Hyperthyroidism

Thyroid overactivity, thyrotoxicosis
> common condition
> commonly affect women, age between 20 - 40 years old
> common hyperthyroidism conditions: Graves' disease. toxic multinoduular goitre, toxic adenoma, de
                                                           Quervain's thyroiditis, postpartum thyroiditis
> Clinical features -
    Symptoms:
    - weight loss                    - muscle weakness       - itching                  
    - increased appetite         - stiffness                      - thirst                  
    - irritability                       - malaise                      - vomiting              
    - restlessness                   - choreoathetosis          - diarrhoea            
    - tremor                          - breathlessness             - eye complaints    
    - heat intolerance             - palpitation                  - goitre                  
    - oligoamenorrhoea         - loss of libido               - gynaecomastia
    - onycholysis                   - sweating                     - tall stature (in children)
   Signs:
    - tremor                                        - psychosis                                
    - hyperkinesia                               - systolic hypertension          
    - tachycardia or atrial fibrillation     - cardiac failure                  
    - full pulse                                     - conjunctival oedema        
    - warm peripheries                        - ophthalmoplegia              
    - exophthalmos                             - periorbital oedema
    - lid lag and 'stare'                         - weight loss
    - goitre, carotid bruit                     - proximal myopathy
    - onycholysis                                 - palmar erythema
    - Graves' dermopathy                    - Thyroid acropacity
    - pretibial myxoedema

> Investigations:
   - Serum TSH: low (< 0.05 mU/L)
   - Elevated free T4 and t3 hormones
   - Presence of microsomal and thyroglobulin antibodies in Graves' disease
   - Ultrasound: differentiate Graves' disease from toxic adenoma

> Management
1) Antithyroid drugs
     - carbimazole, methimazole
     - block thyroid biosynthesis
     - side effects: agranulocytosis
     - if toxicity occurs, propylthiouracil
2) Beta blockers
     -  to provide rapid symptomatic control
3) Radioactive iodide
     - Iodine - 131
     - contraindicated in pregnancy and in breast-feeding mother
     - accumulates in gland and results in irradiation and tissue damage
4) Surgery
     - subtotal thyroidectomy indicated in patients that rendered euthyroid
     - complications: bleeding, hypocalcemia, hypothyroidism, hypoparathyroidism, recurrent laryngeal nerve
        palsy, recurrent hyperthyroidism
     - indications: large goitre, drug side-effects, poor compliance, defaulted radioiodine, suspicion of
                         malignancy

Endometriosis

Definition: presence of normal endometrial mucosa abnormally implanted in locations other that the uterine cavity

Typical locations of endometriosis:
 - ovaries
 - fallopian tubes
 - vagina
 - cervix
 - uterosacral ligaments
 - rectovaginal septum

Pathophysiology:
- commonly located in the dependent portions of the female pelvis
- ectopic foci respond to cyclic hormonal fluctuations the same way as intrauterine endometrium (proliferation, secretory activity, and cyclic sloughing of menstrual material)
- products of metabolic activity, release of cytokines and prostaglandins, leading to an altered inflammatory response characterized by neovascularization and fibrosis formation

Risk Factors:
1) Family History of Endometriosis
2) Early age of menarche
3) Short menstrual cycles (<27d)
4) Long duration of menstrual flow (>7d)
5) Heavy bleeding during menses
6) Inverse relationship to parity
7) Delayed childbearing
8) Defects in the uterus or fallopian tubes
9) Hypoxia and iron deficiency may contribute to early onset of endometriosis

History:
1) one-third of the patients are asymptomatic
2) Symptoms:
       - secondary dysmenorrhoea,
       - metromenorrhagia,
       - pelvic pain,
       - lower abdominal/ back pain,
       - dyspareunia,
       - dyschezia often with cycles of diarrhoea and constipation,
       - bloating,
       - nausea,
       - vomiting,
       - inguinal pain,
       - dysuria,
       - increased frequency of urination,
       - pain during exercise

Physical Examination:
1) tenderness at sides of involvement
2) nonspecific pelvic tenderness
3) tenderness best detected during menses
4) acute abdomen in case of rupture of an ovarian endometrioma
5) involvement of GI tract may cause adhesions and obstructions
6) should also include evaluation for cervicitis, abnormal discharge, STDs

Differential Diagnoses:
1) Appendicitis,
2) Chlamydial GU infection
3) Diverticulitis
4) Ectopic pregnancy
5) Gonorrhoea
6) Ovarian cysts
7) Ovarian torsion
8) Pelvic inflammatory disease
9) UTI

Laboratory Studies:
1) Complete blood cell - differentiate pelvic infection from endometriosis
2) Urinalysis, urine culture -  to rule out UTI
3) Serum cancer antigen 125 (CA - 125) test - serial measurements useful as prognosticators of treatment outcome

Ultrasonography
1) transvaginal ultrasonography - endometriomas - internal echoes to solid masses
                                                - chocolate cyst - homogenous internal echoes consistent with old blood

Laparoscopy
- considered as primary diagnostic modality for endometriosis
- 97% sensitivity, 77% specificity
- protean in appearance
- classic lesions: blue-black or have a powder-burned appearance
- can be red, white, or nonpigmented
- peritoneal defects and adhesions are also indicative
- common sites: ovaries, posterior cul-de-sac, broad ligament, uterosacral ligament, rectosigmoid colon, bladder, distal ureter
- Histologic features: endometrial glands and stroma in biopsy specimens obtained from outside of uterine cavity. Finding of fibrosis in combination with hemosiderin-laden macrophages.

Treatment:

Medical
1) Progesterone: medroxyprogesterone acetate, norethindrone acetate, megestrol
              - induce decidualization and resorption of endometriosis
2) Combined contraceptive pill:
             - desogestrel and ethynil estradiol, norgestimate/ ethinyl estradiol
             - induces decidualization of ectopic endometrium
3) Danazol
             - steroid hormone closely related to testosterone, inhibits pituitary gonadotrophins
             - antioestrogenic, antiprogestational, androgenic and anabolic
4) Gonadotrophin releasing hormone analogues (GnRH analogue)
             - goserelin, leuprolide, nafarelin
             - depot injection or nasal spray
             - causing desensitization of Pituitary receptors, suppressing ovarian function, causing hypo-
                oestrogenism state and regression of endometrioid deposits

Surgical
1) radical surgery
              + total hysterectomy and bilateral oophorectomy indicated for women who has completed her
                 family
              + adhesiolysis is performed to restore mobility and normal intrapelvic organ relationships
2) conservative surgery:
              + reproductive potential is retained
              + using laparoscopic bipolar diarthermy or laser
              + recurrence 19%, relieving pelvic pain in 87% of patients
3) semiconservative surgery:
              + indicated for women who already completed family but too young for surgical menopause
              + hysterectomy and cytoreduction of pelvic endometriosis
              + ovarian function is retained

Atrial Fibrillation

- Characterized by an irregular and often rapid heartbeat

- strongly associated with heart failure, coronary artery disease, valvular heart disease, diabetes mellitus, hypertension

History:

 - 90% of AF are asymptomatic

 - wide range of symptoms: palpitations, dyspnoea, fatigue, dizziness, angina, decompensated heart failure

 - history should include: 

                  + type, duration and frequency of symptoms

                  + precipitating factors

                  + modes of termination

                  + documentation of prior use of anti-arrhythmics and rate-controlling agents

                  + presence of underlying heart disease

                  + history of any previous surgical or percutaneous AF ablation procedures

Physical examination:

 - Vital signs: irregularly irregular pulse, tachycardic

 - Head and neck: exophthalmos, thyromegaly, elevated jugular venous pressure, cyanosis, carotid artery bruits

 - Pulmonary: rales, pleural effusion, wheeze

 - Cardiac: displaced apex beat, prominent P2 points

 - Abdomen: ascites, hepatomegaly, hepatic capsular tenderness, splenic infarct

 - Lower extremities: cyanosis, clubbing, oedema, pulseless extremity

 - Neurologic: signs of transient ischaemic attack or cerebrovascular accident, increased reflex

Differential Diagnosis:

- Atrial flutter

- Atrial tachycardia

- Atrioventricular Nodal Reentry Tachycardia

- Multifocal Atrial Tachycardia

- Paroxysmal Supraventricular Tachycardia

- Wolff-Parkinson-White Syndrome

Investigation: 

1) Electrocardiography

    

                            - Rate irregularly irregular, 110-140 bpm

                            - No P waves

                            - Irregular baseline

                            - Normally shaped QRS complexes

                            - Lead V1 - no flat baseline between P waves

2) Laboratory studies

• Complete blood count - look for anaemia or infection
• Serum electrolyte and blood urea nitrogen/creatinine ratio - electrolyte disturbances or renal failure
• Cardiac enzymes - CK and/ or troponin level - investigate myocarcial infaction
• B-type Natriuretic Peptide - to evaluate congestive heart failure
• D-dimer - if the patient has risk factors for pulmonary embolism
• Thyroid function studies - to look for thyrotoxicosis
• Digoxin level - toxicity level

3) Echocardiography

• evaluate for valvular heart disease
• evaluate for left and right size
• evaluate for left ventricular size and function and left ventricular hypertrophy
• evaluate for pericardial disease

4) Computed Topography and Magnetic Resonance Imaging

• Chest CT angiography to rule out pulmonary embolism
• 3D imaging technique are helpful to evaluate atrial anatomy for intervention

5) Chest radiography

• evidence of congestive heart failure
• signs of lung pathology i.e. pulmonary embolism, pneumonia

6) Stress test - to rule out inschemia

Diagnostic Criteria for Manic Episode

DSM-IV-TR Diagnostic Criteria for Manic Episode

A) Distinct period of abnormality and persistently elevated, expansive, or irritable mood, lasting of least 1 week
B) During period of mood disturbance, three or more of the following symptoms have persisted and present to a certain degree
i - inflated self-esteem or grandiosity
ii - decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
iii - more talkative than usual or pressure to keep talking
iv - flight of ideas or subjective experience that thoughts are racing
v - distractibility
vi - increase in goal-directed activity or psychomotor agitation
vii - excessive involvement in pleasurable activities that have high potential for painful consequences
C) Symptoms do not meet criteria for mixed episode
D) Mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self to others, or there are psychotic features
E) Symptoms are not due to the direct physiologic effects of a substance or a general medical condition

Problems in Down Syndrome

Medical Problem

1. Newborn
1. cardiac defects: atrio-ventricular septal defect, ventricular septal defect, atrial septal defect, Tetralogy of Fallot, patent ductus arteriosus
2. gastrointestinal: duodenal atresia, pyloric stenosis, anorectal malformation, tracheo-oesophageal  fistula, and Hirshsprung disease
3. vision: congenital cataracts, glaucoma
4. hypotonia, joint laxity
5. Feeding problems
6. congenital hypothyroidism
7. congenital dislocation of the hips
2. Infancy and childhood
1. delayed developmental milestones
2. mild to moderate intellectual impairment
3. seizure disorder
4. recurrent respiratory infections
5. hearing loss 
6. visual impairment
7. sleep related upper airway obstruction
8. leukaemia
9. atlantoaxial instability
10. hypothyroidism
11. short stature
12. over/ underweight
3. Adolescence and adulthood
1. Puberty: in girls, menarche only slightly delayed. fertility presumed. in boys, usually infertile due to low testosterone levels
2. Increased risk of dementia and Alzheimer disease
3. Shorter life expectancy 

Schizophrenia

Kurt-Schneider Criteria
1) First-rank symptoms
- audible thoughts
- voices arguing or discussing or both
- voices commenting
- somatic passitivity experiences
- thought withdrawal and other experiences of influenced thought
- thought broadcasting
- delusional perceptions
- all other experiences involving volition made affects, and made impulses
2) Second-rank symptoms
- other disorders of perception
- sudden delusional ideas
- perplexity
- depressive and euphoric mood changes
- feelings of emotional impoverishment
- "....and several others as well"

DSM-IV-TR Diagnostic Criteria for Schizophenia
A) Characteristic symptoms: two or more of the following, each present for a significant portion of time during 1-month period:
    - delusions
    - hallucinations
    - disorganized speech
    - grossly disorganized or catatonic behaviour
    - negative symptoms: affective flattening, alogia, avolition
B) Social/ occupational dysfunction
    - major areas of functioning i.e. work, interpersonal relations, or self-care are markedly below the level achieved prior to onset
C) Duration: continuous signs of disturbances persist for at least 6 months.
D) Schizoaffective and mood disorder exclusion
E) Substance/ general medical condition exclusion
F) Relationship to a pervasive developmental disorder

Mental Status Examination

1) Appearance
+ Physical appearance - clothing, hygiene, posture, grooming
+ Behaviour - mannerism, tics, eye contact
+ Attitude - cooperative, hostile, guarded, seductive, apathetic

2) Speech
+ Rate - slow, average, rapid, pressured
+ Volume - soft, average, loud
+ Articulation - well articulated, lisp, stutter, mumbling
+ Tone - angry, pleading, etc

3) Mood

4) Affect
+ Quality - flat, blunted, constricted, full, intense
+ Motility - sluggish, supple, labile
+ Appropriateness

5) Thought process
+ loosening of associations
+ flight of ideas
+ neologisms
+ word salad
+ clang association
+ thought blocking
+ tangentiality
+ circumstantiality

6) Thought content
+ poverty of thought
+ overabundance
+ delusions
+ suicidal/ homicidal thoughts
+ phobias
+ obsessions
+ compulsions

7) Perception
+ hallucinations
+ illusions

8) Sensorium and cognition
+ conciousness - alert, drowsy, lethargic, stuporous, coma
+ orientation - place, person, time
+ calculation
+ memory - immediate, recent, recent past, remote
+ fund of knowledge
+ attention/ concentration
+ reading/ writing
+ abstract concepts

9) Insight

10) Judgement

DSM-IV-TR Diagnostic Criteria for Major Depressive Episode

A) Five or more following symptoms presented for at 2 weeks period and represent a change from previous functioning: at least depressed mood or loss of interest or pleasure

1 - depressed mood most of the day, almost every day
2 - diminished pleasure or interest markedly in all or almost activities,most of the day, almost every day
3 - significant weight loss without dieting or weight gain or decrease in appetite almost every day
4 - insomnia or hypersomnia almost every day
5 - psychomotor agitation or retardation
6 - fatigue or loss of energy almost every day
7 - feelings of worthlessness or excessive and inappropriate guilt
8 - diminished ability to think or concentrate, or indecisiveness, nearly every day
9 - Recurrent thoughts of death, recurrent suicidal ideation without plan, or a suicide attempt or a specific plan for commiting suicide

B) symptoms do not meet criteria for a mixed episode
C) symptoms causes clinically significant distress or impairment in social, occupational, or other important areas or functioning
D) symptoms are not due to direct physiologic effects of a substance or general medical condition
E) Symptoms are not better accounted for by bereavement, or symptoms persist longer than 2 months orone characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation

Psychiatric Glossary

• Affect: Observed external expression of emotion. A pattern of observable behaviour that is the expression of a subjectively experienced feeling state.
• Agitation: Excessive motor activity with a feeling of inner tension
• Agoraphobia: Literally a fear of the market place. It may include a fear of crowds, open and closed spaces and travelling by public transport.
• Alexithymia: Difficulty in being aware of or describing one’s emotion.
• Ambivalence: The simultaneous presence of opposing impulses towards the same thing.
• Amnesia:The inability to recall past experiences.
• Amoke: Seen in South-east Asia. There is an outburst of aggressive behaviour in which the patient runs amoke after a depressive episode.
• Anhedonia: loss of interest in, and withdrawal from, all regular and pleasurable activities.
• Apathy: Detachment or indifference and a loss of emotional tone
• Attention: The ability to focus on an activity
• Belle indifference: the patient shows a bland emotional indifference to one situation; emotion associated with an event is dissociated.
• Bereavement literally means the state of being deprived of someone by death; it can also result from other losses.
• Blunted affect: A reduction in emotional expression.
• Capgras syndrome: A person who is familiar to the patient is believed to be replaced by a double.
• Catatonia: It literally means extreme muscular tone or rigidity; however, it commonly describes any excessive or decreased motor activity that is apparently purposeless. Note that catatonic symptoms are not diagnostic of schizophrenia; they may also be caused by brain disease, metabolic abnormalities, and psychoactive substances and can also occur in mood disorders.
• Circumstantiality: Slowed thinking incorporating unnecessary trivial details. The goal of thought is finally, but slowly, reached.
• Clang association: Speech in which words are chosen because of their sounds rather than their meanings. It includes rhyming and punning.
• Clouding of consciousness: Drowsiness and not reacting completely to stimuli due to disturbance of attention, concentration and memory, orientation and thinking.
• Compulsions or compulsive rituals: Repetitive, stereotyped, seemingly purposeful behaviour associated with obsessional thoughts e.g. excessive repetition of checking, counting and cleaning rituals.
• Concentration: The ability to think about something carefully or for a long time: a process in which you put a lot of attention, energy etc into a particular activity.
• Concrete thinking: A lack of abstract thinking, normal in childhood, and occurring in adults with organic brain disease or schizophrenia.
• Confabulation: Gaps in memory are unconsciously filled up with false memories.
• Cotard’s syndrome: A nihilistic delusional disorder in which, for example, the patient believes their money, friends or body parts do not exist. Nihilism is extreme. Some patients may complain that their bowels have been destroyed so that they will never pass faeces again. Still others may believe that their whole family had ceased to exist and that they themselves are dead.
• Counter transference: the therapist’s emotions and attitudes to the patient.
• Couvade syndrome: A hysterical disorder in which a prospective father develops symptoms characteristic of pregnancy.
• Couture-bound syndromes: certain pattern of unusual behaviour, which may reflect psychological mechanism of dissociation, occurring in non-western countries.
• Delirium: a global impairment in consciousness with disorientation to time and place, which typically fluctuates. In which the patient is bewildered and restless with associated with fear and hallucinations.
• Delusion: A false and fixed personal belief firmly held out of proportion to his or her cultural and educational background. It is unshakable or affected by rational argument or evidence to contrary.
• Delusion of doubles: The delusional belief that a person known to the patient has been replaced by a double.
• Delusion of infidelity (morbid/pathological jealousy, delusional jealousy, Orthello syndrome): The delusional belief that one’ spouse or lover is being unfaithful.
• Delusion of reference: the behaviour of others, objects, and events, e.g. television broadcasts or TV personalities, is believed to refer to oneself in particular; when similar thoughts are held with less than delusional intensity they are ideas of reference.
• Delusional perception: A new and delusional significance is attached to a familiar real perception without any logical reason.
• Dementia: A global organic impairment of intellectual functioning without impairment of consciousness.
• Depersonalization: One feels that one altered or not real in some way; experience of detachment from self as if looking at him or herself from a mirror. Depersonalization and de-realization are variants of dissociation that are not necessarily pathological.
• De-realization: the term used to describe the experience when external reality or environment seems or unreal. Depersonalization and de-realization may be caused by psychiatric illness (e.g. depression, anxiety, schizophrenia) physical illness (e.g. epilepsy), psychosocial stress and substance abuse.
• Dissociation: The event where a disruption occurs in the usually integrated functions of consciousness, memory, identity, perception and movement. There is some evidence of psychological causation (stressful events or disturbed relationships)
• Distractibility: The attention is frequently drawn to irrelevant external stimuli.
• Dysphoria: An unpleasant mood.
• Dysthymia: A chronic depression of mood for more than two years which does not fulfill the criteria for recurrent depressive disorder. Most of the time the patient feel tired and depressed.
• Echolalia: The automatic imitation of another’s speech.
• Echopraxia: The automatic imitation of another’s movement.
• Ecstacy: A feeling of extreme happiness.
• Elevated mood: A mood more cheerful than normal.
• Erotomania: the delusional belief that another person is deeply in love with one.
• Euphoric mood: An exaggerated feeling of well-being. It is pathological.
• Expansive mood: Feelings are expressed without restraint.
• Extracampine hallucination: The hallucination occurs outside’s sensory field.
• Flat affect: There is no emotional expression at all and the patient typically has an immobile face and monotonous voice.
• Flight of ideas: The speech consists of a stream of accelerated thoughts and connected concepts, with abrupt changes from one topic to another with no central direction. The link between concepts can be as in normal communication where one idea follows directly on from the next; through a pun or clang association; or through some vague idea which is not part of the original goal of speech.. as patient becomes increasingly manic. Their associations tend to become loosen as they find it increasingly difficult to link their thoughts. Eventually they start approaching the incoherent thoughts of schizophrenic patient.
• Formal thought disorder: see loosening of association
• Formication: A somatic hallucination in which insects are felt to be crawling under one’s skin.
• Fregoli syndrome: The patient believes that a familiar person, who is often believed to be his persecutor, has take on different appearances.
• Fugue: A state of wandering from usual surroundings and loss of memory.
• Functional hallucination: This occurs when a normal sensory stimulus is required to precipitate a hallucination of the same sensory modality, e.g. voices that are only heard when the doorbell rings.
• Grief: The emotional expressions that accompany bereavement.
• Hallucination: A false sensory perception without real external stimuli.\
• Hallucinosis: Hallucinations (usually auditory) occur in clear consciousness e.g. in alcoholism.
• Hypnagogic hallucination: Pseudo-hallucination occurring in the process of falling asleep. It occurs in normal people.
• Hypnopompic hallucination: Pseudo-hallucination occurring while waking from sleep. It occurs in normal people.
• Hypochondriaisi: A preoccupation with a fear of having a serious physical illness, not based on real organic pathology.
• Ideas of reference: see delusion of reference.
• Illness behavior: Actions of people who see themselves as ill, for the purpose of defining their health status and finding a remedy.
• Illusion: A misperception of a real external stimulus.
• Inappropriate affect: An affect that is inappropriate to the circumstances, for example appearing cheerful immediately following the death of a loved one.
• Induced psychosis (folie a deux): folie a deux (pronounced as desk) is shared by two people who are closely related emotionally.
• Koro: Seen in south East Asia, particularly Malaysians of Chinese extraction. Affected men have an overwhelming fear that their penis is retracting into the abdomen and that death will then occur.
• Labile affect: the affect repeatedly and rapidly shifts.
• Latah: Seen in Fareast and North Africa. It is a hysterical state in which patients exhibit echolalia, echopraxia and automatic obedience.
• Made actions (made acts, made feelings, made impulses): The delusional belief that one’s free will has been removed and an external agency is controlling one’s actions, feelings and impulses.
• Loosening of associations (derailment): The patient’s train of thought shifts suddenly from one very loosely connected or unrelated ideas to the next. It reflects deterioration in the capacity to think formally or logically. Commonly the schizophrenic patient uses a private logic, with over personalised concrete symbols. Conceptual boundaries are blurred and thinking patterns are metaphorical and idiosyncratic. Thus, to the observer, when such thoughts are expressed, they appear on the surface to be diffuse or bizarre. Some psychiatrists use the term ‘formal thought disorder’ synonymously.
• Mannerisms: repeated involuntary movements that appear to be goal directed.
• Mood: A pervasive and sustained emotion that colours the person’s perception of the world.
• Mutism: total loss of speech
• Negativism: A motiveless resistance to commands and attempts to be moved.
• Neologism: A word newly made up, or an every day word used in a special way or a new meaning for the patient.
• Nihilistic delusion: The delusional belief that others, oneself, or the world do nor exist or are about to cease to exist.
• Obsessions: repetitive senseless intrusive and unwelcome thoughts, recognized by the patient as his own thoughts but as irrational or ridiculous which, at least initially are unsuccessfully resisted.
• Overvalued ideas: An unreasonable and sustained intense preoccupation with less delusional intensity.
• Para-suicide (deliberate self-harm): Any act deliberately undertaken by a patient who mimics the act of suicide, which does not results in a fatal outcome.
• Passing by the point: The answers to questions, though obviously wrong, show that the questions have been understood. It is seen in Ganser syndrome, first describe in criminals awaiting trials.
• Passivity phenomenon: the delusional belief that an external agency is controlling aspects of the self which are normally entirely under’ one’s own control (e.g. alienation of thought. Made feelings. Made impulses, made actions, somatic passivity)
• Perseveration (of speech and movement): Mental operations carry on beyond the point at which they are appropriate.
• Posturing: An inappropriate or bizarre bodily posture is adopted continuously over a long period.
• Poverty of speech: Very reduce speech, sometimes with monosyllabic answers to questions.
• Pressure of speech: Increased quantity and rate of speech, which is difficult to interrupt.
• Primary delusion: A delusion arising fully formed without any discernible connection with previous events. It may be preceded by a delusional mood in which there is awareness of something unusual and threatening occurring.
• Pseudo-dementia: Clinically similar to dementia, but has a non-organic cause e.g. depression.
• Schneiderian first-rank symptoms: In the absence of organic cerebral pathology the presence of any of Schneider’s first-rank symptoms is indicative of, though not pathognomonic of, schizophrenia.
• Selective inattention: Anxiety-provoking stimuli are blocked out.
• Sick-role behaviour: Activity by individuals who consider themselves as ill for the purpose of getting well.
• Somatic passivity: the delusional belief that one is a passive recipient of bodily sensations from an external agency.
• Somnambulism: Sleep walking.
• Somnolence: Abnormal drowsiness.
• Stereotypy: A repeated regularly fixed pattern of movement or speech that is not goal directed.
• Stupor: A clinical presentation of akinesis  (lack of voluntary movement), mutism and extreme unresponsiveness in an otherwise alert patient staring blankly and taking nothing in.
• Systematized delusion: A group of delusions united by a single theme or a delusion, with multiple elaborations.
• Tactile hallucinations: Superficial somatic hallucinations
• Talking past the point: The point of what is being said is never quite reached.
• Thought alienation: It includes thought  broadcasting, thought insertion and thought withdrawal
• Thought broadcasting (thought diffusion): The delusional belief that one’s thoughts are being read by others, as if they were broad cast.
• Thought insertion: The delusional belief that thoughts are being put into one’s mind by an external agency.
• Thought withdrawal: The delusional belief that thoughts are removed from one’s mind by an external agency.
• Thought blocking: A sudden interruption in the train of thought occurs, leaving a blank, after which what was said cannot be recalled.
• Trailing phenomenon: Moving objects are seen as a series of discrete discontinuous images. It is associated with hallucinogens.
• Transference: The unconscious process in which emotions and attitudes experienced in childhood are transferred to the therapist.
• Unit of alcohol: the mass of alcohol contained in a standard measure of spirits, in a standard glass of table wine, and in a pint of beer. It is around 8-10 g.
• Visceral hallucinations: Somatic hallucinations of deep sensations.
• Waxy flexibility: When the part of the body is moved it gives a feeling of plastic resistance as if bending a soft wax rod. The bodily part remains moulded in a new position.
• Windigo: Seen in north American Indian tribes with a depressive disorder in which patients believe they have mutated in to cannibalistic monsters.
• Word salad (schizophasia or speech confusion): The speech is an incoherent and incomprehensible mix of words and phrases.

Cholelithiasis

Cholelithiasis = Gallstones disease

Choledocholithiasis = stone in bile ducts

History of Presenting illness:

1. asymptomatic gallstones: no symptoms or complications
2. Biliary colic:
• gallstones impact in cystic duct during gallbladder contraction, increasing gallbladder tension
• pain relieve over 30-90 minutes
• sporadic and unpredictable pain
• pain localise at epigastrium/ right hypochondrium
• may radiate to right scapular tip
• pain not relieve by emesis, antacids, defecation, flatus or positional changes
• may be accompanied by diaphoresis, nause, vomiting, dyspepsia, bloating, fat intolerance

Physical Examination:

• uncomplicated biliary colic: no fever, pain poorly localized, no guarding or rebound tenderness
• acute cholecystitis: localized pain, with rebound or guarding. positive Murphy sign. Fever may be present
• severe cases: absent/ hypoactive bowel sounds
• Charcot triad: severe right upper quadrant tenderness + jaundice + fever = suggestive of ascending cholangitis

Pathophysiology:
- occurs because certain substances in bile are present in high concentrations that approach the limits of their solubility
- supersaturated bile will precipitate and forming microscopic crystals
- crystals trapped in gallbladder mucus, producing gallbladder sludge
- over time, the crystals grow, aggregate, and fuse to form macroscopic stones
- occlusions of the ducts by stones produces complications of gallstone diseases

Common gallstones:

Cholesterol gallstones

• 80% of the cases
• factors affecting cholesterol gallstones formation: 
• amount of cholesterol secreted by liver cells relative to lecithin and bile salts
• degree of concentration and extent of stasis of bile in gallbladder

Calcium, bilirubin, and pigment gallstones

• unconjugated bilirubin tends to form insoluble precipitates with calcium
• calcium enters bile passively along with other electrolytes
• calcium bilirubinate may then crystallize and form stones
• various oxidations cause bilirubin precipitates to take on jet-black colour
• bacteria hydrolyze conjugated bilirubin and resulting increase in unconjugated bilirubin which can precipitate formation of stones
• bacteria also hydrolyze lecithin to release fatty acids, which also may bind calcium and precipitate
• these stones have claylike consistency and termed brown pigment stones.

Mixed gallstones

• cholesterol gallstones may become colonized with bacteria and can elicit gallbladder mucosal inflammation
• enzymes from bacteria hydrolyze bilirubin conjugate and fatty acids
• cholesterol stones may accumulate substantial proportion of calcium bilirubinate and other calcium salts, producing mixed gallstones

Aetiology:

1. Cholesterol gallstones: associated with female sex, increasing age, obesity, pregnancy, gallbladder stasis, drugs, hereditary
2. Black and brown pigment gallstones
   • occur in person with high heme turnover i.e disorder of haemolysis
   • intraductal statis and chronic colonization of bacteria: predispose to brown pigment gallstones
3. Other comorbidities:

• Crohn disease, ileal resection, other diseases of ileum that decreases bile salt reabsorption
• predisposing condition to gallstones formation: burns, total parenteral nutrition, paralysis, ICU care, major trauma

Complications of gallbladder stones:

- acute cholecystitis due to persistent stone impaction

- gallbladder empyema due to colonization of bacteria and pus formation

- fibrosis of gallbladder wall: chronic cholecystitis

- gallbladder adenocarcinoma

- cholecystoenteric fistula

Complications of stones in common bile duct (choledocholithiasis):

- increased liver enzymes and jaundice

- ascending cholangitis

- acute pancreatitis: due to stone impaction in ampulla of Vater that obstruct pancreatic duct

- Other complications: Mirizzi syndrome (fusion of gallbladder to extrahepatic biliary tree), gallstone ileus


Differential diagnoses:

1. appendicitis
2. bile duct strictures
3. bile duct tumours
4. cholangiocarcinoma
5. cholecystitis
6. gallbladder cancer

Treatment:

Asymptomatic

• surgical treatment not recommended. higher risks of developing complications with interventions
• cholecystectomy indicated if: large gallstones (>2cm), non-functional or calcified gallbladder, spinal cord injuries/ sensory neuropathies, sickle cell anaemia
• elective cholecystectomy: cirrhosis, portal hypertension, children, transplant candidates, diabetes with minor symptoms 
• Medical Dissolution
• Ursodeoxycholic acid (ursodiol) - 
• gallstone dissolution agent
• reduces cholesterol saturation of bile
• reduce liver cholesterol secretion

Symptomatic

• Cholecystectomy
• removal of gallbladder
• indicated for patient with symptoms and complications
• Cholecystostomy
• placing of drainage tube in gallbladder
• results in clinical improvements
• Endoscopic sphincterotomy
• incision through sphincter of Oddi and intraduodenal portion of common bile duct, creating opening for stones to pass through

Prevention

• Ursodeoxycholic acid treatment can prevent gallstone formation

Short Note: Hypertension

Definition: Persistent elevation of systolic blood pressure of 140mmHg or greater and/or diastolic blood pressure of 90mmHg or more.

Classifications:

1)     Aetiological

a.     Primary Hypertension

b.     Secondary Hypertension

                                                    i.     Hyperaldosteronism (Conn’s syndrome)

                                                   ii.     Pheochromocytoma

                                                  iii.     Cushing’s syndrome

                                                 iv.     Hyperparathyroidism

                                                   v.     Hyper/hypothyroidism

                                                 vi.     Renal artery stenosis

                                                vii.     Chronic renal failure

                                               viii.     Drugs

                                                 ix.     Obstructive sleep apnoea

                                                   x.     Neurofibromatosis

2)     Blood pressure reading

a.     Optimal: systolic less than 120mmHg, diastolic less than 80mmHg

b.     Prehypertension: systolic 120-139mmHg and/or diastolic 80-89mmHg

c.      Stage 1 Hypertension: systolic 140-159mmHg and/or diastolic 90-99mmHg

d.     Stage 2 Hypertension: systolic 160-179mmHg and/or diastolic 100-109mmHg

e.     Stage 3 Hypertension: systolic ≥180mmHg, diastolic ≥110mmHg

Symptom of Hypertension: None

Sign of Hypertension: Elevated blood pressure

Cardiovascular risk factors:

a)     Hypertension
b)     Cigarette smoking
c)     Central obesity
      i)     Men: waist circumference >90 cm
      ii)   Women: waist circumference >80 cm
d)     Physical inactivity
e)     Dyslipidaemia
f)       Diabetes mellitus
g)     Microalbuminuria
h)     GFR <60 mL/min
i)       Age: men >55 years old, women >65 years old
j)       Family history of cardiovascular disease

History should include:

a)     Duration and level of elevated blood pressure
b)     Symptoms of secondary causes of hypertension
c)     Symptoms of target organ damage
d)   Symptoms of concomitant disease that affect prognosis of hypertension i.e. diabetes mellitus, gout, renal disease
e)     Family history of hypertension, heart diseases, stroke, diabetes, renal disease, dyslipidaemia
f)       Dietary history: salt, fat, caffeine and alcohol intake
g)     Drug history
h)     Lifestyle and environmental factors: smoking, physical inactivity, work stress, weight gain

Physical examination:
a)     Height, weight, waist circumference
b)     Two or more blood pressure measurements: each supine, seated, after standing for at least one minute
c)     Blood pressure of both arms
d)     Fundoscopy
e)     Carotid bruit, abdominal bruit, presence of peripheral pulses, radio-femoral delay
f)       Cardiac examination
g)     Examination for evidence of cardiac failure
h)     Abdominal examination: renal masses, aortic aneurysm, abdominal obesity
i)       Neurological examination to look for evidence of stroke
j)       Signs of endocrine diseases

Target organ damage or complication
a)     Cardiac: left ventricular hypertrophy (displaced apex beat), coronary heart disease, heart failure
b)     Cerebrovascular: transient ischaemic attack, stroke
c)     Peripheral vasculature: absence peripheral pulse, intermittent claudication
d)   Renal: chronic kidney disease (GFR <60ml/min, proteinuria, microalbuminuria 2 out of 3 positive tests
     over 4-6 months)
e)     Retinopathy: haemorrhages, exudates, papilloedema