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Periodic Limb Movement

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3061. 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

3062. 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

3063. 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

3064. 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

3065. 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

3066. Parkinsonism and Parkinson's Disease

is usually apparent in one limb or the limbs on one side for months or even years before becoming generalised. Rigidity presents as an increase in resistance to passive movement that can produce a characteristic flexed posture in many patients. It may be increased by asking the patient to perform an action in the opposite limb - contralateral synkinesis. Bradykinesia presents as a slowness of voluntary movement and reduced automatic movements. It is particularly noticeable in a reduced arm swing whilst (...) as a unilateral or bilateral, low-frequency intention tremor. It may be caused by stroke, brainstem tumour, or multiple sclerosis. Pyschogenic tremor - the tremor is variable, increases under direct observation, decreases with distraction and changes with voluntary movement of the contralateral limb. The 'atypical Parkinsonism syndromes' are a group which look like Parkinson's disease but are much more severe. Median survival is only seven years compared with the normal lifespan in Parkinson's disease

2008 Mentor

3067. Opiate Poisoning

Morphine Opium Oxycodone Pentazocine Tramadol They may come alone or in combination when the situation becomes more complex. Epidemiology [ ] It is difficult to get reliable incidence figures. The elderly are more liable to poisoning from opiates and more likely to be taking them, especially drugs like co-codamol for arthritis. The Office for National Statistics (ONS) published figures for deaths related to drug poisoning in England and Wales for the year 2012. During this period there were 579 deaths (...) an accidental overdose of an opiate. [ ] Differential diagnosis There may be no clear indication of what the patient has taken. He or she may be a known drug abuser or there may be needle track marks on the limbs. Beware of multiple drug ingestion (eg, antidepressants, alcohol or benzodiazepines), especially in drug abusers or with suicidal intent. [ ] Other conditions which may need to be considered include: . . . Hyperosmolar hyperglycaemic nonketotic coma. . . . . . . . Investigations It is possible

2008 Mentor

3068. 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

3069. 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

3070. 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

3071. 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

3072. 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

3073. Paediatric Examination

whether the child has normal development in motor functions, speech and language and social interaction. Note whether there are any specific concerns stated by the parent/s. Always examine the anterior fontanelle by palpation in babies and infants. Note any pulsation and if it is normal. The fontanelle should close by the middle of the second year. It should be full or flat. Note if the child can hear, see, move the eyes and head well in all directions, move all limbs and whether this movement (...) is normal and full. Note whether contour and position of each limb are normal with good power. Handle the child and note the tone of movement of the limb and whether there is any limitation to this. Note if the joints are unduly lax and hyperextendable. Watch the child's face while you move the limbs. [ ] Although rarely useful, you may be able to elicit reflexes with the percussing finger instead of a hammer. Examination at different ages Examination will be outlined in different age groups

2008 Mentor

3074. Osteomyelitis

and is a high risk factor for adverse outcome. Early diagnosis is crucial to ensure correct management [ ] . Peripheral arterial disease. Chronic joint disease. Alcoholism. Intravenous drug abuse. Chronic steroid use. Immunosuppression. Tuberculosis. HIV and AIDS. Sickle cell disease. Presence of catheter-related bloodstream infection. Presentation Haematogenous osteomyelitis Long bone Classic presentation : The acutely febrile and bacteraemic patient presents with a markedly painful, immobile limb (...) . There may be swelling and extreme tenderness over the affected area with associated erythema and warmth. The pain is exacerbated by movement and there may be sympathetic effusion of neighbouring joints. In neonates and infants, there may be an associated septic arthritis. Other presentations : Occasionally, the patient may present with mild symptoms, perhaps a history of blunt trauma to the area which may or may not be remembered (eg, a bump against a hard surface) 24-48 hours previously and mild

2008 Mentor

3075. Osteoarthritis

. 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

3076. Pain Control in Terminal Care

Bisphosphonates Bone pain Ketamine (specialist use only) Refractory pain Neuropathic pain Ischaemic limb pain Where pain is continuous, analgesia needs to be prescribed on a regular not 'as-required' basis. Explain that pain is easier to prevent than it is to relieve and drugs should be prescribed on a prophylactic basis with no other consideration than maintaining quality of life. Prescribe also for breakthrough or incident/episodic pain that occurs with everyday activities such as walking. Explain (...) relaxation, hypnosis. Capsaicin cream. Local nerve blocks and epidurals. Acupuncture. Transcutaneous electrical nerve stimulation (TENS). Episodic/incident pain Bony pain due to metastases in the spine, pelvis or femora, exacerbated by walking or weight-bearing can be particularly problematic. Opioids plus NSAIDs are the mainstay; however, doses sufficient to control pain on movement cause sedation when the patient is at rest. Advise prn doses of immediate-release opioid in anticipation of movement

2008 Mentor

3077. Epidural analgesia for pain relief following hip or knee replacement. (Abstract)

conclusions on the edural analgesia compared to systemic analgesia. There were insufficient numbers to draw conclusions on the effect of epidural analgesia on serious postoperative complications, functional outcomes, or length of hospital stay.Epidural analgesia may be useful for postoperative pain relief following major lower limb joint replacements. However, the benefits may be limited to the early (four to six hours) postoperative period. An epidural infusion of local anesthetic or local anesthetic (...) Epidural analgesia for pain relief following hip or knee replacement. Hip and knee replacement are common operative procedures to improve mobility and quality of life. Adequate pain relief is essential in the postoperative period to enable ambulation and initiation of physiotherapy. Lumbar epidural analgesia is a common modality for pain relief following these procedures. However, there is no systematic review of the evidence comparing the efficacy of epidural analgesia with other postoperative

2003 Cochrane database of systematic reviews (Online)

3078. Medications for the Treatment of Sleep Disorders: An Overview Full Text available with Trip Pro

, including amphetamines, may be used to induce daytime alertness. Parasomnias include disorders of arousal and of REM sleep. Chronic medical illnesses can become symptomatic during specific sleep stages. Many medications affect sleep stages and can thus cause sleep disorders or exacerbate the effect of chronic illnesses on sleep. Conversely, medications may be used therapeutically for specific sleep disorders. For example, restless legs syndrome and periodic limb movement disorder may be treated (...) Medications for the Treatment of Sleep Disorders: An Overview Sleep disorders can be divided into those producing insomnia, those causing daytime sleepiness, and those disrupting sleep. Transient insomnia is extremely common, afflicting up to 80% of the population. Chronic insomnia affects 15% of the population. Benzodiazepines are frequently used to treat insomnia; however, there may be a withdrawal syndrome with rapid eye movement (REM) rebound. Two newer benzodiazepine-like agents, zolpidem

2001 Primary Care Companion to the Journal of Clinical Psychiatry

3079. Neonatal outcome after prolonged rupture of the membranes starting in the second trimester. Full Text available with Trip Pro

compressive limb abnormalities, all of which responded to passive physiotherapy. Pulmonary hypoplasia was significantly associated with earlier onset of rupture of the membranes, and the absence of fetal breathing movements. Compressive limb abnormalities were significantly associated with longer periods of oligohydramnios. We conclude that premature rupture of the membranes, even with onset in the second trimester, may be associated with a favourable outcome and this may be predicted by the persistence (...) of fetal breathing movements. We therefore, recommend expectant management of such pregnancies, but suggest elective delivery at 34 weeks to limit fetal exposure to uterine compression and minimise the risks of prematurity.

1988 Archives of Disease in Childhood

3080. Altered sensorimotor integration with cervical spine manipulation. (Abstract)

), motor evoked potentials, and cortical silent periods (CSPs) were recorded from the abductor pollicis brevis and the extensor indices proprios muscles of the dominant limb after single- and paired-pulse transcranial magnetic stimulation of the contralateral motor cortex. The experimental measures were recorded before and after spinal manipulation of dysfunctional cervical joints, and on a different day after passive head movement. To assess spinal excitability, F wave persistence and amplitudes were (...) of dysfunctional cervical joints may alter specific central corticomotor facilitatory and inhibitory neural processing and cortical motor control of 2 upper limb muscles in a muscle-specific manner. This suggests that spinal manipulation may alter sensorimotor integration. These findings may help elucidate mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation.

2008 Journal of Manipulative and Physiological Therapeutics

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