Professional Documents
Culture Documents
2010
!"# %&'%#'(') %(**+#, -./.
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!"# %&'%#'(') %(**+#, -./.
0
With thanks to
Alex, Phill, Tess, Ryan , PQ, Lee, Niki, Lionel, Lorato, Steph, Mark, Quinton,
Tas, Allya, Gaya, Jess, Christl, Hasna, Sarah W, Audrey, Henry, Arty, Sarah H,
Keflewe, Flik, Michelle, Neha, Anita
!"# %&'%#'(') %(**+#, -./.
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!"#$% '( )'*+%*+,
)-./012-3)45-. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"
+*1"+1 "#&,! %+*#&*#"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" #
$%&'()'*+,-*"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" ./
$%&'(0,&,12'3,2 """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" ..
1&,%+&1 3&+45,#""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .4
1&,%+&1 &,,#*!"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .5
62(1,-3%-&2)$%"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .7
6-*8'*,)20 $'2() 1,+'2+' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .9
62(1,26 )23&-*21'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .:
6&4654&, "#&,! %+*#&*#"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .;
,"#52&!+1 <#6#, """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .=
&'(,62(1,),+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" .#
'*1-62(1,),+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4/
62(-),1 +)'*-+,+ """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4.
2-(),6 2*'>(,+3+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 44
&'(,&$'(20 ?2+6>02( 1,+'2+'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 45
?2(,6-+' ?',*+ """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 47
6$(-*,6 ?'*->+ ,*+><<,6,'*6% """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 49
#$%&'#()*#+!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ,-
2+)$32""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4;
@(-*6$,'6)2+,+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4=
6%+),6 <,@(-+,+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 4#
,*)'(+),),20A-66>&2),-*20 0>*8 1,+'2+' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5/
('+&,(2)-(% <2,0>(' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5.
0>*8 62*6'( """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 54
+-0,)2(% &>03-*2(% *-1>0'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 55
@(-*6$,20 -@+)(>6),-*"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 57
26>)' @(-*6$,),+ """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 59
>(),"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5:
&0'>(,+%""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5;
&0'>(20 '<<>+,-* """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5=
&*'>3-)$-(2B """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 5#
6-( &>03-*20'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7/
&>03-*2(% $%&'()'*+,-*"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7.
-@+)(>6),?' +0''& 2&*-'2 """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 74
6-3!.107!83!07-5!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ./
26>)' 0,?'( <2,0>(' 2*1 $'&2),),+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 77
206-$-0,6 0,?'( 1,+'2+'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7:
6,(($-+,+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7;
&2*6('2),6 62(6,*-32"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 7#
26>)' &2*6('2),),+ """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9/
6$(-*,6 &2*6('2),),+"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9.
8-(1"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 94
,((,)2@0' @-C'0 +%*1(-3'""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 95
6-'0,26 1,+'2+' """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 97
82+)(-'*)'(,),+""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 97
&'&),6 >06'( 1,+'2+'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9:
82+)(,),+ 2*1 82+)(-&2)$%""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9;
-'+-&$28'20 62*6'("""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9=
82+)(,6 62*6'(""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9=
6(-$*D+ 1,+'2+'"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 9#
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0LCERATIvE C0LITIS................................................................................................................................................................................ 6u
APPENBICITIS............................................................................................................................................................................................. 61
INTESTINAL 0BSTR0CTI0N ..................................................................................................................................................................... 62
ISCBAENIC B0WEL.................................................................................................................................................................................... 6S
BIvERTIC0LAR BISEASE........................................................................................................................................................................... 64
C0L0RECTAL CANCER............................................................................................................................................................................... 6S
BERNIA........................................................................................................................................................................................................ 66
PERIT0NITIS............................................................................................................................................................................................... 67
!"#$%&'($#)(*++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ,-
NEPBR0TIC ANB NEPBRITIC SYNBR0NE ............................................................................................................................................. 69
AC0TE RENAL FAIL0RE............................................................................................................................................................................ 7u
CBR0NIC RENAL FAIL0RE ....................................................................................................................................................................... 71
AC0TE T0B0LAR NECR0SIS .................................................................................................................................................................... 7S
0R0LITBIASIS............................................................................................................................................................................................. 74
P0LYCYSTIC KIBNEY BISEASE................................................................................................................................................................. 7S
0TIPYEL0NEPBRITIS............................................................................................................................................................................. 76
0R0L0uICAL CANCERS ............................................................................................................................................................................. 77
BENIuN PR0STATIC BYPERTR0PBY ...................................................................................................................................................... 78
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TYPE 1 BIABETES NELLIT0S .................................................................................................................................................................. 8u
PIT0ITARY BYSF0NCTI0N........................................................................................................................................................................ 82
u0ITRE......................................................................................................................................................................................................... 84
BYPERTBYR0IBISN................................................................................................................................................................................... 8S
BYP0TBYR0IBISN..................................................................................................................................................................................... 86
PARATBYR0IB BYSF0NCTI0N................................................................................................................................................................. 87
ABRENAL BYPERF0NCTI0N: C0SBINu'S............................................................................................................................................... 88
ABRENAL BYP0F0NCTI0N: ABBIS0N'S................................................................................................................................................. 89
"!+&$($)*+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ /0
SEIZ0RES..................................................................................................................................................................................................... 91
NIuRAINE.................................................................................................................................................................................................... 92
CEREBRAL BAEN0RRBAuE ..................................................................................................................................................................... 9S
TIA............................................................................................................................................................................................................... 96
CRANIAL NERvE PALSY............................................................................................................................................................................ 97
SPINAL C0RB BISEASE ............................................................................................................................................................................. 99
BENENTIA.................................................................................................................................................................................................1uu
NE0R0N0SC0LAR BIS0RBERS..............................................................................................................................................................1u1
N0LTIPLE SCLER0SIS .............................................................................................................................................................................1u2
1"($&1"()%$2" 4)("++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 506
AIRWAYSRESPIRAT0RY S0PP0RT .....................................................................................................................................................1u4
BL00B TRANSF0SI0NS...........................................................................................................................................................................1u6
I.v. FL0IB REPLACENENT......................................................................................................................................................................1u7
ANALuESIA................................................................................................................................................................................................1u8
P0ST 0PERATIvE FEvER........................................................................................................................................................................1u9
W00NBS....................................................................................................................................................................................................11u
&,!+-./$($)* +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 555
0STE0ARTBRITIS.....................................................................................................................................................................................112
0STE0NALACIA........................................................................................................................................................................................11S
RBE0NAT0IB ARTBRITIS ......................................................................................................................................................................114
u00T..........................................................................................................................................................................................................11S
SYSTENIC L0P0S ERYTBENAT0S0S ....................................................................................................................................................116
vASC0LITIS ...............................................................................................................................................................................................117
PAuET'S BISEASE 0F B0NE....................................................................................................................................................................118
0STE0NYELITIS .......................................................................................................................................................................................119
FRACT0RES...............................................................................................................................................................................................12u
L0WER LINB FRACT0RE........................................................................................................................................................................121
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1PL uAnuLnCnC uCSSlL8 2010
9
!"#$%&'(# *&%+, -("&%"&
-&.(/(,(0/ 123 45%""(.(#%,(0/
lschaemlc PearL ulsease ls broadly deflned as myocardlal
lschaemla from a lack of blood supply.
67(8&'(0509:
nA
;("< =%#,0+"
As wlLh aLherosclerosls:
Age
Male
lamlly hlsLory
Smoklng
SedenLary llfesLyle, CbeslLy
ulabeLes
PyperLenslon
PypercholesLerolaemla
>&,(0509:24%?"&"2@%,$07$:"(0509:
lPu ls largely due Lo aLherosclerosls of Lhe coronary arLerles
(!"" $%&'()%*+ ,-."*/&')"*/&0&) leadlng Lo vessel sLenosls.
CLher causes of anglna lnclude:
Anaemla
Coronary emboll
Smoklng cessaLlon
1C Ca
2+
blockers are dlvlded lnLo 2 classes
o nonhydropyrldlne Ca
2+
blockers reduce cardlac
ouLpuL (P8 and conLracLlllLy) and cause modesL
vasodllaLlon: 6)2&)3G$7D A$%3#)7)2
o ulhydropyrldlne Ca
2+
blockers have a predomlnanL
vasodllaLory acLlon: 372*6)#)'$D ')-$6)#)'$
,C ulureLlcs
o 1hlazldes are Lhe flrsL llne dlureLlc LreaLmenL for
slmple hyperLenslon: H"6%*4H2*%*&H)3G)6$D
)'63#37)6$
o Loop dlureLlcs are used for paLlenLs wlLh renal
lmpalrmenL: -%=($7)6$
o oLasslum sparlng dlureLlcs are used for
hypokalaemlc paLlenLs: (#)%*'*234&*'$
1*7#2)43&)*'(
1he compllcaLlons of hyperLenslon are chronlc and common
amongsL Lhe general populaLlon
CeneLlc facLors
!)$%"3"89024*+)+0=4$>"6>9+%"3"89
A Lrue aneurlsm affecLs all Lhree layers of Lhe vessel wall.
1hey are furLher sub-characLerlsed by shape ln Lo saccular
(locallsed) or fuslform (clrcumferenLlal)
8esplraLory sympLoms
o 8ecurrenL slnuslLls, nasal polyps
o 8ronchlecLasls, producLlve cough wlLh vlscous
purulenL spuLum, Lachypnoea, hyperexpanslon
o Clubblng, cyanosls are common
Cl sympLoms
o lallure Lo Lhrlve, assoclaLed wlLh delayed growLh
and puberLy
o vlLamln or nuLrlenL deflclencles
o SomeLlmes hepaLosplenomegaly, gall sLones,
pancreaLlLls
A%#$+*" 4/7 5B48%/4$%+/
8esplraLory hlsLory
aedlaLrlc growLh hlsLory
C/D-#$%94$%+/#
1he screenlng LesL for Cl ls sweaL sodlum conLenL looklng
for greaLer Lhan 60mmol/L, usually wlLh a greaLer Cl- Lhan
na+.
Skln
o LryLhema nordosum appear as palnful purpllsh
nodules over Lhe shlns, whlch leave brulses on
regresslon
o yoderma gangrenosum
Skln
o LryLhema nordosum
o yoderma Cangrenosum - ofLen appears before
colonlc sympLoms and follows an lndependenL
dlsease course
1akayasu arter|t|s
o CranulomaLous lnflamaLlon of Lhe aorLa and ma[or
branches
o resenLs wlLh absenL pulses and hyperLenslon
(pulseless dlsease)
! arLlcularly ln younger lndlvlduals ln !apan
Medlum vessel vascullLls affecLs small arLerles and
arLerloles
o|yarter|t|s nodosa
o necroLlslng or flbrlnold vascullLls of medlum and
small arLerles and mlcroaneurlsm formaLlon
! 1yplcally mlddle-aged men
o usually presenLs wlLh vague, lnspeclflc
consLlLuLlonal sympLoms progresslng Lo acuLe
mulLl-organ fallure
kawasak| d|sease
o Medlum and small vessel lnvolvemenL, usually ln
chlldren, ofLen lnvolvlng Lhe coronary arLerles
o resenLs wlLh fever > 3 days, bllaLeral con[uncLlval
congesLlon, lymphadenopaLhy, rash and palmar
eryLhema
c-AnCA poslLlve small vessel vascullLls ls found ln
arLerloles, caplllarles and venules
Wegener's Granu|omatos|s
o CranulomaLous lnflammaLlon of small arLerles
o arLlcularly affecLs upper and lower resplraLory
LracL as well as necroLlslng glomerulonephrlLls
! resenLs wlLh rhlnorrhoea, haemopLysls and
pleurlLlc paln
o ulagnosed on resplraLory or renal blopsy
! Cx8 shows 'mlgraLlng' nodular lung masses
M|croscop|c po|yang|t|s
o necroLlslng vascullLls lnvolvlng Lhe resplraLory
Llssue and causlng glomerulonephrlLls
c-AnCA negaLlve small vessel vascullLls ls llmlLed Lo Lhe
caplllarles and venules
nenoch-Scho|e|n purpura
o lgA deposlLlon ln skln, guL and renal glomerulus
8ehcet's D|sease
o Causes recurrenL oral ulceraLlon, alLhough Lhe
paLhogenesls ls unclear
o May also cause ollgoarLhrlLls, Cl upseL, pulmonary
or renal leslons or neurologlcal lnvolvemenL
Management
vascullLls ls almosL always LreaLed wlLh corLlcosLerolds or
dlrecL lmmunosuppresslon
Comp||cat|ons
CompllcaLlons are speclflc Lo Lhe slLe of vascullLls, usually
resulLlng from local lschaemla or lnfarcLlon
1PL uAnuLnCnC uCSSlL8 2010
118
!"#$%&' )*'$"'$ +, -+.$
)$,*.*%*+.
local dlsorder of unknown aeLlology, characLerlsed by
excesslve bone resorpLlon by osLeoclasLs and a
compensaLory (buL dlsorganlsed) lncrease ln bone
formaLlon by osLeoblasLs ! bones LhaL are enlarged and
deformed
/0*1$2*+3+#4
AffecLs Lhose over 40, men more Lhan women, Lhere ls
famlllal clusLerlng
5$%*+3+#4 ".1 6"7'$'
? lnfecLlous cause, e.g. measles vlrus, 8Sv
CeneLlc llnk - muLaLlons found ln 8Ank and CC
genes
!"%8+084'*+3+#4
1. CsLeoclasLlc acLlvlLy: locallsed marked lncrease ln
bone resorpLlon, osLeoclasLs look dysfuncLlonal
and polynuclear
2. CompensaLory lncrease ln bone formaLlon, wlLh
dlsorganlsed ('mosalc') deposlLlon of lamellar
bone, hypervascularlLy and replacemenL of bone
marrow wlLh connecLlve Llssue
3. 8urnL ouL phase, wlLh loss of hypercelluarlLy
MosL ofLen affecLs splne, skull, pelvls, Lhlghs and lower
legs, causlng a range of locallsed sympLoms
9* ".1 ':
CfLen asympLomaLlc
8one paln, fracLures
Peadaches, hearlng loss, enlarged head
local neurologlcal slgns e.g. sclaLlca
Somnolence
aralysls
kyphosls, bowed legs
ArLhrlLls
;.<$'%*#"%*+.'
8lood LesLs
LlevaLed AL - used Lo monlLor dlsease acLlvlLy
AL1, Ca and C
4
all normal
urlne
urlnary hydroxyprollne elevaLed
xray
Involveu bones look expanueu anu uensei than
noimal
Nultiple fissuie fiactuies in long bones
Initial lesion may be uestiuctive anu
iauiolucent, especially in skull ("osteopoiosis
ciicumsciipta")
Saicomatous change suggesteu by appeaiance
of new lytic lesion
Bone scan
="."#$2$.%
needed lf sympLomaLlc, exLenslve lnvolvemenL, or young
paLlenL
=$1*6"3
8lsphosphonaLes, e.g.
rlsedronaLe (Laken dally for
2-6/12 whllsL dlsease ls
acLlve)
CalclLonln (noL usually
used)
nSAluS, analgeslcs, cardlo
drugs as needed
97>#*6"3
!olnL replacemenL
Max-fax surgery
Splnal cord decompresslon
?+203*6"%*+.'
lracLures, splnal cord
compresslon
vlsual changes/loss
Pearlng loss
Cranlal and perlpheral
nerve dysfuncLlon
ArLhrlLls
kldney sLones
Cardlac fallure (due Lo hypervascularlLy of bone)
Cancer e.g. sarcoma
1PL uAnuLnCnC uCSSlL8 2010
119
!"#$%&'$()#)"
*$+),)#)%, ./0 1(2"")+)32#)%,
lnfecLlon of bone. SlLe and causaLlve organlsm are hosL-
dependenL. 1ypes as follows:
- PaemaLogenous
o lvuu, slckle-cell anaemla
- LxLenslon from lnfecLlon ln ad[acenL [olnL or sofL
Llssue or LraumaLlc lmplanLaLlon afLer compound
fracLures or orLhopaedlc procedures
o 1rauma (open #), posL-surgery, pressure
sores
- AssoclaLed w/vascular lnsufflclency
o ulabeLlcs (bone paln usually absenL due
Lo assoclaLed neuropaLhy)
- oLL's uz (18 of verLebral bodles)
o 8e wary of verLebral collapse and splnal
cord compresslon
45)6$&)%(%7'
Cverall, S.aureus mosL common cause
ulabeLes ! S.aureus, gram -ve
lvuu ! S.aureus
Slckle cell anaemla ! Salmonella common
CounLrles w/hlgh 18 prevalence ! splnal 18
8)"9 :23#%;"
ulabeLes melllLus (S.aureus and/or gram negaLlve
lnfecLlon)
lv caLheLers, luC
Slckle-cell dz (predlspose Lo salmonella lnfecLlon)
lvuu ! (S.aureus)
osL-op ([olnL replacemenL, neurosurgery)
<$#)%(%7'/12="$"
- yogenlc bacLerla (eg. S.aureus), mycobacLerlum
18 mosL common paLhogens
>)7," 2,6 >'&5#%&"
lever and chllls
aln (absenL ln dlabeLlcs) and Lenderness ln
lnvolved bone
LxLremely hlgh LS8 (>100mm/h)
8adlographlc flndlngs negaLlve earller on
?)"#%;' 2,6 4@2&),2#)%,
Ask for presence of fever.
Ask for bone paln.
Cuery rlsk facLors: ulabeLes, lvuu, slckle-cell dz.
Any hx of 18?
Pas paLlenL had any surgery? 1rauma?
A,B$"#)72#)%," C%, #%5 %+ #D$ ="=2( %,$"E
- M8l mosL senslLlve and shows exLenL of Llssue
lnvolvemenL
- 8lood culLures
- 8one bx requlred (unless haemaLogenous
osLeomyellLls as blood culLures wlll be +ve)
o So can sLarL abx rx
F2,27$&$,#
F$6)32(
- Lmplrlcal rx
o llucox
o Cephazolln, vancomycln (lf penlclllln
allergy)
- MSSA rx
o As above
- M8SA rx
o vancomycln Lhen
" rlfamplcln + sodlum fusldaLe (lf
suscepLlble)
>=;7)32(
- uebrlde necroLlc bone
! neurologlcal decompresslon (urgenL) - ln pLs
w/verLebral body osLeomyellLls and epldural
abscess
1%&5()32#)%,"
- rogresslon Lo chronlclLy
- LxLenslon Lo ad[ bones or [olnLs
- S.aureus lnfecLlon ! epldural abscess
- verLebral osLeomyellLls ! verLebral collapse and
cord compresslon
- 8ecurrenL bone lnfecLlons: anaemla, ralsed LS8,
welghL loss, weakness
1PL uAnuLnCnC uCSSlL8 2010
120
Iractures
Def|n|t|on
8reak ln Lhe conLlnulLy of Lhe corLex of bone
C|ass|f|cat|on
1ype of fracture
1. Cpen]C|osed
2. Intra-art|cu|ar]extra-art|cu|ar
(lnvolvlng Lhe [olnL surface)
3. Comm|nuted
(many fragmenLs of bone)
4. Segmented
(occurs ln Lhe dlaphysls aL Lwo levels, leavlng a
floaLlng segmenL)
Deform|ty of fragments of bone
- uegree of angulaLlon
o LaLeral/Medlal
o Pand: volar/uorsal
- ulsplacemenL
- ShorLenlng
- 8oLaLlon
Ch||dren
lracLures may occur Lhrough Lhe growLh plaLe/physls
l - S- /SLralghL across: # Lhrough carLllage of physls
ll- A - Above: # above Lhe physls
lll- L - Lower: # below Lhe physls ln eplphysls
lv- 1 - 1hru: # Lhru meLaphysls, physls & eplphysls
v - 8 - 8ammed: physls has been crushed
Aet|o|ogy]Causes
1rauma type Iracture
1ype of lorce 8esulLanL lracLure
1wlsL Splral
ulrecL 1ransverse/Cbllque
atho|og|ca| Iracture
CsLeoporosls
1umour 8enlgn
MallgnanL - rlmary/MeLs
ageL's ulsease
MeLabollc bone dlsease CsLeomalacla/8lckeLs
PyperparaLhyroldlsm
CsLeogenesls lmperfecLa
CLher mallgnancy Lymphoma
Myeloma
8A
lnfecLlon/CsLeomyellLls
n|story and Lxam|nat|on
n|story
- Mechanlsm of ln[ury
Lxam|nat|on
- Skln condlLlon: open/closed, any
bllsLers/laceraLlons
- erlpheral nerve funcLlon:
o Weakness?
o araesLhesla/AnaesLhesla
- ulsLal vascular sLaLus
o Assess perlpheral pulse
o Caplllary fracLure
- Lvldence of comparLmenL syndrome
o aln ouL of proporLlon
o alpable pulse on # slLe
Invest|gat|ons
1. x8 - 2 vlews aL leasL (A and laLerally)
CLher vlews: MorLlse vlew (for ankle #)
Scaphold vlews (for scaphold #)
2. C1 - for severe mulLl-fragmenLary lnLra-arLlcular
#
3. M8l/lsoLope bone scans - ux of lracuLre where
doubL exlsL, and for Avn (avascular necrosls)
Management
Immed|ate
1. u8A8Cu
- ensure haemodynamlc sLablllLy from
hypovolaemla (lf large #)
- Check for lnLernal haemorrhage
2. lracLure reducLlon and lmmoblllsaLlon
- SpllLLlng of fracLures: lmmoblllsLaLlon of # slLe
3. Analgesla
- lv morphlne/oLher narcoLlc analgesla
4. lluld resuslLaLlon
- Lspeclally wlLh severe #, e.g. pelvls/femur
3. Assess for neurovascular sLablllLy
Surg|ca|
rlnlcples of Mx:
1. # reducLlon wlLh mlnlmal secondary Lrauma
Cpen reducLlon: vla surg
Closed manlpulaLlve reducLlon and
lmmoblllsaLlon: (LAM [local
anaesLhesla]/CAM[general anaesLheLlc])
2. SLablllsaLlon
- lasLer/C8ll/Sllng/8andage
3. 8esLoraLlon of funcLlon
4. 8ehab
Comp||cat|ons
lmmedlaLe Larly LaLe
Compresslon on
nerves and blood
vessels
ComparLmenL
syndrome
uelayed unlon/non-
unlon
Paemorrhage/
hypovolaemla
lnfecLlon Malunlon
Complex reglonal
paln syndrome
CA
uv1 SLlffness
laL embolus ConLracLure
CrowLh ulsLurbance
1PL uAnuLnCnC uCSSlL8 2010
121
Lower L|mb Iracture
Def|n|t|on +]- C|ass|f|cat|on
-fracLure of Lhe lower llmb:
athophys|o|ogy
1. 1rauma: acuLe vs chronlc/sLress (eg. maraLhon runners,
also meLaLarsal>flbula>Llbla)
2. paLhologlcal weakness (eg.osLeoporosls, ageL's. )
athophys|o|ogy of hea||ng:
1. lnflammaLlon:
-dlsrupLlon of vascular supply! bleedlng from fracLure !
swelllng and brulslng.
-damaged bone Llssue aL edges dle! release cyLoklnes
-osLeoclasLs remove necroLlc bone.
-w/ln hours, blood forms mesh, 4-10 days granulaLlon
Llssue formlng scaffold for callus formaLlon.
2. sofL callus formaLlon: flbroblasLs ln granulaLlon Llssue
form carLllage, flbrocarLllaLe-avold exLernal sLress for 6
weeks, lmmoblllze. AL 2 weeks, anglogenesls + osLeoblasLs
aL perlosLeum 3. Pard callus formaLlon: sofL callus!
woven bone Lhrough Ca, C4 deposlLlon lnLo carLllage.
upper llmb=6/32, lower llmb=12/32.
4. bone remodellng: woven bone replaced by lamellar
bone. Chlldren> adulLs.
C|ass|f|cat|on
1. open (wound communlcaLlon w/ouLslde) vs closed (no
communlcaLlon)
2. Lransverse /obllque/splral
3. segmenLed/commlnuLed/clean break
4. angulaLed: dlsLal vs prox, measured ln degrees
3. roLaLed: measured relaLlve Lo prox, requlres mulLlple
vlews.
6. dlsplaced: dlsLal vs prox, measured ln mm or of
corLlcal conLacL
7. shorLened: lmpacLlon (as ln Lorus) vs overlap
8. whlch bone, locaLlon (mldshafL, prox/dlsL).
9. exLraarLlcular / lnLraarLlcular (rlsk of arLhrlLls)
10. avulslon
11. assoclaLed sympLoms: nvS lnLacL
12. Lorus & greensLlck: occurs ln chlldren
S|gns and Symptoms
-paln, swelllng, deformlLy.
n|story and Lxam|nat|on
nx:
-WWAA8, s|tuat|on, |n[ury mechan|sm
Lx:
Assessment:
1. wound commun|cat|ng w|th fracture?
-bone on v|ew]|acerat|on: prophy|act|c Abx and tetanus
vacc|nat|on.
2. vascu|ar |n[ury: |dent|fy d|sta| pu|ses
- obvlous ln[ury: arLerlal vs venous bleed
-paln ouL of proporLlon Lo ln[ury:
compartment syndrome, mosL commonly ln anLerlor
compL. lower leg.
aln
allor
ulselessness
aresLheslas
aralysls
erlshlngly cold
3. neuro|og|ca| |n[ury: exam|ne dermatomes
4. v|scera| |n[ury
1. Invest|gat|ons
x8ay : helps classlfy fracLure
M8l : sofL Llssue lnvolvemenL, CM.
l8L Lo rule ouL lnfecLlon
Management
-acuLely: LreaL acuLe lssues, especlally bleedlng,
decompresslon of comparLmenLs lf necessary. SpllnL.
1eLanus shoL. 8esusc lf necessary.
-uncomp||cated c|osed fractures: reducLlon vla closed
manlpulaLlon/mechanlcal LracLlon, hang welghLs.
lmmoblllzaLlon vla exLernal spllnLs, C, exLernal flxaLlon.
Surglcal opLlon: open reducLlon, lnLernal flxaLlon.
-uncomp||cated open fractures: clean wound, remove all
dead/devlLallzed Llssue and exLraneous maLerlal. revenL
osLeomyellLls.
-comp||cated #s-surglcal lnLervenLlon. C8ll vla plns,
wlres, plaLes, [olnL replacemenL.
kehab|||tat|on: acLlve use/acLlve exerclses Lo prevenL
muscle aLrophy, conLlnuous passlve moLlon Lo preserve
healLhy arLlcular carLllage.
Comp||cat|ons
Larly: (laLe ccx ln followlng Lable, for uL+LL)
SysLemlc: LeLanus, gangrene, sepsls, crush syndrome, faL
embolus (esp ln femur), renal fallure 2ry Lo
rhabdomyolysls, ulC, Lhromboembollsm, shock.
Local: hemorrhage, hemarLhrosls, comparLmenL
syndrome.
NLUkC INIUkILS:
h|p, posLerlor dlsplacemenL:
sclaaLlc nerve
h|p, anLerlor dlsplacemenL:
femoral nerve
knee: common peroneal, Llblal
nerve
|eg, lf ln[ury exLenslve: superflclal
peroneal.
NLUkC INIUkILS:
h|p, posLerlor dlsplacemenL:
sclaLlc nerve
h|p, anLerlor dlsplacemenL:
femoral nerve
knee: common peroneal, Llblal
nerve
|eg, lf ln[ury exLenslve:
superflclal peroneal.
!"# %&'%#'(') %(**+#, -./.
/--
1PL uAnuLnCnC uCSSlL8 2010
123
!""#$ &'() *$+,-.$#/
0#1'2'-'32 456 78+//'1',+-'32
-fracLure of Lhe upper llmb:
9+-:3":;/'383<;
See lower llmb #
78+//'1',+-'324 ='<2/ +2> /;("-3(/
lor general classlflcaLlon, see lower llmb #
Speclflc:
?32-#<<'+: # proxlmal 1/3 ulna (+/- fracLure radlal shafL
+/- angulaLlon posLerlorly or laLerally.) + dlslocaLlon radlal
head: seen ln dlrecL Lrauma Lo upper forearm (eg.
nlghLsLlck ln[urles), lCCSP w/ excesslve pronaLlon.
Complex # requlrlng C8ll Lo prevenL malunlon.
@+8#+AA': lsolaLed # aL dlsLal 1/3
rd
of radlus +
subluxaLlon/dlslocaLlon of radloulnar [olnL. MusL be
LreaLed surglcally ln order Lo prevenL recurrenL
dlslocaLlons.
7388#/B: dlnner fork deformlLy. ulsLal radlus # wlLh dorsal
dlsplacemenL+angulaLlon. Common ln osLeoporoLlcs. Look
for dorsal LllL, radlal shorLenlng, radlal angulaLlon of wrlsL.
1reaL wlLh casL ln palmar flexlon, ulnar devlaLlon. lf
slmple, closed reducLlon. lf angulaLlon + deformlLy severe,
C8ll or exLernal flxaLlon.
C#22#--BD # 1
sL
meLacarpal, usually +
subluxaLlon/dlslocaLlon of CMC. MosL common Lhumb
fracLure. Look for lnsLablllLy of CMC aL Lhumb, wlLh paln +
weak plnch grasp as well as ecchymosls around base of
Lhumb. lf dlsplacemenL <3mm, k-wlres Lo [oln meLacarpal
Lo Lrapezlum ln correcL anaLomlcal poslLlon. lf
dlsplacemenL >3mm, C8ll. lmmoblllse ln splca Lhumb
spllnL 4-6 weeks. CompllcaLlons serlous: dysfuncLlonal
Lhumb, llmlLed 8CM, palnful unsLable [olnL.
=,+".8+$D seen ln hlgh speed MvA-Lhlck muscle of
lnfrasplnaLus, subscapularls, prevenL #.
=('-:B/D reverse Colles': # of dlsLal radlus. Caused by
lCCSP onLo flexed wrlsL! venLral dlsplacemenL of dlsLal
fragmenL. Can lnvolve arLlcular surface wrlsL [olnL. lf
undlsplaced, LreaL wlLh casL. lf mlldly angulaLed/dlsplaced,
closed reducLlon. lf slgnlflcanLly dlsplaced/angulaLed,
requlres surglcal lnLervenLlon.
C3E#$B/: # neck 3
Lh
meLacarpal, common ln punch ln[urles.
78+F',8#: dlsLal 1/3 #, damage Lo brachlal plexus, usually
axlllary. Shoulder drop, medlal roLaLlon of humerous,
dropped SCM.
=,+":3'>: mosL common wrlsL #, evaluaLe Lenderness ln
snuff box. 1reaL Lo avold avascular necrosls.
G.(#$./: (surglcal neck): axlllary nerve damage, bulglng
of proxlmal parL, medlal roLaLlon of dlsLal parL, shorLenlng
of arm.
G.(#$./ (mldshafL): radlal nerve damage
G.(#$./ (supracondylar): medlan nerve damage
G.(#$./ (medlal eplcondyle): ulnar nerve damage
='<2/ +2> =;("-3(/ H<#2#$+8I
-paln, swelllng, deformlLy.
G'/-3$; +2> JE+('2+-'32
-See Px & Lx for lower llmb #.
1. K2F#/-'<+-'32/
x8ay : helps classlfy fracLure
M8l : sofL Llssue lnvolvemenL, CM.
l8L Lo rule ouL lnfecLlon
?+2+<#(#2-
-acuLely: LreaL acuLe lssues, especlally bleedlng,
decompresslon of comparLmenLs lf necessary. SpllnL.
1eLanus shoL. rophylacLlc Abx lf wound open. 8esusc lf
necessary (unllkely).
6.2,3("8',+-#> ,83/#> 1$+,-.$#/: manage conservaLlvely
wlLh reducLlon vla closed manlpulaLlon/mechanlcal
LracLlon. SpllnL.
-.2,3("8',+-#> 3"#2 1$+,-.$#/: clean wound, remove all
dead/devlLallzed Llssue and exLraneous maLerlal. revenL
osLeomyellLls. lmmoblllse
-,3("8',+-#> L/-surglcal lnLervenLlon. C8ll vla plns, k-
wlres. lmmoblllse
M#:+)'8'-+-'32: acLlve use/acLlve exerclses Lo prevenL
muscle aLrophy, conLlnuous passlve moLlon Lo preserve
healLhy arLlcular carLllage.
73("8',+-'32/
-See compllcaLlons for lower llmb fracLure
-upper llmb #s, parLlcularly ln Lhe hand, Lend Lo be much
more dlsabllng-Lherefore lL ls parLlcularly lmporLanL Lo
prevenL deformlLy and preserve funcLlon and range of
movemenL, ln #s compllcaLed by commlnuLlon,
dlsplacemenL or angulaLlon, surgery ls almosL always
requlred.
!"# %&'%#'(') %(**+#, -./.
/-0
!"#$"%&'&()
1PL uAnuLnCnC uCSSlL8 2010
123
!"#$%"&'%(
*"+','-'.,
MallgnanL dlsorders of Lhe haemaLopoleLlc sLem cell
comparLmenL assoclaLed wlLh lncreased numbers of whlLe
cells ln Lhe bone marrow and/or perlpheral blood.
/0%(('+'1%-'.,
acuLe myelold leukaemla (AML)
acuLe lymphoblasLlc leukaemla (ALL)
chronlc myelold leukaemla (CML)
chronlc lymphocyLlc leukaemla (CLL)
23'4"&'.0.56
x are acuLe leukaemlas
Male: female 3:2 - acuLe leukaemlas
Male: female 2:1 - chronlc lymphocyLlc leukaemla
Male:female 1.3:1 chronlc myelold leukaemla
7'($ 8%1-.9(:1%#("(
lonlslnlng radlaLlon
CyLoLoxlc drugs
8eLrovlruses
CeneLlc
lmmunologlcal e.g. hypogammaglobullnaemla
;%-<.3<6('.0.56
AcuLe leukamlas: rollferaLlon of prlmlLlve sLem cells
leadlng Lo an accumulaLlon of blasLs, predomlnanLly ln Lhe
bone marrow, whlch cause bone marrow fallure.
AML subclasslfled lnLo: AML wlLh recurrenL geneLlc
abnormallLles, AML wlLh mulLlllneage dysplasla, AML
MuS, Lherapy relaLed, and AML noL oLherwlse speclfled.
ALL can elLher be precursor 8 ALL or precursor 1 ALL.
Chronlc myelold leukaemla: MyeloprollferaLlve sLem cell
dlsorder resulLlng ln prollferaLlon of all haemaLopoleLlc
llneages, manlfesLlng predomlnanLly ln Lhe granulocyLlc
serles. AbouL 93 have Lhe hlladelphla chromosome
Chronlc lymphocyLlc leukaemla: 8 lymphocyLes do noL
respond Lo anLlgens by LransformaLlon and anLlbody
formaLlon leadlng Lo an accumulaLlon of useless 8 cells.
Cll can ransform Lo hlgh-grade lymphoma. lL has sLages
A,8 and C.
='5,( %,4 =6&3-.&(
anaemla - shorLness of breaLh on efforL,
excesslve Llredness, weakness
leucopoenla - recurrenL lnfecLlons
LhrombocyLopenla - bleedlng and brulslng
marrow lnfllLraLlon - bone paln
pallor
fever (due Lo lnfecLlon, noL Lhe dlsease lLself)
lymphadenopaLhy, hepaLosplenomegaly
volavlous skln leslons
LesLlcular enlargemenL
cranlal nerve palsles
welghL loss
headache (occaslonally) due Lo hyperleucoyLosls
8eLlnal haemorrhage due Lo leucosLasls
>,?"(-'5%-'.,(
8lood counL
8lood fllm
8one marrow asplraLe
ChesL x-ray
lluoresceln-ln-slLu hybrldlzaLlon (llSP)
Leukaemla AssoclaLed roLeln (LA)
lmmunophenoLyplng
CyLogeneLlcs
Coombs' LesL
lmmunoglobullns
@%,%5"&",-
@"4'1%0
!"#$% '%#()%*+), -!./ 0 !//1
SupporLlve Lherapy:
1reaLmenL for anaemla, lnfecLlon, bleedlng,
hyperurlcaemla (allupurlnol), meLabollc
problems andpsychologlcal problems.
Speclflc Lherapy:
!"#$%%$&' $')*+,$&': ComblnaLlon Lherapy Lo
deLroy Lumour, e.g. vlncrlasLlne, daunorublcln
and prednlsolone
!"#$%%$&' +&'%&-$).,$&': ChemoLherapy Lo aLLack
resldual dlsease,e.g. cyLarablne, meLhoLraxaLe
and eLoposlde
!"#$%%$&' #.$',"'.'+": 8epeaLlng cycle of drug
admlnlsLraLlon for ouLpaLlenLs, e.g. vlncrlsLlne,
prednlsolone and mercapLopurlne.
8one marrow LransplanLaLlon
23456+" .7%'5+8 '%#()%*+)
/01&'$+ 20.%": 1
sL
llne Lherapy ls lmaLlnlb
(Lyroslne klnase lnhlblLor), oLhers lnclude 2
nd
generaLlon Lyroslne klnase lnhlblLors (dasaLlnlb,
nlloLlnlb), hydroxycarbamlde and lnLerferon.
3++"-"1.,") 20.%" .') /1$%$%4 lmaLlnlb,
hydroxycarbamlde, cyLarablne, 2
nd
generaLlon
Lyroslne klnase lnhlblLors
23456+" '7*935"7$+" '%#()%*+)
5,.6" 3 - no LreaLmenL requlred unless evldence
of progresslon
5,.6" 7 8 / 9Chlorambucll, fludarablne (purlne
analogue), cychlophosphamlde (alkyalaLlng
agenL) and corLlcosLerolds (for marrow fallure or
auLolmmune cyLopenlas)
5*22&1,$:" ,0"1.2;-same as for acuLe leukaemlas
=#95'1%0
SplenecLomy
1PL uAnuLnCnC uCSSlL8 2010
126
!"##$%"&'($) +&(,'-'#./0', 12'3/0'("2& 4!+15
!$6"&"("2& 789 10'##"6".'("2&
ulC ls Lhe resulL of sysLemlc acLlvaLlon of Lhe paLhways
lnvolved ln coagulaLlon and lLs regulaLlon. lL resulLs ln
lnLravascular flbrln cloLs causlng organ fallure, wlLh
slmulLaneous consumpLlon of coagulaLlon facLors (v &
vlll), flbrlnogen and plaLeleLs causlng bleedlng.
:$("2023;81'/#$#
lnfecLlon/ sepsls: vlral, bacLerlal or fungal
1rauma
CbsLeLrlc: e.g. amnloLlc fluld embollsm, placenLal
abrupLlon, pre-eclampsla
Severe llver fallure
Mallgnancy: solld Lumours and leukaemla
1lssue desLrucLlon: pancreaLlLls, burns, exLenslve
surgery
vascular abnormallLles: vascular aneurysms, llver
haemanglomas
1oxlc/ lmmunologlc: A8C lncompaLlblllLy, snake
blLes, recreaLlonal drugs
<'(=2>=;#"2023;
1he maln paLhways leadlng Lo flbrln deposlLlon are (1)
Llssue facLor-medlaLed Lhrombln generaLlon and (2)
dysfuncLlonal physlologlc anLlcoagulanL mechanlsms, such
as Lhe anLlLhrombln sysLem and Lhe proLeln C sysLem.
A Lhlrd paLhway, ln addlLlon Lo enhanced flbrln formaLlon,
ls lmpalred flbrln removal due Lo depresslon of Lhe
flbrlnolyLlc sysLem. 1hls lmpalrmenL of endogenous
Lhrombolysls ls malnly caused by hlgh clrculaLlng levels of
Lhe flbrlnolyLlc lnhlblLor Al-1. llbrln degradaLlon
producLs lnclude u-dlmers. 8arely, flbrlnolyLlc acLlvlLy may
be lncreased and conLrlbuLe Lo bleedlng.
?"3&# '&) ?;%>(2%#
acuLely lll
shock
wldespread haemorrhage (mouLh, nose and
venepuncLure slLes)
exLenslve brulslng
renal fallure
gangrene eLc
@"#(2,; '&) AB'%"&'("2&
SympLoms of underlylng condlLlon e.g
lnfecLlon/sepsls, mallgnancy, Lrauma, severe
hepaLlc fallure eLc...
Paemorrhage, peLechlae, ecchymoses
Slgns and sympLoms of venous Lhromboemollsm
+&-$#("3'("2&#
l8L
u-dlmer LesL
SequenLlal measuremenLs of flbrlnogen
ulssemlnaLed lnLravascular coagulaLlon (ulC)
scorlng sysLem
CloLLlng screen:
12&)"("
2&
<,2(=,2%
C"& ("%$
<',("'0
D=,2%C2>0'
#("& D"%$
E0$$)"&
3 D"%$
<0'($0$(
.2/&(
!+1 rolonged rolonged rolong
ed
uecreas
ed
F'&'3$%$&(
F$)".'0
1reaLmenL of underlylng dlsease: llrsL llne Lherapy
Ad[uncLlve LreaLmenL sLraLegles: laLeleL and plasma
(componenL) Lransfuslon
AnLlcoagulaLlon: Peparln
8esLoraLlon of anLlcoagulaLlon paLhways: admlnlsLraLlon
of recomblnanL human acLlvaLed proLeln C or
anLlLhrombln concenLraLe.
?/,3".'0
Surglcal LreaLmenL llmlLed Lo prlmary LreaLmenL for
cerLaln underlylng eLlologles
12%>0".'("2&#
8leedlng
Crgan dysfuncLlon and llmb lshemla
ueaLh
1PL uAnuLnCnC uCSSlL8 2010
127
!"#$%&'(#) +(,$-.$)/'$%01#) 23,%3,& 4!+25
607#1#'#$1 8 9:&;;#7#)&'#$1
lL ls deflned as lsolaLed LhrombocyLopenla wlLh normal
bone marrow and Lhe absence of oLher causes of
LhrombocyLopenla. AcuLe l1 ofLen follows an acuLe
lnfecLlon and has a sponLaneous resoluLlon wlLhln 2
monLhs. Chronlc l1 perslsLs longer Lhan 6 monLhs
wlLhouL a speclflc cause.
<%#"0-#$:$=/
1he 2 dlsLlncL cllnlcal syndromes manlfesL as an acuLe
condlLlon ln chlldren (usually self-llmlLlng) and a chronlc
condlLlon ln adulLs. 1he female Lo male raLlo ls 2.6:1.
laLeleL auLoanLlbodles are deLecLed ln abouL 60-70 of
paLlenLs.
>#;? @&)'$,;
osL vlral lnfecLlon,e.g. Plv
AuLolmmune dlsorders such as SLL, Lhyrold
dlsease and auLolmmune haemolyLlc anaemla
Chronlc lymphocyLlc leukaemla and solld
Lumours
A0'#$:$=/B9&3;0;
lmmunoglobulln C (lgC) auLo-anLlbodles on Lhe
plaLeleL surface
2&'($%(/;#$:$=/
lL ls prlmarlly a dlsease of lncreased perlpheral plaLeleL
desLrucLlon, wlLh mosL paLlenLs havlng anLlbodles Lo
speclflc plaLeleL membrane glycoproLelns. 8elaLlve
marrow fallure may conLrlbuLe Lo Lhls condlLlon.
C#=1; &1" C/-%'$-;
Lasy brulslng
urpura
LplsLaxls (nose bleed)
Menorrhogla
Paemorrhage-ln severe LhrombocyLopenla,
hence rare
D#;'$,/ &1" <E&-#1&'#$1
hyslcal examlnaLlon normal excepL for evldence
of bleedlng
Splenomegaly-rare
!1F0;'#=&'#$1;
l8L-1hrombocyLopenla
8one marrow-normal/! megakaryocyLes
laLeleL auLoanLlbodles: noL essemLlal for
dlagnosls
G&1&=0-01'
9(#:",01
usually requlres no LreaLmenL
When necessary,
o hlgh-dose prednlsolone
o l.v. lgC-for serlous bleedlng or urgenL
surgery
A"3:';
1reaL paLlenLs wlLh plaLeleL counL< 30 x 10
9
/L
llrsL-llne Lherapy
o Cral corLlcosLerolds
o l.v. lgC for rapld rlse ln plaLeleL counL
o SomeLlmes hlgh-dose corLlcosLerolds as
lnlLlal Lherapy
Second-llne Lherapy
o SplenecLomy
o Plgh-dose corLlcosLerolds, hlgh-dose l.v.
lgC, l.v. anLl-u, vlnca alkalolds, danazol,
lmmunosuppresslve agenLs such as
azaLhloprlne, cyclosporlne and dapsone
o Monoconal anLlbody-8uLlxlmab
o 8ecomblnanL LhrompoleLln
o laLeleL Lransfuslons- 8eserved for
lnLracranlal or exLreme haemorrhage
1PL uAnuLnCnC uCSSlL8 2010
128
!"#$%&$'"()(*+
-./(0(1($0 234 5)*++(/(6*1($0
lnherlLed or acqulred defecLs of haemosLasls causlng a
predlsposlLlon for Lhrombosls (venous or arLerlal)
formaLlon
1ypes:
- lacLor v Lelden
- roLhrombln varlanL
- AnLlLhrombln (A1) ueflclency
- roLeln C
- roLeln S
- AnLlphosphollpld AnLlbody
7(+8 9*61$#+
Conslder Lhrombophllla ln people wlLh:
8ecurrenL venous Lhrombosls
llrsL venous Lhrombosls when <40 yrs
unusual venous Lhrombosls (le ln mesenLerlc or
cerebral veln)
unexplalned neonaLal Lhrombosls
8ecurrenL mlscarrlage
ArLerlal Lhrombosls wlLh no arLerlal dlsease
lacLor v Lelden 8lsk lacLors: regnancy, CC
:.1($)$;<3=*1"$'"<+($)$;<
lacLor v Lelden
- AuLosomal domlnanL
- Slngle nucleoLlde subsLlLuLlon ln lacLor v gene
(so facLor v can'L be cleaved & lnacLlvaLed by
proLeln C, Lherefore acLlvaLed lacLor v leads Lo
lncreased Lhrombosls)
roLhrombln varlanL
- MuLaLlon ln proLhrombln gene causes lncrease
proLhrombln levels
AnLlLhrombln (A1) ueflclency
- auLosomal domlnanL lnherlLance (LhromboLlc
eplsodes begln when young)
- acqulred afLer surgery/Lrauma/CC use
- low A1 ln nephroLlc syndrome
roLelns C & S ueflclency
- auLosomal domlnanL condlLlons
- heLerozygoLe: lncreased Lhrombosls <40yrs
- homozygoLlc: neonaLal purpure fulmlnans (faLal
wlLhouL lmmedlaLe Lherapy)
AnLlphosphollpld AnLlbody
>(;0+ *0? ><%'1$%+
lncreased rlsk of LhromboLlc eplsodes:
uv1
L
mural Lhrombl ln Lhe lefL aLrlum/venLrlcle)
@0A.+1(;*1($0+
CoagulaLlon Screen:
- l8L: plaLeleLs
- roLhrombln 1lme/ln8: exLrlnslc paLhway
- a11: lnLrlnslc paLhway
- flbrlnogen: common paLhway
- Ll1s
!"#$%&'()*+ -./*
lacLor v Lelden a11 LesL (one wlLh
acLlvaLed roLeln C & one
wlLhouL)
Molecular LesLlng
Assay
AnLlLhrombln,
roLeln C,
roLeln S, AnLlphosphollpld
AnLlbody
Assays
roLhrombln varlanL Assay
Molecular LesLlng
B*0*;.%.01C B.?(6*)
AnLlplaLeleLs:
- Asplrln
- ulpyrldamole
- Clopldogrel
- Abclxlmab
AnLlcoagulanLs:
- Peparln
- Warfarln
1hrombolyLlc urugs:
- SLrepLoklnase
- 1lssue-Lype plasmlnogen acLlvaLor (alLeplase)
- 8eLeplase
- 1enecLeplase
1PL uAnuLnCnC uCSSlL8 2010
129
!"#$%&'$( *+$$(&", -&./%($%.
-$0&"&'&/" 123 4+5..&0&65'&/"
lnherlLed deflclencles of coagulaLlon facLors.
MosL commonly:
lacLor vlll (Paemophllla A)
lacLor lx (Paemophllla 8)
vW facLor (von Wlllebrand dlsease)
7&.8 956'/%.
Male sex (haemophlllas)
lamlly hlsLory
:$'&/+/,;245<.$.
x-llnked Lransmlsslon (haemophllla A & 8)
AuLosomal domlnanL / recesslve Lransmlsslon
(vWu)
SponLaneous muLaLlon
Acqulred (auLolmmune, eLc.)
=5'#/>#;.&/+/,;
Paemophllla A & 8
uefecL / deflclency of facLor vlll / lx (cofacLors ln
acLlvaLlon of facLor x ln coagulaLlon cascade)
lormaLlon of flbrln deflclenL cloLs
CoagulaLlon more prolonged, cloLs more
unsLable
vWu
AuLosomal domlnanL / recesslve Lransmlsslon
uefecL / deflclency of vWl (funcLlons: 1. plaLeleL
adheslon Lo damaged endoLhellum 2. sLablllse
clrculaLlng facLor vlll)
uefecL ln prlmary haemosLasls (plaLeleL
aggregaLlon) and secondary deflclency of facLor
vlll
?&,". 5"( ?;@>'/@.
SympLoms
8leedlng on mlld / moderaLe Lrauma
SponLaneous bleedlng
Superflclal (skln) bleedlng, eplsLaxls, menorrhagla
rolonged bleedlng
Slgns
PaemarLhrosls
8leedlng lnLo muscle
eLechlae, purpura
Clnglvlal bleedlng, eplsLaxls, Cl bleedlng
A&.'/%; 5"( BC5@&"5'&/"
Px
lamlly hlsLory
asL surglcal hlsLory and bleedlng compllcaLlons
neonaLal hlsLory of bleedlng / brulslng
8ecenL Lrauma
PlsLory of recelved blood Lransfuslons
MensLrual hlsLory
Lx
!olnL / sofL Llssue dlsease
Cl / oropharyngeal bleedlng
Skln / mucous membrane bleedlng
!"D$.'&,5'&/".
l8L (88C, plaLeleLs)
CoagulaLlon facLor assays
A11, 1
mlxlng sLudles
x-rays (haemarLhrosls)
C18 (lf head Lrauma)
E5"5,$@$"'
Avoldance of Lrauma, asplrln, anLlplaLeleLs
lacLor replacemenL (durlng bleedlng eplsodes)
uesmopressln
CC
CeneLlc counselllng, LesLlng
4/@>+&65'&/".
8lsks of Lransfuslons (lnfecLlon, developmenL of
anLl-facLor anLlbodles, eLc.)
Llfe-LhreaLenlng haemorrhages (lnLracranlal,
reLropharyngeal, reLroperlLoneal)
Shock from unrecognlsed haemorrhage (lnLra-
abdomlnal, lnLragluLeal)
!olnL dlsease (haemarLhrosls)
!"# %&'%#'(') %(**+#, -./.
/0.
!"#$%&'()* ,'*$-*$*
1PL uAnuLnCnC uCSSlL8 2010
131
!"#$%$&#$'(
*+,-./!0/ *01- 1-. 2034.5/!03*06 !0/*7*-/*85
72659 5:!,49 8-++-0 5*/45 -1
*0148/*-0
,&(($%;< !7=
6.!+ ,-5*/*>4
SLaph Aureus Cram + Coccl
normal flora of skln
Skln (boll, abscess, wound),
food polsonlng, endocardlLls,
osLeomyellLls
llucloxaclllln
M8SA: vancomycln
SLrep yogenes (+ vlrldlans) Cram + Coccl
normal flora of skln, mouLh,
nasopharynx
Skln, sofL Llssue, pharynglLls,
rheumaLlc fever
vlrldlans: bacLerlal
endocardlLls
Amoxy/Amplclllln
SLrep neumonlae Cram + Coccl
normal flora of nasopharynx
1yplcal neumonla,
menlnglLls
Amoxlclllln, 8enzylpenlclllln
LnLerococcl Cram + Coccl (normal flora
large bowel)
u1l, Abdo sepsls Amoxy/Amplclllln, vanc
v8L: walL for senslLlvlLles
6.!+ 046!/*>4
L. Coll Cram - 8acllll (normal flora,
large bowel)
u1l, abdo sepsls, food
polsonlng
Amoxlclllln, LrlmeLhaprlm
seudomonas Cram - 8acllll u1l, Abdo sepsls, 8esplraLory
ln CysLlc llbrosls
CenLamlcln + a penlclllln
(Llcarclllln?)
Cr Clproflaxln
P. lnfluenzae Cram - 8acllll (normal flora
nasopharynx)
MenlnglLls
neumonla
Amplclllln (2
nd
or 3
rd
gen
cephalosporln, macrollde)
klebslella Cram - 8acllll
(normal flora large bowel)
neumonla, u1l, Abdo
Sepsls
CenLamlcln plus Ll1PL8
plperaclllln/Llcarclllln
Shlgella Cram - 8acllll (? normal
flora of large bowel)
lood borne enLerlLls uoesn'L usually need Abx
nlsserla MenlnglLldls Cram - dlplococcus MenlnglLls, sepLlcaemla 8enzylpenlclllln
-/:4.
M. 1uberculosls CLher 18 lsonlazld + 8lfamplcln + eLhambuLol
+ pyrazlnamlde
M. neumonla CLher ALyplcal neumonla 8oxlLhromycln
Leglonella CLher (Cram - 8acllll) 8esplraLory ClarlLhromycln +/- rlfampln or
fluoroqulonolone alone
Chlamydla neumonlae CLher ALyplcal neumonla uoxycyclne,
ClarlLhromycln/roxlLhromycln
!0!4.-745
ClosLrldlum Anaerobe Cram + 8acllll MeLronldazole, vanc
Ceneral anaeroblc lnfecLlon normal flora: mouLh, Cl1,
vaglna, skln
ueep wounds, abscess
formaLlon, foul-smelllng pus,
Llssue desLrucLlon
MeLronldazole
1PL uAnuLnCnC uCSSlL8 2010
132
!"##"$ &$'(!)&"$*
&+,-./01+2 !1331+ 45/617-+82 '098/ :0+- )9-5/3-+/2
;)6-95<-=/0. >=0?-@0+-8A
B=8/0,0.5/01+2
1yplcal neumonla SLrep neumonlae
P. lnfluenzae
SLaph
klebslella (only gram-)
Amoxlclllln/8enzylpen
lf sLaph: fluclox
lf klebsllla: genL
ALyplcal neumonla Mycoplasma neumonlae
Chlamydla,
Leglonella neumonlae
LryLhromycln/8oxlLhromycln
PosplLal Acqulred neumonla Cram negaLlve Cef + CenL
AsplraLlon neumonlae Anaerobes MeLronldazole + Cef
CellullLls SLrep , SLaph A llucloxaclllln
u1l L. Coll 1rlmeLhoprlm
Sepsls Could be anyLhlng, depends
on source of lnfecLlon
lluclox + CenL + meLronldazole
(someLlmes add cefLrlaxone,
depends on cllnlcal susplclon)
lluclox - cover Cram poslLlves
lncludlngSLaph
CenL - Cover gram negaLlves
MeLronldazole - cover
anaerobes
M8SA MeLhlclllln-8eslsLanL SLaph
Aureus
vacomycln
v8L vancomycln reslsLanL
enLerococcus
Check senslLlvlLles
8acLerlal LndocardlLls SLaph Aureus, SLrep vlrldlans
(or LnLerococcus)
8enzylpenlclllln + llucloxaclllln
+ CenLamlcln C8 vanc+genL
(esp lf prosLheLlc valve)
8en: SLrep,
lluc: SLaph,
CenL: LnLero
8acLerlal MenlnglLls SLrep neumonlae, nelserrla
MenlnglLldls,
P. lnfluenzae,
8enzylpenlclllln
uexameLhasone
Cefrlaxone + 8enzylpenlclllln
8enpen - SLrep
1uberculosls M 1uberculosls lsonlazld + 8lfamplcln +
eLhambuLol + pyrazlnamlde
!"# %&'%#'(') %(**+#, -./.
/00
!"#$ &'#()&
*+!&, &-#./, !"#$ &'#(),
!"#$ .0&('(1/
*1234 &56758 )629 : ;<==>
?852@@A >B C5B=478D C51
B<1 2@E2A8 FG62378H
*1673 IA<G7B78 F: J>6>K>2B8H )629 : ;<==>
?852@@A >B =42>B8
*1673 IB759<B>27 )629 : ;<==>
%>3@<=<==>
#B176<=<==> )629 : ;<==>
;42>B8
1PL uAnuLnCnC uCSSlL8 2010
134
!"#$ &'!#()*'
L. Coll
seudomonas
P. lnfluenzae
klebslella
Shlgella
Cram - 8acllll
All look Lhe same
nlsserla MenlnglLldls Cram - coccus
ln palrs
1PL uAnuLnCnC uCSSlL8 2010
133
!"#$% "! $'() '!#*+*"#*(
+,-. /.0-.12
.3 4,560677652
o !"#$%&'"#()(&&(#* ,-./%)(&&(#
! Cover: Cram poslLlve (+ n MenlnglLldls)
! Amoxyclllln ls drug of cholce for enLerococcal lnfecLlons
o 0&1)&./2)(&&(#
! Cover: SLaph Aureus (MSSA)
83 $9-,5:,: %;,0-<=1 4,56067765
o ,13-"#4(#* 5(-"#4(#* 52$.)(#
! 8road specLrum penlclllln plus 8eLa
LacLamase lnhlblLor Lo provlde broader
coverage and lnclude seudomonas
cover (see box on slde for deLalls)
! Lxpenslve
! Also used for reslsLanL gram negaLlve
bacLeraemla
o !"42 &2)4(-26" (#7(8(4.96
! ClavulanaLe, SulbacLam, 1azobacLam
! lnlhlblL enzymes Lo do wlLh: SLaph A, L. Coll, klebslella, n Conorrhoeae, P. lnfluenzae
! LlLLle acLlvlLy, buL effecLlve when comblned wlLh: Amoxy, Llcarclllln, plperaclllln
! 8eserve for lf reslsLance
03 (,;>.7?2;?<652@ (lncreaslng gram neg cover LhroughouL generaLlons)
o :
64
;"#< ="'72$.&(#* ="'72&"/(#
! ModeraLe specLrum. MosLly gram poslLlves
Cram poslLlve: SLrep, SLaph. nC1 enLerococcl
Cram negaLlve: L.Coll. nC1 LnLerobacLer or seudomonas
! 8arely a flrsL llne drug
o >
#?
;"#< noL lmporLanL for us
o @
9?
;"#< ="A49(2/.#"
! 8road SpecLrum. ln parLlcular gram negaLlves
Ma[orlLy of gram negaLlve bacllll
nC1 M8SA or Ln1L8CCCCCuS
! eneLraLes 888
! 1herefore: noL very useful ln Cl1 lnfecLlons
o B
47
;"#< ="A42$(?(#"* ="A('(-"
! LxLended specLrum.
! lncludes seudomonas
! Lxpenslve
:3 (.<8.;,5,12
o C"9.'"#"-* D942'"#"-
! Lxpenslve reserve agenL
! very very broad specLrum
! Wlde acLlvlLy agalnsL gram negaLlve rods and seudomonas
! LffecLlve agalnsL anaerobes
! LffecLlve agalnsL gram poslLlves
A7B0?;,;-6:,2
o E2#).-%)(#
! Wlde range of gram poslLlves
! llrsL llne for M8SA
! use for severe lnfecLlons ln pL allerglc Lo penlclllln
! 8acLerlosLaLlc
*50<,.265C %;,0-<=1 ?D 4,560677652@
!.<<?E: !"#$%&'"#()(&&(#
!.<<?E F %-.;>: 0&1)&./2)(&&(#* ?()&./2)(&&(#* -"47()(&&(#
G?:,<.-,H+<?.: %;,0-<=1: ,-./%)(&&(#* ,-'()(&&(#
+<?.: %;,0-<=1 F +,-. 7.0-.1.2, 65>686-?<: ,13-"#4(#
(Amoxlclllln + ClavulanaLe), 5(-"#4(# (1lcarclllln + ClavulanaLe),
52$.)(# (lperclllln + 1azobacLam), (Amplclllln + SulbacLam)
1PL uAnuLnCnC uCSSlL8 2010
136
!"#$%&'()*
o !"#$%"&'#()*+ -.)$%"&'#()*+ /&0#$%"&'#()*
! Wlde specLrum:
Cram poslLlve coccl, leglonella, bordeLella
Cram negaLlve coccl
Mycoplasma, Chlamydla
! used for communlLy acqulred pneumonla
,)-$"#.#&'/)*
o 1&0#(#(2)*3
! 8road
MosL gram neg and poslLlve
lncludes Mycoplasma and Chlamydla
! 8acLerlosLaLlc
01'/%&%/)*
o 4)5"&62&07()*+ 8&"62&07()*+ 9&0)62&07()*
! Lxpenslve
! Cram negaLlve: P. lnfluenzae, pseudomonas, gram neg coccl
23'/%4&.#%*'()*
o :3*$7')()*+ -');7()*
! 93 of Aeroblc Cram-neg are suscepLlble ('&*3 %)$ <&*=3" 6&" :"7' *3>7$)?3@AB
! lncludlng pseudomonas
! oLenLlally oLoLoxlc and nephroLoxlc
5'-$%
o 93$"&*)=7.&*3
! 1
sL
llne lor Anaeroblc lnfecLlons
! Lspeclally Cl1 lnfecLlons
6'7"3.#'/*
o /)67'5)()*
! LffecLlve agalnsL: 18, M8SA
! 8apld emergence of reslsLance, always use wlLh oLhers
! Slde effecLs:
Crange secreLlons
PepaLoLoxlclLy
!"# %&'%#'(') %(**+#, -./.
/01
1PL uAnuLnCnC uCSSlL8 2010
138
!"#$%&"' )**+&$,"#$%& -.%/."* 01234+'3
5/3 6"11$&3
7$.#2 PepaLlLls 8
8 9%, PepaLlLls 8
ulphLherla, LeLanus and acellular perLussls (u1a)
Paemophllus lnfluenza Lype 8 (Plb)
ln acLlvaLed pollomyellLls (lv)
neumococcal con[ugaLe (7vCv)
8oLavlrus
: 9%, PepaLlLls 8
ulphLherla, LeLanus and acellular perLussls (u1a)
Paemophllus lnfluenza Lype 8 (Plb)
ln acLlvaLed pollomyellLls (lv)
neumococcal con[ugaLe (7vCv)
8oLavlrus
; 9%, PepaLlLls 8
ulphLherla, LeLanus and acellular perLussls (u1a)
Paemophllus lnfluenza Lype 8 (Plb)
ln acLlvaLed pollomyellLls (lv)
neumococcal con[ugaLe (7vCv)
8oLavlrus
<8 9%, PepaLlLls 8
Paemophllus lnfluenza Lype 8 (Plb)
Measles, Mumps and 8ubella (MM8)
Menlngococcal C (MenCCv)
<8=8: 9%, PepaLlLls A (Aborlglnal and 1orres SLralL lslander chlldren ln hlgh rlsk areas)
<> 9%, varlcella (vZv)
<>=8: 9%, neumococcal polysaccharlde (23vv) (Aborlglnal and 1orres SLralL lslander chlldren ln
hlgh rlsk areas)
PepaLlLls A (Aborlglnal and 1orres SLralL lslander chlldren ln hlgh rlsk areas)
: ?3"., ulphLherla, 1eLanus, and acellular perLussls (u1a)
Measles, Mumps and 8ubella (MM8)
lnacLlvaLed pollomyellLls)
<@=<A ?3"., PepaLlLls 8
varlcella (vZv)
<8=<A ?3"., Puman aplllomavlrus (Pv)
<B=<C ?3"., ulphLherla, 1eLanus, and acellular perLussls (u1a)
<B=:D ?3"., lnfluenza (Aborlglnal and 1orres SLralL lslander people medlcally aL-rlsk)
neumococcal polysaccharlde (23vv) (Aborlglnal and 1orres SLralL lslander people
medlcally aL-rlsk)
B@ ?3"., "&4 %E3. lnfluenza (Aborlglnal and 1orres SLralL lslander people)
neumococcal polysaccharlde (23vv) (Aborlglnal and 1orres SLralL lslander people)
;B ?3"., "&4 %E3. lnfluenza
neumococcal polysaccharlde (23vv)
hLLp://lmmunlse.healLh.gov.au/lnLerneL/lmmunlse/publlshlng.nsf/ConLenL/L8738A3436C6ul98CA23738u001C808l/$llle/nl
p-schedule-card-[uly07.pdf
1PL uAnuLnCnC uCSSlL8 2010
139
!"#$%&'()&"*+
MenlnglLls w/o shock-
morLallLy 10 and
neurologlcal sequelae
uncommon
Coma - poor prognosLlc slgn
lulmlnanL menlngococcemla
- moraLllLy relaLed Lo organ
fallure (20-80)
-.*&*/&)&+
0.1&*&)&"* 234 !%(++&1&'()&"*
lnflammaLlon of menlnges characLerlsed by:
lever
Peadache
CSl leukocyLosls
ulfferenLlaLe !"#$%&' from $()(*#+%
5.)&"%"/63!(7+.+
MosL commonly due Lo bacLerlal lnfecLlon by Lhe followlng bugs
8(.#"$9&%7+ &*1%7.*:(.; <.&++.=&( #.*&*/&)&>&+; ?)=.$)"'"''7+
$*.7#"*&(. (plos 5tteptococcos oqoloctlcoe lo lofoots ooJ llstetlo
mooocytoqeses lo tbe elJetly/lmmooocomptomlseJ)
Powever, aeLlology may be vlral or paraslLlc
@()9"$96+&"%"/6
?6#$)"# "= ?&/* A=.B7.*'6
8.(>('9. >90
A.C.= >90
-.*&*/&+#7+ >83
5%).=.> +.*+"=&7# >80
D"#&)&*/ ~33
?.&:7=.+ ~30
-.'!* +#().*./&'!* 0&+1&+/" 10-20
2!$&**.#1#3! <3
!%&*&'(% E.> A%(/+ (*> !"==.%()&*/ E&+F A(')"=+
0&+)7=G(*'. "1 '.=.G=(% 17*')&"*H
cbooqe lo cooscloos stote, focol oeotoloqlcol slqos,
coovolsloos
lnvolvemenL of cerebral Llssue
urgenL acLlon requlred
I"J&'&)6H
nlqb fevets, tocbycotJlo, bypoteosloo
8acLerlal sepsls
!%&*&'(% +.))&*/ K '"==.%()&"* L&)9 E&+F A(')"=+H
ltevloos skoll ftoctote (e.q. ctlbtlfotm #) ot ctoolotomy, c5l
leok, potooosol sloos lofectloo & sotqety, eot Jlscbotqe &
mostolJ polo
aramenlngeal sepsls
lmpolteJ bost Jefeoces
Mallgnancles: leukaemla, lymphoma osL-op paLlenL
Crgan LransplanLaLlon Asplenla (surglcal or funcLlonal)
CorLlcosLerold Lherapy Advanced lllness
Alcohollsm
CpporLunlsLlc lnfecLlons - LlsLerla monocyLogenes, 18 menlnglLls,
crypLococcal menlnglLls
8octetlol oJocotJltls
S. Aureus or oLher Cram -ve bacllll
lost blstoty of 18 ot ftom blqb eoJemlc teqloo
18 menlnglLls
1tovel blstoty
araslLlc lnfecLlon e.g .malarla or Lrlchlnosls
Occopotloool exposote
LepLosplrosls, brucellosls
utoqs
nSAlus, co-Lrlmoxazole, oLhers
ltevloos oseptlc meoloqltls
L.g. PSv menlnglLls, Lyme dlsease
woxloq & wooloq cootse- CrypLococcal menlnglLls
!?A 1&*>&*/+ G(').=&(%:
!openlng pressure (200-300 mm P
2
0!)
" glucose-slnlsLer flndlng
roLeln >100mg or cell counL >1000
Cram sLaln- very useful
MJ)=(4*.7="%"/&'(% 1&*>&*/+H
Mocolopopolot tosb- early menlngococcaemla
letecblol ot potpotlc tosb(cottelote wltb Jlseose ptoqtessloo
-tbtombocytopoeolo ooJ ulc)- Menlngococcaemla,
SLaphylococcal sepLlcaemla
lteseoce of extto-ctoolol lofectloos
Motmot & oLher slgns of endocardlLls
N*C.+)&/()&"*+
8lood culLures - lMMLulA1L, also ask for
o Lu1A sample for C8, LhroaL swab. l8C, u&Ls,
glucose, Ll1, cloLLlng
8raln C1
o erformed prlor Lo L ln all cases wlLh depressed
consclousness or focal neurologlcal slgns
o Clve anLlbloLlc 8LlC8L C1 do nC1 delay 8x.
L
o uo noL perform ln pLs wlLh predomlnanLly
sepLlcaemla (delays Lhelr vlLal Mg and may be
dangerous lf ulC)
o ALLempL before C1 head when slmple menlnglLls
l.e. noL sepLlc and w/o focal neurologlcal slgns
-(*(/.#.*)
1. O%""> '7%)7=.+
2. 5*)&G&")&'+ < 30 mlns +
0.J(
ltlot to bospltol lf sospecteJ
(fever+rash)
O.*:6%$.*&'&%%&* 1.2 g lv sLaL
nospltol mpltlcol
!.1)=&(J"*. 4 g lv d 2
D('"#6'&* 300 mg lv Clu
lf >30/lmmunocompromlsed
8enzylpenlclllln1.6-2.4g 4
hrly
3. ?7$$"=)&C.- lCu for
shocked (urgenL flulds +
lnvaslve monlLorlng) pL
or CCS<12
!"# %&'%#'(') %(**+#, -./.
/0.
1PL uAnuLnCnC uCSSlL8 2010
141
!"#$% '##"%()*+,-,*%-. /,0"1 2!'/3
MosL common lnfecLlous cause of deaLh
40mllllon people Plv poslLlve worldwlde
4$56(7*%*1,1
Plv ls a slngle sLranded 8nA reLro-vlrus
ldenLlfled Lypes Plv1 and Plv 2, wlLh 2 more
common
Plv causes profound lmmunodeflclency resulLlng
from desLrucLlon and low levels of Cu4 1-
lymphocyLes
1he Cu4 serves as Lhe prlmary cellular recepLor
for Plv wlLh oLher co-recepLors (CC83 or CxC84)
AfLer enLry lnLo Lhe cell, vlral reverse
LranscrlpLase makes a unA copy of Lhe 8nA
genome and lnLegraLes lL lnLo hosL unA
SynLheslslng core vlLal proLelns
CompleLed vlrlons are released from cell vla
buddlng
vlral load predlcLs progresslon Lo AluS
80$%1#,11,(%
Pomosexual or heLerosexual lnLercourse
lvuu
1ransfuslon of blood producLs
MaLernal-chlld Lransfer-durlng pregnancy,
dellvery or breasLfeedlng
9$5"0$: !,15(0.
AcuLe-seroconverslon lllness (30-80)
Sx occur 2-4 wks afLer lnfecLlon
lnclude fever, malalse , maculopapular rash,
myalgla and pharynglLls
AnLl-Plv anLlbodles appear 3-12 wks
(seroconverslon)
!"#$%&'$(&)* ,-.
AfLer seroconverslon
MosL paLlenL are asympLomaLlc for upLo 10 years
wlLhouL LreaLmenL
8uL vlrus conLlnue Lo repllcaLe
/#$%&'$(&)* ,-.
aLlenL mlghL geL AluS deflnlng lllness wlLh
slgnlflcanL sysLemlc feaLures e.g. LCW, perslsLenL
fever and dlarrhoea
;5$7* (+ <,1*$1*
uescrlbed by sympLoms, AluS deflnlng lllness and
Cu4 counL
L severely lmmunosuppresed
<,$7%(1,1
ueLecLlon of anL-Plv anLlbodles by LLlSA
Seroconverslon occurs 1-3 mnLhs posL lnfecLlon
Plv should be consldered ln anyone presenLlng
wlLh shlngles, unexplalned welghL loss and
lymphadenopaLhy
0'$$'1 '%%'2&31)"&)* )145*&)'1"
kaposl's sarcoma
non-Podgkln's lymphoma
neumocysLls carlnll
CyLomegalovlrus lnfecLlon
80*$5#*%5
!==>8
1hree maln classes
nucleoslde reverse LranscrlpLase lnhlblLor
roLease lnhlblLors
non-nucleoslde reverse LranscrlpLase lnhlblLors
1PL uAnuLnCnC uCSSlL8 2010
142
!"#$%&"'()*)
,$-*.*/*(. 012 3'4))*-*&4/*(.
lnfecLlous dlsease caused by sLralns of mycobacLerla,
usually mycobacLerlum Luberculosls, ln humans. lL usually
affecLs Lhe lungs, buL can affecL any oLher parL of Lhe
body.
56*7$8*('(9:
1ransmlsslon by resplraLory dropleLs from close proxlmlLy
Lo an lnfecLed lndlvldual
;*)< =4&/(%)
ueveloplng world resldenLs
ConLacL of spuLum +ve cases
overLy, overcrowdlng, malnuLrlLlon
Alcohollc
ulabeLes
lmmunosuppressed sLaLes
o PaemaLologlcal mallgnancy
o Plv +ve
o SLerolds
>$/*('(9:134")$)
lnfecLlon beglns when suscepLlble person lnhales alrborne
dropleL nuclel conLalnlng vlable organlsms
?4/@(6@:)*('(9:
rlmary 18
M.Luberculosls reach alveoll ! lngesLed by alveolar
macrophages ! lnfecLlon occurs lf organlsm escapes
macrophage mlcroblcldal acLlvlLy ! lymphaLlc,
haemaLogenous spread before body mounLs effecLlve
lmmune response ! cllnlcally and radlographlcally
sllenL! ln pLs w/lnLacL lmmunlLy, macrophages, 1 cells
surround organlsms ln granulomas ! dormancy (no
acLlve dz, noL Lransmlsslble, laLenL 18 lnfecLlon)
lf lmmune response lnadequaLe ! progresslve prlmary 18
occurs (sx as below)
8eacLlvaLlon of 18
When hosL lmmune defences lmpalred ! acLlve 18
develops (esp lf above rlsk facLors presenL)
LxLrapulmonary 18
- Mlllary 18 (sysLemlc dlssemlnaLlon) - Lhe young,
Plv +ve, Lhe elderly (organlsms found ln spuLum,
8M, llver, genlLourlnary LracL)
- leural, lymph node, bone/[olnL, perlcardlal 18,
18 menlnglLls
A*9.) 4.7 A:86/(8)
erslsLenL cough
WelghL loss
nlghL sweaLs
lever
Malalse
PaemopLysls
B.C$)/*94/*(.)
Zlehl-neelsen sLalnlng of Al8 ln spuLum
SpuLum culLure (abouL 8 weeks)
C8 LesLlng
needle bx of pleura (granulamaLous lnflammaLlon ln abL
60 of pLs w/resulLlng pleural effuslons)
CuanLlferon gold LesL (does noL ddx bLw acLlve and laLenL)
ManLoux LesL (does noL ddx bLw acLlve and laLenL)
lmaglng (Cx8)
- leural effuslon, hllar and paraLracheal Ln
enlargemenL, segmenLal aLelacLasls
o rlmary 18
- Chon and 8anke focus
o Lvldence of healed prlmary 18
- upper lobe cavlLaLlon
o rogresslve prlmary 18
o 8eacLlvaLlon 18
- ulffuse small nodular denslLles
o Mlllary 18
D4.49$8$./
D$7*&4'
8lL
- 8lfamplcln: Lurns secreLlons orange
- lsonlazld: hepaLlLls, pyrldoxlne deflclency causlng
neuropaLhy (chemoprophylacLlc drug ln Lhose
w/laLenL 18)
- yrazlnamlde: PepaLlLls
- LLhambuLol: opLlc neurlLls
CorLlcosLerold
- 1uberculous perlcardlLls and menlnglLls
- Speed resoluLlon of pleural effuslon
A"%9*&4'
18 osLeomyellLls (oLL's dz) w/resulLlng splnal cord
compresslon
Chronlc consLrlcLlve perlcardlLls
E/@$%
lnfecLlon conLrol ! paLlenL lsolaLlon
1PL uAnuLnCnC uCSSlL8 2010
143
Ma|ar|a
Def|n|t|on +]- C|ass|f|cat|on
Malarla ls a mosqulLo borne paraslLlc dlsease caused by
Lhe plasmodlum paraslLe.
Lp|dem|o|ogy
Lndemlc ln mosL of Lhe Lroplcs - SouLh and
CenLral Amerlca, Afrlca, Mlddle LasL, lndla, SLA.
1ransmlsslon, morbldlLy and morLallLy are
greaLesL ln Afrlca, young chlldren.
Common ln Lravellers from non-endemlc areas Lo
Lhe Lroplcs.
k|sk Iactors
8esldence or exposure Lo malarla -endemlc
area.
venLurlng ouL aL dusk.
noL uslng lnsecLlcldes, repellenLs, bed neLs.
noL Laklng chemoprophylaxls.
noL wearlng long cloLhlng
Aet|o|ogy]Causes
4 specles of Lhe genus lasmodlum.
falclparum ls responslble for nearly all dlsease.
vlvax, ovale and malarlae are much less
common causes of sever dlsease.
noLe: vlvax and ovale paraslLes also form
dormanL llver hypnozolLes, whlch are noL kllled
by mosL drugs ! recurrence lf subopLlmal
LreaLmenL.
athophys|o|ogy
1ransmlLLed by Lhe blLe of lnfecLed female
anophellne mosqulLoes.
uurlng feedlng, sporozolLes are ln[ecLed, whlch
clrculaLe Lo Lhe llver, causlng asympLomaLlc llver
lnfecLlon.
MerozolLes are subsequenLly released from Lhe
llver, and rapldly lnfecL eryLhrocyLes.
MulLlple rounds of 88C developmenL, producLlon
of more merozolLes ! large numbers of
clrculaLlng paraslLes.
Some merozolLes develop lnLo gameLocyLes !
lnfecLlous Lo mosqulLoes (when blLLen agaln)
CompleLlon of llfe cycle and lnfecLlon of oLhers.
S|gns and Symptoms
Peadache and faLlgue, followed by chllls, sweaLs
and hlgh fever.
levers are usually lrregular.
Malalse, myalglas, arLhralglas, cough, chesL paln,
abdomlnal paln, anorexla, n&v, dlarrhoea.
Selzures may represenL slmple febrlle
convulslons or sever neurologlcal dlsease.
Slgns of anaemla, [aundlce, splenomegaly and
mlld hepLomegaly.
8ash and lymphadenopaLhy are noL Lyplcal of
malarla, and suggesLlve of anoLher cause of
fever.
ALL ILVLk IN A kL1UkN 1kAVLLLLk IS MALAkIA
UN1IL kCVLN C1nLkWISL.
n|story and Lxam|nat|on
1ravel hlsLory and exposure deLalls lmporLanL.
Invest|gat|ons
1hlck and Lhln blood fllms. 1hlck Lells you
paraslLe load and ls more senslLlve because more
blood ls examlned. 1hln Lells you Lhe specles of
paraslLe. lf LesL ls negaLlve buL cllnlcal susplclon ls
hlgh, repeaL ln 8 hrs.
Serologlc LesLs - C8 - noL useful for dlagnosls of
acuLe lnfecLlon, especlally ln endemlc areas.
l8L - May show LhrombocyLopenla, anaemla,
leukocyLosls
Ll1 - deranged.
Management
noLe: SympLomaLlc malarla ls caused only by Lhe
eryLhrocyLlc sLage of lnfecLlon. Avallable anLl-malarlal
drugs acL agalnsL Lhls sLage, excepL for prlmaqulne, whlch
acLs prlnclpally agalnsL hepaLlc paraslLes.
Med|ca|
Pydroxychloroqulne - LreaLmenL and
chemoprophylaxls. 8eslsLance ls wldespread.
Culnlne, Culnldlne - Cral and l.v Lherapy for
sever lnfecLlons.
Mefloqulne - Chemoprophylaxls and LreaLmenL
of sLralns reslsLanL Lo chloroqulne.
rlmaqulne - ovale and vlvax - eradlcaLe
hepaLlc lnfecLlon.
Malarone - 1reaLmenL and chemoprophylaxls
uoxycyclln and Cllndamycln - 1reaLmenL of
mulLldrug reslsLanL lnfecLlons.
ArLesunaLe, arLemeLher - 1reaLmenL of severe
and mulLldrug reslsLanL lnfecLlons.
Comp||cat|ons
uysfuncLlon of any organ sysLem.
neurologlc abnormallLles - alLered
consclousness, selzures, coma (cerebral malarla)
Severe anaemla, hypoLenslon, shock.
non-cardlogenlc pulmonary oedema, A8uS.
A1n, hypoglycaemla, acldosls, haemolysls +
[aundlce, hepaLlc dysfuncLlon, ulC.
Secondary bacLerlal lnfecLlons - pneumonla and
salmonella.
MosL common causes of deaLh ln chlldren are
cerebral malarla and severe anaemla.
1PL uAnuLnCnC uCSSlL8 2010
144
!"#$%$
'"(%)%*%+)
!,$*"-%. %)(/0--0*+1, 1"$#+)$" $,)21+-" 3!45!6
2 or more of Lhe followlng:
1emperaLure >38C or <36C
P8 >90 bpm
88 >20 breaLhs/mln or aCC2 <4.3 ka
WCC >12 x 10L, <4 s 10L or >10 band forms
7/0$$%(%.0*%+)
!"#$%$: Sl8S occurrlng ln Lhe presence of lnfecLlon
!"8"1" $"#$%$: sepsls wlLh organ hypoperfuslon e.g.
hypoxaemla, ollgurla, lacLlc acldosls, alLered cerebral funcLlon
!"#*%. $9+.:: severe sepsls wlLh hypoLenslon (sysLollc 8
<90mmPg), or requlremenL for vasopressors/lnoLropes Lo
malnLaln blood pressure
5%$: ;0.*+1$
Age
lnvaslve procedures, prosLheLlc lmplanLs and devlces
lmmunosuppresslve drugs, chemoLherapy, LransplanLaLlon
AnLlmlcroblal reslsLance
<"*%+/+=,>70?$"$
ulrecL lnLroducLlon of mlcrobes lnLo Lhe bloodsLream
vla lnLravenous lnfuslon (e.g. lnLravenous llne, oLher
devlce-assoclaLed lnfecLlons)
erforaLlon of lnLra-abdomlnal or pelvlc sLrucLures
8acLeremla due Lo urosepsls, pyelonephrlLls, renal
abscess, acuLe prosLaLlLls, or prosLaLlc abscess (esp ln
lmmunocompromlsed hosLs)
Severe pneumococcal lnfecLlon ln paLlenLs wlLh
lmpalred or absenL splenlc funcLlon.
Menlngococcemla
@0*9+#9,$%+/+=,
Sepsls resulLs when Lhe lnflammaLory response Lo lnfecLlon
becomes generallzed, and exLends Lo lnvolve normal Llssue
remoLe from Lhe lnlLlal slLe of ln[ury or lnfecLlon.
CuLer membrane componenL of mlcroorganlsms (frequenLly
bacLerla, e.g. endoLoxln of gram-negaLlve bacLerla) blnd Lo Loll-
llke recepLors on monocyLes - cyLoklne release
CyLoklnes:
1. produce Loxlc downsLream medlaLors -
vasodllaLaLlon, free radlcal producLlon, damage Lo
endoLhellal llnlng causlng lncreased caplllary leakage
2. AcLlvaLe exLrlnslc coagulaLlon cascade and lnhlblL
flbrlnolysls - mlcrovascular Lhrombosls - organ
dysfuncLlon
AcLlvaLlon of Lhe coagulaLlon sysLem leads Lo
consumpLlon of endogenous anLlcoagulanLs (e.g.,
proLeln C and anLlLhrombln - ulC
!%=)$ 0)2 !,-#*+-$
yrexla and rlgors, nausea and vomlLlng, vasodllaLaLlon, Warm
perlpherles, 8oundlng pulse, 8apld caplllary reflll, PypoLenslon
A%$*+1,
Sources of lnfecLlon:
4B /%)"$ (esp. CenLral llnes > 1 week)
4)*10C0D2+-%)0/ +1 #"/8%. source: condlLlons LhaL predlspose Lo
perforaLlon or abscess (e.g. chronlc or reLrocecal subacuLe
appendlclLls, dlverLlcullLls, Crohn dlsease, prevlous abdomlnal
surgery, cholecysLlLls)
E1%)01, *10.* source: pyelonephrlLls, renal sLones, congenlLal
abnormal collecLlng sysLem, prosLaLe enlargemenL, or prevlous
prosLaLe or renal surgery
4--?)+.+-#1+-%$"2: dlabeLes, sysLemlc lupus eryLhemaLosus
(SLL), alcohollsm or sLerold Lherapy
FG0-%)0*%+)
Lvldence of lnfecLlon (redness, warmLh, oedema) aL lv slLe
1enderness over:
8lghL upper abdomlnal quadranL - cholecysLlLls, cholanglLls
LefL lower quadranL - dlverLlcullLls
8lghL lower quadranL - appendlclLls, Crohn's dlsease
CvA Lenderness - pyelonephrlLls
ulffuse abdomlnal paln suggesLs pancreaLlLls (noL sepsls) or
generallsed perlLonlLls.
4)8"$*%=0*%+)$
!"#*%. $.1"")H l8L, blood + CSl + urlne MCS, spuLum culLure,
MSu, Cx8, C8, LS8
I77H LeukocyLosls or leukopenla
@/0*"/"*$: 1rombocyLosls (acuLe-phase response) or
LhrombocyLopenla (ulC)
@1+*"%) 7J 0)*%*91+-D%) deflclency
LlevaLed 'C2%-"1 level
rolonged @K 0)2 <@KK
71"0*%)%)": ^, doubllng lndlcaLes acuLe renal ln[ury
L0.*%. 0.%2: > 4 mmol/L lndlcaLes Llssue hypoxla
L;K$: ^AL, AS1, AL1, blllrubln levels lndlcaLe acuLe
hepaLocellular ln[ury caused by hypoperfuslon
!"1?- #9+$#90*"H j, lnversely correlaLed wlLh
prolnflammaLory cyLoklne levels
@1+.0/.%*+)%) level: ^- dlfferenLlaLes lnfecLlous Sl8S from
nonlnfecLlous Sl8S
M0)0="-")*
Lmplrlcal anLlbloLlcs (deLermlned by slLe of lnfecLlon, gram
sLaln, culLure)
8emove source of lnfecLlon (lf posslble)
CpLlmlse Llssue oxygenaLlon
lluld resusclLaLlon (conservaLlve lf acuLe lung ln[ury)
vasopressor LreaLmenL
CorLlcosLerolds: anLl-lnflammaLory
8ecomblnanL Puman AcLlvaLed roLeln C: anLl-lnflammaLory,
anLlLhromboLlc and pro-flbrlnolyLlc properLles
Clycemlc ConLrol
venLllaLor LreaLmenL for A8uS
8lood Lransfuslon
7+-#/%.0*%+)$
MulLl-organ fallure
1PL uAnuLnCnC uCSSlL8 2010
143
!"#$%&' )* +,-,)., /#&0&,
1$*&,&2&), 345 67'88&*&9'2&),
1emperaLure > 38.3C for aL leasL 3 weeks wlLhouL
dlagnosls afLer aL leasL 1 week of lnvesLlgaLlons ln
hosplLal
1&**$#$,2&'7 1&'0,)8&8
:;<=6>:/;
8acLerlal lnfecLlon
18
Abscess
u1ls
LndocardlLls (rare)
PepaLoblllary lnfecLlons e.g. cholanglLls
CsLeomyellLls
1hyphold
vlral
Perpes (CMv/L8v)
Plv
lungl lnfecLlons (ln lmmunosuppressed)
araslLes
1oxoplasmosls
Malarla
?@A:B;@;6C
neoplasms
Leukaemlas and Lymphomas
8enal Cell Carclnoma
6/AA@B=; D@E6+A@F 1:E=@E=EG
AuLolmmune
SysLemlc onseL [uvenlle 8A
olyarLerlLls nodosa
vasculaLldes
ClanL cell arLerlLls
olymyalgla 8heumaLlca
BF@;+A/?@>/+E
Sarcoldosls
Crohn's
CranulomaLous PepaLlLls
?:E6=AA@;=/+EG
erlpheral L
lnherlLed
lamlllal MedlLerranean fever
PyperLhyroldlsm/SubacuLe 1hyroldlLls
urug fevers
8eLa-lacLam AnLlbloLlcs, lsonlazld
H&82)#"
ConsLlLuLlonal SympLoms (LCW, LCA, laLlgue)
nlghL sweaLs/8lgors/Chllls, Peadaches, 8ashes
nuLrlLlon
urug hlsLory
o lmmunosuppresslve agenLs
lmmunlsaLlon sLaLus
1ravel hlsLory (osslble Lxposures (e.g. mosqulLo
blLes) + rophylaxls (dependlng on slLe of Lravel)
CccupaLlonal Px
Sexual Px
MPx: AuLolmmune condlLlons, Plv eLc
lPx
=%'I&,'2&),:
LveryLhlng and AnyLhlng
ln parLlcular: 8ashes, LymphadenopaLhy, Sgs arLhrlLls,
murmurs, fundoscopy, neurologlcal deflclLs
:,J$82&0'2&),8 K'8 'LL#)L#&'2$M
l8L, LS8, u&Ls, C8, Ll1s, AnA, 8h lacLor, 1l1s
8lood CulLures
SLool/urlne/SpuLum CulLures
CSl CulLure
Mornlng gasLrlc asplraLes CulLure (18)
ChesL x8A?
Abdo C1
Lcho (endocardlLls)
L (headache)
Skln blopsy (rash)
Lymph asplraLlon/blopsy (lymphadenopaLhy)
8one marrow asplraLlon/blopsy (Plv+ve)
Llver 8lopsy (abnormal Ll1s)
H)8L&2'7&8'2&),G
Sx: Chllls/8lgors/nlghL SweaLs
aLlenL sLaLus (e.g. vlLal Slgns)
:II$N&'2$ ?%G
lf fever ls deblllLaLlng, slmple anLl-pyreLlcs may be
glven (e.g. asplrln, paraceLamol)
Cenerally, no Lherapy should be glven before
dlagnosls made (non-speclflc Lherapy lneffecLlve and
delays dlagnosls)
LxcepLlon: neuLropenlc paLlenLs (Lake blood culLures,
LreaL aggresslvely wlLh broad specLrum anLlbloLlcs)
!"# %&'%#'(') %(**+#, -./.
/01
!"# %&'%#'(') %(**+#, -./.
/01
!"#$%&'(')*
1PL uAnuLnCnC uCSSlL8 2010
148
!"#$%&'$
)"*+%+,+&% -./ 0#$11+*+2$,+&%
MallgnanL Lumour of Lhe melanocyLes. 20-23 morLallLy.
lemales sllghLly > males. 4
Lh
mosL common ln AusLralla
345"1 &* '"#$%&'$6
Superflclal Spreadlng Melanoma (80): slow growlng,
laLe meLasLasls, dark brown/black, sLaln-llke
nodular melanoma: lnvades deeply, early meLasLasls,
forms ralsed lump
LenLlgo mallgna: 8eglns as large freckle, slow and
superflclal growLh.
Acral lenLlglnous: lound on palms/sole of feeL/under
Lhe nalls.
7+18 9$2,&:1
uv8 exposure
ale skln
naevl numbers
lamlly hlsLory (<10 melanoma, muLaLlons ln
Cukn2A, Cuk4)
revlous melanoma
;"4 9"$,<:"1 &* !$#+=%$%, !"#$%&'$ >?@0)AB
?symmeLry
@order lrregular
0olour lrregular
)lameLer, ofLen greaLer Lhan 0.3cm
AlevaLlon lrregular (+ loss of skln marklngs)
CLhers: flrm Lo Louch, lnflammaLlon,
crusLlng/bleedlng, paraneoplasLlc syndromes: loss of
appeLlLe/welghL, nausea/vomlLlng, faLlgue
0$<1"1
Lxposure Lo uv radlaLlon from Lhe sun or solarlum.
C+1,&:4 $%D AE$'+%$,+&%
PlsLory: Ask abouL onseL, lLch, paln, bleedlng and
ulceraLlon.
lndlvldual: Age? lalr-skln? Pad loLs of sun exposure? Pave
Lhey always used sun proLecLlon?
SlLe: ls lL ln a sun-exposed or covered area?
Are Lhere slmllar leslons?
Morphology of leslon.
uermaLoscopy: useful ln leslons LhaL are noL melanocyLlc
F%G"1,+=$,+&%1
l8L, u&L, Ll1, LuP (meLaLasls)
C1, M8l, L1, xrays (meLasLasls)
Skln blopsy
SenLlnel lymph node blopsy wlLh lymphosclnLlgraphy (lf
melanoma > 1mm)
H,$="1 >0#$:8 I"G"#B
1. Melanoma conflned Lo Lhe epldermls (Mls)
2. lnvaslon lnLo Lhe paplllary dermls
3. lnvaslon Lo Lhe [uncLlon of Lhe paplllary and
reLlcular dermls
4. lnvaslon lnLo Lhe reLlcular dermls
3. lnvaslon lnLo Lhe subcuLaneous faL
!$%$="'"%,
Lxclslonal skln blopsy: leslon and surroundlng normal
Llssue removed. MusL have clear margln. Skln flaps or
grafLs someLlmes needed.
Lymph node exclslon
ChemoLherapy
lnLerferon-alpha/lmmunoLherapy
8adloLherapy (ofLen used posL surgery)
J:&=%&1+1
@:"1#&K 3L+28%"11 ?55:&E+'$," M 4"$: 1<:G+G$#
<1 mm 93-100
1-2 mm 80-96
2.1-4 mm 60-73
>4 mm 30
8reslow depLh ls a prognosls facLor for melanoma.
1PL uAnuLnCnC uCSSlL8 2010
149
!"#$%&#' )*++ $,- .$'$+ )*++ )$/01,&%$
231-*%1&+&45
8CC ls Lhe mosL common human cancer. SCC 2
nd
mosL
common skln cancer afLer 8CC. Male > female.
)+1,10$+ 6*$7#/*'
.$'$+ )*++ )$/01,&%$
Cllnlcal Lypes
1. CysLlc nodular - LranslucenL or pale grey
2. ulceraLed - nodular 8CC wlLh cenLral necrosls.
3. lgmenLed - usually spoLLed, maybe all black.
4. Superflclal - eryLhemaLous scaly paLch
3. Morphoelc (flbroLlc) - scar-llke, poorly deflned
margln.
6. **Common: rolled pearly, gllsLenlng edge,
LelanglecLasla, ulceraLed.
CfLen found on Lhe face of elderly lndlvlduals and rarely
meLasLaslses. Slow growlng. Causes local desLrucLlon lf
lefL unLreaLed. Called Lhe '8odenL ulcer'.
!"#$%&#' )*++ )$/01,&%$
rollferaLlve Lumour LhaL grows over a few monLhs.
resenLs as an ulceraLed leslon, wlLh hard, ralsed
edges, flrm Lhlckenlng of skln, surroundlng eryLhema,
hard nodules soon ulceraLes.
1ends Lo arlse ln premallgnanL areas or areas wlLh
long-sLandlng lnflammaLlon such as solar keraLoses,
burns, chronlc ulcers, leucoplakla and 8owen's
dlsorder.
SCCs of ear, llp, oral cavlLy, Longue and genlLalla are
serlous and need speclal managemenL. Also affecLs
esophagus, bladder and lungs.
)$#'*'
.))8 8CCs develop ln Lhe basal cell layer of Lhe skln.
rolonged exposure Lo uv8 causes unA damage Lo
accumulaLe leadlng Lo prollferaLlon of basal cells.
!))8 Puman papllloma vlrus has been assoclaLed wlLh SCC
of Lhe oropharynx, lung, flngers and anogenlLal reglon.
uv8 and lmmunosuppresslon are rlsk facLors for SCC of
Lhe skln. CasLrlc oesophageal reflux dlsease, Lobacco,
alcohol and beLel nuL consumpLlon are also rlsk facLors.
9/*:;$+14,$,7 <#%&#/' $,- =7>*/'
Solar kerasLose (acLlnlc kerasLosls): Appears on sun-
exposed skln as crumbly, yellow-whlLe crusL. 8x: cauLery,
cryoLherapy or 3-fluorouracll cream.
8owen's dlsease: SCC ln slLu. Slow-growlng redbrown
scaly plaque. lull Lhlckness dysplasla whlch may progress
Lo SCC. 8x: cryoLherapy, Loplcal 3-fluorouracll or
phoLodynamlc Lherapy.
Leucoplakla: WhlLe paLches on oral/genLlal mucosa where
lL may lLch.
Secondary carclnoma: MosL common meLasLases Lo skln
are from breasL, kldney or lung. usually a flrm nodule.
CfLen found on scalp.
?,@*'714$71&,'
Shave blopsy of 8CC
;$,$4*%*,7
Surglcal exclslon ls besL. >4mm free surglcal margln.
Moh's mlcrographlc surgery: exclsed Lumour ls
lmmedlaLely examlned under mlcroscope so lf
marglns are lnsufflclenL, more skln ls removed from
paLlenL wlLhouL delay. LffecLlve for hlgh-rlsk prlmary
and recurrenL 8CC.
hoLodynamlc Lherapy: LffecLlve ln prlmary
superflclal 8CC. AppllcaLlon of phoLosenslLlzers Lo
LargeL area. When acLlvaLed, Lhey become Loxlc.
1oplcal chemoLherapeuLlc agenLs such as 3-
lluorouracll or lmlqulmod
8adloLherapy
CureLLage and elecLrodesslcaLlon
9/&4,&'1'
Around 93 of recurrences and meLasLases of SCCs occur
wlLhln 3 years.
8ecurrence of 8CC wlLh Moh's surgery ls ~1 and up Lo
10 for oLher forms of LreaLmenL.
!"# %&'%#'(') %(**+#, -./.
/0.
!"#
1PL uAnuLnCnC uCSSlL8 2010
131
!"# % & '(()*+),-./
012-3-+-43/
normal hearL raLe: 60-100 bpm
1achyarrhyLhmla ls > 100bpm
8rady arrhyLhmla ls <60bpm
543678+-43 9*/+1, 42 +)1 )1.(+
See plcLure !
:-/; <.8+4(/ 24( '(()*+),-./
ALherosclerosls
AMl
ulabeLes
valvulopaLhy
Sleep Apnoea
1hyrold dlsease
urugs
%= '+(-.> <-?(->>.+-43
rocess:
MulLlple lmpulses Lravel Lhrough aLrla aL same Llme,
leadlng Lo lrregular, rapld conLracLlons. noL all lmpulses
make lL Lhrough Av node, venLrlcles conLracL slower.
Lpldemlology:
2 revalence. 3 lf over 63
1 ln 4 people over 40y wlll develop lL aL some polnL
Causes:
P1n, prevlous AMl, hyperLhyroldlsm, sLlmulanL
medlcaLlons, vlral lnfecLlons.
Slck slnus syndrome
Cllnlcal resenLaLlon
Sx: alplLaLlons, ChesL paln, dyspnoea,
presyncope/dlzzlness
Sg: lrregularly lrregular pulse,
@3 A5BC
:.+1 :)*+), ! D.E1 !: -3+1(E.> F:9
ALrla: 330-630bpm
venLrlcles: slow Lo
rapld
lrregular llbrlllaLory. no
vlslble waves
n/A narrow (<
G= '+(-.> <>7++1(
rocess:
8e-enLranL slgnal essenLlally causes Lhe 8A Lo shorL
clrculL" slgnal from Lhe Av node, causlng lL Lo beaL
beLween 230-330 beaLs per mlnuLe. 1hls slgnal ls unable
Lo be passed Lhrough Lhe SA node aL such a rapld pace,
commonly resulLlng ln 2:1 or 4:1 hearL block
Lpldemlology:
2.3x more common ln males. Much less common Lhan
Aflb
Causes:
ALrlal enlargemenL, urugs, AMl, L, erlcardlLls
Cllnlcal resenLaLlon
Sx: alplLaLlons, ChesL paln, dyspnoea,
presyncope/dlzzlness
Sg: usually regular pulse. usually Lachycardlc.
1PL uAnuLnCnC uCSSlL8 2010
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"# $%&'
()*+ (,-*,. / 0)1+ /( 2#*+31)4 5(6
ALrla: 230-330bpm
venLrlcle:
2:1 block ! 130bpm
3:1 block ! 100bpm
4:1 block ! 73bpm
ALrlal: regular
venLrlcular: regular
lf Av node conducLs
conslsLenLly
SawLooLh
appearance
n/A narrow
*!"#$%%$& "(()"*"+,) -+ .)"/0 112 111 "+/ "34
78 /)39:-;.)4 6<=3)1+#*32><4)3 ?)>,->)3@2)
rocess:
Cccaslonal rapld hearL beaL, comes and goes.
CfLen due Lo re-enLry paLhway/accessory paLhways whlch
loop back lnLo aLrla causlng aLrla Lo depolarlse before SA
node lnlLlaLes nexL conLracLlon.
Lpldemlology:
2.3x more common ln males. Much less common Lhan
Aflb
Causes:
ALrlal enlargemenL, urugs, AMl, L, erlcardlLls. Wolff-
arklnson-WhlLe syndrome. congenlLal
Cllnlcal resenLaLlon
Sx: AnxleLy, palplLaLlons, dyspnoea
Sg: 1achycardlc.
"# $%&'
()*+ (,-*,. / 0)1+ /( 2#*+31)4 5(6
130-230bmp 8egular Can be noLched,
flaLLened, or losL wlLhln
C8S. 8uL wave should
be presenL
0.12-0.20 seconds
(normal).
ConslsLenL
narrow
*$% /-"5+%0) 6!37 890$ &":) ;<= /9*-+5 ()*-%/ %> $",&?,"*/-"
1PL uAnuLnCnC uCSSlL8 2010
133
!" $%&'()*+,-( .-*/0*-(1)-
rocess:
8hyLhm fasLer Lhan 100bpm orlglnaLlng ln venLrlcles.
usually re-enLry paLhway LhaL conLlnuously sLlmulaLes
venLrlcles
Lpldemlology:
2.3x more common ln males. Much less common Lhan
Aflb
Causes:
ullaLed cardlomyopaLhles, CAu, 8undle block, AMl,
LlecLrolyLe abnormallLles, drugs
Cllnlcal resenLaLlon
Sx: alplLaLlons, dyspnoea, presyncope/syncope,
sweaLlng
Sg: 1achycardlc, hypoLenslve, Lachypnoelc,
2& 3456
7-'% 7/0'/8 9 :-;% 97 )&'%(;-, <7=
130-230bmp usually
8egular
noL usually vlslble, lf
vlslble, noL assoclaLed
wlLh C8S
n/A Wlde and blzarre,
dlfflculL Lo see
separaLlon
beLween C8S and
1 wave
>" $%&'()*+,-( ?)@(),,-')A&
>" BC0C'A,%
1PL uAnuLnCnC uCSSlL8 2010
134
!" $
%&
'()*(( +(,*& -./01 (bradycardla)
rocess:
lmpulse ls conveyed slowly Lhrough Av node.
Causes:
Av nodal dlsease, enhanced vagal Lone (aLhleLes), AMl,
elecLrolyLe dlsLurbance, drugs
Cllnlcal resenLaLlon
Sx: none
Sg: none
23 4567
8,&( 89:&9; < =,>( <8 ?3&(*>,. @8A
uepends on underlylng
rhyLhm. 1
sL
degree
hearL block causes
underlylng rhyLhm Lo
be slower.
8egular 1x wave precedes each
C1S
ConslsLenLly
lengLhened.
>0.20seconds
narrow
B" C
3D
'()*(( +(,*& -./01 (bradycardla)
rocess:
Some waves conducL Lhrough Av node, oLhers do noL.
(some cases of 1ype ll are caused by blockage ln
conducLlon sysLem afLer Lhe Av node)
Causes:
Av nodal dlsease, AMl, eLc
Cllnlcal resenLaLlon
Sx: usually none, may have: ulzzlness, presyncope
Sg: none
E:F( $ -./01 G =(31H,09 (rogresslvely lengLhened 8s unLll a dropped C8S)
23 4567
8,&( 89:&9; < =,>( <8 ?3&(*>,. @8A
uepends on underlylng
rhyLhm. 1
sL
degree
hearL block causes
underlylng rhyLhm Lo
be slower.
8egularly
lrregular
8egular lnLervals
beLween waves.
rogresslve
prolongaLlon of 8
followed by a
dropped C8S
narrow
1PL uAnuLnCnC uCSSlL8 2010
133
"#$% & '()*+ (1:2 or 1:3 block)
,- ./01
234% 25#456 7 839% 72 :-4%;93( <2=
ALrlal raLe - normal
venLrlcular - slower
(1/2 or 1/3 of aLrlal
raLe)
lf conslsLenL
conducLlon,
regular. Lg lf
always 2:1
block
8egular lnLervals
beLween
waves.
1here ls noL a C8S
followlng every wave.
8uL where Lhere ls Lhe
lnLerval ls conslsLenL.
narrow
>? @
;A
B%C;%% D%3;4 '()*+ (compleLe)
rocess:
8lockage ln conducLlon sysLem. 1he aLrlum beaLs,
conLrolled by Lhe slnus node. 1he venLrlcles beaL
lndependenLly of Lhls aL a slower raLe.
Causes:
AMl, congenlLal, progresslve degeneraLlon of conducLlon
sysLem, endocardlLls
Cllnlcal resenLaLlon
Sx: Lxerclse lnLolerance, chesL paln eLc
Sg: 8radycardla, hypoLenslon, posslble haemodynamlc
lnsLablllLy
1PL uAnuLnCnC uCSSlL8 2010
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"# $%&'
()*+ (,-*,. / 0)1+ /( 2#*+31)4 5(6
ALrlal raLe: 60-100
venLrlcular: 20-60
8oLh wlll be regular buL
unrelaLed Lo each oLher.
8egular waves presenL and
normally shaped.
no relaLlonshlp
beLween wave
and C8S
Wlde
1PL uAnuLnCnC uCSSlL8 2010
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!"# % & '()*+ ,-.(/012/3 456/0(*2.5
7+6252*2.5 89& :3/;;262(/*2.5
lrreverslble lschaemlc damage Lo Lhe myocardlum, usually
resulLlng from coronary arLery occluslon
<=21+>2.3.?-
nA
@2;A B/(*.0;
lschaemlc PearL dlsease
ALherosclerosls
Male
Age
lamlly Px - 1
sL
degree relaLlve wlLh an AMl before 33
Smoklng
PyperLenslon
ulabeLes
SedenLary llfesLyle
? sLress
'+*2.3.?-9!/*C.=C-;2.3.?-
lnfarcLlon usually follows damage or rupLure Lo
aLheroscleroLlc plaque ln Lhe coronary arLerles. 1hls leads
Lo acuLe Lhrombosls as Lhe subendoLhellal collagen ls
exposed and subsequenL occluslon.
ConLracLlle funcLlon ls losL wlLhln 60 seconds of blood
flow occluslon, however myocyLes survlve for a fuLher 20-
30 mlnuLes
1he subendocardlal myocardlal Llssue (lnner half Lo
1/3) ls mosL vulnerable Lo lschaemlc damage, wlLh cellular
deaLh occurlng here flrsL
ChesL paln
o vague, radlaLes Lo neck, [aw, arms, back or
eplgasLrlum
o resenLaLlons wlLhouL chesL paln are 'aLyplcal' or
sllenL. 1hese are more llkely ln dlabeLlcs, elderley,
women
o Many lnfarcLlons are heralded by prevlous
lschaemlc anglnal evenLs
laLlgue
uyspnoea
resyncope/syncope
nausea
AuLonomlc slgns
o SweaLlng, cold, clammy, pallor
o AnxleLy
E2;*.0- /51 <F/>25/*2.5
Cardlac PlsLory & Lxam
Also 8esp, CasLro Lo exclude dlfferenLlals
45G+;*2?/*2.5;
LCC
o 1yplcally demonsLraLe an lschaemlc evenL by acuLe
elevaLlon of Lhe S1 segmenL >1mm or Lall 1 waves
o AfLer several days Lhe S1 segmenL wlll drop back Lo
normal and 1 waves may lnverL
Cardlac enzymes
o 1roponln levels
! 8eleased as myocardlum dles
! usually Lakes 8 hrs Lo rlse, however mosL speclflc
LesL avallable
o CreaLlne klnase - muscle and braln (CkM8)
! 8eleased before Lroponln buL less speclflc Lo hearL
problems
o Myoglobln
! llrsL cardlac marker Lo be released
! Many confoundlng facLors such as skeleLal muscle
damage so noL usually used
,/5/?+>+5* H'()*+I
1. AssessmenL - A8Cu, esp. LCC
2. Cxygen
3. Asplrln/Clopldegrel
4. aln managemenL - Morphlne,nlLraLes
3. blockers
6. ueLermlne course of LreaLmenL
llbrlnolysls
o ldeally wlLhln 12 hrs of onseL
o lncreases rlsks lf comblned wlLh sLenLlng
vessel sLenosls
o Around 73 occluslon ls requlred before
sympLoms are evldenL - anglna, 1lAs or
claudlcaLlon
!"# %&'%#'(') %(**+#, -./.
-00
!"#$ & '())*+,(,
*11 234567 8599:3;5;
1PL uAnuLnCnC uCSSlL8 2010
234
!"#$ & '() *+,-./
01/2+3 4,+5126 17 58. !512+-8
lcLure above: normal appearance of Lhe sLomach whlch
has been opened along
Lhe greaLer curvaLure.
Lsophagus ls on Lhe lefL. ln
Lhe fundus can be seen
Lhe lesser curvaLure. !usL
beyond Lhe anLrum ls Lhe
pylorus empLylng lnLo Lhe
flrsL porLlon of duodenum
aL Lhe lower rlghL.
noLe Lhe ruggae are
presenL LhroughouL.
9:;5131<6=
CasLrlc lLs: Small sunken
glands LhaL exLend Lo
Lamlna proprla
Above: normal hlsLology of sLomach
Layers of Lhe sLomach:
Mucosa (mucous secreLlng eplLhellum, glands,
lamlna proprla
Muscularls Mucosae
Submucosa
Muscularls roprla
Serosa
>>? 71/ '+;5/:- @A53.5 @B;5/A-5:1, :, 4CA35;
67 of CasLrlc ouLleL obsLrucLlon are mallgnanL causes
(gasLrlc carclnoma, pancreaLlc, ampullary, duodenal,
meLs)
uux:
uu (duodenal or gasLrlc)
o AcuLely - due Lo lnflammaLlon
o Chronlcally - scarrlng/flbrosls
CasLrlc olyps
CallsLone
ancreaLlc seudocysLs
non-mechanlcal causes eg: dlabeLlc
gasLroparesls
9:;5131<:-+3 4DD.+/+,-. 17 9E #631/:
1hls small curved Lo splral rod-shaped bacLerlum ls found
ln Lhe surface eplLhellal mucus of mosL paLlenLs wlLh
acLlve gasLrlLls. 1he rods are seen here wlLh a meLhylene
blue sLaln.
1PL uAnuLnCnC uCSSlL8 2010
233
D|sease: ept|c U|cer
oss|b|e Symptoms
Abdo paln, bloaLlng, waLerbrash, nausea,
vomlLlng, loss of appeLlLe, hemaLemesls,
maleana
Causes]athophys|o|ogy
MosL common causes: P.ylorl, nSAlu use
Can have benlgn and mallgnanL ulcers,
essenLlal Lo blopsy Lo deLermlne lf
mallgnanL
8enlgn: due Lo lmbalance beLween pepsln
secreLlon and gasLrlc mucosal defences.
usually assoclaLed wlLh P.ylorl gasLrlLls
!"#$%$&"'& )*$&#%&%$ *#+,'- *' ,./"# 0*1
,'-"#)+ 0"&*2.*$&%/ ! -1$2.*$&%/ /3*')"
&+ 4+#0 * /*#/%'+0*
A mallgnanL ulcer ls generally an
Adenocarclnoma (wlLh ulceraLlon). See below
Comp||cat|ons
erforaLlon
8leedlng and PaemeLemesls lf ulcer lnvades 8v
CasLrlc ouLleL obsLrucLlon
SympLoms relaLlng Lo peneLraLlng Lo oLher organs
Gross atho|ogy 1 - U|cer
Above lcLure: A 1 cm acuLe gasLrlc ulcer ls shown here ln
Lhe upper fundus. 1he ulcer ls shallow and sharply
demarcaLed, wlLh surroundlng hyperemla. lL ls probably
benlgn. Powever, all gasLrlc ulcers should be blopsled Lo
rule ouL a mallgnancy.
n|sto|ogy
lcLure Above: Mlcroscoplcally, Lhe ulcer here ls sharply
demarcaLed, wlLh normal gasLrlc mucosa on Lhe lefL
falllng away lnLo a deep ulcer whose base conLalns
lnflamed, necroLlc debrls. An arLerlal branch aL Lhe ulcer
base ls eroded and bleedlng.
Gross atho|ogy 2 - 1ransverse sect|on through
U|cer and under|y|ng t|ssue
1he speclmen shows a 1.S cm u|cer ln Lhe anLrum of Lhe
sLomach. 1he edges of Lhe ulcer show Lhe gasLrlc mucosa
conLracLlng lnLo lL. 1he base of Lhe ulcer appears red and
sllghLly granular and appears Lo have eroded Lhrough Lhe
sLomach wall Lo Lhe level of Lhe deep muscularls proprla.
Deep to the base of Lhe ulcer Lhere are conLracLed whlLe
bands of Llssue LhaL exLend Lo Lhe level of Lhe serosa of
Lhe sLomach. 1here ls no heaplng up of Lhe mucosa
ad[acenL Lhe ulcer. 1here ls no evldence of perforaLlon of
Lhe ulcer. no promlnenL and exposed blood vessel ls seen
ln Lhe ulcer base.
1PL uAnuLnCnC uCSSlL8 2010
236
!"#$%#$& (%#)*"+ ,-$./+%*+"./0%
1203)/0#
CfLen asympLomaLlc, maybe lndlgesLlon, loss of
appeLlLe
LaLe sLage: aln, nausea vomlLlng, dysphagla, bloaLlng
eLc.. And slgns relaLlng Lo meLasLases
423$#
56 !"778#$ (%#)*"+ 9%.+$*: oorly dlfferenLlaLed.
lndlvldual cells lnfllLraLe lnLo sLomach wall causlng
Lhlckenlng of Lhe wall (llnlLls plasLlca) wlLhouL formlng
a dlsLlncL mass.
- Cross feaLures: LeaLher boLLle appearance (llnlLls
plasLlca), Lhlckenlng of mucosal wall, loss of ruggae
- PlsLologlcal feaLures: SlgneL rlng cells (full of mucous
wlLh nuclel pushed Lo slde)
:6 ;.)$#)".%< (%#)*"+ 9%.+$* (le locallsed): Lends Lo grow
ouLwards and ofLen are ulceraLlng. MallgnanL CasLrlc
ulcer.
AssoclaLed wlLh lnLesLlnal meLaplasla and P.ylorl. More
llkely ln dlsLal sLomach.
- Cross feaLures: usually normal ruggae surroundlng. Area
of Lhlckenlng, whlLe, lnfllLraLlng Llssue. oorly deflned eLc,
spread beyond mucosa.
- PlsLologlcal feaLures: As wlLh oLher cancers,
pleomorphlsm eLc eLc eLc eLc
=whllsL noL an adenocarclnoma, you musL always
conslder <203>/0% of Lhe sLomach (usually MAL1).
1hls appears slmllarly Lo Lhe dlffuse Lype.
?%)>/3>2#"/</@2
!" $%&'() ls Lhe maln rlsk facLor ln 63-80 of
gasLrlc cancers, buL only 2 of such lnfecLlons
progress Lo cancer.
13*$%- (and in brackets how they may present)
Local spread lnLo Lhe wall of Lhe sLomach
(anorexla, welghL loss, vague eplgasLrlc paln,
vomlLlng, and dysphagla.)
LymphaLlcs (Supraclavlcular lymph node
enlargemenL)
1ranscoelomlc (enlarged ovarles/recLal shelf on
palpaLlon, asclLes)
PaemaLogenous/MeLasLases (hepaLomegaly, [aundlce
,back paln)
"#$%&'()*(+,' -.#)$/ ,% +(#) /)0$,*1
1umour spreads Lhrough full Lhlckness of sLomach wall,
Lhrough perlLoneum lnLo perlLoneal space. 1umour cells
seed lnLo perlLoneal fluld ! AsclLes. CLher perlLoneal
surfaces, eg Serosa of Cvarles, are llkely slLes of
meLasLases.
(*/## ?%)> 5& !"778#$ ,-$./+%*+"./0%
hoLo Above: arLlally resecLed sLomach lncorporaLlng
Lhe body and anLrum wlLh aLLached greaLer omenLum.
normal rugae are losL and an lrregular smooLh Lo nodular
surface ls vlslble. 1he mucosa and submucosa parLlcularly
appear Lhlckened dlffusely by a whlLe Llssue. Shrunken
'LeaLher boLLle' appearance.
MosL llkely: Lymphoma, or ulffuse/oorly dlfferenLlaLed
gasLrlc Lumour. Lymphoma ls generally llLLle more
locallsed and more fleshy.
(*/## ?%)> :& A%<"@.%.) (%#)*"+ B<+$*
Pere ls a gasLrlc ulcer ln Lhe cenLer of Lhe plcLure. lL ls
shallow and ls abouL 2 Lo 4 cm ln slze. 1hls ulcer on blopsy
proved Lo be mallgnanL, so Lhe sLomach was resecLed as
shown here.
C"#)/</@2
noL speclflcally covered ln case
1PL uAnuLnCnC uCSSlL8 2010
237
!"#$ & !'()*+,-./ 012345
637()(.(,)
Croup of dlseases caused by auLoreacLlve anLlbodles Lo
consLlLuenLs of Lhe eplLhellum or basemenL membrane.
81955(7(29.(,)
8llsLerlng dlsorders are classlfled accordlng Lo Lhe
epldermal layer where separaLlon occurs.
#3:;/(<-5 ls a rare auLolmmune bllsLerlng dlsorder
resulLlng from loss of lnLegrlLy of normal lnLercellular
aLLachmenLs wlLhln epldermls and mucosal eplLhellum.
=> #3:;/(<-5 ?-1<94(5 (deeper)
AcanLholysls lnvolves layer of cells lmmedlaLely above Lhe
basal cell layer - suprabasal acanLholyLlc bllsLer (deeper)
"> #3:;/(<-5 7,1(923-5 (superflclal)
AcanLholysls lnvolves superflclal epldermls aL Lhe level of
sLraLum granulosum - subcorneal bllsLer
@-11,-5 ;3:;/(<,(A
Subepldermal, nonacanLholyLlc bllsLer
#9./,;/B5(,1,<B*#9./,<3)35(5
LplLhellal cells are held LogeLher by desmosomes, whlch
are ln Lurn anchored lnLo Lhe cyLoplasm by LonofllamenLs.
ln ;3:;/(<-5, Lhere are paLhogenlc lgC anLlbodles Lo
lnLerceullar desmosomal proLelns of skln and mucous
membranes.
1hls ls a Lype ll hypersenslLlvlLy reacLlon (anLlbody
dlrecLed agalnsL a flxed Llssue anLlgen).
ln C-11,-5 ;3:;/(<,(A, Lhere are anLlbodles dlrecLed
agalnsL proLelns aL Lhe dermal-epldermal [uncLlon.
ClrculaLlng lgC anLlbody reacLs wlLh anLlgen ln Lhe basal
cell-basemenL membrane aLLachmenL plaques
(hemldesmosomes). 1here ls perlveascular lnfllLraLe of
lymphocyLes, eoslnophlls, neuLrophlls, superflclal dermal
oedema and basal cell layer vacuollsaLlon once
complemenL ls bound.
vacuolaLed basal cell layer evenLually glves rlse Lo a fluld-
fllled bllsLer. 8llsLer roof lnvolves full-Lhlckness epldermls,
more reslsLanL Lo rupLure Lhan pemphlgus bllsLers.
D4,55 ;9./,1,<B
emphlgus vulgarls: lnvolves mucosa and skln.
rlmary leslons are superflclal veslcles and bullae LhaL
rupLure easlly, leavlng eroslons covered wlLh serum crusL.
emphlgus vulgarls:
unlform deposlLlon of lmmunoglobulln and complemenL
along cell membranes of keraLlnocyLes - characLerlsLlc
flshneL appearance.
8ullous pemphlgold: Lense, fluld fllled bllsLers resulL from
vacuollsaLlon of basal layer, produclng subepldermal
bllsLers
8ullous pemphlgold: lgC anLlbody and C3 deLecLed by
dlrecL lmmunofluorescence as a llnear band ouLllnlng
subepldermal basemenL membrane zone
E(5.,1,<B
emphlgus vulgarls: suprabasal acanLholysls resulLs ln an
lnLraepldermal bllsLer conLalnlng rounded keraLlnocyLes
LhaL are separaLlng from Lhelr nelghbours
8ullous pemphlgold: subepldermal veslcle has an lnflammaLory lnfllLraLe rlch ln eoslnophlls
1PL uAnuLnCnC uCSSlL8 2010
238
!"#$ & '()*+, -*./)(
0)12.2,23. 456 /7*++212/*,23.+ 31 /3.82,23.
vlrLually all breasL carclnomas are adenocarclnomas
derlved from Lhe eplLhellal cells of Lhe ducLs or glands.
non-lnvaslve means LhaL Lhe mallgnanL cells are conflned
Lo elLher Lhe ducLs of Lhe aclnl of Lhe lobules, wlLh no
evldence of peneLraLlon of Lhe Lumour cells Lhrough Lhe
basemenL membranes.
!"#$%#&'(%&)
uucLal carclnoma ln slLu
Lobular carclnoma ln slLu
+#&'(%&)
lnfllLraLlng ducLal
lnfllLraLlng lobular
Muclnous
1ubular
Medullary
aplllary
CLhers
!9()*8 31 :()*+, /*(/2.3;*+
1. ulrecL spread - local lnfllLraLlon lnLo Lhe
underlylng muscles and Lhe overlylng skln
(ulceraLlon & LeLherlng).
2. LymphaLlcs - permeaLlon of lymphaLlc channels
- 'peau d' orange'. Axlllary lymph nodes
commonesL slLe. SenLlnel node removal -
lmporLanL ln sLaglng.
3. 8lood sLream - lrequenLly lnvolves Lhe lungs,
bones, llver, adrenals and braln.
<(3++ 9*,=373>?
1he Llssue seen comprlses faL and a cenLral area of poorly
clrcumscrlbed dense whlLe and focally cream Llssue LhaL
exLends lnLo Lhe palnLed surface. Some ad[acenL whlLe
Llssue exLends as sLreaks lnLo Lhe surroundlng faL.
@2+,373>?
Leslon ls composed of nesLed cells LhaL are lnfllLraLlng
lnLo Lhe surroundlng Llssue. Cells have a hlgh nuclear Lo
cyLoplasmlc raLlo and small nucleoll are seen. Cells are
pleomorphlc and Lhere ls a hlnL of gland formaLlon. no
mlLoslses are seen.
!"#$% '()*%"+," *-.$/"'0$1 2%*( /+1$
,%--).)#/ 0'1()( "- ' 2.)'(/ 3145
laL necrosls
Mammary ducL ecLasla
llbrocysLlc change
llbroadenomas
Llpoma
6."7#"(/%0 -'0/".( %# 2.)'(/ 0'.0%#"4'
1ype of carclnoma - Medullary, Muclnous and
1ubular behave less aggresslvely Lhan oLher
Lypes.
PlsLologlcal grade - 1umour cells glven a grade
vla 1nM. Crade 1 -good prognosls, Crade 3 -
worsL.
SLage - ManagemenL depends on Lhe sLage of
dlsease. Slgns of axlllary lymph node lnvolvemenL
- bad.
CesLrogen recepLors - presence wlLhln a
carclnoma lndlcaLes LhaL Lhe Lumour cells have a
hlgher degree of funcLlonal dlfferenLlaLlon.
(1amoxlfen -SL8M)
PL8-2 - oncogene - ampllflcaLlon leads Lo
overexpresslon of membrane-relaLed proLeln -
poorer prognosls. (PercepLln - monoclonal
anLlbody)
CrowLh klneLlcs - growLh acLlvlLy - low, medlum
or hlgh. noLe: 1umours wlLh a hlgh raLe of
dlvlslon may also have a hlgh cell deaLh raLe by
apopLosls.
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neumoconlosls ls an occupaLlonal lung dlsease and a resLrlcLlve lung dlsease caused by Lhe lnhalaLlon of dusL, ofLen ln
mlnes.
1ypes lnclude: asbesLosls, slllcosls, berylllosls (berylllum), coalworker's pneumoconlosls, arLhracosls (carbon).
#213+435.-+6+758#213+7('(.-.
!"#$"%&"'" - scarrlng/flbrosls of lung Llssue resulLlng from Lhe lnhalaLlon of asbesLos flbres. When asbesLos flbres are lnhaled,
Lhey deposlL aL alveolar ducL blfurcaLlons and cause an alveolar macrophage alveollLls. 1hese acLlvaLed macrophages release
cyLoklnes, such as Lumour necrosls facLor and lnLerleukln-1 and oxldanL specles, whlch lnlLlaLe a process of flbrosls.
(&)*+&,-$,." 01$23&4&1'&"'" - caused by coal/dusL parLlcles, approxlmaLely 2-3 m ln dlameLer, LhaL are reLalned ln Lhe
small alrways and alveoll of Lhe lung.
5'*'4&"'" - caused by Lhe lnhalaLlon of slllca (slllcon dloxlde) whlch ls parLlcularly Loxlc Lo alveolar macrophages and readlly
lnlLlaLes flbrogenesls.
9:+.. 4213+6+75
1here ls essenLlally no normal lung alLhough small resldual areas of red Llssue are seen beLween Lhe dense grey black
nodules. 1hese nodules are of varylng callbre buL are all less Lhan 10mm and show areas of coalescence. 1he nodules are
presenL ln all Lhe areas of Lhe lung seen and lnclude Lhe upper and lower lobes. 1here ls no spared area. Some resldual
vascular and bronchlole sLrucLures are evldenL, alLhough appearlng compressed. 1he pleural surface ls unremarkable.
;-.1+6+75
llbroblasLs produce collagen LhaL leads Lo flbrosls as Lhe collagen flbres accumulaLe. llbroblasLs are sLlmulaLed buL
flbrlnogenlc facLors (lCl) released by macrophages. CLher facLors sLlmulaLlng flbroblasLlc growLh lnclude plaLeleL derlved
growLh facLor (uCl), 1Cl and plasma flbronecLln. Macrophage release lCl followlng Lhe engulfmenL of Lhe lrrlLanL parLlcles,
ln Lhls case slllca.
1he plnk sLuff ls Lhe collagen. lL ls plnk because lL ls acldlc and acldlc Lhlngs are plnk uslng a sLandard PaemaLoxylln and Losln
sLalned secLlon. 1here ls a problem wlLh gas exchange lf Lhese collagenous nodules are replaclng and desLroylng Lhe gas
exchange poLenLlal over such a large proporLlon of Lhe lung. 1hls man's lung changes are parLlcularly florld and relaLlvely
acuLe. 1hls probably relaLes Lo Lhe amounL of exposure Lo slllca he recelved.
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lnfecLlous dlsease caused by sLralns of mycobacLerla,
usually mycobacLerlum Luberculosls, ln humans. lL
usually affecLs Lhe lungs, buL can affecL any oLher parL
of Lhe body. CharacLerlzed by caseaLlng granulomas.
#5.8/98:6,/4/;:1#5.8/;*-*6,6
lnlLlal exposure Lo mycobacLerlum resulLs ln
developmenL of an lmmune response LhaL
confers reslsLance buL also leads Lo
hypersenslLlvlLy (caseaLlng granulomas). Cu4 1-
cells have cruclal role ln cell-medlaLed lmmunlLy.
1hls ls prlmary 18. Secondary (reacLlvaLlon) 18
arlses ln prevlously exposed lndlvlduals when
lmmunosuppressed, usually manlfesLlng as
cavlLaLlng leslons ln lung aplces. rogresslve
prlmary 18 and secondary 18 can resulL ln
sysLemlc seedlng, causlng llfe-LhreaLenlng forms
such as mlllary 18 and Luberculous menlnglLls.
Plv ls a known rlsk facLor for recurrence of acLlve
18.
<=/66 95.8/4/;:
>,6./4/;:
CaseaLlng granulomas of 18 (due Lo Cu4 1
cell medlaLed hypersenslLlvlLy reacLlon)
Al8 sLalnlng
Mllllary 18 (showlng numerous Lan
granulomas)
CavlLaLlng aplcal leslons of reacLlvaLed 18
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Chon complex (plcLure shows calclfled rlghL nodule
wlLh assoclaLed calclfled hllar lymph nodes)
Chon focus: prlmary 18 leslon, appearlng as grey-
whlLe lnflammaLory area of consolldaLlon on Cx8
Chon complex: parenchymal leslon + nodal
lnvolvemenL
Cnce cell-medlaLed lmmunlLy conLrols Lhe
lnfecLlon, Lhe Chon complex undergoes
progresslve flbrosls, followed by radlographlcally
deLecLable calclflcaLlon (8anke complex).
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!"#$% ' !()*+ ,**-(./01 2+3/40 45 67+ 89)/0
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Leslons of varlous aeLlologles wlLhln Lhe cranlal vaulL
whlch dlsplace oLher sLrucLures ln Lhe CnS.
;+6/4<41.
Can be dlvlded lnLo Lhree maln causes
Abscess
rlmary Lumour
MeLasLaLlc Lumour
Along wlLh aneurysms, chronlc subdural
haemaLomas, granulomas, or cysLs.
#)674(7.3/4<41.=#)6741+0+3/3
;>3*+33 - a focal lnfecLlon of Lhe braln parenchyma,
lnvolvlng a necroLlc collecLlon of pus whlch ls
evenLually walled off by a vascularlsed capsule.
1here are 3 maln mechanlsms of bacLerlal enLry Lo
Lhe braln -
ulrecL - lnfecLlons sLemmlng from Lhe slnuses, LeeLh,
mlddle ear, or masLold galn access Lo Lhe venous
dralnage of Lhe braln vla valveless emlssary velns
LhaL draln Lhese reglons. PaemoLogenous - Seedlng
of Lhe braln occurs from dlsLanL lnfecLlon slLes and
ofLen resulLs ln mulLlple braln abscesses. lollowlng
peneLraLlve ln[ury or neurosurgery.
#9/?)9. 6-?4-9 Lhese can arlse from Lhe Menlnges
(menlgnlomas) as slow-growlng exLra-axlal benlgn
Lumours whlch rarely lnvade Lhe parenchyma.
Cllal cells (asLrocyLomas, schwannomas eg acousLlc
neuromas, glloblasLoma mulLlform eLc), lnLra-axlal
Lumours ranglng from benlgn Lo lncredlbly lnvaslve.
@+6)36)3+3 reach Lhe braln Lhrough haemogenous
spread, frequenLly from lung carclnoma, breasL
carclnoma, mallgnanL melanoma and colorecLal
cancer. 1hey are usually mulLlple, round and
slgnlflcanLly dlfferenL from Lhe surroundlng Llssue
@;!! ABBACD occurs as Lhe leslon enlarges wlLh shlfL
of Lhe hemlspheres, compresslon of venLrlcles Lhen
occurlng, flxed dllaLed puplls (due Lo 3Cn palsy)
followlng, cheynes-sLroke breaLhlng (due Lo
depresslon of resplraLory cenLres ln Lhe pons and
medulla), conlng and deaLh.
E9433 ()674<41.
Clloma of Lhe CnS demonsLraLlng mass effecL
A secLlon of Lhe braln demonsLraLlng lung meLs.
F/364<41.
1hls sllde ls of Lhe cerebral corLex as deflned by Lhe
presence of neurons whlch LransmlL messages from Lhe
cerebral corLex Lo oLher areas of Lhe braln or Lo splnal
cord
1hls shows whlLe maLLer whlch conLalns many myellnaLed
axons. 1he cells ln Lhe lmage are ollgodendrocyLes, whlch
have rounded regular small nuclel whlch slL aL regular
lnLervals wlLhln Lhe surroundlng neurophll. 1he maln
funcLlon of Lhe ollgodendrocyLe ls Lo form a myelln sheaLh
around ad[acenL axons. 1hls myelln sheaLh, as ln Lhe
perlphery, allows Lransmlsslon of Lhe message down Lhe
axon