Friday, December 6, 2013

Right Upper Quadrant Pain

Right Upper Quadrant Pain
1. Biliary colic/bile duct obstruction
2. Acute cholecystitis/cholangitis
1. Acute hepatitis: alcoholic, viral, drug-related, toxic
2. Hepatic abscess
3. Hepatic tumor: metastases, hepatocellular carcinoma, hemangioma, focal nodular hyperplasia,
hepatic adenoma
4. Hemorrhagic cyst
5. Hepatic congestion: acute hepatic congestion, Budd-Chiari syndrome
6. Perihepatitis from gonococcal/chlamydial infection (Fitz-Hugh-Curtis syndrome)
1. Acute pancreatitis
1. Acute appendicitis
2. Peripyloric ulcer
3. Small bowel obstruction
4. Irritable bowel
5. Colitis/ileitis
6. Intestinal tumor
1. Pneumonia
2. Pulmonary infarction
1. Acute pyelonephritis
2. Ureteral calculus
3. Renal/perirenal abscess
4. Renal infarction
5. Renal tumor
1. Costochondritis
2. Herpes zoster

Saturday, December 3, 2011

Thursday, December 9, 2010

Restless Legs Syndrome

Restless legs syndrome (RLS) is the third most common reported sleep disorder, and one of the most common causes of severe insomnia. Including its mild form, this irritating disorder affects between 10 and 15 percent of the population. Although its classified separately as a movement disorder  its important to note that all sleep related movement disorders are technically parasomnias.

Together they comprise the movement and behavioral disorders related to sleep. The way people describe their symptoms is often imprecise and can vary considerably, but the common denominator is an unpleasant sensation in the legs.

Sufferers may say they feel a "creepy, crawly" sensation in their legs when they trying to sleep or when they're just resting quietly. Or they describe extreme discomfort, pain, pulling, searing, boring, or deep itching sensations down the legs. Some patients have even described this sensation as 'electric ants' or bugs running up and down the legs.

The symptoms are typically relieved only by movement or stimulation of the legs. Doctors call this paresthesias -"abnormal sensations". For some people the feelings are a minor annoyance, and for others they're sheer torture. In all cases there's an urge to move the legs, getting the legs moving eases the symptoms temporarily.

WHO GETS RLS (Restless Legs Syndrome)

It can strike people of any age, RLS (Restless Legs Syndrome) is most commonly reported among people over the age of 40, and is classified as early onset if it strikes before the person is 45 years old. It's 1.5 to 2 times more common in women than in men. Many people who are later diagnosed with RLS ( Restless leg syndrome ) reporting having symptoms in childhood , and there's mounting evidence to suggest that its often misdiagnosed among children as attention deficit /  hyperactivity disorder or " growing pains."

In more than half cases,  primary RLS (  Restless legs syndrome ) runs in families. If you have an immediate family member with RLS ( Restless legs syndrome ), your risk is three to six times greater of developing the disorder.

Current  exciting research shows that there may  be a gene marker for RLS (Restless leg syndrome ) that explains this familial connection.

WHAT CAUSES RLS ( Resless legs syndrome ) ?

RLS ( Restless legs syndrome ) may be primary or secondary .  Primary RLS ( Restless legs syndrome ) means that there is no underlying disorder causing it , whereas secondary RLS ( Restless legs syndrome) means that another condition ( medical or neurological ) or a medication is really at the root of it . In the latter case, treating the underlying condition or stopping and offending medication should resolve the RLS ( Resless leg syndrome ). Although the majority of cases of  RLS ( Restless legs syndrome ) are primary ( with presumed problems with the brain's iron and dopamine systems), there are some known causes and associations with other conditions.

  • Iron deficiency and anemia are known to increase the risk of RLS (Restless legs syndrome ).
  • Several types of medications may bring on or aggravate RLS ( Restless legs syndrome ) , including many cold and allergy medications , antinausea  medications, antidepressants ( except Wellbutrin, a adopmine-enhancing  medication that may actually help ), antiseizure drugs, and antipsychotic drugs.
  • About 20-40 percent of those with chronic kidney failure on dialysis have RLS (Restess legs syndrome). The RLS (Restless leg syndrome ) symptoms disappear after a successful kidney transplant. The strong link between kidney disease and RLS ( Restless legs syndrome ) is still greatly under-recognised ,especially among kidney specialists.
  • Peripheral neuropathy , Parkason's disease, Lyme-disease myelitis,and diabetes mellitus have all been linked with RLS ( Restless legs syndrome )
  • Caffeine, tobacco, and nicotine can aggravate or trigger RLS ( Restless legs syndrome ) symptoms.
There is no evidence that RLS  ( Restless legs syndrome ) is linked with any sort of underlying psychological problems. nor does it signal the onset of any other neurological disorder. However, because the distressing symptoms and resulting sleep deprivation of RLS ( Restless legs syndrome ) can be chronic, it can induce depressive and anxiety disorders.

PREGNANT WOMEN AND RLS ( Restless legs syndrome )

About 26 percent of pregnant women get RLS ( Restless legs syndrome ), and it gets worse in the second and third trimesters. Ten percent of them already had th disorder before they got pregnant,but it generally gets much worse during pregnancy. The remaining 16 percent didn't have the disorder before, and some worry that its going to harm the baby,or that it is a sign of something wrong. It isn't RLS ( Restless legs syndrome )in the mother does not pose any known risk for the baby. The problem that requires treatment is when the mother is losing significant amounts of sleep most nights because of the RLS ( Restless legs syndrome ). Dopamine medications,which are the most-recommended treatments for RLS ( Restless legs syn

Tuesday, November 30, 2010

Narcolepsy and Excessive Daytime Sleepiness

Narcolepsy and Excessive Daytime Sleepiness
Narcolepsy is a serious, but relatively uncommon, disorder characterized by sudden and uncontrollable attacks of sleep. These attacks can be brief - lasting just 30 seconds - or longer, lasting as long as 30 minutes or more. Sometimes the attacks are accompanied by hallucinations and/or temporary paralysis. Narcolepsy can be quite debilitating, causing lack of muscle control and dream experiences occurring at inappropriate times.

Sufferers often unexpectedly fall asleep in the middle of important activities, including driving and while playing sports. This can be quite dangerous for themselves and others. In addition, they can fall asleep during conversations and at work, harming their personal and professional relationships.

Those with Narcolepsy often experience a temporary paralysis, which can be physically harmful if they fall down, and also very frightening when it occurs.

Research to date reveals that Narcolepsy appears to affect the part of the central nervous system that controls sleep and wakefulness and that it is not a psychological disorder. While there is no "cure" yet, recent advances in medicine, technology and pharmacology allow those with Narcolepsy to lead nearly normal lives. The finding that the Brain Protein called Orexin or Hypocretin is deficient in patients with Narcolepsy by leading researchers, including our own, is bringing hope of a cure. The doctors at the Sleep Medicine group of sleep centres are actively pursuing this research.

Diagnosing Narcolepsy needs to be done in a clinic that is familiar with sleep medicine. The patient's complete medical history is considered and the patient is given a thorough physical examination. Most often, patients are also given two tests, a polysomnogram and a multiple sleep latency test (MSLT) to confirm a suspected diagnosis and also to determine the extent of the Narcolepsy.

Excessive Daytime Sleepiness (EDS) is an essential part of the diagnosis of Narcolepsy but may have a variety of other causes including Obstructive Sleep Apnoea (OSA), Restless Legs Syndrome (RLS), Circadian Rhythm Disorder and the syndrome of Primary Hypersomnolence.

The symptom of EDS is important because it is associated with feeling drowsy and tired; having an overwhelming need to sleep during the day, being unable to stay awake in the daytime, even after getting a good night's sleep and falling asleep at times you need to be fully awake and alert.

It could mean ineffective work performance or dangerous levels of driving or other activities and, interference with a person's ability to concentrate or perform daily tasks or routines. Some people affected by EDS often feel frustration and anger about being misunderstood and being regarded as unintelligent or not interested in personal growth or learning. They often have low self-esteem and/or poor personal relationships as a result.



Narcolepsy is characterized by the classic tetrad of excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Note that this tetrad is seen only rarely in children. The term "narcolepsy" is derived from Greek, "seized by somnolence." Gelineau was the first to delineate the syndrome in 1880.

Narcolepsy frequently is unrecognized, with a typical delay of 10 years between onset and diagnosis. Approximately 50% of adults with the disorder retrospectively report symptoms beginning in their teenage years. This disorder may lead to impairment of social and academic performance in otherwise intellectually normal children. The implications of the disease are often misunderstood by patients, parents, teachers, and health care professionals.

Narcolepsy is treatable. However, a multimodal approach is required for the most favourable outcome.

Narcolepsy is thought to result from genetic predisposition, abnormal neurotransmitter functioning and sensitivity, and abnormal immune modulation. Current data implicate certain human leukocyte antigen (HLA) subtypes and abnormalities in monoamine synaptic transmission, particularly in the pontine reticular activating system.

Understanding of the neurochemistry of narcolepsy stems primarily from research involving narcoleptic dogs (eg, special laboratory-bred Dobermans and Labradors). In these animal models, the disorder is transmitted in an autosomal recessive fashion with full penetrance and is characterized mainly by cataplexy.

Excessive daytime sleepiness (EDS) is the primary symptom of narcolepsy.

Sleepiness is a normal experience that cycles and invariably occurs after prolonged wakefulness. In healthy persons, mild sleepiness is apparent only during boring situations (eg, falling asleep while watching TV).
In patients with narcolepsy, severe EDS leads to involuntary somnolence during more active conditions such as eating and talking. Sleepiness in narcolepsy may be severe and constant, with paroxysms during which patients may fall asleep without warning (ie, sleep attacks).
Patients with narcolepsy tend to take short and refreshing naps (ie, REM type naps) during the day.
Several questionnaires evaluate sleepiness. The most commonly used is the 8-question Epworth Sleepiness Scale (1991).
Patients respond to each question on a scale from 0 (not at all likely to fall asleep) to 3 (very likely to fall asleep).
The resulting total score is between 0 and 24.
Although what score constitutes abnormal sleepiness is controversial, total scores above 10 generally warrant investigation.
Cataplexy (Latin, "to strike down with fear") is an abrupt attack of muscle weakness.

If severe and generalized, it may cause a fall.
More subtle forms exist with only partial loss of tone (eg, head nod).
The most characteristic feature of cataplexy is that it usually is triggered by emotions (usually laughter and anger).
Cataplexy is seen in about 70% of patients with narcolepsy, and its presence with EDS strongly suggests the diagnosis of narcolepsy. Specific historical questions concerning cataplexy are required.
Sleep paralysis is the inability to move upon falling asleep or awakening with consciousness intact.

It often is accompanied by hallucinations.
Sleep paralysis occurs during REM sleep in healthy subjects.
Sleep-related hallucinations may occur at sleep onset (ie, hypnagogic) or awakening (ie, hypnopompic) and are usually vivid (dreamlike) visual, auditory, or tactile in nature.

The classic picture of narcolepsy may be somewhat different in young children.

Children may deny EDS because of embarrassment.
Sometimes restlessness and motor overactivity may predominate.
Academic deterioration, inattentiveness, and emotional lability are common.
In one study of 51 prepubertal patients with narcolepsy, the following initial complaints were noted:
Children younger than 5 years presented with unexplained falls and "drop attacks," aggressive behavior, abrupt irritability, sleep terrors, and abrupt dropping of objects.
In children aged 5-10 years, the most common initial complaint was repetitive sleepiness, followed by difficulty with morning arousal associated with aggressive behavior and abrupt falls in school. These children often were misdiagnosed as having attention deficit hyperactivity disorder (ADHD), learning disability, or another neurologic disorder.
In children aged 10-12 years, poor academic performance was a common complaint. Other presenting symptoms included inappropriate low level of alertness, falling asleep in class, and inability to wake up in the morning.