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12.12.04 Ward notes

Lacunar syndromes

NameLocation of infarctPresentation
Pure motor stroke/hemiparesis (33-50%)Posterior limb of the internal capsule
Basal pons
Corona radiata
Unilateral hemiparesis or hemiplegia
May involve dysarthria, dysphagia or transient sensory symptoms 
Ataxic hemiparesis Posterior limb of the internal capsule
Basal pons
Corona radiata
Red nucleus
Lentiform nucleus
SCA infarcts
ACA infarcts
Combination of ipsilateral cerebellar and motor symptoms
Usually affects the leg more than it does the arm
Onset of symptoms is often over hours or days
Dysarthria/clumsy hand Basal pons
Anterior limb or genu of internal capsule
Corona radiata
Basal ganglia
Thalamus
Cerebral peduncle
Dysarthria and clumsiness (i.e., weakness) of the hand
Often most prominent when the patient is writing
Pure sensory strokeContralateral thalamus (VPL)
Internal capsule
Corona radiata
Midbrain
Persistent or transient unilateral numbness, tingling, pain or burning
Mixed sensorimotor strokeThalamus 
Adjacent posterior internal capsule
Lateral pons
Hemiparesis or hemiplegia with ipsilateral sensory impairment

Treatment of hypercalcaemia
  • Restrict input
  • IV fluids
  • Loop diuretics
  • Bisphosphonates
  • Dialysis 
    • If > 3.5 mM

Risk factors for cholangiocarcinoma
  • Primary sclerosing cholangitis / UC (themselves closely associated)
  • Chronic infection
    • Parasitic liver diseases
    • Hepatitis
  • Chronic liver disease
    • Alcoholic liver disease
    • Cirrhosis
  • Congenital liver abnormalities
    • Caroli's syndrome
    • Choledochal cysts
  • Hepatolithiasis

Nerves running through the cavernous sinus
  • III, IV, V1, V2, VI
  • VI is closest to the internal carotid and is affected first by an aneurysm

Indications for AAA surgery
  • > 5.5 cm
  • > 3 cm and growing > 1 cm per year

Metformin side-effects
  • Gastrointestinal upset
    • Diarrhoea, cramps, nausea, vomiting, increased flatulence
  • Lactic acidosis
    • Very rare
    • Generally only with comorbid conditions (impaired liver r kidney function)

Kartagener syndrome
  • Primary ciliary dyskinesia, accompanied by:
    • Situs inversus
    • Chronic sinusitis
    • Bronchiectasis

Causes of bronchiectasis
  • Congenital
    • Primary ciliary dyskinesia
    • Cyctic fibrosis
    • Alpha-1 antitrypsin deficiency
    • Primary immunodeficiencies
    • Marfan syndrome
  • Acquired
    • AIDS
    • TB
    • UC
    • Smokers with RA
    • Aspiration

Child-Pugh score
  • Used to assess the prognosis of chronic liver disease
Measure1 point2 points3 points
Total bilirubin, μmol/l<34 34-50 >50 
Serum albumin, g/l>3528-35<28
INR<1.71.71-2.30> 2.30
AscitesNoneMildModerate to Severe
Hepatic encephalopathyNoneGrade I-II (or suppressed with medication)Grade III-IV (or refractory)


PointsClassOne year survivalTwo year survival
5-6A100%85%
7-9B81%57%
10-15C45%35%


MELD score
  • Scoring system for assessing the severity of chronic liver disease
  • MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.57[Ln serum creatinine (mg/dL)] + 6.43
  • 3 month mortality:
    • 40 or more — 71.3% mortality
    • 30–39 — 52.6% mortality
    • 20–29 — 19.6% mortality
    • 10–19 — 6.0% mortality
    • <9 — 1.9% mortality

Sick euthyroid syndrome
  • State of adaptation or dysregulation of thyrotropic feedback control
  • Levels of T3 and/or T4 are at unusual levels, but the thyroid gland does not appear to be dysfunctional
  • Causes:
    • Pneumonia
    • Fasting
    • Starvation
    • Sepsis
    • Trauma
    • Cardiopulmonary bypass
    • Malignancy
    • Stress
    • Heart failure
    • Hypothermia
    • Myocardial infarction
    • Chronic renal failure
    • Cirrhosis
    • Diabetic ketoacidosis

Complications of MI
  • S udden death
  • P ump failure
  • R upture
    • VSD
    • Papillary rupture
    • Both => Systolic murmur
  • E mbolus
  • A rrhythmia
  • D ressler syndrome
    • Pericarditus, 1 month afterwards

Fluid on the lungs
  • Exudate (high protein, high LDH)
    • Infection
    • Inflammation
    • Cancer
  • Transudate
    • Heart failure
    • Liver failure
    • Kidney failure
    • Meigs syndrome
      • Triad of ascites, pleural effusion and benign ovarian tumour
      • Classically on right side (larger transdiaphragmatic lymphatic channels)
    • Hypotyroidism

Notes
  • PUD = Peptic ulcer disease
  • Docusate = Anionic surfactant = Stool softener
  • Tirofiban = Glycoprotein IIb/IIIa inhibitor - Antiplatelet
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