduced postural reflexes
  • Manifestations of Radiculopathy

  • Lower motor neuron weakness affecting a myotomal distribution
  • Sensory loss affecting a dermatomal distribution

Motor Assessment

  • Upper and Lower Motor Neuron Signs


Overview

Distal weakness is more commonly a manifestation of neuropathy, though may also occur in certain muscular conditions.
Peripheral polyneuropathy presents with motor, sensory or mixed deficits affecting multiple (usually symmetrical) nerve distributions, without a clear pattern of involvement affecting a nerve root or peripheral nerve distribution.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

Biceps tendon - anteriorly, inserting onto the radial tuberosity.
  • How to Assess

  • Ask the patient to rotate their wrist, with the palm facing downward. Repeat this movement passively.

Muscles Acting on the Elbow Joint

Flexors (anterior) - biceps brachii, brachialis, brachioradialis, pronator teres

Overview

  • How to Assess

  • Ask the patient to open their elbow joint. Then ask them to relax as it is extended passively.

Bony Landmarks of the Elbow

Olecranon - posterior projection of the ulna

Overview

  • How to Assess

  • With the back of the hand, feel from the top of the shoulder to the forearm. Compare both sides.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • Look For

  • Generalised swelling over one or both upper limbs. May be associated with redness, tenderness or warmth.

Muscle Wasting

  • Look For

  • Decreased mass of the muscles affecting the elbow. Note whether wasting is isolated to a single muscle or muscle group, isolated to the upper limb or generalised.

Overview

  • How to Assess

  • Ask the patient to rotate their wrist, with the palm facing upward. Repeat this movement passively.
  • How to Assess

  • Ask the patient to close their elbow joint. Then ask them to relax as it is flexed passively.
  • How to Assess

  • Ask the patient to push their foot upwardly, or push their toes toward their head.
Achilles tendon - posteriorly, attaching the planteris, calcaneus and soleus muscles to the calcaneus.
  • Look For

  • The height of the foot arch - high, normal or flattened.

Muscle Wasting

  • Look For

  • Decreased mass of the muscles affecting the ankle. Note whether wasting is isolated to a single muscle or muscle group, isolated to the lower limb or generalised.

Bony Landmarks of the Ankle

Medial malleolus - of the distal tibia.

Overview

  • How to Assess

  • Ask the patient to push their foot downwardly, or push their toes toward the floor.
  • How to Assess

  • With the back of the hand, assess the temperature around the ankle joint. Compare both sides.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Ask the patient to roll their ankle inwardly, such that the sole of the foot is pointing toward the other foot.
Tibiotalar joint - articulation of the talus with the tibia medially and the fibula laterally, allowing for dorsiflexion and plantar flexion.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
Posterior tibial - palpate posteriorly and inferiorly to the medial malleolus.
  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.

Muscles Acting on the Ankle Joint

Plantar flexors (posterior) - peroneus longus, peroneus brevis, soleus, gastrocnemius, plantaris, tibialis posterior, flexor digitorum longus, flexor hallucis longus

Overview

  • How to Assess

  • Ask the patient to roll their ankle outwardly, such that the sole of the foot is pointing away from the other foot.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
Biceps tendon - lateral, inserting posteriorly onto the fibular head.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Muscles Acting on the Knee Joint

Flexors (posteriorly) - biceps femoris, semitendinosus, semimembranosus, sartorius, gracilis, popliteus, gastrocnemius

Overview

  • How to Assess

  • Inspect the patient's posture while they are standing, sitting and squatting. Inspect from laterally, anteriorly and posteriorly.
  • How to Measure

  • Bend the patient's knee to 90 degrees, gently grasp both sides of the knee joint and palpate within the popliteal fossa posteriorly.
  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.
  • Look For

  • Shoulder drop
  • Abducted arm swing
  • Lateral pelvic tilt
  • Leg circumduction
  • Excessive knee flexion
  • How to Assess

  • Move the knee joint passively through flexion and extension. Note whether any clicks, cracks, snaps or clunks are present.
  • Feel For

  • Tenderness or fullness of the joint line. Palpate in both internal and external rotation.
The medial and lateral collateral ligaments may be palpated on either side of the knee joint.

Muscle Wasting

  • Look For

  • Decreased mass of the muscles affecting the knee. Note whether wasting is isolated to a single muscle or muscle group, isolated to the lower limb or generalised.

Overview

  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • How to Assess

  • With the back of the hand, assess the temperature around the knee joint. Compare both sides.
  • How to Assess

  • Ask the patient to actively extend their knee, and then ask them to relax the joint as it is extended passively.
  • How to Assess

  • With the knee in a neutral position, ask the patient to rotate their foot inwardly. Repeat at 30-90 degrees of flexion.

Bony Landmarks of the Knee

Patella - palpate the superior and inferior poles of the patella, noting its position and mobility.

Overview

Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • How to Assess

  • Ask the patient to actively flex their knee, and then ask them to relax the joint as it is flexed passively.

Major Bursae of the Knee

Prepatellar bursa - between the patella and the overlying subcutaneous tissue. Bursitis presents as pain and swelling over the patella.

Overview

  • How to Assess

  • With the knee in a neutral position, ask the patient to rotate their foot inwardly. Repeat at 30-90 degrees of flexion.
Language assessment is a crucial element of the mental status examination, providing insight into a patient's cognitive and communicative abilities. Key aspects of evaluating language include comprehension, word repetition, object naming, reading, and writing.
Listen to the patient speak on order to assess for a potential speech disorder. Listen to the rate of speech, volume, quantity, fluency and tonality.
The patient's level of arousal is an assessment of how awake and active they are. Patients may be hyperactive or display psychomotor agitation, or conversely show evidence of psychomotor retardation or even stupor.
Thought form refers to the formation and coherence of a patient's thoughts. Formal thought disorders are derangements of this form, resulting in thoughts that are often difficult to follow or understand.
Thought content refers to the subject matter, themes, and ideas that an individual expresses during a mental status examination or clinical interview. Assessing thought content is essential for understanding the individual's current mental state, identifying potential psychiatric conditions, and formulating an appropriate treatment plan.
Attention and concentration are essential cognitive functions that enable individuals to focus on tasks and process information. Key components of assessment include distractibility and digit span.

Assessing Retrograde Memory

The ability to recall old memories prior to significant brain injury or psycho-trauma.

Overview

  • How to Assess

  • Gestures - ask the patient to mirror both meaningful (waving) and non-meaningful (hand positioning) movement.
  • Fist-palm-edge - ask the patient to place a fist onto the table (or onto their knee), and then their palm, and then the edge of their hand. Begin by performing these tasks with the patient and then watch as they attempt them alone.
  • Ask the patient to demonstrate how they would use a hammer, comb or scissors.
Hallucinations are abnormal sensory symptoms that may manifest as visual, auditory, tactile or extraordinary disturbances. Hallucinations may be caused by organic disease or psychiatric disorders.

Constructional Ability

  • Overlapping Pentagons

  • Ask the patient to copy a diagram of overlapping pentagons.
  • Ask the patient to copy a diagram of overlapping pentagons.

Overview

  • Ask About

  • Recent decision-making or by posing a practical dilemma (what should you do if you see smoke coming out of a house?)

Conceptualisation

  • How to Assess

    Ask the patient to identify the similarity between two objects, such as:
  • Bananas and oranges are... both fruit
  • Trains and bicycles are… both modes of transport
  • A watch and a ruler are… both used for measurement

Overview

  • How to Assess

  • Place a hand on the right shoulder and ask the patient to tilt their head to the right. Provide resistance by placing a hand just above the right ear. Repeat the movement on the opposite side.
  • Feel For

  • Costochondral & sternochondral jointsBetween the sternum and the ribs anteriorly. Especially palpate for tenderness.
  • Spinous processesPosterior processes of the vertebrae
  • Interspinous & supraspinous ligamentsConnecting adjacent spinous processes posteriorly
  • Facet jointsBetween vertebrae, lateral to the midline. Especially palpate the cervical facet joints.
  • Costovertebral jointsOf the thoracic vertebrae
  • Sacroiliac joint

Muscle Wasting

  • Look For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle or muscle group, isolated to the back or generalised.

Overview

  • How to Assess

  • Place a hand on the patient's upper back to stabilise the thoracic spine and ask them to look upward. Provide resistance by placing the palm of the other hand on the patient's occiput.
  • How to Assess

  • Ask the patient to lean forward as if to touch their toes.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • How to Assess

  • Ask the patient to run their hand down the side of their right leg, without leaning forward or backward. Repeat on the opposite side.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Ask the patient to lean backward.
  • How to Assess

  • Place a hand on the patient's sternum to stabilise the thoracic spine and ask them to look downward. Provide resistance by placing the palm of the other hand on the patient's forehead.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Stabilise the pelvis and ask the patient to turn their body to the right side. Repeat on the opposite side.
  • Look For

  • The amount of antero-posterior curvature of the cervical spine.
  • How to Assess

  • Place a hand on the right shoulder and ask the patient to turn their head to the left. Provide resistance by placing a hand on the patient's jaw. Repeat the movement on the opposite side.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • Look For

  • The amount of antero-posterior curvature of the thoracic spine. Especially pronounced if the patient leans forward.
  • Look For

  • The amount of antero-posterior curvature of the lumbar spine.

Muscles Acting on the Cervical Spine

Flexors - sternocleidomastoid, scalenes, longus muscles, rectus capitis

Overview

The oropharynx performs both respiratory and digestive functions, and allows for passage of air into the lower airways. Oropharyngeal examination can reveal pathology of the mucosa or tonsils.
Tactile fremitus is an assessment of the low-frequency vibration of a patient's chest, which is used as an indirect measure of the amount of air and density of tissue present within the lungs.
Breath sounds are normally heard on auscultating the chest, and their intensity and character can be used to assess for the presence of pulmonary pathology.
There are several pathognomonic and diagnostic signs to be found on inspection of the eyes.
Watch the patient's pattern of breathing, taking into account the rate, regularity and depth of respiration. Specific patterns of breathing may suggest an underlying pathology.
Chest wall deformities may be an external sign of an underlying disease, or may themselves cause significant restrictive pulmonary disease.

Heart Rate

  • How to Measure

  • Count the number of beats over 15, 30 or 60 seconds and multiply to estimate beats per minute.

Overview

Vocal resonance is an assessment of the density of lung tissue, performed by auscultating the chest and asking the patient to speak. Increased vocal resonance suggests increased density, while reduced vocal resonance suggests an increase in the amount of air present.
  • How to Measure

  • Count the patient's breaths over 30 seconds to one minute while ostensibly measuring the pulse.
The nasal cavity warms, filters and adds moisture to inhaled air. By inspecting the nasal cavity it may be possible to assess for obstruction impeding respiration, inflammation or other pathology.
Carefully inspect the patient's fingers, looking for discolouration of the nail beds and distal digits.

Wasting of Hand Muscles

In the context of the respiratory examination, we examine for muscle wasting as a sign of denervation secondary to an apical lung tumour. A Pancoast tumour in the apex of the lung may compress the brachial plexus and result in localised wasting of the hand.

Digital Clubbing

  • Look For

  • Enlargement of the distal segments of the fingers and / or toes, due to proliferation of connective tissue.

Overview

Chest percussion is used to assess the resonance of the lungs as a surrogate for the amount of air in the alveoli.
The character of a patient's cough suggest of the cause of their respiratory illness.
  • Signs of Lung Cancer

  • General Signs

  • Oxygen
  • Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
  • Cough
  • Sputum - purulent, bloody
  • Lymphadenopathy - cervical, supraclavicular, axillary
  • Signs of Complications

  • Pleural effusion - dull percussion note, reduced breath sounds, reduced vocal resonance
  • Laryngeal nerve involvement - hoarse voice, dysphonic cough
  • SVC obstruction - facial swelling, plethora, upper limb oedema, positive Pemberton's sign
  • Pancoast tumour - Horner's syndrome (partial ptosis, miosis, anhydrosis), wasting of the small muscles of the hand
  • Hypertrophic pulmonary osteodystrophy
  • Signs of Management

  • Scars - from lobectomy or pneumonectomy
  • Radiation tattoos
  • Signs of Bronchiectasis

  • Oxygen requirement - reduced SpO2, nasal prongs
  • Halitosis
  • Cough - moist
  • Sputum - purulent / haemoptysis
  • Clubbing
  • Central cyanosis
  • Coarse crepitations
  • Wheeze
  • Signs of Complications

  • Evidence of empyema - dull percussion note, reduced breath sounds, reduced vocal resonance
  • Evidence of right ventricular failure - raised JVP, ascites, pleural effusions, peripheral oedema
  • Evidence of pulmonary hypertension - raised JVP, parasternal heave, loud / palpable P2
  • Signs of Interstitial Lung Disease

  • General Signs

  • Dry cough
  • Cyanosis
  • Reduced chest expansion
  • Crepitations - fine, end-expiratory
  • Signs Suggesting a Cause

  • Symmetric arthropathy (rheumatoid arthritis)
  • Skin thickening (scleroderma)
  • Lymphadenopathy (sarcoidosis)
  • Signs of Complications

  • Cor pulmonale - raised JVP, ascites, pleural effusions, peripheral oedema
  • Pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
The oxygen saturation is a reflection of the percentage of haemoglobin that is bound to oxygen.
Adventitious sounds are abnormal sounds heard on the chest in inspiration or expiration, in addition to the normal breath sounds.
  • Signs of Pleural Effusion

  • Oxygen requirement - reduced SpO2, oxygen delivery
  • Dull percussion note
  • Reduced tactile fremitus
  • Reduced breath sounds
  • Reduced vocal resonance
Several clinical signs allow for the clinical suspicion of chronic obstructive pulmonary disease, which can then be confirmed with pulmonary function testing.
  • How to Assess

  • The thumb is extended posteriorly, toward the palm.
  • How to Assess

  • The fingers are moved apart in the coronal plane.

Muscles Acting on the Wrist Joint

Flexors (anteromedial) - flexor carpi radialis, palmaris longus, flexor carpi ulnaris

Overview

  • How to Assess

  • The thumb is angulated laterally, away from the hand.
  • Test For

  • Carpal tunnel syndrome (median nerve compression)
  • How to Assess

  • With the back of the hand, feel over the joints of the hands and wrist. Compare both sides.
  • How to Assess

  • The fingers are moved together in the coronal plane.
  • Test For

  • Carpal tunnel syndrome (median nerve compression)
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis
  • How to Assess

  • The fingers are flexed anteriorly, with closing of the fist.
  • How to Assess

  • The wrist is angulated laterally.
  • How to Assess

  • The thumb is flexed anteriorly, away from the palm.
  • How to Assess

  • The thumb is moved diagonally across the palm.

Muscle Wasting

  • Look For

  • Decreased mass of the thenar and/or hypothenar eminence.

Bony Landmarks of the Wrist

Head of ulna - proximally, articulating with the radial head.

Overview

  • How to Assess

  • The wrist joint is extended posteriorly.

Wrist Drop

  • Look For

  • Abnormal flexion of the wrist, due to inability to extend the joint.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Soft Tissue Landmarks of the Wrist

Flexor retinaculum - arches anteriorly over the carpals, covering the carpal tunnel.

Overview

  • How to Assess

  • The wrist is angulated medially.
  • How to Assess

  • The thumb is angulated medially, toward the palm.
  • How to Assess

  • The fingers are extended posteriorly, with opening of the fist.
  • Look For

  • Generalised swelling over a joint, which may be unilateral, bilateral or widespread. May be associated with redness, tenderness or warmth.
  • How to Assess

  • The wrist is flexed anteriorly.
  • Look For

  • Swelling of the lower limb due to fluid accumulation.
  • How to Assess

  • Palpate the common carotid arteries, located in the anterior neck medial to the sternocleidomastoid. Palpate the arteries one at a time. Care should be taken to avoid stimulating the carotid sinus.
Skin changes and overall poor skin condition of the lower limb may occur due to soft tissue disease; arterial, venous or lymphatic insufficiency; loss of afferent nerve supply or simply poor self-care.
Femoral - palpate within the inguinal region, halfway between the pubic symphysis and iliac crest.

Inspection of Pupils

  • Look For

  • The size of the pupils (dilated, normal, constricted) and equality of size bilaterally.

Rashes Associated with Diabetes

Xerosis cutis: abnormally dry skinCold weather, excessive bathing, irritants, advanced age, uraemia, diabetes, hypothyroidism

Overview

In diabetics, always ask to perform fundoscopy. This may provide valuable information regarding the presence of diabetic retinopathy.
Inspection of the colour of the lower limbs in diabetics can suggest the presence of arterial insufficiency, venous insufficiency or infection.
Folate, also known as vitamin B9, is an important coenzyme in DNA and amino acid metabolism pathways.
Vitamin B12, also known as cobalamin, is an important cofactor in the homocysteine metabolism, haemoglobin synthesis and myelination.
A copper-containing protein produced by the liver that binds ~90% of plasma copper.
Lactate dehydrogenase (LDH) is an enzyme present in the cytoplasm of most cells that catalyses the conversion of lactate to pyruvate.
AST and ALT are enzymes that are commonly used in conjunction to identify active hepatocellular injury.
Bilirubin is a breakdown product of haem that is conjugated in hepatocytes with glucuronic acid and then excreted in bile.
A nitrogen-containing compound that is normally cleared by the liver.
Alkaline phosphatase (ALP) is an enzyme normally found in liver, bone, intestine, late placenta and kidney. Its elevation is often used to diagnose cholestatic liver dysfunction, though it may also be elevated in bone disease as well as certain other conditions.
AST and ALT are enzymes that are commonly used in conjunction to identify active hepatocellular injury.
    • Normal Range

    • Prothrombin time - 11 - 15 sec
    • INR - 0.9 - 1.3
Gamma glutamyl transferase (GGT) is an enzyme found in hepatocytes and biliary epithelial cells, and is a sensitive yet non-specific marker of hepatocyte damage.
Albumin is a group of serum proteins produced by the liver that maintain oncotic pressure and transport certain hydrophobic compounds.
  • Look For

    Pelvic disruption with fracture-dislocation both anteriorly and posteriorly, resulting in a 'floating' acetabulum.
  • Anteriorly - superior & inferior pubic rami, or pubic symphysis
  • Posteriorly - sacroiliac joint, ilium or sacrum
  • Look For

  • Transverse fracture of a vertebral body, usually of the lumbar spine.
The Weber classification is used to class lateral malleolar fractures, based on the location of the fibular fracture - below, at the level of or above the distal tibiofibular joint. The Weber classification indicates the stability of the fracture, and is used to guide treatment.
  •  
    Oral
    Ezetimibe
    Ezetrol 
  •  
    Oral
    Amlodipine
    Amlo, Norvasc 
  •  
    Oral
    Atenolol
    Tenormin, Noten 
  •  
    Oral
    Hydrochlorothiazide
    Diathiazide 
  •  
    IV / IM / Oral
    Frusemide
    Lasix 
  •  
    Oral / Subling / IV / Topical / Patch
    Glyceryl Trinitrate (GTN)
    Anginine tablet, Nitrolingual spray, Nitro-Dur Patch 
     
    Very short acting, to be used PRN when symptomatic
  •  
    IV / Oral
    Verapamil
    Isoptin 
  •  
    IV / IM / Subcut
    Atropine

  •  
    Oral / IV
    Flecainide

  •  
    IV / Oral
    Amiodarone
    Cordarone 
  •  
    Oral
    Propranolol
    Deralin / Inderal 
  •  
    Oral
    Prazosin
    Minipress 
  •  
    IV
    Adenosine

  •  
    Oral
    Captopril
    Capoten 
  •  
    IV / Oral
    Verapamil
    Isoptin 
  •  
    Oral
    Nicorandil
    Ikorel 
  •  
    Oral / IV
    Quinidine

  •  
    Oral / IV
    Magnesium Sulfate

  •  
    Oral
    Fenofibrate
    Lipidil 
  •  
    Oral
    Atorvastatin
    Lipitor, Trovas 
  •  
    Oral
    Atenolol
    Tenormin, Noten 
  •  
    Local / Regional / Topical / Nasal / IV
    Lidocaine / Lignocaine / Xylocaine

  •  
    Oral
    Indapamide
    Natrilix 
  •  
    Oral
    Candesartan
    Atacand 

Cardiomyocyte Action Potentials

Action potentials in non-pacemaker cells are governed by balanced opening and closing of fast sodium channels, slow calcium channels and potassium channels.
  •  
    Oral
    Spironolactone
    Aldactone, Spiractin 
  •  
    Oral / IV
    Hydralazine
    Alphapress 
  •  
    IV / Oral
    Digoxin
    Lanoxin 
  •  
    Oral
    Pyrazinamide

  •  
    Oral
    Ethambutol

  •  
    Oral
    Dapsone

  •  
    Oral / IV
    Rifampicin
    Rifadin 
  •  
    Oral
    Isoniazid
    Tuberculosis only
  •  
    Oral / IV
    Dipyridamole
    Persantin 
  •  
    IV
    Idarucizumab
    Praxbind 
  •  
    Oral / IV
    Phytomenadione
    Konakion 
  •  
    IV
    Whole Blood Plasma
    Plasma separated from whole blood collection
  •  
    IV
    Urokinase
    Abbokinase 
  •  
    IV
    Adexanet Alfa
    AdexXa 
  •  
    Subcut / IV
    Heparin Sodium

  •  
    Oral
    Apixaban
    Eliquis 
  •  
    Subcut
    Enoxaparin
    Clexane 
  •  
    IV / Intraarterial
    Alteplase
    Actilyse 
  •  
    Oral / IV
    Tranexamic Acid
    Cyklokapron 
  •  
    IV
    Protamine Sulfate

  •  
    IV
    Prothrombinex

  •  
    Oral
    Warfarin
    Coumadin, Marevan 
  •  
    Oral
    Clopidogrel
    Plavix 
     
    A prodrug that requires enzymatic activation
  •  
    Oral
    Dabigatran
    Pradaxa 
  •  
    Oral
    Aspirin
    Aspro, Astrix 
  •  
    IV
    Abciximab
    Reopro 
     
    Long half-life (8-12 hours) and effect (haemostasis 72 hours)

Overview

  •  
    IV / Subcut
    Rituximab
    Mabthera 
  •  
    IV infusion
    Trastuzumab-Emtansine
    Kadcyla 
  •  
    Subcut
    Denosumab
    Prolia, Xgeva 
     
    Six-monthly injections
  •  
    IV infusion / Subcut
    Trastuzumab
    Herceptin 
     
    Inhibits ligand-independent HER signalling
  •  
    IV
    Gemtuzumab-Ozogamicin
    Mylotarg 
Monoclonal antibodies are named based on standard nomenclature that describes the target and species of origin of the antibody.
  •  
    IV infusion
    Atezolizumab
    Tecentriq 
  •  
    IV
    Cetuximab
    Erbitux 
  •  
    IV
    Alemtuzumab
    MabCampath (CLL), LemTrada (MS) 
  •  
    IV infusion
    Ipilimumab
    Yervoy 
  •  
    IV infusion
    Nivolumab
    Opdivo 
  •  
    IV
    Bevacizumab
    Avastin 
  •  
    Oral / IV
    Fluconazole
    Diflucan 
  •  
    IV
    Amphotericin B

  •  
    IV
    Caspofungin

  •  
    Oral
    Anastrozole
    Arimidex 
  •  
    Oral
    Bicalutamide

  •  
    Oral
    Cyproterone

  •  
    IM
    Fulvestrant
    Faslodex 
     
    Monthly injections
  •  
    Oral
    Tamoxifen
    Genox 
  •  
    Oral
    Abiraterone
    Zytiga 
  •  
    Goserelin
    Zoladex 
     
    Implant
  •  
    Inhaled
    Desflurane
    Airway irritant - causes cough, apnoea, laryngospasm
  •  
    IV
    Ketamine
    Ketalar 
  •  
    Local / Regional / Epidural
    Bupivacaine
    Marcain 
  •  
    IV
    Atracurium
    Onset 2 minutes
    Duration 40 minutes
  •  
    IV / IM
    Suxamethonium / Succinylcholine

  •  
    IV
    Propofol

  •  
    Oral
    Fludrocortisone
    Florinef 
  •  
    Oral
    Propylthiouracil
    PTU
  •  
    Oral
    Calcitriol

  •  
    Oral
    Pioglitazone
    Actos 
  •  
    Oral
    Metformin
    Diabex, Diaformin 
     
    Reduce dose in renal insufficiency
  •  
    Subcut
    Insulin Glargine
    Lantus, Toujeo 
     
    Once daily dosing
  •  
    Subcut
    Teriparatide
    Forteo 
  •  
    IV / Oral
    Prednisolone / Prednisone
    Panafcort, Predsone, Sone 
  •  
    Oral
    Carbimazole
    Neo-Mercazole
  •  
    Subcut
    Liraglutide
    Victoza 
  •  
    Oral
    Linagliptin
    Trajenta 
  •  
    Subcut / IV
    Insulin Aspart
    Novorapid 
  •  
    Oral
    Strontium Ranelate
    Protos 
  •  
    Oral
    Calcium Carbonate
    Caltrate 
  • Mechanism of Action

  • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.
  •  
    Subcut
    Neutral + Isophane Insulin
    Humulin 30/70, Mixtard 30/70, Mixtard 50/50 
  •  
    Subcut
    Isophane Insulin
    Protaphane, Humulin NPH 
  •  
    Oral
    Empagliflozin
    Jardiance 
  •  
    Oral
    Raloxifene
    Evista 
  •  
    Subcut
    Denosumab
    Prolia, Xgeva 
     
    Six-monthly injections
  •  
    Oral
    Cholecalciferol
    Ostelin, Ostevit-D 
  •  
    Oral
    Thyroxine
    Oroxine, Eutroxig 
     
    Adjust every 6-8 weeks according to TSH
  •  
    Subcut / IV
    Neutral Insulin
    Actrapid, Humulin R 
     
    Given 30 minutes before meals
  •  
    Oral
    Gliclazide
    Diamicron 
  •  
    Oral
    Alendronate
    Fosamax 
     
    Once weekly dosing
  •  
    Oral
    Amantadine
    Symmetrel 
  •  
    Oral
    Atazanavir
    Reyataz 
  •  
    Oral
    Dolutegravir
    Tivicay 
  •  
    IV
    Foscarnet
    Foscavir 
  •  
    Oral
    Abacavir

  •  
    IV
    Cidofovir
    Empovir 
  •  
    Oral / IV
    Aciclovir
    Herpex, zovirex 
     
    20% bioavailability; mainly used for HSV and VZV
  •  
    Oral
    Efavirenz

  •  
    Oral
    Tenofovir TAF

  •  
    Oral
    Oseltamivir
    Tamiflu 
  •  
    Oral
    Alprazolam
    Alpraz, Xanax 
     
    Very short half-life - used for panic disorder
    [Peak] 1 hour
    Half-life 6-26 hours
  •  
    Oral / IV / IM
    Diazepam
    Valium 
     
    [Peak] 1-2 hours
    Half-life 20-48 hours
  •  
    Oral
    Citalopram
    Cipramil, Celexa 
     
    First line agent for depression
  •  
    IM / IV
    Midazolam
    Used to induce anaesthesia
  •  
    Oral
    Mirtazapine
    Avanza 
  •  
    Oral / IV
    Sodium Valproate
    Epilim, Valpro 
  •  
    Oral / IV
    Chlorpromazine
    Largactil 
  •  
    Oral
    Carbamazepine
    Tegretol 
  •  
    Oral
    Amitriptyline
    Endep 
  •  
    Oral
    Moclobemide

  •  
    Oral
    Amisulpride
    Solian 
     
    Pure D2/D3 receptor blocker
    Used for patients with predominantly negative symptoms
  •  
    Oral
    Lithium Carbonate
    Lithicarb 
  •  
    Oral
    Desvenlafaxine
    Pristiq 
     
    Some additional inhibition of dopamine reuptake
  •  
    Oral
    Trimethoprim
    Alprim 
  •  
    Oral / IV
    Trimethoprim + Sulfamethoxazole
    Bactrim, Septrin 
  •  
    Oral / IV / PR
    Metronidazole
    Flagyl 
  •  
    Oral / IV
    Flucloxacillin
    Flopen, Fluclox, Staphylex 
  •  
    IV / oral
    Azithromycin
    Zithromax 
  •  
    Oral / IV
    Vancomycin
    May be used in patients allergic to beta lactams
  •  
    Oral / IV
    Clindamycin

  •  
    Oral / IV
    Linezolid

  •  
    Oral
    Cefuroxime
    Useful against Haemophilus influenzae
  •  
    Oral / IV
    Rifampicin
    Rifadin 
  •  
    IM / IV
    Benzylpenicillin (Penicillin G)
    BenPen 
  •  
    IV
    Cefepime
    Useful against Pseudomonas spp.
  •  
    IV
    Cefotaxime

  •  
    Oral
    Amoxycillin-Clavulanate
    Augmentin 
  •  
    IV
    Meropenem
    For severe infections suspected to be resistant to other antibiotics
  •  
    Oral
    Amoxicillin
    Amoxil, alphamox 
  •  
    Oral
    Doxycycline

  •  
    Oral / IV
    Ciprofloxacin
    Cipro 
Taking notes is a key part of many students' learning process. If done correctly, they allow you to filter, process and actively learn information, and are a very useful tool when studying. Notes can be returned to multiple times or turned into questions, flashcards or other learning tools.
  • Ask About

  • Diagnosis - when the diagnosis was made, cause
  • Exercise tolerance
  • Frequency of exacerbations
  • Colonisation - bacteria that have been isolated in the past (e.g. Moraxella, Haemophilus, Pseudomonas, Staphylococcus aureus, Burkholderia cepacia, Mycobacterium)
  • Complications - infections, haemorrhage, cor pulmonale
  • Management - sputum clearance strategies, long-term antibiotics

Aetiology

  • Causes of Chest Pain

  • Cardiac

  • Stable angina
  • Acute coronary syndrome - unstable angina, NSTEMI, STEMI
  • Other cardiac ischaemia - vasospasm (prinzmetal angina), severe aortic stenosis, hypertensive ischaemia, rate-related ischaemia, dilated cardiomyopathy, Tako-tsubo cardiomyopathy
  • Non-ischaemic - pericarditis, myocarditis, myocardial contusion
  • Non-Cardiac

  • Vascular - aortic dissection, pulmonary embolism
  • Respiratory - pneumonia with pleurisy, pneumothorax, lung cancer
  • Gastrointestinal - peptic ulcer, gastritis, oesophagitis, oesophageal spasm, oesophageal rupture
  • Musculoskeletal - costochondritis, osteomyelitis, rib fracture, cervical spinal disease
  • Psychogenic - panic disorder, malingering

Overview

  • Ask About

  • Diagnosis - when ILD was diagnosed, cause
  • Pace of progression
  • Exacerbations
  • Management - lifestyle, pharmacologic, supportive, surgical measures
  • Complications
  • Ask About

  • Diagnosis - presenting symptoms, type of lung cancer
  • Functional status
  • Risk factors - environmental exposures, chronic scarring
  • Family history of lung cancer
  • Management - surgery, chemotherapy, radiotherapy, targetted therapy
  • Complications - pleural effusion, metastases, local compression, paraneoplastic
  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
Patients with asthma are at risk of exacerbations, which may cause significant morbidity or mortality. By understanding the natural history of their airways disease it is possible to create a management plan that prevents complications in the future.
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
  • Ask About

  • Travel to other countries - especially developing countries
  • Prophylaxis before travelling - vaccines, malaria prophylaxis
  • Exposure to animals - especially bites or scratches
  • Food intake - especially raw meat, fish, unpasteurised dairy products
  • Contact with fresh water
  • Contact with sick people
  • Insect bites
  • Sexual contacts
  • Needle exposures
  • Ask About

  • Diagnosis - when diagnosed, sleep study results
  • Severity - symptoms, impact on function
  • Management - weight loss, CPAP, surgery
  • Complications - cardiovascular disease, pulmonary hypertension, depression
Tuberculosis is the disease caused by the bacteria Mycobacterium tuberculosis, and may affect almost any organ in the body resulting in a wide range of clinical presentations. In patients with a history of tuberculosis, it is important to understand the risk factors, natural history and past treatment of disease.
Chronic obstructive pulmonary disease is a severely functionally limiting condition primarily affecting previous tobacco smokers. Management is targeted to the severity of the disease, and underpinned by smoking cessation.
  • Ask About

  • Diagnosis - age at diagnosis, presenting symptoms, mutation
  • Family history of cystic fibrosis
  • Respiratory - symptoms, bacteria colonised, frequency of admission
  • Pancreatic - steatorrhoea, diet, insulin requirement
  • Gastrointestinal - constipation, reflux, cirrhosis
  • Musculoskeletal - joint pain, osteoporosis
  • Fertility - previous infertility, plans to conceive, genetic counselling
  • Other - symptoms of depression
  • Ask About

  • Diagnosis - provoked or unprovoked PE, preceding DVT
  • Management - anticoagulation
  • Complications - infarction, right heart failure, pulmonary hypertension
  • Ask About

  • Any medications the patient is on
  • What pharmacy they get their medications from
  • Whether they use any dosing aids, such as a Webster pack
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
Heart failure can be functionally debilitating, though proper management can have a significant positive effect on a patient's mortality risk and quality of life.
  • Ask About

  • Any medications the patient is on
  • What pharmacy they get their medications from
  • Whether they use any dosing aids, such as a Webster pack
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
  • Ask About

  • Diagnosis - when hypertension was diagnosed
  • Severity - blood pressure measurements
  • Management - nonpharmacologic / pharmacologic
  • Complications - cardiovascular, cerebrovascular, ocular, renal
  • Ask About

  • BMI - height, weight
  • Associated diseases - metabolic syndrome, IHD, stroke, OSA, GI, PCOS, OA, gout
  • Management - attempts to lose weight, diet, level of exercise, pharmacologic or surgical approaches
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
  • Ask About

  • Whether the patient takes any recreational drugs
  • How long they have been taking the drug for
  • How often they take the drug
  • Whether they have injected drugs
  • Past attempts to quit
  • Willingness to cut down or stop
Alcohol abuse, binging and dependence is very common in the community, and can result in significant acute and chronic complications.
  • Ask About

  • Diagnosis - when pulmonary hypertension was diagnosed, symptoms, cause
  • Severity - functional impact, last echo / right heart catheter result
  • Management - treatment of underlying disease, PAH drugs
  • Complications - particularly right ventricular failure
Patients with stable ischaemic heart disease are at great risk of cardiovascular death in the future. By taking a thorough history and understanding the natural history of their disease it is possible to estimate this risk, and identify ways to prevent future complications.
Atrial fibrillation is an often insidious condition involving irregular contraction of the ventricles due to fibrillation of the atria. If not properly managed this condition can result in significant complications including cardioembolic stroke.
  • Ask About

  • Diagnosis - when diagnosed, primary / secondary, lipid results
  • Management - lifestyle changes, medications
  • Complications - atherosclerotic complications, NAFLD
Dyspnoea, or shortness of beath, refers to the feeling of 'not getting enough air' or 'air hunger'. Thi may herald cardiorespiratory disease, though may also occur in the context of many other acute and chronic conditions.
  • Ask About

  • Diagnosis - cause of chronic kidney disease, stage
  • Complications - acidosis, fluid overload, electrolyte derangements, cardiovascular disease, anaemia, mineral bone disease, malnutrition
  • Management - management of complications, dialysis, renal transplant
  • Dialysis - copmmencement, modality, access, timing, fluid removal
Diabetes is a common disease, and is often poorly controlled. When assessing a patient with diabetes it is important to get an idea of how long they have had diabetes, what microvascular and macrovascular complications they have had, how good their control is, and whether they have had any hypoglycaemic episodes.
  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
  • Ask About

  • Diagnosis - when diagnosed, presenting symptoms
  • Family history of colorectal cancer
  • Stage - tumour size, lymph node involvement, metastases
  • Complications - bleeding, obstruction, perforation, management-related
  • Management - surgery, chemotherapy, targetted therapies
Inflammatory bowel disease (IBD) is a heterogeneous autoimmune condition that encompasses Crohn's disease and ulcerative colitis. Flares of IBD should be diagnosed and treated promptly.
  • Ask About

  • Diagnosis - when diagnosed, risk factors
  • Complications - hepatic, cardiometabolic, malignant
  • Management - previous attempts at weight loss
  • Ask About

  • Any medications the patient is on
  • What pharmacy they get their medications from
  • Whether they use any dosing aids, such as a Webster pack
Smoking tobacco places patients at risk of multiple respiratory, cardiovascular and other complications. By understanding our patients' smoking history and overall exposure to tobacco it is possible to estimate this risk and guide them in attempting to quit smoking.
  • Ask About

  • Meals - number per day, whether they eat meals at the same time each day, skipping meals
  • Snacks between meals
  • Where they eat - at home, restaurants, fast food
  • What they eat - on a typical day, or in the last 24 hours
  • Foods they cannot eat
  • Foods they do not like
  • Any special diets - and whether it is medically necessary (e.g. for coeliac disease, allergy or food intolerance)
  • Vitamin / mineral supplements
  • Ask About

  • Pretransplant history - cause and complications of chronic liver disease, past transplant, medical and social considerations
  • Peritransplant history - timing, indication, donor, graft type, anastomosis
  • Complications - past rejection episodes, infections, cardiovascular, metabolic, malignancy
  • Post-transplant management - immunosuppression, infective prophylaxis, cancer screening
A detailed travel history can help to define a patient's risk of certain infectious diseases. A patient presenting with fevers after recent travel to a developing country may have a much wider range of potential infections than a patient who resides in a developed country and has not recently travelled.
Gastroesophageal reflux disease is a condition in which there is incompetence of the lower oesophageal sphincter, resulting in reflux of gastric acid.
  • Ask About

  • Whether the patient takes any recreational drugs
  • How long they have been taking the drug for
  • How often they take the drug
  • Whether they have injected drugs
  • Past attempts to quit
  • Willingness to cut down or stop
Alcohol abuse, binging and dependence is very common in the community, and can result in significant acute and chronic complications.
Peptic ulcer disease is a common condition where ulcers may form in the stomach or duodenum. This may be as a result of Helicobacter pylori infection, medications, stress or dietary factors.
  • Ask About

  • Diagnosis - when their cirrhosis was diagnosed, cause of cirrhosis
  • Severity - Child-Pugh grade, MELD, compensated / decompensated
  • Complications - ascites, varices, encephalopathy
  • Management - diet, treatment of complications, HCC and variceal surveillance
  • Liver transplant - whether this has been discussed
  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, lichen planus, cryoglobulinaemia, glomerulonephropathy
  • Management - direct acting antivirals, surveillance
  • Ask About

  • Diagnosis - cause (if known), when diagnosed
  • Manifestations - cirrhosis, polyarteritis nodosa, membranous glomerulonephropathy
  • Management - antivirals, surveillance
Scleroderma is also known as systemic sclerosis.
  • Ask About

  • Time spent exercising - per day or per month
  • Type of exercise - e.g. walking, running, cycling, team sports
These questions are incredibly valuable for elderly patients who are poorly mobile, though are likely to be inappropriate in younger patients who are fit and active.
  • Ask About

  • Diagnosis - when OA was diagnosed, what joints are involved
  • Risk factors - occupation, sport, trauma, obesity
  • Functional limitation
  • Management - non-pharmacologic / pharmacologic
  • Ask About

  • Diagnosis - when rheumatoid arthritis was diagnosed, presentation, duration of symptoms
  • Family history of rheumatoid arthritis
  • Manifestations - extent / severity of articular involvement, extra-articular disease
  • Functional impact
  • Management - non-pharmacologic, steroids, DMARDs
  • Ask About

  • Diagnosis - when gout was diagnosed, joints affected
  • Severity - frequency of flares, monoarticular / polyarticular
  • Complications - tophi, joint destruction, nephropathy
  • Management - during flares, dietary changes, urate-lowering therapy
  • Ask About

  • Diagnosis - when lupus was diagnosed, active or in remission, causes of flares
  • Family history of SLE
  • Manifestations - systemic, skin, MSK, cardiovascular, respiratory, neurologic, haematologic, renal
  • Management - sun avoidance, smoking cessation, hydroxychloroquine, immunosuppression
  • Role

  • Special sensory (sight).
  • Roles

  • Special sensory - equilibrium (vestibular nerve) and hearing (cochlear nerve)
The term nystagmus is used mainly to refer to jerk nystagmus, abnormal rhythmic eye movements that may occur due to peripheral nervous system, central nervous system or vestibular pathology.
Also known as the 'gag' reflex.
  • Role

  • Special sensory (smell)
Pseudobulbar palsy is a neurologic syndrome that occurs due to an upper motor neuron lesion affecting cranial nerves IX, X and XII.
The glabellar reflex is a primitive reflex - normally present in infants and absent in adults. In patients with frontal lobe damage or or Parkinsonism, 'frontal release' signs such as glabellar, grasp, suck, snout and palmomental reflexes will be present.
  • Roles

  • V1 Ophthalmic Nerve

  • Somatic sensory: forehead, cornea, nasal cavity, oral cavity
  • V2 Maxillary Nerve

  • Somatic sensory: maxillary face, palate, nasal cavity, oral cavity
  • V3 Mandibular Nerve

  • Somatic sensory: mandibular face
  • Motor: muscles of mastication
  • Role

  • Somatic motor - intrinsic and extrinsic tongue muscles.
  • Roles

  • Somatic motor - pharyngeal & laryngeal muscles, palatoglossus
  • Visceral motor (parasympathetic) - pharynx, larynx, thoracic and abdominal viscera
  • Somatic sensory - back of ear, external auditory meatus, external tympanic membrane
  • Visceral sensory -larynx, oesophagus, trachea, thoracic and abdominal viscera, aortic arch stretch receptors, aortic body chemoreceptors
  • Special sensory (taste) - epiglottis
  • Role

  • Special sensory (smell).
  • Role

  • Somatic motor - eye abduction (lateral rectus).

II Optic Nerve

  • Role

  • Special sensory (sight)

Overview

Receptors
Cornea
 
 
Foramen
Superior orbital fissure
V1
Ophthalmic branch
 
Trigeminal Ganglion
 
 
Spinal nucleus
Pons, medulla
 
 
Intermediate neuron
 
 
Facial Motor Nucleus
Pons
 
Foramen
Internal auditory meatus
 
Geniculate Ganglion
 
Facial Nerve (VII)
Temporal & zygomatic branches
 
 
Muscle
Orbicularis oculi
  • Roles

  • Special sensory (taste) - anterior â…” of tongue
  • Somatic sensory - external ear, posterior auricle (Ramsay-Hunt zone)
  • Somatic motor - facial expression, eye closing
  • Visceral motor (parasympathetic) - submandibular & sublingual salivary glands, lacrimal glands, nasal & palatine glands
  • Signs of Multiple Sclerosis

  • Signs of optic neuritis - reduced visual acuity, central visual loss, optic disc atrophy
  • Internuclear ophthalmoplegia - inability to adduct one eye, with nystagmus in the other eye
  • Lhermitte's sign - electric sensation in the limbs on neck flexion
  • Upper motor neuron weakness - increased tone, reduced power, hyperreflexia
  • Dorsal column (vibration / proprioception) sensory loss
  • Signs of cerebellar involvement - ataxia, dysarthria, dysmetria, dysdiadochokinesis, nystagmus

V Trigeminal Nerve

  • Roles

  • V1 Ophthalmic Nerve

  • Somatic sensory: forehead, cornea, nasal cavity, oral cavity
  • V2 Maxillary Nerve

  • Somatic sensory: maxillary face, palate, nasal cavity, oral cavity
  • V3 Mandibular Nerve

  • Somatic sensory: mandibular face
  • Motor: muscles of mastication

XI Accessory Nerve

  • Role

  • Motor: laryngeal & pharyngeal muscles, sternocleidomastoid, trapezius

Overview

Light Receptors
Rods / cones of retina
 
 
Bipolar Cells
Retina
 
Foramen
Optic canal
Optic Nerve (II)
Optic chiasm, optic tract
 
Pretectal nucleus
Midbrain
 
 
Edinger-Westphal nucleus
Superior colliculus (midbrain)
 
Oculomotor Nerve (III)
Foramen
Superior orbital fissure
 
 
Ciliary Ganglion
 
 
Muscle
Constrictor pupillae, ciliary muscles
  • Role

  • Motor - laryngeal & pharyngeal muscles, sternocleidomastoid, trapezius

XII Hypoglossal Nerve

  • Roles

  • Somatic motor: intrinsice and extrinsic tongue muscles

Overview

  • Role

  • Somatic motor - eye intorsion and depression (through contraction of the contralateral superior oblique).
The patient's level of consciousness is an assessment of their wakefulness and responsiveness to external stimuli.
  • Look For

  • The size of the pupils (dilated, normal, constricted) and equality of size bilaterally.

Oculomotor Nerve (III) Palsy

  • Look For

  • Eye deviated down and out
  • Diplopia
  • Ptosis
  • Mydriasis (pupillary dilatation)
  • Loss of pupillary reflexes

Overview

Bulbar palsy is a neurologic syndrome that occurs due to a lower motor neuron lesion affecting cranial nerves IX, X and XII.
Patients with myaesthenic syndromes exhibit muscle fatigability, or the inability to maintain contraction of muscles over time.
  • Roles

  • Special sensory (taste) - posterior 1/3 of tongue
  • Visceral sensory - carotid sinus baroreceptors, carotid body chemoreceptors
  • Somatic sensory - external ear, internal tympanic membrane, upper pharynx, posterior 1/3 of tongue
  • Somatic motor - stylopharyngeus
  • Visceral motor (parasympathetic) - parotid gland
When performing a cranial nerve examination, always ask to perform fundoscopy. This may provide valuable information regarding ocular or cranial nerve pathology, and reveals signs of diabetic or hypertensive nephropathy.
  • Signs of Myotonic Dystrophy

  • Myopathic facies - temporalis wasting, mandibular wasting, frontal baldness
  • Flaccid dysarthria - nasal speech, breathiness, monotony, impaired articulation
  • Warm-up phenomenon - grip myotonia, repeated eye closure
  • Percussion myotonia - muscle contraction with percussion of the thenar eminence
  • Wasting of the forearm and small muscles of the hand
  • Distal muscle weakness
  • Hyporeflexia
  • How to Elicit

  • Ask the patient to open their mouth and say 'ahh'. Move the tongue using a tongue depressor, and use a light to visualise the oral cavity.
  • Signs of Cerebellopontine Angle Syndrome

  • Trigeminal (V) nerve palsy - reduced facial sensation
  • Facial (VII) nerve palsy - facial droop / weakness
  • Vestibulocochlear (VIII) nerve palsy - unilateral sensorineural hearing loss, nystagmus, ataxia

VII Facial Nerve

  • Roles

  • Special sensory (taste) - anterior â…” of tongue
  • Somatic sensory - external ear, posterior auricle (Ramsay-Hunt zone)
  • Somatic motor - facial expression, eye closing
  • Visceral motor (parasympathetic) - submandibular & sublingual salivary glands, lacrimal glands, nasal & palatine glands

Horner's Syndrome

Horner's syndrome is a classic triad that occurs due to compression of the sympathetic chain.

Overview

  • Roles

  • Somatic motor - eye movement, eye opening
  • Visceral motor (parasympathetic) - pupillary & ciliary muscles

Facial Asymmetry

  • Look For

  • Drooping of one side of the face. Compare the angles of the mouth on both sides. Determine whether the eyebrow is spared on the affected side or not.

VIII Vestibulocochlear Nerve

  • Roles

  • Special sensory: equilibrium (vestibular nerve), hearing (cochlear nerve)

Overview

Cerebellar pathology produces a specific set of clinical findings that can be readily elicited on clinical examination. Patients with lesions within the cerebellum typically present with a wide-based, unsteady gait with dyscoordination and nystagmus.
Femoral - palpate within the inguinal region, halfway between the pubic symphysis and iliac crest.
Capillary refill time is a marker of perfusion, and prolonged refill time suggests poor perfusion of the area being examined.
Blood pressure is a measure of the arterial pressure during systole and diastole; this may also be used to calculate the mean arterial pressure. Low blood pressure can result in poor organ perfusion, which high blood pressure puts patients at risk of cardiac, cerebrovascular, retinal and renal complications.

The Abdominal Aorta

  • How to Assess

  • Place the hands on either side of the midline and identify the outermost margin of the aorta.

Overview

  • How to Assess

  • Light touch - Ask the patient to close their eyes. Using a cotton ball or microfilament, gently touch each dermatome / nerve distribution and ask the patient if they can feel the stimulus. Compare sides and proximally / distally.Spinothalamic tract & dorsal column - medial lemniscus pathway
  • Pain - demonstrate a sharp stimulus by touching the patient lightly on the chest with a neurotip. Ask the patient to close their eyes, and test each dermatome / nerve distribution alternating between sharp and dull sides of the neurotip. Ask the patient if they feel sharpness or dullness.Free nerve endings → spinothalamic pathway → sensory cortex
  • Vibration - with the patient's eyes closed, place a vibrating 128hz tuning fork over the IP joint of the great toe. Ask the patient to describe the sensation. If they can feel it vibrating, progressively diminish the vibration until they cannot feel it. If they cannot feel it vibrating, test on the medial / lateral malleolus and then the tibial tuberosity.Pacinian corpuscles → dorsal column → medial lemniscus → sensory cortex
  • Proprioception - ask the patient to observe as you move the great toe up and down, holding either side of the IP joint. With their eyes closed, slowly move the joint up or down. Ask the patient whether the toe has moved up or down. Repeat several times, and repeat on the other side.Neuromuscular spindles → dorsal column → medial lemniscus → sensory cortex

Lower Limb Erythema

  • Look For

  • Redness - unilateral, bilateral, localised or diffuse.

Overview

  • How to Perform

  • Ask the patient to cross their arms over their chest and take deep breaths in and out through their mouth. Auscultate the lung fields, alternating from left to right. Make sure to auscultate the axillae and supraclavicular fossae.
Skin changes and overall poor skin condition of the lower limb may occur due to soft tissue disease; arterial, venous or lymphatic insufficiency; loss of afferent nerve supply or simply poor self-care.
The presence of ballotable or tender kidneys may provide a significant amount of information about the cause of a patient's renal disease, and in particular the presence of polycystic kidney disease.
Inspect the abdomen for skin changes, scars, distension or visible masses.
  • How to Perform

  • Ask the patient to lean forward and hold their breath in full expiration.
  • How to Perform

  • With the patient sitting, place one palm over the costovertebral angle and use the ulnar aspect of the other hand (in a fist) to gently percuss the kidneys.

Palmar Crease Pallor

  • Look For

  • Loss of colour in the creases of the palm.

Rashes Associated with Renal Disease

Xerosis cutis: abnormally dry skinCold weather, excessive bathing, irritants, advanced age, uraemia, diabetes, hypothyroidism

Overview

Asterixis, also known as hepatic flap or uraemic flap, is an important sign of metabolic encephalopathy that occurs due to dysregulation of the diencephalic motor centers in the brain that regulate innervation of muscles responsible for maintaining position.
  • How to Assess

  • Palpate the common carotid arteries, located in the anterior neck medial to the sternocleidomastoid. Palpate the arteries one at a time. Care should be taken to avoid stimulating the carotid sinus.

Oral Candidiasis

  • Look For

  • Creamy white lesions present on the tongue or inner cheeks, which may be associated with angular cheilitis or glossitis.

Overview

  • How to Elicit

  • Listen over the abdomen for bruits
  • Look For

  • Swelling of the lower limb due to fluid accumulation.

Heart Rate

  • How to Measure

  • Count the number of beats over 15, 30 or 60 seconds and multiply to estimate beats per minute.

Purpura

  • Look For

  • Red / purple lesions that do not blanch with pressure. May be present over the head, arms, legs, chest or abdomen.

Overview

  • How to Perform

  • Auscultate within the triangle bound by the mandible, sternocleidomastoid and thyroid cartilage. Ask the patient to hold their breath.
The jugular venous pulsation can often be difficult to visualise, though can be a useful indicator of the fluid status of a patient. The JVP can also provide valuable clues regarding the presence of right ventricular failure, pulmonary hypertension and tricuspid regurgitation.
The patient's body habitus provides insight into a patient's diet and metabolic status as well as their overall risk of cardiovascular and non-cardiovascular complications in the future. While static measures such as body habitus and waist-hip ratio can estimate future risk, unexpected change in weight may suggest active disease.
In patients with renal disease, always ask to perform fundoscopy. This may provide valuable information regarding the presence of hypertensive or diabetic retinopathy.
Assessing a patient's fluid status can often be very difficult, and relies on multiple different clinical measurements.

Halitosis

Also known as foetor ex ore, oral malodour and 'bad breath'.

Overview

Ulcers, or non-healing open wounds, may occur in the lower limb in the context of arterial disease, venous disease or peripheral neuropathy.
Patients with chronic kidney disease may exhibit signs in the nails such as leukonychia or onycholysis.
  • Interpretation

  • Palpate the lower back, assessing for the presence of oedema.
  • How to Assess

  • With the back of the hand, feel from the top of the calf to the dorsum of the foot. Note if there is any change in temperature distally.
  • Signs of Chronic Kidney Disease

  • General Signs

  • Sallow complexion
  • Leukonychia
  • Sarcopaenia
  • Signs Suggesting a Cause

  • Finger prick markings (diabetes)
  • Palpable polycystic kidneys
  • Signs of Complications

  • Acidosis - tachypnoea
  • Fluid overload - hypertension, raised JVP, sacral / pedal oedema, pulmonary crepitations
  • Anaemia - palmar crease pallor, conjunctival pallor
  • Uraemia - scratch marks, confusion, asterixis, pericardial rub
  • Signs of Management

  • Haemodialysis - VasCath, arteriovenous fistula, graft
  • Peritoneal dialysis - Tenkhoff catheter
  • Scars - nephrectomy, renal transplant, parathyroidectomy
  • Palpable renal transplant (usually right lower quadrant)
  • How to Assess

  • The thumb is flexed anteriorly, away from the palm.

Wrist Drop

  • Look For

  • Abnormal flexion of the wrist, due to inability to extend the joint

Overview

The pattern of joint involvement in arthritis can be used clinically to identify the most likely pathology.
There are several pathognomonic signs in the hand and wrist that are suggestive of rheumatoid arthritis or osteoarthritis. This page outlines these findings.
  • How to Assess

  • The wrist joint is extended posteriorly.
  • How to Assess

  • The thumb is moved diagonally across the palm.

Elbow Lesions

  • Feel For

  • Firm masses over the dorsum of the elbow, noting associated swelling, erythema or tenderness.

Overview

  • Signs of Scleroderma

  • General Signs

  • Calcinosis cutis: hard masses beneath the skin, due to calcium deposition
  • Raynaud's phenomenon: areas of white, blue or red change in the hands
  • Sclerodactyly: thickening of the fingers / toes
  • Telangiectasia: visible dilated blood vessels
  • Reduced oral aperture
  • Nailfold abnormalities
  • Tendon friction rubs (severe disease)
  • Signs of Complications

  • Evidence of pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
  • Evidence of interstitial lung disease - fine fibrotic crepitations
  • Evidence of renal crisis - significant hypertension
  • How to Assess

  • The fingers are moved apart in the coronal plane.
  • Signs of Rheumatoid Arthritis

  • General Signs

  • Symmetrical arthropathy with sparing of DIP joints
  • Prominence of the ulnar styloid
  • Radial deviation of the wrist
  • Ulnar (medial) deviation of the MCP joints
  • Volar (palmar) subluxation of the MCP joints
  • Swan neck deformity: hyperextension at the PIP joint with flexion at the MCP and DIP joints
  • Boutonniere deformity: flexion at the PIP joints with hyperextension at the MCP and DIP joints
  • Z-thumb deformity: flexion at the IP joint of the thumb with hyperextension at the MCP joint
  • Signs of Complications

  • Evidence of compressive neuropathy - e.g. signs of carpal tunnel syndrome
  • Evidence of vasculitis - palpable purpura
  • Evidence of interstitial lung disease - fine fibrotic crepitations
  • Splenomegaly (Felty's syndrome)
  • Signs of Gout

  • Active monoarthritis - particularly of the first MTP joint (podagra) or tarsal joint
  • Asymmetric polyarthritis
  • Gouty tophi - particularly over joints; the olecranon bursa at the elbow; the helix of the ear; the infrapatellar and achilles tendons
  • How to Assess

  • The thumb is angulated laterally, away from the hand.
  • How to Assess

  • The wrist is angulated laterally.

Soft Tissue Landmarks of the Wrist

Flexor retinaculum - arches anteriorly over the carpals, covering the carpal tunnel.

Overview

  • Signs of Psoriatic Arthritis

  • General Signs

  • Symmetric polyarthritis affecting digits as a whole (rather than in rays of digits)
  • Nail changes - onycholysis, pitting, crumbling of the nail plate
  • Psoriatic plaques - particularly on the extensor surfaces of joints, scalp, periumbilicus, skin folds
  • Dactylitis: 'sausage-like' digits due to synovitis of each joint
  • Enthesitis: inflammation of a tendon insertion; affecting the Achilles tendon or the plantar fascia
  • Evidence of sacroiliitis - tender sacroiliac joints
  • Signs of Complications

  • Evidence of iritis - painful, erythematous eye

Muscles Acting on the Wrist Joint

Flexors (anteromedial) - flexor carpi radialis, palmaris longus, flexor carpi ulnaris

Overview

  • How to Assess

  • The wrist is flexed anteriorly.
  • How to Assess

  • The thumb is angulated medially, toward the palm.
  • Signs of Osteoarthritis

  • Muscle wasting
  • Evidence of active arthritis - swelling, erythema, tenderness
  • Reduced joint range of motion
  • Heberden's nodes: firm swelling over the distal interphalangeal joints
  • Bouchard's nodes: firm swelling over the proximal interphalangeal joints
  • Varus knee deformity
  • How to Assess

  • The fingers are flexed anteriorly, with closing of the fist.

Tinel's Sign

  • Test For

  • Carpal tunnel syndrome (median nerve compression)

Overview

  • How to Assess

  • The fingers are extended posteriorly, with opening of the fist.
  • How to Assess

  • The fingers are moved together in the coronal plane.
Examination of the nails may reveal pathognomonic signs suggestive of rheumatologic disease.
  • How to Assess

  • The wrist is angulated medially.
If present, Cushing's syndrome is potentially an indicator of significant steroid use in the treatment of the patient's musculoskeletal disease.

Bony Landmarks of the Wrist

Head of ulna - proximally, articulating with the radial head.

Overview

  • How to Assess

  • The thumb is extended posteriorly, toward the palm.
  • How to Assess

  • Ask the patient to shrug their shoulders.
  • How to Assess

  • Ask the patient to hold their arms by their sides, and push inward.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Bony Landmarks of the Shoulder

Sternoclavicular joint - the articulation of the proximal end of the clavicle and the clavicular notch of the manubrium

Overview

  • Look For

  • Deformity of the shoulder joint, both anteriorly and posteriorly.
  • How to Assess

  • Ask the patient to 'hug' themselves, moving the scapulae apart.
  • How to Assess

  • With the elbow flexed to 90°, ask the patient to rotate their forearm outwardly. Repeat the movement passively.
  • How to Assess

  • After asking the patient to shrug their shoulder (elevation), ask them to then drop them as far as they can.
  • How to Assess

  • Ask the patient to move their arm forward. Then ask them to relax as the shoulder is flexed passively.
  • How to Assess

  • Ask the patient to move their arm out to the side and then as far upward toward their head as possible. Repeat the movement passively.

Muscle Wasting

  • Look For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle or muscle group, isolated to the upper limb or generalised.

Muscles Acting on the Shoulder Joint

Flexors - pectoralis major, anterior deltoid, biceps brachii

Overview

  • How to Assess

  • Ask the patient to push their shoulders back, bringing the scapulae together.
  • How to Assess

  • Ask the patient to move their arm backward. Then ask them to relax as the shoulder is extended passively.
  • Look For

  • Generalised swelling over one or both shoulders. May be associated with redness, tenderness or warmth.
The Hawkins-Kennedy test is used to assess for coracoacromial impingement, by attempting to precipitate the pain of impingement of the subscapularis tendon against the coracoacromial ligament.
  • How to Assess

  • With the back of the hand, feel from the top of the shoulder to the forearm. Compare both sides.
  • How to Assess

  • With the elbow flexed to 90°, ask the patient to rotate their forearm inwardly. Repeat the movement passively.
  • Look For

  • Rashes - comment on colour, morphology, size, distribution, symmetry and any secondary changes.
  • Scars - indicative of past trauma or surgery.
  • Erythema - unilateral, bilateral, localised or diffuse.May be due to rash, cellulitis, septic arthritis or tenosynovitis

Measuring Blood Pressure

  • Prior to Testing Blood Pressure

  • Ask the patient whether they have had dialysis (have an AV fistula), whether they have had breast cancer surgery (and lymph node dissection) or whether there is some other reason their blood pressure should not be measured on a particular arm.

Overview

  • How to Assess

  • Ask the patient to extend their hip (forward), and then relax the joint as it is flexed passively.

Hip Disclocation

  • Look For

  • Posterior dislocation - flexion, internal rotation, adduction of the hip with shortening of the leg
  • Anterior dislocation - flexion / extension and external rotation of the hip with less shortening of the leg

Overview

  • How to Assess

  • Ask the patient to extend their hip (backward), and then relax the joint as it is extended passively.
Assessing a patient's gait can be a useful screening tool for identifying pathology affecting mobility. Impairment of gait may be due to pain, weakness, deformity or joint instability.
  • Look For

  • Generalised swelling over one or both lower limbs. May be associated with redness, tenderness or warmth.

Muscles Acting on the Hip Joint

Flexors (anterior) - iliacus, psoas major and minor, rectus femoris, sartorius, tensor fascia lata, pectineus, gracilis

Overview

  • How to Assess

  • Inspect the patient's posture while they are standing, sitting and squatting. Inspect from laterally, anteriorly and posteriorly.
  • How to Assess

  • Ask the patient to flex their knee to 90° and everttheir knee (point the toes outwardly). Then relax the joint as it is externally rotated passively.
The straight leg raise is a rest for lumbar radiculopathy, particularly of the L5 and S1 nerve roots.
  • How to Assess

  • Ask the patient to abduct their hip (laterally, away from the midline), and then relax the joint as it is abducted passively.

Active Movement

  • How to Assess

  • Ask the patient to move the joint themselves. Assess the neutral position and the range of motion, and ask whether range of motion is limited by pain, weakness or stiffness.

Overview

  • How to Assess

  • Ask the patient to flex their knee to 90° and invert their knee (point the toes inwardly). Then relax the joint as it is internally rotated passively.

Bony Landmarks of the Hip

Iliac crest - the highest point of the pelvis, extending anterior to posterior.

Overview

Examine for herniae while sitting on a stool with the patient standing.
  • How to Assess

  • Ask the patient to adduct their hip (medially, into the midline), and then relax the joint as it is adducted passively.

Muscle Wasting

  • Look For

  • Decreased muscle mass. Note whether wasting is isolated to a single muscle or muscle group, isolated to the upper limb or generalised.

Overview

Marfan syndrome occurs due to one of many mutations in the gene encoding the extracellular matrix protein fibrillin 1.

Abdominal Distension

  • Causes of Abdominal Distension

  • FatCentral obesity
  • FaecesLifestyle, age, obstruction, drugs, endocrine / neurological
  • FlatusIrritable bowel syndrome, mechanical or paralytic gut obstruction
  • FluidAscites, blood, pus, urine, bile, lymph, enteric contents
  • FoetusPregnancy
  • MassCancer, abscess, abdominal wall fibrosis

Overview

A ventricular septal defect, or hole in the ventricular wall, manifests as a harsh pansystolic murmur best heard over the left lower sternal edge.
During the cardiovascular examination, inspection of the palms may reveal signs suggestive of anaemia, dyslipidaemia or infective endocarditis.
The respiratory rate is an important vital sign that is an early marker of deterioration.
The body mass index (BMI) is used an an estimate of body habitus that assesses the patient's weight in the context of their height, allowing for a more accurate measurement.
The first heart sound (S1) indicates closure of the mitral and tricuspid valves.
Auscultation of the carotids may identify a carotid bruit due to turbulent flow, or radiation of a murmur.
  • Look For

  • Enlargement of the distal segments of the fingers and / or toes, due to proliferation of connective tissue.
In the context of the cardiovascular examination, inspection of the nails can aid in identifying evidence of anaemia, cyanosis and endocarditis.

Down Syndrome

Trisomy 21

Overview

The PaO₂ is the partial pressure of oxygen dissolved in plasma. This is a marker of the amount of oxygen available to be delivered to tissues, and a reduced PaO₂ is indicative of hypoxia.
  • Primary Abnormality

  • Alkalaemia with decreased PaCO₂.
The gap-gap ratio is used to further assess patients with a high anion gap metabolic acidosis (HAGMA).
The anion gap is used to further assess a patient with metabolic acidosis. 
Oxyhaemoglobin refers to the percentage of haemoglobin that is bound to oxygen.
The PaCO₂ is the arterial partial pressure of carbon dioxide, as measured on an arterial blood gas.
Bicarbonate (HCO₃) is one of the major alkali present in the blood, and plays a crucial role in acid-base balance.
Atelectasis refers to alveolar volume loss resulting in collapse of a portion of the lung.
Normally, six anterior ribs and nine posterior ribs should be seen above the diaphragm.
Potential bony lesions visible on chest x-ray include rib fractures, lytic (punched out) lesions and sclerotic (hyperopacified) lesions.
The chest x-ray is a useful tool for determining the type of cardiac device present.
An endotracheal tube should be below the larynx and above the carina, optimally at the level of the aortic knuckle.
The chest x-ray has low sensitivity and specificity for the diagnosis of interstitial lung disease, and a high resolution CT is the imaging modality of choice.
A nasogastric or orogastric tube should be visualised below the diaphragm. If not then there is a chance that it is in the airway.
  • Signs of Pulmonary Oedema on Chest X-Ray

  • Bat-wing appearance - opacities extending laterally in a fan shape from each hilum
  • Kerley A lines - 5-10cm lines extending from the hila to the periphery (fluid in the deep septa)
  • Kerley B lines - 1.5-2cm lines seen in the periphery of the lower lung extending into the pleura (interlobular septal thickening)
  • Air bronchograms - tubular outlines of the smaller airways
  • Upper lobe diversion (cephalisation) - enlarged upper lobe vessels and smaller lower lobe vessels
  • Associated cardiomegaly (cardiogenic)
The projection of the chest x-ray refers to the direction that the x-rays travel through the body. This is determined by the placement of the x-ray generator and the x-ray plate.
  • Chest X-Ray Signs of Pneumonia

  • Pulmonary consolidation without volume loss - may be lobar (lobar pneumonia) or multifocal
  • Air bronchograms - tubular outlines of the smaller airways
  • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
Breast shadows are normal on chest xrays, and should not be mistaken for opacities within the lungs.
Before interpreting findings on a chest x-ray, it is important to assess the x-ray's quality.
  • Look For

  • The presence of a drain within the pleural cavity.
A wide range of large bore and central catheters are used in clinical practice. The chest x-ray is used to confirm that such catheters are in the correct position and are safe to use.
The patient's position during a chest x-ray can have a large impact on the interpretation of the x-ray. There is generally a marking over the chest x-ray to indicate whether the patient was erect (standing, or at least sitting up) or supine (lying down.
  • Normal Position

  • The right diaphragm is usually 1cm higher than the left, due to the presence of the liver.
The left hilum is normaly 1-2cm higher than the right hilum.
  • Signs of Pneumothorax on Chest X-Ray

  • Reduction in lung markings in the apices (erect)
  • Deep sulcus sign - abnormally sharp costophrenic angle (supine)
  • Diaphragmatic flattening
  • Signs of Tension Pneumothorax

  • Tracheal deviation away from the pneumothorax
  • Mediastinal shift away from the pneumothorax

Silhouette Signs

  • Look For

  • Obliteration of normally clear outlines between the lung fields and adjacent structures such as the heart, aorta or hemidiaphragm.

Overview

  • Chest X-Ray Signs of Pleural Effusion

  • Loss of the costophrenic angle
  • Increased density of the affected hemithorax
  • Pseudo-elevation of the diaphragm
  • Loss of lower lobe vessels
  • Chest X-Ray Signs of Emphysema

  • Hyperinflation - hyperlucency of lung fields, diaphragmatic flattening, mediastinal narrowing
  • Bullae
  • Lung scarring
The cardiac silhouette is normally ovoid in apperance, with the apex pointing toward the left.
Anti-dsDNA is a subset of antinuclear antibodies (ANA) directed toward double-stranded DNA.
The complement pathway plays an important role in inflammatory processes, and involves many different measureable components including C1q, C3, C4 and factor B.
  • Look For

    Joint disassociation.
  • Shoulder - anterior / posterior / inferior
  • Finger - interphalageal / metacarpophalangeal
  • Elbow - posterior / posterolateral / posteromedial
  • Patella - lateral / medial
  • Hip - posterior / anterior
  • Wrist - lunate / perilunate
  • Look For

  • Obvious protrusion of bone through the soft tissues
  • Air within the soft tissues
The Salter-Harris classification is a system for classifying fractures involving the growth plate. Such fractures have the potential of interrupting the proliferative zone, halting bone growth; higher grade fractures are at higher risk.
The ascitic fluid cell count provides a measure of the number of red blood cells, white blood cells and white cell differential; this information can be used to guide the differential diagnosis of a patient with ascites.
The serum-ascites albumin gradient (SAAG) is used to differentiate between portal hypertension and other causes of ascites.
Cirrhosis / CCFMalignancySBPPancreatitis
AppearanceClearMilky / BloodyTurbidMilky / Turbid
SAAG>1.1 g/dL<1.1 g/dL<1.1 g/dL<1.1 g/dL
LDHNormal / ReducedElevatedNormal / ElevatedNormal / Elevated
GlucoseNormalReducedReducedReduced
AmylaseNormalNormal / ElevatedNormalElevated
Neutrophils<300/μL>500/μL

Cirrhosis / CCFMalignancySBPPancreatitis
AppearanceClearMilky / BloodyTurbidMilky / Turbid
SAAG>1.1 g/dL<1.1 g/dL<1.1 g/dL<1.1 g/dL
LDHNormal / ReducedElevatedNormal / ElevatedNormal / Elevated
GlucoseNormalReducedReducedReduced
AmylaseNormalNormal / ElevatedNormalElevated
Neutrophils<300/μL>500/μL

Sinoatrial exit block is a delay in conduction between the sinoatrial node and atrial myocardium.
Atrioventricular (AV) block occurs due to delayed conduction of an impulse between the atria or ventricles, due to intrinsic or extrinsic causes.
Atrial escape is an impulse generated by an atrial focus in the context of a long sinus pause, such as due to sinus arrest or third degree sinoatrial exit block.
Junctional escape is an impulse generated by a focus at the AV junction when the supraventricular conduction system fails, such as due to sinus arrest or complete AV block.
Bradycardia may generally be caused by sinus node dysfunction, atrioventricular block or escape rhythms in the setting of either of the above.
Atrial flutter is typically a regular, narrow complex tachycardia with 2:1 or even higher levels of AV block. In some patients the AV block is variable; this may be either idiopathic or in the context of complete heart block.
Sinus arrhythmia occurs physiologically due to changes in intrathoracic pressure and resultant variation in vagal tone through the respiratory cycle.
Atrial fibrillation is most commonly associated with a rapid ventricular response, though AF with a slow ventricular response may occur when there is reduced conduction of fibrillatory waves through the conduction pathways.
Tachycardia-bradycardia syndrome is a manifestation of sinus node dysfunction where bradycardia is interspersed with periods of supraventricular tachycardia.
Ventricular escape is an impulse generated by a ventricular focus when the conduction system fails, most commonly due to complete heart block.
Sick sinus syndrome (SSS) occurs when the sinus node is not functioning correctly, due to either intrinsic or extrinsic causes.
Sinus arrest is the temporary interruption of sinoatrial node automaticity, that may occur due to intrinsic or extrinsic factors affecting the sinoatrial node.
Sinus bradycardia is initiated by the sinus node, and occurs in the setting of reduced automaticity due to either intrinsic or extrinsic causes.

Poikilocytosis

Abnormally shaped red blood cells.

Overview

Haptoglobin is an alpha-2 glycoprotein secreted mainly by the liver that binds plasma free haemoglobin following red cell lysis, and as such is reduced in the presence of haemolysis (particularly intravascular haemolysis).
Lactate dehydrogenase (LDH) is an enzyme present in the cytoplasm of most cells that catalyses the conversion of lactate to pyruvate.
Reticulocytes are non-nucleated immature red blood cells.
  • Markers of Intravascular Haemolysis

  • Elevated plasma free haemoglobin
  • Elevated urine haemoglobin - urine dipstick positive for blood but no RBC
  • Elevated urine haemosiderin - brownish urine due to excess iron stored as haemosiderin
Bilirubin is a breakdown product of haem that is conjugated in hepatocytes with glucuronic acid and then excreted in bile.
  • Causes of Pleural Effusion

  • Exudative

  • Malignancy
  • Infection - parapneumonic effusion, empyema, viral, fungal, TB, ruptured abscess / cyst
  • Pulmonary embolism (90% exudative)
  • Autoimmune disease - rheumatoid pleuritis, SLE
  • Pancreatitis
  • Haemothorax
  • Chylothorax
  • Asbestosis
  • Uraemia
  • Oesophageal rupture
  • Transudative

  • Heart failure
  • Cirrhosis
  • Hypoalbuminaemia
  • Nephrotic syndrome
  • Pulmonary embolism (10% transudative)
  • Myxoedema
  • Meig's syndrome
  • Constrictive pericarditis
  • SVC obstruction
  • Urinothorax
Iron overload refers to an excess of total body iron stores. This may be due to haemochromatosis, or one of several secondary causes.
Ferritin is an intracellular iron storage protein whose levels are indicative of the body's total iron stores.
Iron is an important mineral that plays a role in multiple physiologic processes including oxygenation, protein synthesis and cellular respiration. The metabolism of iron is outlined below.
Iron deficiency may occur due to poor intake, poor absorption or loss of iron. The most common complication of iron deficiency is anaemia, which presents as a microcytic, hypochromic anaemia.
Total serum iron is a measure of the ferric (Fe3+) ions bound to serum transferrin. There is significant variation of iron levels with due to multiple factors, and therefore the serum iron is a poor marker of iron status.
The transferrin saturation (TSat) is the percentage of transferrin that is bound to iron. This is a more accurate measure of total body iron than the serum iron concentration, which fluctuates significantly.
Transferrin receptors are receptors on cell surfaces that internalise transferrin.
Transferrin is an transport protein that binds to iron in plasma.
Monocytes are large leukocytes of myeloid origin with a blue-grey ground glass cytoplasm and an irregularly shaped nucleus. Monocytes often contain vacuoles.
Megaloblastic anaemia is a condition where the bone marrow produces large immature red blood cells called megaloblasts which go on to become large, ineffective red blood cells.
Extra staining of blood films may reveal red blood cell findings not seen using typical stains.
Poikilocytosis refers to the presence of abnormally shaped red blood cells on a blood film. There are a wide variety of red cell morphological changes which may suggest various hereditary or acquired conditions.
Eosinophils are granulocytes with a bilobed nucleus, blue cytoplasm and orange to red cytoplasmic granules.
Assessment of red blood cell size - the presence of normocytosis, microcytosis or macrocytosis - is the first step in the assessment of patients with anaemia as it can rapidly be used to narrow down the likely causes.
Plasma cells are specialised immune cells derived from B cells which secrete antibodies. They are not usually seen within the peripheral blood except in severe infection and plasma cell dyscrasias.
Certain characteristic findings on a blood film are suggestive of hyposplenism or asplenism. This may be congenital, iatrogenic (particularly post splenectomy) or associated with acquired medical conditions.
Neutrophils are the most prevalent white blood cells in circulation. They are a type of polymorphonuclear (PMN) leukocyte, with 3-5 nuclear lobes and fine granules within the cytoplasm.
Platelets are very small non-nucleated cells with fine granules that derive from fragmentation of megakaryocytes.
Lymphocytes tend to be small leukocytes with a large nucleus, though may be larger with a lower nuclear:cytoplasmic ratio if reactive. These cells play several key roles in the adaptive immune response.
Immature granulocytes, such as band forms, metamyelocytes, myelocytes and promyelocytes, are not usually seen in peripheral blood.
Mature red blood cells are anuclear, as they extrude their nuclei in the bone marrow prior to entering circulation. The presence of nucleated red blood cells is an abnormal finding.
Smudge cells are remnants of cells, without clear cytoplasmic borders. Such cells are mainly formed when the blood film is made, due to pressure on fragile cells.
Blasts are not usually present in the peripheral blood; their presence in the circulation is highly abnormal and classically suggestive of acute leukaemia.
Red blood cell inclusion bodies are pieces of stainable material within red blood cells, mainly due to retained remnants of cellular components.
A leukoerythroblastic blood film refers to the presence of granulocyte left shift as well as nucleated red blood cells on the same blood film.
The intensity of the colour of red blood cells is representative of the red blood cell haemoglobin concentration.
Basophils are granulocytes with large bluish (basophilic) granules. These uncommon cells play a role in the pathogenesis of allergy.
Free T3 is a measure of the triiodothyronine not bound to serum proteins such as thyroid-binding globulin, albumin or transthyretin.
Triiodothyronine (T3) and thyroxine (T4) are secreted by the thyroid gland and produce a variety of effects on metabolism. Their release is mediated via a negative feedback loop involving the hypothalamus and anterior pituitary gland.
Thyroid stimulating hormone (TSH) is secreted by the anterior pituitary, in response to the stimulating effect of thyroid releasing hormone (TRH) from the hypothalamus. TSH acts on the thyroid gland to stimulate release of T3 and T4.
Hypothyroidism refers to underactivity of the thyroid, with reduced circulating thyroid hormones. This is usually accompanied by typical signs and symptoms of hypothyroidism.
Nonthyroidal illness (also known as sick euthyroid syndrome) is an adaptive response of the thyroid to acute of chronic illness.
Free T4 is a measure of the thyroxine not bound to serum proteins such as thyroid-binding globulin, albumin or transthyretin.
The TSH is a useful screening tool for thyroid disease. If the TSH is elevated or reduced, then the T4 is the next useful test for distinguishing the pattern of derangement.
Hyperthyroidism refers to hyperactivity of the thyroid gland, with increased circulating thyroid hormones. This tends to be accompanied by typical signs and symptoms of thyrotoxicosis such as those listed below.
Caeruloplasmin is a copper-containing protein that may be measured for use as an inflammatory marker, however it is very uncommonly used in this fashion.
Ferritin is an intracellular iron storage protein whose levels are indicative of the body's total iron stores; ferritin is also an acute phase reactant.
Albumin is a group of serum proteins produced by the liver that maintain oncotic pressure and transport certain hydrophobic compounds.
Fibrinogen is a coagulation factor that is converted to fibrin and is essential for the formation of a clot. Inflammation and coagulation are tightly linked, and as such the fibrinogen level will rise in the presence of acute inflammation.
The acute phase response is a facet of the innate immune system that occurs in response to infection, trauma or other insults. Certain mediators, known as acute phase reactants, are increased or decreased in the context of acute inflammation. These markers are commonly measured in clinical practice as indicators of acute illness.
Haptoglobin is an alpha-2 glycoprotein secreted mainly by the liver that binds plasma free haemoglobin following red cell lysis, and as such is reduced in the presence of haemolysis (particularly intravascular haemolysis).
Urinary casts are tubular structures formed by the precipitation of Tamm-Horsfall mucoprotein. These may contain red cells, white cells or other substances, and their presence may suggest specific disease processes.
There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.
Squamous epithelial cells seen in urine originate from the urethral wall. If these are present in urine then this suggests a contaminated, non-midstream urine sample that likely also contains urethral normal flora.
The cardiac axis represents the overall direction of depolarisation of the cardiac conduction system, and is assessed by looking at the depolarisation of the individual leads.
The ST segment on an ECG trace reflects early ventricular repolarisation, and is classically used to assess for cardiac ischaemia.
The U wave reflects repolarisation of mid-myocardial cells, between the endocardium and epicardium. It is not normally visible on the electrocardiogram.
The QRS complex indicates ventricular depolarisation.
The QT interval indicates of the time from ventricular depolarisation (phase 0) to ventricular repolarisation (phases 1-3). It is the duration of activation and recovery of the ventricular myocardium.
When assessing rhythm on an ECG, look at both the regularity of P waves (sinoatrial rhythm) and R waves (ventricular rhythm).
Correct technique in recording ECGs is imperative for the diagnosis of electrical disorders of the heart. Incorrect technique may result in artefact, an unusable result or even misinterpretation of the ECG.
The PR interval is the time between atrial depolarisation and ventricular depolarisation. It is an indicator of atrioventricular conduction time, involving conduction from the atria, through the AV node and down the His-Purkinje system.
A poor quality ECG trace can be incredibly difficult to interpret and, more dangerously, may be misinterpreted.
The P wave on an ECG trace is indicative of atrial depolarisation, which may be initiated by the sinoatrial node or by an ectopic atrial focus.
The heart rate is the ventricular rate, or the rate of ventricular depolarisation.
  • Square Sizes

    The standard ECG is recorded at a speed of 25mm/sec and gain of 10mm/mV.
  • 40ms = 1mm = 1 small square
  • 200ms = 5mm = 1 large square
  • 0.1mV = 1mm = 1 small square
The T wave on an ECG trace is indicative of ventricular repolarisation.

Monomorphic Ventricular Tachycardia

Monomorphic VT is a focal or reentrant ventricular rhythm that requires rapid assessment and management, due to its risk of haemodynamic instability and collapse.

Overview

Supraventricular tachycardias in the presence of either bundle branch block or pre-excitation (accessory pathway) will present with a regular wide complex tachycardia that is often difficult to distinguish from ventricular tachycardia.
Multifocal atrial tachycardia is an irregular rhythm that occurs due to multiple atrial ectopic foci.
Atrial flutter is most commonly due to a right atrial macro-reentrant circuit, and has significant crossover with atrial fibrillation in its pathogenesis.
Sinus tachycardia originates from the sinus node and is a physiologic response that occurs due to changes in autonomic regulation - either sympathetic activation or reduction in parasympathetic tone.
AV reentrant tachycardias occur when an atrial impulse is conducted through an accessory pathway - either retrogradely following AV conduction (orthodromic) or anterogradely (antidromic).
Focal atrial tachycardia is a rapid atrial rhythm originating from a single atrial focus.
Atrial fibrillation in the presence of either bundle branch block or pre-excitation (accessory pathway) will result in an irregular wide complex tachycardia that may be mistaken for polymorphic VT. It is important to carefully check the ECG for the typical highly irregular rhythm of atrial fibrilation.
Atrial fibrillation is a common cardiac arrhythmia that originates from an ectopic atrial focus.
Ventricular fibrillation is a chaotic ventricular rhythm that is not compatible with haemodynamic stability.
AV nodal reentrant tachcardia (AVNRT) is the most common type of paroxysmal supraventricular tachycardia (pSVT), and occurs due to a reentrant loop within the AV node.
Serum protein electrophoresis (EPG) separates serum proteins based on their electrical charge, producing a characteristic pattern.
MGUS and smouldering myeloma by definition do not manifest clinically. Multiple myeloma presents classically with hypercalcaemia, renal dysfunction, anaemia and lytic bony lesions (denoted by the acronym CRAB); myeloma should be suspected in patients with any of these manifestations without any other clear cause.
Antibodies are secreted by plasma cells, and are made up of two identical heavy chains and two identical light chains. There are two types of light chain - κ (Kappa) and λ (Lambda).
Immunoglobulins, secreted by plasma cells, are made up of five classes - IgG, IgM, IgA, IgD and IgE.
Immunofixation is used with serum electrophoresis to determine the type and amount of monoclonal protein (M-protein, or paraprotein) present in a patient with a suspected plasma cell neoplasm, such as MGUS or multiple myeloma.
Urea is a nitrogenous waste product that allows the kidneys to excrete nitrogen; it also drives the countercurrent exchange system within the nephron.
    • Normal Range

    • 50 - 120 μmol/L
In the presence of raised creatinine, urea disproportionately higher than creatinine suggests a prerenal cause such as hypovolaemia, heart failure or shock.
eGFR is the most common means for estimating glomerular filtration rate (GFR) in clinical practice in the context of assessing chronic kidney disease; equations rely on serum creatinine measurements and are adjusted depending on the patient's demographic information.
    • Normal Range

    • 3.0 - 8.0 mg/dL
Measured creatinine clearance is an estimate of the GFR based on a 24-hour urine sample. It was previously more popular and is now not often used in clinical practice due to newer eGFR formulae that are based on serum creatinine.
Pulmonary embolism can produce a wide variety of ECG changes. 
Catacholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited disorder that occurs due to mutations in the ryanodine receptor, affecting calcium release from the sarcoplasmic reticulum.
Hypothermia refers to a reduction in body temperature below 35 degrees celcius. ECG findings may be seen with profound hypothermia, and particularly below 32 degrees.
Brugada syndrome is an inherited condition that strongly predisposes to sudden cardiac death. The condition is autosomal dominant in inheritance and involves a loss of function mutation in sodium channels, predominantly affecting the right ventricle.
Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited disorder in which there is fibro-fatty replacement of the right ventricular myocardium. The condition is the second most common of sudden cardiac death in young people.
Acute myocardial infarction (MI) may be diagnosed using a 12 lead ECG. 
Patients with acute stroke - ischaemic or haemorrhagic - may develop ECG findings that mimic an acute myocardial infarction, in the abscence of significant cardiovascular disease.
Hypercalcaemia, or an increased serum calcium concentration >2.60 mmol/L, shortens action potentials which primarily results in early ventricular repolarisation (shortened QT) on ECG.
Pericardial effusions tend to cause ECG changes only when they are massive, and ECG changes are a poor indicator of pericardial effusions overall.
Certain ECG findings suggest myocardial ischaemia without infarction. These may be seen in a patient following exertion (e.g. during an exercise stress test), or may occur at rest (in unstable angina or non-ST elevation myocardial infarction).
Several hereditary conditions are associated with a prolonged QT interval, which increases the risk of life-threatening arrhythmia.
The electrocardiogram is a useful tool in the diagnosis of pericarditis, which can often present with chest pain that is similar in nature to an acute coronary syndrome.
Potassium is important in maintaining membrane potentials, particularly in cardiac myocytes. 
Hypocalcaemia, or a reduced serum calcium concentration >2.15 mmol/L, prolongs action potentials which primarily results in delayed ventricular repolarisation (prolonged QT) on ECG.
Potassium is important in maintaining membrane potentials, particularly in cardiac myocytes. 
Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac pre-excitation syndrome that occurs due to the presence of an accessory conduction pathway.
A wide variety of medications achieve a therapeutic effect by blocking sodium channels. Toxicity of these medications can produce characteristic ECG findings.
Early repolarisation syndrome (ERS) refers to the presence of J point elevation on an ECG. 
Digoxin is a cardiac glycoside which can be associated with significant toxicity. Certain ECG findings are characteristic.
  • Look For

  • Acidaemia with reduced bicarbonate.
    • Normal Range

    • 80-100mmHg on room air
  • Secondary Response

  • Acute respiratory alkalosis - 2mmol/L [HCO₃] decrease for every 10mmHg PaCO₂ below 40mmHg
  • Chronic respiratory acidosis - 4mmol/L [HCO₃] decrease for every 10mmHg PaCO₂ below 40mmHg
In these patients, it is difficult to determine whether the HAGMA is the only process occurring, or whether there is additional process present such as a normal anion gap metabolic process, or a metabolic alkalosis.
It is a calculation of the unmeasured anions and cations in the blood, based on anions and cations that we can measure (sodium, chloride and bicarbonate). This assumes that the body is electrochemically neutral, i.e.:
    • Normal Range

    • >90%
An increase or decrease in the PaCO₂ level suggests the presence of a respiratory process causing an acid-base imbalance. This can either be primary (the derangement is due to a respiratory issue) or secondary (there is respiratory compensation for a metabolic issue).
    • Normal Range

    • 22 - 26 mmol/L
  • Signs of Atelectasis on Chest X-Ray

  • Pulmonary opacification
  • Air bronchograms - tubular outlines of the smaller airways
  • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
  • Evidence of Volume Loss

  • Crowding of pulmonary vessels
  • Underinflation
  • Hemidiaphragmatic elevation
  • Tracheal deviation toward the area of atelectasis
  • Mediastinal shift toward the area of atelectasis
  • Hilar displacement
Both PA and lateral films should be used to identify the location of leads associated with a cardiac device.
  • Examples

Interstitial lung disease may be suggested by reticular or reticulonodular opacities on chest x-ray.
  • Indications for Nasogastric Tube Placement

  • Aspiration or drainage of gastric contents
  • Feeding
  • Enteral administration of medications
  • Causes of Pulmonary Oedema

  • Cardiogenic

  • Heart failure
  • Fluid overload
  • Renal failure
  • Transfusion-associated circulatory overload (TACO)
  • Non-Cardiogenic

  • Acute respiratory distress syndrome
  • Pulmonary embolism
  • Re-expansion pulmonary oedema (e.g. with drainage of a pleural effusion or pneumothorax)
  • Neurogenic pulmonary oedema
  • Transfusion-related acute lung injury (TRALI)
  • High altitude pulmonary oedema (HAPE)
Different projections are used in various clinical situations, and can affect the interpretation of the x-ray.
  • Classification

  • Community-acquired pneumonia
  • Hospital-acquired pneumonia
  • Ventilator-associated pneumonia
  • Look For

  • Exposure - underpenetrated or overpenetrated
  • Inspiratory film - the x-ray should be taken in deep inspiration
  • Rotation - look at the medial ends of the clavicles, and the vertebrae
  • Examples

Central Venous Catheters (CVCs)

A central venous catheter is a large bore catheter inserted into a large vein for the purpose of central venous access.

Erect Film

The erect film is the standard film, and is performed with the patient standing. This type of film makes it easier to identify pleural effusions and pneumothoraces.

Overview

  • Causes of Pneumothorax

  • Primary Spontaneous Pneumothorax

  • Idiopathic (ruptured pleural bleb / bulla)
  • Secondary Spontaneous Pneumothorax

  • Connective tissue disease - Marfan syndrome, Ehlers-Danlos syndrome, rheumatoid arthritis, scleroderma, ankylosing spondylitis, dermatopolymyositis
  • Airway disease - emphysema (bullous rupture), cystic fibrosis, severe asthma
  • Infections - PJP pneumonia, tuberculosis, necrotising pneumonia
  • Interstitial lung disease
  • Lung cancer
  • Thoracic endometriosis
  • Non-Spontaneous

  • Traumatic - blunt, penetrating
  • Iatrogenic - CVC placement, transthoracic procedures, mechanical ventilation

Silhouette Signs

  • Significance

  • Loss of normal borders appears when the adjacent area of lung is consolidated or collapsed.

Overview

  • Examples

  • Examples

The presence of anti-ds-DNA antibodies is highly suggestive of systemic lupus erythematosus (SLE), with a specificity of 97%.
  • Interpretation

  • Simple - dislocation without fracture
  • Complex - dislocation with fracture of any of the bones involved
  • Interpretation

  • Simple (closed) fracture - doesn't communicate with the skin surface
  • Compound (open) fracture - communicates with the skin surface

Red Blood Cells

Red blood cells within ascitic fluid may simply be due to a traumatic tap or inadvertent sampling from an abdominal vessel; blood may also be present within ascites in the presence of an intra-abdominal bleed as well as certain other conditions.

Overview

  • Formula

  • SAAG = [serum albumin] - [ascitic albumin]
  • Causes of Sinoatrial Exit Block

  • Intrinsic

  • Idiopathic degeneration
  • Myocardial infarction
  • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
  • Connective tissue disease - SLE, scleroderma, RA
  • Cardiac surgery - valvular surgery, correction of congenital heart disease
  • Infections - Lyme disease, endocarditis
  • Extrinsic

  • Physiologic - sleep, athletes
  • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
  • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
  • Hypothyroidism
  • Hypothermia
  • Hyperkalaemia
  • Obstructive sleep apnoea
  • Raised intracranial pressure
  • Causes of Atrioventricular (AV) Block

  • Intrinsic

  • Idiopathic degeneration
  • Myocardial infarction
  • Congenital - congenital heart disease, neonatal lupus
  • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
  • Cardiac procedures - valvular surgery, correction of congenital heart disease, catheter ablation
  • Systemic lupus erythematosus
  • Myocarditis
  • Extrinsic

  • Physiologic - sleep, athletes
  • Autonomic - carotid sinus massage, carotid sinus hypersensitivity
  • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, amiodarone
  • Hyperkalaemia
  • Hypothyroidism
  • Look For

  • Ventricular rate <60bpm
  • Abnormal P wave morphology (e.g inverted or biphasic)
  • Look For

  • Bradycardia with rate 40 - 60 bpm
  • Narrow QRS complexes
  • Absence of P waves
  • Bradyarrhythmias

  • Regular

  • Sinus bradycardia
  • Sinus arrest with escape rhythm
  • Complete heart block with escape rhythm
  • Irregular

  • Sinus arrhythmia
  • Sinus arrest
  • Second or third degree sinoatrial exit block
  • Atrial fibrillation with slow ventricular rate
  • Atrial flutter with variable block
  • Second or third degree AV block
  • Look For

  • Irregular rhythm
  • Saw-toothed baseline 'flutter' waves at ~300bpm
  • Variable atrioventricular block (inconsistent number of flutter waves between QRS complexes)
  • Look For

  • Irregular RR interval
  • Normal PR interval with P waves preceding each QRS complex
  • Normal axis - positive P waves in leads I and II
  • Look For

  • Bradycardia with ventricular rate <60
  • Irregular rhythm
  • No P waves, with oscillating baseline waves
  • Look For

  • Alternating episodes of bradycardia and supraventricular tachycardia (AF, flutter, atrial tachycardia or AVNRT).
  • Look For

  • Bradycardia with ventricular rate <40bpm
  • Wide QRS complexes (120ms)
  • Regular non-conducted P waves (complete heart block) or no P waves (sinus arrest)
  • Manifestations of Sinus Node Dysfunction

  • Sinus bradycardia
  • Sinus arrhythmia
  • Sinus pause / arrest
  • Sinoatrial exit block
  • Tachy-brady syndrome
  • Look For

  • A pause of at least three seconds, without P waves or QRS complexes
  • An escape rhythm may be present
  • Look For

  • Decreased heart rate - <60bpm (or 50bpm when asleep)
  • Regular rhythm - normal PR interval with P waves preceding each QRS complex
  • Normal axis - positive P waves in leads I and II

Poikilocytosis

  • Significance

  • Certain red cell morphologies may be more suggestive of certain causes of haemolysis.

Overview

    • Normal Range

    • 36 - 195 mg/dL
    • Normal Range

    • 120 - 280 U/L
    • Normal Range

    • Absolute reticulocyte count: 50 - 100 x 10⁹/L
    • Reticulocyte percentage: 0.5 - 2.5%
  • Causes of Intravascular Haemolysis

  • Microangiopathic haemolytic anaemia - TTP, HUS, DIC, preeclampsia / HELLP, SLE, malignant hypertension, severe burns, brown snake bite
  • Intravascular trauma - valvular leaks, cardiac prostheses, renal replacement, ECMO, march haemoglobinuria
  • Alloimmune haemolysis - transfusion of mismatched red blood cells, haemolytic disease of the newborn, post stem cell transplant
  • Infection - severe malaria, Clostridium toxin
  • Copper (Wilson's disease)
  • Certain cold agglutinin haemolysis disorders
  • Paroxysmal nocturnal haemoglobinuria
  • G6PD deficiency
    • Normal Range

    • Total bilirubin - <1 mg/dL or <20 μmol/L
    • Direct (conjugated) bilirubin - <0.3 mg/dL or <7 μmol/L

Aetiology

  • Causes of Iron Overload

  • Haemochromatosis
  • Iron loading anaemias - thalassaemias, sideroblastic anaemia, congenital dyserythropoietic anaemia
  • Multiple blood transfusions
  • Excessive iron administration

Overview

    • Normal Range

    • 15 - 300μg/L
  • Roles of Iron

  • Oxygen transport (as haemoglobin)
  • Muscle oxygenation (as myoglobin)
  • Synthesis of DNA, RNA and proteins
  • Cellular respiration (as cytochromes)
  • Immune function
  • Myelin sheath formation

Aetiology

  • Causes of Iron Deficiency

  • Nutritional deficiency
  • Malabsorption - e.g. coeliac disease, gastric surgery, PPIs
  • Blood loss - particularly menstrual and gastrointestinal loss; regular blood donation
  • Pregnancy

Overview

    • Normal Range

    • 10-30 μmol/L
    • Normal Range

    • Males: 15 - 45%
    • Females: 15 - 55%
An increased soluble transferrin receptor level can aid in the diagnosis of iron deficiency if uncertain, particularly in differentiating iron deficiency from anaemia of chronic disease. Haemolysis will also caused a raised level.
    • Normal Range

    • 1.5 - 3.2 g/L
  •  
  • Blood Film Findings in Megaloblastic Anaemia

  • Macrocytic hyperchromic anaemia (may be normocytic in early disease)
  • Anisocytosis: variation in size of red blood cells
  • Macroovalocytes: large, round cells
  • Teardrop cells
  • Hypersegmented neutrophils (5 or more nuclear lobes)
  •  
  •  
Patients with hyposplenism are at increased risk of infections - particularly with encapsulated bacteria (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae).

Neutrophil Physiology

  • Morphology

  • Mature neutrophils exhibit 3-5 nuclear lobes, with immature forms exhibiting less lobes and hypersegmented exhibiting more. Females may display a 'drumstick' that protrudes from the nucleus.

Overview

  •  

Lymphocytosis

Lymphocytosis refers to an increase in circulating lymphocytes. These cells may be small mature lymphocytes, reactive lymphocytes or atypical lymphocytes and therefore it is important to assess the morphology of these cells histologically.

Overview

  •  
Blasts tend to be medium to large cells with a large nucleus that takes up most of the cell (high nuclear : cytoplasmic ratio), fine nuclear chromatin pattern, nucleoli and a grey to blue cytoplasm.
Myelodysplasia refers to the presence of morphologically and functionally abnormal blood cells. 
  • Common Red Cell Inclusions

  • Howell Jolly bodies - DNA fragmentsSeen post splenectomy and in functional hyposplenism
  • Basophilic stippling - RNA fragmentsSeen in haemoglobinopathies and heavy metal poisoning
  • Pappenheimer bodies - clumps of ferritinSeen post splenectomy, in sideroblastic anaemia and in lead poisoning
  • Cabot ring - strings of mitotic spindle remnantsSeen in megaloblastic anaemia, MDS and myelofibrosis
  • Heinz bodies - clumps of denatured haemoglobinSeen on supravital staining in oxidative haemolysis, e.g. G-6-PD deficiency
  • HbH bodies - clumps of haemoglobin H (four beta chains)Seen on supravital staining in HbH disease, i.e. alpha thalassaemia major
This is always an abnormal finding, and may indicate a major acute stress or bone marrow infiltration.
  •  
    • Normal Range

    • 2.0 - 3.5 pg/mL
The release of TSH is suppressed by circulating thyroid hormone, and its levels are affected by small changes in circulating T3 and T4 such that TSH changes in a logarithmic scale compared to the linear scale of the thyroid hormones.
  • TFT Interpretation

  • Primary hypothyroidism - elevated TSH with reduced T4
  • Subclinical hypothyroidism - elevated TSH with normal T4
  • Central hypothyroidism - reduced TSH with reduced T4
  • Causes of Nonthyroidal Illness

  • Starvation
  • Sepsis
  • Burns
  • Trauma
  • Surgery
  • Myocardial infarction
  • Malignancy
  • Chronic liver disease
  • Chronic kidney disease
    • Normal Range

    • 0.8 - 1.8 ng/dL
Low TSHHigh TSH
Low T4Central HypothyroidismPrimary hypothyroidism
Normal T4Subclinical hyperthyroidismSubclinical hypothyroidism
High T4Primary hyperthyroidismCentral hyperthyroidism
  • TFT Interpretation

  • Primary hyperthyroidism -  reduced TSH with elevated T4
  • Subclinical hyperthyroidism - reduced TSH with normal T4
  • Central hyperthyroidism - elevated TSH with elevated T4
  • Causes of Elevated Caeruloplasmin

  • Infection
  • Inflammation
  • Malignancy - particularly lymphoma
  • Alzheimer's disease
  • Pregnancy
    • Normal Range

    • 15 - 300μg/L
    • Normal Range

    • 32 - 45 g/L
    • Normal Range

    • 1.5 - 4.5 g/L

Pathogenesis

The acute phase response is predominantly mediated by the pro-inflammatory cytokines tumour necrosis factor (TNF), interleukin 1 (IL-1) and interleukin 6 (IL-6) secreted by macrophages and other immune cells.

Overview

    • Normal Range

    • 36 - 195 mg/dL
  • Interpretation

  • Acellular Casts

  • Hyaline casts (solidified mucoprotein) - dehydration, exercise, diuretics
  • Granular casts (degenerated cells) - glomerulonephritis, acute tubular necrosis, pyelonephritis
  • Muddy brown casts (likely denatured haemoglobin) - acute tubular necrosis
  • Waxy casts (severely degenerated cells) - severe acute or chronic renal failure
  • Fatty casts (lipids) - nephrotic syndrome, diabetic nephropathy
  • Pigment casts (haemoglobin, myoglobin, bilirubin) - haemolysis, rhabdomyolysis, liver disease
  • Cellular Casts

  • Red cell casts (bleeding through the glomerulus or into the tubules) - glomerulonephritis, acute interstitial nephritis
  • White cell casts (interstitial or glomerular inflammation) - pyelonephritis, glomerulonephritis, acute interstitial nephritis
  • Renal tubular epithelial cell casts (sloughed cells) - acute tubular necrosis, acute interstitial nephritis
  • Bacterial casts - pyelonephritis
  • Types of Urine Collection

  • Random urine - taken at any time; Used for testing of electrolytes etc.
  • Morning urine - the first urine of the day is the most concentrated, increasing the yield; Used for urinalysis, microscopy and beta-HCG testing
  • Clean catch / midstream urine - the first few mL are discarded and then urine is collected, removing urethral bacterial flora from the sample; Best for urine culture and sensitivity testing
  • 24 hour urine - all of the urine passed over 24 hours is collected; Used to measure certain analytes, such as creatinine, protein, electrolytes, uric acid, cortisol, catecholamines / metanephrines
  • Catheterised sample - e.g. from an in and out / indwelling / suprapubic catheter
  • Suprapubic aspiration - a needle is used to aspirate urine; May be required if a patient cannot be catheterised, or if sterile urine absolutely must be collected
    • Normal Axis

    • -30° to +90°
  • Look For

  • The section between the end of the QRS complex (J point) and the beginning of the T wave.
  • Look For

  • A low amplitude deflection after the T wave, most evident in the precordial leads.
  • Look For

  • Q wave - an initial negative deflection
  • R wave - a positive deflection
  • S wave - a negative deflection after the R wave
    • Normal Range

    • Men 390 - 450ms
    • Women - 390 - 460ms
ECG Rhythm is best assessed using the rhythm strip, which is usually lead II.
  • How to Perform

  • 1
    Prepare the skin - ensure that it is dry; shave excessive chest hair; gently abrade the skin if required
  • 2
    Place the electrodes as below
  • 3
    Ask the patient to remain still, not speak and breath slowly (if possible)
  • 4
    Record the ECG - at speed 25mm/sec and gain 10mm/mV
  • 5
    Look for electrical interference and baseline wander, and assess need to rerecord ECG
  • 6
    Consider a rhythm trace if arrhythmia is evident
    • Normal Duration

    • 120-200ms (3-5mm)
  •  
    • Normal Range

    • 60 - 100bpm

The ECG Trace

A normal ECG trace includes a P wave, a QRS complex and a T wave.

Overview

  • Look For

  • A deflection following the QRS complex that is normally asymmetrical, with a slow upslope and a rapid downslope. Usually positive, though negative T waves are normal in aVR and V1.

Monomorphic Ventricular Tachycardia

  • Look For

  • Heart rate >100bpm
  • Regular rhythm (RR interval)
  • Broad QRS complexes >120ms

Overview

  • Look For

  • Heart rate 100-250bpm
  • Regular rhythm
  • Broad QRS complex >120ms
  • On Old ECGs

  • Bundle branch block
  • Wolff-Parkinson-White pattern
  • Look For

  • Heart rate >100bpm
  • At least three different P wave morphologies
  • Variable PP intervals
  • An isoelectric baseline (to differentiate from atrial fibrillation or flutter)
  • Look For

  • Heart rate ~150bpm
  • Regular rhythm (RR interval)
  • Saw-toothed baseline 'flutter' waves at ~300bpm
  • Atrioventricular block (not every flutter wave is followed by a QRS complex)
  • Look For

  • Heart rate >100bpm
  • Regular rhythm (RR interval)
  • Each P wave followed by a QRS complex
  • Positive P wave in leads I and II
  • Look For

  • Orthodromic AVRT (90%) - regular narrow complex tachycardia with no P waves (hidden in QRS) or P waves after QRS complex. No delta wave will be seen.
  • Antidromic AVRT (10%) - regular broad complex tachycardia (easily mistaken for VT)
  • Look For

  • Narrow complex tachycardia
  • Regular ventricular rhythm
  • Abnormal P wave morphology (e.g. inverted or biphasic) that is consistent
  • An isoelectric baseline (to differentiate from atrial fibrillation or flutter)
  • Look For

  • Heart rate 100-250bpm
  • Irregular rhythm
  • Broad QRS complex >120ms
  • On Old ECGs

  • Atrial fibrillation
  • Bundle branch block
  • Wolff-Parkinson-White pattern
  • Look For

  • Ventricular rate 100-180bpm (may be <100 with block or medications)
  • Irregular rhythm
  • No P waves, with oscillating baseline waves
  • Look For

  • Irregular, rapid, chaotic electrical activity without P waves, QRS complexes or T waves.
  • Look For

  • Heart rate 100-250bpm
  • Regular rhythm
  • Late P waves - may be hidden within the QRS complex, cause a pseudo S wave in inferior leads / pseudo R wave in right precordial leads (slow-fast AVNRT), or appear after the QRS complex (fast-slow AVNRT)
Electrophoresis is a useful screening test for plasma cell neoplasms such as multiple myeloma and MGUS. If a plasma cell neoplasm is suspected then serum EPG should be ordered in conjunction with immunofixation electrophoresis (IFE) in order to quantify a paraprotein if present.
  • Manifestations of Multiple Myeloma

  • Classical (CRAB)

  • Calcium - hypercalcaemia
  • Renal failure (multifactorial) - due to cast nephropathy, glomerular light chain deposition, hypercalcaemia, amyloidosis
  • Anaemia - normocytic, normochromic
  • Bone lesions - lytic lesions, due to osteoclastic change
  • Other

  • Hyperviscosity syndrome - due to hypergammaglobulinaemia
  • Amyloidosis - GI, cardiac, hepatic, renal, muscular or nerve infiltration
  • Recurrent infections - due to relative hypogammaglobulinaemia
Serum free light chains is a measure of the light chains (Bence-Jones protein) not bound to antibody.
  • Roles of Immunoglobulins

  • IgG - the most abundant immunoglobulin; also crosses the placenta
  • IgM - the first immunoglobulin secreted in response to foreign antigens
  • IgA - present in saliva, sweat, tears, breast milk and blood
  • IgD - bound to B-cell membranes; triggers B-cell activation
  • IgE - present in skin, mucous membranes and the lungs; involved in certain hypersensitivity reactions and response to parasitic infection
Immunofixation electrophoresis (IFE) is performed by separating plasma proteins by electrophoresis, followed by addition of specific antisera against each type of immunoglobulin.
    • Normal Range

    • 3.0 - 8.0 mmol/L
  • Key Concepts

  • Creatinine is mainly produced by creatine metabolism from muscle breakdown; it is also present in dietary sources like cooked meat
  • Approximately 15% of creatinine is actively secreted into the tubules
  • Patients with stable renal function will have stable creatinine levels with daily variability ~8%
  • Interpretation

  • Elevated ratio: >100:1
  • Reduced ratio: <40:1
eGFR calculators can be found in the tools section of the app.
  • Formula

  • Creatinine clearance = (urine creatinine x volume) / serum creatinine
The most common ECG finding in PE is sinus tachycardia. The S1Q3T3 pattern is a classic finding, however this is uncommon and is only seen in ~12% of cases.
Catacholaminergic polymorphic ventricular tachycardia may present as syncope or sudden cardiac death due to polymorphic ventricular tachycardia, following an adrenergic stress such as exercise.
Osborn waves, or J waves, are a classic finding in hypothermia. They may also be seen in hypercalcaemia and early repolarisation syndrome. A J wave is a hump-like deflection after the J point, which is the junction between the QRS complex and the ST segment. 
  •  
The most classic ECG finding in ARVD is epsilon waves. Patients with ARVD may develop ventricular tachycardia, which is of right ventricular origin (with left bundle branch morphology).
ST elevation MI (STEMI) requires immediate coronary intervention and as such rapid assessment of the patient and ECG is imperative. Non-ST elevation MI may present with many features of STEMI, without ST elevation.
  •  
The classical ECG changes in pericardial effusion are sinus tachycardia, low QRS voltage and electrical alternans.
  • ECG Findings in Myocardial Ischaemia

  • Downsloping ST depression
  • T wave flattening / inversion
  • U wave inversion
A prolonged QT interval represent delayed ventricular repolarisation, and increases the risk of a re-entry circuit from froming (i.e. Torsade de Pointes).
The important distinguishing factor on ECG is the fact that the ST elevation affects all leads (i.e. is global), as opposed to the localised ST elevation in myocardial infarction. PR depression is also a characteristic finding.
Hypokalaemia, or a reduced serum potassium concentration of <3.5mmol/L, is associated with hyperpolarisation of cardiac myocytes. If severe, hypokalaemia causes abnormal ventricular automaticity which may result in ventricular arrhythmias.
Hyperkalaemia, or an increased serum potassium concentration of >5mmol/L, shortens action potentials and reduces conduction velocity in cardiac myocytes.
Normal cardiac impulses are conducted from the atria to the ventricle via the AV node. In WPW, an accessory pathway (the Bundle of Kent) is present which bypasses the normal conduction pathway. This produces a classic preexcitation pattern on ECG, and places the patient at risk of arrhythmias.
Sodium channel blockers prevent influx of sodium into cardiac myocytes during phase 0 of the action potential, resulting in widening of the QRS complex.
Early repolarisation syndrome is also known as benign early repolarisation (BER) and was previously considered a normal variant, however the condition is associated with an increased risk of ventricular arrhythmias and sudden cardiac death.
Digoxin inhibits the Na+/K+ ATPase pump, which results in sodium influx and potassium efflux. This subsequently increases the activity of the Na+/Ca2+ exchange pump, resulting in calcium influx which increases automaticity and has a positive inotropic effect (increases contractility). Digoxin also increases parasympathetic (vagal) tone, causing reduced conduction through the AV node.

Lower Limb Erythema

  • Look For

  • Redness - unilateral, bilateral, localised or diffuse.

Overview

  • Interpretation

  • Spacticity (clasp knife): velocity dependant, quick flexion / extension of the joint (works best on knee / elbow)Upper motor neuron lesion
  • Lead pipe rigidity: continuous and not velocity dependant, slow flexion / extensionParkinsonism / Parkinson's disease, contractures
  • Cogwheel rigidity: rigidity associated with tremor, resulting in jerky stop / start movement of the jointParkinsonism / Parkinson's disease
  • Normal: minimal resistance
  • Decreased: no resistanceLower motor neuron or cerebellar lesion

Weight

  • Look for

  • The patient's current weight
  • Change in weight - compare to past weights
  • Time course - sudden / gradual

Cheyne-Stokes Respiration

  • Significance

  • Cheyne-Stokes respiration occurs when hyperventilation lowers the arterial CO₂ below the apnoeic threshold.

Overview

  • How to Assess

  • Ask the patient to move their fingers, thumb, wrist, elbow and shoulder through each movement.

Oral Candidiasis

  • Significance

  • Infection with Candida species.

Dehydration

  • Causes of Dehydration

  • Poor fluid intake
  • Fluid loss - diarrhoea, vomiting, sweating, diuresis (diabetes, diuretics)

Overview

  • How to Assess

  • Apply pressure to the nail bed until it blanches, release and measure the time taken for colour to return.
If the reflex is difficult to elicit, reassess the reflex while the patient clenches their teeth.

Onycholysis

  • Look For

  • Separation of the nail from the nail bed, either distally or laterally.

Overview

If the patient wears corrective lenses, perform the test with and without them.
  • Interpretation

  • Hum - low, constant murmurNormal jugular venous hum
  • Bruit - abnormal systolic sound (turbulent flow)Carotid stenosis, transmitted murmur of aortic stenosis
  • Significance

  • Due to thickening of the palmar and digital fascia, resulting in fibrous band formation and flexion contractures of the MCP and PIP joints.

Arterial Ulcers

The presence of white, painful ulcers suggests a partial or complete arterial occlusion.

Overview

  • Interpretation

  • Central - tends to involve an entire upper and / or lower limbIschaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis
  • Axon - Begins distally and migrates proximally → glove and stocking' distributionDiabetes, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
  • Myelin sheath (demyelination) - impaired proprioception and vibration sensation with intact pain sensationGuillain-Barré syndrome, CIDP, Charcot-Marie-Tooth
  • Nerve root - in the distribution of a single dermatomeTrauma, radiculopathy, neoplasm
  • Peripheral nerve - in the distribution of a peripheral nerveTrauma, entrapment, focal ischaemia, neoplasia, shingles, nerve block
  • Skin receptors - localised to an area not in keeping with a dermatomal or peripheral nerve patternTrauma, local anaesthesia, full thickness burns
  • Causes of Cool Extremities

  • Peripheral arterial disease
  • Compartment Syndrome
  • Shock
  • Low cardiac output, due to cardiac disease

Comprehension

CLOSE YOUR EYES

The Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is a 15-point scale indicating level of consciousness.

Overview

  • Wire cube - ask the patient to copy a diagram of a wire cube.
  • Wire cube - ask the patient to copy a diagram of a wire cube.
  • Causes of Myotonia

  • Myotonic Dystrophy

  • Dystrophia myotonia
  • Myotonia congenita
  • Non-Dystrophic Myotonia

  • Paramyotonia congenita
  • Acid maltase deficiency
  • How to Assess

  • Buttoning: ask the patient to button and unbutton their shirt front or shirt cuff.Fine motor coordination
  • Unscrewing: ask the patient to unscrew a jar or bottle cap.Hand strength
  • Key turning: ask the patient to demonstrate how they would pick up a key, insert it into a lock and unlock the door.Fine motor coordination
  • How to Elicit

  • Biceps - ask the patient to relax their arms in their lap. Identify the biceps tendon within the antecubital fossa and strike it with a tendon hammer.C5 / C6 myotome
  • Supinator - ask the patient to relax their arms in their lap and strike the brachioradialis tendon, proximal to the wrist on the lateral aspect of the forearm.C7 myotome
  • Triceps - lift the patient's shoulder into abduction and internal rotation, with the arm flexed to 90°. Identify the triceps tendon on the posterior aspect of the arm proximal to the olecranon, and strike it with a tendon hammer.C6 myotome
Central cord syndrome - bilateral upper motor neuron weakness affecting the upper limbs more than the lower limbs, and loss of proprioception and vibration sensation (dorsal column)Commonly due to trauma or hyperextension of the cervical spine
  • Causes of Radiculopathy

  • Intervertebral disc herniation
  • Osteoarthritis (osteophytosis)
  • Diabetes
  • Haematoma - epidural / subdural
  • Malignancy - spine, spinal cord
  • Infection - epidural abscess, tuberculosis, Lyme disease, syphilis, herpes zoster
  • How to Assess

  • Ask the patient to relax and allow you to move their arms. Move the wrists and elbows passively through their range of motion, assessing for rigidity.

Cutaneous Manifestations of Neurologic Disease

  • Signs of Tuberous Sclerosis Complex (TSC)

  • Angiofibromata: pink papules in the nasolabial folds
  • Shagreen patches: soft flesh-coloured patches on the trunk
  • Ash leaf macules: hypopigmented flat spots

Overview

  • Causes of Brachial Plexopathy

  • Trauma - shoulder dystocia, motor vehicle accident, blunt trauma, penetrating injury
  • Malignancy - apical lung tumour, metastasis
  • Neurogenic thoracic outlet syndrome
  • Brachial neuritis
  • Radiation
  • How to Perform

  • Ask the patient to forcibly flex their wrists into a reverse prayer position for 30-60 seconds.
  • Signs of Peripheral Polyneuropathy

  • Lower motor neuron weakness affecting multiple nerve distributions
  • Sensory loss affecting multiple nerve distributions
  • How to Perform

  • Ask the patient to move their fingers, thumb, wrist, elbow and shoulder through each movement.
  • Signs of Myaesthenia Gravis

  • Skeletal Muscle Fatiguability

  • Simpson's test - ptosis on sustained upward gaze
  • Peek sign - inability to maintain sustained eye closure
  • Bulbar fatiguability - development of nasal speech with reading
  • Proximal muscle fatigability - inability to maintain arms above the head
  • Signs of Management

  • Thymectomy scar
  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus
  • Causes of Peripheral Mononeuropathy

  • Compression (particularly carpal tunnel and ulnar tunnel) - prolonged pressure, hereditary neuropathy with liability to pressure palsies (HNPP)
  • Trauma - blunt trauma, penetrating injury (e.g. knife, gunshot, glass)
  • Nerve ischaemia - trauma, thromboembolism, diabetes, atherosclerosis, excessive tourniquet use
  • Radiation injury
  • Signs of Mononeuritis Multiplex

  • Lower motor neuron weakness affecting two or more distinct peripheral nerve distributions
  • Sensory loss affecting two or more distinct peripheral nerve distributions
  • Sensory Modalities

  • Dorsal column pathway - proprioception, vibration sensation, soft touch
  • Spinothalamic pathway - pain sensation, temperature sensation, soft touch
Motor neurone disease does not present with sensory involvement or ocular palsy.
  • Causes of Parkinsonism

  • Parkinson's disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
  • Parkinson's Plus Syndromes

  • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
  • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
  • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
  • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
  • Others

  • Drugs - antipsychotics, metoclopramide, lithium
  • Normal pressure hydrocephalus
  • Hypoxic brain injury
  • Wilson's disease
  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus

Abnormal Posturing

  • Interpretation

  • Decorticate - flexion, adduction and internal rotation of the arms; supination of the forearms and extension of the legs.Damage to cerebral hemispheres with brain stem preservation
  • Decerebrate - extension of the arms, pronation of the forearms extension of the legsDamage to upper brain stem
  • Opisthotonic - secerebrate posturing with posterior arching of the neck and back.Severe damage to the upper brain stem

Overview

  • Differential Diagnosis of Proximal Weakness

  • Proximal myopathy
  • Neuromuscular disorder - myaesthenia gravis, Lambert-Eaton myaesthenic syndrome
  • Neurologic disorder - polyneuropathy, motor neurone disease
  • How to Elicit

  • Ask the patient to place their arms up and out in front of them with the wrists extended. 
  • Look for an intermittent loss of tone in the wrists, with the appearance of a flap. 

Weight

  • Look for

  • The patient's current weight
  • Change in weight - compare to past weights
  • Time course - sudden / gradual

Candidiasis

  • Significance

  • Infection with Candida species.

Overview

  • How to Assess

  • Using the pulps of the fingers, gently palpate each of the lymph node groups within the cervical and axillary regions.

Digital Clubbing

  • Causes of Digital Clubbing

  • Cyanotic congenital heart disease
  • Pulmonary malignancy - lung cancer, lymphoma, mesothelioma
  • Chronic infection / inflammation - bronchiectasis, lung abscess, empyema, interstitial lung disease, coeliac disease, IBD, infective endocarditis
  • Cirrhosis

Rashes Associated with GI Disease

Dermatitis herpetiformis: itchy papules and vesicles found on the scalp and extensor surfaces.Coeliac disease

Rectal Masses

  • Causes of Rectal Masses

  • Haemorrhoid (thrombosed / prolapsed)
  • Polyp / cancer
  • Perianal abscess
  • Prostatic enlargement - BPH, prostatitis, cancer
  • Malpositioned pessary

Renal Bruits

  • Significance

  • Turbulent blood flow due to renal artery stenosis - either fibrotic or atherosclerotic.

Common Signs on the Tongue

Microglossia: small tonguePseudobulbar palsy

Overview

The internal anal sphincter (IS, autonomic) is responsible for the majority of resting anal tone, while the external sphincter (ES, voluntary) is responsible for the act of squeezing.

Poor Dentition

  • Causes of Poor Dentition

  • Poor oral hygiene
  • High-sugar diet
  • Malnutrition
  • Lack of fluoride
  • Diabetes
  • Alcoholism
  • Smoking

Overview

  • Causes of Peritonitis

  • Infection post perforation - appendix, diverticulitis, IBD, perforated ulcer, surgical anastomosis
  • Spontaneous bacterial peritonitis (SBP)
  • Blood - endometriosis, ruptured ovarian cyst, trauma
  • Bile - post-surgical
  • Urine - pelvic trauma
  • Pancreatic fluid - pancreatitis

Xanthelasma

  • Look For

  • Yellowish plaques on the eyelids.

Dehydration

  • Causes of Dehydration

  • Poor fluid intake
  • Fluid loss - diarrhoea, vomiting, sweating, diuresis (diabetes, diuretics)

The Glasgow Coma Scale (GCS)

15-point scale indicating level of consciousness.

Overview

Chaperone - where possible, have a chaperone present.
  • How to Elicit

  • Using the pulps of the fingers, gently palpate the lymph nodes along the inguinal ligament and down the medial aspect of the thigh.

Segments of the Abdomen

For the purposes of clinical examination, the abdomen is broken into nine segments, each of which contain important organs to assess.

Overview

  • Causes of Ascites

  • Cirrhosis
  • Heart failure
  • Constrictive pericarditis
  • Peritonitis - tuberculous, neoplasmic, bacterial
  • Hypoalbuminaemia - nephrotic syndrome, malnutrition
  • Pancreatitis
  • Cancer - liver, stomach, pancreas, adrenals, gut
  • Thrombosis - portal vein, mesenteric vessels
  • Ovarian disease
  • Hypothyroidism
  • Dialysis
  • How to Assess

  • Place the hands on either side of the midline and identify the outermost margin of the aorta.

Rashes Associated with GI Disease

Dermatitis herpetiformis: itchy papules and vesicles found on the scalp and extensor surfaces.Coeliac disease

Gingival Inflammation

Abscess - localised swelling and erythema.Bacterial infection

Renal Percussion

Flank tenderness to percussion is a relatively sensitive sign for renal pathology, especially pyelonephritis and perinephric abscess.

First Steps

Chaperone - where possible, have a chaperone present.

Overview

  • Signs of Chronic Liver Disease

  • General Signs

  • Sarcopaenia
  • Jaundice (a late sign)
  • Leukonychia
  • Signs Suggesting a Cause

  • Obesity (NAFLD)
  • Scratch marks (cholestasis)
  • Tattoos (viral hepatitis)
  • Kayser-Fleischer rings (Wilson's disease)
  • Cerebellar signs (alcohol misuse)
  • Signs of Complications

  • Portal hypertension - splenomegaly, caput medusae
  • Ascites - shifting dullness, fluid thrill
  • Oestrogen excess - palmar erythema, spider naevi, gynaecomastia
  • Encephalopathy - confusion, asterixis
  • Hepatic hydrothorax - reduced breath sounds, dull percussion note
  • Spontaneous bacterial peritonitis - fever, rigid / tender abdomen
  • Coagulopathy / thrombocytopaenia - bruising, bleeding
  • Signs of Management

  • Dressing over recent abdominocentesis site
  • Liver transplant scar
  • Causes of Weight Gain

  • Dietary intake
  • Physical exercise
  • Endocrine - hypothyroidism, Cushing's, PCOS
  • Medications - steroids, antidepressants, antipsychotics, OCP
  • Fluid overload - excessive IV fluids, renal disease, heart failure
  • Genetic (rare)

Joint Swelling

  • Significance

  • May be a sign of an intra-articular bleed.

Focal Abdominal Tenderness

Epigastrium - liver, gallbladder, stomach, transverse colon, pancreas, heartPancreatitis, peptic ulcer, reflux

Pallor

Skin pallor is a sign of anaemia.

Chest Wall Tenderness

  • Causes of Chest Wall Tenderness

  • Trauma - sprain, strain, haematoma, rib fracture
  • Costochondritis
  • Fibromyalgia
  • Rheumatic disease - rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, lupus, septic arthritis
  • Neoplastic bone pain

Palmar Crease Pallor

  • Causes of Palmar Crease Pallor

  • Anaemia
  • Low cardiac output, due to cardiac disease
  • Peripheral shutdown, due to increased sympathetic activity

Overview

  • How to Assess

  • Using the pulps of the fingers, gently palpate each of the lymph node groups within axillary region.
  • How to Elicit

  • Apply gentle pressure to the right lower quadrant. Ask the patient to take a deep breath in. Move the hand superiorly and medially each time the patient breathes out and repeat until the left costal margin is reached. Repeat with the patient in the right lateral decubitus position.

Bony Tenderness

  • Significance

  • May be an indicator of malignancy.

Hepatomegaly

  • How to Perform

  • Percussion of upper liver edge - Percuss down the midclavicular line from the level of the third rib, with the struck finger held horizontal to the ribs. Once the top edge of the liver is percussed the percussion note will become dull.

Joint Swelling

  • Significance

  • May be a sign of an intra-articular bleed.

Purpura

  • Significance

  • Liver disease can result in purpura due to both clotting factor deficiency (intrahepatic) and vitamin K malabsorption (obstructive).

Overview

  • How to Perform

  • Using the pulps of the fingers, gently palpate each of the lymph node groups within the cervical and axillary regions.

Oropharyngeal Inspection

  • Look For

  • Erythema
  • Swelling of tonsils
  • Exudate
  • Ulcers - viral infection, neoplasm
  • Petechiae on soft palate - pathognomonic for bacterial infection

Abdominal Mass

Right hypochondrium - liver, gallbladder, head of pancreasHepatomegaly, gallbladder enlargement, pancreatic head carcinoma

Overview

  • Feel For

  • Size - normally <10mm
  • Tenderness
  • Consistency - hard (metastasis), rubbery (lymphoma), soft (reactive)
  • Mobility - mobile or tethered to underlying structures
Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.

Jerk Nystagmus

  • How to Perform

  • Ask the patient to look at your finger, held ~50cm in front of their eyes (in primary position). Repeat in the extremes of left and right lateral gaze, as well as in superior and inferior gaze.

Overview

  • Look For

  • Wide-based, ataxic gait
  • Dysarthria
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Muscle wasting
  • Nystagmus
  • Significance

  • Patients with cerebellar disease will have particular difficulty with this task as it eliminates their normally wide-based gait.

Testing for Station

  • Abnormal If

  • Loss of balance.

Overview

  • How to Assess

  • Ask the patient to touch their nose with the tip of their index finger, and then touch your finger. Repeat after moving your finger. Repeat with the other side.
  • How to Elicit

  • Ask the patient to place one hand in the palm of the other hand. Demonstrate rapidly flipping (pronation and supination) of the hand, asking for them to mimic this movement.
  • Significance

  • If the motor and sensory modalities are intact, inability to perform this test smoothly is suggestive of ipsilateral cerebellar disease.
  • Abnormal If

  • Inability to rapidly alternate movements.
  • Significance

  • Inability to maintain plantar flexion is indicative of muscular weakness or an S1 lesion.
  • Interpretation

  • Inability to maintain dorsiflexion is indicative of muscular weakness or an L4/L5 lesion.
  • Significance

  • Suggests a lesion affecting the arcuate fasciculus of the dominant hemisphere, which connects Wernicke's and Broca's areas.
  • Signs of Ataxic Dysarthria

  • Slurred speech - imprecise consonants
  • Slow speech rate - e.g. inability to say 'eye-aye' repeatedly
  • Irregular errors in speech

Facial Asymmetry

  • Interpretation

  • Eyebrow sparing (central palsy) - upper motor neuron lesionIschaemia, haemorrhage, tumour, trauma
  • Eyebrow involvement - facial nerve (VII) lesionBell's palsy, herpes zoster (Ramsay-Hunt Syndrome), tumour, skull fracture

Overview

  • Significance

  • Occurs in the setting of a lower motor neuron lesion (bulbar palsy), neuromuscular or muscular weakness.
  • Interpretation

  • Nasal speech - a sign of flaccid dysarthriaLower motor neuron lesion
  • Strained-strangled speech - a sign of spastic dysarthriaUpper motor neuron lesion 
  • Slurred / 'scanning' speech - a sign of ataxic dysarthriaCerebellar lesion
  • Incorrect repetition (e.g. ifs no buts) - suggestive of conductive dysphasiaArcuate fasciculus lesion
  • Significance

  • The progressive development of hypernasal speech while reading is suggestive of fatigability, a sign of myaesthenia.
  • Significance

  • Orientation is a quick way of assessing patients for confusion.
  • How to Assess

    Ask the patient to repeat back single syllable sounds:
  • Pa pa paLip muscles
  • Ta ta taTongue muscles
  • Ka ka kaPalatal muscles
  • Ba ba baVocal cords
  • Aye-eyeSlow repetition suggests a cerebellar lesion

Dysphonia

  • Causes of Dysphonia

  • Neurological

  • Trauma - vagus / recurrent laryngeal nerve
  • Small-vessel ischaemia
  • Infection  - meningitis, diptheria
  • Tumour
  • Multiple sclerosis
  • Parkinson's disease
  • Neuromuscular / Muscular

  • Myasthenia gravis
  • Spasmodic dysphonia
  • Upper Respiratory

  • Irritation - alcohol, tobacco, reflux, pollutants, inhaled chemicals
  • Laryngitis - viral, bacterial, fungal
  • Vocal cord trauma - direct trauma, chronic cough, vocal abuse
  • Vocal cord mass - nodules, polyps, cyst, tumour
  • Medications - ACE inhibitors, antihistamines, inhaled steroids
  • Other

  • Psychogenic

Overview

  • Signs of Receptive Dysphasia

  • Normal speech fluency
  • Poor comprehension
  • Lack of awareness of errors
  • Inability to follow commands - simple, two-step or three-step commands
  • Paraphasias: switching of a word in a sentence for another incorrect word
  • Neologisms: new words created by the patient
  • Significance

  • Suggests a lesion within the basal ganglia.
  • Significance

  • Spastic dysarthria occurs in the setting of an upper motor neuron lesion (pseudobulbar palsy).
  • Significance

  • Suggestive of Parkinsonism.
  • Signs of Expressive Dysphasia

  • Non-fluency of speech
  • Relatively preserved comprehension
  • Agrammatism - poor use of grammar
  • Telegraphic speech - using short sentences with verbs, nouns and no joining words (e.g. boy throw ball)
  • Inability to describe objects
  • Significance

  • Suggests a lesion affecting the angular gyrus of the dominant hemisphere
  • How to Perform

  • Position the patient at 45 degrees and ask them to turn their head to the left. Hold a flashlight tangentially to the skin of the neck and inspect for the highest level of the jugular venous pulsation. Measure the vertical distance between the sternal angle and this level.

Heart Sounds

  • Heart Sounds

  • Normal

  • First heart sound (S1) - indicates closure of the mitral and tricuspid valves (a loud S1 suggests MS; a soft S1 suggests MR)
  • Second heart sound (S2) - indicates closure of the aortic (A2) and pulmonary (P2) valves (a loud P2 suggests pulmonary hypertension; a soft A2 suggests severe AS / AR)
  • Abnormal

  • Third heart sound (S3) - a pathological finding associated with rapid ventricular filling (left ventricular failure, severe MR / AR, constrictive pericarditis)
  • Fourth heart sound (S4) - a pathological finding associated with turbulence during atrial systole (hypertension, AS, PS, MR, HOCM, MI)

Overview

    • Normal Blood Pressure

    • < 120 / 80 mmHg
    • Normal Range

    • 36.0 - 37.5°C
  • How to Assess

  • Pinch a fold of skin on the patient's arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.
  • Causes of Upper Airway Obstruction

  • Soft tissue swelling - anaphylaxis, burns, peritonsillar abscess, epiglottitis, laryngotracheobronchitis (croup)
  • Foreign body aspiration
  • Deformity - laryngomalacia, laryngeal mass / web, tracheomalacia
  • Tongue enlargement / displacement
  • Vocal cord lesion / paralysis
The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
In order to be sure that bowel sounds are absent, it is important to listen for at least five minutes.
  • Interpretation

  • Regular: sinus rhythm
  • Sinus arrhythmia: rhythmic variations in vagal tone with respiration
  • Regularly irregular (regular heart rate with occasional missed or extra beats): sinus arrhythmia, second degree heart block, premature ventricular contractions
  • Irregularly irregular: atrial fibrillation
  • Causes of Oedema

  • Pitting

  • Fluid overload - excessive IV fluids, renal failure, heart failure
  • Right ventricular failure
  • Venous pathology - thrombosis / insufficiency
  • Dependency (the effect of gravity)
  • Hypoalbuminaemia - malnutrition, malabsorption, nephrotic syndrome, liver (synthetic) failure
  • Non-Pitting

  • Impaired lymphatic drainage
  • Pretibial myxoedema (hypothyroidism)
    • Normal Range

    • Most patients: >95%
    • Chronically hypoxic patients: 88 - 92%
  • How to Assess

  • If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.

Breath Sounds

  • Causes of Reduced Breath Sounds

  • Shallow breathing - e.g. due to anxiety or CNS depression
  • Obstruction - foreign body, tumour, asthma, COPD
  • Pleural effusion
  • Pneumothorax
  • Obesity

Abdominal Tenderness

  • Interpretation

  • Right hypochondrium - liver, gallbladder, stomach, hepatic flexure of colon, lungGallstones, peptic ulcer
  • Epigastrium - liver, gallbladder, stomach, transverse colon, pancreas, heartPancreatitis, peptic ulcer, reflux
  • Left hypochondrium - spleen, pancreas, stomach, splenic flexure of colon, lungPeptic ulcer, pancreatitis
  • Right lumbar - ascending colon, kidneyKidney stone, pyelonephritis
  • Umbilicus - small bowel, aortaPancreatitis, early appendicitis, peptic ulcer, IBD
  • Left lumbar - descending colon, kidneyKidney stone, diverticulitis, IBD
  • Right iliac fossa - appendix, terminal ileum, caecum, ovary, fallopian tube, ureterAppendicitis, caecal diverticulitis, ovarian pathology, ectopic pregnancy, PID, inguinal hernia
  • Hypogastrium - uterus, bladder, sigmoid colonCystitis, appendicitis, diverticulitis, IBD, uterine pathology
  • Left iliac fossa - sigmoid colon, ovary, fallopian tube, ureterSigmoid diverticulitis, ovarian pathology, ectopic pregnancy, PID, inguinal hernia

Overview

    • Normal Range

    • 60 - 100bpm

Assessing the Calves

  • Signs of DVT

  • Erythema
  • Swelling
  • Tenderness

Hypoglycaemia

A blood sugar level of <3.9 is generally considered to indicate hypoglycaemia. This is a clinical emergency and should be rapidly treated.

Overview

Inspection of Pupils

    • Normal Pupillary Size

    • In the dark - 4-8mm
    • Under bright light - 2-4mm

Overview

  • Signs of Respiratory Distress

  • Tachypnoea
  • Psychomotor agitation
  • Nasal flaring
  • Pursed lips
  • Speech - phrases → words → none
  • Tripod position - sitting forward with hands on thighs
  • Accessory muscle use
  • Intercostal recession
  • Subcostal recession
  • Paradoxical abdominal breathing
    • Normal Range

    • 36.0 - 37.5°C
    • Normal Range

    • Most patients: >95%
    • Chronically hypoxic patients: 88 - 92%
The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
    • Normal Blood Pressure

    • < 120 / 80 mmHg
    • Normal Range

    • 60 - 100bpm
  • Pulmonary Function Test Findings

  • FEV₁ reduced (<80% predicted)
  • FVC reduced (<80% predicted)
  • FEV₁:FVC ratio normal (>0.7)
  • Reduced volume in flow-volume loop
  • TLC <80% predicted
  • DLCO normal (extrapulmonary) or decreased (parenchymal)
  • Methods for Estimating Lung Volumes

  • Nitrogen washout - the patient exhales fully and breaths 100% oxygen; the exhaled nitrogen concentrations are used to assess lung volumes
  • Helium equilibration - the patient exhales fully and then breaths a combination of oxygen and helium; helium concentrations are used to assess lung volumes
  • Body plethysmography - the patient sits in an airtight room and breaths into a spirometer; the pressures in the room are used to assess lung volumes
A reduced ;FEV₁:FVC ratio of <0.7 is diagnostic of obstructive lung disease.

Obstructive & Restrictive Patterns

  • Obstructive & Restrictive Patterns

Overview

  • Procedure

    Performed with the patient breathing into a pneumotachograph:
  • Maximal breath in
  • Forced expiration as hard and fast as possible
  • Maximal breath in as fast as possible
  • Procedure

  • The patient inhales a mixture of helium (10%), carbon monoxide (0.3%), oxygen (21%) and nitrogen (68.7%), hold their breath for ten seconds and then exhale fully.
  • The levels of exhaled helium and carbon monoxide are used to calculate DLCO
  • The results may need to be corrected for the patient's haemoglobin
    • Normal Range

    • 80 - 120% predicted
  • Significance

  • A marker of compliance of the lungs and chest wall.
  • How to Perform

  • Attach the mouthpiece to spirometer
  • Ask the patient to breath in deeply
  • Ask the patient to blow into the spirometer as hard and as fast as possible, until there is no breath left
  • Encourage the patient to keep blowing out for at least six seconds
  • Repeat the procedure three times total, ensuring that the best two are within 100mL or 5% of each other
  • Calculate the predicted values based on the patient's sex, age and height
  • Calculate the percent predicted, based on the patient's results
  • Important Lab Points

  • Collected in a sodium citrate tube to prevent coagulation prior to testing.
  • Performed by contact activation - methods vary between labs.
  • Tests the intrinsic and common pathways - kininogen, prekallikrein, XII, XI, IX, VIII, X, V, II, fibrinogen
  • Practical Points

  • The factor Xa level may be used to monitor the efficacy of medications that inhibit factor Xa, such as low molecular weight heparins, rivaroxaban, apixaban, fondaparinux and danaparoid.
  • Monitoring of low molecular weight heparins (enoxaparin / dalteparin) using factor Xa is not routine and is reserved for specific circumstances such as renal impairment, pregnancy or obesity.
  • Monitoring of factor Xa inhibitors (rivaroxaban / apixaban), fondaparinux and danaparoid is generally not performed except in certain circumstances as guided by a haematologist.
  • The target range depends on the medication, dose and frequency.
    • Normal Range

    • Prothrombin time - 11 - 15 sec
    • INR - 0.9 - 1.3
    • APTT - 25 - 40 sec
    • Thrombin time - <24 sec
    • Fibrinogen - 1.5 - 4.5 g/L
    • Normal Range

    • <24 seconds
  • Important Lab Points

  • Fibrinogen is not routinely measured as part of a coagulation screen.
  • The 'derived' fibrinogen level is often reported with the coag result and is estimated based on the prothromin time curve. It is not an accurate estimate of fibrinogen concentrations and should not be used.
  • A dedicated fibrinogen assay should be ordered to determine the fibrinogen concentration.
    • Normal Range

    • <250 ng/mL
    • Normal Range

    • Prothrombin time - 11 - 15 sec
    • INR - 0.9 - 1.3
When performing mixing studies, the patient's plasma is mixed 50:50 with control plasma, and then the PT/INR or APTT is measured.
NormalViralBacterialFungal / TB
Opening
Pressure
5-20 cmH2ONormal /
Elevated
ElevatedElevated
AppearanceClearClearTurbidClear / Turbid / Opaque
WBC<5
No PMNs
10-1000>100
>80% PMNs
50-500
RBC<10<10<10<10
Protein15-45
mg/dL
ElevatedElevatedElevated
Glucose>60%
serum
>60%
serum
<40%
serum
<40%
serum
OtherPCR for
HSV/VZV
Gram stain & 
culture
Fungal culture, AFB

Urine Colour

Urine is normally clear and pale yellow. Dark yellow or brown urine is classically a sign of dehydration, though urine may be a variety of colours that suggest underlying pathology.

Overview

This is an indicator of the kidney's ability to concentrate or dilute urine, and correlates with the urine osmolality. 
    • Normal Range

      4.5 - 8.0
    • Types of Urine Collection

    • Random urine - taken at any time; Used for testing of electrolytes etc.
    • Morning urine - the first urine of the day is the most concentrated, increasing the yield; Used for urinalysis, microscopy and beta-HCG testing
    • Clean catch / midstream urine - the first few mL are discarded and then urine is collected, removing urethral bacterial flora from the sample; Best for urine culture and sensitivity testing
    • 24 hour urine - all of the urine passed over 24 hours is collected; Used to measure certain analytes, such as creatinine, protein, electrolytes, uric acid, cortisol, catecholamines / metanephrines
    • Catheterised sample - e.g. from an in and out / indwelling / suprapubic catheter
    • Suprapubic aspiration - a needle is used to aspirate urine; May be required if a patient cannot be catheterised, or if sterile urine absolutely must be collected
    • Causes of Pyuria

    • Infection - urethritis, prostatitis, cystitis, pyelonephritis, tuberculosis
    • Neoplasm - renal, bladder, protate
    • Inflammation - interstitial nephritis, interstitial cystitis, Kawasaki disease, SLE
    • Foreign body - renal calculus, indwelling catheter, ureteric stents
    • Polycystic kidney disease
    • Pelvic irradiation
    • Pregnancy
    • Look For

    • Constant PR interval with intermittently dropped QRS complexes.
    Type I second degree sinoatrial exit block occurs when there is progressively delayed SA transmission eventually resulting in a missed P wave due to failure of conduction to the atrial myocardium.
    • Look For

    • Initial normal PR interval with progressive prolongation of PR interval followed by a dropped QRS complex.
    • Causes of Sinoatrial Exit Block

    • Intrinsic

    • Idiopathic degeneration
    • Myocardial infarction
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Connective tissue disease - SLE, scleroderma, RA
    • Cardiac surgery - valvular surgery, correction of congenital heart disease
    • Infections - Lyme disease, endocarditis
    • Extrinsic

    • Physiologic - sleep, athletes
    • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
    • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
    • Hypothyroidism
    • Hypothermia
    • Hyperkalaemia
    • Obstructive sleep apnoea
    • Raised intracranial pressure
    • Causes of Atrioventricular Block

    • Intrinsic

    • Idiopathic degeneration
    • Myocardial infarction
    • Congenital - congenital heart disease, neonatal lupus
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Cardiac procedures - valvular surgery, correction of congenital heart disease, catheter ablation
    • Systemic lupus erythematosus
    • Myocarditis
    • Extrinsic

    • Physiologic - sleep, athletes
    • Autonomic - carotid sinus massage, carotid sinus hypersensitivity
    • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, amiodarone
    • Hyperkalaemia
    • Hypothyroidism
    • Look For

    • Two or more consecutive p waves without subsequent QRS complexes
    • May be in a 3:1, 4:1 or higher pattern
    • Look For

    • Complete dissociation of P waves and QRS complexes.
    • Look For

    • Prolonged PR interval >200ms (5mm).
    • Look For

    • Complete lack of P waves and QRS complexes
    • An escape rhythm may be present
    • Look For

    • A constant PP interval, with a pause that is a multiple of the PP interval.
      • Normal Range

      • Absolute reticulocyte count: 50 - 100 x 10⁹/L
      • Reticulocyte percentage: 0.5 - 2.5%
      • Normal Range

      • 2.0 - 8.0 x 10⁹
      • 40 - 75% of total leukocytes
      • Normal Range

      • 0.0 - 0.5 x 10⁹/L
      • 1 - 4% of total leukocytes
    • Look For

    • Reduced serum haemoglobin (Hb) concentration
    • Reduced haematocrit (HCT) / packed cell volume (PCV)
    • Reduced red cell count (RCC)
    Beta thalassaemia is common in people from Mediterranean countries, South East Asia and India. It is rarely seen in those of caucasian descent.
    Assessment of red blood cell size - the presence of normocytosis, microcytosis or macrocytosis - is the first step in the assessment of patients with anaemia as it can rapidly be used to narrow down the likely causes.
      • Normal Range

      • 1.0 - 4.0 x 10⁹/L
      • 20 - 40% of total leukocytes
      • Normal Range

      • 11 - 15%
      • Normal Range

      • 150 - 400 x 10⁹/L
      • Normal Range

      • Males: 4.3 - 5.7 x 10¹²/L
      • Females: 3.9 - 5.0 x 10¹²/L
    Four alpha chain genes are inherited (two from each parent), and the type of alpha thalassaemia depends on how many of the four alpha chains are defective.
      • Normal Range

      • Males: 3.7 - 9.5 x 10⁹/L
      • Female: 3.9 - 11.1 x 10⁹/L
      • Normal Range

      • 0.0 - 0.1 x 10⁹/L
      • 0.5 - 1% of total leukocytes
    Haemoglobin transports oxygen and other molecules in the blood.
      • Normal Range

      • 0.2 - 1.0 x 10⁹/L
      • 2 - 8% of total leukocytes
    This value is often calculated by an automatic analyser based on the red cell count and mean cell volume (MCV).

    Pathogenesis

    • The condition is multifactorial, and occurs in the context of:
    • Reduced effective incorporation of iron into haemoglobinDue to increased production and release of hepcidin and cytokines
    • Reduced responsiveness to erythropoietin
    • Reduced red cell survival

    Overview

    Sickle cell disease is a more broad term that includes sickle cell anaemia, sickle beta thalassaemia and haemoglobin SC disease.
    The PF ratio is an assessment of PaO2₂ taking into account the FiO₂ - correcting for this discrepancy.
    • Look for

    • Reduced pH (acidaemia) with increased PaCO₂.
    The base excess is the amount of strong acid that is required to return a patient's sample to a pH of 7.4, pCO₂ to 40mmHg and temperature to 37°.
      • Normal Range

      • 7.35 - 7.45
      • Normal Range

      • 0.5 - 2.2 mmol/L
    • Expected Compensation

    • Increase in PaCO₂ = 0.8 x HCO₃ + 20
    •  
      IV
      Cephazolin
      Used for severe infections and for surgical prophylaxis
    •  
      IV
      Amikacin
      Second-line treatment when other aminoglycosides ineffective
    • Mechanism of Action

    • Naturally occurring hormone that binds to oxytocin receptors (G-protein coupled receptors).
    • Mechanism of Action

    • Inhibit L-type calcium channels, resulting in myometrial smooth muscle relaxation.
    Combination oxytocics combine both oxytocin and an ergot alkaloid, which stimulate contraction of uterine and vascular smooth muscle.
    • Mechanism of Action

    • Bind to β2 adrenoceptors, stimulating smooth muscle relaxation through induction of cAMP with resulting phosphorylation of muscle regulatory proteins and modification of cellular calcium concentration.
    • Mechanism of Action

    • Stimulate contraction of uterine and vascular smooth muscle, through agonism of alpha-adrenergic, dopaminergic and serotonin (5-HT) receptors.
    •  
      IV
      Pooled Platelets
      Equivalent to 5 units of apheresis platelets
    • Composition

    • Concentrated factor VIII.
    •  
      IV
      Apheresis Plasma
      Blood is removed, plasma collected and blood returned to patient
    • Composition

    • Concentrated factor IX.
    •  
      IV
      Apheresis Cryoprecipitate
      Blood is removed, plasma collected, blood returned to patient and then cryoprecipitate is isolated from plasma
    Many of these adverse effects are avoided by testing donors and donated for infection, as well as correctly typing and identifying patients who will be transfused.
    Prothrombinex contains purified coagulation factors specifically prepared for the reversal of warfarin.
    • Composition

    • Concentrated antithrombin-III.
    • Composition

    • Concentrated factor VIII and Von Willebrand factor.
    •  
      MDI / Neb
      Formoterol
      Oxis 
    •  
      MDI
      Fluticasone / Salmeterol
      Seretide 
    •  
      IV / IM / Oral
      Methylprednisolone
      Medrol 
    • Mechanism of Action

    • A humanised monoclonal antibody directed toward immunoglobulin E (IgE).
    • Mechanism of Action

    • Inhibit muscarinic (M3) receptors, leading to bronchial smooth muscle relaxation and bronchodilation through reduction in acetylcholine-mediated vagal tone.
    •  
      Inhaler / Nebule
      Budesonide
      Pulmicort 
    • Mechanism of Action

    • Directly bind to airway β2 adrenoceptors, stimulating smooth muscle relaxation and bronchodilation through induction of cAMP with resulting phosphorylation of muscle regulatory proteins and modification of cellular calcium concentration.
    •  
      MDI
      Aclidinium
      Bretaris Genuair 
    These combination inhalers contain a long-acting muscarinic agent (LAMA) and a long-acting beta 2 agonist (LABA) as bronchodilators, as well as an inhaled corticosteroid (ICS) to reduce airway inflammation.
    •  
      Oral
      Zafirlukast
      Accolate 
    • Mechanism of Action

    • A humanised monoclonal antibody directed against IL-5, a cytokine that stimulates maturation, growth and activation of eosinophils.
    •  
      MDI
      Aclidinium / Formoterol
      Brimica Genuair 
    •  
      MDI
      Terbutaline
      Bricanyl 
    •  
      Oral
      Galantamine
      Galantyl 
    • Mechanism of Action

    • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity. Also inhibits enzymes that breakdown GABA, resulting in increased GABA-mediated inhibition.
    •  
      Oral
      Naratriptan
      Naramig 
       
      Slow onset
    • Mechanism of Action

    • Inhibits histamine H1 and serotonin receptors.
    • Mechanism of Action

    • A humanized monoclonal antibody that binds to CD-52 receptors found on mature lymphocytes, initiating complement-mediated and antibody-dependent cell-mediated cytotoxicity.
    • Mechanism of Action

    • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity. Also inhibits enzymes that breakdown GABA, resulting in increased GABA-mediated inhibition.
    •  
      IV / IM / Oral
      Methylprednisolone
      Medrol 
    • Mechanism of Action

    • Inhibits voltage-gated sodium channels and enhances GABA-mediated inhibition, resulting in suppression of seizure activity.
    • Mechanism of Action

    • Competitively inhibit the action of adrenaline and noradrenaline on β1 and β2 receptors, resulting in suppression of the sympathetic nervous system.
    •  
      Subcut
      Interferon Beta-1b
      Betaferon 
    • Mechanism of Action

    • Block presynaptic reuptake of serotonin (5-HT) and noradrenaline (NA) through an unknown mechanism.
    • Mechanism of Action

    •  Inhibits T-type calcium channels in the thalamus, preventing propagation of action potentials and thus suppressing seizure activity

    Clinical Use

    • Mechanism of Action

    • Inhibits the release of T cells from lymph nodes, resulting in redistribution of T cells and decreased entry into the central nervous system.

    Overview

    • Mechanism of Action

    • Monoclonal antibody toward leucocyte adhesion molecules, resulting in slowed entry of T cells into the CNS.
    • Mechanism of Action

    • Inhibits voltage-gated sodium channels and enhances GABA-mediated inhibition, resulting in suppression of seizure activity.
    •  
      Oral / IV
      Clonazepam
      Paxam, Rivotril 
       
      [Peak] 2-3 hours
      Half-life 18-50 hours
    • Mechanism of Action

    • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity.
    • Mechanism of Action

    • Inhibits voltage-gated sodium channels, preventing the propagation of action potentials and thus suppressing seizure activity.
    • Mechanism of Action

    • Act directly on dopamine D2 and D3 receptors, addressing the severe depletion of dopamine within the striatum pallidum and substantia nigra in Parkinson's disease.
    •  
      Oral
      Levodopa + Benserazide
      Madopar 
    • Mechanism of Action

    • Unknown, though anticonvulsant effects may be through inhibition of neuronal N-type calcium channels and reduced breakdown of GABA.
    • Mechanism of Action

    • Unknown mechanism, though believed to be a weak inibitor of prostaglanding synthesis. Also thought to inhibit COX-2, though without anti-inflammatory effects.
    •  
      Oral
      Diclofenac
      Voltaren 
    •  
      Oral
      Cyclizine Hydrochloride
      Nausicalm 
       
      Used to treat nausea / vomiting
    •  
      Oral
      Fexofenadine
      Allegra, Telfast 

    Efficacy of Contraceptive Methods

    Typical UseCorrect & Consistent Use
    No Method15%15%
    Spermicide72%82%
    Timing Method76%97%
    Withdrawal Method78%96%
    Female Condom79%95%
    Male Condom92%98%
    Diaphragm88%94%
    Oral Contraception91%99.7%
    Vaginal Ring91%99.7%
    Depot Injection94%99.8%
    Copper IUD99.2%99.4%
    Intrauterine System99.8%99.8%
    Implant99.95%99.95%
    Female Sterilisation99.5%99.5%
    Male Sterilisation99.85%99.9%

    Overview

    Contain a progestin ± an oestrogen, with a dose equivalent of ~25 contraceptive pills.
    • Mechanism of Action

    • Thicken cervical mucus, resulting in reduced sperm penetration through the cervix. Less of an effect on follicular development and prevention of ovulation than combined contraceptives.
    Depot injection for long-acting contraception.
    Implanted under the skin of the upper arm for long-acting contraception.
    • Mechanism of Action

    • Contain an oestrogen and a progesterone, which inhibit follicular development, prevent ovulation and thicken cervical mucus resulting in reduced sperm penetration.
    •  
      Oral
      Ethinyloestradiol + Drospirenone
      Yaz, Yasmin 
    • Mechanism of Action

    • A selective oestrogen receptor modulator (SERM) that inhibits hypothalamic oestrogen receptors, resulting in reduced negative feedback of oestrogen on FSH and LH release. Increased FSH and LH stimulates ovarian follicle maturation, ovulation and development of the corpus luteum.
    •  
      Oral
      Norethisterone
      Micronor, Primolut N 
    •  
      Oral
      Misoprostol
      GyMiso 
       
      Given 36 - 48 hours after mifepristone
    • Mechanism of Action

    • Binds to cyanide ions to form non-toxic cyanocobalamin.
    5% dextrose is a crystalloid fluid made up of glucose. This fluid is often used in hypoglycaemic or hyponatraemic patients, and is also used to balance out insulin administration in patients with diabetic ketoacidosis.
    • Mechanism of Action

    • Inhibits acetylcholinesterase, resulting in reduced breakdown of acetylcholine which overcomes anticholinergic agents' competitive inhibition of nicotinic and muscarinic receptors.
    • Mechanism of Action

    • Provides cysteine for use in the synthesis of glutathione, which facilitates metabolism of the toxic paracetamol metabolite N-acetyl-p-benzoquinoneimine.
    • Mechanism of Action

    • Binds to and inactivates heparin.
    • Mechanism of Action

    • An iron chelator that binds to iron molecules and forms a stable compound that is excreted by the kidneys.
    • Mechanism of Action

    • Directly inhibits ADH, which metabolizes methanol and ethylene glycol into toxic metabolites formic acid and glycolic acid respectively.
    • Mechanism of Action

    • Competitively inhibits the action of benzodiazepines on the GABAA receptor.
    • Mechanism of Action

    • A hormone naturally produced by pancreatic alpha cells that is responsible for regulation of glucose  and lipid metabolism.
    • Mechanism of Action

    • A competitive antagonist of μ, κ, and δ opioid receptors, reversing the action of exogenous opioids.
    • Mechanism of Action

    • A heavy metal chelator that binds to metals such as lead and arsenic, forming a stable compound that can be excreted.
    • Mechanism of Action

    • A heavy metal chelator that binds to metals such as lead and arsenic, forming a stable compound that can be excreted.
    • Mechanism of Action

    • Repletes the body's stores of vitamin K, overcoming the effect of warfarin on its inhibition of the clotting cascade.
    • Mechanism of Action

    • A heavy metal chelator that binds to metals such as lead, copper and arsenic, forming a stable compound that can be excreted.
    • Mechanism of Action

    • Competitively inhibits the action of acetylcholine on muscarinic receptors.
    • Mechanism of Action

    • Competitively inhibits ADH-mediated metabolism of methanol and ethylene glycol into toxic metabolites formic acid and glycolic acid, respectively.
    • Mechanism of Action

    • Enhances endogenous detoxification of cyanide by providing sulfur ions for rhodanese, an enzyme that converts cyanide and thiosulfate to non-toxic thiocyanate.
    50% dextrose is a strongly hypertonic fluid containing a high concentration of dextrose; it is used to treat patients with severe hypoglycaemia and raised intracranial pressure.
    • Mechanism of Action

    • A human monoclonal antibody directed against p40, a shared subunit present in both IL-12 and IL-23. Inhibition of IL-12 results in reduced differentiation of TH1 cells, while inhibition of IL-23 results in reduced induction of TH17 cells.
    •  
      Oral
      Tofacitinib
      Xeljanz 
       
      Inhibits JAK1, JAK2 and JAK3
    •  
      Subcut
      Adalimumab
      Humira 
       
      Human monoclonal antibody to TNF
    • Mechanism of Action

    • A mouse / human chimaeric monoclonal antibody that binds and inhibits IL-2 receptors (CD-25) on activated T cells, resulting in reduced T cell proliferation.
    • Mechanism of Action

    • A fusion protein with the Fc fragment of human IgG1 linked to the extracellular domain of CTLA-4. Binds to CD80 / CD86 on antigen presenting cells and prevents binding by CD28 on T lymphocytes, resulting in lack of a costimulatory response and reduced T cell activation.
    • Mechanism of Action

    • A humanised monoclonal antibody directed against the terminal complement protein C5 that inhibits its cleavage into C5a and C5b, thus preventing formation of the membrane attack complex.
    • Mechanism of Action

    • A monoclonal antibody that targets CD20, a transmembrane protein on the surface of B cells, resulting in antibody-dependent and complement-dependent cytotoxicity.
    • Nomenclature

    • Prefix - random
    • Substem A - based on the target
    • Substem B - based on the species of origin of the antibody
    • Stem - mab
    • Mechanism of Action

    • A humanised monoclonal antibody that binds to and inhibits IL-6 receptors, resulting in reduced IL-6 binding and a reduction in acute inflammation.
    • Mechanism of Action

    • A human monoclonal antibody that binds to IL-1β and inhibits its activity, resulting in reduced acute phase response.
    • Mechanism of Action

    • A human monoclonal antibody to B lymphocyte stimulator (BLyS, also known as BAFF), a member of the TNF family that inhibits B cell apoptosis and stimulates differentiation of B cells.
    • Mechanism of Action

    • Interleukin-1 receptor antagonist (IL1-RA) is a naturally occurring protein that inhibits the binding of IL-1 to its receptor.
    • Mechanism of Action

    • A human monoclonal antibody directed against IL-17A, a cytokine produced mainly by TH17 cells that activates neutrophils and promotes inflammation.
    • Mechanism of Action

    • A humanised monoclonal antibody directed toward immunoglobulin E (IgE).
    • Mechanism of Action

    • A humanised monoclonal antibody directed against IL-5, a cytokine that stimulates maturation, growth and activation of eosinophils.
    • Mechanism of Action

    • A humanized monoclonal antibody that binds to CD-52 receptors found on mature lymphocytes, initiating complement-mediated and antibody-dependent cell-mediated cytotoxicity.
    • Mechanism of Action

    • A prodrug that is metabolized by the liver into phosphoramide mustard. This active metabolite shares nitrogen atoms between guanine residues in DNA, creating intrastrand and interstrand DNA crosslinks. Disruption of DNA results in cytotoxicity.
    •  
      Oral
      Sirolimus
      Rapamune 
       
      Half-life ~60 hours
    • Mechanism of Action

    • A purine analogue that inhibits purine synthesis, disrupting DNA synthesis and reducing T cell activation.
    • Mechanism of Action

    • Rabbit immunoglobulin directed mainly against T cells that causes rapid central and peripheral lymphocyte depletion.
    • Mechanism of Action

    • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
    • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
    •  
      IV / IM / Oral
      Methylprednisolone
      Medrol 
    • Mechanism of Action

    • A prodrug of mycophenolic acid (MPA), a non-competitive, reversible inhibitor of inosine monophosphate dehydrogenase (IMPD). IMPD is a key enzyme in the synthesis of guanosine triphosphate; T cells and B cells are critically dependent on this pathway and thus its inhibition results in impaired lymphocyte proliferation.
    • Mechanism of Action

    • Believed to inhibit the mitochondrial enzyme dihydroorotate dehydrogenase, which is involved in pyramidine synthesis.
    •  
      Oral / IV
      Tacrolimus
      Prograf 
    Contains pooled IgG antibodies from at least 1,000 donors.
    • Composition

    • Sodium 513mmol/L
    • Chloride 513mmol/L
    5% dextrose is a crystalloid fluid made up of glucose. This fluid is often used in hypoglycaemic or hyponatraemic patients, and is also used to balance out insulin administration in patients with diabetic ketoacidosis.
    • Mechanism of Action

    • Inhibit the action of aldosterone on sodium-potassium exchange pumps in the distal convoluted tubule.
    •  
      IV
      Intravenous Potassium Chloride
      Indicated if PO intake not possible / K⁺
    0.9% sodium chloride is a crystalloid fluid commonly used for fluid resuscitation and maintenance. This fluid contains supraphysiologic amounts of sodium and chloride, and should be avoided in large quantities.
    • Composition

    • Human albumin 20g/L
    • Sodium 50-100mmol/L
    •  
      Oral
      Sodium Polystyrene Sulfonate
      Resonium A 
       
      Useful for patients with hypercalcaemia
    Hartmann's solution, also known as compound sodium lactate (or Ringer's lactate in a research setting) is a crystalloid that is more physiologic than 0.9% sodium chloride; this results in less metabolic acidosis.
    •  
      Subcut / IV
      Neutral Insulin
      Actrapid, Humulin R 
       
      Given 30 minutes before meals
    • Mechanism of Action

    • Normalises serum magnesium concentrations in the case of hypomagnesaemia.
      Magnesium is involved in many physiologic processes including cardiac Na⁺ / K⁺ ATPase, and hypomagnesaemia can result in depolarisation and torsades de pointes.
    • Composition

    • Human albumin 40g/L
    • Sodium 140mmol/L
    • Chloride 128mmol/L
    • Mechanism of Action

    • Act on opioid receptors (δ, κ and μ) and nociceptin orphanin FQ (NOF) receptors on neuronal cell membranes within the thalamus, diencephalon, midbrain and medulla, resulting in reduced neurotransmitter release.
    •  
      Oral / IV
      Methadone
      Dolophine 
       
      Used for long-term treatment of opioid addiction
    • Mechanism of Action

    •  Synthetic weak μ opioid agonist, and also inhibits nociception through enhancement of noradrenergic and serotonergic pathways.
    • Mechanism of Action

    • Not fully described, though effects are believed to be due to binding of the α2δ-1 subunit of voltage-gated calcium channels with resultant reduction in nociceptive neurotransmission.
    Acetaminophen in the US, Paracetamol in other countries.
    • Mechanism of Action

    • A GABA analogue that agonises GABAB receptors.
    •  
      Oral
      Oxycodone + Naloxone
      Targin 
       
      Includes a reversal agent, to reduce adverse effects (particularly constipation)
    •  
      Oral
      Codeine
      Weakly agonises all opioid receptors
      Up to 10% of the population lack the enzyme required to convert codeine (weak) to morphine (potent) - in these cohorts codeine has nearly no effect
    Gabapentin was developed as an anticonvulsant, however it is also used for the treatment of neuropathic pain.
    •  
      Local / Regional
      Lignocaine
      Xylocaine 
    • Mechanism of Action

    • Inhibit cyclooxygenase, the enzyme responsible for production of thromboxanes, prostacyclin and prostaglandins from arachidonic acid.
    •  
      Oral
      Diclofenac
      Voltaren 
    • Mechanism of Action

    • A fusion protein with the Fc fragment of human IgG1 linked to the extracellular domain of CTLA-4. Binds to CD80 / CD86 on antigen presenting cells and prevents binding by CD28 on T lymphocytes, resulting in lack of a costimulatory response and reduced T cell activation.
    •  
      Subcut
      Adalimumab
      Humira 
       
      Human monoclonal antibody to TNF
    • Mechanism of Action

    • Purine analogue that inhibits purine synthesis, disrupting DNA synthesis and reducing T cell activation.
    • Mechanism of Action

    • Inhibits phosphodiesterase 4 (PDE4), an enzyme that hydrolyses cAMP in many cell types. Increased cAMP results in reduced proinflammatory TNFα, IL-23 and IL-17, as well as increased anti-inflammatory IL-10.
    • Mechanism of Action

    • Inhibits T cell activation as well as transcription of IL-2 and other cytokines, through inhibition of calcineurin-mediated activation of NFAT.
    • Mechanism of Action

    • Believed to inhibit the mitochondrial enzyme dihydroorotate dehydrogenase, which is involved in pyramidine synthesis.
    • Mechanism of Action

    • A human monoclonal antibody directed against p40, a shared subunit present in both IL-12 and IL-23. Inhibition of IL-12 results in reduced differentiation of TH1 cells, while inhibition of IL-23 results in reduced induction of TH17 cells.
    • Mechanism of Action

    • A humanised monoclonal antibody that binds to and inhibits IL-6 receptors, resulting in reduced IL-6 binding and a reduction in acute inflammation.
    • Mechanism of Action

    • Inhibit microtubule polymerisation, resulting in reduced mitosis. Also inhibits the release of a crystal-derived factor from neutrophils.
    • Mechanism of Action

    • Interleukin-1 receptor antagonist (IL1-RA) is a naturally occurring protein that inhibits the binding of IL-1 to its receptor.
    • Mechanism of Action

    • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
    • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
    • Mechanism of Action

    • A monoclonal antibody that targets CD20, a transmembrane protein on the surface of B cells, resulting in antibody-dependent and complement-dependent cytotoxicity.
    •  
      Oral
      Tofacitinib
      Xeljanz 
       
      Inhibits JAK1, JAK2 and JAK3
    While classically an anti-malarial medication, hydroxychloroquine is now used to treat rheumatologic disorders such as rheumatoid arthritis and lupus.
    •  
      Oral
      Febuxostat
      Adenuric 
    • Mechanism of Action

    • Inhibit 5-aminoimidazole-4-carboxamidoribonucleotide (AICAR) transformylase, which results in increased adenosine release at the inflamed site. Adenosine binds to A2 receptors on inflammatory cells resulting in reduced inflammation.
    •  
      Oral
      Dasatinib
      Sprycel 
       
      Binds both active & inactive conformation of Bcr-Abl kinase, resulting in reduced resistance
    •  
      Oral
      Ceritinib
      Zykadia 
       
      Better CNS penetration than crizotinib
    •  
      Oral
      Gefitinib
      Iressa 
       
      Acneiform rash can be a major concern
    •  
      Oral
      Vemurafenib + Cobimetinib
      Zelboraf + Cotellic 
    •  
      Oral
      Sunitinib
      Sutent 
    •  
      Oral
      Dabrafenib
      Tafinlar 
       
      Given as monotherapy or in combination with trametinib (MEK inhibitor)
    • Mechanism of Action

    • Inhibit poly ADP ribose polymerase (PARP) enzymes that repair single strand DNA breaks, resulting in DNA double strand breaks
    • In normal (BRCA wildtype) cells, these are repaired by homologous functional repair which requires functional BRCA genes
    • In BRCA (1 / 2) gene mutations (germline or somatic), these breaks are not repaired which results in genomic instability and cell death
    •  
      Oral
      Palbociclib
      Ibrance 
    • Mechanism of Action

    • Not fully elucidated, though effects are thought to be secondary to inhibition of dopamine D2 receptors and α-adrenoceptors within the chemoreceptor trigger zone.
    •  
      Oral / IV
      Esomeprazole
      Nexium 
    •  
      Oral
      Sulfasalazine
      Salazopyrin 
       
      Not absorbed well - therefore most effective within the gut
    • Mechanism of Action

    • Selectively antagonize serotonin (5-HT3) receptors within the central nervous system.
    •  
      IV / IM / Oral
      Methylprednisolone
      Medrol 
    •  
      Oral
      Macrogol 3350
      Movicol, Glycoprep, Osmolax 
       
      Iso-osmotic with the gut, preventing water and electrolyte loss
    •  
      Oral
      6-Mercaptopurine
      Purinethol 
    • Mechanism of Action

    • Act as a surfactant that increase fluid penetration into faeces, resulting in softening of the stool.
    • Mechanism of Action

    • Absorb water, resulting in increased faecal size and stimulation of peristalsis.
    • Mechanism of Action

    • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
    • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
    •  
      Subcut
      Adalimumab
      Humira 
       
      Human monoclonal antibody to TNF
    •  
      Oral
      Domperidone
      Motilium 
       
      Binds D2 and D3 receptors; doesn't cross the BBB
    •  
      Oral
      Sodium Picosulphate
      Picolax 
       
      2-3 sachets the day prior to the procedure, in 3-4 hour intervals
    • Mechanism of Action

    • A human monoclonal antibody directed against p40, a shared subunit present in both IL-12 and IL-23. Inhibition of IL-12 results in reduced differentiation of TH1 cells, while inhibition of IL-23 results in reduced induction of TH17 cells.
    • Mechanism of Action

    • Competitively inhibit action of histamine on parietal cell H2 receptors, directly resulting in suppression of acid secretion.
    • Mechanism of Action

    • Inhibit protein synthesis by binding to the 30s ribosomal subunit, resulting in inaccurate mRNA translation.
    • Mechanism of Action

    • Unknown.
    • Mechanism of Action

    • Believed to inhibit haem polymerisation, resulting in a buildup of toxic haem molecules into non-toxic haemozoin within the food vacuole of plasmodia.

    Diagnosis

    • ECG Findings

    • A pause of at least three seconds, without P waves or QRS complexes
    • An escape rhythm may be present

    Overview

    Four alpha chain genes are inherited (two from each parent), and the type of alpha thalassaemia depends on how many of the four alpha chains are defective.

    Pathogenesis

    • Causes of Metabolic Alkalosis

    • Bicarbonate excess - milk alkali syndrome (antacids), massive transfusion, dialysis
    • GI acid loss - vomiting, NG aspirates, gastric fistula
    • Renal acid loss - diuretics, hyperaldosteronism, Cushing's, steroids
    • Compartmental shift - hypokalaemia
    • Causes of Heart Failure

    • Ischaemic heart disease
    • Cardiomyopathy
    • Myocarditis
    • Pericardial disease
    • Valvular disease
    • Congenital heart disease
    • Hypertension

    Overview

    • Classification

    • Paroxysmal AF - occurring for <7 days
    • Persistent AF - occurring for >7 days
    • Permanent AF - long-standing despite attempts at cardioversion

    Pathogenesis

    • Causes of Hyperlipidaemia

    • Primary

    • Familial lipoprotein lipase deficiency
    • Familial hypercholestolaemia
    • Familial combined hyperlipidaemia
    • Familial dysbetalipoproteinaemia
    • Familial hypertriglyceridaemia
    • Secondary: Predominantly LDL

    • Hypothyroidism
    • Cholestatic liver disease
    • Nephrotic syndrome
    • Secondary: Predominantly TAGs

    • Obesity
    • Diabetes
    • Alcohol abuse
    • Chronic kidney disease
    • Drugs - corticosteroids, antipsychotics, immunosuppressants, protease inhibitors, oral contraceptive pill, hormone replacement therapy
    • Pregnancy
    • Causes of Left Ventricular Failure

    • Ischaemic heart disease
    • Cardiomyopathy
    • Myocarditis
    • Pericardial disease
    • Valvular disease
    • Congenital heart disease
    • Hypertension

    Presenting Complaint

    The first step in the renal history is to identify the main issue that the patient is presenting with.
    Start by asking the patient what their main reason for presenting was.
    Start by asking the patient what their main reason for presenting was.
    Start by asking the patient what their main reason for presenting was.
    The first step is to ask the patient why they presented with their current issue.
    Start by asking the patient about their main reason for presenting.

    First Steps

    Before commencing the cranial nerve exam, wash your hands, introduce yourself to the patient and gain consent.

    Overview

    When performing a cardiovascular examination, always try to get to the chest as quickly as possible.

    Urine Collection

    There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.

    Red Cell Count & Haemoglobin

    The first step in the identification of red blood cell pathology is to look at the haemoglobin, haematocrit and red cell count. A reduction in each of these indices is used to diagnose anaemia, while an increase in these values is used to diagnose erythrocytosis.

    Assessing Oxygenation

    While oxygen saturations are a useful non-invasive test for assessing a patient's oxygenation, greater information can be gained by assessing a patient's arterial blood gas.

    Overview

    Concerns may be raised for the presence of haemolysis in patients with  anaemia, reticulocytosis or hyperbilirubinaemia.

    Iron Physiology

    Iron is an important mineral that plays a role in multiple physiologic processes including oxygen transport (as haemoglobin); muscle oxygenation (as myoglobin); synthesis of DNA, RNA and proteins; and cellular respiration (as cytochromes).

    Overview

    An acute phase reaction classically presents with fevers, rigors and tachycardia.

    Urine Collection

    There are many ways in which a urine sample can be collected. The method of collection depends on the type of test performed, and certain patient factors.

    Equipment

    • The following equipment is required for collecting blood:

    Overview

    • Indications for Oxygen Administration
    • Hypoxia
    • Cardiac or respiratory arrest
    • Acute respiratory distress
    • Specific conditions - pulmonary hypertension, myocardial infarction, pneumothorax
    Indications for arterial blood gas collection include to assess respiratory and acid base status, as well as for detection of carboxyhaemoglobin and methaemglobin.
    Male catheterisation can be more difficult and higher risk than female catheterisation due to the length and course of the male urethra.
    • Indications for IV Cannulation

    • Fluid administration
    • Medications
    • Blood products
    • IV contrast

    Airway Patency

    Before using any airway manoeuvres or adjuncts, first assess whether the airway is patent.
    •  
      IV / IM
      Artesunate
      Severe falciparum malaria

    Overview

    • Mechanism of Action

    • Atovaquone - inhibits nucleic acid and ATP synthesis through disruption of the protozoal electron transport chain.
    • Proguanil - inhibits dihydrofolate reductase, resulting in reduced parasitic synthesis of deoxythymidilate.
    • Mechanism of Action

    • Believed to inhibit haem polymerisation, resulting in a buildup of toxic haem molecules into non-toxic haemozoin within the food vacuole of plasmodia.
    • Mechanism of Action

    • Believed to inhibit haem polymerisation, resulting in a buildup of toxic haem molecules into non-toxic haemozoin within the food vacuole of plasmodia.
    • Mechanism of Action

    • Broken down into its active form selectively by anaerobic and protozoal cells. Binds to and disrupts DNA, resulting in DNA degradation and cell death.
    • Mechanism of Action

    • Inflammatory diseases: inhibits interleukin-1 and interleukin 6 activity, and altering the numbers of different lymphocyte subsets.
    • In cancer treatment: inhibits dihydrofolate reductase (DHFR), reducing synthesis of folate, which is involved in synthesis of the purine and pyramidine precursors required for DNA / RNA and cell proliferation.
    •  
      IV
      Bleomycin
      Cytotoxicity is cell cycle-specific to G2 phase
    •  
      IV
      Ifosfamide
      Ifex, Holoxan 
    •  
      Oral / IV
      Fludarabine

    • Mechanism of Action

    • Unknown, though appears to inhibit DNA synthesis through inhibition of topoisomerase II.
    • Mechanism of Action

    • Incorporated into DNA, resulting in disruption of DNA synthesis through inhibition of DNA polymerase activity.
    •  
      Oral
      Capecitabine
      Xeloda 
       
      Converted to 5-fluorouracil once absorbed orally
    • Mechanism of Action

    • Unknown, though believed to act as an alkylating agent.
    •  
      IV
      Cisplatin
      Platinol 
    •  
      IV
      Vinblastine

    • Mechanism of Action

    • Inhibits the activity of topoisomerase I, which is normally responsible for repairing DNA damage resulting from torsional strain.
    •  
      Oral
      Temozolomide

    •  
      IV
      Paclitaxel
      Taxol 
       
      Inhibits the cell cycle at the G2-M phase junction
    •  
      IV
      Daunorubicin

    • Mechanism of Action

    • Causes DNA strand breakage through inhibition of topoisomerase II.

    The Safe Triangle

    The chest drain is generally inserted into the 5th intercostal space in the midaxillary line.

    Blockage

    • Causes of Intercostal Catheter Blockage

    • Clot in the catheter / tubing
    • Kinking of the catheter / tubing
    • Catheter not in the correct position
    • Drainage system is above the level of the chest

    Troubleshooting

    Flashback but no blood coming out (penetrated too far, vein has collapsed) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again

    Overview

    Trough levels - take the blood just prior to the next dose (do not withhold the dose while you wait for the result unless you're concerned that it's too high)
    • Prevention of Coag Contamination

    • Take the sample from a different limb
    • Turn off the infusion for 5-20 minutes prior to taking the sample
    • Potential Sites to Collect Blood From

    • Back of the hand
    • Cephalic or basilic veins
    • Antecubital fossa
    • Significance

    • Due to blood leaking from the vein into surrounding tissue.

    Sample Clotting

    • Affects

    • White cell count
    • Red blood cell indices
    • Platelets
    • Coagulation profile

    Overview

    Ideally the tourniquet should be left on for no longer than a minute at a time - if you are having difficulty finding a vein, then release the tourniquet, wait for blood flow to return, then reapply the tourniquet.
    • Prevention

    • Cool the sample to 0-4 degrees using ice if it is unlikely to be processed within 15 minutes.

    Sample Haemolysis

    • Affects

    • Potassium
    • LFTs
    • Amylase
    • CK
    • Folate
    • Glucose
    • LDH
    • Crossmatch

    Overview

    Place samples for cryoglobulins at 37 degrees.

    Stress

    • Prevention

    • Ensure that the patient is comfortable and have been resting for at least 15 minutes before collecting.

    Overview

    The oxygen from the circuit is passively mixed with room air as the patient inspires, resulting in a variable FiO2 that depends on many factors including the respiratory rate, tidal volume and whether the patient is breathing through their nose or mouth.

    CPAP

    Continous positive airway pressure (CPAP) splints the upper airways open, and relieves upper airway obstruction. This device does not actively ventilate the patient.

    Overview

    The  oxygen that enters the reservoir bag is passively mixed with room air, and therefore the amount of oxygen delivered by these systems is variable depending on the patient's respiratory rate and tidal volume.
    • Indications for Invasive Ventilation

    • Airway

    • Inability to maintain airway patency (upper airway obstruction) - soft tissue swelling, deformity, obesity, tongue displacement
    • Inability to protect the airway - sedation (e.g. for procedures), upper airway bleeding, excessive secretions
    • Breathing

    • Inability to ventilate - unconsciousness, sedation, neuromuscular disease, exhaustion
    • Inability to oxygenate - severe acute respiratory failure
    • Circulation

    • Cardiac arrest

    Venturi Mask

    A Venturi mask contains an entrainment device that uses the Bernoulli principle to entrain a precise amount of oxygen along with room air. This allows for a predictable FiO2 in patients where this is required.

    Overview

    • Indications for Supplemental Oxygen

    • Hypoxia
    • Cardiac or respiratory arrest
    • Acute respiratory distress
    • Specific conditions - pulmonary hypertension, myocardial infarction, pneumothorax

    Troubleshooting

    Not pulsating blood - potentially in a vein
    Not pulsating blood - potentially in a vein

    Overview

    • Causes

    • Clotting
    • Vasospasm
    • Prevention

    • Ensure that the pulse is easily palpable before inserting the needle, and avoid advancing the needle multiple times.
    • Causes

    • Poor aseptic technique
    • Prolonged use of the same cannula
    • Causes

    • Clot in the cannula
    • Kinking of the cannula
    • Prevention

    • Avoid inserting an arterial line into a patient with a coagulopathy where possible, or consider reversing anticoagulation or withholding it and waiting
    • Place pressure on the insertion site for 3-5 minutes any time the needle or cannula is removed
    • Avoid too many attempts
    • Potential Sites for Arterial Line Insertion

    • Radial artery -laterally on the anterior aspect of the forearmThe most commonly used site
    • Brachial artery - medially within the antecubital fossa
    • Femoral artery - centrally within the femoral triangle, between the inguinal ligament, adductor longus and sartorius
    Radial - ask the patient to place their arm outward with palm up, wrist extended slightly. Place a towel underneath their arm. Consider taping the hand down to reduce movement.
    Radial - ask the patient to place their arm outward with palm up, wrist extended slightly
    • Prevention

    • Avoid performing an ABG on a patient with a coagulopathy where possible, or consider reversing anticoagulation / withholding it and waiting
    • Place pressure on the insertion site for 3-5 minutes once the needle is removed

    Troubleshooting

    Needle is not self-filling (may be a venous sample) - withdraw and try again

    Overview

    • Prevention

    • Ensure that the pulse is easily palpable before inserting the needle, and avoid advancing the needle multiple times.
    • Causes

    • Clotting
    • Vasospasm
    • Potential Sites for Arterial Blood Gas Collection

    • Radial artery - laterally on the anterior aspect of the forearmThe most commonly used site
    • Brachial artery - medially within the antecubital fossa
    • Femoral artery - centrally within the femoral triangle, between the inguinal ligament, adductor longus and sartorius

    Catheter Sizing

    Bigger is usually easier - go up a size rather than down if insertion is difficult

    Use of Catheters

    • Not Indications

    • Urinary incontinence
    • Confusion
    • Prolonged bed rest with no indication for catheterisation
    • Measuring urine output in patients who are able to void where hourly output is not required
    • Prolonged postoperative catheterisation without an indication
    • Not Indications

    • Urinary incontinence
    • Confusion
    • Prolonged bed rest with no indication for catheterisation
    • Measuring urine output in patients who are able to void where hourly output is not required
    • Prolonged postoperative catheterisation without an indication

    Catheter-Associated UTI

    • Clinical Features of Pyelonephritis

    • As with cystitis
    • Flank pain
    • Nausea / vomiting
    • Fevers / systemic features

    Overview

    Left internal jugular: 20 - 22cm(Height / 10) + 4
    Subclavian - identify the vein using landmarks. Identify the junction of the medial third and lateral two-thirds of the clavicle. The needle should be inserted 1cm inferior and lateral to this, pointing toward the sternal notch, upward and away from the underlying lung apex.

    Confirming Venous Placement

    Ultrasound - place the sterile probe over the insertion site and examine the vein both parallel and perpendicular to the direction of insertion, looking for presence of the needle / guidewire in the vein (a non-pulsatile, compressible vessel)

    Overview

    • Prevention

    • Avoid inserting a central line into a patient with a coagulopathy where possible
    • Place pressure on the insertion site for 1-2 minutes any time the needle is removed
    • Avoid too many attempts
    • Prevention

    • Use the smallest possible CVC
    • Minimise CVC duration where possible
    Subclavian - identify the vein using landmarks. Identify the junction of the medial third and lateral two-thirds of the clavicle. The needle should be inserted 1cm inferior and lateral to this, pointing toward the sternal notch, upward and away from the underlying lung apex.
    • Don't

    • Don't insert a needle through a burn, oedema or infected tissue
    • Don't insert a CVC into an area with localised deformity, e.g. clavicular or femoral fracture
    • Don't insert a subclavian CVC on the same side as a pacemaker
    • Don't insert a subclavian CVC into a coagulopathic patient
    • Avoid a femoral CVC in a patient who is incontinent - especially of faeces
    Flashback but no blood coming out (penetrated too far) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again
    • Prevention

    • Use ultrasound guidance to identify the desired vessel
    • Proceduralist Position

    • Internal jugular - at the head of the bed
    • Subclavian - on the side of insertion, toward the head of the bed
    • Femoral - on the side of insertion, toward the bottom of the bed

    Inserting the Guidewire

    If unable to advance the guidewire, retract it and confirm that there is still flashback from the needle. If so, then gently re-attempt to insert the guidewire. If resistance is repeatedly met then remove the needle, place pressure on the site and start again.

    Overview

    • Prevention

    • Estimate the correct CVC insertion length prior to placement.
    • Causes

    • Clot in the cannula
    • Kinking of the cannula
    • Causes of Line-Related Infection

    • Poor aseptic technique
    • Prolonged use of the same cannula

    Types of NG Tube

    Feeding tubes - small bore (6-8 Fr), single lumen tubes that can be used for feeding but are unable to be aspirated

    Confirming NG Placement

    Aspirate - aspirate stomach contents and check the pH (<5.5) using litmus paper.

    Avoiding Incorrect NG Placement

    Oropharyngeal - ask the patient to open their mouth and check that the tube has not become looped around in the mouth. This should be suspected if there is excessive gagging.

    Difficult NG Insertion

    Try placing the NG tube in the fridge to make it more rigid and easier to insert.

    Identifying the Right Site

    The spinal cord ends at L1/L2, so the L3/L4, L4/L5 or L5/S1 interspaces can be used for lumbar puncture.

    Overview

    Sitting position - Patient sitting up, leaning against a table in front of them (shouldn't be used to measure CSF pressure)
    • Mechanism

    • Unknown, but thought to relate to reduced CSF pressure / compensatory venodilatation.
    CSF pressure measurement
    Perform a CT scan prior to performing an LP if concerns for raised ICP, e.g. decreased level of consciousness, papilloedema, focal neurological findings or recent seizures.
    • Relative

    • Coagulopathy - based on clinical situation
    Sitting position - Patient sitting up, leaning against a table in front of them (shouldn't be used to measure CSF pressure)

    Identifying the Right Site

    The spinal cord ends at L1/L2, so the L3/L4, L4/L5 or L5/S1 interspaces can be used for lumbar puncture.

    Measuring Opening Pressure

    Hold the 0 mark on the manometer at the level of the needle, and hold the manometer tubing up vertically.

    Troubleshooting

    If unable to advance the guidewire, retract it and confirm that there is still flashback from the needle. If so, then gently re-attempt to insert the guidewire. If resistance is repeatedly met then remove the needle, place pressure on the site and start again.

    Jugular Placement

    • Prevention

    • Ask the patient to abduct their arm and put their chin on the ipsilateral shoulder when inserting the PICC.

    Overview

    • Prevention

    • Use the smallest possible PICC line
    • Minimise PICC line duration where possible

    Troubleshooting

    Flashback but no blood coming out (penetrated too far, vein has collapsed) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again

    Overview

    • Causes of PICC Blockage

    • Clot in the PICC
    • Kinking of the PICC

    Tips for Finding a Vein

    • Do

    • Ask the patient about their preference of arm
    • Use the nondominant arm if possible

    Overview

    • Prevention

    • Place pressure on the insertion site any time the needle or guidewire is removed.
    • Causes of PICC-Related Infection

    • Poor aseptic technique on insertion
    • Poor aseptic technique on accessing the line
    • Prolonged use of the same line
    • Causes of Line-Related Infection

    • Poor insertion technique
    • Prolonged use of the same site
    • Significance

    • Due to blood leaking from the vein into surrounding tissue.
    • Causes of Cannula Extravasation

    • Needle out of vein
    • Leakage around the cannula
    • Causes of Cannula Blockage

    • Clot in the cannula
    • Kinking of the cannula
    Explain the procedure and ask for patient's consent.
    • Causes of Thrombophlebitis

    • Injury
    • Irritation (e.g. potassium infusion)
    • Infection

    Troubleshooting

    Flashback but no blood coming out (penetrated too far, vein has collapsed) - pull back slightly, adjust the angle of the needle against the skin, pull back and try again

    Overview

    22 - paediatrics, fragile veins

    Potential Cannula Sites

    Cephalic vein (lateral) in the forearm - large vein, doesn't limit movement

    Choosing the Right Site

    • Do

    • Use the vastus lateralis where possible

    Injection of Incorrect Site

    • Prevention of Intravascular Injection

    • Inject into the correct site - avoid the medial / inferior gluteal muscle, the medial thigh etc.
    • Draw back to check for blood prior to injecting the medication

    Lignocaine

    • Strength

    • 1% (10mg/mL)

    Indications for Ascitic Tap

    Therapeutic tap - for symptomatic relief of ascites in haemdynamically stable patients

    Overview

    • Causes of Upper Airway Obstruction

    • Soft tissue swelling - anaphylaxis, burns, peritonsillar abscess, epiglottitis, laryngotracheobronchitis (croup)
    • Foreign body aspiration
    • Deformity - laryngomalacia, laryngeal mass / web, tracheomalacia
    • Tongue enlargement / displacement
    • Vocal cord lesion / paralysis

    Bag-Valve-Mask

    A bag-valve-mask system may be used with an oropharyngeal or nasopharyngeal airway in situ, to aid in opening the airway.

    Overview

    • Airway Manoeuvres

    • Head tilt and chin lift -  tilt the head backward into the sniffing position, opening the airway, and use the index and middle fingers to pull the mandible forward.
    • Jaw thrust - use the index and middle fingers on each hand to push the mandible anteriorly, moving the tongue forward.

    Oropharyngeal Airway

    An oropharyngeal airway is also known as a Guedel airway.

    Injection of Incorrect Site

    • Prevention of Intravascular Injection

    • Inject into the correct site - avoid the medial / inferior gluteal muscle, the medial thigh etc.
    • Draw back to check for blood prior to injecting the medication

    Overview

    • Potential Sites for Subcutaneous Injections

    • Abdomen - anywhere except around the umbilicusThe most commonly used site
    • Upper arm - posteriorly or laterallyHigher chance of injecting intramuscularly
    • Thigh - anterolaterallyHigher chance of injecting intramuscularly
    • Upper buttocks - laterallyHas the slowest absorption rate
    Myelodysplasia may be seen in the context of myelodysplastic syndromes (MDS), where clonal expansion of mutated stem cells results in ineffective haematopoiesis. This condition is at risk of transforming to acute myeloid leukaemia (AML).

    Manifestations

    • Complications of Scleroderma

    • Pulmonary hypertension
    • Pulmonary fibrosis
    • Scleroderma renal crisis
    • Oesophageal dysmotility
    • Pericarditis
    • Arrythmias
    • Erectile dysfunction

    Overview

    • Causes of Nonthyroidal Illness

    • Starvation
    • Sepsis
    • Burns
    • Trauma
    • Surgery
    • Myocardial infarction
    • Malignancy
    • Chronic liver disease
    • Chronic kidney disease

    Manifestations

    • Clinical Features

      Only occur in the presence of resultant biochemical abnormalities
    • Hypocalcaemia - hyperreflexia, tetany, seizures, heart failure
    • Hypokalaemia - weakness, hypotonicity, depression, constipation, ileus

    Diagnosis

    • X-Ray Findings in Psoriatic Arthritis

    • Pencil-in-cup deformity: erosions with new bone formation
    • Dactylitis: soft tissue swelling in all of the joints of a single digit
    • Fluffy periostitis: cortical thickening
    • Ankylosis: fusion of joints
    • Sacroiliitis

    Pathogenesis

    • Causes of Chronic Kidney Disease

    • Diabetic nephropathy
    • Hypertensive nephropathy
    • Glomerulonephritis
    • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
    • Congenital disease - polycystic kidney disease

    Overview

    • Clinial Phenotypes of Motor Neuron Disease

    • Amyotrophic lateral sclerosis (ALS) - mixed upper and lower motor neuron involvement
    • Primary lateral sclerosis - mainly upper motor neuron involvement
    • Progressive muscular atrophy - mainly lower motor neuron involvement
    • Progressive bulbar palsy - mainly bulbar involvement
    • ECG Findings

    • Bifascicular block (RBBB and LAFB or LPFB) with first degree AV block
    • Alternating LBBB and RBBB
    • Fixed RBBB with alternating LAFB and LPFB
    • Complete heart block

    Pathogenesis

    • Causes of Bronchiectasis

    • Congenital

    • Cystic fibrosis
    • Primary ciliary dyskinesia (e.g. Kartegener's syndrome)
    • Hypogammaglobulinaemia
    • Acquired

    • Recurrent pneumonia (e.g. in the setting of immunosuppression) - bacterial, tuberculous, fungal
    • Chronic obstructive pulmonary disease (COPD)
    • Allergic bronchopulmonary aspergillosis (ABPA)
    • Autoimmune diseases - rheumatoid arthritis, Sjogren's syndrome, ulcerative colitis
    • Chronic aspiration (e.g. secondary to gastroesophageal reflux)
    • Airway foreign body

    Diagnosis

    • X-Ray Findings in Osteoarthritis

    • Reduced joint space - generally asymmetric
    • Subchondral sclerosis - increased bone deposition surrounding the joint
    • Subchondral cysts: cystic formations around the joint
    • Osteophytes: bony projections along the joint line

    Pathogenesis

    • Mechanism

    • Focal atrial tachycardia originates from a single source of micro reentry, most commonly in the right atrium.

    Manifestations

    • Clinical Features

    • Musculoskeletal

    • Wrist sign: when the patient wraps their thumb and fifth finger around their opposite wrist, the thumb and fifth finger overlap
    • Thumb sign: when the patient adducts their thumb, it extends beyond the ulnar border of the palm
    • Pectus carinatum: forward angulation of the sternum
    • Hindfoot deformities - particularly hindfoot valgus
    • Pes planus: flat foot
    • Scoliosis / lumbar kyphosis
    • Reduced upper segment / lower segment ratio (with the pubic symphysis separating the upper and lower segments)
    • Increased arm span / height ratio (i.e. arms longer than the patient's height)
    • Facial

    • Dolichocephaly: abnormally long head (anterior-posterior)
    • Enophthalmos: posterior displaceemnt of the eye within the orbit
    • Downslanting palpebral fissures (the line between the medial canthus and the lateral canthus of the eye)
    • Malar hypoplasia: underdeveloped cheek bones
    • Retrognathia: posterior displacement of the mandible
    • Other

    • Reduced elbow extension
    • Skin striae

    Pathogenesis

    • Causes of B12 Deficiency

    • Atrophic gastritis - pernicious anaemia, H pylori infection
    • Malabsorption - coeliac disease, tropical sprue, Crohn's disease, alcohol abuse
    • Surgical resection - gastrectomy, gastric bypass, resection of terminal ileum
    • Pancreatic insufficiency - chronic pancreatitis
    • Inherited disorders - Imerslund-Gräsbeck syndrome
    • Causes of Epilepsy

    • Genetic
    • Trauma - open or closed head injury, neurosurgery
    • Cerebrovascular - haemorrhage, ischaemia, arteriovenous malformation
    • Malignancy - glioma, meningioma, metastasis
    • CNS infection - meningitis, encephalitis, malaria, tuberculosis
    • Autoimmune - systemic lupus erythematosus
    • Degeneration - Alzheimer's, multiple sclerosis
    • Idiopathic

    Overview

    Hyperkalaemia, or an increased serum potassium concentration of >5mmol/L, shortens action potentials and reduces conduction velocity in cardiac myocytes.
    Hepatitis A IgM is detectable at the time of symptom onset, after an incubation period of 14-28 days.

    Pathogenesis

    • Causes of B12 Deficiency

    • Atrophic gastritis - pernicious anaemia, H pylori infection
    • Malabsorption - coeliac disease, tropical sprue, Crohn's disease, alcohol abuse
    • Surgical resection - gastrectomy, gastric bypass, resection of terminal ileum
    • Pancreatic insufficiency - chronic pancreatitis
    • Inherited disorders - Imerslund-Gräsbeck syndrome
    • Causes of Hypernatraemia

    • Water Loss

    • Inadequate water intake
    • Diabetes insipidus (neurogenic / nephrogenic)
    • Loop diuretics
    • Acute tubular necrosis (polyuric phase)
    • Osmotic diuresis (e.g. poorly controlled diabetes)
    • Non-urinary loss - insensible, sweat, burns, diarrhoea
    • Salt Gain

    • Excessive administration - dietary excess, hypertonic saline, hypertonic dialysis
    • Endocrine - hyperaldosteronism, Cushings
    • Water Redistribution

    • Strenuous exercise
    • Seizure

    Manifestations

    • Signs and Symptoms

      Generally asymptomatic unless severe.
    • Hypocalcaemia - hyperreflexia, tetany, seizures, heart failure
    • Clinical Features

    • Short stature
    • Brachycephaly: flat head
    • Flat nasal bridge
    • Open mouth with protuberant tongue
    • Epicanthal folds: a fold of skin of the upper eyelid that covers the inner corner of the eye
    • Ligamentous laxity
    • Hypotonia: low muscle tone
    • Brachydactyly: short fingers and toes
    • Fifth finger clinodactyly: bending of the little finger toward the ring finger
    • Broad hands, single palmar crease
    • Wide 1-2 toe gap

    Pathogenesis

    • Mechanism

    • AVRT requires the presence of a distinct accessory pathway, most commonly in the setting of Wolff-Parkinson-White syndrome.
    • Causes of Atrioventricular (AV) Block

    • Intrinsic

    • Idiopathic degeneration
    • Myocardial infarction
    • Congenital - congenital heart disease, neonatal lupus
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Cardiac procedures - valvular surgery, correction of congenital heart disease, catheter ablation
    • Systemic lupus erythematosus
    • Myocarditis
    • Extrinsic

    • Physiologic - sleep, athletes
    • Autonomic - carotid sinus massage, carotid sinus hypersensitivity
    • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, amiodarone
    • Hyperkalaemia
    • Hypothyroidism
    • Risk Factors for Non-Alcoholic Fatty Liver Disease

    • Obesity
    • Type 2 diabetes
    • Hypercholesterolaemia
    • Hyperuricaemia
    • Risk Factors for Obstructive Sleep Apnoea

    • Obesity
    • Male gender
    • Craniofacial abnormalities - retrognathia
    • Upper airway narrowing - enlarged tonsils, macroglossia, narrow nasal cavity
    • Alcohol excess
    • Smoking
    • Causes of Hypokalaemia

    • Inadequate intake
    • GI loss - vomiting, high NG output, diarrhoea, fistula, laxative abuse
    • Renal loss - Conns, Cushings, ectopic ACTH, loop diuretics, osmotic diuresis, corticosteroids, hypomagnesaemia, RTA
    • Compartmental shift - alkalaemia, insulin, refeeding, beta agonists
    Pulmonary emboli almost always originate from venous thrombi, most commonly in the deep veins of the leg. Proximal lower limb DVTs are significantly more likely to embolise than distal (below knee) DVTs. Less commonly, thrombi may form in the iliac veins, veins of the upper limb or within the right heart.

    Diagnosis

    The most classic ECG finding in ARVD is epsilon waves. Patients with ARVD may develop ventricular tachycardia, which is of right ventricular origin (with left bundle branch morphology).

    Pathogenesis

    • Causes of Right Ventricular Failure

    • Pulmonary hypertension - pulmonary arterial hypertension, left heart failure, lung disease, chronic pulmonary embolism
    • Right ventricular pathology - cardiomyopathy, myocarditis, ischaemic heart disease
    • Tricuspid regurgitation - rheumatic heart disease, infective endocarditis, Ebstein's anomaly, carcinoid syndrome, trauma
    • Pericardial disease - constrictive pericarditis
    • Mechanism

    • Typical atrial flutter occurs as a macro-reentrant circuit around the tricuspid valve annulus, most commonly in a counter-clockwise direction. The slow aspect of the sawtooth wave occurs as the impulse is conducted through the cavotricuspid isthmus.

    Manifestations

    • Clinical Features

    • Angina - frequency, onset, management
    • Heart failure symptoms - exertional dyspnoea, orthopnoea, paroxysmal noctural dyspnoea, peripheral oedema
    • Exercise tolerance

    Overview

    • Classification

    • Nonsustained VT - three or more ventricular beats at a rate of >100bpm, lasting less than 30 seconds, without haemodynamic instability
    • Sustained VT - a ventricular rhythm at a rate of >100bpm, lasting at least 30 seconds or with haemodynamic instability

    Manifestations

    • Clinical Features

    • Female
    • Short stature
    • Puffy hands and feet (congenital lymphoedema)
    • Added skin folds on the back of the neck

    Pathogenesis

    • Precipitants of Myaesthenic Crisis

    • Infection
    • Surgical procedures
    • Drugs - neuromuscular blockers, aminoglycosides, macrolides, beta blockers, calcium channel blockers, corticosteroids
    • Pregnancy
    • Causes of Sinus Tachycardia

    • Physical exertion
    • Anxiety
    • Pain
    • Trauma
    • Fever
    • Infection
    • Hypovolaemia
    • Shock
    • Hypoxia
    • Anaemia
    • Pulmonary embolism
    • Coronary ischaemia / infarction
    • Hypoglycaemia
    • Thyrotoxicosis
    • Phaeochromocytoma
    • Drugs - beta agonists, anticholinergics, theophylline, caffeine, amphetamine, cocaine, alcohol

    Manifestations

    • Complications of Cystic Fibrosis

    • Respiratory

    • Bronchiectasis
    • Respiratory infections
    • Sinusitis
    • Pancreatic

    • Exocrine - fat malabsorption, malnutrition, vitamin A/D/E/K deficiency
    • Endocrine - diabetes mellitus
    • Pancreatitis
    • Gastrointestinal

    • Meconium ileus
    • Distal intestinal obstruction syndrome (DIOS)
    • Gastroesophageal reflux
    • Biliary cirrhosis
    • Malnutrition
    • Musculoskeletal

    • Arthropathy
    • Osteoporosis
    • Reproductive

    • Infertility - congenital absence of vas deferens, thick cervical mucus
    • Risk of transmission to children
    • Other

    • Significant functional impact
    • Depression

    Pathogenesis

    • Causes of Thyrotoxicosis

    • Primary

    • Grave's disease
    • Toxic multinodular goitre
    • Toxic nodule
    • Thyroiditis - postviral, postpartum, lymphocytic
    • Thyroxine - excess replacement, thyrotoxicosis factitia
    • Drugs - amiodarone, iodine
    • Pregnancy-related - hyperemesis gravidarum, hydatidiform mole
    • Struma ovarii
    • Congenital hyperthyroidism
    • Secondary

    • TSH-secreting pituitary tumour
    • Causes of Multifocal Atrial Tachycardia

    • COPD exacerbation
    • Cor pulmonale
    • Ischaemic heart disease
    • Rheumatic heart disease
    • Hypokalaemia / hypomagnesaemia
    • Digoxin toxicity

    Diagnosis

    • ECG Findings

    • Right bundle branch block - wide QRS (>120ms), RSR' pattern in V1 or V2, slurred S wave in I, V5, V6
    • Either left (LAFB) or right (LPFB) axis deviation

    Pathogenesis

    • Risk Factors for Colorectal Cancer

    • Familial syndromes - Lynch syndrome, familial adenomatous polyposis
    • Family history of colorectal cancer
    • Past polyps / colorectal cancer
    • Inflammatory bowel disease
    • Dietary factors - red meats, processed meats; lack of fruit and vegetables
    • Physical inactivity
    • Obesity
    • Smoking
    • Alcohol

    Overview

    • Risk Factors for Hepatitis C Infection

    • Certain ethnic groups
    • Children of hepatitis C positive mothers
    • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
    • Healthcare workers
    • IV drug use
    • Prisoners
    • Tattoos

    Pathogenesis

    • Mechanism

    • The AV node normally contains two pathways - a slow pathway (short refractory period) and fast pathway (long refractory period) - that then combine to form a common pathway into the bundle of His. Normally, an atrial impulse is conducted down the two pathways with no recirculation of the impulse, as both pathways are within their refractory periods.
    • Risk Factors for Multiple Sclerosis

    • Female sex
    • Family history of multiple sclerosis
    • High lattitude (further from equator)
    • EBV infection
    • Smoking

    Overview

    Beta thalassaemia is common in people from Mediterranean countries, South East Asia and India. It is rarely seen in those of caucasian descent.
    Sinus arrhythmia occurs physiologically due to changes in intrathoracic pressure and resultant variation in vagal tone through the respiratory cycle.

    Manifestations

    • Manifestations of Rheumatoid Arthritis

    • Symmetrical inflammatory polyarthropathy with sparing of the distal interphalangeal (DIP) joints
    • Rheumatoid nodules
    • Tendon rupture
    • Atlantoaxial instability (severe cases)
    • Systemic features - fatigue, weight loss

    Pathogenesis

    • Causes of Hypophosphataemia

    • Reduced Intake / Uptake

    • Severe malnutrition - starvation, alcoholism, anorexia, TPN
    • Malabsorption
    • Vitamin D deficiency
    • Phosphate binders (CKD patients)
    • Antacids
    • Compartmental shift

    • Insulin - recovery post DKA, refeeding syndrome, insulin infusion, glucose infusion
    • Severe respiratory alkalosis
    • Hungry bone syndrome
    • Increased excretion

    • Hyperparathyroidism
    • Vitamin D deficiency
    • Diuretics - acetazolamide, thiazides, loop diuretics
    • Osmotic diuresis (e.g. poorly controlled diabetes)
    • Iron infusion
    • Post renal transplant
    • Fanconi syndrome

    Diagnosis

    • Clinical Signs

    • Active monoarthritis - particularly of the first MTP joint (podagra) or tarsal joint
    • Asymmetric polyarthritis
    • Gouty tophi - particularly over joints; the olecranon bursa at the elbow; the helix of the ear; the infrapatellar and achilles tendons

    Overview

    Hypothermia refers to a reduction in body temperature below 35 degrees celsius. 

    Pathogenesis

    • Causes of Sinoatrial Exit Block

    • Idiopathic degeneration
    • Myocardial infarction
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Connective tissue disease - SLE, scleroderma, RA
    • Cardiac surgery - valvular surgery, correction of congenital heart disease
    • Infections - Lyme disease, endocarditis

    Pathogenesis 

    • Causes of SIADH

    • Malignancy - lung cancers, pancreatic cancer, colorectal cancer, bladder cancer, lymphoma, sarcoma
    • CNS - tumours, demyelination, ischaemic stroke, haemorrhage, infection, vasculitis, traumatic brain injury
    • Pulmonary - pneumonia, tuberculosis, abscess, vasculitis
    • Drugs - desmopressin, SSRIs, TCAs, carbemazepine, levetiracetam, haloperidol, cyclophosphamide, vincristine
    • Postoperative state

    Overview

    Sickle cell disease is a more broad term that includes sickle cell anaemia, sickle beta thalassaemia and haemoglobin SC disease.

    Pathogenesis

    • Causes of Iron Deficiency

    • Nutritional deficiency
    • Malabsorption - e.g. coeliac disease, gastric surgery, PPIs
    • Blood loss - particularly menstrual and gastrointestinal loss; regular blood donation
    • Pregnancy

    Overview

    • Risk Factors for Hepatitis B Infection

    • Certain ethnic groups
    • Children of hepatitis B positive mothers
    • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
    • High risk sexual behaviour
    • Healthcare workers
    • IV drug use
    • Prisoners
    • Tattoos

    Differential Diagnosis

    • Causes of Parkinsonism

    • Parkinson's disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
    • Parkinson's Plus Syndromes

    • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
    • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
    • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
    • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
    • Others

    • Drugs - antipsychotics, metoclopramide, lithium
    • Normal pressure hydrocephalus
    • Hypoxic brain injury
    • Wilson's disease

    Overview

    • Classification

    • Community-acquired pneumonia
    • Hospital-acquired pneumonia
    • Ventilator-associated pneumonia
    Catacholaminergic polymorphic ventricular tachycardia may present as syncope or sudden cardiac death due to polymorphic ventricular tachycardia, following an adrenergic stress such as exercise.

    Pathogenesis

    • The condition is multifactorial, and occurs in the context of:
    • Reduced effective incorporation of iron into haemoglobinDue to increased production and release of hepcidin and cytokines
    • Reduced responsiveness to erythropoietin
    • Reduced red cell survival
    • Causes of Sinus Node Dysfunction

    • Idiopathic degeneration
    • Myocardial infarction
    • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
    • Connective tissue disease - SLE, scleroderma, RA
    • Cardiac surgery - valvular surgery, correction of congenital heart disease
    • Infections - Lyme disease, endocarditis

    Overview

    • Conditions Associated with Physical Inactivity

    • Obesity
    • Type 2 diabetes mellitus
    • Dyslipidaemia
    • Ischaemic heart disease
    • Stroke
    • Cancers - especially colorectal and breast
    • Significance

    • Travel to certain countries is associated with increased infection risk, especially with organisms rarely seen in developed countries.
    • Long plane journeys are associated with increased risk of DVT.
    • For Each Procedure

    • Timing - when they had the procedure
    • Surgeon - who performed the procedure
    • Indication - why the procedure was performed, and what symptoms they were experiencing prior
    • Complications - whether the surgery resulted in any undesired effects, such as infection, bleeding or pain
    • Follow up - whether they continue to see their surgeon
    • Ask About

    • Medical conditions
    • Recent hospital admissions
    • Admissions to the intensive care unit

    IV Drug Use

    • Ask About

    • What drug they inject
    • Where they get their needles from
    • Whether they have tried to quit
    • How they tried to quit - methadone / suboxone program, cold turkey

    Overview

    • Significance

    • Without support, patients who are unable to perform their activities of daily living are at risk of living in squalor and of significant deterioration in health.
    • Ask About

    • Everyone

    • Whether the patient currently smokes or has smoked
    • What age they started smoking
    • How many years they smoked in total
    • How many cigarettes per day
    • Heavy Smokers

    • Past attempts to quit
    • Length they were able to quit for
    • Cravings between cigarettes
    • Aids used in attempting to quit - nicotine gum / patches, champix
    • Willingness to cut down or stop
    • Ask About

    • Steadiness - how steady the patient feels on their feet with or without mobility aids
    • Walking aids - whether the patient requires any aids to mobilise, such as a walking stick, 4-wheel walker or rollator frame
    • Transfers - whether the patient can transfer from bed to chair or chair to toilet independently, with assistance, or if they require hoist transfers
    • Stairs - whether the patient is able to climb stairs independently
    • Modifications - whether the patient has had anything added onto their home, such as ramps or toilet / shower rails
    • Common Allergens

    • Pollens - grass, tree, weed
    • Spores
    • Animals - cats, dogs, small pets, birds, horses, cockroaches
    • Food - peanuts, tree nuts, legumes, seafood, soy, fruits, eggs, wheat
    • Drugs - antibiotics, NSAIDs, ACEi, oestrogens, contrast, anaesthetic drugs
    • Venom - bees, wasps
    • Latex
    • Specific Conditions to Ask About

    • Heart disease
    • Stroke
    • Autoimmune conditions
    • Cancers
    • Ask About

    • Any medications the patient is on
    • What pharmacy they get their medications from
    • Whether they use any dosing aids, such as a Webster pack
    • Significance

    • Generally, avoid the drug in question
    • Not all adverse drug reactions are absolute contraindications - e.g. many medications cause nausea / vomiting
    • Not all adverse drug reactions are true - they may be misinterpretations
    • Ask About

    • Everyone

    • Whether they drink alcohol regularly
    • How often - daily, weekly, monthly, or on social occasions only
    • What type of alcohol they drink
    • How many drinks on each occasion / each day
    • The most they drink at any given time
    • Where they drink - restaurants, bars, parties, at home
    • Amount spent on alcohol
    • Heavy Drinkers

    • Withdrawal symptoms - sweating, rigors, nausea, past seizures
    • Alcohol free days
    • Past attempts to quit drinking
    • Willingness to cut down or stop

    Diagnosis

    • Causes of Chronic Kidney Disease

    • Diabetic nephropathy
    • Hypertensive nephropathy
    • Glomerulonephritis
    • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
    • Congenital disease - polycystic kidney disease

    Overview

    • Dialysis Modalities

    • Home haemodialysis
    • In-centre haemodialysis
    • Continuous ambulatory peritoneal dialysis (CAPD)
    • Automated peritoneal dialysis (APD)
    • Ask About

    • Pretransplant history - cause and complications of CKD, dialysis, past transplant, medical and social considerations
    • Peritransplant history - timing, indication, donor
    • Complications - past rejection episodes, infections, cardiovascular, metabolic, malignancy
    • Post-transplant management - immunosuppression, infective prophylaxis, osteoporosis prophylaxis, cancer screening
    • Clinical Phenotypes of Multiple Sclerosis

    • Clinically isolated syndrome - a single episode of symptoms
    • Relapsing-remitting - relapses with improvement between episodes
    • Primary progressive - progression without relapses
    • Secondary progressive - progressive disability with fewer relapses and no return to baseline between episodes

    Differential Diagnosis

    • Causes of Parkinsonism

    • Parkinson's disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
    • Parkinson's Plus Syndromes

    • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
    • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
    • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
    • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
    • Others

    • Drugs - antipsychotics, metoclopramide, lithium
    • Normal pressure hydrocephalus
    • Hypoxic brain injury
    • Wilson's disease

    Overview

    • Causes of Epilepsy

    • Genetic
    • Trauma - open or closed head injury, neurosurgery
    • Cerebrovascular - haemorrhage, ischaemia, arteriovenous malformation
    • Malignancy - glioma, meningioma, metastasis
    • CNS infection - meningitis, encephalitis, malaria, tuberculosis
    • Autoimmune - systemic lupus erythematosus
    • Degeneration - Alzheimer's, multiple sclerosis
    • Idiopathic
    • Clinial Phenotypes of Motor Neuron Disease

    • Amyotrophic lateral sclerosis (ALS) - mixed upper and lower motor neuron involvement
    • Primary lateral sclerosis - mainly upper motor neuron involvement
    • Progressive muscular atrophy - mainly lower motor neuron involvement
    • Progressive bulbar palsy - mainly bulbar involvement

    Manifestations

    • Manifestations of Myaesthenia Gravis

    • Fatiguing muscle weakness (worse with use and improved with rest) affecting the eyes, face, oropharynx, trunk and limbs
    • Myaesthenic crisis (respiratory failure)

    Overview

    • Pearls

    • Warfarin is initially procoagulant in the first few days of its use, due to its inhibition of natural anticoagulants protein C and protein S.
    • Though tranexamic acid is a procoagulant, there is very little evidence that it increases thrombosis risk in a statistically significant way.
    Allogeneic stem cell transplants are associated with a high risk of complications and mortality, and require long-term immunosuppression.
    • Ask About

    • Peritransplant history - when the transplant was done, indication, mobilisation, conditioning
    • Complications
    • Post-transplant management - infective prophylaxis
    • Prognosis
    In this article, we will highlight some of the top clinical medicine apps, either specifically designed for medical students or aimed at the greater medical community. We will cover the features and benefits of each app, as well as their cost and availability. 
    With the rise of technology, flashcard platforms have become an even more convenient way to study any time, anywhere. There are many flashcard platforms available offering a variety of features, and it can be difficult to know which to use. 
    Many medical students take notes digitally, and there is a massive number of apps available for note-taking on different devices. This page is a guide to the most popular and most widely used note apps available.
    While understanding of medical science is relatively fixed compared to the rapidly changing environment of clinical medicine, these topics are complex and it can be daunting to learn then. Luckily, there is a wide range of online video resources that concisely explain medical science topics in an engaging way. These resources are a great adjunct to your other study tools.
    In this article, we’ll explore some of the best and most popular video resources for learning clinical medicine. These include YouTube channels, comprehensive lecture series and even patient simulations.
    One approach that has been around for a long time but has really gained popularity over the past few years is mindfulness. This is the practice of focusing one’s attention on the present moment with acceptance, and without judgment. Regular mindfulness has been found to reduce anxiety and depression, lower blood pressure, improve sleep and even help people cope with pain. In the lecture hall, mindfulness has been found to improve focus and reduce distractions when completing challenging tasks, resulting in greater academic success. Academic benefits aside, mindfulness can be a really useful tool for medical students and doctors to help reduce stress and enhance our overall wellbeing.
    Examples of such clinical tools include the body mass index (BMI) for body habitus; the estimated glomerular filtration rate (eGFR) for renal function; the CHA2DS2VASC score for atrial fibrillation; and the Wells criteria for DVT. 
    In this article, we’ll highlight some of the best productivity apps for medical students that can help you stay on top of your game while keeping up with the rigours of med school. From to-do list apps to focus and concentration tools, time management apps, and writing assistants, these resources can make a real difference in your academic journey. Let’s get into it.
    Fortunately, there is a multitude of resources available for medical students that can help you learn and practice ECG interpretation. In this article, we’ll explore some of the best resources, including online courses, websites, apps and books. Consider using some of these resources to jumpstart your ECG learning and set you on a course to electrocardiographic mastery!
    This section will outline different types of thinking, types of knowledge, learning styles and key resources to optimise each dimension of learning.

    How Memory Works

    • It is useful to understand a bit about how we form and solidify memories before focusing on how to improve recall. There are several steps involved in this process:
    • Encoding
    • Storage
    • Retrieval

    Overview

    The truth about study is that it adheres to the 80:20 principle: 80% of your learning will happen with 20% of your effort. This can mean that you may be hitting your head against a wall for a long time! Fortunately, there are ways to optimise your study time to get the most out of it.
    Flashcards have been used for a very long time to study, and there is a good reason for this. Flashcards offer a simple and effective way to review information multiple times, consolidating your knowledge and strengthening your retention. Flashcards are a flexible learning tool, and can be adapted to suit your personal study style.
    This section outlines some of the major note-taking methods, and provides tips about how to improve your notes.
    • Causes of Bronchiectasis

    • Congenital

    • Cystic fibrosis
    • Primary ciliary dyskinesia (e.g. Kartegener's syndrome)
    • Hypogammaglobulinaemia
    • Acquired

    • Recurrent pneumonia (e.g. in the setting of immunosuppression) - bacterial, tuberculous, fungal
    • Chronic obstructive pulmonary disease (COPD)
    • Allergic bronchopulmonary aspergillosis (ABPA)
    • Autoimmune diseases - rheumatoid arthritis, Sjogren's syndrome, ulcerative colitis
    • Chronic aspiration (e.g. secondary to gastroesophageal reflux)
    • Airway foreign body

    History of Presenting Complaint

    • Site  

      Where the pain is - central, the left or right side, the ribs, or generalised.
    • Retrosternal chest painReflux, angina
    • Pain in chest wall / ribs - unlikely to be anginalSuggestive of a musculoskeletal cause

    Overview

    • Causes of Interstitial Lung Disease

    • ILD of Known Association

    • Connective tissue disease - rheumatoid arthritis, scleroderma, systemic lupus erythematosus, Sjogren's syndrome, polymyositis / dermatomyositis
    • Medications - methotrexate, nitrofurantoin, bleomycin
    • Occupational exposure - silicosis, asbestosis
    • Granulomatous ILD

    • Sarcoidosis
    • Hypersensitivity pneumonitis
    • Idiopathic Interstitial Pneumonias

    • Idiopathic pulmonary fibrosis
    • Others - idiopathic non-specific interstitial pneumonia, acute interstitial pneumonia, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia
    • Risk Factors for Lung Cancer

    • Genetic factors
    • Smoking (active or passive)
    • Air pollution
    • Occupational exposure - asbestosis, silicosis,
    • Chronic scarring - interstitial lung disease, tuberculosis, COPD
    • Alcohol
    • Conditions Associated with Physical Inactivity

    • Obesity
    • Type 2 diabetes mellitus
    • Dyslipidaemia
    • Ischaemic heart disease
    • Stroke
    • Cancers - especially colorectal and breast
    • Ask About

    • Diagnosis - when asthma was diagnosed, risk factors, triggers
    • Severity - symptoms, FEV1, exacerbations
    • Management - lifestyle, pharmacologic, supportive
    • Complications
    • Ask About

    • Everyone

    • Whether the patient currently smokes or has smoked
    • What age they started smoking
    • How many years they smoked in total
    • How many cigarettes per day
    • Heavy Smokers

    • Past attempts to quit
    • Length they were able to quit for
    • Cravings between cigarettes
    • Aids used in attempting to quit - nicotine gum / patches, champix
    • Willingness to cut down or stop
    • Significance

    • Travel to certain countries is associated with increased infection risk, especially with organisms rarely seen in developed countries.
    • Long plane journeys are associated with increased risk of DVT.
    • Risk Factors for Obstructive Sleep Apnoea

    • Obesity
    • Male gender
    • Craniofacial abnormalities - retrognathia
    • Upper airway narrowing - enlarged tonsils, macroglossia, narrow nasal cavity
    • Alcohol excess
    • Smoking
    • Ask About

    • Diagnosis - symptoms, affected organs, how TB was diagnosed
    • Risk factors - immunosuppression, alcohol, malnutrition, diabetes
    • Travel history - immigrant status, recent travel
    • Management - which medications over how long
    • Public health implications - exposure to contacts, family
    • Ask About

    • Diagnosis - when their COPD was diagnosed, risk factors
    • Severity - symptoms, FEV1, exacerbations
    • Management - lifestyle, pharmacologic, supportive, surgical
    • Complications - respiratory, cardiovascular, haematologic

    Complications

    • Complications of Cystic Fibrosis

    • Respiratory

    • Bronchiectasis
    • Respiratory infections
    • Sinusitis
    • Pancreatic

    • Exocrine - fat malabsorption, malnutrition, vitamin A/D/E/K deficiency
    • Endocrine - diabetes mellitus
    • Pancreatitis
    • Gastrointestinal

    • Meconium ileus
    • Distal intestinal obstruction syndrome (DIOS)
    • Gastroesophageal reflux
    • Biliary cirrhosis
    • Malnutrition
    • Musculoskeletal

    • Arthropathy
    • Osteoporosis
    • Reproductive

    • Infertility - congenital absence of vas deferens, thick cervical mucus
    • Risk of transmission to children
    • Other

    • Significant functional impact
    • Depression

    Overview

    • Risk Factors for Pulmonary Embolism

    • Genetic Predisposition

    • Inherited hypercoagulability - protein C or S deficiency, factor V Leiden, prothrombin gene mutation, sickle cell disease, hyperhomocysteinaemia, antithrombin III deficiency
    • Family history of VTE
    • Patient  Factors

    • Advanced age
    • Past history of VTE
    • Acquired hypercoagulability - antiphospholipid syndrome, hyperviscosity, PNH, TTP, HITS
    • May-Thurner syndrome (anatomical variant where the right common iliac artery overlies and compresses the left common iliac vein)
    • Malignancy
    • Hormonal therapy - oestrogen-containing oral contraceptives, hormone replacement, SERMs
    • Venous pathology - varicose veins, superficial vein thrombosis
    • Environmental Triggers

    • Trauma
    • Surgery - particularly hip / knee surgery or major surgery
    • Pregnancy / peripartum period
    • Continuous immobilisation >72 hours - bedrest, neurologic pathology, cast
    • Hospital or nursing home admission
    • Long-distance travel (air, land or sea)
    • Sources of Medication Lists

    • It is often best to derive your list from at least two sources, especially when there is doubt.
    • The patient - sometimes patients present with a useful list of their medications
    • Collateral - from family or friends
    • Medication boxes - often patients present with their medications; ask if there are any missing
    • The patient's file - especially discharge summaries
    • Other hospitals - especially discharge summaries or transfer letters
    • The patient's GP
    • The patient's pharmacy
    • Ask About

    • Diagnosis - when heart failure was diagnosed, symptoms, cause
    • Severity - exercise tolerance / NYHA class, ejection fraction
    • Functional impact of disease
    • Management - non-pharmacologic, pharmacologic, devices
    • Complications - arrhythmias, peripheral oedema, pulmonary oedema, pulmonary hypertension
    • Sources of Medication Lists

    • It is often best to derive your list from at least two sources, especially when there is doubt.
    • The patient - sometimes patients present with a useful list of their medications
    • Collateral - from family or friends
    • Medication boxes - often patients present with their medications; ask if there are any missing
    • The patient's file - especially discharge summaries
    • Other hospitals - especially discharge summaries or transfer letters
    • The patient's GP
    • The patient's pharmacy
    • Ask About

    • Everyone

    • Whether the patient currently smokes or has smoked
    • What age they started smoking
    • How many years they smoked in total
    • How many cigarettes per day
    • Heavy Smokers

    • Past attempts to quit
    • Length they were able to quit for
    • Cravings between cigarettes
    • Aids used in attempting to quit - nicotine gum / patches, champix
    • Willingness to cut down or stop
    • Classification

      Hypertension is defined as persistently elevated blood pressure, based on at least two readings over at least two visits.
    • Normal <120 / 80
    • Pre-hypertension 120 / 80 - 139 / 89
    • Stage I hypertension 140 / 90 - 159 / 99
    • Stage II hypertension >160 / 100
    • Classification

    • Based on body mass index (BMI)

    • Underweight - <18.5
    • Normal - 18.5 - 24.9
    • Overweight - 25 - 29.9
    • Obese - 30 - 34.9
    • Severely obese - 35 - 39.9
    • Morbidly obese - 40+

    IV Drug Use

    • Ask About

    • What drug they inject
    • Where they get their needles from
    • Whether they have tried to quit
    • How they tried to quit - methadone / suboxone program, cold turkey

    Overview

    In the context of the cardiovascular history, alcohol is an important risk factor for hypertension and dilated cardiomyopathy; it is also a precipitant for atrial fibrillation.
    • Causes of Pulmonary Hypertension

    • Type 1: Pulmonary Arterial Hypertension

    • Idiopathic
    • Inherited
    • Drugs / toxins
    • HIV-related
    • Connective tissue disease - scleroderma, mixed connective tissue disease
    • Portopulmonary hypertension
    • Congenital heart disease
    • Schistosomiasis
    • Type 2: Left Heart Disease

    • Left ventricular systolic / diastolic dysfunction
    • Valvular disease - aortic stenosis, aortic regurgitation, mitral stenosis
    • Type 3: Lung Disease

    • Chronic obstruction pulmonary disease
    • Interstitial lung disease
    • Mixed lung disease
    • Sleep-disordered breathing
    • Alveolar hypoventilation
    • Type 4: Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

    • Chronic pulmonary emboli
    • Type 5: Other

    • Haematologic - chronic haemolytic anaemia, myeloproliferative disorders, splenectomy
    • Systemic - sarcoidosis, pulmonary histiocytosis, lymphangioleiomyomatosis
    • Metabolic - glycogen storage disorders, Gaucher disease
    • Other - tumour obstruction, chronic kidney disease
    • Ask About

    • Diagnosis - when diagnosed, presentation
    • Past myocardial infarction
    • Family history of ischaemic heart disease
    • Severity - exercise tolerance, stress test results, echo results, angiogram results
    • Management - revascularisation, risk factor management, CABG
    • Complications - particularly heart failure
    • Ask About

    • Diagnosis - when diagnosed, persistence
    • Management - previous DC cardioversion, rate / rhythm control, anticoagulation
    • Complications - past stroke, heart failure
    • Causes of Hyperlipidaemia

    • Primary

    • Familial lipoprotein lipase deficiency
    • Familial hypercholestolaemia
    • Familial combined hyperlipidaemia
    • Familial dysbetalipoproteinaemia
    • Familial hypertriglyceridaemia
    • Secondary: Predominantly LDL

    • Hypothyroidism
    • Cholestatic liver disease
    • Nephrotic syndrome
    • Secondary: Predominantly TAGs

    • Obesity
    • Diabetes
    • Alcohol abuse
    • Chronic kidney disease
    • Drugs - corticosteroids, antipsychotics, immunosuppressants, protease inhibitors, oral contraceptive pill, hormone replacement therapy
    • Pregnancy

    Aetiology

    • Causes of Acute Dyspnoea

    • Respiratory

    • Obstruction - asthma, COPD
    • Bronchiectasis - cystic fibrosis, ABPA
    • Vascular - pulmonary embolus, pulmonary hypertension
    • Interstitial lung disease
    • Pneumonia
    • Aspiration
    • Lung cancer
    • Pneumothorax
    • Pleural effusion
    • Anaphylaxis
    • Obesity hypoventilation syndrome
    • Cardiovascular

    • Heart failure
    • Pulmonary oedema
    • Myocardial ischaemia
    • Cardiomyopathy
    • Congenital heart disease
    • Valvular disease - aortic stenosis, aortic regurgitation
    • Tamponade
    • Other

    • Anaemia
    • Kyphoscoliosis
    • Metabolic acidosis
    • Late pregnancy
    • Neurologic - Guillain Barre, motor neuron disease
    • Muscular dystrophy
    • Anxiety

    Diagnosis

    • Causes of Chronic Kidney Disease

    • Diabetic nephropathy
    • Hypertensive nephropathy
    • Glomerulonephritis
    • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
    • Congenital disease - polycystic kidney disease

    Overview

    • Ask About

    • Diagnosis - type of diabetes; age at diagnosis; presenting symptoms
    • Control - HbA1c, home BSL monitoring, admissions
    • Complications - acute, microvascular, macrovascular, infections
    • Hypoglycaemia - awareness, symptoms, frequency, BSLs, management
    • Management - non-pharmacologic, oral hypoglycaemics, insulins
    • Follow up - who manages their diabetes (e.g. GP or endocrinologist); regular podiatry visits; regular optometrist visits
    • Conditions Associated with Physical Inactivity

    • Obesity
    • Type 2 diabetes mellitus
    • Dyslipidaemia
    • Ischaemic heart disease
    • Stroke
    • Cancers - especially colorectal and breast
    • Risk Factors for Colorectal Cancer

    • Familial syndromes - Lynch syndrome, familial adenomatous polyposis
    • Family history of colorectal cancer
    • Past polyps / colorectal cancer
    • Inflammatory bowel disease
    • Dietary factors - red meats, processed meats; lack of fruit and vegetables
    • Physical inactivity
    • Obesity
    • Smoking
    • Alcohol
    • Ask About

    • Diagnosis - presenting symptoms
    • Family history of inflammatory bowel disease
    • Severity - number of bowel motions, systemic symptoms, frequency of flares
    • Complications - intestinal / extra-intestinal
    • Management - nutritional status, smoking cessation, medications, surgery
    • Risk Factors for Non-Alcoholic Fatty Liver Disease

    • Obesity
    • Type 2 diabetes
    • Hypercholesterolaemia
    • Hyperuricaemia
    • Sources of Medication Lists

    • It is often best to derive your list from at least two sources, especially when there is doubt.
    • The patient - sometimes patients present with a useful list of their medications
    • Collateral - from family or friends
    • Medication boxes - often patients present with their medications; ask if there are any missing
    • The patient's file - especially discharge summaries
    • Other hospitals - especially discharge summaries or transfer letters
    • The patient's GP
    • The patient's pharmacy
    • Ask About

    • Everyone

    • Whether the patient currently smokes or has smoked
    • What age they started smoking
    • How many years they smoked in total
    • How many cigarettes per day
    • Heavy Smokers

    • Past attempts to quit
    • Length they were able to quit for
    • Cravings between cigarettes
    • Aids used in attempting to quit - nicotine gum / patches, champix
    • Willingness to cut down or stop

    Pretransplant History

    • Ask About

    • Chronic liver disease - underlying cause, complications
    • Past liver transplant
    • Medical comorbidities - particularly cardiovascular and respiratory
    • Psychological factors - depression / anxiety
    • Social situation - family, living arrangement, occupation
    • Adherence - to management plan, dialysis, medications

    Overview

    Additionally, long plane journeys are a risk factor for deep venous thrombosis and this should be considered in a patient with shortness of breath, chest pain or leg swelling after a long flight.
    • Ask About

    • Diagnosis - years since diagnosis, risk factors, symptoms
    • Severity - frequency of symptoms
    • Complications - benign / malignant
    • Management - lifestyle changes, medications, surgery

    IV Drug Use

    • Ask About

    • What drug they inject
    • Where they get their needles from
    • Whether they have tried to quit
    • How they tried to quit - methadone / suboxone program, cold turkey

    Overview

    In the context of the gastrointestinal history, alcohol is an important cause of acute hepatitis, cirrhosis, pancreatitis and oesophagitis.
    • Ask About

    • Diagnosis - cause, location of ulcer(s), symptoms
    • Complications - bleeding, perforation, obstruction
    • Management - H pylori eradication,
    • Causes of Cirrhosis

    • Chronic hepatitis - B or C
    • Alcoholic liver disease
    • Non-alcoholic fatty liver disease
    • Autoimmune hepatitis
    • Obstructive disease - primary biliary cirrhosis, primary sclerosing cholangitis, chronic biliary obstruction
    • Infiltration - haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, sarcoidosis, glycogen storage disease type IV
    • Hepatocellular carcinoma
    • Drugs - methotrexate, methyldopa, amiodarone
    • Budd-Chiari syndrome (hepatic vein occlusion)
    • Right heart failure (cardiac cirrhosis)
    • Risk Factors for Hepatitis C Infection

    • Certain ethnic groups
    • Children of hepatitis C positive mothers
    • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
    • Healthcare workers
    • IV drug use
    • Prisoners
    • Tattoos
    • Risk Factors for Hepatitis B Infection

    • Certain ethnic groups
    • Children of hepatitis B positive mothers
    • Iatrogenic exposure - surgery, colonoscopy, haemodialysis, blood transfusion prior to 1990
    • High risk sexual behaviour
    • Healthcare workers
    • IV drug use
    • Prisoners
    • Tattoos
    • Ask About

    • Diagnosis - when scleroderma was diagnosed, presenting symptoms, limited or diffuse
    • Manifestations - cardiovascular, GI, respiratory, renal, MSK, neurological
    • Functional impairment
    • Management
    • Conditions Associated with Physical Inactivity

    • Obesity
    • Type 2 diabetes mellitus
    • Dyslipidaemia
    • Ischaemic heart disease
    • Stroke
    • Cancers - especially colorectal and breast
    • Ask About

    • Steadiness - how steady the patient feels on their feet with or without mobility aids
    • Walking aids - whether the patient requires any aids to mobilise, such as a walking stick, 4-wheel walker or rollator frame
    • Transfers - whether the patient can transfer from bed to chair or chair to toilet independently, with assistance, or if they require hoist transfers
    • Stairs - whether the patient is able to climb stairs independently
    • Modifications - whether the patient has had anything added onto their home, such as ramps or toilet / shower rails
    • Risk Factors for Osteoarthritis

    • Advanced age
    • Obesity
    • Past trauma
    • Joint overuse (occupational / sport-related)
    • Risk Factors for Rheumatoid Arthritis

    • Female sex
    • Family history of rheumatoid arthritis
    • Infections - EBV, CMV, E coli, periodontal disease (Porphyromonas gingivalis)
    • Smoking
    • Risk Factors for Gout

    • Male gender
    • Obesity
    • Chronic kidney disease
    • Drugs - diuretics, ethambutol, certain chemotherapeutic agents
    • Excess purine-rich foods - beer, shellfish, liver, marmite
    • Excess sucrose / fructose intake
    • Alcohol excess
    • Risk Factors for Systemic Lupus Erythematosus

    • Family history of SLE
    • Female sex
    • Smoking
    • Obesity

    Optic Nerve Palsy

    • Abnormalities

    • Loss of visual acuity
    • Visual field loss
    • Loss of light reflexes
    • Loss of accommodation

    Vestibulocochlear Nerve Palsy

    • Abnormalities

    • Sensorineural hearing loss
    • Vertigo
    • Nystagmus

    Overview

    • How to Elicit

    • Ask the Patient to open their mouth and gently touch the soft palate with a tongue depressor. Warn the patient beforehand.
    • Abnormality

    • Anosmia
    • Signs of Pseudobulbar Palsy

    • Increased jaw jerk
    • Absent palate rise
    • Increased / normal pharyngeal reflex
    • Tongue spasticity
    • Spastic dysarthria - strained-strangled, slow speech
    • How to Elicit

    • Percuss repeatedly between the eyebrows, looking for reactive blinking.

    Trigeminal Nerve Palsy

    • Abnormalities

    • Decreased facial sensation
    • Weak muscles of mastication
    • Increased / decreased jaw jerk
    • Loss of corneal reflex

    Hypoglossal Nerve Palsy

    • Abnormalities

    • Tongue atrophy
    • Fasciculations (nuclear lesion)
    • Diversion of tongue toward lesion
    • Inability to point tongue away from the side of lesion

    Vagus Nerve Palsy

    • Abnormalities

    • Dysphagia
    • Palate droop
    • Diversion of uvula to one side
    • Hoarseness
    • Loss of gag reflex

    Olfactory Nerve Palsy

    • Abnormality

    • Anosmia.

    Abducens Nerve Palsy

    • Abnormalities

    • Inwardly-turned eye
    • Horizontal diplopia
    • Strabismus
    • Inability to look laterally

    II Optic Nerve

    • Abnormalities

    • Loss of visual acuity
    • Visual field loss
    • Loss of light reflexes
    • Loss of accommodation

    Facial Nerve Palsy

    • Abnormalities

    • Facial droop / weakness
    • Inability to close eye
    • Loss of taste
    • Dry eyes / mouth

    V Trigeminal Nerve

    • Abnormalities

    • Decreased facial sensation
    • Weak muscles of mastication
    • Increased / decreased jaw jerk
    • Loss of corneal reflex

    XI Accessory Nerve

    • Abnormalities

    • Shoulder drop
    • Inability to turn head to contralateral side

    Accessory Nerve Palsy

    • Abnormalities

    • Shoulder drop
    • Inability to turn head to contralateral side

    XII Hypoglossal Nerve

    • Abnormalities

    • Tongue atrophy
    • Fasciculations (nuclear lesion)
    • Diversion of tongue toward lesion
    • Inability to point tongue away from the side of lesion

    Trochlear Nerve Palsy

    • Abnormalities

    • Eye deviation upward and rotation outward
    • Vertical diplopia
    • Inability to look down and in - difficulty descending stairs
    • Head tilting away from the side of the lesion

    The Glasgow Coma Scale (GCS)

    15-point scale indicating level of consciousness.

    Overview

    • Normal Pupillary Size

    • In the dark: 4-8mm
    • Under bright light: 2-4mm

    Oculomotor Nerve (III) Palsy

    • Causes of Occulomotor Nerve Palsy

    • Small-vessel ischaemia
    • Midbrain infarct
    • Head trauma
    • Tumour
    • Aneurysm (commonly PCA)

    Overview

    • Signs of Bulbar Palsy

    • Absent jaw jerk
    • Absent palate rise
    • Absent pharyngeal reflex
    • Tongue wasting and fasciculations
    • Flaccid dysarthria - nasal speech with impaired articulation and shortened phrases
    • Signs of Myaesthenia Gravis

    • Skeletal Muscle Fatiguability

    • Simpson's test - ptosis on sustained upward gaze
    • Peek sign - inability to maintain sustained eye closure
    • Bulbar fatiguability - development of nasal speech with reading
    • Proximal muscle fatigability - inability to maintain arms above the head
    • Signs of Management

    • Thymectomy scar

    Glossopharyngeal Nerve Palsy

    • Abnormalities

    • Loss of pharyngeal sensation / gag reflex
    • Loss of taste of posterior 1/3 of tongue
    • Xerostomia (dry mouth)

    Overview

    • How to Perform

    • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.
    • Causes of Myotonia

    • Myotonic Dystrophy

    • Dystrophia myotonia
    • Myotonia congenita
    • Non-Dystrophic Myotonia

    • Paramyotonia congenita
    • Acid maltase deficiency
    • Significance

    • Caused by malignancy affecting the cerebellopontine angle.

    VII Facial Nerve

    • Abnormalities

    • Facial droop / weakness
    • Inability to close eye
    • Loss of taste
    • Dry eyes / mouth

    Horner's Syndrome

    • Look For

    • Partial ptosis: drooping of the eyelid
    • Miosis: pupillary constriction
    • Anhidrosis: lack of sweating

    Occulomotor Nerve Palsy

    • Abnormalities

    • Eye deviated down and out
    • Diplopia
    • Ptosis
    • Mydriasis (pupillary dilatation)
    • Loss of pupillary reflexes

    Facial Asymmetry

    • Interpretation

    • Eyebrow sparing (central palsy) - upper motor neuron lesionIschaemia, haemorrhage, tumour, trauma
    • Eyebrow involvement - facial nerve (VII) lesionBell's palsy, herpes zoster (Ramsay-Hunt Syndrome), tumour, skull fracture

    VIII Vestibulocochlear Nerve

    • Abnormalities

    • Sensorineural hearing loss
    • Vertigo
    • Nystagmus

    Overview

    • Look For

    • Wide-based, ataxic gait
    • Dysarthria
    • Intention tremor
    • Dysmetria
    • Dysdiadochokinesis
    • Muscle wasting
    • Nystagmus
    Popliteal - bend the patient's knee to 90 degrees, gently grasp both sides of the knee joint and palpate using tips of fingers within the popliteal fossa posteriorly.
    • How to Elicit

    • Apply pressure to the nail bed until it blanches, release and measure the time taken for colour to return.
      • Normal Blood Pressure

      • <120 / 80mmHg

    The Abdominal Aorta

    • Interpretation

    • Absent / diminished pulse - aortic coarctation
    • Pulsatile mass - abdominal aortic aneurysm

    Overview

    • Interpretation

    • Central - tends to involve an entire upper and / or lower limbIschaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis
    • Axon - Begins distally and migrates proximally → 'glove and stocking' distributionDiabetes, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
    • Myelin sheath (demyelination) - impaired proprioception and vibration sensation with intact pain sensationGuillain-Barré syndrome, CIDP, Charcot-Marie-Tooth
    • Nerve root - in the distribution of a single dermatomeTrauma, radiculopathy, neoplasm
    • Peripheral nerve - in the distribution of a peripheral nerveTrauma, entrapment, focal ischaemia, neoplasia, shingles, nerve block
    • Skin receptors - localised to an area not in keeping with a dermatomal or peripheral nerve patternTrauma, local anaesthesia, full thickness burns

    Lower Limb Erythema

    • Causes of Lower Limb Erythema

    • CellulitisTender, red, swollen, warm calf ± site of injury
    • Skin conditionsMacules, papules, patches or plaques - localised / diffuse
    • Lipodermatosclerosis (fibrosis of subcutaneous fat)Inverted bowling pin appearance with erythema / induration
    • LymphoedemaNon-pitting oedema, usually bilateral
    • Deep venous thrombosisRed, swollen, tender calf
    • Superficial ThrombophlebitisTender area with erythema tracking along the course of a superficial vein
    • Venous insufficiencyHyperpigmentation that may be associated with varicose veins or oedema.
    • Dependent rubor(peripheral arterial disease)Dusky-red discolouration when the leg is elevated above the heart

    Crepitations

    • Listen For

    • Short popping sounds. May be fine or coarse, and may be cleared by coughing (if due to secretions).

    Venous Skin Changes

    • Look For

    • Oedema
    • Venous eczema
    • Hyperpigmentation
    • White scar tissue (atrophie blanche)
    • Induration - fibrosis of subcutaneous fat (lipodermatosclerosis)

    Overview

    • How to Perform

    • With the patient supine, place one hand on the abdomen over the kidney and the other hand over the flank posteriorly. Attempt to ballot the kidney between the two hands. Repeat on both sides.

    Abdominal Scars

    Scars on the abdomen can suggest past surgery, trauma, burns and healed skin conditions.

    Overview

    • Listen For

    • A superficial, scratching sound present in mid-systole, mid-diastole and late diastole.
    • Significance

    • Flank tenderness to percussion is a relatively sensitive sign for renal pathology, especially pyelonephritis and perinephric abscess.

    Palmar Crease Pallor

    • Causes of Palmar Crease Pallor

    • Anaemia
    • Low cardiac output, due to cardiac disease
    • Peripheral shutdown, due to increased sympathetic activity

    Rashes Associated with Renal Disease

    Livedo reticularis: mottled, lace-like lesions, commonly on the legsBenign, cholesterol emboli, calciphylaxis, cryoglobulinaemia, anticardiolipin syndrome, SLE, rheumatoid arthritis, malignancy

    Overview

    • How to Elicit

    • Ask the patient to place their arms up and out in front of them with the wrists extended.
    • Look for an intermittent loss of tone in the wrists, with the appearance of a flap.

    Contour

    Rapid rate of risePremature ventricular contraction, mitral regurg, VSD, aortic regurgitation, HOCM

    Oral Candidiasis

    • Significance

    • Infection with Candida species.

    Overview

    • Listen For

    • Aortic bruits - over upper abdomen in the midline.
    • Renal bruits - over the upper abdomen, approximately 2cm superior and lateral to the umbilicus on either side.
    • Iliac bruits - over the lower abdomen, either side of the midline.

    Pitting Oedema

    • How to Elicit

    • Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release.

    Heart Rate

      • Normal Range

      • 60 - 100bpm

    Purpura

    • Causes of Purpura

    • Trauma

    • Platelet Disorders

    • Idiopathic thrombocytopaenic purpura (ITP)
    • Thrombotic thrombocytopaenic purpura (TTP)
    • Disseminated intravascular coagulation (DIC)
    • Bone marrow failure - aplastic anaemia, leukaemia, chemotherapy
    • Platelet sequestration - splenomegaly, haemangioma
    • Haemolytic-uraemic syndrome
    • Inherited disorders of platelet function
    • Disorders of Coagulation

    • Factor deficiencies - haemophilia, Von Willebrand disease
    • Vitamin K deficiency - malabsorption, poor diet
    • Anticoagulants
    • Disseminated intravascular coagulation (DIC)
    • Vascular Disorders

    • Connective tissue diseases - Ehlers-Danlos, scurvy
    • Infection - mengingococcal, streptococcal, viral
    • Henoch-Schönlein purpura
    • Senile purpura
    • Steroids

    Overview

    • Interpretation

    • Hum - low, constant murmurNormal jugular venous hum
    • Bruit - abnormal systolic sound (turbulent flow)Carotid stenosis, transmitted murmur of aortic stenosis
    • Look For

    • The pulsation of the jugular vein, between the sternal and clavicular heads of the sternocleidomastoid.

    Weight

    • Look for

    • The patient's current weight
    • Change in weight - compare to past weights
    • Time course - sudden / gradual

    Overview

    • How to Perform

    • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.
    An accurate fluid status assessment can be useful for assessing for dehydration or overload, and for titrating a patient's fluid management - whether that be by giving more fluid or removing fluid through diuresis or dialysis.

    Halitosis

    • Smell For

    • An offensive odour that may resemble rotten eggs / meat / fish or faeces.

    Arterial Ulcers

    The presence of white, painful ulcers suggests a partial or complete arterial occlusion.

    Leukonychia

    • Look For

    • Whiteness of the nail beds.

    Overview

    • Significance

    • In patients with fluid overload, lying down for an extended period, fluid may migrate from the legs to the sacral region.
    • Causes of Cool Extremities

    • Peripheral arterial disease
    • Compartment Syndrome
    • Shock
    • Low cardiac output, due to cardiac disease

    Aetiology

    • Causes of Chronic Kidney Disease

    • Diabetic nephropathy
    • Hypertensive nephropathy
    • Glomerulonephritis
    • Tubulointerstitial disease - analgesic nephropathy, reflux nephropathy
    • Congenital disease - polycystic kidney disease

    Overview

    • Muscles Involved

    • Flexor pollucis longus, flexor pollucis brevis

    Wrist Drop

    • Significance

    • Radial nerve lesion.

    Overview

    Arthritis may affect one joint or multiple joints in a symmetric or asymmetric pattern.
    • Muscles Involved

    • Extensor carpi radialis longus & brevis, extensor carpi ulnaris
    • Muscles Involved

    • Opponens pollucis

    Elbow Lesions

    • Differential Diagnosis of Elbow Mass

    • Rheumatoid nodules
    • Gouty tophi
    • Olecranon bursitis

    Complications

    • Complications of Scleroderma

    • Pulmonary hypertension
    • Pulmonary fibrosis
    • Scleroderma renal crisis
    • Oesophageal dysmotility
    • Pericarditis
    • Arrythmias
    • Erectile dysfunction

    Overview

    • Muscles Involved

    • Dorsal interossei, abductor digiti minimi (5th finger)
    • Signs of Severity

    • Evidence of active synovitis
    • Severe deformity
    • Rheumatoid nodules (indicate seropositive disease)
    • X-Ray Findings in Gout

    • Soft tissue swelling
    • Joint space preservation (no joint space narrowing)
    • Tophi - periarticular radiolucent masses
    • Juxta-articular 'punched-out' erosions
    • Joint destruction (late)
    • Muscles Involved

    • Abductor pollucis longus, abductor pollucis brevis
    • Muscles Involved

    • Flexor carpi radialis, extensor carpi radialis longus & brevis

    Soft Tissue Landmarks of the Wrist

    Ulnar canal (Guyon's canal) - medial & volar aspect of the hand, superficial to the flexor retinaculum

    Overview

    • X-Ray Findings in Psoriatic Arthritis

    • Pencil-in-cup deformity: erosions with new bone formation
    • Dactylitis: soft tissue swelling in all of the joints of a single digit
    • Fluffy periostitis: cortical thickening
    • Ankylosis: fusion of joints
    • Sacroiliitis

    Muscles Acting on the Wrist Joint

    Extensors (posterolateral) - extensor carpi radialis longus & brevis, extensor carpi ulnaris

    Overview

    • Muscles Involved

    • Flexor carpi radialis, palmaris longus, flexor carpi ulnaris
    • Muscles Involved

    • Adductor pollicis
    • X-Ray Findings in Osteoarthritis

    • Reduced joint space - generally asymmetric
    • Subchondral sclerosis - increased bone deposition surrounding the joint
    • Subchondral cysts: cystic formations around the joint
    • Osteophytes: bony projections along the joint line
    • Muscles Involved

    • Flexor digitorum profundus & superficialis, flexor digiti minimi brevis (5th finger)

    Tinel's Sign

    • How to Perform

    • Percuss over the flexor retinaculum.

    Overview

    • Muscles Involved

    • Extensor digitorum, extensor digiti minimi, extensor indicis
    • Muscles Involved

    • Palmar interossei
    • Muscles Involved

    • Flexor carpi ulnaris, extensor carpi ulnaris
    • Signs of Cushing's Syndrome

    • Central obesity (95% of cases)
    • 'Moon' face
    • Buffalo hump (fat pad over the posterior shoulders / neck
    • Thin skin
    • Peripheral oedema
    • Striae (stretch marks)
    • Bruising
    • Proximal myopathy

    Bony Landmarks of the Wrist

    Styloid process of ulna - distally.

    Overview

    • Muscles Involved

    • Extensor pollicis longus, extensor pollucis brevis
    • Muscles Involved

    • Trapezius, rhomboid major & minor
    • Muscles Involved

    • Pectoralis major, trapezius, teres major, latissimus dorsi

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Bony Landmarks of the Shoulder

    Clavicle - medial to lateral, comparing both sides.

    Anterior Shoulder Dislocation

    • Look For

    • Abduction and external rotation of the shoulder with anterior fullness of the shoulder joint.

    Overview

    • Muscles Involved

    • Pectoralis major, serratus anterior
    • Muscles Involved

    • Posterior deltoid, infraspinatus, teres minor
    • Muscles Involved

    • Pectoralis major, trapezius
    • Muscles Involved

    • Pectoralis major, anterior deltoid, biceps brachii
    • Muscles Involved

    • Lateral deltoid, supraspinatus

    Muscle Wasting

    • Causes of Muscle Wasting

    • Normal aging
    • Disuse
    • Malnutrition - poor diet, malabsorption, cancer
    • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
    • Muscular disorders - inflammatory myopathy, muscular dystrophies
    • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

    Muscles Acting on the Shoulder Joint

    Extensors - pectoralis major, posterior deltoid, teres major, trapezius, latissimus dorsi, triceps brachii

    Overview

    • Muscles Involved

    • Trapezius, rhomboid major & minor
    • Muscles Involved

    • Pectoralis major, posterior deltoid, teres major, trapezius, latissimus dorsi, triceps brachii
    • Causes of Shoulder Swelling

    • Trauma - fracture, patellar dislocation, muscle sprain or rupture, compartment syndrome
    • Bursitis - commonly subacromial
    • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
    • Skin / soft tissue infection - cellulitis, abscess
    • Vascular - acute ischaemia, DVT, superficial thrombophlebitis
    • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition
    • How to Perform

    • Flex the patient's elbow and shoulder to 90°, stabilitse the shoulder joint and forcibly internally rotate the shoulder.
    • Causes of a Warm Joint

    • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
    • Bursitis
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - DVT, superficial thrombophlebitis, venous insufficiency
    • Muscles Involved

    • Pectoralis major, anterior deltoid, teres major, subscapularis, latissimus dorsi
    • Tip

    • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.

    Measuring Blood Pressure

    Ask the patient not to talk or move while the blood pressure is measured as this can cause a false elevation in BP.

    Overview

    • Muscles Involved

    • Iliacus, psoas major and minor, rectus femoris, sartorius, tensor fascia lata, pectineus, gracilis.

    Hip Disclocation

    • Causes of Hip Disclocation

    • Congenital - hip dysplasia
    • Acquired - major trauma e.g. road traffic accidents or sporting injuries

    Overview

    • Muscles Involved

    • Biceps femoris, semitendinosus, semimembranosus, gluteus maximus.
    Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
    • Causes of Joint Swelling

    • Trauma - fracture, dislocation, muscle sprain or rupture, compartment syndrome
    • Musculoskeletal - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, bursitis
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
    • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition

    Muscles Acting on the Hip Joint

    Extensors (posterior) - biceps femoris, semitendinosus, semimembranosus, gluteus maximus

    Overview

    • Look For

      The relationship between the positions of the head, trunk, upper and lower limbs.
    • Head & neck - tilt and rotation
    • Shoulders - level of shoulders, scapular prominence
    • Chest - deformities
    • Spine - kyphosis, lordosis and scoliosis
    • Pelvis - pelvic tilt
    • Legs - angle between thigh and leg (genu valgum / varum)
    • Feet - position, pronation
    • Muscles Involved

    • Sartorius, gluteus maximus, iliacus, psoas major and minor, obturator internus and externus, piriformis, quadratus femoris.
    • How to Perform

    • With the patient supine, lift their leg so as to flex the hip while maintaining a straight leg.
    • Muscles Involved

    • Gluteus maximus, medius and minimus; tensor fascia lata, sartorius, piriformis.

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Overview

    • Muscles Involved

    • Pectineus; gluteus medius and minimus; tensor fascia lata.

    Bony Landmarks of the Hip

    Anterior superior iliac spine - a sharp notch anterior to the iliac crest.

    Overview

    • Look For

    • Bulge, above or below the inguinal crease. Examine with an light source shone at an oblique angle. Ask the patient to cough.
    • Muscles Involved

    • Pectineus; adductor longus, brevis and magnus; gracilis, pectineus.

    Muscle Wasting

    • Causes of Muscle Wasting

    • Normal aging
    • Disuse
    • Malnutrition - poor diet, malabsorption, cancer
    • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
    • Muscular disorders - inflammatory myopathy, muscular dystrophies
    • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

    Overview

    • Signs of Marfan Syndrome

    • Musculoskeletal

    • Wrist sign: when the patient wraps their thumb and fifth finger around their opposite wrist, the thumb and fifth finger overlap
    • Thumb sign: when the patient adducts their thumb, it extends beyond the ulnar border of the palm
    • Pectus carinatum: forward angulation of the sternum
    • Hindfoot deformities - particularly hindfoot valgus
    • Pes planus: flat foot
    • Scoliosis / lumbar kyphosis
    • Reduced upper segment / lower segment ratio (with the pubic symphysis separating the upper and lower segments)
    • Increased arm span / height ratio (i.e. arms longer than the patient's height)
    • Facial

    • Dolichocephaly: abnormally long head (anterior-posterior)
    • Enophthalmos: posterior displaceemnt of the eye within the orbit
    • Downslanting palpebral fissures (the line between the medial canthus and the lateral canthus of the eye)
    • Malar hypoplasia: underdeveloped cheek bones
    • Retrognathia: posterior displacement of the mandible
    • Other

    • Reduced elbow extension
    • Skin striae
    • Signs of Ventricular Septal Defect

    • Central Signs

    • Volume-loaded apex beat - displaced apex with forceful, non-sustained impulses
    • Soft first heart sound (S1)
    • Harsh pan-systolic murmur loudest at the left lower sternal edge
    • Signs of Complications

    • Evidence of mitral regurgitation
    • Evidence of pulmonary hypertension - raised JVP, parasternal heave, loud / palpable P2
    • Evidence of Eisenmenger's syndrome - cyanosis, clubbing
    The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
    However, the BMI has several limitations - particular in its overestimation of obesity in people with a significant amount of muscle bulk.
    S1 is normally heard best over the apex.
    • How to Perform

    • Auscultate within the triangle bound by the mandible, sternocleidomastoid and thyroid cartilage. Ask the patient to hold their breath.
    • Causes of Clubbing of the Toes

    • Cyanotic congenital heart disease
    • Pulmonary malignancy - lung cancer, lymphoma, mesothelioma
    • Chronic infection / inflammation - bronchiectasis, lung abscess, empyema, interstitial lung disease, coeliac disease, IBD, infective endocarditis
    • Cirrhosis

    Down Syndrome

    • Look For

    • Short stature
    • Brachycephaly: flat head
    • Flat nasal bridge
    • Open mouth with protuberant tongue
    • Epicanthal folds: a fold of skin of the upper eyelid that covers the inner corner of the eye
    • Ligamentous laxity
    • Hypotonia: low muscle tone
    • Brachydactyly: short fingers and toes
    • Fifth finger clinodactyly: bending of the little finger toward the ring finger
    • Broad hands, single palmar crease
    • Wide 1-2 toe gap
    • Intellectual disability

    Overview

    • Signs of Left Ventricular Failure

    • Sarcopaenia (muscle wasting)
    • Tachycardia
    • Pulsus alternans: regular alternation between strong and weak beats
    • Displaced apex
    • Presence of third heart sound (S3)
    • Pulmonary crepitations / wheeze
    You may find it useful to start at the left sternal edge (tricuspid area) as an initial screening test, and then listen to the other areas.

    Pacemakers

    • Indications

    • AV block
    • Symptomatic bradycardia

    Pallor of the Lower Limb

    • Look For

    • Loss of colour in one or both lower limbs.

    Overview

    • Interpretation

    • 1/6: The faintest murmur, audible with the most careful auscultation.
    • 2/6: A faint murmur that is easily heard.
    • 3/6: Prominent, louder than the heart sounds.
    • 4/6: A loud murmur, accompanied by a thrill.
    • 5/6: A very loud murmur that can be heard with the edge of the stethoscope in contact with the skin.
    • 6/6: A murmur audible with the stethoscope off the chest.
    • How to Perform

    • Ask the patient to cross their arms over their chest and take deep breaths in and out through their mouth. Auscultate over the lung fields, alternating from left to right. Make sure to auscultate the axillae and supraclavicular fossae.

    Inspiration & Expiration

    Inspiration and expiration can be used when assessing for murmurs in order to localise a murmur to the left or right side of the heart.

    Overview

    • Signs of Right Ventricular Failure

    • Sarcopaenia (muscle wasting)
    • Tachycardia
    • Raised jugular venous pressure
    • Right ventricular heave
    • Palpable P2
    • Loud second heart sound (P2)
    • Pleural effusions - reduced breath sounds with dull percussion note basally
    • Ascites - fluid thrill / shifting dullness
    • Tender hepatomegaly
    • Peripheral oedema - sacral / pedal
    • Signs of Aortic Stenosis

    • Peripheral Signs

    • Anacrotic pulse - small volume pulse with a slow upstroke and a notched wave on the upstroke
    • Narrow pulse pressure
    • Central Signs

    • Aortic thrill
    • Pressure-loaded apex beat - forceful and sustained impulses
    • Soft second heart sound (S2)
    • Ejection systolic murmur - heard best over the aortic area in expiration
    • Signs of Complications

    • Evidence of left ventricular failure - pulsus alternans, pulmonary crepitations
      • Normal Blood Pressure

      • < 120 / 80 mmHg
    • Signs of Aortic Regurgitation

    • Peripheral Signs

    • Collapsing Pulse
    • Widened Pulse Pressure
    • Central Signs

    • Soft A2 - loss of normal splitting of S2 on inspiration
    • Volume-loaded apex beat - displaced apex with forceful, non-sustained impulses
    • Decrescendo diastolic murmur loudest on sitting forward, in expiration
    • Signs of Complications

    • Evidence of left ventricular failure - pulsus alternans, pulmonary crepitations
    • Signs of Mitral Regurgitation

    • Peripheral Signs

    • Small volume pulse
    • Central Signs

    • Apical thrill (palpable murmur)
    • Soft or absent first heart sound (S1)
    • Presence of a fourth heart sound (S4)
    • Volume-loaded apex beat -  displaced apex with forceful, non-sustained impulses
    • Pansystolic murmur heard greatest over the apex on expiration
    • Radiation to the left sternal edge and neck - suggests posterior mitral valve leaflet prolapse
    • Radiation to the axilla - suggests anterior mitral valve leaflet prolapse
    • Signs of Complications

    • Evidence of pulmonary hypertension - elevated JVP, parasternal heave, loud / palpable P2
    • Evidence of left ventricular failure - pulsus alternans, presence of S3, pulmonary crepitations

    Heart Rate

    The heart rate is an invaluable vital sign that is commonly used as part of the assessment of a patient's haemodynamic state.

    Overview

    • Signs of Down Syndrome

    • Short stature
    • Brachycephaly: flat head
    • Flat nasal bridge
    • Open mouth with protuberant tongue
    • Epicanthal folds: a fold of skin of the upper eyelid that covers the inner corner of the eye
    • Ligamentous laxity
    • Hypotonia: low muscle tone
    • Brachydactyly: short fingers and toes
    • Fifth finger clinodactyly: bending of the little finger toward the ring finger
    • Broad hands, single palmar crease
    • Wide 1-2 toe gap
    • Signs of Hypertrophic Cardiomyopathy

    • Peripheral Signs

    • Double carotid impulse
    • Prominent a waves within the jugular venous pulsation
    • Central Signs

    • Double apical impulse
    • Paradoxical splitting of the second heart sound (S2): single S2 during inspiration and split S2 during expiration
    • Presence of a fourth heart sound (S4)
    • Late systolic murmur (LV outflow tract obstruction) that increases with valsalva manoeuvre and decreases with squatting
    • Pansystolic murmur loudest at the apex (mitral regurgitation)
    • Signs of Pulmonary Hypertension

    • General Signs

    • Raised JVP
    • Parasternal heave
    • Palpable P2
    • Loud second heart sound (P2)
    • Evidence of tricuspid regurgitation - pansystolic murmur loudest at the lower left sternal edge on inspiration
    • Signs Suggesting a Cause

    • Evidence of connective tissue disease - Raynaud's, sclerodactyly, skin thickening, telangiectasia, synovitis
    • Evidence of portal hypertension - caput medusae, ascites, splenomegaly
    • Evidence of left ventricular failure - pulsus alternans, presence of S3, pulmonary crepitations
    • Evidence of pulmonary disease - hypoxia, hyperexpansion, crepitations, wheeze
    • Signs of Complications

    • Evidence of right ventricular failure - raised JVP, ascites, pleural effusions, peripheral oedema
    • Signs of Mitral Stenosis

    • Peripheral Signs

    • Narrow pulse pressure
    • Central Signs

    • Apical diastolic thrill
    • Early opening snap - high frequency sound after S2 in early diastole, heard best between the apex and left sternal edge
    • Loud first heart sound (S1)
    • Low-pitched, mid-diastolic murmur loudest in the apex in the left lateral position
    • Signs of Complications

    • Evidence of pulmonary hypertension - elevated JVP, parasternal heave, loud / palpable P2
    • Signs of Turner Syndrome

    • Female
    • Short stature
    • Puffy hands and feet (congenital lymphoedema)
    • Added skin folds on the back of the neck
    • How to Perform

    • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.
    • Signs of Pulmonary Stenosis

    • Peripheral Signs

    • Prominent a wave within the jugular venous pressure
    • Central Signs

    • Parasternal heave
    • Splitting of the second heart sound (S2)
    • Presence of a fourth heart sound (S4)
    • Ejection systolic murmur best heart in the pulmonary area on inspiration
    • Signs of Complciations

    • Evidence of right heart failure - raised JVP, ascites, pleural effusions, peripheral oedema
    The second heart sound normally splits on inspiration and is single during expiration, and A2 (closure of the aortic valve) is louder than P2 (closure of the pulmonary valve), even in the pulmonary area.
    • Signs of Patent Ductus Arteriosus

    • Peripheral Signs

    • Peripheral cyanosis
    • Collapsing pulse
    • Widened pulse pressure
    • Central Signs

    • Displaced apex beat
    • Continuous murmur
    • Paradoxical splitting of the second heart sound (S2): single S2 during inspiration and split S2 during expiration
    • Evidence of Eisenmenger's syndrome - cyanosis, clubbing
    • Signs of Tricuspid Regurgitation

    • Peripheral Signs

    • Prominent V wave within the jugular venous pulsation
    • Central Signs

    • Right ventricular heave
    • Pansystolic murmur that is maximal at the lower end of the sternum; louder on inspiration
    • Large, pulsatile, tender liver
    • Signs of Complications

    • Evidence of right heart failure - raised JVP, ascites, pleural effusions, peripheral oedema

    Valsalva Manoeuvre

    The valsalva manoeuvre reduces preload, which makes the murmur of hypertrophic cardiomyopathy louder.

    Overview

    • How to Assess

    • Measure the waist circumference at the midpoint between the lowest palpable rib and the top of the iliac crest. Measure the hip circumference around the widest part of the buttocks. Divide the first measurement by the second.

    Resting Tremor

    The tremor of Parkinsonism is classically pill-rolling, meaning that the thumb and forefinger and rubbed together, at a rate of 3-6hz.

    Anosmia

    • How to Perform

    • Ask the patient whether their sense of smell has been abnormal recently. Ask them to close their eyes and present common smells such as hand sanitizer, coffee, peppermint etc. and ask the patient to identify them.

    Overview

    • How To Perform

    • Measure the blood pressure with the patient lying down, and then remeasure it after the patient has been standing for one minute.
    • Interpretation

    • Increased: resistance to passive movementUpper motor neuron lesion
    • Normal: minimal resistance
    • Decreased: no resistanceLower motor neuron or cerebellar lesion
    • Look For

    • An expressionless face (like the person is wearing a mask)
    • Reduced blinking
    • Drooling
    • Significance

    • Orientation is a quick way of assessing patients for confusion.
    • Causes of Parkinsonism

    • Parkinson's disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
    • Parkinson's Plus Syndromes

    • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
    • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
    • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
    • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
    • Others

    • Drugs - antipsychotics, metoclopramide, lithium
    • Normal pressure hydrocephalus
    • Hypoxic brain injury
    • Wilson's disease
    • Interpretation

    • Decreased - no blinking in response to stimulusOphthalmic nerve (V1) / facial nerve (VII) palsy, pons / medullary lesion
    • Normal - up to five blinks and then no further blinking following habitualization
    • Look For

    • Wide-based, ataxic gait
    • Dysarthria
    • Intention tremor
    • Dysmetria
    • Dysdiadochokinesis
    • Muscle wasting
    • Nystagmus
    • Signs of Myaesthenia Gravis

    • Skeletal Muscle Fatiguability

    • Simpson's test - ptosis on sustained upward gaze
    • Peek sign - inability to maintain sustained eye closure
    • Bulbar fatiguability - development of nasal speech with reading
    • Proximal muscle fatigability - inability to maintain arms above the head
    • Signs of Management

    • Thymectomy scar
    • How to Elicit

    • Patellar - with the patient supine, support the knee from underneath providing slight flexion and strike the patellar tendon below the patella.L3 / L4 myotome
    • Ankle - flex the knee, externally rotate the hip and dorsiflex the foot. Strike the Achilles tendon of the heel.L5 / S1 myotome

    Abnormal Posturing

    • Interpretation

    • Decorticate - flexion, adduction and internal rotation of the arms; supination of the forearms and extension of the legs.Damage to cerebral hemispheres with brain stem preservation
    • Decerebrate - extension of the arms, pronation of the forearms extension of the legsDamage to upper brain stem
    • Opisthotonic - secerebrate posturing with posterior arching of the neck and back.Severe damage to the upper brain stem

    Cutaneous Manifestations of Neurologic Disease

    • Signs of Tuberous Sclerosis Complex (TSC)

    • Angiofibromata: pink papules in the nasolabial folds
    • Shagreen patches: soft flesh-coloured patches on the trunk
    • Ash leaf macules: hypopigmented flat spots

    Overview

    • Causes of Peripheral Mononeuropathy

    • Compression (particularly carpal tunnel and ulnar tunnel) - prolonged pressure, hereditary neuropathy with liability to pressure palsies (HNPP)
    • Trauma - blunt trauma, penetrating injury (e.g. knife, gunshot, glass)
    • Nerve ischaemia - trauma, thromboembolism, diabetes, atherosclerosis, excessive tourniquet use
    • Radiation injury
    • How to Assess

    • Demonstrate a sharp stimulus by touching the patient lightly on the chest with a neurotip. Ask the patient to close their eyes, and test each dermatome / nerve distribution alternating between the sharp and dull sides of the neurotip at random. Ask the patient if they percieve the stimulus as sharp or dull.
    • How to Perform

    • Ask the patient to move their hips, knees and ankles through each movement.
    • Causes of Sensory Loss

    • Central Nervous System

    • Brain lesion - ischaemia, haemorrhage, tumour, trauma, encephalitis, vasculitis, demyelination
    • Spinal cord lesion - infarct, haemorrhage, abscess, transverse myelitis
    • Peripheral Nervous System

    • Nerve root pathology - trauma, radiculopathy, neoplasm
    • Brachial plexopathy - trauma, tumour, brachial neuritis
    • Focal peripheral nerve pathology - trauma, entrapment, focal ischaemia, sarcoidosis, tumour
    • Mononeuritis multiplex - vasculitis, diabetic neuropathy, Lyme disease, leprosy, paraneoplastic, amyloidosis, sarcoidosis
    • Peripheral polyneuropathy - diabetic neuropathy, hypothyroidism, B12 deficiency, alcohol, paraneoplastic, Guillain-Barre, CIDP
    • Other

    • Poor compliance with examination
    • How to Assess

    • Ask the patient to relax and allow you to move their arms. Move the shoulder, elbow, wrist and fingers passively through their range of motion, looking for rigidity.
    • Causes of Myoclonus

    • Physiological (e.g. while falling asleep)
    • Epilepsy
    • Parkinson's disease
    • Drugs - lamotrigine, carbamazepine, TCAs, anaesthetic / analgesic withdrawal
    • Psychogenic
    • Causes of Chorea

    • Inherited disorders - Huntington's disease, Friedrich's ataxia, ataxia-telangiectasia, tuberose sclerosis, benign hereditary chorea, mitochondrial disease
    • Vascular - ischaemic / haemorrhagic stroke
    • CNS tumour
    • Drugs - levodopa, antiepileptics, antipsychotics, stimulants, benzodiazepines, OCP, lithium
    • Infectious - Sydenham's chorea (rheumatic fever), herpes simplex encephalitis, HIV, prions
    • Metabolic - pregnancy, thyrotoxicosis
    • Autoimmune - SLE, antiphospholipid, scleroderma
    • Causes of Tics

    • Tourette's disorder
    • Drugs - lamotrigine, stimulants
    • Significance

    • Loss of balance with the feet together suggests the presence of a cerebellar lesion (as the patient normally compensates by keeping their feet apart), though this can also occur in the setting of vestibular pathology and visual abnormalities.
    Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
    • Interpretation

    • Weakness affecting a single myotome  - likely due to spinal nerve root pathology
    • Weakness affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
    • Weakness affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion or mononeuritis multiplex
    • Generalised weakness - suggests a polyneuropathy, neuromuscular pathology or myopathy

    Muscle Wasting

    • Causes of Muscle Wasting

    • Normal aging
    • Disuse
    • Malnutrition - poor diet, malabsorption, cancer
    • Denervation - trauma, motor neurone disease, Guillain-barré Syndrome, peripheral neuropathy, polio
    • Muscular disorders - inflammatory myopathy, muscular dystrophies
    • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

    Overview

    • Signs of Mononeuritis Multiplex

    • Lower motor neuron weakness affecting two or more distinct peripheral nerve distributions
    • Sensory loss affecting two or more distinct peripheral nerve distributions
    • Causes of Dystonia

    • Genetic mutations
    • Perinatal brain injury
    • Vascular - ischaemic or haemorrhagic stroke
    • CNS tumour
    • Encephalitis
    • Drugs - metoclopramide, calcium-channel blockers, antipsychotics
    • Psychogenic
    Motor neurone disease does not present with sensory involvement or ocular palsy.
    • How to Assess

    • Ask the patient to observe as you demonstrate upward and downward movement of the great toe.
    • With their eyes closed, slowly move the joint over one to two seconds to the upward or downward position. 
    • Ask the patient to report whether the toe has been moved up or down.
    • Repeat several times, and then repeat on the other side.

    Resting Tremor

    • Look For

    • Tremor while at rest, that decreases with target-directed movement.

    Overview

    • How to Assess

    • Ask the patient to close their eyes. Using a cotton ball or microfilament, gently touch each dermatome / nerve distribution and ask the patient if they can feel the stimulus. Compare sides and proximally / distally.
    • How to Assess

    • With the patient's eyes closed, place a vibrating 128hz tuning fork over the interphalangeal joint of the great toe. Ask the patient to describe the sensation. If they can feel it vibrating, progressively diminish the vibration until they cannot feel it. If they cannot feel it vibrating, test on the medial / lateral malleolus and then the tibial tuberosity.
    • Look For

    • Wide-based, ataxic gait
    • Dysarthria
    • Intention tremor
    • Dysmetria
    • Dysdiadochokinesis
    • Muscle wasting
    • Nystagmus
    • Causes of Coexistent UMN and LMN Weakness

    • Separate UMN and LMN lesions
    • Motor neurone disease (amyotrophic lateral sclerosis)
    • Cervical myelopathy
    • Syringomyelia
    Central cord syndrome - bilateral upper motor neuron weakness affecting the upper limbs more than the lower limbs, and loss of proprioception and vibration sensation (dorsal column)Commonly due to trauma or hyperextension of the cervical spine
    • Significance

    • The presence of upper motor neuron weakness suggests a lesion within the central nervous system, involving the cerebrum, brainstem or spinal cord.
    • Differential Diagnosis of Proximal Weakness

    • Proximal myopathy
    • Neuromuscular disorder - myaesthenia gravis, Lambert-Eaton myaesthenic syndrome
    • Neurologic disorder - polyneuropathy, motor neurone disease
    • Causes of Parkinsonism

    • Parkinson's disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
    • Parkinson's Plus Syndromes

    • Progressive supranuclear palsy (PSP) - Parkinsonism with supranuclear downward gaze palsy (inability to look down)
    • Multiple systems atrophy (MSA) - Parkinsonism, autonomic dysfunction, cerebellar involvement and pyramidal signs
    • Dementia with Lewy Bodies (DLB) - Parkinsonism, visual hallucinations, fluctuating cognition
    • Corticobasal degeneration (CBD) - rigidity, dystonia, focal myoclonus, ideomotor apraxia, alien limb syndrome
    • Others

    • Drugs - antipsychotics, metoclopramide, lithium
    • Normal pressure hydrocephalus
    • Hypoxic brain injury
    • Wilson's disease
    • Causes of Radiculopathy

    • Intervertebral disc herniation
    • Osteoarthritis (osteophytosis)
    • Diabetes
    • Haematoma - epidural / subdural
    • Malignancy - spine, spinal cord
    • Infection - epidural abscess, tuberculosis, Lyme disease, syphilis, herpes zoster

    Motor Assessment

    • Causes of Weakness

    • Upper Motor Neuron

    • CNS lesions - decreased power with increased tone, clonus and reflexes.Ischaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis, prions
    • Lower Motor Neuron

    • Nerve root pathology - loss of a single myotomeTrauma, radiculopathy, neoplasm
    • Focal peripheral nerve pathology - in the muscles supplied by a single nerveTrauma, entrapment, focal ischaemia, sarcoidosis, neoplasia, Bell's palsy (face)
    • Axonal pathology (peripheral neuropathy)Diabetes, motor neurone disease, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
    • Peripheral demyelinationGuillain-Barré syndrome, Charcot-Marie-Tooth
    • Other

    • Neuromuscular pathologyMyasthenia gravis, amyloidosis
    • Muscular pathologyPolymyositis, rhabdomyolysis
    • Poor compliance with examination

    Overview

    • Signs of Distal Weakness

    • Wasting of the small muscles of the hand
    • Foot drop
    • Distal weakness - particularly affecting the hands, wrists and ankles
    • Distal functional impairment - difficulty opening jars, turning a key, buttoning a shirt
    • Signs of Peripheral Polyneuropathy

    • Lower motor neuron weakness affecting multiple nerve distributions
    • Sensory loss affecting multiple nerve distributions

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Overview

    Triceps tendon - posteriorly, inserting onto the olecranon.
    • Muscles Involved

    • Pronator teres, pronator quadratus, brachioradialis.

    Muscles Acting on the Elbow Joint

    Extensors (posterior) - triceps brachii, aconeus

    Overview

    • Muscles Involved

    • Triceps brachii, aconeus.

    Bony Landmarks of the Elbow

    Medial epicondyle - medial projection of the humerus.

    Overview

    • Causes of a Warm Joint

    • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
    • Bursitis
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - DVT, superficial thrombophlebitis, venous insufficiency
    • Tip

    • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
    Look between the olecranon, radial head and lateral epicondyle for a subtle concavity - loss of this is indicative of joint effusion.

    Muscle Wasting

    • Causes of Muscle Wasting

    • Normal aging
    • Disuse
    • Malnutrition - poor diet, malabsorption, cancer
    • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
    • Muscular disorders - inflammatory myopathy, muscular dystrophies
    • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

    Overview

    • Muscles Involved

    • Supinator, biceps brachii, barchioradialis
    • Muscles Involved

    • Biceps brachii, brachialis, brachioradialis, pronator teres.
    • Muscles Involved

    • Tibialis anterior, extensor digitorum longus, extensor hallucis longus.
    Peroneal tendons (peroneus longus and brevis) - laterally, passing posterior to the lateral malleolus.

    Muscle Wasting

    • Causes of Muscle Wasting

    • Normal aging
    • Disuse
    • Malnutrition - poor diet, malabsorption, cancer
    • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
    • Muscular disorders - inflammatory myopathy, muscular dystrophies
    • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

    Bony Landmarks of the Ankle

    Lateral malleolus - of the distal fibula.

    Overview

    • Muscles Involved

    • Peroneus longus, peroneus brevis, soleus, gastrocnemius, plantaris, tibialis posterior, flexor digitorum longus, flexor hallucis longus.
    • Causes of a Warm Joint

    • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
    • Bursitis
    • Baker's cyst
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Overview

    • Muscles Involved

    • Tibialis anterior, tibialis posterior
    Subtalar joint - articulation of the talus and calcaneus, allowing inversion and eversion of the ankle.
    Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
    Dorsalis pedis - palpate lateral to the extensor tendon of the great toe. This can be identified by asking the patient to extend their great toe.
    • Causes of Joint Swelling

    • Trauma - fracture, muscle sprain or rupture, compartment syndrome
    • Musculoskeletal - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, tenosynovitis
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
    • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition

    Muscles Acting on the Ankle Joint

    Dorsiflexors (anterior) - tibialis anterior, extensor digitorum longus, extensor hallucis longus

    Overview

    • Muscles Involved

    • Peroneus longus, peroneus brevis
    • Tip

    • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
    Semitendinosus tendon - medial, inserting posteriorly onto the medial body of the tibia. More lateral and more superficial than the semimembranosus tendon.

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Muscles Acting on the Knee Joint

    Extensors (anteriorly) - rectus femoris, vastus medialis, vastus lateralis, vastus intermedius

    Overview

    • Look For

      The relationship between the positions of the head, trunk, upper and lower limbs.
    • Head & neck - tilt and rotation
    • Shoulders - level of shoulders, scapular prominence
    • Chest - deformities
    • Spine - kyphosis, lordosis and scoliosis
    • Pelvis - pelvic tilt
    • Legs - angle between thigh and leg (genu valgum / varum)
    • Feet - position, pronation
    • Causes of Absent Pulse

    • Trauma
    • Atherosclerosis
    • Abdominal aortic aneurysm
    • Shock
    • Causes of Joint Swelling

    • Trauma - fracture, patellar dislocation, muscle sprain or rupture, compartment syndrome
    • Popliteal (Baker's) cyst
    • Bursitis
    • Tenosynovitis
    • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
    • Skin / soft tissue infection - cellulitis, abscess
    • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
    • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition

    True Leg Length Discrepancy

    • How to Assess

    • Measure from the anterior superior iliac spine (ASIS) to the medial malleolus

    Overview

    • Significance

    • Joint line tenderness and fullness are both indicative of menisceal tears.
    The anterior and posterior cruciate ligaments lie within the knee joint and therefore may not be palpated.

    Muscle Wasting

    • Causes of Muscle Wasting

    • Normal aging
    • Disuse
    • Malnutrition - poor diet, malabsorption, cancer
    • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
    • Muscular disorders - inflammatory myopathy, muscular dystrophies
    • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

    Overview

    • Tip

    • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
    • Causes of a Warm Joint

    • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
    • Bursitis
    • Baker's cyst
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
    • Muscles Involved

    • Rectus femoris, vastus medialis, vastus lateralis, vastus intermedius
    • Muscles Involved

    • Popliteus, semimembranosus, semitendinosus

    Bony Landmarks of the Knee

    Tibial tuberosity - palpate for the attachment of the patellar tendon. Note any tenderness, which may be indicative of avulsion fracture or inflammation of the insertion of the patellar tendon (Osgood Schlatter disease)

    Overview

    Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
    • Muscles Involved

    • Biceps femoris, semitendinosus, semimembranosus, sartorius, gracilis, popliteus, gastrocnemius

    Major Bursae of the Knee

    Infrapatellar bursa - superficial or deep; inferior to the patella. Bursitis presents as a palpable swelling inferior to the patella.

    Overview

    • Muscles Involved

    • Biceps femoris, sartorius

    Comprehension

    • Written comprehension

    • Show a written instruction, e.g.

    Overview

    Mood is the patient's subjective assessment of their emotional status.
    • Causes of Abnormal Speech

    • Psychiatric disorder - mood disorder, anxiety, schizophrenia
    • Confusion - delirium, dementia, intellectual disability
    • Dysphasia / aphasia
    • Dysarthria - stroke, brain injury, Parkinson's, MS
    • Dysphonia - laryngitis, neuropathology, trauma, mass, atrophy, systemic disease
    • Hearing impairment
    • English as a non-native language
    • Intoxication

    Normal Variations of Thought Form

    Concrete thinking: thought that is almost exclusively informed by immediate sensory experiences, rather than abstractions.

    Delusions

    Delusions are rigidly held false beliefs not consistent with a person's background.

    Distractability

    • How to Assess

    • Serial sevens - ask the patient to subtract 7 from 100. Ask them to repeat this subtraction five times.
    • DLROW - ask the patient to spell WORLD backward.
    • Months - ask the patient to recite the months of the year backward.

    Assessing Retrograde Memory

    • Ask About

    • Recent memory - what is my name; what did you have for breakfast; what meds did you take today?
    • Remote memory - when and where did you get married?

    Apraxia

    The inability to perform movements despite intact motor and sensory systems.

    Overview

    • Types of Hallucinations

    • Auditory hallucinations - including commentary, insulting voices, Gedanklautwerden, echo de la pensee
    • Visual hallucinations - may be simple (such as flashes or colours) or complex (such as people, animals or objects)
    • Olfactory / gustatory hallucinationsSuggestive of frontal / temporal injury
    • Tactile hallucinationsCan occur in delerium tremens or with cocaine
    • Extracampine hallucinations: sensations that would be physically impossible, such as seeing through walls

    Constructional Ability

    • Wire Cube

    • Ask the patient to copy a diagram of a wire cube.
    • Ask the patient to copy a diagram of a wire cube.

    Overview

    • Causes of Impaired Judgement

    • Organic disorder
    • Acute intoxication
    • Schizophrenia
    • Bipolar disorder

    Conceptualisation

    • Significance

    • Loss of abstract processing is common in fronto-temporal dementia.

    Overview

    • Muscles Involved

    • Scalenes, levator scapulae

    Vertebral Landmarks

    C1 - feel for the transverse processes between the angle of the mandible and the mastoid, asking the patient to turn their head.

    Muscle Wasting

    • Causes of Muscle Wasting

    • Normal aging
    • Disuse
    • Malnutrition - poor diet, malabsorption, cancer
    • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy, polio
    • Muscular disorders - inflammatory myopathy, muscular dystrophies
    • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

    Overview

    • Muscles Involved

    • Splenius muscles, semispinalis muscles, erector spinae, trapezius
    • Muscles Involved

    • Rectus abdominis, internal & external oblique.
    Gait involves many different systems - vision, proprioception, upper motor neurons, lower motor neurons, basal ganglia, cerebellum and higher planning centres. Full neurological assessment is required to correlate gait disturbances.
    • Muscles Involved

    • Quadratus lumborum, internal & external oblique, multifidus

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Overview

    • Muscles Involved

    • Erector spinae, latissimus dorsi.
    • Muscles Involved

    • Sternocleidomastoid, scalenes, longus muscles, rectus capitis

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Overview

    • Muscles Involved

    • Internal & external oblique, multifidus.
    • Significance

    • The cervical spine is normally lordosed, and loss of lordosis or hyperlordosis may result in neck pain and headaches.
    • Muscles Involved

    • Sternocleidomastoid, splenius muscles, levator scapulae, erector spinae
    • Tip

    • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.

    Muscles Acting on the Cervical Spine

    Extensors - splenius muscles, semispinalis muscles, erector spinae, trapezius

    Oropharyngeal Examination

    • How to Perform

    • Ask the patient to open their mouth and make an 'ahh' sound, in order to contract the palate and uvula. Depress the tongue if required in order to visualise the posterior pharynx.

    Overview

    • How to Assess

    • Palpate the patient's posterior chest and ask them to say ' blue balloons'. Start at the top of the chest and move to the bottom, comparing both sides.
    • How to Assess

    • Ask the patient to take deep breaths in and out through their mouth. Auscultate from left to right, noting symmetry of breath sounds.

    Conjunctival Pallor

    Conjunctival pallor is a useful sign of severe anaemia.

    Heart Rate

      • Normal Range

      • 60 - 100bpm

    Overview

    • How to Assess

      Auscultate the patient's chest, starting at the top and moving to the bottom, as they perform the following:
    • Bronchophony - ask the patient to say ' blue balloons'.
    • Egophony - ask the patient to say 'eeee'.
    • Whispered pectoriloquy - ask the patient to whisper 'blue balloons'.
      • Normal Range

      • 12 - 20 breaths per minute
    • How to Perform

    • Use an otoscope to inspect straight backward into the nasal cavity.

    Wasting of Hand Muscles

    • Look For

    • Decreased mass of the thenar and/or hypothenar eminence.

    Digital Clubbing

    • Causes of Digital Clubbing

    • Cyanotic congenital heart disease
    • Pulmonary malignancy - lung cancer, lymphoma, mesothelioma
    • Chronic infection / inflammation - bronchiectasis, lung abscess, empyema, interstitial lung disease, coeliac disease, IBD, infective endocarditis
    • Cirrhosis

    Overview

    • How to Perform

    • Place your left middle finger over the patient's chest, and strike the distal interphalangeal joint with your right middle finger. Tap 2-3 times, rotating the right wrist and allowing it to fall with consistent force.

    Pathogenesis

    • Risk Factors for Lung Cancer

    • Genetic factors
    • Smoking (active or passive)
    • Air pollution
    • Occupational exposure - asbestosis, silicosis,
    • Chronic scarring - interstitial lung disease, tuberculosis, COPD
    • Alcohol

    Overview

    • Causes of Bronchiectasis

    • Congenital

    • Cystic fibrosis
    • Primary ciliary dyskinesia (e.g. Kartegener's syndrome)
    • Hypogammaglobulinaemia
    • Acquired

    • Recurrent pneumonia (e.g. in the setting of immunosuppression) - bacterial, tuberculous, fungal
    • Chronic obstructive pulmonary disease (COPD)
    • Allergic bronchopulmonary aspergillosis (ABPA)
    • Autoimmune diseases - rheumatoid arthritis, Sjogren's syndrome, ulcerative colitis
    • Chronic aspiration (e.g. secondary to gastroesophageal reflux)
    • Airway foreign body

    Pathogenesis

    • Causes of Interstitial Lung Disease

    • ILD of Known Association

    • Connective tissue disease - rheumatoid arthritis, scleroderma, systemic lupus erythematosus, Sjogren's syndrome, polymyositis / dermatomyositis
    • Medications - methotrexate, nitrofurantoin, bleomycin
    • Occupational exposure - silicosis, asbestosis
    • Granulomatous ILD

    • Sarcoidosis
    • Hypersensitivity pneumonitis
    • Idiopathic Interstitial Pneumonias

    • Idiopathic pulmonary fibrosis
    • Others - idiopathic non-specific interstitial pneumonia, acute interstitial pneumonia, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia

    Overview

      • Normal Range

      • >90%
    • Causes of Pleural Effusion

    • Exudative

    • Malignancy
    • Infection - parapneumonic effusion, empyema, viral, fungal, TB, ruptured abscess / cyst
    • Pulmonary embolism (90% exudative)
    • Autoimmune disease - rheumatoid pleuritis, SLE
    • Pancreatitis
    • Haemothorax
    • Chylothorax
    • Asbestosis
    • Uraemia
    • Oesophageal rupture
    • Transudative

    • Heart failure
    • Cirrhosis
    • Hypoalbuminaemia
    • Nephrotic syndrome
    • Pulmonary embolism (10% transudative)
    • Myxoedema
    • Meig's syndrome
    • Constrictive pericarditis
    • SVC obstruction
    • Urinothorax
    • Signs of Chronic Obstruction Pulmonary Disease

    • General Signs

    • Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
    • Barrel chest (emphysema)
    • Tar-stained fingers (smoking)
    • Asterixis (CO2 retention)
    • Reduced chest expansion
    • Reduced breath sounds
    • Wheeze
    • Signs of Complications

    • Infective exacerbation - fevers, green sputum
    • Cor pulmonale - raised JVP, ascites, pleural effusions, peripheral oedema
    • Pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
    • Polycythaemia - polycythaemic facies
    • Steroid complications - Cushing's syndrome, oral candidiasis
    • Signs of Management

    • Oxygen
    • Inhalers
    • Lung transplant scar
    • Muscles Involved

    • Extensor pollicis longus, extensor pollucis brevis
    • Muscles Involved

    • Dorsal interossei, abductor digiti minimi (5th finger)

    Muscles Acting on the Wrist Joint

    Extensors (posterolateral) - extensor carpi radialis longus & brevis, extensor carpi ulnaris

    Overview

    • Muscles Involved

    • Abductor pollucis longus, abductor pollucis brevis
    • How to Elicit

    • Percuss over the flexor retinaculum.
    • Causes of a Warm Joint

    • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
    • Bursitis
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - DVT, superficial thrombophlebitis, venous insufficiency
    • Muscles Involved

    • Palmar interossei
    • How to Perform

    • Ask the patient to forcibly flex their wrists into a reverse prayer sign for 30-60 seconds.
    • Tip

    • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
    • Muscles Involved

    • Flexor digitorum profundus & superficialis, flexor digiti minimi brevis (5th finger)
    • Muscles Involved

    • Flexor carpi radialis, extensor carpi radialis longus & brevis
    • Muscles Involved

    • Flexor pollucis longus, flexor pollucis brevis
    • Muscles Involved

    • Opponens pollucis

    Muscle Wasting

    • Causes of Localised Wasting

    • Forearm flexor wasting - median nerve lesion, e.g. entrapment at or above the cubital fossa
    • Thenar wasting - median nerve lesion, e.g. entrapment at or above the carpal tunnel
    • Hypothenar wasting (ulnar nerve) - ulnar nerve lesion e.g. entrapment at or above the cubital fossa

    Bony Landmarks of the Wrist

    Styloid process of ulna - distally.

    Overview

    • Muscles Involved

    • Extensor carpi radialis longus & brevis, extensor carpi ulnaris

    Wrist Drop

    • Significance

    • A classical sign of radial nerve lesion.

    Active Movement

    • Significance

    • Active movement is an indicator of the patient's ability to move the joint. It may be limited due to weakness, pain, mechanical stiffness or poor compliance.

    Soft Tissue Landmarks of the Wrist

    Ulnar canal (Guyon's canal) - medial & volar aspect of the hand, superficial to the flexor retinaculum

    Overview

    • Muscles Involved

    • Flexor carpi ulnaris, extensor carpi ulnaris
    • Muscles Involved

    • Adductor pollicis
    • Muscles Involved

    • Extensor digitorum, extensor digiti minimi, extensor indicis
    • Causes of Wrist Swelling

    • Trauma - fracture, muscle sprain or rupture, compartment syndrome
    • Musculoskeletal - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, tenosynovitis
    • Skin / soft tissue infection - cellulitis, abscess, necrotizing fasciitis, gas gangrene
    • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
    • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition
    • Muscles Involved

    • Flexor carpi radialis, palmaris longus, flexor carpi ulnaris

    Pitting Oedema

    • How to Elicit

    • Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release.

    Contour

    Rapid rate of risePremature ventricular contraction, mitral regurg, VSD, aortic regurgitation, HOCM

    Venous Skin Changes

    • Look For

    • Oedema
    • Venous eczema
    • Hyperpigmentation
    • White scar tissue (atrophie blanche)
    • Induration - fibrosis of subcutaneous fat (lipodermatosclerosis)

    Overview

    Popliteal - bend the patient's knee to 90 degrees, gently grasp both sides of the knee joint and palpate using tips of fingers within the popliteal fossa posteriorly.

    Inspection of Pupils

    • Normal Pupillary Size

    • In the dark - 4-8mm
    • Under bright light - 2-4mm

    Rashes Associated with Diabetes

    Granuloma annulare: smooth, ring-like erythematous plaquesBenign, diabetes

    Overview

    • How to Perform

    • Dim the lights and examine the fundus using a traditional direct or PanOptic ophthalmoscope.
      • Normal Range

      • Serum folate: >9 nmol/L
      • Red cell folate: 360 - 1400 nmol/L
      • Normal Range

      • 150 - 750 pmol/L
    Caeruloplasmin is an acute phase reactant.
    As LDH is present in all tissues, its elevation is a nonspecific marker of cell damage. Elevation of specific LDH isoenzymes may point toward a specific pathology, as below.
    AST is found in the liver, cardiac muscle, skeletal muscle, kidneys, brain, pancreas, lungs, leukocytes and erythrocytes.
      • Normal Range

      • Total bilirubin - <1 mg/dL or <20 μmol/L
      • Direct (conjugated) bilirubin - <0.3 mg/dL or <7 μmol/L
      • Normal Range

      • 35 - 100 U/L
    AST is found in the liver, cardiac muscle, skeletal muscle, kidneys, brain, pancreas, lungs, leukocytes and erythrocytes.
    • Significance

    • PT/INR is often elevated in patients with significant liver disease.
      • Normal Range

      • Males: <50 U/L
      • Females: <30 U/L
      • Normal Range

      • 32 - 45 g/L
    • Mechanism

    • High-energy pelvic trauma.
    • Mechanism

    • Hyperflexion of the spine, often in car accidents with patients wearing a lap seatbelt without a shoulder strap.
    • Mechanism of Action

    • Inhibits intestinal absorption of cholesterol.
    •  
      Oral
      Lercanidipine
      Zanidip 
    •  
      Oral
      Bisoprolol
      Bicor 
       
      Used to treat stable heart failure only
    • Mechanism of Action

    • Inhibit sodium-chloride transporters in the distal convoluted tubule, resulting in reduced sodium and chloride reabsorption.
    •  
      Oral
      Bumetanide

    •  
      Oral / sublingual
      Isosorbide Dinitrate
      Isordil 
    •  
      Oral
      Diltiazem
      Cardizem 
       
      Less cardio depression than with verapamil
    • Mechanism of Action

    • Inhibits the action of acetylcholine on muscarinic receptors, resulting in reduced vagal (parasympathetic) stimulation of the heart.
    • Mechanism

    • Bind to and inhibit fast sodium channels responsible for rapid depolarisation during phase 0 of the cardiomyocyte action potential.
    •  
      IV / Oral
      Sotalol

    •  
      Oral
      Carvedilol
      Dilatrend 
       
      β1, β2 and α1 antagonist effects
    •  
      Oral
      Tamsulosin
      Flomaxtra 
       
      Preferred agent for urinary obstructive symptoms related to BPH
    • Mechanism of Action

    • A naturally ocurring purine nucleoside that supresses the sinoatrial node, shortens phase 2 of the cardiomyocyte action potential and supresses AV nodal conduction through effects on potassium and calcium currents.
    •  
      Oral
      Enalapril
      Renitec 
    •  
      Oral
      Diltiazem
      Cardizem 
       
      Less cardio depression than with verapamil
    • Mechanism of Action

    • Stimulates opening of ATP-dependant potassium channels in vascular smooth muscle, resulting in arterial dilatation and reduced afterload. Also has nitrate activity, resulting in venous dilatation and reduced preload.
    •  
      Oral / IV
      Procainamide

    • Mechanism of Action

    • Normalises serum magnesium concentrations in the case of hypomagnesaemia.
      Magnesium is involved in many physiologic processes including cardiac Na⁺ / K⁺ ATPase, and hypomagnesaemia can result in depolarisation and torsades de pointes.
    •  
      Oral
      Gemfibrozil
      Lopid 
    •  
      Oral
      Pravastatin
      Lipostat 
    •  
      Oral
      Bisoprolol
      Bicor 
       
      Used to treat stable heart failure only
    • Mechanism

    • Bind to and inhibit fast sodium channels responsible for rapid depolarisation during phase 0 of the cardiomyocyte action potential.
    • Mechanism of Action

    • Not completely known, though believed to have an effect at the distal convoluted tubule. Also thought to stimulate production of prostaglandin E2, resulting in vasodilation and decreased total peripheral resistance.
    •  
      Oral
      Irbesartan
      Avapro, Karvea 

    Cardiomyocyte Action Potentials

    • Cardiomyocyte Action Potentials

    Overview

    • Mechanism of Action

    • Inhibit the action of aldosterone on sodium-potassium exchange pumps in the distal convoluted tubule.
    • Mechanism of Action

    • Relaxes vascular smooth muscle (predominantly arterioles) through opening of potassium channels, resulting in reduced afterload.
      • Mechanism of Action

      • Inhibits mycobacterial membrane transporters, disrupting membrane potentials.
      • Mechanism of Action

      • Believed to inhibit the incorporation of mycolic acids into the mycobacterial cell wall.
      • Mechanism of Action

      • Inhibits dihydrofolate synthesis by competitively inhibiting dihydropteroate synthetase (DHPS).
      • Mechanism of Action

      • Inhibit bacterial RNA polymerase, resulting in disruption of DNA transcription.
      • Mechanism of Action

      • Inhibits lipid and nucleic acid biosynthesis through an unknown mechanism.
      •  
        Oral
        Aspirin + Dipyridamole
        Asasantin 
      • Mechanism of Action

      • A monoclonal antibody that strongly binds to dabigatran, preventing its effect on prothrombin.
      • Mechanism of Action

      • Repletes the body's stores of vitamin K, overcoming the effect of warfarin on its inhibition of the clotting cascade.
      •  
        IV
        Apheresis Plasma
        Blood is removed, plasma collected and blood returned to patient
      • Mechanism of Action

      • Activates plasminogen, resulting in its activation to plasmin and thus fibrinolysis.
      • Mechanism of Action

      • Inactivated recombinant factor Xa that strongly binds the factor Xa inhibitors apixaban and rivaroxaban, inactivating them and preventing their anticoagulant effect.
      Unfractionated heparin has a short half life, and is often used in an inpatient setting for rapidly titratable anticoagulation.
      •  
        Oral
        Rivaroxaban
        Xarelto 
      •  
        Subcut
        Dalteparin
        Fragmin 
      •  
        IV
        Reteplase
        Rapilysin 
      • Mechanism of Action

      • Blocks lysine binding sites on plasminogen, preventing its conversion to plasmin and thus preventing fibrinolysis.
      • Mechanism of Action

      • Binds to and inactivates heparin.
      Prothrombinex contains purified coagulation factors specifically prepared for the reversal of warfarin.
      • Mechanism of Action

      • Inhibits regeneration of vitamin K from vitamin K epoxide, resulting in reduced synthesis of clotting factors II, VII, IX and X, as well as proteins C and S.
      •  
        Oral
        Prasugrel
        Effient 
         
        A prodrug that requires enzymatic activation
      • Mechanism of Action

      • Reversibly inhibit factor IIa (thrombin), resulting in reduced fibrin clot formation.
      • Mechanism of Action

      • Inhibit cyclooxygenase, the enzyme responsible for production of thromboxanes, prostacyclin and prostaglandins from arachidonic acid.
      •  
        IV
        Eptifibatide
        Integrilin 
         
        Short half-life (2.5 hours) and effect (haemostasis 3-4 hours)
      • Mechanism of Action

      • A monoclonal antibody that targets CD20, a transmembrane protein on the surface of B cells, resulting in antibody-dependent and complement-dependent cytotoxicity.
      • Mechanism of Action

      • Contains a monoclonal antibody directed toward HER2 (trastuzumab), linked to a chemotherapeutic agent (DM1), allowing for targeted delivery of cytotoxic chemotherapy to HER2-positive tumour cells.
      • Trastuzumab inhibits HER2 signalling pathways resulting in cell cycle arrest, and also mediates antibody-dependent cell-mediated cytotoxicity.
      • DM1 is a cytotoxic agent that binds to tubulin, preventing polymerisation and resulting in cell cycle arrest in the G2/M phase.
      • Mechanism of Action

      • An IgG monoclonal antibody that binds to and inhibits RANK ligand, a cytokine normally responsible for stimulation of osteoclastic maturation and function.
      •  
        IV infusion
        Pertuzumab
        Inhibits ligand-dependent HER2 dimerisation and signalling
      • Mechanism of Action

      • Contains a monoclonal antibody directed toward CD-33, linked to a chemotherapeutic agent, allowing for targeted delivery of cytotoxic chemotherapy to CD33-positive cells.
      • The chemotherapeutic agent, N-acetyl gamma calicheamicin, is activated within targeted cells and induces double-standed DNA breaks.
      • Nomenclature

        Monoclonal antibodies are named based on a combination of the following:
      • Prefix - random
      • Substem A - based on the target
      • Substem B - based on the species of origin of the antibody
      • Stem - mab
      •  
        IV infusion
        Durvalumab
        Imfinzi 
      •  
        IV
        Panitumumab
        Vectibix 
      • Mechanism of Action

      • A humanized monoclonal antibody that binds to CD-52 receptors found on mature lymphocytes, initiating complement-mediated and antibody-dependent cell-mediated cytotoxicity.
      • Mechanism of Action

      • A monoclonal antibody against cytotoxic T-lymphocyte antigen 4 (CTLA-4), a T cell inhibitory molecule that binds to B7 and prevents its binding to CD28.
      • The B7 : CD28 complex normally potentiates the binding of T cell receptors to MHC/antigen complexes on antigen-presenting cells, stimulating T cell proliferation and differentiation.
      • CTLA-4 is expressed on the surface of T cells after activation, and provides inhibitory signalling to T cells by binding B7.
      • Binding to anti-CTLA-4 antibodies to CTLA-4 leaves B7 free to continue to bind to CD28 and provide ongoing T cell costimulation.
      •  
        IV infusion
        Pembrolizumab
        Keytruda 
      • Mechanism of Action

      • A humanised monoclonal antibody directed against vascular endothelial growth factor (VEGF), whose expression is up-regulated during angiogenesis in certain cancers. Binding to VEGF reduces tumour bloodflow by promoting breakdown of tumour vasculature and inhibiting new blood vessel growth.
      •  
        Oral
        Itraconazole
        Cover against years and moulds
      •  
        IV
        Liposomal Amphotericin B
        AmBisome 
         
        Lipid suspension results in binding directly to the fungal cell, resulting in low doses and significantly less toxicity
      •  
        IV
        Anidulafungin
        Eraxis 
         
        No liver metabolism - can be used in patients with liver failure
      •  
        Oral
        Exemestane

      •  
        Oral
        Enzalutamide
        Xtandi 
      • Mechanism of Action

      • Directly inhibit the binding of androgens to androgen receptors.
      • Mechanism of Action

      • Antagonise oestrogen receptors without agonist activity.
      • Mechanism of Action

      • Antagonise oestrogen receptors in breast tissue and agonise oestrogen receptors in endometrial tissue and bone.
      • Mechanism of Action

      • Inhibits 17-α hydroxylase / C17,20-lyase (CYP17) which is expressed in prostatic tumour tissue and is required for androgen synthesis.
      •  
        Subcut
        Leuprorelin / Leuprorelide
        Lucrin, Eligard 
      •  
        Inhaled
        Halothane
        Pleasant odour - preferred for paediatrics
      • Mechanism

      • Acts as a non-competitive antagonist at the NMDA receptor
      • Reduces presynaptic release of glutamate
      • Agonises α and β adrenoceptors
      • Agonises opioid σ receptors
      •  
        Local / Regional
        Lignocaine
        Xylocaine 
      •  
        IV
        Cisatracurium
        More potent isomer of atracurium
        Onset 3 minutes
        Duration 40 minutes
      Depolarising muscle relaxants such as suxamethonium are ultra short-acting medications that cause depolarisation of voltage-gated channels, resulting in muscle relaxation due to inability to further depolarise muscle cells.
      • Mechanism of Action

      • Augments the inhibitory action of GABA by decreasing the rate of dissociation of GABA from GABAA receptors.
      • Mechanism of Action

      • Bind to aldosterone receptors, resulting in sodium / water retention and potassium excretion through the kidneys, gut, salivary and sweat glands.
      • Mechanism of Action

      • Prevents utilization of iodine by the thyroid by inhibiting thyroperoxidase-catalysed iodination of tyrosine residues within the thyroid
      • Suspected to have immunosuppressive effects by affecting signaling pathways between thyroid cells and T cells.
      • Also inhibits conversion of T4 to T3.
      • Mechanism of Action

      • Synthetic 1,25-dihydroxy-vitamin D₃, which stimulates intestinal calcium / phosphate absorption and increased expression of RANK-ligand on osteoblast cell surfaces, resulting in a net increase in serum calcium and phosphate.
      •  
        Oral
        Rosiglitazone
        Avandia 
      Metformin is an oral hypoglycaemic of the biguanide class that reduces serum glucose without directly stimulating insulin secretion.
      •  
        Subcut
        Insulin Detemir
        Levemir 
      • Mechanism of Action

      • Synthetic parathyroid hormone (PTH). Continuous PTH administration primarily stimulates osteoclast differentiation, while intermittent PTH administration (daily teriparatide) primarily stimulates osteoblast differentiation.
      •  
        IV / Topical
        Hydrocortisone
        Cortef 
      • Mechanism of Action

      • Prevents utilization of iodine by the thyroid by inhibiting thyroperoxidase-catalysed iodination of tyrosine residues within the thyroid
      • Suspected to have immunosuppressive effects by affecting signaling pathways between thyroid cells and T cells.
      •  
        Subcut
        Exenatide
        Byetta (daily), Bydureon (weekly) 
      •  
        Oral
        Sitagliptin
        Januvia 
      •  
        Subcut / IV
        Insulin Lispro
        Humalog 
      • Mechanism of Action

      • Stimulates osteoblastic differentiation / activity, and inhibits osteoclastic differentiation / activity.
      Calcium carbonate is a calcium preparation used to treat hypocalcaemia and hyperphosphataemia.
      • Effects

      • Glucose

      • Increased glycogen synthesis
      • Reduced hepatic glycogenolysis (glycogen breakdown)
      • Reduced hepatic gluconeogenesis (glucose formation)
      • Increased GLUT-4 mediated glucose uptake into adipose tissue and skeletal muscle
      • Fat

      • Increased triglyceride synthesis
      • Reduced lipolysis
      • Protein

      • Increased amino acid uptake
      • Reduced protein breakdown
      • Potassium

      • Increased cellular potassium uptake
      •  
        Subcut
        Lispro + Isophane Insulin
        Humalog Mix25, Humalog Mix50
      Intermediate-acting insulins such as protaphane have a moderate onset of action and intermediate duration, making this medication a useful part of combination insulin preparations.
      •  
        Oral
        Dapagliflozin
        Forxiga 
      • Mechanism of Action

      • A selective oestrogen receptor modulator (SERM) that agonises oestrogen receptors in bone and antagonises oestrogen receptors in the breast and uterus. Prevents bone resorption and thus presents bone loss.
      • Mechanism of Action

      • An IgG monoclonal antibody that binds to and inhibits RANK ligand, a cytokine normally responsible for stimulation of osteoclastic maturation and function.
      • Mechanism of Action

      • Synthetic vitamin D₃, which stimulates intestinal calcium / phosphate absorption and increased expression of RANK-ligand on osteoblast cell surfaces, resulting in a net increase in serum calcium and phosphate.
      • Mechanism of Action

      • Synthetic T4 is converted to T3 that binds to nuclear thyroid hormone receptors, inducing alterations in gene transcription and subsequent effects on metabolism.
      Short-acting insulins such as actrapid have an incredibly rapid onset and short duration, meaning that they are useful for bolus dosing and insulin infusions.
      •  
        Oral
        Glimepiride
        Amaryl 
      •  
        IV
        Pamidronate
        Aredia 
         
        Used to treat lytic lesions / hypercalcaemia of malignancy
      •  
        Oral
        Rimantadine
        Flumadine 
      • Mechanism of Action

      • Inhibit HIV-1 protease, suppressing processing of viral polyproteins and preventing the formation of mature virions.
      •  
        Oral
        Raltegravir
        Isentress 
      • Mechanism of Action

      • Directly inhibit the pyrophosphate binding sites of viral DNA polymerase, resulting in premature DNA termination.
      •  
        Oral
        Emtricitabine

      • Mechanism of Action

      • Analogues of nucleotides that are incorporated into viral DNA by viral DNA polymerase, resulting in premature DNA termination.
      •  
        Oral
        Valaciclovir
        Prodrug of aciclovir, with 55% bioavailability
      • Mechanism of Action

      • Prevent viral reverse transcription of single-stranded RNA into double-stranded DNA, by inhibiting HIV reverse transcriptase.
      • Mechanism of Action

      • Analogues of deoxyribonucleotides. Prevent viral reverse transcription of single-stranded RNA into double-stranded DNA, by inhibiting HIV reverse transcriptase.
      • Mechanism of Action

      • Selectively inhibit viral neuroaminidase on the viral surface, preventing release of the virus from infected cells.
      •  
        Oral / IV
        Clonazepam
        Paxam, Rivotril 
         
        [Peak] 2-3 hours
        Half-life 18-50 hours
      • Mechanism of Action

      • Positively modulate GABAA receptors (BZ1 and BZ2), augmenting the inhibitory effects of the GABA neurotransmitter.
      •  
        Oral
        Escitalopram
        Lexapro 
      Midazolam is a short-acting benzodiazepine with a rapid onset and offset, making it useful for acute sedation and termination of seizures.
      • Mechanism of Action

      • Inhibit the action of noradrenaline on alpha-2 receptors, resulting in increased serotonin release.
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing propagation of action potentials and thus suppressing seizure activity. Also inhibits enzymes that breakdown GABA, resulting in increased GABA-mediated inhibition.
      •  
        IM
        Flupenthixol
        Depot - fortnightly / monthly dosing for schizophrenia
      • Mechanism of Action

      • Inhibits voltage-gated sodium channels, preventing the propagation of action potentials and thus suppressing seizure activity.
      •  
        Oral
        Doxepin
        Deptran 
      •  
        Oral
        Phenelzine
        Nardil 
      •  
        Oral / IM
        Aripiprazole
        Abilify 
         
        Partial agonist of D2 and 5-HT1A and antagonist of 5-HT2A receptors
      • Mechanism of Action

      • Modulates neurotransmission through complex effects on signal transduction mechanisms including  glycogen synthase kinase-3β, cyclic AMP-dependant kinase and protein kinase C.
      •  
        Oral
        Duloxetine
        Cymbalta 
         
        Primarily inhibits noradrenaline reuptake
      • Mechanism of Action

      • Inhibits the production of dihydrofolate reductase (DHFR), resulting in reduced conversion of dihydrofolic acid to active tetrahydrofolic acid - interfering with bacterial synthesis of nucleic acids.
      • Mechanism of Action

      • Trimethoprim inhibits the production of dihydrofolate reductase (DHFR), resulting in reduced conversion of dihydrofolic acid to active tetrahydrofolic acid - interfering with bacterial synthesis of nucleic acids.
      • Mechanism of Action

      • Broken down into its active form selectively by anaerobic and protozoal cells. Binds to and disrupts DNA, resulting in DNA degradation and cell death.
      •  
        Oral
        Dicloxacillin

      •  
        Oral
        Clarithromycin
        Biaxin 
      •  
        IV
        Teicoplanin
        Alternative to vancomycin if severe red man syndrome
      •  
        IV / IM
        Lincomycin

      • Mechanism of Action

      • Inhibit bacterial protein synthesis by preventing initiation of translation.
      •  
        IV
        Cefoxitin
        Useful against anaerobes
      • Mechanism of Action

      • Inhibit bacterial RNA polymerase, resulting in disruption of DNA transcription.
      •  
        IM
        Benzathine Penicillin
        Bicillin 
         
        Benzathine is a stabiliser - weekly / fortnightly dosing
      • Mechanism of Action

      • Beta lactam antibiotics, which inhibit bacterial cell wall synthesis.
      •  
        IV
        Ceftriaxone

      •  
        IV
        Piperacillin-Tazobactam
        PipTaz, Tazosin 
         
        Used for severe infections only
      • Mechanism of Action

      • Beta lactam antibiotics, which inhibit bacterial cell wall synthesis.
      •  
        IV
        Ampicillin

      • Mechanism of Action

      • Inhibit protein synthesis by binding to the 30s ribosomal subunit, resulting in inaccurate mRNA translation.
      •  
        Oral
        Norfloxacin
        Noroxin 

      Physiology

      • Absorption

      • Vitamin B12 is isolated from ingested food by the action of stomach acid. If then binds to transcobalamin-1, which is secreted into salivary and gastric fluid. In the alkaline small bowel transcobalamin-1 is degraded by pancreatic enzymes. Free B12 then binds to intrinsic factor, a protein secreated by gastric parietal cells. The intrinsic factor-B12 complex is then absorbed within the terminal ileum.

      Overview

      • Significance

      • Used as a test for Wilson's disease, in conjunction with serum copper concentration.
      • Causes of Elevated Lactate Dehydrogenase

      • Factitious (haemolysed sample)
      • Heart - myocardial infarction, heart failure
      • Brain - ischaemic stroke, traumatic brain injury
      • Kidneys - nephritis, nephrotic syndrome, acute tubular necrosis, infarction
      • Anaemia - haemolytic or megaloblastic
      • Malignancy (especially haematological)
      • Lungs - pulmonary embolism, infarction, obstructive disease, interstitial lung disease, pneumonia
      • Spleen - infarction
      • Pancreas - pancreatitis
      • Liver - hepatitis, infarction, cirrhosis, malignancy, trauma
      • Skeletal muscle - strenuous exercise, rhabdomyolysis, myositis
      • Shock
      • Trauma
      • Hypoxia
      ALT is found mainly in the liver, and is more specific for hepatocellular injury.
      • Significance

      • ALP is used as a marker of cholestasis, though may also be raised in the setting of certain non-hepatic conditions.
      ALT is found mainly in the liver, and is more specific for hepatocellular injury.
      Liver disease produces coagulopathy through multiple mechanisms including coagulation factor deficiencies, vitamin K deficiency (due to fat malabsorption), dysfibrinogenaemia, thrombocytopaenia and reduced platelet function.
      GGT is used as a marker of cholestasis, though may also be raised in the setting of certain other conditions, especially due to alcohol intake.
      Albumin has a plasma half-life of three weeks, meaning that its concentration changes very slowly in response to changes in synthesis.
      • Classification

      • A
        Transverse fracture below the level of the tibial plafondMost stable - ligaments intact
      • B
        Spiral fracture at the level of the distal tibiofibular jointLigaments may be disrupted
      • C
        Fracture above the level of the distal tibiofibular jointLeast stable - complete disruption of syndesmosis and tearing of anterior & posterior tibiofibular ligaments and interosseous membrane

      Clinical Use

      • Indication

      • Elevated low density lipoprotein (LDL).
      •  
        Oral
        Nifedipine
        Adalat 
      •  
        Oral / IV
        Metoprolol
        Betaloc, Minax, Lopressor 
      • Indications

      • Essential hypertension - first line therapy, in combination with an ACEi or ARB
      • Peripheral oedema - due to congestive cardiac failure / renal failure / nephrotic syndrome / cirrhosis

      Overview

      • Mechanism of Action

      • Inhibit the sodium-potassium-chloride cotransporters in the thick ascending limb of the loop of Henle, normally responsible for 25% of tubular sodium reabsorption. Inhibition results in increased excretion of sodium and, with it, water.
      •  
        Oral
        Isosorbide Mononitrate (ISMN)
        Imdur, Duride 
         
        Long-acting, to be used to control stable angina pectoris
      • Mechanism of Action

      • Non-selectively inhibit L-type calcium channels on ventricular myocardial, cardiac nodal and arteriolar smooth muscle cells.
      • Effects

      • Increased heart rate (positive chronotropy)
      • Increased electrical conduction (positive dromotropy)
      • Pharmacology

      • Act on cardiomyocytes, with no action on pacemaker cells whose phase 0 is mediated by calcium influx.
      • Mechanism of Action

      • Bind to and inhibit potassium channels responsible for repolarisation in phase 3 of the cardiomyocyte action potential, thus increasing the absolute refractory period (ARP).
      •  
        Oral / IV
        Labetalol
        Trandate 
         
        Useful for rapid BP lowering in acute hypertensive crisis
      • Mechanism of Action

      • Block α1-adrenoceptors, resulting in arteriolar smooth muscle relaxation and reduced peripheral resistance.

      Clinical Use

      • Indications

      • Acute management of paroxysmal supraventricular tachycardia
      • Diagnosis of supraventricular tachycardia
      •  
        Oral
        Lisinopril
        Zestril 

      Overview

      • Mechanism of Action

      • Inhibit L-type calcium channels on ventricular myocardial, cardiac nodal and arteriolar smooth muscle cells.

      Clinical Use

      • Indication

      • Stable angina pectoris.

      Overview

      • Mechanism

      • Bind to and inhibit fast sodium channels responsible for rapid depolarisation during phase 0 of the cardiomyocyte action potential.
      Also stimulates calcium delivery to the sarcoplasmic reticulum and competes with calcium for binding to troponin C, resulting in vasodilation and reduced contractility.
      • Mechanism of Action

        Alter gene transcription, resulting in various effects on lipid metabolism:
      • Fenofibrate - stimulates catabolism of lipoproteins, resulting in reduction of circulating triglyceride and cholesterol.
      • Gemofibrozil - increases faecal excretion of cholesterol and inhibits hepatic triglyceride production.
      •  
        Oral
        Rosuvastatin
        Crestor 
      •  
        Oral / IV
        Metoprolol
        Betaloc, Minax, Lopressor 
      • Pharmacology

      • Act on cardiomyocytes, with no action on pacemaker cells whose phase 0 is mediated by calcium influx.

      Clinical Use

      • Indication

      • First line therapy for hypertension, in combination with an ACEi or ARB.
      •  
        Oral
        Olmesartan
        Olmetec 

      Cardiomyocyte Action Potentials

      • Phases

      • 0
        Depolarisation - rapid sodium influx due to opening of fast sodium channels; reduced potassium effluxInhibited by sodium channel blockers (class I)
      • 1
        Fast repolarisation - potassium efflux due to opening of transient outward potassium channels
      • 2
        Plateau - calcium influx due to opening of voltage-gated calcium channels; potassium efflux due to closing of certain potassium channels
      • 3
        Repolarisation - greater potassium efflux due to opening of voltage-gated potassium channels; less calcium influx due to closing of calcium channels
      • 4
        Resting potential (~-90mV)- maintained by balancing potassium influx and efflux via the Na⁺/K⁺ -ATPase pump and the Na⁺/Ca²⁺ exchange pump.

      Overview

      • Pharmacology

      • Potassium-sparing.

      Clinical Use

      • Indications

      • Hypertensive crisis (IV)
      • Refractory hypertension (oral)

      Overview

      • Mechanism of Action

      • Inhibit Na⁺ / K⁺ ATPase, causing sodium influx which results in calcium influx through reduced action of the Na⁺ / Ca²⁺ exchange pump.

      Clinical Use

      • Indication

      • Treatment of tuberculosis.
      • Indications

      • Tuberculosis
      • Mycobacterium avium complex (MAC)
      • Indications

      • Leprosy
      • Dermatitis herpetiformis

      Overview

      • Microbiology

      • Active against gram positive bacteria and Mycobacterium species.
      • Indications

      • Prophylaxis of tuberculosis in those exposed to infected individuals
      • Treatment of tuberculosis
      • Mechanism of Action

      • Inhibits platelet cAMP-phosphodiesterase, preventing platelet aggregation. Also augments the platelet inhibitory effect of adenosine by preventing reuptake and degradation of adenosine by endothelial and red blood cells.

      Clinical Use

      • Indications

      • Reversal of dabigatran prior to emergency surgery
      • Reversal of dabigatran in the event of life-threatening or uncontrolled bleeding
      • Indications

      • Warfarin reversal - following bleed, due to high INR or before emergency surgery
      • Haemorrhage due to hypoprothrombinaemia
      • Vitamin K deficiency
      •  
        IV
        IgA-Deficient Plasma
        Tested for IgA, for use in IgA-deficient patients who may have developed anti-IgA antibodies.
      • Indication

      • Pulmonary embolism with haemodynamic compromise, or massive pulmonary embolism.

      Overview

      • Pharmacology

      • Recurrence of anticoagulation may occur following the end of the infusion.
      • Mechanism of Action

      • Binds to and activates antithrombin III, which as a heparin-ATIII complex inactivates factors IIa (thrombin) and Xa.
      • Mechanism of Action

      • Directly inhibit factor Xa, resulting in reduced clot formation.
      • Mechanism of Action

      • Bind to and activate antithrombin III, which as heparin-ATIII complexes inactivate factors Xa and IIa.
      •  
        IV
        Tenecteplase
        Metalyse 

      Clinical Use

      • Indications

      • Reduction in blood loss post total hip / knee arthroplasty
      • Menorrhagia

      Overview

      • Pharmacology

      • 1mg of protamine sulfate is expected to neutralize 100 units of heparin, though smaller doses should be given depending on time elapsed since heparin administration.
      • Composition

      • Factor II
      • Factor IX
      • Factor X
      • Factor VII (small amount)
      • Heparin + antithrombin III
      • Additives - sodium, phosphate, citrate, chloride
      • Pharmacology

      • Delayed onset and initial procoagulant effect - bridging heparin / clexane should be used until warfarin is therapeutic.
      •  
        Oral
        Ticagrelor
        Brilinta 
         
        Directly inhibits P2Y12 receptors, and does not require enzymatic activation.

      Clinical Use

      • Indications

      • Prevention of venous thromboembolism post hip / knee surgery
      • Treatment of venous thromboembolism (DVT / PE)
      • Non-valvular atrial fibrillation (prevention of stroke)

      Overview

      • Pharmacology

      • Bind irreversibly to COX, unlike other NSAIDs. Though COX can resynthesize in minutes, platelets (which lack a nucleus) cannot create new COX and thus new platelets need to be produced, which can take up to a week. As a result aspirin is the only NSAID that significantly inhibits platelets and thus is also used for cardiovascular protection.
      •  
        IV
        Tirofiban
        Aggrastat 
         
        Short half-life (2 hours) and effect (haemostasis 4 hours)

      Clinical Use

      • Indications

      • Chronic lymphocytic leukaemia (CLL)
      • Non-Hodgkin's lymphoma (NHL)
      • Rheumatoid arthritis
      • Granulomatosis with polyangiitis (GPA)
      • Microscopic polyangiitis (MPA)
      • Indication

      • HER2-positive metastatic breast cancer refractory to trastuzumab.
      • Indications

      • Osteoporosis in men and postmenopausal women
      • Increased risk of fracture due to long-term corticosteroids
      • Bone metastases from solid organ malignancies
      • Hypercalcaemia of malignancy (refractory to bisphosphonates)

      Overview

      • Mechanism of Action

      • Monoclonal antibodies directed against the HER2 receptor, which is involved in cell signalling and is overexpressed in certain cancers. Inhibition of HER2 signalling pathways results in cell cycle arrest; the monoclonal antibody also mediates antibody-dependent cell-mediated cytotoxicity.

      Clinical Use

      • Indication

      • CD33 positive acute myeloid leukaemia.

      Substem A (Target)

      -b(a)-: bacterial (e.g. raxibacumab)
      •  
        IV infusion
        Avelumab
        Bavencio 

      Overview

      • Mechanism of Action

      • Monoclonal antibodies directed against epidermal growth factor receptor (EGFR / HER1), which is involved in cell signalling and is overexpressed in certain cancers. Inhibition of EGFR signalling pathways results in cell cycle arrest.

      Clinical Use

      • Indications

      • B cell chronic lymphocytic leukaemia (CLL)
      • Relapsing multiple sclerosis (MS)

      Overview

      • Mechanism of Action

      • Monoclonal antibodies directed against programmed cell death protein 1 (PD-1), a surface co-inhibitory receptor on circulating activated T cells, B cells and NK cells.
      • PD-1 binds to two ligands (PD-L1 and PD-L2) and inhibit T cell receptor signalling, downregulating immune responses and promoting tolerance.
      • Many tumours express or overexpress PD-L1.
      • Binding of anti-PD1 monoclonal antibodies to PD-1 leaves the ligand unable to bind, and therefore stimulates an ongoing immune response.

      Clinical Use

      • Indications

      • Metastatic colorectal cancer
      • Locally recurrent or metastatic breast cancer
      • Advanced, metastatic or recurrent non-squamous non-small cell lung cancer (NSCLC)
      • Advanced or metastatic renal cancer
      • Metastatic or unresectable melanoma
      • Epithelial ovarian, fallopian tube or primary peritoneal cancer
      • Recurrent or metastatic cervical cancer
      • Grade IV glioma
      •  
        Oral / IV
        Voriconazole
        Vfend 
         
        Activity against moulds, including Aspergillus
      •  
        IV
        Amphotericin B Lipid Complex
        Abelcet 
         
        Less toxicity due to direct fungal cell binding

      Overview

      • Mechanism of Action

      • Inhibit synthesis of beta (1,3)-D-glucan, an essential component of the fungal / yeast cell wall.
      •  
        Oral
        Letrozole

      •  
        Oral
        Flutamide

      • Pharmacology

      • Interact with androgen receptors as well as progestin and glucocorticoid receptors, resulting in associated side effects.

      Clinical Use

      • Indication

      • Hormone receptor positive, locally advanced or metastatic breast cancer that does not respond to tamoxifen.
      • Indication

      • Endocrine therapy for ER positive breast cancer.
      • Indication

      • Metastatic prostate cancer.

      Overview

      • Mechanism of Action

      • Analogues of gonadotropin-releasing hormone that suppress release of FSH and LH , resulting in chemical castration.
      •  
        Inhaled
        Isoflurane
        Pungent, rarely used for induction
      • Effects

      • Analgesia
      • Anaesthesia
      • Amnesia
      •  
        Local / Regional / Epidural
        Ropivacaine
        Naropin 
      •  
        IV
        Pancuronium
        Onset 4 minutes
        Duration 60 minutes
      • Mechanism of Action

      • Composed of two acetylcholine molecules joined at the acetate methyl group.
      • Bind to nicotinic receptors, resulting in depolarization with opening of voltage-gated channels and muscle contraction. Voltage-gated sodium channels then close and are inactivated, while the membrane remains depolarized.
      • Suxamethonium is not metabolized by acetylcholinesterase and therefore membrane depolarization is prolonged, resulting in prolonged inactivation of sodium channels and muscle relaxation.
      • As the membrane remains depolarized, no further acetylcholine molecules are able to produce further depolarization.
      • Pharmacology

      • Highly lipophilic with slight water solubility, therefore formulated as a milky-white emulsion.
      • Three-compartment model of elimination
      • Onset <60 seconds
      • Duration 5 minutes

      Clinical Use

      • Indications

      • Adrenal insufficiency - Addison's, congenital adrenal hypoplasia
      • Orthostatic hypotension due to autonomic failure
      • Indication

      • Hyperthyroidism, either as a sole agent or prior to surgery / radioiodine.

      Overview

      • Pharmacology

      • Significantly more potent than cholecalciferol.
      • Mechanism of Action

      • Activate peroxisome proliferator-activated receptor (PPAR), nuclear receptors that regulate transcription of certain genes involved in glucose and lipid metabolism.
      • Mechanism of Action

      • Inhibits hepatic gluconeogenesis
      • Reduces intestinal absorption of glucose
      • Stimulates peripheral glucose uptake
      Long-acting insulins such as lantus, toujeo and levemir have a moderate onset of action and long duration, making them ideal for basal dosing.

      Clinical Use

      • Indication

      • Severe post-menopausal osteoporosis or osteoporosis in males, that is refractory to other medications.

      Overview

      Glucocorticoids such as hydrocortisone and prednisolone are used to replace deficient endogenous steroid in the context of adrenocortical insufficiency.

      Clinical Use

      • Indication

      • Hyperthyroidism, either as a sole agent or prior to surgery / radioiodine.

      Overview

      • Mechanism of Action

      • Directly agonise GLP-1 receptors, resulting in glucose-dependant insulin secretion.
      •  
        Oral
        Vildagliptin
        Galvus 
         
        Reduce dose in renal insufficiency
      Very short-acting insulins such as novorapid and humalog have a rapid onset and short duration, making them ideal for bolus dosing.

      Clinical Use

      • Indication

      • Severe post-menopausal osteoporosis or osteoporosis in males, that is refractory to other medications.
      • Indications

      • Hypocalcaemia
      • Hyperphosphataemia
      • Prevention and treatment of osteoporosis

      Overview

      • Pharmacology

      • Varied formulations of insulin are created through substitution of amino acids within the dual-chained insulin molecule.
      •  
        Subcut
        Aspart + Isophane Insulin
        NovoMix 
         
        Onset 10-20 minutes
        Peak effect 1-4 hours
        Duration 24 hours
      • Mechanism of Action

      • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.
      • Mechanism of Action

      • Inhibit sodium-glucose co-transporter 2 (SGLT2) in the proximal tubules, resulting in reduced glucose reabsorption and glycosuria.

      Clinical Use

      • Indication

      • Post-menopausal osteoporosis.
      • Indications

      • Osteoporosis in men and postmenopausal women
      • Increased risk of fracture due to long-term corticosteroids
      • Bone metastases from solid organ malignancies
      • Hypercalcaemia of malignancy (refractory to bisphosphonates)
      • Indications

      • Vitamin D deficiency
      • Prevention and treatment of osteoporosis
      • Indications

      • Hypothyroidism
      • TSH-responsive thyroid tumours
      • Myxoedema coma

      Overview

      • Mechanism of Action

      • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.
      •  
        Oral
        Glipizide
        Melizide 
      •  
        Oral
        Risedronate
        Actonel 
         
        Daily, weekly or monthly dosing
      • Mechanism of Action

      • Inhibit the ion channel function of M2 proteins on the viral membrane, preventing uncoating and disassembly of the virus once it enters cells.

      Clinical Use

      • Indication

      • HIV-1 infection.

      Overview

      • Mechanism of Action

      • Inhibit HIV integrase, preventing the integration of viral genetic material into the DNA of infected cells.
      • Microbiology

      • Broad spectrum of activity against HSV1/2, VZV, CMV, hepatitis B and HIV.
      •  
        Oral
        Entecavir

      • Microbiology

      • Active against cytomegalovirus (CMV).
      •  
        Oral
        Famciclovir
        77% bioavailability
      Directly inhibit reverse transcriptase, and thus do not require intracellular metabolism in order to be active.

      Clinical Use

      • Indication

      • HIV infection.

      Overview

      • Microbiology

      • Active against influenza A and B.
      •  
        Oral
        Flunitrazepam
        Hypnodorm, Rohypnol 
         
        Used only for severe insomnia
        [Peak] 1-2 hours
        Half-life 20-30 hours
      • Effects

      • BZ1 receptor (cortex, thalamus, cerebellum) - sedation, anterograde amnesia, anticonvulsant
      • BZ2 receptor (limbic system, motor neurons) - anxiolysis, muscle relaxation
      •  
        Oral
        Fluoxetine
        Prozac, Lovan 
      • Mechanism of Action

      • Positively modulate GABAA receptors (BZ1 and BZ2), augmenting the inhibitory effects of the GABA neurotransmitter.

      Clinical Use

      • Indication

      • Depression.

      Overview

      Effective against absence seizures due to inhibition of T-type calcium channels in the thalamus.
      •  
        Oral / IM / IV
        Haloperidol
        Haldol, Serenace 

      Clinical Use

      • Indications

      • Partial (focal) seizures
      • Acute mania
      • Trigeminal neuralgia

      Overview

      • Mechanism of Action

      • Block presynaptic reuptake of serotonin (5-HT) and noradrenaline (NA) through an unknown mechanism.
      • Mechanism of Action

      • Inhibit the activity of monoamine oxidase, responsible for breakdown of monoamines. Inhibition results in increased synaptic noradrenaline, dopamine and serotonin.
      •  
        Oral
        Clozapine
        Clopine, Clozaril 
         
        5-HT2A and D4 receptor blocker, with weak D2 receptor antagonism
        Used for treatment-resistant schizophrenia

        Causes myocarditis / myopathy, agranulocytosis

      Clinical Use

      • Indications

      • Acute mania
      • Maintenance (prophylaxis) of bipolar disorder
      •  
        Oral
        Venlafaxine
        Effexor 

      Overview

      • Microbiology

      • Active against most GI normal flora, the most common cause of UTI.
      Sulfamethoxazole inhibits the production of dihydrofolate from para-aminobenzoic acid.
      • Microbiology

      • Good anaerobic cover (e.g. Clostridium spp, Bacteroides fragilis), with additional activity against protozoa such as Trichomonas vagilanis, Giardia lamblia and Entamoeba histolytica.
      Flucloxacillin and dicloxacillin are more active against Staphylococcus species than other penicillins.
      •  
        Oral
        Erythromycin
        Erythrocin 
         
        Diarrhoea is a significant side effect
      • Mechanism of Action

      • Inhibit bacterial cell wall peptidoglycan synthesis.
      • Mechanism of Action

      • Inhibit protein synthesis by binding to the 50s ribosomal subunit, resulting in inaccurate mRNA translation.
      • Microbiology

      • Effective against multi-resistant gram positive organisms, including MRSA, VRE and vancomycin-resistant Staph aureus.
      • Mechanism of Action

      • Beta lactam antibiotics, which inhibit bacterial cell wall synthesis.
      • Resistance

      • Rapid resistance when used alone, therefore often given in combination with other antimicrobials.
      •  
        Oral
        Phenoxymethylpenicillin

      • Resistance

      • Broken down by beta lactamase enzymes produced by some bacteria.
      •  
        IV
        Ceftazidime
        Fortaz 
         
        Can be used against Pseudomonas aeruginosa
      •  
        IV
        Ticarcillin-Clavulanate
        Timentin 
         
        Used for severe infections only
      • Resistance

      • Broken down by beta lactamase enzymes produced by some bacteria.
      • Mechanism of Action

      • Beta lactam antibiotics that inhibit bacterial cell wall synthesis.
      • Microbiology

      • Broad range of activity against gram positives, gram negatives, atypical respiratory organisms (Legionella, Chlamydia, Mycoplasma), rickettsia and some spirochaetes
      •  
        Oral / IV
        Moxifloxacin
        Avelox 
         
        Useful for pneumonia in patients with severe penicillin / cephalosporin allergy, due to Staph and atypical cover
      • Mechanism of Action

      • Unknown.
      • Pharmacology

      • Must be taken the same time every day.
      • Microbiology

      • Widespread resistance, therefore rarely used in many countries.

      Clinical Use

      • Indication

      • Plasmodium falciparum infection.

      Overview

      • Microbiology

      • Good anaerobic cover, with additional activity against protozoa.
      • Pharmacology

      • Serum half-life 8 hours
      • Renal excretion - caution in combination with NSAIDs
      •  
        IV
        Mitomycin
        Activity is not cell-cycle specific
      • Mechanism of Action

      • A prodrug that is metabolized by the liver into phosphoramide mustard. This active metabolite shares nitrogen atoms between guanine residues in DNA, creating intrastrand and interstrand DNA crosslinks. Disruption of DNA results in cytotoxicity.
      •  
        IV
        Gemcitabine

      Clinical Use

      • Indications

      • Certain solid organ and haematologic organ malignancies, as guided by cancer specialists and local guidelines
      • Multiple sclerosis

      Clinical Use

      • Indications

      • Certain haematologic organ malignancies, as guided by cancer specialists and local guidelines.

      Overview

      • Mechanism of Action

      • Inhibit thymidylate synthase, resulting in reduced production of dTMP and reduced DNA synthesis.

      Clinical Use

      • Indications

      • Certain solid organ and haematologic organ malignancies, as guided by cancer specialists and local guidelines.
      •  
        IV
        Oxaliplatin

      Overview

      • Mechanism of Action

      • Inhibit cell proliferation by preventing polymerization of tubulin into microtubules.

      Clinical Use

      • Indications

      • Certain solid organ organ malignancies, as guided by cancer specialists and local guidelines.

      Overview

      • Mechanism of Action

      • Create DNA adducts that cause base-base mismatches and DNA instability.
      • Mechanism of Action

      • Prevent cellular proliferation by binding to the beta unit of tubulin and inhibiting microtubule polymerization.
      •  
        IV
        Epirubicin

      Clinical Use

      • Indications

      • Certain solid organ and haematologic organ malignancies, as guided by cancer specialists and local guidelines.

      Troubleshooting

      Bright red blood that is pulsating out (arterial sample) - remove the needle and place pressure for at least 3 minutes

      Overview

      Peak levels - find out the optimal time to take the sample

      Choosing the Right Limb

      • Do

      • Use the nondominant arm if possible
      • Try to use the AC fossa where possible

      Overview

      • Prevention

      • Insert the needle into the vein the first time
      • Avoid multiple attempts at the same site
      • Apply pressure to the site on removal of the needle
      Always remember to release the tourniquet when leaving a patient's bedside, as very prolonged tourniquet application can result in significant complications.

      Nasal Prongs

      Low flow nasal prongs deliver 100% oxygen at a low flow rate, which is then entrained with room air. Nasal prongs are comfortable and allow the patient to eat, however at flow rates higher than 4 L/min can cause drying of the nasal cavity.

      CPAP

      • Indications for CPAP

      • Obstructive sleep apnoea
      • Acute pulmonary oedema

      Overview

      These systems are used acutely in severely hypoxic patients. They should not be used for more than a few hours as they do not supply humidified air and can cause dehydration of the upper airway.
      • Basic Summary of Common Ventilation Modes

      • Volume Control

      • Continuous mandatory ventilation (CMV) - the ventilator delivers a set number of breaths per minute at a set volume; the patient cannot trigger breaths
      • Volume Assist / Control - the ventilator delivers a set number of breaths per minute at a set volume; the patient can trigger assisted breaths at the same tidal volume
      • Pressure Control

      • Continuous Positive Airway Pressure (CPAP) - the ventilator delivers a set positive pressure (PEEP), with no additional inspiratory pressure
      • Pressure support (PS) - the ventilator supports the patient's spontaneous breaths with a set positive inspiratory pressure, with or without positive end expiratory pressure (PEEP)
      • Pressure Assist / Control - the ventilator delivers a set number of breaths per minute at a set inspiratory pressure; the patient can trigger assisted breaths at the same pressure
      • Other

      • Syncronised Intermittent Mandatory Ventilation (SIMV) - the ventilator waits for the patient to breath, and supports each breath with set volume or pressure. If the patient does not breath within a set timing window, the ventilator delivers a mandatory supported breath
      Supplemental oxygen is not indicated for patients with breathlessness.

      Troubleshooting

      Unable to advance the guidewire - withdraw the guidewire and make sure that there is flashback of blood. If there is, then gently try to advance the guidewire further. If the guidewire continues to meet resistance then withdraw and start again.
      Unable to advance the guidewire - withdraw the guidewire and make sure that there is flashback of blood. If there is, then gently try to advance the guidewire further. If the guidewire continues to meet resistance then withdraw and start again.

      Overview

      • Prevention

      • Avoid a limb with peripheral vascular disease
      • Perform Allen's test before placing the cannula
      • Reconsider need for arterial line
      • Prevention

      • Proper aseptic technique
      • Don't insert a cannula through infected tissue
      • Don't leave the line in for too long
      • Management

      • Check for kinks, and remove the cannula if unable to flush.
      • Treatment

      • Compress the site for 3-5 minutes
      • Place a compression bandage
      • Observe the site
      • Consider reversing anticoagulation if bleeding is major

      Tips for Identifying an Artery

      • Do

      • Try to use the radial artery if possible
      • Perform Allen's test prior to inserting the needle

      Overview

      Brachial - ask the patient to place their arm outward as far as possible with the antecubital fossa easily accessible
      Brachial- ask the patient to place their arm outward as far as possible with the antecubital fossa easily accessible
      • Treatment

      • Compress the site for 3-5 minutes
      • Place a compression bandage
      • Observe the site
      • Consider reversing anticoagulation if bleeding is major
      • Prevention

      • Avoid a limb with peripheral vascular disease
      • Perform Allen's test before inserting the needle
      • Reconsider need for the ABG

      Tips for Identifying an Artery

      • Do

      • Try to use the radial artery if possible
      • Perform Allen's test prior to inserting the needle

      Catheter Sizing

      • Types of Catheters

      • Straight, single lumen - for collection of urinary specimens
      • Double lumen (with balloon) - most patients
      • Triple lumen - continuous irrigation for patients with clots or haematuria or post urologic surgery

      Use of Catheters

      • Contraindications

      • Urethral trauma - e.g. due to pelvic fracture
      • Urethral stricture
      • Recent urologic surgery (men) - discuss with a urologist first
      • Contraindications

      • Urethral trauma - e.g. due to pelvic fracture
      • Urethral stricture
      • Recent urologic surgery (men) - discuss with a urologist first

      Catheter-Associated UTI

      • Pathogenesis of Catheter-Associated UTI

      • The catheter acts as a bridge for ascension of bacteria into the bladder
      • Residual bladder volume increases risk of infection
      • Risk of biofilm creation

      Overview

      Right subclavian: 14 - 16cm(Height / 10) - 2
      Femoral - identify the vein using ultrasound. Place the probe in the groin over the femoral triangle, below the inguinal ligament. Look for a large-bore, non-pulsating, collapsible vessel medial to the femoral artery.

      Confirming Venous Placement

      Manometry - attach the needle to a transducer system to determine intraluminal pressure.

      Overview

      • Treatment

      • Compress the site for 1-2 minutes
      • Place a compression bandage
      • Observe the site
      • Consider reversing anticoagulation if bleeding is major
      • Management

      • Watch for signs and symptoms for early diagnosis
      • Ultrasound to confirm thrombosis
      • Remove the CVC
      • Look for signs and symptoms of pulmonary embolism
      • Commence anticoagulation as apppropriate
      Femoral - identify the vein using ultrasound. Place the probe in the groin over the femoral triangle, below the inguinal ligament. Look for a large-bore, non-pulsating, collapsible vessel medial to the femoral artery.

      Internal Jugular Vein

      • Look

      • Between the two heads of the sternocleidomastoid muscle - ask the patient to turn their head.

      Overview

      Bright red blood that is pulsating out (arterial sample) - remove the needle and apply pressure for at least 3 minutes
      • Management

      • Under sterile conditions, withdraw the CVC into the superior vena cava as measured on chest x-ray, and then resuture the line.
      • Prevention

      • Proper aseptic technique
      • Don't insert a needle through infected tissue
      • Don't leave the line in for too long

      Types of NG Tube

      Salum sump - large bore (14-18Fr) dual lumen tubes that can be used for feeding and can be aspirated. Have a distal hole and a side hole

      Confirming NG Placement

      Chest x-ray - ensure that the distal tip and side hole are below the diaphgram.

      Avoiding Incorrect NG Placement

      Tracheobronchial - withdraw the NG if the patient starts excessively gagging or coughing.

      Difficult NG Insertion

      Some pressure may be required to advance the tube against mild resistance, but do not keep pushing the tube against significant resistance.

      Overview

      • Prevention

      • Use an atraumatic needle rather than a cutting (bevelled) needle
      • Use the smallest bore needle possible
      • Reinsert the stylet prior to removing the needle
      Intrathecal injection of anaesthesia, chemotherapy or other medications
      Suspected raised intracranial pressure is an emergency that should be treated immediately.

      Measuring Opening Pressure

      The opening pressure is indicated by the level that the fluid reaches in the manometer fluid.

      Jugular Placement

      • Management

      • Remove the PICC.

      Overview

      • Management

      • Watch for signs and symptoms for early diagnosis
      • Ultrasound to confirm thrombosis
      • Remove the PICC
      • Look for signs and symptoms of pulmonary embolism
      • Commence anticoagulation as apppropriate

      Troubleshooting

      Bright red blood that is pulsating out (arterial sample) - remove the needle and apply pressure for at least 3 minutes

      Overview

      • Prevention

      • Regular flushing of the line
      • Regular checks to ensure the line is not kinked

      Tips for Finding a Vein

      • Don't

      • Absolutely do not use the same arm as an AV fistula
      • Don't use the same arm as a past lymph node dissection or mastectomy
      • Don't insert a PICC on the same side as a pacemaker
      • Don't use a limb affected by stroke
      • Don't insert a needle through a burn, oedema or infected tissue
      • Don't use a limb that has a DVT

      Overview

      • Treatment

      • Compress the site
      • Place a compression bandage
      • Observe the site
      • Consider reversing anticoagulation if bleeding is major
      • Prevention

      • Proper aseptic technique on insertion and accessing the line
      • Don't insert a PICC through infected tissue
      • Don't leave the line in for too long
      • Prevention

      • Proper aseptic technique
      • Don't insert a cannula through infected tissue
      • Don't leave the line in for too long
      • Prevention

      • Insert the cannula properly
      • Apply pressure to the site on removal of the cannula
      • Management

      • Stop the infusion
      • Remove the cannula
      • Elevate the arm
      • Management

      • Check for kinks, and remove the cannula if unable to flush
      Wash your hands.
      • Management

      • Stop any infusions
      • Remove the cannula

      Troubleshooting

      Bright red blood that is pulsating out (arterial sample) - remove the needle and apply pressure for at least 3 minutes

      Overview

      20 - everyday use, fluids, antibiotics, analgesia

      Potential Cannula Sites

      Basilic vein (medial) in the forearm large vein, doesn't limit movement, more difficult to access due to positioning

      Choosing the Right Site

      • Don't

      • Don't inject through burns, infections or oedema
      • Don't inject through moles or other skin lesions
      • Avoid the dorsogluteal site in obese patients as subcutaneous injection is likely

      Lignocaine

      Higher concentrations don't improve anaesthetic and increase risk of toxicity.

      Intubation

      If the patient requires intubation, this should be performed by a highly trained member of staff with appropriate planning, monitoring and pre-medication.

      Overview

      • Pearls

      • Use suction to clear the oral cavity of fluid or foreign body
      • If there is concern for c-spine fracture, jaw thrust should be used
      • Otherwise, head tilt and chin lift may be used in an attempt to open the airway

      Oropharyngeal Airway

      • Sizing an Oropharyngeal Airway

      • Measure the airway from the angle of the mandible to the maxillary incisors.

      Diagnosis

      • ECG Findings

      • Left axis deviation -45° to -90° in the absence of other causes
      • Normal QRS duration <120ms
      • qR pattern in aVL: small Q wave with large R wave
      • Long R peak time (time from start of QRS to peak of R) >45ms in aVL

      Overview

      Myelodysplasia may also occur due to secondary causes which may be reversible.

      Pathogenesis

      Digoxin inhibits the Na+/K+ ATPase pump, which results in sodium influx and potassium efflux. This subsequently increases the activity of the Na+/Ca2+ exchange pump, resulting in calcium influx which increases automaticity and has a positive inotropic effect (increases contractility). Digoxin also increases parasympathetic (vagal) tone, causing reduced conduction through the AV node.

      Hormonal Changes

      • Hormonal Changes

      Manifestations

      • Associated Lab Abnormalities

      • Hypokalaemia
      • Hypocalcaemia

      Diagnosis

      • Chest X-Ray Findings

      • Pulmonary opacification
      • Air bronchograms - tubular outlines of the smaller airways
      • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
      • Evidence of Volume Loss

      • Crowding of pulmonary vessels
      • Underinflation
      • Hemidiaphragmatic elevation
      • Tracheal deviation toward the area of atelectasis
      • Mediastinal shift toward the area of atelectasis
      • Hilar displacement
      • Signs of Motor Neurone Disease

      • Bulbar palsy (LMN) - nasal speech, absent gag reflex, tongue wasting and fasciculations, absent palate rise, absent (i.e. normal) jaw jerk
      • Pseudobulbar palsy (UMN) - dysarthria, increased / normal gag reflex, tongue spasticity, absent palate rise, increased jaw jerk
      • Upper motor neuron signs - increased tone, clonus, reduced power, hyperreflexia, upgoing plantar reflex
      • Lower motor neuron signs - muscle wasting, fasciculations, reduced tone, reduced power, hyporeflexia, downgoing plantar reflex

      Manifestations

      • Complications of Bronchiectasis

      • Acute exacerbations
      • Pulmonary haemorrhage
      • Pneumothorax
      • Empyema
      • Lung abscess
      • Cor pulmonale

      Diagnosis

      • Signs of Hypertrophic Cardiomyopathy

      • Peripheral Signs

      • Double carotid impulse
      • Prominent a waves within the jugular venous pulsation
      • Central Signs

      • Double apical impulse
      • Paradoxical splitting of the second heart sound (S2): single S2 during inspiration and split S2 during expiration
      • Presence of a fourth heart sound (S4)
      • Late systolic murmur (LV outflow tract obstruction) that increases with valsalva manoeuvre and decreases with squatting
      • Pansystolic murmur loudest at the apex (mitral regurgitation)
      • ECG Findings

      • Irregular, rapid, chaotic electrical activity without P waves, QRS complexes or T waves.
      • ECG Findings

      • Narrow complex tachycardia
      • Regular ventricular rhythm
      • Abnormal P wave morphology (e.g. inverted or biphasic) that is consistent
      • An isoelectric baseline (to differentiate from atrial fibrillation or flutter)

      Manifestations

      • Complications of Marfan Syndrome

      • Cardiovascular

      • Dilatation of the proximal aorta
      • Aortic root dissection
      • Mitral valve prolapse
      • Ocular

      • Ectopia lentis: lens displacement (pathognomonic)
      • Myopia: nearsightedness
      • Musculoskeletal

      • Protrusio acetabuli: displacement of the medial aspect of the femoral head beyond the ilio-ischial line
      • Other

      • Pneumothorax
      • Dural ectasia: ballooning of the dura in the spine resulting in enlargement of the neural canal

      Pathogenesis

      Dietary deficiency is rare as a cause of B12 deficiency.
      • Potential Precipitants of Seizures

      • Sleep deprivation
      • Fatigue
      • Fasting
      • Drugs
      • Alcohol
      • Flashing lights
      • Fever
      • Stress
      • Menstruation
      • Missed antiepileptic dosing

      Diagnosis

      • Clinical Signs

      • Oxygen requirement - reduced SpO2, oxygen delivery
      • Dull percussion note
      • Reduced tactile fremitus
      • Reduced breath sounds
      • Reduced vocal resonance

      Overview

      Hepatitis A IgG develops later and persists for a long period of time, and its presence is indicative of vaccination or past infection.

      Pathogenesis

      Dietary deficiency is rare as a cause of B12 deficiency.

      Manifestations

      • Clinical Features

      • Thirst
      • Lethargy
      • Weakness
      • Confusion
      • Seizures
      • Coma

      Pathogenesis

      • Causes of Respiratory Alkalosis

        Any process that causes hyperventilation.
      • Hypoxia
      • Anxiety
      • Pain
      • Intracranial pathology
      • Pregnancy

      Diagnosis

      • Bloods

      • Serum phosphate >1.5 mmol/L.

      Manifestations

      • Complications of Down Syndrome

      • Cardiovascular: At Birth

      • Atrioventricular (AV) septal defects
      • Ventricular septal defect
      • Atrial (secundum) septal defect
      • Persistent ductus arteriosus
      • Tetralogy of Fallot
      • Cardiovascular: In Adolescence

      • Mitral valve prolapse
      • Aortic regurgitation
      • Other

      • Developmental Delay

      Pathogenesis

      In orthodromic AVRT, a premature atrial impulse is conducted by the AV node and then is propagated retrogradely up the abnormal accessory pathway, commencing a re-rentry circuit.
      Physiologic and autonomic causes of AV block tend to result in first degree or Mobitz I heart block, while pathologic causes tend to result in Mobitz II, advanced second degree or complete heart block.

      Complications

      • Complications of Non-Alcoholic Fatty Liver Disease

      • Cirrhosis
      • Cardiovascular disease
      • Type 2 diabetes mellitus
      • Chronic kidney disease
      • Colorectal cancer

      Pathogenesis

      • Causes of Peptic Ulcer Disease

      • Helicobacter pylori infection
      • Medications - NSAIDs, steroids, bisphosphonates, chemotherapy
      • Zollinger-Ellison syndrome
      • Gastric malignancy
      • Acute illness

      Manifestations

      • Clinical Features

      • Weakness
      • Hypotonicity
      • Depression
      • Constipation
      • Ileus

      Overview

      Unlike monoclonal gammopathy (MGUS) or smouldering myeloma, multiple myeloma involves end-organ dysfunction.
      • Signs of Pneumothorax on Chest X-Ray

      • Reduction in lung markings in the apices (erect)
      • Deep sulcus sign - abnormally sharp costophrenic angle (supine)
      • Diaphragmatic flattening
      • Signs of Tension Pneumothorax

      • Tracheal deviation away from the pneumothorax
      • Mediastinal shift away from the pneumothorax

      Diagnosis

      A ventricular septal defect, or hole in the ventricular wall, manifests as a harsh pansystolic murmur best heard over the left lower sternal edge.
      • ECG Findings

      • Right axis deviation 90° to 180° in the absence of other causes
      • Normal QRS duration <120ms
      • rS pattern in I and aVL: small R wave with large S wave
      • qR pattern in III and aVF
      • Signs of Patent Ductus Arteriosus

      • Peripheral Signs

      • Peripheral cyanosis
      • Collapsing pulse
      • Widened pulse pressure
      • Central Signs

      • Displaced apex beat
      • Continuous murmur
      • Paradoxical splitting of the second heart sound (S2): single S2 during inspiration and split S2 during expiration
      • Evidence of Eisenmenger's syndrome - cyanosis, clubbing

      Pathogenesis

      • Risk Factors

      • Genetic Predisposition

      • Inherited hypercoagulability - protein C or S deficiency, factor V Leiden, prothrombin gene mutation, sickle cell disease, hyperhomocysteinaemia, antithrombin III deficiency
      • Family history of VTE
      • Patient  Factors

      • Advanced age
      • Past history of VTE
      • Acquired hypercoagulability - antiphospholipid syndrome, hyperviscosity, PNH, TTP, HITS
      • May-Thurner syndrome (anatomical variant where the right common iliac artery overlies and compresses the left common iliac vein)
      • Malignancy
      • Hormonal therapy - oestrogen-containing oral contraceptives, hormone replacement, SERMs
      • Venous pathology - varicose veins, superficial vein thrombosis
      • Environmental Triggers

      • Trauma
      • Surgery - particularly hip / knee surgery or major surgery
      • Pregnancy / peripartum period
      • Continuous immobilisation >72 hours - bedrest, neurologic pathology, cast
      • Hospital or nursing home admission
      • Long-distance travel (air, land or sea)
      • Risk Factors for Inflammatory Bowel Disease

      • Family history of inflammatory bowel disease
      • Smoking (Crohn's only - protective in ulcerative colitis)
      • Western diet - high fat, high sugar
      • Medications - NSAIDs, oral contraceptives
      • Not being breastfed
      • Psychological stress

      Diagnosis

      • ECG Findings in ARVD

      • Epsilon wave - a small upward deflection in leads V1-V3
      • T wave inversion in leads V1-V3
      • Localised QRS widening in leads V1-V3
      • Ventricular tachycardia with left bundle branch morphology

      Manifestations

      • Signs of Right Ventricular Failure

      • Sarcopaenia (muscle wasting)
      • Tachycardia
      • Raised jugular venous pressure
      • Right ventricular heave
      • Palpable P2
      • Loud second heart sound (P2)
      • Pleural effusions - reduced breath sounds with dull percussion note basally
      • Ascites - fluid thrill / shifting dullness
      • Tender hepatomegaly
      • Peripheral oedema - sacral / pedal

      Diagnosis

      • Chest X-Ray Findings

      • Bat-wing appearance - opacities extending laterally in a fan shape from each hilum
      • Kerley A lines - 5-10cm lines extending from the hila to the periphery (fluid in the deep septa)
      • Kerley B lines - 1.5-2cm lines seen in the periphery of the lower lung extending into the pleura (interlobular septal thickening)
      • Air bronchograms - tubular outlines of the smaller airways
      • Upper lobe diversion (cephalisation) - enlarged upper lobe vessels and smaller lower lobe vessels
      • Associated cardiomegaly (cardiogenic)

      Pathogenesis

      Reverse typical atrial flutter is where the reentrant circuit travels in a clockwise direction. There are also several types of atypical atrial flutter, caused by a variety of other reentrant circuits.

      Manifestations

      • Complications of Ischaemic Heart Disease

      • Atrioventricular (AV) block
      • Cardiogenic shock
      • Heart failure
      • Valvular pathology - e.g. acute mitral regurgitation
      • Ventricular rupture - septum / ventricular wall
      • Cardiac arrest

      Pathogenesis

      • Risk Factors for Tuberculosis

      • Immunosuppression - HIV, post transplant, autoimmune disease
      • Alcohol abuse
      • Malnutrition
      • Diabetes
      • Smoking
      • Drug Triggers of Arrhythmia in Brugada Syndrome

      • Antiarrhythmics - flecainide, procainamide
      • Psychotropics - amitriptyline, nortriptyline, lithium
      • Anaesthetics - local anaesthetics, propofol
      • Substances - alcohol, cannabis, cocaine
      • Risk Factors for Lung Cancer

      • Genetic factors
      • Smoking (active or passive)
      • Air pollution
      • Occupational exposure - asbestosis, silicosis,
      • Chronic scarring - interstitial lung disease, tuberculosis, COPD
      • Alcohol

      Manifestations

      • Complications of Turner Syndrome

      • Cardiovascular

      • Bicuspid aortic valve
      • Aortic coarctation
      • Aortic dissection
      • Hyperlipidaemia
      • Reproductive

      • Ovarian failure
      • Poor breast development
      • Other

      • Osteoporosis
      • Horseshoe kidney
      • Autoimmune disorders - thyroiditis, coeliac disease
      • Ocular pathology - myopia (nearsightedness), strabismus
      • Ear pathology - sensorineural hearing loss, recurrent otitis media

      Diagnosis

      • ECG Findings

      • Heart rate >100bpm
      • Regular rhythm (RR interval)
      • Each P wave followed by a QRS complex
      • Positive P wave in leads I and II

      Management

      • Management Strategy

      • Pharmacologic Options

      • CFTR potentiator (G511D mutation) - ivacaftor
      • CFTR potentiator / corrector combination (delta F508 mutation) - ivacaftor / lumacaftor
      • Respiratory

      • Sputum clearance - bronchodilators, mucolytics, hypertonic saline, physiotherapy, postural drainage
      • Manage infection - monitor for colonisation, manage exacerbatons
      • Reduce inflammation - using macrolides (azithromycin)
      • Vaccinations - influenza, pneumococcus
      • Lung transplant
      • Pancreas

      • Exocrine - pancreatic enzyme replacement (creon), vitamin supplementation (A, D, E, K)
      • Endocrine - insulin if required
      • Gastrointestinal

      • Nutritional support
      • Constipation - aperients
      • Reflux - proton pump inhibitor
      • Biliary disease - ursodeoxycholic acid
      • Musculoskeletal

      • Arthropathy - NSAIDs
      • Osteoarthritis - calcium, vitamin D, bisphosphonates
      • Reproductive

      • Infertility - assisted pregnancy if required
      • Genetic counselling and testing of partner
      • Other

      • Maximise social supports
      • Treat depression

      Diagnosis

      Mitral stenosis manifests as a low-pitched, mid-diastolic murmur best heard in the apex in the left lateral position.

      Manifestations

      • Clinical Features

      • Symptoms

      • Weight loss despite increased appetite
      • Hyperactivity / irritability
      • Heat intolerance
      • Tremor
      • Sweating
      • Palpitations
      • Diarrhoea
      • Amenorrhoea
      • Alopecia
      • Signs

      • Sinus tachycardia / atrial fibrillation
      • Psychomotor agitation
      • Fine tremor
      • Warm skin
      • Onycholysis
      • Palmar erythema
      • Muscle wasting / weakness
      • Hyperreflexia
      • Alopecia
      • Gynaecomastia

      Diagnosis

      Aortic regurgitation manifests as a descrescendo diastolic murmur, heard loudest on sitting forward on expiration.

      Pathogenesis

      Normal cardiac impulses are conducted from the atria to the ventricle via the AV node. In WPW, an accessory pathway (the Bundle of Kent) is present which bypasses the normal conduction pathway. This produces a classic preexcitation pattern on ECG, and places the patient at risk of arrhythmias.

      Diagnosis

      • ECG Findings

      • Heart rate >100bpm
      • At least three different P wave morphologies
      • Variable PP intervals
      • An isoelectric baseline (to differentiate from atrial fibrillation or flutter)
      • Right bundle branch block:
      • Right bundle branch block

      Manifestations

      • Complications of Colorectal Cancer

      • Disease-Related

      • Lower GI bleeding
      • Bowel obstruction
      • Perforation
      • Management-Related

      • Surgical complications - bleeding, wound infection, anastomotic leak, intra-abdominal collection, ileus
      • Adverse effects of chemotherapy - fatigue, nausea / vomiting / diarrhoea, myelosuppression
      • Adverse effects of VEGF inhibitors - hypertension, arterial / venous thromboembolism, myelosupression
      • Adverse effects of EGFR inhibitors - acneiform rash, nausea / vomiting / diarrhoea, hypomagnesaemia
      • Manifestations of Hepatitis C Infection

      • Hepatic

      • Chronic hepatitis
      • Cirrhosis
      • Extrahepatic

      • Dermatologic - lichen planus, porphyria cutanea tarda
      • Immune - essential mixed cryoglobulinaemia, Sjogren's syndrome
      • Renal - membranoproliferative glomerulonephropathy
      • Non-Hodgkin lymphoma
      • Type 2 diabetes mellitus
      • Conditions Associated with Obesity

      • Metabolic syndrome - type 2 diabetes mellitus, hypertension, hyperlipidaemia
      • Ischaemic heart disease (IHD)
      • Stroke
      • Respiratory - obstructive sleep apnoea, asthma
      • Gastrointestinal - reflux, cholelithiasis, non-alcoholic fatty liver disease (NAFLD)
      • Polycystic ovarian syndrome (PCOS)
      • Osteoarthritis
      • Varicose veins
      • Gout

      Pathogenesis

      In AVNRT, an atrial impulse is conducted by one pathway and then hits the other pathway when it is outside its refractory period, propagating up the other pathway and creating a re-entry circuit.

      Classification

      GenotypePhenotype
      Beta Thalassaemia Minor / Traitβ / β⁰
      β / β⁺
      Mild or no anaemia with marked microcytosis
      Beta Thalassaemia Intermediaβ⁺ / β⁺
      β⁺ / β⁰
      Moderate microcytic hypochromic anaemia
      Beta Thalassaemia Majorβ⁰ / β⁰
      Severe microcytic hypochromic anaemia
      Bone marrow expansion
      Iron overload

      Diagnosis

      • ECG Findings

      • Irregular RR interval
      • Normal PR interval with P waves preceding each QRS complex
      • Normal axis - positive P waves in leads I and II

      Manifestations

      • Complications

      • Ocular - sicca symptoms, scleritis, episcleritis, scleromalacia, scleromalacia perforans
      • Vasculitis - pulmonary hypertension, palpable purpura, distal gangrene
      • Neurologic - compressive neuropathies (e.g. carpal tunnel syndrome), mononeuritis multiplex
      • Cardiovascular - pericarditis
      • Respiratory - interstitial lung disease, pleurisy, lung nodules
      • Haematologic - Felty's syndrome (arthritis, splenomegaly and neutropaenia)
      • Clinical Features

        Generally asymptomatic except for in severe hypophosphataemia.
      • Anorexia
      • Lethargy
      • Muscle weakness
      • Seizures
      • Coma

      Pathogenesis

      • Causes of Sinus Bradycardia

      • Intrinsic

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis
      • Extrinsic

      • Physiologic - sleep, athletes
      • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
      • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, flecainide, ivabradine, clonidine, acetylcholinesterase inhibitors
      • Hypothyroidism
      • Hypothermia
      • Hyperkalaemia
      • Obstructive sleep apnoea
      • Raised intracranial pressure

      Diagnosis

      • X-Ray Findings

      • Soft tissue swelling
      • Joint space preservation (no joint space narrowing)
      • Tophi - periarticular radiolucent masses
      • Juxta-articular 'punched-out' erosions
      • Joint destruction (late)
      • ECG Findings

      • First degree - not detectable on ECG
      • 2nd Degree: type I (Wenckebach) - progressively shortened PP intervals, followed by a pause
      • 2nd degree: type II - constant PP interval, with a pause that is a multiple of the PP interval.
      • 3rd degree - complete failure of transmission to the atria; indistinguishable from sinus arrest on ECG

      Manifestations

      Mild or gradual onset hyponatraemia generally presents with few symptoms, while severe or rapid onset hyponatraemia can be life-threatening.

      Pathogenesis

      • Risk Factors for Asthma

      • Family history of asthma
      • Atopy
      • Obesity
      Sickle cell disease is inherited in an autosomal recessive fashion, and occurs due to a mutation in beta globin chain gene (genotype βSβS), resulting in haemoglobin S synthesis.
      Blood loss is the most concerning cause of iron deficiency, most commonly due to menstrual or gastrointestinal loss. One study found that healthy women lose an average of 30mL (10-110mL) of blood per menstrual cycle.

      Manifestations

      • Manifestations of Hepatitis B Infection

      • Hepatic

      • Acute hepatitis
      • Chronic hepatitis
      • Cirrhosis
      • Hepatitis D infection
      • Extrahepatic

      • Polyarteritis nodosa
      • Membranous glomerulonephropathy
      • Serum sickness-like syndrome (fevers, rash, myalgias, arthralgias)

      Pathogenesis

      • Causes of Right Bundle Branch Block

      • Right ventricular hypertrophy
      • Pulmonary embolism
      • Rheumatic heart disease
      • Ischaemia

      Manifestations

      • Manifestations of Parkinson's Disease

      • Muscular

      • Tremor
      • Slowless of movement (bradykinesia)
      • Dysarthria
      • Muscular stiffness
      • Hypophonia (quiet voice)
      • Shuffling gait
      • Gait freezing
      • Micrographia
      • Non-Muscular

      • Anosmia
      • REM sleep behavioural disorder (acting out dreams)
      • Autonomic dysfunction - constipation, postural hypotension, urinary hesitancy
      • Depressive symptoms - low mood, anhedonia, fatigue

      Pathogenesis

      • Causes of Hypocalcaemia

      • Hypoparathyroidism - iatrogenic, autoimmune, congenital
      • PTH resistance - pseudohypoparathyroidism, hypomagnesaemia
      • Vitamin D deficiency - inadequate intake, low sun exposure, malabsorption, liver failure, chronic kidney disease
      • Increased excretion / reduced bony turnover - loop diuretics, osteoporosis, cachexia, bisphosphonates, malignancy
      • Extravascular calcium buildup - osteoblastic metastases, sepsis, pancreatitis
      • Calcium chelation - alkalosis, citrate, EDTA, hyperphosphataemia
      • Genetic - familial hypoparathyroidism, DiGeorge syndrome

      Overview

      • Causes of Pneumonia

      • Bacteria - Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staph aureus, Mycoplasma, Legionella, Chlamydia
      • Viruses - influenza, parainfluenza, human metapneumovirus, RSV
      • Fungi - Pneumocystis, aspergillosis

      Diagnosis

      • ECG Findings

      • Polymorphic VT with alternating QRS morphology
      • Ventricular fibrillation

      Pathogenesis

      • Risk Factors for Inflammatory Bowel Disease

      • Family history of inflammatory bowel disease
      • Western diet - high fat, high sugar
      • Medications - NSAIDs, oral contraceptives
      • Not being breastfed
      • Psychological stress
      • Causes of Anaemia of Chronic Disease

      • Chronic infection - bacterial, viral, fungal, parasitic
      • Chronic inflammation - SLE, rheumatoid arthritis, inflammatory bowel disease, vasculitis, sarcoidosis, solid organ transplant rejection
      • Chronic kidney disease
      • Malignancy

      Diagnosis

      Aortic stenosis manifests as an ejection (mid) systolic murmur best heard over the base of the heart, associated with narrowed pulse pressure and reduced intensity of S2.

      Manifestations

      • Manifestations of Sinus Node Dysfunction

      • Sinus bradycardia
      • Sinus arrhythmia
      • Sinus pause / arrest
      • Sinoatrial exit block
      • Tachy-brady syndrome

      Overview

      • Mechanism of Action

      • Beta lactam antibiotics, which inhibit bacterial cell wall synthesis.
      • Mechanism of Action

      • Inhibit protein synthesis by binding to the 30s ribosomal subunit, resulting in inaccurate mRNA translation.
      • Effects

      • Uterine contraction - due to calcium influx into myometrial cells
      • Milk letdown
      • Influence on social behaviour

      Clinical Use

      • Indication

      • Management of premature labour between 24 - 33 weeks gestation.
      • Indications

      • Management of the third stage of labour
      • Prevention and treatment of postpartum haemorrhage due to atonic uterus
      • Indication

      • Management of premature labour between 24 - 33 weeks gestation.
      • Indication

      • Prevention and management of postpartum haemorrhage after delivery of the placenta.

      Overview

      • Indication

      • Prophylaxis and treatment of bleeding associated with haemophilia A.
      •  
        IV
        IgA-Deficient Plasma
        Tested for IgA, for use in IgA-deficient patients who may have developed anti-IgA antibodies.
      • Indication

      • Treatment and prophylaxis of bleeding associated with haemophilia B.
      •  
        IV
        Packed Red Blood Cells
        For patients with clinically significant antibodies - lack specific antigens
      In order to create cryoprecipitate, fresh frozen plasma is thawed to between 1-6°C and the precipitate is collected. This creates a product that is richer in fibrinogen than FFP.
      The most important step in transfusing a patient is correctly identifying the patient and making sure that they receive blood that is compatible with their ABO blood type.
      • Composition

      • Factor II
      • Factor IX
      • Factor X
      • Factor VII (small amount)
      • Heparin + antithrombin III
      • Additives - sodium, phosphate, citrate, chloride
      • Indication

      • Treatment and prophylaxis of thrombosis in patients with hereditary antithrombin-III deficiency.

      Clinical Use

      • Indications

      • Von Willebrand Disease
      • Haemophilia A
      •  
        MDI
        Indacaterol
        Onbrez 
      •  
        MDI
        Fluticasone / Formoterol
        Flutiform 
      •  
        Oral / IV / Local / Topical
        Betamethasone
        Celestone 
      • Indications

      • Severe allergic asthma with elevated IgE
      • Chronic spontaneous urticaria that is refractory to H1 antihistamines
      • Indications

      • Acute asthma (ipratropium)
      • Acute exacerbations of COPD (ipratropium)
      • Maintenance therapy for COPD (tiotropium)
      •  
        Inhaler / Nebule / Nasal
        Fluticasone
        Flixotide 
      • Indications

      • Acute exacerbations of asthma
      • Symptomatic relief of asthma
      • Acute exacerbations of COPD
      •  
        MDI
        Umeclidinium
        Incruse 
      • Indication

      • Maintenance therapy for COPD.

      Overview

      • Mechanism of Action

      • Bind to and inactivate cysLT1 receptors, resulting in bronchodilation, reduced eosinophil recruitment and reduced mucus formation.

      Clinical Use

      • Indication

      • Severe refractory eosinophilic asthma.
      •  
        MDI
        Indacaterol / Glycopyrronium
        Ultibro Breezhaler 

      Overview

      • Mechanism of Action

      • Directly bind to airway β2 adrenoceptors, stimulating smooth muscle relaxation and bronchodilation through induction of cAMP with resulting phosphorylation of muscle regulatory proteins and modification of cellular calcium concentration.
      •  
        Oral / Patch
        Rivastigmine
        Exelon 
      Effective against absence seizures due to inhibition of T-type calcium channels in the thalamus.
      •  
        Subling
        Rizatriptan
        Maxalt 
         
        Wafers are useful if nausea / vomiting

      Clinical Use

      • Indications

      • Prophylaxis of migraine
      • Prophylaxis of cluster headaches
      • Indications

      • Relapsing multiple sclerosis (MS)
      • B cell chronic lymphocytic leukaemia (CLL)

      Overview

      Effective against absence seizures due to inhibition of T-type calcium channels in the thalamus.
      •  
        Oral / IV / Local / Topical
        Betamethasone
        Celestone 

      Clinical Use

      • Indications

      • Second-line therapy for partial (focal) seizures
      • Migraine prophylaxis

      Overview

      • Effects

      • β1 (Heart) Blockade

      • Reduce contractility (negative inotropy)
      • Reduce heart rate (negative chronotropy)
      • Reduce electrical conduction (negative dromotropy)
      • Reduce cardiac relaxation (negative lusiotropy)
      • β2 (Vascular / Bronchial Smooth Muscle) Blockade

      • Vasoconstriction
      • Mechanism of Action

      • Naturally occurring cytokines that mediate antiviral, antineoplastic and immunomodulatory processes within the body.

      Clinical Use

      • Indications

      • Depression
      • Fibromyalgia
      • Migraine prophylaxis
      • Neuropathic pain
      • Post-traumatic stress disorder (PTSD)
      • Indication

      • Absence seizures.
      • Indications

      • Relapsing-remitting multiple sclerosis
      • Secondary progressive multiple sclerosis
      • Indication

      • Relapsing-remitting multiple sclerosis (MS).
      • Indications

      • Second-line therapy for partial (focal) seizures
      • Migraine prophylaxis
      •  
        IM / IV
        Midazolam
        Used to induce anaesthesia

      Overview

      • Pharmacology

      • Non-linear pharmacokinetics - small dose changes can result in large changes in plasma concentration.
      • Co-administration with valproate results in increased serum concentrations of phenytoin

      Clinical Use

      • Indications

      • Partial (focal) seizures
      • Acute mania
      • Trigeminal neuralgia
      • Indications

      • Parkinson's disease
      • Restless legs syndrome (off label)

      Overview

      Levodopa is combined with a decarboxylase inhibitor such as benserazide or carbidopa in order to provide dopamine replacement to the brain while minimising the peripheral effects.

      Clinical Use

      • Indication

      • Second-line therapy for partial (focal) seizures.
      Acetaminophen in the US, Paracetamol in other countries.
      •  
        Oral
        Aspirin
        Aspro, Astrix 
      •  
        IV
        Cyclizine Lactate
        Valoid 
         
        Used to prevent postoperative nausea / vomiting

      Overview

      • Mechanism of Action

      • Directly agonises alpha and beta adrenoceptors, resulting in stimulation of sympathetic activity.
      •  
        Oral
        Loratadine
        Claratyne 

      Clinical Use

      • Indications

      • Emergency contraception within 72 hours of unprotected intercourse.
      • Indications

      • Contraception in patients intolerant of combined oral contraceptives
      • Contraception in women who are breastfeeding

      Overview

      • Mechanism of Action

      • Progesterone-only contraceptives that thicken cervical mucus, resulting in reduced sperm penetration through the cervix. Less of an effect on follicular development and prevention of ovulation than combined contraceptives.
      • Mechanism of Action

      • Progesterone-only contraceptives that thicken cervical mucus, resulting in reduced sperm penetration through the cervix. Less of an effect on follicular development and prevention of ovulation than combined contraceptives.
      Release oestrogen and progestin directly into the vagina.
      •  
        Oral
        Ethinyloestradiol + Cyproterone
        Brenda, Diane, Estelle, Juliet 

      Clinical Use

      • Indication

      • Infertility due to ovulation failure.

      Overview

      • Mechanism of Action

      • Thicken cervical mucus, resulting in reduced sperm penetration through the cervix. Less of an effect on follicular development and prevention of ovulation than combined contraceptives.

      Antiprogestogens

      • Mechanism of Action

      • Mifepristone - an antiprogestogen that competitively inhibits the action of progesterone and glucocorticoids on their receptors
      • Misoprostol - synthetic prostaglandin E1, which stimulates myometrial contraction and expulsion of foetal tissue.

      Clinical Use

      • Indications

      • Megaloblastic anaemias due to B12 deficiency
      • Cyanide poisoning

      Overview

      • Composition

      • Glucose 50g/L.
      • Pharmacology

      • Crosses the blood-brain barrier, therefore able to counteract the central effects of anticholinergics.

      Clinical Use

      • Indication

      • Severe paracetamol / acetaminophen overdose.

      Overview

      • Pharmacology

      • 1mg of protamine sulfate is expected to neutralize 100 units of heparin, though smaller doses should be given depending on time elapsed since heparin administration.

      Clinical Use

      • Indication

      • Severe acute or chronic iron overload.

      Overview

      • Pharmacology

      • Higher affinity for ADH than ethanol.
      • Pharmacology

      • Short duration of action due to rapid hepatic clearance.
      • Effects

      • Increased hepatic glycogenolysis
      • Increased hepatic gluconeogenesis (high doses)
      • Lipolysis (high doses)

      Clinical Use

      • Indications

      • Opioid overdose associated with sedation and/or respiratory depression
      • In combination with oral oxycodone - to reduce GI side effects
      • Indications

      • Lead poisoning
      • Arsenic poisoning
      • Indications

      • Arsenic poisoning (second line)
      • Lead poisoning (second line)
      • Indications

      • Warfarin reversal - following bleed, due to high INR or before emergency surgery
      • Haemorrhage due to hypoprothrombinaemia
      • Vitamin K deficiency
      • Indications

      • Lead poisoning
      • Arsenic poisoning
      • Wilson's disease
      • Indications

      • Acetylcholinesterase inhibitor poisoning - organophosphates, chemical warfare, donepezil, rivastigmine, neostigmine
      • Acute bradyarrhythmia - organic, beta blocker / calcium channel blocker / digoxin overdose
      • Reduction in salivary and bronchial secretions preoperatively
      • Indication

      • Methanol or ethylene glycol poisoning.
      • Indication

      • Cyanide Poisoning.
      • Indications

      • Severe hypoglycaemia
      • Raised intracranial pressure
      • Indications

      • Severe refractory Crohn's disease
      • Refractory psoriatic arthritis
      • Moderate to severe plaque psoriasis

      Overview

      • Mechanism of Action

      • Inhibit Janus Kinases (JAK1, JAK2, JAK3 and TYK2), a group of non-receptor tyrosine kinases involved in signalling downstream to cytokine receptors in immune and haematopoietic cells.
      •  
        Subcut
        Etanercept
        Enbrel 
         
        Soluble TNF receptor fused to the Fc portion of IgG

      Clinical Use

      • Indication

      • Prevention of acute renal transplant rejection.
      • Indications

      • Moderate to severe rheumatoid arthritis
      • Severe juvenile idiopathic arthritis
      • Psoriatic arthritis refractory to other DMARDs
      • Indications

      • Paroxysmal nocturnal haemoglobinuria
      • Atypical haemolytic uraemic syndrome (aHUS)
      • Indications

      • Rheumatoid arthritis
      • Granulomatosis with polyangiitis (GPA)
      • Microscopic polyangiitis (MPA)
      • Non-Hodgkin's lymphoma (NHL)
      • Chronic lymphocytic leukaemia (CLL)

      Substem A (Target)

      -b(a)-: bacterial (e.g. raxibacumab)

      Clinical Use

      • Indications

      • Severe rheumatoid arthritis
      • Giant cell arteritis
      • Severe juvenile idiopathic arthritis
      • Indications

      • Cryopyrin-associated periodic syndromes (CAPS) in adults and children aged 2 years or older
      • Systemic juvenile idiopathic arthritis in patients aged 2 years or older
      • Indication

      • Antibody-positive systemic lupus erythematosus (SLE).

      Overview

      Anakinra is human recombinant IL-1RA that competitively inhibits IL-1 binding, resulting in reduced acute phase response.

      Clinical Use

      • Indications

      • Ankylosing spondylitis
      • Psoriatic arthritis
      • Plaque psoriasis
      • Indications

      • Severe allergic asthma with elevated IgE
      • Chronic spontaneous urticaria that is refractory to H1 antihistamines
      • Indication

      • Severe refractory eosinophilic asthma.
      • Indications

      • B cell chronic lymphocytic leukaemia (CLL)
      • Relapsing multiple sclerosis (MS)
      • Indications

      • Autoimmune diseases refractory to first and second line therapy, in weighing up the risks and benefits of treatment with cyclophosphamide
      • Certain solid organ and haematologic malignancies, as guided by specialists and local guidelines

      Overview

      • Mechanism of Action

      • Form a complex with FKBP-12 to inhibit mTOR, a key regulatory protein, and induce cell cycle arrest of T cells, B cells and other non-immune cells.

      Clinical Use

      • Indications

      • Inflammatory disorders - rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, vasculitis
      • Prevention of rejection in renal transplantation
      • Indications

      • Prevention of graft rejection in renal transplantation
      • Treatment of renal transplant rejection
      • Refractory or relapsing aplastic anaemia

      Overview

      • Pharmacology

      • Serum half-life 8 hours
      • Renal excretion - caution in combination with NSAIDs
      •  
        Oral / IV / Local / Topical
        Betamethasone
        Celestone 

      Clinical Use

      • Indications

      • Prevention of graft rejection following kidney, liver or heart transplantation
      • Lupus nephritis (class III, IV or V)
      • Indications

      • Active rheumatoid arthritis
      • Active psoriatic arthritis

      Overview

      • Mechanism of Action

      • Inhibit T cell activation as well as transcription of IL-2 and other cytokines, through inhibition of calcineurin-mediated activation of NFAT.
      • Mechanism of Action

      • For replacement - restores abnormally low IgG levels
      • For immunomodulation - not fully understood, though believed to have multiple effects on T cells, B cells, cytokines, complement and Fc-receptors.

      Clinical Use

      • Indications

      • Severe hyponatraemia
      • Cerebral oedema secondary to head trauma

      Overview

      • Composition

      • Glucose 50g/L.
      • Pharmacology

      • Potassium-sparing diuretics.
      • Composition

      • Dissolving tablets (Chlorvescent) - K⁺ 14mmol
      • Tablets - K⁺ 8mmol
      • IV - K⁺ 20-40mmol in 1L or K⁺ 10mmol in 100mL
      • Composition

      • Sodium 154mmol/L
      • Chloride 154mmol/L
      • Pharmacology

      • Shifts fluid from the interstitial to the intravascular space, therefore doesn't replace lost volume
      • Mechanism of Action

      • Resins that bind to potassium ions within the gut and release calcium or sodium ions, resulting in reduced absorption of potassium.
      • Composition

      • Sodium 131mmol/L
      • Chloride 112mmol/L
      • Potassium 5mmol/L
      • Calcium 2mmol/L
      • Lactate 28mmol/L
      In the context of hyperkalaemia, short-acting insulins such as novorapid and actrapid draw potassium ions into cells and can be used in conjunction with dextrose to acutely treat an elevated serum potassium.
      Also stimulates calcium delivery to the sarcoplasmic reticulum and competes with calcium for binding to troponin C, resulting in vasodilation and reduced contractility.
      • Pharmacology

      • Maintains fluid 80-100% intravascularly, due to inability to diffuse across semipermeable membranes.
      • Effects

      • μ - analgesia, respiratory depression, miosis, constipation
      • κ - analgesia, sedation, confusion
      • δ - analgesia, respiratory depression, constipation
      • NOF - analgesia, stress / anxiety, tolerance
      •  
        Oral
        Tapentadol
        Palexia 
      • Pharmacology

      • Between 1-10% of patients lack the enzyme required to convert it to its active form - in these patients tramadol will have less of an effect.

      Clinical Use

      • Indication

      • Neuropathic pain.

      Overview

      • Mechanism of Action

      • Unknown mechanism, though believed to be a weak inhibitor of prostaglandin synthesis. Also thought to inhibit COX-2, though without anti-inflammatory effects.

      Clinical Use

      • Indications

      • Suppression of muscle spasm due to multiple sclerosis
      • Suppression of muscle spasm due to spinal lesions such as trauma, infection, degenerative change or neoplasia, with associated hypertonicity.
      •  
        Topical / Subling / IV / IM
        Buprenorphine
        Norspan patch, Temgesic sublingual tablet 
         
        Used for pain relief and opioid addiction

      Overview

      • Mechanism of Action

      • Act on opioid receptors (δ, κ and μ) and nociceptin orphanin FQ (NOF) receptors on neuronal cell membranes within the thalamus, diencephalon, midbrain and medulla, resulting in reduced neurotransmitter release.
      • Mechanism of Action

      • Not fully described, though believed to modulate GABA synthesis. Also binds to the α2δ-1 subunit of voltage-gated calcium channels, resulting in reduced nociceptive neurotransmission.
      •  
        Local / Regional / Epidural
        Ropivacaine
        Naropin 
      • Pharmacology

      • Selectively bind to COX2, resulting in reduced gastritis / peptic ulceration compared to non-selective NSAIDs.
      •  
        Oral
        Meloxicam
        Mobic 

      Clinical Use

      • Indications

      • Moderate to severe rheumatoid arthritis
      • Severe juvenile idiopathic arthritis
      • Psoriatic arthritis refractory to other DMARDs
      •  
        Subcut
        Etanercept
        Enbrel 
         
        Soluble TNF receptor fused to the Fc portion of IgG
      • Indications

      • Inflammatory disorders - rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, vasculitis
      • Prevention of rejection in renal transplantation
      • Indications

      • Psoriatic arthritis
      • Plaque psoriasis
      • Indications

      • Prevention of graft rejection following kidney, liver or heart transplantation
      • Nephrotic syndrome refractory to other medications
      • Severe rheumatoid arthritis refractory to other medications
      • Severe psoriasis refractory to other medications
      • Severe atopic dermatitis refractory to other medications
      • Indications

      • Active rheumatoid arthritis
      • Active psoriatic arthritis
      • Indications

      • Severe refractory Crohn's disease
      • Refractory psoriatic arthritis
      • Moderate to severe plaque psoriasis
      • Indications

      • Severe rheumatoid arthritis
      • Giant cell arteritis
      • Severe juvenile idiopathic arthritis
      • Indications

      • Prophylaxis and treatment of gout flares
      • Pericarditis (off-label)

      Overview

      Anakinra is human recombinant IL-1RA that competitively inhibits IL-1 binding, resulting in reduced acute phase response.
      • Pharmacology

      • Serum half-life 8 hours
      • Renal excretion - caution in combination with NSAIDs

      Clinical Use

      • Indications

      • Rheumatoid arthritis
      • Granulomatosis with polyangiitis (GPA)
      • Microscopic polyangiitis (MPA)
      • Non-Hodgkin's lymphoma (NHL)
      • Chronic lymphocytic leukaemia (CLL)

      Overview

      • Mechanism of Action

      • Inhibit Janus Kinases (JAK1, JAK2, JAK3 and TYK2), a group of non-receptor tyrosine kinases involved in signalling downstream to cytokine receptors in immune and haematopoietic cells.
      • Mechanism of Action

      • Interferes with antigen processing in macrophages and other antigen-presenting cells.
      • Mechanism of Action

      • Inhibit xanthine oxidase, which normally produces uric acid through oxidation of xanthine and hypoxanthine.

      Clinical Use

      • Indications

      • Rheumatoid arthritis
      • Seronegative arthritis - reactive arthritis, psoriatic arthritis, anklyosing spondylitis
      • Acute episodes and maintenance of inflammatory bowel disease
      •  
        Oral
        Nilotinib
        Tasigna 
         
        Binds both active & inactive conformation of Bcr-Abl kinase, resulting in reduced resistance
      •  
        Oral
        Alectinib
        Alecensa 
         
        Better CNS penetration than crizotinib
      •  
        Oral
        Afatinib
        Giotrif 
         
        More diarrhoea than with first generation

      Overview

      • Mechanism of Action

      • Normally, activation of RAS pathway via receptor tyrosine kinases (RTKs) results in activation of BRAF which then activates MEK, and in turn, ERK.
      • The RAS / RAF / MEK / ERK pathway stimulates cell proliferation and survival.
      • In melanoma with BRAF mutations, the mutant BRAF (most commonly V600E) is constitutionally active.
      • BRAF inhibitors bind to mutant BRAF V600 and, in turn, inhibit cellular proliferation in cells with BRAF mutations.
      • MEK inhibitors bind to MEK, which is downstream of BRAF.
      •  
        Oral
        Pazopanib
        Votrient 
      • Mechanism of Action

      • Normally, activation of RAS pathway via receptor tyrosine kinases (RTKs) results in activation of BRAF which then activates MEK, and in turn, ERK.
      • The RAS / RAF / MEK / ERK pathway stimulates cell proliferation and survival.
      • In melanoma with BRAF mutations, the mutant BRAF (most commonly V600E) is constitutionally active.
      • BRAF inhibitors bind to mutant BRAF V600 and, in turn, inhibit cellular proliferation in cells with BRAF mutations.

      Clinical Use

      • Indication

      • BRCA-mutated high grade serous ovarian, fallopian tube or primary peritoneal cancer that has responded to platinum-based themotherapy.

      Overview

      • Mechanism of Action

      • Selectively inhibit cyclin-dependent kinase (CDK) 4 and 6, which act downstream of multiple mitogenic signalling pathways to stimulate cell proliferation.

      Clinical Use

      • Indications

      • Nausea / vomiting
      • Acute vertigo
      •  
        Oral / IV
        Pantoprazole
        Somac 

      Overview

      • Mechanism of Action

      • Inhibit 5-aminoimidazole-4-carboxamidoribonucleotide (AICAR) transformylase, which results in increased adenosine release at the inflamed site. Adenosine binds to A2 receptors on inflammatory cells resulting in reduced inflammation.

      Clinical Use

      • Indications

      • Nausea / vomiting secondary to chemotherapy or radiotherapy
      • Postoperative nausea / vomiting
      •  
        Oral / IV / Local / Topical
        Betamethasone
        Celestone 
      •  
        Oral
        Lactulose
        Actilax 
         
        Also used for treatment of hepatic encephalopathy - metabolized by bacteria into D-lactate, reducing gut pH and preventing absorption of ammonia

      Overview

      • Mechanism of Action

      • Prodrugs that are converted to purine analogues which inhibit purine synthesis, disrupting DNA synthesis and reducing T cell activation.

      Clinical Use

      • Indication

      • Constipation.
      • Indication

      • Prevention of constipation.

      Overview

      • Pharmacology

      • Serum half-life 8 hours
      • Renal excretion - caution in combination with NSAIDs
      • Mechanism of Action

      • Inhibit tumour necrosis factor alpha (TNF-α), a cytokine involved in systemic inflammation and the acute phase response.
      •  

      • Mechanism of Action

      • Promote gastric motility by stimulating secretion of electrolytes and water into the gut.

      Clinical Use

      • Indications

      • Severe refractory Crohn's disease
      • Refractory psoriatic arthritis
      • Moderate to severe plaque psoriasis
      • Indications

      • Gastro-oesophageal reflux disease (GORD)
      • Peptic ulcer disease (PUD)
      • Scleroderma oesophagitis
      • Zollinger-Ellison syndrome (gastrinoma)
      • Indications

      • Prophylaxis of malaria
      • Atypical pneumonia
      • Rickettsial infections
      • Lyme disease
      • Brucellosis
      • Chlamydia
      • Syphilis
      • Acne

      Overview

      • Microbiology

      • Effective against Plasmodium vivax and ovale as they enter a dormant phase in the liver.

      Clinical Use

      • Indications

      • Prophylaxis of malaria in resistant areas
      • Treatment of Plasmodium falciparum infection

      Overview

      • Expected Compensation

      • Decrease in PaCO₂ = 1.5 x HCO₃ + 8
      • Causes of Respiratory Alkalosis

      • Hyperventilation - hypoxia, anxiety, pain, intracranial pathology, pregnancy
      The calculation essentially checks whether the change in anion gap from normal is equivalent to the change in the bicarbonate from normal - i.e. that all of the bicarbonate change is accounted for by a high anion gap process.
      Anions = Cations
        • Normal Range

        • 36 - 44 mmHg
      • Causes of Atelectasis

      • Airway obstruction - mucous plugging, tumour, foreign body, bronchial intubation
      • Airway compression - lymphadenopathy, tumour
      • Lung compression - pleural effusion, pneumothorax
      • Hypoventilation - general anaesthesia, opioids, obesity

      Pacemaker

      A pacemaker is a device that provides an electrical impulse to the myocardium to stimulate contraction in response to bradyarrhythmia.

      Overview

      • An endotracheal tube in the expected position
      • No Overlay
        Overlay
        An endotracheal tube in the expected position
         
      • Example

      • Increased interstitial markings with peripheral and basal predominance
      • Increased interstitial markings with peripheral and basal predominance
         
      • Example

      • An NG tube seen below the diaphragm
      • No Overlay
        Overlay
        An NG tube seen below the diaphragm
         
      • Examples

      Posterior-Anterior (PA)

      In order to take a PA film, the x-ray plate is placed in front of patient, with the beam travelling from posterior to anterior.

      Overview

      • Causes of Pneumonia

      • Bacteria - Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staph aureus, Mycoplasma, Legionella, Chlamydia
      • Viruses - influenza, parainfluenza, human metapneumovirus, RSV
      • Fungi - Pneumocystis, aspergillosis
      • Example

      • Normal breast shadows in a patient with pneumonia
      • Normal breast shadows in a patient with pneumonia
         

      Exposure

      The ideal x-ray allows the right amount of penetration through the chest, so that the x-ray may be properly interpreted. 

      Overview

      • A left-sided pleural effusion prior to drain insertion
      • No Overlay
        Overlay
        A left-sided pleural effusion prior to drain insertion
         

      Central Venous Catheters (CVCs)

      A CVC inserted via the subclavian or internal jugular vein should be within the SVC i.e. angled downward toward the right heart border, but not in the right atrium.

      Erect Film

      X-rays performed in an x-ray department are usually erect. Mobile x-rays may be erect, though keep in mind that mobile erect x-rays are often performed in a semi-recumbent position rather than fully erect.

      Overview

      Tension pneumothorax is a life-threatening condition which is diagnosed clinically - waiting for an x-ray may cost the patient their life.

      Silhouette Signs

      • Interpretation

      • Upper right heart border / ascending aorta - anterior right upper lobe
      • Upper left heart border - anterior left upper lobe
      • Aortic knob / arch - apical left upper lobe
      • Right heart border - right middle lobe
      • Left heart border - lingular lobe
      • Anterior hemidiaphragms - lung bases / lower lobes

      Overview

      • Small bilateral pleural effusions evidenced by bibasal costophrenic blunting
      • Small bilateral pleural effusions evidenced by bibasal costophrenic blunting
         
      • Hyperinflation in a patient with emphysema
      • Hyperinflation in a patient with emphysema
         

      Red Blood Cells

      • Causes of RBC in Ascitic Fluid

      • Traumatic collection
      • Neoplasm
      • Pancreatitis
      • Tuberculous peritonitis
      • Intra-abdominal bleedAssociated with massive numbers of RBC

      Overview

      Sodium is the principle cation in extracellular fluid. Its extracellular concentration is normally 12 mmol/L, while its extracellular concentration is approximately 140 mmol/L.

      1st Degree SA Exit Block

      First degree sinoatrial exit block is due to delayed transmission of an impulse from the sinoatrial node, and is not detectable on ECG.

      Overview

      Physiologic and autonomic causes of AV block tend to result in first degree or Mobitz I heart block, while pathologic causes tend to result in Mobitz II, advanced second degree or complete heart block.
      • Atrial escape beat:
      • Atrial escape beat
         
      • Junctional escape beat:
      • Junctional escape beat
         
      • Causes of Bradycardia

      • Intrinsic (SA or AV Nodal)

      • Idiopathic degeneration
      • Myocardial infarction
      • Congenital - congenital heart disease, neonatal lupus
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac procedures - valvular surgery, correction of congenital heart disease, catheter ablation
      • Infections - Lyme disease, endocarditis, viral myocarditis
      • Extrinsic

      • Physiologic - sleep, athletes
      • Autonomic - neurocardiogenic syncope, carotid sinus massage, carotid sinus hypersensitivity
      • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, amiodarone, ivabradine, clonidine, acetylcholinesterase inhibitors
      • Hypothyroidism
      • Hypothermia
      • Hyperkalaemia
      • Obstructive sleep apnoea
      • Raised intracranial pressure
      •  
      •  
      •  
      •  
      Ventricular escape beats can also occur after a long pause (sinus arrest) if atrial or junctional escape is not triggered.
      • Causes of Sinus Node Dysfunction

      • Intrinsic

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis
      • Extrinsic

      • Physiologic - sleep, athletes
      • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
      • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
      • Hypothyroidism
      • Hypothermia
      • Hyperkalaemia
      • Obstructive sleep apnoea
      • Raised intracranial pressure
      •  
      •  

      Poikilocytosis

      • Poikilocytosis

      Reticulocytosis

      • Significance

      • Elevated reticulocytes are indicative of compensatory erythropoiesis due to haemolysis, recovery from anaemia or increased red blood cell requirement.

      Overview

      • Significance

      • Haemolysis results in unconjugated (indirect) hyperbilirubinaemia, as free haemoglobin is metabolised to haem and then bilirubin.

      Aetiology

      Hereditary haemochromatosis is the classic cause of iron overload, with the potential for iron deposition in major organs including the skin, liver, pancreas and heart. The main gene defect causing haemochromatosis is mutation of the C282Y HFE gene (type I haemochromatosis). Other genes defects that cause haemochromatosis are haemojuvelin (IIa), hepcidin (IIb), transferrin receptor 2 (III) and ferroportin 1 (IV).

      Absorption

      Most iron absorption occurs in the duodenum, from haem and ionic iron sources. All iron is converted to the ferrous (Fe2+) form prior to absorption through DMT1 channels. From the intestinal epithelium, iron is transferred into the circulation via ferroportin 1.

      Aetiology

      Blood loss is the most concerning cause of iron deficiency, most commonly due to menstrual or gastrointestinal loss. Poor iron intake is a common cause of deficiency, and less commonly deficiency can be caused by malabsorption. Iron deficiency may occur in late pregnancy, though the most common obstetric cause of anaemia is haemodilution.

      Overview

      High iron levels may be suggestive of iron overload, though may also represent recent iron intake.
      This test is rarely used in clinical practice.
      Total iron binding capacity (TIBC) is the total amount of iron that can be bound to serum transferrin, and as such the TIBC is proportional to the transferrin level.

      Monocytosis

      Increased circulating monocytes.

      Overview

      • A hypersegmented neutrophil in a patient with megaloblastic anaemia:
      • A hypersegmented neutrophil in a patient with megaloblastic anaemia
         
      The major physiologic role of eosinophils is to identify and mount an immune response against parasites, however they also play a key pathogenic role in allergic reactions.
      On a blood film, the red cell size can be assessed by comparing red cells to small lymphocytes. The nucleus of a small mature lymphocyte is slightly larger than a normal red blood cell.
      Morphologically plasma cells are medium-to-large cells with a deep blue cytoplasm and a perinuclear 'hof' (area of pallor adjacent to the nucleus representing the golgi zone).
      • Blood Film Findings in Hyposplenism

      • Red Cell Findings

      • Target cells
      • Acanthocytes
      • Howell-Jolly bodies
      • Pappenheimer bodies
      • White Cell Findings

      • Neutrophilia (initially)
      • Lymphocytosis
      • Monocytosis
      • Platelet Findings

      • Thrombocytosis

      Neutrophil Physiology

      Neutrophils contain primary and secondary granules. The primary granules are azurophilic (Burgundy-coloured) and contain toxic mediators such as elastase and myeloperoxidase. The secondary granules are pink-staining and contain proteins such as lactoferrin; these are not usually visible by light microscopy.

      Thrombocytosis

      Thrombocytosis is an increase in the number of circulating platelets. This may be primary, in the context of myeloproliferative neoplasms, or secondary to another process.

      Overview

      • Stages of Neutrophil Development

      • Myeloblast
      • Promyelocyte
      • Myelocyte
      • Metamyelocyte
      • Banded neutrophil (<8% normally) - U-shaped nucleus
      • Mature neutrophil - 3-5 nuclear lobes
      The presence of nucleated red blood cells and left shift is referred to as a leukoerythroblastic blood film. If a patient has nucleated red cells on their film, always look for the presence of band forms, metamyelocytes and myelocytes.
      Smudge cells are classically a feature of chronic lymphocytic leukaemia (CLL), which manifests with a small mature lymphocytosis and numerous smudge cells. However, several other conditions may result in smudge cells on a blood film.
      • Types of Blasts

      • Myeloblast - medium to large cells with high nuclear:cytoplasmic ratio, fine nuclear chromatin, prominent nucleoli, pale blue cytoplasm and intracytoplasmic vacuolesSeen in acute myeloid leukaemia
      • Monoblast - large cells with low to moderate nuclear:cytoplasmic ratio, delicate lacy chromatin, large and prominent nucleoli and light grey cytoplasmSeen in acute monoblastic and myelomonoblastic leukaemia
      • Lymphoblast - small to medium cells with high nuclear:cytoplasmic ratio, open nuclear chromatin, less prominent nucleoli and basophilic cytoplasm without granulesSeen in acute lymphoblastic leukaemia
      • Megakaryoblast - small to medium cells with round or indented nuclei, fine reticular chromatin and basophilic cytoplasm with cytoplasmic blebbingSeen in acute megakaryocytic leukaemia and myeloid neoplasms associated with Down syndrome
      • Look For

      • Left shift of granulocytes - the presence of increased band forms, metamyelocytes, myelocytes or sometimes promyelocytes
      • Nucleated red blood cells - immature red cells which have not yet extruded their nuclei

      Basophilia

      Basophilia refers to an increase in the number of circulating basophils.

      Overview

      Measurement of free T3 is not generally required for the diagnosis of thyroid disease.
      Thyrotropin releasing hormone (TRH) is secreted by the hypothalamus, and acts on the anterior pituitary to stimulate release of thyroid stimulating hormone (TSH). The release of TRH is inhibited in the presence of high levels of circulating T3 and T4.
      TSH is a sensitive marker of thyroid function, and the first line test for assessment of thyroid dysfunction.

      Manifestations

      • Clinical Features

      • Symptoms

      • Weakness / lethargy / mental sluggishness
      • Weight gain
      • Cold intolerance
      • Dry, coarse skin
      • Constipation
      • Menorrhagia
      • Alopecia
      • Signs

      • Bradycardia
      • Psychomotor retardation
      • Impaired cognition
      • Cool, dry skin
      • Facial oedema
      • Loss of the outer 1/3 of the eyebrow
      • Tongue enlargement
      • Alopecia
      • Hyporeflexia
      • Non-pitting oedema

      Hormonal Changes

      • Hormonal Changes

      Suppressed TSH with Elevated T4

      If the T4 is elevated and the TSH is appropriately suppressed, then primary hyperthyroidism is present.

      Manifestations

      • Clinical Features

      • Symptoms

      • Weight loss despite increased appetite
      • Hyperactivity / irritability
      • Heat intolerance
      • Tremor
      • Sweating
      • Palpitations
      • Diarrhoea
      • Amenorrhoea
      • Alopecia
      • Signs

      • Sinus tachycardia / atrial fibrillation
      • Psychomotor agitation
      • Fine tremor
      • Warm skin
      • Onycholysis
      • Palmar erythema
      • Muscle wasting / weakness
      • Hyperreflexia
      • Alopecia
      • Gynaecomastia

      Hyperferritinaemia

      Elevated serum ferritin is classically a marker of iron overload.

      Overview

      Albumin has a plasma half-life of three weeks, meaning that its concentration changes very slowly in response to changes in synthesis.

      Pathogenesis

      • Causes of Acute Phase Response

      • Infection - bacterial, viral, fungal, parasitic
      • Tissue infarction - e.g. myocardial infarction, renal infarction, splenic infarction, acute limb ischaemia
      • Exogenous substances (i.e. foreign bodies)
      • Endogenous substances - uric acid crystals, calcium pyrophosphate crystals
      • Autoimmune disease
      • Allergies
      • Neoplasia
      • Trauma
      • Surgery
      • Burns

      Overview

      Haptoglobin is an acute phase reactant, and as such will be increased in the presence of infection, inflammation or malignancy.
      • Einthoven's Triangle

      •  
      •  

      Measuring the QT Interval

      The QT interval is best measured on lead II, V5 or V6. Measure the distance between the start of the Q wave and the end of the T wave.

      Sinoatrial Rhythm

      Sinoatrial rhythm can be assessed by examining the P waves on the rhythm strip.

      Limb Electrode Placement

      • Positions

      • LA - Left wrist / forarm
      • RA - Right wrist / forearm
      • LL - left ankle / leg
      • RL - right ankle / leg

      Overview

      • Look For

      • The distance between the start of the P wave and the start of the R wave.
        • Normal P Wave Size

        • Duration <120ms (3mm)
        • Amplitude <2.5mm
      • How to Measure

      • Count the number of large squares between consecutive R waves (the R-R interval), and divide 300 by that number.

      The ECG Trace

      • The ECG Trace

      Overview

      •  

      Monomorphic Ventricular Tachycardia

      • Monomorphic Ventricular Tachycardia
         

      Overview

      • Examples

      • SVT with left bundle branch block:
      • SVT with left bundle branch block
      •  
      •  
      •  
      •  
      •  
      •  
      •  
      •  
      Elevated serum free light chains alone have little significance, and may be related to polyclonal antibody production or renal impairment.
      IgD and IgE are trace immunoglobulins and are not normally assessed.
      • Results of IFE

      • Type of immunoglobulin present - IgG, IgM, IgA, IgD or IgE
      • Type of light chain present - kappa or lambda
      • Amount of paraprotein (g/L)
      • Key Concepts

      • Urea is less reliable than creatinine as a marker of GFR, as levels are more likely to be variable.
      • 40-50% reabsorbed by the tubules;
      • Urea is mainly useful when the serum urea is disproportionately high compared to elevated creatinine - see urea:creatinine ratio for more information
      • Stages of Chronic Kidney Disease

      • StageeGFR (ml/min/1.73 m²)
        I >90
        I60 - 89
        III30 - 59
        IV15 - 29
        V<15
      • Limitations

      • Tends to overestimate GFR, as 15% of creatinine is actively secreted into the tubules.
      •  
      •  
      • ECG Findings in Brugada Syndrome

      • All findings must occur in at least one right precordial lead (V1-V3).

      • Type 1 - coved ST elevation >2mm in V1-V3, followed by a negative T wave
      • Type 2 - saddle-shaped ST elevation in V1-V3 that is >2mm at the J point and >=1mm at the terminal portion of the ST segment
      • Type 3 - saddle-shaped ST elevation in V1-V3 that is >2mm at the J point and <1mm at the terminal portion of the ST segment
      •  
      • ECG Findings in Acute Myocardial Infarction

      • Hyperacute T waves - tall, symmetrical T waves in contiguous leads
      • ST elevation at the J point
      • Reciprocal ST depression - in contiguous leads
      • T wave inversion - compare with old ECGs
      • Q waves - broad (>1mm in duration) or deep (>2mm or >1/3 of R wave height)
      • New left bundle branch block
      • ECG Findings in Acute Stroke

      • Tachycardia
      • ST depression
      • Prolonged QT interval
      • T wave changes - flattening / inversion
      • Prominent U waves
      •  
      • Examples

      •  
      •  
      • Types of Pre-Excitation

      • Manifest preexcitation - anterograde conduction through the accessory pathway, with retrograde conduction back up the AV node
      • Concealed preexcitation - anterograde conduction through the AV node, with retrograde conduction back up the accessory pathway
      •  
      •  
      • Effects of Digoxin

      • Increased automaticity - due to an increase in intracellular calcium
      • Reduced conduction via the AV node - due to an increase in parasympathetic (vagal) tone
      • Interpretation

      • Serum folate is the total concentration of folate, and can fluctuate rapidly with changes in folate intake. In the case of poor intake the serum folate will fall acutely before true folate deficiency is present.
      • Red cell folate is a measure of the folate in tissues, and is an indicator of true folate deficiency.

      Clonus

      • How to Elicit

      • Move the ankle joint several times to ensure that it is relaxed, and then sharply dorsiflex the joint. Count the number of rhythmic muscle contractions (beats) that occur in response to this stimulus.

      Weight

      • Causes of Weight Gain

      • ↑ Dietary intake
      • Physical exercise
      • Endocrine - hypothyroidism, Cushing's, PCOS
      • Medications - steroids, antidepressants, antipsychotics, OCP
      • Fluid overload - excessive IV fluids, renal disease, heart failure
      • Genetic

      Cheyne-Stokes Respiration

      • Causes of Cheyne-Stokes Respiration

      • Physiological - at high altitudes
      • Obstructive sleep apnoea
      • Congestive cardiac failure
      • CNS - stroke, traumatic brain injury, tumour

      Overview

      Start by asking the patient to move against resistance (5 / 4). If the patient cannot move against resistance, ask them to move the joint against gravity (3). If they still cannot move the joint, eliminate gravity (2). In the absence of signficant movement of the joint look for flicker movement (1 / 0). Grade as appropriate, comparing both sides.

      Oral Candidiasis

      • Risk Factors

      • Dry mouth
      • Inhaled steroids
      • Immunosuppression
      • Antibiotic use
      • Smoking
      • Diabetes

      Dehydration

      • Complications

      • Seizures
      • Renal failure
      • Hypovolaemic shock

      Overview

      • Abnormal If

      • >2 seconds
      • Interpretation

      • 0
        No response (hyporeflexive)Lower motor neuron lesion
      • 1+
        Diminished (low normal)Lower motor neuron lesion
      • 2+
        Average (normal)
      • 3+
        Brisk (high normal)Upper motor neuron lesion
      • 4+
        Very brisk (hyperreflexive)Upper motor neuron lesion

      Onycholysis

      • Causes of Onycholysis

      • Systemic disease - chronic kidney disease, bronchial carcinoma, anaemia, diabetes mellitus, porphyrias, peripheral vascular disease, thyrotoxicosis
      • Nail infection - fungal, bacterial
      • Skin disease - psoriasis, dermatitis, lichen planus
      • Trauma

      Overview

      If the patient's visual acuity is poor, use a pin hole over their eye to test for refractive error.
      • Associations

      • Hereditary Dupuytren's
      • Diabetes
      • Alcohol excess
      • Smoking
      • Epilepsy
      • Trauma
      • Manual labour

      Arterial Ulcers

      • Look For

      • Deep, painful white ulcers with blanched surrounding tissue, affecting the toes, heels and bony prominences. These ulcers may become black with necrosis.

      Peripheral Neuropathy

      • Look For

      • Loss of / altered sensation in the hands and / or feet, in a 'glove and stocking' distribution.

      Overview

      • Causes of Warm Extremities

      • Systemic - fever / hyperthermia
      • Cellulitis
      • Lymphoedema
      • Venous abnormalities - deep venous thrombosis, superficial thrombophlebitis, venous insufficiency

      Comprehension

      Simple verbal comprehension - name objects such as pen, watch and key, and ask the patient to point to them.

      The Glasgow Coma Scale

      • How to Assess

      • If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.

      Overview

      Clock - ask the patient to draw a clock face with numbers and with the hands set to the current time.
      • Manifestations of Myotonic Dystrophy

      • Myotonia
      • Cognitive impairment
      • Cataracts
      • Hearing impairment
      • Endocrine - diabetes, hypogonadism, secondary hyperparathyroidism
      • Cardiovascular - arrhythmia, cardiomyopathy, sudden cardiac death
      • Respiratory - obstructive sleep apnoea
      • Gastrointestinal - transaminase elevation, constipation / diarrhoea
      • Hypogammaglobulinaemia
      If the reflex is difficult to elicit, reassess the reflex while the patient clenches their teeth.
      Ventral cord syndrome - upper motor neuron weakness and loss of pain and temperature sensation (spinothalamic tract), with preservation of proprioception and vibration sensation (dorsal column)Anterior compression of the spinal cord, or anterior spinal artery pathology
      • Cervical Nerve Roots

      • RootDermatomeMyotomeReflex
        C4Superolateral shoulderShoulder abduction and elevationNil
        C5Outer armForearmShoulder abduction
        Elbow flexion
        Biceps
        C6Thumb & 2nd fingerWrist extensionSupinator
        C73rd finger
        Center of palm
        Elbow extension
        Wrist flexion
        Triceps
        C85th finger
        Ulnar border of hand
        Wrist extension
        Finger flexion
        Finger jerk
      • Interpretation

      • Increased: resistance to passive movementUpper motor neuron lesion
      • Normal: minimal resistance
      • Decreased: no resistanceLower motor neuron or cerebellar lesion

      Cutaneous Manifestations of Neurologic Disease

      • Signs of Meningitis

      • Purpura: non-blanching red / purple lesions
      • Maculopapular rash: blanching flat (macular) and raised (papular) lesions

      Overview

      • Abnormal If

      • Symptoms are reproduced, such as burning, tingling or numbness.
      • Causes of Peripheral Polyneuropathy

      • Primarily Sensory

      • Diabetes mellitus
      • Vitamin deficiency - B12, pyridoxine
      • Hypothyroidism
      • Sarcoidosis
      • Paraneoplastic syndrome
      • Vasculitis - rheumatoid arthritis, polyarteritis nodosa, SLE
      • Protein-related - monoclonal gammopathy, amyloidosis, cryoglobulinaemia
      • Infection - lyme disease, HIV neuropathy, leprosy
      • Drugs - ethambutol, platinum-based chemotherapy, taxanes, vinca alkaloids
      • Primarily Motor

      • Guillain-Barre syndrome
      • Chronic inflammatory demyelinating polyneuropathy (CIDP)
      • Motor neurone disease
      • Multifocal motor neuropathy with conduction block
      • Polio
      • Sensorimotor

      • Alcohol
      • Charcot-Marie-Tooth
      • Drugs - amiodarone, lithium, nitrofurantoin
      • Toxins - heavy metals, organophosphates
      • Causes of Weakness

      • Upper Motor Neuron

      • CNS lesions - decreased power with increased tone, clonus and reflexes.Ischaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis, prions
      • Lower Motor Neuron

      • Nerve root pathology - loss of a single myotomeTrauma, radiculopathy, neoplasm
      • Focal peripheral nerve pathology - in the muscles supplied by a single nerveTrauma, entrapment, focal ischaemia, sarcoidosis, neoplasia, Bell's palsy (face)
      • Axonal pathology (peripheral neuropathy)Diabetes, motor neurone disease, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
      • Peripheral demyelinationGuillain-Barré syndrome, Charcot-Marie-Tooth
      • Other

      • Neuromuscular pathologyMyasthenia gravis, amyloidosis
      • Muscular pathologyPolymyositis, rhabdomyolysis
      • Poor compliance with examination
      Start by asking the patient to move against resistance (5 / 4). If the patient cannot move against resistance, ask them to move the joint against gravity (3). If they still cannot move the joint, eliminate gravity (2). In the absence of signficant movement of the joint look for flicker movement (1 / 0). Grade as appropriate, comparing both sides.
      • Causes of Cerebellar Dysfunction

      • Ischaemia
      • Haemorrhage
      • Tumour
      • Trauma
      • Multiple sclerosis
      • Hypothyroidism
      • Paraneoplastic
      • Infection - abscess, tubrculosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      • Peripheral Nerves of the Upper Limb

      • NerveSensoryMotor
        RadialSnuff box
        Anterior forearm + AC fossa (proximal lesion)
        Wrist drop
        Wrist extension
        Finger extension
        Elbow extension (proximal lesion)
        MedianPalmar aspect of thumb, 2nd & 3rd fingers
        Thenar eminence (proximal lesion)
        Hand of benediction
        Thumb abduction
        Wrist flexion & pronation (proximal lesion)
        Ulnar5th finger + medial 4th finger
        Ulnar aspect of forearm (proximal lesion)
        Claw hand
        Finger abduction
        Ulnar deviation (proximal lesion)
        MusculocutaneousLateral forearmElbow flexion
        AxillaryLateral upper armShoulder abduction, flexion & extension
        Long ThoracicNilScapular winging
        Shoulder elevation
        SuprascapularNilShoulder abduction & external rotation
        Spinal AccessorySuperior shoulderShoulder elevation & abduction
      • Causes of Mononeuritis Multiplex

      • Vasculitis - polyarteritis nodosa, EGPA, GPA, cryoglobulinaemia, SLE, rheumatoid arthritis, Sjogren's syndrome, scleroderma, Behcet's disease
      • Diabetes
      • Infection - Lyme disease, leprosy, HIV, hepatitis B / C
      • Malignancy - lymphoma, small cell lung cancer
      • Amyloidosis
      • Sarcoidosis
      • Causes of Sensory Loss

      • Central Nervous System

      • Brain lesion - ischaemia, haemorrhage, tumour, trauma, encephalitis, vasculitis, demyelination
      • Spinal cord lesion - infarct, haemorrhage, abscess, transverse myelitis
      • Peripheral Nervous System

      • Nerve root pathology - trauma, radiculopathy, neoplasm
      • Brachial plexopathy - trauma, tumour, brachial neuritis
      • Focal peripheral nerve pathology - trauma, entrapment, focal ischaemia, sarcoidosis, tumour
      • Mononeuritis multiplex - vasculitis, diabetic neuropathy, Lyme disease, leprosy, paraneoplastic, amyloidosis, sarcoidosis
      • Peripheral polyneuropathy - diabetic neuropathy, hypothyroidism, B12 deficiency, alcohol, paraneoplastic, Guillain-Barre, CIDP
      • Other

      • Poor compliance with examination
      • Clinical Phenotypes of Motor Neurone Disease

      • Amyotrophic lateral sclerosis (ALS) - mixed upper and lower motor neuron involvement
      • Primary lateral sclerosis - mainly upper motor neuron involvement
      • Progressive muscular atrophy - mainly lower motor neuron involvement
      • Progressive bulbar palsy - mainly bulbar involvement
      • Causes of Cerebellar Lesions

      • Trauma
      • Vascular - ischaemia, haemorrhage
      • Infection - abscess, tuberculosis
      • Malignancy
      • Demyelination - multiple sclerosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      • Paraneoplastic syndrome
      • Hypothyroidism

      Abnormal Posturing

      • Causes of Abnormal Posturing

      • Head injury
      • Intracranial bleed
      • Cerebral infarction
      • Intracranial hypertension
      • Encephalopathy - drugs, toxins, infection, hepatic
      • Tumour - primary or secondary

      Weight

      • Causes of Weight Gain

      • ↑ Dietary intake
      • ↓ Physical exercise
      • Endocrine - hypothyroidism, Cushing's disease, polycystic ovarian syndrome
      • Medications - steroids, antidepressants, antipsychotics, OCP
      • Fluid overload - excessive IV fluids, renal disease, heart failure
      • Genetic

      Candidiasis

      • Risk Factors

      • Dry mouth
      • Inhaled steroids
      • Immunosuppression
      • Antibiotic use
      • Smoking
      • Diabetes

      Overview

      • Feel For

      • Size - normally <10mm
      • Tenderness
      • Consistency - hard (metastasis), rubbery (lymphoma), soft (reactive)
      • Mobility - mobile or tethered to underlying structures
      Clubbing was first described by Hippocrates in 400BC after noting the sign in a patient with empyema.

      Rashes Associated with GI Disease

      Erythema nodosum: tender, warm nodules with a bruise-like appearance, typically on the lower limbsCrohn's / ulcerative colitis, lymphoma / leukaemia, malignancy, drugs

      Haemorrhoids

      Haemorrhoids are cushions of anal vascular tissue that may bleed, prolapse, thrombose or cause pain / pruritis.

      Common Signs on the Tongue

      Macroglossia: large tongueDown syndrome, acromegaly, amyloidosis, sarcoidosis

      Poor Dentition

      • Significance

      • Poor dentition is associated with worse overall physical and mental wellbeing. Dental infection can spread systemically, most notably as a cause of infective endocarditis.

      Xanthelasma

      • Significance

      • May be benign or indicative of lipid metabolism disorders.

      Dehydration

      • Complications

      • Seizures
      • Renal failure
      • Hypovolaemic shock

      The Glasgow Coma Scale (GCS)

      • How to Assess

      • If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.

      Overview

      Position - ask the patient to undress and lie in the left lateral decubitus position, with their legs up as close to the chest as possible.
      • Feel For

      • Size - normally <10mm
      • Tenderness
      • Consistency - hard (metastasis), rubbery (lymphoma), soft (reactive)
      • Mobility - mobile or tethered to underlying structures

      Segments of the Abdomen

      • Segments of the Abdomen

      Overview

      • Interpretation

      • Absent or diminished abdominal aortic pulse - aortic coarctation
      • Pulsatile Abdominal mass - abdominal aortic aneurysm

      Rashes Associated with GI Disease

      Erythema nodosum: tender, warm nodules with a bruise-like appearance, typically on the lower limbsCrohn's / ulcerative colitis, lymphoma / leukaemia, malignancy, drugs

      Gingival Inflammation

      Pericoronitis - inflammation surrounding a partially erupted tooth (e.g. wisdom tooth).

      Renal Percussion

      • How to Perform

      • With the patient sitting, place one palm over the costovertebral angle and use the ulnar aspect of the other hand (in a fist) to gently percuss the kidneys.

      First Steps

      Position - ask the patient to undress and lie in the left lateral decubitus position, with their legs up as close to the chest as possible.

      Pathogenesis

      • Causes of Cirrhosis

      • Most Common

      • Chronic hepatitis - B or C
      • Alcoholic liver disease
      • Non-alcoholic fatty liver disease
      • Others

      • Autoimmune hepatitis
      • Obstructive disease - primary biliary cirrhosis, primary sclerosing cholangitis, chronic biliary obstruction
      • Infiltration - haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, sarcoidosis, glycogen storage disease type IV
      • Hepatocellular carcinoma
      • Drugs - methotrexate, methyldopa, amiodarone
      • Budd-Chiari syndrome (hepatic vein occlusion)
      • Right heart failure (cardiac cirrhosis)

      Overview

      • Causes of Weight Loss

      • Dietary intake - anorexia, decreased access to food
      • Physical activity
      • Malignancy
      • Malabsorption - obstruction, IBD, pancreatitis, coeliac disease
      • Endocrine - hyperthyroidism, diabetes, phaeochromocytoma, addison's
      • Neurological - stroke, Parkinson's, dementia
      • Drugs - diuretics, chemotherapy, amphetamines, opioids
      • Organ failure - renal failure, liver failure, CCF, respiratory failure
      • Chronic infection - TB, HIV
      • Psychiatric - eating disorders, depression, alcoholism, schizophrenia

      Joint Swelling

      • Causes of Joint Swelling

      • Intra-articular haemorrhage
      • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
      • Trauma - fracture, dislocation, muscle sprain or rupture, compartment syndrome
      • Skin / soft tissue infection - cellulitis, abscess
      • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
      • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition
      • Tendinitis / bursitis

      Focal Abdominal Tenderness

      Left hypochondrium - spleen, pancreas, stomach, splenic flexure of colon, lungPeptic ulcer, pancreatitis

      Pallor

      General inspection of the patient may provide some clue regarding pallor, though it is more significant to assess pallor of the nail beds, palmar creases and conjunctivae.

      Overview

      • Feel For

      • Size - normally <10mm
      • Tenderness
      • Consistency - hard (metastasis), rubbery (lymphoma), soft (reactive)
      • Mobility - mobile or tethered to underlying structures

      Bony Tenderness

      • Causes of Bony Tenderness

      • Traumatic fracture
      • Pathological fracture - osteoporosis, osteomalacia, osteogenesis imperfecta, Paget's disease of bone
      • Osteolytic lesions - multiple myeloma, bony metastasis, fibrous dysplasia bone cyst
      • Osteosarcoma
      • Infection - osteomyelitis / septic arthritis

      Hepatomegaly

      • Interpretation

      • Normal female liver - 8-10cm
      • Normal male liver - 10-12cm
      • Hepatomegaly - >15cm

      Joint Swelling

      • Causes of Joint Swelling

      • Intra-articular haemorrhage
      • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
      • Trauma - fracture, dislocation, muscle sprain or rupture, compartment syndrome
      • Skin / soft tissue infection - cellulitis, abscess
      • Vascular - acute ischaemia, DVT, superficial thrombophlebitis, venous insufficiency, lymphoedema
      • Systemic - heart failure, cirrhosis, nephrotic syndrome, malnutrition
      • Tendinitis / bursitis

      Purpura

      • Causes of Purpura

      • Trauma

      • Platelet Disorders

      • Idiopathic thrombocytopaenic purpura (ITP)
      • Thrombotic thrombocytopaenic purpura (TTP)
      • Disseminated intravascular coagulation (DIC)
      • Bone marrow failure - aplastic anaemia, leukaemia, chemotherapy
      • Platelet sequestration - splenomegaly, haemangioma
      • Haemolytic-uraemic syndrome
      • Disorders of Coagulation

      • Factor deficiencies - haemophilia, Von Willebrand disease
      • Vitamin K deficiency - malabsorption, poor diet
      • Anticoagulants
      • Vascular Disorders

      • Connective tissue diseases - Ehlers-Danlos, scurvy
      • Infection - mengingococcal, streptococcal, viral
      • Henoch-Schönlein purpura
      • Senile purpura
      • Steroids

      Overview

      • Feel For

      • Size - normally <10mm
      • Tenderness
      • Consistency - hard (metastasis), rubbery (lymphoma), soft (reactive)
      • Mobility - mobile or tethered to underlying structures

      Abdominal Mass

      Epigastrium - pancreas, stomachPancreatic tumour, gastric tumour, colonic tumour, bezoar

      Overview

      • Significance

      • Inguinal lymphadenopathy may be an indicator of infection of the lower limb, genitals or perianal area; of lymphoma; or of a pelvic tumour.
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.

      Jerk Nystagmus

      • Look For

      • Slow drifting movements of the eye interspersed with corrective fast saccadic movements.Note whether these movements are horizontal, vertical or torsional.

      Overview

      • Causes of Cerebellar Lesions

      • Trauma
      • Vascular - ischaemia, haemorrhage
      • Infection - abscess, tuberculosis
      • Malignancy
      • Demyelination - multiple sclerosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      • Paraneoplastic syndrome
      • Hypothyroidism

      Testing for Station

      • Causes of Loss of Station

      • Visual abnormalities (10%)
      • Loss of proprioception (70%)
      • Vestibular pathology (20%)

      Overview

      • Interpretation

      • Normal: the finger moves directly between their nose and your finger.
      • Postural tremor: increasing tremor with movement that doesn't get worse as it approaches the target.Physiologic, essential tremor, metabolic, drugs
      • Intention tremor: smooth start with increasing tremor as the finger approaches the target.Cerebellar lesion
      • Abnormal If

      • Inability to rapidly alternate movements.
      • Causes of Inability to Perform

      • Cerebellar lesion
      • Loss of motor strength
      • Loss of proprioception
      • Significance

      • Indicative of cerebellar disease in the form of stroke, tumour or multiple sclerosis.
      • Significance

      • Suggestive of a cerebellar lesion.

      Facial Asymmetry

      Sparing of the eyebrows (i.e. absence of eyebrow droop) distinguishes an upper motor neuron lesion from a lower motor neuron lesion, as the eyebrows receive innervation from both cerebral hemispheres (collateral supply) and the lower face receives only contralateral supply.

      Overview

      • Causes of Flaccid Dysarthria

      • Surgical cranial nerve trauma
      • Brainstem stroke
      • Motor neurone disease
      • Guillain-Barré
      • Polio
      • Neurosyphilis
      • Myaesthenia Gravis

      Hypophonia

      • Listen For

      • Softness of speech.

      Overview

      • Significance

      • Suggests a lesion affecting Wernicke's area within the superior temporal gyrus of the dominant hemisphere.
      • Causes of Spastic Dysarthria

      • Internal capsular stroke
      • Multiple sclerosis
      • Motor neurone disease
      • Traumatic brain injury
      • Encephalitis
      • Significance

      • Suggests a lesion affecting Broca's area within the inferior frontal gyrus of the dominant hemisphere.
      • Interpretation

      • The JVP is elevated if the vertical distance between the sternal angle and the highest point of the pulse is greater than 3cm.

      Pericardial Rub

      A pericardial rub is a sign of pericarditis. 

      Measuring Blood Pressure

      • Prior to Testing Blood Pressure 

        Ask the patient:
      • Whether they have had dialysis (have an AV fistula)
      • Whether they have had breast cancer surgery (and lymph node dissection)
      • Whether there is any other reason why their blood pressure should not be measured on a particular arm

      Measuring Temperature

      There are a wide variety of methods for measuring body temperature, which may be non-invasive or invasive. The most commonly used methods in clinical practice tympanic and oral methods.

      Overview

        • Normal Range

        • 12 - 20 breaths per minute
      • Interpretation

      • Gurgling sounds: movement of gas and fluid via peristalsis
      • Borborygmi: loud rumbling sounds due to movement of air within the gut
      • Hypoactive: diminished or absent bowel sounds
      • Hyperactive: extremely increased bowel sounds
      • Hollow, high pitched tinkles: similar to rain on a tin roof, due to liquid and gas under pressure within dilated gut
      • Causes of Irregular Pulse

      • Sinus arrhythmia
      • Sinus arrest
      • Second or third degree sinoatrial exit block
      • Atrial fibrillation
      • Atrial flutter with variable block
      • Multifocal atrial tachycardia
      • Second or third degree atrioventricular block
      • Premature ventricular contractions

      Measuring Oxygen Saturations

      Oxygen saturations are usually measured by placing a probe on the patient's finger; other sites include the toes, earlobes or forehead. Oxygen saturation probes may be on a trolley or portable.

      Overview

      If not done in this order, the examiner is unable to determine whether the patient responded to the painful stimulus or the voice.

      Stridor

      Stridor refers to musical, high-pitched heard in the upper airways or even without a stethoscope. This finding is suggestive of upper airway obstruction.

      Signs of Peritonism

      Peritonism refers to inflammation of the peritoneum, which suggests acute abdominal pathology that should be rapidly diagnosed and treated.

      Overview

      • How to Measure

      • Count the number of beats over 15, 30 or 60 seconds and multiply to estimate beats per minute.

      Peripheral Oedema

      Look for swelling of the lower limbs; apply pressure to the anterior aspect of the tibia for fifteen seconds and then release to assess for pitting oedema.

      Hypoglycaemia

      • Causes of Hypoglycaemia

      • Diabetics

      • Insulin - excessive insulin dosing, regular insulin dosing despite reduced carbohydrate intake / missing a meal, use of an insulin infusion perioperatively without dextrose infusion
      • Oral hypoglycaemics - sulfonylureas
      • Non-Diabetics

      • Insulinoma

      Overview

      • Signs of Hypoperfusion

      • Tachycardia
      • Tachypnoea
      • Hypotension
      • Cool peripheries
      • Clamminess
      • Altered mental status
      • Reduced urine output (<0.5mL/kg/hr)

      Inspection of Pupils

      • Causes of Abnormal Pupils

      • Bilateral Pupillary Dilation

      • Cerebral lesion - herniation, encephalitis, visual cortex infarct, tumour, trauma, MS
      • Drugs - anticholinergics, SSRIs / SNaRIs, stimulants, barbiturates, methanol
      • Brain stem death
      • Bilateral Pupillary Constriction

      • Drugs - opiates, antipsychotics, acetylcholine, clonidine
      • Intracranial haemorrhage
      • Horner's syndrome (bilateral) - autonomic failure, amyloidosis, diabetes
      • Unequal Pupils (Anisocoria)

      • Physiological (20% of the population - compare with an old photo)
      • Migraine
      • Post-ictal
      • Horner's syndrome (unilateral)
      • Drugs applied to one eye - pilocarpine, tropicamide, cocaine
      • Intraocular conditions - glaucoma, retinal detachment
      • Optic (II) or oculomotor (III) nerve lesion - trauma, compression, optic neuritis, Guillain barré
      • CNS lesion - trauma, tumour, haemorrhage, infarct, MS

      Cheyne-Stokes Respiration

      Periods of hyperventilation interspersed with periods of apnoea or bradypnoea.

      Measuring Temperature

      There are a wide variety of methods for measuring body temperature, which may be non-invasive or invasive. The most commonly used methods in clinical practice tympanic and oral methods.

      Measuring Oxygen Saturations

      Oxygen saturations are usually measured by placing a probe on the patient's finger; other sites include the toes, earlobes or forehead. Oxygen saturation probes may be on a trolley or portable.

      Overview

        • Normal Range

        • 12 - 20 breaths per minute

      Measuring Blood Pressure

      • Prior to Testing Blood Pressure 

        Ask the patient:
      • Whether they have had dialysis (have an AV fistula)
      • Whether they have had breast cancer surgery (and lymph node dissection)
      • Whether there is any other reason why their blood pressure should not be measured on a particular arm

      Overview

      • How to Measure

      • Count the number of beats over 15, 30 or 60 seconds and multiply to estimate beats per minute.
      • Pulmonary Function Test Findings

      • FEV₁ reduced (<80% predicted)
      • FVC mildly reduced
      • FEV₁:FVC ratio reduced (<0.7)
      • 'Scooped' or 'dipped' flow-volume loop

      Obstructive & Restrictive Patterns

      • Obstructive & Restrictive Patterns

      Overview

      • Interpretation

      • Restrictive Pattern

      • Normal DLCO - chest wall or neuromuscular disorders
      • Low DLCO - interstitial lung disease
      • Obstructive Pattern

      • High DLCO - asthma
      • Normal DLCO - bronchiectasis, chronic bronchitis, α1-antitrypsin deficiency
      • Low DLCO - emphysema
      • Normal Spirometry

      • High DLCO - polycythaemia, pulmonary haemorrhage, left-to right intracardiac shunt
      • Low DLCO - anaemia, pulmonary hypertension, pulmonary embolus

      Increased FRC

      Increased functional residual capacity indicates increased lung compliance.

      Overview

      • Contraindications to Spirometry

      • Acutely unwell
      • Haemoptysis of unknown origin
      • Pneumothorax
      • Recent abdominal, thoracic or eye surgery
      • Recent MI
      • Thoracic or abdominal aneurysm
      • Practical Points

      • APTT can be used to monitor patients on heparin infusions.
      • APTT does not correspond to the coagulative status of patients on novel anticoagulants such as dabigatran, rivaroxaban and apixaban.
      • APTT does not correspond to the coagulative status of patients with liver disease, and most often these patients are also coagulopathic.

      The Coagulation Cascade

      Coagulation pathways are a complex set of interactions that result in the formation of a fibrin mesh in order to achieve secondary haemostasis. The coagulation cascade is a traditional representation of these processes that is useful in understanding and interpreting the coagulation profile.

      Overview

      • Important Lab Points

      • Performed by adding thrombin to a plasma sample.
      • Tests only the final step of fibrin clot formation.
      • If the TT is prolonged, a reptilase test is also performed to distinguish between causes.
      • Important Lab Points

      • Collected in a sodium citrate tube to prevent coagulation prior to testing.
      • Performed by adding calcium and thromboplastin to a plasma sample and measuring the time to clot.
      • Tests the extrinsic and common pathways - VII, V, X, II, fibrinogen
      • Prothrombin time (PT) is the raw clotting time, while international normalised ratio (INR) is a standardised measure to account for variation of reagents between laboratories.
      • Interpretation

      • If the APTT or PT/INR is initially elevated but becomes normal when control plasma is added, this suggests that there is factor deficiency as the cause of coagulopathy.
      • If the APTT or PT/INR remains elevated despite addition of control plasma, this suggests that there is an inhibitor present in the sample.

      Urine Colour

      • Interpretation

      • Clear urine - high fluid intake, diabetes insipidus, diabetes mellitus, diuretic use
      • Yellow / orange urine - concentrated urine (dehydration), bilirubin
      • Brown urine - very concentrated urine (dehydration), haemoglobin (haemolysis), metastatic melanoma
      • Black urine - iron, L-dopa, metastatic melanoma, porphyria
      • Red urine - blood, haemoglobin (haemolysis), myoglobin (rhabdomyolysis), porphyria, beetroot, malingering
      • White urine - lipiduria, propofol infusion, proteinuria, pyuria (UTI), minerals (calcium, oxalate, phosphate)
      • Blue / green urine - amitriptyline, indomethicin, porphyria, pseudomonal infection, food dye
      • Purple urine - purple urine bag syndrome (UTI causing metabolism of tryptophan to indole then indicant)

      Overview

        • Normal Range

        • 1.002 - 1.035
      •  
      • Look For

      • Progressively shortened PP intervals, followed by a pause.
      •  
      Physiologic and autonomic causes of AV block tend to result in first degree or Mobitz I heart block, while pathologic causes tend to result in Mobitz II, advanced second degree or complete heart block.
      •  
      •  
      •  
      •  
      The reticulocyte count should be interpreted in the context of the patient's clinical status and whether they are anaemic.
      It is important to use a reference range that takes into account the patient's gender, age and ethnic background; for example, patients of African ancestry may have a neutrophil count that is normally below the lower limit of normal.
      • Causes of Anaemia

      • Reduced RBC Production

      • Haematinic deficiency - B12, folate, iron
      • Bone marrow pathology - pure red cell aplasia, myelodysplastic syndrome, myelofibrosis, bone marrow metastasis
      • Endocrine - EPO deficiency, hypothyroidism
      • Anaemia of chronic disease (infection / inflammation / malignancy)
      • Sideroblastic anaemia
      • Thalassaemias
      • Increased RBC Destruction (Haemolysis)

      • Immune haemolysis - autoimmune, alloimmune, drug-induced
      • Red cell fragmentation - thrombotic microangiopathies, mechanical haemolysis
      • Intrinsic RBC disorders - enzymopathies, membranopathies, haemoglobinopathies
      • Hypersplenism
      • Other - infection, copper, lead, hypophosphataemia
      • RBC Loss

      • Trauma
      • Gastrointestinal bleed
      • Bleeding from another source e.g. urinary tract
      • Factitious

      • Dilutional - excess fluid administration, pregnancy

      Classification

      GenotypePhenotype
      Beta Thalassaemia Minor / Traitβ / β⁰
      β / β⁺
      Mild or no anaemia with marked microcytosis
      Beta Thalassaemia Intermediaβ⁺ / β⁺
      β⁺ / β⁰
      Moderate microcytic hypochromic anaemia
      Beta Thalassaemia Majorβ⁰ / β⁰
      Severe microcytic hypochromic anaemia
      Bone marrow expansion
      Iron overload

      Overview

        • Normal Range

        • 80-100 fL

      Anisocytosis

      Elevated red cell distribution width (RDW) indicates that red blood cells are at a large range of sizes. This phenomenon is known as anisocytosis.

      Overview

      Due to a lack of alpha chains, there is an increase in haemoglobin H (consisting of four beta chains).
        • Normal Range

        • Males: 130 - 180 g/L
        • Females: 115 - 165 g/L
        • Normal Range

        • Males: 40 - 54%
        • Females: 36 - 44%

      Pathogenesis

      • Causes of Anaemia of Chronic Disease

      • Chronic infection - bacterial, viral, fungal, parasitic
      • Chronic inflammation - SLE, rheumatoid arthritis, inflammatory bowel disease, vasculitis, sarcoidosis, solid organ transplant rejection
      • Chronic kidney disease
      • Malignancy

      Overview

      PF Ratio =
      PaO2₂FiO₂
      • Expected Compensation in Acute Respiratory Acidosis

      • 1mmol/L [HCO₃] increase for every 10mmHg PaCO₂ above 40mmHg
        • Normal Range

        • -2 to +2

      Lactate Physiology

      • Production

      • Lactate is produced via pyruvate metabolism under anaerobic or aerobic glycolytic conditions. In the presence of adequate oxygen and mitochondrial capacity, pyruvate is normally converted to acetyl CoA which then enters the Krebs cycle. In the absence of oxygen or in the presence of excessive glycolysis, pyruvate is shunted into lactate, produced by the enzyme lactate dehydrogenase.

      Overview

      • Causes of Metabolic Alkalosis

      • Bicarbonate excess - milk alkali syndrome (antacids), massive transfusion, dialysis
      • GI acid loss - vomiting, NG aspirates, gastric fistula
      • Renal acid loss - diuretics, hyperaldosteronism, Cushing's, steroids
      • Compartmental shift - hypokalaemia

      Diagnosis

      • ECG Findings

      • Wide QRS >120ms
      • Broad R wave in lateral leads (I, aVL, V5, V6)
      • Absent Q waves in I, V5 and V6
      • Diagnosis
         

      Overview

      Due to a lack of alpha chains, there is an increase in haemoglobin H (consisting of four beta chains).

      Diagnosis

      • Blood Gas Findings

      • Alkalaemia with raised bicarbonate.

      Pathogenesis

      • Precipitants of Heart Failure

      • Arrhythmias
      • Infection
      • Anaemia
      • Myocardial infarction
      • IV fluid excess
      • Alcohol
      • Thyrotoxicosis
      • Surgery
      • Pregnancy
      • Mechanism

      • Atrial fibrillation occurs due rapid impulse generation by an ectopic atrial focus, most commonly adjacent to or within the pulmonary vein orifices. Once atrial fibrillation has commenced it is maintained by abnormalities within atrial tissue, such as atrial remodelling.

      Manifestations

      • Complications of Hyperlipidaemia

      • Atherosclerosis

      • Ischaemic heart disease
      • Ischaemic stroke
      • Erectile dysfunction
      • Peripheral vascular disease
      • Other

      • Non-alcoholic fatty liver disease

      Pathogenesis

      • Causes of Hypercalcaemia

      • Malignancy - local osteolysis, humoral hypercalcaemia of malignancy, multiple myeloma
      • Hyperparathyroidism (primary / secondary / tertiary)
      • Endocrine - thyrotoxicosis, Addison's disease
      • Granulomatous disease - sarcoidosis, tuberculosis
      • Prolonged immobilisation
      • Drugs - calcium supplements, vitamin D, vitamin A, thiazides, lithium, oestrogens, anti-oestrogens, progestins
      • Total parenteral nutrition (TPN)
      • Familial hypercalcaemia-hypercalciuria (FHH)

      Diagnosis

      Tricuspid regurgitation manifests as a pan-systolic murmur best heard at the left lower sternal edge on inspiration.
      Mitral regurgitation examines as a pan-systolic murmur best heard over the apex with a volume-loaded heart, soft S1 and present S3 with or without evidence of left ventricular failure.

      Manifestations

      • Complications of Left Ventricular Failure

      • Arrhythmias - atrial fibrillation, ventricular arrhythmias
      • Stroke
      • Sarcopaenia
      • Pulmonary oedema
      • Pulmonary hypertension

      Presenting Complaint

      • Common renal and urinary symptoms include:
      • An abnormal amount of urine - increased urinary frequency, polyuria, oliguria / anuria
      • Abnormal urine appearance - abnormal colour, haematuria, frothy uria, pyuria
      • Urinary incontinence
      • Obstructive symptoms - urgency, hesitancy, dribbling, nocturia
      • Dysuria (pain on urination)
      • Flank pain
      • Uraemic symptoms - fatigue, pruritis, anorexia, nausea, restless legs
      • Common neurological presenting complaints include:
      • Headache
      • Seizures
      • Presyncope or syncope
      • Muscular symptoms - weakness, tremor, spasm
      • Peripheral sensory symptoms - numbness, paraesthesia
      • Visual changes - blurring, diplopia
      • Hearing changes - hearing loss, tinnitus
      • Olfactory changes - loss of olfactory sensation, altered olfaction
      • Vertigo (sensation of the room spinning)
      • Instability
      • Common symptoms in haematologic disorders include:
      • Constitutional symptoms - fatigue, lethargy, malaise, weight loss, night sweats
      • Symptoms of anaemia - Fatigue, shortness of breath, reduced exercise tolerance, lightheadedness, worsening angina, ankle swelling
      • Symptoms of neutropaenia - mouth ulcers, skin infections, other recurrent infections
      • Symptoms of bleeding diathesis - easy bruising, epistaxis, gum bleeding, joint pain / swelling
      • Symptoms of lymphoma - enlarged / painful lymph nodes, painful splenomegaly, B symptoms
      • Symptoms of hyperviscosity - neuropathy, epistaxis, blurred vision, headache
      • Symptoms of venous thromboembolism - limb pain / swalling, chest pain, shortness of breath, palpitations
      • Common cardiovascular symptoms include:
      • Chest pain - concerning for coronary ischaemia infarction, though there are a wide variety of causes of chest pain
      • Dyspnoea (shortness of breath) - a common symptom of heart failure
      • Palpitations - the sensation of fast, slow or irregular beating of the heart
      • Presyncope / syncope - the feeling of fainting, or being about to faint
      • Peripheral oedema (swelling) - classically a symptom of heart failure
      • Lower limb pain

      First Steps

      Position the patient comfortably, in a sitting position. Sit directly across from the patient with your eyes level with theirs.
      Before commencing the cardiovascular exam, wash your hands, introduce yourself to the patient and gain consent.

      Urine Collection

      • Types of Urine Collection

      • Random urine - taken at any time; Used for testing of electrolytes etc.
      • Morning urine - the first urine of the day is the most concentrated, increasing the yield; Used for urinalysis, microscopy and beta-HCG testing
      • Clean catch / midstream urine - the first few mL are discarded and then urine is collected, removing urethral bacterial flora from the sample; Best for urine culture and sensitivity testing
      • 24 hour urine - all of the urine passed over 24 hours is collected; Used to measure certain analytes, such as creatinine, protein, electrolytes, uric acid, cortisol, catecholamines / metanephrines
      • Catheterised sample - e.g. from an in and out / indwelling / suprapubic catheter
      • Suprapubic aspiration - a needle is used to aspirate urine; May be required if a patient cannot be catheterised, or if sterile urine absolutely must be collected

      Red Cell Count & Haemoglobin

      Assessing Oxygenation

      A venous blood gas is not of use in assessing a patient's oxygen status.

      First Steps

      Ensure that you are looking at the correct patient - check the name and date of birth.

      Overview

      • The following are considered the basic haemolysis screen:
      • Full blood count - reduced haemoglobin indicates anaemia
      • Blood film - assessing for schistocytes, spherocytes, keratocytes or other poikilocytosis
      • Liver function tests - unconjugated hyperbilirubinaemia
      • Haptoglobin - reduced, particularly in intravascular haemolysis
      • Lactate dehydrogenase (LDH) - elevated in haemolysis
      • Reticulocytes - elevated in haemolysis
      • Direct antiglobulin test (DAT) - positive in immune haemolysis.

      Overview

      • Positive acute phase reactants are those whose concentration increases with inflammation. These include:
      • C-reactive protein (CRP)
      • Fibrinogen
      • Ferritin
      • Hepcidin
      • Haptoglobin
      • Caeruloplasmin
      • Complement proteins C3 / C4
      • Serum amyloid A (not measured)

      Urine Collection

      • Types of Urine Collection

      • Random urine - taken at any time; Used for testing of electrolytes etc.
      • Morning urine - the first urine of the day is the most concentrated, increasing the yield; Used for urinalysis, microscopy and beta-HCG testing
      • Clean catch / midstream urine - the first few mL are discarded and then urine is collected, removing urethral bacterial flora from the sample; Best for urine culture and sensitivity testing
      • 24 hour urine - all of the urine passed over 24 hours is collected; Used to measure certain analytes, such as creatinine, protein, electrolytes, uric acid, cortisol, catecholamines / metanephrines
      • Catheterised sample - e.g. from an in and out / indwelling / suprapubic catheter
      • Suprapubic aspiration - a needle is used to aspirate urine; May be required if a patient cannot be catheterised, or if sterile urine absolutely must be collected

      Identifying a Vein

      Apply the tourniquet and feel for a straight, firm, round, elastic, non-pulsatile vein.

      Overview

      Supplemental oxygen is not indicated for patients with breathlessness.
      Contraindications include patients with coagulopathy, as they are likely to bleed significantly; and inadequate collateral circulation.
      • Indications for catherisation are:
      • Bladder drainage - for relief of acute urinary retention or bladder outlet obstruction
      • Prevention of urinary retention due to clots
      • Measurement of urine output
      • Perioperative use - urologic surgery, prolonged surgery, large volumes of intraoperative infusion or diuretics, intraoperative urine output measurement
      • Urine specimen collection in patients who are unable to voluntarily void
      • To assist in the healing of perineal wounds in incontinent patients
      • Instillation of medications into the bladder
      IV cannulas cannot be used for certain therapeutic reasons, such as certain chemotherapeutic agents, vasopressors, total parenteral nutrition, or intravenous potassium running at a rate >10mmol/hour.

      Airway Patency

      If the patient is talking then this suggests that their airway is patent (however, this is not always the case). Look, listen and feel for movement of air.

      Overview

      Cardioverter-Defibrillators

      • Look For

      • A mass in the left subclavicular area.

      Pallor of the Lower Limb

      • Causes of Lower Limb Pallor

      • Peripheral vascular disease
      • Compartment syndrome
      • Low cardiac output, due to cardiac disease
      • Peripheral shutdown, due to increased sympathetic activity

      Overview

      Inspiration & Expiration

      • How to Perform

      • Ask the patient to take a deep breath in and hold it. Ask them to then take a deep breath out and hold it.

      Overview

      • Causes of Right Ventricular Failure

      • Pulmonary hypertension - pulmonary arterial hypertension, left heart failure, lung disease, chronic pulmonary embolism
      • Right ventricular pathology - cardiomyopathy, myocarditis, ischaemic heart disease
      • Tricuspid regurgitation - rheumatic heart disease, infective endocarditis, Ebstein's anomaly, carcinoid syndrome, trauma
      • Pericardial disease - constrictive pericarditis
      • Causes of Aortic Stenosis

      • Calcific degeneration
      • Rheumatic heart disease
      • Congenital bicuspid aortic valve
      • Infective endocarditis

      Measuring Blood Pressure

      • Prior to Testing Blood Pressure 

        Ask the patient:
      • Whether they have had dialysis (have an AV fistula)
      • Whether they have had breast cancer surgery (and lymph node dissection)
      • Whether there is any other reason why their blood pressure should not be measured on a particular arm

      Overview

      • Normal Position

      • The fifth intercostal space in the midclavicular line.
      • Causes of Aortic Regurgitation

      • Acute

      • Infective endocarditis
      • Dissecting aneurysm
      • Hypertension
      • Trauma
      • Chronic

      • Rheumatic heart disease
      • Congenital bicuspid aortic valve
      • Ankylosing spondylitis
      • Marfan syndrome / Ehlers-Danlos syndrome
      • Aortitis
      • Causes of Mitral Regurgitation

      • Acute

      • Acute myocardial infarction
      • Infective endocarditis
      • Trauma
      • Chronic

      • Mitral annular calcification
      • Mitral valve prolapse
      • Rheumatic heart disease
      • Papillary muscle dysfunction
      • Connective tissue disease - systemic lupus erythematosus, rheumatoid arthritis
      • Common Thoracic Surgical Scars

      • A
        Sternotomy (midline)Most cardiac surgery, esp. CABG
      • B
        Anterior thoracotomy (submammary)Lung biopsy, pericardial surgery
      • C
        Posterolateral thoracotomy (axillary)Most non-cardiac thoracic procedures
      • D
        Clamshell (bilateral subpectoral)Lung transplantation
      • E
        Left subclavicularPacemaker insertion

      Heart Rate

        • Normal Range

        • 60 - 100bpm

      Complications

      • Complications of Down Syndrome

      • Cardiovascular: At Birth

      • Atrioventricular (AV) septal defects
      • Ventricular septal defect
      • Atrial (secundum) septal defect
      • Persistent ductus arteriosus
      • Tetralogy of Fallot
      • Cardiovascular: In Adolescence

      • Mitral valve prolapse
      • Aortic regurgitation
      • Other

      • Developmental Delay

      Overview

      • Causes of Pulmonary Hypertension

      • Type 1: Pulmonary Arterial Hypertension

      • Idiopathic
      • Inherited
      • Drugs / toxins
      • HIV-related
      • Connective tissue disease - scleroderma, mixed connective tissue disease
      • Portopulmonary hypertension
      • Congenital heart disease
      • Schistosomiasis
      • Type 2: Left Heart Disease

      • Left ventricular systolic / diastolic dysfunction
      • Valvular disease - aortic stenosis, aortic regurgitation, mitral stenosis
      • Type 3: Lung Disease

      • Chronic obstruction pulmonary disease
      • Interstitial lung disease
      • Mixed lung disease
      • Sleep-disordered breathing
      • Alveolar hypoventilation
      • Type 4: Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

      • Chronic pulmonary emboli
      • Type 5: Other

      • Haematologic - chronic haemolytic anaemia, myeloproliferative disorders, splenectomy
      • Systemic - sarcoidosis, pulmonary histiocytosis, lymphangioleiomyomatosis
      • Metabolic - glycogen storage disorders, Gaucher disease
      • Other - tumour obstruction, chronic kidney disease
      • Causes of Mitral Stenosis

      • Rheumatic heart disease
      • Congenital mitral stenosis
      • Mitral annular calcification

      Complications

      • Complications of Turner Syndrome

      • Cardiovascular

      • Bicuspid aortic valve
      • Aortic coarctation
      • Aortic dissection
      • Hyperlipidaemia
      • Reproductive

      • Ovarian failure
      • Poor breast development
      • Other

      • Osteoporosis
      • Horseshoe kidney
      • Autoimmune disorders - thyroiditis, coeliac disease
      • Ocular pathology - myopia (nearsightedness), strabismus
      • Ear pathology - sensorineural hearing loss, recurrent otitis media

      Overview

      Dilate the eye if possible with tropicamide, atropine or phenylephrine eye drops.
      • Causes of Pulmonary Stenosis

      • Congenital - rubella, Noonan's syndrome, William's syndrome, tetralogy of Fallot
      • Carcinoid syndrome
      • On Inspiration

      • Causes of Tricuspid Regurgitation

      • Rheumatic heart disease
      • Infective endocarditis (particularly associated with IV drug use)
      • Ebstein's anomaly
      • Carcinoid syndrome
      • Trauma

      Valsalva Manoeuvre

      • How to Perform

      • While auscultating the chest, ask the patient to breath out against a closed mouth and nose.

      Overview

        • Normal Range

        • Males <0.9
        • Females <0.85

      Resting Tremor

      • Significance

      • Associated with Parkinsonism, either in the setting of Parkinson's disease or secondary causes.

      Anosmia

      • Causes of Anosmia

      • Mechanical anosmia - inflammation of nasal mucosa, blockage of nasal passages
      • Olfactory anosmia - blunt trauma, frontal lobe damage, meningitis, neurosyphillis
      • Parkinson's disease
      • Congenital anosmia

      Overview

      • Interpretation

      • Postural hypotension is present if there is a fall of >20mmHg systolic and >10mmHg diastolic blood pressure following standing.

      Spasticity

      Also known as clasp-knife rigidity.

      Overview

      • Causes

      • Delirium - stroke, infection, intoxication / withdrawal, metabolic, neoplastic, intra/post-ictal, sleep deprivation, severe pain, psychiatric
      • Dementia - Alzheimer's, vascular dementia, lewy body dementia, frontotemporal dementia
      • Intellectual disability
      • Poor compliance
      The glabellar reflex is a primitive reflex - normally present in infants and absent in adults. In the case of frontal lobe damage, 'frontal release' signs such as glabellar, grasp, suck, snout and palmomental reflexes will be present.
      • Causes of Cerebellar Lesions

      • Trauma
      • Vascular - ischaemia, haemorrhage
      • Infection - abscess, tuberculosis
      • Malignancy
      • Demyelination - multiple sclerosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      • Paraneoplastic syndrome
      • Hypothyroidism
      If the reflex is difficult to elicit, reassess the reflex while the patient clenches their teeth.

      Abnormal Posturing

      • Causes of Abnormal Posturing

      • Head injury
      • Intracranial bleed
      • Cerebral infarction
      • Intracranial hypertension
      • Encephalopathy - drugs, toxins, infection, hepatic
      • Tumour - primary or secondary

      Cutaneous Manifestations of Neurologic Disease

      • Signs of Meningitis

      • Purpura: non-blanching red / purple lesions
      • Maculopapular rash: blanching flat (macular) and raised (papular) lesions

      Overview

      • Peripheral Nerves of the Lower Limb

      • NerveSensoryMotor
        SciaticNilKnee flexion
        Lateral CutaneousLateral thighNil
        Common PeronealLateral calf
        Dorsum of the foot
        Dorsiflexion
        Eversion
        Toe extension
        Posterior TibialPlantar aspect of the footPlantar flexion
        FemoralAnterior thigh
        Medial calf
        Hip flexion
        Knee extension
      • Causes of Isolated Pain and Temperature Sensory Loss

      • Anterior spinal artery occlusion
      • Dorsolateral medulla / pons lesion
      Start by asking the patient to move against resistance (5 / 4). If the patient cannot move against resistance, ask them to move the joint against gravity (3). If they still cannot move the joint, eliminate gravity (2). In the absence of signficant movement of the joint look for flicker movement (1 / 0). Grade as appropriate, comparing both sides.
      • Interpretation

      • Sensory loss affecting an entire limb or entire side - likely due to central pathology
      • Sensory loss affecting a single dermatome  - likely due to spinal nerve root pathology
      • Sensory loss affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
      • Sensory loss affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion, or mononeuritis multiplex
      • Distal sensory loss (glove and stocking distribution) - suggests a peripheral polyneuropathy
      • Isolated dorsal column loss (impaired proprioception and vibration sensation with intact pain and temperature sensation) - suggests peripheral demyelination, e.g. Guillain-Barre, CIDP
      • Interpretation

      • Increased: resistance to passive movementUpper motor neuron lesion
      • Normal: minimal resistance
      • Decreased: no resistanceLower motor neuron or cerebellar lesion
      The term chorea derives from the Greek koreia, 'dance'.
      • Interpretation

      • Swaying backward, forward or to either side - suggests a cerebellar vermis lesion
      • Swaying to either side - suggests ipsilateral cerebellar pathology, or ipsilateral vestibular pathology
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Causes of Lower Motor Neuron Weakness

      • Spinal Nerve Root Pathology

      • Spinal trauma
      • Radiculopathy
      • Tumour
      • Brachial Plexopathy

      • Brachial plexus trauma
      • Brachial neuritis
      • Radiation injury
      • Tumour
      • Focal Peripheral Nerve Pathology

      • Trauma
      • Nerve entrapment (e.g. carpal tunnel syndrome)
      • Focal ischaemia
      • Peripheral nerve tumour
      • Sarcoidosis
      • Mononeuritis Multiplex

      • Vasculitis - polyarteritis nodosa, EGPA, GPA, cryoglobulinaemia, SLE, rheumatoid arthritis, Sjogren's syndrome, scleroderma, Behcet's disease
      • Diabetes
      • Infection - Lyme disease, leprosy, HIV, hepatitis B / C
      • Malignancy - lymphoma, small cell lung cancer
      • Amyloidosis
      • Sarcoidosis
      • Peripheral Polyneuropathy

      • Endocrine / nutritional - diabetic neuropathy, hypothyroidism, B12 deficiency
      • Demyelination - Guillain-Barré syndrome, Chronic inflammatory demyelinating polyneuropathy (CIDP)
      • Vasculitis - rheumatoid arthritis, polyarteritis nodosa, SLE
      • Infection - lyme disease, HIV neuropathy, leprosy, polio
      • Paraneoplastic syndrome
      • Multifocal motor neuropathy with conduction block
      • Motor neurone disease
      • Charcot-Marie-Tooth
      • Sarcoidosis
      • Drugs - ethambutol, certain chemotherapy agents, amiodarone, lithium
      • Toxins - alcohol, heavy metals, organophosphates

      Fasciculations

      • Look For

      • Spontaneous localised muscle contraction and relaxation.

      Overview

      • Causes of Mononeuritis Multiplex

      • Vasculitis - polyarteritis nodosa, EGPA, GPA, cryoglobulinaemia, SLE, rheumatoid arthritis, Sjogren's syndrome, scleroderma, Behcet's disease
      • Diabetes
      • Infection - Lyme disease, leprosy, HIV, hepatitis B / C
      • Malignancy - lymphoma, small cell lung cancer
      • Amyloidosis
      • Sarcoidosis
      • Clinical Phenotypes of Motor Neurone Disease

      • Amyotrophic lateral sclerosis (ALS) - mixed upper and lower motor neuron involvement
      • Primary lateral sclerosis - mainly upper motor neuron involvement
      • Progressive muscular atrophy - mainly lower motor neuron involvement
      • Progressive bulbar palsy - mainly bulbar involvement

      Trendelenburg Test

      • How to Perform

      • Support the patient by holding onto their hands, and then ask them to lift one leg off the ground.

      Overview

      Hold the medial and lateral sides of the interphalangeal joint of the great toe, in order to avoid giving away tactile clues.

      Resting Tremor

      • Causes of Resting Tremor

      • Parkinson's disease
      • Drug-induced parkinsonism - antipsychotics, metoclopramide

      Overview

      • Ask About

      • Anaesthesia - loss of tactile sensation
      • Hypoaesthesia - decreased tactile sensation
      • Hyperaesthesia - increased tactile sensation
      This test is best performed on skin overlying bone rather than soft tissue.
      • Causes of Cerebellar Dysfunction

      • Ischaemia
      • Haemorrhage
      • Tumour
      • Trauma
      • Multiple sclerosis
      • Hypothyroidism
      • Paraneoplastic
      • Infection - abscess, tubrculosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      Ventral cord syndrome - upper motor neuron weakness and loss of pain and temperature sensation (spinothalamic tract), with preservation of proprioception and vibration sensation (dorsal column)Anterior compression of the spinal cord, or anterior spinal artery pathology
      • Causes of Upper Motor Neuron Weakness

      • Ischaemia - ischaemic stroke, spinal cord infart
      • Haemorrhage - subarachnoid haemorrhage, intracerebral haemorrhage
      • Traumatic brain injury
      • Tumour - astrocytoma, meningioma, brain metastases, spinal cord neoplasia
      • Infection - encephalitis, PML, brain abscess
      • Demyelination - ADEM, multiple sclerosis
      • Hereditary spastic paraparesis
      • Idiopathic transverse myelitis
      • CNS vasculitis
      • Sarcoidosis
      • Syringomyelia
      • Prion disease

      Proximal Myopathy

      • Signs of Proximal Myopathy

      • General Signs

      • Proximal muscle wasting - biceps, deltoids, quadriceps, buttocks
      • Symmetrical proximal weakness - particularly the shoulder and hip muscles
      • Trendelenberg gait - dropping of the affected side during the stance phase
      • Trendelenberg test - dropping of the affected hip on standing on the opposite leg
      • Signs Suggesting a Cause

      • Dermatomyositis - heliotrope rash, Gottron's papules
      • Paraneoplastic syndrome - surgical scars, e.g. in the chest

      Overview

      • Lumbosacral Nerve Roots

      • RootDermatomeMyotomeReflex
        L1Inguinal region  
        L2Anterior mid-thighHip flexion 
        L3Anterior kneeKnee extensionPatellar
        L4Medial lower legHip extension & abduction
        Ankle dorsiflexion
        Patellar
        L5Lateral lower leg
        Dorsum of the foot
        Dorsiflexion
        Toe extension
        Inversion & eversion
        Ankle
        S1Lateral foot
        Posterior lower leg
        Plantar flexionAnkle
        S2Posterior thighKnee flexion
        Toe flexion

      The Motor Pathway

      Upper Motor Nucleus
      Primary motor cortex (precentral gyrus)
       
      Central Pathway
      Corticobulbar tract
      (via cerebral peduncle)
      Decussation
      Medullary Pyramids
      Spinal Pathway
      Lateral corticospinal tract
       
      Lower Motor Nucleus
      Ventral horn at the level of entry into the spinal cord
       
      Neuromuscular Junction
       
       
      Muscle

      Overview

      • Causes of Distal Weakness

      • Unilateral

      • Radiculopathy (C8/T1)
      • Brachial plexopathy
      • Peripheral nerve lesion
      • Bilateral

      • Guillain-Barre syndrome
      • Chronic inflammatory demyelinating polyneuropathy
      • Multifocal motor neuropathy with conduction block
      • Motor neurone disease
      • Inclusion body myositis
      • Myotonic dystrophy
      • Congenital distal myopathies
      • Causes of Peripheral Polyneuropathy

      • Primarily Sensory

      • Diabetes mellitus
      • Vitamin deficiency - B12, pyridoxine
      • Hypothyroidism
      • Sarcoidosis
      • Paraneoplastic syndrome
      • Vasculitis - rheumatoid arthritis, polyarteritis nodosa, SLE
      • Protein-related - monoclonal gammopathy, amyloidosis, cryoglobulinaemia
      • Infection - lyme disease, HIV neuropathy, leprosy
      • Drugs - ethambutol, platinum-based chemotherapy, taxanes, vinca alkaloids
      • Primarily Motor

      • Guillain-Barre syndrome
      • Chronic inflammatory demyelinating polyneuropathy (CIDP)
      • Motor neurone disease
      • Multifocal motor neuropathy with conduction block
      • Polio
      • Sensorimotor

      • Alcohol
      • Charcot-Marie-Tooth
      • Drugs - amiodarone, lithium, nitrofurantoin
      • Toxins - heavy metals, organophosphates

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • 70°

      Muscles Acting on the Elbow Joint

      Pronators (anteromedial) - pronator teres, pronator quadratus, brachioradialis

      Overview

      • Normal Range of Motion

      Bony Landmarks of the Elbow

      Lateral epicondyle - lateral projection of the humerus.

      Overview

      • Causes of Elbow Swelling

      • Trauma - olecranon fracture, radial head dislocation, biceps / triceps rupture, compartment syndrome
      • Olecranon bursitis
      • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis
      • Infection - cellulitis, abscess
      • Vascular - acute ischaemia, DVT, superficial thrombophlebitis
      • Fluid overload - cardiac / renal / hepatic failure

      Muscle Spasm

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Overview

      • Normal Range of Motion

      • 85°
      • Normal Range of Motion

      • 145°
      • Normal Range of Motion

      • Active - 20°
      • Passive - 22°
      Tibialis anterior - medially, passing anterior to the medial malleolus.

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Bony Landmarks of the Ankle

      Talus - a tarsal bone that articulates directly with the medial and lateral malleoli.

      Overview

      • Normal Range of Motion

      • Active - 45°
      • Passive - 50°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • Active - 30°
      • Passive - 34°
      Chopart's joint (midtarsal joint) - articulation of the calcaneus with the cuboid and the talus with the navicular, allowing for flexion, extension, inversion and eversion of the foot.
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Causes of Absent Pulses

      • Trauma
      • Atherosclerosis
      • Abdominal aortic aneurysm
      • Shock

      Muscles Acting on the Ankle Joint

      Inverters (anterior) - tibialis anterior, tibialis posterior

      Overview

      • Normal Range of Motion

      • Active - 15°
      • Passive - 20°
      Semimembranosus tendon - medial most tendon, inserting posteriorly onto the medial tibial condyle

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Muscles Acting on the Knee Joint

      Internal rotators - popliteus, semimembranosus, semitendinosus

      Overview

      • Causes of Poor Posture

      • Structural - deformities of the spine, foot and ankle
      • Leg Length discrepancy
      • Poor foot posture
      • Muscular imbalance - habitual poor body position

      True Leg Length Discrepancy

      • Causes of True Leg Length Discrepancy

      • Growth arrest - past fracture, bone infection, tumour or osteonecrosis
      • Bony dysplasia
      • Blount's disease (tibia vara)

      Overview

      Joint line tenderness is approximately 85% sensitive and 30% specific for menisceal tears.

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Overview

      • Normal Range of Motion

      • Active - 5°
      • Passive -
      • Normal Active Range of Motion

      • Neutral position - 10°
      • In flexion - 25°

      Bony Landmarks of the Knee

      Femoral condyles - palpate the medial and lateral femoral condyles.

      Overview

      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Normal Range of Motion

      • Active - 130°
      • Passive - 140°

      Major Bursae of the Knee

      Suprapatellar bursa - between quadriceps tendon and femur. Presents as a palpable mass above the knee joint.

      Overview

      • Normal Active Range of Motion

      • Neutral position - 20°
      • In flexion - 45°

      Comprehension

      CLOSE YOUR EYES

      Overview

      Ask about their mood, and whether they have been happy or sad over recent months.

      Rate of Speech

      The rate of speech refers to the speed at which the patient speaks.

      Normal Variations of Thought Form

      Abstract thinking: thought that is almost exclusively informed by cognitive abstractions, rather than immediate sensory experiences.

      Delusions

      • Examples of Delusions

      • Grandiose delusions - of wealth / power
      • Hypochondriacal / somatic delusions - false convictions of fatal disease, infestations or degeneration of organsPsychosis, psychotic depression
      • Nihilistic delusions: feeling of not existing or having a body
      • Delusional perception: a normal perception followed by a delusional conclusionSchizophrenia
      • Delusions of infidelityPsychosis
      • Delusions of guilt and povertyPsychotic depression
      • Capgras's syndrome: the delusion that a significant person (e.g. spouse) has been replaced with an imposter
      • Erotomania: the delusion that a stranger (e.g. a celebrity) is in love with the patient
      • Delusions of Reference: Beliefs that unrelated events, objects, or people hold personal significance or messages.

      Distractability

      • Causes of Distractability

      • Normal behaviour
      • Mania
      • Depression
      • Anxiety
      • Psychosis
      • Advanced age

      Assessing Retrograde Memory

      • Causes of Amnesia

      • Intracranial - stroke, trauma, tumour, infection, epilepsy, degenerative disease
      • Substances - intoxication, withdrawal, Korsakoff's
      • Psychiatric - schizophrenia, psychogenic amnesia
      • Insufficiency - liver, heart, kidneys
      • Hypoxia / anoxia
      • Malingering

      Apraxia

      • Causes of Apraxia

      • Frontotemporal dementia
      • Alzheimer's disease

      Overview

      • Causes of Hallucinations

      • Psychiatric - schizophrenia, schizoaffective disorder, psychotic depression, delirium, Lewy body dementia
      • Neurological - space-occupying lesion, temporal lobe epilepsy, migraine
      • Metabolic - hepatic encephalopathy
      • Drugs - amphetamines, delirium tremens

      Constructional Ability

      • Clock

      • Ask the patient to draw a clock face with numbers and the hands at the current time.

      Overview

      • Significance

      • Assessing judgement is important for deciding whether a patient is able to give consent.

      Category Fluency

      • How to Assess

      • Ask the patient to name as many words as they can beginning with the letter 'A'.
      • Ask the patient to name as many animals as possible in one minute.

      Overview

      • Normal Range of Motion

      • 45°

      Vertebral Landmarks

      C2 - palpate down from the occiput in the midline. The spinous process of C2 is the first palpable process.

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region or is generalised.

      Overview

      • Normal Range of Motion

      • 45°
      • Normal Range of Motion

      • 90°
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.
      • Normal Range of Motion

      • 30°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • 30°
      • Normal Range of Motion

      • 45°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • 30°
      • Normal Range of Motion

      • 80°

      Muscles Acting on the Cervical Spine

      Lateral flexors - sternocleidomastoid, scalenes, levator scapulae

      Oropharyngeal Examination

      • Look For

      • Erythema
      • Swelling of tonsils
      • Exudate
      • Ulcers - viral infection, neoplasm
      • Petechiae on soft palate - pathognomonic for bacterial infection

      Overview

      Auscultate the chest anteriorly and posteriorly, as well as in the axillae and supraclavicular fossae.

      Conjunctival Pallor

      • How to Elicit

      • Pull the lower eyelid downward and inspect the inner eyelid. Conjunctival pallor is present if there is loss of the normal redness of the anterior rim of the conjunctiva.

      Heart Rate

      • Causes of Bradycardia (

      • Physiological - high cardiac fitness
      • Beta blockers
      • Hypothyroidism
      • Raised intracranial pressure
      • Heart block
      • Sick sinus syndrome

      Overview

      • Significance

      • The diaphragm has both somatic and autonomic innervation, and thus the respiratory rate can be altered both voluntarily and and involuntarily in response to physiologic or pathologic stimuli.
      • Look For

      • Nasal mucosa - swelling / erythema, ulcers, polyps, irregular masses, foreign bodies
      • Nasal septum - deviation, perforation
      • Nasal discharge - mucus or blood
      Clubbing was first described by Hippocrates in 400BC after noting the sign in a patient with empyema.
      Percuss the intercostal spaces from the bases to the apices, alternating from left to right and comparing the two sides.

      Complications

      • Complications of Lung Cancer

      • Pleural effusion
      • Metastases - brain, liver, adrenal, bone
      • Local compression - SVC obstruction, sympathetic chain compression (Pancoast tumour) , laryngeal nerve palsy, phrenic nerve palsy, brachial plexopathy
      • Paraneoplastic syndromes - hypercalcaemia, SIADH, Cushing's, hypertrophic pulmonary osteoarthropathy, neurologic syndromes

      Overview

      • Complications of Bronchiectasis

      • Acute exacerbations
      • Pulmonary haemorrhage
      • Pneumothorax
      • Empyema
      • Lung abscess
      • Cor pulmonale

      Complications

      • Complications of Interstitial Lung Disease

      • Acute exacerbation of ILD
      • Cor pulmonale
      • Pulmonary hypertension
      • Lung cancer

      Reduced Oxygen Saturation

      The level of haemoglobin saturated by oxygen may be reduced in the context of reduced oxygen, right shift of the oxygen saturation curve, displacement of oxygen by carbon dioxide, or in the setting of haemoglobinopathies.

      Pathogenesis

      • Risk Factors for COPD

      • Smoking
      • Occupational exposure - coal, toluene (plastics)
      • Environmental air pollution
      • Alpha-1 antitrypsin deficiency

      Overview

      • Normal Range of Motion

      • 10°
      • Normal Range of Motion

      • 20°

      Muscles Acting on the Wrist Joint

      Abductors - flexor carpi radialis, extensor carpi radialis longus & brevis

      Overview

      • Normal Range of Motion

      • 70°
      • Abnormal If

      • Paraesthesia / reproduction of the patient's symptoms.
      • Normal Range of Motion

      • 20°
      • Abnormal If

      • Symptoms are reproduced, such as burning, tingling or numbness.
      • Normal Range of Motion

      • Metacarpophalangeal joint - 80°
      • Proximal interphalangeal joint - 100°
      • Distal interphalangeal joint - 70°
      • Normal Range of Motion

      • 20°
      • Normal Range of Motion

      • 50°
      • Normal Range of Motion

      • 70°

      Muscle Wasting

      • Causes of Generalised Wasting

      • Normal aging
      • Disuse
      • Malnutrition - poor diet, malabsorption, cancer
      • Denervation - trauma, ALS, Guillain-Barre Syndrome, neuropathy
      • Muscular disorders - inflammatory myopathy, muscular dystrophies
      • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

      Bony Landmarks of the Wrist

      Head of radius - proxiamlly, articulating with the distal humerus and radial head.

      Overview

      • Normal Range of Motion

      • 70°

      Hand of Benediction

      • How to Elicit

      • Ask the patient to make a fist. Benediction hand is present if the patient is unable to flex the index and middle fingers.

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Soft Tissue Landmarks of the Wrist

      Snuffbox - on the radial aspect of the dorsum of the hand, at the base of the thumb. Contains the scaphoid and trapezium. Snuffbox tenderness is characteristic of scaphoid fracture.

      Overview

      • Normal Range of Motion

      • 30°
      • Normal Range of Motion

      • 70°
      • Normal Range of Motion

      • 0° or slightly more
      • Normal Range of Motion

      • 80°

      Pitting Oedema

      • Look For

      • Persistence of the depressed area after pressure is removed.

      Contour

      Slow rate of rise Aortic stenosis

      Venous Skin Changes

      • Significance

      • Venous insufficiency.

      Overview

      Posterior tibial - palpate posteriorly and inferiorly to the medial malleolus.

      Inspection of Pupils

      • Causes of Bilateral Pupillary Dilation

      • Cerebral lesion - herniation, encephalitis, visual cortex infarct, tumour, trauma, MS
      • Drugs - anticholinergics, SSRIs / SNaRIs, stimulants, barbiturates, methanol
      • Brain stem death

      Rashes Associated with Diabetes

      Diabetic dermopathy: <10mm well-dermarcated atrophic lesions around the proximal shinType 1 and 2 diabetes

      Overview

      Dilate the eye if possible with tropicamide, atropine or phenylephrine eye drops.

      Lower Limb Erythema

      • Causes of Lower Limb Erythema

      • CellulitisTender, red, swollen, warm calf ± site of injury
      • Skin conditionsMacules, papules, patches or plaques - localised / diffuse
      • Lipodermatosclerosis (fibrosis of subcutaneous fat)Inverted bowling pin appearance with erythema / induration
      • LymphoedemaNon-pitting oedema, usually bilateral
      • Deep venous thrombosisRed, swollen, tender calf
      • Superficial ThrombophlebitisTender area with erythema tracking along the course of a superficial vein
      • Venous insufficiencyHyperpigmentation that may be associated with varicose veins or oedema.
      • Dependent rubor(peripheral arterial disease)Dusky-red discolouration when the leg is elevated above the heart

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Overview

      • Important Travel-Related Infections

      • Diarrhoeal illnesses - giardia, amoeba, salmonella, shigella, cryptosporidia, cyclospora
      • Intestinal worms - strongyloidiasis, ascariasis, hookworm, whipworm, trichinosis, schistosomiasis
      • Mosquito-borne diseases - yellow fever, Japanese encephalitis, malaria, dengue fever, zika virus, chikungunya
      • Rickettsial illnesses - scrub typhus, spotted fevers
      • Tuberculosis
      • Other bacterial infections - meningococcal meningitis, typhoid fever, diptheria, leptospirosis, brucellosis, tetanus, lyme disease
      • Other viral infections - hepatitis A / B / C, HIV / AIDS, avian flu, measles, mumps, polio, rabies, ebola
      • Other parasitic infections - leishmaniasis
      • Specific Conditions To Ask About 

        Use simple terms when asking questions, rather than medical terms such as 'hypertension' or 'dyslipidaemia'.
      • Asthma
      • Diabetes
      • Heart disease
      • High blood pressure
      • High cholesterol
      • Cancer

      IV Drug Use

      • Consequences of IV Drug Use

      • Blood-borne viral infections - hepatitis B, hepatitis C, HIV
      • Bacterial septicaemia
      • Infective endocarditis - especially right-sided (tricuspid) disease
      • Cutaneous infection - skin abscess, cellulitis, necrotising fasciitis
      • Venous damage - superficial thrombophlebitis, deep venous thrombosis

      Overview

      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis
      Also ask about whether the patient's mobility has changed recently, and why.
      • For Each Condition

      • How many people in the family affected
      • How old they were when diagnosed
      • If passed, how old they were when they passed away
      • If a genetic condition - whether the patient or anyone else in the family has been tested
      • Sources of Medication Lists

      • It is often best to derive your list from at least two sources, especially when there is doubt.
      • The patient - sometimes patients present with a useful list of their medications
      • Collateral - from family or friends
      • Medication boxes - often patients present with their medications; ask if there are any missing
      • The patient's file - especially discharge summaries
      • Other hospitals - especially discharge summaries or transfer letters
      • The patient's GP
      • The patient's pharmacy
      • Types of Adverse Drug Reaction

      • Dose-related - narrow therapeutic index; generally improve with reduction in dose (may be required in renal or hepatic dysfunction)
      • Idiosyncratic - genetic susceptibility that is not dose-related
      • Allergic - occurs after sensitization
      • Consequences of Alcohol Abuse

      • Oesophagitis
      • Pancreatitis
      • Alcoholic liver disease - steatosis, hepatitis, cirrhosis
      • Cardiovascular disease - hypertension, dilated cardiomyopathy, atrial fibrillation
      • Neurologic complications - Wernicke encephalopathy, Korsakoff syndrome, cerebellar atrophy, peripheral neuropathy, myopathy
      • Malignancy - mouth, oesophagus, throat, liver, breast
      • Bone marrow suppression
      • Osteoporosis
      • Malnutrition
      • Trauma - high risk behaviour, MVA
      • Psychiatric disorders - depression, anxiety, suicide

      Diagnosis

      • Stages of Chronic Kidney Disease

      • GFR Categories (mL/min/1.73m²)

      • G1 - ⩾90
      • G2 - 60-89
      • G3a - 45-59
      • G3b - 30-44
      • G4 - 15-29
      • G5 - <15
      • Albuminuria Categories

      • A1 - <30mg/g / <3mg/mmol
      • A2 - 30-300mg/g / 3-30mg/mmol
      • A3 - >300mg/mg / >30mg/mmol

      Pretransplant History

      Before a patient is considered or listed for a transplant they must go through a comprehensive process that includes medical investigation, social assessment and counselling.

      Overview

      • Risk Factors for Multiple Sclerosis

      • Female sex
      • Family history of multiple sclerosis
      • High lattitude (further from equator)
      • EBV infection
      • Smoking

      Manifestations

      • Manifestations of Parkinson's Disease

      • Muscular

      • Tremor
      • Slowless of movement (bradykinesia)
      • Dysarthria
      • Muscular stiffness
      • Hypophonia (quiet voice)
      • Shuffling gait
      • Gait freezing
      • Micrographia
      • Non-Muscular

      • Anosmia
      • REM sleep behavioural disorder (acting out dreams)
      • Autonomic dysfunction - constipation, postural hypotension, urinary hesitancy
      • Depressive symptoms - low mood, anhedonia, fatigue

      Overview

      • Potential Precipitants of Seizures

      • Sleep deprivation
      • Fatigue
      • Fasting
      • Drugs
      • Alcohol
      • Flashing lights
      • Fever
      • Stress
      • Menstruation
      • Missed antiepileptic dosing

      Management

      • Management Options for Motor Neuron Disease

      • Non-Pharmacologic

      • Physiotherapy
      • Non-invasive ventilation (NIV)
      • Speech pathology assessment
      • Consideration of PEG feeding
      • Psychological sypport
      • Pharmacologic

      • Rulizole
      • Anti-spasmodics - baclofen, diazepam, botox
      • Neuropathic agents - pregabalin, amitriptyline

      Manifestations

      • Precipitants of Myaesthenic Crisis

      • Infection
      • Surgical procedures
      • Drugs - neuromuscular blockers, aminoglycosides, macrolides, beta blockers, calcium channel blockers, corticosteroids
      • Pregnancy

      Overview

      • Ask About

      • Peritransplant history - when the transplant was done, indication, type of transplant, conditioning
      • Complications
      • Post-transplant management
      • Snapshot

      • UpToDate: extremely comprehensive guides to medical conditions that are evidence-based and peer reviewed.
      • PEPID: a comprehensive medical app including diagnoses, drugs, investigations, and calculators with a symptom checker to aid in diagnosing patients.
      • Amboss: a large amount of clinical information in note form, with comprehensive diagnostic and treatment tools.
      • MedSchool: a clinical reference app for medical students with guides to history, examination, investigations, and drugs.
      • Geeky Medics: guides to history and examination, videos, quizzes, with a large amount of free content.
      • Prognosis: interactive clinical cases presented in a fun way and feedback about each case including diagnostic reasoning, test results, and learning points.
      • Eponyms: descriptions of hundreds of medical eponyms.
      In this article, we’ll explore some of the best flashcard platforms for medical students. Whether you are preparing for the USMLE, medical school exams or simply looking for a way to memorize medical concepts, these platforms are an incredibly useful way of leveraging the power of flashcards.

      Key Features

      There are several features that we look at when deciding to use a note-taking app. These can be broken into usability, the ability to organise notes, and the ability to communicate with other apps and devices.

      Overview

      In this article, we will explore some of the best YouTube channels and video platforms available to help medical students to build their knowledge in this domain.
      In this article, we will explore five of the best mindfulness apps and websites for medical students to help you cultivate a mindful outlook. These resources are useful for both beginners and seasoned practitioners to support mental and physical health. Let’s get into it.
      In this article, we will explore five top apps that provide clinical tools and calculators, for you to consider incorporating into your arsenal. 

      Key Considerations

      When selecting which resources to include in this article, we considered several key types of apps that you may find useful as a medical student. These include:

      Key Features

      When creating our comprehensive list of the best ECG resources for medical students, we considered several key factors:

      Types of Cognition

      Bloom's Taxonomy is a hierarchical ordering of cognitive skills that can guide both teaching and learning. Integrating different levels of the taxonomy into your learning can enable a comprehensive understanding on the topic and application in a practical sense.

      How Memory Works

      • Encoding

      • When we experience the outside world, we are constantly taking in new information through multiple senses - visual inputs, auditory inputs, tactile inputs and often olfactory inputs. For example - your first time on the ward you may see the bustling movement, hear the sounds of the ward (often alarms) and smell one of several unpleasant odours. Our brains encode this information and processes it so that it may be stored for retrieval later.

      Plan Your Study

      It can be difficult and demoralising to study effectively without knowing what you're working toward, or what timeline you're on. When starting a new year or new block, identify your study goal (e.g. end of term exams or the USLME part 1) and consider creating a study plan that works toward this. Planning in this way will ensure that you're steadily working toward your end goal, rather than floating along to begin with and cramming before exams.

      Overview

      This article provides and overview of the methods you can use to develop a variety of practical skills during your medical education. As opposed to specific guides to procedures, which are covered elsewhere on this site, here we will provide you with a general approach to procedural skills, from the basics through to mastery. 
      In this article, we’ll discuss the basics of how flashcards work, the different types of flashcards you can use, and effective strategies for getting the most out of your flashcards. Let’s get into it!

      Why Take Notes?

      Note-taking helps to filter a large amount of information to find the key ideas and compress them into a format that can easily be returned to later. Notes are used to study, to practice recall and to self-test. 

      Complications

      • Complications of Bronchiectasis

      • Acute exacerbations
      • Pulmonary haemorrhage
      • Pneumothorax
      • Empyema
      • Lung abscess
      • Cor pulmonale

      History of Presenting Complaint

      • Onset

        Whether the pain began suddenly or gradually, and what the patient was doing at the time.
      • Onset at restSuggestive of acute coronary syndrome over stable angina if typical ischaemic pain
      • Onset during exertionSuggestive of stable angina if typical ischaemic pain
      • Onset post traumaMay represent pneumothorax or rib fractures

      Complications

      • Complications of Interstitial Lung Disease

      • Acute exacerbation of ILD
      • Cor pulmonale
      • Pulmonary hypertension
      • Lung cancer

      Diagnosis

      • Types of Lung Cancer

      • Non-Small Cell Lung Cancer - adenocarcinoma, squamous cell carcinoma, large cell carcinoma
      • Small Cell Lung Cancer

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Overview

      • Risk Factors for Asthma

      • Family history of asthma
      • Atopy
      • Obesity
      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis
      • Important Travel-Related Infections

      • Diarrhoeal illnesses - giardia, amoeba, salmonella, shigella, cryptosporidia, cyclospora
      • Intestinal worms - strongyloidiasis, ascariasis, hookworm, whipworm, trichinosis, schistosomiasis
      • Mosquito-borne diseases - yellow fever, Japanese encephalitis, malaria, dengue fever, zika virus, chikungunya
      • Rickettsial illnesses - scrub typhus, spotted fevers
      • Tuberculosis
      • Other bacterial infections - meningococcal meningitis, typhoid fever, diptheria, leptospirosis, brucellosis, tetanus, lyme disease
      • Other viral infections - hepatitis A / B / C, HIV / AIDS, avian flu, measles, mumps, polio, rabies, ebola
      • Other parasitic infections - leishmaniasis

      Severity

      • Ask About

      • Symptoms - snoring, apnoeas, excessive daytime somnolence, poor concentration
      • Impact on functional status
      • Motor vehicle accidents
      • Sleep study result - apnoea-hypopnoea index

      Overview

      • Risk Factors for Tuberculosis

      • Immunosuppression - HIV, post transplant, autoimmune disease
      • Alcohol abuse
      • Malnutrition
      • Diabetes
      • Smoking
      • Risk Factors for COPD

      • Smoking
      • Occupational exposure - coal, toluene (plastics)
      • Environmental air pollution
      • Alpha-1 antitrypsin deficiency

      Management

      • Management Strategy

      • Pharmacologic Options

      • CFTR potentiator (G511D mutation) - ivacaftor
      • CFTR potentiator / corrector combination (delta F508 mutation) - ivacaftor / lumacaftor
      • Respiratory

      • Sputum clearance - bronchodilators, mucolytics, hypertonic saline, physiotherapy, postural drainage
      • Manage infection - monitor for colonisation, manage exacerbatons
      • Reduce inflammation - using macrolides (azithromycin)
      • Vaccinations - influenza, pneumococcus
      • Lung transplant
      • Pancreas

      • Exocrine - pancreatic enzyme replacement (creon), vitamin supplementation (A, D, E, K)
      • Endocrine - insulin if required
      • Gastrointestinal

      • Nutritional support
      • Constipation - aperients
      • Reflux - proton pump inhibitor
      • Biliary disease - ursodeoxycholic acid
      • Musculoskeletal

      • Arthropathy - NSAIDs
      • Osteoarthritis - calcium, vitamin D, bisphosphonates
      • Reproductive

      • Infertility - assisted pregnancy if required
      • Genetic counselling and testing of partner
      • Other

      • Maximise social supports
      • Treat depression

      Complications

      • Complications of Pulmonary Embolism

      • Disease-Related

      • Pulmonary infarction
      • Right heart failure
      • Chronic thromboembolic pulmonary hypertension (CTEPH)
      • Treatment-Related

      • Major bleeding

      Medication History

      • Prescription

      • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
      • Administration - e.g. oral, IM or IV
      • Dose - the strength of the medication and how much they take eg how many tablets
      • Frequency - how often they take the medication

      Overview

      • Causes of Heart Failure

      • Ischaemic heart disease
      • Cardiomyopathy
      • Myocarditis
      • Pericardial disease
      • Valvular disease
      • Congenital heart disease
      • Hypertension

      Medication History

      • Prescription

      • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
      • Administration - e.g. oral, IM or IV
      • Dose - the strength of the medication and how much they take eg how many tablets
      • Frequency - how often they take the medication

      Overview

      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis
      • Causes of Hypertension

      • Primary

      • Primary (essential) hypertension: chronically elevated blood pressure of unknown aetiology (the most common cause of hypertension in the community)
      • Secondary

      • Chronic kidney disease
      • Renovascular - fibromuscular dysplasia, atherosclerosis
      • Endocrine - hyperthyroidism, hypothyroidism, Cushing's syndrome, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
      • Drugs - NSAIDs, amphetamines, glucocorticoids, fludrocortisone, erythropoietin, VEGF inhibitors, calcineurin inhibitors
      • Aortic coarctation
      • Obstructive sleep apnoea
      • Factitious

      • White coat hypertension: falsely elevated blood pressure may occur due to by anxiety in a healthcare setting, recent exercise or recent caffeine intake.
      • Recent exercise or caffeine intake

      IV Drug Use

      • Consequences of IV Drug Use

      • Blood-borne viral infections - hepatitis B, hepatitis C, HIV
      • Bacterial septicaemia
      • Infective endocarditis - especially right-sided (tricuspid) disease
      • Cutaneous infection - skin abscess, cellulitis, necrotising fasciitis
      • Venous damage - superficial thrombophlebitis, deep venous thrombosis

      Overview

      • Ask About

      • Everyone

      • Whether they drink alcohol regularly
      • How often - daily, weekly, monthly, or on social occasions only
      • What type of alcohol they drink
      • How many drinks on each occasion / each day
      • The most they drink at any given time
      • Where they drink - restaurants, bars, parties, at home
      • Amount spent on alcohol
      • Heavy Drinkers

      • Withdrawal symptoms - sweating, rigors, nausea, past seizures
      • Alcohol free days
      • Past attempts to quit drinking
      • Willingness to cut down or stop

      Diagnosis

      • Symptoms of Pulmonary Hypertension

      • Fatigue
      • Exertional dyspnoea
      • Exertional chest pain
      • Exertional syncope
      • Symptoms of right heart failure - peripheral oedema, ascites

      Overview

      • Risk Factors for Ischaemic Heart Disease

      • Family history of ischaemic heart disease
      • Advanced age
      • Smoking
      • Hypertension
      • Hyperlipidaemia
      • Diabetes mellitus
      • Physical inactivity
      • Obesity
      • Classification

      • Paroxysmal AF - occurring for <7 days
      • Persistent AF - occurring for >7 days
      • Permanent AF - long-standing despite attempts at cardioversion

      Complications

      • Complications of Hyperlipidaemia

      • Atherosclerosis

      • Ischaemic heart disease
      • Ischaemic stroke
      • Erectile dysfunction
      • Peripheral vascular disease
      • Other

      • Non-alcoholic fatty liver disease

      Aetiology

      • Causes of Chronic Dyspnoea

      • Other

      • Anaemia
      • Late pregnancy
      • Kyphoscoliosis
      • Muscular dystrophy
      • ALS

      Diagnosis

      • Stages of Chronic Kidney Disease

      • GFR Categories (mL/min/1.73m²)

      • G1 - ⩾90
      • G2 - 60-89
      • G3a - 45-59
      • G3b - 30-44
      • G4 - 15-29
      • G5 - <15
      • Albuminuria Categories

      • A1 - <30mg/g / <3mg/mmol
      • A2 - 30-300mg/g / 3-30mg/mmol
      • A3 - >300mg/mg / >30mg/mmol

      Diabetic Diagnosis

      • Ask About

      • Type of diabetes - type 1, type 2, late autoimmune diabetes in adults (LADA), steroid-induced diabetes, gestational diabetes
      • When the patient's diabetes was diagnosed
      • Symptoms at diagnosis - polyuria, polydipsia, thirst, weight loss, ketoacidosis, asymptomatic glycosuria
      • What test was used to diagnose their diabetes

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Complications

      • Complications of Colorectal Cancer

      • Disease-Related

      • Lower GI bleeding
      • Bowel obstruction
      • Perforation
      • Management-Related

      • Surgical complications - bleeding, wound infection, anastomotic leak, intra-abdominal collection, ileus
      • Adverse effects of chemotherapy - fatigue, nausea / vomiting / diarrhoea, myelosuppression
      • Adverse effects of VEGF inhibitors - hypertension, arterial / venous thromboembolism, myelosupression
      • Adverse effects of EGFR inhibitors - acneiform rash, nausea / vomiting / diarrhoea, hypomagnesaemia

      Overview

      • Risk Factors for Inflammatory Bowel Disease

      • Family history of inflammatory bowel disease
      • Smoking (Crohn's only - protective in ulcerative colitis)
      • Western diet - high fat, high sugar
      • Medications - NSAIDs, oral contraceptives
      • Not being breastfed
      • Psychological stress

      Complications

      • Complications of Non-Alcoholic Fatty Liver Disease

      • Cirrhosis
      • Cardiovascular disease
      • Type 2 diabetes mellitus
      • Chronic kidney disease
      • Colorectal cancer

      Medication History

      • Prescription

      • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
      • Administration - e.g. oral, IM or IV
      • Dose - the strength of the medication and how much they take eg how many tablets
      • Frequency - how often they take the medication

      Overview

      • Consequences of Tobacco Smoking

      • Atherosclerosis - coronary artery disease, cerebrovascular disease, peripheral vascular disease
      • Cancer - lung, throat, liver, gastric, colorectal, pancreatic, genitourinary
      • Chronic obstructive pulmonary disease
      • Pregnancy / neonatal complications - infertility, growth restriction, placental abruption, preterm delivery, SIDS
      • Increased infection risk
      • Peptic ulcer disease
      • Osteoporosis

      Peritransplant History

      • Ask About

      • When
      • Indication for liver transplant
      • Graft type - orthotopic vs split graft
      • Anastomosis - duct to duct (recipient to donor) vs roux-en-y (no recipient bile duct)

      Overview

      • Ask About

      • Travel to other countries - especially developing countries
      • Prophylaxis before travelling - vaccines, malaria prophylaxis
      • Exposure to animals - especially bites or scratches
      • Food intake - especially raw meat, fish, unpasteurised dairy products
      • Contact with fresh water
      • Contact with sick people
      • Insect bites
      • Sexual contacts
      • Needle exposures
      • Risk Factors for Gastroesophageal Reflux

      • Family history of reflux
      • Advanced age
      • Obesity
      • Hiatus hernia
      • Pregnancy
      • Scleroderma
      • Smoking

      IV Drug Use

      • Consequences of IV Drug Use

      • Blood-borne viral infections - hepatitis B, hepatitis C, HIV
      • Bacterial septicaemia
      • Infective endocarditis - especially right-sided (tricuspid) disease
      • Cutaneous infection - skin abscess, cellulitis, necrotising fasciitis
      • Venous damage - superficial thrombophlebitis, deep venous thrombosis

      Overview

      • Ask About

      • Everyone

      • Whether they drink alcohol regularly
      • How often - daily, weekly, monthly, or on social occasions only
      • What type of alcohol they drink
      • How many drinks on each occasion / each day
      • The most they drink at any given time
      • Where they drink - restaurants, bars, parties, at home
      • Amount spent on alcohol
      • Heavy Drinkers

      • Withdrawal symptoms - sweating, rigors, nausea, past seizures
      • Alcohol free days
      • Past attempts to quit drinking
      • Willingness to cut down or stop
      • Causes of Peptic Ulcer Disease

      • Helicobacter pylori infection
      • Medications - NSAIDs, steroids, bisphosphonates, chemotherapy
      • Zollinger-Ellison syndrome
      • Gastric malignancy
      • Acute illness

      Complications

      • Complications of Cirrhosis

      • Ascites (due to portal hypertension, RAAS activation and splanchnic vasodilatation)
      • Varices (due to portal hypertension)
      • Splenomegaly (due to portal hypertension)
      • Hepatic encephalopathy (due to ammonia buildup)
      • Spontaneous bacterial peritonitis (due to gut translocation)
      • Hepatorenal syndrome (due to splanchnic vasodilatation)
      • Hepatic hydrothorax (due to leakage of ascitic fluid into the pleural space)
      • Portopulmonary hypertension (due to portal hypertension)
      • Hepatopulmonary syndrome (due to vasodilation / shunting)
      • Malnutrition / sarcopaenia
      • Coagulopathy (due to poor synthetic function + vitamin K malabsorption)
      • Thrombocytopaenia (due to splenic sequestration)
      • Hepatocellular carcinoma (HCC)

      Manifestations

      • Manifestations of Hepatitis C Infection

      • Hepatic

      • Chronic hepatitis
      • Cirrhosis
      • Extrahepatic

      • Dermatologic - lichen planus, porphyria cutanea tarda
      • Immune - essential mixed cryoglobulinaemia, Sjogren's syndrome
      • Renal - membranoproliferative glomerulonephropathy
      • Non-Hodgkin lymphoma
      • Type 2 diabetes mellitus
      • Manifestations of Hepatitis B Infection

      • Hepatic

      • Acute hepatitis
      • Chronic hepatitis
      • Cirrhosis
      • Hepatitis D infection
      • Extrahepatic

      • Polyarteritis nodosa
      • Membranous glomerulonephropathy
      • Serum sickness-like syndrome (fevers, rash, myalgias, arthralgias)

      Overview

      • Types of Scleroderma

      • Limited scleroderma (CREST syndrome) - slowly progressive; less associated with cardiac disease and renal crisis
      • Diffuse scleroderma - rapidly progressive; associated with lung disease, renal crisis and cardiac disease

      Exercise Tolerance


      • Exercise tolerance is a strong prognostic marker for many chronic conditions such as ischaemic heart disease, heart failure, peripheral vascular disease and COPD.

      Overview

      Also ask about whether the patient's mobility has changed recently, and why.

      Management

      • Management Options

      • Non-Pharmacologic

      • Weight loss
      • Exercise - gym programs, tai chi, hydrotherapy
      • Physiotherapy
      • Walking aids
      • Joint protection - taping, splinting, orthotics
      • Pharmacologic

      • Simple analgesia - paracetamol, NSAIDs
      • Opioids (to be avoided)
      • Intra-articular corticosteroids
      • Surgical

      • Osteotomy (change in alignment)
      • Arthroplasty (joint replacement)
      • Arthrodesis (joint fusion)

      Manifestations

      • Manifestations of Rheumatoid Arthritis

      • Articular

      • Symmetrical inflammatory polyarthropathy with sparing of the distal interphalangeal (DIP) joints
      • Tendon rupture
      • Atlantoaxial instability (severe cases)
      • Extra-Articular

      • Rheumatoid nodules
      • Systemic - fatigue, weight loss
      • Skin - rheumatoid nodules
      • Ocular - sicca symptoms, scleritis, episcleritis, scleromalacia, scleromalacia perforans
      • Vasculitis - pulmonary hypertension, palpable purpura, distal gangrene
      • Neurologic - compressive neuropathies (e.g. carpal tunnel syndrome), mononeuritis multiplex
      • Cardiovascular - pericarditis
      • Respiratory - interstitial lung disease, pleurisy, lung nodules
      • Haematologic - Felty's syndrome (arthritis, splenomegaly and neutropaenia)

      Complications

      • Complications of Gout

      • Gouty tophi - in bursae, tendons, subcutaneous tissues
      • Joint destruction
      • Nephrolithiasis
      • Urate nephropathy

      Overview

      • Precipitants of Lupus Flares

      • UV light
      • Stress
      • Infections
      • Pregnancy
      • Rapid tapering of immunosuppression
      • Drugs - procainamide, hydralazine, minocycline, quinidine, diltiazem, isoniazid, phenytoin, carbamazepine

      Optic Nerve Palsy

      • Causes of Optic Nerve Palsy

      • Intraorbital - trauma, ischaemia, aneurysm, tumour, optic neuritis, optic nerve hypoplasia
      • Optic chiasm - pituitary tumour, craniopharyngioma, pituitary apoplexy
      • Optic tract - ischaemia, trauma, tumour, MS

      Vestibulocochlear Nerve Palsy

      • Causes of Vestibulocochlear Nerve Palsy

      • Tumour - cerebellopontine angle, internal auditory canal
      • Meningitis
      • Guillain-Barre
      • Sarcoidosis
      • Congenital absence

      Overview

      • Causes of Palsy

      • Trauma - coup / contrecoup
      • Frontal lobe - trauma, ischaemia, tumour
      • Meningitis
      • Neurosyphillis
      • Causes of Pseudobulbar Palsy

      • Internal capsular stroke
      • Multiple sclerosis
      • Motor neurone disease
      • Head injury
      • Interpretation

      • Increased - ongoing blinking without habitualizationParkinsonism or frontal lobe pathology
      • Normal - up to five blinks and then no further blinking following habitualization
      • Decreased - no blinking in response to stimulusUpper or lower motor neuron weakness

      Trigeminal Nerve Palsy

      • Causes of Trigeminal Nerve Palsy

      • Trigeminal ganglion lesion - herpes zoster, tumour
      • Trigeminl (V) nerve lesion - trauma, tumour, ICA aneurysm, cavernous sinus thrombosis, SLE

      Hypoglossal Nerve Palsy

      • Causes of Hypoglossal Nerve Palsy

      • Tumour
      • Trauma
      • Infarction
      • Haemorrhage
      • Demyelination
      • Motor neurone disease

      Vagus Nerve Palsy

      • Causes of Vagus Nerve Palsy

      • Peripheral nerve trauma
      • Peripheral nerve ischaemia
      • Base of skull fractureInvolving the jugular foramen
      • Motor neurone disease

      Olfactory Nerve Palsy

      • Causes of Olfactory Nerve Palsy

      • Trauma - coup / contrecoup
      • Frontal lobe - trauma, ischaemia, tumour
      • Meningitis
      • Neurosyphillis

      Abducens Nerve Palsy

      • Causes of Abducens Nerve Palsy

      • Small-vessel ischaemia
      • Head trauma
      • Tumour
      • Aneurysm

      II Optic Nerve

      • Causes of Palsy

      • Intraorbital - trauma, ischaemia, aneurysm, tumour, optic neuritis, optic nerve hypoplasia
      • Optic chiasm - pituitary tumour, craniopharyngioma, pituitary apoplexy
      • Optic tract - ischaemia, trauma, tumour, MS
      • Optic radiation - ischaemia, demyelination, PML, tumour
      • Occipital lobe - ischaemia, trauma, trauma

      Facial Nerve Palsy

      • Causes of Facial Nerve Palsy

      • Supranuclear
      • Ischaemic stroke (lacunar or superior cerebellar artery)
      • Tumour - primary / secondary
      • Nuclear / Infranuclear
      • Bell's palsy (idiopathic)
      • Ramsay-Hunt syndrome (Herpes zoster)
      • Tumour - primary / secondary
      • Parotid gland pathology
      • Otitis media / externa
      • Skull fracture
      • Guillain-Barre
      • Ischaemia
      • Lyme disease
      • Leprosy

      V Trigeminal Nerve

      • Causes of Palsy

      • CNS lesion - ischaemia, haemorrhage, tumour, syringobulbia, syringomyelia
      • Trigeminal ganglion lesion - herpes zoster, tumour
      • Peripheral nerve lesion - trauma, tumour, ICA aneurysm, cavernous sinus thrombosis, SLE

      XI Accessory Nerve

      • Causes of Palsy

      • Trauma - blunt, cervical stretch injury, iatrogenic (e.g. lymph node biopsy)
      • Tumour
      • Medullary infarction

      Accessory Nerve Palsy

      • Causes of Accessory Nerve Palsy

      • Trauma - blunt, cervical stretch injury, iatrogenic (e.g. lymph node biopsy)
      • Tumour
      • Medullary infarction

      XII Hypoglossal Nerve

      • Causes of Palsy

      • Tumour
      • Trauma
      • Infarction
      • Haemorrhage
      • Demyelination
      • Motor neurone disease

      Trochlear Nerve Palsy

      • Causes of Trochlear Nerve Palsy

      • Congenital absence
      • Closed head injury

      The Glasgow Coma Scale (GCS)

      • How to Assess

      • If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.

      Trochlear Nerve (IV) Palsy

      • Look For

      • Head tilting away from the side of the lesion
      • Eye deviation upward and rotation outward
      • Vertical diplopia
      • Inability to look down and in - difficulty descending stairs

      Overview

      • Causes of Bulbar Palsy

      • Motor neurone disease
      • Guillain-barré
      • Polio
      • Neurosyphilis
      • Brainstem stroke

      Glossopharyngeal Nerve Palsy

      • Causes fo Glossopharyngeal Nerve Palsy

      • Tumour
      • Infarction
      • Base of skull fractureInvolving the jugular foramen
      • Diptheria

      Overview

      Dilate the eye if possible with tropicamide, atropine or phenylephrine eye drops.
      • Manifestations of Myotonic Dystrophy

      • Myotonia
      • Cognitive impairment
      • Cataracts
      • Hearing impairment
      • Endocrine - diabetes, hypogonadism, secondary hyperparathyroidism
      • Cardiovascular - arrhythmia, cardiomyopathy, sudden cardiac death
      • Respiratory - obstructive sleep apnoea
      • Gastrointestinal - transaminase elevation, constipation / diarrhoea
      • Hypogammaglobulinaemia
      • Causes of Cerebellopontine Angle Syndrome

      • Vestibular schwannoma
      • Meningioma
      • Cerebellar astrocytoma
      • Brain metastasis

      VII Facial Nerve

      • Causes of Palsy

      • Supranuclear
      • Infarction (lacunar or superior cerebellar artery)
      • Tumour - primary / secondary
      • Nuclear / Infranuclear
      • Bell's palsy (idiopathic)
      • Ramsay-Hunt syndrome (Herpes zoster)
      • Tumour - primary / secondary
      • Parotid gland pathology
      • Otitis media / externa
      • Skull fracture
      • Guillain-Barre
      • Ischaemia
      • Lyme disease
      • Leprosy

      Horner's Syndrome

      • Causes of Horner's Syndrome

      • Brain lesion - hypothalamus, thalamus, pons, medullaTumour, bleed
      • Spinal cord lesionTrauma, inflammation, AVM, demyelination, tumour, infarct
      • Apical lung lesion (Pancoast syndrome)
      • Brachial plexus lesion

      Occulomotor Nerve Palsy

      • Causes of Oculomotor Nerve Palsy

      • Small-vessel ischaemia
      • Midbrain infarct
      • Head trauma
      • Tumour
      • Aneurysm (commonly PCA)

      Facial Asymmetry

      Sparing of the eyebrows (i.e. absence of eyebrow droop) distinguishes an upper motor neuron lesion from a lower motor neuron lesion, as the eyebrows receive innervation from both cerebral hemispheres (collateral supply) and the lower face receives only contralateral supply.

      VIII Vestibulocochlear Nerve

      • Causes of Palsy

      • Tumour - cerebellopontine angle, internal auditory canal
      • Meningitis
      • Guillain-Barre
      • Sarcoidosis
      • Congenital absence

      Overview

      • Causes of Cerebellar Lesions

      • Trauma
      • Vascular - ischaemia, haemorrhage
      • Infection - abscess, tuberculosis
      • Malignancy
      • Demyelination - multiple sclerosis
      • Drugs / toxins - alcohol, lithium, phenytoin, chemotherapy
      • Inherited - Friedrich's ataxia, spinocerebellar ataxia
      • Paraneoplastic syndrome
      • Hypothyroidism
      Posterior tibial - palpate posteriorly and inferiorly to the medial malleolus.

      Extra Credit

      • Complications of Peritoneal Dialysis

      • Catheter obstruction
      • Catheter infection
      • Peritonitis
      • Pleural effusion
      • Pericatheter leak
      • Abdominal wall (Spigelian) hernia

      Overview

      • Abnormal If

      • >2 seconds

      Measuring Blood Pressure

      • Prior to Testing Blood Pressure

      • Ask the patient whether they have had dialysis (have an AV fistula), whether they have had breast cancer surgery (and lymph node dissection) or whether there is some other reason their blood pressure should not be measured on a particular arm.

      Hepatomegaly

      Apply gentle pressure to the right lower quadrant with the palpating hand parallel to the edge of the liver. Ask the patient to take a slow breath in to bring the liver edge toward the fingertips. Move the hand 2cm superiorly each time the patient breathes out and repeat until the lower edge of the liver is palpable.

      Peripheral Neuropathy

      • Look For

      • Loss of / altered sensation in the hands and / or feet, in a 'glove and stocking distribution.

      Pallor of the Lower Limb

      • Look For

      • Loss of colour in one or both lower limbs.

      Crepitations

      • Causes of Pulmonary Crepitations

      • Fine Crackles

      • Pulmonary oedema - congestive cardiac failure, fluid overload
      • Pneumonia
      • Pulmonary interstitial fibrosis
      • Coarse Crackles

      • Chronic bronchitis
      • Bronchiectasis
      • Cystic fibrosis

      Venous Skin Changes

      • Significance

      • Venous insufficiency.

      Overview

      The kidneys are not palpable in most normal patients, though may be palpable in thin patients and children.

      Abdominal Scars

      • Abdominal Scars

      Overview

      • Significance

      • Pericarditis.
      • Causes of Flank Tenderness

      • Infection - pyelonephritis, perinephric abscess
      • Malignancy - renal cell carcinoma, transitional cell carcinoma
      • Renal infarction
      • Trauma

      Xanthomata

      • Look For

      • Red to yellow lipid-filled nodules, papules or plaques, which may overly tendons, extensor surfaces, flexor surfaces or the palms.

      Rashes Associated with Renal Disease

      Porphyria cutanea tarda: blisters over sun-exposed areas such as the scalp, dorsal hands and forearms, neck and face.Uraemia, liver disease

      Overview

      • Causes of Asterixis

      • Bilateral Asterixis

      • Hepatic encephalopathy
      • Uraemia (renal failure)
      • Hypercarbia
      • Medications - clozapine, carbemazepine, valproate, levodopa
      • Unilateral Asterixis

      • CNS lesions - thalamus, midbrain, basal ganglia, frontal lobe
      • Subdural haematoma

      Contour

      Slow rate of rise Aortic stenosis

      Oral Candidiasis

      • Risk Factors

      • Dry mouth
      • Inhaled steroids
      • Immunosuppression
      • Antibiotic use
      • Smoking
      • Diabetes

      Overview

      • Significance

      • Turbulent blood flow due to endothelial narrowing.

      Pitting Oedema

      • Look For

      • Persistence of the depressed area after pressure is removed.

      Heart Rate

      • Causes of Bradycardia (

      • Physiological - high cardiac fitness
      • Beta blockers
      • Hypothyroidism
      • Raised intracranial pressure
      • Heart block
      • Sick sinus syndrome

      Scratch Marks

      • Look For

      • Scratch marks over the skin of the face, arms, chest or abdomen.

      Overview

      Position the patient at 45 degrees and ask them to turn their head to the left. Hold a flashlight tangentially to the skin of the neck and inspect for the highest level of the jugular venous pulsation. Measure the vertical distance between the sternal angle and this level.

      Weight

      • Causes of Weight Gain

      • Dietary intake
      • Physical exercise
      • Endocrine - hypothyroidism, Cushing's, PCOS
      • Medications - steroids, antidepressants, antipsychotics, OCP
      • Fluid overload - excessive IV fluids, renal disease, heart failure
      • Genetic

      Overview

      Dilate the eye if possible with tropicamide, atropine or phenylephrine eye drops.

      Dehydration

      • Look For

      • Abnormal obs - tachycardia, hypotension
      • Fluid balance chart - negative fluid balance, oliguria
      • Weight loss - an acute decrease in weight may indicate short-term change in fluid status
      • Dry mucous membranes - especially the tongue
      • Sunken eyes
      • Increased capillary refill time (>2 seconds)
      • Weak radial pulse
      • Decreased skin turgor - pinch a fold of skin on the patient's arm and then release it. Decreased skin turgor is present if the fold takes an abnormal time to return to its normal contour.

      Halitosis

      • Significance

      • Suggestive of bacterial colonisation in the mouth, pharynx, respiratory or gastrointestinal tracts.

      Arterial Ulcers

      • Look For

      • Deep, painful white ulcers with blanched surrounding tissue, affecting the toes, heels and bony prominences. These ulcers may become black with necrosis.

      Leukonychia

      • Interpretation

      • True Leukonychia

      • Total leukonychia: generalised whitening of the nails.Inherited - rare
      • Transverse leukonychia (Mee's lines): single white bands running parallel to the nail base, that do not disappear when depressed.Intermittent insult during nail growth - arsenic, chemotherapy, trauma, infection
      • Apparent Leukonychia

      • Muehrcke's lines: double white bands that disappear when the nail is depressed.Chronic hypoalbuminaemia
      • Half and half nails (Lindsay's nails): proximal white nail bed and distal brown nail, separated by a transverse ridge.Uraemia
      • Terry's nails: white proximal nail bed with loss of the lunula (proximal white crescent-shaped area).Cirrhosis, CCF, diabetes, malnutrition, renal transplant

      Overview

      • Causes of Sacral Oedema

      • Excessive IV fluids
      • Renal disease
      • Heart failure
      • Causes of Warm Extremities

      • Systemic - fever / hyperthermia
      • Cellulitis
      • Lymphoedema
      • Venous abnormalities - deep venous thrombosis, superficial thrombophlebitis, venous insufficiency

      Complications

      • Complications of Chronic Kidney Disease

      • Disease-Related

      • Acidosis (poor clearance of hydrogen ions)
      • Fluid overload
      • Electrolyte derangements - hyperkalaemia, hyperphosphataemia
      • Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
      • Anaemia (EPO deficiency)
      • Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
      • Uraemia - encephalopathy, uraemic pericarditis
      • Malnutrition
      • Treatment-Related

      • Lethargy
      • Muscle cramps
      • Restless legs syndrome
      • Access-related complications - thrombosis, infection

      Overview

      • Normal Range of Motion

      • 50°

      Benediction Hand

      • How to Perform

      • Ask the patient to make a fist. Benediction hand is present if the patient is unable to flex the index and middle fingers.

      Overview

      • Normal Range of Motion

      • 70°
      • Normal Range of Motion

      • 70°

      Psoriatic Plaques

      • Look For

      • Raised erythematous patches, particularly affecting the extensor surfaces of joints, scalp, periumbilicus, lower back and skin folds

      Overview

      • Normal Range of Motion

      • 20°
      • X-Ray Findings in Rheumatoid Arthritis

      • Reduced joint space - generally symmetric
      • Articular surface erosions: discontinuities in the bone plate
      • Periarticular osteopaenia - hypodensity of bone surrounding the joint
      • Soft tissue swelling

      Pathogenesis

      • Risk Factors for Gout

      • Male gender
      • Obesity
      • Chronic kidney disease
      • Drugs - diuretics, ethambutol, certain chemotherapeutic agents
      • Excess purine-rich foods - beer, shellfish, liver, marmite
      • Excess sucrose / fructose intake
      • Alcohol excess

      Overview

      • Normal Range of Motion

      • 70°
      • Normal Range of Motion

      • 20°

      Soft Tissue Landmarks of the Wrist

      Snuffbox - on the radial aspect of the dorsum of the hand, at the base of the thumb. Contains the scaphoid and trapezium. Snuffbox tenderness is characteristic of scaphoid fracture.

      Muscles Acting on the Wrist Joint

      Abductors - flexor carpi radialis, extensor carpi radialis longus & brevis

      Overview

      • Normal Range of Motion

      • 80°
      • Normal Range of Motion

      • 70°
      • Normal Range of Motion

      • Metacarpophalangeal joint - 80°
      • Proximal interphalangeal joint - 100°
      • Distal interphalangeal joint - 70°

      Tinel's Sign

      • Abnormal If

      • Paraesthesia / reproduction of the patient's symptoms.

      Overview

      • Normal Range of Motion

      • 0° or slightly more
      • Normal Range of Motion

      • 20°
      • Normal Range of Motion

      • 30°

      Bony Landmarks of the Wrist

      Head of radius - proxiamlly, articulating with the distal humerus and radial head.

      Overview

      • Normal Range of Motion

      • 10°
      • Normal Range of Motion

      • 40-50°
      • Normal Range of Motion

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Bony Landmarks of the Shoulder

      Acromioclavicular joint - the articulation between the distal end of the clavicle and the acromion of the scapula.

      Posterior Shoulder Dislocation

      • Look For

      • Internal rotation of the shoulder with prominent coracoid process and posterior fullness of the shoulder joint.

      Overview

      • Normal Range of Motion

      • 20°
      • Normal Range of Motion

      • 90°
      • Normal Range of Motion

      • 0-10°
      • Normal Range of Motion

      • 135°
      • Normal Range of Motion

      • 170°

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Muscles Acting on the Shoulder Joint

      Abductors - lateral deltoid, supraspinatus

      Overview

      • Normal Range of Motion

      • 15°
      • Normal Range of Motion

      • Abnormal If

      • Pain.
      • Normal Range of Motion

      • 70°

      Measuring Blood Pressure

      • Sizing the Blood Pressure Cuff

      • The blood pressure cuff should measure approximately 80% of the circumference of the arm.

      Overview

      • Normal Range of Motion

      • Active - 120°
      • Passive - 125°
      • Normal Range of Motion

      • Active - 15°
      • Passive - 20°
      • How to Assess

      • Ask the patient to walk ~5m and return to their starting point.

      Muscles Acting on the Hip Joint

      Adductors (medial) - pectineus; adductor longus, brevis and magnus; gracilis, pectineus

      Overview

      • Causes of Poor Posture

      • Structural - deformities of the spine, foot and ankle
      • Leg Length discrepancy
      • Poor foot posture
      • Muscular imbalance - habitual poor body position
      • Normal Range of Motion

      • Active - 35°
      • Passive - 40°
      • Abnormal If

      • Reproduction of the patient's symptoms - pain or paraesthesia.
      • Normal Range of Motion

      • Active - 40°
      • Passive - 45°

      Active Movement

      • Causes of Limited Active Movement

      • Joint pain / stiffness - see below
      • Upper motor neuron lesion - stroke, tumour, trauma, hypoxia, demyelination, deposition, inflammation
      • Lower motor neuron lesion - trauma, compression, demyelination, neuromuscular disorders, diabetes
      • Poor compliance

      Overview

      • Normal Range of Motion

      • Active - 35°
      • Passive - 45°

      Bony Landmarks of the Hip

      Posterior superior iliac spine - the most posterior aspect of the iliac crest, identified by dimples at approximately the level of S2

      Overview

      • Feel For

      • Placing the fingers over the femoral region, external & internal inguinal rings, palpate for bulge or impulse on coughing.
      • Normal Range of Motion

      • Active - 20°
      • Passive - 25°

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Complications

      • Complications of Marfan Syndrome

      • Cardiovascular

      • Dilatation of the proximal aorta
      • Aortic root dissection
      • Mitral valve prolapse
      • Ocular

      • Ectopia lentis: lens displacement (pathognomonic)
      • Myopia: nearsightedness
      • Musculoskeletal

      • Protrusio acetabuli: displacement of the medial aspect of the femoral head beyond the ilio-ischial line
      • Other

      • Pneumothorax
      • Dural ectasia: ballooning of the dura in the spine resulting in enlargement of the neural canal

      Overview

      Smaller VSDs tend to be louder.
        • Normal Range

        • 12 - 20 breaths per minute
      BMI =
      WeightHeight²
      A hum will be heard normally, which is due to normal jugular venous flow.
      Clubbing was first described by Hippocrates in 400BC after noting the sign in a patient with empyema.

      Pallor of the Nail Bed

      • Look For

      • Whitening of the nail beds.

      Down Syndrome

      • Cardiac Sequelae

      • At Birth

      • Atrioventricular (AV) septal defects (45%)
      • Ventricular septal defects (35%)
      • Atrial (secundum) septal defect (8%)
      • Persistent ductus arteriosus (7%)
      • In Adolescence

      • Tetralogy of Fallor (4%)
      • Mitral valve prolapse (46%)
      • Aortic regurgitation (17%)

      Overview

      • Causes of Left Ventricular Failure

      • Ischaemic heart disease
      • Cardiomyopathy
      • Myocarditis
      • Pericardial disease
      • Valvular disease
      • Congenital heart disease
      • Hypertension

      Management

      • Management Strategy

      • Treat the underlying cause
      • Sputum clearance - bronchodilators, mucolytics, hypertonic saline, physiotherapy, postural drainage
      • Reduce inflammation - using macrolides (azithromycin)
      • Manage infection - monitor for colonisation, consider antimicrobial prophylaxis
      • Vaccinations - influenza, pneumococcus
      • Nutritional support
      • Home oxygen
      • Lung transplant

      History of Presenting Complaint

      • Character

         The type of pain - sharp, dull, tight, crushing, burning or tearing.
      • Central, crushing chest painTypical of acute coronary syndrome
      • Tearing pain that radiates to the backCharacteristic of aortic dissection
      • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE, chest wall pain (unlikely anginal)

      Management

      • Management Strategies

      • Lifestyle

      • Avoid exposure to irritants
      • Pulmonary rehabilitation
      • Pharmacologic

      • Idiopathic pulmonary fibrosis - pintedanib, pirfenidone
      • Connective tissue disease-related ILD - immunosuppression
      • Supportive Measures

      • Home oxygen
      • Vaccinations - influenza, pneumococcus
      • Surgical Options

      • Lung transplant

      Diagnosis

      • Potential Presentations

      • Disease-Related

      • Respiratory symptoms - cough, haemoptysis, dyspnoea, pleuritic chest pain
      • Constitutional symptoms - anorexia, weight loss, fatigue
      • Complication-Related

      • SVC obstruction - facial swelling, plethora, upper limb oedema, positive Pemberton's sign
      • Pancoast tumour - Horner's syndrome (partial ptosis, miosis, anhydrosis), wasting of the hand
      • Laryngeal nerve involvement - hoarse voice
      • Paraneoplastic - hypercalcaemia, neurologic symptoms, hypertrophic pulmonary osteoarthropathy, Cushing's syndrome

      Exercise Tolerance

      • Ask About

      • How far the patient is able to walk before they are limited by shortness of breath, chest pain or lower limb claudication pain.

      Overview

      • Potential Asthma Triggers

      • Environmental

      • Aeroallergens - pollens, dust mits, pet dander, mold
      • Cigarrette smoke
      • Air pollution
      • Other

      • Respiratory viral infections
      • Medications - beta blockers, NSAIDs
      • Exercise
      • Stress
      • Cold

      Pack-Years

      The number of 'packs' a patient has smoked per day over how many years. A useful measure of the amount of tobacco exposure the patient has had.

      Severity

      • Severity of Obstructive Sleep Apnoea

        Based on the apnoea-hypopnoea index on sleep study
      • Mild: 5-15
      • Moderate: 15-30
      • Severe: >30

      Management

      • Management Options

      • Latent TB

      • Isoniazid
      • Rifampicin
      • Active TB

      • First line (HRZE) - isoniazid, rifampicin, pyrazinamide and ethambutol
      • Other options - amikacin, capreomucin, moxifloxacin, linezolid, cycloserine, clofazimine, meropenem, augmentin

      Severity of COPD

      • Ask About

      • Symptoms - exertional dyspnoea, cough, chest tightness
      • Spirometry results - FEV1, FVC
      • Exacerbations - frequency, ED visits, hospital admissions, ICU admissions
      • Hypoxia - saturations, home oxygen
      • CO2 retention

      Management

      • Management Options

      • Thrombolysis (haemodynamically unstable patients)
      • Anticoagulation - heparin, low molecular weight heparin, warfarin, dabigatran, rivaroxaban, apixaban

      Medication History

      • Indication

      • Why the patient is taking the medication. This is often evident but sometimes not. Often the patient does not know themselves!

      Overview

      • Precipitants of Heart Failure

      • Arrhythmias
      • Infection
      • Anaemia
      • Myocardial infarction
      • IV fluid excess
      • Alcohol
      • Thyrotoxicosis
      • Surgery
      • Pregnancy

      Medication History

      • Indication

      • Why the patient is taking the medication. This is often evident but sometimes not. Often the patient does not know themselves!

      Pack-Years

      The number of 'packs' a patient has smoked per day over how many years. A useful measure of the amount of tobacco exposure the patient has had.

      Complications

      • Complications of Hypertension

      • Cardiovascular - left ventricular hypertrophy, heart failure, ischaemic heart disease, peripheral vascular disease, arrhythmia
      • Cerebrovascular - ischaemic stroke, haemorrhagic stroke, posterior reversible encephalopathy syndrome
      • Hypertensive retinopathy
      • Hypertensive nephropathy
      • Erectile dysfunction

      Overview

      • Conditions Associated with Obesity

      • Metabolic syndrome - type 2 diabetes mellitus, hypertension, hyperlipidaemia
      • Ischaemic heart disease (IHD)
      • Stroke
      • Respiratory - obstructive sleep apnoea, asthma
      • Gastrointestinal - reflux, cholelithiasis, non-alcoholic fatty liver disease (NAFLD)
      • Polycystic ovarian syndrome (PCOS)
      • Osteoarthritis
      • Varicose veins
      • Gout
      • Consequences of Alcohol Abuse

      • Oesophagitis
      • Pancreatitis
      • Alcoholic liver disease - steatosis, hepatitis, cirrhosis
      • Cardiovascular disease - hypertension, dilated cardiomyopathy, atrial fibrillation
      • Neurologic complications - Wernicke encephalopathy, Korsakoff syndrome, cerebellar atrophy, peripheral neuropathy, myopathy
      • Malignancy - mouth, oesophagus, throat, liver, breast
      • Bone marrow suppression
      • Osteoporosis
      • Malnutrition
      • Trauma - high risk behaviour, MVA
      • Psychiatric disorders - depression, anxiety, suicide

      Complications

      • Complications of Pulmonary Hypertension

      • Pulmonary haemorrhage
      • Pulmonary arterial thrombosis
      • Right ventricular failure
      • Arrhythmias

      Severity

      • Ask About

      • Angina - frequency, onset, management
      • Heart failure symptoms - exertional dyspnoea, orthopnoea, paroxysmal noctural dyspnoea, peripheral oedema
      • Exercise tolerance
      • Last stress test results - chest pain, ECG changes
      • Last echo results - ejection fraction, regional wall motion abnormalities
      • Last angiogram results - degree of stenosis, intervention

      Overview

      • Causes of Atrial Fibrillation

      • Severe acute illness - especially in septic or postoperative patients
      • Cardiac - post cardiac surgery, myocardial infarction, valvular disease, cardiomyopathy, congestive cardiac failure, congenital heart disease, Wolff-Parkinson-White
      • Cardiovascular risk factors - hypertension, diabetes, obesity
      • Pulmonary embolism
      • Obstructive sleep apnoea
      • Thyrotoxicosis
      • Alcohol abuse

      Management

      • Heart Foundation Lipid Targets

      • Total cholesterol: <4.0
      • LDL cholesterol: <2.0 (<1.8 if very high risk)
      • HDL cholesterol: >1.0
      • Triglycerides: <2.0

      History of Presenting Complaint

      • Onset

        Whether the shortness of breath came on suddenly or gradually; during the day or at night; on exertion; or whether the patient  wakes up short of breath.
      • Sudden onsetSuggestive of severe cause e.g. PE, MI, pneumothorax, anaphylaxis, aspiration, APO, tamponade
      • Paroxysmal nocturnal dyspnoea - suddenly waking with shortness of breathSuggestive of heart failure
      • Onset after surgeryMay be due to PE, ACS or APO
      • Onset post traumaMay represent pneumothorax or rib fracture

      Complications

      • Complications of Chronic Kidney Disease

      • Disease-Related

      • Acidosis (poor clearance of hydrogen ions)
      • Fluid overload
      • Electrolyte derangements - hyperkalaemia, hyperphosphataemia
      • Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
      • Anaemia (EPO deficiency)
      • Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
      • Uraemia - encephalopathy, uraemic pericarditis
      • Malnutrition
      • Treatment-Related

      • Lethargy
      • Muscle cramps
      • Restless legs syndrome
      • Access-related complications - thrombosis, infection

      Glycaemic Management

      • Ask About

      • Type 1 Diabetes

      • Insulin regimen - basal-bolus, insulin pump
      • Type 2 Diabetes

      • Diet
      • Exercise
      • Weight loss
      • Oral hypoglycaemics - doses, side effects
      • Insulin - basal, basal-bolus, mixed
      • Both

      • Latest HbA1c - and the target, if they know it
      • BSL monitoring - whether they measure their BSLs at home and
      • Carbohydrate counting - patients on pre-meal insulin, to guide dosing

      Exercise Tolerance

      • Ask About

      • How far the patient is able to walk before they are limited by shortness of breath, chest pain or lower limb claudication pain.

      Management

      • Management Strategy

      • Depends on stage and the patient's functional status.
      • Non-Metastatic

      • Surgical resection with or without adjuvant chemotherapy
      • Surveillance - CEA level, CT, colonoscopy
      • Metastatic

      • Surgical resection (solitary metastasis) with adjuvant chemotherapy
      • VEGF inhibitors - bevacizumab
      • EGFR inhibitors - cetuximab, panitumumab

      Manifestations

      • Manifestations of Inflammatory Bowel Disease

      • Ulcerative Colitis

      • Bloody diarrhoea
      • Toxic megacolon
      • Fulminant colitis
      • Stricturing
      • Colorectal cancer
      • Crohn's Disease

      • Mouth ulcers
      • Malabsorption
      • Intestinal obstruction
      • Anorectal disease - fissures, fistulae, abscesses
      • Fistulae - anorectal, rectovaginal, enterocutaneous
      • Malignancy - small bowel or colorectal cancer
      • Extra-Intestinal

      • Dermatologic - erythema nodosum, pyoderma gangrenosum
      • Musculoskeletal - enteropathic arthritis, osteoporosis
      • Hepatic - primary sclerosing cholangitis, non-alcoholic fatty liver disease, cirrhosis, cholelithiasis (Crohn's)
      • Renal - nephrolithiasis (calcium oxalate)
      • Ocular - uveitis, episcleritis, conjunctivitis

      Management

      • Management of Non-Alcoholic Fatty Liver Disease

      • Weight loss
      • Reduced alcohol intake
      • Cirrhosis surveillance
      • HCC surveillance

      Medication History

      • Indication

      • Why the patient is taking the medication. This is often evident but sometimes not. Often the patient does not know themselves!

      Pack-Years

      The number of 'packs' a patient has smoked per day over how many years. A useful measure of the amount of tobacco exposure the patient has had.

      Complications

      • Complications of Liver Transplant

      • Surgical

      • Wound - bleeding, infection, poor healing
      • Biliary - stricture, leak, haematoma, collection
      • Vascular - hepatic artery stenosis, hepatic vein stenosis, thrombosis
      • Immunologic

      • Rejection - T-cell mediated, antibody-mediated
      • Infectious

      • Fungal infections - candida, aspergillus, cryptococcus
      • Viral infections - herpes simplex, varicella, CMV, EBV, influenza
      • Bacterial infections - mycobacterial, pneumococcal
      • Protozoal infections - pneumocystis, toxoplasmosis
      • Other

      • Cardiovascular disease
      • Diabetes mellitus
      • Osteoporosis
      • Malignancy - skin, bowel, gynaecologic, post-transplant lymphoproliferative disease
      • Disease recurrence

      Overview

      • Important Travel-Related Infections

      • Diarrhoeal illnesses - giardia, amoeba, salmonella, shigella, cryptosporidia, cyclospora
      • Intestinal worms - strongyloidiasis, ascariasis, hookworm, whipworm, trichinosis, schistosomiasis
      • Mosquito-borne diseases - yellow fever, Japanese encephalitis, malaria, dengue fever, zika virus, chikungunya
      • Rickettsial illnesses - scrub typhus, spotted fevers
      • Tuberculosis
      • Other bacterial infections - meningococcal meningitis, typhoid fever, diptheria, leptospirosis, brucellosis, tetanus, lyme disease
      • Other viral infections - hepatitis A / B / C, HIV / AIDS, avian flu, measles, mumps, polio, rabies, ebola
      • Other parasitic infections - leishmaniasis

      Complications

      • Complications of Gastroesophageal Reflux

      • Oesophagitis
      • Oesophageal strictures
      • Barrett's oeseophagus
      • Oesophageal adenocarcinoma
      • Aspiration pneumonitis

      Overview

      • Consequences of Alcohol Abuse

      • Oesophagitis
      • Pancreatitis
      • Alcoholic liver disease - steatosis, hepatitis, cirrhosis
      • Cardiovascular disease - hypertension, dilated cardiomyopathy, atrial fibrillation
      • Neurologic complications - Wernicke encephalopathy, Korsakoff syndrome, cerebellar atrophy, peripheral neuropathy, myopathy
      • Malignancy - mouth, oesophagus, throat, liver, breast
      • Bone marrow suppression
      • Osteoporosis
      • Malnutrition
      • Trauma - high risk behaviour, MVA
      • Psychiatric disorders - depression, anxiety, suicide

      Complications

      • Complications of Peptic Ulcer Disease

      • Upper GI bleeding
      • Perforation
      • Gastric outlet obstruction

      Management

      • Management of Hepatitis C Infection

      • Non-Pharmacologic

      • Cirrhosis surveillance
      • HCC surveillance
      • Pharmacologic

      • NS3/4A inhibitors - grazoprevir, pariteprevir, simepravir
      • NS5A inhibitors - daclatasvir, elbasvir, ledipasvir, ombitasvir
      • NS5B inhibitors - dasabuvir, sofosbuvir

      Manifestations

      • Phases of Hepatitis B Infection

      • Immune tolerant - very early infection, prior to significant hepatitis
      • Immune active - attempted clearance of the virus by the immune system
      • Immune control - low viraemia due to clearance
      • Immune escape - recrudescence of viral replication and hepatitis
      • Manifestations of CREST Syndrome

      • Calcinosis cutis: hard masses beneath the skin, due to calcium deposition
      • Raynaud's phenomenon: areas of white, blue or red change in the hands
      • (O)Esophageal dysmotility
      • Sclerodactyly: thickening of the fingers / toes
      • Telangiectasia: visible dilated blood vessels

      Exercise Tolerance

      • Ask About

      • How far the patient is able to walk before they are limited by shortness of breath, chest pain or lower limb claudication pain.

      Overview

      • Significance

      • Poor mobility significantly increases risk of falls, and affects the patient's ability to perform their activities of daily living.

      Management

      • Ask About

      • Disease-modifying anti-rheumatic drugs (DMARDs) - effectiveness, adverse effects
      • Steroids - duration, continuous / intermittent, maximum dose, adverse effects, osteoporosis screening
      • Management Options

      • Acute Management of Flares

      • NSAIDs - indomethacin, naproxen, celecoxib
      • Colchicine
      • Steroids - oral / intra-articular
      • Non-Pharmacologic

      • Weight loss
      • Avoidance of risk factors - alcohol, sugar, purine-rich foods
      • Pharmacologic

      • Xanthine oxidase inhibitors - allopurinol, febuxostat
      • Uricosurics - probenecid, benzbromarone

      Manifestations

      • Manifestations of Systemic Lupus Erythematosus

      • Systemic - fatigue, fevers, weight loss
      • Skin - photosensitivity (malar) rash, discoid rash, alopecia
      • Musculoskeletal - arthralgias, non-erosive arthritis, myalgias, tenosynovitis
      • Cardiovascular - pericarditis, Raynaud's phenomenon, Libman Sacks (sterile) endocarditis, valvular disease, risk of atherosclerosis
      • Respiratory - pleurisy, interstitial lung disease
      • Neurologic (neuropsychiatric lupus) - cognitive dysfunction, psychosis, seizures
      • Haematologic - antiphospholipid syndrome, lymphopaenia, anaemia, thrombocytopaenia
      • Renal - lupus nephritis

      Special Sensory Pathway

      Cortical Centre
      Primary visual cortex (occipital lobe)
       
      Upper Pathway
      Optic radiations
      (parietal / occipital lobes)
       
      Nucleus
      Lateral geniculate nucleus (thalamus)
       
      Lower Pathway
      Optic tract
      Partial Decussation
      Of nasal / temporal visual field
      Optic chiasm
      Foramen
      Optic canal
       
      Bipolar Cells
      Retina
       
       
      Light Receptors
      Rods / cones of retina
      Cortical Centre
      Primary auditory cortex (temporal lobe)
       
       
      Nucleus
      Pons, medulla
       
      Cerebellopontine Angle
      Foramen
      Internal auditory meatus
      Division
       
       
       
       
      Cochlear Nerve
       
      Spiral Ganglion
       
       
      Receptors
      Organ of Corti
       
       
      Vestibular Nerve
       
      Vestibular Ganglion
       
       
      Receptors
      Vestibulae

      Pathway

      Processing / Association Centres
      Uncus, hippocampus, frontal lobe
       
       
      Olfactory Nucleus
      Olfactory Bulb
       
      Foramen
      Cribriform plate
       
      Olfactory Receptor Nuclei
      Osmoreceptors within nasal mucosa

      Sensory Pathway

      Cortical Centre
      Primary sensory cortex (parietal lobe)
       
       
      Sensory Nuclei
      Midbrain, pons, medulla, upper cervical cord
      Mesencephalic nucleus: proprioception of face, orbit, mastication, tongue
      Main sensory nucleus: tactile sensation
      Spinal nucleus: pain and temperature sensation
       
       
      Trigeminal Ganglion
       
       
       
       
      V1
      Ophthalmic branch
      Foramen
      Superior orbital fissure
       
       
      Receptors
      Forehead, nose, cornea, conjunctiva
       
       
      V2
      Maxillary branch
      Foramen
      Foramen rotundum
       
       
      Receptors
      Maxillary face, nasal mucosa, upper jaw, roof of mouth
       
       
      V3
      Mandibular branch
      Foramen
      Foramen ovale
       
       
      Receptors
      Mandibular face, temple, external ear, lower mouth, anterior â…” of tongue

      Motor Pathway

      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Hypoglossal Nucleus
      Medulla
       
      Foramen
      Hypoglossal canal
       
       
      Muscles
      Intrinsic & extrinsic tongue muscles

      Somatic Motor Pathway

      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Nucleus Ambiguus
      Medulla
       
      Foramen
      Jugular foramen
       
       
      Muscles
      Pharyngeal & laryngeal muscles, palatoglossus

      Pathway

      Processing / Association Centres
      Uncus, hippocampus, frontal lobe
       
       
      Olfactory Nucleus
      Olfactory Bulb
       
      Foramen
      Cribriform plate
       
      Olfactory Receptor Nuclei
      Osmoreceptors within nasal mucosa

      Motor Pathway

      Cortical Centre
      Primary motor cortex (frontal lobe)
       
       
      Abducens Nucleus
      Pons
       
      Foramen
      Superior orbital fissure
       
       
      Muscle
      Lateral rectus

      Special Sensory Pathway

      Cortical Centre
      Primary visual cortex (occipital lobe)
       
      Upper Pathway
      Optic radiations
      (parietal / occipital lobes)
       
      Nucleus
      Lateral geniculate nucleus (thalamus)
       
      Lower Pathway
      Optic tract
      Partial Decussation
      Of nasal / temporal visual field
      Optic chiasm
      Foramen
      Optic canal
       
      Bipolar Cells
      Retina
       
       
      Light Receptors
      Rods / cones of retina

      Motor Pathway

      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Facial Motor Nucleus
      Pons
       
      Foramen
      Internal auditory meatus
       
      Geniculate Ganglion
       
      Division
      Temporal, zygomatic, buccal, marginal mandibular and cervical branches
       
       
      Muscles
      Facial expression, orbicularis oculi

      Sensory Pathway

      Cortical Centre
      Primary sensory cortex (parietal lobe)
       
       
      Sensory Nuclei
      Midbrain, pons, medulla, upper cervical cord
      Mesencephalic nucleus: proprioception of face, orbit, mastication, tongue
      Main sensory nucleus: tactile sensation
      Spinal nucleus: pain and temperature sensation
       
       
      Trigeminal Ganglion
       
       
       
       
      V1
      Ophthalmic branch
      Foramen
      Superior orbital fissure
       
       
      Receptors
      Forehead, nose, cornea, conjunctiva
       
       
      V2
      Maxillary branch
      Foramen
      Foramen rotundum
       
       
      Receptors
      Maxillary face, nasal mucosa, upper jaw, roof of mouth
       
       
      V3
      Mandibular branch
      Foramen
      Foramen ovale
       
       
      Receptors
      Mandibular face, temple, external ear, lower mouth, anterior â…” of tongue

      Motor Pathway

      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Accessory Nucleus
      Medulla
       
      Foramen
      Jugular foramen
       
      Division
      Cranial and spinal branches
       
       
      Muscles
      Laryngeal & pharyngeal, sternocleidomastoid, trapezius
      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Accessory Nucleus
      Medulla
       
      Foramen
      Jugular foramen
       
      Division
      Cranial and spinal branches
       
       
      Muscles
      Laryngeal & pharyngeal, sternocleidomastoid, trapezius
      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Hypoglossal Nucleus
      Medulla
       
      Foramen
      Hypoglossal canal
       
       
      Muscles
      Intrinsic & extrinsic tongue muscles
      Cortical Centre
      Primary motor cortex (frontal lobe)
       
       
      Trochlear Nucleus
      Tegmentum (midbrain)
       
      Decussation
      Upper medulla
      Foramen
      Superior orbital fissure
       
       
      Muscle
      Superior oblique

      The Glasgow Coma Scale (GCS)

      If not done in this order, the examiner is unable to determine whether the patient responded to the painful stimulus or the voice.

      Trochlear Nerve (IV) Palsy

      • Causes of Trochlear Nerve Palsy

      • Congenital absence
      • Closed head injury
      • Small-vessel ischaemia
      • Multiple sclerosis

      Motor Pathway

      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Nucleus Ambiguus
      Medulla
       
      Foramen
      Jugular foramen
       
      Ganglia
      Superior (jugular) and
      inferior (petrous) ganglia
       
      Division
      Stylopharyngeal branch
       
       
      Muscles
      Stylopharyngeus

      Overview

      • Interpretation

      • Increased cup-disc ratio (>0.8, normally <0.5): the ratio of the size between the optic cup and the surrounding optic disc (entry point of the optic nerve and vessels)Glaucoma, giant cell arteritis, optic nerve compression / trauma / inflammation
      • Papilloedema: swelling of the disc with venous engorgement, cotton wool spots and haemorrhageRaised ICP, severe hypertension
      • Cotton wool spots: small white, cotton wool-like microinfarcts on the retinaHypertension, diabetes, HIV, anaemia, thrombocytopaenia, connective tissue disorders
      • Arteriovenous nicking: arteries displacing veins at points of crossingHypertension
      • Silver wiring: glistening bronze / silver arterial wallsHypertension
      • Retinal haemorrhages - e.g. small dots or flame-shapedDiabetes, leukaemia, pernicious anaemia, subarachnoid haemorrhage, DIC
      • Roth spots: haemorrhages with pale centresInfective endocarditis
      • Emboli: small white flecks over vessels, with distal narrowing.Generally cholesterol emboli from carotid artery disease

      Motor Pathway

      Cortical Centre
      Primary motor cortex (precentral gyrus)
       
       
      Facial Motor Nucleus
      Pons
       
      Foramen
      Internal auditory meatus
       
      Geniculate Ganglion
       
      Division
      Temporal, zygomatic, buccal, marginal mandibular and cervical branches
       
       
      Muscles
      Facial expression, orbicularis oculi

      Oculomotor Nerve (III) Palsy

      • Look For

      • Eye deviated down and out
      • Diplopia
      • Ptosis
      • Mydriasis: pupillary dilatation
      • Loss of pupillary reflexes

      Motor Pathway

      Eye movement and eye opening

      Blepharospasm

      • Look For

      • Bilateral involuntary spasm of the eyelid muscles.

      Special Sensory Pathway

      Cortical Centre
      Primary auditory cortex (temporal lobe)
       
       
      Nucleus
      Pons, medulla
       
      Cerebellopontine Angle
      Foramen
      Internal auditory meatus
      Division
       
       
       
       
      Cochlear Nerve
       
      Spiral Ganglion
       
       
      Receptors
      Organ of Corti
       
       
      Vestibular Nerve
       
      Vestibular Ganglion
       
       
      Receptors
      Vestibulae

      Overview

      Dorsalis pedis - palpate lateral to the extensor tendon of the great toe. This can be identified by asking the patient to extend their great toe.
      • Causes of Prolonged Capillary Refill Time

      • Shock
      • Dehydration
      • Decreased peripheral perfusion

      Measuring Blood Pressure

      Ask the patient not to talk or move while the blood pressure is measured as this can cause a false elevation in BP.

      Hepatomegaly

      • Scratch Test for Lower Liver Edge

      • Place the stethoscope over the liver just above the costal margin. Gently scratch the lower abdomen in the midclavicular line and slowly move up. Once the finger scratches over the lower liver edge the sound will be transmitted to the stethoscope.

      Peripheral Neuropathy

      • Causes of Peripheral Neuropathy

      • Endocrine - diabetes, hypothyroidism, acromegaly
      • Deficiency - B12 / folate deficiency, alcoholism
      • Connective tissue disease - rheumatoid arthritis, polyarteritis nodosa, SLE
      • Deposition - amyloidosis, sarcoidosis
      • Infection - AIDS, lyme disease
      • Toxins - arsenic, mercury, organic phosphates, carbon monoxide
      • Critical illness polyneuropathy

      Pallor of the Lower Limb

      • Causes of Lower Limb Pallor

      • Anaemia
      • Peripheral arterial disease
      • Compartment syndrome
      • Low cardiac output, due to cardiac disease
      • Peripheral shutdown, due to increased sympathetic activity

      Venous Skin Changes

      • Causes of Venous Skin Changes

      • Venous hypertension due to incompetent valves
      • Venous outflow obstruction
      • Calf-muscle pump failure - obesity, immobility

      Palpable Kidney

      The kidneys are not palpable in most normal patients, though may be palpable in thin patients and children.

      Abdominal Scars

      • Common Abdominal Surgical Scars

      • A
        Midline laparotomy: xiphoid process to above or below the umbilicusMost abdominal procedures
      • B
        Paramedian: either side of the midlineLateral structures - kidney, adrenals, spleen
      • C
        Subcostal: diagonally and parallel to the costal margin on either side.Gallbladder, biliary tract, spleen
      • D
        Chevron: bilateral subcostal incision meeting in the midlineGastrectomy, B/L adrenalectomy, liver surgery
      • E
        Loin: transverse, from lateral mid-abdomen to flankKidneys
      • F
        McBurney's: oblique incision made two thirds of the way fromthe umbilicus to the right anterior superior iliac spine.Appendicectomy
      • G
        Lanz: transverse incision across McBurney's pointAppendicectomy (better scar healing)
      • H
        Pfannenstiel: long, convex incision along the suprapubic creaseLower GIT, urinary tract, reproductive organs incl. caesarean
      • Laparoscopy: 3-4 small incisions on the abdomen; one at the umbilicus.Laparoscopic procedures

      Overview

      • Causes of Pericardial Rub

      • Infection
      • Trauma
      • Uraemia
      • Inflammatory conditions - rheumatoid arthritis, lupus
      • Cancers

      Xanthomata

      • Significance

      • Occurs in the setting of hyperlipidaemia or disturbances to lipid metabolism.

      Rashes Associated with Renal Disease

      Kyrle's disease: hyperpigmented papules with a central keratin plug.Chronic kidney disease, diabetes, liver failure

      Contour

      Bisferiens pulse (double beating pulse)Aortic regurgitation

      Mouth Ulcers

      • Look For

      • Ulcers in the mouth, noting their number, size, colour and distribution.

      Overview

      • Causes

      • Arterial stenosis
      • Atherosclerosis
      • Arterial occlusion with collateral flow

      Pitting Oedema

      • Causes of Pitting Oedema

      • Fluid overload - excessive IV fluids, renal failure, heart failure
      • Right ventricular failure
      • Venous pathology - thrombosis / insufficiency
      • Dependency (the effect of gravity)
      • Hypoalbuminaemia - malnutrition, malabsorption, nephrotic syndrome, liver (synthetic) failure

      Heart Rate

      • Causes of Tachycardia (>100bpm)

      • Sinus tachycardia - physical exertion, infection, anxiety, thyrotoxicosis, stimulant drugs, shock
      • Atrial fibrillation / flutter - aberrant conduction, parenchymal damage
      • Supraventricular tachycardia - aberrant conduction pathways/ re-entry

      Scratch Marks

      • Significance

      • An indicator that the patient has been pruritic.

      Overview

      • Interpretation

      • The JVP is elevated if the vertical distance between the sternal angle and the highest point of the pulse is greater than 4cm.

      Weight

      • Causes of Weight Loss

      • ↓ Dietary intake - anorexia, low access to food
      • Physical activity
      • Malignancy
      • Malabsorption - obstruction, IBD, pancreatitis, coeliac disease
      • Endocrine - hyperthyroidism, diabetes, phaeochromocytoma, addison's
      • Neurological - stroke, Parkinson's, dementia
      • Drugs - diuretics, chemotherapy, amphetamines, opioids
      • Organ failure - renal, hepatic, cardiac, respiratory, gut
      • Chronic infection - TB, HIV
      • Psychiatric - eating disorders, depression, alcoholism, schizophrenia

      Overview

      • Interpretation

      • Increased cup-disc ratio (>0.8, normally <0.5): the ratio of the size between the optic cup and the surrounding optic disc (entry point of the optic nerve and vessels)Glaucoma, giant cell arteritis, optic nerve compression / trauma / inflammation
      • Papilloedema: swelling of the disc with venous engorgement, cotton wool spots and haemorrhageRaised ICP, severe hypertension
      • Cotton wool spots: small white, cotton wool-like microinfarcts on the retinaHypertension, diabetes, HIV, anaemia / thrombocytopaenia, connective tissue disorders
      • Arteriovenous nicking: arteries displacing veins at points of crossingHypertension
      • Silver wiring: glistening bronze / silver arterial wallsHypertension
      • Retinal haemorrhages - e.g. small dots or flame-shapedDiabetes, leukaemia, pernicious anaemia, SAH, DIC
      • Roth spots: haemorrhages with pale centresInfective endocarditis
      • Emboli: small white flecks over vessels, with distal narrowing.Generally cholesterol emboli from carotid artery disease

      Dehydration

      • Causes of Dehydration

      • Poor fluid intake
      • Fluid loss - diarrhoea, vomiting, sweating, diuresis (diabetes, diuretics)

      Halitosis

      • Causes of Halitosis

      • Oropharyngeal

      • Xerostomia (dry mouth)
      • Poor oral hygiene
      • Mouth ulcer
      • Dental caries
      • Gingivitis
      • Tongue colonisation
      • Tonsilitis
      • Sinusitis
      • Gastrointestinal

      • Reflux
      • H pylori infection
      • Inflammatory bowel disease
      • Respiratory

      • Bronchiectasis
      • Bronchial tumour
      • Systemic

      • Cirrhosis
      • Ketosis
      • Alcohol
      • Uraemia

      Arterial Ulcers

      • Causes of Arterial Ulcers

      • Atherosclerosis
      • Diabetes
      • Thromboangiitis
      • Vasculitis

      Onycholysis

      • Look For

      • Separation of the nail from the nail bed, either distally or laterally.

      Benediction Hand

      • Significance

      • Median nerve lesion.

      Overview

      • Myotome

      • C6 / C7Radial nerve

      Psoriatic Plaques

      • Significance

      • In a patient with a symmetric polyarthritis, the presence of psoriatic plaques is pathognomonic for psoriatic arthritis, and are very useful in distinguishing this from rheumatoid arthritis - the other major differential.

      Overview

      • Myotome

      • T1Ulnar nerve

      Complications

      • Complications of Rheumatoid Arthritis

      • Ocular - sicca symptoms, scleritis, episcleritis, scleromalacia, scleromalacia perforans
      • Vasculitis - palpable purpura, distal gangrene, mononeuritis multiplex
      • Neurologic - compressive neuropathies (e.g. carpal tunnel syndrome)
      • Pulmonary - interstitial lung disease, pleural effusions, lung nodules
      • Felty's syndrome (arthritis, splenomegaly and neutropaenia)

      Overview

      • Myotome

      • T1Median nerve
      • Myotome

      • C6 / C7Radial / median nerves

      Muscles Acting on the Wrist Joint

      Adductors - flexor carpi ulnaris, extensor carpi ulnaris

      Overview

      • Myotome

      • C6 / C7Radial nerve
      • Myotome

      • C8Median nerve
      • Myotome

      • C7Radial nerve
      • Myotome

      • T1Ulnar nerve
      • Myotome

      • C8Ulnar / radial nerves

      Bony Landmarks of the Wrist

      Styloid process of radius - distally, attaching to the brachioradialis.

      Overview

      • Myotome

      • C8Radial nerve
      • Myotome

      • C6 / C7 / C8

      Passive Movement

      • How to Assess

      • Move the patient's joint. Note the range of motion and whether it is limited by pain, swelling or stiffness. Note any crepitus.

      Bony Landmarks of the Shoulder

      Acromion - just lateral to the acromioclavicular joint; a triangular process jutting out over the glenohumeral joint.

      Posterior Shoulder Dislocation

      Rare.

      Overview

      Depending on shoulder posture, the patient may be at the limit of shoulder depression while at rest.
      • Myotome

      • C5Axillary nerve

      Muscle Spasms

      • Causes of Muscle Spasms

      • Exercise-induced spasm (cramping)
      • Dehydration
      • Electrolyte abnormalities - hyper/hyponatraemia
      • Hereditary dystonia - idiopathic, Huntington's, Wilson's
      • Acquired dystonia - brain damage, encephalitis, parkinsonism, brain tumour, stroke, drug-induced
      • Factitious dystonia

      Muscles Acting on the Shoulder Joint

      Adductors - pectoralis major, trapezius, teres major, latissimus dorsi

      Measuring Blood Pressure

      • How to Measure

      • Place a blood pressure cuff of the correct size around the bulk of the biceps with the artery indicator over the brachial artery. Inflate the cuff until the radial pulse can no longer be palpated, plus a further 30mmHg.

      Overview

      • Myotome

      • L2-L4Femoral nerve
      • Myotome

      • L5/S1Sciatic nerve
      • Look For

      • Posture - position of the head, shoulders and spine.
      • Symmetry - symmetrical rise and fall of the shoulders, hips, knees and feet.
      • Rhythm - natural movement through the stance and swing phases.
      • Coordination - steadiness of the gait and amount of sway. Dyscoordination may indicate an ataxic or spastic gait.
      • Foot separation - wide-based or narrow-based. A wide base  is used to compensate for poor coordination.
      • Stride length - the distance between heel placements of one foot over one gait cycle.
      • Cadence - the number of steps per minute.

      Muscles Acting on the Hip Joint

      Abductors (lateral) - gluteus maximus, medius and minimus; tensor fascia lata, sartorius, piriformis

      Centre of Gravity

      • Look For

      • The line that falls from the earlobe down through the chest, abdomen, pelvis and lower limb (line of gravity).

      Overview

      • Myotome

      • L4 / L5Superior gluteal nerve

      Passive Movement

      • How to Assess

      • Move the patient's joint. Note the range of motion and whether it is limited by pain, swelling or stiffness. Note any crepitus.

      Bony Landmarks of the Hip

      Ischial tuberosity - deep to the gluteal fold posteriorly.

      Overview

      In the male, invert the scrotum on each side and palpate along the course of the spermatic cord to the inguinal canal. Ask the patient to cough. Feel if it is possible to get above the hernia
      • Myotome

      • L2 / L3Obturator Nerve

      Muscle Spasms

      • Causes of Muscle Spasms

      • Exercise-induced spasm (cramping)
      • Dehydration
      • Electrolyte abnormalities - hyper/hyponatraemia
      • Hereditary dystonia - idiopathic, Huntington's, Wilson's
      • Acquired dystonia - brain damage, encephalitis, parkinsonism, brain tumour, stroke, drug-induced
      • Factitious dystonia

      Overview

      • Causes of Ventricular Septal Defect

      • Congenital - associated with Down syndrome
      • Acquired - septal myocardial infarction, iatrogenic
      • How to Measure

      • Count the patient's breaths over 30 seconds to one minute while ostensibly measuring the pulse.

      Pallor of the Nail Bed

      • Causes of Nail Bed Pallor

      • Anaemia
      • Low cardiac output, due to cardiac disease
      • Peripheral shutdown, due to increased sympathetic activity.

      Turner Syndrome

      Monosomy X. All or part of an X chromosome missing, or duplication of the long arm of one X chromosome.

      Pallor of the Lower Limb

      • Look For

      • Loss of colour in one or both lower limbs.

      Clonus

      • Significance

      • Indicative of an upper motor neuron lesion.

      Weight

      • Causes of Weight Loss

      • ↓ Dietary intake - anorexia, low access to food
      • ↑ Physical activity
      • Malignancy
      • Malabsorption - obstruction, IBD, pancreatitis, coeliac disease
      • Endocrine - hyperthyroidism, diabetes, phaeochromocytoma, addison's
      • Neurological - stroke, Parkinson's, dementia
      • Drugs - diuretics, chemotherapy, amphetamines, opioids
      • Organ failure - renal, hepatic, cardiac, respiratory, gut
      • Chronic infection - TB, HIV
      • Psychiatric - eating disorders, depression, alcoholism, schizophrenia

      Kussmaul Respiration

      • Look For

      • Deep, rapid respiration.

      Overview

      • Interpretation

      • 0/5: No movement
      • 1/5: Flicker of movement
      • 2/5: Movement without gravity
      • 3/5: Movement against gravity
      • 4/5: Against weak resistance
      • 5/5: Normal power

      Dentition

      • Look For

      • The number and overall health of the teeth, and the presence of any carious or erosive lesions.

      Fluid Overload

      • Look For

      • Hypertension
      • Positive fluid balance in obs chart
      • Weight gain - look for a recent weight and compare to current weight
      • Bounding pulses
      • Raised JVP
      • Presence of S3 (gallop rhythm)
      • Crackles on lung field auscultation
      • Ascites - shifting dullness or fluid thrill
      • Pitting oedema to the sacrum and lower limbs, as well as elsewhere in the body in severe hypervolaemia

      Overview

      • Causes of Prolonged Capillary Refill Time

      • Shock
      • Dehydration
      • Decreased peripheral perfusion
      • Causes of Poor Visual Acuity

      • Refractory error
      • Corneal opacification - cataract, infection, trauma
      • Vitreal opacification - intraocular haemorrhage
      • Retinal disorders - macular degeneration, retinal detachment, diabetic retinopathy, retinal artery occlusion
      • Optic nerve disorders - glaucoma (raised intraocular pressure), ischaemia, optic neuritis
      • Intracranial disorders - pituitary disorders, aneurysm
      Liver disease in the absence of alcohol abuse is not a risk factor for Dupuytren's contracture, rather the presence may be suggestive of alcoholic liver disease.

      Arterial Ulcers

      • Causes of Arterial Ulcers

      • Atherosclerosis
      • Diabetes
      • Thromboangiitis
      • Vasculitis

      Peripheral Neuropathy

      • Causes of Peripheral Neuropathy

      • Endocrine - diabetes, hypothyroidism, acromegaly
      • Deficiency - B12 / folate deficiency, alcoholism
      • Connective tissue disease - rheumatoid arthritis, polyarteritis nodosa, SLE
      • Deposition - amyloidosis, sarcoidosis
      • Infection - AIDS, lyme disease
      • Toxins - arsenic, mercury, organic phosphates, carbon monoxide
      • Critical illness polyneuropathy

      Comprehension

      Complex verbal comprehension - ask the patient to take a piece of paper into their right hand, fold it in half and then place the paper onto the floor.

      The Glasgow Coma Scale

      If not done in this order, the examiner is unable to determine whether the patient responded to the painful stimulus or the voice.

      Overview

      • Grading of Reflexes

      • 0: no response (hyporeflexive)Lower motor neuron lesion
      • 1+: diminished (low normal)Lower motor neuron lesion
      • 2+: average (normal)
      • 3+: brisk (high normal)Upper motor neuron lesion
      • 4+: very brisk (hyperreflexive)Upper motor neuron lesion
      Dorsal cord syndrome - loss of proprioception and vibration sensation (dorsal column), with preservation of motor function (corticospinal tract) and pain and temperature sensation (spinothalamic tract)Posterior compression of the spinal cord, or posterior spinal artery pathology
      • Causes of Carpal Tunnel Syndrome

      • Mechanical - repeated movements, sustained positions
      • Diabetes
      • Pregnancy
      • Rheumatoid arthritis
      • Hypothyroidism
      • Amyloidosis
      • Chronic kidney disease
      • Multiple myeloma

      The Motor Pathway

      Upper Motor Nucleus
      Primary motor cortex (precentral gyrus)
       
      Central Pathway
      Corticobulbar tract
      (via cerebral peduncle)
      Decussation
      Medullary Pyramids
      Spinal Pathway
      Lateral corticospinal tract
       
      Lower Motor Nucleus
      Ventral horn at the level of entry into the spinal cord
       
      Neuromuscular Junction
       
       
      Muscle

      Overview

      • Grading of Power

      • 0: no movement
      • 1: flicker of movement
      • 2 : movement without gravity
      • 3: movement against gravity
      • 4: against weak resistance
      • 5: normal power

      Radial Nerve Palsy

      • Signs of Radial Nerve Palsy

      • Sensory

      • Sensory loss over the snuff box
      • Anterior forearm & AC fossa (proximal lesion)
      • Motor

      • Wrist drop - inability to extend the wrist
      • Weakness of wrist extension and finger extension
      • Weakness of elbow extension (proximal lesion)

      Overview

      • Interpretation

      • Sensory loss affecting an entire limb or entire side - likely due to central pathology
      • Sensory loss affecting a single dermatome  - likely due to spinal nerve root pathology
      • Sensory loss affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
      • Sensory loss affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion, or mononeuritis multiplex
      • Distal sensory loss (glove and stocking distribution) - suggests a peripheral polyneuropathy
      • Isolated dorsal column loss (impaired proprioception and vibration sensation with intact pain and temperature sensation) - suggests peripheral demyelination, e.g. Guillain-Barre, CIDP

      Abdominal Pulsation

      • Look For

      • An obvious pulsation within the abdomen.

      Overview

      It is important to note that asterixis is a loss of motor control, rather than a tremor.

      Bronzed Skin

      • Look For

      • Bronze discolouration of the skin.

      Weight

      • Causes of Weight Loss

      • Dietary intake - anorexia, low access to food
      • ↑ Physical activity
      • Malignancy
      • Malabsorption - obstruction, IBD, pancreatitis, coeliac disease
      • Endocrine - hyperthyroidism, diabetes, phaeochromocytoma, Addison's disease
      • Neurological - stroke, Parkinson's, dementia
      • Drugs - diuretics, chemotherapy, amphetamines, opioids
      • Organ failure - renal, hepatic, cardiac, respiratory, gut
      • Chronic infection - TB, HIV
      • Psychiatric - eating disorders, depression, alcoholism, schizophrenia

      Mouth Ulcers

      • Look For

      • Ulcers in the mouth, noting their number, size, colour and distribution.

      Overview

      • Causes of Lymphadenopathy

      • Infection - bacterial, viral, fungal, protozoal
      • Inflammatory disorders - lupus, rheumatoid arthritis
      • Malignancy - leukaemia, lymphoma, metastasis
      • Medications - allopurinol, atenolol, cephalosporins, penicillin, phenytoin
      • Benign idiopathic lymphadenopathy

      Rashes Associated with GI Disease

      Pyoderma gangrenosum: deep, painful, non-infected ulcers surrounded by erythema. Typically on the legs or around stoma sites.Ulcerative colitis, multiple myeloma, amyloidosis, myeloproliferative disorders

      Haemorrhoids

      • Look For

      • Perianal or rectal mass - flesh / mucosal appearance
      • Thrombosed mass - purple or blue, may be associated with overlying clot
      • Blood
      • Mucus discharge

      Common Signs on the Tongue

      Smooth tongue (atrophic glossitis): loss of the normal texture of the tongue.Use of dentures, iron / folate / B12 deficiency, low oestrogen

      Fluid Overload

      • Look For

      • Hypertension
      • Positive fluid balance in obs chart
      • Weight gain - look for a recent weight and compare to current weight
      • Bounding pulses
      • Raised JVP
      • Presence of S3 (gallop rhythm)
      • Crackles on lung field auscultation
      • Ascites - shifting dullness or fluid thrill
      • Pitting oedema to the sacrum and lower limbs, as well as elsewhere in the body in severe hypervolaemia

      The Glasgow Coma Scale (GCS)

      If not done in this order, the examiner is unable to determine whether the patient responded to the painful stimulus or the voice.

      Overview

      Perform - using a well lubricated finger.
      • Causes of Lymphadenopathy

      • Infection - bacterial, viral, fungal
      • Inflammatory disorders - lupus, rheumatoid arthritis
      • Malignancy - leukaemia, lymphoma, metastasis
      • Medications - allopurinol, atenolol, cephalosporins, penicillin, phenytoin
      • Benign idiopathic lymphadenopathy

      Segments of the Abdomen

      • Abdominal Segments

      • A
        Right hypochondrium - liver, gallbladder, stomach, hepatic flexure of colon, lung
      • B
        Epigastrium - liver, gallbladder, stomach, transverse colon, pancreas, heart
      • C
        Left hypochondrium - spleen, pancreas, stomach, splenic flexure of colon, lung
      • D
        Right lumbar - ascending colon, kidney
      • E
        Umbilicus - small bowel, aorta
      • F
        Left lumbar - descending colon, kidney
      • G
        Right iliac fossa- appendix, terminal ileum, caecum, ovary, fallopian tube, ureter
      • H
        Hypogastrium - uterus, bladder, sigmoid colon
      • I
        Left Iliac Fossa - sigmoid colon, ovary, fallopian tube, ureter

      Rashes Associated with GI Disease

      Pyoderma gangrenosum: deep, painful, non-infected ulcers surrounded by erythema. Typically on the legs or around stoma sites.Ulcerative colitis, multiple myeloma, amyloidosis, myeloproliferative disorders

      Gingival Bleeding

      • Look For

      • Bleeding from the gums.

      First Steps

      Perform - using a well lubricated finger.

      Complications

      • Complications of Cirrhosis

      • Ascites (due to portal hypertension, RAAS activation and splanchnic vasodilatation)
      • Varices (due to portal hypertension)
      • Splenomegaly (due to portal hypertension)
      • Hepatic encephalopathy (due to ammonia buildup)
      • Spontaneous bacterial peritonitis (due to gut translocation)
      • Hepatorenal syndrome (due to splanchnic vasodilatation)
      • Hepatic hydrothorax (due to leakage of ascitic fluid into the pleural space)
      • Portopulmonary hypertension (due to portal hypertension)
      • Hepatopulmonary syndrome (due to vasodilation / shunting)
      • Malnutrition / sarcopaenia
      • Coagulopathy (due to poor synthetic function + vitamin K malabsorption)
      • Thrombocytopaenia (due to splenic sequestration)
      • Hepatocellular carcinoma (HCC)

      Joint Range of Motion

      • How to Assess

      • Ask the patient to move the joint themselves, and then passively move it for them. Note the range of motion and whether it is limited by pain, swelling or stiffness

      Focal Abdominal Tenderness

      Right lumbar - ascending colon, kidneyKidney stone, pyelonephritis

      Pallor

      • Causes of Pallor

      • Physiologicaly pale skin
      • Anaemia
      • Chronic disease
      • Low cardiac output, due to cardiac disease
      • Peripheral shutdown, due to increased sympathetic activity

      Koilonychia

      • Look For

      • Spoon-shaped nails.

      Overview

      • Causes of Lymphadenopathy

      • Bacterial infection - localised infection, skin infection, tuberculosis / MAC, syphilis, cat-scratch disease
      • Viral infection - EBV, CMV, HIV, herpez simplex, rubella
      • Parasitic infection - toxoplasmosis
      • Malignancy - lymphoma, leukaemia, metastasis
      • Inflammatory disorders - lupus, rheumatoid arthritis
      • Sarcoidosis
      • Medications - allopurinol, atenolol, cephalosporins, penicillin, phenytoin, carbemazepine
      • Storage disorders
      • Benign idiopathic lymphadenopathy
      • Causes of Splenomegaly

      • Congestion - congestive cardiac failure, portal vein thrombosis, cirrhosis
      • Infection - bacterial / viral / parasitic
      • Inflammation - SLE, IBD, rheumatoid arthritis
      • Haematological - leukaemia / lymphoma, thalassaemia, sickle cell anaemia, haemolytic anaemia
      • Systemic - sarcoidosis, amyloidosis
      • Malignancy - leukaemia, lymphoma, splenic tumours, metastases

      Hepatomegaly

      • Causes of Hepatomegaly

      • Congestion - congestive cardiac failure, hepatic vein thrombosis, cirrhosis
      • Hepatitis - alcoholic, fatty, hepatitis, drug-induced
      • Metabolic liver disease - amyloidosis, haemochromatosis, Wilson's disease
      • Cancers - liver, stomach, pancreas, lung, colorectal, melanoma
      • Infection - acute
      • Haematological - leukaemia / Hodgkin lymphoma
      • Diaphragmatic depression - emphysema, pleural effusion

      Reduced Joint Range of Motion

      • How to Perform

      • Ask the patient to move the joint themselves, and then passively move it for them. Note the range of motion and whether it is limited by pain, swelling or stiffness

      Purpura

      • Interpretation

      • Petechiae - flat lesions, <4mmThrombocytopaenia / abnormal platelet function, DIC
      • Ecchymoses - flat lesions, >4mmTrauma, DIC, coagulation disorders, senile purpura
      • Palpable purpura associated with arthralgia, abdominal pain and renal diseaseHenoch-Schönlein purpura

      Overview

      • Causes of Lymphadenopathy

      • Bacterial infection - localised infection, skin infection, tuberculosis / MAC, syphilis, cat-scratch disease
      • Viral infection - EBV, CMV, HIV, herpes simplex, rubella
      • Parasitic infection - toxoplasmosis
      • Malignancy - lymphoma, leukaemia, metastasis
      • Inflammatory disorders - lupus, rheumatoid arthritis
      • Sarcoidosis
      • Medications - allopurinol, atenolol, cephalosporins, penicillin, phenytoin, carbemazepine
      • Storage disorders
      • Benign idiopathic lymphadenopathy

      Abdominal Mass

      Left hypochondrium- spleen, pancreas, stomach, colonPancreatic tumour, gastric tumour

      Overview

      • Causes of Lymphadenopathy

      • Bacterial infection - localised infection, skin infection, tuberculosis / MAC, syphilis, cat-scratch disease
      • Viral infection - EBV, CMV, HIV, herpez simplex, rubella
      • Parasitic infection - toxoplasmosis
      • Malignancy - lymphoma, leukaemia, metastasis
      • Inflammatory disorders - lupus, rheumatoid arthritis
      • Sarcoidosis
      • Medications - allopurinol, atenolol, cephalosporins, penicillin, phenytoin, carbemazepine
      • Storage disorders
      • Benign idiopathic lymphadenopathy
      • Look For

      • Posture - position of the head, shoulders and spine.
      • Symmetry - symmetrical rise and fall of the shoulders, hips, knees and feet.
      • Rhythm - natural movement through the stance and swing phases.
      • Coordination - steadiness of the gait and amount of sway. Dyscoordination may indicate an ataxic or spastic gait.
      • Foot separation - wide-based or narrow-based. A wide base  is used to compensate for poor coordination.
      • Stride length - the distance between heel placements of one foot over one gait cycle.
      • Cadence - the number of steps per minute.

      Jerk Nystagmus

      The direction of the nystagmus is describes as the direction of the fast-beating movement.

      Romberg Test

      • How to Perform

      • Ask the patient to stand still with their heels together. Ask them to close their eyes and stand still for thirty seconds. Stand by to ensure that they do no fall over.

      Overview

      • Significance

      • Indicative of cerebellar disease due to ischaemia, haemorrhage, tumour or multiple sclerosis.

      Blepharospasm

      • Look For

      • Bilateral involuntary spasm of the eyelid muscles.

      Hypophonia

      • Significance

      • Hypophonia is classically suggestive of Parkinsonism.

      Overview

      • Causes of Elevated JVP

      • Fluid overload - excessive IV fluids, renal disease, heart failure
      • Right ventricular systolic failure - cor pulmonale, left ventricular failure
      • Right ventricular diastolic failure - constrictive pericarditis, tamponade
      • Pulmonary hypertension

      Pericardial Rub

      • How to Assess

      • Ask the patient to lean forward and hold their breath in full expiration. Listen for a superficial, scratching sound present in mid-systole, mid-diastole and late diastole. 

      Measuring Blood Pressure

      • Sizing the Blood Pressure Cuff

      • The blood pressure cuff should measure approximately 80% of the circumference of the arm.

      Measuring Temperature

      • Methods of Measuring Body Temperature

      • Non-invasive

      • Orally - an electronic or chemical probe is placed underneath the tongue
      • Axillary - an electronic or chemical probe is placed in the axilla
      • Tympanic - an infrared probe is placed within the external auditory canal 
      • Forehead (non-contact) - an infrared scanner is pointed at the forehead
      • Rectally - an electronic or chemical rectal probe is placed within the rectum
      • Invasive

      • Urinary bladder - a probe is placed in the bladder with an indwelling catheterUsed in intensive care
      • Oesophageal - a probe is placed within the oesophagusUsed in intensive care
      • Ventricular - a probe is placed within the ventricle of the brainUsed in neurosurgical patients in intensive care
      • Pulmonary artery catheter - a probe is placed within the pulmonary arteryGold standard and not used clinically

      Overview

      • How to Measure

      • Count the patient's breaths over 30 seconds to one minute while ostensibly measuring the pulse.

      Measuring Oxygen Saturations

      The oxygen saturation probe works by emitting light at fixed wavelengths corresponding to oxygenated and deoxygenated haemoglobin. A detector then measures the difference in transmitted light, and this is used to calculate the percentage of oxyhaemoglobin.

      Overview

      • Interpretation

      Signs of Peritonism

      • Signs of Peritonism

      • Generalised abdominal tenderness
      • Percussion tenderness - gently percuss the abdominal wall over an area of tenderness. Note whether percussion tenderness is localised or generalised.
      • Rebound tenderness - apply pressure to the patient's abdomen over a tender area for 5-10 seconds. Remove the pressure suddenly, and ask the patient if it hurts more when you press or remove your hand.

      Overview

      Peripheral Oedema

      • Causes of Oedema

      • Pitting

      • Fluid overload - excessive IV fluids, renal failure, heart failure
      • Right ventricular failure
      • Venous pathology - thrombosis / insufficiency
      • Dependency (the effect of gravity)
      • Hypoalbuminaemia - malnutrition, malabsorption, nephrotic syndrome, liver (synthetic) failure
      • Non-Pitting

      • Impaired lymphatic drainage
      • Pretibial myxoedema (hypothyroidism)

      Hypoglycaemia

      • Symptoms

      • Autonomic (mild / moderate hypoglycaemia) - hunger, anxiety, diaphoresis, tremor, palpitations, paraesthesiae
      • Neuroglycopaenic (severe hypoglycaemia) - fatigue, confusion, visual changes, seizures, unconsciousness

      Overview

      • Pearls: Hypoperfusion

      • If shock is suspected, escalate immediately.
      • Patients with distributive shock (sepsis, anaphylaxis) are generally significantly vasodilated and will not be peripherally cool.

      Pupillary Light Reflexes

      • How to Perform

      • Shine a light into each pupil. Watch to see that both the ipsilateral (direct response) and contralateral (consensual response) pupils constrict as a result of the stimulus.

      Cheyne-Stokes Respiration

      Occurs when hyperventilation (due to increased CO₂ sensitivity) lowers the arterial CO₂ below the apnoeic threshold.

      Measuring Temperature

      • Methods of Measuring Body Temperature

      • Non-invasive

      • Orally - an electronic or chemical probe is placed underneath the tongue
      • Axillary - an electronic or chemical probe is placed in the axilla
      • Tympanic - an infrared probe is placed within the external auditory canal 
      • Forehead (non-contact) - an infrared scanner is pointed at the forehead
      • Rectally - an electronic or chemical rectal probe is placed within the rectum
      • Invasive

      • Urinary bladder - a probe is placed in the bladder with an indwelling catheterUsed in intensive care
      • Oesophageal - a probe is placed within the oesophagusUsed in intensive care
      • Ventricular - a probe is placed within the ventricle of the brainUsed in neurosurgical patients in intensive care
      • Pulmonary artery catheter - a probe is placed within the pulmonary arteryGold standard and not used clinically

      Measuring Oxygen Saturations

      The oxygen saturation probe works by emitting light at fixed wavelengths corresponding to oxygenated and deoxygenated haemoglobin. A detector then measures the difference in transmitted light, and this is used to calculate the percentage of oxyhaemoglobin.

      Overview

      • How to Measure

      • Count the patient's breaths over 30 seconds to one minute while ostensibly measuring the pulse.

      Measuring Blood Pressure

      • Sizing the Blood Pressure Cuff

      • The blood pressure cuff should measure approximately 80% of the circumference of the arm.

      Overview

      • Causes of Restrictive Disease

      • Parenchymal

      • Pulmonary fibrosis
      • Sarcoidosis
      • Atelectasis
      • Extrapulmonary

      • Pleural - pleural effusion, pneumothorax
      • Chest wall deformity - kyphosis, scoliosis, morbid obesity
      • Neurologic / neuromuscular / muscular disorder - motor neurone disease, Guillain-Barre, muscular dystrophy, myasthenia gravis
      • Lung Volumes

      • ERV 
        Expiratory reserve volume
      • FRC 
        Functional residual capacity
      • IC 
         Inspiratory capacity
      • IRV 
        Inspiratory reserve volume
      • RV 
         Residual volume
      • TLC 
        Total lung capacity
      • VC 
         Vital capacity
      • VT 
         Tidal volume

      Poor Readings

      • Poor Readings

      Overview

      • Interpretation

      • Normal - symmetric and convex inspiratory limb, with linear expiratory limb
      • Obstructive - 'dipping' or 'steeple' pattern, with reduced flow and expiratory prolongationCOPD, asthma, bronchiectasis, CF, bronchiolitis, α1-antitrypsin deficiency
      • Restrictive - reduced overall volume, with grossly normal shapePulmonary fibrosis, sarcoidosis, chest wall deformity, neuromuscular
      • Fixed upper airway obstruction - flattening of inspiratory and expiratory limbsTracheal stenosis, goitre
      • Variable extrathoracic obstruction - flattening of inspiratory limb only, with no impairment of expirationUnilateral vocal cord paralysis
      • Variable intrathoracic obstruction - diminished expiratory limb with no impairment of inspirationTracheomalacia

      Increased FRC

      • Causes of Increased FRC

      • Erect posture
      • Advanced age
      • Emphysema
      • Asthma

      Overview

      • Contributors to Poor Readings

      • Incomplete inhalation prior to the test
      • Lack of effort on exhalation
      • Stopping exhalation early
      • Poor seal around the mouthpiece
      • Exhalation through the nose
      • Coughing

      The Coagulation Cascade

      The extrinsic pathway is activated by tissue factor, produced within subendothelial tissue and exposed to the circulation in the setting of endothelial damage. Tissue factor activates factor VII which in turn activates factor X in the common pathway.

      Overview

      Diluted thrombin time may have a role in the monitoring of factor IIa inhibitors (e.g. dabigatran).
      • Practical Points

      • PT/INR can be used to monitor patients on warfarin
      • PT/INR does not correspond to the coagulative status of patients on novel anticoagulants such as dabigatran, rivaroxaban and apixaban
      • INR does not correspond to the coagulative status of patients with liver disease, and most often these patients are also coagulopathic
      • Heparin can also prolong the INR, and so heparin neutralisers are used when performing the test - excess heparin in the sample can overcome this and prolong the PT/INR

      Urine Consistency

      • Interpretation

      • Cloudy / turbid - suggests pyuria (infection / inflammation), chyluria, lipiduria, calcium phosphate crystals
      • Frothy - suggests proteinuria

      Overview

      •  

      Neutrophil Physiology

      • Morphology

      • Mature neutrophils exhibit 3-5 nuclear lobes, with immature forms exhibiting less lobes and hypersegmented exhibiting more. Females may display a 'drumstick' that protrudes from the nucleus.

      Classification

      • β - normal beta chains
      • β⁺ - reduced production of beta chains
      • β⁰ - no production of beta chains

      Overview

      • Interpretation

      • Microcytosis: abnormally small red blood cellsIron deficiency, anaemia of chronic disease, thalassaemia, lead poisoning
      • Normocytosis: normally sized red blood cellsAplastic anaemia, acute haemorrhage, haemolysis
      • Macrocytosis: abnormally large red blood cellsB12/folate deficiency, alcoholism, myelodysplastic syndrome
        • Normal Range

        • MCH: 27 - 32pg
        • MCHC: 300 - 350 g/L

      Anisocytosis

      In iron deficiency and megaloblastic anaemia, the RDW may elevate before the MCV becomes abnormal, and as such the RDW can be an early marker.

      Overview

      Alpha thalassaemia commonly occurs in people from South-East Asia, Mediterranean countries, Africa, the Middle East and India. The condition is very uncommon in caucasian populations.
      • Interpretation

      • Reduced serum haemoglobin - suggests anaemia
      • Increased serum haemoglobin - suggests relative or absolute erythrocytosis
      • Interpretation

      • Reduced haematocrit / PCV - suggests anaemia
      • Elevated haematocrit / PCV - suggests erythrocytosis

      Pathogenesis

      Sickle cell disease is inherited in an autosomal recessive fashion, and occurs due to a mutation in beta globin chain gene (genotype βSβS), resulting in haemoglobin S synthesis.

      Overview

        • Normal Range

        • >400
      • Expected Compensation in Chronic Respiratory Acidosis

      • 4mmol/L [HCO₃] increase for every 10mmHg PaCO₂ above 40mmHg

      Lactate Physiology

      • Metabolism

      • Lactate is mainly metabolised by the liver and partially by myocytes, though the kidney plays more of a role in metabolism in the presence of hyperlactataemia.

      Overview

      • Mechanism of Action

      • Inhibit DNA gyrase, preventing supercoiling of DNA and disrupting cell division.
      • Resistance

      • Broken down by beta lactamase enzymes produced by some bacteria.
      • Microbiology

      • Active against Pseudomonas and most Enterobacteriaciae. No significant activity against gram positive organisms.

      Clinical Use

      • Indications

      • Induction of labour
      • Augmentation of labour
      • Management of the third stage of labour
      • Postpartum haemorrhage
      • Contraindication

      • Heart failure.
      • Contraindications

      • Severe hypertension / eclampsia / preeclampsia
      • Peripheral vascular disease / ischaemic heart disease
      • Contraindications

      • Intrauterine foetal death
      • Severe hypertension / eclampsia / preeclampsia
      • Diabetes
      • Contraindications

      • Suspected retained placenta
      • Severe hypertension / eclampsia / preeclampsia
      • Peripheral vascular disease / ischaemic heart disease
      •  
        IV
        Low Titre Anti-T Plasma
        Tested for anti-T, for use in patients at risk of haemolytic reactions

      Overview

      • Composition

      • Factor VIII
      • Fibrinogen
      • Factor XIII
      • Von Willebrand factor
      • Fibronectin
      • Infectious Adverse Effects

      • Hepatitis B - 1 in 500,000
      • Hepatitis C - 1 in 1 million
      • Human T-lymphotropic virus 1 or 2 - 1 in 2 million
      • HIV - 1 in 2 million
      • Others (Creutzfeldt-Jakob, human herpesvirus 8, malaria, influenza, west nile virus) - rare

      Clinical Use

      • Indications

      • Warfarin reversal for non-bleeding patients with INR >9.0
      • Warfarin reversal for patients with active bleeding

      Overview

      • Contraindication

      • Past history of heparin-induced thrombocytopaenia.
      • Mechanism of Action

      • Directly bind to airway β2 adrenoceptors, stimulating smooth muscle relaxation and bronchodilation through induction of cAMP with resulting phosphorylation of muscle regulatory proteins and modification of cellular calcium concentration.
      •  
        MDI
        Fluticasone / Vilanterol
        Breo Ellipta 
      •  
        IV / Topical
        Hydrocortisone
        Cortef 

      Clinical Use

      • Adverse Effects

      • Anaphylactoid reactions
      • Fevers
      • Headache
      • Abdominal pain
      • Adverse Effects

      • Dry mouth
      • Headache
      •  
        Inhaler
        Ciclesonide
        Alvesco 
      • Adverse Effects

      • Tremor
      • Palpitations
      • Hypokalaemia / hypomagnesaemia
      • Ketoacidosis (diabetics)
      •  
        MDI
        Glyropyrronium
        Seebri 
      • Adverse Effects

      • Tremor
      • Palpitations
      • Headache
      • Oesophageal candidiasis
      • Dry mouth
      • Indications

      • Asthma maintenance
      • Symptomatic relief of allergic rhinitis
      • Adverse Effects

      • Injection site reactions
      • Upper respiratory tract infections
      • Myalgias
      • Fatigue
      •  
        MDI
        Umeclidinium / Vilanterol
        Anoro Ellipta 
      • Indications

      • Acute exacerbations of asthma
      • Symptomatic relief of asthma
      • Acute exacerbations of COPD

      Overview

      • Mechanism of Action

      • Inhibit acetylcholinesterase, resulting in increased CNS concentrations of acetylcholine.

      Clinical Use

      • Indications

      • Generalised seizures
      • Absence seizures
      • Acute mania
      • Maintenance therapy for bipolar disorder
      • Migraine prophylaxis
      •  
        Oral / Rectal / Nasal / Subcut / IV
        Sumatriptan
        Imigran 
      • Adverse Effects

      • Drowsiness
      • Nausea
      • Increased appetite / weight gain
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Nausea / vomiting / diarrhoea / anorexia
      • Headache
      • Confusion
      • Hypotension
      • Dyspnoea
      • Arthralgia / myalgia
      • Rash
      • Fatigue
      • Indications

      • Generalised seizures
      • Absence seizures
      • Acute mania
      • Maintenance therapy for bipolar disorder
      • Migraine prophylaxis
      •  
        IV / Topical
        Hydrocortisone
        Cortef 
      • Adverse Effects

      • CNS disturbances - drowsiness, dizziness / ataxia, diplopia, tremor, cognitive slowing
      • Nausea / vomiting
      • Weight loss
      • Indications

      • Hypertension - second line therapy, indicated for patients with heart failure
      • Prophylaxis of migraine
      • Essential tremor
      • Indication

      • Relapsing forms of multiple sclerosis (MS).
      • Contraindication

      • Not for concurrent use with monoamine oxidase inhibitors (MAOi).
      • Adverse Effects

      • Nausea / vomiting
      • CNS disturbances - drowsiness, headache, ataxia
      • Adverse Effects

      • Headache
      • Elevated LFTs
      • Diarrhoea
      • Upper respiratory tract infection
      • Contraindications

      • Other immunomodulatory agents
      • Immunocompromised patients
      • Adverse Effects

      • CNS disturbances - drowsiness, dizziness / ataxia, diplopia, tremor, cognitive slowing
      • Nausea / vomiting
      • Weight loss

      Overview

      • Mechanism of Action

      • Positively modulate GABAA receptors (BZ1 and BZ2), augmenting the inhibitory effects of the GABA neurotransmitter.

      Clinical Use

      • Indications

      • Generalised tonic-clonic seizures
      • Status epilepticus (IV)
      • Adverse Effects

      • CNS disturbances - drowsiness, ataxia, headache, diplopia
      • Nausea / vomiting
      • Rash
      • Anticonvulsant hypersensitivity syndrome (prolonged admin) - fever, rash, lymphadenopathy, hepatitis, myositis
      Always warn patients commencing on dopamine agonists of the risk of addictive behaviours, as the increased dopamine delivery to the brain can increase the risk of reward-based activities such as gambling, high risk sexual behaviour and online shopping.

      Overview

      • Mechanism of Action

      • Levodopa - a dopamine precursor that is converted to dopamine, which is severely depleted within the striatum pallidum and substantia nigra in Parkinson's disease.
      • Decarboxylase inhibitor (benserazide / carbidopa) - inhibits peripheral conversion of levodopa to dopamine.

      Clinical Use

      • Adverse Effects

      • Drowsiness
      • Headache
      • Anxiety / agitation / aggression
      • Indications

      • Pain
      • Fever
      •  
        Oral
        Meloxicam
        Mobic 
      •  
        Oral
        Doxylamine
        Doxylin 
         

      Overview

      • Effects

      • α1 - vasoconstriction à increased total peripheral resistance
      • α2 - inhibition of noradrenaline release
      • β1 - increase contractility (positive inotropy) and heart rate (positive chronotropy)
      • β2 - vasodilatation, airway smooth muscle relaxation, uterine smooth muscle relaxation
      • Mechanism of Action

      • Inverse agonists to histamine H1 receptors, having the opposite effect of histamine.

      Clinical Use

      • Adverse Effects

      • Fatigue
      • Nausea / vomiting
      • Dizziness
      • Breast pain
      • Contraindications

      • Pregnancy
      • Past DVT / PE
      • Ischaemic heart disease
      • Past stroke / TIA
      • Breast cancer within the past five years
      • Ischaemic heart disease
      • Indications

      • Contraception in patients intolerant of combined oral contraceptives
      • Contraception in women who are breastfeeding
      • Indications

      • Contraception in patients intolerant of combined oral contraceptives
      • Contraception in women who are breastfeeding
      • Indication

      • Contraception.

      Overview

      • Mechanism of Action

      • Contain an oestrogen and a progesterone, which inhibit follicular development, prevent ovulation and thicken cervical mucus resulting in reduced sperm penetration.

      Clinical Use

      • Contraindications

      • Ovarian failure
      • Pituitary, thyroid or adrenal dysfunction
      • Liver disease
      • Indications

      • Contraception in patients intolerant of combined oral contraceptives
      • Contraception in women who are breastfeeding

      Antiprogestogens

      • Effects of Mifepristone

      • Endometrial degeneration
      • Cervical dilatation
      • Prostaglandin release
      • Reduced progesterone release
      • Reduced β-HCG production

      Clinical Use

      • Adverse Effects

      • Rare.

      Overview

      • Pharmacology

      • Taken up by cells, resulting in expansion of intracellular fluid.

      Clinical Use

      • Indication

      • Anticholinergic toxicity, due to agents such as atropine, scopolamine or benztropine.
      • Adverse Effects

      • Hypersensitivity - rash, oedema, bronchospasm, anaphylaxis
      • Nausea / vomiting
      • Indications

      • Reversal of heparin-associated bleeding
      • Reversal of heparin preoperatively or after renal dialysis
      • Adverse Effects

      • Tachycardia / hypotension
      • Restrictive pulmonary disease
      • Indication

      • Methanol or ethylene glycol poisoning.
      • Indication

      • Benzodiazepine overdose.
      • Indication

      • Severe hypoglycaemia due to administration of insulin or oral hypoglycaemics.
      • Adverse Effects

      • Opioid withdrawal - nausea, vomiting, diaphoresis, tachycardia, tremor, seizure.
      • Adverse Effects

      • Rash
      • Elevated LFTs
      • Zinc & copper deficiency
      • Adverse Effects

      • Rash
      • Nausea / vomiting
      • Hypotension
      • Elevated LFTs
      • Nephrotoxicity
      • Zinc & copper deficiency
      • Adverse Effects

      • Rash
      • Nephrotic syndrome
      • Elevated LFTs
      • Contraindications

      • Severe ulcerative colitis
      • Gastrointestinal obstruction
      • Obstructive uropathy
      • Glaucoma
      • Adverse Effects

      • CNS depression
      • Hypoglycaemia
      • Hepatotoxicity
      • Adverse Effects

      • Rare.
      • Contraindications

      • Intracranial / intraspinal haemorrhage
      • Hyperglycaemia
      • Adverse Effects

      • Injection site reactions
      • Upper respiratory tract infection
      • Dizziness
      • Headache
      • Nausea / vomiting / diarrhoea
      • Myalgias / arthralgias
      • Fatigue

      Overview

      JAK inhibition results in reduced cytokine-induced cell activation and a consequent reduction in inflammation.
      •  
        Subcut
        Golimumab
        Simponi 
         
        Human monoclonal antibody to TNF

      Clinical Use

      • Adverse Effects

        Does not appear to significantly add to the adverse events already seen in transplant patients due to underlying disease or immunosuppressant medications.
      • Infections
      • Headache
      • Hypertension
      • Nausea / vomiting / diarrhoea / constipation
      • Contraindications

      • Not to be used concurrently with other biologic DMARDs.
      • Adverse Effects

      • Headache
      • Fevers
      • Nausea / vomiting
      • Upper respiratory tract infection
      • Meningococcal infection
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Injection site reactions
      • Progressive multifocal leukoencephalopathy (PML)
      • Nausea / vomiting
      • Angioedema

      Substem A (Target)

      -c(i)-: cardiovascular (e.g. abciximab)

      Clinical Use

      • Adverse Effects

      • Injection site reactions
      • Infections (particularly upper respiratory tract infections)
      • Headache
      • Hypertension
      • Diarrhoea
      • Adverse Effects

      • Injection site reactions
      • Infections
      • Neutropaenia
      • Abdominal pain
      • Adverse Effects

      • Hypersensitivity reactions
      • Infections
      • Nausea / vomiting / diarrhoea
      • Indications

      • Cryopyrin-associated periodic syndromes (CAPS) in adults and children 2 years or older
      • Systemic juvenile idiopathic arthritis refractory to non-biologic DMARDs
      • Rheumatoid arthritis refractory to one or more other DMARDs
      • Adverse Effects

      • Infections (particularly upper respiratory tract infections)
      • Oral herpes
      • Diarrhoea
      • Adverse Effects

      • Fevers
      • Injection site reactions
      • Headache
      • Abdominal pain
      • Adverse Effects

      • Injection site reactions
      • Upper respiratory tract infections
      • Myalgias
      • Fatigue
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Nausea / vomiting / diarrhoea / anorexia
      • Headache
      • Confusion
      • Hypotension
      • Dyspnoea
      • Arthralgia / myalgia
      • Rash
      • Fatigue
      • Adverse Effects

      • Haemorrhagic cystitis
      • Bone marrow suppression - leucopaenia, thrombocytopaenia, anaemia
      • Renal dysfunction
      • Nausea / vomiting
      • Alopecia
      • Indications

      • Prevention of graft rejection following renal transplantation
      • Prevention of graft rejection following liver or heart transplantation (everolimus)
      • Adverse Effects

      • Bone marrow suppression - anaemia / leukopaenia / thrombocytopaenia
      • Gastrointestinal - nausea / vomiting / diarrhea
      • Hepatotoxicity - elevated LFTs
      • Skin - rash
      • Adverse Effects

      • Fevers (ocur without infection in the majority of patients)
      • Rash
      • Arthralgias / myalgias
      • Nausea / vomiting / diarrhoea
      • Indications

      • Inflammatory diseases - refractory inflammatory bowel disease, rheumatoid arthritis, psoriasis
      • Chemotherapy - for certain cancers
      •  
        IV / Topical
        Hydrocortisone
        Cortef 
      • Adverse Effects

      • Malignancies (particularly lymphoma, skin cancers)
      • Opportunistic infections
      • Leukopaenia, anaemia, thrombocytopaenia
      • Headache
      • Pulmonary fibrosis
      • Nausea / vomiting / diarrhoea
      • LFT derangement
      • Arthralgias / myalgias
      • Adverse Effects

      • Nausea / vomiting / diarrhoea
      • Rash
      • Hypertension
      • Elevated LFTs
      • Indications

      • Prevention of graft rejection following kidney, liver or heart transplantation
      • Nephrotic syndrome refractory to other medications (cyclosporin)
      • Severe rheumatoid arthritis refractory to other medications (cyclosporin)
      • Severe psoriasis refractory to other medications (cyclosporin)
      • Severe atopic dermatitis refractory to other medications (cyclosporin)
      • Indications

      • Replacement Therapy

      • Primary immunodeficiency disease
      • Symptomatic hypogammaglobulinaemia secondary to underlying disease or treatment
      • Immunomodulation

      • Idiopathic Thrombocytopaenic Purpura (ITP) in patients with high risk of bleeding or prior to surgery
      • Guillain Barré syndrome (GBS)
      • Kawasaki disease
      • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
      • Multifocal Motor Neuropathy (MMN)
      • Acute exacerbations of myaesthenia gravis (MG)
      • Lambert-Eaton Myasthenic Syndrome (LEMS)
      • Stiff person syndrome (SPS)
      • Contraindications

      • Normal or elevated serum sodium
      • Fluid overload - congestive cardiac failure, severe renal impairment, excessive IV fluids

      Overview

      • Pharmacology

      • Taken up by cells, resulting in expansion of intracellular fluid.

      Clinical Use

      • Indications

      • Refractory hypertension
      • Refractory heart failure
      • Peripheral oedema - due to congestive cardiac failure / renal failure / nephrotic syndrome / cirrhosis
      • Symptomatic ascites
      • Maintenance therapy for hypokalaemia
      • Primary aldosteronism
      • Hirsutism

      Overview

      • Pharmacology

      • 10mmol of potassium replacement is expected to increased serum potassium concentration by approximately 1mmol/L.
      • Pharmacology

      • Not 'normal' or isotonic - higher sodium (154mmol vs. 140mmol) and chloride (154mmol vs. 105mmol) concentrations than in serum
      • Mostly migrates extravascularly, resulting in oedema
      • Draws fluid out of cells due to hypertonicity

      Clinical Use

      • Indication

      • Severe hypoalbuminaemia.

      Overview

      • Pharmacology

      • Each gram of resin is expected to bind approximately 1mmol of potassium.

      Clinical Use

      • Indications

      • Maintenance fluids
      • Dehydration
      • Fluid replacement for burns patients (via Parkland formula)

      Overview

      • Mechanism of Action

      • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.

      Clinical Use

      • Indications

      • Hypomagnesaemia
      • Severe acute asthma
      • Torsades de pointes
      • Ecclampsia
      • Indication

      • Hypovolaemic shock.

      Overview

      • Adverse Effects

      • Nausea / vomiting
      • Constipation
      • Sedation
      • Respiratory depression
      • Diaphoresis
      • Delirium
      • Hypersensitivity - bronchospasm, urticaria
      • Bradycardia
      • Tolerance
      • Dependence
      • Hypogonadism
      • Mechanism of Action

      • Act on opioid receptors (δ, κ and μ) and nociceptin orphanin FQ (NOF) receptors on neuronal cell membranes within the thalamus, diencephalon, midbrain and medulla, resulting in reduced neurotransmitter release.
      Less likelihood of tolerance, low potential for abuse than opioids.

      Clinical Use

      • Adverse Effects

      • Fatigue
      • Weight gain
      • Dizziness / ataxia
      • Indications

      • Pain
      • Fever
      • Adverse Effects

      • Nausea / vomiting
      • Drowsiness
      • Myalgia / muscle weakness
      • Tinnitus
      • Visual changes
      • Hypotension
      • Rash
      •  
        Oral / IV / Subcut
        Hydromorphone
        Dilaudid (IR), Jurnista (SR) 
         
        Able to be used in renal dysfunction

      Overview

      • Effects

      • μ - analgesia, respiratory depression, miosis, constipation
      • κ - analgesia, sedation, confusion
      • δ - analgesia, respiratory depression, constipation
      • NOF - analgesia, stress / anxiety, tolerance

      Clinical Use

      • Indications

      • Partial seizures
      • Neuropathic pain

      Overview

      • Mechanism of Action

      • Bind to and inhibit neuronal voltage-gated sodium channels, suppressing neuronal depolarization and preventing axonal propagation of action potentials.

      Clinical Use

      • Indications

      • Pain - including migraine and musculoskeletal injury
      • Fever
      • Inflammation - especially associated with arthritides
      • Prophylaxis (aspirin) - of acute coronary or cerebrovascular events in patients with known cardiovascular or cerebrovascular disease
      •  
        Oral
        Naproxen
        14 hour half-life
      • Contraindications

      • Not to be used concurrently with other biologic DMARDs.
      •  
        Subcut
        Golimumab
        Simponi 
         
        Human monoclonal antibody to TNF
      • Adverse Effects

      • Bone marrow suppression - anaemia / leukopaenia / thrombocytopaenia
      • Gastrointestinal - nausea / vomiting / diarrhea
      • Hepatotoxicity - elevated LFTs
      • Skin - rash
      • Adverse Effects

      • Diarrhoea / nausea / vomiting
      • Infections (particularly upper respiratory tract infection)
      • Headache
      • Fatigue
      • Hypertension
      • Arthralgias / myalgias
      • Monitoring

      • Baseline and regular electrolytes, renal function, LFTs, FBC and lipids.
      • Adverse Effects

      • Nausea / vomiting / diarrhoea
      • Rash
      • Hypertension
      • Elevated LFTs
      • Adverse Effects

      • Injection site reactions
      • Upper respiratory tract infection
      • Dizziness
      • Headache
      • Nausea / vomiting / diarrhoea
      • Myalgias / arthralgias
      • Fatigue
      • Adverse Effects

      • Injection site reactions
      • Infections (particularly upper respiratory tract infections)
      • Headache
      • Hypertension
      • Diarrhoea
      • Adverse Effects

      • Diarrhoea / nausea / vomiting
      • Fatigue
      • Indications

      • Cryopyrin-associated periodic syndromes (CAPS) in adults and children 2 years or older
      • Systemic juvenile idiopathic arthritis refractory to non-biologic DMARDs
      • Rheumatoid arthritis refractory to one or more other DMARDs
      • Indications

      • Inflammatory diseases - refractory inflammatory bowel disease, rheumatoid arthritis, psoriasis
      • Chemotherapy - for certain cancers
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Injection site reactions
      • Progressive multifocal leukoencephalopathy (PML)
      • Nausea / vomiting
      • Angioedema

      Overview

      JAK inhibition results in reduced cytokine-induced cell activation and a consequent reduction in inflammation.

      Clinical Use

      • Indications

      • Rheumatoid arthritis
      • Systemic lupus erythematosus
      • Discoid lupus erythematosus
      • Indications

      • Gout - acute gouty arthritis, reduction in gouty tophi
      • Tumour lysis syndrome
      • Adverse Effects

      • CNS - headache
      • Gastrointestinal - abdominal pain / nausea / vomiting / diarrhoea
      • Worsening of ulcerative colitis
      • Hepatotoxicity - elevated LFTs
      •  
        Oral
        Ponatinib
        Iclusig 
         
        Used only if resistance to all other agents, or if T315I mutation

      Overview

      • Mechanism of Action

      • Anaplastic lymphoma kinase (ALK) is a novel receptor tyrosine kinase associated with ~60% of anaplastic large-cell lymphoma and ~5% of non-small cell lung cancer. Inhibition of these receptors interrupts downstream signalling pathways and suppresses cellular proliferation.
      •  
        Oral
        Osimertinib
        Tagrisso 
         
        May be used in patients with T790M mutations which would otherwise confer resistance to other generations of EGFR inhibitors
      • Mechanism of Action

      • Inhibit multiple receptor tyrosine kinases involved in tumour growth, angiogenesis and metastasis.

      Clinical Use

      There is emerging evidence for the use of PARP inhibitors in breast cancer, prostate cancer and somatic DNA repair mutations.
      • Indication

      • HER2 negative, ER / PR positive advanced or metastatic breast cancer in men or postmenopausal women (in combination with an aromatase inhibitor).
      • Adverse Effects

      • Drowsiness
      • Constipation
      • Dry mouth
      • Parkinsonism
      •  
        Oral
        Rabeprazole
        Pariet 
      • Indications

      • Acute episodes and maintenance of inflammatory bowel disease
      • Rheumatoid arthritis (sulfasalazine)
      • Seronegative arthritis (sulfasalazine) - reactive arthritis, psoriatic arthritis, anklyosing spondylitis
      • Adverse Effects

      • Headache
      • Diarrhoea
      • Fatigue
      •  
        IV / Topical
        Hydrocortisone
        Cortef 
      •  
        Oral / Rectal
        Sorbitol
        Microlax enema 
      • Indications

      • Inflammatory bowel disease non-responsive to other medications (6-mercaptopurine)
      • Other inflammatory disorders (azathioprine) - rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, vasculitis
      • Prevention of rejection in renal transplantation (azathioprine)
      • Acute leukaemia (6-mercaptopurine)
      • Adverse Effects

      • Abdo pain
      • Diarrhoea
      • Adverse Effects

      • Flatulence
      • Borborygmus
      • Indications

      • Inflammatory diseases - refractory inflammatory bowel disease, rheumatoid arthritis, psoriasis
      • Chemotherapy - for certain cancers
      • Indications

      • Severe Crohn's disease nonresponsive to other medications
      • Rheumatoid arthritis
      • Seronegative arthritis - psoriatic arthritis, anklyosing spondylitis
      • Psoriasis

      Overview

      • Mechanism of Action

      • Antagonise CNS dopamine receptors, resulting in reduction in nausea and increased upper GI motility.

      Clinical Use

      • Indications

      • Treatment of severe constipation (sennosides)
      • Bowel preparation prior to procedures such as colonoscopy (sodium picosulphate)
      • Adverse Effects

      • Injection site reactions
      • Upper respiratory tract infection
      • Dizziness
      • Headache
      • Nausea / vomiting / diarrhoea
      • Myalgias / arthralgias
      • Fatigue
      • Adverse Effects

      • Rare.
      • Adverse Effects

      • Oesophagitis
      • Photosensitivity
      • Tooth discolouration
      • Nausea / vomiting / diarrhoea
      • Pseudomembranous colitis (C difficile)

      Clinical use

      • Indications

      • Elimination of intrahepatic Plasmodium vivax and ovale, once erythrocytic forms have been eradicated by a blood schizonticide.
      • Elimination of Plasmodium falciparum gametocytes, once erythrocytic forms have been eradicated by a blood schizonticide.

      Clinical Use

      • Contraindications

      • History of seizures, psychosis or cardiac conduction disorders.

      Clinical

      • Indications

      • Uncomplicated malarial infection (artemether+lumefantrine)
      • Severe falciparum malaria (artesunate)

      Physiology

      Folate is a group of compounds that derive from tetrahydrofolate.
      Free B12 is not effectively absorbed by itself.

      LDH Isoenzymes

      There are five LDH isoenzymes composed of two H (heart) and M (muscle) subunits. The isoenzymes are classified depending on their migration on electrophoresis.

      Elevated Aminotransferases

      • Causes of Elevated Transaminases

      • Hepatocellular Injury

      • Viral hepatitis - A, B, C, E, HSV, EBV, CMV, VZV
      • Alcoholic liver disease - alcoholic hepatitis, steatohepatosis, cirrhosis
      • Non-alcoholic hepatosteatosis (fatty liver disease)
      • Drug or toxin-induced liver disease - paracetamol, NSAIDs, statins, ciprofloxacin, azole antifungals, methotrexate, amiodarone, isoniazid, phenytoin, sulfonylureas, rifampicin, anabolic steroids, cocaine, ecstasy, PCP, glues, solvents, certain herbal remedies
      • Vascular disease - ischaemic hepatitis, portal venous thrombosis, congestive cardiac failure
      • Infiltrative disease - sarcoidosis, amyloidosis, tuberculosis, Hodgin lymphoma, liver metastases
      • Autoimmune liver diseases - autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis
      • Haemochromatosis
      • Wilson's disease
      • Alpha-1 antitrypsin deficiency
      • Hepatocellular carcinoma
      • Non-Hepatic

      • Myopathy - vigorous exercise, myositis
      • Hypothyroidism
      • Coeliac disease

      Overview

      ALP and GGT may also be mildly elevated in the presence of hepatocellular disease, with predominant derangement of the transaminases.
      PT/INR does not directly correspond to the true coagulative status of patients with liver disease. Most often these patients are also coagulopathic due to elevated Von Willebrand factor and deficiencies in protein C, protein C, antithrombin and plasminogen.
      ALP and GGT may also be mildly elevated in the presence of hepatocellular disease, with predominant derangement of the transaminases.

      Clinical Use

      • Effects

      • Reduces LDL by 15-25%
      • Not yet proven to reduce CHD

      Overview

      • Mechanism of Action

      • Selectively inhibit L-type calcium channels on arteriolar smooth muscle cells, resulting in significant vasodilation without cardiodepression.
      • Mechanism of Action

      • Competitively inhibit the action of adrenaline and noradrenaline on β1, resulting in suppression of the sympathetic nervous system.

      Clinical Use

      • Adverse Effects

      • Hypersensitivity - urticarial, anaphylaxis
      • Dizziness
      • Anorexia
      • Hyperglycaemia
      • Hyperuricaemia
      • Indications

      • Peripheral oedema - due to congestive cardiac failure / renal failure / nephrotic syndrome / cirrhosis
      • Acute pulmonary oedema
      • Symptomatic ascites (second line treatment)
      • Hypertension (frusemide) - short-term therapy, in combination with ACEi / ARB

      Overview

      • Mechanism of Action

      • Converted to nitrous oxide which stimulates vascular smooth muscle relaxation through stimulation of cGMP-dependant protein kinase with resultant reduction in intracellular calcium.
      • Effects

      • Myocardial

      • Reduced contractility (negative inotropy)
      • Sinoatrial & AV Nodes (Phase 0)

      • Reduced heart rate (negative chronotropy)
      • Reduced AV conduction (negative dromotropy)
      • Vascular

      • Vasodilation → reduced peripheral resistance

      Clinical Use

      • Indications

      • Severe bradyarrhythmias - sinus bradycardia, atrioventricular (AV) block
      • Anticholinesterase poisoning

      Overview

      • Mechanism of Action

      • Competitively and non-selectively inhibit the action of adrenaline and noradrenaline on β1 and β2 receptors, resulting in suppression of the sympathetic nervous system.
      • Pharmacology

      • Short acting. Safe for use in patients with impaired renal function.

      Clinical Use

      • Adverse Effects

      • Bradyarrhythmias - bradycardia, heart block
      • Dyspnoea
      • Headache
      • Lightheadedness
      • Nausea
      • Chest pain
      •  
        Oral
        Perindopril Arginine
        Coversyl 

      Overview

      Nonhydropyridines non-selectively inhibit calcium channels in the heart and arterioles, resulting in cardiac depression and vasodilation.

      Clinical Use

      • Adverse Effects

      • Headache
      • Lethargy
      • Tachycardia
      • Nausea / vomiting

      Overview

      • Pharmacology

      • Act on cardiomyocytes, with no action on pacemaker cells whose phase 0 is mediated by calcium influx.

      Clinical Use

      • Indications

      • Hypomagnesaemia
      • Severe acute asthma
      • Torsades de pointes
      • Ecclampsia
      • Indications

      • Hypertriglyeridaemia (gemfibrozil)
      • Adjunctive treatment (along with statins) for elevated LDL (fenofibrate)
      • Secondary prevention of coronary artery / cerebrovascular / peripheral vascular disease / diabetes
      •  
        Oral
        Simvastatin
        Zocor 
      •  
        Oral
        Nebivolol
        Nebilet 
         
        β1 antagonism, as well as vasodilatation due to increased endothelial NO release

      Overview

      Weak sodium channel blockade, and decrease the absolute refractory period (ARP).

      Clinical Use

      • Adverse Effects

      • Dizziness
      • Headache
      • Fatigue
      • Muscle cramps
      •  
        Oral
        Telmisartan
        Micardis 

      Cardiomyocyte Action Potentials

      • Refractory Periods

      • Absolute refractory period (ARP) - stimulation by an adjacent cell will not elicit a new action potential. This prevents multiple concurrent action potentials and limits heart rate.Lengthened by most anti-arrhythmic medications
      • Relative refractory period (RRP) - greater stimulation is required in order to elicit an action potential

      Clinical Use

      • Indications

      • Refractory hypertension
      • Refractory heart failure
      • Peripheral oedema - due to congestive cardiac failure / renal failure / nephrotic syndrome / cirrhosis
      • Symptomatic ascites
      • Maintenance therapy for hypokalaemia
      • Primary aldosteronism
      • Hirsutism
      • Adverse Effects

      • Headache
      • Flushing
      • Nausea / vomiting / diarrhoea
      • Tachycardia / palpitations
      • Arthralgia / myalgia

      Overview

      • Effects

      • Increased contractility (positive inotropy)
      • Decreased heart rate (negative chronotropy) through lengthening of phases 1 and 0

      Clinical Use

      Standard therapy for tuberculosis involves ethambutol, isoniazid, pyrazinamide and rifampicin given simultaneously.
      Standard therapy for tuberculosis involves ethambutol, isoniazid, pyrazinamide and rifampicin given simultaneously.
      • Adverse Effects

      • Haemolytic anaemia
      • Leukopaenia
      • Rash
      • Nausea / vomiting
      • Peripheral neuropathy
      • Indications

      • Mycobacteria - tuberculosis, Mycobacterium avium complex (MAC), leprosy
      • Methicillin-resistant Staphylococcus aureus (MRSA)

      Overview

      Standard therapy for tuberculosis involves ethambutol, isoniazid, pyrazinamide and rifampicin given simultaneously.

      Clinical Use

      • Indications

      • Secondary prevention of stroke (in combination with aspirin)
      • Prevention of thromboembolism post prosthetic heart valve surgery (in combination with anticoagulants)
      • Adverse Effects

      • No specific adverse reactions identified in clinical trials.
      •  
        IV
        Low Titre Anti-T Plasma
        Tested for anti-T, for use in patients at risk of haemolytic reactions
      Approved by the FDA in the US. Not approved in Australia.
      • Indication

      • Reversal of apixaban or rivaroxaban in the event of life-threatening or uncontrolled bleeding.

      Overview

      • Pharmacology

      • Variable bioavailability, non-linear pharmacokinetics and unpredictable response.

      Clinical Use

      • Indications

      • Prevention of venous thromboembolism post hip / knee surgery
      • Treatment of venous thromboembolism (DVT / PE)
      • Non-valvular atrial fibrillation (prevention of stroke)

      Overview

      • Pharmacology

      • More potent (2-4x) than unfractionated heparin due to higher activation of antithrombin III
      • Smaller molecules are able to bind primarily to factor Xa, with little to no effect on IIa
      • Better bioavailability and more predictable response than heparin
      • Mechanism of Action

      • Bind to fibrin on the clot surface and activate plasminogen, resulting in its activation to plasmin and thus fibrinolysis.

      Clinical Use

      • Contraindications

      • History of / high risk of / active thrombosis
      • Subarachnoid haemorrhage
      • Indications

      • Reversal of heparin-associated bleeding
      • Reversal of heparin preoperatively or after renal dialysis
      • Indications

      • Warfarin reversal for non-bleeding patients with INR >9.0
      • Warfarin reversal for patients with active bleeding
      • Indications

      • Treatment of venous thromboembolism (DVT / PE)
      • Prosthetic heart valve (prevention of thromboembolism)
      • Atrial fibrillation (prevention of stroke) - particularly valvular AF
      • Large myocardial infarction

      Overview

      • Mechanism of Action

      • Irreversibly inhibit the binding of adenosine diphosphate (ADP) to platelet P2Y₁₂ receptors, resulting in reduced platelet activation and aggregation.

      Clinical Use

      • Contraindications

      • Active bleeding or risk of major bleeding
      • Use of other anticoagulants
      • Mechanical heart valve
      • Severe renal impairment (eGFR <30mL/min)
      • Severe hepatic disease with coagulopathy
      • Concurrent use of azole antimycotics

      Overview

      Low dose aspirin inhibits TXA2 synthesis, preventing thrombosis, while high dose aspirin inhibits PGI2 synthesis, promoting thrombosis.
      • Mechanism of Action

      • Inhibit glycoprotein IIb/IIIa receptors, preventing them from binding to plasma adhesive proteins such as fibrinogen and von Willebrand factor (vWF) and facilitating platelet adhesion.

      Clinical Use

      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Injection site reaction
      • Progressive multifocal leukoencephalopathy (PML)
      • Nausea / vomiting
      • Angioedema
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Immunosuppression (susceptibility to infection)
      • Nausea / vomiting / diarrhoea
      • Abdominal pain
      • Cardiac dysfunction
      • Dyspnoea / wheeze
      • Peripheral neuropathy
      • Arthralgias / myalgias
      • LFT derangement
      • Headache
      • Dizziness
      • Flushing
      • Weight loss
      • Insomnia
      • Rash
      • Adverse Effects

      • Back pain / myalgia / arthralgia
      • Hypertension
      • Dyslipidaemia
      • Rash
      • Indications

      • HER2 positive breast cancer
      • HER2 positive advanced gastric cancer (trastuzumab)
      • Adverse Effects

      • Infusion reactions
      • Hepatotoxicity
      • Haemorrhage
      • Infections

      Substem A (Target)

      -c(i)-: cardiovascular (e.g. abciximab)

      Overview

      • Mechanism of Action

      • Monoclonal antibodies directed against PD-L1, an inhibitory molecule expressed on certain tumour cells.
      • PD-L1 and PD-L2 are ligands that bind to PD-1 receptors on activated lymphocytes and inhibit T cell receptor signalling, downregulating immune responses and promoting tolerance.
      • Binding of anti-PD-L1 monoclonal antibodies leaves the ligand unable to bind to PD-1, and therefore stimulates an ongoing immune response.

      Clinical Use

      • Indications

      • Metastatic colorectal cancer that is EGFR positive, RAS wild type
      • Locally advanced / metastatic squamous cell cancer of the head & neck (cetuximab)
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Nausea / vomiting / diarrhoea / anorexia
      • Headache
      • Confusion
      • Hypotension
      • Dyspnoea
      • Arthralgia / myalgia
      • Rash
      • Fatigue
      • Indications

      • Unresectable or metastatic melanoma
      • Intermediate / poor risk advanced renal cell carcinoma
      • Indications

      • Certain solid organ and haematologic malignancies with high levels of microsatellite instability (MSI). Malignancies of particular interest are melanoma, non-small cell lung cancer, renal cancer and bladder cancer, though this is a rapidly growing field.
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Peripheral neuropathy
      • Arterial / venous thromboembolism
      • Hypertension
      • Proteinuria
      • Nausea / vomiting / diarrhoea
      • Fatigue

      Overview

      • Mechanism of Action

      • Bind to ergosterol on the cell membrane, resulting in the formation of pores, leakage of cytoplasmic components and cell death.
      • Microbiology

      • Effective against invasive candidiasis and invasive aspergillosis.
      • Mechanism of Action

      • Selectively inhibit aromatase, preventing aromatization of androgens into oestrogens.
      • Mechanism of Action

      • Directly inhibit the binding of androgens to androgen receptors.

      Clinical Use

      • Indication

      • Androgen deprivation therapy for prostate cancer.
      • Adverse Effects

      • Elevated LFTs
      • Nausea / vomiting / diarrhoea
      • Hot flushes
      • Headache
      • Adverse Effects

      • Hot flushes
      • Vaginal bleeding
      • Nausea / vomiting
      • Headache
      • Fluid retention
      • Alopecia
      • Deep venous thrombosis
      • Endometrial cancer
      • Adverse Effects

      • Fatigue
      • Hot flushes
      • Hypokalaemia
      • Hypertension
      • Peripheral oedema
      • LFT derangement
      • Diarrhoea
      • Anaemia
      • Indication

      • Androgen deprivation therapy for prostate cancer.
      •  
        Inhaled
        Sevoflurane
        Non-irritant, commonly used in children
      • Indications

      • Analgesia
      • General anaesthesia for procedures not requiring muscle relaxant
      • Induction of anaesthesia in conjunction with other agents

      Overview

      • Mechanism of Action

      • Bind to and inhibit neuronal voltage-gated sodium channels, suppressing neuronal depolarization and preventing axonal propagation of action potentials.
      •  
        IV
        Rocuronium
        Onset 2 minutes
        Duration 30 minutes
      • Pharmacology

      • Ultra short-acting
      • Onset 30-60 seconds
      • Duration 10 minutes

      Clinical Use

      • Indications

      • Induction and maintenance of general anaesthesia
      • Sedation of ventilated patients in ICU
      • Adverse Effects

      • Sodium / fluid retention
      • Hypokalaemia
      • Muscle weakness
      • Osteoporosis
      • Peptic ulceration
      • Seizure
      • Cushing's - central obesity, 'moon' face, buffalo hump, thin skin, peripheral oedema, striae, bruising
      • Adverse Effects

      • Rash
      • Neutropaenia / thrombocytopaenia
      • Liver failure
      • ANCA vasculitis
      • Indications

      • Prevention and treatment of osteoporosis
      • Uraemic osteodystrophy
      • Hypoparathyroidism
      • Rickets
      • Hypocalcaemia
      • Indication

      • Glycaemic control for severe type II diabetes.
      • Indications

      • Glycaemic control for type II diabetes - first line
      • Gestational diabetes mellitus
      • Polycystic ovarian syndrome (PCOS) with menstrual irregularity

      Overview

      • Mechanism of Action

      • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.

      Clinical Use

      Teriparatide should not be given for more than 18 months over a  lifetime.

      Overview

      • Mechanism of Action

        Suppress the body's normal inflammatory response through:
      • Reduced monocyte recruitment
      • Suppression of arachidonic acid metabolites - prostaglandin, leukotriene, platelet-activating factor
      • Reduced production of interleukins, TNF-α, GM-CSF

      Clinical Use

      • Contraindication

      • Retrosternal goitre.

      Overview

      The incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic hormone (GIP), are released from the gastrointestinal tract. The incretins stimulate insulin secretion and inhibit glucagon secretion only under hyperglycaemic conditions, with additional effects of delayed gastric emptying, appetite suppression and weight loss.
      •  
        Oral
        Saxagliptin
        Onglyza 
         
        Reduce dose in renal insufficiency
      • Mechanism of Action

      • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.

      Clinical Use

      • Contraindications

      • Past DVT / PE
      • Blood pressure >160/90
      • Immobilisation
      • Severe renal impairment

      Overview

      A combination of a short / very short-acting insulin and an intermediate insulin.
      • Pharmacology

      • Onset 90 minutes
      • Peak effect 4-12 hours
      • Duration 24 hours

      Clinical Use

      • Indications

      • Glycaemic control in type 2 diabetes mellitus
      • Prevention of cardiovascular events in patients with cardiovascular disease and type 2 diabetes
      • Contraindication

      • Past DVT / PE.
      • Adverse Effects

      • Back pain / myalgia / arthralgia
      • Hypertension
      • Dyslipidaemia
      • Rash
      • Adverse Effects

      • Thyrotoxicosis - palpitations, tachycardia, tachypnoea, fever, anxiety, headache, poor concentration
      • Nausea / vomiting / diarrhoea

      Overview

      • Pharmacology

      • Onset 30 minutes
      • Peak effect 2.5-5 hours
      • Duration 8 hours
      • Mechanism of Action

      • Inhibit potassium channels on pancreatic beta cell membranes, resulting in calcium influx and thus insulin release.
      •  
        IV
        Zoledronic Acid
        Aclasta, Zometa
      • Microbiology

      • Active against influenza A; no activity against influenza B.

      Clinical Use

      Multiple agents are used at once - two NRTIs + one NNRTI / PI / integrase inhibitor.
      • Indication

      • HIV infection.
      • Indication

      • Treatment of CMV retinitis in patients with AIDS
      • Aciclovir-resistant herpes simplex virus (HSV) infections
      •  
        Oral
        Lamivudine

      • Indication

      • Treatment of CMV retinitis in patients with AIDs.
      •  
        IV, intravitreal
        Ganciclovir

      • Indication

      • HIV infection.
      Multiple agents are used at once - two NRTIs + one NNRTI / PI / integrase inhibitor.
      • Indication

      • Influenza A and B infection.
      •  
        Oral
        Lorazepam
        Ativan 
         
        [Peak] 2 hours
        Half-life 10-20 hours
      Long-acting benzodiazepines such as diazepam may be used for acute anxiety, however should be avoided for long-term management of anxiety disorders.
      •  
        Oral
        Fluvoxamine
        Luvox 

      Overview

      • Effects

      • BZ1 receptor (cortex, thalamus, cerebellum) - sedation, anterograde amnesia, anticonvulsant
      • BZ2 receptor (limbic system, motor neurons) - anxiolysis, muscle relaxation

      Clinical Use

      • Contraindication

      • Not for concurrent use with monoamine oxidase inhibitors (MAOi).
      • Indications

      • Generalised seizures
      • Absence seizures
      • Acute mania
      • Maintenance therapy for bipolar disorder
      • Migraine prophylaxis
      •  
        IM / IV
        Droperidol
        Used for acute episodes + nausea / vomiting
      • Adverse Effects

      • CNS disturbances - drowsiness, ataxia, headache, diplopia
      • Nausea / vomiting
      • Rash
      • Anticonvulsant hypersensitivity syndrome (prolonged admin) - fever, rash, lymphadenopathy, hepatitis, myositis
      • Indications

      • Depression
      • Fibromyalgia
      • Migraine prophylaxis
      • Neuropathic pain
      • Post-traumatic stress disorder (PTSD)
      • Indication

      • Depression refractory to more commonly used medications.
      •  
        Oral / IM
        Olanzapine
        Zyprexa 
      • Adverse Effects

      • Nausea / vomiting / diarrhoea
      • Hypothyroidism
      • Tremor / muscle weakness
      • Fatigue
      • Polyuria / thirst
      • Memory difficulty

      Overview

      • Mechanism of Action

      • Inhibit presynaptic reuptake of both serotonin and norepinephrine, resulting in greater concentrations within the synapse.
      • Pharmacology

      • Higher affinity for bacterial dihydrofolate reductase than for human DHFR.
      • Mostly excreted unmetabolised into urine in high concentrations, resulting in its effect directly within the bladder.
      • Microbiology

      • Broad spectrum, including many aerobic gram-negative and gram-positive organisms.
      • No cover against pseudomonas.

      Clinical Use

      • Indications

        Anaerobic and protozoal infections:
      • Bacteria - intra-abdominal sepsis, Clostridium difficile diarrhoea, bacterial vaginosis
      • Protozoa - giardiasis, amoebiasis, trichomoniasis

      Overview

      • Mechanism of Action

      • Beta lactam antibiotics that inhibit bacterial cell wall synthesis.
      • Mechanism of Action

      • Inhibit protein synthesis by binding to the 50s ribosomal subunit, resulting in inaccurate mRNA translation.
      • Microbiology

      • Broad cover against gram positive organisms, including Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococci.
      • Microbiology

      • Effective against staphylococci, streptococci, pneumococci and most anaerobes.

      Clinical Use

      • Indications

        Severe resistant gram positive infections:
      • Pneumonia
      • Septicaemia
      • Skin / soft tissue infections
      • Osteomyelitis / septic arthritis
      • Meningitis

      Overview

      • Resistance

      • Broken down by beta lactamase enzymes produced by some bacteria.
      • Microbiology

      • Active against gram positive bacteria (including Staphylococci) and Mycobacterium species.
      • Mechanism of Action

      • Beta lactam antibiotics that inhibit bacterial cell wall synthesis.
      • Microbiology

      • Variable activity against gram positive and negative bacteria. Active against Pseudomonas spp.
      • Mechanism of Action

      • Beta lactam antibiotics, which inhibit bacterial cell wall synthesis.
      • Mechanism of Action

      • Penicillin is a beta lactam antibiotic that inhibits bacterial cell wall synthesis.
      • Microbiology

      • Have a broad range of activity against staphylococci, streptococci and most gram negatives (including Pseudomonas). No effect against MRSA.
      • Resistance

      • Broken down by beta lactamase enzymes produced by some bacteria.

      Clinical Use

      • Indications

      • Atypical pneumonia - Legionella, Chlamydophyla, Myoplasma
      • Rickettsial infections - typhus, African tick bite fever, Rocky Mountain spotted fever, Australian tick typhus
      • Malaria prophylaxis
      • Lyme disease
      • Brucellosis
      • Chlamydia
      • Syphilis
      • Acne
      • Indications

      • Treatment and prevention of malaria (in combination with proguanil).
      • Indications

      • Prevention of malaria
      • Acute Plasmodium malariae or falciparum infection
      • Contraindications

      • G-6-PD deficiency
      • Haemolytic anaemia
      • Indications

        Anaerobic and protozoal infections:
      • Bacteria - intra-abdominal sepsis, Clostridium difficile, bacterial vaginosis
      • Protozoa - giardiasis, amoebiasis, trichomoniasis
      • Indications

      • Inflammatory diseases - refractory inflammatory bowel disease, rheumatoid arthritis, psoriasis
      • Chemotherapy - for certain cancers

      Overview

      • Mechanism of Action

      • Bind to DNA, resulting in prevention of RNA transcription and protein synthesis.

      Clinical Use

      • Indications

      • Certain solid organ and haematologic malignancies, as guided by specialists and local guidelines
      • Autoimmune diseases refractory to first and second line therapy, in weighing up the risks and benefits of treatment (cyclophosphamide)

      Overview

      • Mechanism of Action

      • Converted intracellularly into diphosphate and triphosphate forms. The diphosphate form inhibits ribonucleotide reductase resulting in reduced intracellular deoxynucleotides, while the triphosphate form is incorporated into DNA and disrupts DNA polymerase activity.

      Clinical Use

      • Adverse Effects

      • Bone marrow suppression - leucopaenia / anaemia / thrombocytopaenia
      • Nausea / vomiting
      • Stomatitis
      • Alopecia
      • Blue / green discolouration of urine

      Clinical Use

      • Adverse Effects

      • Bone marrow suppression - anaemia / leukopaenia / thrombocytopaenia
      • Nausea / vomiting / diarrhoea / anorexia
      • Stomatitis / mouth ulcers
      • Elevated LFTs
      • Alopecia
      • Indications

      • Certain solid organ malignancies, as guided by cancer specialists and local guidelines.
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Nausea / vomiting / anorexia
      • Headache
      • Peripheral neuropathy

      Overview

      • Mechanism of Action

      • Alkylating agents that bind to DNA, causing intrastrand and interstrand crosslinks that change DNA conformation and affect replication.

      Clinical Use

      • Indication

      • Certain solid organ and haematologic malignancies, as guided by cancer specialists and local guidelines.
      • Adverse Effects

      • Neutropaenia
      • Anaemia
      • Dyspnoea
      • Nausea / vomiting
      • Cholinergic effects - lacrimation, sweating, diarrhoea
      • Indications

      • Certain solid organ and haematologic organ malignancies, as guided by cancer specialists and local guidelines.
      • Indications

      • Certain solid organ malignancies, as guided by cancer specialists and local guidelines.

      Overview

      • Mechanism of Action

      • Inserted between DNA base pairs, resulting in inhibition of topoisomerase II.

      Clinical Use

      • Adverse Effects

      • Bone marrow suppression - leucopaenia, thrombocytopaenia, anaemia
      • Nausea / vomiting / anorexia
      • Fever
      • Alopecia

      Troubleshooting

      Haematoma - remove the needle and apply pressure to the area.

      Overview

      Area under the curve (e.g. gentamicin) - consult guidelines and take blood at two set points following drug administration

      Choosing the Right Limb

      • Don't

      • Absolutely do not use the same arm as an AV fistula
      • Don't use the same arm as a past lymph node dissection or mastectomy
      • Don't use a limb affected by stroke
      • Don't insert a needle through a burn, oedema, haematoma or infected tissue
      • If testing coags, do not take from the same limb as a heparin infusion
      • If an infusion is running, either stop the infusion prior to taking the sample or use another limb

      Overview

      • Management

      • Apply a pressure bandage to the site.
      • Effects of Prolonged Tourniquet Application

      • On Blood Results

      • Haemoconcentration - water and certain solutes extravasate into the extracellular space, resulting in falsely elevated results
      • Elevated lactate
      • Elevated total protein, AST, lipids, cholesterol and iron
      • On the Patient

      • Bruising
      • Nerve palsies - numbness, paraesthesias or weakness
      • Limb ischaemia

      Nasal Prongs

      FlowFiO₂
      1 L/min~0.24
      2 L/min~0.28
      3 L/min~0.32
      4 L/min~0.36

      BiPAP

      Bilevel positive airway pressure (BiPAP) provides both expiratory positive airway pressure (EPAP), which opens the airways; and inspiratory positive airway pressure (IPAP), which ventilates the patient.

      Partial Rebreather Mask

      A partial rebreather mask includes a reservoir bag, allowing for higher amounts of entrained oxygen. Unlike a non-rebreather mask, they do not contain an exhalation port and therefore the patient will rebreath some of their expired gas.

      Venturi Mask

      ColourO₂ FlowFiO₂
      Blue2 L/min0.24
      White4 L/min0.28
      Orange6 L/min0.31
      Yellow8 L/min0.35
      Red10 L/min0.40
      Green15 L/min0.60

      Overview

      • Complications of Supplemental Oxygen

      • Hypoventilation - due to suppression of the hypoxic respiratory drive; particularly in patients with COPD
      • Absorption atelectasis (due to washout of nitrogen, which noramlly splints the airways open)
      • Oxygen toxicity - damage to upper or lower airways due to oxygen radical formation
      • Management

      • Remove the cannula
      • Observe the site
      • Treat for cellulitis or sepsis if clinically indicated

      Tips for Identifying an Artery

      • Don't

      • Absolutely do not use the same arm as an AV fistula
      • Don't use the radial artery on a limb with a fractured wrist
      • Avoid areas with inadequate collateral circulation (e.g. peripheral vascular disease)
      • Avoid inserting a needle through cellulitis, burns or oedema

      Overview

      Femoral - ensure privacy, then expose the femoral triangle
      Femoral - ensure privacy, then expose the femoral triangle

      Tips for Identifying an Artery

      • Don't

      • Absolutely do not use the same arm as an AV fistula
      • Don't use the radial artery on a limb with a fractured wrist
      • Avoid areas with inadequate collateral circulation (e.g. peripheral vascular disease)
      • Avoid inserting a needle through cellulitis, burns or oedema

      Catheter Sizing

      • Sizing

      • 6-10 French - paediatric patients
      • 12-14 French - most patients
      • 16-20 French - patients with clots or haematuria
      • 22 French (triple lumen) - continuous irrigation for patients with clots or haematuria or post urologic surgery

      Catheter-Associated UTI

      • Prevention

      • Insert catheters only when clinically indicated
      • Rationalise the duration of the catheter

      Overview

      Left subclavian: 18 - 20cm(Height / 10) + 2

      Confirming Venous Placement

      Blood gas - send a blood sample for analysis. Compare this with the patient's arterial sample or look at indicators of oxygenation in the result.

      Internal Jugular Vein

      To identify the vein using ultrasound, place the probe between the two heads of the sternocleidomastoid and look for a large-bore, non-pulsating, collapsible vessel lateral to the carotid artery.

      Overview

      Haematoma - remove the needle and apply pressure to the area.
      • Management

      • Remove the catheter and send the tip for culture
      • Observe the site
      • Treat for cellulitis or sepsis if clinically indicated

      Avoiding Incorrect NG Placement

      Intracranial - do not insertion an NG tube for patients with suspected base of skull fracture, as you may cannulate the brain.

      Difficult NG Insertion

      Withdraw the NG if the patient starts excessively gagging or coughing.

      Overview

      Several studies (Straus et al, Spriggs et al) suggest that bed rest post LP has no preventative effect on post-LP headache.
      Injection of dye for myelography

      Subclavian Placement

      • Look For

      • Placement of the PICC in the subclavian vein on chest x-ray.

      Troubleshooting

      Haematoma - remove the needle and apply pressure to the area.

      Overview

      • Management

      • Check for kinks, and remove the cannula if unable to flush.
      • Management

      • Remove the PICC and send the tip for culture
      • Observe the site
      • Treat for cellulitis or sepsis if clinically indicated
      • Management

      • Remove the cannula
      • Observe the site
      • Treat for cellulitis or sepsis if clinically indicated
      • Management

      • Apply a pressure bandage to the site.
      Position the patient appropriately - raise the bed, lower the bed rail, and position the limb appropriately. Consider using a pillow to elevate the limb.

      Troubleshooting

      Haematoma - remove the needle and apply pressure to the area

      Overview

      18 - everyday use, blood products, potassium, large volumes, surgery, IV contrast

      Potential Cannula Sites

      Antecubital fossa veins - limit movement, may extravasate due to flexion at the elbow

      Lignocaine

      Buffering with sodium bicarbonate can reduce the pain of injection.

      Intubation

      • Indications for Intubation

      • Airway

      • Inability to maintain airway patency (upper airway obstruction) - soft tissue swelling, deformity, obesity, tongue displacement
      • Inability to protect the airway - sedation (e.g. for procedures), upper airway bleeding, excessive secretions
      • Breathing

      • Inability to ventilate - unconsciousness, sedation, neuromuscular disease, exhaustion
      • Inability to oxygenate - severe acute respiratory failure
      • Circulation

      • Cardiac arrest

      Oropharyngeal Airway

      • How to Insert

      • Use suction to ensure that the mouth is clear of secretions
      • Angle the airway superiorly, toward the palate
      • Insert the airway into the oral cavity
      • Once the airway reaches the oropharynx, rotate it 180 degrees toward the larynx

      Diagnosis

      • Diagnosis

      Pathogenesis

      • Causes of Myelodysplasia

      • Primary

      • Myelodysplastic syndromes (MDS)
      • Myelodysplastic / myeloproliferative neoplasms - chronic myelomonocytic leukaemia (CMML)
      • Secondary

      • Cytotoxic chemotherapy
      • Benzene exposure
      • Ionising radiation
      • Effects of Digoxin

      • Increased automaticity - due to an increase in intracellular calcium
      • Reduced conduction via the AV node - due to an increase in parasympathetic (vagal) tone

      Hormonal Changes

      • Look For

      • Mild - normal / elevated TSH with elevated T4 and reduced T3
      • Moderate - normal / elevated TSH with normal T4 and reduced T3
      • Severe - reduced TSH, T4 and T3
      • Recovery - elevated TSH with normal T4 and reduced T3

      Diagnosis

      • Bloods

      • Serum magnesium <0.7 mmol/L.
      • Causes of Atelectasis

      • Airway obstruction - mucous plugging, tumour, foreign body, bronchial intubation
      • Airway compression - lymphadenopathy, tumour
      • Lung compression - pleural effusion, pneumothorax
      • Hypoventilation - general anaesthesia, opioids, obesity

      Manifestations

      • Complications of Chronic Kidney Disease

      • Disease-Related

      • Acidosis (poor clearance of hydrogen ions)
      • Fluid overload
      • Electrolyte derangements - hyperkalaemia, hyperphosphataemia
      • Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
      • Anaemia (EPO deficiency)
      • Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
      • Uraemia - encephalopathy, uraemic pericarditis
      • Malnutrition
      • Treatment-Related

      • Lethargy
      • Muscle cramps
      • Restless legs syndrome
      • Access-related complications - thrombosis, infection

      Diagnosis

      • Signs of Bronchiectasis

      • Oxygen requirement - reduced SpO2, nasal prongs
      • Halitosis
      • Cough - moist
      • Sputum - purulent / haemoptysis
      • Clubbing
      • Central cyanosis
      • Coarse crepitations
      • Wheeze
      • Signs of Complications

      • Evidence of empyema - dull percussion note, reduced breath sounds, reduced vocal resonance
      • Evidence of right ventricular failure - raised JVP, ascites, pleural effusions, peripheral oedema
      • Evidence of pulmonary hypertension - raised JVP, parasternal heave, loud / palpable P2
      • Diagnosis
      • Diagnosis
         

      Overview

      • Epilepsy Syndromes

      • Neonatal / Infantile

      • Ohtahara syndrome
      • West syndrome
      • Doose syndrome
      • Dravet syndrome
      • Myoclonic epilepsy of infancy
      • Childhood

      • Lennox-Gastaut syndrome
      • Childhood absence epilepsy
      • Benign Rolandic epilepsy
      • Adolescence / Adulthood

      • Juvenile absence epilepsy
      • Juvenule myoclonic epilepsy
      • Temporal lobe epilepsy

      Pathogenesis

      • Causes of Respiratory Acidosis

      • Hypoventilation - drugs, chronic obstructive pulmonary disease, obstructive sleep apnoea, encephalopathy, neuromuscular disease, chest wall abnormalities
      • Dead space ventilation - emphysema

      Diagnosis

      • Interpretation

        Assess the urinary osmolality and sodium.
      • Low urine osmolality (<800mOsm/kg) - due to renal water lossDiabetes insipidus, loop diuretics, ATN, uncontrolled diabetes
      • High urine osmolality (>800mOsm/kg) - due to other causesInsensible loss, sweat, GI loss, excessive administration
      • Blood Gas Findings

      • Alkalaemia with decreased PaCO₂.

      Pathogenesis

      In antidromic AVRT, an atrial impulse is conducted by the abnormal accessory pathway and is then propagated retrogradely back through the AV node, commencing a re-entry circuit.

      Diagnosis

      • ECG Findings

      • 1st degree - prolonged PR interval >200ms (5mm)
      • 2nd degree: type I Mobitz (Wenckebach) - initial normal PR interval with progressive prolongation of PR interval followed by a dropped QRS complex.
      • 2nd degree: type II Mobitz - constant PR interval with intermittently dropped QRS complexes
      • 2nd degree: advanced - two or more consecutive P waves without QRS complexes; may be in a 3:1, 4:1 or higher pattern
      • 3rd degree - complete dissociation of P waves and QRS complexes

      Management

      • Management of Non-Alcoholic Fatty Liver Disease

      • Weight loss
      • Reduced alcohol intake
      • Cirrhosis surveillance
      • HCC surveillance

      Severity

      • Severity of Obstructive Sleep Apnoea

        Based on the apnoea-hypopnoea index on sleep study
      • Mild: 5-15
      • Moderate: 15-30
      • Severe: >30

      Manifestations

      • ECG Findings in Hypokalaemia

      • Moderate to Severe

      • PR prolongation
      • ST depression
      • T wave flattening or inversion
      • Prominent U wave (resulting in an apparent prolonged QT interval)
      • Life-Threatening

      • Torsade de pointes
      • Ventricular tachycardia
      • Ventricular fibrillation
      Multiple myeloma presents classically with hypercalcaemia, renal dysfunction, anaemia and lytic bony lesions (denoted by the acronym CRAB); myeloma should be suspected in patients with any of these manifestations without any other clear cause.

      Overview

      Tension pneumothorax is a life-threatening condition which is diagnosed clinically - waiting for an x-ray may cost the patient their life.

      Diagnosis

      • Signs of Ventricular Septal Defect

      • Central Signs

      • Volume-loaded apex beat - displaced apex with forceful, non-sustained impulses
      • Soft first heart sound (S1)
      • Harsh pan-systolic murmur loudest at the left lower sternal edge
      • Signs of Complications

      • Evidence of mitral regurgitation
      • Evidence of pulmonary hypertension - raised JVP, parasternal heave, loud / palpable P2
      • Evidence of Eisenmenger's syndrome - cyanosis, clubbing
      • Diagnosis
      • History

      • Symptoms of PE - pleuritic chest pain, shortness of breath, haemoptysis
      • Symptoms of DVT - painful, swollen upper or lower limb
      • Recent travel - long flights, car rides, bus rides or train rides
      • Long periods of immobilisation
      • Recent trauma, surgery
      • Pregnancy or recent delivery
      • Past medical history - past VTE, clotting disorder, malignancy, varicose veins
      • Medications - hormonal therapy
      • Family history - VTE, clotting disorder

      Manifestations

      • Manifestations of Inflammatory Bowel Disease

      • Mouth ulcers
      • Malabsorption
      • Intestinal obstruction
      • Anorectal disease - fissures, fistulae, abscesses
      • Fistulae - anorectal, rectovaginal, enterocutaneous
      • Malignancy - small bowel or colorectal cancer
      • Extra-Intestinal

      • Dermatologic - erythema nodosum, pyoderma gangrenosum
      • Musculoskeletal - enteropathic arthritis, osteoporosis
      • Hepatic - primary sclerosing cholangitis, non-alcoholic fatty liver disease, cirrhosis, cholelithiasis (Crohn's)
      • Renal - nephrolithiasis (calcium oxalate)
      • Ocular - uveitis, episcleritis, conjunctivitis

      Diagnosis

      • Diagnosis
         

      Manifestations

      • Complications of Right Ventricular Failure

      • Arrhythmias - atrial fibrillation, ventricular arrhythmias
      • Sarcopaenia
      • Ascites
      • Peripheral oedema
      • Cardiac cirrhosis

      Diagnosis

      • Examples

      Pathogenesis

      • Causes of Atrial Flutter

      • Severe acute illness - especially in septic or postoperative patients
      • Cardiac - post cardiac surgery, myocardial infarction, valvular disease, cardiomyopathy, congestive cardiac failure, congenital heart disease, Wolff-Parkinson-White
      • Cardiovascular risk factors - hypertension, diabetes, obesity
      • Pulmonary embolism
      • Obstructive sleep apnoea
      • Thyrotoxicosis
      • Alcohol abuse
      • Risk Factors for Gastroesophageal Reflux

      • Family history of reflux
      • Advanced age
      • Obesity
      • Hiatus hernia
      • Pregnancy
      • Scleroderma
      • Smoking

      Diagnosis

      • ECG Findings in Pericardial Effusion

      • Sinus tachycardia
      • Low voltage (reduced QRS amplitude)
      • Electrical alternans - variation of the QRS amplitude between beats (thought to be due to swinging of the heart while suspended in fluid)

      Overview

      • ECG Findings in Pericarditis

      • Widespread concave (saddle-shaped) ST elevation (may not be present in aVR or V1)
      • PR depression
      • T wave changes - flattening then inversion

      Management

      • Management of Stable Ischaemic Heart Disease

      • Non-Pharmacologic

      • Smoking cessation
      • Dietary optimisation
      • Exercise
      • Pharmacologic

      • Antiplatelet - aspirin
      • Manage risk factors - hypertension, hyperlipidaemia, diabetes
      • Surgical Options

      • Surgery - coronary artery bypass graft

      Manifestations

      • Potential Presentations

      • Disease-Related

      • Respiratory symptoms - cough, haemoptysis, dyspnoea, pleuritic chest pain
      • Constitutional symptoms - anorexia, weight loss, fatigue
      • Complication-Related

      • SVC obstruction - facial swelling, plethora, upper limb oedema, positive Pemberton's sign
      • Pancoast tumour - Horner's syndrome (partial ptosis, miosis, anhydrosis), wasting of the hand
      • Laryngeal nerve involvement - hoarse voice
      • Paraneoplastic - hypercalcaemia, neurologic symptoms, hypertrophic pulmonary osteoarthropathy, Cushing's syndrome

      Pathogenesis

      • Causes of Pulmonary Hypertension

      • Type 1: Pulmonary Arterial Hypertension

      • Idiopathic
      • Inherited
      • Drugs / toxins
      • HIV-related
      • Connective tissue disease - scleroderma, mixed connective tissue disease
      • Portopulmonary hypertension
      • Congenital heart disease
      • Schistosomiasis
      • Type 2: Left Heart Disease

      • Left ventricular systolic / diastolic dysfunction
      • Valvular disease - aortic stenosis, aortic regurgitation, mitral stenosis
      • Type 3: Lung Disease

      • Chronic obstruction pulmonary disease
      • Interstitial lung disease
      • Mixed lung disease
      • Sleep-disordered breathing
      • Alveolar hypoventilation
      • Type 4: Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

      • Chronic pulmonary emboli
      • Type 5: Other

      • Haematologic - chronic haemolytic anaemia, myeloproliferative disorders, splenectomy
      • Systemic - sarcoidosis, pulmonary histiocytosis, lymphangioleiomyomatosis
      • Metabolic - glycogen storage disorders, Gaucher disease
      • Other - tumour obstruction, chronic kidney disease
      • Mechanisms

      • Monomorphic VT occurs most commonly in the context of a macro-reentrant pathway in a structurally abnormal heart. The rhythm may also be caused by a focal arrhythmogenic ventricular focus.

      Manifestations

      • Manifestations of Myaesthenia Gravis

      • Fatiguing muscle weakness (worse with use and improved with rest) affecting the eyes, face, oropharynx, trunk and limbs
      • Myaesthenic crisis (respiratory failure)

      Diagnosis

      • Diagnosis
         
      • Signs of Mitral Stenosis

      • Peripheral Signs

      • Narrow pulse pressure
      • Central Signs

      • Apical diastolic thrill
      • Early opening snap - high frequency sound after S2 in early diastole, heard best between the apex and left sternal edge
      • Loud first heart sound (S1)
      • Low-pitched, mid-diastolic murmur loudest in the apex in the left lateral position
      • Signs of Complications

      • Evidence of pulmonary hypertension - elevated JVP, parasternal heave, loud / palpable P2

      Manifestations

      • Manifestations of Grave's

      • Exophthalmos
      • Proptosis
      • Periorbital / lid swelling and chemosis
      • Lid lag
      • Diplopia, poor convergence, limited upward gaze
      • Corneal ulcers (exposure keratitis)
      • Decreased visual acuity (retinal and optic nerve oedema)
      • Pretibial myxoedema

      Diagnosis

      • Signs of Aortic Regurgitation

      • Peripheral Signs

      • Collapsing Pulse
      • Widened Pulse Pressure
      • Central Signs

      • Soft A2 - loss of normal splitting of S2 on inspiration
      • Volume-loaded apex beat - displaced apex with forceful, non-sustained impulses
      • Decrescendo diastolic murmur loudest on sitting forward, in expiration
      • Signs of Complications

      • Evidence of left ventricular failure - pulsus alternans, pulmonary crepitations

      Pathogenesis

      • Types of Pre-Excitation

      • Manifest preexcitation - anterograde conduction through the accessory pathway, with retrograde conduction back up the AV node
      • Concealed preexcitation - anterograde conduction through the AV node, with retrograde conduction back up the accessory pathway

      Diagnosis

      • Diagnosis
         
      • Left anterior fascicular block:
      • Left anterior fascicular block

      Management

      • Management Strategy

      • Depends on stage and the patient's functional status.
      • Non-Metastatic

      • Surgical resection with or without adjuvant chemotherapy
      • Surveillance - CEA level, CT, colonoscopy
      • Metastatic

      • Surgical resection (solitary metastasis) with adjuvant chemotherapy
      • VEGF inhibitors - bevacizumab
      • EGFR inhibitors - cetuximab, panitumumab
      • Management of Hepatitis C Infection

      • Non-Pharmacologic

      • Cirrhosis surveillance
      • HCC surveillance
      • Pharmacologic

      • NS3/4A inhibitors - grazoprevir, pariteprevir, simepravir
      • NS5A inhibitors - daclatasvir, elbasvir, ledipasvir, ombitasvir
      • NS5B inhibitors - dasabuvir, sofosbuvir

      Management of Obesity

      • Management Options

      • Non-Pharmacologic

      • Diet - very low calorie; in conjunction with a dietician
      • Exercise - increase incidental exercise and reduce sedentary time; consider exercise classes involving a physiotherapist
      • Pharmacologic

      • Orlistat - an intestinal lipase inhibitor (essentially cases steatorrhoea)
      • Phentermine (Duramine) - an appetite suppressant
      • Naltrexone + buproprion (Contrave)
      • Surgical

      • Restrictive - gastric banding, sleeve gastrectomy
      • Malabsorptive - Roux-en-Y gastric bypass

      Pathogenesis

      In slow-fast AVNRT (90%), a premature atrial impulse travels down the slow pathway and is propagated up the fast pathway.

      Manifestations

      • Clinical Phenotypes

      • Clinically isolated syndrome - a single episode of symptoms
      • Relapsing-remitting - relapses with improvement between episodes
      • Primary progressive - progression without relapses
      • Secondary progressive - progressive disability with fewer relapses and no return to baseline between episodes

      Pathogenesis

      • Risk Factors for COPD

      • Smoking
      • Occupational exposure - coal, toluene (plastics)
      • Environmental air pollution
      • Alpha-1 antitrypsin deficiency

      Classification

      • β - normal beta chains
      • β⁺ - reduced production of beta chains
      • β⁰ - no production of beta chains

      Pathogenesis

      • Causes of Cirrhosis

      • Chronic hepatitis - B or C
      • Alcoholic liver disease
      • Non-alcoholic fatty liver disease
      • Autoimmune hepatitis
      • Obstructive disease - primary biliary cirrhosis, primary sclerosing cholangitis, chronic biliary obstruction
      • Infiltration - haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, sarcoidosis, glycogen storage disease type IV
      • Hepatocellular carcinoma
      • Drugs - methotrexate, methyldopa, amiodarone
      • Budd-Chiari syndrome (hepatic vein occlusion)
      • Right heart failure (cardiac cirrhosis)

      Diagnosis

      • Diagnosis
         
      • Examination

      • Symmetrical arthropathy with sparing of DIP joints
      • Wrists

      • Prominence of the ulnar styloid
      • Radial deviation of the wrist
      • MCP, PIP and DIP Joints

      • Ulnar (medial) deviation of the MCP joints
      • Volar (palmar) subluxation of the MCP joints
      • Swan neck deformity: hyperextension at the PIP joint with flexion at the MCP and DIP joints
      • Boutonniere deformity: flexion at the PIP joints with hyperextension at the MCP and DIP joints
      • Z-thumb deformity: flexion at the IP joint of the thumb with hyperextension at the MCP joint
      • Non-Articular Manifestations

      • Evidence of compressive neuropathy - e.g. signs of carpal tunnel syndrome
      • Evidence of vasculitis - palpable purpura
      • Evidence of interstitial lung disease - fine fibrotic crepitations
      • Splenomegaly (Felty's syndrome)
      If the cause is not apparent, urinary phosphate (either 24-hour urine or fractional excretion) may be useful in differentiating increased excretion from other causes.
      • ECG Findings in Hypothermia

      • Movement artefact due to shivering
      • Osborn waves (J waves) - a dome or hump-shaped deflection following the J point
      • PR, QRS and QT prolongation
      • Arrhythmias

      • Bradyarrhythmias - bradycardia, AV block, slow AF, progression to asystole
      • Tachyarrhythmias - atrial fibrillation, ventricular tachycardia, ventricular fibrillation
      • Examples

      Manifestations

      Acute hyponatraemia may present with nausea, vomiting, headaches or confusion; as the sodium level falls patients may present with seizures (including status epilepticus) or coma.

      Pathogenesis

      • Potential Asthma Triggers

      • Environmental

      • Aeroallergens - pollens, dust mits, pet dander, mold
      • Cigarrette smoke
      • Air pollution
      • Other

      • Respiratory viral infections
      • Medications - beta blockers, NSAIDs
      • Exercise
      • Stress
      • Cold
      Haemoglobin S tends to polymerise in low oxygen settings, resulting in sickling of red blood cells; these deformed cells have a shortened lifespan and cause occlusions within blood vessels as well as endothelial dysfunction.
      Poor iron intake is a common cause of deficiency, and less commonly deficiency can be caused by malabsorption. Iron deficiency may occur in late pregnancy, though the most common obstetric cause of anaemia is haemodilution.

      Manifestations

      • Phases of Hepatitis B Infection

      • Immune tolerant - very early infection, prior to significant hepatitis
      • Immune active - attempted clearance of the virus by the immune system
      • Immune control - low viraemia due to clearance
      • Immune escape - recrudescence of viral replication and hepatitis

      Management

      • Management Options for Parkinson's Disease

      • Levodopa / decarboxylase inhibitor combos - levodopa / carbidopa, levodopa / benserazide
      • Dopamine agonists - bromocriptine, pramipexole, rotigotine
      • Monoamine oxidase-B inhibitors - rasagiline, selegiline
      • Catecholo-methyltransferase (COMT) inhibitors - entecapone
      • NMDA receptor antagonists - amantadine
      • Anticholinergics - benztropine

      Manifestations

      • Clinical Features

      • Hyperreflexia
      • Tetany (Chvostek's & Trousseau's signs)
      • Seizures
      • Heart failure (due to reduced  contractility)

      Overview

      • Examples

      Diagnosis

      • Diagnosis
         

      Manifestations

      • Manifestations of Inflammatory Bowel Disease

      • Bloody diarrhoea
      • Toxic megacolon
      • Fulminant colitis
      • Stricturing
      • Colorectal cancer
      • Extra-Intestinal

      • Dermatologic - erythema nodosum, pyoderma gangrenosum
      • Musculoskeletal - enteropathic arthritis, osteoporosis
      • Hepatic - primary sclerosing cholangitis, non-alcoholic fatty liver disease, cirrhosis, cholelithiasis (Crohn's)
      • Renal - nephrolithiasis (calcium oxalate)
      • Ocular - uveitis, episcleritis, conjunctivitis

      Diagnosis

      • Test Findings in Anaemia of Chronic Disease

      • Full Blood Count & Film

      • Anaemia - normocytic normochromic, or microcytic hypochromic
      • Evidence of chronic inflammation - rouleaux, thrombocytosis
      • Other Tests

      • Iron studies - reduced serum iron and transferrin; normal or increased ferritin, normal soluble transferrin receptor
      • Inflammatory markers - increased ESR / CRP, reduced albumin
      • Signs of Aortic Stenosis

      • Peripheral Signs

      • Anacrotic pulse - small volume pulse with a slow upstroke and a notched wave on the upstroke
      • Narrow pulse pressure
      • Central Signs

      • Aortic thrill
      • Pressure-loaded apex beat - forceful and sustained impulses
      • Soft second heart sound (S2)
      • Ejection systolic murmur - heard best over the aortic area in expiration
      • Signs of Complications

      • Evidence of left ventricular failure - pulsus alternans, pulmonary crepitations

      Overview

      • Causes of Metabolic Acidosis

      • Ingestion of acid - methanol, ethylene glycol, salicylic acid
      • Acid production - lactic acidosis, ketoacidosis, rhabdomyolysis
      • Reduced acid excretion - renal failure, distal RTA
      • Loss of alkali - diarrhoea, proximal RTA
      Gap-gap ratio
      anion gap - 12 24 - HCO₃
      Or in other words:
      • Examples

      Pacemaker

      • Types of Pacemaker

      • Single chamber pacemaker - a single lead within the right atrium or right ventricle
      • Dual chamber pacemaker - leads within the right atrium and right ventricle
      • Biventricular pacemaker - also known as a cardia resynchronisation therapy (CRT) device (see below)

      Overview

      • An endotracheal tube within the right main bronchus
      • No Overlay
        Overlay
        An endotracheal tube within the right main bronchus
         
      • Causes of Interstitial Lung Disease

      • ILD of Known Association

      • Connective tissue disease - rheumatoid arthritis, scleroderma, systemic lupus erythematosus, Sjogren's syndrome, polymyositis / dermatomyositis
      • Medications - methotrexate, nitrofurantoin, bleomycin
      • Occupational exposure - silicosis, asbestosis
      • Granulomatous ILD

      • Sarcoidosis
      • Hypersensitivity pneumonitis
      • Idiopathic Interstitial Pneumonias

      • Idiopathic pulmonary fibrosis
      • Others - idiopathic non-specific interstitial pneumonia, acute interstitial pneumonia, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia
      • Perihilar opacification and increased interstitial markings in keeping with early pulmonary oedema
      • Perihilar opacification and increased interstitial markings in keeping with early pulmonary oedema
         

      Dextrocardia

      • Look For

      • Inversion of the cardiac shadow, with the apex pointing toward the right side.

      Posterior-Anterior (PA)

      The PA film is the most common film, and is usually only taken in X-ray departments.

      Overview

      • Examples

      Exposure

      In order to assess penetration, check that the vertebrae are just visible behind the heart.

      Overview

      • A left-sided pleural effusion with a chest drain in situ
      • No Overlay
        Overlay
        A left-sided pleural effusion with a chest drain in situ
         

      Central Venous Catheters (CVCs)

      • Example

      • A right internal jugular CVC within the superior vena cava
      • No Overlay
        Overlay
        A right internal jugular CVC within the superior vena cava
         

      Erect Film

      • Erect Film
         

      Overview

      • Examples

      Silhouette Signs

      • Examples

      Overview

      • Left-sided pleural effusion
      • No Overlay
        Overlay
        Left-sided pleural effusion
         
      • Hyperinflation with multiple right apical bullae
      • Hyperinflation with multiple right apical bullae
         
      • Classification

      • I
        Straight through - fracture directly across the growth plate, not involving surrounding boneGood prognosis
      • II
        Above - fracture across the growth plate and up through the metaphysis (most common)Good prognosis
      • II
        Lower - fracture across the growth plate and down through the epiphysisPoor prognosis - interruption of proliferative zone
      • IV
        Transverse - fracture directly through the metaphysis, growth plate and epiphysisPoor prognosis - interruption of proliferative zone
      • V
        Ruined / rammed - direct compression of the growth plateWorst prognosis

      White Blood Cells

      White blood cells within ascitic fluid suggest infection or malignancy.

      Overview

      • Roles of Sodium

      • Maintenance of blood volume
      • Maintenance of cellular osmotic pressure gradients
      • Maintance of membrane potentials, and activation of action potentials
      • Nerve conduction

      2nd Degree SA Exit Block: Type I

      Also known as Wenkebach sinoatrial exit block.

      1st Degree AV Block

      First degree AV block indicates delayed conduction between the atria and the ventricles.

      Overview

      • Atrial escape rhythm:
      • Atrial escape rhythm
         
      • Junctional escape rhythm:
      • Junctional escape rhythm
         
      • Pearls

      • Sinoatrial exit block and sinus arrest present as pauses without P waves or QRS complexes.
      • Escape rhythms are likle to be present if there are pauses or non-conducted P waves followed by bradycardia with junctional or ventricular complexes.
      • Atrial fibrillation with slow ventricular rate produces fibrillation waves without P waves and with irregular QRS complexes.
      • Atrial flutter with variable block manifests as a sawtooth wave at ~300bpm with irregular QRS complexes.
      • Second degree heart block presents with intermittently non-conducted P waves (without a subsequent QRS complex); the pattern of PR interval prolongation determines the type.
      • Complete AV block produces complete dissociation between P waves and QRS complexes.
      • Causes of Atrial Fibrillation

      • Severe acute illness - especially in septic or postoperative patients
      • Cardiac - post cardiac surgery, myocardial infarction, valvular disease, cardiomyopathy, congestive cardiac failure, congenital heart disease, Wolff-Parkinson-White
      • Cardiovascular risk factors - hypertension, diabetes, obesity
      • Pulmonary embolism
      • Obstructive sleep apnoea
      • Thyrotoxicosis
      • Alcohol abuse
      • Causes of Tachy-Brady Syndrome

      • Intrinsic

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis
      • Extrinsic

      • Physiologic - sleep, athletes
      • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
      • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
      • Hypothyroidism
      • Hypothermia
      • Hyperkalaemia
      • Obstructive sleep apnoea
      • Raised intracranial pressure
      • Ventricular escape in the setting of sinus arrest:
      • Ventricular escape in the setting of sinus arrest
         
      • Causes of Sinus Arrest

      • Intrinsic

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis
      • Extrinsic

      • Physiologic - sleep, athletes
      • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
      • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
      • Hypothyroidism
      • Hypothermia
      • Hyperkalaemia
      • Obstructive sleep apnoea
      • Raised intracranial pressure
      • Causes of Sinus Bradycardia

      • Intrinsic

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis
      • Extrinsic

      • Physiologic - sleep, athletes
      • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
      • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, flecainide, ivabradine, clonidine, acetylcholinesterase inhibitors
      • Hypothyroidism
      • Hypothermia
      • Hyperkalaemia
      • Obstructive sleep apnoea
      • Raised intracranial pressure

      Poikilocytosis

      • Interpretation

      • Schistocytes: small irregular fragments of red blood cells of varying shapesMicroangiopathic haemolytic anaemia, mechanical haemolysis, thalassaemia
      • Sickle cells (drepanocytes): crescent-shaped cells caused by aggregation of haemoglobin SSickle cell disease
      • Spherocytes: round cells with loss of central pallor, due to removal of a portion of the cell membrane by phagocytesHereditary spherocytosis, immune haemolysis, Clostridium
      • Microspherocytes: small round cells with loss of central pallor (essentially spherocytic schistocytes)Hereditary spherocytosis, microangiopathic haemolysis, burns
      • Irregularly contracted cells: loss of central pallor with an irregular borderOxidative haemolysis - G6PD deficiency, unstable haemoglobins, drugs
      • Prekeratocytes (blister cells)  - central holeOxidative haemolysis - G6PD deficiency, unstable haemoglobins, drugs
      • Keratocytes (bite cells): bite-like defect in the membrane of the cell, due to phagocytosis of a Heinz bodyOxidative haemolysis - G6PD deficiency, unstable haemoglobins, drugs

      Reticulocytosis

      • Causes of Reticulocytosis

      • Haemolytic anaemia
      • Haemorrhage (acute or chronic)
      • Recovery post bone marrow suppression
      • Late pregnancy
      • High altitude

      Overview

      • Causes of Elevated Bilirubin

      • Unconjugated (Indirect)

      • Haemolysis - immune, thrombotic microangiopathy, mechanical, inherited, infection, hypersplenism, drugs
      • Haematoma resorption
      • Drugs - choramphenicol, probenecid, irinotecan
      • Neonatal - neonatal jaundice, jaundice of prematurity
      • Inherited conjugation disorders - Gilbert syndrome, Crigler-Najar syndrome
      • Unconjugated /Conjugated

      • Acute hepatitis - viral hepatitis, HSV, EBV, CMV, VZV, alcoholic hepatitis, drug-induced hepatitis, ischaemic hepatitis, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson's disease
      • Cirrhosis - chronic hepatitis B or C, alcoholic liver disease, non-alcoholic fatty liver disease, autoimmune hepatitis, primary biliary cirrhosis, chronic bile duct obstruction, primary sclerosing cholangitis, haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, hepatocellular carcinoma, sarcoidosis, glycogen storage disease type IV, methotrexate, methyldopa, amiodarone, Budd-Chiari syndrome, right heart failure
      • Conjugated (Direct)

      • Intrahepatic cholestasis - primary biliary cirrhosis, primary sclerosing cholangitis, sepsis, HCC, liver metastases, cystic liver disease, intrahepatic cholestasis of pregnancy, cystic fibrosis, total parenteral nutrition, viral / alcoholic hepatitis, amyloidosis, sarcoidosis, augmentin, isoniazid, rifampicin, chlorpromazine
      • Extrahepatic cholestasis - choledocholithiasis, bile duct stenosis, bile duct strictures, primary sclerosing cholangitis, bile duct / ampullary / pancreatic malignancy
      • Inherited secretion disorders - Dubin-Johnson syndrome, Rotor's syndrome

      Aetiology

      Frequent blood transfusion can result in iron overload, as one unit of packed red blood cells contains approximately 250mg of iron. Overload can also be caused by excessive iron administration; this is mainly through parenteral means as oral intake is unlikely to be sufficient to cause significantly elevated stores.

      Absorption

      • Absorption

      Manifestations

      • Clinical Features of Iron Deficiency

      • History

      • Symptoms of anaemia - fatigue, lethargy, lightheadedness, shortness of breath, chest pain, headache
      • Pica - craving of non-foods such as ice, chalk and dirt
      • Restless legs syndrome
      • Bleeding - trauma, haematemesis, malaena, haematochezia, menorrhagia
      • Plummer-Vinson syndrome: iron deficiency anaemia, dysphagia and oesophageal webs
      • Family history - bowel cancer
      • Examination

      • Signs of anaemia - conjunctival pallor, pale hand creases, tachycardia
      • Koilonychia: spoon-shaped nails
      • Brittle nails
      • Alopecia
      • Atrophic glossitis
      • Angular stomatitis

      Overview

      Reduced serum iron levels should not be used in the diagnosis of iron deficiency.

      Monocytosis

      • Causes of Monocytosis

      • Chronic infection / inflammation - tuberculosis, EBV, bacterial endocarditis, autoimmune diseases
      • Malignancy - acute myeloid leukaemia, chronic myeloid leukaemia, lymphoma
      • Post splenectomy

      Overview

      • Causes of Megaloblastic Anaemia

      • Haematinic Deficiency

      • B12 deficiency - pernicious anaemia, H pylori gastritis, malabsorption, resection of the stomach or terminal ileum, chronic pancreatitis
      • Folate deficiency - nutritional deficiency, alcohol abuse, malabsorption, pregnancy, folate antagonists
      • Drugs

      • Folate antagonists - methotrexate, trimethoprim
      • Purine analogues - azathioprine, 6-mercaptopurine, allopurinol, cladribine, fludarabine
      • Pyramidine antagonists - 5-fluorouracil, cytarabine, gemcitabine, capecitabine
      • Anticonvulsants - valproate, phenytoin
      • Reverse transcriptase inhibitors - abacavir, emtricitabine, entecavir, lamivudice, zidovudine, tenofovir, efavirenz

      Eosinophilia

      Eosinophilia refers to an increase in circulating eosinophils.

      Microcytosis

      Microcytes are small red blood cells with mean corpuscular volume (MCV) <80 fL. On a blood film, they are significantly smaller than small mature lymphocytes.

      Overview

      • Causes of Circulating Plasma Cells

      • Severe infection / inflammation / malignancy
      • Plasma cell myeloma
      • Plasma cell leukaemia
      • Causes of Hyposplenism

      • Congenital

      • Prematurity
      • Congenital hyposplenism
      • Iatrogenic

      • Post splenectomy
      • High dose steroids
      • Bone marrow transplant
      • Acquired Conditions

      • Vascular - splenic artery / vein thrombosis
      • Haematologic - sickle cell disease, leukaemia, graft vs host disease
      • Gastrointestinal - coeliac disease, inflammatory bowel disease, Whipple's disease
      • Hepatic - liver cirrhosis, portal hypertension, active chronic hepatitis
      • Autoimmune - SLE, Sjogren's syndrome rheumatoid arthritis, polyarteritis nodosa
      • Infiltrative - amyloidosis, sarcoidosis
      • Infection - HIV/AIDS

      Neutrophil Physiology

      • Roles of Neutrophils

      • Neutrophils make up part of the innate immune system, and as such act immediately and are non-specific in their action. They migrate to a site of infection and phagocytose pathogens such as bacteria, fungi and protozoa.

      Thrombocytosis

      • Thrombocytosis
         

      Lymphocytosis

      • Causes of Lymphocytosis

      • Relative Lymphocytosis

      • Acute viral infection
      • Autoimmune disease
      • Thyrotoxicosis
      • Adrenocortical insufficiency
      • Hyposplenism
      • Absolute Lymphocytosis

      • Acute viral infection - EBV, CMV, viral hepatitis
      • Chronic infection - TB, brucellosis
      • Mature lymphocytic leukaemias - CLL, hairy cell leukaemia, T-LGL
      • Leukaemic phase of lymphomas - follicular, mantle cell, SMZL, DLBCL, burkitt

      Left Shift of Granulocytes

      Left shift refers to the presence of neutrophil precursors in the circulation. This may be an increase in band forms or the presence of any metamyelocytes, myelocytes or promyelocytes.

      Overview

      •  
      • Causes of Smudge Cells

      • Mature lymphocytic leukaemias - e.g. chronic lymphocytic leukaemia, T-large granulocytic leukaemia
      • Others - infectious mononucleosis, cardiac arrest
      • Artefact - incorrect storage
      • Causes of Circulating Blasts

      • Acute leukaemia - acute myeloid leukaemia, acute lymphoblastic leukaemia, others
      • Other bone marrow pathologies - e.g. myelodysplastic syndrome, CML, CMML, myelofibrosis
      • Acute stress - sepsis, haemorrhage, shock
      • G-CSF administration
      • Causes of a Leukoerythroblastic Blood Film

      • Acute stress - haemorrhage, shock
      • Bone marrow infiltration - myeloproliferative neoplasms, leukaemias, lymphomas, myeloma, metastatic cancer
      • G-CSF administration

      Basophilia

      • Basophilia
         

      Overview

      • Pearls

      • Free T3 measurement is useful for diagnosing T3 thyrotoxicosis in patients with reduced TSH and normal T4.
      • Free T3 may be useful to confirm suspected hyperthyroidism, as it becomes elevated prior to T4.
      • Free T3 is not useful in the diagnosis of hypothyroidism as it is the last test to become abnormal in this setting.
      Thyroid stimulating hormone (TSH) is secreted by the anterior pituitary, in response to the stimulating effect of TRH. TSH acts on the thyroid gland to stimulate release of T3 and T4. The release of TSH is inhibited in the presence of high levels of circulating T3 and T4.
        • Normal Range

        • 0.4 - 4.1 mIU/L

      Primary Hypothyroidism

      Hypothyroidism that originates from thyroid tissue.

      Hormonal Changes

      • Look For

      • Mild - normal / elevated TSH with elevated T4 and reduced T3
      • Moderate - normal / elevated TSH with normal T4 and reduced T3
      • Severe - reduced TSH, T4 and T3
      • Recovery - elevated TSH with normal T4 and reduced T3

      Suppressed TSH with Elevated T4

      Primary hyperthyroidism is hyperthyroidism that originates from thyroid tissue.

      Manifestations

      • Manifestations of Grave's

      • Exophthalmos
      • Proptosis
      • Periorbital / lid swelling and chemosis
      • Lid lag
      • Diplopia, poor convergence, limited upward gaze
      • Corneal ulcers (exposure keratitis)
      • Decreased visual acuity (retinal and optic nerve oedema)
      • Pretibial myxoedema

      Hyperferritinaemia

      Ferritin is also an acute phase reactant and can be non-specifically elevated with alcohol intake, liver disease or chronic inflammation.

      Overview

      Albumin is a negative acute phase reactant, meaning that its level will fall in the context of acute inflammation. This occurs as a result of reduced hepatic production, as well as proteolysis.

      Manifestations

      • Clinical Features

      • Fever
      • Rigors
      • Tachycardia
      • Severe Cases

      • Distributive shock
      • Disseminated intravascular coagulation

      Overview

      • Causes of Increased Haptoglobin

      • Infection
      • Inflammation
      • Malignancy
      • Trauma (including surgery)

      Quadrant Method

      An ECG lead will be positive if the direction of depolarisation is in the same direction as that lead, and will be negative if the direction of depolarisation is in the opposite direction.

      Overview

      • Causes of Prominent U Waves

      • Athletes
      • Hypokalaemia
      • Hypercalcaemia

      Measuring the QT Interval

      Compare QT intervals between sequential ECGs in order to determine change in QT.

      Sinoatrial Rhythm

      Check whether each QRS complex is preceded by a P wave, as well as the regularity of the interval between P waves (PP interval).

      Limb Electrode Placement

      Placement of arm leads on the shoulders and leg leads on the pelvis can lead to significant changes in amplitude and waveform that can affect interpretation, and therefore the ECG should be marked if this alternative placement is used. An ECG measured using torso lead placement should not be compared to an ECG measured using standard limb placement.

      Overview

      •  
      The P wave is directed inferiorly and therefore should be positive in leads I and II. It is often biphasic in lead V1.
      Heart rate = 300 / no. of large squares between R waves

      The ECG Trace

      • Look For

      • PQRST Complex

      • P wave - indicative of atrial depolarisation
      • QRS complex - indicative of ventricular depolarisation
      • T wave - indicative of ventricular repolarisation
      • Intervals

      • PR interval - the time between atrial depolarisation and ventricular depolarisation, suggestive of AV conduction time
      • QT interval - the time between ventricular depolarisation and repolarisation

      Monomorphic Ventricular Tachycardia

      A left bundle branch morphology classically suggests a right ventricular focus of VT, while a right bundle morphology pattern suggests a left ventricular focus. A septal focus may manifest as either a left or right bundle branch morphology.

      Overview

      • SVT with right bundle branch block:
      • SVT with right bundle branch block

      Distinguishing Between VT and SVT with Aberrancy

      Several ECG features can be used to distinguish between ventricular tachycardia and supraventricular tachycardia with aberrant conduction.

      Overview

      • Causes of Multifocal Atrial Tachycardia

      • COPD exacerbation
      • Cor pulmonale
      • Ischaemic heart disease
      • Rheumatic heart disease
      • Hypokalaemia / hypomagnesaemia
      • Digoxin toxicity
      In typical atrial flutter, 2:1 AV block is present with every second flutter wave resulting in a QRS complex. The block may also be 3:1, 4:1 or variable. 1:1 conduction is associated with extreme tachycardia and is immediately life-threatening.
      • Causes of Sinus Tachycardia

      • Physical exertion
      • Anxiety
      • Pain
      • Trauma
      • Fever
      • Infection
      • Hypovolaemia
      • Shock
      • Hypoxia
      • Anaemia
      • Pulmonary embolism
      • Coronary ischaemia / infarction
      • Hypoglycaemia
      • Thyrotoxicosis
      • Phaeochromocytoma
      • Drugs - beta agonists, anticholinergics, theophylline, caffeine, amphetamine, cocaine, alcohol
      • Mechanism

      • AVRT requires the presence of a distinct accessory pathway, most commonly in the setting of Wolff-Parkinson-White syndrome.
      • Mechanism

      • Focal atrial tachycardia originates from a single source of micro reentry, most commonly in the right atrium.
      • Classification

      • Paroxysmal AF - occurring for <7 days
      • Persistent AF - occurring for >7 days
      • Permanent AF - long-standing despite attempts at cardioversion
      • Causes of Ventricular Fibrillation

      • Myocardial infarction
      • Cardiomyopathy
      • Pulmonary embolism
      • Cardiac tamponade
      • Severe electrolyte disturbance
      • Cardiotoxic medications
      • Environmental - electrocution, drowning, hypothermia
      • Mechanism

      • The AV node normally contains two pathways - a slow pathway (short refractory period) and fast pathway (long refractory period) - that then combine to form a common pathway into the bundle of His. Normally, an atrial impulse is conducted down the two pathways with no recirculation of the impulse, as both pathways are within their refractory periods.
      • Elements of Protein Electrophoresis

      • Albumin
      • Alpha-1 - alpha 1-antitrypsin, thyroid-binding globulin
      • Alpha-2 - caeruloplasmin, alpha 2-macroglobulin, haptoglobulin
      • Beta-1 - transferrin
      • Beta-2 -  beta-lipoprotein
      • Gamma - immunoglobulins
      Antibodies directed against specific pathogens (e.g. hepatitis B IgM and IgG) are useful in clinical practice, though total serum immunoglobulin levels are also useful for detecting inflammation, oligoclonal / monoclonal gammopathies and hypogammaglobulinaemia.
      Standard IFE assesses the levels of immunoglobulins IgG, IgA and IgM, as these are the most commonly present in plasma cell neplasms; IgE and IgD may be tested if required. IFE also assesses for kappa or lambda free light chains.

      MDRD Formula

      The MDRD formula was created for the modification of diet in renal disease (MDRD) study based on data from patients with advanced renal failure. This formula is commonly used by labs to calculate an eGFR to be reported along with the creatinine.

      Overview

      • ECG Findings in Pulmonary Embolism

      • Sinus tachycardia
      • Atrial fibrillation / flutter
      • Right bundle branch block
      • T wave inversion in right precordial leads
      • Right axis deviation
      • P pulmonale (right atrial dilatation) - prominent P waves in inferior leads 
      • S1Q3T3 pattern - S wave in lead I, Q wave in in lead III, T wave inversion in lead III
      • ECG Findings in CPVT

      • Polymorphic VT with alternating QRS morphology
      • Ventricular fibrillation
      • ECG Findings in Hypothermia

      • Movement artefact due to shivering
      • Osborn waves (J waves) - a dome or hump-shaped deflection following the J point
      • PR, QRS and QT prolongation
      • Arrhythmias

      • Bradyarrhythmias - bradycardia, AV block, slow AF, progression to asystole
      • Tachyarrhythmias - atrial fibrillation, ventricular tachycardia, ventricular fibrillation
      The presence of a type 1 pattern with at least one clinial criterion is diagnostic of Brugada syndrome. 
      • ECG Findings in ARVD

      • Epsilon wave - a small upward deflection in leads V1-V3
      • T wave inversion in leads V1-V3
      • Localised QRS widening in leads V1-V3
      • Ventricular tachycardia with left bundle branch morphology
      • Diagnostic Criteria for ST Elevation Myocardial Infarction

      • ST elevation in at least two contiguous leads:

      • >2.5mm in V2-V3 (males <40 years)
      • >2mm in V2-V3 (males >40 years)
      • >1.5mm in V2-V3 (females)
      • >1mm in all other leads
      • ECG Findings in Hypercalcaemia

      • Shortened QT interval (due to a shortened ST segment)
      • Osborn waves (J waves) - dome or hump-shaped deflections following the J point
      • QRS prolongation
      • PR prolongation
      • ECG Findings in Pericardial Effusion

      • Sinus tachycardia
      • Low voltage (reduced QRS amplitude)
      • Electrical alternans - variation of the QRS amplitude between beats (thought to be due to swinging of the heart while suspended in fluid)
      • Downsloping ST depression
      • Downsloping ST depression
         
      • Congenital Long QT Syndromes

      • Romano-ward syndrome (LQT1-6) - isolated prolonged QT precipitated by various triggers
      • Jervell and Lange-Nielsen syndrome (JLNS)
      • Anderson-Tawil syndrome (LQT7) - prolonged QT, periodic paralysis, facial abnormalities
      • Timothy syndrome (LQT8) - prolonged QT, AV block, congenital heart disease, developmental delay, dysmorphic features
      • ECG Findings in Pericarditis

      • Widespread concave (saddle-shaped) ST elevation (may not be present in aVR or V1)
      • PR depression
      • T wave changes - flattening then inversion
      • Severity of Hypokalaemia

      • Mild - 3.0 - 3.5 mmol/L
      • Moderate - 2.5 - 3.0 mmol/L
      • Severe - <2.5 mmol/L
      • ECG Findings in Hypocalcaemia

      • Prolonged QT interval (due to a prolonged ST segment)
      • Torsade de pointes (rare)
      • Severity of Hyperkalaemia

      • Mild - 5.0 - 6.5 mmol/L
      • Moderate - 6.5 - 7.0 mmol/L
      • Severe - >7.0 mmol/L
      Manifest preexcitation produces the classic ECG findings listed below, while concealed preexcitation may produce no ECG changes at rest.
      • ECG Findings in Sodium Channel Blocker Toxicity

      • QRS widening >100ms
      • Ventricular arrhythmias - ventricular tachycardia, ventricular fibrillation
      • ECG Findings in Early Repolarisation Syndrome

      • ST elevation at the J point (the terminal portion of the QRS complex)
      • J-point notching - a positive deflection directly after the QRS complex
      Certain ECG changes with digoxin may purely indicate a therapeutic effect (such as the ST depression and T wave flattening), while other changes (such as T wave inversion and arrhythmias) indicate toxicity.

      Exercise Tolerance

      • Ask About

      • How far the patient is able to walk before they are limited by shortness of breath, chest pain or lower limb claudication pain.

      Overview

      • Sources of Past Medical History

      • The patient
      • Collateral - from family or friends
      • The patient's file - especially discharge summaries
      • Other hospitals - especially discharge summaries or transfer letters
      • The patient's GP
      • Letters from specialists

      Pack-Years

      The number of 'packs' a patient has smoked per day over how many years. A useful measure of the amount of tobacco exposure the patient has had.

      Overview

      • Significance

      • Poor mobility significantly increases risk of falls, and affects the patient's ability to perform their activities of daily living.
      It is often helpful to draw a pedigree chart to visualise the relationship between those affected by the condition.

      Medication History

      • Prescription

      • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
      • Administration - e.g. oral, IM or IV
      • Dose - the strength of the medication and how much they take eg how many tablets
      • Frequency - how often they take the medication

      The CAGE questionnaire

      A screening tool for alcohol dependence.

      Complications

      • Complications of Chronic Kidney Disease

      • Disease-Related

      • Acidosis (poor clearance of hydrogen ions)
      • Fluid overload
      • Electrolyte derangements - hyperkalaemia, hyperphosphataemia
      • Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
      • Anaemia (EPO deficiency / anaemia of chronic disease)
      • Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
      • Uraemia - encephalopathy, uraemic pericarditis
      • Malnutrition
      • Treatment-Related

      • Lethargy
      • Muscle cramps
      • Restless legs syndrome
      • Access-related complications - thrombosis, infection

      Pretransplant History

      • Ask About

      • Chronic kidney disease - underlying cause, complications
      • Dialysis history - duration of dialysis, type of dialysis, access
      • Past renal transplant
      • Medical comorbidities - particularly cardiovascular and respiratory
      • Psychological factors - depression / anxiety
      • Social situation - family, living arrangement, occupation
      • Adherence - to management plan, dialysis, medications

      Relapses

      • Ask About

      • Symptoms during relapses - weakness, paraesthesia, visual loss, ataxia, bladder / bowel / sexual dysfunction
      • Frequency of relapses
      • Duration of relapses
      • Partial or complete resolution of symptoms between relapses

      Management

      • Management Options for Parkinson's Disease

      • Levodopa / decarboxylase inhibitor combos - levodopa / carbidopa, levodopa / benserazide
      • Dopamine agonists - bromocriptine, pramipexole, rotigotine
      • Monoamine oxidase-B inhibitors - rasagiline, selegiline
      • Catecholo-methyltransferase (COMT) inhibitors - entecapone
      • NMDA receptor antagonists - amantadine
      • Anticholinergics - benztropine

      Overview

      • Epilepsy Syndromes

      • Neonatal / Infantile

      • Ohtahara syndrome
      • West syndrome
      • Doose syndrome
      • Dravet syndrome
      • Myoclonic epilepsy of infancy
      • Childhood

      • Lennox-Gastaut syndrome
      • Childhood absence epilepsy
      • Benign Rolandic epilepsy
      • Adolescence / Adulthood

      • Juvenile absence epilepsy
      • Juvenule myoclonic epilepsy
      • Temporal lobe epilepsy

      Management

      • Management Options for Myaesthenia Gravis

      • Maintenance

      • Anticholinesterase agents - pyridostigmine, neostigmine
      • Immunosuppression (uncommonly)
      • Thymectomy
      • Myaesthenic Crisis

      • IV immunoglobulin
      • Plasmapheresis
      • Respiratory support

      Peritransplant History

      • Ask About

      • When
      • Indication for allogeneic stem cell transplant
      • Type of transplant - syngeneic, matched sibling, MUD, haploidentical, cord blood
      • Donor - HLA match, CMV status
      • Recipient - CMV status
      • Conditioning - myeloablative or reduced intensity (RIC)
      • Ask About

      • When
      • Indication
      • Stem cell mobilisation - using G-CSF or chemotherapy + G-CSF
      • Conditioning - e.g. melphalan, BEAM

      Key Considerations

      When deciding which clinical medicine apps to use, there are several key factors to take into account. Consider these features when determining which apps are most likely to meet your needs and help you succeed in your studies.

      Key Features

      • Usability

      • Easy to use - the app should be easy to get started with, easy to enter information into, and allow for easy organisation of notes.
      • Rich text - the best note apps allow for standard features such as bold and italics; it is also desirable to be able to add headings, dot points, checklists, images and links.

      Key Features

      We considered several key features when assessing each of the video resources listed in this article.
      When deciding which mindfulness resources to include in this list, we looked for features that were particularly relevant to the needs of medical students. Here are some of the key features we considered.
      To provide you with this list of the most effective clinical tools apps for medical students, we have carefully evaluated various resources based on several key features:

      Key Considerations

      • Task Management

      • It is relatively common to be juggling multiple tasks, projects, and assignments during your years of med school, making it essential to have a reliable task management app that can help you stay on top of your workload and deadlines. A good to-do list is essential.

      Key Features

      • Comprehensive Information

      • It is important to have a directed and comprehensive approach to ECG interpretation, so you don’t miss any key findings. With this in mind, we favoured resources that provided a core overall approach to looking at an ECG trace, as well as comprehensive information about specific findings.

      Types of Cognition

      • Bloom's taxonomy includes six categories of learning: 
      • Remember - the ability to recall facts and simple ideas E.g. remember a list of causes for chest pain; write lists; memorise; repeat things
      • Understand - the ability to explain conceptsCategorise information into a greater structure; discuss with others; compare concepts; explain
      • Apply - the ability to use information in new situationsAnswer a question or solve a problem
      • Analyse - the ability to connect ideas togetherExperiment
      • Evaluate - the ability to justify a position relating to a topicAppraise the evidence; defend an idea
      • Create - the ability to produce new work on a topicDevelop and investigate a hypothesis; assemble information in a new way; write about a topic

      How Memory Works

      Semantic encoding is when these sensory inputs are then associated with a specific meaning. Multiple studies have demonstrated that attaching meaning to new information (encoding them semantically) improves recall. For example, associating a disease with a specific patient you have seen with that disease will help you to remember key aspects of the disease.

      Plan Your Study

      • Set SMART goals while studying:
      • Specific - make sure that your study goals are clear and well defined
      • Measurable - consider how much and how you will know you when you have achieved what you set out, so that you can measure success
      • Achievable - be realistic - avoid too little, not too much
      • Relevant - choosing what makes sense to study at this time. How will it benefit you for this study session or sessions?
      • Time-bound - realistic timing and a target date / time for completion

      Overview

      You may decide to go on and specialise in a field of medicine that is primarily practical, such as surgery or obstetrics - the principles in this article are relevant from your first cannula to your first major surgery.

      Flashcards: The Basics

      Flashcards consist of two sides: a cue on the front, and an answer on the back.

      Why Take Notes?

      Note taking while in a lecture or while reading a textbook can keep you focused and engaged. Processing and filtering the information presented is the first step to committing it into memory.

      Diagnosis

      • Diagnosis

      Pathogenesis

      • Causes of Sinus Arrest

      • Idiopathic degeneration
      • Myocardial infarction
      • Infiltrative disease - sarcoidosis, amyloidosis, haemochromatosis
      • Connective tissue disease - SLE, scleroderma, RA
      • Cardiac surgery - valvular surgery, correction of congenital heart disease
      • Infections - Lyme disease, endocarditis

      Overview

      Alpha thalassaemia commonly occurs in people from South-East Asia, Mediterranean countries, Africa, the Middle East and India. The condition is very uncommon in caucasian populations.

      Pathogenesis

      • Causes of Hypertension

      • Primary

      • Primary (essential) hypertension: chronically elevated blood pressure of unknown aetiology (the most common cause of hypertension in the community)
      • Secondary

      • Chronic kidney disease
      • Renovascular - fibromuscular dysplasia, atherosclerosis
      • Endocrine - hyperthyroidism, hypothyroidism, Cushing's syndrome, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
      • Drugs - NSAIDs, amphetamines, glucocorticoids, fludrocortisone, erythropoietin, VEGF inhibitors, calcineurin inhibitors
      • Aortic coarctation
      • Obstructive sleep apnoea
      • Factitious

      • White coat hypertension: falsely elevated blood pressure may occur due to by anxiety in a healthcare setting, recent exercise or recent caffeine intake.
      • Recent exercise or caffeine intake

      Manifestations

      • Symptoms of Heart Failure

      • Fatigue
      • Dyspnoea
      • Orthopnoea
      • Paroxysmal nocturnal dyspnoea
      • Reduced exercise tolerance
      • Peripheral oedema

      Pathogenesis

      • Causes of Atrial Fibrillation

      • Severe acute illness - especially in septic or postoperative patients
      • Cardiac - post cardiac surgery, myocardial infarction, valvular disease, cardiomyopathy, congestive cardiac failure, congenital heart disease, Wolff-Parkinson-White
      • Cardiovascular risk factors - hypertension, diabetes, obesity
      • Pulmonary embolism
      • Obstructive sleep apnoea
      • Thyrotoxicosis
      • Alcohol abuse

      Manifestations

      • Signs and Symptoms

      • Renal ('stones') - nephrolithiasis, nephrocalcinosis, nephrogenic diabetes insipidus
      • GI ('groans') - nausea, reflux, peptic ulcers, pancreatitis, constipation
      • CNS ('moans') - lethargy, depression, confusion, memory loss, coma
      • MSK ('bones') - osteopaenia, bone pain, pathologic fractures
      • Cardiovascular - hypertension, shortened QT

      Diagnosis

      • Signs of Tricuspid Regurgitation

      • Peripheral Signs

      • Prominent V wave within the jugular venous pulsation
      • Central Signs

      • Right ventricular heave
      • Pansystolic murmur that is maximal at the lower end of the sternum; louder on inspiration
      • Large, pulsatile, tender liver
      • Signs of Complications

      • Evidence of right heart failure - raised JVP, ascites, pleural effusions, peripheral oedema
      • Signs of Mitral Regurgitation

      • Peripheral Signs

      • Small volume pulse
      • Central Signs

      • Apical thrill (palpable murmur)
      • Soft or absent first heart sound (S1)
      • Presence of a fourth heart sound (S4)
      • Volume-loaded apex beat -  displaced apex with forceful, non-sustained impulses
      • Pansystolic murmur heard greatest over the apex on expiration
      • Radiation to the left sternal edge and neck - suggests posterior mitral valve leaflet prolapse
      • Radiation to the axilla - suggests anterior mitral valve leaflet prolapse
      • Signs of Complications

      • Evidence of pulmonary hypertension - elevated JVP, parasternal heave, loud / palpable P2
      • Evidence of left ventricular failure - pulsus alternans, presence of S3, pulmonary crepitations
      • Signs of Left Ventricular Failure

      • Sarcopaenia (muscle wasting)
      • Tachycardia
      • Pulsus alternans: regular alternation between strong and weak beats
      • Displaced apex
      • Presence of third heart sound (S3)
      • Pulmonary crepitations / wheeze

      History of Presenting Complaint

      When asking for more information about a patient's symptoms, start by asking general questions such as "could you please tell me more about that", and then narrow down the questions as more information is provided.
      Ask for more information about the patient's presentation. Start by asking general questions, and then narrow down your questioning over the course of history-taking.

      Presenting Complaint

      Patients with haematologic disorders are often also referred in because they have abnormal blood tests; they may themselves be asymptomatic.

      History of Presenting Complaint

      When asking for more information about a patient's symptoms, start by asking general questions such as "could you please tell me more about that", and then narrow down the questions as more information is provided.
      When asking for more information about a patient's symptoms, start by asking general questions such as "could you please tell me more about that", and then narrow down the questions as more information is provided.
      When asking for more information about a patient's symptoms, start by asking general questions such as "could you please tell me more about that", and then narrow down the questions as more information is provided.

      The Patient

      • General Inspection

      • Look around the room, particularly looking for mobility devices, orthoses or other assistance devices.

      First Steps

      • First Steps

      Inspection

      The colour and consistency of a patient's urine can provide significant information regarding the cause of their urinary complaint. 

      Red Cell Count & Haemoglobin

      Assessing Oxygenation

        • Normal Ranges
        • Arterial partial pressure of oxygen (PaO₂) - 80 - 100mmHg (room air)
        • Oxyhaemoglobin (HbO₂) - >90%

      First Steps

      Look at the film details - the date and time the film was taken, what site has been imaged, and what side was imaged.

      Causes of Haemolysis

      Haemolysis can be caused by a wide variety of immune and non-immune conditions.

      Measures of Iron Status

      Iron DeficiencyAnaemia of Chronic DiseaseAcute Phase ReactionIron Overload
      Serum Iron
      Transferrin / TIBCN / ↓
      Transferrin Saturation
      FerritinNormal
      Soluble Transferrin ReceptorNormalNormal

      Overview

      • Negative acute phase reactants are those whose concentrations decrease in an acute phase response. These include:
      • Serum albumin
      • Transferrin
      • Alpha-foetoprotein

      Squamous Epithelial Cells

      It is useful to first check whether the urine contains squamous epithelial cells (SECs), which are a marker of contamination.

      Identifying a Vein

      Potential sites for venepuncture include the antecubital fossa, the cephalic or basilic veins in the forearm, or the small veins on the back of the hand.

      Overview

      • Complications

        The potential complications of supplemental oxygen are:
      • Hypoventilation - due to suppression of the hypoxic respiratory drive; particularly in patients with COPD
      • Absorption atelectasis (due to washout of nitrogen, which noramlly splints the airways open)
      • Oxygen toxicity - damage to upper or lower airways due to oxygen radical formation

      Equipment and Preparation

      • The following equipment is required for collection of an arterial blood gas:

      Overview

      • Contraindications to catheterisation include:
      • Urethral trauma - e.g. due to pelvic fracture
      • Urethral stricture
      • Recent urologic surgery (men) - discuss with a urologist first
      Avoid taking blood from a peripheral cannula that is already in situ as this may collapse / damage the vein or affect the sample through haemolysis, dilution or contamination.

      Airway Patency

      Stridor and snoring are both signs of airway compromise.

      Complications

      • Complications of Left Ventricular Failure

      • Arrhythmias - atrial fibrillation, ventricular arrhythmias
      • Stroke
      • Sarcopaenia
      • Pulmonary oedema
      • Pulmonary hypertension

      Overview

      Central Cyanosis

      • Interpretation

      • blue discolouration of the skin and mucous membranes.

      Cardioverter-Defibrillators

      • Indications

      • Past ventricular tachycardia (VT)
      • Past ventricular fibrillation (VF)
      • Past myocardial infarction with left ventricular ejection fraction <35%

      Crackles

      • Listen For

      • Short, popping sounds. May be fine or coarse, and may be cleared by coughing (if due to secretions)

      Inspiration & Expiration

      • Interpretation

      • Right-sided murmurs (tricuspid / pulmonary) are louder on inspiration.
      • Left-sided murmurs (aortic / mitral) are louder on expiration.
      • The fourth heart sound (S4) is best heard during inspiration.

      Complications

      • Complications of Right Ventricular Failure

      • Arrhythmias - atrial fibrillation, ventricular arrhythmias
      • Sarcopaenia
      • Ascites
      • Peripheral oedema
      • Cardiac cirrhosis

      Measuring Blood Pressure

      • Sizing the Blood Pressure Cuff

      • The blood pressure cuff should measure approximately 80% of the circumference of the arm.

      Overview

      • Interpretation

      • Displaced apex beat - palpable in the axillaCardiomegaly, right tension pneumothorax
      • Forceful and sustained impulse (pressure loaded)Left ventricular hypertrophy
      • Forceful and non-sustained impulse (volume loaded)Hypermetabolic states, aortic / mitral regurgitation, ventricular septal defect
      • Double impulseHypertrophic cardiomyopathy

      Cyanosis

      • Interpretation

      • Blue discolouration of the skin and mucous membranes - look for both peripheral (hands / feet) and central (lips / tongue)

      Heart Rate

      • How to Measure

      • Count the number of beats over 15, 30 or 60 seconds and multiply to estimate beats per minute.

      Complications

      • Complications of Pulmonary Hypertension

      • Pulmonary haemorrhage
      • Pulmonary arterial thrombosis
      • Right ventricular failure
      • Arrhythmias

      Hypertensive Eye Changes

      • Look For

      • Silver wiring: glistening bronze / silver arterial walls
      • Arteriovenous nicking: arteries displacing veins at points of crossing
      • Flame-shaped retinal haemorrhages
      • Cotton wool spots: small white, cotton wool-like microinfarcts on the retina
      • Papilloedema: swelling of the disc with venous engorgement, cotton wool spots and haemorrhage

      Overview

      • On Expiration

      Valsalva Manoeuvre

      • Interpretation

      • The murmur of hypertrophic cardiomyopathy is louder with valsalva.
      • The murmurs of aortic stenosis and mitral regurgitation are softer with valsalva.

      Overview

      • Causes of Postural Hypotension

      • Autonomic dysfunction
      • Low intravascular volume - blood / fluid / electrolyte loss
      • Vasodilation - nitrates, alcohol, fever
      • Addison's disease
      • Paraneoplastic syndrome

      Spasticity

      • Feel For

      • Velocity dependant rigidity, with quick flexion / extension of the joint. Works best on the knee or elbow.

      Overview

      • Grading of Reflexes

      • 0: no response (hyporeflexive)Lower motor neuron lesion
      • 1+: diminished (low normal)Lower motor neuron lesion
      • 2+: average (normal)
      • 3+: brisk (high normal)Upper motor neuron lesion
      • 4+: very brisk (hyperreflexive)Upper motor neuron lesion

      Sciatic Nerve Palsy

      The sciatic nerve branches into the tibial nerve and the common peroneal nerve, and as such palsy of the sciatic nerve will affect both of these nerves

      The Spinothalamic Pathway

      Cortical Centre
      Primary sensory cortex (postcentral gyrus)
       
       
      3rd Order Nuclei
      Ventral posterolateral (VPL) nucleus of thalamus
       
       
      Spinal Pathway
      Lateral spinothalamic tract
      Decussation
      Level of entry into spinal cord
       
      2nd Order Nuclei
      Dorsal horn at level of entry into spinal cord
       
       
      1st Order Nuclei
      Dorsal root ganglion
       
       
      Receptors
      Free nerve endings

      Overview

      • Grading of Power

      • 0: no movement
      • 1: flicker of movement
      • 2 : movement without gravity
      • 3: movement against gravity
      • 4: against weak resistance
      • 5: normal power

      Spasticity

      Also known as clasp-knife rigidity.

      Overview

      • Look For

      • Posture - position of the head, shoulders and spine.
      • Symmetry - symmetrical rise and fall of the shoulders, hips, knees and feet.
      • Rhythm - natural movement through the stance and swing phases.
      • Coordination - steadiness of the gait and amount of sway. Dyscoordination may indicate an ataxic or spastic gait.
      • Foot separation - wide-based or narrow-based. A wide base  is used to compensate for poor coordination.
      • Stride length - the distance between heel placements of one foot over one gait cycle.
      • Cadence - the number of steps per minute.

      Pes Cavus

      • Look For

      • A high-arched foot.

      Fasciculations

      • Causes of Fasciculations

      • Benign / normal
      • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob (prion) disease
      • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

      Trendelenburg Test

      • Abnormal If

      • The hip on the non-weightbearing side falls, as the patient is unable to elevate their hip.

      Overview

      If proprioception is impaired at the great toe, repeat at the foot (Chopart's joint). If also impaired, repeat at the ankle, knee and then hip.

      Postural Tremor

      • Look For

      • Tremor that increases with voluntary muscle contraction, but does not increase with target-directed movement.

      Light Touch Pathway

      Cortical Centre
      Primary sensory cortex (postcentral gyrus)
       
       
      3rd Order Nuclei
      Ventral posterolateral (VPL) nucleus of thalamus
       
       
      Decussation
      Medulla (spinothalamic tract), level of entry into spinal cord (dorsal column)
       
      2nd Order Nuclei
      Dorsal horn (spinothalamic tract),
      lower medulla (dorsal column)
       
       
      1st Order Nuclei
      Dorsal root ganglion
       
       
      Receptors
      Meissner's corpuscles, Merkel discs, Ruffini endings, pacinian corpuscles and hair follicle receptors

      Overview

      • Causes of Isolated Vibration and Proprioceptive Loss

      • Demyelination - proprioceptive and vibration fibres are myelinated while pain sensation fibres are not.
      • Brainstem lesions involving the medial lemniscus
      • Dorsal spinal artery occlusion (unilateral impairment)
      Dorsal cord syndrome - loss of proprioception and vibration sensation (dorsal column), with preservation of motor function (corticospinal tract) and pain and temperature sensation (spinothalamic tract)Posterior compression of the spinal cord, or posterior spinal artery pathology

      Proximal Myopathy

      • Causes of Proximal Myopathy

      • Congenital

      • Muscular dystrophy - e.g. Duchenne's, Becker's, Emery-Dreyfuss, limb girdle, fascioscapulohumeral
      • Metabolic myopathies - e.g. glycogen and lipid storage disorders
      • Acquired

      • Inflammatory myositis - polymyositis, dermatomyositis
      • Paraneoplastic syndrome
      • Infection - Lyme disease, HIV, infectious pyomyositis, trichinosis, cysticercosis, coxsackievirus
      • Endocrine - thyroid disease, Cushing's, acromegaly, hypopituitarism
      • Metabolic - periodic paralysis
      • Toxins - alcohol, steroids, statins, cocaine
      • Sarcoidosis

      Overview

      Exaggerated swaying may be an indicator of somatization or conversion disorder.

      Passive Movement

      • How to Assess

      • Move the patient's joint. Note the range of motion and whether it is limited by pain, swelling or stiffness. Note any crepitus.

      Muscles Acting on the Elbow Joint

      Supinators (posterolateral) - supinator, biceps brachii, barchioradialis

      Overview

      • Myotome

      • C7Radial Nerve

      Bony Landmarks of the Elbow

      Radial head - trace the lateral arm distally to proximally, palpating where the radial head articulates with the humerus.

      Muscle Spasm

      • Causes of Muscle Spasm

      • Exercise-induced spasm (cramping)
      • Dehydration
      • Electrolyte abnormalities - hyper/hyponatraemia
      • Hereditary dystonia - idiopathic, Huntington's, Wilson's
      • Acquired dystonia - brain damage, encephalitis, parkinsonism, brain tumour, stroke, drug-induced
      • Factitious dystonia

      Overview

      • Myotome

      • C5Musculocutaneous nerve
      • Myotome

      • L4Deep peroneal nerve
      Tibialis posterior - medially, passing posterior to the medial malleolus.

      Muscle Spasms

      • Causes of Muscle Spasms

      • Exercise-induced spasm (cramping)
      • Dehydration
      • Electrolyte abnormalities - hyper/hyponatraemia
      • Hereditary dystonia - idiopathic, Huntington's, Wilson's
      • Acquired dystonia - brain damage, encephalitis, parkinsonism, brain tumour, stroke, drug-induced
      • Factitious dystonia

      Bony Landmarks of the Ankle

      Navicular - a tarsal bone of the medial foot, distal to the talus.

      Overview

      • Myotome

      • L5/S1Tibial nerve

      Passive Movement

      • How to Assess

      • Move the patient's joint. Note the range of motion and whether it is limited by pain, swelling or stiffness. Note any crepitus.

      Overview

      • Myotome

      • L4/L5Tibial nerve
      • Look For

      • Posture - position of the head, shoulders and spine.
      • Symmetry - symmetrical rise and fall of the shoulders, hips, knees and feet.
      • Rhythm - natural movement through the stance and swing phases.
      • Coordination - steadiness of the gait and amount of sway. Dyscoordination may indicate an ataxic or spastic gait.
      • Foot separation - wide-based or narrow-based. A wide base  is used to compensate for poor coordination.
      • Stride length - the distance between heel placements of one foot over one gait cycle.
      • Cadence - the number of steps per minute.

      Muscles Acting on the Ankle Joint

      Everters (lateral) - peroneus longus, peroneus brevis

      Overview

      • Myotome

      • L5/S1Peroneal nerve

      Passive Movement

      • How to Assess

      • Move that patient's joint. Note the range of motion and whether it is limited by pain, swelling or stiffness. Note any crepitus.

      Muscles Acting on the Knee Joint

      External rotators - biceps femoris, sartorius

      Centre of Gravity

      • Look For

      • The line that falls from the earlobe down through the chest, abdomen, pelvis and lower limb (line of gravity).

      Apparent Leg Length Discrepancy

      • How to Assess

      • Measure from the umbilicus to the medial malleolus on both sides and compare

      Muscle Spasms

      • Causes of Muscle Spasms

      • Exercise-induced spasm (cramping)
      • Dehydration
      • Electrolyte abnormalities - hyper/hyponatraemia
      • Hereditary dystonia - idiopathic, Huntington's, Wilson's
      • Acquired dystonia - brain damage, encephalitis, parkinsonism, brain tumour, stroke, drug-induced
      • Factitious dystonia

      Overview

      • Myotome

      • L3 / L4Femoral nerve

      Bony Landmarks of the Knee

      Gerdy's tubercle (lateral tubercle of the tibia) - palpate for the insertion of the ileotibial band.

      Overview

      • Look For

      • Posture - position of the head, shoulders and spine.
      • Symmetry - symmetrical rise and fall of the shoulders, hips, knees and feet.
      • Rhythm - natural movement through the stance and swing phases.
      • Coordination - steadiness of the gait and amount of sway. Dyscoordination may indicate an ataxic or spastic gait.
      • Foot separation - wide-based or narrow-based. A wide base  is used to compensate for poor coordination.
      • Stride length - the distance between heel placements of one foot over one gait cycle.
      • Cadence - the number of steps per minute.
      • Myotome

      • S1Sciatic nerve

      Major Bursae of the Knee

      Others - anserine bursa, medial collateral ligament bursa, iliotibial bursa, gastrocnemius-semimembranosus bursa.

      Comprehension

      • Simple Verbal Comprehension

      • Name objects such as pen, watch and key, and ask the patient to point to them.

      Rate of Speech

      • Interpretation

      • Slow speech (bradylalia)Depression, Parkinson's disease, cognitive impairment
      • Normal speech rate
      • Rapid speech (tachylalia) - fast speech but able to be redirectedNormal, mania, anxiety, stimulants
      • Pressured speech - fast and without taking breaks, talking over other people and unable to be redirectedMania, anxiety

      Digit Span

      • How to Assess

      • Tell the patient a series of numbers and ask them to immediately repeat them back. Start with three digits (e.g. 6 2 3) and increase until the patient is unable to repeat them back correctly.

      Assessing Retrograde Memory

      • Interpretation

      • Loss of recent memory - minutes or hours prior to injuryMild to moderate brain damage (concussion)
      • Loss of remote memory - months to yearsConvulsive therapy
      • Temporal grading: sparing of the most distant memoriesKorsakoff syndrome, thalamic or frontal damage
      • Flat profile: equal loss of memory with no temporal gradingHerpes simplex encephalitis, multiple sclerosis, frontotemporal dementia

      Overview

      Once hallucinations stop, patients with organic disease tend to recognise that they were false, while patients with functional illness tend to maintain a lack of insight.

      Visual Neglect

      • Look For

      • Lack of grooming to half of the body
      • Eating half of a plate of food
      • Not acknowledging someone standing to their left / right

      Category Fluency

      • Significance

      • Difficulty with categories may be a result of dysphasia, dysarthria, confusion or poor compliance.

      Vertebral Landmarks

      C7 - the most prominent spinous process posteriorly.

      Muscle Spasms

      • Causes of Muscle Spasms

      • Exercise-induced spasm (cramping)
      • Dehydration
      • Electrolyte abnormalities - hyper/hyponatraemia
      • Hereditary dystonia - idiopathic, Huntington's, Wilson's
      • Acquired dystonia - brain damage, encephalitis, parkinsonism, brain tumour, stroke, drug-induced
      • Factitious dystonia

      Overview

      • Myotome

      • C1 / C2
      • Look For

      • Posture - position of the head, shoulders and spine.
      • Symmetry - symmetrical rise and fall of the shoulders, hips, knees and feet.
      • Rhythm - natural movement through the stance and swing phases.
      • Coordination - steadiness of the gait and amount of sway. Dyscoordination may indicate an ataxic or spastic gait.
      • Foot separation - wide-based or narrow-based. A wide base  is used to compensate for poor coordination.
      • Stride length - the distance between heel placements of one foot over one gait cycle.
      • Cadence - the number of steps per minute.
      • Myotome

      • C3

      Extra Credit

      • Additional Causes of Limited Thoracic / Lumbar Spine Range of Motion

      • Fracture - compression, spinous process, vertebral body
      • Degenerative disc disease
      • Disc herniation
      • Spinal stenosis
      • Ankylosing spondylitis

      Overview

      • Myotome

      • C1 / C2

      Extra Credit

      • Additional Causes of Limited Cervical Spinal Range of Motion

      • Infection - meningitis, osteomyelitis, discitis
      • Vertebral fracture
      • Congenital torticollis
      • Spinal stenosis
      • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis
      • Muscle strain

      Overview

      Instead of stabilising the pelvis manually you may ask the patient to sit down and perform this motion, accomplishing the same stabilisation.

      Muscles Acting on the Cervical Spine

      Rotators - sternocleidomastoid, splenius muscles, levator scapulae, erector spinae

      Pharyngeal Erythema

      • Look For

      • Redness of the posterior pharynx.

      Overview

      • Types of Breath Sounds

      • Vesicular breath sounds - soft, non-musical, heard in inspiration and early expirationNormal breath sounds
      • Bronchial breath sounds - hollow sounds similar to those normally heard over the tracheaConsolidation or fibrosis

      Horner's Syndrome

      Horner's syndrome is a classic triad that occurs due to compression of the sympathetic chain. This may be due to a pancoast tumour in the apex of the lung, though there are several other causes to be aware of.

      Heart Rate

      • Causes of Tachycardia (>100bpm)

      • Sinus tachycardia - physical exertion, infection, anxiety, thyrotoxicosis, stimulant drugs, shock
      • Atrial fibrillation / flutter - aberrant conduction, parenchymal damage
      • Supraventricular tachycardia - aberrant conduction pathways/ re-entry

      Tachypnoea

      Respiratory rate greater then 20 breathes per minute.

      Wasting of Hand Muscles

      • Causes of Wasting of Hand Muscles

      • Localised Wasting

      • Median nerve lesion
      • Ulnar nerve lesion
      • Brachial plexus compression
      • Generalised Wasting

      • Normal aging
      • Disuse
      • Malnutrition - poor diet, malabsorption, cancer
      • Denervation - trauma, motor neuron disease, Guillain-Barre Syndrome, polyneuropathy
      • Muscular disorders - inflammatory myositis, muscular dystrophies
      • Chronic disease - cancer, heart failure, COPD, infection, cirrhosis, kidney disease

      Overview

      Note whether the sound is resonant, hyperresonant or dull. Keep in mind that dullness will be present over the liver (right side) and heart (left side).

      Respiratory Muscles

      • Muscles Used at Rest

      • Diaphragm - flattens itself
      • External intercostals - move ribs up and out
      • Exhalation occurs passively at rest.

      Reduced Oxygen Saturation

      • Causes of Reduced Oxyhaemoglobin

      • Reduced Environmental Oxygen

      • High altitude
      • Hypoventilation

      • CNS - drugs, trauma, encephalopathy, motor neurone disease, Guillain-Barré
      • Muscular / neuromuscular - myaesthenia, paralytics, myopathy, fatigue, malnutrition
      • Airway obstruction - foreign body, asthma, COPD, bronchiectasis
      • Decreased compliance - interstitial lung disease
      • Chest wall abnormalities
      • Ventilation / Perfusion Mismatch

      • Physiological shunt - atelectasis, pulmonary oedema, pneumonia, ARDS
      • Anatomical shunt - cardiac shunt e.g. tetralogy of Fallot
      • Dead space - asthma, COPD, pulmonary embolus, heart failure
      • Other

      • Right shift of the oxygen dissociation curve - acidaemia, hyperthermia, high 2,3-DPG
      • Carbon monoxide poisoning
      • Haemoglobinopathy - methaemoglobinaemia, foetal haemoglobin

      Complications

      • Complications of COPD

      • Disease-Related

      • Pneumonia
      • Cor pulmonale
      • Pulmonary hypertension
      • Pneumothorax
      • Respiratory failure
      • Polycythaemia
      • Treatment-Related

      • Cushing's syndrome (steroids)
      • Oral candidiasis (steroids)
      • Tremor (beta agonists)

      Overview

      • Myotome

      • C8Radial nerve
      • Myotome

      • T1Ulnar nerve

      Muscles Acting on the Wrist Joint

      Adductors - flexor carpi ulnaris, extensor carpi ulnaris

      Overview

      • Myotome

      • T1Median nerve
      • Myotome

      • T1Ulnar nerve
      • Myotome

      • C8Median nerve
      • Myotome

      • C6 / C7Radial / median nerves

      Muscle Wasting

      • Tip

      • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.

      Bony Landmarks of the Wrist

      Styloid process of radius - distally, attaching to the brachioradialis.

      Overview

      • Myotome

      • C6 / C7Radial nerve

      Hand of Benediction

      • Significance

      • A classical sign of median nerve lesion.

      Passive Movement

      • How to Assess

      • Move the patient's joint. Note the range of motion and whether it is limited by pain, swelling or stiffness. Note any crepitus.

      Overview

      • Myotome

      • C8Ulnar / radial nerves
      • Myotome

      • C7Radial nerve
      • Myotome

      • C6 / C7Radial nerve

      Pitting Oedema

      • Causes of Pitting Oedema

      • Fluid overload - excessive IV fluids, renal failure, heart failure
      • Right ventricular failure
      • Venous pathology - thrombosis / insufficiency
      • Dependency (the effect of gravity)
      • Hypoalbuminaemia - malnutrition, malabsorption, nephrotic syndrome, liver (synthetic) failure

      Contour

      Bisferiens pulse (double beating pulse)Aortic regurgitation

      Venous Skin Changes

      • Causes of Venous Skin Changes

      • Venous hypertension due to incompetent valves
      • Venous outflow obstruction
      • Calf-muscle pump failure - obesity, immobility

      Overview

      Dorsalis pedis - palpate lateral to the extensor tendon of the great toe. This can be identified by asking the patient to extend their great toe.

      Inspection of Pupils

      • Causes of Bilateral Pupillary Constriction

      • Drugs - opiates, antipsychotics, acetylcholine, clonidine
      • Intracranial haemorrhage
      • Horner's syndrome (bilateral) - autonomic failure, amyloidosis, diabetes

      Rashes Associated with Diabetes

      Kyrle's disease: hyperpigmented papules with a central keratin plug.Chronic kidney disease, diabetes, liver failure

      Overview

      • Interpretation

      • Increased cup-disc ratio (>0.8): the ratio of the size between the optic cup and the surrounding optic disc (entry point of the optic nerve and vessels)Glaucoma, giant cell arteritis, optic nerve compression / trauma / inflammation
      • Papilloedema: swelling of the disc with venous engorgement, cotton wool spots and haemorrhageRaised ICP, severe hypertension
      • Cotton wool spots: small white, cotton wool-like microinfarcts on the retinaHypertension, diabetes, HIV, anaemia / thrombocytopaenia, connective tissue disorders
      • Arteriovenous nicking: arteries displacing veins at points of crossingHypertension
      • Silver wiring: glistening bronze / silver arterial wallsHypertension
      • Retinal haemorrhages - e.g. small dots or flame-shapedDiabetes, leukaemia, pernicious anaemia, SAH, DIC
      • Roth spots: haemorrhages with pale centresInfective endocarditis
      • Emboli: small white flecks over vessels, with distal narrowing.Generally cholesterol emboli from carotid artery disease
      Aortic Area - the second intercostal space at the right sternal border. The murmurs of aortic stenosis and regurgitation are loudest in this area, as is the aortic component of the second heart sound (A2).

      Central Cyanosis

      • Significance

      • Elevated levels of deoxygenated haemoglobin (hypoxaemia).

      Crackles

      • Causes of Crackles

      • Fine Crackles

      • Pulmonary oedema - congestive cardiac failure, fluid overload
      • Pneumonia
      • Pulmonary interstitial fibrosis
      • Coarse Crackles

      • Chronic bronchitis
      • Bronchiectasis
      • Cystic fibrosis

      Left Lateral Position

      Asking a patient to lie in the left lateral position is a useful manoeuvre for identifying mitral stenosis.

      Measuring Blood Pressure

      • How to Measure

      • Place a blood pressure cuff of the correct size around the bulk of the biceps with the artery indicator over the brachial artery.
      • Inflate the cuff until the radial pulse can no longer be palpated, plus a further 30mmHg.
      • Place the diaphragm of the stethoscope over the brachial artery and slowly deflate the cuff (2mmHg/sec)
      • Note when the beating sound is first heard
      • Note when the sound disappears entirely

      Cyanosis

      • Significance

      • High levels of deoxygenated haemoglobin (hypoxaemia).

      Hepatomegaly

      Apply gentle pressure to the right lower quadrant with the palpating hand parallel to the edge of the liver. Ask the patient to take a slow breath in to bring the liver edge toward the fingertips. Move the hand 2cm superiorly each time the patient breathes out and repeat until the lower edge of the liver is palpable.

      Conjunctival Pallor

      The conjunctiva is a continuous cellular layer covering the outer eye and underside of the eyelid.

      Hypertensive Eye Changes

      • Grading of Hypertensive Retinopathy

      • Grade 1: silver wiring
      • Grade 2: arteriovenous nicking
      • Grade 3: flame-shaped haemorrhages, cotton wool spots
      • Grade 4: papilloedema

      Squatting

      Squatting increases preload, which makes the murmur of hypertrophic cardiomyopathy softer.

      Spasticity

      • Significance

      • Indicative of upper motor neuron lesion.

      Hyperreflexia

      • Look For

      • Very brisk reflexes.

      Sciatic Nerve Palsy

      • Signs of Sciatic Nerve Palsy

      • Sciatic nerve proper - weakness of knee extension
      • Common peroneal nerve - sensory loss over the lateral calf and dorsum of the foot; weakness of dorsiflexion, foot eversion and toe extension
      • Posterior tibial nerve - sensory loss over the plantar aspect of the foot; weakness of plantar flexion

      Overview

      • Causes of Weakness

      • Upper Motor Neuron

      • Brain lesion - ischaemia, haemorrhage, tumour, trauma, encephalitis, vasculitis, demyelination
      • Spinal cord lesion - infarct, haemorrhage, abscess, transverse myelitis
      • Lower Motor Neuron

      • Nerve root pathology - trauma, radiculopathy, neoplasm
      • Brachial plexopathy
      • Focal peripheral nerve pathology - trauma, entrapment, focal ischaemia, sarcoidosis, tumour
      • Peripheral polyneuropathy - diabetic neuropathy, hypothyroidism, B12 deficiency, alcohol, paraneoplastic, Guillain-Barre, CIDP, Charcot-Marie-Tooth
      • Other

      • Neuromuscular pathology - myasthenia gravis, Lambert Eaton myaesthenic syndrome
      • Muscular pathology - muscular dystrophy, inflammatory myositis, paraneoplastic, thyroid disease, Cushing's, statins, sarcoidosis
      • Poor compliance with examination

      Spasticity

      • Feel For

      • Velocity dependant rigidity, with quick flexion / extension of the joint. Works best on the knee or elbow.

      Overview

      • Causes of Abnormal Gait

      • Pain - inflammation, infection, malignancy, trauma
      • Weakness - muscular, neuromuscular or neurological
      • Deformity - arthritis, surgery, shortening post fracture, congenital malformations
      • Instability - peripheral neuropathy, cerebellar or brainstem pathology

      Pes Cavus

      • Significance

      • Pes cavus is strongly associated with Charcot-Marie-Tooth, though can also occur following trauma or in the setting of other neurologic diseases.

      Trendelenburg Test

      • Significance

      • Suggests proximal myopathy, causing hip abductor (gluteus medius / minimus) weakness.

      Overview

      • Causes of Isolated Vibration and Proprioceptive Loss

      • Demyelination - proprioceptive and vibration fibres are myelinated while pain sensation fibres are not.
      • Brainstem lesions involving the medial lemniscus
      • Dorsal spinal artery occlusion (unilateral impairment)

      Postural Tremor

      • Causes of Postural Tremor

      • Physiologic tremor
      • Essential tremor
      • Metabolic disturbances
      • Drug induced - alcohol, amphetamine, caffeine, beta agonists, lithium, steroids, thyroxine, TCAs, valproate
      • Withdrawal - alcohol, benzodiazepines, opioids

      Overview

      Tacticle sensitivity is greatest on the glabrous hair of the hands, the soles of the feet and the lips.

      Dorsal Column Pathway

      Cortical Centre
      Primary sensory cortex (postcentral gyrus)
       
       
      3rd Order Nuclei
      Ventral posterolateral (VPL) nucleus of thalamus
       
       
      Central Pathway
      Medial lemniscus
      Decussation
      Medulla
       
      2nd Order Nuclei
      Lower medulla - nucleus cuneatus (UL) / gracilis (LL)
       
       
      Spinal Pathway
      Dorsal column - fasciculus cuneatus (UL) / gracilis (LL)
       
      1st Order Nuclei
      Dorsal root ganglion
       
       
      Receptors
      Pacinian corpuscles / Merkel disc receptors / Meisner's corpuscles (vibration)
      Neuromuscular spindles (proprioception)

      Overview

      Brown-Sequard syndrome - ipsilateral upper motor neuron weakness and loss of proprioception and vibration (dorsal column), with contralateral loss of pain and temperature sensation (spinothalamic tract)Hemitransection of the cord

      Proximal Myopathy

      • Proximal Muscles of the Upper Limb

      • Deltoids
      • Biceps
      • Triceps
      • Brachioradialis

      Passive Movement

      • Significance

      • Passive movement is a measure of the objective range of motion of the joint. It may be limited by stiffness of the joint, or active resistance on the patient's part.

      Fasciculations

      • Look For

      • Visible, spontaneous localised muscle contraction and relaxation.

      Overview

      Extensor hallucis longus tendon - on the medial aspect of the dorsum of the foot, inserting into the base of the distal phalanx of the great toe.

      Fasciculations

      • Look For

      • Visible, spontaneous localised muscle contraction and relaxation.

      Bony Landmarks of the Ankle

      Cuneiforms  - three tarsal bones of the medial foot, distal to the navicular bone.

      Passive Movement

      • Significance

      • Passive movement is a measure of the objective range of motion of the joint. It may be limited by stiffness of the joint, or active resistance on the patient's part.

      Overview

      • Causes of Abnormal Gait

      • Pain - inflammation, infection, malignancy, trauma
      • Weakness - muscular, neuromuscular or neurological
      • Deformity - arthritis, surgery, shortening post fracture, congenital malformations
      • Instability - peripheral neuropathy, cerebellar or brainstem pathology

      Passive Movement

      • Significance

      • Passive movement is a measure of the objective range of motion of the joint. It may be limited by stiffness of the joint, or active resistance on the patient's part.

      Centre of Gravity

      • Significance

      • Optimal posture involves the balanced distribution of body mass around the centre of gravity, with minimal muscular energy use. Any deviation from this results in instability, weakness and pain.

      Apparent Leg Length Discrepancy

      • Interpretation

      • Apparent shortening - flexion contractures of the hip or knee
      • Apparent lengthening - abduction contractures of the hip, equinus deformity of the ankle

      Fasciculations

      • Look For

      • Visible, spontaneous localised muscle contraction and relaxation.

      Bony Landmarks of the Knee

      Fibular head - palpate below the knee joint laterally for the fibular head. Note its position and mobility.

      Overview

      • Causes of Abnormal Gait

      • Pain - inflammation, infection, malignancy, trauma
      • Weakness - muscular, neuromuscular or neurological
      • Deformity - arthritis, surgery, shortening post fracture, congenital malformations
      • Instability - peripheral neuropathy, cerebellar or brainstem pathology

      Comprehension

      • Complex Verbal Comprehension

      • Ask the patient to take a piece of paper into their right hand, fold it in half and then place the paper onto the floor.

      Volume of Speech

      The loudness or softness of a person's speech can be indicative of emotional factors, cultural background, or hearing impairments.

      Digit Span

      • Normal Span

      • 6 ± 1 digits

      Assessing Anterograde Memory

      The ability form new memories after significant brain injury or psycho-trauma.

      Visual Neglect

      • How to Assess

      • Give the patient a page with many lines oriented at various angles. Ask the patient to cross every line. Examine the page to see whether they have missed one side of the page.
      • Ask the patient to draw a clock face, looking for missing numbers on one side of the clock.

      Inhibitory Control

      Inhibitory control tests one's ability to inhibit, a part of frontal lobe executive function.

      Vertebral Landmarks

      T2 - palpate medially to the superior angle of the scapula.

      Fasciculations

      • Look For

      • Visible, spontaneous localised muscle contraction and relaxation.

      Overview

      • Causes of Abnormal Gait

      • Pain - inflammation, infection, malignancy, trauma
      • Weakness - muscular, neuromuscular or neurological
      • Deformity - arthritis, surgery, shortening post fracture, congenital malformations
      • Instability - peripheral neuropathy, cerebellar or brainstem pathology
      Normal lumbar lordosis is unique to humans and is a result of our upright posture and habitual bipedalism. Such lordosis develops as infants begin to stand and walk.

      Muscles Acting on the Thoracic / Lumbar Spine

      Flexors - rectus abdominis, internal & external oblique

      Pharyngeal Erythema

      • Causes of Pharyngeal Erythema

      • Viral infection - influenza, coronavirus, rhinovirus, enterovirus, HIV, EBV, CMV, HSV
      • Bacterial infection - group A Streptococcus, pneumococcus, Staph aureus, haemophilus
      • Irritation - postnasal drip, reflux, malignancy, chemical ingestion
      • Tonsillitis

      Horner's Syndrome

      • Look For

      • Partial ptosis: drooping of the eyelid
      • Miosis: constriction of the pupil
      • Anhidrosis: lack of sweating

      Tachypnoea

      • Causes of Tachypnoea

      • Physiologic - during exercise or at high altitude
      • Anxiety
      • Metabolic acidosis - abdominal pathology, sepsis
      • Pulmonary embolism
      • Pneumonia
      • Asthma
      • Respiratory failure

      Overview

      • Tip

      • Muscle wasting and shiny skin with reddish discolouration is a very specific for reflex sympathetic dystrophy.
      • Interpretation

      • Resonance - vibration of the lung parenchymaNormal percussion note
      • Hyperresonance - increased thoracic gas
      • Dullness - fluid or soft tissue within pleura or lung parenchyma

      Respiratory Muscles

      • Inspiratory Accessory Muscles

      • Sternocleidomastoid
      • Scalenes

      Cervical Lymph Nodes

      Submental nodes - immediately below chinTeeth, oral mucosa, tongue

      The Oxygen Dissociation Curve

      The oxyhaemoglobin dissociation curve describes the relationship between PaO₂ and HbO₂. At high PaO₂ (alveolar-capillary membrane) oxygen readily binds to haemoglobin. At low PaO₂ (systemic capillaries) oxygen is readily released from haemoglobin.

      Muscles Acting on the Wrist Joint

      Pronators (anteromedial) - pronator teres, pronator quadratus

      Muscle Spasms

      • Look For

      • Spontaneous, uncontrollable contraction(s) of muscle. Note whether the spasm affects a single region, is generalised or affects the ipsilateral arm and leg.

      Bony Landmarks of the Hand

      Proximal carpal bones - scaphoid, lunate, triquetrum, pisiform

      Claw Hand

      • Look For

      • Extension of the MCP joints and flexion of the IP joints of the ring and little fingers.

      Passive Movement

      • Significance

      • Passive movement is a measure of the objective range of motion of the joint. It may be limited by stiffness of the joint, or active resistance on the patient's part.

      Non-Pitting Oedema

      • Look For

      • Oedema to the lower limbs that does not pit.

      Amplitude

      Bounding pulse - strong, sustainedHypertension, hypermetabolic states

      Arterial Skin Changes

      • Look For

      • Absent pedal pulses
      • Thin / shiny skin
      • Cool skin
      • Hair loss

      Absent Lower Limb Pulses

      • Causes of Absent Lower Limb Pulses

      • Trauma
      • Atherosclerosis / peripheral vascular disease
      • Abdominal aortic aneurysm
      • Shock

      Inspection of Pupils

      • Causes of Unequal Pupils (Anisocoria)

      • Physiological (20% of the population - compare with an old photo)
      • Migraine
      • Post-ictal
      • Horner's syndrome (unilateral)
      • Drugs applied to one eye - pilocarpine, tropicamide, cocaine
      • Intraocular conditions - glaucoma, retinal detachment
      • Optic (II) or oculomotor (III) nerve lesion - trauma, compression, optic neuritis, Guillain barré
      • CNS lesion - trauma, tumour, haemorrhage, infarct, MS

      Rashes Associated with Diabetes

      Acanthosis nigricans: dark, velvety, nonerythematous lesions on the axillae, antecubital fossae or around the neck.Type 2 diabetes, obesity, gastrointestinal malignancy

      Diabetic Retinopathy

      Retinal disease of the eye in diabetics manifests initially as small haemorrhages, while in advanced disease the eye develops new blood vessels that are at risk of major bleeding.

      Pallor of the Lower Limb

      • Causes of Pallor of the Lower Limb

      • Anaemia
      • Peripheral arterial disease
      • Compartment syndrome
      • Low cardiac output, due to cardiac disease
      • Peripheral shutdown, due to increased sympathetic activity

      Clinical

      • Adverse Effects

      • Rare.

      Clinical Use

      • Adverse Effects

      • Nausea / vomiting / abdo pain.
      • Adverse Effects

      • Nausea / vomiting
      • Elevated LFTs
      • Headache
      • Adverse Effects

      • Cinchonism - tinnitus, deafness, headache, nausea / vomiting, visual disturbance
      • Hypersensitivity - rash, oedema
      • Hypoglycaemia
      • Haemolysis
      • Thrombocytopaenia / neutropaenia
      • Adverse Effects

      • Disulfuram-like effect (severe 'hangover' with alcohol)
      • Nausea, vomiting
      • Headache
      • Adverse Effects

      • Gastrointestinal - mouth ulcers, nausea / vomiting / abdominal pain
      • Hepatotoxicity - elevated LFTs, cirrhosis
      • Pulmonary - hypersensitivity pneumonitis
      • Bone marrow suppression - leukopaenia / thrombocytopaenia / anaemia

      Overview

      • Pharmacology

      • Bone marrow-sparing, therefore often used when other antineoplastics are contraindicated.

      Clinical Use

      • Adverse Effects

      • Haemorrhagic cystitis
      • Bone marrow suppression - leucopaenia, thrombocytopaenia, anaemia
      • Renal dysfunction
      • Nausea / vomiting
      • Alopecia
      • Indications

      • Certain haematologic organ malignancies, as guided by cancer specialists and local guidelines.
      • Adverse Effects

      • Severe diarrhoea
      • Nausea / vomiting
      • Alopecia
      • Leucopaenia

      Clinical Use

      • Indications

      • Certain solid organ and haematologic organ malignancies, as guided by cancer specialists and local guidelines.

      Clinical Use

      • Adverse Effects

      • Neurotoxicity - numbness / paraesthesia / weakness
      • Leukopaenia / anaemia / thrombocytopaenia
      • Nausea / vomiting / constipation / paralytic ileus
      • Alopecia
      • Adverse Effects

      • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
      • Nausea / vomiting / diarrhoea
      • Adverse Effects

      • Bone marrow suppression - neutropaenia / anaemia / thrombocytopaenia
      • Oedema
      • Peripheral neuropathy
      • Nausea / vomiting / diarrhea
      • Elevated LFTs
      • Rash
      • Alopecia
      • Indications

      • Certain solid organ and haematologic organ malignancies, as guided by cancer specialists and local guidelines.

      Overview

      • Methods to Assist with Finding a Vein

      • Warm the area
      • Tap the area
      • Ask the patient to pump their fist
      • Hang the limb over the bed to improve blood flow
      • Devices

      • Use an ultrasound machine
      • Use a vein viewer

      Simple Face Mask

      A simple face mask, also known as a Hudson mask, allows a larger amount of oxygen to be entrained with room air. As they have no reservoir bag, the maximum FiO2 possible is around 0.60.

      BiPAP

      • Indications for BiPAP

      • Acute hypercapnic respiratory failure - e.g. due to COPD, chest wall deformities, neuromuscular disorders
      • Immunocompromised patients with acute respiratory failure
      • Step-down after extubation of high-risk patients

      High Flow Nasal Prongs

      High flow nasal prongs (HFNP) allow high flow of a precise amount of oxygen, and are useful in patients with hypoxic respiratory failure. The system is humidified, meaning that they can be used for longer periods of time. These systems also provide a small amount of positive end-expiratory pressure (PEEP), helping to keep the airways open.

      Monitoring

      Oxygen saturations should be used to guide supplemental oxygen administration. The target oxygen saturation for most patients should be 92-96%, while in patients with chronic respiratory failure this target should be 88-92%.

      Allen's Test

      A clinical test used to determine the patency of the radial and ulnar arteries, used as a predictor of distal ischaemia risk post radial arterial cannulation or catheterisation.
      A clinical test used to determine the patency of the radial and ulnar arteries, used as a predictor of distal ischaemia risk post radial arterial cannulation or catheterisation.

      Overview

      Femoral: 15 - 20cm

      Internal Jugular Vein

      • Considerations

      • Use the right internal jugular vein where possible, due to its larger diameter and proximity to the superior vena cava.

      Avoiding Incorrect NG Placement

      Pleural / Peritoneal (i.e. perforation) - some pressure may be required to advance the tube against mild resistance, but do not keep pushing the tube against significant resistance.

      Subclavian Placement

      • Prevention

      • Properly measure the intended PICC line insertion length by measuring from the sternal angle to the sternal notch and then down the arm to the insertion site.

      Preparation

      Set up all of your equipment on a trolley, and prime the line if required.

      Overview

      16 - trauma, major surgery, obstetrics, GI bleeds, large volumes

      Choosing the Right Vein

      • Do

      • Ask the patient about their preference of site
      • Use the nondominant arm if possible
      • Try to use the forearm where possible

      Lignocaine

      • Maximum Dose

      • Without adrenaline - 4mg/kg
      • With adrenaline - 7mg/kg

      Intubation

      • Complications of Intubation

      • During Insertion

      • Incorrect placement - oesophagus / bronchus
      • Trauma - teeth / oral cavity / pharynx / larynx / trachea
      • Hypoxia (due to delayed intubation)
      • While Intubated

      • Mechanical issues - tube obstruction / kinking, loss of cuff integrity
      • Infection - ventilator-associated pneumonia
      • Self extubation
      • After Extubation

      • Sore throat
      • Laryngeal / tracheal pathology - oedema, spasm, stenosis
      • Vocal cord paralysis

      Oropharyngeal Airway

      • Contraindications

      • Conscious patients
      • If the patient can cough or has a gag reflex

      Diagnosis

      • Diagnosis
      • Investigations

      • Blood film - evidence of dysplasia
      • Bone marrow aspirate + trephine - histology, cytogenetics, molecular, flow cytometry

      Hormonal Changes

      In mild nonthyroidal illness reduced deiodination of T4 to T3 results in elevated T4 and reduced T3. TSH may initially be normal or elevated due to lack of T3.

      Diagnosis

      • ECG Findings

      • Long QTc → torsade de pointes
      • Atrial or ventricular ectopics
      • Atrial fibrillation
      • Ventricular arrhythmias
      • Hypokalaemia - ST depression, prolonged QT interval, T wave flattening or inversion, prominent U wave
      • Examples

      • Signs of Chronic Kidney Disease

      • General Signs

      • Sallow complexion
      • Leukonychia
      • Sarcopaenia
      • Signs Suggesting a Cause

      • Finger prick markings (diabetes)
      • Palpable polycystic kidneys
      • Signs of Complications

      • Acidosis - tachypnoea
      • Fluid overload - hypertension, raised JVP, sacral / pedal oedema, pulmonary crepitations
      • Anaemia - palmar crease pallor, conjunctival pallor
      • Uraemia - scratch marks, confusion, asterixis, pericardial rub
      • Signs of Management

      • Haemodialysis - VasCath, arteriovenous fistula, graft
      • Peritoneal dialysis - Tenkhoff catheter
      • Scars - nephrectomy, renal transplant, parathyroidectomy
      • Palpable renal transplant (usually right lower quadrant)

      Pathogenesis

      • Causes of Ventricular Fibrillation

      • Myocardial infarction
      • Cardiomyopathy
      • Pulmonary embolism
      • Cardiac tamponade
      • Severe electrolyte disturbance
      • Cardiotoxic medications
      • Environmental - electrocution, drowning, hypothermia

      Overview

        Diagnosis

        • Chest X-Ray Signs of Pleural Effusion

        • Loss of the costophrenic angle
        • Increased density of the affected hemithorax
        • Pseudo-elevation of the diaphragm
        • Loss of lower lobe vessels
        • ECG Findings

        • Orthodromic AVRT (90%) - regular narrow complex tachycardia with no P waves (hidden in QRS) or P waves after QRS complex. No delta wave will be seen.
        • Antidromic AVRT (10%) - regular broad complex tachycardia (easily mistaken for VT)
        • Examples

        Manifestations

        • Complications of Obstructive Sleep Apnoea

        • Hypertension
        • Ischaemic heart disease
        • Cerebrovascular disease
        • Pulmonary hypertension
        • Atrial fibrillation
        • Depression
        • Complications of Peptic Ulcer Disease

        • Upper GI bleeding
        • Perforation
        • Gastric outlet obstruction
        • Manifestations
           
        • Manifestations of Multiple Myeloma

        • Classical (CRAB)

        • Calcium - hypercalcaemia
        • Renal failure (multifactorial) - due to cast nephropathy, glomerular light chain deposition, hypercalcaemia, amyloidosis
        • Anaemia - normocytic, normochromic
        • Bone lesions - lytic lesions, due to osteoclastic change
        • Other

        • Hyperviscosity syndrome - due to hypergammaglobulinaemia
        • Amyloidosis - GI, cardiac, hepatic, renal, muscular or nerve infiltration
        • Recurrent infections - due to relative hypogammaglobulinaemia

        Diagnosis

        Smaller VSDs tend to be louder.
        • Examination

        • Signs of PE - tachycardia, tachypnoea, hypoxia
        • Signs of right ventricular failure (massive PE) - tricuspid regurgitation, hypotension
        • Signs of DVT - upper or lower limb erythema / pitting oedema / tenderness
        • Perihilar opacification and increased interstitial markings in keeping with early pulmonary oedema
        • Perihilar opacification and increased interstitial markings in keeping with early pulmonary oedema
           
        • ECG Findings

        • Heart rate ~150bpm
        • Regular rhythm (RR interval)
        • Saw-toothed baseline 'flutter' waves at ~300bpm
        • Atrioventricular block (not every flutter wave is followed by a QRS complex)

        Manifestations

        • Complications of Gastroesophageal Reflux

        • Oesophagitis
        • Oesophageal strictures
        • Barrett's oeseophagus
        • Oesophageal adenocarcinoma
        • Aspiration pneumonitis

        Overview

        •  

        Management

        • Management Options

        • Latent TB

        • Isoniazid
        • Rifampicin
        • Active TB

        • First line (HRZE) - isoniazid, rifampicin, pyrazinamide and ethambutol
        • Other options - amikacin, capreomucin, moxifloxacin, linezolid, cycloserine, clofazimine, meropenem, augmentin

        Diagnosis

        • ECG Findings

        • All findings must occur in at least one right precordial lead (V1-V3).

        • Type 1 - coved ST elevation >2mm in V1-V3, followed by a negative T wave
        • Type 2 - saddle-shaped ST elevation in V1-V3 that is >2mm at the J point and >=1mm at the terminal portion of the ST segment
        • Type 3 - saddle-shaped ST elevation in V1-V3 that is >2mm at the J point and <1mm at the terminal portion of the ST segment

        Manifestations

        • Complications of Lung Cancer

        • Pleural effusion
        • Metastases - brain, liver, adrenal, bone
        • Local compression - SVC obstruction, sympathetic chain compression (Pancoast tumour) , laryngeal nerve palsy, phrenic nerve palsy, brachial plexopathy
        • Paraneoplastic syndromes - hypercalcaemia, SIADH, Cushing's, hypertrophic pulmonary osteoarthropathy, neurologic syndromes
        • Symptoms of Pulmonary Hypertension

        • Fatigue
        • Exertional dyspnoea
        • Exertional chest pain
        • Exertional syncope
        • Symptoms of right heart failure - peripheral oedema, ascites

        Pathogenesis

        • Causes of Monomorphic Ventricular Tachycardia

        • Myocardial infarction
        • Cardiomyopathy
        • Congestive cardiac failure

        Diagnosis

        Patients with myaesthenic syndromes exhibit muscle fatigability, or the inability to maintain contraction of muscles over time.
        • TFT Interpretation

        • Primary hyperthyroidism -  reduced TSH with elevated T4
        • Subclinical hyperthyroidism - reduced TSH with normal T4
        • Central hyperthyroidism - elevated TSH with elevated T4

        Pathogenesis

        Manifest preexcitation produces the classic ECG findings listed below, while concealed preexcitation may produce no ECG changes at rest.

        Diagnosis

        • Left posterior fascicular block:
        • Left posterior fascicular block

        Overview

        Serology may be used to assess for active or past infection with hepatitis C.

        Management of Obesity

        • Pearls

        • Set realistic weight loss goals (e.g. 5-10%)
        • Aim to improve comorbid conditions, such as diabetes
        • Use non-pharmacologic and pharmacologic strategies

        Pathogenesis

        In fast-slow AVNRT (10%) an impulse travels retrogradely up the slow pathway.
        Due to the lack of beta chains, there is an increase in haemoglobin A₂ (consisting of two alpha and two delta chains) and haemoglobin F (foetal haemoglobin, consisting of two delta and two gamma chains).

        Manifestations

        • Complications of Cirrhosis

        • Ascites (due to portal hypertension, RAAS activation and splanchnic vasodilatation)
        • Varices (due to portal hypertension)
        • Splenomegaly (due to portal hypertension)
        • Hepatic encephalopathy (due to ammonia buildup)
        • Spontaneous bacterial peritonitis (due to gut translocation)
        • Hepatorenal syndrome (due to splanchnic vasodilatation)
        • Hepatic hydrothorax (due to leakage of ascitic fluid into the pleural space)
        • Portopulmonary hypertension (due to portal hypertension)
        • Hepatopulmonary syndrome (due to vasodilation / shunting)
        • Malnutrition / sarcopaenia
        • Coagulopathy (due to poor synthetic function + vitamin K malabsorption)
        • Thrombocytopaenia (due to splenic sequestration)
        • Hepatocellular carcinoma (HCC)

        Diagnosis

        • Signs of Severity

        • Evidence of active synovitis
        • Severe deformity
        • Rheumatoid nodules (indicate seropositive disease)
        • ECG Findings

        • Decreased heart rate - <60bpm (or 50bpm when asleep)
        • Regular rhythm - normal PR interval with P waves preceding each QRS complex
        • Normal axis - positive P waves in leads I and II
        • Diagnosis
           
        • 2nd degree SA exit block: type I
        • 2nd degree SA exit block type I
           

        Manifestations

        Chronic hyponatraemia may also present with nausea, vomiting or headaches. Patients may also report polydipsia, lethargy or muscle cramps.
        • Complications of Sickle Cell Anaemia

        • Haemolytic anaemia
        • Hypersplenism (early) - anaemia, thrombocytopaenia
        • Hyposplenism (late) - increased risk of infection, thrombocytosis
        • Vaso-occlusive disease - acute pain crises, stroke, acute chest syndrome, avascular necrosis, pulmonary hypertension, renal infarction, other micro-infarcts
        • Aplastic crisis (acute anaemia)

        Management

        • Management of Hepatitis B

        • Non-Pharmacologic

        • Cirrhosis surveillance
        • HCC surveillance
        • Pharmacologic

        • Nucleoside analogues - entecavir, lamivudine
        • Nucleotide analogues - tenofovir
        • Pegylated interferon

        Diagnosis

        • ECG Findings

        • Wide QRS >120ms (complete BBB) or 110-120ms (incomplete BBB)
        • Added R wave in right precordial leads (R') - RSR' pattern in leads V1 or V2
        • Slurred S wave in lateral leads - S wave duration > R wave duration (or >50ms) in leads I, V5 and V6

        Overview

        • Left lower zone pneumonia
        • Left lower zone pneumonia
           

        Management

        • Management Options for Ulcerative Colitis

        • Non-Pharmacologic

        • Nutritional optimisation
        • Psychologic supports
        • Cancer surveillance
        • Pharmacologic

        • Steroids
        • 5-Aminosalicylates - sulfasalazine, mesalazine
        • Thiopurines - azathioprine, 6-mercaptopurine
        • Calcineurin inhibitors - cyclosporin, tacrolimus
        • TNF blockers - infliximab, adalimumab
        • Other biologics - vedolizumab, ustekinumab
        • Surgical

        • Colectomy + ileoanal pouch

        Overview

        • Microbiology

        • Most effective against gram positive cocci (streptococci and staphylococci), as well as Enterobacteriaciae (Proteus spp., E coli and Klebsiella spp.)

        Clinical Use

        • Indications

        • Gram negative septicaemia
        • Directed therapy for severe and susceptible respiratory infections, UTI, skin infections, osteomyelitis or peritonitis
        • Contraindications

        • Foetal distress
        • Vaginal delivery contraindicated
        • Adverse Effects

        • Fatigue
        • Oedema
        • Dizziness
        • Headache
        • Nausea / abdo pain
        • Adverse Effects

        • Nausea / vomiting / diarrhoea
        • Hypertension
        • Coronary vasospasm
        • Rash
        • Adverse Effects

        • Tremor
        • Palpitations
        • Headache
        • Hypokalaemia / hypomagnesaemia
        • Ketoacidosis (diabetics)
        • Adverse Effects

        • Headache
        • Nausea / vomiting / diarrhoea
        • Coronary artery spasm
        • Hypertension
        • Gangrene
        •  
          IV
          Donor Secretor Plasma
          For use prior to bone marrow transplant with major ABO mismatch, in order to reduce the risk of haemolysis and pure red cell aplasia
        • Indications

        • Massive transfusion
        • Large haemorrhage during surgery

        Overview

        • Non-Infectious Adverse Effects

        • Acute

        • Acute haemolysis
        • Allergic reaction
        • Anaphylaxis
        • Coagulation disorder (massive transfusion)
        • Fever
        • Transfusion-related circulatory overload (TACO)
        • Transfusion-related acute lung injury (TRALI)
        • Delayed

        • Delayed haemolysis
        • Iron overload
        • Purpura
        • Graft-vs-host disease

        Clinical Use

        • Contraindications

        • Active thrombosis
        • Disseminated intravascular coagulation
        • Indication

        • COPD maintenance therapy.

        Overview

        These combination puffers contain an inhaled corticosteroid (ICS) to reduce airway inflammation, as well as a long acting beta 2 agonist (LABA) as a bronchodilator.
        •  
          IV
          Dexamethasone

        • Mechanism of Action

          Suppress the inflammatory response in the airways through:
        • Reduced monocyte recruitment
        • Suppression of arachidonic acid metabolites - prostaglandin, leukotriene, platelet-activating factor
        • Reduced production of interleukins, TNF-α, GM-CSF
        • Mechanism of Action

        • Inhibit muscarinic (M3) receptors, leading to bronchial smooth muscle relaxation and bronchodilation through reduction in acetylcholine-mediated vagal tone.

        Clinical Use

        • Adverse Effects

        • Headache
        • Nausea / diarrhoea
        • Fatigue

        Overview

        These combination inhalers contain a long acting muscarinic agent (LAMA) as well as a long-acting beta 2 agonist (LABA), and are used for maintenance therapy of COPD.

        Clinical Use

        • Adverse Effects

        • Tremor
        • Palpitations
        • Hypokalaemia / hypomagnesaemia
        • Ketoacidosis (diabetics)
        • Indication

        • Alzheimer's disease.
        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • CNS disturbances - drowsiness, tremor
        • Thrombocytopaenia
        • Alopecia
        • Weight gain
        •  
          Oral
          Zolmitriptan
          Zomig 
        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • CNS disturbances - drowsiness, tremor
        • Thrombocytopaenia
        • Alopecia
        • Weight gain
        •  
          IV
          Dexamethasone

        • Contraindications

        • Asthma
        • Decompensated heart failure
        • AV block
        • Adverse Effects

        • Upper respiratory tract infection
        • Hypersensitivity
        • Elevated LFTs
        • Thrombocytopaenia / leukopaenia
        • Thyroid dysfunction
        • Depression
        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • Adrenergic - postural hypotension
        • Histaminic - sedation, weight gain
        • Anticholinergic - dry mouth, blurred vision, constipation, urinary retention
        • Adverse Effects

        • Progressive multifocal leukencephalopathy (PML)
        • Headache
        • Fatigue
        • Arthralgia
        • Increased risk of infection

        Overview

        • Effects

        • BZ1 receptor (cortex, thalamus, cerebellum) - sedation, anterograde amnesia, anticonvulsant
        • BZ2 receptor (limbic system, motor neurons) - anxiolysis, muscle relaxation

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting
        • Hirsutism
        • CNS disturbances - drowsiness, tremor, dysarthria, diplopia
        • Purple glove syndrome (IV) - distal limb discolouration, pain and swelling
        • Anticonvulsant hypersensitivity syndrome (prolonged admin) - fever, rash, lymphadenopathy, hepatitis, myositis
        • Adverse Effects

        • Increased addictive behaviours
        • Fatigue
        • Confusion
        • Dizziness
        • Nausea / vomiting
        • Peripheral oedema

        Overview

        • Pharmacology

        • Levodopa crosses the blood brain barrier.

        Clinical Use

        • Adverse Effects

        • Rare.
        •  
          Oral
          Naproxen
          14 hour half-life

        Overview

        • Mechanism of Action

        • Inverse agonists to histamine H1 receptors, having the opposite effect of histamine.
        • Pharmacology

        • Greater beta adrenoceptor affinity than noradrenaline, resulting in greater inotropic and chronotropic effects.
        • Effects

        • Reduced secretions - sweat, lacrimal, salivary, gastric, pancreatic, bronchial glands
        • Vasoconstriction
        • Prevention of decreased vessel permeability / oedema

        Clinical Use

        • Adverse Effects

        • Headache
        • Breast pain
        • Nausea / vomiting / bdominal pain
        • Dizziness
        • Depression
        • Irregular bleeding
        • Acne
        • Contraindications

        • Pregnancy
        • Past DVT / PE
        • Ischaemic heart disease
        • Past stroke / TIA
        • Breast cancer within the past five years
        • Ischaemic heart disease
        • Contraindications

        • Pregnancy
        • Past DVT / PE
        • Ischaemic heart disease
        • Past stroke / TIA
        • Breast cancer within the past five years
        • Ischaemic heart disease
        Useful for patients who are poorly compliant with oral therapy, and for patients with malabsorption.
        • Indication

        • Contraception.
        • Adverse Effects

        • Ovarian enlargement
        • Abdominal pain / distension
        • Nausea / vomiting
        • Flushing
        • Visual symptoms
        • Breast tenderness
        Must be taken at the same time every day, as its mechanism of action relies on its effect on vaginal mucus.  If not taken within three hours of the normal time the dose should be skipped and another form of contraception (condoms / diaphragm) should be used for 48 hours.
        • Indication

        • Termination of intrauterine pregnancy up to 49 days of gestation.
        • Indications

        • Hypoglycaemia
        • Hypernatraemia
        • Diabetic ketoacidosis, in conjunction with insulin
        • Co-administration for insulin infusion
        • Adverse Effects

        • Nausea / vomiting
        • Salivation
        • Bradycardia
        • Convulsions
        • Adverse Effects

        • Bradycardia
        • Hypotension
        • Dypnoea
        • Nausea / vomiting
        • Adverse Effects

        • Headache
        • Nausea / vomiting
        • Dizziness
        • Drowsiness
        • Metallic taste
        Due to short duration, the benzodiazepine reversal is often short-lived and the patient will likely have ongoing sedation once the dose wears off.
        • Contraindications

        • Phaeochromocytoma
        • Insulinoma
        • Glucagonoma
        • Adverse Effects

        • Tachycardia
        • Dry mouth / nose / eyes / skin
        • Constipation
        • Urinary retention
        • Dilated pupils
        • Monitoring

        • Blood alcohol and glucose levels.
        • Adverse Effects

        • Electrolyte disturbances - hyponatraemia, hypokalaemia, hypomagnesaemia, hypophosphataemia
        • Hyperglycaemia
        • Dehydration
        • Thrombophlebitis
        • Indication

        • Moderate to severe rheumatoid arthritis refractory to methotrexate.
        •  
          Subcut
          Certolizumab
          Cimzia 
           
          Fab portion of immunoglobulin
        • Adverse Effects

        • Injection site reactions
        • Infections (particuarly upper respiratory tract infection)
        • Headache
        • Dizziness
        • Nausea / vomiting / diarrhoea
        • Abdominal pain
        • Mouth ulcers
        • Hypertension
        • LFT derangement
        Patients should be provided with meningococcal vaccination prior to commencing on eculizumab.

        Substem A (Target)

        -f(u): fungal (e.g. efungumab)

        Clinical Use

        As a result of its IL-6 inhibition, patients on tocilizumab tend not to develop markers of an acute phase response (such as raised CRP) in the context of superimposed infection or inflammatory process.
        • Contraindications

        • Concurrent treatment with TNF-alpha inhibitors
        • Neutropaenia
        • Monitoring

        • Regular monitoring of FBC and renal function.
        • Adverse Effects

        • Pancytopaenia
        • Infections (particularly respiratory and urinary tract)
        • Poor wound healing
        • Mouth ulcers
        • Male hypogonadism
        • Dyslipidaemia
        • Insomnia
        • Anxiety
        • Headache
        • Monitoring

        • Monthly full blood count, renal function and LFTs.
        • Adverse Effects

        • Gastrointestinal - mouth ulcers, nausea / vomiting / abdominal pain
        • Hepatotoxicity - elevated LFTs, cirrhosis
        • Pulmonary - hypersensitivity pneumonitis
        • Bone marrow suppression - leukopaenia / thrombocytopaenia / anaemia
        •  
          IV
          Dexamethasone

        • Monitoring

        • Baseline and regular electrolytes, renal function, LFTs, FBC and lipids.
        • Adverse Effects

        • Infusion site reactions
        • Fevers
        • Headache
        • Lethargy
        • Nausea / vomiting
        • Arthralgias / myalgias
        • Aseptic meningitis
        • Adverse Reactions

        • Fluid overload
        • Hypernatraemia
        • Osmotic demyelination
        • Indications

        • Hypoglycaemia
        • Hypernatraemia
        • Diabetic ketoacidosis, in conjunction with insulin
        • Co-administration for insulin infusion
        • Adverse Effects

        • Gynaecomastia
        • Nausea / vomiting / cramping / diarrhoea
        • Fatigue
        • Hyperkalaemia
        • Indication

        • Hypokalaemia.
        • Indications

        • Volume resuscitation for shock
        • Fluid replacement in diabetic ketoacidosis
        • Dehydration
        • Metabolic alkalosis secondary to fluid loss
        • Severe hypercalcaemia
        • Vehicle for intravenous medication administration
        • Contraindications

        • Fluid overload - congestive cardiac failure, severe renal impairment, excessive IV fluids
        • Severe anaemia
        • Jehovah's witnesses who refuse human-derived albumin.
        • Indication

        • Severe hyperkalaemia.
        • Contraindications

        • Fluid overload - congestive cardiac failure, severe renal impairment, excessive IV fluids
        • Lactic acidosis

        Overview

        • Effects

        • Glucose

        • Increased glycogen synthesis
        • Reduced hepatic glycogenolysis (glycogen breakdown)
        • Reduced hepatic gluconeogenesis (glucose formation)
        • Increased GLUT-4 mediated glucose uptake into adipose tissue and skeletal muscle
        • Fat

        • Increased triglyceride synthesis
        • Reduced lipolysis
        • Protein

        • Increased amino acid uptake
        • Reduced protein breakdown
        • Potassium

        • Increased cellular potassium uptake

        Clinical Use

        • Adverse Effects

          Due to hypermagnesaemia:
        • Drowsiness
        • Muscle weakness / hyporeflexia
        • Vasodilation / hypotension
        • Blurred vision / diplopia
        • Contraindications

        • Head injury
        • Fluid overload - congestive cardiac failure, severe renal impairment, excessive IV fluids
        • Severe anaemia
        • Jehovah's witnesses who refuse human-derived albumin.

        Opioid Overdose

        • Signs of Overdose

        • Reduced consciousness
        • Constricted pupils
        • Respiratory depression

        Overview

        • Pharmacology

        • Synthetic opioids cause less histamine release (flushing, itching, rash) and are less constipating than natural opioids.

        Clinical Use

        • Indication

        • Acute and chronic pain.
        • Adverse Effects

        • Rare.

        Overview

        • Mechanism of Action

        • Act on opioid receptors (δ, κ and μ) and nociceptin orphanin FQ (NOF) receptors on neuronal cell membranes within the thalamus, diencephalon, midbrain and medulla, resulting in reduced neurotransmitter release.

        Clinical Use

        • Indications

        • Acute and chronic pain.
        • Adverse Effects

        • Fatigue
        • Weight gain
        • Dizziness / ataxia
        • Indications

        • Procedural anaesthesia - local anaesthesia, nerve block or epidural block
        • Analgesia - local anaesthesia or epidural block
        • Adverse Reactions

        • Gastritis / peptic ulceration
        • Nephrotoxicity
        • Hypertension / fluid retention / congestive cardiac failure / MI
        • Hypersensitivity reactions
        • Delirium
        • Headache
        • Elevated LFTs
        • Neutropaenia
        •  
          Oral / IM
          Ketorolac
          Stronger but more likely to cause renal failure / peptic ulceration
        • Adverse Effects

        • Injection site reactions
        • Infections (particuarly upper respiratory tract infection)
        • Headache
        • Dizziness
        • Nausea / vomiting / diarrhoea
        • Abdominal pain
        • Mouth ulcers
        • Hypertension
        • LFT derangement
        •  
          Subcut
          Certolizumab
          Cimzia 
           
          Fab portion of immunoglobulin
        • Monitoring

        • Monthly full blood count, renal function and LFTs.
        • Adverse Effects

        • Increased risk of infection (immunosuppression)
        • Fluid overload
        • Hypertension
        • Fevers
        • Hirsutism
        • LFT derangement
        • Renal impairment
        • Dyslipidaemia
        As a result of its IL-6 inhibition, patients on tocilizumab tend not to develop markers of an acute phase response (such as raised CRP) in the context of superimposed infection or inflammatory process.
        • Contraindications

        • Concurrent treatment with TNF-alpha inhibitors
        • Neutropaenia
        • Adverse Effects

        • Gastrointestinal - mouth ulcers, nausea / vomiting / abdominal pain
        • Hepatotoxicity - elevated LFTs, cirrhosis
        • Pulmonary - hypersensitivity pneumonitis
        • Bone marrow suppression - leukopaenia / thrombocytopaenia / anaemia
        • Indication

        • Moderate to severe rheumatoid arthritis refractory to methotrexate.
        • Adverse Effects

        • Rash
        • Headache
        • Blurred vision
        • Elevated LFTs
        • Anorexia / Nausea / vomiting / diarrhoea
        • Adverse Effects

        • Headache
        • Nausea / vomiting / diarrhoea
        • Hypersensitivity reactions
        • Rash

        Overview

        • Mechanism of Action

        • Inhibit the Bcr-Abl tyrosine kinase as well as the stem cell receptor factor (cKIT) and several other receptor tyrosine kinases.

        Clinical Use

        • Indication

        • ALK-positive locally advanced or metastatic non small cell lung cancer (NSCLC).

        Overview

        • Mechanism of Action

        • Inhibit epidermal growth factor receptor (EGFR), a transmembrane amino acid receptor tyrosine kinase found in approximately 15% of non small cell lung cancers
        • EGFR mutations affect downstream signalling pathways resulting in cell proliferation
        • Inhibition of these receptors disrupts this proliferation pathway.

        Clinical Use

        MEK inhibitors are used in combination with BRAF inhibitors to overcome cellular resistance to BRAF inhibitors.

        Overview

        • Targets

        • Vascular endothelial growth factor receptors (VEGF)
        • Platelet-derived growth factor β (PDGFRβ)
        • Stem cell factor receptor (cKIT)
        • Resistance

        • Resistance to BRAF inhibitors is common, and occurs through multiple mechanisms. To overcome resistance, BRAF inhibitors are commonly combined with MEK inhibitors to target multiple points in the RAS / RAF / MEK / ERK pathway.

        Clinical Use

        • Adverse Effects

        • Nausea
        • Fatigue
        • Myelosuppression
        • Adverse Effects

        • Neutropaenia (~75% of cases)
        • Nausea / vomiting / diarrhoea
        • Fatigue
        • Alopecia
        • Rash
        • LFT derangement

        Overview

        • Mechanism of Action

        • Inhibit H⁺ / K⁺ ATPase, the channel responsible for pumping gastric acid into the lumen.

        Clinical Use

        • Adverse Effects

        • CNS - headache
        • Gastrointestinal - abdominal pain / nausea / vomiting / diarrhoea
        • Worsening of ulcerative colitis
        • Hepatotoxicity - elevated LFTs
        •  
          IV
          Dexamethasone

        Overview

        • Mechanism of Action

        • Osmotically active agents that draw water into the lumen of the gut.

        Clinical Use

        • Adverse Effects

        • Bone marrow suppression - anaemia / leukopaenia / thrombocytopaenia
        • Gastrointestinal - nausea / vomiting / diarrhea
        • Hepatotoxicity - elevated LFTs
        • Skin - rash
        • Adverse Effects

        • Gastrointestinal - mouth ulcers, nausea / vomiting / abdominal pain
        • Hepatotoxicity - elevated LFTs, cirrhosis
        • Pulmonary - hypersensitivity pneumonitis
        • Bone marrow suppression - leukopaenia / thrombocytopaenia / anaemia
        • Adverse Effects

        • Severe infections
        • Reactivation of tuberculosis
        • Anaemia
        • Headache
        • Nausea / diarrhoea
        • Exacerbation of congestive cardiac failure
        • Demyelinating disease
        • Indications

        • Nausea / vomiting
        • Gastroparesis
        • Adverse Effects

        • Abdominal cramps
        • Hypokalaemia (with prolonged use)
        • Warning

        • May render the oral contraceptive pill ineffective.

        Clinical use

        • Contraindications

        • Pregnancy
        • G-6-P deficiency
        • Active rheumatoid arthritis or lupus

        Clinical Use

        • Adverse Effects

        • Nausa / vomiting
        • Nightmares / depression / psychosis
        • Vertigo
        • Headache
        • Bradycardia
        • Rash

        Why Take Notes?

        Notes can then be used to study from, so that you are reading a high-yield summary rather than going back to the original source material constantly.

        History of Presenting Complaint

        • Radiation  

          Whether the pain radiates anywhere else, such as the shoulder, arm, jaw or back.
        • Pain radiating to the shoulders / arms or jawTypical of acute coronary syndrome
        • Pain radiating to the backSuggestive of aortic dissection

        Complications

        • Complications of Lung Cancer

        • Pleural effusion
        • Metastases - brain, liver, adrenal, bone
        • Local compression - SVC obstruction, sympathetic chain compression (Pancoast tumour) , laryngeal nerve palsy, phrenic nerve palsy, brachial plexopathy
        • Paraneoplastic syndromes - hypercalcaemia, SIADH, Cushing's, hypertrophic pulmonary osteoarthropathy, neurologic syndromes

        Severity

        • Ask About

        • Frequency of puffer use
        • Spirometry results - FEV1, FVC
        • Exacerbations - frequency, ED visits, hospital admissions, ICU admissions

        Pack-Years

        • Formula

        • Pack years = ( Cigarettes per day / 20 ) * number of years smoked

        Complications

        • Complications of Obstructive Sleep Apnoea

        • Hypertension
        • Ischaemic heart disease
        • Cerebrovascular disease
        • Pulmonary hypertension
        • Atrial fibrillation
        • Depression
        • Complications of COPD

        • Disease-Related

        • Pneumonia
        • Cor pulmonale
        • Pulmonary hypertension
        • Pneumothorax
        • Respiratory failure
        • Polycythaemia
        • Treatment-Related

        • Cushing's syndrome (steroids)
        • Oral candidiasis (steroids)
        • Tremor (beta agonists)

        Management

        • Pearls: Choice of Anticoagulant

        • Heparin infusion - short-term, for bridging or in the perioperative period. APTT must be monitored regularly as per local protocol.
        • Low molecular weight heparin (e.g. enoxaparin) - first line for patients with active malignancy; also used for bridging. Contraindicated if CrCl <30.
        • Warfarin - must be bridged. INR must be monitored. Can be used in renal failure. Inferior to enoxaparin in active malignancy.
        • Dabigatran - contraindicated if CrCl <30.
        • Rivaroxaban - contraindicated if CrCl <30, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding. Potential role in active malignancy.
        • Apixaban - contraindicated if CrCl <25, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding.

        Medication History

        • Prescriber

        • Who prescribed the medication initially, and who continues to prescribe it.

        Diagnosis

        • Classification

        • Heart failure with reduced ejection fraction (HFrEF)
        • Heart failure with preserved ejection fraction (HFpEF)

        Medication History

        • Prescriber

        • Who prescribed the medication initially, and who continues to prescribe it.

        Pack-Years

        • Formula

        • Pack years = ( Cigarettes per day / 20 ) * number of years smoked

        Management

        • Pearls

        • Set realistic targets
        • Use non-pharmacologic and pharmacologic strategies
        • Titrate medications to the patient's blood pressure and side effects, e.g. electrolytes / renal function (ACEi / ARBs), cough (ACEi), oedema (CCBs)
        • Titrate up to the maximum dose of an antihypertensive before adding an additional medication
        • If the patient's blood pressure is not responding: consider white coat hypertension, non-adherence or secondary causes

        Management of Obesity

        • Pearls

        • Set realistic weight loss goals (e.g. 5-10%)
        • Aim to improve comorbid conditions, such as diabetes
        • Use non-pharmacologic and pharmacologic strategies

        What is a Standard Drink?

        One standard drink in Australia contains 10g of alcohol.

        Management

        • Management Options

        • Treat / optimise the underlying disease
        • Pulmonary Arterial Hypertension Only

        • Endothelin receptor antagonists - bosentan, macitentan, ambrisentan
        • Phosphodiesterase 5 (PDE-5) inhibitors - sildenafil, tadalafil
        • Prostacyclin receptor agonists - prostacyclin, iloprost, tropostinil
        • Guanylate cyclase stimulants - riociguat

        Severity

        • Typical Cardiac Chest Pain

        • Chest pain radiating to one or both arms
        • Associated with exertion, nausea, vomiting or diaphoresis
        • Pressure
        • Relieved by glyceryl trinitrate

        Complications

        • Complications of Atrial Fibrillation

        • Thromboembolic stroke
        • Heart failure
        • Syncope

        Management

        • Management Options

        • Non-Pharmacologic

        • Dietary changes
        • Fish oil supplementation
        • Exercise
        • Alcohol avoidance
        • Smoking cessation
        • Pharmacologic

        • Statins - atorvastatin, pravastatin, rosuvastatin, simvastatin
        • Fibrates - fenofibrate, gemfibrozil
        • Ezetimibe
        • PCSK-9 inhibitors - alirocumab

        History of Presenting Complaint

        • Timing

        • How long the shortness of breath has been going on for, and whether it is intermittent or constant.

        Management

        • Management Strategies

        • Slow Progression

        • Treat the cause of CKD - e.g. diabetes, hypertension
        • ACE inhibitors - captopril, perindopril, ramipril
        • Angiotensin II receptor blockers - candesartan, irbesartan, telmisartan
        • Treat Complications

        • Acidosis - consider sodium bicarbonate
        • Fluid overload - fluid restriction, salt restriction
        • Anaemia - iron replacement if required, consider EPO
        • Cardiovascular disease - control hypertension, statin, consider aspirin
        • Mineral bone disease - dietary phosphate restriction, phosphate binders (calcium / non-calcium-based), calcitriol, parathyroidectomy
        • Malnutrition - high protein intake
        • Other

        • Dialysis - consider when to start and what modality
        • Renal transplant - consider suitability

        Glycaemic Management

        Management

        • Management Options for Ulcerative Colitis

        • Non-Pharmacologic

        • Nutritional optimisation
        • Psychologic supports
        • Cancer surveillance
        • Pharmacologic

        • Steroids
        • 5-Aminosalicylates - sulfasalazine, mesalazine
        • Thiopurines - azathioprine, 6-mercaptopurine
        • Calcineurin inhibitors - cyclosporin, tacrolimus
        • TNF blockers - infliximab, adalimumab
        • Other biologics - vedolizumab, ustekinumab
        • Surgical

        • Colectomy + ileoanal pouch

        Medication History

        • Prescriber

        • Who prescribed the medication initially, and who continues to prescribe it.

        Pack-Years

        • Formula

        • Pack years = ( Cigarettes per day / 20 ) * number of years smoked

        Post-Transplant Management

        • Management Strategy

        • Immunosuppression

        • Induction - steroids, basaliximab
        • Maintenance - steroids, tacrolimus / cyclosporine, mycophenolate mofetil
        • Prophylaxis & Screening

        • Infection prophylaxis - valaciclovir / valganciclovir, bactrim
        • Cancer screening - skin checks, pap smears, colorectal cancer screening

        Management

        • Management of Gastroesophageal Reflux

        • Non-Pharmacologic

        • Weight loss
        • Smoking cessation
        • Avoidance of certain foods - fatty, spicy, acidic
        • Elevation of the head of the bed
        • Pharmacologic

        • Antacids
        • Proton pump inhibitors - omeprazole, esomeprazole, pantoprazole
        • H2 receptor antagonists - ranitidine, nizatidine
        • Surgical

        • Fundoplication

        The CAGE questionnaire

        A screening tool for alcohol dependence.

        Management

        • Management of Peptic Ulcer Disease

        • Pharmacologic

        • H pylori eradication - triple or quadruple therapy
        • Proton pump inhibitors - omeprazole, esomeprazole, pantoprazole
        • H2 receptor antagonists - ranitidine, nizatidine
        • Interventional

        • Endoscopic management - injection of adrenaline, coagulation, endoscopic clipping
        • Surgical management (rare) - vagotomy, partial gastrectomy
        • Pearls

        • Treat the underlying cause of cirrhosis - e.g. treat viral hepatitis, alcohol cessation, weight loss
        • Treat complications
        • Monitor for further complications - varices and HCC
        • Management of Hepatitis B

        • Non-Pharmacologic

        • Cirrhosis surveillance
        • HCC surveillance
        • Pharmacologic

        • Nucleoside analogues - entecavir, lamivudine
        • Nucleotide analogues - tenofovir
        • Pegylated interferon

        Manifestations

        • Manifestations of Scleroderma

        • Cardiovascular - Raynaud's phenomenon, telangiectasias, pulmonary hypertension, pericarditis, arrhythmias, erectile dysfunction
        • Gastrointestinal - oesophageal dysmotility, reflux, GI bleeding, bacterial overgrowth
        • Respiratory - interstitial fibrosis, aspiration pneumonia
        • Renal - scleroderma renal crisis
        • Musculoskeletal - sclerodactyly, calcinosis cutis, tendon fibrosis
        • Neurological - entrapment neuropathies (e.g. carpal tunnel), autonomic neuropathy

        Falls History

        • Ask About

        • Whether the patient has had any falls recently
        • What they were doing when they fell
        • Why they fell
        • Whether the hit their head or other part of the body
        • Whether they have pain in any part of their body
        • How long they were on the ground for
        • How often they fall over

        Management

        • Management Options

        • Non-Pharmacologic

        • Smoking cessation
        • Pharmacologic

        • Steroids (for acute flares or bridging therapy only)
        • Conventional DMARDs - methotrexate, sulfasalazine, leflunomide, hydroxychloroquine
        • Targetted DMARDs - JAK inhibitors
        • Biologic DMARDs - TNF blockers, IL-6 blockers, CTLA4-Ig, rituximab
        • Pearls

        • The goal for acute management is symptomatic relief
        • Don't stop urate-lowering therapy during an acute flare
        • Wait until an acute flare resolves completely before starting urate-lowering therapy
        • Commencing urate-lowering therapy can precipitate an acute flare of gout!
        • Management Options

        • Non-Pharmacologic

        • Sun avoidance / use of sunscreen
        • Smoking cessation
        • Pharmacologic

        • Hydroxychloroquine
        • NSAIDs
        • Immunosuppression - mycophenolate, cyclophosphamide, azathioprine, leflunomide, cyclosporin
        • Belimumab (anti-BLys/BAFF)
        • Treatment of Manifestations

        • Skin disease - topical or intralesional steroids
        • Raynaud's - cold avoidance, smoking cessation, calcium channel blockers, topical nitrates, PDE5 inhibitors, prostacyclin
        • Antiphospholipid syndrome - anticoagulation
        • Lupus nephritis (class III / IV) - immunosuppression

        Overview

        The optic nerve is encased in meninges, making it the only cranial nerve that is part of the central nervous system. As a result peripheral neuropathies such as Guillain-barré do not affect the optic nerve.

        Motor Pathway

        Cortical Centre
        Primary motor cortex (frontal lobe)
         
         
        Trigeminal Motor Nucleus
        Upper pons
         
        Trigeminal Nerve
        Mandibular branch (V3)
        Foramen
        Foramen ovale
         
         
        Muscles
        Masseter, temporalis, medial & lateral pterygoids

        Visceral Motor Pathway

        Dorsal Motor Nucleus
        Medulla
         
        Foramen
        Jugular foramen
         
         
        Muscles
        Pharynx, larynx, thoracic & abdominal viscera

        Overview

        The optic nerve is encased in meninges, making it the only cranial nerve that is part of the central nervous system. As a result peripheral neuropathies such as Guillain-barré do not affect the optic nerve.

        Special Sensory Pathway

        Gustatory Cortex
        Insula
         
         
        Thalamus
         
         
        Facial Sensory Nucleus
        Pons
         
         
        Foramen
        Internal auditory meatus
         
        Geniculate Ganglion
         
        Chorda Tympani Nerve
        Sensory and parasympathetic fibres
         
         
        Receptors
        Anterior â…” of tongue

        Motor Pathway

        Cortical Centre
        Primary motor cortex (frontal lobe)
         
         
        Trigeminal Motor Nucleus
        Upper pons
         
        Trigeminal Nerve
        Mandibular branch (V3)
        Foramen
        Foramen ovale
         
         
        Muscles
        Masseter, temporalis, medial & lateral pterygoids

        Overview

        The trochlear nerve is the longest intracranial nerve in the body and has the least axons, making it the most susceptible to stretch damage in the case of closed head trauma.

        The Glasgow Coma Scale (GCS)

        • Interpretation

        • The Glasgow Coma Scale (GCS)

        Abducens Nerve (VI) Palsy

        • Look For

        • Inwardly-turned eye
        • Horizontal diplopia
        • Inability to look laterally

        Parasympathetic Pathway

        Hypothalamus
         
         
        Inferior Salivatory Nucleus
        Medulla
         
        Foramen
        Jugular foramen
         
        Superior (jugular) and
        inferior (petrous) ganglia
         
        Tympanic Nerve
         
        Tympanic Plexus
         
        Lesser petrosal nerve
         
        Otic ganglion
         
         
        Parotid Gland

        Extra Credit

        • Signs of Diabetic Retinopathy

        • Microaneurysms: tiny dot-like outpouchings
        • Cotton wool spots
        • Haemorrhages (small dots)
        • Macular oedema
        • Neovascularisation: formation of abnormal and fragile vessels

        Special Sensory Pathway

        Gustatory Cortex
        Insula
         
         
        Thalamus
         
         
        Facial Sensory Nucleus
        Pons
         
         
        Foramen
        Internal auditory meatus
         
        Geniculate Ganglion
         
        Chorda Tympani Nerve
        Sensory and parasympathetic fibres
         
         
        Receptors
        Anterior â…” of tongue

        Oculomotor Nerve (III) Palsy

        • Causes of Occulomotor Nerve Palsy

        • Small-vessel ischaemia
        • Midbrain infarct
        • Head trauma
        • Tumour
        • Aneurysm (commonly PCA)

        Motor Pathway

        Cortical Centre
        Primary motor cortex (frontal lobe)
         
         
        Oculomotor Nucleus
        Superior colliculus (midbrain)
         
        Pathway
        Tegmentum, red nucleus, medial substantia nigra
        Foramen
        Superior orbital fissure
        Division
        Superior and inferior branches
         
         
        Muscle
        Superior branch - superior rectus, levator palpabrae superioris
        Inferior branch - inferior rectus, medial rectus, inferior oblique

        Blepharospasm

        • Causes of Blepharospasm

        • Benign essential blepharospasm
        • Facial nerve damage
        • Herpes zoster infection
        • Stroke
        • Brainstem trauma

        Absent Pulses

        • Causes of Absent Pulses

        • Trauma
        • Atherosclerosis / peripheral vascular disease
        • Abdominal aortic aneurysm
        • Shock

        Overview

        • Note

        • Capillary refill time (CRT) is a useful test in children, though has little clinical utility in adults due to its variability with age, sex, ambient temperature among many other factors.

        Measuring Blood Pressure

        • Sizing the Blood Pressure Cuff

        • The blood pressure cuff should measure approximately 80% of the circumference of the arm.

        Hepatomegaly

        • Percussion of Upper Liver Edge

        • Percuss down the midclavicular line from the level of the third rib, with the struck finger held horizontal to the ribs. Once the top edge of the liver is percussed the percussion note will become dull.

        Arterial Skin Changes

        • Look For

        • Absent pedal pulses
        • Thin / shiny skin
        • Cool skin
        • Hair loss

        Palpable Kidney

        • Causes of Palpable Kidney

        • Hydronephrosis - kidney stone, ureteric clot, tumour, stricture
        • Congenital - horseshoe kidney, nephroblastomatosis
        • Cysts - benign cyst, polycystic kidney disease, Von-Hippel-Lindau disease
        • Malignancy - renal cell carcinoma, lymphoma
        • Renal hypertrophy - single kidney, contralateral reduced renal function

        Abdominal Distension

        • Interpretation

        • FatCentral obesity
        • FaecesLifestyle, age, obstruction, drugs, endocrine / neurological
        • FlatusIrritable bowel syndrome, mechanical or paralytic gut obstruction
        • FluidAscites, blood, pus, urine, bile, lymph, enteric contents
        • FoetusPregnancy
        • MassCancer, abscess, abdominal wall fibrosis

        Rashes Associated with Renal Disease

        Prurigo nodularis: firm, crusty, pruritic papules and nodules with a symmetrical distribution.CKD, Hepatitis C, HIV, H pylori, lymphoproliferative disorders

        Amplitude

        Bounding pulse - strong, sustainedHypertension, hypermetabolic states

        Mouth Ulcers

        • Causes of Mouth Ulcers

        • Trauma - mechanical / chemical / radiation
        • Aphthous stomatitis
        • Dermatoses - pemphigus, lichen planus, erythema multiforme
        • Infection - herpes simplex (cold sore), varicella zoster (chickenpox / shingles), coxsackie (hand, foot and mouth), syphilis, bacteria, candidiasis
        • Rheumatological - SLE, Reiter's syndrome
        • GIT - Crohn's / ulcerative colitis, coeliac disease
        • Drugs - antineoplastics
        • Malignancy

        Non-Pitting Oedema

        • Look For

        • Oedema to the lower limbs that does not pit.

        Rhythm

        • How to Assess

        • Feel the pulse for at least thirty seconds and determine whether the beats fall in time or are irregular.

        Scratch Marks

        • Causes of Pruritis

        • Obstructive jaundice (bile acid deposition)
        • Chronic kidney disease (urea deposition)
        • Skin conditions - dry skin, atopic eczema, psoriasis, lichen planus, ichthyosis
        • Infection - herpes zoster, scabies, fungal infections
        • Myeloproliferative disorders
        • Hyperthyroidism
        • Pregnancy
        • Neuropathic itch
        • Psychogenic itch

        Overview

        • Significance

        • Elevated JVP is indicative of increased right ventricular filling pressure.

        Waist-Hip Ratio

        • How to Assess

        • Measure the waist circumference at the midpoint between the lowest palpable rib and the top of the iliac crest. Measure the hip circumference around the widest part of the buttocks. Divide the first measurement by the second.

        Hypertensive Retinopathy

        • Look For

        • Grade 1 - silver wiring
        • Grade 2 - arteriovenous nicking
        • Grade 3 - flame-shaped haemorrhages, cotton wool spots
        • Grade 4 - papilloedema

        Dehydration

        • Complications

        • Seizures
        • Renal failure
        • Hypovolaemic shock

        Uraemic Foetor

        • Smell For

        • Ammonia, or a urine-like odour.

        Venous Ulcers

        Red, painless ulcers are suggestive of venous insufficiency.

        Onycholysis

        • Causes of Onycholysis

        • Systemic disease - chronic kidney disease, bronchial carcinoma, anaemia, diabetes mellitus, porphyrias, peripheral vascular disease, thyrotoxicosis
        • Nail infection
        • Skin disease - psoriasis, dermatitis, lichen planus
        • Trauma

        Claw Hand

        • Look For

        • Extension of the MCP joints and flexion of the IP joints of the ring and little fingers.

        Muscles Acting on the Wrist Joint

        Pronators (anteromedial) - pronator teres, pronator quadratus

        Bony Landmarks of the Hand

        Proximal carpal bones - scaphoid, lunate, triquetrum, pisiform

        Passive Movement

        • Significance

        • Passive movement is a measure of the objective range of motion of the joint. It may be limited by stiffness of the joint, or active resistance on the patient's part.

        Bony Landmarks of the Shoulder

        Spine of scapula - palpate posteriorly from the acromion, lateral to medial.

        Fasciculations

        • Look For

        • Visible, spontaneous localised muscle contraction and relaxation.

        Muscles Acting on the Shoulder Joint

        Internal rotators - pectoralis major, anterior deltoid, teres major, subscapularis, latissimus dorsi

        Overview

        • Causes

        • Subacromial bursitis
        • Rotator cuff tendinitis
        • Rotator cuff tear

        Measuring Blood Pressure

        Place the diaphragm of the stethoscope over the brachial artery and slowly deflate the cuff (2mmHg/sec). Note when the pulse is first heard (indicative of the systolic pressure) and when it disappears (indicative of the diastolic pressure).

        Overview

        • Causes of Abnormal Gait

        • Pain - inflammation, infection, malignancy, trauma
        • Weakness - muscular, neuromuscular or neurological
        • Deformity - arthritis, surgery, shortening post fracture, congenital malformations
        • Instability - peripheral neuropathy, cerebellar or brainstem pathology

        Muscles Acting on the Hip Joint

        Internal rotators - pectineus; gluteus medius and minimus; tensor fascia lata

        Centre of Gravity

        • Significance

        • Optimal posture involves the balanced distribution of body mass around the centre of gravity, with minimal muscular energy use. Any deviation from this results in instability, weakness and pain.

        Passive Movement

        • Significance

        • Passive movement is a measure of the objective range of motion of the joint. It may be limited by stiffness of the joint, or active resistance on the patient's part.

        Bony Landmarks of the Hip

        Symphysis pubis - palpate down the abdomen until a hard bony prominence if felt

        Overview

        If any hernia is palpated, gently attempt to reduce it with the patient supine. Do not attempt to reduce a tender hernia or a hernia associated with nausea or vomiting (as it may be strangulated).

        Fasciculations

        • Look For

        • Visible, spontaneous localised muscle contraction and relaxation.

        Tachypnoea

        Tachypnoea is an increase in the respiratory rate.

        Overview

        • Classification

        • Underweight - <18.5
        • Normal - 18.5 - 24.9
        • Overweight - 25 - 29.9
        • Obese - 30 - 34.9
        • Severely obese - 35 - 39.9
        • Morbidly obese - 40+

        Nail Bed Cyanosis

        • Look For

        • Blue discolouration of the nail beds

        Turner Syndrome

        • Look For

        • Gender (female)
        • Short stature
        • Puffy hands and feet (congenital lymphoedema)
        • Redundant skin on the back of the neck

        Body Mass Index

        BMI =
        WeightHeight²

        Kussmaul Respiration

        • Significance

        • Associated with severe metabolic acidosis, especially diabetic ketoacidosis.

        Overview

        • Causes of Weakness

        • CNS lesion - results in decreased power with increased tone and reflexesIschaemia, SAH / ICH, tumour, trauma, encephalitis, vasculitis, MS, ADEM, PML, sarcoidosis, prions
        • Nerve root pathology - loss of a single myotomeTrauma, radiculopathy, neoplasm
        • Focal peripheral nerve pathology - in the muscles supplied by a single nerveTrauma, entrapment, focal ischaemia, sarcoidosis, neoplasia, Bell's palsy (face)
        • Peripheral neuropathy (axonal polyneuropathy)Diabetes, motor neuron disease, hypothyroidism, B12 / folate deficiency, alcoholism, connective tissue disease, amyloid / sarcoidosis, toxins
        • Peripheral demyelinationGuillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP), Charcot-Marie-Tooth
        • Neuromuscular pathologyMyasthenia gravis, amyloidosis
        • Muscular pathologyPolymyositis, rhabdomyolysis

        Dentition

        • Causes of Poor Dentition

        • Poor oral hygiene
        • High-sugar diet
        • Malnutrition
        • Lack of fluoride
        • Diabetes
        • Alcoholism
        • Smoking

        Fluid Overload

        • Causes of Fluid Overload

        • Excessive IV fluids
        • Heart failure
        • Renal failure
        • Hepatic cirrhosis
        • SIADH
        • Pregnancy

        Overview

        • Note

        • Capillary refill time (CRT) is a useful test in children, though has little clinical utility in adults due to its variability with age, sex, ambient temperature among many other factors.

        Venous Ulcers

        Red, painless ulcers are suggestive of venous insufficiency.

        Comprehension

        Conceptual comprehension (understanding) - show the patient the same pen, watch and key as above and ask them to point to the object that shows the passage of time.

        The Glasgow Coma Scale

        • Interpretation

        • The Glasgow Coma Scale

        Overview

        Brown-Sequard syndrome - ipsilateral upper motor neuron weakness and loss of proprioception and vibration (dorsal column), with contralateral loss of pain and temperature sensation (spinothalamic tract)Hemitransection of the cord
        • Causes of Weakness

        • Upper Motor Neuron

        • Brain lesion - ischaemia, haemorrhage, tumour, trauma, encephalitis, vasculitis, demyelination
        • Spinal cord lesion - infarct, haemorrhage, abscess, transverse myelitis
        • Lower Motor Neuron

        • Nerve root pathology - trauma, radiculopathy, neoplasm
        • Brachial plexopathy - trauma, tumour, brachial neuritis
        • Focal peripheral nerve pathology - trauma, entrapment, focal ischaemia, sarcoidosis, tumour
        • Mononeuritis multiplex - vasculitis, diabetic neuropathy, Lyme disease, leprosy, paraneoplastic, amyloidosis, sarcoidosis
        • Peripheral polyneuropathy - diabetic neuropathy, hypothyroidism, B12 deficiency, alcohol, paraneoplastic, Guillain-Barre, CIDP, Charcot-Marie-Tooth
        • Other

        • Neuromuscular pathology - myasthenia gravis, Lambert Eaton myaesthenic syndrome
        • Muscular pathology - muscular dystrophy, inflammatory myositis, paraneoplastic, thyroid disease, Cushing's, statins, sarcoidosis
        • Poor compliance with examination

        Radial Nerve Palsy

        • Radial Nerve Syndromes

        • Radial neuropathy at the spiral groove
        • Posterior interosseous syndrome - palsy affecting the posterior interosseous nerve, a branch of the radial nerve
        • Crutch palsy - prolonged crutch use resulting in compression of the radial nerve in the axilla
        • Saturday night palsy - compression of the radial nerve during sleep, usually while intoxicated
        • Handcuff neuropathy - radial neuropathy at the wrist

        Abdominal Pulsation

        • Significance

        • Suggestive of abdominal aortic aneurysm, though the normal pulsation of the abdominal aorta may be visible in thin people.

        Overview

        • Causes of Asterixis

        • Bilateral Asterixis

        • Hepatic encephalopathy
        • Uraemia (renal failure)
        • Hypercarbia
        • Medications - clozapine, carbemazepine, valproate, levodopa
        • Unilateral Asterixis

        • CNS lesions - thalamus, midbrain, basal ganglia, frontal lobe
        • Subdural haematoma

        Bronzed Skin

        • Significance

        • An indicator of haemochromatosis, a genetic disorder of iron metabolism resulting in excessive iron deposition.

        Body Mass Index

        BMI =
        WeightHeight²

        Mouth Ulcers

        • Causes of Mouth Ulcers

        • Trauma - mechanical / chemical / radiation
        • Aphthous stomatitis
        • Dermatoses - pemphigus, lichen planus, erythema multiforme
        • Infection - herpes simplex (cold sore), varicella zoster (chickenpox / shingles), coxsackie (hand, foot and mouth), syphilis, bacteria, candidiasis
        • Rheumatological - SLE, Reiter's syndrome
        • GIT - Crohn's / ulcerative colitis, coeliac disease
        • Drugs - antineoplastics
        • Malignancy

        Cervical Lymph Nodes

        Submental nodes - immediately below chinTeeth, oral mucosa, tongue

        Rashes Associated with GI Disease

        Acanthosis nigricans: dark, velvety, nonerythematous lesions on the axillae, antecubital fossae or around the neck.Obesity, T2DM, GIT malignancy

        Haemorrhoids

        • Severity

        • First degree - non-prolapsed
        • Second degree - prolapse and reduce spontaneously
        • Third degree - reduce with manual pressure
        • Fourth degree - unable to be reduced

        Common Signs on the Tongue

        Fissured tongue - deep grooves, especially on the edges of the tongueAcromegaly, psoriasis, Sjogren's

        Flank Tenderness

        • Feel For 

        • Tenderness over the lower back, lateral to the spine on either side.

        Fluid Overload

        • Causes of Fluid Overload

        • Excessive IV fluids
        • Heart failure
        • Renal failure
        • Hepatic cirrhosis
        • SIADH
        • Pregnancy

        The Glasgow Coma Scale (GCS)

        • Interpretation

        • The Glasgow Coma Scale (GCS)

        Rashes Associated with GI Disease

        Acanthosis nigricans: dark, velvety, nonerythematous lesions on the axillae, antecubital fossae or around the neck.Obesity, T2DM, GIT malignancy

        Gingival Bleeding

        • Causes of Gingival Bleeding

        • Trauma - mechanical, chemical, radiation
        • Bleeding disorder - defects of bone marrow / platelets / factors / vitamin K, medications
        • Infection - viral / bacterial / fungal
        • Dermatosis
        • Erythema multiforme
        • Connective tissue disorders - SLE, scurvy
        • Drugs

        Joint Range of Motion

        • Significance

        • May be a sign of an intra-articular bleed.

        Focal Abdominal Tenderness

        Umbilicus - small bowel, aortaPancreatitis, early appendicitis, peptic ulcer, IBD

        Plethora

        Plethora is a change of appearance in the skin due to increased blood flow.

        Koilonychia

        • Significance

        • May be an indicator of iron deficiency anaemia.

        Axillary Lymph Nodes

        Pectoral nodes - anteriorly, behind the pectoralis major muscleAnterolateral chest wall, central / lateral breast

        Overview

        Massive splenomegaly is uncommon and occurs in the setting of CML, myelofibrosis, certain lymphomas, malaria and leichmaniasis.

        Liver Consistency

        • Feel For

        • The consistency of the liver.

        Reduced Joint Range of Motion

        • Significance

        • May be a sign of an intra-articular bleed.

        Cervical Lymph Nodes

        Submental nodes - immediately below the chinTeeth, oral mucosa, tongue

        Abdominal Mass

        Right lumbar - ascending colon, kidneyRenal tumour

        Overview

        • Causes of Abnormal Gait

        • Pain - inflammation, infection, malignancy, trauma
        • Weakness - muscular, neuromuscular or neurological
        • Deformity - arthritis, surgery, shortening post fracture, congenital malformations
        • Instability - peripheral neuropathy, cerebellar or brainstem pathology

        Jerk Nystagmus

        • Interpretation

        • Physiologic nystagmus - a few beats of horisontal nystagmus at the extremes of lateral gaze
        • Positional nystagmus - transient (
        • Upbeat nystagmus - downward slow movements with upward fast movements in primary position
        • Downbeat nystagmus - upward slow movements with downward fast movements

        Romberg Test

        • Abnormal If

        • Loss of balance.

        Blepharospasm

        • Causes of Blepharospasm

        • Benign essential blepharospasm
        • Facial nerve damage
        • Herpes zoster infection
        • Stroke
        • Brainstem trauma

        Murmurs

        • Interpretation of Cardiac Murmurs

        • Systolic

        • Early systolic - ventricular septal defect, mitral regurgitation, tricuspid regurgitation
        • Ejection systolic - aortic or pulmonary stenosis
        • Late systolic - mitral valve prolapse
        • Pansystolic - tricuspid or mitral regurgitation
        • Diastolic

        • Early diastolic - aortic or pulmonary regurgitation
        • Mid-diastolic - mitral stenosis
        • Late diastolic / presystolic - tricuspid stenosis
        • Continuous

        • Patent ductus arteriosus, AV fistula, ruptured sinus of Valsalva aneurysm, aortopulmonary window

        Measuring Blood Pressure

        • How to Measure

        • Place a blood pressure cuff of the correct size around the bulk of the biceps with the artery indicator over the brachial artery.
        • Inflate the cuff until the radial pulse can no longer be palpated, plus a further 30mmHg.
        • Place the diaphragm of the stethoscope over the brachial artery and slowly deflate the cuff (2mmHg/sec)
        • Note when the beating sound is first heard
        • Note when the sound disappears entirely

        Increased Body Temperature

        Increased temperature most often is related to fevers, however it is important to consider non-inflammatory causes of hyperthermia.

        Tachypnoea

        Respiratory rate greater then 20 breathes per minute.

        Overview

        • Causes of Reduced Glasgow Coma Scale

        • Intracranial

        • Haemorrhage - intracerebral, subarachnoid, subdural, extradural
        • Infarction
        • Infection - meningitis, encephalitis, abscess
        • Tumour - mass effect, cerebral oedema
        • Post ictal state
        • Head trauma - vascular, hypoxia, cerebral oedema, parenchymal injury
        • Psychiatric - conversion disorder, depression, catatonia
        • Extracranial

        • Cardiovascular - shock, hypertension
        • Infection - septicaemia
        • Metabolic - hypo/hyperosmolar states, hypo/hyperglycaemia, hypoadrenalism, hypothyroidism, hypopituitarism, electrolyte abnormality, hypercapnia
        • Drugs / toxins - sedatives, analgesics, alcohol
        • Physical injury - hyper / hypothermia, electrocution

        Stridor

        • Causes

        • Soft tissue swelling - peritonsillar abscess, epiglottitis
        • Deformity - laryngomalacia, laryngeal mass / web, tracheomalacia
        • Foreign body aspiration (infants)
        • Laryngotracheobronchitis (croup)
        • Vocal cord lesion / paralysis
        • Psychogenic stridor

        Signs of Peritonism

        • Causes of Peritonism

        • Infection post perforation - appendix, diverticulitis, IBD, perforated ulcer, surgical anastomosis
        • Spontaneous bacterial peritonitis (SBP)
        • Blood - endometriosis, ruptured ovarian cyst, trauma
        • Bile - post-surgical
        • Urine - pelvic trauma
        • Pancreatic fluid - pancreatitis

        Tachycardia

        Heart rate greater than 100 beats per minute.

        Lower Limb Pulses

        Strong femoral, popliteal, posterior tibial and dorsalis pulses are reassuring, while weak or absent lower limb pulses represent vascular compromise that may be limb-threatening if acute.

        Pupillary Light Reflexes

        • Causes of Absent Pupillary Reflexes

        • Intraocular conditions - glaucoma, retinal detachment
        • Optic (II) nerve lesion - trauma, compression, optic neuritis
        • Midbrain lesion - encephalitis, tumour, trauma, haemorrhage, MS, midbrain infarct
        • Oculomotor (III) nerve lesion - trauma, compression, small vessel ischaemia, Guillain barré
        • Medications - sympathomimetic, parasympatholytic (anticholinergics), barbiturates

        Cheyne-Stokes Respiration

        • Significance

        • A poor prognostic sign in patients with heart failure, and a symptom of CNS pathology.

        Measuring Blood Pressure

        • How to Measure

        • Place a blood pressure cuff of the correct size around the bulk of the biceps with the artery indicator over the brachial artery.
        • Inflate the cuff until the radial pulse can no longer be palpated, plus a further 30mmHg.
        • Place the diaphragm of the stethoscope over the brachial artery and slowly deflate the cuff (2mmHg/sec)
        • Note when the beating sound is first heard
        • Note when the sound disappears entirely

        Overview

        • Severity of Restrictive Disease

          Based on TLC:
        • Mild - 70-80% predicted
        • Moderate - 60-70% predicted
        • Moderately severe - 50-60% predicted
        • Severe - <50% predicted
        • Causes of Obstructive Disease

        • COPD
        • Asthma
        • Bronchiectasis
        • Cystic fibrosis
        • Bronchiolitis
        • α1-antitripsin deficiency

        Poor Readings

        • Poor Readings

        The Coagulation Cascade

        The intrinsic pathway is activated primarily by collagen. XIIa and HMW activate factor XI, which then activates factor IX. Factor IXa acts with factor VIII to then activate factor X in the common pathway. Von Willebrand factor is a glycoprotein that stabilises factor VIII in the circulation.

        Hypofibrinogenaemia

        Reduced serum fibrinogen.

        Urine Smell

        Urine smell has historically been useful, however is currently rarely used in clinical practice.

        Neutrophil Physiology

        Neutrophils contain primary and secondary granules. The primary granules are azurophilic (Burgundy-coloured) and contain toxic mediators such as elastase and myeloperoxidase. The secondary granules are pink-staining and contain proteins such as lactoferrin; these are not usually visible by light microscopy.

        Pathogenesis

        Due to the lack of beta chains, there is an increase in haemoglobin A₂ (consisting of two alpha and two delta chains) and haemoglobin F (foetal haemoglobin, consisting of two delta and two gamma chains).

        Microcytosis

        Microcytosis refers to the presence of small red cells with mean corpuscular volume <80 fL.

        Hypochromia

        Reduced red cell haemoglobin (MCH / MCHC), or increased central pallor on blood film.

        Anisocytosis

        • Causes of Anisocytosis

        • Predominantly Microcytic

        • Iron deficiency anaemia
        • Sideroblastic anaemia
        • Predominantly Normocytic

        • Early iron deficiency anaemia
        • Early megaloblastic anaemia
        • Red cell fragmentation
        • Immune haemolysis
        • Sickle cell anaemia
        • Sideroblastic anaemia
        • Blood transfusion
        • Predominantly Macrocytic

        • Megaloblastic anaemia (B12 / folate deficiency, drugs)
        • Myelodysplastic syndrome
        • Chronic liver disease

        Classification

        GenotypePhenotype
        Silent Carrier α α / α -Mild to no anaemia
        Alpha Thalassaemia Minor / Traitα - / α - (cis)
        α α / - - (trans)
        Hypochromic microcytic anaemia
        Haemoglobin H (HbH) Diseaseα - / - -Severe hypochromic microcytic anaemia
        HbH inclusions (supravital staining)
        Hydrops Foetalis- - / - -Fatal in utero

        Diagnosis

        • Test Findings in Anaemia of Chronic Disease

        • Full Blood Count & Film

        • Anaemia - normocytic normochromic, or microcytic hypochromic
        • Evidence of chronic inflammation - rouleaux, thrombocytosis
        • Other Tests

        • Iron studies - reduced serum iron and transferrin; normal or increased ferritin, normal soluble transferrin receptor
        • Inflammatory markers - increased ESR / CRP, reduced albumin

        Pathogenesis

        Haemoglobin S tends to polymerise in low oxygen settings, resulting in sickling of red blood cells; these deformed cells have a shortened lifespan and cause occlusions within blood vessels as well as endothelial dysfunction.

        Overview

        • Causes of Respiratory Acidosis

        • Hypoventilation - drugs, chronic obstructive pulmonary disease, obstructive sleep apnoea, encephalopathy, neuromuscular disease, chest wall abnormalities
        • Dead space ventilation - emphysema

        Lactate Physiology

        • Lactate Physiology

        Physiology

        • Roles

        • Vitamin B12 is required for the action of methionine synthese, which converts homocysteine to the essential amino acid methionine. Methionine is converted to S-adenosyl-methionine, which is involved in methylation of DNA and RNA.

        LDH Isoenzymes

        The isoenzyme electrophoresis pattern is relatively non-specific, though specific patterns of isoenzyme elevation are classically (yet loosely) associated with certain diseases.

        Elevated Aminotransferases

        • Interpretation

        • Mild derangement (<5x normal)Non-alcoholic steatohepatosis, chronic viral hepatitis, liver metastases, drugs
        • Moderate derangement (5-20x normal)Chronic viral hepatitis, alcoholic hepatitis, autoimmune hepatitis
        • Severe derangement (>20x normal)Acute viral hepatitis, drug-induced hepatitis, ischaemic hepatitis

        Overview

        • Causes of Prolonged PT/INR

        • Isolated Prolonged PT/INR

        • Warfarin (low dose)
        • Mild vitamin K deficiency
        • Factor VII deficiency
        • Prolonged PT/INR and APTT

        • Artefactual - high haematocrit
        • Liver disease
        • Disseminated intravascular coagulation (DIC)
        • Common pathway deficiency - X, V, II, fibrinogen
        • Severe vitamin K deficiency
        • High dose heparin
        • Warfarin
        • Factor IIa inhibitors (dabigatran)
        • Factor Xa inhibitors (rivaroxaban, apixaban)

        Cholestatic LFT Derangement

        • Look For

        • Elevated ALP and GGT
        • Mildly elevated ALT / AST
        • Elevated conjugated bilirubin

        Clinical Use

        • Adverse Effects

        • Myalgia
        • Abdominal pain / diarrhea
        • Fatigue
        • Indications

        • Hypertension - first line treatment
        • Stable angina pectoris (amlodipine / nifedipine)

        Overview

        Cardio-selective beta blockers selectively inhibit β1-adrenoceptors (the predominant β receptors in the heart) resulting in negative inotropy, chronotropy, dromotropy and lusiotropy.

        Clinical Use

        Loop and thiazide diuretics allow for increased sodium delivery to the distal convoluted tubule, resulting in stimulation of the aldosterone-sensitive sodium pump that reabsorbs sodium in exchange for potassium. This is the mechanism for the hypokalaemia seen with these diuretics.
        • Adverse Effects

        • Hypokalaemia
        • Hyponatraemia
        • Dehydration / hypovolaemia
        • Hyperuricaemia
        • Muscle cramps
        • Headache
        • Hepatic encephalopathy in patients with liver disease

        Overview

        • Effects

        • Venous dilatation - reduced preload
        • Arterial dilatation - reduced afterload
        • Coronary dilatation - improved myocardial oxygen supply

        Clinical Use

        • Indications

        • Hypertension
        • Angina pectoris
        • Rate control of atrial fibrillation
        • Prophylaxis for paroxysmal supraventricular tachycardia (verapamil)
        • Prevention  of cluster headaches (verapamil)
        • Prophylaxis of migraine (verapamil)
        • Contraindications

        • Prostatic hypertrophy
        • Pyloric obstruction
        • Glaucoma
        • Myaesthenia gravis
        • Indications

        • Prophylaxis of paroxysmal supraventricular tachycardia
        • Acute management of ventricular tachycardia

        Overview

        Due to their lengthening of the refractory period, class III antiarrhythmics are effective at treating re-entrant tachycardias.
        • Effects

        • β1 (Heart) Blockade

        • Reduce contractility (negative inotropy)
        • Reduce heart rate (negative chronotropy)
        • Reduce electrical conduction (negative dromotropy)
        • Reduce cardiac relaxation (negative lusiotropy)
        • β2 (Vascular / Bronchial Smooth Muscle) Blockade

        • Vasoconstriction

        Clinical Use

        • Indications

        • Hypertension (prazosin) - second line therapy, especially indicated for patients with benign prostatic hyperplasia
        • Severe congestive cardiac failure (prazosin)
        • Benign prostatic hyperplasia
        • Renal colic (tamsulosin)
        •  
          Oral
          Perindopril Erbumine
          Aceon 

        Overview

        • Effects

        • Myocardial

        • Reduced contractility (negative inotropy)
        • Sinoatrial & AV Nodes (Phase 0)

        • Reduced heart rate (negative chronotropy)
        • Reduced AV conduction (negative dromotropy)
        • Vascular

        • Vasodilation → reduced peripheral resistance
        Moderate sodium channel blockade, but increase the absolute refractory period (ARP).

        Clinical Use

        • Adverse Effects

          Due to hypermagnesaemia:
        • Drowsiness
        • Muscle weakness / hyporeflexia
        • Vasodilation / hypotension
        • Blurred vision / diplopia
        • Effects

        • Reduce triglycerides by 25-50%
        • Reduce LDL by 5-20%
        • Increase HDL by 10-20%
        • Reduce incidence of coronary artery disease in type II diabetics

        Overview

        • Mechanism of Action

        • Inhibit HMG-CoA reductase, which acts as a catalyst in the production of cholesterol.
        • Mechanism of Action

        • Selectively and competitively inhibit the action of adrenaline and noradrenaline on β1, resulting in suppression of the sympathetic nervous system.
        • Mechanism of Action

        • Competitively inhibit the action of angiotensin II at AT1 receptors.

        Pacemaker Action Potentials

        Action potentials in pacemaker cells of the sinoatrial node are spontaneously generated through opening and closing of sodium, calcium and potassium channels.

        Clinical Use

        • Adverse Effects

        • Gynaecomastia
        • Nausea / vomiting / cramping / diarrhoea
        • Fatigue
        • Hyperkalaemia

        Overview

        • Pharmacology

        • Takes 5-7 days to achieve a therapeutic effect.

        Clinical Use

        • Adverse Effects

        • Arthralgia
        • Elevated LFTs
        • Contraindications

        • Past optic neuritis
        • Inability to report visual symptoms (e.g. young age)
        Standard therapy for tuberculosis involves ethambutol, isoniazid, pyrazinamide and rifampicin given simultaneously.

        Overview

        • Contraindication

        • Acute hepatitis.

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting / diarrhoea
        • Headache / dizziness
        • Vasodilation - flushing, hypotension
        •  
          IV
          Donor Secretor Plasma
          For use prior to bone marrow transplant with major ABO mismatch, in order to reduce the risk of haemolysis and pure red cell aplasia
        • Contraindications

        • Active bleeding
        • Recent GI / urinary bleeding
        • Recent major trauma / surgery
        • Recent ischaemic stroke
        • Intracranial haemorrhage, aneurysm, AVM or neoplasm
        • Current anticoagulant use
        • Pregnancy
        • Adverse Effects

        • Thrombotic events - due to reversal of anticoagulant
        • Infections - urinary tract infections, pneumonia

        Overview

        • Effective Half-Life

        • Subcutaneous - 90 minutes
        • Intravenous - 30 minutes

        Clinical Use

        • Contraindications

        • Active bleeding or risk of major bleeding
        • Use of other anticoagulants
        • Mechanical heart valve
        • Severe renal dysfunction (<25mL/min for apixaban or <30mL/min for rivaroxaban)
        • Severe hepatic disease with coagulopathy
        • Concurrent use of azole antimycotics

        Overview

        • Effective Half-Life

        • 4 hours.

        Clinical Use

        • Indications

        • ST elevation myocardial infarction, within 12 hours of onset of chest pain
        • Acute ischaemic stroke, within 4.5 hours of onset of symptoms (alteplase)
        • Pulmonary embolism with haemodynamic compromise (alteplase)
        • Adverse Effects

        • Nausea / vomiting / diarrhoea
        • Change in colour vision
        • Adverse Effects

        • Bradycardia
        • Hypotension
        • Dypnoea
        • Nausea / vomiting
        • Contraindications

        • Active thrombosis
        • Disseminated intravascular coagulation
        • Contraindications

        • Active bleeding, or high risk of bleeding (risk / benefit analysis)
        • Cancer-associated venous thromboembolism (enoxaparin / factor Xa inhibitors are superior)
        • Pregnancy
        • Indications

        • Acute coronary syndrome (in conjunction with aspirin)
        • Prevention of in-stent thrombosis following percutaneous coronary intervention
        • Prevention of vascular ischaemia following stroke, MI or peripheral vascular disease (clopidogrel)
        • Adverse Effects

        • Haemorrhage
        • Oesophageal ulceration
        • Indications

        • Prophylaxis - of acute coronary or cerebrovascular events in patients with known cardiovascular or cerebrovascular disease
        • Pain - including migraine and musculoskeletal injury
        • Fever
        • Inflammation - especially associated with arthritides
        • Indications

        • Prevention of cardiac ischaemia post percutaneous coronary intervention (abciximab / eptifibatide + aspirin + heparin)
        • Acute coronary syndrome (tirofiban)
        • Contraindication

        • Left ventricular dysfunction, as evidenced by an LVEF <45%, or symptomatic heart failure (trastuzumab).

        Substem A (Target)

        -f(u): fungal (e.g. efungumab)

        Overview

        PD-L2 is not inhibited, allowing PD-1 / PD-L2 mediated inhibitory signals to continue

        Clinical Use

        • Contraindications

        • May not be used in the presence of RAS or BRAF mutations (must be wild type).
        • Adverse Effects

        • Immune-Related

        • Endocrinopathies - hypopituitarism, hypothyroidism, adrenal insufficiency
        • GI toxicity - colitis
        • Hepatotoxicity - LFT derangement
        • Skin - rash / pruritis
        • Other

        • Nausea / vomiting / diarrhoea
        • Fatigue
        • Headache
        • Tremor
        • Cough
        • Adverse Effects

        • Immune-Related

        • Endocrinopathies - thyroiditis, adrenalitis, hypophysitis, diabetes mellitus
        • Pulmonary toxicity - pneumonitis
        • Hepatotoxicity - hepatitis, LFT derangement
        • GI toxicity - colitis
        • Rheumatological - flares of previous disease, PMR, arthralgias / myalgias
        • Skin - maculopapular rash, Stevens-Johnson syndrome, Sweet syndrome
        • Other

        • Fatigue
        • Anorexia
        • Headache
        • Dizziness
        • Peripheral neuropathy
        • Nausea / vomiting / diarrhoea
        • Neutropaenia
        • Infections (particularly upper respiratory tract infection)

        Overview

        • Mechanism of Action

        • Inhibit fungal synthesis of ergosterol, an element of the fungal cell membrane.
        • Microbiology

        • Effective against Candida, Cryptococcus and Aspergillus.

        Clinical Use

        • Indications

        • Febrile neutropaenia with suspected fungal source
        • Invasive candidiasis
        • Refractory invasive aspergillosis
        • Indication

        • Endocrine therapy for ER positive breast cancer.

        Overview

        • Pharmacology

        •  Interact only with androgen receptors, producing no progestin or glucocorticoid effects.

        Clinical Use

        • Adverse Effects

        • Fatigue
        • Weight gain
        • Nausea / vomiting / diarrhoea
        • Gynaecomastia / breast tenderness
        • Hot flushes
        • Dizziness
        • Elevated LFTs
        • Osteoporosis (long-term)
        • Adverse Effects

        • Hot flushes
        • Fatigue
        • Mood changes
        • Decreased libido / erectile dysfunction
        • Gynaecomastia / breast tenderness
        • Osteoporosis

        Overview

        • Mechanism of Action

        • Not clearly defined. Alter the configuration of cell membrane ion channels, reducing the rate of firing of action potentials and resulting in CNS depression.

        Clinical Use

        • Contraindications

        • Severe cardiovascular disease - heart failure, poorly controlled hypertension, recent MI
        • Past stroke / brain tumour / intracerebral haemorrhage
        • Indications

        • Procedural anaesthesia - local anaesthesia, nerve block or epidural block
        • Analgesia - local anaesthesia or epidural block
        •  
          IV
          Vecuronium
          6-8x more potent than rocuronium
          Onset 3 minutes
          Duration 30 minutes
        • Indication

        • Relaxation of skeletal muscle for periods of brief anaesthesia such as for:
        • Endotracheal intubation
        • Endoscopy
        • Orthopaedic manipulation
        • Short surgical procedures
        • Electroconvulsive therapy
        • Adverse Effects

        • Hypotension (20-30% decrease)
        • Bradycardia
        • Involuntary movements
        • Apnoea
        • Reduced intracranial pressure
        • Propofol infusion syndrome - bradycardia, metabolic acidosis, rhabdomyolysis, hyperlipidaemia
        • Adverse Effects

        • Hypercalcaemia
        • Headache
        • Nausea / abdominal pain
        • Rash
        • Contraindications

        • Heart failure (past or present)
        • Insulin
        • Contraindication

        • Renal failure with eGFR <30mL/min.

        Overview

        • Pharmacology

        • Onset 1-3 hours
        • No peak
        • Duration 24 hours (Lantus)
        • Tend to suppress hepatic gluconeogenesis, preventing hyperglycaemia in fasting conditions
        • Prevent ketogenesis

        Clinical Use

        • Contraindications

        • Paget's disease of bone
        • Hypercalcaemia
        • Malignancy
        • Renal disease

        Overview

        • Non-Inflammatory Effects of Corticosteroids

        • Increased circulating glucose - ↑gluconeogenesis, ↓glucose usage
        • Redistribution of fats - in face, neck, shoulder
        • ↓ Absorption of Ca²⁺
        • Muscle homeostasis

        Clinical Use

        • Adverse Effects

        • Rash
        • Neutropaenia / thrombocytopaenia
        • Foetal abnormalities
        • Cholestatic LFT derangement

        Overview

        These hormones normally have a short half-life as they are degraded by the enzyme dipeptidyl peptidase-4 (DPP-4).
        •  
          Oral
          Alogliptin
          Nesina 
           
          Reduce dose in renal insufficiency
        • Pharmacology

        • Onset 15 minutes
        • Peak effect 1-3 hours
        • Duration 3-5 hours

        Clinical Use

        • Adverse Effects

        • Headache
        • Nausea / vomiting / diarrhea
        • Myocardial infarction
        • DVT / PE

        Overview

        • Management Options

        • Type I Diabetes

        • Basal-bolus insulin - once or twice daily intermediate / long-acting insulin, with short / very short-acting insulin before meals.
        • Insulin pump - continuous basal insulin infusion with programmable boluses.
        • Type II Diabetes

        • Basal insulin - once daily intermediate / long-acting insulin, in combination with an oral hypoglycaemic.
        • Basal-bolus insulin - once or twice daily intermediate / long-acting insulin, with short / very short-acting insulin before meals.
        • Mixed insulin - twice daily combination of a short / very short-acting insulin and an intermediate insulin.
        • Mechanism of Action

        • Insulin is an hormone normally produced by pancreatic beta cells that is responsible for regulation of glucose, fat and protein metabolism.

        Clinical Use

        • Indication

        • Generally used as part of a combination insulin formulation.
        • Adverse Effects

        • Genitourinary infections (due to glycosuria)
        • Polyuria
        • Adverse Effects

        • URTI
        • Nausea / vomiting
        • Hot flushes
        • Arthralgia / myalgia
        • DVT / PE
        • Indications

        • Bolus dosing for type I or II diabetes
        • Insulin infusion for perioperative hyperglycaemic management
        • Insulin infusion for diabetic ketoacidosis
        • Severe hyperkalaemia
        • Indication

        • Second line agent for glycaemic control in type II diabetes.

        Overview

        • Mechanism of Action

        • Structural analogues of pyrophosphate that bind to the resorptive surface of osteoclasts and are internalised. Disruption of key regulatory proteins results in inhibition of osteoclastic function and reduction in bone resorption.

        Clinical Use

        • Indication

        • Influenza A prophylaxis.
        • Adverse Effects

        • Headache
        • Nausea / vomiting
        • Rash
        Multiple agents are used at once - usually two NRTIs + one NNRTI / PI / integrase inhibitor.
        • Adverse Effects

        • Rash
        • Headache
        • Nausea / vomiting / diarrhoea
        • Neutropaenia / anaemia
        •  
          Oral
          Zidovudine

        • Adverse Effects

        • Rash
        • Headache
        • Nausea / vomiting / diarrhoea
        • Neutropaenia
        •  
          Oral
          Valganciclovir

        Multiple agents are used at once - two NRTIs + one NNRTI / PI / integrase inhibitor.
        • Adverse Effects

        • Nausea / vomiting
        • Headache
        Treatment must be commenced within 48 hours of symptom onset, and has been shown in a Cochrane review to reduce duration of symptoms by 0.4 - 0.9 days.
        •  
          Oral
          Nitrazepam
          Mogadon, Alodorm 
           
          Used for insomnia
          [Peak] 2 hours
          Half-life 16-48 hours
        • Indications

        • Acute anxiety
        • Withdrawal - from alcohol, benzodiazepines, opioids
        • Status epilepticus
        •  
          Oral
          Paroxetine
          Aropax, Paxil 
        • Indications

        • Tranquilization - in the acute psychiatric setting
        • Status epilepticus
        • Sedation - for short surgical procedures or intensive care
        • Adverse Effects

        • Increased appetite
        • Weight gain
        • Drowsiness
        • Dry mouth
        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • CNS disturbances - drowsiness, tremor
        • Thrombocytopaenia
        • Alopecia
        • Weight gain

        Overview

        • Mechanism of Action

        • Inhibit dopamine D2 receptors, resulting in reduced dopaminergic transmission within the four dopaminergic pathways. Also inhibit serotonin (5-HT), muscarinic and α1-adrenergic receptors.

        Clinical Use

        • Contraindication

        • Not for concurrent use with monoamine oxidase inhibitors (MAOi).
        • Contraindication

        • Not for concurrent use with selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs).
        •  
          Oral / IM
          Paliperidone
          Invega 
           
          Available as depot - monthly dosing for schizophrenia
        • Indications

        • Depression
        • Generalised anxiety disorder (duloxetine / venlafaxine)
        • Panic disorder (venlafaxine)
        • Indication

        • Uncomplicated symptomatic urinary tract infection.
        • Indications

        • Otitis media
        • Lower respiratory tract infection
        • Genitourinary tract infections
        • Gastrointestinal infections
        • Skin / wound infections
        • Adverse Effects

        • Disulfuram-like effect (severe 'hangover' with alcohol)
        • Nausea, vomiting
        • Headache

        Overview

        • Resistance

        • Broken down by beta lactamase enzymes produced by some bacteria. MRSA is resistant due to alterations in penicillin-binding peptides.
        • Microbiology

        • A wide spectrum of activity against gram positives, atypical respiratory organisms (Legionella, Chlamydia, Mycoplasma) and Bordatella pertussis (whooping cough)

        Clinical Use

        • Indications

        • Proven MRSA
        • Life-threatening staphylococcal infections
        • Enterococcal endocarditis
        • Indications

          Severe gram positive infections:
        • Upper / lower respiratory tract infections
        • Skin infections
        • Osteomyelitis / septic arthritis
        • Septicaemia
        • Adverse Effects

        • Bone marrow suppression
        • LFT derangement
        • Abnormal taste
        • Nausea / vomiting / diarrhoea
        • Headache

        Overview

        • Microbiology

        • Active against gram positive cocci (streptococci and staphylococci) as well as some gram negative bacilli - Haemophilus influenzae, Enterobacter, Neisseria, Proteus, E coli, Klebsiella and Serratia.

        Clinical Use

        • Indications

        • Methicillin-resistant Staphylococcus aureus (MRSA)
        • Mycobacteria - tuberculosis, Mycobacterium avium complex (MAC), leprosy

        Overview

        • Resistance

        • Broken down by beta lactamase enzymes produced by some bacteria.

        Clinical Use

        • Indications

        • Febrile neutropaenia
        • Hospital-acquired pneumonia

        Overview

        • Resistance

        • Broken down by beta lactamase enzymes produced by some bacteria.
        • Pharmacology

        • Combination penicillins contain both a broad spectrum penicillin and a beta lactamase inhibitor (clavulanate or tazobactam), which have no intrinsic antimicrobial activity but prevent breakdown of beta lactam by the beta lactamase enzyme.

        Clinical Use

        • Indications

        • Hospital-acquired pneumonia
        • Complicated UTI
        • Intra-abdominal infections (peritonitis)
        • Complicated skin/bone/soft tissue infections
        • Meningitis
        • Septicaemia
        • Febrile neutropaenia
        • Bacterial endocarditis

        Overview

        • Microbiology

        • More active than narrow spectrum penicillins against certain gram negatives, such as E coli and Haemophilus influenzae.

        Clinical Use

        • Adverse Effects

        • Oesophagitis
        • Photosensitivity
        • Tooth discolouration
        • Nausea / vomiting / diarrhoea
        • Pseudomembranous colitis (C difficile)

        Overview

        • Microbiology

        • Broad spectrum of activity against most gram negatives including Pseudomonas

        Diagnosis

        May be associated with left axis deviation, ST / T wave changes in the opposite direction to the QRS complex, or poor R wave progression.

        Classification

        GenotypePhenotype
        Silent Carrier α α / α -Mild to no anaemia
        Alpha Thalassaemia Minor / Traitα - / α - (cis)
        α α / - - (trans)
        Hypochromic microcytic anaemia
        Haemoglobin H (HbH) Diseaseα - / - -Severe hypochromic microcytic anaemia
        HbH inclusions (supravital staining)
        Hydrops Foetalis- - / - -Fatal in utero

        Manifestations

        • Complications of Hypertension

        • Cardiovascular - left ventricular hypertrophy, heart failure, ischaemic heart disease, peripheral vascular disease, arrhythmia
        • Cerebrovascular - ischaemic stroke, haemorrhagic stroke, posterior reversible encephalopathy syndrome
        • Hypertensive retinopathy
        • Hypertensive nephropathy
        • Erectile dysfunction
        • Complications of Heart Failure

        • Arrhythmias - atrial fibrillation, ventricular arrhythmias
        • Stroke
        • Sarcopaenia
        • Left Heart Failure

        • Pulmonary oedema
        • Pulmonary hypertension
        • Right Heart Failure

        • Ascites
        • Peripheral oedema
        • Cardiac cirrhosis
        • Complications of Atrial Fibrillation

        • Thromboembolic stroke
        • Heart failure
        • Syncope

        Management

        • Management Options

        • Non-Pharmacologic

        • Dietary changes
        • Fish oil supplementation
        • Exercise
        • Alcohol avoidance
        • Smoking cessation
        • Pharmacologic

        • Statins - atorvastatin, pravastatin, rosuvastatin, simvastatin
        • Fibrates - fenofibrate, gemfibrozil
        • Ezetimibe
        • PCSK-9 inhibitors - alirocumab

        History of Presenting Complaint

        • Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
        • Site - localised or generalised; unilateral or bilateral
        • Onset - sudden or gradual, and what the situation was (e.g. following trauma)
        • Character - sharp, dull, burning or pressure-like
        • Radiation - e.g. down the arm or across the back
        • Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
        • Timing - duration of symptoms, frequency of episodes, changes through the day
        • Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
        • Severity - on a scale of 1 to 10, with 10 being the worst
        • Handedness

        • Ask the patient if they are left or right-handed. This is an indicator of the dominant hemisphere (usually contralateral to the dominant hand).
        When asking for more information about a patient's symptoms, start by asking general questions such as "could you please tell me more about that", and then narrow down the questions as more information is provided.
        • Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
        • Site - localised or generalised; unilateral or bilateral
        • Onset - sudden or gradual, and what the situation was (e.g. following trauma)
        • Character - sharp, dull, burning or pressure-like
        • Radiation - e.g. down the arm or across the back
        • Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
        • Timing - duration of symptoms, frequency of episodes, changes through the day
        • Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
        • Severity - on a scale of 1 to 10, with 10 being the worst
        • Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
        • Site - localised or generalised; unilateral or bilateral
        • Onset - sudden or gradual, and what the situation was (e.g. following trauma)
        • Character - sharp, dull, burning or pressure-like
        • Radiation - e.g. down the arm or across the back
        • Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
        • Timing - duration of symptoms, frequency of episodes, changes through the day
        • Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
        • Severity - on a scale of 1 to 10, with 10 being the worst
        • Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
        • Site - localised or generalised; unilateral or bilateral
        • Onset - sudden or gradual, and what the situation was (e.g. following trauma)
        • Character - sharp, dull, burning or pressure-like
        • Radiation - e.g. down the arm or across the back
        • Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
        • Timing - duration of symptoms, frequency of episodes, changes through the day
        • Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
        • Severity - on a scale of 1 to 10, with 10 being the worst

        The Patient

        Look at the patient, assessing for general comfort, any scars present around the face, and their general posture.

        First Steps

        Position the patient correctly, with the bed angled at 45 degrees. Ensure that the bed is at a comfortable height in order to avoid an awkward examination.

        Inspection

        Urine is normally clear and pale yellow.

        Red Cell Count & Haemoglobin

        Ref Interval (Males)Ref Interval (Females)
        Hb130 - 180 g/L115 - 165 g/L
        Hct / PCV40 - 54%36 - 44%

        Assessing Oxygenation

        • Arterial Partial Pressure of Oxygen (PaO₂)

        • The PaO₂ is the partial pressure of oxygen dissolved in plasma. This is a marker of the amount of oxygen available to be delivered to tissues.

        First Steps

        Look at what projections have been taken. Aim to get at least two views for any fracture film - e.g. AP, lateral or oblique.

        Causes of Haemolysis

        • Causes of Haemolysis

        • Immune

        • Warm autoimmune haemolytic anaemia - idiopathic, lymphoproliferative disorders, infection, autoimmune disorders, methyldopa, penicillins, cephalosporins, rifampicin, quinine, paracetamol, ibuprofen
        • Cold agglutinin haemolysis - idiopathic, mycoplasma pneumoniae, EBV, lymphoma, paroxysmal cold haemoglobinuria
        • Alloimmune haemolysis - transfusion of mismatched red blood cells, haemolytic disease of the newborn, post stem cell transplant
        • Drug-induced haemolysis
        • Red Cell Fragmentation

        • Microangiopathic haemolytic anaemia - TTP, HUS, DIC, preeclampsia / HELLP, SLE, malignant hypertension, brown snake bite
        • Mechanical haemolysis - valvular leaks, cardiac prostheses, renal replacement, ECMO, march haemoglobinuria
        • Inherited Intrinsic RBC Disorders

        • Enzymopathies - G6PD deficiency, pyruvate kinase deficiency
        • Membranopathies - hereditary spherocytosis
        • Haemoglobinopathies - sickle cell disease, thalassaemias
        • Other

        • Infection - severe sepsis, malaria, babeosis, Clostridium toxin, Meningococcus
        • Hypersplenism
        • Heavy metals - copper (Wilson's disease), lead
        • Paroxysmal nocturnal haemoglobinuria
        • Hypophosphataemia

        Measures of Iron Status

        • Serum Iron

        • Total serum iron is a measure of the ferric (Fe3+) ions bound to serum transferrin. There is significant variation of iron levels with due to multiple factors, and therefore the serum iron is a poor marker of iron status.

        Pathogenesis

        The acute phase response is predominantly mediated by the pro-inflammatory cytokines tumour necrosis factor (TNF), interleukin 1 (IL-1) and interleukin 6 (IL-6) secreted by macrophages and other immune cells.

        Squamous Epithelial Cells

        SECs seen in urine originate from the urethral wall. If these are present in urine then this suggests a contaminated, non-midstream urine sample that likely also contains urethral normal flora.

        Identifying a Vein

        • Tips for Choosing a Vein

        • Do

        • Use the nondominant arm if possible
        • Try to use the antecubital fossa where possible
        • Don't

        • Absolutely do not use the same arm as an AV fistula
        • Don't use the same arm as a past lymph node dissection or mastectomy
        • Don't use a limb affected by stroke
        • Don't insert a needle through a burn, oedema, haematoma or infected tissue
        • If testing coags, do not take from the same limb as a heparin infusion
        • If an infusion is running, either stop the infusion prior to taking the sample or use another limb

        Overview

        • Monitoring

        • Oxygen saturations should be used to guide supplemental oxygen administration. The target oxygen saturation for most patients should be 92-96%, while in patients with chronic respiratory failure this target should be 88-92%.

        Equipment and Preparation

        • Positioning the Patient

          Raise the bed to waist level to allow for comfortable collection; the position of the patient depends on the artery to be used. 
        • Radial artery - ask the patient to place their arm outward with palm up, wrist extended slightly
        • Brachial- ask the patient to place their arm outward as far as possible with the antecubital fossa easily accessible
        • Femoral - ensure privacy, then expose the femoral triangle

        Overview

        Urinary catherisation is not always appropriate - particularly given the risk of infection while a catheter is in situ. Catheters should not be used to control urinary incontinence, or manage confused patients. Prolonged bed rest is also not an indication for insertion. While catheters are often inserted to allow measuring of urine output, this is generally not required and in fact invasive then hourly urine output measuring is not required.

        Equipment and Preparation

        • The equipment required for inserting a cannula includes:

        Airway Patency

        • Causes of Upper Airway Obstruction
        • Soft tissue swelling - anaphylaxis, burns, peritonsillar abscess, epiglottitis, laryngotracheobronchitis (croup)
        • Foreign body aspiration
        • Deformity - laryngomalacia, laryngeal mass / web, tracheomalacia
        • Tongue enlargement / displacement
        • Vocal cord lesion / paralysis

        Overview

        • Approach

        • Check the anion gap to further distinguish between causes.
        The expected value for the gap-gap ratio (assuming a HAGMA) is 1.
        Na⁺ + unmeasured cations = HCO₃⁻ + Cl⁻ + unmeasured anions

        Oxygen Dissociation Curve

        • Oxygen Dissociation Curve

        Overview

        • Left-sided pleural effusion with evidence of volume loss
        • No Overlay
          Overlay
          Left-sided pleural effusion with evidence of volume loss
           

        Pacemaker

        • Examples

        Overview

        • Upper lobe venous diversion
        • Upper lobe venous diversion
           

        Dextrocardia

        • No Overlay
          Overlay
          Dextrocardia
           

        Posterior-Anterior (PA)

        • Example

        • A PA film - note the normal mediastinal size.
        • A PA film - note the normal mediastinal size.
           

        Overview

        • Left lower zone pneumonia
        • Left lower zone pneumonia
           

        Exposure

        Underpenetration occurs when not enough x-rays pass through the body. This results in an overly dense x-ray, with no structures visible behind the cardiac silhouette.

        Overview

        • A chest drain within a right pneumothorax
        • No Overlay
          Overlay
          A chest drain within a right pneumothorax
           

        Central Venous Catheters (CVCs)

        • Indications for Central Venous Catheter

        • Administration of certain medications - high-dose potassium, vasopressors, TPN, certain chemotherapy
        • Haemodynamic monitoring - central venous pressure
        • Large transfusion requirement

        Supine Film

        A supine film is performed with the patient lying down. This will result in a wider mediastinum and smaller lung fields. Detection of pleural effusion and pneumothorax will be more difficult with supine films.

        Overview

        • Large right-sided pneumothorax
        • No Overlay
          Overlay
          Large right-sided pneumothorax
           

        Extra Cervical Rib

        An extra cervical rib is a rare phenomenon where an extra rib arises from the C7 vertebra, usually bilaterally. This may be benign or cause vascular complications such as subclavian artery compression and thoracic outlet obstruction.

        Silhouette Signs

        • Obscuration of the right hemidiaphragm suggesting right lower lobe consolidation
        • Obscuration of the right hemidiaphragm suggesting right lower lobe consolidation
           

        Overview

        • Large right-sided pleural effusion
        • Large right-sided pleural effusion
           
        • Risk Factors for Emphysema

        • Smoking
        • Occupational exposure - coal, toluene (plastics)
        • Environmental air pollution
        • Alpha-1 antitrypsin deficiency

        White Blood Cells

          • Normal Range

          • <250 polymorphonuclear cells/μL

        Overview

        • Intake

        • Dietary sodium comes from many different sources. Average dietary salt intake is much higher than recommended levels for most western people.

        2nd Degree SA Exit Block: Type I

        Type I second degree sinoatrial exit block occurs when there is progressively delayed SA transmission eventually resulting in a missed P wave due to failure of conduction to the atrial myocardium.

        1st Degree AV Block

        • Look For

        • Prolonged PR interval >200ms (5mm).

        Overview

        • Causes of Slowed Ventricular Response

        • Complete heart block
        • Drugs - beta blockers, calcium channel blockers, digoxin
        • Ventricular escape in the setting of complete AV block:
        • Ventricular escape in the setting of complete AV block
           

        Inclusion Bodies

        Stainable material within red blood cells, mainly due to retained remnants of cellular components.

        Reduced Reticulocytes

        Examination of multiple fields may be required to diagnose a low reticulocyte count.

        Aetiology

        Iron loading anaemias such as sideroblastic anaemia, thalassaemia and congenital dyserythropoietic anaemia tend to cause significant anaemia with clinical iron overload, even in the absence of frequent blood transfusions.

        Iron Transport

        Once in plasma, iron is oxidised by hephaestin and then bound to transferrin, which transports iron in the blood. Transferrin enters cells (mainly red blood cells, hepatic and immune cells) via receptor-mediated endocytosis through binding to transferrin receptors (TfR).

        Diagnosis

        • Test Findings in Iron Deficiency

        • Full Blood Count & Film

        • Microcytic, hypochromic anaemia
        • Anisocytosis: variation in red cell size
        • Elliptocytosis: oval-shaped or pencil-shaped cells
        • Target cells: dark central discolouration of cells
        • Thrombocytosis: increased platelet count
        • Iron Studies

        • Reduced ferritin
        • Increased serum transferrin with reduced transferrin saturation
        • Increased soluble transferrin receptor

        Activated Monocytes

        Monocytes may become activated in the context of infection, inflammation or recovery from bone marrow suppression.

        Eosinophilia

        • Causes of Eosinophilia

        • Allergy - asthma, allergic rhinitis, chronic sinusitis, atopic dermatitis, drug allergy, eosinophilic oesophagitis, allergic bronchopulmonary aspergillosis (ABPA), chronic eosinophilic pneumonia
        • Parasites - helminths (especially Strongyloides), protozoa
        • Autoimmune - eosinophilic granulomatosis with polyangiitis (Churg-Strauss), other autoimmune diseases (rarely)
        • Malignancy - chronic eosinophilic leukaemia, lymphoma, certain solid organ malignancies
        • Primary eosinophilia

        Microcytosis

        • Microcytosis
           

        Overview

        • Examples

        • Target cells:
        • Target cells
           

        Neutrophil Physiology

        • The Neutrophil Life Cycle

        • Neutrophils are of granulocyte origin. They mature in the bone marrow and are then released into blood and tissues. Neutrophil proliferation and maturation is stimulated by granulocyte colony stimulating factor (G-CSF).

        Thrombocytosis

        • Causes of Thrombocytosis

        • Primary

        • Myeloproliferative neoplasms - essential thrombocythaemia, polycythaemia vera, chronic myeloid leukaemia, myelofibrosis
        • Secondary

        • Infection
        • Inflammation - autoimmune disease, major surgery, trauma, fracture, burns, pancreatitis, infarction
        • Malignancy
        • Post splenectomy
        • Iron deficiency anaemia
        • Acute haemorrhage
        • Acute haemolysis
        • Drugs - adrenaline, corticosteroids, vinca alkaloids, thrombopoietin

        Lymphopaenia

        Lymphopaenia is a reduction in circulating lymphocytes. This may be reactive, reflect immunodeficiency or occur secondary to drugs.

        Left Shift of Granulocytes

        This may be physiologic in response to a stress on the body such as pregnancy, infection or inflammation; it may occur with administration of granulocyte colony stimulating factor (G-CSF); or it may be a sign of bone marrow infiltration.

        Overview

        • Causes of Nucleated Red Blood Cells

        • Increased Erythropoiesis

        • Severe anaemia
        • Severe sepsis
        • Hypoxia
        • Pregnancy
        • Bone Marrow Infiltration

        • Myeloproliferative neoplasms
        • Leukaemias
        • Lymphoma
        • Myeloma
        • Metastatic cancer
        • Examples

        Myelodysplasia may be seen in the context of myelodysplastic syndromes (MDS), where clonal expansion of mutated stem cells results in ineffective haematopoiesis. This condition is at risk of transforming to acute myeloid leukaemia (AML).
        • Examples

        Basophilia

        • Causes of Basophilia

        • Viral infection
        • Allergies - asthma, atopic dermatitis, allergic rhinitis
        • Inflammation - autoimmune disease, graft vs host disease
        • Myeloproliferative neoplasms - CML, polycythaemia vera, myelofibrosis
        • Hodgkin lymphoma

        Overview

        Thyroxine (T4) is produced by the thyroid gland in response to the stimulating effect of TSH. Thyroxine is transported in plasma in either its free form or bound to protein. Thyroxine is converted to T3 and reverse T3 (rT3) in both the circulation and in tissues.
        • Interpretation

        • Reduced TSH - suggestive of primary hyperthyroidism
        • Elevated TSH - suggestive of primary hypothyroidism

        Primary Hypothyroidism

        • Look For

        • Elevated TSH with reduced T4.

        Hormonal Changes

        In mild nonthyroidal illness reduced deiodination of T4 to T3 results in elevated T4 and reduced T3. TSH may initially be normal or elevated due to lack of T3.

        Suppressed TSH with Elevated T4

        • Causes of Primary Hyperthyroidism

        • Grave's disease
        • Toxic multinodular goitre
        • Toxic nodule
        • Thyroiditis - postviral, postpartum, lymphocytic
        • Thyroxine - excess replacement, thyrotoxicosis factitia
        • Drugs - amiodarone, iodine
        • Pregnancy-related - hyperemesis gravidarum, hydatidiform mole
        • Struma ovarii
        • Congenital hyperthyroidism

        Primary Hyperthyroidism

        Hyperthyroidism that originates from thyroid tissue.

        Hyperferritinaemia

        • Causes of Hyperferritinaemia

        • Acute phase response - infection / inflammation / malignancy
        • Liver disease
        • Iron overload
        • Haemophagocytic lymphohystiocytosis

        Overview

        • Causes of Hypoalbuminaemia

        • Reduced synthesis - malnutrition, malabsorption, liver disease
        • Increased breakdown - infection, inflammation, malignancy, hyperthyroidism
        • Increased loss - nephrotic syndrome, protein-losing enteropathy, severe burns
        • Dilutional
        • Causes of Hyperfibrinogenaemia

        • Physiological in elderly patients
        • Acute phase reactant - infection, inflammation, malignancy
        • Pregnancy

        Manifestations

        • Acute Phase Reactants

        • Positive Acute Phase Reactants (increase)

        • C-reactive protein (CRP)
        • Fibrinogen
        • Ferritin
        • Hepcidin
        • Haptoglobin
        • Caeruloplasmin
        • Complement proteins C3 / C4
        • Serum amyloid A (not measured)
        • Negative Acute Phase Reactants (decrease)

        • Serum albumin
        • Transferrin
        • Alpha-foetoprotein

        Quadrant Method

        • Quadrant Method

        Measuring the QT Interval

        • Measuring the QT Interval

        Sinoatrial Rhythm

        • Causes of Irregular Atrial Rhythm

        • Sinus Node

        • Sinus arrhythmia
        • Sinus pause
        • Second degree sinoatrial exit block
        • Atrium

        • Premature atrial complexes
        • Multifocal atria tachycardia

        Chest Electrode Placement

        • Chest Electrode Placement

        Overview

        If the rhythm is irregular, the average R-R interval can be used to calculate the rate.

        ECG Leads

        A standard 12-lead ECG includes bipolar limb leads, unipolar limb leads and chest leads.

        Monomorphic Ventricular Tachycardia

        To find out how to distinguish VT from SVT with aberrancy, read the section called 'distinguishing VT and SVT with aberrancy'.

        Overview

        To find out how to distinguish SVT with aberrancy from VT, read the section called 'distinguishing VT and SVT with aberrancy'.

        Distinguishing Between VT and SVT with Aberrancy

        • Factors favouring VT over SVT with Aberrancy

        • Patient History

        • Structural heart disease (95% of wide complex tachycardias in patients with heart disease will be VT)
        • Normal baseline ECG - no bundle branch block or preexcitation
        • ECG Findings

        • Extreme axis deviation (-90 to 180°)
        • Atypical LBBB or RBBB morphology
        • QRS duration >140 with RBBB pattern or >160 with LBBB pattern
        • AV dissociation - visible, regular P waves (Almost 100% specific for VT)
        • Positive or negative concordance - precordial leads all positive or all negative
        • RS interval >100ms in precordial leads - from onset of R wave to deepest point of S wave
        • R wave peak time >50ms in lead II - from isoelectric line to peak of R wave
        • Onset and Offset

        • Wide complex tachycardia initiated by a ventricular complex
        • Fusion beats: a hybrid between a normal QRS complex and a ventricular ectopic
        • Capture beats: a normal, narrow QRS complex produced during due to a conducted atrial beat

        Overview

        • Atrial flutter with 3:1 block:
        • Atrial flutter with 31 block
           
        In orthodromic AVRT, a premature atrial impulse is conducted by the AV node and then is propagated retrogradely up the abnormal accessory pathway, commencing a re-rentry circuit.
        • Mechanism

        • Atrial fibrillation occurs due rapid impulse generation by an ectopic atrial focus, most commonly adjacent to or within the pulmonary vein orifices. Once atrial fibrillation has commenced it is maintained by abnormalities within atrial tissue, such as atrial remodelling.
        In AVNRT, an atrial impulse is conducted by one pathway and then hits the other pathway when it is outside its refractory period, propagating up the other pathway and creating a re-entry circuit.
        The elements of the complement pathway are present between the beta and gamma bands.
        There is normally no monoclonal protein (paraprotein) present in serum. If there is a paraprotein present at a level that is quantifiable, a measure of the amount of paraprotein will be provided. This is important in the diagnosis of MGUS (<30g/L) and smouldering myeloma (>30g/L), as well as for estimating risk of progression to multiple myeloma.

        MDRD Formula

        • Formula

        • eGFR = 186.3 × Creatinine-1.154 × Age-0.203 ( × 0.742 if female) ( × 1.212 if African origin)

        Overview

        • Clinical Criteria for Diagnosis

          At least one of:
        • Documented VT / VF
        • FHx sudden cardiac death <45 years
        • Coved ECGs in family members
        • Inducibility of VT with programmed electrical stimulation
        • Syncope
        • Nocturnal agonal respiration
        • The first ECG finding in acute myocardial infarction is hyperacute T waves, which are tall and symetrical and occur within the first few minutes. 
        • The first ECG finding in acute myocardial infarction is hyperacute T waves, which are tall and symetrical and occur within the first few minutes. 
           
        Severe hypercalcaemia may produce ST elevation and T wave inversion that mimics an acute myocardial infarction.
        • Examples

        • T wave inversion
        • T wave inversion
           
        •  
        • Stages of ECG Findings in Pericarditis

        • Stage I - widespread concave ST elevation
        • Stage II - resolution of ST elevation, T wave flattening
        • Stage III - T wave inversion
        • Stage IV - resolution of T wave inversion
        ECG changes are not typically seen until the potassium concentration is <3.0.
        •  
        •  
        • Common Sodium Channel Blockers

        • Class Ia/Ic antiarrhythmics - quinidine, procainamide, flecainide
        • Tricyclic antidepressants - amitryptiline, nortriptyline
        • Local anaesthetics - bupivacaine, lidocaine, ropivacaine
        • Hydroxychloroquine
        • Carbamazepine
        • Propranolol
        • Quinine
        • Cocaine
        The ST elevation of ERS is concave and is different in morphology to the ST elevation that occurs with acute myocardial infarction.
        •  

        Physiology

        • Absorption

        • Dietary folate is most commonly in polyglutamate forms, which in themselves are not absorbable and require cleaving by brush border enzymes prior to absorption within the jejunum.

        Overview

        Often the patient's medication list also provides clues regarding the patient's medical conditions.

        Pack-Years

        • Formula

        • Pack years = ( Cigarettes per day / 20 ) * number of years smoked

        Falls History

        • Ask About

        • Whether the patient has had any falls recently
        • What they were doing when they fell
        • Why they fell
        • Whether the hit their head or other part of the body
        • Whether they have pain in any part of their body
        • How long they were on the ground for
        • How often they fall over

        Overview

        • Commonly Inherited Conditions

        • Genetic conditions - thalassaemia, sickle cell anaemia, haemophilia, cystic fibrosis
        • Cancers
        • Diabetes
        • Cardiovascular disease
        • Asthma
        • Autoimmune disease

        Medication History

        • Indication

        • Why the patient is taking the medication. This is often evident but sometimes not. Often the patient does not know themselves!

        The CAGE questionnaire

        • Ask About

        • Cut down - have they ever felt that they should cut down on their drinking?
        • Annoyed - do they get annoyed when other people talk to them about how much they drink?
        • Guilty - have they ever felt guilty about something they did as a result of their drinking
        • Eye opener - do they use alcohol to help them wake up in the morning?

        Management

        • Management Strategy

        • Slow Progression

        • Treat the cause of CKD - e.g. diabetes, hypertension
        • ACE inhibitors - captopril, perindopril, ramipril
        • Angiotensin II receptor blockers - candesartan, irbesartan, telmisartan
        • Treat Complications

        • Acidosis - consider sodium bicarbonate
        • Fluid overload - fluid restriction, salt restriction
        • Anaemia - iron replacement if required, consider EPO
        • Cardiovascular disease - control hypertension, statin, consider aspirin
        • Mineral bone disease - dietary phosphate restriction, phosphate binders (calcium / non-calcium-based), calcitriol, parathyroidectomy
        • Malnutrition - high protein intake
        • Other

        • Dialysis - consider when to start and what modality
        • Renal transplant - consider suitability

        Peritransplant History

        • Ask About

        • When they received their transplant
        • The indication for the renal transplant
        • Type of donor

        Management

        • Management Options for Multiple Sclerosis

        • Non-Pharmacologic

        • Smoking cessation
        • Vitamin D supplementation
        • Exercise
        • Weight loss
        • Pharmacologic

        • Beta interferon
        • Glatiramer acetate
        • Teriflunomide
        • Fingolimod
        • Cladribine
        • Natalizumab
        • Ocrelizumab
        • Alemtuzumab
        • Advanced Therapy

        • Autologous stem cell transplant
        • Management Options for Epilepsy

        • Non-Pharmacologic

        • Avoidance of precipitants
        • Avoidance of driving (consult local guidelines)
        • Pharmacologic

        • Carbamazepine
        • Phenytoin
        • Sodium valproate
        • Topiramate
        • Levetiracetam
        • Lamotrigine
        • Lacosamide
        • Ethosuxamide
        • Benzodiazepines
        • Invasive Options

        • Surgical resection of an epileptogenic lesion
        • Vagus nerve stimulation
        • Deep brain stimulation

        Peritransplant History

        • Indications for Allogeneic Stem Cell Transplant

        • Acute myeloblastic leukaemia
        • Acute lymphoblastic leukaemia
        • Aplastic anaemia
        • Relapsed refractory lymphoma
        • Indications for Autologous Stem Cell Transplant

        • Multiple myeloma
        • Relapsed / refractory lymphoma
        • Certain autoimmune diseases - e.g. multiple sclerosis, scleroderma

        Key Considerations

        • Aspects of Clinical Medicine Covered

        • Look for apps that provide comprehensive clinical medical education resources. This may include guides to history, examination, investigations, and drugs, as well as videos and quizzes to test your knowledge.

        Key Features

        We considered several key features of each platform when putting together this list.
        • Organisation

        • Nested hierarchy - notes should be easily organisable, ideally with the ability to add many nested folders of notes.
        • Tagging - notes should be able to be tagged (e.g. #cardiology), so that similar notes can be grouped together.
        • Search - notes should be able to be searched, so that we can find the information we need more easily.
        There are several key factors to consider when assessing medical sciences video resources. We looked at the following:
        • Coverage

        • A good resource that keeps you coming back is one that provides videos on a wide range of topics including diagnosis, management and practical skills. We also looked for resources that provided sufficiently indepth coverage of each topic.
        • Guided Meditations

        • For many beginners, guided meditations can be a useful way to learn how to practice mindfulness. We prioritised resources that offered a variety of guided meditations, as well as options for silent meditation practice.
        • Range of Calculators and Tools

        • We prioritized resources that offer a wide range of formulae, clinical calculators, decision-making tools, and medical scoring systems across multiple specialties. This ensures that you have access to the most relevant and comprehensive information.

        Key Considerations

        • Focus and Concentration

        • Studying anatomy, pathology, clinical medicine and everything else requires a high level of focus and concentration. Focus and concentration apps are a valuable resource for eliminating distractions and improving your productivity. Also, it is important to tap into resources that ensure that you take enough breaks to rest and digest all of the information that you’re taking in during focused study sessions.

        Key Features

        • Interactive Learning Experience

        • In addition to providing comprehensive information, we considered resources that offered interactive learning experiences such as quizzes, case studies, and video tutorials. Interactive learning can be particularly helpful if you learn best through practice.

        Types of Cognition

        • How Can Bloom's Taxonomy Help Me Learn? 

        • You can use Bloom-type questions to prompt deeper thinking on a topic, and ensure that you are not just learning at a superficial level. By using higher-level thinking skills you will be more likely to retain concepts because you have a deeper understanding and ability to apply, evaluate, analyse and even create new thinking. 

        How Memory Works

        • Storage

        • Memories are stored as connections between neurons in the brain, which may later be retrieved.

        Plan Your Study

        Before you start each study session, try to take some time to plan the session. Decide on your goals, what tools you'll use and how long you plan to study for. Are you studying cardiology? Will you be watching recorded lectures and making notes, or reviewing your flashcards with last week's content?

        Start in a Controlled Environment

        In most cases, it is not possible (or safe) for you to practice your skills on real patients straight away. For many procedural skills, there are commercial kits and even dummy models available for you to practice your skills on initially, before you try with real people.

        Flashcards: The Basics

        • The Cue

        • The text on the front of the card can take many forms, such as a questions, concept, trigger word or phrase. This cue is designed to prompt active recall, which strengthens connections in your brain to improve your retention.

        Falls History

        • Significance

        • Falls in the elderly significantly increase the risk of devastating injuries - especially hip fractures and intracranial bleeds.

        Medication History

        • Prescriber

        • Who prescribed the medication initially, and who continues to prescribe it.

        What is a Standard Drink?

        One standard drink in Australia contains 10g of alcohol.

        Management

        Most patients with chronic kidney disease will die due to cardiovascular disease, so it is important to manage the risk factors of this.

        Peritransplant History

        • Types of Renal Transplant Donor

        • Live donor
        • Donor after brain death (DBD)
        • Donor after circulatory death (DCD)

        Peritransplant History

        • Types of Allogeneic Stem Cell Transplant

        • Syngeneic allograft - identical twin donor with the same major and minor HLA antigens
        • Matched sibling allograft - all major HLA antigens matched; minor antigens more likely to match
        • Matched unrelated donor (MUD) allograft - major HLA antigens matched; minor antigens partially matched
        • Mismatched unrelated donor allograft- some major and minor HLA antigens matched
        • Haploidentical allograft (unmatched sibling, parent, child or other family member) - half of major HLA antigens matched
        • Cord blood allograft

        Complications

        • Complications of Autologous Stem Cell Transplant

        • Mucositis
        • Infections
        • Bone marrow suppression
        • Sinusoidal obstructive syndrome (jaundice, hepatomegaly, fluid retention)
        • Secondary myelodysplasia / acute myeloblastic leukaemia

        Key Considerations

        • Diagnosis Support

        • Medical diagnosis apps can be incredibly useful. Some apps offer symptom checkers to aid in diagnosing patients, as well as guides to interpreting investigations.

        Key Features

        • Spaced Repetition

        • Spaced repetition is a learning technique that involves challenging recall at increasing intervals to help you remember more information over the long term. Flashcard platforms that use spaced repetition are more effective at helping users retain information than those that don't.
        • Communication

        • Multiple devices - the app should be usable across devices, as many of us use our phones, tablets and laptops together.
        • Cloud sync - the app should sync with the cloud, so that we can open our notes on other devices and have our changes visible as soon as possible.
        • Interfaces with other software - ideally, the app would be able to communicate with other related software. For example, Microsoft OneNote works well with other Office apps.
        • Collaboration - in some circumstances, it is desirable for the app to allow use to collaborate with others in writing and editing notes.
        • Coverage

        • We looked for YouTube channels and video platforms that cover a wide range of medical science domains including anatomy, physiology, pathology, histology, microbiology, pharmacology and more. We also prioritised resources that provided indepth coverage of each domain.
        • Quality

        • The quality of videos is paramount - not just the medical accuracy, but also the production value of the audio and visual elements. We found some channels that had good content but relatively monotonous videos. The resources listed below are accurate and provide an engaging experience using diagrams and animations.
        • Personalisation

        • Everyone's mindfulness journey is different, and we wanted to find resources that could adapt to individual needs using features such as personalised recommendations and progress tracking.
        • Ease of Use

        • Resources with intuitive and user-friendly interfaces were prioritise to allow for quick access to the tools you need in fast-paced environments, such as on clinical rotations.

        Key Considerations

        • Writing Assistance

        • During your medical degree it is likely that you will be writing a lot of assignments, articles and emails. Writing assistants are great for improving writing skills and ensuring error-free work - we’ve included a couple of resources that can help you with this.

        Key Features

        • Affordability

        • We prioritised resources that were financially accessible to all medical students - ECG mastery should not come at a major financial cost.

        Types of Cognition

        Integrating different levels can broaden your learning experiences - this can alleviate the boredom of trying to simply retain facts. 

        How Memory Works

        Information is initially stored in short-term memory, or working memory. This form of memory has a relatively small capacity of approximately five to seven items; more information can be stored using chunking (e.g. grouping numbers together in a phone number). Short-term memory is only stored for a short period of time, thought to be between fifteen to thirty seconds. An item may be kept in working memory for longer using rehearsal (e.g. repeating a phone number over and over). Counting backwards in 3s (the Brown-Peterson technique) is a way of ensuring that items do not remain in short-term memory, by preventing rehearsal.

        Plan Your Study

        Use chunking to avoid feeling overwhelmed at the amount of information that you have to learn - break your learning goals into manageable chunks and focus on each chunk one at a time. For example, focus on neuroanatomy before moving onto neurophysiology.

        Start in a Controlled Environment

        • Start in a Controlled Environment
        • Mannequins & Models

        • Mannequins are (approximately) anatomically correct models that are used to similar a variety of medical procedures. There are CPR dummies to practice BLS and ALS on; fake arms to practice phlebotomy and cannulation on; and fake pelvises for catheterisation practice. Some are incredibly sophisticated and can simulate entire resuscitation scenarios, to allow you to practice critical thinking and decision-making skills.

        Flashcards: The Basics

        • The Answer

        • The back of the flashcard contains the answer to the cue, in your own words. Comparing your response to the cue and the answer on the back of the card allows you to reinforce that you were correct, or adjust your understanding if not. This process is known as meta-cognition, which can aid in understanding your own thought process.

        Why Take Notes?

        Notes can also be used to write your own questions and flashcards, which will allow you to really lock concepts in your memory.

        Dentition

        • Significance

        • Poor dentition is associated with worse overall physical and mental wellbeing. Dental infection can spread systemically, most notably as a cause of infective endocarditis.

        Venous Ulcers

        • Look For

        • Superficial painless red ulcers with moderate exudate, most commonly over the gaiter area (from mid-calf to 1cm below the malleoli)

        The Glasgow Coma Scale

        • Causes of Reduced Glasgow Coma Scale

        • Intracranial

        • Haemorrhage - intracerebral, subarachnoid, subdural, extradural
        • Infarction
        • Infection - meningitis, encephalitis, abscess
        • Tumour - mass effect, cerebral oedema
        • Post ictal state
        • Head trauma - vascular, hypoxia, cerebral oedema, parenchymal injury
        • Psychiatric - conversion disorder, depression, catatonia
        • Extracranial

        • Cardiovascular - shock, hypertension
        • Infection - septicaemia
        • Metabolic - hypo/hyperosmolar states, hypo/hyperglycaemia, hypoadrenalism, hypothyroidism, hypopituitarism, electrolyte abnormality, hypercapnia
        • Drugs / toxins - sedatives, analgesics, alcohol
        • Physical injury - hyper / hypothermia, electrocution

        Overview

        Conus medullaris syndrome - distal upper and lower motor neuron weakness, with perineal loss of sensation (saddle anaesthesia), urinary retention and faecal incontinence
        • Interpretation

        • Weakness affecting an entire limb or entire side - likely due to central pathology
        • Weakness affecting a single myotome  - likely due to spinal nerve root pathology
        • Weakness affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
        • Weakness affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion, or mononeuritis multiplex
        • Generalised weakness - suggests a polyneuropathy, neuromuscular pathology or myopathy

        Median Nerve Palsy

        • Signs of Median Nerve Palsy

        • Sensory

        • Sensory loss over the palmar aspect of the thumb, 2nd and 3rd fingers
        • Sensory loss over the thenar eminence (proximal lesion)
        • Tinel's sign - percuss over the flexor retinaculum and ask about symptoms
        • Phalen's sign - reverse prayer position and ask about symptoms
        • Motor

        • Weakness of thumb abduction
        • Hand of benediction (proximal lesion) - inability to flex the index and middle fingers
        • Thenar eminence wasting (proximal lesion)
        • Weakness of wrist pronation and flexion (proximal lesion)
        • Inability to maintain an O between the thumb and index finger (proximal lesion)

        Bronzed Skin

        • Manifestations of Haemochromatosis

        • Systemic - fatigue / lethargy
        • Skin - hyperpigmentation
        • Hepatic - chronic liver disease, cirrhosis, hepatocellular carcinoma
        • Pancreatic - diabetes mellitus ("bronze diabetes")
        • Joints - arthralgias, arthritis
        • Hypogonadism - male impotence, loss of libido
        • Cardiac - arrhythmia, myopathy

        Cervical Lymph Nodes

        Submandibular nodes - Along angle of mandibleFloor of mouth

        Palmar Crease Pallor

        • Look For

        • Loss of colour in the creases of the palm.

        Rashes Associated with GI Disease

        Prurigo nodularis: firm, crusty, pruritic papules and nodules with a symmetrical distribution.Hepatitis C, HIV, H pylori, CKD, lymphoproliferative disorders

        Haemorrhoids

        • Causes of Haemorrhoids

          Essentially idiopathic, though predisposition is associated with:
        • Straining while defaecating
        • Raised intra-abdominal pressure
        • Congenital

        Common Signs on the Tongue

        Geographic tongue (benign migratory glossitis): painless discoloured patches with a punched-out appearance, that may resolve and reappear in a new configuration.Benign - 2% of the population

        Flank Tenderness

        • Causes of Flank Tenderness

        • Infection - pyelonephritis, perinephric abscess
        • Malignancy - renal cell carcinoma, transitional cell carcinoma
        • Renal infarction
        • Trauma

        Conjunctival Pallor

        • How to Elicit

        • Pull the lower eyelid downward and inspect the inner eyelid. Conjunctival pallor is present if there is loss of the normal redness of the anterior rim of the conjunctiva.

        The Glasgow Coma Scale (GCS)

        • Causes of Unconsciousness

        • Intracranial

        • Haemorrhage - intracerebral, subarachnoid, subdural, extradural
        • Infarction
        • Infection - meningitis, encephalitis, abscess
        • Tumour - mass effect, cerebral oedema
        • Post ictal state
        • Head trauma - vascular, hypoxia, cerebral oedema, parenchymal injury
        • Psychiatric - conversion, depression, catatonia
        • Extracranial

        • Cardiovascular - shock, hypertension
        • Infection - septicaemia
        • Metabolic - hypo/hyperosmolar states, hypo/hyperglycaemia, hypoadrenalism, hypothyroidism, hypopituitarism, electrolyte abnormality, hypoxia, hepatic failure, renal failure
        • Drugs / toxins - sedatives, analgesics, alcohol, encephalopathy
        • Physical injury - hyper / hypothermia, electrocution

        Rashes Associated with GI Disease

        Prurigo nodularis: firm, crusty, pruritic papules and nodules with a symmetrical distribution.Hepatitis C, HIV, H pylori, CKD, lymphoproliferative disorders

        Joint Range of Motion

        • Causes of Limited Range of Motion

        • Intra-articular haemorrhage
        • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, Reiter's syndrome
        • Trauma - dislocation, fracture, ligamentous / menisceal tear
        • Loose intra-articular body
        • Fibrous adhesions
        • Muscle tightness
        • Prolonged joint immobilisation
        • Compartment syndrome
        • Tendinitis / bursitis

        Focal Abdominal Tenderness

        Left lumbar - descending colon, kidneyKidney stone, diverticulitis, IBD

        Plethora

        • Look For

        • Red discolouration, especially of the face.

        Koilonychia

        • Causes of Koilonychia

        • Chronic iron deficiency
        • Upper GI carcinoma
        • High altitude
        • Trauma
        • Hypothyroidism
        • Systemic lupus erythematosus

        Scleral Icterus

        • Look For

        • Yellowness of the conjunctiva overlying the sclera.

        Axillary Lymph Nodes

        Subscapular nodes - posteriorly, in front of the subscapularis musclePosterior neck and chest wall

        Liver Consistency

        • Interpretation

        • Smooth enlargementCongestion, acute hepatitis, fatty liver, leukaemia / lymphoma
        • Firm ± enlargementChronic hepatitis, cirrhosis
        • Nodular enlargementHepatocellular carcinoma, metastatic carcinoma

        Reduced Joint Range of Motion

        • Causes of Limited Range of Motion

        • Intra-articular haemorrhage
        • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, Reiter's syndrome
        • Trauma - dislocation, fracture, ligamentous / menisceal tear
        • Loose intra-articular body
        • Fibrous adhesions
        • Muscle tightness
        • Prolonged joint immobilisation
        • Compartment syndrome
        • Tendinitis / bursitis

        Cervical Lymph Nodes

        Submandibular nodes - Along the angle of the mandibleFloor of mouth

        Abdominal Mass

        Umbilicus - small bowel, aortaAbdominal aortic aneurysm, umbilical hernia

        Antalgic Gait

        The presence of an antalgic gait indicates injury or other pathology causing pain on weightbearing.

        Jerk Nystagmus

        • Causes of Jerk Nystagmus

        • Physiologic
        • Congenital
        • Central (brainstem / cerebellum) - multiple sclerosis, stroke, trauma, tumour
        • Visual impairment - intra-ocular, optic nerve (II), total blindness
        • Vestibular disturbance - Meniere's, benign paroxysmal positional vertigo, labyrinthitis
        • Drugs - alcohol, sedatives, phenytoin

        Romberg Test

        • Significance

        • Asking the patient to close their eyes and stand still eliminates visual and vestibular pathology, making loss of proprioception the most likely pathology.

        Facial Spasm

        • Look For

        • Involuntary spasm of the muscles on one or both sides of the face.

        Measuring Blood Pressure

        • Measuring Blood Pressure

        Increased Body Temperature

        • Classification

        • Fever - 37.5 - 38.3°C
        • Hyperthermia - 38.4 - 39.9°C
        • Hyperpyrexia - 40 - 41°C
        • Extreme hyperpyrexia - >41.5°C

        Tachypnoea

        • Causes of Tachypnoea

        • Physiologic - during exercise or at high altitude
        • Anxiety
        • Metabolic acidosis - abdominal pathology, sepsis
        • Pulmonary embolism
        • Pneumonia
        • Asthma
        • Respiratory failure

        Measuring Oxygen Saturations

        • Factors that Reduce Accuracy

        • Peripheral shutdown
        • Nail polish
        • Skin hyperpigmentation
        • Excessive movement
        • Severe hypoxia (

        Wheeze

        Wheeze refers to high-pitched musical sounds, which suggest small airway narrowing.

        Tachycardia

        • Causes of Tachycardia

        • Sinus Tachycardia

        • Stress - physical exertion, anxiety, emotional stress, trauma, pain
        • Fever
        • Haemodynamic insufficiency - hypovolaemia, shock
        • Anaemia
        • Cardiovascular - pulmonary embolism, coronary ischaemia / infarction
        • Endocrine - hypoglycaemia, thyrotoxicosis, phaeochromocytoma
        • Drugs - beta agonists, anticholinergics, theophylline, caffeine, amphetamine, cocaine, alcohol
        • Other Rhythms

        • Atrial - atrial fibrillation, atrial flutter, focal atrial tachycardia, multifocal atrial tachycardia
        • Junctional - AV nodal reentrant tachycardia, AV reentrant tachycardia
        • Ventricular tachycardia

        Lower Limb Pulses

        • Pulses in the Lower Limb

        • Femoral - palpate within the inguinal region, halfway between the pubic symphysis and iliac crest.
        • Popliteal - bend the patient's knee to 90 degrees, gently grasp both sides of the knee joint and palpate using tips of fingers within the popliteal fossa posteriorly.
        • Posterior tibial - palpate posteriorly and inferiorly to the medial malleolus.
        • Dorsalis pedis - palpate lateral to the extensor tendon of the great toe. This can be identified by asking the patient to extend their great toe.

        Hyperglycaemia

        • Symptoms

        • Fatigue
        • Polyuria
        • Polydipsia
        • Thirst
        • Weight loss

        Cheyne-Stokes Respiration

        • Causes of Cheyne-Stokes Respiration

        • Congestive cardiac failure
        • CNS pathology - infarct, haemorrhage, trauma, tumour, meningitis
        • Physiologic - sleep, high altitude

        Measuring Oxygen Saturations

        • Factors that Reduce Accuracy

        • Peripheral shutdown
        • Nail polish
        • Skin hyperpigmentation
        • Excessive movement
        • Severe hypoxia (<80%)

        Measuring Blood Pressure

        • Measuring Blood Pressure

        Overview

        • Severity of Obstructive Disease

          Based on FEV₁:
        • Mild - >70% predicted
        • Moderate - 60-69% predicted
        • Moderately severe - 50-59% predicted
        • Severe - 35-49% predicted
        • Very severe - <35% predicted

        Poor Readings

        • Poor Readings

        The Coagulation Cascade

        The common pathway involves the formation of the fibrin clot via thrombin activation. Factor Xa, activated through either the extrinsic or intrinsic pathway, converts prothrombin (factor II) to thrombin (IIa). Thrombin then converts fibrinogen to fibrin and activates factor XIII. Factor XIIIa creates fibrin closslinks that are incorporated into a platelet plug and stabilise the clot.

        Hypofibrinogenaemia

        • Causes of Hypofibrinogenaemia

        • Congenital deficiency - hypofibrinogenaemia, afibrinogenaemia, dysfibrinogenaemia
        • Reduced synthesis - liver impairment
        • Consumption - DIC, cancers, thrombolytic therapy, snake bite
        • Haemodilution - massive transfusion

        Elevated D-Dimer and PE

        • Practical Points

        • The D-dimer is sometimes tested as part of the diagnostic workup for pulmonary embolism.
        • The test has a high negative predictive value for PE, meaning that a negative result is useful for ruling out PE in patients who have a low pre-test probability.
        • A positive value should be interpreted with caution and taken in the context of the patient's other clinical features.

        Urine Smell

        • Interpretation

        • Strong urine smell - concentrated urine (e.g. dehydration)
        • Sweet smell - diabetic ketoacidosis
        • Ammonia smell - urinary tract infection
        • Strong asparagus smell - normal following asparagus ingestion
        • Faecal smell - colovesical fistula

        Neutrophil Physiology

        • Roles of Neutrophils

        • Neutrophils make up part of the innate immune system, and as such act immediately and are non-specific in their action. They migrate to a site of infection and phagocytose pathogens such as bacteria, fungi and protozoa.

        Pathogenesis

        An excess of alpha chains, combined with ineffective haemoglobin production, lead to ineffective red cell production and shorted red cell lifespan. The resulting anaemia stimulates erythropoietin release and further red cell production, eventually producing bone marrow expansion and iron overload.

        Microcytosis

        • Causes of Reduced Mean Cell Volume

        • Iron deficiency anaemia - nutritional deficiency, blood loss, malabsorption, pregnancy
        • Anaemia of chronic disease (chronic infection / inflammation / malignancy)
        • Thalassaemia
        • Congenital sideroblastic anaemia
        • Lead poisoning
        • Hyperthyroidism

        Hypochromia

        • Causes of Hypochromia

        • Microcytic

        • Iron deficiency anaemia
        • Anaemia of chronic disease (infection / inflammation / malignancy)
        • Thalassaemia
        • Congenital sideroblastic anaemia
        • Lead poisoning
        • Hyperthyroidism
        • Macrocytic

        • Reticulocytosis

        Diagnosis

        • Test Findings in Alpha Thalassaemia

        • Full Blood Count & Film

        • Microcytic hypochromic anaemia
        • Anisocytosis: variation in red blood cell size
        • Poikilocytosis - target cells, teardrop cells, elliptocytes, fragments
        • HbH bodies (on supravital staining)HbH disease only
        • Basophilic stippling
        • Nucleated red blood cells
        • Other Tests

        • High performance liquid chromatography / haemoglobin electropheresis - increased haemoglobin HNormal in thalassaemia trait - used for the diagnosis of HbH disease only

        Clinical Use

        • Indications

        • Upper / lower respiratory tract infections
        • Skin infections
        • Urinary tract infections
        • Adverse Effects

        • Nephrotoxicity - reversible, higher risk with poor renal function
        • Ototoxicity -  irreversible vestibular and auditory dysfunction
        • Peripheral neuropathy
        • Hypersensitivity reactions
        • Adverse Effects

        • Headache
        • Tachycardia
        • Nausea / vomiting

        Overview

        Human platelets are used to treat patients with thrombocytopaenia due to a variety of causes.
        Fresh frozen plasma (FFP) is a blood product made up of the plasma portion of whole blood, following removal of all cells.
        Red blood cells are a commonly transfused blood product; they are used to treat acute bleeding or severe anaemia due to a variety of causes.

        Clinical Use

        Each unit of cryoprecipitate is expected to increase the serum fibrinogen by 5-10mg/dL.
        Not normally used in asthma without inhaled corticosteroids - see combination therapy.
        • Indications

        • Asthma resistant to inhaled corticosteroids
        • COPD maintenance therapy

        Overview

        • Mechanism of Action

          Suppress the body's normal inflammatory response through:
        • Reduced monocyte recruitment
        • Suppression of arachidonic acid metabolites - prostaglandin, leukotriene, platelet-activating factor
        • Reduced production of interleukins, TNF-α, GM-CSF
        • Non-Inflammatory Effects of Corticosteroids

        • Increased circulating glucose - ↑gluconeogenesis, ↓glucose usage
        • Redistribution of fats - in face, neck, shoulder
        • ↓ Absorption of Ca²⁺
        • Muscle homeostasis

        Clinical Use

        • Indications

        • Acute asthma (ipratropium)
        • Acute exacerbations of COPD (ipratropium)
        • Maintenance therapy for COPD (tiotropium)
        • Indication

        • Maintenance therapy for COPD.
        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • Anorexia
        • Headache
        • Muscle cramps
        • Dizziness
        • Fatigue
        • Depression

        Overview

        • Mechanism of Action

        • Selectively agonise serotonin 5-HT1 receptors, mainly found in cerebral and dural blood vessels.
        • Mechanism of Action

          Suppress the body's normal inflammatory response through:
        • Reduced monocyte recruitment
        • Suppression of arachidonic acid metabolites - prostaglandin, leukotriene, platelet-activating factor
        • Reduced production of interleukins, TNF-α, GM-CSF

        Clinical Use

        • Adverse Effects

        • Fatigue / headache
        • Bradycardia
        • Postural hypotension
        • Vivid dreams
        • Monitoring

        • 3-6-monthly testing of FBC, LFTs and thyroid function.
        • Indications

        • Acute anxiety
        • Tranquilization - in the acute psychiatric setting
        • Withdrawal (diazepam) - from alcohol, benzodiazepines, opioids
        • Status epilepticus (clonazepam / diazepam / midazolam)
        • Sedation (midazolam) - for short surgical procedures or intensive care
        • Monitoring

        • Plasma concentration should be monitored in order to ensure therapeutic effect.

        Clinical USe

        • Indication

        • Parkinson's disease.

        Clinical Use

        • Overdose

        • Liver toxicity can occur if doses greater than 10g or 200mg/kg (whichever is lower) are ingested within a 24-hour period.
        •  
          Oral / rectal
          Indomethacin
          Indocid 

        Overview

        • Effects

        • Reduced secretions - sweat, lacrimal, salivary, gastric, pancreatic, bronchial glands
        • Vasoconstriction
        • Prevention of decreased vessel permeability / oedema

        Clinical Use

        • Indications

        • Cardiac arrest
        • Anaphylaxis
        • Severe asthma
        • Profound hypotension
        • Adjunct to local anaesthetic

        Overview

        • Pharmacology

        • Do not readily cross the blood-brain barrier and thus are less sedative than first generation antihistamines

        Clinical Use

        • Adverse Effects

        • Headache
        • Breast pain
        • Nausea / vomiting / abdominal pain
        • Dizziness
        • Depression
        • Irregular bleeding
        • Acne
        • Adverse Effects

        • Headache
        • Breast pain
        • Nausea / vomiting / bdominal pain
        • Dizziness
        • Depression
        • Irregular bleeding
        • Acne
        • Contraindications

        • Pregnancy
        • Past DVT / PE
        • Ischaemic heart disease
        • Past stroke / TIA
        • Liver failure
        • Breast / uterine / cervical / ovarian cancer
        • Migraine with aura
        • Pearls

        • Useful for patients seeking OCP who have severe acne or hirsutism.
        • If a dose is missed, two tablets should be taken the following day.
        • Contraindications

        • Pregnancy
        • Past DVT / PE
        • Ischaemic heart disease
        • Past stroke / TIA
        • Breast cancer within the past five years
        • Ischaemic heart disease
        For the medical termination of pregnancy, mifepristone is given initially with misoprostol given 36 to 48 hours afterward.
        • Contraindications

        • Intracranial / intraspinal haemorrhage
        • Hyperosmolar hyperglycaemia (without concurrent insulin)
        • Adverse Effects

        • Nausea / vomiting.
        • Adverse Reactions

        • Nausea / vomiting.
        • Adverse Effects

        • Severe infections (particularly respiratory and urinary tract infections)
        • Anaemia
        • Headache
        • Dizziness
        • Nausea / vomiting / diarrhoea
        • Hypertension
        • Hypercholesterolaemia
        • Abdominal pain
        • Prolonged QT

        Overview

        • Mechanism of Action

        • Inhibit tumour necrosis factor alpha (TNF-α), a cytokine involved in systemic inflammation and the acute phase response.

        Substem A (Target)

        -k(i)-: interleukin (e.g. ustekinumab)

        Clinical Use

        • Adverse Effects

        • Hypersensitivity reactions
        • Infections
        • Neutropaenia
        • Thrombocytopaenia
        • Headache
        • Nausea / vomiting / diarrhoea
        • LFT derangement
        • Hypercholesterolaemia
        • Monitoring

        • Monthly full blood count, renal function and LFTs.

        Overview

        • Mechanism of Action

          Suppress the body's normal inflammatory response through:
        • Reduced monocyte recruitment
        • Suppression of arachidonic acid metabolites - prostaglandin, leukotriene, platelet-activating factor
        • Reduced production of interleukins, TNF-α, GM-CSF

        Clinical Use

        • Adverse Effects

        • Increased risk of infection (immunosuppression)
        • Fluid overload
        • Hypertension
        • Fevers
        • Hirsutism
        • LFT derangement
        • Renal impairment
        • Dyslipidaemia
        Correcting hyponatraemia too quickly can result in permanent CNS damage due to osmotic demyelination. Aim to increase the serum sodium by 4-8mmol per day.
        • Contraindications

        • Intracranial / intraspinal haemorrhage
        • Hyperosmolar hyperglycaemia (without concurrent insulin)
        • Adverse Effects

        • Hyperkalaemia
        • Nausea / vomiting / diarrhoea (oral)
        • Thrombophlebitis (IV)
        • Contraindications

        • Fluid overload - congestive cardiac failure, severe renal impairment, excessive IV fluids
        • Adverse Effects

        • Hypersensitivity - urticaria, anaphylaxis
        • Renal toxicity (shock patients)
        • Fluid overload
        • Contraindications

        • Bowel obstruction
        • Complete lack of oral intake (e.g. TPN)
        • Hypercalcaemia (calcium polystyrene sulfonate)
        • Adverse Reactions

        • Fluid overload - electrolyte abnormalities, oedema
        • Adverse Effects

        • Hypersensitivity - urticaria, anaphylaxis
        • Fluid overload

        Opioid Overdose

        • Reversal

        • Naloxone.

        Overview

        • Effects

        • μ - analgesia, respiratory depression, miosis, constipation
        • κ - analgesia, sedation, confusion
        • δ - analgesia, respiratory depression, constipation
        • NOF - analgesia, stress / anxiety, tolerance

        Clinical Use

        • Adverse Effects

        • Dizziness
        • Sweating
        • Dry mouth
        • Nausea / vomiting
        • Constipation
        • Fatigue
        • Overdose

        • Liver toxicity can occur if doses greater than 10g or 200mg/kg (whichever is lower) are ingested within a 24-hour period.

        Overview

        • Effects

        • μ - analgesia, respiratory depression, miosis, constipation
        • κ - analgesia, sedation, confusion
        • δ - analgesia, respiratory depression, constipation
        • NOF - analgesia, stress / anxiety, tolerance

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting
        • Constipation
        • Sedation
        • Respiratory depression
        • Diaphoresis
        • Delirium
        • Hypersensitivity - bronchospasm, urticaria
        • Bradycardia
        • Tolerance
        • Dependence
        • Hypogonadism
        • Adverse Effects

        • Hypersensitivity reactions - rash, oedema, anaphylaxis
        • Inadvertent IV administration - agitation, drowsiness, bradycardia, hypotension, ventricular arrhythmia, hyperkalaemia, hypoxia
        •  
          Oral / rectal
          Indomethacin
          Indocid 

        Overview

        • Mechanism of Action

        • Inhibit tumour necrosis factor alpha (TNF-α), a cytokine involved in systemic inflammation and the acute phase response.

        Clinical Use

        • Adverse Effects

        • Hypersensitivity reactions
        • Infections
        • Neutropaenia
        • Thrombocytopaenia
        • Headache
        • Nausea / vomiting / diarrhoea
        • LFT derangement
        • Hypercholesterolaemia
        • Monitoring

        • Monthly full blood count, renal function and LFTs.
        • Adverse Effects

        • Severe infections (particularly respiratory and urinary tract infections)
        • Anaemia
        • Headache
        • Dizziness
        • Nausea / vomiting / diarrhoea
        • Hypertension
        • Hypercholesterolaemia
        • Abdominal pain
        • QT prolongation

        Overview

        Bcr-Abl TK is encoded by a chimaeric oncogene that results from the formation of the Philadelphia chromosome, and is present in most patients with CML as well as in patients with certain other malignancies.

        Clinical Use

        • Adverse Effects

        • Visual phenomena
        • Nausea / vomiting / diarrhoea
        • Neutropaenia
        • Pneumonitis
        • LFT derangement
        • Bradycardia
        • Oedema

        Overview

        • Resistance

        • Resistance to EGFR inhibitors may develop due to binding pocket mutations, T790M mutations or changes in pathway reliance of the tumour cells.

        Clinical Use

        • Indications

        • Unresectable stage III or metastatic (stage IV) melanoma with BRAF (V600) mutation
        • Adjuvant treatment of melanoma with BRAF (V600) mutation and lymph node involvement (dabrafenib + trametinib)

        Overview

        • Pharmacology

        • Many off-target effects due to inhibition of multiple targets.

        Clinical Use

        BRAF inhibitors are most commonly used in combination with MEK inhibitors.

        Overview

        • Pharmacology

        • Prodrugs that require gastric acid in order to be activated.
        • Mechanism of Action

          Suppress the body's normal inflammatory response through:
        • Reduced monocyte recruitment
        • Suppression of arachidonic acid metabolites - prostaglandin, leukotriene, platelet-activating factor
        • Reduced production of interleukins, TNF-α, GM-CSF

        Clinical Use

        • Indications

        • Constipation
        • Bowel preparation prior to procedures such as colonoscopy (macrogol 3350)
        • Hepatic encephalopathy (lactulose)
        • Monitoring

        • Monthly full blood count, renal function and LFTs.
        • Monitoring

        • Monthly full blood count, renal function and LFTs.
        • Adverse Effects

        • Restlessness / anxiety / agitation
        • Fatigue
        • Headache / dizziness
        • Diarrhoea
        • Dystonic reactions (rare)
        For malaria prophylaxis, should be commence one day before travel and continued for four weeks after returning.

        Clinical use

        • Adverse Effects

        • Nausea / vomiting
        • Haemolysis
        • Methaemoglobinaemia

        Overview

        Pulmonary Area - the second intercostal space at the left sternal border. The murmurs of pulmonary stenosis and regurgitation are loudest in this area, as is the pulmonary component of the second heart sound (P2)

        Central Cyanosis

        • Causes of Central Cyanosis

        • High altitude
        • Obstructive lung disease, pulmonary oedema, pneumonia, pulmonary embolism
        • Congenital heart disease
        • Methaemoglobinaemia / sulfhaemoglobinaemia / carboxyhaemoglobinaemia

        Wheeze

        Wheeze typically suggests airway narrowing, however "cardiac wheeze" refers to a wet-sounding wheeze that occurs with pulmonary oedema.

        Left Lateral Position

        • How to Perform

        • Ask the patient to roll over and lie in the partial left lateral decubitus position.

        Measuring Blood Pressure

        • Measuring Blood Pressure

        Cyanosis

        • Causes of Cyanosis

        • Central Cyanosis

        • High altitude
        • Obstructive lung disease, pulmonary oedema, pneumonia, pulmonary embolism
        • Congenital heart disease
        • Methaemoglobinaemia / sulfhaemoglobinaemia / carboxyhaemoglobinaemia
        • Peripheral Cyanosis

        • As for central cyanosis
        • Reduced cardiac output
        • Vasoconstriction

        Hepatomegaly

        • Hepatomegaly

        Conjunctival Pallor

        • How to Elicit

        • Pull the lower eyelid downward and inspect the inner eyelid. Conjunctival pallor is present if there is loss of the normal redness of the anterior rim of the conjunctiva.

        Heart Rate

        • Causes of Tachycardia

        • Sinus Tachycardia

        • Stress - physical exertion, anxiety, emotional stress, trauma, pain
        • Fever
        • Haemodynamic insufficiency - hypovolaemia, shock
        • Anaemia
        • Cardiovascular - pulmonary embolism, coronary ischaemia / infarction
        • Endocrine - hypoglycaemia, thyrotoxicosis, phaeochromocytoma
        • Drugs - beta agonists, anticholinergics, theophylline, caffeine, amphetamine, cocaine, alcohol
        • Other Rhythms

        • Atrial - atrial fibrillation, atrial flutter, focal atrial tachycardia, multifocal atrial tachycardia
        • Junctional - AV nodal reentrant tachycardia, AV reentrant tachycardia
        • Ventricular tachycardia

        Squatting

        • How to Perform

        • While auscultating the chest, ask the patient to squat and then stand from a squatting position.

        Lead Pipe Rigidity

        • Feel For

        • Continuous rigidity that is not velocity dependant, resulting in slow flexion and extension.

        Hyperreflexia

        • Significance

        • Suggestive of an upper motor neuron lesion.

        Sciatic Nerve Palsy

        • Causes of Sciatic Nerve Palsy

        • Direct trauma
        • Stretch injury
        • Hip dislocation
        • Intramuscular injections incorrectly performed in the gluteal region
        • Total hip replacement

        Overview

        • Interpretation

        • Weakness affecting an entire limb or entire side - likely due to central pathology
        • Weakness affecting a single myotome  - likely due to spinal nerve root pathology
        • Weakness affecting a single peripheral nerve distribution - likely due to a focal peripheral nerve palsy
        • Weakness affecting multiple peripheral nerve distributions - potentially due to a brachial plexus lesion
        • Generalised weakness - suggests a polyneuropathy, neuromuscular pathology or myopathy

        Spasticity

        • Signifiance

        • Indicative of upper motor neuron lesion.

        Pes Cavus

        • Causes of Pes Cavus

        • Congenital pes cavus
        • Trauma - malunion of fracture, burn contracture
        • Neurologic - Charcot-Marie-Tooth, Friedrich's ataxia, cerebral palsy, polio, spinal tumour

        Dorsal Column Pathway

        Cortical Centre
        Primary sensory cortex (postcentral gyrus)
         
         
        3rd Order Nuclei
        Ventral posterolateral (VPL) nucleus of thalamus
         
         
        Central Pathway
        Medial lemniscus
        Decussation
        Medulla
         
        2nd Order Nuclei
        Lower medulla - nucleus cuneatus (UL) / gracilis (LL)
         
         
        Spinal Pathway
        Dorsal column - fasciculus cuneatus (UL) / gracilis (LL)
         
        1st Order Nuclei
        Dorsal root ganglion
         
         
        Receptors
        Pacinian corpuscles / Merkel disc receptors / Meisner's corpuscles (vibration)
        Neuromuscular spindles (proprioception)

        Intention Tremor

        • Look For

        • Tremor that increases with target-directed movement.

        Overview

        CNS disorders tend to spare tactile stimulation as both the dolumn column-medial lemniscus and spinothalamic pathways send tactile information to the brain.
        • Note

          Vibration sense is mediated by
        • Merkel disc receptors (low frequencies 5-15 Hz)
        • Meissner's corpuscles (mid frequencies 20-50 Hz)
        • Pacinian corpuscles (high frequencies 60-400 Hz)
        Conus medullaris syndrome - distal upper and lower motor neuron weakness, with perineal loss of sensation (saddle anaesthesia), urinary retention and faecal incontinence

        Passive Movement

        • Causes of Limited Range of Motion

        • Trauma - dislocation, fracture
        • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, Reiter's syndrome
        • Intra-articular haemorrhage
        • Tendinitis
        • Bursitis
        • Intra-articular bleed
        • Tear - meniscus, ligament
        • Loose intra-articular body
        • Fibrous adhesions - surgery, trauma, overuse, inflammation
        • Muscle tightness
        • Prolonged joint immobilisation
        • Compartment syndrome

        Fasciculations

        • Causes of Fasciculations

        • Benign / normal
        • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob disease
        • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

        Overview

        Extensor digitorum longus tendons - on the lateral aspect of the dorsum of the foot, inserting into the intermediate and distal phalanges of the lesser toes.

        Fasciculations

        • Causes of Fasciculations

        • Benign / normal
        • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob disease
        • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

        Bony Landmarks of the Ankle

        Calcaneus - a posterior tarsal bone that constitutes the heel.

        Passive Movement

        • Causes of Limited Range of Motion

        • Trauma - dislocation, fracture
        • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, Reiter's syndrome
        • Intra-articular haemorrhage
        • Tendinitis
        • Bursitis
        • Intra-articular bleed
        • Tear - meniscus, ligament
        • Loose intra-articular body
        • Fibrous adhesions - surgery, trauma, overuse, inflammation
        • Muscle tightness
        • Prolonged joint immobilisation
        • Compartment syndrome

        Nail Discolouration

        • Look For

        • Discolouration of the nail or nail bed.

        Antalgic Gait

        The presence of an antalgic gait indicates injury or other pathology causing pain on weightbearing.

        Passive Movement

        • Interpretation

        • Decreased Knee Range of Motion

        • Arthritis - rheumatoid, osteoarthritis, septic arthritis
        • Bursitis - prepatellar, infrapatellar, pes anserine, iliotibial
        • Tendonitis - patellar, biceps, semitendinosus, semimembranosus
        • Tear - meniscus, ligament
        • Loose intra-articular body
        • Patellar Crepitus

        • Chondromalacia
        • Patellar fracture
        • Snapping Knee Joint

        • Dislocation - tibio-fibular joint, patello-femoral joint
        • Discoid meniscus
        • Menisceal cyst
        • Snapping of tendons

        Extra Credit

        • Shoulder Cross Syndrome

        • Elevation of shoulders - tight upper shoulder girdle fixators / weak lower shoulder girdle fixators
        • Protraction of shoulders -  tight shoulder girdle protractors / weak shoulder girdle retractors
        • Head forward + cervical lordosis - tight neck extensors / weak deep neck flexors

        Fasciculations

        • Causes of Fasciculations

        • Benign / normal
        • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob disease
        • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

        Antalgic Gait

        The presence of an antalgic gait indicates injury or other pathology causing pain on weightbearing.

        Comprehension

        • Conceptual comprehension

        • Show the patient the same pen, watch and key as above and ask them to point to the object that shows the passage of time.

        Volume of Speech

        • Interpretation

        • Loud (hyperphonia)Personality trait, hearing impairment, mania
        • Normal speech volume
        • Weak (hypophonia) - low or soft speechShyness, anxiety, depression, Parkinson's disease

        Digit Span

        • Causes of Impairment

        • Delirium
        • Dementia
        • Aphasia

        Assessing Anterograde Memory

        • How to Assess

        • Ask the patient to remember three words (colour, animal, object) and ask them to repeat them in five minutes.

        Visual Neglect

        • Significance

        • Classically a sign of contralateral stroke, though may occur with any sort of contralateral brain lesion.

        Inhibitory Control

        • How to Assess

        • Ask the patient to tap once when you tap once. Tap once several times.
        • Ask the patient to not tap when you tap twice. Tap twice several times.
        • Alternate randomly between tapping once and tapping twice, asking the patient to tap once when you tap once and not tap when you tap twice.

        Extra Credit

        • Shoulder Cross Syndrome

        • Elevation of shoulders - tight upper shoulder girdle fixators / weak lower shoulder girdle fixators
        • Protraction of shoulders -  tight shoulder girdle protractors / weak shoulder girdle retractors
        • Head forward + cervical lordosis - tight neck extensors / weak deep neck flexors

        Vertebral Landmarks

        T6 - palpate medially from the inferior angle of the scapula.

        Fasciculations

        • Causes of Fasciculations

        • Benign / normal
        • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob disease
        • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

        Antalgic Gait

        The presence of an antalgic gait indicates injury or other pathology causing pain on weightbearing.

        Muscles Acting on the Thoracic / Lumbar Spine

        Extensors - erector spinae, latissimus dorsi

        Tonsils

        • Look For

          Enlarged, inwardly displaced tonsils. Look for erythema and pus.
        • Palatine (faucial) tonsils - lateral walls of oropharynx
        • Adenoids - posterior wall of nasopharynx
        • Lingual tonsil - base of tongue

        Horner's Syndrome

        • Causes of Horner's Syndrome

        • Apical lung lesion (Pancoast syndrome)
        • Brain lesion - hypothalamus, thalamus, pons, medullaTumour, bleed
        • Spinal cord lesionTrauma, inflammation, AVM, demyelination, tumour, infarct
        • Brachial plexus lesion

        Bradypnoea

        Respiratory rate less than 12 breaths per minute.

        Respiratory Muscles

        • Expiratory Accessory Muscles

        • Internal intercostals
        • Abdominal muscles - rectus abdominis, internal and external obliques, transversus abdominis

        Cervical Lymph Nodes

        Submandibular nodes - Along angle of mandibleFloor of mouth

        The Oxygen Dissociation Curve

        • The Oxygen Dissociation Curve

        Muscles Acting on the Wrist Joint

        Supinator (posterolateral) - supinator

        Muscle Spasms

        • Causes of Muscle Spasms

        • Exercise-induced spasm (cramping)
        • Dehydration
        • Electrolyte abnormalities - hyper/hyponatraemia
        • Hereditary dystonia - idiopathic, Huntington's, Wilson's
        • Acquired dystonia - brain damage, encephalitis, parkinsonism, brain tumour, stroke, drug-induced
        • Factitious dystonia

        Bony Landmarks of the Hand

        Distal carpal bones - trapezium, trapezoid, capitate, hamate (including hook of hamate)

        Claw Hand

        • Significance

        • A classical sign of ulnar nerve lesion.

        Passive Movement

        • Causes of Limited Range of Motion

        • Trauma - dislocation, fracture
        • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, Reiter's syndrome
        • Intra-articular haemorrhage
        • Tendinitis
        • Bursitis
        • Intra-articular bleed
        • Tear - meniscus, ligament
        • Loose intra-articular body
        • Fibrous adhesions - surgery, trauma, overuse, inflammation
        • Muscle tightness
        • Prolonged joint immobilisation
        • Compartment syndrome

        Non-Pitting Oedema

        • Causes of Non-Pitting Oedema

        • Impaired lymphatic drainage
        • Pretibial myxoedema (hypothyroidism)

        Amplitude

        Waterhammer / collapsing pulse: strong pulse with sudden collapse.Aortic regurgitation, patent ductus arteriosus

        Arterial Skin Changes

        • Significance

        • Partial or complete arterial occlusion.

        Pupillary Light Reflexes

        • How to Elicit

        • Shine a light into each pupil. Watch to see that both the ipsilateral (direct response) and contralateral (consensual response) pupils constrict as a result of the stimulus.

        Rashes Associated with Diabetes

        Eruptive xanthoma: yellow papules with underlying erythemaHypertriglyceridaemia, poor controlled type 2 diabetes

        Diabetic Retinopathy

        • Signs of Diabetic Retinopathy

        • Microaneurysms: tiny dot-like outpouchings
        • Cotton wool spots
        • Haemorrhages (small dots)
        • Macular oedema
        • Neovascularisation: formation of abnormal and fragile vessels

        Lower Limb Cyanosis

        • Look For

        • Blue discolouration of the lower limb.

        Clinical Use

        For prophylaxis, should be commenced one day before travel and continued for one week after returning.
        • Monitoring

        • Monthly full blood count, renal function and LFTs.
        • Indications

        • Certain solid organ and haematologic organ malignancies, as guided by cancer specialists and local guidelines.
        • Monitoring

        • Regular monitoring of FBC and renal function.
        • Adverse Effects

        • Bone marrow suppression - leucopaenia / thrombocytopaenia / anaemia
        • Anxiety
        • Tachycardia
        • Headache / dizziness
        • Nausea / vomiting / anorexia / diarrhoea
        • Arthralgia / myalgia

        Clinical Use

        • Adverse Effects

        • Bone marrow suppression - leucopaenia, thrombocytopaenia, anaemia
        • Renal dysfunction
        • Nausea / vomiting
        • Elevated LFTs
        • Ototoxicity - tinnitus, hearing loss
        • Transient loss of vision
        • Peripheral neuropathy

        Clinical Use

        • Adverse Effects

        • Bone marrow suppression - leucopaenia / anaemia / thrombocytopaenia
        • Cardiomyopathy / congestive cardiac failure
        • Nausea / vomiting / diarrhoea / anorexia
        • Stomatitis
        • Alopecia
        • Rash

        Simple Face Mask

        The flow into a Hudson mask should be at least 5 L/min, to reduce rebreathing of carbon dioxide.

        BiPAP

        • Contraindications to BiPAP

        • Absolute

        • Severe impairment of consciousness
        • Severe facial deformity
        • Inability to maintain or protect the airway
        • Upper airway injury - burns, trauma, surgery
        • Haemodynamic instability
        • Untreated pneumothorax

        Partial Rebreather Mask

        FlowFiO₂
        7 L/min~0.65
        8-10 L/min~0.80

        Monitoring

        Arterial blood gases are also used to guide oxygen therapy in certain patients.

        Allen's Test

        • How to Perform

        • Ask the patient to clench their fist, and apply pressure to both the radial and ulnar arteries. Ask the patient to relax their hand, looking for blanching - if the hand does not blanch then both vessels are not occluded. Release pressure on the ulnar nerve, and look for flushing as the hand is reperfused.
        • How to Perform

        • Ask the patient to clench their fist, and apply pressure to both the radial and ulnar arteries. Ask the patient to relax their hand, looking for blanching - if the hand does not blanch then both vessels are not occluded. Release pressure on the ulnar nerve, and look for flushing as the hand is reperfused.

        Subclavian Vein

        Identify the junction of the medial third and lateral two-thirds of the clavicle. The needle should be inserted 1cm inferior and lateral to this, pointing toward the sternal notch, upward and away from the underlying lung apex.

        Subclavian Placement

        • Management

        • Remove the PICC.

        Preparation

        Apply the tourniquet, then wash your hands and don gloves.

        Overview

        14 - trauma, rapid infusion of large volumes

        Choosing the Right Vein

        • Don't

        • Absolutely do not use the same arm as an AV fistula
        • Don't use the same arm as a past lymph node dissection or mastectomy
        • Don't use a limb affected by stroke
        • Don't insert an IVC through a burn, oedema or infected tissue
        • Don't use a limb that has a DVT
        • Avoid the lower limb if possible due to risk of DVT and the fact that they limit mobility

        Lignocaine

        • Onset

        • 2 - 5 minutes

        Cricothyroidotomy

        Cricothyroidotomy can be considered as an emergency airway technique in a patient with a difficult airway. This should be performed by an experienced operator with appropriate equipment and staff available.

        Nasopharyngeal Airway

        • Sizing a Nasopharyngeal Airway

        • Measure the airway from the tip of the earlobe to the nostril.

        Diagnosis

        • Blood Film Findings in Myelodysplasia

        • Red Blood Cells

        • Macrocytic hyperchromic anaemia
        • Anisocytosis: variation in the size of red blood cells
        • Poikilocytosis (abnormal red cell shape)
        • Basophilic stippling
        • Nucleated red blood cells
        • White Blood Cells

        • Leukocytosis or leukopaenia
        • Hypogranular neutrophils
        • Pseudo Pelger-Huet neutrophils: hypolobated neutrophils with peanut-shaped or spectacle-shaped nuclei
        • Platelets

        • Thrombocytopaenia
        • Platelet anisocytosis: variation in size of platelets, with large and sometimes giant platelets seen
        • Other

        • Circulating blasts may be seen
        Certain ECG changes with digoxin may purely indicate a therapeutic effect (such as the ST depression and T wave flattening), while other changes (such as T wave inversion and arrhythmias) indicate toxicity.

        Hormonal Changes

        As nonthyroidal illness progresses and becomes more severe, T4 levels begin to fall; the mechanism of this is more complex. The total T4 level falls more significantly than the free T4, partly due to reduction in levels of thyroid binding globulin. TSH also becomes reduced, likely due to reduced hypothalamic function.

        Pathogenesis

        • Causes of Metabolic Acidosis

        • High Anion Gap Metabolic Acidosis

        • Lactic acidosis
        • Ketoacidosis - diabetic, alcoholic
        • Uraemia (end-stage renal failure)
        • Methanol / ethanol / ethylene glycol
        • Salicylates
        • Cyanide
        • Carbon monoxide
        • Normal Anion Gap Metabolic Acidosis

        Diagnosis

        • Left-sided pleural effusion with evidence of volume loss
        • No Overlay
          Overlay
          Left-sided pleural effusion with evidence of volume loss
           
        • Stages of Chronic Kidney Disease

        • GFR Categories (mL/min/1.73m²)

        • G1 - ⩾90
        • G2 - 60-89
        • G3a - 45-59
        • G3b - 30-44
        • G4 - 15-29
        • G5 - <15
        • Albuminuria Categories

        • A1 - <30mg/g / <3mg/mmol
        • A2 - 30-300mg/g / 3-30mg/mmol
        • A3 - >300mg/mg / >30mg/mmol

        Management

        • Management Options for Motor Neuron Disease

        • Non-Pharmacologic

        • Physiotherapy
        • Non-invasive ventilation (NIV)
        • Speech pathology assessment
        • Consideration of PEG feeding
        • Psychological sypport
        • Pharmacologic

        • Rulizole
        • Anti-spasmodics - baclofen, diazepam, botox
        • Neuropathic agents - pregabalin, amitriptyline

        Diagnosis

        • Complications of Bronchiectasis

        • Acute exacerbations
        • Pulmonary haemorrhage
        • Pneumothorax
        • Empyema
        • Lung abscess
        • Cor pulmonale

        Management

        • Management Options for Epilepsy

        • Non-Pharmacologic

        • Avoidance of precipitants
        • Avoidance of driving (consult local guidelines)
        • Pharmacologic

        • Carbamazepine
        • Phenytoin
        • Sodium valproate
        • Topiramate
        • Levetiracetam
        • Lamotrigine
        • Lacosamide
        • Ethosuxamide
        • Benzodiazepines
        • Invasive Options

        • Surgical resection of an epileptogenic lesion
        • Vagus nerve stimulation
        • Deep brain stimulation

        Pathogenesis

        • Causes of Hyperkalaemia

        • Factitious

        • Haemolysis (e.g. poor collection, delay in lab processing)
        • Leukocytosis / thrombocytosis
        • Increased Intake / Production

        • Exogenous administration - massive transfusion, potassium supplements, TPN
        • Endogenous production - rhabdomyolysis
        • Reduced Excretion

        • Renal failure - acute or chronic
        • Medications - NSAIDs, ACE inhibitors, ARBs, spironolactone, trimethoprim
        • Addison's
        • Compartmental Shift

        • Type 4 renal tubular acidosis
        • Metabolic acidosis
        • Hyperglycaemia
        • Beta blockers
        • Trauma / burns

        Diagnosis

        • Blood Gas Findings

        • Reduced pH (acidaemia) with increased PaCO₂.
        • Diagnosis
           
        • 1st degree AV block
        • 1st degree AV block
           

        Management

        • Management Options

        • Weight loss
        • Treatment of upper airway obstruction - mandible advancement splints, surgical correction
        • Continuous positive airway pressure (CPAP) at night
        • Smoking cessation
        • Alcohol reduction
        • Management of Peptic Ulcer Disease

        • Pharmacologic

        • H pylori eradication - triple or quadruple therapy
        • Proton pump inhibitors - omeprazole, esomeprazole, pantoprazole
        • H2 receptor antagonists - ranitidine, nizatidine
        • Interventional

        • Endoscopic management - injection of adrenaline, coagulation, endoscopic clipping
        • Surgical management (rare) - vagotomy, partial gastrectomy

        Manifestations

        ECG changes are not typically seen until the potassium concentration is <3.0.

        Diagnosis

        • History

        • Constitutional symptoms - fatgue, lethargy, fevers
        • Symptoms of anaemia - fatigue, lethargy, lightheadedness, exertional dyspnoea, worsening angina, headache
        • Symptoms of hypercalcaemia - lethargy, confusion, nausea, reflux, constipation, renal stones
        • Bone pain
        • Hyperviscosity syndrome - neuropathy, epistaxis, blurred vision, headache
        • Recurrent infections

        Pathogenesis

        • Causes of Primary Hypothyroidism

        • Primary

        • Autoimmune thyroiditis - Hashimoto's, atrophic
        • Hypothyroid phase of thyroiditis
        • Iatrogenic - radioiodine therapy, thyroidectomy, external irradiation of the neck
        • Drugs - amiodarone, lithium, interferons, interleukin-2, iodide
        • Iodine deficiency
        • Thyroid infiltration - amyloidosis, tumour
        • Congenital hypothyroidism
        • Secondary

        • Pituitary / hypothalamic pathology - trauma, tumour, surgery, radiation, infection, infarction, infiltration

        Overview

        • Large right-sided pneumothorax
        • No Overlay
          Overlay
          Large right-sided pneumothorax
           

        Diagnosis

        • Investigations

        • D-dimer (if Well's score <2)
        • ECG - sinus tachycardia, RBBB, right axis deviation, S1Q3T3
        • Arterial blood gas
        • Chest x-ray
        • Imaging - CT pulmonary angiogram vs. V/Q scan
        • Renal function (to guide choice of anticoagulant)
        • Consider

        • Venous duplex ultrasound - to assess for DVT
        • Echocardiogram - to assess for RV dilatation / strain
        • Pulmonary angiography (gold standard; rarely used)

        Management

        • Management Options for Crohn's Disease

        • Non-Pharmacologic

        • Smoking cessation
        • Nutritional optimisation
        • Psychologic supports
        • Cancer surveillance
        • Pharmacologic

        • Steroids - prednisolone, budesonide
        • Thiopurines - azathioprine, 6-mercaptopurine
        • Methotrexate
        • TNF blockers - infliximab, adalimumab
        • Surgical

        • Anorectal disease - fistulotomy, seton insertion

        Diagnosis

        • Upper lobe venous diversion
        • Upper lobe venous diversion
           
        • Diagnosis
           

        Management

        • Management of Gastroesophageal Reflux

        • Non-Pharmacologic

        • Weight loss
        • Smoking cessation
        • Avoidance of certain foods - fatty, spicy, acidic
        • Elevation of the head of the bed
        • Pharmacologic

        • Antacids
        • Proton pump inhibitors - omeprazole, esomeprazole, pantoprazole
        • H2 receptor antagonists - ranitidine, nizatidine
        • Surgical

        • Fundoplication

        Diagnosis

        • A low voltage ECG trace
        • A low voltage ECG trace
           

        Overview

        • Stages of ECG Findings in Pericarditis

        • Stage I - widespread concave ST elevation
        • Stage II - resolution of ST elevation, T wave flattening
        • Stage III - T wave inversion
        • Stage IV - resolution of T wave inversion

        Diagnosis

        • Diagnosis
           
        • Clinical Signs

        • General Signs

        • Oxygen
        • Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
        • Cough
        • Sputum - purulent, bloody
        • Lymphadenopathy - cervical, supraclavicular, axillary
        • Signs of Complications

        • Pleural effusion - dull percussion note, reduced breath sounds, reduced vocal resonance
        • Laryngeal nerve involvement - hoarse voice, dysphonic cough
        • SVC obstruction - facial swelling, plethora, upper limb oedema, positive Pemberton's sign
        • Pancoast tumour - Horner's syndrome (partial ptosis, miosis, anhydrosis), wasting of the small muscles of the hand
        • Hypertrophic pulmonary osteodystrophy
        • Signs of Management

        • Scars - from lobectomy or pneumonectomy
        • Radiation tattoos

        Manifestations

        • Signs of Pulmonary Hypertension

        • General Signs

        • Raised JVP
        • Parasternal heave
        • Palpable P2
        • Loud second heart sound (P2)
        • Evidence of tricuspid regurgitation - pansystolic murmur loudest at the lower left sternal edge on inspiration
        • Signs Suggesting a Cause

        • Evidence of connective tissue disease - Raynaud's, sclerodactyly, skin thickening, telangiectasia, synovitis
        • Evidence of portal hypertension - caput medusae, ascites, splenomegaly
        • Evidence of left ventricular failure - pulsus alternans, presence of S3, pulmonary crepitations
        • Evidence of pulmonary disease - hypoxia, hyperexpansion, crepitations, wheeze
        • Signs of Complications

        • Evidence of right ventricular failure - raised JVP, ascites, pleural effusions, peripheral oedema

        Diagnosis

        • Clinical Signs

        • Skeletal Muscle Fatiguability

        • Simpson's test - ptosis on sustained upward gaze
        • Peek sign - inability to maintain sustained eye closure
        • Bulbar fatiguability - development of nasal speech with reading
        • Proximal muscle fatigability - inability to maintain arms above the head
        • Signs of Management

        • Thymectomy scar
        • ECG Findings in WPW

        • Resting ECG

        • Short PR interval <120ms
        • Delta wave - slow rise of the initial portion of the QRS complex
        • Prolonged QRS duration >120ms
        • ST / T wave changes
        • Associated Arrhythmias

        • AV re-entrant tachycardia - a regular tachycardia with P waves during or after the QRS complex (orthodromic) or broad complex tachycardia (antidromic)
        • Atrial fibrillation - an irregular broad complex tachycardia
        • Atrial flutter - a regular broad complex tachycardia

        Overview

        Diagnosis

        • ECG Findings

        • Heart rate 100-250bpm
        • Regular rhythm
        • Late P waves - may be hidden within the QRS complex, cause a pseudo S wave in inferior leads / pseudo R wave in right precordial leads (slow-fast AVNRT), or appear after the QRS complex (fast-slow AVNRT)
        • Signs of Multiple Sclerosis

        • Signs of optic neuritis - reduced visual acuity, central visual loss, optic disc atrophy
        • Internuclear ophthalmoplegia - inability to adduct one eye, with nystagmus in the other eye
        • Lhermitte's sign - electric sensation in the limbs on neck flexion
        • Upper motor neuron weakness - increased tone, reduced power, hyperreflexia
        • Dorsal column (vibration / proprioception) sensory loss
        • Signs of cerebellar involvement - ataxia, dysarthria, dysmetria, dysdiadochokinesis, nystagmus

        Manifestations

        • Complications of COPD

        • Disease-Related

        • Pneumonia
        • Cor pulmonale
        • Pulmonary hypertension
        • Pneumothorax
        • Respiratory failure
        • Polycythaemia
        • Treatment-Related

        • Cushing's syndrome (steroids)
        • Oral candidiasis (steroids)
        • Tremor (beta agonists)

        Pathogenesis

        An excess of alpha chains, combined with ineffective haemoglobin production, lead to ineffective red cell production and shorted red cell lifespan. The resulting anaemia stimulates erythropoietin release and further red cell production, eventually producing bone marrow expansion and iron overload.

        Diagnosis

        • Signs of Chronic Liver Disease

        • General Signs

        • Sarcopaenia
        • Jaundice (a late sign)
        • Leukonychia
        • Signs Suggesting a Cause

        • Obesity (NAFLD)
        • Scratch marks (cholestasis)
        • Tattoos (viral hepatitis)
        • Kayser-Fleischer rings (Wilson's disease)
        • Cerebellar signs (alcohol misuse)
        • Signs of Complications

        • Portal hypertension - splenomegaly, caput medusae
        • Ascites - shifting dullness, fluid thrill
        • Oestrogen excess - palmar erythema, spider naevi, gynaecomastia
        • Encephalopathy - confusion, asterixis
        • Hepatic hydrothorax - reduced breath sounds, dull percussion note
        • Spontaneous bacterial peritonitis - fever, rigid / tender abdomen
        • Coagulopathy / thrombocytopaenia - bruising, bleeding
        • Signs of Management

        • Dressing over recent abdominocentesis site
        • Liver transplant scar
        • X-Ray Findings

        • Reduced joint space - generally symmetric
        • Articular surface erosions: discontinuities in the bone plate
        • Periarticular osteopaenia - hypodensity of bone surrounding the joint
        • Soft tissue swelling
        • Diagnosis
           
        • 2nd degree SA exit block: type II
        • 2nd degree SA exit block type II
           
        In order to further investigate the cause of hyponatraemia, first check the serum and urine sodium and osmolality at the same time.

        Manifestations

        • Complications of Asthma

        • Pneumonia
        • Atelectasis
        • Mucous plugging
        • Pneumothorax
        • Pneumomediastinum

        Diagnosis

        • Test Findings in Sickle Cell Anaemia

        • Full Blood Count & Film

        • Normocytic normochromic anaemia
        • Anisocytosis: variation in red cell size
        • Poikilocytosis - sickle cells, elliptocytes
        • Basophilic stippling
        • Immature red cells - polychromasia / nucleated red blood cells
        • Evidence of hyposplenism - target cells, Howell Jolly bodies, Pappenheimer bodies
        • Other Tests

        • Sickle solubility testing - 
        • High performance liquid chromatography / haemoglobin electrophoresis - presence of haemoglobin S with a lack of haemoglobin A
        • History

        • Symptoms of anaemia - fatigue, shortness of breath, reduced exercise tolerance, lightheadedness, worsening angina, ankle swelling
        • Pica - craving of non-foods such as ice, chalk and dirt
        • Restless legs syndrome
        • Blood loss - trauma, haematemesis, malaena, haematochezia, menorrhagia, haematuria
        • Plummer-Vinson syndrome: iron deficiency anaemia, dysphagia and oesophageal webs
        • Family history - bowel cancer
        • Diet

        Approach to Diagnosis

        Serological markers are useful for assessing for active or past hepatitis B infection.

        Diagnosis

        • Diagnosis

        Overview

        • Right middle lobe pneumonia - PA film
        • Right middle lobe pneumonia - PA film
           

        History of Presenting Complaint

        • Associated Symptoms

          Whether the pain is associated with any other symptoms.
        • Nausea, vomiting and diaphoresisSuggestive of angina / acute coronary syndrome
        • FeversSuggestive of pneumonia, pericarditis or costochondritis
        • Shortness of breathSuggestive of respiratory cause such as pneumonia, pneumothorax or PE
        • CoughSuggestive of pneumonia or reflux
        • Sour taste / acid refluxSuggestive of reflux pain

        Management

        • Non-Small Cell Lung Cancer

          Depends on the stage and the patient's functional status.
        • Non-Metastatic

        • Surgical resection (lobectomy) with or without adjuvant chemotherapy
        • Chemoradiotherapy
        • Metastatic

        • Immunotherapy - pembrolizumab, nivolumab
        • Targetted therapy - EGFR inhibitors, ALK inhibitors
        • Surgical resection
        • Chemotherapy
        • Radiotherapy

        Complications

        • Complications of Asthma

        • Pneumonia
        • Atelectasis
        • Mucous plugging
        • Pneumothorax
        • Pneumomediastinum

        Management

        • Management Options

        • Weight loss
        • Treatment of upper airway obstruction - mandible advancement splints, surgical correction
        • Continuous positive airway pressure (CPAP) at night
        • Smoking cessation
        • Alcohol reduction
        • Pearls

        • Smoking cessation has the greatest ability to influence the course of COPD
        • Tailor pharmacologic options to the severity of disease
        • Ensure that the patient has an exacerbation management plan in place
        • Contraindications to Anticoagulation

        • Absolute - active bleeding, major trauma, platelets <50, bleeding diathesis, perioperative
        • Relative - past incompressible bleed, intracranial or spinal tumour, platelets <100, large AAA, high falls risk

        Medication History

        • Timing

        • When they were started on the medication
        • If they are not on the medication indefinitely, how long they will take it for and whether they are on a weaning dose regimen.

        Diagnosis

        • Symptoms of Heart Failure

        • Fatigue
        • Dyspnoea
        • Orthopnoea
        • Paroxysmal nocturnal dyspnoea
        • Reduced exercise tolerance
        • Peripheral oedema

        Medication History

        • Timing

        • When they were started on the medication
        • If they are not on the medication indefinitely, how long they will take it for and whether they are on a weaning dose regimen.

        Management

        • Common Blood Pressure Targets

        • Most patients: <140/90
        • Diabetics: <130/80

        Management of Obesity

        • Management Options

        • Non-Pharmacologic

        • Diet - very low calorie; in conjunction with a dietician
        • Exercise - increase incidental exercise and reduce sedentary time; consider exercise classes involving a physiotherapist
        • Pharmacologic

        • Orlistat - an intestinal lipase inhibitor (essentially cases steatorrhoea)
        • Phentermine (Duramine) - an appetite suppressant
        • Naltrexone + buproprion (Contrave)
        • Surgical

        • Restrictive - gastric banding, sleeve gastrectomy
        • Malabsorptive - Roux-en-Y gastric bypass

        What is a Standard Drink?

        • One Standard Drink

        • Beer

        • 285mL full strength beer (4.8%) - 1.1 standard drinks
        • 375mL full strength beer (4.8%) - 1.4 standard drinks
        • 425mL full strength beer (4.8%) - 1.6 standard drinks
        • 285mL mid strength beer (3.5%) - 0.8 standard drinks
        • 375mL mid strength beer (3.5%) - 1 standard drink
        • 425mL mid strength beer (3.5%) - 1.2 standard drinks
        • 285mL low strength beer (2.7%) - 0.6 standard drinks
        • 375mL low strength beer (2.7%) - 0.8 standard drinks
        • 425mL low strength beer (2.7%) - 0.9 standard drinks
        • Wine

        • 150mL red wine (13%) - 1.5 standard drinks
        • 150mL white wine (11.5%) - 1.4 standard drinks
        • 150mL sparkling wine (12%) - 1.4 standard drinks
        • 60mL port (17.5%) - 1.4 standard drinks
        • Spirits

        • 30mL standard spirit (40%) - 1 standard drink

        Complications

        • Complications of Ischaemic Heart Disease

        • Atrioventricular (AV) block
        • Cardiogenic shock
        • Heart failure
        • Valvular pathology - e.g. acute mitral regurgitation
        • Ventricular rupture - septum / ventricular wall
        • Cardiac arrest

        Management

        • Management Options

        • Rate control - beta blockers, calcium channel blockers, digoxin
        • Rhythm control - DC cardioversion, flecainide, sotalol, amiodarone
        • Catheter ablation - of the pulmonary vein orifices
        • Anticoagulation (to prevent stroke) - warfarin, dabigatran, rivaroxaban, apixaban

        History of Presenting Complaint

        • Associated Symptoms

          Whether the shortness of breath is associated with any other symptoms.
        • Central chest painSuggestive of pneumonia, pneumothorax, MI or PE
        • Pleuritic chest painSuggestive of pneumonia, pleural effusion or PE
        • PalpitationsMay suggest arrhythmia or anxiety
        • CoughSuggestive of pneumonia, COPD, interstitial fibrosis or bronchiectasis
        • HaemoptysisMay be due to PE, lung cancer or tuberculosis
        • FeversSuggestive of pneumonia
        • WheezeSuggestive of asthma, COPD or pulmonary oedema
        • Leg pain and swellingThink about DVT and risk of PE

        Management

        Most patients with chronic kidney disease will die due to cardiovascular disease, so it is important to manage the risk factors of this.

        Complications

        • Complications of Diabetes

        • Glycaemic Instability

        • Diabetic ketoacidosis (mainly type 1, can occur with type 2) - ICU admissions, hospitalisations
        • Hyperglycaemic hyperosmolar state - ICU admissions, hospitalisations
        • Hypoglycaemic episodes
        • Microvascular Complications

        • Diabetic nephropathy - degree of chronic kidney disease; whether they see a nephrologist
        • Diabetic retinopathy - regular optometry review; past photocoagulation
        • Peripheral neuropathy - ulcers, amputations
        • Autonomic neuropathy - syncope, erectile dysfunction, gastroparesis, nocturnal diarrhoea
        • Macrovascular Complications

        • Ischaemic heart disease
        • Peripheral vascular disease
        • Cerebrovascular disease - past stroke / TIA
        • Infections

        • Mucocutaneous infections - candidiasis, Staphylococcus
        • Urinary tract infections - cystitis, pyelonephritis
        • Pulmonary infections - pneumonia

        Management

        • Management Options for Crohn's Disease

        • Non-Pharmacologic

        • Smoking cessation
        • Nutritional optimisation
        • Psychologic supports
        • Cancer surveillance
        • Pharmacologic

        • Steroids - prednisolone, budesonide
        • Thiopurines - azathioprine, 6-mercaptopurine
        • Methotrexate
        • TNF blockers - infliximab, adalimumab
        • Surgical

        • Anorectal disease - fistulotomy, seton insertion

        Medication History

        • Timing

        • When they were started on the medication
        • If they are not on the medication indefinitely, how long they will take it for and whether they are on a weaning dose regimen.

        The CAGE questionnaire

        • Ask About

        • Cut down - have they ever felt that they should cut down on their drinking?
        • Annoyed - do they get annoyed when other people talk to them about how much they drink?
        • Guilty - have they ever felt guilty about something they did as a result of their drinking
        • Eye opener - do they use alcohol to help them wake up in the morning?

        Management

        • Management Options

        • Non-Pharmacologic

        • Diet - high protein, high energy; salt restriction
        • Alcohol cessation
        • Treatment of Complications

        • Ascites - salt restriction, diuretics, paracentesis, TIPS
        • Varices - emergency management of bleeding, banding, beta blocker
        • Encephalopathy - identify and treat trigger, high protein diet, branched chain amino acids, lactulose, rifaximin
        • Spontaneous bacterial peritonitis - antibiotics, 20% albumin
        • Hepatorenal syndrome - exclude other causes of AKI, 20% albumin, terlipressin
        • Hepatopulmonary syndrome - liver transplant
        • Coagulopathy - consider vitamin K / factor replacement prior to procedures
        • Surveillance

        • Variceal surveillance - gastroscopies
        • HCC surveillance - liver ultrasound
        There is no specific treatment available for scleroderma, and therefore treatment is aimed at addressing organ involvement.

        Falls History

        • Significance

        • Falls in the elderly significantly increase the risk of devastating injuries - especially hip fractures and intracranial bleeds.

        Management

        • Pearls

        • Start treatment as early as possible
        • Aim for sustained remission or low disease activity
        • Monitor patients frequently
        • Change medications if they are not working
        • Pearls

        • Aim to prevent further damage
        • Minimise use of steroids

        Somatic Sensory Pathway

        Cortical Centre
        Primary sensory cortex (postcentral gyrus)
         
         
        Spinal Trigeminal Nucleus
        Medulla
         
         
        Foramen
        Jugular foramen
         
        Superior Ganglion
         
         
        Receptors
        Back of ear, external auditory meatus, external tympanic membrane

        Parasympathetic Pathway

        Visceral Nuclei
        Superior salivatory & lacrimal nuclei (pons)
         
        Pathway
        Tegmentum, red nucleus, medial substantia nigra
        Foramen
        Internal auditory meatus
         
        Geniculate Ganglion
         
         
        Muscle
        Lacrimal glands, salivary glands, nasal & palatine glands

        The Glasgow Coma Scale (GCS)

        • Causes of Unconsciousness

        • Intracranial

        • Haemorrhage - intracerebral, subarachnoid, subdural, extradural
        • Infarction
        • Infection - meningitis, encephalitis, abscess
        • Tumour - mass effect, cerebral oedema
        • Post ictal state
        • Head trauma - vascular, hypoxia, cerebral oedema, parenchymal injury
        • Psychiatric - conversion, depression, catatonia
        • Extracranial

        • Cardiovascular - shock, hypertension
        • Infection - septicaemia
        • Metabolic - hypo/hyperosmolar states, hypo/hyperglycaemia, hypoadrenalism, hypothyroidism, hypopituitarism, electrolyte abnormality, hypoxia, hepatic failure, renal failure
        • Drugs / toxins - sedatives, analgesics, alcohol, encephalopathy
        • Physical injury - hyper / hypothermia, electrocution

        Jaw Jerk Pathway

        Receptors
        Muscle spindle within mandible
         
         
        Foramen
        Foramen ovale
        V3
        Mandibular branch
         
        Trigeminal Ganglion
         
         
        Mesencephalic nucleus
        Midbrain, pons
         
         
        Trigeminal Motor Nucleus
        Upper pons
         
        V3
        Mandibular branch
        Foramen
        Foramen ovale
         
         
        Muscle
        Masseter

        Abducens Nerve (VI) Palsy

        • Causes of Palsy

        • Small-vessel ischaemia
        • Head trauma
        • Tumour
        • Aneurysm

        Visceral Sensory Pathway

        Cardiovascular & Respiratory Centres
        Reticular formation and hypothalamus
         
         
        Solitary Nucleus
        Medulla
         
         
        Foramen
        Jugular foramen
         
        Ganglia
        Superior (jugular) and
        inferior (petrous) ganglia
         
        Nerve to sinus
         
         
        Receptors
        Carotid sinus baroreceptors, carotid body chemoreceptors

        Extra Credit

        • Signs of Hypertensive Retinopathy

        • Grade 1 - silver wiring
        • Grade 2 - arteriovenous nicking
        • Grade 3 - flame-shaped haemorrhages, cotton wool spots
        • Grade 4 - papilloedema

        Warm-Up Phenomenon

        • How to Assess

        • Repeated eye closure - ask the patient to repeatedly close and open their eyes, looking for initial lag followed by improvement with repetition.
        • Grip myotonia - ask the patient to repeatedly grip and release your fingers, watching for initial muscle stiffness followed by relaxation with repeated performance

        Parasympathetic Pathway

        Visceral Nuclei
        Superior salivatory & lacrimal nuclei (pons)
         
        Pathway
        Tegmentum, red nucleus, medial substantia nigra
        Foramen
        Internal auditory meatus
         
        Geniculate Ganglion
         
         
        Muscle
        Lacrimal glands, salivary glands, nasal & palatine glands
        Pupillary and ciliary movement

        Facial Spasm

        • Look For

        • Involuntary spasm of the muscles on one or both sides of the face.

        Measuring Blood Pressure

        • How to Measure

        • Place a blood pressure cuff of the correct size around the bulk of the biceps with the artery indicator over the brachial artery. Inflate the cuff until the radial pulse can no longer be palpated, plus a further 30mmHg.

        Hepatomegaly

        • Interpretation

        • Measure the liver size by estimating the location of the upper and lower liver edges. Hepatomegaly is present if the liver span is greater than 15cm.

        Arterial Skin Changes

        • Significance

        • Partial or complete arterial occlusion.

        Renal Percussion

        Flank tenderness to percussion is a relatively sensitive sign for renal pathology, especially pyelonephritis and perinephric abscess.

        Rashes Associated with Renal Disease

        Calciphylaxis (calcific uraemic arteriopathy): mottled skin progressing to painful subcutaneous plaques / nodules that eventually form necrotic ulcersRare complication of CKD, especially dialysis patients

        Amplitude

        Waterhammer / collapsing pulse: strong pulse with sudden collapse.Aortic regurgitation, patent ductus arteriosus

        Non-Pitting Oedema

        • Causes of Non-Pitting Oedema

        • Impaired lymphatic drainage
        • Pretibial myxoedema (hypothyroidism)

        Rhythm

        • Interpretation

        • Regular: sinus rhythm
        • Sinus arrhythmia: rhythmic variations in vagal tone with respiration
        • Regularly irregular (regular heart rate with occasional missed or extra beats): second degree heart block, premature ventricular contractions
        • Irregularly irregular: atrial fibrillation

        Overview

        • Causes of Elevated JVP

        • Fluid overload - excessive IV fluids, renal disease, heart failure
        • Right ventricular systolic failure - cor pulmonale, left ventricular failure
        • Right ventricular diastolic failure - constrictive pericarditis, tamponade

        Waist-Hip Ratio

          • Normal Range

          • Males <0.9
          • Females <0.85

        Fluid Overload

        • Look For

        • Hypertension
        • Positive fluid balance in obs chart
        • Weight gain - look for a recent weight and compare to current weight
        • Bounding pulses
        • Raised JVP
        • Presence of S3 (gallop rhythm)
        • Crackles on lung field auscultation
        • Ascites - shifting dullness or fluid thrill
        • Pitting oedema to the sacrum and lower limbs, as well as elsewhere in the body in severe hypervolaemia

        Uraemic Foetor

        • Significance

        • Occurs in patients with end-stage renal failure.

        Venous Ulcers

        • Look For

        • Superficial painless red ulcers with moderate exudate, most commonly over the gaiter area (from mid-calf to 1cm below the malleoli)

        Claw Hand

        • Significance

        • Ulnar nerve lesion.

        Muscles Acting on the Wrist Joint

        Supinator (posterolateral) - supinator

        Splinter Haemorrhages

        • Look For

        • Painless longitudinal red / brown lines between 1-3mm on the nail bed.

        Bony Landmarks of the Hand

        Distal carpal bones - trapezium, trapezoid, capitate, hamate (including hook of hamate)

        Passive Movement

        • Causes of Limited Range of Motion

        • Trauma - dislocation, fracture
        • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, Reiter's syndrome
        • Intra-articular haemorrhage
        • Tendinitis
        • Bursitis
        • Intra-articular bleed
        • Tear - meniscus, ligament
        • Loose intra-articular body
        • Fibrous adhesions - surgery, trauma, overuse, inflammation
        • Muscle tightness
        • Prolonged joint immobilisation
        • Compartment syndrome

        Bony Landmarks of the Shoulder

        Greater tubercle of humerus - just lateral and inferior to the acromion. Tenderness may indicate rotator cuff tendinitis.

        Fasciculations

        • Causes of Fasciculations

        • Benign / normal
        • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob disease
        • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

        Muscles Acting on the Shoulder Joint

        External rotators - posterior deltoid, infraspinatus, teres minor

        Measuring Blood Pressure

        • Normal Blood Pressure

        • <120 / 80mmHg

        Antalgic Gait

        The presence of an antalgic gait indicates injury or other pathology causing pain on weightbearing.

        Muscles Acting on the Hip Joint

        External rotators - sartorius, gluteus maximus, iliacus, psoas major and minor, obturator internus and externus, piriformis, quadratus femoris

        Extra Credit

        • Shoulder Cross Syndrome

        • Elevation of shoulders - tight upper shoulder girdle fixators / weak lower shoulder girdle fixators
        • Protraction of shoulders -  tight shoulder girdle protractors / weak shoulder girdle retractors
        • Head forward + cervical lordosis - tight neck extensors / weak deep neck flexors

        Passive Movement

        • Causes of Limited Range of Motion

        • Trauma - dislocation, fracture
        • Arthritis - osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, reactive arthritis, psoriatic arthritis, Reiter's syndrome
        • Intra-articular haemorrhage
        • Tendinitis
        • Bursitis
        • Intra-articular bleed
        • Tear - meniscus, ligament
        • Loose intra-articular body
        • Fibrous adhesions - surgery, trauma, overuse, inflammation
        • Muscle tightness
        • Prolonged joint immobilisation
        • Compartment syndrome

        Bony Landmarks of the Hip

        Greater trochanter of femur - palpate by starting at the ischial tuberosity and moving laterally.

        Overview

        • Interpretation

        • Above the inguinal crease - indicative of a femoral hernia.
        • Below the inguinal crease - indicative of a direct or indirect inguinal hernia.
        • Can get above the mass - likely related to lesion within the scrotum such as a hydrocoele or varicocoele

        Fasciculations

        • Causes of Fasciculations

        • Benign / normal
        • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob disease
        • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

        Tachypnoea

        • Causes of Tachypnoea

        • Physiologic - during exercise or at high altitude
        • Anxiety
        • Metabolic acidosis - abdominal pathology, sepsis
        • Pulmonary embolism
        • Pneumonia
        • Asthma
        • Respiratory failure

        Nail Bed Cyanosis

        • Significance

        • Nail bed cyanosis is a type of peripheral cyanosis, characterised by elevated levels of deoxygenated haemoglobin (hypoxaemia) in the peripheries. Always look for central cyanosis (under the tongue) when this is present.

        Turner Syndrome

        • Cardiac Sequelae

        • Aortic coarctation
        • Bicuspid aortic valve
        • Mitral valve prolapse

        Overview

        • Interpretation

        • Normal gap-gap (1) - isolated high anion gap metabolic acidosis.
        • Low gap-gap (<1) - coexistant high anion gap and normal anion gap metabolic acidoses.
        • High gap-gap (>1) - coexistant metabolic acidosis and metabolic alkalosis.
        Therefore, the anion gap is the "gap" between measured cations and measured anions, suggesting the amount of unmeasured cations and anions present:

        Oxygen Dissociation Curve

        • The oxyhaemoglobin dissociation curve describes the relationship between PaO₂ and HbO₂:
        • At high PaO₂ (e.g. at the alveolar-capillary membrane) oxygen readily binds to haemoglobin.
        • At low PaO₂ (e.g. at systemic capillaries) oxygen is readily released from haemoglobin.

        Overview

        • Large right-sided pneumothorax resulting in significant atelectasis
        • No Overlay
          Overlay
          Large right-sided pneumothorax resulting in significant atelectasis
           

        Pacemaker

        • A single chamber pacemaker: PA film
        • No Overlay
          Overlay
          A single chamber pacemaker PA film
           

        Overview

        • Batwing opacities consistent with acute pulmonary oedema
        • Batwing opacities consistent with acute pulmonary oedema
           

        Dextrocardia

        Detrocardia commonly coexists with situs invertus, where the intraabdominal organs are on the contralateral side.

        Anterior-Posterior (AP)

        In order to take an anterior-posterior film, the x-ray plate is placed behind the patient, resulting in enlargement of the mediastinum.

        Overview

        • Right middle lobe pneumonia - PA film
        • Right middle lobe pneumonia - PA film
           

        Exposure

        Overpenetration results in an x-ray that is too radiolucent, where the fine details of the lung fields are unable to be properly visualised.

        Overview

        • A right-sided chest tube inserted post surgery
        • No Overlay
          Overlay
          A right-sided chest tube inserted post surgery
           

        PICC Lines

        A peripherally inserted venous catheter (PICC) line is a small but long line inserted into the arm and advanced into the central veins.

        Supine Film

        • Supine Film
           

        Overview

        • Right-sided rib fractures with a right pneumothorax and subcutaneous emphysema
        • No Overlay
          Overlay
          Right-sided rib fractures with a right pneumothorax and subcutaneous emphysema
           

        Silhouette Signs

        • Obscuration of the left hemidiaphragm suggesting right lower lobe consolidation
        • Obscuration of the left hemidiaphragm suggesting right lower lobe consolidation
           

        Overview

        • Causes of Pleural Effusion

        • Exudative

        • Malignancy
        • Infection - parapneumonic effusion, empyema, viral, fungal, TB, ruptured abscess / cyst
        • Pulmonary embolism (90% exudative)
        • Autoimmune disease - rheumatoid pleuritis, SLE
        • Pancreatitis
        • Haemothorax
        • Chylothorax
        • Asbestosis
        • Uraemia
        • Oesophageal rupture
        • Transudative

        • Heart failure
        • Cirrhosis
        • Hypoalbuminaemia
        • Nephrotic syndrome
        • Pulmonary embolism (10% transudative)
        • Myxoedema
        • Meig's syndrome
        • Constrictive pericarditis
        • SVC obstruction
        • Urinothorax

        White Blood Cells

        • Interpretation

        • Polymorphonuclear predominance (>500PMNs/μL) - suggestive of spontaneous bacterial peritonitis
        • Lymphocytic predominance - present in tuberculous peritonitis

        Overview

        • Excretion

        • Sodium is primarily excreted by the kidneys; it is freely filtered through the glomerulus and reabsorbed within the proximal convoluted tubule. Sodium is also excreted through sweat, tears, and faeces.

        2nd Degree SA Exit Block: Type I

        • Look For

        • Progressively shortened PP intervals, followed by a pause.

        1st Degree AV Block

        • 1st Degree AV Block
           

        Inclusion Bodies

        • Inclusion Bodies

        Reduced Reticulocytes

        • Significance

        • Near absence of reticulocytes is caused by bone marrow suppression, e.g. due to aplastic anaemia or cytotoxic chemotherapy.

        Manifestations

        • Clinical Features of Iron Overload

        • History

        • Fatigue
        • Cardiac involvement - palpitations, exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema
        • Hepatic involvement - jaundice, ascites, haematemesis, malaena, confusion
        • Endocrine involvement - diabetes mellitus, evidence of hypopituitarism or hypogonadism
        • Joint involvement - arthralgias
        • Examination

        • Bronze discolouration of skin
        • Hepatomegaly
        • Signs of heart failure - raised JVP, displaced apex beat, third heart sound, murmurs, crepitations, ascites, pedal oedema
        • Signs of decompensated liver disease - jaundice, leukonychia, palmar erythema, spider naevi, gynaecomastia, caput medusae, ascites, splenomegaly

        Iron Transport

        • Iron Transport

        Diagnosis

        The most specific marker of iron deficiency is serum ferritin, and as such a reduced serum ferritin makes iron deficiency likely. Ferritin can be elevated in the setting of an acute phase response and can appear normal, though a serum concentration above 100μg/L makes iron deficiency unlikely.

        Activated Monocytes

        • Features of Activated Monocytes

        • Increased nuclear : cytoplasmic ratio
        • Cytoplasmic vacuoles

        Microcytosis

        • Causes of Microcytosis

        • Iron deficiency anaemia - nutritional deficiency, blood loss, malabsorption, pregnancy
        • Anaemia of chronic disease (chronic infection / inflammation / malignancy)
        • Thalassaemia (alpha / beta)
        • Congenital sideroblastic anaemia
        • Hyperthyroidism
        • Lead poisoning
        • Copper deficiency

        Overview

        • Howell-Jolly bodies:
        • Howell-Jolly bodies
           

        Neutrophil Physiology

        • Neutrophil Physiology

        Thrombocytopaenia

        Thrombocytopaenia refers to a reduction in the number of circulating platelets.

        Lymphopaenia

        • Causes of Lymphopaenia

        • Primary immunodeficiency disorders - e.g. severe combined immunodeficiency, Wiskott-Aldrich syndrome
        • Infection - viral (especially HIV), bacterial, TB, malaria, fungal
        • Medications - corticosteroids, cytotoxic chemotherapy, methotrexate, azathioprine, rituximab
        • Dietary deficiency - severe malnutrition, alcohol abuse, zinc deficiency
        • Autoimmune disease (especially SLE)
        • Sarcoidosis
        • Hodgkin lymphoma
        • Aplastic anaemia
        • Radiotherapy
        • Post surgery

        Left Shift of Granulocytes

        • Causes of Left Shift of Granulocytes

        • Pregnancy
        • Infection / inflammation
        • G-CSF administration
        • Bone marrow infiltration - MPNS, leukaemias, lymphomas, myeloma, metastatic cancer

        Overview

        •  
         Myelodysplasia may also occur due to secondary causes which may be reversible.
        • A myelocyte, demonstrating left shift.
        • A myelocyte, demonstrating left shift.
           
        Triiodothyronine (T3) is both directly secreted by the thyroid and converted from T4.
        • Pearls

        • After treatment for thyrotoxicosis, TSH may remain suppressed even once the T4 has returned to normal.
        • Unwell patients with nonthyroidal illness may have a reduced TSH, while the TSH may elevate during the recovery phase of the illness.
        • In patients with pituitary or hypothalamic pathology (central hyper or hypothyroidism) the TSH will be deranged in the same direction as the thyroid hormones.
        • Resistance to thyroid hormone or TSH may result in an elevated TSH.
        • The presence of heterophile antibodies may result in falsely elevated or reduced TSH levels.

        Primary Hypothyroidism

        • Causes of Primary Hypothyroidism

        • Autoimmune thyroiditis - Hashimoto's, atrophic
        • Hypothyroid phase of thyroiditis
        • Iatrogenic - radioiodine therapy, thyroidectomy, external irradiation of the neck
        • Drugs - amiodarone, lithium, interferons, interleukin-2, iodide
        • Iodine deficiency
        • Thyroid infiltration - amyloidosis, tumour
        • Congenital hypothyroidism

        Hormonal Changes

        As nonthyroidal illness progresses and becomes more severe, T4 levels begin to fall; the mechanism of this is more complex. The total T4 level falls more significantly than the free T4, partly due to reduction in levels of thyroid binding globulin. TSH also becomes reduced, likely due to reduced hypothalamic function.

        Suppressed TSH with Normal T4

        Reduced TSH with a normal T4 level is suggestive of subclinical hyperthyroidism, a condition which is often asymptomatic. There are several other causes that make up the differential diagnosis.

        Primary Hyperthyroidism

        • Look For

        • Suppressed TSH with elevated T3 and elevated or normal T4.

        Hypoferritinaemia

        A reduced ferritin level is the most specific indicator of iron deficiency, as there are no other major causes of hypoferritinaemia.

        Quadrant Method

        Lead I has a purely leftward direction, and aVF has a purely inferior direction. Therefore, if leads I and aVF are positive then the direction of depolarisation is inferior and leftward, and the cardiac axis is normal.

        Measuring the QT Interval

        • Tangent Method

        • In order to accurately measure the QT interval, draw a tangent to the steepest part of the downsloping portion of the T wave and find the intersection between this tangent and the baseline - this is the true end of the T wave.

        Sinoatrial Rhythm

        • Examples

        Chest Electrode Placement

        • Positions

        • V1 - 4th intercostal space at the right sternal edge
        • V2 - 4th intercostal space at the left sternal edge
        • V3 - between V2 and V4
        • V4 - fifth intercostal space in the mid-clavicular line
        • V5 - fifth intercostal space between V4 and V6
        • V6 - fifth intercostal space in the mid-axillary line

        ECG Leads

        • Bipolar Limb Leads

        • Electrical potential difference is measured between two limb electrodes.

        Monomorphic Ventricular Tachycardia

        • Classification

        • Nonsustained VT - three or more ventricular beats at a rate of >100bpm, lasting less than 30 seconds, without haemodynamic instability
        • Sustained VT - a ventricular rhythm at a rate of >100bpm, lasting at least 30 seconds or with haemodynamic instability

        Extreme Axis Deviation

        Extreme axis deviation, also known as northwest axis, is highly suggestive of ventricular tachycardia.

        Overview

        • Mechanism

        • Typical atrial flutter occurs as a macro-reentrant circuit around the tricuspid valve annulus, most commonly in a counter-clockwise direction. The slow aspect of the sawtooth wave occurs as the impulse is conducted through the cavotricuspid isthmus.
        In antidromic AVRT, an atrial impulse is conducted by the abnormal accessory pathway and is then propagated retrogradely back through the AV node, commencing a re-entry circuit.
        • Causes of Atrial Fibrillation

        • Severe acute illness - especially in septic or postoperative patients
        • Cardiac - post cardiac surgery, myocardial infarction, valvular disease, cardiomyopathy, congestive cardiac failure, congenital heart disease, Wolff-Parkinson-White
        • Cardiovascular risk factors - hypertension, diabetes, obesity
        • Pulmonary embolism
        • Obstructive sleep apnoea
        • Thyrotoxicosis
        • Alcohol abuse
        In slow-fast AVNRT (90%), a premature atrial impulse travels down the slow pathway and is propagated up the fast pathway.

        Albumin

        The most abundant serum protein, produced by the liver. Important in maintaining oncotic pressure and transporting certain hydrophobic compounds.

        Diagnostic Criteria

        • Monoclonal Gammopathy of Uncertain Significance (MGUS)

        • Serum monoclonal protein <30g/L
        • Clonal bone marrow plasma cells <10%
        • No evidence of end-organ damage (hypercalcaemia, renal dysfunction, anaemia, bony lesions) or amyloidosis

        MDRD Formula

        There are also five-variable (including BUN) and six-variable (including albumin) MDRD formulae for eGFR.

        Overview

        The Brugada pattern in isolation is of unclear clinical significance, while the presence of clinical criteria with a type 2 or 3 pattern requires further investigation.
        • These then resolve and ST elevation develops in affected leads over minutes to hours, with ST depression in reciprocal leads. The ST elevation associated with myocardial infarction tends to be convex, and may become elevated above the T wave (tombstoning).
        • These then resolve and ST elevation develops in affected leads over minutes to hours, with ST depression in reciprocal leads. The ST elevation associated with myocardial infarction tends to be convex, and may become elevated above the T wave (tombstoning).
           
        • A low voltage ECG trace
        • A low voltage ECG trace
           
        • U wave inversion
        • U wave inversion
           
        LQT1LQT2LQT3
        ECG MorphologyBroad T wavesBifid T wavesLate T waves
        TriggerExertion, fright, swimmingAuditorySleep / rest
        • Causes of Pericarditis

        • Infection - viral, bacterial, tuberculous, fungal
        • Autoimmune - lupus, rheumatoid arthritis
        • Post myocardial infarction
        • Neoplastic
        • Uraemic pericarditis
        • Myxoedema
        •  
        • ECG Findings in Hyperkalaemia

        • Mild

        • Tall, tented T waves
        • Moderate

        • Reduction in P wave height
        • Long PR interval
        • Severe

        • Short QT interval
        • Widening of QRS complex
        • Sine wave QRS pattern
        • Life-Threatening

        • Asystole
        • ECG Findings in WPW

        • Resting ECG

        • Short PR interval <120ms
        • Delta wave - slow rise of the initial portion of the QRS complex
        • Prolonged QRS duration >120ms
        • ST / T wave changes
        • Associated Arrhythmias

        • AV re-entrant tachycardia - a regular tachycardia with P waves during or after the QRS complex (orthodromic) or broad complex tachycardia (antidromic)
        • Atrial fibrillation - an irregular broad complex tachycardia
        • Atrial flutter - a regular broad complex tachycardia
        Each of the classes of medications may be associated with other effects, for example due to concomitant sympathomimetic or anticholinergic actions of the drugs.
        • ECG Findings in Digoxin Toxicity

        • ST depression - down-sloping or scooped
        • T wave changes - flattening, inversion or biphasic T waves
        • Due to Increased Automaticity

        • QT shortening (due to reduced ventricular repolarisation time)
        • Premature beats - atrial, junctional or ventricular
        • Tachyarrhythmias - atrial tachycardia, accelerated junctional tachycardia
        • Due to Reduced Conduction

        • Prolonged PR interval
        • Bradyarrhythmias - sinus bradycardia, bundle branch block, AV block

        Physiology

        • Physiology
        B12 is also a cofactor for the conversion of L-methylmalonyl-CoA into succinyl-CoA by L-methylmalonyl-CoA mutase. Succinyl CoA is an intermediate in the citric acid cycle and is also involved in the synthesis of haemoglobin.

        LDH Isoenzymes

        • Interpretation

        • Elevated LDH1 and LDH2 - myocardial infarction, brain injury, renal pathology, haemolytic or megaloblastic anaemias
        • LDH1 > LDH2 ('flipped' LDH) - myocardial infarction
        • Elevated LDH2 and LDH3 - acute leukaemia
        • Elevated LDH3 and LDH4 - splenic or lung pathology
        • Elevated LDH5 - liver or skeletal muscular pathology

        Cholestatic LFT Derangement

        • Causes of Cholestasis

        • Intrahepatic Cholestasis

        • Hepatitis (viral or alcoholic)
        • Autoimmune liver disease - primary biliary cirrhosis, primary sclerosing cholangitis
        • Infiltrative liver disease - amyloidosis, sarcoidosis, tuberculosis, lymphoma
        • Malignancy - hepatocellular carcinoma, cholangiocarcinoma, metastasis
        • Non-malignant mass - abscess, cystic liver disease, haematoma
        • Sepsis
        • Acalculous cholecystitis
        • Intrahepatic cholestasis of pregnancy
        • Total parenteral nutrition
        • Drugs - augmentin, isoniazid, rifampicin, chlorpromazine
        • Extrahepatic Cholestasis

        • Choledocholithiasis
        • Bile duct stricture
        • Parasitic infection of bile duct
        • Primary sclerosing cholangitis
        • Pancreatitis
        • Pancreatic cyst
        • Malignancy - pancreas, ampulla, common bile duct, gallbladder

        Clinical Use

        • Contraindication

        • Heart failure.

        Overview

        • Effects

        • Reduce contractility (negative inotropy)
        • Reduce heart rate (negative chronotropy)
        • Reduce electrical conduction (negative dromotropy)
        • Reduce cardiac relaxation (negative lusiotropy)

        Clinical Use

        Loop and thiazide diuretics allow for increased sodium delivery to the distal convoluted tubule, resulting in stimulation of the aldosterone-sensitive sodium pump that reabsorbs sodium in exchange for potassium. This is the mechanism for the hypokalaemia seen with these diuretics.
        • Indications

        • Stable angina pectoris
        • Acute chest pain (GTN)
        • Oesophageal spasm (GTN)
        • Acute hypertension (GTN infusion)
        • Heart failure (GTN infusion / ISDN) - especially in the setting of hypertension or MI
        • Anal fissure (topical GTN)
        • Contraindications

        • AV block
        • Heart failure
        • Beta blockers - due to cardio depression
        • Adverse Effects

        • Anticholinergic - dry mouth, anhydrosis, tachycardia, blurred vision, urinary retention, constipation, raised intraocular pressure
        • Adverse Effects

        • Dizziness / headache / visual changes
        • Ventricular arrhythmias - VT / VF
        • Bradyarrhythmia - sinus bradycardia, heart block
        • Heart failure
        • Dyspnoea
        • Indications

        • Cardioversion of atrial fibrillation (Amiodarone)
        • Acute management of ventricular tachycardia
        • Severe refractory tachyarrhythmias - Wolff-Parkinson-White / supraventricular tachycardia, atrial fibrillation / flutter
        • Indications

        • Hypertension - second line therapy, indicated for patients with heart failure
        • Heart failure (carvedilol)
        • Prophylaxis of migraine (propranolol)
        • Essential tremor (propranolol)
        Alpha blockers provide symptomatic relief only in BPH - they do not affect the size of the prostate.
        •  
          Oral
          Ramipril
          Tritace, Prilace 
        • Indications

        • Hypertension
        • Angina pectoris
        • Rate control of atrial fibrillation
        • Prophylaxis for paroxysmal supraventricular tachycardia (verapamil)
        • Prevention  of cluster headaches (verapamil)
        • Prophylaxis of migraine (verapamil)

        Overview

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • Dyspepsia
        • Elevated LFTs
        • Indications

        • Elevated low-density lipoprotein (LDL)
        • Secondary prevention of coronary artery / cerebrovascular / peripheral vascular disease / diabetes

        Overview

        • Effects

        • Reduce contractility (negative inotropy)
        • Reduce heart rate (negative chronotropy)
        • Reduce electrical conduction (negative dromotropy)
        • Reduce cardiac relaxation (negative lusiotropy)
        • Vasoconstriction

        Clinical Use

        • Indications

        • Local anaesthesia / nerve blocks
        • Acute ventricular tachycardia
        • Torsades de pointes

        Overview

        • Effects

        • Vascular smooth muscle relaxation
        • Reduced tubular sodium and water reabsorption
        • Reduced aldosterone secretion
        • Reduced ADH secretion and water retention

        Pacemaker Action Potentials

        Although they are spontaneous, pacemaker action potentials can be modulated by external influences such as the autonomic nervous system, the endocrine system and electrolyte concentrations.

        Clinical Use

        • Indications

        • Heart failure
        • Atrial fibrillation
        • Adverse Effects

        • Reduced visual acuity
        • Peripheral neuropathy
        • Adverse Effects

        • Orange discolouration of bodily fluids
        • Hepatitis
        • Reflux

        Overview

        • Adverse Effects

        • Peripheral neuropathy
        • Nausea / vomiting / diarrhoea
        • Composition

        • Proteins - albumin, (immuno)globulins, fibrinogen
        • Coagulation factors
        • Carbohydrates
        • Lipids
        • Electrolytes
        • Hormones

        Clinical Use

        • Adverse Effects

        • Life-threatening haemorrhage
        • Hypersensitivity - rash, oedema, anaphylaxis
        • Cardiac arrhythmia
        • Hypotension
        • Indications

        • Prevention of venous thromboembolism (DVT / PE)
        • Treatment of venous thromboembolism (DVT / PE)
        • ST elevation myocardial infarction (STEMI)
        • Bridging anticoagulation for initiation / withholding of warfarin
        • Prevention of thrombosis during haemodialysis
        • Acute limb ischaemia
        • Adverse Effects

        • Haemorrhage
        • Nausea / vomiting
        • Indications

        • Prevention of venous thromboembolism (DVT / PE)
        • Treatment of venous thromboembolism (DVT / PE)
        • ST elevation myocardial infarction (STEMI)
        • Bridging anticoagulation for initiation / withholding of warfarin
        • Contraindications

        • Active bleeding
        • Recent GI / urinary bleeding
        • Recent major trauma / surgery
        • Recent ischaemic stroke
        • Intracranial haemorrhage, aneurysm, AVM or neoplasm
        • Current anticoagulant use
        • Pregnancy
        • Duration of Therapy

        • DVT due to transient cause - 3 months
        • PE due to transient cause - 6 months
        • DVT / PT with no obvious cause - 6-12 months
        • DVT/PE due to irreversible cause - indefinite
        • Contraindications

        • Active bleeding
        • Intracranial haemorrhage
        • Monitoring

        • A dilute thrombin time assay may be used to monitor dabigatran.
        • Adverse Reactions

        • Gastritis / peptic ulceration
        • Nephrotoxicity
        • Hypertension / fluid retention / congestive cardiac failure / MI
        • Hypersensitivity reactions
        • Delirium
        • Headache
        • Elevated LFTs
        • Neutropaenia
        • Contraindications

        • Active or recent internal bleeding
        • Past ischaemic stroke with residual deficit
        • Recent major trauma or surgery
        • Intracranial neoplasm, AVM or aneurysm
        • Past vasculitis
        • Adverse Effects

        • Cardiac dysfunction
        • Bone marrow suppression - leucopaenia, anaemia, thrombocytopaenia
        • Immunosuppression (susceptibility to infection)
        • Nausea / vomiting / diarrhoea
        • Abdominal pain
        • Dyspnoea / wheeze
        • Peripheral neuropathy
        • Arthralgias / myalgias
        • Headache
        • Dizziness
        • Flushing
        • Weight loss
        • Insomnia
        • Rash

        Substem A (Target)

        -k(i)-: interleukin (e.g. ustekinumab)

        Clinical Use

        • Indications

        • Locally advanced or metastatic non-small cell lung cancer (NSCLC) with progression post chemotherapy / targeted therapy (atezolizumab)
        • Locally advanced non-small cell lung cancer (NSCLC) without progression post chemoradiotherapy (durvalumab)
        • Locally advanced or metastatic urothelial carcinoma with progression post platnium-based chemotherapy (durvalumab)
        • Metastatic Merkel cell carcinoma (avelumab)
        • Adverse Effects

        • Acneiform rash
        • Nausea / vomiting / diarrhoea / constipation
        • Abdominal pain
        • Headache
        • Fatigue
        • Anorexia
        • Hypomagnesaemia
        • Elevated LFTs
        • Anaemia

        Overview

        • Microbiology

        • Effective against Cryptococcus and Candida. Voriconazole is also effective against moulds, including Aspergillus.

        Clinical Use

        • Indications

        • Invasive candidiasis
        • Cryptococcal meningitis
        • Aspergillosis
        • Adverse Effects

        • Hypersensitivity reactions
        • Nausea / vomiting / diarrhoea
        • Headache
        • Contraindication

        • Premenopausal patients (must be postmenopausal).
        • Indication

        • Androgen deprivation therapy for metastatic castrate-resistant prostate cancer.
        • Indication

        • Induction and maintenance of general anaesthesia.
        • Adverse Effects

        • Tachycardia
        • Hypertension
        • Diplopia / nystagmus
        • Raised intracranial pressure
        • Nausea / vomiting / anorexia
        • Adverse Effects

        • Hypersensitivity reactions - rash, oedema, anaphylaxis
        • Inadvertent IV administration - agitation, drowsiness, bradycardia, hypotension, ventricular arrhythmia, hyperkalaemia, hypoxia

        Overview

        Non-depolarising muscle relaxants such as atracurium, cisatracurium and rocuronium cause muscle relaxation without prolonged depolarisation of muscle cells.

        Clinical Use

        • Contraindications

        • Myopathies - including muscular dystrophy and rhabdomyolysis
        • Past history of malignant hyperthermia
        • Acute burns / multitrauma
        • Hyperkalaemia
        • Adverse Effects

        • Headache
        • URTI
        • Myalgia
        • Fluid overload
        • Weight gain
        • Increased risk of bladder cancer
        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • Lactic acidosis
        • Indication

        • Basal insulin for hyperglycaemic control over 24 hours, either alone or in combination with bolus dosing.
        • Adverse Effects

        • Headache
        • Hypertension
        • Nausea / vomiting / diarrhea / constipation
        • Arthralgia
        • Dizziness
        • Osteosarcoma (in rats)
        • Indications

        • Replacement therapy for adrenocortical insufficiency
        • Acute asthma
        • Exacerbations of COPD
        • Croup
        • Other inflammatory conditions - dermatitides, ulcerative colitis, autoimmune haemolytic anaemia, acute gout, rheumatoid arthritis, seronegative arthritides, systemic lupus erythematosus, polyarteritis nodosa
        • Cerebral oedema
        • Nephrotic syndrome
        • Immunosuppression post organ transplant

        Overview

        • Effects

        • Stimulation of insulin secretion in hyperglycaemia
        • Inhibition of glucagon secretion in hyperglucagonaemia
        • Slowed gastric emptying
        • Appetite suppression
        • Weight loss
        • Mechanism of Action

        • Stimulate insulin secretion by inhibiting dipeptidyl peptidase-4 (DPP-4), an enzyme that normally degrades incretin hormones.

        Clinical Use

        • Indications

        • Bolus dosing for type I or II diabetes
        • Insulin infusion for perioperative hyperglycaemic management
        • Insulin infusion for diabetic ketoacidosis

        Overview

        • Adverse Effects

        • Hypoglycaemia
        • Weight gain
        • Hypersensitivity reactions
        • Effects

        • Glucose

        • Increased glycogen synthesis
        • Reduced hepatic glycogenolysis (glycogen breakdown)
        • Reduced hepatic gluconeogenesis (glucose formation)
        • Increased GLUT-4 mediated glucose uptake into adipose tissue and skeletal muscle
        • Fat

        • Increased triglyceride synthesis
        • Reduced lipolysis
        • Protein

        • Increased amino acid uptake
        • Reduced protein breakdown
        • Potassium

        • Increased cellular potassium uptake

        Clinical Use

        • Adverse Effects

        • Hypoglycaemia
        • Weight gain
        • Hypersensitivity reactions
        To be given 30 minutes before meals when used as bolus dosing.
        • Adverse Effects

        • Hypoglycaemia
        • Nausea / vomiting / diarrhea
        • Thrombocytopaenia / leukopaenia / haemolytic anaemia
        • Weight gain

        Overview

        • Pharmacology

        • Patients should remain upright for at least 20 minutes after taking oral bisphosphonates, in order to reduce risk of oesophagitis / gastritis.
        • Often given in combination with calcium carbonate and cholecalciferol.

        Clinical Use

        • Adverse Effects

        • Neuropsychiatric - dizziness, lethargy, ataxia, agitation, insomnia
        • Palpitations
        • Orthostatic hypotension
        • Dry mouth
        • Nausea / vomiting
        • Constipation
        • Livedo reticularis
        • Contraindication

        • Dolutegravir is contraindicated in pregnancy due to risk of neural tube defects.

        Overview

        • Mechanism of Action

        • Analogues of deoxyribonucleosides that are converted to nucleotides.  Prevent viral reverse transcription of single-stranded RNA into double-stranded DNA, by inhibiting HIV reverse transcriptase.
        • Mechanism of Action

        • Analogues of nucleosides that are incorporated into viral DNA by viral DNA polymerase, resulting in premature DNA termination.

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting
        • Headache
        • Adverse Effects

        • Nausea / vomiting
        • Headache
        •  
          Oral
          Oxazepam
          Serepax 
           
          [Peak] 2-3 hours
          Half-life 5-15 hours
        • Adverse Effects

        • Drowsiness
        • Hypersalivation
        • Muscle weakness
        • Vertigo
        •  
          Oral
          Sertraline
          Zoloft 
        • Adverse Effects

        • Drowsiness
        • Hypersalivation
        • Muscle weakness
        • Vertigo

        Overview

        • Effects

        • Mesocortical pathway - cognitive impairment
        • Mesolimbic pathway - antipsychotic effects
        • Nigrostriatal pathway - extrapyramidal adverse effects
        • Tuberoinfundibular pathway - hyperprolactinaemia

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting / diarrhea
        • Adrenergic - postural hypotension
        • Histaminic - sedation, weight gain
        • Anticholinergic - dry mouth, blurred vision, constipation, urinary retention
        • Adverse Effects

        • Dry mouth
        • Constipation
        • Dizziness / headache
        • Drowsiness
        • Elevated LFTs
        • Weight gain
        • Sexual dysfunction
        • Postural hypotension
        • Serotonin syndrome (when MAOis given with SSRIs / SNRIs) - confusion, agitation, ataxia, hyperreflexia, fevers, diaphoresis
        •  
          Oral
          Quetiapine
          Seroquel 
        • Contraindication

        • Not for concurrent use with monoamine oxidase inhibitors (MAOi).
        • Contraindication

        • Megaloblastic anaemia due to folate deficiency.
        • Contraindications

        • Severe liver damage
        • Megaloblastic anaemia due to folate deficiency

        Overview

        • Microbiology

        • Effective against most staphylococci due to their ability to resist breakdown by beta lactamase. No activity against methicillin-resistant Staphylococcus aureus (MRSA).

        Clinical Use

        • Indications

        • Community-acquired pneumonia (including atypical pneumonia)
        • Mycobacterium avium complex (clarithromycin)
        • Group A streptococcus (erythromycin)
        • Chlamydia (azithromycin)
        • Pertussis (whooping cough)
        • Adverse Effects

        • Red man syndrome (vancomycin only) - immediate onset (4-10min after start of infusion) of pruritis and erythematous rash involving the face, neck and upper torso. Occurs when vancomycin is administered too rapidly.
        • Anaphylaxis
        • Nausea / vomiting / diarrhoea
        • Nephrotoxicity (rarely)
        • Adverse Effects

        • Hypersensitivity reactions
        • Nausea / vomiting / diarrhoea
        • Elevated LFTs
        • Indications

        • Respiratory tract infections (cefuroxime)
        • Skin infections (cefuroxime)
        • Abdominal surgical prophylaxis (cefoxitin)
        • Adverse Effects

        • Orange discolouration of bodily fluids
        • Hepatitis
        • Reflux

        Overview

        • Microbiology

        • Mostly active against gram positive cocci such as streptococci and enterococci; not effective against staphylococci

        Clinical Use

        • Adverse Effects

          Very few compared to penicillins.
        • Thrombophlebitis
        • Hypersensitivity reactions
        • Nausea / vomiting / diarrhoea
        • Pseudomembranous colitis (C difficile)
        • Thrombocytopaenia / leukopaenia
        • Nephrotoxicity

        Overview

        • Microbiology

        • Third generation cephalosporins are more active against gram negative bacteria (Haemophilus, Enterobacteriaciae) and less active against gram positive bacteria compared to earlier generation cephalosporins. They are inactive against MRSA.
        • Microbiology

        • Broad spectrum including most gram positives including Staph aureus, anaerobes, and some E coli

        Clinical Use

        • Adverse Effects

        • Rare.
        • Indications

        • Skin infections
        • Otitis media
        • Community-acquired pneumonia
        • Meningococcal meningitis
        • Genitourinary infections
        • Indications

        • Gastroenteritis (empirical agents of choice)
        • Genitourinary infections - UTI, PID, bacterial prostatitis
        • Skin infections
        • Osteomyelitis / septic arthritis
        • Anthracosis

        Pathogenesis

        • Causes of Left Bundle Branch Block

        • Ischaemic heart disease
        • Hypertension
        • Dilated cardiomyopathy
        • Rheumatic heart disease
        • Aortic stenosis

        Diagnosis

        • Test Findings in Alpha Thalassaemia

        • Full Blood Count & Film

        • Microcytic hypochromic anaemia
        • Anisocytosis: variation in red blood cell size
        • Poikilocytosis - target cells, teardrop cells, elliptocytes, fragments
        • HbH bodies (on supravital staining)HbH disease only
        • Basophilic stippling
        • Nucleated red blood cells
        • Other Tests

        • High performance liquid chromatography / haemoglobin electropheresis - increased haemoglobin HNormal in thalassaemia trait - used for the diagnosis of HbH disease only

        Management

        • Management Options

        • Non-Pharmacologic

        • Diet - low in salt
        • Exercise - increase incidental exercise and reduce sedentary time
        • Smoking cessation
        • Alcohol reduction
        • Pharmacologic

        • ACE inhibitors (ACEi) - captopril, ramipril, perindopril
        • Angiotensin II receptor blockers (ARBs) - candesartan, irbesartan
        • Calcium channel blockers (CCBs) - amlodipine
        • Thiazides - hydrochlorothiazide
        • Aldosterone antagonists - spironolactone
        • Alpha blockers - prazosin

        Diagnosis

        • Diagnostic Tests

        • ECG - single ECG or continuous inpatient monitoring
        • Holter monitor (24-48 hours)
        • External loop recorder
        • Implanted loop recorder
        • Bloods

        • Total calcium >2.60 mmol/L
        • Ionised calcium >1.35 mmol/L

        History of Presenting Complaint

        • Fluid Status

        • In patients with chronic kidney disease, assessment of fluid status is key. Ask about symptoms of fluid overload, such as lower limb swelling, orthopnoea or weight gain. Also ask about symptoms of fluid depletion, such as lightheadedness, thirst, weight loss or oliguria.
        • Description of a Single Episode

          Following a seizure, headache, syncope, presyncope or other concerning episode, certain questions can help to narrow down the list of differential diagnoses:
        • Before the episode - palpitations, lightheadedness, visual changes, other sensory changes
        • During the episode - length of the episode, loss of consciousness, arm / leg movement, eye movement, loss of consciousness, tongue biting
        • After the episode - focal limb weakness, fatigue, confusion
        • Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
        • Site - localised or generalised; unilateral or bilateral
        • Onset - sudden or gradual, and what the situation was (e.g. following trauma)
        • Character - sharp, dull, burning or pressure-like
        • Radiation - e.g. down the arm or across the back
        • Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
        • Timing - duration of symptoms, frequency of episodes, changes through the day
        • Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
        • Severity - on a scale of 1 to 10, with 10 being the worst

        Past Medical History

        Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.
        Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.
        Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.

        The Patient

        • Level of Consciousness

        • Gauge the patient's level of alertness and interactivity. For a more formal measure, assess the patient's glasgow coma scale.

        First Steps

        Always stand on the right side of the bed during the cardiovascular examination.

        Inspection

        • Colour

          Dark yellow or brown urine is classically a sign of dehydration, though urine may be a variety of colours that suggest underlying pathology:
        • Clear urine - high fluid intake, diabetes insipidus, diabetes mellitus, diuretic use
        • Yellow / orange urine - concentrated urine (dehydration), bilirubin
        • Brown urine - very concentrated urine (dehydration), haemoglobin (haemolysis), metastatic melanoma
        • Black urine - iron, L-dopa, metastatic melanoma, porphyria
        • Red urine - blood, haemoglobin (haemolysis), myoglobin (rhabdomyolysis), porphyria, beetroot, malingering
        • White urine - lipiduria, propofol infusion, proteinuria, pyuria (UTI), minerals (calcium, oxalate, phosphate)
        • Blue / green urine - amitriptyline, indomethicin, porphyria, pseudomonal infection, food dye
        • Purple urine - purple urine bag syndrome (UTI causing metabolism of tryptophan to indole then indicant)

        Red Cell Count & Haemoglobin

        Haemoglobin (Hb) is a protein within red blood cells which is composed of a haem molecule and four subunits. Haemoglobin transports oxygen and other molecules in blood. This is the most commonly used marker of anaemia.

        Assessing Oxygenation

        Normally, the PaO₂ is between 80 - 100mmHg, though this can be less in patients with chronic respiratory disease.

        First Steps

        Assess the exposure of the film - whether the image appears overpenetrated or underpenetrated.

        Causes of Haemolysis

        Thrombotic microangiopathies such as thrombotic thrombocytopaenic purpura (TTP), haemolytic-uraemic syndrome (HUS) and disseminated intravascular coagulation (DIC) are important causes of haemolysis and should not be missed. HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) may occur in pregnant patients. Mechanical haemolysis may be caused by severe valvular leaks, mechanical valves and other cardiac prostheses, by dialysis or ECMO circuits, or by repetitive trauma (e.g. by prolonged marching).

        Measures of Iron Status

        • Ferritin

        • Ferritin is an intracellular iron storage protein whose levels are indicative of the body's total iron stores.

        Pathogenesis

        • Causes of Acute Phase Response

        • Infection - bacterial, viral, fungal, parasitic
        • Tissue infarction - e.g. myocardial infarction, renal infarction, splenic infarction, acute limb ischaemia
        • Exogenous substances (i.e. foreign bodies)
        • Endogenous substances - uric acid crystals, calcium pyrophosphate crystals
        • Autoimmune disease
        • Allergies
        • Neoplasia
        • Trauma
        • Surgery
        • Burns

        White Blood Cells

        The presence of white blood cells in urine is referred to as pyuria. This tends to be an indicator of urinary tract infection, though there are several non-infective causes.

        Overview

        Arterial blood gases are also used to guide oxygen therapy in certain patients.

        Identifying an Artery

        When looking for an artery, place the index and middle fingers over the desired artery and feel for the area of maximal impulse.

        Equipment and Preparation

        • The following are required for catheter insertion:
        • Choosing the appropriate cannula size

          A variety of cannula sizes are available for different uses. These include:
        • 24 - paediatrics, fragile veins
        • 22 - paediatrics, fragile veins
        • 20 - everyday use, fluids, antibiotics, analgesia
        • 18 - everyday use, blood products, potassium, large volumes, surgery, IV contrast
        • 16 - trauma, major surgery, obstetrics, GI bleeds, large volumes
        • 14 - trauma, rapid infusion of large volumes

        Airway Manoeuvres

        Airway manoeuvres are used to relieve upper airway obstruction, and maintain a patent airway.

        Management

        • Common Blood Pressure Targets

        • Most patients: <140/90
        • Diabetics: <130/80

        Overview

        • New York Heart Association Classes

        • I
          No limitation of physical activity; ordinary physical activity does not cause symptoms
        • II
          Slight limitation of physical activity; comfortable at rest though ordinary physical activity causes symptoms
        • III
          Marked limitation of physical activity; comfortable at rest though less than ordinary activity causes symptoms
        • IV
          Unable to carry out any physical activity without discomfort; symptoms are present at rest and increase with any physical activity

        Diagnosis

        • ECG Findings

        • Ventricular rate 100-180bpm (may be <100 with block or medications)
        • Irregular rhythm
        • No P waves, with oscillating baseline waves
        • ECG Findings

        • Shortened QT interval (due to a shortened ST segment)
        • Osborn waves (J waves) - dome or hump-shaped deflections following the J point
        • QRS prolongation
        • PR prolongation

        History of Presenting Complaint

        • Other Key Aspects of History

          In patients with acute kidney disease, several features suggest a specific cause of renal failure. These may include:
        • Recent infections (recent pharyngitis may suggest post-streptococcal glomerulonephritis; diarrhoea, renal failure and thrombocytopaenia suggests HUS)
        • Extended immobility - time spent on the ground (a risk factor for rhabdomyolysis)
        • Recent imaging with contrast - when the contrast was given, and what type of contrast (a risk factor for contrast-induced nephropathy)
        • Pattern of Events over Time

        • If the type of episode has happened before, attempt to understand the natural history of these episodes. Ask about when the first event was, then the latest event was, the approximate frequency of events, and whether they remain complement normal between events.

        Past Medical History

        Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.

        I - Smell

        The olfactory nerve (cranial nerve I) provides olfactory sensation.

        The Patient

        • Inspect the Room

          Look around the room, as this can provide clues regarding the patient's diagnosis:
        • Cigarrettes are a sign of smoking, a significant cardiovascular risk factor.
        • Oxygen delivery suggests that the patient is hypoxic; this may for several reasons including pulmonary oedema or pulmonary hypertension.
        • GTN spray suggests that the patient has ischaemic heart disease.
        • Intravenous antibiotics in a patient with a murmur suggest infective endocarditis.
        • Any other medications that the patient may be taking, including intravenous infusions, puffers or tablets, may provide additional information.

        Inspection

        • Consistency

        • Turbid or cloudy urine suggests pyuria, due to infection or inflammation; the turbidity may also be due to lipids (lipiduria) or lymphatic fluid (chyluria). Frothy urine suggests the presence of proteinuria.

        Red Cell Count & Haemoglobin

        The haematocrit (Hct), also known as the packed cell volume (PCV), is the volume of red blood cells as a percentage of total blood volume. This value is often calculated by an automatic analyser based on the red cell count and mean cell volume (MCV).

        Assessing Oxygenation

        • Hypoxia, suggested by a reduced PaO₂, may occur in the context of many causes that can be roughly broken into four groups:
        • Low partial pressure of oxygen - high altitude
        • Hypoventilation - drugs, chronic obstructive pulmonary disease, obstructive sleep apnoea, encephalopathy, neuromuscular disease, chest wall abnormalities
        • V/Q mismatch - physiological shunt (atelectasis, APO, pneumonia), anatomical (intracardiac) shunt, dead space ventilation (airways disease, PE)
        • Decreased diffusion capacity (rare)

        Assessment of Bone

        To assess for a fracture, follow the edges of the bone around carefully looking for an obvious discontinuity of the cortex.

        Causes of Haemolysis

        Autoimmune haemolytic anaemias may be either warm or cold. Their causes are wide ranging and include infections, autoimmune disorders, lymphoproliferative disorders and drugs. Alloimmune haemolysis may occur following mismatched blood transfusion, in newborns, or post stem cell transplantation. Certain drugs may also cause immune haemolysis.

        Measures of Iron Status

        A reduced ferritin level is the most specific indicator of iron deficiency, as there are no other major causes of hypoferritinaemia. Note that inflammation or liver disease can falsely elevate serum ferritin, masking a concomitant iron deficiency.

        C-Reactive Protein

        C-reactive protein is an acute phase protein that is involved in innate immunity, and is responsible for activating the complement pathway.

        White Blood Cells

        • Causes of Pyuria

        • Infection - urethritis, prostatitis, cystitis, pyelonephritis, tuberculosis
        • Neoplasm - renal, bladder, protate
        • Inflammation - interstitial nephritis, interstitial cystitis, Kawasaki disease, SLE
        • Foreign body - renal calculus, indwelling catheter, ureteric stents
        • Polycystic kidney disease
        • Pelvic irradiation
        • Pregnancy

        Identifying a Vein

        • Methods to Assist with Finding a Vein

        • If you're having difficulty finding a vein, warm the area using blankets or a heat pack. Tap the vein repeatedly, which may make it more prominent. Ask the patient to pump their fist repeatedly, or hang the limb over the bed to increase the blood flow.

        Low Flow Oxygen

        Low flow oxygen devices deliver an amount of gas that is less than the patient's total minute ventilation.

        Identifying an Artery

        • Potential sites for arterial blood gas collection are:
        • Radial artery - laterally on the anterior aspect of the forearmThe most commonly used site
        • Brachial artery - medially within the antecubital fossa
        • Femoral artery - centrally within the femoral triangle, between the inguinal ligament, adductor longus and sartorius

        Equipment and Preparation

        • Choosing a catheter

        • A larger catheter is usually easier - go up a size rather than down if insertion is difficult.

        Identifying a Vein

        When identifying a vein, there are multiple factors to take into account. Ideally the vein should be large and the placement of the cannula should not limit movement.

        Airway Manoeuvres

        • Airway Manoeuvres

        • Head tilt and chin lift -  tilt the head backward into the sniffing position, opening the airway, and use the index and middle fingers to pull the mandible forward.
        • Jaw thrust - use the index and middle fingers on each hand to push the mandible anteriorly, moving the tongue forward.

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting / diarrhoea / anorexia
        • Pneumonitis
        • Alopecia
        • Soft tissue damage (if extravasation)

        Simple Face Mask

        FlowFiO₂
        5 L/min~0.36
        6 L/min~0.42
        7 L/min~0.48
        8 L/min~0.54

        Non-Rebreather Mask

        A non-rebreather mask includes a reservoir bag and an exhalation port - preventing gas from being reinspired. This requires a tight seal over the patient's face.

        Allen's Test

        • Interpretation

        • If the hand does not flush in 10-15 seconds then the ulcer circulation is inadequate, a contraindication to radial puncture on the limb in question.
        • Interpretation

        • If the hand does not flush in 10-15 seconds then the ulcer circulation is inadequate, a contraindication to radial puncture on the limb in question.

        Subclavian Vein

        • Considerations

        • Avoid in patients with clavicular fracture
        • Avoid in coagulopathic patients, as it is impossible to compress the artery if it is punctured
        • Avoid on the same side as a pacemaker

        Right Atrial Placement

        • Look For

        • Placement of the PICC in the right atrium or beyond.

        Preparation

        Prepare the site by decontaminating with an alcohol swab then allowing the area to air dry. 

        Lignocaine

        • Duration

        • 30 - 120 minutes

        Nasopharyngeal Airway

        • How to Insert

        • Point the bevel of the airway toward the midline
        • Insert the airway backward into the nasal cavity, until the flange reaches the nostril.

        Diagnosis

        • ECG Findings in Digoxin Toxicity

        • ST depression - down-sloping or scooped
        • T wave changes - flattening, inversion or biphasic T waves
        • Due to Increased Automaticity

        • QT shortening (due to reduced ventricular repolarisation time)
        • Premature beats - atrial, junctional or ventricular
        • Tachyarrhythmias - atrial tachycardia, accelerated junctional tachycardia
        • Due to Reduced Conduction

        • Prolonged PR interval
        • Bradyarrhythmias - sinus bradycardia, bundle branch block, AV block

        Hormonal Changes

        Severity of reduction in T3 and T4 in nonthyroidal illness is associated with risk of mortality.

        Diagnosis

        • Blood Gas Findings

        • Acidaemia with reduced bicarbonate.
        • Large right-sided pneumothorax resulting in significant atelectasis
        • No Overlay
          Overlay
          Large right-sided pneumothorax resulting in significant atelectasis
           

        Management

        • Management Strategies

        • Slow Progression

        • Treat the cause of CKD - e.g. diabetes, hypertension
        • ACE inhibitors - captopril, perindopril, ramipril
        • Angiotensin II receptor blockers - candesartan, irbesartan, telmisartan
        • Treat Complications

        • Acidosis - consider sodium bicarbonate
        • Fluid overload - fluid restriction, salt restriction
        • Anaemia - iron replacement if required, consider EPO
        • Cardiovascular disease - control hypertension, statin, consider aspirin
        • Mineral bone disease - dietary phosphate restriction, phosphate binders (calcium / non-calcium-based), calcitriol, parathyroidectomy
        • Malnutrition - high protein intake
        • Other

        • Dialysis - consider when to start and what modality
        • Renal transplant - consider suitability
        • Management Strategy

        • Treat the underlying cause
        • Sputum clearance - bronchodilators, mucolytics, hypertonic saline, physiotherapy, postural drainage
        • Reduce inflammation - using macrolides (azithromycin)
        • Manage infection - monitor for colonisation, consider antimicrobial prophylaxis
        • Vaccinations - influenza, pneumococcus
        • Nutritional support
        • Home oxygen
        • Lung transplant

        Manifestations

        • Clinical Features

        • Paraesthesia
        • Flaccid paralysis
        • Hypotension
        • Bradycardia
        • Arrhythmia

        Diagnosis

        • Small bilateral pleural effusions evidenced by bibasal costophrenic blunting
        • Small bilateral pleural effusions evidenced by bibasal costophrenic blunting
           
        • 2nd degree AV block: type I Mobitz
        • 2nd degree AV block type I Mobitz
           
        • Severity of Hypokalaemia

        • Mild - 3.0 - 3.5 mmol/L
        • Moderate - 2.5 - 3.0 mmol/L
        • Severe - <2.5 mmol/L
        • Examination

        • Signs of anaemia - conjunctival pallor, pale hand creases, tachycardia
        • Mucosal bleeding
        • Sepsis

        Overview

        • Right-sided rib fractures with a right pneumothorax and subcutaneous emphysema
        • No Overlay
          Overlay
          Right-sided rib fractures with a right pneumothorax and subcutaneous emphysema
           

        Diagnosis

        The D-dimer has high sensitivity (97-100%) and is very likely to be positive in the presence of PE. However, the test has poor specificity and positive predictive value as many other conditions can cause a positive result. The d-dimer is useful only in patients with a low pre-test likelihood of PE (as assessed using a tool such as the Well's Criteria) - a negative test in low risk patients makes a diagnosis of PE very unlikely. Ordering this test in non-low risk patients is likely to cloud the clinical picture as a positive result is difficult to interpret.
        • Batwing opacities consistent with acute pulmonary oedema
        • Batwing opacities consistent with acute pulmonary oedema
           
        In typical atrial flutter, 2:1 AV block is present with every second flutter wave resulting in a QRS complex. The block may also be 3:1, 4:1 or variable. 1:1 conduction is associated with extreme tachycardia and is immediately life-threatening.
        • Electrical alternans
        • Electrical alternans
           
        The presence of a type 1 pattern with at least one clinial criterion is diagnostic of Brugada syndrome.

        Management

        • Non-Small Cell Lung Cancer

          Depends on the stage and the patient's functional status.
        • Non-Metastatic

        • Surgical resection (lobectomy) with or without adjuvant chemotherapy
        • Chemoradiotherapy
        • Metastatic

        • Immunotherapy - pembrolizumab, nivolumab
        • Targetted therapy - EGFR inhibitors, ALK inhibitors
        • Surgical resection
        • Chemotherapy
        • Radiotherapy

        Manifestations

        • Complications of Pulmonary Hypertension

        • Pulmonary haemorrhage
        • Pulmonary arterial thrombosis
        • Right ventricular failure
        • Arrhythmias

        Diagnosis

        • ECG Findings

        • Heart rate >100bpm
        • Regular rhythm (RR interval)
        • Broad QRS complexes >120ms

        Management

        • Management Options for Myaesthenia Gravis

        • Maintenance

        • Anticholinesterase agents - pyridostigmine, neostigmine
        • Immunosuppression (uncommonly)
        • Thymectomy
        • Myaesthenic Crisis

        • IV immunoglobulin
        • Plasmapheresis
        • Respiratory support

        Diagnosis

        • Diagnosis
           

        Overview

        • Interpretation

        • Hepatitis C antibody (Anti-HCV) - indicative of past or current (acute or chronic) infection
        • Hepatitis C RNA - indicative of active infection

        Diagnosis

        • Diagnosis
           

        Management

        • Management Options for Multiple Sclerosis

        • Non-Pharmacologic

        • Smoking cessation
        • Vitamin D supplementation
        • Exercise
        • Weight loss
        • Pharmacologic

        • Beta interferon
        • Glatiramer acetate
        • Teriflunomide
        • Fingolimod
        • Cladribine
        • Natalizumab
        • Ocrelizumab
        • Alemtuzumab
        • Advanced Therapy

        • Autologous stem cell transplant

        Diagnosis

        • Signs of Chronic Obstruction Pulmonary Disease

        • General Signs

        • Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
        • Barrel chest (emphysema)
        • Tar-stained fingers (smoking)
        • Asterixis (CO2 retention)
        • Reduced chest expansion
        • Reduced breath sounds
        • Wheeze
        • Signs of Complications

        • Infective exacerbation - fevers, green sputum
        • Cor pulmonale - raised JVP, ascites, pleural effusions, peripheral oedema
        • Pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
        • Polycythaemia - polycythaemic facies
        • Steroid complications - Cushing's syndrome, oral candidiasis
        • Signs of Management

        • Oxygen
        • Inhalers
        • Lung transplant scar

        Manifestations

        Beta thalassaemia minor / trait tends to be asymptomatic, while beta thalassaemia intermedia and major may present with significant signs and symptoms.

        Management

        • Pearls

        • Treat the underlying cause of cirrhosis - e.g. treat viral hepatitis, alcohol cessation, weight loss
        • Treat complications
        • Monitor for further complications - varices and HCC
        • Pearls

        • Start treatment as early as possible
        • Aim for sustained remission or low disease activity
        • Monitor patients frequently
        • Change medications if they are not working

        Diagnosis

        • 3rd degree SA exit block
        • 3rd degree SA exit block
           
        • Diagnosis

        Management

        • Management Strategies

        • Lifestyle Measures

        • Avoidance of triggers
        • Smoking cessation
        • Pharmacologic Measures

        • Short-acting beta agonists (SABAs) - salbutamol, terbutaline
        • Long-acting beta agonists (LABAs) - salmeterol, formoterol, indacaterol
        • Inhaled corticosteroids (ICS) - beclomethasone, budesonide, fluticasone, ciclesonide
        • ICS / LABA combinations - budesonide / formoterol, fluticasone / salmeterol, fluticasone / formoterol, fluticasone / vilanterol
        • Monoclonal antibodies - omalizumab, mepolizumab

        Diagnosis

        • Diagnosis
           
        • Examination

        • Signs of anaemia - conjunctival pallor, pale hand creases, tachycardia
        • Nails - koilonychia, brittle nails
        • Scalp - alopecia
        • Mouth - atrophic glossitis, angular stomatitis
        • Abdomen - tenderness, mass

        Manifestations

        • Manifestations of Myotonic Dystrophy

        • Myotonia
        • Cognitive impairment
        • Cataracts
        • Hearing impairment
        • Endocrine - diabetes, hypogonadism, secondary hyperparathyroidism
        • Cardiovascular - arrhythmia, cardiomyopathy, sudden cardiac death
        • Respiratory - obstructive sleep apnoea
        • Gastrointestinal - transaminase elevation, constipation / diarrhoea
        • Hypogammaglobulinaemia

        Phases of Infection

        The immune active phase represents the immune system attempting to clear the infection. Active hepatitis will manifest as elevated ALT, while the HBV DNA titre will fall. The HBeAg may be positive; many patients seroconvert with development of anti-HBe antibodies during this phase.

        Diagnosis

        May be associated with ST depression / T wave inversion in V1 and V2
        • Bloods

        • Total calcium <2.15 mmol/L
        • Ionised calcium < 1.15 mmol/L

        Overview

        • Right middle lobe pneumonia - lateral film
        • Right middle lobe pneumonia - lateral film
           

        Clinical Use

        • Adverse Effects

          Very few compared to penicillins.
        • Thrombophlebitis
        • Hypersensitivity reactions
        • Nausea / vomiting / diarrhoea
        • Pseudomembranous colitis (C difficile)
        • Thrombocytopaenia / leukopaenia
        • Nephrotoxicity
        • Monitoring

          To ensure therapeutic levels and prevent toxic levels.
        • Clinically - monitor for ataxia and hearing loss
        • Bloods - monitor serum gentamicin levels and creatinine / urea

        Overview

        • Composition

        • Platelets
        • Additive solution - sodium chloride, sodium acetate, sodium citrate, sodium dihydrogenophosphate, disodium hydrogenophosphate, potassium chloride, magnesium chloride
        • Composition

        • Proteins - albumin, (immuno)globulins, fibrinogen
        • Coagulation factors
        • Carbohydrates
        • Lipids
        • Electrolytes
        • Hormones
        • Composition

        • Red blood cells
        • Additive solution - dextrose, sodium chloride, mannitol, adenine

        Clinical Use

        • Adverse Effects

        • Tremor
        • Palpitations
        • Hypokalaemia / hypomagnesaemia
        • Ketoacidosis (diabetics)
        • Adverse Effects

        • Headache
        • Tremor
        • Palpitations
        • Oropharyngeal candidiasis

        Overview

        • Non-Inflammatory Effects of Corticosteroids

        • Increased circulating glucose - ↑gluconeogenesis, ↓glucose usage
        • Redistribution of fats - in face, neck, shoulder
        • ↓ Absorption of Ca²⁺
        • Muscle homeostasis

        Clinical Use

        • Indication

        • Maintenance therapy for asthma
        • Adverse Effects

        • Dry mouth
        • Headache
        • Adverse Effects

        • Tremor
        • Palpitations
        • Headache
        • Dry Mouth
        • Indication

        • Second-line therapy for acute migraine.

        Overview

        • Non-Inflammatory Effects of Corticosteroids

        • Increased circulating glucose - ↑gluconeogenesis, ↓glucose usage
        • Redistribution of fats - in face, neck, shoulder
        • ↓ Absorption of Ca²⁺
        • Muscle homeostasis

        Clinical Use

        Benzodiazepines should be avoided for long-term management of anxiety.

        Clinical USe

        • Adverse Effects

        • Involuntary movements
        • Nausea / vomiting
        • Confusion
        • Postural hypotension

        Clinical Use

        • Reversal

        • N-acetylcysteine (NAC).

        Overview

        • Mechanism of Action

        • Inhibit cyclooxygenase, the enzyme responsible for production of thromboxanes, prostacyclin and prostaglandins from arachidonic acid.
        • Pharmacology

        • Readily cross the blood-brain barrier, resulting in drowsiness as a side effect.

        Clinical Use

        • Adverse Effects

        • Anxiety / restlessness / tremor
        • Tachycardia
        • Dyspnoea
        • Dizziness
        • Cold peripheries
        • Nausea / vomiting
        • Ischaemic injury
        • Indications

        • Allergic rhinitis
        • Urticaria
        • Adverse Effects

        • Nausea / abdominal pain
        • Weight gain
        • Headache
        • Depression
        • Breast pain
        • Contraindications

        • Pregnancy
        • Past DVT / PE
        • Ischaemic heart disease
        • Past stroke / TIA
        • Liver failure
        • Breast / uterine / cervical / ovarian cancer
        • Migraine with aura
        • Adverse Effects

        • Headache
        • Breast pain
        • Nausea / vomiting / bdominal pain
        • Dizziness
        • Depression
        • Irregular bleeding
        • Acne
        • Contraindications

        • Bleeding disorder / anticoagulants
        • Uncertainty about age of pregnancy
        • Suspected ectopic pregnancy
        • Adverse Effects

        • Electrolyte disturbances - hyponatraemia, hypokalaemia, hypomagnesaemia, hypophosphataemia
        • Hyperglycaemia
        • Dehydration
        • Indications

        • Moderate to severe rheumatoid arthritis
        • Psoriatic arthritis
        • Ankylosing spondylitis
        • Severe juvenile idiopathic arthritis (adalimumab, etanercept)
        • Severe refractory ulcerative colitis (adalimumab, infliximab, golimumab)
        • Severe refractory Crohn's disease (adalimumab, infliximab)
        • Psoriasis (adalimumab, infliximab, etanercept)
        • Hydradenitis suppuritiva (adalimumab)
        • Uveitis (adalimumab)

        Substem A (Target)

        -l(i)-: immunomodulating (e.g. adalimumab)

        Overview

        • Non-Inflammatory Effects of Corticosteroids

        • Increased circulating glucose - ↑gluconeogenesis, ↓glucose usage
        • Redistribution of fats - in face, neck, shoulder
        • ↓ Absorption of Ca²⁺
        • Muscle homeostasis

        Clinical Use

        • Adverse Effects

        • Electrolyte disturbances - hyponatraemia, hypokalaemia, hypomagnesaemia, hypophosphataemia
        • Hyperglycaemia
        • Dehydration
        • Adverse Effects

        • Fluid overload - electrolyte abnormalities, peripheral oedema, pulmonary oedema
        • Hyperchloraemic metabolic acidosis (NAGMA)
        • Adverse Reactions

        • Nausea / vomiting / diarrhea
        • Gastrointestinal ischaemia
        Does not result in an appreciable increase in serum lactate.
        • Indications

        • Severe hyperkalaemia
        • Glycaemic control for patients with type I or II diabetes

        Opioid Withdrawal

        • Signs of Withdrawal

        • Peak at day 2-3, resolved after 5-7 days
        • Agitation
        • Diaphoresis
        • Nausea / vomiting / diarrhea
        • Seizures

        Clinical Use

        • Indications

        • Acute and chronic pain
        • Opioid addiction (methadone)
        • Reversal

        • N-acetylcysteine (NAC).

        Overview

        • Pharmacology

        • Less histamine release (flushing, itching, rash) and less constipating than natural opioids.
        Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, diclofenac and meloxicam are commonly used to treat pain, fever and inflammation.

        Clinical Use

        • Indications

        • Moderate to severe rheumatoid arthritis
        • Psoriatic arthritis
        • Ankylosing spondylitis
        • Severe juvenile idiopathic arthritis (adalimumab, etanercept)
        • Severe refractory ulcerative colitis (adalimumab, infliximab, golimumab)
        • Severe refractory Crohn's disease (adalimumab, infliximab)
        • Psoriasis (adalimumab, infliximab, etanercept)
        • Hydradenitis suppuritiva (adalimumab)
        • Uveitis (adalimumab)
        • Indications

        • Chronic Myeloid Leukaemia

        • First line treatment for chronic myeloid leukaemia (imatinib)
        • Philadelphia chromosome positive chronic myeloid leukaemia in the chronic phase or with resistance or intolerance to imatinib (dasatinib, nilotinib)
        • Chronic myeloid leukaemia with resistance or intolerance to at least two other tyrosine kinase inhibitors, other with T315I mutation (ponatinib)
        • Others

        • Philadelphia chromosome positive acute lymphoblastic leukaemia (imatinib, dasatinib)
        • Hypereosinophilic syndrome (imatinib)
        • cKIT positive unresectable or metastatic gastrointestinal stromal tumours (imatinib)
        • Indications

        • Advanced or metastatic non-small cell lung cancer (NSCLC) with EGFR mutation
        • Locally advanced or metastatic non-small cell lung cancer after failure of primary chemotherapy (erlotinib)
        • Locally advanced, unresectable or metastatic pancreatic cancer (erlotinib)
        • Adverse Effects

          Paradoxically have less side effects than BRAF inhibitors alone.
        • Rash
        • Alopecia
        • Hyperkeratosis
        • Visual disturbance
        • Photosensitivity
        • Papillomas / squamous cell carcinomas
        • Nausea / vomiting / diarrhoea
        • Arthralgia / myalgia
        • Headache
        • Indications

        • Advanced renal cell carcinoma
        • Gastrointestinal stromal tumour (GIST) that has failed imatinib (sunitinib)
        • Unresectable, well-differentiated pancreatic neuroendocrine tumours (sunitinib)
        • Advanced soft tissue sarcoma (pazopanib)
        • Hepatocellular carcinoma (sorafenib)
        • Differentiated thyroid carcinoma (sorafenib)
        • Indications

        • Unresectable stage III or metastatic (stage IV) melanoma with BRAF (V600) mutation
        • Adjuvant treatment of melanoma with BRAF (V600) mutation and lymph node involvement (dabrafenib + trametinib)
        • Indications

        • Gastro-oesophageal reflux disease
        • Peptic ulceration
        • Zollinger-Ellison syndrome

        Overview

        • Non-Inflammatory Effects of Corticosteroids

        • Increased circulating glucose - ↑gluconeogenesis, ↓glucose usage
        • Redistribution of fats - in face, neck, shoulder
        • ↓ Absorption of Ca²⁺
        • Muscle homeostasis

        Clinical Use

        • Adverse Effects

        • Flatulence / diarrhea
        • Nausea / vomiting
        • Electrolyte disturbances
        • Resistance

        • Resistance to thiopurines may occur due to shunting of the 6-MP metabolism pathway to produce excess 6-MMP. Medication changes may be required if resistance develops.

        Disease History

        These are examples of questions to ask to further ellucidate the course of each of the patient's medical conditions.

        Falls History

        • Risk Factors for Falling

        • Poor vision
        • Cognitive impairment
        • Past stroke
        • Parkinson's disease
        • Cerebellar pathology
        • Impaired proprioception
        • Pain
        • Vertigo
        • Hypotension
        • Medications - especially sedatives, antihypotensives
        • Dangerous home environment - e.g. stairs, pets, clutter

        Medication History

        • Timing

        • When they were started on the medication
        • If they are not on the medication indefinitely, how long they will take it for and whether they are on a weaning dose regimen.

        What is a Standard Drink?

        • One Standard Drink

        • Beer

        • 285mL full strength beer (4.8%) - 1.1 standard drinks
        • 375mL full strength beer (4.8%) - 1.4 standard drinks
        • 425mL full strength beer (4.8%) - 1.6 standard drinks
        • 285mL mid strength beer (3.5%) - 0.8 standard drinks
        • 375mL mid strength beer (3.5%) - 1 standard drink
        • 425mL mid strength beer (3.5%) - 1.2 standard drinks
        • 285mL low strength beer (2.7%) - 0.6 standard drinks
        • 375mL low strength beer (2.7%) - 0.8 standard drinks
        • 425mL low strength beer (2.7%) - 0.9 standard drinks
        • Wine

        • 150mL red wine (13%) - 1.5 standard drinks
        • 150mL white wine (11.5%) - 1.4 standard drinks
        • 150mL sparkling wine (12%) - 1.4 standard drinks
        • 60mL port (17.5%) - 1.4 standard drinks
        • Spirits

        • 30mL standard spirit (40%) - 1 standard drink

        Complications

        • Complications of Renal Transplant

        • Surgical

        • Wound - bleeding, infection, poor healing
        • Urologic - obstruction, leak, haematoma, collection
        • Vascular - renal artery stenosis, renal vein stenosis, thrombosis
        • Acute tubular necrosis
        • Immunologic

        • Rejection - hyperacute, acute T-cell mediated, acute antibody-mediated, chronic
        • Infectious

        • Fungal infections - candida, aspergillus, cryptococcus
        • Viral infections - herpes simplex, varicella, CMV, EBV, influenza, BK virus, JC virus
        • Bacterial infections - mycobacterial, pneumococcal
        • Protozoal infections - pneumocystis, toxoplasmosis
        • Other

        • Cardiovascular disease
        • Diabetes mellitus
        • Osteoporosis
        • Malignancy - skin, bowel, gynaecologic, post-transplant lymphoproliferative disease
        • Disease recurrence
        • Complications of Allogeneic Stem Cell Transplant

        • Infectious

        • Fungal infections - candida, aspergillus, cryptococcus
        • Viral infections - herpes simplex, varicella, CMV, EBV, influenza, BK virus, JC virus
        • Bacterial infections - mycobacterial, pneumococcal
        • Protozoal infections - pneumocystis, toxoplasmosis
        • Non-Infectious

        • Mucositis
        • Bone marrow suppression
        • Graft vs host disease (GVHD) - acute / chronic
        • Post-transplant lymphoproliferative disorder
        • Sinusoidal obstructive syndrome (jaundice, hepatomegaly, fluid retention)
        • Rejection
        • Disease relapse

        Post-Transplant Management

        • Management Strategy

        • Transfusion support
        • Infective prophylaxis - e.g. bactrim, valaciclovir, fluconazole
        • Vaccinations

        Key Considerations

        • Clinical Cases

        • Interactive clinical cases can be an effective way to learn and practice diagnostic skills. Look for apps that offer a large number of case scenarios that have been edited by specialists, with feedback on each case including diagnostic reasoning, test results, and learning points. 

        Key Features

        • Customisability

        • The ability to customise flashcards is important because it allows you to create flashcards tailored to your individual learning needs. Platforms that offer a range of customisation options, such as the ability to add images, audio and video to flashcards, are more versatile and useful for medical study.

        Microsoft OneNote

        • Platforms

        • Mac, iOS, Android, Windows, web

        Key Features

        • Quality

        • The quality of the information presented, as well as the production value, are important factors in deciding which video resources to use. We priorisited resources that provide accurate and informative content through engaging visuals such as diagrams and animations.
        • Credibility

        • The videos in the channels and platforms below were created by reputable educators, medical professionals or institutions.
        • Focus on Stress Reduction

        • As stress and burnout can be a major concern to those in the medical field, we prioritised resources that were specifically designed to reduce stress and anxiety. Specific tools for achieving these include breathing exercises and body scans.
        • Evidence-Based Information

        • We chose resources that provide evidence-based information and are regularly updated.

        Notion

        • Platforms

        • Web, Windows, OSX, iOS, Android

        Life in the Fast Lane

        • Platforms

        • Web

        Types of Knowledge

        Knowledge may be subclassified into several different types, or dimensions. In order to succeed as a medical student and develop a mature understanding of the medical field, you will need a good measure of each of the different types of knowledge below.

        How Memory Works

        • Long-term memory has a much larger (almost limitless) capacity and can last for a lifetime. There are two types of long-term memory:
        • Explicit (declarative) - semantic (knowledge), episodic (experiences)
        • Implicit (non-declarative) - procedural (skills), emotional

        Optimise Your Study Environment

        It is important to set up a clearly designated space for study, and make sure that you have all of the materials you need close at hand. Everyone learns optimally in a different way, and over time you'll come to find what works best for you in terms of study environment.

        Flashcards: The Basics

        Flashcards are separated into decks, which may be grouped in different ways - for example, body systems or specialties - to help you focus your study efforts.

        Tools for Note-Taking

        The simplest tools for note-taking are a pen and paper. If handwriting notes, you may want to invest in a book to keep everything together. This can be further expanded with coloured pens, glued-in images, crayons, glitter or whatever it takes to help you learn.

        Lower Limb Cyanosis

        • Significance

        • Nail bed cyanosis is a type of peripheral cyanosis, or high levels of deoxygenated haemoglobin (hypoxaemia) in the peripheries. Always look for central cyanosis (under the tongue) when this is present.

        Body Mass Index

        • Classification

        • Underweight - <18.5
        • Normal - 18.5 - 24.9
        • Overweight - 25 - 29.9
        • Obese - 30 - 34.9
        • Severely obese - 35 - 39.9
        • Morbidly obese - 40+

        Venous Ulcers

        • Causes of Venous Ulcers

        • Venous hypertension due to incompetent valves
        • Venous outflow obstruction
        • Calf-muscle pump failure - obesity, immobility

        Upper Limb Myotomes

        Shoulder abduction: axillary nerve (C5)Lateral deltoid, supraspinatus

        Median Nerve Palsy

        • Median Nerve Syndromes

        • Carpal tunnel syndrome - compression of the median nerve beneath the flexor retinaculum at the wrist
        • Pronator teres syndrome - entrapment of the median nerve by the pronator teres
        • Anterior interosseous syndrome - palsy affecting the anterior interosseous nerve, a branch of the median nerve

        Pallor

        General inspection of the patient may provide some clue regarding pallor, though it is more significant to assess pallor of the nail beds, palmar creases and conjunctivae.

        Body Mass Index

        • Classification

        • Underweight - <18.5
        • Normal - 18.5 - 24.9
        • Overweight - 25 - 29.9
        • Obese - 30 - 34.9
        • Severely obese - 35 - 39.9
        • Morbidly obese - 40+

        Cervical Lymph Nodes

        Anterior cervical nodes - over sternocleidomastoidPosterior pharynx, tonsils, parotid

        Rashes Associated with GI Disease

        Porphyria cutanea tarda: blisters over sun-exposed areas such as the scalp, dorsal hands and forearms, neck and face.Liver disease (esp. hepatitis C), uraemia

        Common Signs on the Tongue

        Tongue mass - note the size, shape, consistency and colourTraumatic fibroma, SCC, papilloma

        Conjunctival Pallor

        • Significance

        • A sign of severe anaemia.

        Assessing Orientation

        • Ask About

        • Time - day, date, month, year, season
        • Place - floor, building, city, state, country
        • Person - full name, date of birth, address

        Purpura

        • Look For

        • Red / purple lesions that do not blanch with pressure. May be present over the head, arms, legs, chest or abdomen.

        Rashes Associated with GI Disease

        Porphyria cutanea tarda: blisters over sun-exposed areas such as the scalp, dorsal hands and forearms, neck and face.Liver disease (esp. hepatitis C), uraemia

        Focal Abdominal Tenderness

        Right iliac fossa- appendix, terminal ileum, caecum, ovary, fallopian tube, ureterAppendicitis, caecal diverticulitis, ovarian pathology, ectopic pregnancy, PID, inguinal hernia

        Plethora

        • Causes of Plethora

        • Cushing's syndrome
        • Polycythaemia rubra vera

        Scleral Icterus

        • Significance

        • A relatively sensitive indicator of jaundice, occurring prior to the development of colour change in the skin.

        Axillary Lymph Nodes

        Lateral nodes - lateral aspect of armpitMedial hand, forearm and arm

        Cervical Lymph Nodes

        Anterior cervical nodes - over the sternocleidomastoidPosterior pharynx, tonsils, parotid

        Abdominal Mass

        Left lumbar - descending colon, kidneyRenal tumour

        Antalgic Gait

        • Look For

        • A painful gait, with quick stance on the affected lower limb.

        Pendular Nystagmus

        Pendular nystagmus is less common, and manifests as equal movement to both sides (i.e. no fast or slow phase).

        Overview

        Exaggerated swaying may be an indicator of somatization or conversion disorder.

        Facial Spasm

        • Interpretation

        • Hemifacial spasm - compression of the facial nerve root in the cerebellopontine angle.
        • Bilateral facial spasm - oromandibular dystonia, associated with grinding of the teeth.

        Measuring Blood Pressure

        • Interpretation

        • The systolic blood pressure is the pressure where the first beating sound is heard (the first Korottkoff sound)
        • The diastolic blood pressure is the pressure where the beating sound disappears entirely (the fifth Korottkoff sound)

        Increased Body Temperature

        Fevers occur when the body's 'set point' of temperature is set to a higher level than normal. This results in responses aimed at increasing body temperature, including vasoconstriction and shivering.

        Bradypnoea

        Respiratory rate less than 12 breaths per minute.

        Measuring Oxygen Saturations

        • Troubleshooting

          If the pulse oximeter is not producing an accurate measurement, several measures can be attempted:
        • Remove any nail polish and clean the area
        • Warm the skin
        • Attempt at a different site
        • Attempt with a different probe or machine

        Bradycardia

        Heart rate less than 60 beats per minute.

        Lower Limb Pulses

        • Causes of Absent Lower Limb Pulses

        • Vascular trauma
        • Compartment syndrome
        • Peripheral vascular disease
        • Abdominal aortic aneurysm
        • Shock

        Hyperglycaemia

        • Acute Complications

        • Diabetic ketoacidosis (DKA)
        • Hyperglycaemic hyperosmolar state (HHS)

        Kussmaul Respiration

        Kussmaul respiration is associated with severe metabolic acidosis, especially due to diabetic ketoacidosis.

        Measuring Oxygen Saturations

        • Troubleshooting

          If the pulse oximeter is not producing an accurate measurement, several measures can be attempted:
        • Remove any nail polish and clean the area
        • Warm the skin
        • Attempt at a different site
        • Attempt with a different probe or machine

        Measuring Blood Pressure

        • Interpretation

        • The systolic blood pressure is the pressure where the first beating sound is heard (the first Korottkoff sound)
        • The diastolic blood pressure is the pressure where the beating sound disappears entirely (the fifth Korottkoff sound)

        APTT Mixing Studies

        The patient's plasma is mixed 50:50 with control plasma, and then the APTT is measured.

        The Coagulation Cascade

        • The Coagulation Cascade

        PT/INR Mixing Studies

        The patient's plasma is mixed 50:50 with control plasma, and then the PT/INR is measured.

        Neutrophil Physiology

        • The Neutrophil Life Cycle

        • Neutrophils are of granulocyte origin. They mature in the bone marrow and are then released into blood and tissues. Neutrophil proliferation and maturation is stimulated by granulocyte colony stimulating factor (G-CSF).

        Manifestations

        Beta thalassaemia minor / trait tends to be asymptomatic, while beta thalassaemia intermedia and major may present with significant signs and symptoms.

        Macrocytosis

        Macrocytosis refers to the presence of large red blood cells with mean corpuscular volume >100 fL.

        Hyperchromia

        Increased red cell haemoglobin (MCH / MCHC), or reduced central pallor on blood film.

        Haematocrit or Haemoglobin?

        Haematocrit and haemoglobin values are often used interchangeably. The haematocrit : haemoglobin ratio is often stable and usually  approximately 0.3.
        Haematocrit and haemoglobin values are often used interchangeably. The haematocrit : haemoglobin ratio is often stable and usually  approximately 0.3.

        Manifestations

        • Complications of Sickle Cell Anaemia

        • Haemolytic anaemia
        • Hypersplenism (early) - anaemia, thrombocytopaenia
        • Hyposplenism (late) - increased risk of infection, thrombocytosis
        • Vaso-occlusive disease - acute pain crises, stroke, acute chest syndrome, avascular necrosis, pulmonary hypertension, renal infarction, other micro-infarcts
        • Aplastic crisis (acute anaemia)

        Overview

        Tricuspid Area - the fifth intercostal space at the left sternal border. The murmurs of tricuspid stenosis and regurgitation are loudest in this area, as is the first heart sound (S1).

        Wheeze

        • Listen For

        • High-pitched musical sounds; usually expiratory.

        Left Lateral Position

        • Left Lateral Position

        Measuring Blood Pressure

        • Interpretation

        • The systolic blood pressure is the pressure where the first beating sound is heard (the first Korottkoff sound)
        • The diastolic blood pressure is the pressure where the beating sound disappears entirely (the fifth Korottkoff sound)

        Hepatomegaly

        • Scratch Test for Lower Liver Edge

        • Place the stethoscope over the liver just above the costal margin. Gently scratch the lower abdomen in the midclavicular line and slowly move up. Once the finger scratches over the lower liver edge the sound will be transmitted to the stethoscope.

        Conjunctival Pallor

        • Significance

        • A sign of severe anaemia.

        Heart Rate

        • Causes of Bradycardia

        • Sinus Bradycardia

        • Sinus node disease - idiopathic degeneration, myocardial infarction, infiltration, connective tissue disease, cardiac surgery, Lyme disease, endocarditis
        • Physiological - high cardiac fitness
        • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
        • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
        • Hypothyroidism
        • Hypothermia
        • Hyperkalaemia
        • Obstructive sleep apnoea
        • Raised intracranial pressure
        • Other Rhythms

        • Sinus node - sinus arrhythmia, sinus arrest, second or third degree sinoatrial exit block
        • Atrial - atrial fibrillation with slow ventricular response, atrial flutter with variable block, trial escape rhythm
        • AV node - second or third degree atrioventricular block, junctional escape rhythm
        • Ventricular escape rhythm

        Squatting

        • Interpretation

        • The murmur of hypertrophic cardiomyopathy is softer on squatting, and louder on standing.
        • The murmur of aortic stenosis is louder on squatting, and softer on standing.

        Lead Pipe Rigidity

        • Significance

        • Caused by Parkinson's disease, other causes of parkinsonism, and contractures.

        Hyporeflexia

        • Look For

        • Diminished or absent reflexes.

        Lateral Cutaneous Nerve Palsy

        Lateral cutaneous nerve palsy is also known as meralgia paraesthetica.

        Myotomes

        Hip flexion: femoral nerve (L2-L4)Iliopsoas

        Lead Pipe Rigidity

        • Feel For

        • Continuous rigidity that is not velocity dependant, resulting in slow flexion and extension.

        Intention Tremor

        This is best demonstrated with the finger-nose test, where the patient is asked to use their index finger to touch their nose and then your finger. Their finger will tremor increasingly as it approaches its target.

        Overview

        Therefore clinical testing of vibration is mediated by pacinian corpuscles.

        Extra Credit

        • Additional Causes of Limited Elbow Range of Motion

        • Fracture - humerus, radius, ulna
        • Epicodylitis - medial (golfer's elbow), lateral (tennis elbow)
        • Olecranon bursitis
        • Biceps tendinitis
        • Radial head dislocation
        • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis

        Bony Landmarks of the Ankle

        Cuboid - a tarsal bone of the lateral foot, distal to the calcaneus.

        Overview

        • Causes of Limited Ankle Range of Motion

        • Achilles tendinitis
        • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis

        Nail Discolouration

        • Interpretation

        • Brown / black nail - may indicate subungal haematoma, fungal infection or subungal melanoma.
        • Yellow nail - may be indicative of bronchiectasis, chronic bronchitis, lymphoedema
        • Leukonychia (white nail) - associated with low serum albumin

        Antalgic Gait

        • Look For

        • A painful gait, with quick stance on the affected lower limb.

        Extra Credit

        • Pelvic Cross Syndrome

        • Increased lumbar lordosis - tight hip flexors / weak hip extensors
        • Protuberant abdomen - tight lumbar extensors / weak lumbar flexors
        • AP pelvic tilt - tight tensor fascia lata / weak hip abductors
        • Lateral pelvic tilt - tight quadratus lumborum

        Antalgic Gait

        • Look For

        • A painful gait, with quick stance on the affected lower limb.

        Word Repetition

        • How to Assess

          Ask the patient to repeat back words or sentences of increasing complexity.
        • Orange
        • Watch
        • Hippopotamus
        • Aubergine
        • Emerald
        • Perimeter
        • No ifs, ands or buts
        • British Constitution
        • The orchestra played and the audience applauded

        Quantity of Speech

        Speech quantity is the amount of speech produced by an individual, helping to identify patterns of over-talkativeness or paucity of speech.

        Assessing Anterograde Memory

        • Causes of Amnesia

        • Intracranial - stroke, trauma, tumour, infection, epilepsy, degenerative disease
        • Substances - intoxication, withdrawal, Korsakoff's
        • Psychiatric - schizophrenia, psychogenic amnesia
        • Insufficiency - liver, heart, kidneys
        • Hypoxia / anoxia
        • Malingering

        Extra Credit

        • Pelvic Cross Syndrome

        • Increased lumbar lordosis - tight hip flexors / weak hip extensors
        • Protuberant abdomen - tight lumbar extensors / weak lumbar flexors
        • AP pelvic tilt - tight tensor fascia lata / weak hip abductors
        • Lateral pelvic tilt - tight quadratus lumborum

        Antalgic Gait

        • Look For

        • A painful gait, with quick stance on the affected lower limb.

        Muscles Acting on the Thoracic / Lumbar Spine

        Lateral flexors - quadratus lumborum, internal & external oblique, multifidus

        Tonsils

        • Interpretation

        • Asymmetric swelling - may be associated with uvular deviationPeritonsilar abscess (quinsy)
        • Symmetric swellingTonsillitis

        Bradypnoea

        • Causes of Bradypnoea

        • Respiratory suppression
        • Drugs - opioids
        • Respiratory failure
        • Hypothyroidism
        • Raised intracranial pressure

        Cervical Lymph Nodes

        Anterior cervical nodes - over sternocleidomastoidPosterior pharynx, tonsils, parotid

        The Oxygen Dissociation Curve

        • Significance

        • As the curve shifts to the left, oxygen will more readily bind to haemoglobin. As the curve shifts to the right, oxygen will more readily be released from haemoglobin.

        Muscles Acting on the Hand

        Extrinsic Finger flexors - flexor digitorum superficialis, flexor digitorum profundus

        Fasciculations

        • Look For

        • Visible, spontaneous localised muscle contraction and relaxation.

        Bony Landmarks of the Hand

        Metacarpals - palpate the bases, bodies and heads of each of the metacarpals. Squeeze across the metacarpal heads.

        Extra Credit

        • Additional Causes of Limited Wrist Range of Motion

        • Fracture - radius, ulna, carpals
        • Nerve damage - radius, ulna, median nerve

        Amplitude

        Pulsus tardis & parvis: weak pulse with a delayed systolic peakAortic stenosis

        Arterial Skin Changes

        • Causes of Arterial Skin Changes

        • Atherosclerosis
        • Diabetes
        • Thromboangiitis
        • Vasculitis

        Pupillary Light Reflexes

        • Causes of Absent Pupillary Reflexes

        • Intraocular conditions - glaucoma, retinal detachment
        • Optic (II) nerve lesion - trauma, compression, optic neuritis
        • Midbrain lesion - encephalitis, tumour, trauma, haemorrhage, MS, midbrain infarct
        • Oculomotor (III) nerve lesion - trauma, compression, small vessel ischaemia, Guillain barré
        • Medications - sympathomimetic, parasympatholytic (anticholinergics), barbiturates, methanol

        Rashes Associated with Diabetes

        Necrobiosis lipoidica: painless irregular plaques over the proximal shin with a yellow centre and purple peripheryType 1 diabetes

        Physiology

        • Physiology

        Hyperalbuminaemia

        Increased serum albumin is uncommon, and strongly suggests dehydration.

        Clinical Use

        • Adverse Effects

        • Fatigue
        • Oedema
        • Dizziness
        • Headache
        • Nausea / abdo pain
        • Indications

        • Hypertension - second-line therapy, especially indicated for patients with stable angina or post MI.
        • Stable heart failure (bisoprolol / metoprolol)
        • Rate control for atrial fibrillation
        • Prophylaxis for paroxysmal supraventricular tachycardia
        • Post myocardial infarction (12 hours after onset of chest pain)
        • Adverse Effects

        • Flushing
        • Headache / dizziness
        • Nausea / vomiting
        • Postural hypotension / tachycardia / syncope
        • Adverse Effects

        • Constipation
        • Dizziness
        • Headache
        • Nausea
        • Adverse Effects

        • Elevated LFTs
        • Torsade de pointes
        • Bradycardia
        • Hypotension
        • Hypo / Hyperthyroidism
        • Extrapyramidal effects
        • Contraindications

        • Asthma
        • Decompensated heart failure
        • AV block
        • Contraindications

        • Renal artery stenosis (precipitates renal failure)
        • Pregnancy
        • Hyperkalaemia

        Overview

        • Mechanism of Action

        • Inhibit angiotensin converting enzyme, which converts angiotensin I to angiotensin II.

        Clinical Use

        • Contraindications

        • AV block
        • Heart failure
        • Beta blockers - due to cardio depression
        Rarely used due to replacement by other drugs.
        • Effects

        • Reduce LDL by 20-60%
        • Reduce triglycerides by 10-35%
        • Increase HDL by 5-15%
        • Reduce total mortality
        • Reduce incidence of coronary artery disease
        • Reduce recurrence of unstable angina
        • Indications

        • Hypertension - second-line therapy, especially indicated for patients with stable angina or post MI (atenolol / metoprolol / nebivolol)
        • Stable heart failure (bisoprolol / metoprolol / nebivolol)
        • Rate control for atrial fibrillation (atenolol / metoprolol)
        • Prophylaxis for paroxysmal supraventricular tachycardia (atenolol / metoprolol)
        • Post myocardial infarction (12 hours after onset of chest pain) (atenolol / metoprolol)
        • Migraine prophylaxis (metoprolol)
        • Adverse Effects

        • Lightheadedness
        • Confusion
        • Drowsiness
        • Bradycardia / hypotension / cardiac arrest
        • Indications

        • Hypertension - first line management, especially in patients with chronic kidney disease (CKD)
        • Heart failure (candesartan / irbesartan)
        • Diabetic nephropathy (irbesartan)

        Pacemaker Action Potentials

        • Pacemaker Action Potentials

        Clinical Use

        Digoxin was previously the preferred agent for rate control of AF, though other medications such as beta blockers and calcium channel blockers have taken over. Many patients are still on digoxin for rate control of AF.
        • Indications

        • INR >1.6 in patients not on warfarin
        • Warfarin reversal - major haemorrhage, emergent presurgical
        • Disseminated intravascular coagulation (DIC)
        • Massive transfusion
        • Adverse Effects

        • Haemorrhage
        • Heparin-induced thrombocytopaenia (HIT) - thrombocytopaenia with arterial and venous thrombosis
        • Hypersensitivity
        • Skin necrosis
        • Monitoring

        • Anti-factor Xa assays may be used to assess for the therapeutic effect of apixaban and rivaroxaban, though there are no established target levels.
        • Adverse Effects

        • Haemorrhage
        • Hypersensitivity
        • Elevated LFTs
        • Thrombocytopaenia (less commonly than heparin)
        • Adverse Effects

        • Life-threatening haemorrhage
        • Hypersensitivity - rash, oedema, anaphylaxis
        • Cardiac arrhythmia
        • Hypotension
        • Adverse Effects

        • Haemorrhage
        • Skin necrosis
        • Cholesterol microemboli
        • Adverse Effect

        • Haemorrhage.
        • Reversal

        • Idarucizumab (praxbind) may be used to reverse dabigatran in life-threatening situations only.
        • Adverse Effects

        • Bleeding
        • Thrombocytopaenia
        • Nausea / vomiting

        Substem A (Target)

        -l(i)-: immunomodulating (e.g. adalimumab)

        Clinical Use

        • Adverse Effects

        • Immune-Related

        • Endocrinopathies - thyroiditis, adrenalitis, hypophysitis, diabetes mellitus
        • Pulmonary toxicity - pneumonitis
        • Hepatotoxicity - LFT derangement, hepatitis
        • GI toxicity - colitis
        • Rheumatological - flares of previous disease
        • Skin - rash, pruritis
        • Other

        • Fatigue
        • Anorexia
        • Headache
        • Dizziness
        • Nausea / vomiting / diarrhoea
        • Thrombocytopaenia
        • Indications

        • Cryptococcal meningitis
        • Invasive candidiasis
        • Aspergillosis (voriconazole)
        • Adverse Effects

        • Infusion reactions - fevers, rigors, arthralgias, hypotension, bronchospasm
        • Nephrotoxicity
        • Anaemia
        • Adverse Effects

        • Hot flushes
        • Vaginal dryness / bleeding
        • Reduced libido
        • Arthralgia / joint stiffness
        • Headache
        • Nausea / vomiting / diarrhoea / anorexia
        • Rash
        • Alopecia
        • Osteopaenia
        • Contraindications

        • Seizure disorders.
        • Contraindications

        • Past unexplained jaundice or malignant hyperthermia following halothane administration
        • Raised intracranial pressure
        Minimal effect on respiratory drive.

        Overview

        • Mechanism of Action

        • Competitively inhibit the action of acetylcholine on postsynaptic nicotinic receptors, preventing acetylcholine-mediated muscle contraction.

        Clinical Use

        • Adverse Effects

        • Hypersensitivity reactions - rash, flushing, anaphylaxis
        • Bradycardia
        • Hyperkalaemia
        • Raised intracranial, intraabdominal and intraocular pressures
        • Muscle pain / weakness
        • Rhabdomyolysis
        • Malignant hyperthermia
        Only reduce blood glucose levels in the case of hyperglycaemia, therefore don't cause hyperglycaemia as much as sulfonylureas.
        • Adverse Effects

        • Hypoglycaemia
        • Weight gain
        • Hypersensitivity reactions
        • Adverse Effects

        • Immunosuppression (risk of infection)
        • Osteoporosis
        • Steroid-induced diabetes mellitus
        • Cushing's - central obesity, 'moon' face, buffalo hump, thin skin, peripheral oedema, striae, bruising
        • CNS - cognitive impairment / emotional instability / fatigue
        • Renal - sodium & water retention / hypertension / oedema
        • GIT - peptic ulceration, nausea / vomiting
        • Muscle wasting
        • Ocular - cataract / glaucoma
        • Indications

        • Glycaemic control for type II diabetics
        • Adjunctive therapy for weight loss

        Overview

        The incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic hormone (GIP), are released from the gastrointestinal tract. The incretins stimulate insulin secretion and inhibit glucagon secretion only under hyperglycaemic conditions, with additional effects of delayed gastric emptying, appetite suppression and weight loss.

        Clinical Use

        To be given 15 minutes before meals when given as bolus dosing.
        • Indication

        • Glycaemic control for type II diabetics.
        • Adverse Effects

        • Hypoglycaemia
        • Weight gain
        • Hypersensitivity reactions
        • Indications

        • Osteoporosis
        • Paget's disease of bone
        • Lytic lesions (pamidronate) - breast cancer metastasis, multiple myeloma
        • Hypercalcaemia of malignancy (pamidronate, zoledronic acid)
        • Adverse Effects

        • Rare.
        • Indication

        • HIV infection.

        Overview

        • Microbiology

        • Effective against Herpes simplex virus (HSV), varicella zoster virus (VZV) and cytomegalovirus (CMV).
        •  
          Oral
          Temazepam
          Temaze, Normison 
           
          [Peak] 30-60 minutes
          Half-life 5-15 hours

        Clinical Use

        • Signs of Withdrawal

        • Anxiety / agitation
        • Insomnia
        • Myoclonus
        • Seizures
        • Anterograde memory loss (especially midazolam)

        Overview

        • Mechanism of Action

        • Selectively inhibit the presynaptic serotonin (5-HT) transporter, resulting in reduced reuptake of serotonin and greater serotonin concentrations within the synapse.

        Clinical Use

        • Signs of Withdrawal

        • Anxiety / agitation
        • Insomnia
        • Myoclonus
        • Seizures
        • Anterograde memory loss (especially midazolam)
        • Indications

        • Psychosis - schizophrenia, and related disorders
        • Acute mania
        • Maintenance therapy for bipolar I disorder (low-dose second generation antipsychotics)
        • Tranquilization - in the acute psychiatric setting (chlorpromazine / haloperidol / droperidol / olanzapine / risperidone)
        • Agitation / hallucinations associated with delirium or dementia ( olanzapine / risperidone)
        • Severe nausea / vomiting associated with surgery or anaesthesia (droperidol)
        • Status migrainosus (chlorpromazine / droperidol)
        •  
          Oral / IM
          Risperidone
          Risperdal 
           
          Available as depot - fortnightly dosing for schizophrenia
        • Adverse Effects

        • Fatigue
        • Insomnia
        • Dry mouth
        • Weight loss / gain
        • Dizziness / headache
        • Nausea / vomiting / diarrhea
        • Sexual dysfunction - decreased libido, ejaculatory disorders, erectile dysfunction
        • Serotonin syndrome (when SNRIs given with MAOis / SSRIs) - confusion, agitation, ataxia, hyperreflexia, fevers, diaphoresis
        • Adverse Effects

        • Rash / pruritis
        • Nausea / vomiting
        • Elevated LFTs
        • Adverse Effects

        • Nausea / vomiting
        • Rash / pruritis
        • Elevated LFTs
        • Indications

        • Skin infections / cellulitis
        • Osteomyelitis / septic arthritis
        • Pneumonia
        • Adverse Effects

        • Nausea / vomiting / diarrhoea
        • Elevated LFTs
        • Monitoring

        • To ensure therapeutic levels, check serum concentration before the fourth dose.
        • Adverse Effects

          Very few compared to penicillins.
        • Thrombophlebitis
        • Hypersensitivity reactions
        • Nausea / vomiting / diarrhoea
        • Pseudomembranous colitis (C difficile)
        • Thrombocytopaenia / leukopaenia
        • Nephrotoxicity
        • Indications

        • Community-acquired pneumonia
        • Peritonsillar abscess
        • Bacterial endocarditis
        • Rheumatic fever
        • Syphilis

        Overview

        • Pharmacology

        • Cross the blood brain barrier - useful against meningitis.

        Clinical Use

        • Indications

        • UTI
        • URTI / LRTI
        • Intra-abdominal infection
        • Skin infections
        • Septicaemia
        • Adverse Effects

        • Hypersensitivity - urticarial rash, oedema, anaphylaxis
        • GIT - nausea / vomiting / diarrhoea
        • Thrombocytopaenia / leukopaenia
        • Adverse Effects

        • Nausea, vomiting, diarrhoea
        • Headache / dizziness / fatigue
        • QT prolongation
        • Tendinopathy (in children)

        History of Presenting Complaint

        • Timing

          How long the pain has been going on for.
        • Central crushing chest pain lasting >20 minutesSuggestive of acute coronary syndrome rather than stable angina

        Management

        • Small Cell Lung Cancer

          Depends on whether the disease is limited or extensive.
        • Chemoradiotherapy with or without cranial irradiation to prevent brain metastasis
        • Chemotherapy
        • Management Strategies

        • Lifestyle Measures

        • Avoidance of triggers
        • Smoking cessation
        • Pharmacologic Measures

        • Short-acting beta agonists (SABAs) - salbutamol, terbutaline
        • Long-acting beta agonists (LABAs) - salmeterol, formoterol, indacaterol
        • Inhaled corticosteroids (ICS) - beclomethasone, budesonide, fluticasone, ciclesonide
        • ICS / LABA combinations - budesonide / formoterol, fluticasone / salmeterol, fluticasone / formoterol, fluticasone / vilanterol
        • Monoclonal antibodies - omalizumab, mepolizumab
        • Management Strategies

        • Lifestyle Measures

        • Smoking cessation
        • Pulmonary rehab
        • Nutritional support
        • Develop social support
        • Pharmacologic

        • Long-acting beta agonists (LABAs) - salmeterol, formoterol, indacaterol
        • Long-acting anti-muscarinic agents (LAMAs) - tiotropium, aclidinium, umeclidinium, glycopyrronium
        • LAMA / LABA combinations - tiotropium / olodaterol, aclidinium / formoterol, glycopyrronium / indacaterol, umeclidinium / vilanterol
        • Inhaled corticosteroid (ICS) / LABA combinations - budesonide / formoterol, fluticasone / salmeterol, fluticasone / formoterol, fluticasone / vilanterol
        • LAMA / LABA / ICS combination - fluticasone / umeclidinium / vilanterol
        • Supportive Measures

        • Home oxygen
        • Vaccinations - influenza, pneumococcal
        • Surgical Options

        • Lung volume reduction surgery
        • Lung transplantation
        • Duration of Anticoagulation

        • Provoked VTE (transient risk factors) - 3 months then reassess based on risk of recurrence and bleeding
        • First unprovoked VTE - 3 months then continue depending on risk of recurrence and bleeding
        • Recurrent unprovoked VTE - long-term anticoagulation
        • Thrombophilia - consider long-term anticoagulation

        Medication History

        • Side Effects

        • Whether the medication is associated with any unwanted side effects.

        Severity

        • Ask About

        • Exercise tolerance - use NYHA classes
        • Recent echocardiogram results - ejection fraction, regional wall motion abnormalities, valvular dysfunction

        Medication History

        • Side Effects

        • Whether the medication is associated with any unwanted side effects.

        The CAGE questionnaire

        A screening tool for alcohol dependence.

        Management

        • Management of Acute Coronary Syndromes

        • Initial management (MOAN) - morphine, oxygen, antiplatelet, nitrate
        • STEMI

        • Anticoagulation - heparin / low molecular weight heparin
        • Revascularisation - coronary angiography / thrombolysis (depending on timing)
        • Secondary prevention - antiplatelets, statin, ACE inhibitor, beta blocker
        • Cardiac rehabilitation
        • NSTEACS

        • Anticoagulation - heparin / low molecular weight heparin
        • Dual antiplatelets - aspirin + ticagrelor / clopidogrel
        • Revascularisation - coronary angiography
        • Secondary prevention - antiplatelets, statin, ACE inhibitor, beta blocker
        • Cardiac rehabilitation
        Stroke prevention is a major priority in the management of atrial fibrillation, though anticoagulation is not without risks. Clinical calculators such as CHA₂DS₂VASc are used to estimate risk of stroke and assist in deciding whether anticoagulation is necessary.

        History of Presenting Complaint

        • Exacerbating Factors

          Whether the shortness of breath is worse on exertion, on lying flat, or after exposure to dust.
        • Exertional dyspnoeaMay represent heart failure, interstitial fibrosis or COPD
        • Orthopnoea - shortness of breath when lying flatCharacteristic of congestive cardiac failure

        Hypoglycaemic Awareness

        • Ask About

        • Past hypoglycaemic episodes
        • Symptoms of these episodes
        • Frequency of hypoglycaemic episodes
        • BSLs at the time
        • Management of hypoglycaemia

        Medication History

        • Side Effects

        • Whether the medication is associated with any unwanted side effects.

        What is a Standard Drink?

        One standard drink in Australia contains 10g of alcohol.

        Management

        • Management Options

        • Raynaud's - cold avoidance, smoking cessation, calcium channel blockers, topical nitrates, PDE5 inhibitors, prostacyclin
        • Skin thickening - physiotherapy, immunosuppression
        • Reflux - proton pump inhibitors
        • Interstitial lung disease - immunosuppression
        • Pulmonary arterial hypertension - PDE5 inhibitors, endothelin antagonists, prostacyclin analogues
        • Renal crisis - ACE inhibitors, dialysis
        • Advanced Options

        • Autologous stem cell transplant

        Falls History

        • Risk Factors for Falling

        • Poor vision
        • Cognitive impairment
        • Past stroke
        • Parkinson's disease
        • Cerebellar pathology
        • Impaired proprioception
        • Pain
        • Vertigo
        • Hypotension
        • Medications - especially sedatives, antihypotensives
        • Dangerous home environment - e.g. stairs, pets, clutter

        Visceral Sensory Pathway

        Cardiovascular & Respiratory Centres
        Reticular formation and hypothalamus
         
         
        Solitary Nucleus
        Medulla
         
         
        Foramen
        Jugular foramen
         
        Inferior Ganglion
         
         
         
        Receptors
        Larynx, oesophagus, trachea, thoracic and abdominal organs

        Assessing Orientation

        • Ask About

        • Time - day, date, month, year, season
        • Place - floor, building, city, state, country
        • Person - full name, date of birth, address

        General Sensory Pathway

        Cortical Centre
        Primary sensory cortex (postcentral gyrus)
         
         
        Sensory Nucleus
        Medulla
         
         
        Foramen
        Jugular foramen
         
        Ganglia
        Superior (jugular) and
        inferior (petrous) ganglia
         
        Pharyngeal branch
         
         
        Receptors
        External ear, internal tympanic membrane, upper pharynx, posterior 1/3 of tongue

        Warm-Up Phenomenon

        • Significance

        • Initial stiffness and lag that improves with repetition is a sign of myotonia.

        Parasympathetic Pathway

        Edinger-Westphal nucleus
        Superior colliculus (midbrain)
         
        Pathway
        Tegmentum, red nucleus, medial substantia nigra
        Foramen
        Superior orbital fissure
         
         
        Ciliary Ganglion
         
         
        Muscle
        Constrictor pupillae, ciliary muscles

        Facial Spasm

        • Interpretation

        • Hemifacial spasm - compression of the facial nerve root in the cerebellopontine angle.
        • Bilateral facial spasm - oromandibular dystonia, associated with grinding of the teeth.

        Measuring Blood Pressure

        Place the diaphragm of the stethoscope over the brachial artery and slowly deflate the cuff (2mmHg/sec). Note when the pulse is first heard (indicative of the systolic pressure) and when it disappears (indicative of the diastolic pressure).

        Hepatomegaly

        • Causes of Hepatomegaly

        • Congestion - congestive cardiac failure, hepatic vein thrombosis, cirrhosis
        • Hepatitis - alcoholic, fatty, viral, drug-induced
        • Metabolic liver disease - amyloidosis, haemochromatosis, Wilson's disease
        • Cancers - liver, stomach, pancreas, lung, colorectal, melanoma
        • Infection - bacterial, viral, parasitic
        • Haematological - leukaemia / Hodgkin lymphoma

        Arterial Skin Changes

        • Causes of Arterial Skin Changes

        • Atherosclerosis
        • Diabetes
        • Thromboangiitis
        • Vasculitis

        Renal Percussion

        • How to Perform

        • With the patient sitting, place one palm over the costovertebral angle and use the ulnar aspect of the other hand (in a fist) to gently percuss the kidneys.

        Amplitude

        Pulsus tardis & parvis: weak pulse with a delayed systolic peakAortic stenosis

        Character

        Weak pulseAtherosclerosis, tamponade, LV failure, cervical rib, aortic dissection, dehydration

        Hepatojugular Reflex

        • How to Elicit

        • Gently press over the right upper quadrant for 10-15 seconds while inspecting the JVP.

        Waist-Hip Ratio

        • Significance

        • An estimate of central obesity. Waist circumference and WH ratio are used to estimate cardiovascular risk.

        Fluid Overload

        • Causes of Fluid Overload

        • Excessive IV fluids
        • Heart failure
        • Renal failure
        • Hepatic cirrhosis
        • SIADH
        • Pregnancy

        Foetor Hepaticus

        • Smell For

        • A musty smell, sometimes described as a mix between rotten eggs and garlic.

        Venous Ulcers

        • Causes of Venous Ulcers

        • Venous hypertension due to incompetent valves
        • Venous outflow obstruction
        • Calf-muscle pump failure - obesity, immobility

        Extra Credit

        • Additional Causes of Limited Wrist Range of Motion

        • Fracture - radius, ulna, carpals
        • Nerve damage - radius, ulna, median nerve

        Muscles Acting on the Hand

        Extrinsic Finger flexors - flexor digitorum superficialis, flexor digitorum profundus

        Splinter Haemorrhages

        • Causes of Splinter Haemorrhages

        • Trauma
        • Infective endocarditis
        • Vasculitis - rheumatoid arthritis, antiphospholipid syndrome, systemic lupus erythematosus, Behcet disease
        • Skin conditions - psoriasis, lichen planus

        Bony Landmarks of the Hand

        Metacarpals - palpate the bases, bodies and heads of each of the metacarpals. Squeeze across the metacarpal heads.

        Overview

        • Causes of Limited Shoulder Range of Motion

        • Fracture - clavicle, scapula, humerus
        • Glenohumeral dislocation
        • Adhesive capsulitis (frozen shoulder)
        • Rotator cuff pathology -  tear, impingement, tendinitis
        • Biceps tendinitis
        • Subacromial bursitis
        • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis

        Bony Landmarks of the Shoulder

        Coracoid process - slightly medial and inferior to the acromioclavicular joint.

        Muscles Acting on the Shoulder Joint

        Scapular elevators - trapezius, rhomboid major & minor

        Hypertension

        • Classification

          Persistent high blood pressure
        • Normal
        • Pre-hypertension 120/80 - 139/89
        • Stage I hypertension 140/90 - 159/99
        • Stage II hypertension >160/100

        Antalgic Gait

        • Look For

        • A painful gait, with quick stance on the affected lower limb.

        Extra Credit

        • Pelvic Cross Syndrome

        • Increased lumbar lordosis - tight hip flexors / weak hip extensors
        • Protuberant abdomen - tight lumbar extensors / weak lumbar flexors
        • AP pelvic tilt - tight tensor fascia lata / weak hip abductors
        • Lateral pelvic tilt - tight quadratus lumborum
        • Causes of Limited Hip Range of Motion

        • Fracture - pelvis, femur
        • Dislocation
        • Trochanteric bursitis
        • Avascular necrosis (Perthe's disease)
        • Slipped capital femoral epiphysis
        • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis
        • Loose intra-articular body

        Overview

        • Significance

          Herniae represent portions of bowel or ommentum that have passed outside of the abdominal cavity. Herniae may be reducible but may become trapped (encarcerated) or vascularly compromised (strangulated)
        • Femoral herniae - pass through a defect within the femoral canal medial to the femoral vein.
        • Indirect inguinal herniae - pass through the deep inguinal ring and through the inguinal canal into the scrotum
        • Direct inguinal herniae - pass through a weakness in the transversalis fascia, rarely into the scrotum.

        Bradypnoea

        Bradypnoea refers to a reduction in respiratory rate.

        Nail Bed Cyanosis

        • Causes of Nail Bed Cyanosis

        • Central Cyanosis

        • High altitude
        • Obstructive lung disease, pulmonary oedema, pneumonia, pulmonary embolism
        • Congenital heart disease
        • Methaemoglobinaemia / sulfhaemoglobinaemia / carboxyhaemoglobinaemia
        • Peripheral Cyanosis

        • As for central cyanosis
        • Reduced cardiac output
        • Vasoconstriction

        Marfan Syndrome

        Mutations in extracellular matrix protein fibrillin 1.

        Overview

        The gap-gap ratio is often used in diabetic ketoacidosis to determine whether an ongoing metabolic acidosis is due to ongoing ketoacidosis, or is due to isotonic saline infusion in the resuscitory period.
        Anion Gap = Na⁺ - ( Cl⁻ + HCO₃⁻ )

        Oxygen Dissociation Curve

        As the curve shifts to the left, oxygen will more readily bind to haemoglobin. As the curve shifts to the right, oxygen will more readily be released from haemoglobin.

        Pacemaker

        • A single chamber pacemaker: lateral film
        • No Overlay
          Overlay
          A single chamber pacemaker lateral film
           

        Anterior-Posterior (AP)

        This type of film is usually taken in acute / critical care settings, where a patient is sitting up in bed and the plate can be placed behind them.

        Overview

        • Right middle lobe pneumonia - lateral film
        • Right middle lobe pneumonia - lateral film
           

        Inspiration

        If there is adequate inspiration, the diaphragm should be at the level of the posterior 10th rib.

        Overview

        • Indications for Chest Drain

        • Pneumothorax
        • Empyema
        • Symptomatic pleural effusion
        • Access for pleurodesis

        PICC Lines

        A PICC line should be within the SVC i.e. angled downward toward the right heart border, but not in the right atrium.

        Silhouette Signs

        • Obscuration of the ascending aorta, suggesting right upper lobe consolidation
        • Obscuration of the ascending aorta, suggesting right upper lobe consolidation
           

        Overview

        Pleural effusions should only be assessed for on an erect film as they are difficult to diagnose on a supine or prone film.

        Hip Dislocation

        • Look For

        • Disassociation of the femoral head from the acetabulum.

        White Blood Cells

        • Causes of WBC in Ascitic Fluid

        • Cirrhosis
        • Bacterial peritonitis
        • Tuberculous peritonitis
        • Neoplasm

        2nd Degree SA Exit Block: Type I

        • 2nd Degree SA Exit Block: Type I
           

        2nd Degree AV Block: Type I Mobitz

        Also known as Wenckebach AV block.

        Inclusion Bodies

        • Interpretation

        • Nucleated red blood cellsSevere anaemia, severe sepsis, hypoxia, myelofibrosis, bone marrow infiltration
        • Heinz bodies (denatured haemoglobin): basophilic inclusions adjacent to the cell membrane on supravital stainingOxidative haemolysis - G6PD deficiency, unstable haemoglobins, drugs

        Diagnosis

        • Markers of Iron Overload

        • Elevated ferritin
        • Elevated transferrin saturation

        RBC Lifecycle

        Most serum iron is transported into erythroid cells, where it is incorporated into haem molecules that combine with globular proteins to form haemoglobin.

        Diagnosis

        Iron deficiency will present with an elevated serum transferrin and elevated total iron binding capacity; these two measures are proportional to each other and relatively interchangeable. The transferrin saturation (TSat) is the percentage of iron that is bound to transferrin and is reduced in iron deficiency, though inflammation, infection and malignancy can also reduce the TSat.

        Activated Monocytes

        • Causes of Activated Monocytes

        • Infection
        • Inflammation
        • Malignancy
        • Recovery from bone marrow suppression
        • G-CSF

        Microcytosis

        • Practical Points

        • Microcytosis is often associated with anaemia, but not always.
        • In thalassaemia, the MCV tends to be inappropriately low compared to the degree of anaemia.

        Neutrophil Physiology

        • Stages of Neutrophil Development

        • Myeloblast
        • Promyelocyte
        • Myelocyte
        • Metamyelocyte
        • Banded neutrophil (<8% normally) - U-shaped nucleus
        • Mature neutrophil - 3-5 nuclear lobes

        Thrombocytopaenia

        In a patient with new thrombocytopaenia, look for platelet clumping and fibrin strands which may indicate a factitiously low platelet count, or pseudothrombocytopaenia.

        Small Mature Lymphocytes

        Mature lymphocytes are small cells with high nuclear : cytoplasmic ratio (i.e. a very small amount of cytoplasm). These cells are normally seen in peripheral blood however if present in a large number then they may suggest chronic lymphocytic leukaemia.

        Left Shift of Granulocytes

        The presence of nucleated red blood cells and left shift is referred to as a leukoerythroblastic blood film. If left shift is present then look for nucleated red cells.

        Overview

        •  
        • Blood Film Findings in Myelodysplasia

        • Red Blood Cells

        • Macrocytic hyperchromic anaemia
        • Anisocytosis: variation in the size of red blood cells
        • Poikilocytosis (abnormal red cell shape)
        • Basophilic stippling
        • Nucleated red blood cells
        • White Blood Cells

        • Leukocytosis or leukopaenia
        • Hypogranular neutrophils
        • Pseudo Pelger-Huet neutrophils: hypolobated neutrophils with peanut-shaped or spectacle-shaped nuclei
        • Platelets

        • Thrombocytopaenia
        • Platelet anisocytosis: variation in size of platelets, with large and sometimes giant platelets seen
        • Other

        • Circulating blasts may be seen
        • A nucleated red blood cell.
        • A nucleated red blood cell.
           
        Reverse triiodothyronine (rT3) is an inactive form of T3 that is secreted in stress states.

        Subclinical Hypothyroidism

        Patients with subclinical hypothyroidism have TFT abnormalities without overt clinical features of hypothyroidism, or with nonspecific symptoms.

        Hormonal Changes

        Severity of reduction in T3 and T4 in nonthyroidal illness is associated with risk of mortality.

        Suppressed TSH with Normal T4

        • Causes of Reduced TSH with Normal T4

        • Subclinical hyperthyroidism
        • Recent treatment of hyperthyroidism
        • Intermittent thyroxine
        • T3 thyrotoxicosis
        • Nonthyroidal illness
        • Drugs - steroids, dopamine, dobutamine

        Primary Hyperthyroidism

        • Causes of Primary Hyperthyroidism

        • Grave's disease
        • Toxic multinodular goitre
        • Toxic nodule
        • Thyroiditis - postviral, postpartum, lymphocytic
        • Thyroxine - excess replacement, thyrotoxicosis factitia
        • Drugs - amiodarone, iodine
        • Pregnancy-related - hyperemesis gravidarum, hydatidiform mole
        • Struma ovarii
        • Congenital hyperthyroidism

        Hypoferritinaemia

        Note that inflammation or liver disease can falsely elevate serum ferritin, masking a concomitant iron deficiency.

        Quadrant Method

        • Quadrant Method

        Measuring the QT Interval

        • Measuring the QT Interval

        Sinoatrial Rhythm

        • Second degree sinoatrial block, Mobitz type I - note progressively shortened PP intervals, followed by a pause:
        • Second degree sinoatrial block, Mobitz type I - note progressively shortened PP intervals, followed by a pause
           

        ECG Leads

        ElectrodesDirectionComplex
        IRA → LA0Lateral
        IIRA → LL+60Inferior
        IIILA → LL+120Inferior

        Monomorphic Ventricular Tachycardia

        • Mechanisms

        • Monomorphic VT occurs most commonly in the context of a macro-reentrant pathway in a structurally abnormal heart. The rhythm may also be caused by a focal arrhythmogenic ventricular focus.

        Extreme Axis Deviation

        • Look For

        • Negative lead I
        • Negative lead aVF

        Overview

        Reverse typical atrial flutter is where the reentrant circuit travels in a clockwise direction. There are also several types of atypical atrial flutter, caused by a variety of other reentrant circuits.
        • Diagnostic Tests

        • ECG - single ECG or continuous inpatient monitoring
        • Holter monitor (24-48 hours)
        • External loop recorder
        • Implanted loop recorder
        In fast-slow AVNRT (10%) an impulse travels retrogradely up the slow pathway.

        Albumin

        • Significance of Elevated Albumin

        • Indicative of dehydration.

        Diagnostic Criteria

        • Smouldering Myeloma

        • Serum paraprotein >30g/L or urinary paraprotein >500mg/24h and/or bone marrow plasma cells 10-60%
        • No evidence of end-organ damage (hypercalcaemia, renal dysfunction, anaemia, bony lesions) or amyloidosis

        MDRD Formula

        • Limitations

        • Not validated for patients with normal renal function
        • Not validated for acute kidney injury and for patients with rapidly changing renal function, as the data is from CKD
        • Not accurate in pregnancy, severe malnutrition and in children

        Overview

        • Drug Triggers of Arrhythmia in Brugada Syndrome

        • Antiarrhythmics - flecainide, procainamide
        • Psychotropics - amitriptyline, nortriptyline, lithium
        • Anaesthetics - local anaesthetics, propofol
        • Substances - alcohol, cannabis, cocaine
        • Tombstoning:
        • Tombstoning
           
        • Electrical alternans
        • Electrical alternans
           
        • ECG Findings in Hypokalaemia

        • Moderate to Severe

        • PR prolongation
        • ST depression
        • T wave flattening or inversion
        • Prominent U wave (resulting in an apparent prolonged QT interval)
        • Life-Threatening

        • Torsade de pointes
        • Ventricular tachycardia
        • Ventricular fibrillation
        The presence of an accessory pathway is part of the differential diagnosis for wide complex tachycardia, as an accessory pathway coupled with a tachycardia of supraventricular origin can produce a wide complex rhythm ressembling ventricular tachycardia.
        Tricyclic antidepressants tend to also cause sinus tachycardia and right axis deviation.
        The ST depression of digoxin toxicity is characteristically scooped - this is often referred to as a reverse tick or Salvador Dali's moustache ST depression.

        Physiology

        • Transport and Storage

        • Folate is transported in plasma mainly through binding to albumin, and is mainly stored by the liver. Folate is taken up by proliferating cells.

        Overview

        If there is significant elevation of the anion gap then this suggests that there is an abundance of unmeasured ion present - usually an acid such as lactic acid or ketones.

        Oxygen Dissociation Curve

        • Causes of Left Shift

        • Alkalaemia (Bohr effect)
        • Hypothermia
        • Decreased 2,3-DPG

        Pacemaker

        • A multi-chamber pacemaker with old leads present: PA film
        • No Overlay
          Overlay
          A multi-chamber pacemaker with old leads present PA film
           

        Anterior-Posterior (AP)

        • Example

        • An AP film - note the artificially enlarged mediastinum.
        • An AP film - note the artificially enlarged mediastinum.
           

        Inspiration

        An expiratory film may resemble a pneumothorax.

        PICC Lines

        • Examples

        Hip Dislocation

        • Interpretation

        • Posterior dislocation (90%) - posterior, superior and lateral displacement of the femoral headAxial load onto flexed hip (e.g. dashboard injury)
        • Anterior dislocation (10%) - anterior displacement, with the femoral head lying either superior (pubic) or inferior (obturator) to the acetabulum.Direct trauma while in abduction and external rotation

        2nd Degree SA Exit Block: Type II

        Type II second degree sinoatrial exit block occurs when there is an intermittently missed P wave due to failure of conduction to the atrial myocardium.

        2nd Degree AV Block: Type I Mobitz

        Type I second degree AV block occurs when there is progressively delayed AV transmission eventually resulting in a missed QRS complex.

        Polychromasia

        Red cells with a bluish tinge due to persistence of ribosomes.

        Diagnosis

        Elevated ferritin is a key marker of iron overload. Ferritin is also an acute phase reactant, and as such an isolated elevation of ferritin is not necessarily an indicator of iron overload. Ferritin levels >200 ug/L in premenopausal women or >300 ug/L in men and postmenopausal women are concerning for true iron overload.

        RBC Lifecycle

        Once red cells are lysed, the iron is salvaged from the haem molecule by macrophages and is reentered into the circulation.

        Diagnosis

        Serum iron (Fe3+) concentration tends to fluctuate with iron intake, acute and chronic disease and in itself is a poor marker of iron status.

        Macrocytosis

        Macrocytes are large red blood cells with mean corpuscular volume (MCV) >100 fL. On a blood film, they are larger than small mature lymphocytes.

        Neutrophilia

        Neutrophilia is the presence of increased circulating neutrophils, and is a common finding in the full blood count of acutely unwell patients.

        Thrombocytopaenia

        • Causes of Thrombocytopaenia

        • Reduced Production

        • Congenital thrombocytopaenia
        • Bone marrow failure - aplastic anaemia, paroxysmal nocturnal haemoglobinuria
        • Bone marrow suppression - cytotoxic chemotherapy, radiotherapy, alcohol abuse
        • Bone marrow infiltration - leukaemia, multiple myeloma, lymphoma, metastasis, myelofibrosis
        • Myelodysplasia
        • B12 / folate deficiency
        • HIV infection
        • Increased Destruction

        • Idiopathic thrombocytopaenic purpura (ITP)
        • Heparin-induced thrombocytopaenia (HIT)
        • Drug-induced thrombocytopaenia - heparin, quinine, bactrim, vancomycin, rifampin, paracetamol, NSAIDs, glycoprotein IIb/IIIa inhibitors
        • Immune thrombocytopaenia - SLE, antiphospholipid syndrome, rheumatoid arthritis, transfusion reaction
        • Thrombotic microangiopathies - thrombotic thrombocytopaenic purpura (TTP), haemolytic-uraemic syndrome (HUS), disseminated intravascular coagulation (DIC)
        • Infection - hepatitis C, EBV, CMV, H pylori, sepsis
        • Pregnancy - gestation thrombocytopaenia, preeclampsia / HELLP syndrome
        • Splenic Sequestration

        • Hypersplenism
        • Factitious

        • Platelet clumping
        • Haemodilution (e.g. massive transfusion)

        Small Mature Lymphocytes

        • Small Mature Lymphocytes
           

        Left Shift of Granulocytes

        • Examples

        Overview

        •  
        Thyroid binding globulin (TBG) is a plasma protein that binds and transports the majority (~75%) of thyroid hormones. Thyroid hormones are also transported to a lesser degree by transthyretin and albumin.

        Subclinical Hypothyroidism

        • Look For

        • Elevated TSH with normal T4
        • No clinical features of hypothyroidism

        Hormonal Changes

        During recovery from nonthyroidal illness,  the T3 and T4 return to normal and there is often an increase in TSH as hypothalamic function returns.

        Suppressed TSH with Normal T4

        • Pearls

        • Ask about symptoms of hyperthyroidism.
        • If the patient is clinically thyrotoxic, consider T3 toxicosis and check the patient's T3.
        • Take a careful medication history, including past treatment for hyper or hypothyroidism.
        • Ask about recent illnesses.

        Subclinical Hyperthyroidism

        Patients with subclinical hyperthyroidism have TSH suppression and normal T4 without overt clinical features of hyperthyroidism, or with nonspecific symptoms.

        Quadrant Method

        To identify which quadrant the axis falls into, look at the direction of the QRS complex in leads I and aVF:

        Correcting the QT Interval (QTc)

        The QT interval shortens with rapid heart rates and lengthens at slower heart rates, as a compensatory mechanism. In order to truly estimate risk it is important to correct for the heart rate, i.e. estimatinng what the QT interval would be at 60 beats per minute.

        Sinoatrial Rhythm

        • Multifocal atrial tachycardia - a variety of P wave morphologies with variable PP intervals indicates several atrial foci:
        • Multifocal atrial tachycardia - a variety of P wave morphologies with variable PP intervals indicates several atrial foci
           

        ECG Leads

        • Unipolar (Augmented) Limb Leads

        • Electrical potential difference is measured between one limb electrode and a combination of the other limb electrodes.

        Monomorphic Ventricular Tachycardia

        • Causes of Monomorphic Ventricular Tachycardia

        • Myocardial infarction
        • Cardiomyopathy
        • Congestive cardiac failure

        Extreme Axis Deviation

        • Extreme Axis Deviation

        Overview

        • Causes of Atrial Flutter

        • Severe acute illness - especially in septic or postoperative patients
        • Cardiac - post cardiac surgery, myocardial infarction, valvular disease, cardiomyopathy, congestive cardiac failure, congenital heart disease, Wolff-Parkinson-White
        • Cardiovascular risk factors - hypertension, diabetes, obesity
        • Pulmonary embolism
        • Obstructive sleep apnoea
        • Thyrotoxicosis
        • Alcohol abuse

        Albumin

        • Causes of Hypoalbuminaemia

        • Malnutrition
        • Hepatic synthetic dysfunction
        • Chronic infection
        • Protein-losing enteropathies
        • Nephrotic syndrome
        • Severe burns
        • Pregnancy

        Diagnostic Criteria

        • Multiple Myeloma

        • Clonal bone marrow plasma cells >10%
        • AND evidence of end-organ damage (hypercalcaemia, renal dysfunction, anaemia, bony lesions)
        • OR presence of biomarkers - >60% clonal plasma cells; serum free light chain ratio >100; more than one focal lesion >5mm on MRI

        CKD-EPI Formula

        Uses the same variables as the MDRD formula but with a slightly different equation that tends to be more predictive, especially at higher GFRs.

        Overview

        • As ST elevation improves, pathologic Q waves and T wave inversion develop. Pathologic Q waves may persist for life.
        • As ST elevation improves, pathologic Q waves and T wave inversion develop. Pathologic Q waves may persist for life.
           

        Body Mass Index

        • Associated with Obesity

        • Metabolic syndrome - type 2 diabetes mellitus, hypertension, dyslipidaemia
        • Ischaemic heart disease
        • Stroke
        • Respiratory - obstructive sleep apnoea, asthma
        • Gastrointestinal - reflux, cholelithiasis, non-alcoholic steatohepatitis (NASH)
        • Polycystic ovarian syndrome
        • Osteoarthritis
        • Varicose veins
        • Gout

        Neuropathic Ulcers

        Neuropathic ulcers occur due any cause of sensory loss to the foot, resulting in greater likelihood of damage and unawareness of injury.

        Object Naming

        Items around the room - point to objects and ask the patient to name them. Avoid frequently named items such as pen and watch - ask them to name objects such as cufflink or stethoscope.

        Upper Limb Myotomes

        Shoulder adduction: C6/C7/C8Pectoralis major, trapezius, teres major

        Median Nerve Palsy

        • Causes of Carpal Tunnel Syndrome

        • Idiopathic
        • Trauma - Colle's fracture
        • Endocrine - hypothyroidism, acromegaly, diabetes
        • Rheumatoid arthritis
        • Amyloidosis
        • Gout
        • Pregnancy

        Pallor

        • Causes of Pallor

        • Physiologically pale skin
        • Anaemia
        • Chronic disease
        • Low cardiac output, due to cardiac disease
        • Peripheral shutdown, due to increased sympathetic activity

        Body Mass Index

        • Associated with Obesity

        • Metabolic syndrome - type 2 diabetes mellitus, hypertension, dyslipidaemia
        • Ischaemic heart disease
        • Stroke
        • Respiratory - obstructive sleep apnoea, asthma
        • Gastrointestinal - reflux, cholelithiasis, non-alcoholic steatohepatitis (NASH)
        • Polycystic ovarian syndrome
        • Osteoarthritis
        • Varicose veins
        • Gout

        Cervical Lymph Nodes

        Posterior cervical nodes - posterior to sternocleidomastoidsScalp, posterior neck

        Palmar Crease Pallor

        • Causes of Palmar Crease Pallor

        • Anaemia
        • Low cardiac output, due to cardiac disease
        • Peripheral shutdown, due to increased sympathetic activity

        Hyperpigmentation

        • Look For

        • Areas of hyperpigmented skin.

        Common Signs on the Tongue

        Thrush - painless white plaques that are easily scraped offCandida infection

        Assessing Orientation

        • Significance

        • Orientation is a quick way of assessing patients for confusion.

        Purpura

        • Causes of Purpura

        • Trauma

        • Platelet Disorders

        • Idiopathic thrombocytopaenic purpura (ITP)
        • Thrombotic thrombocytopaenic purpura (TTP)
        • Disseminated intravascular coagulation (DIC)
        • Bone marrow failure - aplastic anaemia, leukaemia, chemotherapy
        • Platelet sequestration - splenomegaly, haemangioma
        • Haemolytic-uraemic syndrome
        • Inherited disorders of platelet function
        • Disorders of Coagulation

        • Factor deficiencies - haemophilia, Von Willebrand disease
        • Vitamin K deficiency - malabsorption, poor diet
        • Anticoagulants
        • Disseminated intravascular coagulation (DIC)
        • Vascular Disorders

        • Connective tissue diseases - Ehlers-Danlos, scurvy
        • Infection - mengingococcal, streptococcal, viral
        • Henoch-Schönlein purpura
        • Senile purpura
        • Steroids

        Spider Naevi

        • Look For

        • A central red vessel with multiple small twisted vessels radiating from it, that disappears when pressure is applied. Commonly over the face, neck, forearms, hands and chest.

        Flank Tenderness

        • Causes of Flank Tenderness

        • Infection - pyelonephritis, perinephric abscess
        • Malignancy - renal cell carcinoma, transitional cell carcinoma
        • Renal infarction
        • Trauma

        Focal Abdominal Tenderness

        Hypogastrium - uterus, bladder, sigmoid colonCystitis, appendicitis, diverticulitis, IBD, uterine pathology

        Jaundice

        In the context of the haematology examination, jaundice may be an indicator of haemolytic anaemia.

        Axillary Lymph Nodes

        Central nodes - within the centre of the axillaDrainage from pectoral, subscapular and lateral nodes

        Cervical Lymph Nodes

        Posterior cervical nodes - posterior to sternocleidomastoidsScalp, posterior neck

        Abdominal Mass

        Right iliac fossa - appendix, caecum, ovaryAppendiceal abscess, caecal tumour, hernia, faecal loading

        Ataxic Gait

        An ataxic gait occurs with cerebellar lesions or with loss of proprioception.

        Measuring Blood Pressure

        Ask the patient not to talk or move while the blood pressure is measured as this can cause a false elevation in BP.

        Increased Body Temperature

        Non-inflammatory hyperthermia occurs when there is an imbalance in heat production and heat dissipation.

        Bradypnoea

        • Causes of Bradypnoea

        • Respiratory suppression
        • Drugs - opioids
        • Respiratory failure
        • Hypothyroidism
        • Raised intracranial pressure

        Measuring Oxygen Saturations

        If unable to measure oxygen saturations and none of these measures are working, consider that the patient may in fact be severely hypoxic - look for cyanosis!

        Wheeze

        • Causes

        • Asthma
        • Chronci obstructive pulmonary disease (COPD)
        • Viral bronchospasm
        • Bronchiectasis
        • Pulmonary oedema
        • Aspiration
        • Bronchial / tracheal obstruction - foreign body, tumour, stenosis
        • Churg-Strauss syndrome
        • Carcinoid syndrome
        • Allergic bronchopulmonary aspergillosis (ABPA)

        Bradycardia

        • Causes of Bradycardia

        • Sinus Bradycardia

        • Sinus node disease - idiopathic degeneration, myocardial infarction, infiltration, connective tissue disease, cardiac surgery, Lyme disease, endocarditis
        • Physiological - high cardiac fitness
        • Autonomic - neurocardiogenic syncope, carotid sinus hypersensitivity
        • Drugs - beta blockers, calcium channel blockers, digoxin, adenosine, ivabradine, clonidine, acetylcholinesterase inhibitors
        • Hypothyroidism
        • Hypothermia
        • Hyperkalaemia
        • Obstructive sleep apnoea
        • Raised intracranial pressure
        • Other Rhythms

        • Sinus node - sinus arrhythmia, sinus arrest, second or third degree sinoatrial exit block
        • Atrial - atrial fibrillation with slow ventricular response, atrial flutter with variable block, trial escape rhythm
        • AV node - second or third degree atrioventricular block, junctional escape rhythm
        • Ventricular escape rhythm

        Kussmaul Respiration

        • Look For

        • Deep, rapid respiration.

        Measuring Oxygen Saturations

        If unable to measure oxygen saturations and none of these measures are working, consider that the patient may in fact be severely hypoxic - look for cyanosis!

        Measuring Blood Pressure

        Ask the patient not to talk or move while the blood pressure is measured as this can cause a false elevation in BP.

        APTT Mixing Studies

        • Significance

        • APTT mixing studies to determine the cause of prolonged APTT.

        Measures of Coagulation

        The PT/INR and APTT are the most commonly measured screening tests to assess a patient's coagulative state.

        PT/INR Mixing Studies

        • Significance

        • PT/INR mixing studies are used to determine the cause of prolonged PT/INR.

        Neutrophil Physiology

        • Neutrophil Physiology

        Manifestations

        • Clinical Features of Beta Thalassaemia

        • Symptoms of anaemia - fatigue, lethargy, lightheadedness, shortness of breath, chest pain, headache
        • Jaundice: yellow discolouration of the skin
        • Hepatomegaly: enlarged liver
        • Splenomegaly: enlarged spleen
        • Beta Thalassaemia Major

        • Iron overload - hypogonadotrophic hypogonadism, hypothyroidism, hypoparathyroidism, diabetes mellitus, liver cirrhosis, heart failure
        • Bone marrow expansion - bony deformities, osteoporosis, muscle wasting

        Macrocytosis

        Macrocytic cells may occur in the context of megaloblastic anaemia, which is typically associated with macroovalocytes (large oval-shaped cells) and hypersegmented neutrophils; they may be seen due to an overabundance of reticulocytes (immature non-nucleated red cells); or may be due to other causes such as liver disease, hypothyroidism or myelodysplastic syndrome.

        Hyperchromia

        • Significance

        • Hyperchromic cells may be spherocytes, microspherocytes, macrocytes or sickle cells.

        Haematocrit or Haemoglobin?

        Serum haemoglobin concentration is a better marker of anaemia because it more directly reflects the blood's ability to transport oxygen.
        Serum haemoglobin concentration is a better marker of anaemia because it more directly reflects the blood's ability to transport oxygen.

        Diagnosis

        • Test Findings in Sickle Cell Anaemia

        • Full Blood Count & Film

        • Normocytic normochromic anaemia
        • Anisocytosis: variation in red cell size
        • Poikilocytosis - sickle cells, elliptocytes
        • Basophilic stippling
        • Immature red cells - polychromasia / nucleated red blood cells
        • Evidence of hyposplenism - target cells, Howell Jolly bodies, Pappenheimer bodies
        • Other Tests

        • Sickle solubility testing - 
        • High performance liquid chromatography / haemoglobin electrophoresis - presence of haemoglobin S with a lack of haemoglobin A

        Clinical Use

        Consult local guidelines regarding the use of blood products in your area.
        • Indications

        • INR >1.6 in patients not on warfarin
        • Warfarin reversal - major haemorrhage, emergent presurgical
        • Disseminated intravascular coagulation (DIC)
        • Massive transfusion
        Consult local guidelines regarding the use of blood products in your area.
        Ask the patient to wash their mouth out after using inhaled corticosteroids, in order to avoid oropharyngeal candidiasis.
        • Indications

        • Acute asthma
        • Exacerbations of COPD
        • Croup
        • Other inflammatory conditions - dermatitides, ulcerative colitis, autoimmune haemolytic anaemia, acute gout, rheumatoid arthritis, seronegative arthritides, systemic lupus erythematosus, polyarteritis nodosa
        • Cerebral oedema
        • Nephrotic syndrome
        • Replacement therapy for adrenocortical insufficiency
        • Immunosuppression post organ transplant
        • Adverse Effects

        • Headaches
        • Hoarseness
        • Cough
        • Oral candidiasis
        • Contraindications

        • Ischaemic heart disease, or high risk of IHD
        • Cerebrovascular disease
        • Peripheral vascular disease
        • Uncontrolled hypertension
        • Indications

        • Acute asthma
        • Exacerbations of COPD
        • Croup
        • Other inflammatory conditions - dermatitides, ulcerative colitis, autoimmune haemolytic anaemia, acute gout, rheumatoid arthritis, seronegative arthritides, systemic lupus erythematosus, polyarteritis nodosa
        • Cerebral oedema
        • Nephrotic syndrome
        • Replacement therapy for adrenocortical insufficiency
        • Immunosuppression post organ transplant
        • Adverse Effects

        • Drowsiness
        • Hypersalivation
        • Muscle weakness
        • Vertigo
        • Indications

        • Pain - including migraine and musculoskeletal injury
        • Fever
        • Inflammation - especially associated with arthritides
        • Prophylaxis (aspirin) - of acute coronary or cerebrovascular events in patients with known cardiovascular or cerebrovascular disease
        • Indications

        • Allergic rhinitis
        • Urticaria
        • Motion sickness
        • Nausea / vomiting
        • Sedation
        • Adverse Effects

        • Headache
        • Dry mouth
        • Fatigue
        • Adverse Effects

        • Nausea / abdominal pain
        • Weight gain
        • Headache
        • Depression
        • Breast pain
        • Thrombosis
        • Adverse Effects

        • Uterine contractions
        • Per vaginal bleeding
        • Headache
        • Dizziness
        • Nausea / vomiting / diarrhoea
        • Adverse Effects

        • Serious infections
        • Relapse of tuberculosis
        • Anaemia
        • Headache
        • Nausea / diarrhoea
        • Exacerbation of congestive cardiac failure
        • Demyelinating disease

        Substem A (Target)

        -n(e)-: neurological (e.g. solanezumab)

        Clinical Use

        • Indications

        • Acute asthma
        • Exacerbations of COPD
        • Croup
        • Other inflammatory conditions - dermatitides, ulcerative colitis, autoimmune haemolytic anaemia, acute gout, rheumatoid arthritis, seronegative arthritides, systemic lupus erythematosus, polyarteritis nodosa
        • Cerebral oedema
        • Nephrotic syndrome
        • Replacement therapy for adrenocortical insufficiency
        • Immunosuppression post organ transplant
        • Contraindication

        • Hypoglycaemia.

        Opioid Withdrawal

        • Management of Withdrawal

        • Low-dose opioids, such as buprenorphine
        • Diazepam

        Clinical Use

        • Adverse Effects

        • Nausea / vomiting
        • Constipation
        • Sedation
        • Respiratory depression
        • Diaphoresis
        • Delirium
        • Hypersensitivity - bronchospasm, urticaria
        • Bradycardia
        • Tolerance
        • Dependence
        • Hypogonadism
        • Indications

        • Acute and chronic pain
        • Opioid addiction (buprenorphine)

        Overview

        • Mechanism of Action

        • Competitively and reversibly bind and inhibit cyclooxygenase, the enzyme responsible for production of thromboxanes, prostacyclin and prostaglandins from arachidonic acid.

        Clinical Use

        • Adverse Effects

        • Severe infections
        • Reactivation of tuberculosis
        • Anaemia
        • Headache
        • Nausea / diarrhoea
        • Exacerbation of congestive cardiac failure
        • Demyelinating disease
        • Adverse Effects

        • Rash
        • Fatigue
        • Oedema
        • Nausea / vomiting / diarrhoea
        • Muscle cramping
        • Peripheral neuropathy
        • LFT derangement
        • Myelosuppression - anaemia, neutropaenia, thrombocytopaenia
        • Respiratory (dasatinib) - pleural effusions, pulmonary hypertension
        • Cardiovascular (nilotinib, ponatinib) - cardiac ischaemia, stroke, peripheral vascular disease, hypercholesterolaemia
        • Adverse Effects

        • Acneiform rash
        • Diarrhoea
        • Ocular changes
        • Alopecia
        • Nail changes
        • Interstitial lung disease
        • Adverse Effects

        • Fatigue
        • Anorexia
        • Mucositis
        • Diarrhoea (particularly pazopanib)
        • Hand-foot syndrome (sunitinib)
        • Cardiotoxicity - CCF, MI, thromboembolism, hypertension
        • Hypothyroidism
        • Adverse Effects

        • Rash
        • Alopecia
        • Hyperkeratosis
        • Papillomas / squamous cell carcinomas
        • Nausea / vomiting / diarrhoea
        • Arthralgia / myalgia
        • Headache
        • Adverse Effects

        • Headache
        • Nausea / vomiting / diarrhea
        • Hypomagnesaemia
        • Indications

        • Acute asthma
        • Exacerbations of COPD
        • Croup
        • Other inflammatory conditions - dermatitides, ulcerative colitis, autoimmune haemolytic anaemia, acute gout, rheumatoid arthritis, seronegative arthritides, systemic lupus erythematosus, polyarteritis nodosa
        • Cerebral oedema
        • Nephrotic syndrome
        • Replacement therapy for adrenocortical insufficiency
        • Immunosuppression post organ transplant

        Diagnosis

        • Diagnosis
           
        • Diagnosis
           

        Past Medical History

        • Chronic Kidney Disease

        • By asking a few questions it is possible to understand the natural history of a patient's chronic kidney disease (CKD).

        History of Presenting Complaint

        • Circumstances

        • Ask about what brings on the episodes. For example, any changes in position; preceding trauma; whether the events happen during the day or at night; and whether the patient was indoors or outdoors.

        Past Medical History

        • Common haematologic disorders include:
        • Haematologic malignancy - AML, ALL, CML, CLL, myeloma, lymphoma
        • Myeloproliferative neoplasms - polycythaemia vera, essential thrombocytosis, myelofibrosis
        • Myelodysplastic syndrome
        • Anaemias - aplastic anaemia, iron deficiency Anaemia, anaemia of chronic disease, haemolytic anaemia, thalassaemias, sickle cell anaemia
        • Bleeding disorders - haemophilias, Von Willebrand disease
        • Thrombotic disorders - DVT / PE, antiphospholipid syndrome
        • Platelet disorders - ITP, DIC, TTP, HUS, HELLP, HITS
        • Haemochromatosis
        • Amyloidosis

        The Patient

        Generally inspect the patient, taking note of their age, gender and general comfort.

        Inspection

        • Smell

        • Urine smell has historically been useful, however is currently rarely used in clinical practice. 

        Red Cell Count & Haemoglobin

        The red cell count reflects the number of circulating red blood cells. The red cell count is particularly useful in identifying erythrocytosis; a normal red cell count with elevated haemoglobin / haematocrit suggests relative erythrocytosis (e.g. dehydration), while an elevated red cell count suggests absolute erythrocytosis (e.g. polycythaemia vera).

        Assessing Oxygenation

        • Oxyhaemoglobin

        • Oxyhaemoglobin (HbO₂) refers to the percentage of haemoglobin that is bound to oxygen. This is the same concept as the peripheral oxygen saturation, and these two measures should be equivalent - if not, then this suggests a sampling error with one of the measurements.

        Assessment of Bone

        • Location of Fracture

        • If a fracture is seen, note the location of the fracture: whether it is proximal or distal, and whether it involves the growth plate in children.

        Causes of Haemolysis

        Severe infections, malaria, meningococcal and Clostridium infections can cause haemolysis. Certain heavy metals such as copper and lead are also implicated. The syndrome of hypersplenism is a common cause in patients with liver disease, CCF or certain other conditions.

        Measures of Iron Status

        A Elevated serum ferritin is classically a marker of iron overload, though ferritin is also an acute phase reactant and can be non-specifically elevated with alcohol intake, liver disease or chronic inflammation.

        C-Reactive Protein

        Serum CRP rises rapidly, with a maximal concentration reached within two days; it falls quickly once inflammation has resolved.

        White Blood Cells

        The presence of eosinophils in urine is classically a sign of acute interstitial nephritis, however the actual correlation between eosinophiluria and AIN is relatively poor.

        Identifying a Vein

        Certain devices may also be used to assist with finding a vein. Ultrasound-guided blood collection can be performed if no veins are identifiable on inspection and palpation. Certain hospitals have vein viewers which use technologies such as infrared light to highlight veins.

        Low Flow Oxygen

        The oxygen from the circuit is passively mixed with room air as the patient inspires, resulting in a variable FiO2 that depends on many factors including the respiratory rate, tidal volume and whether the patient is breathing through their nose or mouth.

        Identifying an Artery

        • Tips for Choosing an Artery

        • Do

        • Try to use the radial artery if possible
        • Perform Allen's test prior to inserting the needle
        • Don't

        • Absolutely do not use the same arm as an AV fistula
        • Don't use the radial artery on a limb with a fractured wrist
        • Avoid areas with inadequate collateral circulation (e.g. peripheral vascular disease)
        • Avoid inserting a needle through cellulitis, burns or oedema

        Equipment and Preparation

        • There are several types of catheters:
        • Straight, single lumen - for collection of urinary specimens
        • Double lumen (with balloon) - most patients
        • Triple lumen - continuous irrigation for patients with clots or haematuria or post urologic surgery

        Identifying a Vein

        A useful first step is to ask patient where they have been cannulated in the past, or where their best veins are found.

        Airway Manoeuvres

        • Pearls
        • Use suction to clear the oral cavity of fluid or foreign body
        • If there is concern for c-spine fracture, jaw thrust should be used
        • Otherwise, head tilt and chin lift may be used in an attempt to open the airway

        Clinical Use

        • Monitoring

        • Lung function.

        Femoral Vein

        To identify the vein using ultrasound, place the probe in the groin over the femoral triangle, below the inguinal ligament. Look for a large-bore, non-pulsating, collapsible vessel medial to the femoral artery.

        Right Atrial Placement

        • Prevention

        • Properly measure the intended PICC line insertion length by measuring from the sternal angle to the sternal notch and then down the arm to the insertion site.

        Preparation

        Inject 1% lignocaine if appropriate - some people prefer this, though it can distort the anatomy and make a vein more difficult to find.

        Bupivacaine

        • Duration

        • 6 hours

        Nasopharyngeal Airway

        Lubricant may be used to facilitate insertion of a nasopharyngeal airway.

        Diagnosis

        • Diagnosis
           

        Hormonal Changes

        During recovery from nonthyroidal illness,  the T3 and T4 return to normal and there is often an increase in TSH as hypothalamic function returns.

        Diagnosis

        • Approach

        • Check the anion gap to further distinguish between causes.

        Management

        Most patients with chronic kidney disease will die due to cardiovascular disease, so it is important to manage the risk factors of this.

        Diagnosis

        • Left-sided pleural effusion
        • No Overlay
          Overlay
          Left-sided pleural effusion
           
        • 2nd degree AV block: type II Mobitz
        • 2nd degree AV block type II Mobitz
           
        • Investigations

        • Myeloma Screen

        • Serum immunoglobulins - may demostrate elevation of a single Ig
        • Serum free light chains - abnormally high or low kappa : lambda ratio
        • Serum protein electrophoresis - demonstrating a monoclonal band
        • Serum immunofixation electrophoresis - presence of paraprotein
        • Other Tests for Suspected Myeloma

        • FBC - cytopaenias
        • Blood film - normocytic normochromic anaemia with rouleaux
        • EUC - renal failure
        • Uric acid
        • CMP - hypercalcaemia
        • Albumin - hypoalbuminaemia
        • LFT - elevated ALP
        • Beta-2 microglobulin - for staging
        • Skeletal survey (x-ray or CT) - for lytic lesions
        • Bone marrow biopsy - for morphology, cytogenetics and FISH
        An ECG should be performed in all patients suspected of pulmonary embolus, mainly to exclude cardiac ischaemia. The most common ECG finding in the case of PE is sinus tachycardia, though right bundle branch block and/or right axis deviation may be present. The classic S1Q3T3 sign (deep S wave in I, pathologic Q wave in 3 and T wave inversion in 3) is both uncommon and non-specific.
        • Atrial flutter with 3:1 block:
        • Atrial flutter with 31 block
           
        • Clinical Criteria for Diagnosis

          At least one of:
        • Documented VT / VF
        • FHx sudden cardiac death <45 years
        • Coved ECGs in family members
        • Inducibility of VT with programmed electrical stimulation
        • Syncope
        • Nocturnal agonal respiration

        Management

        • Small Cell Lung Cancer

          Depends on whether the disease is limited or extensive.
        • Chemoradiotherapy with or without cranial irradiation to prevent brain metastasis
        • Chemotherapy

        Diagnosis

        • Diagnosis
           
        The presence of an accessory pathway is part of the differential diagnosis for wide complex tachycardia, as an accessory pathway coupled with a tachycardia of supraventricular origin can produce a wide complex rhythm ressembling ventricular tachycardia.

        Diagnosis

        • Chest X-Ray Signs of Emphysema

        • Hyperinflation - hyperlucency of lung fields, diaphragmatic flattening, mediastinal narrowing
        • Bullae
        • Lung scarring

        Manifestations

        • Clinical Features of Beta Thalassaemia

        • Symptoms of anaemia - fatigue, lethargy, lightheadedness, shortness of breath, chest pain, headache
        • Jaundice: yellow discolouration of the skin
        • Hepatomegaly: enlarged liver
        • Splenomegaly: enlarged spleen
        • Beta Thalassaemia Major

        • Iron overload - hypogonadotrophic hypogonadism, hypothyroidism, hypoparathyroidism, diabetes mellitus, liver cirrhosis, heart failure
        • Bone marrow expansion - bony deformities, osteoporosis, muscle wasting

        Management

        • Management Options

        • Non-Pharmacologic

        • Diet - high protein, high energy; salt restriction
        • Alcohol cessation
        • Treatment of Complications

        • Ascites - salt restriction, diuretics, paracentesis, TIPS
        • Varices - emergency management of bleeding, banding, beta blocker
        • Encephalopathy - identify and treat trigger, high protein diet, branched chain amino acids, lactulose, rifaximin
        • Spontaneous bacterial peritonitis - antibiotics, 20% albumin
        • Hepatorenal syndrome - exclude other causes of AKI, 20% albumin, terlipressin
        • Hepatopulmonary syndrome - liver transplant
        • Coagulopathy - consider vitamin K / factor replacement prior to procedures
        • Surveillance

        • Variceal surveillance - gastroscopies
        • HCC surveillance - liver ultrasound
        • Management Options

        • Non-Pharmacologic

        • Smoking cessation
        • Pharmacologic

        • Steroids (for acute flares or bridging therapy only)
        • Conventional DMARDs - methotrexate, sulfasalazine, leflunomide, hydroxychloroquine
        • Targetted DMARDs - JAK inhibitors
        • Biologic DMARDs - TNF blockers, IL-6 blockers, CTLA4-Ig, rituximab

        Diagnosis

        Normal serum osmolality (280 - 285 mOsm/kg) indicates either a spurious result (pseudohyponatraemia) or excessive administration of isotonic solutes like isotonic mannitol.  Pseudohyponatraemia is the false laboratory measurement of sodium due to an increased solid phase of plasma, such as with hyperproteinaemia or hyperlipidaemia.

        Diagnosis

        • Investigations

        • Full blood count + blood film  - microcytic, hypochromic anaemia
        • Iron studies - reduced serum iron, reduced ferritin, increased serum transferrin, reduced transferrin saturation
        • Gastroscopy - in men and postmenopausal women, unless there is a clearly evident cause of iron deficiency anaemia
        • Colonoscopy - in patients over 50 or with family history of colorectal cancer
        • Coeliac disease screening - tissue transglutaminase (tTG) antibody

        Phases of Infection

        The immune surveillance (or immune control) phase represents clearance of the infection. As hepatitis resolves the ALT will fall. Patients in this phase will remain hepatitis B carriers at risk of recurrence.

        Diagnosis

        • ECG Findings

        • Prolonged QT interval (due to a prolonged ST segment)
        • Torsade de pointes (rare)

        Disease History

        • Diagnosis

        • When they were diagnosed
        • Who diagnosed the condition
        • How it was diagnosed - clinically, based on blood tests, imaging or invasive investigations
        • Underlying cause (if known) - e.g. diabetic nephropathy as a cause of chronic kidney disease, or alcohol as a cause of cirrhosis

        Medication History

        • Side Effects

        • Whether the medication is associated with any unwanted side effects.

        Post-Transplant Management

        • Management Strategy

        • Immunosuppression

        • Induction - steroids, basaliximab, thymoglobulin
        • Maintenance - steroids, tacrolimus / cyclosporine, mycophenolate mofetil, azathioprine, sirolimus / everolimus
        • Prophylaxis & Screening

        • Infection prophylaxis - valaciclovir / valganciclovir, bactrim
        • Osteoporosis prophylaxis - calcitriol
        • Cardiovascular risk management - of hypertension, hypercholesterolaemia, diabetes and vascular disease
        • Cancer screening - skin checks, pap smears, colorectal cancer screening
        • Management Strategy

        • Transfusion support
        • GVHD prophylaxis - cyclosporine, methotrexate
        • Infective prophylaxis - e.g. bactrim, posaconazole, ganciclovir / valganciclovir
        • Vaccinations

        Key Considerations

        • Point-of-Care Tools

        • Some apps offer point-of-care tools such as clinical calculators and checklists. These can be incredibly helpful for when you need to make quick decisions in a clinical setting.

        Key Features

        • Syncing

        • While mobile phones are a great way to study flashcards, it is not always easy to create cards on a phone. As a result, many platforms have desktop apps (or web apps) that sync with mobile apps to allow you to easily build and access your flashcard decks anywhere.

        Microsoft OneNote

        • Cost

        • Free, with no premium version

        Key Features

        • Credibility

        • The videos in the platforms below were developed by reputable educators, medical professionals and institutions.
        • Cost

        • We prioritised resources that were free or affordable for students of all backgrounds.
        • Accessibility

        • Mindfulness should be available to everyone, not just those that can afford it - financial constraints are often a limiting factor for med students. We looked for resources that were free or low cost. Additionally, we gave more weight to resources that could be used on a variety of devices.
        • Mobile App Availability

        • We favoured clinical tools and calculators available as mobile apps for iOS and Android devices, allowing you to access them anytime, anywhere.

        Notion

        • Cost

        • Free for individuals

        Life in the Fast Lane

        • Cost

        • Free with ads

        Types of Knowledge

        • Factual Knowledge

        • During your time at medical school you will learn a massive number of facts. This may include definitions, lists and details. This may include facts about anatomy, physiology, pathology, pharmacology or clinical medicine.

        How Memory Works

        The retention interval is the period of time between learning information and being asked to recall it. During this time, information is consolidated; this particularly occurs during idle time and during sleep. Consolidation may be disrupted by learning new information. For example, if you were to participate in a resuscitation of a cardiac arrest and then debrief about it, hearing others' accounts of the incident can disrupt your own recollections of the incident. This is known as retroactive interference.

        Optimise Your Study Environment

        • Timing

        • Are you a morning studier, waking up and getting an early start on learning, or do you learn best at night? You will find a rhythm to when you retain information best as you continue to study.

        Start in a Controlled Environment

        • Practice Kits

        • Suture kits are great for providing you with the opportunity to practice your suture skills; these include fake skin that allows you to make incisions and then try different suturing methods.

        Types of Flashcards

        • Flashcards way be written in many different ways. Here are some of the most common types of flashcards for you to try out:
        • Definition cards - These cards present a term or concept and ask for its definition. This type of card can be useful for memorizing specific terms and their meanings.
        • Recall cards - These cards present a question or prompt that requires you to recall information from memory. This type of card can help you to reinforce your understanding of key concepts and improve your ability to recall information.
        • Fill-in-the-blank cards - These cards present a sentence or phrase with a missing word or words, which you must fill in. This type of card can help you to focus on specific details and improve your understanding of how concepts fit together, or your memory of anatomical landmarks.
        • List cards - These cards present a series of items that you must list or identify. This type of card can be useful for memorizing specific details or sequences, such as the steps involved in a particular procedure or the names of the bones of the hand.

        Tools for Note-Taking

        If taking notes digitally, laptop computers are portable, and offer more usability than mobile devices. Tablets are widely used for note-taking, and these devices are becoming easier to use in terms of typing, editing and multitasking. Digital paper devices are also becoming more popular as they simulate hand-writing notes but with additional features such as text recognition and the ability to categorise notes.

        History of Presenting Complaint

        • Exacerbating Factors

          Whether anything makes the pain worse, such as breathing in or sitting forward.
        • Exertional chest painSuggestive of cardiac pain
        • Pleuritic chest painSuggestive of pneumonia, pericarditis, PE or chest wall pain (unlikely anginal)
        • Brought on with foodSuggestive of reflux
        • Worsened by sitting forward or lying downSuggestive of reflux

        Severity

        • New York Heart Association Classes

        • I
          No limitation of physical activity; ordinary physical activity does not cause symptoms
        • II
          Slight limitation of physical activity; comfortable at rest though ordinary physical activity causes symptoms
        • III
          Marked limitation of physical activity; comfortable at rest though less than ordinary activity causes symptoms
        • IV
          Unable to carry out any physical activity without discomfort; symptoms are present at rest and increase with any physical activity

        Management

        • Management Options

        • Non-Pharmacologic

        • Diet - low in salt
        • Exercise - increase incidental exercise and reduce sedentary time
        • Smoking cessation
        • Alcohol reduction
        • Pharmacologic

        • ACE inhibitors (ACEi) - captopril, ramipril, perindopril
        • Angiotensin II receptor blockers (ARBs) - candesartan, irbesartan
        • Calcium channel blockers (CCBs) - amlodipine
        • Thiazides - hydrochlorothiazide
        • Aldosterone antagonists - spironolactone
        • Alpha blockers - prazosin

        The CAGE questionnaire

        • Ask About

        • Cut down - have they ever felt that they should cut down on their drinking?
        • Annoyed - do they get annoyed when other people talk to them about how much they drink?
        • Guilty - have they ever felt guilty about something they did as a result of their drinking
        • Eye opener - do they use alcohol to help them wake up in the morning?

        Management

        • Management of Stable Ischaemic Heart Disease

        • Non-Pharmacologic

        • Smoking cessation
        • Dietary optimisation
        • Exercise
        • Pharmacologic

        • Antiplatelet - aspirin
        • Manage risk factors - hypertension, hyperlipidaemia, diabetes
        • Surgical Options

        • Surgery - coronary artery bypass graft

        History of Presenting Complaint

        • Alleviating Factors

          Whether the shortness of breath is relieved with rest, GTN, or with puffers.
        • Relief with bronchodilatorPotential exacerbation of asthma or COPD

        Hypoglycaemic Awareness

        • Symptoms of Hypoglycaemia

        • Autonomic symptoms - palpitations, tremor, anxiety, sweating, hunger, paraesthesiae
        • Neuroglycopaenic symptoms - confusion, fatigue, visual changes, seizure, loss of consciousness

        What is a Standard Drink?

        • One Standard Drink

        • Beer

        • 285mL full strength beer (4.8%) - 1.1 standard drinks
        • 375mL full strength beer (4.8%) - 1.4 standard drinks
        • 425mL full strength beer (4.8%) - 1.6 standard drinks
        • 285mL mid strength beer (3.5%) - 0.8 standard drinks
        • 375mL mid strength beer (3.5%) - 1 standard drink
        • 425mL mid strength beer (3.5%) - 1.2 standard drinks
        • 285mL low strength beer (2.7%) - 0.6 standard drinks
        • 375mL low strength beer (2.7%) - 0.8 standard drinks
        • 425mL low strength beer (2.7%) - 0.9 standard drinks
        • Wine

        • 150mL red wine (13%) - 1.5 standard drinks
        • 150mL white wine (11.5%) - 1.4 standard drinks
        • 150mL sparkling wine (12%) - 1.4 standard drinks
        • 60mL port (17.5%) - 1.4 standard drinks
        • Spirits

        • 30mL standard spirit (40%) - 1 standard drink

        Special Sensory Pathway

        Gustatory Cortex
        Insula
         
         
        Thalamus
        Ventral posteromedial nucleus (VPN)
         
         
        Solitary Nucleus
        Medulla
         
         
        Foramen
        Jugular foramen
         
        Inferior Ganglion
         
         
        Taste Receptors
        Epiglottis

        Assessing Orientation

        • Significance

        • Orientation is a quick way of assessing patients for confusion.

        Special Sensory Pathway

        Gustatory Cortex
        Insula
         
         
        Thalamus
         
         
        Sensory Nucleus
        Medulla
         
         
        Foramen
        Jugular foramen
         
        Ganglia
        Superior (jugular) and
        inferior (petrous) ganglia
         
        Lingual branch
         
         
        Taste Receptors
        Posterior 1/3 of tongue

        Hypertension

        • Classification

          Persistent high blood pressure
        • Normal
        • Pre-hypertension 120/80 - 139/89
        • Stage I hypertension 140/90 - 159/99
        • Stage II hypertension >160/100

        Splenomegaly

        Splenomegaly is present if the spleen is palpable. This may be a sign of portal hypertension due to liver, vascular or pulmonary disease; splenomegaly also occurs with certain infections and haematologic malignancies.

        Overview

        The term trophic derives from the Greek trophe, meaning 'nourishment'.

        Amplitude

        Pulsus alternans: regular alternation between strong and weak beatsLeft ventricular failure

        Character

        Strong pulseExercise, pregnancy, anxiety, fever, hyperthyroidism, acute alcoholism

        Hepatojugular Reflex

        • Significance

        • The reflex temporarily increases venous return to the right atrium, making the jugular venous pulsation more pronounced.

        Body Mass Index

        BMI =
        WeightHeight²

        Foetor Hepaticus

        • Significance

        • Associated with severe liver cirrhosis, likely due to sulphur compounds such as methyl mercaptan and dimethylsulphide.

        Neuropathic Ulcers

        Neuropathic ulcers occur due any cause of sensory loss to the foot, resulting in greater likelihood of damage and unawareness of injury.

        Extra Credit

        • Additional Causes of Limited Finger / Thumb Range of Motion

        • Dupuytren's contracture
        • De Quervain's tenosynovitis
        • Trigger finger (entrapment of tendon within tendon sheath)
        • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis

        Muscles Acting on the Hand

        Extrinsic Finger extensors - extensor digitorum, extensor digiti minimi, extensor indicis

        Bony Landmarks of the Hand

        Phalanges - proximal, intermediate (2-5), and distal.

        Muscles Acting on the Shoulder Joint

        Scapular depressors - pectoralis major, trapezius

        Hypertension

        • Causes of Hypertension

        • Situational

        • White coat hypertension: due to by anxiety in a healthcare setting
        • Recent exercise or caffeine intake
        • Primary

        • Essential hypertension: unknown aetiologyThe most common cause of hypertension
        • Secondary

        • Renal - chronic kidney disease, hydronephrosis
        • Renovascular - renal artery stenosis, atherosclerosis, aortic coarctation
        • Endocrine - thyroid disease (hyper / hypo), Cushings, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
        • Obstructive sleep apnoea

        Ataxic Gait

        An ataxic gait occurs with cerebellar lesions or with loss of proprioception.

        Extra Credit

        • Causes of Clicking / Snapping Hip

        • Fascial band over greater trochanter
        • Loose intra-articular body
        • Extra-articular tenodesis
        • Dislocation (newborn)

        Overview

        The herniae mentioned above are those that are palpable within the groin. Other types of herniae to not forget include obturator, umbilical, epigastric, ncisional and Spigelian herniae.

        Bradypnoea

        • Causes of Bradypnoea

        • Respiratory suppression
        • Drugs - opiates
        • Respiratory failure
        • Hypothyroidism
        • Raised intracranial pressure

        Marfan Syndrome

        • Look For

        • Tall stature (due to long bone overgrowth)
        • High arched palate
        • Joint hypermobility
        • Poor visual acuity (due to lens dislocation)

        Overview

        Mitral Area - the fifth intercostal space in the midclavicular line. The murmurs of mitral stenosis and regurgitation are loudest in this area, as are the first heart sound (S1) and third heart sound (S3)

        Wheeze

        • Causes of Wheeze

        • Asthma
        • Chronic obstructive pulmonary disease
        • Viral bronchospasm
        • Lung cancer
        • Pulmonary oedema
        • Aspiration
        • Carcinoid syndrome
        • Churg-Strauss syndrome
        • Allergic bronchopulmonary aspergillosis (ABPA)

        Left Lateral Position

        The third heart sound and the murmur of mitral stenosis are made louder in the left lateral position.

        Measuring Blood Pressure

        Ask the patient not to talk or move while the blood pressure is measured as this can cause a false elevation in BP.

        Hepatomegaly

        • Percussion of Upper Liver Edge

        • Percuss down the midclavicular line from the level of the third rib, with the struck finger held horizontal to the ribs. Once the top edge of the liver is percussed the percussion note will become dull.

        Cog Wheel Rigidity

        • Feel For

        • Rigidity associated with tremor, resulting in jerky start / stop movement of the joint.

        Hyporeflexia

        • Significance

        • Suggestive of a lower motor neuron lesion.

        Lateral Cutaneous Nerve Palsy

        • Signs of Lateral Cutaneous Nerve Palsy

        • Sensory loss over the lateral thigh
        • No motor manifestations

        Myotomes

        Hip extension: sciatic nerve (L5/S1/S2)Biceps femoris, semitendinosus, semimembranosus

        Lead Pipe Rigidity

        • Significance

        • Caused by Parkinson's disease, other causes of parkinsonism, and contractures.

        Intention Tremor

        • Significance

        • Cerebellar disease in the form of stroke, tumour or multiple sclerosis.

        Bony Landmarks of the Ankle

        Metatarsal bones - palpate the heads, shafts and bases of the five metatarsal bones. Squeeze across the metatarsal heads.

        Overview

        • Causes of Limited Foot Range of Motion

        • Fracture
        • Plantar fasciitis
        • Calcaneal bursitis
        • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis

        Onycholysis

        Look For Separation of the nail plate from the nail bed or nail fold.

        Ataxic Gait

        An ataxic gait occurs with cerebellar lesions or with loss of proprioception.
        An ataxic gait occurs with cerebellar lesions or with loss of proprioception.

        Extra Credit

        • Prepatellar bursa - between the patella and the overlying subcutaneous tissue. Bursitis presents as pain and swelling over the patella.
        • Infrapatellar bursa - superficial or deep; inferior to the patella. Bursitis presents as a palpable swelling inferior to the patella.
        • Suprapatellar bursa - between quadriceps tendon and femur. Presents as a palpable mass above the knee joint.
        • Anserine bursa - in the medial knee, over the distal sartorius, gracilis and semitendinosus tendons, between the tibial collateral ligament and medial tibial condyle.
        • Medial collateral ligament bursa - between the superficial and deep layers of the collateral ligament. Bursitis presents similarly to a medial meniscus tear or medial collateral ligament tear.
        • Iliotibial bursa - between the distal iliotibial band and Gerdy's tubercle. Presents with lateral knee swelling.
        • Gastrocnemius-semimembranosus bursa - between the medial femoral condyle, semimembranosus tendon and medial head of gastrocnemius. Becomes distended to form a Baker's cyst.

        Word Repetition

        • Significance

        • Patients may not be able to repeat the terms back due to dysarthria, dysphasia, confusion or poor compliance.

        Quantity of Speech

        • Interpretation

        • Excessive talking (logorrhoea) - speaking at length and apparently without endMania, ADHD, anxiety
        • Talkative - actively takes part in conversation.Normal
        • Poverty of speech - very little speech, even with persuasion.Shyness, depression, schizophrenia, cognitive impairment

        Overvalued Ideas

        Overvalued ideas are unreasonable beliefs that the patient spends a large amount of time and energy on.

        Ataxic Gait

        An ataxic gait occurs with cerebellar lesions or with loss of proprioception.

        Muscles Acting on the Thoracic / Lumbar Spine

        Rotators - internal & external oblique, multifidus

        Pharyngeal Exudate

        • Look For

        • Pus or mucus on the posterior wall of the pharynx.

        Cervical Lymph Nodes

        Posterior cervical nodes - posterior to sternocleidomastoidsScalp, posterior neck

        Muscles Acting on the Hand

        Extrinsic Finger extensors - extensor digitorum, extensor digiti minimi, extensor indicis

        Fasciculations

        • Causes of Fasciculations

        • Benign / normal
        • Lower motor neuron disorders - ALS, radiculopathy, peripheral neuropathy, entrapment, syringomyelia, Creutzfeldt-Jakob disease
        • Metabolic disorders - thyrotoxicosis, tetanus, anticholinesterase medications

        Bony Landmarks of the Hand

        Phalanges - proximal, intermediate (2-5), and distal.

        Extra Credit

        • Additional Causes of Limited Finger / Thumb Range of Motion

        • Dupuytren's contracture
        • De Quervain's tenosynovitis
        • Trigger finger (entrapment of tendon within tendon sheath)
        • Arthritis - gout, septic arthritis, osteoarthritis, rheumatoid arthritis

        Amplitude

        Pulsus alternans: regular alternation between strong and weak beatsLeft ventricular failure

        Overview

        The term trophic derives from the Greek trophe, meaning 'nourishment'.

        Pupillary Light Reflexes

        • Interpretation

        • No direct response - absent reflex in the tested eyeIpsilateral oculomotor nerve (III) lesion
        • No consensual response - absent reflex in opposite eyeContralateral oculomotor nerve (III) lesion
        • No afferent response - absent reflex in one eye when testing either eyeIpsilateral optic nerve (II) lesion
        • No response - absent reflex in both eyes when testing either eyeMidbrain lesion, medications

        Rashes Associated with Diabetes

        Bullosis diabeticorum: non-inflamed bullae over the legs and feetType 1 diabetes (peripheral neuropathy)

        Lower Limb Cyanosis

        • Causes of Lower Limb Cyanosis

        • Central Cyanosis

        • High altitude
        • Obstructive lung disease, pulmonary oedema, pneumonia, pulmonary embolism
        • Congenital heart disease
        • Methaemoglobinaemia / sulfhaemoglobinaemia / carboxyhaemoglobinaemia
        • Peripheral Cyanosis

        • As for central cyanosis
        • Reduced cardiac output
        • Vasoconstriction

        Physiology

        • Roles

        • Folate coenzymes are important for DNA metabolism and amino acid metabolism pathways. They are required for the synthesis of DNA from thymidine and purines, as well as for the synthesis of the amino acids methionine, cysteine, serine, glycine and histidine.

        Clinical Use

        • Contraindications

        • Asthma
        • Decompensated heart failure
        • AV block
        • Adverse Effects

        • Fatigue / headache
        • Bradycardia
        • Postural hypotension
        • Vivid dreams
        • Adverse Effects

        • Postural hypotension
        • Retrograde ejaculation (due to effect on prostate)

        Overview

        • Effects

        • Decreased preload - due to reduced tubular sodium and water reabsorption and reduced ADH secretion, resulting in reduced water retention
        • Decreased afterload - due to vascular smooth muscle relaxation
        • Cardiac remodelling  - in the longer term
        • Reduced aldosterone secretion
        • Increased bradykinin (ACE also catalyses the breakdown of bradykin) → dry cough

        Clinical Use

        • Adverse Effects

        • Constipation
        • Dizziness
        • Headache
        • Nausea
        • Indications

        • Cardioversion of atrial fibrillation / flutter
        • Acute ventricular tachycardia
        It is important that statin use be coupled with dietary reduction in cholesterol and saturated fat.
        • Contraindications

        • Asthma
        • Decompensated heart failure
        • AV block
        A useful alternative to ACE inhibitors in patients who develop cough.

        Pacemaker Action Potentials

        • Phases

        • 4
          Spontaneous depolarisation - slow influx of sodium ('funny' current) that causes spontaneous depolarisation, followed by opening of T-type and then L-type calcium channels
        • 0
          Depolarisation - mainly due to flow of calcium through L-type calcium channelsInhibited by calcium channel blockers (class IV)
        • 3
          Repolarisation - potassium efflux due to opening of potassium channels

        Clinical Use

        • Adverse Effects

        • Electrolyte abnormalities
        • Dizziness / headache
        • Blurred vision
        • Nausea / vomiting / diarrhea
        • Sinus bradycardia
        • Monitoring

        • Intravenous heparin is monitored using activated partial thromboplastin time (APTT). Alternatively (particularly in the setting of antiphospholipid syndrome), a heparin anti-factor Xa assay can be used.
        • Reversal

        • Andexanet alpha may be used to reverse apixaban or rivaroxaban in life-threatening situations only.
        • Monitoring

        • Not monitored in most cases. Anti-factor Xa assays may be used in specific situations such as renal impairment (CrCl <50mL/min), underweight or obese patients, or pregnancy.
        • Monitoring

        • International normalised ratio (INR).
        • AF / VTE - generally aim INR 2.0 - 3.0
        • Prosthetic heart valve - generally aim INR 2.5 - 3.5

        Substem A (Target)

        -n(e)-: neurological (e.g. solanezumab)

        Clinical Use

        • Adverse Effects

        • Rash
        • Nausea / vomiting / diarrhoea
        • Adverse Effects

        • Nausea / vomiting / diarrhoea
        • Gynaecomastia / breast tenderness
        • Hot flushes
        • Dizziness
        • Elevated LFTs
        • Osteoporosis (long-term)
        • Adverse Effects

        • Hypotension
        • Bradycardia (halothane / sevoflurane)
        • Tachycardia (desflurane / isoflurane)
        • Cardiac arrhythmia
        • Reduced tidal volume with increased respiratory rate
        • Reduced renal blood flow and glomerular filtration rate
        • Hepatotoxicity
        • Malignant hyperthermia
        • Indications

        • Relaxation of skeletal muscle for anaesthesia during surgery
        • Relaxation of skeletal muscle to facilitate mechanical ventilation in ICU patients
        • Signs of Withdrawal

        • Worsening of underlying disease
        • Acute adrenal insufficiency
        • Raised ICP / papilloedema
        • Adverse Effects

        • Hypoglycaemia
        • Headache
        • Reflux
        • Nausea / vomiting
        • Pancreatitis

        Overview

        These hormones normally have a short half-life as they are degraded by the enzyme dipeptidyl peptidase-4 (DPP-4).

        Clinical Use

        • Contraindication

        • Hypoglycaemia.
        • Adverse Effects

        • Hypoglycaemia
        • Weight gain
        • Hypersensitivity reactions
        • Contraindications

        • Hypocalcaemia
        • Delayed oesophageal emptying - stricture, achalasia
        • Inability to stand / sit upright
        Multiple agents are used at once - two NRTIs + one NNRTI / protease inhibitor / integrase inhibitor.
        • Indications

        • Genital herpes
        • Cold sores
        • Herpes simplex encephalitis
        • Chickenpox (in adults)
        • Shingles
        • Ophthalmic herpes zoster
        • Treatment / prophylaxis for CMV infection in immunocompromised patients (ganciclovir)

        Overview

        • Mechanism of Action

        • Positively modulate GABAA receptors (BZ1 and BZ2), augmenting the inhibitory effects of the GABA neurotransmitter.

        Clinical Use

        • Indications

        • Depression
        • Obsessive-compulsive disorder
        • Generalised anxiety disorder
        • Panic disorder (paroxetine / sertraline)
        • Post-traumatic stress disorder (paroxetine / sertraline)
        • Adverse Effects

        • Anticholinergic (especially chlorpromazine) - dry mouth, blurred vision, constipation, urinary retention, delirium
        • Extrapyramidal - dystonia, akathisia, parkinsonism, tardive dyskinesia
        • Hyperprolactinaemia - gynaecomastia, galactorrhoea, infertility, sexual dysfunction
        • Drowsiness
        • Postural hypotension
        • Prolonged QTc
        • Dyslipidaemia
        • Weight gain

        Overview

        • Mechanism of Action

        • Seem to cause transient antagonism of D2 receptors, as well as serotonin 5-HT2A antagonism.

        Clinical Use

          • Adverse Effects

          • Hypersensitivity - urticarial rash, oedema, anaphylaxis
          • GIT - nausea / vomiting / diarrhoea
          • Thrombocytopaenia / leukopaenia
          • Adverse Effects

          • Hypersensitivity - urticarial rash, oedema, anaphylaxis
          • GIT - nausea / vomiting / diarrhoea
          • Thrombocytopaenia / leukopaenia
          • Indications

          • Community-acquired pneumonia
          • Meningitis
          • Gram negative septicaemia
          • Intra-abdominal infections
          • Adverse Effects

          • Hypersensitivity - urticarial rash, oedema, anaphylaxis
          • GIT - nausea / vomiting / diarrhoea
          • Thrombocytopaenia / leukopaenia
          • Adverse Effects

          • Fatigue / headache
          • Bradycardia
          • Postural hypotension
          • Nausea / vomiting / diarrhoea
          • Monitoring

          • Electrolytes, urea and creatinine.
          • Indications

          • Hypertension - first line management, especially in patients with chronic kidney disease or heart failure
          • Heart failure
          • Post myocardial infarction
          • Diabetic nephropathy (captopril)
          • Adverse Effects

          • Anticholinergic - dry mouth, blurred vision, constipation, urinary retention
          • Nausea / vomiting / diarrhoea
          • Headache
          • Fatigue
          • Adverse Effects

          • Headache
          • Nausea / vomiting / diarrhea / flatulence
          • Elevated LFTs
          • Hyperglycaemia
          • Myalgia / arthralgia / rhabdomyolysis
          • Adverse Effects

          • Fatigue / headache
          • Bradycardia
          • Postural hypotension
          • Nausea / vomiting / diarrhoea
          • Contraindications

          • Severe renal impairment
          • Severe hepatic impairment
          • Patients on direct renin inhibitors (aliskiren)
          • Monitoring

          • Has a narrow therapeutic index, thus levels must be monitored regularly.
          • Reversal

          • Protamine sulfate.
          • Reversal

          • Protamine sulfate may be used to reverse LMWHs, though this is less effective than with unfractionated heparin as it completely reverses factor IIa inhibition and only partially reverses factor Xa inhibition.
          • Reversal

          • Vitamin K
          • Fresh frozen plasma (all clotting factors)
          • Prothrombinex (purified factors II, IX and X)

          Substem A (Target)

          -s(o)-: bone (e.g. denosumab)

          Clinical Use

          Should not be given prior to induction of unconsciousness, in order to avoid patient distress.
          • Avoiding Withdrawal

          • Taper the dose by 2.5-5mg prednisone every 3-7 days prior to ceasing.

          Overview

          • Effects

          • Stimulation of insulin secretion in hyperglycaemia
          • Inhibition of glucagon secretion in hyperglucagonaemia

          Clinical Use

          • Adverse Effects

          • Hypoglycaemia
          • Weight gain
          • Hypersensitivity reactions
          • Adverse Effects

          • Headache
          • Oesophagitis / gastritis
          • Nausea / vomiting / diarrhea
          • Muscle / bone / joint pain
          • Atypical femoral fractures
          • Osteonecrosis of the jaw
          • Adverse Effects

          • Nausea / vomiting
          • Headache
          • Adverse Effects

          • Nausea / vomiting, headache.

          Overview

          • Effects

          • BZ1 receptor (cortex, thalamus, cerebellum) - sedation, anterograde amnesia, anticonvulsant
          • BZ2 receptor (limbic system, motor neurons) - anxiolysis, muscle relaxation

          Clinical Use

          • Contraindication

          • Not for concurrent use with monoamine oxidase inhibitors (MAOi).
          More extrapyramidal side effects than atypical antipsychotics.
          • Indications

          • Psychosis - schizophrenia, and related disorders
          • Acute mania
          • Maintenance therapy for bipolar I disorder (low-dose second generation antipsychotics)
          • Tranquilization - in the acute psychiatric setting (chlorpromazine / haloperidol / droperidol / olanzapine / risperidone)
          • Agitation / hallucinations associated with delirium or dementia ( olanzapine / risperidone)
          • Severe nausea / vomiting associated with surgery or anaesthesia (droperidol)
          • Status migrainosus (chlorpromazine / droperidol)
          • Adverse Effects

            Very few compared to penicillins.
          • Thrombophlebitis
          • Hypersensitivity reactions
          • Nausea / vomiting / diarrhoea
          • Pseudomembranous colitis (C difficile)
          • Thrombocytopaenia / leukopaenia
          • Nephrotoxicity

          Non-Rebreather Mask

          FlowFiO₂
          15L/minUp to 0.90

          Femoral Vein

          • Considerations

          • Makes ambulation difficult
          • Preferred for coagulopathic patients, due to ability to compress the site
          • Higher risk of infection
          • Higher risk of thrombosis

          Right Atrial Placement

          • Management

          • Under sterile conditions, withdraw the PICC into the superior vena cava as measured on chest x-ray, and then refasten the line.

          Insertion

          Stretch the skin distal to the insertion site, and tell the patient to prepare for a sharp 'scratch'.

          Bupivacaine

          Don't use sodium bicarbonate with bupivacaine as the drug may precipitate.

          Nasopharyngeal Airway

          • Contraindications

          • Suspected nasal / base of skull fracture
          • Active bleeding from the nose

          Diagnosis

          The ST depression of digoxin toxicity is characteristically scooped - this is often referred to as a reverse tick or Salvador Dali's moustache ST depression.

          Hormonal Changes

          Levels of reverse T3 (rT3) tend to rise during stress states, and as such are a marker of nonthyroidal illness. As this is mainly a clinical diagnosis, rT3 is rarely measured in clinical practice.

          Manifestations

          • ECG Findings

          • Mild

          • Tall, tented T waves
          • Moderate

          • Reduction in P wave height
          • Long PR interval
          • Severe

          • Short QT interval
          • Widening of QRS complex
          • Sine wave QRS pattern
          • Life-Threatening

          • Asystole

          Diagnosis

          • Large right-sided pleural effusion
          • Large right-sided pleural effusion
             
          • Advanced 2nd degree AV block
          • Advanced 2nd degree AV block
             
          An arterial blood gas may reveal a reduced PaO₂, though in small pulmonary emboli the patient may not be hypoxic. PaCO₂ may be normal or reduced due to hyperventilation.
          The Brugada pattern in isolation is of unclear clinical significance, while the presence of clinical criteria with a type 2 or 3 pattern requires further investigation.
          A left bundle branch morphology classically suggests a right ventricular focus of VT, while a right bundle morphology pattern suggests a left ventricular focus. A septal focus may manifest as either a left or right bundle branch morphology.
          • Examples

          • Test Findings in Beta Thalassaemia

          • Full Blood Count & Film

          • Microcytic hypochromic anaemia
          • Poikilocytosis - target cells, teardrop cells, elliptocytes, fragments
          • Basophilic stippling
          • Nucleated red cells
          • Other Tests

          • High performance liquid chromatography / haemoglobin electrophoresis - increased haemoglobin A₂ and haemoglobin F
          • Iron studies - elevated ferritin, elevated transferrin saturation (beta thalassaemia major)
          Elevated serum osmolality (>285mOsm/kg) indicates movement of water from cells to the interstitium and intravascularly, driven by extracellular solutes such as sugars. This can occur with hyperglycaemia and hypertonic mannitol. A sodium correction should be performed to account for serum glucose - see the Calculators section for this tool.
          • Diagnosis
          • Clinical Signs

          • Myopathic facies - temporalis wasting, mandibular wasting, frontal baldness
          • Flaccid dysarthria - nasal speech, breathiness, monotony, impaired articulation
          • Warm-up phenomenon - grip myotonia, repeated eye closure
          • Percussion myotonia - muscle contraction with percussion of the thenar eminence
          • Wasting of the forearm and small muscles of the hand
          • Distal muscle weakness
          • Hyporeflexia

          Phases of Infection

          The immune escape phase (also known as HBeAg-negative chronic hepatitic B) occurs when the virus develops mutations to evade the control of the immune system and replicates, producing a recurrence in hepatitis and a high HBV DNA titre.

          Diagnosis

          • Diagnosis
             

          Clinical Use

          • Indications

          • Non-bleeding patients: platelet count <10
          • Major surgery: platelet count <50
          • Ocular / neurosurgery: platelet count <100
          • Defective platelet function
          • Indications

          • Severe anaemia
          • Symptomatic anaemia
          • Acute blood loss >1.5L / 30% of blood volume
          • Adverse Effects

          • Immunosuppression (risk of infection)
          • Osteoporosis
          • Steroid-induced diabetes mellitus
          • Cushing's - central obesity, 'moon' face, buffalo hump, thin skin, peripheral oedema, striae, bruising
          • CNS - cognitive impairment / emotional instability / fatigue
          • Renal - sodium & water retention / hypertension / oedema
          • GIT - peptic ulceration, nausea / vomiting
          • Muscle wasting
          • Ocular - cataract / glaucoma
          Ask the patient to wash their mouth out after using inhaled corticosteroids, in order to avoid oropharyngeal candidiasis.
          • Adverse Effects

          • Drowsiness
          • Dizziness
          • Paraesthesia
          • Weakness
          • Chest tightness
          • Nausea / vomiting
          • Adverse Effects

          • Immunosuppression (risk of infection)
          • Osteoporosis
          • Steroid-induced diabetes mellitus
          • Cushing's - central obesity, 'moon' face, buffalo hump, thin skin, peripheral oedema, striae, bruising
          • CNS - cognitive impairment / emotional instability / fatigue
          • Renal - sodium & water retention / hypertension / oedema
          • GIT - peptic ulceration, nausea / vomiting
          • Muscle wasting
          • Ocular - cataract / glaucoma
          • Signs of Withdrawal

          • Anxiety / agitation
          • Insomnia
          • Myoclonus
          • Seizures
          • Anterograde memory loss (especially midazolam)
          • Adverse Reactions

          • Gastritis / peptic ulceration
          • Nephrotoxicity
          • Hypertension / fluid retention / congestive cardiac failure / MI
          • Hypersensitivity reactions
          • Delirium
          • Headache
          • Elevated LFTs
          • Neutropaenia
          • Adverse Effects

          • Drowsiness
          • Headache
          • Dry mouth
          • Fatigue

          Substem A (Target)

          -s(o)-: bone (e.g. denosumab)

          Clinical Use

          • Adverse Effects

          • Immunosuppression (risk of infection)
          • Osteoporosis
          • Steroid-induced diabetes mellitus
          • Cushing's - central obesity, 'moon' face, buffalo hump, thin skin, peripheral oedema, striae, bruising
          • CNS - cognitive impairment / emotional instability / fatigue
          • Renal - sodium & water retention / hypertension / oedema
          • GIT - peptic ulceration, nausea / vomiting
          • Muscle wasting
          • Ocular - cataract / glaucoma
          • Adverse Effects

          • Hypoglycaemia
          • Weight gain
          • Hypersensitivity reactions
          • Adverse Effects

          • Nausea / vomiting
          • Constipation
          • Sedation
          • Respiratory depression
          • Diaphoresis
          • Delirium
          • Hypersensitivity - bronchospasm, urticaria
          • Bradycardia
          • Tolerance
          • Dependence
          • Hypogonadism
          • Indications

          • Pain - including migraine and musculoskeletal injury
          • Fever
          • Inflammation - especially associated with arthritides
          There is no evidence that long-term PPI use has a clinically significant effect on the absorption of nutrients.
          • Adverse Effects

          • Immunosuppression (risk of infection)
          • Osteoporosis
          • Steroid-induced diabetes mellitus
          • Cushing's - central obesity, 'moon' face, buffalo hump, thin skin, peripheral oedema, striae, bruising
          • CNS - cognitive impairment / emotional instability / fatigue
          • Renal - sodium & water retention / hypertension / oedema
          • GIT - peptic ulceration, nausea / vomiting
          • Muscle wasting
          • Ocular - cataract / glaucoma

          Overview

          Some calculations also take into account potassium, however this is not a major contributor and is more often than not left out.

          Oxygen Dissociation Curve

          • Causes of Right Shift

          • Acidaemia (Bohr effect)
          • Hyperthermia
          • Increased 2,3-DPG

          Lytic Lesions

          • Look For

          • Punched-out lesions within the bone.

          Pacemaker

          • A multi-chamber pacemaker with old leads present: lateral film
          • No Overlay
            Overlay
            A multi-chamber pacemaker with old leads present lateral film
             

          Lateral

          In order to take a lateral film, the x-ray plate is placed beside the patient.

          Rotation

          Look at the medial ends of the clavicle and posterior spinous process - the side to which the patient is rotated normally becomes more translucent.

          PICC Lines

          • A right-sided PICC line at the cavoatrial junction
          • No Overlay
            Overlay
            A right-sided PICC line at the cavoatrial junction
             

          Patellar Dislocation

          • Look For

          • Displacement of the patella. Most commonly lateral, though may be medial.

          2nd Degree SA Exit Block: Type II

          • Look For

          • A constant PP interval, with a pause that is a multiple of the PP interval.

          2nd Degree AV Block: Type I Mobitz

          • Look For

          • Initial normal PR interval with progressive prolongation of PR interval followed by a dropped QRS complex.

          Polychromasia

          • Polychromasia

          Diagnosis

          Transferrin saturations >50% in women or >60% in men are indicative of iron overload.

          Storage

          Iron is mainly stored within macrophages and the liver, though a small amount may also be stored in cardiomyocytes. Iron is mainly stored as ferritin, though a small amount is also stored as haemosiderin.

          Diagnosis

          The anaemia of iron deficiency tends to be microcytic and hypochromic and the blood film may exhibit poikilocytic changes such as target cells or elliptocytes. Often in early iron deficiency the anaemia is normocytic, with anisocytosis (i.e. an elevated RDW) due to a mix of normocytic and microcytic cells.

          Macrocytosis

          • Causes of Macrocytosis

          • Megaloblastic

          • B12 deficiency
          • Folate deficiency
          • Drugs - methotrexate, chemotherapy, reverse transcriptase inhibitors, valproate, phenytoin, nitrous oxide, trimethoprim
          • Non-Megaloblastic

          • Chronic liver disease
          • Chronic alcohol abuse
          • Post splenectomy
          • Aplastic anaemia
          • Myelodysplastic syndrome
          • Hypothyroidism
          • Reticulocytosis (haemolysis, haemorrhage, recovery post anaemia)

          Neutrophilia

          • Neutrophilia
             

          Abnormal Platelet Size

          Platelets are normally very small in size, though occasionally large or giant platelets may be seen. Platelet anisocytosis refers to a significant variation in the size of platelets on a blood film.

          Small Mature Lymphocytes

          • Causes of Small Mature Lymphocytosis

          • Chronic lymphocytic leukaemia
          • Monoclonal B lymphocytosis (pre-CLL)
          • Certain infections
          • Hyposplenism

          Left Shift of Granulocytes

          • A metamyelocyte. : Note the kidney-shaped nucleus and intracytoplasmic granules. This metamyelocyte is hypergranular.
          • A metamyelocyte.  Note the kidney-shaped nucleus and intracytoplasmic granules. This metamyelocyte is hypergranular.
             

          Overview

          • Causes of Myelodysplasia

          • Primary

          • Myelodysplastic syndromes (MDS)
          • Myelodysplastic / myeloproliferative neoplasms - chronic myelomonocytic leukaemia (CMML)
          • Secondary

          • Cytotoxic chemotherapy
          • Benzene exposure
          • Ionising radiation
          Thyroglobulin (Tg) is a storage form of the thyroid hormones produced by follicular cells of the thyroid, and is released into serum in conjunction with T3 and T4.

          Subclinical Hypothyroidism

          • Causes of Subclinical Hypothyroidism

          • As per primary hypothyroidism.

          Hormonal Changes

          Levels of reverse T3 (rT3) tend to rise during stress states, and as such are a marker of nonthyroidal illness. As this is mainly a clinical diagnosis, rT3 is rarely measured in clinical practice.

          Reduced / Normal TSH with Reduced T4

          A reduced or normal TSH with a reduced T4 level is classically suggestive of a central cause of hypothyroidism (i.e. reduced hypothalamic or pituitary release of TRH or TSH respectively). However, central hypothyroidism is rare and perhaps a more common cause is the non-thyroidal illness (sick euthyroid) syndrome.

          Subclinical Hyperthyroidism

          • Look For

          • Reduced TSH with normal T4
          • No clinical features of hyperthyroidism

          Quadrant Method

          IaVFII
          Normal Axis
          0° to 90°
          +++
          Normal Axis
          -30° to 0°
          +-+
          Left axis deviation
          -30° to -90°
          +--
          Right axis deviation
          90° to 180°
          -++/-
          Extreme axis deviation
          -90° to 180°
          ---

          Correcting the QT Interval (QTc)

          Adjust the QT interval according the to heart rate using the Bazett, Fridericia or Framingham method. The Bazett formula is the most commonly used, and is validated for heart rates between 60-100bpm. In the presence of tachycardia or bradycardia, one of the other two formulae should be used.

          Ventricular Rhythm

          Ventricular rhythm can be assessed by examining the QRS complexes on the rhythm strip.

          ECG Leads

          ElectrodesDirectionComplex
          aVLLA-30Lateral
          aVRRA-150Right atrial
          aVFLL+90Inferior

          Atypical LBBB

          • Typical LBBB

          • Wide QRS >120ms
          • Broad R wave in lateral leads (I, aVL, V5, V6)
          • Absent Q waves in I, V5 and V6

          Alpha-1 Globulins

          Include alpha-1 antitrypsin and thyroid-binding globulin.

          CKD-EPI Formula

          • Formula

          • eGFR = 141 × (Creatinine/X)Y × 0.993Age ( × 1.018 if female) ( × 1.159 if african origin)

            Female:
               Cr <0.7mg/dL (62μmol/L): X = 0.7; Y = -0.329
               Cr >0.7mg/dL (62μmol/L): X = 0.7; Y = -1.209
            Male:
               Cr <0.9mg/dL (80μmol/L): X = 0.9; Y = -0.411
               Cr >0.9mg/dL (80μmol/L): X = 0.9; Y = -1.209

          Overview

          New left bundle branch block is also a feature of ST elevation myocardial infarction, because the presence of LBBB makes interpretation of an ECG for STEMI impossible. Right bundle branch block causes no such issue.

          Body Mass Index

          • Associated with Being Underweight

          • Hypoglycaemia
          • Vitamin deficiency - scurvy, rickets
          • Bone marrow suppression - anaemia, thrombocytopaenia, immunosuppression
          • Cardiac - arrhythmia, MI
          • Neurological - cognitive impairment, peripheral neuropathy, Wernicke-Korsakoff syndrome
          • Muscle wasting
          • Endocrine - osteoporosis, amenorrhoea

          Neuropathic Ulcers

          • Look For

          • Deep ulcers surrounded by callus, most commonly on weight bearing areas such as the sole of the foot. Associated with diminished sensation of the foot and normal pedal pulses.

          Object Naming

          Pictures of items - show drawings of objects and ask the patient to name them.

          The Reflex Arc

          Receptors
          Golgi tendon organ / muscle spindle
           
           
          Afferent Neuron
          Within the dorsal root ganglion
           
           
          Interneurons
          Within the spinal cord
           
           
          Efferent Neuron
          Within the ventral horn
           
           
          Muscle
          Stimulation of agonist muscle
          Inhibition of antagonist muscle

          Upper Limb Myotomes

          Elbow flexion: musculocutaneous nerve (C5/C6)Biceps, brachoradialis

          Ulnar Nerve Palsy

          • Signs of Ulnar Nerve Palsy

          • Sensory

          • Sensory loss over the palmar and dorsal aspect of the 5th finger and medial half of the ring finger
          • Sensory loss of the ulnar aspect of the forearm (proximal lesion)
          • Motor

          • Claw hand - extension of the MCP joints and flexion of the IP joints of the ring and little fingers
          • Wasting of the small muscles of the hand (sparing the thenar eminance)
          • Weakness of finger abduction
          • Weakness of ulnar deviation of the wrist (proximal lesion)

          Body Mass Index

          • Associated with Being Underweight

          • Hypoglycaemia
          • Vitamin deficiency - scurvy, rickets
          • Bone marrow suppression - anaemia, thrombocytopaenia, immunosuppression
          • Cardiac - arrhythmia, MI
          • Neurological - cognitive impairment, peripheral neuropathy, Wernicke-Korsakoff syndrome
          • Muscle wasting
          • Endocrine - osteoporosis, amenorrhoea

          Cervical Lymph Nodes

          Suboccipital nodes - below occiputInferior scalp

          Hyperpigmentation

          • Causes of Hyperpigmentation

          • Dermatoses - ephelides (freckles), melanocytosis
          • Post -inflammatory - sunlight exposure (tan), dermatitis, infection, trauma
          • Haemochromatosis
          • Alcoholic liver disease
          • Cirrhosis
          • Renal failure
          • Cutaneous amyloidosis

          Common Signs on the Tongue

          Leukoplakia: white patches that don't scrape off.Premalignant, or EBV infection in HIV patients

          Assessing Orientation

          • Causes of Confusion

          • Delirium - stroke, infection, intoxication / withdrawal, metabolic, neoplastic, seizure, sleep deprivation, severe pain, psychiatric
          • Dementia - Alzheimer's, vascular dementia, lewy body dementia
          • Intellectual disability
          • Poor compliance with examination

          Overview

          • Note

          • Both shifting dullness and fluid wave have poor sensitivity and specificity for the assessment of ascites.

          Scratch Marks

          • Look For

          • Scratch marks over the skin of the face, arms, chest or abdomen.

          Spider Naevi

          • Significance

          • Dilatation of the capillaries due to oestrogen excess.

          Focal Abdominal Tenderness

          Left Iliac Fossa - sigmoid colon, ovary, fallopian tube, ureterSigmoid diverticulitis, ovarian pathology, ectopic pregnancy, PID, inguinal hernia

          Jaundice

          • Look For

          • Yellow discolouration of the skin and mucous membranes, due to deposition of bilirubin.

          Axillary Lymph Nodes

          Infraclavicular nodes - below the distal aspect of the clavicleLateral hand, forearm and arm

          Cervical Lymph Nodes

          Suboccipital nodes - below the occiputInferior scalp

          Abdominal Mass

          Hypogastrium - uterus, bladder, sigmoid colonUrinary retention, faecal loading, sigmoid tumour

          Ataxic Gait

          • Look For

          • An unsteady, staggering, wide-based gait.

          Hypertension

          Hypertension refers to a persistent elevation in blood pressure. This may be primary and of unknown aetiology, or secondary to a process that raises the blood pressure.

          Increased Body Temperature

          • Causes of Increased Body Temperature

          • Fever

          • Infection - bacterial, protozoal, fungal, viral
          • Auto-immune conditions - rheumatoid arthritis, SLE, thyroiditis
          • Thromboembolism - DVT / PE
          • Metabolic disorders - gout
          • Transfusion reactions
          • Abnormal hypothalamic function - stroke, encephalitis, head trauma
          • Non-Inflammatory Causes

          • Excessive heat production - exertion, thyrotoxicosis, phaeochromocytoma, status epilepticus, tetany
          • Poor heat dissipation - heat stroke, dehydration, autonomic dysfunction, excessive clothing
          • Drug-induced - aspirin, stimulants, anticholinergics
          • Malignant hyperthermia (rare reaction to inhaled anaesthetics)

          Reduced Oxygen Saturation

          The level of haemoglobin saturated by oxygen may be reduced in the context of reduced oxygen, right shift of the oxygen saturation curve, displacement of oxygen by carbon dioxide, or in the setting of haemoglobinopathies.

          Crackles / Crepitations

          Crackles / crepitations are short, explosive sounds. These may be fine or coarse, and may be cleared by coughing (if due to secretions)

          Postural Tachycardia

          • How To Elicit

          • Measure the heart rate with the patient lying down, and then remeasure it after the patient has been standing for one minute.

          APTT Mixing Studies

          • Interpretation

          • APTT corrects - factor deficiencyCongenital factor deficiency, Von Willebrand disease, DIC, liver failure, supratherapeutic warfarin
          • APTT does not correct - inhibitor presentHeparin, factor IIa inhibitors, lupus anticoagulant, specific factor inhibitors

          Measures of Coagulation

          Prothrombin time (PT) is a test of the extrinsic and common pathways including factors VII, V, X, II and fibrinogen. It is performed by adding calcium and thromboplastin to a plasma sample and measuring the time to clot. The international normalised ratio (INR) is a correction of the PT to account for variation of reagents between laboratories, to allow for standardisation of values internationally.

          PT/INR Mixing Studies

          • Interpretation

          • PT/INR corrects - factor deficiencyWarfarin, vitamin K deficiency, congenital factor deficiency, DIC, liver failure
          • PT/INR does not correct - inhibitor presentFactor IIa inhibitors, excess heparin

          Neutrophil Physiology

          • Stages of Neutrophil Development

          • Myeloblast
          • Promyelocyte
          • Myelocyte
          • Metamyelocyte
          • Banded neutrophil (
          • Mature neutrophil - 3-5 nuclear lobes

          Diagnosis

          • Test Findings in Beta Thalassaemia

          • Full Blood Count & Film

          • Microcytic hypochromic anaemia
          • Poikilocytosis - target cells, teardrop cells, elliptocytes, fragments
          • Basophilic stippling
          • Nucleated red cells
          • Other Tests

          • High performance liquid chromatography / haemoglobin electrophoresis - increased haemoglobin A₂ and haemoglobin F
          • Iron studies - elevated ferritin, elevated transferrin saturation (beta thalassaemia major)

          Macrocytosis

          • Causes of Macrocytosis

          • Megaloblastic

          • B12 deficiency
          • Folate deficiency
          • Scurvy
          • Drugs - methotrexate, chemotherapy, reverse transcriptase inhibitors, valproate, phenytoin, nitrous oxide, trimethoprim
          • Reticulocytosis

          • Haemolytic anaemia
          • Haemorrhage
          • Recovery following bone marrow suppression
          • Other

          • Chronic liver disease
          • Chronic alcohol abuse
          • Myelodysplastic syndrome
          • Post splenectomy
          • Aplastic anaemia
          • Hypothyroidism

          Hyperchromia

          • Causes of Hyperchromia

          • Spherocytosis - hereditary spherocytosis, immune haemolysis, Clostridium infection
          • Microspherocytosis - microangiopathic haemolytic anaemia, severe burns
          • Macrocytosis - B12/folate deficiency chronic liver disease, alcohol abuse, hypothyroidism, post splenectomy, aplastic anaemia, myelodysplastic syndrome
          • Sickle cells - sickle cell disease

          Haematocrit or Haemoglobin?

          Discrepancies in the haematocrit : haemoglobin ratio occur most commonly in the presence of abnormal red blood cell morphology, and the blood smear should be examined when this is the case.
          Discrepancies in the haematocrit : haemoglobin ratio occur most commonly in the presence of abnormal red blood cell morphology, and the blood smear should be examined when this is the case.

          Diagnosis

          • Diagnosis
             

          Management

          • Pearls

          • Set realistic targets
          • Use non-pharmacologic and pharmacologic strategies
          • Titrate medications to the patient's blood pressure and side effects, e.g. electrolytes / renal function (ACEi / ARBs), cough (ACEi), oedema (CCBs)
          • Titrate up to the maximum dose of an antihypertensive before adding an additional medication
          • If the patient's blood pressure is not responding: consider white coat hypertension, non-adherence or secondary causes
          • Management Options

          • Non-Pharmacologic

          • Cardiac rehabilitation
          • Low sodium diet
          • Fluid restriction
          • Smoking cessation
          • Weight loss
          • Pharmacologic

          • ACE inhibitors (ACEi) - captopril, ramipril, perindopril
          • Angiotensin II receptor blockers (ARBs) - candesartan, irbesartan
          • Beta blockers - carvedilol, metoprolol, bisoprolol, nebivolol
          • Aldosterone antagonists - spironolactone
          • Loop diuretics - frusemide
          • Ivabradine
          • Digoxin
          • Devices

          • Biventricular pacing
          • Automatic implantable cardioverter defibrillator
          • Surgical Options

          • Heart transplant
          • Management Options

          • Rate control - beta blockers, calcium channel blockers, digoxin
          • Rhythm control - DC cardioversion, flecainide, sotalol, amiodarone
          • Catheter ablation - of the pulmonary vein orifices
          • Anticoagulation (to prevent stroke) - warfarin, dabigatran, rivaroxaban, apixaban

          Diagnosis

          Severe hypercalcaemia may produce ST elevation and T wave inversion that mimics an acute myocardial infarction.

          Past Medical History

          Ask about the cause of their CKD. Common causes include diabetic nephropathy and hypertensive nephropathy, however other causes include glomerulonephropathies, reflux nephropathy and polycystic kidney disease.
          Ask about whether the patient has been diagnosed with any medical conditions. If so, ask about the management of these conditions, and any complications.
          Ask about a history of recurrent infections, which suggests immunosuppression and may occur in patients with neutropaenia.
          In any patient with chronic respiratory disease, ask about exercise tolerance. How long the patient can walk without getting short of breath, and how long it takes them to recover following exertion. Patients with severe pulmonary disease (such as COPD, cystic fibrosis or other causes of bronchiectasis) may have intensive pulmonary rehabilitation regimens.
          Finally, ask about any cardiac devices that may be present, such as pacemakers or defibrillators.
          • Procedural History

          • Ask about any abdominal surgery the patient may have had in the past, such as cholecystectomy or appendicectomy. If a patient has had a stoma formed in the past, ask about the location of the stoma (ileostomy / colostomy), output of the stoma, any complications they have had as a result.

          I - Smell

           This nerve is not commonly assessed in detail, however a screening test can be performed by asking the patient to smell and identify a common scent (such as alcohol wipe, coffee or cinnamon). While loss of smell sensation - or anosmia - may be a sign of an olfactory nerve lesion, Parkinson's disease is an important differential to keep in mind.

          The Patient

          Inspection

          A strong urine smell suggests that the patient is dehydrated. Sweet urine classically suggests glycosuria in the context of diabetes, while an ammonia smell suggests urinary tract infection. Faeculant-smelling urine raises concern for a colovesical fistula.

          Red Cell Size & Colour

          • Mean Cell Volume and Mean Corpuscular Haemoglobin

          • These values are used to rapidly narrow down the likely causes of a patient's anaemia, using a few specific patterns.

          Assessing Oxygenation

          A reduction in the level of haemoglobin saturated by oxygen (reduced oxyhaemoglobin) may be due to any cause of hypoxia. 

          Assessment of Bone

          • Type of Fracture

          • Assess for whether the fracture is complete or incomplete, and what type of fracture is present - this will suggest a potential mechanism, and guide management.

          Causes of Haemolysis

          Inherited red blood cell disorders such as hereditary spherocytosis, sickle cell anaemia and thalassaemias are more rare. Glucose-6-phosphate dehydrogenase deficiency may cause oxidative haemolysis and is more common in males of African or Mediterranean descent.

          Measures of Iron Status

          • Transferrin & TIBG

          • Transferrin is an transport protein that binds to iron in plasma. This is proportional to the total iron binding capacity (TIBG: the total amount of iron that can be bound to serum transferrin). An elevated transferrin level or TIBG is a marker of iron deficiency; a reduced transferrin / TIBG may occur in the context of an acute phase reaction, chronic disease or iron overload.

          C-Reactive Protein

          CRP has little efficacy as a screening tool for inflammation, however the trend in CRP is useful for monitoring resolution or progression of an inflammatory process.

          Red Blood Cells

          Urine does not normally contain red blood cells. The presence of red cells in urine suggests glomerulonephropathy, certain other renal conditions, or pathology of the urinary tract.

          Collecting the Sample

          • Introduction

          Low Flow Oxygen

          • Nasal Prongs

          • Low flow nasal prongs deliver 100% oxygen at a low flow rate, which is then entrained with room air. Nasal prongs are comfortable and allow the patient to eat, however at flow rates higher than 4 L/min can cause drying of the nasal cavity.

          Identifying an Artery

          • Allen's Test

          • This is a clinical test used to determine the patency of the radial and ulnar arteries, and is used as a predictor of distal ischaemia risk post radial arterial cannulation or catheterisation.

          Equipment and Preparation

          • Catheter Size Guide

          • 6-10 French - paediatric patients
          • 12-14 French - most patients
          • 16-20 French - patients with clots or haematuria
          • 22 French (triple lumen) - continuous irrigation for patients with clots or haematuria or post urologic surgery

          Identifying a Vein

          Apply the tourniquet to the patient's limb and feel for a straight, firm, round, elastic vein. This should be non-pulsatile.

          Airway Adjuncts

          Airway adjuncts are used to relieve upper airway obstruction.

          Overview

          Left Axilla - the fifth intercostal space in the midaxillary line. The murmur of mitral regurgitation can be heard radiating to this area.

          Sitting Forward

          When assessing for cardiac murmurs, asking a patient to sit forward can greatly assist in the diagnosis of aortic and pulmonary pathology.

          Hypertension

          Hypertension refers to a persistent elevation in blood pressure.

          Hepatomegaly

          • Interpretation

          • Measure the liver size by estimating the location of the upper and lower liver edges. Hepatomegaly is present if the liver span is greater than 15cm.

          Cog Wheel Rigidity

          • Significance

          • Caused by Parkinson's disease, other causes of parkinsonism, and contractures.

          The Reflex Arc

          Receptors
          Golgi tendon organ / muscle spindle   Afferent Neuron
          Within the dorsal root ganglion  Interneurons
          Within the spinal cord   Efferent Neuron
          Within the ventral horn    Muscle
          Stimulation of agonist muscle
          Inhibition of antagonist muscle

          Lateral Cutaneous Nerve Palsy

          • Causes of Lateral Cutaneous Nerve Palsy

          • Occurs due to entrapment of the lateral cutaneous nerve beneath the inguinal ligament.

          • Increased intra-abdominal pressure - obesity, pregnancy
          • Tight clothing - particularly belts and suspenders

          Myotomes

          Hip adduction: obturator nerve (L2-L4)Adductor muscles, pectineus

          Cog Wheel Rigidity

          • Feel For

          • Rigidity associated with tremor, resulting in jerky start / stop movement of the joint.

          Psychogenic Tremor

          • Look For

          • Variable tremor that disappears when not under direct observation.

          Bony Landmarks of the Ankle

          Phalanges - proximal, intermediate (2-5), and distal.

          Onycholysis

          • Causes of Onycholysis

          • Trauma
          • Dermatoses - onychomycosis (fungal infection), lichen planus, psoriasis
          • Systemic disease - thyroid disease, multiple myeloma, scleroderma, anaemia, peripheral vascular disease, diabetes mellitus.
          • Drugs

          Ataxic Gait

          • Look For

          • An unsteady, staggering, wide-based gait.
          • Look For

          • An unsteady, staggering, wide-based gait.

          Object Naming

          Items around the room - point to objects and ask the patient to name them. Avoid frequently named items such as pen and watch - ask them to name objects such as cufflink or stethoscope.

          Fluency

          Fluency refers to the ease and flow of speech, exploring potential disruptions such as stuttering or hesitations, which could be related to anxiety, neurological disorders, or language impairments.

          Stupor

          A stupor is a state that lies somewhere between full awareness and coma.

          Overvalued Ideas

          • Examples of Overvalued Ideas

          • Anorexia / bulimia nervosa - a belief that they are overweight.
          • Body dysmorphic disorder - excessively preoccupied with a perceived flaw in their physical appearance, which may be minor or even nonexistent.
          • Orthorexia - an unhealthy obsession with eating only "pure" or "clean" foods, potentially leading to a highly restricted diet, excessive focus on food quality and preparation, and social isolation.
          • Extreme political or religious beliefs - strong convictions about a particular political or religious belief to the point that it dominates the person's thoughts and daily life, despite limited evidence or rational basis for their beliefs.
          • Hypochondriasis - excessive preoccupation with the idea of having a serious, undiagnosed medical condition despite having no or only mild symptoms, leading to persistent worry, frequent medical consultations, and excessive self-monitoring.
          • Excessive perfectionism - excessive concern with the need to achieve perfection in various aspects of life such as work, academics, or personal appearance.
          • Pseudocyesis: a belief that one is pregnant when they are not.
          • Apotemnophilia: a belief that one or more limbs do not belong to them.

          Ataxic Gait

          • Look For

          • An unsteady, staggering, wide-based gait.

          Pharyngeal Exudate

          • Interpretation

          • PusBacterial pharyngitis, EBV
          • White patchesCandidiasis
          • Grey, membranous exudateDiphtheria

          Overview

          Tactile fremitus was first described by a German physician who called for the patient to say "neunundneunzig" (ninety-nine). "Blue Balloons" is an English phrase that closely resembles the sound and vibration emitted from the lungs when saying "neunundneunzig" (a low frequency 'diphthong' phrase).

          Cervical Lymph Nodes

          Suboccipital nodes - below occiputInferior scalp

          Muscles Acting on the Hand

          Extrinsic Thumb muscles  - flexor pollucis longus, extensor pollucis longus & brevis, abductor pollucis longus

          Swinging Light Test

          • How to Perform

          • Shine a light into one eye, swing it into the other eye, and so on back and forth.

          Disease History

          • Severity

          • Severity of symptoms - e.g. exercise tolerance before shortness of breath, chest pain or claudication
          • Stage of disease
          • Frequency of exacerbations, hospital or ICU admissions
          • Recent test results - e.g. eGFR, HbA1c or echo

          Key Considerations

          • Cost and Availability

          • Finally, it's important to consider the cost of the app. Some clinical medicine apps are free, while others require a subscription or can be quite expensive. Some apps, such as Up To Date, may be available through your university or hospital.

          Key Features

          • Pre-made Decks

          • Some platforms offer a large library of pre-made flashcard decks on a variety of medical topics - this may include decks specifically for the USMLE and other standardised examinations. Whil creating your own cards is the highest yield method, pre-made decks save a lot of time and provide a breadth of information that comes with expertly created flashcards.

          Microsoft OneNote

          • Microsoft OneNote

          Key Features

          • Cost

          • Finally, we prioritised resources that are free or very affordable for medical students of all backgrounds.

          Zero to Finals

          • Platforms

          • YouTube, Website

          Smiling Mind

          • Platforms

          • Web, iOS, and Android

          Key Features

          • Free or Affordable Access

          • Medical students often have tight budgets, and as such we prioritised resources that are either free or offer affordable subscription models.

          Notion

          • Notion

          Life in the Fast Lane

          • Life in the Fast Lane

          Types of Knowledge

          This type of knowledge is best learned using repeated exposure and testing. Useful resources for optimising factual knowledge are notes, multiple choice questions and flashcards.

          How Memory Works

          • Retrieval

          • When we retrieve a memory, the brain pulls the memory from the connections that have formed. Information retrieval is the main limiting factor in memory, rather than storage capacity. Cues, such as visual or auditory cues, can aid in retrieval; if we smell a scent or hear a song that reminds us of a specific situation, then our ability to recall the situation will be greatly improved.

          Optimise Your Study Environment

          • Light

          • Do you prefer a well-lit or dimly lit environment for studying? Natural light is best, but a well-lit environment is a good alternative. Try to avoid very darkly lit rooms as this can result in eye strain and headaches.

          Start in a Controlled Environment

          • Practicing on Each Other

          • Some medical students also practice skills such as venepuncture and cannulation on each other in a controlled environment before attempting them on real patients; this is sometimes appropriate but should always be done under supervision.

          Types of Flashcards

          By using different types of flashcards, you can create a well-rounded study routine that engages different aspects of your memory and comprehension. Experiment with different types of flashcards to find the ones that work best for you and your learning style.

          Tools for Note-Taking

          There are many note-taking apps available for Windows, OSX, iOS and Android, each with different features and at different price points. Some of the most commonly used note-taking apps are Microsoft OneNote, Evernote, Google Keep, Notion and Bear.

          History of Presenting Complaint

          • Alleviating Factors

            Whether anything they've tried has improved or resolved the pain.
          • Relief with GTNStrongly suggestive of cardiac ischaemia, though GTN may also relieve oesophageal pain
          • Relief with reflux medsMore likely to represent reflux pain
          • Relief with passing gasSuggestive of 'pseudo-angina' - gas in stomach or splenic flexure
          • Improved with sitting forwardSuggestive of pericarditis

          Complications

          • Complications of Heart Failure

          • Arrhythmias - atrial fibrillation, ventricular arrhythmias
          • Stroke
          • Sarcopaenia
          • Left Heart Failure

          • Pulmonary oedema
          • Pulmonary hypertension
          • Right Heart Failure

          • Ascites
          • Peripheral oedema
          • Cardiac cirrhosis

          History of Presenting Complaint

          • Exercise Tolerance

          • How far / how many steps they can walk before short of breath, whether this has changed

          Assessing Orientation

          • Causes of Confusion

          • Delirium - stroke, infection, intoxication / withdrawal, metabolic, neoplastic, seizure, sleep deprivation, severe pain, psychiatric
          • Dementia - Alzheimer's, vascular dementia, lewy body dementia
          • Poor compliance with examination
          • Intellectual disability

          Hypertension

          • Causes of Hypertension

          • Primary

          • Essential hypertension: unknown aetiologyThe most common cause of hypertension
          • Secondary

          • Chronic kidney disease
          • Renal artery stenosis - fibromuscular dysplasia, atherosclerosis
          • Endocrine - hyperthyroidism, hypothyroidism, Cushing's syndrome, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
          • Drugs - NSAIDs, amphetamines, glucocorticoids, fludrocortisone, erythropoietin, VEGF inhibitors, calcineurin inhibitors
          • Aortic coarctation
          • Obstructive sleep apnoea
          • Factitious

          • White coat hypertension: due to by anxiety in a healthcare setting
          • Recent exercise or caffeine intake

          Splenomegaly

          • How to Elicit

          • Apply gentle pressure to the right lower quadrant. Ask the patient to take a deep breath in. Move the hand superiorly and medially each time the patient breathes out and repeat until the left costal margin is reached. Repeat with the patient in the right lateral decubitus position.

          Character

          Waterhammer / collapsing pulse: strong pulse with sudden drop in intensity following its peakAortic regurgitation, patent ductus arteriosus

          Structure of the JVP

          • Structure of the JVP

          Neuropathic Ulcers

          • Look For

          • Deep ulcers surrounded by callus, most commonly on weight bearing areas such as the sole of the foot. Associated with diminished sensation of the foot and normal pedal pulses.

          Muscles Acting on the Hand

          Extrinsic Thumb muscles  - flexor pollucis longus, extensor pollucis longus & brevis, abductor pollucis longus

          Muscles Acting on the Shoulder Joint

          Scapular protractors - pectoralis major, serratus anterior

          Hypotension

          Systolic BP <100mmHg or a drop in systolic BP to <80% of the patient's baseline.

          Ataxic Gait

          • Look For

          • An unsteady, staggering, wide-based gait.

          Overview

          Think about an obturator hernia in a patient with lower abdominal / groin pain with pain on hip movement.

          Marfan Syndrome

          • Cardiac Sequelae

          • Proximal aortic aneurysm
          • Aortic dissection
          • Mitral valve prolapse
          • Mitral valve calcification

          History of Presenting Complaint

          • Severity

          • How severe the pain is out of 10, with 10 being the worse possible pain.
          • How the pain is impacting the patient's life, such as work, hobbies or even mobility.

          Management

          • Management Options

          • Non-Pharmacologic

          • Cardiac rehabilitation
          • Low sodium diet
          • Fluid restriction
          • Smoking cessation
          • Weight loss
          • Pharmacologic

          • ACE inhibitors (ACEi) - captopril, ramipril, perindopril
          • Angiotensin II receptor blockers (ARBs) - candesartan, irbesartan
          • Beta blockers - carvedilol, metoprolol, bisoprolol, nebivolol
          • Aldosterone antagonists - spironolactone
          • Loop diuretics - frusemide
          • Ivabradine
          • Digoxin
          • Devices

          • Biventricular pacing
          • Automatic implantable cardioverter defibrillator
          • Surgical Options

          • Heart transplant

          Hypotension

          • Interpretation

          • Systolic BP <100mmHg or a drop in systolic BP to <80% of the patient's baseline.

          Splenomegaly

          • Causes of Splenomegaly

          • Congestion - congestive cardiac failure, portal vein thrombosis, cirrhosis
          • Infection - bacterial / viral / parasitic
          • Inflammation - SLE, IBD, rheumatoid arthritis
          • Haematological - leukaemia / lymphoma, thalassaemia, sickle cell disease
          • Cancers - splenic tumours, metastases

          Character

          Pulsus alternans: regular alternation between strong and weak beats, especially palpated in peripheral arteriesLeft ventricular failure

          Structure of the JVP

          • Significance

          • A wave - right atrial contraction
          • C wave - early ventricular contraction
          • X descent - downward movement of the ventricle during systolic contraction
          • V wave - filling of right atrium
          • Y descent - opening of tricuspid valve in diastole

          Body Mass Index

          • Classification

          • Underweight - <18.5
          • Normal - 18.5 - 24.9
          • Overweight - 25 - 29.9
          • Obese - 30 - 34.9
          • Severely obese - 35 - 39.9
          • Morbidly obese - 40+

          Muscles Acting on the Hand

          Thenar muscles (OAF)- opponens pollucis, abductor pollucis brevis, flexor pollucis brevis

          Muscles Acting on the Shoulder Joint

          Scapular retractors - trapezius, rhomboid major & minor

          Hypotension

          • Causes of Hypotension

          • Postural (orthostatic) hypotension - related to redistribution of blood following change in position from lying to sitting or standing.
          • Cardiac - MI, cardiomyopathy, myocarditis, beta blockers, calcium channel blockers.
          • Obstruction - massive PE, tension pneumothorax, cardiac tamponade.
          • Vasodilation - sepsis, anaphylaxis, CNS damage (neurogenic), endocrine.
          • Hypovolaemia - haemorrhage, dehydration.

          Apraxic Gait

          An apraxic gait is common with frontal lobe pathology.

          Cushing's Syndrome

          Primary or secondary hypercortisolism.

          Waist-Hip Ratio

          • How to Assess

          • Measure the waist circumference at the midpoint between the lowest palpable rib and the top of the iliac crest. Measure the hip circumference around the widest part of the buttocks. Divide the first measurement by the second.

          Object Naming

          The Boston Naming Test (BNT) is an example of a tool used to assess word retrieval in brain damaged patients.

          Upper Limb Myotomes

          Elbow extension: radial nerve (C7)Triceps

          Ulnar Nerve Palsy

          • Ulnar Nerve Syndromes

          • Cubital tunnel syndrome - trauma or compression of the ulnar nerve within the cubital tunnel at the elbow
          • Guyon's canal palsy (cyclist's palsy) - compression of the ulner nerve at the wrist

          Cervical Lymph Nodes

          Preauricular nodes - Anterior to pinnaEyelids, conjunctivae

          Purpura

          • Look For

          • Red / purple lesions that do not blanch with pressure. May be present over the head, arms, legs, chest or abdomen.

          Common Signs on the Tongue

          Black hairy tongueAspergillosis

          Scratch Marks

          • Significance

          • An indicator that the patient has been pruritic.

          Spider Naevi

          • Causes of Spider Naevi

          • Normal in children
          • Liver cirrhosis - alcoholic liver disease, Wilson's disease, haemochromatosis, hepatitis B / C
          • Hyperthyroidism
          • Rheumatoid arthritis
          • Pregnancy
          • Exogenous oestrogen - OCP, HRT
          • Paraneoplastic syndrome

          Generalised Abdominal Tenderness

          • Feel For

          • Generalised tenderness over more than one abdominal segment.

          Jaundice

          • Causes of Jaundice

          • Haemolytic

          • Erythrocyte defects - sickle cell anaemia, thalassaemia, folate deficiency, pernicious anaemia, iron deficiency anaemia, sideroblastic anaemia, spherocytosis, lead poisoning
          • Excessive erythrocyte destruction - haemolytic anaemia, thermal injury, envenomation, DIC, haemodialysis, breast milk jaundice
          • Hepatocellular

          • Dysfunctional uptake - drugs
          • Dysfunctional conjugation - Crigler-Najar, Gilbert's disease
          • Dysfunctional bilirubin storage / excretion - Dubin-Johnson
          • Hepatocyte damage - cirrhosis, hepatitis, tuberculosis, EBV, CMV, varicella, drug-induced hepatitis, autoimmunity, alpha-1 antitrypsin deficiency, Wilson's disease
          • Cholestatic

          • Intrahepatic cholestasis - drugs, pregnancy, cystic liver disease, sepsis, total parenteral nutrition, Hodgkin's disease, biliary cirrhosis, sclerosing cholangitis, liver cancer (primary / metastatic)
          • Extrahepatic cholestasis - cholangitis, cholelithiasis, pancreatitis, tumours (eg. pancreatic), bile duct (stenosis or extrinsic compression)

          Axillary Lymph Nodes

          Apical nodes - medially, at the lateral border of the 1st ribDrainage from all axillary lymph nodes

          Cervical Lymph Nodes

          Preauricular nodes - Anterior to the pinnaEyelids, conjunctivae

          Abdominal Mass

          Left iliac fossa - sigmoid colon, ovaryDiverticular abscess, sigmoid tumour, hernia, faecal loading

          Apraxic Gait

          An apraxic gait is common with frontal lobe pathology.

          Hypertension

          • Classification

          • Normal
          • Pre-hypertension 120/80 - 139/89
          • Stage I hypertension 140/90 - 159/99
          • Stage II hypertension >160/100

          Reduced Body Temperature

          Hypothermia is a reduction in human body temperature. This tends to occur due to heat loss from exposure to cold, vasodilation or burns; hypothermia can also occur in the context of reduced heat production, or due to central temperature dysregulation.

          Reduced Oxygen Saturation

          • Causes of Reduced Oxyhaemoglobin

          • Reduced Environmental Oxygen

          • High altitude
          • Hypoventilation

          • CNS - drugs, trauma, encephalopathy, motor neurone disease, Guillain-Barré
          • Muscular / neuromuscular - myaesthenia, paralytics, myopathy, fatigue, malnutrition
          • Airway obstruction - foreign body, asthma, COPD, bronchiectasis
          • Decreased compliance - interstitial lung disease
          • Chest wall abnormalities
          • Ventilation / Perfusion Mismatch

          • Physiological shunt - atelectasis, pulmonary oedema, pneumonia, ARDS
          • Anatomical shunt - cardiac shunt e.g. tetralogy of Fallot
          • Dead space - asthma, COPD, pulmonary embolus, heart failure
          • Other

          • Right shift of the oxygen dissociation curve - acidaemia, hyperthermia, high 2,3-DPG
          • Carbon monoxide poisoning
          • Haemoglobinopathy - methaemoglobinaemia, foetal haemoglobin

          Crackles / Crepitations

          • Causes

          • Coarse Crepitations

          • Pneumonia
          • Bronchiectasis
          • Chronic bronchitis
          • Pulmonary oedema - congestive cardiac failure, fluid overload
          • Fine Crepitations

          • Interstitial lung fibrosis

          Postural Tachycardia

          • Interpretation

          • Postural tachycardia is present if there is a rise of >20bpm following standing.

          APTT in Heparin Monitoring

          The APTT is used to monitor the coagulative state of patients on heparin infusions, to ensure that they are receiving a therapeutic dose.

          Measures of Coagulation

          Activated partial thromboplastin time (APTT) is a test of the intrinsic and common pathways including kininogen, prekallikrein, XII, XI, IX, VIII, X, V, II and fibrinogen. This test is performed by contact activation, and the method varies between labs.

          INR in Warfarin Monitoring

          The INR is used to monitor coagulative state of patients on warfarin, to ensure that they are receiving a therapeutic dose.

          Clinical Use

          • Contraindications

          • Thrombotic thrombocytopaenic purpura (TTP)
          • Heparin-induced thrombocytopaenia (HIT)
          Each unit (250mL) of packed red blood cells is expected to increase the serum haemoglobin by 10g/L and the haematocrit by 3%.
          • Signs of Withdrawal

          • Worsening of underlying disease
          • Acute adrenal insufficiency
          • Raised ICP / papilloedema
          • Signs of Withdrawal

          • Worsening of underlying disease
          • Acute adrenal insufficiency
          • Raised ICP / papilloedema

          Substem A (Target)

          -tox(a)-: toxin (e.g. obiltoxaximab)

          Clinical Use

          • Signs of Withdrawal

          • Worsening of underlying disease
          • Acute adrenal insufficiency
          • Raised ICP / papilloedema
          • Adverse Reactions

          • Gastritis / peptic ulceration
          • Nephrotoxicity
          • Hypertension / fluid retention / congestive cardiac failure / MI
          • Hypersensitivity reactions
          • Delirium
          • Headache
          • Elevated LFTs
          • Neutropaenia
          • Signs of Withdrawal

          • Worsening of underlying disease
          • Acute adrenal insufficiency
          • Raised ICP / papilloedema
          • Contraindications

          • Renal artery stenosis (precipitates renal failure)
          • Pregnancy
          Avoid the 'triple whammy' - ACEi/ARB, diuretic and NSAID - sure to cause acute kidney injury.

          Substem A (Target)

          -tox(a)-: toxin (e.g. obiltoxaximab)

          Clinical Use

          • Adverse Effects

          • Hypersensitivity reactions - flushing, rash, bronchospasm, anaphylaxis
          • Transient hypotension
          • Tachycardia / bradycardia
          Give in the morning between 6-10am in order to mimic the normal diurnal cycle

          Overview

          No effect on gastric emptying, appetite or weight loss.

          Clinical Use

          Patients should have a dental review prior to commencing bisphosphonates and have any required dental extractions, as the risk of jaw osteonecrosis increases with dental procedures.
          • Indications

          • Acute anxiety
          • Status epilepticus (clonazepam)
          • Insomnia (nitrazepam / flunitrazepam / temazepam)
          • Adverse Effects

          • Insomnia
          • Drowsiness
          • Agitation
          • Dry mouth
          • Headache
          • Weight gain / loss
          • Nausea / vomiting / diarrhoea
          • Sexual dysfunction - decreased libido, ejaculatory disorders, erectile dysfunction
          • Serotonin syndrome (when SSRIs given with MAOis / SNRIs) - confusion, agitation, ataxia, hyperreflexia, fevers, diaphoresis
          • Adverse Effects

          • Anticholinergic (especially chlorpromazine) - dry mouth, blurred vision, constipation, urinary retention, delirium
          • Extrapyramidal (less than with first generation) - dystonia, akathisia, parkinsonism, tardive dyskinesia
          • Hyperprolactinaemia (less than with first generation) - gynaecomastia, galactorrhoea, infertility, sexual dysfunction
          • Drowsiness
          • Postural hypotension
          • Prolonged QTc
          • Dyslipidaemia
          • Weight gain

          Insertion

          Insert the needle bevel up, ~30 degrees from the skin, until flashback is seen. Then flatten the needle out and advance 2mm.

          Bupivacaine

          • Strength

          • 0.25% (2.5mg/ml)

          Manifestations

          • Manifestations
             

          Diagnosis

          • 3rd degree AV block
          • 3rd degree AV block
             
          The chest x-ray in PE is generally normal, and is useful for excluding other differential diagnoses such as pneumonia, pulmonary oedema, pneumothorax or pleural effusion. Pulmonary arterial enlargement may be visible in massive PE.

          Management

          • Management Options

          • Treat / optimise the underlying disease
          • Pulmonary Arterial Hypertension Only

          • Endothelin receptor antagonists - bosentan, macitentan, ambrisentan
          • Phosphodiesterase 5 (PDE-5) inhibitors - sildenafil, tadalafil
          • Prostacyclin receptor agonists - prostacyclin, iloprost, tropostinil
          • Guanylate cyclase stimulants - riociguat

          Diagnosis

          • Hyperinflation in a patient with emphysema
          • Hyperinflation in a patient with emphysema
             
          Low serum osmolality (<280 mOsm/kg) suggests excess total body water in relation to total body sodium, due to sodium loss or water retention. Examine the patient's fluid status to further delineate a cause.
          The most specific marker of iron deficiency is serum ferritin, and as such a reduced serum ferritin makes iron deficiency likely. Ferritin can be elevated in the setting of an acute phase response and can appear normal, though a serum concentration above 100μg/L makes iron deficiency unlikely.

          Phases of Infection

          • Phases of Infection

          Pathogenesis

          • Causes of Folate Deficiency

          • Nutritional deficiency - poor intake, alcohol abuse
          • Malabsorption - coeliac disease, inflammatory bowel disease, jejunal resection
          • Increased requirement - pregnancy, malignancy
          • Impaired metabolism - methotrexate, trimethoprim

          Overview

            • Normal Range

            • 8 - 16

          Lytic Lesions

          • Causes of Lytic Lesions

          • Multiple myeloma
          • Bony metastases
          • Bone cysts

          Automatic Implantable Cardioverter Defibrillator

          An automatic implantable cardioverter-defibrillator (AICD) is capable of delivering a large amount of energy to cardiovert or defibrillate a patient out of a life-threatening tachyarrhythmia.

          Lateral

          A lateral film provides a side view of the chest - this is especially useful for identifying a lobe affected by consolidation.

          Rotation

          • Example

          • A rotated film with the patient's head obscuring the apices.
          • A rotated film with the patient's head obscuring the apices.
             

          PICC Lines

          • A left-sided PICC line at the cavoatrial junction
          • No Overlay
            Overlay
            A left-sided PICC line at the cavoatrial junction
             

          2nd Degree SA Exit Block: Type II

          • 2nd Degree SA Exit Block: Type II
             

          2nd Degree AV Block: Type I Mobitz

          • 2nd Degree AV Block: Type I Mobitz
             

          Polychromasia

          • Significance

          • Indicative of reticulocytosis.

          Regulation

          Hepcidin is the major iron regulatory protein. It regulates the intestinal absorption (by ferroportin 1), the recycling (by macrophages) and hepatic storage of iron. 

          Diagnosis

          If iron deficiency is suspected but not confirmed, improvement in haemoglobin following a trial of iron supplementation can clinch the diagnosis.

          Macrocytosis

          • Practical Points

          • Macrocytosis without anaemia is often normal.
          • The classical findings on blood film for megaloblastic anaemia are macroovalocytes and hypersegmented neutrophils.
          • Macrocytosis with polychromasia is suggestive of reticulocytosis, and haemorrhage / haemolysis should be considered.

          Neutrophilia

          • Aetiology

          • Neutrophilia is classically caused by bacterial infection (or in fact any pyogenic infection), though there are several other important causes. Inflammation of any cause may result in neutrophilia, including the post-surgical state, burns and autoimmune disease. Long-term smoking can also cause a chronic low-grade neutropaenia.

          Abnormal Platelet Size

          • Look For

          • Large platelets - larger than normal size, though smaller than the size of red cells
          • Giant platelets - larger in size than red blood cells

          Reactive Lymphocytes

          Reactive lymphocytes are medium to large cells with mature chromatin abundant cytoplasm 

          Left Shift of Granulocytes

          • A myelocyte. Note the ovoid nucleus that is eccentric (to one side of the cell).
          • A myelocyte. Note the ovoid nucleus that is eccentric (to one side of the cell).
             

          Overview

          Thyroperoxidase (TPO) is an enzyme that catalyses the oxidation of iodide on tyrosine residues in thyroglobulin, enabling production of the thyroid hormones.

          Subclinical Hypothyroidism

          • Differential Diagnosis of TFT Findings

          • Poor compliance with thyroxine
          • Assay interference
          • Drugs - amiodarone, sertaline
          • Nonthyroidal illness (recovery phase)
          • TSH receptor defects
          • TSH resistance

          Reduced / Normal TSH with Reduced T4

          • Causes of Reduced / Normal TSH with Reduced T4

          • Nonthyroidal illness
          • Recent treatment of hyperthyroidism
          • Central hypothyroidism
          • Congenital TSH or TRH deficiency
          • Assay interference

          Subclinical Hyperthyroidism

          • Causes of Subclinical Hyperthyroidism

          • As per primary hyperthyroidism.

          Correcting the QT Interval (QTc)

          • Bazett

          • QTc = QT √RR Interval

          Ventricular Rhythm

          Measure the interval between R waves (RR interval) and whether this interval is regular or irregular across the rhythm strip. This can be assessed by marking the R waves on a separate piece of paper, and then transposing the paper to another part of the rhythm strip to see if the R waves line up.

          ECG Leads

          • Unipolar Chest Leads

          • Electrical potential difference is measured between the chest electrode and the average of the limb electrodes.

          Polymorphic Ventricular Tachycardia

          Polymorphic VT is a wide complex tachycardia with multiple QRS complex morphologies. This most commonly refers to torsade de pointes, however PVT also present in patients with acute myocardial infarction.

          Atypical LBBB

          • Atypical LBBB

          Alpha-1 Globulins

          • Causes of Elevated Alpha-1 Globulins

          • Acute inflammation
          • Malignancy
          • Pregnancy

          CKD-EPI Formula

          • Limitations

          • Younger patients are more likely to have a higher eGFR and be classified in lower stages of CKD compared to other formulae
          • Older patients (>80 years) are more likely to have a lower eGFR and be classified in higher stages of CKD compared to other formulae

          Localising an MI

          The ECG leads may be grouped into contiguous lead complexes, and findings in specific lead complexes can be used to suggest the location of an ST elevation myocardial infarction.

          Disease History

          • Management

          • Watchful waiting
          • Lifestyle changes
          • Medications
          • Surgery
          • Chemotherapy / radiotherapy

          UpToDate

          • Platform

          • Web, iOS, Android

          Key Features

          • Learning Analytics

          • Some platforms allow users to track their progress and identify areas where they need to improve. Such insights on performance can be incredibly useful for maximising your study efficiency.

          Microsoft OneNote

          OneNote is one of the most popular note-taking apps available. It is packed with meaty features such as the ability to clip webpages and extract text from images. 

          Armando Hasudungan

          • Platforms

          • YouTube

          Zero to Finals

          • Cost

          • Free

          Smiling Mind

          • Cost

          • Free

          Key Features

          • Additional Features

          • We also took into account resources that offer additional features, such as personalized notes, sharing capabilities, and favorites lists.

          Notion

          Notion is an all-in-one productivity app that offers a variety of features, including notes, databases, to-do lists and much more. The app uses a flexible and customizable interface that allows you to create and organize your notes and tasks in a way that suits your workflow. 

          Life in the Fast Lane

          Life in the Fast Lane is a popular critical care blog that provides a wealth of information on ECG interpretation. Their website features a comprehensive ECG library with high-quality images to help medical students and doctors understand ECGs better. The blog also offers an ECG quiz and case studies to help you practice your skills. 

          Types of Knowledge

          • Conceptual Knowledge

          • This type of knowledge includes understanding the underlying principles of a topic and how elements fit together with the bigger picture. An example of this is how the cardiovascular system pumps blood around the body, and how each part interrelates. Additionally, conceptual knowledge may include classifications and categories of information, such as the types of bacteria or the organ systems in the body.

          How Memory Works

          Repeated retrieval of information can strengthen connections and solidify memories. This is the underpinning concept behind the benefits of self-testing using memory devices, questions and flashcards.

          Optimise Your Study Environment

          Interestingly, a study on light temperature showed that students were more creative under warm light (3000 K) and concentrated better under cool light (6000 K).

          Start in a Controlled Environment

          Practicing in a controlled environment can help you to develop your skills and confidence in a safe and controlled environment. Your medical school will have many models available, however you are also able to purchase your own (particularly suture kits) online.

          Creating Effective Flashcards

          One of the benefits of flashcards as a study tool is the ability to tailor them to your individual learning needs. Here are some tips for creating flashcards that are effective and maximise retention.

          Management

          Stroke prevention is a major priority in the management of atrial fibrillation, though anticoagulation is not without risks. Clinical calculators such as CHA₂DS₂VASc are used to estimate risk of stroke and assist in deciding whether anticoagulation is necessary.

          Diagnosis

          • Further Investigations

          • Check the patient's PTH
          • If not elevated - check the PTH-related peptide (PTHrp), 25-hydroxy-vitamin D and 1,25-dihydroxy-vitamin D levels
          • Elevated alkaline phosphatase (ALP) is suggestive of local osteolysis
          • Specific tests such as TFTs, cortisol and myeloma screen may be useful

          Past Medical History

          Ask about the stage of their CKD. Patients in earlier stages (CKD I - III) tend to have few symptoms and complications, while patients with CKV IV and V require intensive management of complications.
          Also ask about excessive bleeding or bruising in the past, which may be a symptom of platelet disorders or coagulopathy.
          Ask about allergies and whether the patient gets hay fever or eczema; these suggest atopy which is associated with asthma.

          Medication History

          Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.

          Past Medical History

          Enquire about any past colonoscopies, such as for colorectal cancer screening, and the results.

          II - Vision

          The optic nerve (cranial nerve II) provides special sensory innervation, in the form of sight.

          The Patient

          • Measures of body habitus include:
          • The body mass index (BMI) - assesses the patient's weight in the context of their height, allowing for a more accurate measurement (with several limitations).
          • The waist circumference and waist-hip ratio are markers of central obesity, with evidence to support their use in estimating cardiovascular risk.

          pH

          Urine pH is a measure of the acid content in urine. This often reflects the acidity of serum, however there are certain cases (e.g. renal tubular acidosis) in which the urine pH does not match the serum pH.

          Red Cell Size & Colour

          Ref Interval
          MCV80 - 100 fL
          MCH27 - 32 pg
          MCHC300 - 350 g/L

          Assessing Oxygenation

          • If the PaO₂ is normal but the HbO₂ is reduced, , then hypoxia is not the issue at hand. The potential causes for this are:
          • Right shift of the oxygen dissociation curve - acidaemia, hyperthermia, high 2,3-DPG
          • Carbon monoxide poisoning
          • Haemoglobinopathy - methaemoglobinaemia, foetal haemoglobin

          Assessment of Bone

          A complete fracture is a break all the way through the bone, producing two or more fragments.

          Markers of Haemolysis

          • When ordering a haemolytic screen, start with the following:
          • Full blood count - reduced haemoglobin indicates anaemia
          • Bilirubin (liver function tests) - unconjugated hyperbilirubinaemia
          • Haptoglobin - reduced
          • Lactate dehydrogenase (LDH) - elevated
          • Reticulocytes - elevated

          Measures of Iron Status

          • Transferrin Saturation

          • The transferrin saturation (TSat) is the percentage of transferrin that is bound to iron. This is a more accurate measure of total body iron than the serum iron concentration.

          Ferritin

          Ferritin is an intracellular iron storage protein whose levels are indicative of the body's total iron stores. An elevated ferritin is classically a marker of iron overload, however ferritin is also an acute phase reactant and may be elevated in the context of acute inflammation.

          Red Blood Cells

          Macroscopic haematuria is urinary blood that is evident on inspection of the urine; this is more likely to represent a urinary tract cause. Microscopic haematuria refers to urinary blood that is only visible using a microscope.

          Collecting the Sample

          • Preparation

          Low Flow Oxygen

          FlowFiO₂
          1 L/min~0.24
          2 L/min~0.28
          3 L/min~0.32
          4 L/min~0.36

          Identifying an Artery

          Ask the patient to clench their fist, and apply pressure to both the radial and ulnar arteries. Ask the patient to relax their hand, looking for blanching - if the hand does not blanch then both vessels are not occluded. Release pressure on the ulnar nerve, and look for flushing as the hand is reperfused.

          Catheter Insertion

          • Introduction

          Identifying a Vein

          • Places to Look

          • The ideal location for an IV cannula is the cephalic vein in the lateral forearm, as this is a large vein and insertion here doesn't limit patient movement. 

          Airway Adjuncts

          • Oropharyngeal Airway

          • An oropharyngeal airway is also known as a Guedel airway, and its main role is to move the tongue out of the way.

          Sitting Forward

          • How to Perform

          • Ask the patient to lean forward and hold their breath in full expiration.

          Hypertension

          • Classification

          • Normal <120 / 80
          • Pre-hypertension 120/80 - 139/89
          • Stage I hypertension 140/90 - 159/99
          • Stage II hypertension >160/100

          Hepatomegaly

          • Causes of Hepatomegaly

          • Congestion - congestive cardiac failure, hepatic vein thrombosis, cirrhosis
          • Hepatitis - alcoholic, fatty, viral, drug-induced
          • Metabolic liver disease - amyloidosis, haemochromatosis, Wilson's disease
          • Cancers - liver, stomach, pancreas, lung, colorectal, melanoma
          • Infection - bacterial, viral, parasitic
          • Haematological - leukaemia / Hodgkin lymphoma

          Common Peroneal Nerve Palsy

          • Signs of Common Peroneal Nerve Palsy

          • Foot drop
          • Weakness of ankle dorsiflexion and foot eversion
          • Sensory loss over the dorsum of the foot and lateral shin

          Myotomes

          Hip abduction: superior gluteal nerve (L4/L5/S1)Gluteus muscles

          Cog Wheel Rigidity

          • Significance

          • Caused by Parkinson's disease, other causes of parkinsonism, and contractures.

          Psychogenic Tremor

          Ask the patient to tap a beat with the unaffected limb. A tremor that decreases or aligns with the frequency of the tapping is likely to be psychogenic.

          Apraxic Gait

          An apraxic gait is common with frontal lobe pathology.
          An apraxic gait is common with frontal lobe pathology.

          Object Naming

          Pictures of items - show drawings of objects and ask the patient to name them.

          Fluency

          • Examples of Dysfluency

          • Stuttering - repetition, prolongation, or pauses in speechMay be developmental, neurogenic, or psychogenic
          • Cluttering - rapid, disorganized speech with excessive word and phrase repetitionsOften related to language or learning disabilities

          Stupor

          • Signs of Stupor

          • Mutism
          • Immobility
          • Unresponsiveness to stimuli
          • Disturbances in eating, drinking, defaecating and passing urine
          • Catalepsy: maintenance of an awkward posture or position

          Apraxic Gait

          An apraxic gait is common with frontal lobe pathology.

          Scoliosis

          • How to Elicit

          • Inspect the spine, and then palpate the spinous processes of the vertebrae.

          Cervical Lymph Nodes

          Preauricular nodes - Anterior to pinnaEyelids, conjunctivae

          Muscles Acting on the Hand

          Thenar muscles (OAF) - opponens pollucis, abductor pollucis brevis, flexor pollucis brevis

          Swinging Light Test

          • Interpretation

          • A relative afferent pupillary defect (RAPD) is present if the affected eye dilates, or constricts briefly followed by dilatation.

          Sitting Forward

          • Significance

          • Pericardial rub and the murmurs of aortic and pulmonary regurgitation are made louder on leaning forward after a forced expiration.

          Hypertension

          • Causes of Hypertension

          • Primary

          • Essential hypertension: unknown aetiologyThe most common cause of hypertension
          • Secondary

          • Chronic kidney disease
          • Renal artery stenosis - fibromuscular dysplasia, atherosclerosis
          • Endocrine - hyperthyroidism, hypothyroidism, Cushing's syndrome, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
          • Drugs - NSAIDs, amphetamines, glucocorticoids, fludrocortisone, erythropoietin, VEGF inhibitors, calcineurin inhibitors
          • Aortic coarctation
          • Obstructive sleep apnoea
          • Factitious

          • White coat hypertension: due to by anxiety in a healthcare setting
          • Recent exercise or caffeine intake

          Splenomegaly

          • How to Elicit

          • Apply gentle pressure to the right lower quadrant. Ask the patient to take a deep breath in. Move the hand superiorly and medially each time the patient breathes out and repeat until the left costal margin is reached. Repeat with the patient in the right lateral decubitus position.

          Paradoxical Splitting of S2

          • Listen for

          • A single S2 during inspiration and split S2 during expiration, due to P2 occurring before A2.

          Common Peroneal Nerve Palsy

          • Causes of Common Peroneal Nerve Palsy

          • Trauma - tibial or fibular fracture, ligamentous injury, nerve injury during surgery
          • Compression - tight casts, positioning during surgery, prolonged bed rest

          Myotomes

          Knee flexion: sciatic nerve (L5/S1/S2)Bieps femoris, semitendinosus, semimembranosus

          Apraxic Gait

          • Look For

          • A wide-based gait with short, shuffling steps.
          • Look For

          • A wide-based gait with short, shuffling steps.

          Object Naming

          The Boston Naming Test (BNT) is an example of a tool used to assess word retrieval in brain damaged patients.

          Fluency

          • Causes of Impaired Speech Fluency

          • Dysphasia / aphasia
          • Dysarthria
          • Confusion - delirium, dementia, intellectual disability
          • Hearing impairment
          • Foreign language
          • Intoxication

          Stupor

          • Causes of Stupor

          • Catatonia - depression, schizophrenia, stroke
          • Depressive stupor
          • Organic pathology - cerebral or brainstem lesions

          Apraxic Gait

          • Look For

          • A wide-based gait with short, shuffling steps.

          Scoliosis

          • Look For

          • Lateral curvature of the spine
          • Distortion of the trunk
          • Prominence of the ribs
          • Asymmetry of skin folds around the flank
          • Shoulder elevation
          • Scapular rotation

          Cervical Lymph Nodes

          Postauricular nodes - posterior to pinnaExternal auditory meatus, pinna, scalp

          Muscles Acting on the Hand

          Hypothenar muscles (OAF) - opponens digit minimi, abductor digiti minimi, flexor digiti minimi

          Swinging Light Test

          • Causes of RAPD

          • Intraocular haemorrhage
          • Retinal detachment
          • Optic or oculomotor nerve lesion
          • Midbrain lesion

          Insertion

          Hold the needle still, and advance the cannula to its hilt.

          Bupivacaine

          • Maximum Dose

          • Without adrenaline - 2mg/kg
          • With adrenaline - 3mg/kg

          Diagnosis

          • Severity of Hyperkalaemia

          • Mild - 5.0 - 6.5 mmol/L
          • Moderate - 6.5 - 7.0 mmol/L
          • Severe - >7.0 mmol/L

          Manifestations

          • Clinical Features

          • Symptoms

          • Weakness / lethargy / mental sluggishness
          • Weight gain
          • Cold intolerance
          • Dry, coarse skin
          • Constipation
          • Menorrhagia
          • Alopecia
          • Signs

          • Bradycardia
          • Psychomotor retardation
          • Impaired cognition
          • Cool, dry skin
          • Facial oedema
          • Loss of the outer 1/3 of the eyebrow
          • Tongue enlargement
          • Alopecia
          • Hyporeflexia
          • Non-pitting oedema

          Diagnosis

          • Imaging

          • Pulmonary embolism may be confirmed using one of four imaging modalities. CTPA and ventilation/perfusion (V/Q) scans are the most commonly used in clinical practice; MRI is rarely used due to access and difficulty of obtaining adeqaute images; and pulmonary angiography (the gold standard) is rarely performed.
          • Hyperinflation with multiple right apical bullae
          • Hyperinflation with multiple right apical bullae
             
          Low serum osmolality with dehydration suggests salt and water loss from the kidneys or elsewhere. Low urinary sodium (<20 mEq/L) in these patients is suggestive of GI or sequestrational loss, such as due to vomiting, diarrhoea or third spacing. Normal urinary sodium (>20 mEq/L) is suggestive of renal loss, such as due to diuretics, mineralocorticoid deficiency, renal tubular acidosis, cerebral salt wasting or salt wasting nephropathy.
          Iron deficiency will present with an elevated serum transferrin and elevated total iron binding capacity; these two measures are proportional to each other and relatively interchangeable. The transferrin saturation (TSat) is the percentage of iron that is bound to transferrin and is reduced in iron deficiency, though inflammation, infection and malignancy can also reduce the TSat.

          Phases of Infection

          • Interpretation

          • E-antigen (HBeAg) - early infection
          • Hep B DNA (HBV DNA) - level of viral replication

          Manifestations

          • Manifestations of Folate Deficiency

          • Megaloblastic anaemia
          • Neural tube defects (deficiency during pregnancy)
          • Increased cardiovascular risk
          • Dementia

          Diagnosis

          • Further Investigations

          • Check the patient's PTH, phosphate, vitamin D and magnesium levels. If a cause is not evident and hypocalcaemia is ongoing (i.e. not lab error) then further investigation may be warranted.

          Clinical Use

          One unit of pooled platelets is expected to increase the serum platelet count by 30-50.
          • Avoiding Withdrawal

          • Taper the dose by 2.5-5mg prednisone every 3-7 days prior to ceasing.
          • Avoiding Withdrawal

          • Taper the dose by 2.5-5mg prednisone every 3-7 days prior to ceasing.

          Substem A (Target)

          -t(u)-: tumour (e.g. alemtuzumab)

          Clinical Use

          • Avoiding Withdrawal

          • Taper the dose by 2.5-5mg prednisone every 3-7 days prior to ceasing.
          • Avoiding Withdrawal

          • Taper the dose by 2.5-5mg prednisone every 3-7 days prior to ceasing.

          Extra Credit

          • High Likelihood of Acute Coronary Syndrome

          • Pressure-like sensation (e.g. tight or crushing)
          • Radiating to one or both arms
          • Associated with exertion, nausea, vomiting or diaphoresis

          Hypotension

          • Causes of Hypotension

          • Postural (orthostatic) hypotension - related to redistribution of blood following change in position from lying to sitting or standing.
          • Cardiac - MI, cardiomyopathy, myocarditis, beta blockers, calcium channel blockers.
          • Obstruction - massive PE, tension pneumothorax, cardiac tamponade.
          • Vasodilation - sepsis, anaphylaxis, CNS damage (neurogenic), endocrine.
          • Hypovolaemia - haemorrhage, dehydration.

          Splenomegaly

          Massive splenomegaly is uncommon and occurs in the setting of CML, myelofibrosis, certain lymphomas, malaria and leichmaniasis.

          Extra Credit

          • Complications of AV Fistula

          • Aneurysm
          • Failure to mature
          • Haematoma
          • Stenosis - inflow or outflow
          • Thrombosis
          • Steal syndrome - ischaemia distal to the fistula
          • Infection

          Character

          Bisferiens pulse (double beating pulse)Aortic regurgitation

          Body Mass Index

          • Associated with Obesity

          • Metabolic syndrome - type 2 diabetes mellitus, hypertension, dyslipidaemia
          • Ischaemic heart disease
          • Stroke
          • Respiratory - obstructive sleep apnoea, asthma
          • Gastrointestinal - reflux, cholelithiasis, non-alcoholic steatohepatitis (NASH)
          • Polycystic ovarian syndrome
          • Osteoarthritis
          • Varicose veins
          • Gout

          Muscles Acting on the Hand

          Hypothenar muscles (OAF) - opponens digit minimi, abductor digiti minimi, flexor digiti minimi

          Apraxic Gait

          • Look For

          • A wide-based gait with short, shuffling steps.

          Cushing's Syndrome

          • Clinical Features

          • Central obesity (95% of cases)
          • 'Moon' face
          • Buffalo hump (fat pad over posterior shoulders / neck)
          • Thin skin
          • Peripheral oedema
          • Striae (stretch marks)
          • Bruising
          • Proximal myopathy

          Waist-Hip Ratio

            • Normal Range

            • Males <0.9
            • Females <0.85

          Upper Limb Myotomes

          Wrist flexion: radial nerve (C6/C7)Flexor carpi radialis & ulnaris

          Cervical Lymph Nodes

          Postauricular nodes - posterior to pinnaExternal auditory meatus, pinna, scalp

          Purpura

          • Causes of Purpura

          • Trauma

          • Platelet Disorders

          • Idiopathic thrombocytopaenic purpura (ITP)
          • Thrombotic thrombocytopaenic purpura (TTP)
          • Disseminated intravascular coagulation (DIC)
          • Bone marrow failure - aplastic anaemia, leukaemia, chemotherapy
          • Platelet sequestration - splenomegaly, haemangioma
          • Haemolytic-uraemic syndrome
          • Inherited disorders of platelet function
          • Disorders of Coagulation

          • Factor deficiencies - haemophilia, Von Willebrand disease
          • Vitamin K deficiency - malabsorption, poor diet
          • Anticoagulants
          • Disseminated intravascular coagulation (DIC)
          • Vascular Disorders

          • Connective tissue diseases - Ehlers-Danlos, scurvy
          • Infection - mengingococcal, streptococcal, viral
          • Henoch-Schönlein purpura
          • Senile purpura
          • Steroids

          Faecal Occult Blood

          • How to Assess

          • Smear a sample of stool onto test paper (e.g. guaiac-based), add developer solution, and look for blue colour change.

          Scratch Marks

          • Causes of Pruritis

          • Obstructive jaundice (bile acid deposition)
          • Chronic kidney disease (urea deposition)
          • Skin conditions - dry skin, atopic eczema, psoriasis, lichen planus, ichthyosis
          • Infection - herpes zoster, scabies, fungal infections
          • Myeloproliferative disorders
          • Hyperthyroidism
          • Pregnancy
          • Neuropathic itch
          • Psychogenic itch

          Generalised Abdominal Tenderness

          • Significance

          • A feature of peritonism, suggestive of peritonitis.

          Cervical Lymph Nodes

          Postauricular nodes - posterior to the pinnaExternal auditory meatus, pinna, scalp

          Abdominal Mass

          Flank - kidney, retroperitoneumRenal cyst / tumour, retroperitoneal lymphoma

          Apraxic Gait

          • Look For

          • A wide-based gait with short, shuffling steps.

          Hypertension

          • Causes of Hypertension

          • Primary

          • Essential hypertension: unknown aetiologyThe most common cause of hypertension
          • Secondary

          • Chronic kidney disease
          • Renal artery stenosis - fibromuscular dysplasia, atherosclerosis
          • Endocrine - hyperthyroidism, hypothyroidism, Cushing's syndrome, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
          • Drugs - NSAIDs, amphetamines, glucocorticoids, fludrocortisone, erythropoietin, VEGF inhibitors, calcineurin inhibitors
          • Aortic coarctation
          • Obstructive sleep apnoea
          • Factitious

          • White coat hypertension: due to by anxiety in a healthcare setting
          • Recent exercise or caffeine intake

          Reduced Body Temperature

          • Classification

          • Mild hypothermia - 34 - 35.9°C
          • Moderate hypothermia - 32 - 33.9°C
          • Severe hypothermia - 30.3 - 31.9°C
          • Profound hypothermia -

          The Oxygen Dissociation Curve

          The oxyhaemoglobin dissociation curve describes the relationship between PaO₂ and HbO₂. At high PaO₂ (alveolar-capillary membrane) oxygen readily binds to haemoglobin. At low PaO₂ (systemic capillaries) oxygen is readily released from haemoglobin.

          Pleural Rub

          A pleural rub is a classical sign of pleural inflammation, or pleurisy.

          Postural Tachycardia

          • Causes of Postural Tachycardia

          • Reduced intravascular volume - dehydration, haemorrhage
          • Cardiac - congestive cardiac failure, cardiomyopathy, myocarditis, constrictive pericarditis, aortic stenosis
          • Drugs - nitrates, anticholinergics, antidepressants, antihypertensives, levodopa
          • Prolonged bed rest
          • Alcohol

          The Oxygen Dissociation Curve

          The oxyhaemoglobin dissociation curve describes the relationship between PaO₂ and HbO₂. At high PaO₂ (alveolar-capillary membrane) oxygen readily binds to haemoglobin. At low PaO₂ (systemic capillaries) oxygen is readily released from haemoglobin.

          APTT in Heparin Monitoring

          • Practical Points

          • Consult local guidelines for heparin bolusing, rates and titration.
          • Do not take a sample for APTT testing from the same limb through which the patient is recieving heparin. If there is no other option, then stop the heparin infusion, flush the line and wait several minutes before taking the APTT sample.
          • Excess heparin in the line, e.g. in lines that were heparin locked, will prolong both the PT/INR and APTT.

          Measures of Coagulation

          Thrombin time (TT) tests only the final step of fibrin clot formation, and is not routinely performed as part of a coagulation screen. The test is performed by adding thrombin to a patient's plasma sample. If the TT is prolonged, a reptilase test is also performed to distinguish between fibrinogen disorders and defects higher up in the coagulation cascade.

          INR in Warfarin Monitoring

            • Common INR Targets

            • Atrial fibrillation, DVT/PE: 2.0 - 3.0
            • Mechanical heart valve: 2.5 - 3.5

          Clinical Use

          Avoid the 'triple whammy' - ACEi/ARB, diuretic and NSAID - sure to cause acute kidney injury.
          • Adverse Effects

          • Nausea / vomiting / diarrhoea
          • Fatigue
          • Oedema
          • Upper respiratory tract infection

          Substem A (Target)

          -t(u)-: tumour (e.g. alemtuzumab)

          Clinical Use

          • Reversal

          • Sugammadex.
          • Indication

          • Second line agent for glycaemic control in type II diabetes.
          Benzodiazepines should be avoided for long-term management of anxiety.
          Less extrapyramidal adverse effects and less hyperprolactinaemia than first generation antipsychotics.

          Diagnosis

          • Diagnosis

          Past Medical History

          • Ask about the patient's complications. The pertinent complications of chronic kidney disease are:
          • Acidosis (poor clearance of hydrogen ions)
          • Fluid overload
          • Electrolyte derangements - hyperkalaemia, hyperphosphataemia
          • Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
          • Anaemia (EPO deficiency / anaemia of chronic disease)
          • Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
          • Uraemia - encephalopathy, uraemic pericarditis
          • Malnutrition

          Medication History

          Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.

          Transfusion History

          Ask about whether the patient has recieved any transfusions in the past, and whether they recieved red blood cells, platelets or plasma products.

          Medication History

          Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.

          Past Medical History

          • Liver Transplant

          • The workup and management of liver transplant patients is complex and includes physical, psychological and social factors.

          pH

          The normal urine pH is 4.5 - 8.0.

          Red Cell Size & Colour

          The mean cell volume (MCV) is a measure of the average volume of a red blood cell - whether the cells are microcytic, normocytic or macrocytic. 

          Assessing Oxygenation

          • Assessing Oxygenation

          Assessment of Bone

          • Assessment of Bone

          Markers of Haemolysis

          • Haemoglobin

          • Reduce haemoglobin indicates anaemia, which may be caused by a variety of conditions. Haemolytic anaemia tends to produce a normocytic, normochromic anaemia, and there is often a raised red cell distribution width due to the presence of reticulocytes.

          Measures of Iron Status

          An elevated transferrin saturation is an indicator of iron overload, such as due to haemochromatosis, multiple transfusions and iron-loading anaemias.

          Procalcitonin

          Procalcitonin is a protein normally produced by the thyroid; it is secreted by extrathyroid tissue in the context of infection or inflammation. 

          Red Blood Cells

          • Causes of haematuria include:
          • Glomerulonephropathy - congenital glomerulonephropathy, primary or secondary glomerulonephritis
          • Vascular pathology - arteriovenous malformation, renal vein thrombosis, renal infarct
          • Polycystic kidney disease
          • Urinary tract infection - urethritis, cystitis, pyelonephritis, prostatitis, tuberculosis
          • Neoplasm - renal, bladder, prostate
          • Renal calculus
          • Inflammation - interstitial cystitis
          • Haemorrhagic cystitis (cyclophosphamide)
          • Trauma

          Collecting the Sample

          • Procedure

          Low Flow Oxygen

          • Simple Face Mask

          • A simple face mask, also known as a Hudson mask, allows a larger amount of oxygen to be entrained with room air. As they have no reservoir bag, the maximum FiO2 possible is around 0.60.

          Identifying an Artery

          If the hand does not flush in 10-15 seconds then the ulnar circulation is inadequate - this is a contraindication to radial puncture on this limb.

          Catheter Insertion

          • Preparation

          Identifying a Vein

          The basilic vein in the medial forearm is another good option, however this can be more difficult to access during insertion. 

          Airway Adjuncts

          Measure the airway from the angle of the mandible to the maxillary incisors. First, use suction to ensure that the mouth is clear of secretions. Angle the airway superiorly, toward the palate, and then insert it into the oral cavity. Once the airway reaches the oropharynx, rotate it 180 degrees toward the larynx.

          Overview

          Albumin, an anion, makes up ~10mmol/L of the anion gap. The above formula assumes that the albumin is normal, thus it is important to check that the patient is not hypoalbuminaemic when calculating the anion gap.

          Automatic Implantable Cardioverter Defibrillator

          • Look For

          • A single lead with one or two large coils.

          Lateral

          • Example

          • A lateral chest xray demonstrating right middle lobe consolidation.
          • A lateral chest xray demonstrating right middle lobe consolidation.
             

          PICC Lines

          • A right-sided PICC line seen within the right atrium
          • No Overlay
            Overlay
            A right-sided PICC line seen within the right atrium
             

          3rd Degree SA Exit Block

          In third degree sinoatrial exit block, there is complete failure of transmission to the atria - this is indistinguishable from sinus arrest on ECG.

          2nd Degree AV Block: Type II Mobitz

          Type II second degree AV block occurs when there is an intermittently missed QRS complex due to failure of conduction through the AV node.

          Polychromasia

          • Causes of Polychromasia

          • Haemolytic anaemia
          • Haemorrhage (acute or chronic)
          • Recovery post bone marrow suppression
          • Late pregnancy
          • High altitude

          Regulation

          Hepcidin levels are modulated by many factors including serum iron levels, anaemia, hypoxia and inflammation. 

          Neutrophilia

          Acute stress or exertion can cause shift of neutrophils into the circulation, resulting in pseudoneutrophilia. Corticosteroids may cause neutrophilia through demargination of neutrophils from the endothelial lining, delayed migration from the circulation into tissues and delayed apoptosis. After splenectomy patients will develop neutrophilia.

          Abnormal Platelet Size

          • Abnormal Platelet Size
             

          Reactive Lymphocytes

          • Features of Reactive Lymphocytes

          • Medium to large cells
          • Mature nuclear chromatin - coarse, clumped nuclear material
          • Abundant basophilic cytoplasm
          • Scalloping / invagination - the cells appear to invade around neighbouring red cells

          Left Shift of Granulocytes

          • A promyelocyte. Note the basophilic cytoplasm, prominent nucleolus, prominent intracytoplasmic granules and the perinuclear clearing (the light area adjacent to the nucleus).
          • A promyelocyte. Note the basophilic cytoplasm, prominent nucleolus, prominent intracytoplasmic granules and the perinuclear clearing (the light area adjacent to the nucleus).
             

          Overview

          • Effects of Thyroid Hormones

          • Metabolism - lipolysis, gluconeogenesis, insulin secretion, increased basal metabolic rate, thermogenesis
          • Cardiovascular - positive chronotropy and inotropy resulting in increased cardiac output; vasodilatation
          • Liver - increased blood flow; altered metabolism
          • Kidney - increased blood flow and glomerular filtration rate; altered electrolyte secretion / reabsorption
          • Skeletal muscle - increased blood flow, contractility (fast-twitch fibres) and oxygen consumption

          Subclinical Hypothyroidism

          • Pearls

          • Take a careful medication history
          • Ask about recent illnesses

          Elevated TSH with Reduced T4

          A reduced T4 with an appropriately suppressed TSH is indicative of primary hypothyroidism.

          Subclinical Hyperthyroidism

          • Differential Diagnosis of TFT Findings

          • Recent treatment of hyperthyroidism
          • Intermittent thyroxine
          • T3 thyrotoxicosis
          • Nonthyroidal illness
          • Drugs - steroids, dopamine, dobutamine

          Correcting the QT Interval (QTc)

          • Fridericia

          • QTc =  QT RR 1/3

          Ventricular Rhythm

          • Interpretation

          • Regular rhythm - constant RR interval
          • Regularly irregular rhythm - variable RR interval with a predictable pattern
          • Irregularly irregular rhythm - variable RR interval with a random pattern

          ECG Leads

          Complex
          V1Right atrial
          V2Septal
          V3Anterior
          V4Anterior
          V5Lateral
          V6Lateral

          Polymorphic Ventricular Tachycardia

          • Look For

          • Heart rate >100bpm
          • Irregular rhythm
          • Broad QRS complexes of varying amplitude and morphology

          Atypical LBBB

          • Atypical Findings

          • Initial R wave >30ms
          • Josephson's sign - notching of the S wave
          • RS interval >100ms in precordial leads
          • Q waves in V6

          Alpha-1 Globulins

          • Causes of Decreased Alpha-1 Globulins

          • Alpha-1 antitrypsin deficiency
          • Nephrotic syndrome
          • Cirrhosis

          Localising an MI

          The location of the hyperacute T waves, ST elevation and Q waves suggest the location of an infarct.

          Disease History

          • Follow Up

          • Who manages the condition, such as their GP or a specialist.

          UpToDate

          • Cost

          • Subscription service, relatively expensive without institutional access

          ANKI

          • Platforms

          • Windows, Mac, Linux, iOS, and Android.

          Microsoft OneNote

          OneNote can be used on unlimited devices, and allows for easy collaboration with others. The app also works well with other Microsoft 365 apps. Most importantly, the app is completely free - there is no premium version.

          Armando Hasudungan

          • Cost

          • Free

          Zero to Finals

          • Zero to Finals

          Smiling Mind

          • Smiling Mind

          MDCalc

          • Platforms

          • Web, iOS, Android

          Notion

          You can use the powerful features in Notion such as databases and integrations with other apps to maximise your productivity. If you’re not sure what that means and how to use the app initially, then that’s totally understandable - there is a relatively steep learning curve when you start using Notion, but once you start to understand how it all works the app is very easy to use with a large payoff. Examples of uses for Notion as a medical student include for taking notes, organising tasks and planning research. 

          Life in the Fast Lane

          Life in the Fast Lane is highly recommended by doctors, and is a key resource for ECG learning. While there is no specific iOS or Android app, their website is mobile-friendly and easily accessible on the go. Most importantly, all of the information on the website is free!

          Types of Knowledge

          Concepts are often best learned visually, through diagrams or mind maps, or from listening to others' explanations.

          How Memory Works

          Interestingly, repeated retrieval can also alter memories and make us put weight on certain aspects while underplaying others. Similarly, retrieving distant memories can cause them to be altered. For example, an often-told funny story can slowly change over multiple retellings until we ourselves believe the current telling to be a true recollection of events.

          Optimise Your Study Environment

          • Sound

          • Do you like to study in a loud or quiet environment? Some people study best in a quiet environment, and would benefit from earplugs or noise cancelling headphones when in noisy environments. Others prefer a louder environment for study. There have been studies to suggest that background noise like cafe background noise, white noise and rain can improve concentration and in particular improve creative thinking. Try to avoid music with too many words while studying, as this can negatively affect concentration. There are several good channels on YouTube that have good chilled out music to study to, which avoid having too many lyrics or too much variation.

          See One, Do One, Teach One

          The "see one, do one, teach one" approach is a widely used method for developing medical students’ practical skills. The approach involves three key steps: watching an experienced healthcare provider perform a procedure (see one), practicing the procedure under supervision (do one), and then teaching the procedure to someone else (teach one). This is a practical way for you to gain hands-on experience.

          Creating Effective Flashcards

          • One Question Per Card

          • Keeping each card focused on a single concept or piece of information can help you to stay organized and improve your retention of the material. For example, “Definition of thrombocytopaenia” on the front of the card, and “Platelet count <150 x 10⁹/L” on the back.

          Tips for Taking Notes

          • Understand the Big Picture First

          • Try to chart the overarching structure of a concept first, then dig into the detail. It's much easier to understand that mantle cell lymphoma is a type of B cell non-Hodgkin lymphoma, before trying to memorise the chromosomal translocation that it is associated with.

          Disease History

          • Complications

          • Whether the condition results in any undesired effects, such as diabetic neuropathy.

          UpToDate

          • UpToDate

          ANKI

          • Cost

          • Free on the computer and Android, small upfront payment on iOS.

          Microsoft OneNote

          Unfortunately the app allows little opportunity to organise or tag notes.

          Armando Hasudungan

          Dr Armando Hasudungan is a physician trainee from Sydney, Australia who created a YouTube channel that offers a wide range of medical science videos, including anatomy, physiology, and pharmacology. The videos are created in a hand-drawn style and are designed to be engaging. 

          Zero to Finals

          Zero to Finals is a YouTube channel and website providing free, concise and engaging medical education videos. The channel was created by Dr Thomas Watchman and aims to simplify challenging concepts for medical students preparing for exams.

          Smiling Mind

          Smiling Mind is a not-for-profit mindfulness program that offers a range of meditation exercises lasting from one minute to up to fifteen minutes. The app aims to help users develop mindfulness skills and improve emotional regulation, with a focus on being present in the moment. Smiling mind offers a variety of meditation programs including sleep, calm, and mindful eating. The app allows you to track your progress and also offers wellbeing checkups.

          MDCalc

          • Cost

          • Free

          Notion

          Notion is available on multiple platforms, including web, iOS, and Android, making it a versatile tool with many different potential uses.

          Life in the Fast Lane

          • Life in the Fast Lane

          Types of Knowledge

          • Procedural Knowledge

          • This relates to learning skills, procedures and algorithms. Examples of procedural knowledge include how to take a history, examine a patient or insert a cannula.

          Setting Yourself Up for Success

          Based on the concepts above, there are several things that you can do in order to improve recall.

          Optimise Your Study Environment

          • Location

          • Do you prefer to study at home, or elsewhere? Some learn best at home, which is a familiar environment. Others will study at a library or other public space in order to avoid distractions and be closer to the resources they need.

          See One, Do One, Teach One

          • See One

          • By watching an experienced person perform the procedure, you can see the proper technique for the procedure and understand the rationale behind each step. You have the opportunity to ask questions about the procedure, and develop your confidence before trying yourself.

          Creating Effective Flashcards

          • Ask Specific Questions

          • Avoid being vague in what type of answer you expect. Asking specific questions makes it more likely that the answer you provide is the answer to the question. If the cue is too general, you risk answering it in a way that is completely different to the expected answer - this can slow down your learning. As an example, consider asking “Five groups of causes of pulmonary hypertension” instead of “Pathogenesis of pulmonary hypertension”.

          Waist-Hip Ratio

          • Significance

          • An estimate of central obesity. Waist circumference and WH ratio are used to estimate cardiovascular risk.

          Upper Limb Myotomes

          Wrist extension: radial nerve (C6/C7)Extensor carpi radialis & ulnaris

          Cervical Lymph Nodes

          Right supraclavicular node - in right supraclavicular fossaMediastinum, lungs, oesophagus

          Faecal Occult Blood

          • Significance

          • A positive result is suggestive of the presence of faecal blood not visible by the naked eye - further testing is suggested via faecal immunochemistry and/or endoscopy.

          Generalised Abdominal Tenderness

          • Causes of Peritonitis

          • Infection post perforation - appendix, diverticulitis, IBD, perforated ulcer, surgical anastomosis
          • Spontaneous bacterial peritonitis (SBP)
          • Blood - endometriosis, ruptured ovarian cyst, trauma
          • Bile - post-surgical
          • Urine - pelvic trauma
          • Pancreatic fluid - pancreatitis

          Cervical Lymph Nodes

          Right supraclavicular node - in the right supraclavicular fossaMediastinum, lungs, oesophagus

          Overview

          Ovarian masses are not appreciable by abdominal palpation. Even the largest of ovarian mass may only be palpable by bimanual examination.

          Trendelenburg Gait

          The Trendelenburg gait is indicative of proximal myopathy.

          Hypotension

          Hypotension refers to systolic BP

          Reduced Body Temperature

          • Causes of Hypothermia

          • Heat Loss

          • Exposure to cold - low ambient temperature, inadequate clothing, water immersion
          • Vasodilation - alcohol ingestion, sepsis, vasodilators
          • Skin loss - burns, dermatitis
          • Treatment for hyperthermia
          • Reduced Heat Production

          • Decreased metabolic rate - hypothyroidism
          • Decreased muscular activity - sedatives, opioids, muscle relaxants
          • CNS Temperature Dysregulation

          • Hypoadrenalism, hypopituitarism, head trauma, stroke

          The Oxygen Dissociation Curve

          • The Oxygen Dissociation Curve

          Pleural Rub

          • Listen For

          • Non-musical, explosive sounds best heard at the lung bases

          The Oxygen Dissociation Curve

          • The Oxygen Dissociation Curve

          Measures of Coagulation

          Fibrinogen is not routinely measured as part of a coagulation screen, though a 'derived' (and inaccurate) fibrinogen level is often reported. A dedicated fibrinogen assay should be performed to determine the true fibrinogen concentration. Reduced fibrinogen may be due to consumption (e.g. in DIC), liver impairment, haemodilution or congenital deficiency. Fibrinogen is also an acute phase reactant whose levels will rise with infection, inflammation, malignancy and pregnancy.

          INR in Warfarin Monitoring

          • Practical Points

          • Consult local guidelines when commencing warfarin.
          • Changes in warfarin dosing will take several days to have an effect on the INR, so dose titration should rely on the trend rather then being immediately reactive.

          Clinical Use

          Give in the morning between 6-10am in order to mimic the normal diurnal cycle
          Give in the morning between 6-10am in order to mimic the normal diurnal cycle

          Substem A (Target)

          -v(i)-: viral (e.g. palivizumab)

          Clinical Use

          Give in the morning between 6-10am in order to mimic the normal diurnal cycle
          Give in the morning between 6-10am in order to mimic the normal diurnal cycle

          Hypotension

          Hypotension refers to systolic BP <100mmHg or a drop in systolic BP to <80% of the patient's baseline.

          Splenomegaly

          • Splenomegaly

          Paradoxical Splitting of S2

          • Causes of Paradoxical S2 Splitting

          • Severe aortic stenosis
          • Left bundle branch block
          • Hypertrophic obstructive cardiomyopathy
          • Patent ductus arteriosus

          Posterior Tibial Nerve Palsy

          • Signs of Posterior Tibial Nerve Palsy

          • Weakness of ankle plantar flexion
          • Sensory loss over the plantar aspect of the foot
          • Positive tinel's sign over the nerve posterior to the medial malleolus

          Myotomes

          Knee extension: femoral nerve (L2-L4)Rectus femoris, vastus lateralis, intermedius & medialis

          Trendelenburg Gait

          The Trendelenburg gait is indicative of proximal myopathy.
          The Trendelenburg gait is indicative of proximal myopathy.

          Assessment of Reading

          Show the patient a list of words and ask them to read the words out loud, or ask them to read a few sentences from a newspaper.

          Tonality

          Tonality refers to the pitch, intonation, and expressiveness of an individual's speech.

          Trendelenburg Gait

          The Trendelenburg gait is indicative of proximal myopathy.

          Scoliosis

          • Causes of Scoliosis

          • Idiopathic (80%)
          • Congenital - maldevelopment of vertebrae
          • Neuromuscular disorders - cerebral palsy, muscular dystrophy
          • Syndromal - Marfan, neurofibromatosis, Down syndrome
          • Trauma - fracture, dislocation, burns
          • Degenerative - secondary to facet joint osteoarthritis

          Cervical Lymph Nodes

          Right supraclavicular node - in right supraclavicular fossaMediastinum, lungs, oesophagus

          Muscles Acting on the Hand

          Interossei - palmar and dorsal

          Accommodation

          • How to Assess

          • Ask the patient to focus on a distant object, such as the back wall of the room. Place a finger in front of their field of view and ask them to look at it.

          Insertion

          Release the tourniquet, then remove the needle. Some cannulas will bleed as this point (if they have no stop valve) - this can be avoided by placing pressure on the skin proximal to the cannula, or anticipated by placing a piece of gauze beneath the cannula to catch any blood.

          Bupivacaine

          • Onset

          • 5 - 10 minutes

          Manifestations

          • Manifestations of B12 Deficiency Anaemia

          • Megaloblastic anaemia
          • Atrophic glossitis
          • Peripheral neuropathy
          • Dementia

          Diagnosis

          • TFT Interpretation

          • Primary hypothyroidism - elevated TSH with reduced T4
          • Subclinical hypothyroidism - elevated TSH with normal T4
          • Central hypothyroidism - reduced TSH with reduced T4
          CT pulmonary angiography (CTPA) involves injection of IV contrast followed by imaging of the pulmonary vasculature. If a PE is present, a filling defect may be seen in the main, lobar or segmental arteries; subsegmental PEs are often difficult to visualise. CTPAs are also useful for visualising differential diagnoses for PE such as pneumonia, pulmonary oedema, pneumothorax and pleural effusions. The main drawback of CTPA is that it is relatively contraindicated in patients with renal dysfunction (generally CrCl <30), and a renal physician should be consulted prior to injecting contrast media in these patients. Additionally, CTPA should be avoided in pregnant patients due to the risks of radiation exposure.
          Low serum osmolality with euvolaemia is suggestive of redistribution. Urine osmolality <100 mOsm/kg may be due to primary polydipsia or beer potomania syndrome; urine osmolality >100mOsm/kg suggest SIADH, hypothyroidism or glucocorticoid deficiency.
          Serum iron (Fe3+) concentration tends to fluctuate with iron intake, acute and chronic disease and in itself is a poor marker of iron status.

          Approach to Diagnosis

          • Approach to Diagnosis

          Diagnosis

          • Investigations

          • Reduced serum red cell folate levels
          • Macrocytic, hyperchromic anaemia
          • Hypersegmented neutrophils
          • Diagnosis

          Tips for Taking Notes

          • Don't Copy Verbatim

          • Avoid copying word-for-word from the lecturer, lecture slides or textbooks. You won't learn anything, you won't keep up, it won't be in your style and you'll have much more to read through at the end. Paraphrase in your own words, and focus on getting just the key concepts down!

          Extra Credit

          • Low Likelihood of Acute Coronary Syndrome

          • Stabbing pain
          • Pleuritic pain
          • Positional pain
          • Inframammary pain
          • Reproducible with palpation

          Postural Hypotension

          • How To Elicit

          • Measure the blood pressure with the patient lying down, and then remeasure it after the patient has been standing for one minute.

          Ascites

          • Shifting Dullness

          • Percuss the patient's abdomen from the umbilicus to the left flank, noting where the percussion note changes from resonant to dull. Ask the patient to roll over to their left side and repeat percussion. If ascites is present the area of resonance will move at least 3cm medially.

          Character

          Bigeminal pulse: two close beats followed by a pause.Premature ventricular complexes

          Body Mass Index

          • Associated with Being Underweight

          • Hypoglycaemia
          • Vitamin deficiency - scurvy, rickets
          • Bone marrow suppression - anaemia, thrombocytopaenia, immunosuppression
          • Cardiac - arrhythmia, MI
          • Neurological - cognitive impairment, peripheral neuropathy, Wernicke-Korsakoff syndrome
          • Muscle wasting
          • Endocrine - osteoporosis, amenorrhoea

          Muscles Acting on the Hand

          Interossei - palmar and dorsal

          Trendelenburg Gait

          The Trendelenburg gait is indicative of proximal myopathy.

          Cushing's Syndrome

          • Cardiac Sequelae

          • Hypertension, predisposing to cardiovascular disease.

          Normal Anion Gap Metabolic Acidosis

          A normal anion gap of 8 - 16 suggests that there is loss of bicarbonate as the cause of the patient's acidosis, either renally or due to GI loss.

          Automatic Implantable Cardioverter Defibrillator

          An AICD may be combined with a pacemaker in patients with multiple indications.

          Overview

          On an AP or PA film, don't comment on specific lobes of the lung as the lobes overlap. Instead refer to the right / left upper, middle and lower zones.

          PICC Lines

          • Indications for PICC Line

          • Administration of certain medications - high-dose potassium, vasopressors, TPN, certain chemotherapy, long-term antibiotics
          • Difficult peripheral venous access - with need for frequent blood samples

          3rd Degree SA Exit Block

          • Look For

          • Complete lack of P waves
          • An escape rhythm may be present

          2nd Degree AV Block: Type II Mobitz

          • Look For

          • Constant PR interval with intermittently dropped QRS complexes.

          Regulation

          Overexpression of hepcidin in the setting of (IL-6 mediated) inflammation is suspected to be the driving process in anaemia of chronic disease.

          Neutrophilia

          Myeloproliferative disorders are a less common cause of neutrophilia that are important not to miss.

          Abnormal Platelet Size

          • Causes of Large and Giant Platelets

          • Inherited giant platelet disorders - e.g. Bernard-Soulier
          • Myeloproliferative neoplasms
          • Myelodysplastic syndrome
          • Factitious

          Reactive Lymphocytes

          • Causes of Reactive Lymphocytes

          • Viral infections - EBV, CMV, HIV, COVID
          • Other infections - e.g. toxoplasmosis, bordatella pertussis
          • Certain autoimmune disorders

          Central Hypothyroidism

          Pituitary or hypothalamic lesions are a less common cause of hypothyroidism.

          Elevated TSH with Reduced T4

          Primary hypothyroidism originates from pathology affecting thyroid tissue, resulting in reduced production of thyroid hormones.

          Subclinical Hyperthyroidism

          • Pearls

          • If the patient is clinically thyrotoxic, consider T3 toxicosis and check the patient's T3.
          • Take a careful medication history, including past treatment for hyper or hypothyroidism.
          • Ask about recent illnesses.

          Correcting the QT Interval (QTc)

          • Framingham

          • QTc = QT + 0.154(1000 - RR Interval)

          Ventricular Rhythm

          • Causes of Irregular Ventricular Rhythm

          • Tachycardia

          • Multifocal atrial tachycardia
          • Atrial fibrillation
          • Atrial flutter with variable block
          • Polymorphic ventricular tachycardia
          • Bradycardia

          • Sinus arrhythmia
          • Sinus arrest
          • Second or third degree sinoatrial exit block
          • Atrial fibrillation with slow ventricular rate
          • Atrial flutter with variable block
          • Second or third degree AV block

          Polymorphic Ventricular Tachycardia

          • Causes of Polymorphic Ventricular Tachycardia

          • Torsade de pointes - due to prolonged QT
          • Non-torsades polymorphic VT - most commonly due to coronary ischaemia / infarction

          Atypical LBBB

          • Atypical LBBB

          Alpha-2 Globulins

          Include caeruloplasmin, alpha 2-macroglobulin and haptoglobulin.

          Localising an MI

          • Lead Complexes

          • Lateral - I, aVL, V5, V6
          • Inferior - II, III, aVF
          • Septal - V1, V2
          • Anterior - V3, V4
          • Right ventricular (requires extra leads) - V1R-V6R
          • Posterior (requires extra leads) - V7-V9

          Clinical Use

          • Adverse Effects

          • Dry Cough (due to bradykinin)
          • Hypotension
          • Angioedema
          • Hyperkalaemia
          • Renal impairment

          Substem A (Target)

          -v(i)-: viral (e.g. palivizumab)

          Clinical Use

          • Adverse Effects

          • URTI
          • Headache
          • Pancreatitis
          • Adverse Effects

          • Drowsiness
          • Hypersalivation
          • Muscle weakness
          • Vertigo

          Past Medical History

          And finally, ask about the management of the patient's CKD. Initially this involves slowing the progression of disease by treating the cause and using RAAS-blocking medications, while later in the disease this involves treating complications. Patients with end stage renal failure may be on dialysis, or may have had a renal transplant.

          Transfusion History

          Ask about any previous transfusion reactions (infectious or non-infectious), and whether the patient has any known antibodies.

          Family History

          Ask about family history of cardiac disease, such as ischaemic heart disease, cardiomyopathies or arrhythmias.

          II - Vision

          • Visual Acuity

          • The patient's visual acuity is a useful screening tool for identifying visual loss, which may be caused by a variety of ocular, optic nerve or CNS disorders. Ask the patient to cover one eye (with their corrective lenses if they normally wear any), look at a Snellen chart and identify the smallest line they can read. 

          The Patient

          Look for obvious dysmorphic facies - signs suggestive of congenital syndromes such as Marfan syndrome, Down syndrome and Turner's syndrome - as these conditions are associated with cardiovascular disease.

          pH

          A reduction in urine pH suggests an abundance of acid in the urine. This may be due to a high protein diet, ingestion of acidic foods (like cranberries), any cause of metabolic acidosis, or respiratory acidosis.

          Red Cell Size & Colour

          The mean corpuscular haemoglobin (MCH) is the average amount of haemoglobin per red blood cell, while the mean corpuscular haemoglobin concentration (MCHC) refers to the average concentration of haemoglobin within red blood cells - these two measures are used to determine whether red cells are hypochromic or hyperchromic.

          Assessing Oxygenation

          This diagram is the oxyhaemoglobin dissociation curve, which describes the relationship between PaO₂ and HbO₂. 

          Assessment of Bone

          • Transverse fracture - a fracture straight across the bone
          • Oblique fracture - a fracture at an angle to the bone
          • Spiral fracture - a corkscrew-shaped fracture around the boneOccurs due to twisting of a long bone
          • Comminuted fracture - the bone has been shattered into multiple pieces
          • Avulsion fracture - avulsion of a fragment of bone away from the main body of the bone

          Markers of Haemolysis

          Measures of Iron Status

          A reduced transferrin saturation is a marker of iron deficiency, though can also occur with chronic disease. This is a useful way of differentiating iron deficiency from anaemia of chronic disease: ferritin is unlikely to be reduced in chronic disease though is almost always reduced in iron deficiency.

          Procalcitonin

          Procalcitonin rises rapidly with maximal concentration reached within two days, and falls quickly once inflammation has resolved.

          Urinary Casts

          Urinary casts are tubular structures formed by the precipitation of Tamm-Horsfall mucoprotein. These may contain red cells, white cells or other substances, and their presence may suggest specific disease processes.

          Collecting the Sample

          • Order of Draw

            The order of blood collection is important, as chemicals from one tube can cross-contaminate another tube and affect the results. The optimal order of collection is:
          • Blood culture tubes
          • Citrate tube - coags
          • SST tube - chemistry, immunology, serology, blood bank
          • Heparinised tube - lithium level, ammonia level
          • EDTA - haematology, blood bank
          • Acid-citrate-dextrose - HLA typing, paternity testing, DNA studies
          • Glucose inhibitor tube

          Low Flow Oxygen

          The flow into a Hudson mask should be at least 5 L/min, to reduce rebreathing of carbon dioxide.

          Specimen Collection

          • Introduction

          Catheter Insertion

          • Insertion

          Identifying a Vein

          The dorsum of the hand has smaller veins and IVCs here are more likely to clot, so this should be used as a backup option. 

          Airway Adjuncts

          Oropharyngeal airways are contraindicated in conscious patients, and patients who can cough or have an active gag reflex - these patients will not tolerate the airway.

          Past Medical History

          • Other Renal Disease

            There are many other renal diseases that patients may report. These include:
          • Past acute kidney injury
          • Recurrent urinary tract infections
          • Renal calculi
          • Polycystic kidney disease
          • Glomerulonephropathy

          Family History

          Ask whether anyone in the family has had any neurologic conditions in the past. Attempt to determine whether any conditions have a clear pattern of transmission - autosomal dominant, autosomal recessive or X-linked.

          Transplant History

          Patients with certain haematologic disorders will have had an autologous or allogeneic stem cell transplant in the past.

          Medication History

          In patients with airways disease, ask about what inhalers they use and whether they have an action plan in place.

          Family History

          Also ask about any sudden cardiac death that may have occurred in the family.

          Medication History

          Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.

          II - Vision

          • Peripheral Visual Fields

          • The pattern of a patient's peripheral visual field loss can aid in localising their lesion. To assess these, ask the patient to cover one eye and then slowly move a finger or white examination pin from the upper left, upper right, lower left and then lower right; ask the patient to state when they can see the finger / pen. Repeat with the other eye. The patterns of visual field loss and their corresponding pathologies are:

          The Patient

          • Skin Colour

          • Look at the colour of the patient's skin for pallor or cyanosis.

          pH

          An increase in the urine pH suggests an abundance of base in the urine. This is commonly a sign of infection with a urease-producing bacteria, which convert urea into the alkaline ammonia. Alkaluria may also occur in the presence of metabolic alkalosis, respiratory alkalosis, renal tubular acidosis or a low carbohydrate diet.

          Red Cell Size & Colour

          A microcytic, hypochromic anaemia contains predominantly small and pale cells. This is classically a sign of iron deficiency anaemia, however can also occur with thalassaemia, lead poisoning, congenital sidroblastic anaemia and hyperthyroidism.

          Assessing Oxygenation

          At high PaO₂ (e.g. at the alveolar-capillary membranes in the lung), oxygen readily binds to haemoglobin; at low PaO₂ (e.g. at the systemic capillaries), oxygen is readily released from haemoglobin.

          Assessment of Bone

          An incomplete fracture (fissure, torus or greenstick fracture) is a break that does not pass through the entirety of a bone. This may be associated with bending of a long bone. Incomplete fractures tend to occur in children, whose bones are more flexible than adults. If the force applied on the bone is greater than the mechanical strength of the bone then it will remain bent.

          Markers of Haemolysis

          • Bilirubin

          • Following haemolysis, haemoglobin is metabolised to haem and then bilirubin, which overwhelms the liver's capacity to conjugate it. 

          Measures of Iron Status

          • Soluble Transferrin Receptor

          • The soluble transferrin receptor is rarely performed in clinical practice. Its main utility is in differentiating iron deficiency from anaemia of chronic disease, which can be difficult to distinguish based on standard iron studies. In iron deficiency, the soluble transferrin receptor level will be increased. Haemolysis will also caused a raised level.

          Haptoglobin

          Haptoglobin is an alpha-2 glycoprotein secreted mainly by the liver that binds plasma free haemoglobin. 

          Urinary Casts

          • Acellular casts do not contain cells. Examples include:
          • Hyaline casts (solidified mucoprotein) - dehydration, exercise, diuretics
          • Granular casts (degenerated cells) - glomerulonephritis, acute tubular necrosis, pyelonephritis
          • Muddy brown casts (likely denatured haemoglobin) - acute tubular necrosis
          • Waxy casts (severely degenerated cells) - severe acute or chronic renal failure
          • Fatty casts (lipids) - nephrotic syndrome, diabetic nephropathy
          • Pigment casts (haemoglobin, myoglobin, bilirubin) - haemolysis, rhabdomyolysis, liver disease

          Collecting the Sample

          • Finishing Up

          Low Flow Oxygen

          FlowFiO₂
          5 L/min~0.36
          6 L/min~0.42
          7 L/min~0.48
          8 L/min~0.54

          Specimen Collection

          • Preparation

          Catheter Insertion

          • Finishing Up

          Identifying a Vein

          The veins in the antecubital fossa should be avoided, as insertion here will limit the movement of the patient's arm and the cannula would be at a high risk of extravasating.

          Airway Adjuncts

          • Nasopharyngeal Airway

          • A nasopharyngeal airway is inserted into the nose to relive nasal obstruction.

          Insertion

          Attach the bung to the cannula, which will stop any bleeding. If blood collection is required, attach the 10-20mL syringe to the bung and withdraw the desired amount.

          Adjuvants

          • Adrenaline

          • When used as part of local anaesthesia, adrenaline causes local vasoconstriction that increases duration, reduces bleeding and allows for greater volumes to be injected.

          Manifestations

          • Manifestations of Vitamin B12 Deficiency

          • Megaloblastic anaemia
          • Atrophic glossitis
          • Peripheral neuropathy
          • Dementia

          Diagnosis

          The ventilation/perfusion (V/Q) scan is a nuclear imaging modality used to assess for mismatch between ventilation and perfusion using technitium-99 labelled particles; there is almost always a V/Q defect with PE and therefore a negative scan has a high negative predictive value for PE. Other conditions causing a perfusion defect (such as atelectasis, consolidation, ILD, COPD or tumours) will also result in a positive test, and therefore V/Q scans should be avoided in these patients. It is important to note that as an indirect means of assessing for PE, V/Q scans only provide a probability of PE (low, intermediate or high) and cannot confirm the diagnosis in every case.
          Low serum osmolality with hypervolaemia is suggestive of water retention. Low urinary sodium (<20 mEq/L) in this case is suggestive of renal failure as a cause, while normal urinary sodium (>20 mEq/L) suggests other causes of fluid overload such as heart failure, liver cirrhosis, nephrotic syndrome or hypoalbuminaemia.
          The anaemia of iron deficiency tends to be microcytic and hypochromic and the blood film may exhibit poikilocytic changes such as target cells or elliptocytes. Often in early iron deficiency the anaemia is normocytic, with anisocytosis (i.e. an elevated RDW) due to a mix of normocytic and microcytic cells.

          Approach to Diagnosis

          Hepatitis B surface antigen (HbsAg) is indicative of active hepatitis B infection. This test does not distinguish between acute or chronic infection.

          Substem B (Origin)

          -e-: hamster

          Disease History

          • Functional Impact

          • How the symptoms associated with the condition are affecting their day to day life.

          UpToDate

          UpToDate is an extremely comprehensive clinical medicine app that offers guides to medical conditions based on evidence-based and peer-reviewed information. The website and app are used by medical students and doctors all the way up to consultants, although the content is more useful to medical students in later years. While the information available in UpToDate is comprehensive, it can also be overwhelming, and it can be difficult to filter the information to find what you need.

          ANKI

          • ANKI

          Microsoft OneNote

          • Pros

          • Free
          • Use on unlimited devices
          • Easy collaboration
          • Integrates with other Microsoft apps

          Armando Hasudungan

          All of Armando’s videos are free to watch on the YouTube channel, making this an incredible resource for visual learners.

          Zero to Finals

          The diagrams and animations in the videos are visually appealing and easy to understand, though the videos cover less of a range of disorders compared to other resources. Zero to Finals also offers additional free and paid resources on their website, including podcasts, notes, flashcards and quizzes.

          Smiling Mind

          Most importantly, the website and app are completely free to use!

          MDCalc

          • MDCalc

          Notion

          • Pros

          • Flexible and customizable database-oriented app.
          • Offers a wide range of features for note-taking and task management.
          • Integrates with other apps and services.

          Life in the Fast Lane

          • Features

          • Comprehensive ECG library.
          • ECG quiz.
          • Case studies.

          Types of Knowledge

          While it can be useful to watch others to start with, the best way to gain procedural knowledge is to practice the skill in question - over and over until you have mastered it! 

          Setting Yourself Up for Success

          • Understand the Big Picture First

          • While it is possible to rote-learn large amounts of information, it is much easier to remember these pieces of information if you understand how they integrate into the larger structure of what you're learning. When starting a new topic, try learning the big picture first - how the topic is structured and how the elements interact. When you subsequently start reading about the details, it will be easier to form connections between ideas and you will be more likely to remember the key facts.

          Optimise Your Study Environment

          • Company

          • Do you study better by yourself, or in a group? Often you will find yourself reading, listening, note taking or self-testing alone; you may find that studying in a small group allows you to bounce ideas off others, calibrate to an expected standard, or get motivation to study.

          See One, Do One, Teach One

          • Do One

          • The first time you perform a procedure, it should be under the supervision of an experienced proceduralist. This enables to yo refine your technique in a controlled environment, ask questions as you go, and ask for help if you have difficulty.

          Creating Effective Flashcards

          • Break Down Big Ideas

          • If a single concept is too large or complex to fit on a single flashcard, break it down into several smaller cards. It’s best to avoid large lists or tables on the back of flashcards. For example, instead of listing all of the causes of systolic murmurs, ask about only causes of ejection systolic murmurs.

          Tips for Taking Notes

          • Don't Highlight or Underline

          • When reading or listening to lectures, highlighting and underlying don't provide much active engagement and don't significantly improve your study later on. Further to this, over-highlighting can make it difficult to find the key concepts later on.

          Upper Limb Myotomes

          Wrist ulnar deviation: ulnar / radial nerves (C8)Flexor & extensor carpi ulnaris

          Cervical Lymph Nodes

          Left supraclavicular node (Virchow's node) - in left supraclavicular fossaChest, abdomen

          Faecal Occult Blood

          Perianal causes of bleeding generally cause visible perianal or rectal blood, and faecal occult blood testing is not required.

          Cervical Lymph Nodes

          Left supraclavicular node (Virchow's node) - in the left supraclavicular fossaChest, abdomen

          Trendelenburg Gait

          • Look For

          • Dropping of the affected side during the stance phase and the unaffected side during the swing phase.

          Hypotension

          • Causes of Hypotension

          • Hypovolaemia

          • Bleeding
          • Dehydration
          • Third Spacing
          • Vasodilation

          • Septic shock
          • Anaphylaxis
          • Neurogenic
          • Blood transfusion reaction
          • Adrenocortical insufficiency
          • Cardiogenic

          • Myocardial infarction
          • Tachycarrhythmia
          • Bradyarrhythmia
          • Obstructive

          • Massive pulmonary embolus
          • Tension pneumothorax
          • Cardiac tamponade
          • Other

          • Drug toxicity (e.g. beta blockers, calcium channel blockers)

          The Oxygen Dissociation Curve

          • Significance

          • As the curve shifts to the left, oxygen will more readily bind to haemoglobin. As the curve shifts to the right, oxygen will more readily be released from haemoglobin.

          Pleural Rub

          • Causes of Pleurisy

          • Infection - viral, bacterial, tuberculosis, fungal
          • Malignancy - lung cancer, mesothelioma, lymphoma
          • Autoimmune - rheumatoid arthritis, SLE
          • Pulmonary embolism
          • Familial Mediterranean fever
          • Asbestosis

          The Oxygen Dissociation Curve

          • Significance

          • As the curve shifts to the left, oxygen will more readily bind to haemoglobin. As the curve shifts to the right, oxygen will more readily be released from haemoglobin.

          Measures of Coagulation

          • Causes of Reduced Fibrinogen

          • Consumption - DIC, cancers, thrombolytic therapy, snake bite
          • Reduced synthesis - liver impairment
          • Haemodilution - massive transfusion
          • Congenital deficiency - hypofibrinogenaemia, afibrinogenaemia, dysfibrinogenaemia

          Hypotension

          • Causes of Hypotension

          • Hypovolaemia

          • Bleeding
          • Dehydration
          • Third Spacing
          • Vasodilation

          • Septic shock
          • Anaphylaxis
          • Neurogenic
          • Blood transfusion reaction
          • Adrenocortical insufficiency
          • Cardiogenic

          • Myocardial infarction
          • Tachycarrhythmia
          • Bradyarrhythmia
          • Obstructive

          • Massive pulmonary embolus
          • Tension pneumothorax
          • Cardiac tamponade
          • Other

          • Drug toxicity (e.g. beta blockers, calcium channel blockers)

          Splenomegaly

          Splenomegaly is present if the spleen is palpable.

          Posterior Tibial Nerve Palsy

          • Causes of Posterior Tibial Nerve Palsy

          • Tarsal tunnel syndrome - entrapment within the tarsal tunnel posterior to the medial malleolus
          • Distal tibial fracture

          Myotomes

          Ankle plantar flexion: tibial nerve (L5/S1)Gastrocnemius, soleus, peroneus muscles

          Trendelenburg Gait

          • Look For

          • Dropping of the affected side during the stance phase and the unaffected side during the swing phase.
          • Look For

          • Dropping of the affected side during the stance phase and the unaffected side during the swing phase.

          Assessment of Reading

          • Causes of Disordered Reading

          • Pure alexia - reading of words letter-by-letter.
          • Surface dyslexia - ability to phonetically sound out words (breed, steam), but difficulty reading words with irregular spelling (debt, colonel, broad, steak).
          • Phonological dyslexia - inability to read non-words (neg, bluck, deak) with otherwise normal reading of words.
          • Deep dyslexia - semantic errors (e.g. reading the word 'table' as 'chair' or 'street' as 'road'), and inability to read plausible non-words (neg, bluck, deak).Stroke, traumatic brain injury
          • Neglect dyslexia - the patient omits or substitutes part of a word, especially at the beginning of the word. For example, island / land or fish / dish.Dominant hemispheric damage

          Tonality

          • Interpretation

          • Expressive - varied pitch and intonationNormal tonality
          • Monotone - the patient uses a single tone for vocal expression.Boredom, depression, schizophrenia, autism spectrum disorder

          Trendelenburg Gait

          • Look For

          • Dropping of the affected side during the stance phase and the unaffected side during the swing phase.

          Cervical Lymph Nodes

          Left supraclavicular node (Virchow's node) - in left supraclavicular fossaChest, abdomen

          Muscles Acting on the Hand

          Lumbricals

          Accommodation

          • Causes of Impaired Accommodation

          • Optic (II) nerve lesion - trauma, compression, optic neuritis
          • Thalamic / occipital / midbrain lesion - encephalitis, tumour, trauma, MS, midbrain infarct
          • Oculomotor (III) nerve lesion - trauma, compression, small vessel ischaemia, Guillain barré

          Clinical Use

          • Monitoring

          • Titrate to the patient's blood pressure, electrolytes, urea and creatinine. Also ask about cough, a common side effect.

          Substem B (Origin)

          -e-: hamster

          Clinical Use

          • Signs of Withdrawal

          • Anxiety / agitation
          • Insomnia
          • Myoclonus
          • Seizures
          • Anterograde memory loss (especially midazolam)

          Postural Hypotension

          • Interpretation

          • Postural hypotension is present if there is a fall of >20mmHg systolic and >10mmHg diastolic blood pressure following standing.

          Ascites

          • Fluid Wave

          • Ask the patient or an assistant to apply pressure using the ulnar surface of their hand to the midline of the abdomen. Place the fingertips of one hand along the left flank and with the other hand firmly palpate the opposite flank. Ascites is present if a fluid wave is felt on the opposite side of the abdomen.

          Character

          Pulsus tardis & parvis: weak pulse with a delayed systolic peak.Aortic stenosis

          Trendelenburg Gait

          • Look For

          • Dropping of the affected side during the stance phase and the unaffected side during the swing phase.

          Normal Anion Gap Metabolic Acidosis

          • Causes of Normal Anion Gap Metabolic Acidosis

          • GI loss - diarrhoea, fistula, stoma
          • Isotonic saline infusion
          • Renal tubular acidosis
          • Acetazolamide
          • Addison's disease

          Automatic Implantable Cardioverter Defibrillator

          • Example

          • An AICD with two large coils present
          • No Overlay
            Overlay
            An AICD with two large coils present
             

          Vascaths

          A vascath is a wide bore catheter usually inserted into the subclavian or internal jugular vein. It may be non-tunnelled (short-term) or tunnelled (longer term).

          3rd Degree SA Exit Block

          • 3rd Degree SA Exit Block
             

          2nd Degree AV Block: Type II Mobitz

          • 2nd Degree AV Block: Type II Mobitz
             

          Excretion

          There is no mechanism by which iron is excreted, though 1-2mg of iron is lost daily due to enteric desquamation or minor blood loss.

          Neutrophilia

          • Causes of Neutrophilia

          • Pseudoneutrophilia (granulocyte shift) - vigorous exercise, emotional stress, vomiting, seizure, paroxysmal tachycardia
          • Acute infection (particularly pyogenic) - bacterial, viral, fungal, parasitic
          • Inflammation - e.g. surgery, burns, infarction, autoimmune disease
          • Corticosteroids
          • Myeloproliferative neoplasms - CML, polycythaemia, essential thrombocytosis
          • Solid tumours
          • Post splenectomy
          • Heavy smoking

          Platelet Clumping

          In a patient with new or worsening thrombocytopaenia, look for clumping of platelets which would result in a factitiously low platelet count. This is particularly seen at the tail of a blood film.

          Reactive Lymphocytes

          • Example

          • A reactive lymphocyte in a patient with acute mononucleosis.
          • A reactive lymphocyte in a patient with acute mononucleosis.
             

          Central Hypothyroidism

          • Look For

          • Reduced / normal TSH with reduced T4.

          Elevated TSH with Reduced T4

          • Causes of Primary Hypothyroidism

          • Autoimmune thyroiditis - Hashimoto's, atrophic
          • Hypothyroid phase of thyroiditis
          • Iatrogenic - radioiodine therapy, thyroidectomy, external irradiation of the neck
          • Drugs - amiodarone, lithium, interferons, interleukin-2, iodide
          • Iodine deficiency
          • Thyroid infiltration - amyloidosis, tumour
          • Congenital hypothyroidism

          Central Hyperthyroidism

          TSH-secreting pituitary tumours are rare.

          Ventricular Rhythm

          • Examples

          Polymorphic Ventricular Tachycardia

          Polymorphic VT other than torsade de pointes will have a normal QTc once reverted to sinus rhythm.

          Atypical RBBB

          • Typical RBBB

          • Wide QRS >120ms (complete BBB) or 110-120ms (incomplete BBB)
          • Added R wave (R') in right precordial leads - RSR' pattern in leads V1 or V2 (R' taller than R) (Due to delayed conduction to right ventricle)
          • Slurred S wave in lateral leads - S wave duration > R wave duration (or >50ms) in leads I, V5 and V6

          Alpha-2 Globulins

          • Causes of Elevated Alpha-2 Globulins

          • Acute inflammation
          • Adrenal insufficiency
          • Corticosteroid administration
          • Nephrotic syndrome
          • Cirrhosis

          Anterior Myocardial Infarction

          Anterior and anteroseptal infections tend to occur due to occlusion of the left anterior descending (LAD) artery.

          High Anion Gap Metabolic Acidosis

          An elevated anion gap of >16 suggests that there is an excess of acid within the blood, causing an acidosis.

          Cardiac Resynchronisation Therapy (CRT)

          Leads within the left and right ventricles, used to coordinate contraction of the ventricles in patients with severe heart failure.

          Vascaths

          A vascath should be within the SVC i.e. angled downward toward the right heart border, but not in the right atrium.

          Advanced 2nd Degree Heart Block

          In advanced or 'high-grade' second degree heart block, multiple beats are blocked and it is difficult to distinguish between Mobitz type I and II.

          Neutrophilia

          • Pearls

          • Neutrophilia should be correlated with the patient's clinical state and other markers of inflammation
          • Most often the history and examination will reveal the most likely cause of neutrophilia
          • Neutrophilia with left shift of granulocytes on blood film is highly suggestive of acute bacterial infection

          Platelet Clumping

          • Platelet Clumping
             

          Plasmacytoid Lymphocytes

          Plasmacytoid lymphocytes, or Türk cells, are an intermediate stage between a B lymphocyte and a plasma cell.

          Central Hypothyroidism

          • Causes of Central Hypothyroidism

            Pituitary or hypothalamic pathology.
          • Tumour
          • Trauma
          • Surgery
          • Radiation
          • Infection
          • Infarction
          • Infiltration

          Elevated TSH with Normal T4

          An elevated TSH with a normal T4 is suggestive of subclinical hypothyroidism, though may also occur in several other circumstances.

          Central Hyperthyroidism

          • Look For

          • Normal / elevated TSH with elevated T4.

          Ventricular Rhythm

          • Atrial fibrillation - note a baseline fibrillation wave with irregular ventricular rhythm:
          • Atrial fibrillation - note a baseline fibrillation wave with irregular ventricular rhythm
             

          Torsade de Pointes

          Torsades is a polymorphic VT that occurs as a result of a prolonged QT interval.

          Atypical RBBB

          • Atypical RBBB

          Alpha-2 Globulins

          • Causes of Decreased Alpha-2 Globulins

          • Malnutrition
          • Haemolytic anaemia
          • Protein-losing enteropathies

          Anterior Myocardial Infarction

          On an electrocardiogram, leads V3 and V4 are the anterior leads and V1 and V2 are the septal leads. These leads tend to show signs of infarction in anterior MI.

          Upper Limb Myotomes

          Wrist radial deviation: radial / median nerves (C6/C7)Flexor & extensor carpi radialis

          Axillary Lymph Nodes

          Pectoral nodes - anteriorly, behind pectoralis major muscleAnterolateral chest wall, central / lateral breast

          Faecal Occult Blood

          • Causes of Faecal Occult Blood

          • Colorectal

          • Colorectal cancer
          • Colorectal polyp
          • Colitis - IBD, infection, diverticulitis
          • Radiation proctitis / colitis
          • Angiodysplasia
          • Trauma
          • Upper GI

          • Ulcer - gastric / duodenal
          • Gastritis
          • Oesophagitis
          • Varices - oesophageal / gastricPortal hypertension
          • Cancer - gastric / oesophageal
          • Coeliac disease
          • Mallory-Weiss tear
          • Intussusception
          • Angiodysplasia

          Spastic Gait

          Spastic gait may occur with cerebral palsy or hemiplegia.

          Narrow Pulse Pressure

          A narrow pulse pressure is a reduced difference between the systolic and diastolic blood pressure.

          Aetiology of Coagulopathy

          Isolated INR prolongation is most commonly seen in patients on warfarin, though high doses of warfarin can also prolong the APTT.

          Overview

          • Note

          • D-lactate is an isomer of lactate produced by bacteria that will not be measured by conventional lactate testing.

          Substem B (Origin)

          -i-: primate

          Past Medical History

          • Cardiovascular Disease

          • Of particular importance in the renal history is the presence of cardiovascular disease such as ischaemic heart disease, stroke, peripheral vascular disease. Also ask about cardiovascular risk factors such as diabetes, hyperlipidaemia, hypertension. 

          Family History

          • Inherited neurologic disorders include:
          • Dementias - familial Alzheimer's, CADASIL
          • Ataxia - friedreich ataxia, ataxia-telangiectasia, spinocerebellar ataxia
          • Hereditary neuropathies - Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies
          • Muscular dystrophies - Duchenne, Becker, facioscapulohumeral, myotonic dystrophy
          • Spinal muscular atrophy
          • Inherited forms of epilepsy
          • Hereditary spastic paraplegia
          • Huntington's disease
          • Neurofibromatosis
          • Tuberous sclerosis
          • Mitochondrial disorders

          Transplant History

          An autologous stem cell transplant involves mobilising and collecting a patient's stem cells, providing chemotherapy to deplete the bone marrow, and then retransfusing their stem cells. This process is less complex and has less potential side effects than an allogeneic stem cell transplant.

          Medication History

          Certain medications may cause respiratory symptoms. ACE inhibitors may cause cough by increasing levels of bradykinin; beta blockers may worsen airways disease; and aspirin-induced respiratory disease is an condition to consider in patients with nasal polyps and sinus symptoms. Certain medications, such as methotrexate and bleomycin, may cause interstitial lung disease.

          Social History

          It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility and ability to perform activities of daily living.

          II - Vision

          • II - Vision

          The Patient

          Skin pallor is classically a sign of anaemia, though may also occur due to low output or peripheral shutdown.

          Specific Gravity

          The urine specific gravity is a measure of the amount of solute compared to water. Pure water has a specific gravity of 1.000, and the specific gravity of urine is normally 1.002 - 1.035.

          Red Cell Size & Colour

          A normocytic, normochromic anaemia is where the red blood cells are normal in size and colour. This may be dilutional or occur in the context of acute haemorrhage, chronic kidney disease, bone marrow pathology or haemolytic anaemia.

          Assessing Oxygenation

          As the curve shifts to the left, oxygen will more readily bind to haemoglobin. This may occur in the context of alkalaemia (high pH), hypothermia, or decreased 2,3-DPG.

          Assessment of Bone

          • Assessment of Bone

          Markers of Haemolysis

          Elevated unconjugated bilirubin is an indicator of haemolysis though can be caused by other disorders including resorption of a large haematoma, certain medications, inherited disorders, acute hepatitis or cirrhosis. As such it is important to also look at the remainder of the liver function panel when interpreting the bilirubin.

          Measures of Iron Status

          • Bone Marrow Iron Stores

          • The gold standard for assessing the body's iron status is by performing an iron stain on a bone marrow aspirate specimen. This is almost never used for this purpose, however if a bone marrow aspirate is performed for another reason then this is a useful tool for assessing total body iron.

          Haptoglobin

          Haptoglobin is primarily used as a marker of intravascular haemolysis, in which its level will reduce.

          Urinary Casts

          • Cellular casts contain red cells, white cells or other sloughed cells. These may include:
          • Red cell casts (bleeding through the glomerulus or into the tubules) - glomerulonephritis, acute interstitial nephritis
          • White cell casts (interstitial or glomerular inflammation) - pyelonephritis, glomerulonephritis, acute interstitial nephritis
          • Renal tubular epithelial cell casts (sloughed cells) - acute tubular necrosis, acute interstitial nephritis
          • Bacterial casts - pyelonephritis

          Troubleshooting

          Likely CauseWhat to Do
          No flashbackNeedle is not in the veinAdvance further, or pull back slightly then reinsert slightly more medially / laterally
          Flashback but no blood coming outNeedle penetrated too far, or vein collapsedPull back slightly, adjust the angle of the needle against the skin, pull back and try again
          Bright red blood pulsating outNeedle is in an arteryRemove the needle and apply pressure for at least three minutes
          HaematomaBleed into the subcutaneous spaceRemove the needle and apply pressure to the area

          Reservoir Systems

          Reservoir systems include a reservoir bag, which allows for oxygen to accumulate between breaths. This allows for a higher concentration of oxygen to be inspired.

          Specimen Collection

          • Collection

          Complications

          • Potential complications of urinary catheterisation include:
          • Traumatic insertion - resulting in haematuria, false passage creation or urethral strictures
          • Urinary tract infection - cystitis, pyelonephritis or sepsis
          • Iatrogenic hypospadiasErosion of the urethral meatus due to downward pressure
          • Bladder stonesParticularly with long-term catheterisation
          • Bladder cancerRate, but long-term catheterisation is a risk factor

          Identifying a Vein

          • Places to Avoid

            Certain sites should be avoided in order to prevent complications. These include:
          • The same arm as an AV fistula - you may blow the fistula
          • The same arm as a past mastectomy or lymph node dissection, as the drainage of such limbs is poor and the patient may develop severe oedema that is difficult to reverse
          • A limb affected by stroke
          • An area that is affected by burns, oedema or infection
          • A limb that has a deep venous thrombosis

          Airway Adjuncts

          Measure the airway from the tip of the earlobe to the nostril. Point the airway toward the midline, and then insert it backward into the nasal cavity until the flange reaches the nostril.

          Insertion

          Flush the cannula using 10mL of 0.9% sodium chloride.

          Adjuvants

          Don't inject lignocaine with adrenaline into the nose, ear, fingers, toes or penis as this may cause ischaemia secondary to vasoconstriction.

          Diagnosis

          • Investigations

          • Reduced Vitamin B12 level
          • Macrocytic, hyperchromic anaemia
          • Hypersegmented neutrophils
          • Pearls: CTPA vs V/Q Scan

          • CTPA - superior to V/Q scans, though (relatively) contraindicated in renal dysfunction and pregnancy
          • V/Q - can be used in renal failure and pregnancy, though less likely to be diagnostic and may be confounded by other causes of perfusion defect (atelectasis, consolidation, ILD, COPD, tumours)

          Management

          • Management Strategies

          • Lifestyle Measures

          • Smoking cessation
          • Pulmonary rehab
          • Nutritional support
          • Develop social support
          • Pharmacologic

          • Long-acting beta agonists (LABAs) - salmeterol, formoterol, indacaterol
          • Long-acting anti-muscarinic agents (LAMAs) - tiotropium, aclidinium, umeclidinium, glycopyrronium
          • LAMA / LABA combinations - tiotropium / olodaterol, aclidinium / formoterol, glycopyrronium / indacaterol, umeclidinium / vilanterol
          • Inhaled corticosteroid (ICS) / LABA combinations - budesonide / formoterol, fluticasone / salmeterol, fluticasone / formoterol, fluticasone / vilanterol
          • LAMA / LABA / ICS combination - fluticasone / umeclidinium / vilanterol
          • Supportive Measures

          • Home oxygen
          • Vaccinations - influenza, pneumococcal
          • Surgical Options

          • Lung volume reduction surgery
          • Lung transplantation

          Diagnosis

          If iron deficiency is suspected but not confirmed, improvement in haemoglobin following a trial of iron supplementation can clinch the diagnosis.

          Approach to Diagnosis

          The hepatitis B surface antibody (anti-HBs) is indicative of past hepatitis B infection or past vaccination against hepatitis B. A positive surface antibody suggests immunity against the virus.

          UpToDate

          UpToDate operates on a subscription model, which can be relatively expensive. However, many universities and hospitals provide access to UpToDate for their students, making it a valuable resource for medical students who want access to high-quality clinical information.

          ANKI

          ANKI is a popular open-source flashcard app that uses spaced repetition to help users remember information over the long term. ANKI allows you to create custom flashcards with text, images, and audio, offers a large amount of control over the review of cards, making it a versatile and powerful study tool.

          Microsoft OneNote

          • Cons

          • Little ability to organise
          • Can be slow

          Armando Hasudungan

          • Armando Hasudungan

          Zero to Finals

          The videos are all free, as are the podcasts and notes. Additional resources such as flashcards, books and question banks are available on a subscription on the website.

          Smiling Mind

          • Smiling Mind

          MDCalc

          MDCalc is a valuable resource for medical students and doctors, offering hundreds of clinical calculators and tools in one easy-to-use platform. Each calculator is accompanied by detailed information about the interpretation and creator of the tool. 

          Notion

          • Cons

          • Steep learning curve for new users - can be overwhelming initially.
          • Some features (such as Notion AI) require a paid subscription.

          Life in the Fast Lane

          • Limitations

          • No iOS or Android app available.
          • No structured course - self-guided learning.
          • Not specifically designed for medical students.

          Types of Knowledge

          • Metacognitive Knowledge

          • Metacognition refers to higher order thinking about strategy, conditional knowledge about cognitive tasks, and knowledge of self. Working on your metacognitive knowledge can help you to perform better, achieve more and improve well-being.

          Setting Yourself Up for Success

          • Make Notes Less Easy

          • Many medical students write notes that they can then return to review later with the goal of optimising recall. There is reasonable evidence that handwriting notes improves recall - in a Princeton university study, students using handwritten notes performed better on conceptual questions than those taking digital notes. 

          Optimise Your Study Environment

          • Avoid Distractions

          • Remove distractions such as your phone, and avoid social media. If you're in an area where you could be distracted, inform others that you are studying and need some space and some quiet. 

          See One, Do One, Teach One

          • Teach One

          • Once you’ve learned the procedure and tried it yourself, try teaching the procedure to someone else. Teaching something is a way to consolidate your understanding, by proving that you are able to communicate the steps succinctly. By passing on your skill to a peer or someone more junior, you are taking steps toward mastering the procedure.

          Creating Effective Flashcards

          • Use Words and Pictures

          • Incorporating both words and pictures can help you to reinforce your understanding of the material, particularly if you learn well from visual cues. This technique can be particularly effective for learning anatomy and other visual subjects.

          Tips for Taking Notes

          • Keep Your Notes in One Place

          • Choose a method of note-taking, optimise it and stick to it. Having paper notes, digital outlines and mindmaps on the back of napkins will make it difficult to bring everything together when you want to use it later.

          Postural Hypotension

          • Causes of Postural Hypotension

          • Autonomic dysfunction
          • Low intravascular volume - blood / fluid / electrolyte loss
          • Vasodilation - nitrates, alcohol, fever
          • Cardiac impairment
          • Chronic disease - diabetes mellitus, chronic renal failure, chronic liver disease,
          • Brain tumour - paraneoplastic syndrome

          Ascites

          • Causes of Ascites

          • Cirrhosis
          • Heart failure
          • Constrictive pericarditis
          • Peritonitis - tuberculous, neoplasmic, bacterial
          • Hypoalbuminaemia - nephrotic syndrome, malnutrition
          • Pancreatitis
          • Cancer - liver, stomach, pancreas, adrenals, gut
          • Thrombosis - portal vein, mesenteric vessels
          • Ovarian disease
          • Hypothyroidism
          • Dialysis

          Character

          Pulsus paradoxus: weak pulse during inspiration, strong during expirationConstrictive pericarditis, tamponade, PE, tension PTX, asthma / COPD, shock, pregnancy, obesity

          Spastic Gait

          Spastic gait may occur with cerebral palsy or hemiplegia.

          Narrow Pulse Pressure

          Reduced difference between the systolic and diastolic blood pressure

          Splenomegaly

          • Causes of Splenomegaly

          • Congestion - congestive cardiac failure, portal vein thrombosis, cirrhosis
          • Infection - bacterial / viral / parasitic
          • Inflammation - SLE, IBD, rheumatoid arthritis
          • Haematological - leukaemia / lymphoma, thalassaemia, sickle cell disease
          • Cancers - splenic tumours, metastases

          Femoral Nerve Palsy

          • Signs of Femoral Nerve Palsy

          • Wasting of the quadriceps
          • Weakness of hip flexion and knee extension
          • Reduced / absent patellar reflexes
          • Reduced sensation over the anterior thigh and medial calf

          Myotomes

          Ankle dorsiflexion: deep peroneal nerve (L4)Tibialis anterior

          Spastic Gait

          Spastic gait may occur with cerebral palsy or hemiplegia.
          Spastic gait may occur with cerebral palsy or hemiplegia.

          Assessment of Reading

          • Note

          • The term 'dyslexia' is colloquially used to denote 'developmental dyslexia', which is a global difficulty in reading beginning in childhood that may progress to adulthood. The dyslexias identified above are specific defects that are generally acquired rather than developmental.

          Spastic Gait

          Spastic gait may occur with cerebral palsy or hemiplegia.

          Axillary Lymph Nodes

          Pectoral nodes - anteriorly, behind pectoralis major muscleAnterolateral chest wall, central / lateral breast

          Substem B (Origin)

          -i-: primate
          -o-: mouse

          Insertion

          Dress the area by taping the cannula and applying the transparent dressing. If a patient is likely to move, an elastic or woven bandage can be used to cover an entire part of the limb.

          Adjuvants

          • Bicarbonate

          • Bicarbonate is sometimes added to local anaesthetic in order to increase its pH and reduce the stinging that occurs with injection of the agent.

          Diagnosis

          If PE is confirmed, a venous duplex ultrasound should be performed to assess for a DVT. A DVT is found in 30-50% of cases of pulmonary embolism.

          Management

          A priority in iron deficiency anaemia is to treat the underlying cause of deficiency. Heavy menstrual or intermenstrual blood loss should be investigated and treated. Referral to a gastroenterologist is often required to investigate GI bleeding, and in Helicobacter pylori-infected patients eradication therapy may be required.

          Approach to Diagnosis

          The hepatitis B core antibody (anti-HBc) is indicative of past or current hepatitis B infection.

          Substem B (Origin)

          -o-: mouse

          High Anion Gap Metabolic Acidosis

          • Causes of High Anion Gap Metabolic Acidosis

          • Lactic acidosis
          • Ketoacidosis - diabetic, alcoholic, starvation
          • Uraemia (end-stage renal failure)
          • Methanol / ethanol / ethylene glycol
          • Salicylate toxicity
          • Carbon monoxide toxicity

          Cardiac Resynchronisation Therapy (CRT)

          A cardiac resynchronisation therapy device may also be combined with a defibrillation lead (CRT-D).

          Vascaths

          • Examples

          Advanced 2nd Degree Heart Block

          • Look For

          • Two or more consecutive P waves without QRS complexes
          • May be in a 3:1, 4:1 or higher pattern

          Neutropaenia

          Neutropaenia refers to reduced circulating neutrophils.

          Plasmacytoid Lymphocytes

          • Plasmacytoid Lymphocytes
             

          Central Hypothyroidism

          • Differential Diagnosis of TFT Findings

          • Nonthyroidal illness
          • Recent treatment of hyperthyroidism
          • Congenital TSH or TRH deficiency
          • Assay interference

          Elevated TSH with Normal T4

          • Causes of Elevated TSH with Normal T4

          • Subclinical hypothyroidism
          • Poor compliance with thyroxine
          • Assay interference
          • Drugs - amiodarone, sertraline
          • Nonthyroidal illness (recovery phase)
          • TSH receptor defects
          • TSH resistance

          Central Hyperthyroidism

          • Differential Diagnosis of TFT Findings

          • Thyroid hormone resistance
          • Acute psychiatric illness
          • Drugs - amiodarone, heparin
          • Familial dysalbuminaemic hyperthyroxinaemia
          • Assay interference

          Ventricular Rhythm

          • Third degree (complete) AV block - bradycardia with complete dissociation between P waves and QRS complexes is characteristic:
          • Third degree (complete) AV block - bradycardia with complete dissociation between P waves and QRS complexes is characteristic
             

          P Wave Morphology Due to an Atrial Rhythm

          Focal atrial tachycardia (FAT) - a regular narrow complex tachycardia with abnormal P wave morphology (e.g. inverted or biphasic)

          Torsade de Pointes

          • Look For

          • Polymorphic ventricular tachycardia with 'twisting' around the isoelectric line
          • Prolonged QT interval once reverted to sinus rhythm

          Atypical RBBB

          • Atypical Findings

          • Monophasic R wave
          • R wave taller than R' (taller left rabbit ear)
          • Q wave in V1
          • QS waves in V6
          • R:S ratio <1 in V6 (S wave deeper than R wave is tall)

          Beta Globulins

          The beta-1 band is mostly transferrin, while the beta-2 band is mostly beta-lipoprotein.

          Anterior Myocardial Infarction

          • ECG Findings in Anterior Myocardial Infarction

          • ST elevation in leads V1-V4
          • ST depression in the inferior leads (II, III, aVF) or aVL
          • Poor R wave progression
          • De Winter waves - up-sloping ST depression followed by tall, symmetrical T waves in leads V1-V6 (suggests proximal LAD occlusion)
          • Wellen's syndrome - deeply inverted or biphasic T waves in leads V2-V3 (suggests proximal LAD occlusion)

          Upper Limb Myotomes

          Phalange flexion: median nerve (C8)Flexor digitorum profundus & superficialis

          Axillary Lymph Nodes

          Subscapular nodes - posteriorly, in front of subscapularis musclePosterior neck and chest wall

          Spastic Gait

          • Look For

          • A poorly coordinated gait with short steps and jerky movement.

          Narrow Pulse Pressure

          There is no set reference range for pulse pressure, and this should be taken in the context of the individual patient.

          Aetiology of Coagulopathy

          Isolated APTT prolongation is commonly seen in patients on unfractionated heparin. Heparin can also prolong the PT/INR, and as such heparin neutralisers are added to PT/INR samples. Excess heparin (such as in heparin-locked lines) can overcome these neutralisers and produce a prolonged PT/INR.

          Past Medical History

          Hypertension and diabetes are common and important causes of chronic kidney disease, and conversely patients with chronic kidney disease are more likely to pass away due to cardiovascular disease.

          Social History

          It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.

          Transplant History

          An allogeneic stem cell transplant involves depleting a patient's bone marrow using chemotherapy, and then transfusing another (matched) patient's stem cells. This serves purposes of both replacing their haematopoietic cells with normal cells, and providing some degree of graft-vs-disease effect.

          Medication History

          Finally, ask about oxygen therapy. Patients with severe, end-stage chronic obstructive pulmonary disease or bronchiectasis may be on home oxygen, twenty-four hours a day or only intermittently.

          Social History

          Of particular importance in the cardiovascular history is a patient's diet and exercise history.

          Medication History

          Certain medications are likely to cause gastrointestinal symptoms. Opioids and oral iron supplements are particularly associated with constipation, while NSAIDs, antiplatelets and anticoagulants put patients at risk of GI bleeding. Chemotherapeutic agents are particularly associated with nausea and vomiting.

          II - Vision

          • Interpretation:
          • A
            Unilateral anopia - complete loss of vision in one eyeUnilateral optic nerve lesion or ocular pathology
          • B
            Bitemporal hemianopia - loss of lateral vision in both eyesOptic chiasmal compression
          • C
            Homonymous hemianopia - loss of left or right field in one eyeContralateral optic tract lesion
          • D/E
            Homonymous quadrantanopia - loss of the left or right upper / lower quarters of vision in both eyesContralateral upper (superior loss) or lower (inferior loss) optic radiation lesion
          • F
            Homonymous hemianopia with macular sparingContralateral occipital lobe lesion

          The Patient

          Cyanosis is a blue discolouration of the skin and mucous membranes - this may be either peripheral or central and suggests either severe hypoxia, or severe peripheral shutdown.

          Specific Gravity

          • If the urine specific gravity is increased then this reflects an inability to produce dilute urine. As a result, the urine is excessively concentrated. This may be due to:
          • Dehydration
          • Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
          • Adrenal insufficiency
          • Hypervolaemic hyponatraemia - liver cirrhosis, CCF or nephrotic syndrome
          • Glycosurea (diabetes)
          • Proteinuria (e.g. glomerulonephropathy, myeloma)

          Red Cell Size & Colour

          A macrocytic, hyperchromic anaemia refers to large red cells with loss of central pallor. This is classically a sign of megaloblastic anaemia (B12 / folate deficiency or drugs), though may also occur with myelodysplastic syndrome, alcohol abuse and severe hypothyroidism.

          Assessing Oxygenation

          As the curve shifts to the right, oxygen will more readily be released from haemoglobin. This may occur in the setting of acidaemia (low pH), hyperthermia or increase 2,3-DPG.

          Assessment of Bone

          • Bowing fracture - bending of a bone without a visible breakOccurs due to an angulated longitudinal force
          • Fissure - an incomplete cortical break without bending
          • Torus (buckle) fracture - bending of a bone with a compression fracture and outward bulging of the cortexOccurs due to axial loading
          • Greenstick (buckle) fracture - bending of a bone on one side with a crack on the opposite sideOccurs due to an angulated longitudinal force or direct perpendicular trauma

          Markers of Haemolysis

          • Haptoglobin

          • Haptoglobin is an alpha-2 glycoprotein secreted mainly by the liver. It binds plasma free haemoglobin following red cell lysis, and as such the haptoglobin level will be reduced in the presence of haemolysis (particularly intravascular haemolysis). 

          Iron Deficiency

          Iron deficiency may occur due to poor intake, poor absorption or loss of iron. The most common complication of iron deficiency is anaemia, which presents as a microcytic, hypochromic anaemia.

          Haptoglobin

          It is also an acute phase reactant, however, and haptoglobin will be increased in the presence of infection, inflammation or malignancy.

          Complications

          • Bruising

          • If blood leaks from the vein into surrounding tissue, this can result in red / purple discolouration, swelling and tenderness. If this occurs, then apply a pressure bandage to the site.

          Reservoir Systems

          The  oxygen that enters the reservoir bag is passively mixed with room air, and therefore the amount of oxygen delivered by these systems is variable depending on the patient's respiratory rate and tidal volume.

          Specimen Collection

          • Finishing Up

          Complications

          • Traumatic Insertion

          • While inserting an indwelling catheter, it is possible to damage the urethral mucosa or even perforate the urethral wall, creating a false passage.

          Identifying a Vein

          Avoid inserting a cannula into the lower limb if possible, due to the risk of deep venous thrombosis and the fact that lower limb IVCs limit mobility.

          Airway Adjuncts

          Lubricant may be used to facilitate insertion of a nasopharyngeal airway.

          Narrow Pulse Pressure

          • Causes of Narrow Pulse Pressure

          • Severe aortic stenosis
          • Severe mitral regurgitation
          • Hypovolaemia

          Splenomegaly

          Massive splenomegaly is uncommon and occurs in the setting of CML, myelofibrosis, certain lymphomas, malaria and leichmaniasis.

          Femoral Nerve Palsy

          • Causes of Femoral Nerve Palsy

          • Hanging leg syndrome - prolonged hanging of a leg over an edge e.g. off a mattress
          • Total hip replacement
          • Stretch injury

          Myotomes

          Foot inversion: tibial nerve (L4/L5)Tibialis anterior & posterior

          Spastic Gait

          • Look For

          • A poorly coordinated gait with short steps and jerky movement.
          • Look For

          • A poorly coordinated gait with short steps and jerky movement.

          Assessment of Writing

          Ask the patient to make up and write a sentence. Note whether it contains a subject and a verb.

          Spastic Gait

          • Look For

          • A poorly coordinated gait with short steps and jerky movement.

          Axillary Lymph Nodes

          Subscapular nodes - posteriorly, in front of subscapularis musclePosterior neck and chest wall

          UpToDate

          • Pros

          • Extremely comprehensive guides to medical conditions.
          • Evidence-based and peer-reviewed information.

          ANKI

          All of the various ANKI apps sync to a central database, making your flashcards available on all of your ANKIweb is the free web version, which is mobile friendly. The free ANKI desktop app is available for Windows, Mac and Linux. ANKIDroid, the Android app, is also free. ANKImobile, the iOS app, is available for a small once-off payment.

          Microsoft OneNote

          Armando Hasudungan

          • Pros

          • Free
          • Hand-drawn style is engaging and visually appealing

          Zero to Finals

          • Zero to Finals

          Smiling Mind

          • Pros

          • Free
          • Offers a range of meditation exercise types at a variety of lengths 
          • Personalized progress tracking and goal-setting

          MDCalc

          MDCalc is completely free, making it an accessible and indispensable tool for enhancing learning and decision-making in clinical scenarios.

          Life in the Fast Lane

          Types of Knowledge

          There are a wide range of resources for improving metacognitive knowledge. This may include reading articles (such as this one!) and other written resources, practicing mindfulness and reflecting on past situations.

          Setting Yourself Up for Success

          If you're writing notes digitally, consider using a bad font such as Comic Sans or Bodoni MT - two studies suggested that using such fonts improves recall. This is thought to be due to the difficulty of reading the notes, resulting in more mental work and more active attention.

          Understand the Big Picture

          Before delving deep into the details of a topic, ensure that you understand the overall structure and key topics first. Once you comprehend the underlying 'architecture' of a topic it will be much quicker to fit in the details around this and understand how everything fits together.

          Be Present on the Wards

          It may seem like the ward round is the most important part of being on the ward - seeing the patients, understanding their cases, finding out management plans and writing notes. However, the time after the ward round is when you’ll really have the opportunity to practice your clinical skills.

          Strategies for Using Flashcards

          Now that you’ve created effective flashcards, it’s time to start putting them to use. There are several strategies you can use to optimise your study time and improve your recall of information using flashcards.

          Tips for Taking Notes

          If possible - and particularly while taking notes digitally - try to have a central repository of notes and continually add to it, rather than having a separate note for each lecture or study section. This will mean that you can build on what you learned previously, and just have one place to go to review a concept - rather than many separate notes with overlap. Separate these by body system, specialty, chapter or whatever makes most sense.

          Postural Tachycardia

          • How To Elicit

          • Measure the heart rate with the patient lying down, and then remeasure it after the patient has been standing for one minute.

          Spastic Gait

          • Look For

          • A poorly coordinated gait with short steps and jerky movement.

          Postural Tachycardia

          • Interpretation

          • Postural tachycardia is present if there is a rise of >20bpm following standing.

          Festinating Gait

          Festinating gait may be caused by Parkinson's disease or other causes of parkinsonism.

          Upper Limb Myotomes

          Phalange extension: radial nerve (C7)Extensor digitorum

          Axillary Lymph Nodes

          Lateral nodes - lateral aspect of armpitMedial hand, forearm and arm

          Festinating Gait

          Festinating gait may be caused by Parkinson's disease or other causes of parkinsonism.

          Narrow Pulse Pressure

          • Causes of Narrow Pulse Pressure

          • Severe aortic stenosis
          • Severe mitral regurgitation
          • Hypovolaemia

          Aetiology of Coagulopathy

          Prolongation of INR (and often APTT) is commonly seen in liver disease, and this should be considered as a cause of coagulopathy depending on the patient's risk profile, past medical history, examination and other relevant investigations. It is important to note that the INR does not correspond to the coagulative status of patients with liver disease, and most often these patients are also coagulopathic.

          Substem B (Origin)

          -u-: human
          -u-: human

          Management

          Multiple myeloma must be referred to a haematologist for management.

          Diagnosis

          In patients with a massive pulmonary embolus, an echocardiogram may be useful to assess for right ventricular dilatation, strain and ventricular wall hypokinesis. Thrombi are rarely seen on transthoracic echo.

          Management

          • Pearls

          • Smoking cessation has the greatest ability to influence the course of COPD
          • Tailor pharmacologic options to the severity of disease
          • Ensure that the patient has an exacerbation management plan in place
          • Dietary Changes

          • The suggested iron intake for adult males and postmenopausal females is 8mg daily, while the suggested intake for menopausal women is 18mg daily. In pregnancy this increases to 27mg daily.

          Approach to Diagnosis

          Hepatitis B core IgM is also sometimes ordered when the anti-HBc is positive; a high titre of anti-HBc IgM is suggestive of acute infection and is useful for distinguishing acute and chronic hepatitis B.

          High Anion Gap Metabolic Acidosis

          The Gap-Gap Ratio can be used to determine whether the high anion gap metabolic acidosis is the sole cause of the patient's metabolic acidosis, or if there is a coexistant normal anion gap metabolic acidosis.

          Cardiac Resynchronisation Therapy (CRT)

          • Example

          • A cardiac resynchronisation therapy (CRT) device without a defibrillator lead: PA film.
          • No Overlay
            Overlay
            A cardiac resynchronisation therapy (CRT) device without a defibrillator lead PA film.
             

          Vascaths

          • A non-tunnelled vascath at the cavoatrial junction
          • No Overlay
            Overlay
            A non-tunnelled vascath at the cavoatrial junction
             

          Advanced 2nd Degree Heart Block

          • Advanced 2nd Degree Heart Block
             

          Neutropaenia

          • Neutropaenia
             

          Plasmacytoid Lymphocytes

          The presence of Türk cells in peripheral blood is usually reactive, however they may be present in patients with Waldenstrom's macroglobulinaemia.

          Elevated TSH with Normal T4

          • Pearls

          • Ask about symptoms of hypothyroidism
          • Take a careful medication history
          • Ask about recent illnesses

          P Wave Morphology Due to an Atrial Rhythm

          • P Wave Morphology Due to an Atrial Rhythm
             

          Torsade de Pointes

          • Torsade de Pointes
             

          Atypical RBBB

          • Atypical RBBB

          Beta Globulins

          • Causes of Elevated Beta Globulins

          • Iron deficiency anaemia
          • Hypothyroidism
          • Cushing's
          • Biliary obstruction
          • Polyarteritis nodosa

          Inferior Myocardial Infarction

          Inferior myocardial infarctions tend to occur due to occlusion of the right coronary (RCA) or, less commonly, the distal left circumflex (LCx) artery.

          UpToDate

          • Cons

          • Expensive subscription cost.
          • Information may be too comprehensive for some users.
          • User interface can be difficult to navigate.

          ANKI

          A common comment about ANKI (particularly the iOS app) is the outdated interface, which may feel clunky at times. While the interface and fine-grained settings can be difficult to get used to, the payoff is massive and therefore ANKI is a top option for medical students anywhere.

          Evernote

          • Platforms

          • Mac, iOS, Android, Windows, web

          Armando Hasudungan

          • Cons

          • Not as comprehensive as other resources
          • Has more of a focus on basic concepts

          Zero to Finals

          • Pros

          • Free
          • Concise and engaging videos with clear explanations
          • Additional content available - podcasts, questions, flashcards, notes, books

          Smiling Mind

          • Cons

          • Not as much variety as other mindfulness apps

          MDCalc

          • Pros

          • Extensive collection of hundreds of calculators.
          • Interpretation and creator information for each tool.
          • Free.

          LearnTheHeart by Healio

          • Platforms

          • Web

          Learning Styles

          • Classically, the idea has been that people learn in a particular way - they have a "learning style" that works for them. The learning styles most commonly mentioned are:
          • Visual - use of images, graphic organisers, learning maps etc.
          • Auditory - listening and speaking, particularly in lectures and group discussions
          • Reading / writing - note-taking, reading, extended writing
          • Kinesthetic - hands-on learning, or learning by doing

          Setting Yourself Up for Success

          • Avoid Distractions

          • It can be tempting to multitask while studying - talking to friends, checking social media or watching a video. However, dividing attention significantly reduces our ability to recall information. In a study of forty-eight undergraduate students, accuracy of recall in a standard recognition test was reduced if the memory test was taken while simultaneously performing another task. This means that when trying to learn information, it is best to be in an environment free of distractions, focusing only on the task at hand.

          Understand the Big Picture

          Good ways of quickly gauging the overall structure are by reading the objectives at the start of lecture slides, or checking the table of contents of a textbook.

          Be Present on the Wards

          • Be Present on the Wards

          Strategies for Using Flashcards

          • Use Spaced Repetition

          • Spaced repetition is a technique that involves rechallenging yourself to recall a concept at specific intervals. By reviewing information multiple times at spaced intervals (as opposed to multiple times in the same session) you will strengthen your overall recall. This is based on the Ebbinghaus forgetting curve, which illustrates that we retain less and less information as time goes by; we can increase the amount of information retained by repeatedly challenging ourselves with the same material at times when we are about to forget it.

          Tips for Taking Notes

          • Close the Loop

          • If you miss something or don't fully understand something while taking notes, leave yourself a reminder to come back and fill it in later. If you're writing paper notes, leave some space to fill in this information.

          Past Medical History

          • Other Important Conditions

          • Certain other medical conditions may predispose patients to renal disease. This includes autoimmune conditions such as systemic lupus erythematosus and scleroderma; it also includes conditions associated with an excess of light chains, such as plasma cell myeloma and AL amyloidosis.

          Social History

          Patients with neurologic disease may be significantly functionally impacted by their disease.

          Medication History

          Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.

          Family History

          Ask about whether any conditions run in the family. In particular, ask about family history of atopy - eczema, food allergies, allergic rhinitis and asthma. 

          Social History

          When taking a nutritional history, ask about the number of meals the patient eats per day, any snacking in between, and what they would eat on a usual day. This can provide valuable information about a patient's cardiovascular risk, particularly in an obese or diabetic patient.

          Family History

          Ask about any medical conditions that may be known in the family.

          II - Vision

          • Central Visual Fields

          • Assess the central visual fields by asking the patient to cover on eye, and moving a red examination pin from lateral to medial. Ask the patient when they see the pin as red, and ask if it disappears at any time.

          The Patient

          • Fluid Status

          • Assess whether the patient is dehydrated, euvolaemic or fluid overloaded.

          Specific Gravity

          • If the urine specific gravity is reduced, this reflects an inability to concentrate urine. As a result, the urine is excessively diluted. This may be due to:
          • Polydipsia (excessive fluid consumption)
          • Diabetes insipidus
          • Pyelonephritis
          • Acute tubular necrosis

          Red Cell Size & Colour

          • Red Cell Distribution Width

          • Red cell distribution width (RDW) is the amount of variation in red blood cell size. Cells may be relatively uniform in size and have a low RDW, or have a wide range of sizes and have a high RDW.

          Assessing Oxygenation

          • Taking the FiO2 into Account

          • The PaO₂ on an arterial blood is only relevant for assessing for hypoxia when the patient is on room air.  If they are receiving supplemental oxygen this will artificially increase the PaO₂ which may appear normal. 

          Assessment of Bone

          Markers of Haemolysis

          A reduced haptoglobin may also occur in the context of liver disease due to reduced production. As haptoglobin is an acute phase reactant, it may be increased in infection, inflammation, malignancy or trauma.

          Fibrinogen

          Fibrinogen is a coagulation factor that is converted to fibrin and is essential for the formation of a clot. Inflammation and coagulation are tightly linked, and as such the fibrinogen level will rise in the presence of acute inflammation.

          Complications

          Bruising can be prevented by inserting the needle into the vein on the first attempt; by avoiding multiple attempts at the same site; and by applying pressure on removal of the needle.

          Reservoir Systems

          These systems are used acutely in severely hypoxic patients. They should not be used for more than a few hours as they do not supply humidified air and can cause dehydration of the upper airway.

          Troubleshooting

          Likely CauseWhat to Do
          No flashbackNeedle not in the arteryInsert the needle slightly deeper, or withdraw slightly and reattempt at a slightly different angle
          Needle is not self-fillingMay be a venous sampleWithdraw and try again
          HaematomaNeedle not in the arteryWithdraw and put pressure on the area for at least five minutes

          Complications

          Clinical features of traumatic insertion include haematuria (blood in the urine bag) or urinary retention due to clots.

          Identifying a Vein

          • Difficulty Finding a Vein

            If you are having trouble finding a vein, certain methods can assist. These include:
          • Asking the patient to pump their fist
          • Warm the area using a blanket or heat pack
          • Tap the area repeatedly
          • Hang the limb over the bed
          • Use an ultrasound (this requires extra training)
          • Use a vein viewer, if available

          Airway Adjuncts

          Nasopharyngeal airways are contraindicated in patients with suspected nasal / base of skull fracture, and patients who are actively bleeding from the nose.

          Widened Pulse Pressure

          Increased difference between the systolic and diastolic blood pressure

          Ascites

          • Shifting Dullness

          • Percuss the patient's abdomen from the umbilicus to the left flank, noting where the percussion note changes from resonant to dull. Ask the patient to roll over to their left side and repeat percussion. If ascites is present the area of resonance will move at least 3cm medially.

          Myotomes

          Foot eversion: peroneal nerve (L5/S1)Peroneus longus & brevis

          Festinating Gait

          Festinating gait may be caused by Parkinson's disease or other causes of parkinsonism.
          Festinating gait may be caused by Parkinson's disease or other causes of parkinsonism.
          Festinating gait may be caused by Parkinson's disease or other causes of parkinsonism.

          Axillary Lymph Nodes

          Lateral nodes - lateral aspect of armpitMedial hand, forearm and arm

          Widened Pulse Pressure

          • Causes of Widened Pulse Pressure

          • Aortic regurgitation
          • Patent ductus arteriosus

          Ascites

          • Fluid Wave

          • Ask the patient or an assistant to apply pressure using the ulnar surface of their hand to the midline of the abdomen. Place the fingertips of one hand along the left flank and with the other hand firmly palpate the opposite flank. Ascites is present if a fluid wave is felt on the opposite side of the abdomen.

          Myotomes

          Great toe extension: deep peroneal nerve (L5)Extensor hallucis longus, extensor digitorum longus

          Festinating Gait

          • Look For

          • Quick, shuffling steps with the torso held rigid.
          • Look For

          • Quick, shuffling steps with the torso held rigid.
          • Look For

          • Quick, shuffling steps with the torso held rigid.

          Axillary Lymph Nodes

          Central nodes - within centre of axillaDrainage from pectoral, subscapular and lateral nodes

          Finishing Up

          Dispose of sharps and other waste. Remove the gloves and wash your hands.

          Risk Stratification

          The Well's Criteria are used to stratify risk of PE based on risk factors, and estimate pre-test probability of PE. 

          Management

          Patients with poor iron intake should be advised to add iron-containing foods to their diet, such as beef, chicken, fish, legumes, leafy greens and iron-fortified grains.

          Approach to Diagnosis

          • Interpretation

          • Surface antigen (HBsAg) - active (acute or chronic) infection
          • Surface antibody (anti-HBs) - vaccination or past infection
          • Core antibody (anti-HBc) - past or current infection

          Substem B (Origin)

          -xi-: chimaeric

          Postural Tachycardia

          • Causes of Postural Tachycardia

          • Autonomic dysfunction
          • Low intravascular volume - blood / fluid / electrolyte loss
          • Vasodilation - nitrates, alcohol, fever
          • Cardiac impairment
          • Chronic disease - diabetes mellitus, chronic renal failure, chronic liver disease,
          • Brain tumour - paraneoplastic syndrome

          Festinating Gait

          • Look For

          • Quick, shuffling steps with the torso held rigid.

          Upper Limb Myotomes

          Phalange abduction: T1

          Axillary Lymph Nodes

          Central nodes - within centre of axillaDrainage from pectoral, subscapular and lateral nodes

          Festinating Gait

          • Look For

          • Quick, shuffling steps with the torso held rigid.

          Widened Pulse Pressure

          A widened pulse pressure is an increased difference between the systolic and diastolic blood pressure.

          Aetiology of Coagulopathy

          Disseminated intravascular coagulation (DIC) is an important differential diagnosis in patients with prolonged PT/INR and APTT, and suspicion should be high in systemically unwell patients with coagulopathy and thrombocytopaenia.

          Substem B (Origin)

          -xi-: chimaeric

          Dialysis & Transplant History

          • Dialysis

          • Ask the patient whether they recieve peritoneal dialysis or haemodialysis. Generally start by asking how long the patient has been on dialysis and what the indication for commencing it was (e.g. symptoms).

          Substance History

          Take a detailed smoking history: identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable. 

          Family History

          Patients with cystic fibrosis (autosomal recessive) or alpha-1 antitrypsin deficiency (autosomal co-dominant) often report family members with the disease.

          Social History

          In assessing a patient's exercise history, ask about the amount of time they spend exercising as well as what type of exercise they perform. A sedentary lifestyle is a strong risk factor for cardiovascular disease.

          Family History

          In a patient with GI bleeding or systemic symptoms such as fevers, lethargy and weight loss, always ask about family history of cancer. Gastrointestinal malignancies include oesophageal, gastric, pancreatic and colorectal cancers.

          II - Vision

          • Colour Vision

          • In certain instances, colour vision can be assessed using Ishihara plates. There are several types of plates that may be used to differentiate between types of colour vision loss.

          The Patient

          Dehydration occurs in the setting of poor oral intake or fluid loss (e.g. due to diarrhoea, vomiting, sweating or diuresis). Signs of dehydration include tachycardia, poor urine output, dry mucous membranes and reduced skin turgor.

          Leukocyte Esterase

          Leukocyte esterase (LE) is an enzyme produced by white blood cells. Its presence in urine is indicative of an increase in leukocytes in urine, also known as pyuria. This classically indicates urinary tract infection, however can also occur in the presence of renal or urinary tract inflammation, neoplasia, irradiation or foreign body.

          Red Cell Size & Colour

          An elevated RDW is referred to as anisocytosis, and indicates that red blood cells are a wide range of sizes. This can suggest a developing microcytic / macrocytic pathology such as early iron, B12 or folate deficiency; it may also be seen in haemolysis or following blood transfusion.

          Assessing Oxygenation

          PF Ratio =
          PaO2₂FiO₂

          Assessment of Bone

          • Assessment of Bone

          Markers of Haemolysis

          • Lactate Dehydrogenase

          • Lactate dehydrogenase (LDH) is an enzyme present in the cytoplasm of most cells that catalyses the conversion of lactate to pyruvate. 

          Iron Deficiency

          • Causes

          • Blood loss is the most concerning cause of iron deficiency, most commonly due to menstrual or gastrointestinal loss. Poor iron intake is a common cause of deficiency, and less commonly deficiency can be caused by malabsorption. Iron deficiency may occur in late pregnancy, though the most common obstetric cause of anaemia is haemodilution.

          Erythrocyte Sedimentation Rate

          The erythrocyte sedimentation rate (ESR) is a measure of the number of red bloods cells that precipitate in a tube over an hour. ESR is a surrogate for the fibrinogen, as erythrocyte sedimentation occurs in the context of hyperfibrinogenaemia.

          Timing of Collection

          • Therapeutic Drug Monitoring

            If the blood is being collected to measure a drug level, Find out when the patient took the last dose of the drug in question and determine the best time to take the blood level.
          • Trough levels - take the blood just prior to the next dose (do not withhold the dose while you wait for the result unless you're concerned that it's too high)
          • Peak levels - find out the optimal time to take the sample depending on the drug
          • Area under the curve (e.g. gentamicin) - consult guidelines and take blood at two set points following drug administration

          Reservoir Systems

          • Partial Rebreather Mask

          • A partial rebreather mask includes a reservoir bag, allowing for higher amounts of entrained oxygen. Unlike a non-rebreather mask, they do not contain an exhalation port and therefore the patient will rebreath some of their expired gas.

          Complications

          • The potential complications of arterial blood gas collection include:
          • Haemorrhage / haematoma formation
          • Distal ischaemia
          • Nerve damage
          This can be prevented by using adequate lubrication, and inserting the catheter gently - don't push too hard against resistance.

          IVC Insertion

          • Introduction

          Advanced Airway Interventions

          • Bag-Valve-Mask

          • The bag-valve-mask system is a self-inflating device that is able to deliver high-flow oxygen, expiratory pressure and inspiratory pressure.

          High Anion Gap Metabolic Acidosis

          Cardiac Resynchronisation Therapy (CRT)

          • A cardiac resynchronisation therapy (CRT) device without a defibrillator lead: lateral film
          • No Overlay
            Overlay
            A cardiac resynchronisation therapy (CRT) device without a defibrillator lead lateral film
             

          Vascaths

          • A tunnelled vascath
          • No Overlay
            Overlay
            A tunnelled vascath
             

          3rd Degree AV Block

          Complete atrioventricular block represents complete failure of conduction between the atria and ventricles.

          Neutropaenia

          Neutropaenia confers increased risk of infections - particularly bacterial and fungal - and fevers in these patients (febrile neutropaenia) are medical emergencies that require prompt investigation and treatment.

          Normal / Elevated TSH with Elevated T4

          A normal or elevated TSH with an elevated T4 is classically suggestive of central hyperthyroidism (a TSH-secreting tumour), however this is a rare disease and consideration should be given to other causes.

          P Wave Morphology Due to an Atrial Rhythm

          Multifocal atrial tachycardia (MAT) - an irregularly irregular narrow complex tachycardia with at least three different P wave morphologies and variable PP intervals, with an isoelectric baseline.

          Torsade de Pointes

          • Causes of Prolonged QT

          • Congenital

          • LQTS1 (triggered by exercise)
          • LQTS2 (triggered by stress and loud noises)
          • LQTS3 (triggered by sleep)
          • Others - LQTS4-6, Jervell and Lange-Nielsen syndrome
          • Drugs

          • Antiarrhythmics - amiodarone, sotalol, procainamide, quinidine
          • Antidepressants - amitryptiline, dothiepine, citalopram, escitalopram
          • Antipsychotics - risperidone, haloperidol, clozapine, droperidol, chlorpromazine
          • Antiemetics - ondansetron, domperidone
          • Macrolides - azithromycin, clarithromycin, erythromycin
          • Quinolones - ciprofloxacin, moxifloxacin
          • Antifungals - fluconazole, ketoconazole
          • Antimalarials - chloroquine, mefloquine
          • Anaesthetic gases - halothane, sevoflurane
          • Methadone
          • Others

          • Hypokalaemia
          • Hypomagnesaemia
          • Hypocalcaemia
          • Severe hypothermia
          • Severe bradycardia - sick sinus syndrome, complete heart block
          • Cardiovascular disease - tako-tsubo cardiomyopathy, MI, CCF
          • Cerebrovascular disease - intracranial / subarachnoid haemorrhage, stroke
          • Hypothyroidism

          Atypical RBBB

          • Atypical RBBB

          Beta Globulins

          • Causes of Decreased Beta Globulins

          • Malnutrition

          Inferior Myocardial Infarction

          Inferior MIs may be associated with lateral, posterior or right ventricular infarction.

          ANKI

          • ANKI

          Evernote

          • Cost

          • Limited free version, with premium available for $9.99 per month

          Zero to Finals

          • Cons

          • Limited depth of coverage compared to other resources

          MDCalc

          • Cons

          • Potential information overload - the large number of tools may be overwhelming.

          LearnTheHeart by Healio

          • Cost

          • Free with ads

          Learning Styles

          The concept of learning styles has more modernly come to be thought of as a "neuromyth". In a study of self-identified 'verbalisers' and 'visualisers', participants felt that they performed better when using their preferred study method (word pairs or picture pairs), when in fact there was no difference in objective performance regardless of whether a participant's identified learning style matched the learning style they used (Knoll). 

          Setting Yourself Up for Success

          • Take Breaks

          • Focused study time is the time that we spend in the books, actively studying and testing yourself. In order to consolidate memories, we also need 'diffuse' study time - this is time that we spend taking breaks and allowing our mind to be idle. It is during this idle time that the brain is able to make connections between pieces of information, log ideas into memory, and create new insights. By focusing for too long our ability to lay down new memories can be adversely affected.

          Learn in Short Bursts

          Traditionally, the approach to study has been to study for long hours and attempt to absorb as much information as possible during a set period of time - this is known as a focused study mode.

          Be Present on the Wards

          If you stick around and show that you’re interested, there will be plenty of opportunities to take blood, insert cannulae and watch advanced procedures like lumbar punctures or bone marrow biopsies. On rural rotations or in the emergency department, you may also get a chance to try procedures like suturing.

          Strategies for Using Flashcards

          • Strategies for Using Flashcards

          Tips for Taking Notes

          • Put Your Notes to Work

          • Don't write notes and then never revisit them again! The purpose of note-taking is to have something to return to, reread and text yourself on.

          ANKI

          • Pros

          • Versatile and customisable
          • Uses spaced repetition
          • Sync cards between all of your devices
          • Most apps are free (except iOS)

          Evernote

          • Evernote

          Zero to Finals

          TickTick

          • Platforms

          • Web, Windows, OSX, iOS, Android

          LearnTheHeart by Healio

          • LearnTheHeart by Healio

          Learning Styles

          In another study of 426 anatomy students, self-identified learning styles and actual learning strategies were often misaligned, and there was no difference in learning outcomes when the learning strategies aligned with learning styles (Hussmann).

          Setting Yourself Up for Success

          Consider using the pomodoro technique - focused studying for twenty-five minutes, followed by a five-minute break. During the break, reward yourself with something small, such as a snack, song, video or moment of mindfulness. This cycle can be repeated, using a timer to ensure that you keep to the schedule.

          Learn in Short Bursts

          There has been a switch in thinking over the past decade, and it is now felt that taking breaks is just as important as focused study. These breaks, known as diffuse mode, have important effects on comprehension and retention of information by allowing the brain (in neutral gear) to form connections between pieces of information. As a result, new insights can appear that may not have otherwise materialised.

          Be Present on the Wards

          The opportunities for procedural practice on different wards vary, and so it is important to find out what opportunities are typically available for medical students on the rotation you’re currently on.

          Strategies for Using Flashcards

          • Test Yourself in Both Directions

          • To solidify your understanding, try testing yourself using flashcards in both directions. This means using the back of the card as the cue, and attempting to remember the cue based on the answer. By approaching the same information from a different angle, you can improve your overall comprehension of the concept and identify areas where you may need further review.

          Tips for Taking Notes

          Having said that, don't just read your notes over and over again hoping to remember more with each repetition. A study in Science magazine showed that students who practiced repeated study material performed inferiorly to those who underwent repeated testing.

          The Motor Pathway

          Upper Motor Nucleus
          Primary motor cortex (precentral gyrus)
           
          Central Pathway
          Corticobulbar tract
          (via cerebral peduncle)
          Decussation
          Medullary Pyramids
          Spinal Pathway
          Lateral corticospinal tract
           
          Lower Motor Nucleus
          Ventral horn at the level of entry into the spinal cord
           
          Neuromuscular Junction
           
           
          Muscle

          Axillary Lymph Nodes

          Infraclavicular nodes - below distal aspect of clavicleLateral hand, forearm and arm

          Short Leg Gait

          A short leg gait may occur in the context of any condition in which one leg is shorter than the other.

          Widened Pulse Pressure

          There is no set reference range for pulse pressure, and this should be taken in the context of the individual patient.

          Aetiology of Coagulopathy

          Factor deficiencies and the presence of specific factor inhibitors are less common and may cause prolonged INR, APTT or both. Hereditary factor deficiencies include haemophilia A (factor VIII) and haemophilia B (factor XI)

          Substem B (Origin)

          -xizu-: chimaeric / humanized hybrid

          Postural Hypotension

          • How To Elicit

          • Measure the blood pressure with the patient lying down, and then remeasure it after the patient has been standing for one minute.

          Ascites

          • Causes of Ascites

          • Liver cirrhosis
          • Heart failure
          • Constrictive pericarditis
          • Peritonitis - tuberculous, neoplasmic, bacterial
          • Hypoalbuminaemia - nephrotic syndrome, malnutrition
          • Pancreatitis
          • Cancer - liver, stomach, pancreas, adrenals, gut
          • Thrombosis - portal vein, mesenteric vessels
          • Ovarian disease
          • Hypothyroidism
          • Peritoneal dialysis

          The Motor Pathway

          Upper Motor Nucleus
          Primary motor cortex (precentral gyrus)
           
          Central Pathway
          Corticobulbar tract
          (via cerebral peduncle)
          Decussation
          Medullary Pyramids
          Spinal Pathway
          Lateral corticospinal tract
           
          Lower Motor Nucleus
          Ventral horn at the level of entry into the spinal cord
           
          Neuromuscular Junction
           
           
          Muscle

          Short Leg Gait

          A short leg gait may occur in the context of any condition in which one leg is shorter than the other.
          A short leg gait may occur in the context of any condition in which one leg is shorter than the other.
          A short leg gait may occur in the context of any condition in which one leg is shorter than the other.

          Axillary Lymph Nodes

          Infraclavicular nodes - below distal aspect of clavicleLateral hand, forearm and arm

          Finishing Up

          Document the cannula insertion including the date, site, the cannula gauge and the number of attempts.

          Risk Stratification

          Management

          Certain vitamin C-rich foods such as fruits, potatoes, cauliflower and cabbage enhance the absorption of iron and should also be encouraged.

          Phases of Infection

          In patients with active hepatitis B infection, further tests are available for determining the phase and severity of infection.

          Short Leg Gait

          A short leg gait may occur in the context of any condition in which one leg is shorter than the other.

          Vascaths

          • Indications for Vascath

          • Dialysis
          • Plasmapheresis

          3rd Degree AV Block

          • Look For

          • Complete dissociation of P waves and QRS complexes.

          Neutropaenia

          • Severity of Neutropaenia

          • Mild: 1.0 - 1.5 x 10⁹/L
          • Moderate: 0.5 - 0.9 x 10⁹/L
          • Severe: <0.5 x 10⁹/L

          Normal / Elevated TSH with Elevated T4

          • Causes of Normal / Elevated TSH with Elevated T4

          • TSH secreting pituitary tumour
          • Thyroid hormone resistance
          • Acute psychiatric illness
          • Drugs - amiodarone, heparin
          • Familial dysalbuminaemic hyperthyroxinaemia
          • Assay interference

          Overview

          ST elevation can be used to localise a cardiac lesion, while ST depression cannot.

          P Wave Morphology Due to an Atrial Rhythm

          • P Wave Morphology Due to an Atrial Rhythm
             

          Atypical RBBB

          • Atypical RBBB

          Gamma Globulins

          Represents serum immunoglobulins IgG, IgM, IgA, IgD and IgE.

          Inferior Myocardial Infarction

          On an electrocardiogram, leads II, III and aVF are the inferior leads and these tend show signs of infarction in inferior MI.

          Substem B (Origin)

          -xizu-: chimaeric / humanized hybrid

          Dialysis & Transplant History

          Peritoneal dialysis (PD) may be performed as continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). Ask about the patient's access (Tenckhoff catheter) and whether they have had any issues with it in the past; ask about how much fluid is removed and how often. Ask about any complications they have had in the past, such as PD peritonitis.

          Substance History

          Ask about alcohol intake: how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.

          Medication History

          Family History

          Ask about a family history of cancer, and particularly lung cancer - how old at the time of diagnosis and whether they were a smoker.

          Substance History

          Smoking is a major risk factor for atherosclerotic disease. Ask about how long a patient has smoked for, how many cigarrettes they smoke per day, and how long since they quit (if appropriate).

          Family History

          In patients with jaundice / unexplained liver disease, ask about a family history of haemochromatosis, Wilson's disease and alpha-1 antitrypsin deficiency.

          II - Vision

          The Patient

          Fluid overload may occur in the context of several conditions including, heart failure, renal failure, liver cirrhosis, SIADH, pregnancy or simply due to excessive IV fluid administration. Signs of fluid overload include bounding pulses, raised JVP, pulmonary crepitations and pitting oedema.

          Nitrites

          Bacteria convert nitrates into nitrites within urine, and therefore the presence of nitrites within urine is highly suggestive of (usually gram negative) bacterial urinary tract infection.

          Reticulocytes

          Reticulocytes are non-nucleated immature red blood cells. They are not normally present in the circulation in high numbers, though may be seen if the bone marrow is producing large numbers of red cells.

          Assessing Oxygenation

          The PF ratio is an assessment of PaO2₂ taking into account the FiO₂ - correcting for this discrepancy. If the PaO₂ divided by the FiO₂ is <400, then this suggests that the patient's oxygenation is insufficient despite the oxygen they are recieving.

          Assessment of Bone

          • Displacement - dorsal (posterior), volar (anterior) or lateral displacement of the distal fragment with respect to the proximal fragment.
          • Shortening - overlapping of fracture ends
          • Angulation - the angle created between the distal fragment and the proximal fragment due to the fracture.
          • Rotation - of the bone along its long axis

          Markers of Haemolysis

          It is a non-specific marker of cell damage affecting any tissue, and is elevated in haemolysis. Other causes of elevated lactate dehydrogenase include infarction of any kind, malignancy, cirrhosis, trauma, shock and hypoxia.

          Iron Deficiency

          • Manifestations

          • Patients may present with symptoms of anaemia, such as fatigue and lethargy. A particular symptom that occurs in iron deficiency is pica, which is a craving of non-foods such as chalk and dirt. Patients may also report a history of bleeding: heavy menstrual periods, GI blood or recent trauma.

          Erythrocyte Sedimentation Rate

          An elevated ESR is classically used as a marker of chronic inflammation.

          Timing of Collection

          • Fasting Samples

          • For glucose levels or glucose tolerance testing, the patient should fast for 8-10 hours prior to blood collection.

          Reservoir Systems

          FlowFiO₂
          7 L/min~0.65
          8-10 L/min~0.80

          Complications

          • Haemorrhage / Haematoma formation

          • Due to the high pressure within arteries, there is a high risk of bleeding or bruising around the site. 
          • Urinary Tract Infection

          • Catheterisation, and particularly long-term catheterisation, is associated with infection - this may manifest as cystitis, pyelonephritis or sepsis.

          IVC Insertion

          • Preparation

          Advanced Airway Interventions

          A bag-valve-mask system may be used with an oropharyngeal or nasopharyngeal airway in situ, to aid in opening the airway.

          Dialysis & Transplant History

          Haemodialysis (HD) may be performed in-centre or at home. Ask about their access (vascath, AV fistula or graft), how often they are dialysed, and their dry weight.

          Substance History

          Finally, ask about recreational drug use, and particularly intravenous drug use. 

          Family History

          Ask about a family history of haematologic malignancy, such as AML, ALL, CML, CLL, myeloma or lymphoma.

          Social History

          It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.

          Substance History

          Ask about alcohol intake, as alcohol is an important risk factor for hypertenion, dilated cardiomyopathy and atrial fibrillation. Ask how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.

          Family History

          In patients with suspected inflammatory bowel disease or coeliac disease, ask about a family history of autoimmune conditions. This may include IBD, rheumatoid arthritis, systemic lupus erythematosus or multiple sclerosis.

          II & III - Pupils

          The optic nerve (II) provides the sensory pathway of the pupillary reflexes, interfacing with the Edinger-Westphal nucleus within the midbrain, with the oculomotor nerve (III) providing the motor pathway.

          Hands

          • Clubbing

          • Look at the digits for evidence of clubbing, or enlargement of the distal segments of the fingers / toes. This is classically associated with respiratory pathology such as cancer or chronic lung infection, though may also occur with cyanotic congenital heart disease and liver cirrhosis.

          Blood

          A urine dipstick is able to detect urinary haemoglobin (free or within red cells) as a surrogate for blood. A positive dipstick for blood means one of three things: blood (haematuria), haemoglobin (haemolysis) or myoglobin (rhabdomyolysis).

          Reticulocytes

          Elevated reticulocytes are indicative of compensatory erythropoiesis due to haemolysis, recovery from anaemia or increased red blood cell requirement. Near absence of reticulocytes is caused by bone marrow suppression, such as due to aplastic anaemia or cytotoxic chemotherapy.

          Assessing Oxygenation

          • The A-a Gradient

          • The alveolar-arterial gradient is a comparison of the partial pressure of O₂ in the alveoli and in arterial blood. The alveolar O₂ partial pressure (PAO₂) is calculated using the following simplified equation:

          Assessment of Bone

          • Soft Tissue Involvement

          • Look for obvious protrusion of bone through the soft tissues, or air within the soft tissues. 

          Markers of Haemolysis

          • Reticulocytes

          • Elevated reticulocytes are non-nucleated immature red cells. Reticulocytosis (elevated reticulocytes) is indicative of increased erythropoiesis; this may be due to haemolysis, though may also be present following recovery from anaemia or in the context of an increased red blood cell requirement.

          Iron Deficiency

          Examination findings include conjunctival pallor, pallor of the nail beds and hand creases, as well as tachycardia. A sign specific to iron deficiency is koilonychia, or spoon-shaped nails.

          Caeruloplasmin

          Caeruloplasmin is a copper-containing protein that may be measured for use as an inflammatory marker, however it is very uncommonly used in this fashion.

          Timing of Collection

          For triglyceride testing (fasting lipids), the patient should fast for 10-12 hours prior to collection.

          Reservoir Systems

          • Non-Rebreather Mask

          • A non-rebreather mask includes a reservoir bag and an exhalation port - preventing gas from being reinspired. This requires a tight seal over the patient's face.

          Complications

          In order to prevent bleeding, place pressure on the insertion site for 3-5 minutes once the needle is removed. Avoid performing an ABG on a patient with a coagulopathy where possible, or consider reversing anticoagulation / withholding it and waiting. 
          The catheter acts as a bridge for ascension of bacteria into the bladder; and residual urine within the bladder increased the risk of infection. Biofilms may develop which make the infection more difficult to eradicate.

          IVC Insertion

          • Insertion

          Advanced Airway Interventions

          • Intubation

          • If the patient requires intubation, this should be performed by a highly trained member of staff with appropriate planning, monitoring and pre-medication.

          Prevention

          Prevention of pulmonary embolism is as per deep venous thrombosis, with chemoprophylaxis and/or mechanical prophylaxis. See the deep venous thrombosis page for more information.

          Management

          Certain foods inhibit iron absorption, and these should be either consumed in moderation or timed to not coincide with meals in order to maximise absorption. Examples include phytates in cereals, nuts and seeds; tannins (iron binders) in tea, coffee an cocoa; and calcium found typically in dairy products.

          Phases of Infection

          The immune tolerant phase of hepatitis B infection is seen in very early infection and indicates active viral replication with no immune response. Most patients will progress to the immune active phase almost immediately, though some children infected with hepatitis B at birth will remain in the immune tolerant phase for many years. Hepatitis B DNA (HBV DNA) is a qualitative marker of viral replication, with high titres during the immune tolerant phase. The hepatitis B e-antigen (HBeAg) corresponds to infectivity and will be positive in this early phase of infection.

          Substem B (Origin)

          -zu-: humanized

          ANKI

          • Cons

          • Outdated user interface
          • Steep learning curve for beginners

          Evernote

          Evernote is a very popular note-taking app available on almost any device. It can take and organise multiple file types including PDF and powerpoint files, and has the ability to clip websites. 

          Zero to Finals

          TickTick

          • Cost

          • Free for basic features, affordable premium for everything

          LearnTheHeart by Healio

          LearntheHeart by Healio is a comprehensive online resource that offers a range of cardiology content, including ECG interpretation. The website provides high-quality images of ECGs and detailed explanations of ECG concepts, as well as interactive quizzes and case studies to help students practice their skills.

          Learning Styles

          Thinking that one learning style that suits you can lead to the development of a fixed intelligence mindset. In reality, multiple modalities should be used to learn the massive amount of information in medical school. Learning the same thing in several ways can help to improve your retention even further.

          Setting Yourself Up for Success

          • Get Enough Sleep

          • Similar to taking a break, sleeping stabilises and solidifies memories. In two studies of healthy participants, recall was greater following sleep when compared to a day of wakefulness. Additionally, sleep deprivation significantly impaired attention, short and long term memory as well as concentration.

          Learn in Short Bursts

          The best way to do this is the pomodoro technique. Set a timer for 25 minutes of focused study, and then follow this with a 5-minute break with a reward. This reward can be anything - a song, a video, a snack, or mindfulness. This cycle can then be repeated for as long as you need to study for.

          Learn Something Many Different Ways

          While you may feel immediately confident with performing a procedure, this is not always the case. As practical skills become more complicated, they often become more difficult to master. In order to build your confidence, there are several advanced approaches you can use.

          Strategies for Using Flashcards

          • Say Your Answers Out Loud

          • Reading the answers to yourself out loud can help you to stay focused while studying flashcards. Reading aloud can also help with recall: a study from the University of Waterloo demonstrated that participants recalled approximately 36% of words that they read aloud, compared to 13% of words that they read silently.

          Axillary Lymph Nodes

          Apical nodes - medially, at lateral border of 1st ribDrainage from all axillary lymph nodes

          Short Leg Gait

          • Look For

          • Dipping of the affected leg.

          Widened Pulse Pressure

          • Causes of Widened Pulse Pressure

          • Aortic regurgitation
          • Patent ductus arteriosus

          Aetiology of Coagulopathy

          • Causes of Abnormal Coagulation Profile

          • Isolated Prolonged PT/INR

          • Warfarin (low dose)
          • Mild vitamin K deficiency
          • Factor VII deficiency
          • Isolated Prolonged APTT

          • Unfractionated heparin - therapeutic or contamination
          • Overcoagulation with low molecular weight heparin
          • Factor deficiency - VIII, IX, VI, XII
          • Factor inhibitors
          • Von Willebrand disease
          • Lupus anticoagulant (antiphospholipid antibody)
          • Prolonged PT/INR and APTT

          • Artefactual - high haematocrit
          • Liver disease
          • Disseminated intravascular coagulation (DIC)
          • Common pathway deficiency - X, V, II, fibrinogen
          • Severe vitamin K deficiency
          • Excess heparin (line contamination)
          • Warfarin
          • Factor IIa inhibitors (dabigatran)
          • Factor Xa inhibitors (rivaroxaban, apixaban)

          Postural Hypotension

          • Interpretation

          • Postural hypotension is present if there is a fall of >20mmHg systolic and >10mmHg diastolic blood pressure following standing.

          Short Leg Gait

          • Look For

          • Dipping of the affected leg.
          • Look For

          • Dipping of the affected leg.
          • Look For

          • Dipping of the affected leg.

          Axillary Lymph Nodes

          Apical nodes - medially, at lateral border of 1st ribDrainage from all axillary lymph nodes

          Substem B (Origin)

          -zu-: humanized

          Tips for Taking Notes

          Therefore, the best way to put your notes to work is by using them to promote recall. If you use the outline note-taking method (i.e. you use a lot of dot points) then consider trying the split-page or Cornell methods detailed below. Further to this, use your notes to write questions and flashcards that you can then use to test yourself with

          Short Leg Gait

          • Look For

          • Dipping of the affected leg.

          Portacaths

          A portacath is a subcutaneous port with a line inserted into the subclavian vein, usually for long-term administration of medications such as chemotherapy.

          3rd Degree AV Block

          • 3rd Degree AV Block
             

          Neutropaenia

          • Aetiology

          • Acute neutropaenia is commonly caused by viral infections and certain other infectious states. Dietary deficiency, and in particular B12 and folate deficiency, can cause neutropaenia.

          AV Dissociation

          The presence of P waves that are regular are not associated with QRS complexes is highly suggestive of VT.

          Gamma Globulins

          It is important to determine whether an elevated gamma globulin band is polyclonal (generalised elevation) or monoclonal (elevation of a small part of the band).

          Inferior Myocardial Infarction

          • ECG Findings in Inferior Myocardial Infarction

          • ST elevation in at least 2 inferior leads (II, III, aVF)
          • ST depression in aVL
          • Q waves in II, III and aVF

          Portacaths

          • Example

          • A portacath inserted for chemotherapy in a patient with non-small cell lung cancer
          • No Overlay
            Overlay
            A portacath inserted for chemotherapy in a patient with non-small cell lung cancer
             

          Neutropaenia

          Bone marrow pathologies tend to cause pancytopaenia more commonly than isolated neutropaenia, as does cytotoxic chemotherapy. Other medications may cause dose-related or idiosyncratic neutropaenia.

          AV Dissociation

          • AV Dissociation
             

          Lateral Myocardial Infarction

          The lateral left ventricle is supplied by branches of the left anterior descending (LAD) and left circumflex (LCx) artery.

          Short Leg Gait

          • Causes of Short Leg Gait

          • Congenital short leg
          • Fracture
          • Joint disease

          Postural Hypotension

          Postural hypotension is present if there is a fall of >20mmHg systolic and >10mmHg diastolic blood pressure following standing.

          Aetiology of Coagulopathy

          • Pearls

          • Start by checking whether the patient is on anticoagulants such as unfractionated / low molecular weight heparin, warfarin, direct thrombin or factor Xa inhibitors.
          • Check the patient's haematocrit - if elevated this can falsely elevate the PT/INR and APTT.
          • Look for evidence of chronic liver disease in the history, exam and investigations.
          • Consider DIC as a differential, especially in septic patients with thrombocytopaenia
          • If unsure about the cause of abnormal coagulation profile, mixing studies can be performed to further evaluate the cause.

          Examples

          Abciximab (ab-ci-xi-mab) - chimaeric monoclonal antibody with a cardiovascular target

          Dialysis & Transplant History

          • Renal Transplant

          • The workup and management of renal transplant patients is complex and includes physical, psychological and social factors. For a more detailed guide, read our renal transplant history page.

          Family History

          Also ask about a family history of inherited haematologic disorders such as haemochromatosis, haemophilia, Von Willebrand's disease or thalassaemia.

          Social History

          Ask about occupational exposures - to asbestos, silica dust, coal-mining or industrial chemicals - as these predispose to respiratory disease.

          Hands

          Blood

          • Causes of Positive Dipstick for Blood

          • Haematuria (true blood in urine) - glomerulonephropathy, vascular pathology, polycystic kidney disease, UTI, neoplasm, renal calculus, trauma
          • Haemoglobinuria (haemolysis) - microangiopathic haemolytic anaemia, mechanical haemolysis, alloimmune haemolysis, paroxysmal nocturnal haemoglobinuria
          • Myoglobinuria - immobilisation, strenuous exercise, limb ischaemia, trauma, burns, myositis, electrolyte disturbances, drugs, inherited causes

          White Blood Cells

          Leukocytes are a variety of cells of myeloid and lymphoid lineage that perform a variety of immune functions.

          Assessing Oxygenation

          A-a gradient = ( FiO₂ x 713 ) -
          PaCO₂0.8
          - PaO₂

          Assessment of Bone

          A compound / openfracture communicates with the skin surface and is at much higher risk of complications; a simple / closed fracture does not communicate with the surface.

          Intravascular Haemolysis

          • Haemolysis may occur intravascularly or extravascularly; the latter refers to haemolysis in the spleen or liver. If intravascular haemolysis is suspected, several tests can be performed:
          • Plasma free haemoglobin - elevated
          • Urine haemoglobin - elevated
          • Urine haemosiderin - elevated

          Iron Deficiency

          Albumin

          Albumin is a negative acute phase reactant, meaning that its level will fall in the context of acute inflammation. This occurs as a result of reduced hepatic production, as well as proteolysis.

          Avoiding Confounders

          • Positioning

          • Changing from a supine to an upright position can increase haematocrit, red blood cells, white cell count, calcium, thyroxine, AST, ALP, immunoglobulins, total protein, albumin, lipids, adrenaline, noradrenaline and renin levels.

          Reservoir Systems

          FlowFiO₂
          15 L/minUp to 0.90

          Complications

          If bleeding occurs, compress the site for 3-5 minutes the place a compression bandage over the area. Observe the site, and consider reversing anticoagulation if bleeding is major.
          Clinical features of cystitis (bladder infection) include burning around the catheter, the urge to urinate, lower abdominal pain, cloudy or bloody urine, and foul-smelling urine. Pyelonephritis (kidney infection) may manifest with fevers, nausea, vomiting and flank pain.

          IVC Insertion

          • Finishing Up

          Advanced Airway Interventions

          • Indications for Intubation
          • Airway

          • Inability to maintain airway patency (upper airway obstruction) - soft tissue swelling, deformity, obesity, tongue displacement
          • Inability to protect the airway - sedation (e.g. for procedures), upper airway bleeding, excessive secretions
          • Breathing

          • Inability to ventilate - unconsciousness, sedation, neuromuscular disease, exhaustion
          • Inability to oxygenate - severe acute respiratory failure
          • Circulation

          • Cardiac arrest

          Prevention

          • IVC Filters

          • In patients with deep venous thrombosis who cannot be anticoagulated, an IVC filter may be appropriate to prevent embolism into the pulmonary vasculature. IVC filters are a temporary measure to be used until the patient becomes eligible for anticoagulation.

          Management

          • Iron Supplementation

          • Iron may be supplemented orally or with an intravenous iron infusion.

          PEPID

          • Platform

          • iOS, Android

          Evernote

          Notes can be tagged and searched easily, however there is less hierarchy - notes are organised into notebooks and there is no ability to create nested notebooks. 

          Zero to Finals

          • Zero to Finals

          Dr Najeeb Lectures

          • Platforms

          • YouTube, Website

          Insight Timer

          • Platforms

          • Web, iOS and Android.

          TickTick

          • TickTick

          LearnTheHeart by Healio

          The website is user-friendly and offers a structured learning experience that is suitable for medical students of all levels. While there is no specific iOS or Android app for LearntheHeart.com, the website is mobile-friendly and can be easily accessed on any device with an internet connection.

          Learning Styles

          Develop and use your own profile of styles, and apply different styles. Your set of styles may depend on the particular material to be learnt, your needs and the time you have available. 

          Setting Yourself Up for Success

          Naps can also be useful for consolidating connections between ideas. In one study, a 90-minute nap was associated with greater associative memory (remembering word pairs) but not item memory (remembering individual words) when compared to not taking a nap.

          Practice Recall

          Once you've finished reading about a topic or taking notes, try to recall the key points that you've learned - even just forcing yourself to remember can help to cement a concept in your mind.

          Learn Something Many Different Ways

          Learning a skill in multiple different ways has been proven to improve competence. A study from Johns Hopkins University School of Medicine found that learning a modified version of a skill resulted in better overall performance when compared to repeated practice with the same skill.

          Strategies for Using Flashcards

          • Use Flashcards with Other Study Tools

          • While flashcards are an effective learning tool, they should not be relied on alone. Use flashcards along with other tools such as lectures, reading materials, videos and practice questions to achieve a multimodal understanding of medical topics.

          Handwritten Vs Digital Notes

          • Why Handwritten?

          • While creating notes digitally is quick and efficient, you may want to consider handwriting your notes. Handwritten notes promote recall: in a study of 67 students at Princeton University, those taking written notes performed better on conceptual questions than those taking notes on their laptop.

          Short Leg Gait

          • Causes of Short Leg Gait

          • Congenital short leg
          • Fracture
          • Joint disease

          Postural Hypotension

          • Causes of Postural Hypotension

          • Reduced intravascular volume - dehydration, haemorrhage
          • Autonomic dysfunction - diabetic neuropathy, vitamin B12 deficiency, hypothyroidism, parkinsonism, amyloidosis, paraneoplastic syndrome
          • Cardiac - congestive cardiac failure, cardiomyopathy, myocarditis, constrictive pericarditis, aortic stenosis
          • Endocrine - Addison's disease, phaeochromocytoma
          • Drugs - nitrates, anticholinergics, antidepressants, antihypertensives, levodopa
          • Prolonged bed rest
          • Alcohol

          Short Leg Gait

          • Causes of Short Leg Gait

          • Congenital short leg
          • Fracture
          • Joint disease
          • Causes of Short Leg Gait

          • Congenital short leg
          • Fracture
          • Joint disease
          • Causes of Short Leg Gait

          • Congenital short leg
          • Fracture
          • Joint disease

          Examples

          Abciximab (ab-ci-xi-mab) - chimaeric monoclonal antibody with a cardiovascular target
          Adalimumab (ada-lim-u-mab) - human monoclonal antibody with an immunomodulating target

          Management

          It is important to consult local guidelines (or a haematologist) regarding the management of pulmonary embolism.
          Oral supplementation (usually with ferrous sulphate or ferrous fumarate) - this is often the first pharmacologic step. These are generally well tolerated but may cause nausea, vomiting, abdominal discomfort, diarrhoea or constipation. Patients on oral supplements should be aware that iron will cause their stools to become dark, which may mimic the appearance of malaena. 

          Examples

          Adalimumab (ada-lim-u-mab) - human monoclonal antibody with an immunomodulating target

          Neutropaenia

          Any condition that induces hypersplenism (including cirrhosis, certain infections, myeloproliferative disorders and chronic haemolytic anaemia), can cause sequestrational loss of neutrophils. Felty's syndrome is the triad of rheumatoid arthritis, splenomegaly and neutropaenia, and is associated with poorer prognosis in the RA patient. Other autoimmune conditions such as SLE may also cause neutropaenia and should be considered.

          Concordance

          Concordance, and particularly negative concordance, is highly suggestive of VT.

          Lateral Myocardial Infarction

          Isolated lateral MI is uncommon, and the lateral wall tends to be involved in anterolateral, posterolateral of inferolateral infarcts.

          Medication History

          Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.

          Social History

          It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.
          In patients with hypersensitivity pneumonitis, consider other exposures such as birds (bird-fancier's lung), spa baths (hot tub lung due to mycobacterium avium complex) or mouldy hay (farmer's lung).
          In patients with a suspected infective gastroenteritis, ask about recent travel or any recent dietary changes. 

          II & III - Pupils

          • Light Reflexes

          • Shine a light into each pupil, and watch to see that both the ipsilateral (direct response) and contralateral (consensual response) pupils constrict as a result of the stimulus. Pupillary light reflexes may be absent in certain intraocular, optic (II) nerve, midbrain, oculomotor (III) nerve pathology; it may also occur due to certain medications.

          Hands

          • Hands

          Glucose

          Urine does not normally contain glucose - it is filtered by the glomerulus but almost completely reabsorbed. Glucose may be present in urine in hyperglycaemia where the amount of serum glucose exceeds the kidney's ability to absorb it. 

          White Blood Cells

          Ref Interval
          WCCMales: 3.7 - 9.5 x 10⁹/L
          Females: 3.9 - 11.1 x 10⁹/L
          Neutrophils2.0 - 8.0 x 10⁹/L (40 - 75%)
          Lymphocytes1.0 - 4.0 x 10⁹/L (20 - 40%)
          Monocytes0.2 - 1.0; x 10⁹/L (2 - 8%)
          Eosinophils0.0 - 0.5 x 10⁹/L (1 - 4%)
          Basophils0.0 - 0.1 x 10⁹/L (0.5 - 1%)

          Assessing Oxygenation

          To see how and why this equation is simplified, read more about the A-a gradient.

          Assessment of Bone

          • Joint Involvement

          • Look for involvement of the fracture through a joint, which may be associated with joint dislocation. If a fracture involves a joint, then it is identified as intra-articular; this suggests that the fracture is unstable and unlikely to heal without surgical intervention.

          Intravascular Haemolysis

          • Plasma & Urine Free Haemoglobin

          • Haemoglobin usually resides within red blood cells, and therefore if the amount of free haemoglobin in plasma is increased then this suggests haemolysis that is occuring intravascularly. 

          Iron Deficiency

          Iron studies reveal a reduced ferritin level and reduced transferrin saturation. If a soluble transferrin receptor is ordered, this is usually increased.

          Albumin

          Important differential diagnoses for reduced albumin include malnutrition, liver disease and protein loss (nephrotic syndrome, protein-losing enteropathy, severe burns).

          Avoiding Confounders

          This is not usually sufficient to change a patient's results significantly, though wait for at least a minute after repositioning a patient before collecting blood.

          High Flow Oxygen

          High flow devices deliver an amount of gas that is sufficient to meet the patient's total minute ventilation, allowing for delivery of a precise amount of oxygen.

          Complications

          • Distal Ischaemia

          • Ischaemia of a distal limb may occur following arterial blood gas sampling. This may present with pain, pallor, pulselessness, paralysis, paraesthesia or poikilothermia.
          Catheter-associated UTIs can be prevented by inserting catheters only when clinical indicated; by rationalising the duration of the catheter; and by changing the catheter regularly if it is in long-term.

          Advanced Airway Interventions

          • The potential complications of intubation are:
          • During Insertion

          • Incorrect placement - oesophagus / bronchus
          • Trauma - teeth / oral cavity / pharynx / larynx / trachea
          • Hypoxia (due to delayed intubation)
          • While Intubated

          • Mechanical issues - tube obstruction / kinking, loss of cuff integrity
          • Infection - ventilator-associated pneumonia
          • Self extubation
          • After Extubation

          • Sore throat
          • Laryngeal / tracheal pathology - oedema, spasm, stenosis
          • Vocal cord paralysis

          Postural Hypotension

          • How To Elicit

          • Measure the blood pressure with the patient lying down, and then remeasure it after the patient has been standing for one minute.

          Mixing Studies

          Overall, the prolongation of PT/INR and/or APTT may be caused by either factor deficiencies or the presence of factor inhibitors. Mixing studies may be performed to distinguish between these two broad groups of causes.

          PEPID

          • Cost

          • $300 per year

          Evernote

          Importantly, the free version is relatively feature limited (you will use your 60MB quickly) and the premium version is rather expensive.

          Zero to Finals

          Zero to Finals was created by Dr Thomas Watchman to provide high-quality, engaging medical education videos for free. The Zero to Finals YouTube channel has many videos on a range of topics, though it is worth noting that many of the videos are about clinical medicine with less of a focus on anatomy, physiology and other medical sciences topics.

          Dr Najeeb Lectures

          • Cost

          • Many videos are available for free, with a lifetime membership available to access everything.

          Insight Timer

          • Cost

          • The free version offers quite a few meditations, though an affordable subscription is available to access everything.

          MedCalX

          • Platforms

          • iOS

          TickTick

          TickTick is a task management app that offers a sleek and intuitive design, making it easy to organize your tasks and prioritise your workload. It offers features such as task assignments, tags, sub-tasks, and reminders, allowing you to break down complex projects into actionable steps. TickTick also offers collaborative features, making it easy to share and delegate tasks with others.

          LearnTheHeart by Healio

          • LearnTheHeart by Healio

          Types of Resources

          There are many resources available to help you learn during medical school.

          Setting Yourself Up for Success

          • Get Some Exercise

          • A meta-analysis showed that acute exercise has a significant positive effect on short-term memory, while longer term regular exercise improves long-term memory. This is thought to be due to the activation of cellular signalling pathways involved in the processing of memories and partly due to the exercise-induced secretion of cathepsin B, a key protein involved in memory processing. 

          Practice Recall

          Use the Feynman technique - try to explain the topic to a twelve year-old child in your head. Use the simplest possible language, with metaphors and analogies as illustration. This will force you to focus on the key aspects of the concept. If you're not able to explain something, then take that as a trigger to go back to the source material and go over that part again.

          Learn Something Many Different Ways

          For example, you might try a slightly different suturing method, cannulating both by palpation and ultrasound, or a lumbar puncture in both the sitting and left lateral position. By altering your technique and learning it in a different way, you can start to understand the underpinning principles behind it rather than simply the mechanical steps involved.

          Handwritten Vs Digital Notes

          When writing digital notes there is a tendency to copy lecture slides verbatim, and copy and paste information 'to read later'. As a result, digital notes can be more shallow. Conversely, handwritten notes rely on summarising and synthesising information.

          PEPID

          • PEPID

          Evernote

          • Pros

          • Many useful features
          • Easy to tag and search notes

          Zero to Finals

          The diagrams in the videos look great and are easy to understand. If you visit the website you’ll find free podcasts and notes, as well as optional paid access to flashcards, books and question banks.

          Dr Najeeb Lectures

          • Dr Najeeb Lectures

          Insight Timer

          • Insight Timer

          MedCalX

          • Cost

          • Free for basic tools, subscription to unlock everything.

          TickTick

          With its cross-platform compatibility, including web, iOS, and Android, TickTick is a great choice if you need a flexible and accessible task management tool to help stay organised and productive.

          LearnTheHeart by Healio

          • Features

          • Comprehensive guide to ECG interpretation.
          • Interactive quizzes 
          • Case studies.

          Types of Resources

          • People

            While typically much of your learning will come from your medical school staff, there are many other people who you can learn from. Potential people to learn from include:
          • University staff - lecturers, tutors, facilitators
          • Medical student peers - team-based learning sessions, peer tutoring groups, shared notes
          • Hospital staff - junior doctors, nurses, allied health staff

          Setting Yourself Up for Success

          Practice Recall

          Alternatively, try to imagine that you are explaining a disease to a patient who has just been diagnosed with it.

          Learn Something Many Different Ways

          Learning several different approaches to a procedure can improve your flexibility, and is much more useful than simply practicing the same skill over and over again.

          Flashcard Platforms

          We have moved on from needing to write our own flashcards on index cards. There is now a wide variety of digital flashcard platforms that you can use for your study. Such platforms offer a range of features such as customizable flashcards, pre-made decks on medical topics, and spaced repetition algorithsm to help with memorisation. Here are five popular flashcard platforms that are particularly useful for medical students:

          Handwritten Vs Digital Notes

          When writing handwritten notes, consider using different colours to represent different types of information.

          Sodium Homeostasis

          Pressure natriuresis - increased blood volume and/or pressure will stimulate increased sodium excretion through increased glomerular filtration.

          Neutropaenia

          There are many congenital syndromes that cause chronic neutropaenia; these range from benign to severe and progressive.

          Concordance

          • Features of Concordance

          • Positive concordance - all precordial leads are positive
          • Negative concordance - all precordial leads are negative

          Lateral Myocardial Infarction

          On an electrocardiogram, leads I, aVL, V5 and V6 are the lateral leads.

          Management

          The treatment of multiple myeloma involves induction therapy, followed by autologous stem cell transplants in eligible patients. Choice of chemotherapy depends on multiple clinical factors including functional (ECOG) score, severity and whether the patient is recieving a stem cell transplant.
          • Thrombolysis

          • Patients with acute massive pulmonary embolism may be thrombolysed with tissue plasminogen activator (tPA) if they are haemodynamically unstable. There is emerging evidence that haemodynamically stable patients with evidence of right heart dysfunction may be thrombolysed, though this remains controversial.

          Pathogenesis

          A prolonged QT interval represent delayed ventricular repolarisation, and increases the risk of a re-entry circuit from forming (i.e. Torsade de Pointes).

          Management

          Iron infusions are generally reserved for patients to do not respond to oral iron supplementation. Some common formulations are ferric carboxymaltose, iron polymaltose or iron sucrose. Infusions should be dosed based on the sestimated total body iron deficit, based on the patient's body weight and serum haemoglobin. Patients recieving iron infusions should be monitored closely as they can develop allergic reactions. Consult local guidelines for further information including dosing of iron infusions.

          Examples

          Basiliximab (basi-li-xi-mab) - chimaeric monoclonal antibody with an immunomodulating target
          Basiliximab (basi-li-xi-mab) - chimaeric monoclonal antibody with an immunomodulating target

          Postural Hypotension

          • Causes of Postural Hypotension

          • Reduced intravascular volume - dehydration, haemorrhage
          • Autonomic dysfunction - diabetic neuropathy, vitamin B12 deficiency, hypothyroidism, parkinsonism, amyloidosis, paraneoplastic syndrome
          • Cardiac - congestive cardiac failure, cardiomyopathy, myocarditis, constrictive pericarditis, aortic stenosis
          • Endocrine - Addison's disease, phaeochromocytoma
          • Drugs - nitrates, anticholinergics, antidepressants, antihypertensives, levodopa
          • Prolonged bed rest
          • Alcohol

          Mixing Studies

          Mixing studies are performed by mixing the patient's plasma 50:50 with control plasma, and then measuring the PT/INR and/or the APTT.

          Medication History

          Identify potentially nephrotoxic medications such as NSAIDs, ACE inhibitors and angiotensin II receptor blockers. Older patients with chronic kidney disease may have been exposed to Bex or Vincent's powders in the early 1900s; these are both NSAIDs which have provided a significant contribution to the chronic kidney disease burden.

          Social History

          In patients with suspected venous thromboembolism, ask about recent long-haul travel - particularly long flights.

          Substance History

          A major aspect of the respiratory history is the smoking history, as smoking is associated with chronic obstructive pulmonary disease and lung cancer. Identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable).

          Social History

          In patients being worked up for liver transplant, the social history becomes an even more vital part of decision making. Such patients require a significant level of physical, social and psychological support and it is important to ensure that the patient has these in place prior to considering these interventions. This may include ensuring that they have someone to drop them off to appointments; that they are likely to take their medications regularly; and that they are unlikely to do anything that would put them at risk such as returning to alcohol.

          II & III - Pupils

          • Swinging Light Test

          • The swinging eye test is used to assess for a relative afferent pupillary defect (RAPD), a sign of an asymmetric pathology affecting the pupillary reflex pathway. Shine a light into one eye, swing it into the other eye, and so on back and forth. An RAPD is present if the affected eye dilates, or constricts briefly followed by dilatation.

          Hands

          • Capillary Refill

          • Press on the patient's nail and count how long it takes for colour to return to the nail. A prolonged capillary refill time of <2 seconds is classically a marker of poor perfusion, however this test is highly variable in adults.

          Glucose

          Glycosuria is classically a feature of diabetes, though may also occur with acute tubular necrosis, SGLT2 inhibitors (like empagliflozin), familial renal glycosuria or pregnancy.

          White Blood Cells

          Leukocytosis refers to an increase in circulating white blood cells. This may be due to infection, inflammation, malignancy or certain other conditions. Leukopaenia refers to a reduction in circulating white blood cells; this is almost always caused by neutropaenia, lymphopaenia, or both.

          Assessing Oxygenation

          • An elevated A-a gradient indicates that the partial pressure of O₂ is higher in the alveoli than in arterial blood, indicating a V/Q mismatch. This may occur due to:
          • Dead space ventilation - pneumonia, asthma, COPD, pulmonary embolismVentilation without perfusion
          • Left to right shunt - pulmonary oedema, ARDS, pneumoniaPerfusion without ventilation
          • Alveolar hypoventilation - pulmonary fibrosis, interstitial lung disease

          Assessment of Bone

          • Growth Plate Involvement

          • In children (whose bones are still growing), assess for whether the fracture involves the growth plate. Such fractures have the potential of interrupting the proliferative zone, halting bone growth. Higher grade fractures are at higher risk.

          Intravascular Haemolysis

          Similarly, this free haemoglobin will be excreted in the urine; this will result in a dipstick that is positive for blood but with no red blood cells on microscopy.

          Iron Overload

          This refers to an excess of total body iron stores. This may be due to haemochromatosis, or one of several secondary causes of iron overload.

          Avoiding Confounders

          • Stress

          • Emotional stress can cause a transiently elevated white cell count, cortisol and catecholamines. It can also result in hypercapnia in a blood gas sample, due to hyperventilation.

          High Flow Oxygen

          • Venturi Mask

          • A Venturi mask contains an entrainment device that uses the Bernoulli principle to entrain a precise amount of oxygen along with room air. This allows for a predictable FiO2 in patients where this is required.

          Complications

          To prevent distal ischaemia, avoid performing an ABG in a limb with peripheral vascular disease and perform Allen's test before inserting the needle.
          • Iatrogenic Hypospadias

          • Erosion of the urethral meatus may occur following catheter insertion in males. This occurs due to continuous downward pressure of a long-term catheter on the meatus. 

          Troubleshooting

          Several issues occur commonly when inserting a cannula.

          Advanced Airway Interventions

          • Cricothyroidotomy

          • Cricothyroidotomy can be considered as an emergency airway technique in a patient with a difficult airway. This should be performed by an experienced operator with appropriate equipment and staff available.

          Medication History

          Common medications taken by patients with early to mid-stage chronic kidney disease include antihypertensives, diuretics, statins and diabetic medications. Patients with end-stage renal failure are likely to be on erythropoietin, phosphate binders and several other medications.

          Substance History

          Ask about alcohol intake, as alcohol abuse is associated with bone marrow suppression and myelodysplasia. Ask how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.
          Finally, ask about alcohol intake and recreational drug use to complete any comprehensive history.
          Ask about alcohol intake, as this is a significant risk factor for alcoholic liver disease / cirrhosis, pancreatitis and malnutrition. Ask how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.

          II & III - Pupils

          • Accomodation Reflex

          • To assess the accommodation reflex, ask the patient to focus on a distant object, such as the back wall of the room. Place a finger in front of their field of view and ask them to look at it. Unresponsiveness to light with an intact accommodation reflex is referred to as an Argyll Robertson Pupil, which is classically associated with neurosyphillis.

          Hands

          Protein

          Urine does not normally contain protein, as the glomerular filter is too small to allow for filtration of protein. Protein found in the urine may be albumin or globulins; the urine dipstick is more sensitive for the former rather than the latter.

          White Blood Cells

          • Neutrophils

          • Neutrophils are are the most prevalent white blood cells in circulation.

          Assessment of Bone

          The method used for classifying these fractures is the Salter-Harris classification, which can be remembered using the mnemonic SALTR:

          Intravascular Haemolysis

          • Urine Haemosiderin

          • Urine haemosiderin is the most sensitive test for intravascular haemolysis. The iron that builds up from haemolysis is stored as haemosiderin, which is then excreted - this results in brownish urine with an excess of iron on iron staining.

          Iron Overload

          • Causes

          • Hereditary haemochromatosis is the classic cause of iron overload, with the potential for iron deposition in major organs including the skin, liver, pancreas and heart. The main gene defect causing haemochromatosis is mutation of the C282Y HFE gene (type I haemochromatosis). Other genes defects that cause haemochromatosis are haemojuvelin (IIa), hepcidin (IIb), transferrin receptor 2 (III) and ferroportin 1 (IV).

          Avoiding Confounders

          Ensure that the patient is comfortable and have been resting for at least 15 minutes before collecting blood.

          High Flow Oxygen

          ColourO₂ FlowFiO₂
          Blue2 L/min0.24
          White4 L/min0.28
          Orange6 L/min0.31
          Yellow8 L/min0.35
          Red10L/min0.40
          Green15 L/min0.60

          Complications

          • Nerve Damage

          • Very uncommonly, patients may develop numbness or paraesthesia as a result of nerve damage from an ABG. To prevent this, ensure that the pulse is easily palpable before inserting the needle, and avoid advancing the needle multiple times.
          This may manifest early with erythema surrounding the meatus, and eventually the mucosa will start to break down and erosion can occur. This may be associated with infection.

          Troubleshooting

          • No Flashback is Seen

          • The cannula is unlikely to be in the vein, or has penetrated through the vein to the other side. Try advancing further or pulling back and inserting slightly medially or laterally. Don't pull the cannula all the way out or you'll have to start again.

          Examples

          Trastuzumab (tras-tu-zu-mab) - humanized monoclonal antibody with a tumour target

          Sodium Homeostasis

          Renin-angiotensin-aldosterone system (RAAS) - reduced perfusion within the juxtaglomerular apparatus stimulates renin release, which in turn stimulates the production of angiotensin I. Angiotensin I is converted to angiotensin II by ACE. Angiotensin II modulates pressure natriuresis and increases tubular sodium resorption, both directly and indirectly by stimulating aldosterone.

          Neutropaenia

          • Causes of Neutropaenia

          • Congenital - benign familial neutropaenia, cyclic neutropaenia, severe congenital neutropaenia, certain congenital syndromes
          • Bone marrow pathology -  aplastic anaemia, myelofibrosis, myelodysplasia, acute leukaemia, LGL leukaemia, lymphoma, cancer metastasis
          • Infection - viruses, mycobacteria, typhoid, brucellosis, rickettsia, severe sepsis
          • Autoimmune - primary autoimmune neutropaenia, SLE, rheumatoid arthritis (Felty's syndrome)
          • Drugs - cytotoxic chemotherapy, NSAIDs, sulfasalazine, clozapine, many others
          • Dietary deficiency - B12, folate, copper, alcohol abuse, severe malnutrition
          • Chronic idiopathic neutropaenia
          • Hypersplenism

          Concordance

          • Positive concordance:
          • Positive concordance

          Polyclonal Gammopathy

          • Polyclonal Gammopathy

          Lateral Myocardial Infarction

          • ECG Findings in Lateral Myocardial Infarction

          • ST elevation in the lateral leads (I, aVL, V5, V6)
          • ST depression in leads III and aVF

          PEPID

          PEPID is a comprehensive clinical medicine app that offers diagnoses, drugs, investigations, and calculators to aid in diagnosing patients. The app also includes a symptom checker to help with differential diagnoses and guides to interpreting investigations.

          Brainscape

          • Platforms

          • Web, iOS and Android.

          Evernote

          • Cons

          • Less hierarchical organisation structure
          • Limited free version and expensive premium version

          Zero to Finals

          Best of all, the videos are all free to access!

          Dr Najeeb Lectures

          Dr Najeeb is a well-known and experienced medical educator, and medical students worldwide swear by his lectures. Dr Najeeb Lectures is a comprehensive medical education platform that provides video lectures covering a wide range of topics in both medical sciences and clinical medicine.

          Insight Timer

          Insight Timer offers a large library of guided meditations and talks from a variety of teachers and practitioners. It also offers a timer for silent meditation practice, along with tools for tracking your progress and setting goals. The app includes meditations and talks on a wide range of topics, from stress reduction to sleep.

          MedCalX

          • MedCalX

          TickTick

          • Pros

          • Task management and prioritization features.
          • Collaborative features for sharing tasks and projects.
          • Sleek and intuitive design.

          LearnTheHeart by Healio

          • Limitations

          • No specific iOS or Android app available.

          Types of Resources

          • Written Materials

            For those who learn well by reading information, written resources can be very useful. Additionally, such resources can be a source of information for note-taking. Potential written resources include:
          • Lecture slides - these are often supplied by the lecturer.
          • Textbooks - however, try not to get too bogged down by buying textbooks. Often these are accessible through your library either online or in print, and will only be needed for a specific topic over a short period of time.
          • Journal articles - it is often useful to go straight to the source and read a key guideline or seminal article.
          • Websites - there are a large number of websites on both medical sciences and clinical medicine topics. These may be free (FOAMed), paid or a combination of both.
          • Apps - similarly, there is a multitude of medical apps available to assist with both medical science and clinical topics.

          Methods for Remembering Facts / Lists

          • Mnemonics

            Mnemonics are a group of different memory devices that can be used to promote recall of difficult concepts. Examples of mnemonic devices are:
          • Acronyms - e.g. ESCAPPM organisms
          • Expression mnemonics - e.g. cranial nerves sentences
          • Music mnemonics - e.g. the alphabet song
          • Rhyme mnemonics - e.g. remembering which months have 30 or 31 days

          Practice Recall

          Such recall slows down the rate of forgetting, so that you'll be more likely to remember it next time.

          Find a Coach or Mentor

          Working with a coach or mentor can be incredibly valuable for improving your clinical skills. This is true not only for learning a skill for the first time, but also in mastering a skill and even taking it to the next level. A coach can provide you with personalised guidance to help you to refine your technique.

          Flashcard Platforms

          • ANKI

          • ANKI is a popular open-source flashcard app that uses spaced repetition to help users remember information over the long term. 

          Handwritten Vs Digital Notes

          • Benefits of Going Digital

          • Digital notes  give you much more opportunity to organise, edit and build upon notes. They allow you to have a single note for one topic, and add to it each time you have a lecture on that topic or come across new information.

          Management

          It is also important to treat the manifestations of myeloma such as hypercalcaemia, bony lesions and recurrent infections.
          • Anticoagulation

          • The mainstay of treatment for pulmonary embolism is anticoagulation. There are many different options for anticoagulation, as outlined below. Duration of anticoagulation depends on many factors including whether the PE is thought to be provoked, recurrent and/or in the context of thrombophilia.

          Pathogenesis

          • Congenital Long QT Syndromes

          • Romano-ward syndrome (LQT1-6) - isolated prolonged QT precipitated by various triggers
          • Jervell and Lange-Nielsen syndrome (JLNS)
          • Anderson-Tawil syndrome (LQT7) - prolonged QT, periodic paralysis, facial abnormalities
          • Timothy syndrome (LQT8) - prolonged QT, AV block, congenital heart disease, developmental delay, dysmorphic features

          Management

          Iron may also be given intramuscularly, though it is painful and may cause staining of the skin.

          Mixing Studies

          If the patient's coagulopathy (e.g. prolonged APTT) corrects with addition of control plasma, then factor deficiency is the cause of coagulopathy. If it does not correct, then factor inhibitors are present in the sample.

          Examples

          Trastuzumab (tras-tu-zu-mab) - humanized monoclonal antibody with a tumour target

          Handwritten Vs Digital Notes

          • In Praise of Bad Fonts

          • When writing notes on a device, consider choosing a hard-to-read font. This may sound counterintuitive, but there have been two studies that support this. In these studies, information presented in difficult to read fonts (such as Comic Sans or Bodoni MT) was remembered better than information presented in an easy to read font (Arial). 

          PEPID

          Compared to other offerings, PEPID is very expensive at $300 per year, and the user interface can be quite clunky. While PEPID may not be the most affordable option for many cost-averse med students, it may be a useful resource if you want access to a large amount of clinical information in one place.

          Brainscape

          • Cost

          • Free limited version; premium version available on a monthly or yearly subscription.

          Zero to Finals

          • Zero to Finals

          Dr Najeeb Lectures

          The setup of the lectures is relatively basic, with Dr Najeeb lecturing in front of a whiteboard with diagrams on it. However, the content presented is incredibly easy to understand and process which is why his videos are so popular.

          Insight Timer

          The app provides a decent amount of content, though a subscription is available to unlock everything.

          MedCalX

          MedCalX is a comprehensive medical calculator app designed for medical students and healthcare professionals. It features over 300 medical scoring systems, formulae, and classifications across multiple specialties. 

          TickTick

          • Cons

          • Some features require a paid subscription.
          • Limited customization options.
          • Not suitable for complex project management.

          LearnTheHeart by Healio

          Types of Resources

          • Visual Materials

            If your tend to learn topics visually rather than through reading, many resources are available, such as:
          • Lecture recordings - try watching these at 1.5x or 2x speed!
          • YouTube / other videos - there are many free or paid medical video services that teach topics and an extremely easy to understand way
          • Infographics - these can present information in an interesting way to help you to learn a topic quickly, or from another angle

          Methods for Remembering Facts / Lists

          A commonly used mnemonic device in medical school is acronyms. . Acronyms use the first letter of each word to create a shortened representation that can then be used to jog your memory about each item on the list. For example, the ESCAPPM organisms are organisms with inducible beta-lactamase activity that is chromosomally mediated, meaning that they can initially appear sensitive to beta lactams and later become resistant. The acronym stands for: Enterobacter, Serratia, Citrobacter freundii, Aeromonas, Proteus, Providencia, Morganella morganii.

          Test Yourself

          Unfortunately, it's not enough to read information once and then retain it forever. It's also not enough to read the same piece of information over and over again! 

          Find a Coach or Mentor

          Many great surgeons have coaches or mentors; these may be superiors or colleagues who they are able to bounce ideas off of, plan procedures, and debrief following procedures.

          Flashcard Platforms

          • Flashcard Platforms

          Medication History

          Patients who have recieved a renal transplant are likely to be on a combination of immunosuppressive agents such as steroids, tacrolimus, mTOR inhibitors, cyclosporin and/or mycophenolate; they also usually take antimicrobials for infective prophylaxis.

          Substance History

          Finally, ask about smoking history and recreational drug use to complete any comprehensive history.
          Take a detailed smoking history: identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable. Smoking is a risk factor for gastric, colorectal and pancreatic cancer. 

          III, IV & VI - Eye Movement

          Eye movement is innervated by the oculomotor (III), trochlear (IV) and abducens (VI) nerves.

          Arms

          • Injection Sites

          • Track marks on a patient's arm suggest IV drug use, which is a strong risk factor for bacterial septicaemia and infective endocarditis.

          Protein

          • Causes of proteinuria include:
          • Primary glomerulonephropathies - minimal change disease, membranous nephropathy, FSGS
          • Secondary glomerulonephropathies - lupus nephritis, diabetic nephropathy, pre-eclampsia, amyloidosis, certain viral infection, NSAIDs, certain malignancies
          • Tubular dysfunction - ATN, AIN, fanconi syndrome
          • Overflow - multiple myeloma, rhabdomyolysis, heart failure
          • Other - orthostatic proteinuria

          White Blood Cells

          An increase in neutrophils is known as neutrophilia. This is commonly caused by acute infection (particularly bacterial), though is also seen with inflammation, myeloproliferative neoplasms, corticosteroid administration and with heavy smoking. Pseudoneutrophilia is where there is shift of granulocytes into circulation without an increase in the total number of neutrophils - this can be seen in situations such as vigorous exercise and emotional stress.

          Acid-Base Balance

          The second major role of the arterial blood gas is to assess a patient's acid-base balance.

          Assessment of Bone

          • Assessment of Bone

          Immune vs Non-Immune Haemolysis

          The direct antiglobulin test (DAT), also known as the direct Coomb's, tests for IgG and complement 3 (C3) on the surface of red blood cells. The test is performed by adding antibodies against human IgG or C3 and monitoring for agglutination.

          Iron Overload

          Frequent blood transfusion can result in iron overload, as one unit of packed red blood cells contains approximately 250mg of iron. Overload can also be caused by excessive iron administration; this is mainly through parenteral means as oral intake is unlikely to be sufficient to cause significantly elevated stores.

          Avoiding Confounders

          • Prolonged Tourniquet Application

          • Tourniquets are a very useful tool for identifying veins when taking blood or inserting a cannula. However, leaving a tourniquet on for too long can affect the interpretation of blood test results.

          High Flow Oxygen

          • High Flow Nasal Prongs

          • High flow nasal prongs (HFNP) allow high flow of a precise amount of oxygen, and are useful in patients with hypoxic respiratory failure. The system is humidified, meaning that they can be used for longer periods of time. These systems also provide a small amount of positive end-expiratory pressure (PEEP), helping to keep the airways open.

          Complications

          This complication can be prevented by fixing the catheter to the lower abdomen, in order to prevent downward pressure.

          Troubleshooting

          • There is Flashback, But No Blood is Coming Out

          • The cannula has penetrated through the vein, or the vein has collapsed. Pull back slightly, adjust the angle of the needle against the skin, pull back and try again.

          Sodium Homeostasis

          Aldosterone - once secreted by the adrenal cortex will stimulate increased active reabsorption of sodium.

          Neutropaenia

          • Pearls

          • Ask about family history of low white blood cells
          • Ask about high risk features such as fevers, poor appetite, weight loss and night sweats
          • Examine for lymphadenopathy and splenomegaly
          • Correlate the onset of the patient's neutropaenia with the commencing and cessation of certain medications
          • Do not delay investigation and treatment of febrile neutropaenia!

          Concordance

          • Negative concordance:
          • Negative concordance

          Polyclonal Gammopathy

          • Causes of Polyclonal Gammopathy

          • Infection
          • Inflammatory disease
          • Malignancy

          Lateral Myocardial Infarction

          • Patterns of ECG Changes

          • Isolated lateral MI - ST elevation in the lateral leads (I, aVL, V5, V6)
          • High lateral MI - isolated ST elevation in leads I and aVL [Suggests occlusion of the first diagonal branch of the LAD]
          • Anterolateral MI - ST elevation in the lateral leads (I, aVL, V5, V6) and anterior leads (V3-V4) [Suggests occlusion of the proximal LAD]
          • Inferolateral MI - ST elevation in the lateral leads (I, aVL, V5, V6) and inferior leads (II, III, aVF) [Suggests occlusion of the proximal left circumflex artery]

          Mixing Studies

          • Mixing Studies

          Management

          • Stages of Multiple Myeloma Treatment

          • Initiation - generally with combination chemotherapy
          • Autologous stem cell transplant - in eligible patients
          • Maintenance therapy - with a single agent or combination chemotherapy
          • Relapsed multiple myeloma - complex; multiple treatment options including clinical trials
          • Pearls: Choice of Anticoagulant

          • Heparin infusion - short-term, for bridging or in the perioperative period. APTT must be monitored regularly as per local protocol.
          • Low molecular weight heparin (e.g. enoxaparin) - first line for patients with active malignancy; also used for bridging. Contraindicated if CrCl <30.
          • Warfarin - must be bridged. INR must be monitored. Can be used in renal failure. Inferior to enoxaparin in active malignancy.
          • Dabigatran - contraindicated if CrCl <30.
          • Rivaroxaban - contraindicated if CrCl <30, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding. Potential role in active malignancy.
          • Apixaban - contraindicated if CrCl <25, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding.
          • Blood Transfusion

          • Transfusion is generally avoided except in severe, symptomatic anaemia or active bleeding.
          • Common Regimens Used in Multiple Myeloma

          • Single Agent Therapies

          • Imide immunomodulators - thalidomide / lenalidomide
          • Proteasome inhibitors - carfilzomib / bortezomib
          • Combination Therapies

          • Lenalidomide/dexamethasone (RD)
          • Bortezomib/lenalidomide/dexamethasone (VRD)
          • Bortezomib/thalidomide/dexamethasone (VTD)
          • Bortezomib/cyclophosphamide/dexamethasone (VCD/CyBorD)
          • Carfilzomib/lenalidomide/dexamethasone (KRD)
          • Melphalan/prednisone/lenalidomide (MPL)
          • Contraindications to Anticoagulation

          • Absolute - active bleeding, major trauma, platelets <50, bleeding diathesis, perioperative
          • Relative - past incompressible bleed, intracranial or spinal tumour, platelets <100, large AAA, high falls risk

          Diagnosis

          • Diagnosis
             

          Family History

          Ask about any medical conditions that may be known in the family. In the case of chronic kidney disease, this pertains particularly to autosomal dominant polycystic kidney disease, though other potential inherited causes include Alport syndrome and thin basement membrane disease.

          Substance History

          Finally, ask about recreational drug use, and particularly intravenous drug use. IV drug use is associated with blood-borne viral infections including hepatitis B and C.

          III, IV & VI - Eye Movement

          Arms

          • Radial Pulse

          • Palpate the patient's radial pulse for heart rate and rhythm. Count the heart rate over at least 30 seconds and multiply to estimate beats per minute.

          Ketones

          Urine does not normally contain ketones, though a small amount may be present after vigorous exercise, vomiting or diarrhoea. Significant amounts of urinary ketone suggest the presence of ketosis, such as due to a carbohydrate-free diet, diabetic ketoacidosis, alcoholic ketoacidosis or starvation.

          White Blood Cells

          A reduction in neutrophils is referred to as neutropaenia. This may be congenital or be acquired due to viral infection, autoimmune conditions, bone marrow pathology, dietary deficiency and certain drugs.

          Acid-Base Balance

          • Acid-Base Balance

          Assessment of Bone

          • I
            Straight through - fracture directly across the growth plate, not involving surrounding boneGood prognosis
          • II
            Above - fracture across the growth plate and up through the metaphysis (most common)Good prognosis
          • III
            Lower - fracture across the growth plate and down through the epiphysisPoor prognosis - interruption of the proliferative zone
          • IV
            Transverse - fracture directly through the metaphysis, growth plate and epiphysisPoor prognosis - interruption of the proliferative zone
          • V
            Ruined / rammed - direct compression of the growth plateWorst prognosis

          Immune vs Non-Immune Haemolysis

          A positive direct antiglobulin test indicates an immune (autoimmune, alloimmune or drug-induced) cause of haemolysis, and may be positive before haemolysis occurs.

          Iron Overload

          Iron loading anaemias such as sideroblastic anaemia, thalassaemia and congenital dyserythropoietic anaemia tend to cause significant anaemia with clinical iron overload, even in the absence of frequent blood transfusions.

          Avoiding Confounders

          Ideally the tourniquet should be left on for no longer than a minute at a time - if you are having difficulty finding a vein, then release the tourniquet, wait for blood flow to return, then reapply the tourniquet.

          Non-Invasive Ventilation

          Non-invasive ventilation should occur in an appropriate venue with sufficiently trained staff, such as a respiratory ward, HDU or ICU.

          Troubleshooting

          • Bright Red Blood is Pulsating Out

          • The cannula is likely in an artery. Remove the needle immediately and apply pressure to the area for at least three minutes. This can be avoided by ensuring that there is no palpable pulsatile vessel prior to inserting a cannula.

          PEPID

          • Pros

          • Comprehensive medical app with diagnoses, drugs, investigations and calculators.
          • Symptom checker aids in diagnosing patients.

          Brainscape

          • Brainscape

          Google Keep

          • Platforms

          • iOS, Android, web

          Zero to Finals

          • Pros

          • Excellent illustrations that teach in an engaging way
          • Additional content on the website - podcasts, questions, flashcards, notes, books

          Dr Najeeb Lectures

          A large number of videos are available on Dr Najeeb’s YouTube channel, with a single payment to access everything via his website.

          Insight Timer

          • Insight Timer

          MedCalX

          With support for both US and SI units, a search function, and the ability to add personalized notes, share results, and save favorites, MedCalX is a versatile resource. 

          ECG Learning Centre

          • Platforms

          • Web

          Types of Resources

          • Auditory Materials

          • Instead of listening to music at home or during your commute, consider listening to medical podcasts or lecture recordings. For those who learn by listening, these can be a useful adjunct to other resources.

          Methods for Remembering Facts / Lists

          Expression mnemonics are also commonly used in medical study. This involves the creation of a sentence using the first letters of each word. An example is the cranial nerves:

          Test Yourself

          Long term retention of information can be achieved by learning something and then actively recalling it. In a study of students learning foreign language vocabulary, repeated study had no effect on delayed recall, while repeated testing had a significant positive effect.

          Find a Coach or Mentor

          If you’re struggling with learning a new skill or looking to improve it, consider approaching someone you trust to provide you with feedback and support. An example would be asking a doctor on the ward to give you pointers while you’re inserting a cannula. You’ll be surprised how much this can help you to identify issues with your technique, and get past learning block!

          Flashcard Platforms

          ANKI is available on Windows, Mac, Linux, iOS, and Android, and users can create custom flashcards with text, images, and audio. ANKI is free to use on the web and Android, while the iOS app has an upfront cost.

          Handwritten Vs Digital Notes

          This is thought to be due to the fact that working harder to interpret text requires more mental focus than text that is easy to read, meaning that more active attention is used. 

          Anticoagulants

          Unfractionated heparin can be monitored by regularly testing APTT values. Consult local guidelines for heparin bolusing, rates and titration. Do not take a sample for APTT testing from the same limb through which the patient is recieving heparin. Patients with antiphospholipid syndrome who are on a heparin infusion cannot be monitored using APTT as levels are uninterpretable, and as such heparin anti-Xa levels should be used for monitoring.

          Sodium Homeostasis

          Antidiuretic hormone (ADH) - the pituitary gland secretes ADH in response to reduced serum water concentration, which then acts on the distal convoluted tubule to salvage water and concentrate urine.

          RS Interval in Precordial Leads

          The RS interveal refers to the time from the onset of the R wave to the deepest point of the S wave in the precordial leads.

          Right Ventricular Infarction

          Right ventricular infarcts tend to occur due to occlusion of the proximal right coronary artery (RCA).

          RS Interval in Precordial Leads

          An RS interval >100ms in the precordial leads is suggestive of VT.

          Right Ventricular Infarction

          In order to assess for right ventricular infarction using an electrocardiogram, added leads are required on the right side of the chest (V1R to V6R).

          Family History

          Patients with chronic electrolyte derangements may report a family history of Bartter's, Gitelman's or Liddle's syndrome.

          III, IV & VI - Eye Movement

          Arms

          Note whether the pulse is regular, regularly irregular or irregularly irregular. The implication of an irregularly irregular pulse is likely atrial fibrillation; remember that this is associated with valvular (particularly mitral) pathology.

          Bilirubin & Urobilinogen

          Bilirubin is a breakdown product of the haem portion of haemoglobin. Bilirubin is converted to urobilinogen by bacteria within the intestines, reabsorbed and excreted by the kidneys. 

          White Blood Cells

          • Lymphocytes

          • Lymphocytes are small leukocytes that play several key roles in the adaptive immune response.

          Acid-Base Balance

            • Normal Ranges
            • pH - 7.35 - 7.45
            • Bicarbonate (HCO₃) - 22 - 26
            • Base Excess - -2 to +2
            • Arterial partial pressure of CO (PaCO₂) - 36 - 44

          Assessment of Bone

          • Bone Density

          • Assess the density of the bone - whether it is increased or decreased.

          Immune vs Non-Immune Haemolysis

          For a list of immune and non-immune causes of haemolysis, see the table at the top of the page.

          Iron Overload

          • Manifestations

            Iron overload is generally severe before it begins to manifest: this may occur in the following ways:
          • Skin involvement - bronze discolouration of skin
          • Cardiac involvement - palpitations, exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema
          • Hepatic involvement - jaundice, ascites, haematemesis, malaena, confusion
          • Endocrine involvement - diabetes mellitus, evidence of hypopituitarism or hypogonadism
          • Joint involvement - arthralgias, secondary osteoarthritis

          Avoiding Confounders

          Always remember to release the tourniquet when leaving a patient's bedside, as very prolonged tourniquet application can result in significant complications.

          Non-Invasive Ventilation

          • CPAP

          • Continous positive airway pressure (CPAP) splints the upper airways open, and relieves upper airway obstruction. This device does not actively ventilate the patient.

          Troubleshooting

          • A Haematoma Has Formed

          • The vein has likely blown. Remove the needle and apply pressure to the area.

          Management

          • Other Measures

          • Manage hypercalcaemia - fluids, steroids, bisphosphonates
          • Manage skeletal lesions - bisphosphonates, radiotherapy, surgery
          • Manage hyperviscosity - fluids, leukopheresis
          • Duration of Anticoagulation

          • Provoked VTE (transient risk factors) - 3 months then reassess based on risk of recurrence and bleeding
          • First unprovoked VTE - 3 months then continue depending on risk of recurrence and bleeding
          • Recurrent unprovoked VTE - long-term anticoagulation
          • Thrombophilia - consider long-term anticoagulation

          Diagnosis

          LQT1LQT2LQT3
          ECG MorphologyBroad T wavesBifid T wavesLate T waves
          TriggerExertion, fright, swimmingAuditorySleep / rest

          Anticoagulants

          Low molecular weight heparins (such as enoxaparin and dalteparin) may be monitored by measuring factor Xa levels, though these are rarely performed except in specific circumstances such as obesity, pregnancy or renal dysfunction.

          PEPID

          • Cons

          • More expensive than other offerings.
          • Clunky user interface.

          Brainscape

          Brainscape is a flashcard platform that uses spaced repetition to help you large amounts of information. Create your own flashcards, or access curated and user-generated flashcard decks, including certified ones for USMLE. Brainscape also offers learning analytics to track progress and identify areas of weakness. With its adaptive learning algorithm and focus on personalized study, Brainscape is a great learning tool.

          Google Keep

          • Cost

          • Free, with no premium version

          Zero to Finals

          • Cons

          • Has more of a focus on clinical medicine - few medical sciences videos
          • Releatively limited range of videos

          Dr Najeeb Lectures

          • Dr Najeeb Lectures

          Insight Timer

          • Pros

          • Offers free meditations
          • Large library of content
          • Timer for silent meditation practice

          MedCalX

          The app is free to download with a limited number of tools, and an in-app purchase unlocks everything, making it a valuable addition to any medical student's toolkit.

          ECG Learning Centre

          • Cost

          • Free

          Types of Resources

          • Practical Opportunities

            There are many topics in medical school that are best learned by doing rather than by learning.
          • Lab sessions - these are useful for learning histology, pathology, microbiology and other lab-based topics
          • Anatomy dissection / virtual dissection sessions - while it is possible to learn anatomy by reading textbooks, it is much more efficient to learn anatomy practically. Such sessions can assist with understanding how organs and body systems are anatomically related.
          • Procedure practice sessions - you will learn many procedures during your time at med school, and the only way to master them is to practice. Initially you may be practicing on dummies, while eventually you will have the opportunity to practice procedural skills on real patients.

          Methods for Remembering Facts / Lists

          On Occasion Our Trusty Truck Acts Very Funny Very Good Vehicle Any How.

          Test Yourself

          There are many ways to test yourself. 

          Find a Coach or Mentor

          • Find a Coach or Mentor

          Flashcard Platforms

          • Brainscape

          • Brainscape is a flashcard platform that uses spaced repetition and is great for learning large amounts of information. 

          Handwritten Vs Digital Notes

          Therefore, it may be worth using a font that you hate, such as Comic Sans, Bodoni MT, Haettenschweiler or Monotype Corsiva.

          Brainscape

          • Brainscape

          Google Keep

          • Google Keep

          Dr Najeeb Lectures

          • Pros

          • Comprehensive and detailed video lectures
          • Incredibly easy to understand
          • Many videos are free, and website access is significantly cheaper than other options

          Insight Timer

          • Cons

          • The free version is relatively limited

          MedCalX

          • Pros

          • Wide range of tools.
          • Customization options - add personalized notes and save favorites.
          • Supports US and SI units

          ECG Learning Centre

          • ECG Learning Centre

          Types of Resources

          • Testing Methods

            While there are many sources for taking in new information, it is important to also test yourself
          • Questions - this may include questions from textbooks, past questions and question banks.
          • Flashcards - these may be self-created or flashcard banks.

          Methods for Remembering Facts / Lists

          This is a mnemonic to remember: Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal.

          Test Yourself

          • Use Question Banks

          • There are many question banks available for a wide variety of medical topics - these can be online, shared between peers, or even in the back of textbooks. Try to find a question bank that helps you work toward a specific goal that you have - such as the USMLE.

          Know Your Limitations

          While medical school is a great time to gain experience with procedures, it’s equally important to known your limitations and practice within your scope of competence.

          Flashcard Platforms

          • Flashcard Platforms

          Outline Method

          Outlining is the most commonly used note-taking method. This involves titles, dots points and numbered lists. Indenting is used to demonstrate relationships between pieces of information. If structured and written well, outlines can condense a large amount of information into summarised form with a clear hierarchy.

          Family History

          Also ask about a significant family history of vascular disease and other cardiovascular risk factors. This may include ischaemic heart disease, peripheral vascular disease, diabetes, hyperlipidaemia and hypertension.

          III, IV & VI - Eye Movement

          Arms

          • Arms

          Bilirubin & Urobilinogen

          BilirubinUrobilinogen
          NormalNegativeWeak Positive
          HaemolysisNegativePositive
          Hepatic DiseasePositivePositive
          CholestasisPositiveNegative

          White Blood Cells

          Lymphocytosis is an increase in circulating lymphocytes. This may occur in the context of acute viral infection, adrenocortical insufficiency, post splenectomy, chronic tuberculosis or chronic lymphocytic leukaemia (CLL).

          Acid-Base Balance

          In understanding why the bicarbonate and PaCO₂ are important for assessing acid-base balance, remember the following equilibrium:

          Assessment of Bone

          • Types of reduction in bone density are:
          • Generalised osteopaenia - an overall reduction in bone density. This suggests an imbalance in bone deposition and resorption, placing the bone at risk of pathologic fractures. This commonly occurs in post-menopausal women, in the elderly, as well as due to genetic, endocrine, nutritional, haematologic and drug causes.
          • Periarticular osteopaenia - a reduction in bone density surrounding joints; this is classically a sign of rheumatoid arthritis.
          • Lytic lesions - focal areas of bony hypodensity, which are classically a sign of multiple myeloma.

          The Blood Film in Haemolysis

          Abnormal red blood cell morphology may provide clues regarding the presence or cause of haemolysis.

          Iron Overload

          • Diagnosis

          • Elevated ferritin is a key marker of iron overload. Ferritin is also an acute phase reactant, and as such an isolated elevation of ferritin is not necessarily an indicator of iron overload. Ferritin levels >200 ug/L in premenopausal women or >300 ug/L in men and postmenopausal women are concerning for true iron overload.

          Avoiding Confounders

          • The effects of prolonged tourniquet application include:
          • Effects on the Patient

          • Bruising
          • Nerve palsies - numbness, paraesthesias or weakness
          • Limb ischaemia
          • Effects on Blood Results

          • Haemoconcentration - water and certain solutes extravasate into the extracellular space, resulting in falsely elevated results
          • Elevated lactate
          • Elevated total protein, AST, lipids, cholesterol and iron

          Non-Invasive Ventilation

          • Indications for CPAP
          • Obstructive sleep apnoea
          • Acute pulmonary oedema

          Removing the Cannula

          Wash your hands and don gloves.

          RS Interval in Precordial Leads

          • RS Interval in Precordial Leads
             

          Right Ventricular Infarction

          • Right Ventricular Infarction

          Anticoagulants

          Warfarin can be monitored through regular INR measurement, to ensure that patients are recieving a therapeutic dose. Consult local guidelines when commencing warfarin, and keep in mind that changes in warfarin dosing will take several days to have an effect on the INR, so dose titration should rely on the trend rather then being immediately reactive.

          Management

          In patients undergoing surgical procedures, consult either local guidelines or the team performing the procedure regarding when to withhold the anticoagulant and whether bridging therapy is needed.

          Social History

          It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.

          III, IV & VI - Eye Movement

          • Inspect for Ptosis

          • Look for lowering of the eyelid, either completely or partially; note whether this is unilateral or bilateral. Partial ptosis is classically a sign of Horner's syndrome (along with miosis and anhydrosis), while complete ptosis may be due to structural, neurological or muscular disease.

          Bilirubin & Urobilinogen

          • Bilirubin

          • Urine does not normally contain bilirubin, and only conjugated bilirubin is able to be filtered into urine (it is water soluble, while unconjugated biluribin is fat soluble) and therefore only causes of conjugated hyperbilirubinaemia may result in bilirubinuria. The presence of bilirubin in urine suggests the presence of acute hepatitis, liver cirrhosis or cholestatic disease.

          White Blood Cells

          Lymphopaenia refers to a reduction in the number of circulating lymphocytes. This is seen with primary immunodeficiency syndromes, certain infections, certain medications, bone marrow pathology and with dietary deficiency.

          Acid-Base Balance

          H⁺ + HCO₃⁻⇄ H₂CO₃ ⇄ H₂O + CO₂

          Assessment of Bone

          • Types of increased bone density are:
          • Generalised osteosclerosis - an overall increase in bone density. This may be due to endocrine disease such as hypoparathyroidism; osteoblastic metastasis, or certain congenital diseases.
          • Subchondral osteosclerosis - increased bone density surrounding a joint, in the subchondral layer. This is a classic radiologic sign of osteoarthritis.

          The Blood Film in Haemolysis

          • The Blood Film in Haemolysis

          Iron Overload

          Elevated transferrin saturations >50% in women or >60% in men are indicative of iron overload.

          Avoiding Confounders

          • Heparin infusions

          • Taking blood from the same limb that a heparin infusion is running into will falsely elevate the APTT. In order to avoid this, take the sample from a different limb, or turn off the infusion for 5-20 minutes prior to taking the sample.

          Non-Invasive Ventilation

          • BiPAP

          • Bilevel positive airway pressure (BiPAP) provides both expiratory positive airway pressure (EPAP), which opens the airways; and inspiratory positive airway pressure (IPAP), which ventilates the patient.

          Removing the Cannula

          Remove the dressing and any tape surrounding the cannula.

          Brainscape

          • Pros

          • Uses adaptive learning algorithm to personalize study sessions
          • Curated decks guarantee high quality, accurate information
          • Learning analytics provide insights into user performance

          Google Keep

          Google Keep is essentially a way of storing digital post-it notes. This app is incredibly easy to get started with an use, and can be used across devices. Google Keep has some features such as the ability to colour notes and extract text from images, but is text-only and there is no ability to organise or tag notes.

          Dr Najeeb Lectures

          • Cons

          • Relatively low production value
          • Videos are often very lengthy

          MedCalX

          • Cons

          • In-app purchase required to unlock all tools.
          • iOS app only - no Android app or web-based platform.
          • Some specialties might have fewer tools available.

          Todoist

          • Platforms

          • Web, Windows, OSX, iOS, Android

          ECG Learning Centre

          The ECG Learning Center is a comprehensive online resource for learning about ECG interpretation. Developed by the University of Utah, the website offers an extensive ECG library with detailed explanations of ECG concepts, as well as quizzes

          Methods for Remembering Facts / Lists

          • Story Method

          • This method involves creating a story that is meaningful to you in order to help the concept to stick. For example, if you wanted to learn the words potato, cemetery, penguin, floorboard, rubber you could create and memorise the following sentence:

          Know Your Limitations

          Some procedures, such as catheterisation, lumbar punctures, pleural taps and intubation, should not be performed without approval and supervision from a senior colleague. These procedures can be complex and carry significant risks, and it's important for medical students to recognize when it's safe to perform a given procedure, and when it’s not.

          Flashcard Platforms

          Brainscape is available on the web, iOS and Android, and users can create their own flashcards or access curated and user-generated flashcard decks, including certified ones for MCAT and USMLE. Brainscape also includes learning analytics to track progress and identify areas of weakness. Brainscape is free to download, with a premium version available on a monthly or yearly subscription.

          Outline Method

          • Example

          • Outline Method

          Anticoagulants

          • Common INR Targets

          • AF, DVT/PE: 2.0 - 3.0
          • Mechanical heart valve: 2.5 - 3.5

          R Wave Peak Time in Lead II

          Look for the time from the start of the depolarisation from the isoelectric line to the first deflection in the complex.

          Right Ventricular Infarction

          Right ventricular infarction should be suspected in patients with isolated ST elevation in lead V1. It should also be suspected in patients with inferior MIs.

          R Wave Peak Time in Lead II

          An R wave peak time >50ms in lead II is suggestive of VT.

          Right Ventricular Infarction

          • ECG Findings in Right Ventricular Infarction

          • ST elevation in leads V1-V2
          • ST elevation in leads V3R to V6R

          Social History

          In patients requiring dialysis or renal transplant, the social history becomes an even more vital part of decision making. Such patients require a significant level of physical, social and psychological support and it is important to ensure that the patient has these in place prior to considering these interventions. This may include ensuring that they have someone to drop them off to dialysis or to appointments; that they are likely to take their medications regularly; and that they are unlikely to do anything that would put them at risk.

          III, IV & VI - Eye Movement

          • Inspect for Strabismus

          • Strabismus refers to a misalignment of the eyes, either medially (esotropia) or laterally (exotropia). Strabismus is often quite subtle and difficult to detect, and slight angulation of the head to either side may be a sign of compensation for a subtle strabismus. The cover test can be used to further assess a patient with strabismus.

          Arms

          • Radial Pulse Delay

          • Next, palpate both radial pulses at once to assess for radio-radial delay. If the left radial pulse is slightly later than the right, then this suggests aortic coarctation. Radio-femoral delay may also be assessed for, though ensure that you ask the patient and examiner prior to testing for this.

          Bilirubin & Urobilinogen

          • Urobilinogen

          • Urobilinogen is normally present in small amounts in the urine, though an increase in urine urobiliogen suggests an excess of conjugated or unconjugated bilirubin. An increase in urine urobilinogen cannot occur in the context of cholestasis, as conjugated bilirubin is unable to pass into the gut and be reabsorbed.

          White Blood Cells

          • Monocytes

          • Monocytes are large leukocytes of myeloid origin. An increase in circulating monocytes, or monocytosis, may occur with chronic infection, chronic inflammation, certain haematologic malignancies, or post splenectomy.

          Acid-Base Balance

          Bicarbonate is the metabolic component, and is cleared by the kidneys; CO₂ is the respiratory component, and is cleared by the lungs.

          Assessment of Bone

          • Foreign Body

          • Look for foreign bodies in or surrounding the bone. The patient may have plates, nails or other orthoses in situ from previous surgery. Shrapnel may also be present following trauma.

          The Blood Film in Haemolysis

          • Schistocytes

          • Schistocytes are small, irregular fragments of red blood cells of varying shapes. These are a sign of microangiopathic haemolytic anaemias such as TTP, HUS, aHUS, DIC or HELLP syndrome; they may also occur with mechanical haemolysis such as due to cardiac prostheses, dialysis or extracorporeal membrane oxygenation (ECMO).

          Avoiding Confounders

          • Confounding of Blood Gas Testing

          • Blood gases should be tested straight away, as ongoing cellular metabolism will occur while specimens are left without testing.

          Non-Invasive Ventilation

          • Indications for BiPAP
          • Acute hypercapnic respiratory failure - e.g. due to COPD, chest wall deformities, neuromuscular disorders
          • Immunocompromised patients with acute respiratory failure
          • Step-down after extubation of high-risk patients

          Removing the Cannula

          Remove the cannula in a steady, fluid motion.

          Anticoagulants

          Factor Xa inhibitors (such as apixaban and rivaroxaban) are not monitored, though drug-specific factor Xa levels may be performed under haematology guidance to estimate whether these drugs are therapeutic. Factor Xa inhibitors prolong the APTT and PT/INR, though this is in an unpredictable way.

          Brainscape

          • Cons

          • Premium version required for some features
          • Simplistic interface with limited customisation options compared to other flashcard platforms

          Google Keep

          • Pros

          • Free
          • Incredibly quick and simple to use
          • Use on any device

          Ninja Nerd

          • Platforms

          • YouTube, Web

          Todoist

          • Cost

          • Free for individuals

          ECG Learning Centre

          You may find the interface a little outdated and the site a little difficult to navigate, though this belies the depth of information held within. While there is no specific iOS or Android app for the ECG Learning Center, the website is relatively mobile-friendly and can be easily accessed on any device with an internet connection. 

          Final Thoughts

          The path to becoming a doctor is long and complex. In order to learn everything required you will develop an understanding of your key learning styles, and use those learning styles together to develop a sophisticated understanding of medical concepts.

          Methods for Remembering Facts / Lists

          The rubber floorboards of the cemetery felt like potato under my penguin feet.

          Test Yourself

          • Create Your Own Questions / Flashcards

          • Flashcards are an incredible way of promoting recall. They provide the ability to test yourself on key concepts, and good flashcard platforms use the concept of spacing repetition to ensure that you're presented with cards right when you're about to forget them - using the Ebbinghaus forgetting curve.

          Know Your Limitations

          You may find that you have more opportunities to perform procedures in rural or regional areas which have higher workloads, but it’s important to prioritise safety and so when you’re not comfortable, never hesitate to ask for guidance or help.

          Flashcard Platforms

          • Quizlet

          • Quizlet is a flashcard platform that allows users to create their own flashcards and access millions of pre-made flashcard decks created by others, including those for MCAT, USMLE, and medical school generally. 

          Outline Method

          • Tips for Writing an Outline

          • Try to start by structuring your headings - use the lecture outline or textbook table of contents to write a skeleton that you can then fill in.
          • Choose clear titles and headers
          • Paraphrase information into short phrases
          • Avoid copying information word-for-word
          • Make sure that there is a clear information hierarchy - that information is indented beneath something that it is related to.

          Amboss

          • Platforms

          • Web, iOS, Android

          Google Keep

          • Cons

          • No rich text formatting - text only
          • No hierarchy or tagging of notes

          Ninja Nerd

          • Cost

          • Free

          Todoist

          • Todoist

          ECG Learning Centre

          • ECG Learning Centre

          Final Thoughts

          Good luck!

          Methods for Remembering Facts / Lists

          What a memorable sentence!

          Test Yourself

          Creating your own questions can also help with recall.

          Final Thoughts

          Practical skills are an essential component of your medical education, and there are several ways to jumpstart your procedural learning. By practicing on mannequins, you can build your confidence and competence with real patients. By being present on the ward, you can create opportunities to “see one, do one, teach one” and practice your skills. Through coaching and learning procedures via different methods, you will be well on the way to technical mastery.

          Flashcard Platforms

          • Flashcard Platforms

          Outline Method

          Outlines can be difficult to use if you're adding a lot of images or formulas, or if you're directly comparing multiple pieces of information.

          R Wave Peak Time in Lead II

          • R Wave Peak Time in Lead II
             

          Posterior Myocardial Infarction

          Posterior MI can be difficult to diagnose, as it may not be evident on a 12-lead ECG. Posterior infarcts are associated with inferior MIs and should be considered in patients with this.

          Anticoagulants

          Direct thrombin inhibitors (such as dabigatran) may be monitored by measuring the dilute thrombin time, though this is rarely performed except in specific circumstances as guided by a haematologist. Direct thrombin inhibitors will also prolong the APTT and PT/INR, though this is in an unpredictable way and as such these measures cannot be used to monitor these medications.

          Substance History

          Take a detailed smoking history: identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable.

          III, IV & VI - Eye Movement

          • Look for Nystagmus

          • Nystagmus (usually referring to jerk nystagmus) is an abnormal rhythmic eye movement that commonly occurs due to vestibular, brainstem or cerebellar pathology. Ask the patient to look at your finger, held ~50cm in front of their eyes. Repeat this in the extremes of left and right lateral gaze, as well as in superior and inferior gaze. Look for slow drifting movements of the eye interspersed with corrective fast saccadic movements; note whether these movements are horizontal, vertical or torsional. 

          Arms

          • Arms

          White Blood Cells

          • Eosinophils

          • The primary physiologic role of eosinophils is to defend against parasitic infection, though they also play an important role in the pathogenesis of allergy and certain other hypersensitivity reactions.

          Acid-Base Balance

          • pH

          • The first step is to assess the patient's pH. This is a measure of the acidity of alkalinity of the blood, based on an inverse log of the hydrogen ion concentration. 

          Assessment of Joints

          • Joint Position

            Assess for subluxation or dislocation of the joints. This may affect one of many joints - in particular the:
          • Fingers - including the thumbs
          • Elbows - most commonly dislocate posteriorly, particularly wih fractures of the radial head, olecranon or coranoid process.
          • Shoulders - dislocate anteriorly in 95% of cases
          • Hips - dislocate posteriorly in 90% of cases
          • Patellae - tends to dislocate laterally

          The Blood Film in Haemolysis

          Microspherocytes are counted as schistocytes - they are small round cells with loss of central pallor.

          Avoiding Confounders

          Effects include reduced pO2, increased pCO2, reduced pH, reduced calcium, increased glucose and increased lactate.

          Non-Invasive Ventilation

          • Contraindications to BiPAP
          • Severe impairment of consciousness
          • Severe facial deformity
          • Inability to maintain or protect the airway
          • Upper airway injury - burns, trauma, surgery
          • Haemodynamic instability
          • Untreated pneumothorax

          Removing the Cannula

          Apply pressure to the area using sterile gauze, then place a small dressing (such as a cotton ball) to the area with tape.

          Substance History

          Ask about alcohol intake: how many drinks per week, what type of drinks, and whether they have considered cutting down their intake if heavy.

          III, IV & VI - Eye Movement

          Nystagmus that is transient with onset following change in position is suggestive of benign paroxysmal positional vertigo, while vertical or torsional nystagmus are suggestive of a central cause.

          Arms

          • Respiratory Rate

          • While ostensibly still measuring the pulse, count the patient's respiratory rate over 30 seconds. Resp rate is a sensitive marker of deterioration in hospitalised patients and both tachypnoea (fast resp rate >20) and bradypnoea (slow resp rate <12) are concerning signs.

          White Blood Cells

          • Eosinophilia is an increase in eosinophils, which may be seen with:
          • Allergies - such as asthma, allergic rhinitis or chronic sinusitis
          • Drug reactions - whether allergic or other hypersensitivity reactions
          • Parasitic infections - e.g. helminths or protozoa
          • Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
          • Eosinophilic leukaemia

          Acid-Base Balance

          A reduced pH is referred to as acidaemia, while an increased pH is an alkalaemia - remember that acidosis and alkalosis are processes, not measurements, and cannot be identified based on pH alone.

          Assessment of Joints

          Note whether any dislocations are associated with a fracture, as this would be referred to as a complex dislocation, or fracture-dislocation.

          The Blood Film in Haemolysis

          • Spherocytes

          • Spherocytes are round cells with loss of central pallor, and occur due to removal of a portion of the cell membrane by phagocytes. Spherocytosis may be hereditary, though are also a sign of haemolytic anaemia.

          Avoiding Confounders

          Cool the sample to 0-4 degrees using ice if it is unlikely to be processed within 15 minutes.

          Invasive Ventilation

          Invasive ventilation is performed following either intubation or tracheostomy.

          Complications

          • Cannula Blockage

          • A blocked cannula may occur due to clotting in the cannula or line, or due to kinking of the cannula or line. This should be suspected when the infusion is not able to run and the machine is displaying a high pressure area, or if the patient is in pain.

          Amboss

          • Cost

          • Variable - check website for details

          Ninja Nerd

          • Ninja Nerd

          Geeky Medics

          • Platforms

          • YouTube, Website, iOS, Android

          Headspace

          • Platforms

          • iOS and Android.

          MedSchool 

          • Platforms

          • Web, iOS, Android

          Todoist

          Todoist is a popular to-do list app that allows you to manage your tasks and projects with ease. With its simple yet powerful interface, Todoist allows you to create tasks, set due dates and priorities, and organize your tasks by project or label. It also offers collaborative features, making it easy to share tasks and projects with others. Todoist also integrates with other apps and services, allowing you to manage your tasks from different platforms. 

          ECG Learning Centre

          • Features

          • Comprehensive ECG library.
          • ECG quizzes.

          Methods for Remembering Facts / Lists

          • Memory Palace

          • This method is slightly more involved, however is much more effective in optimising recall. The memory palace uses spatial memory by associating an object with a location. Essentially, you will mentally place representative objects around a room to remind you of the items that you need to remember.

          Test Yourself

          Consider using the MedSchool MyQuizzes and Flashcards sections to create your own questions / flashcards and start testing yourself.

          Final Thoughts

          If you’d like to learn more about how to perform procedures, please consider checking out the interventions section of the MedSchool website and app. We provide detailed guides to performing procedures such as airway management, infection, cannulation, arterial blood gasts, urinary catheterisation and lumbar punctures. The guides are designed to be easy to follow with checklists, tips for troubleshooting and approaches to complications.

          Flashcard Platforms

          Quizlet is available on the web, iOS, and Android, and users can create custom flashcards with text, images, and audio. Quizlet is free to download and use, with a premium version available on a monthly or yearly subscription.

          Writing on Slides

          Writing on or around lecture slides is the most efficient method of note-taking. Notes can be handwritten or added digitally. Many lecturers provide slides with space next to them to write on, or you can set this up in Powerpoint.

          Fusion & Capture Beats

          If present in the context of a wide complex tachycardia, fusion and capture beats are suggestive of VT.

          Posterior Myocardial Infarction

          Using an electrocardiogram, extra leads on the back (V7 to V9) are required for diagnosis of posterior myocardial infarction. 

          Fusion & Capture Beats

          Fusion beats are hybrid complexes that occur when a ventricular beat and a supraventricular beat coincide.

          Posterior Myocardial Infarction

          • Posterior Myocardial Infarction

          Amboss

          • Amboss

          Notion

          • Platforms

          • Mac, iOS, Android, Windows, web

          Ninja Nerd

          Ninja Nerd Lectures is a YouTube channel created by Zach Murphy, Robert and Kristin Beach - three non-doctors (Zach, who presents the videos, is a physician’s assistant) with a passion for teaching. The channel offers a wide range of medical sciences lectures that cover a broad range of topics.

          Geeky Medics

          • Cost

          • Videos are all freely available on Youtube, while the accompanying OSCE guides and notes require a very affordable subscription payment.

          Headspace

          • Cost

          • Time-limited free trial, but requires a subscription for full access to all content.

          MedSchool 

          • Cost

          • Clinical tools are free; the rest of the app requires a subscription.

          Todoist

          Available on web, iOS, and Android, Todoist is a versatile and accessible tool that can help medical students stay on top of their to-do lists and maximize their productivity.

          ECG Learning Centre

          • Limitations

          • No iOS or Android app available.
          • Less interactive than some other resources.
          • Outdated user interface and complex nested navigation.

          Methods for Remembering Facts / Lists

          • In order to get started with the memory palace method, try the following:
          • Create a list of things to remember - this works best when trying to remember large numbers of words or terms.
          • Use mental images that remind you of each item on the list - for example, a tiger for the thyroid, a toaster for the thymus and a book for the sternum. Choose the first image that comes to mind.
          • Imagine a familiar place, such as your bedroom, kitchen or bathroom.
          • Mentally imagine each of the images inside the place. Ideally, imagine each image in the corner of the room. 

          Final Thoughts

          Flashcard Platforms

          • Flashcard Hero

          • Flashcard Hero is a simple an affordable flashcard app that allows users to create flashcards and organise them into decks. 

          Substance History

          Finally, ask about recreational drug use, and particularly intravenous drug use. Uncommonly, patients who develop infective endocarditis in the context of IV drug use may develop septic emboli which migrate to the kidneys and cause renal failure.

          III, IV & VI - Eye Movement

          • Assess the Extraocular Movements

          • Ask the patient to keep their head still and watch your finger as you move it through a modified H pattern:

          Arms

          • Blood Pressure

          • Always offer to measure the patient's blood pressure.

          White Blood Cells

          • Basophils

          • Basophils are uncommon white blood cells. Basophilia may be seen with viral infections, allergy, inflammation and certain haematologic malignancies.

          Acid-Base Balance

          • Bicarbonate (HCO₃)

          • Bicarbonate is one of the major alkali present in the blood, and plays a crucial role in acid-base balance through renal metabolism. Significant derangement suggests the presence of a metabolic process:

          • An elevated bicarbonate suggests a metabolic alkalosis (primary process) or metabolic compensation for respiratory acidosis (secondary process).
          • A reduced bicarbonate suggests a metabolic acidosis (primary process) or metabolic compensation for respiratory alkalosis (secondary process)

          The Blood Film in Haemolysis

          • Prekeratocytes & Keratocytes

          • Keratocytes, or bite cells, are cells with bite-like defects in their membranes, due to phagocytosis of a Heinz body. Keratocytosis may occur in the context of oxidative haemolysis, in the context of glucose-6-phosphate dehydrogenase (G-6-PD) deficiency with a trigger (particularly medications) or in patients with unstable haemoglobins.

          Avoiding Confounders

          • Sample Haemolysis

          • The red blood cells in a sample may break down after sampling. This will affect the validity of potassium, LFT, amylase, creatine kinase (CK), folate, glucose, LDH and crossmatch results.

          Invasive Ventilation

          • Indications for Invasive Ventilation
          • Airway

          • Inability to maintain airway patency (upper airway obstruction) - soft tissue swelling, deformity, obesity, tongue displacement
          • Inability to protect the airway - sedation (e.g. for procedures), upper airway bleeding, excessive secretions
          • Breathing

          • Inability to ventilate - unconsciousness, sedation, neuromuscular disease, exhaustion
          • Inability to oxygenate - severe acute respiratory failure
          • Circulation

          • Cardiac arrest

          Complications

          Check for kinks, and then remove the cannula if it is not flushing.

          Writing on Slides

          However, you may not always have access to the lecture slides. You will also quickly have a buildup of printed or digital slides to go through that you can't necessarily build on - your notes will become a snapshot of that particular lecture. If you're likely to go back and revisit it then that's fine, but if you'd like to build notes up and easily access them then this is not the best method.

          Amboss

          Amboss is a clinical medicine app that offers a large amount of information in note form. The app includes features like case-based learning, a question bank, and a library of study materials. Amboss also offers detailed explanations and reasoning behind each question, which can be helpful for deepening your understanding of the material. 

          Quizlet

          • Platforms

          • Web, iOS and Android.

          Notion

          • Cost

          • Free personal version, with premium available for $4 per month

          Ninja Nerd

          The information is presented in an engaging way using whiteboard diagrams, and Zach is an excellent teacher. The videos are often relatively long, and the content is at times more detailed that medical students need to know (one video about glycolysis was 30 minutes long, with a separate video about regulation of glycolysis that was also 30 minutes long).

          Geeky Medics

          • Geeky Medics

          Headspace

          • Headspace

          MedSchool 

          • MedSchool 

          Todoist

          • Pros

          • Simple and user-friendly interface.
          • Offers task management features and prioritisation options.
          • Integrates with other apps and services.

          Methods for Remembering Facts / Lists

          More objects can be placed in different places (e.g. above the fireplace, next to the doorway) and the room can become more full with items - at times the method can be used to remember hundreds of words.

          Flashcard Platforms

          • Flashcard Platforms

          Tables

          Creating a table can be useful a useful way of categorising information, or comparing and contrasting ideas. They are great for memorising information because they elucidate the relationships between concepts.

          Fusion & Capture Beats

          A capture beat occurs when a sinus impulse is normally conducted down the AV node and 'captured' by the ventricle, resulting in a normal QRS complex.

          Posterior Myocardial Infarction

          • ECG Findings in Posterior Myocardial Infarction

          • ST depression in leads V1-V3
          • ST elevation in posterior leads (V7-V9) of at least 0.5mm

          III, IV & VI - Eye Movement

          • III, IV & VI - Eye Movement

          Arms

          • Arms

          Platelets

          Platelets are very small non-nucleated cells that derive from fragmentation of megakaryocytes. They play an important role in clot formation and haemostasis.

          Acid-Base Balance

          • Base Excess (BE)

          • The bicarbonate level is significantly influenced by acid-base buffering system, and can by affected by the presence of a respiratory process. The base excess is an indicator of a metabolic process that is independent of this buffering system.

          Assessment of Joints

          • Joint Effusions

          • Look for fluid within the joint; also known as a joint effusion. This may be traumatic or associated with inflammation - such as with infection, osteoarthritis, autoimmune arthritis crystal arthropathy or malignancy.

          The Blood Film in Haemolysis

          Prekeratocytes, also known as blister cells, are similar to bite cells with a small sliver of membrane remaining over the bite.

          Avoiding Confounders

          • The most common causes of sample haemolysis are:
          • Vigorous mixing of the sample
          • Drawing blood from a haematoma
          • Drawing too quickly
          • Using a needle that is too small
          • Forcing the blood into a collection tube using a syringe

          Invasive Ventilation

          • Listed below is a summary of common ventilation modes:
          • Volume Control

          • Continuous mandatory ventilation (CMV) - the ventilator delivers a set number of breaths per minute at a set volume; the patient cannot trigger breaths
          • Volume Assist / Control - the ventilator delivers a set number of breaths per minute at a set volume; the patient can trigger assisted breaths at the same tidal volume
          • Pressure Control

          • Continuous Positive Airway Pressure (CPAP) - the ventilator delivers a set positive pressure (PEEP), with no additional inspiratory pressure
          • Pressure support (PS) - the ventilator supports the patient's spontaneous breaths with a set positive inspiratory pressure, with or without positive end expiratory pressure (PEEP)
          • Pressure Assist / Control - the ventilator delivers a set number of breaths per minute at a set inspiratory pressure; the patient can trigger assisted breaths at the same pressure
          • Other

          • Syncronised Intermittent Mandatory Ventilation (SIMV) - the ventilator waits for the patient to breath, and supports each breath with set volume or pressure. If the patient does not breath within a set timing window, the ventilator delivers a mandatory supported breath

          Complications

          • Bruising

          • Haematomas may occur due to blood leaking from the vein into surrounding tissue, either around a cannula or after a cannula has fallen fully out. 

          III, IV & VI - Eye Movement

          • Ask the patient whether they have pain or double vision. Look for limitation of eye movement in any direction, which may be suggestive of specific pathology:
          • Oculomotor nerve palsy - eye deviated down and out, with ptosis, mydriasis and loss of pupillary reflexes
          • Trochlear nerve palsy - head tilted away from the side of the lesion, with the eye deviated upward and rotated outward; inability to look down
          • Abducens nerve palsy - eye deviated inward, with inability to look laterally
          • Internuclear ophthalmoplegia (INO) - inability to adduct one eye, with nystagmus in the other eye. This sign is suggestive of multiple sclerosis in younger patients, and stroke in older patients.

          Arms

          The cuff should measure ~80% of the patient's arm circumference; inflate the cuff to 30mmHg beyond where the pulse is no longer palpable, then slowly deflate until the beating sound is first heard (this is the systolic blood pressure). Then deflate until the beating sound disappears entirely (this is the diastolic blood pressure). Never check the blood pressure on an arm with an AV fistula or axillary clearance for breast cancer.

          Platelets

          Ref Interval
          Platelets150 - 400 x 10⁹/L

          Acid-Base Balance

          A base excess of greater than +2 suggests the presence of a metabolic alkalosis, while a base excess of less than -2 suggests a metabolic acidosis.

          Assessment of Joints

          To assess for an effusion of the knee, look for fluid within the suprapatellar pouch, as well as for fluid in Hoffa's triangle (anteriorly, between the femur and tibia).

          The Blood Film in Haemolysis

          • Sickle Cell

          • Sickle cells, also known as drepanocytes, are crescent-shaped cells caused by aggregation of haemoglobin S. These are pathognomonic of sickle cell disease.

          Avoiding Confounders

          • Sample Coagulation

          • A blood sample is liable to clot if it is left sitting for too long before placing it in the correct tubes, or if the blood is inadequately mixed within a tube. This may affect the validity of multiple results including the white cell count, red cell indices, platelet count and the coagulation profile.

          Complications

          Haematoma formation can be prevented by inserting the cannula properly, and by placing pressure onto the site when a cannula is removed.

          Amboss

          While Amboss is relatively expensive compared to other offerings, it may be a useful resource if you want access to a comprehensive and detailed database of clinical information.

          Quizlet

          • Cost

          • Free limited version; premium version available on a monthly or yearly subscription.

          Notion

          • Notion

          Ninja Nerd

          The videos are all available on YouTube for free. A subscription is available on the website which offers additional notes and digital illustrations.

          Geeky Medics

          Geeky Medics is a web and app platform that provides clinical skills training through videos as well as notes, quizzes and OSCE stations. The platform offers a wide range of high-quality clinical skills training videos including guides to physical examination and procedures. The videos are delivered by experienced clinicians and educators and are designed to help medical students develop practical clinical skills.

          Headspace

          Headspace is a popular mindfulness app that offers guided meditations, mindfulness exercises, and other tools for relaxation and stress reduction. It was started by a former Buddhist monk and has several sections including meditate, sleep, move, and focus. The app encourages users to start with just ten minutes of meditation per day and has a great user interface.

          MedSchool 

          MedSchool is an online platform  and app providing medical students with a curated list of the most useful clinical calculators. The easy-to-use interface allows for easy navigation and use. The Tools section is a subset of the entire platform, which is a clinical reference for medical students including guides to history, examination, tests and drugs.

          Todoist

          • Cons

          • Some features require a paid subscription.
          • Limited customization options.
          • Not suitable for complex project management.

          MedSchool 

          • Platforms

          • Web, iOS, Android

          Methods for Remembering Facts / Lists

          When you need to recall the information, imagine walking through the room and seeing the objects you placed - hopefully each object will remind you of the word you have associated with it.

          Join a Study Group

          Your university may create a study group for you. If not, then consider creating your own study group. This can be to study for a specific assessment, practice practical skills or to generally learn together.

          Flashcard Platforms

          Flashcard hero is available on Mac, iOS and Windows 10. The app is available for a one-off purchase.

          Tables

          • Example: Abdominal Distension

          • Tables

          Fusion & Capture Beats

          • Fusion & Capture Beats
             

          De Winter Waves

          De Winter waves are an ECG finding that suggest acute occlusion of the proximal left anterior descending (LAD) artery. These are a STEMI equivalent, and should be treated immediately.
          • De Winter Waves
             

          Amboss

          • Pros

          • Large amount of clinical information in an easy to read form.
          • Comprehensive diagnostic and treatment tools.

          Quizlet

          • Quizlet

          Notion

          Notion is an absolutely feature-packed and flexible app that can do much more than notes. Notion is database-driven, meaning that pages work together and reference each other. As a result, the app is extremely flexible and customisable. There are a lot of templates that can be used to get started.

          Ninja Nerd

          • Ninja Nerd

          Geeky Medics

          All of the videos are freely available on Youtube, though to view them in the app along with the explanatory notes you’ll need a subscription. The subscription is incredibly affordable compared to other platforms on this list.

          Headspace

          A free trial is available, though this signs you up for a subscription - while you can cancel the subscription after your trial, it would be ideal if even basic meditations were available for free.

          MedSchool 

          The Tools section in MedSchool is free, though a subscription is required to unlock the rest of the app (there is a free trial). 

          MedSchool 

          • Cost

          • Free trial, affordable subscription.

          Methods for Remembering Facts / Lists

          More comprehensive guides to using the memory palace are available if you would like to learn more about this method.

          Join a Study Group

          The benefits of study groups are many - if you're having issues with motivation then a group can hold you to task and push you to keep up with your learning schedule.

          Conclusion

          Flashcards are a versatile and effective tool for working through the vast swathes of information that you’ll need to learn and remember as a medical students. While creating your own flashcards is the best way to learn, pre-made medical flashcards are available through various flashcard platforms.

          Tables

          Tables are difficult to make quickly, and are more useful when you're in your study time. They require understanding of the overarching structure of the content as they are relatively inflexible once the rows and columns are labelled.

          III, IV & VI - Eye Movement

          The patient may also have fatiguability of eye movements, meaning that they can initially look up but not maintain this gaze over time - this is a sign of myaesthenia gravis.

          Arms

          Hypertension (increased BP >140/90) may have primary or secondary causes, and is associated with increased risk of both acute and chronic cardiovascular complications. Hypotension (reduced systolic BP <100mmHg) is associated with postural hypotension, cardiac disease, hypovolaemia and shock.

          Platelets

          Thrombocytosis is an increase in circulating platelets. Primary thrombocytosis is seen with myeloproliferative neoplasms such as essential thrombocytosis or CML, while secondary thrombocytosis may occur in reaction to infection, inflammation or malignancy.

          Acid-Base Balance

          • Arterial Partial Pressure of CO₂ (PaCO₂)

            The PaCO₂ is the arterial partial pressure of carbon dioxide. An increase or decrease in the PaCO₂ level suggests the presence of a respiratory process causing an acid-base imbalance:
          • An elevated PaCO₂ suggests a respiratory acidosis (primary process) or respiratory compensation of metabolic alkalosis (secondary process).
          • A reduced PaCO₂ suggests a respiratory alkalosis (primary process) or respiratory compensation of metabolic acidosis (secondary process).

          Assessment of Joints

          To assess for an effusion of the ankle, look for a teardrop-shaped hyperdensity anterior to the ankle joint, due to displacement of the pretalar fat pad by fluid within the joint space.

          The Blood Film in Haemolysis

          • Polychromasia

          • Polychromasia refers to macrocytic erythrocytes with a bluish tinge - these cells are reticulocytes, which are immature red cells. This finding is an indicator of haemolytic anaemia, though polychromasia may also occur following haemorrhage or during recovery following bone marrow suppression.

          Complications

          To assess for bruising, look for a red/purple discolouration of a cannula, which may be associated with swelling and tenderness.

          V - Facial Sensation & Jaw Muscles

          The trigeminal nerve (V) innervates sensation of the face, corneas, nasal cavity and oral cavity. The third branch of the trigeminal nerve (the mandibular nerve) also innervates the muscles of mastication.

          Arms

          Note the patient's pulse pressure, or the difference between the systolic and diastolic blood pressure. A narrow pulse pressure is a sign of severe aortic stenosis, severe mitral stenosis or hypovolaemia. A widened pulse pressure (often along with a collapsing pulse) is a sign of aortic regurgitation or patent ductus arteriosis.

          Platelets

          Thrombocytopaenia is a reduction in platelets. This may occur within the context of bone marrow failure, suppression or infiltration; dietary deficiency; splenomegaly (e.g. due to cirrhosis); viral infections and immune-mediated thrombocytopaenias (e.g. ITP, HIT, DIC, TTP, HUS). Thrombocytopaenia may also be congenital.

          Acid-Base Balance

          • The Anion Gap

          • The anion gap is used to further assess someone with a metabolic acidosis. It is a calculation of the unmeasured anions and cations in the blood, based on anions and cations that we can measure (sodium, chloride and bicarbonate). 

          Assessment of Joints

          • Signs of Osteoarthritis

          • Four key signs suggest the presence of osteoarthritis:

          • Reduced joint space - generally asymmetric
          • Subchondral sclerosis: increased bone deposition surrounding the joint
          • Subchondral cysts: cystic formations around the joint
          • Osteophytes: bony projections along the joint line

          The Blood Film in Haemolysis

          • Red Cell Inclusions

          • The Blood Film in Haemolysis

          Complications

          Bruising should be treated by applying a pressure bandage to the area. If the cannula is no longer in the vein or ongoing bleeding occurs then the cannula should be removed.

          Amboss

          • Cons

          • Expensive compared to other offerings, with limited free content.

          Quizlet

          Quizlet is a flashcard platform that allows users to create their own flashcards and access millions of pre-made flashcard decks created by others, including those for USMLE and medical topics generally. It can take some digging to find a good pre-made deck, and since these are created by users, there is a risk that the information may be incorrect or outdated.

          Notion

          Notion allows for a clear, nested hierarchy allowing you to organise information in any way you can imagine. The app also allows you to share pages and collaborate with others.

          Ninja Nerd

          • Pros

          • Free
          • Incredible range of videos for a free resource

          Geeky Medics

          • Geeky Medics

          Headspace

          • Headspace

          MedSchool 

          • Pros

          • Curated list of the most clinically relevant calculators.
          • User-friendly interface access.
          • The Tools section is free.

          MedSchool 

          • MedSchool 

          Methods for Remembering Concepts

          Concepts can be more difficult to commit to memory, particularly if the concept is complex. Several methods may be used to optimise our recall of concepts.

          Join a Study Group

          • A few tips in forming a study group are:
          • Keep the group small - aim for three to five members.
          • Find others with similar goals and expectations to you.
          • Avoid being in a study group with close friends, as this can prove to be a distraction.
          • Try to include others with different skill sets so that there are different types of contribution to the group.
          • Have a shared study schedule that you agree on, and stick to the schedule.
          • Study for one to two hours at a time - too short and you won't accomplish much, too long and you'll start getting less productive.

          Conclusion

          Ultimately, the key to success with flashcards is consistent use over time, and incorporating flashcards into your normal study routine that includes other study tools and techniques. Remember to use spaced repetition to get the most out of each flashcard review. Good luck in your studies!

          Mindmapping

          Mind maps are a way of relating ideas to each other. Lines are drawn between concepts and subconcepts to demonstrate hierarchy of the information. It mimics the way that the brain works - we process information and memories in terms of relationships between ideas, rather than sequentially.

          De Winter Waves

          • ECG Features of De Winter Waves

          • Up-sloping ST depression at the J point (1-3mm) in the precordial leads (V1-V6)
          • Tall, positive, symmetrical T waves

          Wellen's Syndrome

          Wellen's syndrome, also known as the 'widowmaker', is an ECG finding that is highly suggestive of proximal left anterior descending (LAD) artery occlusion and imprending anterior myocardial infarction.

          Quizlet

          Quizlet offers a variety of study modes, including flashcards, quizzes, and games. With its vast library of pre-made flashcards and versatile study modes, Quizlet is a popular and effective medical study tool.

          Notion

          The benefit of the app can also be a downside - the number of features can be overwhelming and there is a learning curve to getting started. The way that pages are formatted (in blocks) can be difficult to use when you're writing large amounts of information. Currently the app requires an internet connection to use.

          Ninja Nerd

          • Cons

          • Videos presented by non-doctors - caution around clinical medicine topics
          • The videos are offten relatively long and some content is too detailed for medical students

          Geeky Medics

          • Pros

          • High-quality clinical skills training videos
          • Also provides quizzes, flashcards, notes and OSCE stations
          • A lot of content is free - the rest is very affordable

          Headspace

          • Pros

          • Offers a wide variety of guided meditations and mindfulness exercises
          • Easy to use interface

          MedSchool 

          • Cons

          • Fewer calculators compared to other resources.

          MedSchool 

          MedSchool is a comprehensive clinical reference app designed specifically for medical students. The app features a range of content, including a comprehensive ECG education section covering the basics, tachyarrhythmias, bradyyarrhythmias, conduction block and specific disease patterns. The app also offers an ECG quiz with example ECGs. The ECG education section provides detailed explanations of ECG concepts, with high-quality images to help you understand the material.

          Methods for Remembering Concepts

          • Analogies

          • Analogies are a commonly used method of understanding new ideas, by relating an unfamiliar concept  with a familiar one. By drawing parallels between a concept that you know and a new concept, it is possible to more rapidly understand the key ideas underpinning a new concept.

          Teach Others

          Explaining a concept to others significantly improves your understanding of the topic. In fact, this benefit occurs even when you simply expect to teach a concept. In a Washington University study, 56 students were asked to learn written material; half were told that they would then take a test on the topic and half were told that they would go on to teach the topic to others. Those who believed that they were going to teach demonstrated improved recall compared to the other group.

          Conclusion

          • Conclusion

          V - Facial Sensation & Jaw Muscles

          Acid-Base Balance

          Anion Gap = Na⁺ - ( Cl⁻ + HCO₃⁻ )

          Assessment of Joints

          • Signs of Rheumatoid Arthritis

            There are four key findings on x-ray that suggest a diagnosis of rheumatoid arthritis:
          • Reduced joint space - generally symmetric
          • Articular surface erosions: discontinuities in the bone plate
          • Periarticular osteopaenia: hypodensity of bone surrounding the joint
          • Soft tissue swelling

          The Blood Film in Haemolysis

          Nucleated red blood cells are immature red blood cells that contain nuclei. They may present in the context of severe anaemia, severe sepsis, hypoxia or bone marrow disease.

          Complications

          • Cannula Extravasation

          • Extravasation of infused fluids may occur if a cannula falls out of a vein, or if there is leakage around the cannula. This should be suspected if there is swelling around the site, pain, tightness or coolness due to accumulation of fluid.

          Mindmapping

          Mindmapping is at least non-inferior to standard note taking: in a study of 131 medical students attempting to remember a text passage, there was no significant difference between the group that learned by standard note-taking and the group that learned by drawing mind maps.

          Quizlet

          • Quizlet

          Notion

          There is a free personal version, with a relatively expensive premium version available.

          Geeky Medics

          • Cons

          • Limited coverage of clinical medicine topics beyond clinical skills

          Headspace

          • Cons

          • The free trial requires you to sign up to a subscription (which you can later cancel) - full access requires a subscription, which can be costly

          Focus Keeper

          • Platforms

          • Web, iOS, Android

          MedSchool 

          The app is available on the web, iOS and Android, and while it is free to try, an affordable subscription is required to access all content. 

          Methods for Remembering Concepts

          A classic example of an analogy in medicine is about the heart. The circulation is a series of tubes like a plumbing system, with the heart serving as the pump. The cardiac conduction system is like the electrical wiring. It is often useful to explain the various specialties to a patient by describing a cardiologist as the plumber, an electrophysiologist as the electrician and a cardiothoracic surgeon as the carpenter when it comes to dealing with the cardiovascular system.

          Teach Others

          Teaching can occur in many different ways. Universities often have problem-based or team-based learning sessions where students have the opportunity to teach topics of interest to their colleagues. Medical schools also often have peer tutoring systems where higher year medical students teach early year students. Hospital teams often have journal clubs where students present recent papers. 

          Mindmapping

          • Example

          • Mindmapping

          Vacuolated Neutrophils

          The presence of vacuoles within neutrophils on a blood film is highly suggestive of infection.

          Wellen's Syndrome

          This may be associated with unstable angina, however the finding often occurs while asymptomatic.

          Overview

          Wash your hands and don gloves.

          V - Facial Sensation & Jaw Muscles

          • Assess Facial Sensation

          • Using a piece of cotton wool, lightly touch the patient's face over the three trigeminal areas of innervation, moving from side to side. Ask the patient if there is any area that is numb or has altered sensation in any way. Loss of sensation in the distribution of a single branch suggests a peripheral nerve lesion (V1 / V2 / V3), while complete loss of sensation on one side suggests a CNS lesion.

          Arms

          • Collapsing Pulse

          • Next, feel for collapsing pulse. This can be thought of as palpably widened blood pressure, in the context of aortic regurgitation or patent ductus arteriosis. First ask the patient if they have any pain in their left shoulder, then lift their left shoulder up while palpating the radial pulse. Feel for a strong pulse with sudden drop in intensity following its peak.

          Acid-Base Balance

          The normal range of the anion gap is 8 - 16.

          Assessment of Soft Tissues

          • Air Within Soft Tissues

          • Look for air within the soft tissues, especially around the site of a fracture. Presence of air is indicative of a compound fracture.

          The Blood Film in Haemolysis

          Heinz bodies are basophilic denatured haemoglobin molecules that are present in the context of oxidative haemolysis. These may only be seen on supravital staining.

          Complications

          If extravasation is suspected, stop the infusion and remove the cannula. The limb should be elevated to assist in drainage of fluid. Consider whether the medication is vesicant, or likely to cause significant irritation of the soft tissues; further supportive management may be required in this case.

          V - Facial Sensation & Jaw Muscles

          • V - Facial Sensation & Jaw Muscles

          Arms

          • Arms

          Acid-Base Balance

          A normal anion gap metabolic acidosis (NAGMA) suggests that loss of bicarbonate is ocurring, either due from the gastrointestinal tract (e.g. diarrhoea) or kidneys (e.g. Addison's, renal tubular acidosis, acetazolamide).

          Assessment of Soft Tissues

          • Foreign Body

          • Look for foreign bodies within the soft tissues - particularly shrapnel which may have been deposited during penetrating injury.

          Complications

          • Line-Related Infections

          • Line-related infections vary from small localised reactions to life-threatening staphylococcal bacteraemia. 

          Vacuolated Neutrophils

          • Vacuolated Neutrophils
             

          Wellen's Syndrome

          The presence of Wellen's syndrome is life-threatening and requires rapid intervention, though has the potential to be missed if an ECG is not examined carefully.

          Quizlet

          • Pros

          • Can create custom flashcards with text, images, and audio
          • Large library of pre-made flashcards on various medical topics
          • Offers a variety of study modes above and beyond flashcards

          Notion

          • Pros

          • Extremely flexible and customisable
          • Clear hierarchy
          • Free personal account
          • Allows collaboration

          Focus Keeper

          • Cost

          • Free for a limited number of tasks, affordable subscription for more

          MedSchool 

          • MedSchool 

          Methods for Remembering Concepts

          In a study of nearly two hundred adults, those who learned information using analogies performed superiorly in immediate and delayed recall when compared to those who learned without analogies (Halpern). Those who learned using analogies were also more likely to be able to infer new information about the topic, and create their own analogies about it.

          Teach Others

          More simply, consider using the Feynman technique and pretend to teach a topic that you've just learned to a twelve year old, in the simplest language possible.

          Mindmapping

          This method is useful for understanding complex topics, and maps can easily be changed, edited and built upon. Maps can become difficult to use when it is unclear from a lecture or text how the concepts presented relate to each other. Overly bulky mind maps can be complicated and difficult to follow.

          Overview

          Remove the dressing and any tape surrounding the cannula.
          Remove the cannula in a steady, fluid motion.

          Vacuolated Neutrophils

          • Causes of Vacuolated Neutrophils

          • Infection
          • G-CSF
          • Acute heavy alcohol intake

          Wellen's Syndrome

          • Wellen's Syndrome
             

          V - Facial Sensation & Jaw Muscles

          • Muscles of Mastication

          • Ask the patient to clench their teeth, and palpate the muscles of mastication. Ask the patient to open their mouth against resistance. Weakness of the muscles of mastication may be a sign of a lesion affecting the mandibular branch of the trigeminal nerve (V3), however may also occur due to an upper motor neuron lesion.
          • Abnormal Facies

          • Look at the patient's face for evidence of mitral facies: a rosy complexion of the cheeks with patches of blue discolouration, - a classical sign of mitral stenosis.

          Acid-Base Balance

          A high anion gap metabolic acidosis (HAGMA) suggests that there is an excess of acid within the blood - this may be lactate (lactic acidosis), ketones (diabetic, alcoholic or starvation ketoacidosis), nitrogenous wastes (uraemia) or exogenous acids like methanol, ethanol, salicylates or carbon monoxide.

          Complications

          In order to prevent infection, ensure that proper aseptic technique is used and don't insert a cannula through infected tissue. Cannulas should be reviewed regularly for signs of infection, and not left in for too long.

          MedSchool 

          • Platforms

          • Web, iOS, Android

          Quizlet

          • Cons

          • Premium version required for some features
          • Limited control over spaced repetition scheduling
          • Some pre-made flashcards may contain errors or inaccurate information

          Notion

          • Cons

          • Can be overwhelming with a learning curve to start
          • Can be difficult to edit large amounts of text
          • Need to have an internet connection

          Sketchy

          • Platforms

          • YouTube, Web, Web App

          Focus Keeper

          • Focus Keeper

          MedSchool 

          • Features

          • Comprehensive clinical reference app designed specifically for medical students.
          • Comprehensive ECG education section with detailed explanations and example images.
          • ECG quiz with high quality ECG images.
          • iOS and Android apps for easy use on the wards.

          Methods for Remembering Concepts

          • Mindmaps

          • Drawing a mindmap is a way of relating ideas in terms of their hierarchy. For example, a mindmap may explain the different types of lymphoma and how they develop from B or T lymphocytes and their precursors. Mindmaps tend to start from a key heading at the center of the page and radiate outward. 

          Teach Others

          No matter the opportunities that are available, try to find ways to teach others as it will benefit you as well.

          Flow-Based Note-Taking

          Note-taking using the flow method is a way of simplifying and processing information then representing it visually. Flow-based notes are essentially a transcription of your mental image on a topic, rather than a hierarchical or categorised system.

          MedSchool 

          • Cost

          • Free to try, monthly or yearly subscription to continue

          Sketchy

          • Cost

          • Small number of videos available for free, with a monthly or yearly subscription for everything

          Calculate by QxMD 

          • Platforms

          • Web, iOS, Android

          Focus Keeper

          Focus Keeper is a time management app that uses the Pomodoro technique, which can help you stay focused and manage your time more effectively. The app divides each focus session into timed intervals, typically 25 minutes long, with short breaks in between. 

          MedSchool 

          • Cons

          • Subscription required to access all content.
          • No structured course content.
          • No case studies.

          Methods for Remembering Concepts

          Creating a mindmap about a topic can improve our overall understanding of the structure of the topic, and leave an imprint in our minds that can stimulate recall. In order to improve recall, try redrawing a mindmap from memory and then comparing your copy to the original mindmap.

          Flow-Based Note-Taking

          This method allows for learning during lectures rather than just writing down what is said, and requires the most active processing. While writing flow-based notes, try to focus on listening and paying attention, writing down only the key concepts in as few words as possible. Draw arrows to connect related ideas.

          Dohle Bodies

          Dohle bodies are blue cytoplasmic inclusions seen within neutrophils. These inclusions are remnants of the rough endoplasmic reticulum, and may be seen in cases of significant stress.

          Wellen's Syndrome

          • Wellen's Syndrome
             

          Overview

          Apply pressure to the area using sterile gauze, then place a small dressing (such as a cotton ball) to the area with tape.

          V - Facial Sensation & Jaw Muscles

          • Jaw Jerk

          • The jaw jerk involves the mandibular branch of the trigeminal nerve (V3) as both its afferent and efferent arms. Place a finger horizontally over the chin with the mouth open, and then strike this finger with a tendon hammer. While a slight jerk may be normal, an exaggerated jerk is a sign of an upper motor neuron lesion.

          Complications

          Signs of infection include erythema, swelling, warmth, tenderness and pus surrounding a current or previous cannula site. More severe infection is suggested by fevers and other constitutional symptoms.

          V - Facial Sensation & Jaw Muscles

          • Corneal Reflex

          • Always offer to perform the corneal reflex, however avoid this test if possible because it is very unpleasant. To test the corneal reflex, lightly touch the cornea from the side with a piece of cotton wool. Look for blinking in response to touching the cornea; lack of blinking is a sign of pathology somewhere along the reflex pathway.
          • Head

          Complications

          If infection is suspected, remove the cannula and observe the site. If clinically indicated, the patient may require treatment for cellulitis or bacteraemia.

          Dohle Bodies

          • Dohle Bodies
             

          Wellen's Syndrome

          • Signs of Wellen's Syndrome

          • Type A - biphasic T waves in leads V2-V3
          • Type B - deep T wave inversion in leads V2-V3

          Flow-Based Note-Taking

          • Example

          • Flow-Based Note-Taking

          MedSchool 

          • MedSchool 

          Bear

          • Platforms

          • Mac, iOS

          Sketchy

          • Sketchy

          Calm

          • Platforms

          • iOS, and Android.

          Calculate by QxMD 

          • Cost

          • Free with ads

          Focus Keeper

          This technique encourages you to break down larger tasks into smaller, more manageable segments and guides you to take regular breaks to stay refreshed and focused. Focus Keeper allows you to customize the length of your focus time and breaks and track your focus sessions over time, making it a versatile tool for improving productivity during medical school study sessions. 

          Methods for Remembering Concepts

          • Flowcharts

          • A flowchart is a visual representation of a process that includes multiple steps. An example of a flowchart would be the hypothalamic-pituitary-adrenal (HPA) axis, with all of the hormones and inhibitory effects involved. Flowcharts provide a simple representation of a complex process that make it easier to understand, thus promoting recall. Again, you can optimise recall by trying to redraw a flowchart from memory.

          MedSchool 

          MedSchool is a clinical reference app designed specifically for medical students. The app offers a range of features to help students learn and study more effectively, including guides to history, examination, investigations, and drugs. The app also includes examination checklists to ensure that important steps are not missed during clinical assessments, as well as quizzes to test knowledge and clinical calculators and tools to aid in making quick and accurate calculations in a clinical setting.

          Bear

          • Cost

          • Free version, with premium available for $1.49 per month

          Sketchy

          Sketchy (previously SketchyMicro, SketchyPharm or SketchyMedical) is an incredibly unique medical platform that is very different from the other resources on this list. Each video employes visual storytelling to teach complex medical concepts, using a technique that is reminiscent of the memory palace. The videos start with a background or landscape, and as each concept is explained an item or character appears which represents the concept. This can be a great way to memorise a large amount of important information. 

          Osmosis

          • Platforms

          • YouTube, Website, iOS, Android

          Calm

          • Cost

          • Time-limited free trial, but requires a subscription for full access to all content.

          Calculate by QxMD 

          • Calculate by QxMD 

          Focus Keeper

          The app is free to download and create a limited number of tasks, but a subscription is required to really make the most of the app. Available on web, iOS, and Android, Focus Keeper is a simple yet effective tool for staying on task and making the most of your study time.

          Test Yourself

          One of the more effective ways of improving your memory of a topic is to test yourself. Retrieving a topic from your memory repeatedly (known as practicing retrieval) improves learning more than just studying the same information over and over (Karpicke & Blunt). 

          Flow-Based Note-Taking

          Flow-based note taking highlights important concepts in realtime while minimising irrelevant details. This can allow you to avoid mindless copying that can occur with hierarchical note taking techniques such as outlines or mind maps.

          Dohle Bodies

          • Causes of Dohle Bodies

          • Infection
          • Burns
          • Trauma
          • G-CSF administration

          V - Facial Sensation & Jaw Muscles

          • Glabellar Tap

          • In patients with suspected Parkinsonism, perform the glabellar tap. Percuss repeatedly between the eyebrows, looking for reactive blinking. Up to five blinks are normal, however lack of habitualisation is a sign of frontal damage or Parkinsonism.
          • Fundoscopy

            When performing the cardiovascular exam, always offer to perform fundoscopy - though recognise that the yield will likely be low in a patient without a dilated pupil. Look for:
          • Hypertensive eye changes such as silver wiring, arteriovenous nicking, flame-shaped haemorrhages, cotton wool spots and papilloedema.
          • Roth spots - pale patches on the retina with a ring of surrounding haemorrhage, and are a sign of infective endocarditis.

          Acid-Base Balance

          • The Gap-Gap Ratio

          • The gap-gap ratio is used to further assess patients with a high anion gap metabolic acidosis (HAGMA).

          Complications

          • Thrombophlebitis

          • Thrombosis may occur with any cannula - particularly if it is left in too long, if the area is infected. Irritant medications such as potassium infusions can cause painful phlebitis without thrombosis.

          VII - Facial Movement

          The facial nerve (VII) provides somatic motor supply for facial expression; somatic sensory supply to the external ear; taste to the anterior â…” of the tongue; and parasympathetic innervation of several salivery and lacrimal glands.
          Or, at least, mention that you would look for those things.

          Acid-Base Balance

          The calculation essentially checks whether the change in anion gap from normal is equivalent to the change in the bicarbonate from normal - i.e. that all of the bicarbonate change is accounted for by a high anion gap process.

          Complications

          Suspect thrombosis or thrombophlebitis if there is erythema, oedema, pain or swelling surrounding a cannula site. In some cases there may be erythema and swelling along the course of the vein.

          MedSchool 

          While the app offers a free trial, subscriptions are required to continue using the app after the trial period, with costs varying depending on the length of subscription.

          Flashcard Hero

          • Platforms

          • Mac, iOS and Windows 10.

          Bear

          • Bear

          Sketchy

          Videos are separated into domains such as anatomy, physiology, pathophysiology and pharmacology, with specific programs available for USMLE preparation. The platform is available via the web, as well as a web app for mobile users.

          Osmosis

          • Cost

          • A large number of videos are free on YouTube. The website offers a free seven-day trial, with a subscription for everything.

          Calm

          • Calm

          Calculate by QxMD 

          Calculate by QxMD is a free medical calculator app designed to assist healthcare professionals. With hundreds of clinical tools including risk scores, dosing calculators, and diagnostic criteria, Calculate by QxMD helps users enhance their decision-making abilities and improve overall clinical proficiency. Its user-friendly interface and broad range of tools make it an excellent resource for when you’re on the wards. The app is made by MedScape, and so the interface is the same as MedScape.

          Focus Keeper

          • Pros

          • Keeps you on task during focus sessions.
          • Encourages regular breaks to stay refreshed.
          • Customizable timer and break intervals.

          MedMastery ECG Courses

          • Platforms

          • Web

          Test Yourself

          • There are several ways to test yourself on content and practice retrieval:
          • Post-study recall - after a study session, attempt to remember the key points that you have learned. This may be augmented using the split page or Cornell note-taking methods.
          • Mnemonics - use existing mnemonic devices (e.g. acronyms or expression mnemonics) or create your own. Practice recalling what the acronym or expression stands for.
          • Mindmaps / diagrams - practice redrawing a mindmap or diagram from memory, and compare this to your notes
          • Question banks - use past questions and practice questions to prompt retrieval of information that you've already learned. In order to solidify this, try then retaking only questions that you got wrong.
          • Flashcards - use existing flashcard decks or make your own. Find a flashcard service that uses spaced repetition in order to optimise your flashcard review sessions.

          Flow-Based Note-Taking

          On the other hand, flow-based notes are often messier and miss details - you may need to go back and relisten to the lecture if a detail isn't written down.

          MedSchool 

          • Pros

          • Comprehensive guides and tools.
          • User-friendly interface.
          • Affordable subscription cost.

          Flashcard Hero

          • Cost

          • Low-cost one-off payment.

          Bear

          Bear is a note-taking app available on Apple devices that has a large number of features. The app is easy to use and allows advanced markup, clipping of webpages. Notes can be placed in nested folders and also tagged, allowing for easily organisation.

          Sketchy

          Sketchy provides a small number of videos for free on the website and there is a very small number of example videos on the YouTube channel, however the subscription cost is within the ‘premium’ resource realm. While the learning style takes some getting used to and isn’t for everyone, but if the videos work for you then they can be a powerful resource.

          Osmosis

          • Osmosis

          Calm

          Calm is a popular mindfulness app that is useful for meditation, sleep, and relaxation. It offers guided meditations, sleep stories read by celebrities, soundscapes, and other tools for stress reduction. The user interface is beautiful and easy to use. The app offers a large amount of personalisability, with tailored recommendations based on your mindfulness goals.

          Calculate by QxMD 

          Calculate by QxMD is free to use but requires you to register. 

          Focus Keeper

          • Cons

          • Limited features beyond time management.
          • No integration with other apps or services.
          • Not suitable for all types of tasks.

          MedMastery ECG Courses

          • Cost

          • $39-47 per month

          Test Yourself

          • Use Spaced Repetition

          • If we were to read about a new topic once, it is likely that we would forget most of the information after even a few hours. The more times that we relearn the same information, the more likely we are to retain it. This concept is illustrated using the Ebbinghaus forgetting curve:

          Split Page Method

          The split page method is similar to the outline method, but uses keywords and questions to aid with recall. This is done by drawing a vertical line down a piece of paper (or using a table of writing notes digitally.

          VII - Facial Movement

          • The Mouth

          • Look in the patient's mouth. Note their dentition (the condition of their teeth), as poor dentition is associated with risk of bacteraemia and infective endocarditis. Look for the high-arched palate of Marfan syndrome.

          Acid-Base Balance

          Gap-gap ratio
          anion gap - 12 24 - HCO₃

          Complications

          If thrombophlebitis is suspected, any infusions should be stopped and the cannula should be removed. The area should be monitored.

          VII - Facial Movement

          • Assess for Facial Weakness

          • Inspect the patient's face, looking for facial asymmetry, facial spasm or blepharospasm (spasm of the eyelid muscles).
          • Central Cyanosis

          • Finally, ask the patient to lift their tongue to the roof of the mouth and assess for cyanosis of the tongue. This suggests significant hypoxia - such as due to pulmonary disease or congenital cyanotic heart disease.

          Acid-Base Balance

          • If a HAGMA is the only process present, then the value will be 1 (unity).
          • If there is a concomitant HAGMA and a NAGMA present, then the value will be <1.
          • If there is both a metabolic acidosis and a metabolic alkalosis present, then the value will be >1.

          MedSchool 

          • Cons

          • Limited diagnostic features.
          • Requires a subscription to use.
          • No case-based learning, and limited information about specific diseases.

          Flashcard Hero

          • Flashcard Hero

          Bear

          Unfortunately the app is not available on Windows and Android. Syncing between devices requires a premium account.

          Sketchy

          • Sketchy

          Osmosis

          Osmosis (by Elsevier) is a comprehensive medical education platform that offers a range of videos. With its engaging and interactive learning tools, Osmosis has become a popular resource for medical students worldwide. The platform is primarily focused on the medical sciences - particularly anatomy, physiology, pharmacology, and pathology - and has a relatively limited number of clinical medicine videos.

          Calm

          Similar to Headspace, Calm offers a free trial that requires signing up for a subscription.

          Calculate by QxMD 

          • Pros

          • Hundreds of clinical tools.
          • User-friendly interface.
          • Free with ads.

          MedMastery ECG Courses

          • MedMastery ECG Courses

          Test Yourself

          • Test Yourself

          Split Page Method

          On the right side, outlined notes are written in a concise way, including key concepts and ideas. On the left side, keywords and questions are written that directly relate to the information next to them. Keywords are used as cues to stimulate recall later on, while questions can be used to test yourself on the content.

          Flashcard Hero

          Flashcard Hero is a simple and affordable flashcard platform for Mac, iOS and Windows 10. Create your own custom flashcards with text, images, and audio, and organize them into decks. 

          Bear

          • Pros

          • Simple interface
          • Feature-packed free version and inexpensive premium version

          Sketchy

          • Pros

          • Very unique approach that uses proven recall techniques
          • Very engaging and memorable sketches
          • Covers a wide range of medical sciences topics
          • Specific USMLE resources

          Osmosis

          A large number of videos are available for free on the YouTube channel, with a lot more on their website. The web platform offers a free seven-day trial and requires a subscription for full access, which is relatively expensive compared to other offerings. However, if you try a few videos on the YouTube channel and they work for you, the subscription may be well worth the cost.

          Calm

          • Calm

          Calculate by QxMD 

          • Cons

          • Limited customization: No personalized notes feature.

          MedMastery ECG Courses

          The Medmastery ECG Courses are online video courses that provide in-depth training on ECG interpretation. Medmastery offers three levels of training - yellow belt, blue belt and black belt - providing differing levels of detail. The courses include videos, case studies and quizzes, and provide an overall comprehensive way of learning ECGs. 

          Test Yourself

          By reviewing information multiple times, we are less likely to forget it over time. This repeated review and recall cycle works best if each review is spaced out in time, rather than reviewing the same information multiple times in quick succession (Karpicke & Bauernschmidt). Ideally each review should happen when we're about to forget the information.

          Split Page Method

          • Example

          • Split Page Method

          VII - Facial Movement

          Ask the patient to raise their eyebrows, close their eyes, puff out their cheeks and then show their teeth. Apply resistance if the movement appears to be weak. 

          Neck

          • Jugular Venous Pressure

          • Visualise the patient's jugular venous pulsation (JVP) between the sternal and clavicular heads of the sternocleidomastoid. With the bed at 45 degrees, ask the patient to turn their head away from you. Look for the highest level of the jugular venous pulsation, and measure the vertical distance between the sternum and this pulsation. This is elevated if greater than 4cm, which suggests fluid overload, right ventricular failure or pulmonary hypertension.

          VII - Facial Movement

          It is important to remember that eyebrow-sparing facial weakness is a sign of an upper motor neuron lesion, while eyebrow involvement is classically a sign of a facial nerve lesion - particularly Bell's palsy or Ramsay-Hunt syndrome (herpes zoster).

          Neck

          • Neck

          Lactate

          Serum lactate is an important marker of prognosis and resolution in many critical illnesses. It is produced via pyruvate metabolism under both anaerobic and aerobic glycolytic conditions, and is mainly metabolised by the liver.

          Flashcard Hero

          Flashcard Hero also includes a study mode that uses spaced repetition to present flashcards at increasing intervals for effective memorization. This app is a simple, low cost option with limited customisability.

          Bear

          • Cons

          • Available on iOS and mac only
          • Syncing requires a premium account

          Sketchy

          • Cons

          • Expensive subscription
          • The method isn’t for everyone

          Osmosis

          • Osmosis

          Calm

          • Pros

          • Offers a wide range of content, including sleep stories and soundscapes
          • Has a user-friendly interface and is easy to navigate
          • Offers personalised recommendations based on individual needs

          MedMastery ECG Courses

          While there is no specific iOS or Android app for the course, the website is very mobile-friendly. Access to MedMastery is accessible via a monthly subscription with two price levels, $39 and $47 monthly, which provide full access to all courses on the website.

          Teach Others

          • Teaching others is one of the best ways to learn and improve recall. There are several ways to do this:
          • Join a study group - this will give you the opportunity to both learn from others and teach others.
          • Tutor your peers - many universities have informal opportunities for teaching medical students in earlier years.
          • Journal clubs - if your clinical team at the hospital has a journal club, you may be asked to find a paper and present it.

          Cornell Method

          The Cornell method is similar but slightly more involved that the split page method.

          Geeky Medics

          • Platforms

          • Web, iOS, Android

          Flashcard Hero

          • Flashcard Hero

          Osmosis

          • Pros

          • Comprehensive range of video resources.
          • A lot of free content on the YouTube channel
          • View videos on the web, iOS or Android

          Calm

          • Cons

          • The free trial requires you to sign up to a subscription (which you can later cancel) - full access requires a subscription, which can be costly

          Forest

          • Platforms

          • Chrome extension, iOS, Android

          MedMastery ECG Courses

          • MedMastery ECG Courses

          Teach Others

          The benefit of teaching others extends to expecting to teach - in a study of students learning written material, recall was improved when students were told that they would be teaching others, compared to being told that they would take a test on the subject. 

          Cornell Method

          A piece of paper is divided into three sections. On the write side, an outline is written that explains the key ideas in a concise way. On the left side, keywords and questions are written that stimulate recall. At the bottom is a brief summary of the content on the page.

          VII - Facial Movement

          Neck

          If the jugular venous pulsation is difficult to visualise, assess for hepatojugular reflux. Ask the patient if they have any pain in their abdomen, then gently press over the right upper quadrant for 10-15 seconds - this temporarily increases venous return, making the JVP more pronounced.

          VIII - Hearing

          The vestibulocochlear nerve (VIII) supplies special sensory innervation providing feedback on both equilibrium (vestibular system) and hearing (cochlea).

          Neck

          • Carotid Pulses

          • Palpate the carotid pulses one at a time, within the anterior neck medial to the sternocleidomastoid. This is mainly to assess the character of the pulse - a pulses tardis and parvis (late and weak) is suggestive of aortic stenosis, while a waterhammer pulse (strong with sudden collapse) suggests aortic regurgitation.

          Lactate

          • Hyperlactataemia

          • An elevated serum lactate reflects an imbalance between production and clearance of lactate. Accumulation of lactate is associated with acidosis; lactic acidosis is a high anion gap metabolic acidosis.

          Geeky Medics

          • Cost

          • A large amount of free content on the website, with much of the app paywalled

          Flashcard Hero

          • Pros

          • Affordable one-time payment with no subscription required
          • Customizable flashcards with text, images, and audio
          • Uses spaced repetition for effective memorisation

          Apple Notes

          • Platforms

          • Mac, iOS

          Osmosis

          • Cons

          • Relatively expensive subscription
          • Few videos about clinical medicine topics

          Forest

          • Cost

          • Cheap once-off payment.

          MedMastery ECG Courses

          • Features

          • In-depth training on ECG interpretation.
          • Three levels of complexity - yellow, blue and black belt.
          • Video tutorials covering basic to advanced ECG analysis.
          • Interactive quizzes.
          • Case studies.
          • Offers CME credits.

          Teach Others

          If you don't have any opportunities to teach, try using the Feynman technique. This involves imagining that you are trying to explain a concept to a twelve-year old child. Use the simplest language you can, and illustrate the concept using analogies and metaphors. This can help to solidify the concept in your long-term memory.

          Cornell Method

          Once the notes, keywords and summary are written. Look at the keywords and state what you remember from the content. Try to reflect on how the information links with other similar concepts.

          Geeky Medics

          • Geeky Medics

          Flashcard Hero

          • Cons

          • Limited features compared to some other flashcard platforms
          • No pre-made flashcards available

          Apple Notes

          • Cost

          • Free, with no premium version

          Osmosis

          • Platforms

          • Website, YouTube, iOS, Android

          MedScape

          • Platforms

          • iOS, Android (no tools on the website)

          Forest

          • Forest

          MedMastery ECG Courses

          • Limitations

          • No specific iOS or Android app available.
          • More expensive than other resources.

          Cornell Method

          • Example

          • Cornell Method

          Neck

          Auscultate the carotid arteries for the presence of a bruit, which suggests carotid artery stenosis. You may also hear the transmitted murmur of aortic stenosis.

          Lactate

          Anaerobic lactate buildup occurs in the context of excess lactate production without sufficient oxygen delivery; aerobic lactate buildup occurs when there is shunting of pyruvate into lactate despite adequate oxygen delivery (e.g. due to β2 stimulation or pyruvate dehydrogenase deficiency).

          VIII - Hearing

          Hearing loss may be conductive, due to external autory canal or middle ear pathology; or sensorineural, due to cochlear or neurologic pathology. The Weber and Rinne tests are used to distinguish between these two types.

          Chest Inspection & Palpation

          Inspect the chest wall both anteriorly and posteriorly for thoracic scars, which may suggest previous chest surgery or trauma. A midline scar (sternotomy) suggests past cardiac surgery (bypass graft or valve replacement), while a scar over the left or right upper chest suggests an implantable device.

          Lactate

          The causes of hyperlactataemia may be broken into four major groups, as detailed below:

          Geeky Medics

          Geeky Medics is a popular clinical medicine app that offers a wide range of resources to help medical students learn and prepare for clinical practice. One of the key features of Geeky Medics is its guides to history and examination, which cover a variety of topics including cardiovascular, respiratory, abdominal, and neurological examinations. Additionally, the app includes videos and quizzes to help reinforce learning and test knowledge. 

          Apple Notes

          • Apple Notes

          Osmosis

          • Cost

          • A large number of videos are free on YouTube. The website offers a free seven-day trial, with a subscription for everything.

          MedScape

          • Cost

          • Free with ads

          Forest

          Forest is a unique app that helps you stay focused and avoid distractions while studying. The app uses gamification techniques to motivate you to concentrate on your work by allowing you to grow a virtual forest. 

          Zettelkasten Method

          We will include this highly complicated method for completion. German for 'slip-box', the Zettelkasten method makes use of a system of index cards which allow ideas to be connected together. Links between related ideas allow new insights, which can reportedly be used to improve thinking.

          Geeky Medics

          A major benefit of Geeky Medics is that a large amount of its content on the website is available for free, including all of the history and examination guides, as well as the videos and some of the quizzes. Most of the app is locked but can be unlocked for a very cheap yearly subscription fee.

          Apple Notes

          The Apple notes app is a simple option for notes with a decent number of features. Notes can be formatted with headers, dot points, images, drawings and checklists. Notes can be organised into nested folders, but not tagged. Information can be synced between iPhone, iPad and Mac devices very easily, and can be shared with others to allow for collaboration.

          Final Thoughts

          Mindfulness can be an effective way for medical students to reduce stress, improve concentration, and enhance overall well-being. In this article, we've explored four of the best mindfulness resources for you to try out. If you’re just starting out and looking for free meditations as a taste test, we would suggest trying Smiling Mind or Insight Timer. If you’re looking to expand your horisons and access a wide variety of meditation types and other features, both Headspace and Calm are great resources that are well worth the affordable subscription.

          MedScape

          • MedScape

          Forest

          At the start of a focus session, plant a tree in the app. The tree grows as you work without getting distracted, but if you use your phone or visit blacklisted websites, the tree will die. Over time, you can grow a forest of virtual trees based on your focus and productivity. 

          ECG Made Easy Book

          • Platforms

          • Paperback, e-book

          Zettelkasten Method

          Think of the technique as your own personal Wikipedia - you create links between cards that helps you to understand how the ideas fit together.

          VIII - Hearing

          Chest Inspection & Palpation

          • Apex Beat

          • Next, palpate for the patient's apex beat. This is the most inferior and lateral point at which the patient's cardiac impulse is palpable: this is normally in the fifth intercostal space in the midclavicular line (make a show of palpating the ribs down the chest). Feel for displacement, and whether the apex is pressure-loaded or volume-leaded.

          Lactate

          • A
            Reduced tissue oxygen delivery - heavy exertion, shock, localised ischaemia, severe hypoxia
          • B1
            Underlying disease - fulminant liver failure, endogenous β2 (stress, shock), impaired pyruvate dehydrogenase activity (sepsis), certain cancers
          • B2
            Drugs / toxins - metformin (in renal failure), endogenous β2 (adrenaline, salbutamol), NRTIs, linezolid, cyanide
          • B3
            Inborn errors of metabolism - e.g. pyruvate dehydrogenase deficiency

          VIII - Hearing

          • Weber's Test

          • The Weber test uses conduction of sound via the forehead to determine the type of hearing loss present. Place a 256hz tuning fork onto the centre of the patient's forehead, and ask whether they can hear the vibration. If heard, ask on which side the vibration is louder. If the vibration is louder in the deaf ear, then this suggests conductive hearing loss; if the vibration is louder in the normal ear then this suggests sensineural loss.

          Chest Inspection & Palpation

          • Chest Inspection & Palpation

          Lactate

          D-lactate is an isomer of lactate produced by bacteria that is not measured by conventional lactate testing.

          Geeky Medics

          Overall, Geeky Medics is an excellent option for medical students who want a handy and affordable clinical medicine app.

          Apple Notes

          Although some formatting can be done, there are no advanced features like clipping of webpages. Notes ships for free with Apple devices, and is not available on Windows or Android.

          Osmosis

          Osmosis by Elsevier is a popular e-learning platform that provides a wide range of very high-quality medical education videos created by medical professionals. Many videos are available for free on the YouTube channel, with many more available on the website. The videos are visually very appealing and easy to follow.

          Final Thoughts

          The next time you’re feeling stressed about study, clinical placements and other obligations - remember that mindfulness can be a great tool for getting centred and getting your focus back!

          MedScape

          MedScape is a popular medical platform by WebMD, providing medical students and healthcare professionals with a wealth of information and resources. Among its many features, MedScape offers hundreds of clinical calculators to support evidence-based decision-making.

          Forest

          Forest has a beautiful user interface and provides an engaging way to keep you on task. The app is available on web, iOS, and Android and has a relatively cheap one-off payment.

          ECG Made Easy Book

          • Cost

          • Variable depending on location

          Zettelkasten Method

          The method was created by Niklas Luhmann, a German sociologist; he used the technique to write 70 books and 500 articles over 30 years.

          Geeky Medics

          • Pros

          • Large amount of free content on the website, with a very cheap subscription for everything else.
          • Engaging and interactive learning tools.
          • Detailed history and examination guides.

          Apple Notes

          • Pros

          • Free
          • Simple and easy to use
          • Nested hierarchy
          • Sync between devices

          Osmosis

          The web platform operates on a subscription model, with a free seven-day trial available. While the high subscription cost may be a bit intimidating, try some of the videos and if you find the model of delivery useful then the incredible range of videos makes the investment well worth it in the long run.

          MedCram

          • Platforms

          • YouTube, Website

          Final Thoughts

          • Final Thoughts

          MedScape

          In addition to clinical tools, MedScape provides news, articles, and continuing medical education (CME) opportunities, making it a comprehensive resource for medical students. 

          Forest

          • Pros

          • Gamification to encourage focus and productivity.
          • Beautiful and engaging user interface.
          • Relatively cheap one-off payment.

          ECG Made Easy Book

          • ECG Made Easy Book

          Zettelkasten Method

          The system is very complex, and there are many other resources online for learning about it.

          VIII - Hearing

          • Rinne's Test

          • The Rinne test compares sound heard through the ears with sound conducted via the mastoid process. Place a 256hz tuning fork onto the patient's mastoid process, and ask them to indicate when they can no longer hear the vibration. Then move the tuning fork in from of the auditory meatus and ask them whether they can still hear the sound.

          Chest Inspection & Palpation

          • Abnormal Pulsations

          • Palpate the chest for parasternal heave (over the left side of the sternum) and thrills (palpable murmurs).

          VIII - Hearing

          If the sound is louder via the auditory meatus, then this is normal or may occur in patients with sensorineural hearing loss. If the sound is louder via the mastoid process, then this suggests conductive hearing loss.

          Chest Inspection & Palpation

          • Chest Inspection & Palpation

          Geeky Medics

          • Cons

          • Limited information about diseases.
          • Premium subscription required for a lot of the app content.

          Final Thoughts

          Flashcards are a great way to memorise and retain information. We have presented four of the best flashcard platforms for use during your medical study, from simple to heavily customisable. Each platform offers something unique, and so we encourage you to try a few different platforms and find what works best for you.

          Apple Notes

          • Cons

          • iOS and Mac only
          • Limited formating tools

          Osmosis

          • Osmosis

          MedCram

          • Cost

          • A small number of videos are free on YouTube. The website offers a yearly or three-yearly subscription.

          MedScape

          With a user-friendly interface and dedicated mobile apps for iOS and Android, MedScape ensures easy access to vital medical tools and information anytime, anywhere. MedScape also make the Calculate by QxMD app, and so the interface is the same as this app.

          Forest

          • Cons

          • Limited features beyond focus and productivity.
          • Not suitable for all types of tasks.

          ECG Made Easy Book

          ECG Made Easy is a highly regarded book that has been used by medical students and professionals for over 40 years. The book provides a comprehensive and practical guide to ECG interpretation, with an emphasis on simplicity and practical applications. The book includes high-quality images of ECG recordings, and provides clear explanations of normal and abnormal ECG patterns.

          Final Thoughts

          Try using a few different note-taking techniques through the course of your study and find what works for you in terms of style, ease and recall. You may find that a combination of a few methods works - outlines for the heirarchical information, tables for categorical information, and flowcharts for processes.


          Final Thoughts

          • Final Thoughts

          Osmosis

          • Pros

          • Very comprehensive range of medical science videos
          • Very visually appealing and concise
          • Use the platform on any device

          MedCram

          • MedCram

          MedScape

          The app is free to use, though requires you to register.

          ECG Made Easy Book

          The book is available as a paperback or Kindle e-book. It is a great resource to have available!

          IX & X - Throat

          The glossopharyngeal nerve (IX) and vagus nerve (X) serve multiple somatic, visceral and special sensory functions. Together, they provide motor and sensory supply to the pharynx.

          Chest Auscultation

          When auscultating the heart, systematically listen to each of the cardiac regions for a heart sounds, murmurs or a rub. If added heart sounds or a murmur are noted, determine which area the extra sound is loudest in, and then perform manoeuvres to further isolate the added sound. You may find it useful to start at the left sternal edge (tricuspid area) as an initial screening test, and then listen to the other areas.

          Chest Auscultation

          • Chest Auscultation

          SimpleNote

          • Platforms

          • Mac, iOS, Android, Windows, Linux

          Osmosis

          • Cons

          • Subscription-based - relatively expensive

          MedCram

          MedCram is a great medical student resource that offers videos on a variety of medical sciences and clinical medicine topics. Each topic is explained very clearly using simple but colourful diagrams, and the videos are designed to be engaging. The videos were created by Dr Roger Seheult, a quad-certified internal medicine, pulmonology, critical care and sleep medicine physician.

          MedScape

          • Pros

          • Comprehensive platform: clinical calculators, news, articles, and CME opportunities.
          • User-friendly interface.
          • Free with ads.

          ECG Made Easy Book

          • Features

          • Comprehensive and practical guide to ECG interpretation.
          • Simple explanation of easy to complex topics.

          SimpleNote

          • Cost

          • Free, with no premium version

          MedCram

          A small number of videos are freely available on the MedCram YouTube channel, but a subscription to their website is required to access everything. Compared to other video platforms, MedCram is a relatively expensive resource - but it can be worth it if you’re willing to put in the time to watch a lot of the videos.

          MedScape

          • Cons

          • Overwhelming content: may be difficult to navigate.

          ECG Made Easy Book

          • Limitations

          • No website or app.
          • No interactive features.

          IX & X - Throat

          Chest Auscultation

          • Chest Auscultation

          IX & X - Throat

          • Hoarseness  & Cough

          • Listen for hoarseness while the patient speaks, and ask them to cough. A hoarse voice (also known as dysphonia) or a hoarse cough may be a sign of a vagus (X) nerve lesion, however there are many causes for these findings.

          Chest Auscultation

          • A
            Aortic area - the second intercostal space at the right sternal border
          • P
            Pulmonary area - the second intercostal space at the left sternal border
          • T
            Tricuspid area - the fifth intercostal space at the left sternal border
          • M
            Mitral area - the fifth intercostal space in the midclavicular line
          • Left axilla - the fifth intercostal space in the midaxillary lineListen to each of the areas with the diaphgram of the stethoscope, and also listen to the apex of the heart with the bell - this makes the lower-pitched murmur of mitral stenosis easier to appreciate.

          Prognosis

          • Platforms

          • iOS, Android

          SimpleNote

          • SimpleNote

          MedCram

          • MedCram

          Focus@Will

          • Platforms

          • Web, iOS, Android

          Prognosis

          • Cost

          • Free with ads

          SimpleNote

          Simplenote is a free, very simple notes app. The app allows for simple formatting only, with no advanced features. Notes can be tagged and searched, but with no ability to organise notes in a hierarchy. Simplenote syncs with the cloud allowing for use on multiple devices.

          MedCram

          • Pros

          • High-quality videos created by medical professionals
          • Some free content on YouTube
          • Very simple and easy to understand explanations of complex topics

          Focus@Will

          • Cost

          • $9.99 per month or $69.99 per year.

          Final Thoughts

          ECG interpretation is an essential skill for medical students that you will use every day as a junior doctor - so it is important to become a master at interpreting ECGs! There are a variety of resources available to help you to master this skill including online courses, apps, blogs and textbooks. 

          IX & X - Throat

          Chest Auscultation

          • Heart Sounds

          • First, listen for the heart sounds.

          IX & X - Throat

          Chest Auscultation

          • Chest Auscultation

          Prognosis

          • Prognosis

          SimpleNote

          • Pros

          • Free
          • Very quick and simple to use
          • Cloud sync - use on multiple devices

          MedCram

          • Cons

          • Expensive subscription

          Focus@Will

          • Focus@Will

          Final Thoughts

          In this article, we have reviewed six of the best ECG resources for medical students, each with its own unique features and benefits. Figure out what works for you and interpreting ECGs can be made easy.

          Prognosis

          Prognosis is a clinical medicine app for iOS and Android that offers interactive clinical cases in a fun and engaging way. The app features hundreds of case scenarios that have been edited by specialists, with feedback on each case including diagnostic reasoning, test results, and learning points. This feature can be especially helpful for improving your diagnostic skills. The app has cool graphics, but the user interface can be a bit clunky at times. 

          SimpleNote

          • Cons

          • No hierarchy
          • Simple formatting only - lacks advanced features

          Lecturio

          • Platforms

          • Website, YouTube, iOS

          Final Thoughts

          Evidence-based clinical tools and calculators play an important role in medical assessment and decision-making, and it is important to familiarise yourself with the most commonly used tools during your time in medical school. 

          Focus@Will

          Do you listen to music while you study? If so, consider checking out Focus@Will, a music streaming service that provides background music specifically designed to improve your productivity and focus. The app uses AI to choose music suited to the type of task you're working on, your energy level, and your preferred music style. This helps to create a personalized and optimized environment for studying and working.

          Final Thoughts

          • Final Thoughts

          XI - Neck & Shoulders

          The accessory nerve (XI) supplies motor innervation to laryngeal and pharyngeal muscles; the sternocleidomastoid; and the trapezius.

          Chest Auscultation

          The first heart sound (S1) indicates closure of the mitral and tricuspid valves, and is normal heart best over the apex. Listen for presence of S1, and whether it is loud or soft.

          XI - Neck & Shoulders

          Chest Auscultation

          The second heart sound (S2) indicates closure of the aortic (A2) and pulmonary (P2) valves. Normally on expiration, S2 splits into separately audible A2 and P2 sounds. Note whether the second heart sound is loud or soft.

          Prognosis

          The app is free to use with advertising, making it a great option to help with working on your clinical skills.

          Lecturio

          • Cost

          • Subscription-based

          Final Thoughts

          The resources mentioned in this article—MDCalc, MedCalX, MedSchool, Calculate by QxMD and MedScape —each offer unique features, catering to different preferences and needs. Try them out and find what works for you!

          Focus@Will

          The app is available on web, iOS, and Android, making it a versatile tool for optimizing your study environment.

          Prognosis

          • Pros

          • Interactive learning tools make for enjoyable case-based learning.
          • Provides feedback on diagnostic reasoning.
          • Free to use (with advertising).

          Final Thoughts

          In conclusion, there are various note-taking apps available for medical students, each with its own set of features, strengths, and limitations. Key features to consider when choosing a note-taking app include usability, organization, and compatibility with other devices and apps.

          Lecturio

          • Lecturio

          Final Thoughts

          Videos are a great way to rapidly learn clinical medicine, and there are some excellent resources available to medical students. Many of the resources above have free videos available on YouTube, with the option of subscribing to access a larger bank of resources.
          • Final Thoughts

          Focus@Will

          • Pros

          • Customized music to improve productivity and focus.
          • Wide range of music and soundtracks to choose from.

          XI - Neck & Shoulders

          • Inspect for Torticollis

          • Look for twisting of the head and neck toward a shortened sternocleidomastoid, with rotation of the chin in the opposite direction.

          Chest Auscultation

          • Chest Auscultation

          XI - Neck & Shoulders

          • Assess the SCM and Trapezius

          • Ask the patient to turn their head against resistance (sternocleidomastoid), and then shrug their shoulders against resistance (trapezius). This tests the two major muscle groups supplied by the accessory nerve.

          Chest Auscultation

          The third heart sound (S3) is a pathological finding associated with rapid ventricular filling. This is a gallop rhythm, with an extra heart sound heard just after S2.

          Final Thoughts

          To select the best app for your needs, consider factors such as the device you will use, the level of organization and customization you require, and your budget.

          Lecturio

          Lecturio is an online medical education platform that provides courses on medical science topics as well as exam-directed courses for exams like the USMLE. The content is presented by medical educators in a lecture format, and the production value of the videos is high. The videos are accompanied by interactive features such as questions and concept pages.

          Final Thoughts

          If you’re looking to learn clinical skills such as history, examination, investigations and procedures, then GeekyMedics is an excellent resource. If you’re looking to understand common medical concepts in greater detail, then Zero to Finals and Dr Najeeb lectures provide great free Youtube channels. If you’re looking for a greater range of high quality videos, it’s worth considering an investment into Osmosis or MedCram.

          Focus@Will

          • Cons

          • Requires a paid subscription.
          • Relatively narrow range of music available - not suitable for everyone.

          Final Thoughts

          Ultimately, the best note-taking app for you will depend on your personal preferences and study habits.

          Lecturio

          A large number of videos are available for free on the Lecturio YouTube channel, however these are primarily focused on clinical medicine. The cost of the subscription is steep given that there are other free resources out there, though the production value of the videos, the range of videos available, interactive features and the exam-oriented format justify the price tag.

          Final Thoughts

          Best of luck with your study!

          XII - Tongue

          The hypoglossal nerve (XII) provides motor innervation to the intrinsic and extrinsic tongue muscles.

          Chest Auscultation

          • Chest Auscultation

          Chest Auscultation

          The fourth heart sound (S4) is a pathological finding associated with turbulence during atrial systole. This is also a gallop rhythm, with an extra heart sound heard just before S1, usually best heard during inspiration.

          Eponyms

          • Platforms 

          • iOS and Android

          Lecturio

          • Lecturio

          Final Thoughts

          • Final Thoughts

          Eponyms

          • Cost

          • Free

          Lecturio

          • Pros

          • Comprehensive range of high-quality medical sciences videos
          • Specific USMLE-directed video lectures
          • Quiz questions and concept summaries available

          XII - Tongue

          Ask the patient to open their mouth, without protuding the tongue. Look for wasting and fasciculations of the tongue.

          Chest Auscultation

          • Pericardial Rub

          • Next, listen for a pericardial rub. This is a superficial, scratching sound present in mid-systole, mid-diastole and late diastole; the presence of a rub suggests pericarditis due to infection, trauma, uraemia, autoimmunity or malignancy.

          XII - Tongue

          Next ask the patient to protrude their tongue, looking for tongue deviation, and then ask them to move their tongue to either side. Deviation of the tongue may be a sign of ipsilateral hypoglossal nerve palsy, though may also occur with a contralateral upper motor neuron lesion, motor neurone disease or trauma.

          Chest Auscultation

          • Listen for Murmurs

          • Next, auscultate the chest for cardiac murmurs. If a murmur is present, palpate the carotid pulse while auscultating to determine whether the murmur is systolic, diastolic (between S2 and S1 of the next cardiac cycle) or continuous. Grade the intensity of the murmur from 1 (incredibly faint) to 6 (audible with the stethoscope off the chest).

          Eponyms

          • Eponyms

          Lecturio

          • Cons

          • Expensive subscription
          • More didactic lecture-like teaching - no hand-drawn diagrams like other resources

          Grammarly

          • Platforms

          • Windows, OSX, browser extension, iOS, Android

          Eponyms

          Eponyms is a clinical medicine app for iOS and Android that provides descriptions of hundreds of medical eponyms, from Rovsing's sign to Argyll-Robertson pupils. The app includes a search function that makes it easy to find specific eponyms, and it also has a favorites list where users can save their most frequently used eponyms for quick reference.

          Grammarly

          • Cost

          • Free for basic spelling / grammar, $12 monthly for premium

          Finishing Up

          Thank the patient, turn around and present your findings.

          Finishing Up

          Depending on findings, you may offer to perform an upper or lower limb examination looking for signs to confirm your suspicion.

          Chest Auscultation

          A systolic murmur is present between S1 and S2. An ejection (or mid) systolic murmur is a classical sign of aortic stenosis, while a pansystolic murmur is associated with mitral regurgitation. Click to read more about murmurs that occur during systole.

          Eponyms

          While Eponyms is a relatively simple app, it can be a useful resource for earning about different medical conditions and their associated eponyms. Additionally, the app is free to use, making it a cost-effective option for those on a budget.

          Grammarly

          • Grammarly

          Eponyms

          • Pros

          • Hundreds of medical eponyms.
          • User-friendly search function.
          • Free.

          Grammarly

          Grammarly is a writing assistant app that helps you to improve your writing skills. This includes not just basic grammar and spelling - the app uses AI to analyze your writing and offer suggestions for sentence structure, style, and vocabulary. This app is a game-changer if you’re looking to create high quality, error-free documents such as assignments, journal articles and even important emails.

          Finishing Up

          Try to localise the patient's lesion - e.g. to the cerebrum, cerebellum, brainstem, spinal cord, dorsal nerve root, peripheral nerve, neuromuscular junction or muscle. This can be difficult to begin with but with experience, signs will begin to become constellations characteristic of specific lesions.

          Chest Auscultation

          A diastolic murmur is present between S2 and S1. An early diastolic murmur is classically a sign of aortic regurgitation, while a mid-diastolic murmur (usually heard with the bell of the stethoscope) suggests mitral stenosis. Click to read more about diastolic murmurs.
          Continuous murmurs are uncommon and are associated with rare conditions such as patent ductus arteriosus and AV fistulas.

          Eponyms

          • Cons

          • Limited content beyond eponyms.
          • May not be as useful for advanced learners.
          • Limited interactivity and diagnostic features.

          Grammarly

          Grammarly is available as a browser extension, desktop app, and mobile app, meaning that you can use it anywhere.

          MedCram

          • Platforms

          • Web, iOS, Android

          Grammarly

          • Pros

          • Writing help - from basic spelling and grammar to advanced style suggestions.
          • Integrates with multiple other apps and services.

          Chest Auscultation

          • Listen in Inspiration and Expiration

            It is important to listen to cardiac murmurs in both inspiration and expiration. 
          • A murmur that is louder on inspiration suggests right-sided (tricuspid or pulmonary) valvular disease
          • A murmur that is louder on expiration suggests left-sided (aortic or mitral) valve disease.
          A fourth heart sound is also best heard during inspiration.

          MedCram

          • Cost

          • A small number of videos are free on YouTube. The website offers a yearly or three-yearly subscription.

          Grammarly

          • Cons

          • Advanced features require a paid subscription - only basic spelling and grammar are free.
          • May not catch all errors or nuances in writing.

          Final Thoughts

          Clinical medicine apps are an invaluable resource during your time in medical school, providing a wealth of information and tools to help you learn and prepare for clinical practice. From comprehensive clinical references like UpToDate to engaging interactive apps like Prognosis, there are a variety of apps available to suit different learning styles and needs. 

          MedCram

          • MedCram

          Chest Auscultation

          • Left Lateral Position

          • Ask the patient to roll to the left lateral position and listen to the cardiac apex with the bell of the stethoscope. The murmur of mitral stenosis is louder in this position, as is a third heart sound.
          • Chest Auscultation

          Final Thoughts

          When choosing a clinical medicine app, keep in mind factors like cost, ease of use, and the specific features and resources offered by each app. 

          MedCram

          MedCram is a video platform that offers a large range of videos about medical science and clinical medicine topics. The videos are presented by Dr Roger Sehault, board certified specialist in internal medicine, pulmonology, critical care and sleep medicine. Each topic is clearly explained in an engaging way with colourful diagrams.

          Final Thoughts

          • Final Thoughts

          MedCram

          The MedCram YouTube channel has a small number of videos, but most of the content is available on the website for a subscription. The high subscription cost definitely places MedCram in the ‘premium’ category, but if you enjoy the YouTube videos and are likely to watch a large number of the videos on the website then it can be worth the cost.

          Chest Auscultation

          • Sitting Forward

          • Ask the patient to sit forward, breath in deeply and then hold their breath in full expiration. This will make the murmurs of aortic and pulmonary regurgitation louder, and will also accentuate a pericardial rub.
          • Dynamic Manoeuvres

            In patients with suspected hypertrophic cardiomyopathy (i.e. patients with a systolic murmur), offer to perform dynamic manoeuvres:
          • Asking the patient to valsalva (breath out hard against a closed mouth and nose) will make the murmur of hypertrophic cardiomyopathy louder, but reducing preload on the heart.
          • Asking the patient to squat increases preload, which makes the murmur of hypertrophic cardiomyopathy softer; then asking the patient to stand up acts as a physiologic bolus which increases preload and makes the murmur louder.

          MedCram

          • MedCram

          ChatGPT

          • Platforms

          • Web, API (for programmers)

          MedCram

          • Pros

          • Videos created by a quad-certified physician
          • Some free videos on YouTube
          • Engaging and clearly explained explanations of complex topics

          ChatGPT

          • Cost

          • Free option is accessible only intermittently, paid option is $20 per month

          Back

          • Sacral Oedema

          • Palpate the lower back for sacral oedema, as often fluid overloaded patients who are lying down with their legs up will accumulate fluid in this area rather than in their feet.

          MedCram

          • Cons

          • Expensive subscription - need to commit to watching a lot of videos to justify it
          • The diagrams are relatively basic

          ChatGPT

          • ChatGPT

          ChatGPT

          ChatGPT is an AI language model released in November 2022 that you can interact with via a web interface. You can input text into the chat and ChatGPT will respond in a human-like way based on its general knowledge.

          Back

          • Back
          • Lung Fields

          • Auscultate the lung fields, listening for crepitations and wheeze (signs of left ventricular failure / pulmonary oedema) and reduced air entry (a sign of pleural effusions). Often in the cardio exam it is quicker to auscultate only the lung bases to conserve time. Consider percussing the chest for dullness, to prove suspected pleural effusions.

          ChatGPT

          Potential uses of ChatGPT for medical students include helping you to understand medical topics in greater detail, planning study sessions, helping with research and helping you to write flashcards. If there is a topic that you’re struggling to understand, you can ask ChatGPT in natural language and it will provide you with an explanation about the topic at hand. It can also help to write assignments and articles, though it is important to note that that output from ChatGPT is not always of high literary quality and is not always correct - you will need to review anything it produces before using it for any sort of writing.

          Pathoma

          • Platforms

          • Web

          ChatGPT

          • Pros

          • Quick and accessible source of information and research help.
          • Able to provide information on a wide range of medical topics.

          Abdomen

          If you are running out of time, skip to the legs at this point as these will provide the highest yield.
          • Inspection

          • Inspect the abdomen for distension and any abnormal movements. A visible abdominal pulsation is a sign of abdominal aortic aneurym, though this sign can also be normal in thin patients.

          Pathoma

          • Cost

          • Subscription-based - comes with a textbook

          ChatGPT

          • Cons

          • Only available on web.
          • Not always available due to high demand.
          • Responses often lack nuance, and are not always accurate or reliable.

          Pathoma

          Pathoma is a popular medical website that offers a pathology textbook and 35 hours of video lectures on pathology. The lectures were created by Dr. Husain Sattar, a well-respected pathologist, and cover a wide range of pathology topics. The videos are presented in a more didactic way, with slides that Dr Sattar draws on to stress important concepts.

          Abdomen

          • Auscultation

          • Auscultate for abdominal bruits. Listen for aortic bruits, over the upper abdomen in the midline, and renal bruits, over the upper abdomen on either side of the umbilicus. The presence of bruits would suggest arterial stenosis, due to atherosclerosis or other pathology.

          Pathoma

          A free one-month trial is available offering access to six example videos, while the full subscription provides access to all videos as well as a copy of the Fundamentals of Pathology textbook. While the subscription is cheaper than other platforms on this list, it only covers pathology subjects and thus has more limited coverage. If you’re looking for a comprehensive guide to pathology, many medical students swear by Pathoma and it’s definitely worth trying out.

          Final Thoughts

          Your journey through medical school can be demanding and challenging, and you may at times find that you have too many things on your plate. Whether it’s keeping up with lectures, study time, extracurricular activities or squeezing in a part-time job, time management apps can help you to keep all of your balls in the air. Additionally, focus apps are useful to ensuring that study sessions and other focus times are distraction-free.

          Pathoma

          • Pathoma

          Final Thoughts

          Consider using some of the resources outlined in this article to maximise your productivity, and best of luck during your studies!

          Abdomen

          • Abdomen

          Legs

          Pathoma

          • Pros

          • Comprehensive range of pathology lectures
          • High-quality videos created by a well-respected pathologist

          Final Thoughts

          • Final Thoughts

          Pathoma

          • Cons

          • Didactic lecture-based videos - some users may find this less engaging
          • Relatively expensive for a resource that covers pathology only

          Legs

          • Palpation

          • Palpate the extremities for temperature, tenderness and pedal oedema.
          Cool extremities are a sign of poor perfusion; localised hypoperfusion may occur due to arterial disease or compartment syndrome, while more generalised hypoperfusion is a sign of shock. Warm extremities have a wide variety of causes. Significant unilateral warmth suggests cellulitis or a DVT, while milder warmth suggests fluid accumulation due to venous insufficiency or lymphoedema.

          Final Thoughts

          Watching videos can be a great way to supplement your study of the medical sciences. There are a range of free and paid video resources available. There are several YouTube channels detailed above that provide a number of free medical sciences videos, and multiple premium platforms available with a more comprehensive range of videos. Some of the platforms are more expensive; If you’re looking to commit to a platform and watch a lot of the videos, it’s worth trying out a few and finding out what works for you.

          Legs

          Next, palpate for pedal oedema. Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release, looking for persistence of the depressed area after the finger is removed. If the oedema is pitting, this suggests fluid overload, right ventricular failure, venous pathology or hypoalbuminaemia; non-pitting oedema suggests lymphoedema.
          • Legs

          Final Thoughts

          Happy watching!
          • Final Thoughts

          Legs

          • Pulses

          • Palpate the lower limb pulses - dorsalis pedis, posterior tibial and popliteal. Absent pulses are a sign of acute or chronic arterial insufficiency, though patients with shock or severe hypotension may also have absent pulses.
          • Legs

          Finishing Up

          Thank the patient, turn around and present your findings.
          Ask for an electrocardiogram (ECG), urinalysis, and fundoscopy to complete your assessment.
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