A Family Doctor's Tale - LEGIONNAIRE'S DISEASE

DOC I HAVE LEGIONNAIRE'S DISEASE

Legionnaire's disease is getting more common especially in air-conditioned offices or factories with poor ventilation.

The bacteria causing Legionnaire's disease grows in water and soil.

It is transmitted through the air from contaminated air from dirty air-conditioners.

The patient usually presents with a high fever, cough and breathing difficulty.

Diagnosis is confirmed if there is a high legionna bacteria antibodies in the blood.

Treatment is with antibiotics such as erythromycin.

Complications are pneumonia, liver dysfunction and kidney failure.

However prognosis is usually good.


Legionnaire's Disease is an acute, infectious disease of the respiratory tract caused by the bacillus Legionella pneumophilia, a Gram negative, non-sporulating aerobic micro-organism.

Legionnaire's Disease has nothing to to do with the mercenary French legionnaire.

It was named because in 1976 during the American Legion Convention a major outbreak of infectious bacterial disease occur in Philadelphia. The bacteria found was named the Legionella bacillus because of the American Legion Convention.

The bacteria is found mostly in soil and water.

Legionnaire's Disease is transmitted through the air or in dust associated with movement of soil or contaminated air from air conditioner units, hot water tanks or cooling towers.


It is highly infectious.


Incubation period is 2-10 days.


The organism enters the blood and then enter the cells of the lower respiratory tract

The infections occur in persons of all ages but peak incidence is 50-60 years.

Males are affected twice as often as females.


Predisposing factors are:
1. Patients with pre-existing lung disease


2.heavy smoking


3.low immune patients such as cancer

Symptoms start off with:
1. sudden onset of malaise


2. high fever of 39-40 degrees centigrade


3. chills and rigors


4. headache and body aches


5. dry cough


6. diarrhea


7. upper and lower gastrointestinal bleeding


8. difficult breathing


9. slow heart rate


10. confusion and dilerium

Diagnosis  of  Legionnaire's Disease is through:
1.Symptoms of
a.prodromal viral like disease (myalgia, malaise, headache)
b.dry cough, confusion, diarrhea
c.lymphopenia without neutropenia
d.hyponatremia

2.ESR raised very high sometimes > 80


3.moderate leucocytosis with lymphopenia


4.low blood sodium


5.low blood calcium


6.abnormal liver function tests with albumin and raised SGOT


7.Urine shows protein and blood


8.Chest x-ray show patchy consolidation usually confined to one lobe


9.Indirect legionna bacterial antibody higher than 1.256


10.symptoms of renal failure

The complications of Legionnaire's Disease are:
1.pneumonia


2.liver infection and dysfunction


3.renal failure

Treatment of Legionnaire's Disease is with:


Isolation in hospital is unnecessary.
1.Antibiotics (erythromycin or rifampicn) are used in the treatment of Legionnaire's Disease.


2.Tetracycline can be given


3.pulmonary care -

a.nebuliser,

b.oxygen,

c.deep breathing exercises may be necessary if there is breathing difficulty

4.Besides antibiotics, the following will help:
a.Steam inhalation


b.cough mixtures


c.avoid smokes, dust, moist air, sudden temperature change

Prevention for Legionnaire's Disease is by:


1.Avoiding dust


2.Proper cleaning of air conditioners and ventilation system

Prognosis of Legionnaire's Disease is usually good:
1.Early therapy with antibiotics produce good results


2.Low mortality rates as early cases are detected


3.Rarely pulmonary fibrosis develops as remnant from disease.

A Family Doctor's Tale - TORTICOLLIS

DOC I HAVE WRY NECK

Wry neck or torticollis  is common in many patients with poor postures especially when they do desk work or are driving in a car.

The patient usually complains of pain or stiffness of the neck muscles.

Neck movements are limited usually on one side.

Relaxation of the neck muscles can be done with physiotherapy such as traction and neck exercises or with muscle relaxant medicines or tranquillizers.


Torticollis or wry neck is a spasm of the sternomastoid, trapezius or other neck muscle causing pain in the neck and spasm in the neck muscle.


Every one can get Torticollis.
The age of onset is usually in the young people in the 20's except for congenital torticollis which appear in babies as early as 2 weeks from birth.


It is also more common in men than women.

The causes of Torticollis are:
1.Spasmodic torticollis - is usually a form of dystonia (abnormal tone) of the neck muscles


2.Trauma and injury of the neck muscle or deep cervical ligament such as whip lash injury can also indirectly injure the muscle and cause an acute wry neck.


3. Posture may also play a part in this condition especially ill fitting neck rest in cars or chairs or sleeping position

4.Congenital torticollis occurs as a swollen tender sternocleidomastoid muscle in a newborn baby appearing at the age of 2-4 weeks causing the neck to to be pulled to one side.

It may be due to birth trauma or abnormal position of the baby in the uterus.

Traction of the neck is usually done to stretch the swollen muscle.

It may disappear at the age of 5-8 months of age with treatment or spontaneously.

Very rarely is surgery required to release the contracted muscle.


Most torticollis cases presents with:

1.The onset is usually sudden with painful spasm of the neck muscles often without obvious precitating cause.


2.There may be a history of trauma to the neck or prolonged neck strain.


3.Movements of the head and neck is very painful and the head cannot be turned away from the affected side.


4.Neck movements may be restricted on the affected side.


5.Most cases are acute and wears off after a transitional period but may recur.


6.In spasmodic torticollis, there is sudden. usually short lived, with involuntary tipping or turning of head. Spasm may be prolonged in some cases.

Pain may be aggravated by stress, general health, prolonged period of the neck in one position.

An x-ray of the cervical spine can exclude degenerative cervical spondylosis.

Treatment involve:

1. application of warmth to the affected muscle


2.analgesic tablets especially muscle relaxant


3.analgesic cream


4.pain relieving sprays


5. soft neck support


6. Spasmodic torticollis tranquillizers like diazepam may help
to relieve the spasm


7.Rarely neurectomy may be required for severe cases of spasmodic torticollis.

Prognosis:
Acute wry neck usually resolves with treatment of underlying cause.
Spasmodic torticollis is usually more resistant to treatment.

A Family Doctor's Tale - BEE STINGS

DOC I WAS STUNG BY BEES

Bee stings can be quite common especially if you stay in a landed property with gardens and plants.

Bees are often found in these gardens.

Sometimes if you are passing by a tree or shrub you may come across beehives hanging on the tree.

In one case a Filipino maid was passing a tree along the road when something happened to irritate one of the beehives and the bees flew out and began to stung her.

I actually removed more than 100 stings from her scalp and neck and arms.

Luckily she had no adverse effect from the bee stings venom.

In some more sensitive people the bee stings can cause anaphylactic (allergic reaction ) shock and the organs like the kidneys may shut down leading to death.


Bee stings include stings by different bees, wasps and hornets.

The most common sting is by the common honeybee.

Usually the bee stings the patient's skin, leaving its stinger behind and dies.

Symptoms of Bee stings:

1. stinger left on the skin

2. pain and mild discomfort may last a few hours

3. swelling of the skin at the sting site in sensitive patients reacting to the venom of the sting

4. itch at the site may lasts for a week

The main component of bee venom responsible for pain is the toxin melittin.

Histamine and amines in the bee sting contribute to the pain and itching.

Most bee sting are acidic in nature.

Treatment of Bee stings:


1.Remove the barbed stinger.

2.Apply cold compress to reduce pain and swelling.

3.Use baking soda solution to counter act the acid in the venom.


4.Give paracetamol and antihistamines for pain and itch

For more severe reactions such as allergy and anaphylactic shock to the bee stings, emergency treatment may be required:

1.Give adrenaline injection subcutaneously slowly over a minute period

followed by:

2.antihistamine like diphenhydramine intravenously

3.Treat shock

4.Corticosteroids may be needed to counter allergy

Multiple bee stings may cause severe reaction with shock and hemaglobinuria.

This may require hospitalization.

Multiple bee stings have been known to cause the kidneys and vital organs to shut down and should be treated urgently.

A Family Doctor's Tale - OSTEOGENESIS IMPERFECTA

DOC I HAVE OSTEOGENESIS IMPERFECTA

Osteogenesis imperfecta is also known as brittle bones disease, usually inherited.In a case of one patient with this condition it was due to genetic mutation during in-vitro fertilization.

The boy who is now about 16 years old had 5 fractures since his childhood and has been excused from national service.


Osteogenesis imperfecta (OI) is an inherited disorder of the connective tissue resulting in imperfect bone formation and hence causing fractures in childhood.


It also causes fractures in adults.



Osteogenesis Imperfecta is a congenital condition affecting 2 forms of genetic disorder:
1.autosomal dominant - usually milder with frequent fractures

2.autosomal recessive - usually more severe and can lead to early death

Therefore there is always a family history of fractures of children in the family.

Osteogenesis Imperfecta is a condition resulting from impaired maturation of the collagen fibres or synthesis of abnormal collagen.

Collagen is the main protein in bone and is necessary for the bone to form strong bone matrix.
The abnormal collagen results in soft fragile bones, ligamentous laxity and thin sclera.

In the autosomal dominant form of Osteogenesis Imperfecta, the condition can be passed from one generation to the next.

Sometime the cause is a new genetic mutation which results in the Osteogenesis Imperfecta.
There is no previous history of Osteogenesis Imperfecta.
This has been seen in IVF of frozen egg from mothers trying for a pregnancy.

Symptoms:


1.fractures is the most common symptom especially in newborns.
Multiple fractures may occur easily in the newborns and pose a danger to life.
As the child grow older the rsik of fractures decreases especially after puberty.

2.lax joints

3.eyes conjunctiva(white)may be blue or grey.

4.teeth may be discolored and fragile.

5.increased liability to bruising due to the abnormal collagen in the lining of small blood vessels.

6.Deafness is due to problems in the small bones in the middle ear which may be fractured or deformed so that sound waves cannot be transmitted easily to the inner ear

7.Hernias are due to poor formation of collagen fibers or abnormal collagen in the muscles.

8.Excessive sweating or intolerance of heat - the cause of this is unknown.

9.Dwarfism and structural abnormalities may occur due to basic defect and frequent fractures

10.Mental development is not affected



Diagnosis of Osteogenesis Imperfecta is often based on
1. history and pattern of fractures

2. blue or grey whites of the eyes.

3.X-rays in severe cases -shows previous fractures and deformities
The bones may appear demineralized .

4.wormian bones are additional small bones seen in the sutures between the scalp bones.
They occur in 50% cases of Osteogenesis Imperfecta.

5.Specialized test for diagnosis of Osteogenesis Imperfecta involve taking a small piece of skin, culturing the cells and chemically examining the collagen produced.

6.Another specialized test uses a blood sample to search for mutations of the genes coding for the collagen of bone.

The complications of Osteogenesis Imperfecta are:

1. multiple frequent fractures of the bone,

2. deformities of the bone and body

3. death in newborns from multiple fractures

The treatment of Osteogenesis Imperfecta is through:


1.Good treatment of fractures to make sure that the bones healed without deformities.
Immobilization of fractures can lead to the loss of bone so early mobilization of the patient is important.

2.Surgical use of fixed or telescopic metal rods inserted into the shafts of bones can prevent appreciable deformity.

3.occupational therapy is important in preventing falls especially with handrails and other adaptation to the home.

4.no drug treatment including growth hormone have been effective.
Various bisphosphonate drugs trials are in progress.
There has encouraging evidence of their effectiveness in some patients.

5.Women with Osteogenesis Imperfecta may try HRT at menopause since HRT has been know to improve the bone structure and also prevent heart attacks.
However there is a very small risk of breast cancer.

In the case of Osteogenesis Imperfecta ,the advantages of HRT may be greater than the disadvantages as the chances of fractures is higher after the menopause.

6.Stopping smoking is important because smoking diminishes the bone by up to 5 per cent, thus increasing the risk of fractures.



Prognosis depends on the severity of Osteogenesis Imperfecta.

In very severe cases, death within several years

In less severe cases, multiple and frequent fractures may occur followed by deformities.

A Family Doctor's Tale - ANTHRAX

DOC I HAVE ANTHRAX

Anthrax has been in the news since the September 11 2001 attack on New York.

The spores of the anthrax bacteria can cause serious illness in those exposed to them.

These spores have been sent to people in high positions in letters which when open will expose the spores to these recipients of the letters.

Many postal employees were affected during a spate of terrorist attacks using this method to target the people in high government position.

However the bacterial infection can be cured with ciprofloxacin if detected early.


Anthrax is a disease caused by a gram positive spore forming bacterium that primarily infects mainly animals but can cause serious illness in humans if one is exposed to these spores. It can affect the skin, the intestines or the lungs.

There are  different forms of Anthrax:
1.Cutaneous anthrax is the most common type of anthrax.
It occurs 1-2 days after the skin is scratched and exposed to soil, animal parts or faeces containing the spores.


The affected skin forms an itchy black swelling that becomes a blister that breaks into an ulcer.

The bacteria then enter the bloodstream and cause septicaemia (blood poisoning).


20% of cases will die if they are not treated promptly.

2.Intestinal anthrax happens 2 to 5 days after one eats contaminated meat containing the spores.

The intestinal lining breaks and bleeding occurs.


The victim feels nausea, loss of appetite, vomiting, fever and suffers from severe abdominal pain, bloody vomiting and diarrhoea.


Blood poisoning occurs and the loss of blood can result in shock.
25% to 75% of cases will eventually die.

3.Inhalation anthrax is the least common.
However  it is the most serious form of anthrax because the spores are inhaled into the lungs.

Flu-like symptoms occur for 2 to 3 days with fever, cough and then breathlessness before the lungs starts to bleed internally like a person drowning in his own blood.


Death occurs rapidly most of the time.


This is the type that is used as a biological weapon by terrorists.

Treatment of Anthrax is with antibiotics:
The bacterium is easily killed by several antibiotics (penicillin,tetracycline etc), the most effective one being ciprofloxacin given intravenously or  directly into the bloodstream.


Oral ciprofloxacin is also effective in less severe cases.

There is no need to take antibiotics to prevent anthrax.


Doing so, it can also cause the bacteria to become resistant to the antibiotic and make it more difficult to treat.

A cell-free vaccine has been developed for people who are at risk of contracting anthrax. This vaccine may be mass produced in the future for common use.

Although anthrax is a much feared disease, it can be prevented and treated with careful and alert practices.


Its use as a biological warfare agent is currently very limited with very effective counter measures in place.

A Family Doctor's Tale - CYTOMEGALOVIRUS

DOC I HAVE CYTOMEGALOVIRUS

Cytomegalovirus is viral infection which is transmitted through body fluid.

It may be transmitted to the  babies through body fluids (urine, blood, saliva, tears, semen and breast milk)  of the mother and may cause deformities.

In children and adults the symptoms are usually mild with some fever.

There is no treatment or cure for this virus.

Prognosis for deformed babies are usually poor.


Cytomegalovirus is an acute viral disease of all ages which can be transmitted to the fetus before birth.

It affects people at all ages but seldom causes any symptoms in adults.



Cytomegalovirus is a virus of the herpes group characterized by its ability to stay dormant in the body over a long period.

It is transmitted in body fluid (urine, saliva ,blood, semen, tears and breast milk)



Adult and children Cytomegalovirus infection do not normally give rise to symptoms except for mild fever and a mononucleosis-like illness.

Congenital Cytomegalovirus infections presents itself at birth:

1.Microcephaly( small brain)


2.Hepatosplenomegaly (enlarged liver and spleen) with jaundice

3.Hearing impairment

4.Blindness

5.Chorioretinitis (inflammation of the  retinal cells)


6.Hemolytic anemia with petechiae

7.Seizures

8.Respiratory distress

Diagnosis of Cytomegalovirus is made through:


1.blood tests for igG or igM for Cytomegalovirus are positive within 3 weeks of birth

2.Usually appears normal at birth

3.Ultrasound during pregnancy to identify any brain abnormalities .

4.Saliva , urine may be taken to test if there is presence of the Cytomegalovirus.

The complications of Cytomegalovirus:

1.Respiratory distress

2.Mental retardation

3.Hemolytic anemia

4.Blindness

5.Deafness

Treatment of Cytomegalovirus:


There is no effective treatment of Cytomegalovirus at the present moment.

A antiviral drug ganciclovir which is used to treat AIDS may help babies with Cytomegalovirus infection.

A vaccine is also being developed for prevention.



Prognosis for congenital Cytomegalovirus infection is poor.

Adult Cytomegalovirus infection do not have any problem.



There is no vaccine at the present moment for Cytomegalovirus.

Transmission of Cytomegalovirus infection is always preventable because it is transmitted through body fluid from hand,nose and mouth of a susceptible person.

People who interacts with children and pregnant mothers should practise good safe hygiene methods such as washing of hand and wearing of clothes when changing diapers.

Pregnant women are also advised to practice safe hygiene methods and to seek advice in the presence of a mononucleosis-like illness.

A Family Doctor's Tale - ATHLETE FOOT

DOC I HAVE ATHLETE'S FOOT

Athlete's foot (Hong Kong foot) is actually a fungal infection affecting the webs of the toes.

In most cases the condition is mild but in severe cases there is an unpleasant smell from the affected feet.

Treatment is good with antifungal medicine.

However recurrence is frequent especially in tropical countries where the feet tend to sweat more frequently.


Athlete's Foot is a common disease caused by superficial fungi infection affecting the webs and toes of the foot



A group of fungi called dermatophytes thrive in the warm, moist environment of webs and toes of the feet caused by trapped sweats and the closed environment of the shoes.

They grow on the keratin a protein found in hair, nails and skin.

Fungal infection is mildly contagious and can spread by direct contact with the infected skin cells found on socks and other clothing.



Symptoms are:

1.Unpleasant foot odor.

2.Small itchy blisters on the soles of the feet.

3.Itchy, scaly, red rash usually in the webs of the toes.

4.cracked, blistered skin of the toes and nails

5.Dry scaly skin on the soles.

The complications of Athlete's foot are:


Secondary bacterial infections with cellulitis, lymphangitis and lymphadenitis may occur especially in diabetic patients.

Treatment of Athlete's Foot is :

1.Antifungal powder, creams and oral medicines

2.basic good foot hygiene

It is important to prevent the fungal infection from spreading.

Avoid scratching of the infected area as this will cause the fungi to spread to other areas.

Dry the feet thoroughly after bathing and before sleep.

Socks or stockings should be changed daily.

Anti fungal powder may be placed in socks before wearing.

Clean and air shoes.

Even after treatment and clearing of the fungal infection, recurrence of the infection may take place because of the presence of spores of the fungus under the skin.

The spores are very resistant to treatment and only when they germinate to the mycelia stage, the fungus can be eliminated through the anti fungal creams, ointment, powder or oral medication.

The antifungal creams must be applied each time there is wetness or trapped sweat so as to get rid of the germinated spores.

Once the spores are completely removed from the skin, then you can be sure that the fungal infection will be unlikely to recur.

Treatment may take up to 6-8 weeks before the fungal infection disappear.

A Family Doctor's Tale - OTITIS MEDIA

DOC I HAVE OTITIS MEDIA

Otitis Media is a fairly common infection of the middle ear.

The danger is infection from the nose spreading through the eustachian tube to the middle ear.

Infection of the middle ear can result in the bursting of the ear drum, with pus coming out of the external ear.

In addition infection can spread to the bones of the skull (the mastoid) and the brain .

Proper treatment with antibiotics can normally clear the infection.


Otitis media is acute or chronic inflammation of the middle ear.

Otitis media occurs in the area between the ear drum (the end of the outer ear) and the inner ear, including a duct known as the Eustachian tube.

Otitis media occurs in:
1.childhood, usually related to viral upper respiratory tract infection

2.family history of middle ear disease.

The Causes of Otitis media are:


Bacterial Infections:

1.Streptococcus pneumoniae

2.Haemophilus influenzae

3.staphylococcus aureus

4.Moraxella catarrhalis, a gram-negative diplococcus.

5.Mycobacterium tuberculosis.

6.E.coli

Viral infections:

1.common cold.

2.measles

The Types of Otitis Media are:

1. Acute otitis media

Acute otitis media is an acute infection of the middle ear which usually occurs as a result of viral upper respiratory tract infection that can occur at least twice a year

2.Chronic otitis media

Chronic otitis media occurs following acute otitis media with chronic infection of the middle ear and ear perforation.

3.Otitis media with effusion:

Otitis media with effusion occurs when fluid occurs in the middle ear due to blockage of the eustachian  tube.

The complications of Otitis media are:

1.mastoiditis

2.labrynthitis

3.facial nerve palsy

4.meningitis,

5.brain abscess,

6.febrile seizures.

7.death if a severe infection goes untreated long enough

Symptoms and signs of Otitis media:

1. cold: stuffy nose

2. earache - The pain lasts a day or two.

3. high fever - may cause seizures if very high

4. discharging pus from the ruptured eardrum

Usually the ruptured drum will usually heal spontaneously

5.Eustachian tube becomes blocked resulting in hearing loss

Signs:

1.Ear drum (tympanic membrane) inflamed and bulging with loss of normal outline

2.Decreased or displaced light reflex of ear drum


3.perforation of ear drum

4.mucopurulent discharge from ear after perforation

Diagnosis of Otitis media is made by:

1.Inflamed ear drum with loss of normal outline, decreased light reflex, bulging and perforation and purulent discharge.

2.Culture and sensitivity of pus swab

3.Nasal and pharyngeal swabs my also be done

4.X-rays or MRI of the mastoid air cells

5.Audiogram for hearing loss

Treatment of Otitis media:

Acute otitis media

1. Antibiotics may be commenced if fever is high or the culture showed bacterial infections.

2.Fever and pain may be treated with paracetamol

3.Antihistamines may be given for rhinitis or runny nose.

4.Decogestants may be necessary for blockage of eustachian tube

5.Bed rest and Fluids

6.Myringoplasty -

Puncture of bulging ear drum if painful and aspiration of

pus or fluid in the middle ear.

7.Tympanoplasty for eardrum whose perforation does not heal.

8.Mastoidectomy to remove cholesteatoma(growing of skin into middle ear cavity) in chronic otitis media with mastoiditis.

The prognosis of Otitis media with appropriate treatment is generally good.

Ear drum perforation usually heal spontaneously in most cases.

Preventive measures for Otitis media  are:

Avoid swimming and diving.

Proper ear hygiene.

A Family Doctor's Tale - BRONCHITIS

DOC I HAVE BRONCHITIS

Bronchitis is caused by infections and chemical fumes which irritates the air tubes and produce narrowing of the air tubes resulting in wheezing and breathlessness in the patient.

The danger is pneumonia especially in the very young and very old.

Treatment is with bronchodilators, oxygen, rest and adequate fluids.

Antibiotics, antivirals and antifungals are used to treat the infections.

Avoid dust and chemical fumes as preventive measures.


Bronchitis is an acute disease which causes inflammation and infection of the trachea, bronchi and bronchioles of the lungs.

The mucous membranes of the bronchi of the lungs becomes inflamed from bacterial or viral infection or irritated by fumes and dust in the air resulting in swelling of the bronchial mucosa with excess mucous discharge causing narrowing of the air passages.

Because of the congestion of the bronchi there is difficulty in breathing and insufficient oxygen to the body thus posing a danger to the patient's life .

The causes of Bronchitis are:


Bacterial Infections:

1.Gram positive bacteria such as Streptococcus Bronchitise and Staphphylococcus may be serious and fatal in some cases.

2.Gram negative bacteria such as Klebsiella,  E.coli,  Pseudomonas, Mycobacteria(including tuberculosis),  Legionaire's Disease, chlamydia

Viral infections:

Influenza,  arbovirus,  Severe Acute Respiratory Syndrome(SARS) virus,  coxsackie virus

Fungal infections:

Cryptococcus neoformans

Non-infectious:


1.chemicals such as fumes can damage the lungs and cause Bronchitis

2.Othostatic Bronchitis occurs in people who are bedridden and are unable to get rid of the fluids accumulated in their lungs

3.Aspiration Bronchitis occurs with saliva or fluids in the throat become sucked into the windpipe and the lungs.
This occurs in comatose patients and people having seizures or stroke.



Symptoms:

1.cold or runny nose is usually the first symptom

2.Fever may be present

3.cough initially dry, followed by productive purulent sputum which can yellow, green or bloody

4.Breathlessness due to airway obstruction

5.chest pain especially the sides of the chest due to coughing and fever

6.Myalgia (bodyaches) and headache which may be related to the fever

Signs:

1.Moist sounds and wheezing on auscultation with stethoscope due to narrowing of the airways(bronchi)

2.rhonchi or wheezing sounds due to narrowing of the airways from pressure in the congested lungs

3.Reduced breath sounds - air movement is reduced in the lungs

4.Hyporesonance on percussion of the lungs

5.Cyanosis (blue color) of the lips and fingers if not enough oxygen is entering.This will considered as a medical emergency.

Children and babies with Bronchitis may not have signs of a chest infection.
They are however quite ill, with fever and lethargy.

Diagnosis of Bronchitis is made through:


1.Symptoms and signs of fever, breathless and productive cough

2.blood tests (complete blood count, ESR and blood culture)

3.Sputum culture to determine the type of micro-organism

4.Chest X-rays to establish site and character of the bronchial infection

5.CT or MRI of the lungs may be done if required especially if there is suspicion of lung cancer.

The complications of Bronchitis are:


1.Pneumonia

2.adult respiratory distress syndrome

3.Emphysema

Treatment of Bronchitis is by:


1.Rest, fluids and oxygen

2.Bronchodilators such as aminophylline, ventolin, bricanyl

3.Antibiotics depending on the organism found:

a.cephalosporin, penicillin, ampicillin, tetracycline, for most streptococci, staphalococci, hemophilus

b.cephalosporins, gentamycin for pseudomonas

c.Tetracycline or erythromycin for mycoplasma and chlamydia

d.Erythromycin and rifampicin for Legionaire's disease.

3.Antivirals such as Tamiflu for Influenza infection
Acyclovir may be given for herpes virus infection

4.High dosages of antifungals may be given for Fungal Bronchitis for a prolonged period of time

5.corticosteroids is useful to reduce complications

6.Humidifiers and steam inhalations

5.cough mixtures and mucolytic agents such as bisolvon

The prognosis of Bronchitis  depends on the severity and type of infection.

Most cases if treated early and correctly recovered completely with return of normal lung function.

In elderly and debilitated patients, breathing can be a problem and recurrence can occur.

Preventive measures taken for Bronchitis are:


1.Avoid smoking and dusty environment.

2.Healthy lifestyle with balanced diet and exercise.

3.Vaccination against the influenza virus may help.

A Family Doctor's Tale - WHOOPING COUGH

DOC I HAVE WHOOPING COUGH

Whooping cough or pertussis is rare now a day since the introduction of the vaccine to all children.

However the vaccine may have some side effect such as seizures in some children.

However a recent acellular vaccine for pertussis has reduced this risk considerably.


Whooping cough is an acute infectious childhood disease of the respiratory tract caused by the bacillus Bordetella pertussis.



Whooping Cough is transmitted by droplets from coughing spells.

It is highly infectious.

The early stage when it appears to be a cold is the most infectious period.

Most infections occur in children under six years of age.

One attack usually confers immunity



The incubation period is usually 10 - 12 days after contact with an infected child.

Symptoms start off with:

1.an ordinary cold (runny nose, sneezing, cough, fever) for 1-2 weeks followed by:

2.uncontrolled coughing that can last 1 - 2 months.

Cough persists and become paroxysmal ending in a noisy inspiration "whoop" sound causing the child to go blue and vomit.

Between the spasms of coughing the child seems relatively well



The worst affected are children below the 1 year old.

Some serious complications are:

1.pneumonia,

2.seizures,

3.brain damage

4.nose bleeds

5.death can occur during the severe coughing stage.

Serious complications are less with older children or adults.

Adults rarely get whooping cough because their immunity from vaccination usually last 10 years after the last dose.

When adults get whooping cough, a prolonged, irritating cough may be present instead of whooping type of cough.

Treatment of Whooping Cough:


Antibiotics (erythromycin) are used in the treatment of Whooping cough.

Once severe coughing has begun, antibiotics are less effective. They can reduce the duration of the illness and stop the spread to others.

Family members should be treated once there is an infected person.

Tetracycline is used if the patient is allergic to erythromycin but should avoided in children because of the staining of the teeth.

Besides antibiotics, the following will help:

1.Steam inhalation

2.cough mixtures

3.oxygen therapy

4.avoid smokes,  dust,  dry air, sudden temperature change



Vaccination against whooping cough is the best prevention .

Since vaccination began, the worldwide incidence of whooping cough has declined.

Vaccination against diphtheria, pertussis (whooping cough), tetanus (DPT) is usually given to a baby at 3 months of age and repeated at 4 and 5 months of age.

There is a booster vaccination at 18 months.

In very rare cases (1 in 100,000 cases), there has been serious reactions such as seizures to the whooping cough part of the vaccination.

Recently, an improved acellular pertussis vaccine is now available. There are fewer side effects such as high fever and seizures with this new vaccine.

A Family Doctor's Tale - POLYCYSTIC KIDNEYS

DOC I HAVE POLYCYSTIC KIDNEYS

Polycystic kidneys can be inherited.

The danger is that it is progressive and may lead to kidney failure.

Most patients do not realize that they have the condition until a ultrasound or MRI of the kidneys  is done.

There may not be any symptoms  or there may be urinary infections or mild back pain.

During the investigations for urinary infection or blood in the urine, the polycystic kidneys may be detected.

Polycystic kidney disease is a progressive genetic condition of the kidneys in which multiple cysts (polycystic)are present in both kidneys.

The disease can produce cysts in the liver, pancreas, and rarely, the heart and brain.

Any one with a family history of polycystic kidneys.

There are 2 main causes of polycystic kidney disease.

Both are determined by their genetic inheritance:

1.Autosomal dominant
It is  generally a late-onset disease with progressive cyst development.

The kidneys are bilaterally enlarged and have multiple cysts.

There may be kidney dysfunction resulting in hypertension and kidney failure by the age of 60 years.

Beside this there are also cysts in other organs such as the liver, spleen, pancreas, and arachnoid mater.

Other abnormalities includes intracranial aneurysms, dissection of the aorta, mitral valve prolapse.

2.Autosomal recessive
This disease is less common than the above.


Most cases died during the pregnancy or in the first month of birth.

Early manifestations of the disease is apparent at birth or in early infancy.

Many Polycystic kidney patients do not have any symptoms.

In some cases there may be:

1.hypertension,

2.Abdominal colic due to urinary stones

3.back or flank pain

4.urinary tract infections with hematuria and proteinuria

5.Palpable large kidneys

6.Abdominal swelling

7.fatigue

8.Xrays of the kidneys on routine checkup

9.Ultrasound of the kidneys

10.MRI of the kidneys

Genetic counseling may help families at risk for polycystic kidney disease.

There is no cure for Polycystic kidney disease.

Although a cure for Polycystic kidney disease is not possible, treatment can ease the symptoms and prolong life.

1.Back Pain:
Mild pain killers such as paracetamol can relieve pain.

2.Urinary tract infections:
urinary tract infections can be treated with antibiotics.

Any urinary infection can spread from the urinary tract to the kidney cysts so early treatment is important.

Once the infection enter the cyst, treatment is difficult  because many antibiotics cannot enter the walls of the cysts.

3.High blood pressure:
All hypertensions due to Polycystic kidney disease must be kept under control with medications and lifestyle changes such as exercise, de-stressing, low salt and fats

4.Renal disease:
Eventually in all cases the kidney function will fail and chronic real failure develop.

Treatment will then be by dialysis or kidney transplant.

5.Surgery:
Surgery is rarely needed except to remove large cysts.

Even then the kidney disease is progressive and will still end in chronic renal failure.

Generally poor after the age of 60 when renal disease may set in.

The condition eventually ends in chronic renal failure with loss of kidney function.

A Family Doctor's Tale - PNEUMOTHORAX

DOC I HAVE PNEUMOTHORAX

Pneumothorax is always a emergency.

It is due to the loss of air from the air sac of the lungs leading to pressure on the lung space in the pleural cavity.

The cause may be spontaneous or due to trauma.

It will definitely lead to loss of air in one part of the lungs.

The patient is hospitalized and air is pumped out of the pleural cavity using a one way valve tubing until the leak has been sealed either spontaneously or by surgical methods.

Chest X-ray monitoring may be needed.

Recurrence can be common in spontaneous pneumothorax.


Pneumothorax is a medical emergency caused by collection of air in the pleural space between the perietal and visceral pleura.

Types of pneumothorax:


1.Tension pneumothorax:

This ia a medical emergency as air builds up in the pleural space with each breath.
The rising intrathoracic pressure pushes the mediastinum away from the affected lung to the other compressing intrathoracic vessels and causing collapse of the lung.
Tension pneumothorax are life threatening.

2.Non-tension pneumothorax:


A non-tension pneumothorax is less serious because there is no increasing pressure of air in the thoracic region and hence no increasing pressure on the intrathoracic organs.

3.Hemopneumothorax:


When blood accumulates in the thoracic cavity (hemothorax), there is even more increased pressure in the pleural cavity. This is called a hemopneumothorax and also be life threatening.



It is most commonly due to:

A.Spontaneous pneumothorax


This is due to the rupture of superficial air sacs following severe coughing or strenous exercise in:

1.tall young males and in Marfan syndrome

2.Tuberculosis

3.Bronchial obstruction

4.Cancer

B.Non-spontaneous pneumothorax


1.penetrating chest wound

2.surgical trauma

3.pleural effusion tap



Symptoms:


1.Sudden onset of chest pain, back

2.shortness of breath,

3.dry coughs,

4.cyanosis (turning blue)

5.coma

Signs:


1.Pale or cyanotic

2.Percussion show resonance at normal lung while none at the pneumothorax lung area

3.Auscultation  reveals breath sounds on the normal side but none at the pneumothoracic lung

4.There may be a characteristic clicking sound with respiration.

5.In penetrating chest wounds, there is a typical "sucking" sound of air flowing through the puncture hole .

6.The flopping sound of the punctured lung can sometimes be heard

Diagnosis of Pneumothorax is made by:


Physical examination:
a. absence of audible breath sounds through a stethoscope
b. hyperresonance (higher pitched sounds than normal) to percussion of the chest wall is suggestive of the diagnosis.
c.Two coins when tapped on the affected side results in a tinkling resonant sound

Chest X-ray  reveals a typical pattern of complete lung collapse with air space surrounding the lung edge.
Medistinal shifts can be seen on inspiratory and expiratory films

CT scan and MRI can revealed a clearer picture of the pneumothorax and even the bubbles on the lung surface which may burst and cause a pneumothorax.

Complication of Pneumothorax:


Respiratory failure with circulatory collapse

Treatment of Pneumothorax:


All pneumothorax patients are to be admitted to hospital for treatment.

1. Small spontaneous pneumothorax


A small spontaneous pneumothorax can be left alone to reabsorb on its own.
The patient is monitored in hospital and given oxygen until the pneumothorax has disappeared.

2.Tension Pneumothorax


Tension Pneumothorax is a medical emergency.
Any perimedic or doctor attending to the patient should insert a needle immediately into the pleural cavity to allow the air to escape.

Tube drainage can also be done if available. If the tube is not available, immediate evacuation to the hospital should be done for advanced medical care.

The tube should be inserted with underwater seal and suction of the air out of the pleural cavity done using a simple one way valve or vacuum and a water valve device, depending on severity.

The lung should re-expand in the thoracic cavity and the result is monitored by frequent x-rays

Where rarely the chest tube does not help healing of the lung , surgery may be done to staple the lung closed.

Penetrating wounds:


A chest drain is inserted first before any treatment of the wounds is done.

Supportive treatment:


1.Oxygen therapy
2.Rest
3.Antibiotics for infections
4.Painkillers for pain

Recurrent pneumothorax


1.pleurodesis may be required in recurrent pneumothorax.
2.bullectomy (the removal or stapling of bullae).
3.Chemical pleurodesis uses chemical irritant that leads to adhesion of the lung to the parietal pleura.
4.Mechanical pleurodesis  The inside chest wall is roughened so the lung attaches to the peural wall with scar tissues
5.pleurectomy is the removal of the parietal pleura which can be performed using keyhole surgery

Prognosis of Pneumothorax is usually good following treatment.

However treatment always need to address the cause of the underlying diseases causing the pneumothorax.

A Family Doctor's Tale - PLEURAL EFFUSION

DOC I HAVE PLEURAL EFFUSION

Pleural effusion is quite common in old patients with pneumonia and lung cancer.

X-rays of the chest will usually detect any fluids in the pleural cavities.

If the fluid does cause breathing difficulties, a pleural tap to withdraw the fluid to detect the cause of the fluid (bacterial or cancer) is done.

Proper treatment in a hospital may be necessary.

The cause is then treated


Pleural effusion is excess fluid collection in the pleural space between the parietal and visceral layers of the pleural cavity.

Excessive fluid can limit the expansion of the lungs and cause breathing difficulty.



There are 4 types of pleural effusion which can occur in the pleural space:

1.Serous fluid (hydrothorax)

This is essentially passive collection of extracellular fluid with a specific gravity of <1.015 and protein < 2-3g/dl.

It is translucent in color.

It occur as part of :
a.generalized edema

b.left heart failure

c.liver cirrhosis giving rise to hydrothorax

2.Pus (pyothorax or empyema)

This consists of inflammatory or neoplastic fluid with high protein content.

It is usually yellow or orange in color.

There may be cells or pus or bacteria.

Causes include:
a.bacterial and viral infections such as pneumonia

b.tuberculosis

c.intra-abdominal abscess

d.autoimmune diseases like SLE, rheumatoid arthritis

e.neoplasm(cancer of the lung)

3.Blood (hemothorax)

The exudate is typically blood stained.

Causes are:
a.pulmonary  embolism and infarction

b.neoplasm especially with secondaries to lungs

4.Chyle (chylothorax)

Here the exudate arise from the leakage of thoracic duct.

It is milky in appearance.

Causes are:
a.Trauma including chest and heart surgery

b.filiarisis in the tropics

Symptoms:

1.Breathless

2.Side Chest pain

3.dry cough

Signs:


1.Dullness to percussion

2.Faint or absent beath sounds

3.Decreased movement of the chest

4.Decreased vocal resonance

5.Fremitus

6.pleural friction rub



Pleural effusion is usually diagnosed on:
1.medical history and physical exam,

2.chest x-ray.
Chest films with the patient lying on their side are more accurate and can show fluid level as low as 50 ml of fluid.

Upright chest films can show fluid level of at least 300ml of pleural effusion

In large effusion there may be tracheal deviation away from the effusion.

3.CT scan of chest showing left sided pleural effusion.

Effusion fluid often settles at the lowest space due to gravity;

4.Pleural tap or thoracentesis.

A needle is inserted through the back of the chest wall in sixth, seventh or eight intercostal space in midaxillary line, into the pleural space.
The fluid may then be evaluated for the following:

Chemical composition including
protein,
lactate dehydrogenase (LDH),
albumin,
amylase,
pH and
glucose

Gram stain and culture to identify possible bacterial infections

Cell count and differential white cell count

Cytology to identify cancer cells

Cytology to identify some infective organisms

Other tests :
lipids,
fungal culture,
viral culture,
specific immunoglobulins

5.Thoracoscopy
If cytology does not show cancer but cancer is still suspected, then a thoracoscopy, or needle biopsy of the pleura may be done to exclude cancer.

Treatment of Pleural Effusion consists of:


1.Pleural Aspiration is done for relief of  chest discomfortand breathlessness.

The Chest Drainage Device is usually connected to an underwater seal below the level of the chest.

Air or pleural fluid is allowed to escape from the pleural space but nothing is allowed to  return to the pleural cavity.

Larger effusions may need insertion of an intercostal drain .

2.Treatment depends on the underlying cause of the pleural effusion.

a.Therapeutic aspiration may be sufficient in some cases of trauma and leakage.

b.Installation of antibiotics( eg.bleomycin, tetracycline/doxycycline) in pleural cavity

c.Installation of chemotherapy drugs for cancer into the pleural cavity.

d.treatment of filariasis cases with antiparasitic drugs

e.surgical pleurodesis- here the parietal and visceral pleural surfaces are made to adhere to  each other to prevent accumulation of fluid.



Recovery of patient from the pleural effusion after appropriate treatment of the underlying disease is the rule.

Recurrence from returning cancer or infections may be common.

A Family Doctor's Tale - PERICARDITIS

DOC I HAVE PERICARDITIS

Pericarditis is the inflammation of the pericardiac sac surrounding the heart resulting in the pericardiac fluid compressing the heart.

All such cases of pericarditis should be hospitalized and where there is fever treated with antibiotic and NSAID pain killers.

In severe cases fluid from the pericardiac sac should withdrawn with a needle.

Very rarely surgery may be needed.


Pericarditis is a heart condition where there is inflammation of the pericardiac sac surrounding the heart and roots of the great vessels coming from the heart.

Pericarditis is the most common of all pericardial condition

It is more common in females than males



Pericarditis is caused by:

A.Infections
1.Bacterial- streptococcus

2.Viral - adenovirus, enterovirus, cytomegalovirus, influenza virus, hepatitis B virus, and herpes simplex virus

3.mycotic

4.tuberculosis

B.Non- infection:
1.Autoimmune diseases include:

a.Rheumatic fever

b.rheumatoid arthritis

c.systemic lupus erythrematosis

d.drug induced

2.Neoplastic

3.Uremia

4.myxedema

5.trauma

6.myocardial infarction

7.myocarditis,

8.dissecting aortic aneurysm,

9.radiation



Symptoms:

1.Chest pain of sudden onset in the anterior chest

2.Pain is sharp and becomes worse with inspiration due to pleural inflammation.

3.Pain is relieved with sitting up and leaning forward and become worse on lying down

4.Pericardial rub is a diagnostic sign of acute pericarditis.
Absence of this sign does not mean that it is not pericarditis.

This rub is best heard at the left sternal border as a squeaky or scratching sound using the diaphragm of the stethoscope.

The pericardial rub is due to the friction generated by the two inflamed layers of the pericardium.

5.Fever may be present.

Diagnosis of Pericarditis is made by:


1. History and physical examination
chest pain, Pericarditis episodes

2.Blood tests:
a. A Complete Blood Count may show an elevated white count.

b. serum C-reactive protein may be elevated.

c.increase in serum creatine kinase MB  and cardiac troponin I ( both of which are also markers for myocardial injury.

3.Electrocardiogram
ECG changes in acute pericarditis show inflammation of the epicardium (the layer directly surrounding the heart).

Typical ECG changes in acute pericarditis are:

stage 1 -- diffuse, positive, ST elevations with reciprocal ST depression in aVR and V1.
stage 2 -- normalization of ST and PR deviations
stage 3 -- diffuse T wave inversions
stage 4 -- ECG becomes normal OR T waves may be indefinitely inverted

4.Echocardiography
Usually normal in acute pericarditis.

It can reveal pericardial effusion, the presence of which supports the diagnosis.

5. Chest X-ray
Chest X-ray is generally only performed if a pulmonary cause of Pericarditis is suggested.

It is normal in acute pericarditis, but can reveal cardiomegaly (enlarged heart) if the pericardial effusion is more than 200 mL.

6.Cardiac catherisation -Coronary angiography in those patients should indicated normal vascular perfusion.

7. Pericardial fluid examination and biopsy- rarely done except for confirmation of neoplasm and tuberculosis.

Complications of Pericarditis are:


Cardiac tamponade is accumulation of fluid in the pericardial space to cause blockage to the inflow of blood to the heart.

Cardiac tamponade is an emergency and must be treated urgently.

Treatment of Pericarditis :


Patients with uncomplicated acute pericarditis can be treated by a heart specialist on outpatient basis.

Those with high risk factors will need to be admitted to hospital:

1.sudden onset
2.high fever
3.leukocytosis
4.presence of cardiac tamponade
5.large pericardial effusion (echo-free space > 20 mm) resistant to NSAID treatment
6.low immunity
7.oral anticoagulation therapy
8.acute trauma

Removal of the pericardial fluid:
Pericardiocentesis is done to remove the fluid in a pericardial effusion  through a needle.
It is performed under the following conditions:

moderate or severe cardiac tamponade
diagnosis of suspected purulent, tuberculosis, or neoplastic pericarditis
persistent pericardial effusion
viral or idiopathic pericarditis.

Treatment of underlying cause :


a.In idiopathic or viral pericarditis, NSAID(ibuprofen) is the mainstay treatment.

Goal of therapy is to reduce pain and inflammation.

Failure to respond to NSAIDs within one week (indicated by persistence of fever, worsening of condition, new pericardial effusion, or continuing chest pain) indicate the cause is not viral or idiopathic.

Colchicine can be used alone or in conjunction with NSAIDs in prevention of recurrent pericarditis and treatment of recurrent pericarditis.

b.Anti tuberculous treatment must be given to Tuberculous patients.

c.Chemotherapy is given for cancer patients.

d.Autoimmune disease:
Systemic corticosteroids are usually reserved for those with autoimmune disease.

Surgery
Pericardial window or removal of pericardium is done especially when there is possiblity of cardiac tamponade.

Proteolytic enzymes:
Proteolytic enzymes is used to dissolve the fluid in the pericardial sac.



Most cases of patients have recurrent pericarditis and become chronic after acute episode.

Response to surgery may not be very satisfactory especially with long standing chronic pericarditis.



Rest and a healthy lifestyle may help to prevent an onset or recurrence of Pericarditis.

Avoid stress and anxiety.

A Family Doctor's Tale - ATRIAL FIBRILLATION

DOC I HAVE ATRIAL FIBRILLATION

Atrial fibrillation usually happens in an older patient with hypertension, heart  or lung problems.

The main symptoms is a fast heart beat with irregularities and breathing difficulties.

It is important to thin the blood to prevent blood clots to be thrown out from the heart causing possible strokes or heart attacks.

The best treatment is cardioversion of the irregular heart beats to normal.

In the meantime the heart can be controlled with medications to reduce the heart beats.


Atrial Fibrillation is a heart condition where the disordered electrical impulses of the atrial muscle leads to irregular electrical impulses to the ventricular heart muscles resulting in irregular heart beats.

Atrial Fibrillation can occur in the following:


1.Age: 8% of people over 80 has AF

2.family history of AF increases risk by 30%.



Atrial Fibrillation is caused by underlying heart conditions such as:

1.Primary heart diseases:
a.coronary artery disease
b.mitral stenosis
c.mitral regurgitation
d.hypertrophic cardiomyopathy
e.pericarditis
f.congenital heart disease
g.previous heart surgery

2.Hypertension (High blood pressure)

3.Lung diseases such as
a.pneumonia,
b.lung cancer,
c.pulmonary embolism,
d.sarcoidosis

4.Excessive alcohol consumption

5.Hyperthyroidism



Atrial fibrillation often do not present with symptoms.

When they do the symptoms are generally non -life threatening:

Symptoms:

1.fast heartbeat or palpitations

2.Breathlessness

3.fainting

4.chest pain

Signs:


1.Pulse is fast and irregular in rhythm and strength

2.Angina pectoris (pain over heart area)

3.Congestive cardiac failure with ankle swelling and breathlessness

4.exercise intolerance

5.Abnormal ECG reading with absent P waves and irregular rhythm

6.Underlying heart disease such as hypertension, pericarditis, valvular disease of heart,

7.Underlying systemic disease such as hyperthyroidism, diabetes, stroke

Diagnosis of Atrial Fibrillation is made by:


1. History and physical examination
Palpitations, atrial fibrillation episodes

2. Blood tests:
renal function and electrolytes,
thyroid hormones, thyroid-stimulating hormone,
blood count.

Where there is chest pain,
blood cardiac enzymes and
coagulation tests are also done

3.Electrocardiogram

a.absence of P waves,
b.irregularity of R-R interval due to irregular conduction of impulses

4.Echocardiography
transthoracic echocardiogram is done in newly diagnosed AF to detect
valvular heart disease ,
left and right atrial size,
left ventricular size and function,
peak right ventricular pressure ,
presence of left ventricular hypertrophy
pericardial disease

5. Chest X-ray
chest X-ray is generally only performed if a pulmonary cause of atrial fibrillation is suggested,

6.Transesophageal echocardiogram
transesophageal echocardiogram (TEE) is done to detect thrombus formation

7.Ambulatory holter monitoring
A holter monitor is a heart monitor which can be worn by the patient to check the heart rate and heart rhythm for 24 hours.
It can detect presence of AF.

8.Exercise stress testing
A threadmill test can gauge the heart rate in response to exertion.

Complications of Atrial Fibrillation are:


1.fibrosis of the atria

2.Enlarged atria and heart

3.Thrombosis to the brain(stroke),
intestines(ischemia),
fingers and toe(ischemia or gangrene)



The treatment of atrial fibrillation is aimed at

1.regulating the heart beat and rhythm- digoxin, dilatrend,  betablockers


2.preventing blood clots to be thrown out in the blood stream  -anticoagulants such as warfarin and aspirin
3.In cases of uncontrolled tachycardia, immediate cardioversion may be done.

Regulating the heart beat:
a.rate control
Rate control is by drugs to reduce the heart rate to 60 to 100 bpm without changing to a regular rhythm.
The medications work by blocking the AV node reducing the electrical impulses to the ventricles.

1.Beta blockers  such as metoprolol, atenolol, bisoprolol
2.Cardiac glycosides ( digoxin)
3.Calcium channel blockers (i.e. diltiazem or verapamil)
4.amiodarone has AV node blocking effects which can be used when other agents are contraindicated (eg.hypotension).

b.rhythm control
Rhythm control work to restore the regular heart rhythm and maintain it with drugs.
The anti-arrhythmic medications makes the heart tissue less excitable.
These medications are often used in concert with electrical cardioversion.

Prevention of blood clots in blood stream:

Anticoagulation with drugs as below reduce the risk of blood clots being thrown out from the heart and blocking the passage of blood in the arteries of the heart or brain

1.aspirin
2.clopidogrel in those who are allergic to aspirin
3.warfarin or similar drugs.
4.heparin intravenously prevents blood clotting in urgent cases.

Cardioversion


Cardioversion is the conversion of an abnormal heartbeat to a normal heartbeat using electrical or chemical means
1.Electrical cardioversion restores the heart rhythm by applying a DC electrical shock to the heart.


2.Chemical cardioversion uses medicine such as amiodarone, dronedarone, procainamide, ibutilide, propafenone or flecainide.
Cardioversion should not be done unless adequate anticoagulation has been given to patients for 48 hours.
There is a relapse rate of 1% following cardioversion.


3.Catheter ablation
It is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the atrioventricular node - which regulates heart rate, and to implant a pacemaker Another method involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate.This method do not need a pacemaker.


4. Radiofrequency ablation  uses radiofrequency energy to remove abnormal electrical pathways in heart tissue.


5. laser, cryothermy and high intensity ultrasound has been use to eliminate the responsible heart tissue causing the irregular heart beats.

Surgical Maze procedure
A series of incisions is made in the atria in a maze-like pattern.
This block abnormal electrical circuits that AF requires.

Minimaze surgery is a minimally invasive cardiac surgery that do not require a median sternotomy or cardiopulmonary bypass.
Laser, cryothermy, radiofrequency, or acoustic energy are used to destroy atrial tissue near the pulmonary veins and and other ablations to mimic the maze.



Most cases of patients treated with rate control and cardioversion with ablation has excellent prognosis, usually better than those with rhthym control.

Recurrence may recur especially if there is an underlying condition which cannot be cured.

Prevention measures for Atrial Fibrillation are:


1.Rest and a healthy lifestyle may help to prevent an onset or recurrence of atrial fibrillation.

2.Avoid stress and anxiety.

A Family Doctor's Tale -ANAL FISSURE

DOC I HAVE ANAL FISSURE

An anal fissure is a tear in the anus usually caused by constipation and straining at stools.

There may be a skin tag covering the fissure.

Children and pregnant women are more prone to it.

However treatment is effective with antibiotic creams and proper diet with more fruits and vegetables.


Anal fissure is a superficial linear tear at the edge of the anus.



Anal fissure occur after a tear in the posterior midline of the anus caused by the passage of hard large stools and constipation.

The tear is covered by a sentinel skin tag at the lower end(sentinel pile).

The tear may occur at any age but are more common in young children and pregnant women.

Sometime the tear may occur at the anterior midline of the anus.



Symptoms:

1.Pain during and after passing motions

2.Serous discharge from tear

3.Itch (pruritis ani)

4.blood streak on stools

Signs:

1.sentinel skin tag covering a posterior midline tear of the anus

2.spasm of the anal sphincter

3.perianal infection

Diagnosis of Anal fissure is by:


1.Digital examination of the anus

2.Proctoscopy to exclude piles

3.Sigmoidoscopy may be required in adults.

Treatment of Anal fissure is by:


1.Stool softener

2.low residue diet

3.Avoid constipation -take more fruits and water

4.Give painkiller if necessary

5.Apply anti-itch cream

6.Use antibiotic cream if there is evidence of perianal infection

Prognosis is usually good.

Prevention is usually by:

avoid straining at stools

regular bowel habits

stool softeners

more fruits and vegetables

A Family Doctor's Tale - DIVERTICULOSIS

DOC I HAVE DIVERTICULOSIS

Diverticulosis are pouches in the wall of the colon.

Main symptoms are abdominal pain and bloating and constipation.

Treatment is mainly by control of diet, prevention of constipation and antispasmodics for pain.

Rarely diverticulitis  a infection of the colon pouches may be needed to be treated with antibiotics.

Generally prognosis is good.


Diverticulosis is a disorder of the colon or large intestine where there are one or more sac-like pouches(called diverticula) in the walls of the colon.

It is more common in the descending and sigmoid colon.



Diverticulosis becomes more obvious with age.
50% of people over the age 0f 60 years have Diverticulosis.



The exact cause of Diverticulosis is not known.

It has been suggested that a low-fiber diet is the main cause of diverticular disease.

Diverticulosis is common in developed countries where low-fiber diets are common whereas it is rare in Asia and Africa where people eat high-fiber vegetable diets.

Fiber prevents constipation which can make the muscles strain and increase pressure in the colon.

This increased pressure makes the weak spots in the colon lining to bulge out like pouches and become diverticula.



Most cases of Diverticulosis have no or little symptoms.

In the more severe cases, the main symptoms of Diverticulosis are:

1.Abdominal pain or cramps-usually over the left side or over the lower abdomen

2.Bloating

3.constipation

The symptoms can range from mild to severe.

Diagnosis of Diverticulosis is made by:


1.A history of abdominal pain especially on the left lower abdomen, bloating and constipation

2.The physical exam consists of
a.palpation of the left abdomen for tenderness or masses
b.digital rectal exam to detect tenderness or blood.

3.stool may be tested for blood

4.blood tests(WBC,ESR,bood culture) are done for evidence of infection.

5.Xrays of the abdomen and barium enema may be done to show evidence of pouches in the colon

6.Colonoscopy is also done to confirm evidence of diverticulosis and exclude malignant tumours.

Complications of Diverticulosis are:

1.Diverticulitis
Diverticulitis occurs when diverticula become infected with bacteria, viruses or become inflamed.
Bacteria are caught in the pouches and develops into diverticulitis suddenly.

The symptoms and signs of diverticulitis are:
1.abdominal pain usually continuous in the lower left abdomen with tenderness

2.fever due to infection,

3.nausea, vomiting,

4.cramping,

5.constipation

6.rectal tenderness

Diverticulitis can lead to:

1.Bleeding,
rare.
Bleeding can be severe caused by a small blood vessel in a diverticulum that weakens and finally bursts.
Surgery may be needed to stop bleeding if bleeding continues.

2.Abscess, Perforation, and Peritonitis
Often a few days of treatment with antibiotics will cure the diverticulitis.
If the infection gets worse, an abscess which is an infected area with pus may form in the colon.

Small abscesses usually clear up with antibiotics.

More severe abscesses may require drainage of the pus using a catheter.

If pus leaks from perforations in the lining of the colon, then it can cause infection in the abdominal cavity and results in peritonitis.

This is an emergency and requires immediate surgery to clean up the pus in the abdominal cavity and removal of the damaged part of the colon.

3.Intestinal Obstruction
The infection of the diverticula can cause scarring of the lining of the colon resulting in partial or total blockage of the large intestine.

If the obstruction blocks the intestine completely, emergency surgery is required to allow faecal matter to pass through.

A temporary colostomy may be necessary.

4.Fistula
occurs as an abnormal connection between two organs or between an organ and the skin.

It results from the damaged tissues coming together and an opening is left between the two tissues.

Usually the bladder, small intestine, vagina, and skin are the organs involved.

The most common fistula occurs between the bladder and the colon especially in men. This can cause a long-lasting infection of the urinary tract.

Surgery may be necessary to remove the fistula as well as the damaged part of the colon.

5.Urinary tract infections occurs frequently due to the fistula and proximity of the bladder to the infected colon.

6.Discharge of faecal material may occur through a fistula between the colon and vagina in some women.

Treatment of Diverticulosis is by:


Medication:
1.pain medications will relieve any pain symptoms.

2.Antispasmotic medication for spams of the colon

3.Antibiotics may be needed in diverticulitis and complications such as urinary infection and peritonitis.

Diet:
1.high-fiber diet

a.whole grain breads and cereals;
b.fruit like apples and peaches;
c.vegetables like carrots, broccoli, spinach, carrots, cabbage, beans.

2.fiber product such as Metamucil once a day.

3.Avoid nuts, popcorn, pumpkin, and sesame seeds or any food which can cause discomfort in the abdomen

Diverticulitis
1.Antibiotics to treat the infection and inflammation,

2.resting the colon by bed rest, nasogastric suction and a liquid diet

3.hospital stay to prevent complications such as abscess.

4.surgery if the attacks are severe or there are complications.
The surgeon resects the affected part of the colon and then joins the remaining sections.

Surgery is also done for complications such as a fistula or intestinal obstruction.

Emergency surgery may be done for a large abscess, perforation, peritonitis, or continued bleeding.

Prognosis of Diverticulosis is fair.


About 1% develop diverticulitis.
70% of patients with acute attacks of diverticulitis can be treated with medical management and have no further attacks

A Family Doctor's Tale - ULCERATIVE COLITIS

DOC I HAVE ULCERATIVE COLITIS

Ulcerative colitis is almost similar to Crohn's Disease except that it is mainly localized in the colon.

The symptoms are similar : abdominal pain, diarrhea, and bleeding.

Because of the ulcerations and bleeding, ulcerative colitis is more dangerous than Crohn's Disease.

Immunosuppressive drugs are used to control the disease.

In severe cases surgery may be necessary.


Ulcerative Colitis is a inflammatory disease of the colon and rectum which causes ulcers in the lining of the colon and rectum.
These ulcers can then bleed, produce pus, and lead to the rapid emptying of the colon and diarrhea.



Ulcerative Colitis is more common in Jews than non-Jews and in whites than non-whites

Most cases begin at the age range of 15-30 years and occurs less frequently between the age of 50-70 years.

Those above the age of 60 years have more severe symptoms and signs.

It occurs equally in men and women and can be found in families.



The exact cause of Ulcerative Colitis is not known.

It has been suggested that an autoimmune disease is the main cause of Ulcerative Colitis disease.

Psychological problems like stress and anxiety is not a cause of Ulcerative Colitis but has been known to trigger off the disease.



Symptoms:
The symptoms can range from mild to severe.

Mild cases (about 50%)usually have:

1.an insidious onset

2.lower abdominal pain

3.Slight blood stained diarrhea

4.malaise

In the more severe cases, the main symptoms may be:

1.abrupt onset

2.severe diffuse abdominal pain

3.Bloody diarrhea

4.fever

5.shock

6.fatigue

7.weight loss

8.loss of appetite

9.loss of body fluids and nutrients

10.joint pain

Signs:
1.Abdominal distension and tenderness

2.Rectal examination may show blood in the stool
There is also tightness of the anal sphincter

3.pallor due to anemia

4.Wasting of muscles

5.skin lesions

Diagnosis of Ulcerative Colitis is made by:


1.A history of lower abdominal pain , bloating and bloody diarrhea

2.The physical exam consists of
a.palpation of the abdomen for tenderness

b.digital rectal exam to detect tenismus or blood.

3.stool may be tested for blood

4.blood tests( HB, WBC, ESR, blood culture) are done for evidence of infection.

5.Xrays of the abdomen and barium enema may be done to show evidence of extent of ulcers in the colon

6.Colonoscopy is also done to confirm evidence of ulcerative colitis and exclude malignant tumors.

Complications of Ulcerative Colitis:

Bowel complications:

1.Strictures of colon

2.Fistula

3.Toxic dilatation(toxic megacolon)

4.Perforation of the colon

5.hemorrhage

6.shock

7.rarely carcinoma(5%)

Non-bowel complications:

1.Bones: arthritis, sacroiliatis
osteoporosis

2.Eyes: uveitis, iritis

3.Skin: eczema

Treatment of Ulcerative Colitis is by:


Mild Cases:
Medications:

1.Antidiarrheal and bulk forming agents

2.Antispasmotic medication for spasm of the colon

3.Sulfasalazine (immunosuppressant) given indefinitely
Other 5-ASA agents, such as olsalazine, mesalamine, and balsalazide, may be used by people who cannot take sulfasalazine.

4.Topical corticosteroids as retention enema or suppositories only where the rectum is involved.

5.Correction of anemia

6.Regular hemoglobin, blood counts and liver function tests

Severe cases:

1.Hospitalization with bed rest, fluids, electrolyte replacement and blood transfusion if necessary

2.Systemic corticosteroids(intravenous initially, followed by oral medications) These should not be given for long term usage.

3.Sulphasalazine (immuno-suppressant) given indefinitely

4.azathioprine and 6-mercapto-purine (6-MP) can also reduce inflammation by suppressing the immune system

5.Antibiotics in toxic megacolon syndrome

5.surgery if the attacks are severe, do not respond to treatment, toxic megacolon or uncontrollable bleeding.
Surgery is also done for complications such as a fistula or intestinal obstruction.

In more severe cases a total proctocolectomy with ileostomy( a stoma is left in the abdomen for disposal of faeces) is done and is usually curative.

Ileoanal anastomosis in which the ileum is attached to the anus allows the patient to have normal bowel movements because the anus is preserved.

Emergency surgery may be done for perforation, peritonitis, or continued bleeding.



The prognosis depends on the severity of the disease

Mortality is o.4% for mild cases, 2.2% for moderate disease and 10-25% for severe disease.

5% will die within the first year.

75% will have recurrence for the rest of their life.

Only 10% will have remissions lasting 15 years.