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).