SA Medical - General Medicine And Imaging of Disease

Increasing immunization coverage and the importance of missed opportunities The most important reasons for a child or woman of childbearing age coming to a health facility and not receiving the vaccines for which he/she is eligible: The failure to administer simultaneously all the vaccines for which a child is eligible. False contraindications for vaccination  Health worker practices, including not opening a multi-dose vial for a small number of persons to avoid vaccine wastage. Logistical problems such as vaccine shortage, poor clinic organization, and inefficient clinic scheduling. Missed opportunities can be reduced by health centres that see women and children by: Offering immunizations as often as possible. Routinely screening the immunization status of all women and children that the centre serves. Teaching health workers which are true and which are false contraindications. Ensuring that good practice procedures are followed. Abbreviations for particular vacc

New vaccines under development and required New and better vaccines are continually required. Important vaccines currently under development include vaccines for: Enterotoxigenic E. coli,  Malaria, Dengue, Para-influenza viruses, Respiratory syncitial virus, Human papillomavirus, HIV, Meningococcus B, Rotaviruses, Shigellae, Schistosomiasis

Headache The brain parenchyma is insensitive to pain. Headaches result from distension, traction, or inflammation of the cerebral blood vessels and dura mater. Pain is referred from the anterior and middle cranial fossae to the forehead and eye via the trigeminal nerve, and from the posterior fossa and upper cervical spine to the occiput and neck via the upper three cervical nerves. Both infratentorial and supratentorial masses can lead to frontal headaches by causing hydrocephalus. Causes of a headache Acute meningeal irritation: due to subarachnoid haemorrhage or meningitis caused by bacteria, viruses, fungi, or metastases. Rising intracranial pressure Infectious diseases: cause a headache during the acute phase. Locally important infections need to be determined (e.g. malaria; meningitis including TB; trypanosomiasis; typhoid, arboviral and typhus fevers; fungal infections). Giant-cell arteritis: may rapidly result in blindness. Occurs in elderly people

What is Coma?  A persistent pathological state of unconsciousness.  What do I do about it? In the comatose patient immediately ensure a clear airway, check that they are breathing, establish haemodynamic stability, and check for life-threatening injuries. Take a history from relatives or bystanders and ask if anyone saw how the patient became unconscious? Is there any past medical history such as diabetes, alcohol abuse, or drug overdose that might explain the coma? Examine the patient in an attempt to distinguish metabolic causes of coma from brainstem causes. It is particularly important to identify coma due to brainstem compression since surgical relief of the enlarging mass may be urgently required. Use the Glasgow coma score (GCS). Look for the following signs when reviewing the patient: Fever Meningitis or encephalitis Cerebral malaria Metabolic coma of infection Hypothermia Hypothyroidism; hypothermic coma Hypertension Coma may be due

Common causes of acute confusion/delirium at presentation (they may all progress to coma) CNS infection (malaria; meningitis including TB meningitis; encephalitis; HIV-related infections Systemic infections Hypoxia Metabolic causes (e.g. hypoglycaemia, hyerglycaemia) Alcohol excess or withdrawal Drugs Head injury/concussion Stroke Mental illness such as schizophrenia Raised intracranial pressure Epilepsy (post-ictal)

Dementia Unlike confusional states and delirium, there is no disturbance of consciousness in dementia. It is a chronic or progressive condition characterized by impairment of higher mental function (e.g. memory, reasoning, comprehension) and emotional and behavioural changes. Common causes are Alzheimer's disease and multiple strokes (vascular dementia). Uncommon but treatable causes include communicating hydrocephalus; vitamin B 12 or B 1 deficiency; hypothyroidism; syphilis; cysticercosis; brain tumour; chronic subdural haematoma. HIV can cause a dementia that is responsive to antiretroviral therapy. What is my Management: identify the few patients with treatable causes. Aim to supply others with general support so that they may have the highest quality of life possible. Remember that the family will also need support. 

Delirium This is more florid than ACS. It also manifests typically with disorientation, confusion, and reduced attention but, in addition, the patient is often frightened, irritable, and more profoundly disorientated. The patient may have frightening hallucinations and/or delusions, and exhibit aggressive behaviour. Causes:  Most common causes will vary with age.  Systemic infection:  check chest, urinary tract, surgical wounds, IV cannula sites, CSF.  Chronic subdural haematoma  may present with ACS. What is my Management?  Treat cause if one can be recognized. At night, turn the lights on to improve the patient's orientation. Give 50 ml of 50% dextrose IV if hypoglycaemia is suspected. Treat disturbed behaviour with chlorpromazine 25 to 50 mg IM/PO q6h or haloperidol 1.5 to 3 mg PO tds initially or 2 to 10 mg IM, repeated as necessary every 4 to 8 hours to a maximum daily dose of 18 mg. Avoid benzodiazepines. Nursing  is very important, Attempt to reassure the patient.

Acute confusional state (ACS) Clinical features: clouding of consciousness is the most important sign. Patients also have a short attention span and are easily distractible. They may be disorientated in time and place. They often appear bewildered and have impaired immediate recall and recent memory. What do I do? Check carefully for signs of reduced consciousness, particularly drowsiness. This may be a warning of impending coma. Psychiatric causes of confusion (e.g. schizophrenia, paranoid state) and early dementia do not present with drowsiness.

My dear patient thank you for this question. As those that know this is a complex question - I will try to explain this in the simplest possible way? Monogenic Inheritance - Mendel 1866:  A dominant characteristic is expressed in at least one parent is expressed in half of the offspring. Recessive characteristic - is evident in a quarter of the siblings born to parents who are both hetrozygous - and do not themselves express the characteristics. X-Linked Recessive Trait: The female carriers of the X-Chromosome are unaffected due to the presence of a second normal X Chromosome (Females have 2 X chromosomes), while the male offspring inherit the abnormal gene and suffer the disease because males do not have the relevant normal gene on the Y Chromosome (Males are XY). This genetic transmission is seen in the genetic transmission of hemophillia.  Polygenic Inheritance - is much more difficult to work out. 

Do I have to tell people that I am HIV positive? When you are diagnosed you will speak to a health adviser who will discuss this and similar issues with you. You should be careful who you tell as once it's done, there's no going back. Although safety precautions are taken you should inform anyone who could come into contact with infected body fluids (e.g. dentists, surgeons) and your doctor especially if you develop unusual symptoms which may be related to or altered by the HIV infection. If you are a healthcare professional (HCP) you should seek appropriate counselling as certain invasive procedures cannot be performed by HIV positive HCP. It is important to act responsibly where others are concerned, especially sexual (or drug-sharing) partners. There are court cases where HIV positive individuals have been prosecuted for infecting partners without informing them that they are HIV positive.