Medical Examination

Thorough Clinical Examination

• General Inspection – Blood pressure, pulse rate, height, weight, body mass index
• Heart
• Lung
• Abdomen
• Nervous system
• Bones & Joints
• For females: Breast Examination & Pap Smear
  
  *Mammogram & pap smear is suggested for Female patients with an additional charges.

Comprehensive Blood & Urine Tests

• Lipid studies
• Liver function test
• Renal function test
• Electrolytes
• Infectious disease - Syphilis, Hepatitis A, Hepatitis B Antigen + Hepatitis B Antibody, HIV Screening
• Arthritis screen
• H.pylori
• Thyroid screen
• Tumour markers - eg: AFP, CEA, CA19-9, CA15-3, CA125 - depending on profile
• HBA1c
• Full Blood Count + ESR
• ABO + Rh grouping
• Blood film comment
• Urinalysis

H. pylori Bacteria

H. pylori is always associated with superficial gastritis and sometimes, with chronic atrophic gastritis, which can lead to the development of gastric cancer. H. pylori increases one's risk of getting gastric cancer as high as 6 fold. In some countries, 60% of gastric cancer is attributed to H.pylori.

Cause of Stomach Cancer

• Stomach Cancer associated with H. pylori bacteria:
  H. pylori bacteria is cancer causing agent. It is known to be responsible for most duodenal ulcers and over two third of stomach ulcers with symptoms displayed like heartburn, indigestion and discomfort or pain in the abdomen.
• Stomach Cancer not associated with H. pylori bacteria – it is less common.

How Stomach Cancer develops

Active Gastritis Chronic Inflammation Intestinal Metaplasia (abnormal cell changes) Dysplasia and carcinoma (Cancer cells development)

Early Symptoms for Stomach Cancer

Unexplained weigh loss and abnormal fatique together with the following symptoms:-

• Indigestion or burning sensation (heartburn)
• Discomfort or pain in the abdomen.
• Bloating of the stomach after meals.
• Loss of appetite.
• Bleeding (vomiting blood or having blood in the stool).

Early Detection H. pylori bacteria

• Serology Test – a quantitative determination of anti- H.pylori Ig G antibodies in human blood, which already inclusive in the HSC Diagnostic Packages.
• Endoscopy Based Test – for the diagnosis of stomach cancer, available at HSC Medical Center.

High Sensitivity C–Reactive Protein (hs-CRP)

• CRP is a protein produced by liver, when there is any inflammation in our body.
• High CRP can be caused by heart diseases, cancer, infection, inflammatory diseases like Rheumatoid Arthritis.
• No special preparation or injection are required.
• Therefore, CRP Test is done to:
  - monitor inflammatory diseases.
  - evaluate a person's risk of heart disease like heart attack.
• hs-CRP test can be easily done by testing blood sample.
• hs-CRP is a more important measure of heart attack or stroke risk than cholesterol.

Treatment effects/Benefits of testosterone replacement.

• Increase in libido, improvement of sexual satisfaction.
• Increase in muscle mass and muscle strength.
• Increase in bone mass.
• Decrease in adipose tissue (particularly in abdominal; fat).
• Positive effect on the metabolic syndrome ( decrease in visceral fats).
• Improvement in wellbeing, mood, performance and cognitive functions.
• Alleviations of vegetative symptoms such as hot flashes.
• Maintenance of male pattern body hair and pubic hair, stimulation of beard growth.
• Improvement in appearance of skin.
• Improvement in erythropoiesis.

Treatment for testosterone deficiency/Androgen Therapy

The doctor will discuss with you the Age Management Programme and testosterone replacement. Testosterone replacement with Oral tablet testosterone or with injectable testosterone– Convenient, 4 to 5 times a year.

• Testosterone encouraging in the elderly with heart failure
• Testosterone in Obesity, Metabolic Syndrome and Type 2 Diabetes
• Testosterone and Coronary Artery Disease

Global Risk Score

HSC Medical Center - Heart Disease Risk Assessment Report
Patient ID	Patient Name	Gender	Date of Birth	MRN	Date
xxxxxxxxx	xxxxxxxxxx	Female	22/ 5 / 1937	xxxxxxx	3/ 1/2007

Framingham System - Risk
	Risk Factor	Your Factors	Points	Relative Risk
1	Gender	Female
2	Age(Years)	69	12
3	Smoker	No	0	1 x
4	Diabetes	No	0	1 x
5	Premature heart attack or Stroke Family history	No	0	1 x
6	Blood Pressure Medication	No
7	Systolic Blood Pressure(mm Hg)	120-129	1	1.5 x
8	Total Cholesterol(mg / dl)	160-199	1	1 x
9	HDL Cholesterol(mg / dl)	Over than 59	-1	0.5 x
		Total Points	13	2%	Your 10 years heart attack risk
				9%	Average 10 years risk (for others in your age group)

Framingham with DSCT Heart Scan Calcium Score - Risk
1	Your total calcium score	10
2	Average heart scan coronary calcium score for your age & gender	150
	DSCT Heart Scan Calcium Score	10 years risk of heart disease
3	1 - 80	1.1%

DSCT coronary calcium score is not applicable in post-CABG and post-stenting.

1. Normal score for any age is ideally zero.
2. A negative test implies a low risk of cardiovascular event in next 2-5 years.
3. A high coronary calcium score, adjusted for age and sex, is a risk factor for adverse coronary events.
4. The results should always be interpreted in conjunction with the total clinical picture.
5. Zero score does not absolutely rule out the presence of atherosclerotic plaque,
   including unstable plaque, but does imply a very low likelihood (<5%) of significant coronary narrowing.

Welcome to contact HSC Medical Center, your One-stop Medical,
Heart and Diagnostic Center for futher information about your DSCT heart scan that helps your prevention of heart attacks.

DSCT Coronary Calcium Score

CT Calcium Score is indicator for early detection of coronary arteris disease. Cardiac Calcium Scoring is a fast, painless and noninvasive test designed for identifying plaque build-up in the heart. Calcified plaque, known as hardening of the arteries, is a risk factor that can lead to heart disease. As plaque builds, the arteries become narrow thereby hindering the blood flow. The newest CT scanner is an advanced multi-slice technology that captures cross-sectional images of the heart at sub-second rates. This test helps to present an overall picture of your heart health. Total time for the exam is less than 10 minutes.

DSCT - Coronary Angiogram

Low-dose DSCT of the lung

Same radiation dose as chest x-ray but far more sensitive for detection of lung cancer.

MRI brain/neck (stroke study)

MRI Whole Body Scan (With Contrast)

Eye Screening

• Visual Acuity
• External Examination
• Fundus Examination



Sample Report

Pap Smear

Key points

1. Improves Pap test's sensitivity to as high as nearly 95%
2. Able to send for adjunctive testing such as HPV testing, CT/GC DNA testing.
3. 100% cell collected send to lab for processing - more accurate results. (speacial collection device)
4. Better time management - Fully automotion system.
5. Reduce unsatisfactory rate compare to conventional pap smear.
6. 64.4% Increase HSIL + dectection as compare to conventional smear.

Limitations Conventional Pap Smear

1. Relatively low sensitivity (50-60% in routine screening setting)
2. Dysplastic cervical cells not transferred to the slide occasionally
3. Cells obscured by artifacts such as blood, mucus, red blood cells and inflammatory cells

Cervical Cancer & HPV: The Basics

1. Cervical Cancer Still A Health Issue
• An estimated 12,200 new cases of cervical cancer were diagnosed, in the U.S., in 2010
• More than 9,700 women were diagnosed with cervical cancer in 2007
• 4,200 of those diagnosed will die of the disease
• The annual death rate from cervical cancer, globally, in 2008 was 275,000
2. Women are Still Dying of Cervical Cancer
• Despite a decline in overall mortality, rates are rising in women aged 20–34 years
• Morbidities associated with treatment of late-stage cancer are:
• Infertility
• Localized fluid retention and tissue swelling
• Sexual dysfunction
• Bowel and bladder dysfunction
• Women in the Prime of Life are Victims of Cervical Cancer
• Eg Jade Gody (1981-2009): UK celebrity, a newly wed, mother of two, and died at the age of 27 years old
3. Cervical Cancer is Asymptomatic
• Most cervical pre-cancers and cancers are asymptomatic
• Only advanced disease that extends beyond the cervix* may present with vaginal bleeding
• Cervical Cancer Usually Develops Over 10 Years
4. HPV: The Facts
• Leading cause of cervical cancer
• The most common sexually transmitted infection
• More than 4 out of 5 women will be infected at some point in their lives
• Approximately 20 million Americans are currently infected with HPV
• Another 6 million people become newly infected each year
• Behind all Cervical Cancers there is HPV
5. Not All HPV Genotypes are the Same
• There are more than 118 different genotypes of HPV categorized by their risk:
• Low-risk genotypes infect the cervix, but rarely cause cancer
• Genotypes 16 and 18 are responsible for 70% of cervical cancer but there are other high-risk genotypes
• Vaccines do not protect against all high-risk genotypes

HPV Vaccination: Where We Are Now

1. The Introduction of Vaccines
• First HPV vaccine approved by FDA in June 2006; second in October 2009
• Gardasil – Protects against HPV 16 and 18, as well as HPV 6 and 11 (genital warts)
• Cervarix – Protects against HPV 16 and 18
• Both vaccines are given as shots and require 3 doses
• Vaccination of men
2. HPV Vaccines – Where We Are
• Only 10 percent of eligible women have taken all three doses of the vaccine
• Reasons for slow uptake:
• Eligibility
• Personal choice
• Social choice
3. The Gap
• It will take a generation to have significant impact on rates of HPV 16 and 18
• Vaccines do not protect against all high-risk genotypes
• HPV Screening Is Important Despite Availability of Vaccines

HPV Screening: Understanding It All

1. The Aim of Screening
• Identify the few at risk from the many who are not
2. Screening: Not Happening Enough
• Patients diagnosed with an invasive cervical malignancy are either unscreened or underscreened with Pap smear
3. Current American Society for Colposcopy and Cervical Pathology (ASCCP) Guidelines



4. Test Specifically for HPV
• Pap tests are effective for screening, but can miss incidences of cervical pre-cancer
• In the ATHENA trial, 1 in 10 women age 30-years and older, who tested positive for HPV genotypes 16 and/or 18 had cervical pre-cancer although their Pap test was normal
• Testing for HPV specifically is available

Vaccinated or Not: What Women Need to Know and Do to Prevent Cervical Cancer

1. Knowledge = Prevention
• Continue routine screening, even if vaccinated
• Women age 30+ or those with abnormal/unequivocal Pap test
• Ask about being screened for high-risk genotypes of HPV, specifically genotypes 16 and 18
• Cervical cancer is preventable and curable if detected early

References

1. Jemal A, et al. Cancer Statistics, 2010. CA Cancer J Clin. 2010; 60: 277-300.
2. Jemal, A, et al. Cancer Statistics, 2007. CA Cancer J Clin. 2007; 57(1), 43-66.
3. M Arbyn, X, et al. Worldwide burden of cervical cancer in 2008. Ann Oncol. 2011.
4. Peto J, et al. Lancet. 2004; 364: 249–256.
5. Waggoner S, Lancet. 2003; 361: 2217–25.
6. Kumar, V et al. Robbins Basic Pathology(8th ed.). Saunders Elsevier. 2007; 718–721.
7. Doorbar J. J Clin Sci. 2006; 110: 525–541.
8. Genital HPV infection - fact sheet. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/std/hpv/stdfact-hpv.htm. Updated November 24, 2009. Accessed April 19, 2011
9. Wright and Schiffman. NEJM. 2003.
10. Doorbar J. J Clin Sci. 2006; 110: 525–541.
11. Munoz N, et al. Int J Cancer. 2004; 111:278-285
12. Gardasil and Cervarix PI's
13. Dempsey A, et al. Worsening disparities in HPV vaccine utilization among 19-26 year old women. Vaccine. 2011; 29 (3): 528-534. doi:10.1016/j.vaccine.2010.10.051
14. Saskiw D, et al. CA Cancer J Clin. 2007; 57:7-28. doi: 10.3322/canjclin.57.1.7
15. Subramaniam A, et al. Invasive cervical cancer and screening: what are the rates of unscreened and underscreened women in the modern era? J Low Genit Tract Dis. 2011; 15(2): 110-113.
16. ASCCP Guidelines, 2009.
17. Roche Molecular Diagnostics. Data on file. 2010.

Chest X-Ray

A chest x ray is a painless, noninvasive test that creates pictures of the structures inside your chest, such as your heart, lungs, and blood vessels. "Noninvasive" means that no surgery is done and no instruments are inserted into your body. This test is done to find the cause of symptoms such as shortness of breath, chest pain, chronic cough (a cough that lasts a long time), and fever.

Cervical Spine X-Ray Examination

A cervical spine X-ray is a safe and painless test that uses a small amount of radiation to take a picture of the bones in the back of the neck (cervical vertebrae).

During the examination, an X-ray machine sends a beam of radiation through the neck, and an image is recorded on special film or a computer. This image includes the seven vertebrae in the neck area, the first vertebrae of the thoracic spine, and the disk spaces in between them.

The X-ray image is black and white. Dense body parts that block the passage of the X-ray beam through the body, such as the bones, appear white on the X-ray image. Hollow body parts, such as the airways, allow X-ray beams to pass through them and appear black.

A radiographer takes the X-rays. Usually, two different images are taken of the cervical spine: one from the front (AP or anterior-posterior view), and another from the side (lateral view). Occasionally, additional images like open-month view, flexion and extension views of the cervical spine might be needed.