Carpal tunnel

Carpal tunnel syndrome
:Compression of median nerve

Symptoms:

{
Sensory - too little (numbness)
              - too much (tingling, pain)
Motor - weakness, clumsiness
}

Numbness (thenar eminence is spared - supplied by palmar branch which lies outside the carpal tunnel)
Tingling
Pain (in Hand and arm. Pain may radiate from ventral aspect of wrist proximally to forearm and upper arm. Maybe worse at night)
Clumsiness
Weakness of hand

Tests:
EMG
U/S wrist
MRI wrist

Differential:
c6, c7 radiculopathy
brachial plexopathy

Rx:

Splint

NSAIDs

Corticosteroid injection

Surgical release

Dementia

Dementia

majority of cases of dementia are caused by :
1.degenerative causes and by
2.vascular causes

Degenerative causes include Alzheimer's disease (the most common cause of dementia accounting for an estimated 60% of

cases), Parkinson's disease, etc.

Note: 10% to 20% of dementias are caused by potentially reversible conditions
(e.g. infections, inflammatory diseases, neoplasm, toxic insults, metabolic disorders, and trauma )

NB Differential - Delirium is an acute (hours to days), usually reversible, metabolically induced state of fluctuating consciousness.


Adjunct Therapy - antipsychotic (controversial) - haloperidol 0.5 mg bd PO

Behavioural management

-consider stopping all benzo & antipsychotic ( paradoxical aggrevation )

-Mood stabilizer: carbamazepine 100 mg bd po

-lorazepam 0.5 mg PO/IMI when required,

Organophosphate poisoning

Organophosphate poisoning

-Acetylcholine esterase inhibitor -> inc Ach level at the synapses

Signs/Symps:

-increased secretions: lacrimation, salivation, pulmonary edema -> crepitation
-bronchospasm -> wheeze
-pinpoint pupils
-decreased level of consciousness


Dx:

-Atropine trial: poisoned pt show little/no anticholinergic effect. (Look at heart rate (inc), skin dryness, pupil dilatation)

-plasma cholinesterase measurement

-others: ecg, bld gas, CXR

Rx:

- Resus + supportive care: IV + airway + ventilation
- Decontamination ( discard clothes, wash skin, stomach contents aspirated if airway is protected )
- Atropine:
(atropine : 2 mg intravenously initially, followed by double doses (e.g., 4 mg, 8 mg, 16 mg, etc.) every 5 minutes until secretions are controlled. Atropine requirements are extremely variable; daily doses range between 10 and 1000 mg or more.)


{간단히
눈 - constricted pupil, lacrimation
입 - salivation
폐 - pulmonary edema (crepitation), bronchospalsm ( wheeze )
심장 - bradycardia}

Paed Hx Taking

Paed Hx Taking

-Coughing
-Vomiting
-Diarrhoea

-Feeding
-Fever

-Birth
-Vaccine
-Growth

-HIV
-TB

Burn wound / Stevens-Johnson

============================
Burn
============================

classification:

1st degree
-involves epidermis
-red, painful, dry
-blanch with pressure

2nd degree
-involves epidermis + dermis
-red, painful, wet
- (+-)blisters
-blanches with pressure

3rd degree
-involves epidermis + dermis + skin appendages
-white/black, insensate, dry
-does not blanch with pressure

4th degree
-involves epidermis + dermis + skin appendages + subcutaneous tissue / tendon / bone
-white/black, insensate, dry
-does not blanch with pressure

{mem tip:
pain / blanch/ colour / dry-wet

p b c d
}

indication for admission:
-partial-thickness burns of >10% TBSA;
-face, hands, feet, genitalia, perineum, or major joints;
-electrical burns, including lightning injury;
-chemical burns;
-inhalation injury;
-burn injury in patients with pre-existing medical disorders

Rx:

topical antibiotic prophylaxis
(Silver is an excellent antiseptic and is used in burn wound care
The silver helps to prevent infection and remains active for 3 to 4 days, allowing less frequent dressing changes.)

tetanus immunisation

morphine 10 to 30 mg orally every 3-4 hours when required

Fluid resuscitation:

If burns involve >15% of the body surface, loss of capillary integrity becomes significant, requirng fluid resuscitation.
Parkland formula is often used and suggests 4 mL/kg/% burn over the first 24 hours, half in the first 8 hours, generally as lactated

Ringer's solution. Capillary integrity is typically restored at approximately 24 hours.
(Young children should receive 5% dextrose in lactated Ringer's solution (D5LR) at a maintenance rate to ensure that they do not

develop hypoglycaemia.)

infected wound -> debridement + antibiotic

circumferential burns -> escharotomy

Nutrition / physio / occupational therapy


[dose: midazolam : 0.04 mg/kg IVI
morphine: 0.1 mg/kg IVI]

{Burn description 간략히

-깊이
-넓이
-어디
-EIC (에 이 씨) - electrical ( myoglobin inc -> renal impairment, hyperkalemia -> arrhythmia),  inhalational burn, chemical // open fire,

boiling water...
}

{Burn Rx 간략히

-Fluid
-Analgesic
-Antibiotic

-Dressing (Silver dressing)
-escharotomy
}

============================
Steven-Johnson syndrome
============================

Rx:

Stop offending agent ( common causative agent: sulfonamide (bactrim), NSAIDS (therefore NSAIDs should not be used for analgesic

unless other medicines, such as opioids or paracetamol, do not work), corticosteroids, etc)

ABC (airway edema -> obstruction)

Dressing (silver dressing (e.g. silver sulfadizine) )

Analgesic (avoid NSAIDs)

Fluid (Parkland formula)

Nutrition / physio / occupational therapy

morphine sulphate : children: 0.1 mg/kg orally/intravenously every 2-4 hours when required, maximum 15 mg/kg;
adults: 7.5-10 mg orally/intravenously every 4 hours when required


adjunct:

1) glucocorticoids

advese effect: may increase risk of infection - infection is the main reason for mortality
use: it can be used in - Adults with burn (%) less than 30 %. Don't use in paed pt, or burn > 30 %.
prednisone 2 mg/kg/day not more than 7 days ( or equivalent amount of prednisolone or methylprednisolone )

2) IV immunoglobulin

Hepatitis B

Hep B e Ag > 3 months
-> high likelihood of chronic infection

Hep B e Ag positive
-> majority have active infection
-> it also indicates greater infectivity.

Hep B core Ab
-> indicates exposure to hepatitis B virus

Hep B surface Ag > 6 months
-> indicates chronic hepatitis B infection

Hep B DNA Qualitative assay

Window period:

[ HBsAg: neg, HBsAb: neg, HBcAb: pos]

The disappearance of HBsAg (hepatitis B surface antigen) is followed by the appearance of anti-HBs. In some patients, however,

anti-HBs may not be detectable until after a window period of several weeks to months. At this time, neither HBsAg nor anti-HBs can

be detected, the serologic diagnosis may be made by the detection of IgM antibodies against hepatitis B core antigen (IgM anti-

HBc).


Rx:

Acute Hep B - fulminant infection:
- supportive
- lamivudine +- liver transplant

Chronic
-interferon
-antiviral therapy (tenofovir, lamivudine, etc)

indication for Rx in chronic infection:
-co-infection with HIV or Hep D
-cirrhosis
-if no coinection/comorbidity:
 -HBeAg positive, HBV DNA > 20 000 IU, ALT > twice upper normal limit
 -HBeAg negative, HBV dNA > 2 000 IU, ALT > upper normal limit

Haemorrhoids

Causes of haemorrhoids:
-------------------------
The primary aetiology is believed to be excessive straining due to either chronic constipation or diarrhoea.
Other causes:an increase in intra-abdominal pressure can be caused by pregnancy or ascites;
the presence of space-occupying lesions within the pelvis

Types of haemorrhoids:
-------------------------
1) External haemorrhoids
:Haemorrhoids that are located in the distal anal canal, distal to the dentate line, and covered by sensate anoderm or skin.

2) Internal haemorrhoids
:Haemorrhoids that originate proximal to the dentate line and covered by insensate transitional epithelium

    Grade 1 - protrusion is limited to within the anal canal.

    Grade 2 - protrudes beyond the anal canal but spontaneously reduces on cessation of straining.

    Grade 3 - protrudes outside the anal canal and reduces fully on manual pressure.

    Grade 4 - protrudes outside the anal canal and is irreducible.

This grading of internal haemorrhoids is only a reflection of the degree of prolapse but is not a measure of either the disease severity or of the size of haemorrhoidal prolapse.


Rx:
--------------------------
For all grades:
 Straining or spending excessive time at stool should be discouraged.
 Constipation can be avoided by adding fibre and fluids to the diet; consuming 25 to 30 g of fibre daily .

(+- stool softeners short-term)


grade 1 haemorrhoids

 Creams and ointments are generally used for external haemorrhoids
 and suppositories are generally used for internal haemorrhoids

 hydrocortisone rectal :
 (1 to 2.5%) apply twice daily for a maximum of 5-7 days;
 25 mg (1 suppository) into the rectum twice daily for 14 days


grade 2

 rubber band ligation or sclerotherapy or infrared photocoagulation or haemorrhoid arterial ligation or stapled haemorrhoidopexy


grade 3

 rubber band ligation

grade 4

 Surgical haemorrhoidectomy


Thrombosed haemorrhoid:

Treatment of acute thrombosis of internal hemorrhoids is usually conservative.

In thrombosed external hemorrhoids, surgical evacuation of the hemorrhoid with excision of the skin overlying the thrombosed hemorrhoid can produce immediate relief. As an alternative, oral and topical analgesics, stool softeners, and sitz baths may provide adequate relief until spontaneous resolution occurs


{간략히

똥
stool softener
누기
don't strain
dietary fiber
아파
topical analgesic

grade I : corticosteroid cream / suppository

> grade I: band ligation / haemorrhoidectomy
}