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Periodic Limb Movement

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3021. Insomnia Full Text available with Trip Pro

, sleepwalking, sleep talking, limb movement disorders, . . Stress Situational stress: Relationships Financial problems Academic stress Job-related stress Medical worries Noise stress Psychiatric comorbidity and . . . . Paranoia and . Medication and substance abuse Alcohol. Caffeine. Recreational drugs. Nicotine. Drug withdrawal - eg, hypnotics, alcohol (reduces the time to onset of sleep, but disrupts it later in the night). Chronic benzodiazepine misuse. Some antidepressants, especially selective serotonin (...) identify sleep trends or predominant sleep patterns. Sleep diaries can be used as a starting point for managing insomnia and for monitoring progress. An example of a sleep diary is available on the American Academy of Sleep Medicine website. [ ] Polysomnography (overnight sleep study): this measures brain and muscle activity and assesses oxygen saturation overnight. It can be used to confirm sleep apnoea and limb movement disorders or restless legs syndrome. Management Treatment is appropriate when

2008 Mentor

3022. Ulnar Nerve Disorders

to the use of mobile phones, as the elbow is held flexed for long periods of time. [ ] The wrist is the second most common area of entrapment. Entrapment of the ulnar nerve may occur simultaneously at more than one level. [ ] History and examination See separate article dealing with upper limb neurological examination: . Lesions at the elbow [ ] The term cubital tunnel syndrome is often used for ulnar nerve compression at the elbow. Total paralysis of the nerve, including those branches of the nerve (...) in the ulnar fingers. There may be wasting of the hypothenar muscles, interossei and the medial part of the thenar eminence. Also, there may be weakness in movement of fingers and abduction to the extended thumb against the palm. There is sensory loss of the dorsal and palmar aspects of the medial side of the hand together with the medial one and a half fingers. With compression of the ulnar nerve, the ulnar nerve is often palpably enlarged in the ulnar groove and for a short distance proximal to the elbow

2008 Mentor

3023. Tremor

. Arsenic, heavy metal, organophosphate or industrial solvent poisoning. Vitamin deficiency (especially B1). Classification of tremors Tremors can be initially classified as rest or action tremors. [ ] Rest tremors occur when the body part is supported against gravity - eg, hands at rest in one's lap. Mental stress or general movement makes rest tremors worse. Action tremors are further subdivided into static, postural or kinetic tremors: Static - occurs in a relaxed limb when fully supported at rest (...) movement or sensation. Symptoms Essential tremor (ET) : This is usually a distal symmetrical postural tremor of the upper limbs, usually of low amplitude with a fairly rapid frequency of 8-10 Hz. It may initially be transient but usually progresses to become persistent. The neck muscles may be involved, causing tremor of the head (about 40% of cases). Voice, face and jaw muscles may be involved. [ ] Frequency of the tremor tends to remain constant but amplitude is highly variable depending on emotional

2008 Mentor

3024. Rheumatic Fever

important. In hot countries, skin infection is a more important source of streptococci than pharyngitis. Young age is a risk factor [ ] . Presentation [ ] Symptoms appear between one and five weeks after a sore throat, with an average of three weeks. In recurrent cases this incubation period is shorter, in keeping with a faster immune response. The diagnosis is based on major and minor criteria. In the acute disease the arthritis and toxicity are obvious but it can be more insidious with mild carditis (...) infection (eg, history of scarlet fever, positive throat swab or rising or increased antistreptolysin O titre (ASOT) >200 U/mL or DNase B titre). Plus two major criteria; or One major and two minor criteria. Definitions of these criteria are set out below. Major criteria Arthritis: The most obvious presenting feature is a flitting or migratory arthritis affecting large joints like the knees, ankles, wrists and elbows. The joints are hot and red with decreased range of movement. Typically, one joint

2008 Mentor

3025. Temporal Lobe Epilepsy

, due to a or . Periodic limb movement disorder. Tardive dyskinesia. . Occipital lobe epilepsy: may spread to the temporal lobe and be clinically indistinguishable from a temporal lobe seizure. Psychogenic seizures: patients with psychogenic seizures may also have epileptic seizures. Investigations [ ] Interictal EEG: one third of patients with TLE have bilateral, independent, temporal interictal epileptiform abnormalities. MRI is the neuroimaging investigation of choice. Positron emission (...) and sweating. Patients may experience an epigastric fullness sensation or nausea. Following the aura, a temporal lobe focal dyscognitive seizure begins with a wide-eyed, motionless stare, dilated pupils and behavioural arrest. Lip-smacking, chewing and swallowing may be noted. Manual automatisms or unilateral dystonic posturing of a limb may also occur. A focal dyscognitive seizure may evolve to a generalised tonic-clonic (GTC) seizure. Patients usually experience a postictal period of confusion

2008 Mentor

3026. Sports Injuries - Basic Principles

technique predisposes to overuse or other injuries, or poor equipment may be at fault. Examination [ ] Apart from the usual examination specific to the area in question (eg, a joint), assessment of sports injuries should include a functional examination and a biomechanical assessment. Functional examination will be specific to the sports activity undertaken and may include agility, co-ordination, power and flexibility. The patient should be assessed through the full range of movements involved (...) movements in all directions. Some joints have a great variety of movements - for example, the shoulder can flex, extend, abduct, adduct and internally and externally rotate. Ask the patient to perform that range of movement actively. Test active movement against resistance. Stress the joint to detect instability of ligaments. Palpate the joint and around it for local tenderness, swelling or effusion and muscle spasm. If a cause for the pain has not been found, look elsewhere. For example, trouble

2008 Mentor

3027. Snake Bites

, an affected limb should be immobilised. In Australia most of the venomous snakes are systemically neurotoxic. [ ] Where a venomous snake other than an adder is thought to have been involved (or snake not identified) the first aim is to prevent the snake venom from being systemically absorbed. In such cases a pressure immobilisation (PIM) bandage including a splint to reduce movement should be applied to the affected limb as soon as possible following the bite. The wound should not be cleaned prior (...) ). Mark the site of the bite on the outside of the bandage to allow a small window to be cut in the bandage for venom swabs to be taken. Apply a splint to immobilise the limb; transport the patient to the nearest accident and emergency department. Keep movement to a minimum. For bites to the head neck and torso, local pressure should be applied. Hospital care In the UK, experience of treating snake bites is likely to be limited. Patients should be resuscitated and monitored appropriately in the normal

2008 Mentor

3028. Shoulder Pain

suggests a significant tear of the acromioclavicular ligament . Acromioclavicular osteoarthritis may cause subacromial impingement. Referred neck pain See also separate article . Typically, this presents with pain and tenderness of the lower neck and suprascapular area, with pain referred to the shoulder and upper arm. There may be a restriction of shoulder movement and movement of the neck and shoulder may reproduce more generalised upper back, neck and shoulder pain. There may also be upper limb (...) cuff tendon. [ ] Epidemiology [ ] Shoulder pain is the third most common cause of musculoskeletal consultation in primary care. 1% of adults with new shoulder pain consult their GP each year. Self-reported prevalence of shoulder pain is between 16% and 26%. Risk factors Physical factors related to occupation including repetitive movements and exposure to vibration from machine tools. [ ] Psychosocial factors related to work may also be risk factors for shoulder pain, including stress, job pressure

2008 Mentor

3029. Obstructive Sleep Apnoea (OSA)

diagnosis Fragmented sleep (quality of sleep). Sleep deprivation (quantity of sleep). Shift work. . . . /periodic limb movement disorder. Drugs: Sedatives. Stimulants (caffeine, theophyllines, amfetamines). Beta-blockers. Selective serotonin reuptake inhibitors (SSRIs). Idiopathic hypersomnolence. Excess alcohol. Neurological conditions: Dystrophica myotonica. . . . Diagnosis OSAS is defined by five or more respiratory events (apnoeas, hypopnoeas or arousals) per hour, in association with symptoms (...) at night and excessive sleepiness during the day. Complete apnoea is defined as a ten-second pause in breathing activity. Partial apnoea, also known as hypopnoea, is characterised by a ten-second period in which ventilation is reduced by at least 50%. Research is focusing on the concept of sleep fragmentation (the poor-quality sleep produced by repeated episodes of apnoea or hypopnoea) and objective measurements of upper airways obstruction. Epidemiology OSAS is a worldwide phenomenon. The prevalence

2008 Mentor

3030. Night Terrors and Parasomnias

, the symptoms are frequently amenable to medication. Restless legs syndrome and periodic limb movement disorder These two conditions may co-exist. RLS tends to cause insomnia due to a constant, involuntary irritation of the legs causing their movement, on retiring to bed. Periodic limb movement disorder (PLMD) causes temporally-periodic, sleep-disturbing limb movements that rarely completely wake the sufferer but may cause them to feel excessively sleepy during the next day, due to disturbance of the sleep (...) of parasomnia. Clin Neurol Neurosurg. 2010 Jan112(1):72-5. Epub 2009 Sep 17. ; REM sleep behavior disorder: Updated review of the core features, the REM sleep behavior disorder-neurodegenerative disease association, evolving concepts, controversies, and future directions. Ann N Y Acad Sci. 2010 Jan1184:15-54. doi: 10.1111/j.1749-6632.2009.05115.x. ; Epidemiology of restless legs syndrome: The current status. Sleep Med Rev. 2006 Jun ; Restless legs syndrome and periodic limb movement disorder in the elderly

2008 Mentor

3031. Newborn Screening

. But the following specific aspects of the examination are part of the screening programme and subject to pathway standards. This is used to screen for: - by ophthalmoscope examination. - by examination of the cardiovascular system. - by palpation of the scrotum and inguinal canals. - by the Barlow and Ortolani tests and examination of the lower limbs for asymmetry or limited abduction. Newborn hearing screening Parents are offered a hearing screen for their baby within 4-5 weeks of birth. The screen is usually (...) or heterozygous compound mutation in the gene encoding glutaryl-CoA dehydrogenase on chromosome 19p13. Gliosis and neuronal loss in the basal ganglia lead to a progressive neurodegenerative and movement disorder that usually begins in the first year. Untreated patients characteristically develop dystonia during infancy, resulting in a high morbidity and mortality. Initiation of treatment after the onset of symptoms is generally not effective in preventing permanent damage and so early diagnosis is essential

2008 Mentor

3032. Neonatal Examination

, chest, abdomen, spine and limbs to exclude major abnormalities. A strong cry and a widespread pink blush over the face and body are good signs that all is well. Some children may be born with . Ambiguous genitalia is a medical emergency and requires urgent assessment by a paediatrician. If you have sufficient clinical experience, an orogastric tube should be passed when the neonate's mother has suffered polyhydramnios. This excludes oesophageal atresia. The Apgar score gives a reproducible (...) . Observe whether there is any evidence of or pilonidal sinus hidden by flesh creases or dimples. Palpate the spine gently. Hips : Specifically test for congenital dislocation of the hip (aka ) using a combination of Barlow and Ortolani manoeuvres (follow the link for more detail). Legs : Watch movements at each joint. Check for any evidence of . Count toes and check their shape. CNS : Observe tone, behaviour, movements and posture. Elicit newborn reflexes only if there is cause for concern. Further

2008 Mentor

3033. Myopathies Full Text available with Trip Pro

affecting proximal muscle groups (shoulder and limb girdles) is typical. Weakness manifests itself in different ways at different ages: Decreased fetal movements in utero. Floppy infant neonatally. Motor delay in the toddler years. Reduced muscle strength and power in older children and adults. Myalgia may occur in inflammatory myopathies. Muscle-stretch reflexes are preserved. Somatosensory reflexes are preserved. Variation of strength with exercise (either increasing or decreasing) can occur (...) be associated including cardiomyopathy and conduction defects. Some metabolic myopathies: Hypokalaemia: oral supplements, cautious use of intravenous potassium, and prophylactic drugs (spironolactone and acetazolamide). Hyperkalaemia: carbohydrate loading (for example, early in attacks with hyperkalaemic periodic paralysis), glucose and insulin. : causes life-threatening renal complications and associated metabolic problems (hyperkalaemia). Usually requires intensive care management. Polymyalgia rheumatica

2008 Mentor

3034. Multiple Sclerosis

cord. In this way movement and sensation may be impaired. The causes of MS are not completely understood but the autoimmune process appears to be caused both by genetic and environmental factors - eg, viral infections in early life. Minor viral infections frequently precipitate relapses. There are different patterns of MS: Relapsing-remitting MS : symptoms come and go. Periods of good health or remission are followed by sudden symptoms or relapses (80% of people at onset). Secondary progressive MS (...) : follows on from relapsing-remitting MS. There are gradually more or worsening symptoms with fewer remissions (about 50% of those with relapsing-remitting MS develop secondary progressive MS during the first ten years of their illness). Primary progressive MS : from the beginning, symptoms gradually develop and worsen over time (10-15% of people at onset). Acute attacks are followed by periods of remission when there is remyelination but, with advancing disease, this process begins to fail and periods

2008 Mentor

3035. Motor Neurone Disease

is not a normal feature but can affect some patients with bulbar palsy. Signs LMD dysfunction in the limbs manifests as weakness, atrophy, fasciculations and hyporeflexia. The thighs are often a site of marked fasciculation. Fasciculation can be difficult to distinguish from arterial pulsation, so consider if there is an underlying arterial course before defining twitching movements as fasciculation. UMN dysfunction manifests as weakness predominating in the arm extensors and leg flexors with evidence (...) of the disease is also called amyotrophic lateral sclerosis (ALS). It tends to be focal in onset, with a particular group of muscles affected first. This presents In three recognised patterns: Limb onset - by far the most common . Bulbar onset - 20% of cases . Respiratory onset - the least common . ALS: [ ] Presents with symptoms and signs of degeneration of the upper and lower motor neurons, leading to progressive weakness of the bulbar, limb, thoracic and abdominal muscles. Other brain functions, including

2008 Mentor

3036. Managing Epilepsy in Primary Care

, which lower the seizure threshold. It is common for seizure frequency to vary throughout the menstrual cycle. In ovulatory cycles, peaks occur around the time of ovulation and in the few days before menstruation. In anovulatory cycles, there is an increase in seizures during the second half of the menstrual cycle. [ ] Possible seizure-related symptoms include: Sudden falls. Involuntary jerky movements of limbs whilst awake. Blank spells. Unexplained incontinence of urine with loss of awareness (...) , or in sleep. Odd events occurring in sleep - eg, fall from bed, jerky movements, automatisms. Episodes of confused behaviour with impaired awareness. Possible simple focal seizures. Epigastric fullness sensation. Déjà vu. Premonition. Fear. Elation, depression. Depersonalisation, derealisation. Inability to understand or express language (written or spoken). Loss of memory, disorientation. Olfactory, gustatory, visual, auditory hallucinations. Focal motor or somatosensory deficit, or positive symptoms

2008 Mentor

3037. Neck Pain (Cervicalgia) and Torticollis

of neurological symptoms and signs in the upper limbs. Spinal cord compression in the neck may lead to lower limb problems and abnormal gait, as well as bladder and bowel disturbance. Nonspecific neck pain Symptoms of nonspecific neck pain vary with different physical activities and over time. It is aggravated by particular movements, posture and activities, and relieved by others. Pain is often, but not always, aggravated by exercise and relieved by rest. It radiates in a non-segmental distribution (...) restriction or limited range of movement (also common with normal ageing). Tenderness of muscles or intervertebral joints is usually poorly localised. Localised nodules or tender bands of increased muscle. Cervical radiculopathy Cervical radiculopathy is usually due to compression or injury to a nerve root in the cervical spine, which may present as pain, motor dysfunction, sensory deficits, or alteration in tendon reflexes. The most common causes are cervical disc herniation and degenerative changes. See

2008 Mentor

3038. Delay In Walking

? Talipes or inversion of the foot can suggest imbalance of muscle tone and neurological abnormality. Examination is largely neurological and should be thorough. Look for strength, asymmetry of movement and the presence of primitive reflexes. Note particularly: Muscle tone. Passively flex and extend the limbs and pick up the child to assess muscle tone and control. Is there any asymmetry between sides? Does the head flop on being lifted? Do tone and muscle control feel normal for a baby of this age (...) motor skills but this is rare. However, a similar process can be seen in children who have been ill and bed-bound for long periods of time. Emotional deprivation doesn't tend to affect these skills as much as others. has been reported to delay walking; this is reversible if the disease is not too advanced. [ ] It is worth noting that obesity and are not causes of delayed walking. [ ] The issue surrounding baby walkers is not entirely clear but they are unlikely to cause significant harm. Two

2008 Mentor

3039. Diving Accidents

hours later. Pain is often dull, poorly localised, of gradual onset and not exacerbated by movement of the joint. Untreated pain will reduce and disappear over 2 or 3 days with rapid improvement on recompression. Neurological symptoms may also occur. There is usually sensory disturbance with numbness and paraesthesia but no clear dermatomal or peripheral nerve distribution. In its severe form, it starts with girdle pain with loss of sensation and movement in lower limbs. Cerebral involvement (...) the density of inhaled gas increases as pressure increases, breathing can be restricted. Lung volume is also reduced because of displacement of blood from the periphery to the thorax. Diving accidents The British Sub Aqua Club reported 364 diving incidents in 2010, including 98 decompression incidents and 17 fatalities. [ ] The Health and Safety Executive reported 24 fatal accidents in the 8-year period from 1996/97 to 2003/04, many amongst people receiving recreational diving training by instructors

2008 Mentor

3040. Epilepsy in Adults Full Text available with Trip Pro

, which lower the seizure threshold. It is common for seizure frequency to vary throughout the menstrual cycle. In ovulatory cycles, peaks occur around the time of ovulation and in the few days before menstruation. In anovulatory cycles, there is an increase in seizures during the second half of the menstrual cycle. [ ] Possible seizure-related symptoms include: Sudden falls. Involuntary jerky movements of limbs whilst awake. Blank spells. Unexplained incontinence of urine with loss of awareness (...) , or in sleep. Odd events occurring in sleep - eg, fall from bed, jerky movements, automatisms. Episodes of confused behaviour with impaired awareness. Possible simple focal seizures. Epigastric fullness sensation. Déjà vu. Premonition. Fear. Elation, depression. Depersonalisation, derealisation. Inability to understand or express language (written or spoken). Loss of memory, disorientation. Olfactory, gustatory, visual, auditory hallucinations. Focal motor or somatosensory deficit, or positive symptoms

2008 Mentor

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