Bulas pontificias de la Balma

This  I  hope  will  help  you  remember    

O-­‐  Oral  ulcer   R-­‐  malar  Rash   D-­‐  Discoid  rash  

E-­‐  Exaggerated  photosensitivity  

R-­‐  Renal  disorders  (proteinuria,  cellular  casts)    

H-­‐  Haematology  disorders  (haemolytic  anemia,  leukopenia,  lymphopenia,                          thrombocytopenia)  

I-­‐  Immunological  disorders  (anti-­‐DNA  antibody,  anti-­‐Sm,  antiphospholipid  antibody)   S-­‐  Serositis  

A-­‐  ANA  

N-­‐  Neurological  problems   A-­‐  Arthritis  

1.  95%  of  SLE  are  ANA  +ve.  

2.  50%  dsDNA  +ve,  but  is  specific  for  SLE.  

3.  25%  RF  +ve.  

Prof  Esha  :  Even  if  you  forget  the  pnemonic,  remember  there  are  4  mucocutaneous   features,(malar  rash,photosensitive  rash,discoid  rash  and  oral  ulcer),4  systemic   involvement(  CNS,serositis,kidney  and  arthritis)  and  3  lab  finding(  

Heamatology,Immunology  and  ANA  stands  on  its  own)  Recent  addition  in  lab   features  are  positive  anti  Sm  antibody,antiphospholipis  antibody,and  low   complements,along  with  direct  positive  coomb's  test.  

36)  ON  MONOFILAMENT  testing   Dear  Yin  Ling,  

Are  you  familiar  with  Monofilament  sensory  testing  devices  which  consist  of  a  single   strand  of  nylon  (typically  attached  to  a  plastic  or  paper  handle)  that  can  produce  a  

characteristic  downward  force  when  buckled  onto  a  surface?  

Are  you  aware  that  they  come  in  different  sizes?  

The  monofilaments  commonly  used  to  screen  for  sensory  neuropathy  are  4.17,  5.07,   and  6.10.  The  use  of  a  single  5.07  monofilament  is  the  accepted  standard  in  medical   practice  to  screen  for  the  minimum  level  of  protective  sensation  in  the  foot.  Ten   grams  of  reproducible  buckling  stress  force  are  required  to  bend  the  5.07  

monofilament.    

Why  do  we  use  monofilament  testing?  Why  do  we  not  just  use  our  usual  pin,  cotton   and  tuning  fork??  

When  the  monofilament  bends,  its  tip  is  exerting  a  pressure  of  10  grams  (therefore   this  monofilament  is  often  referred  to  as  the  10gram  monofilament).  If  the  patient   cannot  feel  the  monofilament  at  certain  specified  sites  on  the  foot,  he/she  has  lost   enough  sensation  to  be  at  risk  of  developing  a  neuropathic  ulcer.  

Testing  of  diabetic  patients  for  protective  sensation  may  be  simplified  to  testing   under  both  first  metatarsal  heads.  If  a  patient  cannot  sense  the  application  under   either  first  metatarsal  head,  he  or  she  probably  has  lost  protective  sensation  and   should  be  considered  to  be  at  risk  for  undetected  injury.  

Generally,  No  person  with  a  foot  ulceration  could  feel  the  5.07  (10g)  filament,   concluding  that  monofilaments  are  an  effective,  inexpensive  and  simple  screening   device  in  identifying  the  ‘at  risk’  foot.\  

In  contrast,  a  person  who  can  feel  the  10-­‐gram  filament  in  the  selected  sites  is  at   reduced  risk  for  developing  ulcers.  

The  patient  must  not  watch  while  the  examiner  applies  the  filament.  

Pre-­‐Test  the  monofilament  on  the  patient's  hand  or  sternum  so  he/she  knows  what   to  anticipate.  

Typically  we  test  five  sites  and  document  the  findings.  The  number  of  sites  may  vary   from  centre  to  centre.  

Apply  the  monofilament  perpendicular  to  the  skin's  surface     Apply  sufficient  force  to  cause  the  filament  to  bend  or  buckle      

Pls  Apply  the  filament  along  the  perimeter  and  NOT  ON  an  ulcer,  callus,  scar  or   necrotic  tissue.  Do  not  allow  the  filament  to  slide  across  the  skin  or  make  repetitive   contact  at  the  test  site.  

Have  patients  identify  at  which  time  they  were  touched.  To  avoid  guessing,   randomize  the  sequence  of  applying  the  filament  throughout  the  examination.  

Patients  should  have  their  feet  examined  at  least  annually  for  impaired  sense  of   pressure,  vibration,  pain,  or  temperature,  which  is  characteristic  of  peripheral   neuropathy.    

Pressure  sense  is  best  tested  with  a  monofilament  esthesiometer  as  this  picks  up   patients  with  high  risk  of  diabetic  ulcers  

Yin  Ling,    

The  overall  risk  of  developing  a  diabetic  foot  ulcer  is  determined  by  a  combination  of   factors.    

In  general,  the  risk  is  higher  if:  

Neuropathy  is  more  severe  (because  more  sensation  is  lost  and  multiple  small   trauma  breaks  the  skin)  

Peripheral  vascular  disease  is  more  severe  (because  there  is  less  circulation  to  bring   enough  oxygen  to  repair  tissue  damage.  Just  look  at  the  dry  black  feet  with  curled   up  nails  and  you  see  feet  which  are  deserts)  

There  are  coexisting  abnormalities  of  the  shape  of  the  foot  which  make  the  local   effects  of  neuropathy  or  vascular  disease  more  severe  (because  it  increases  local   pressure  and  callus;  heavens  let  us  ban  all  those  fashionable  but  cruel  footwear  that   ladies  wear  as  it  deforms  the  feet  into  an  abnormal  shape)  

The  patient  who  is  unable  to  practise  reasonable  self  care  of  the  feet  and  to  prevent  

trauma  (because  there  are  more  chances  of  damaging  the  feet  with  fungal  infections   in  the  webs,  poor  nail  hygiene  and  cutting)  

The  diabetic  control  is  very  poor  (because  of  susceptibility  to  infection  and  poor   wound  healing)  

There  is  a  past  history  of  foot  ulceration  due  to  diabetes  (because  all  the  above   factors  persist)  

Dear  Yin  Ling,      

People  often  ask  which  is  the  earliest  abnormality  and  expect  a  single  answer  that  is   dogmatic.  The  truth  is  however  much  more  complex  and  the  answer  is  "It  varies!"  

Sensory  or  sensorimotor  distal  polyneuropathy  is  the  most  common  of  the  diabetic   neuropathies.  With  this,  numbness  and  paresthesias  begin  in  the  toes,  and  gradually   and  insidiously  ascend  to  involve  the  feet  and  lower  legs.  Very  common,  we  see  it  all   the  time.  

With  a  sensory  or  sensorimotor  distal  polyneuropathy,  both  lightly  myelinated  and   unmyelinated  small  nerve  fibers  and  the  myelinated  large  nerve  fibers  are  affected.  

Small  and  large  fiber  dysfunction  occurs  in  varying  combinations;    

however,  in  most  cases,  the  earliest  deficits  involve  the  small  nerve  fibers.  

Features  characteristic  of  a  small  fiber  peripheral  neuropathy  include  burning  or   lancinating  pain,  hyperalgesia,  paresthesias  and  dysesthesias,  **deficits  in  pain   and  temperature  perception**  leading  to  foot  ulceration.  

Features  characteristic  of  large  fiber  peripheral  neuropathy  include  the  loss  of   position  and  vibration  perception  sense  and  loss  of  deep  tendon  reflexes,  tested   with  tuning  fork  and  Ankle  jerks.  

So  based  on  this  what  will  you,  yin  ling,  select  as  a  mode  for  screening  which  must  of   course  pick  up  the  pathology  early!?  

37)  ON  ISOLATED  RAISED  GAMMA  GT