A Family Doctor's Tale - ENCEPHALITIS

DOC I HAVE ENCEPHALITIS

Encephalitis is a serious medical disease which causes inflammation and infection of the brain.

The causes of Encephalitis may be divided into:

Infections:
1.viral infections are the most common
(herpes simplex virus, mumps, measles, rubella, chickenpox, West Nile Encephalitis, Japanese Encephalitis, St Lious Encephalitis).

Of these viruses, herpes simplex virus is the most serious and can cause fatality.

2.bacterial infections such as meningoccocus (Neisseria meningitidis) and pneumococcus(Streptococcus pneumoniae) can be serious and fatal in some cases.

Meningococcal Encephalitis can cause outbreaks(spread easily).

3.fungi,
Cryptococcus neoformans is the most common cause of fungal Encephalitis

4.Parasitic
Examples are Toxoplasmosis, malaria, amoeba, Lyme Disease

The symptoms which often defines Encephalitis are:

1.Severe headache

2.Fever

3.Irritabilty

4.Confusion

5.Drowsiness and fatigue

Other symptoms are:

6.seizures and convulsions

7.vomiting

8.hallucinations

9.memory problems

10.tremors

11.weakness of the hands and legs

12.incontinence of urinary and bowel movement

The diagnosis of Encephalitis is made by:
1.Typical symptoms of fever, headache, confusion .

2.Physical examination shows confusion ,drowsiness and signs of neck rigidity

3.blood tests (complete blood count, ESR and blood culture)

4.cerebrospinal fluid analysis (CSF) via lumbar puncture is examined for increased white blood cells and protein content,  normal glucose level. Red blood cells may be present if there is bleeding. Sometimes the CSF may show the presence of micro-organisms.

This test should not be done if there is suspected cerebral mass lesion or raised intracranial pressure (head injury, localizing neurological signs, or signs of raised ICP).

5.CT or MRI of the brain and spine with MRI preferred over CT because it can detect more easily areas of cerebral edema,tumors, ischemia, and meningeal inflammation.

The complications of Encephalitis are:
1.Neurological deficits

2.deafness

3.learning disorders in children

4.brain infarction,

5.septic shock,

6.adult respiratory distress syndrome

7.seizures also more in children

8.pneumonia especially in the elderly

The treatment of Encephalitis is:
1.Hospitalisation should be immediate as Encephalitis can be a life threatening condition.

2.Antibiotics such as cephalosporin, ampicillin, chloramphenicol, intravenous vancomycin to be started even before doing lumbar puncture.

Acyclovir may be given for herpes virus infection

High dosages of antifungals may be given for Fungal Encephalitis for a prolonged period of time

3.corticosteroids is useful to reduce swelling and inflammation in the brain

4.Sedatives may be needed for irritabilty and restlessness

5.High-flow oxygen

6.intravenous fluids

The prognosis of Encephalitis is:
This depends on the severity and type of infection.

Viral infections except for herpes simplex usually recover quickly.

Bacterial infections such as meningococcus and pneumonia are more dangerous.

The Preventive measures taken for Encephalitis are:
Vaccinations against Haemophilus influenzae in children and adults has reduced the incidence of this form of meningitis and encephalitis.

Mumps vaccination as part of Measles,mumps and rubella vaccine(MMR) has reduced the incidence of mumps related form of meningitis and encephalitis

Vaccinations against Japanese Encephalitis is given for travelers going to endemic places with Japanese Encephalitis.

A Family Doctor's Tale - CANCER OF VULVA

DOC I HAVE CANCER OF THE VULVA

Cancer of the vulva is  a rare cancer in women which affects the vulva occurring usually in older women past menopause.

The average age is over 60.

The cancer is usually a squamous carcinoma.

Rare tumors are melanoma, basal cell carcinoma and sarcoma.

The most common site is the labium majus(side wall of the vulva) , followed by the clithoris but it may arise anywhere including the urethral area.

The cancer can spread locally to involve the whole vulva and invade the vagina.

Secondary spread of the cancer is along the lymphatic system.

The symptoms and signs of  cancer of the vulva are:

1.The cancer is usually symptomless until it ulcerates.

2.It can presents as a lump which is cauliflower in appearance or ulcerated or indurated.

3.inguinal lymph nodes may be enlarged in cases of spread.

4.There may be pain with ulceration or long standing itch.

Diagnosis of cancer of the vulva is by:

1.Physical examination may revealed a lump or more in the vulva region.

2.Biopsy of the lump may reveal cancer

3.Ultrasound may be able to detect any spread to the vagina, uterus or lymph gland.

The treatment of Cancer of the vulva is  :

1.Surgery:
If there is no evidence of spread, usually removal of the cancerous lump is sufficient.

If the evidence of spread to the entire vulva region, radical vulvectomy may be done together with removal of the inguinal lymph nodes.

Chemotherapy:
Chemotherapy may help to prevent the spread of the cancer or to prevent a reccurance.

Radiotherapy :
Radiotherapy is not a treatment of choice


Squamous cell carcinoma is relatively resistant to radiotherapy.


The vulval skin is also very sensitive the burning effect of radiotheray.


However in the very old and frail patients, radiotherapy may be considered as an alternative to multilating operation.

Prognosis of cancer of the vulva is:
If the lymph nodes are not involved, there is a chance of 70% 5 year cure rate.

If the superficial lymph nodes are involved, the cure rate drops to 40%.

If the pelvic lymph nodes are involved the cure rate drops to only 20%.

A Family Doctor's Tale - VESICOVAGINAL FISTULA

DOC I HAVE A VESICOVAGINAL FISTULA

Vesicovaginal Fistula is a chronic granulous track which communicate between the bladder base and the vagina.

Vesicovaginal Fistula usually result from :
1.operation through the vagina causing a hole through vaginal wall to bladder wall

2.follows surgery for hysterectomy

3.Pressure necrosis on the vaginal and bladder walls during a
prolonged and difficult labor.

4.Radiation burns during treatment of cancer of cervix

5.untreated cancer of bladder or genital tract in women

6.Chronic illness such as tuberculosis of bladder or genital tract in women

7.Congenital fistula between bladder and vagina

A veiscovaginal fistula have a natural tendency to close by granulation and fibrosis.

Factors interfering with this are:

1.continual flow of urine

2.sepsis

3.persistance of causative factor such as malignancy or radiation necrosis.

However if the urinary stream can be diverted by a cathether and good bladder drainage and if the sepsis is treated, the natural decrease in size will occur.

Many small fistula of 1 cm diameter or less can be expected to close in 2 to 3 months

Symptoms:
1.incontinence

2.painful urination

3.frequent urination

4.vaginal discharge or wetness

5.painful vagina

Diagnosis:
1.Vaginal examination can show presence of fistula on the roof of vagina

2.Dye instilled into the bladder shows the dye leaking from the roof of vagina

3.Intravenous pyelogram also can show the contrast leaking into the vagina on X-ray.

Treatment of small fistula:
1.The urinary stream can be diverted by a cathether and good bladder drainage

2.The sepsis is treated with antibiotics
Without infection and the constant leakage of urine, the fistula will naturally decrease in size.

Many small fistula of 1 cm diameter or less can be expected to close in 2 to 3 months

3.If this does not happened, the fistula can be easily stitched up.

Treatment of larger fistula:
The vaginal skin is cut open bigger than the fistula for the fresh edges to be stitched.

The granulated hardened edges of the original fistula will not join together so easily as when fresh new tissues are cut and stitched together.

A catheter is left in the bladder to drain the urine and antibiotics are given to prevent infection.

Painkillers may be given if there is pain after the operation.

General treatment:
1.Treatment of associated diseases like diabetes,  carcinoma

2.Antibiotics - a full course of at least 2 weeks of antibiotics is needed

3.toilet and dressing of the wounds, with application of antibiotic creams

4.tub baths of the Vesicovaginal region several times a day in plain, warm water for about 10 minutes

Prognosis is good with surgery.
Rarely there may undesirable complication like urinary incontinence.

A Simple Guide to Encephalitis

A Simple Guide to Encephalitis
-----------------------------------

What is Encephalitis?
---------------------------

Encephalitis is a serious medical disease which causes inflammation and infection of the brain.

What are the causes of Encephalitis?
----------------------------------------

The causes of Encephalitis may be divided into:

Infections:
------------
1.viral infections are the most common
(herpes simplex virus, mumps, measles, rubella, chickenpox, West Nile Encephalitis, Japanese Encephalitis, St Lious Encephalitis).

Of these viruses, herpes simplex virus is the most serious and can cause fatality.

2.bacterial infections such as meningoccocus(Neisseria meningitidis) and pneumococcus(Streptococcus pneumoniae) can be serious and fatal in some cases.

Meningococcal Encephalitis can cause outbreaks(spread easily).

3.fungi,
Cryptococcus neoformans is the most common cause of fungal Encephalitis

4.Parasitic
Examples are Toxoplasmosis, malaria, amoeba, Lyme Disease

What are Signs and symptoms of Encephalitis?
---------------------------------------------

The symptoms which often defines Encephalitis are:

1.Severe headache

2.Fever

3.Irritabilty

4.Confusion

5.Drowsiness and fatigue

Other symptoms are:

6.seizures and convulsions

7.vomiting

8.hallucinations

9.memory problems

10.tremors

11.weakness of the hands and legs

12.incontinence of urinary and bowel movement

How is the diagnosis of Encephalitis made?
------------------------------------------

1.Typical symptoms of fever, headache, confusion .

2.Physical examination shows confusion ,drowsiness and signs of neck rigidity

3.blood tests (complete blood count, ESR and blood culture) 

4.cerebrospinal fluid analysis (CSF) via lumbar puncture is examined for increased white blood cells and protein content,  normal glucose level. Red blood cells may be present if there is bleeding. Sometimes the CSF may show the presence of micro-organisms.

This test should not be done if there is suspected cerebral mass lesion or raised intracranial pressure (head injury, localizing neurological signs, or signs of raised ICP).

5.CT or MRI of the brain and spine with MRI preferred over CT because it can detect more easily areas of cerebral edema,tumors, ischemia, and meningeal inflammation.

What are the complications of Encephalitis?
-----------------------------------------------

1.Neurological deficits

2.deafness

3.learning disorders in children

4.brain infarction,

5.septic shock,

6.adult respiratory distress syndrome 

7.seizures also more in children

8.pneumonia especially in the elderly

What is the treatment of Encephalitis?
------------------------------------

1.Hospitalisation should be immediate as Encephalitis is an life threatening condition.

2.Antibiotics such as cephalosporin, ampicillin, chloramphenicol, intravenous vancomycin to be started even before doing lumbar puncture.

Acyclovir may be given for herpes virus infection

High dosages of antifungals may be given for Fungal Encephalitis for a prolonged period of time

3.corticosteroids is useful to reduce swelling and inflammation in the brain

4.Sedatives may be needed for irritabilty and restlessness

5.High-flow oxygen

6.intravenous fluids

What is the prognosis of Encephalitis?
------------------------------------------

This depends on the severity and type of infection.

Viral infections except for herpes simplex usually recover quickly.

Bacterial infections such as meningococcus and pneumonia are more dangerous.

What are the Preventive measures taken for Encephalitis?
--------------------------------------------------------

Vaccinations against Haemophilus influenzae in children and adults has reduced the incidence of this form of meningitis and encephalitis.

Mumps vaccination as part of Measles,mumps and rubella vaccine(MMR) has reduced the incidence of mumps related form of meningitis and encephalitis

A Family Doctor's Tale -UTERINE PROLAPSE

DOC I HAVE UTERINE PROLAPSE

Uterine prolapse occurs when the ligaments and muscles holding the uterus in place has weakened to allow it to drop out of the vagina especially in a squatting position.

Causes of Uterine Prolapse:

1.Pregnancy and childbirth  -the physical trauma of  child birth can strain the pelvic muscles and ligaments to the extent that they are not as strong as before childbirth

2.large fibroids or pelvic tumors can cause pressure on the pelvic muscles downward by gravity

3.age  and menopause can weaken the pelvic muscles and the elasticity of the ligaments

4.Heavy lifting as in manual work can also strain and damage pelvic muscles

5.overweight women are more prone to prolapse

6.Pelvic or spinal surgery may damage nerves and  pelvic muscles increasing the risk of prolapse.

7.Genetic conditions or muscle dystrophy conditions may be responsible for weak muscles

8.Chronic coughing from smoking or the straining due to  constipation, increases the risk of prolapse

Symptoms and signs of uterine prolapse are:

1.Heaviness or protrusion out of the vagina

2.Some thing dropping out of the vaginal area

3.Discomfort or pain in pelvis, abdomen or back

4.Vaginal discharge is excessive or unusual

5.Frequency of urination or urine infection

6.Loss of control of urination(incontinence)

Symptoms may be worse in the evening after prolonged standing or walking

Signs of Uterine prolapse are:

1.Physical examination may show a protrusion of the uterus on squatting.

2.Vaginal examination show the degree of uterine prolapse especially in the standing position:

Stage I   Descent of the uterus to any point in the vagina above the level of the hymen

Stage II Descent to the level of the hymen

Stage III - Descent beyond the hymen

Stage IV - Total prolapse

3.Ultrasound of the pelvis may exclude other conditions than uterine prolapse

Treatment of Uterine Prolapse :

Conservative usually for mild cases of uterine prolapse:

1.Kegel exercises help to strengthen the pelvic floor muscles.

The patient is asked  to tighten the pelvic muscles by tightening the anus for a few seconds and then release many times a day.

2.Vaginal pessary is a rubber or plastic device which is placed around or under the cervix to  support the uterus and hold it in position.

Regular removal and cleaning is important to prevent infection.

It is a temporary measure.

Surgery:

This is the more permanent method of treatment.

1.Colpocleisis involves the removal of a part of anterior and posterior vaginal wall and closing of the margins of the two walls resulting in a small vaginal canal.

The uterus is thus unable to drop out of the smaller vaginal canal.

Success is 90-100%.

2.Sacrospinous fixation is a procedure where the uterosacral ligaments bilaterally is  sutured to the sacrospinous ligaments preventing the prolapse.

3.Sacrohysteropexy make use of a strip of synthetic mesh to hold the uterus in place in an operation done through a 15-cm incision or laparoscopy. One end of the mesh is attached to the cervix and top of the vagina and the other to the sacrum thus supporting the uterus.

4.Vaginal hysterectomy -the uterus is removed through the vagina and the uterosacral and cardinal ligaments are sutured together.

5.Abdominal hysterectomy is done when there is pelvic inflammatory disease or previous intra-abdominal operation when a vaginal hysterectomy is not advisable. The uterus is removed followed by a vaginal anterior and posterior colporrhaphy.

Prognosis of uterine prolapse indicates the treatment in most cases will relieve the symptoms and discomfort.

Prevention of uterine prolapse :

1.Avoid constipation by taking a healthy diet

2.Pelvic muscle exercise (Kegel exercises) should be done regularly

3.Avoid straing of pelvic muscle by using correct lifting techniques

4.Avoid smoking to prevent a chronic cough

A Family Doctor's Tale -ATROPHIC VAGINITIS

DOC I HAVE ATROPHIC VAGINITIS

Vaginal atrophy is the thinning of the vaginal wall of a woman appearing during or after menopause (the end of menstrual cycles).

Menopause in women usually occur between the age of 45 - 55 years old.

The cause of atrophic vaginitis is the decline of estrogens level in the female as she reaches menopause.

The loss of estrogen cause the lining of the vagina to become thinner and dryer.

Symptoms and signs of Atrophic Vaginitis are:

1.Irritation and itchiness from the dryness of the vaginal wall

2.Pain on sexual intercourse ( dyspareunia) as result of the dryness and lack of lubrication

3.Atrophic urethritis (inflammation of the opening of the bladder) -there is discomfort and frequent passing of urine with resultant urinary tract infections

4.Other menopausal symptoms such as hot flushes and night sweats, mood changes and tiredness

5. The vaginal mucosa is dry thin and shiny and bleeds easily.

The vagina is thus prone to infections.

The Pap smear show presence of small blue staining basal and parabasal cells in the mucosa of the vagina and cervix

The treatment of Atrophic Vaginitis is:

If the patient do not show any discomfort from the dryness and thinning of the vaginal wall , no treatment is necessary.

In Patients with symptoms, treatment involves:

1.Oestrogens  is an effective treatment for vaginal atrophy -reducing dryness and discomfort but must be used with precaution as it can cause stroke and thrombosis and endometrial cancer of the uterus.

It can prevent osteoporosis if taken early enough.

It however do not cause breast cancer or heart disease.

Estrogens can be given in the form of oral pills and skin implants.

2.Combined estrogen and progesterone therapy also reduce the effect of menopause such as vaginal atrophy, dryness of the internal lining of the genital tract and the skin and hot flushes.

It has been found that there is an increased risk of heart attack, cancer of the breast , thrombosis, and stroke.

Because of all these risks,  female hormone replacement therapy has fallen out of favor.

Instead of chemical hormones , natural plant female hormones such as primrose, soy, etc are used instead to reduce the symptoms of menopause.

3.Topical estrogen cream can be applied to the lining of the vagina once a week to reduce the dryness and discomfort in the vaginal wall.

4. Other moisturizer such as KY Vaginal moisturizer can also be used to reduce the dryness in atrophic vaginitis.

Prognosis of Atrophic Vaginitis is good if precautions are taken to prevent the dangerous side effects of female hormonal treatment.

 

A Family Doctor's Tale - BARTHOLIN CYST

DOC I HAVE  A BARTHOLIN CYST

Bartholin cyst is an acute cystic inflammation of the Bartholin gland at the vulva region in females.

Bartholin Gland lies behind the bulb of the vestibule which is the erectile tissue of the female.

When stimulated the bartholin gland which is covered by the erectile tissue(the bulb of the vestibule) will produce a mucoid discharge through a 2 cm duct opening in the vaginal orifice lateral to the hymen.

This mucoid discharge act as a lubricant during the sexual act.

Bartholin cyst occurs when the duct is blocked and forms a painless cyst occurring in the lower half of the vulval wall.

Normally only 1 bartholin gland is affected, rarely two at the same time.

If infection is present an acute abscess results.

Bartholin cyst and abscess can be usually caused by the following:

1.when the duct of the Bartholin gland is blocked by dirt or dead cell or injury.

The fluid which is produced by the gland then cause the gland to swell and forms a painless cyst occurring in the lower half of the vulval wall.

2.A Bartholin abscess occurs when a cyst becomes infected by a number of bacteria.

These bacterial organisms may be:

a.sexually transmitted diseases such as  gonorrhea and chlamydia

b.Escherichia coli and other bacteria normally found in the intestinal tract

Many of these abscesses may be infected by more than one micro-organism.

Symptoms of Bartholin cyst or abscess are:
1.swelling of the labia on one side, near the entrance to the vagina.

2.significant pain may indicate an abscess has formed.
Large cysts can be painful because their size may press against the vulva wall and the nerves.

3.Bartholin's abscess forms a swollen area with extremely tender and reddened skin

4.Walking and sitting may be very painful because of the swollen tender abscess may rub against the opposite vulva wall.

5.Vaginal discharge  is present  especially if the infection is caused by a sexually transmitted organism.

Diagnosis of Bartholin's cyst or abscess is usually made by:

1.physical examination :

a. presence of a lump at the lower part of the vulva wall
The vulva may  show inflammation and excoriation of lining

b.A painful swollen and red lump suggests that an abscess has formed.

2..Vulva and vaginal swab to culture for bacteria and sexually transmitted organisms and the antibiotic most appropriate for it.

3. biopsy of the suspicious vulva swelling to exclude other causes of vulva problem such as tumor

Treatment of Bartholin cyst or abscess involves the following:

1.Small Bartholin's cyst

sitz baths

2.Recurrent cysts or painful abscesss

antibiotics and sitz baths
Approprate Antibiotics is given  for infections especially after the results of the bacterial culture

3.Bartholin's abscesses and cysts that are large and painful

a.Incision and drainage of the abscess which is pus enclosed within an enclosed space.

Since antibiotics cannot adequately enter the enclosed space, incision of the enclosed bag of pus under local anesthetic followed by drainage of a Bartholin's abscess must be done .

After the infected material is drained, the abscess cavity is packed
with gauze keeping the cavity open and promotes further drainage.

Antibiotics and painkillers can be given to relieve the pain after the anesthetic wears off.


The gauze packing is removed after 24 hours.

b.Another surgery called marsupialization can be carried out for recurrent Bartholin cyst or abscess.

After cutting into the cyst wall, drainage of the fluid from the cyst is done.

Then the lining of the cyst wall is sutured to the overlying skin in such a way as to create a permanent hole which acts as a drain site.

This operation usually prevents recurrence of the cyst.

Prognosis of Bartholin cyst:

Prognosis is usually good with medical treatment and surgery.
Most patients  have relief after the 24 hours of drainage.

Prevention of Bartholin cyst:
1.Proper hygience after urination, sexual intercourse and bathing

2.Use of lubricants during sexual intercourse

3.Prompt treatment with sitz baths can prevent the formation of an abscess.

4.Safe sex practices with a single partner can decrease the spread of sexually transmitted diseases

A Family Doctor's Tale - POLYCYSTIC OVARIAN SYNDROME

DOC I HAVE POLYCYSTIC OVARIAN SYNDROME

Polycystic ovarian syndrome (PCOS) is a hormonal disease that causes women to have a combination of symptoms:

1.Oligomenorrhea -less menses than before

2.Obesity

3.Hirsutism -skin is more hairy

4.Infertility

Most women with PCOS have some small cysts in the ovaries hence the name Polycystic ovarian syndrome.

However cysts in the ovaries can be caused by a number of other illness than PCOS.

It is the characteristic  symptoms rather than the presence of the cysts that is important in the the diagnosis of PCOS.

PCOS occurs in 5% to 10% of women and is present in all races.

It is the main cause of infertility in women.

Symptoms of polycystic ovarian syndrome are:

1.menstrual disturbances  -

a.fewer than normal menstrual periods (oligomenorrhea),

b.the absence of menstruation for more than three months (secondary amenorrhea)

c.heavy bleeding (menorrhagia).

2.excess hair growth on the body (hirsutism),

3.obesity -excess weight gain,

4.infertility - due to  irregular or no release of eggs from the ovaries

5.multiple, small cysts in the ovaries.

Other symptoms are:

1.skin discolorations,

2.high cholesterol levels,

3.elevated blood pressure

4.raised insulin levels

5.raised androgen levels

6.oily skin,

7.dandruff,

The causes of polycystic ovarian syndrome (PCOS) are unknown but could be due to :
1.Genetic - Women with PCOS often have a mother or sister with the condition,

2. environmental factors:

a.exposure to male hormones

b chronic inflammation of the body from childhood illnesses

The diagnosis of PCOS is based on:

1.clinical signs and symptoms as  above

2.Serum male hormones (DHEA and testosterone) are usually raised

3.Blood luteining hormone which is secreted by the pituitary gland in the brain is usually raised

4.Ultrasound can also detect cysts in the ovaries

5.CT scan and MRI  detect cysts but are used mainly to exclude ovarian or adrenal gland tumors

The complications associated with PCOS are:
1. high blood pressure

2.diabetes

3.heart disease

4.cancer of the uterus (endometrial cancer).

5.infertility

6. abnormal levels of LDL ("bad") cholesterol and blood triglycerides

Treatment of PCOS is as follows:

1. Oral contraceptic pill with low androgenic (male hormone) side effects can help to  regulate menses and reduce the risk of cancer of the uterus

2.Oral Progesterone treatment used intermitently can induce regular menses

3.spironolactone (Aldactone)  can reduce water retention and acne

4. clomiphene (Clomid) can be given to infertile women with PCOS to induce ovulation (cause egg production)

5.Metformin used to treat type 2 diabetes reduce the action of insulin and reduce the symptoms and complications of PCOS such as irregular periods, ovulation induction, weight loss, prevention of type 2 diabetes

6.gonadotropin hormones injection can help women who wish to have babies and do not want to be on Clomid treatment which cause multiple pregnancies

7.weight loss in obese females with PCOS can cause menstrual cycles to be normal and increases the possibility of pregnancy.

Weight loss can help reduce or prevent the complications associated with PCOS, including diabetes and heart disease.

8. ovarian drilling (some ovarian tissue is removed bypassing an electric current through a needle inserted into the ovary)can  induce ovulation in women who are not responding  to other treatments

Prognosis is good for patient to regulate menses but not so good for infertility.

A Family Doctor's Tale - MISCARRIAGE

DOC I HAVE A MISCARRIAGE

Miscarriage or spontaneous abortion is defined as the premature expulsion of contents from a pregnant uterus.

About 10-15 per cent of all pregnancies ends in spontaneous abortion.

Spontaneous abortion is most likely to occur between the 6th and 10th week of pregnancy.

Causes of miscarriage:
1.Fetus development:
most common cause is the fetus is unable to develop a heart or brain to sustain living and hence dies on its own with fetus remnants being expelled from the womb

2.Hormonal
low progesterone secretion prevents the the placenta to attach securely to the wall of the womb and hence the the detached fetus is expelled from the womb

3.Iatrogenic:
attempts by pregnant mothers to induce an abortion by taking poisons, ergometrine, hormones, chinese medicines may sometimes be successful

4.Maternal factors:
In later pregnancies, maternal factors like acute illness, hypertension, endocrine disease like diabetes, uterine abnormalities may play a part in spontaneous abortion

Signs and Symptoms:

1.Threatened Abortion:

vaginal bleeding occurs during the first 28 weeks of pregnancy, starting from the uterus with uterine contractions and without dilatation of the cervical os.

2. Inevitable Abortion:

miscarriage is inevitable if uterine contractions are strong and the cervical os is open.

3.Complete Abortion:

This occurs when the products of conception are passed out through the vagina.

It is incomplete abortion if the miscarriage is partial.

4.Missed Abortion:

This happened when the dead embryo and placenta are not passed spontaneously.

If there is incomplete abortion there is a danger of septic abortion.

5.Septic Abortion:

There is fever, rapid heart beat, foul smelling vaginal discharge, tender uterus and leucocytosis  , all symptoms of septicemia.

The cause is usually E. coli or clostridium bacteria.

Habitual abortion :

This occurs when the uterus has cervical incompetance or is bicornuate


Investigations and diagnosis of abortion need to be confirmed by :

1. Vaginal examination

2.Ultrasound scan of the uterus

3. Blood human placenta lactogen and human choriongenic hormones should be helpful to determine the strength of the pregnancy

4.High vaginal swab is important to determine cause of infection

5.Dilation and curretage of missed abortion

Treatment of Miscarriage:

1. Threatened abortion :

Bed rest is very important


Avoid sexual intercourse

2. Incomplete Abortion:

Treatment of shock

Dilation and currettage of the uterus

3.Septic Abortion:

Appropriate antibiotics should be given

4.Missed Abortion:

Dilatation and currettage

5.Habitual Abortion:

a suture should be sewn around the cervical os to tighten the opening and prevent the embryo sac to slip through the os .

A Family Doctor's Tale -G6PD DEFICIENCY

DOC I HAVE G6PD DEFICIENCY

G6PD Deficiency  is an inherited disorder of the Red blood cells which has a lack of the glucose-6-phosphate dehydrogenase enzyme.

This causes the red blood cells to burst (hemolysis) in certain circumstances when certain food, herbs or medicines are taken.

It is a lifelong disease and there is no cure for it.

10 per cent of the world population is believed to have it.


It is  more common in Asians and Africans, less so in Caucasians.

There are 2 types of G6PD Deficiency:
1.G6PD Deficiency major which is a serious illness which occurs as a sex linked genetic disease affecting the males.

2.G6PD Deficiency minor occurs in the females and can also cause red blood cells break up as in the the major form of the disease.

Here the female can pass the gene to the male child(resulting in the major illness) and the female child(resulting in the female child as the carrier of the gene).

Not all mothers with the gene will pass it to the son or daughter.

The  risk of G6PD Deficiency is:
G6PD Deficiency results from a defective gene which provides for the enzyme in the red blood cell which preserve the integrity of the red blood cell.

When the child takes certain food, herbs or chemicals, the absence of the enzyme cause the red blood cell to burst resulting in hemolytic anemia, release of bilirubin and passing of blood through the urine.

If both parents has this faulty gene then the male child will have G6PD Deficiency major and the female child may have the minor illness which allows her to pass the gene to her son.

If the female parent has the faulty gene then the child may have the gene passed to him or her.

If only male parent has the faulty gene then the child will not have the gene passed to him or her.

The red blood cells are normal sized and breaking up easily under certain circumstances to cause a severe anemia.

Triggers which can cause an attack of red blood cells breakup (hemolysis) in G6PD Deficiency are:
1. Certain food - fava beans (also known as broad beans)


2. Chinese herbs especially Huang Lian

3. Medicines
a. Sulphonamides, septrin

b. Antimalaria drugs such as chloroquine, quinine,

c.analgesics such as aspirin,

d.Non-sulphonamide antibiotic such as nalidixic acid, nitrofurantoin, isoniazide, dapsone

4.naphthalene or moth balls

5.some bacterial or viral infections


The symptoms of hemolysis in G6PD Deficiency are:
1.Anemia - pale

2.blood in the urine

3.vomiting

4.abdominal pain

5.Slight jaundice

6.rapid heart beats , lethargy and symptoms of shock


Diagnosis of G6PD Deficiency is often based on
1. blood test for G6PD deficiency - rapid fluorescent spot test detecting the generation of NADPH from NADP

2. microscopic examination of red blood cells(Heinz bodies can be seen in G6PD deficient patients red blood cells)


3. Genetic analysis

The complications of hemolysis in G6PD Deficiency are:

1. Anemia

2. damage to liver

3. shock and death

The treatment of hemolysis in G6PD Deficiency is:
1.Blood transfusion

2.treatment for shock

3.Folic acid to build up the blood


The prognosis of hemolysis in G6PD Deficiency is:

Prognosis is good if treatment is early.

The patient must take care of himself or herself and remembers what are the food, medicines or herbs he cannot take.

Prevention of G6PD Deficiency is by:
1.testing cord blood for G6pd deficiency at birth


2.patient education of his condition and avoidance of certain food or medicines.

A Family Doctor's Tale -EDEMA

DOC I HAVE EDEMA
Edema is a symptom defined as excess of fluid (water and sodium) in extracellular spaces that include a large number of medical conditions.

It usually in the ankle and foot but can spread up the legs to the abdomen where the excessive fluid is known as ascites.

The abdomen will appear bloated.

It can also spread to the lungs causing pulmonary edema and breathlessness.

Of course edema of the face will cause puffiness of the face .

Generalized edema is called anasarca.

The Causes of Edema are:

1.Cardiac edema from right or left heart failure

2.Renal edema from renal failure or nephrotic syndrome


3.Hepatic edema from liver failure or cirrhosis

4.endocrine edema from cushing  syndrome or use of  steroids

5.malnutrition syndrome - lack of protein leads to edema

6.Pregnancy pressure on the lower limbs blood vessels

7.Standing too long resulting in gravity pulling fluid to the feet and ankles

8.local edema from obstruction such as

a.venous obstruction - varicose veins,

b.lymphatic obstruction from filaria or other parasites

c. tight garments

d.local injuries,

e.carcinomatous obstruction

The Signs and Symptoms of Edema are:
Symptoms:

1.The skin of the lower legs may be swollen, stretched and shiny.

2.Gentle pressure on the swollen skin will cause a depression in the swollen area.

3.Abdomen may be swollen or distended due to accumulation of fluid

4.Crepitation can be heard at the bases of the lungs suggesting fluid in the lower prt of the lungs

5. The face may be swollen and puffy

The Complications of edema are :


1.overload of fluid in the body leading to overload on the heart

2.too much fluid in the lungs can cause breathlessness

3.renal failure can be dangerous and may need dialysis

4.Liver failure is also dangerous and may require a liver transplant

The Treatment of Edema is usually by:
1.Medicines like diuretics can force the fluid out through the urine.

The diuretic should be cautiously used in renal cases.


2.Treat the underlying cause whether it is heart , kidney or liver failure.

3.Careful institution of high protein feedings in malnutrition cases

4.surgery may be required  to remove obstruction

5.chemotherapy may also be required in carcinomatous obstruction

General Measures:
1.No strenuous exertion

2.Avoid stress

3.Any breathlessness must be treated quickly


4.Reduce the salt intake

5.Raise the legs when sitting down or lying down

6.Do not stand for long periods

Prognosis of edema:

Mild edema due to excess salts or medicines can be treated easily by reducing the salt or medicine.

Underlying diseases like heart failure, renal failure or liver failure may need specific medication, treatment and may not be completely cured.

Prevention of edema is by:

1.avoid too much salt

2.avoid standing or sitting for too long a period

3.Pregnancy can cause edema of the legs due to pressure of the fetus on the major veins of the legs - avoid over exertion and salty food

A Family Doctor's Tale - CARDIOGENIC SHOCK

DOC I HAVE CARDIOGENIC SHOCK
Cardiogenic shock occurs when there is a sudden reduction of cardiac muscle contractibity and blood output from the heart following myocardial infarction or heart attack.

Cardiogenic shock can lead to sudden death.

Cardiogenic shock occurs when
1.Heart attack -there is a sudden interference with the pumping action of the heart from ischemic heart muscle damage ofeten involving 50 per cent of the left ventricle.

2.Injury to the heart muscle from trauma such as knife wounds,direct impact of heavy object on the heart.

3.Drug overdosage such as beta blockers or calcium antagonist affecting the slowing of heart and poor output of blood.

The symptoms of Cardiogenic shock are :
1.Pale, sweaty patient with rapid weak pulse

2.Severe hypotension

3.Urinary output reduced

4.Breathlessness and pulmonary edema

5.Fatique and tiredness

6.Confusion,dizziness,

Diagnosis of Cardiogenic shock is usually confirmed by:
1.History of chest pain, shock and physical examination showing low blood pressure

2.ECG(electrocardiogram)shows typical features of large depression in Q wave, ST segment and raised RS segment. A 12 leads ECG may showed the presence of severe myocardial infarct

3. Blood cardiac enzymes and ESR may be raised.

Any cardiogenic shock is an EMERGENCY!
Immediate treatment is urgent!
Admit to hospital as an emergency.

Severe cases are admitted to Cornary care unit(CCU) for constant monitoring of the heart, blood pressure and abnormal rhythm of heart rate.

Intravenous fluids such as glucose should be given on admission together with insulin to help raise the blood pressure.

Blood pressure can be further raised with dopamine or dobutamine.

Vasodilators like isorbide are give to help dilate the artery to the heart

Diuretics may be necessary to relieve congestion of the lungs and edema.

Any abnormal rhythm of the heart must also be treated with medications or pacemaker if severe as damage to heart may affect the conduction of the electrical impulse of the heart to the cardiac muscles.

Because of the psychological effect of a heart attack on the patient, sometimes antidepressant or tranquilliser may be given.

Interventional Procedures:
--------------------------
Once stable the patient may be requred to have a ballooning of the narrowed artery or a stent inserted in the narrowed artery. This can be done during the cardiac catheterisation.
1.balloon angioplasty
balloon is inflated to compress fatty matter in the wall of narrowed artery and dilate the blood vessel
2.Stent:
balloon angioplasty is performed in combination with placement of a stent which is a small, metal mesh tube that provide support inside the coronary artery.
3.drug eluting stents (DES):
Drug-eluting stents contain a medication that is actively released at the stent implantation site to prevent recurrence of narrowing of the artery
4.rotablation
The Rotoblation special catheter, with an acorn-shaped, diamond-coated tip,  spins around at a high speed and grinds away the heavily calcified  plaque on the arterial walls.
5.cutting balloon
The cutting balloon catheter has a balloon tip with small blades which are activated  when the ballon is inflated. The small blades remove the plaque and the balloon compresses the fatty matter into the arterial wall.

Surgery :
-------------
If the narrowing involved too many arteries, then a coronary artery bypass graft (CABG) surgery will have to be done.

Usually a heart attack patient stays in hospital for 2-4 weeks depending on the severity of his condition.

Mild exercise is started once his condition is stable. Exercise is good for the patient because it helps the blood circulation.


Prognosis of cardiogenic shock depends on the degree of ventricular recovery.

Treatment is aimed at maintaining circulation until some recovery takes place.

Overall prognosis is poor.

Prevention of a cardiogenic shock is the same as prevention of a heart attack  or a stroke as both involve the avoiding the blockage of a major artery to the brain or heart.

1.Control the Blood Pressure


2.Control the Diabetes


3..Control the diet.


4.Check with the doctor regularly.

5.Don't Smoke

6.Regular exercise is good for you.


7.Learn To Relax

8.Time management is important.

A Simple Guide to Tropical Sprue

A Simple Guide to Tropical Sprue

A Simple Guide to Tropical Sprue
————————————————–
What is Tropical Sprue?
—————————————
Tropical Sprue is a malabsoption disease of unknown etiology associated with temporary or permanent stay in the tropics and characterized by abnormalities in the lining of the small intestine.
The small bowel mucosa shows
1.villous atrophy
2.columnal to cuboidal changes in absorbing cells
3.infiltration of lamina propia with lymphocytes, plasma cells and eosinophils
Who is affected by Tropical Sprue? ———————————————————————————————-
Tropical Sprue cause is unknown but some possible causes are: 1.Nutritional deficiency
2.intestinal infection
There is a possibility of enzyme deficiency and abnormal immunological response.
Tropical Sprue can be found in all ages but are more common in the 10-30 years age group.
What are the Symptoms and signs of Tropical Sprue? ————————————————————————————-
Symptoms varies from mild to severe:
Early symptoms are:
1.fatigue
2.bulky stools
3.Weight loss despite good appetite and intake
After some months malnutrition is noted with evidence of malnutrition syndrome:
1.weight loss
2.glossitis
3.stomatitis
4.pigmentation
5.edema
5.diarrhea and steatorrhea
6.megaloblastic anemia
7.iron,folic acid and vitamin b12 deficiency
The Diagnosis of Tropical Sprue is confirmed by: ————————————————————————————
1.A history of abdominal pain , diarrhea and weight loss
2.small bowels radiology
a.thickening and coarsening of mucosal folds
b.dilatation of smaa intestinal lumen
c.flocculation and segmentation of barium
3.tests for malabsorption syndrome 4.fecal fat assessment
5.Jejunal biopsy
What are the complications of Tropical Sprue? ————————————————————————————-
1.weight loss
2.Nutrition: malabsorption and vitamin deficiency
What is the treatment of Tropical Sprue? —————————————————————————————————
Treatment is :
Control of Diet
1.Folic acid is given for at least 6 months
2.Vitamin B12 injection is given
3.food containing iron, folic acid and vitamin B12 are are given
4,Enough protein supplement
5.lots of fluids
Medication
1.Antispasmotic medication for abdominal pain
2.lomotil or imodium to suppress diarrhea
3.Tetracycline is given daily for at least 6 months
Start with high doses at first, followed by reduction of dosage.
4.Correction of anemia and nutritional deficiencies is important to enhance the immune system
What is the prognosis of Tropical Sprue? ———————————————————————————————-
The prognosis is usually very good Treatment is very effective in producing weight gain and correcting nutritional deficiency.
Abnomal morphology and bowel function may persist despite treatment
There may be spontaneous remission especially leaving the tropics.
What are preventive measures in Tropical Sprue? ————————————————————————–
A nutritious diet with vitamin supplements can strengthen the body resistance against illness.
Avoid the tropics.

A Family Doctor's Tale - THYROID NODULES

DOC I HAVE THYROID NODULES

Thyroid nodules are abnormal swellings in the thyroid gland which occurs when the thyroid tissues starts to proliferate in one part of the thyroid gland.

People who are at risk of thyroid nodule are:
1.Thyroid nodules are more common in females than in male.

2.However the thyroid nodule in males are more prone to malignancy than in females

3.Thyroid nodules occurs more in the 30- 60 age group.

The types of Thyroid Nodules are:
1.solid - solid thyroid nodules which may or not feel hard

2.cystic - the nodules is filled with fluid.

3.benign - non malignant

4.malignant - cancerous

Symptoms and signs of Thyroid Nodules:
In mild cases there is usually no obvious symptoms.

In moderate or severe cases of thyroid nodules:
Symptoms:
1.Obvious swelling in the thyroid gland

2.Neck swelling suggest presence of spread to the lymph node

3.Hoarseness of voice may occur if there is pressure on the vocal cord or recurrent nerve to vocal cord

4.Dyspnea or breathlessness if there is pressure on the trachea

5.Dysphagia or difficulty in swallowing due to pressure on the esophagus

Signs:

1.Thyroid nodules are felt only if they are more than 1.5 to 2cm in diameter.

2.Cystic nodules may feel hard while solid nodules may be soft to firm.

3. The vocal cords should always be examined to exclude lesions in the vocal cords causing hoarseness.

4.Malignant thyroid nodules present similarly to benign nodules but can spread to other parts of the body.

Diagnosis of Thyroid Nodules are made by:
1.blood test for thyroxine and TSH levels

2.fine needle aspiration biopsy is a simple way to determine if a nodule is benign or malignant.

The biopsied material is then sent to the lab for tests to look for any malignant cells.

3.ultrasound scans are done to differentiate between solid and cystic nodules,

4.thyroid scans which help to show if a nodule is producing excessive thyroid hormone(hot) or not.

5.CT Scan or MRI are not routine to thyroid nodules investigation except where there is suspected compression of teachea.

The Treatment of Thyroid Nodules is:
Benign lumps can be monitored by doctors at regular intervals.

If there are symptoms of compressing a neighbouring organ or the nodule is cancerous, surgery is required.

Patients who has symptoms of hyperthyroidism are advised to go for radioactive iodine treatment or surgery.

The Prognosis of Thyroid Nodules:
Prognosis is good in all benign cases.

Malignant thyroid nodules will depend on any spread to other organs.

A Family Doctor's Tale - URTICARIA

DOC I HAVE URTICARIA

Urticaria is an itchy rash that occurs rapidly anywhere on the body.

The rash may occur often simultaneously at multiple sites.

It is usually temporary disappearing after 24 hours although new rashes may occur at other sites.

Urticaria is usually due to known mast cell stimulants although in the majority of cases the cause is unknown.

Urticaria is not contagious and for most patients the condition may be managed well with treatment and avoidance of mast cell stimulants:

1. Certain foods: eggs, nuts, fruits,shellfish, fish, chocolates

2. Certain drugs: antibiotics, NSAIDs

3. Physical stimulants: pressure, sweating, cold temperature, sunlight

4. Infections: viral, bacteria

5. Others: flowers, pollen, beestings, animal furs, soaps

The symptoms and signs of Urticaria are:
1.The rash is typically itchy and appear rapidly as localised red swelling on the skin measuring a few mm to more than 10 cm in size in different shapes.

2.The swelling can also occur on eyelids, lips, palms and soles.

3.Urticaria is usually harmless and disappear within a few days or week.

4.However because it can involve very extensive areas of the body, it can cause a lot of irritation and a lot of anxiety.

5.Very rarely the urticaria can lasts months to years causing disruption to work and social life.

In people with Urticaria, the mast cell stimulant can cause histamine release from mast cells.

The histamine is the predominant chemical which is responsible for the inflammatory response which leads to changes of the blood vessels of the skin.

This leads to more blood flow to the affected skin and excessive fluid moving into the surrounding tissues , causing itching and swelling.

Treatment of  Urticaria:
1.One of the most important part of treatment is to to try to identify the substance or underlying medical condtion which may cause the Urticaria.

2.Avoidance of the causative substance or treatment of the underlying medical conditions such as infections will lead to the resolution of the urticaria.

3.One of the most important components of an Urticaria treatment routine is to prevent scratching.

4.Cold compresses applied directly to itchy skin can also help relieve itching.

5.Antihistamine tablets will usually relieve the itch and suppress the eruption of the rash.

The antihistamine need to be taken regularly for long as the urticaria is active.

6.If the condition persists, worsens, or does not improve satisfactorily, another effective treatment is the application of nonprescription corticosteroid creams and ointments to reduce itch.

7.Corticosteroid tablets may be prescribed if necessary.

Prevention of Urticaria is by:
1.Find the causative agent and avoid it.

2.Avoid sudden changes in temperature or humidity

3.Avoid sweating or overheating

4.Avoid certain foods (e.g.,eggs, nuts, seafood, chocolates)

5.Avoid harsh soaps, detergents, and solvents

6.Avoid environmental factors that trigger allergies (e.g., pollens, molds, mites, and animal dander)

A Family Doctor's Tale - INTUSSUSCEPTION

DOC I HAVE INTUSSUSCEPTION

Intussusception is the telescoping of one part of the intestine into the distal(lower) part of the intestine.

Intussusception is most common in children between 3 months and 1 years of age.

Boys are affected 2 times more than girls.

It seldom occurs in children under 3 months of age or in older children.

It rarely occurs in adults.

The process of  intussusception involves a part of intestine (called the intussusceptum) telescopes into a more distal part (called the intussuscipiens) and pulls the accompanying mesentery, vessels, and nerves together into the intussuscipiens.


As a result the compression of the veins and swelling of the region results in blockage of the lumen of the intestine and reduce the blood flow to the affected part of the intestine.

Most cases affect the junction where the small intestine meets the large intestine.

Intussusception because of its obstruction effect on the intestine requires urgent attention and treatment.

The causes of of intussusception are not fully known although some viral and bacterial infections of the intestine may be a possible cause.

In older children and adults possible causes of intussusception may be due to polyps or tumors.

Typical Symptoms of intussusception are:
1.abdominal pain or cramps often with the baby drawing up its knees
when crying

2.vomiting episodes together with the abdominal pain.

The vomiting is not associated with food and may be  like bile in
color(yellow-green).

3.bloody and mucous stool(also called black currant jelly stools)may be present

Others symptoms are:
1.paleness,
2.lethargy,
3.fever
4.shock

Intussusception is diagnosed by:
1.history of abdominal pain, vomiting and black currant stools may suggest the diagnosis of intussusception.

2.On examination  an abdominal "sausage-shaped" mass (the intussusception itself) can sometimes be felt on palpation of the abdomen.
Diminished bowel sounds may suggest obstruction.

3.abdominal X-rays can show signs of an intestinal obstruction, with air-fluid levels, decreased gas, and unexplained masses, usually seen in the right lower region of the abdomen.

4.Ultrasound and CT scans are not necessary to make the diagnosis.

Early diagnosis and treatment of intussusception is essential in
order to prevent complications such as :
1.injury to the intestine from blockage


2.perforation of the  bowel,

3.sepsis

4.death.

The treatment of intussusception may not require surgery.

1.In some cases, the intestinal obstruction can be reversed using a barium enema.

The barium liquid enters the large intestine and pushes its way up to the small intestine. The pressure of the flow of the enema may push the telescoped small intestine out of its receptor and reverse the process of telescoping.


There is a risk of intestinal rupture.

2.If the above procedure is unsuccessful, surgery is necessary to reverse the intussusception and relieve the obstruction.

Any part of the intestine which has become gangrenous must be removed.

Intravenous feeding and fluids after surgery are continued until normal bowel movements returns.

The prognosis for intussusception is usually good with early diagnosis and treatment.

A Family Doctor's Tale - BED SORES

DOC I HAVE BEDSORES

A bed sores is skin which is damaged most commonly by
ischemic necrosis(lack of blood supply leading to breakdown of tissue cells) and ulceration of tissues overlying a bony prominence that has been subjected to prolonged pressure against an external object.

This typically occurs in a incapacitated person lying over a prolonged periods in bed hence the term bed sores.

Blood supply is impaired as a result of constant pressure on the blood vessel resulting in localized gangrene(death of tissue due to lack of blood supply)

The following are considered when determining the severity of the bed sores:

1.Degree of bed sores
2.Extent of the bed sores
3.Age of patient
4.Location of bed sores
5.Other illnesses and injuries

There are 6 stages of a bed sores:

First stage bed sores:
superficial redness of the skin

Second stage bed sores:
The skin is red, hot, swollen with induration. blister formation and desquamation(dropping of skin layer).
There may be some pain

Third stage bed sores:
The full thickness of the skin is damaged with ulceration.

Fouth stage bed sores:
The skin damage extends to the muscle often causing pain because of impingement on the nerve

Fifth stage bed sores:
The necrosis of skin tissue affects the muscles and fat tissue

Sixth stage bed sores:
There is associated bone destruction , bone or joint infection and septicemia(infection of the blood)

Illnesses such as those below can aggravate the severity of the bed soress and affect the healing:
1.Respiratory diseases
2.Diabetes
3.Heart disease
4.Injuries like fractures

Complications of bed sores are:
1.Septicemia or blood infection

2.Cellulitis or abscess formation

Treatment of bed sores:
In the early stage such as redness of the skin, prevention is the best treatment:
1.Encourage regular movement of the body every 2 hours

2.In cases of paralyzed or unconscious patients change position of the patients every 2 hours.

3.apply talcum powder or  soothing cream or lotion on the skin

4.Try not to break a blister. If a blister is already broken, apply an antiseptic lotion.

5.Painkillers may be necessary for pain.

6.Regular inspection of the skin for cleanliness and dryness.

7. Use of water beds, ripple mattress, inflatable rings, protective padding and Stryker frame for those with spinal cord paralysis all help to prevent bed sores.

More severe cases may need to be treated in a hospital:
1.the bed sores  gets infected(fever, pus formation and increasing pain, redness and swelling).

2.Appropriate antibiotics to treat infection

3.Hydrophilic beads of dextronomer may be useful to clean oozing lesions and promote granulation and recovery

4.Regular debridement(removal of infected tissues) with enzymatic digestive agents

5.In severe cases surgical debridement and skin grafts may be necessary.

6.Underlying medical illnesses such as diabetes, heart attack and stroke should be treated

Prognosis:
In early stage the prognosis is good with preventive measures.

Once ulcers are formed the prognosis is fair.