A Family Doctor's Tale -EDEMA

DOC I HAVE EDEMA
Edema is a symptom defined as excess of fluid (water and sodium) in extracellular spaces that include a large number of medical conditions.

It usually in the ankle and foot but can spread up the legs to the abdomen where the excessive fluid is known as ascites.

The abdomen will appear bloated.

It can also spread to the lungs causing pulmonary edema and breathlessness.

Of course edema of the face will cause puffiness of the face .

Generalized edema is called anasarca.

The Causes of Edema are:

1.Cardiac edema from right or left heart failure

2.Renal edema from renal failure or nephrotic syndrome


3.Hepatic edema from liver failure or cirrhosis

4.endocrine edema from cushing  syndrome or use of  steroids

5.malnutrition syndrome - lack of protein leads to edema

6.Pregnancy pressure on the lower limbs blood vessels

7.Standing too long resulting in gravity pulling fluid to the feet and ankles

8.local edema from obstruction such as

a.venous obstruction - varicose veins,

b.lymphatic obstruction from filaria or other parasites

c. tight garments

d.local injuries,

e.carcinomatous obstruction

The Signs and Symptoms of Edema are:
Symptoms:

1.The skin of the lower legs may be swollen, stretched and shiny.

2.Gentle pressure on the swollen skin will cause a depression in the swollen area.

3.Abdomen may be swollen or distended due to accumulation of fluid

4.Crepitation can be heard at the bases of the lungs suggesting fluid in the lower prt of the lungs

5. The face may be swollen and puffy

The Complications of edema are :


1.overload of fluid in the body leading to overload on the heart

2.too much fluid in the lungs can cause breathlessness

3.renal failure can be dangerous and may need dialysis

4.Liver failure is also dangerous and may require a liver transplant

The Treatment of Edema is usually by:
1.Medicines like diuretics can force the fluid out through the urine.

The diuretic should be cautiously used in renal cases.


2.Treat the underlying cause whether it is heart , kidney or liver failure.

3.Careful institution of high protein feedings in malnutrition cases

4.surgery may be required  to remove obstruction

5.chemotherapy may also be required in carcinomatous obstruction

General Measures:
1.No strenuous exertion

2.Avoid stress

3.Any breathlessness must be treated quickly


4.Reduce the salt intake

5.Raise the legs when sitting down or lying down

6.Do not stand for long periods

Prognosis of edema:

Mild edema due to excess salts or medicines can be treated easily by reducing the salt or medicine.

Underlying diseases like heart failure, renal failure or liver failure may need specific medication, treatment and may not be completely cured.

Prevention of edema is by:

1.avoid too much salt

2.avoid standing or sitting for too long a period

3.Pregnancy can cause edema of the legs due to pressure of the fetus on the major veins of the legs - avoid over exertion and salty food

A Family Doctor's Tale - CARDIOGENIC SHOCK

DOC I HAVE CARDIOGENIC SHOCK
Cardiogenic shock occurs when there is a sudden reduction of cardiac muscle contractibity and blood output from the heart following myocardial infarction or heart attack.

Cardiogenic shock can lead to sudden death.

Cardiogenic shock occurs when
1.Heart attack -there is a sudden interference with the pumping action of the heart from ischemic heart muscle damage ofeten involving 50 per cent of the left ventricle.

2.Injury to the heart muscle from trauma such as knife wounds,direct impact of heavy object on the heart.

3.Drug overdosage such as beta blockers or calcium antagonist affecting the slowing of heart and poor output of blood.

The symptoms of Cardiogenic shock are :
1.Pale, sweaty patient with rapid weak pulse

2.Severe hypotension

3.Urinary output reduced

4.Breathlessness and pulmonary edema

5.Fatique and tiredness

6.Confusion,dizziness,

Diagnosis of Cardiogenic shock is usually confirmed by:
1.History of chest pain, shock and physical examination showing low blood pressure

2.ECG(electrocardiogram)shows typical features of large depression in Q wave, ST segment and raised RS segment. A 12 leads ECG may showed the presence of severe myocardial infarct

3. Blood cardiac enzymes and ESR may be raised.

Any cardiogenic shock is an EMERGENCY!
Immediate treatment is urgent!
Admit to hospital as an emergency.

Severe cases are admitted to Cornary care unit(CCU) for constant monitoring of the heart, blood pressure and abnormal rhythm of heart rate.

Intravenous fluids such as glucose should be given on admission together with insulin to help raise the blood pressure.

Blood pressure can be further raised with dopamine or dobutamine.

Vasodilators like isorbide are give to help dilate the artery to the heart

Diuretics may be necessary to relieve congestion of the lungs and edema.

Any abnormal rhythm of the heart must also be treated with medications or pacemaker if severe as damage to heart may affect the conduction of the electrical impulse of the heart to the cardiac muscles.

Because of the psychological effect of a heart attack on the patient, sometimes antidepressant or tranquilliser may be given.

Interventional Procedures:
--------------------------
Once stable the patient may be requred to have a ballooning of the narrowed artery or a stent inserted in the narrowed artery. This can be done during the cardiac catheterisation.
1.balloon angioplasty
balloon is inflated to compress fatty matter in the wall of narrowed artery and dilate the blood vessel
2.Stent:
balloon angioplasty is performed in combination with placement of a stent which is a small, metal mesh tube that provide support inside the coronary artery.
3.drug eluting stents (DES):
Drug-eluting stents contain a medication that is actively released at the stent implantation site to prevent recurrence of narrowing of the artery
4.rotablation
The Rotoblation special catheter, with an acorn-shaped, diamond-coated tip,  spins around at a high speed and grinds away the heavily calcified  plaque on the arterial walls.
5.cutting balloon
The cutting balloon catheter has a balloon tip with small blades which are activated  when the ballon is inflated. The small blades remove the plaque and the balloon compresses the fatty matter into the arterial wall.

Surgery :
-------------
If the narrowing involved too many arteries, then a coronary artery bypass graft (CABG) surgery will have to be done.

Usually a heart attack patient stays in hospital for 2-4 weeks depending on the severity of his condition.

Mild exercise is started once his condition is stable. Exercise is good for the patient because it helps the blood circulation.


Prognosis of cardiogenic shock depends on the degree of ventricular recovery.

Treatment is aimed at maintaining circulation until some recovery takes place.

Overall prognosis is poor.

Prevention of a cardiogenic shock is the same as prevention of a heart attack  or a stroke as both involve the avoiding the blockage of a major artery to the brain or heart.

1.Control the Blood Pressure


2.Control the Diabetes


3..Control the diet.


4.Check with the doctor regularly.

5.Don't Smoke

6.Regular exercise is good for you.


7.Learn To Relax

8.Time management is important.

A Simple Guide to Tropical Sprue

A Simple Guide to Tropical Sprue

A Simple Guide to Tropical Sprue
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What is Tropical Sprue?
—————————————
Tropical Sprue is a malabsoption disease of unknown etiology associated with temporary or permanent stay in the tropics and characterized by abnormalities in the lining of the small intestine.
The small bowel mucosa shows
1.villous atrophy
2.columnal to cuboidal changes in absorbing cells
3.infiltration of lamina propia with lymphocytes, plasma cells and eosinophils
Who is affected by Tropical Sprue? ———————————————————————————————-
Tropical Sprue cause is unknown but some possible causes are: 1.Nutritional deficiency
2.intestinal infection
There is a possibility of enzyme deficiency and abnormal immunological response.
Tropical Sprue can be found in all ages but are more common in the 10-30 years age group.
What are the Symptoms and signs of Tropical Sprue? ————————————————————————————-
Symptoms varies from mild to severe:
Early symptoms are:
1.fatigue
2.bulky stools
3.Weight loss despite good appetite and intake
After some months malnutrition is noted with evidence of malnutrition syndrome:
1.weight loss
2.glossitis
3.stomatitis
4.pigmentation
5.edema
5.diarrhea and steatorrhea
6.megaloblastic anemia
7.iron,folic acid and vitamin b12 deficiency
The Diagnosis of Tropical Sprue is confirmed by: ————————————————————————————
1.A history of abdominal pain , diarrhea and weight loss
2.small bowels radiology
a.thickening and coarsening of mucosal folds
b.dilatation of smaa intestinal lumen
c.flocculation and segmentation of barium
3.tests for malabsorption syndrome 4.fecal fat assessment
5.Jejunal biopsy
What are the complications of Tropical Sprue? ————————————————————————————-
1.weight loss
2.Nutrition: malabsorption and vitamin deficiency
What is the treatment of Tropical Sprue? —————————————————————————————————
Treatment is :
Control of Diet
1.Folic acid is given for at least 6 months
2.Vitamin B12 injection is given
3.food containing iron, folic acid and vitamin B12 are are given
4,Enough protein supplement
5.lots of fluids
Medication
1.Antispasmotic medication for abdominal pain
2.lomotil or imodium to suppress diarrhea
3.Tetracycline is given daily for at least 6 months
Start with high doses at first, followed by reduction of dosage.
4.Correction of anemia and nutritional deficiencies is important to enhance the immune system
What is the prognosis of Tropical Sprue? ———————————————————————————————-
The prognosis is usually very good Treatment is very effective in producing weight gain and correcting nutritional deficiency.
Abnomal morphology and bowel function may persist despite treatment
There may be spontaneous remission especially leaving the tropics.
What are preventive measures in Tropical Sprue? ————————————————————————–
A nutritious diet with vitamin supplements can strengthen the body resistance against illness.
Avoid the tropics.

A Family Doctor's Tale - THYROID NODULES

DOC I HAVE THYROID NODULES

Thyroid nodules are abnormal swellings in the thyroid gland which occurs when the thyroid tissues starts to proliferate in one part of the thyroid gland.

People who are at risk of thyroid nodule are:
1.Thyroid nodules are more common in females than in male.

2.However the thyroid nodule in males are more prone to malignancy than in females

3.Thyroid nodules occurs more in the 30- 60 age group.

The types of Thyroid Nodules are:
1.solid - solid thyroid nodules which may or not feel hard

2.cystic - the nodules is filled with fluid.

3.benign - non malignant

4.malignant - cancerous

Symptoms and signs of Thyroid Nodules:
In mild cases there is usually no obvious symptoms.

In moderate or severe cases of thyroid nodules:
Symptoms:
1.Obvious swelling in the thyroid gland

2.Neck swelling suggest presence of spread to the lymph node

3.Hoarseness of voice may occur if there is pressure on the vocal cord or recurrent nerve to vocal cord

4.Dyspnea or breathlessness if there is pressure on the trachea

5.Dysphagia or difficulty in swallowing due to pressure on the esophagus

Signs:

1.Thyroid nodules are felt only if they are more than 1.5 to 2cm in diameter.

2.Cystic nodules may feel hard while solid nodules may be soft to firm.

3. The vocal cords should always be examined to exclude lesions in the vocal cords causing hoarseness.

4.Malignant thyroid nodules present similarly to benign nodules but can spread to other parts of the body.

Diagnosis of Thyroid Nodules are made by:
1.blood test for thyroxine and TSH levels

2.fine needle aspiration biopsy is a simple way to determine if a nodule is benign or malignant.

The biopsied material is then sent to the lab for tests to look for any malignant cells.

3.ultrasound scans are done to differentiate between solid and cystic nodules,

4.thyroid scans which help to show if a nodule is producing excessive thyroid hormone(hot) or not.

5.CT Scan or MRI are not routine to thyroid nodules investigation except where there is suspected compression of teachea.

The Treatment of Thyroid Nodules is:
Benign lumps can be monitored by doctors at regular intervals.

If there are symptoms of compressing a neighbouring organ or the nodule is cancerous, surgery is required.

Patients who has symptoms of hyperthyroidism are advised to go for radioactive iodine treatment or surgery.

The Prognosis of Thyroid Nodules:
Prognosis is good in all benign cases.

Malignant thyroid nodules will depend on any spread to other organs.

A Family Doctor's Tale - URTICARIA

DOC I HAVE URTICARIA

Urticaria is an itchy rash that occurs rapidly anywhere on the body.

The rash may occur often simultaneously at multiple sites.

It is usually temporary disappearing after 24 hours although new rashes may occur at other sites.

Urticaria is usually due to known mast cell stimulants although in the majority of cases the cause is unknown.

Urticaria is not contagious and for most patients the condition may be managed well with treatment and avoidance of mast cell stimulants:

1. Certain foods: eggs, nuts, fruits,shellfish, fish, chocolates

2. Certain drugs: antibiotics, NSAIDs

3. Physical stimulants: pressure, sweating, cold temperature, sunlight

4. Infections: viral, bacteria

5. Others: flowers, pollen, beestings, animal furs, soaps

The symptoms and signs of Urticaria are:
1.The rash is typically itchy and appear rapidly as localised red swelling on the skin measuring a few mm to more than 10 cm in size in different shapes.

2.The swelling can also occur on eyelids, lips, palms and soles.

3.Urticaria is usually harmless and disappear within a few days or week.

4.However because it can involve very extensive areas of the body, it can cause a lot of irritation and a lot of anxiety.

5.Very rarely the urticaria can lasts months to years causing disruption to work and social life.

In people with Urticaria, the mast cell stimulant can cause histamine release from mast cells.

The histamine is the predominant chemical which is responsible for the inflammatory response which leads to changes of the blood vessels of the skin.

This leads to more blood flow to the affected skin and excessive fluid moving into the surrounding tissues , causing itching and swelling.

Treatment of  Urticaria:
1.One of the most important part of treatment is to to try to identify the substance or underlying medical condtion which may cause the Urticaria.

2.Avoidance of the causative substance or treatment of the underlying medical conditions such as infections will lead to the resolution of the urticaria.

3.One of the most important components of an Urticaria treatment routine is to prevent scratching.

4.Cold compresses applied directly to itchy skin can also help relieve itching.

5.Antihistamine tablets will usually relieve the itch and suppress the eruption of the rash.

The antihistamine need to be taken regularly for long as the urticaria is active.

6.If the condition persists, worsens, or does not improve satisfactorily, another effective treatment is the application of nonprescription corticosteroid creams and ointments to reduce itch.

7.Corticosteroid tablets may be prescribed if necessary.

Prevention of Urticaria is by:
1.Find the causative agent and avoid it.

2.Avoid sudden changes in temperature or humidity

3.Avoid sweating or overheating

4.Avoid certain foods (e.g.,eggs, nuts, seafood, chocolates)

5.Avoid harsh soaps, detergents, and solvents

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

A Family Doctor's Tale - INTUSSUSCEPTION

DOC I HAVE INTUSSUSCEPTION

Intussusception is the telescoping of one part of the intestine into the distal(lower) part of the intestine.

Intussusception is most common in children between 3 months and 1 years of age.

Boys are affected 2 times more than girls.

It seldom occurs in children under 3 months of age or in older children.

It rarely occurs in adults.

The process of  intussusception involves a part of intestine (called the intussusceptum) telescopes into a more distal part (called the intussuscipiens) and pulls the accompanying mesentery, vessels, and nerves together into the intussuscipiens.


As a result the compression of the veins and swelling of the region results in blockage of the lumen of the intestine and reduce the blood flow to the affected part of the intestine.

Most cases affect the junction where the small intestine meets the large intestine.

Intussusception because of its obstruction effect on the intestine requires urgent attention and treatment.

The causes of of intussusception are not fully known although some viral and bacterial infections of the intestine may be a possible cause.

In older children and adults possible causes of intussusception may be due to polyps or tumors.

Typical Symptoms of intussusception are:
1.abdominal pain or cramps often with the baby drawing up its knees
when crying

2.vomiting episodes together with the abdominal pain.

The vomiting is not associated with food and may be  like bile in
color(yellow-green).

3.bloody and mucous stool(also called black currant jelly stools)may be present

Others symptoms are:
1.paleness,
2.lethargy,
3.fever
4.shock

Intussusception is diagnosed by:
1.history of abdominal pain, vomiting and black currant stools may suggest the diagnosis of intussusception.

2.On examination  an abdominal "sausage-shaped" mass (the intussusception itself) can sometimes be felt on palpation of the abdomen.
Diminished bowel sounds may suggest obstruction.

3.abdominal X-rays can show signs of an intestinal obstruction, with air-fluid levels, decreased gas, and unexplained masses, usually seen in the right lower region of the abdomen.

4.Ultrasound and CT scans are not necessary to make the diagnosis.

Early diagnosis and treatment of intussusception is essential in
order to prevent complications such as :
1.injury to the intestine from blockage


2.perforation of the  bowel,

3.sepsis

4.death.

The treatment of intussusception may not require surgery.

1.In some cases, the intestinal obstruction can be reversed using a barium enema.

The barium liquid enters the large intestine and pushes its way up to the small intestine. The pressure of the flow of the enema may push the telescoped small intestine out of its receptor and reverse the process of telescoping.


There is a risk of intestinal rupture.

2.If the above procedure is unsuccessful, surgery is necessary to reverse the intussusception and relieve the obstruction.

Any part of the intestine which has become gangrenous must be removed.

Intravenous feeding and fluids after surgery are continued until normal bowel movements returns.

The prognosis for intussusception is usually good with early diagnosis and treatment.

A Family Doctor's Tale - BED SORES

DOC I HAVE BEDSORES

A bed sores is skin which is damaged most commonly by
ischemic necrosis(lack of blood supply leading to breakdown of tissue cells) and ulceration of tissues overlying a bony prominence that has been subjected to prolonged pressure against an external object.

This typically occurs in a incapacitated person lying over a prolonged periods in bed hence the term bed sores.

Blood supply is impaired as a result of constant pressure on the blood vessel resulting in localized gangrene(death of tissue due to lack of blood supply)

The following are considered when determining the severity of the bed sores:

1.Degree of bed sores
2.Extent of the bed sores
3.Age of patient
4.Location of bed sores
5.Other illnesses and injuries

There are 6 stages of a bed sores:

First stage bed sores:
superficial redness of the skin

Second stage bed sores:
The skin is red, hot, swollen with induration. blister formation and desquamation(dropping of skin layer).
There may be some pain

Third stage bed sores:
The full thickness of the skin is damaged with ulceration.

Fouth stage bed sores:
The skin damage extends to the muscle often causing pain because of impingement on the nerve

Fifth stage bed sores:
The necrosis of skin tissue affects the muscles and fat tissue

Sixth stage bed sores:
There is associated bone destruction , bone or joint infection and septicemia(infection of the blood)

Illnesses such as those below can aggravate the severity of the bed soress and affect the healing:
1.Respiratory diseases
2.Diabetes
3.Heart disease
4.Injuries like fractures

Complications of bed sores are:
1.Septicemia or blood infection

2.Cellulitis or abscess formation

Treatment of bed sores:
In the early stage such as redness of the skin, prevention is the best treatment:
1.Encourage regular movement of the body every 2 hours

2.In cases of paralyzed or unconscious patients change position of the patients every 2 hours.

3.apply talcum powder or  soothing cream or lotion on the skin

4.Try not to break a blister. If a blister is already broken, apply an antiseptic lotion.

5.Painkillers may be necessary for pain.

6.Regular inspection of the skin for cleanliness and dryness.

7. Use of water beds, ripple mattress, inflatable rings, protective padding and Stryker frame for those with spinal cord paralysis all help to prevent bed sores.

More severe cases may need to be treated in a hospital:
1.the bed sores  gets infected(fever, pus formation and increasing pain, redness and swelling).

2.Appropriate antibiotics to treat infection

3.Hydrophilic beads of dextronomer may be useful to clean oozing lesions and promote granulation and recovery

4.Regular debridement(removal of infected tissues) with enzymatic digestive agents

5.In severe cases surgical debridement and skin grafts may be necessary.

6.Underlying medical illnesses such as diabetes, heart attack and stroke should be treated

Prognosis:
In early stage the prognosis is good with preventive measures.

Once ulcers are formed the prognosis is fair.

A Family Doctor's Tale -HYPERKALEMIA

DOC I HAVE HYPERKALEMIA

Hyperkalemia is defined as high Potassium in the blood.

Normal blood potassium varies from 3.4 to 5.7 mmol per liter.
Extracellular potassium level represents only 2 per cent of the total body potassium.

Potassium is a major determinent of intracellular volume of cells and intracellur osmolarity.
It is a also an important cofactor in many metabolic processes.
The resting membrane potential and excitable tissues like nerves is mainly determined by ratio of intracellular to extracellular potassium concentrations.

Plasma and extracellular potassium levels are influenced by many factors particularly acid based balance. Acidosis moves potassium out of cells while alkalosis shifts potassium into cells.

Hyperkalemia occurs with impaired renal function

Symptoms of Hyperkalemia:
1.cardiac arrhythmias

2.muscle weakness especially peripheral muscles

Diagnosis:
1.Plasma potassium levels

2.Electrocardogram shows peaked T waves, prolonged PR intervals,
complete heart block and atrial asystole

Treatment:
1.glucose with insulin infusion  can drives potassium into cells lowering the plasma potassium( U insulin for every 2gms of glucose)

2.Infusion of sodium bicarbonate to induce alkalosis

3.Infusion of calcium bicarbonate to induce alkalosis

4.administer potassium binding resins by mouth

5.hemodialysis

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

A Family Doctor's Tale -HYPOKALEMIA

DOC I HAVE HYPOKALEMIA

Hypokalemia is defined as low Potassium in the blood.

Normal blood potassium varies from 3.4 to 5.7 mmol per liter.
Extracellular potassium level represents only 2 per cent of the total body potassium.

Potassium is a major determinent of intracellular volume of cells and intracellur osmolarity.
It is a also an important cofactor in many metabolic processes.
The resting membrane potential and excitable tissues like nerves is mainly determined by ratio of intracellular to extracellular potassium concentrations.

Plasma and extracellular potassium levels are influenced by many factors particularly acid based balance. Acidosis moves potassium out of cells while alkalosis shifts potassium into cells.

Hypokalemia occurs with gastrointestinal or urinary loss especially following use of potassium wasting diuretics or in diabetes mellitus.

Symptoms of hypokalemia:
1.lethargy

2.generalized fatigue

3.muscle weakness

4.polyuria

5.myocardial irritabilty is increased with hypokalemia and the use of digitalis becomes more dangerous.

Diagnosis:
1.Plasma potassium levels

2.Electrocardogram shows flattening of the T waves, U waves and sagging ST segment

Treatment:
1.oral potassium is given in most cases with improvement of blood potassium level

2.Intravenous potassium is given in emergency cases. The concentration of infused potassium should not exceed 40 mEQ per liter except in rare cases.

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

A Family Doctor's Tale - UNDESCENDED TESTES

DOC I HAVE UNDESCENDED TESTES

Undescended Testis is incomplete or improper descent of one or both testes through the  canal which is the tunnel which leads the spermatic duct from the abdomen to the testis.

The causes of  Undescended Testis are:
1.Normally the testes in the fetus are in the abdomen and make their way to the inguinal canal by the 23rd week of pregenancy and enter the scrotum by the 39th week of pregnancy.

2.Sometimes one or rarely both testes fail to enter the scrotum before birth.They may remain in the abdomen or may be not fully descended to the scrotum at birth.

3.The undescended testes can either be normal or dyplastic(cells may turn abnormal)

4.Intra-abdominal testes may be unable to produce sperm and also susceptible to malignant change.

5.Testis situated outside the usual course of descent is termed ectopic.

Diagnosis:
All male babies are examined at birth to determine whether their testes have descended into the scrotum normally.

Where the testes are not found in the scrotum an ultrasound scan of the pelvis can determine where the testes are located.

Where there is no testes to be found, a human chorionic gonadotrophin test help to rule out anorchia(complete absence of testes) and whether there is a need for counseling later on at puberty.

The complications for Undescended Testis are:
Untreated undescended testes may have increased risk for

1.infertility

2.testicular torsion

3.malignant change

The treatment of Undescended Testis is:
1.In the absence of both testes, there is nothing that can be done.

2.If there is one Undescended Testis, the testis can be brought down to their scrotum.
Similarly if both testes are undescended the testes can be brought down to the scrotum by surgery.

This surgery is preferably done between 2 to five years old.

3.If there is associated indirect inguinal hernia that should be repaired simultaneously.

4.In some cases descent of the testes may occur up to the 3rd month of age.So hypermobile testes found at birth are observed if they can descend by themselves by that age.

The Prognosis of Undescended Testis is:
Most cases of Undescended Testis usually will recover with proper surgical treatment.

If there is bilateral occurence of undescended testes and test shows that they are intra-abdominal, there is high risk of subfertility or sterilty.

Even a single viable testis can have good prognosis for fertility.

Very rarely there may be complications such as postoperative infections or recurrence.

A Family Doctor's Tale - PREMENSTRUAL TENSION

DOC I HAVE PREMENSTRUAL SYNDROME

Premenstrual syndrome is a condition occurring seven to ten days before menses more common in women over the age of 30.

Premenstrual Syndrome may manifested itself as a period of irritability, abdominal discomfort, headache and other various symptoms for the patient presenting just before the menses.

The cause of Premenstrual Syndrome is still not known.
There are a few theories:
1.Fluctuation in estrogen and progesterone hormonal concentration may affect the body's function and emotions

2.The fluid retention action of estrogen may cause abdominal discomfort, irritability of the brain, and weight gain

3.changes in the other glands such as the adrenal gland may also be involved

4.Stress aggravates the symptoms of excessive hormones before the menses.

Symptoms of Premenstrual syndrome may consists of:
1.feeling of fullness in lower abdomen


2.Bloated abdomen and ankle edema(swelling due to fluid retention)


3.Weight gain during the second half of menstrual cycle due to fluid retention which is reversed after the onset of menses


4.Low back pain


5.headache and exacerbation of migraine,


6.painful breasts,


7.depression, anxiety, irritabilty


8.emotional instabilty and mood changes


9.interpersonal problems and social unhappiness

Treatment for premenstrual Syndrome are as follows:


Mild premenstrual Syndrome symptoms:
reassurance without other treatment

More severe Premenstrual syndrome symptoms:
1.ankle edema may require diuretics to pass out fluids or decreased salt intake

2.Tranquillizer or antidepressant for anxiety or depression

3.Analgesics or Muscle relaxant for headaches and back pain

4.breast support with properly fitting brassieres for painful breasts

Very severe symptoms:
a course of low combination female hormones may help

Family counseling may be indicated

Prognosis of Premenstrual syndrome:
It may improve spontaneously over years or it may recur on and off until menopause.

A Family Doctor's Tale - CHRONIC FATIGUE

DOC I HAVE CHRONIC FATIGUE 

Chronic Fatigue is a collection of symptoms with the predominance of severe fatigue(tiredness) which can last for months or years.

There are 2 main causes of Chronic Fatigue 

1.Pathological Chronic Fatigue :
Viral Infections may be a trigger
Others are:
Anemia
Dehydration and electrolyte disturbance
Diabetes
Fibromyalgia
Heart disease
Hypothyroidism
Narcotics
Paraneoplastic syndrome
Pulmonary disease
Renal disease
Chemotherapy

2.Psychological Chronic Fatigue :
Anxiety
Depression
sedentary lifestyle
Sleep disorders

Symptoms are:
1.Severe fatigue that prevents the patient from getting up of bed

2.weakness in the limbs

3.Pain in the head, abdomen, or muscles of the limbs

4.Poor appetite

5.reluctance to take part in social activities

6.Tired after any physical or mental exercise

7.difficulty in concentration

Diagnosis is by:
1.Blood tests to exclude anemia and infections

2.Tests to exclude diabetes, low thyroid hormones, endocrine disease

3.Psychological evaluation

Treatment is by :
1. No specific treatment eexcept for rest

2.Counseling in cases of psychological causes

3.Gradual return to work or school

4.Treat underlying causes such as diabetes, hypothyroidism

Prognosis:
usually good

P.S (on 22nd April 2011)

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I was advised by my expert readers that what I was writing about is Chronic Fatigue and not Chronic Fatigue Syndrome. Having gone through all their comments and their links, they are all correct and this post is all about Chronic Fatigue.

I am grateful for all these experts for their comments.

Please send me more comments.

A Simple Guide to Photo Dermatitis

A Simple Guide to Photo Dermatitis
----------------------------------------

What is Photo Dermatitis?
-------------------------------------

Photo Dermatitis is a common skin condition which presents as a erythematous or vesicular rash on face, neck, hands and other areas exposed to sunlight.


What causes Photo Dermatitis?
-------------------------------------

The cause of Photo Dermatitis is related to the exposure of the skin to the sun.
However some possible triggers are:
1.Genetic

Genes play a part in Photo Dermatitis as the condition runs in families

2.External causes

Photo sensitivity:certain exogenous sensitizers play a part in the development of Photo Dermatitis.

a.drugs such as phenothiazines, thiazides and tetracycline

b.cosmetic such as lipstick, perfumes, soaps, shaving cream, antiseptic creams, even sun screening agents (especially if they contain coal tar)

c.irritating chemicals which exaggerated the photosensitzing effect of the sun

d.sunburn reaciion which aggarvated the skin to react as rashes.

e.Photo allergic rash which persist for years

f. injury by ultraviolet light

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

h.Stress can also sometimes aggravate an existing flare-up.

Photo Dermatitis affects both sexes equally.

What are the symptoms and signs of Photo Dermatitis?
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Typical features of Photo Dermatitis are:

1.vesicular or bubbles in areas most exposed to light

2.erythrematous or red rashes in areas most exposed to light

3.some occurs following severe sunburn

4.some are seasonal with recurrance in early spring and summer

5.actinoid reticuloid skin rash affecting the face and hands are also seen in chronic photo dermatitis patients

How is Photo Dermatitis diagnosed?
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1.History and appearance of the rash

2.Photo patch testing

3.Determination of light wavelength causing photo dermatitis

How can Photo Dermatitis be treated?
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Treatment of an Photo Dermatitis treatment routine is:

1. Avoid ultraviolet light especially long wave ultraviolet light

2. application of lotions or creams to protect the skin against the sun

3.chloroquine sulphate 200mg daily may be useful for some patients over short periods

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

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

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

6.sedative antihistamines are sometimes used to reduce the itch

Prognosis:

1.good to excellent in most cases with phot toxic eruptions

2.good to fair with photo allergic reactions

3.Some patients reacts persistently to light without exposure to an antigen.

How can Photo Dermatitis be prevented?
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Photo Dermatitis outbreaks can usually be avoided with some simple precautions.

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

1.use sun screen

2.Avoid drugs or cosmetics which can trigger off photo dermatitis

3.Avoid sweating or overheating

4.Reduce stress

5.Avoid harsh soaps, detergents, and solvents

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

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

A Family Doctor's Tale - ADDISON DISEASE

DOC I HAVE ADDISON DISEASE

Addison Disease is a  disease which is caused by the deficiency of  circulating glucocorticoids steroids and mineralocorticoids (aldosterone) hormones as a result of disease of the adrenal glands.

The causes are believed to be:
1. Auto-immune disease of the adrenals with destruction of the adrenal parenchyma is associated with circulating antibodies and decreased production of glucocorticosteroids.

2.Tuberculosis of the adrenal glands

3.Adrenal tumors which may be benign or malignant can reduce production of corticosteroids.

4.Rare causes are metastatic carcinoma, amyloidosis and hemachromatosis

5.Iatrogenic -sudden cessation of chronic corticosteroids or failure to increase therapy in corticosteroid dependent patients undergoing stress, surgery or infection.

Symptoms of Addison Disease are:

A.Acute Addison Crisis
The symptoms are :
1.vomiting


2.abdominal pain


3.back and extremity pain


4.extreme muscle weakness


5.dehydration leading to hypotension


6.shock


7.confusion


8.coma


Addison crisis is fortunately rare

B.Chronic Addison disease:
1.Chronic adrenal hypofunction begins gradually

2.fatique

3.loss of appetite and weight

4.abdominal pain.

5.vomiting

6.dizziness

7.craving for salty food

8.increased pigmentation especially palmar flexures, nipples, genitalia, mouth lining, scars and exposed areas.

9.postural hypotension is common with giddiness

10.occasionally hypoglycemic symptoms may occur in early morning or when a meal is missed

Diagnosis of Addison Disease:
1.The increased pigmentation and loss of weight can suggest the diagnosis of Addison Disease

2.Electrolytes especially sodium is low, potassium and urea nitrogen is high

3.ACTH stimulation test with impaired corticol response is required to confirm diagnosis

4.Plasma adrenal antibodies may be present

5.Chest and abdominal X-rays for tuberculosis

Complications of Addison Disease:
1.coma from Addison's crisis

2.Hypotension

Treatment of Addison Disease:
1.Addison crisis is treated by intravenous normal saline and hydrocortisone 100mg every eight hours
Treatment must be done before laboratory confirmation of
diagnosis because of the danger of coma

2.Chronic Addison disease requires replacement of glucocorticoid:
a.hydrocortisone 30mg daily or
b.cortisone acetate 37.5 mg daily or
c.fludrocortisone 0.05 to 0.2 mg daily

Prognosis of Addison Disease:
The prognosis of Addison Disease is usually very good.

Addison crisis patients have excellent recovery with appropriate treatment

Chronic Addison disease patients also recovered well with replacement therapy.

Care is needed when there is trauma, infection and surgery.

A Family Doctor's Tale - CUSHING SYNDROME

DOC I HAVE CUSHING SYNDROME

Cushing Syndrome is a  disease which is caused by the exposure of the body to excessive quantities of glucocorticoids steroids.

People of all ages are affected but more are seen in females between 30 to 50 years of age.

The causes are believed to be:
1. Cushing Disease -excessive production of adrenocorticotrophin hormone(ACTH) by the pituary gland causes bilateral adrenal(gland above kidney)hyperplasia(overgrowth of gland tissue).The enlarged adrenal gland will produce excessive corticosteroids.
A pituitary basophil or chromphobe adenoma may be present.

2.Adrenal tumors which may be benign or malinant can produce excessive corticosteroids

3.Ectopic ACTH syndrome
Production of ACTH by a tumor such as cancer of the lungd leads to adrenal hyperplasia

4.Iatrogenic -patients receiving excessive doses of corticosteroids may present as Cushing syndrome

Symptoms of Cushing Syndrome:
1.Obesity predominally truncal often with pad of fat between shoulders(buffalo hump)

2.Round flat plethoric(red) face (moon face)

3.Skin is thin and bruises easily

4.Purole striae on abdomen, thighs, and shoulders.

5.Proximal myopathy leads to difficulty in getting out of chairs and walking upstairs

6.Excessive adrenal androgen secretions leads to hirsutism, amenorrhea and acne

7.Osteoporis can lead to back pain

8.Hypertension and glycosuria(glucose in urine) are common

9.Depression and other psychiatric disturbance common

10.In children there may stunting of growth

Diagnosis of Cushing Syndrome:
1.The typical moon face and buffalo hump can suggest the diagnosis of Cushing Syndrome

2.24 hour urine cortisol tests

3.Overnight dexamethasone suppression test

4.Plasma ACTH level

5.Chest X-ray to exclude lung cancer

6.X-ray of pituitary fossa to exclde pituitary tumors

7.Ultrasound of adrenal glands for enlargement

Complications of Cushing Syndrome:
1.Hypertension

2.fractures from osteoporosis

3.stunted growth in children

Treatment of Cushing Syndrome:
1.Anti-sdrenal drug such as aminogluthemide

2.bilateral adrenalectomy

3.Surgery to remove pituitary tumor

4.surgery to remove primary neoplasm in lungs or pancreas

Prognosis of Cushing Syndrome:
The prognosis of Cushing Syndrome varies with cause.

The response is often excellent in cases of pituitary tumor removal. However recurrence of tumor or increase in size of the tumor will affect the prognosis.

Benign adrenal tumors have excellent response to treatment.

Iatrogenic Cushing syndrome often responds well to decreasing doses of corticosteroids.

In cases of lung cancer, treatment may have poor response.

A Family Doctor's Tale - NEPHROTIC SYNDROME

DOC I HAVE NEPHROTIC SYNDROME

Nephrotic Syndrome is a rare disease characterized by the edema(accumulation of fluid in the body) and hypo-albumemia (low blood protein due to protein loss through the kidneys).

The cause is the increased capillary permeability of the glomeruli to plasma protein  due to the inflammation and allows loss of blood and protein in the urine and retention of salt, water and nitrogen.

Loss of negative charges on the filtering membrane allows negatively charged molecules including albumin to enter the urinary tract.

Reduced protein in the blood leads to edema.

There are 3 types of Nephrotic Syndrome:
1.Minimal Change Nephropathy (MCN) occurs in children with very little microscopic changes in the glomerular tissues of the kidney.

2.Focal glomerulonephritis has appearance of MCN above but develop sclerosis of the glomeruli later.

3.Diffuse proliferative glomerulonephritis and membranous nephropathy are more common in adults and be secondary to other diseases such as:


a.SLE and other connective tissues
b.diabetes
c.allergies to drugs such as penicillinamine, tolbutamide, probenecid
d.certain infections
e.cancer (carcinomas and lymhomas)

Symptoms:
1.Urine may show the presence of protein at least 3.5g/day

2.low protein in blood causes decreased plasma mass pressure resulting in retention of water and salts

3.swelling of the face and ankle occurs as a result

4.edema ranges from puffiness of eyes, ascites (water in abdominal cavity), pleural effusions(water in the lungs) to generalized edema

5.With increasing edema and nitrogen retention, headaches, nausea and vomiting may occur.

6.high blood pressure may occur in one third of patients

7.The blood in nephrotic syndrome tend to clot easily and the patient may develop blood clots in his leg veins.

8.Lipids may be raised in the blood especially triglicerides and cholesterol

9.Symptoms and signs of underlying diseases such as diabetes, SLE etc may be present

Diagnosis:
1.A history of recent kidney infection followed by swelling of face ang legs

2.Urinary protein loss of 15g per day

3.Full examination of fresh urine for red blood cells and casts(indicating glomerulonephritis) and lipid

4.Full blood count and tests for kidney function

5.Ultrasound of kidneys

6.Biopsy of kidney and histology of specimen

Complications:
1.Renal failure

2.hemolytic uremic stndrome

Treatment should be in hospital:
1.Minimal change nephropathy in children are treated with high doses of corticosteroids up to 1mg prednisolone per kg per day.
In most cases within 10 days there should be reduction of fluid in the body with increased urinary passage of urine.
Relapses may occur and should be treated with more corticosteroids or cyclophosphamide

2.In adults treatment with corticosteroids should help to treat the edema.

3.In addition thiazide diuretics or frusemide to reduce edema.
Spironolactone and amiloride may also help

4.Hypertension may require anti hypertensive. The use of corticosteroids may aggravate hypertension.

5.Diet with low salt and protein

6.Intake of fluids are restricted
These 2 measures will reduce the strain on the kidneys and prevent accumulation of fluids

Prognosis:
1.In most cases of MCN the illness will clear up with proper treatment.

Some may have relapses.

After 3 years of remission 99% of MCN will not have relapses
MCN cases seldom progress to renal failure.

2.In focal glomerulonephritis cases nephrotic syndrome may develop into chronic renal failure.

3.In Membranous nephropathy
25% complete remission
25% improves in renal function
25% have persistent nephrotic syndrome
25% will have chronic renal failure

A Family Doctor's Tale -GLOMERULONEPHRITIS

DOC I HAVE GLOMERULONEPHRITIS

Glomerulonephritis is a disease characterized by the inflammation of the glomeruli, the filtering units of the kidneys.

The glomeruli are unable to function properly due to the inflammation and allows loss of blood and protein in the urine and retention of salt, water and nitrogen.

Both kidneys are affected usually.

It is not contagious.

The exact cause of Glomerulonephritis is not known.

1.It has been suggested that an autoimmune disease is the main cause of Glomerulonephritis disease.

The antibodies produced by the body to fight germs starts to attack the body's own healthy kidney tissue.

2.Sometimes Glomerulonephritis disease may follow an infection by the streptococcus bacteria or by viruses.

Symptoms of Glomerulonephritis disease:
1.Urine may show the presence of protein, red blood cells, casts.

2.less urine is passed than normal

3.swelling of the face and legs is quite common

4.high blood pressure may occur in rare cases

5.With increasing edema and nitrogen retention, headaches, nausea and vomiting may occur.

Diagnosis of Glomerulonephritis disease is made by:

1.A history of recent infection followed by swelling of face and legs

2.Urine test for blood, protein and casts

3.Full blood count and tests for kidney function

4.Blood Tests for raised ESR,  anti-streptolysin titer, C reactive protein

5.Ultrasound of kidneys

6.Biopsy of kidney if required

Complications of Glomerulonephritis disease are:
1.Nephrotic syndrome

2.hemolytic uremic syndrome

3.renal failure

Treatment of Glomerulonephritis disease is by:
1.Diet with low salt and protein

2.Intake of fluids are restricted
These 2 measures will reduce the strain on the kidneys and prevent accumulation of fluids

3. antibiotics are given if the glomerulonephritis is suspected to be caused by a bacteria

4.hypertension is usually controlled with drugs until the blood pressure returns to normal

5.Corticosteroids and cytotoxic drugs have not been found to be effective against glomerulonephritis

Prognosis of Glomerulonephritis disease:
In most cases the illness will clear up with proper treatment.

In rare cases nephrotic syndrome may develop with ensuing chronic renal failure.