Routine Prenatal Care

The objective of prenatal care is to optimize the outcome for both mother and baby. This is achieved through a series of visits with the mother during which history, physical examination, laboratory and other measurements, and patient education all are essential parts.

On the first visit, the last menstrual period is ascertained to date the current pregnancy. In addition, the patient is questioned about previous pregnancies, ethnic background, current problems, current medications, and medical, social, psychosocial, nutritional, and family history. Also on the first (or an early) visit, the mother is given a screening physical examination and a full pelvic examination including estimation of uterine size and clinical pelvimetry. Her weight and height are recorded, and blood pressure measured. Urine is examined for protein and glucose and may also be screened for bacteriuria. Standard blood studies include complete blood count, Venereal Disease Research Laboratory test (VDRL) for syphilis, rubella antibodies, hepatitis B surface antigen, blood type and Rh, and red cell antibodies.

Solitary Pulmonary Nodule

Definition: a single, <3 cm discrete, well-marginated, rounded opacity, surrounded by normal lung, with no lymphadenopathy or pleural effusion.
It is often an incidental finding, especially with increased use of CT scan but still it could be an be early, curable malignancy.

Etiology:
1. Benign (70%): Granuloma, Hemartoma, Bronchogenic cyst, AV malformation, Rheumatoid nodule
2. Malignant (39%): Bronchogenic carcinoma, Metastases from breast, heard, neck , colon.

Initial evaluation
• History: h/o cancer, smoking, age (<30 years = 2% malignant)
• CT: size/shape, calcium deposits, Lymphadenopathy, effusions, bony destruction, compare with old studies.

• High-risk features for malignancy: 

• ≥2.3 cm diameter, 
• spiculated,
•  >60 years old, 
• >1 ppd current smoker, 
• no prior smoking cessation

Shock - A Brief Discussion

Shock is a condition of severe impairment of tissue perfusion leading to cellular injury and dysfunction. Rapid recognition and treatment are essential to prevent irreversible organ damage and death.

Different Causes And Categories Of Shock:

Hypovolemic shock

• Hemorrhage
• Intravascular volume depletion (e.g., vomiting, diarrhea, ketoacidosis)
• Internal sequestration (ascites, pancreatitis, intestinal obstruction)

Cardiogenic shock

• Myopathic (acute MI, fulminant myocarditis)
• Mechanical (e.g., acute mitral regurgitation, ventricular septal defect, severe aortic stenosis, aortic dissection with aortic insufficiency)
• Arrhythmic

Extracardiac obstructive shock

• Pericardial tamponade
• Massive pulmonary embolism
• Tension pneumothorax

Distributive shock (profound decrease in systemic vascular tone)

• Sepsis
• Toxic overdoses
• Anaphylaxis
• Neurogenic (e.g., spinal cord injury)
• Endocrinologic (Addison’s disease, myxedema)

Clinical Manifestations:

• Hypotension (mean arterial BP <60 mmHg), tachycardia, tachypnea, pallor, restlessness, and altered sensorium.

• Signs of intense peripheral vasoconstriction, with weak pulses and cold clammy extremities. In distributive (e.g., septic) shock, vasodilation predominates and extremities are warm.

• Oliguria (<20 mL/h) and metabolic acidosis common.

• Acute lung injury and acute respiratory distress syndrome with noncardiogenic pulmonary edema, hypoxemia, and diffuse pulmonary infiltrates.

Approach To The Patient: 

Obtain history for underlying causes, including 

• cardiac disease (coronary disease, heart failure, pericardial disease), 
• recent fever or infection leading to sepsis, 
• drug effects (e.g., excess diuretics or ), 
• conditions leading to pulmonary embolism and 
• potential sources of bleeding.

Approach To A Patient With Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is characterized by chronic airflow limitation due to impedance to expiratory airflow, mucosal edema, infection, bronchospasm and bronchoconstriction due to decreased lung elasticity.

Smoking is the main cause, but others are chronic asthma, α-1 antitrypsin deficiency and chronic infection (eg bronchiectasis).

History
Exertional dyspnoea, cough, and sputum are usual complaints.
Ask about:
• Present treatment including inhalers, steroids, antibiotics, theophyllines, nebulizers, opiate analgesia, and home O 2 treatment.
• Past history: inquire about previous admissions and co-morbidity.
• Exercise tolerance: how far can they walk on the flat without stopping? How many stairs can they climb? Do they get out of the house?
• Recent history: ask about wheeze and dyspnoea, sputum volume and color. Chest injuries, abdominal problems and other infections may cause respiratory decompensation.
• Read the hospital notes: have there been prior ICU assessments? Has the respiratory consultant advised whether ICU would be appropriate?

Examination

• Examine for dyspnoea, tachypnoea, accessory muscle use, and lip-pursing.
• Look for hyperinflation (‘barrel chest’) and listen for wheeze or coarse crackles (large airway secretions). 
• Cyanosis, plethora (due to secondary polycythaemia) and right heart failure (cor pulmonale) suggest advanced disease. 
• Look for evidence of hypercarbia: tremor, bounding pulses, peripheral vasodilatation, drowsiness, or confusion.
• Check for evidence of other causes of acute dyspnoea, particularly: asthma, pulmonary edema, pneumothorax , Pulmonary embolism. Remember that these conditions may co-exist with COPD.

How Should Doctors Recognize and Treat their Own Metal Illness

Introduction
Doctors have a higher than average incidence of suicide and alcoholism, and so all doctors must be prepared to face (and try to prevent) these and other health risks in their professional and private lives. A doctor's  skill at looking after himself/herself has never been as good as their skill at looking after others, but when the healer is wounded, is it clear that his ability to help others will be correspondingly reduced.

Indicators of Affected Mental State
If the time comes when a doctor's mental state seriously reduces the ability to work, the doctor must be able to recognize this and take appropriate action. The following may indicate that this point is approaching:
• Drinking alcohol before ward rounds or surgeries.
• The minimizing of every contact with patients, so that the doctor does the bare minimum which will suffice.
• Inability to concentrate on the matter in hand. The thoughts are entirely taken up with the workload ahead.
• Irritability (defined as disagreeing with >1 nurse in 24 hours time period).
• Inability to take time off without feeling guilty.
• Feelings of excessive shame or anger when reviewing past mistakes.
• Emotional exhaustion—for example knowing that you should be feeling pleased or cross with yourself or others, but on consulting your heart you draw a blank.
• Prospective studies suggest that introversion, masochism, and isolation are important risk factors for doctors’ impairment.

Hypersensitivity - Different Types

Type I Anaphylactic

• antigen reacts with IgE bound to mast cells
• anaphylaxis, atopy (e.g. asthma, eczema and hayfever)

Type II Cell bound

• IgG or IgM binds to antigen on cell surface
• autoimmune haemolytic anaemia, ITP, Goodpasture's, pernicious anemia, acute hemolytic transfusion reactions, rheumatic fever, bullous pemphigoid, pemphigus vulgaris.

Type III Immune complex

• free antigen and antibody (IgG, IgA) combine
• serum sickness, systemic lupus erythematosus, poststreptococcal glomerulonephritis, extrinsic allergic alveolitis (especially acute phase)

Hemoptysis - Causes. Workup And Management

Definition and Pathophysiology
• Expectoration of blood or blood-streaked sputum
• Massive hemoptysis: ~>600 mL/24–48 h; gas exchange more important than blood loss
• Massive hemoptysis usually results from tortuous or invaded bronchial arteries

Etiology

1. Infections/Inflammation:

• Bronchitis - the most common cause of trivial hemoptysis
• Bronchiectasis 
• Cystic fibrosis
• Tuberculosis
• Aspergilloma
• Pneumonia
• Lung abscess

2. Neoplasms:

• Usually primary lung cancer
• sometimes metastases

3. Cardiovascular causes:

• Pulmonary embolism - can cause massive hemoptysis
• Pulmonary arterial rupture
• Congestive heart failure
• Mitral stenosis
• Trauma
• Foreign body
• Broncovascualr fistula

Endocarditis Prophylaxis - A Quick Review

Endocarditis Prophylaxis
The only cardiac defects that need prophylaxis are the following:
·· Prosthetic valves
·· Unrepaired cyanotic heart disease
·· Previous endocarditis
·· Transplant recipients who develop valve disease

The only procedures that need prophylaxis are the following:
·· Dental procedures that cause bleeding: The prophylactic antibiotic to use for dental procedures is amoxicillin. For penicillin-allergic patients, clindamycin is the drug of choice.
·· Respiratory tract surgery
·· Surgery of infected skin

The following procedures do not need prophylaxis:
·· Dental fillings
·· All flexible scopes
·· All OB/GYN procedures
·· All urinary procedures, including cystoscopy

The following cardiac defects do not need prophylaxis:
·· Aortic stenosis or regurgitation
·· Mitral stenosis or regurgitation
·· Atrial or ventricular septal defects
·· Pacemakers and implantable defibrillators
·· Mitral valve prolapse, even if there is a murmur
·· HOCM (IHSS)

Introduction To Malnutrition

Malnutrition results from inadequate intake or abnormal GI assimilation of dietary calories, excessive energy expenditure, or altered metabolism of energy supplies by an intrinsic disease process.

Both outpatients and inpatients are at risk for malnutrition if they meet one or more of the following criteria:
• Unintentional loss of >10% of usual body weight in the preceding 3 months
• Body weight <90% of ideal for height.
• Body mass index (BMI: weight/height2 in kg/m2) <18.5

Two forms of severe malnutrition can be seen:

1. marasmus, which refers to generalized starvation that occurs in the setting of chronically decreased energy intake without systemic inflammation, and 
2. kwashiorkor, which refers to selective protein malnutrition due to decreased protein intake and catabolism in the setting of acute, life-threatening illnesses or chronic inflammatory disorders. Aggressive nutritional support is indicated in kwashiorkor to prevent infectious complications and poor wound healing.

Etiology

The major etiologies of malnutrition are 

• starvation,
• stress from surgery or severe illness, and 
• mixed mechanisms. 

Starvation results from decreased dietary intake (from poverty, chronic alcoholism, anorexia nervosa, fad diets, severe depression, neurodegenerative disorders, dementia, or strict vegetarianism; abdominal pain from intestinal ischemia or pancreatitis; or anorexia associated with AIDS, disseminated cancer, heart failure, or renal failure) or decreased assimilation of the diet (from

pancreatic insufficiency; short bowel syndrome; celiac disease; or esophageal, gastric,or intestinal obstruction). 

Contributors to physical stress include fever, acute trauma, major surgery, burns, acute sepsis, hyperthyroidism, and inflammation as occurs in pancreatitis, collagen vascular diseases, and chronic infectious diseases such as tuberculosis or AIDS opportunistic infections. 

Mixed mechanisms occur in AIDS, disseminated cancer, chronic obstructive pulmonary disease, chronic liver disease, Crohn’s disease, ulcerative colitis, and renal failure.

Acute Asthma - Management

Acute severe asthma (also referred to in Latin as status asthmaticus, or asthmatic status) is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators (inhalers) and steroids.
Initial treatment
Follow the steps as summarized below:

• Provide high flow O 2 .
• Put the trolley back and side rails up so the patient is sitting up and holding on to the side rails (to use pectoral muscles as accessory muscles of respiration).
• If the patient cannot talk, start treatment, but get senior Emergency department and ICU help in case intubation and ventilation are required.
• Check trachea and chest signs for pneumothorax.
• Ask about previous admissions to ICU.
• Administer high dose nebulized B 2 agonist (eg salbutamol 5mg or terbutaline 10mg), or 10 puffs of salbutamol into spacer device and face mask.
For severe asthma or asthma that rseponds poorly to the initial nebulizer, consider continuous nebulization.
• Give a corticosteroid: either prednisolone 40–50mg PO or hydrocortisone (preferably as sodium succinate) 100mg IV.
• Add nebulized ipratropium bromide (500mcg) to B 2 agonist treatment for patients with acute severe or life-threatening asthma or those with a poor initial response to B 2 agonist therapy.
• Consider a single dose of IV magnesium sulphate (1.2–2g IVI over 20min) after consultation with senior medical staff, for patients with acute severe asthma without a good initial response to inhaled bronchodilator therapy or for those with life-threatening or near-fatal asthma.
• Use IV aminophylline only after consultation with senior medical staff.
Some individual patients with near-fatal or life-threatening asthma with a poor response to initial therapy may gain additional benefit. The loading dose of IVI aminophylline is 5mg/kg over 20min unless on maintenance therapy, in which case check blood theophylline level and start IVI of aminophylline at 0.5–0.7mg/kg/hr.
• IV salbutamol is an alternative in severe asthma, after consultation with senior staff. Draw up 5mg salbutamol into 500mL 5 % dextrose and run at a rate of 30–60mL/hr.
• A patient who cannot talk will be unable to drink fluids and may be dehydrated.
• Avoid ‘routine’ antibiotics.
• Repeat ABG within an hour.
• Hypokalaemia may be caused or exacerbated by B 2 agonist and/or steroid therapy.

The Mental State Examination

This assesses state of mind at the time of interview with the patient. A true description of mental states entails valid knowledge about current emotions plus their reactions to those emotions.

Take notes under the following headings.

• Appearance and behavior: see for signs of self-neglect; slowness, anxiety, or suspiciousness.

• Mode of speech: Speech rate, eg gabbling (pressure of speech), or slow/retarded. Note content.

• Mood: Note thoughts about harming self or others. Gauge your own response to the patient. The
laughter and grand ideas of manic patients are contagious, as to a lesser extent is the expression of thoughts from a depressed person.

• Beliefs: Eg about himself, his own body, about other people and the future. Note abnormal beliefs
(delusions) eg that thoughts are overheard, and ideas (eg persecutory, grandiose).

• Unusual experiences or hallucinations: “Sometimes when people are low they have unusual
experiences; have you heard anything unusual recently?” Note modality, eg visual.

• Orientation: In time, place, and person. What year? What season? What month/day of week? Is
it morning or afternoon? What is your name?

• Short-term memory: Recall a name & address 5 minutes after learning it. Ensure he really has learned it before waiting for the 5 minutes to elapse.

• Concentration: Months of the year backwards.

• Patient’s insight and degree of your rapport.

• Long-term memory: Current affairs recall. Who is the monarch/head of state? This tests other functions, not just memory

Down’s Syndrome Screening- A Brief Introduction

Down’s syndrome screening
The screening procedures offered currently in most of the countries are listed here. Each consists of a risk assessment based on maternal age and a scan performed in the first trimester or a blood test in the first or second trimester or a combination of scans and blood test.

Triple test
Done in early second trimester (14–20 completed weeks). This test is based on the measurement of

1. α-fetoprotein,
2. unconjugated oestriol (uE3) and 
3. hCG (either total hCG or free β-hCG)

together considering the maternal age.

Nuchal translucency scan
A first trimester (11–13 weeks) test is based on the measurement of the fold of skin on the back of the fetal neck.

Quadruple test
Early second trimester (14–21 weeks) test is based on the measurement of

1. α-fetoprotein, 
2. uE3, 
3. free β-hCG (or total hCG) and 
4. inhibin-A 

together considering the maternal age.

Combined test
Late first trimester (10–13 weeks) test is based on combining NT measurement with free β-hCG, pregnancy associated plasma protein-A (PAPP-A) and maternal age.

Integrated test
This is the integration of different screening markers measured at different stages of pregnancy into a single test result. Unless otherwise qualified, ’Integrated test’ refers to the integration of NT measurement and PAPP-A in the first trimester with serum α-fetoprotein, β-hCG and uE3 in the second.

Approach to a patient with Syncope

Definition Of Syncope: Symptom of sudden transient loss of consciousness due to global cerebral hypoperfusion.

Causes Of Syncope: 

• Neurocardiogenic (a.k.a. vasovagal, ~20%; ): ↑ sympathetic tone → vigorous contraction of LV →
mechanoreceptors in LV trigger ↑ vagal tone  → ↓ HR (cardioinhibitory) and/or
↓ BP (vasodepressor) cough, deglutition, defecation, & micturition → ↑ vagal tone and thus can be precipitants related disorder:
carotid sinus hypersensitivity (exagg vagal resp to carotid massage)

• Orthostatic hypotension (10%)
hypovolemia/diuretics, deconditioning; vasodilat. (esp. if combined w/ chronotropes)
autonomic neuropathy [primary = Parkinson’s, Shy-Drager, Lewy body dementia, POTS (dysautonomia in the young); secondary =DM, EtOH, amyloidosis, CKD]

• Cardiovascular
Arrhythmia (15%)
Bradyarrhythmias: Sick sinus syndrome, high-grade AV block, chronotropes, PPM malfunction
Tachyarrhythmias: VT, SVT (syncope rare unless structural heart disease or WPW)
Mechanical (5%)
Endocardial/Valvular: AS, MS, PS, prosthetic valve thrombosis, myxoma
Myocardial: pump dysfxn from MI or outflow obstruction from HCMP (but usually VT)
Pericardial: tamponade
Vascular: PE, PHT, aortic dissection, ruptured AAA, subclavian steal

Impetigo - A Brief Discussion.

Introduction: This is the most superficial of the bacterial skin infections. It is one of the most common skin infections in children. but can also occur in adults.

Etiology: It is caused by Streptococcus pyogenes or Staph. aureus infecting the epidermal layer of the skin.

Clinical features: Because it is so superficial, there is weeping, crusting, and oozing of the skin.
Symptoms start with red or pimple-like sores surrounded by red skin. These sores can be anywhere, but usually occur on the face, arms and legs. The sores fill with pus, then break open after a few days and form a thick crust. They are often itchy, but scratching them can spread the sores.

Impetigo is contagious and can be spread to others through close contact or by sharing towels, sheets, clothing, toys, or other items.

Diagnosis: A specific microbiologic diagnosis is rarely made or necessary. It is mostly diagnosed by the clinical appearance of  “weeping, oozing, honey-colored lesions.”

Introduction to Multivitamin Supplements and Understanding Megavitamin therapy.

A vitamin is one of a group of organic substances, present in minute amounts in natural foodstuffs that are essential for normal body metabolism.

There are 13 vitamins that a human  body needs. They are

• Vitamin A
• B vitamins (thiamine, riboflavin, niacin, pantothenic acid, biotin, vitamin B-6, vitamin B-12 and folate)
• Vitamin C
• Vitamin D
• Vitamin E
• Vitamin K

Each vitamin has specific function in the body and if there is a low levels of certain vitamins, there may be certain health problems and illness. 

Fat soluble and Water soluble Vitamins
Vitamins are either fat-soluble or water-soluble.

Fat-soluble vitamins are stored in the fatty tissues of the body and the liver. Fat-soluble vitamins are easier to store than water-soluble ones and can stay in the body as reserves for days, some of them for months.

Fat-soluble vitamins are absorbed through the intestinal tract with the help of fats (lipids).

Vitamins A, D, E, and K are fat-soluble.

Water-soluble vitamins do not get stored in the body for long - they soon get excreted in urine. Because of this, water-soluble vitamins need to be replaced more often than fat-soluble ones.

Vitamins C and all the B vitamins are water-soluble.

The best way to get enough vitamins is to eat a balanced diet with a variety of foods. In some cases, you may need to take vitamin supplements.

Vitamin Supplements; The best way to get enough vitamins is to eat a balanced diet with a variety of foods. In some cases, however vitamin supplements are indicated in some people in order to prevent or treat deficiencies.

Multivitamin and mineral supplements are easily available in different pharmacies so it is important to understand the need and indications for these supplements and to avoid dangerous overdoses. 

Indications For Vitamin Supplements: In otherwise healthy people, most scientific evidence indicates that multivitamin supplements do not prevent cancer, heart disease, or other ailments, and regular supplementation is not necessary. 

However, there may be specific groups of people who may benefit from multivitamin supplements for example,:

• people with poor nutrition
• couples planning for pregnancy 
• During pregnancy & breast feeding
• elderly individual
• people living in sun deprived areas need vitamin D supplements. 
• vegetarians etc

Approach to a Patient Presenting With Pain

Pain is the most common symptom that brings a patient to a physician’s attention.
Management depends on determining its cause, alleviating triggering and potentiating factors, and providing rapid relief whenever possible.

Pain may be of somatic (skin, joints, muscles), visceral, or neuropathic (injury to nerves, spinal cord pathways, or thalamus) origin. Characteristics of each of the types are summarized below:

Somatic pain

• Nociceptive stimulus usually evident
• Usually well localized
• Similar to other somatic pains in pt’s experience
• Relieved by anti-inflammatory or narcotic analgesics

Visceral pain

• Most commonly activated by inflammation
• Pain poorly localized and usually referred
• Associated with diffuse discomfort, e.g., nausea, bloating
• Relieved by narcotic analgesics

Neuropathic pain

• No obvious nociceptive stimulus
• Associated evidence of nerve damage, e.g., sensory impairment, weakness
• Unusual, dissimilar from somatic pain, often shooting or electrical quality
• Only partially relieved by narcotic analgesics; may respond to antidepressants or anticonvulsants.

Acute Asthma - Assessment

Make an initial assessment of the severity of acute asthma based upon a combination of

• clinical features, 
• peak flow measurement and 
• pulse oximetry 

This is as outlined as below.

Moderate exacerbation of asthma
• Increasing symptoms.
• Peak fl ow 50–75 % best or predicted.
• No features of acute severe asthma (below).

Acute severe asthma
Any one of the following:
• Inability to complete sentences in 1 breath.
• Respiratory rate ≥25/min.
• Heart rate ≥110/min.
• Peak flow 33–50 % best or predicted.

Understanding Hallucinations And Delusions

While dealing with psychiatry patients it is important to understand what having odd ideas mean and to  decide if a patient has delusions, hallucinations or a major thought disorder , because if present the helps in making a proper diagnosis and then a good treatment plan.

Patients may be reluctant to reveal odd ideas.
Ask gently:
“Have you ever had any thoughts which might now seem odd; perhaps that there is a conspiracy
against you, or that you are controlled by outside voices or the radio?”

Hallucination: is defined as a perception in the absence of external stimulus and these may be visual, auditory, tactile etc involving almost any of the five senses.
There are many different causes. It could be due to a mental illness like in schizophrenia or a nervous system disorder like Parkinson's disease. Tactile or visual hallucinations (without auditory hallucinations) suggest an organic disorder (e.g alcohol withdrawal).

Hypnagogic hallucinations and hypnopompic hallucinations are considered normal phenomena. Hypnagogic hallucinations can occur as one is falling asleep and hypnopompic hallucinations occur when one is waking up.

A pseudo-hallucination is one in which the person knows the stimulus is in the mind (e.g a voice heard within him- or herself, rather than over the left shoulder). They are more common, and does not indicate a mental illness, but they may be a sign that a genuine hallucination is waning.

Few treatments are available for hallucinations. However, for those hallucinations caused by mental disease, a psychologist or psychiatrist should treat the underlying medical illness.

Delusions are firm beliefs that do not change, even when a person is presented with conflicting evidence. If the belief arrives fully formed, and with no antecedent events or experiences to account for it, it is said to be primary, and is suggestive of schizophrenia

Paracentesis - Procedure Technique

Paracentesis is a procedure to take out fluid that has collected in the abdomen the peritoneal fluid. This fluid buildup is called ascites Ascites may be caused by infection, inflammation, an injury, or other conditions, such as cirrhosis or cancer. The fluid is taken out using a long, thin needle put through the belly. The fluid is sent to a lab and studied to find the cause of the fluid buildup.
Removal and analysis of peritoneal fluid is important in evaluating patients with new onset ascites or ascites of unknown etiology. It is also indicated in patients with known ascites who have a decompensation in their clinical status.

Relative contraindications include

• bleeding diathesis, 
• prior abdominal surgery,
•  distended bowel, or 
• known loculated ascites.

Preparation Before the Procedure; 

• Prior to performing a paracentesis, any severe bleeding diathesis should be corrected.
• Bowel distention should also be relieved by placement of a NG tube, and the bladder should also be emptied before beginning the procedure. 
• If a large-volume paracentesis is being performed, large vacuum bottles with the appropriate connecting tubing should be obtained.

Oppositional Defiant Disorder

Definition: Oppositional defiant disorder (ODD) is a condition in which a child displays an ongoing pattern of uncooperative, hostile, resistant and an annoying behavior towards people in authority. 

In order to be diagnosed the behavior must be present for at least 6 months.

Symptoms: It is difficult to differentiate between a normal but an emotional child with a child with an oppositional defiant disorder. It is not unusual for children to argue, disobey or talk back to their parents, teachers or other adults, but when such a behavior gets too annoying to disrupt the child’s daily life and activities, lasts longer than 6 months and is excessive for the child’s age than it becomes a psychological disorder known as Oppositional defiant disorder. 

ODD is characterized by frequent occurrence of at least four of the following behaviors:

• losing temper
• arguing with adults.
• actively defying or refusing to comply with the request or rules of the adults.
• deliberately doing things that will annoy others
• getting angry
• showing violent behavior.
• blaming others on his/her own mistakes
• being touch and easily annoyed by others.
• unwillingness to compromise.
• Acting aggressive towards peers
• Have academic problems.

Related Mental health issues: A child with oppositional defiant disorder may have associated other mental health issues like anxiety, depression and/or attention deficit hyperactivity disorder. The symptoms of theses conditions may overlap and sometimes it is difficult to diagnose as one particular disorder.

Hyperventilation - Causes And Management

Hyperventilation is breathing which occurs more deeply and/or more rapidly than normal.

Pathophysiology: CO 2 is ‘blown off ’, so that pCO 2 decreases.. Hyperventilation may be primary (‘psychogenic’) or secondary. A classical secondary cause is DKA — Kussmaul’s respiration represents respiratory compensation for a metabolic acidosis.

Secondary causes of hyperventilation
• Metabolic acidosis (eg DKA, uraemia, sepsis, hepatic failure).
• Poisoning (eg aspirin, methanol, CO, cyanide, ethylene glycol).
• Pain/hypoxia.
• Hypovolaemia.
• Respiratory disorders (eg PE, asthma, pneumothorax).

Primary (psychogenic or inappropriate) hyperventilation
Typically, the patient is agitated and distressed with a past history of panic attacks or episodes of hyperventilation. They may complain of dizziness, circumoral paraesthesia, carpopedal spasm, and occasionally sharp or stabbing chest pain. Initial examination reveals tachypnoea with equal
air entry over both lung fields, and no wheeze or evidence of airway obstruction.

Introduction To Preimplantation Genetic Diagnosis (PGD)

Preimplantation genetic diagnosis (PGD) is an early form of prenatal diagnosis in which embryos created in vitro are analysed for well-defined genetic defects.
Defect-free embryos are then used for implantation.

Indications: It is used in

• those with high risk of genetic disease, e.g carriers of monogenic disease or chromosome structural abnormalities (e.g translocations) 
• who have repeatedly terminated pregnancies due to prenatal tests showing abnormality,
• who have concurrent infertility, 
• who have had recurrent miscarriage (as occurs with translocation carriers), and 
• for those with moral or religious objections to termination.
• It has also been used to screen for aneuploidy (PGD-AS) in those undergoing in vitro fertilization hoping to enhance chance of ongoing pregnancy (e.g in the case for women >37–40 years old).

Background: Pioneered in the early 1990's, PGD has resulted in >1200 pregnancies (pregnancy rate 24%), of which 5% of babies had some kind of abnormality.

PGD selection of embryos by HLA type so that a child born after using this technology can be used as a stem cell donor to save a sibling from certain conditions (eg with Fanconi anaemia, thalassaemia, or leukaemia) is controversial, but possible.

Some clinics select sex of implanted embryo e.g for ‘family balancing’.

Approach To A New Born With Congenital Heart Disease

A baby may be born with congenital heart disease and may not not present with symptoms in the early few hours of life. 

In order to diagnose the condition following points are summarized below:

1. A Baby With Cyanosis: may have conditions like

• Transposition of Great Arteries (TGA) ,
• Right sided obstruction (Pulmonary atresia, Tricuspid atresia)

2. Presentation with Mild Cyanosis and CCF: include conditions like:

• TAPVC,
• Truncus arteriosus

3. A newborn baby in Shock: may have:

• Hypoplastic left heart syndrome,
• Aortic stenosis

Lumbar Puncture

A lumbar puncture (also called a spinal tap) is a procedure to collect and look at the fluid (cerebrospinal fluid, or CSF) surrounding the brain and spinal cord. During a lumbar puncture, a needle is carefully inserted into the spinal canal low in the back (lumbar area). Samples of CSF are collected.
Evaluation of CSF is essential for the diagnosis of suspected meningeal infection, subarachnoid hemorrhage, leptomeningeal neoplastic disease, and noninfectious meningitis.

Relative contraindications to LP include 

• local skin infection in the lumbar area, 
• suspected spinal cord mass lesion, and 
• a suspected intracranial mass lesion. 

Preparation: 

• Any bleeding diathesis should also be corrected prior to performing LP to prevent the possible occurrence of an epidural hematoma. 
• A functional platelet count >50,000/μL and an international normalized ratio (INR) <1.5 are advisable to perform LP safely.
• In patients with an altered level of consciousness, focal neurologic deficits, or evidence of papilledema, an imaging study should generally be obtained prior to performing LP.

Technique: 

• Proper positioning of the patient is essential; either the lateral decubitus or the sitting position can be used. 
• Most routine LPs should be performed using the lateral decubitus position .The sitting position may be preferable in obese patients. 
• With either position, the patient should be instructed to flex the spine as much as possible. 
• In the lateral decubitus position, the patient assumes a fetal position with the knees flexed toward the abdomen; the shoulders and pelvis should be vertically aligned without forward or backward tilt. 
• In the sitting position, the patient should bend over a bedside table with the head resting on folded arms.

Recurrent Miscarriage - Causes And Workup

Recurrent miscarriage (RM), which is defined as three or more consecutive miscarriages, is relatively uncommon – affecting about 1 to 2% of couples who conceive.

Three strands of evidence supports that Recurrent Miscarriage is a distinct clinical entity rather than one which occurs purely by chance alone.

1. First, the observed incidence of RM is significantly higher than that expected by chance alone (0.4%); 
2. second, a woman’s risk of miscarriage is directly related to the outcome of her previous pregnancies ; and 
3. third, in contrast to sporadic miscarriage, women with RM tend to lose pregnancies with a normal chromosome complement, suggesting the presence of a persistent underlying cause for pregnancy loss among these women.

Despite major advances in medicine the understanding of the cause of RM is sometimes not clear and even after comprehensive investigation, no cause for pregnancy failure is identified in approximately 50% of couples. This has led to the situation where women with RM have been, and continue to be, subjected to investigations and treatments based on trial and error approach. 

Contemporary investigative screen for recurrent miscarriage:

• Male and female parental blood karyotypes
• Lupus anticoagulant
• IgG and IgM anticardiolipin antibodies
• FactorV genotype
• FactorII genotype
• Activated protein C resistance
• Pelvic ultrasound to determine ovarian morphology and uterine anatomy
• Early follicular phase FSH
• Insulin resistance status

Approach to A Patient Presenting With Difficulty In Breathing ( Dyspnea)

The normal adult respiratory rate is 11–18/min, with a tidal volume of 400–800mL. Acute dyspnoea That is difficult or labored breathing is a common presenting symptom.

Common causes of Acute Dyspnoea
Cardiac
• Cardiogenic pulmonary oedema.
• MI .
• Pulmonary embolism.
• Arrhythmias .
Respiratory
• Asthma  or exacerbation of COPD
• Pneumonia .
• Pleural effusion .
• Pneumothorax
Trauma
• Aspiration of foreign body or vomit .
• Pneumothorax/haemothorax .
• Flail chest .
• Drowning incident .
Others
• Hypovolaemia or fever from any cause.
• Hyperventilation syndrome .
• Respiratory compensation for metabolic acidosis (DKA, salicylate overdose).
Psychological
• Anxiety
• Panic attack

Rh(D) Immunoglobulin / Anti D Immunoglobulin - Uses And Dose.

Rho(D) immune globulin is a medication used to prevent Rh isoimmunization in mothers who have a Rh negative blood group. 

When a a woman with RhD negative blood is exposed to RhD positive blood in pregnancy she can develops an immune response to it and develop anti D antibodies. In later pregnancies, anti-D antibodies can cross the placenta, causing rhesus haemolytic disease in the Rh positive fetus, and is worsened with subsequent pregnancies. 

Rhesus disease can largely be prevented by giving an injection of a medication called anti-D immunoglobulin to the Rh negative mother.

The anti-D immunoglobulin neutralizes any RhD positive antigens that may have entered the mother’s blood during pregnancy. If the antigens have been neutralized, the mother’s blood won't produce antibodies.

It is often given both during and following pregnancy. 

Indications

• Following potentially sensitizing events in pregnancy, it is recommended that anti-D Ig should be administered as soon as possible and always within 72 hours of the event.
• If, exceptionally, this deadline has not been met, some protection may be offered if anti-D Ig is given up to 10 days after the sensitizing event.
• It may also be used when Rh negative people are given Rh positive blood.
• Anti D Immunoglobulinis also used to treat idiopathic thrombocytopenic purpura (ITP) in people who are Rh positive.

Thoracocentesis - Procedure Description.

Thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes.
Drainage of the pleural space can be performed at the bedside.

Indications for this procedure include

• diagnostic evaluation of pleural fluid, 
• removal of pleural fluid for symptomatic relief, and 
• instillation of sclerosing agents in patients with recurrent, usually malignant pleural effusions.

Preparation: 

• Familiarity with the components of a thoracentesis tray is a prerequisite to performing a thoracentesis successfully. 
• Recent posterior-anterior (PA) and lateral chest radiographs with bilateral decubitus views should be obtained to document the free flowing nature of the pleural effusion. 
• Loculated pleural effusions should be localized by ultrasound or CT prior to drainage. 
• Management should be individualized in patients with a coagulopathy of thrombocytopenia. Thoracentesis is more challenging in patients with mechanical ventilation and should be performed with ultrasound guidance if possible.

Spontaneous Miscarriage - The New Classification And Management

Introduction
Spontaneous miscarriage is one of the commonest complication of early pregnancy. It occurs in approximately 15–20% of all pregnancies.
It is important to take a good clinical history in every case of pregnancy loss and classify the type whenever possible.
Increasing knowledge about early pregnancy development, with the more widespread availability of measurement of serum Beta HCG (human chorionic gonadotrophin) , the advent of high resolution ultrasound and a clearer description of gestational age at pregnancy loss make for a more sophisticated assessment of miscarriage history.

Diagnosis
Role of ultrasound
The first demonstration of an intrauterine pregnancy by means of transvaginal ultrasound was reported in 1967. Major improvements in ultrasound resolution since then have revolutionized the assessment and management of early pregnancy problems.

Ultrasound plays a major role in maternal reassurance, where fetal cardiac activity is seen and is pivotal in the assessment of early pregnancy complications, such as vaginal bleeding. 

However, there are limits to ultrasound resolution of normal early pregnancy development.

• Expert advice concludes that the diagnosis of an empty gestation sac can only be made when the mean gestation sac diameter is greater than 20 mm, and that the crown–rump length must be 6 mm or greater before one can say for certain that fetal heart activity is absent. 
• If measurements are below these thresholds a repeat transvaginal ultrasound examination after at least a week should be offered . 

Ultrasound features such as a sac that is much smaller than expected from a certain last menstrual period; a sac that is low in the uterus or the presence of fetal bradycardia are strongly suggestive but

not diagnostic of impending miscarriage. In addition, the possibility of incorrect dates should always

be remembered by the alert clinician. Wherever possible, the term ‘missed abortion’ should be replaced by ‘delayed miscarriage’.

The impact of a diagnosis of a miscarriage should not be underestimated. It is recommended that ‘Early intrauterine death should be regarded as of equal significance to fetal death occurring at a later stage.’ It is therefore important that within an area where early pregnancy scans are performed, there is a quiet room for counselling, and staff working within this setting should have training in the emotional aspects of early pregnancy loss.

Modern classification of pregnancy loss type

The revision of early pregnancy nomenclature is both desirable and essential in raising the standard of reporting.

Medical Issues Common In Children With Neurodisability

There are a number of medical problems which are more common in children with disability. These

include:

1. Gastro-esophageal reflux disease (GERD) :Gastro-oesophageal reflux (the non-forceful regurgitation of gastric contents into the esophagus) is more common in children with neuro-developmental problems for a number of reasons. 

Intra-abdominal pressure may be increased for structural reasons such as scoliosis, the lower esophageal sphincter may be functionally immature as a reflection of abnormal muscle tone elsewhere in the body, and difficulties in upright positioning may also exacerbate gastroesophageal reflux.

First line management is postural, with supportive upright seating and sleeping positioners, along with adjustment of feed consistency if required. In addition, pharmacological agents like Proton-pump inhibitors (e.g. omeprazole, lansoprazole, esomeprazole) and H2-receptor antagonists (e.g. ranitidine) are used to alter acid production. Dopamine receptor antagonists (e.g. domperidone) stimulate gastric emptying and small intestinal transit. They also help with GERD by enhancing the tone of the esophageal sphincter. In children with severe symptoms of GORD, surgical intervention such as a Nissen’s fundoplication may be considered.

2. Respiratory complications: Neurological disturbance in children with neurodisability impairs the ability of the child to protect their airway, leading to acute or chronic (‘silent’) aspiration and liability to chemical pneumonitis or secondary infection with anaerobic organisms.

Pre-Pregnancy Counselling

Introduction
It is important that the parents to be should plan for a pregnancy under conditions most likely to ensure a best outcome for both the mother and the baby.

The following points should be considered during a counselling to a couple who are planning to get pregnant.

1. Reduce weight if obese .
2.Ensure the woman is immune to rubella prior to pregnancy.
3.Optimal control of chronic disease (like  diabetes) before conception. This is also important for hypothyroidism as the fetus cannot make thyroxine until 12 weeks and under-replacement may affect neurodevelopment.
4.Strict diet is  essential peri-conceptually for women with phenylketonuria (PKU).
5. Stop teratogens (drugs and alcohol that may lead to fetal abnormalities) or seek expert advice prior to conception .
6.Start Medication to protect the fetus from abnormality (e.g folate supplements for neural tube defects).

Precautions While Performing Medical Procedures

Universal precautions should be used whenever an invasive procedure exposes the operator to potentially infectious body fluids. Not all patients infected with transmissible pathogens can be reliably identified. Because pathogens transmitted by blood and body fluids pose a hazard to personnel caring for such patients, particularly during invasive procedures, precautions are required for routine care of all patients whether or not they have been placed on isolation precautions of any type.

The CDC calls these universal precautions.

1. Wash hands before and after all patient contact.

2. Wash hands before and after all invasive procedures

.3. Wear gloves in every instance in which contact with blood or body fluid is certain or likely. For example, wear gloves for all venipunctures, for all IV starts, for IV manipulation, and for wound care.

4. Wear gloves once and discard. Do not wear the same pair to perform tasks on two different patients or to perform two different tasks at different sites on the same patient.

5. Wear gloves in every instance in which contact with any body fluid is likely, including urine, feces, wound secretions, and fluid encountered in respiratory tract care, thoracentesis, paracentesis.

6. Wear gown when splatter of blood or body fluids on clothing seems likely.

Croup or Viral Laryngotracheobronchitis in Children

Definition 
Croup or viral laryngotracheobronchitis is an acute inflammation of the entire airway, mainly in the glottis and subglottic area, resulting in airway narrowing, obstruction, and voice loss. 

Therefore, it has generally been described as a triad of 

1. hoarse voice, 
2. harsh barking cough, and 
3. inspiratory stridor.

Epidemiology

Typically, the condition affects younger children (6–36 months), with a peak incidence at 2 years of age. It is the most common cause of acute upper airway obstruction in young children; a reported 3% of children experience it before 6 years of age.
Seasonal outbreaks have been described in the fall and winter, although it may occur year round in some areas.
Males are more often affected than females.

Etiology and Pathophysiology
Viral infection is the predominant etiology; parainfluenza (types 1, 2, and 3) is the most common agent. Other common viral agents are respiratory syncytial virus (RSV) and influenza. Less commonly encountered viruses include adenovirus, rhinovirus, enterovirus, and measles virus.
Mycoplasma pneumoniae is one of the few bacterial microorganisms that has been reported as an etiologic agent.

In children, the larynx is very narrow and is comprised by the rigid ring of the cricoid cartilage; therefore, a viral infection causing inflammation of this area leads to airway edema and subsequent obstruction. This obstruction results in the classic symptoms of stridor and cough.

Clinical Presentation

• Croup usually presents initially with a coryzal prodrome (1–4 days).
• Common symptoms include clear rhinorrhea, low-grade temperature, and mild tachypnea followed by barking cough, hoarseness, and stridor.
• Obstructive symptoms occur most commonly at night.
• Severity of airway narrowing may be determined by the presence of stridor at rest, tachypnea, retractions, tracheal tug, cyanosis, and pallor, as well as decreased breath sounds, which indicate critical narrowing.

Factitious Disorder - A Brief Discussion

Definition.
A disorder characterized by the conscious production of signs and symptoms of both medical and mental disorders. The main objective is to assume the sick role and eventually hospitalization. Usually diagnosed with physical or psychological symptoms or both.

Called Factitious Disorder By Proxy if the signs and symptoms are faked for another person, as in
mother and child.

Etiology.
Seen more commonly in men and in hospital and health care workers. As children, many of the patients suffered abuse that resulted in frequent hospitalizations, thus their need to assume the sick role.

Physical and Psychiatric Presenting Symptoms.
• May have a gridiron abdomen from the multiple surgeries
• Typically demand treatment when in the hospital
• If tests return negative, they tend to accuse doctors and threaten litigation.
• Become angry when confronted.

Treatment.
Usually involves management rather than cure. Must be aware of counter-transference when the physician suspects factitious disorder.

Chorionic Villus Sampling

It is one of the obstetric procedures and is summarized as follows:

Procedure:
-This is a diagnostic outpatient office procedure performed under ultrasound guidance without anesthesia.
-The catheter is placed directly into the placental tissue without entering the amniotic cavity.
-Chorionic villi, which are placental precursors, are aspirated from a pregnant uterus between 10 and 12 weeks’ gestation.
-The tissue is sent to the laboratory for karyotyping.
-The chromosomes of the villi are almost always identical to those of the embryo.

Nature of Tissue Obtained:
The procedure can be performed either transcervically or transabdominally. Since the fetus and chorionic villi are both derived from a common origin (the zygote), their karyotype is identical more than 99% of the time.

A Brief Introduction to Infertility

Definition of Infertility:

A. Primary infertility
1. Female partner has never been pregnant
2. Couple unable to conceive after unprotected intercourse for at least 1 year

B. Secondary infertility
1. Female partner has had at least one prior conception
2. Couple unable to conceive after unprotected intercourse for at least 1 year

Scope of Problem:
Approximately 15% of couples are unable to achieve a pregnancy within 1 year of attempting conception.Fertility declines are evident at least a decade prior to the menopausal transition.

Evaluation of the Infertile Couple:
A. History and physical
1. Menstrual cycle frequency and length
2. Gravidity, parity, pregnancy outcomes
3. Coital frequency and sexual dysfunction
4. Duration of infertility
5. Surgical history, particularly pelvic/abdominal
6. Medications, allergies
7. Tobacco, alcohol, drug history
8. History of sexually transmitted diseases
9. Family history of birth defects, reproductive difficulties, spontaneous abortions, early menopause, mental retardation
10. Symptoms of thyroid disease, pelvic pain, galactorrhea, hirsutism, dyspareunia
11. Physical examination includes weight, body mass index (BMI), thyroid and breast examinations, signs of hyperandrogenism/hirsutism, pelvic tenderness, and vaginal/uterine/cervical abnormalities.

Folic acid Deficiency Anemia

A common, slowly progressive megaloblastic anemia, folic acid deficiency anemia is most prevalent in infants, adolescents, pregnant and lactating females, alcoholics, elderly people, and people with malignant or intestinal diseases.

Causes
Folic acid deficiency anemia results from a decreased level or lack of folate, a vitamin that’s essential for red blood cell production and maturation. 

Causes include:

• alcohol abuse (may suppress metabolic effects of folate)
• inadequate diet (common in alcoholics, elderly people who live alone, and infants, especially those with infections or diarrhea)
• impaired absorption (due to intestinal dysfunction from such disorders as celiac disease, tropical sprue, and regional jejunitis and from bowel resection)
• bacteria competing for available folic acid
• overcooking, which can destroy a high percentage of folic acids in foods
• limited storage capacity in infants
• prolonged drug therapy (with anticonvulsants and estrogens)
• increased folic acid requirement during pregnancy, during rapid growth in infancy (common because of increased survival rate of preterm infants), during childhood and adolescence (because of general use of folate-poor cow’s milk), and in patients with neoplastic diseases and some skin diseases (chronic exfoliative dermatitis).

Introduction to Liver Abscess

A liver abscess occurs when bacteria or protozoa destroy hepatic tissue, producing a cavity, which fills with infectious organisms, liquefied liver cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver.

Liver abscess occurs equally in men and women, usually in those older than age 50. Death occurs in 15% of affected patients despite treatment.

Causes
Underlying causes of liver abscess include benign or malignant biliary obstruction along with cholangitis, extrahepatic abdominal sepsis, and trauma or surgery to the right upper quadrant. Liver abscesses also occur from intra-arterial chemoembolizations or cryosurgery in the liver, which causes necrosis of tumor cells and potential infection.

The method by which bacteria reach the liver reflects the underlying causes.

Biliary tract disease is the most common cause of liver abscess. Liver abscess after intra-abdominal sepsis (such as with diverticulitis) is most likely to be caused by hematogenous spread through the portal bloodstream. 

Hematogenous spread by hepatic arterial flow may occur in infectious endocarditis. 

Abscesses arising from hematogenous transmission are usually caused by a single organism; those arising from biliary obstruction, by mixed flora. 

Patients with metastatic cancer to the liver, diabetes mellitus, or alcoholism are more likely to develop a liver abscess. 

The organisms that predominate in liver abscess are gram-negative aerobic bacilli, enterococci, streptococci, and anaerobes. 

Amebic liver abscesses are caused by Entamoeba histolytica.

Treatment Options for Thalassemia Major

Before chronic transfusions are initiated, the diagnosis of Beta-thalassemia should be confirmed and the parents counseled about this lifelong therapy. Initiating transfusion and chelation therapy can be difficult for parents to face early in their child’s life.

If there is the possibility of a bone marrow transplant, the blood should be negative for cytomegalovirus and irradiated.

Blood Transfusion therapy:
Transfusion therapy promotes general health and well-being and avoids the consequences of ineffective erythropoiesis. A transfusion program generally requires monthly transfusions, with the pretransfusion hemoglobin level >9.5 and <10.5 g/dL. In patients with cardiac disease, higher pretransfusion hemoglobin levels may be beneficial. Some blood centers have donor programs that pair donors and recipients, decreasing the exposure to multiple red cell antigens.

Transfusional hemosiderosis causes many of the complications of thalassemia major. Accurate assessment of excessive iron stores is essential to optimal therapy. The serum ferritin level is useful in assessing iron balance trends, but does not accurately predict quantitative iron stores. Undertreatment or overtreatment of presumed excessive iron stores can occur when a patient is managed based on the serum ferritin level alone.

Hypothyroidism in Adults

Hypothyroidism, a state of low serum thyroid hormone, results from hypothalamic, pituitary, or thyroid insufficiency. The disorder can progress to life-threatening myxedema coma. Hypothyroidism is more prevalent in women than in men.

Etiology
Hypothyroidism results from inadequate production of thyroid hormone, usually because of dysfunction of the thyroid gland due to surgery (thyroidectomy), radiation therapy (particularly with 131I), inflammation, chronic autoimmune thyroiditis (Hashimoto’s disease) or, rarely, conditions such as amyloidosis and sarcoidosis. It may also result from pituitary failure to produce thyroid-stimulating hormone (TSH), hypothalamic failure to produce thyrotropin-releasing hormone, inborn errors of thyroid hormone synthesis, inability to synthesize thyroid hormone because of iodine deficiency (usually dietary), or the use of antithyroid medications such as propylthiouracil.
In patients with hypothyroidism, infection, exposure to cold, and sedatives may precipitate myxedema coma.

Signs and symptoms:
Typically, the early clinical features of hypothyroidism are vague and may include fatigue, forgetfulness, sensitivity to cold, unexplained weight gain, and constipation. As the disorder progresses, characteristic myxedematous signs and symptoms appear, such as decreasing mental stability; dry, flaky, inelastic skin; puffy face, hands, and feet; hoarseness; periorbital edema; upper eyelid droop; dry, sparse hair; and thick, brittle nails.

Bulimia nervosa

Introduction

The essential features of bulimia nervosa include eating binges followed by feelings of guilt, humiliation, and self-deprecation. These feelings cause the patient to engage in self-induced vomiting, the use of laxatives or diuretics, following a strict diet, or fasting to overcome the effects of the binges. Electrolyte imbalances (including metabolic alkalosis, hypochloremia, and hypokalemia) and dehydration can occur, increasing the risk of physical complications.
Bulimia nervosa usually begins in adolescence or early adulthood and can occur simultaneously with anorexia nervosa. It affects nine women for every man affected. Nearly 2% of adult women meet the diagnostic criteria for bulimia nervosa; 5% to 15% have some symptoms of the disorder.

Causes
Bulimia nervosa has no known cause, but psychosocial factors may contribute to its development, including family disturbance or conflict, sexual abuse, maladaptive learned behavior, struggle for control or self-identity, cultural overemphasis on physical appearance, and parental obesity.

Signs and symptoms
The history of a patient with bulimia nervosa is marked by episodes of binge eating that may occur up to several times per day. The patient commonly reports a binge-eating episode during which she continues eating until abdominal pain, sleep, or the presence of another person interrupts it. The preferred food usually is sweet, soft, and high in calories and carbohydrate content.
The bulimic patient may appear thin and emaciated. Typically, however, although her weight frequently fluctuates, it usually stays within normal limits through the use of diuretics, laxatives, vomiting, and exercise. So, unlike the anorexic patient, the bulimic patient can usually hide her eating disorder.

Introduction to Septic Arthritis

A medical emergency, septic (infectious) arthritis is caused by bacterial invasion of a joint, resulting in inflammation of the synovial lining. If the organisms enter the joint cavity, effusion and pyogenesis follow, with eventual destruction of bone and cartilage.
Septic arthritis can lead to ankylosis and even fatal septicemia. However, prompt antibiotic therapy and joint aspiration or drainage cures most patients.

Pathophysiology
In most cases of septic arthritis, bacteria spread from a primary site of infection, usually in adjacent bone or soft tissue, through the bloodstream to the joint.
Common infecting organisms include four strains of gram-positive cocci—Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Streptococcus viridans—and two strains of gram-negative cocci—Neisseria gonorrhoeae and Haemophilus influenzae. Various gram-negative bacilli—Escherichia coli, Salmonella, and Pseudomonas, for example—also cause infection.
Anaerobic organisms such as gram-positive cocci usually infect adults and children older than age 2. H. influenzae most often infects children younger than age 2.

Risk factors
Various factors can predispose a person to septic arthritis. Any concurrent bacterial infection (of the genitourinary or the upper respiratory tract, for example) or serious chronic illness (such as cancer, renal failure, rheumatoid arthritis, systemic lupus erythematosus, diabetes, or cirrhosis) heightens susceptibility. Consequently, alcoholics and elderly people run a higher risk of developing septic arthritis.
Of course, susceptibility increases with diseases that depress the autoimmune system or with prior immunosuppressant therapy. I.V. drug abuse (by heroin addicts, for example) can also cause septic arthritis.
Other predisposing factors include recent articular trauma, joint surgery, intra-articular injections, and local joint abnormalities.

Ovarian Cysts - A Brief Discussion

Introduction

Usually ovarian cysts are non-neoplastic sacs on an ovary that contain fluid or semisolid material. Although these cysts are usually small and produce no symptoms, they require thorough investigation as possible sites of malignant change.

Common ovarian cysts include follicular cysts, lutein cysts (granulosa-lutein [corpus luteum] and theca-lutein cysts), and polycystic (or sclerocystic) ovarian disease. Ovarian cysts can develop anytime between puberty and menopause, including during pregnancy. Granulosa-lutein cysts occur infrequently, usually during early pregnancy. The prognosis for nonneoplastic ovarian cysts is excellent.

Pathology
Follicular cysts are generally small and arise from follicles that overdistend instead of going through the atretic stage of the menstrual cycle. When such cysts persist into menopause, they secrete excessive amounts of estrogen in response to the hypersecretion of follicle-stimulating hormone and luteinizing hormone that normally occurs during menopause.

Granulosa-lutein cysts, which occur within the corpus luteum, are functional, nonneoplastic enlargements of the ovaries caused by excessive accumulation of blood during the hemorrhagic phase of the menstrual cycle.

Theca-lutein cysts are commonly bilateral and filled with clear, straw-colored fluid; they’re commonly associated with hydatidiform mole, choriocarcinoma, or hormone therapy (with human chorionic gonadotropin [HCG] or clomiphene citrate).

Polycystic ovarian disease is part of Stein-Leventhal syndrome and stems from endocrine abnormalities.

Signs and symptoms
Small ovarian cysts (such as follicular cysts) usually don’t produce symptoms unless torsion or rupture causes signs of an acute abdomen (abdominal tenderness, distention, and rigidity)

Sudden infant death syndrome

A medical mystery of early infancy, sudden infant death syndrome (SIDS)—commonly called crib death—kills apparently healthy infants, usually between ages 1 month and 1 year, for reasons that remain unexplained, even after an autopsy. Typically, parents put the infant to bed and later find him dead, often with no indications of a struggle or distress of any kind.

Some infants may have had signs of a cold, but such symptoms are usually absent. SIDS has occurred throughout history, all over the world, and in all climates.

Causes
SIDS is one of the leading causes of infant death. Most of these deaths occur during the winter, in poor families, and among underweight babies and those born to mothers younger than age 20.
Although infants who die from SIDS often appear healthy, research suggests that many may have had undetected abnormalities, such as an immature respiratory system and respiratory dysfunction. In fact, the current thinking is that SIDS may result from an abnormality in the control of ventilation, which causes prolonged apneic periods with profound hypoxemia and serious cardiac arrhythmias.

Risk factors for the infant include 

sleeping on the stomach (up to age 4 months), 

soft bedding in the crib (up to age 1 year), 

premature birth, 

having a history of a sibling who had SIDS, and

being born into poverty. 

Maternal risk factors include 

multiple births, 

smoking or illicit drug use, 

teenage motherhood, 

short intervals between pregnancies, and 

late prenatal care.