Ulnar Nerve Palsy/ Claw Hand

EXAMINATION
         •CLAW HAND
           WEAKNESS          •Hypothenar eminence
                                          •Abductor digiti minimi
                                          •Median 2 lumbricals (finger flexion)
                                          •All interrossei (adduction & abduction)
           WASTING              •Medial side of forearm
           SENSORY             •Medial 1 1/2 fingers
           SYMPATHETIC     •Sweating

CAUSES
         •# Dislocation @ elbow
         •Occupational (leaning on elbows)
         •OA
         •Mononeuritis multiplex

Fig 1: Claw Hand

Causes of Delirium (Medical Mnemonics)

DELIRIUMS

D	Drugs
E	Eyes, ears (Disorientation)
L	Low oxygen (MI, ARDS, PE, CHF, COPD)
I
R	Retention (Urine, Stool)/ Restrains
I	Ictal
U	Underhydration/ Undernutrition
M	Metabolic
S	Subdural/ Sleep deprivation

Further Reading

Drugs Causing Delirium (Medical Mnemonics)

ACUTE CHANGE IN MS

A	Antibiotics	(Biaxin, Penicillin, Ciprofloxacin)
C	Cardiac drugs	(Digoxin, Lidocaine)
U	Urinary incontinence drugs	(Anticholinergics)
T	Theophylline
E	Ethanol
C	Corticosteroids
H	H2 Blockers
A	Antiparkinsonian drugs
N	Narcotics	(Mepridine)
G	Geriatric psychiatric drugs
E	ENT drugs
I	Insomnia drugs
N	NSAIDs	(Indomethacin, Naproxin)
M
S	Seizure medicines

Further Reading

Clinical Features of Delirium (Medical Mnemonics)

DELIRIUM

D	Disordered thinking
E	Euphoria, fearful, depressed, or angry
L	Language impaired
I	Illusions, delusions, hallucinations
R	Reversal od sleep-wake cycle
I	Inattention
U	Unaware/ disoriented
M	Memory deficit

Further Reading

The Ulnar Nerve

Fig 1: Claw Hand

The ulnar nerve (usually) supplies sensation to the skin of the fifth and the ulnar side of the fourth finger, front and back. There is sympathetic interruption, with absence of sweating in the affected area. The thenar muscles are supplied by the median nerve and are therefore spared. Although the fourth and fifth digits are held in the clawed position when the nerve is injured at the wrist, a high lesion paralyses the long flexors to these two fingers and results in the loss of this sign. A test for paralysis of the palmar interossei, supplied by the ulnar nerve, is the inability to adduct the fingers and thus to be unable to grip a sheet of paper between them. 

Causes of Chorea (Medical Mnemonics)

St. VITUS'S DANCE

St	Sydenham
V	Vascular
I	Increased RBC (Polycythaemia)
T	Toxins (CO, Mg, Hg)
U	Uraemia
S	SLE
'
S	Senile chorea
D	Drugs
A	Alpha syndrome
N	Neurodegenerative disorders (Huntington's disease, Neuroacanthocytosis, DPRLA)
C	Conception related (Pregnancy, OCP)
E	Endocrine (Hyperthyroidism, Hypo/ hyperglycaemia)

Fig 1: Sydenham Chorea

Further Reading

Clinical Features of Fragile X Syndrome (Medical Mnemonics)

FEMALES

F	FMR1 Gene
E	Exhibits anticipation
M	Macro-orchidism
A	Autism
L	Long face with large Jaw
E	Everted eyes
S	Second most common cause of genetic retardation

Fig 1 : Fragile X Syndrome

Further Reading

Drugs Causing Hyperkalaemia (Medical Mnemonics)

K	K Sparing
B	Beta Blockers
A	ACEi	Angiotensin Converting Enzyme Inhibitors
N	NSAIDS	Non-Steroidal Anti-Inflammatory Drugs
K	K Supplements

Fig 1: ECG Changes in Hyperkalaemia

Further Reading

Clinical Features of Hypokalaemia (Medical Mnemonics)

T	Tetany	Fig 1: T wave and U wave in Hypokalaemia
I	Increases paralytic ileus (aggravates)
M	Muscle weakness
I	Increases possibility of hepatic encephalopathy
D	Digoxin toxicity
C	Cardiac arrhythmias
H
I	Increases PR interval, T wave and prominent U wave
M	Muscle cramps
P	Polyuria

Further Reading | Fig 1

Lingula of the Left Lung

Fig 1: Lingula Lung

The lingula of the lung is the region of the left superior lobe that is the equivalent to the right middle lobe in terms of segmental bronchi equivalents. It constitutes the two segmental lobes:

• superior lingular bronchopulmonary segment

• inferior lingular bronchopulmonary segment

Further Reading | Fig 1

Diagnosis of Cushing's Syndrome

Fig 1: Diagnosis Cushing's Syndrome
ACTH: AdrenoCorticoTropic Hormone; IPSS: Inferior Petrosal Sinus Sampling; CRH: Corticotrophin Releasing Hormone

↓DOSE:    1-2mg  →  ↓Cortisol  →  ΘEndogenous pathology

↑DOSE:    8mg     →    -Feedback on pituitary

                             → ΘFeedback on  →   Ectopic ACTH

                                                          →  Adrenal Adenoma                 

↓DOSE  →   ↓Cortisol  →   Normal -feedback

              →   =Cortisol  →  ↑DOSE  →   ↓Cortisol  →  1ºAdrenal

                                                     →   =Cortisol  →  Ectopic ACTH  →  CXR/ CT Abdo

                                                     →   ↑Cortisol  →  Cushing's dis     →  MRI Pituitary, ΘCushingoid    

Relevant articles

Causes of Red Eye

• Allergic conjunctivitis
• Bacterial conjunctivitis
• Blepharitis (inflammation that affects your eyelids)
• Corneal abrasion (rubbing off of the very top layers of the cornea, the transparent cover of your eye)
• Corneal herpetic infections (herpes)
• Corneal ulcers
• Dry eyes
• Ectropion (condition in which your eyelid turns out)
• Entropion (condition in which your eyelid turns in)
• Episcleritis (inflammation of the membrane covering the white part of the eye)
• Foreign object in eye
• Hay fever
• Iritis (inflammation of the colored part of the eye)
• Keratitis (inflammation of the cornea)
• Orbital cellulitis (severe infection of tissues around the eye)
• Scleritis (inflammation of the white part of the eye)
• Sty (a red, painful lump near the edge of your eyelid)
• Subconjunctival hemorrhage (broken blood vessel in eye)
• Uveitis (inflammation of the middle layer of the eye)
• Viral conjunctivitis

Further Reading

Myasthenia Gravis

Fig 1: Unilateral ptosis

•AI
•vs ACh receptors (NMJ postsynaptic memb)

SYMPTOMS
           •Facial weakness
           •Slurred speech
           •Dyspnoea
           •(Prox) Limb weakness
           •Worse @ end of day
            AUTONOMIC    •Nil

SIGNS
           CRANIAL      •Ptosis (episodic, unilateral, bilateral)
                                 •Ophthalmoplegia (episodic)
                                 •Dysarthria
                                 •Bulbar symptoms & nasal regurgitation
                                 •Head drooping (weakness of neck musculature)
            MOTOR        •Fatigable weakness of striated muscle
                                 •Respiratory muscle (ife-threatature)
                                 •n/↑ Reflexes

CAUSES
           •AI
           •Penicillamine

INVESTIGATIONS
           •90%Anti-ACh receptor antibody
           •Antistriated muscle antibody
           •80%Thymoma
            EMG                           •↓ Muscle action potential + rapid stimulation
                                               •Post activation exhaustion
            TENSILON TEST       •IV edrophonium (short acting anticholinesterase)
            CT THORAX               •?associated thymoma
            TFT                             •10%Thyrotoxicosis;

TREATMENT
           •Thymectomy
           •Steroids
           •Immunosuppression (Cyclophosphamide, Ciclosporin)
           •Plasmapheresis
           •IV Ig

Further Reading

Diabetic Ketoacidosis (DKA)

Fig 1: Diabetes Ketoacidosis

•Type 1 (?1st presentation)
•Uncontrolled catabolism due to ↓insulin

↓insulin → Lipolysis →Ketosis → Acidosis

PRECIPITANTS
            •Insulin omission
            •MI
            •Stroke
              INFECTIONS      •UTI
                                          •RTI
                                          •Gangrene


SYMPTOMS & SIGNS
            •Vomiting
            •Polyuria
            •Dehydration & thirst
            •Abdominal pain
            •Kausmaul breathing (acidosis)
            •↓Conscious level

              DKA    Dehydrated   Ketones/ Kussmaul breathing/ K drops   Acidosis

INVESTIGATIONS 
             •Ketonuria
             •Hyperglycaemia
             •Metabolic acidosis
             •Hyperkalaemia
             •Renal failure

MANAGEMENT
            •Rehydration (Saline, KCl)
             •Insulin
             •LMWH
             •Treat underlying precipitant

Further Reading | Fig 1

Causes of Erythema Nodosum (Medical Mnemonics)

Fig 1: Erythema Nodosum

NODOOSSSUM

N	NSAIDs
O	Oral contraceptive pills
D	Darling's disease (Histoplasmosis)
O	Ohio valley disase
O	COccidiodomycosis
S	Sulphonamides
S	Strep A Haemolytic
S	Syphilis
S	Sarcoidosis
U	Ulcerative COlitis
M	Mycobacterium TB
M	RheuMatic Fever

Also Pregnancy

Further Reading | Fig 1

Sideroblastic Anaemia

Fig 1: Sideroblastic Anaemia

Fe         Θ+ Hb
            → Accumulates in mitochondria → Poisoned
            → Iron granules lying in a ring around
                 erythroblast nucleus → Ring sideroblast





CAUSES
            CONGENITAL                     •X •Rare •Pyridoxine responsive
            ACQUIRED                           1º    •Myelodysplastic dis
                                                          2º     •Malignancy
                                                                  •Alcohol
                                                                  •CTD
                                                                  •Heavy metal poisoning
                                                                  •Isoniazid
                                                                  •Chloramphenicol
INVESTIGATIONS 
          •↓/n/↑ MCV
            BLOOD FILM    •Dimorphic (normal & microcytic)
                                      •Ring sideroblasts (normoblasts + iron around nucleus)

MANAGEMENT
          •Pyridoxine
          •Iron chelation

Further Reading |  Fig 1

Prolactinoma

•25%Pituitary tumour •Large♂ •Small♀   •MEN I

Diagnosis            •MRI pituitary
                            •Hormone levels

Treatment           •Bromocriptine
                            •Pergolide
                            •Cabergoline
                            •Pituitary irradiation
                            •Pituitary surgery

Further Reading

Prolactin

Fig 1: Prolactin Structure

•Anterior pituitary hormone
•-ve Hypothalamus control
•↑Dopamine→↓Prolactin

HYPOPROLACTINAEMIA

Causes                •Dopamine
                            •Dopamine agonists (Bromocriptine)


HYPERPROLACTINAEMIA

Symptoms          •Galactorrhoea
                            •Secondary hypogonadism

Causes                •Prolactinoma
                            •Stress (Epileptic fit)
                            •Pregnancy
                            •Polycystic ovary
                            •Damage to hypothalamus/pituitary stalk
                            •Renal/hepatic failure
                            •Dopamine antagonist (Metoclopramide, Phenothiazines)
                            •Oestrogens (OCP)

                             MNEMONICS     Please Buy Raspberries Or Melons To Calm Ellen
                                                         Phenothiazines   Butyrophenones   Reserpine   Opiates
                                                         Metoclopramide   TriCylic   Estrogens

Further Reading | Fig 1

Panhypopituitarism

•↓Adrenal •Hypothyroidism •HypoG •↓GH •DI

CAUSES 
          •Pituitary tumours (incl metastases)
          •Craniopharyngiomas
          •Empty sella syndrome
          •Infiltration (TB, Sarcoidosis, Histiocytosis X)
          •Encephalitis
          •Syphilis
          •Trauma
          •Sheehan's (Pituitary infarction with postpartum haemorrhage)

MANAGEMENT
         •Replace all deficient hormones

Further Reading

Pituitary Tumours

• Benign>>Metastases (Breast ca)
• 50%Non-secreting 
• •Secreting (Prolactinoma) 

SYMPTOMS

• Bitemporal hemianopia (macro) 
• Cranial Nerve palsy (macro) 
• Hormonal effects 

TYPES

• Microadenoma<1cm 
• Macroadenoma>1cm

Lichen Planus

Fig 1: Lichen Planus

Lichen planus is characterised by an itchy, purplish, polygonal, flat-topped rash developing over the wrists and ankles. A lacy fine network of papules develops in over 60% of the patients.

It is commonly seen in patients with autoimmune chronic liver disease such as primary biliary cirrhosis and chronic active hepatitis. 

Fig 2: Wickham's Striae

The presence of  Wickham’s striae – a fine, white lacy pattern, over the papules helps in diagnosis. It usually resolves in 12–18 months. 

Causes of Hypercalcaemia (Mnemonics)

MD PIMP ME           Malignancy   Diuretics (thiazide is main culprit)   ↑PTH      
                                    Immobilisation/Idiopathic   Megadoses of vit A, D   Paget's
                                    Milk alkali   Endocrine (Addison's, Thyrotoxicosis)

VITAMIN TRAPS    ↑VitA & D   Immobilisation   Thyrotoxicosis    Addison's dis/ Acidosis
                                    Milk-alkali   Inflammatory dis   Neoplastic   Thiazides, other drugs
                                    Rhabdomyolysis   AIDS   Paget's/ Parenteral nutrition/ Parathyroid dis
                                    Sarcoidosis    
             
GRIM FED                Granulomas (Sarcoid, TB)   Renal failure   Immobility (esp LT)   Malignancy
                                    Familial (eg familial hypocalciuric hypercalcaemia)   Endocrine
                                    Drugs (esp thiazide diuretics, lithium)

Causes of Hypercalcaemia

ENDOCRINE MALIGNANCY SARCOID DRUGS Ca INTAKE & MILK ALKALI

•1º/3º↑PTH •↑VitD •HyperT •Breast •Kidney •Thyroid •SqCC •Macrophages → 1,25VitD3 •Thiazides •Lithium