Physical therapy for focal hand dystonia

Some Key Words for understanding Focal dystonia/ Writing cramp is that it's Debilitating, specific to a certain group of Muscles, specific to a certain group of tasks(Playing music / typing through a keyboard), usually due to the "misrepresentation of the area in the Primary motor area/ hyperactivity of the brain cells), management is through Physical therapy and CNS depressants, and they are mainly compensatory therapies to improve the functionality.

Unfortunately there's no cure for this condition

Torticollis is also considered a variant in this condition.

BRCA 1/BRCA 2 screening

BRCA 1 & BRCA 2 genes are believed to be associated with hereditary development of Breast/ Ovarian cancers, but the important question is when to screen for those two genes and when not ?

Screening is essential in one of the following conditions:

1- a Positive family history of an early onset breast or ovarian cancers at an age less than 35 years old, in a first degree relative

2- a Positive family history of MALE breast cancer.

3- a strong family history suggestive of development of breast cancer in multiple generations in the family.

4- development of a Breast/Ovarian cancer in the patient herself.

Being an Ashkenazi Jewish is NO LONGER considered to be a risk factor that requires screening.

WORK-UP of ANY Breast Mass

1- Breast clinical examination, is the first step to perform upon a complaint of a palpable breast mass.

2- Ultrasonography: it's done for diagnosis of breast masses in young females less than 40 years old, though you may skip the U/S directly to the FNAB.

3- Mammography(coupled with Biopsy): In females older than 40 years old with;

 -Bloody  discharge/ or the cyst didn't collapse completely after aspiration

 -Inflammatory breast changes/Paget's disease

 -presence of a bloody nipple discharge

 -Recurrent masses at least TWICE within less than 6 weeks after aspiration

 4- Biopsy (fine needle or excisional):

It may be done with or without U/S in young females, or done together with mammography in females that are meeting the above criteria mentioned above, 

it can be both curative and diagnostic and the resultant from aspiration should be sent to cytology.

N.B. if mammography was showing micro-calcifications then most probable the case is benign, however you still should perform core biopsy because in 15% of conditions those micro-calcifications may be an early sign of malignancy.

If a cyst recurs after FNAB ONCE in 6 weeks in a female older than 50 years old, then you would repeat clinical examination and perform a FNAB.

If a cyst didn't collapse completely or occurred twice within less than 6 weeks or released a bloody discharge or there was inflammatory changes suggestive of malignancy, then you should perform a mammography coupled with core (excisional) biopsy.

Cavernous Sinus thrombosis

both CT scan are 2 different cuts in the same person who is suffering from left sided cavernous sinus thrombosis as demonstrated by the thick arrow at slide (B) and as a result there's markedly congested and thrombosed left ophthalmic vein as demonstated in slide (A), notice also the proptosis in the left eye and subsequently expected associated papilledema

- Usually cavernous sinus thrombosis is a SEPTIC thrombosis that occurs due hematogenous spread of severe infections of nearby head structures that drain into the cavernous sinus, as in severe chronic bacterial sinusitis, or in meningitis.

- Cavernous sinus thrombosis is associated with increased intracranial pressure, cerebral edema, manifested by papilledema, sometimes proptosis, bradycardia and hypertension. (Cushing's triad)

-The best INITIAL step is to perform a head CT scan, although corticosteroids administration is mandatory and highly beneficial in that conditions, CT scan should be performed first to establish the diagnosis.

- Other causes of increased intracranial pressure include subdural hematoma, or extradural hematoma, but you have to consider Cavernous sinus thrombosis if there's no history of recent trauma or a positive history of sinusitis  or head infection,

- never perform a lumbar puncture even if meningitis is suspected.

Wolf-Parkinson-White (WPW) OR Pre-excitation syndrome:

Wolf-Parkinson-White (WPW)

                                  Notice short PR interval and gradual upstroke of QRS complex

It's the premature excitation of the ventricular muscle before the normal conduction pathway delivers the normal electrical impulse due to the presence of an accessory bundle between Atria and Ventricle.

ECG would show:

1- Short PR interval

2- Wide QRS complex with an initial slow upstroke (called DELTA wave) before QRS complex

Management:

1- If the patient is clinically stable: use Procainamide, the use of B blockers or calcium channel blockers are absolutely contraindicated, because they may lead to over-riding of the bundle of Kent which may predispose to SVTs and VTs.

2- If the patient is Unstable: Electric cardio-version.

3- Ablation of the accessory bundle is the Definitive treatment.

Uric acid stones

- Uric acid renal stones develop in patients with chronic gout due to hyperuricosuria,
 

- Uric acid stones present with loin pain radiating to the flanks, hematuria, and history of previous attacks of gouty arthritis or hyperuricemia.

- Uric acid stones are RADIOLUCENT and don't appear on X-ray, so for diagnosis CT scan (without contrast) is required.

- Management:

It's mandatory to start with adequate hydration, analgesics and pain killers.

Also you have to add either Potassium Citrate or alkalization of urine using Potassium bicarbonate; you have in general to avoid alkalization of urine with sodium bicarbonate in order to prevent formation of calcium stones.

Renal stones less than 2 cm are treated with Extra-Corporeal shock wave lithotripsy (ECSWL), multiple or stones greater than 2 cm in size should undergo per-cutaneous extraction.

Chondrocalcinosis

Pseudogout:

-Due to the deposition of calcium pyrophosphate crystals into the joints, clinically it presents identical to the acute gouty arthritis, most commonly occurring in the knee, ankle, shoulder and Wrist joints.

-Most commonly occurs in joints with a previous damage; in elderly with no history of joint lesion always think about metabolic causes like hyperparathyroidism, hemochromatosis, hypophosphatemia and hypomagnesaemia.

Diagnosis is established through aspiration of the synovial fluid showing characteristic rectangular, rhomboid shaped POSITIVE BIREFRINGENCE crystals.

X-ray will show characteristic chondrocalcinosis. (IMPORTANT)

Management is identical to acute gouty arthritis, with NSAIDs, or steroids in elderly patients with renal impairments whom cannot tolerate NSAIDs or colchicine which is rarely used in general.