Chronic Kidney Disease (CKD)

Definition - The irreversible and sometimes progressive loss of renal function over a period of months to years.

Causes - Can be exaggerated/precipitated by an AKI and is often caused by other chronic co-morbidities e.g. Diabetes, hypertension, autoimmune diseases (e.g. Vasculitis) and adult polycystic kidney disease.

Common risk factors -

• Alcohol
• Obesity
• Diabetes
• Hypertension
• Autoimmune conditions, e.g. Vasculitis
• Genetic pre-disposition, e.g. Polycystic Kidney Disease

Investigations -

• CKD progression is staged based off the patient's eGFR, calculated using serum Creatinine levels
• Proteinuria levels
• Urinalysis
• Bloods
• Auto-antibody tests
• Ultrasound to check for obstructions

Pharmacological and surgical interventions -

Management is generally supportive, pharmacology is based on underlying cause of CKD.

• Haemodialysis (HD, 4 hours, 3 times a week, in the hospital, attached to a machine)
• Home HD
• Peritoneal dialysis
• Kidney transplant (if no other available options and donor available)

Lifestyle interventions -

Modifiable risk factors:

• Regular exercise (obesity is a risk factor) and a good, regulated electrolyte diet can improve CKD progression rates
• Alcohol removal
• Smoking cessation
• Controlling diabetes adequately
• Controlling hypertension adequately

Non-drug lifestyle options:

• Vitamin D tablets to make up for reduced Vitamin D synthesis from the kidney
• Iron/B12/Folate to make up for reduced EPO production by the kidney

Symptoms -

• Tiredness (overwhelmingly fatigued)
• Difficulty sleeping
• Difficulty concentrating
• Symptoms and signs of volume overload (SoB, oedema)
• Nausea & vomiting / reduced appetite
• Cramps, pruritus
• Increased frequency of infections

Alcoholic Liver Disease

Definition - Damage to liver cells (Hepatocytes) caused by prolonged exposure to large quantities of alcohol. Progresses in 3 stages:

• Reversible fatty change in days to weeks
• Reversible hepatitis in moths to years
• Irreversible Cirrhosis after years

Causes - Alcoholism

Investigations - Liver function tests derived from a blood sample

Lifestyle interventions - 

• Reduce alcohol consumption to nothing
• Refer to a self help group

Pharamacological interventions - 

• Disulfiram to aid with compliance to alcohol abstinence
• B vitamins especially thiamine to rectify vitamin deficiency
• Statins to reduce cholesterol and reduce fat deposition in the liver
• Anti-hypertensives eg. amlodipine to reduce blood pressure

Complications - 

• Liver failure
• Portal hypertension

Further intervention - Liver transplant

Symptoms -

• Tiredness and weakness
• Nausea
• Jaundice
• Diarrhoea and Vomiting
• Fever and shivering attacks

Non-Alcoholic Liver Cirrhosis

Definition - Although alcoholism is the most common cause of cirrhosis it may be caused by any inflammation of the liver.

Causes -

• Hepatitis B/C Virus
• Non alcoholic fatty liver disease (NAFLD)
• Paracetamol overdose

Risk factors -

• Illicit IV Drug use
• Genetics
• High cholesterol
• Obesity
• Paracetamol overdose

Investigation -

• Liver function tests

Pharmacological/Surgical Interventions -

• Statins
• Anti-virals for HCV
• Prophylactic HBV vaccine
• Acetylcysteine for paracetamol overdose

Lifestyle interventions -

• Exercise
• Smoking cessation 
• Lower fat intake
• Healthy balanced diet

Symptoms - See alcoholic liver cirrhosis

Anaemia

Definition - A reduction in the haemoglobin concentration of the blood reducing the body's ability to transport oxygen. 

Causes -

• Iron deficiency
• Vitamin B12/folate deficiency
• Any inflammatory chronic disease
• Haemolytic diseases
• Sickle cell disease
• Malaria

Common risk factors -

• Veganism/Vegetarianism
• Poor iron intake
• Any inflammatory chronic disease
• Menorrhagia
• Genetics
• Alcoholism

Investigations -

• Blood tests (haemoglobin concentration (diagnostic), haematocrit, mean cell volume, reticulocyte count, iron levels, folate levels (to aid identification of specific pathology)
• Blood films (identify shapes, sizes and colours of red blood cells)
• Kidney function tests (e.g. Creatinine levels, eGFR to identify a loss of EPO production)

Pharmacological/Surgical Interventions -

• B12/Folate/Iron supplements
• Treatment for underlying chronic conditions
• Blood transfusions if sickle cell homozygous
• Anti-malarials if malaria causative factor

Lifestyle interventions -

• Dietary changes dependent on cause of anaemia (B12/Folate-related cause: eat more meat, or take tablets to replace, Iron-related – eat more “leafy greens”)

Symptoms -

• Fatigue
• Tachycardia/palpitations
• Shortness of Breath
• Dizziness
• Pale skin
• Leg cramps
• Insomnia

Atrial Fibrillation (AF)

Definition - A heart condition causing an irregularly irregular rhythm and tachycardia, with increased risk of clotting related morbidities.

Causes - Secondary to many conditions:

• Myocardial infarction
• Hypertension
• Congenital heart defects
• Overactive thyroid gland

Common risk factors -

• Increasing age
• Heart conditions
• Co-morbidities listed above

Investigations -

• ECG
• Blood tests (can highlight anaemia, problems with kidney function, or an overactive thyroid gland (hyperthyroidism))

Pharmacological/Surgical Interventions -

• Class 1 antiarrhythmics, e.g. Lidocaine
• B-blockers, e.g. Bisoprolol
• Anticoagulants to prevent clot formation and minimise risk of embolization
• Suspend any prothrombotic or proarrhythmic drugs if possible

Lifestyle interventions -

• Diet improvements to reduce further risk of acute coronary syndromes
• Avoidance of exacerbations (e.g. alcohol, caffeine, illicit drugs)
• Smoking cessation

Symptoms - +/- exertion

• Fatigue/Lethargy
• Palpitations
• Shortness of Breath
• Chest pain
• Feeling faint 

Cerebrovascular disease (TIA/Stroke)

Definition - Lack of oxygen supply to the brain either from blockage or bleeding.

Causes - Ischaemic (caused by an embolus in a cerebral artery) or Haemorrhagic (caused by a bleed on the brain)

Common risk factors -

Modifiable:

• Smoking
• Hypertension
• Obesity
• High cholesterol
• High alcohol intake
• COCP usage
• Atrial Fibrillation

Non-modifiable:

• Increasing age
• Family History
• S. Asian, African or Caribbean ethnicity

Investigations -

To determine stroke risk: 

• Blood tests for cholesterol level and coagulability (INR)
• Blood pressure
• BMI
• ECG do determine AF or other heart condition

To diagnose stroke or TIA if indicated by symptoms on presentation

• CT head
• Electrocardiograms
• Cerebral angiography

Pharmacological/Surgical Interventions - 

Only to treat underlying co-morbidities increasing stroke risk:

• Anticoagulants
• Antihypertensives
• Antiarrythmics

Lifestyle interventions -

Key in reducing stroke risk:

• Increased exercise
• Balanced healthy diet (reducing cholesterol intake)
• Smoking cessation
• Alcohol cessation

Chronic Obstructive Pulmonary Disease (COPD)

Definition - A long-term progressive lung disease causing increasing breathlessness that isn’t fully reversible. Encompasses emphysema and chronic bronchitis.

• Emphysema: airflow obstruction in the in the small airways causing hyperinflation
• Chronic bronchitis: chronic mucus hypersecretion 

Causes -

• Smoking (may be second hand)
• Air pollution
• Alpha-1-antitrypsin deficiency (a very small minority of cases

Investigations - Diagnosed using a peak flow meter and spirometry, which shows a non-reversible obstructive pattern

Pharmacological/Surgical Interventions -

• SABA (salbutamol - short-acting B2 agonist)
• Corticosteroids (inhaled - beclamethosone)
• LABAs (salmeterol - long-acting B2 agonist)
• Mucolytics (reduce mucus production)

Lifestyle interventions -

• Smoking cessation
• Flu jabs (patients are more prone to infection which can cause exacerbation)
• Increased exercise
• Oxygen therapy (to reduce mortality- has no effect on breathlessness)

Symptoms -

• Chronic productive cough
• Shortness of breath whilst doing everyday activities
• Recurrent respiratory infections
• Cyanosis 
• Fatigue
• Increased sputum production
• Wheezing

Asthma

Definition - A chronic lung disease causing airways to become hypersensitive and inflamed

Causes -

• Unclear true cause, thought to be attributed to pollution, genetics or hygiene.

Common risk factors -

• Family history
• History of atopy (e.g. hay-fever, eczema, general allergies)

Investigations - Diagnosed using spirometry, which shows a reversible obstructive pattern

Pharmacological/Surgical Interventions -

• SABA (salbutamol - short-acting B2 agonist)
• Corticosteroids (inhaled - beclamethosone)
• LABAs (salmeterol - long-acting B2 agonist)

Lifestyle interventions -

• Avoidance of possible triggers
• Smoking cessation
• Compliance with treatment
• Consistent check-ups

Symptoms -

• Cough (worse at night)
• Wheeze (either audibly or through a stethoscope)
• Breathlessness
• Tight chest
• Acute exacerbations of bronchoconstriction

Lung Cancer

Definition - A malignant mass in the lung that can spread and invade other tissues. 

Common risk factors -

• Smoking
• Obesity
• Environmental exposure to carcinogens eg Asbestos, air pollution
• Family history

Investigations -

• Chest X-ray
• CT/PET-CT
• Bronchoscopy, Biopsy of mass

Pharmacological/Surgical Interventions -

• Radiotherapy
• Chemotherapy
• Surgery
• Targeted therapies

Lifestyle interventions -

• Smoking cessation (most important)
• Weight loss
• Personal protective equipment if exposed to dangerous chemicals at work

Symptoms -

• Weight loss
• Haemoptysis (coughing up blood)
• Shortness of breath
• Persistent cough
• Persistent chest infections
• Fatigue 

Diabetes

Definition -

Type 1: Autoimmune destruction of Pancreatic B cell leading to inability to produce insulin and chronic hyperglycaemia

Type 2: Resistance to insulin and eventual reduction in production of insulin and chronic hyperglycaemia

Causes -

Type 1: Idiopathic cause with potential genetic link

Type 2: Obesity, high-sugar diet, low levels of exercise, pregnancy, metabolic syndrome

Common risk factors -

• Genetic predisposition- unmodifiable and can contribute to both types
• High sugar diet
• Obesity

Investigations -

• Blood glucose tests after fasting and after taking a set amount of glucose
• HbA1c blood test 
• Consistent finger-prick testing to check glucose levels throughout the day

Pharmacological/Surgical Interventions -

Type 1: Insulin injections. Frequency depends on specific formulation

Type 2: Multiple treatment options:

• Metformin - Decreases resistance to insulin, decreases liver gluconeogenesis
• Sulphonylurea - Increases insulin release from B cells

Lifestyle interventions -

• Carefully controlled sugars within the diet
• Increased exercise
• Smoking cessation

Symptoms -

• Polydipsia
• Dry mouth
• Polyuria
• Unexplained weight loss
• Fatigue
• Headaches

Epilepsy

Definition - A condition characterised by recurrent random electrical activity in the brain causing a seizure. Seizures are broadly categorised into partial or generalsed. Status epilepticus is a medical emergency characterised by a extremely prolonged seizure or multiple seizures without the patient regaining consciousness in between.

Causes - Although epilepsy is idiopathic in its cause it is linked with:

• Low oxygen during birth
• Head injuries
• Brain tumours
• Infections such as meningitis or encephalitis
• Stroke or any other type of damage to the brain

Common risk factors -

• Birth injuries
• Head trauma
• Hypertension
• Infections/sepsis
• Genetic conditions
• Family history
• Illegal drug use (e.g. cocaine)

Investigations -

• EEG
• CT head
• Full blood count 
• Taking a collateral history from any possible witnesses to a seizure

Pharmacological/Surgical Interventions -

• Partial seizures: Carbamazepine 
• General seizures: Sodium valproate, Lamotrigine 
• Status epilepticus: Lorazepam 

Lifestyle interventions -

• Avoidance of epileptic triggers (e.g. noises, flashing lights, stress)
• Discussion of how to adjust to life with epilepsy (e.g. loss of driving license)
• Regular check-ups
• Caution with pregnancy

Symptoms - Dependent on seizure type. All involve loss of consciousness.

• Tonic - rigidity
• Tonic-clonic/ Grand Mal - rigidity with muscular convulsions
• Myoclonic - muscular convulsions
• Absent- patient will pause for a period of time before continuing as before without noticing the pause. 
• Atonic - patient will lose all muscle strength and may fall to the floor

Anxiety

Definition - Continuous feelings of worry and anxiousness, persisting for most days of the week for 6 months or more.

Causes - Stress within life e.g. at school, work, due to other medical illnesses or due to illicit drug use (eg. cocaine)

Common risk factors -

• Stress
• Genetic predisposition/ Family history of mental health conditions

Investigations - The diagnosis is clinical. Blood tests may be helpful to rule out other differential diagnoses

Pharmacological/Surgical Interventions -

• SSRIs 
• Benzodiazepines (short-term only)
• Mood stabilisers (Lithium, Sodium valproate)

Lifestyle interventions -

• Reduction in stress within life if possible
• Family/ Self help groups
• Cognitive behavioural therapy

Diagnostic criteria - The patient must have both the core symptoms and 3/6 of the additional symptoms for a period of at least 6 months.

•  Two core symptoms:
  • Excessive anxiety and worry - occurs on most days for at least 6 months
  • Difficulty controlling the worry or feelings of anxiety
• Additional symptoms:
  • Feeling of tension or restlessness
  • Become easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Significant muscle tension
  • Difficulty sleeping

Other symptoms -

• Feeling nervous, restless or tense
• Sense of impending danger, panic or doom
• Tachycardia
• Hyperventilation
• Sweating
• Tight chest
• Fatigue
• Trouble concentrating

Depression

Definition - Feelings of low mood, depression or hopelessness and a lack of interest or enjoyment in doing things for 2 weeks consistently

Causes -

• Stress
• Adverse childhood experience
• Certain drugs
• Death or loss (NB do not confuse depression with an adjustment reaction which has a clear trigger and limited duration)
• Genetic pre-disposition
• Co-morbidities
• Substance abuse

Common risk factors -

• Unstable/ poor home life
• Stressful life
• Substance abuse
• Family history of mental health conditions

Investigations - The diagnosis is clinical. Blood tests may be helpful to rule out other differential diagnoses eg. Hypothyroidism

NB- If indicated (eg if the patient has depressive symptoms) you MUST asses suicide risk and self-harm in a sensitive and sympathetic manner. Failure to do so is a patient safety issue. 

Pharmacological/Surgical Interventions -

• SSRIs 
• Benzodiazepines (short-term only)
• Mood stabilisers (Lithium, Sodium valproate)

Lifestyle interventions -

• Reduction in stress within life if possible
• Family support
• Cognitive behavioural therapy

Diagnostic criteria - Must have at least 5/9 of the symptoms with at least one of the core symptoms for 2 weeks.

•  Two core symptoms:
  • Feelings of depression, hopeless or generally feeling down most days during the last month
  • Little interest or pleasure in doing things 
• Other typical symptoms:
  • Fatigue/loss of energy
  • Worthlessness/excessive or inappropriate guilt
  • Recurrent thoughts of death, suicidal thoughts or suicide attempts
  • Diminished ability to think or concentrate
  • Psycho-motor agitation or retardation
  • Insomnia/hyper-insomnia
  • Significant appetite and/or weight loss

Other symptoms -

• Low mood
• Lack of interest in anything
• Lack of enjoyment in things
• Fatigue
• Feeling hopeless and helpless
• Having low self-esteem
• Feeling irritable and intolerant of others

Headaches

Definition - A symptom of pain felt anywhere in the head

Causes - Headaches can be classed into primary and secondary causes

Primary 

• Idiopathic
• Stress-related

Secondary (generally more concerning as may indicate potentially life threatening underlying conditions) 

• Sub-arachnoid haemorrhage
• Medication-induced (e.g. GTN)
• Medication-overuse (e.g. painkillers)
• Brain tumour
• Dehydration

Risk factors -

• Obesity
• Stress
• Alcohol overuse
• Dehydration
• High caffeine intake
• Smoking
• Hypertension
• NSAID/opioid overuse
• Bad posture

Investigations - Commonly none, if presenting with “red flags” then refer to secondary care for imaging:

Red flags - SNOOP mnemonic:

• Systemic Signs
• Neurological signs 
• Onset unusually or new onset over 55 
• Onset in a thunderclap presentation - SAH
• Papilloedema - increased intracranial pressure

Pharmacological/Surgical Interventions -

• Over the counter painkillers (paracetamol or ibuprofen, an NSAID)
• Prescription medications (codeine (opioid receptor agonist))
• Triptans (for migraines specifically)

Lifestyle interventions -

• Increase exercise
• Improve diet and fluid intake
• Smoking cessation
• Reduce caffeine and alcohol
• Reduce stress levels where possible
• Avoid triggers

Symptoms -

Dependent on headache type:

• Tension - band like pain across the forehead
• Migraine - commonly one sided pain, associated aura and nausea
• Cluster - extreme pain behind one eye, commonly occurs for months at a time
• Trigeminal neuralgia - electric-shock type pain around one eye, prompted by touch to the face

Gall Stones

Definition - A condition caused by stones forming in the gallbladder and causing obstruction.

Key risk factors -

• Obesity
• High fat diet
• Alcoholism

Investigations -

• Ultrasound scan
• Bloods to test for Bilirubin/AST/ALT/ALP/Gamma-GT levels (Liver function tests)
• CRP/white cell count to check for infection (primary ascending cholangitis)

Pharmacological/Surgical Interventions -

• Painkillers (NSAIDs)
• Statins

Further intervention-

• Laproscopy (Key hole surgery) to remove the gallbladder (most common)
• Open surgery to remove the gallbladder (indicated in pregnancy, obesity and structural abnormalities of the gallbladder)

Lifestyle interventions -

• Eating a balanced diet
• Avoiding ‘trigger foods’ (can include fatty or spicy foods)
• Avoiding alcohol
• Exercise to lose weight

Possible complications/Symptoms -

• Biliary colic (abdominal pain common around 30 minutes after eating fatty foods)
• Fever
• Jaundice
• Impaction and development of cholangitis
• Pain can radiate to the shoulder tip
• Can cause pancreatitis if impacting the Ampulla of Vater

Heart Failure

Definition - The inability of the heart to meet the demands of the body, characterised by reduced cardiac output, reduced tissue perfusion and increased pulmonary blood pressure

Causes -

• Ischaemic heart disease
• Hypertension, Aortic stenosis, Aortic regurgitation all leading to left ventricular hypertrophy 
• Cardiomyopathy
• Arrhythmias
• Chronic lung diseases e.g. COPD, pulmonary fibrosis, bronchiectasis (cor pulmonale)

Risk factors -

• Obesity
• Smoking
• Diabetes
• High alcohol intake
• Lack of exercise
• Chronic lung disease
• Family history
• Previous rheumatic fever

Pharmacological/Surgical Interventions - Adopt a ‘start low, go slow’ approach when introducing these drugs due to risks of low blood pressure, or worsening of heart failure symptoms:

- 1st line: ACE inhibitors or Angiotensin receptor blockers
If above are not tolerated, hydralazine + nitrate
- 2nd line: β-blocker
- 3rd line: Aldosterone antagonist (spironolactone)

Lifestyle interventions -

• Maintain BMI in a healthy range
• Smoking cessation
• Reduce alcohol consumption
• Exercise
• Weigh yourself regularly (to see if you’re retaining fluid)
• Healthy diet

Symptoms -

Left sided heart-failure:

• Fatigue
• Breathlessness on exertion
• Orthopnoea and Paroxysmal Nocturnal Dyspnoea 
• Displaced apex beat due to cardiomegaly

Right sided heart-failure:

• Fatigue
• Breathlessness
• Peripheral oedema
• Raised JVP
• Enlarged and tender liver

Infectious Presentations: Pneumonia

Definition - Inflammation of the lung parenchyma caused by bacterial or viral infection, in which the alveoli may fill with pus.

Causes - Viral or bacterial infections of the lung, usually droplet transmitted.

Common risk factors -

• Immunocompromised
• Extremes of age
• Close-contact-communities

Investigations -

• Chest X-ray (look for consolidation, potentially pulmonary oedema/pleural effusion if later stages)
• Sputum sample
• Chest examination
• Blood test (test for CRP, raised white cell count)

Pharmacological/Surgical Interventions -

• Antibiotics if bacterial cause (Moderate: Amoxicillin, Doxycycline, Serious: Co-amoxiclav and Clarithromycin)
• Aspiration of effusion if present

Lifestyle interventions -

• Smoking cessation
• Should avoid other patients or at risk individuals if immunocompromised and take prophylactic antibiotics
• Good diet with adequate vitamin consumption to improve immune defences

Symptoms -

• Productive cough
• Haemoptysis (coughing-up blood)
• Shortness of breath
• Pleuritic chest pain
• Tachycardia
• Fever
• Sweating/shivering

Infectious Presentations: Meningitis

Definition - Infection causing inflammation of the leptomeninges of the brain.

Causes -

• Bloodstream infection
• Ear infection
• Sinusitis
• Iatrogenic- Surgery in the head or neck/ Blood stream infection from a catheter or other line

Common risk factors -

• Immunocompromised condition
• Living in close proximity (e.g. students)
• Extremes of age (< 5 or >60 years)

Investigations -

• Blood tests and cultures
• Lumbar puncture to sample CSF turbidity testing and culture (+ antibiotic sensitivity)

Pharmacological/Surgical Interventions -

• IV Ceftriaxone empirically until culturing results returned to identify to actual causative organism
• Meningococcal Vaccine

Lifestyle interventions -

• If immunocompromised give prophylactic antibiotics
• Clean living conditions
• Good diet
• Good dental hygiene

Symptoms -

• Fever
• Cold hands and feet
• Stiff neck
• Headache
• Vomiting
• Drowsiness
• Difficult to wake
• Confusion and irritability
• Severe muscle pain
• Non-blanching rash if meningococcal
• Photophobia

Infectious Presentations: Urinary Tract Infection/Pyelonephritis

Definition - Infection of the urinary tract - can affect the lower urinary tract (Cystitis) or the upper urinary tract (Pyelonephritis)

Causes - A number of bacterial organisms, most commonly E. coli and Coagulase Negative Staphylococci

Common risk factors - 

• Female gender (shorter urethra)
• Obstruction of the tract (enlarged prostate, pregnancy, stones) leading to fluid stasis
• Neurological problems leading to incomplete voiding and leading to fluid stasis
• STIs
• Not urinating after sex
• Unprotected sex
• COCP

Investigations - Usually none are carried out unless the patient is declared at risk of a "complicated" UTI, in which case the following occurs:

• Mid stream catch urine sample. Observe turbidity, dipstick and culture. 

If Sepsis is suspected (a potential risk of UTIs), then the standard "Sepsis 6" package is initiated prior to any testing

Pharmacological/Surgical Interventions -

• Antibiotics indicated by the nature of the infection
• Decompression of the kidney if obstructed using either a JJ stent or a nephrostomy

Lifestyle interventions -

• Maintenance of good hydration
• Emptying of the bladder soon after intercourse
• Avoidance of irritating feminine products
• Changing from the COCP

Symptoms -

Lower UTI (Cystitis)

• Dysuria
• Frequency
• Urgency
• Possible low grade fever

Upper UTI (Pyelonephritis)

• Fever
• Loin pain
• Dysuria/ frequency
• Nausea and vomiting

Hypertension

Definition - Sustained increase in blood pressure, greater than 140/90 mmHg.

Causes -

• Primary hypertension has an unknown cause, however several factors may contribute to it
• Secondary hypertension has an identifiable cause, such as renal artery stenosis, Cushing’s syndrome (high cortisol), Conn’s syndrome (hyperaldosteronism)

Risk factors -

• Smoking
• Obesity
• Lack of physical activity
• Stress
• Old age
• Family history
• Excess salt in diet
• Excess alcohol consumption

Pharmacological/Surgical Interventions -

For a patient <55 years old:

• Step 1: ACE inhibitor, ramipril, or Angiotensin receptor blocker, Losartan

• Step 2: Calcium channel blocker, amlodipine

• Step 3: Diuretic, bendroflumethiazide

• Step 4: β-blocker, spironolactone

For a patient >55 years old, or of Afro-Caribbean descent:

• Step 1: Calcium channel blocker, amlodipine

• Step 2: ACE inhibitor, ramipril, or Angiotensin receptor blocker, Losartan

• Step 3 and 4 are the same as above

Lifestyle interventions -

• Healthy diet and regular exercise
• Smoking cessation
• Reduce stress where possible
• Reduce alcohol intake
• Reduce caffeine intake

Symptoms - Hypertension often has no symptoms, however it can present with:

• Severe headache
• Fatigue
• Vision problems
• Difficulty breathing
• Palpitations

Hypercholesterolaemia

Definition - High levels of cholesterol in the blood.

Causes -

• Familial hypercholesterolaemia
• Obesity
• Diabetes
• Metabolic syndrome

Risk factors -

• High fat diet
• Smoking
• Diabetes
• Hypertension
• Family history of stroke or heart disease

Investigations -

• Blood cholesterol tests
• Cardiovascular risk score evaluation 

Pharmacological/Surgical Interventions -

• Statins, e.g. atorvastatin
• Aspirin

Lifestyle interventions -

• Reduce fat intake
• Eat a healthy balanced diet
• Smoking cessation
• Increase exercise levels

Signs and symptoms -

Xanthelasma, tendon xanthoma and corneal arcus, but most commonly causes no symptoms.

It does however drastically increase the risk of many diseases:

• Atherosclerosis
• Heart attack
• Stroke
• Peripheral artery disease
• Coronary heart disease

Inflammatory Bowel Disease: Ulcerative Colitis

Definition - Chronic inflammation affecting the rectum and colon, impairing nutrient absorption.

Causes - Idiopathic - a combination of genetic and environmental factors.

Risk factors -

• Recent infection of the colon (shigella)
• Family history of IBD
• Caucasian ethnicity 

Investigations -

• Blood tests (anaemia)
• Abdominal examination
• Stool sample 
• Sigmoidoscopy
• Colonoscopy
• Abdominal X-ray/CT 

Pharmacological/Surgical Interventions -

• Immunosuppressants including DMARDS and/or Steroids
• Curative surgery (colectomy)

Lifestyle interventions -

• Reducing trigger foods 
• Reducing stress
• Probiotics

Signs and symptoms -

• Recurrent bloody diarrhoea (may contain mucus)
• Abdominal pain and a tender abdomen on examination - commonly left iliac fossa/left lower quadrant
• Fatigue, weight loss
• Painful red eye, arthritis, tachycardia, fever (severe UC)

Inflammatory Bowel Disease: Crohn's disease

Definition - An inflammatory bowel disease that may affect any location in the GI tract, but most commonly the ileum.

Causes - Idiopathic. Likely a combination of genetic and environmental factors.

Risk factors -

• Family history of inflammatory bowel disease
• Smoking
• NSAIDs
• Recurrent infections

Investigations -

• Ileocolonoscopy to visualise skip lesions, ulceration with a characteristic 'cobblestone' appearance, trans-mural inflammation, strictures and fistulas
• Biopsy to assess for granulomatous transmural inflammation
• Blood test for CRP to assess inflammation, and anaemia

Pharmacological intervention -

• Steroids for flares
• DMARDS to attempt to achieve and sustain remission
• If fistulas are present, surgery may be needed to remove a small part of the bowel. This surgery is not curative as the disease will recur. 

Lifestyle intervention -

• Stop smoking
• Healthy balanced diet
• Avoid NSAIDs
• Get yearly flu vaccinations and the pneumococcal vaccine due to immunosuppressant therapy

Symptoms -

Periods of acute exacerbations interspersed with remissions:

• Diarrhoea
• Abdominal pain and tenderness often in the right lower quadrant (right iliac fossa most likely)
• Weight loss
• Anal pathology e.g. fissures, abscesses or tags
• Peri-anal inflammation
• Mouth ulcers
• Anaemia
• Extra-intestinal features such as conjunctivitis, arthritis, malnutrition, fever
• Change in bowel habits

Bowel Cancer

Definition - Bowel cancer is a general term for cancer which originates from the large bowel. 

Causes - The exact cause of bowel cancer is unknown, however there are many risk factors which contribute to it. Most develop from polyps within the bowel.

Risk factors -

• Older age
• A diet high in red or processed meat
• Low fibre diet
• Obesity
• Lack of exercise
• Excess alcohol intake
• Smoking
• Family history of bowel cancer including inherited conditions eg. FNPCC, FAP
• Inflammatory bowel disease - Crohn’s or UC

Investigations -

• There is a national screening programme in place- faecal occult blood test (looks for blood that may be in stool, available for individuals aged 60-74, every 2 years)
• Colonoscopy or flexible sigmoidoscopy
• CT scan
• Blood test - FBC
• Tumour markers

Pharmacological/Surgical Interventions -

• Chemotherapy if the primary tumour has metastasised, otherwise there is a high risk of recurrence. 
• Surgical removal of the tumour if possible.
• Treatment of IBD

Lifestyle interventions -

• Balanced diet with plenty of fruit and vegetables, and low in saturated fats and sugars
• Reduce red meat consumption
• Increase fibre consumption
• Smoking cessation
• Alcohol-intake reduction

Symptoms -

• Obstruction - results in abdominal distension and pain (distension, obstruction and pain affecting the large bowel generally results in constipation)
• Haematochezia - bright-red bleeding from the anus
• Change in bowel habit (a change in frequency or consistency)
• Weight loss

Ischaemic Heart Disease: Myocardial Infarction

Definition - Sudden deprivation of blood supply to the myocardium of the heart causing ischaemic damage leading to infarction

Causes - Occlusion of the coronary arteries usually by atherosclerosis/ thrombosis. The lack of blood supply will cause ischaemic damage

Common risk factors -

• Increasing age
• Tobacco/Smoking
• Hypertension
• Obesity
• Diabetes
• Metabolic syndrome
• Family history of heart attack

Investigations -

• ECG - check for changes (ST elevation/depression, pathological Q waves)
• Blood test - Troponin I and T
• Echocardiogram

Pharmacological/Surgical Interventions -

• PCI (stent to widen blocked vessel)
• CABG (surgery that bypasses blocked artery)
• Aspirin (reduces the clotting risk)
• Clopidogrel (antiplatelet)- prescribed after a heart attack

Lifestyle interventions -

• Improved diet with reduced fat consumption
• Increased exercise
• Smoking cessation

Symptoms -

• Chest pain (tight, dull, radiating)
• SOB
• Nausea
• Sweating
• Dizziness

Ischaemic Heart Disease: Angina (Unstable/Stable)

Definition - Temporary occlusion of the coronary arteries that causes pain.

Stable Angina: Pain only occurs on exertion

Unstable Angina: Pain at rest

Causes - Partial occlusion of the coronary arteries of the heart leading to temporary ischaemia (loss of oxygen supply)

Common risk factors -

• Increasing age
• Tobacco/Smoking
• Hypertension
• Obesity
• Diabetes
• Metabolic syndrome
• Family history of heart attack

Investigations -

• ECG - check for changes
• Blood test - Troponin I and T- should be negative as no infarction should have occurred
• Echocardiogram

Pharmacological/Surgical Interventions -

• Calcium channel blockers eg. Diltiazem - causes dilation of vessels to relieve ischaemia
• Aspirin (reduces the clotting risk)

Lifestyle interventions -

• Improved diet with reduced fat consumption
• Increased exercise
• Smoking cessation

Symptoms -

• Chest pain (tight, dull, radiating)
• SOB 

Osteoarthritis

Definition - Degeneration of the joint hyaline cartilage and erosion of the underlying bone

Causes - Destruction of the hyaline cartilage of the articulating bones in joints due to age-related degeneration, trauma or infection of the bone

Common risk factors - 

• Obesity
• Previous injury to the affected joint
• Occupational factors (e.g. heavy lifting)
• Genetics
• Old age
• Female sex
• Sedentary lifestyle

Investigations -

• X-ray - Signs on an x-ray are subchondral sclerosis, reduced joint space, osteophytes, subchondral cysts
• Joint fluid aspirate analysis/blood tests to rule out RA

Pharmacological/Surgical Interventions -

• OTC pain killers/NSAIDs
• Opioid pain killers
• Joint replacement

Lifestyle interventions -

• Weight loss
• Improving lifting techniques 

Symptoms -

• Deep, aching joint pain that is exacerbated by use
• Reduced range of motion
• Crepitus - a grinding sensation on movement of the joint 
• Stiffness during rest 

Rheumatoid Arthritis

Definition - An autoimmune condition causing damage and destruction of the joint capsule 

Causes - Autoimmune condition leading to a Type 3 hypersensitivity reaction and immune complex deposition within the synovial membranes of the joints

Common risk factors -

• Genetics
• Female sex 
• Smoking (unclear link)

Investigations -

• X-Ray of the joint (no changes will be seen in the early stages of the disease)
• Blood test for ACPA antibody and RF (non-diagnostic)

Pharmacological/Surgical Interventions -

• Methotrexate and folate supplement
• Hydroxychloroquine
• Prednisolone

Lifestyle interventions -

• Ensure to have a annual flu jab and any other vaccinations due to the immunosuppressant properties of the medications
• During flare ups ensure plenty of rest to help ease any pain or inflammation
• Smoking cessation

Symptoms - Usually begin in the small joints i.e. hands and toes

• Joint swelling
• Joint pain and stiffness that is usually symmetrical and on waking in the morning
• Tiredness
• Fever
• Poor appetite and weight loss
• Systematic symptoms (e.g. eye pain (Sjogren's syndrome - dry eyes and dry mouth - commonly presents with RA), chest pain (rheumatoid nodules/lung disease) if they are affected)
• Joint pain lasts longer than 1 hour (as opposed to osteoarthritis, in which joint pain comes in <1 hour "bursts")

Peptic Ulcer Disease

Definition - Ulcers occurring within the stomach (gastric ulcer) or duodenum (duodenal ulcers). To be classified as an ulcer it must extend through the muscularis mucosae. Most commonly affects the first part of the duodenum

Causes - Ulcers occur when there is breach in the defences of the stomach which exist to protect the stomach from the acid. This can be due to:

• Chronic use of NSAIDs, such as ibuprofen or aspirin
• H pylori infection
• Chronic alcohol consumption

Risk factors -

• Stress
• Alcoholism
• Smoking

Investigations -

• Test for H pylori (urease breath test)
• Endoscopy (used to visualise the ulcers and obtain a biopsy to determine if the ulcer is malignant)

Pharmacological/Surgical Interventions -

• Proton pump inhibitors
• H2 receptor antagonists
• Antibiotics (if due to H. Pylori infection)

Lifestyle interventions -

• Reduce alcohol intake
• Discontinue NSAIDS
• Avoid aggravating factors eg spicy food
• Reduce stress where possible 

Symptoms -

• Epigastric pain
• Indigestion
• Loss of appetite
• Nausea and vomiting
• Weight loss
• Malaena - dark, tar-like stool
• Haematemesis (if ulcer has eroded into a blood vessel)

Deep Vein Thrombosis

Definition - A venous clot that forms in the deep veins of the legs.

Causes - Any thrombosis is generated by 3 factors known as Virchow’s Triad - blood stasis/ sluggish flow, abnormal vessel walls, abnormal blood coaguability

Risk factors-

• Recent surgery
• Blood vessel damage
• Cancer
• Heart disease
• Hepatitis
• Rheumatoid arthritis
• Thrombophilia
• Pregnancy 
• Smoking
• Dehydration
• COCP
• HRT 
• Inactivity for a long period of time (eg. long haul flight)

Investigations -

• D-dimer tests (raised when clots are present)
• Ultrasound scan of the leg veins
• Venogram (contrast study)

Pharmacological/Surgical Interventions -

• Heparins, e.g. heparin, dalteparin
• Warfarin
• IVC filters

Lifestyle interventions -

• Compression stockings
• Increase exercise
• Losing weight
• Stopping smoking
• Performing regular leg exercises when immobile

Symptoms -

• Pain or swelling in one leg
• Warm or red skin
• Can cause a Pulmonary Embolism (clot of the lungs -> breathlessness, chest pain, haemoptysis)

Pulmonary Embolism

Definition - Blockage of a blood vessel in the lungs caused by a embolus from elsewhere in the body

Causes - Caused by an embolus; most commonly a thrombus from the deep veins in the calf (DVT) (may be anything including; talc, air, fat, bullets). The embolus travels through the veins to the right side of the heart and then lodges in the pulmonary circulation. 

Risk factors -

• Over 55 years old
• Pregnancy
• COCP
• Cancer
• Heart failure
• Smoking
• Obesity
• Recent surgery
• Thrombophilia

Investigations -

• Well’s score -assesses risk of thromboembolism
• D-dimers- to determine presence of clots
• CT pulmonary angiography - used to confirm diagnosis

Pharmacological/Surgical Interventions -

• LMWH to prevent thrombus propagation, e.g. dalteparin 
• Thrombolysis treatment
• Thrombectomy
• Oxygen
• Preventative: anticoagulatives such as Warfarin, or DOACs such as Rivaroxaban

Lifestyle Interventions -

• Compression stockings
• Regular exercise, and avoiding long periods of immobilisation
• Good hydration
• Maintaining a healthy BMI

Symptoms -

Often doesn’t present with any symptoms, but may have:

• Breathlessness
• Pleuritic chest pain
• Cough
• Haemoptysis (suggests a PE with pulmonary infarction)
• Signs of a DVT (e.g. unilateral leg pain, leg swelling)

Hyperthyroidism

Definition - A condition caused by an overactive thyroid leading to overproduction of thyroid hormone

Causes -

• Autoimmune (eg. Graves’ Disease)
• Excessive intake of thyroid hormones (over-treating hypothyroidism)
• Abnormal secretion of TSH from the anterior pituitary gland (TSH/TRH secreting tumour)

Risk factors -

• Female sex
• Personal or family history of autoimmune disease
• Recent pregnancy
• Taking iodine supplements
• Trauma to the thyroid

Investigations -

• Blood tests to test for TSH, T3 and T4 levels. TSH will be low, while T3 and T4 levels will be high
• Can also do radioactive iodine or technetium capturing tests can evaluate the thyroid gland's function

Pharmacological/Surgical Interventions -

• Anti-thyroid drugs, e.g. Carbimazole
• Thyroidectomy 
• Supportive treatment of symptoms 
• Plasmapheresis to remove auto-antibodies (Graves) 
• Radioactive Iodine

Lifestyle interventions -

• Reduced iodine diet
• Exercise
• Reducing stress

Symptoms -

• Goitre
• Sweating
• Tremor
• Tachycardia
• Fatigue
• Weight loss
• Difficulty concentrating
• Irregular periods
• Thinning of hair
• Anxiety
• Lid lag

Graves disease specific symptoms: Exophthalmos, Tibial Myxoedema

Hypothyroidism

Definition - A condition caused by an underactive thyroid leading to underproduction of thyroid hormone

Causes -

• Autoimmune disease (Hashimoto’s thyroiditis)
• Response to medication (over-treatment of hyperthyroidism)
• Thyroid surgery
• Radiation therapy
• Medications (e.g. lithium)
• Pituitary adenoma
• Iodine deficiency

Risk factors -

• Female sex
• family or personal history of autoimmune disease or thyroid disease
• Recent pregnancy

Investigations -

• TSH assay (high), T3 and T4 assay (low)
• Thyroid peroxidase antibody assay (high in autoimmune thyroiditis)
• Ultrasound only if if suspicious structural abnormalities exist

Pharmacological/Surgical Interventions - Levothyroxine (replacement therapy)

Lifestyle interventions - 

• Ensure sleep is adequate (insomnia is a common side effect of Levothyroxine)
• Eat healthily

Symptoms -

• Fatigue
• Constipation
• Weight gain
• Muscle or joint pain
• Heavy periods
• Alopecia - especially outer 1/3 of eyebrows
• Depression
• Bradycardia
• Goitre
• Myxoedema