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5921. Labyrinthitis

after several days to a few weeks in the majority of cases of both vestibular neuritis and viral labyrinthitis, with or without symptomatic treatment. Labyrinthitis: recovery of hearing loss is more variable: Suppurative labyrinthitis usually leaves permanent and profound hearing loss. Hearing loss associated with viral labyrinthitis may recover. Disequilibrium or positional vertigo may be present long-term following resolution of the acute infection. Anxiety disorders and depression have been shown (...) to be associated with self-reported vestibular vertigo, as has cognitive impairment [ ] . A study of 68 patients with organic vertigo syndromes found [ ] : Psychiatric comorbidity rates for those with vestibular neuritis corresponded roughly with those in the general population. Anxiety, phobic disorders and depression are increased in people with vestibular migraine and those with Ménière's disease; the reasons for this may be neuro-anatomical and neuro-biological. Did you find this information useful? Thanks

2008 Mentor

5922. Jaundice in Pregnancy

or chronic form. The presence of HB e Ag is associated with a very high risk of neonatal infection. All women should now be offered hepatitis B screening as part of routine antenatal screening. Infants of HB s Ag-positive women should receive hepatitis B immune globulin immunoprophylaxis at birth and hepatitis B vaccine at 1 week, 1 month and 6 months of age. This regime reduces the incidence of hepatitis B vertical transmission to less than 3%. The prevalence of neonatal infection depends on the time (...) of pregnancy (AFLP) tends to occur in late pregnancy. [ ] Risk factors include first pregnancies, pre-eclampsia, twin pregnancies and male fetuses. It may be associated with a mutant gene producing a defect in mitochondrial fatty acid oxidation and infants born to mothers with AFLP should be screened for defects in this system. Presentation [ ] This usually presents acutely with nausea, vomiting and abdominal pain, fevers, headache and pruritus, beginning typically at about 35 weeks of gestation but can

2008 Mentor

5923. Irritable Bowel Syndrome (IBS)

with IBS. Psychological problems (anxiety and depression) are also more common, although some psychological morbidity appears to be associated with health care-seeking rather than with IBS per se. Signs On abdominal examination, signs may be few and nonspecific (eg, tender, palpable colon). A rectal ± pelvic examination may be appropriate. Differential diagnosis . Inflammatory bowel disease (IBD): , . Bile acid malabsorption. . - eg, . . Gynaecological problems - eg, , , . ± , and . Investigations (...) . CRP. Coeliac screen. CA 125 for women with symptoms which could be ovarian cancer [ ] . Faecal calprotectin for those with symptoms which could be IBD [ ] . The following tests are NOT required to confirm IBS in those who meet the diagnostic criteria: TFTs. Ultrasound. Colonoscopy/sigmoidoscopy/barium enema. Faecal occult blood. Faecal ova and parasite tests. Hydrogen breath tests. Referral criteria Refer patients in the event of diagnostic uncertainty, alarm symptoms, or severe resistant symptoms

2008 Mentor

5924. Intracranial Venous Thrombosis

count is raised in infection. Platelets are low in thrombotic thrombocytopenia and they have to be monitored if heparin is used in treatment. Autoantibody screen includes antiphospholipid and anticardiolipin antibodies. A thrombophilia screen should be performed. Other tests include albuminuria for nephrotic syndrome and LFTs for cirrhosis. D-dimer testing may be of value in people who present with a headache. High D-dimer levels correlate with greater thrombus extension and acute onset of symptoms (...) from both the neurological consequences and also from the associated contributory diseases. Complications include seizures, hydrocephalus, intracranial hypertension and neurological deterioration. [ ] Prognosis Long-term follow-up suggests a generally good prognosis but there may be residual pyramidal symptoms, epilepsy, visual field defects and depression. [ ] Recurrence rates of 2.8% and mortality rates of 10% have been reported, despite anticoagulation treatment. [ ] Risk factors for a poorer

2008 Mentor

5925. Insomnia Full Text available with Trip Pro

only quiet, relaxing activities before bedtime. Heavy meals just before bedtime should be avoided but a light snack may be helpful. Ensure that the bedtime environment is comfortable and conducive to sleep. Using computers: looking at a computer screen in the hours before bed may delay sleep onset. Looking at a clock during awakenings can increase frustration at being awake and so further delay sleep. Advise restricting their total time in bed to their estimated total sleep time. Use the bed (...) hypnotic drugs - antidepressants are associated with increased risks of road accidents especially early in treatment in depression. There are no controlled studies for the use of low-dose amitriptyline for insomnia, but it is widely used in this way in primary care. [ ] Antipsychotics In the past, sedative antipsychotics were used for insomnia, but concerns over their cardiac safety prevents their use. Atypical antipsychotics, particularly olanzapine and quetiapine, are occasionally used to improve

2008 Mentor

5926. Mild Memory Loss and its Assessment

impairment See separate article. Several tools are available: The - this was developed by psychiatrists and is widely regarded as the 'gold standard' test for dementia. - the Kingshill test - this was developed in 1983 by regression analysis of a more detailed assessment, the Blessed Information Memory Concentration (BIMC) Scale. The - this was developed by geriatricians and is probably the best known score test in general hospital usage. The 6CIT is probably the best compromise between specificity (...) of having been a boxer. Deficiencies of folate, vitamin B12 and vitamin B6 are associated with neurological and psychological dysfunction and are potential factors for cognitive impairment and the development of dementia in the elderly. [ ] Open heart surgery with cardiopulmonary bypass. Medication use, especially sedatives. Hepatic impairment. Sleep disorders - eg, obstructive sleep apnoea. Depression. Psychological stress. Drug or alcohol abuse. Toxins, infections, metabolic (eg, hypoglycaemia

2008 Mentor

5927. Menopause and its Management

and vaginal symptoms Urogenital symptoms arise directly from loss of the trophic effect of oestrogen. These may include dyspareunia, vaginal discomfort and dryness, recurrent lower urinary tract infection and urinary incontinence. Urinary symptoms may not manifest until 5-10 years after the menopause. Sleep disturbance This is a common symptom reported by women. Symptoms may be secondary to vasomotor symptoms, are affected by psychosocial factors and may contribute to depression, irritability and poor (...) concentration [ ] . Mood changes These may include anxiety, nervousness, irritability, memory loss and difficulty concentrating. Perimenopause is accompanied by an increased risk of new and recurrent depression [ ] . There is some evidence that those women who have a history of premenstrual and postnatal depression have a higher risk of depression during their menopause [ ] . These women are typically well during pregnancy. Loss of libido This can be caused by a number of hormonal factors; oestrogen

2008 Mentor

5928. Neck Pain (Cervicalgia) and Torticollis

, anxiety and depression. Generalised musculoskeletal problems - eg, , , , . . . Spinal stenosis. Infection of the spine - eg, . Bone cancer involving the spine. Trauma - eg, . Acute spasm: torticollis (see heading following 'Prognosis', below). Non-musculoskeletal causes - eg, cardiovascular, respiratory and upper gastrointestinal causes, acute upper respiratory tract infections, meningitis. Risk factors Workplace-associated risks: poor workplace design, awkward neck postures, neck flexion, arm posture (...) causes, including: After sleeping in an awkward position. Symptoms usually resolve spontaneously within a few days and last no more than 1-2 weeks. Upper respiratory and soft tissue infections of the neck can cause an inflammatory torticollis secondary to muscle contracture or adenitis. Any abnormality or trauma of the cervical spine. The cause of torticollis is often not known but it may be due to bad posture - for example, poor positioning at a computer screen, inappropriate seating, sleeping

2008 Mentor

5929. Myxoedema Coma

Respiratory depression and retention of carbon dioxide Epidemiology Myxoedema coma is around four times more common in women than in men (reflecting the higher incidence of hypothyroidism in women, which has a prevalence of 8% in women aged over 50). Myxoedema coma occurs almost exclusively in patients over 60 years of age. In communities with iodine deficiency (mountain regions of Asia, Africa and South America) the prevalence of hypothyroidism is higher. It is therefore likely that the incidence (...) , deepened voice and dry, pale, cool skin. However, elderly patients with hypothyroidism may have atypical symptoms. They may just present with reduced mobility, and some patients with compensated hypothyroidism are asymptomatic. Hypothyroidism of long standing can therefore easily be missed. Myxoedema coma usually affects the mental state: patients may present with apathy, low mood, cognitive decline, confusion and even coma. The changes can be subtle and may be misdiagnosed as dementia or depression

2008 Mentor

5930. Myocarditis

, fluorouracil, lithium, interleukin-2 and trastuzumab may exert a direct cytotoxic effect. Heavy metal poisoning : lead, copper, iron. Others : arsenic, insect stings and bites, phosphorus, carbon monoxide and inhalants. Physical agents Electric shock Hyperpyrexia Radiation/radiotherapy Investigations ECG: changes may include ST-segment elevation/depression, T-wave inversion, atrial arrhythmias, transient atrioventricular (AV) block. Blood tests: FBC (leukocytosis in 25%), U&E, creatine kinase (often (...) elevated, as are other markers of myocardial cell damage, including troponin I and troponin T), ESR or CRP (elevated in 60%), LFT. CXR: Normal cardiac silhouette but pericarditis or overt clinical congestive heart failure is associated with cardiomegaly. Vascular redistribution. Interstitial and alveolar oedema. Pleural effusion. Viral or Chagas' serology may be helpful occasionally, as may autoantibodies (to screen for systemic autoimmune disease - eg, scleroderma) [ ] . Endomyocardial biopsy

2008 Mentor

5931. Mania and Hypomania

or depression. Any suicidal or homicidal thoughts. Any self-neglect. Family history. Substance misuse, smoking and alcohol intake. General physical health. Self-rating scales are available - eg, Mood Disorder Questionnaire. These have been found to be useful in screening purposes although their cost-effectiveness in routine clinical practice has been questioned. [ ] These questionnaires have not been validated for use in children and young people. Differential diagnosis [ ] or . . . . Other psychiatric (...) . doi: 10.1016/j.jad.2017.08.068. ; World Health Organization ; Rapid-cycling bipolar disorder: cross-national community study. Br J Psychiatry. 2010 Mar196(3):217-25. ; Screening for bipolar disorder with the Mood Disorders Questionnaire: a review. Harv Rev Psychiatry. 2011 Sep-Oct19(5):219-28. ; Mental Health- Consent, the law and depression- management in emergency settings. Emerg Med J. 2005 Apr22(4):279-85. ; NICE Guideline (May 2015) ; Evidence-based psychosocial treatments for child

2008 Mentor

5932. Management of Type 2 Diabetes Full Text available with Trip Pro

. Refer men with type 2 diabetes to a service offering other medical, surgical or psychological management of erectile dysfunction if treatment (including a phosphodiesterase-5 inhibitor, as appropriate) has been unsuccessful. See also the separate article. Other management issues See the separate article. People with diabetes should be offered influenza vaccination and pneumococcal vaccination. Managing diabetes and intercurrent illness is covered in the separate article. Depression screening; early (...) detection, support and effective management. See the separate article. Be alert for the potential development of metabolic syndrome. Referral The precise arrangements for referrals will depend on local service provisions and guidelines Most patients with type 2 diabetes can be managed within primary care but referrals such as to podiatry, the multidisciplinary footcare team and the local retinal screening programme, may be required. Referral to a diabetes specialist may be required depending

2008 Mentor Controlled trial quality: predicted high

5933. Management of Rheumatoid Arthritis

, metacarpophalangeal joints, proximal interphalangeal joints and the knees), the ESR, and the patient's 'assessment of global health'. A DAS28 score greater than 5.1 implies active disease, less than 3.2 well-controlled disease, and less than 2.6 remission. [ ] Screen for comorbid conditions - eg, osteoporosis, depression, infection and cardiovascular disease (CVD). [ ] Non-drug management The importance of the MDT is emphasised in the NICE guidance: [ ] RA patients should have access to a named member of the MDT (...) ability - using, for example, the Health Assessment Questionnaire (HAQ). Check for the development of comorbidities, such as hypertension, coronary heart disease, osteoporosis and depression. Assess for complications, such as vasculitis and disease of the cervical spine, lung or eyes. Organise appropriate referrals within the MDT whenever appropriate. Assess the need for referral for surgery. Also, review the effectiveness and adverse effects of medication. Assess the effect the disease is having

2008 Mentor

5934. Malnutrition Full Text available with Trip Pro

and likelihood of this continuing in the future. Several screening tools exist to aid this assessment, including: The 'Malnutrition Universal Screening Tool' (MUST), which was developed by the Malnutrition Advisory Group, a standing committee of the British Association of Parenteral and Enteral Nutrition (BAPEN); it has been reviewed regularly since its launch in 2003 [ ] . The Mini Nutritional Assessment Short Form (MNA®-SF), which is a practical tool for identification of nutritional status (...) of infectious diseases. Availability and effectiveness of nutrition programmes and health services. In elderly people Living alone. Institutionalisation. People with severe learning difficulties or mental health problems (depression, dementia). Diseases that affect appetite, eating/swallowing or gastrointestinal function (gastric surgery, malabsorption, stroke and neurological disorders such as motor neurone disease). Catabolic states. Presentation Presentation in adults Adults tend to lose weight, often

2008 Mentor

5935. Malaria Prophylaxis

contact dermatitis with DEET [ ] . Permethrine is a useful insecticide to spray on clothing. Pre-treated clothing is available for purchase. Patients should be advised to sleep in air-conditioned rooms if possible, or screened accommodation. Use of sprays with knockdown insecticide or electrical pyrethroid vapourisers every evening after dusk is recommended. Insecticide-treated nets should be used by those sleeping outdoors or in unscreened rooms. The effectiveness is about 50%. Pyrethroid-impregnated (...) in some areas of Southeast Asia, and it is reported sporadically in the Amazon basin). [ ] Major adverse events (convulsions, coma and psychotic disturbances) are rare - 1 in every 10,000 users; however, they have been given high media profile. [ ] There is no evidence that mefloquine use increases the risk of first-time diagnosis of depression and no association between mefloquine prescriptions and hospitalisation. [ ] Lesser side-effects are similar to chloroquine and proguanil. Avoid in patients

2008 Mentor

5936. Macular Oedema

lamp. A clue might be the loss of the foveal reflex compared to the fellow eye. In 'wet' AMD, there may also be an associated bleed, seen as a well-demarcated deep-red patch over the macular area. Even if the view is limited, the history and an abnormal Amsler grid will raise suspicions and should prompt referral. Using an Amsler grid This is a useful simple tool that can help screen for macular disease. The patient can use it at home to monitor progression. It consists of a piece of paper on which (...) of cone photoreceptors. It is situated at the back of the retina (the posterior pole), lying about 3 mm lateral to the optic disc. It has a central depression known as the fovea centralis. The fovea contains tightly packed cone photoreceptors in the fovea with no overlying blood vessels. This is the area of the retina where visual acuity is ultimately determined, where reading takes place and where form, shape and colour are most accurately detected. Macular fluid accumulation alters cell function

2008 Mentor

5937. Multiple Endocrine Neoplasia Type 2 (MEN 2)

lesions or a lump in the neck (which may cause compressive symptoms). Hypercalcaemia may lead to constipation, polyuria, polydipsia, memory problems, depression, nephrolithiasis, glucose intolerance, gastro-oesophageal reflux and fatigue. Around 40% of patients with MEN2 develop phaeochromocytoma. [ ] Cutaneous lichen amyloidosis in MEN2A presents with multiple pruritic, hyperpigmented, lichenoid papules in the scapular area of the back. MEN type 2A [ ] MEN2A is also known as Sipple's syndrome. Those (...) who are not identified by screening usually present in the fourth and fifth decades. occurs in nearly all MEN2A patients and is generally the first manifestation of MEN2A, whereas occurs in 30-50% and hyperparathyroidism occurs in about 20% of MEN2A patients. Parathyroid hyperplasia occurs in up to 80% of patients with MEN2A but only about 20% have hypercalcaemia. The remainder are identified at the time of thyroidectomy. is the least common manifestation of MEN2A and usually presents after

2008 Mentor

5938. Turner's Syndrome

dysgenesis and are at a high risk for gonadoblastoma. Gonadotrophins: LH and FSH may be elevated in untreated patients aged younger than 4 years. Gonadotrophins are later suppressed to normal or near-normal levels, and then increase to menopausal levels after the age of 10 years. LH and FSH levels should be measured before initiating oestrogen replacement therapy. TFTs, thyroid antibodies. Haemoglobin A1c or fasting glucose level to screen for diabetes mellitus. Renal: renal function tests, electrolytes (...) material and for gonadal, adrenal or midline tumours. Hearing tests. Prenatal diagnosis Initial screening is by ultrasound. [ ] Turner syndrome can be diagnosed by amniocentesis or chorionic villous sampling which allows karyotyping of the fetus. Differential diagnosis Other causes of and . is associated with some of the clinical features of Turner syndrome. Management Turner syndrome is obviously a lifelong condition and, although the majority of patients are healthy, they are susceptible to a number

2008 Mentor

5939. Tuberous Sclerosis

and attentional switching). Executive deficits (planning, poor sequencing, perseveration). Memory deficits (working memory, episodic memory). Motor abnormalities (fine motor, gross motor, movement disorders). Autism, Asperger’s syndrome and other autism spectrum disorders (ASDs). Attention deficit hyperactivity disorder (ADHD) and related disorders. Aggression, rage outbursts and temper tantrums. Negativity (temporary resistance to change). Emotional lability. Depressive disorders. Anxiety disorders. Sleep (...) epilepticus or bronchopneumonia. Renal failure is another common cause. Epilepsy can be difficult to control and can contribute to developmental delay. Functional outcome is improved when seizures are controlled at an early age. [ , ] If significant hydrocephalus develops, this can lead to neurological sequelae and blindness. The prognosis of SEGA is excellent. This should be monitored clinically and radiologically and removed if growing or causing symptoms. Genetic counselling and screening [ ] Genetic

2008 Mentor

5940. Subarachnoid Haemorrhage

-15% of patients. The most common symptoms are headache (48%), dizziness (10%), orbital pain (7%), diplopia (4%) and visual loss (4%). Signs may accompany these sentinel bleeds: sensory or motor disturbance (6%), seizures (4%), ptosis (3%), bruits (3%) and dysphasia (2%). If a sentinel bleed is suspected, patients should be admitted urgently for investigations (treat as if an SAH has occurred). Examination Conscious level: on admission to hospital two thirds have a depressed level of consciousness (...) , of whom half are in coma. However, SAH patients can also walk into the surgery, complaining of sudden onset of headache. Neck stiffness may occur due to meningeal irritation by blood in the CSF, but it is not invariable. Ophthalmoscopy will show intraocular haemorrhages in around 15%, especially in those with a depressed level of consciousness. Isolated pupillary dilation with loss of light reflex may indicate brain herniation as a result of rising intracranial pressure. There may be focal

2008 Mentor

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