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Dr Emmyoung, Juba (2026)

20/02/2026

Premenstrual Syndrome (PMS) Lecture Notes
By
Mr.Emmanuel Nyong

Introduction
- Definition: Premenstrual Syndrome (PMS) encompasses a range of psychological, physical, and behavioral symptoms that occur cyclically during the luteal phase of the menstrual cycle and resolve with the onset of menstruation.
- Prevalence: Affects approximately 40% of women in the general population, with 5-8% experiencing severe symptoms.

Clinical Features
- Psychological Symptoms: Depression, anxiety, irritability, mood swings, and loss of confidence.
- Physical Symptoms: Bloating, breast tenderness (mastalgia), headaches, and fatigue.
- Behavioral Symptoms: Increased appetite, food cravings, and diminished interest in activities.

Pathophysiology
- Central Role of Ovarian Activity: Cyclical ovarian activity is a key trigger, with ovulation initiating a cascade of events.
- Neurochemical Factors: Altered responsiveness to steroids and neurotransmitters (e.g., serotonin, GABA) may contribute.
- Psychological Sensitivity: Increased sensitivity to hormonal changes may exacerbate symptoms.

Diagnosis
- Self-Diagnosis: Many women self-identify their symptoms as PMS.
- Symptom Diary: Prospective recording of symptoms over at least two consecutive menstrual cycles is essential for diagnosis. The Daily Record of Severity of Problems (DRSP) is a commonly used tool.
- Exclusion of Other Conditions: Rule out organic diseases and psychiatric disorders. Consider GnRH analogues for definitive diagnosis in complex cases.

Classification
- Physiological (Mild) Premenstrual Disorder: Symptoms are cyclical, relieved by menstruation, and do not affect quality of life.
- Core Premenstrual Disorder: Symptoms affect quality of life but are relieved by menstruation.
- Premenstrual Exacerbation: Symptoms exacerbate an existing non-menstrual condition and affect quality of life.
- Progestogen-Induced Premenstrual Disorder: Symptoms occur in women taking progesterone treatment.
- Non-Ovulatory Premenstrual Disorder: Symptoms occur without ovulation but in the presence of ovarian activity.
- Underlying Psychological Disorder: Non-cyclical symptoms with no symptom-free week, constantly affecting quality of life.

Premenstrual Dysphoric Disorder (PMDD)
- Definition: A severe form of PMS characterized by prominent symptoms of anger, irritability, and internal tension.
- Diagnostic Criteria: As per DSM-5, requires ≥5 symptoms, including at least one affective symptom, causing significant impairment.

Impact on Quality of Life
- Functional Impairment: Moderate to severe PMS can lead to decreased work productivity, increased absenteeism, and more frequent healthcare visits.
- Su***de Risk: Elevated risk of suicidal ideation in women with severe PMDD symptoms.

Natural History
- Onset and Course: Symptoms typically begin after menarche, peak in the late reproductive years, and resolve after menopause.
- Transient Resolution: Symptoms may temporarily resolve during pregnancy or any disruption of ovulatory cycles.

Evaluation and Management
- Detailed Menstrual History: Confirm the relationship between symptoms and menstrual cycle phase.
- Prospective Monitoring: Use symptom diaries like the DRSP for accurate diagnosis.
- Exclude Other Disorders: Rule out endocrine disorders and chronic mood disorders.

- Management Strategies: Lifestyle modifications, pharmacotherapy (e.g., SSRIs, hormonal treatments), and cognitive-behavioral therapy may be considered.

Conclusion
- PMS is a common condition with significant variability in symptomatology and impact on quality of life. Accurate diagnosis and tailored management are crucial for improving patient outcomes. Always consult updated guidelines specific to your region for the most appropriate management strategies.

19/02/2026

Dysmenorrhoea
By Mr. Emmanuel Nyong
At NEV.

Introduction
Dysmenorrhoea, or painful menstruation, is a prevalent condition affecting females during their reproductive years. It is categorized into two main types: primary and secondary dysmenorrhoea. Understanding the pathophysiology, clinical presentation, and management of dysmenorrhoea is crucial for medical students, as it significantly impacts the quality of life and daily functioning of affected individuals.

Types of Dysmenorrhoea
Primary Dysmenorrhoea
- Definition: Recurrent, crampy lower abdominal pain during me**es without an identifiable pelvic pathology.

Pathophysiology: Primarily due to increased prostaglandin production leading to uterine vasospasm, ischemia, and contractions.

Epidemiology: Common in adolescents and young women; prevalence decreases with age.
- Risk Factors: Younger age, smoking, stress, and familial predisposition.

Secondary Dysmenorrhoea
- Definition: Menstrual pain associated with an underlying pelvic pathology.

Common Causes: Endometriosis, adenomyosis, pelvic inflammatory disease (PID), fibroids, and pelvic adhesions.

Epidemiology: Tends to develop later in life as the underlying pathology progresses.
Clinical Presentation
Symptoms
- Pain Characteristics: Crampy, lower abdominal pain starting 1-2 days before menstruation and lasting 12-72 hours. Pain may radiate to the back or thighs.

Additional Symptoms: Nausea, diarrhea, fatigue, headache, and malaise.

Impact: Can lead to absenteeism from school or work and decreased productivity.

Examination
- Primary Dysmenorrhoea: Normal pelvic examination.
- Secondary Dysmenorrhoea: May reveal pelvic masses, tenderness, or other abnormalities.
Diagnostic Evaluation
- History: Detailed menstrual history, timing, and characteristics of pain.
- Physical Examination: To rule out pelvic pathology.

Investigations:
- STI Screening: To exclude infections.
- Ultrasound: To identify structural abnormalities like fibroids or endometriosis.
- Laparoscopy: Reserved for cases with abnormal imaging or treatment failures.

Management
Primary Dysmenorrhoea
- First-line Treatment: Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce prostaglandin levels.
- Hormonal Therapy: Combined oral contraceptive pills (COCPs) to suppress ovulation and reduce menstrual flow.
- Supportive Measures: Heat application, TENS, vitamin B1, and magnesium supplements.

Secondary Dysmenorrhoea
- Treat Underlying Cause:
- Endometriosis: Hormonal therapy or surgery.
- PID: Antibiotics.
- Fibroids: Surgical intervention if necessary.
- Surgical Options: Therapeutic laparoscopy for diagnosis and treatment of endometriosis or adhesions.

Conclusion
Dysmenorrhoea is a common but often underdiagnosed condition that requires a comprehensive approach to diagnosis and management. Medical students should be familiar with the clinical features, evaluation, and treatment strategies to effectively manage patients and improve their quality of life. Always consider the specific needs of transgender and gender-diverse individuals in clinical practice.

29/01/2026

Nipah virus is a zoonotic virus, meaning it can spread from animals to humans. It's caused by the Henipavirus and is typically found in fruit bats, also known as flying foxes. The virus can be transmitted through direct contact with infected animals, contaminated food or drinks, or close contact with an infected person

Symptoms:

- Fever
- Headache
- Dizziness
- Muscle pain
- Vomiting
- Sore throat
- Respiratory distress
- Altered mental status and confusion

In severe cases, it can cause acute encephalitis, seizures, and coma. The fatality rate is quite high, ranging from 40% to 75%

Prevention:

- Avoid contact with bats and sick animals
- Refrain from consuming raw date palm sap or partially eaten fruits
- Practice good hand hygiene and safe food practices
- Wear protective gear in healthcare settings

There's currently no approved vaccine or treatment, but researchers are working on monoclonal antibody therapies and vaccines. Treatment is mainly supportive care, focusing on symptom management and reducing neurological and respiratory complications

20/01/2026

Part 2
Lecture Notes on Eclampsia.

Introduction
Eclampsia is a severe complication of preeclampsia characterized by the onset of seizures in a pregnant woman with no prior history of seizure disorder. It is a critical condition requiring immediate medical intervention to prevent maternal and fetal morbidity and mortality.

Pathophysiology
- Eclampsia is thought to result from endothelial dysfunction, leading to cerebral edema, vasospasm, and increased intracranial pressure.
- The exact mechanism of seizures in eclampsia is not fully understood but is associated with severe hypertension and cerebral vasculopathy.

Clinical Presentation
- Seizures: Generalized tonic-clonic seizures.
- Other symptoms: Severe headache, visual disturbances, altered mental status, and upper abdominal pain.

Diagnosis
- Clinical diagnosis based on the presence of seizures in a patient with preeclampsia.
- Laboratory tests: Proteinuria, elevated liver enzymes, thrombocytopenia, and renal impairment may be present.

Management

Magnesium Sulfate Therapy
Magnesium sulfate is the drug of choice for both the prevention and treatment of eclamptic seizures.

1. Loading Dose:
- Intravenous (IV): 4 to 6 g of magnesium sulfate administered over 15 to 20 minutes.
- Intramuscular (IM): 5 g in each buttock (total of 10 g), mixed with 1 mL of 2% lidocaine to reduce pain.

2. Maintenance Dose:
- IV Infusion: 1 to 2 g/hour. For patients with normal renal function, 2 g/hour is commonly used.
- IM: 5 g every four hours. In resource-limited settings, a lower dose of 2.5 g every four hours may be effective.

3. Monitoring:
- Clinical assessment every 1-2 hours for signs of magnesium toxicity, such as loss of deep tendon reflexes, respiratory depression, and decreased urine output.
- Serum magnesium levels are typically maintained between 4.8 to 8.4 mg/dL (2.0 to 3.5 mmol/L).

4. Toxicity Management:
- Antidote: Calcium gluconate 1 g IV to counteract magnesium toxicity.
- Monitor for hypotension, especially when used with calcium channel blockers.

Alternative Antiseizure Medications
- For patients with contraindications to magnesium sulfate (e.g., myasthenia gravis):
- Levetiracetam or Valproic Acid may be used.

Management of Recurrent Seizures
- Administer an additional bolus of 2 to 4 g magnesium sulfate IV over five minutes.
- If seizures persist, consider discontinuing magnesium sulfate and administering:
- Fosphenytoin: 20 mg PE/kg IV at 100 to 150 mg PE/min.
- Phenytoin: 20 mg/kg IV at a rate of up to 50 mg/min, with cardiac monitoring.

Delivery Considerations
- Timing: Prompt delivery is the definitive treatment for eclampsia, but maternal stabilization is prioritized.
- Mode of Delivery: Depends on gestational age, cervical status, and fetal condition. Induction of labor is reasonable for pregnancies ≥32 to 34 weeks with a favorable cervix.

Postpartum Care
- Continue magnesium sulfate therapy for 24 to 48 hours postpartum.
- Monitor for resolution of symptoms and diuresis as indicators of recovery.

Conclusion
Eclampsia is a medical emergency requiring prompt recognition and treatment. Magnesium sulfate remains the cornerstone of therapy, with careful monitoring for toxicity. Delivery is the ultimate treatment, with the timing and mode tailored to the individual clinical scenario.

19/01/2026

Lecture Notes: Pre-eclampsia
By Tutor Nyong Emmanuel

Definition:
Pre-eclampsia is a pregnancy-induced condition characterized by hypertension and proteinuria, typically occurring after 20 weeks of gestation.

Epidemiology:
- Affects approximately 5% of pregnancies.
- More common in women experiencing their first pregnancy (nulliparous women).

Aetiology and Pathogenesis:
- Abnormal Placentation: The primary underlying issue is abnormal placentation.
- Pathophysiological Mechanism:
- Shallow invasion of trophoblasts leads to inadequate transformation of spiral arteries into low-resistance vessels.
- Resultant placental ischemia causes the release of toxic substances into maternal circulation.
- These substances cause endothelial damage, leading to systemic hypertension.
- Severe progression can lead to eclampsia, characterized by widespread fibrin thrombi and risks of multi-organ failure.

Clinical Presentation:
- Symptoms: Often asymptomatic in early stages. Severe disease may present with:
- Headache
- Visual disturbances (e.g., flashing lights)
- Epigastric or right upper quadrant pain
- Nausea and vomiting
- Rapid facial edema
- Signs:
- Hypertension (BP >140/90 mmHg; severe if ≥160/110 mmHg)
- Proteinuria (Protein-Creatinine Ratio [PCR] ≥30)
- Facial edema
- Epigastric/RUQ tenderness (suggestive of liver involvement)
- Confusion or cortical blindness
- Uterine tenderness or vaginal bleeding (possible placental abruption)
- Fetal growth restriction, especially if

31/12/2025

Shout out to my newest followers! Excited to have you onboard! Aham Dizzy, Mollicier Sijali

28/12/2025

Understanding and Applying the Bishop’s Scoring System simplified by Nyong Emmanuel

The Bishop's score is a pre-labor scoring system that helps in evaluating the readiness of the cervix for induction of labor. It assesses several cervical and fetal factors to predict the likelihood of a successful induction. Understanding and accurately applying this score is crucial for improving clinical outcomes in obstetric practice.

Components of the Modified Bishop’s Score

1. Position of the Cervix
- Score 0: Posterior
- Score 1: Axial
- Score 2: Anterior

Clinical Note: An anterior position of the cervix indicates a more favorable condition for labor induction.

2. Length of the Cervix
- Score 0: 2 cm
- Score 1: 1 cm
- Score 2: 2 cm

Clinical Note: Greater dilatation shows readiness for labor and suggests a higher probability of successful induction.

5. Station of the Presenting Part (relative to the ischial spines)
- Score 0: -2
- Score 1: -1
- Score 2: 0

Clinical Note: A station of 0 indicates that the presenting part is fully engaged in the pelvis, a positive sign for induction.

Interpreting the Total Score

- A total Bishop’s score of >8 generally indicates a "favorable" cervix for induction, suggesting a higher likelihood of successful vaginal delivery.
- Scores between 6 and 8 are considered “intermediate.”
- Scores

23/12/2025

Lecture Notes on Galactorrhea by Nyong Emmanuel

Definition:
Galactorrhea is typically characterized by the inappropriate production and release of breast milk or milk-like discharge not associated with childbirth or nursing. It predominantly presents as bilateral, nonbloody discharge from the ni***es.

Etiology and Pathophysiology:
The condition can have various underlying causes, centered primarily on hormonal imbalances, particularly of prolactin. Key causes include:

1. Hormonal Causes:
- Hyperprolactinemia: Excess production of prolactin can be due to pituitary adenomas (prolactinomas), other pituitary disorders, or hypothalamic lesions affecting the prolactin-inhibiting pathway.
- Thyroid Disorders: Hypothyroidism can lead to increased TRH (thyrotropin-releasing hormone), which subsequently raises prolactin levels.
- Endocrine Disturbances: Hypogonadism and other endocrine imbalances.

2. Pharmacological Causes:
- Medications such as metoclopramide, phenothiazines, SSRIs, and some antipsychotics can disrupt dopamine pathways, thereby increasing prolactin secretion.

3. Physiological Causes:
- Normal or variant conditions such as pregnancy, postpartum states, or excessive breast stimulation can lead to transient galactorrhea.
- Some individuals may develop galactorrhea with normal prolactin levels, termed idiopathic galactorrhea.

4. Other Causes:
- Chronic stress, chest wall lesions, or ni**le stimulation can sometimes lead to galactorrhea.

Clinical Features:
- Bilateral Discharge: Typically milky and not associated with blood.
- Associated Symptoms: May include menstrual irregularities, infertility, visual changes, or headache if associated with pituitary tumors.

Diagnosis:
1. History and Physical Examination:
- Detailed drug history and assessment of associated symptoms (e.g., menstrual irregularities).
- Evaluation for physiological causes like pregnancy or recent breastfeeding.

2. Laboratory Tests:
- Serum Prolactin Levels: To confirm hyperprolactinemia. Levels significantly above 250 ng/mL suggest a prolactin-secreting pituitary tumor.
- Thyroid Function Tests: To rule out secondary causes like hypothyroidism.
- Renal Function Tests: As renal insufficiency can alter prolactin metabolism.

3. Imaging Studies:
- MRI of the brain, particularly the pituitary region, if a tumor is suspected.

4. Additional Tests:
- If the diagnosis remains uncertain, further endocrinological assessments may include evaluating other hormone levels such as LH and FSH.

Management:
1. Pharmacological Treatment:
- Dopamine Agonists (e.g., Cabergoline, Bromocriptine): Mainstay treatment for prolactin-secreting adenomas.
- Address underlying causes like adjusting or discontinuing implicated medications.

2. Surgical Intervention:
- Considered in cases of significant pituitary adenomas or failure of medical therapy.

3. Observation and Reassurance:
- For patients with idiopathic or transient galactorrhea with normal prolactin levels, reassurance and periodic monitoring may suffice.

4. Patient Education:
- Instruct patients about the condition's benign nature in many cases and the importance of follow-up, particularly if underlying conditions are present.

Follow-Up and Monitoring:
- Regular monitoring of prolactin levels and clinical reassessment for changes in symptoms or development of complications is advised.

Conclusion:
Galactorrhea is a condition with a wide differential, and a structured approach involving history, physical examination, lab tests, and imaging is crucial for effective diagnosis and management. Addressing underlying causes, where possible, leads to the best patient outcomes.

Note: Always refer to up-to-date guidelines and consult specialists when considering specific interventions, as practice recommendations can vary significantly based on local resources and protocols.

23/12/2025

Endocarditis Lectures

Definition:
- Endocarditis is the inflammation or infection of the heart valves, often due to bacterial infection. It can lead to severe complications such as heart damage and heart failure, characterized by the heart's inability to pump blood effectively.

Causes:
- Commonly caused by bacteria, often entering through:
- Infections elsewhere in the body.
- Entry via skin breaches, dental surgery, IV drug use, or indwelling catheters.
- Patients with pre-existing heart conditions or valve implants are at higher risk.

Clinical Presentation:
- General Symptoms:
- Fever, chills, malaise, anorexia, weight loss, night sweats, and rigors.
- Anemia, clubbing, and splenomegaly in chronic cases.

- Cardiac Manifestations:
- New or changing heart murmur potentially indicating valve destruction.
- Heart failure symptoms, such as dyspnea and edema.
- Possible complications include tachycardia, hypotension due to sepsis, or embolic events leading to stroke-like symptoms.

- Septic Emboli Risks:
- Occur in 20-45% of patients, possibly affecting the brain, limbs, kidneys, or lungs (notably with tricuspid valve involvement).
- Risk factors include organism type (Gram-negative bacteria, Staphylococcus aureus, or Candida) and vegetation size.

- Immune and Extracardiac Manifestations:
- Skin: Petechiae, splinter hemorrhages, Osler’s nodes, Janeway lesions.
- Eye: Roth spots, retinal hemorrhages.
- Renal: Hematuria, glomerulonephritis.
- Musculoskeletal: Arthralgia or arthritis.
- Neurological: Toxic encephalopathy or embolic strokes.

Diagnosis:
- History taking focusing on recent dental work, injections, surgeries, or any potential infection sources.
- Physical examination accentuating the presence of heart murmurs, embolic phenomena, and peripheral signs.
- Investigations:
- Blood cultures to identify causative organisms.
- Echocardiography (TTE/TEE) detecting vegetations.
- ECG, chest X-ray, and other specific labs as needed.

Management:
- Medical Treatment:
- Prolonged IV antibiotics tailored to culture results, usually starting empirically initially.
- Management of heart failure and other complications.

- Surgical Treatment:
- Indicated in cases of refractory infection, heart failure due to valve dysfunction, or prevention of embolic events.
- Valve replacement is often necessary for severely damaged valves.

Prevention:
- Antibiotic prophylaxis during dental procedures for high-risk individuals.
- Maintaining excellent oral hygiene and minimizing sources of infection, including managing chronic skin lesions or sources of bacteremia effectively.

Prognosis & Follow-up:
- Prognosis depends on the organism's virulence, patient's underlying heart condition, and timely initiation of therapy.
- Regular follow-up is crucial to monitor treatment response, manage comorbidities, and prevent recurrence.

Conclusion:
Endocarditis demands a high index of suspicion, particularly in at-risk populations, and prompt, aggressive treatment to prevent serious complications. Regular updates on local and international guidelines are crucial for best practice management.

22/12/2025

Varicose Veins Lecture Notes by Nyong Emmanuel
Definition
- Varicose Veins: Tortuous and dilated superficial leg veins resulting from valvular incompetence, predominantly in the saphenous venous systems.

Epidemiology
- Affects up to 20% of the population.
- Marked female predilection with a female:male ratio of 9:1.
- More common in women, with symptoms often exacerbated during pregnancy.

Aetiology
- Primary (Idiopathic): Most cases; occur without an apparent underlying cause.
- Secondary Causes:
- Pregnancy, due to increased abdominal pressure and hormonal effects.
- Large pelvic tumors such as fibroids or ovarian masses.

Pathogenesis
- Degeneration of valve cusps leads to holes, causing valvular incompetence.
- Increased strain on valves downstream, leading to sequential incompetence.
- Results in dilation and tortuosity of superficial veins.

Pathophysiology
- Normal blood flow: From skin → superficial veins → perforating veins → deep veins → iliac veins → inferior vena cava.
- Competent valves are essential to prevent reflux; aided by muscle contractions.
- Incompetent valves lead to increased distal pressure and further valvular incompetence.
- Chronic venous hypertension results in soft tissue changes and potential skin ulceration.

Clinical Presentation
- Many present due to cosmetic concerns.
- Symptoms:
- Discomfort, aching, itching, and swelling.
- Worsened by prolonged standing, often aggravated by end-of-day fatigue.
- Physical signs: Dilated, visible superficial veins typically in the distribution of the great and small saphenous veins.

Complications
- Stasis (Varicose) Dermatitis: Red, itchy skin due to poor circulation.
- Varicose Ulceration: Chronic wounds typically around ankles.
- Lipodermatosclerosis: Skin hardening and changes from chronic inflammation.
- Bleeding: Especially in thin-walled veins close to skin surface.
- Thrombosis: Superficial thrombophlebitis, often painful but less serious than deep venous thrombosis.

Management
- Conservative: Compression stockings to help support circulation.
- Medical: Analgesics for symptomatic relief.
- Surgical Interventions:
- Ligation and "stripping" (removal) of affected veins.
- Sclerotherapy: Injection of sclerosant to obliterate veins.
- Endovenous thermal ablation: Minimally invasive procedure using radiofrequency or laser.
- Valvular reconstruction in select cases where deep system support is viable.

Chronic Consequences
- Chronic Venous Insufficiency: Chronic pain, heaviness, skin changes, ulceration due to sustained high venous pressure.
- Skin Changes: Brown pigmentation and venous eczema from extravasation of blood products

Genetic Predisposition
- Some individuals inherit weaker vein walls or valvular defects increasing susceptibility.

Dr Emmyoung

20/02/2026

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