CEREBELLAR DISORDER

COMMON CAUSES OF CEREBELLAR SYNDROMES

Acute (hours to days)
Cerebellar infarcts (Wallenberg / PICA syndrome)
Cerebellar hemorrhage
Encephalitis
Phenytoin toxicity

Subacute (weeks to month)
Alcohol abuse
Metastases
Paraneoplastic syndromes
Multiple sclerosis

Chronic (months to years)
Hereditary cerebellar degenaration (spinocerebellar ataxia)

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SHORTCASE
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UPPER LIMB (4)
1. arms outstretched and eyes closed --> limb of affected side DRIFT AWAY
2. arms outstretched, same level, quick push downward --> affected side REBOUND
3. finger-nose test --> INTENTIONAL TREMOR + DYSMETRIA
4. rapid alternating movement --> DYSDIADOCHOKINESIA

HEAD (3)
1. Eye --> HORIZONTAL NYSTAGMUS (> when look toward affected side)
2. Speech --> SCANNING/STACCATO
3. Head --> TITUBATION

TRUNK (1)
1. Sit patient up without support --> TRUNCAL ATAXIA

LOWER LIMBS (2)
1. Heel-shin test --> DYSMETRIA + INTENTIONAL TREMOR
2. Knee reflex --> PENDULAR KNEE JERK

GAIT (2)
1. Walk --> BROAD BASE + REEL TOWARD AFFECTED SIDE
2. Rombergs test --> NEGATIVE (in cerebellar disorders)

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Notes
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Unsteadiness + broadbase gait
= ?cerebellar OR ?vestibular OR ?proprioceptive

Vestibular
nystagmus; no other definite cerebellar signs; romberg negative

Proprioceptive
cerebellar sign may present; typically worse when eyes closed; romberg positive

Cerebellar
cerebellar signs; romberg negative

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FOOT CARE IN DIABETIC PATIENT

Keep diabetis under good control and do not smoke.

Check your feet daily. Report any sores, infection, or unusual signs.

Wash your feet daily.
Use lukewarm water (beware of scalds)
Dry thoroughly, especially between toes
soften dry skin, especially around the heels, with ?lanoline
apply methylated spirits between toes to help stop dampness

attend to toenails regularly
clip them straight cross
do not cut them deep into the corners or too short across

wear clean cotton or wool socks daily; avoid socks with tight elastic tops

exercise the feet each day to help the circulation in them

avoid injury to the foot
wear good-fitting, comfortable leather shoes
shoes must not be too tight
do not walk barefoot, especially ot of doors
do not cut your own toenails if you have difficulty reaching them or have poor eyesight
avoid home treatments and corn pads that contain acids
be careful when you walk
do not use hot water bottles or heating pads on feet
do not test the temperature of water with your feet
take extra care when sitting in front of an open fire or heater

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Causes of unilateral leg swelling:

Vessel - Artery - acute limb ischemia
Vein - Chronic venous insufficiency (varicose vein), DVT, post-phlebitic leg synd
Lymph - lymphedema (non pitting)
Bone - # , tibia osteomyelitis
Soft tissue - swelling (post-trauma - knee sprain/injury, gastrocnemius muscle tear/haematoma, cruciate knee ligament tear)
Skin - cellulitis
Tumor - osteosarcoma (compression of large veins by tumor)
infection eg filariasis
others:
necrotising fascitis
compartment synd
Ruptured baker's cyst

find it easier to rmb based on the anatomical structure thr:)
Hope it helps:)

Posted by CP,
feel free to comment if i am wrong and if thr's any additional info pls feel free to add:) TQ!

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basic breath sounds and heart sounds/murmurs

download here..hope this will be beneficial to refresh our memory.

click link below to download

breath sounds

heart sounds application

edited :)

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addition
--------------------

breath and heart sounds
(not sure whether it is the same with above or not...)

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Simple Acid-Base Disorders and Expected Compensation

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Contraindications to lumbar puncture

A lumbar puncture should not be performed in a patient with suspected meningococcemia when certain conditions are present. This is intended to minimize the risk for cerebral herniation or other adverse effect when there may be little additional information obtained from the CSF studies.

Contraindications to lumbar puncture:

(1) confident clinical diagnosis of meningococcal disease, with typical hemorrhagic rash

(2) drowsiness or impaired consciousness

  Glasgow coma scale <>

  deteriorating Glasgow coma scores

  signs of raised intracranial pressure

(3) focal neurologic signs

(4) signs of raised intracranial pressure, including marked instability in blood pressure and heart rate

(5) evidence of septic shock, with signs of poor perfusion

(6) infection at the planned lumbar puncture site

(7) moderate to severe bleeding disorder

Additional notes:

(1) A normal CT scan does not exclude a raised intracranial pressure.

(2) If lumbar puncture is not performed and the patient has not improved within 24 hours despite therapy, then reassess the need for lumbar puncture.

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2010 Rheumatoid Arthritis Classification Criteria

click image to enlarge

Application of these criteria provides a score of 0–10, with a score of >/= 6 being indicative of the presence of definite RA.

A patient with a score below 6 cannot be classified as having definite RA, but might fulfill the criteria at a later time point.

for details, you may need to read journal on "2010 Rheumatoid Arthritis Classification Criteria" by An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative

or

READ ONLINE HERE

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scabies

Treatment of scabies

topical medications:

1. topical benzyl benzoate lotion

• (25% for adults, 12.5% for children aged 3 to 12)
• 3 applications at 24-hour intervals

2. topical lindane (1%)

• 2 applications for 8 hours

3. topical permethrin 5% lotion

• single application, washed after 8 hours

4. crotamiton cream (eurax) repeat nightly for 3 to 5 nights

5. sulphur in calamine lotion: useful in pregnant or nursing mother and neonates

oral medication

• ivermectin
• 200ug/kg

Procedures

• apply the entire skin from neck below
• pay special attention to the groin, fingerwebs, toewebs

Adjuvant therapy

• antihistamine for relief of itch
• topical corticosteroids

Environment measures

• treatment of all close contacts even if asymptomatic
• wash all bed linens, towels and clothes that were worn in the 2 days before each application. use hot water.

source: if not mistaken it's from the dermato lecture

jh A111218

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addition pictures
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upper motor neuron vs lower motor neuron

upper motor neuron and lower motor neuron

compare both.

read below.

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fever, chills, rigors

DEFINITION FEVER
elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point—for example, from 37C to 39C (shift of the set point from “normothermic” to febrile levels)

CHILLS
a sensation of coldness

RIGORS
exaggerated shivering

how all of these related?
fever comes with abnormally high body temperature, but why the patient can has chills and rigors (or shivering)?

read more below

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vital signs

heart rate
respiratory rate
blood pressure
temperature
pain score

i'm not very sure whether pain score is still the vital sign, but in 2008, KKM add in the 5th vital sign which is PAIN SCORE.

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ESTIMATED PEFR IN ASTHMATIC PATIENT

[5 x (height in centimetre)] - 400

however, in exam, please mentioned that you will compare the result with PEF chart.


thanks to hanim

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MOCK OSCE SURGERY - X-Ray

Describe the salient features. (5 marks)
Increased radiolucency right hemithorax
Trachea shifted to the left
Loss of vascular markings
Mediastinal shift
Collapsed right lung

What is the diagnosis. (3 marks)
Right Tension Pneumothorax

What is the immediate treatment? (2marks)
Needle thoracocentesis at right 2nd ICS midclavicular line

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Peak Expiratory Flow (PEF) - How to use it?

Medical students MUST know how to instruct patient on the technique of using Peak Expiratory Flow.
I dont know whether it can come out in exam, but i'm sure you will have to instruct the patient some other day, maybe when you become a houseman.
Sorry if there are any mistakes in the information below.

ONE
Your mouth must be empty.
For best results, you should stand.
If you are unable to stand, sit-up straight.

TWO
Set the peak flow meter to zero at the bottom of the meter.

THREE
Hold in your hand with your thumb and forefinger on the grips and the mouthpiece facing toward you.
Younger children may opt to hold the device with both thumbs underneath and fingers on the grips.
Avoid blocking the vent holes as much as possible and do not allow fingers to interfere with the Peak Indicator.

FOUR
Take as deep a breath as possible filling your lungs completely with air.

FIVE
Place your mouth on the mouthpiece, past your teeth and form a tight seal with your lips.
Place your tongue below the mouthpiece.
Make sure your tongue is not blocking the opening at any time.

SIX
Blow, or exhale, the air out into the meter as strongly (HARD!) and quickly (FAST!) as you can in a single blow.
This will cause the indicator to move and indicate your peak flow.
Do not spit or cough into the device. If this occurs, repeat this step again.

SEVEN
Reset peak indicator.
(some people say do not reset because the device will automatically point to only the best reading effort)

EIGHT
Repeat the whole test another two times more for a total of three maneuvers.

NINE
Once you have completed three maneuvers, record your best effort
(DO NOT TAKE THE AVERAGE!)

TEN
You have to know what is normal reading for you.
There is normogram based on age, height and weight. (find out yourself)
There is also a PEF chart. (find out yourself)
Is there any formula for the normogram? i cant find it~

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Dengue Fever - WARNING SIGNS!

Abdominal Pain or Tenderness

Persistent Vomiting

Clinical Fluid Accumulation (pleural effusion/ascites)

Mucosal Bleed

Restlessness or Lethargy

Tender Enlarged Liver

Increase in HCT concurrent with rapid decrease in platelet

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Sail Sign

Sail Sign

1) Elbow X-ray

-suggest an occult frature

-with some imagination, we can see the shape of a spinnaker (sail)

-it rise from the displacement of the fat pad around the elbow joint

-in children : suggest supracondylar fracture of the humerus

-in adult : suggest radial head fracture

2)Chest X-ray

-in adult : suggest left lower lobe collapse (cannot see left diaphragm margin)

-in children : at the mediastinum suggest thymus-->sharply demarcated triangle radiopacity (disappear on inspiration)

A114954

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Morning hyperglycemia in Diabetics

There are 2 conditions which can cause this :

1. Somogyi Effect
2. Dawn Phenomenon

1. Somogyi Effect

• Also known as "rebound hyperglycemia"
• Usually due to:
  
  • missed night meals despite taking insulin regularly
  • a person who takes long-acting insulin without supper
  • night/ long-acting insulin dose too high
• Relative Insulin Excess-> Early morning (2-3am) hypoglycemia -> Body's counter-regulatory mechanism activated -> Hormones (cortisol, glucagon, epinephrine) released to counter insulin effect -> Morning Hyperglycemia

2. Dawn Phenomenon

• Can occur in normal person
• Exaggerated response in diabetics
• In a normal human physiology, counter-regulatory hormones (cortisol, glucagon, epinephrine) are released during early morning hours to sustain blood glucose level without food. These hormones also antagonize insulin effect, hence there is a relative higher insulin resistance during the night.
• In patients with Type I diabetics esp, insulin production is low, hence there is an exaggerated Dawn phenomenon --> morning hyperglycemia
• It typically occurs (more often) in Type I diabetic patients during puberty or pregnancy due to marked production of counter-regulatory hormones (cortisol, glucagon, epinephrine, growth hormone), thus also causing exaggerated Dawn phenomenon.

How to differentiate then ?
Check blood sugar levels (Dextrostix) around 2 - 3 a.m. for several nights.

• If the blood sugar level is low at 2 a.m. to 3 a.m., suspect Somogyi effect (Rebound phenomenon).
• If the blood sugar level is normal or high at 2 a.m. to 3 a.m., it's most likely Dawn phenomenon.
  (which is even more likely if the patient is a type I diabetic at early onset of puberty/ pregnancy, although Somogyi effect must be ruled out first)

How to prevent/treat ?

Somogyi effect

• Have regular meals and never skip them.
• Have a light snack (preferably protein) before bedtime.
  
• Go to bed with a glucose level slightly higher than usual.
• Bring your diabetic logbook (with your result of early morning 2am-3am blood glucose) while consulting your physician, in case your insulin dose may require adjustments.

Dawn Phenomenon

• Exercise later in the day. It may have more glucose-lowering effect throughout the night.
• Limit bedtime carbohydrates and try more of a protein/fat type of snack (nuts, peanut butter, cheese, or meat).
• Talk with your doctor of a possible medication adjustment (usually insulin) to control the higher fasting readings (common in DM Type I at onset of puberty).
• Eat breakfast to limit the dawn phenomenon’s effect. By eating, your body will signal the counterregulatory hormones to turn off. -> peliknya...

Why bother ?
Good blood glucose control is essential for diabetic patients. The adjustment of medication (insulin) dose depends on which is the culprit, as one needs to lower the blood glucose prior to bedtime (Dawn phenomenon) or increase the blood glucose level prior to bedtime (Somogyi effect). 

Therefore, if the patient is having persistent morning hyperglycemia despite increased insulin dose, suspect Chronic Somogyi.

Thanks to Dr.Ngiu for asking us weeks ago.

Source : Wikipedia, 2 other internet sources (by Alvis Lee) - July 26th, 2010
Edited by Wong Yee Ming - May 15th, 2011

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Sepsis & SIRS

Infection:  Inoculation of pathogen into normally sterile tissue

Systemic inflammatory response is triggered by ischaemc, inflammation, trauma, infection to protect the host from the damaging effect of insult. However, the response can be overexaggerated when the damage and insult is too great.

Systemic inflammatory response syndrome (SIRS) criteria---> 2 or more of the following:

• Temp: <36 or >38
• HR: > 90 bpm
• RR: > 20/ min
• WCC: >12 X 10^9/L or <4X10^9/L
• MAP: <65 mmHg (Systolic BP < 90 mmHg/ Diastolic BP < 60mmHg)

Sepsis: SIRS with the presence of infection (documented).

Severe sepsis : SIRS with organ dysfunction (SOFA criteria)

Septic shock : Sepsis-induced hypotension despite fluid resuscitation

Sepsis Organ Failure Assessment (SOFA) criteria

Goal in treating sepsis :

1. MAP > 65 mmHg (To maintain BP > 90/60 mmHg)

2. ScvO2 > 70%

3. CVP: 8-12mmHg

4. Urine output > 0.5ml/kg/h

Recap MAP calculation:

MAP : (systolic - diastolic)1/3 + diastolic

A114954

Edited by: Wong Yee Ming

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Stroke and TIA

Rule Out Stroke In Emergency Room (ROSIER scale)

The aim of this assessment tool is to enable medical and nursing staff to differentiate patients with stroke and stroke mimics.

* Stroke is likely if total scores are > 0. Scores of completely excluded.

The ROSIER scale is not suitable for patients with suspected TIA with no neurological signs when seen. Please use the ABCD2 assessment for patients with suspected TIA. This assessment assists in the identification of patients with a high or low risk of early disabling stroke.

High risk TIA patients (scoring 5 or more on ABCD2 score) should be:-

�� Seen within 24 hours of the event at the TIA clinic (patients referred to the TIA clinic at the RVI need a TIA clinic referral form completed)

or

�� Out of hours (e.g. at weekends), contact the on-call Stroke Consultant and admit for review,

urgent investigation and initiation of secondary prevention.

Any patient with more than one episode in the last week is at a greater than 30% risk of stroke within a week and should be admitted to EAU for investigation and review by a Consultant Stroke Physician.

This ABCD2 scale is not a substitute for a full medical assessment.

The modified Rankin Scale (mRS) is widely used to assess global outcome after stroke.

A114954

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Unilateral Pleural Effusion of Adults

Please download more details BTS guideline info HERE.

Thanks to Dr Ngiu for teaching us on British Thoracic Society (BTS) guidelines for investigation of unilateral pleural effusion.

A115262

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