@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 - 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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 - 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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 - 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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 - Piperacillin)TeicoplaninTelomeresTemazepamTemozolomide (Temodal)Template XTemplate two columns listTemporal (Giant Cell GCA) ArteritisTenecteplaseTennis ElbowTensilon testTension PneumothoraxTerbutalineTeriparatideTerlipressinTertiary hyperparathyroidismTesticular CancerTesticular torsionTestingTetrabenazineTetracosactide (Synacthen)TetracyclinesTetralogy of Fallot (Children)Thalamic HaemorrhageThalamic Pain SyndromeThalamic Stroke SyndromeThalidomideTheophyllineTheophylline toxicityThiamineThird Degree (complete) Heart BlockThoracic TraumaThoracic anatomyThoracic outlet syndromeThrombocytosisThrombolysisThrombophilia testingThrombotic Thrombocytopenic purpura (TTP)Thyroglossal Cyst (Children)Thyroid CancerThyroid Function Tests and antbodiesThyroid GlandThyroid Storm - Thyrotoxic crisisThyroid Surgery (Thyroidectomy)Thyroid noduleThyrotoxicosis and HyperthyroidismTiagabineTibia and Fibula fractures and InjuriesTicagrelorTick ParalysisTimololTinea capitisTinidazoleTinzaparin (Innohep)Tiotropium (Spiriva)Titre - 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Paratyphoid fever (Enteric Fever)Tyrosine Kinase receptorsUS vs UK Drug namesUbiquitinUlcerative ColitisUlnar nerveUltrasound - Echo basicsUndifferentiated Inflammatory Arthritis (Children)Unexplained symptomsUpper Gastrointestinal Bleed (GI Bleed)Upper-Lower Motor Neurone signsUrea and ElectrolytesUrethral syndomeUrinary CatheterisationUrinary Incontinence (Stress and Urge)Urinary Tract Infection (UTI Children)Urinary Tract InfectionsUrinary Tract ObstructionUrinary UTI Antibiotic guidanceUrine AnalysisUrothelial tumoursUrticariaUterusVIPomasVTE DVT PE in PregnancyVaginal CarcinomaValaciclovirValsartanVancomycinVariable rate intravenous insulin infusion VRIIIVariant (Prinzmetal) AnginaVaricella-Zoster (Chickenpox Shingles) InfectionVariegate PorphyriaVascular DementiaVasculitis - General Issues and ClassificationVasopressin (AVP) Antidiuretic hormoneVasovagal syncopeVaughan-Williams ClassificationVecuroniumVedolizumab (Entyvio)VenlafaxineVenous Insufficiency and Leg UlcersVenous access Venflons and Central linesVentilator associated pneumonia (VAP)Ventricular FibrillationVentricular Septal defect (VSD) (Children)Ventricular TachycardiaVentricular ectopic beatsVerapamilVertebral artery dissectionVertigoVesicoureteric reflux (VUR) (Children)Vibrio parahaemolyticusVibrio vulnificusVibrio vulnificus Vigabatrin (Sabril)VinblastineVincristineViral MeningitisViral associated cancersVirusesVisual acuityVitamin A deficiency (Children)Vitamin B1 Thiamine deficiencyVitamin B12 deficiencyVitamin B12 excessVitamin C deficiency (Scurvy)Vitamin D (1,25 OH2)Vitamin D (25 OH D)Vitamin D deficiencyVitamin D resistant rickets (Children)Vitamin K (Phytomenadione)Vitamin K deficiencyVitiligoVoltarol (Diclofenac)Von Gierke Disease (Children)Von Hippel LindauVon Willebrand DiseaseWaardenburg's syndrome (Children)Wagner Classification Diabetic foot ulcersWaldenstrom Macroglobulinaemia (WM)Wallerian DegenerationWarfarinWarfarin and BleedingWater PhysiologyWatershed InfarctsWerdnig Hoffman Disease (Children)Wernicke Korsakoff SyndromeWhite Blood Cells - LeukocytesWilliams Syndrome (Children)Wilson diseaseWiskott-Aldrich syndrome (Children)Wolff-Parkinson White syndrome (WPW)Wolfram syndrome (DIDMOAD)Wound healingX linked Agammaglobulinaemia (Bruton)X linked Hypophosphataemic ricketsX-linked IchthyosisX-linked lymphoproliferative disease (Children)Xeroderma pigmentosumYellow FeverYellow Nail SyndromeYersinia enterocoliticaYersinia pestis - Bubonic PlagueYersinia pseudotuberculosisZZAAAZZ_Abnormal charZabramski Classification of CavernomasZidovudine (Retrovir) AZT - ZDVZieve's syndromeZika virusZinc deficiencyZoledronic acidZollinger Ellison syndromeZolpidemZopicloneeGFR

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Case #9 Weakness


John is a 62-year-old right-handed male. He was found collapsed in the town centre today. He was lying beside his car. He was conscious. He was FAST positive (abnormal speech and couldn't lift his right arm) and has been brought in by a paramedic crew and is now in the resus area of the ED. He is having his observations assessed. You have been prealeted by the paramedics who are concerned that he is having a stroke and so go to meet him on arrival in the ED.
He has just arrived and the stroke nurse is arranging an urgent CT head. He is mute. The parmedics show you a parking ticket which shows that he entered the car park at 11.00 am. He is awake but there is no speech. He also does not appear to be moving his right arm and leg. He has a right facial weakness.
His BP is 150/80 mmHg and Pulse 80/min and O2 sats 95%. He does not appear to see visual stimuli on his right side. You quickly examine him and calculate his NIHSS score to be 15. The consultant advises get a CT and blood and is on her way. The team attempts to call his wife from details proved by paramedics.

Questions

1. What is the FAST test

This is the Face Arm Speech Test and is a screening test for stroke which can be done by the public or a paramedic. It is a very useful screening test for those suspected of having an acute stroke in those out of the hospital and can be done with very little training. It has been advertised widely to try to improve the public knowledge of the signs of stroke so that emergency services are alerted and patients get to the hospital early and so can have the benefit of reperfusion strategies such as thrombolysis and thrombectomy. It is not 100% reliable and some patients with very mild or posterior circulation strokes can be fast negative.

2. What is NIHSS score

This is a very quick reproducible neurological assessment on those likely to have a stroke and is done in the hospital. It focuses on very quickly picking up typical stroke deficits. The higher the score the larger the stroke and the worse the prognosis. It tends to underscore in posterior circulation strokes. Swallowing is not included. There is no need for any further neurological assessment when quickly preparing for reperfusion therapies. It is very important that this is done quickly before escalating. It is one of the first things that on telemedicine consult that the consultant stroke physician will ask for and will often go through the marking with the referring person. See more information at NIHSS. There is free online training for it.

3. Why is contacting his wife so crucial

  • His wife may know about past medical history e.g. a recent episode of GI bleeding or that patient is on Warfarin or that the patient has another condition that would be a contraindication to Thrombolysis.
  • Wife or any witness may also be able to help with time of onset if there is uncertainty from other sources.
  • Wife cannot give consent for anyone else but can support a best interest decision to thrombolyse a patient who lacks capacity. She may even have a Power of attorney for health and welfare and so be able to make decisions for the patient. Otherwise she can try to reflect what would be the patient's views.
  • It is both kind and considerate to inform family as early as possible to come and emotionally support and be with the patient.

See Imaging

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  • The CT shows a long clot/thrombus in the Left MCA M1
  • The consultant checks inclusion and exclusion criteria
  • The consultant checks that the BP is < 185/110 mmHg. It is 160/90 mmHg
  • The consultant rechecks that the CT is compatible with ischaemic stroke
  • The consultant speaks to his wife by phone and explains that he needs thrombolysis and risk and benefits
  • He is treated in best interests as he lacks capacity due to loss of capacity due to aphasia

4. What are the usual signs of a blocked Left and Right MCA (dominant)

Assuming right-handed and dominant left cortex
Blocked Left MCA
  • Right sided weakness (hemiparesis) - right face/arm/leg
  • Right sided hemisensory loss
  • Right homonymous hemianopia
  • Dysphasia

Blocked Right MCA
  • Left sided weakness (hemiparesis) - left face/arm/leg
  • Left sided hemisensory loss
  • Left homonymous hemianopia
  • Neglect/Inattention

5. His weight is 70 kg and Alteplase is given as 0.9 mg/kg. How much is given and how is it given

  • His weight is 70 kg so Alteplase dose is therefore 0.9 mg/kg x 70 = 63 mg
  • This is prepared by the stroke nurse specialist
  • This is prescribed and 10% (6 mg) is given as a bolus and the remaining 90% is given through an infusion pump
  • This will usually require the opening of 2 x 50 mg vials which are made up
  • The remaining 90% ( 57 mg) is given as an infusion over 1 hour
  • The patient must be closely monitored for complications with 15 minute obs

6. What is Alteplase

A drug that activates tissue plasminogen which breaks down fibrin strands and therefore dissolves clots and allows blood to flow again. The main risks are anaphylaxis, angioneurotic oedema and bleeding which may be intracranial or extracranial. This is why very close monitoring is needed once Alteplase is started and patients need nursed in an environment that allows frequent observations with access to key support if any of the complications happen.

7. During the infusion he suddenly becomes less responsive and has a seizure . What would you do now.

  • Immediately stop the Alteplase and check ABC and a set of observations.
  • Start Oxygen. Check BM if hypoglycaemia possible.
  • Escalate to the Medical Registrar or the stroke team.
  • Once stabilised get a second CT scan to look for haemorrhage.
  • Consider a phenytoin infusion if seizure persists or recures
  • Continue frequent monitoring on the HASU
  • If GCS < 9 then get anaesthetic review and discuss need for ventilatory support in an ITU bed

Signs of a new intracranial haemorrhage include increasing headache, nausea, vomiting, reduced GCS, a seizure or pupil changes. These warrant urgent repeat CT head and the Alteplase must be stopped immediately until the scan is done and reported.
The CT scan show no haemorrhage. His GCS is now 10. He is on the HASU. IV fluids are started. Because he is still within the window for thrombolysis it is now restarted. He is closely monitored. A CT is booked for the following day.

8. Why is a CT scan needed the next day

Alteplase can cause intracerebral bleeding and this may be seen in up to 5-6% of patients after having received it. This can be seen on the CT.

9. When can Aspirin be given

Aspirin is usually withheld until after a repeat CT head scan which is done approximately 24 hours after thrombolysis does not show any evidence of intracerebral haemorrhage. Once that is done the current stroke policy is to give Aspirin 300 mg either orally, by NG tube or rectally (PR) to patients with suspected ischaemic strokes. Aspirin 300 mg is usually given for 14 days and then switched to Clopidogrel 75 mg OD long term. If there is a history of dyspepsia or at high risk of peptic ulcer disease then Lansoprazole or another similar agent may be given. Some units give it as standard but it should be stopped once the patient is commenced on Clopidogrel. Occasionally the transition from Aspirin 300 mg to Clopidogrel 75 mg is started before 14 days.

10. What else do I need to check

All patients need an early swallowing assessment. This can be done simply by the bedside. This is very important as giving food or drink to someone with a poor swallow can result in aspiration and pneumonia. This is usually don by stroke specialist nurse.

11. The thrombolysis has finished and the patient is agitated and the BP is 210/110 mmHg. What would you do next

The patient is agitated, and we know is dysphasic so cannot tell us what is wrong. Look for pain and distress. It didn't take long to realise that he had not passed urine for several hours and had had 1L of IV fluids. He was made comfortable and given a urine bottle and assisted. Unfortunately he still could not pass urine. Usually catheterisation is avoided in stroke patients especially after thrombolysis but acute urinary retention is an absolute indication. It is key to be extra gentle to avoid any urethral bleeding. A bladder scan suggested a residual of 500 mls. Once catheterised his BP settled to 150/80 mmHg and the patient was comfortable.

12. If there had been no identifiable cause for the BP rise what would you have treated him with ?

IV labetalol is the usual drug of choice in those who can take a beta blocker. It can be given as 10 mg doses which may be repeated. The key is to go slowly and avoid large drops in BP but target is to get BP comfortably under 180/110 mmHg in the 12-24 hrs after alteplase to minmise the risks of haemorrhagic transformation and bleeding into the stroke. For those who cannot take a beta blocker consider a GTN infusion though this can cause a severe headache. If the patient can swallow I might start a small dose of oral amlodipine 5 mg in addition to parenteral agents but the best advice is to follow local guidelines.

References