No Domestic violence....... Make woman safe at home ...

Domestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. It includes physical violence, sexual violence, psychological violence, and emotional abuse. The frequency and severity of domestic violence can vary dramatically; however, the one constant component of domestic violence is one partner’s consistent efforts to maintain power and controle ver the other.

In 1994, 1995, and again in 2000, Michigan changed the laws that deal with domestic violence to make it easier for the victims of abuse to get protection through the legal system.

• The abuser may begin making threats, calling the other person names, and slamming doors or breaking dishes. This is a form of emotional abuse that is sometimes used to make the person feel bad or weak.
• Physical abuse that starts with a slap might lead to kicking, shoving, and choking over time.
• As a way to control the person, the abuser may make violent threats against the person's children, other family members, or pets.
• Abusers may also control or withhold money to make the person feel weak and dependent. This is called financial abuse.
• Domestic violence also includes sexual abuse, such as forcing to have sex against her wish.

Woman with multiple presentation with multiple injuries bruise burn facial injuries teeth break and eye injuries are a typical presentation of severe grade home violence. She may be presenting with depression or vague symptoms, sleep disorder diarrhea eating disorders may be associated with long term home violence. Confidentiality at the beginning and  Previous marriages, suicidal ideas  and psycho social history are important peace of information.

Admission may require if injuries are alarming. management of injuries and ensure her safety as well as psychological aspect of management is included. Always suspicion of home violence is the way to find more cases.If patient wishes we can help with the involvement of police. If her life is under threat it is gps responsibility to make sure her safety

Refering Social and other support groups, negotiation with  Family meetings with her consent liaise with  Domestic violence resource center/ social worker and documenting for future use and regular followup are inclueded in the management process.

Free legal services are available.Telephone numbers GP, Police , women protection service  domestic violence 24 hour help line will secure her adequately. It is our and  society responsibility to protect woman for home violence.

How do you suspect child abuse ?

Child abuse is more than bruises and broken bones. While physical abuse might be the most visible, other types of abuse, such as emotional abuse and neglect, also leave deep, lasting scars. The earlier abused children get help, the greater chance they have to heal and break the cycle—rather than perpetuate it. By learning about common signs of abuse and what you can do to intervene, you can make a huge difference in a child’s life.

It is true that abused children are more likely to repeat the cycle as adults, unconsciously repeating what they experienced as children. On the other hand, many adult survivors of child abuse have a strong motivation to protect their children against what they went through and become excellent parents.

How do you suspect a child being abused ?

Child abuse is not always obvious. But by learning some of the common warning signs of abuse and neglect, you can catch the problem as early as possible and get both the child and the abuser the help that they need

Warning signs of emotional abuse in children

• Excessively withdrawn, fearful, or anxious about doing something wrong.
• Shows extremes in behavior (extremely compliant or extremely demanding; extremely passive or extremely aggressive).
• Doesn’t seem to be attached to the parent or caregiver.
• Acts either inappropriately adult (taking care of other children) or inappropriately infantile (rocking, thumb-sucking, throwing tantrums).

Warning signs of physical abuse in children

• Frequent injuries or unexplained bruises, welts, or cuts.
• Injuries of different ages and different kinds.
• Delay presentation
• Injuries appear to have a pattern such as marks from a hand or belt.
• Shies away from touch, flinches at sudden movements, or seems afraid to go home.
• Wears inappropriate clothing to cover up injuries, such as long-sleeved shirts on hot days.

Warning signs of neglect in children

• Clothes are ill-fitting, filthy, or inappropriate for the weather.
• Hygiene is consistently bad (unbathed, matted and unwashed hair, noticeable body odor).
• Untreated illnesses and physical injuries.
• Is frequently unsupervised or left alone or allowed to play in unsafe situations and environments.
• Is frequently late or missing from school.

Warning signs of sexual abuse in children

• Trouble walking or sitting.
• Displays knowledge or interest in sexual acts inappropriate to his or her age, or even seductive behavior.
• Makes strong efforts to avoid a specific person, without an obvious reason.
• Doesn’t want to change clothes in front of others or participate in physical activities.
• An STD or pregnancy, especially under the age of 14.
• Runs away from home.

 Risk factors of child abuse are domestic violence, Alcohol and drug abuse, Untreated mental illnesses, Multiple marriage and social situations.

Tips for talking to an abused child

Avoid denial and remain calm. A common reaction to news as unpleasant and shocking as child abuse is denial. However, if you display denial to a child, or show shock or disgust at what they are saying, the child may be afraid to continue and will shut down. As hard as it may be, remain as calm and reassuring as you can.

Don’t interrogate. Let the child explain to you in his or her own words what happened, but don’t interrogate the child or ask leading questions. This may confuse and fluster the child and make it harder for them to continue their story.

Reassure the child that they did nothing wrong. It takes a lot for a child to come forward about abuse. Reassure him or her that you take what is said seriously, and that it is not the child’s fault.

Management of child abuse is multidisplinary approach. It is mandatory to report.
Child may need admission for most of cases and assessment by Judicial medical officer. Blood investigations, x rays photography and accurate documentation is necessary. If home not safe organize relative or holster care in case where admission not necessary.
Management of injuries and complications with appropriate counselling and referral and then   ( Case Conference ) to assess all situation participated by pediatrician, psychiatrist ,Judicial medical officer, police officer, social worker , myself , police officer, nursing officer
Financial support, social worker, family counselor as well as checking other children whether they are safe also important. Avoid stigmatization and long term followup is also necessary.

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Hypertension

Hypertension is a serious community disorder and the most common condition requiring long-term

drug therapy.It is a silent killer because most people with hypertension are asymptomatic and unaware of their problem.Epidemiological studies have demonstrated the association between hypertension and stroke, coronary heart disease, kidney disease, heart failure and atrial fibrillation. Treatment may be lifelong, hence the need for careful work-up.

• Target organs (including some specific examples) that can be damaged by hypertension include the

heart (failure, LVH, ischaemic disease), the kidney (kidney insufficiency), the retina (retinopathy), the blood vessels (peripheral vascular disease, aortic dissection) and the brain (cerebrovascular disease).

Isolated systolic hypertension is that of ≥ 140 mmHg in the presence of a diastolic pressure <90 mmHg.
Category Systolic Diastolic
Normal <120 <80
High normal 120–139 80–89
Grade 1 hypertension (mild) 140–159 90–99
Grade 2 hypertension
(moderate)
160–179 100–109
Grade 3 hypertension (severe) ≥180 ≥110
Isolated systolic hypertension ≥140 <90

Clinical features	Likely cause
Abdominal systolic bruit	Kidney artery stenosis
Proteinuria, haematuria, casts	Glomerulonephritis
Bilateral kidney masses with or without haematuria	Polycystic disease
History of claudication and delayed femoral pulse	Coarctation of the aorta
Progressive nocturia, weakness	Primary aldosteronism (check serum potassium)
Paroxysmal hypertension with headache, pallor, sweating, palpitations	Phaeochromocytoma
truncal obesity with pigmented striae	Cushing's syndrome

Factors associated with the prognosis are age,smoking , diabetes , dyslipidemia ,family history, obesity,CRP,brain heart kidney eye vascular complications,target organ damage ( echo LVH, Urine MA/EGFR,angio/opthalmo evidence , socio economic , ethnic factors, sedentary life, alcohol.

Conn's syndrome: clinical features Weakness due to hypokalaemia Polyuria and polydypsia Na ↑, K ↓, alkalosis Aldosterone ↑ (serum and urine) Plasma renin ↓

Phaeochromocytoma: clinical features Paroxysms or spells of: hypertension headache (throbbing) sweating palpitations pallor/skin blanching rising sensation of tightness in upper chest and throat (angina can occur) Investigation: 24 hour urinary free catecholamines ↑ (VMA)

FH,MXH –OCP,HRT, Nasal decongests, NSAID , Steroids ,salt ,alcohol

G/A , BP Standing and sitting , PL RR O2 , H/W/BMI/Waist circumference

 Pallor cyanosis, dyspnea temperature Face Plathora, Alcohol abuse, Hyper LIP

Neck- Carotid bruit , Thyroid

Heart -HS,M, Added , Peripheral pulse , Apex ---  Chest - Crepts , wheeze ,

ABD- EPIGASTRIC BRUIT, H/S,

 Fundy HE, EXU, AVN,PAPD

Investigations - U FOR Cast, Cell, Protein, GLC,

RBS , FBC , RFT , LFT, SE, LP , SC, EGFR, S uric acid, ECG, Albumin/Creatinin ratio

SPC test- Atherosclerotic kidney artery stenosis – Dropler USS, ECHO, Carotid USS, Micro albuminuria, 24 hour proteinuria,  Fundoscopy.

Non pharmacological and pharmacological ……4-6 weeks take to act ADTC----- if end organ damage start drug straight away . some times for aboriginal

Systolic (mm Hg)	Diastolic (mm Hg)	Action/recommended follow-up *
< 120	< 80	Recheck in 2 years.
120 - 139	80 - 89	Recheck in 1 year - lifestyle advice.
140 - 159	90 - 99	* Confirm within 2 months - lifestyle advice.
160 - 179	100 - 109	* Evaluate or refer within 1 month - lifestyle advice.
≥ 180	≥ 110	* Further evaluate and refer within 1 week (or immediately depending on clinical situation). If blood pressure has been confirmed at ≥ 180 mm Hg systolic and/or ≥ 110 diastolic mm Hg (after multiple readings and excluding ‘white coat’ hypertension), drug treatment should be commenced.

Ambulatory blood pressure monitoring may distinguish from established from transient hypertension .Measurement of BP at home 

 SNAPS – caffeine no , salt no , MX OSA for 3 months

Start ACEI lower dose X rew 6 WK to 3 M ( take to work ) Ramipril ( 2.5 mg bd)

Still high add HCT if old or Nifidipin if 40- 50

Start lowest dose and allow 6- 12 weeks to work

Then increase one

If high BP record  BP twice a day for 1/52 home meter

Keep < 140/90 or < 120/ 80 if proteinuria

If 180 / 110 or 180/70  ( gap) treat straight away or aboriginal or proteinuria 

Say Cant go hospital --- Explain --à Still give antihypertensives and rew tomorrow

Aboriginal -  not sure come back so start drug

ACEI or ARB

How much you drop BP – DBP about 10 systolic about 20-30

Manage risk factures -  

Obstructive sleep apnoea

Obstructive sleep apnoea is a very common condition affecting 2-4% of adults to a significant degree. It characterised by repeated episodes of obstruction of the throat during sleep and is usually associated with loud snoring and excessive daytime sleepiness. OSA is an independent risk factor for the development of hypertension and insulin resistance, and is associated with heart attack, cardiac arrhythmia, and stroke. Treatment includes lifestyle changes, continuous positive airway pressure (CPAP), mandibular advancement spints and surgery.

History

Loud and chronic snoring, Chocking or grasping, day time sleepiness, morning head ache

Time to time wake up night , difficult to control , mood

Risk-  over weight  , FH , > 65 , Smoker, ----

Examination

Thick neck, enlarge tonsils, nasal congestion , allergy , polycythemia

Management

·          Sleep disorder center - Sleep study Polysongrapic ( Observe patients sleep pattern when the patient sleep  involve a camera noisy breathing duration frequency )  , FBC, BSL LP ECG Cx ray,  X ray neck SE, UFR , ESR ( Cheep ) CRP ( Change rapid so monitor )

    2^nd Iron study if FBC , Na Ca , blood film, B12 folic HBV Etc

·         SNAPS (lifestyle modification )

·         Avoid caffeine , sleeping tablets, heavy meal

·         Elevate head end

·         Commercial standard  not met for DL

·         Regular health check

·         4 R

·         Breathing devises – O2 RX , CPAP delivered by nasal or facial masks , Dental devises ( The mandibular advancement splint )

·         ENT for Corrective Surgery  ( tonsillectomy , nasal obstruction )

·         Medicating ( Amitriptyline ) , If nasal – nasal decongestion and topical steroid 

Sleep apnea refers to brief interruption  of ventilation resulting hypoxemia and biochemical effects . That is nott recognized by the patients. OSA which involves intermittent narrowing and occlusion of pharyngeal area of the upper airway. that you feel difficult to breath time to time at night  as a result of an obstruction at throat

4 Main DD for fatigue are depression , sleep apnea , stress and anxiety , post viral illness

Airway size- Obesity, tonsiller adenoidal hypertrophy.    U/ Airway muscle hypotonia –alcohol , neuron .   Nasal obstruction

Sleepiness  Day  ( Day time somnolence ) , Depression,  personality changes , Family meeting ,  ( family problem ? Why wife sleep separately , Sexual dysfunction )

Ass  obesity  ( sleep  hygiene not good ) ,  alcohol drugs , hypothyroidism

Sleep on the side , 8 hour sleep enough quantities but check for the quality . commercial driving but can private car .

Stiff 

Head ache

Welcome ,Introduce, rapport ,inquire  P/C 

Vitals , pain management  ---- if stable history

Interpreter, Appreciate

Patient centered nonjudgmental history focusing patient's ICE depending on DD , red flags-and other issues.Open ended aproach

My DD are -----RTI migraine,tension headache ,head injury,Hypertensive encephalopathy, SAH,ICH,Temporal arteritis,Sinositis ,Cluster headache,Meningitis,tumor,glaucoma,Drug withdrawal,Alcohol ,Refractive error, Dental, Depression ,epilepsy,TMJ, alcohol , cervical 

DDDAPSUN  

explore the presenting complain and back ground history 

Headache – Duration , Onset, Progression, What does he think, impact , severity ,location,bilateral or unilateral.

 radiation, aggravating and revealing factors, timing ,associated symptoms DOLTRARST, 

Ruleout DD one by one 

Does he have F/O upper or lower respiratory tract symptoms -cough, SOB,Throat pain,ear pain or discharge , tooth pain , pain o chowing 

sudden,onset progressive , thunder cap …a stiff neck, being sick, sensitivity to light, blurred seen  , seizures (fits) or loss of consciousness  5 S….. Associated nausea vomiting

 subarachnoid haemorrhage

 Migraine -UL, Throbbing UL,pulsating pain , N/V , flickering , Sound light sensitive , associated with trigger and activity  . in classical - tingling arm leg , flashing zigzag ,speech facial paralysis

Meningitis – 5 S and high fever, lethargy rash , behavior change (Encephalitis )

Tumor – early morning head ache ,vomiting, aggravate by sneezing coughing , Headache numb arm , Memory personality  , FNS,

Cluster - Tearing tearing stuffy red eye ,ptosis flashy face

Temporal arteritis - Throbbing tender temporal jaw , girdle pain ,lethargy , blur vision

Sinusitis – facial pain , dental pain , nasal stiff , discharge , loss smell , bad breath

Tension – continues ,evening , band ,scalp muscle tenderness , keep working ,stress

associated symptoms and systemic review 

Palpitation , chest pain , SOB

Epigastria pain , Back ache ,

Sleep mood water loose Vision  energy level

PMH- Migraine , HTN , DM HD Sinusitis , Drugs – CCB OCP Whether he is a regular patient or not

 FH- Brain tumor ,migraine , DM HD, stroke 

Contact history , Travel history 

AH-

Social – Smoking alcohol drugs ,occupation, Stress- mood suicidal ideas 

OE G/A, GCS, HT WT BMI,

 BP Pulse RR

      Pallor cyanosis  Dyspnea temperature ENT , LNE , Sinus , Teeth , Hydration ,temporal artery , scalp tenderness 

      Rash, Xan Facial asymmetry,drooping of eye, Neck Neck stiffness 

Thyroid , Cervical vertebra- palpate over C2 – C3 ,  Nicotine,  drug IV 

edema ,

Heart – Apex  ,HF  Pulse Bp Carotid bruit  

CHEST

ABD - HS

CNS – CN ( 2346 /57 ), UL , LL CNS examination including planter reflex  ----specially eye ( acuity field reactions, movements ,with Ophthalmoscope

thanks

 @ ECG shows LVH No other symptoms or signs -----HTN So rule out 2 ry causes

Going back to history , Examination , IX

Investigations- ECG , RBS , urine 

FBC , ESR , CRP , LP , Frontal X , Chest X ray , X ray spine

CTS or MRI at hospital-----LP?

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 Explanation and reassurance 

Sinusitis is an inflammation, or swelling, of the tissue lining the sinuses. Normally, sinuses are filled with air, but when sinuses become blocked and filled with fluid, germs (bacteria, viruses, and fungi) can grow and cause an infection. Amoxicillin , Mucolitics , Steam , Nasal decongesion , ENT refer - drain sinuses ----- orbital cellulitis cavernus sinus abcess  

Meningitis is an infection of the meninges (protective membranes) that surround the brain and spinal cord. The infection causes the meninges to become inflamed (swollen), which in some cases can damage the nerves and brain.

Migraine - is a severe, painful headache that is often preceded or accompanied by sensory warning signs such as flashes of light, blind spots, tingling in the arms and legs, nausea, vomiting, and increased sensitivity to light and sound. The excruciating pain that migraines bring can last for hours or even days.

Migraine -  like BA – Assess – mild – Aspirine 600 – 900 , maxalon , moderate – ergotamine 1mg + caffeine + maxalone , severe – ergotamine 1mg IM or sumitriptan 6mg SC                                                                                                                                           

Tension headache-  is pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas. 

Massage hot bath , relaxation , yoga , meditation , counseling, CBT , Aspirin PCM Amitriptyline, diazepam  

Cervical problem -  X ray

Osteophytes , CX disk prolapse , osteosclerosis , erosion, Joint space widening

MX – CX color , Pain , Physio , Neck exercise , Hydrotherapy , trance electrical nerve therapy, swining , low dose TCA   ,

Deteriorating patient

Go to the patient and look how do you feel any discomfort? Input , UOP, Pain, vomiting  ?

G/A, Level of consousness  ( GCS) , Vitals  ( BP PULSE RR O2 T ), hydration , look for observation chart

Dillirium – When get hx what happen , Vitals ,cause for dillirium  pain , dehydration , infection , PE, alcohol withdrawal , rabdomyalosis ( CPK ) , constipation , urinary retention , problem with environment  unfamiliar , psychiatric , electrolyte imbalance , HF------- ECG and Blood IX …….PAID REC p for PE, A for alcohol , I for infection ,  d for drug/dehydration ,R –r for redo/ retention  , e for electrolyte and environment 

                  If agitated sedate with resperidone 0.5 mg  assess severity whether need to admit to ICU

Sudden deterioration – danger , response ( No response – CPR) , Seek for help ,

                               Air way – patent or not

                             breathing – rate air entry , trachea , muscle using , saturation  ,< 95% oxygen   

                            Circulation – BP Pulse capillary refill , Canula  and IVF ,

                           Disability and exposure  , examine and relevant investigations .

BP drop  after surgery – drs ABC 2 wide bore canula , fluid bolus N/S 1 L, catheter ,  blood for cross match , call to consultant , sent to hospital .

Chest pain – DRS If response mean airway + , AB (RR Regular trachea muscles ) C breaf history  LOTARDAR ST Worse pain             Risk assessment – PMH Dm S/A,    obese, FHX             

After surgery C/O abdominal pain – go , check for vitals , Hx EX , cause for pain ,Check charts , surgical note about pain management , which analgesic given , addicted , infection bleeding peritonitis, dehisions 

Prepare for a surgery – Premed , IX , Mentally stable , any worries , make sure drugs given

Procedure – NGT , Catheter , tube cannula

Anuria – fluid bolus , UOP hourly , SE, UEC