A Family Doctor's Tale - GIANT CELL ARTERITIS

DOC I HAVE GIANT CELL ARTERITIS

Giant Cell Arteritis is an inflammatory syndrome of cranial arteries especially the temporal artery.

It may be associated with blindness and may be part of the polymyalgia rheumatica syndrome.

It is rare under the age of 50 years.

Women are more affected than men.

There are some signs that Giant cell cell arteritis may be inherited because the illness have found to run in families.

The causes of Giant Cell Arteritis are:
The cause is unknown although it may be postulated that an immune response may have caused the inflammation.

It has been associated with severe infection and high doses of antibiotics.


There is inflammation of all layers of medium sized arteries within the carotid distribution from the neck, head, arms and even other arteries in the rest of the body.


The symptoms and signs of Giant Cell Arteritis are:
1.pain and tenderness of the scalp arteries with palpable thickening

2.headache and systemic upset such as weight loss

3.visual disturbance with loss of visual fields and blindness in severe cases

4.loss of appetite

5.Fever and sweating

6.weakness and fatigue

7.associated depression

8.claudication pain of jaw muscles while talking or eating

Other symptoms may be:

1.bleeding gums

2.mouth ulcers

3.hearing loss

4.joint pains of jaws, face and body

The Diagnosis of Giant Cell Arteritis is made by:
1.classical symptoms of headache and tenderness of the temporal arteries of the scalp


2.high ESR rate


3.biopsy of temporal artery under local anesthetic is diagnostic with multinucleared giant cells seen with fibrous proliferation of intima and fragmentation of elastic tissue

4.MRI of the brain

5.Ultrasound of the temporal arteries

The Complications of Giant Cell Arteritis are:

1.Development of aneurysm of blood vessels in the brain

2.Sudden transient ischemic attacks or stroke

3.sudden blindness of eyes or weakness of the eyelids

The Treatment of Giant Cell Arteritis is by using:
1.high dose corticosteroids (60mg prednisolone by mouth daily).

2.Dosage of corticosteroids can be reduced 2-3 weeks after symptoms disappear

3.maintenance dose of corticosteroids should be continues for six to eight months

Because of the prolonged use of corticosteroids, the bones may become porous and fragile:

1.additional calcium and collagen producing drugs are needed to strengthen the bones

2.walking and weight bearing exercises are needed

3.avoid smoking and alcohol

The Prognosis of Giant Cell Arteritis is:
Prognosis is good with prompt onset of corticosteroids treatment before loss of vision however treatment may be needed to continue for 1-2 years. Even then recurrence may occur.


Any loss of vision is irreversible once it occurred

A Family Doctor's Tale - DIABETES INSIPUS

DOC I HAVE DIABETES INSIPUS


Diabetes Insipidus is an endocrine disease resulting from the loss of antidiuretic hormone (ADH) also known as vasopressin stored in the pituitary gland in the brain.

It is characterized by the copious flow of dilute urine (hence the term diabetes) and excessive thirst .

The Causes of Diabetes Insipidus are:
The cause of diabetes insipidus is unknown in 45 per cent of cases.

A.When it is caused by the lack of ADH, it is called Central Diabetes Insipus.

This usually results from any condition damaging the the neuro-hypophyseal (pituitary gland) system of the brain

It can occur at any age and affects either sex.

It is unusual in infants but can commence in early childhood.

Possible causes of central diabetes insipus are:
1.head injuries or birth injuries


2.neoplasm of the pititary gland


3.eosinophilic granuloma


4.primary or secondary cancer (particlarly breast cancer)


5.sarcoidosis

6.familial diabetes insipus

B.When it is caused by a failure of the kidneys to respond to the ADH hormone, the condition is known as Nephrogenic Diabetes Insipus

There is a defect in the parts of the kidneys that help to reabsorb water back into the bloodstream.

It may occur as a sex-linked inherited disorder where male children receive the abnormal gene  from their mothers.

Nephrogenic diabetes insipus can also be caused by:

1.drugs such as lithium or amphotericin B

2.hypercalcemia or high blood calcium

 3. Kidney problems such as polycystic kidney disease


The symptoms of Diabetes Insipidus are:
Symptoms:
1.polyuria or frequent passing of urine
a.urine output of 5-10 liters per 24 hours
b.specific gravity of urine 1.001 to 1.005

2.polydipsia or excessive thirst (with craving for cold water)

3.no other evidence of ill health

Diagnosis of Diabetes Insipidus is often based on
1. medical symptoms of polyuria and polydipsia


2.Urinary volume and specific gravity

3.Infusion of vasopressin

4.MRI of brain

The complications of Diabetes Insipidus are:

1. dehydration - fever, tachycardia or fast heart beats, sunken eyes, dry skin or mucosa, low blood pressure


2.electrolyte imbalance - which can affect the heart rhythm, fatigue, muscle aches and irritability of the nervous system


3.death from primary or secondary lesion in the brain

The treatment of Diabetes Insipidus is:

The underlying cause must first be treated.

In the case of Central Diabetes Insipus:

1.vasopressin can be given intravenously  or intranasally or as oral medication with very good effect


In the case of Nephrogenic Diabetes Insipus (hereditary or lithium induced)

1. stopping the use of lithium may restore kidney function

2.thiazide diuretics may lower urine output


3.anti-inflammatory medications such as indomethocin given orally may help

The prognosis of Diabetes Insipidus is:
generally good with replacement therapy and if the underlying cause can be treated

A Family Doctor's Tale - MARFAN'S SYNDROME

DOC MY CHILD HAVE MARFAN'S SYNDROME


Marfan's Syndrome is an inherited disorder of the connective tissue as a result of a defective  gene called fibrillin-1.

This gene causes defects involving the the collagen and glyccosaminoglycans tissue.

It is characterized by generally weak connective tissue which includes

1.muscles, ligaments and bones.

2.lung tissue

3.the heart and aorta

4.the eyes

5. the skin

6.the meninges

The Causes of Marfan's Syndrome are:
It is an inherited disease caused by an autosomal dominant gene.

Inheritance is passed to 50 per cent of offspring if one parent is affected and 100 per cent of offspring if both parents are affected.

Marfan Syndrome can also occur from mutation of the genes in 30 per cent of cases.

The symptoms of Marfan's Syndrome are:
Symptoms:
1.Long slender extremities with arm span exceeding height and long tapered fingers (also called spider fingers)


2.Skeletal deformities include:
a.kyphoscoliosis


b.pectus excavatum

c.pigeon chest

d.long narrow face


e.high arched palate


f.pronathism

3.Lax ligaments resulting in:
a.hyperflexiblity of joints


b.easily strained ligaments and joints


c.flat feet

4.Eye problems:
a.dislocation of lens due to lax ligaments


b.myopia

5.Heart problems:
a.dilatation of aorta and aortic aneurysm


b.dilatation of pulmonary artery

6.Learning disabilities

Diagnosis of Marfan's Syndrome is often based on
1. medical examination and  appearance

2. measurement of metacarpal index from X-rays
Ratio of length to midpoint width is greater than 8.5

3.Urinary hydroxyproline is excessive indicating increased collagen turnover

4. Genetic analysis

5.ECG and echocardiogram

6.Eye examination and tests

The complications of Marfan's Syndrome are:

1. dissecting aortic aneurym may cause death

2.collapsed lungs

3.retinal detachment

4.heart valve problems

Marfan Syndrome patients generally have a shorter life span because of skeletal deformities and heart problems

The treatment of Marfan's Syndrome:
1.Genetic counseling

2.Prevention of joint strains especially spinal joints

3.Beta blockers can reduce aortic blood flow and prevent dilatation of aorta

4.Avoid competitive sports or strenuous physical activities

5.Antibiotic should be given to prevent endocarditis before any dental treatment

6.Pregnancy should be monitored carefully especially in the third trimester because of the strain on the heart

The prognosis of Marfan's Syndrome:
1.Shorter life span because of heart and skeletal problems

2. Good care and surgery treatment of the heart and eyes may extend the lifespan further.

Prevention of Marfan's Syndrome:


Genetic counseling and testing for Marfan's Syndrome

A Family Doctor's Tale - TURNER'S SYNDROME

DOC MY CHILD HAS TURNER'S SYNDROME

Turner's Syndrome is an inherited disorder of the sex chromosone in which one of the X chromosone is missing(XO)

It occurs in females and is associated with amenorrhea and infertility.

The Causes of Turner's Syndrome:
It is an inherited disease caused by a missing X sex chromosone(XO) during cell division.

It occurs in 1 :2000 females births.

Normal females have two of the X sex chromosomes (XX)

Variations include mosaicism(XX/XO)

The ovary formation is affected result in streak ovaries and low estrogen production.

The symptoms of Turner's Syndrome are:

In infants there may signs of :

1.wide and webbed neck

2.swelling of feet and hands


Symptoms in older females:
1.short stature females

2.distinct facial features with small jaws, ptosis, low set ears,  short neck

3.broad shield like chest with small nipples

4.amenorrhea

5.infertility

6.sparse pubic hairs

7.Vaginal dryness


8.short fourth metacarpals

9.wide carrying angle of arm

10.autoimmune thyroid disease

11.abnormal urograms -horseshoe kidneys

12.heart problems like coarctation of aorta and bicuspid aortic valves

The diagnosis of Turner's Syndrome:
Diagnosis of Turner's Syndrome is often based on
1. medical examination and appearance

2. buccal smear for cells to test for chromosones

3.karyotyping

4.blood test for estrogen (low), follicle stimulating hormone(raised), luteinizing hormones (raised or normal)

5.Thyroid level may be low
TSH high

6.X-rays for cardiac and urinary abnormalities

7.ECG

8.MRI of the chest

9.Ultrasound of the kidneys

10.Pelvic examination

The complications of Turner's Syndrome are:

1. infertility

2.  Arthritis

3.   Cataracts

4.    Diabetes

5.   Hashimoto's thyroiditis

6.    Heart defects and coarctation of aorta

7.   High blood pressure

8.    Kidney problems

9.    Middle ear infections

10.    Obesity

The treatment of Turner's Syndrome:

1.female hormone treatment from the age of puberty

This may help to  trigger the growth of breasts, pubic hair, and other sexual characteristics of a female giving her confidence.

Thyroxine may be given for low thyroid hormones.

2.therapeutic support from:

a.physical

b.psychological

c.speech

d.occupational

e.behavioral therapists

3.Educational treatments:

a.Special services by special needs teachers to build up confidence in the child

b.Making tasks simpler by breaking up big tasks into smaller simpler tasks

Women with Turner syndrome  may consider using a donor egg if they wish to be pregnant.

The prognosis of Turner's Syndrome:
1.Short stature may not be changed


2.infertility even with treatment

3.Can lead normal life with treatment

Prevention of Turner's Syndrome:


Genetic counseling and testing for Turner's Syndrome

A Simple Guide to Amblyopia

A Simple Guide to Amblyopia
------------------------------

What is Amblyopia?
---------------------

Amblyopia, commonly known as ‘lazy eye’, is reduced visual acuity in one eye that appears normal on examination.
It usually develop during early childhood.
If left untreated, amblyopia will usually continue into adulthood.

What are the Causes of Amblyopia?
----------------------------------

1. Squint

Squint or misalignment of the eyes occurs when one eye is looking straight and the other is looking in another direction.
The vision from the deviating eye is suppressed.
The part of the brain that receives the vision from the deviating eye does not develop normally.
Therefore there is a severe reduction of vision in the deviating eye.

2. Different refractive powers of the eyes

A significant difference in the degree of short-sightedness, long-sightedness or astigmatism between the two eyes may result in failure to form clear image in the eye with the greater refractive error resulting in Amblyopia.

3. Blurred vision in one eye

This occurs with:
1.An opaque cornea
2.Cataract
3.Drooping upper eyelids due to weakness of the muscles that lift the eyelids
4.Eye trauma or eye surgery
5.Toxic causes such as arsenic, lead, smoking,vitamin B1 and B12 deficiency
6.Neurological causes are chiasmal lesions in the brain
7.Amaurosis: complete loss of vision in one eye occurs in uremia, nephritis and eclampsia
8.Psychological causes like hysteria

Symptoms may include:
1.decreased vision in one eye
2.squint
3.drooping eyelid

Diagnosis and Early detection

1.Amblyopia in young children can only be discovered if vision in each eye is tested separately.

Treatment is usually more successful if amblyopia is detected early especially before the age of four.

2.regular eye and vision tests should be done by the family doctor, paediatrician or ophthalmologist.

Treatment

1.underlying conditions causing the ‘lazy eye’ such as refractive errors, drooping eye lid or squint should be treated.

2.The main purpose of treatment is to cause the part of the brain that reads images from the ‘lazy eye’ to work more harder to read images than the better eye.
The earlier the treatment is started, the better is the results.
Once the child is over 8 years of age, he/she may not respond well to treatment, resulting in permanently impaired vision.

Treatment can be given in two ways:
1.Eye Patch
 An opaque, adhesive patch is worn over the better eye for weeks to months. This treatment forces the child to use the weaker eye and stimulate the brain to read the images in the weaker eye.
The main problem with the eye patch is that no child likes to have his eye patched. Parents need to ensure that the eye patch is worn properly as advised by the eye doctor.

2.Atropine eye drops
In some cases where the child cannot tolerate eye patches, a drop of atropine is instilled in the stronger eye once a day to blur the vision temporarily in order that the child will prefer to use the ‘lazy eye’.

Prognosis:

Amblyopia if left untreated can lead to loss of vision in the ‘lazy eye’.

Even with treatment 1% - 2% of the population will remain amblyopic. This occurs especially if:
1.the amblyopic stimuli is excessive
2.detection of amblyopia is too late;
3.the child responds poorly to treatment.

Even with one good eye the child can go about his life provided he/she takes good care of the good eye and protect it from harm.

A Family Doctor's Tale - KLINEFELTER'S SYNDROME

DOC MY CHILD HAVE KLINEFELTER'S SYNDROME


Klinefelter's Syndrome is an inherited disorder of the sex chromosone in which an extra X chromosone is present(XXY).

It is named after Dr. Henry Klinefelter.

It occurs in males 1:500 and is associated with hypogonads and infertility.

The Cause of Klinefelter's Syndrome are:



It is an inherited disease caused by an extra X sex chromosone(XXY).

Variations include XXXY and mosaicism(XY/XXY)

The testis formation is affected result in hypogonadism and low testosterone production.

The symptoms of Klinefelter's Syndrome are:
Symptoms:
A.Physical Development:


As babies, they have weak muscles and reduced strength resulting in later development in walking and crawling.

After 4 years of age, they are usually:

1.taller with long legs

2.less muscular body

3.testes are small,insensitive and firmer than usual

4.Penis is small

5.gynecomastia in 50 per cent

6.less facial and body hair

7.Sexual desire and ability to have erections impaired

8.infertility

B.Language Development:

About 25- 75 per cent of the boys has some language problem:

1.difficulty in speech

2.difficulty in expression

3.difficulty in reading

4.difficulty in comprehension

C.Social Development:

1.quiet and unassuming

2.helpful

3.obedient

4.less assertive

5.less self confidence

In spite of these, they have very often normal social relationships

Diagnosis of Klinefelter's Syndrome is often based on
1. medical examination and appearance of the boy


2. buccal smear for cells to test for chromosones

3.karyotyping

4.blood test for testosterone (low), follicle stimulating hormone(raised), luteinizing hormones (raised or normal)

The complications of Klinefelter's Syndrome are:

1. infertility

2. erectile dysfunction

3.autoimmune disorders,

4.breast cancer,

5.vein diseases,

6.osteoporosis

The treatment of Klinefelter's Syndrome is:

There is no way the chromosomes can be changed however there are treatments to relieve the symptoms and improve the lives of these males.

A.Medical treatments:
1.Male hormone replacement treatment can increase the testosterone hormones to normal level for the males starting from puberty.

There may be improvement in muscle mass and more facial and body hairs.


2.mastectomy may be needed for obvious gynecomastia

3.therapeutic support from:

a.physical

b.psychological

c.speech

d.occupational

e.behavioral therapists

C.Educational treatments:

1.Special services by special needs teachers to build up confidence in the child

2.Making tasks simpler by breaking up big tasks into smaller simpler tasks


The prognosis of Klinefelter's Syndrome is:
1.infertility may occur even with male hormone treatment.

2.However there may be improved self confidence and more muscular body.

Prevention of Klinefelter's Syndrome :

Genetic counseling and testing for Klinefelter's Syndrome

A Family Doctor's Tale - VINCENT'S ANGINA

DOC I HAVE VINCENT'S ANGINA

Vincent's Angina is the non contagious infection affecting the interdental papillae named after Dr. Henri Vincent .

It extends to the gums causing necrotizing ulcerative gingivitis .

It is also known as Trench Mouth because of the smell from the mouth.

The cause of Vincent's Angina:
Vincent's Angina is caused by bacteria which are anaerobes such as  fusiform bacteria as well as spirochete such as treponema.

Vincent's Angina can occur in the mouth as a result of:
1.poor oral hygiene

2.nutritional deficiency

3.blood dyscrasias

4.debilitating diseases

5.heavy smoking

The Symptoms of Vincent's Angina are:
1.malaise, loss of appetite and weight loss

2.Painful bleeding gums

3.unpleasant breath or halitosis


4.increased saliva production

5.ulcers on the mucosa of mouth have
a.punched out appearance,
b.covered by greyish membrane
c.bleed easily  
d.affects neighboring gums

6.local lymph node enlargement

Diagnosis of Vincent's Angina:


Vincent's Angina is diagnosed by:

1.Dental examination .

2.buccal smear for culture and sensitivity of micro-organisms to antibiotics

Complications of Vincent's Angina:

If untreated, Vincent's Angina can lead to the following complications:

1.Destruction of the periodontium

2.necrotizing stomatitis

3.destruction of cheek tissues, lip mucosa and underlying jaw bone

Treatment of Vincent's Angina:
1.good oral hygiene
a.Brushing teeth twice a day with fluoride toothpaste.
b.Cleaning between teeth daily with floss.

2.dental debridement (cleaning and removal of debris)


3.mouth washes especially after eating food


4.Antibiotics -penicillin or erythromycin may be necessary to clear infection

5.avoid smoking

6.treatment of underlying diseases

Prognosis of Vincent's Angina:
good with proper dental treatment

Prevention of Vincent's Angina:

1.proper nutrition

2.good oral hygiene

3.avoid smoking

A Family Doctor's Tale - TOOTH DISCOLORATION

DOC I HAVE TOOTH DISCOLORATION

Teeth discoloration is seen as teeth that have stained yellow or darker and presents as a blemish on the facial appearance of a person.

It can affect self esteem.

The causes of Tooth Discoloration:
Discoloration can be caused by:
A.External factors stains the outer layer of the tooth and include
1.smoking,

2.beverages such as coffee, wine, cola

3.foods such as apples and potatoes.

B.Internal factors affects the inner structure of the tooth (the dentin) causing it to darken or become yellowish through:
1.excessive exposure to fluoride during early childhood

2.tetracycline antibiotics use during the second half of pregnancy and children 8 years old or younger.

3.tooth injury in a child with damage to the developing permanent tooth.

4.Systemic illness during tooth formation such as hemolytic disease of the newborn

5.Ageing discoloration - the dentin turns yellow naturally with ageing making the teeth look discolored.

6.infection(dental caries) result in greyish discoloration.

7.Dentinogenesis imperfecta - rare condition in which children are born with gray, amber or purple discolorations in the teeth

8.Amelogenesis imperfecta - genetic condition in which enamel formed during tooth development is abnormal and causes discoloration of teeth.

Symptoms include:

1.stains on the enamel such as yellow or brown spots.

2.yellow stains on the teeth from dentin showing through the worn away enamel.

Diagnosis

A dental examination can diagnose tooth discoloration.

Treatment

Treatment depends on the cause of the discoloration and may include.
1.Tooth hygiene -proper tooth brushing and flossing techniques

2.Avoid foods and beverages that can cause stains

3.Microabrasion of the stains on the outer surface of teeth

4.Bonding -tooth can be covered with a color-matched composite bonding material

5.Veneers are color-matched thin ceramic shells that cover the outer surfaces of the teeth.

6.applying a bleaching agent to the enamel of the teeth.
a.Vital bleaching over-the-counter whitening agents or in-office whitening procedures
b.Non-vital bleaching

7..Intrinsic stains that are caused by damage to a nerve or blood vessel in a tooth sometimes can be prevented such as removing the inner part of the tooth (the pulp) followed by non-vital bleaching.

Prevention

With some healthy lifestyle changes, teeth discoloration can be prevented.
1.Heavy coffee drinkers can reduce intake


2.smokers can consider quitting .


3.dental hygiene through regular brushing, flossing or


4.have teeth cleaned by a dentist every 6-12 months.

Prognosis

The prognosis is very good for teeth stains caused by external factors such as smoking, beverages.
Stains caused by internal factors may be harder to remove.

A Family Doctor's Tale - COLIC

DOC MY BABY HAS COLIC

Colic is defined as constant inconsolable crying by a baby   of about 2 weeks to 3 month for more than three hours a day, three days a week.

The baby draws up his/her legs as in extreme pain and becomes very red in the face.

This usually starts a few weeks after birth and often improves by age 3 months and ends by age 9 months in 90 percent of cases.

What are the causes of Colic?
-----------------------------------

1.Failure to bring up wind that enters the stomach during feeding or crying with the result gas passes into the small intestine and cause pain and excessive contractions.

2.Hunger may be a cause especially with breatfed babies as the milk may not be sufficient to satisfy the baby's hunger.

3.Allergies or lactose tolerance especially with cow's milk may also be a factor

What are Symptoms of Colic?
----------------------------

Typical symptoms of colic include:

1.Regular crying episodes. A baby who has colic often cries about the same time every day, usually in the late afternoon or evening.

2.Intense crying. Colic crying is often intense. It will be extremely difficult to pacify and comfort the baby.

3.Posture changes include curled up legs with clenched fists and tensed abdominal muscles during colic episodes.

Diagnosis:

A physical examination is performed to identify any possible causes for your baby's distress such as an intestinal obstruction.

Diagnostic tests are usually not required.

Treatment

Colic improves on its own, often by age 3 months.

Prescription medications such as simethicone have not shown to be very useful for colic.

It has been suggested that treatment with probiotics which help maintain the natural balance of "good" bacteria in the digestive tract can soothe colic. More research is awaited to determine the beneficial effects of probiotics on colic.

Tips to soothe your baby during colic include:
1.Feed your baby with frequent small feeds and burp the baby.

2.Offer a pacifier to the baby as sucking is a soothing activity for babies and calms the baby down.

3.Hold your baby close to you as cuddling may help some babies to quieten and calm down.

4.Keep your baby in motion by gently rocking the baby in your arms or in an infant swing. Alternatively you may lay your baby tummy down on your knees and then sway your knees slowly or take a walk with your baby.

5.Sing to your baby to soothe your baby.

Support for the mother

These suggestions may help the mother to cope with the stress.

1.Take a break from care giving by requesting help from your spouse or family.

2.It is all right to express your feelings. It is normal for parents to feel helpless, depressed or angry. Confide in your spouse, partner or friend.

3.Remember that it is temporary and improves as the baby grows older. Colic episodes often improve by age 3 months.

A Simple Guide to Diarrhea

A Simple Guide to Diarrhea
-------------------------------------
What is Diarrhea?
---------------------------
Diarrhea is a symptom defined as an increase in the volume, water content and frequency of bowel movements.
What are the causes of Diarrhea?
--------------------------------------------
Diarrhea is a symptom of many gastrointestinal disorders:
1.Infections:
Bacterial infections such as:
a.Shigella
b.Salmonella and typhoid
c.cholera
Viral infections such as:
a,enterovirus
b.rotavirus
Protozoan infections such as:
a.amoebic
b.giardia
2.Toxins from bacteria in contaminated food:
a.E.coli food poisoning (enterotoxins)
b.staphaloccal food poisoning (preformed toxins)
3.Antibiotic usage:
pseudomembraous enterocolitis
4.Food Intolerance
a.Lactose or sugar intolerance
b.Gluten sensitive enteropathy:
celiac disease, nontropical sprue
5.Inflammatory diseases of the intestine:
a.crohn's disease or regional ileitis
b.ulcerative colitis
6.Malabsorption syndromes
a.malabsorption of bile acids
b.pancreatic steatorrhea
c.ileal resection
7.Cancers:
a.colon
b.rectal cancers
8.Tumors especially hormonal producing tumors:
a,gastrinoma
b.Zollinger-Ellison syndrome
c.glucaglonoma
d.carcinoid tumors
9.Drug induced:
a.excessive use of laxatives
b.magnesium antacids which absorbs water into intestine
c.stimulant cathartics
10.Rapid intestinal movement:
a.Irritable bowel syndrome
b.resection of bowels in tumors or fistula
c.vagotomy
d.other surgery of intestine
rhea with blood and mucus
How is Diarrhea investigated?
------------------------------------------
1.full investigation of the possible underlying causes
2.Macroscopic and microscopic examination of the stools:
e.g rice water is typical of cholera
3.culture and sensitivity to antibiotic of the stools
4.Full blood count and electrolytes
How is Diarrhea treated?
-------------------------------------
1.Because of the excessive fluid loss, correction of fluid and electrolyte balance is the most important part of treatment.
Prompt treatment may be needed to prevent dehydration which is the loss of fluids from the body. Important salts or minerals, known as electrolytes, can also be lost with the fluids. Dehydration can be caused by diarrhea, excessive urination, excessive sweating, or by not drinking enough fluids because of nausea, difficulty swallowing, or loss of appetite.
The symptoms of dehydration are
excessive thirst
dry mouth
little or no urine or dark yellow urine
sunken eyes
severe weakness or lethargy
dizziness or lightheadedness
Mild dehydration can be treated by drinking liquids.
Severe dehydration may require intravenous fluids and hospitalization.
Untreated severe dehydration can be life threatening especially in babies, young children and the elderly.
2.Specific treatment if available for underling conditions eg.antibiotic the choice of which depends on the sensitivity of bacteria to the antibiotic.
3.Relief of symptoms include an antispasmodic drug to stop abdominal cramps, medicine to harden the stools such as kaolin and slow down the intestinal movement (lomotil or loperamide).
The following steps may help relieve the symptoms of Diarrhea.
1.Allow your gastrointestinal tract to settle by not eating for a few hours.
2.Sip small amounts of clear liquids or suck on ice chips if vomiting is still a problem.
3.Give infants and children oral rehydration solutions to replace fluids and lost electrolytes. 4.Gradually reintroduce food, starting with bland, easy-to-digest food, like porridge or soups.
5.Avoid dairy products, caffeine, and alcohol until recovery is complete.
6.Get plenty of rest.
Prognosis:
depends on the cause.
Usual outcome of acute diarrhea is excellent if treated early.
For chronic diarrhea, the underlying cause must be treated.
Outcome is usually excellent with appropriate treatment.
How is Diarrhea prevented?
----------------------------------------
You can avoid infection by:
1.washing your hands thoroughly for 20 seconds after using the bathroom or changing diapers
2.washing your hands thoroughly for 20 seconds before eating
3.disinfecting contaminated surfaces such as counter tops and baby changing stations
4.Avoid eating or drinking foods or liquids that might be contaminated

A Family Doctor's Tale -ENURESIS

DOC MY CHILD HAVE ENURESIS


Bedwetting or functional enuresis is the repeated involuntary voiding of urine during day or night at an age where continence or control of urine is expected.

Bedwetting or functional enuresis is common in children.
Prevalence of bedwetting:
5 years old - 7 per cent for boys and 3 per cent for girls
10 years old -3 per cent for boys and 2 per cent for girls
18 years old -1 per cent for boys and 0 per cent for girls

It usually occurs during non rapid-eye-movement (REM) sleep.

The causes of bedwetting are:



1.family history of bedwetting often present

2.prevalence of emotional and mental disorder greater than in general population such as anxiety or rejection

3.slow physical development,

4.an overproduction of urine at night,

5.a lack of ability to recognize bladder filling when asleep

Symptoms

1.day or night involuntary voiding of urine after the age of 5 years at least twice a month or continuously.

2.In older children more than once a month

3.Sometimes a child develops bedwetting in response to jealousy or reduced attention from parents or caretaker after a new child is born into the family

Complications:
Amount of urinary incontinence is related to effect on the child's emotional or psychological well being:
1.self esteem is affected

2.social ostracism by peers

3.anger at caretakers

4.rejection by caretakers

Diagnosis and treatment

1.an underlying condition such as urinary tract infection, developmental bladder abnormalities or nervous system disorders must be ruled out by tests conducted.

2.A "wait and see" approach is the preferred course of action. Record the days when the child is dry and give a reward as a form of motivation.

3.Regulate the amount of fluid taken before bedtime

4.Patient and family counseling will take out the anxiety and fear of rejection by the child

5.Use of urine sensitive device that detects wetness and activate auditory stimulus can help the child condition the response of waking up before he loses control of his bladder. This method is called behavioral conditioning.

6.Medicine such as antidepressant can help to control bedwetting in children but only as as a short-term measure.

Prognosis:
Fairly good with counseling and motivation

A Family Doctor's Tale - AMBLYOPIA

DOC I HAVE AMBLYOPIA


Amblyopia, commonly known as ‘lazy eye’, is reduced visual acuity in one eye that appears normal on examination.

It usually develop during early childhood.

If left untreated, amblyopia will usually continue into adulthood.

The Causes of Amblyopia are:
1. Squint

Squint or misalignment of the eyes occurs when one eye is looking straight and the other is looking in another direction.
The vision from the deviating eye is suppressed.
The part of the brain that receives the vision from the deviating eye does not develop normally.
A severe reduction of vision in the deviating eye may occur.

2. Different refractive powers of the eyes

A significant difference in the degree of short-sightedness, long-sightedness or astigmatism between the two eyes may result in failure to form clear image in the eye with the greater refractive error resulting in Amblyopia.

3. Blurred vision in one eye

This occurs with:
1.An opaque cornea
2.Cataract
3.Drooping upper eyelids due to weakness of the muscles that lift the eyelids
4.Toxic causes such as arsenic, lead, smoking,vitamin B1 and B12 deficiency
5.Neurological causes are chiasmal lesions in the brain


Symptoms may include:
1.decreased vision in one eye
2.squint
3.drooping eyelid

Diagnosis and Early detection

1.Amblyopia in young children can only be discovered if vision in each eye is tested separately.

Treatment is usually more successful if amblyopia is detected early especially before the age of four.

2.regular eye and vision tests should be done by the family doctor, paediatrician or ophthalmologist.

Treatment

1.underlying conditions causing the ‘lazy eye’ such as refractive errors, drooping eye lid or squint should be treated.

2.The main purpose of treatment is to cause the part of the brain that reads images from the ‘lazy eye’ to work more harder to read images than the better eye.
The earlier the treatment is started, the better is the results.
Once the child is over 8 years of age, he/she may not respond well to treatment, resulting in permanently impaired vision.

Treatment can be given in two ways:
1.Eye Patch
 An opaque, adhesive patch is worn over the better eye for weeks to months. This treatment forces the child to use the weaker eye and stimulate the brain to read the images in the weaker eye.
The main problem with the eye patch is that no child likes to have his eye patched. Parents need to ensure that the eye patch is worn properly as advised by the eye doctor.

2.Atropine eye drops
In some cases where the child cannot tolerate eye patches, a drop of atropine is instilled in the stronger eye once a day to blur the vision temporarily in order that the child will prefer to use the ‘lazy eye’.

Prognosis:

Amblyopia if left untreated can lead to loss of vision in the ‘lazy eye’.

Even with treatment 1% - 2% of the population will remain amblyopic. This occurs especially if:
1.the amblyopic stimuli is excessive
2.detection of amblyopia is too late;
3.the child responds poorly to treatment.

Even with one good eye the child can go about his life provided he/she takes good care of the good eye and protect it from harm.

A Family Doctor's Tale - DOWN'S SYNDROME

DOC MY CHILD HAS DOWN'S SYNDROME

Down syndrome is a genetic condition in which the affected person is born with mental disability and characteristic features.

These characteristic features have been called mongolism with:
1.obliquely set eyes
2.short stubby nose
3.flattened facies
4.short stature
5.generalized muscular hypotonia


Most people with Down's Syndrome are not able to look after themselves because of their mental diability.

But many of them have gentle and endearing personalities.

There is no medical cure for this condition.

Causes of Down's Syndrome:
Chromosomes are tiny structures in our body cells which can seen only with a special microscope.
They contains the genes which determines the characteristics of a person.

A normal person has 23 pairs of matching chromosomes in each cell.
Each pair is different and given a number except for the sex chromosomes which are named XY in the male and XX in the female.

A person with Down's Syndrome has an extra chromosone no.21

Types of Down Syndrome:

There are  three genetic variations that can cause Down syndrome:
1.Trisomy 21 

the commonest type in which all the cells have an extra chromosome 21.Here something goes wrong during egg formation in the mother so that the mother has an abnormal egg with extra chromosomes no.21. The child will then get an extra chromosone no.21. The cause of this abnomal egg formation is unknown but occurs more frequency with the mother's age.

2.Translocation Down syndrome

happens when the extra chromosome 21  is attached to another chromosome. During cell division the embryo may get the attached chromosome and so have an extra chromosome no 21 and get Down's Syndrome.

3.Mosaic Down syndrome

a another form of Down's Syndrome in which only some cells have an extra chromosome 21.

Risk factors of getting Down's Syndrome are:
1.maternal age above 35 years.

Most cases of Down's syndrome are born to women aged 35 and above.

The risk of a woman above age 36 conceiving a child with Down syndrome is 1 in 350. The risk increases to 1 in 100 by the age of 40 and to 1 in 25 at the age of 45.

2.Mothers with one Down syndrome child have a 1 in 100 chance of having another child with Down syndrome.

3.Parents who are known to carry the translocated chromosome for Down syndrome can pass the abnormal gene to their offspring.

Symptoms of Down's Syndrome are:
Mongolian features:
1.distinct flat facial profile
2.Upward slanting eyes
3.Flat nose
4.Protruding tongue
5.Flat back of the head
6.Small statue
7.Poor muscle tone
8.Broad, short hands with short fingers and a single crease in the palm
9.dry skin
10.thin fine hair

Mental retardation
1.mental disability
2.unable to look after themselves

Congenital defects:
1.congenital heart disease
2.other birth defects

Screening tests are done for all pregnant women above 35 years of age and include:

1.Triple test - is a blood test done for older pregnant mothers above 35 years which measures specific proteins in the mother’s blood. This may indicates the possibility of Down's Syndrome

2.Nuchal translucency test is an ultrasound scan of the embryo at 10-13 weeks of pregnancy. It measures the width of the spinal cord at the back of the baby’s neck.

If the screening tests suggest a possible high risk of Down syndrome, then the following diagnostic tests may be performed to determine or confirm whether the baby actually has Down syndrome:

1.Amniocentesis. A small amount of the amniotic fluid is obtained through a needle inserted into the mother's womb after 16 weeks of pregnancy. This fluid contains cells shed from the baby and can be examined to see if the chromosomes are normal.

2.Chorionic Villous Sampling (CVS) involves obtaining some cells from the mother's placenta to examine the baby’s chromosones.It is usually done around the 14th week of pregnancy.

3.Percutaneous umbilical blood sampling (PUBS) involves obtaining blood from a vein in the umbilical cord after 18 weeks of pregnancy. The blood cells are examined for chromosomal defects.

Complications of Down's Syndrome are:

1.Heart defects.
2.Leukemia  
3.Infectious diseases such as pneumonia
4.Dementia often appear before age 40
5.intestinal obstruction,
6.thyroid problems,
7.hearing loss
8.poor vision.

Treatment of Down's Syndrome:

There is no medical cure for Down syndrome.
However, children with Down syndrome do benefit from medical help and early interventions starting in infancy which improve the life expectancy and quality of life.

Prevention of Down's Syndrome:

Down syndrome cannot be prevented.
1.genetic counselling in high risk translocation genetic group before considering pregnancy.

2.Coping and support from a team of doctors, teachers and therapists who can  provide the resources and support to  take better care of your child.

3.Joining a Down Syndrome support group and families who are dealing with the same problem

Prognosis:
1.A better understanding of Down syndrome and early interventions have improved the quality of life of children and adults with Down syndrome.

2.If there is no major complications such as heart disease and leukemia, a person with Down Syndrome may have a slightly shortened life span than a normal person.

A Family Doctor's Tale - CANCER SCREENING 5

DOC DO I NEED TO GO FOR CANCER SCREENING 5

Cancer screening - conclusion

H.Prostate Cancer

Prostate cancer is the third most common cancer in males in Singapore.


It is seldom seen in men less than 50 years of age.


Most prostate cancers are slow growing and may not cause symptoms or shorten life.

Majority of patients diagnosed with prostate cancer do not die from it.


Having said that, there are rare instances where the prostate cancer is aggressive and can cause death very fast.

Men who are at high risk of prostate cancer are those with:
1.Aged 50 years and above
2.family history of prostate cancer diagnsed below the age of 60 years of age

Cancer screening procedures for prostate cancer includes:
1.Digital rectal examination or DRE is a quick and reliable rectal examination of the prostate gland with a gloved finger through the rectum.


If the prostate gland feels enlarged, hard and nodular(lumpy), there is a possibility of prostate cancer unlike the smooth enlargement of benign prostate hypertrophy.


A prostate biopsy will then be needed to eliminate the prostate for cancer cells.


2.Blood test- tumor marker Prostate Specific Antigen(PSA) may be raised indicating a possibility of prostate cancer.


However raised Prostate Specific Antigen (PSA) may also be due to non-cancerous enlargement or inflammation of the prostate gland.

Prostate Specific Antigen therefore serves as a guide to the presence and severity of prostate cancer especially where prostate cancer seldom kill a person being slow growing.


Summary of Cancer screening:
a.Colorectal Cancer (above 50 years of age)
1.Yearly Fecal Occult Blood Test after the age of 50 years
2.5 years once Colonoscopy if there is a family history of colorectal cancer

b.Lung Cancer (all adult ages)
Yearly CT scan for lung cancer for chronic smokers and family history of lung cancer

c.Liver Cancer (all adult ages)
1.6 monthly Alpha feto-protein blood test for those with chronic hepatitis B, liver cirrhosis or hepatitis C


2.Yearly Ultrasound of liver for those with chronic hepatitis B, liver cirrhosis or hepatitis C

d.Prostate Cancer (above the age of 50)
1.2 yearly Digital Rectal Examination(DRE) for all men with a family history


2.2 yearly PSA blood test

e.Nasopharyngeal Cancer (above the age of 40)
1.2 yearly EBV IgA antibodies test


2.2 yearly nasoendoscopy

f.Breast Cancer (above age of 40)
1.Monthly Breast Self Examination (BSE)


2.2 yearly mammogram and ultrasound of the breasts


g.Ovarian Cancer (all ages above puberty 16 years)
1.Yearly pelvic ultrasound


2.Yearly blood CA 125

h.Cervical Cancer (all ages who had sexual intercourse)
2 yearly Pap's smear test and vaginal examination

CANCER SCREENING 4

DOC DO I NEED TO GO FOR CANCER SCREENING 4

Cancer screening :

F.Cervical Cancer

Cervical Cancer is the sixth most common cancer in women in Singapore but can be prevented and treated early if regular screening is done.

Women who are at high risk of cervical cancer are those with:
1.sexual intercourse at an early stage


2.sexual intercourse with multiple partners


3.history of sexually transmitted infections


4.infection with certain high risk strains of human papilloma virus (HPV)


5.weakened immune system such as HIV infection


6.prolonged use of combined oral contraceptive (birth control)pills

Cancer screening procedures includes:
1.Pap smear test should be done yearly in women who has sexual intercourse or abnormal vaginal bleeding.
The Pap smear test involve a simple procedure in which the doctor obtains some scraping from the neck of the womb or cervix to detect abnormal cell changes.
Early detection of cancer of the cervix means early treatment and cure.
Patients who had HPV vaccination should also continue to go for regular Pap smear every 3 years


2.Yearly vaginal examination and pelvic examination which involve the Pap smear

G.Nasopharyngeal Cancer

Nasopharyngeal Cancer or NPC is a common cancer of the head and neck region especially common in Chinese men between the age of 40-65.

People who are at risk of developing Nasopharyngeal Cancer or NPC are:
1.family history of nasopharyngeal cancer -common in Chinese males, less so in other races and females


2.Viral infection of the nose-Epstein-Barr (EBV) virus has been shown to be present in most cases of nasopharyngeal cancer

3.Smoking with its 40 or more toxic chemicals in cigarette smoke can stimulate abnormal cells in the nose to mutate and become cancerous

Cancer screening procedures of nasopharyngeal cancer includes:
1.Blood test-tumor marker EBV. Blood is tested for raised level of EBV IgA antibodies against Viral Capsid Antigen(VCA) and Early Antigen).
Patients with raised EBV IgA antibody have a higher risk of developing NPC.
If these antibodies are seen to rise significantly, there is an indication of possibility of NPC in which case an endoscope examination of the upper nose and nasal biopsy can be done to exclude NPC.


VCA IgA test is more sensitive than EBV but remains high for 6 months following a viral upper respiratory tract infection.


EA IgA test is more specific in diagnosing NPC but the levels are also high in cancers of salivary glands, lung and stomach.


2.nasoendoscopy for patients with family history of of nasopharyngeal cancer or NPC.

A Family Doctor's Tale - CANCER SCREENING 3

DOC DO I NEED TO GO CANCER SCREENING 3

Cancer Screening:

C. Breast cancer

Breast Cancer is the most common cancer in women.
Women who are at high risk are those with:
1.family history of breast cancer
A gene has been identified which indicates high incidence of breast cancer.


2.family history of other cancers such as ovary and colon


3.women of age 55 years and above

Cancer screening procedures includes:
1.monthly breast self examination(BSE) is recommended for all women from the age of 30 to detect breast lumps which may be early cancer


2.Mammography once every 2 years from the age of 50 years can help to detect breast cancer.


3.Ultrasound of the breasts together with mammogram  also helps in the detection of breast cancer.


4.Blood test-tumor markers such as CEA, CA 125 and CA 15.3 may be raised in cancer of the breast but are not significant in making a diagnosis.

D.Liver Cancer

Liver Cancer is the 4th most common cancer in men in Singapore.


Men are more often 4 times affected than women.


People who are at risk of developing liver cancer are:
1.Chronic hepatitis B carriers and infections


2.Hepatitis C liver cirrhosis and infection


3.Liver cirrhosis from other causes (eg alcohol)

Screening for hepatitis B is recommended for:
1.Healthcare workers because they are exposed to hepatitis patients


2.Pregnant women because the hepatitis infection can spread to her baby at birth


3.Dialysis patients because the fluid or plasma used in dialysis may contain the hepatitis B infection


4.Those people with a history of hepatitis B infection or liver cancer in the family


5.Those people with high risk behaviour having unprotected sex, multiple sex partners, drug addicts who share needles.

Cancer screening procedures includes:
1.Blood test-tumor marker alpha feto-protein level should be done every 3-6 months.


Patients with hepatitis and liver cancer has been found to have raised levels of serum alpha feto-protein.


However patients with germ cell cancers of the testes and ovary also have raised level of alpha feto-protein.

Pregnant women may also have raised alpha feto-protein at certain stage of their pregnancy.

2.Ultrasound of the liver including the gallbladder and bile ducts
should be done every 6 to 12 months.

E.Ovarian Cancer

Ovarian Cancer is the fifth commonest cancer in Singapore and can be potentially fatal if not detected early.

Early ovarian cancer may not have any symptoms and may be undetected unless screening is done.

Women who are at high risk are those with:
1.family history of ovarian cancer


2.abnormal menses

Cancer screening procedures includes:
1.Annual pelvic examination


2.pelvic ultrasound


3.Blood test-tumor markers CA125 and alpha feto-protein level should be done yearly for those with high risk of ovarian tumors

 

A Simple Guide to Down's Syndrome

A Simple Guide to Down's Syndrome
----------------------------------
What is Down's Syndrome?
------------------------------

Down syndrome is a genetic condition in which the affected person is born with mental disabilty and characteristic features.

These characteristic features have been called mongolism with:
1.obliquely set eyes
2.narrow palpebral fissures
3.epicanthyl folds
4.short stubby nose
5.flattened facies
6.short stature
7.generalized muscular hypotonia
8.dry skin
9.thin fine hair
10.underdeveloped genitalia

Most people with Down's Syndrome are not able to look after themselves because of their mental diability.

But many of them have gentle and endearing personalities.

There is no medical cure for this condition.

What causes Down's Syndrome?
-----------------------------------

Chromsomes are tiny structures in our body cells which can seen only with a special microscope.
They contains the genes which determines the characteristics of a person.

Anormal person has 23 pairs of matching chromosomes in each cell.
Each pair is different and given a number except for the sex chromosomes which are named XY in the male and XX in the female.

A person with Down's Syndrome has an extra chromosone no.21

What are the Types of Down Syndrome?
---------------------------------------

There are  three genetic variations that can cause Down syndrome:
1.Trisomy 21 is the commonest type in which all the cells have an extra chromosome 21.Here something goes wrong during egg formation in the mother so that the mother has an abnormal egg with extra chromosomes no.21. The child will then get an extra chromosone no.21. The cause of this abnomal egg formation is unknown but occurs more frequency with the mother's age.

2.Translocation Down syndrome happens when the extra chromosome 21  is attached to another chromosome. During cell division the embryo may get the attached chromosome and so have an extra chromosome no 21 and get Down's Syndrome.

3.Mosaic Down syndrome is a another form of Down's Syndrome in which only some cells have an extra chromosome 21.

What are the Risk factors of getting Down's Syndrome?
------------------------------------------------------

Risk factors include:

1.maternal age above 35 years. Most cases of Down's syndrome are born to women aged 35 and above. The risk of a woman above age 36 conceiving a child with Down syndrome is 1 in 350. The risk increases to 1 in 100 by the age of 40 and to 1 in 25 at the age of 45.
   
2.Mothers with one Down syndrome child have a 1 in 100 chance of having another child with Down syndrome.

3.Parents who are known to carry the translocated chromosome for Down syndrome can pass the abnormal gene to their offspring.

What are the Symptoms of Down's Syndrome?
------------------------------------------------
Mongolian features:
1.distinct flat facial profile
2.Upward slanting eyes
3.Flat nose
4.Protruding tongue
5.Flat back of the head
6.Small statue
7.Poor muscle tone
8.Broad, short hands with short fingers and a single crease in the palm
9.dry skin
10.thin fine hair

Mental retardation
1.mental disability
2.unable to look after themselves

Congenital defects:
1.congenital heart disease
2.other birth defects

Screening tests are done for all pregnant women above 35 years of age and include:

1.Triple test - is a blood test done for older pregnant mothers above 35 years which measures specific proteins in the mother’s blood. This may indicates the possibility of Down's Syndrome

2.Nuchal translucency test is an ultrasound scan of the embryo at 10-13 weeks of pregnancy. It measures the width of the spinal cord at the back of the baby’s neck.

If the screening tests suggest a possible high risk of Down syndrome, then the following diagnostic tests may be performed to determine or confirm whether the baby actually has Down syndrome:

1.Amniocentesis. A small amount of the amniotic fluid is obtained through a needle inserted into the mother's womb after 16 weeks of pregnancy. This fluid contains cells shed from the baby and can be examined to see if the chromosomes are normal.

2.Chorionic Villous Sampling (CVS) involves obtaining some cells from the mother's placenta to examine the baby’s chromosones.It is usually done around the 14th week of pregnancy.

3.Percutaneous umbilical blood sampling (PUBS) involves obtaining blood from a vein in the umbilical cord after 18 weeks of pregnancy. The blood cells are examined for chromosomal defects.

Complications of Down's Syndrome are:

1.Heart defects.
2.Leukemia 
3.Infectious diseases such as pneumonia
4.Dementia often appear before age 40
5.intestinal obstruction,
6.thyroid problems,
7.hearing loss
8.poor vision.

Treatment of Down's Syndrome:

There is no medical cure for Down syndrome.
However, children with Down syndrome do benefit from medical help and early interventions starting in infancy which improve the life expectancy and quality of life.

Prevention of Down's Syndrome:

Down syndrome cannot be prevented.
1.genetic counselling in high risk translocation genetic group before considering pregnancy.

2.Coping and support from a team of doctors, teachers and therapists who can  provide the resources and support to  take better care of your child.

3.Joining a Down Syndrome support group and families who are dealing with the same problem

Prognosis:
1.A better understanding of Down syndrome and early interventions have improved the quality of life of children and adults with Down syndrome.

2.If there is no major complications such as heart disease and leukemia, a person with Down Syndrome may have a slightly shortened life span than a normal person.