A Family Doctor's Tale - DISLOCATION OF ELBOW

DOC I HAVE DISLOCATION OF THE ELBOW

Dislocation of the Elbow is a common injury of the elbow.

It is usually posterior in direction and results from a fall on the outstretched hand with the elbow extended.

It is more likely to occur in people who do strenuous physical activities.

The cause of Dislocation of Elbow is:

1.Injury or trauma to the elbow bones from a fall resulting in the humerus end sliding out of the olecranon socket.

2.Somtimes when a child is lifted by the hand or wrist, subluxation of the elbow bones may occur

The symptoms and signs of Dislocation of Elbow are:Symptoms:
Symptoms:

1.Pain and deformity of the  affected elbow

2.Swelling of the affected elbow joint
 
3.Pain often radiates into the forearm

Signs:

1.swelling and difficulty in movement of the elbow

2.typically the other arm is holding on to the affected arm
 
3. X-rays show usually normal bones with displacement of the  locations of the humerus and radius at the elbow joint.
No fractures are seen

The complications of Dislocation of Elbow is:

Deformity and loss of function of the elbow if left untreated.

The Treatment of Dislocation of Elbow is:

Conservative treatment:
1.reduction of the dislocation is done under local anesthesia

2.Use a gentle steady traction on the wrist with counter action on the shoulder.

3.Extend the elbow to unlock the olecranon

4.Bend the elbow slowly and keep it immobilized at 90 degree of flexion in plaster of paris or bandage for at least 3 weeks to allow for ligaments and capsular healing.

5.Do another x-ray to check the position of the elbow joint and exclude fracture during reduction.

5.Pain killers such as NSAID(non-steroidal anti-inflammatory drugs) may be given for pain

6.Gentle range of movement exercises are instituted after removal of bandage or plaster of paris

7.Temporary stiffness may be present and recovery may take several months. Motion should never be forced

8.There should be a gradual return of the elbow  to normal movement
and weight bearing.

Surgery :
surgery is never necessary

The prognosis of Dislocation of Elbow is:

Prognosis is usually good  with proper treatment.

The prevention of Dislocation of Elbow is:

1. Avoid any traumatic injury to elbow.

2.Avoid pulled elbow in children

A Family Doctor's Tale -DISLOCATION OF SHOULDER

DOC I HAVE DISLOCATION OF THE SHOULDER

Dislocation of Shoulder is a common injury of the Shoulder.
It is usually anterior in direction and results from a fall on the externally rotated abducted arm.


This forces the humerus out of the glenoid cavity of the shoulder blade into its anterior position.


Posterior dislocation is less common and may results from a force directed against the internally rotated arm.
It may occur during a seizure in patients with convulsive orders.

The cause of anterior Dislocation of Shoulder is:

Injury or trauma to the Shoulder bones from an anterior force directed on the externally rotated abducted arm.

The symptoms and signs of Dislocation of Shoulder are:

Symptoms:
1.Pain and deformity of the Shoulder

2.Acromial protrusion of the Shoulder joint
 
3.Absense of the normal fullness of the humeral head beneath the deltoid and acromial process

Signs:

1.Little and painful movement of the Shoulder

2.typically the other arm is holding on to the affected arm
 
3.With anterior dislocations the arn is held externally rotated, the shoulder is full and internal rotation is painful.

4. X-rays should be taken at different angles and will show usually dislocations of the humerus ball from its socket of the shoulder blade.
No fractures are seen if it is a pure dislocation

The complications of Dislocation of Shoulder are:

Deformity and loss of function of the Shoulder if left untreated.

The Treatment of Dislocation of Shoulder is:

Conservative treatment:
1.reduction of the dislocation is done under local anesthesia
No general anesthesia is needed.

2.Use a gentle steady straight traction on the arm with counter action on the shoulder.

3.Extend the Shoulder under traction to loosen the muscles

4.Flex the Shoulder slowly forward and keep it immobilized at 90 degree of flexion in a sling for 1 to 2 weeks to allow for ligaments and capsular healing.

5.Do another x-ray to check the position of the Shoulder joint and exclude fracture during reduction.

5.Pain killers such as NSAID(non-steroidal anti-inflammatory drugs) may be given for pain

6.Gentle range of movement exercises are instituted after symptoms have subsided

7.Temporary stiffness may be present and recovery may take a few months. Movements should never be forced

8.There should be a gradual return to normal movement

Another method of reduction is called the Stimson's method for anterior dislocation:
1.Patient is placed in a prone position on the bed with the affected arm hanging over the side of the bed.

2.A 5kg to 10 kg weight is tied to the wrist for traction.

3.As the shoulder muscle relax, spontaneous reduction frequently occurs.

4.The patient's shoulder is placed in a sling for 1 to 2 weeks to allow for ligaments and capsular healing and the shoulder joint immobilized until it recovers with rehabilitation.

Surgery :
1.Surgery is seldom necessary and requires open reduction under general or regional anesthesia

2.Surgery is also done for correction of recurrent dislocations of the shoulder.

These procedures usually restrict the rotation of the shoulder joint or reinforce the weakened shoulder joint capsule.

The prognosis of Dislocation of Shoulder is:

Prognosis is usually good .

Recurrences of dislocation of the shoulder can occur due to the loosening of the capsule of the shoulder and weakening of its ligaments.

The prevention of Dislocation of Shoulder is:

 Avoid any traumatic injury to Shoulder.

 

A Simple Guide to Bedwetting (enuresis)

A Simple Guide to Bedwetting (enuresis)
---------------------------------------
What is Bedwetting?
___________________
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.
What are the causes of bedwetting?
------------------------------------
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 recognise 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.Somtimes a child develops bedwetting in responce to jealousy or reduced attention from parents or caretaker after a new child is born into the family
Complications:
Amount of urinary incontinenc 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 behavioural conditioning.
6.Medicine such as antidressant 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 - KNEE LIGAMENTS INJURY

DOC I HAVE A KNEE LIGAMENT INJURY


Knee Ligaments Injury is a common disorder of the knee caused by damage of the ligaments of the knee.

There are 4 ligaments, 4 bands of tough tissues in the knee to stabilize the joint :

1.Anterior Cruciate Ligaments (ACL) - starts from front of middle of lower tibia to middle of the back of femur
2.Posterior Cruciate Ligaments (PCL)- starts from middle of front of femur to the middle of back of tibia.
3.Medial Collateral ligaments (MCL) located on the inside of the knee
4.Lateral Collareral Ligaments (LCL) located on the outside of the knee

The causes of Knee Ligaments Injury are:
Injury to the knee ligaments are the main cause.

1.Anterior Cruciate ligament of the knee-soccer players who use rapid twisting movements of the knee (as when the knee stops and changes directions suddenly) are at higher risk of Knee Ligaments Injury .
The anterior Cruciate ligaments can also be injured when the twists on landing or as a direct result of a direct contact or collision during a soccer tackle.

2.Posterior Cruciate Ligament of the the Knee- injury to the posterior Cruciate Ligaments of the knee occurs when direct force is applied to the the front of the knee especially when the knee is bent.
The ligament can also be pulled or stretched in a twisting or hyperextension injury.

3.Collateral ligaments - injury to the Collateral Ligaments such as a fall or direct hit to the knee.
It can also occur as a twisting injury.
It can also occur together with ACL and PCL ligaments injury.

4.Obesity cause more strain on the Knee Ligaments

The symptoms and signs of Knee Ligaments Injury are:
Symptoms:
1.Immediate Pain in the knee after injury

2.Swelling of the knee within 1 to 12 hours

3.Difficulty in bending or straightening the knee

4.A popping sound occurs when the anterior cruciate ligament ruptures

5.difficulty in walking because of the pain

6.instability in the knee with the joint giving way during sport or daily activities.

Diagnosis:
1.history of a fall or injury followed by limitation of movement of the knee

2.MRI will show if there is Knee Ligaments damage

3. An X-ray is done to exclude fracture of the bone

The Treatment of Knee Ligaments Injury is:
Conservative treatment:
1.rest,elevation and ice compress treatment of the knee upon injury

2.Pain killers such as NSAID(non-steroidal anti-inflammatory drugs) for pain relief and reducing inflammation

3.Muscle relaxant to relax muscles

4.crutches can reduce the weight off the affected limb

5.Physiotherapy such as traction, shortwave diathermy help to increase knee muscle strength and improve flexibility of movement of the knee

Surgery is usually indicated in Knee Ligaments Injury if the condition does not improve with conservative treatment.
1.A keyhole or arthroscopic repair is done to repair the torn ligaments

2. A cast is placed around the knee to protect followed by physiotherapy 1-2 days after surgery.

Prognosis depends on the severity of the ligament injury

In most cases Knee Ligaments Injury may recover with conservative methods.

Some cases however may require surgical treatment

Prognosis is good after surgical treatment.

Prevention is to avoid weight bearing, reduce obesity and muscle strengthening exercises.

A Family Doctor's Tale - MENISCUS TEARS

DOC I HAVE A MENISCUS TEAR


Meniscus tear is a common disorder of the knee caused by contact or non-contact activity when a weight bearing knee moves or twists suddenly resulting in a tear of the meniscus.

It can also occur from wear and tear through repeated usage of the meniscus which is a cartilage acting as a shock absorber during weight bearing activities.

The meniscus helps to maintain the knee stability .

It is more common in footballers especially above the age of 30.

The causes of Meniscus tears are:
Several conditions has been blamed:
1.Repetitive movements of the knee-soccer players who use repetitive movements are at higher risk of Meniscus tears.

2.Normal wear and tear- with age the blood supply to the knee is reduced resulting in degeneration of the meniscus.

3.trauma - injury to the meniscus such as a fall or direct hit to the knee

4.Obesity cause more weight bearing effect on the meniscus

Symptoms of Meniscus tears:
1.Pain in the knee

2.swelling of the knee

3.inability to bend or straighten the knee

4.locking of the knee

5.difficulty in walking because of the pain

Diagnosis:
1.history of a fall or injury followed by limitation of movement of the knee

2.MRI will show if there is a meniscus tear in the knee joint


The Treatment of meniscus tears is:

Conservative treatment:
1.rest,elevation and ice compress treatment of the knee

2.Pain killers such as NSAID(non-steroidal anti-inflammatory drugs) for pain

3.Muscle relaxant to relax muscles

4.crutches can reduce the weight off the affected limb

5.Physiotherapy such as traction, shortwave diathermy help to increase knee muscle strength and improve flexibility of movement of the knee

Surgery is usually indicated in Meniscus tears if the condition does not improve with conservative treatment.

A keyhole or arthroscopic repair is done to remove the torn meniscus

Physiotherapy starts the day after surgery.

The prognosis of meniscus tears is:
Prognosis depends on the severity of the meniscus tear.

In most cases Meniscus tears may require surgical treatment

Prognosis is good after surgical treatment.

Prevention of Meniscus tears is:

Avoid obesity and weight bearing on the knee

Avoid strenuous physical activity of the knee

Avoid sudden turning and twisting of the knee

A Family Doctor's Tale - MALE MENOPAUSE

DOC  I HAVE MALE MENOPAUSE

Male menopause or andropause is a condition which is due to lack of or absence of testosterone in men especially at the age above 50 years .

There are two types of andropause found in adult men:
1.Normal hormone levels through puberty and adulthood with normal sexual development is presented with the rapid drop of testosterone levels around the age of 50
2.Psychological type of andropause occurs gradually with gradual drop of male hormones, DHEA and human growth hormones.
This usually occur in older patients such as in the 60 to 70 age group.

What are the causes of Male Menopause?
Common causes for male menopause are:
1.age related lowering of blood testesterone
2.injury to the testes and male reproductive system
3.Surgical removal of testes and male reproductive system due to cancer
4.auto-immune diseases such as systemic lupus erythrematosis
5.geneteic abnormalities which cause premature testicular failure such as chromosomal mosiacism
6.generalized vascular conditions such as diabetes
7.orchitis or infections of the testes such as mumps(which is fortunately almost eradicated by immunization)
8.heavy smoking reduce blood flow to testes
9.chemotherapy which destroy the production of male hormones
10.pituitary tumors which control the production of male hormones.

What are the symptoms and signs of male menopause?
Symptoms of andropause:
1.Tiredness, general weakness
2.Reduced libido
3.Reduced sexual potency
4.Hot flushes
5.Sleep problem
6.Joint pain
7.Irritability and anger
8.depression
9.Changes in skin and hair growth
10.Pre-aging

 How is the diagnosis of Male Menopause made?
Male menopause is a simple endocrine problem which causes the testosterone in the blood to diminish with age.
The diagnosis is made by measuring
1. free testosterone blood levels (mean=700ng/dl , range =300-1100ng/dl)
2. computing the free androgen index (FAI) (total testosterone x 100 /sex hormone binding globulin). (range=70-100%).
If the free androgen index is less than 50% , symptoms of male menoopause appears.
3.A comprehensive medical and psychological assessment should also be done

What is the treatment of Male Menopause?
Testosterone Replacement Therapy like the Hormone Replacement Therapy of female menopause is the main form of treatment:
1.Tablets:
Methyltestosterone (Android,Virilon,Testred, Oreton) 10mg,
Testosterone undecanoate (Restandol, Andriol) 40mg, essentially a testosterone in oil preparation (not available in the USA)
Mesterolone (Proviron) 25mg -- less potent
2.Transdermal therapy
Testosterone--transdermal (Testoderm, Testoderm TTS, Androderm)
3.Injections
Testosterone cyprionate 100mg/dl
Testosterone Propionate in oil 100mg/ml
Testosterone Enaanthanate 200mg/dl
The usual dose is 1cc injected weekly or bi-weekly. This method of administration removes the risk of liver damage which may be caused by oral methyl testosterone .
4.Sub dermal Pellets
Testosterone pellets for male hormone deficiencies are inserted under the skin and dissolve slowly over a period of approximately three to four months.

What are the risks?
1.Prostate cancer-- There is no evidence in the medical literature that testosterone replacement therapy increases the risk of prostate cancer.

2.Heart disease-- increasing male androgen levels would also increase serum cholesterol and serum LDL-Cholesterol levels. .
3.Liver Disease--the only orally available forms of testosterone for men contain methyl testosterone.
If used for sustained periods of time, it can damage the liver.

4.Suppression of testicular function-- whenever any hormone is administered, the gland which normally produces it ceases to function.
Patients with borderline low testosterone levels may commit themselves to lifelong therapy if they start with testosterone replacement.

What are the benefits?
The administration to testosterone to men with true testosterone deficiency states will improve their health and sense of well being.

A Family Doctor's Tale - SLEEPING SICKNESS

DOC I HAVE SLEEPING SICKNESS

Sleeping Sickness is a acute infection of humans and cattle caused by the protozoan hemoflagellate of the genus Trypanosoma.

The trypanosoma brucei protozoan is an elongated protozoan hemoflagellate with prominent nucleus kinetoplast and flagellum (hair).

It can occur in 2 forms:
1.West African caused by T.gambiense
This protozoan has a human host and is spread by the tsetse fly (also known as Glossina palpalis)
These flies inhabit shady areas by rivers or streams.

2.East African caused by T.rhodesiense
This protozoan is mainly a parasite of the wild animals especially the the bushbuck.
Humans are incidental hosts.

When the tsetse fly bites an infected host the trypanasomes pass into the midgut , migrates to the salivary glants, muliply in 2 bto 5 weeks and pass out in the saliva when feeding on a new host.

Early in the human disease, the lymph nodes and spleen are enlarged, infiltrated with plasma cells and macrophages (enlarged neutrophils and lymphocytes).

The disease can spread to the brain and result in swelling and damage of the brain.

Symptoms:
Incubation period is usually 10 days.

1.Anodular lesion (chancre) occur at the site of the bite of the tsetse fly and persist for 2-3 weeks.

2.Systemic invasion of the trypanosomes occur months after the bite resulting in:
a.fever
b.lymphadenopathy - nodes are firm but not tender usually
c.spleen enlargement
d.rashes erythematous and urticarial forms
e.localized edema

3.Months after the first symptoms:
a.mild behavior changes
b.mild personality changes
c.hallucinations
d.delusions
e.drowsiness during the day
f.manic depression
g.chorea
h.convulsions
i.coma

In Rhodesian sleeping sickness, the symptoms are more acute in onset:
1.fever
2.jaundice
3.malaise
4.heart failure
Rhodesian sleeping sickness is more rapidly fatal and occur in outbreaks.

Diagnosis:
1.characteristic fever, jaundice and drowsiness

2.Fluid from chancre and enlarged lymph nodes are taken to test for trypanosomes

3.Blood test for trypanosomes using thick blood film especially in Rhodesian Sleeping Sickness

4.Cerebrospinal fluid is taken to examine for trypanosomes in advanced stage of the diesease.
The IgM antibodies may be markedly increased with only moderate increase in total protein.

5.MRI of the brain my be necessary to find cause of drowsiness

The complications of Sleeping Sickness Fever are:
1.Psychiatric disease may affect victims

2.neurological disturbances(seizures,cranial nerve signs and coma) may indicate damage in the brain

3.Coma and death

Treatment:
1.Sleeping Sickness can be treated with Suramin an anti-protozoan drug if the central nervous system is not affected.

2.Melarsoprol with or without suramin is given if the central nervous system is infected.

Both medicines have serious side effects but their use can be life saving.

Other medicines include:

1.Eflornithine (for gambiense only)

2.Pentamidine

3.General measures which are mainly supportive:
1. Rest
2. drinking lots of water to prevent dehydration will help.
3. Paracetamol for fever, severe headaches and body aches to reduce the discomfort.
4. Intravenous fluids for hytopotension and dehydration.
5. Dietary supplements to build up nutrition and health

Prognosis:
1.depends on the virulence of the strain of trypanosome infecting the patient

2.depends on the stage of disease when treatment is instituted.
The earlier the stage of illness, the better will be the effect of the treatment.

Prevention:
Sleeping Sickness Fever is spread only through the bite of the infected tsetse fly.

To prevent Sleeping Sickness fever, you must prevent the breeding of its carrier, the tsetse fly.

1.THe use of mosquito nets prevents bites from the tsetse flies at night.

2.Wear clothes that are not brightly colored and covers the wrists and ankles.

Pentamidine injections protect against Trypanosome gambiense, but not against rhodesiense.

A Family Doctor's Tale - YELLOW FEVER

DOC I HAVE YELLOW FEVER

YELLOW FEVER fever is a acute viral infection caused by the YELLOW FEVER virus which is usually transmitted by the bite of an infected female Aedes msoquito.

The YELLOW FEVER virus is a flavivirus which are spherically enveloped RNA-containing particles.

2 epidemiologic forms of Yellow fever are present:
1.urban which has a human-mosquito-human cycle


2.jungle whivh has a monkey-mosquito-monkey cycle.
Humans get infected when accidentally bitten by the mosquito.

The incubation period in mosquito is 8-12 days and 3-6 days in humans.
Symptoms usually last 3-14 days.

A.Mild form:

1.Mild non specific fever
2.Headache
3.Pain behind the eyes
4.Muscle and joint pains
5.Nausea , vomiting
6.last several days with eventual recovery

B.Severe form

1.High, acute, prolonged fever  
2.Severe headache
3.Myalgia and bodyaches
4.nausea, vomiting
5.loss of appetite
6.anxious and distressed
7.Abdominal discomfort
8.gum hemorrhages and epistaxis
9.Fatigue

This stage called the viremic stage lasts about 3 days folled by a period of remission for 24 hours.

C.Recurrent Stage:

1.The fever then returns even higher
2.severe vomiting
3.epigastric pain
4.jaundice (hence the name yellow fever)
5.hematemesis
6.melena

Diagnosis of Yellow Fever:
1.characteristic fever, jaundice and vomiting in the later stages

2.inflammation of nerves and meninges

3.contraction of muscles of face, scalp and neck

4.neuralgia

5.MRI of the brain

6.blood tests for antibodies

The complications of YELLOW FEVER  are:
1.Hemorrhages in the stomach
a.hematemesis
b.melena

2.neurological disturbances(seizures,cranial nerve signs and coma) may indicate bleeding in the brain

3.Dilatation and distension of the cranial arteries

4.Inflammation of the cranial nerves, meninges, neuralgia

Treatment of Yellow Fever:
There is no specific anti-viral drug to treat the disease or a vaccine to prevent a person from being infected with the YELLOW FEVER virus.
Treatment is mainly supportive.
1. Rest
2. drinking lots of water to prevent dehydration will help.
3. Paracetamol for fever, severe headaches and body aches( Avoid aspirin and NSAIDs due to the risk of bleeding) to reduce the discomfort.
4. Intravenous fluids for hyto 10 days, but complete recovery can take as long as a month.potension and dehydration.
5. Antidepressant medicines are helpful

The illness can last up to one month before recovery

Prevention of Yellow Fever:

1.A vaccine against Yellow Fever was developed in 1951 and is effective against Yellow Fever for 10 or more years.

2.YELLOW FEVER Fever is spread only through the bite of the infected Aedes mosquitoes.

To prevent YELLOW FEVER fever, it is important to prevent the breeding of its carrier, the Aedes mosquitoes, identified by their black and white stripes on the body .
A puddle of water about the size and depth of 20-cent coin is sufficient for an Aedes mosquito to breed in.

The Aedes mosquitoes are commonly found breeding in clear stagnant water in flower vases, flower pot plates, roof gutters, earthen jars for water storage or decorative purposes, watering cans, and bamboo pole holders.

The Aedes mosquito can also breed in unusual places such as water trapped in the hardened soil in potted plates, and the rim of unwanted pails

 

A Family Doctor's Tale - HEMOPHILIA

DOC I HAVE HEMOPHILIA

Hemophilia is an inherited disorder of bleeding associated with deficiency of Factor VIII (a clotting factor) in the blood.

The cause of Hemophilia is:
It is an inherited X-linked recessive disorder.

Women are carriers .
50 per cent of the sons of carriers will get the disease and 50 per cent of the daughters will be carriers.

This condition is present in the Royal family of England.

It is also associated with Christmas disease which is a deficiency of Factor IX and von Willebrand disease (deficiciency of Factor VIII and platelet abnormalities leading to prologed skin bleeding)

It is a lifelong disease and there is no cure for it.

In Hemophilia patients, the deficiency of a clotting factor can lead to severe bleeding during injury or spontaneous bleeding into the joints.

The Symptoms of Hemophilia are:
1.excessive bleeding during mild trauma(example: tooth extraction)

Sometimes internal bleeding may occur without the knowledge of the patient because the injury is so mild.

2.soft tissue hematomas (big blood clots) which can cause nerve compression

3.Hemarthroses (bleeding in the joints) and joint contactures

4.hematuria (bleeding in the urine) or epistaxis (nose bleeds)


Diagnosis of Hemophilia is often based on
1. family history of Hemophilia

2. history of bleeding following minor trauma

3. Blood clotting Factor VIII low on testing

4.Skin bleeding time and blood clotting time abnormal

The complications of Hemophilia are:
1. Anemia

2. damage to bleeding joints

3. shock and death

The treatment of Hemophilia is by:

1.Blood transfusion or replacement of blood clotting factors VII cryoprecipitates

2.Aspiration of blood from bleeding joints

3.Avoid joint immobility to prevent contractures

4.Avoidance of injury

5.Careful preparation for dentistry or surgery

6.Proper genetic counseling

The prognosis of Hemophilia is:
Prognosis is good for hemophilia patients with modern therapy.

Most patients are able to live normal lives.

Rarely life threatening bleeding may occur.

The Prevention of Hemophilia is through:
Genetic counseling and testing for Hemophilia

A Family Doctor's Tale - PORPHYRIA

DOC I HAVE PORPHYRIA

Porphyria is an autosomal dominant inherited disorder of hemoglobin biosynthesis.


Porphyrins are produced in the process of hemoglobin synthesis.

Because of the deficiency of enzymes in the porphyria patients, the porphyrins are not converted into hemogloblins.

As a a result excessive porphyrins accumulates and less hemoglobin is formed.

The  red blood cells formation is affected resulting in neurological dysfunction or photosensitive rashes.


The causes of Porphyria is:
It is an inherited deficiency of one or more enzymes helping to synthesize hemoglobin.

Acute intermittent porphyria can be precipitated by
1.many drugs:
a.barbiturates
b.sulphonamides
c.methyl dopa
d.oral contaceptives

2.infection

3.alcohol

4.starvation

5.hypoglycemia

Chronic cutaneous porphyria may also be precipitated by
1.the same agents as above

2.hepatotoxins

It is a lifelong disease and there is no cure for it.

The symptoms of Porphyria are:
Symptoms:


Acute intermittent porpyria
1.recurrent attacks of neurologic dysfunction affecting the autonomic nervous system:
a.fever
b.tachycardia
c.nausea
d.vomiting
e.abdominal pain -main recurring symptom
f.sweating
g.hypertension
h.leucocytosis

2.peripheral nervous system
a.mononeuritis multiplex with nerve pain
b.polyneuropathies
c.cranial neuropathies

3.central nervous system
a.psychiatric disturbance
b.seizures

Chronic cutaneous tarda:
1.bullous eruption on exposure to sunlight
2.evidence of hepatic disease

The diagnosis of Porphyria is made by:
Diagnosis of Porphyria is often based on
1. family history of Porphyria

2. porphyrins in the urine with urine turning dark red or brown on exposure to light

3. 24 hour excretion of urinary porphoblininogen and delta-aminolevulinic acid increased in acute porphyria

4. 24 hour excretion of urnary porphobilinogen and other porpyrins increased in other porphyrias

5.50 per cent reduction of uroporphyrinogen I synthesase in red blood cells diagnostic of acute intermittent porphyria

6.MRI or ultrasound of the abdomen may be necessary due to persistant recurrent abdominal pain

The complications of Porphyria are:

1. Anemia

2. damage to liver and gallstone formation


3. seizures and brain damage

4.Paralysis

5.Scarring of the skin

The treatment of Porphyria is by:
1.Blood transfusion of hematin in severe cases

2.high carbohydrate diet helps limit the production of porphyrins


3.Avoid causative agents especially medications

4.propanolol for tachycardia

5.anagesics for pain

Other treatment includes:

1.chloroquine

2.Vitamin A supplements

3.Removal of blood to reduce the porphyrins

4.Avoid alcohol

The prognosis of Porphyria is :
Prognosis is fair for Porphyria patients with modern treatment however the illness is a lifelong condition.

There is recurrence of attacks and high rates of hospitalization

The Prevention of Porphyria is by:
Genetic counseling and testing for Porphyria

A Family Doctor's Tale - NASAL POLYPS

DOC I HAVE A NOSE POLYP

Nose Polyp is a benign tumor with soft round body rising on a stalk from the nose inner lining or nasal mucosa.

It is usually the result of chronic inflammation within the nasal cavity.

Nose Polyp can occur at any age.

The causes of nasal polyps is unknown but predisposing conditions are:
1.chronic inflammation of the nasal cavity or sinuses

2.allergies as some people with nasal polyp test positive for environmental allergen

3.Asthma

4.smoking

5.Aspirin sensitivity

Symptoms :
1.Nose Polyp is a well encapsulated round swelling rising from the nasal mucosa on a stalk called the peduncle.

2.mutiple swellings may also be present.

3.They are usually painless

4.They may block the nasal passage giving rise to the sensation of nasal obstruction.

5.There is decreased sense of smell or even complete loss of smell

6.excessive nasal secretions may also be present

Diagnosis:
1.nasoendoscopy may be done to confirm the presence of nasal polyps

2.Allergy skin tests to detect if there are any allergy contributing factors

3.CT Scan of the sinuses may be done to see the extent of the nasal polyps as well as to localize their position and other possible obstructions in the nasal cavity

There can be complications such as:
1. bleeding

2. infection of sinuses

Treatment:
Medical:
1.antibiotics to treat infections

2.antihistamine to treat allergy

Surgery:
The only surgical treatment is removal of the Nose Polyp if the medications do not work or if there is suspicion of cancer.

This can be done by nasal endoscopy sugery under general anesthesia
1.Excision of the nasal polyp with a knife or scissors through the endoscpoe

2.Clearing of any obstruction which can prevent the flow of discharge from the sinuses.

3.use of nasal steroid after surgery to prevent reccurrence of polyps

4.nasal washes to prevention the accumulation of dried mucus or crusts in the nasal cavity.

The prognosis is usually excellent.

Recurrence at the same spot is rare but do occur due to regrowth of the blood vessel supplying the Polyp.

Prevention:
Avoid any irritants or allergies as much as possible

Avoid smoking

Manage asthma or allergies with medication.

A Family Doctor's Tale - VOCAL CORD POLYP

DOC I HAVE VOCAL CORD POLYP, NODULE AND CYST

Vocal polyp is a benign tumor with soft round body rising on a stalk from one of the vocal cords.

Vocal nodules are thickened area occurring on both vocal cords
and are also known as singer's nodules or callusese of the vocal cords.

Vocal cysts are swellings (containing fluid in a sac) found on the vocal cords.  

Vocal polyp,nodules and cysts can occur at any age.

The causes of vocal polyp and nodules are:

1.Vocal polyps and nodules are usually the result of chronic inflammation or repetitive trauma to the vocal cords such as frequent shouting or voice overuse.

2.reflux of acid from stomach to larynx

3.smoking irritates the vocal cors

4.cysts occur due to blockage of a mucous gland in the mucosa of  the vocal cords.

Symptoms of Vocal Cord Polyp, Nodule and Cyst:
1.Hoarse voice

2.breathless voice

3.low pitch husky voice

4.vocal faigue

5.inability to sing high pitched notes

6.increased effort to speak or sing

7.frequent throat clearing

Diagnosis of Vocal Cord Polyp, Nodule and Cyst:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords and confirm the presence of nodules, polyp or cysts

3.test for laryngopharyngeal reflux

4.Sensitive nose and sinusitis may be excluded with CT Scan of skull from nose to vocal box.

There can be complications of Vocal Cord Polyp, Nodule and Cyst such as:
1. bleeding (rare)

2. chronic hoarseness of voice

Treatment of Vocal Cord Polyp, Nodule and Cyst:
Medical:
1.antibiotics to treat infections

2.antihistamine to treat allergy

3.antacid to reduce acid reflux

4.voice rest

Most benign vocal cord growths will resolve with conservative medical treatment especially voice rest.

Surgery:
The only surgical treatment is phono-microsurgical removal of the Vocal polyp,nodules and cysts if the medications do not work or if there is suspicion of cancer.

Phono-microsurgery is surgery to the vocal cord using micro-surgical techniques and instruments and sometimes lasers.

This surgery can also be done to improve the voice or remove a growth for microscopic analysis.

If a lesion is found to be cancerous, further treatment may be required.

The prognosis of a Vocal Cord Polyp, Nodule and Cyst is usually excellent.

Recurrence at the same spot is rare but do occur due to regrowth of the blood vessel supplying the Polyp or nodule.

Prevention of Vocal Cord Polyp, Nodule and Cyst:
Avoid strenuous use of the vocal cords

Avoid smoking and alcohol

Avoid any irritants or allergies as much as possible

A Family Doctor's Tale - SNORING

DOC I HAVE SNORING

Snoring is the symptom of spectrum of problems including Sleep disorders such as Obstructive Sleep Apnea during which breathing is interrupted during sleep.

About 24 per cent of the local population are loud habitual snorers.

Causes of snoring:
The cause of snoring is due to the vibration or flapping of the tissues lining the upper respratory passages.

Snoring in most people are due to multiple factors each playing some part in the snoring process:
1.Inadequate muscle tone of the palate, tongue and pharynx leads to airway collapse during inspiration causing the walls of the airway to vibrate.

2.bulky tissue in the upper respiratory airway(adenoids and tonsillar hypertrophy, cysts and tumors)cause narrowing of the airway and result in snoring.

3.excessive soft palatial tissue or long uvula can also vibrate during breathing causing snoring.

4.a backward prolapsing tongue may fall backwards into the throat when sleeping on the back and contribute to snoring

5.anatomical abnormalities in the nose(deviated nasal septum, hypertrophied inferior turbinates) or congested nasal passages (allergies, sinusitis, nasal polyps) can cause poor nasal inflow and make the soft tissues of the palate and throat vibrate.

Systemic disorders:
1.Hypothyroidism -large tongue

2.Acromegaly - large tongue

3.heartburn resulting in congestion of the throat

4.Obesity - enlarged tongue or uvula

Symptoms:

1.snoring present in 20% of men and 5% of women at age 30-35 years.
At age 60 years or more, 60% of men and 40% of women snore habitually

2.unrefreshed sleep

3.daytime sleepiness

4.poor concentration

5.forgetfulness

6.morning headaches

7.dryness of mouth in the morning

8.irritabilty

9.depression

10.sexual dysfunction

Signs:

1.Enlarged nasal turbinates, polyps , and nasal blockage

2.Enlarged tonsils and adenoids

3.Long uvula

4.large protruding tongue


Diagnosis of Snoring is made:
1.Symptoms of snoring, nasal congestion and inadequate sleep

2.observation of airway obstruction during sleep

3.Sleep study using monitoring devices such as

a. electroencephalogram(EEG)

b electro-oculogram(EOG)

4.Electrocardiogram(ECG)

5.Blood oxygen studies

6.Nasal and oral airflow

7.Thoracic and abdominal movement

8.Snoring sounds

Complications:
1.higher risk of hypertension

2.cardiovascular disease

3.Congestive heart failure

4.cardia arrhythmias

5.cerebrovascular accidents

Treatment:
A.Non Surgical treatment:

1.Continuous Positive Airway Pressure(CPAP)
CPAP administered by mask through the nose is the single most effective least invasive treatment for Obstructive Sleep Apnea.
It can improve all the bad effects of OSA.

2.Oral appliances which pushes the mandible forward and prevent it from falling open during sleep

3.Nasal Congestion treatment:
Patients with nasal congestion and blockage should be treated with antihistamine and decongestant

4. Weight reduction:
Any obese patients should have at least 10% of his weight reduced over a 6 months period

B.Surgical Treatments:
1.Surgery on the upper pharyngeal airway(uvula and palate)

a.Radiofrequency reduction of the palate and uvula shrinks the tissues of these and is indicated in simple snorer or mild OSA.

b.Uvulopalatopharyngoplasty (UPPP) surgery includes uvulectomy, palatal releasing and shortening incisions.

2.Surgery of the Tongue base:
Radiofrequency reduction is done for mild cases.
Advancement of the tongue, hyoid suspension is done under general anesthesia. All these enlarge the posterior airway space.

3.Maxillomandibular Advancement:
This is the most effective surgical procedure for treatment of OSA.It causes enlargement of the pharyngeal and hypopharyngeal airway by physically expanding the skeletal framework.

Prognosis depends on the severity of the condition but is generally good.

Prevention:
1.Lose weight in obese individual with snoring

2.Healthy lifestyle with balanced diet and exercise.

3.Neck elevation to prevent obstruction of airways and heartburn

4.Sleep on the side rather than on the back.
Snoring is worse when sleeping on the back

A Family Doctor's Tale - MUSCLE TENSION DYSPHONIA

DOC I HAVE A MUSCLE TENSION DYSPHONIA

Muscle Tension Dysphonia is an excessive tightness or imbalnce of the muscles in and around the vocal box resulting in hoarseness and difficulty in using the voice.

The causes of Muscle Tension Dysphonia are:
1.Direct problem with the use of vocal technique

2.voice muscle habitual misuse

3.acid reflux from the stomach or laryngopharyngeal reflux

4.underlying inflammation of the vocal cord

5.growth on the vocal cord

6.neurological condition affecting the vocal cord

Symptoms  of Muscle Tension Dysphonia:
1.Hoarse voice

2.strained voice

3.pain or sore throat when talking

4.vocal fatigues easily

5.difficulty controlling pitch

Diagnosis of Muscle Tension Dysphonia:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords

3.videostroboscopy to view the vocal cords ( a thick endocscope with camera is passed down the nose to the vocal cords to examine its movements on video)

4.CT or MRI Scanning of skull from nose to vocal box to look for underlying causes.

5.evaluation of laryngopharyngeal reflux

There can be complications of Muscle Tension Dysphonia such as:
1.chronic hoarseness of voice

2.damage to the vocal cords

Treatment of Muscle Tension Dysphonia:
Medical:
1.Speech therapy
a.to improve voicing techniques
b.overcome bad vocal habits which strain on the voice
c.avoid unneccesary voice use to allow the voice muscles to relax and rest

2.medication to treat acid reflux

Surgery is usually not required.
The prognosis of Muscle Tension Dysphonia is usually fairly good .

Prevention of Muscle Tension Dysphonia:
1.It would be wise to hydrate the throat
2.warm up the voice before talking for long periods of time
3.use a microphone rather than shouting or using a loud voice to convey your message to a large crowd of people
4. Always rest the voice whenever possible

A Family Doctor's Tale - VOCAL PARALYSIS

DOC I HAVE A VOCAL PARALYSIS

Vocal paralysis is a paralysis of one or both of the vocal cords and results in inability to close the the vocal cords completely.

Vocal paralysis usually involve one of the vocal cords.

If the vocal cords do not close completely:
1.the voice becomes weak and hoarse

2.there may be choking on swallowing due to food or liquids going down the windpipe.

The causes of vocal paralysis are:
1.tumors pressing on the nerve that control vocal cord movement
Examples are cancers of the larynx, thyroid, nasopharynx or esophagus

2.injury of the nerve controlling vocal cord movement
a.during thyroid and chest surgery
b.following radiation treatment to the neck  
c.neck injury.

3.stroke or neurological condition affecting the movement of the vocal cords

Symptoms  of vocal paralysis:
1.Hoarse voice

2.breathless voice

3.low pitch husky voice

4.vocal fatigue

5.choking or coughing especially on drinking liquids

Diagnosis of vocal paralysis:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords and confirm the presence of  paralysis

3.videostroboscopy to view the vocal cords

4.CT or MRI Scanning of skull from nose to vocal box to look for cause of paralysis.

5.Laryngeal electromyography which use a fine needle to measure function of the vocal cord muscle

There can be complications of vocal paralysis such as:
1.choking with effect to breathing difficulty

2.chronic hoarseness of voice

Treatment of vocal paralysis:
Sometimes the recovery occurs by itself and no action is needed.
This may take up to one year.
Medical:
1.Speech therapy

2.injection of collagen to increase the bulk of paralysed vocal cord may help

Surgery:
1.Surgical treatment (medialization thyroplasty)may be needed to permently shift the paralysed vocal cord to improve the voice.
This operation is done under local anesthetic.

Phono-microsurgery is surgery to the vocal cord using micro-surgical techniques and instruments and sometimes lasers.

2.Rarely if both vocal cords are affected by paralysis there may be difficulty in breathing or noisy breathing because of the narrowed airway at the vocal box.
A tracheostomy may be needed. This involves making an opening in the windpipe and putting a trachecstomy tube into the opening to help breathing.

3.A laser procedure may be done to widen the the airway.

The prognosis of vocal paralysis is usually fairly good except when cancer is involved.

Prevention of vocal paralysis:
surgery around the neck and throat region should done carefully to avoid cutting the nerve to the vocal cords.

A Family Doctor's Tale - LARYNGOPHARYNGEAL REFLUX

DOC I HAVE LARYNGOPHARYNGEAL REFLUX

Laryngopharyngeal reflux disease (LPR) is a chronic disease of the pharynx (throat) and larynx (voice box) whose mucosa is damaged by abnormal acid backflow (reflux) of gastric acid from the stomach to the esophagus.

The following causes are responsible for LPR:
There are 2 sphincter muscles in the esophagus:
1.the Lower Esophageal sphincter (LES) prevents the backflow of food and acid from the stomach and acid from the stomach into the esophagus

2.the Upper esophageal sphincter (UES) prevents the food and acid from backflowing into the larynx

An incompetant Lower Esophageal Sphincter(LES) allow the acid and gastric juice to reflux up the esophagus giving rise to gastroesophageal reflux disease or GERD.

If the acid and digestive enzymes from the stomach back flows into the larynx then the condition is called laryngopharyngeal reflux or LPR.

An incompetant lower esophageal sphincter may also result from:
1.Hiatus hernia - hole in diaphragm separating esophagus from stomach is enlarged allowing the easier flow of acid up the esophagus

2.Obesity and pregnancy: increased body weight cause pressure in the abdomen to push gastric contents upwards towards esophagus

The most common symptoms are
1.frequent throat clearing

2.throat itchiness

3.sensation of something in the throat

4.excess phlegm in the throat

5.hoarseness- due to inflammation of the vocal cords from the acid reflux

6.frequent sore throat

7.chronic cough - the acid flow up the esophagus can irritate the larynx and spark off the cough reflex

8.Heartburn - there is a burning discomfort behind the breastbone due to acid flow up the esophagus

Diagnosis:
A detailed history of acid reflux into the larynx and pharynx

Useful investigations may include
1.barium swallow X-rays to check the flow a barium dye from the oral cavity down the esophagus to the stomach. It can detect any reflux of the dye into the esophagus and the presence of any growths in the esophagus and stomach.

2.nasoendoscopy - an endoscope is passed through the nose to the level of voice box in the throat under local anethesia to check on the vocal cords

3.24-hour esophageal pH monitoring - measures the acidity of the esophagus

4.Esophagogastroduodenoscopy (EGD) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

Treatment is aimed at
A. prevention of reflux:
1.weight loss for the Obese

2.Positional therapy
a.Sleeping on the left side has been shown to drastically reduce nighttime reflux episodes in patients

b.Elevating the head of the bed is also effective.
The head of the bed can be raised by wooden bed risers that support bed posts or legs.
Elevation must be at least 6 to 8 inches (15 to 20 cm) to be able to prevent the backflow of gastric fluids.

c.a bed wedge pillow will also help to raise the patient's body higher

3.Certain foods should be avoided to prevent Laryngopharyngeal reflux:
a.Coffee,


b.alcohol,


c.Acidic foods, such as oranges,tomatoes and excess amounts of Vitamin C


d.Antacids based on calcium carbonate actually increase the acidity of the stomach.


e.Foods high in fats -delay stomach emptying


f.Carbonated soft drinks with or without sugar.


g.Chocolate and peppermint.


h.Cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussels sprouts.


i.Milk and milk-based products containing calcium and fat,


j.Eating within 2 hours before bedtime.

k.Large meals- smaller meals reduces reflux as it means there is less food in the stomach at any one time.

4.Smoking reduce lower esophageal sphincter competence, and should be avoided

5.Avoid stress.
Learn to relax or meditate.
Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.

B. Neutralizing the Gastric Acid Reflux
1. Drug treatment
a.Proton pump inhibitors are the best drugs used in reducing gastric acid secretion. (eg Nexium, Losec)

b.Antacids taken before meals half hourly after symptoms begin can reduce gastric acidity (liquid antacid are more useful than tablets)

c.Alginic acid (Gaviscon) protects the mucosa as well as increase pH and decrease reflux.

d.Gastric H2 receptor blockers such as ranitidine or famotidine decrease gastric secretion of acid.

2. Surgical treatment
The standard surgical treatment, done laparoscopically, is the Nissen fundoplication.
The upper part of the stomach is wrapped around the Lower Esophageal Sphincter(LES) to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.

3.New treatments
Eight years ago some new endoscopic devices to treat chronic heartburn were approved:
a.The Endocinch apply stitches in the LES to help strengthen the muscle.

b.The Stretta Procedure uses electrodes to use radio frequency energy to strengthen the LES.

c.The Plicator creates a plication, or fold, of tissue near the Laryngopharyngeal junction, and fix the fold using a suture-based implant.

Prognosis:
It is a chronic disease so treatment is lifelong and recurrences are common.

Prevention:
1.Prevent heartburn by limiting acidic foods, such as grapefruit, oranges, tomatoes, or vinegar
2.Spicy foods -Cut back on pepper or chilies.
3.Avoid lying down for two to three hours after meals.
When you are sitting up, gravity helps drain food and stomach acid into your stomach.
4.Eat lean meats and non-fatty foods.
Greasy foods (like French fries and cheeseburgers) can trigger heartburn.
5.Avoid drinks that can trigger reflux, such as alcohol, drinks with caffeine, and carbonated drinks.
6.Eat smaller meals to avoid triggering reflux symptoms.
7.Avoid stress.
Learn to relax or meditate.
8.Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.

A Family Doctor's Tale - EARLOBE INFECTION

DOC I HAVE A EARLOBE INFECTION

The earlobe or pinna is the outer lobe of the ear which help to protect the ear canal.


Infection can affect the earlobe which is made up of cartilage covered by skin,                                  


Earlobes can be of different sizes and fleshiness.


Some earlobes may be deformed as a result of earlobe infection leading to cauliflower ears.

Causes of earlobe infections are:
1.normal bacteria resides on the skin of the pinna or earlobe.
When the skin is broken as a result of
a.tears of the skin from scratching


b.injury of the skin


c.multiple earlobe piercing


the normal bacteria residing on the skin of the earlobe will infect the skin and the underlying cartilage.


If the cartilage is involved the condition is called perichondritis.


Sometimes the infection is severe enough to destroy the cartilage and cause an abscess.


Infection of the external ear canal may also spread to the pinna.

Symptoms of earlobe infections:
The infected earlobe is usually:
1.red
2.swollen
3.warm to touch
4.extremely painful especially to touch
5.Fever and chills in some cases

Diagnosis of earlobe infections:
1.The diagnosis is usually obvious from the history and physical examination.

2.A swab of the pus may be obtained for test and sensitivity to antibiotics

The Treatment for Earlobe infection:
Earlobe infections caused by bacterial infections are treated with 1.antibiotics both orally and topically


2.analgesics for pain

If the infection progress to an abscess formation, incision and drainage of the abscess may need to be done as well as daily cleansing and dressing.

The abscess may destroy the underlying cartilage and as it heals new cartilage growth may lead to a deformity called the cauliflower ear.

Prognosis of earlobe infections:
All earlobe infections normally will heal but recurrences are common.

Prevention of earlobe infections:
1.avoid unhygienic ear piercing


2.avoid wearing multiple ear rings


3.avoid scratching the skin of the earlobe too hrad because the skin is generally thin over the earlobe region.

What are complications of ear infections?
---------------------------------------------

Most external ear infections can be treated easily and resolved without any damage to the surrounding tissues.
In Otitis Media,there is danger of spread of the infections to the surrounding bone tissue,labrynth, meninges and brain.
Acute mastoiditis
labrynthitis
Meningitis
Brain abscess
Facial palsy
Deafness

A Family Doctor's Tale - CHRONIC SUPPURATIVE OTITIS MEDIA

DOC I HAVE CHRONIC SUPPURATIVE OTITIS MEDIA

Chronic Suppurative Otitis media is chronic inflammation and infection of the middle ear which can result in a persistent foul smelling ear discharge and hearing loss.

Chronic Suppurative Otitis media occurs in the area between the ear drum (the end of the outer ear) and the inner ear and is caused by a perforation of the eardrum and recurrent infection of the middle ear.

The ear drum perforation is usually due to previous injury to the eardrum or severe infection of the middle ear.

Part of the skin of the ear will grow into the bone of of the middle ear forming what is known as a cholestestoma. This can grow causing chronic ear discharge and hearing loss.

The Causes of Chronic Suppurative Otitis media are:
Bacterial infections:

1.Streptococcus pneumoniae

2.Haemophilus influenzae

3.staphylococcus aureus

4.Moraxella catarrhalis, a gram-negative diplococcus.

5.Mycobacterium tuberculosis.

6.E.coli

Viral infections:

1.common cold.

2.measles

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

The complications of  Chronic Suppurative Otitis media are:
1.mastoiditis

2.labrynthitis

3.facial nerve palsy

4.meningitis,

5.brain abscess,

6.febrile seizures.

7.death if a severe infection goes untreated long enough

The Symptoms and signs of Chronic Suppurative Otitis media are:
1.Recurrent ear discharge from infection of the middle ear and pus escaping through a perforated ear drum


2. Recurrent earache  from the collection of pus and infection in the middle ear


3.hearing loss from perforation of the eardrum and erosion of the ossicles of the middle ear


Signs:

1.Ear drum usually has a perforation


2.Pus present in the external canal


3.cholestestoma present in the middle ear


4.facial paralysis


The diagnosis of  Chronic Suppurative Otitis media is made on the basis of:
1.Inflamed ear drum with  perforation and purulent discharge.

2.Culture and sensitivity of pus swab from the ear discharge


3.X-rays or MRI of the mastoid air cells and temporal bones


5.Audiogram for hearing loss

The treatment of Chronic Suppurative Otitis media is based on:


Medical:

1. Antibiotics both oral and topical are given especially if the culture showed bacterial infections.

2. pain may be treated with paracetamol or analgesics


3.Antihistamines may be given for stuffed nose


Surgery:

1.Myringoplasty -Puncture of bulging ear drum if painful and aspiration of pus or fluid in the middle ear.

2.Tympanoplasty for eardrum whose perforation does not heal.

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

The prognosis of Chronic Suppurative Otitis media is:
Healing with appropriate treatment is generally good but recurrence is quite common.

Ear drum perforation can be closed with surgery.

Hearing loss may still be present in spite of treatment.


The Preventive measures for Otitis media are:
Avoid chronic infection of the ear


Avoid swimming and diving.

Proper ear hygiene.

A Family Doctor's Tale - DEAFNESS

DOC I HAVE HEARING LOSS
Deafness or hearing loss is the inability to hear.

The causes of Deafness are:

A.Conductive hearing loss
Here sound waves cannot be transmitted from the external environment to the cochlea.
The problem may lie in
1.the external ear canal
a.obstruction caused by wax
b.obstruction caused by foreign body
c.obstruction caused by infection (otitis externa)
d.obstruction caused by ear polyps

2.eardrum
a.perforation caused by trauma
b.perforation caused by infection
c.scarred eardrum from injury or infection

3.middle ear bones
a.dislocation of the bones from injury or infection
b.damage to the bones from injury or infection
c.fixed bones or osteosclerosis (hardening of the bones from aging)

4.middle ear infection
infection of the middle ear occurs with fluid in the middle ear cavity preventing sound from passing through

B.Sensorineural Hearing Loss
a.damage to hearing organ or cochlea which send nerve impulse to the hearing nerve and on to the brain
b.damage to the hearing nerve (auditory nerve)from loud sounds, infection or injury

Common causes of hearing loss are:
1.aging (presbycusis)
2,acute or chronic exposure to loud noise can cause damage to sensory cells of cochlea
3.infection of the inner ear by viruses and bacteria such as mumps, measles or influenza
4.Meniere's disease - a disease with tinnitus, deafness and dizziness
5.Acoustic neuroma - tumour of the vestibular nerve which lies near to the auditory nerve and affects its function
6.Ototoxic drugs which can damage the nerves involved in hearing or sensory cells in the cochlea such as:
a.antibiotics especially gentamycin and vancomycin
b.diuretics such as frusemide
c.chemotherapy drugs

The symptoms of Deafness are:
1.Deafness is a lack of hearing.

The hearing loss is gradual or sudden and can affect one or both ears.

There is difficulty in holding a normal conversation in a noisy environment.

People may complin the affected person does not respond when called or speak louder than usual

2.tinnitus (ringing in the ear) may be present

3.vertigo (spinning sensation) may be associated with it

4.pain and discharge from ear is associated with ear infections

Diagnosis:
1.complete history, ENT examination

2.examination of ear canal and eardrum

3.endoscopy examination of nose and nasopharynx

4.neurological examination

5.hearing test (audiogram) can confirm the presence and severity and type of hearing loss

6.Tympanogram may be performed to detect problems of eardrum and middle ear.

7.X-rays, CT scan or MRI may used to exclude acoustic neuroma or brain tumors.

Treatment
-----------------
Medical treatment depends on the underlying problem.
1.Removal of wax and foreign body in the ear
Ear polyps can be dissolved away with medicines.

2.Antibiotics oral and topical may be necessary in severe external ear infections.

3.In the case of eardrum perforation, once the underlying infection is cleared and the perforation still do not close after 3 months, then surgical repair of the perforation may be needed.

4.If the cause of deafness is due to medication, then the medication should be stopped or changed.

5.If the cause is prebycusis (due to aging) no medical treatment is needed.
The deaf person is assessed to see whether hearing aids will help.

Hearing Aids:
1.hearing aids can amplify the external sound and help the hearing process.
2.They are useful for both conductive as well as sensorineural hearing loss.
3.The side effects from wearing hearing aids include:
obstruction effect
sound feedback
tendency to ear infections

Hearing implants:
Surgical hearing implants are of 2 types:
1.middle ear implants are used for those with sensorineural and conductive hearing loss.
It consists of a transducer that is attached to the middle ear ossicles or directly to the round window of the cochlea.
It vibrates the middle ear structures and amplifies the transmission of sound.

2.Cochlear implants are used in people with moderate to severe sensorineural hearing loss.
The electical electrode of the implant is inserted directly into the cochlea and stimulates the neve endings in the cochlea to bypass any problem in the cochlea.
They can be used in both children and adults.

Prevention of Deafness
--------------------------------
1.Avoid loud sounds especially at concerts or construction sites

2.Avoid toys with sharp points, shafts, spikes, rods and sharp edges to prevent eardrum injuries in children.

3.Avoid medicines which cause cause damage to the hearing nerve.

A Family Doctor's Tale - BLINDNESS

DOC I AM BLIND

Blindness is the inability to see.

The degree of blindness depends on the extent of loss of vision.

The causes of blindness are:
1.cataract


2.glaucoma
Glaucoma is due to a build-up of pressure within the eye causing damage to the  optic nerve transmitting visual information from eye to the brain.

The damage is progressive with loss of peripheral vision  followed by reduction in central vision resulting in blindness.

3.Age-related macular degeneration
Age-related Macular degeneration (AMD) is a degenerative disorder affecting the macula at the back the eye.

4.Corneal opacities are often caused by infections or damage to the cornea


5.Retinal detachment
Retinal detachment occurs with ageing and myopia (nearsightedness) may cause the retina to be pulled and  detached.

6.Trachoma and other infections of the eye often cause loss of vision

7.Accidents (such as chemical burns,fireworks or sports injuries) affects the cornea of the eye


8.Vitamin A deficiency
Vitamin A deficiency leads to decreased production of a photosensitive pigment in the rods of the eye resulting in night blindness .


Three-quarters of all blindness can be prevented or treated.

Blindness is a lack of vision.
It may also refer to a loss of vision that cannot be corrected with glasses or contact lenses.

1.Partial blindness means that there is  very limited visual ability


2.Complete blindness means a total loss of visual or light perception .

3.People with a vision worse than 20/200 are usually legally blind.

Treatment of blindness:
1.Blindness due to some causes such as infection, Vitamin A deficiency or glaucoma can be prevented through early detection and appropriate treatment.

2.Although visual loss cannot be completely restored,  medical and surgical treatment can prevent the loss from further progress and  complete blindness.

3.Because many serious forms of visual loss are painless, any forms of vision loss will need to be detected early and treated to prevent blindness.

Prevention of blindness
1.Vitamin A deficiency cna be treated with Vitamin A to prevent scarring of the eye and the ensuing blindness

2.Diabetes must be well controlled and regular eye examinations are necessary to prevent retinopathy


3.Majority of eye injuries can be prevented by using safe physical activities and proper eye protection.


4.Ensure good lighting and install handrails along stairs to prevent falling especially among the elderly.

5.Sharp corners and edges of furniture may be padded or cushioned.

6.Protective eye glasses are used to prevent insecticides and corrosive liquids from entering the eyes


7.Children should avoid toys with sharp points, shafts, spikes, rods and sharp edges to prevent eye injuries.

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