A Family Doctor's Tale -POSTMENOPAUSAL BLEEDING

DOC I HAVE POSTMENOPAUSAL BLEEDING

Postmenopausal bleeding is a symptom defined as heavy or prolonged occurring one year or more after menopause.

Bleeding can occur from any part of the genital tract.

Causes:
Physiological:
most common 25 per cent show no demonstrable cause
(dysfunctional uterine bleeding)

Iatrogenic:
estrogen replacement therapy

Vulva:
infection
atrophy
granulomatous lesions
carcinoma

Vagina:
atrophy
infection
carcinoma

Cervix:
polyp
carcinoma

Uterus:
polyp
carcinoma
myomas

Others:
tubal or ovarian carcinoma
pelvic inflammatory disease
endometriosis

Diagnosis:
History:
Menstrual history:
cycle length, number of bleeding days, degree of blood loss(number of pads used per day), presence of blood clots, dysmenorrhea (painful Menstruation)


Symptoms suggesting underlying pathology:
Metabolic disorders:
symptoms of hypothyroidism

Bleeding disorders:
easy bruising
anticoagulants

Pelvic inflammatory Disease:
pelvic pain especially during intercourse
vaginal discharge
dysmenorrhea

Endometriosis:
pelvic pain
dysmenorrhea

Medication:
use of post menopausal estrogen

Physical Examination:
Signs of underlying diseases:
infection of vulva and cervix
hypothyroid features
pallour(anaemia)

Abdominal examination:
palpable uterine or ovarian masses

Pelvic examination:
vulval and vaginal examination
bimanual palpation for masses
cervical smear

Investigation:
Full blood count including hemoglobin(to exclude anemia from loss of blood) and platelets(low platelets can cause bleeding)
Transvaginal ultrasound to exclude uterine fibroids and polyps -postmenstrual scans is best when the endometrium is at its thinest.
Endometrial hysteroscopy and biopsy in women
Laparoscopy if required

Treatment:
Medications:
1.Tranexamic acid- oral antifibrinolytic, given only when there is heavy bleeding

2.oral estrogen - prevent proliferation of the endometrium, reduces blood flow. Should be given for 21 days only to assess its effect on menstrual bleeding

3. Injected progesterone -also prevent proliferation of the endometrium, induce uterine atrophy and stop menstruation

4. Levonorgestrel-releasing intrauterine system(LNG-IUS)
-also prevent proliferation of the endometrium

5.Application of estrogen cream for atrophic vulvitis and vaginitis

6.treatment of underlying causes such as bleeding causes, low platelets, hypothyroidism, and cancers

7.treat any anemia caused by post menopausal bleeding

Surgery
1.Endometrial ablation
may be done only if medications has failed

Usually involve the removal of the endometrium through the cervical opening.


There are various forms of endometrial ablation:
First generation:
hysteroscopy with general anaesthesia
-Rollerball ablation
-Transcervical resection of the endometrium

Second Generation:
non-hysteroscopy, no general anaethesia, day surgery,fast recovery
-Impedance-controlled bipolar radiofrequency ablation
-balloon thermal ablation
-microwave ablation
-free fluid thermal ablation

2. Hysterectomy
used only as a last resort in treatment of Postmenopausal bleeding
if other treatment are contraindicated
there is a desire for amenorrhea
there is no desire to retain uterus

Treatment of Underlying causes:
hypothyroidism with thyroxine tablets
reduce anticoagulant treatment if possible
treat any bleeding disease with platelets or blood factor deficient infusion
treatment of endometriosis,
antibiotic treatment of pelvic inflammatory disease
treatment of uterine carcinoma
surgical removal of fibroids and polyps

Prognosis:
generally good after hysterectomy and removal of ovaries,treatment of underlying causes.

Cancer treatment prognosis depends on severity of cancer.

A Family Doctor's Tale - SUBARACHNOID HEMORRHAGE

DOC I HAVE SUBARACHNOID HEMORRHAGE

A Subarachnoid Hemorrhage is bleeding into the cerebrospinal fluid filled space between the pial and arachnoid membrane of the brain.

A Subarachnoid Hemorrhage occurs when:
1.Rupture of a congenital arterial aneurym (weak arterial wall) is the most common cause.

2.Rupture of an arterial capillary or venous bleeding from one or multiple sites of origin. This can be from high blood pressure or head injury .

3.Capillary damage leading to hemorrhage can occur in certain form of encephalitis.

4.Hemorrhagic diseases such as dengue fever, hemophilia, thrombocytopenia of unknown origin

5.Intracranial tumors such as angioblastic meningioma, glioma, pituitary adenoma and intracranial metastases are rare but possible causes

6.Anticoagulant therapy especially overdosage of warfarin

7.Smoking has been associated with subarachnoid hemorrhage.

The symptoms and signs of a Subarachnoid Hemorrhage are:
The affected person may have:
1.sudden severe headache with no known cause,initially excruciating, intense, aching pain, later becoming dull and throbbing but still severe.

2.difficulty in speaking or understanding

3.difficulty in swallowing

4.severe neck and back pain

5.Pain on attempted head movement

6.dizziness

7.vomiting

8.confusion and agitation

9.loss of concentration and memory

10.sudden vision loss in one eye

11.loss of consciousness

12.convulsions

13.coma and death

14.Stiff neck usually appears with onset of meningeal inflammatory reaction up to 6 to 12 hours after onset suggesting meningeal stretching and herniation of cerebellum into foramen magnum.

Other neurological signs:
1.Pupils unequal

2.paresis of vertical and medial movements of one eye

3.optic field may have round smooth hemorrhages near optic disc,
usually unilateral which will indicate site of bleeding in the brain.

Special investigations:
1.lumbar puncture:
pressure of cerebrospinal fluid may be raised
red blood cells present for first week
protein content raised

2.MRI or CAT scan with intravenous dyes can determine the source of the bleeding

The treatment of Subarachnoid Hemorrhage:
Subarachnoid Hemorrhage is an emergency.
Purpose of treatment is to:
1. preserve life
2. limit the amount of brain damage
3. lessen the extent of disability and deformity
4. prevent recurrence.

Admission to hospital is necessary to determine
1. the cause of the Subarachnoid Hemorrhage
2. the extent of damage to the brain using MRI of the brain
3. immediate treatment with medicines(usually anticoagulant,blood circulation,nerve vitamins).
4. whether Surgery is necessary to stop bleeding or remove a blood clot
5. risk factors for Subarachnoid Hemorrhage are investigated and treated (diabetes, high blood pressure etc)

During the acute phase of Subarachnoid Hemorrhage:
1. A clear airway must be maintained
2. Sufficient fluid and electrolyte intake must be maintained
3. adequate nutrition in the form of glucose, proteins and calories must be given
4. bed rest with adequate nursing care is provided to prevent bed sores etc
5. Proper medicines are given

Once the Subarachnoid Hemorrhage is stable:
The Subarachnoid Hemorrhage patient is started on a rehabilitation programme.
This will include
a.exercises to strengthen his muscles,
b.speech training for patients with dysphasia (difficulty in talking)
c.training on how to carry out his daily activities.
d.advice about his diet

Immediate care improves the chance of a complete recovery.

A Subarachnoid Hemorrhage can be very devastating and depressing for a patient.
He will feel that part of his body and brain function is incapacitated.
Therefore he need all the support from everyone involved in the treatment of his condition:
1.doctors,
2.nurses,
3.physiotherapist,
4.speech therapist
5.occupational therapists
6.family members and friends

Family members can provide the most important means of support.
They should be familiar with his disabilities and help him accordingly:
Please do:
1.be understanding and patient.

2. keep the patient cheerful and hopeful

3.learn how to help him with the diet, daily exercises and other care necessary for him

4.allow the person more time to do any task

5.encourage and praise the patient to do as much as possible for himself at his own pace.

6.involve the person in family discussions and activities.

7.be encouraging and praise his daily efforts.

Prognosis of subarachnoid hemorrhage:
1.Recurrence may occur

2.Can be life threatening

A Simple Guide to LEPTOSPIROSIS

A Simple Guide to LEPTOSPIROSIS
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What is LEPTOSPIROSIS?
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LEPTOSPIROSIS is an acute infectious illness caused by the bacteria Leptospira with a wide spectrum of illness from inapparent to fatal.
What is the cause of LEPTOSPIROSIS?
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The bacteria which causes LEPTOSPIROSIS is the Leptospira interrogans which is an extremely hardy bacteria occuring in domestic and wild animals. Humans are accidental hosts.
Human infections occur through abraded skin and exposed mucous membranes from urine or tissues of infected animal or through contaminated water soil and vegetation.
The bacteria can affect the liver, kidney, sketal muscle, heart, spleen, lungs and central nervous system.
Hemorrhagic changes and necrosis of tissues may occur together with interstitial edema and lympocytic, plasma cell and neutrophilic leucocyte infiltration.
What are symptoms of LEPTOSPIROSIS?
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Incubation period is approximately 10 days.
Illness is typically biphasic.
A.Leptospiremic or First Phase
1.Organisms found in the blood and cerebrospinal fluid
2.Abrupt onset of headache, myalgia, high fever and chills
This will last 4-9 days
3.Anorexia, nausea, vomiting, cough, chest pain, hemoptysis, conjunctival suffusion, cutaneous rash and hemorrhages seen.
B.Immune or Second Phase:
1.Correlates with appearance of circulating IgM antibodies
2.Clinical manifestations in this phase varies:
Patient may be asymptomatic for 1-3 days with return of fever and other symptoms of first stage.
3.Iridocyclitis, optic neuritis, encephalitis, myelitis,
and perpheral neuropathy and meningismus may occur.
Specific Sterotypes:
Weil's Disease:
is severe leptospirosis with
1.liver involvement withjaundice,hyperbilirubinemia
2.renal involvement with proteinuria, pyuria, hematuria
2.hemorrhagic manifestations with epistaxis, hemoptysis, GIT bleeding,subarachnoid hemorrhage
3.anemia
4.changes in consciousness
5.continuous fever
6.pneumonitis
7.aseptic meningitis
8.myocarditis
How is the diagnosis of LEPTOSPIROSIS made?
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Doctors generally diagnose LEPTOSPIROSIS based on:
1. blood test and cultures.
2.cerebrospinal tests
3.animal innoculation
4.liver scan and ultrasound
What are the complications of LEPTOSPIROSIS?
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LEPTOSPIROSIS is a disease which can kill especially through its complications:
1.Liver disease due to damage to the liver leading to cirrhosis
2.Kidney disease can occur from damage to the kidney
3.Brain damage is rare but can occur from spread to the brain and meninges
4.Severe hemorrhage uncommon but can cause death
How is LEPTOSPIROSIS treated?
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LEPTOSPIROSIS is an infectious disease which can spread to other people through contaminated food and water.
1.Antibiotics such as penicillin and tetracycline are started once the diagnosis is confirmed.
2.intravenous drip and blood transfusion if necessary
Symptomatic treatment includes:
1.Paracetamol for relief of fever and headache
2.antispasmodic drug to stop abdominal cramps
3.medicine to stop vomiting and itch
4.Gradually reintroduce food, starting with bland, easy-to-digest food, like porridge or soups.
5.Get plenty of rest.
How is LEPTOSPIROSIS prevented?
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Prevention of LEPTOSPIROSIS can be by:
1..Avoid eating or drinking foods or liquids that might be contaminated especially by the germ and animals
5.Good food hygience and hand washing
What is the prognosis of LEPTOSPIROSIS?
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Prognosis depends on the virulence of disease and general condition of the patient.
It is excellent with prompt treatment of leptospirosis infection.
Weil's disease is more serious but will respond well to treatment.
Infection of pregnant women may be associated with increased risk of fetal loss.

A Family Doctor's Tale - DUPUYTREN'S CONTRACTURE

DOC I HAVE DUPUYTREN'S CONTRACTURE

DUPUYTREN'S CONTRACTURE is the PROGRESSIVE FIBROSIS OF THE PALMA FASCIA LEADING TO PAINLESS contractures of one or mor finger at metacarpophayngeal joints.
At least one or more fingers will be flexed against the palm.

DUPUYTREN'S CONTRACTURE occur as a result of proliferation and thickening of the connective tissues of the palmar fascia.
Nodules of irregular fibroblasts are formed.
Contraction of proliferated fibrous tissues leads to the deformity.

It is inherited as a Mendelian dominant in some cases.
It occurs predominently among Caucasians.
Men are affected 8 times more than women.

It has been associated with:

1.epilepsy

2.diabetes

3.alcoholism

4.as a late result of post myocasrdial infarction shoulder hand syndrome

Symptoms:
The onset is usually gradual with a wide spectrum of manifestations from simple contracture alone to plantar fascial involvement in the foot.

1.minimal flexion deformity in the early stages

2.palmar fascia can be seen puckering the skin

3.thickened or nodular underlying tissue can be felt

4.on or all fingers of either or both hands may be affected especially the ring and little fingers

5.Affected fingers are partly or completely held in fixed flexion and cannot be extended.

Treatment:
1.In mild cases no treatment is required

2.Corticosteroid injection to reduce inflammation at the thickened or nodular underlying tissues may help some patients

3.Surgery may be necessary as last resort to release the palmar fascia by cutting the tightened fascia

Complication:
If left untreated. it can lead to the permanent loss of the hand

Prognosis :
1.usually good with injection of corticosteroid

2.recurrence may occur after injection in which case surgery should be done

3.Amputation may be considered if the affected fingers interferes with activities of the hand