A Family Doctor's Tale - ADHD

DOC I HAVE ATTENTION DEFICIT HYPERACTIVE DISORDER

ADHD is defined as developmentally inappropriate inattention, impulsivity and hyperactivity with onset before 7 years old and duration of at least 6 months.

There are 3 subcategories:
1.without hyperactivity
2.with hyperactivity
3.with other specified manifestation of the hyperkinetic syndrome

It may be a hereditary problem with some parents having the same traits in their childhood.
There are neurophysiological causes like the lack of serotonin and other chemicals in the body which affect their behavior.
There is psychosocial causes of this condition.

Symptoms:
1.intractability
2.impulsive activity
4.excessive motor activity
4.difficulty in concentration
5.Insomnia or restless sleep

Diagnosis:
psychological assessment
IQ test
Observation of patient's behavior through parents teacher and friends

Treatment:
explanation to family and patient
environmental manipulation
psychotherapy
healthy lifestyle
treatment with methylphenidate

Prognosis
variable may remit with age

A Family Doctor's Tale - AUTISM

DOC I HAVE AUTISM
Autism is defined as a group of the developmental disorder of childhood with pervasive lack of responsiveness to other people.


There is
1.gross deficit of language development
2.bizarre and lack of response to meaningful interaction

There may be hereditary predisposition.
The illness is more prevalent in boys than in girls
No specific neurological abnormalities may be present.

Symptoms of autism:
There is gross sustained impairment in social relationships or motor skills while general knowledge, reading or vocabulary skills are well above normal for child's age
1.lack of affective response to other
a.avoid touch
b.do not smile in response to another's smile
c.poor or inappropriate eye contact
d.do not imitate complex actions like clapping
e.do not participate in early social games like hide and seek
f.prefer to play alone
g.unable to join in imaginary games or play
h.uncooperative in classroom activities
i.lack of interest in others

2.resistance to change in environment
a.cannot cope with sudden changes
b.inappropriate clinging
c.repetitions of actions with toys or objects
d.repetitive behavior or movements
e.Abnormal motor movements -posturing, rhythmic rocking, hyperactivity
f.problems with imaginative play or creativity
g.unusual focus on certain parts of objection (example air conditioner)
h.difficulty in self control especially in open spaces

3.abnormalities of speech
a.difficulty in understanding simple commands
b.delayed or unusual expression of language
c.limited use of speech for communication
d.difficulty in understanding gestures or using gestures

4.Over or under sensitivity to certain stimulation:
a.sudden excessive anxiety
b.fear of unknown
c.very sensitive to loud sounds
d.difficulty in standing close to other or in a line
e.smell inappropriate areas of body such an adult hair
f.unusual response to pain or high threshold of pain
g.Poor concentration

5.Other problems
a.Insomnia or poor sleep
b.self mutilation

Diagnosis:
1.loss of language or social skills
2.no babbling, pointing,or other gestures at 12 months
3.no meaningful word by 18 months
4.no spontaneous 2 word phrase by 24 months

A full evaluation of the child is done
1.neurological assessment
2.psychological assessment

Treatment of autism:
There is no medication to cure autism although medications may be helpful with anxieties, hyperactivity and aggressive behavior.

The best way to treat autism is by intervention using:
1.counseling
2.psychotherapy
3.family support
4.Behavior modifications
5.psychosocial intervention
6.remedial education
7.healthy lifestyle

Prognosis
1.chance of normal adaptation poor
2.symptoms reduce with age
3.some children may be able to attend school

A Family Doctor's Tale - DYSLEXIA

DOC I HAVE DYSLEXIA

Dyslexia is defined as the serious impairment in development of reading or spelling skills not explainable in general intellectual ability, inadequate schooling or visual perceptual capacity.

It is a hereditary problem with family history of language problems.
There is central nervous system deficit defect in the synthesis of graphic symbols.

Symptoms:
1.MARKED DISCREPANCY BETWEEN INTELLIQUENCE AND LEVEL OF ACADEMIC SPELLING AND READING SKILLS
2.impairments manifested in reversals(dig for pig,was for saw)
3.inability to recognize words seen many times before
4.Poor concentration or inattention in class
5.social withdrawal
6.truancy
7.subjective feeling of being 'stupid'
Boys affected more than girls

Diagnosis:
1.physical and neurological exam
2.eye and hearing tests
3.psychological and educational testing

Treatment:
counseling with parents and patient
psychotherapy
remedial education
healthy lifestyle

Prognosis
lifelong handicap
minimize by special tutring technique emphasizing phonics

A Family Doctor's Tale - OBSESSIVE COMPULSIVE DISORDER

DOC I HAVE OBSESSIVE COMPULSIVE DISORDER

Obsessions are defined as the persistent recurrent ideas, thoughts, images or impulses that are voluntarily produced but invade the consciousness of the affected person.


It is a psychological problem with patient becoming so conscious with his or her obsession that he or she becomes not interested in any else.


This condition is more prevalent in women than in men.


Onset usually occur in the second or third decade of life.

Compulsions are repetitive and seemingly purposeful behaviors performed accordingly to certain rules or in a stereotyped fashion.


Patients most of the time realize that they have such an obsession or compulsion but are unable to control them.

There is no organic demonstrable cause to the illness.
The disease may present in a mild form and may be exeraberated by some trivial incident.
Development conflicts may sometimes lead to obsession and compulsion behavior.

Symptoms:
thoughts of violence or contamination
thoughts of weight loss
mounting anxiety with some efforts to resist obsessive or compulsive behavior
common compulsive behabiors:
hand washing(contamination)
counting
touching
repetitive checking of locked doors
Associated with depression

Diagnosis:
neurological examination
psychological and psychiatric assessment

Treatment:
Alteration of lifestyle and job to reduce anxiety
Psychotherapy focused on explanation of immediate problems
Correction and modification of behavior
Use of antidepressant and serotonin blockers

Prognosis
Good in mild cases
Varies with severity
Rituals in obsessive behavior partially allay anxiety
Rarely requires hospitalization

A Family Doctor's Tale - PARANOIA

DOC I HAVE PARANOIA

Paranoia is defined as the psychotic disorders characterized by persistent delusions of persecution by other people.

Cause is unknown.
Develops slowly and is complex logically elaborated delusions.
Seen in patient of superior or unique ability.
Basic personality is intact and preserved.
Hallucinations not present.

Paranoid states:
1.Paranoid:
Delusions lack logical and systemic nature
2.Paranoid schizophrenia:
Delusions bizarre or fragmented
3.Duration is shorter than paranoid
4.Associated with disabilities such as deafness, alcoholism, social deprivation, amphetamine abuse

Symptoms:
1.Jealousy rests on unreasonable evidence
2.patients denies their own wishes and project on their lowers
3.Eroticsm:
persons that patients project emotion to may be real (but not true social contacts) or imagined
4.Grandiosity:
patient regress to an omnipotent idea of himself
5.Persecution:
deep distrust of others
patients project own hostility towards people
They feel they live in a threatening world amy react or attack to defend themselves

Treatment:
Hospitalization may be necessary in a few cases
Psychotherapy is the most important mode of treatment
Tranquillizers may be necessary in some cases
Phenothiazine are useful in paranoid psychotic states

Prognosis
usualy poor (incurable)
Paranoid reaction may be improved with prolonged psychotherapy
Persecutory paranoid patient may be dangerous to others

A Family Doctor's Tale - DEPRESSION

DOC I HAVE DEPRESSION


Depression is a very common mental illness seen in a family doctor's clinic.
There is an alteration of mood which exceeds normal sadness.

Everyone has felt sad at one time or another.


It may be due to a disappointment, frustration or losing someone.


Time heals, the mood lifts and people continue to get on with their lives.

In some people, depression can be so severe that it dominates their lives, preventing them from living their lives as they used to.
Depression of this degree is a medical illness and needs treatment.

The severe form of depression may take 2 forms:

1.Major depression is manifested by a combination of symptoms that affect our work, interests and feelings towards family and friends.


2.Dysthymia is a less severe type of long term depression with symptoms that prevents them from functioning at an optimal level.

Many patients suffer from Depression because of:

1.hereditary or genetic factors in the transmission of depressive disorders.

2.biological component in depression.

It may be associated with having too little or too much chemicals in the brain.

3. medications have mood altering properties.

Antidepressant medication act by altering and normalizing the biochemical imbalances in the brain.

4. Life events such as loss of a job, retirement, divorce, death of a loved one or moving to a new house can precipitate a depressive illness.

Social circumstances also play a part. If we are alone, have few or no friends, suffer from a chronic illness, then we may be more vulnerable to depression.

5. People with life threatening or long-term physical illness such as cancer, stroke, arthritis or heart disease are also more vulnerable to depression.

6. Personality may also play a part in depression. Some of us are more vulnerable than others because of the individual make-up or early life experiences.

Very often, a combination of genetic, psychological and environmental factors is involved in the onset of depression.

The good news is that whatever the cause, depression is treatable.

Certain characteristic symptoms can give you or your family a clue that you are depressed:

1.Depressed mood


2.lethargy and fatigue


3.loss of interest and enjoyment in life


4.lack of drive or motivation that makes even simple tasks or decisions difficult or impossible


5.loss of concentration


6.Loss of self confidence, avoiding people


7.Sleeplessness or excessive sleeping


8.Agitation or restlessness


9.ideas of being useless, inadequate, helpless or hopeless


10.Feeling guilty or worthless


11.Loss or gain in appetite with loss or gain in weight,libido


12.Thoughts of suicide;


These symptoms are very common in depression and they are much better admitted than covered up.

The most important part of treatment of depression is:

Reassurance and support is most important in treatment of depression.


Recognition of suicide risk must be remembered when treating a depressed person.


Treatment for depression is well established.


Majority up to 90% of people with major depression have fairly good treatment outcome.


Treatment consists of drug (antidepressant medication) and non-drug therapy.
Usually, a combined treatment is best:
1.medication to gain relatively quick relief and


2.psychotherapy to learn more effective ways to deal with life stresses.

Antidepressant Medication


All antidepressant medications are equally effective but they have different side effects. The most often used antidepressants include tricyclics, monoamine oxidase inhibitors, lithium and selective serotonin inhibitors (SSRI).

Antidepressant medications do not begin working the day you take them but your mood will improve after one to two weeks. However, you may notice some improvement on the first day, especially in your sleep and feeling less tense and anxious.

The medications are compatible with painkillers, antibiotics and contraceptives. However, you should avoid alcohol as the medication and alcohol combined can make you too drowsy.

Do not stop the medication once you start to feel better as you may relapse into depression again. You should discuss this with your doctor and let him advise you when to stop.

Antidepressants like all drugs have some side effects, though these are usually mild and tend to wear off as treatment goes on.
The common side effects and their remedies are:

Dry mouth - drink more water
Constipation - eat more fruits, cereals, prunes and vegetables
Drowsiness - this will pass soon; do not drive or operate heavy machinery if feeling sedated
Dizziness - rise from bed or chair slowly

Some side effects with the newer medications:
Headache - this will usually go away
Nausea and stomach discomfort - transient; take medication with food
Nervousness and insomnia - these may occur during the first few weeks, reducing the dose will usually resolve them.

Non Drug Therapy
Psychotherapy
Psychotherapy involves talking things through with a trained counselor or therapist. Talking to someone who can really listen and understand you without passing judge ment can be a tremendous relief. You learn how to solve problems and cope with life stresses better.
Exercise Exercise not only improves your health but it also gives you a sense of accomplishment. Endorphins ('feel good' hormones) are released during exercise and this can elevate your mood.
Relaxation Therapy
This involves deep breathing exercises and progressive muscle relaxation.
Support groups offer fellowship and you get to hear first hand accounts of how others with depression, like you, have learnt to cope. Presently SAMH, IMH and the Behavioural Medicine Clinic at HPB run support groups. The group at IMH is a psychoeducation group, i.e. you learn about the depressive illness and methods of coping.

Electroconvulsive Theraphy (ECT)
ECT is only indicated for those with severe depression who have not responded to treatment or are highly suicidal.
It involves giving a light general anaesthetic and an electric current is passed through the brain for a few seconds.
The whole procedure takes only about 15 minutes and the patient is only aware of having gone to sleep.

We should try to prevent depression through :

1.try to talk to close friends about bad news

2. Be realistic. Set priorities and do what you can.

3. Do something - get out of the house for a walk or some exercise. While you may not be able to work, it is always good to try to keep up with some light activities such as housework. This will help take your mind off those painful feelings.

4. Eat a good balanced diet, even though you may not feel like eating.

5. Resist the temptation to drown your sorrows with alcohol. Alcohol actually depresses the mood, so while it may give you immediate relief, this is very temporary and you may end up more depressed. It is also bad for your physical health.

6. Remind yourself that you are suffering from depression, something that many other people have gone through, and that you will eventually come out of it, as they did.

7.Get a friend or relative to help you make appointments to see the doctor and provide support both emotional or encouragement to take medication

A Family Doctor's Tale - STRESS

DOC I HAVE STRESS

Stress is usually considered the buildup of anxiety and pressures on a  person.

There are  different types of stress depending on what the person is worried about.

He could be stressed about work, money, or family relationship.

Causes of Stress may be:

1.Sleep problems resulting not enough rest for the brain.

The patient becomes an  easier target for getting stress , becomes irritable and tense.

2.Work Problems especially if the patient work  too many hours .

His boss may be too demanding or yell at him for no good reason.

This can cause him to feel upset and depressed.

There is also the stress of going to work especially if distance is far and drivers are inconsiderate.

3.Job Loss problems for a person who is fired or laid off from a job.

There is worry that he may be unable to get another job and enough money to support his family.There is also the feeling of inadequacy and depression.

4.Money problems also have an effect of stress  in a person.

His job may not pay enough to support his family or he may have overspend his salary on unnecessary things.

He cannot pay his bills or if not earning enough money, feel stressed from all the worrying.

5.Family problems  - relationship problems at home and money troubles may affect the relationship between husband and wife and family.

All these problems are adding stress into the patient's  life.
Sometimes talking about the  problems  with the family member my solve the
problem and make it less stressful.

Stress is very common and  is found in almost everyone.

It can be hard to deal with but working through it can be a good way to eliminate it and help the person live a happier and healthier life.

Symptoms of Stress:

1.Gastric problems or indigestion
1. Indigestion of food in the stomach can cause the undigested food in the stomach to produce gas in the stomach which goes upwards to the throat

2.gastroesophageal reflux of food can also cause the acid and undigested food to travel to the mouth and produce mucus secretions.

3.Gas in the abdomen my press upwards against the heart giving rise to breathless and chest tightness

4.There may be  palpitations of the heart and difficulty in breathing

5.panic attack where the person feels as though his heart is constricted and  and excessive fear and panic about his health

Treatment of stress:

Non-medicinal procedures:

1.psychotherapy

A Family Doctor's Tale - ANXIETY

DOC I HAVE ANXIETY

Anxiety is defined as the severe or protracted fear reactions that are inappropriate.

It is a hereditary problem with patient becoming fearful of minor problems
There is association with personality types
This condition is more prevalent in women than in men.
Certain factors like:
1.stress


2.exhaustion


3.fatigue


4.infections


5.endocrine disease like hyperthyroidism


6.drug induced especially loss of weight drug, cns stimulants


7.Also seen in depression and other psychotic illness like schizophrenia

Symptoms:
1.tension


2.nervousness


3.fear


4.Poor concentration


5.Insomnia


6.loss of appetite


7.loss of libido


8.physical manifestations such as:
tachycardia


chest discomfort


breathless

tiredness

dyspepsia


diarrhea


dry mouth


increased sweating


fainting attacks


hypochondriacal ideas


phobia


obsessions

Treatment:


counseling


psychotherapy


treat underlying depression


avoid stress


healthy lifestyle


tranquilliser

Treatment:
Hospitalization


Psychotherapy


Correction of nutrition and metabolic deficiency


Use of antidepressant and serotonin blockers

Prognosis
Good in mild cases


Poor in severe cases

A Family Doctor's Tale - ANOREXIA NERVOSA

DOC I HAVE ANOREXIA NERVOSA

Anorexia nervosa is defined as the persistent refusal to eat resulting in marked loss of weight.

It is a psychological problem with patient becoming obsessed with his or her so called obesity with
intent to lose weight as a result.

There is 3 components to this eating problem:

1.fear of weight gain

2.distorted image of  thin body as the perfect body

3.refusal to eat to gain a healthy body weight


This condition is more prevalent in women than in men.

Onset usually occur in puberty.

The most common causes are:

1.obstensible fear of obesity resulting in excessive dieting.

2. distorted image of the body size related to psychosexual conflicts in the brain.

3.fear of eating resulting in low weight and thin body size

Risk factors in anorexia:

1.familial - can occur in families and more common in females

2.Dissatisfaction about body size

3.Low self esteem about his or her appearance

4.perfectionism in every thing he or she does


5.family problems

6.Dieting history in family

7.Difficulty in communication

8.history of physical or emotional abuse


Symptoms:
1.progressive and excessive weight loss


2.obsessed about being thin -

a.reduce food,

b.eating low calorie foods

3.preoccupied about food and meal times -

a.avoiding certain food,lying about food eaten,

b.throwing away or hiding food,

c.complains of stomach pain during meal time


4.secret meal time rituals

a.refuse to eat with the rest of family

b.chewing food and then spitting it out

5.taking laxatives, diuretics and diet pills to lose weight

6.excessive physical exercise to burn off fats

7.Fixation on a thin image

a.checking on body in the mirror

b.constant monitoring and measurement  of weight

Complications of anorexia nervosa are:


1.Associated induced endocrine changes (amenorrhea, hirsutism)


2.Loss of energy and weakness


3.vitamin deficiency and anemia


4. depression and mood changes

5.bloating of abdomen and constipation

6.gingivitis (gum infection) and tooth decay

7.brittle finger nails

8.dry skin

9.giddiness and headaches

10.poor memory and concentration


Anorexia nervosa may be associated with bulinia and induced vomiting

Treatment of anorexia nervosa:

Psychotherapy:

1.The patient must acknowledge  that she or he has a eating problems which need to be treated

2.counseling by psychologist or psychiatrist can help by:

a.remove negative thoughts about body size

b.provide positive thoughts about a healthy body and mind

c.help to deal with stress, family relationships, emotional upsets

d.stay away from friends who advocate bad eating habits


Medical treatment:
1.Hospitalization and forced feeding in severe cases


2.Correction of nutrition and metabolic deficiency

-a nutritionist will help teach healthy food habits and a proper meal plan to achieve a healthy weight


3.Use of antidepressant and serotonin blockers may reduce low self esteem and depression


Prognosis
Good in mild cases.


Poor in severe cases,may be fatal as in the case of Mary Carpenter.

Prevention:

1.Nutritional education regarding the needs of the body for nutrients which will help the mind, endocrine system, physical appearance


2.Psychotherapy to emphasize the importance  and positive effects of nutrients on the person to develop  a healthy mind and  body

A Family Doctor's Tale - AMEBIASIS

DOC I HAVE AMEBIASIS

Amebiasis is an acute infectious illness caused by the  parasite Entoameba histolytica.

The bacteria which causes Amebiasis is the Entmoeba histolytica which is an extremely hardy parasite able to live in  polluted water, contaminated food and soiled clothes.

Amebic infections occur most common in the caecum and rectosigmoid region of the colon.

Initial infections are small ulcers, usually discrete erosions which may extend more deeply ,coalescing to form bigger lesions resulting in extensive mucosal loss.

Penetration through the muscle lining may occur causing peritonitis.

Liver involvement may occur with the ameba traveling through the portal vein.

Liver abscesses consists of necrotic liver tissue.

Secondary bacterial infection are rare.

Most liver abscesses are solitary, rarely multiple and occur long after clinically evident bowel ulceration.

Single and multiple liver abscesses may occur shortly after a bout of amebic dysentery.

Abscesses of the brain and lung may occur.

Ulcers heal rapidly after treatment and permanent scarring is rare.

The main symptoms of Amoebiasis are
1. Many people with E.histolytica in stools are passive carriers

2. Invasive bowel disease begins 1-6 months after infection sometimes later

3. abdominal pain especially at the lower flanks

4. altered bowel habit

5.diarrhea with blood or mucus in stools

6.foul stools

7.adominal bloating or gas

8.tenderness on palpation at caecum or sigmoid colon regions

Severe cases may have:
1.more severe symptoms as above

2.bloody stools

3.fever

4.weight loss

5.liver enlargement and tenderness on palpation

6.dehydration and its effects such as delirium and disorientation

7. lassitude and tiredness

8. convulsions

9.tender abdominal mass with obstruction

Doctors generally diagnose Amebiasis based on:
1. stool cultures.

2.blood tests

3.colonoscopy

4.liver scan and ultrasound

The complications of Amebiasis are:

Amebiasis is a disease which can kill espcially through its complications:
1.Perforation of bowel leading to peritonitis or intra-abdominal abscesses

2.Severe hemorrhage uncommon but can cause death

3.Intussusception or insertion of part of colon into another part of colon is rare but can follow amebic ulceration and may cause intestinal obstruction

4.irritable bowel syndrome may persist for some months

5.Lung and pericardial involvement rare but can pose danger

6. cutaneous amebiasis cause deep painful and rapidly spreading ulceration

7.Liver infection can cause damage to liver and result in cirrhosis

8.Liver abscess may perforate and cause peritonitis or produce lung abscess or amebic pericarditis

9.Amebic brain abscess are rare but can occur.

Treatment of Amebiasis is by the following:

Amebiasis is an infectious disease which can spread to other people through contaminated food and water and must be treated as soon as possible.


Medicines:

1.Anti-parasitic medicines like metronidazole 750mg three times a day for 10 days should work for mild to moderate disease.

2.Metronidazole 750mg three times a day for 10 days and chloroquine or diiodohydroquin (1000mg for 2 days followed by 500mg per day up to 3 weeks) for hepatic amebiosis

3.Emetine hydrochloride 1mg pere kg per day by intramuscular injections for 5 days in acute amebic dysenery

4.tetracycline 250mg four times a day for 10 days my be needed for some with invasive intestinal disease.

5.Diloxanide furoate 500mg three a day for 10 days for asymptomatic amebic cyst carrier

Symptomatic treatment includes:
1.Paracetamol for relief of fever and headache

2.antispasmodic drug to stop abdominal cramps

3.medicine to harden the stools such as kaolin

4.slow down the intestinal movement (lomotil or loperamide).

Gradually reintroduce food, starting with bland, easy-to-digest food, like porridge or soups.

Get plenty of rest.

Prevention of Amebiasis can be by:
1.boil drinking and cooking water for 5 minutes

2.Proper filtration of water

3.Examination of stools of food handlers

4.Avoid eating or drinking foods or liquids that might be contaminated especially by flies

5.Good food hygience and hand washing

Prognosis depends on the stage of disease

It is excellent with prompt treatment of amebic infection.

Luminal disease or dysentery usually respond well to treatment.

In refractory cases chloroquine may be added to metronidazole.

Surgery is rarely necessary.

A Family Doctor's Tale -BUERGER'S DISEASE

DOC I HAVE BUERGER'S DISEASE

Buerger's Disease is an uncommon form of arterial obstructive disease of the large and medium sized peripheral arteries of legs in men under age 40 giving rise to intermittent claudication.

Occasionally the arteries of the arms and the veins may be involved.

Causes of Buerger's Disease are:
1.heavy smoking

2.arterial lesions are inflammatory rather than degenerative.

3.The appearance is non-suppurative (no pus) panvasculitis

4.arterial obstructions in the legs are often associated with obstructive arterial lesion elsewhere(Example:angina pectoris)

5.Diabetes and high lipid patterns are aggravating factors.



Symptoms:

1.onset is sudden


2.classic symptom of heavy aching pain in the legs when walking(intermittent claudication)


3.loss of arterial pilses


4.leg pallor and coldness especially on raising the legs


5.Raynaud's phenomenon


6.Other arterial diseases:
a.retinopathy
b.coronary ischemia
c.renal ischemia


7.evidence of peripheral ischemia or gangrene

Diagnosis of  Buerger's Disease is by:

1.Symptoms and signs as above


2.pallor on raising legs


3.angiography to determine site of lesion

The complications of Buerger's Disease are


The complications are:
gangrene of the legs

Treatment of Buerger's Disease is by :


1.Patient is to stop smoking immediately


2.general measures:
a.graded exercise
b.physical training
c.weight loss


3.avoid injury from
a.heat
b.cold
c.trauma
d.infections

Medicines:
vasodilator drugs like persantin, nitrates

Surgery:
reconstructive surgery for localized blockage but may not work

Amputation is preferable with gangrene in elderly

Prevention for Buerger's Disease is by:


Avoiding smoking

Prognosis of Buerger's Disease:

The disease is often progressive and amputation may be necessary.

A Family Doctor's Tale - REYE'S SYNDROME

DOC I HAVE REYE'S SYNDROME


Reye's Syndrome is an acute hepatitis and metabolic encephalopathy occurring in children.

1.Liver usually shows micro vesicular fatty infiltration

2. The brain shows cerebral edema with herniation

Causes are not completely known but:

1.Reye's syndrome was found to be caused by the usage of aspirin and salicylate during treatment of chickenpox and influenza.

Since the stoppage of aspirin in children below 12 years old. the illness seems to become very rare.


2.A number of fatty acids has also been postulated as toxic agents



Symptoms:

1.acute onset with:
a.vomiting


b.confusion

c.delirium


d.lethargy


e.seizures

f. unusual position of the arms and legs, the arms are  held straight and turned towards the body , legs are straightened and toes turned down

g.stupor


e.coma within 24-48 hours

2.Other symptoms include:


a.hearing loss

b.speech difficultioes

c.double vision

d.weakness of muscles

e.paralysis of arms and legs

Signs:
1.Liver enzymes markedly elevated with normal alkaline phosphatase

2.Increased serum ammonia

3.Raised prothrombin time

4.Low blood glucose especially in younger children

5.Intracranial pressure markedly increased

6.Cerebrospinal fluid normal except for increased protein.

7.Respiratory alkalosis with metabolic alkalosis may occur

Clinical progression with marked cerebral edema occurs with improving liver function.

Outcome depends on reversibility and control of intra cranial hypertension

Worse case scenerio will be rapid progression to coma and death.



The complications of Reye's Syndrome are:
1.liver damage

2.brain damage - seizures and coma


Treatment of Reye's Syndrome:

Treatment is urgent:
1.Hospitalization with intensive care management

2.Respiratory support

3.Intravenous fluid and glucose to maintain blood glucose

4.Immediate treatment of intra cranial pressure important - sometimes corticosteroid is used to reduce swelling in the brain


5.In coma cases, intra cranial pressure monitoring with treatment of pressure over 30mm mercury with mannitol, hyper ventilation and removal of CSF if necessary through spinal tap

6. No protein given by mouth because of liver condition

7.Vitamin K as well fresh blood platelets transfusion to control coagulation problems

Other treatments include:
1.exchange blood transfusion with fresh blood can remove toxic metabolic products from the blood


2.dialysis - works by filtering the toxic materials of the blood through a special filter membrane


3.plasmapheresis - the removal of plasma from the patient , detoxified and returned to the patient


4.Glucose plus insulin can reduce the production of fatty cells in the liver


5.citrulline is a amino acid from food which can detoxify and remove ammonia from the body


Prognosis of Reye's Syndrome:


Mortality is 50% if initial ammonia is more than 300micrograms per dl and coma present on admission

Outcome depends on management of intra cranial pressure

Sub clinical cases are more common than previously thought.

Prevention of Reye's Syndrome:

Avoid the use of aspirin in children below 12 years old.

Other medicines which contains aspirin or salicylates such as wintergreen  oil , chinese medicines should be avoided.

A Family Doctor's Tale - SYNCOPE

DOC I HAVE SYNCOPE


Syncope is a temporary loss of consciousness resulting from inadequate cerebral blood supply.

It is also called fainting.

It can occur at all ages but is more common in the elderly.


The Causes of syncope are:
A.Vasomotor:
1.Vagal slowing of heart and reduction of blood pressure from fear, severe pain, the sight of blood, prolonged standing  or psychogenic disturbance

2.Hemorrhage or circulatory fluid loss from burns resulting in a fall in blood pressure and reduced blood flow to the brain


3.Postural hypotension  - blood pressure drops from sleeping or sitting position to upright position and less blood flows to the brain causing fainting


4.Vasoactive drugs such as anti-hypertensive (prazosin, methyl dopa) and heart medicines(nitrates, adrenergic blockers) also affect the blood flow to the brain


5.Carotid sinus compression from turning of the head or wearing a neck collar affects the blood flow of the main artery to the brain ( the carotid artery)


B.Cardiac:
1.Asystole or heart blockage - causes a slow down of the heart resulting a reduction of blood flow to the brain.

There is fainting with or without fits.

It is also called Adams–Stokes disease.

2.Sudden arrhythmias with high ventricular rate also affects the blood flow to the brain and fainting


3.Heart valve prosthesis - the ball valve prosthesis of the heart sometimes block blood flow to the brain


4.Aortic stenosis with exertion affects the blood flow from the aorta of the heart to the body including the brain


5.Cardiogenic shock following myocardial infarction - a heart attack weakens the heart muscle to squeeze blood out of the heart resulting in shock and fainting


6.Sudden cardiac compression as in pericarditis may cause the same problem as myocardial infarction


Signs and Symptoms of Syncope
A.Vasomotor:
Symptoms:
1.cold sweats, pallor, yawning,

2.Urge to urinate or defecate can sometimes cause fainting


3.low blood pressure from drugs, loss of sweats, salts and fluids


4.dilated pupils

5.Drug therapy such as adrenagenic blockers

B.Cardiac:
1.ECG evidence of arrhythmia, heart block, asystole, or myocardial infarction

2.history of heart ball valve prosthesis, aortic stenosis or chest injury

The complications of Syncope are:

1.head injury from falls


2.fractures also from falls in elderlies


Treatment of Syncope is by the following :



1. Patients with postural or psychogenic syncope recover in recumbent position

2.Cardiac syncope from myocardial infarction needs the patient to be hospitalized and managed in cardiac care unit

3. heart blocks or asystole may need pacemaker implantation

4.Tachycardia with arrhythmia must be treated with special medicines to slow the heart

5.review drug therapy and dosage of potentially causative medicines such as adrenergenic blocking drugs, beta blockers or vasodilators such as nitrates

Prognosis:
1.depends on cause -vasomotor are less serious than cardiac.

2.it may present as a life threatening condition requiring immediate treatment in cardiac syncope

A Family Doctor's Tale - TRACHOMA

DOC I HAVE TRACHOMA

Trachoma is a bacteria infection of the eye and eyelids which is common in developing countries especially in rural areas, crowded unhygienic communities often affecting children.

It is rare in Singapore.


Trachoma is a contagious follicular conjunctivitis of the eye and is endemic in tropical and subtropical regions.

It can be spread by flies.

Trachoma is caused by the bacteria chlamydia trachomatis.

The organism is seen in the epithelial cells from the conjunctival scrapings.

Lymphocytic infiltration of conjunctiva can be seen with aggregates of the lymphocytes forming follicles seen histologically.

Fibrosis can lead to scarring.

Secondary infections and complications are common.

Incubation period is 7 days.

The infection then involve both conjunctiva and cornea.

Trachoma can spread easily from person to person, by secretions from  infected eye, nose, or throat  or by contact with contaminated  towels or clothes

However it is not a serious health risk if diagnosed promptly.

Symptoms:
1.Redness in the white of the eye or inner eyelid

2.tears overflowing

3.lid edema

4.yellow discharge that crusts over the eyelashes, especially after sleep

5.Pain in the eyes

6.photophobia

7.Eyelids presents with red velvety surfaces on the inner linings with follicles that form over 7 to 10 days, enlarge and become infiltrated with inflammatory tissues.

8.Large follicles are diagnostic of trachoma.

9.The follicles are seen first in the lower eyelid lining but soon appear in the upper eyelid lining often forming a row along the upper margin of the eyelid.

10.Infiltration may spread deeply forming papilla(raised follicles) resulting in scarring of the eyelid and retraction of the eyelid.

Complications:
1.Trachoma can also be spread through hand contact when rubbing the eyes.

2.corneal keratitis, pannus and scarring

3.entropion of eyelids

4.Trichiatis - infection of eyelashes

Treatment:
Trachoma of eye is treated with antibiotics.

The antibiotic can be given as eye drops, ointments, or pills.

Eye drops or ointments may need to be applied to the inside of the eyelid three to four times a day for five to seven days.

The antibiotic of choice is erythromycin, septrin and tetracycline eyedrops or ointment.

Treatment must be continued for months.

Secondary infections (other bacteria or fungal) must be eliminated.

Prognosis:

Normally there is good response to early treatment

Recurrence may occur if exposed to chlamydia through sexually transmitted diseases or if the environment is unhygienic.

Trachoma is a common cause of blindness because of corneal complications.

Eyelid deformities may also occurred

Prevention:
1.Protect your eyes from dirt and flies.

2.Avoid getting chlamydia infection through safe sex.

A Family Doctor's Tale - PHIMOSIS

DOC I HAVE PHIMOSIS


PHIMOSIS is a congenital or acquired constriction of the prepuce of the penis that cannot be retracted.

Paraphimosis is retracted foreskin which cannot be reduced over the glans penis.

The cause of PHIMOSIS is due to:
1.congenital narrowing of the preputial opening associated with long foreskin

2.inflammation of undersurface of prepuce

3.scarring following inflammation of the glans penis(balanitis)

Paraphimosis occur :
1.after accidentally from retraction of prepuce

2.after circumcision

Symptoms :
Phimosis:
1.tight prepuce with difficulty in urination

2.ballooning of prepuce during urination

Paraphimosis:
1.tight prepuce retracted cannot be reduced

2.glans engorged and edematous

3.bluish discoloration of glans

4.severe pain and difficulty in urination

Treatment:
Phimosis:
regular retraction

use of steroid to help retraction

circumcision

Paraphimosis:
cold compress
lubricant
adrenaline inj
reduction
incision of constricting band
circumcision

Prognosis:
cure after appropriate treatment

A Family Doctor's Tale -VAGINISMUS

DOC I HAVE VAGINISMUS

Vaginismus is the tightening of the muscles surrounding the vaginal opening and lower vagina to prevent penetration.

The adductor muscles of  the thighs may also be involved(squeezing of the thighs to prevent penetration)

Vaginismus is usually caused by the following:

Psychological:
1.fear of pain during sex.

2.Inadequate or faulty sex education

Physical:
1.Previous sexual assault or rape

2.Clumsy inept sexual technique by male partner

3.Scarring or injury to vulva area previously

4.Bartholin cyst infection or other infection around the vulva

5.menopause with dryness of the vagina

6.vagina tumors, cancers, inflammations

7.Pelvic trauma or surgery in the past


Persons who has Acute vaginismus has the following
Symptoms:

1.Penetration impossible or partial


2.Ignorance of sexual anatomy,physiology or sex technique


3.Abnormal sexual or psychological history

Signs:
1.Vaginal examination using a single finger causes intense spasm

2.Vulva may show previous injuries, bartholin cyst infection or other infection

Diagnosis can usually be made by :
1.History of unfulfilled vaginal penetration due to spasm

2.psychological fear of sexual intercourse

Treatment:
1.Counseling and psychological education of both partners

2.sex education of the anatomy of the female vagina and male penis , also the anatomy of pelvic pain and muscle spasms

3.progressive insertion of fingers

4.insertion of well lubricator dilators useful

4.dilation under anesthesia helpful

5.plastic surgery to enlarge opening

6.treat any physical cause of vaginismus

7.pelvic muscle exercises and relaxation methods

8.co-operation between the sexual partners


Prognosis is usually good with counseling.


Sexual partner may need to be educated.


Better if patient accepts the sex education

A Family Doctor's Tale - ANORECTAL ABSCESS

DOC I HAVE ANORECTAL ABSCESS

Recently I have an elderly patient who had a bad fall on his buttocks.

He developed an anal abscess which spread up to the rectum.

He was sent to the hospital and incision and drainage of the abscess was done.

He was sent home and daily dressing was done by a home visiting nurse.

However he developed a high fever and was sent to another hospital where the surgeon felt the surgery was too shallow and never reach the ischio rectal abscess.

A second surgery was done to reach the deeper abscess which was finally drained properly.

After 2 months the wound finally healed.

It is important to note that sometimes the abscess may be deeper than usual or another deeper abscess may be present.

So if the patient do not improve a MRI should be done to detect a deeper abscess.


Anorectal abscess is a pocket of pus in the anal  and rectal region.


Perianal abscess lies under the mucosa within the external anal sphincter.

Ischiorectal abscess is situated in deeper tissues above the anal sphincter and in the ischiorectal fossa.

People who are prone to anorectal abscess are:

1.Diabetic patients who are always prone to infections


2.AIDS or immunity compromised diseases

3.Cancer patients or other patients (SLE, rheumatoid arthritis, psoriasis ) who are on anti cancer drugs

4.Patients with Crohn's disease and ulcerative colitis are also prone to anorectal abscess


Anorectal abscess is caused by infection in the anal glands of the anal mucosa and becomes abscesses or pockets of pus.

1.Trauma or injury causes cell damage and infection

2.Small mucosal tears from hard feces(constipation) may lead to infection

3.Anal fissures, hemorrhoids can also lead to abscess

Most infections are E.coli infections which is common in the small and large intestine.

Less often the causative agent is  staphylococcus



Symptoms start off with:
1. throbbing pain around the anus


2. sitting, walking, defecation painful

3.Fever, chills, malaise

4.Abscess may be seen on inspection or rectal exam

Diagnosis of  Anorectal abscess is by:
1.Symptoms of
a.anal swelling and pain

b.proctoscopy of anus and rectum


c.swab & culture of any infected area

2.ESR raised very high sometimes > 30

3.moderate leucytosis

4.Trans-rectal Ultrasound and MRI will detect clearly the abscess and its extent




The complications are:
1.colitis - further infections of the lower colon


2. Anal fistula usually develop if the abscess is left untreated

3.Septicemia and rarely death


Treatment of Anorectal abscess is by:

1.Incision & drainage of the anorectal abscess under local anesthetic or general anesthesia is the treatment of choice as there is need to release the pus before the infection spread further.

Hospitalisation is therefore necessary as the wound is never stitched but left  open for the pus to drain out and healing to occur naturally


2.Antibiotics is needed after the causative agent is determined

3. Analgesics and pain killers is needed for pre and post-operative pain

4.The patient is advised to soak in a basin of warm water with small amount of salt


Prevention for Anorectal abscess is :


1.Avoiding constipation using stool softeners


2.Proper control of underlying diseases such as diabetes, immunity deficient diseases

Prognosis of Anorectal abscess is usually good with proper surgical treatment.

Early therapy with antibiotics may produce good results

A Family Doctor's Tale - PERITONSILLAR ABSCESS

DOC I HAVE PERITONSILLAR ABSCESS

When I was working at the ENT department, I had many cases of peritonsillar abscess.

Most of them thought they need to be admitted.

In actual fact, a day surgery to incise and drain the pus from the peritonsillar abscess was all that was needed.

There was a Japanese tourist who had a severe peritonsillar abscess, could swallow, could not talk properly and had to return home by airplane the next day.

I sprayed his throat with local anesthetic and after 10 minutes incised the abscess and drained the pus from the peritonsillar space.

The swelling went down rapidly and he was surprised that he could swallow and talk as normal.

He was also able to take his flight home the next day.

He was advised to see a ENT surgeon for removal of his tonsils 6 weeks later.

Most patients are surprised by the speed of their recovery.


Peritonsillar abscess is an acute infection of the peritonsillar space in the capsule surrounding the tonsils.

It is more common in young adults 20-30 years of age.

Peritonsillar abscess is usually caused by the following:

1.The causative agent is usually group A beta hemolytic streptococci.

Other bacteria such as staphylloccocus, E. coli are less common

Viral infection such herpes and Epstein Barr viruses attack children but seldom cause peritonsillar abscess

2. It usually follows an acute attack of tonsillitis about 7 days after the tonsillitis

Persons who has Acute Peritonsillar abscess has the following symptoms:
1.severe pain on swallowing with referred pain to the ear

2.high fever, headache and bodyaches

3.Tenderness of the jaw and throat

4.Voice changes, loss of voice

5.Foul breath, drooling of saliva

Signs:
1.the enlarged tonsil on one side displaced medially

2.the soft palate is red and swollen

3. the uvula is edematous and pushed to the opposite side

4.throat swab may help to identify the specific bacteria and the best antibiotic for treatment.

Treatment:
1.Analgesic medicine in liquid form

2.Antibiotics for infections is usually Penicillin injection for 2days followed by oral penicillin

3.Erythromycin is an alternative for pencillin sensitive patients

4.Incision and drainage is done if pus is present.

The patient must be co-operative and in an upright position.

Local anesthetic is sprayed on the middle of the palate midpoint between the uvula and the upper wisdom tooth.

A blade is inserted at this spot and usually pus and blood will flow out.

The patient spits the pus and blood into a basin and usually the swelling of the peritonsillar abscess will shrink considerably

5.Lots of fluids

Prognosis is usually good with medication.

Recurrence is quite common.

Tonsillectomy is done 4-6 weeks after the peritonsillar abscess attack to prevent further attacks.

A Family Doctor's Tale- MALABSORPTION SYNDROME

DOC I HAVE MALABSORPTION SYNDROME

Malabsorption syndrome is a disease resulting from poor intestinal absorption of nutrients, vitamins and minerals no matter how much the patient eats.

Malabsorption syndrome is usually caused by the following:

A.Intraluminal defects
1. pancreatic enzymes or bile salt deficiencies

2.gastric or intestinal resection as a result of cancer or obstruction

3.bacterial overgrowth in the intestine resulting in less nutrients absorption


4.acid hypersecretion(Zollinger-Ellison) syndrome

B.Intestinal Mucosal Defects
1.Tropical or non tropical sprue characterized by abnormalities of the intestinal villi resulting in poor absorption of food

2.parasitic disease of the intestinal such as tape-worms which feeds through the mucosa of the intestine


3.tuberculosis of the intestine can cause damage to inner lining of intestine impeding absorption of food

4.food allergies like celiac disease, crohn's disease, irritable bowel syndrome, lactose intolerance, Whipple's disease


5.Chemotherapy, drug abuse, radiation can damage the mucosa of the intestines

C.Intestinal lymphatic abnormalities
1.lymphanigiectasia causing obstruction to the lymphatic system


2.congestive heart failure leading to poor lymphatic circulation


3.constrictive pericarditis also affects the lymphatic system


Persons who has Malabsorption syndrome has the following symptoms:
1.Weight loss

2.anorexia or loss of appetite

3.abdominal distension and bloating

4.diarrhea

5.steatorrhea(pale bulky frothy stools) usually frequent

6.muscle wasting

7.weakness and fatigue

8.depression and poor concentration

9.dry skin, anal itch and thinning hair

10.glossitis,visual difficulties


Signs:
1.vitamin deficiency especially vitamin B12 and K and folic acid

2.mineral deficiencies and anemia leads to malaise and muscle cramps


3.Low protein may lead to edema  and muscle wasting


Diagnosis can usually be made by :
1.History of weight loss

2.Steatorrhea - measurement of fecal fat is low

3.D-xylose test is abnormal indicating poor carbohydrate absorption

4.Pancreatic function tests by duodenal aspiration

5.Tests for bacterial overgrowth such as:
bile acid breath test
jejunal cultures
urinary tryptophan metabolites

6.Intestinal biopsy

Treatment depends on the cause:

Non-medicinal :
1.Intravenous fluids, electrolytes, minerals, vitamins

2.Intravenous nutrients and feeding

3.Gluten free diet

4.Restriction of dietary fat

5.Medium chain triglycerides

6.Lactose free diet

7.Probiotics helps to replace the bacteria overgrowth in the intestines and restore the bacteria flora in the bowels

8.Small frequent feeding of food helps digestion of food


Medicinal:
1.Symptomatic treatment of abdominal pain(anticholinergics)and diarrhea(Imodium)

2.Pancreatic enzymes for pancreatic deficiency

3.Folic acid, vitamins and minerals replacements

4.Antibiotics and anti-parasitics for intestinal infections.

5.Long term tetracycline is important in the treatment of Whipple's Disease


Prognosis depends on the underlying cause.

Most patients usually recover if appropriately treated

Recurrence is quite common.

A Family Doctor's Life - NARCOLEPSY

DOC I HAVE NARCOLEPSY
NARCOLEPSY is a condition characterized by sleeping at inappropriate times with intense feeling of sleepiness which ironically result in normal number of hours of sleep.

NARCOLEPSY is usually caused by the following:

1. There is a familial incidence of 60 times in a close family member.

2.There is also a one in twenty possibility of inheriting lifelong syndrome

It is a rare condition with onset in adolescence or young adults.

It is much more common in men than in women.

The danger of inappropriate sleepiness is that it may result in poor productivity, social isolation, confusion and depression.

Persons who has Acute NARCOLEPSY has the following symptoms:
1.excess daytime sleepiness - sleep episodes  occur at inappropriate times lasting minutes to hours

2.cataleptic attacks - overwhelming feelings of helplessness associated with momentary paralysis as a consequence of loss of muscle tone following laughter, anger, excitement, fear or surprise

3.hypnogogic hallucinations - vivid auditory or visual sensations occurring at onset of sleep

4.sleep paralysis - occasional motor inhibition occurring just before falling asleep or immediately on awakening

5.rapid eye movement sleep (REM) classically begins when a narcoptic falls asleep unlike normal progression from non-REM to REM sleep

Diagnosis can usually be made by :
1.History of inappropriate sleep

2.neurological examination to exclude organic central nervous system conditions

3.Pupillography and electro-encephalography

4.Polysomnography and investigation in a sleep laboratory

Treatment is by:
Non medicinal methods:
1.Explanation to family and patient with advice on how to cope with the sleepiness problem.

a.Avoiding sudden emotional upsets such as anger, laughter which could spark off an attack of sleep paralysis or catalepsy

b.Safe driving is important as car accidents are 10 times more common in narcoleptic patients than normal persons. He must keep himself awake while driving. If sleepy , he must stop the car and park somewhere safe to have a good sleep.

c.Negotiating a work schedule with the patient's employer will allow the patient to work when he feels most alert and rest when he is feeling sleepy

d.Children and adolescents can also modify their class schedule if their parents can inform the school of their conditions and get the co-operation of the school teachers and principal.

2.Instructions on how to regulate sleep habits:

a.Maintain a regular night sleep routine

b.Avoid smoking, alcohol or caffeine a few hours before sleep

c.Avoid excitement and over exercising before sleep

d.Relaxing before sleep makes falling to sleep easier

e.Keep the bedroom environment comfortable and conducive to sleep


A proper night sleep can reduce the excess daytime sleepiness.

Medicinal methods:
1.Pyschostimulants such as amphetamines, ephedrine, pseudoephedrine in dosages enough to maintain the patient's ability to work


2.Antidepressant of tricyclic type may help prevent sleep paralysis and catalepsy


Prognosis:

Narcolepsy is considered a lifelong illness and cannot be cured.

A Family Doctor's Tale - HYPOCHONDRIASIS

DOC I HAVE HYPOCHONDRIASIS

Hypochondriasis is a neurotic disorder with excessive concern about health in general. Hypochondriacs believe that they are sick when they are really not sick even after a thorough medical examination shows no evidence of medical illness.

Hypochondriacs are overly obsessed with their health.

Concern about symptoms of alleged disease may have obsessive
quality.

The hypochondriacs are usually unable to control their thoughts about their symptoms.


Hydrochondriasis  occurs equally in both males and females and may be associated with anxiety and depression.

There is resistance to negative medical examination.

Usually there is no organic basis for the patient's symptoms.

Often there is a history of familial predisposition which may suggest inherited condition.

Early development factor such as parental and sexual abuse may predispose to this condition.

The condition usually starts in middle age although it may occur in children.


Diagnosis:
1.Preoccupation about health


2.Inappropriate concern about minor symptoms believed to be symptoms of serious illnesses like cancer,  heart disease or venereal disease


3.Failure of reassurance from family, friends or doctors by repeated negative examinations


4.Insistance that some factor has been overlooked or undiscovered in the medical examination


5.Involved frequently with diet and exercise fads


6.Neurological and psychiatric assessment of the patient to reassure him or her regarding her health

Complications:

1.Frequent medical examinations and changes of doctors to find the cause of their "illness" or symptoms

2.Anxiety, depression or panic attacks whenever symptoms occurs

3.Loss of time from work through searching for medical treatment and alternative medicines to get their symptoms cured




Treatment:
1.Psychotherapy -

a psychologist who can talk to the patient, make the patient understand his or her fear of illness, help to recognize when the symptoms are worse and how to cope with them


2.Behavior therapy

Behavior therapy can help the patient analyze his behavior sometimes even to the extent that their fear is irrational or unfounded.

They can be made to recognize that their symptoms are not indicative of a serious illness.

They should try to a live a healthy lifestyle and not persist in worrying about their condition.

They may keep themselves active by doing mild physical exercises or learn to relax through meditation , yoga or even prayers.


3.Medicine for anxiety and depression


Antidepressant especially selective serotonin reuptake inhibitors (SSRIs) can control their thoughts of illness and reduce their obsession with the symptoms


Prognosis:
1.Poor to fair because there will always be new symptoms and doubts of their health


2.Recurrence of  multiple complaints for which medical attention has been sought with negative results

A Family Doctor's Tale - INSOMNIA

DOC I HAVE INSOMNIA

Insomnia is a very common illness which is present in at least 1% of patients seen in a family practice.

However most of them are transient form of insomnia caused by emotional upheavals such as death of a family member or divorce, stress or change of shift duties.

In such cases a mild transquillizer or antidepressant will usually help.

Counseling especially by a psychiatrist will help in more severe cases of insomnia.


Insomnia is defined as a sleep disorder characterized by:
1.difficulty in falling and remaining asleep
2.Early morning final wakening
3.frequent awakenings during the night
4.lack of restful sleep
5.a combination of these.

Many of us have Insomnia at least once in our lifetime.
Insomnia can be classified as:
1.Transient Insomnia -usually difficulty to sleep properly or consistently for less than 1 week usually related to sudden stress, death in a family, emotional upset

2.Acute Insomnia - usually difficulty to sleep properly or consistently for less than 1 month also related to stress, emotional upset or change in sleep environment. Gradually the brain adapts to the environment or overcome the stress or emotion upset.

3.Chronic Insomnia - usually difficulty to sleep properly or consistently for more than 1 month :
Causes may be:
1.Anxiety

2.Depression

3.Use of stimulants such as caffeine, nicotine and other central nervous system stimulants

4.Shift duties affects the pattern of the sleep

5.Obstructive sleep apnea

6.Restless leg syndrome

7.Medical conditions which cause pain (arthritis, cancer,nerve pain)

8.Sleep habits such as sleeping after a heavy meal,alcohol,  coffee, strenuous activity before sleep

9.Jet lag, change of time zone

10.Menopause or hormonal changes

11.Trauma or injuries to the brain or body

12.Withdrawal of drugs, cigarettes or alcohol

Symptoms of Insomnia:
1.Difficulty falling asleep

2.Waking up in the morning and unable to get back to sleep

3.Restless disturbed sleep with frequent wakening

4.Associated other disturbances such as sleep walking or enuresis
(passing urine frequently at night)

5.Associated symptoms such as anxiety, depression, alcoholism, medicine abuse

Diagnosis is by:
1.Typical history of difficulty in sleeping

2.Electroencephalogram(EEG) for brain wave pattern

3.Sleep Laboratory Analysis

Treatment of Insomnia:
A.Non-medicine:
1.Avoid drinking alcohol, coffee, caffeinated drinks, and tea late at night

2.Avoid smoking

3.Avoid eating and exercising just before sleep

4.Avoid watching exciting television or reading exciting books before sleep

5.Behavior modifications through relaxation techniques, hypnosis, biofeedback techniques, psychological counseling

6.Treat obstructive sleep apnea with high pressure airflow device

B.Medicine
depends on the cause of insomnia:
1.Painkillers for those in pain

2.Antidepressant for those with depression

3.Tranquillizer for anxiety patients

4. Melatonin has been used for inducing sleep without affecting the sleep pattern and may be used in mild cases.

5.Antihistamines such as diphenhydramine and doxylamine have also been shown to induce sleep without dependence unlike hypnotics such as the benzodiazepine group. Another antihistamine cyproheptadine previously used as appetite stimulant has been found to improve sleep quality.

6.Hypnotic of the non-benzodiazepine group such as zolpidem or zopiclone may be given if the patient is still unable to sleep.

Benzodiazepines are to be avoided because of the danger of abuse and dependency.

Always start with short acting hypnotics and preferably for short
period because of danger of abuse by patients.

Prognosis depends on the cause of insomnia.
Psychoanalysis and discussion of the cause will help patient to
respond positively although rebound insomnia may recur.

Hypnotics should be withdrawn slowly to prevent rebound insomnia.

A Family Doctor's Tale - MOTION SICKNESS

DOC I HAVE MOTION SICKNESS

Motion sickness is very common in people who are are very sensitive to traveling.

Somehow the body , the eye and the organ of balance in the inner ear  send conflicting signals to the vomiting center in the brain.

As a result nausea and vomiting occurs during the travel in a car, ship or airplane.

Many patients often get medicines such as stemetil, cyclizine or dimenhydrinate from the family doctor or scolopamine transdermal patch from the pharmacy before traveling.


Motion Sickness is nausea and vomiting occurring when traveling on land, sea, air or in space or precipitated by any movement of the body.

The movement of the body send an impulse in the vestibular body (organ of balance in the inner ear) which travel through a nerve to the vomiting center in the medulary reticulum.

The risk of getting Motion Sickness is:


1.One third of population has great susceptibility
One third react only to rough condition
One third had little or no difficulty

2.Younger children and infants are more susceptible becoming more tolerant with increasing age.

3.Overindulgence in food and alcohol may increase susceptibility

4.Position in a vehicle may increase the Motion Sickness:
back of cars
below deck in a boat
tail end of airplane

5. Reading and looking out the side of a moving vehicle may precipitate attack.

6.Heightened level of fear and anxiety

7.Poor ventilation in vehicle

8.Psychological factors and stress can cause motion sickness



Common symptoms of Motion Sickness are:

1.Pallor, cold sweats

2.stomach upset with malaise

3.Nausea and excessive salivation

4.Vomiting follows rapidly

5.Dizziness and headache

6.symptoms may wax and wane before vomiting



Complications may develop with progression of the Motion Sickness.

1.dehydration


2.fatique


3.confusion


Treatment of Motion Sickness is by:


In all cases of Motion Sickness,  assessment of the patient's condition needed.
1. avoid excessive food and drinks before a trip

2. Use the favorable position in the vehicle:
sit in front of car looking straight ahead
stay on deck of boat
sit near the wing of airplane

3.take medicine half an hour before trip:
stemetil
buscopan
librax
promethazine
dimenhydrinate
cyclizine
maxolon

4.Apply transdermal patch of scopolamine

Prognosis for Motion Sickness is as follows:


1.Motion sickness decreases with increasing age


2.Motion Sickness response well to treatment


3.May be recurrent

Prevention for Motion Sickness is through:


1. taking medicine before traveling


2. avoiding excess food and drink before a trip

3.certain spicy food and greasy food can make motion sickness worse -advisable not to take them


4.be mentally prepared for the motion


5.Breathing exercises may help to relax and calm the person before the trip

A Family Doctor's Tale - ALCOHOLISM

DOC I HAVE ALCOHOLISM

Alcohol has an adverse effect on the brain first stimulating it then depressing it.

It can damage the liver and the pancreas as well as the stomach and bleeding in the intestinal tract.

Nowadays teenagers are starting early to drink alcohol.

Stress is another problem causing a person to drink. I know of one patient who drinks in order to sleep.


Once addicted to alcohol the danger is the difficulty to withdraw from alcohol.

So prevention is always better than cure.


Alcoholism is a chronic disease manifested by a pattern of pathological alcohol usage with inability to stop drinking more than temporary resulting in physical, psychological and social consequences.

People who are at risk of getting Alcoholism are:


1.People with a Family history of alcoholism

2.Men have a higher rate of alcoholism than women


3.Cultural factors especially alcohol drinking friends

4.Social pressure and Stress

5.Depression may be a cause of Alcoholism

6.broken homes




Common symptoms of Alcoholism are:

1.Need for daily use of alcohol

2.Binge drinking

3.Inability to stop drinking more than a temporary phase

4.Impairment of social and occupational function

5.Blackouts and amnesia

6.Violent behavior when intoxicated with arguments with friends and family

7.Absence from work or loss of job

8.Legal problems such as arrests for drink driving or traffic accidents

9.Evidence of tolerance for more alcohol to achieve sense of comfort

10.Development of alcohol withdrawal (tremors on awakening, insomnia, hallucinations)

Diagnosis of Alcoholism  is made through:


1. level of blood alcohol above the permitted limit.

2.Liver function tests are abnormal:
a.Aminotransferases  -

AST and ALT are moderately elevated, with AST > ALT.
b.Alkaline phosphatase  - usually slightly elevated.


c.GGT  - correlates with AP levels- much higher in chronic liver disease from alcohol.

3. ECG and EEG to detect heart and brain disturbances


Complications of Alcoholism are:


Complications may develop with progression of the alcoholism.

1.Delirium tremors

2.Acute alcohol delusional states

3.Untidy appearance
a.neglect of personal appearance,
b.unresponsiveness,
c.forgetfulness,
d.trouble concentrating,
e.changes in sleep habits.

5.Alcoholic hepatitis and cirrhosis

6.Wernicke's encephalopathy

7.Alcoholic cerebellar degeneration

8.gastric ulcers,  gastrointestinal bleeding

9.Pancreatitis

10.nutritional deficiency

11.high blood pressure and heart disease

12.low bone mineral deficiency and osteoporosis


Treatment of Alcoholism is:


In all cases of Alcoholism,  assessment of the patient's alcoholism and complications are needed.
1. Detoxification in special centers

2. treatment of complications

3.Alcohol withdrawal with the help of transquilizers and vitamin supplements

4.Antabuse or Revia therapy to cure alcohol dependence

5.Psychological therapy and Alcoholic Anonymous

6.Healthy lifestyle with adequate exercise and proper diet

Other unconventional methods of treatment includes:

1.Herbal therapy

2.Acupuncture

3.Mind/body medicine


Prognosis for Alcoholism is:

Prognosis is dependent on initial severity and the patient's motivation to return to sobriety

Alcoholism is a serious chronic disease which can be controlled but seldom cured.

Prevention for Alcoholism is:


1. No drinking of any form of alcohol

2. Family support and psychotherapy and self help groups

3.Early intervention for teenagers who are drinking

A Family Doctor's Tale - ADVANCED MACULAR DEGENERATION

DOC I HAVE ADVANCED MACULAR DEGENERATION

Advanced Macular Degeneration of the eye is due to age so the older you grow the worse it will become.

Blurring of vision and partial blindness will happen regardless of treatment.

There is no complete cure for this condition.


Advanced Macular Degeneration is a painless age-related eye condition in which the macula ( a small yellow spot in the center of the retina responsible for fine straight sharp vision) has degenerated giving rise to loss of central vision.

There are 2 types of AMD:
1.dry AMD occurs when the cells in the macula slowly breaks down giving rise to gradual blurring of central vision in the affected eye.


2.wet AMD occurs when the abnormal blood vessels behind the retina starts to grow under the macula and starts to leak blood and fluid under the macula. Damage to the macula occurs rapidly with loss of central vision.Growth of the abnormal blood vessels behind the retina is activated by a protein called vascular endothelial growth factor (VEGF)

Wet AMD is also known as advanced AMD.

The following are at risk from Advanced Macular Degeneration:

1. age above 55 yrs

2. atherosclerosis of  blood vessels

3. family history of Advanced Macular Degeneration

A deficiency of the genes complement F (CFH) and B (CFB) is associated with 50% cases of macular degeneration.

4.Smoking has been known to be a main cause of AMD

5.High Blood pressure leading to atherosclerosis




Symptoms:

1.gradual blurring of central vision

2.Straight lines that become curved

Signs:


1. In early stage, direct opthalmoscopy show some pigmentary changes

2. Later stage shows exudates and colloid formations together with retinal hemorrhage

Advanced Macular Degeneration is  diagnosed through:


1. Direct opthalmoscopy shows exudates and colloid formations together with retinal hemorrhage

2. Amsler chart is a simple test designed to test your vision. There is a criss-crossed lines on a white pages with small squares and a black dot in the middle of the page.

A normal person is able to see straight lines and squares.


A person with AMD may see wavy lines or a distorted image.
Mark any line which is distorted or missing.

Complications of Advanced Macular Degeneration are


Partial to complete loss of central vision.

Treatment for Advanced Macular Degeneration is:


Advanced Macular Degeneration cannot be cured.

1.Laser photocoagulation are used to create a adhesion around the retinal hole so that fluid cannot enter the hole and accumulate behind the retina resulting in the Advanced Macular Degeneration.

2.Adatomed Silicone Oil is injected into the eye and mechanically holds the retina in place.
The oil is usually removed within a year.

3.Photodynamic therapy may help to dry up the fluids behind the macula and reduce damage to the retina.

4.Drugs  such as Lucentis, Macugen and Visudyne can be used to stop abnormal blood vessel growth.

Advanced Macular Degeneration must be monitored:


1.regular follow up with the eye doctor.

2.examining the retina for further damage

3.analyzing the visual fields.

With proper monitoring and treatment most patients will be less likely to be at risk of blindness.

Prognosis of Advanced Macular Degeneration is:


The prognosis is generally poor.

Most cases of AMD may progress despite treatment