Selected Notes gerries Flashcards
What is benign paroxysmal positional vertigo?
<ul><li>Sudden episodic attacks of vertigo induced by changes in head position</li></ul>
Describe the epidemiology of benign paroxysmal positional vertigo
<ul><li>Leading cause of vertigo</li><li>Increased incidence in the elderly</li><li>Increased risk in those with gallstones(calcium deposits)</li></ul>
Describe the aetiology of benign paroxysmal positional vertigo
<ul><li>Detachment of otoliths from the utricle of the inner ear</li><li>Detached particles migrate into semicircular canals where they stimulate hair cells and lead to vertigo symptoms</li><li>Acummulation of cholelithiasis in semi circular cells of inner earrr</li></ul>
Describe the presentation of patient with benign paroxysmal positional vertigo
<ul><li>Vertigo triggered by changes in head position (e.g. rolling in bed, looking up)</li><li>Recurrent episodes lasting aroung 30secs-1 minute</li><li>May be associated with nausea </li><li>No auditory symptoms</li></ul>
How is benign paroxysmal positional vertigo diagnosed?
<ul><li>Positive Dix-Hallpike maneouvre</li><li>Lie down with one ear pointed to ground-> check for nystagmus</li></ul>
Name some differentials for benign paroxysmal positional vertigo
<ul><li>Menieres disease</li><li>Vestibular neuritis</li><li>Labyrinthitis</li></ul>
How is benign paroxysmal positional vertigo managed?
<ul><li>Epley manouvere-works in around 80%(aims to detach otoliths out of semicircular canal and back to utricle)</li><li>Usuaully resolves spontaneously after a few weeks/months</li><li>Can teach patients at home exercises: 'vestibular rehab': e.g Brandt-Daroff exercises</li><li>Betahistine not very useful</li></ul>
Describe the prognosis for benign paroxysmal positional vertigo
<ul><li>1/2 will have recurrence of sx 3-5 years after diagnosis</li></ul>
What group of patients are more at risk of developing pressure ulcers?
<ul><li>Patients who are unable to move parts of their body due to illness, paralysis or advancing age</li></ul>
Where do pressure ulcers typicallly develop?
<ul><li>Over bony prminences like the sacrum or heel</li></ul>
Name some risk factors for developing pressure ulcers?
<ul><li>Malnourishment</li><li>Incontinence-> urinary and faecal</li><li>Lack of mobility</li><li>Pain-> leads to decreased mobility</li></ul>
What scoring system is used to grade pressure ulcers?
<ul><li>Waterlow score</li></ul>
<b>Pressure ulcers grading:</b><br></br>Grade 1: {{c1::non-blanchable erythema of intact skin. Discolourationof skin, warmth, oedema or hardness used as indicators}}<br></br>Grade 2: {{c2::Partial thickness skin loss involving epidermis/dermis or both. Ulcer is superficial and present clinically as an abrasion/blister}}<br></br>Grade 3: {{c3::Full thickness skin loss involving damage to or necrosis of SC tissue that may extend down to but not through underlying fascia}}<br></br>Grade 4: {{c4::Extensive destruction, tissue necrosis ordamage to muscle, bone or supporting structures with/wihtout full thickness skin loss}}
How are pressure ulcers manageed?
<ul><li>Moist wound environemnt: hydrocolloid dressings and hydrogels(no soap)</li><li>Wound swabs not routinely done-> systemic abx use decided on clinical basis(surrounding cellulitis etc)</li><li>Consider referral to tissue viability nurses</li><li>Surgical debriedement for selected wounds</li></ul>
Whata re lower urinary tract sympotms?
<ul><li>Group of sx that occur as a result of abnormal storage, voiding or post micturition function of bladder, prostate or urethra</li></ul>
Describe the aetiology of LUTS
<ul><li>Neurological</li><li>Bladder</li><li>Prostate</li><li>Urethral</li><li>Other mass effect</li></ul>
How can LUTS be classified?
<ul><li>Voiding</li><li>Storage</li><li>Post-micturition</li></ul>
Name somee voiding symptoms LUTS
<ul><li>Hesitancy</li><li>Straining</li><li>Terminal dribbling</li><li>Incomplete emptying</li><li>Weak/intermittent urinary stream</li></ul>
Name some storage sx LUTS
<ul><li>Urgency</li><li>Frequency</li><li>Nocturia</li><li>Urinary incontinence</li></ul>
Name some post-micturition sx LUTS
<ul><li>Post-micturition dribbling</li><li>Sensation of incomplete emptying</li></ul>
Name some differentials for LUTS
<ul><li>Bladder outlet obstruction</li><li>Overactive bladder syndorme</li><li>Urethral stricture</li><li>Prostatitis</li><li>Bladder cancer</li></ul>
What investigations might be done in a patient presenting with LUTS?
<ul><li>Urinalysis: exclude infection and check for haematuria</li><li>DRE: size and consistency of prostate</li><li>PSA test may be considered</li><li>Bladder diary</li><li>Urodynamic studies</li></ul>
How are LUTS managed?
<ul><li>Treat undelrying cause</li><li>Depends on type of LUTS</li></ul>
How aare voiding LUTS managed?
<ul><li>Conservatrive: pelvic floor/bladder trianing</li><li>BPH-5-alpha reductase inhibitor-finasteride</li><li>Alpha blocker if severe-doxazosin</li></ul>
How are voiding and storage LUTS managed?
<ul><li>Alpha blocker-doxazosin</li><li>Add anticholinergic-oxybutinin</li></ul>
How are overactive bladder symptoms managed?
<ul><li>Conservative: fluid management</li><li>Antimuscarininc if persistent-oxybutinin, tolteridone</li></ul>
How is nocturia managed?
<ul><li>Manage fluid intake at night</li><li>Furosemide 40mg in late afternoon</li><li>Desmopressin</li></ul>
What are the different types of urinary incontinence?
<div><ul><li>Stress-> leaking small amounts when laughing/coughing</li><li>Urge/overactive-> detrusor overactivityy</li><li>Mixed: urge/stress</li><li>Overflow-> bladder outlet obstruction</li><li>Functional</li></ul></div>
What causes overflow incontinence
<ul><li>Bladder outlet obstruction(e.g. prostate enlargement)</li></ul>
Name some reversible causes of urinary incontinence
DIAPPERS<br></br><ul><li>Delirium</li><li>Infection</li><li>Atrophic vaginitis/urethritis</li><li>Pharmaceutical(medications)</li><li>Psychiatric disorders</li><li>Endocrine disorders(diabetes)</li><li>Restricted mobility</li><li>Stool impaction</li></ul>
What investigations migh tbe done to look for causes of urinary incontinence?
<ul><li>Physical exam: organ prolapse ad ability to contract pelvic floor muscles</li><li>Bladder diary: number and types of incontinence</li><li>Urinalysis: rule out infection</li><li>Cytometry: measurees bladder presure whilse voiding(not recommended where clear diagnosis)</li><li>Cystogram: Contrast in bladder and imaging(fistula)</li></ul>
What is stress incontinence?
Leaking of urine when abdominal pressure is high-> increases pressure on bladder
Name some risk factors for stress incontinence
<ul><li>Childbirth(especially vaginal)-> injury to pelvic floor muscles and connective tissue</li><li>Hysterectomy</li></ul>
Name some triggers for stress incontinence
<ul><li>Coughing</li><li>Laughing</li><li>Sneezing</li><li>Exercise</li><li>Anything that increases abdominal pressure</li></ul>
Describe the management of stress icontinence
<ul><li>Conservative: avoid fizzy, caffeinated drinks, pelvic floor exercises</li><li>Medical: Duloxetine</li><li>Surgical: GS: mid urethral slings(minimally nvasive, done as outpatients)</li></ul>
Name some risk factors for urge incontinence
<ul><li>Recurrent UTI</li><li>High BMI</li><li>Increasing age</li><li>Smoking</li><li>Caffeine</li></ul>
Describe the management of urge incontinence
<ul><li>Conservative: Bladder training, avoid alcoholic/caffeinted/sugary drinks</li><li>Medical: anticholinergics: oxybutinin, tolterodine, fesoterodine</li><li>Surgical: bladder instillation, sacral neuromodulation</li></ul>
Name a side effect of tolterodine
<ul><li>Increased risk of delirium</li></ul>
Name the causes of overflow incontinence
<ul><li>Underactivity of detrusor muscle(e.g from nerve damage) or if urinary outlet pressures are too high(constipation, prostatism)</li></ul>
What is functional incontinence?
<ul><li>Urge to pass urine but can't access facilities so experience incontinence</li></ul>
Name some causes/risk factors for functional incontinence
<ul><li>Sedating meds</li><li>Alochol</li><li>Dementias</li></ul>
What is quamous cell carcinoma?
<ul><li>Locally invasive malignant tumour of epidermal keratinocytes</li><li>With invasion of basement membrane as it is a cancer</li></ul>
Name some risk factors for SCC
<ul><li>Excessive exposure to sunlight/UV light</li><li>Actinic keratosis and Bowen's disease-> predisposing lesions</li><li>Genetics: xeroderma pigmentosum</li><li>Immunosuppresion</li><li>Smoking</li><li>Old age</li><li>Male</li></ul>
How might patients with SCC present?
<ul><li>Keratinised, scaly irregular nodules</li><li>Might be ulcerating or have everted edges</li><li>Often in sun exposed areas</li><li>Usually slow growing(months)</li><li>Pain, tenderness, bleeding</li><li>Complicaotins for local invasion-distant metastases is rare</li></ul>
How is SCC diagnosed?
<ul><li>Excision biopsy with 4mm margin</li><li>Might require 6mm margin if high risk</li></ul>
Name some features of a possible SCC that make it more high risk
<ul><li>>2cm diameter</li><li>Located on ear, lip, hands, feet or genitals</li><li>Elderly or immunosuppressed</li><li>Histology: poor differentiation, blood/nerve involvement, SC tissue invasion</li></ul>
How is SCC treated?
<div><ul><li>Surgical excision</li><li>Radiotherapy may be needed</li><li>Lifestyle to prevent further lesions-> sunscreen</li></ul></div>
What is the prognosis for SCC
<ul><li>5 year survival of 99% if detected early</li></ul>
Name some poor prognostic factors for SCC
<ul><li>Poorly differentiated</li><li>>2cm diameter</li><li>>4mm deep</li><li>Immunosuppression</li></ul>
How can constipation be classified?
<ul><li>Primary: no organic cause: dysregulation of function of colon/anorectal muscles</li><li>Secondary: diet, medications, metabolic, endocrinee, neuro, obstruction</li></ul>
What criteria is used for classifying constipation?
<ul><li>Rome 6 criteria</li></ul>
Describe the Rome 6 criteria for constipation
<ul><li><3 bowel movements/week</li><li>Hard stool in >25% of movements</li><li>Teenesmus in >25% of movements</li><li>Increased straining in >25% of movements</li><li>Need for manual evacuation</li></ul>
<div><br></br></div>
<div>Any or all of them can constitute a diagnosis of constipation</div>
Name some risk factors for constipation
<ul><li>Increasing age</li><li>Inactivity</li><li>Low calorie diet</li><li>Low fibre diet</li><li>Certain medications</li><li>Female</li></ul>
Name some possible causes of constipation
<ul><li>Inadequate fibre or fluid intake</li><li>Behavioural: inactivity of avoidance of defaecation</li><li>Electrolyte distrubances like hypercalcaemia</li><li>Drugs: opiates, CCBs, antipsychotics</li><li>Neurological: spinal cord lesions, Parkinson's, diabetic neuropathy</li><li>Endocrine-> hypothyroidism</li><li>Colon disease-> strictures/cancer/obstruction</li><li>Anal disease-> fissures</li></ul>
Name some red flag associated features of constipation
ALARMS<br></br><ul><li>Anaemia</li><li>Lost weight</li><li>Anorexia</li><li>Recent onset</li><li>Melaena/bleeding</li><li>Swallowing difficulties</li></ul>
What investigations might be done in a patient with constipation?
<ul><li>Constipation/diarrhoea+ weight loss+ >60yrs-> 2wwk wait urgent CT/US to rule out pancreatic cancer</li><li>Often no need for further ix</li><li>PR exam</li><li>Stool sample: mcs, ova, cysts, parasites</li><li>FIT testing</li><li>Faecal calprotectin</li><li>Bloods: anaemia, hypercalcaemia, hypothyroidism</li><li>Barium enema if suspicion of impaction/rectal mass</li><li>Colonoscopy-> lower GI malgnancy</li></ul>
Describe the management of constipation
<ul><li>Conservative: dietary imrpovements and increase exercise</li><li>Laxatives</li></ul>
What are the different types of laxatives
<ul><li>Bulking agents</li><li>Stool softeners</li><li>Stimulants</li><li>Osmotic laxatives</li><li>Phosphate enemas</li></ul>
Give an example of a bulking agent
<ul><li>Ipsaghula husk</li></ul>
How do bulking agents work?
<ul><li>Increase faecal bulk and peristalsis</li></ul>
