Meningitis and SAH (sub-arachnoid haemorrhage) Both cause meningism (neck stiffness, photophobia and headache) SAH – more sudden, ‘worse headache ever’ Associated with PCKD – aneurysms in the Circle of Willis Meningitis – look for fever and rashes; Kernigs sign Tension headache – stress, ‘tight band’ Trigeminal neuralgia – pain on TOUCHING the face Division of the trigeminal nerve Cf. temporal arteritis/giant cell arteritis – ‘tender’ to touch... Epidemiology: rare, typically > 50, 2:1 F:M Presentation: Unilateral/bilateral FRONTAL headache with scalp tenderness Reproduced by pressing on temples, may feel thickened pulseless temporal arteries Jaw claudication (pain on chewing), amaurosis fugax Associated: polymyalgia rheumatica (painful shoulders) Ix: temporal artery biopsy, high ESR Tx: STEROIDS urgently (empirical high dose prednisolone) without awaiting results of biopsy, as untreated risk of BLINDNESS. 3000 people/yr are blinded by temporal arteritis. Sinusitis Fever obstruction/ purulent nasal discharge Loss of smell Aggrevated by bending over Subdural Haematoma Presentation: Insidious; over days/weeks, no symptoms/worsening confusion as venous pressure builds slowly. Is a slow bleed (cf. extradural). Typically fluctuating loss of consciousness, confusion, ataxia. Typical groups: Alcoholics: as fall over Elderly: brain atrophies, pulls on venous sinuses which are then more likely to tear Aetiology: Can occur after minor head trauma! So there may be no history of head trauma. Ix: URGENT CT head, see crescent shaped bleed. Management: May need neurosurgical decompression. Extradural Haemorrhage. A Neurosurgical emergency. Presentation: High impact trauma e.g. cricket ball, RTA. impact at pterion, MMA (middle meningeal artery) sheared. Typically short history; blackout on impact, then lucid interval, followed by rapidly declining neurological status (to unconscious/dead) Increasing pressure: risk of brain herniation Ix: URGENT CT head, see lens shape bleed (see below).
‘Overflow incontinence’ Alpha blockers such as terazosin relax smooth muscle at neck of bladder so aid voiding. Prostate cancer can also lead to overflow incontinence, so also look for weight loss UTI Very very common Elderly women Frequency, urgency and fever Can also present insidiously, NO URINARY SYMPTOMS….sepsis UTI is an example of urge incontinence Stress Incontinence Leak of urine when intra-abdominal pressure rises. Event in the past has weakened the pelvic muscles Child birth Pelvic surgery Summary of Incontinence Overflow – BPH and Spinal Cord Compression Urge – Idiopathic in Women. Treat with anticholinergics Stress – Increase in abdominal pressure. Treat with pelvic floor exercises/bladder retraining Functional – dementia, poor mobility Polycystic kidney disease —ADPKD = 1/1000. Adults. Mutation in PKD1 or PKD2. Bilateral ballotable masses +/- abdo pain + haematuria, infections, calculi, progressive renal failure. Associated risk berry aneurysms -> SAH. —ARPKD = RARE (1/40,000). Infancy. Mutation PKHD1 gene. Causes CKD, HTn, hepatic fibrosis. Scrotal Swellings 4 questions Can you get above the swelling Can you identify the testis and epididymis Is the swelling translucent Is the swelling painful Swellings NOT confined to the scrotum Hernia – you CANNOT get above it! –
Phaeochromocytoma – phenoxybenzamine followed by propanolol 10% rule – bilateral, malignant, familial, extra-adrenal Von-Hippel Lindau, neurofibromatosis, MEN II Other adrenal problems: Waterhouse-Friedrichson syndrome – adrenal haemorrhage following massive G –ive meningitis Nelson’s syndrome: pituitary enlargement following bilateral adrenalectomy – high ACTH and pigmentation Failure: Primary – TB, Addison’s Secondary – low ACTh (pituitary failure) Short SynACTHen test – if cortisol rises then the problem is probably in the pituitary Long SynACTHen test – fails to rise Cushing’s Learn the features May be iatrogenic – Rheum patients! Pseudo-Cushing’s – depression/alcohol with normal cortisol and ACTH Cushing’s disease – pituitary over-producing ACTH Low dose dexamethasone suppression test – won’t suppress any hyperACTH state High dose will suppress only Cushing’s disease, not SCC of the lung Prolactinoma Galactorrhoea Infertility in women DA agonists inhibit PL secretion – cabergoline and bromocriptine ...TRH increases it – could be d/t hypothyroidism Growth Hormone Acromegaly – glucose tolerance test – GH levels fail to suppress Big tongue, hat sizes Diabetes and hypertension; cardiomyopathy Acne
Arthritis Diabetes Insipidus Two forms – cranial and nephrogenic ‘Dilute Diagnosed with water deprivation test Getting up at to drink water Nephrogenic (renal insensitivity) vs central DDAVP controlled – central MEN syndromes 1 – The Ps – parathyroid, pituitary, pancreatic cell 2(a) – (also parathyroid, medullary thyroid carcinoma) 2(b) or 3 – mmmm.... Marfanoid and mucousal neuromas Brief Notes on Emergencies (look at OCHM and other handout notes) Acute Asthma (please see OCHM for details!!) High dose 100% Oxygen Salbutomol nebulised with oxygen Steroid CXR to exclude pneumothorax If no real improvement move to ITU and prepare to intubate. Cricothyroidotomy is a small incision in the neck…thus avoiding trauma area. Symptomatic AF: Oxygen heparin synchronised DC shock Chronic / Asymptomatic AF: Rate (Beta-blocker, digoxin) Rhythm (Anti-arrhythmics, Verapamil) Anti-coagulant (warfarin) Hyperkalaemia:Urgent Tx if >7 mmol/L or there are ECG changes
SMALL Wegener’s granulomatosis URT + LRT + glomerulonephritis cANCA 90% Immunosuppsn. Microscopic polyangitis Glomerulonephritis, purpura, haemoptysis 90% Churg-Strauss Allergic rhinitis, asthma, sinusitis, eosinophilia Eosinophilia, c/pANCA 40% High dose pred More detail: Wegener’s granulomatosis —Presentation: Rare. —Systemic: Tired, lethargic, fever, purpuric rash, arthralgia. —Triad: —URT symptoms: Epistaxis, nasal septum destruction, rhinorrhoea, laryngeal damage. —LRT symptoms: Haemoptysis, cough, fibrosis, SOB. —Glomerulonephritis: Haematuria, proteinuria, HTn. —Ix: positive in 90%. —Tx: High dose immunosuppressants e.g. corticosteroids, cyclophosphamide. Churg-Strauss. Allergic granulomatosis. —Presentation: Middle aged: —Allergic rhinitis, asthma. —Eosinophilic disease: eosinophilic pneumonia, gastrenteritis, Eosinophilia >10% peripheral blood. —Systemic vasculitis: nerves, GIT. —Ix: p and cANCA +ve in 40% —Tx: High dose prednisolone —Polyarteritis nodosa, Necrotizing vasculitis -> aneurysms and thrombosis medium sized arteries. —Presentation: Young-middle aged men —Systemically unwell —Skin: haemorrhagic rash, punched out ulcers —Renal aneurysms (75%, main cause of death). Also haematuria, proteinuria and HTn. —Tx: Immunosuppression Kawasaki disease —Presentation: Child, protracted fever over 5 days - acute systemic febrile vasculitis + 4 of:
—Aetiology: Gluten enteropathy -> circulatinG IgA complexes containing transglutaminase, lodge in skin And cause inflammation —Ix: Coeliac antibodies +ve e.g. antiendomysial —Tx: Gluten free diet life long. Dapsone. Erythema nodosum. Nodular, red, raised, tender, not itchy, ill-defined, typically shin. Due to panniculitis = fat inflammation. —Associations: —Infections: TB, post-streptococcus —Drugs: OCP, antibiotics. —Systemic: SLE, sarcoidosis, IBD —Pregnancy & idiopathic