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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Neuroleptic Malignant Syndrome

Mnemonic

FALTER

F - fever

A - autonomic instability

L - leucocytosis

T - tremor

E - elevated CPK

R - rigidity

medical emergency!!!but rare

and NOT an allergic reaction

those who take HIGH POTENCY antipsychotic (eg: Haloperidol, Fluphenazine, Pimozide)

How to manage?

1. DISCONTINUE treatment
2. Supportive therapy
3. Pharmocotherapy

- Benzodiazepines

- Bromocriptine

- Dantrolene

- Amantadine

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Cincinnati Stroke Scale

if 1 findings abnormal : probability having stroke >72%
if 3 findings abnormal : probability having stroke >85%

this scale usually use in prehospital setting.

Once the diagnosis of stroke is suspected, time in the field must be minimized.

The presence of a patient with acute stroke is a “load and go”.

A more extensive examination or initiation of supportive therapies should be accomplished en route to the hospital.

another similar name :
FAST (facial, arm, speech test)

p/s : doctor in emergency department apply this scale during patient's arrival to ED during my oncall shift in Red Box. So i think we can also use this scale to quickly assess probability of having stroke so that we can decide our further management.

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6H's & 5T's

reversible causes associated with cardiac arrest

6H
Hypoxia
Hypovolemia
Hypothermia
Hypo/Hyperglycemia
Hypo/Hyperkalemia
H2 (acidosis)

5T
Tension pneumothorax
Tamponade (cardiac tamponade)
Thrombosis (pulmonary embolism / MI)
Trauma
Toxin

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SEVEN PRIMARY MASQUERADES

Seven Primary Masquerades (John Murthagh)

1. Depression
2. Diabetis Mellitus
3. Drugs
- iatrogenic
- self abuse (alcohol, narcotics, nicotine, others)
4. Anaemia
5. Thyroid and other endocrine disorders
- hyperthyroidism
- hypothyroidism
6. Spinal dysfunction
7. Urinary Tract Infection (UTI)

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Suicide Risk Assessment (SAD PERSONS) - UPDATED

Score >7 = high suicide risk

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MANNED OSCE
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1. Have you attempted suicide?
# A : No --> low risk
# B : Yes --> higher risk

2. Have you thought about dead?

3. Have you thought about suicidal (suicidal ideation)?
# No : lower risk
# Yes : higher risk

4. If yes to questions (3) :
# what kind of thought?
# method? (> serious/dangerous method, > higher risk)
# how often you thought of it?
# any specific plan?
# have you told others about the plan?
# have you actually ever attempted? (to reconfirm back with patient)
# what stop you from attempt suicide? (protective factors)
# have you make any suicidal note?
# have you make the will?
# conditions
***if patient method is to drink paraquat, have he bought the paraquat?
***if patient want to jump from high places, ask him whether he live in terrace, condo, apartment

5. ask this to patient who had attempt suicide previously (additional)
# what is the method? evaluate how dangerous is the method
# what is the chance of dying? (lock door, nobody at home, alone, etc...)
# what is the chance of rescue? (anybody at home? has tell others? etc..)
# intention of attempt? (very high? not really want to attempt?)
# what is his/her feeling after being rescued? (relief? angry to the rescuer? etc..)

6. ask to all (other factors)
# psychotic illness?
# severe depression
# alcoholism / substance abuse
# physical illness
# severe stressor
# no support
# live alone
# others.......

So evaluate this patient suicide risk subjectively based on the answers you get prof the patients.
Use logical thinking. ^_^

Teaching from Prof Maniam.
A115262.

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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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