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Periodic Limb Movement

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3021. 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

3022. 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

3023. 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

3024. 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

3025. 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

3026. Developmental Dysplasia of the Hip Full Text available with Trip Pro

skin folds. Limb length discrepancy (see Galeazzi sign below). Limitation and asymmetry of hip abduction when the hip is flexed to 90°. The Ortolani and Barlow tests are the most common clinical tests for newborn babies: In the Ortolani test (screen for a dislocated hip), the examiner applies gentle forward pressure to each femoral head in turn, in an attempt to move a posteriorly dislocated femoral head forwards into the acetabulum. Palpable movement suggests that the hip is dislocated or subluxed (...) ; there is a 7-fold increase for breech babies delivered by elective caesarean section [ ] . Restriction of movement as with oligohydramnios increases the risk. The risk is also increased in multiple pregnancy and prematurity. It is more common with neuromuscular disorders, such as cerebral palsy, meningomyelocele and arthrogryposis. Those presenting with late DDH (presenting after 3 months of age) have fewer of the above risk factors: they are more likely to have been a cephalic delivery and more likely

2008 Mentor

3027. Chorea

. The arms, legs, neck and tongue may also be affected. Causes include asphyxia, neonatal jaundice, Huntington's chorea, cerebrovascular disease and trauma. Management can be difficult but treatment options include medications (eg, diazepam, haloperidol, tetrabenazine), surgery and retraining techniques. Chorea Continuous jerky movements in which each movement is sudden and the resulting posture is held for a few seconds. This usually affects the head, face or limbs. The focus may move from one part (...) in a relaxed limb when fully supported at rest. Causes include Parkinson's disease, Parkinsonism, other extrapyramidal diseases, multiple sclerosis. Postural - occurs if a limb is static (can also remain during movement). Types include physiological tremor, exaggerated physiological tremor - eg, in thyrotoxicosis, anxiety states, alcohol abuse, drugs (eg, sympathomimetics, antidepressants, valproate, lithium), heavy metal poisoning ('hatter's shakes' from mercury). Neurological disease - eg, severe

2008 Mentor

3028. Cerebellar Signs including Cerebellar Ataxia

hypoplasia, , . . There are various other uncommon neurological or metabolic diseases which may involve the cerebellum. Idiopathic cerebellar ataxia - a diagnosis of exclusion. Presentation As the cerebellum is associated with motor control, lesions produce a range of movement disorders (ataxias). These can be differentiated by their time course. Lesions of the midline vermis of the cerebellum cause truncal ataxia, while lesions of the cerebellar hemispheres cause limb ataxia of the ipsilateral side (...) , and linguistic abilities, with affective disturbance ranging from emotional blunting and depression, to disinhibition and psychotic features. Examination Check eye movement - looking for ophthalmoplegia or nystagmus. Check fundi for papilloedema. Get the patient to stick his/her tongue out and move it from side to side (movement slowed). Ask the patient to repeat "baby hippopotamus" - look for dysarthria and abnormal speech rhythm and syllable emphasis. Examine arms for limb ataxia (see above): rebound

2008 Mentor

3029. Abnormal Gait Full Text available with Trip Pro

. The related affect may seem inappropriately unperturbed, or unusually hostile to investigatory questions. Choreic gait Wide-based gait, with slow leg raising and simultaneous knee flexion. Associated with choreoathetoid movements of the upper limbs. Causes include Huntington's chorea and dopaminergic medication. Medication-related gait disturbance [ ] Medications are a factor in at least 30% of the elderly with balance or gait problems. Polypharmacy (more than four medications) is a risk factor for falls (...) . You may find one of our more useful. In this article In This Article Abnormal Gait In this article Balance is the ability to stand, and gait is rhythmic stepping movements for travel (locomotion). Balance and gait problems tend to be found in the same individuals. Walking messages are initiated by the motor and premotor cortex and modified by the subcortical nuclei, brainstem, and cerebellum. These all activate the spine's central pattern generator, which coordinates arm and leg movements

2008 Mentor

3030. Abbreviations

PIVKA-II protein induced from vitamin K absence PJRT permanent junctional re-entrant tachycardia PLDH pegylated liposomal doxorubicin hydrochloride PLHA people living with HIV/AIDS PLMS periodic limb movements of sleep PLP1 proteolipid protein-1 PLS primary lateral sclerosis PM polymyositis PMA progressive muscular atrophy PMETB Postgraduate Medical Education Training Board PML progressive multifocal leukoencephalopathy PMN polymorphonuclear PMR polymyalgia rheumatica PND postnasal drip po per os (...) LLETZ large loop excision of the transformation zone LMA laryngeal mask airway LMP last menstrual period LMWH low molecular weight heparin LOC loss of consciousness LOD laparoscopic ovarian 'drilling' LSCS lower segment Caesarean section LSD lysergic acid diethylamide LTK laser thermal keratoplasty μg (mcg) microgram m metre m3 cubic metre mm3 cubic millimetre mm Hg millimetre of mercury mol mole m/r modified-release MAC membrane attack complex MALT mucosa-associated lymphoid tissue MAOIs monoamine

2008 Mentor

3031. Behçet's Disease

systems. In many patients the activity of this disease diminishes with time. The International Classification Criteria of Behçet's Disease are as follows: [ ] In the absence of other clinical explanations, patients must have recurrent oral ulceration (aphthous or herpetiform) observed by the physician or patient, recurring at least three times in a 12-month period, and two of the following: Recurrent genital ulceration. Eye lesions: anterior uveitis, posterior uveitis, cells in the vitreous by slit (...) of patients have uveitis. Other ocular manifestations include hypopyon, retinal vasculitis, retinal haemorrhage, blurred vision and photophobia. Neurological: central nervous system (CNS) involvement occurs late in the disease. Memory impairment is the most common CNS manifestation. Impairment of balance, speech and movement can also occur. Thrombosis within the dural venous sinuses may occur. Peripheral nerve involvement is rare. [ ] Cardiovascular: Vascular lesions include vasculitis of the small

2008 Mentor

3032. Acute Abdomen

(including whether new pain or previously experienced). Site (ask the patient to point), localised or diffuse. Nature (constant/intermittent/colicky). Radiation. Severity. Relieving/aggravating factors (eg, if worsened by movement/coughing, suspect active peritonitis; pancreatitis is relieved by sitting forward). Associated symptoms: Vomiting and the nature of vomitus (undigested food or bile suggests upper GI pathology or obstruction; faeculent vomiting suggests lower GI obstruction). Haematemesis (...) period. History of sexually transmitted infections/pelvic inflammatory disease. Previous gynaecological or tubal surgery. Previous ectopic pregnancy. Vaginal bleeding. Drug history and allergies - including any complementary medication. Examination See also the separate article on . Pulse, temperature and blood pressure. Assess respiratory rate and pattern. Patients with peritonitis may take shallow, rapid breaths to reduce pain. If there is altered consciousness, check Glasgow Coma Scale (GCS

2008 Mentor

3033. Blepharospasm

find one of our more useful. In this article In This Article Blepharospasm In this article The normal adult blinks at a rate of 10 to 20 times per minute. This tends to be reduced when reading or using the computer. An increase in lid closure frequency and tone is known as blepharospasm. This is a focal dystonia appearing in adults with recurrent spasms of eye closure; the orbicularis oculi muscle contracts forcibly and involuntarily. This lasts for periods varying from seconds to minutes and often (...) to a failure of contraction of the levator palpebrae muscle, which is the case in apraxia of eyelid opening, which occurs in Parkinsonian conditions. The aetiology of blepharospasm is not understood. It has been thought to be caused by pathology within the basal ganglia, although this has not been proven. It appears that multiple cortical and subcortical structures may be involved. [ ] The circuit involved in blinking involves a sensory limb, a central control area in the midbrain and a motor limb

2008 Mentor

3034. Compartment Syndromes

be relatively minor. Intense exercise can also cause acute compartment syndrome. Acute compartment syndrome requires prompt diagnosis and urgent treatment. Chronic compartment syndrome is usually caused by exercise and presents with recurrent pain and disability, which subside when the cause (usually running) is stopped but return when the activity is resumed. Sites affected Compartment syndrome can occur wherever a compartment is present. Therefore, although the upper and lower limbs are most commonly (...) affected, other sites may be affected, particularly the abdomen and gluteal regions: Forearm compartments and structures at risk: Ventral compartment: median and ulnar nerves; radial and ulnar arteries. Dorsal compartment: posterior interosseous nerve; no major vessels. Lower limb and structures at risk: Anterior tibial compartment: deep peroneal nerve, anterior tibial artery. Superficial posterior compartment: no major nerves or vessels. Deep posterior compartment: posterior tibial nerves and vessels

2008 Mentor

3035. Acromioclavicular Joint Problems

and/or localised AC joint pain. May be simply an ache in the deltoid area. Often worse at night. Local tenderness with exacerbation on passive and active shoulder movements. Cross-adduction (ie reach over front of opposite shoulder) often worsens pain; further passive cross-adduction by the examiner may aggravate this. It is important to differentiate OA from instability. Reduced range of movement is rare unless there is a prolonged period of arthritis. Differential diagnosis Clavicular fracture. Shoulder (...) on research evidence, UK and European Guidelines. You may find the article more useful, or one of our other . In this article In This Article Acromioclavicular Joint Problems In this article Synonyms: collar bone/clavicle disorders Description The acromioclavicular (AC) joint is the articulation between the acromion process of the scapula and the lateral end of the clavicle. It is one of the important functional joints that allows a full range of movement at the glenohumeral joint. A joint capsule

2008 Mentor

3036. Whiplash and Cervical Spine Injury

injury occur as the result of rear-end vehicle collisions at speeds of less than 14 miles per hour. Patients present with neck pain and stiffness, occipital headache, thoracic back pain and/or lumbar back pain and upper-limb pain and paraesthesia. [ ] There are two types of injury: Typical cervical hyperextension injuries occur in drivers/passengers of a stationary or slow-moving vehicle that is struck from behind. The person's body is thrown forward but the head lags, resulting in hyperextension (...) of the neck. When the head and neck have reached maximum extension, the neck then snaps into flexion. A rapid deceleration injury throws the head forwards and flexes the cervical spine. The chin limits forward flexion but the forward movement may be sufficient to cause longitudinal distraction and neurological damage. Hyperextension may occur in the subsequent recoil. Whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms: [ ] Grade 0: no complaints or physical signs

2008 Mentor

3037. Werdnig-Hoffmann Disease

than distal, with lower limbs generally weaker than upper limbs. Deep tendon reflexes are absent or diminished but sensitivity is preserved. In the most severe forms decreased intrauterine movements suggest prenatal onset of the disease and present with severe weakness and joint contractures at birth (this has been labeled SMN0). Some of these children may also show congenital bone fractures and extremely thin ribs. The spared diaphragm, combined with weakened intercostal muscles, results (...) . Within SMA1 at least three clinical subgroups can be defined according to the severity of clinical signs: Severe weakness since birth/neonatal period - head control is never achieved. Onset of weakness after the neonatal period but generally within two months - head control is never achieved. Onset of weakness after the neonatal period but head control is achieved. Some of these children may be able to sit with support. Differential diagnosis Includes: Amyotrophic lateral sclerosis. Congenital

2008 Mentor

3038. Hyaluronates and Viscosupplementation

. Reduced function and participation restriction. Signs Reduced range of joint movement. Pain on movement of the joint or at extremes of joint movement. Joint swelling/synovitis (warmth, effusion, synovial thickening). Periarticular tenderness. Crepitus. Absence of systemic features such as fever or rash. Bony swelling and deformity due to osteophytes - in the fingers this presents as swelling at the distal interphalangeal joints (Heberden's nodes) or swelling at the proximal interphalangeal joints (...) on their joints and help to improve pain. The use of local heat or cold (thermotherapy) should be considered as an adjunct to core treatments. Aids and devices: Advice on appropriate footwear (including shock-absorbing properties) as part of core treatments for people with lower-limb OA. Biomechanical joint pain or instability: should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments. Assistive devices (eg, walking sticks and tap turners) should

2008 Mentor

3039. Huntington's Disease

with HD it has been reported to be as common as 69%. [ ] HD then leads to progressive chorea, rigidity and dementia. It is frequently associated with seizures. Chorea is initially mild but may be severe and cause uncontrollable limb movements. As the disease progresses, chorea is gradually replaced by dystonia and Parkinsonian features. Dysarthria, dysphagia and abnormal eye movements are common. There may also be other movement disorders - eg, tics and myoclonus. HD patients can develop a wide array (...) variable. JHD (6% of all cases of HD) is defined as an age of onset of younger than 20 years. It causes Parkinsonian features, dystonia, pyramidal tract signs, dementia and epilepsy. Chorea is often mild and may be absent. Differential diagnosis Neuroacanthocytosis: a group of genetic conditions that are characterised by movement disorders and acanthocytosis (abnormally-shaped red blood cells). and other causes of . Other causes of . Investigations MRI and CT scans in moderate-to-severe HD show a loss

2008 Mentor

3040. Hand Arm Vibration Syndrome

Guidelines. You may find the article more useful, or one of our other . In this article In This Article Hand-arm Vibration Syndrome In this article Synonyms: HAVS, vibration white finger, VWF Prolonged exposure to hand-arm vibration may cause a potentially disabling chronic disorder of the upper limbs, which is called the hand-arm vibration syndrome (HAVS). As well as vascular and neurological injury, HAVS may also involve damage to bones, joints, muscles and tendons in the upper limbs. There may also (...) (little finger) in each hand at two frequencies. The thermal aesthesiometry test, which assesses the thermal receptors' threshold. Readings are again taken from the median nerve and the ulnar nerve. The Purdue Pegboard test, which is a measure of dexterity and detects loss of fine movement to both hands. The grip force measurement test, which measures the grip strength of both hands. This test is not scored but is a useful indication of vibration damage to muscles of the hand and forearm. In addition

2008 Mentor

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