Characteristic features: Low MCV. (under 80 fl).
2. Mechanisms of TIA:
Sudden loss of function in one region of the brain. Symptoms reach peak in seconds, lasts for minutes or hours. But stops in under 24 hours.
Site of lesion is suggested by the pattern of attack.
Diagnosis of TIA is often based on description of event. During attack loss of function can be demonstrated. Consciousness is usually preserved.
Clinical evidence of embolus:
-Carotid artery stenosis (arterial bruit)
-Atrial fibrillation (or other disrhythmia)
-Valvular Heart disease or endocarditis
-Recent Myocardial Infarction
-Difference between right and left brachial blood pressure (subclavian stenosis)
Atheroma
Hypertension
Postural hypotension
Bradycardia or low cardiac output
Diabetes mellitus
Rare – Arteritis polycythaemia
Anterior Circulation (Carotoid system)
Amaurosis fugax (sudden loss of vision in one eye)
Aphasia (generation and content of speech and understanding)
Hemiparesis
Hemisensory loss
Hemianopic Visual loss
Hence in this scenario it is an Anterior Circulation obstruction.
Posterior circulation (vetebrobasilar system)
Diplopia, vertigo, vomiting
Choking and dysarthria
Ataxia (shaky, unsteady gait)
Hemisensory loss
Hemianopic visual loss
Transient global amnesia
Tetraparesis
Loss of consciousness (rare)
Prognosis:
TIA is a important prognostic event. Prospective studies have shown that 5 years after a TIA:
- 1/6 suffer a stroke
- ¼ die from either Heart disease or stroke
An anterior TIA is of serious prognostic significance compared with posterior.
Immediate Management:
Admit to hospital? Most TIA’s and mild stokes managed at home. Immediate supportive measures and nasogastric fluids given. Frequent turning to avoid bed sores is necessary.
If unconscious - Careful nursing. Meticulous attention to the airway and frequent observation to detect any changes in vital functions
Long term – Oral hygiene, Skin turning, remove rings, eye care – irrigation, taping lids.
Fluids – GI or IV 3000Kcal.
Sphincters: catheterization if necessary avoidance of constipation.
3. Mechanism - Anaemia of Chronic Disease
One of commonest types of anaemia. Occurs in chronic infections like infective endocarditis and TB and osteomyelitis in developing countries, chronic inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus and polymyalgia rheumatica and in patients with malignant disease.
There is decreases release of iron from bone marrow to developing erythroblasts, an inadequate erythropoietin response to the anaemia and decreased red cell survival. The exact mechanisms responsible for these effects are not clear but they seem to be mediated by inflammatory cytokines such as IL-1, TNF and interferons.
The serum iron is low and the TIBC is also low. Serum ferritin is normal or raised. There is stainable iron present in the bone marrow and therefore patients do not respond to iron therapy. However iron is not seen in the developing erythroblasts. Treatment is, in general, that of the underlying disorder, although trials are being carried out with recombination erythropoietin in some patients, for example those with rheumatoid arthritis.
4. Endocarditis and its Management
There are four one-way heart valves that allow blood to be pumped forward from one chamber to another and throughout the body. At the same time these valves prevent blood from backing up into other chambers and the lungs.
Endocarditis is a medical term that refers to infection of a heart valve. Although several different types of organisms can cause endocarditis, it is usually caused by a bacterial infection. Endocarditis occurs when bacteria in the bloodstream "take up residence" and begin to grow and multiply on the heart valve. Untreated, this bacterial infection can gradually "eat away" at and damage the heart valve, causing it to malfunction. Infection of the heart valve can spread through the bloodstream to other parts of the body, causing infection in the blood (septicemia) and in other parts of the body.
Causes
The vast majority of cases of endocarditis are caused by a bacterial infection. Heart valves that have previously been damaged in some way or are dysfunctional are believed to be more prone to develop infections, though infection can also occur on a perfectly normal heart valve.
There are numerous ways that bacteria can get into the bloodstream to cause infection of the heart valve. Something as minor as a small cut can enable bacteria that normally live on the skin to get into the bloodstream. In some cases, this can occur during a dental procedure. In hospitalized patients, the IVs and catheters that are often inserted into the veins may be the portal through which bacteria get into the blood. For many endocarditis patients, however, no clear explanation is ever found regarding how the bacteria first got into the bloodstream.
Fungal infection is a rare cause of endocarditis. This occurs most commonly in patients with compromised immune systems, such as those with AIDS or those who have undergone chemotherapy.
Signs and Symptoms
Endocarditis can cause a wide variety of symptoms, particularly in the earlier stages of infection. Patients may experience such general symptoms as fevers, chills, fatigue, weight loss, muscle aches, and sweating. These general, nonspecific, symptoms can make it hard both for the patient and the doctor to recognize endocarditis.
As infection progresses, other symptoms may develop. If the infection begins to damage the heart valve, the valve may become leaky. A leaky heart valve can eventually lead to blood backing up into the lungs. This accumulation of fluid in the lungs can cause shortness of breath. If the infection spreads to the kidneys, patients may notice blood in the urine. If the infection spreads to the brain, it can cause headaches, confusion, or even stroke.
Treatment
There are three main goals when treating : quickly destroy the infection, repair or replace a heart valve, if needed, and treat complications.
ref: http://www.heartpoint.com/endocarditis.html
Destroy the infection
If you have endocarditis, you will need several weeks of treatment with one or more antibiotics. Initially, you will be treated in the hospital because the antibiotics are given intravenously (IV), and you may need additional tests during treatment. Once your fever is gone and you are stable, you may be able to continue IV antibiotics at home with the help of a home health nurse.
Antibiotics are usually given for 4 to 8 weeks, but some people may require only 2 to 4 weeks of treatment. The antibiotics must be given long enough and at a strong enough dose to destroy all of the bacteria.
After the initial IV antibiotics, your doctor may want you to take antibiotic pills. If so, it is critical that you take them exactly as prescribed until they are gone. If your symptoms return, call your doctor right away. You probably will need more antibiotics if testing shows that the bacteria were not completely destroyed.
If endocarditis is caused by a fungus, you may need intravenous antifungal medication. However, heart valve surgery usually is required for endocarditis caused by a fungus.
These patients are usually given antibiotics prior to any procedure which may introduce bacteria into the bloodstream. This includes routine dental work, minor surgery, and procedures that may traumatize body tissues such as colonoscopy and gynecologic or urologic examinations. Examples of antibiotics used include oral and (Emycin, Eryc,PCE), as well as intramuscular or intravenous , gentamicin, and vancomycin.
Surgery
If your heart valve becomes severely damaged from or if infection develops in an artificial heart valve, surgery may be needed to repair or replace the valve. Before recommending surgery, your doctor will evaluate:
- Your age. People over age 60 may have complications following surgery.
- Your history of heart failure. People with severe heart failure have a higher risk of complications during and following heart valve surgery.
- Whether you have significant and recurrent blood clots (emboli).
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Whether the growths resulting from infection have enlarged, increased in number, or are causing additional problems. If so, surgery may help prevent serious complications, such as a heart attack.
- The type of bacterium or fungus that is causing the endocarditis. Fungal infection is especially hard to destroy with medication. Surgical removal of the fungus and replacement of an infected heart valve may be the best way to control endocarditis caused by a fungus.
- Whether abscesses have developed in the heart.
Complications
If develop, additional treatment may be needed.
Treatment for endocarditis is usually guided by an . A may also be involved if there is damage to the heart muscle or valves. A is needed if you have heart valve replacement surgery