Indications for Tonsillectomy

1. recurrent infection

2. sleep apnoea

3. tumour growth

Steroids

1. Examples: Methylprednisolone, betamethasone, dexamethasone, hydrocortisone, cortisone acetate, triamcinolone, deflazacort

2. Side-effects:

• diabetes
• osteoporosis
• AVN of femoral head
• euphoria + other paranioa; also depression
• proximal myopathy --> muscle wasting
• peptic ulceration
• Cushing's
• suppression of growth in children
• adrenal atrophy (long-term). Important to avoid abrupt after long term use (>3 wks) as: 1) acute adrenal insufficiency; then 2) hypotension; then 3) death!
• Atypical infections
• chickenpox with atypical features (i.e. rash not a feature e.g. pneumonia, hepatitis, DIC)
  

Case Study

• 66 yr old gentleman
• 2 yrs hx of unsteadiness on feet - shuffle when walking
• noticed weakness in the legs
• loss of balance
  
• increase in freqeuncy of micturition
• reduced in memory
  
• in recent 2-3 months, starts to develop tremors in hands when try to do something
• loss of bladder control
• symptoms get worst
• no significant finding in PMHx, DHx, FHx and SHx

Dx:

• Normal pressure hydrocephalus(NMH) aka adult onset hydrocephalus

Triad of NMH:

• ataxia
• dementia
• incontinence

Investigation:

• MRI

Management:

• ventriculo-peritoneal shunt
  

Leg Claudication

Neurogenic (nerve root compression)

• pain on exertion (walking a distance/climbing up hills or stairs)
• relieved by bending forward
• sensory symptoms ie pins and needles

Cardiogenic (peripheral vascular disease)

• pain on exertion (walking a distance/climbing up hills or stairs)
• relieved by hanging legs over side of bed (at night)
• no sensory symptoms
  

Parkinson's disease

Pathology

• Idiopathic, degenerative
• progressive death of dopaminergic neurone in substantia nigra
• relative excess of acetylcholine

Onset usually around 6th-7th decade

Triad of classical symptoms

• akinesia/bradykinesia (usually upper body)
  
• resting tremor (asymmetrical, abolished by movement)
  
• rigidity (asymmetrical)

Other features

• lack of arm swing
• short step
  
• Parkinsonian face (flat face?)
• postural instability
• dementia

Examination

• bradykinesia: do alternate supination/pronation tap
• rigidity: check tone, remember to distract the patient

Investigation

• therapeutic trial of levodopa (walking test before and after taking levodopa)

Management

• education and support
• physiotherapy, occupational therapy, speech and language therapy
• drugs (levodopa, sinemet, selegiline)

Differentials

• essential tremor
• Alzheimer
• drug
• Lewy body dementia
• multisystem atrophy
• progressive supranuclear palsy
  

Headache

• commonest headache - tension headache
• commonest debilitating headache - migraine
• commonest brain tumour - brain mets

1 question that would distinguish between different types of headache:

what would you do when you get the headache?

• lie down and sleep - migraine
• keep on doing activity as before - tension headache
• bang head with hand/on the wall - cluster headache
  

Acute asthma in children

Assessment of severity

1. respiratory rate
2. work on breathing (accessory muscles, recession/tug)
3. oxygen saturation

Management

• nebulized oxygen
• nebulized salbutamol
• ipratropium bromide (only in acute severe episode)
• steroid (given PO, but if the child is vomitting or in comatose, can use IV)