Problems in returned travelers**

Most will present within 2wk except HIV infection Common infections are 1 Giradiasis 2 Amoebiasis 3 Hepatitis A, B or E 4 Gonorrhoea 5 Chalmydia trachomatis An important non-infectious problem DVT and thromboembolism Asymptomatic traveler comes for advise for exposure or for an acquired illness s/as rabies, malaria, schistosomiasis and STIs

Heparin**
Indication for heparin 1 Tx and prevention of DVT 2 3 Pulmonary embolism 4 Post-thrombolysis for MI, to prevent coronary reocculsion 5 Unstable angina pectoris 6 A/c peripheral arterial occlusion Low molecular wt heparin (dalteparin, enoxaparin, tinzaparin) Given SC (denatured by GI secretion no oral, danger of hematoma no IM) Inactivate factor Xa (but not thrombin) LMWH does not prolong APTT As inj of LMWH need only once daily SC and no monitoring required can be treated at home Elderly, low body wt or renal failure increased risk of bleeding (reduce dose) Unfractionated heparin (Daltons) IV or SC Pontentiate antithrombin activity (2, 7, 9 , 10) Rapid onset, short T1/2 Monitor and adjust dose with APTT Antidote is protamine sulphate Side effect for both Increased blding( at operative site, GI, intracranial) Heparin induced thrombocytopenia (HIT) (less common with LMWH) Osteoporsis with long term use (less common with LMWH) Hyperkalaemia Contraindication 1 Bleeding disorders 2 Platelet < 60 *10 9 /L 3 Previous HIT 4 PU 5 Cerebral haemorrhage 6 Severe hypertension 7 Neurosurgery IV heparin dosing APTT ratio >5 4-5 3-4 2.5-3 1.5-2.5 1.2-1.4 <1.2 Change rate(iu/h)by -500* -300 -100 -50 0 +200 +400 *stop for 1hr then recheck APTT. Reduce dose by 500iu/h and restart if <5 Heparin induced thrombocytopenia(HIT) in small proportion of pt with heparin platelet count declines after 5-7days d/t development of antibody to the heparin-platelet factor 4 on the platelet surface HIT s/be considered in all pts whose plt count fall by more than 50% after starting heparin Very serious cx bcoz it is asso: with a high incidence of arterial and venous thrombosis

Dx by detecting antibody to PF4-heparin complex Heparin should be discontinued as soon as HIT dx and direct thrombin inhibitor, hirudin given instead

Warfarin** Indications
Prophylaxis against DVT Tx of DVT & PE Arterial embolism Atrial fibrillation with specific stroke risk factors Mobile mural thrombus on echo post MI Extensive anterior MI Recurrent DVT whilst on warfarin Mechanical prosthetic cardiac valves Used orally once daily as long-term anticoagulation Inhibit reductase enzyme responsible for regenerating the active form of vit K (produce VitK deficiency) Achieve full anticoagulation effect after 5-7days Prothrombin ratio(INR) of 2-3times normal control indicates therapeutic effect Duration of effect is 4-5 days after cessation Use with caution in elderly and those with past GI bleeds Antidote is VitK +/_ plasma or prothrombin complex concentrate Contraindication Active bleeding h/o intracranical haemorrhage PU Bleeding d/o Severe hypertension Liver d/s with impaired synthetic function Pregnancy(teratogenic) Protection of Venous thrombosis (Davidson)** Following patient should be considered for specific antithrombotic prophylaxis Moderate risk of DVT Major Sx in patients>40yrs or with other risk factor Major medical illness Eg.Ht failure Chest infection Malignancy Inflammatory bowel d/s High risk of DVT Hip or knee surgery Major abdominal or pelvic Sx for malignancy or with history of DVT or known thrombophilia Antithrombotic prophylaxis All hospitalized patient should be assessed for risk factors for DVT Early mobilization is important Medium or high risk pt require additional antithrombotic measures In medium risk full length compression stockings are effective SH or LMWH can also be used (should be started 12hr pre-op and continue till the pt is fully mobile) High risk anti-embolism stocking and LMWH at a higher prophylactic dose Other preventive measures Physiotherapy Pneumatic compression (esp n high-risk pt where heparin is CI)(until 16hr post-op) Electrical calf m/s stimulation d/r Sx Air Travel and DVT (economy-class $)** 1 2 3 4 5 6 7 8

Risk 0.01_0.04% for general population 4-6% in High-risk group (fights > 10hr) Prophylaxis with one dose of LMWH Increased risk of PE with long distance air travel Compression stockings may reduce risk but can cause superficial thrombophlebitis (CI in peripheral A d/s) Leg exercises(foot pumps, ankle circle ,knee lifts), increased water intake, and avoid alcohol or caffeine during flight Inj LMWH just prior to flying and on arrival for those at high risk. Use a prophylactic dose eg. Enoxaparin 40mg or dalteparin 5000U

Venous thromboembolism** Stasis + increased coagubility(thrombophilia)+tissue injury

Risk Factors Family history Thrombophilia H/o previous DVT Drugs ( OCpill, tamoxifen, HRT) Malignancy Increasing age: >40 Varicose vein Significant illness (eg. Ht failure, cancer) Other chronic illness Recent Sx Major/ orthopedic Sx Immobility Long flights Pregnancy/ puerperium Obesity Dehydration C/F 20% asso: with PE 65% above knee( m/b asymptomatic)(rarely embolize to lung) Usually causes tenderness in calf May present with painless unilateral leg swelling InVx Duplex US (accurate for above knee thrombosis) If test normal repeat in 1 wk Contrast venography if US doubtful Pretest clinical probability scoring for DVT: the Wells score In patients with symptoms in both legs, the more symptomatic leg is used C/F Score Active CA (Tx within last 6mth or palliative) 1point Paralysis, paresis or recent plaster immobilization of leg 1point Major Sx or recently bedridden for >3ds in last 4wks 1point Local tenderness along distribution of deep venous sys: 1point Entire leg swollen 1point Calf swelling>3cm compared with asymptomatic leg (measured 10cm below tibial tuberosity) 1point Pitting oedema (greater in the symptomatic leg) 1point Collateral superficial veins (non-varicose) 1point Alternative diagnosis as likely or more likely than that of DVT _2points Wells score 3 or >3 points High pretest probability tx as suspected DVT and perform compression US 1-2 points Intermediate probability Tx as suspected DVT and perform compression US

0 or < 0

Low pretest probability

Perform D-dimer test ,if + tx as suspected DVT and perform US If _ DVT reliably excluded

Treatment 1 Collect blood for APTT, INR and platelet count 2 LMW heparin (eg. Enoxaparin 1.5mg/kg SC daily or enoxaparin 1mg/kg SC bd) 3 Oral anticoagulant (warfarin) for 3 to 6months 4 Inferior Vena Cava filter (m/b used in active blding or when anticoagulant fails) 5 Do not give aspirin 6 Mobilisation within the limits of pain, tenderness and swelling 7 Class II graded compression stocking to affected leg in proximal DVI asso: with significant swelling Therapeutic anticoagultion For Tx of venous thromboembolism Initiation of warfarin Tx Measure INR first LMWH or UFH are used initially and warfarin is given in combination usually from day1 or a/f heparin is commenced Heparin should be continued until INR has reached target therapeutic range until day 5 as warfarin has an initial prothrombotic effect. Heparin can be ceased when INR > 2 for 2 consecutive days Typical loading dose of warfarin is 5-10mg (o) daily for 2days (avoid dose >30mg over 3days without INR) Adjust dose a/c to INR from third day Establish the INR in the therapeutic range usually 2_3 Maintenance dose is usually reached by day 5 INR reflects the warfarin dose given 48hrs earlier Warfarin Dosage adjustment* DAY INR Dose 1 _5-10mg** 2 <1.8 5mg** 1.8 to 2.0 1mg >2.0 Hold 3 <2 5mg 2.0 to 2.5 4mg 2.6 to 2.9 3mg 3.0 to 3.2 2mg 3.3 to 3.5 1mg >3.5 Hold 4 and until stabilised < 1.4 10mg 1.4 to 1.5 7mg 1.6 to 1.7 6mg 1.8 to 1.9 5mg 2.0 to 2.3 4mg 2.4 to 3.0 3mg 3.1 to 3.2 2mg 3.3 to 3.5 1mg >3.5 Hold **5mg of warfarin should be given to patients who are likely to be sensitive to warfarin. This includes the elderly, the very ill, the malnourished and patients with abnormal liver function or significant chronic renal failure. *This table should be used only if the pretreatment INR is normal INR measurement schedule Before Tx on third day Daily for 1wk

2times daily for 2weeks Weekly for 4weeks monthly Notes: Warfarin should be continued for 3 to 6months and longer if major risk factors are present Watch for potential drug interactions Duration of anticoagulation in DVT/PE If the cause will go away (eg post op immobility) At least 6wks for below knee DVT At least 3mnths for above knee DVT or PE At least 6mtns if no cause found Indefinitely for identified, enduring causes eg. thrombophilia Recommended INR target valure 2.0 to 3.0 1 Prevention of DVT 2 Tx of DVT or PE 3 Preventing systemic embolism : AF, post MI, t/s ht valve, valvular ht d/s 4 prevent recurrence of MI 5 Antiphospholipid antibody $ thrombosis 2.5 to 3.5 Mechanical prosthetic ht valve Overdose of warfarin Signs Unexpected blding after minor trauma Epistaxis Spontaneous bruising Usu: heavy menstrual blding GI blding

Management of overdosage(a/c to oxfd bk) 1 Urgent measurement of INR 2 Small increase of INR cessation of warfarin for 1 to 2 days f/by a continuation at lower dose 3 Markedly increase (>5.0) small dose of oral vit K (1-2mg) 4 Minor bleeding cessation of warfarin for 1 to 2 days f/by a continuation at lower dose 5 Persistent or severe bleeding or involves closed body cavity( s/as pericardium, intracranial, fascial compartment) Urgent admission oral or parenteral vit K + infusion of FFP(15ml/kg=1L for 70kg man) +/_ prothrombin complex concentrate *vit K take several hrs to work and can cause prolonged resistance when restarting warfarin, so should be avoided if possible when long term anticoagulation is needed. *Prothrombin complex concentrate contains a concentrate of factor IX and provides a more complete and rapid reversal of warfarin than FFP

Drug interaction Avoid polypharmacy Aspirin is CI bcoz of combined antiplatelet and anticoagulation effects

Increased warfarin activity Allopurinol Amiodarone Anabolic steroids Antibiotics (BS) Antifungals Aspirin (high dose) Chloral hydrae Cimetidine Clofibrate Gemfibrozil Metronidazole Miconazole NSAIDs, including COX 2 inhibitors Paracetamol ( large dose) Phenytoin PPI Quinidine/quinine Raniditine SSRIs Sulphonamides Tamoxifen Thyroxine Herbal medicine Decreased warfarin activity Antacid Antihistamines Barbituates Antiepileptics (CPZ) Cholestyramine (reduced absorption) Grieseofulvin Haloperidol Oestrogen/ OC pill Rifampicin Vit C Increased or decreased Alcohol Chloral hydrate Diuretics Ranitidine

Pulmonary Embolism
Risk factor Recent Sx esp abd/pelvic or hip/knee replacement Leg fracture Prolong bed rest/reduced mobility Malignacy Pregnancy/postpartum, pill/ HRT Previous PE Asso: symptoms Dyspnoea, pleuritic chest pain,syncope, sweating, voimiting, cyanosis, agitation, haemoptysis InVx 1 CT pulmonary angiography(CTPA) very specific and as sensitive as V/Q scan

3 4 5 6 Tx

Thus currently 1st line of InVx ECG (non-specific) Most common ECG finding tachycardia Others may show normal, RBBB, Rt ven: strain(inverted Tin V1 to V4) Classical S1 Q3 T3 (rare) D-dimer (for low risk gp) CXR Normal or dilated pul A Droppler US of lower limbs ABG PaO2 and PaCO2

Need supportive medical care and anti-coagualtion Heparin IV : 5000U as immediate bolus contiuous infusion 30 000U over 24hrs Or Heparin 12 500 U(sc) bd Dose adjusted daily to maintain APTT bet: 1.5 and 2 Continue heparin 5 to 10 days Warfarin (o) after 3 to 4 days: then continue heparin for 3 days after INR at desired level Thrombolytic Tx for major embolism Surgical embolectomy rarely necessary (needed if very extensive) Preventing systemic embolism in AF *As a general rule, all patients with AF should start on warfarin unless < 65yrs old or have a major CI to its use *It is not indicated in pt with lone AF who are <60yrs old with no risk factors *If using warfarin, start with a low dose (eg 2-4mg) and maintain an INR of 2-3 with regular checks *Anticoagulation Tx is also required to prevent embolism after cardioversion Snake Bites First aid** 1 Keep the patient as still as possible 2 Do not wash, cut, manipulate the wound, apply ice or use a tourniquet 3 Immediately bandage the bite site very firmly (not too tight). A 15cm crepe bandage is ideal: it should extend above the bite site for 15cm (e.g if bitten around the ankle the bandage should cover the leg to knee) 4 Splint the limb to immobilize it : a firm stick or slab of wood would be ideal 5 Transport to a medical facility for definitive tx. Do not give alcoholic beverages or stimulants. 6 If possible, the dead snake should be brought along Note A venom detection kit is used to examine a swab of the bitten area or a fresh urine specimen (the best) or blood. The bandage can be removed when the patient is safely under medical observation. Observe for s/- & -/s of envenomation. Envenomation Not all patients envenomated Only if evidence of envenomation(+) antivenom Early symptoms of envenomation Nausea and vomiting (reliable) Abdominal pain Excessive perspiration Severe headache Blurred vision Difficulty speaking or swallowing Coagulation defects (eg haematuria) Tender lymphadenopathy Pseudomembranous colitis a/f taking amoxicillin, clindamycin, cephalosporin d/t anaerobic spore-forming gram-positive spore forming bacillus Clostridium difficile Tx Metronidazole (preferred), Vancomycin

Causes of vertigo (dizziness with sense of room spinning) Peripheral (labyrinth, 8th nerve) 1 Labyrinthitis (vestibular neuritis)*most common* 2 Menieres d/s 3 BPPV 4 Vestibular failure/ insufficiency 5 Herpes zoster ( Ramsay hunt $) Central (BS, cerebellum) 1 Acoustic neuroma 2 MS 3 Head injury 4 Inner ear syphilis 5 Vertebrobasillar insufficiency Drugs 1 Gentamycin(neuronitis) 2 Diuretics 3 Co-trimoxazole 4 Metronidazole Miscellaneous 1 Cholesteatoma 2 Trauma Vestibular neuritis Abrupt onset Severe vertigo, (worsen by head m/m) may persist for days or wks N, V +/-prostration (systemic illness) Nystagmus (in a/c phase) HSV type 1 (etio) NO Deafness or tinnitus Complete recovery 3-4wks Tx Reassure, sedate Drugs cyclizine , methylprednisolone Meneires d/s Endolymphatic hydrop Vertigo (recurrent) > 20mins +/- N,V Progressive unilateral Hearing loss (sensorineural) flatuating or permanent Loudness recruitment (hearing is better with background noise) Tinnitus (with sense of aural fullness) Drop attack (rare) no LOC, fall to side Audiometry sensorineural mid-low frequency loss with loudness recruitment Caloric test impaired vestibular function on the affected side Tx Bed rest, reassure Antihistamine (if prolong) Prochlorperazine (if severe) for 7ds In very severe endolymphatic sac sx or ablation of the vestibular o/g with gentamycin BPPV Sudden rotational vertigo> 30sec Head turning (a/f head injury) Dx hallpike Tx reassure, Epley maneuvour

Vertebrobasilar ischaemia Vertigo in older patient Asso: with BS and cerebellar effects ataxia, Rombergism, crossed sensory loss and cranial nv lesion Herpes zoster(Ramsay-hunt $) Herpetic eruption of the external auditory meatus Facial palsy +/_ deafness Tinnitus and vertigo Acoustic neuroma Schwannoma arising from the vestibular nv(8th CN) Unilateral hearing loss with tinnitus, episodic vertigo and gait instability( ipsilateral cereballer signs) 7th nv paresis Facial paraesthesia from 5th CN irritation s/t dysarthria or dysphagia d/t 9th ,10th, 11th nv involvement Sing of increased ICP (late) 80% of cerebello-pontine angle tu Multiple sclerosis Demyelination d/t plaque optic nv optic neuritis, INO (internulcear opthalmoplegia), horizontal nystagmus BS + cerebellar sp cord (motor(usu UMNL) + sensory) weakness (d/t involvement of pyramidal tract) + increased reflexes *monosymtomatic* 1 Fulminant form 2 Resmission & relapsing 3 4 Tx Primary progression Secondary progression

a/c attack Immunsupressive relapse prevention motor neurone d/s bilateral weakness and spasticity in legs brisk reflexes d/t the concomitant UMNL brisk reflexes persist even when the m/s are wasted Rinne test AC > BC (normal) BC > AC conduction deafness AC > BC (both decreased frequency) sensorineural deafness Weber test CD better heard in the affected side SD better heard in the normal side Otosclerosis cause of conduction deafness affect the ossicle chain progressive deafness and tinnitus usually bilateral first dx in pregnancy asso: family h/o often associated with paracusis/loudness recruitment Sx by stapedectomy and vein grafting with insertion of prosthesis can be helpful Hearing aids are also affective *Most commom cerebral tumors in adult secondary neoplasm * *Most common primary site lung (small cell CA)* Other commom primary site malignant melanoma, renal CA, Breast CA

*Most common primary brain tumor

glioblastoma multiforme

RSVP-----Proximal joints R Rheumatoid arthritis S Systemic Lupus Erythematosus -SLE V Viral arthritis rubella,mumps,hep B,AIDS P Proximal joints Distal joints ---OA ,osteoarthritis , psoriatic arthritis Rheumatoid arthritis
commonest chronic inflammatory polyarthritis insidious onset of pain and stiffness of small joints of hand and feet MCP, PIP > DIP Criteria 1 Small joints of hand & feet 2 Swelling of > 3joints 3 Stiffness (morning) >1hr for at least > 6wk 4 Symmetrical jt 5 Subcutaneous nodules 6 Serum RF +(>95% asso: with rheumatoid nodule) 7 Synovial fluid inflammation (x-ray) 8 X ray changes erosion of jt margin (mouse-bitten) appearance loss of jt space (m/b destruction) jt deformity (swan-neck)(late) juxta-articular osteoporosis cysts advanced : subluxation or ankylosing RA is typically asso: with inflammatory jt and soft t/s Spontaneous rupture of the long tendon of extensor pollicis longus (EPL) joint of the thumb Osteoarthritis Mostly interphalangeal jts(in hand) Can be seen secondary to the RA Pain on movement of the base of the thumb Pain comes with use of jt and relieved by rest Later, pain in the hip may occur at rest at night Control pain with simple analgesic is usually the best Tx X-ray 1 Jt space narrowing 2 later , subchondral bone sclerosis (increased density of bone ends) 3 later, subchondral cysts 4 marginal osteophytes
Osteoarthritis Joint space narrowing Maximal at weight bearing joints Erosions do not occur Subchondral cysts,sclerosis may be seen Sclerosis is a prominent feature No osteoporosis Rheumatoid arthritis Joint space narrowing uniform * * Erosions -characteristic Not a feature Not a feature ** Osteoporosis

inability to straighten the end

Ankylosing spondylitis

Males(90%) , young Spinal fusion ,progresive X ray --Bamboo spine HLA B27 association Reduce the mobility of spine and ribs and will reduce the lung vital capacity Commonly involve the sacroiliac jts Most of the spine including the cervical region are commonly involved X-ray First in sacroiliac jt with blurring of the cortical margins of subchondral bone f/by erosion and sclerosis In the lumber spine straightening of the lumber lodosis and reactive sclerosis in the ant borders of the vertebral bodies Then progressive ossification of the superficial layer of the annulus fibrosis Intervertebral disc space is usu maintained when sclerosis develops in the annulus Osler weber $ Hereditary haemorrhagic telangeictasia Typical telangiectic lesions on the lower lip Autosomal dominant Present with IDA d/t bleeding telangeictases in the bowel More urgent and a/c GI blding Haematemesis and melaena Occasionally telangeictases in can cause cerebral haemorrhage Wernicke encephalopathy Altered level of consciousness Brain stem signs ataxia,ophthalmoplegia and nystgamus d/t petechial haemorrhage within the mid-brain and brain stem d/t thiamine deficiency usually asso: with alcoholism in alcoholics with wernicke encephalopathy, other neuronal d/os with LMN feactures may coexist s/as central pontine myelinolysis or subdural haematoma dystrophia myotonica weakness of facial, palatal and neck m/s dysphagia probably related to weakness of constrictors of the pharynx involvement of the periphery and weakness and slowness of hand grip slowly progressive hereditary disorder may not become apparent until the age of 40 asso: with receding hairline and in males, testicular atrophy later, cataracts and cardiomyopathy may develop Syndrome of parkinsonism 1 manganese intoxication 2 phenothiazine intoxication 3 methyldopa(Aldomet0 intoxication) 4 carbon monoxide intoxication 5 dementia pugilistica 6 designer drugs related to pethidine 3rd heart sound diastolic filling sound normal before the age of 30 it is not dependent on the atrial contraction and is not influenced by the presence of AF it is asso: with rapid ventricular filling Abnormal in >40yrs indicate ventricular d/s Commonly heard in A/c LVF a/f MI, most cases in MR. Constrictive pericarditis(rare) represent sundden cessation of ventricular fillng Sputum Rust-coloured pneumococcal pnia Thick and tenacious chronic asthma

 Foul-smelling lung abscess Pink and frothy pulmonary oedema Clear mucoid sputum chronic bronchitis Lactose intolerance(lactase defincency) Can frequently complicate Gluten-sensitive enteropahty Viral GE in any ethnic group Crohn d/s Gluten-sesitive enteropahty (celiac d/s) Most common presentation is IDA Pretreatment biopsy shows a flat mucosa with absence of villi Gluten is specific protein in wheat The response to gluten-free diet is slow and some pt may take 24-36months Long term risk of developing intestinal lymphoma A/c thrombocytopenia can be asso: with recent viral infection a recent bld transfusion taking qunine recent onset of pain and stiffness in finger (RA) lithium toxicity ataxia, anorexia, nausea and tremulousness Travellers diarrhoea Hepatitis

Hand deformity
Depuytren contracture thickening and fibrosis of palmar aponeurosis/fascia any finger or fingers affected but rarely thumb characteristically ivolves the ring and the little fingers cause usu: unknown hereditary some drugs chronic alcoholism acquired flexion deformity affects the metacarpophalangeal and proximal interphalangeal jts of fingers,sparing most distal jts there can be prominent palmar nodule with skin pitting and early contracture can present with subcutaneous nodules in the soles and inner aspects of the feet however contracture in feet is very rare Ulnar claw hand hyperextension of MCP jt and flexion of PIP and DIP jts asso: with ulnar nv palsy Leprosy (mycobacterium leprae or Hansen d/s) Compression of Ulnar nv at the elbow asso: with an increased carrying angle Positive prayer test-diabetic cheiropathy DM asso: with limited jt mobility ,most marked in the small jts of hands Asso: skin thickening and waxiness, particularly on the dorsum of the fingers d/t deposition of abnormal collagen with increasing duration of DM All fingers are affected diffusely No nodule nor fibrous contracture Waiters tip deformity C5 and C6 nv lesion Erbs paralysis Klumpkes paralysis

 C8 and T1 Thoracic outlet $ Horners $ Ulnar claw hand and apes hand (UN+MN lesion) Radius nv Wrist drop(crutch palsy) d/t fracture of the shaft of humerus weakness of abd and add of hand Axillary nv d/t fracture of the surgical neck of humerus or inferior dislocation of humerus weakness of lateral rotation and abduction of arm paraesthesia of skin over deltoid area

Poisoning
Lead poisoning most common sources lead-based household paint,old household pipes and household dust s/- & -/s anaemia, loss of appetite, irritability, fatigue, abdominal pain N, V, ataxia, m/s weakness and seizures Basophilic stippling of red blood cells in a film is commonly seen in the chronic lead poisoning Mercury poisoning Ingestion of contaminated fish, in dentist, millinery(hat)industry Chronic poisoning CNS toxicity intention tremor,excitability, memory loss and delirium mad as hatter Arsenic poisoning Tasteless and colourless when added to drink or food Chr: poisoning skin rashes and GI symptoms Carbon monoxide poisoning Old gas heaters Ppl are died of carbon monoxide poisoning in the shower because of lack of ventilation Iron poisoning Cooking in iron pots Resulted in secondary haemochromatosis Tremor Action or postural tremor causes Essential Senile Physiological Anxiety/Emotion Hyperthyroid Alcohol Drugs: (drugs withdrawal heroin,cocaine,alcohol,Dexedrine,lithium) Resting tremor Parkinsonism Intentional tremor cerebellar d/s Flapping tremor Metabolic tremor Uraemia Hepatic failure Respiratory failure Wilsons d/s Benign essential tremor Benign, familial, senile or Juvenile tremor (AD) Peak-2nd decade Increased age coarse tremor+/-disability Head movement +

 Normal gait Characteristic postural & kinetic tremor of upper limb interfere with fine manual task Alcohol benefit 1st choice propanalol Meralgia paraesthetica Lateral cutaneous nv of thigh (compression) Aetio: pregnancy Pendulous lower abdominal fold (in obese pt) Physical training (strenuous) in army cruit Pain & parathesia in upper outer thigh & decreased sensation, self-limiting Tx cortisone & LA at ASIS , Sx Weber's syndrome (superior alternating hemiplegia) is a form of stroke characterized by the presence of an oculomotor nerve palsy and contralateral hemiparesis or hemiplegia. It is caused by midbrain infarction as a result of occlusion of the paramedian branches of the posterior cerebral artery or of basilar bifurcation perforating arteries. Red urine+muscle weakness+ Increase in CK+ Statin Therapy =Rhabdomyolysis Egypt+hemospermia= schistosomiasis Acute epidydimo-orchitis usually associate with UTI and Prostatomegaly Bladder infection of residual urine secondary infections of epididymis via vas deferens Do Urine culture and chose antibiotics Ca testis risk factors Cryptorochidism (X5) Testicular atrophy Pervious history of TT cancer Orchidopexy TT t para-aortic (palpation, CT abdo and chest) T marker alpha-feto protein, beta hcG teratoma *avoid scrotal needle biopsy-- seeding, & avoid scrotal incision for surgery