A Family Doctor's Tale - BACKACHE

DOC I HAVE A BACKACHE

Backache (A Simple Guide to Backache) is one of the most common complaints by patients seen in a family doctor's clinic.

The complaint may be:
1.Constant aching, pain or stiffness that occurs anywhere along your spine, from the base of the neck to the hips.  

2.Sharp pain in the neck, upper back, or lower back, especially after lifting heavy objects or other strenuous activity. 

4.Chronic ache in the middle or lower back, especially after sitting or standing for long period of time. 

More men suffer from it than women. 
Backache is most common among people in their middle age.
Backache also occurs among young people aged between 20 - 30

I usually asked for a history of:

1.back strain from the lifting of a heavy object, 

2.from a fall,

3.Prolonged sitting with poor posture can also lead to chronic backache such as slouching in a couch when watching TV.
If the bad posture is  prolonged, backache may occur.

4.wearing high heeled shoes also put a lot of strain on the back muscles

5.associated pain in legs or weakness and tingling in the legs or back. 

6.pain increases when you cough or bend forward at the waist. 

7.Back pain radiates into the legs,sciatica. 
This could be a sign of a herniated disk. 

8.dull pain in one area of your spine when trying to lie down or getting out of bed, especially if you are over 50 years of age. You may be suffering from osteoarthritis(A Simple Guide to Osteoarthritis)

9.pain is felt in both thighs when walking. This can be a symptom of spinal stenosis (the narrowing of the lower spinal canal).

10.persistent backache may also be an indication of an undetected cancer of the colon,ovary,bladder or prostate( A Simple Guide to Cancer).

11.gynecological problems (such as ovarian tumors( A Simple Guide to Ovarian Cancer), fibroids) and pregnancy.


I will then a full medical examination with emphasis on movement of the back:

1. Full medical examination  especially of movement of the back ,any deformity of the spine, abdominal swelling, straight leg raising test

2. X-ray of the Spine: to exclude fracture, osteoarthritis, dislocation,

3. X-ray of abdomen to exclude any tumours in the abdomen pressing against the spine

4.MRI of spine for slipped disc,tumours,fracture if necessary

5.Bone density test to exclude osteoporosis

6.Blood tests for calcium, protein,kidney function,cancer markers, RA factor

7. Urine and stool tests for blood,



If no serious illness is found, the most common cause is a strained back muscle.

Treatment is directed at relief of the backache:

Symptomatic:
Painkillers and muscle relaxants
Ice packs or heat treatment
Physiotherapy to strengthen muscles
Good posture and firm mattress
Avoid aggravating factors like high heels, overstretched muscles,excessive strenuous activities

Curative:
The cause must be found and treated. Examples are fractures due to injury. Patient should sent to hospital in case he/she needs surgery

Causes like cancer and aged related illness(osteoarthritis) may not be able to cured but may improved with treatment.

Prevention of backache
 
1.Maintain the correct posture at all times. 
When standing or sitting, ensure that your back is kept straight instead of a slouched position. 

2.support your back and use a cushion when necessary. 

3.Correct  furniture can also help to prevent the occurrence of backache. 
Use chairs of a proper height in relation to the table or desk. 

4.Sleep on a firm mattress 

5. Do not wear high heels

6. Keep your back straight when carrying heavy item.Keep the item close to the body.

7.Do not bend the back to carry heavy objects. 
Bend the knees and keep the back straight

8.Exercise is another good way to prevent backache by strengthening the back muscles. 
However, if you have had back injuries before such as a slipped disc, do be cautious when you exercise.

A Family Doctor's Tale -HEADACHE

DOC I HAVE A HEADACHE

Headache is a fairly common complaint in any family doctor clinic. 

It is important to ask for 
nausea, 
vomiting,
stiffness of the neck, 
fits, 
stress, 
lack of sleep, 
flashes of light in the eyes, and 
weakness of one side of the body. 

I always check for any high fever (one of the common causes) and high blood pressure in all my headache patients.

The most common cause of headache is 
tension headache which can present as a 'tight band' especially over the temples. 
There may associated tight neck muscles . 
It is usually related to stress. 
Treatment is by simple painkillers, rest and removal of aggravating factors.

Migraine is also frequent in some patients with a heavy throbbing pain usually over one side of the scalp, forehead and around the eye caused by abnormally dilated blood vessels. There may be nausea and sensitivity to loud noises or bright lights .
It may be triggered by menstruation, alcohol or anxiety. Treatment is by special anti-migraine drugs that reduce the dilatation of blood vessels and painkillers together with resting in a cool, dark and quiet room.

Referred headaches are caused by any pain in structures around the head.
Common ones are earaches, toothache causing pain over an entire part of the face and temporamandibular joint dysfunction from mechanical pain from the jaw joint.

Serious Types of Headaches should be referred to hospital for MRI brain investigation and further treatment:

Meningitis / Encephalitis headaches which is due to infection of the brain tissue (encephalitis) or the membranes surrounding the brain (meningitis). 
One of the most cause of encephalitis here is dengue hemorrhagic fever.( A Simple Guide to Dengue Fever)
There is usually stiffness of the neck, fever and vomiting.

Cerebrovascular Accidents (A Simple Guide to Stroke) happens when a blood vessel in the brain is blocked or bursts. 
There is weakness of one side of the body.

Bleeding in the brain blood vessel aneurysm (A Simple Guide to Cerebral Aneurysm) can cause a sudden severe headache. 

One of my patient had what he describes as  the 'worst headache ' he ever had  followed by difficulty in swallowing. He was sent for brain scan which show bleeding from a swollen blood vessel in the brain. Because he was in China, his wife got hold of the SOS and manage to get him back to Singapore where I manage to get a neurosurgeon waiting to check on him on arrival. Luckily for him his bleeding was mild and his operation to clip the aneurysm was successful.

For prevention I usually advise patients to:

Lie down in a dark, quiet room.
Try muscle relaxation techniques or a gentle massage.
For tension headaches, take a warm bath.
For migraines, put an ice bag or cold towel on your forehead. 


Headache is a symptom which all of us have experienced at one time or another.
Most of the time it is not serious but in certain cases headache may be a symptom of something more sinister and dangerous.

A Family Doctor's Tale - ALOPECIA AREATA

DOC I HAVE A BALD SPOT ON MY HEAD

ALOPECIA AREATA( A Simple Guide to Alopecia) is a condition where the hair of the scalp would drop leaving a patch of bald area like a coin on the scalp.

The size and occurrence of alopecia areata are more common than females than in males. 

The cause is unknown although some believe it to be

1.due to excessive male hormones( like male baldness)
2.auto immune (where the cells of the body attack the cells in the scalp causing the hair to drop)
3.chemicals and dye affecting the roots of the hair
4.stress and nervous tension which was the definite cause in one of my patient.


I have a few cases of this conditions. 
Treatment was usually an injection of steroids into the scalp -a rather painful procedure because the scalp have a lot of nerves - and an application of a steroid cream into the scalp.


One patient was a teenage girl who had her first bald patch after her O Level examination. 
She had the injections and cream to help her hair to grow. 
After this incidence she had a recurrence every year after a major examination.
Each time she had an injection of steroid and cream. 
She did well enough in her examinations to enter medical school in the University of London.
After her yearly examination she would return to Singapore to have her bald patch injected by me with steroid and application of steroid cream.
After her graduation as a doctor, the condition disappeared. 
It would appear that her stress over her examinations was the triggering factor in production of the bald spots in her hair.

I had a few other young patients male and female who also had this condition each time after a stressful experience.
They were all treated with the steroid injection with improvement.

Recently I had an elderly patient who also developed 2 holes in the hair of the scalp. Growth of hair was slower than the younger patient. The new hair was white compared to his other hairs which were dyed.
I told him not to dye his hair because it could be a contributing factor. In the end he was persuaded by his wife to remove the dye. Since then his hair grew faster until it was normal. I guess that he had to live without dying his hairs.

The cause of this condition is still unknown but definitely stress and chemical dye are 2 factors to consider.

During the procedure of treating this condition, I found that somehow steroid creams do help in the growth with hairs. 
I have asked a few patients with male baldness to try massaging their scalp with steroid creams with some success.

A Family Doctor's Tale - RASHES

DOC I HAVE A RASH

A rash is a very common symptom seen in a family doctor clinic.
A rash can be itchy and uncomfortable.
They can be painful in cases of shingles rashes, chickenpox and infected rashes.
They can very small, raised, patchy in urticaria, spread over the body or blister like in appearance(chickenpox or herpes)


In Babies atopic eczema is a common skin condition which presents as a chronic, relapsing, and very itchy rash at some point during childhood.
Atopic eczema clears and often disappears with age.
It is usually genetic as the condition runs in families


In Children the causes are :
Allergy
Infections


In adults the causes are:
Allergy
Infections
Autoimmune -abnormal response of the body’s immune system


Rashes can be genetic or due to environmental triggers:

a.rough or coarse materials coming into contact with the skin causes itchiness.

b.feeling too hot and/or sweating will cause an outbreak

c.certain soaps, detergents, disinfectants,


One of my Singaporean patient who has just relocated back after 3 years in UK had hives or patchy itchy rashes after moving to a service apartment after staying at a hotel for 2 days.
The apartment provides free soap different from the hotel.
She was given an injection of antihistamine and some steroid which clears her hives.
But after a bath the hives came back and I had to give her another injection to clear the rashes. We suspected the soap was the problem and change it to her normally used soap.
After that the rashes disappeared. It was due to a sosp which she was allergic to.

d.contact with juices from fresh fruits and meats,

e.food allergens in childhood such as cow's milk, hen's egg,peanuts, nuts, shellfish, duck flesh

f.dust mites,

g.animal saliva and danders may trigger itching.

h.Upper respiratory infections (caused by viruses) may also be triggers.

i.Stress can also sometimes aggravate an existing flare-up.
j.Pollens from flowers


I had another patient who was given about 100 different types of flowers just the day before her wedding. Normally she was not allergic to most flowers but in this case one of the hundred flowers probably cause very itchy hives all over her body.
I had to give her an anhistamine injection and 8 tablets of steroid tablets before the hives disappear 3 hours later. Happily she was able to go through her wedding the next day.

Rashes can occur on just about any part of the body

In infants, Atopic eczema typically occurs on the forehead, cheeks, forearms, legs, scalp, and neck.


In children and adults, rashes typically occurs on the face, neck, and the insides of the elbows, knees, and ankles.


In some people, rashes may form bubbles which can ooze when broken.


In others, the condition may appear more scaly, dry, and red.


Chronic scratching usually make the skin worse taking on a leathery texture because the skin thickens (lichenification).


Typical features of rashes are:

1.dry,

2.red,

3.extremely itchy patches on the skin.

4.Oozing of the rash

5.Thickening of the skin


All rashes can be diagnosed from:
1.History and appearance of the rash

2.Screening test for food allergy

3.Blood test for specific antibodies to food substance



Treatment of rashes is:


1 application of lotions or creams to keep the skin as moist as possible after bathing2.Cold compresses applied directly to itchy skin can also help relieve itching.

3.application of nonprescription corticosteroid creams and ointments to reduce inflammation if the condition persists, worsens, or does not improve satisfactorily.

Hydrocortisone cream and ointment are preferred to prevent side effects such as skin thinning.

4.For severe flare-ups, I may prescribe oral corticosteroids (this treatment is not recommended for long-term use).

5.topical or oral antibiotics may be needed for the skin infection which may affect the dry inflammed skin.

6.sedative antihistamines are sometimes used to reduce the itch

7.Tar treatments can have positive effects; however, tar can be messy.

8.Phototherapy requires special equipment (lights).

9.cyclosporine A, an anticancer drug, modifies autoimmune response; however, this is used only in extreme cases because of its association with serious side effects on the blood cells.
10.prevent scratching.
   
Do not SCRATCH because damage to the skin barrier may lead to dryness and inflammation of the skin


Rashes can usually be avoided with some simple precautions.

The following suggestions may help to reduce the severity and frequency of flare-ups:

Moisturize frequently

Avoid sudden changes in temperature or humidity

Avoid sweating or overheating

Dress the child in breathable cotton clothes

Reduce stress

Avoid scratchy materials (e.g., wool or other irritants)

Avoid harsh soaps, detergents, and solvents

Avoid environmental factors that trigger allergies (e.g., pollens, molds, mites, and animal dander)

Be aware of any foods that may cause an outbreak and avoid those foods

A Family Doctor's Tale - WARTS, CORNS And CALLUSES

DOC I HAVE A WART,CORN OR CALLUS

WARTS, CORNS And CALLUSES was supposed to be in the blog after skin infections but I decided the Common Cold and Influenza are more common illnesses seen by family doctors and should be read first.


Warts are cauliflowered swellings present on the foot(plantar wart), hand(palmar) and even genitalia of the body(sexually transmitted). 
The cause is a viral infection called the human Papilloma virus which can spread from one person to another through direct contact provided there is a break in the skin exposed to the wart.

Sometimes they may disappear by themselves after several months. 
However in the worst cases they become bigger and can spread to the other parts of the body.

There are all sorts of treatments for warts:
1.Traditional: 
Vinegar and Chinese herbal medicine has been used to dissolve the wart. The cure rate is low.

2.Duct tape has been used over the wart to occlude it from air in the hope of it disappearing. Again the cure rate is low.


3.Western medicine include:

a.Salicylate acid in over the counter Duofilm, Compound W , Wartgone are applied over the wart for about ten to fourteen days giving rise to a white coat over the wart for several days before peeling off together with the wart. 
However the recurrence rate is quite high.

The medicine can also dissolve corns and calluses in the same way because the medicine removes thick skin. They may be called Collomack or Corn therapy. 
Again the recurrence rates are high because corns are caused by pressure points and calluses by friction.

b.Podophyllum resin cream has also being used on warts with good effect except again the recurrence rate is high.

c.Liquid nitrogen spray can also be bought in England and other countries to freeze the wart but often it did not work.

d. 5flourouracil ointment is an anticancer drug which when applied to the wart seems to be the best for the removal of the wart but act slowly. 
After a few months of application the wart usually disappeared. Only problem is that it is difficult to get in Singapore.


I had a patient from England who had tried salicylate lotion, liquid nitrogen and then tried the Fluorouracil ointment find his wart disappeared after a few weeks of constant application.

e. Silver nitrate pen used for stopping nosebleeds can also work in burning the wart. However it is a bit painful.

4. Surgery:
a.Surgical removal of the wart usually get rid of the wart but recurrence can occur unless the root is removed.
Even then the wart can grow again in the excised operation wound.

b.The best treatment in a family practice is electrical cautery removal of the wart. 
Not only does it remove the wart but it destroy the root of the wart preventing the virus to grow on dead tissue.

A patient with wart is given a local anesthetic at the cleansed wart site.
Once the wart site is numb (completely anesthetised) , the wart is burned using the cautery machine until the root of the wart is removed. The wound is cleansed and antibiotic cream is applied. Because of burning of the root area, the virus do not have a living tissue to regrow in. So the chances of the wart recurring is very low.

Corns and calluses are thickened usually caused by pressure points and friction.

Surgical removal of the corn and callus just removed the hard thickened skin which caused pain by pressing on the nerves in the skin temporarily. 
But if the pressure points and friction points are still there, recurrence of the corn and callus will happened. 
Prevention is by soaking the skin wound in warm water to soften the skin and antibiotic cream is applied to prevent infection of the skin.


Sport shoes are actually the best cure for corn and callus of the foot because the air cushion in shoes can prevent pressure and friction on the skin. 
The corn and callus will be less likely to recur.

Removal of warts, corns and calluses will temporarily remove the lesions but recurrence will occur unless the underlying cause like the virus, the pressure points and friction is removed totally.

A Family Doctor's Tale - INFLUENZA

DOC I HAVE THE FLU

INFLUENZA is probably the most common illness seen by family doctors all over the world.

There are more than 2000 strains of influenza virus which can mutate every few months resulting in more strains.
Influenza A strains are more dangerous than the Influenza B strains and Influenza strain C.

In the northern hemisphere the incidence of influenza occurs during the winter season (October to March) whereas in the southern hemisphere the incidence again is higher during their winter(May to September).

The influenza virus is highly contagious and usually spread by droplets through the air. 
Patients should always avoid crowded places and keep their hands clean. 
If possible wear a mask to prevent the spread of germs.


Because of the convenience of air travel the spread of influenza is very high throughout the world.
The recent case was the 'pandemic' of H1N1 influenza (which is an A strain Influenza) declared by the WHO in 2009.


Unlike the common cold viruses, influenza viruses produces more severe symptoms which can last more than 2 weeks:


1.Fever usually above 38 centigrade
2.Body aches
3.Cough dry or productive of yellow and green phlegm
4.Tiredness
5.Headache
6.Sneezing ot blocked nose occasionally
7.Breathlessness
8.vomiting especially in young children


Usually a influenza runs its course without complications in one to two weeks.


However the more deadly influenza viruses can cause a lot of complications in the very young, very old or those with low immune system(chronic diseases, pregnant women, AIDS (A Simple Guide to AIDS)). 

Serious complications can occur like:
1.Pneumonia (infection of the lungs) which kill the very old or young patients every winter. I normally check on the lungs on every patient with influenza. 
All pneumonia cases should be treated in hospital where there is oxygen and respirators to treat breathing difficulty.

2.Bronchitis( A Simple Guide to Bronchitis) and reactivation of asthma (A Simple Guide to Asthma) attacks may also cause breathing problems. I always ask for a history of asthma or wheezing in influenza patients and check their lungs carefully.


3.Meningitis ( A Simple Guide to Meningitis) is another complication which is due to the influenza virus attacking the membranes of the spinal cord or meninges.
I always check for high fever, headache and vomiting. Any patient with stiffness of the neck should be sent to hospital for further investigation and treatment.

Less serious complications like sinusitis ( A Simple Guide to Sinusitis) and otitis media ( A Simple Guide to Otitis Media)may also aggravate the patient's recovery.
X-ray of the sinuses should be taken if necessary and the ear checked for eardrum infection.


Treatment is aimed at relieving symptoms and preventing complications.


1.Rest is the most important part of treatment. 
A rested patient will recover faster.


2.Adequate warm fluids helps to keep the mucus membranes moist to allow infected mucus to flow better and also prevent dehydration especially in children below 5 years


3.If there is any fever, headaches and pains, paracetamol can be given to relieve symptoms.


4.Oral (tablet or syrup) cough medicine may also relieve cough. Mucolytic agents may help in dissolving mucus.


5.Bronchodilators help to open the airway for the cough to expel the germs from the lungs.

6.Antibiotics and vitamin C are not helpful in relieving symptoms of the influenza. 
Antibiotics should be given if there is associated secondary bacterial infection like sinusitis.

However recently there are antiviral agents such as Tamiflu and Relenza which can cure the influenza.



Prevention is by taking yearly seasonal vaccines injections against the influenza virus especially in the very old (after 65 years), very young (below 5 years) and those with low immune system or chronic disease.


Other preventive measure against influenza is to live a healthy life style:
Proper hygienic care of the hands and body
Avoid crowded places
Well balanced diet with enough fluids
Adequate mild exercise. 
Do not do any strenuous activities during or after Influenza because of the danger of viral myocarditis.

Please note that Influenza is a very infectious viral disease which can spread quickly and kill  the young and old easily.

A Family Doctor's Tale - THE COMMON COLD

DOC I HAVE A COLD

Who has never have the common cold? The code words are "Ah Choo" or sneezing, dripping of nose, pain in the throat and occasional fever. Cold weather, rain, snow, freezer, air conditioner are the precursor of a common cold. Once one person gets the common cold, every one in a closed environment gets it. That is why they called it the common cold.

The Common Cold (A Simple Guide to Coryza(Common Cold))is one of the most common infections seen by the family doctor.


Unlike Influenza, the patient suffer more from inflammation of the mucous membranes of the nose and throat, with sneezing, sore throat, and usually mild coughing. 

There are over 200 different viruses which can cause a common cold: rhinovirus, respiratory syncytial virus (RSV), corona virus, rotavirus.


Generally the common cold viruses produces mild but uncomfortable symptoms which seldom last more than 1 week:

1.Runny nose
2.Sneezing
3.Nasal congestion
4.Tiredness
5.Headache especially around the eyes and forehead
6.Fever - low grade rare


Usually a common cold runs its course without complications in one week. Because there is no cure for a viral infection, I usually aim at relieving the symptoms:


1.Rest is the most important part of treatment. 
A rested patient will recover faster.


2.Adequate warm fluids keep the mucus membranes moist to allow infected mucus to flow better and also to replace wet mucus lost during the runny nose.


3.If there is any fever, headaches and pains, paracetamol can be given to relieve symptoms.


4.Oral (tablet or syrup) decongestants may also relieve nasal symptoms. 
Antihistamines may help to reduce mucus production.


5.Decongestant sprays can relieve block nose temporarily, but should not be used for more than three days. 
Longer use can lead to rebound congestion with more symptoms of congestion.


6.Antibiotics and vitamin C are not helpful in relieving symptoms of the common cold.


Very rarely young children may develop complications such as bronchitis, viral pneumonia, and croup.  
I would check the lungs of young children carefully to make sure there is no breathing problem.

Acute otitis media ( A Simple Guide to Otitis Media) , an infection of the middle ear occurs in 2% of patients with a cold. 
I would ask all patients with cold whether there is pain in the ear or blockage in the ear.

Bacterial Sinusitis (A Simple Guide to Sinusitis) occurs in 0.5% of people with a cold. I would ask them for pain in the cheek and forehead area. If necessary an X-ray of the Sinuses should be done.

People with chronic obstructive pulmonary disease ( A Simple Guide to Chronic Obstructive Lung Disease) who have a rhinovirus infection are more likely to have a more serious or longer duration of illness.

Prevention is by :
1.Proper hygienic care of the hands and body
2.Well balanced diet with enough fluids
3.Adequate exercise

It is important to distinguish a Common Cold from Influenza which is usually more serious.

A Family Doctor's Tale - SKIN INFECTIONS

DOC I HAVE A SKIN INFECTION

SKIN INFECTIONS are part and parcel of the types of diseases seen by family doctors.

Scratching of the skin is one of the causes of breakage of the protective skin layer and infection from germs caught in the finger nails can enter the broken skin and cause pus formation in the skin. 

Abscesses are easily formed in any part of the body. 
Most large abscesses require incision(cut into the abscess) and drainage to release the pus collected to prevent infection spreading further and causing septic shock.


One memorable case was a small 3 year old girl who developed a large abscess on her scalp. 
There was no other way except to incise and drain the large abscess. 
She was very brave and cried once when the needle for local anesthetic injection entered the skin to provide local anesthetic. Then the knife was used to open the abscess and the pus was allowed to drain out.
After that she had the wound bandaged and given antibiotics, painkiller and antibiotic cream. 
Although she was told to wash her hands and not use them to scratch her head, she had a recurrence 2 years later and had the same procedure done on her again. 
Since then she did not have any more skin infection.


Infected acne can occur in adolescent boy or girl through hand contact with the acne. 
Antibiotics and antibiotic creams may be necessary for the treatment of the infected skin. 
The best antibiotics are those of the tetracycline group and erythromycin. 


In women who are breastfeeding, engorgement of the breast may occur due to blocked breast milk ducts.
If this happened warm compress may soften the milk stuck in the breast milk duct. 
If this does not happened the accumulated milk stuck in the duct may become infected resulting in abscess formation . 
If safe antibiotics such as ampicillin does not clear the infection the abscess may require incision and drainage.

Other infection may also occur at the nipple due to infected skin and clogged milk ducts.

Skin infection may also occur in the vulval area of any women if unhygienic conditions are present during sexual intercourse, urination and defaecation ( passing bowel motion). 
Very often infected Bartolin cysts in the vulva region may occur and require incision and drainage.

Infection of the penis may also occur due to traditional circumcision in children.
Some infection may also result from scratching the genital area and from sexual intercourse. 
In most cases blood tests and urethral (internal tube that leads from the bladder to the opening of the penis) swabs for bacteria may be done for sexual infections. 
Those sexually transmitted which can be treated  are given antibiotics and flagyl. 
Herpes infections can be treated with antiviral drugs sometimes successfully.
HIV infections however cannot be cured as yet.

 In housewives, a common infection is paronychia of the finger nails - infection of the side of the fingernail due to pressure or injury to the side of the nail. 
Very often the patient will have an abscess of the side of the nail by the time she sees a doctor. 
The abscess is usually pricked with a sterile needle to release the pus which normally cause pain due to pressure on the nail. 
This is followed by antibiotic and antibiotic creams.

Infection of the naval is very common in babies and are usually treated with antibiotic powder or creams.
Less often infection of the navels may occur in adults due to attempts at removing dirt in deep navels.

I had a elderly female patient who was actually referred to me by another family doctor who was unsuccessful in getting rid of the pus discharge from her navel in spite of  antibiotic treatment. There was an abscess in the lower part of the navel which was discharging pus. I had to incise the abscess completely and do daily antibiotic dressing of the navel until she was completely cured.


In Diabetic patient foot care is very important. 
Any wound in the foot can developed into abscesses and carbuncles (collection of abscesses) which needed special control of his diabetic condition, removal of all the abscess and carbuncle, strong antibiotic and daily dressing of his foot wound.

One of my diabetic patient had to be treated for about 4 weeks before his infected wound in the foot finally cleared up. 
However the next time he had his foot wound, he was bought to the Hospital where the doctor immediately sent him to a surgeon to do an amputation of the leg below the knee.


The worst infection I had seen in my family practice was that of the infected toe of a lorry driver.

He was dirty and smelly and obviously had not bathed for several weeks.
He complained of pain and swelling in his right big toe which was obviously very infected. 
So what I did was removal of the pus in the wound. 
What came out besides the pus was maggots about almost a hundred of them. 
I had to catch these wriggling maggots one by one until I finally reach the bottom of his wound. 
I cleaned the wound and did daily antibiotic dressing for about 2 weeks before the wound finally recovered. 
I also advised the patient to bathe daily. 
It was obvious that there was total neglect of his wound that allowed flies to lay eggs in the wound resulting in the maggots.


All skin infections can be treated if you are persistent with daily cleaning and antibiotic dressing of the wound.
However in Diabetes there is always the danger of the wound spreading in uncontrolled diabetes which may require amputation to stop the infection from spreading. 

It is important to emphasize to any patient with skin infection never to scratch or touch their skin with hands which may be dirty and full of germs

A Family Doctor's Tale - PIN IN THE FOOT

DOC I HAVE A PIN IN THE FOOT

This memorable case was a 8 year boy who was brought by the mother to see me because of pain and swelling in his right foot for 2 weeks.
The mother gave a history of the boy jumping on his bed which had small head pins left by his younger sister. 
The boy claimed one of the pin entered his right foot and caused pain in his foot. 
So the mother brought him to a nearby clinic where the young doctor examined his foot and told the mother there may be just a slight infection of his foot. 
He was given some antibiotic and painkiller and an antibiotic cream to apply to the sole of his foot. 

After 5 days the foot became more swollen and painful and the boy was brought to the same doctor again . He was given an injection and an another antibiotic.

After 2 weeks when the swelling of the foot did go down and remains red and painful she was recommended by a friend to bring the child to consult me.

The first thing after I heard the history of a possible pin entering his right foot was to examine the foot carefully. There was indeed a red painful swelling of  the dorsum or the top surface of his foot. 
The second thing that I did was to send him for an X-ray of his right foot.
As suspected the urgent x-ray showed the presence of a pin stuck in his foot in the flesh between the 3rd and 4th toes.

I had to do an urgent surgery to remove the pin. 
Luckily the boy was quite brave and although he cries a bit he knew it was for his own good. 
In an operation that lasted almost 1 hour I had to search for the pin guided by the x-ray and finally retrieved a small rusty pin which was surrounded by fibrous tissues from his foot.
The mother was so relieved to see the pin.
She said she was praying so hard for me to find the pin. 

As the mother did not know whether the boy was given a tetanus toxoid injection to prevent lockjaw in his 2nd visit to the doctor, I had to call the doctor to ask whether he had given the tetanus injection. 
He was shocked to hear that the boy had a rusty pin in his foot for 2 weeks. He said that he gave the boy only an antibiotic injection and not the tetanus toxoid injection which was to prevent lockjaw. 

Lockjaw( A Simple Guide to Tetanus) was a dangerous condition where a rusty nail or metal can cause the tetanus bacteria to grow in the foot resulting in the contraction of muscles including the the heart muscle and then death.

I gave the boy the tetanus toxoid injection and hoped that he will not get tetanus. 

Only once in my work as a family doctor, I have seen a lockjaw patient who had to be sent to hospital where her breathing stopped and had to be resuscitated back to life.

After another x-ray showed the pin was no longer in the foot, I gave him some antibiotics, painkiller and reviewed him the next day.

Happily he was well and he was given an antibiotic cream to apply to his surgery wound. 
After the stitches were removed and the pain and swelling was gone, I was satisfied that the boy was going to be all right.

Any body who has a possibility of a metal foreign body in his flesh should be sent for an x-ray. 
The x-ray can detect any metal in the body easily and knowledge of this can prevent any tragic consequences to the patient.

It was a lesson to all new young general practitioners.

A Family Doctor's Tale - FOREIGN BODIES And OTHERS

DOC I HAVE A FOREIGN BODY


Children:
Children have a tendency to experiment with their hands. 
Small objects like small marbles, parts of a toy,small coins etc may inevitably found their way into the inside of nose, ears or mouth and may not come out. 
I have removed at least 100 of these small objects from the nose, ears or throats of many crying children thanks to my training in the Ear Nose Throat  Department.

The most important part of the removals is for the anxious mother or father to grip the child tightly in order for the instrument to enter the nose or ear or throat to remove it without the child moving otherwise the instrument may injure the child. 

Rarely a child may swallow a coin and usually you have to send the child to the hospital for an x-ray. 
If present in the stomach or intestine, the only thing you can do is to wait for the child to pass it out through his faeces or poo.
Then another x-ray may be done to confirm the coin is out and that there is no other coin still stuck in the intestine.

Adults:
Foreign bodies ( A Simple Guide to Ear Infections)like cotton buds may get stuck in the ear canal.
They can be easily removed by using a crocodile forceps or by sucking it out using a suction machine. 
Sometimes syringing of the ear with warm water can also flushed out the cotton buds or other foreign bodies. 

Wax in the ears is also commonly seen in the ear canals of young and old adults. 
One of the best ways to remove the wax is to flush them out by syringing of the ears with warm water. 
After the wax comes out and is shown to the patient , they are shocked by the amount of wax that can be found in their ear canals. 
Prevention is by giving the patient olive oil ear drops or Waxsol ear drops to apply to their ear daily and advising them not to dig their ears with cotton buds which will inevitably pushed the wax further into the ear.

Foreign bodies can also be found in the eyes like dust, small particles, drill bits, some iron bits from construction sites.
Small dust particles and metal bits can be removed easily if not stuck to the cornea. 
Any particles that is stuck on the cornea need to be examined by an eye specialist who may need to check for any metal particles passing into the cavity of the eyeball. 
Iron particles are especially dangerous because the iron can cause damage to the eye.

Fish bones and chicken bones are also common foreign objects found in the throat. 
Usually if they can be seen these can be removed easily especially if you have Ear Nose and Throat experience. 
In some cases if the fish bone or chicken bone cannot be seen, the patients may need to have an X-ray of the throat. 
If present or too far down the throat, removal may be required to be done by endoscopy by an ENT specialist. 

Splinters of wood, glass or metal ( A Simple Guide to Lacerations)which are stuck in the fingers or other parts of the body can be removed easily with special tweezers with or without local anesthetic. 

Bee stings ( A Simple Guide to Bee Stings)are also some of the foreign bodies which family doctors are asked to remove.

One of the worst case of bee stings was a Filipino maid who had almost a hundred bee stings stuck to her scalp. She had disturbed a nest of bees and was attacked by them. Luckily she did not have any bad allergic reactions to the bees' venom and did not go into shock. I had to patiently remove the stings one by one until all the stings are out.

One of the  work of a family doctor is the removal of foreign bodies in children and adults. Ear Nose Throat experience is useful where removals are concerned because of the  frequency of occurrence in children.
Parents should not allow children not to play with coins, small toys or parts of a toy.
People should be careful when eating fish and chicken with bones.
Construction workers must wear goggles when using drills with metal bits.
Avoid disturbing bees or other insect nests

A Family Doctor's Tale - TRIGEMINAL NEURALGIA

DOC I HAVE A PAIN ON MY FACE

Trigeminal Neuralgia ( A Simple Guide to Trigeminal Neuralgia)is pain in the face due to hypersensitivity of the fifth or trigeminal nerve which supply sensation to the facial muscle and skin. 

All nerve pain can be excruciating. 

This elderly gentleman had this condition on the right side of his face for about 12 years. 
He was on constant painkillers.

The pain was so bad that he had to ask an ENT surgeon to cut off the branch of the nerve that leads to his nose and lip about 10 years ago. 
After the surgery there was no pain for 3 years though he has a bit of facial muscle droop. 
However the pain recurred after the third year of surgery. 

This time he did not want surgery because of the cost and also because the recurrence occurred even with surgery. 
There was also the side effect of a drooped facial muscle.
He was seeing instead a neurologist and his pain was relieved not totally with pain killers and a nerve pain drug called tegretol. 
However he had some gastric problem because of the strong pain killer.

Hearing about my injection for osteoarthritis and rheumatism, he came to consult me. 
I told him that the injection only worked with joint pain and not nerve pain.
In his case he needed an injection which will kill the nerve. 
In those days there were no botox injection which could kill the nerve. 
So what I used was (as recommended by an old medical book) surgical spirit. 
This was mixed with a local anesthetic and injection was done  into the nerve branch between the nose and lips. 
There was a slight droop of the face after the nerve was injected. 
Together with some painkiller, antacid and his Tegretol, the pain was reduced considerably. 

Each time there was recurrence of pain another injection was given. 

He had a total of 4 injections of the surgical spirit before the pain disappear completely.

He still comes to see me together with his wife for rheumatic pain but not for the nerve pain.

Nowadays the new aesthetic or cosmetic physician will probably inject him with botox which can cost a few thousand dollars.
Sometime an old method worked equally well. 

This is the one and only case in which I had treated with the injection of surgical spirit and successfully too.

A Family Doctor's Tale - GASTROENTERITIS

DOC I HAVE DIARRHEA

How many of us have taken hawkers food and ended up puking and rushing to the toilet to pass out watery stools. Then there are the abdominal cramps which strike every now and then causing the victims to double up in pain and clutching their stomachs. Food poisoning or gastroenteritis is very real and very common.

Gastroenteritis is one of the most common medical condition seen in a family practice other than colds and coughs.
It occurs at all ages from babies to elderly adults. 
The most important danger is the dehydration and loss of nutrients and salts that it can cause  resulting in fatalities.

Gastroenteritis is usually due to food poisoning from eating unhygienic food. 
A common cause is from non-home hawker or even restaurant food and overnight food. 
Most of the germs are viral in nature but there may be rarely bacterial infection such as salmonella infection.

A survey of the food causing gastroenteritis at one stage found that 50 per cent of the illness is brought about by eating chicken or duck rice in Singapore probably because the chicken or duck are left hanging on the stall exposed to germs, flies, spittle,dust etc. 
The Environment ministry have now insisted that all stalls should have 3 quarters of the stall covered by glass or plastic shelves.

1.Since then the incidence of food poisoning due to chicken or duck rice has been reduced to 25 percent. 
2.Another 25 per cent was contributed by seafood especially those bought from contaminated waters such as oil spills or waste discharge.
3.Another 25 per cent was from fruits and fruit juice vendors who handle the cut fruits with unhygienic hands and dirty utensils.
4.The last 25 per cent was from all the other food sold. 

The safest food was those that are boiled at 100 degree centigrade such as soups.


Gastroenteritis may present with symptoms of vomiting and diarrhea. 
The worst is when there is vomiting involved because of the inability to swallow medicines without vomiting it out.   
In the case of babies dehydration can quickly set in. 
They should always be sent to hospital for intravenous nutrition. 

Most cases of diarrhea in children comes from dirt on the ground or from other children in child care facilities. 
It is difficult for a child not  to explore the floor or the toys with their hands which is then put into the mouth. 
Sometimes the toy itself is put into the mouth. 
All toys which the children may come into contact should cleaned properly . 
The importance of an hygienic environment must also be emphasized. 
The hands of the children must be cleansed with a clean cloth once in a while. 
Some illness such as hand mouth and foot disease can be caused by certain rotavirus which can spread to the air and cause gastroenteritis.

I usually treat most gastroenteritis with lomotil or imodium with good results. 
Sometime a stool hardener such as kaolin will also help to stop the diarrhea faster. 

An anticholinergic may be given to stop pain. 
Rarely antibiotic are given if bacterial infection is suspected.

Diarrhea itself may not be due to food poisoning. 

In babies lactose intolerance to cow's milk may be a cause of diarrhea and the cow's milk must be substituted with soya bean milk. 

Some diarrhea in adults are due to Irritable Bowel Syndrome and can be controlled with anticholinergic or tranquillisers.

A unique case of chronic diarrhea was seen in a baby of one and half years who had diarrhea or watery stools since the age of 6 months. He probably had a mild case of food poisoning and was treated by his pediatrician who told him to stop his milk and change to soya bean milk and gave him some kaolin. 
The diarrhea did not stop so he was brought to another pediatrician who again change his milk. 
Again the diarrhea did not stop . 
So he was brought to many other doctors before coming to see me.
Each doctor asked the parents to change to another type of milk or soya bean milk and gave medicines.
By the time the child saw me he was slightly dehydrated but otherwise quite healthy. He already had X-rays of the abdomen, blood and stools tested by the pediatricians without obvious abnormally. 
I had suspected that it was the frequent change of milk that caused the problem in the child. I asked the parents what milk the child was taking before the diarrhea and advised them to return to that milk but given at half strength. I also gave the child some mild anti diarrhea medicine. The parents were to increase the strength of the milk once the diarrhea improved. 
After 1 week the child made a complete recovery. 
It was the constant change of milk that caused the child's intestine irritable. Just by returning to the old milk and diluting the milk the child was able to handle the digestion of his milk.

It was a case of the proverb "If it ain't broken don't change it."
In fact for all children with diarrhea, I do not ask them to change milk just dilute it to half strength and take the medicines that I gave.

A Family Doctor's Tale - GASTRITIS

DOC I HAVE A STOMACH PAIN

Irregular meals, incomplete time for eating, hunger, stress, tension, smoking, alcohol, black coffee and certain medications all will lead to gastritis. You will feel bloated, heartburn and stomach pain. That is what you will feel as a victim of this very common condition.


Gastritis(A Simple Guide to Gastritis) is a common medical condition in a lot of people including myself. 

I developed gastritis after working night shifts in the hospital as a result of incomplete meals from emergency resuscitation and stress. 

It usually manifests itself as bloating of the stomach , heartburn, indigestion and epigastric pain(below the ribs and between the ribs). 
There may be gastroesophageal reflux with acid coming upwards to the throat. 
The patient usually feel that the food is not well digested.

It is important to explain the causes of the gastric problem to the patient so that the patient will 
1.avoid irregular meals and take small but frequent regular meals
2.avoid stress and nervous tension and learn to relax
3.avoid smoking and alcohol
4.tested for helicobacter pylori and if confirmed treated for the bacteria for at least six weeks of antibiotics.


The patient should always be advised to have a gastroscopy to exclude other causes of gastric pain such as gastric polyps and cancer. 
One of my patient was very lucky to have a biopsy of his gastric ulcer during a gastroscopy and was found to have very early lymphoma. He was treated immediately with chemotherapy and has no more recurrence of his lymphoma. That was 20 years ago.

An ultrasound of the gallbladder and liver should also be done to exclude pain due to gallbladder trouble.

One of my patients was found to have gallstones and after the removal of her gallbladder did not have any more abdominal discomfort.


Patients with gastritis should always be advised not to rush through their meals and to take more diluted food or liquids to dilute the food. 
I would advise patients to walk for a short period after the meals to help the food to move through the intestines and stomach especially the night meals.
It is important for the patient to relax after a meal but not on the couch in front of the television.

In patients with gastroesophageal reflux not to sleep flat on his/her back but with the upper body slightly raised to prevent the acid from flowing upwards to the throat. 
This can done with a slightly raised pillow so that the acid cannot flow to the mouth so easily.

The other thing is to watch the diet taken. 
A bland diet with no rough food, spicy food, fried or oily food , sour or acidic fruits and food or even very cold food from the refrigerator is better in preventing an attack of gastritis. 
Any food that is noticed to cause more gastric discomfort should also be avoided.

Smoking and alcohol is definitely to be avoided as they stimulate the production of gastric acid. 


Black coffee(Caffiene), strong tea(Tannic acid), aspirin, pain killers and drugs which irritate the stomach lining should also be avoided.


My treatment inevitably contains 
1.a mild tranquillizer for the stomach combined with a anticholinergic to reduce the acid

2.a H2 antagonist(cimetidine,famotidine or ranitidine) or Proton pump antagonist (omeprazole or nexium) to 
prevent the production of the gastric acid

3.most importantly an antacid to counter the acid in the stomach. 
The best way to take the antacid is to take the antacid like a milk drip (chew a antacid or take a tablespoon of antacid suspension every half hourly until the stomach pain or discomfort disappears). 
This also works for most cases of hiccups. 

I had one patient who had tried everything (Drinking water, shock techniques, chinese medicines etc) without effect except by the taking the antacid continuously just like the milk drip.

4. If a bacteria is causing the gastritis, it is important to take a six week course of antibiotic to get rid of the helicobacter pylori.

In fact one of my patient who had chronic gastric problem was cured after the bacteria was found and removed. 

In fact this bacteria can also be a cause of gastric cancer. 


Gastritis is a common condition but can be cured with educated knowledge of your condition and taking prevention

A Family Doctor's Tale - ASTHMA & BREATHLESSNESS

DOC I AM BREATHLESS

Ever get woken up by your child or old parents gasping for breath and wheezing away. Many cases of asthma have their attacks of asthma worse at night. Some may even call you for a house call.

Asthma was another medical condition that affects the life of many patients.

Bronchial asthma  has its origin in hereditary allergy - skin ( A Simple Guide to Eczema), nose (A Simple Guide to Vasomotor Rhinitis) and lungs ( A Simple Guide to Asthma) .

Avoidance of dust, dirt, and changes of temperature was very important in helping the patient regain a normal life.
Stress (A Simple Guide to Stress)and smoking are the other triggering factors.
In fact some doctors especially pediatricians (children doctor) classified prolonged cough above 2 weeks as asthma and often give bronchodilators to open the narrowed air tubes.

My treatment for asthma after doing a X-ray of the chest to exclude other conditions such as tuberculosis was typically to give an intravenous injection of aminophylline which work very well and fast for acute asthmatic attack. Intravenous injection delivers the drug within 2 minutes and the asthma subsides rapidly.  
I became well known for my intravenous injection and its rapid relief. 
Intravenous injection was something I learned to give even with small veins during my anesthetic days.

Besides the injection a bronchodilator such as diprophylline  and a steroid such as dexamethasone( I do not like prednisolone)
was given on a tapering dosage.
An antihistamine may be given at the same time to prevent allergies. 

It is also important to stress to the patient to live in a dust free environment and avoid sudden changes of temperature. 
At the same time the patient was advised to learn to relax and do deep breathing exercises. 
One of the best exercises for asthmatics was swimming which help the patient to learn to breathe properly. 
It was one of the reason why many champion swimmers had an asthmatic history. Some of them are even allowed to use a ventolin inhaler before their swim.

The ventolin inhaler is prescribed for acute attacks. 
Sometimes a steroid inhaler is used to prevent the attacks of asthma.
The correct use of the inhaler must be taught in order to get maximum effect from the medicine in the inhaler.

In some young children a respiratory nebuliser may be used to provide air, steroid and bronchodilator into the lungs during an emergency asthmatic attack.

Because I was able to treat quite a number of asthmatic patients successfully , many patients were referred to me for breathlessness and chronic cough ( A Simple Guide to Coughing). 

It was important that every patient should have a X-ray of the Chest done to exclude other serious illness such as tuberculosis or cancer of the lungs.

In elderly patients above 50 years old there is such a condition known as cardiac asthma which is basically a mild form of heart failure due to their age. 
One of the ways to find out is to ask whether there is breathlessness on climbing 3 flights of stairs or walking long distance. 
The other way is to check for the presence of ankle edema and basal creps in the lungs.
Because of the heart failure congestion of blood builds up in the lungs and reduce the capacity of the lungs to breathe.

It is my normal routine to check for ankle edema in all elderly patients. 
A small dose of diuretic (to help pass water out) helps to reduce the congestion in the lungs and relieve the breathlessness  of the patient and his/her chronic cough.

With these simple treatments I was able to control asthma, breathlessness and chronic cough.

Many patients come to see me when their chronic cough cannot be cured by other doctors.

One notable case was a patient who was given enapril by her doctor for hypertension(A Simple Guide to Hypertension). Enapril and other ace-inhibitors for hypertension has a reputation for causing cough in patients. 
From her history I found out that her cough started after the change of medicine to enapril by another doctor. 
So I stopped her enapril and put her on another hypertension medication.
After the change her cough disappear totally and she was happy enough to recommend any friend with chronic cough to see me.

Health education and a proper history is very important in the treatment of any disease including asthma. 
A doctor must always be ready to listen in order to treat properly.

A Family Doctor's Tale - ARTHRITIS CASES

DOC I HAVE A JOINT PAIN

Every person grows old. As you grow there is degeneration or wear and tear of the joints. Because of the degeneration of the joints there is pain. The worse pain are are the back , knees, shoulder, neck and fingers.
This is osteoarthritis .

Osteoarthritis (A Simple Guide to Osteoarthritis) is a joint disease which occur mostly in people above 50 years old although there are cases of people having the illness at 35 years old. 

It was caused by wear and tear of the cartilage of the joints as well as loss of joint fluid and swelling of bones. The frequent strain exerted on the bones of the joints over a period of time cause inflammation of the joints or arthritis.

It was a common disease in the 1970s and is still very common today. Part of the reason was the high rise living where people have to climb stairs unlike in the kampong (rural village) which is built on flat grounds.

In those days other than the specialist orthopedic surgeons there were very few general practitioners who knew how to do intra-articular injections. I was one of the few family doctors who knew how to inject into joints effectively.

One of my first patient was an old lady who shared her provision shop with a Chinese medicine shop. She had pain in both knees for some time now but Western and Chinese medicine and treatment could not help her. I was able to give an intra-articular injections into her knees which relieved her pain for several years.

Because of this she and the proprietor of the Chinese  medicine shop would recommend customers to see me when the Chinese medicines did not help to relieve the pain. It was through them that I develop a reputation for treating joint pains.

I always tell my patients that there was no 'cure' but temporary relief.

There was a patient of 35 years old who had knee joints pain after doing some taichi exercises. After the injections she recovered and after my advice on avoiding climbing stairs and practicing taichi  she did not have any problems with her knees up to today.

It was very important that the patient realized that the injection is not a cure and that they have to help themselves in order to get well:

1. lose weight if obese. The heavier you are the greater strain on the hips, knees and ankles.
2. avoid carrying heavy things
3. avoid over straining the joints by climbing steep stairs
4. avoid wearing high heels which cause more strains on the legs and back


Rheumatoid arthritis( A Simple Guide to Rheumatoid Arthritis) is an even more severe condition than osteoarthritis. I had a young woman in the 1970s who had just graduated from Nanyang University who developed this severe and swollen joint pains. After x-rays and blood tests it was confirmed that she had Rheumatoid arthritis. 
She was referred to Tan Tock Seng Hospital for treatment.  She was given steroids and painkillers. 
Sometimes the pain was so bad that she had to call me for house calls to relieve her pain.
It was depressing to see her becoming worse by the year with deformities of he wrists and ankles.

Finally she had to be admitted to hospital for a new anti-cancer medicines which did relieve her pain. Unfortunately the deformities could not be remedied. It was sad to see a young woman ready for work become a recluse with deformities unable to work or help herself.


Gouty arthritis ( A Simple Guide to Gout) was one of the most painful arthritis.
I had a patient who would limped into my clinic every time after a night out drinking alcohol. I would give him an injection into the most painful joint and an uricosuric drug( to pass out the uric acid from the body through the urine) and pain killer.
He would be well until the next episode of gouty arthritis.
Some other patient will have the same problem after taking peanuts, soya beans, seafood and internal organs.
Prevention was to avoid the above food, drink lots of water to dilute the uric acid in the blood and take a drug called allopurinol which help to turn the uric acid to urea.
One of the danger of this drug was a severe allergic reaction called Steven Johnson Syndrome.


Arthritis is a one of the most common medical condition which is why I first wrote about Osteoarthritis in my blog " A Simple Guide to Medical Conditions". This is particularly so with an increasing population of elderly people.

I still get an occasional referral for treatment of arthritis cases.
I had to tell them that the injection I gave them was not a 'cure' but temporary relief. Health education and prevention was better than cure.