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

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