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Thread: Rahabilitation in TB & MI patient

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    Default Rahabilitation in TB & MI patient

    Comment briefly on Rahabilitation in TB & MI [Truck driver] patient.

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    Thumbs up Medical Aspects of Rehabilitation in Tuberculosis

    Medical Aspects of Rehabilitation in Tuberculosis

    A. Pathological and Immunological Basis for Rehabilitation.
    The average patient with tuberculosis takes active treatment for a period of one to two years, and is dtscharged as apparently arrested several months after his sputum has become negative and he has become symptom free.

    There are two questions which must confront the physician when this point is reached. The first is what is the actual residual disease in the lung of this patient whose lesion appears by x-ray to have resolved or to have undergone fibrosis.
    The second is what is the immunological status of the patient with respect to the residual infection in his body.

    In answer to the first question it may be said that the course of reinfection tuberculosis is modified by the indeterminable factors, native immunity, degree of allergy, the dose as well as the virulence of invading organisms, and many other factors more difficult to evaluate. There are consequently extreme variations in the rate of progress of the disease as well as in its rate of healing. The careful studies of healing and resolution cited below preclude any assumption that a patient discharged from the sanatorium with the usual criteria of an apparently arrested case can conceivably be cured and out of danger. The studies of Sweaneyl2 show that the average rate of encapsulation and resolution in both primary and reinfection tubercles of moderate size (3-12 mm.) is a relatively uniform function of time over a period of ten to twenty years. Amberson1 summarizing his observations in several thoussnd cases states as follows:

    "Clinical observation suggests that competent encapsulation requires a year or two and sometimes more after resolution has exhausted its role, a point needing strict attention in attempting to guard against relapse."

    Cases are presented by Amberson' and by PinnerB to demonstrate the fact that tracing a fading lesion to the point of invisibility by x-ray films does not prove its actual dlsappearance. The presence of caseation over many years' duration is demonstrated by the appearance of calcification after a lapse of five to ten years during which tlme the x-ray has been clear. Experimentally
    slmilar discrepancies between roentgenological and anatomical evidence of disease in rabbits infected with tubercle bacilli have been demonstrated by Austrian and Willisa and by Burke.3

    The above teachings constitute the basis for the customary vigilance toward the discharged sanatorium patient. We recognkv that describing him as arrested furnishes a clinical picture of bis disease; that anatomical changes are still in progress, and will continue to be for years to come. The frequent flare ups are understandable in the light of this knowledge Faced with the problem of guiding a patient with residual infection, the answer to the second question is highly desirable.

    What is the immunological status of the patient with respect to his infection? The problem here is similar to that in the handling of an acute infection such as Lobar pneumonia. In the days before the advent of chemotherapy a crisis or lysis indicated the establishment of Immunity in the patient, and the disease was known to be under control from this point on. With the use of antibiotics remarkable cures were established within a few days. It was a
    common experience for those who discontinued the use of drugs upon the first x-ray evidence that the lung had cleared to find within two or three days that the disease had retuned in the same or in another lobe. The obvious explanation was that treatment had been discontinued prematurely-before the establishment of adequate immune mechanisms on the part of the body.

    Minute areas of residual disease were therefore capable of serving as centers from which renewed attacks upon a defenseless body take place.
    The immunological mechanisms in tuberculosis are infinitely more complex than those in lobar pneumonia although they may be similar in basic pattern. Some insight into this complexity may be gained from Rich's detailed dlscussions.It is obvious from the clinical course of this. chronlc infectious disease that the defense mechanisms are developed slowly, and do not attain
    their maximum height until several years after the onset of the infection. Furthermore, marked fluctuations in the level of immunity occur constantly under the influence of factors such as pregnancy, the puerperlum, fatigue, emotional strain, and many others. Under the circumstances it becomes virtually impossible in any individual patient, discharged as arrested from a sanatorium, to predict to what degree he will withstand the various
    untoward influences upon his Immune level.

    B. Medical Problem Encountered in the Course of Rehabilitation

    Medical problems arising during rehabilitation are frequently different from those arising during the earlier part of the patient's treatment. Two reasons for these differences are as follows:
    First, the increased activity of the rehabilitation period brings to light physical disorders which may be masked while the patient is on markedly restricted activity.

    Second, the very treatment instituted in the sanatorium to convert the patient from sputum positive to negative occasionally introduces complications which retard or make impossible full physical rehabilltation. It is hoped, by summarizing our experiences, to contribute to a long ranged
    point of view with regard to the medical management of pulmonary tuberculosis: that the all important efforts during the first part of the patient's illness to save his life and convert him from sputum positive to negative might avoid so far as possible irreversible measures interfering with subsequent rehabilitation, The various problems encountered are readily grouped as follows:

    1. Non Tubercular Complications.
    These serve only to delay the course of rehabilitation to some degree. Thus, episodes of acute appendicitis, gall bladder disease, hernias, and other surgical problems are to be expected and are handled with ease. Of greater importance are the pneumonias and other respiratory infections. During these illnesses the question is repeatedly presented as to whether a reactivation of the tuberculosis has taken
    place. Even minor episodes of acute bronchitis or tracheitis may lead to disturbing hemoptysis necessitating reevaluation of the medical status in each case and significant interruptions of programs.
    Relatively minor respiratory infections may have serious consequences through operation of heteroallergic reactions or through the ShwarUman phenomen as elaborated by Rich.lo We have adopted the policy, therefore, of administering penicillin freely by inhalation to all patients suffering from respiratory infections of more than forty eight hours duration without significant improvement in an effort to mlnimlze their disturbing
    influences.

    Occasionally metabolic diseases in their incipiency may tax the physician. Hyperthyroidism was encountered several times in young women during rehabilitation. The difficulty in distinguishing symptoms of this disease in its earliest stage from evidence of reactivating tuberculosfs is obvious.
    Non allergic asthma is a rather common finding, although no figures are available at this time indicating its exact frequency in tuberculosis. We have found very commonly among ow trainees the symptom complex of wheeze, cough, and mild to severe paroxysms of dyspnea, occurring throughout the year, aggravated by exposure to dampneas and occasionally to cold air, frequently precipitated by exercise and emotional disturbances, associated
    with the production of mucoid sputum never found positive. Until the exact nature of the symptomatology is clarified in each case frequent interruptions for evaluation of the status of these patients is necessary.

    2. Problem Arising from Inadequate Measures During the First Perfod of Active Treatment.
    These are common. The restricted regime of the sanatorium frequently gives a false sense of security with respect to a variety of conditions. Outstanding among these are two. One is the patient with a unilateral pneumothorax whose opposite side is not collapsed although a considerable amount of infiltration is present therein. Many breakdowns occur among these patients as their rehabilitation is attempted. Often symptoms
    are of sufficient magnitude to prevent these patients from passing beyond three to four hours of activity although they may maintain negative sputum.
    Another common source of trouble is the patient with a pneumothorax apparently successful during residence in the sanatorium despite the presence of adhesions. These patients find rehabilitation difficult. Loss of weight and strength and other complaints frequently make progress slow or impossible. In a few cases where pneumolysis was carried out after attempts at rehabilitation were found difficult, the prompt increase in appetite and strength which followed appears to have justified our wish that pneumolysis be carried out in every case during the first few weeks of pneumothorax
    whenever possible regardless of the apparently satisfactory result which may have been achieved without it. This long ranged view of our medical treatment would thus allow these patients to undergo a smoother course of rehabilitation.

    Patients with a predilection for bronchial tuberculosis are frequently difficult to manage. We have repeatedly seen patients with negligible disease in the lung, who appear to be satisfactorily controlled while in the sanatorium, but after beginning to undertake a program of increased activity, develop positive sputum referable only to intrabronchial disease. These patients may have
    transient areas of atelectasis in their lungs. Collapse measures are of no benefit and frequently introduce further complications.

    Resection is futile because the disease ordinarily is not limited to a single area. Although they undeigo frequent remissions, when increased activity is permitted, symptoms and positive sputum commonly reappear. It can only be hoped that chemotherapy may prove of value to these patients in the future.


    3. Extrapulmonary Tuberculosis.
    This complication will commonly manifest itself more readily during periods of increased activity. The most commonly encountered sites of extrapulmonary disease in our experience have been the glands, the kidneys, and the intestinal tract. In most cases symptoms had been present early in the sanatorium period of treatment. It was obvious that
    the restricted life of the sanatorium had masked the disease which became apparent as activity was allowed to increase. Only involvement of the genitourinary tract was considered sufficient to warrant immediate return to the sanatorium. No case of tuberculous adenitis was returned or held back appreciably in his progress. Cases of tuberculous enteritis were all considered individually.

    Thus far with adequate dietary management and moderate restriction of activity uninterrupted progress has been maintained in all cases.


    4. Problems Arising from Therapeutic Measures Instituted During the Earlier Phase of Active Treatment.

    These have been the most serious and the most difficult to manage. Chief among these is the unexpandable lung following a period of pneumothorax treatment.
    Recently summarized by Jacobs,this problem is confronted sufficiently often to warrant great concern and a definite plan of management. The etiology of this predicament is obviously the combination of the following circumstances: a fixed mediastinum and a fibrotic lung enclosed by a thickened pleura. Bronchial stenosis is probably an early factor predisposing to the pulmonary
    fibrosis. Progressive negative pressure develops rapidly after introduction of air is abandoned. Fluid accumulates but does not prevent the subsequent discomfort and dyspnea which all these patients complain of. Repeated introduction of air must be continued indefinitely in order to insure an intrapleural pressure compatible with comfort. Occasionally these patients develop empyema, and an additional complication is thereby presented.

    These patients, then, face the necessity of maintaining an undesirable pneumothorax for the rest of their lives and must ever be fearful of a possible empyema. It is felt that these cases can for the most part be recognized while they are still in the sanatorium, and their future freed of its uncertainty there by a thoracoplasty. To carry out such a procedure on a patient after
    he has left the sanatorium involves obvious difficulty in obtaining the proper surgical sku for this procedure besides the emotional disturbances which necessarily follow the advice that a thoracoplasty is necessary after the first period of active treatment has been completed and the patient is well along on his way to rehabilitation.

    Similar to the problem of the unexpandable lung is the problem of extrapleural pneumothorax. Like the patients with unexpandable lungs collapsed by intrapleural pneumothorax, thoracoplasty presents the only reasonable solution, when the lung fails to re-expand, and for the same reasons these patients are best handled by terminating the extrapleural pneumothorax while
    they are still being treated in the sanatorium.

    Another complication which should be recognized early, because it is best handled while the patient is in the sanatorium, is intermittent bronchial obstruction with bronchlectasis. This is not an unusual complication especially following collapse measures such as pneumothorax and thoracoplasty.' We are, therefore, occasionally called upon to rehabilitate patients whose sputum is negative but who have evidence of chronic pulmonary suppuration, which on investigation proves to be due to bronchiectasis. Although mild degrees of bronchiectasis need no treatment, those associated with severe symptoms, especially in conjunction with intermittent bronchial obstruction, can look forward to a normal life only
    after resection of their disease areas. It is otherwise futile to attempt a program of rehabilitation.

    A syndrome pointed out recently,which interferes with the nutrition of patients undergoing pneumothorax treatment to the left lung, is due to mechanical paralysis of the left hemidiaphragm. By elevation of the left intrapleural pressure, mobility of the left hemidiaphragm is mechanically impaired. This condition, in turn, leads to impaired adjustability of the stomach beneath it to increasing contents, thereby interfering with nutrition. This symptom complex of impaired appetite, loss of strength and weight.
    wholly unrelated to active disease, has been an occasional stumbling block to many who attempt rehabilitation with this handicap.

    These patients are frequently helped by reducing the frequency and doses of refills. Occasionally it is necessary to abandon pneumothorax prematurely before rehabilitation can progress.


    SUMMARY
    Upon discharge from a sanatorium as clinically arrested, the patient with tuberculosis is confronted with two unknowns: the residual disease in his lung and the level of his immunity. The available evidence indicates that anatomical healing of tuberculous disease goes on for years after all clinical evidence of disease has gone, that the defense mechanisms of the body against the tubercle bacillus are elaborated slowly, and for many years the level of immunity fluctuates in response to many influences.

    These facts constitute the basis for the program of rehabilitation which permits the patient's activity to keep pace with his increasing immunity. Medical problems which are confronted during this period are classified and described. Suggestions for their handling are presented.



    Oooops...I am not going yo give BRIEF account on it... .....
    Last edited by dhaval; 02-08-2008 at 07:09 AM.
    Thank you GOD

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