A Family Doctor's Tale -BRADYCARDIA

DOC I HAVE BRADYCARDIA

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

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

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

b.ischemic heart disease

c.congeital heart disease

3.Underlying systemic disease:
a.myxedema

b.increased intracranial disease

4.Medicines:
a.Beta blockers

b.digoxin overdosage

c.reserpine

Symptoms:
1.slow pulse at wrist

2.confirmation with ECG

3.fainting

4.asymptomatic in many cases

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

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

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

4. Treat underlying conditions such as myxedema

5. heart blocks or asystole may need pacemaker implantation

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

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

A Family Doctor's Tale - CHILD SCHOOL PROBLEMS

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

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

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

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

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

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

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

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

Here is the url to her article:

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

A Simple Guide to Threadworms

A Simple Guide to Threadworms
---------------------------------
What is Threadworms?
---------------------------
Threadworms are parasitic worms (also called pinworms) which are found in the intestines of children in undeveloped countries.
It is rare in developed countries because of the modern sanitary conditions and better hygiene.
Several members of the same household may be infested at the same time so all the family should be treated together.
What is the cause of Threadworms infection?
------------------------------------------
Threadworms eggs or larva are present on the hands or food prepared by people who has threadworms infestations. When the eggs or larvae are swallowed  they developed into adult worms in the intestines. The adult worms will cling on to the mucosal lining of the intestine and absorb nutrients from the food taken into the intestines by the affected person.
The female worms emerge from the rectum at night to lay their eggs on the skin around the anus.
What are symptoms of Threadworms?
----------------------------------------------
The main symptoms of Threadworms are
1. Itch in the anal region especialy at night when the worms lay the eggs.
2. Itch in the vulva in girls
3. inflammation of the anus as a result of constant scratching.
4.Rarely tiny white worms can be seen wriggling in the feces.
How is the diagnosis of Threadworms made?
-----------------------------------------------------
Doctors generally diagnose Threadworms based on:
1.sticky tape pressed to the anal area in the morning before the patient bathes or go to the toilet will collect the eggs for microscopic examination and confirmation of the presence of threadworms
2.Stool examination and culture
Treatment of threadworm infestation is by the use of anti-parasitic medicine:
1.Zentel or Abendazole 400mg in a single dose
2.Pyrantel pamoate 10mg/kg in a single dose
3.Mebendazole 100mg in a single dose
A single dose will usually cure the patient of threadworms but to prevent re-infection a second dosage is taken 2 weeks later.
All the family members should also be treated.
Prevention is through:
1.good personal hygiene and hand washing
2. good food hygiene
What is the prognosis of Threadworms?
-------------------------------------
Prognosis is excellent with treatment.

A Family Doctor's Tale -ECU tendonitis

DOC I HAVE EXTENSOR CARPI ULNARIS TENDONITIS

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

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

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

Women are affected more than men.

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

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

3.repetitive use of the wrist on keyboard of computer

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

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

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

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

2.unable to move wrist  or carry heavy objects

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

2.tenderness on flexion of the wrist

2.diagnosis is confirmed with CAT scan or MRI

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

2.wrist exercise usually good.

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

4.Corticosteroid injection to reduce inflammation under the narrowed sheath

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

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

Prognosis :
1.usually good with injection of corticosteroid

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

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

2.Avoid repetitive movement of the wrist.

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

DOC I HAVE DE QUERVAIN'S DISEASE

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

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

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

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

Women are affected more than men.

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

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

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

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

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

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

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

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

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

2.tenderness on flexion of the thumb

3.diagnosis is confirmed with CAT scan or MRI

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

2.wrist exercise usually good.

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

4.Corticosteroid injection to reduce inflammation under the narrowed sheath

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

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

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

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

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

2.Avoid carrying newborn baby with head on the wrist

3.Avoid repetitive movement of the thumb.

A Family Doctor's Tale - TRIGGER FINGER

DOC I HAVE TRIGGER FINGER

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

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

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

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

Women are affected more than men.

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

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

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

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

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

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

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

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

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

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

2.no active finger flexion

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

4.diagnosis is confirmed with CAT scan or MRI

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

2.finger exercise usually good.

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

4.Corticosteroid injection to reduce inflammation under the narrowed sheath

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

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

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

Prevention:
1.Avoid forceful use of the fingers

2.Avoid carrying heavy plastic bags

3.Avoid repetitive movement of the fingers.

A Family Doctor's Tale - Lumbar Spinal Stenosis

DOC I HAVE A LUMBAR SPINAL STENOSIS

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

Every one can get Lumbar Spinal Stenosis.

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

It is also more common in men than women .

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

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

b.trauma or injury to the spine or pelvic bone

c.staying in crouched or seated positions for too long

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

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

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

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

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

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

3.Spinal movements are restricted

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

4.sphincter impairments may be present rarely

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

2.neurological examinations of deficits in the spinal nerve

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

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

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

2.spinal support with corset or light weight brace

3.Proper usage of back muscles

4. medications such as NSAIDs

5.epidural steroid injections

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

2.the symptoms become progressively worse

3.weakness of legs

4.loss of bowel or bladder function

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

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

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

Prognosis:
Usually very good after surgery

Prevention:
Symptoms comes and go.

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

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

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

A Family Doctor's Tale - TENNIS ELBOW

DOC I HAVE TENNIS ELBOW

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

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


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

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

Recently it has also been called golf elbow.

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

Risk factors:
1.Age above 40

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

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

4.Other factors - over exertion of muscles

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

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

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

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

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

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

2.correction of playing techniques in sports

3.improved ergonomic in work related usage of elbow

4.stretching exercises

5. counterforce bracing

6.pain killers and anti-inflammation drugs

7.Topical injection of steroid into the tendon

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

2.arthroscopic release

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

Prognosis:
Usually very good with injections or surgery

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

2.limit duration of play or activity

3.use correct technique

A Simple Guide to Amoebiasis

A Simple Guide to Amoebiasis
------------------------------------------
 
What is Amoebiasis?
---------------------------

Amoebiasis is an acute infectious illness caused by the  parasite Entoamoeba histolytica.

What is the cause of Amoebiasis?
----------------------------------

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

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

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

Penetration through the muscle lining may occur causing peritonitis.

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

Liver abscesses consists of necrotic liver tissue. 
Secondary bacterial infection are rare.

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

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

Abscesses of the brain and lung may occur.

Ulcers heal rapidly after treatment and permanent scarring is rare.

What are symptoms of Amoebiasis?
----------------------------------------------

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

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

3. abdominal pain especially at the sides

4. altered bowel habit

5.diarrhea with blood or mucus in stools

6.foul stools

7.adominal bloating or gas

8.tenderness on palpation at caecum or sigmoid colon regions

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

2.bloody stools

3.fever

4.weight loss

5.liver enlargement and tenderness on palpation

6.dehydration and its effects such as delirium and disorientation

7. lassitude and tiredness

8. convulsions

9.tender abdominal mass with obstruction

How is the diagnosis of Amoebiasis made?
-----------------------------------------------------

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

2.blood tests

3.colonoscopy

4.liver scan and ultrasound

What are the complications of Amoebiasis?
-------------------------------------------------------

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

2.Severe hemorrhage uncommon but can cause death

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

4.irritable bowel syndrome may persist for some months

5.Lung and pericardial involvement rare but can pose danger

6. cutaneous amebiasis cause deep painful and rapidly spreading ulceration

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

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

9.Amebic brain abscess are rare but can occur.

How is Amoebiasis treated?
-------------------------------------

Amoebiasis is an infectious disease which can spread to other people through contaminated food and water.

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

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

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

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

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

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

2.antispasmodic drug to stop abdominal cramps

3.medicine to harden the stools such as kaolin

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

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

Get plenty of rest.

How is Amoebiasis prevented?
----------------------------------------

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

2.Proper filtration of water

3.Examination of stools of food handlers

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

5.Good food hygience and hand washing

What is the prognosis of Amoebiasis?
------------------------------------------------

Prognosis depends on the stage of disease

It is excellent with prompt treatment of amebic infection.

Luminal disease or dysentery usually respond well to treatment.

In refractory cases chloroquine may be added to metronidazole.

Surgery is rarely necessary.

A Simple guide to Reye's Syndrome

A Simple Guide to Reye's Syndrome
--------------------------------------------------

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

1.Liver usually shows microvesicular fatty infiltration

2. The brain shows cerebral edema with herniation

Causes are not completely known but:
1.Aspirin and salicylate has been suspected as an aggravating cause

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

What are the Signs and Symptoms of Reye's Syndrome
----------------------------------------------------------------------

Symptoms:
1.mild prodromal illness like influenza
Mild cases occur without progression to coma.

2.acute onset with:
a.vomiting
b.delirium
c.lethargy
d.stupor
e.coma within 24-48 hours

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

2.Increased serum ammonia

3.Raised prothrombin time

4.Low blood glucose especially in younger children

5.Intracranial pressure markedly increased

6.Cerebrospinal fluid normal except for increased protein.

7.Respiratory alkalosis with metabolic alkalosis may occur

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

Outcome depends on reversibility and control of intracranial hypertension

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

What are the complications of Reye's Syndrome?
---------------------------------------------

The complications are:
1.liver damage

2.brain damage

What is the Treatment of Reye's Syndrome?
--------------------------------------------
Treatment is urgent:
1.Hospitalization with intensive care management

2.Respiratory support

3.Intravenous fluid and glucose to maintain blood glucose

4.Immediate treatment of intracranial pressure important

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

6. No protein given by mouth because of liver condition

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

Other treatments include:
1.exchange blood transfusion

2.dialysis

3.plasmapheresis

4.Glucose plus insulin

5.citrulline

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

Outcome depends on management of intra cranial pressure

Subclinal cases are more common than previously thought

A Simple guide to Buerger's Disease

A Simple guide to Buerger's Disease
--------------------------------------------------

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

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

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

2.arterial lesions are inflammatory rather than degenerative.

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

4.arterial obstructions in the legs are often associated with obstructive arterial lesion elsewhereExample:angina pectoris

5.Diabetes and high lipid patterns are aggravating factors.

What are the Signs and Symptoms of Buerger's Disease
---------------------------------------------------

Symptoms:

1.onset is sudden
2.classic symptom of heavy aching pain in the legs when walking(intermittent claudication)
3.loss of arterial pilses
4.leg pallor and coldness
5.Raynaud's phenomenon
6.Other arterial diseases:
a.retinopathy
b.coronary ischemia
c.renal ischemia
7.evidence of peripheral ischemia or gangrene

How to diagnose Buerger's Disease?
-------------------------------------------------------------
1.Symptoms and signs as above
2.pallor on raising legs
3.angiography to determine site of lesion

What are the complications of Buerger's Disease?
---------------------------------------------

The complications are:
gangrene of the legs

What is the Treatment of Buerger's Disease?
--------------------------------------------

1.stop smoking
2.general measures:
a.graded exercise
b.physical training
c.weight loss
3.avoid injury from
a.heat
b.cold
c.trauma
d.infections

Medicines:
vasodilator drugs like persantin, nitrates

Surgery:
reconstructive surgery for localized blockage but may not work

Amputation is preferable with gangrene in elderly

What is the Prevention for Buerger's Disease?
-----------------------------------------

Avoiding smoking

Prognosis of Buerger's Disease
-------------------------------------
disease is often progressive and amputation may be necessary.

A Simple Guide to Syncope

A Simple guide to Syncope
------------------------------------

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

Causes:
A.Vasomotor:
1.Vagal slowing of heart and reduction of blood pressure from fear, severe pain or psychogenic disturbance

2.Hemorrhage or circulatory fluid loss from burns

3.Postural hypotension  - blood pressure drops from sleeping or sitting position to upright position

4.Vasoactive drugs such as anti-hypertensive (prazosin, methyl dopa) and heart medicines(nitites, adrenergic blockers)

5.Carotid sinus compression

B.Cardiac:
1.Asystole or heart blockage

2.Sudden arrhythmias with high ventricular rate

3.Heart valve prosthesis

4.Aortic stenosis with exertion

5.Cardiogenic shock following myocardial infarction

6.Sudden cardiac compression

What are the Signs and Symptoms of Syncope
---------------------------------------------------
A.Vasomotor:
Symptoms:
1.cold sweats, pallor, yawning,

2.Urge to urinate or defecate

3.low blood pressure

4.dilated pupils

5.Drug therapy such as adrenagenic blockers

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

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

What are the complications of Syncope?
---------------------------------------------

The complications are:
1.head injury

2.fractures

What is the Treatment of Syncope?
--------------------------------------------
1. Patients with postural or psychogenic syncope recover in recumbent position

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

3. heart blocks or asystole may need pacemaker implantation

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

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



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

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

A Simple Guide to Anorectal Abscess

A Simple guide to Anorectal abscess
-------------------------------------------

What is Anorectal abscess?
-----------------------------------
Anorectal abscess is a pocket of pus in the anal region below the anal sphincter muscles.

Perianal abscess lies within the external anal sphincter.

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

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

1.Trauma or injury causes cell damage and infection

2.Small mucosal tears from hard fecesmay lead to infection

3.Anal fissures, hemorrhoids or colis can also lead to abscess

Most infections are E.coli infections less often staphylococcus

What are the Signs and Symptoms of Anorectal abscess?
---------------------------------------------------

Symptoms start off with:
1. throbbing pain around

2. sitting walking defecation painful

3.Fever, malaise

4.Abscess seen on inspection or rectal exam

How to diagnose Anorectal abscess?
-------------------------------------------------------------
1.Symptoms of
a.anal swelling pain

b.proctoscopy

c.swab & culture
2.ESR raised very high somtimes > 80
3.moderate leucytosis with lymphopenia

What are the complications of Anorectal abscess?
---------------------------------------------

The complications are:
1.colitis
What is the Treatment of Anorectal abscess?
--------------------------------------------
Incision & drainage.
1.Antibiotics

What is the Prevention for Anorectal abscess?
-----------------------------------------

Avoiding infection
Prognosis of Anorectal abscess
-------------------------------------
Early therapy with antibiotics produce good results

A Simple Guide to Alcoholism

A Simple Guide to Alcoholism
-------------------------------------------

What is Alcoholism?
---------------------------

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

Who is at risk of getting Alcoholism?
-------------------------------------------

1.Familial

2.Cultural factors especially alcohol drinking friends

3.Social pressure and Stress

4.Depression may be a cause of Alcoholism

What are the Symptoms and signs of Alcoholism?
-----------------------------------------------

Common symptoms of Alcoholism are:

1.Need for daily use of alcohol

2.Binge drinking

3.Inability to stop drinking more than a temporary phase

4.Impairment of social and occupational function

5.Blackouts and amnesia

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

7.Absence from work or loss of job

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

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

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

How is the diagnosis of Alcoholism made?
-----------------------------------------------------

1. level of blood alcohol above the permitted limit.

2.Liver function tests are abnormal:
a.Aminotransferases  - AST and ALT are moderately elevated, with AST > ALT.
b.Alkaline phosphatase  - usually slightly elevated.
c.GGT  - correlates with AP levels- much higher in chronic liver disease from alcohol.

3. ECG and EEG

What are the complications of Alcoholism?
-----------------------------------------------------

Complications may develop with progression of the alcoholism.

1.Delirium tremors

2.Acute alcohol delusional states

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

5.Alcoholic hepatitis and cirrhosis

6.Wernicke's encephalopathy

7.Alcoholic cerebellar degeneration

8.Pellagra

What is the treatment of Alcoholism?
-----------------------------------------------------

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

2. treatment of complications

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

4.Antabuse therapy to cure alcohol dependence

5.Psychological therapy and Alcoholic Anonymous

What is the prognosis for Alcoholism?
---------------------------------------------------

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

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

What is the best prevention for Alcoholism?
---------------------------------------------------

1. No drinking of any form of alcohol

2. Family support and psychotherapy and self help groups

A Simple Guide to Coeliac Disease

A Simple Guide to Coeliac Disease
---------------------------------------------

What is Coeliac Disease?
--------------------------------

Coeliac Disease(Gluten Enteropathy) is a chronic disease of the small intestine which affects the lining of the small intestine to develop abnormalities on contact with gluten.

The small bowel mucosa shows
1.villous atrophy
2.columnal to cuboidal changes in absorbing cells
3.infiltration of lamina propia with lymphocytes and plasma cells

Who is affected by Coeliac Disease?
---------------------------------------------------

Coeliac Disease is more common in people with certain HLA antigens and blood group O.

There is a possibility of enzyme deficiency and abnormal immunological response.

Coeliac Disease can be found in all ages but are more common in the 10-30 years age group.

What is the Cause of Coeliac Disease?
-----------------------------------------------------

The exact cause of Coeliac Disease is not known.

It has been suggested that an autoimmune disease is the main cause of Coeliac Disease.

A protein produced by the immune system, called HLA antigen may be a possible cause of the body's reaction in the lining of the  small intestinal tract resulting in inflammation.

What are the Symptoms and signs of Coeliac Disease?
---------------------------------------------------------------------

Symptoms varies from mild to severe:

1.severe abdominal pain, bloating

2.diarrhea and steatorrhea

3.Weight loss despite good appetite and intake

4.edema

5.glossitis

6.apthous ulcers

7.finger clubbing

8.hypotension

9.Polyneuritis

10.psychiatric symptoms

In children there may be:
1.failure of weight gain
2.irritability
3.general malaise

How do you make the Diagnosis of Coeliac Disease?
-------------------------------------------------------------------

1.A history of abdominal pain , diarrhea and weight loss

2.small bowels radiology

3.D-xylose absorption study

4.fecal fat assessment

5.Jejunal biopsy 

What are the complications of Coeliac Disease?
------------------------------------------------------------

1.weight loss

2.Nutrition: malabsorption and vitamin deficiency

What is the treatment of Coeliac Disease?
---------------------------------------------------

Treatment is :
Control of Diet
1.gluten free diet especially wheat, oats, barley, rye
use rice corn potato in place
2.avoid beer, ale, whisky, vodka which contains a lot of gluten
3.Special diet for gluten sensitive patients
4.Question diet and review diagnosis if no response

Medication

1.Antispasmotic medication for abdominal pain

2.Oral corticosteroids may help in patients not responding after 3 months of careful adherence to diet
Start with high doses at first, followed by reduction of dosage.
These are for short term use only because of the side effects.

3.Correction of anemia and nutritional deficiencies is important to enhance the immune system

What is the prognosis of Coeliac Disease?
-----------------------------------------

The prognosis depends on the conition of the disease

Improvement occurs within 1-3 days following institution of diet seen in 30% of patients.
80% will respond within a month.
the remaining 20%may take up to 2 years for symptoms control.

There may be recurrence if therapy is stopped.

What are preventive measures in Coeliac Disease?
------------------------------------------------------------------

A nutritious diet with vitamin supplements can strengthen the body resistance against illness.
A gluten free diet will prevent recurrence 

A Simple guide to Raynaud's Disease

A Simple Guide to Raynaud's Disease
------------------------------------------------

What is Raynaud's Disease?
------------------------------------
 
Raynaud's Disease is a transient vasospasm of small arteries of the hand precipitated by cold.
There is typical whiteness and blueness of fingers.

Causes are:
1.classically cold precipitated, more common in winter
2.Emotional factors such as fear and anxiety

It may secondary to other conditions such as:

1.auto immune disease such as SLE
2.arterial compression syndrome from cervical ribs
3.hypothyroidism
4.pulmonary hypertension
5.medicines such as ergotamine
6.vinyl chloride exposure
7.low immune patients such as cancer

It occurs more commonly in women and usually rare in men

What are the Signs and Symptoms of Raynaud's Disease?
-----------------------------------------------------------------------

Symptoms start off with:
cold extremities with at least 2 of the following changes for diagnosis:
1.blanching and numbness of fingers spreading up to the rest of hand
2.blanching and whiteness of fingers then blue mottling followed by red as circulation returns
3.pain during color changes common
4.skin shiny or wax like
5.feet may be involved, also nose and tongue
6.gangrene of finger tips

How to diagnose Raynaud's Disease?
-------------------------------------------------------------
1.Symptoms and signs as above
2.skin capillary microscopy
3.hand films may show terminal tuft atrophy in vinyl chloride exposure

What are the complications of Raynaud's Disease?
---------------------------------------------

The complications are:
gangrene of the fingers

What is the Treatment of Raynaud's Disease?
--------------------------------------------

1.Avoid of cold temperature
2.Avoid emotional upset and stress
3.Keep body and environment warm
4.treat underlying cause
5.calcium channel blockers
  reserpine
  methyl dopa
6.sympathectomy 
 
What is the Prevention for Raynaud's Disease?
-----------------------------------------------------------

Avoiding cold temperature and stress

Prognosis of Raynaud's Disease
----------------------------------------------
 
depends on cause and response to therapy

A Simple guide to Legionnaire's Disease

A Simple guide to Legionnaire's Disease
----------------------------------------------------

What is Legionnaire's Disease?
-------------------------------------------
Legionnaire's Disease is an acute, infectious disease of the respiratory tract caused by the bacillus Legionella pneumophilia, a Gram negative, non-sporulating aerobic micro-organism..
The bacteria is found mostly in soil and water.

How is Legionnaire's Disease transmitted?
---------------------------------
Legionnaire's Disease is transmitted through the air or in dust associated with movement of soil or contaminated air from air conditioner units.
It is highly infectious.
Incubation period is 10-20 days.
The organism enters the blood and then enter the cells of the lower respiratory tract

The infections occur in persons of all ages but peak incidence is 50-60 years. Males are affected twice as often as females.
Predisposing factors are:
pre-existing lung disease
heavy smoking
low immune patients such as cancer
What are the Signs and Symptoms of Legionnaire's Disease?
------------------------------------------------------------------------------

Symptoms start off with:
1. sudden onset of malaise
2. high fever 39-40 degrees centigrade
3. chills and rigors
4. headache
5. dry cough
6. diarrhea
7. upper and lower gastrointestinal bleeding
8. difficult breathing
9. slow heart rate
10. confusion and dilirium

How to diagnose Legionnaire's Disease?
-------------------------------------------------------------
1.Symptoms of
a.prodromal viral like disease (myalgia, malaise, headache)
b.dry cough, confusion, diarrhea
c.lymphopenia without neutropenia
d.hyponatremia

2.ESR raised very high somtimes > 80
3.moderate leucocytosis with lymphopenia
4.low blood sodium
5.low blood calcium
6.abnormal liver function tests with albumin and raised SGOT
7.Urine shows protein and blood
8.Chest x-ray show patchy consolidation usually confined to one lobe
9.Indirect legionna bacterial antibody higher than 1.256
10.symptoms of renal failure

What are the complications of Legionnaire's Disease?
---------------------------------------------

The complications are:
1.pneumonia
2.liver dysfunction
3.renal failure

What is the Treatment of Legionnaire's Disease?
--------------------------------------------
Isolation in hospital is unnecessary.
1.Antibiotics (erythromycin or rifampicin) are used in the treatment of Legionnaire's Disease.
2.Tetracycline can be given
3.pulmonary care -nebulizer, oxygen, deep breathing exercises may be necessary if there is breathing difficulty

Besides antibiotics, the following will help:
Steam inhalation
cough mixtures
avoid smokes, dust, dry air,sudden temperature change

What is the Prevention for Legionnaire's Disease?
-----------------------------------------

Avoiding dust
Proper cleaning of air conditioners and ventilation system

Prognosis of Legionnaire's Disease
---------------------------------------------
Early therapy with antibiotics produce good results
low mortality rates as early cases are detected
Rarely pulmonary fibrosis develops as remnant from disease.