Aseptic Meningitis
Steven Wilson, M.D.
I. Background
A.Terminology. Aseptic meningitis refers to subarachnoid inflammation from any cause other than pyogenic bacteria or fungi. The differential includes viruses, other microorganisms, and non-infectious causes. Sinc most cases are caused by viruses, the terms "aseptic" and "viral" meningitis are often used synonymously
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Monday, April 6, 2009
Viral Hepatitis Update
Spencer Wilson, MD
Acute viral hepatitis has been defined as a systemic viral infection in which there is hepatocellular necrosis and inflammation. There are characteristic clinical, biochemical, immuno-serologic, and morphologic features. There are five major viruses: Hepatitis A virus (HAV), hepatitis B virus (HBV), Hepatitis C virus (HCV), hepatitis D virus (delta Virus, HDV), and Hepatitis E virus (enterically transmitted, epidemic non-A, non-B hepatitis, HEV). Chronic viral hepatitis is a necro-inflammatory disorder of the liver initiated by viruses and persisting for longer than six months. It occurs in association with HBV, HCV, and delta virus infection. In contrast, patients with acute hepatitis A and hepatitis E virus infection have no propensity whatsoever to develop a chronic carrier state or chronic liver disease.
Hepatitis A
The hepatitis A virus (HAV) is a 27 nm RNA virus classified as an enterovirus and belonging to the picornovirus family The nucleic acid of HAV is single-stranded RNA and. to date, only a Single serotype has been identified. The virus is stable for several months at 40cbut can be inactivated by exposure to heat to 100BC for five minutes. The virus can be transmitted to chimpanzees and marmosets and has been recently grown in tissue culture.
Susceptibility to HAV infection increases linearly with age and bears an inverse correlation to socioeconomic status. In major metropolitan centers in the United States, 50% of persons 50 years of age or older have detectable antibody to HAV. HAV is spread predominantly by the fecal-oral route via contaminated food and water. Overcrowding, poor hygiene, and poor sanitation favor the spread of this infection. A chronic viremic or fecal carrier state does not occur. Hence, patients are only transiently infectious. Viremia and fecal shedding occur over a short and finite period of time lasting several days to a few weeks. Transmission occurs via serial spread from one infected individual to another susceptible individual. Parenteral transmission of hepatitis A infection is extremely rare. Intravenous drug users, dialysis patients, transfusion recipients, and health care workers are not at increased risk of infection. Acquisition of HAV secondary to frequent oral-anal sexual contact has been documented in homosexual men.
The diagnosis is accomplished by testing the serum for antibody to hepatitis A. The IgM antibody appears during the acute phase and is detected by immune adherence hemagglutination, as well as by radioimmunoassay and usually disappears within 4 to 12 weeks. Persistent anti-HAV IgG antibody, is then detectable and confers homologous immunity. Fecal shedding of the hepatitis A virus occurs in the early phase of the illness. HAV is detected in stool during the first week of infection in 50% of patients, during the second week in 25% of patients, and in the third and fourth weeks only rarely.
In the United States, HAV is responsible for 25% of sporadic cases of hepatitis. In most persons, the disorder is mild, self-limited, and anicteric. Constitutional symptoms of fever, malaise, and anorexia are common and an abrupt onset is characteristic. If the patient develops jaundice, the urine may darken and the stool may lighten a few days before the onset of jaundice. When jaundice begins, the other symptoms usually subside. Tender hepatomegaly is common. Splenomegaly and lymphadenopathy are present in less than a third of patients.
Hepatitis A has an incubation period is 15 to 50 days. The virus is present in the blood stream for a short final period of time. The viremic phase is very short lived. It is shed in the stool for a short period of time. The majority of individuals do not develop jaundice. The ratio of anicteric hepatitis to jaundice is 20 to 1. Patients recover by in large. There are 2 antibodies, which are the IgM and the IgG. The way to make the diagnosis of acute hepatitis A is to look at a single sample of serum and if it is positive for IgM Anti-HV your patient with acute hepatitis has acute hepatitis A infection. IgG antibody appears during the convalescence phase, and confers life long immunity. There are 3 variants of hepatitis A virus infection which are cholestatic hepatitis, relapsing, and fulminant. Fulminant occurs rarely but can lead to fatalities and the only treatment in that setting is to do a liver transplant. Cholestatic hepatitis occurs more often in middle-aged or elderly individuals. They can have bilirubins in excess of 20 or 30 mg/dL. They develop marked pruritus. We can do an IgM antibody and make the diagnosis of acute hepatitis A. The patient has a bilirubin of 30, so we can get an ultrasound and make sure the bile ducts are not dilated and make the diagnosis of hepatitis A infection. This is the one time to consider a short course of corticosteroids. Prednisone, 30 or 40 mg, for week and then taper it, will significantly truncate or abrogate the illness.
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Acute viral hepatitis has been defined as a systemic viral infection in which there is hepatocellular necrosis and inflammation. There are characteristic clinical, biochemical, immuno-serologic, and morphologic features. There are five major viruses: Hepatitis A virus (HAV), hepatitis B virus (HBV), Hepatitis C virus (HCV), hepatitis D virus (delta Virus, HDV), and Hepatitis E virus (enterically transmitted, epidemic non-A, non-B hepatitis, HEV). Chronic viral hepatitis is a necro-inflammatory disorder of the liver initiated by viruses and persisting for longer than six months. It occurs in association with HBV, HCV, and delta virus infection. In contrast, patients with acute hepatitis A and hepatitis E virus infection have no propensity whatsoever to develop a chronic carrier state or chronic liver disease.
Hepatitis A
The hepatitis A virus (HAV) is a 27 nm RNA virus classified as an enterovirus and belonging to the picornovirus family The nucleic acid of HAV is single-stranded RNA and. to date, only a Single serotype has been identified. The virus is stable for several months at 40cbut can be inactivated by exposure to heat to 100BC for five minutes. The virus can be transmitted to chimpanzees and marmosets and has been recently grown in tissue culture.
Susceptibility to HAV infection increases linearly with age and bears an inverse correlation to socioeconomic status. In major metropolitan centers in the United States, 50% of persons 50 years of age or older have detectable antibody to HAV. HAV is spread predominantly by the fecal-oral route via contaminated food and water. Overcrowding, poor hygiene, and poor sanitation favor the spread of this infection. A chronic viremic or fecal carrier state does not occur. Hence, patients are only transiently infectious. Viremia and fecal shedding occur over a short and finite period of time lasting several days to a few weeks. Transmission occurs via serial spread from one infected individual to another susceptible individual. Parenteral transmission of hepatitis A infection is extremely rare. Intravenous drug users, dialysis patients, transfusion recipients, and health care workers are not at increased risk of infection. Acquisition of HAV secondary to frequent oral-anal sexual contact has been documented in homosexual men.
The diagnosis is accomplished by testing the serum for antibody to hepatitis A. The IgM antibody appears during the acute phase and is detected by immune adherence hemagglutination, as well as by radioimmunoassay and usually disappears within 4 to 12 weeks. Persistent anti-HAV IgG antibody, is then detectable and confers homologous immunity. Fecal shedding of the hepatitis A virus occurs in the early phase of the illness. HAV is detected in stool during the first week of infection in 50% of patients, during the second week in 25% of patients, and in the third and fourth weeks only rarely.
In the United States, HAV is responsible for 25% of sporadic cases of hepatitis. In most persons, the disorder is mild, self-limited, and anicteric. Constitutional symptoms of fever, malaise, and anorexia are common and an abrupt onset is characteristic. If the patient develops jaundice, the urine may darken and the stool may lighten a few days before the onset of jaundice. When jaundice begins, the other symptoms usually subside. Tender hepatomegaly is common. Splenomegaly and lymphadenopathy are present in less than a third of patients.
Hepatitis A has an incubation period is 15 to 50 days. The virus is present in the blood stream for a short final period of time. The viremic phase is very short lived. It is shed in the stool for a short period of time. The majority of individuals do not develop jaundice. The ratio of anicteric hepatitis to jaundice is 20 to 1. Patients recover by in large. There are 2 antibodies, which are the IgM and the IgG. The way to make the diagnosis of acute hepatitis A is to look at a single sample of serum and if it is positive for IgM Anti-HV your patient with acute hepatitis has acute hepatitis A infection. IgG antibody appears during the convalescence phase, and confers life long immunity. There are 3 variants of hepatitis A virus infection which are cholestatic hepatitis, relapsing, and fulminant. Fulminant occurs rarely but can lead to fatalities and the only treatment in that setting is to do a liver transplant. Cholestatic hepatitis occurs more often in middle-aged or elderly individuals. They can have bilirubins in excess of 20 or 30 mg/dL. They develop marked pruritus. We can do an IgM antibody and make the diagnosis of acute hepatitis A. The patient has a bilirubin of 30, so we can get an ultrasound and make sure the bile ducts are not dilated and make the diagnosis of hepatitis A infection. This is the one time to consider a short course of corticosteroids. Prednisone, 30 or 40 mg, for week and then taper it, will significantly truncate or abrogate the illness.
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Surgery Documentation
Surgical Documentation
S. E. Wilson, MD
Surgical History and Physical Examination
Identifying Data: Patient's name, age, race, sex; referring physician.
Chief Compliant: Reason given by patient for seeking surgical care and the duration of the symptom. History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent, cramping, stabbing, radiating); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or relieving factors. Vomiting (color, character, blood, coffee-ground emesis, frequency, associated pain). Change in bowel habits; rectal bleeding, character of blood (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing. Past Medical History (PMH): Previous operations and indications; dates and types of procedures; serious injuries, hospitalizations; diabetes, hypertension, peptic ulcer disease, asthma, heart disease; hernia, gallstones. Medications: Aspirin, anticoagulants, hypertensive and cardiac medications, diuretics. Allergies: Penicillin, codeine, iodine. Family History: Medical problems in relatives. Family history of colon cancer, cardiovascular disease. Social History: Alcohol, smoking, drug usage, occupation, daily activity.
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S. E. Wilson, MD
Surgical History and Physical Examination
Identifying Data: Patient's name, age, race, sex; referring physician.
Chief Compliant: Reason given by patient for seeking surgical care and the duration of the symptom. History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent, cramping, stabbing, radiating); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or relieving factors. Vomiting (color, character, blood, coffee-ground emesis, frequency, associated pain). Change in bowel habits; rectal bleeding, character of blood (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing. Past Medical History (PMH): Previous operations and indications; dates and types of procedures; serious injuries, hospitalizations; diabetes, hypertension, peptic ulcer disease, asthma, heart disease; hernia, gallstones. Medications: Aspirin, anticoagulants, hypertensive and cardiac medications, diuretics. Allergies: Penicillin, codeine, iodine. Family History: Medical problems in relatives. Family history of colon cancer, cardiovascular disease. Social History: Alcohol, smoking, drug usage, occupation, daily activity.
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Pediatric History
Identifying Data: Patient's name, age, sex; significant medical conditions,
informant (parent).
Chief Compliant (CC): Reason that the child is seeking medical care and
duration of the symptom.
History of Present Illness (HPI): Describe the course of the patient's illness,
including when and how it began, character of the symptoms; aggravating or
alleviating factors; pertinent positives and negatives, past diagnostic testing.
Past Medical History (PMH): Medical problems, hospitalizations, operations;
asthma, diabetes.
Perinatal History: Gestational age at birth, obstetrical complications, type of
delivery, birth weight, Apgar scores, complications (eg, infection, jaundice),
length of hospital stay.
Medications: Names and dosages.
Nutrition: Type of diet, amount taken each feed, change in feeding habits.
Developmental History: Age at attainment of important milestones (walking,
talking, self-care). Relationships with siblings, peers, adults. School grade and
performance, behavioral problems.
Immunizations: Up-to-date?
Allergies: Penicillin, codeine?
Family History: Medical problems in family, including the patient's disorder;
diabetes, seizures, asthma, allergies, cancer, cardiac, renal or GI disease,
tuberculosis, smoking.
Social History: Family situation, alcohol, smoking, drugs, sexual activity.
Parental level of education. Safety: Child car seats, smoke detectors, bicycle
helmets.
Review of Systems (ROS)
General: Overall health, weight loss, behavioral changes, fever, fatigue. Skin: Rashes, moles, bruising, lumps/bumps, nail/hair changes. Eyes: Visual problems, eye pain.
Ear, nose, throat: Frequency of colds, pharyngitis, otitis media. Lungs: Cough, shortness of breath, wheezing. Cardiovascular: Chest pain, murmurs, syncope.
Gastrointestinal: Nausea/vomiting, spitting up, diarrhea, recurrent abdominal pain, constipation, blood in stools.
Genitourinary: Dysuria, hematuria, polyuria, vaginal discharge, STDs. Musculoskeletal: Weakness, joint pain, gait abnormalities, scoliosis. Neurological: Headache, seizures.
Endocrine: Growth delay, polyphagia, excessive thirst/fluid intake, menses duration, amount of flow.
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informant (parent).
Chief Compliant (CC): Reason that the child is seeking medical care and
duration of the symptom.
History of Present Illness (HPI): Describe the course of the patient's illness,
including when and how it began, character of the symptoms; aggravating or
alleviating factors; pertinent positives and negatives, past diagnostic testing.
Past Medical History (PMH): Medical problems, hospitalizations, operations;
asthma, diabetes.
Perinatal History: Gestational age at birth, obstetrical complications, type of
delivery, birth weight, Apgar scores, complications (eg, infection, jaundice),
length of hospital stay.
Medications: Names and dosages.
Nutrition: Type of diet, amount taken each feed, change in feeding habits.
Developmental History: Age at attainment of important milestones (walking,
talking, self-care). Relationships with siblings, peers, adults. School grade and
performance, behavioral problems.
Immunizations: Up-to-date?
Allergies: Penicillin, codeine?
Family History: Medical problems in family, including the patient's disorder;
diabetes, seizures, asthma, allergies, cancer, cardiac, renal or GI disease,
tuberculosis, smoking.
Social History: Family situation, alcohol, smoking, drugs, sexual activity.
Parental level of education. Safety: Child car seats, smoke detectors, bicycle
helmets.
Review of Systems (ROS)
General: Overall health, weight loss, behavioral changes, fever, fatigue. Skin: Rashes, moles, bruising, lumps/bumps, nail/hair changes. Eyes: Visual problems, eye pain.
Ear, nose, throat: Frequency of colds, pharyngitis, otitis media. Lungs: Cough, shortness of breath, wheezing. Cardiovascular: Chest pain, murmurs, syncope.
Gastrointestinal: Nausea/vomiting, spitting up, diarrhea, recurrent abdominal pain, constipation, blood in stools.
Genitourinary: Dysuria, hematuria, polyuria, vaginal discharge, STDs. Musculoskeletal: Weakness, joint pain, gait abnormalities, scoliosis. Neurological: Headache, seizures.
Endocrine: Growth delay, polyphagia, excessive thirst/fluid intake, menses duration, amount of flow.
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Outpatient and Primary Care Medicine
Cardiovascular Disorders
Stable Angina Pectoris
Angina pectoris is a symptom complex caused by myocardial ischemia. Stable angina refers to chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved with rest or nitroglycerin. Unstable angina includes new onset of chest pain, progressing effort angina, rest angina, post-myocardial infarction angina, and angina after revascularization.
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Stable Angina Pectoris
Angina pectoris is a symptom complex caused by myocardial ischemia. Stable angina refers to chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved with rest or nitroglycerin. Unstable angina includes new onset of chest pain, progressing effort angina, rest angina, post-myocardial infarction angina, and angina after revascularization.
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Nutrition Infant
Nutrition for the Term Infant
Breast milk is universally recommended as the preferred source of infant nutrition, in part because of its superior nutrient and immunologic properties. Successful breast feeding requires nursing on demand, prevention of sore nipples and convenient access to medical advice. For mothers relying on bottle feeding, cow's-milk-based formula is the preferred choice. Because soy-based formulas are lactose-free, they may be tolerated by infants who are allergic to cow's-milk protein. Protein hydrolysate formulas should be used only in infants who cannot tolerate cow's-milk-based or soy-based formulas. Low-iron formulas and whole cow's milk should not be used during the first year. Breast-fed infants rarely require vitamin supplementation. Fluoride supplementation is no longer recommended for infants less than six months of age.
Benefits of Breast Feeding
Breast milk is universally recognized as the preferred source of infant nutrition, and the nutritional advantages of breast milk have been well documented. Colos-trum, the first milk produced after delivery, provides an initial dose of enzymes that promote gut maturation, facilitate digestion and stimulate passage of meco-nium. Colostrum is also high in protein, primarily because of high levels of im-munoglobulins and secretory IgA. The protein in human milk is ideal not only for absorption, but also for utilization, especially by the rapidly developing infant brain. Human milk also contains predominantly polyunsaturated fats with stable amounts of cholesterol, an important constituent of brain and nerve tissue.
Human milk also protects against infection by providing cellular immunity through macrophages and humoral factors, such as antibodies. Numerous studies have verified that breast-fed infants have a lower incidence of bacterial and viral illnesses than bottle-fed infants. This low incidence is of particular clinical significance in developing nations? Ongoing research suggests that breast feeding may provide immuno-logic protection against diabetes mellitus, cancer and lymphoma. Finally, breast feeding has been found to provide protection from allergic diseases, including eczema, asthma and allergic rhinitis. This protection is most likely the result of breast milk decreasing intestinal permeability to large, allergenic molecules.
Recognizing these as well as other advantages, the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) have identified breast milk as the preferred source of infant nutrition. In addition, the U.S. Public Health Service (USPHS) has established a national goal that, by the turn of the century, 75 percent of new mothers will be breast-feeding at the time of hospital discharge. Despite an emphasis on breast feeding by both private and government organizations, only 54 percent of U.S. mothers initiate breast feeding, and fewer than half of these mothers continue nursing for at least six months. Clearly, all health care providers should actively promote breast feeding if the goal set by the USPHS is to be accomplished.
To successfully promote breast feeding, family physicians should consider the influence of marketing campaigns aimed at expectant and new mothers by the manufacturers of infant formulas. Historically, their dogged marketing efforts have included the distribution of free cases of infant formula to expectant mothers, as well as the inclusion of formula samples in commercial hospital discharge packs designed for breast-fed infants. Physicians must work proactively to weigh the risks and benefits of promotional materials and develop appropriate policies governing their distribution in their hospitals or academic institutions.
Counseling Strategies
Breast feeding should be initiated as soon after delivery as possible, and mothers should be encouraged to nurse on demand, usually eight to 10 times a day.
Signs of Successful Breast Feeding
Audible swallowing
Eight to 10 feedings per day
Six to eight wet diapers per day
Three to five bowel movements per day
Infant regains birth weight by two weeks of age
This strategy enables the milk supply to quickly become well established. Table 1 lists reassuring signs of successful breast feeding, which can be used to assess the infant's nutritional intake as well as to bolster the new mother's confidence in her breast-feeding success. Supplemental formula feedings should be discouraged in the early postpartum period, since they may result in a decreased milk supply or infant confusion between the artificial and maternal nipples?
The first weeks of nursing represent a pivotal time for success or failure of breast feeding. And with the trend toward increasingly abbreviated inpatient stays, nursing mothers will be relying more than ever before on their physicians and office staff to provide much of the breast-feeding counseling that previously took place in the hospital.
To be successful, nursing mothers must learn proper positioning of the infant. Since sore nipples can derail even the best intentions to breast feed, nursing mothers should learn techniques for preventing sore nipples, such as varying the nursing position and using the little finger to break the infant's suction before removing the infant from the breast. Should these efforts fail to prevent soreness, mothers should have quick access to effective treatment regimens.
The ability of the breast-feeding couple to weather difficulties and setbacks can be enhanced by close contact with a responsive physician and office staff. Early physician visits, home nursing visits and even telephone contacts can provide opportunities to offer support and guidance to nursing mothers? For example, a staff member might routinely call nursing mothers the day after hospital discharge. The physician's office environment can be structured to allow privacy and comfort for nursing mothers. Often this can be accomplished by simply making an examination room available.
Once nursing is well established, the physician should encourage the mother to continue nursing throughout the infant's first year of life. Physicians should avoid recommending unnecessary disruptions in breast feeding. Recent guidelines on the management of hyperbilirubinemia in the healthy term newborn, for example, discourage the interruption of breast feeding and, instead, provide the option of frequent breast feeding.
....CLICK HERE TO DOWNLOAD FULL ARTICLE
Breast milk is universally recommended as the preferred source of infant nutrition, in part because of its superior nutrient and immunologic properties. Successful breast feeding requires nursing on demand, prevention of sore nipples and convenient access to medical advice. For mothers relying on bottle feeding, cow's-milk-based formula is the preferred choice. Because soy-based formulas are lactose-free, they may be tolerated by infants who are allergic to cow's-milk protein. Protein hydrolysate formulas should be used only in infants who cannot tolerate cow's-milk-based or soy-based formulas. Low-iron formulas and whole cow's milk should not be used during the first year. Breast-fed infants rarely require vitamin supplementation. Fluoride supplementation is no longer recommended for infants less than six months of age.
Benefits of Breast Feeding
Breast milk is universally recognized as the preferred source of infant nutrition, and the nutritional advantages of breast milk have been well documented. Colos-trum, the first milk produced after delivery, provides an initial dose of enzymes that promote gut maturation, facilitate digestion and stimulate passage of meco-nium. Colostrum is also high in protein, primarily because of high levels of im-munoglobulins and secretory IgA. The protein in human milk is ideal not only for absorption, but also for utilization, especially by the rapidly developing infant brain. Human milk also contains predominantly polyunsaturated fats with stable amounts of cholesterol, an important constituent of brain and nerve tissue.
Human milk also protects against infection by providing cellular immunity through macrophages and humoral factors, such as antibodies. Numerous studies have verified that breast-fed infants have a lower incidence of bacterial and viral illnesses than bottle-fed infants. This low incidence is of particular clinical significance in developing nations? Ongoing research suggests that breast feeding may provide immuno-logic protection against diabetes mellitus, cancer and lymphoma. Finally, breast feeding has been found to provide protection from allergic diseases, including eczema, asthma and allergic rhinitis. This protection is most likely the result of breast milk decreasing intestinal permeability to large, allergenic molecules.
Recognizing these as well as other advantages, the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) have identified breast milk as the preferred source of infant nutrition. In addition, the U.S. Public Health Service (USPHS) has established a national goal that, by the turn of the century, 75 percent of new mothers will be breast-feeding at the time of hospital discharge. Despite an emphasis on breast feeding by both private and government organizations, only 54 percent of U.S. mothers initiate breast feeding, and fewer than half of these mothers continue nursing for at least six months. Clearly, all health care providers should actively promote breast feeding if the goal set by the USPHS is to be accomplished.
To successfully promote breast feeding, family physicians should consider the influence of marketing campaigns aimed at expectant and new mothers by the manufacturers of infant formulas. Historically, their dogged marketing efforts have included the distribution of free cases of infant formula to expectant mothers, as well as the inclusion of formula samples in commercial hospital discharge packs designed for breast-fed infants. Physicians must work proactively to weigh the risks and benefits of promotional materials and develop appropriate policies governing their distribution in their hospitals or academic institutions.
Counseling Strategies
Breast feeding should be initiated as soon after delivery as possible, and mothers should be encouraged to nurse on demand, usually eight to 10 times a day.
Signs of Successful Breast Feeding
Audible swallowing
Eight to 10 feedings per day
Six to eight wet diapers per day
Three to five bowel movements per day
Infant regains birth weight by two weeks of age
This strategy enables the milk supply to quickly become well established. Table 1 lists reassuring signs of successful breast feeding, which can be used to assess the infant's nutritional intake as well as to bolster the new mother's confidence in her breast-feeding success. Supplemental formula feedings should be discouraged in the early postpartum period, since they may result in a decreased milk supply or infant confusion between the artificial and maternal nipples?
The first weeks of nursing represent a pivotal time for success or failure of breast feeding. And with the trend toward increasingly abbreviated inpatient stays, nursing mothers will be relying more than ever before on their physicians and office staff to provide much of the breast-feeding counseling that previously took place in the hospital.
To be successful, nursing mothers must learn proper positioning of the infant. Since sore nipples can derail even the best intentions to breast feed, nursing mothers should learn techniques for preventing sore nipples, such as varying the nursing position and using the little finger to break the infant's suction before removing the infant from the breast. Should these efforts fail to prevent soreness, mothers should have quick access to effective treatment regimens.
The ability of the breast-feeding couple to weather difficulties and setbacks can be enhanced by close contact with a responsive physician and office staff. Early physician visits, home nursing visits and even telephone contacts can provide opportunities to offer support and guidance to nursing mothers? For example, a staff member might routinely call nursing mothers the day after hospital discharge. The physician's office environment can be structured to allow privacy and comfort for nursing mothers. Often this can be accomplished by simply making an examination room available.
Once nursing is well established, the physician should encourage the mother to continue nursing throughout the infant's first year of life. Physicians should avoid recommending unnecessary disruptions in breast feeding. Recent guidelines on the management of hyperbilirubinemia in the healthy term newborn, for example, discourage the interruption of breast feeding and, instead, provide the option of frequent breast feeding.
....CLICK HERE TO DOWNLOAD FULL ARTICLE
Non-invasive Cardiac Imaging
Janet Wong, M.D.
Chest X-Ray
The chest X-ray provides information about the size and configuration of the heart and great vessels, as well as pulmonary vasculature, and pleural effusions. Cardiac chamber dilation, rather than wall thickening is generally perceived as an alteration in cardiac silhouette. Routinely posteroanterior (PA) and lateral chest films are obtained. Enlargement of the fight atrium may cause bulging of the heart to the fight on the PA film, while fight ventricular enlargement is generally perceived as a filling of the anterior clear space on the lateral film. Left atrial enlargement may be detected by an upward displacement of the left main-stem bronchus, or posterior displacement of the barium filled esophagus on lateral films. Left ventricular enlargement is the most common finding on chest x-ray, generally results in an increased cardiothoracic ratio (> 0.50). Pericardial effusions may be suspected by an enlarged cardiac silhouette with "water bottle" appearance. Fluoroscopy, more often performed in the cardiac catheterization suite, generally confirms minimal motion of cardiac borders. Fluoroscopy is also more sensitive for detection of cardiac valve calcium as well as epicardial calcium (see cine CT). The chest x-ray is also helpful to demonstrate upper zone redistribution, pleural effusions, and Kerley B-lines indicative of congestive heart failure.
Echocardiography
Echocardiography uses ultrasound to image the heart and great vessels. It is widely regarded as the technique of choice for evaluation of suspected valvular heart disease. Its ease of use, high temporal and spatial resolution, and lack of complications also makes it ideal for assessment of cardiac chamber size and systolic function, though comprehensive left ventricular endocardial borders may be difficult to identify in a significant minority (20%) of patients. Three general types of studies may be performed, M-mode echocardiography, two-dimensional (2D) echocardiography, and Doppler echocardiography. M-mode and 2D imaging are useful for quantifying chamber sizes, ventricular systolic function, wall thickness, and valvular morphology while Doppler echocardiography, which measures blood flow velocity and includes pulsed wave, continuous wave and color Doppler methods, is most valuable for assessing valvular function.
Quantitative data regarding left ventricular wall thickness and chamber dimensions are generally measured using M-mode methods, a technique which uses very high temporal (>1000 Hz) resolution, while qualitative global and regional left ventricular systolic function is generally best appreciated using 2D methods. Automated endocardial edge-detection techniques have recently been introduced for "real-time" analysis of global systolic indices, but these algorithms make many assumptions regarding the ventricular geometry (symmetry) which may not be applicable to the individual patient. Complications of myocardial infarction such as left ventricular aneurysm or left ventricular apical thrombi are readily identified by 2D transthoracic echocardiography. The crescent shaped right ventricle is more difficult to assess, and only qualitative analyses from 2D data are generally used. Left atrial chamber size may also be quantified by 2D transthoracic echocardiography. While left ventricular thrombi are easily appreciated from transthoracic approaches, left atrial thrombi are best visualized using The physical examination provides a tremendous amount of information we get from that. Just the general appearance of our patients. Is there evidence of peripheral cyanosis? Are they dyspneic? Is there evidence of exophthalmus, the fundi? Again, in patients with hypertension especially diabetes. Looking at jugular venous distension. Examining the carotid pulse. Is it delayed, is there a bi-fib pulse - the bi-fib pulse being suggestive of a hypertrophic obstructive cardiomyopathy? Examining the lungs for rales, effusions. The heart for PMI as well as murmurs. It is important in your patients to have the patients turn in the left lateral decubitus position to hear mitral murmurs and if you are concerned about aortic insufficiency, certainly have them sit up and forward with an exhalation examination. Finally, the abdominal examination - ascites, organomegaly and the extremities.
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Chest X-Ray
The chest X-ray provides information about the size and configuration of the heart and great vessels, as well as pulmonary vasculature, and pleural effusions. Cardiac chamber dilation, rather than wall thickening is generally perceived as an alteration in cardiac silhouette. Routinely posteroanterior (PA) and lateral chest films are obtained. Enlargement of the fight atrium may cause bulging of the heart to the fight on the PA film, while fight ventricular enlargement is generally perceived as a filling of the anterior clear space on the lateral film. Left atrial enlargement may be detected by an upward displacement of the left main-stem bronchus, or posterior displacement of the barium filled esophagus on lateral films. Left ventricular enlargement is the most common finding on chest x-ray, generally results in an increased cardiothoracic ratio (> 0.50). Pericardial effusions may be suspected by an enlarged cardiac silhouette with "water bottle" appearance. Fluoroscopy, more often performed in the cardiac catheterization suite, generally confirms minimal motion of cardiac borders. Fluoroscopy is also more sensitive for detection of cardiac valve calcium as well as epicardial calcium (see cine CT). The chest x-ray is also helpful to demonstrate upper zone redistribution, pleural effusions, and Kerley B-lines indicative of congestive heart failure.
Echocardiography
Echocardiography uses ultrasound to image the heart and great vessels. It is widely regarded as the technique of choice for evaluation of suspected valvular heart disease. Its ease of use, high temporal and spatial resolution, and lack of complications also makes it ideal for assessment of cardiac chamber size and systolic function, though comprehensive left ventricular endocardial borders may be difficult to identify in a significant minority (20%) of patients. Three general types of studies may be performed, M-mode echocardiography, two-dimensional (2D) echocardiography, and Doppler echocardiography. M-mode and 2D imaging are useful for quantifying chamber sizes, ventricular systolic function, wall thickness, and valvular morphology while Doppler echocardiography, which measures blood flow velocity and includes pulsed wave, continuous wave and color Doppler methods, is most valuable for assessing valvular function.
Quantitative data regarding left ventricular wall thickness and chamber dimensions are generally measured using M-mode methods, a technique which uses very high temporal (>1000 Hz) resolution, while qualitative global and regional left ventricular systolic function is generally best appreciated using 2D methods. Automated endocardial edge-detection techniques have recently been introduced for "real-time" analysis of global systolic indices, but these algorithms make many assumptions regarding the ventricular geometry (symmetry) which may not be applicable to the individual patient. Complications of myocardial infarction such as left ventricular aneurysm or left ventricular apical thrombi are readily identified by 2D transthoracic echocardiography. The crescent shaped right ventricle is more difficult to assess, and only qualitative analyses from 2D data are generally used. Left atrial chamber size may also be quantified by 2D transthoracic echocardiography. While left ventricular thrombi are easily appreciated from transthoracic approaches, left atrial thrombi are best visualized using The physical examination provides a tremendous amount of information we get from that. Just the general appearance of our patients. Is there evidence of peripheral cyanosis? Are they dyspneic? Is there evidence of exophthalmus, the fundi? Again, in patients with hypertension especially diabetes. Looking at jugular venous distension. Examining the carotid pulse. Is it delayed, is there a bi-fib pulse - the bi-fib pulse being suggestive of a hypertrophic obstructive cardiomyopathy? Examining the lungs for rales, effusions. The heart for PMI as well as murmurs. It is important in your patients to have the patients turn in the left lateral decubitus position to hear mitral murmurs and if you are concerned about aortic insufficiency, certainly have them sit up and forward with an exhalation examination. Finally, the abdominal examination - ascites, organomegaly and the extremities.
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