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@About this App@Contributers@DeveloperACTH (Adrenocorticotropic hormone)AFP (Alpha-fetoprotein) TestingAIDS Dementia Complex (HIV)AIDS HIV InfectionAPGAR Scoring (Children)APTT and CoagulationAbacavirAbataceptAbbreviated Mental Test Score (AMTS)AbciximabAbdominal Aortic AneurysmAbdominal paracentesis for ascitesAbducent NerveAbetalipoproteinaemiaAbnormal Vaginal bleedingAcamprosateAcanthocytosisAcanthosis NigricansAcarboseAccelerated Idioventricular RhythmAcetazolamideAcetylcholine Receptor AntibodiesAcetylcholinesterase inhibitorsAchalasiaAchilles Tendon ruptureAchondroplasia (Children)AciclovirAcid maltase deficiency (Pompe disease)Acne RosaceaAcne VulgarisAcoustic Neuroma (Schwannoma)Acrodermatitis enteropathica (Children)Acromegaly and GiantismAcromio-clavicular jointActinomyces israeliAction PotentialActivated CharcoalActrapid (Insulin)Acute Abdominal Pain - Acute PeritonitisAcute Acalculous CholecystitisAcute Anaphylactoid ReactionsAcute AnaphylaxisAcute Angle Closure GlaucomaAcute AppendicitisAcute Bacterial MeningitisAcute BronchitisAcute CholangitisAcute CholecystitisAcute Colonic Pseudo-obstructionAcute Coronary Syndrome (ACS) GeneralAcute Coronary Syndrome (ACS) NSTEMI USAAcute Coronary Syndrome (ACS) STEMIAcute Coronary Syndrome (Cardiac Troponins)Acute Coronary Syndrome Grace scoreAcute DeliriumAcute Disc lesionsAcute Disseminated EncephalomyelitisAcute Diverticulitis - Diverticular diseaseAcute Dystonic ReactionAcute EncephalitisAcute Eosinophilic PneumoniaAcute EpiglottitisAcute Exacerbation of COPDAcute HepatitisAcute HydrocephalusAcute HypotensionAcute InflammationAcute Intermittent Porphyria (AIP)Acute Interstitial nephritisAcute Kidney Injury (AKI)Acute Limb IschaemiaAcute Liver FailureAcute Lymphoblastic Leukaemia (ALL)Acute MastoiditisAcute MonoarthritisAcute Myeloid Leukaemia (AML)Acute MyocarditisAcute PancreatitisAcute Pelvic Inflammatory DiseaseAcute PericarditisAcute Phase reactantsAcute PorphyriasAcute Promyelocytic LeukaemiaAcute Respiratory Distress Syndrome (Adults)Acute Retroviral Syndrome (HIV)Acute RhabdomyolysisAcute Rheumatic feverAcute Rotator cuff tearAcute Severe AsthmaAcute Severe ColitisAcute SinusitisAcute Stroke Assessment (ROSIER&NIHSS)Acute TonsilitisAcute Urinary RetentionAcute and Chronic GoutAcute and Chronic Heart FailureAcute on Chronic Liver Disease DecompensationAcutely Ill PatientAdalimumabAddenbrooke's Cognitive Examination-Revised (ACER)Addison Disease (Adrenal Insufficiency)AdefovirAdenosineAdenosine deaminase deficiencyAdhesive Capsulitis (Frozen Shoulder)Adjustment - Anxiety disordersAdrenal AntibodiesAdrenal PhysiologyAdrenaline (Epinephrine)AdrenoleukodystrophyAdrenomyeloneuropathyAdult Onset Still's DiseaseAfrican Trypanosomiasis (Sleeping sickness)Age related macular degenerationAicardi syndromeAir EmbolismAlbuminAlbumin-Protein Creatinine Ratio (PCR)Alcohol AbuseAlcohol Withdrawal (Delirium Tremens)Alcoholic (Steato)HepatitisAlcoholic KetoacidosisAldosterone PhysiologyAlendronate (Alendronic acid)AlfacalcidolAlkaline phosphatase (ALP)Alkalinisation of urineAlkaptonuriaAllergic Bronchopulmonary AspergillosisAllogeneic stem cell transplantationAllopurinolAlogliptin (Vipidia)AlopeciaAlpha FetoproteinAlpha ThalassaemiaAlpha subunit (ASU) of TSHAlpha-1 Antitrypsin (AAT) deficiencyAlport's SyndromeAlteplaseAltitude sicknessAluminium and Magnesium AntacidsAlveolar Gas EquationAlzheimer disease (Dementia)AmantadineAmenorrhoeaAmerican Trypanosomiasis (Chagas Disease)AmilorideAmino acidsAminoglycosidesAminophyllineAminosalicylatesAmiodaroneAmiodarone and Thyroid diseaseAmitriptylineAmlodipineAmmonia EncephalopathyAmnestic syndromesAmoebiasis (Entamoeba histolytica)AmoxicillinAmphetamine toxicityAmphotericin BAmpicillinAnaemia of Chronic DiseaseAnagrelideAnakinraAnal CancerAndexanet alfaAndrogen insensitivity syndromeAneurysmsAngina bullosa haemorrhagicaAngiodysplasiaAngiomyolipomaAngioneurotic OedemaAngiotensin Converting Enzyme InhibitorsAngiotensin Converting enzyme (ACE)Angular Stomatitis - CheilitisAnion GapAnkle and Foot fractures and InjuriesAnkle-Brachial pressure Index (ABPI)Ankylosing spondylitisAnorexia NervosaAntacid medicationAntepartum haemorrhageAnterior Horn Cell diseasesAnterior circulationAnti Dementia DrugsAnti-Cyclic Citrullinated Peptide (CCP) AntibodyAnti-D immunoglobulinAnti-Hu antibodiesAnti-OKT3 antibodiesAnti-RNP AntibodyAnti-Yo antibodiesAnti-neutrophilic cytoplasmic antibodies (ANCA)Antibiotics for Abdominal InfectionsAnticholinergic BurdenAnticholinergic syndromeAnticipationAnticoagulation and AntithromboticsAntidiuretic hormone (Vasopressin)Antigen presenting cellsAntimicrobial ChoicesAntimuscarinic drugsAntiphospholipid syndromeAntithrombin III deficiency (AT3)Aorta anatomyAortic DissectionAortic Regurgitation (Incompetence)Aortic SclerosisAortic StenosisAortoenteric fistulaApathetic thyrotoxicosisApixabanAplastic anaemiaApomorphineAppendix Cancer TumoursApproach to Assessing Sick ChildApproach to child with Acute GastroenteritisApproach to child with respiratory DistressArnold Chiari malformationArrhythmogenic Right ventricular CardiomyopathyArtemisininsArterial Blood gas analysisArterial Pulse assessmentArterial blood gas samplingArterial vs Venous vs Other Leg UlcersArteriovenous malformationsArtery of Percheron strokeArtery-to-artery embolic strokeArtesunateAsbestos Related Lung diseaseAscites Assessment and ManagementAspergillomaAspergillus fumigatusAspirinAspirin Salicylates toxicityAssessing Abdominal PainAssessing BreathlessnessAssessing Chest PainAssessing FallsAsteatotic eczemaAsthmaAstigmatismAstrocytomasAsystoleAtaxia TelangiectasiaAtazanavirAtenololAtherosclerosisAtopic Eczema or Atopic DermatitisAtorvastatinAtracuriumAtrial Ectopic beatsAtrial Fibrillation (Chemical cardioversion)Atrial Natriuretic Peptide (ANP)Atrial fibrillation (AF)Atrial flutterAtrial myxomaAtrial septal defect (ASD)Atrioventricular nodal reentrant tachycardiaAtropine SulfateAutoantibodiesAutoimmune Haemolytic anaemia (AIHA)Autoimmune HepatitisAutonomic neuropathyAutosomal DominantAutosomal Dominant Polycystic kidney diseaseAutosomal RecessiveAzathioprineAzithromycinB lymphocytesBRCA genes (Familial Breast Cancer)Bacillus anthracisBacillus cereus poisoningBackpain / BackacheBaclofenBacteriaBacteroides fragilisBalanitis (Adults)Balanitis (Children)Balkan endemic nephropathy (BEN)Balsalazide (Aminosalicylate)Barrett's oesophagusBartonellaBartters syndromeBasal Cell Carcinoma (BCC)Basic Fracture managementBasilar artery thrombosisBecker Muscular dystrophyBeclometasoneBeer PotomaniaBehavioural and Psychological Symptoms of DementiaBehcet's syndromeBell's palsyBendroflumethiazide (Bendrofluazide)Benign Paroxysmal Positional Vertigo (BPPV)Benign Prostatic HyperplasiaBenign recurrent intrahepatic cholestasisBenzodiazepine ToxicityBenzodiazepinesBenzylpenicillin Sodium (Penicillin G)Berg Balance ScaleBeriplexBerylliosisBeta AgonistsBeta Blocker toxicityBeta ThalassaemiaBeta-2 MicroglobulinBeta-lactamasesBetahistine (Serc)BezafibrateBiceps ruptureBilateral adrenalectomyBiliary atresiaBilirubinBiochemical Lab valuesBisacodylBisoprololBisphosphonatesBladder CancerBladder StonesBleedingBleeding disordersBleeding due to DrugsBleomycinBlindness - global causesBlood products - Packed cells blood transfusionBlood Products - CryoprecipitateBlood Products - Fresh Frozen PlasmaBlood Products - PlateletsBlood film interpretationBlood gas valuesBloody DiarrhoeaBlotting Techniques: Gel ElectrophoresisBone Marrow TransplantationBone disease Lab resultsBone metabolism RANK RANKL OPG pathwayBone scintigraphy (Bone scan)Bordetella pertussis - Whooping coughBorrelia burgdorferiBorrelia recurrentisBotulismBrachial neuritis (neuralgic amyotrophy)Brachial plexus anatomyBrachial plexus and associated injuryBrain AbscessBrain Anatomy and functionBrain MRIBrain Natriuretic Peptide (BNP)Brain PhysiologyBrain Tumours (Cancer)Brainstem anatomyBranchial cleft cystBreast CancerBreast FibroadenomaBretyliumBroad complex TachycardiaBromocriptineBronchial adenomaBronchiectasisBronchiolitisBronchoscopyBrown-Sequard syndromeBrucellaBrugada syndromeBudd-Chiari syndromeBudesonideBuerger disease (Thromboangiitis obliterans )Bulbar vs Pseudobulbar palsyBulimia NervosaBullous PemphigoidBumetanideBunionsBuprenorphineBupropionBurkholderia cepaciaBurkitt's lymphomaBurnsBusulphan (Busulfan)ByssinosisC reactive protein (CRP)CADASILCARASILCHADS2 - CHA2DS2-VASc scoreCMV retinitisCNS fungal InfectionsCNS infectionsCSF RhinorrhoeaCT Head Basics (Stroke)CT Pulmonary angiogram (CTPA)CT imaging basics for StrokeCURB 65 scoreCabergolineCaecal VolvulusCaisson Disease - Decompression sicknessCalcitoninCalcitriol (1,25 Dihydroxycholecalciferol)Calcium Chloride or GluconateCalcium PhysiologyCalcium Pyrophosphate Deposition (Pseudogout)Calcium ResoniumCalcium channel blockers toxicityCalot's triangleCampylobacterCancer of Unknown PrimarCandesartanCandidiasisCannabis toxicityCapecitabineCapnocytophaga canimorsusCapnographyCapreomycinCaptopriCarbamazepineCarbapenemase-producing EnterobacteriaceaeCarbimazoleCarbon monoxide poisoningCarcinoembryonic antigen (CEA)Carcinoid Heart DiseaseCarcinoid Tumour SyndromeCarcinoma of the Bile DuctCarcinoma of the GallbladderCardiac Amyloid heart diseaseCardiac Anatomy and PhysiologyCardiac Catheter ablationCardiac InfectionsCardiac MRICardiac Resynchronisation Therapy (CRT) PacemakerCardiac Valve replacementCardioembolic strokeCardiogenic Pulmonary OedemaCardiogenic shockCardiology - History TakingCardiology Exam ListCardiology ExaminationCardiology Valves SummaryCardiopulmonary bypassCarmustineCarotid Artery anatomyCarotid Body TumourCarotid EndarterectomyCarotid Sinus SyncopeCarotid StentingCarotid artery DissectionCarotid sinus massageCarpal tunnel syndromeCarvedilolCase 01 Sudden weaknessCase 02 Loss of speechCase 03 Adult male weak legsCase 04 High calciumCase 05 High Potassium and heart failureCase 06 High calcium and weight lossCase 07 Weak eyesCase 08 Weak faceCase 09 A cause of DeliriumCase 10 Older patient presenting post strokeCase 11 Young patient with acute headacheCase 20 Young patient with acute headacheCase 21 HypoglycaemiaCase 22Case 23 Old man with tremorCase 24 Cancer and weakCase 99 (Acute breathlessness)Case TemplateCat Scratch DiseaseCataractCatheter Related Urinary Tract infection UTICatheter related Blood stream infectionCatheter related UTICauda equina syndromeCaudate NucleusCauses of Airway ObstructionCauses of Avascular Necrosis of Femoral headCauses of Sore throatCauses of WeaknessCavernous angiomas (Cavernomas)Cavernous sinusCavernous sinus thrombosisCefaclorCefalexinCefotaximeCeftazidimeCeftriaxoneCefuroximeCelecoxibCell Response to InjuryCellular Anatomy and PhysiologyCellulitisCentral Cord SyndromeCentral Retinal Vein Occlusion (CRVO)Central Retinal artery Occlusion (CRAO)Central Venous line InsertionCentral pontine myelinolysisCephalosporinsCerebellar Anatomy Physiology Signs DiseaseCerebellar HaemorrhageCerebellar StrokeCerebral Amyloid angiopathy (CAA)Cerebral AneurysmsCerebral AngiitisCerebral Atrophy vs HydrocephalusCerebral CortexCerebral MetastasesCerebral PalsyCerebral PerfusionCerebral Salt WastingCerebral Venous Sinus thrombosisCerebral arteritisCerebral microbleedsCervical Cancer screeningCervical Spine injuryCervical cancerCervical spondylosisCetirizineChancroidCharcot Foot Syndrome (CFS)Charcot Marie Tooth (CMT) diseaseChediak Higashi syndromeChest Abdomen anatomyChest X Ray #1Chest X Ray InterpretationChest drain InsertionChlamydia - Chlamydophila pneumoniaeChlamydia psittaciChlamydia trachomatisChlorambucilChloramphenicolChlordiazepoxideChloroquineChlorphenamine(Chlorpheniramine)ChlorpromazineCholangiocarcinomaCholera (Vibrio cholera)Cholestatic JaundiceCholesteatomaCholesterol - LipidsCholinergic crisis-syndromeChondrocalcinosisChorea - BallismusChoreoacanthocytosisChromosome instability syndromesChronic BronchitisChronic HepatitisChronic InflammationChronic Inflammatory Demyelinating polyneuropathyChronic Interstitial NephritisChronic Kidney Disease (CKD)Chronic Lymphocytic leukaemia (CLL)Chronic Myeloid Leukaemia (CML)Chronic Obstructive Pulmonary Disease (COPD)Chronic PancreatitisChronic PeritonitisChronic Radiation EnteritisChronic Urinary RetentionChronic Vision Uni-Bilateral loss (Blindness)Chronic and recurrent MeningitisChronic liver diseaseChronic mucocutaneous candidiasisChronic stable anginaChylomicronsCiclosporinCimetidineCinacalcetCiprofloxacinCirrhosisCisplatinCitalopramCladribineClarithromycinCleft lip or palateClindamycinClopidogrelClostridium botulinumClostridium difficileClostridium perfringensClostridium tetani - TetanusClotrimazole creamClotting pathwaysClozapineCo Careldopa (Sinemet)Co-Amoxiclav (Augmentin)Co-Beneldopa (Madopar)Co-codamolCo-trimoxazoleCoagulopathyCoal Worker's PneumoconiosisCoarctation of the Aorta (CoA aortopathy)Cocaine abuseCocaine induced chest painCocaine toxicityCoccidioidomycosisCodeineCoeliac diseaseCogan SyndromeColchicineCold Agglutinin Disease (CAD/AIHA)CollagenColloid cyst in the third ventricleColloidsColonic (Large bowel) ObstructionColonoscopyColorectal cancerColorectal polypsColposcopyComa managementCombined Oral contraceptive pill (COCP)Common Peroneal Nerve (CPN)Common variable immunodeficiencyComparing Rheumatoid and OsteoarthritisComplementComprehensive Geriatric Assessment (CGA)Confirming DeathCongenital Acyanotic Heart Disease (Children)Congenital Adrenal hyperplasiaCongenital Complete Heart BlockCongenital Cyanotic Heart Disease (Children)Congenital HypothyroidismCongenital Talipes Equinovarus - ClubfootConstipationConstrictive PericarditisContact allergic dermatitisContinuous Positive Airways Pressure (CPAP)Continuous ambulatory peritoneal dialysisContraceptionConus Medullaris syndromeCor PulmonaleCoronary artery bypass graft surgeryCoronavirus SARS-CoV-2 COVID 19Corticobasal degeneration (Dementia)Corticosteroid-related psychosisCorticosteroidsCorynebacterium diphtheriaeCotard delusionCoxiella BurnetiiCranial nerves and examinationCraniopharyngiomaCreatinine ClearanceCremation forms (UK)Creutzfeldt Jakob disease (Dementia)Crimean-Congo haemorrhagic feverCritical illness neuromuscular weaknessCrohn's diseaseCroupCryptococcus neoformans infectionsCryptogenic Fibrosing AlveolitisCryptogenic Organising Pneumonia (COP-BOOP)CryptosporidiosisCrysal arthritisCrystalloidsCushing diseaseCushing syndromeCutaneous LeishmaniasisCyanide toxicityCyanosis - Central and PeripheralCyclizineCyclo-oxygenase (COX) enzymesCyclophosphamideCycloserineCys leukotriene receptor antagonistsCystic FibrosisCystinosisCystinuriaCytokinesCytomegalovirus infectionsD DimerDNA and RNA short notesDNA replicationDabigatranDalteparinDandy Walker syndromeDantroleneDapagliflozinDarier's DiseaseDarunavirDeQuervain's thyroiditisDeath Certificates (UK)Deep brain stimulationDeep vein thrombosis (DVT)Dehydration PhysiologyDelayed Puberty CriteriaDemeclocyclineDementia with Lewy bodiesDementiasDemyelinating DiseasesDengue FeverDenosumab (Prolia)Dental AnatomyDentatorubral pallidoluysian atrophyDepressionDermatitis HerpetiformisDermatology termsDermatomesDermatomyositisDermoid cystsDesferrioxamineDesmopressin (DDAVP)Desogestrel (Progestogen Only Pill)Developmental Dislocation (Dysplasia) of the HipDevelopmental MilestonesDexamethasoneDiGeorge syndrome (thymic aplasia)Diabetes Insipidus (Cranial and Nephrogenic)Diabetes Mellitus Type 1Diabetes Mellitus Type 1 and DKA (children)Diabetes Mellitus Type 2Diabetes Mellitus in pregnancyDiabetes on the wardDiabetic Autonomic Neuropathy (DAN)Diabetic Ketoacidosis (DKA) AdultsDiabetic Ketoacidosis (DKA) with SGLT2 InhibitorsDiabetic NephropathyDiabetic RetinopathyDiabetic amyotrophyDiabetic footDiamond-Blackfan anaemiaDiamorphineDiaphragmatic disordersDiarrhoeaDiazepamDidanosine (ddI)DiethylstilbestrolDifferentials causes of Foot DropDifferentials of ABCDifferentials of Generalised lymphadenopathyDifferentials of Painful thighDifferentials of XXXDiffuse Oesophageal spasmDiffuse large B-cell lymphomaDiffusion CapacityDigoxinDigoxin ToxicityDihydrocodeineDilated cardiomyopathyDiltiazemDiphtheriaDipyridamoleDischarges against adviceDiscoid lupus erythematosus (DLE)Disease templateDiseases with associated cancersDislocation Sternoclaivcular jointDisopyramideDisseminated Intravascular Coagulation (DIC)Distributive ShockDisulfiram (Antabuse)DobutamineDog BitesDog Bites HandDominant R wave in V1DomperidoneDonepezil (Aricept)DonovanosisDopamine HydrochlorideDopamine agonistsDown's syndrome (Trisomy 21)DoxapramDoxazosin (Cardura)DoxepinDoxorubicin (Adriamycin)DoxycyclineDrivingDrowningDrug Induced Parkinson diseaseDrug Reaction Eosinophilia Systemic Symptoms DRESSDrug TemplateDrug Toxicity - clinical assessmentDrug Toxicity with Specific AntidotesDrug induced Lupus ErythematosusDrug induced liver diseaseDrugsDrugs ListDrugs to Avoid in Acute Renal failureDrugs to avoid ElderlyDrugs to avoid in Liver failureDry and Wet GangreneDual X-ray absorptiometry (DEXA)Duchenne muscular dystrophyDulaglutide GLP-1 agonistDuloxetineDuodenal Atresia (Children)Dupuytrens contractureDysenteryDysphagiaECG - Acute Coronary SyndromeECG - Acute ST Elevation Myocardial InfarctionECG - Atrial fibrillationECG - Atrial flutterECG - BasicsECG - Broad complex tachycardia (possible VT)ECG - Brugada syndromeECG - Causes of a Dominant R wave in V1ECG - Early Repolarisation vs STEMIECG - First degree AV BlockECG - Heart BlockECG - HyperkalaemiaECG - InterpretationECG - Ischaemic Heart DiseaseECG - Left Axis DeviationECG - Left Bundle Branch Block LBBBECG - Left Ventricular HypertrophyECG - Low Voltage ComplexesECG - Narrow complex tachycardiaECG - Normal appearanceECG - Pathological Q wavesECG - QT intervalECG - Right Axis DeviationECG - Right Bundle Branch Block RBBBECG - ST-T T waves changesECG - Supraventricular tachycardia ECG - The QRS complexECG - Tutorial from Queens UniversityECG - Ventricular fibrillationECG - Ventricular tachycardiaECG - Wolff Parkinson White syndrome (WPW)ECG - short PR intervalECG - sinus pauseECG - tall R wave V1ENT Exam - Assessing hearingENT infectionsEbola Virus DiseaseEbstein anomalyEchinocytesEchocardiogramEcstasy toxicityEctopia lentis (subluxation of the lens)Ectopic PregnancyEctropionEculizumabEdoxaban (Lixiana)Edward syndrome (trisomy 18 syndrome)Efavirenz (Sustiva) EFVEhlers-Danlos syndromesEhrlichiosisEikenella corrodensEisenmenger's syndrome (Children)Elbow fractures and InjuriesElectrical injuryEloquent brainEmergency DrugsEmphysemaEmpty sella syndromeEmtricitabine (Emtriva) FTCEnalaprilEnd of Life Care PrescribingEndocarditis and StrokeEndocrinology Lab valuesEndometrial (Uterine) CancerEndometriosisEndoscopic Retrograde Cholangiopancreatography XEndothelinsEnfuvirtideEnoxaparin Sodium (Clexane-Lovenox)EnoximoneEntacaponeEnterococciEnteropathic SpondyloarthritisEnzyme inducers and inhibitorsEosinophilic granulomatosis (Churg Strauss)EpendymomaEpidural HaematomaEpidural abscessEpilepsy - General ManagementEpilepsy - Idiopathic Generalised EpilepsyEpilepsy - Mesial temporal lobe epilepsyEpilepsy - Post TraumaticEpilepsy in PregnancyEpiscleritisEpistaxisEplerenoneEponymous brainstem strokesEpstein-Barr Virus infectionEquivalent doses of OpiatesErb PalsyErgocalciferol (Calciferol)Erlotinib (Tarceva)Erysipelothrix rhusiopathiaeErythema MultiformeErythema NodosumErythrocyte Sedimentation rate (ESR)ErythrocytesErythrodermic PsoriasisErythromycinEscherichia coliEscitalopramEsomeprazoleEssential Thrombocythaemia (ET)Essential TremorEtanerceptEthambutolEthanolEthanol toxicityEthylene glycol toxicityEtomidateEtravirine (intelence) ETREwing sarcomaExenatide (Byetta) GLP1 agonistExercise stress testExploding head syndromeExtradural haematomaExtrapyramidal symptomsExtrinsic Allergic alveolitis (Hypersensitivity)Eye infectionsEzetimibeFabry diseaseFacial NerveFacioscapulohumeral muscular dystrophyFactor V Leiden DeficiencyFaecal CalprotectinFahr syndromeFailure to thrive or Faltering growthFamilial Adenomatous polyposis (FAP)Familial AmyloidosisFamilial HypercholesterolaemiaFamilial Mediterranean Fever (FMF)Familial hypocalciuric hypercalcaemia (FHH)Family Tree (Pedigree)FamotidineFanconi AnaemiaFanconi SyndromeFat embolismFatigue - CausesFatty acidsFebrile seizuresFelodipine (Dihydropyridine)Femoral HerniaFemoral triangleFemur fractures and InuriesFentanyl - FentanilFerritinFerrous Fumarate - Gluconate - SulphateFetal Alcohol SyndromeFetal circulationFever - Pyrexia of unknown origin (FUO PUO)Fever in a travellerFibratesFibrinogenFibromuscular dysplasiaFibromyalgiaFidaxomicinFinasteride (5 alpha-reductase inhibitor)First SeizureFitz-Hugh Curtis SyndromeFlail ChestFlecainide AcetateFlexor sheath infection (flexor tenosynovitis)FlucloxacillinFluconazoleFlucytosineFludrocortisoneFluid balances statusFlumazenil (Annexate - Romazicon)FluoxetineFocal Segmental Glomerulosclerosis (FSGS)Foix-Alajouanine syndromeFolate (Folic) acidFolate deficiencyFolinic acid (Leucovorin)FomepizoleFondaparinuxFood borne diseaseFoscarnet SodiumFosfomycinFosphenytoinFoster Kennedy SyndromeFournier's gangreneFracture TemplateFractured ClavicleFractured Neck of FemurFractured Pubic RamusFractured ScapulaFractured Shaft FemurFractured Tibia and FibulaFractures Shaft HumerusFractures in ChildrenFractures of Upper humerusFragile X syndromeFrailtyFraser guidelines and Gillick CompetenceFree RadicalsFriedreich's AtaxiaFrontotemporal dementiaFull or Complete Blood Count (FBC CBC)FungiFurosemide (Frusemide)Fusidic acidFusobacteria - Tropical ulcerFusobacteriumG protein-coupled receptorsGP Emergency Drugs CarriedGabapentinGalactorrhoeaGalantamineGamete intra-fallopian tube transfer (GIFT)Gamma Glutamyl Transferase (GGT)Gamma hydroxy butyrate (GHB) toxicityGanciclovir - ValganciclovirGardner syndromeGardnerella vaginalisGas GangreneGastric (MALT) LymphomaGastric CancerGastric Outlet obstruction (pyloric stenosis)GastrinomaGastro Intestinal Stromal Tumours (GIST)Gastro-Oesophageal Reflux (Adult GORD)Gastro-Oesophgeal Reflux (Paediatrics GORD)GastroenteritisGastroenterology Exam ListsGastroenterology ExaminationGastroenterology HistoryGastroenterology assessment - JaundiceGastrointestinal anatomy and physiologyGastrointestinal perforationGastrostomy (PEG) tubesGaucher's diseaseGene componentsGenetic DiseasesGentamicinGiardiasisGilbert's syndromeGingival (Gum) hyperplasia-hypertrophyGitelman's syndromeGlasgow Blatchford ScoreGlasgow Coma scaleGlatiramer acetate (Copaxone)GlibenclamideGliclazideGlimepirideGlipizideGlobus PallidusGlomerulonephritisGlossitisGlucagonGlucagonomaGlucose 6 phosphate dehydrogenase deficiencyGlucose Tolerance TestGlutamateGlycated HaemoglobinGlyceryl Trinitrate (GTN)Glycogen storage diseasesGlycolysis_Krebs_Electron_Transport_ChainGlycopyrronium BromideGoitreGolfer's ElbowGolimumab (Simponi)Goodpasture's syndrome (Anti GBM disease)Goserelin (Zoladex)Gradenigo's syndromeGrades of RecommendationGram StainGranuloma annulareGranulomatosis with Polyangitis GPA (Wegener)Graves DiseaseGriseofulvinGrowth Hormone DeficiencyGuillain Barre SyndromeGum hypertrophyGuthrie test New Born blood spotGynaecological History TakingGynaecomastiaHAS-BLED scoreHIV and Post-Exposure Prophylaxis (PEP)HIV and Pre-exposure prophylaxisHIV associated nephropathy (HIVAN)HIV disease AssessmentHTLV-1 Associated myelopathyHaematemesisHaematology Examination - SplenomegalyHaematology Lab valuesHaematuria Mild to SevereHaemodialysisHaemoglobinsHaemolysisHaemolytic AnaemiaHaemolytic Uraemic syndromeHaemolytic disease of the newbornHaemophilia AHaemophilia BHaemophilus aegyptiusHaemophilus ducreyiHaemophilus influenzaeHaemophilus parainfluenzaeHaemopoiesisHaemorrhagic TransformationHaemorrhagic strokeHaemorrhoids (Piles)Hairy Cell LeukaemiaHairy LeukoplakiaHallervorden-Spatz disease (PKAN)HaloperidolHamman-Rich syndromeHand foot and mouth diseaseHand fractures and InjuriesHantavirus infectionsHartmann's solution (Ringer's lactate)Hartnup disease*Hashimoto's (Steroid responsive) EncephalopathyHashimoto's thyroiditisHbA1cHead (Brain) InjuryHead and Neck CancersHeadache - Analgesic overuseHeadache - Assessing Acute and SevereHeadache - Basilar MigraineHeadache - ClusterHeadache - Low CSF pressureHeadache - MigraineHeadache - TensionHeadaches - GeneralHearing aidsHeat StrokeHelicobacter pyloriHelvetica Spotted feverHemicraniectomyHenoch-Schonlein purpuraHeparin - GeneralHeparin - Low Molecular Weight HeparinHeparin - Unfractionated HeparinHeparin-induced thrombocytopenia (HIT)Hepatic EncephalopathyHepatitis AHepatitis BHepatitis CHepatitis DHepatitis EHepatocellular CarcinomaHepatorenal syndromesHereditary ElliptocytosisHereditary HaemochromatosisHereditary Haemorrhagic TelangiectasiaHereditary Spastic ParaparesisHereditary SpherocytosisHereditary angio-oedemaHereditary neuropathy with pressure palsiesHereditary non polyposis coli (Lynch syndrome)Herpes GestationisHerpes SimplexHerpes Simplex Encephalitis (HSV)Herpes VirusesHerpes Zoster Ophthalmicus (HZO) ShinglesHerpes simplex keratitis (HSK)Heyde syndromeHiatus herniaHiccups (Singultus)High Dose Dexamethasone Suppression TestHip pain in childrenHirschsprung disease (congenital megacolon)Hirsuitism XXXHistonesHistoplasmosisHodgkin LymphomaHolt-Oram syndromeHolter monitor (tape) 24-72 hHomocystinuriaHookwormHorner's syndromeHospital acquired Pneumonia (NICE 139)Human albumin solution (HAS)Human prion diseasesHumeral fractures and injuriesHunter's syndrome (MPS-2)Huntington ChoreaHurler's syndrome (MPS-1)Hydatid disease (Echinococcus)Hydatidiform moleHydralazineHydrocortisoneHydrogen BondsHydrops fetalisHydroxocobalaminHydroxocobalamin - Cyanocobalamin (B12)HydroxychloroquineHydroxyurea-HydroxycarbamideHyoscine (Buscopan)Hyper IgM syndromeHyperbaric Oxygen therapyHypercalcaemiaHyperglycaemic Hyperosmolar State (HHS)Hyperinsulinaemic-euglycemic therapy (HIET)HyperkalaemiaHyperkalaemic and Hypokalaemic Periodic ParalysisHypermagnesaemiaHypernatraemiaHyperphosphataemia (High phosphate)HyperprolactinaemiaHypersensitivity reactionsHypertensionHypertension in PregnancyHypertriglyceridaemia (HTG)Hypertrophic cardiomyopathy (HCM - HOCM)Hyperventilation SyndromeHyperviscosity syndromeHypocalcaemiaHypoglycaemiaHypogonadism (Female)Hypogonadism (male)HypokalaemiaHypokalaemic Periodic ParalysisHypomagnesaemiaHyponatraemiaHypoparathyroidismHypophosphataemia (Low phosphate)Hypopituitarism (Pituitary Failure)HypospadiasHypothermiaHypothyroidismHypovolaemic or Haemorrhagic ShockIL-12 receptor deficiencyIV ImmunoglobulinIbandronic acid (Bisphosphonate)IbuprofenIcatibantIdiopathic Intracranial hypertensionIdiopathic Parkinson diseaseIdiopathic Pulmonary FibrosisIgA Nephropathy (Berger's disease)Images - Spot diagosesImatinib mesylateImipenem (Primaxin) with CilastinImmune Reconstitution SyndromeImmune(Idiopathic) Thrombocytopenic Purpura (ITP)Immunoglobulin G4-related disease (IgG4-RD)ImpetigoImplantable cardioverter defibrillator (ICD)Impulse control disordersInclusion Body MyositisIncubation periodsIndapamideIndinavir (IND)Infection screening in Septic patientInfections and their Microbial causeInfectious MononucleosisInfective ConjunctivitisInfective EndocarditisInfertilityInfliximabInfluenzaInguinal HerniaInitial Trauma AssessmentInjury Severity Score (ISS)Insomnia - sleep issuesInsulinInsulinomaInterferon BetaIntermittent ClaudicationInternal CapsuleInternuclear OphthalmoplegiaInterpreting HaematinicsInterstitial KeratitisIntestinal obstruction (Children)Intra Aortic Balloon PumpIntraabdominal abscessIntracerebral Haemorrhage (ICH) ScoreIntracranial HypertensionXIntravenous Iron Replacement (Ferrous)Intraventricular haemorrhage (neonates)Intubation and Mechanical VentilationIntussusception (Adults)Intussusception (Children)Iodine deficiency GoitreIpratropium Bromide (Atrovent)IrbesartanIron SaltsIron deficiency AnaemiaIron toxicityIrritable bowel syndromeIschaemic ColitisIschaemic StrokeIschaemic heart diseaseIsoniazidIsoprenalineIsosorbide DinitrateIsosorbide mononitrateIsotretinoin (Accutane)Ispaghula Husk (Fybogel)IvabradineJansen DiseaseJanus kinase 2Jervell and Lange-Nielsen syndromeJob Syndrome (Hyper IgE syndrome)Jugular Venous Pressure (JVP)Junctional TachycardiaJuvenile DermatomyositisJuvenile Idiopathic arthritis (Stills Disease)Juvenile Myoclonic epilepsy (JME)Kallmann's syndromeKaposi sarcoma (KS)Karnofsky performance status scaleKawasaki diseaseKennedy SyndromeKeratoconusKernicterusKetamineKetoconazoleKlebsiella pneumoniaKlinefelter Syndrome (Children)Klumpke palsyKnee fractures and InjuriesKoebner phenomenonKugelberg Welander syndromeKwashiorkorL-Thyroxine (T4)Labetalol (Trandate)Labyrinthitis - Vestibular NeuronitisLactateLactate dehydrogenase (LDH)Lactic acidosisLactobacillus acidophilusLactose IntoleranceLactuloseLady Windermere syndromeLambert-Eaton syndrome (LEMS)Lamivudine (3TC)LamotrigineLangerhans Cell Histiocytosis XLansoprazoleLanthanumLateral Medullary SyndromeLaxativesLe Fort FracturesLead toxicityLeber hereditary optic neuropathy (LHON)LeflunomideLegal definition of BlindnessLegionella pneumophilaLeishmaniasis (Cutaenous and Visceral)Lemierre's syndromeLenalidomide (Revlimid)Length Dependent PolyneuropathyLennox-Gastaut syndromeLenticulostriate branch occlusionLeprosyLeptinLeptospira interrogansLeptospirosis (Weil's Disease) (Notifiable)Leriche syndrome (aortoiliac occlusive disease)Lesch-Nyhan syndrome (Children)LeukaemiaLeukaemias in GeneralLeukoariosisLeukocytoclastic vasculitisLeukotrienesLevetiracetam (Keppra)LevodopaLevomepromazineLevosimendanLi Fraumeni syndromeLichen PlanusLiddle's syndromeLidocaine(Lignocaine)Lightning strikeLimb girdle dystrophyLimbic EncephalitisLinagliptin (Trajenta)LinezolidLinkageLiothyronine Sodium L-Triodothyronine (T3)Lipid emulsion therapy - IntralipidLipid management [NICE 2014]LipoatrophyLipoprotein lipase deficiencyLiraglutide (Victoza)LisinoprilListerial MeningitisListeriosisLithiumLithium toxicityLivedo ReticularisLiver Anatomy PhysiologyLiver BiopsyLiver Function TestsLiver TransplantationLiver abscessLiver disease in PregnancyLocalisation of cortical functionLofepramineLong QT syndrome (LQTS) AcquiredLong QT syndrome (LQTS) CongenitalLong term Oxygen therapy (LTOT)Loop diureticsLooser's zonesLoperamideLopinavirLoratadineLorazepamLosartanLow Dose Dexamethasone Suppression TestLower Gastrointestinal BleedingLugol iodineLumbar puncture and CSF interpretationLumbrosacral radiculopathyLung AbscessLung CancerLung ComplianceLung EmpyemaLung TransplantLupus NephritisLupus VulgarisLyme diseaseLymphocytic HypophysitisLymphogranuloma Venereum (LGV)LyonizationLysosomal storage diseasesMCune Albright syndromeMELASMacrocytic anaemiaMacroglossiaMagnesium PhysiologyMagnesium Sulphate - SulfateMagnetic resonance cholangiopancreatographyMagnetic resonance imagingMajor Histocompatibility complexMalabsorption - small intestineMalaria (non falciparum)Malaria FalciparumMale InfertilityMale Urethral CatheterisationMale erectile dysfunctionMalignant AscitesMalignant Hyperpyrexia (Malignant Hyperthermia)Malignant HypertensionMalignant MelanomaMalignant pleural mesotheliomaMallet FingerMallory-Weiss TearMalnutrition Universal Screening ToolManiaMannitolMantle cell lymphomaMarantic EndocarditisMarasmusMaraviroc (Celsentri)Marfan syndromeMarginal Zone LymphomaMassive HaemoptysisMaturity Onset Diabetes of the Young (MODY)McArdles disease (type V)Measles (notifiable)MebeverineMeckel's diverticulumMeconiumMedian NerveMedical Mnemonics Basic SciencesMedical Mnemonics CardiologyMedical Mnemonics EndocrineMedical Mnemonics Mental HealthMedical Mnemonics MiscellaneousMedical Mnemonics NeurologyMedical ProceduresMedical TeethMedullary Sponge kidneyMedulloblastomaMefenamic acidMefloquine (Larium)Megaloblastic anaemiaMelatoninMelioidosisMemantine HydrochlorideMembranous GlomerulonephritisMenetrier diseaseMeniere diseaseMeningiomaMeningitis in the ImmunocompromisedMenopauseMenstrual cycleMental Capacity Act 2005Mental Health Act 1983Mental State ExaminationMercaptopurineMeropenemMesalazine (Aminosalicylate)Mesangiocapillary GlomerulonephritisMesenteric infarctionMetabolic Syndrome XMetabolic acidosisMetabolic alkalosisMetachromic leucodystrophyMetastatic AdenocarcinomaMetastatic bone diseaseMetforminMethaemoglobinaemiaMethanol ToxicityMethodoneMethods to reduce toxin absorptionMethotrexateMethylcelluloseMethylprednisoloneMetoclopramideMetolazoneMetoprololMetronidazole (Flagyl)Metyrapone (Metopirone)MiconazoleMicroangiopathic Haemolytic anaemiaMicrocytic anaemiaMicroscopic PolyangiitisMicroscopic colitisMicrostomiaMidazolamMiddle East Resp Syndrome (MERS) CoronavirusMidodrineMigraine Disability Assessment (MIDAS)Miller-Fisher syndromeMilwaukee shoulder syndromeMini Mental State Examination (MMSE)Minimal Change Disease GlomerulonephritisMinocyclineMinoxidilMirabegronMirizzi syndromeMirtazapineMiscarriageMisoprostolMitochondrial diseasesMitral Regurgitation (Incompetence)Mitral StenosisMitral Stenosis vs Regurgitation - DominanceMitral Valve prolapseMittleschmerzMixed Connective Tissue Disease (MCTD)Mobility aidsModified Duke Criteria for EndocarditisModified Oxford Handicap Scale (MOHS)Modified Rankin ScoreMolluscum contagiosumMonoclonal gammopathy of undetermined significanceMonocular loss of visionMonocytesMonosodium glutamate (MSG) syndromeMontelukastMontreal Cognitive Assessment (MOCA)Moraxella catarrhalisMorphine SulphateMosquito borne diseasesMotor Neuron Disease (MND-ALS)Moyamoya diseaseMucormycosisMultifocal Atrial TachycardiaMultifocal Motor Neuropathy with Conduction blockMultiple Antithrombotics AnticoagulantsMultiple Endocrine Neoplasia type 1 (MEN1)Multiple Endocrine Neoplasia type II (MEN2)Multiple MyelomaMultiple PregnancyMultiple Sclerosis (MS) DemyelinationMultiple System Atrophy (MSA)Mumps (Notifiable)Muscles of the Abdominal RegionMuscles of the BackMuscles of the Head and NeckMuscles of the Lower LimbMuscles of the Pelvis and PerineumMuscles of the Thoracic RegionMuscles of the Upper limbMyasthenia GravisMycobacterium TuberculosisMycophenolate mofetilMycoplasma pneumoniaeMycoplasmasMycosis Fungoides (Sezary Syndrome)Myelodysplastic syndrome (Myelodysplasia)MyelofibrosisMyelofibrosis vs CMLMyelopathyMyeloproliferative disordersMyobacterium avium Complex InfectionMyocardial perfusionMyoclonusMyotonic dystrophy - Dystropica myotonicaMyxoedema comaN-Acetylcysteine (Parvolex)NEWS Reacting to Low Oxygen SaturationsNICE Guidelines LinksNICE Trauma Guidance Summary 2016NSAID toxicityNaloxone (Narcan) Opiate antagonistNaproxenNarcolepsyNasal polypsNasogastric tube insertionNatalizumab (Tysabri)National Early Warning Score NEWS 2 ScoreNeck PainNeck swellings and lumpsNecrotising Enterocolitis (Infants)Necrotising fasciitisNeedlestick injuryNefopamNeisseria gonorrhoeaeNeisseria meningitidisNelson SyndromeNeomycinNeonatal Abstinence Syndrome NASNeonatal JaundiceNeonatal Lupus ErythematosusNeonatal meningitisNeostigmineNephritic syndromeNephroblastoma (Wilm's tumour)Nephrotic syndromeNephrotoxic drugsNerve conduction studiesNerve fibresNeuroanatomy 101Neuroanatomy imagesNeuroblastomaNeurocysticercosisNeuroferrinopathyNeurofibromatosis Type 1Neurofibromatosis Type 2Neuroleptic Malignant SyndromeNeurological - Relative Afferent pupillary defectNeurological - Vision and Eye movementsNeurological Examination - CognitionNeurological Examination - Cortical FunctionsNeurological Examination - MotorNeurological Examination - SensoryNeurological Examination - Speech&LanguageNeurological ListsNeurological assessment - PtosisNeurological examination - EyesNeurological or ENT Examination - NystagmusNeurology - History takingNeurology Exam - Reflex findingsNeuromyelitis optica*Neuropathic Pain ManagementNeurotransmittersNeutropeniaNeutropenic SepsisNeutrophil Alkaline PhosphataseNeutrophilsNevirapine (Viramune) NEV-NVPNiacin deficiency (Pellagra Vitamin B6)Nicardipine (Cardene)NicorandilNiemann-Pick diseaseNifedipineNimodipine (Nimotop)Nitric OxideNitrofurantoinNitrous oxideNizatidineNocardiaNoise induced hearing lossNon Alcoholic Fatty Liver Disease NAFLDNon Convulsive Status EpilepticusNon Hodgkin LymphomaNon alcoholic steatohepatitis (NASH)Non gonococcal urethritisNon invasive ventilation (NIV)Non steroidal anti inflammatory drugs (NSAIDs)Non sustained Ventricular tachycardiaNoonan syndromeNoradrenalineNormal DistributionNormal Pressure HydrocephalusNormal Saline 0.9%Normocytic anaemiaNortriptylineNosocomial infectionsNotifiable disease and organisms UKNutrition in Infants BreatsfeedingNystatinOSCE - Administer IV InjectionOSCE - Blood cultureOSCE - VenepunctureOSCE - Venous Cannula InsertionObsessive-Compulsive disorderObstetric definitionsObstructive ShockObstructive Sleep ApnoeaOctreotideOculomotor Nerve (IIIrd Cranial Nerve)OedemaOesophageal CarcinomaOesophageal Perforation - RuptureOesophageal Variceal BleedingOesophagogastroduodenoscopyOlanzapineOlfactory Nerve (I)OligodendrogliomaOlmersartanOlsalazine (Aminosalicylate)OmalizumabOmeprazoleOnchocerciasisOncogenic virusesOncological emergenciesOndansetronOne Table TemplateOphthalmology Exam ListsOpiate ToxicityOpiatesOpicaponeOpioid toxicityOptic Neuritis-NeuropathyOptic atrophyOptic tract anatomyOral Aphthous UlcersOral CandidiasisOral LeukoplakiaOrbital vs Preorbital CellulitisOrganism and sensitivitiesOrganophosphate (OP) PoisoningOrphenadrineOrthopaedic infectionsOrthostatic - Postural hypotensionOscillopsiaOseltamivir - TamifluOsteoarthritisOsteogenesis ImperfectaOsteogenic sarcoma (Osteosarcoma)Osteomalacia-Rickets-Vitamin DOsteomyelitisOsteonecrosis of the jawOsteopetrosisOsteoporosisOtitis Externa (Malignant)Otitis MediaOtosclerosisOttawa rules for ankle and foot x-rayOvarian CancerOvarian CystOvaryOxford community stroke project (Bamford)Oxybutynin (Ditropan)Oxycodone (Oxycontin-Oxynorm)Oxygen delivery devicesOxytetracyclinePEDIS Score for Diabetic Foot UlcersPOEMS syndromePabrinexPacemaker DDDPacemaker VVIPacemaker syndromePacemakersPacing - Indications for temporary pacingPaediatric emergenciesPaediatricsPaget's (Bone) diseasePain ManagementPainful Shoulder syndromesPalliatiion - Nausea Dyspnoea Secretions PainPalliation prescribingPalpitationsPamidronate (Bisphosphonate)Pancoast tumour (Cancer)Pancreatic CancerPanton-Valentine leucocidin toxinPantoprazolePapilloedemaParacetamol (Acetaminophen)Paracetamol toxicityParadoxical embolisationParaneoplastic Encephalitis with NMDA antibodiesParaneoplastic Limbic Encephalitis (Dementia)Paraneoplastic cerebellar degenerationParaphimosisParaquat toxicityParkinson Plus syndromesParkinsonismParonychiaParoxetineParoxysmal Nocturnal HaemoglobinuriaParvovirus (Erythrovirus 19) B19 infectionPasteurella multocidaPatau syndrome (trisomy 13)Patent Ductus arteriosus (PDA) (Children)Patent Foramen Ovale (PFO)Pathogen - pattern recognition receptorsPathological bone fracturePegvisomantPelvic fracturesPemphigus VulgarisPenetrating Abdominal TraumaPenetrating Thoracic TraumaPenicillaminePenicillinsPenile CancerPeptic ulcer diseasePercutaenous Coronary Intervention (PCI ACS)PergolidePericardial Effusion_TamponadePerimesencephalic Subarachnoid haemorrhagePerindoprilPerinephric abscessPerioperative AnticoagulationPeripartum cardiomyopathyPeripheral Arterial Disease (PAD)Peripheral Cannula InsertionPeripheral Nerve Palsies*Peripheral neuropathyPeripherally inserted central cathetersPernicious anaemiaPerthes disease (Osteochondritis of the Hip)PethidinePeutz-Jeghers syndromePhaeochromocytomaPhagocytesPharmacokinetic notesPharmacokineticsPharyngeal arch derivativesPhenobarbital sodiumPhenoxymethylpenicillin (Penicillin V)PhentolaminePhenylketonuria (PKU)Phenytoin (Dilantin)Philadelphia chromosomePhimosisPhobic disordersPhocomelia and ThalidomidePhosphorusPhysiology of visionPicolax - CitrafleetPilonidal Abscess (sinus)Pioglitazone (Thiazolidinediones)Pituitary AdenomaPituitary Anatomy and PhysiologyPituitary ApoplexyPityriasis or Tinea versicolor infectionsPityriasis roseaPivmecillinam (a penicillin antibiotic)Placenta praeviaPlacental abruptionPlantar fasciitisPlasmacytomaPlasmapharesisPlasmidsPleural effusionPleural tap (thoracentesis)Pneumococcal meningititisPneumoconiosisPneumocystis jirovecii pneumoniaPneumoniaPneumothoraxPoisons eliminated Haemodialysis - perfusionPoliomyelitisPolyarteritis nodosa (PAN)Polyarticular arthritisPolycystic Ovary syndromePolycythaemia Vera (primary polycythaemia)Polymerase chain reactionPolymorphic light eruptionPolymyalgia RheumaticaPolymyositisPolypharmacy Start CriteriaPolypharmacy Stop CriteriaPolyuriaPontine-Midbrain haemorrhagePorphyria Cutanea Tarda (PCT)Porphyria TestingPortal HypertensionPositron Emission TomographyPost Menopausal BleedingPost Operative ManagementPost Partum ThyroiditisPost Polio SyndromePost SplenectomyPost Streptococcal/Infectious GlomerulonephritisPost Stroke Epilepsy (PSE)Post traumatic stress disorderPost-exposure prophylaxis with ImmunoglobulinsPosterior Reversible Encephalopathy Syndrome (PRESPosterior circulationPostpartum haemorrhagePotassium PhysiologyPralidoximePramipexole (Mirapexin)PrasugrelPravastatinPraxbind - IdarucizumabPraziquantelPrazosinPre-Operative AssessmentPreEclampsia, Eclapsmia and HELLPPrednisolonePrednisonePregabalinPremature LabourPremature MenopausePresbyacusisPrescribing InformationPrescribing in PregnancyPressure soresPrevotella (Bacteroides) melaninogenicaPriapismPrimaquinePrimary (Chronic simple) Open angle GlaucomaPrimary Biliary CirrhosisPrimary CNS LymphomaPrimary HyperparathyroidismPrimary Sclerosing CholangitisPrimary ciliary dyskinesiaPrimary hyperaldosteronism (Conn's syndrome)Primary progressive aphasia (Dementia)ProbenicidProchlorperazine (Stemetil)ProcyclidineProgressive Multifocal Leukoencephalopathy (PML)Progressive Supranuclear Palsy (PSP)ProlactinomaPropafenonePropanthelinePropionibacteriumPropofolPropranololPropylthiouracilProstate cancerProsthetic ValvesProtamine SulfateProtein C DeficiencyProtein S DeficiencyProtein losing enteropathyProtein p53Protein synthesisProteusProthrombin 20210A mutationProthrombin Complex Concentrates (PCC)Prothrombin time and CoagulationProthrombotic disordersProton Pump InhibitorsProximal myopathyPrucalopridePsammoma bodiesPseudohypoparathyroidismPseudomonas infection (Pseudomonas aeruginosa)Psoas AbscessPsoriasisPsoriatic arthritisPsychogenic PolydipsiaPubic Lice (Pediculosis Pubis)Pulmonary Alveolar ProteinosisPulmonary Arteriovenous malformationPulmonary EmbolismPulmonary Eosinophilia and CXR changesPulmonary HypertensionPulmonary Hypertension - PrimaryPulmonary RegurgitationPulmonary StenosisPulmonary hypertension - SecondaryPulse oximetryPutamenPutaminal HaemorrhagePyloric stenosis (Children)Pyoderma gangrenosumPyonephrosisPyrazinamidePyridostigminePyruvate Kinase deficiencyQuetiapineQuinineQuinine toxicityRabiesRadial PulseRadial nerveRadiation exposureRadioactive iodine (I 131)Radiofrequency Catheter AblationRadius and Ulna fractures and InjuriesRaloxifeneRaltegravirRamiprilRamsay Hunt syndromeRanitidineRanolazineRapid sequence intubation (RSI)Rapidly Progressive GlomerulonephritisRasagilineRasburicaseRaynaud's PhenomenonReactive arthritisRectal ProlapseRed cell aplasiaRed eyeRefeeding syndromeReferring to Level 2 or 3 care (ITU ICU HDU)Refractive ErrorsRefsum's diseaseRelapsing polychondritisRemdesvir (Veklury)Renal Artery StenosisRenal Papillary NecrosisRenal Physiology IRenal Stones (Nephrolithiasis)Renal TransplantationRenal Tubular AcidosisRenal Vein ThrombosisRenal cell carcinomaRenal physiologyRenin and Aldosterone Renin ratio (ARR)Renin-angiotensin systemRespiratory (Chest) infections and pneumoniaRespiratory - History TakingRespiratory AcidosisRespiratory AlkalosisRespiratory Anatomy and PhysiologyRespiratory Disease InvestigationsRespiratory Distress Syndrome (Neonates)Respiratory ExaminationRespiratory Examination - Finger ClubbingRespiratory Failure (hypoxia-hypercarbia)Resting membrane potentialRestless legs syndromeRestriction enzymesRestrictive CardiomyopathyResuscitation - Adult Bradycardia AlgorithmResuscitation - Adult Tachycardia AlgorithmResuscitation - Advanced Life SupportResuscitation - Basic Life Support ABCDEResuscitation - Choking AlgorithmResuscitation - Post Resuscitation AlgorithmReteplaseReticulocytesRetinal detachmentRetinitis pigmentosaRetinoblastomaRetinoidsRetroperitoneal fibrosisRett SyndromeReversible cerebral vasoconstriction syndromeReye syndromeRhesus haemolytic diseaseRheumatoid arthritisRheumatology AutoantibodiesRheumatology Lab valuesRhodococcus equiRibavirinRicin ToxicityRickettsia (General Principles)Rickettsia africae (Tick Bite Fever)Rickettsia akariRickettsia conorii (Tick Bite Fever)Rickettsia prowazekiiRickettsia rickettsiiRickettsia tsutsugamushiRickettsia typhiRifampicin (Rifabutin Rifampin)RifaximinRilipivirine (Edurant) RVPRiluzole (Rilutek)Risedronate (Bisphosphonate)RisperidoneRitonavir (Norvir) RTVRituximab (Mabthera)Rivaroxaban (Xarelto)Rivastigmine (Exelon)Rocky Mountain Spotted FeverRocuroniumRotigotineRubella (German Measles) NotifiableSCL70 AntibodySMASH U Intracerebral Haemorrhage ClassificationSOCRATES mnemonicST segment changesSacubitril with ValsartanSalivary Gland DiseaseSalivary glandsSalmonella entericaSalmonella typhiSaquinivir (Invirase) SQVSarcoidosisSaxagliptin (Onglyza)ScabiesScarlet Fever (Scarlatina)SchistosomiasisSchizophreniaSchmidt's syndromeSciaticaSeborrheic DermatitisSecondary Brain TumoursSecondary MessengersSecondary dysmenorrhoeaSecondary hyperparathyroidismSedation and Analgesia on ITUSelective IgA deficiencySelective Serotonin reuptake Inhibitor toxicitySelective serotonin reuptake inhibitors (SSRI)SelegilineSelenium deficiencySennaSeptic Shock and Sepsis 3Septic arthritisSepticaemiaSeronegative SpondyloarthropathiesSerotonin syndromeSerratiaSevelamerSevere combined immunodeficiency disordersSex Linked RecessiveSheehan's syndromeShigella characteristicsShigellosis (Bacillary Dysentery)Shock (General Assessment)Short Synacthen test (SST)Short and Tall stature Growth in ChildrenShoulder dislocationsSick Euthyroid SyndromeSickle Cell DiseaseSideroblastic AnaemiaSigmoid VolvulusSildenafil (Viagra)SilicosisSilver Trauma - Age over 65SimvastatinSinus BradycardiaSinus Node diseaseSinus TachycardiaSitagliptinSitosterolemiaSjogren's syndromeSkin and soft tissue infectionsSkull AnatomySleep physiologySlipped Upper Femoral Epiphysis (SUFE)Small Bowel IschaemiaSmall Bowel ObstructionSmall vessel diseaseSmallpoxSmokingSnake BitesSneddon SyndromeSodium BicarbonateSodium NitroprussideSodium PhysiologySodium PicosulfateSodium Thiopental - Sodium ThiopentoneSodium Valproate (Epilim Depakote)Sodium Zirconium Cyclosilicate (Lokelma)Soft tissue injuries (sprains, strains)SolifenacinSolitary Pulmonary NoduleSotalol HydrochlorideSpetzler-Martin Grading of AVMSpina BifidaSpinal Cord AnatomySpinal Cord Arteriovenous MalformationsSpinal Cord CompressionSpinal Cord HaematomaSpinal Cord InfarctionSpinal StenosisSpirometrySpironolactoneSpleenSplenic RuptureSpondylolisthesisSpontaneous Bacterial PeritonitisSpontaneous intracranial hypotensionSquamous Cell CarcinomaSt John's WortStaphylococcal InfectionsStaphylococcus aureusStaphylococcus epidermidisStaphylococcus saprophyticusStatinStatus Epilepticus (Epilepsy)Stavudine (Zerit) d4TStevens-Johnson SyndromeStiff Person SyndromeStrabismus (Lazy Eye)Streptobacillus moniliformisStreptococci - anaerobesStreptococcusStreptococcus agalactiaeStreptococcus milleriStreptococcus pneumoniae (Pneumococcus)Streptococcus pyogenesStreptococcus viridansStreptokinaseStreptomycinStridorStroke - Arterial Occlusion and clinical correlateStroke - Epidemiology and risk factorsStroke - General ManagementStroke - ImagingStroke ASPECTS scoringStroke CollateralsStroke Risk FactorsStroke ThrombolysisStrongyloides stercoralis (threadworm)StrontiumSubacute Sclerosing PanencephalitisSubacute ThyroiditisSubarachnoid HaemorrhageSubclavian Steal SyndromeSubclavian vein thrombosisSubdural haematomaSucralfateSudden Cardiac Death (SCD)Sudden Infant Death Syndrome (SIDS)Sudden sensorineural hearing loss (SNHL)SuicideSulfasalazine - SulphasalazineSulphonamide (Sulphamethoxazole)SumatriptanSuperior Mesenteric Artery (SMA) SyndromeSuperior Sagittal Sinus ThrombosisSuperior vena caval obstruction syndromeSupracondylar Femur FracturesSupracondylar Humerus FracturesSupraspinatus tendonitisSupraventricular TachycardiaSurgical CricothyroidotomySurgical prophylaxisSurgical site infectionSusac syndromeSuxamethoniumSydenham's choreaSynchronised DC CardioversionSyncopeSyndrome X (Cardiology)Syndrome of Inappropriate ADH (SIADH) secretionSyndromes with Severe Cognitive IssuesSyphilisSyringobulbiaSyringomyeliaSystemic AmyloidosisSystemic Lupus Erythematosus (SLE)Systemic MastocytosisSystemic SclerosisT cellsTIMI scoreTMN Staging tumoursTNF receptor-associated periodic syndromeTORCH infectionsTURP Hyponatraemia syndromeTabes dorsalisTacrolimusTafamidisTakayasu arteritis (pulseless disease)Takotsubo CardiomyopathyTamoxifenTamsulosin (Flomax)Tanner Stages of Pubertal DevelopmentTardive DyskinesiasTay-Sachs diseaseTazocin (Tazobactam - 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Acute Heart Failure and Pulmonary Oedema



Even a simple bedside echo can help in the diagnosis and treatment. Get one as soon as possible. Causes of flash pulmonary oedema include severe left ventricular (LV) dysfunction, paroxysmal arrhythmias, three-vessel or left main stem coronary disease, in the context of hypertension, renal artery stenosis and phaeochromocytoma.

Initial Cardiogenic Pulmonary Oedema Management Summary
  • Sit patient up legs dependent, ensure comfort. O2 target > 92%
  • IV Furosemide 40-80 mg IV. Repeated doses may be needed
  • Morphine 2.5-5 mg slow IV or Diamorphine 2.5-5 mg slow IV + Ondansentron or Metoclopramide 10 mg IV
  • Consider GTN spray and IV Nitrate if BP > 110 mmHg
  • Consider Continuous positive airways pressure 5-10 mmHg
  • Control rate with Digoxin if AF. Amiodarone or DC countershock
  • Look for cause: STEMI, Arrhythmias, Aortic stenosis.
  • A Bedside Echo can be invaluable
  • Treat hypertension with IV Nitrates.
  • Dialysis/Ultrafiltration if oliguric and renal failure

About
  • Presence of Cardiogenic pulmonary oedema due to cardiac dysfunction
  • Leads to progressive dyspnoea and respiratory failure
  • Acute heart failure has a 30-day mortality of 15% in those with NT-proBNP > 5000ng/L
  • Prognosis for cardiac failure is often worse than many cancers
  • LV systolic function largely determines prognosis 
  • Look for treatable, transient and transplantable causes
  • Can worsen to become cardiogenic shock
Aetiology
  • There are forces at balance keeping fluid within the vessels
  • Plasma oncotic pressure POP (generally about 25 mmHg) holds water in the vessels
  • Pulmonary capillary pressure (about 7-12 mmHg) pushes fluid
  • A barrier formed by connective tissue and membranes
  • When POP > PCP then liquid accumulates in interstitial spaces
  • Raised LV end diastolic pressure increases pulmonary vein pressures
  • Movement of interstitial fluid into alveolar spaces
  • Impaired gaseous exchange soon leads to hypoxia
  • Oedematous boggy lungs increase difficulty in breathing
Terminologies
  • Heart failure preserved Ejection fraction (HFpeEF) (diastolic heart failure)
  • Heart failure with reduced Ejection fraction (<35%)
  • Left heart failure vs right heart failure
  • Forward failure vs Backward failure
  • Systolic (emptying) failure vs diastolic (filling) failure
  • High output (Paget's disease, anaemia) vs Low output
  • Congestive cardiac failure = LHF + RHF
  • Afterload - Blood pressure/peripheral resistance
  • Preload - venous return
Pathophysiological Causes
  • Poor systolic function - problems emptying the LV
  • Poor diastolic function - problems filling the LV
  • Valve regurgitation - forward flow goes backwards
  • Valve stenosis - forward flow impeded
  • Tachycardias - can limit filling
  • Bradycardias - can limit emptying especially if Stroke volume fixed
  • Severe Anaemia
Pathological Causes
  • Ischaemic heart disease: ACS, STEMI, NSTEMI
  • Myocarditis: Viral, Idiopathic, Toxic
  • Hypertension
  • Cardiomyopathy: Dilated, Restrictive, Hypertrophic
  • Valve failure: Acute or Chronic MR, AR, AS, Endocarditis
  • Arrhythmia: VT, SVT, Fast AF, Bradycardia
  • Fluid overload: Blood transfusion, IV fluids
  • Altered medications: Beta blockade, Stopping of diuretics, NSAIDs, Steroids.
  • Drug overdose: negative inotropes with myocardial depression
  • Cardiac tamponade
Epidemiology
  • Heart failure is a chronic condition predominantly affecting people over the age of 50 years. The incidence of heart failure in the UK is 140 per 100,000 men and 120 per 100,000 women.
  • Approximately 900,000 people in England and Wales have heart failure, of which at least half have left ventricular systolic dysfunction.
  • The incidence and prevalence of heart failure increase with age and the average age at first diagnosis is 76 years. Seen in 10% of those over aged 80.
  • People with heart failure are at risk from sudden cardiac death; this is the most common cause of death in people with mild to moderate heart failure.

Clinical:Right vs Left heart failure
  • Left heart failure
    • Breathless, distressed, Cyanosed
    • Orthopnea, Paroxysmal noctural dyspnoea
    • Tachycardia, Pulsus alternans, Gallop rhythm S3
    • Bibasal fine inspiratory crepitations
    • Bat wings pumonary oedema on CXR
  • Right heart failure
    • Elevated JVP
    • Hepatomegaly (pulsatile if TR) ascites and even a coagulopathy and deranged LFTs
    • Peripheral oedema
    • Parasternal heave
    • Nocturia due to redistribution of fluid at night
    • Pleural effusion (Right sided usually)
  • Causes of Right Heart Failure
    • MI, Cor Pulmonale (Lung disease)
    • PE, Pulmonary hypertension,
    • Tricuspid/Pulmonary Valve disease
    • Left heart failure
  • Causes of Left Heart Failure
    • IHD/MI
    • Systemic hypertension
    • Aortic/Mitral valve disease
    • Cardiomyopathy
  • Biventricular heart failure: both sides of the heart are affected. Seen with IHD and cardiomyopathies. Left heart failure eventually causes right heart failure. Biventricular - both RHF + LHF also called Congestive cardiac failure is the term for a combination

A reduced EF < 35% is a poor prognostic indicator and needs expert assessment and management

Clinical assessment using NYHA
New York Heart Association (NYHA) Heart Failure Class Patient Symptoms
I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnoea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
Investigations: bedside echo can be very valuable
  • FBC: severe anaemia can cause or exacerbate failure
  • U&E: renal function and keep a close watch of potassium and other electrolytes during treatment
  • TFT: rarely thyroid disease can be a precipitant of failure
  • Troponin: exclude MI in all patients with acute LVF
  • NT proBNP: HF is likely if NT-proBNP is above
    • 450 in those aged < 50
    • 900 in those aged 50-75
    • 1800 in those aged over 75
    • If < 300 ng/L then probably not heart failure.
  • ABG: hypoxia but beware of hypercarbia which may suggest Type 2 RF or exhaustion (DDx COPD, Pneumonia)
  • LFT: often deranged with congestion
  • Chest x-ray: Findings include
    • Cardiomegaly (CTR > 0.5)
    • Enlarged Pulmonary arteries and increased vascular markings and possibly oedema.
    • Kerley B lines (engorged pulmonary lymphatics).
    • Pleural effusion
    • Dilated upper lobe vessels
  • ECG: may be normal or signs of IHD, old infarcts, hypertension, AF or bradycardia or CHB or bundle branch blocks, May show arrhythmia, LV hypertrophy or strain. Normal ECG makes heart failure unlikely.
  • Echocardiography: can demonstrate global or focal LV dysfunction and valve disease. If the NT proBNP is significantly elevated (see above) acute heart failure is likely and should be confirmed by echocardiography if not already documented. The exception would be the frail elderly for whom an echocardiogram is very unlikely to alter management. The ejection fraction is key when assessing systolic heart failure. It may be expressed as a ratio or percentage
    • Ejection Fraction (EF) %: 55% to 70% is normal
    • Ejection Fraction (EF) %: 40% to 54% below normal
    • Ejection Fraction (EF) %: 35% to 39% Moderately below normal
    • Ejection Fraction (EF) %: Less than 35% significant reduction
  • Nuclear cardiology: using SPECT or PET can assess the viability of dysfunctional myocardium
  • Cardiac MRI: can help identify myocardial issues combined with dobutamine
  • Myocardial biopsies: in a tiny fraction of cases with unexplained disease
  • Angiography - if IHD is suspected to be the underlying cause
Other causes of "non cardiogenic" Pulmonary Oedema
  • High altitude pulmonary oedema
  • Acute Respiratory distress syndrome
  • Neurogenic pulmonary oedema
  • Heroin or other overdoses
  • Pulmonary embolism
  • Eclampsia, Postcardioversion
Ask What is the cause ?
  • MI: 12 lead ECG: STEMI can be silent. May need reperfusion. LV infarct. Papillary muscle ischaemia + Mitral regurgitation
  • Tachyarrhythmias: fast AF, VT, Amiodarone. DC cardioversion
  • Bradycardia needing Atropine and/or Pacemaker
  • Hypertension: Use IV GTN infusion
  • Valve damage or dysfunction:
  • Loud Systolic murmur, acute MR or VSD
  • EDM, Acute AR from endocarditis or Type A dissection
  • PSM: Functional MR from acute cardiomyopathy or myocarditis or endocarditis or a VSD.
  • Assess valve repair/replacement with cardiology
  • Infection: General sepsis. Manage with antibiotics.
  • Failure to take meds: Not taking diuretics, is taking NSAIDS or steroids.
  • End stage renal failure: Dialysis.
  • Anaemia: Transfuse cautiously
  • Fluid overload: seen commonly as a risk of blood transfusion or excess IV fluid or alcohol

Batwing type pulmonary oedema

Complications
  • Type 1 Respiratory failure with hypoxia. May become Type 2 if exhausted and hypoventilating or excess opiates.
  • Atrial fibrillation: assess CHADS-VASC and HAS-BLED score to reduce thromboembolic risk. Control rate with beta-blockade or Digoxin.
  • Renal failure: forward failure and use of diuretics and ACEI/ARB. Serum creatinine needs closely monitored
  • Liver congestion with abnormal LFTS and deranged coagulation
  • Cardiac cachexia:sarcopenia, fatigue and frailty
  • Hypokalaemia: usually due to loop diuretics
  • Hyperkalaemia: as part of AKI or secondary to spironolactone/eplenerone or ACEI/ARB
  • Hyponatraemia: due to failure medications or SIADH
  • VTE: risk of DVT/PE and VTE so needs effective thromboprophylaxis when inpatient.
  • Ventricular Tachycardia: sustained and non sustained VT. High risk may need ICD.
  • Sudden cardiac death
Management: Immediate Actions
  • Position: Sit up with legs dependent and get patient comfortable.
  • Give High flow O2 target SaO2 > 94-98 % unless COPD then 24-28%
  • Nitrates: GTN spray or GTN tablet S/L if SBP > 110 mmHg. IV nitrates may help e.g. GTN Infusion may be considered especially if the BP is actually high.
  • Opiates: Chest pain or APO: Give slowly over several minutes Morphine 5-10 mg IV or Diamorphine 2.5-5 mg IV Metoclopramide 10 mg IV (Avoid cyclizine)
  • Furosemide 50-100 mg stat IV which venodilates and causes diuresis
  • Salbutamol (Albuterol) 5mg Neb if significant wheeze and bronchospasm. It may worsen tachycardia. IV formulation can worsen acidosis.
  • Fast AF: Digoxin loading for Fast AF can help. IV Amiodarone is an alternative when compromised
  • CPAP may help to reduce oedema and improve oxygenation if respiratory failure and exhausted : take senior advice and mechanical ventilation and IPPV may be needed.
  • Inotropes may be considered
  • Mechanical assist/Balloon pump where there is myocardial or valve failure to improve coronary and cerebral perfusion. Not if aortic regurgitation.
  • Diastolic Heart failure may be difficult to diagnose
  • A proportion of elderly patients are on diuretics but have no objective evidence of heart failure (systolic or diastolic).
  • Echo should be performed in all patients to identify an aetiology.
  • ACEIs should be given to all patients unless contraindicated (i.e. renal impairment, aortic stenosis, renal artery stenosis)
Ongoing therapies
  • Loop Diuretics:Furosemide 20-120 mg od or iv in divided doses, Bumetanide 1-3 mg daily orally Diuretics remain a key element in the treatment of heart failure. Diuretics preceded the advent of randomised control trials, and there are no large or long-term placebo-controlled trials of their use. A systematic review of a number of small randomised trials indicated a possible benefit from diuretics in terms of mortality, compared to placebo. However, evidence is very light mainly due to the inability to do an ethical trial. Infusions of Furosemide are used with intractable oedema and a maximum dose of 120 mg over 30 minutes may be administered via a syringe driver.
  • ACE inhibitors: Ramipril 1.25 mg od to 5 mg bd, Enalapril 2.5 mg od to 10 mg bd: Systematic reviews of randomised controlled trials comparing ACE inhibitor to placebo have found that ACE inhibitor therapy in patients with heart failure due to left ventricular systolic dysfunction increases life expectancy compared to placebo. The effect is more marked in patients with more severe LV systolic impairment, or more severe symptoms, although there is a benefit for all NYHA classes. Compared with placebo, ACE inhibitor therapy also reduces the risk of hospitalisation for heart failure in such patients, and also for patients with asymptomatic left ventricular systolic dysfunction. Measure renal function after each increase in dose.
  • Angiotensin II receptor blockers: used as second-line therapy when ACEI not tolerated. Monitor serum urea, electrolytes, creatinine and eGFR for signs of renal impairment and hyperkalaemia
  • Beta-Blockers : Bisoprolol 1.25-10 mg od or Carvedilol 3.125-50 mg od : Many large clinical trials reviewed in four meta-analyses, and one subsequent RCT have shown that several Beta-blockers increase life expectancy in patients with heart failure due to LV systolic dysfunction, compared with placebo. This effect has been seen
  • Aldosterone antagonists: are licensed for heart failure (option for second-line treatment) usually under specialist advice. Used in moderate to severe heart failure (NYHA class III-IV) or MI in the past month. Monitor potassium and creatinine levels and eGFR. Seek specialist advice if hyperkalaemia develops or renal function deteriorates.
  • Digoxin 125-250 mcg per day: In those not on it start with normal renal function Digoxin 500 mcg PO stat and then 125 mcg daily after that: Despite a small systematic review that suggests that fewer patients withdraw from randomised trials of therapy when on Digoxin than on placebo, there are no published data from randomised control trials on the effect of Digoxin on the signs and symptoms (except for exercise performance) and quality of life of patients with heart failure. Digoxin reduces the risk of admission to hospital with worsening heart failure in patients with heart failure due to LV systolic dysfunction in sinus rhythm and may reduce heart failure-specific mortality. However, a large systematic review and two additional RCT's with medium-term follow up, suggest that it does not increase overall life expectancy. Advised to maintain potassium level > 4.5 mmol/l when on Digoxin.
  • Potassium Sparing diuretics:Spironolactone or Eplenerone: 12.5-25 mg od with moderate to severe heart failure (NYHA Class III and IV) due to LV systolic dysfunction, the addition of low-dose spironolactone to therapy with a loop diuretic and ACE inhibitor has been shown in a large randomised controlled trial to increase life expectancy when compared to placebo. In addition, hospitalisation for cardiac causes is greatly reduced.
  • Metolazone: potent thiazide diuretic sometimes used under close supervision
  • Amiodarone: A small number of RCT and meta-analyses have demonstrated that Amiodarone is effective against most ventricular arrhythmias. Evidence from one-meta analysis with long-term outcome assessment suggests a neutral effect on mortality in patients with heart failure
  • Ivabradine: acts on the If inward current in the SAN. Reduction in hospital admission and mortality rates in patients with heart failure due to moderate or severe left ventricular systolic impairment. Useful in those with fast HR but cannot take beta-blockers. No use in atrial fibrillation.
  • Levosimendan: Short-term treatment of acutely decompensated severe chronic heart failure. Often used where conventional therapy is not considered adequate
  • Hydralazine and Nitrates: were one of the earliest combined treatments for heart failure before ACE inhibitors and are still used in whom ACE/AT2 blockers cannot be used. Especially in people of African or Caribbean origin with moderate to severe heart failure (NYHA class III-IV).
  • Sacubitril: Inhibitor of neprilysin which breaks down ANP and BNP thus enhancing their effects. Sacubitril is often combined with Valsartan in the treatment of symptomatic heart failure
  • Anticoagulation: Warfarin or DOAC or LMWH: may be indicated if there is a failure as CCF gains a point in CHADS scoring. May also be indicated for PE or for LV thrombus or severely impaired LV function and a worry over cardioembolic emboli.
  • End stage disease: Consider opiates and patient centred end of life care where appropriate
  • Cardiac resynchronization therapy: CRT is recommended in patients with advanced HF (usually NYHA class III or IV), severe systolic dysfunction (eg, left ventricular ejection fraction <35 percent) or intraventricular conduction delay (eg, QRS >120 msec).
  • LV assist devices useful bridge to transplant or where there is an expected return of cardiac function e.g. myocarditis.
  • Heart Transplant: Contemplated in those with end stage heart failure and under 60 but limited by donor heart shortage
Further
  • Is revascularisation needed - angiogram and assessment
  • Is valve repair or replacement needed - angiogram and assessment
  • Salt restriction
  • Start ACE Inhibitor or ARBI and uptitrate to max tolerated dose
  • Start Regular diuretic e.g.Furosemide or Bumetanide
  • Start Beta blocker (Bisoprolol or Carvedilol) and titrate up
  • Exercise rehab program
  • Possible angiogram and revascularization by PCI or CABG
Other treatments
  • Treat arrhythmias e.g. Defibrillate if VT or SVT
  • Treat severe hypertension if a hypertensive crisis
  • Defibrillate or Rate control AF (Digoxin or Amiodarone)
  • Consider Pacemaker if Heart block
  • ECG shows acute MI then Revascularise e.g. Aspirin + thrombolysis (May be too unstable to attempt PCI)
  • Intra arterial balloon pump can augment coronary and cerebral perfusion
  • Cardiac transplant if end-stage cardiac failure in the young patient
  • Progressive failure will ultimately need palliation
Ongoing care
  • Daily weights. Check U&E, Creatinine, Watch I/O and NEWS score.
  • Start Regular diuretics. Watch renal function. Start ACEI/ARB if no C/I and up-titrate dose
  • Spironolactone or Eplenerone cause hyperkalaemia so watch K
  • Beta blockade watch heart rate.
  • Manage causes: PCI/CABG, Valve replacement or repair. CRT pacing. Transplant/Ventricular assist devices
References

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