Академический Документы
Профессиональный Документы
Культура Документы
Past Spotters
Parkinsons Disease Pagets Disease Stomas AV Fistulas Neurofibromatosis Atrial Fibrillation Duputyrens Contracture
Parkinsons Disease
History
Gait
Inspection
Festinant gait, reduced arm swinging, flexed posture, difficulty starting and stopping, turning, retropulsion Micrographia
Examine
Other tests
Rigidity- cog wheeling Tremor Bradykinesia Loss of postural reflexes Glabellar Tap
reinforced by synkinesis
Parkinsons Continued
TriadTriad- tremor, rigidity, bradykinesia Differential Vascular events-strokes events Orthostatic hypotension+ atonic bladder= MSA Dementia + vertical gaze= SRO Syndrome Kayser Fleisher rings = Wilsons disease Apraxic gait= communication hydrocephalus Antipsychotics, antiemetics
Management
MDT Approach Assess disability/cognition eg time to walk 10m, dress alone Medication when QoL affected eg L-Dopa + Dopa LDecarboxylase Inhibitor, MR forms, newer drugs eg D agonist- Ropinirole, agonistcarbergoline Anticholinergics (help motor symptoms) ModafinilModafinil- daytime sleepiness (all in OHCM)
Pagets Disease
Briefly Examine legs Inspection: Sabre Tibia, lateral bowing of femur Feel: Warmth Complete examination by: Examine skull appearance (>55cm abnormal) Hearing defect (conductive(conductiveossicles or VIII nerve compression OA involvement Raised JVP (HF, Hyperdy Circ) Kyphosis (Auscultate vertebral bodies for bruits)
Diagnosis Normal Ca & Phosphate ALP Urinary hydroxyproline secretion Complications Bone- #s, sarcomatous change Bone1% in 10 yrs Neurology- CN palsies, cord Neurologycompression, headache, fits Cardiac- high output HF CardiacManagement Symptomatic- analgesia, Symptomaticbisphosphonates, calcitonins Surgical- for OA Surgical-
Pagets Continued
Radiological Features:
Local bony enlargement, patchy cortical thickening, scelrosis, osteolysis, deformity SkullSkull- Honeycomb, Cotton wool VertebraVertebra- Picture frames sclerotic changes PelvisPelvis- Brim Sign, thickening iliopectineal line, enlargement of pubic and ischial bones
Stomas
Stoma Type Location Features
Perm/Temp, mucosa sutures to skin (flush)
Output
SemiSemi-solid, intermittent passage
Indication
Colorectal Ca, Diverticular Dis, Bowel Isch, Trauma
Colostomy
LIF/ R Hypochondrium
Ileostomy
RIF
Liquid stool, bile Usually stained, permanent, spout, (non flush) continuous
Bowel Ca, IBD (UC), Trauma, Bowel Isch, Obstruction, Renal Tract Ca, Obstruction, Hydronephrosis
Urostomy
Stomas Continued
Complications
Early
Haemorrhage Stoma Ischaemia High Output Obstruction (adhesions) Stoma retraction Dermatitis, Stoma Prolapsed Parastomal hernia Fistulae Obstruction
Delayed
Psychosocial, physical prep and support Clinical stoma nurse specialist Counselling How to manage stomas Stoma site avoided:
RRT
Types of dialysis
BrachioBrachio-cephalic, RadioRadiocephalic, ulna-basilic ulna2-3 months arterialised matured Scar, dilated veins, thrill, bruit Venous stenosis, Thrombosis, Distal Ischaemia, infection, aneurysm.
Indications
Examination
Complications
ARF/CRF
RRT Continued
Peritoneal dialysis
Renal Transplantation
Tenkoff catheter Peritonitis Infection around catheter site Constipation Pleural effusions CI- Peritoneal adhesions, stoma, hernia, intra-abdo
Complications
ESRF Cadaver/ live donor Lifelong immunosuppression CI- HIV, Cancer, Severe heart disease
Complications
Neurofibromatosis
caf au lait macules >5mm (prepubertal) >15mm (postpubertal 2 neurofibromas or 1 plexiform Freckling Optic glioma 2 lisch nodules Osseous lesions First degree relative affected MDT Annual BP & cutaneous survey Genetic counselling Removal of dermal neurofibromas
Bilateral vestibular schwannomas First degree relative affected or Unilateral vestibular schwanoma Neurofibroma, meningioma, glioma, jeuvenille cataract
Management
Management
Annual hearing test and MRI from puberty Clear scan 30 yr- unlikely inherited Neurosurgery Complication, hearing loss, facial palsy
Atrial Fibrillation
Examine pulse & comment: Radial-rate/rhythm Radial Carotid- character/volume Carotid Discrepancy in radial and apical rate Examine CVS DifferentialDifferential- AF/ Multiple Ventricular Ectopics Causes: CARDIAC- Hypertension, HF, CARDIACcardiomyopathy, mitral valve disease RESP- pneumonia, lung ca, RESPsarcoidosis Other- hyperthyroidism, post-op, Otherpostalcohol, PE
Diagnosis + tests: ECG, U&Es, TFTs, Cardiac enzymes, echo Complications: Embolic Stroke, Intestinal Ischaemia, Acute Limb Ischaemia Management: Treat cause eg MI, PE, Pneumonia Are they Haemodynamically Stable? DC cardioversion or Drug Cardioversion. Acute AF/ Chronic AF (OHCM) ANTICOAGULATION, Warfarin (INR 2-3 / Aspirin 300mg + PPI), 2Warfarin CI. Ablative therapy
Hypercholesterolemia
Screen
Management
CHD/ risk f/h CHD or 65yr <CHD Xanthomata, xanthelasmata 50yr <Corneal arcus Pls be aware of 5 types (OHCM)
Primary Hyperlipidaemia
Secondary Lipidaemia
Exclude familial/2 hyperlipidaemias Lifestyle advice, BMI, Omega3, exercise 1st Statins CI porphyria, myositis, LFTs (decrease synthesis) 2nd Fibrates (decreases absorption) Hypertriglyceridaemia, fibrates, nicotinic acid, fish oils Residual plaques- excision, cryotherapy
Ankle Oedema
Inspection
Swollen, bi/unilateral, hyperkeratosis, discoloured nails Pitting/ non-pitting Inguinal lymphadenopathy Signs of right HF, JVP Hepatomegaly, fluid overload
Palpate
CENTRAL- RHF, hypoalbuminaemia, nephrotic syn, hypothyroidism PERIPHERAL- DVT, venous insufficiency 1-congenital disease eg Milroys 2- malignancy, infection, post surgery/radiotherapy Non Surgical- Stockings, elevation, Rx cellulitis Surgical- rare, done when occlusion of lymphatics
1/2 lymphoedema
Completion
Management
Duputyrens Contracture
Progressive painless thickening of palmar fascia, skin puckering & teathering Ring + little finger Bilateral Huestons Table Tops Test +ve Causes
Management
Complications
GOOD LUCK!!
Any Question ?