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

A Family Doctor's Tale - HALLUX VALGUS

DOC I HAVE HALLUX VALGUS

HALLUX VALGUS also known as BUNION deformity is the deformity of the big toe metatarsopharyngeal(MTP) joint in whivh there is medial protrusion and lateral deviation of the great toe.

Shoewear does not cause hallux valgus.

HALLUX VALGUS occur as a result of :
1.heredity

2.flat foot (pes planus)

3.metatarsal primus varus

4.hypermobile first metarsal cuneiform joints

5.abnormal length of first metatarsal

6.joint laxity

Symptoms:
The onset is usually gradual with a wide spectrum of manifestations from simple deviation to severe deviation and deformity.

1.Normal intermetatarsal angle (the angle between the first and second metatarsals is 9 degrees or less.

2.the normal first MTP joint angle is less than 15 degrees.
Any increase of 15 degrees angle is considered as lateral deviation of the first metatarsopharygeal joint.

3.The big toe is turned inwards towards the second causing a medial protrusion of the MTP joint called a bunion.

4.in severe cases the first toe can overlap the second toe or the second toe may cover the inturned big toe.

5.there is pain on walking

6.there is difficulty in wearing shoes

Treatment:
Conservative:
1.In mild cases no treatment is required

2.Shoe wear modifications to increase the width of the toe box will relieve pressure of the MTP joint and help in walking.

3.Pads and splints may also help to relieve symptoms.

Surgery:
The main purpose is to restore the normal anatomical relation of the big toe MTP joint.
1.Osteotomy to realign the first metatarsal

2.Fusion of MTP joint

Prognosis:
90 per cent of patients will have good results after surgery

Conservative treatment can relieve the pain on walking but the deviation may still become worse.

A Family Doctor's Tale - TACHYCARDIA

DOC I HAVE TACHYCARDIA


Tachycardia is a symptom defined as heart rate above 100 per minute.

Causes of Tachycardia:

1.Abnormality of the sinus or atrial node in the heart may be continuous or paroxymal in nature

2.Abnormalities of the ventricular conducting system: a.ischemic heart disease b.congenital heart disease

3.Underlying systemic disease:

a.fever

b.anemia

c.thyrotoxicosis

4.Medicines:

a.ephedrine or pseudoephedrine

b.asthmatic drugs like ventolin or bricanyl

c.anticholinergic drugs like atropine, buscopan

5.Psychosomatic like anxiety, emotional upsets, panic attacks

Symptoms:

.palpitations

2.breathlessness

3.fainting

4.polyuria

Signs:

1.heart beat above 100 per minute

2.abnormal heart rhythm

3.ECG will determine

a.location of stimulus of fast heart beat

b.abnormal rhythm -flutter or fibrillation

Treatment of Tachycardia is:


1. Atrial tachycardia can be slowed by carotid sinus massage or Valsalva maneuver

2. Paroxysmal atrial Tachycardia can be terminated by vagal stimulation maneuvers (Valsalva or carotid sinus pressure).

3.Acute atrial attacks if not improved after vagal massage can be treated with: a.digoxin

b.beta blockers such as propanolol or atenolol

c.calcium channel blockers like nefidipine

d.anti-cholinesterase like edrophonium

e.alpha blockers

4.Persistent atrial tachycardia can be treated with a.quinidine, b.beta blockers or c.digoxin or dilatrend

5.Ventricular tachycardia is more dangerous usually associated with coronary heart disease or infarction may be treated with:

a.lidocaine 1-2mg per kg stat followed by infusion of 2-4 mg per kg per min

b.Electo-cardioversion

c.radiofrequency ablation

6. Treat underlying conditions such as thyrotoxicosis

7. No smoking, alcohol or caffiene intake

8.No strenuous exertion or stress

Prognosis:

1.atrial tachycardia may occur in normal young adults and may not indicate heart disease

2.Ventricular tachycardia may herald more serious illness such as life threatening arrthythmia or infarction