Possible Causes of Amenorrhea and Hirsutism in Women

Amenorrhea, the absence of menstrual periods, and hirsutism, excessive hair growth, are symptoms that can be caused by various conditions. Polycystic ovarian syndrome (PCOS) is a common cause of anovulatory infertility and is diagnosed by the presence of two out of three criteria: ultrasound appearance of enlarged ovaries with multiple cysts, infrequent ovulation or anovulation, and clinical or biochemical evidence of hyperandrogenism. Turner syndrome, characterized by short stature, webbed neck, and absence of periods, is a genetic disorder that would not cause primary amenorrhea. Hyperprolactinemia, a syndrome of high prolactin levels, can cause cessation of ovulation and lactation but not an increase in BMI or hair growth. Premature ovarian failure has symptoms similar to menopause, such as flushing and vaginal dryness. Virilizing ovarian tumor can also cause amenorrhea and hirsutism, but PCOS is more likely and should be ruled out first.

To prevent skin contact with the enzymes in the small intestine, a loop ileostomy is created. This type of ileostomy is typically located on the right iliac fossa and has a spouted shape, containing liquid faecal material. It is often performed as part of an anterior resection procedure, which involves removing the upper rectum and sigmoid colon. The loop ileostomy is temporary and will be reversed at a later time.

To distinguish between a colostomy and an ileostomy, several factors can be considered. The location of the stoma is one clue, with ileostomies typically found on the right side of the abdomen and colostomies on the left. However, the appearance of the output is also important. A spouted output indicates an ileostomy, as the small intestine’s contents can be irritating to the skin. In contrast, a flush output suggests a colostomy, as the large intestine’s contents are less likely to cause skin irritation. Additionally, ileostomy output is typically liquid, while colostomy output may be more solid.

Other types of ostomies include end and loop colostomies, which are flush to the skin and contain semi-solid faecal matter. A nephrostomy is a tube inserted into the renal pelvis and collecting system to relieve obstruction caused by kidney stones or infection. A urostomy is a bag used to collect urine after bladder removal, with the ureters connected to a segment of the small bowel that opens onto the abdominal wall.

Abdominal stomas are created during various abdominal procedures to bring the lumen or contents of organs onto the skin. Typically, this involves the bowel, but other organs may also be diverted if necessary. The type and method of construction of the stoma will depend on the contents of the bowel. Small bowel stomas should be spouted to prevent irritant contents from coming into contact with the skin, while colonic stomas do not require spouting. Proper siting of the stoma is crucial to reduce the risk of leakage and subsequent maceration of the surrounding skin. The type and location of the stoma will vary depending on the purpose, such as defunctioning the colon or providing feeding access. Overall, abdominal stomas are a necessary medical intervention that requires careful consideration and planning.

The development of fast atrial fibrillation (AF) in a patient who has undergone a right-hemicolectomy is concerning and warrants investigation for anastomotic leak (2) as a potential cause. This is especially important as the patient has no prior history of AF or cardiac issues. The timing of the onset of AF, 5 days post-op, and the presence of feculent material in the wound drain are additional red flags. Ischaemic colitis (1) is less likely as the patient is not experiencing severe abdominal pain or passing bloody stools. Ruptured abdominal aortic aneurysms (3) are also less likely due to the recent surgery. A myocardial infarction is unlikely as the patient does not have chest pain radiating to the left arm and jaw or shortness of breath.

Complications can occur in all types of surgery and require vigilance in their detection. Anticipating likely complications and appropriate avoidance can minimize their occurrence. Understanding the anatomy of a surgical field will allow appreciation of local and systemic complications that may occur. Physiological and biochemical derangements may also occur, and appropriate diagnostic modalities should be utilized. Safe and timely intervention is the guiding principle for managing complications.

Differential diagnosis of a patient with muscle pain, fatigue, skin dots, bleeding gums, and weight loss

Scurvy, a rare condition in the general population, is a relatively common nutritional finding in the elderly and socially disadvantaged groups. It results from a deficiency of vitamin C, which is needed to make collagen. Without vitamin C, collagen cannot be replaced and tissue breaks down, leading to symptoms such as muscle and joint pain, fatigue, red dots on the skin (perifollicular haemorrhages), bleeding and inflammation of the gums (gingivitis), decreased wound healing, and easy bruising. Treatment involves vitamin C supplementation and dietary changes.

Lead poisoning, although not likely to cause the signs present in this patient, can cause abdominal pain, confusion, and headaches, and in severe cases, seizures, coma, and death. It is usually caused by exposure to lead in the environment, such as from contaminated water, soil, or paint.

Vitamin K deficiency, although rare, can cause bleeding and easy bruising, but it is much less common than vitamin C deficiency. Vitamin K is needed for blood clotting and bone health, and it is found in green leafy vegetables, liver, and eggs.

Hypothyroidism, a common endocrine disorder, is more likely to cause weight gain than weight loss, as it slows down the body’s metabolism. It can also cause dry, coarse skin, fatigue, and depression. Treatment involves thyroid hormone replacement therapy.

Pellagra, a rare condition caused by a deficiency of niacin (vitamin B3), can cause diarrhoea, dermatitis, and dementia. It may also cause aggression and red skin lesions, but it is less common than vitamin C deficiency. Treatment involves niacin supplementation and dietary changes.

The classic presentation of androgen insensitivity is primary amenorrhoea, with the key symptom being groin swellings. When combined with the absence of pubic hair, this points towards a diagnosis of androgen insensitivity, also known as testicular feminisation syndrome. This condition occurs in individuals who are genetically male (46XY) but appear phenotypically female due to increased oestradiol levels, which cause breast development. The groin swellings in this case are undescended testes. While non-Hodgkin’s lymphoma could also cause groin swellings, it is less likely as it would typically present with systemic symptoms and is not a common cause of delayed puberty.

Disorders of sex hormones can have various effects on the body, as shown in the table below. Primary hypogonadism, also known as Klinefelter’s syndrome, is characterized by high levels of LH and low levels of testosterone. Patients with this disorder often have small, firm testes, lack secondary sexual characteristics, and are infertile. They may also experience gynaecomastia and have an increased risk of breast cancer. Diagnosis is made through chromosomal analysis.

Hypogonadotrophic hypogonadism, or Kallmann syndrome, is another cause of delayed puberty. It is typically inherited as an X-linked recessive trait and is caused by the failure of GnRH-secreting neurons to migrate to the hypothalamus. Patients with Kallmann syndrome may have hypogonadism, cryptorchidism, and anosmia. Sex hormone levels are low, and LH and FSH levels are inappropriately low or normal. Cleft lip/palate and visual/hearing defects may also be present.

Androgen insensitivity syndrome is an X-linked recessive condition that causes end-organ resistance to testosterone, resulting in genotypically male children (46XY) having a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome. Patients with this disorder may experience primary amenorrhoea, undescended testes causing groin swellings, and breast development due to the conversion of testosterone to oestradiol. Diagnosis is made through a buccal smear or chromosomal analysis to reveal a 46XY genotype. Management includes counseling to raise the child as female, bilateral orchidectomy due to an increased risk of testicular cancer from undescended testes, and oestrogen therapy.

Functions of the Facial Nerve

The facial nerve, also known as the seventh cranial nerve, has several important functions. It carries secretomotor fibers to the lacrimal gland through the greater petrosal nerve and is secretomotor to the submandibular and sublingual glands. It also supplies the muscles of facial expression and is associated developmentally with the second branchial arch. The facial nerve carries special taste sensation to the anterior two-thirds of the tongue via the chorda tympani nerve and somatic sensation to the external auditory meatus. However, it does not innervate the levator palpebrae superioris or the principal muscles of mastication, which are supplied by other nerves.

Common Terms in Psychiatry

Confabulation is the act of unintentionally reporting false memories that seem plausible. This can occur in individuals with Alzheimer’s disease or Korsakoff syndrome. Concrete thinking is a type of thinking where a person has difficulty thinking abstractly and may interpret proverbs literally. Hallucinations are sensory experiences that are not caused by external stimuli. Thought blocking is when a person suddenly stops their train of thought. Thought insertion is a delusion where a person believes that their thoughts are being placed in their mind by an external force.

These terms are commonly used in psychiatry to describe various symptoms and conditions. It is important to understand their meanings in order to properly diagnose and treat patients. Confabulation and concrete thinking may be indicative of cognitive impairment, while hallucinations and delusions may be symptoms of a psychotic disorder. Thought blocking may occur in individuals with schizophrenia, while thought insertion may be a symptom of delusional disorder. By these terms, healthcare professionals can provide better care for their patients.

Causes of Dilated and Small Pupils

Dilated pupils can be caused by various factors such as Holmes-Adie (myotonic) pupil, third nerve palsy, and drugs or poisons like atropine, CO, and ethylene glycol. On the other hand, small pupils can be caused by Horner’s syndrome, old age, pontine hemorrhage, Argyll Robertson pupil, and drugs or poisons like opiates and organophosphates.

Holmes-Adie (myotonic) pupil and third nerve palsy are conditions that affect the muscles that control the size of the pupil. Meanwhile, drugs and poisons like atropine, CO, and ethylene glycol can cause dilation of the pupils as a side effect. On the other hand, Horner’s syndrome, old age, pontine hemorrhage, Argyll Robertson pupil, and drugs or poisons like opiates and organophosphates can cause the pupils to become smaller.

Smoking has been found to decrease the risk of hyperemesis gravidarum, which is believed to occur due to rapidly rising levels of human chorionic gonadotropin (HCG) and oestrogen. This is because smoking is considered to be anti-oestrogenic. Therefore, despite having other risk factors, the fact that the patient is a smoker may decrease her incidence of hyperemesis gravidarum. On the other hand, hypothyroidism is not a risk factor, but hyperthyroidism increases the risk of hyperemesis gravidarum. Obesity and underweight are associated with an increased risk of hyperemesis, but women with these conditions who smoked before pregnancy have been found to have no increased risk. Primigravida status is also associated with an increased risk of hyperemesis, but the reason for this is not clear. Finally, twin pregnancies carry an increased risk of hyperemesis gravidarum due to higher levels of beta-hCG released from the placenta.

Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.

Codeine phosphate and dihydrocodeine are drugs that activate the μ opioid receptor and are commonly used to alleviate moderate pain. Codeine can also be used as a cough suppressant, but it should be avoided in cases of acute infective diarrhea and ulcerative colitis. Long-term use in the elderly is not recommended due to its constipating effects and potential contribution to delirium. Co-prescribing with a laxative is advisable for those at risk. Digoxin, on the other hand, does not cause constipation but may lead to arrhythmias, blurred vision, conduction disturbances, diarrhea, dizziness, eosinophilia, nausea, rash, vomiting, and yellow vision. Carvedilol and atenolol are beta blockers that are not commonly associated with constipation. While atenolol may cause gastrointestinal disturbances, its side-effects are not well documented. Paroxetine, a selective serotonin reuptake inhibitor, is used to treat anxiety and major depression. It may cause constipation and abdominal pain, but its side-effects are dose-dependent, and in this case, codeine is more likely to be the cause of constipation than paroxetine.