DOC WHAT ARE OCCUPATIONAL MUSCULOSKELETAL DISORDERS?

Transverse section across the wrist and digits. (Photo credit: Wikipedia)

Occupational Musculoskeletal Disorders

Investigation to establish Work relatedness:
A good occupational history to establish worker exposure to the types of job activities in the work place is important in diagnosis of an occupational Musculoskeletal Disorders.
1.Carpal tunnel syndrome affecting the median nerve of the hand and confirmed by Phalen’s test(complexion of the wrist for 1 minute) and Tinel’s test(percussion of carpal tunnel for 30 seconds) wasting of the thenar muscles. The job activities causing this condition are buffing, polishing, hammering, grinding, assembly work, typing, keying of data, cashier work.
2.Ulnar nerve neuropathy at the elbow affecting the ulnar nerve with Tinel’s test positive over ulnar grove at elbow, positive Wartenburg’s sign (weakness in abduction of small finger), wasting of hypothenar muscles, weakness in pinch and grip, clawing of the ring and little fingers. The job activities are resting forearms on hard surface and excessive flexion or extension of the elbow such as typing, assembly work.
3.Tennis elbow with pain and tenderness of lateral part of a fully extended elbow on resisted extension of wrist and fingers, pain on gripping or twisting of elbow .
The job activities are in small part assembly work, hammering, turning of screws, and meat cutting.
4.DeQuarvian’s tenosynovitis affecting  radial tendons of the wrist with a positive Finkelstein’s test(passive ulnar deviation of the wrist with thumb adducted resulting in pain) , pain on resisted extension and abduction of thumb, local tenderness at radial styloid. Job activities involved are sawing, cutting, butchering, use of pliers, insertion of screws in holes, grinding, polishing, forceful wringling of hands
5.Trigger finger affecting any of the tendon of the hands resulting in locked tendon on flexion, palpable nodule at base of finger proximal to the metacarpophalangeal joint. Job activities involve using of tools with sharp edges or chopper to press into tissues or meat, sawing, butchering, forceful use of pliers, grinding, pressing
6.Rotater cuff tendinitis affecting the shoulder muscles with pain on active or resisted abduction of shoulder  or internal and external rotation, local tenderness on supraspinatus tendon or rotator cuff, sometimes limited abduction of shoulder.
Job activities involve overhead assembly, overhead welding, overhead car repair,
reaching, lifting, carrying load on shoulder
7.Tense neck muscles affecting the neck muscles with stiffness on movement of the neck and local tenderness of muscles.Job activities involved are typing or data entry  with prolonged flexion, extension or twisting of neck.
8.Low back pain affecting the back muscles and dislocation of intervertebral disc with sciatica down the leg with localized tenderness, limitation of movement of back and limitation in straight leg raising test. Job activities involve heavy lifting, carrying or pushing, sudden overload, repetitive loading of goods.

Correlate the exposure to the symptoms of workers at work and relief when on leave.

Get reports of details of work from company to see if work exposure is related to  musculoskeletal conditions.

Management:
1.Treatment at an early stage will be to relieve pain and inflammation of muscles and bones
2.restore the worker’s limitations to normal range of movement
3.prevent recurrence by modifying the work environment
a.adopt proper postures when lifting loads (keep knees bent,back straight and carry close to body)
b.ask for help if load is too heavy
c.have rests in between tasks
d.use mechanical lifting of loads whenever possible
e.reduce frequency of lifting
f.automate some of repetitive work
g.job rotation so that muscles affected can recover
h.provide ergometric furnitures

Training and education will help patient to return to work without fear of recurrence of musculoskeletal disordes.

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DOC WHAT IS OCCUPATIONAL ANEMIA?

DIC With Microangiopathic Hemolytic Anemia (Photo credit: euthman)

Occupational Anemia
An occupational Anemia is a toxic Anemia condition caused by excessive exposure to chemicals, drugs and other circulating metabolites resulting in the damage in the blood cells. Toxic Anemia occur when the red blood cells are reduced in number and volume or are deficient in hemaglobin from damage caused by work related chemicals, drugs and metabolites.
Toxic Anemia can be followed by leucopenia, thrombocytopenia and aplastic anemia.

What are the Signs and symptoms of occupational anemia?
The appearance of occupational Anemia may vary from mild to severe presentation :
1.pallor
2.anorexia
3.weakness
4.giddiness
5.exercise intolerance
6.breathlessness
7.abnormal blood count test can be an early sign of blood disorder.

Some symptoms are indicative of certain underlying cause or toxin.
A blue line on the gums suggest lead poisoning while peripheral neuropathy and transverse lines on the nails (arsenic).
Some chemicals can cause specific blood disorders (leukemia from exposure to benzene and ionizing radiation and aplastic anemia from trinitrotoluene).

In most cases toxic Anemia may take months of exposure before symptoms occur. Very rarely toxic Anemia develops within hours or days of exposure to a toxin(an example is arsine which can cause massive intravascular hemolysis). Often the symptoms of toxic anemia clears when there is no more exposure to the toxin .
Prolonged exposure however can damage the kidney and nerves permanently resulting in chronic renal failure.

Diagnostic Criteria of Work relatedness:
A good occupational history of work exposure to toxic chemicals is important in diagnosing work place anemia. Supporting workplace monitoring and reports will provide more evidence to determine the diagnosis of work related Anemia.

Investigation to establish work relationship to Anemia:

Get an occupational history to establish if the worker is exposed to toxic agents such as :
1.Metals such as
a.arsenic in manufacture and use of pesticides
b.lead from manufacture of lead acid battery,cutting of scrap metals containing lead, production of PVC devices,manufacture of paint pigments
c.mercury from petrochemical industry, repair and manufacture of blood pressure sets containing mercury, analytical laboratories.

2.Solvents such as:
Benzene in petrochemical industry

3. gases such as:
a.arsine in semiconductor industry where there is galvanising, soldering and lead plating occurs,
b.arsine in cleaning of acid storage tanks
c.arsine in smelting and refinery industry
d.waste treatment plants where arsine is released when acid comes into contact with metals containing arsenic

4.Other chemicals such as:
a.trinitrotoluene in manufacture of explosives
b.aniline in rubber dyes manufacture

5.physical agents  such as:
ionizing radiation from radio- isotopes  imaging in medical and industrial work areas such as the evaluation of welding joints in ship and aircraft maintenance.

Get records of exposure monitoring from factories and companies to correlate with the worker’s test results such as:
a.patient’s periodical hemoglobin results
b.urine and blood levels of chemicals and metabolites
c.review of peripheral blood film for levels of red and white blood cells.
Basophilic stippling of the red blood cells may indicate lead exposure.
Heinz bodies are seen in hemolytic conditions which are due to exposure of arsine, naphthalene and benzene.

Management:

1.Treatment will depend on the type of presentation.

2.All workers with abnormal blood cells or hemoglobin results should be investigated and the blood tests repeated after every 3 months until results are normal.

3.All workers with toxic Anemia should be monitored.No specific treatment is required except for removal of exposure to toxic agent. Some workers recovered quickly once removed from the toxic agent. Others may take months to recover.

4.maintain good personal hygiene , wear personal protective equipment and  practice good work practices to prevent absorption of toxic agent.

5.A good nutritive diet with hematinics (blood producing vitamins and iron) should be advised for all workers suffering from anemia.

6.In lead poisoning chelation therapy is specific in removing excessive lead.

7.follow up on cases to monitor disease and whether the patient need hospitalization or blood transfusion

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DOC WHAT ARE WORKPLACE TOXIC HEPATITIS?

Occupational Hepatitis

Low magnification micrograph of an adverse drug reaction leading to a hepatitis, also known as chemical-induced hepatitis, with non-caseating granulomata. Liver biopsy. H&E stain. (Photo credit: Wikipedia)

An occupational Hepatitis is a toxic liver condition caused by excessive exposure to chemicals, drugs and other metabolites resulting in the damage in the liver. Toxic hepatitis due to occupational causes (except from liver angiosarcoma which is due to vinyl chloride or arsenic) is no different from the liver damage caused by non-occupational causes such as statin drugs and excessive alcoholism.

Under WICA toxic hepatitis can be compensated if a worker is exposed to tetrachloroethane, nitro or amino derivatives of benzene or vinyl chloride monomer.

What are the Signs and symptoms of Occupational Hepatitis?
The appearance of occupational Hepatitis may vary from mild to severe presentation :
1.anorexia
2.weakness
3.anemia
4.jaundice
5.palmar erythema
6.liver enlargement
7.abnormal liver function test can be an early sign of liver damage.

In most cases toxic hepatitis may take months of exposure before symptoms occur. Very rarely toxic hepatitis develops within hours or days of exposure to a hepatotoxic agent.
Quite often the symptoms of toxic hepatitis clear when the exposure to the hepatotoxic agent stops.
Prolonged exposure however can damage the liver permanently resulting in liver cirrhosis and failure.

Diagnostic Criteria of Work relatedness:
A good occupational history of work exposure to hepatotoxic chemicals together with supporting workplace monitoring and reports will help to determine the diagnosis of work related hepatitis.

Investigation to establish work relationship to Hepatitis:

Get an occupational history to establish if the worker is exposed to hepatotoxic agents such as :
1.Metals such as
a.arsenic in manufacture and use of pesticides
b.beryllium in manufacture of nuclear devices,satellites and radar system,aircraft bearings in defence and aeronautical industry

2.Solvents such as:
a.carbon tetrachloride in dry cleaning
b.chloroform in laboratories
c.dimethylformamide in solvent manufacture
d.2-nitropropane in painting
e.perchloroethylene and tricloroethylene in cleaning with solvents
f.tetrachloroethane in manufacture of paints and varnishes

3.Anesthetic gases such as:
halothane in operation rooms

4.Other chemicals such as:
a.trinitrotooluene in manufacture of explosives
b.vinyl chloride monomer in rubber and plastic manufacture

5.Biological agents such as:
a.dengue fever in construction sites and farms

b.malaria in military and farm workers

c..hepatitis A,B,C,D in healthcare and sewerage workers

d.leptospirosis in sewerage and drainage workers, waste collectors, abattoir workers

e.meliodosis in construction site,military and farm workers

Get records of exposure monitoring from factories and companies

Management:

1.Treatment will depend on the type of presentation.

2.An abnormal liver function test should be investigated and repeated after every 3 months until results are normal.

3.All workers with toxic Hepatitis should be monitored.No specific treatment is required except for removal of exposure to hepatotoxic agent. Some workers recovered quickly once removed from the hepatotoxic agent. Others may take months to recover.

4.maintain good personal hygiene , wear personal protective equipment and  practice good work practices to prevent absorption of hepatotoxic agent.

5.avoid alcohol consumption

6.follow up on cases to monitor disease and whether the patient need hospitalization

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DOC WHAT ARE OCCUPATIONAL HEAT DISORDERS?

Occupational Heat Disorders

Medical mercury-in-glass thermometer showing the temperature of 40 ºC. (Photo credit: Wikipedia)

An occupational Heat Disorder is an Heat Disorder condition caused by excessive heat exposure resulting in the body’s cooling mechanism to break down especially in unclimatized workers.The Heat rise in the core body temperature may lead to temporary or permanent disturbances  in the body function which may be aggravated by strenuous physical activity.

Predisposing Factors are:
1.lack of acclimatization for workers coming from a colder country
2.poor hydration
3.illness for example a diabetic worker on medication
4.older workers
5.obesity
6.alcohol consumption

What are the Signs and symptoms of Occupational heat disorders?
The appearance of occupational heat disorder may vary from mild presentation as heat rash, syncope or cramps to the more severe presentation of heat stroke and exhaustion.

Mild presentations may include:
1.heat rash with itchy red papules to prickly sensation to blistering especially in a hot and humid environment
2.heat syncope with temporary loss of consciousness, preceded by pallor, blurring of vision, dizziness and nausea
3.heat cramps with painful leg muscle cramps, weakness, nausea and vomiting

More severe presentations are:
1.heat exhaustion which if untreated may develop into life threatening heat stroke.
a.core temperature of 37.7 to 40 degree centigrade
b.profuse sweating, cool clammy skin, fast heart beats , hyperventilation
c.nausea, vomiting, headache, giddiness, light headed
d.intestinal  cramps
e.fatigue, weakness and inability to continue strenuous physical activity
f.normal mental state and stable neurological status

2.heat stroke can be fatal if not treated quickly
a.core temperature above 40 degree centigrade
b.hot and dry skin
c.central nervous system changes include giddiness, drowsiness, confusion, irritability, aggressiveness, apathy,disorientation, loss of bladder and bowel functions, seizures and even coma
d.cardiovascular deterioration
e.multi-organ failure and death

Diagnostic Criteria of Work relatedness:
A good occupational history of work in a hot environment to determine the worker’s work process, materials, practice and habits is important in diagnosis of an occupational Heat Disorders.

Reports on temperature, humidity and air ventilation are useful measures of heat stress in the environment. One of the indices of these is the Wet Bulb Globe Temperature.

Investigation to establish work relationship to Heat Disorders:

1.Get an occupational history to establish if the worker is exposed to physical work in a hot environment.
At risk are workers who are newly assigned to work in such an environment:
a.construction workers especially whose work is in the hot sun
b.steel workers
c.oven and furnace workers
d.shipyard workers
e.landscaping and agriculture workers

New workers would need at least 2 weeks to slowly acclimatized to working moderately under the hot weather.

2.Get records of temperature, humidity and other measures of heat indices.

Management:

1.Treatment will depend on the type of presentation.
a.rest
b.replacement of fluid and electrolytes
c.immediate cooling efforts to reduce core body temperature in heat stroke

2.All heat stroke and exhaustion patients should be referred to hospitals for further evaluation and treatment.

3.All workers with mild heat disorders should drink enough water before returning to work.

4.maintain good personal hygiene , wear personal protective equipment and  practice good work practices to prevent  Heat Disorder.

5.followup on cases to monitor disease and whether the patient need hospitalization

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DOC WHAT ARE OCCUPATIONAL INFECTIONS?

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Occupational

Infections

An occupational Infection is an Infectious condition caused by biological agents such as bacteria, viruses, fungi and parasites at the work place.

These infections can occur from contact with infected people or animals or their tissues, secretions or excretions.

What are the Signs and symptoms of Occupational Infections?
The appearance of occupational Infectious disorder is no different from any other Infectious disorder.

Acute presentations may include:
1.fever
2.malaise
3.headache
4.vomiting
5.cough
6.diarrhea
7.rashes
8.breathing difficulty

Diagnostic Criteria of Work relatedness:
A good occupational history to determine the worker’s work process, materials, practice and habits is important in diagnosis of an occupational Infections disease.
The onset of the infection should co-related to:
1.duration of employment
2.occupational exposure to germs
3.history of a work related accident followed by the infection
4.Isolating of biological agent in a patient and correlated to the other workers exposed to patient.

Investigation to establish work relationship to infections:
Viruses:
1.AIDS, hepatitis B and C, SARS in health care workers, laboratory staff, biological waste handlers
2.Chickenpox, measles, rubella, hand mouth foot disease in healthcare workers, childcare workers, teachers
3.Chikungunya and dengue fever at construction sites, agriculture, and farms
4.Avian influenza in poultry houses with close contact with infected birds
5.Swine influeza, nipal virus in abbatoir workers, pork vendor, veterinary and healthcare workers
6.Rabies in animal handlers and veterinary workers

Bacteria:
1.Tuberculosis in healthcare workers, mortician and laboratory personnel
2.Tetanus and melioidosis in agriculture and farm workers, construction workers, military personnel
3.Anthrax in cleaning, preparation and treatment of hides and wool from animals
4.Leptospirosis in drainage and sewerage workers, veterinary workers, abattoir worker, waste and refuse collectors, road sweeping and military personnel.

Parasite:
1.Malaria in agriculture, farm and military personnel working in endemic areas.

Conduct the relevant diagnostic laboratory test to establish and confirm diagnosis of suspected infection and correlate this with presentation, incubation period and modes of transmission.

Inform the notifiable diseases department of the health ministry.

Management:

1.Isolate worker immediately to prevent spread of infection.

2.maintain good personal hygiene , wear personal protective equipment and  practice good work practices to prevent spread of infection.

3.followup on cases to monitor disease and whether the patient need hospitalization

4.Put in place a procedure for infection control allowing work restriction of infected workers and allowing time away from work during period of illness, promoting good health lifestyle and hygiene.

5.Have a schedule of immunizations in high risk personnel in workplace.

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DOC WHAT ARE OCCUPATIONAL LUNG DISEASES?

Occupational Lung Diseases

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An occupational Lung disorder is a Lung condition caused by or aggravated by work.

The most common lung disorders are asthma, silicosis and mesothelioma.

What are the Signs and symptoms of occupational lung diseases?
The appearance of occupational Lung disorder is no different from any other Lung disorder.

Acute presentations may include:
1.rhinosinusitis
2.laryngitis
3.bronchitis
4.pneumonitis
5.upper respiratory obstruction

Chronic lung reactions may present as:
1.asthma
2.bronchitis
3.bronchiolitits
4.fibrosis
5.cancer

Other presentations may be:
1.cough
2.wheezing
3.tightness of chest
4.shortness of breath

Physical examination of the lungs may reveal:
1.crepitations in the lungs
2.rhonchi or wheezing
3.hyper-resonance of the lungs
4.clubbing of the fingers

Diagnostic Criteria of Work relatedness:
A good occupational history to determine the worker’s work process, materials, practice and habits is important in diagnosis of an occupational Lung disease.
X-rays of the chest may show pneumoconiosis and obstructive lung disease or cancer
Lung function test such as spirometer will indicate severity of the disease.
Isolation of organism such as tuberculosis in the sputum is useful for treatment.

Investigation to establish work relationship to lung disease:
1.Occupational asthma -
a.from exposure to animal and plant proteins in laboratories and food processing industry,
b.antibiotics from pharmaceutical industries
c.acid anhydydrides, isocyanates, polyurethanes in manufacture of epoxy plastic, paints, glues and adhesives
d.colophony from soldering
e.welding fumes from welding
f.metal  dust from metal grinding

2.Reactive Airway Dysfunction Syndrome: from inhalation of smoke, acid fumes, irritant gases(such as chlorine, hydrogen sulphide,ammonia) where air flow is poor and exposure is very high such as spraying,  painting, electroplating, parquet laying

3.Silicosis: breathing silicon dioxide and silica in crystal forms from mining, sandblasting, tunneling, quarry work, foundry work, stone carving, ceramic work and construction work

4.Asbestosis: inhalation of asbestos fibers (all classes of asbestosis can cause mesothelioma) in work such as manufacture of pipes which contain asbestos, demolition of building with asbestos in roofs, walls and rubbish chutes, usage of asbestos as insulation material in boilers for ships or buildings

Correlate exposure history and work periods to symptoms of lung disease

Correlate symptoms with periods (for example asthma is worse during work and improve after work or on leave).
For diseases with long latency periods such as silicosis, asbestosis or mesothelioma emphasis must be placed on past exposure many years ago.

Chest x-rays may show eggshell calcifications or small round opacities in silicosis.

Management:

1.treatment involve giving bronchodilators, steroids to removal from exposures in the workplace. In some cases the workers are given a change of jobs to avoid the offending chemical irritant.

2.complete removal from further exposure remains the most effective treatment of occupational lung disease.

3.workers with silicosis should be followed up with chest x-rays to exclude tuberculosis especially those with cough.

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Occupational Eye Diseases

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An occupational Eye disorder is a Eye condition caused by or aggravated by work.

The most common types of work related eye disorders are eye injuries which can result from small foreign objects ejected by tools or during work involving grinding, welding and hammering.

What are the Signs and symptoms of Occupational eye disorders:
The appearance of occupational Eye disorder is no different from any other Eye disorder.

The symptoms include:
1.redness
2.swelling,
3.pain
4.blurring or loss of vision.

Examination should include assessment of the eyelid, eyeball and the face.
A slit lamp microscope will aid in the diagnosis.

The doctor should suspect a work place eye injury when the mechanism of injury appears to be a penetrating injury of the eye.

The most common eye disorders in work injuries are :
1.foreign bodies in the eye – foreign bodies in the eye cause little or no damage if they remain on the conjunctiva (the white part of the eye)

Any rubbing of the eye can cause severe conjunctival lacerations or corneal abrasions.Any penetrating foreign bodies may require surgery for removal and repair.

2.chemical irritation – the doctor should also check for other signs of poisoning or exposure to the specific chemical. An example is trichloroethylene which can cause optic neuritis  and retinitis .It can also cause neurological dysfunction and liver cirrhosis.

Diagnostic Criteria of Work relatedness:
A good occupational history to determine the worker’s work process, details of the accident, mechanism of  injury and what chemicals were involved.
A good understanding of the working conditions, mechanism and a good medical examination is important in diagnosis of an occupational Eye disease.

1.eye irritation or burning sensation could be due to:
a.foreign body in the cornea or conjunctiva from construction work especially chiseling and hacking, wood working, metal working, and grit blasting in ship repair.
Management will be immediate irrigation with sterile water or isotonic saline solution, followed by removal of penetrating foreign bodies best done by an eye specialist and antibiotic eye ointment if there is possible eye infection

b.chemicals such as acids, alkali, solvents, ammonia in chemical industries, electronics, dry cleaning and metal industries.
Management will be immediate irrigation of sterile water or isotonic saline solution followed by antibiotic eye ointment if there is infection.

c.non-ionising radiations such as microwaves, infra red light ,laser radiation in welding work. Management is the same as above .Follow up is necessary to exclude corneal scars .

2.Tired eyes or dryness of eye from prolonged computer use especially with inadequate lighting, glare and low humidity.
Management is to have 15 minutes rest for every hour of continuous work, use of computer screen to avoid glare and proper lighting.

3.Cataracts from ionizing radiation and ultraviolet light radiation from welding work, exposure to the sun outdoors.
Management is to use eye protection devices.

4.corneal ulcerations due to tar, bitumen, mineral oils, solvents from petrochemical industry and refinery.
Management should done by eye protection and examination by an eye specialist if possible.

Prevention:
Occupational eye disorders can be prevented . in dealing with chemical injuries the most important is copious irrigation of water or isotonic saline solutions.
Eye protection with welding shields and protective glasses is important.
Proper lighting, adequate humidity and avoidance of continuous computer work are also important in protecting the eyes.

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DOC I HAVE A HEAD INJURY

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What is Head Injury?
Head Injury is a direct trauma to the head.
There is acceleration or deceleration injuries to the brain cells, meninges or blood vessels in the brain.

It is important to ask for nausea, vomiting, stiffness of the neck, fits, (indications of brain injury), loss of unconsciousness and weakness of one side of the body (stroke due to hemorrhage in the brain).

What are the causes of Head Injury?

The most common cause of Head Injury :

1. Falling in children and the elderly resulting in the head hitting the ground or hard object. This may result in a linear fracture or concusion of the brain.

2.Blows to the head – high speed blows to the head may cause a depressed fracture or penetrating injuries or just concussion to the brain

3.Accidents in the car, bus , train, areoplane and other form of transport.  

What are the types of Head injuries?

Serious Types of Head Injuries with loss of consciouness and bleeding from the nose should be referred to hospital for MRI brain investigation and further treatment:

1.Contusion of the scalp:
There is a bruise or bump on the head caused by diect trauma.
It is usually harmless in the absence of other symptoms as the injury is superficial to the skull bone

2.Fracture of the skull:
This can occur with direct trauma to the head.There may be pain and tenderness at the area of the fracture.A small in the skull without any underlying bleeding or damage to the brain can be left alone and the fracture can heal by itself.However if there is a depressed fracture or signs of bleeding under the skull , it is better to monitor the person in a hospital in case of increased pressure in the brain.

3.Bleeding beneath the skull bone:
This can occur after a direct trauma to the head or after a forceful jerk to the head.There may not any external sign of bleeding but there will be headache or weakness or numbness on one side of the body. There may be also loss of memory of the events leading to the trauma. Onset of symptoms may occur within the first 24 hours of the injury.

4.Contusion of the Brain:
This can occur from direct trauma to the brain even if there is no fracture on the skull.The brain is injured directly or through the movement of the brain against the other side of the skull (contrecoup injury).There may be edema of the brain and capillary hemorrhage especially in the frontal and temporal lobes.

What are the symptomss and signs of Head Injury?

1.laceration or bruise of the scalp
2.various degree of consciousness:
a.stable
b.unconscious – require hospitalization
3.bleeding from wound in head or from nose(internal bleeding from brain)
or from ear
4.symptoms of pressure in  the brain:
a.nausea,giddy, vomiting
b.blurring of vision
c.difficulty in speech
5.Motor strength on one or both sides of arms and legs affected
6.pain at site of injury

Diagnosis:
1.Skull and neck xrays
2.MRI or CAT scan of the brain to identify fractures, intracranial hematoma, edematous brain
3.Cerebral angiography to detect subdural hematoma
4.Search for other injuries and hemorrhage
5.neurological deficits

Treatment:
1.stop bleeding from scalp
2.hospitalization if signs of brain pressure present
3.protect spine in case of neck injury
4.intracranial pressure monitoring
5.use of steroid to decrease edema in brain

Prognosis:
depends on the degree of head injury

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DOC I HAVE SIALADENITIS

What is Sialadenitis?

Sialadenitis is an inflammation of the salivary glands .

There are 3 salivary glands:

1.Parotid – the largest salivary gland is located at the cheeks in front of the ears. An inflammation of the parotid gland is called parotitis.

2.Submandibular – this salivary gland is located at the back of the cheek below the lower jaw.

3.Sublingual – this salivary gland is located below the jaw near the front of the mouth below the  front of the tongue.

Inflammation of the salivary glands are usually viral  (example mumps) or bacterial.

They are common in most people and can recur after infections.

What is the cause of Sialadenitis?

1.Viral (mumps) infection

2.bacterial infection such as staphylococcus or pneumococcus

3.It can be associated with the presence of salivary stones (sialothiasis) in the duct.

It can occur as a result of poor oral hygiene or debilitating disease

Acute post operative parotitis used to be a common problem caused by ascending infection from the mouth but has been avoided by appropriate fluid therapy following surgery.

What are the symptoms of Sialadenitis?
Symptoms are:

1.acute swelling of the involved salivary glands or entire side of face

2.abnormal tastes , often foul

3.fever, general toxemia and malaise

4.pus or purulent saliva may discharge from the Stensen’s duct(opening of the salvary duct )

5.dry mouth

6.Pain  on opening of the mouth or eating food

How is the diagnosis of  Sialadenitis made?

Diagnosis:
1.presence of swelling of salivary gland especially the parotid

2.Xrays may show the presence of stones in the salivary duct

3.CT Scan or ultrasound may be necessary if there is suspected abscess or stones causing obstruction to the saliva duct

What are the complications of Sialadenitis?

The complications of Sialadenitis Fever are:

1.pneumonia

2.abscess formation

3.cellulitis or spread of infection to other parts of the face or neck

What is the treatment of Sialadenitis?

Treatment may not be necessary in mild cases.

1.Viral infections may only require symptomatic treatment such as for bed rest. anti fever medicine, pain killer, mouth rinses , oral hygiene and lots of fluid (water).

2.If the infection is suspected to be bacterial, antibiotics are given according to culture and sensitivity to antibiotics.

3. If there is abscess or blockage of the salivary duct, surgical drainage of pus or removal of stone may be necessary

What is the prognosis of Sialadenitis?

Prognosis depends on extent of disease.

Most viral mild salivary gland infections will disappear with symptomatic treatment . Bacterial infections are cured with antibiotic treatment.  Rarely there are complications such as difficulty in breathing or swallowing.

How do you prevent sialadentis?

1.Proper oral hygiene

2.Avoid smoking

3.Drink adequate fluids.

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DOC  HOW DO I PREPARE FOR TRAVEL ABOARD?

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General Medical Advice for Travelers

Consult a doctor 4-6 weeks before departure.
This allow sufficient time for the relevant vaccinations to take effect and to address any specific health concerns.

If there is a chronic medical condition such as asthma, diabetes and high blood pressure, make sure you have enough medicine to last you for the duration of your trip.

Falling sick or sustaining injury during your trip can be costly, it is important that you buy travel insurance for your trip.

Prepare a travel kit .Depending on your plans you may want to include the following which can be bought at a pharmacy:
1.Painkiller/fever tablets such as paracetamol (Tylenol)

2.diarrhea tablets such as imodium or lomotil

3.antihistamines for cold and rash such as Piriton, Actifed

4.motion sickness tablets such as stemetil, dramine patches

5.oral rehydration salts for treating dehydration in diarrhea

6.antiseptic lotion or cream such as dettol cream for wounds and insect bites

7.cotton wool or buds for cleaning wounds, eyes, ears

8.adhesive dressing or plaster for wounds

9.bandages for sprains and wounds

10.thermometer to check on temperature

11.insect repellant to prevent insect bites

12.sunscreen to prevent sun burns

13.eyedrop for dry eyes or wash eyes

Illnesses likely to encountered in other Countries:
1.Malaria – especially in South East Asia, India, Pakistan,Bangladesh

2.Japanese Encephilitis is a mosquito borne disease affecting most Africa and middle East.

3.Yellow Fever in sub-saharan Africa and South America

4.Traveler’s Diarrhea – Personal food hygiene is important here

5.Amebiasis is common in India, Africa and South America

6.Shigella Dysentery is a bloody form of diarrhea caused by the shigella bacteria, occurs mostly in India and Africa

7.Cholera is also a waterborne disease caused by a bacteria in South East Asia, India, Africa

8.Typhoid and other salmonella diseases are also infections of the salmonella bacteria where food hygiene is poor.

9.Hepatitis A, B viral infections are spread by carriers and unhygienic food.

10.Altitude illness in Tibet,  Nepal and some South American countries with high attitude cities

11.Bird flu is getting more common in the last few years

12.Seasonal Influenza can be dangerous during winter 

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DOC I HAVE EXCESSIVE SECRETION OF MILK

What is Galactorrhea  ?

Galactorrhea is an abnormal milky breast secretion or non puerperal (non post-pregnancy) lactation or secretion of milk. .

What is the cause of Galactorrhea?

The cause of Galactorrhea is due to:
1.Chiari-Frommel Syndrome where there is persistent galactorrhea and amenorrhea after pregnancy, excessive prolactin, and deficient gonadotrophin.

2.Prolactin secreting microadenomatoma of the pituitary

3.Chromophobe adenoma of the pituitary(Forbes-Albright Syndrome)

4.small, noncancerous growth in the breast called an intradermal papilloma

5.Injury to the breast or chest wall resulting in milky discharge.

6.Widening of the milk ducts called ductal ectasia normally not cancerous

7.Hypothyroidism due to high thyrotrophin releasing hormone

8. drug induced lactation by taking:
a.phenothiazines, tricyclic antidepressants
b.maxolon,
c.methyl dopa
d.reserpine
e.cimetidine
f.estrogen and birth control pills

What are the Symptoms of Galactorrhea?

1.Excessive milk production

2.Breast lump or swelling

3.Pain and tenderness of the breast sometimes due to engorgement of breast

4.oligomenorrhea or amenorrhea

How is Galactorrhea diagnosed?

1.Serum prolactin levels is high

2.Thyroid hormone function

3.Skull x rays to exclude enlargement of pituitary gland area

4.MRI of the brain is more accurate in diagnosing abnormality of the pituitary tumor

5.Mammography to exclude any malignant tumors

6.Ultrasound of the breast is similarly done to exclude malignant tumors

7.Ductography  an x-ray with contrast dye injected into the affected milk duct to see any blockage of some ducts or widening of other ducts

8.Biopsy of the breast lump if the mammogram is abnormal, or if the discharge is occurring on its own with no pressure on the breast

What is the Treatment of Galactorrhea?

1.Stop drugs in case of drug induced Galactorrhea

2.Bromocriptine (a dopamine antagonist ) prevent the pituitary gland to stimulate production of milk

3.Radiation to pituitary gland to reduce hormones which stimulate production of milk

4.Surgical resection of pituitary gland if there is a tumor

5.Treatment for hypothyroidism with thyroxine daily

6.Abnormal findings on a mammogram or breast ultrasound will need breast biopsy and often removed.

7.Removing all or some of the breast ducts may be done right away or over  a period of observation. Often a repeat ductography is done before surgery.

8.Finally most women with breast discharge with a normal mammogram, breast ultrasound, and physical exam should be followed up over 1 – 2 years with a mammogram and physical exam .

What is the prognosis of Galactorrhea?

Prognosis depends on the cause.

Most cases will have reduction or disappearance of the milky discharge over a period of time or with treatment. Prognosis is generally good if mammography does not show any abnormality.

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DOC I HAVE RHEUMATIC FEVER

What is Rheumatic Fever?

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Rheumatic Fever is a febrile disease characterized by arthritis, heart disease, chorea, appearing alone or in combination with subcutaneous nodules and erythema marginatum.

What causes Rheumatic Fever?

The cause is infection with Group A beta-hemolytic Streptococcus.

The streptococcus bacteria usually affects the pharynx or tonsils resulting in an immune response which affects the heart, joints,and skin.

It usually affects children from the age of 5 to 15 years especially in the lower income families.

What are the symptoms of Rheumatic Fever?

1.history of sore throat one to three weeks before onset.

2.fever which is sustained

3.polyarthritis of large joints especially knees, elbows, ankles

4.Migratory arthritis -moves from joint to joint rarely persisting in one joint for more than a few days. The migratory arthritis usually lasts for several weeks.

5.During the arthritis joints are hot, red. swollen and painful but no permanent damage occurs even without treatment.

6.Carditis occurs in 40 per cent and may present as pericardial rub, pericardial effusion, myocarditis with tacycardia with murmur from valvular incompetance(mitral, aortic)
Carditis usually develops early.

7.Skin nodules occur if disease persists.

8.Erythema marginatum also uncommon.

9.Sydenham Chorea ( with emotional instabilty, muscle weakness and quick, uncoordinated jerky movements) is an unusual feature and may persists up to 6 months

10.nosebleeds rarely occurs in Rheumatic Fever

How is the diagnosis of Rheumatic Fever made?

The diagnosis of  Rheumatic Fever involve
1.throat swabs for streptococcus positive in 25 per cent early cases

2.Anti-Streptolysin O titers raised in 80 % of patients

3.ESR rate high

4.C-reactive protein is high in cardiac failure

5.ECG will show prolonged PR intervals and evidence of myocarditis or pericarditis

6.chest xrays show pericardial effusion or cardiomegaly

What are the complications for Rheumatic Fever ?

1.heart valve damage

2.various skin joint and bone problems

3.Sydenham Chorea

What is the treatment for Rheumatic Fever?

Treatment for Rheumatic Fever:

Supportive treatment:
1.bed rest
2.fever medicine
3.treat heart failure with diuretic

Suppresive treatment:
1.Penicillin  intramuscular injection or oral daily or sulphadiazine or erythromycin daily until 18 years old

2.Corticosteroids will suppress severe cardiac lesions.
Duration and dosage depends on severity in a dose of 2mg per kgm per day prednisolone dosage until ESR has gone down then slowly tapered off.

What is the prognosis of Rheumatic Fever?

No permanent joint damage

Cardiac lesions persist and becomes worse each time there is a recurrence of rheumatic fever

Effectiveness of antibiotics against streptococcus determines prognosis.

Outcome is worse with systemic manifestations of disease

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DOC I HAVE GAS
GANGRENE

What is Gas Gangrene?

Gas Gangrene is a toxic rapidly progressive clostridial infection causing muscle necrosis.

What is the cause of Gas Gangrene?

The known cause is the clostridium perfringens bacteria which are spore forming, anaerobic, gram positive bacilli.Rarely it also can be caused by Group A streptococcus, Staphylococcus aureus and Vibrio vulnificus. 

It normally live a saprophytic existence in intestinal tract of humans and animals and in soil.

There are 4 reasons which predispose to muscle invasion by the bacilli and exotoxin production:
1.impaired local blood supply
2.metallic bodies, clothing or dirt in wound
3.presence of necrotic tissue and hemorrhage
4.growth of aerobic germs in wound or uterine cavity

Under these conditions, the bacilli multiply anaerobically. As the bacteria grows it produces gas in body tissues and releases toxins which can damage tissues .
Toxins diffuse to surrounding muscle and causes tissue death, damage to blood cells and blood vessels resulting in gangrene.

What are the symptoms of Gas Gangrene

The symptoms are:

1. inflammation of the tissue at the site of infection-pale skin color, later becoming dusky and changing to dark red or purple

2.very painful tissue swelling

3.The edges of the infected area expand so quickly that destruction of the involved tissue  can be seen over a few minutes.

4.Air can be felt under the skin

5.Blisters filled with brown-red fluid

6.foul-smelling brown-red or bloody fluid

7.Increased heart rate

8.Moderate fever

9.sweating

10.jaundice

If the condition is not treated, the person can develop shock with decreased blood pressure (hypotension), kidney failure, coma, and finally death.

Prevention of gas gangrene:

1.Always clean the wound thoroughly with hydrogen peroxide

2. watch for signs of infection such as redness, pain or swelling around a wound

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DOC I HAVE ACTINOMYCOSIS

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What is Actinomycosis?
Actinomycosis fever is a chronic infection caused by the Actinomycosis anaerobic gram positive bacteria (Actinomyces israeli) associated with multiple draining abscesses.

There are 4 forms of Actinomycosis:
1.General:

affects the whole body including skin, brain, bones, kidney, liver and female pelvic organs

2.Cervicofacial (neck and face) form arises in decayed teeth

3.Respiratory form is caused by aspiration of oral secretions

4.Abdominal form has transmucosal (through the mucosal lining of the intestine) spread.

Discharge from multiple communicating abscesses contain sulfur granules in the fluid.

They are yellowish granules made of clumped micro-organisms.

The most common location is in the neck and facial region.

The bacteria enters the tissues of the neck or face through injury, dental surgery and infection.

Very common cause of infection is a dental abscess or dental surgery.

Sometimes Intra uterine Device in the womb of women may also cause infection by the Actinomycosis bacteria.

Once inside the tissues of the neck or face it forms a lump (abscess) at the lower jaw. Once the abscess burst , pus pours out from a sinus tract in the skin of the jaw.

What are the symptoms of Actinomycosis?
Symptoms are:

A.Cervicofacial:
1.affects the cheeks, tongue, pharynx, salivary glands, skull bones, meninges and brain

2.small flat hard swellings which soften forming sinuses and fistula

B.Thoracic form:
same symptoms as tuberculosis
1.fever
2.pain
3.chronic cough
4.perforation of chest wall with sinuses

C.Abdominal form:

affects appendix and caecum
1.pain,
2.fever
3.constipation
4.diarrhea
5.palpable mass
6.draining sinuses and fistula

D.General:

has blood spread to the whole body including skin, brain, bones, kidney, liver and female pelvic organs

Diagnosis of Actinomycosis is by:
1.presence of Actinomyces israeli in sputum, pus or biopsy specimen

2.Examination of drained fluid under a microscope shows sulfur granules in the fluid

3.X rays of the chest and jaws

What are the complications of Actinomycosis?

The complications of Actinomycosis are:

1.pneumonia

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

3.large abscesses which may lead to sepsis

What is the treatment of Actinomycosis?

Treatment of Actinomycosis:
1.antibiotic according to sensitivity
2.continuous antibiotic for months
3.surgical drainage of abscesses
4.laparotomy and surgical excision of abdominal forms

What is the prognosis of Actinomycosis?

Prognosis:
This depends on extent of disease
It is a slow progressive disease
The best prognosis is treatment of the cervicofacial form
The prognosis is poor in pulmonary, abdominal and generalized forms respectively.

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DOC I HAVE BRUCELLOSIS

What is Brucellosis?
Brucellosis is an infectious disease caused by the Brucella bacteria which commonly cause infection in animals.

What is the cause of Brucellosis?

There are 5 forms of Brucella:
1.B.abortis present in cattle
2.B.melitensis -goat
3.B suis -pigs
4.B.canis dogs
5.B.ovis sheep

Infection occurs through contact with tissues of infected animals or by ingesting infected milk products of these animals

They are particularly found in farmers , veterinary surgeons and slaughter house workers.

They are usually found in young males.

The germs localize in the reticuloendothelial cells of liver, spleen, bone marrow, and lymph glands.

What are the symptoms of Brucellosis?

Incubation peroid is 2 to 4 weeks.
Symptoms are:

Mild flu-like attacks with symptoms of:
1.fever

2.headache

3.malaise

4.abdominal pain

5.chills

6.loss of appetite
sometimes episodes of infection can continue for months to years.

Relapses and recurring attacks of fever are usually seen in B.melitensis (or undulant fever -here the fever rises and falls in waves)
Symptoms in these cases are:
1.severe sweating

2.Abdominal pain

3.pains in limbs,back  and joints

4.headache

5.sore throat

6.irritability,insomnia

7.loss of appetite

8.erythematous rash

9.enlarged liver, spleen and lymph glands

10.loss of weight

In more severe cases there may be bleeding

Chronic brucellosis:
1.fever

2.fatigue and weakness

3.tremors

4.rheumatic and muscle pains

5.swollen lymph glands

How is Diagnosis of Brucellosis made?

Diagnosis of Brucellosis is made using:
1.blood, urine and bone marrow cultures

2.raised antibodies titers(more than 1:80) of brucella

3.radioimmunology of specific Brucella immunoglobulins

4.CSF Culture

What are the complications of Brucellosis?

The complications of Brucellosis Fever are:

1.arthritis

2.neurological disturbances and neuritis

3.meningoencephelitis

4.infective endocarditis

5.hepatitis

6.orchitis

What is the treatment of Brucellosis?

Treatment of Brucellosis is by:
1.antibiotic treatment such as tetracycline, septrin, streptomycin

2.continuous antibiotic for months

3.general supportive care:
a.rest
b.analgesics

4.corticosteroids in severe or chronic cases

What is the Prognosis of Brucellosis?

Prognosis:
1.acute uncomplicated disease may remit by itself

2.generally good if treated properly

3.rarely fatal

What are the preventive measures for Brucellosis?

Prevention:

Taking only pasteurized milk and cheeses is the most important way to prevent brucellosis. People who come in contact with animals should wear protective glasses and clothing to avoid  infection.Any skin breaks should be protected from contact with infected animals.

Vaccination is available for cattle but not humans.

Early detection of the disease in animals is important in isolation of animals and preventing infections.

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DOC I HAVE ERYTHEMA NODOSUM

What is Erythema nodosum?

Erythema nodosum is an acute erythematous disease of the skin and subcutaneous tissues characterized by painful nodular erythemous reactions associated with a systemic disease or process.

Erythema Nodosum  is more common in women than it is in men.

What causes Erythema nodosum?

50% per cent of the erythema nodosum has unknown causes .

The remainder 50 per cent has known causes as below:

1.The commonest cause is streptoccocal infections.

Other infections are:
coccideomycosis

histoplasmosis

tuberculosis

Cat scratch disease

Leptospirosis

Infectious Mononucleosis

Psittacosis

Syphilis

Chlamydia

Hepatitis B

Mycoplasma

Mycobacteria

2.Systemic diseases:

sarcoidosis

ulcerative colitis

leukemia

lymphoma

Tularemia

rheumatic fever

3.Drug reaction to antibiotics such as sulphonamides, sometimes tetracycline and

amoxillin and penicillin drugs

oral contraceptives.

progestin

sulphones

What are the symptoms of Erythema nodosum?

Erythema nodosum symptoms is acute in onset with fever and transient joint pain.

1.lesions are bright red, shiny nodules 3-4cm in diameter

2.typically found on shin(anterior tibial surfaces)  but can also occur on the thighs, buttocks, arms

3.lesions can change from pink to blue to brown with appearance like a bruise

4.the lesions are painful throbbing and tender initially

5.legs may be swollen

6.lesions often symmetrical on both legs

7.scattered lesions may occured elsewhere

8.joint swelling

How is the diagnosis of Erythema nodosum made?

The diagnosis of  Erythema nodosum involve
1.typical appearance of skin and mucosa

2.history of bacterial and medical causes.

3.Full blood count showed raied white blood cells and Erythrocytes Sedimentation Rate (ESR)

4.Antistreptococcal titers raised in streptococcal cases

5. mantoux test for tuberculosis

6.Chest X rays showed hilar nodes and evidence of sarcoidosis or tuberculosis

7. Throat swabs for streptococcus

8. Most important is a punch biopsy of a nodule which will confirm the illness under the microscope

What are the complications for Erythema nodosum ?
1.heart valve and kidney disease from streptococcus infection (rheumatic fever)

2. Underlying conditions such as lymphoma , leukemia, sarcoidosis, tuberculous, ulcerative colitis, can be dangerous and fatal

What is the treatment for Erythema nodosum?

Treatment for Erythema nodosum :
1.bed rest and fluids

2.legs with nodules relieved of pressures by elevation with foot rests

3.treat infections with antibiotics

4.Hot or cold compresses to help reduce discomfort

5.analgesis and non steroidal anti-inflammatory drugs for pain and swelling

6.treat underlying cause and remove offending drug or radiation

7.Potassium iodide (SSKI) solution to clear up the nodules.

What is the prognosis of Erythema nodosum?

generally good with proper treatment. It is not dangerous.

However the condition usually go away within about 6 weeks, but may recur.

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DOC I HAVE SARCOIDOSIS

What is Sarcoidosis?

Sarcoidosis is a disease characterized by the formation of non-caseating granulomas in a variety of tissues which usually resolve spontaneously.

Incidence is 0.01 per cent of population.
It is more common in Africans.

What causes Sarcoidosis?

The cause is unknown.

1.Most common site of involvement is the lungs with hilar lymph nodes enlargement.
2.Lymph nodes,
3.liver
4.spleen
5.skin
6.eyes
7.heart
8.kidney
9.bone marrow

Non caseating granulomatous lesions are seen in all these tissues and may be related to infection or collagen disease.
Histology showed giant cells of Langhan’s type.
Eventually the lesions go on to fibrosis and scarring

What are the symptoms of Sarcoidosis?

Sarcoidosis symptoms may be none.
Sometimes bilateral hilar enlargement are discovered only on routine chest X rays.
Intrathoracic Sarcoidosis may be divided into 4 stages:
1.Stage 0:
normal chest x rays
slight or no pulmonary function anormalities

2.Stage 1
hilar adenopathy
slight or no pulmonary function changes

3.Stage 2
hilar adenopathy
chronic intrinsic restrictive lung disease

4.Stage 3
intrinsic restrictive lung disease
obstructive lung disease
no hilar adenopathy but parenchymal infiltration

Other symptoms suggestive of sarcoidosis are:
1.erythema nodosum
2.cough
3.breathlessness
4.weight loss
5.lassitude
6.mild fever
7.superficial lymph nodes enlargement
8.enlarged liver and spleen felt on palpation
9.skin lesions
10.ocular lesions such as iridocyclitis, uveitis and retinal sarcoidosis
11.infiltrations in salivary glands, bones, joints, heart and CNS

How is the diagnosis of Sarcoidosis made?

The diagnosis of  Sarcoidosis involve
1.Biopsy and demonstration of non caseating granulomas with giant cells

2.scalene node biopsy may indicate lung disease

3.liver biopsy for forms of abdominal sarcoid

4.Kveim’s test (intradermal injection of 0.2 ml sarcoid suspension).
Mantoux test is usually negative

5.Hypercalcemia may be present

6.Angiotensin converting enzyme activity may be elevated

What are the complications for Sarcoidosis ?

1.Progression of uveitis
2.various skin joint and bone problems

What is the treatment for Sarcoidosis?

Treatment for Sarcoidosis depend on the stage:
1.Stage 0 patients do not need treatment

2.Stage 1 patients should never be treated unless there is lung function impairment

3.Stage 2 patients should be treated if pulmonary function is impaired or chest x rays reveals extensive involvement.
Observation of the condition for 3 to 6 months and treat with steroids if condition become worse

4.Stage 3 patients should be treated if the pulmonary function is affected. Corticosteroids are prescribed more freely in these patients

Corticosteroids will suppress active lesions and are particularly indicated for extra thoracic disease in a dose of 40mg to 60mg prednisolone dosage per day
for one year then slowly tapered off.
Corticosteroids also reduce the formation of fibrosis in the lungs

Local steroids are required for eye disease but systemic steroids are necessary for posterior uveitis.

What is the prognosis of Sarcoidosis?

Overall remission is 87 per cent
A clear chest x ray for 2 years means complete remission
Stage 0: very high spontaneous resolution
Stage 1: 65 per cent spontaneous remission
Stage 2: 50 per cent  spontaneous remission
Stage 3: no spontaneous remission; likely to result in respiratory failure and pulmonary hypertension

Overall mortality is 4 per cent usually from respiratory complication
Outcome is worse with systemic manifestations of disease

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The story of the amazing cold sore virus (Herpes simplex) in comic form by Kenneth Kee and Illustrated by Kelvin Kee . ALL RIGHTS RESERVED

From my website: http://coldsore.biz

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DOC I HAVE MULTIPLE SCLEROSIS

What is Multiple Sclerosis?

Multiple Sclerosis is a progressive degenerative disease of the central nervous system with recurrent episodes of neurologic

dysfunction disconnected in time and space and associated with evidence of demyelination of the central nervous system.

It affects the patient in different areas of the nervous system at various points in time.

What causes Multiple Sclerosis?

The cause is unknown but believed to be related to an auto immune disease resulting from a viral infection.

Multiple sclerosis results in destruction of the myelin surrounding the nerves of the CNS. The destruction is thought to be

caused by the body’s immune system attacking the myelin sheath disrupting the transmission of information in the CNS and

lead to the symptoms seen in multiple sclerosis.

1.In Multiple Sclerosis, there is multiple scattered greying well defined lesions from few small mm size to few cm in size

present in the white matter and extending to the grey matter of the brain.

2.The lesions vary from partial to complete destruction of the myelin sheath with relative sparing of the axon , glia and

other structure.

Who is at risk of Multiple Sclerosis?

Multiple Sclerosis occurs between 20 to 50 years old.

It is more common in Northern Europeans.

Women are affected 2 times more than men.

Triggers that can cause the onset of MS are:
infections
trauma
surgery
emotional upset,
stress
pregnancy

What are the symptoms of Multiple Sclerosis?

The typical symptoms of Multiple Sclerosis are multiple and variable which explains its name.
There may be mild cases which may not need treatment or severe cases which need confinement to wheelchairs.

There is a typical course of exacerbations and remissions over a peroid of years and increased residual neurological deficit

1.impairment of vision is usually an early sign of MS
2.diplopia can occur with optic neuritis
3.unsteady gait due to the effect of the disease on the cerebellum which control balance and co-ordination
4.paresthesia or tingling sensation in the fingers and toes
5.weakness of the muscles leading to hemiplegia
6.facial paresis, vertigo and hearing loss
7.seizures when foci in the brain are over stimulated
8.Constipation and urinary incontinence may also occur as a result of the weakened muscles
9.one peculiar trait is that higher temperatures aggravate the symptoms in MS patients. Nerve conduction at higher

temperature such as a hot shower cause the slowing in the transmission of messages in nerves that have already lost myelin.

How is the diagnosis of Multiple Sclerosis made?

The diagnosis of  Multiple Sclerosis is difficult and involve
1.History of a multiple symptoms involving the nervous system
2.physical and neurological examinations for peripheral neurological deficit.
3.blood count and chemistry, urine analysis are all routine laboratory tests used to rule out other diagnoses
4.Cerebral spinal fluid evaluation may show mild mononuclear pleocytosis (less than 40 cells per cubic meter, protein normal

or increased and high gamma globulin IgG.
5.MRI can search for changes within the brain or spinal cord that are particular to multiple sclerosis.

What are the complications for Multiple Sclerosis ?

1.Weakness of the muscles leading to hemiplegia

2.spasticity of the muscles with rigidity and cramps

3.Poor co-ordination and imbalance

4.urinary and bladder problems

5.visual loss and pain suggesting optic neuritis , an inflammation of the eyeball

What is the treatment for Multiple Sclerosis?

Multiple Sclerosis cannot be cured but can be suppressed:

Supportive measures
1.Bed rest
2.Proper diet and nutrition to strengthen the muscles of the body
3.physiotherapy to strengthen muscles
4.occupational therapy to help stimulate the mind
5.Speech therapy for speech and awallowing
6.social support
7.Avoid triggers

Medications:
1.Glatiramer acetate is able to reduce the relapse rates of multiple sclerosis by about one-third and appears to reduce the

overall progression of multiple sclerosis

2.Natalizumab is a monoclonal antibody that binds to white blood cells which are thought to play a role in causing the

nervous system damage in multiple sclerosis. It also reduces the rates of relapses of MS by two thirds.

3.Fingolimod is a daily oral medication to treat MS by reducing the number of lymphocytes which is believe to cause

inflammation in MS.

4.Interferon which are anti-viral agents has found to reduce relapses of MS by one third.
What is the prognosis of Multiple Sclerosis?

5.Previous treatment used to be ACTH injections and corticosteroids. These are are seldom used.

What is the prognosis of Multiple Sclerosis?
MS is unfortunately still not curable at this time.
Most patients about 65 % with the relapsing and remitting form may improve to a stage where relapses are very much reduced.

Unfortunately they continue to have more disabling symptoms or secondary progressive multiple sclerosis.
15% become worse with progressive relapses.
10% has primary progressive MS with no remissions in between.
Death usually results from pneumonia and heart trouble.

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DOC I HAVE HUNTINGTON’S CHOREA

What is Huntington’s Chorea?

Huntington’s Chorea is a progressive degenrative disease affecting basal ganglia characterized by choeiform movements (movements such as writhing, twisting, and turning in a constant, uncontrollable dancing motion) and mental deterioration.

What causes Huntington’s Chorea?

The cause is believed to be genetic with autosomal dominance transmission from parent to offspring with full penetrance.

In Huntington’s Chorea, there is widespread degeneration changes with cell loss and reactive gliosis mainly in the cerebral cortex (thinking and perception), basal ganglia (balance) and caudate nucleus (co-ordination).

There is the belief that the deficiency of gamma-aminobutyric acid (GABA) in the cells may have contribute to the impairment of the nerve cells.

Who is at risk of Huntington’s Chorea?

Huntington’s Chorea affects sexes in equal numbers.

It is an inherited condition. On average 50 per cent of children of the sufferers will be affected.

What are the symptoms of Huntington’s Chorea?

The typical course of Huntington’s Chorea usually appear between 30 to 45 years but may be earlier or later.

1.choreiform movements (movements such as writhing, twisting, and turning in a constant, uncontrollable dancing motion )

2.emotional disturbance with mental changes

3.cognitive impairment

4.mood swings with inertia followed by irritability

5.apathy

6.anger

7.depression

8.delusion and hallucinations

9.The speech can become  slurred and vital functions, such as eating, speaking, swallowing and especially walking, begin to decline.

10.All the above may occur to varying degree but rate of progression is  generally parallel.

How is the diagnosis of Huntington’s Chorea made?

The diagnosis of  Huntington’s Chorea involve:
1.Typical history of choreiform movements,emotional and mental impairment with family history.

2.physical and neurological examinations for brain neurological deficit.

3.CT scan or MRI may show selective atrophy of the caudate nucleus and putamen. In addition there are enlargement of fluid-filled cavities within the brain called ventricles. These tests do not completely differentiate Huntingson’s Chorea from other conditions such as dementia but they will together with the choreiform movements,emotional and mental impairment point towards Huntingdon’s chorea.

What are the complications for Huntington’s Chorea ?

1.Progression of nerve involvement to whole body with paralysis

2.Dementia may gradually result from mental impairment

What is the treatment for Huntington’s Chorea?

The is no cure for Huntington’s Chorea but symptomatic control of choreiform movements and delusions with haliperidol or clonazepam may help.

Proper nutrition , fluids and exercise will help the patient to stay healthy and fit.

As the condition progress hospitalization or institutional care (such as nursing homes) is usually indicated.

Genetic counseling is important for treatment and prevention of  
Huntington’s Chorea.

What is the prognosis of Huntington’s Chorea?

Except for a few cases there is a relentless progression to death.
Death usually occurs in 10 to 15 years although the course may more acute or prolonged.

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DOC I HAVE CONSTIPATION

Constipation

( A Simple Guide to

Intestines (Photo credit: Wikipedia)

Constipation)  by definition is a condition which is characterized by fewer than normal bowel movement than usual.
It is accompanied by straining, incomplete evacuation and passage of hard stools. 


Many people do not realize the discomfort and abdominal cramps a patient with constipated hard stool stuck in his rectum and anus. Because of the pressure of the hard stool, he is sometimes unable to pass urine. His tummy feels bloated and constant peristaltic wave causes constant abdominal cramps and cold sweats. 
There are even patients who are unable to stand straight because of the pain. 
In the severe cases I have to evacuate the hard stools manually. Once the hard stools comes out from his anus, the patient could relax and breathe again. Unfortunately the stink in the consultation room may need the family doctor evacuate his room and use another consultation room.
 
Constipation is particularly common among the elderly and younger children because of:

1. Insufficient fiber (fruits,vegetables) to form bulk in the stools.

2. Insufficient fluid in the diet(at least 8 glasses of water).

3. Insufficient time to go to toilet when there is the urge to pass motion.

4. Insufficient exercise to help the intestine to move especially after meals, common in sedentary jobs and older people

5. Stress cause the constriction of the anal sphincter preventing the stools from passing.

6. Depression on the other hand depress the movement of the intestines.

7. Drugs like cough mixture containing codeine, antispasmodic, antacids may also reduce the motility of the intestine.

8. Pregnancy in the later stage cause the womb to press against the intestine.

9. People with low thyroid hormone slows down the movement of the intestines.

10.People with piles or pelvic space occupying swelling which may press against the intestine or rectum.

Avoidance of constipation include:

1. Increase in daily fiber intake to at least 15gm (eg. 1 bowl of bran cereal for breakfast), fruits and vegetables).
Fiber increases the bulk of the stool allowing easy passage of stools through the large intestine.

2. Drink at least 8 glasses of water a day (2 liters). Water reduces the hardness of stools.

3. Regular exercises at least 2-3 times a day especially after meals. Exercise will enhance intestinal movement.

4. Allow a distraction free period of 15 min a day for bowel movement. The strongest intestinal movement occurs after breakfast.

5. Do not ignore or suppress the urge to pass bowel movement. This may impair the sensation to detect initiation of bowel movement leading to constipation.

Treatment of  Constipation
1.Follow the advice above.

2.Consult your family doctor to exclude any abdominal swelling which may be blocking the passage of stools.
A colonoscopy may be needed to check the large intestines for tumors or early cancer.
Your piles may be removed during the colonoscopy if found to be obstructing passage of stools.

3.Try Yogurt or fermented milk with lactobacillus as a method to stimulate more production of bulk in stools.

4.Try not to take laxatives unless it is deemed necessary by your doctor.
Most doctors preferred not to use medicine in combating constipation because it may lead on dependency on laxatives.

5. Learn to relax the anal sphincter by doing some pelvic exercises. This will help your constipation

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DOC I AM VOMITING

Vomiting and nausea are common symptoms seen by the family doctor.

Vomiting has been described as forceful emptying of food and liquids in the stomach out through the mouth.

Nausea  on the other hand is a feeling that the patient feels like he wants to vomit.

There are many causes of vomiting:
1.acute gastritis

2.acute food poisoning

3.giddiness

4.motion sickness or labyrinthitis,

5.Migraine

6.Pregnancy especially in the first 3 months

7.Noxious stimulus like certain smells

8.Heat stroke or dehydration

Most vomiting are minor and disappear after a major vomit.

However, vomiting can also point to more serious disorders.
These include:

1.Liver and gall bladder disease
Liver and gall bladder disease is often accompanied by nausea and vomiting.
Pancreatitis is another disease which can cause nausea and vomiting

2.People with Diabetes

3.Intestinal obstruction

4.Infection of the brain and meninges

5.Eating disorders like bulimia

6.Cancer and anticancer drugs and radiation therapy

When the family doctor see a case of nausea or vomiting, he will ask for

1.duration of vomiting – to determine if whether if it is till happening or has stopped.

2.If the vomiting has stopped then he will try to determine the cause eg gastroenteritis

3.If it still persist, then he will want to find out whether the patient can swallow the anti emetic medicines that I will giving the patient

4.If the patient cannot hold  the medicines after swallowing, the patient may need an injection to stop the vomiting or an anti emetic suppository in a child who is scared of injections.

5. If the injection still do not stop the vomiting the patient may need to be referred to the hospital to exclude some condition more serious like liver disease and intestinal obstruction

The family doctor will examine for any possible cause of the vomiting:

1.An abdominal examination will exclude conditions such as intestinal obstruction, liver problem or acute gastritis

2.Blood pressure taken when lying down and again after rapidly arising to standing position. Very High blood pressure may cause giddiness and associated vomiting
Low blood pressure or postural drop in blood pressure may also cause giddiness and associated vomiting

3.A blood sugar test will also exclude low blood sugar or diabetic ketosis with associated vomiting.

4.Complete nervous system examination should be performed including visual acuity, inspecting for nystagmus, cranial nerve and cerebellar signs.

5.dehydration after vomiting may require rehydration

Treatment of vomiting depends on whether the symptom indicates a more serious condition.
Most cases of nausea and vomiting are mild and self-treatable disorders.

1.Medications given usually act to stop the vomiting and nausea

Other than medicines, the following may relieve some of your discomfort:

2.Medicines to reduce abdominal discomfort and gas

3.rehydration of dehydrated patient with isotonic drinks and rehydration salts

4.Avoid full strength liquid or food. Always start with small amount of food so the stomach is not over bloated.

5.Avoid stress or anxiety which may aggravate the nausea sensation and vomiting

6.Treating balance disorders and motion sickness.

If the vomiting do not stop the best treatment is to admit to hospital for intravenous nutrition and medication. 

The cause can also be determined and treated.

All Patients who cannot control their vomiting should always carry a plastic bag with them to prevent them from vomiting in the taxis, cars, public transport or in public places.

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DOC I AM GIDDY

Giddiness or Dizziness ( A Simple Guide to Dizziness) is a common symptom seen by the family doctor more in the elderly than the young.

Giddiness has been described as light-headedness, unsteadiness or simply feeling faint.

Vertigo on the other hand is a feeling that the room is moving or spinning, or that the person is moving when they are not.

Balance difficulty is when a person feels they are about to fall, has difficulty staying balanced, or may actually fall.

There are many causes of giddiness:
1.insufficient blood flow to the brain

2.Stress and Anxiety

3.Lack of sleep

4.Low blood sugar

A Patient on diabetic medication should always carry a sweet with him in case his blood sugar drops too low and suck the sweet if he feels giddy.

I once made a house call to a elderly man’s house because he was in a comatose state. When I check his medicine, it appeared that he was given a diabetic medicine. When I check his blood sugar it was way below normal. I gave an intravenous glucose solution and that cause him to wake out immediately. Later he was given a glucose tolerance test and found that he has no diabetes. It was a misdiagnosis by another doctor.
It is dangerous to give diabetes medicine to a person unless he has been confirmed by blood test to be diabetic. 

5.Low or very high blood pressure

6.Anemia (A Simple Guide to Anemia)

7.Fever

8.Cochlear imbalance(Motion Sickness)

9. Medicines especially tranquillizers, antidepressant, anti diabetic, anti hypertensives

10.Brain condition such as Parkinson( A Simple Guide to Parkinson’s Disease),brain tumors

Most giddiness spells are minor and go away after a while.

However, giddiness can also point to more serious disorders.

These include:
1.Vertigo
There is a spinning sensation or feeling that your surrounding is moving around you.
It is often accompanied by nausea and vomiting.
Nystagmus, a jerky movement in the eye, is a common sign.
Vertigo often indicates an inner ear problem.

2.Viruses, such as those causing the common cold or flu, can also attack the inner ear and the organ of balance resulting in severe vertigo.
In a more serious case, a bacterial infection such as mastoiditis can make a person lose his hearing and sense of balance.

3.Poor blood flow to the inner ear can also lead to vertigo. 
This is often due to the hardening of the arteries (arteriosclerosis) which is commonly seen in patients with diabetes, high blood pressure or high blood cholesterol.

2.Light-headedness
A typical form of light-headedness occurs when you stand up too fast for the blood to reach your brain. 
This form of light-headedness is often transient and harmless. More persistent forms of light-headedness can be caused by:
Loss of body fluids, for instance, loss of water in excessive sweating and diarrhea( A Simple Guide to Gastroenteritis).

This is quite common in people who had lost a lot of fluids as in diarrhea or jogging. Just lifting the head upwards can cause giddiness.

Changes to your blood pressure caused by medicines such as anti-hypertensives, diuretics and anti-depressants.
Medical conditions such as diabetes, Parkinson’s disease and Anemia.


3.Motion sickness or sea-sickness
People prone to this condition can experience nausea and even vomiting when traveling in cars, airplanes, boats, or ships.
The mechanism of motion sickness is described in my blog A Simple Guide to Dizziness so I will not elaborate on it.

Often a patient with motion sickness will ask for some medicines for traveling in a coach or airplane. I always advise them to take 2 of these medicine half an hour before traveling.

When the family doctor see a case of giddiness, he will ask for
1.duration of dizziness – to determine if acute or chronic.

2.any evidence of vertigo i.e. episodic sudden sensation of circular turning motion of your body or your surroundings – this is a sign of nervous system or ear disease.

3.sensation of lightheadedness, floating, giddiness, unsteadiness, fainting – all known as pseudovertigo and are more likely to be a sign of cardiovascular disease.

4.occasional dizziness episodes – e.g. benign positional vertigo attacks are brief, usually lasting a minute, and then subside rapidly.

There is a manoevre called the BPV (Benign Positional Vertigo) manoevre which is believe to clear the debris in the tubes of the cochlea or organ of balance in the inner ear. The debris cause blockage in the tubes of the cochlea resulting in vertigo or imbalance. 
In a typical manoevre, the patient is seated at 90 degree vertical on the bed.  He is then turned to lie on the right of the bed for 30 seconds( sometimes you may have to hold his head down because he cannot stand the spinning). He usually feels better after 30 seconds. He is then brought to the vertical position for another 30 seconds. Then he is turned again to lie down on the left side of the bed for another 30 seconds. Although initially uncomfortable, this manoevre can get rid of the benign positional vertigo in 90 per cent of the cases.

5. Continous giddiness episodes may indicate Meniere’s syndrome which is characterized by paroxysmal attacks lasting 30 minutes to several hours of vertigo, tinnitus, nausea and vomiting, sweating and pallor and progressive deafness.

6. effect of position (of head or body) or a change in posture on the giddiness – e.g. benign positional vertigo is a common type of vertigo that is induced by changing head position, especially tilting the head backwards, changing from lying to sitting position or turning to the affected side.

Physical examination

1.Observe for pallor of skin or conjunctiva. 
Moderate or severe anemia will cause lightheadedness and giddiness, but usually not true vertigo

2.Blood pressure taken when lying down and again after rapidly arising to standing position. 
Very High blood pressure may cause true vertigo or lightheadedness.
Low blood pressure or postural drop in blood pressure is more likely to cause lightheadedness not true vertigo

3.Examine the ear for abnormalities. 
Abnormalities on ear examination with no other abnormalities found on nervous system examination may suggest ear wax,

otitis media (middle ear infection), cholesteatoma or petrositis

4.Complete nervous system examination should be performed including visual acuity, inspecting for nystagmus, cranial nerve and cerebellar signs.
If abnormalities are found may suggest multiple sclerosis, advanced brain stem tumor, acoustic neuroma( A Simple Guide to Acoustic Neuroma) or basilar artery insufficiency

Treatment of giddiness depends on whether the symptom indicates a more serious condition.

Most cases of giddiness and motion sickness are mild and self-treatable disorders.
1.Medications such as stemetil or sturgeron are given to balance the inner ear nerves or increase blood flow to the inner ear. 
Iron and vitamin supplements may be given to treat anemia.

Other than medicines, the following may relieve some of your discomfort:
2.Avoid rapid changes in position, especially standing up quickly from lying down or turning around from one side to the other.

3.Avoid extremes of head motion (especially looking up) or rapid head motion (especially turning or twisting).

4.Remove or reduce using products that impair circulation, e.g. nicotine, caffeine, and salt.

5.Avoid stress or anxiety, or substances that can trigger giddiness. 
These include substances that you are allergic to.

6.Avoid hazardous activities such as driving a car, operating dangerous equipment or climbing a ladder.

7.Avoiding motion sickness
Always travel in a manner such that your eyes will see the same motion that your body and inner ears feel.
When in a car, look forward into the distance.
On a ship, watch the horizon.
In a plane, choose the window seat if you can, and look out of the window.
Do not read while traveling and do not sit in a seat facing backwards.

8.Treating balance disorders
The main way is to treat the underlying disease or disorder that may be causing the imbalance in the first place. 
These diseases include ear infection, stroke, multiple sclerosis and other diseases of the nerve.

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DOC I HAVE A HEADACHE

Headache is a fairly common complaint in any family doctor clinic. 

It is important to ask for 
1.nausea, 
2.vomiting,
3.stiffness of the neck, 
4.fits, 
5.stress, 
6.lack of sleep, 
7.flashes of light in the eyes, and 
8.weakness of one side of the body. 

I always check for any high fever (one of the common causes) and high blood pressure in all my headache patients.

The most common cause of headache is
tension headache which can present as a ‘tight band’ especially over the temples. 
There may associated tight neck muscles . 
It is usually related to stress. 
Treatment is by simple painkillers, rest and removal of aggravating factors.

Migraine is also frequent in some patients with a heavy throbbing pain usually over one side of the scalp, forehead and around the eye caused by abnormally dilated blood vessels. There may be nausea and sensitivity to loud noises or bright lights .

Headache may be triggered by menstruation, alcohol or anxiety. Treatment is by special anti-migraine drugs that reduce the dilatation of blood vessels and painkillers together with resting in a cool, dark and quiet room.

Referred headaches are caused by any pain in structures around the head.
Common ones are earaches, toothache causing pain over an entire part of the face and temporamandibular joint dysfunction from mechanical pain from the jaw joint.

Serious Types of Headaches should be referred to hospital for MRI brain investigation and further treatment:

1.Meningitis / Encephalitis headaches which is due to infection of the brain tissue (encephalitis) or the membranes surrounding the brain (meningitis). 
One of the most cause of encephalitis here is dengue hemorrhagic fever.( A Simple Guide to Dengue Fever)
There is usually stiffness of the neck, fever and vomiting.

2.Cerebrovascular Accidents (A Simple Guide to Stroke) happens when a blood vessel in the brain is blocked or bursts. 
There is weakness of one side of the body.

3.Bleeding in the brain blood vessel aneurysm (A Simple Guide to Cerebral Aneurysm) can cause a sudden severe headache. 

One of my patient had what he describes as  the ‘worst headache ‘ he ever had  followed by difficulty in swallowing. He was sent for brain scan which show bleeding from a swollen blood vessel in the brain. Because he was in China, his wife got hold of the SOS and manage to get him back to Singapore where I manage to get a neurosurgeon waiting to check on him on arrival. Luckily for him his bleeding was mild and his operation to clip the aneurysm was successful.

For prevention I usually advise patients to:

1.Lie down in a dark, quiet room.
2.Try muscle relaxation techniques or a gentle massage.
3.For tension headaches, take a warm bath.
4.For migraines, put an ice bag or cold towel on your forehead.


Headache is a symptom which all of us have experienced at one time or another.
Most of the time it is not serious but in certain cases headache may be a symptom of something more sinister and dangerous.

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DOC I HAVE A BALD SPOT ON MY HEAD

ALOPECIA AREATA( A Simple Guide to Alopecia) is a condition where the hair of the scalp would drop leaving a patch of bald area like a coin on the scalp.

The size and occurrence of alopecia areata are more common than females than in males. 

The cause is unknown although some believe it to be

1.due to excessive male hormones( like male baldness)
2.auto immune (where the cells of the body attack the cells in the scalp causing the hair to drop)
3.chemicals and dye affecting the roots of the hair
4.stress and nervous tension which was the definite cause in one of my patients.

I have a few cases of this conditions. 
Treatment was usually an injection of steroids into the scalp -a rather painful procedure because the scalp have a lot of nerves – and an application of a steroid cream into the scalp.


One patient was a teenage girl who had her first bald patch after her O Level examination. 
She had the injections and cream to help her hair to grow. 
After this incidence she had a recurrence every year after a major examination.
Each time she had an injection of steroid and cream. 
She did well enough in her examinations to enter medical school in the University of London.
After her yearly examination she would return to Singapore to have her bald patch injected by me with steroid and application of steroid cream.
After her graduation as a doctor, the condition disappeared. 
It would appear that her stress over her examinations was the triggering factor in production of the bald spots in her hair.

I had a few other young patients male and female who also had this condition each time after a stressful experience.
They were all treated with the steroid injection with improvement.

Recently I had an elderly patient who also developed 2 holes in the hair of the scalp. Growth of hair was slower than the younger patient. The new hair was white compared to his other hairs which were dyed.
I told him not to dye his hair because it could be a contributing factor. In the end he was persuaded by his wife to remove the dye. Since then his hair grew faster until it was normal. I guess that he had to live without dying his hairs.

The cause of this condition is still unknown but definitely stress and chemical dye are 2 factors to consider.

During the procedure of treating this condition, I found that somehow steroid creams do help in the growth with hairs. 
I have asked a few patients with male alopecia to try massaging their scalp with steroid creams with some success.

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DOC I HAVE A WART,CORN OR

Plantar wart on the bottom of the big toe (mine), of a 24 year old male. Aside from some shaving of the skin when it first appeared a year ago it's been left untouched for the last 5 months. (Photo credit: Wikipedia)

CALLUS

WARTS, CORNS And CALLUSES was supposed to be in the blog after skin infections but I decided the Common Cold and Influenza are more common illnesses seen by family doctors and should be read first.


Warts are cauliflowered swellings present on the foot(plantar wart), hand(palmar) and even genitalia of the body(sexually transmitted). 
The cause is a viral infection called the human Papilloma virus which can spread from one person to another through direct contact provided there is a break in the skin exposed to the wart.

Sometimes warts may disappear by themselves after several months. 
However in the worst cases the warts become bigger and can spread to the other parts of the body.

There are all sorts of treatments for warts:
1.Traditional: 
Vinegar and Chinese herbal medicine has been used to dissolve the wart. The cure rate is low.

2.Duct tape has been used over the wart to occlude it from air in the hope of it disappearing. Again the cure rate is low.

3.Western medicine include:

a.Salicylate acid in over the counter Duofilm, Compound W , Wartgone are applied over the wart for about ten to fourteen days giving rise to a white coat over the wart for several days before peeling off together with the wart. 
However the recurrence rate is quite high.

The medicine can also dissolve corns and calluses in the same way because the medicine removes thick skin. They may be called Collomack or Corn therapy. 
Again the recurrence rates are high because corns are caused by pressure points and calluses by friction.

b.Podophyllum resin cream has also being used on warts with good effect except again the recurrence rate is high.

c.Liquid nitrogen spray can also be bought in England and other countries to freeze the wart but often it did not work.

d. 5flourouracil ointment is an anticancer drug which when applied to the wart seems to be the best for the removal of the wart but act slowly. 
After a few months of application the wart usually disappeared. Only problem is that it is difficult to get in Singapore.

I had a patient from England who had tried salicylate lotion, liquid nitrogen and then tried the Fluorouracil ointment find his wart disappeared after a few weeks of constant application.

e. Silver nitrate pen used for stopping nosebleeds can also work in burning the wart. However it is a bit painful.

4. Surgery:
a.Surgical removal of the wart usually get rid of the wart but recurrence can occur unless the root is removed.
Even then the wart can grow again in the excised operation wound.

b.The best treatment in a family practice is electrical cautery removal of the wart. 
Not only does it remove the wart but it destroy the root of the wart preventing the virus to grow on dead tissue.

A patient with wart is given a local anesthetic at the cleansed wart site.
Once the wart site is numb (completely anesthetised) , the wart is burned using the cautery machine until the root of the wart is removed. The wound is cleansed and antibiotic cream is applied. Because of burning of the root area, the virus do not have a living tissue to regrow in. So the chances of the wart recurring is very low.

Corns and calluses are thickened usually caused by pressure points and friction.

Surgical removal of the corn and callus just removed the hard thickened skin which caused pain by pressing on the nerves in the skin temporarily. 
But if the pressure points and friction points are still there, recurrence of the corn and callus will happened. 
Prevention is by soaking the skin wound in warm water to soften the skin and antibiotic cream is applied to prevent infection of the skin.

Sport shoes are actually the best cure for corn and callus of the foot because the air cushion in shoes can prevent pressure and friction on the skin. 
The corn and callus will be less likely to recur.

Removal of warts, corns and calluses will temporarily remove the lesions but recurrence will occur unless the underlying cause like the virus, the pressure points and friction is removed totally.

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DOC I HAVE A COMMON COLD

Who has never have the common cold? The code words are “Ah Choo” or sneezing, dripping of nose, pain in the throat and occasional fever. Cold weather, rain, snow, freezer, air conditioner are the precursor of a common cold. Once one person gets the common cold, every one in a closed environment gets it. That is why they called it the common cold.

The Common Cold (A Simple Guide to Coryza(Common Cold))is one of the most common infections seen by the family doctor.


Unlike Influenza, the patient suffer more from inflammation of the mucous membranes of the nose and throat, with sneezing, sore throat, and usually mild coughing. 

There are over 200 different viruses which can cause a common cold: rhinovirus, respiratory syncytial virus (RSV), corona virus, rotavirus.


Generally the common cold viruses produces mild but uncomfortable symptoms which seldom last more than 1 week:

1.Runny nose
2.Sneezing
3.Nasal congestion
4.Tiredness
5.Headache especially around the eyes and forehead
6.Fever – low grade rare


Usually a common cold runs its course without complications in one week. Because there is no cure for a viral infection, I usually aim at relieving the symptoms:


1.Rest is the most important part of treatment. 
A rested patient will recover faster.


2.Adequate warm fluids keep the mucus membranes moist to allow infected mucus to flow better and also to replace wet mucus lost during the runny nose.


3.If there is any fever, headaches and pains, paracetamol can be given to relieve symptoms.


4.Oral (tablet or syrup) decongestants may also relieve nasal symptoms. 
Antihistamines may help to reduce mucus production.


5.Decongestant sprays can relieve block nose temporarily, but should not be used for more than three days. 
Longer use can lead to rebound congestion with more symptoms of congestion.


6.Antibiotics and vitamin C are not helpful in relieving symptoms of the common cold.


Very rarely young children may develop complications such as bronchitis, viral pneumonia, and croup.  
I would check the lungs of young children carefully to make sure there is no breathing problem.

Acute otitis media ( A Simple Guide to Otitis Media) , an infection of the middle ear occurs in 2% of patients with a cold. 
I would ask all patients with cold whether there is pain in the ear or blockage in the ear.

Bacterial Sinusitis (A Simple Guide to Sinusitis) occurs in 0.5% of people with a cold. I would ask them for pain in the cheek and forehead area. If necessary an X-ray of the Sinuses should be done.

People with chronic obstructive pulmonary disease ( A Simple Guide to Chronic Obstructive Lung Disease) who have a rhinovirus infection are more likely to have a more serious or longer duration of illness.

Prevention of the common cold is by :
1.Proper hygienic care of the hands and body
2.Well balanced diet with enough fluids
3.Adequate exercise

It is important to distinguish a Common Cold from Influenza which is usually more serious.

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DOC I HAVE A SKIN INFECTION

Pus oozing from an abscess caused by bacteria—pus contains millions of phagocytes (Photo credit: Wikipedia)

SKIN INFECTIONS are part and parcel of the types of diseases seen by family doctors.

Scratching of the skin is one of the causes of breakage of the protective skin layer and infection from germs caught in the finger nails can enter the broken skin and cause pus formation in the skin. 

Abscesses are easily formed in any part of the body. 
Most large abscesses require incision(cut into the abscess) and drainage to release the pus collected to prevent infection spreading further and causing septic shock.


One memorable case was a small 3 year old girl who developed a large abscess on her scalp. 
There was no other way except to incise and drain the large abscess. 
She was very brave and cried once when the needle for local anesthetic injection entered the skin to provide local anesthetic. Then the knife was used to open the abscess and the pus was allowed to drain out.
After that she had the wound bandaged and given antibiotics, painkiller and antibiotic cream. 
Although she was told to wash her hands and not use them to scratch her head, she had a recurrence 2 years later and had the same procedure done on her again. 
Since then she did not have any more skin infection.


Skin infections such as infected acne can occur in adolescent boy or girl through hand contact with the acne. 
Antibiotics and antibiotic creams may be necessary for the treatment of the skin infections. 
The best antibiotics are those of the tetracycline group and erythromycin. 


In women who are breastfeeding, engorgement of the breast may occur due to blocked breast milk ducts.
If this happened warm compress may soften the milk stuck in the breast milk duct. 
If this does not happened the accumulated milk stuck in the duct may become infected resulting in abscess formation . 
If safe antibiotics such as ampicillin does not clear the infection the abscess may require incision and drainage.

Other infection may also occur at the nipple due to infected skin and clogged milk ducts.

Skin infection may also occur in the vulval area of any women if unhygienic conditions are present during sexual intercourse, urination and defecation ( passing bowel motion). 
Very often infected Bartolin cysts in the vulva region may occur and require incision and drainage.

Infection of the penis may also occur due to traditional circumcision in children.
Some skin infection may also result from scratching the genital area and from sexual intercourse. 
In most cases blood tests and urethral (internal tube that leads from the bladder to the opening of the penis) swabs for bacteria may be done for sexual infections. 
Those sexually transmitted which can be treated  are given antibiotics and flagyl. 
Herpes infections can be treated with antiviral drugs sometimes successfully.
HIV infections however cannot be cured as yet.

 In housewives, a common skin infection is paronychia of the finger nails – infection of the side of the fingernail due to pressure or injury to the side of the nail. 
Very often the patient will have an abscess of the side of the nail by the time she sees a doctor. 
The abscess is usually pricked with a sterile needle to release the pus which normally cause pain due to pressure on the nail. 
This is followed by antibiotic and antibiotic creams.

Infection of the naval is very common in babies and are usually treated with antibiotic powder or creams.
Less often infection of the navels may occur in adults due to attempts at removing dirt in deep navels.

I had a elderly female patient who was actually referred to me by another family doctor who was unsuccessful in getting rid of the pus discharge from her navel in spite of  antibiotic treatment. There was an abscess in the lower part of the navel which was discharging pus. I had to incise the abscess completely and do daily antibiotic dressing of the navel until she was completely cured.


In Diabetic patient foot care is very important. 
Any skin infection or wound in the foot can developed into abscesses and carbuncles (collection of abscesses) which needed special control of his diabetic condition, removal of all the abscess and carbuncle, strong antibiotic and daily dressing of his foot wound.

One of my diabetic patient had to be treated for about 4 weeks before his infected wound in the foot finally cleared up. 
However the next time he had his foot wound, he was bought to the Hospital where the doctor immediately sent him to a surgeon to do an amputation of the leg below the knee.


The worst infection I had seen in my family practice was that of the infected toe of a lorry driver.

He was dirty and smelly and obviously had not bathed for several weeks.
He complained of pain and swelling in his right big toe which was obviously very infected. 
So what I did was removal of the pus in the wound. 
What came out besides the pus was maggots about almost a hundred of them. 
I had to catch these wriggling maggots one by one until I finally reach the bottom of his wound. 
I cleaned the wound and did daily antibiotic dressing for about 2 weeks before the wound finally recovered. 
I also advised the patient to bathe daily. 
It was obvious that there was total neglect of his wound that allowed flies to lay eggs in the wound resulting in the maggots.


All skin infections can be treated if you are persistent with daily cleaning and antibiotic dressing of the wound.
However in Diabetes there is always the danger of the wound spreading in uncontrolled diabetes which may require amputation to stop the infection from spreading. 

It is important to emphasize to any patient with skin infection never to scratch or touch their skin with hands which may be dirty and full of germs

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DOC I HAVE A PAIN ON MY FACE

Trigeminal Neuralgia ( A Simple Guide to

Sensory areas of the head, showing the general distribution of the three divisions of the fifth nerve. (Photo credit: Wikipedia)

Trigeminal Neuralgia)is pain in the face due to hypersensitivity of the fifth or trigeminal nerve which supply sensation to the facial muscle and skin. 

All nerve pain can be excruciating. 

This elderly gentleman had this condition on the right side of his face for about 12 years. 
He was on constant painkillers.

The pain was so bad that he had to ask an ENT surgeon to cut off the branch of the nerve that leads to his nose and lip about 10 years ago. 
After the surgery there was no pain for 3 years though he has a bit of facial muscle droop. 
However the pain recurred after the third year of surgery. 

This time he did not want surgery because of the cost and also because the recurrence occurred even with surgery. 
There was also the side effect of a drooped facial muscle.
He was seeing instead a neurologist and his pain was relieved not totally with pain killers and a nerve pain drug called tegretol. 
However he had some gastric problem because of the strong pain killer.

Hearing about my injection for osteoarthritis and rheumatism, he came to consult me. 
I told him that the injection only worked with joint pain and not nerve pain.
In his case he needed an injection which will kill the nerve. 
In those days there were no botox injection which could kill the nerve. 
So what I used was (as recommended by an old medical book) surgical spirit. 
This was mixed with a local anesthetic and injection was done  into the nerve branch between the nose and lips. 
There was a slight droop of the face after the nerve was injected. 
Together with some painkiller, antacid and his Tegretol, the pain was reduced considerably. 

Each time there was recurrence of pain another injection was given. 

He had a total of 4 injections of the surgical spirit before the pain disappear completely.

He still comes to see me together with his wife for rheumatic pain but not for the nerve pain.

Nowadays the new aesthetic or cosmetic physician will probably inject him with botox which can cost a few thousand dollars.
Sometime an old method worked equally well. 

This is the one and only case in which I had treated with the injection of surgical spirit and successfully too.

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THE ART OF COMMUNICATION IN A FAMILY PRACTICE

“Courtesy begets courtesy”

Symbol Table for Non Verbal communication with patients (Photo credit: Wikipedia)

In order to treat and diagnose a patient it is important to communicate with the patient well.

Treat every patient with the respect you would want them to show to you.

When it is their turn to enter the consultation room, call them by their name rather than by a number.

This is a person that you are dealing with you, not a case.
If you are free open the door for them to enter the consultation room.


When they are comfortably seated ask them
” How can I help you?” or
“What can I do for you?” rather than
“What are your complaints?” or
“What is wrong with you?”.

Always put them at ease.
Talk to them as equals and never talk down to them.
Always make the patient feel they are important to you.


You must be able to listen attentively to the patient’s every complaint and make sure that every complaint is addressed in your treatment.

In 90% of the patients, the history provides the diagnosis even before the physical examination is done.

If you can try to talk directly to the patient in his own Chinese dialect, Malay and English rather than through an interpreter, know a bit of his culture and diet, you will be able to get more information out of the patient to form a diagnosis and treat according to their complaints.

Each complaint should be written down so that you do not forget to treat it.

Other information can be elicited by a series of questions so that most of the usual complaints are covered.

Always ask if there is any else that the patient may have forgotten to add to the history.

In children usually the mother or grandmother will be around to help in providing a history.

In the case of the deaf or hearing handicapped, try to write out the questions if he is able to understand written instructions and allowed him to answer back either verbally or in written form.

I had a patient who is deaf together with his wife. However he is able to communicate through his son.

In the case of the blind if he is able to talk, getting a history is of course no problem except maybe for description of color of his stools or things which they cannot see. Otherwise getting a history from a blind person is easier than from the deaf.

The only problem is that you may need to guide him in and out of the clinic without knocking into chairs or other people.

For foreigners such as Thai and Japanese a few choice word like pain and gestures will help in communication. Of course if they have a friend who can communicate in English it will definitely be easier to get a history.

With a good history, the physical examination can be restricted to the main complaints.

For example in a fall you will want to know whether the patient is able to walk after his fall, any disability, abrasions, cuts, swellings, or blackouts. Any symptoms of head injury such as loss of consciousness, nausea, vomiting, or blurring of vision or symptoms of brain injury.

Every effort should be spent on explaining why you are asking the questions and what physical signs you are looking out for.

Treatment is then based on the illness diagnosed as well as symptomatic treatment for all the complaints.

The culture and religion of the patient is important when treating the patient. In the Taoist the seventh lunar month is the hungry ghost month and many patients are worried that their illness may become worse during this time or the ghost relative may want to take their spirit away. You have to reassure them that the medicines will help them rather than make them more sick. Then there is the Chinese new year where all sort of goodies are eaten and there is a lot of visiting so the chance of getting infectious disease is higher.
For the Muslims the month of fasting means they can only eat before sunrise and after sunset. Some Muslims also do not allow injection during this period. The medicines sometimes have to be adjusted to two times a day (after sunset and before sunrise) instead of three or four times a day.
Some Indian women who may want to visit temples may request for stoppage of their menstruation during their visits to the temple
as the menses are considered contamination of their temple visits.

The rationale of the medicines given and the side effects to be expected must be also explained as well as preventive measures to be done by the patient himself (eg drinking more warm water, avoiding certain foods, doing certain exercises and living a healthy lifestyle.)

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A front page of The Family Doctor from 1889 (Photo credit: Wikipedia)

THE FAMILY DOCTOR

“I WILL FOLLOW that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous.”
The Hippocratic Oath


When I first started as a family doctor in 1974, the medical doctor was regarded like a fatherly figure to most patients. He was kind, compassionate and caring for his patients and a friend to their family.
It was something I aspire to become.

Not every general practitioner can be a family doctor.
The family doctor knows the family of his patients like the back of his hands.

For example I see the father for his monthly review of  high blood pressure( A Simple Guide to Hypertension), his wife for osteoporosis( A Simple Guide to Osteoporosis), the younger son for weekly injections of vitamin when he was suffering from leukemia( A Simple Guide to Blood Cancer) and undergoing chemotherapy, the oldest son who is married and now worried about finances ( I promised that I will help him out if he does not abort the child) because his wife is confirmed as pregnant. The oldest son now has 2 children of school going age. The younger son whom the father was worried may be infertile as a result of his chemotherapy is now a proud father of a baby boy. The father himself had hoarseness of the voice which after not improving for 2 weeks was sent for biopsy of his vocal cord and found to have cancer of the larynx( A Simple Guide to Laryngeal Cancer). He was treated for this and has been free of cancer for 10 years.

Somehow the family of the patient becomes intertwined with your life and you find yourself asking the patient about his wife, sons and their children each time you meet .That is only one family.

Another patient whose wife was diagnosed with cancer of the breast ( A Simple Guide to Breast Cancer) after routine mammogram found several lumps in her breast (one of which turned up to cancerous on biopsy) consulted me regarding the removal of the breast which her surgeon wanted to do. It was a small lump which showed early cancer. My advice was remove the lump and then do radiation therapy. However her surgeon thought otherwise and opted to remove the breast. The removed breast was found to be free of cancer. Apparently the cancerous cells had been removed during the earlier biopsy. So an unnecessary major operation

was done . The wife asked me not to tell her teenage daughter about the removal of the breast and up to today her daughter who now has a five year daughter still does not know about her mother’s breast removal.
Her husband who had been smoking cigarettes in the toilet for many years subsequently had a bypass operation for his coronary artery blockage( A Simple Guide to Ischemic Heart Disease) . After the operation he asked for me to come to his house to remove all the stitches instead of going to the hospital.
His brother subsequently had cancer of the prostate ( A Simple Guide to Prostate Cancer)and had a catheter inserted into his bladder in order for him to pass urine into a bag. One morning I was called to attend to him because the catheter had slipped out and he was unable to pass urine.
I had to go to the nearest pharmacy to get a similar catheter which can be inserted into his bladder and can be retained inside the bladder. The extent that the family doctor goes out his way to make sure his patient is well showed his commitment to the family and their trust in him.

These are just another example of the trust between the family doctor and the patients. There are many many other families whose trust in their family doctor make us go all out to help and treat them like part of a family.
The family doctor not only diagnose the pregnancy for a newly married couple. He also see pregnant woman for antenatal monthly reviews up to the 5th month of her pregnancy before sending to a obstetrician in a private or public hospital for her further checkup and delivery.

He sees the baby as early as 5 days after their birth for treatment of the baby’s jaundice or infection of the navel.

He teaches the mother breastfeeding methods through pregnancy and baby guides published by milk companies and advises on how to feed the child  and burping of the child.
He also follows up with the necessary childhood vaccinations and medical checkups.

As the child grows older, treatment of infectious diseases like influenza, common cold, measles , rubella and mumps follows.

Once in a while you will have a child with high fever having fits coming to the clinic. These are attended to immediately because of the danger of damage to the brain.

Parents of the children will come to see you occasionally for cold, cough and diarrhea and sometimes conjunctivitis.

Grandparents will see you for old age illness like rheumatism pains, diarrhea or incontinence.

I remember frequent cases where I will have to catherize the patient in order to relieve them of their urine blockage and bloated bladders. Then there are the chronic cases of diabetes, hypertension and strokes.I was often called for house calls sometimes in the middle of the night to attend to febrile fits in children, asthma, strokes, heart attacks and severe infections which prevent them from coming to the clinic.

In the past the family doctor was like a friend to the family. He treats the baby, the older children, the pregnant mothers, working fathers and their grandparents. Even now there are families who still bring their grandchildren to consult me.
Most of  the family know how to contact me during an emergency.

I know their names and the children’s names and also their family situation.

In many cases the patients who are poor are charged a token amount otherwise they will not see you due to their pride.
They however do not have to pay their medical fees or medicines.

During our recent relocation of our clinic while going through the medical record cards in order to discard those patients who have not seen me for at least 10 years. I found that there were patients still owing money since 1974 when I first started the clinic. I do not believe in chasing patients for their money.

There was this Indian foreman who was in charge of our estate rubbish removal. He was poor but he brought his family to see me asking the money to be owed. For 10 years he brought his family for treatment . Knowing that he was poor I did not expect any payment for all these treatments. Yet at the age of 55 years ( the retirement age at that time) he was able to withdraw funds from the government Central Provident Fund( A compulsory saving scheme meant for retirement). To my surprise he asked my nurses to calculate all the medical bills over the years to added up so that he can pay the whole sum. It was a pleasant surprise for me.

At that time a family doctor was really a family doctor looking after babies, children, pregnant mothers, working fathers and grandparents.

Times have changed since the 1990s. Pregnant women goes to their obstetrician.

Babies and children are treated by their pediatricians.

Working parents are treated by their company doctors.

Grandparents may be treated by geriatricians.

In spite of all these changes there are still many families who still remember their family doctors and come back to us when the other doctor’s medicines do not work.
They know that they can depend on us and can come to us for advice.
That is the essence of a family doctor whose duty is to guide, treat and educate a full generation of patients.

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WORD OF MOUTH

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Word of mouth as spread by your patients is the most important factor in the promotion of a family doctor’s reputation and treatment.

In the 1970s there was no such thing as advertising.
Medical ethics do not allow the doctor to advertise his clinic. There were a few cases where new clinic doctors were found to have breached medical ethics and were fined or suspended for distributing their cards or flyers to people passing their clinics. It was just not the ethical thing to do unlike the present day when clinics were now allowed to announce in the newspapers that they are officially open.

At that time the best way to promote your clinic is to communicate well and treat your patients well and then the patient will spread your ability to their family, friends, colleagues or neighbors by word of mouth.

To me what was important was the treatment and the attitude of the family doctor to his patients.
Whether the patient was a CEO of a company or a lowly worker, they were treated equally by me.
As  I said before, I was a socialist.
The ability to communicate effectively in English, Chinese and their different dialects and Malay was important to get their complaints and explained to them their illness and how to take their medicines.

I have always believed in health education as part of the treatment of a patient.
Knowledge of his illness enable the patient to understand his disease and how to prevent getting the disease again or making it worse.
There were many pamphlets which can be obtained at the Health Promotion Board which I was a member on hypertension, diabetes, gout, gastric problem, asthma, high cholesterol, obesity, prostate problem, stroke, cancers (A Simple Guide to Medical Conditions) of different organs etc in English, Chinese, Malay and Tamil. There were also pamphlets and booklets which are given by various drug companies which help to explain diseases like hypertension, diabetes, gout, skin diseases and at the same time promote their products.
There were also useful posters to display in the clinic.
To me all these were useful adjuvants to the advice and treatment given by me to the patients.
I used to distribute the pamphlets with  the appropriate illness and help to explain what is important in the pamphlets

As for my treatment having tweaked various variations to my medicines during my stint at the Run Down Clinic, I was able to treat more effective the colds, coughs and diarrhea (which made up of 90 per cent of the illnesses of the patients) with my combination of medicines.
There were also separate combination for rheumatism, arthritis, gout, asthma and gastritis.
However medicines are never fixed and must be individualized for each patient.
There were patients who were allergic to some medicines and substitutes had to be given.

When patients find their conditions improving as compared to those given by other doctors, they would recommend their families, friends and neighbors to see me by their words of mouth.
At that time the cost medicines were low at that time and my rental was low so I could charge the patients very reasonable fees.
In addition for those who were unable to pay because they were poor they were allowed to owe money.
While doing a review of the increasing number of record cards, I found that I have patients who still owed me money since 1974.
I have never chased any patient for their money.

It was because of my pleasant caring attitude, my reasonable fees and most of all my effective treatment that I was able to build up my family practice mostly through word of mouth.

All you need was to cure one patient who has been treated by several doctors for a certain condition without improvement for your reputation to spread the word of mouth all over the country.

Health education was very important in the prevention of the recurrence of a disease and the main topic in my dissertation in my doctorate in health care administration.

That was something I hope to spread by word of mouth as well.

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MY FIRST PATIENT

Journal of Asthma (Photo credit: Wikipedia)

My first patient came on my first day of the opening of my clinic. I was alone in the clinic at that time doing some arrangement of medicines.

She was an old lady staying nearby in a four room housing apartment registered in her name and her 2 children.
She happened to be walking around the estate after moving in and requested for a complete examination and some joint pain medicines.
She had a history of asthma and gastric problem.
On that day she appeared to be in good condition except for some knee joint swelling.
Her lungs were clear, blood pressure and heart normal.
No gastric problem was detected.
Her brain and nervous system were normal.
In fact her mind was so very sharp for her age of 65 years old.
I gave her some medicine for her joint pain.

I refused payment as she was my very first patient.
I told her that she was the number one patient in the clinic so I cannot take money from her.

1 hour later she was back to the clinic with a red packet containing some money for good luck.

It was a satisfying moment for me -my first patient and a red packet for good luck to boot.

She was to come back to the clinic on and off for the next fifteen years always reminding the clinic assistant that she was the number one patient.

We had a good laugh about that and soon got know each other very well.
I used to give her injections for her asthma( A Simple Guide to Asthma) and gastric pain (A Simple Guide to Gastritis) and vitamins to strengthen her up.

She would call me for house calls at night because of her attacks of asthma and gastric pain.

She was very well educated and although she dressed plainly, she was actually quite rich.

She confided in me that she had a few large properties in Indonesia which were rented out.
Once in a while she would go to Indonesia to handle her business for a few months and returned back to Singapore.

She was actually quite rich although she stayed in a public housing estate.
Her son and daughter were adopted but did not know about their adoption or about her wealth.
Her son and daughter used to see me for the usual cold, cough and diarrhea.

Her son as he grew older began to give her financial problems with his get quick schemes which always failed.


After he married, she had even more problems with her daughter-in-law.
Every time she had stressful problems , her asthma attacks and gastric problems become worse.

She was happier with her daughter.
However after her daughter got married, she had problems with her son-in-law.
With each problem her attacks of asthma and gastric problem became more frequent.

I advised her not to get so upset because it was affecting her health.
Also as she grew older, she had other problems like joint pains( A Simple Guide to Osteoarthritis)  and difficulty in sleeping.

Eventually her daughter and husband moved to Australia to stay and work.
After a few months she decided to join them. She would come back two times a year to Singapore as a vacation from her daughter.

Each time she returned she would visit me for some vitamin injections and medicines for asthma. Slowly the visits become less frequent.

One day I heard from her neighbor that her apartment had been sold to another family.

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800px-Blood_film_01 (Photo credit: Lab Science Career)

MALARIA PATIENT

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Coming back to my first day of posting to the Medical Department of Thomson Road General Hospital, I mentioned that there was a woman who had stayed in the ward for 1 month with a diagnosis of unexplained fever. The medical officers and housemen were asked their diagnosis of the patient. I mentioned that I suspected that it was malaria( A Simple Guide to Malaria).

The diagnosis of malaria as the cause of her fever was suspected when she was first admitted to the Hospital. However it was discarded when the blood film test for malaria parasite was found to be negative a few times.

She also had all the blood and urine tests done and X-rays taken of her chest, abdomen, brain and bones.
She has also being examined by
1.the kidney specialist for urinary tract infection and disease, 2.the heart specialist for any heart and lung problems,
3. the gastrointestinal specialist for any abnormal liver, gallbladder or gastrointestinal disease,
4.an endocrinologist (specialized in hormonal diseases like thyroid diseases, diabetes, etc) for thyroid conditions which may cause fever,
5. a neurologist to exclude any abnormal brain or nerve disease which may cause fever, and finally
6.the gynecologist to exclude woman diseases.
All possible diagnoses have been excluded and the consultant was still at a loss at what her illness was.


Going through her case notes, I noted there were regular daily spikes of  fever especially at night which was very suspicious of malaria.
In addition any rigors (or shaking of the body ) will be missed especially at night when the lights were dimmed for sleep.
Blood films for the malaria parasite were usually taken by the laboratory technician during the day when the fever was down.

I decided on my own that I would like to get a blood film from the patient when I was on night duty.
This happened on the second night of my posting.
I observed the patient until her fever started rising in the night about 11pm. She did not have any rigors but that did not exclude malaria. Malarial parasites are usually released from its reservoir in the spleen at a certain time into the blood stream. That was the time the body reacts by raising its temperature. It was also the time when the malarial parasites were highest in the blood.


It was also the best time to do a blood film for malaria parasite.
I did a prick on her finger and managed to get 2 thick blood films of her blood and sent it to the laboratory myself.
A thick blood film was important as a thin film may not contain sufficient malaria parasites to show up under the microscope.

The next morning our laboratory technician called to inform the ward that in deed the blood film was positive for malaria.
The diagnosis was confirmed. The patient was treated with anti malarial drugs and after 2 days her fever had subsided and she was discharged after staying for 1 month in the ward.
I was very happy that I could help her to be diagnosed and be cured of her condition.

It just showed how a simple change of procedure could help to effect the outcome of  a patient’s illness.

Doctors should not order tests routinely for the laboratory technician to do.
Certain tests may require the laboratory technician to come when there is a high fever(such as at night) and do a thick film instead of a thin blood film.

It would definitely save the patient the unnecessary stay of 1 month in hospital and ease the worry of  the patient and her relatives.

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THE NEW DOCTOR
It was the first day of my life as a new doctor.

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It was exhilarating. It was exciting.

It was quickly brought down to earth or hospital ward.
The head of Ear Nose Throat Department of Singapore
General Hospital spent little time to introduce his
consultants  and medical officers to me
(the only houseman and the most junior doctor
around to do all the ward work).

We then make a ward round of all the inpatients
to update the latest information on their medical
conditions and also which patient will be fit for
discharge on that day.

The houseman (me) doctor was of course supposed to do
these (so called red tape) as well as to take blood
tests and fill out all the information on new
patients admitted to the ward.

After the ward round I got around to do all the
paper work and blood tests.
It was a small department which was why only 1
houseman doctor was attached to it.

The patients were generally post-surgical recovery
cases who of course may need pain killers and
constant monitoring for post operation complications.

Of course there were also the odd nasopharyngeal cancer
(A Simple Guide to Nasopharyngeal Cancer) patient
who were on chemotherapy because their cancer was
fairly advanced.

So it was work and work and work again as new cases
come and old cases had the usual pain and bleeding
after operations.

I had never like the word “cases” because it was so
impersonal.

I would try to know my patient’s name, what sort of
work they were in.

I also believe in helping the nurses and nursing aides in their work as I do not consider myself superior to them.
After all I had just started on my medical journey while they had so much more experience in their many years in nursing.

One of the many disadvantage of being a doctor was the long hours we are expected to work.
When there is a night duty, a doctor has to work from
8am in the morning up to 1pm the next day.
Of course the main work was from 8am to 5pm.
From 5.01pm onwards we have to attend to the
new cases admitted to the ward as well as the
inpatients in the wards who has complications
like bleeding postoperatively or had severe pain
or unable to sleep.


Because the Ear Nose Throat Department has less
emergencies, life at night was not too bad and
usually there was some time to sleep.

However because there were fewer medical officers and houseman in the ENT dept, night duty happened about every 3 days including Sundays and public holidays.
Meals such as dinner and breakfast were served by the ward assistants.

For me , I was allowed to see some outpatients when
I had finished my ward work.

In addition I was allowed to assist in some operations.
I was lucky enough to be able to do  a tonsillectomy
operation (A Simple Guide to Tonsillitis) with
a trainee medical doctor guiding me with instructions.

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