Understanding The Basic Workup Done For Infertility

Infertility is defines as the failure to conceive after 1 year of unprotected intercourse in women under 35 years of age and after six months in women 35 or older
The workup for infertility begins with the clinical history and examination.

The ability of a couple to become pregnant depends on normal fertility in both the male and female partners and so both must be evaluated.
EVALUATION OF INFERTILITY IN WOMEN
Although a variety of tests are available for evaluating female infertility, it may not be necessary to have all of these tests. Doctors usually begin with a medical history, a thorough physical examination, and some preliminary tests.

Medical History :
A woman's past health and medical history may provide some clues about the cause of infertility. Following questions are usually asked during the history:

• Age at which menses started.
• The duration of menstrual cycle and if its regular or not.
• Any pain during periods / intercourse
• Frequency of sexual intercourse
• any history of illness /surgeries in the past
• Any medications which the patient might be taking.
• Any children from previous relationships (if any)

Examination:

A physical examination usually includes a general examination, with special attention to any signs of hormone deficiency or signs of other conditions that might impair fertility. The points that are noticed include:

• Pallor for anemia
• Acne, excessive facial hair
• Breast development
• Pelvic examination for any masses. 

Workup:

After a detailed clinical history and examination , doctor may need some basic investigations to find out the cause for infertility. These tests are explained below: 

1. Blood test for hormones: FSH, LH, estradiol, prolactin & AMH are done on day 1-3 of the menstrual cycle. 

FSH- Follicle stimulating hormone is one of the most important hormones in the normal menstural cycle. It helps in producing mature eggs by stimulating the ovaries. If the ovaries are not working and the eggs are not developing, the body response is to increases FSH production.

LH- Luteinizing hormone, again an important hormone that helps an egg to grow and be released once mature. 

The time when the egg is released from the ovary it is called ovulation. Ovulation can be tracked by urine testing strips which detect a rise in LH at the time of ovulation. 

Estradiol-is tested to check the quantity and quality of egg production. 

Prolactin- hormone is normally responsible to produce milk for breast feeding.This hormone naturally prevents conception by inhibiting ovulation in breast feeding mothers. If abnormally high without a woman breast feeding it may lead to irregular menstrual cycles and lack of ovulation. 

AMH- a recent test introduced to check ovarian reserve. If low means the woman is approaching menopause and chances to conceive are low. 

Understanding Polycystic Ovarian Syndrome

Polycystic ovary syndrome  (PCOS)  is a problem in which a woman's hormones are out of balance. It can cause problems with the periods and make it difficult to get pregnant.

Most women with PCOS grow many small cysts on their ovaries. That is why it is called polycystic ovary syndrome. The cysts are not harmful but lead to hormone imbalances.

The exact cause of polycystic ovary syndrome is unknown but doctors believe that hormonal imbalances and genetics play a role. Women are more likely to develop PCOS if their mother or sister also has the condition.

Risk factors for having PCOS are being overweight and not doing enough physical exercise.

Symptoms Of PCOS

Some of the symptoms of PCOS include:

 -Irregular menstrual cycle. Women with PCOS may miss periods or have fewer periods (fewer than eight in a year). Or, their periods may come every 21 days or more often. Some women with PCOS stop having menstrual periods.

 -Too much hair on the face, chin, or parts of the body where men usually have hair. This is called "hirsutism."

 -Acne on the face, chest, and upper back

 -Thinning hair or hair loss on the scalp.

 -Weight gain or difficulty losing weight

 -Darkening of skin, particularly along neck creases, in the groin, and underneath breasts

-  Difficulty in conceiving .

A Common Question: Can I get pregnant if i have PCOS?

Cardio Pulmonary Resuscitation (CPR) - Steps To Be Followed In Case Of Emergency

Get Smart About Stroke - Know The Signs & Symptoms To Limit The Damage

Every 40 second in America someone suffers from a stroke, while every 4  minutes someone dies from it. These statistics are not as grim as they could be. Although with the widespread use of blood pressure medications and measures to control the blood pressure and cholesterol, the number of people who die from stroke has decreased but still it remains the number one cause for disability in the United States.

Stroke can even occur in younger people (about a quarter of strokes occur in people less than 65 years of age).

Unfortunately only about 30% of stroke victims recognize the symptoms and get to the hospital in time to receive brain saving medications.

You lose somewhere on the order of 2 million brain cells a minute during a stroke and so it is important to educate the common people to know the symptoms so that they can get the immediate help and prevent the brain damage and resulting disability.

In this article i would like to mention some of the more subtle symptoms of stroke, how you can prevent one and the new developments in the diagnosis and treatment of this debilitating brain disease.

Be FAST:
You may have probably seen the FAST acronym from the American Heart Association which says

• F is for Face
• A is for Arm weakness
• S is for Speaking difficulties
• T is for Time to call.

If you notice any facial asymmetry, or weakness in your arms or any difficulty with speech you must seek immediate medical help. Here we can add balance difficulties or any visual problems as well. 

Don't Second Guess Yourself: 

Many times when people even know the symptoms they may not recognize what is happening or may

Understanding Fatty Liver Disease.

Introduction: Fatty liver is a term used to define a condition in which too much fat is stored in the liver. Some fat in the liver is normal but if it makes up more than 5%-10% of the organ's weight, it may lead to a condition known as fatty liver disease.

Fatty liver disease is increasingly common around the world, especially in Western nations. In the United States, it is the most common form of chronic liver disease, affecting an estimated 80 to 100 million people.

The liver is the second largest organ in the body. The liver’s function is to process everything we eat or drink and filter any harmful substances from the blood. This process is interrupted if too much fat is in the liver.

In people who drink little or no alcohol, the condition is sometimes known as non-alcoholic fatty liver disease. 

Nonalcoholic fatty liver disease  can occur in any age group but is mostly seen in people ages 40's and 50's and in those who are at high risk of heart disease because of underlying risk factors like obesity and type 2 diabetes.

Causes: It's not clear what causes fatty liver disease but it may run in families.

It's also more likely to happen to those who are middle-aged and overweight or obese. People like that often have high cholesterol and diabetes as well.

Other causes are:

• Medications (steroids, tamoxifen, methotrexate)
• Viral hepatitis
• Autoimmune or inherited liver disease
• Fast weight loss
• Malnutrition

Some studies show that too much bacteria in the small intestine and other changes in the intestine may be linked to nonalcoholic fatty liver disease.

Risk Factors : A wide range of diseases and conditions can increase the risk of nonalcoholic fatty liver disease, including:

• High cholesterol
• High levels of triglycerides in the blood
• Metabolic syndrome
• Obesity, particularly when fat is concentrated in the abdomen
• Polycystic ovary syndrome
• Sleep apnea
• Type 2 diabetes
• Under active thyroid (hypothyroidism)
• Under active pituitary gland (hypopituitarism)

How To Survive Your First Heart Attack

Every 34 seconds , someone in US has a heart attack, and every 60 seconds , someone dies from it. What a person does or does not in the critical first moments can make a difference between life and death. Shortening the time between arrival at ER and treatment contributes to decrease in deaths from coronary artery disease.

When your heart is in danger, every second counts. Take these steps to identify the symptoms and make it to the hospital in time.

Step 1; Recognize the symptoms (more important the less typical symptoms) :
People with a type of arterial disease called atherosclerosis in which there is build up of fat and cholesterol in the arteries in the form of plaques, can get a heart attack if a piece of this plaque breaks off and forms a clot which in turn blocks the blood flow to the heart muscle.
The classic signs of a heart attack are:

• Chest pain
• Pain or discomfort in one or both arms
• Pain in the back or shoulders,
• Sweating
• Shortness of breath
• Nausea and vomiting

Studies have shown that as many as one third of heart attack patients have no chest pain. These patients are more likely to be older, females or diabetic. In fact the older you are it is more likely you will not have the typical symptoms of heart attack. The atypical symptoms include:

Basic Information On Zika Virus

Zika Virus: 6 Facts:
1. Zika virus is transmitted by mosquitoes.
2. The current out break originated in Brazil and has since spread to 20 countries in the America.
3. There is no treatment or vaccine available.
4. Symptoms can include a mild fever, skin rash, joint pain and conjunctivitis, normally lasting 2- 7 days.
5. Pregnant woman are mostly at risk as the virus may cause brain defects in the unborn baby.
6. Prevent transmission by avoiding contact with mosquitoes all together. Use insect repellent and cover skin with long sleeves.

Epidemiology:

• Only about 1 in 5 people infected will fall ill.
• 22 areas in Latin America and the Caribbean have active Zika virus transmission. 
• There is also presence of an outbreak of the virus in Thailand and Indonesia. 

Mode of Transmission: Zika virus is transmitted by Aedes mosquito which also transmits dengue. 

Clinical Symptoms include:

New Ways To Get A Quick Post Operative Recovery

New post-operative recovery techniques, introduced in Europe and now being adopted in many hospitals across the USA has made dramatic improvements in how fast patients recover from major operations, like hip or knee replacement, heart, colorectal and abdominal surgeries.
Experts say these new procedures called as Enhanced recovery after surgery (ERAS)- not only speed healing with fewer complications , but also result in patients having less pain and spending less time in the hospital.
A study of colorectal surgical patients at the University of Virginia Medical Center, published that ERAS procedures cut  hospital stay for patients by more than 2 days , decreased complication rate by 17% and increased patient satisfaction with pain control by 55%.
A few of the key elements of ERSA are described below:

1. Encouraging More Fluids: Traditionally patients were told not to eat or drink after midnight before surgery in order to empty the stomach, so that they won't vomit while under general anesthesia. But because of this starving, the body gets the nutrition by breakdown of own body cells. It turns out the the energy that is needed to recover quick after a surgery is already depleted while fasting preoperative. The new recommendations allow patients to eat solids up to six hours before surgery and to drink clear liquids containing electrolytes and carbohydrates up to two hours before surgery to aid in recovery.

2. Pre medicating With Non Narcotics: In addition to being potentially addictive, postoperative narcotic painkillers can complicate recovery by slowing bowel function and causing dizziness. A dizzy patient is more inclined to fall and feel clumsy after a surgery. The ERSA recommendations include analgesic pain medications given before surgery as well as non narcotic pain relief delivered by catheter directly into surgical site.

3. Walking More: Getting out of bed within 24 hours after having a major surgery is better than a prolonged bed rest.

Breaking Bad News To A Patient- Medical Ethics

Breaking bad news to a patient is one of the most difficult duties for a physician. Without proper training and formal preparation the discomfort and the uncertainty associated with breaking a bad news can lead to emotional misunderstandings between the physician and the patient.

What Is Bad News?
Information that can drastically alter the life and the world of the patient is termed as a bad news.

Reasons Why It is a Difficult Task To Break Bad News?
Conveying a bad news to the patient is a skilled communication and not at all easy. There are many reasons why it is a challenging task for the physicians and doctors.

1. The amount of truth to be disclosed is subjective.
2. There is a feeling of incompetence on the part of the physician and a fear of a negative reaction from the patient and the relatives.
3. The physician is reminded of his/her own vulnerability to a terminal illness and many times they find themselves helpless over the emotional distress.
4. Lack of sufficient training in breaking bad news is a major drawback to most physicians and health care workers.

A Few Protocols To Learn For breaking Bad News:
In order to deliver a bad news to the patient in a diciplined and a structured manner different protocols have been adviced and few of them are discussed below:

Who's Who In Your Doctor's Office

As a patient when you visit your doctor's office you see a number of professionals dedicated to take care of you. Let us know who's who in your doctor's office. These descriptions are related to USA. There may be differences depending on different countries.

1. Physician (MD): The physicians are still the ones in charge- and those with the most training, as indicated by the length of their white coats, the longest of any health care professionals. MDs have 3 to 7 years of training after medical school.

2. Physician Assistant (PA) : Physician assistants can diagnose and prescribe lab tests, treatments and medications. They typically have a master's degree plus 2,000 hours of training with patients while in PA school. A PA's white coat is a little shorter than a physician's.

3. Nurse Practitioner (NP) : A Nurse practitioner has a master's degree which includes 500 to 700 hours of direct patient care during nursing school. NPs can do much of what doctors do, including diagnosis and can also prescribe medicines.

4. Medical Student: A medical student is a physician in training and wears a hip length white coat. he or she can take a medical history, but the prescribing of medicines or diagnostic tests needs approval from a supervising physician.

5. Registered Nurse (RN): Certified and licensed by the state, RNs administer medicines, provide care and otherwise manage patient care. The iconic nurse's cap all but disappeared by the 1980's, as more men become nurses and there was a switch to unisex scrubs.

6. Technician: Technicians are in charge of performing routine tests, such as drawing blood, running EKGs etc. They are usually certified by the state, and they typically wear scrubs. Many technicians have an associate degree in clinical laboratory science.

Low Back Pain - Causes And Management

Introduction: The lower part of the back helps to support the body, helps in movement and protects certain body parts. The lower back is an intricate structure with muscles, tendons, soft tissues as well as highly sensitive nerves and nerve roots that arise from the spinal cord. The lower spine is made up of small and complex joints and the bones of the spine are known as vertebra.

Causes Of Lower Back Pain: 
Symptom of main in the lower back is very common and about 8 in 10 people have suffered from a bout of lower back pain sometime in their life. In most cases it is not due to any serious disease. A few types and causes of the Lower back pain are described as follows:

1. Non-Specific Lower Back Pain: It is the most common type and the majority of people with back pain fall in this category. It is called non-specific because it is not clear what exactly causes the pain. The severity of pain may vary from mild to severe. It is thought that this type of pain may be caused by some strain or stretch of the muscle or the ligaments. It may sometimes develop suddenly following some awkward twisting movement or after lifting something heavy. Some people may sometimes just wake up with a lower back pain. It can also occur after standing for a long time or sitting in an abnormal posture.

2. Age Related Osteoarthritis: Older adults more than 60 years old may suffer from lower back pain secondary to age related degeneration of the joint and osteoarthritis.

3. Muscle Or Ligament Strain: Repeated heavy lifting, awkward movement during workouts may sometimes lead to a stretch or strain to the muscles and the ligaments causing pain.

4. Bulging or Ruptured Discs: Vertebral discs acts as cushions between the individual vertebra in the spine. Sometime the soft material inside the disc may bulge out or rupture and press on a nerve causing pain.

5. Ankylosing Spondylitis: It is a type of arthritis most commonly seen in young adult males and causes pain and stiffness in the lower back.

6. Skeletal Irregularities: Back pain may occur if the spine has an abnormal curvature. Scoliosis is one of such conditions in which the spine curves to the sides and can lead to back pain.

7. Radicular Pain (Sciatica): This pain is caused by irritation or compression of spinal nerve roots of the sciatic nerve. It is characterized by lower back pain, pain in the buttock, and pain along with numbness or weakness in one or both the legs and the foot.

8. Osteoporosis: A condition in which the bones become porous and brittle leading to minor fractures within the vertebra can cause lower back pain.

9. Pregnancy: Pregnancy can commonly cause lower back pain by mechanically stressing the lower back. The effects of hormones that loosen the ligaments as well as the anatomical change in curvature of the spine due to the growing fetus can cause pain.

Migraine Headaches.

Introduction: Migraine is a type of headache which is characterized by intense throbbing or pulsation usually localized to one area of the head and commonly accompanied by a feeling of nausea, sometimes vomiting and sensitivity to light and noise.
A migraine attack can cause significant pain and discomfort with inability to perform normal activities and may last for hours or even days.

A Brief Overview: According to some statistics nearly 30 million people in United States suffer from Migraine. Headaches caused by migraine are more common in women than in men and also has some family predisposition. Migraine headaches may occur infrequently or as often as several times a week. Although it can begin at any time and different people may have different triggers it usually starts early in the morning. A person may start suffering from migraines at an age as young as 5 yrs. It is a treatable but not a curable condition, it is also not considered to be a life threatening condition although it always lead to significant discomfort to the patient.

Etiology: Although the exact cause is still not known it is believed to be a mixture of environmental and genetic factors. Changing hormone levels in the body may also play some role. Pathphysiologically it is believed to be a neurovascular disorder and the primary theory is related to increased excitability of the cerebral cortex and abnormal control of pain in the neurons of the trigeminal nucleus of the brain stem.

Risk Factors: Some individuals are more prone to develop Migraines and there are some common trigger factors. these may include;

• Genetics
• Female gender
• Stress
• Hunger and missed meals
• Menstruation
• Oral contraceptive use
• Drinking Alcohol
• Getting too little or too much sleep. 
• Sudden change in sleeping routine
• Eating food like those that are high in caffeine, aged cheese and preserved meats. 
• Pregnancy may sometimes decrease the attacks of migraine. 
• Weather changes
• Being exposed to flashing lights or under the sun etc

General Care For Elderly Patients

All humans undergo physiological and psychological changes with aging. If anyone of us has to deal with caring for an elderly person it is important to take into consideration these normal changes. The patient may be at home, hospitalized or at a nursing home who ever cares for the elderly person should understand a few basic needs and ways to deal with them.
Even in hospitals there are few professionals that are really trained in specialized care for geriatric patients.
Caring for elderly people needs patience, effort, kindness as well as many times a hard work. Here are a few tips to help you understand the ways to manage them better:

1. If you are caring for an old person who is your parent always remember that there was a time when you were so weak and dependent and they were the ones who cared for you day and night to make you a person what you are now.

2. Many times your loved one is getting old and sick but he/she resists the need for a care. Never take it easy and remember even if they resist they need a proper care and it is your responsibility to provide them the care and attention they need.

3, Take time and determine the type of care that is needed. If they are not too sick to be hospitalized provide them the appropriate care at home. Many people when they get old find difficult getting a shower on their own, changing clothes, cooking, going to toilet, doing the grocery, driving etc. But initially they will deny a need for help with these daily chores. Talk to them and make them feel that you understand them and are always there to help.

4. It is very important to give elderly people a warm emotional support. Never isolate them. Talk to them and let your children play with them. Even if they are sick, bed ridden or hospitalized it is important for the loved ones to visit them on a daily basis, give them time, sit with them and eat together, keep on asking them if they need anything, stay positive and talk with them in a positive way giving them hope.

5. Elderly people at times needed to be psychologically prepared to understand the gradual visual and hearing impairment, difficulty with walking , skin changes etc.

6. If  an elderly person is grieving the death of a loved one like the spouse, close relative or friend , those are the times when the care giver needs to give more attention and help them not go into depression or commit suicide or self harm.

Care In The Hospital: Among half of the adults who occupy hospital beds are more than 65 years old. As the life expectancy is increasing the number may also increase over the next few years.

New Thinking On Alzheimer's Disease

Rates of Alzheimer's disease in the USA are not climbing as fast as they were in the past, may be because people are getting their blood pressure and cholesterol under control- two heart healthy measures that may also be good for the brain and somehow helping in prevention or delaying Alzheimer's disease.

Prevention Is The Key!
A half-dozen trials are under way to test whether life style changes that are good for heart such as exercising and adopting a healthy diet free from fat can some how also prevent and postpone Alzheimer's disease.

Brain Stimulation Works
Many types of brain stimulation devices are being tested not only to treat and prevent Alzheimer's disease, but also to improve cognition in people without dementia. Some of these devices are implanted into the brain and some are worn externally like a head band.

Get Walking
For keeping your brain healthy, research shows that walking is as good as running, as it enhances blood supply to the brain and the memory centers.

Reference:
This article has been taken from a publication by P Murali Doraiswamy a director of neuro cognitive disorders at Duke University.

Facts About Ebola

Ebola Virus is not spread through:

• Casual contact
• Air
• Water
• Food grown or legally purchased in USA

How do You get The Ebola Virus?

Ebola virus is spread by direct contact with:

• Body fluids of a person who is sick with or has died from Ebola ( blood, vomit, sweat, semen, spit, other fluids )
• Objects contaminated with the virus ( needles, medical equipment )
• Infected animals ( by contact with blood or fluids or infected meat )

Early symptoms:

Ebola can only be spread to others after symptoms begin. Symptoms can appear from 2 to 21 days after exposure. The symptoms include:

• Fever
• Stomach pain
• Headache
• Unexplained bleeding or bruising. 
• Diarrhea
• Vomiting
• Muscle pain

When is someone able to spread disease to others?

Duke Criteria For Infective Endocarditis

Major Criteria:
1. Positive blood culture

• typical organism in 2 separate cultures or
• persistently +ve blood culture 

2. Endocardium involved

• positive echocardiogram  showing vegetations, abscess or dehiscence of prosthetic valves or
• new valvular regurgitation (change in murmur is not sufficient)

Minor Criteria:

1. Predisposition like cardiac lesion, Iv drug abuse

2. Fever >38C

3. Vascular /Immunological signs

4. Positive blood culture that does not meet major criteria

5. Positive echocardiogram that does not meet major criteria.

Definite infective endocarditis is diagnosed if 2 major OR 1 major and 3 minor OR all 5 minor criteria are met. 

Causes Of Upper Gastrointestinal Bleeding

Hemetemesis is vomiting of blood which may be bright red or look like coffee grounds and Melaena means black stools with a characteristic smell of altered blood. Both conditions indicate upper gastrointestinal bleeding. The conditions that may lead to upper GI bleeding are summarized as follows:

Common causes:
Peptic ulcers
Mallory-Weiss tear
Esophageal varices
Gastritis / Gastric erosions.
Drugs like NSAIDs, aspirin, steroids
Esophagitis
Duodenitis
Malignancy

Rare causes:
Bleeding disorders
Portal hypertensive gastropathy
Aorto-enteric fistula
Angiodysplasia
Hemophila
Meckel's diverticulum

Complications Of Nephrotic Syndrome

Nephrotic syndrome is a condition which consists of a triad of proteinuria (> 3 g/24 hrs), hypoalbuminaemia (albumin <25g/L) and edema.Severe hyperlipedaemia is often present. (total cholestrol>10mmol/L)

Complications:
Patients suffering from Nephrotic syndrome may have many complication due to underlying disturbance in the body function. some of them are briefly described here:

1. Increased susceptibility to Infections: Infections eg cellulitis, streptococcus infections and spontaneous bacterial peritonitis happen in upto 20% of adult patients. It is because of decreased serum IgG and decreased complement levels. Also T cell function is decreased due in part to loss of immunoglobulin in urine and also due to effect of immunosuppresssive treatments.

2. Thromboembolism:Conditions like deep vein trombosis and pulmonary embolism may occur due to increased clotting factors and platelet abnormalities.

3. Hyperlipidaemia: Increased cholesterol and triglycerides are thought to be due to hepatic lipoprotein synthesis in response to low oncotic pressure.

4. Poor Nutrition: Loss of too much blood protein may lead to malnutrition and weight loss but it is usually not readily observed due to masking effect of edema.

5.High Blood pressure: damage to the glomeruli and the resulting build up of wastes in the blood stream can lead to a high blood pressure.

Causes Of Still Birth

Definition
When a baby dies in uterus at 20 weeks of pregnancy or later it is known as Still birth.

Causes 
A greater proportion of still births seem to occur in otherwise healthy babies and most often the cause is unexplained.
Common causes include:
1. Poor or significantly decreased fetal growth.
2. Placental abruption which means placenta begins to separate before the baby is delivered.
3. Birth defects or chromosomal disorders
4. Infections affecting mother, baby or the placenta.
5. Problems with the umbilical cord like prolapse or knot in the cord.
6. Severe lack of nutrition
7. Lack of oxygen or trauma during delivery
8.Medical conditions in mother like diabetes or high blood pressure.
9.Exposure to toxic environmental agents like pesticides or carbon monoxide.
10. A personal or family history of blood clotting conditions like thrombosis.
11. A previous still birth.
12. Use of Alcohol and drugs during pregnancy.
13.Obese mother
14. Mother age over 35 years.