Oxford summary 5 Flashcards
Prostate cancer
early Sx
asymptomatic
incidental increased PSA
hard nodule on DRE
Prostate cancer
Local disease Sx
Prostatism, hard and nontender on DRE Retention haematuria LE odemea
Prostate cancer
Metastatic
Malaise, weight loss
Bone pain, pathological #, spinal cord compression
Ureteric compression –> RF
UTI cystitis PC
frequency dysuria urgency strangury low pain incontinence retention cloudy/ offensive urine haematuria
UTI pyelonephritis PC
loin pain fever rigors malaise V haematuria
UTI Dx
- Urine for leukocytes and nitrates
- Bloods: U&E, Cr, eGFR, PSA if >40 male
- USS, KUB
UTI Tx
• fluid, alkanize urine with potassium citrate
• Trimethoprim 200mg bd, 3d for women, 7d for males, GU malformation, immunosuppression, relapse, recurrent
• Ciprofloxacin 500mg bd 7 days if pyelonephritis
HRT
Urethral Syndrome
- Cystitis with –ve MSU, unknown cause
- A/w cold, stress, nylon under wear, CHC, intercourse
- Tx: fluids, lifestyle, topical E, doxycycline 100mg bd 14d or azithromycin 500mg od 6days
interstitial cystitis
• Middle-aged women
• Can lead to fibrosis of bladder wall
• Px: frequency, urgency, suprapubic pain
-ve MSU
BPH Sx
• Obstructive: stream, double micturition, hesitancy, dribbling, incomplete empyting, straining
Irritative (detrusor hypertrophy): F, U, D, N
BPH Dx
- RFT: U&E, Cr, eGFR
- MSU: blood, glucose, M, C&S
- US measurement of post-micturition residual
- PSA
BPH comp
• Recurrent UTI, stones, haematuria
• Acute and chronic retention
• Overflow incontinence
Obstructive nephropathy
BPH tx
• Watchful waiting: if mild/ moderate and no complications
o fluid/ caffeine intake, bladder retraining
• Medications
o α-adrenorecptor antagonists- prazosin, doxazoskin
5α-reductase inhibitors- finasteride. Takes 6mo to work
Acute bacterial prostatitis
- Px: UTI symptoms + fever, arthralgia/ myalgia, low back/perineal/penile/ rectal pain
- DRE: swollen, tender prostate
- Investigation: MSU
- Tx: ciprofloxacin 500mg bd or ofloxacin 200mg bd 4/52
- Complications: acute retention, chronic prostatitis, abscess
Chronic prostatitis (chronic pelvic pain syndrome)
• Unknown cause.
• Px: >3mo
o Urological pain: lower abdo, pelvis/ perineum, penis, testicles, rectum, low back
o Irritative/ obstructive symptoms or ejaculatory probz
• Dx of exclusion
• Investigations: DRE, MSU, cytology, STI, PSA ± urodynamics
Tx: info, support, doxazosin 4mg od 6months
Low back pain red flags
• <20 or >55
• Non-mechanical pain, worse when supine, pain at night, thoracic pain
• Past hx of cancer, HIV, immunosuppression, IVDU
• Steroids
• Unwell, weightloss
• Widespread neurology
Structural deformity
Low back pain Hx
• Injury, duration
• Pain/ stiffness at rest/ night (inflammation= better with movement)
Numbness, weakness, bowel/ bladder symptoms
Low back pain Exam
• Deformity: kyphosis, loss of lumbar lordosis, scoliosis
• Palpate for tenderness, step deformity, muscle spasm
• Assess: flexion, extension, lateral flexion, rotation
• LE wasting, power, sensory, reflexes
Straight leg raise: sciatica present if back/ butt pain
Low back pain causes by age
• 15-30: postural, mechanical, disk, trauma, #, AS, spondylolisthesis, pregnancy
• 30-50: postural, disk, spondylarthropathies, discitis, degenerative join disease
• >50: postural, degenerative, pagets, cancer, osteoporotic collapse, myeloma
Other: referred pain, spinal stenosis, CE tumour, infection
Low back pain Sx
• Early: asymptomatic, incidental PSA, hard nodule on DRE • Local disease o Prostatism, hard and nontender on DRE o Retention, haematuria o LE odemea • Metastatic o Malaise, weight loss o Bone pain, pathological #, spinal cord compression
low back pain
Xray indications:
• <25 to exclude Ankolysing spondylitis
• Elderly: collapse, malignancy
History of trauma
Cauda Equina Syndrome
• Compression below L3- most likely a disk
• Px: numbness of buttocks, backs of thighs, urinary/ faecal incontinence, LMN weakness
o L4: loss of dorsiflexion of foot
o S1: loss of ankle reflex, plantarflexion, eversion of foot
Spinal cord compression
• 5% of cancer patients, 70% in thoracic region
• Px: back pain worse with movement
o Neurologic: constipation, weakness, hesitancy, lesions above L1= UMN and below L1= LMN and CE syndrome
• Management: tx <48hrs from first neurological symptom
Scoliosis
Lateral curvature a/w rotation of vertebrae ± ribs or wedging of vertebrae
Causes
o Idiopathic, congenital (butterfly vertebrae)
o TB, metabolic- bone dysplasia, cancer, RT
o NM: cerebral palsy, NF, freidreichs ataxia, muscular dystrophy
o S1: loss of ankle reflex, plantarflexion, eversion of foot
Px: difference in shoulder height, spinal curvature, difference in space btw trunk and UL
Shoulder problems Hx
Pain and stiffness
o Joint pain- anterior and radiates down arm
o Top of shoulder= AC joint or cervical spine
o Referred pain from neck, heart, mediastinum, diaphragm
Deformity: swelling, winging
LOF
Shoulder problems exam
- Look: posture, asymmetry, wasting, swelling, scars
- Feel: tenderness, warmth, swelling, crepitus
- Move/ measure: compare sides, range of movements, power
Shoulder problems clues
Intra-articular: painful limitation of movement- all directions
Tendonitis: painful limitation of movement in one plane
Tendon rupture/ neurological: painless weakness
Shoulder problems red falgs
History of cancer, constitutional symptoms
Recent bacterial infection, IVDU, immunosuppression
Constant/ worsening rest pain
Structural deformity
Stiff, painful shoulder joint DDx
- Adhesive capsulitis- 1° or 2° to DM/ Intrathoracic pathology
- Inflammation, infection
- OA, polymyalgia rheumatica
- Prolonged immobilization
Shoulder dislocation- anterior>
- Due to fall on arm/ shoulder
- Flattening of deltoid and head of humerus anterior bulge
- Damage axillary nerve no sensation on deltoid patch
- Recurrent dicloation: follows trauma, usually bc labral tear
- 25% elderly a/w rotator cuff injury
Acromiocalcivular joint problems
- Pain on top of shoulder due to trauma or OA
- Px: joint tenderness, painful palpation + passive horizontal add
- Management: NSAIDS ± local steroid injection
Shoulder OA
Hx of trauma
A/w crystal-induced inflam and 2° to gout, haemochromatosis
Imaging for synovitis- USS/ MRI
Should replacement if severe
Frozen shoulder aka adhesive capsulitis
40-60years, diabetics and intrathoracic path (MI, lung disease)
Painful, stiff shoulder with global limitation of movement- ER>
Pain worse at night
Management: blood glucose, NSAIDs, physiotherapy, steroid IA
Rotator cuff injury
Acute tendonitis
- Excessive use/ trauma in <40
- Px: severe pain in upper arm, immobile, cant lie on that side
- Resolves spontanelously after few days
- Middle age- due to inflamm around calcific deposits- steroid IA
Rotator cuff injury
Subacromial impingement
- Pain in limited arc of abduction- 60-120° or during IR
- <40 a/w glenohumeral instability- CT laxity or labral injury
- > 40: due to chronic rotator cuff tendinitis or functional cuff weakness/ tear
Rotator cuff injury
Investigations Dx + Tx
Dx
Xray- calcification of supraspinitious tendon in acute tendinitis & irregularities/ cysts at humeral GT if chronic cuff tendonitis
Tx
Rest, immobilization + physiotherapy
NSAIDS, subacromial steroid injections
Rotator cuff injury DDx
Acute tendonitis
Rotator cuff tear (+ subacromial impingemet)
Subacromial impingement
Elbow problems Hx
• Pain and stiffness o Joint pain- diffuse o Tendonitis- localized on epicondyles • Deformity: swelling, winging • LOF Neurology: numbness/ paraesthesia distal to elbow
Elbow problems exam
• Look: carrying angle, effusion, swelling, muscle wasting
• Feel: tenderness, warmth, swelling, crepitus, pulses
Move: active and passive
Elbow problems DDx
Tennis elbow: epicondylitis Golfer’s elbow Dislocated elbow Olecranon bursitis Ulnar neuritis Pulled elbow
Dislocated elbow
- Due to fall on outstretched hand with flexed elbow
* Ulna displaced back, swollen in fixed flexion, can be with #
Olecranon bursitis
- Traumatic due to repeated pressure on elbow
- Pain and swelling
- Aspirate fluid microscopy to exclude gout/ sepsis
- Hydrocortisone if not sepsis
Ulnar neuritis
- Narrowing of ulnar grove due to OA, RA, # pressure on ulnar nerve ulnar neuropathy
- Px: clumsiness of hand weakness ± muscle wasting, sensation
- Tx: surgical decompression ± nerve conduction studies
Pulled elbow
- <5- traction injury to elbow subluxation of radial head
- Occurs when pulled by hand
- Px: child not using arm, L>
- Management: anterior pressure with thumb on randial head while supinating and extending forearm
Tennis elbow: epicondylitis def
Tenderness over lateral epicondyle + lateral pain on resisted wrist extension
Golfer’s elbow def
Tenderness over medial epicondyle + medial pain on resisted wrist pronation
Acute gout
Risks:
- FH
- Obesity, alcohol, high purine diet
- Diuretics, cytotoxic treatment
- RF, leukaemia, psoriasis, ketosis, surgery, acute infection
Acute gout Px:
painful swollen joint, red skin ± fever
Acute gout Investigations:
- Bloods: WCC, ESR, blood urate
- Microscopy of synovial fluid: sodium monourate crystals
- Xray
Acute gout Management:
Rest, elevate joint, ice packs
NSAIDs- naproxen 500mg bd- caution if GI issues
Or colchine 500mg bd increased to qds. SE: N, V, D
Steroid injection of IM- depo- medrone 80-120mg
Acute gout Prevention:
Weight loss, avoid alcohol, red meat, yeasts, muscles
Avoid thiazides and aspirin
Allopurinol 100-300mg od + colchine 500mcg bd OR NSAIDs
Febuxostate if not working or uricosuric- sulfinpyrazone
Hyperuricaemia causes
- Drugs: cytotoxics, thiazides, ethambutol
- increased cell turnover: lymphoma, leukaemia, psoriasis, haemolysis, muscle necrosis
- decreased excretion: primary gout, CRF, lead nephropathy, hyperPT
Chronic gout:
- Recurrent attacks
* Tophi in pinna, tendons, joints + joint damage
Calcium pyrophosphate deposition disease: pseudogout
A/w OA, hyperPT, haemochromatosis
Acute attack can be triggered by intercurrent illness/ metabolic disturbance
PC:
Investigations:
Tx
less severe, knee/ wrist/ shoulder
Xray- chondrocalcinosis- calcification of articular cartilage + joint crystals
Tx like gout
chronic = erosive = refer
Septic arthritis:
<5, hip and knee
Systematically unwell, immobilizes joint
Swollen, hot tender joint
Tx: IV abx ± surgical washout
T-score:
Osteoporosis:
Osteopenia:
Z-score:
Dexa scan:
compare bone mineral density with young adult mean
BMD >2.5 SD below young adult mean
T-score between -1 and -2.5
compare BMD of subjects and age-matched control
Predict osteoporosis risk for future
measure BMD
Osteoporosis Causes: 1° or 2°
- Endocrine: Hypogonadism, hyperthyroidism, hyperparathyroidism, hyperprolactinaemia, cushings, T1DM
- GI: coeliac, malabsorption, IBD, chronic liver, chronic pancr
- RA, inflammatory arthropathies
- Immobility, MM, haemoglobinopathy, systemaic mastocysosis, CF, COPD, CKD, homocystinuria
Fragility fracture
Due to fall ≤ standing height
#: hip, wrist- colles
Osteoporotic vertebral collapse: pain, height, kyphosis
Analgesia 3-6months, Calcitonin after 3mo if all fail
Predicting fracture risk
Glucocorticoid use + OP
FRAX and Qfracture- don’t need BMD and 10y prob of hip #
Minimize use and add bisphosphonate if >65 or hx fragility #
Osteoporosis Tx
lifestyle alendronic acid 70mg once a week raloxifene SERM Denosumab 60mg q6 months HRT Teriparitide injection
alendronic acid SE
osteonecrosis of jaw
atypical femoral fracture
Osteoarthritis Sx
• Pain ± stiffness, synovial thickening, deformity, effusion, crepitus, muscle weakness and wasting, function
• Hip, knee and base of thumb
Exaggerbations that last weeks to months
Osteoarthritis Dx
Xray: loss of joint space, cysts, sclerosis of subchondral bone, osteophytes
FBC, ESR, ANA
Osteoarthritis Tx non meds
Rest, NSAIDs, steroid injection, physiotherapy
weight reduction, walking still, physiotherapy
Aspiration of joint effusion and LA steroid joint injections
Osteoarthritis meds
Nonpharm: exercise, weight loss, footwear, stick, TENS
Paracetomol 1g qds and/or topical NSAIDs
+ opioids, oral NSAIDs or Cox-2 inhibitors (+ omeprazole 20mg)
Antideppressant- amitriptyline 10-75mg nocte
Capsaicism cream if knee/ hand
Other drugs
Glucosamine: OTC- modifies progression
Strontium ranelate: progression & pain and mobility
RA PC
- Middle age>, females >
- Symmetrical small joints- pain, stiffness, swelling, LOF
- Joint damage, deformity, and instability occur later
- Other: monoarthritis, migratory arthritis, systemic features
RA signs
Peripheral joints>, symmetrical pain, effusions, swelling
Morning stiffness
Feet: subluxation of metatarsal heads in feet and claw toes –> painful walking, bakers cysts
Cervical spine: pain, subluxation, atlanto-axial instability –> cord compression
RA nonarticular features
o Nodules on extensor surfaces
o Eye: sjogren’s, episcleritis, scleritis
o Lungs: effusions, fibrosing alveolitis, nodules
o Heart: pericarditis, MV disease, conduction probz
o Skin: palmar erythema, vasculitis, rashes
o Neuro: nerve entrapement, mononeuritis, peripheral neuropathy
o Feltys syndrome: RA, leucopenia, splenomegaly anemia and thrombocytopenia
RA Dx
• FBC, ESR/ CRP, ANA, Rheumatoid factor, anti-CCP
X-ray: periarticular OP/ soft tissue swelling loss of joint space, erosions, joint destruction
RA Comp
• Physical disability, depression
• Osteoporosis
• Infections, lymphoma
CVD, amyloidosis
RA Tx
Physical therapy: exercise, splints, appliances, strapping
NSAIDs + simple analgesia
Ibuprofen 200-400mg tds
Naproxen 500mg bd
Celecoxib 100mg bd- COX2 inhibitor if no CVD
Corticosteroids
IA injection- triamcinolone up to 3x/year
DMARDs
Check baseline U&E, Cr, eGFR, LFTs, FBC, urinalysis
DMARD examples
Methotrexate 7.5-25mg weekly Sulfasalazine 1g bd/tds IM gold 50mg monthly Pencillamine 500-750mg/day Azathioprine 1.5-2.5mg/kg/day Ciclosporin 1.25mg/kg bd Hydroxychloroquine 200-400mg/day Leflunomide 10-20mg/day
Methotrexate 7.5-25mg weekly
Chest XRAY within 1 year of starting, baseline lung function
SE: signs of infection, respiratory symptoms, B12/folate def
Sulfasalazine 1g bd/tds
SE
rash, N&D, BM suppression, B12/folate def
IM gold 50mg monthly
SE
Chest XRAY within 1 year of starting
sore throat, bleeds, bruising, SOB, cough, oral ulcers, rashes, altered taste
Pencillamine 500-750mg/day
SE
rash, altered taste
Azathioprine 1.5-2.5mg/kg/day
SE
GI, rash, BM suppression, avoid live vaccines
Ciclosporin 1.25mg/kg bd
SE:
rash, gum soreness, hirsutism, RF, HT
Hydroxychloroquine 200-400mg/day
SE
Baseline eye check and annual visual acuity
rash, GI, ocular- rare
Leflunomide 10-20mg/day
rash, GI, HT, increased ALT
Fit Hx
- What happened? Where? When? Witnesses?
- Any warning signs? Precipitating events?
- LOC? do they remember?
- Incontinence? Biting tonge? Jerking?
- How did they feel after
Fits exam
• Skin: café-
o Au- lait spots- NF
o Adenoma sebaceum- tuberous sclerosis
o Trigeminal capillary haemangioma- Sturge Weber synd
• CV abnormalities- HR, rhthym, mumers, bruits, BP
• Neurological deficits
Dizziness and giddiness
Vertigo: room spinning
Imbalance: cant walk straight- nerve disease, PC, cerebellum
Faintness: seizure diseases, postural hypo, vasovagal fainting, hyperventilation, hypoglycemia, arrhythmia, cough syncope
Syncope
Abrupt and transient LOC due to reduced CF
Dx:
o Prodromal symptoms: N, sweating, blurring, loss of vision, light- headedness, dizziness, tinnitus
o Anoxic phase: LOC, pallor, sweating, pupil dilates, tachypnea, bradycardia, muscle tone so eyes roll up and may fall
o Recovery: lie horizontal- color, pulse and consciousness will return
o After: confusion, amnesia, drowsiness not prolonged. In continence and injury rare
Hypoglycaemia
Pallor, sweating, tachycardia, confusion, behavioral changes
Can lead to hyperglycaemia, coma ± fit
headache Hx + exam
socrates
Examination
• Fever, purpuric skin rash
• BP, neuro exam- fundi, acuity, gait
• Palpate sinuses, examine neck
Headaches red flags
- Fever + worsening headache ± purpuric rash
- Thunderclap headache- peak intensity <5min
- Progressive
- A/w postural change
- Head trauma, personality/ cognitive/ personality change
Acute new headache
• Meningitis: fever, photophobia, stiff neck, rash
o IV/ IM penicillin V + admit
• Encephalitis: fever, confusion, consciousness
• Subarachnoid haemorrhage: thunder clap ± stiff neck
• Head injury” injury, conscious, lucidity period, amnesia
• Viral illness, sinuisitis, dental caries, tropical illness
Acute recurrent headache
- Migraine: aura, visual probz, N/V, triggers
- Cluster headache: pain at night in 1 eye for 2-3mo, pain free >1y
- Exertional or coital headache : NSAID or propranolol before
- Trigeminal neuralgia: pain for secs in nerve disturb
- Glaucoma: red eye, haloes, acuity, pupils abnormal
Subacute headache
Giant cell arteritis:
>50
scalp tenderness
INCREASED ESR
Chronic headache
Tension type headache: band around head, stress, low mood
Carvicogenic headache: uni or bi band, scalp tenderness
Medication overuse: rebound on stopping analgesia
ICP: worse at morning, sneezing, DECREASED pulse, INCREASED BP, neuro signs
Pagets disease: >40y, bowed tibia, INCREASED Alk Phos
Status Epilepticus: >1 minute without regaining consciousness or >5minutes with medication
airway is clear
recovery position
No medications for first 5 minutes
>5min: midazolam buccal liquid or recal diazepam or IV lorazepam
call for ambulance
administer drugs again after 10-15 min, check blood glucose
Delirium tremens:
Major alcohol withdrawl symptoms 2-3 days after cessation
pyrexia, tachy, HT, tachypnea
visual/ tactile hallucinations, acute delirium, apprehension
tremor, fits, fluctuation consciousness
Migraine
Tx acute attack
combination with
Sumatriptan 50-100mg po +
naproxen 500mg bd or paracetamol 1g qds ±
prochlorperazine 5mg/ metoclopramide 10mg/domperidone 10-20mg-antiemetic
Migraine Tx chronic attack
Psychological factors: stress, anxiety, depression
Environment: noise, bright/ flickering lights, strong smells, stuff atmosphere, extreme heat
Food: lack of, infrequent meals, caffeine, chocolates
Sleep: overtiredness, change in sleep pattern, travel
Health: hormonal, HT, toothache/ pain in eye, sinuses
Migraine Prophylaxis if ≥4 attacks/ month or severe
Propranolol 80-160mg or topiramate 20-50mg od/bd
Gabapentin up to 1200mg/d or acupuncture
Botulinum type A toxin
Riboflavin 400mg od
Trigeminal neuralgia Tx
o Carbamazepine 100mg od/bd and increase dose 200-400
o Pregabalin 75mg bd- max 300mg bd
Amitriptyline start at 25mg at night and increase by 10-25mg every 5-7days to max of 75mg- 10mg in elderly
Cluster headache Tx
o Acute: O2 for 10-20min, sumatriptan 6mg sc or 20mg nasal- 5HT1 agonist
o Prophylaxis: verapamil 80mg tds/qds if frequent + ECG
Facial pain tx
- Atypical= no cause, tx with Paracetamol or NSAIDS
* If doesn’t work- amitriptyline 1075mg nocte
Raised ICP PC
- Headache + drowsiness, LOC, V, focal neuology ± seizures
- Irritability, VI nerve palsy, pupil change, papilloedema
- Dropping pulse, raising BP
Benign intracranial hypertension
Symptoms without cause
Young, obese women
Tx: repeat LP, ventriculo-peritoneal shunt, diuretics, dexameth
Brain abscess
Haematological spread, direct, or local extension
Px: ICP, focal neurology, systemic/ local effects over 2-3wk
Tx: IV abx ± surgical drainage
Hydrocephalus
Communicating: decreased reabsorption of CSF. Post meningitis, SAH, trauma, neoplastic infiltration of subarachnoid space
Non- communicating: CSF flow blocked due to obstruction in ventricles. Congenital malformation, tumour, brain abscess, SAH, meningeal scarring, trauma
Px: infants with macrocephaly, convulsions, developmental delay ± spacity. Adults with
increasing ICP
Intracranial tumours
1° tumours
2°
Astrocytoma Oligodendroglioma Glioblastoma multiforme Ependymoma Meningioma Cerebellar haemangioblastoma
met from breast, lung or melanoma
Intracranial tumours Px:
increased ICP
Seizures- 25-30%
Evolving neurology: >50%
False localizing signs: VI nerve palsy –> double vision
Local effects- skull base masses, proptosis, epistaxis
Personality change
Intracranial tumours Prognosis:
Intracranial tumours DDx:
gliomas have <50% 5 year survival
stroke MS injury vasculitis encephalitis Todd’s palsy metabolic/ electrolyte disturbance space occupying lesion
Meningitis and Encephalitis early PC
rapid onset <48hrs Fever, vomiting, malaise, poor feeding, lethargy Severe leg pain- cant walk Cold hands/ feet with fever Pale skin ± cyanosis around lips
Meningitis and Encephalitis
Sx
Headache, stiff neck, photophobia, Kernig’s sign +ve
Increased ICP symptoms
Septicaemia symptoms
Meningitis and Encephalitis
late onset effects
Hearing loss
Ongoing neurological probz- fits, hemiparesis
Orthopaedic probx- bone/ joint damage poor limb growth
Psychosocial effects
increased ICP
Drowsiness, reduced consciousness Abnormal tone/ posture Focal neurological signs, fits, vomiting Irritability Bradycardia, hypertension Bulging fontanelle in baby
Septicemia
Fever, arthiritis Hypotension, tachycardia, tachpnoea Cold peripheries, mottled skin, cyanosis, cap refill >2sec Peripheral O2 sat ≤95% ± rash= meningococcus
Meningitis and Encephalitis prophylactic Abx
Ciprofloxacin 500mg single dose OR
Rifampicin 600mg bd for 2 days, turns urine red
Meningococcal Vaccinations
• Group C: 40% meningococcal disease
Group B: for the rest
Group A: in other parts of world
• Meningoccocal A + C vaccine: travelling to high risk area • Meningitis B vaccination- Bexsero o Need booster after 1 month o 2-11: after 2 months o <2: 3 doses 1 month apart • Meningitis C conjugate vaccine o Infants: 3 and 12 months, booster at 13years o HIV+v
Parkinsonism
Tremor- coarse, mostly at rest, “pill-rolling”
Cogwheel rigidity
Difficulty initiating movement
Slowness of movement
Shufflng and festinant gait: small steps, flexed to “catch up”
Micrographia- small handwriting
Parkinsonism Causes
PD/ AD
Post- encephalitis, toxins, trauma, normal P hydrocephalus
Drugs: haloperidol, chlorpromazine, metoclopramide
Stop drug. If schiz- do not stop but add procyclidine 2.5mg tds- antimuscarinic
Parkinsons meds
Dopamine receptor agonists- bromocriptine, pergolide
L-dopa: precurose or dopamine
MAO B inhibitors: selegline, rasagaline
Amantadine: for bradykinesia, dyskinesia, tremor, rigidity
Inhibit dopamine breakdown: entacapone, tolcapone
Bromocriptine, pergolide
first line
Gradually increase and withdraw
Can use with L-Dopa during off times and motor impairment
A/w pulmonary, retroperitoneal, pericardial fibrosis check CXR ± spirometry, ESR, Cr
L-Dopa
start with low dose and slowly increase
Only in PD
Given with cardidopa or benserazide- prevent peripheral breakdown- don’t cross BBB
Improves bradykinesia and rigidity > tremor
With time: increased response and SE:
On-off effect- fluctuation between exaggerated involuntary movements and periods of immobility
End- of- dose effect- duration of benefit reduces with each dose
decreased with selegiline/ rasagaline OR entacpone/ tolcapone
abnormal involuntary movements
Acute Stroke causes
- Cerebral infarction: thrombus or embolus from LA or LV
- Intracerebral or subarachnoid haemorrhage: direct neuronal injury and pressure adjacent ischaemia
- Sudden BP, vasculitis, venous- sinus thrombosis, CA dissection
Acute Stroke PC
- Hx: sudden CNS symptoms or stepwise progression
* Ex: neurological signs (dysphagia, incontinence), BP, HR and rhythm, murmur, carotid bruits, systemic signs
TIA risk
ABCD2 o Age: <60= 2 or ≥60=1 o BP: systolic ≥140 or diastolic ≥90 o Clinical: uni weakeness= 2, speech w/o weakness =1 o Duration: ≥1hr=2, 10-59min=1, <10min=0 o Diabetes: 1
TIA management
Symptoms <24 hours
Admit if > TIA in <1 week
If symptoms stopped- aspirin 75mg od
FBC, ESR, U&E, Cr, eGFR, lipids, glucose, thrombophilia, clotting
Tx HT, hyperlipideamia
CHA2DS2- VASc score CCF= 1 HT=1 >75=2 and 65-74= 1 DM= 1 F= 1 or Prior stroke/ TIA= 2 Vascular disease= 2
0= low risk. No antithrombotic or aspirin
1= moderate. Aspirin or anticoagulation po
≥2= high. Anticoagulant PO
secondary prevention
• Lifestyle: smoking, exercise, diet, salt, alcohol
• Antiplatelet: not on warfarin and non-hemorrhagic stroke
o Clipidogrel 75mg od OR
o Aspirin 75mg od + dipyridamole S/R 200mg bd
• Oral anticoagulation: rheumatic MV disease, prosthetic valves, dilated cardiomyopathy, AF
o Warfarin vs dabigatran
• Antihypertensives
o Cholesterol: simvastatin 40mg od if total is >3.5mmol/L
Carotid stenosis and carotid endarterectomy
Endarterectomy decreases mortality if carotid stenosis symptomatic
HAS-BLEED: risks vs benefits
• Uncontrolled, SBP>160=1
• Abnormal LFT= 1
• Abnormal RFT=1
• Stroke hx= 1
• Prior major bleed/ predisposition of bleed= 1
• Labile INR= 1
• ≥65= 1
• Drugs predisposing to bleeding- antiplatelet, NSAIDs=1
• Alcohol= 1
≥3= 1 year bleed risk on anticoagulation
