A Family Doctor's Tale- LEPTOSPIROSIS

DOC I HAVE LEPTOSPIROSIS

LEPTOSPIROSIS is an acute infectious illness caused by the bacteria Leptospira with a wide spectrum of illness from inapparent to fatal.

The bacteria which causes LEPTOSIROSIS is the Leptospira interrogans which is an extremely hardy bacteria occurring in domestic and wild animals.

Humans are accidental hosts.

Human infections occur through abraded skin and exposed mucous membranes from urine or tissues of infected animal or through contaminated water soil and vegetation.

The bacteria can affect the liver, kidney, skeletal muscle, heart, spleen, lungs and central nervous system.

Hemorrhagic changes and necrosis of tissues may occur together with interstitial edema and lympocytic, plasma cell and neutrophilic leucocyte infiltration.

Symptoms and Signs of LEPTOSPIROSIS are:
Incubation period is approximately 10 days.


Illness is typically biphasic.

A.Leptospiremic or First Phase
1.Organisms found in the blood and cerebrospinal fluid

2.Abrupt onset of headache, myalgia, high fever and chills

This will last 4-9 days

3.Anorexia, nausea, vomiting, cough, chest pain, hemoptysis, conjunctival suffusion, cutaneous rash and hemorrhages seen.

B.Immune or Second Phase:
1.Correlates with appearance of circulating IgM antibodies

2.Clinical manifestations in this phase varies:
Patient may be asymptomatic for 1-3 days with return of fever and other symptoms of first stage.

3.Iridocyclitis, optic neuritis, encephalitis, myelitis,
and perpheral neuropathy and meningismus may occur.

Specific Leptospirosis Disease:
Weil's Disease:
is severe leptospirosis with
1.liver involvement with jaundice, hyperbilirubinemia
2.renal involvement with proteinuria, pyuria, hematuria
2.hemorrhagic manifestations with epistaxis, hemoptysis, GIT bleeding, subarachnoid hemorrhage
3.anemia
4.changes in consciousness
5.continuous fever
6.pneumonitis
7.aseptic meningitis
8.myocarditis

Doctors generally diagnose LEPTOSPIROSIS based on:
1. blood test and cultures.

2.cerebrospinal tests

3.animal innoculation

4.liver scan and ultrasound

LEPTOSIROSIS is a disease which can kill especially through its complications:
1.Liver disease due to damage to the liver leading to cirrhosis

2.Kidney disease can occur from damage to the kidney

3.Brain damage is rare but can occur from spread to the brain and meninges

4.Severe hemorrhage uncommon but can cause death

Treatment of  LEPTOSPIROSIS is :
LEPTOSPIROSIS is an infectious disease which can spread to other people through contaminated food and water.

1.Antibiotics such as penicillin and tetracycline are started once the diagnosis is confirmed.

2.intravenous drip and blood transfusion if necessary

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

2.antispasmodic drug to stop abdominal cramps

3.medicine to stop vomiting and itch

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

5.Get plenty of rest.

Prevention of LEPTOSPIROSIS can be by:
1..Avoid eating or drinking foods or liquids that might be contaminated especially by the germ and animals

5.Good food hygiene and hand washing

Prognosis of LEPTOSPIROSIS depends on the virulence of disease and general condition of the patient.

It is excellent with prompt treatment of leptospirosis infection.

Weil's disease is more serious but will respond well to treatment.

Infection of pregnant women may be associated with increased risk of fetal loss.

A Family Doctor's Tale -NIGHT BLINDNESS

DOC I HAVE Night Blindness

Night Blindness is defective vision in conditions of lowered illumination.

The main causes of Night Blindness is classified into 2 :

1.Congenital Night Blindness:
This is a simple congenital defect of:
a.dominant trait
b.recessive trait
c.recessive sex linked trait

2.Acquired Night Blindness:
This pathological state occurs when the rod function of the retina cells are depressed:
a.Vitamin A deficiency - prolonged deficiency can affect marked degenerative changes in the rods, then cones and subsequently in the neuronal layers of the retina


Causes of Vitamin A deficiency:
inadequate dietary intake
impaired absorption in celiac disease, tropical sprue or liver cirrhosis

b.retinitis pigmentosa - a degenerative disease of the retina affecting the cones and rods starting in the equatorial region and then spreading to the macular region

c.liver disease not associated with vitamin deficiency

d.rare mucopolysaccharidase deficiencies

e.Refsum disease

f.Choroideremia:
progressive atrophy of the choroid -very rare

g.Neuronal ceroid lipofuscinosis

h.Abetalipoproteinuria
Diffuse Night Blindness is inflammation in all areas of the uvea.

Night Blindness affects both eyes and are more common in the elderly:

Symptoms of night blindness:
1.inability to see well at dusk

2.worse after long phases in bright sunlight

Diagnosis of night blindness:
1.History, physical examination and family history eliminates the rarer causes of night blindness.

2.measurement of Vitamin A or carotene levels

3.An early clinical sign of Vitamin A deficiency is conjunctival prexerosis associated with triangular areas of keratinised epithelium at the temporal limbus .

These are called Bitot's spots.

Treatment of night blindness:
1.Most genetic causes of night blindness cannot be cured

2.Vitamin A deficiency:
high doses of Vitamin A of 50,000 to 100,000 units per day up to 14 days.
Longer treatment may cause Vitamin A toxicity and damage the liver.

3.Maintenance dose of 2500 units of Vitamin A(or 750mg) is recommended daily.

Prognosis of night blindness:
depends on the cause -no cure for genetic causes

Poor when due to secondary causes

Excellent in early treatment of Vitamin A deficiency

Prevention of night blindness:
1.knowledge of family history

2. avoid prolonged bright lights

3.Take natural forms of Vitamin A such as carotene in carrots, tomatoes, papaya and other vegetables and natural vitamin A in fish liver oils, liver and meat.

A Family Doctor's Tale - EYE INJURIES

DOC I HAVE AN EYE INJURY

EYE INJURY is an traumatic accident to the eye which is a delicate organ and cause permanent loss of vision.

The greatest danger of eye injury comes from sharp objects such as pencils, nails, and knife.
Sharp objects injury to the eye can lead to puncture of the eyeball with extrusion of the eye contents and will require surgery.

Scratches and cuts that damage the cornea and the white of the eye are the most common eye injuries.

Causes of EYE INJURIES can be divided into:
1.Superficial injuries that include corneal scratches and superficial cuts even by the edge of a paper,sand ,or grainy dirt particles.

2.Chemical injuries that occur when liquids such as acids or alkali(bleach, thinner, battery acid) enter the eye

3.Blunt injuries to structures of the eye that give rise to swelling of the eyelid or bruising of the tissues around the eye(examples are sports like basketball, football, boxing or martial arts or home repairs where balls, fists or hammer may hit the eye)

4.Penetrating injuries are serious injuries or cuts in the eye which may result in foreign objects including metal bodies being left in the eye. They require urgent medical attention and surgery.

Symptoms varies from mild to severe:

1.Severe pain in the eye or around the eye

2.burning sensation in the eye especially exposed to chemicals

3.blurred vision

4.Discharge -may be due to eye infection


5.Light sensitivity - sensitive to bright lights

6.bruises around the eyelids or cuts

Signs of injury to surface of or area around the eye:
1.bruising of the eyelid and surrounding area usually due to trauma

2.swelling of the eye or eyelid

3.tenderness of the eye


4.blurred vision

5.redness of the eye

6.feeling of something in the eye

Signs of injury to the inside of the eye:
1.blurred vision

2.seeing floating bodies or flashes of light

3.bleeding into the back of the eye(vitreous hemorrhage)

Diagnosis of EYE INJURIES:
1.Mild cases like chemical splash or small dust particles can be treated by a family doctor

2.More severe cases require an eye specialist to examine the eye with a slit lamp microscope to determine the inside of the eye including the retina and cornea.

3.Movements of the eye and testing of the nerves to eye may be needed.

4.X-rays of the may reveal fractures of the eye socket.

5.Ultrasound of the eye may be needed if there is a lot of bleeding in the eye

6.CAT scan or MRI of the eye may be necessary if a penetrating eye injury is suspected or a foreign body may be present.

The complication is always the risk of :
1.Severe infection of the eye especially with pseudomonas infection causing infection of the anterior chamber of the eye and then spreading to the rest of eye resulting in loss of an eye.

2.Scarring of the EYE INJURY resulting in partial loss of vision

3.metal from foreign body in the eye can cause loss of vision

Treatment depends on the type and extent of EYE INJURY:
A.Superficial injuries can be diagnosed with a stain called fluorescin.
Abrasions and depth of lacerations can be seen clearly with this. They require antibiotics and an eye patch.

Close follow up is needed when there is infection.

B. Chemical injuries require copious flushing of the eye to remove as much chemicals as possible and to minimize damage to the eye. Follow up is necessary to watch up for late complications such as raised eye pressure.

C.Traumatic Injuries to the eye
Bruises to the eye or eyelid -ice packs can be used to reduce swelling during the first 49 hours followed by warm compression to clear the blood

D. Penetrating injuries to the eye :
when there is vitreous hemorrhage or retinal detachment, a surgical procedure called vitreotomy may be necessary to restore vision.
This is a retina surgery where fine instruments are used to remove blood from the the inside of the eye or repair retinal detachment. An air bubble or silicone oil may be injected at the end of procedure to keep the eye in the normal shape.
Vitreotomy may also be necessary in penetrating injuries to remove any foreign body and repair any cuts or laceration inside the eye.
Foreign bodies that are not removed or untreated can result in severe eye infections and blindness.

The prognosis depends on the severity of the eye injury.

Most cases can be restored to normal if treated early.

Some cases may have minimum scarring of the cornea with possible loss of some vision.

Rarely the eye may be lost if there is severe infection and no treatment.

Prevention of Eye Injuries:
1.Take proper safety precautions when dealing with chemicals
and cleaning fluids.

2.Wear goggles when working with sharp instruments or poer tools like drill or saw

3.Avoid rubbing the eyes with hands when handling household cleaning fluids or chemicals of any kind

4. wash the hands thoroughly after handling chemicals or dusts from saws or drills.

A Family Doctor's Tale -POSTMENOPAUSAL BLEEDING

DOC I HAVE POSTMENOPAUSAL BLEEDING

Postmenopausal bleeding is a symptom defined as heavy or prolonged occurring one year or more after menopause.

Bleeding can occur from any part of the genital tract.

Causes:
Physiological:
most common 25 per cent show no demonstrable cause
(dysfunctional uterine bleeding)

Iatrogenic:
estrogen replacement therapy

Vulva:
infection
atrophy
granulomatous lesions
carcinoma

Vagina:
atrophy
infection
carcinoma

Cervix:
polyp
carcinoma

Uterus:
polyp
carcinoma
myomas

Others:
tubal or ovarian carcinoma
pelvic inflammatory disease
endometriosis

Diagnosis:
History:
Menstrual history:
cycle length, number of bleeding days, degree of blood loss(number of pads used per day), presence of blood clots, dysmenorrhea (painful Menstruation)


Symptoms suggesting underlying pathology:
Metabolic disorders:
symptoms of hypothyroidism

Bleeding disorders:
easy bruising
anticoagulants

Pelvic inflammatory Disease:
pelvic pain especially during intercourse
vaginal discharge
dysmenorrhea

Endometriosis:
pelvic pain
dysmenorrhea

Medication:
use of post menopausal estrogen

Physical Examination:
Signs of underlying diseases:
infection of vulva and cervix
hypothyroid features
pallour(anaemia)

Abdominal examination:
palpable uterine or ovarian masses

Pelvic examination:
vulval and vaginal examination
bimanual palpation for masses
cervical smear

Investigation:
Full blood count including hemoglobin(to exclude anemia from loss of blood) and platelets(low platelets can cause bleeding)
Transvaginal ultrasound to exclude uterine fibroids and polyps -postmenstrual scans is best when the endometrium is at its thinest.
Endometrial hysteroscopy and biopsy in women
Laparoscopy if required

Treatment:
Medications:
1.Tranexamic acid- oral antifibrinolytic, given only when there is heavy bleeding

2.oral estrogen - prevent proliferation of the endometrium, reduces blood flow. Should be given for 21 days only to assess its effect on menstrual bleeding

3. Injected progesterone -also prevent proliferation of the endometrium, induce uterine atrophy and stop menstruation

4. Levonorgestrel-releasing intrauterine system(LNG-IUS)
-also prevent proliferation of the endometrium

5.Application of estrogen cream for atrophic vulvitis and vaginitis

6.treatment of underlying causes such as bleeding causes, low platelets, hypothyroidism, and cancers

7.treat any anemia caused by post menopausal bleeding

Surgery
1.Endometrial ablation
may be done only if medications has failed

Usually involve the removal of the endometrium through the cervical opening.


There are various forms of endometrial ablation:
First generation:
hysteroscopy with general anaesthesia
-Rollerball ablation
-Transcervical resection of the endometrium

Second Generation:
non-hysteroscopy, no general anaethesia, day surgery,fast recovery
-Impedance-controlled bipolar radiofrequency ablation
-balloon thermal ablation
-microwave ablation
-free fluid thermal ablation

2. Hysterectomy
used only as a last resort in treatment of Postmenopausal bleeding
if other treatment are contraindicated
there is a desire for amenorrhea
there is no desire to retain uterus

Treatment of Underlying causes:
hypothyroidism with thyroxine tablets
reduce anticoagulant treatment if possible
treat any bleeding disease with platelets or blood factor deficient infusion
treatment of endometriosis,
antibiotic treatment of pelvic inflammatory disease
treatment of uterine carcinoma
surgical removal of fibroids and polyps

Prognosis:
generally good after hysterectomy and removal of ovaries,treatment of underlying causes.

Cancer treatment prognosis depends on severity of cancer.

A Family Doctor's Tale - SUBARACHNOID HEMORRHAGE

DOC I HAVE SUBARACHNOID HEMORRHAGE

A Subarachnoid Hemorrhage is bleeding into the cerebrospinal fluid filled space between the pial and arachnoid membrane of the brain.

A Subarachnoid Hemorrhage occurs when:
1.Rupture of a congenital arterial aneurym (weak arterial wall) is the most common cause.

2.Rupture of an arterial capillary or venous bleeding from one or multiple sites of origin. This can be from high blood pressure or head injury .

3.Capillary damage leading to hemorrhage can occur in certain form of encephalitis.

4.Hemorrhagic diseases such as dengue fever, hemophilia, thrombocytopenia of unknown origin

5.Intracranial tumors such as angioblastic meningioma, glioma, pituitary adenoma and intracranial metastases are rare but possible causes

6.Anticoagulant therapy especially overdosage of warfarin

7.Smoking has been associated with subarachnoid hemorrhage.

The symptoms and signs of a Subarachnoid Hemorrhage are:
The affected person may have:
1.sudden severe headache with no known cause,initially excruciating, intense, aching pain, later becoming dull and throbbing but still severe.

2.difficulty in speaking or understanding

3.difficulty in swallowing

4.severe neck and back pain

5.Pain on attempted head movement

6.dizziness

7.vomiting

8.confusion and agitation

9.loss of concentration and memory

10.sudden vision loss in one eye

11.loss of consciousness

12.convulsions

13.coma and death

14.Stiff neck usually appears with onset of meningeal inflammatory reaction up to 6 to 12 hours after onset suggesting meningeal stretching and herniation of cerebellum into foramen magnum.

Other neurological signs:
1.Pupils unequal

2.paresis of vertical and medial movements of one eye

3.optic field may have round smooth hemorrhages near optic disc,
usually unilateral which will indicate site of bleeding in the brain.

Special investigations:
1.lumbar puncture:
pressure of cerebrospinal fluid may be raised
red blood cells present for first week
protein content raised

2.MRI or CAT scan with intravenous dyes can determine the source of the bleeding

The treatment of Subarachnoid Hemorrhage:
Subarachnoid Hemorrhage is an emergency.
Purpose of treatment is to:
1. preserve life
2. limit the amount of brain damage
3. lessen the extent of disability and deformity
4. prevent recurrence.

Admission to hospital is necessary to determine
1. the cause of the Subarachnoid Hemorrhage
2. the extent of damage to the brain using MRI of the brain
3. immediate treatment with medicines(usually anticoagulant,blood circulation,nerve vitamins).
4. whether Surgery is necessary to stop bleeding or remove a blood clot
5. risk factors for Subarachnoid Hemorrhage are investigated and treated (diabetes, high blood pressure etc)

During the acute phase of Subarachnoid Hemorrhage:
1. A clear airway must be maintained
2. Sufficient fluid and electrolyte intake must be maintained
3. adequate nutrition in the form of glucose, proteins and calories must be given
4. bed rest with adequate nursing care is provided to prevent bed sores etc
5. Proper medicines are given

Once the Subarachnoid Hemorrhage is stable:
The Subarachnoid Hemorrhage patient is started on a rehabilitation programme.
This will include
a.exercises to strengthen his muscles,
b.speech training for patients with dysphasia (difficulty in talking)
c.training on how to carry out his daily activities.
d.advice about his diet

Immediate care improves the chance of a complete recovery.

A Subarachnoid Hemorrhage can be very devastating and depressing for a patient.
He will feel that part of his body and brain function is incapacitated.
Therefore he need all the support from everyone involved in the treatment of his condition:
1.doctors,
2.nurses,
3.physiotherapist,
4.speech therapist
5.occupational therapists
6.family members and friends

Family members can provide the most important means of support.
They should be familiar with his disabilities and help him accordingly:
Please do:
1.be understanding and patient.

2. keep the patient cheerful and hopeful

3.learn how to help him with the diet, daily exercises and other care necessary for him

4.allow the person more time to do any task

5.encourage and praise the patient to do as much as possible for himself at his own pace.

6.involve the person in family discussions and activities.

7.be encouraging and praise his daily efforts.

Prognosis of subarachnoid hemorrhage:
1.Recurrence may occur

2.Can be life threatening

A Family Doctor's Tale - DUPUYTREN'S CONTRACTURE

DOC I HAVE DUPUYTREN'S CONTRACTURE

DUPUYTREN'S CONTRACTURE is the PROGRESSIVE FIBROSIS OF THE PALMA FASCIA LEADING TO PAINLESS contractures of one or mor finger at metacarpophayngeal joints.
At least one or more fingers will be flexed against the palm.

DUPUYTREN'S CONTRACTURE occur as a result of proliferation and thickening of the connective tissues of the palmar fascia.
Nodules of irregular fibroblasts are formed.
Contraction of proliferated fibrous tissues leads to the deformity.

It is inherited as a Mendelian dominant in some cases.
It occurs predominently among Caucasians.
Men are affected 8 times more than women.

It has been associated with:

1.epilepsy

2.diabetes

3.alcoholism

4.as a late result of post myocasrdial infarction shoulder hand syndrome

Symptoms:
The onset is usually gradual with a wide spectrum of manifestations from simple contracture alone to plantar fascial involvement in the foot.

1.minimal flexion deformity in the early stages

2.palmar fascia can be seen puckering the skin

3.thickened or nodular underlying tissue can be felt

4.on or all fingers of either or both hands may be affected especially the ring and little fingers

5.Affected fingers are partly or completely held in fixed flexion and cannot be extended.

Treatment:
1.In mild cases no treatment is required

2.Corticosteroid injection to reduce inflammation at the thickened or nodular underlying tissues may help some patients

3.Surgery may be necessary as last resort to release the palmar fascia by cutting the tightened fascia

Complication:
If left untreated. it can lead to the permanent loss of the hand

Prognosis :
1.usually good with injection of corticosteroid

2.recurrence may occur after injection in which case surgery should be done

3.Amputation may be considered if the affected fingers interferes with activities of the hand

A Family Doctor's Tale - HALLUX VALGUS

DOC I HAVE HALLUX VALGUS

HALLUX VALGUS also known as BUNION deformity is the deformity of the big toe metatarsopharyngeal(MTP) joint in whivh there is medial protrusion and lateral deviation of the great toe.

Shoewear does not cause hallux valgus.

HALLUX VALGUS occur as a result of :
1.heredity

2.flat foot (pes planus)

3.metatarsal primus varus

4.hypermobile first metarsal cuneiform joints

5.abnormal length of first metatarsal

6.joint laxity

Symptoms:
The onset is usually gradual with a wide spectrum of manifestations from simple deviation to severe deviation and deformity.

1.Normal intermetatarsal angle (the angle between the first and second metatarsals is 9 degrees or less.

2.the normal first MTP joint angle is less than 15 degrees.
Any increase of 15 degrees angle is considered as lateral deviation of the first metatarsopharygeal joint.

3.The big toe is turned inwards towards the second causing a medial protrusion of the MTP joint called a bunion.

4.in severe cases the first toe can overlap the second toe or the second toe may cover the inturned big toe.

5.there is pain on walking

6.there is difficulty in wearing shoes

Treatment:
Conservative:
1.In mild cases no treatment is required

2.Shoe wear modifications to increase the width of the toe box will relieve pressure of the MTP joint and help in walking.

3.Pads and splints may also help to relieve symptoms.

Surgery:
The main purpose is to restore the normal anatomical relation of the big toe MTP joint.
1.Osteotomy to realign the first metatarsal

2.Fusion of MTP joint

Prognosis:
90 per cent of patients will have good results after surgery

Conservative treatment can relieve the pain on walking but the deviation may still become worse.

A Family Doctor's Tale - TACHYCARDIA

DOC I HAVE TACHYCARDIA


Tachycardia is a symptom defined as heart rate above 100 per minute.

Causes of Tachycardia:

1.Abnormality of the sinus or atrial node in the heart may be continuous or paroxymal in nature

2.Abnormalities of the ventricular conducting system: a.ischemic heart disease b.congenital heart disease

3.Underlying systemic disease:

a.fever

b.anemia

c.thyrotoxicosis

4.Medicines:

a.ephedrine or pseudoephedrine

b.asthmatic drugs like ventolin or bricanyl

c.anticholinergic drugs like atropine, buscopan

5.Psychosomatic like anxiety, emotional upsets, panic attacks

Symptoms:

.palpitations

2.breathlessness

3.fainting

4.polyuria

Signs:

1.heart beat above 100 per minute

2.abnormal heart rhythm

3.ECG will determine

a.location of stimulus of fast heart beat

b.abnormal rhythm -flutter or fibrillation

Treatment of Tachycardia is:


1. Atrial tachycardia can be slowed by carotid sinus massage or Valsalva maneuver

2. Paroxysmal atrial Tachycardia can be terminated by vagal stimulation maneuvers (Valsalva or carotid sinus pressure).

3.Acute atrial attacks if not improved after vagal massage can be treated with: a.digoxin

b.beta blockers such as propanolol or atenolol

c.calcium channel blockers like nefidipine

d.anti-cholinesterase like edrophonium

e.alpha blockers

4.Persistent atrial tachycardia can be treated with a.quinidine, b.beta blockers or c.digoxin or dilatrend

5.Ventricular tachycardia is more dangerous usually associated with coronary heart disease or infarction may be treated with:

a.lidocaine 1-2mg per kg stat followed by infusion of 2-4 mg per kg per min

b.Electo-cardioversion

c.radiofrequency ablation

6. Treat underlying conditions such as thyrotoxicosis

7. No smoking, alcohol or caffiene intake

8.No strenuous exertion or stress

Prognosis:

1.atrial tachycardia may occur in normal young adults and may not indicate heart disease

2.Ventricular tachycardia may herald more serious illness such as life threatening arrthythmia or infarction

A Family Doctor's Tale -BRADYCARDIA

DOC I HAVE BRADYCARDIA

Bradycardia is a symptom defined as heart rate below 55 per minute.

Causes of Bradycardia:
1.Bradycardia can occur normally in athletes as a result of training through increased cardiac vagal tone.

2.Abnormalities of the heart conducting system:
a.complete heart block

b.ischemic heart disease

c.congeital heart disease

3.Underlying systemic disease:
a.myxedema

b.increased intracranial disease

4.Medicines:
a.Beta blockers

b.digoxin overdosage

c.reserpine

Symptoms:
1.slow pulse at wrist

2.confirmation with ECG

3.fainting

4.asymptomatic in many cases

Treatment of bradycardia:
1. None if no symptoms and no underlying cause

2. Cardiac bradycardia from heart block may be treated with atropine

3.Sympathommetics such as isoproterenol may be given as temporary measure before treatment of underlying conditions or insertion of pacemaker

4. Treat underlying conditions such as myxedema

5. heart blocks or asystole may need pacemaker implantation

Prognosis:
1.depends on underlying cause -myxedema is less serious than intracranial pressure

2.Patient receiving pacemakers often have an excellent long term survival

A Family Doctor's Tale - CHILD SCHOOL PROBLEMS

DOC WHY DOES MY CHILD DOES NOT DO WELL IN SCHOOL?

This is an article written by my daughter Carolyn Kee who is the senior Child Psychologist at the Child Guidance Clinic in the Singapore Medical News recently.

She has been working with children and adolescents who feel anxious, depressed or troubled.

She has been with the Child Guidance Clinic for the past 15 years.

Her work includes psychological assessment, individual and group therapy, school consultation, emergency behavior management, as well as conducting talks and workshops on mental health issues.

She has written books and contributed articles on depression,
stress and other mental health conditions.

Her illustrated children’s books on attention deficit hyperactivity disorder (ADHD) and eating disorder (Anorexia Nervosa) are currently being sold at the CGC and other helping agencies.

Although I have written posts on ADHD, anorexia nervosa, autism, dyslexia, depression, anxiety and stress, nothing beats the hands on approach and experience of these dedicated psychologists and psychiatrists at the Child Guidance Clinic in Singapore.

Here is the url to her article:

http://news.sma.org.sg/4302/Child.pdf

A Family Doctor's Tale -ECU tendonitis

DOC I HAVE EXTENSOR CARPI ULNARIS TENDONITIS

EXTENSOR CARPI ULNARIS TENDONITIS OR ECU is the inflammation of the tendon sheath of the tendon to the small finger at wrist region.

EXTENSOR CARPI ULNARIS TENDONITIS occur occur as a result of narrowing of the tendon sheath of the thumb and the inflammation of the tendon at the level of the wrist.

When the tendon gets caught in the narrowed sheath, the finger becomes locked in the narrowed tendon sheath resulting in pain and swelling.

Women are affected more than men.

Local causes:
-------------
1.trauma of the tendon of the small finger from repetitive weight bearing of the wrist

2.direct injury on the tendon of the wrist from a direct blow to the hand

3.repetitive use of the wrist on keyboard of computer

4.tenosynovitis(inflammation of the tendon and their synovial sheath)as the tendon becomes swollen in the tendon shift as a result of overusage of the wrist

5.common among young and active especially those who play racket sports and basketball

Symptoms:
The onset is usually spontaneous with gradual increasing pains and tightness of the wrist tendons which causes the patient to seek treatment:

1.swelling and pain of the back of the wrist near the small finger side (opposite De Quarvian's Disease)

2.unable to move wrist  or carry heavy objects

Physical examination
1.tendon nodules in flexor tendon of the small finger at wrist level

2.tenderness on flexion of the wrist

2.diagnosis is confirmed with CAT scan or MRI

Treatment:
1.Rest and splinting of affected finger and wrist

2.wrist exercise usually good.

3.Non-steroidal anti-inflammatory drugs for inflammation and pain

4.Corticosteroid injection to reduce inflammation under the narrowed sheath

5.Surgery as last resort to release the tendon by cutting the top part of the  narrowed inflammed sheath

Complication:
If left untreated. it can lead to the permanent loss of rotation of the wrist

Prognosis :
1.usually good with injection of corticosteroid

2.recurrence may occur after injection in which case surgery should be done

Prevention:
1.Avoid forceful use of the wrist and small finger

2.Avoid repetitive movement of the wrist.

A Family Doctor's Tale - DE QUARVIAN'S DISEASE

DOC I HAVE DE QUERVAIN'S DISEASE

DE QUERVAIN'S DISEASE is the compression of the tendon sheath of one of the two tendons to the thumb at wrist region.

The tendon sheath is a protective cover for the tendon which provides protection for the tendon as it travels across the radius bone especially at the joints.

DE QUERVAIN'S DISEASE occur as a result of narrowing of the tendon sheath of the thumb and the inflammation of the tendon at the level of the wrist.

When the tendon gets caught in the narrowed sheath, the finger becomes locked in the narrowed tendon sheath resulting in pain and swelling

Women are affected more than men.

It is also known as the washer woman's sprain or recently Blackberry thumb after the name of the popular smart  phone because of repetitive movement of the thumb on the keys of the phone.

Causes of De Quarvian's Disease:
1.trauma of the tendon sheath of the thumb from too much stress on their thumb from carrying their newborn child especially first time parents

2.pressure on the tendon sheath from weight of the newborn's head on the wrist while feeding the baby

3.repetitive use of the thumb on keyboard of Blackberry phone

4.tenosynovitis (inflammation of the tendon and their synovial sheath) as the tendon becomes swollen in the tendon shift as a result of over usage of the wrist especially when wringing clothes

5.common among middle-aged, housewives and those who often use their thumbs or wrists

Symptoms:
The onset is usually spontaneous with gradual increasing pains and tightness of the wrist tendons which causes the patient to seek treatment:

1.swelling and pain of the thumb side of the wrist
2.unable to open door, bottle caps or wring clothes

Physical examination
1.tendon nodules in flexor tendon of the thumb at wrist level

2.tenderness on flexion of the thumb

3.diagnosis is confirmed with CAT scan or MRI

Treatment of De Quarvian's Disease:
1.Rest and splinting of affected thumb and wrist

2.wrist exercise usually good.

3.Non-steroidal anti-inflammatory drugs for inflammation and pain

4.Corticosteroid injection to reduce inflammation under the narrowed sheath

5.Surgery as last resort to release the tendon by cutting the top part of the  narrowed inflamed sheath

Complication of De Quarvian's Disease:
If left untreated. it can lead to the permanent loss of the thumb

Prognosis of De Quarvian's Disease:
1.usually good with injection of corticosteroid

2.recurrence may occur after injection in which case surgery should be done

Prevention of De Quarvian's Disease:
1.Avoid forceful use of the wrist and thumb

2.Avoid carrying newborn baby with head on the wrist

3.Avoid repetitive movement of the thumb.

A Family Doctor's Tale - TRIGGER FINGER

DOC I HAVE TRIGGER FINGER

TRIGGER FINGER is the compression of the tendon sheath of one of the tendon to the fingers or thumb(trigger thumb)
The tendon sheath is a protective cover for the tendon which provides protection for the tendon as it travels across the finger's bones especially at the joints.

TRIGGER FINGER occur as a result of narrowing of the tendon sheath and the inflammation of the tendon.

When the tendon gets caught in the sheath, the finger becomes locked in the narrowed tendon sheath until the tendon is freed from the tight area from forced movement of the locked finger using the other hand.

If left untreated an affected finger can become permanently bent inwards.

Women are affected more than men.

Causes of Trigger Finger:
1.trauma of the tendon sheath especially carrying heavy plastic bags and other bags

2.pressure on the tendon sheath from exertion of pressure through use of chopper knife and tools on the tendon sheath

3.repetitive use of the fingers such as computer keyboard or mouse

4.tenosynovitis(inflammation of the tendon and their synovial sheath)as the tendon becomes swollen in the tendon shift preventing movement of finger.

5.common among middle-aged, taxi drivers gripping the wheel for long hours every day, housewifes and those who often use their fingers in a gripping motion.

6.Also common among people who use the computer or mobile phones

Symptoms:
The onset is usually spontaneous with gradual increasing pains and tightness of the finger which causes the patient to seek treatment:

1.Finger is unable to extend after bending.
As you try harder to straighten the finger, it snaps open as the swollen tendon that was restrained is freed suddenly

2.pain at the base of the affected finger on the palm

Physical examination
1.tendon nodules in flexor tendon at metacarpal head that moves with the tendon

2.no active finger flexion

3.finger locks in flexion in active movement;
extension only can be performed passively
slight pain occurs with clicking sound when passively moved

4.diagnosis is confirmed with CAT scan or MRI

Treatment of Trigger Finger:
1.Rest and splinting of affected finger

2.finger exercise usually good.

3.Non-steroidal anti-inflammatory drugs for inflammation and pain

4.Corticosteroid injection to reduce inflammation under the narrowed sheath

5.Surgery as last resort to release the tendon by cutting the top part of the  narrowed inflammed sheath

Prognosis of Trigger Finger:
1.usually good with injection of corticosteroid

2.recurrence may occur after injection in which case surgery should be done

Prevention:
1.Avoid forceful use of the fingers

2.Avoid carrying heavy plastic bags

3.Avoid repetitive movement of the fingers.

A Family Doctor's Tale - Lumbar Spinal Stenosis

DOC I HAVE A LUMBAR SPINAL STENOSIS

Lumbar Spinal Stenosis is a condition due to the narrowing of the spinal canal either in the central part or peripheral(lateral) to the the side in the nerve root canal.
This results in pain in one leg without back pain

Every one can get Lumbar Spinal Stenosis.

The age of onset is usually in the late 40's.

It is also more common in men than women .

The causes of lumbar spinal stenosis are:
1.congenital - in born narrowing of the spinal canal

2.Acquired
a.carrying heavy objects improperly with the back instead of the knees

b.trauma or injury to the spine or pelvic bone

c.staying in crouched or seated positions for too long

Symptoms:
1.The onset is usually gradual with bouts of back pain and stiffness over weeks or months.

2.Early morning stiffness and pain occurs,then wears off during the day.

3.It gradually affects the lower limbs with pain and stiffness.

4.Typically there is low back pain radiating to the buttocks and leg which is aggravated by activity especially walking

Signs:
1.Physical signs are not present in early cases

2. there may be a Simian stance (like a monkey) with flexion at the hips and knees

3.Spinal movements are restricted

4.motor, sensory and reflex abnormalities present in one or both lower limbs

4.sphincter impairments may be present rarely

Diagnosis:
1.medical history of duration of symptoms and the extent of pain in the back and legs

2.neurological examinations of deficits in the spinal nerve

3.Confirmation is usually by a  x-ray of the spine and pelvis.
-disk height, narrowing of intervertebral space, bone spurs or osteophytes

4.MRI or CAT scans will show clearly the spinal narrowing or narrowing of the nerve root canals

Treatment:
Conservative Management:
1.physiotherapy with traction and short wave diathermy
strengthening of spinal muscles

2.spinal support with corset or light weight brace

3.Proper usage of back muscles

4. medications such as NSAIDs

5.epidural steroid injections

Surgery:
surgery may be needed if:
1. the patients do not improve with above treatments

2.the symptoms become progressively worse

3.weakness of legs

4.loss of bowel or bladder function

There is lumbar decompression surgery
1.Laminectomy or removal of disk

2.foraminotomy to widen the hole where the nerve root comes out.

3.Spinal fusion to strenthen the spine  and prevent abnormal loose movement of the spine

Prognosis:
Usually very good after surgery

Prevention:
Symptoms comes and go.

There should proper posture during sitting, standing and carrying heavy things

With exercise and strengthening of the spinal muscles, pain is reduced and flexibility of the spine is improved especially with regular exercise and proper posture.

Lumbar Spinal Stenosis is never life threatening and can be controlled but not cured.

A Family Doctor's Tale - TENNIS ELBOW

DOC I HAVE TENNIS ELBOW

Tennis Elbow or Lateral Epicondylitis is a common conditions in adults which is due to small tear in the tendons on the lateral or outside part of the elbow.

These tendons attach the forearm muscles to the lateral epicondle of the elbow.


Repeated tears tears leads to damage in the tendon a condition called angiofibroblastic hyperplasia.

The microtears and subsequent development of the damaged tissue is due to forceful or repeated use of the forearm muscles.

Recently it has also been called golf elbow.

In fact any repetitive forceful usage of the forearm muscle during work or sports can give to this condition.

Risk factors:
1.Age above 40

2.Activity - regular tennis of more than 2 hours playing per session or a similar activity such as golf

3.Technique - poor stroke technique in tennis or golf (hitting the ball with flexed muscle) and improper grip size

4.Other factors - over exertion of muscles

Symptoms:
1.pain and tenderness over the lateral part of the elbow joint

2.Pain is worse on resisted wrist and finger extension with elbow in full extension.

Diagnosis :
1.Diagnosis is based mainly of history and site of tenderness of the elbow

2.X-rays of elbow are done to evaluate the bone surrounding the muscles and exclude other causes of pain.

It may also reveal calcification of development of bone spurs of the lateral epicondylar region in chronic cases.

Treatment:
Conservative management with rest and observation for 6 months:
1.activity modification

2.correction of playing techniques in sports

3.improved ergonomic in work related usage of elbow

4.stretching exercises

5. counterforce bracing

6.pain killers and anti-inflammation drugs

7.Topical injection of steroid into the tendon

Surgery:
3 surgical options are:
1.open release of affected tendons with excision of damaged tissues

2.arthroscopic release

3.new techniques which improved blood supply to the affected area.

Prognosis:
Usually very good with injections or surgery

Prevention:
1.Adequate warm up exercise before strenuous activity to forearm

2.limit duration of play or activity

3.use correct technique