Archive for the Category ◊ Clinical ◊

Communication Skill in medicine
Author: jito soulfly
• Friday, July 30th, 2010

Factors which influence doctor-patient communication

The setting: requirements
Privacy
Comfortable surroundings
An appropriate setting arrangement

Factors which influence doctor-patient communication

Patient-related factors (patient’s feel at that time)
Physical symptoms
Psychological factors related to illness and/or medical care (e.g. anxiety., depression, anger, denial)
Previous experience of medical care
Current experience of medical care

Factors which influence doctor-patient communication

Doctor-related factors
Training in communication skills
Self-confidence in ability to communicate’personality
Physical factors (e.g. Tirdeness)
Psychological factors (e.g. Anxiety)

Factors which influence doctor-patient communication

Others
The patient’s beliefs about health and illness
The problem they wish to discuss
Their expectation of the doctor will do (often based on previous experience)
How they perceive the doctor

The setting of the inteview

In each case every effort should be made to provide a setting that facilitates communication
Privacy is essencial
Try to avoid interruptions and make sure that the lighting and temperature are as comfortable as possible
The arrangements of the seat
There are 3 possible setting (see pictures)
Try to drag a chair when we’re having consultation with the patient is on the bed. This would create the same “level”, so the patient wont feel threatened

Guideline for conducting an interview

Beginning the interview
Greet the patient by name and shake hands, if it seems appropriate
Ask the patient to sit down
Introduce yourself
Explain the purpose of the interview
Say how much time is available
Explain the need to take the notes and ask if this is acceptable

The main part of the interview
Maintain a positive atmosphere, warm manner, good eye contact
Use open question at the beginning
Listen carefully
Be alert and responsive to verbal and non ferbal cues
Facilitate the patient, both verbally and non-verbally
Use spesific questions when appropriate
Calrify what the patient has told you
Encourage the patient to be relevant

Ending the interview
Summaries what the patient has told you and ask if your summary is accurate
Ask if the would like to add anything
Thank the patient

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Osteoporosis
Author: jito soulfly
• Wednesday, July 21st, 2010

A major public threat for more than 28 million Americans. 80 % are women.
One in 2 women and One in 8 men over 50 will have an osteoporosis related fracture.
The estimated cost for osteoporosis and associated fractures is 38 million a day!

What is it?
A disease in which bones become fragile and more likely to break.
Breaks usually occur in the hip, spine and wrist

What causes osteoporosis?
Scientist have not yet learned all the reasons this occurs.
When you are young your body makes new bone faster than it breaks down old bones.
As you get older, this process slows down and you start losing bone density.
The risk for osteoporosis depends on how much bone mass you attained between ages 25 and 35 and how fast you lose it.

Risk Factors
Anorexia nervosa or bulimia
Diet low in calcium
Use of certain medications
Low testosterone levels in men
An inactive lifestyle
Cigarette smoking
Excessive use of alcohol
Being Asian or Caucasian

Bone Health
Bones are living tissue, they provide structural support, protect vital organs and store calcium.
Until age 30, we store and build bone effectively.
As part of the aging process, bones begin to break down faster than they are formed.
Accelerates after menopause. Estrogen is the hormone that protects against bone loss.

Bone Mass Density
The National Osteoporosis Foundation
Recommends you have a BDT if:
You use medications that cause osteoporosis
You have type I diabetes, liver disease, kidney disease or a family history
You experience early menopause
You’re postmenopausal over 50 and have at least one risk factor.
You’re postmenopausal over 65 and never had a test.

Calcium
Is needed for heart muscles, and nerves to function properly.
Inadequate amounts contribute to osteoporosis.
Appropriate calcium intake falls between 1000 and 1300 mg a day

How to get enough Calcium every day!
Follow the Food Guide Pyramid
for Dietary Calcium Sources
Dairy- low fat yogurt, skim milk, cheese, chocolate pudding, ice milk, ice cream or frozen yogurt.
Protein- tofu, sardines, salmon
Vegetables- turnip greens, Bok Choy, Broccoli, collard greens
Other foods: vegetable lasagna, cheese enchilada, cheese pizza, calcium fortified orange juice.

Exercise
Exercising regularly in childhood and adolescence can ensure that you will reach peak bone density.
Need to participate in weight bearing exercise. For example, walking, dancing, jogging, stair climbing, racquet sports and hiking.

Medications
There is no cure, but several medications have been approved.
Each stops or slows bone loss, increases bone density, and reduces fracture risk.
Estrogen Replacement,
Alendronate,raloxitene and risedronate are prescribed to prevent and treat the disease.

Bone-Building Checklist
Maintain a calcium rich diet.
Get plenty of vitamin D
Engage in weight-bearing exercise
Don’t smoke and limit alcohol intake
Consider Hormone Replacement or other medications if you are at risk.

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BREAKING BAD NEWS
Author: jito soulfly
• Tuesday, July 20th, 2010

Breaking bad news is an inevitable part of medical practice
Most of us worry about ability to communicate
Relationship between doctor and patient important to focus in  communications skills

WHAT IS A BAD NEWS..??
Why is it difficult to give bad news??

may feel responsible and fears being blamed
not knowing how best to do it
possible inhibition
reluctance to change the exiting doctor-patient relationship
Fear of upsetting the patient’s exiting family roles

Not knowing the patient their resources and limitations
Fear of the implications for the patient
Fear of the patient’s emotional reaction
Uncertainty as to what may happen next
Lack of clarity about own role as a health-care provider

Options for managing difficult situations

To whom should bad news be given?
Who should give bad news?
When should bad news be given?
Should you give hope and reassurance along with bad news?

How to give bad news
There are five main consideration:
Personal preparation
The physical setting
Talking to the patient and responding to their concerns
Arranging follow-up or referral
Feedback and handover to professional colleagues

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Hypertension in Pregnancy
Author: jito soulfly
• Saturday, February 27th, 2010

Hypertension-related problems in pregnancy are classified in four ways
• Chronic hypertension
• Pregnancy – induced chronic hypertension
• Preeclampsia
• Eclampsia

The hypertension in each of these dignoses is classified as:
Mild : Systolic > 140 mmHg and/or diastolic > 90 mmHg
Severe : Systolic > 160 mmHg and/or diastolic > 110 mmHg

The only cure for hypertension in pregnancy is delivery

Pathophysiology of Hypertension in Pregnancy
Normal : Arachdonic acid triggers two pathways:
1. Prostacycline: Decreases blood pressure via: decreased vasoconstriction, Increased uteroplacental blood flow
2. Thromboxane: Increases blood pressure via: increased vasoontriction, decreased uteroplacental blood flow

In Pregnancy-Hypertensive States
The balance is thought to be tipped toward the thromboxane pathway.
Hypertension related deaths in pregnancy account for 15% of maternal deaths
Chronic hypertension and pregnancy
If during pregnandy a chronic hypertensive patient’s systolic blood pressure rises by 30 mmHg or diastolic rises by 15 mmHg, it is pregnancy induced hypertension superimposed on chronic hypertension.
Management
Mild : Early and serial ultrasounds, biophysicals
Severe : serial ultrasounds and biophysicals, antihypertensives (methyldopa/nifedipine)

PREGNANCY INDUCED HYPERTENSION
Defined as hypertension during pregnancy in a previously normotensive woman (the patient had normal blood pressure prio to 20 weeks gestation)

Subsets of pregnancy-induced hypertension
1. Pregnancy induced hypertension
2. Preeclampsia : renal involvement leads to proteinuria
3. Eclampsia : central nervous system involvement leads to seizures
4. HELLP Syndrome : the clinical picture is dominated by hematoloic and hepatic manifestations

Complication
• Heart failure
• Cerebral hemorrhage
• Placental abruption
• Fetal growth restriction
• Fetal death

Management

Mild : observe, bed rest
Severe : always hospitalize + antihypertensive pharmacotherapy (hydralazine or labetalol short term, nifedipine or methyldopa long term)
In pregnancy induced hypertension we must monitor for intrauterine growth retardation and progression to superimposed preeclampsia

Severe Pregnancy induced hypertension usually occurs in the third trimester

Generally for all pregnancy-hypertensive states:
If > 36 weeks/fetal lung maturity : Induce labor
If < 34 weeks/fetal lung immaturity : steroids plus expectant management
If fetal or maternal deterioration at any gestational age, induce labor

PREECLAMPSIA
Preeclampsia is pregnancy induced hypertension with proteinuria +/- pathological edema. It is classified as mild or severe
Preeclampsia rarely develops before 20 weeks and usually occurs in a first pregnancy
Preeclampsia is usually asymptomatic; itscrucial to pick up during routine prenatal visits

Criteria for mild preeclampsia
• Blood pressure : ? 140 systolic or ? 90 diastolic
• Proteinuria : 300 mg to 5 g/24 hrs ( normal : < 300 mg/24 hrs in pregnancy, < 150 mg/24 hrs in nonpregnant state)

Manifestations of severe disease
• Blood pressure : > 160 systolic or > 110 diastolic
• Proteinuria : 5 g/24 hrs
• Elevated serum creatinine
• Oliguria (< 500 ml/24 hrs)
• Symptoms suggesting end organ involvement (headache, visual disturbances, epigastric pain)
• Pulmonary edema
• Hepatocellular dysfunction
• Thrombocytopenia
• IUGR or oligohydramnions
• Microangiophatic hemolysis
• Grand mal seizures (eclampsia)

Predisopsing Factors
• Nulliparity
• Family history of preeclampsia-eclampsia
• Multiple fetuses
• Diabetes
• Chronic vascular disease
• Renal disease
• Hydatidiform mole
• Fetal hydrops

HELLP SYNDROME

Hellp syndrome is a manifestation of preeclampsia with hemolysis, elevated liver enzyms and low platelets. In contrast to typical presentations of preeclampsia, it is associated with :
• High morbidity
• Multiparous mothers
• Mothers older than 25
• Less than 36 weeks gestation
The prime objectives in severe cases are to forestall convulsions, prevent intracranial hemorrhage and serious damage to other vital organs, and deliver a healthy infant

Diagnosis of Preeclampsia

Once preeclampsia is suspected, the following tests should be done :
• Blood : Electrolytes, blood urea nitrogen (BUN), creatinine, liver function tests (LFTs) (ALT, AST), complete blood count (CBC), uric acid, and platelet count
• Urine : Sediment, 24 hour protein, 24 hour creatinine
• Fetal : ultrasound, nonstress test, biophysical profile

Management

Varies depending on severity of disease and gestational age of fetus:
Mild Preeclampsia
• Hospitalize, observe, bedrest, low-salt diet, monitor labs closely

Severe Preeclampsia

• Hospitalize, bed rest, low salt, low calories
• Antihypertensive pharmacotherapy: hydralazine or labetalol short term nifedipine or methyldopa long term
• Anticonvulsive theraphy : magnesium sulfate

Plus the following :
• If > 36 weeks/fetal lung maturity : induce labor
• If < 34 weeks/fetal llung immaturity : steroids plus expectant management
• If fetal or maternaldeterioration at any gestational age : induce labor
The only cure is delivery

ECLAMPSIA

Criteria : Mild or severe preeclampsia ; generalized seizures
25% of seizures are before labor, 50 % of seizures are during labor, 25% of seizures are post labor (maybe encountered up to 10 days post partum)

Management

1. Control of the convulsions (magnesium sulvate IV and IM). Magnesium toxicity is associated with loss of patellar reflexes. Treat with calcium gluconate 10% solution 1g iv
2. Correction of hypoxia and acidosis
3. Blood Pressure control (hydralazine or labetolol)
4. Delivery after control of convulsions

Antihypertensive agents used in pregnancy
Short term control : hydralazine , labetolol
Long term control : methyldopa, nifedipine, atenolol

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menopause
Author: jito soulfly
• Monday, February 15th, 2010

Definitions

  • Menoupause is the final menstruation marking the termination of menses (defined as 6 months of amenorrhea)
  • Menopause is preceded by the climacteric or perimenioausal period the multiyear transition from optimal menstrual condition to menoupause
  • The postmenopause period is the time after menopause

Factors affecting age of onset

Genetics

  • Smoking (decreases age by 3 years)
  • Chemo / radiation therapy

Physioology during the perimenopausal period

Oocytes die

Women’s immature eggs, or oocytes, begin to die precipitously and become resistant to follicle-stimulating hormone (FSH),  the pituitary hormone that causes their marturation

  • FSH levels rise for two reasons :
    1. Decreased inhibin (inhibin inhibits FSH secretion; it is produced smaller amounts by the fewer oocytes)
    2. Resistant oocytes require more FSH to successfully mature, triggering greater FSH release

Ovulation becomes less frequent

Women ovulate less frequently, initially one to two fewer times per year and eventually just before menopause, perhaps once every 3 to 4 months. This is due to shortened follicular phase. The luteal phase does not change.

Estrogen levels fall

Estrogen levels begin to decline, resulting in hot flashes (may also be due to increased luteinizing hormone) Hot flashes usually occur on the face, neck and upper chest and last a few minutes followed by intense diaphoresis.

Physiology during the menopausal period

Levels of androstenedione fall, a hormone that is primarily produced by the follicle.

  • Ovaries increase production of testosterone which may result in hirsutism and virilism
  • Decrease in estradiol level and decrease in estrone level
  • FSH and LH levels rise secondary to absenece of negative feedback.

Treatment of the adverse effects of menopause

Hormone replacement therapy or estrogen replacement therapy has been shown to counteract the complications of estradiol loss.

Estrogen replacement therapy

Indicated in women status post hysterectomy.

Hormone replacement therapy

The progesterone component is needed to protect the endometrium for constant stimulation and resultant increase in endometrial cancer. It is indicated for women who still have their uterus.

Manual traffic exchange

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Infertility
Author: jito soulfly
• Sunday, January 10th, 2010

Definition

  • The inability to conceive after 12 months of unprotected sexual intercourse
  • Affects 15 % of couples

There are two types :

  • Primary infertility : Infertility in the absence of previous pregnancy
  • Secondary infertility : Infertility after previous pregnancy

Female factors affecting infertility

Tubal diseases 20%, Anovulation 15%, Unexplained 10%, Multifactoral 40%

Infertility workup

Semen analysis

Performed after at least 48 hours of abstinence, with examination maximum 2 hours from time of ejaculation (for those who prefer to donate at home)

Characteristics of semen analysis

  • Volume – normal , > 2ml
  • Semen count – normal, >20 million/ml
  • Motility – normal, > 50% with forward movement
  • Morphology – normal, > 40% normal

Treatment for abnormal sperm findings

  • Urology referral
  • Quitting smoking
  • Avoidance of lubricans
  • Intrauterine insemination
  • Intracytoplasmic injection
  • Artificial insemination

If semen analysis normal, continue workup with analysis of ovulation

Methods of analyzing ovulation

  • History of monthly menses is a strong indicator of normal ovulation
  • Basal body temperature; rises about 0.5 to 1 F during the luteal phase due to the increase level of progesterone. Presence of basal body temperature increase is a good indicator that ovulation is occurring
  • Measurement of luteal phase progesterone level
  • Sonogram = determines normal or abnormal endometrial anatomy
  • Endometrial biopsy – determines histologically the presence/absence ovulation

Possible causes and treatments of anovulation

  • Pituitary insufficiency : treat with intramuscular luteinizing hormone / follicle stimulating hormone
  • Hypotalamic disfunction  : treat with bromocriptine ( a dopamine antagonist)
  • Polycsystic ovary syndrome : treat with clomiphene or human menopausal gonadotropin
  • Other causes: Hyper/hypothyroid, androgen excess, obesity/starvation, galactorrhea

If ovulation analysis and semen analysis are normal, analysis of the internal architecture is performed to determine if there is an anatomical impediment to pregnancy.

Internal  architecture study

Hysterosalpingogram

  • Performed during follicular phase
  • Radio opaque dye is injected into cervix and uterus and shoul fill both fallopian tubes and spill into peritoneal cavity
  • Allows visualization of uterus and fallopian tubes
  • There is risk of salpingitis

Treatment for structural abnormalities

  • Microsurgical tuboplasty
  • Neosalpingostomy
  • Tubal reimplantation for intramural obstruction

If findings of the semen analysis, ovulation analysis and hysterosalpingogram are normal, an exploratory laparoscopy can be done.

Exploratory laparoscopy

A laparoscope is inserted transabdominally to visualize the pelvis :

  • Check for adhesions
  • Check for endometriosis

Treatment

  • Laparoscopic lysis of adhesions
  • Laparoscopic endometriosis ablation
  • Medical treatment of endometriosis

Assisted reproductive technologies

Definition

Directly retrieving eggs from ovary followed by manipulation and replacement. Generally employed for inadequate spermatogenesis. The following are examples.

In vitro fertilization and embryo transfer

Fertilization off eggs in a lab followed by uterine placement: Intracytoplasmic sperm injection is a subtype of IVF to aid severe male factors. Success rate of IVF is about 20%

Gamete intrafallopian transfer

Egg and sperm placement in an intact fallopian tube for fertilization: Success rate of this is about 25%.

Zygote intrafallopian transfer

Zygote (fertilized in vitro) is created and placed in fallopian tube, where it procceds to uterus for natural implantation: Success rate of this is about 30%

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Medical conditions in pregnancy
Author: jito soulfly
• Thursday, January 07th, 2010

Risk Factors

Alcohol

  • Alcohol is teratogenic
  • An occasional drink during pregnancy carries no known risk
  • Fetal alcohol syndrome (FAS) may occur with chronic exposure to alcohol in the later stages of pregnancy. Features  may include :
    • Growth retardation
    • Central nervous disfunction :
      • Microcephaly
      • Mental retardation
      • Abnormal neurobehaviour (hyperactivity disorder)
  • Facial anomalies :
    • Small palpebral  fissures
    • Indistinct / Absent philtrum
    • Epichantic folds
    • Flattened nasal bridge
    • Short length of nose
    • Thin upper lip
    • Low set, unparallel ears
    • Retarded midfacial development

Tobacco

  • The leading preventable cause of low birth weight
  • Smoking is associated with decreased birth weight and increased prematurity
  • There is a positive association between sudden infant death syndrome and smoking
  • Use of nicotine patch is controversial

Marijuana

  • No evidence of significant teratogenesis in humans
  • Metabolites detected in urine of users for days to weeks
  • Commonly used by multiple substance abusers; thus. Its presence in urine may identify patients at high risk for being current users of substances as well

Cocaine

  • Pregnancy does not increase one’s suspectibility to cocaine’s toxin effects
  • Complication of pregnancy :
    • Spontaneous abortion and fetal death in utero
    • Preterm labor and delivery
    • Meconium stained amniotic fluid
    • Teratogenic effects of cocaine :
      • Growth retardation
      • Microcephaly
      • Neurobehavioral abnormalities ; impairment in orientation and motor function

Opiates

Heroin

  • Three to sevenfold increase in incidence of stillbirth, fetal growth retardation, prematurity, and neonatal mortalitiy
  • Signs of infant withdrawal occur 24 to 72 hours after birth
  • Treatment with methadone improves pregnancy outcome

Newborn infants born to narcotic addicts are at risk for severe, potentially fatal narcotic withdrawal syndrome, characterized by :

  • High pitched cry
  • Poor feeding
  • Hypertonicity or tremors
  • Irritability
  • Sneezing
  • Sweating
  • Vomiting
  • Seizures

Hallucinogens

  • No evidence that lysergic acid diethylamide or other hallucinogens cause chromosal damage or other deleterious effects on human pregnancy
  • There have been no studies on the potential long term effects on neonatal neurodevelopment

Amphetamines

Crystal methamphetamine, a potent iv stimulant has been associated with :

Decreased fetal head circumference

  • Placental abruption
  • Intrauterine growth retardation
  • Fetal death in utero
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Pregnancy
Author: jito soulfly
• Tuesday, January 05th, 2010

History

The majority of women have amenorrhea from the last menstrual period until after the birth of their baby.

Symptoms

Although not specific to pregnancy, these symptoms may alert the patient to the fact that she is pregnant :

  • Breast enlargement and tenderness from about 6 weeks gestational age.
  • Areolar enlargement and increased pigmentation after 6 weeks gestational age.
  • Colustrum secretion may begin after 16 weeks gestational age.
  • Nausea with or without vomiting, from about the date of the missed period.
  • Urinary frequency, nocturia, and bladder irritability due to increased bladder circulation and pressure from the enlarging uterus.

Signs

Some clinical signs can be noted, but may difficult to quantify :

  • Breast enlargement, tension, and venous distention
  • Bimanual examination reveals a soft, cystic, globular uterus with enlargement consistent with the duration of pregnancy.
  • Chadwick’s sign : Bluish discoloration of vagina and cervix, due to congestion of pelvic vasculature.

Pregnancy Testing

How ?

The beta subunit of human chorionic gonadotropin (hCG) is detected in maternal serum or urine.

  • hCG is a glycoprotein produced by the developing placenta shortly after implantation.
  • A monoclonal antibody to the hCG antigen is utilized.

When ?

  • Blood levels become detectably elevated 8 to 10 days after fertilization ( 3 to 3.5 weeks after the LMP ).
  • hCG rises in a geometric fashion during T1, producing diferent ranges for each weeks of gestation.

Fetal Heart Tones

The electronic Doppler device can detect fetal heart tones as early as 8 weeks gestational age

Ultrasonic scanning

When ?

  • To confirm an intrauterine pregnancy.
  • To confirm the presence of a fetal heartbeat in a patient with a history of miscarriage.
  • To diagnose multiple pregnancy.
  • To estimate gestational age.
  • To screen for fetal structural anomalies.
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