Index Conditions for OSCE exams

Chronic Kidney Disease (CKD)

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

Causes - CKD can be started or made worse by an AKI. It is often caused by other long-term conditions, e.g. diabetes, hypertension, autoimmune diseases (e.g. vasculitis, inflammation of blood vessel walls) and adult polycystic kidney disease (an inherited condition in which cysts grow in the kidneys).

Common risk factors -

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

Investigations -

• CKD is staged using the eGFR (estimated GFR, calculated from serum creatinine) together with the level of proteinuria (protein in the urine), measured as the urine albumin:creatinine ratio (ACR)
• Urinalysis
• Blood tests, e.g. urea and electrolytes and a full blood count
• Autoantibody tests (to look for an autoimmune cause)
• Ultrasound of the kidneys, e.g. to check for a blockage of the urinary tract

Pharmacological and surgical interventions -

Treatment aims to slow the loss of kidney function and depends on the cause. Many patients take an ACE inhibitor or an angiotensin receptor blocker (ARB, a similar blood pressure drug), and many also take an SGLT2 inhibitor such as dapagliflozin (originally a diabetes drug). When the kidneys fail, the options are:

• Haemodialysis (HD: a machine filters the blood, usually for 4 hours, 3 times a week, in hospital)
• Home haemodialysis
• Peritoneal dialysis (fluid is put into the abdomen through a tube to draw waste out of the blood, usually done at home)
• Kidney transplant (often the most effective treatment for kidney failure, if the patient is fit for major surgery and a donor kidney is available)

Lifestyle interventions -

Modifiable risk factors:

• Regular exercise (obesity is a risk factor) and a healthy diet that limits salt and, if advised, potassium can help slow the progression of CKD
• Keeping alcohol within 14 units a week
• Smoking cessation
• Controlling diabetes adequately
• Controlling hypertension adequately

Drug treatment of complications:

• Bone problems: vitamin D supplements if vitamin D is low. In advanced CKD, an active form of vitamin D (alfacalcidol or calcitriol) may be needed
• Anaemia: damaged kidneys make less erythropoietin (EPO, the hormone that drives red blood cell production). This is treated with erythropoiesis-stimulating agents (ESAs, injections that act like EPO), plus iron if iron levels are low

Symptoms -

• Tiredness (can be overwhelming)
• Difficulty sleeping
• Difficulty concentrating
• Symptoms and signs of fluid overload (too much fluid in the body), e.g. shortness of breath (SoB) and oedema
• Nausea & vomiting / reduced appetite
• Cramps and pruritus (itching)
• 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
• Alcohol-related hepatitis (a swollen, damaged liver) over months to years, which may partly recover if the person stops drinking
• Cirrhosis (scarring of the liver) after years, which cannot usually be reversed

Causes - Drinking too much alcohol over months or years

Investigations - Liver function tests (blood tests that show how well the liver is working) and an ultrasound scan of the liver

Lifestyle interventions - 

• Stop drinking alcohol completely, with medical help, as stopping suddenly can be dangerous for heavy drinkers
• Referral to a self-help group, such as Alcoholics Anonymous

Pharmacological interventions - 

• Acamprosate or naltrexone, with talking therapy, to reduce cravings and help prevent relapse after withdrawal. Disulfiram (which makes drinking alcohol cause unpleasant effects) is used if these are not suitable.
• B vitamins, especially thiamine (vitamin B1), to prevent Wernicke's encephalopathy (brain damage caused by a lack of thiamine)
• A beta-blocker, such as carvedilol or propranolol, for some people with portal hypertension (high blood pressure in the vein that carries blood from the gut to the liver), to lower the risk of bleeding

Complications - 

• Liver failure
• Portal hypertension

Further intervention - A liver transplant may be considered if the liver is badly damaged

Symptoms -

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

Non-Alcoholic Liver Cirrhosis

Definition - Cirrhosis is scarring of the liver caused by long-term liver damage. Alcohol is a common cause, but any long-term inflammation of the liver can cause it.

Causes -

• Hepatitis B virus (HBV) or hepatitis C virus (HCV)
• Metabolic dysfunction-associated steatotic liver disease (MASLD, fat build-up in the liver linked to obesity and type 2 diabetes; previously called non-alcoholic fatty liver disease, NAFLD)
• Autoimmune liver conditions, e.g. autoimmune hepatitis
• Genetic conditions, e.g. haemochromatosis (too much iron builds up in the body)

Risk factors -

• Illicit IV Drug use
• Genetics
• High cholesterol
• Obesity
• Type 2 diabetes

Investigation -

• Liver function tests

Pharmacological/Surgical Interventions -

• Antivirals for hepatitis B or C, to treat the cause
• Hepatitis B vaccine to prevent infection
• Medicines to prevent complications, e.g. a beta-blocker to lower the risk of bleeding

Lifestyle interventions -

• Stopping drinking alcohol
• Exercise
• Smoking cessation
• Lower fat intake
• Healthy balanced diet

Symptoms - See Alcoholic Liver Disease

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 long-term inflammatory disease
• Haemolytic diseases (where red blood cells are destroyed too quickly)
• Sickle cell disease
• Malaria

Common risk factors -

• Veganism/Vegetarianism
• Poor iron intake
• Any long-term inflammatory disease
• Menorrhagia (heavy periods)
• Genetics
• Alcoholism

Investigations -

• Blood tests: haemoglobin concentration (to diagnose anaemia), then haematocrit, mean cell volume (the average size of the red blood cells), reticulocyte count (young red blood cells, which show how fast new ones are being made), and iron and folate levels, to help find the cause
• Blood film (a drop of blood looked at under a microscope, to see the shape, size and colour of the red blood cells)
• Kidney function tests (e.g. creatinine and eGFR), because kidney disease lowers EPO production and can cause anaemia

Pharmacological/Surgical Interventions -

• B12/Folate/Iron supplements
• Treatment for underlying chronic conditions
• In sickle cell disease, hydroxycarbamide (a medicine that can reduce pain crises) and blood transfusions when needed
• Antimalarial drugs if malaria is the cause

Lifestyle interventions -

• Diet changes depend on the cause. For low iron, eat more meat, dark-green leafy vegetables and fortified cereals. For low folate, eat more green vegetables such as broccoli and peas. For low B12 from diet, eat more meat, fish, eggs and dairy, or fortified foods if vegan. B12 deficiency from pernicious anaemia (where the body cannot absorb B12) is not caused by diet and needs injections.

Symptoms -

• Fatigue
• Tachycardia (a fast heart rate) or palpitations (being aware of your heartbeat)
• Shortness of breath
• Dizziness
• Pale skin
• Leg cramps
• Headaches

Atrial Fibrillation (AF)

Definition - A heart rhythm problem where the heart beats in an irregularly irregular way (with no pattern to the beats), often fast. It raises the risk of blood clots forming in the heart, which can travel to the brain and cause a stroke.

Causes - Often caused by other conditions, such as:

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

Common risk factors -

• Increasing age
• Heart conditions
• The conditions listed under Causes

Investigations -

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

Pharmacological/Surgical Interventions -

• Rate control (slowing the heart) is usually first: a beta-blocker (e.g. bisoprolol), or a calcium channel blocker that slows the heart (diltiazem or verapamil)
• Rhythm control (restoring a normal rhythm) for some patients: cardioversion (an electric shock to the heart), or antiarrhythmic drugs (drugs that control heart rhythm) such as flecainide or amiodarone
• Anticoagulants (drugs that stop blood clotting), usually a DOAC (direct-acting oral anticoagulant, e.g. apixaban), if the stroke risk score (CHA2DS2-VASc) is raised. They prevent clots forming and travelling to block a blood vessel (embolisation). Aspirin alone is not used.
• Stop, if possible, any drugs that raise the risk of clots or abnormal heart rhythms

Lifestyle interventions -

• A balanced diet and keeping to a healthy weight
• Avoiding triggers of attacks (e.g. alcohol, caffeine, illicit drugs)
• Smoking cessation

Symptoms - These may come at rest or on exertion, and some people have none:

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

Cerebrovascular disease (TIA/Stroke)

Definition - A stroke is a sudden loss of blood supply to part of the brain, from a blockage or a bleed. A TIA (transient ischaemic attack, or mini-stroke) is a short blockage whose symptoms last less than 24 hours.

Causes - Ischaemic (a blood clot blocks an artery in the brain; the clot may form there or travel from elsewhere, such as the heart) or haemorrhagic (a blood vessel in or around the brain bursts and bleeds)

Common risk factors -

Modifiable (can be changed):

• Smoking
• Hypertension
• Obesity
• High cholesterol
• High alcohol intake
• Taking the combined oral contraceptive pill (COCP)
• Atrial fibrillation (AF)

Non-modifiable (cannot be changed):

• Increasing age
• Family History
• South Asian, African or Caribbean ethnicity

Investigations -

To determine stroke risk: 

• Blood tests for cholesterol level and coagulability (INR)
• Blood pressure
• BMI
• ECG to look for AF or another heart condition

To diagnose stroke or TIA if indicated by symptoms on presentation

• CT head, to tell a clot from a bleed
• MRI head, which may be used after a TIA, as CT is not routinely done for TIA
• Angiography (scans of the blood vessels supplying the brain), e.g. CT angiography if thrombectomy might be needed

Pharmacological/Surgical Interventions - 

Only to treat underlying co-morbidities increasing stroke risk:

• Anticoagulants
• Antihypertensives
• Antiarrythmics

Lifestyle interventions -

These lower the risk of a first or repeat stroke:

• Increased exercise
• Balanced healthy diet (reducing cholesterol intake)
• Smoking cessation
• Cutting down on alcohol

Chronic Obstructive Pulmonary Disease (COPD)

Definition - A long-term lung disease that gets worse over time and causes increasing breathlessness. The narrowing of the airways is not fully reversible. It includes emphysema and chronic bronchitis.

• Emphysema: damage to the air sacs (alveoli) in the lungs, which traps air and causes hyperinflation (the lungs stay over-filled with air)
• Chronic bronchitis: long-term inflammation of the airways, with too much mucus (chronic mucus hypersecretion)

Causes -

• Smoking, including second-hand smoke
• Air pollution
• Alpha-1 antitrypsin deficiency, an inherited lack of a protein that protects the lungs (a very small minority of cases)

Investigations - Diagnosed with spirometry (a breathing test that measures how much and how fast you can breathe out), done after a bronchodilator (an inhaler that opens the airways). It shows narrowed airways that do not fully recover.

Pharmacological/Surgical Interventions -

• First, a short-acting bronchodilator when needed, e.g. a SABA (short-acting beta-2 agonist) such as salbutamol
• If still breathless or having flare-ups: a LABA (long-acting beta-2 agonist, e.g. salmeterol) plus a LAMA (long-acting muscarinic antagonist, another long-acting bronchodilator, e.g. tiotropium)
• If there are asthma-like features: a LABA plus an ICS (inhaled corticosteroid, a steroid that reduces airway inflammation, e.g. beclometasone) instead
• All three (LAMA, LABA and ICS) if symptoms or flare-ups continue
• Mucolytics, e.g. carbocisteine, which thin the mucus so it is easier to cough up. They are used for a long-term cough with phlegm and continued only if they help.

Lifestyle interventions -

• Smoking cessation
• Vaccines: a yearly flu jab and a pneumococcal vaccine, because infections can trigger flare-ups (exacerbations)
• Increased exercise, e.g. pulmonary rehabilitation (a supervised programme of exercise and education)
• Long-term oxygen therapy for people who do not smoke and have very low blood oxygen levels. It helps them live longer. Oxygen is not used for breathlessness alone if blood oxygen is normal or only mildly low.

Symptoms -

• Chronic productive cough (a long-term cough that brings up phlegm)
• Shortness of breath whilst doing everyday activities
• Recurrent respiratory infections
• Cyanosis (a blue tinge to the lips or skin)
• Fatigue
• Increased sputum (phlegm) production
• Wheezing

Asthma

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

Causes -

• The cause is not fully understood. Genes and the environment, such as air pollution or cigarette smoke in childhood, both play a part.

Common risk factors -

• Family history
• History of atopy (a tendency to allergies, e.g. hay fever, eczema)
• Being born prematurely or with a low birth weight

Investigations - Diagnosed from the history plus tests. In adults, first a blood eosinophil count (a type of white blood cell raised in allergy) or a FeNO test (a breath test for airway inflammation). If these do not confirm it, spirometry before and after a bronchodilator shows narrowing that improves. Peak flow readings twice a day for 2 weeks can be used if spirometry is not available.

Pharmacological/Surgical Interventions -

• Age 12 and over: an inhaler that combines an ICS (inhaled corticosteroid) with formoterol (a fast-acting LABA), taken when needed for symptoms. This is AIR (anti-inflammatory reliever) therapy.
• If asthma is not controlled: the same inhaler taken every day and when needed (MART, maintenance and reliever therapy), at a higher dose if needed
• A SABA (e.g. salbutamol) is never prescribed without an ICS, and a LABA (e.g. salmeterol) is never used without an ICS
• Children aged 5 to 11 follow a separate plan

Lifestyle interventions -

• Avoidance of possible triggers
• Smoking cessation
• Taking treatment as prescribed
• Regular check-ups

Symptoms -

• Cough (worse at night)
• Wheeze (either audibly or through a stethoscope)
• Breathlessness
• Tight chest
• Asthma attacks: sudden worsening (exacerbations) caused by narrowing of the airways (bronchoconstriction)

Lung Cancer

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

Common risk factors -

• Smoking, including passive smoking
• COPD
• Environmental exposure to carcinogens (substances that cause cancer), e.g. asbestos, radon gas or air pollution
• Family history

Investigations -

• Chest X-ray
• CT scan or PET-CT (a scan that also shows how active the tissues are)
• Bronchoscopy (a camera passed into the airways), with a biopsy (tissue sample) of the mass

Pharmacological/Surgical Interventions -

• Radiotherapy
• Chemotherapy
• Surgery
• Targeted therapies (drugs aimed at specific features of the cancer cells)

Lifestyle interventions -

• Smoking cessation (most important)
• Staying active and eating a healthy diet
• 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: The immune system destroys the beta cells of the pancreas (the cells that make insulin), so no insulin is made and blood glucose stays high (chronic hyperglycaemia)

Type 2: The body becomes resistant to insulin and later makes less of it, so blood glucose stays high

Causes -

Type 1: Autoimmune (the immune system attacks the body's own cells). It is more likely if family members have type 1 diabetes or another autoimmune condition.

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
• Being overweight and not very active (type 2)
• Being over 40, or over 25 if from a South Asian, Chinese, Black African or Black Caribbean background (type 2)

Investigations -

• Blood glucose tests after fasting and after taking a set amount of glucose
• HbA1c blood test (shows the average blood glucose over the past 2 to 3 months)
• For monitoring rather than diagnosis: finger-prick blood glucose checks, or continuous glucose monitoring (CGM), which NICE offers to all adults with type 1 diabetes

Pharmacological/Surgical Interventions -

Type 1: Insulin for life, usually as several injections a day (basal-bolus): a long-acting insulin for background needs plus a rapid-acting insulin with meals

Type 2: Multiple treatment options:

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

Lifestyle interventions -

• A healthy diet that limits sugar
• Increased exercise
• Smoking cessation

Symptoms -

• Polydipsia (feeling very thirsty)
• Dry mouth
• Polyuria (passing a lot of urine)
• Unexplained weight loss
• Fatigue
• Blurred vision, slow-healing cuts and repeated thrush

Epilepsy

Definition - A condition in which a person has repeated seizures, caused by sudden bursts of abnormal electrical activity in the brain. Seizures are grouped as focal (starting in one part of the brain, once called partial) or generalised (affecting both sides of the brain). Status epilepticus is a medical emergency: a seizure lasting 5 minutes or more, or repeated seizures without recovering in between.

Causes - Epilepsy is often linked to genes. It can also follow damage to the brain, such as the causes below. For many people, the cause is not clear.

• 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 (a recording of the brain's electrical activity)
• MRI head; CT if MRI cannot be done
• 12-lead ECG, to look for heart conditions that can look like a seizure
• Blood tests, e.g. full blood count
• A collateral history (an account of the seizure from anyone who saw it)

Pharmacological/Surgical Interventions -

• Focal seizures: the antiseizure drugs lamotrigine or levetiracetam first line
• Generalised tonic-clonic seizures: lamotrigine, levetiracetam or sodium valproate
• Absence seizures: ethosuximide first line
• Sodium valproate is not started in anyone under 55 unless 2 specialists agree that no other treatment is suitable, because of the risks to their future children. Women and girls who could become pregnant can only take it within a pregnancy prevention programme.
• Status epilepticus: a benzodiazepine (a fast-acting sedative), e.g. buccal midazolam (given inside the cheek) in the community, or IV lorazepam in hospital

Lifestyle interventions -

• Avoiding the person's own seizure triggers, e.g. tiredness, stress, too much alcohol, or flashing lights in some people
• Not stopping or changing medicines without advice
• Adjusting to life with epilepsy, e.g. after any seizure the person must stop driving and tell the DVLA
• Regular check-ups
• Planning pregnancy with a specialist, because some epilepsy medicines can harm the baby

Symptoms - These depend on the seizure type. Some cause loss of consciousness or awareness, but in others, such as some focal seizures, the person stays aware.

• Tonic - the muscles suddenly stiffen (rigidity)
• Tonic-clonic (once called grand mal) - the person loses consciousness, stiffens, then the body jerks and shakes (convulsions)
• Myoclonic - brief jerks of the muscles
• Absence - the person briefly loses awareness, often staring into space, then carries on without noticing the pause
• Atonic - the muscles suddenly go floppy and the person may fall to the floor
• Focal - unusual feelings, sensations or movements; the person may stay aware

Anxiety

Definition - This section covers generalised anxiety disorder (GAD): excessive worry about many things, on most days for at least 6 months. Panic disorder is a separate condition.

Causes - Often linked to stress (e.g. at school or work), other medical illnesses, or illicit drug use (e.g. cocaine)

Common risk factors -

• Stress
• Genetic predisposition (inherited genes that raise the risk) or a 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 core symptoms and at least 3 of the 6 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
  • Becoming easily tired
  • 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 (fast, deep breathing)
• Sweating
• Tight chest
• Fatigue
• Trouble concentrating

Depression

Definition - Low mood or hopelessness, or a loss of interest or enjoyment in doing things, on most days for at least 2 weeks

Causes -

• Stress
• Adverse childhood experience
• Some prescribed medicines or illicit drugs
• Bereavement (the death of someone close) or another loss. Note: an adjustment reaction is a short-lived response to a clear trigger, and is not depression.
• Genetic pre-disposition
• Other illnesses (co-morbidities), especially long-term physical health problems
• Substance misuse

Common risk factors -

• Unstable or poor home life
• Stressful life
• Substance misuse
• Family history of mental health conditions

Investigations - The diagnosis is clinical. Blood tests may be helpful to rule out other conditions with similar symptoms (differential diagnoses), e.g. hypothyroidism (an underactive thyroid)

Note - If a patient has depressive symptoms, you MUST ask directly about thoughts of suicide and self-harm, in a sensitive and sympathetic way. Failing to assess this risk is a patient safety issue.

Pharmacological/Surgical Interventions -

• Less severe depression: guided self-help or a talking therapy first. Antidepressants are only offered if the person prefers them.
• More severe depression: CBT combined with an antidepressant, such as an SSRI, is the first option NICE lists
• If these do not work, a specialist may add other drugs, such as lithium (a mood stabiliser that needs regular blood tests)

Lifestyle interventions -

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

Diagnostic criteria - At least 5 of the 9 symptoms below, including at least one core symptom, present for at least 2 weeks.

•  Two core symptoms:
  • Low mood, hopelessness or feeling down, most days, most of the time
  • 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
  • Psychomotor agitation or retardation (restlessness, or slowed movements and thoughts)
  • Insomnia (difficulty sleeping) or hypersomnia (sleeping too much)
  • A significant change in appetite or weight, usually a decrease but sometimes an increase

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 - Pain felt anywhere in the head

Causes - Headaches can be classed into primary and secondary causes

Primary (not caused by another condition; most headaches are primary)

• Tension-type headache (stress can make it worse)
• Migraine
• Cluster headache

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

• Subarachnoid haemorrhage (SAH, bleeding around the brain)
• Medication-induced (e.g. GTN, glyceryl trinitrate, used for angina)
• 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 - Usually no tests are needed. If there are red flags (warning signs of a serious cause), arrange urgent referral or hospital admission, which may include a brain scan:

Red flags - SNOOP mnemonic (a memory aid; each letter is one warning sign):

• Systemic signs (signs of illness in the whole body, e.g. fever)
• Neurological signs (e.g. new weakness, confusion or drowsiness)
• Older age: a new headache at age 50 or over (think of giant cell arteritis, inflamed arteries in the head)
• Onset like a thunderclap (very sudden, severe pain that peaks within 5 minutes), which may be SAH
• Papilloedema (swelling of the optic disc at the back of the eye), a sign of raised pressure inside the skull

Pharmacological/Surgical Interventions -

• Over-the-counter painkillers: paracetamol, or ibuprofen (an NSAID, non-steroidal anti-inflammatory drug)
• Opioids such as codeine are not used for tension-type headache or migraine. Taking painkillers too often can cause medication-overuse headache.
• Migraine: a triptan (a migraine-specific drug, e.g. sumatriptan) together with an NSAID or paracetamol. Preventive medicines, e.g. propranolol or amitriptyline, can be considered.
• Cluster headache: oxygen, or a triptan given by injection or nasal spray

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 - throbbing pain, often on one side, with nausea. Some people first get an aura (warning signs such as flashing lights or zigzag lines).
• Cluster - very severe pain around one eye, often with a red, watering eye on the same side. Each attack lasts 15 minutes to 3 hours, and attacks come in bouts that last weeks or months.
• Trigeminal neuralgia (pain from the trigeminal nerve, which carries feeling from the face) - sudden electric-shock pain in the jaw, teeth or gums, often set off by lightly touching the face

Gall Stones

Definition - Stones that form in the gallbladder. They often cause no symptoms, but a stone can block a bile duct (a tube that carries bile from the liver and gallbladder to the gut).

Key risk factors -

• Obesity
• A diet high in fat and low in fibre
• Being a woman, or over 40
• Losing weight quickly, e.g. after weight loss surgery

Investigations -

• Ultrasound scan
• Blood tests (liver function tests): bilirubin and the liver enzymes AST, ALT, ALP and gamma-GT
• CRP (a blood marker of inflammation) and white cell count, to look for infection, e.g. ascending cholangitis (infection of a blocked bile duct)

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 food and drink that trigger symptoms (often fatty foods) until the gallbladder is removed
• Avoiding alcohol
• Exercise, and losing weight gradually if overweight, as losing weight quickly raises the risk

Possible complications/Symptoms -

• Biliary colic (severe pain in the upper middle or upper right of the abdomen, lasting from 30 minutes to several hours, often with nausea or vomiting)
• Fever
• Jaundice
• A stone stuck in the bile duct (impaction) can lead to cholangitis (infection of the bile ducts)
• Pain can spread (radiate) to the shoulder tip
• A stone stuck at the ampulla of Vater (where the bile and pancreatic ducts open into the gut) can cause pancreatitis (an inflamed pancreas)

Heart Failure

Definition - The heart cannot pump enough blood to meet the body's needs. Less blood reaches the tissues (reduced perfusion), and pressure can build up in the blood vessels of the lungs.

Causes -

• Ischaemic heart disease
• Hypertension and aortic valve disease (aortic stenosis, a narrowed valve, or aortic regurgitation, a leaking valve). Each can thicken the wall of the left ventricle (left ventricular hypertrophy).
• Cardiomyopathy (disease of the heart muscle)
• Arrhythmias (abnormal heart rhythms)
• Chronic lung diseases, e.g. COPD, pulmonary fibrosis (scarring of the lungs) or bronchiectasis (widened, damaged airways). These strain the right side of the heart (cor pulmonale).

Risk factors -

• Obesity
• Smoking
• Diabetes
• High alcohol intake
• Lack of exercise
• Chronic lung disease
• Family history
• Previous rheumatic fever (an immune reaction after a throat infection that can damage the heart valves)

Investigations -

• NT-proBNP blood test (a hormone released when the heart is under strain)
• Echocardiogram (an ultrasound scan of the heart), to confirm the diagnosis and check the valves and pumping
• ECG and chest X-ray, to look for other causes

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
• Weighing regularly (to spot fluid retention)
• Healthy diet

Symptoms -

Left-sided heart failure (fluid backs up into the lungs):

• Fatigue
• Breathlessness on exertion
• Orthopnoea (breathlessness when lying flat) and paroxysmal nocturnal dyspnoea (waking at night short of breath)
• A sign on examination: a displaced apex beat (the heartbeat felt further out on the chest) because the heart is enlarged (cardiomegaly)

Right-sided heart failure (fluid backs up into the body):

• Fatigue
• Breathlessness
• Peripheral oedema
• Raised JVP (jugular venous pressure: the neck veins look swollen)
• Enlarged and tender liver

Infectious Presentations: Pneumonia

Definition - Inflammation of the lung tissue (parenchyma), usually caused by a bacterial or viral infection. The air sacs (alveoli) may fill with pus.

Causes - Viral or bacterial infections of the lung, usually spread in droplets from coughs and sneezes.

Common risk factors -

• A weakened immune system (immunocompromised)
• Very young or older age
• Living in close contact with others, e.g. in care homes

Investigations -

• Chest X-ray, to look for consolidation (an area of lung filled with fluid or pus) and, in later stages, a pleural effusion (fluid around the lung)
• 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
• Vaccines: the pneumococcal vaccine (for babies, adults over 65 and people at higher risk) and the flu vaccine (for adults over 65, during pregnancy and for people with some long-term conditions)
• Covering coughs and sneezes and washing hands, to reduce spread
• People with a weakened immune system should avoid people who have infections. Preventive antibiotics (prophylaxis) are only given in specific situations, e.g. after removal of the spleen or during chemotherapy.
• A varied and balanced diet, which gives most people all the vitamins they need

Symptoms -

• Productive cough
• Haemoptysis (coughing up blood)
• Shortness of breath
• Pleuritic chest pain (sharp chest pain that is worse on breathing in)
• Tachycardia
• Fever
• Sweating/shivering

Infectious Presentations: Meningitis

Definition - Infection causing inflammation of the leptomeninges (the inner layers of the meninges, which cover the brain and spinal cord). It is a medical emergency: it can be life-threatening if not treated quickly.

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 -

• A weakened immune system, e.g. HIV or chemotherapy
• Living in close contact with others (e.g. students in halls of residence), because the infection spreads by close contact
• Age: babies and young children, teenagers and young adults, and older people
• Missed vaccinations
• Reduced or absent spleen function

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
• A non-blanching rash (it does not fade when a glass is pressed on it; harder to see on brown or black skin), in meningococcal infection
• Photophobia (eye pain when looking at bright lights)

Infectious Presentations: Urinary Tract Infection/Pyelonephritis

Definition - Infection of the urinary tract. It can affect the lower urinary tract (cystitis, a bladder infection) or the upper urinary tract (pyelonephritis, a kidney infection).

Causes - Usually bacteria from the gut entering through the urethra. The most common is Escherichia coli (E. coli). Less common causes include Staphylococcus saprophyticus, Proteus and Klebsiella.

Common risk factors - 

• Female sex (a shorter urethra, so bacteria reach the bladder more easily)
• Blockage of the urinary tract (e.g. an enlarged prostate or kidney stones), so urine stays in the tract (stasis)
• Pregnancy
• Nerve problems that stop the bladder emptying fully (incomplete voiding), so urine stays in the tract
• Sexual intercourse, a new sexual partner, or spermicide used with contraception
• Not urinating after sex
• Urinary catheters
• A weakened immune system, e.g. poorly controlled diabetes
• Having been through the menopause

Investigations - A woman under 65 with typical symptoms and no risk of a complicated UTI (one more likely to cause problems, e.g. in pregnancy, in men or with a catheter) may need no tests. Otherwise:

• Urine dipstick test (a strip that changes colour with signs of infection), mainly in women under 65 with fewer typical symptoms
• A mid-stream urine sample sent for culture, instead of a dipstick, in pregnancy, in people over 65 and when symptoms persist or come back; men and pregnant women have a sample sent before antibiotics

If sepsis is suspected, the person is assessed urgently using the NEWS2 score (based on vital signs such as pulse, blood pressure and breathing rate). Antibiotics are given within a time limit set by the level of risk, at most 1 hour for the highest risk.

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
• Avoiding scented soap around the genital area
• Wiping from front to back after using the toilet
• Avoiding spermicide (on condoms, a diaphragm or a cap); a different type of contraception can be used

Symptoms -

Lower UTI (Cystitis)

• Dysuria (pain or burning when passing urine)
• Frequency (passing urine more often than usual)
• Urgency (a sudden, strong need to pass urine)
• Cloudy urine
• Fever is not typical; it suggests the infection has reached the kidney

Upper UTI (Pyelonephritis)

• Fever
• Loin pain (pain in the back, just under the ribs)
• Dysuria or frequency
• Nausea and vomiting

Hypertension

Definition - Blood pressure that stays high: a clinic reading of 140/90 mmHg or higher, confirmed by an average of 135/85 mmHg or higher on ambulatory monitoring (a portable monitor worn for 24 hours) or home monitoring.

Causes -

• Primary hypertension has no single known cause, but the risk factors below raise the chance of getting it
• Secondary hypertension has an identifiable cause, such as renal artery stenosis (narrowing of the artery to a kidney), Cushing’s syndrome (too much cortisol) or Conn’s syndrome (hyperaldosteronism: too much of the hormone aldosterone)

Risk factors -

• Smoking
• Obesity
• Lack of physical activity
• Long-term stress
• Older age
• Family history
• A Black African, Black Caribbean or South Asian family background
• Excess salt in diet
• Excess alcohol consumption

Pharmacological/Surgical Interventions -

NICE uses steps: a drug is added at each step if blood pressure is still not controlled.

For a patient aged under 55 who is not of Black African or African-Caribbean family origin, or anyone with type 2 diabetes:

• Step 1: an ACE (angiotensin-converting enzyme) inhibitor, e.g. ramipril, or an angiotensin receptor blocker (ARB), e.g. losartan

• Step 2: add a calcium channel blocker (CCB), e.g. amlodipine, or a thiazide-like diuretic, e.g. indapamide

For a patient aged 55 or over, or of Black African or African-Caribbean family origin, without type 2 diabetes:

• Step 1: a calcium channel blocker, e.g. amlodipine

• Step 2: add an ACE inhibitor, an ARB or a thiazide-like diuretic. For people of Black African or African-Caribbean family origin, an ARB is preferred to an ACE inhibitor.

For both groups:

• Step 3: an ACE inhibitor or ARB, plus a CCB, plus a thiazide-like diuretic

• Step 4 (resistant hypertension): check blood potassium. If it is 4.5 mmol/l or less, consider low-dose spironolactone (a diuretic). If it is higher, consider an alpha-blocker (relaxes blood vessels) or a beta-blocker. Seek specialist advice if blood pressure is still not controlled on 4 drugs.

Lifestyle interventions -

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

Symptoms - Hypertension usually has no symptoms, so it is found by measuring blood pressure. Rarely, it can cause:

• Headaches
• Blurred vision
• Chest pain

A clinic blood pressure of 180/120 mmHg or higher needs same-day specialist assessment if there is bleeding or swelling at the back of the eye (retinal haemorrhage or papilloedema), new confusion, chest pain, signs of heart failure or acute kidney injury.

Hypercholesterolaemia

Definition - High levels of cholesterol in the blood.

Causes -

• Familial hypercholesterolaemia (an inherited condition that causes high cholesterol)
• Obesity
• Uncontrolled diabetes
• Metabolic syndrome
• Other secondary causes: excess alcohol, hypothyroidism, liver disease and nephrotic syndrome (a kidney condition in which protein leaks into the urine)

Risk factors -

• A diet high in fatty food
• Not exercising enough
• Smoking
• Drinking alcohol
• Being over 50, being a man, or having been through the menopause
• South Asian or sub-Saharan African family origin
• A family history of high cholesterol, or of early (premature) coronary heart disease

Investigations -

• Blood tests: total cholesterol and HDL (high-density lipoprotein) cholesterol, as part of a full lipid profile (blood fats)
• A cardiovascular risk score, e.g. QRISK3, which estimates the chance of a heart attack or stroke in the next 10 years

Pharmacological/Surgical Interventions -

• Statins (drugs that reduce the amount of cholesterol the body makes), e.g. atorvastatin. NICE offers atorvastatin 20 mg if the 10-year QRISK3 score is 10% or more, and 80 mg to people who already have cardiovascular disease.
• If statins do not work or cannot be taken: other tablets, e.g. ezetimibe, or injections, e.g. inclisiran
• Aspirin does not lower cholesterol. It is not routinely offered to prevent a first heart attack or stroke.

Lifestyle interventions -

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

Signs and symptoms -

Usually no symptoms: high cholesterol is found with a blood test. Some people have signs: xanthelasma (yellow fatty patches around the eyes), tendon xanthoma (fatty lumps in tendons) or corneal arcus (a pale ring around the edge of the cornea).

Too much cholesterol builds up in the walls of arteries and narrows them (atherosclerosis). This raises the risk of:

• Coronary heart disease and heart attack
• Stroke
• Peripheral artery disease (narrowed arteries, usually supplying the legs)

Inflammatory Bowel Disease: Ulcerative Colitis

Definition - Long-term (chronic) inflammation of the rectum and colon (large bowel). A possible complication is not getting enough vitamins and minerals from food.

Causes - The exact cause is unknown (idiopathic). It is thought to be an autoimmune condition, where the immune system attacks healthy tissue. Environmental triggers are thought to act in people whose genes make them more likely to get it.

Risk factors -

• A family history of inflammatory bowel disease (IBD), with the highest risk in a parent, brother, sister or child
• Being an ex-smoker. Smoking itself seems to lower the risk, unlike in Crohn's disease.
• Ethnicity: ulcerative colitis occurs in all ethnic groups. One UK study found it was more common in people of Indian origin than in White Europeans.
• A bowel infection, e.g. Shigella (a bacterium that causes infective diarrhoea), may trigger the first episode

Investigations -

• Blood tests: full blood count (to look for anaemia from blood loss) and inflammatory markers, e.g. CRP
• Abdominal examination
• Stool sample: culture to rule out infection, including Clostridioides difficile (C. difficile, a bacterium that causes diarrhoea), and faecal calprotectin (a marker of inflammation in the bowel)
• Sigmoidoscopy (a camera test of the rectum and lower colon)
• Colonoscopy (a camera test of the whole colon). This is the main test, and a biopsy of the bowel lining is taken.
• Abdominal X-ray or CT scan

Pharmacological/Surgical Interventions -

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

Lifestyle interventions -

• Keeping a food diary to find foods that make symptoms worse, and checking with the care team before changing the diet
• Managing stress, e.g. with breathing exercises
• Avoiding NSAIDs, e.g. ibuprofen, which can trigger flare-ups
• A balanced diet and regular exercise

Signs and symptoms -

• Recurrent bloody diarrhoea, which may contain mucus or pus. Bloody diarrhoea for more than 6 weeks suggests ulcerative colitis.
• Needing to poo often, urgently or at night
• Abdominal pain and a tender abdomen on examination, commonly in the left iliac fossa (the lower left part of the abdomen)
• Fatigue, weight loss
• Fever or tachycardia, which may mean a severe flare that needs urgent help
• During a flare, problems outside the bowel: painful red eyes, swollen or painful joints (arthritis), mouth ulcers and erythema nodosum (swollen, red or darker patches of skin)

Inflammatory Bowel Disease: Crohn's disease

Definition - A type of inflammatory bowel disease that can affect any part of the gastrointestinal (GI) tract, from the mouth to the anus. It most commonly affects the ileum (the last part of the small intestine).

Causes - The exact cause is unknown (idiopathic). It is thought that the immune system causes the inflammation, triggered by environmental factors in people whose genes make them more likely to get it.

Risk factors -

• Family history of inflammatory bowel disease
• Smoking
• NSAIDs, which can trigger flare-ups in people who have the condition
• A recent bout of infectious gastroenteritis

Investigations -

• Blood tests: full blood count (to check for anaemia) and CRP (to assess inflammation)
• Stool tests: culture to rule out infection, and faecal calprotectin (a marker of bowel inflammation)
• Ileocolonoscopy (a camera test of the colon and the end of the ileum) to look for skip lesions (patches of disease with normal bowel in between), ulcers with a typical 'cobblestone' appearance, transmural inflammation (through the full thickness of the bowel wall), strictures (narrowed sections of bowel) and fistulas (abnormal tunnels from the bowel to another organ or the skin)
• Biopsy (a small tissue sample) to look for granulomas (small clusters of immune cells) and transmural inflammation
• Scans, e.g. MRI, CT or ultrasound

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 -

Symptoms come and go: flare-ups alternate with periods of remission. The most common symptoms are diarrhoea, abdominal pain and weight loss.

• Persistent diarrhoea (for more than 4 to 6 weeks), sometimes with blood or mucus
• Abdominal pain and tenderness, often in the right iliac fossa (the lower right part of the abdomen)
• Weight loss
• Problems around the anus (perianal), e.g. inflammation, fissures (small tears), abscesses or skin tags
• Mouth ulcers
• Anaemia
• Tiredness, fever and signs of malnutrition (poor absorption of nutrients from food)
• Extra-intestinal features (problems outside the gut), e.g. arthritis, red and sore eyes (episcleritis or uveitis, types of eye inflammation) and erythema nodosum
• Change in bowel habits

Bowel Cancer

Definition - Bowel cancer is cancer that starts anywhere in the large bowel, which includes the colon and rectum.

Causes - The exact cause of bowel cancer is unknown, however there are many risk factors which contribute to it. Most bowel cancers develop from polyps (small growths) in 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
• A family history of bowel cancer, including inherited conditions, e.g. Lynch syndrome (once called hereditary non-polyposis colorectal cancer, HNPCC) and familial adenomatous polyposis (FAP)
• Inflammatory bowel disease: Crohn’s disease or ulcerative colitis
• Bowel polyps

Investigations -

• Screening: the NHS sends a home test kit every 2 years to people aged 50 to 74. The faecal immunochemical test (FIT) checks a poo sample for blood that cannot be seen.
• FIT is also used by GPs to decide which people with symptoms need urgent referral
• Colonoscopy (the main test) or flexible sigmoidoscopy, with a biopsy
• CT scan, to see if the cancer has spread
• Blood test: full blood count (FBC), to look for anaemia
• Tumour markers, e.g. carcinoembryonic antigen (CEA), a blood test used to check whether the cancer has come back after treatment, not to diagnose it

Pharmacological/Surgical Interventions -

• Surgery to remove the cancer, with part or all of the bowel around it. Some people need a stoma (an opening of the bowel onto the abdomen, e.g. a colostomy or ileostomy), which may be temporary or permanent.
• Chemotherapy (medicine that kills cancer cells): before surgery to shrink the cancer, after surgery to lower the chance of it coming back, if surgery is not possible, or if the cancer has spread (metastasised)
• Radiotherapy (radiation that kills cancer cells), mainly for cancer of the rectum or cancer that has spread
• Targeted medicines or immunotherapy (medicines that help the immune system kill cancer cells) for some advanced cancers that have spread
• For people with inflammatory bowel disease: treating it, and regular colonoscopies to check for cancer, because it raises the risk of bowel cancer

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
• Reducing alcohol intake
• Staying active, and losing weight if overweight

Symptoms -

• Change in bowel habit (a change in how often someone poos, or how soft it is) that is not usual for them
• Haematochezia (bright red blood passed from the anus), or blood in the poo, which may look red or black
• Abdominal pain, bloating or a lump in the abdomen
• Weight loss
• Tiredness or shortness of breath, which are signs of anaemia
• Bowel obstruction (a blockage), which causes abdominal distension (swelling), pain and constipation

Ischaemic Heart Disease: Myocardial Infarction

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

Causes - Blockage (occlusion) of a coronary artery, usually by a blood clot (thrombosis) in an artery narrowed by atherosclerosis. The lack of blood supply causes ischaemic damage to the heart muscle.

Common risk factors -

• Increasing age
• Tobacco/Smoking
• Hypertension
• Obesity
• Diabetes
• Metabolic syndrome
• High cholesterol
• A family history of heart attack

Investigations -

• ECG, to look for changes such as ST elevation or depression and pathological Q waves (changes in the shape of the trace that suggest damage to the heart muscle). ST elevation means a STEMI (ST-elevation myocardial infarction), which needs the artery reopened as quickly as possible.
• Blood test: high-sensitivity troponin I or T (a protein released when heart muscle is damaged), taken on arrival in hospital and often repeated
• Echocardiogram (an ultrasound scan of the heart), to see if the heart has been damaged
• Coronary angiogram (an X-ray of the heart arteries using dye), to find the blockage, which can be treated at the same time

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 that feels tight, dull or crushing, and may spread (radiate) to the arms, neck or jaw
• Shortness of breath
• Nausea
• Sweating
• Dizziness

Ischaemic Heart Disease: Angina (Unstable/Stable)

Definition - Chest pain caused by the heart muscle not getting enough blood (ischaemia), usually because the coronary arteries are narrowed. The pain comes and goes.

Stable angina: pain brought on by exertion, stress, emotion or cold. It usually lasts less than 10 minutes and stops with rest or GTN (glyceryl trinitrate) spray.

Unstable angina: angina that is getting worse, happening more often, lasting longer or happening at rest. It is an acute coronary syndrome and needs urgent hospital treatment, like a heart attack.

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
• High cholesterol
• A family history of heart problems

Investigations -

• ECG, to look for changes. A normal ECG does not rule out angina.
• Stable angina: CT coronary angiography (a CT scan of the heart arteries using dye) to look for narrowing
• Unstable angina: troponin blood test. Troponin is normal in unstable angina because the heart muscle is not damaged; a raised level means a heart attack.
• Echocardiogram

Pharmacological/Surgical Interventions -

• GTN spray, to treat an attack or before exercise to prevent one. If pain continues 5 minutes after a second dose, call 999.
• To prevent attacks: a beta-blocker or a calcium channel blocker, e.g. diltiazem or amlodipine (drugs that lower blood pressure and make it easier for the heart to pump). If one is not enough, both can be used together, choosing a calcium channel blocker such as amlodipine.
• Aspirin 75 mg daily (reduces the clotting risk) and a statin, to lower the risk of a heart attack or stroke
• If medicines do not control the symptoms: PCI or CABG to improve blood flow to the heart

Lifestyle interventions -

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

Symptoms -

• Chest pain that feels tight, dull or squeezing, and may spread (radiate) to the neck, shoulders, jaw or arms
• Shortness of breath
• Feeling sick, dizzy or sweaty

Osteoarthritis

Definition - Wear and breakdown (degeneration) of the hyaline cartilage, the smooth, protective cartilage that covers the ends of the bones in a joint. The bone underneath is also damaged (eroded).

Causes - The exact cause is not fully known. The hyaline cartilage on the ends of the bones that meet at a joint (the articulating bones) is destroyed. This can be caused by:

• Age-related wear (degeneration)
• Injury (trauma) to the joint
• Damage from other conditions, e.g. rheumatoid arthritis, gout or an infection of the bone

Common risk factors - 

• Obesity
• Previous injury to the affected joint
• Jobs that put frequent strain on the joints, e.g. heavy lifting, or repeated squatting and kneeling
• Genetics
• Old age
• Female sex
• Sedentary lifestyle

Investigations -

• Diagnosis is usually clinical (from the history and examination), without imaging. This applies if the person is 45 or over, has joint pain that is worse with activity, and has no morning stiffness or stiffness that lasts 30 minutes or less.
• X-ray only if there are unusual (atypical) features or another diagnosis is possible. Signs on an X-ray are subchondral sclerosis (thickened bone under the cartilage), reduced joint space, osteophytes (bony spurs) and subchondral cysts (fluid-filled spaces in the bone under the cartilage).
• Blood tests or analysis of fluid drawn from the joint (joint aspirate) are not usually needed. They may be used to rule out other conditions, e.g. rheumatoid arthritis (RA).

Pharmacological/Surgical Interventions -

• Medicines are used alongside exercise and weight loss, at the lowest dose that works for the shortest possible time
• A topical NSAID (a gel or cream rubbed on the skin) is offered for knee osteoarthritis, and can be considered for other joints
• If topical medicines do not work or are unsuitable: an oral NSAID, taken with a proton pump inhibitor (a drug that reduces stomach acid) to protect the stomach
• Paracetamol and weak opioids (e.g. codeine) are not routinely offered. They are only for occasional, short-term pain relief when other medicines are unsuitable or have not worked.
• Strong opioids are not offered, because the risks outweigh the benefits
• A corticosteroid (steroid) injection into the joint can give short-term relief, for about 2 to 10 weeks
• Joint replacement (e.g. of the hip or knee), if symptoms greatly affect quality of life and other treatments have not worked or are unsuitable

Lifestyle interventions -

• Therapeutic exercise for everyone with osteoarthritis, tailored to the person, e.g. muscle strengthening and general aerobic fitness. This is a core treatment.
• Weight loss for people living with overweight or obesity. It improves pain, physical function and quality of life.
• Improving lifting techniques

Symptoms -

• Deep, aching joint pain that is made worse (exacerbated) by use
• Reduced range of motion
• Crepitus: a grinding or crackling sensation when the joint moves
• Stiffness after the joint has not been moved for a while. Morning stiffness, if present, lasts 30 minutes or less.

Rheumatoid Arthritis

Definition - A long-term (chronic) autoimmune condition. The immune system attacks the synovium (synovial membrane), the thin layer of cells lining the joint. This causes inflammation (synovitis), which damages the nearby cartilage and bone. It can also affect other parts of the body (it is systemic).

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, which raises the risk of developing RA

Investigations -

• Urgent referral to a rheumatologist (a specialist in joint conditions) if persistent synovitis is suspected and it affects the small joints of the hands or feet, or more than one joint, or symptoms lasted 3 months or more before the person sought help. Tests should not delay the referral.
• Blood test for rheumatoid factor (RF). If this is negative, consider testing for anti-CCP antibodies (anti-cyclic citrullinated peptide antibodies, also called ACPA). RF is found in only 60 to 70% of people with RA, so a negative test does not rule it out.
• X-ray of the hands and feet (no changes will be seen in the early stages of the disease)

Pharmacological/Surgical Interventions -

• Disease-modifying anti-rheumatic drugs (DMARDs), which ease symptoms and slow the disease down. They are started as soon as possible, ideally within 3 months of persistent symptoms.
• Methotrexate is usually the first DMARD. Leflunomide or sulfasalazine are alternatives. Folic acid (a folate supplement) is given with methotrexate to reduce its side effects.
• Hydroxychloroquine (another DMARD) can be used first for mild disease
• More DMARDs are added if the disease is not controlled. Biological treatments, e.g. adalimumab, etanercept or infliximab, are used if DMARDs alone have not worked. They are injections that stop chemicals in the blood from activating the immune system.
• Prednisolone (a steroid), as a short course when starting a new DMARD or to treat flare-ups
• The aim (treat-to-target) is remission, or low disease activity if remission cannot be reached

Lifestyle interventions -

• Have a yearly flu jab and any other vaccines advised, e.g. the pneumococcal vaccine. This is because many RA medicines weaken the immune system (they are immunosuppressants), which raises the risk of infection.
• Rest during flare-ups to help ease pain and inflammation, balanced with regular exercise
• Smoking cessation

Symptoms - Usually begin in the small joints, e.g. of the hands and feet

• Joint swelling
• Joint pain and stiffness, usually on both sides of the body equally (symmetrical). Both are often worse in the morning or after a period of rest.
• Morning stiffness that usually lasts more than 1 hour. In osteoarthritis, morning stiffness wears off within 30 minutes.
• Tiredness
• Fever
• Poor appetite and weight loss
• Rheumatoid nodules: firm lumps under the skin around affected joints
• Symptoms in other parts of the body (systemic symptoms), e.g. dry eyes if the eyes are affected, and chest pain if the heart or lungs are affected. Dry eyes and a dry mouth can be due to Sjogren's syndrome, another immune condition that can occur with RA.

Peptic Ulcer Disease

Definition - Ulcers (breaks in the lining) occurring within the stomach (gastric ulcers) or duodenum (duodenal ulcers). To be classified as an ulcer, the break must go through the muscularis mucosae, a thin layer of muscle in the lining. Peptic ulcers most commonly affect 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
• Helicobacter pylori (H. pylori) infection, a bacterium that infects the stomach. In people who do not take NSAIDs, about 90% of those with a duodenal ulcer and 70 to 80% of those with a gastric ulcer have it.

Risk factors -

• Smoking, now or in the past
• Older age
• Other medicines, e.g. corticosteroids (steroids) and SSRIs (a type of antidepressant)
• Alcohol and stress may play a part, but the evidence is conflicting

Investigations -

• Test for H. pylori: a urea breath test (the person takes a special drink or tablet, then breathes into a tube) or a stool antigen test (a test on a poo sample). Proton pump inhibitors (PPIs) must be stopped 2 weeks before the test.
• Endoscopy (a camera on a thin, flexible tube passed down into the stomach), used to see the ulcers and take a biopsy to find out whether an ulcer is cancerous (malignant)

Pharmacological/Surgical Interventions -

• Proton pump inhibitors (PPIs, e.g. omeprazole), which reduce stomach acid. A full dose is given for 4 to 8 weeks to heal the ulcer.
• H2 receptor antagonists (another type of drug that reduces stomach acid) are an alternative to a PPI
• If the H. pylori test is positive: eradication therapy, a 7-day, twice-daily course of a PPI with two antibiotics (amoxicillin and either clarithromycin or metronidazole). People allergic to penicillin take clarithromycin and metronidazole instead.
• If the ulcer is caused by an NSAID: stop the NSAID where possible and give a PPI for 8 weeks, then eradication therapy if H. pylori is present

Lifestyle interventions -

• Stop smoking
• Reduce alcohol intake
• Stop taking NSAIDs where possible
• Avoid food and drink that trigger symptoms, e.g. spicy or fatty foods, coffee and chocolate
• Reduce stress where possible 

Symptoms -

• Epigastric pain (pain in the upper middle part of the abdomen), which may feel like burning
• Indigestion
• Loss of appetite
• Nausea and vomiting
• Weight loss
• Melaena: black, sticky, tar-like stool, caused by bleeding from the ulcer
• Haematemesis (vomiting blood, which may be bright red or look like coffee grounds), if the ulcer has eroded into a blood vessel
• Melaena and haematemesis are signs of bleeding and need emergency care

Deep Vein Thrombosis

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

Causes - A thrombosis (blood clot) forms because of 3 factors, known as Virchow’s triad: slow blood flow (stasis), damage to the vessel wall, and blood that clots more easily than normal (increased coagulability)

Risk factors-

• Recent surgery, injury or a stay in hospital
• Blood vessel damage
• Immobility, which slows blood flow, e.g. being in bed for long periods or travelling for more than 4 hours (e.g. a long-haul flight)
• Cancer and its treatment (chemotherapy)
• A previous DVT
• Age over 60
• Overweight or obesity
• Heart failure
• Varicose veins
• Inflammatory disorders, e.g. inflammatory bowel disease, vasculitis (inflammation of blood vessels) or rheumatoid arthritis
• Thrombophilia (an inherited or acquired condition in which the blood clots more easily)
• Pregnancy, and the 6 weeks after giving birth
• Smoking
• Dehydration
• Medicines containing oestrogen: the combined oral contraceptive pill (COCP) and hormone replacement therapy (HRT)

Investigations -

• The 2-level DVT Wells score, which uses clinical features to estimate how likely a DVT is
• If a DVT is likely (Wells score 2 or more): an ultrasound scan of the leg veins (proximal leg vein ultrasound), ideally with the result within 4 hours. A D-dimer test is done if the scan is negative.
• If a DVT is unlikely (Wells score 1 or less): a D-dimer test (a blood test for a breakdown product of clots). A negative result helps rule out a DVT. A positive result needs an ultrasound scan, because D-dimer is also raised in other conditions, e.g. after surgery, in pregnancy, in cancer and with inflammation.
• If a result will take more than 4 hours, an anticoagulant is given while waiting (interim anticoagulation)

Pharmacological/Surgical Interventions -

• Anticoagulants (blood-thinning medicines), usually for at least 3 months
• First choice: a direct oral anticoagulant (DOAC) tablet, either apixaban or rivaroxaban
• If neither is suitable: a low molecular weight heparin (LMWH) injection, e.g. dalteparin, for at least 5 days, then dabigatran or edoxaban. Or LMWH is given together with warfarin (a vitamin K antagonist tablet) until blood tests (the INR) show warfarin is working, then warfarin alone.
• Inferior vena cava (IVC) filters, which are placed in the inferior vena cava to trap clots. They are only used if anticoagulants cannot be given, or a PE happens despite treatment.

Lifestyle interventions -

• Compression stockings are not used to stop a DVT coming back. They may be used to ease leg symptoms after a DVT, and to help prevent DVT in some people in hospital.
• Increase exercise
• Losing weight
• Stopping smoking
• Performing regular leg exercises when immobile

Symptoms -

• Throbbing pain and swelling in one leg (rarely both), usually in the calf or thigh
• Warm skin, and red, blue or darkened skin around the painful area (this may be harder to see on brown or black skin)
• Swollen veins
• A DVT can cause a Pulmonary Embolism (PE), when the clot travels to the lungs. This causes breathlessness, chest pain and coughing up blood (haemoptysis), and needs emergency treatment.

Pulmonary Embolism

Definition - Blockage of a blood vessel in the lungs caused by an embolus (a clot or other material carried in the blood) from elsewhere in the body

Causes - Caused by an embolus, most commonly a thrombus (blood clot) from the deep veins of the legs (DVT). It can also be other material, e.g. fat, air, talc or a bullet. The embolus travels through the veins to the right side of the heart and then lodges in the pulmonary circulation. 

Risk factors - These make the blood clot more easily, slow the blood flow or damage the vessel walls (Virchow’s triad, see Deep Vein Thrombosis).

• A DVT, now or in the past, or a previous PE
• Immobility, e.g. a stay in hospital or bed rest
• Increasing age (the risk rises with age)
• Pregnancy
• COCP
• Cancer
• Heart failure
• Smoking
• Obesity
• Recent surgery
• Thrombophilia

Investigations -

• Chest X-ray, to look for other causes of the symptoms
• The 2-level PE Wells score, which uses clinical features to estimate how likely a PE is
• If a PE is likely (Wells score more than 4): a CT pulmonary angiogram (CTPA, a CT scan using contrast dye to show the arteries in the lungs) straight away if possible, to confirm the diagnosis
• If a PE is unlikely (Wells score 4 or less): a D-dimer test. A negative result helps rule out a PE. A positive result needs a CTPA.
• If a result will be delayed, an anticoagulant is given while waiting (interim anticoagulation)

Pharmacological/Surgical Interventions -

• Anticoagulants (blood-thinning medicines), which stop the clot getting bigger (propagation) and prevent new clots. They are given for at least 3 months.
• First choice: a direct oral anticoagulant (DOAC), either apixaban or rivaroxaban
• If neither is suitable: a low molecular weight heparin (LMWH) injection, e.g. dalteparin, for at least 5 days, then dabigatran or edoxaban. Or LMWH is given together with warfarin until warfarin is working, then warfarin alone.
• Thrombolysis (drugs that break down the clot), only if the PE is causing haemodynamic instability (very low blood pressure or shock)
• Thrombectomy (removing the clot)
• Oxygen

Lifestyle Interventions -

• Compression stockings (flight socks) on long journeys. They are not used to stop a clot coming back after a DVT.
• Regular exercise, and avoiding long periods of immobilisation
• Good hydration
• Maintaining a healthy BMI

Symptoms -

Symptoms usually start suddenly. A PE can sometimes cause no symptoms and be found by chance on a scan for something else. Symptoms include:

• Breathlessness, the most common symptom
• Pleuritic chest pain (sharp chest pain that is worse on breathing in)
• Cough
• Haemoptysis (coughing up blood), which suggests the pulmonary embolism (PE) has caused pulmonary infarction (death of part of the lung tissue)
• Fainting (syncope), a fast heart rate (tachycardia) and fast breathing (tachypnoea)
• A PE is an emergency: call 999 for sudden breathlessness, chest pain or collapse
• 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 -

• Graves’ disease, the cause in about 4 in 5 people. It is an autoimmune condition: the immune system makes antibodies that make the thyroid produce too much hormone.
• Thyroid nodules (lumps) that make too much hormone, e.g. toxic multinodular goitre
• Thyroiditis (inflammation of the thyroid), which releases stored thyroid hormone, usually for a short time
• Too much iodine, e.g. from the heart medicine amiodarone
• Taking too much thyroid hormone medicine, e.g. over-treating hypothyroidism (an underactive thyroid) with levothyroxine
• Rarely, a TSH-secreting pituitary adenoma: a non-cancerous tumour of the anterior pituitary gland that makes too much thyroid-stimulating hormone (TSH)

Risk factors -

• Female sex (it is about 10 times more common in women than men)
• Personal or family history of autoimmune disease, e.g. type 1 diabetes
• Smoking, which raises the risk of Graves’ disease
• Recent pregnancy, as the thyroid can become inflamed in the months after giving birth (postpartum thyroiditis)
• Taking iodine supplements, e.g. kelp, as extra iodine can make the thyroid produce too much hormone
• 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 -

• Antithyroid drugs (thionamides), e.g. carbimazole or propylthiouracil, which stop the thyroid making too much hormone. They control the condition while waiting for radioactive iodine or surgery. In Graves’ disease, a 12 to 18 month course may be used instead if it is likely to lead to remission.
• Safety with carbimazole: effective contraception is needed, as it can harm an unborn baby. A less common but serious side effect of these drugs is agranulocytosis (a sudden drop in white blood cells, raising the risk of infection). Anyone with a sore throat, fever or mouth ulcers must tell their doctor straight away. Carbimazole can also cause acute pancreatitis (inflammation of the pancreas), and must then be stopped for good.
• Supportive treatment of symptoms, e.g. a beta-blocker while other treatment starts to work
• Radioactive iodine, which destroys thyroid cells so the gland makes less hormone. NICE recommends it as the first long-term (definitive) treatment for adults with Graves’ disease, unless antithyroid drugs are likely to work or it is unsuitable.
• Thyroidectomy (surgical removal of the thyroid gland), e.g. if a goitre is pressing on the neck or cancer is suspected. Levothyroxine is then needed for life.
• Rarely, plasma exchange (plasmapheresis), which removes thyroid hormones from the blood. It is only used if standard treatments fail or cannot be used, or in a life-threatening thyroid storm.

Lifestyle interventions -

• Avoiding extra iodine, e.g. kelp supplements, as too much iodine can make the thyroid produce more hormone
• Stopping smoking, as smoking is the main avoidable risk factor for Graves’ eye disease
• Exercise
• Reducing stress

Symptoms -

• Goitre (a swelling in the neck caused by an enlarged thyroid gland)
• Sweating and heat intolerance (feeling uncomfortably hot)
• Tremor
• Tachycardia
• Fatigue
• Weight loss
• Difficulty concentrating
• Irregular periods
• Thinning of hair
• Anxiety
• Lid lag (the upper eyelid is slow to follow the eye as it looks down)

Features specific to Graves’ disease: thyroid eye disease (Graves’ orbitopathy), e.g. exophthalmos (bulging eyes), and, rarely, pretibial myxoedema (thickened, swollen skin over the shins)

Hypothyroidism

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

Causes -

• Autoimmune thyroiditis, e.g. Hashimoto’s thyroiditis, in which the immune system attacks the thyroid. This is the most common cause in the UK.
• Treatment for hyperthyroidism, e.g. radioactive iodine or antithyroid drugs
• Thyroid surgery
• Radiotherapy to the head or neck
• Other medicines, e.g. lithium or amiodarone
• Rarely, a pituitary adenoma (a non-cancerous tumour of the pituitary gland). This causes secondary hypothyroidism, because the pituitary does not make enough TSH.
• Iodine deficiency: the most common cause worldwide, but rare in the UK

Risk factors -

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

Investigations -

• Thyroid function blood tests. TSH is measured first. If it is high, free T4 is measured in the same blood sample. In primary hypothyroidism (a problem in the thyroid itself), TSH is high and free T4 is low. T3 is not usually needed.
• If a pituitary cause is suspected, TSH and free T4 are measured together, because in secondary hypothyroidism TSH may be low or normal
• Thyroid peroxidase (TPO) antibody blood test, which is raised in autoimmune thyroiditis. It does not need repeating.
• Ultrasound only if there are suspicious structural abnormalities, e.g. a lump that could be cancer

Pharmacological/Surgical Interventions - Levothyroxine, a daily tablet that replaces the missing thyroid hormone. It is the first-line treatment and is usually taken for life. It is taken on an empty stomach in the morning, before food or other medicines. A lower starting dose is used for people aged 65 and over or with heart disease. The dose is adjusted to keep TSH in the normal range, but not so high that TSH is suppressed (pushed below normal). TSH is checked every 3 months until stable, then once a year. Liothyronine (a T3 tablet) is not routinely offered, and natural thyroid extract is not offered.

Lifestyle interventions - 

• Report new sleep problems (insomnia), palpitations or diarrhoea to a doctor. Side effects of levothyroxine usually happen when the dose is too high, and a blood test can check this.
• Eat healthily, as weight gain is a common symptom of hypothyroidism

Symptoms -

• Fatigue
• Feeling cold more than usual (cold intolerance)
• Constipation
• Weight gain
• Muscle or joint pain
• Heavy periods
• Alopecia (hair loss), especially the outer third of the eyebrows
• Depression
• Bradycardia (a slow heart rate)
• Goitre
• Myxoedema (swelling of the skin and soft tissues, e.g. around the eyes)