New diseases Flashcards
What is an RAPD
Relative Afferent Pupillary Defect (RAPD) is a condition in which pupils respond differently to light stimuli shone in one eye at a time (swinging light test) due to unilateral or asymmetrical disease of the retina or optic nerve.
Ex// Upon performing the swinging light there is a normal constriction of both pupils when the light is shone into the right eye. When the light is shone into the left eye there is a reduced constriction of both pupils (i.e. left afferent defect)
Causes of RAPD
- Acute glaucoma -> aqueous humour drainage becomes occluded.
Severe pain, N+V, red eye, reduced vision. (usually bilateral disease i.e. APD but
if one damaged more then can cause RAPD) - Vitreous haemorrhage -> Haemorrhage into vitreous humour. Painless, unilateral floaters. +/- visual loss.
- Retinal detachment -> painless flashes, floaters, curtain over part of vision - stiffer, slower than vitreous haemorrhage.
- Optic neuritis -> reduced acuity, poor discrimination of colours ‘red desaturation’, pain worse on eye movement, central scotoma
What are the sx of Meniere’s disease and how tx
EPISODIC, SUDDEN ATTACKS of vertigo, AURAL FULLNESS, tinnitus, ataxia, unilateral or bilateral sensorineural hearing loss.
- Management relies on prophylactic use of betahistine to reduce the frequency of attacks, and the acute use of prochlorperazine.
What are the sx of Vestibular schwannoma (acoustic neuroma)
- Vertigo - usually comes on slowly and GRADUALLY gets worse over time, Unilateral Sensorineural hearing loss, ataxia, tinnitus, ABSENT CORNEAL REFLEX.
- Associated with neurofibromatosis type 2
What is the presentation of benign paroxysmal positional vertigo
- ELDERLY, calcium deposits within semicircular canals
- BPPV is provoked by MOVEMENTS of the head usually to one side when turning in bed or on looking upwards.
- These sudden attacks of ROTATIONAL VERTIGO last for 30s to 1 minute and are provoked the changing position of the head.
- There are no auditory symptoms for BPPV.
Episodes will usually disappear within a few weeks or months, but they often recur.
Dx and Mx of benign paroxysmal positional vertigo
The diagnostic test is the Dix-Hallpike manoeuvre
The therapeutic manoeuvre is the Epley manoeuvre.
Px of Viral labyrinthitis vs Vestibular neuronitis
Both: recent viral infection, vertigo/N+V
Viral labyrinthitis: HEARING LOSS
Vestibular neuronitis: NO HEARING LOSS
Causes of LMN facial nerve palsy and Tx
Bells -> idiopathic. Prednisolone (<72hrs) + lubricating eye drops. Paralysis no improvement after 3 weeks, then refer urgently to ENT.
Ramsey Hunt -> VZV. Vesicular rash around their ear, hearing loss/tinnitus/vesicles in ear (abnormal ENT) and a facial nerve palsy. prednisolone + aciclovir + eye lubricating drops
Px of Multiple Sclerosis
- YOUNG ADULTS, COMMONLY WOMEN
- Episodes of sensory and/or motor weakness, most commonly UNILATERAL.
- FOCAL weakness i.e. left arm, bells palsy, horners
- FOCAL sensory i.e. numbness, Lhermitte’s sign
- Optic neuritis -> pain on eye movement, loss of visual acuity, color desaturation
- Ataxia
- Uthoffs phenomenon: neurological symptoms are exacerbated by increases in body temperature is typically associated with multiple sclerosis
Ix and Tx of MS
- Ix: MRI, LP - oligoclonal bands in CSF
- Mx: Acute relapse: Methylprednisolone (high dose steroid)
Remission: Natalizumab, fingolimod (only oral - fingers)
Spasticity -> baclofen, gabapentin
Px of cervical spondylosis
- OLDER AGE
Neck pain +/- Lhermittes. Worse with movement
Radiculopathy - LMN signs
Myelopathy - UMN signs
Headache
Px of eczema
- Itchy, erythematous rash
repeated scratching may exacerbate affected areas - Face + trunk (infants), Extensor surfaces (young children), Flexor surfaces + creases (older children)
Mx of eczema
- avoid irritants + simple emollients
- topical steroid - emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
What is Eczema Herpeticum and tx
- Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2.
-> child with atopic eczema and widespread vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes). - Tx: As it is potentially life-threatening children should be admitted for IV aciclovir
What is Asherman’s syndrome
- cause of SECONDARY amennorhea
- Characterised as uterine adhesions, commonly as a result of previous uterine surgery.
- Hysteroscopy is gold standard
What is Sheehans syndrome
- cause of SECONDARY amennorhea, complication of PPH
= avascular necrosis of anterior pituitary
Sx:
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)
Causes of secondary amenorrhea
- Pregnancy (most common cause) and breastfeeding
- Menopause or premature ovarian insufficiency -> RAISED FSH, raised LH, decreased oestrogen
- Intrauterine adhesions causing outflow tract obstruction (Asherman’s syndrome)
- PCOS -> raised LH and LH:FSH ratio
- Drug-induced amenorrhoea (e.g. oral contraceptive)
- Physical stress, excess exercise and weight loss
- Pituitary gland pathology such as Sheehan syndrome or hyperprolactinaemia
- Hypothyroidism or hyperthyroidism
What is the Pierre Robin sequence
Pierre Robin sequence or syndrome is a genetic condition in which an infant is born with micrognathia (small jaw), glossoptysis (posterior tongue) and often cleft palate. As a result the infant may have breathing or feeding difficulties shortly after birth.
What is the classic triad of Henoch Schonlein Purpura
Purpura or petechiae on the buttocks and lower limbs
Abdominal pain
Arthralgia
What important test need to look for in Henoch Schonlein Purpura
Urine dipstick for 12 months - renal impairment is a common complication
Causes of acute confusional state
D - Drugs and Alcohol
E - Eyes, ears and emotional
L - Low Output state (MI, ARDS, PE, CHF, COPD)
I - Infection
R - Retention (of urine or stool)
I - Ictal
U - Under-hydration/Under-nutrition
M - Metabolic (Electrolyte imbalance, thyroid, wernickes
(S) - Subdural, Sleep deprivation
What type of drugs most commonly cause delirium and Mx of delirium
- Anti-cholinergics: Amitriptyline, Antihistamines - chlorpheniramine, Oxybutinin (dont use for urge incontinence in elderly - mirabegron)
- Opiates
- Anti-convulsants
- Recreational
- STEROIDs
- Mx: Treat the underlying cause. Maintaining an environment with good lighting and frequent reassurance is helpful.
-> HALOPERIDOL (1st), olanzapine
-> If pt. has parkinsons or lewy-body dementia, then avoid antipsychotics (cause EPSE’s) and use benzo’s
Features suggesting delirium over dementia
- impaired consciousness
- Fluctuates and worse at night
- Abnormal perception - illusions and hallucinations
- Agitation, Fear
- delusions
Px + Dx of Acute lymphoblastic leukaemia
- Bruising, enlarged lymph nodes/lymphadenopathy and systemic illness
- may have hepatospleenomegaly, epistaxis, fatigue
- dx = bone marrow biopsy
- Urgent referral to hospital
Sepsis 6 in paeds
Sepsis 6:
1)High flow O2 If indicated2) Obtain IV and take blood cultures, glucose3) Give IV or IO Abx4) Consider Fluid resuscitation5) Involve senior clinicians early6) Consider inotropic support
RF’s for DDH
Female
Firstborn
Family history
Fanny first (breech)
Fluid (oligohydramnios).
Maneouvres for DDH + Imaging?
The manoeuvres to screen for DDH are Barlow (posterior dislocation) and Ortalani (relocation on abduction of the hip) manoeuvres.
Mnemonic to remember Barlow and Ortolani:
Barlow’s is Bad (dislocate) -
ORTolani- ORThopaedic doctors relocate joints
- US
How does an amniotic fluid embolism present
The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
What is infantile colic and how manage?
Infantile colic describes a relatively common and benign set of symptoms seen in young infants. It typically occurs in infants less than 3 months old and is characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.
- Reassurance and support
What is polyneuropathy
Disorder that involves damage to multiple peripheral nerve fibres. Distal nerves usually affected most prominently. Usually symmetrical, bilateral.
What is mononeuropathy
Damage to single peripheral nerve e.g. carpal tunnel syndrome
What is mononeuritis multiplex
- Damage to multiple nerves in an asymmetrical distribution i.e. cranial nerve palsy + foot drop
- Associated with vasculitis, diabetes, infections, immune mediated diseases.
Types of polyneuropathy that are predominantly motor loss and predominantly sensory loss
Predominately motor loss:
Guillain-Barre syndrome
Charcot-Marie-Tooth
Chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria
Predominately sensory loss:
diabetes
vitamin B12 deficiency
alcoholism
uraemia
Complications of diabetes
Diabetic neuropathy:
- typically sensory loss in ‘glove and stocking’ distribution, with lower legs affected first.
GI neuropathy - gastroparesis, chronic diarrhoea, GORD.
Diabetic retinopathy:
- reduced vision/blindness due to vascular disease
Heart disease
CKD
Dementia
Sx of following peripheral nerve palsies:
Peroneal nerve palsy
Radial nerve palsy
Ulnar nerve palsy
Median nerve palsy
Bell’s (LMN) palsy
- Peroneal nerve palsy: (branch of sciatic) Foot drop or sensory changes in foot
- Radial nerve palsy: Wrist drop, + cant extend/numbness fingers or wrist
- Ulnar nerve palsy: clawing/tingling/weakness of 4th,5th fingers, disability to abduct/adduct fingers of hand
- Median nerve palsy: inability to abduct and oppose thumb (ape hand), weakened finger flexion, loss of sensation to thumb, Index and middle finger, the lateral half of ring finger
- Bell’s palsy: LMN facial nerve palsy, forehead affected
What signs in a blood test may indicate sepsis
- Lactate: high + metabolic acidosis
- CRP: high
- FBC: abnormal neutrophils
- Blood culture
- Lumbar puncture
What is subacute combined degeneration of the cord
= vitamin B12 deficiency
Bilateral/symmetrical:
- Dorsal column loss (sensory + LMN)
-> propriception, vibration, fine touch, pressure sensation
lost first: imbalance/ataxia +
parenthesia
- Corticospinal tract loss (motor + UMN)
Classic triad: Extensor plantar response/babinski sign, brisk knee jerks, absent ankle jerks (LMN signs more distally)
- Clinical picture is often complicated by a coexistent peripheral neuropathy, optic atrophy and cognitive impairment.
Features of alcohol withdrawal + tx
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
Mx: PO chlordiazepoxide + IV thiamine (pabrinex) - seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
- tx of tremens = IV pabrinex (vtiamin B1 to offset kortsokoffs) + high dose benzodiazepine
What is Wernicke’s-Korsakoff’s
COAT-RACK -> when go parties hang coat on the rack
Confusion, Opthalmoplegia/Nystagmus, Ataxia, Thymine deficiency
Retrograde amnesia, Anterograde amnesia, Confabulation, Korsakoff
Tx of ADHD
Methylphenidate
Sx of serotonin syndrome
SHIVERS
- shivering
- hyper-reflexia and myoclonus
- Increased temperature
- vital sign abnormalities - Tachycardia, tachypnea, and labile blood pressure
- encephalopathy: Mental status changes such as agitation, delirium, and confusion
- Restlessness/rigidity: Common due to excess serotonin activity
- Sweating: Autonomic response to excess serotonin. This symptom can help differentiate from anticholinergic toxicity in which the patients would present with increased temperature but dry to the touch
- dilated pupils
Side effects of Antipsychotics
- EPSE (anti dopamine - block motor fn): parkinsonism, acute dystonias -> sustained muscle contraction, akathisia (severe restlessness), tardive dyskinesia
- Endocrine pathway blocked -> Increased prolactin = Gynaecomastia/ galactorrhoea, block mACH = cant see, cant pee, cant spit, cant shit, block H1 receptors = sedation (like antihistamines), 5-HT (increased weight gain)
- QT interval
- Neuroleptic malignant syndrome -> Fever, Encelapothay - confusion/mental retardation, Vital signs unstable (hyperthermia, sweating), Enzymes elevated (creatinine kinase increased), Rigidity of muscles - lead pipe. Pupils normal.
Ex. of acute dystonias
- involuntary upward eye movements (oculogyric = eye)
- Muscle spasms of neck = torticollis (tortoise neck), tongue, face
- mx: procyclidine
Ex. of tardive dyskinesia
(Tardive = slowly developing/late + dyskinesia + Dyskinesia = involuntary movements) Irreversible.
- Involuntary movements of face, tongue, jaw movements.
-> Commonly is chewing and pouting of jaw.
Adverse effects of atypical antipsychotics
- Weight gain, hyperprolactinaemia
- Clozapine -> agranulocytosis, neutropenia. Introduced if not controlled despite use of 2+ antipsychotic drugs (1 of which is a atypical). Increases risk of seizures, myocarditis, CONSTIPATION, INCREASED SALIVATION
Side effects of lithium
Lethargy, Insipidus (diabetes) - thirst/urination, Tremor, Hypothyroidism, Impaired memory + cognition, Upset stomach, Muscle weakness
Features and Likely blood results in someone with anorexia nervosa
- Oral: dental caries/decay
- CVS: hypotension, long QT, arrhythmia, bradycardia, cardiomyopathy
- Endocrine: low sodium/potassium/glucose/body temp/T3 hormone. High cortisol/growth hormone/cholesterol. Osteoporosis
Low sex hormones - amenorrhea/delayed puberty - Derm: dry scaly skin, brittle hair, fine body hair
- Haem: anaemia, leukopenia, thrombocytopenia
What is an Osteosarcoma
- Femur 2. Tibia + Humerus
- persistent bone pain, particularly worse at night time
- bone swelling, a palpable mass and restricted joint movements
- XRAY: periosteal reaction (irritation of the lining of the bone) that is classically described as a “sun-burst” appearance.
What is Ewings sarcoma + what are features of xray
- It most commonly affects teenagers and young adults with the pelvis, thigh bone and shin bone being the most commonly affected areas.
- Bone pain particularly occurring at night
- A mass or swelling, restricted movement in a joint
- XRAY: onion skin appearance. Small, round blue cell tumour.
What type of HRT to give to peri/post menopausal women
+ Risks with HRT
Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT
- The risk of endometrial cancer is greatly reduced by adding progesterone (combined) in women with a uterus
- The risk of VTE is reduced by using patches rather than pills
- Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
What are the phases in 1st stage of labour and what is classed as delay/fail to progress
- Latent: 0-3cm dilation cervix. 0.5cm/hr + irregular contractions
- Active: 3-7cm dilation. 1cm/hr + regular contractions
- Transition: 7-10cm dilation. 1cm/hr + regular contractions
Delay = Less than 2cm of cervical dilatation in 4 hours orSlowing of progress in a multiparous women
What happens in 2nd stage of labour and what is classed as delay/fail to progress
Lasts from 10cm dilatation of cervix to delivery of the baby.Success depends on the 3 P’s (power/contractions, passenger/size/pres/position, passage/shape/size of pelvis)
Delay = 1hr in multiparous, 2hr in nulliparous
What happens in 3rd stage of labour and what is classed as delay/fail to progress
From delivery of baby to delivery of placenta.
30+ minutes with active mx
60+ minutes with physiological mx
Active mx: INTRAMUSCULAR oxytocin/ergometrine, controlled cord traction
