DOC WHAT IS OCCUPATIONAL ARSENIC POISONING?

Occupational Arsenic poisoning

Arsenic poisoning (Photo credit: AJC1)

An occupational Arsenic poisoning is a toxic metal poisoning condition caused by excessive exposure to Arsenic resulting in neurological, gastrointestinal and renal symptoms.
Arsenic poisoning occurs when workers are exposed to it due to accidents. Poisoning can occur when the arsenic is absorbed into the body by inhalation(organic) or skin contact(inorganic).

What are the Signs and symptoms of occupational Arsenic poisoning?
Acute Arsenic exposure at high levels can cause sudden onset of gastrointestinal and neurological symptoms such as nausea, vomiting,abdominal pain or dark urine.
The appearance of occupational Arsenic poisoning may be divided into inorganic  and organic arsenic poisoning

Acute presentation of inorganic arsenic poisoning:

General:
1.dehydration
2.fever
3.anorexia
4.shock

GIT:
1.nausea
2.vomiting
3.diarrhea
4.abdominal pain

Neurological:
1.headache
2.delirium
3.vertigo
4.paresthesia
5.encephalopathy

Lungs:

breathlessness, bronchitis, cough

Blood:

acute hemolysis of red blood cells resulting in dark colored urine (termed black water urine)

Cardiovascular:

heart failure and arrhythmia

Long time exposure to inorganic arsenic may cause symptoms:
Skin changes:
1.discoloration -redness or darkening
2.swelling or hyperkeratosis (callus or corns)
3.whitish lines (Mee’s lines) in the finger nails

Neurological:
motor and sensory loss in nerves

Blood:
1.hemolysis of red blood cells
2.anemia

Liver:
liver enlargement and failure

Renal:
chronic nephritis and tubular degeneration

Acute presentation in organic arsenic or arsine poisoning:
General:
1.dehydration

2.chills
3.malaise
4.nausea

Cardiovascular:
1.abnormal heart condition and ECG.

Blood -Massive hemolysis of red blood cells with triad of
1.abdominal pain
2.bloody urine (Portwine urine)
3.jaundice

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

Investigation to establish work relationship to arsenic poisoning:

Get an occupational history to establish if the worker is exposed to inorganic arsenic during:
1.manufacture of pesticides, wood preservatives containing arsenic
2.manufacture and use of semiconductors in particular wafer
production and maintenance of ion implant machines)
3.manufacture of lead alloys, anti-fouling paints and pigments
4.Sawing, sanding and burning of wood treated with arsenical preservatives
5.manufacture and use of additives in animal and poultry feeds
6.Smelting of  arsenic containing ores

Organic arsenic poisoning:
1.Manufacture of semiconductors (in particular wafer production and
maintenance of ion implant machines)
2.Accidental exposures during metal refining, waste treatment and
cleaning of tanks containing acid sludge
3.Smelting of  arsenic containing metals

Get records of exposure monitoring from factories and companies to correlate with the worker’s test results such as:
a.patient’s periodical urine arsenic results
b.neurological and hematological examination

Management:

1.Treatment of all workers with abnormal urine and blood arsenic level results should be done and the blood tests repeated after every 3 months until results are normal

2.All workers with arsenic poisoning should be reassigned to another area without exposure to arsenic.

3.Some workers with severe signs of arsenic poisoning may required hospitalization.

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

5.Avoid smoking and eating at workplaces which may be exposed to arsenic.

6.Put in place control measures to reduce exposure to arsenic

7.Education of workers of the dangers of arsenic poisoning and how to reduce exposure.

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

   Send article as PDF   

DOC WHAT IS OCCUPATIONAL CARBON DIOXIDE POISONING?

Occupational carbon dioxide poisoning.

Main symptoms of carbon dioxide toxicity (See Wikipedia:Carbon_dioxide#Toxicity). References: Toxicity of Carbon Dioxide Gas Exposure, CO2 Poisoning Symptoms, Carbon Dioxide Exposure Limits, and Links to Toxic Gas Testing Procedures By Daniel Friedman - InspectAPedia Davidson, Clive. 7 February 2003. "Marine Notice: Carbon Dioxide: Health Hazard". Australian Maritime Safety Authority. Model: Mikael Häggström. To discuss image, please see Template talk:Häggström diagrams (Photo credit: Wikipedia)

An occupational carbon dioxide poisoning is a toxic gas poisoning condition caused by excessive exposure to carbon dioxide resulting in neurological respiratory and heart symptoms.
carbon dioxide poisoning occurs when workers are exposed to it due to accidents. Poisoning can occur when the carbon dioxide is absorbed through the skin or by inhalation.

What are the Signs and symptoms of occupational carbon dioxide poisoning?
Acute carbon dioxide exposure at high levels can cause sudden onset of respiratory symptoms such as coughing , wheezing or breathlessness. It can also cause effects on the neurological system and the heart.
The appearance of occupational carbon dioxide poisoning may vary from mild to severe presentation:
Acute presentation:
General:
1.anorexia
2.lethargy
3.panic attacks

Neurological:
1.headache
2.nausea
3.vertigo
4.irritability
5.weakness
6.unconsciousness

Senses:

1.poor eyesight
2.reduced hearing

Cardiovascular:
1.chest pain
2.angina
3.ischemia

Respiratory:
1.breathless
2.cyanosis
3.wheezing

Long time exposure to carbon dioxide may cause symptoms:
General:
1.anorexia
2.headache
3.giddiness

Neurological:
1.headache
2.nausea
3.vertigo
4.irritability
5.poor co-ordination
6.ataxia

Cardiac damage can occur due to lack of sufficient oxygen.

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

Investigation to establish work relationship to carbon dioxide poisoning:

Get an occupational history to establish if the worker is exposed to carbon dioxide during:
1.refrigerant use
2.brewing and wine industries
3.manufacture and use of dry ice
4.greenhouses
5.combustion of fuel and wood
6.pharmaceutical processing
7.Arc welding
8.cleaning work in confined spaces such as manholes and ship tanks
9.accidental leakage from fire retardant equipment containing carbon dioxide

Get records of exposure monitoring from factories and companies to correlate with the worker’s test results such as:
a.patient’s periodical blood carbon dioxide results
b.partial pressure of carbon dioxide.
c.ECG or electrocardiogram for heart conditions
d.chest x-rays of lungs

Management:

1.Treatment of all workers with abnormal blood carbon dioxide results should be done and the blood tests repeated after every 3 months until results are normal.

2.All workers with carbon dioxide poisoning should be reasigned to another area without exposure to carbon dioxide.

3.Some workers with severe signs of carbon dioxide poisoning may required hospitalization.

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

5.Avoid smoking and eating at workplaces which may be exposed to carbon dioxide.

6.Put in place control measures to reduce exposure to carbon dioxide

7.Education of workers of the dangers of carbon dioxide poisoning and how to reduce exposure.

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

   Send article as PDF   

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.

   Send article as PDF   

DOC WHAT ARE OCCUPATIONAL MUSCULOSKELETAL DISORDERS?

Collage of several of Gray's muscle pictures, by Mikael Häggström (User:Mikael Häggström) (Photo credit: Wikipedia)

Occupational Musculoskeletal Disorders

An occupational Musculoskeletal Disorder is a condition with muscle and skeletal pain and aches with numbness and limited movement which occur frequently in the life of a worker. It is no different from the musculoskeletal pains which occurs in many housewives or people in ordinary life who do not work in factories or offices and look after children and elderly.

The Musculoskeletal disorders occur during repetitive work and are called strain injury or cumulative trauma disorders.

Predisposing Factors are:
1.awkward or static postures
2.repetitive motion
3.carrying of excessive loads
4.forceful movements of the limbs and body
5.overhead work procedures.
6.twisting movements of the wrist or hands

What are the Signs and symptoms of Musculoskeletal disorders?
The appearance of occupational Musculoskeletal disorder may vary from mild presentation of aches and pain to the more severe presentation of disability and weakness of muscles.

1.aches and stiffness of muscles in the neck and interscapular region
2.pain in the shoulder on abduction, elbow and arms on extension or flexion.
3.nerve compression may give rise to numbness, tingling sensation, paresthesia and reduced sensitivity of the fingers and thumb of the hand
4.weakness and wasting of muscles of the hand and fingers such as weakness of hand grasp and thumb pinch or clumsiness of the hand.
5.stiffness and clicking of the finger on extension
6.fingers locked in flexion or extension
7.localized nodule at the base of palmar area of the fingers
8.localized tenderness over the elbow (lateral epicondyle) or wrist (radial styloid)
9.low back pain worse on flexion or extension with sciatica (compression of sciatic nerve due to prolapsed intervertebral disc) down the legs
10.difficulty in sleeping because of pain

Diagnostic Criteria of Work relatedness:
A good occupational history of worker exposure to the trauma or workload is important in diagnosis of an occupational Musculoskeletal Disorders.
He or she must exposed to the work activity such as:
1.poor posture during work (ergometric furniture are important in preventing this)
2.change in work process or practice such handling of excessive loads may aggravate or precipitate the symptoms
3.Overhead work and over reaching may cause strain on the shoulder and neck
4.repetitive movement tend to strain muscles and tendons
5.time relationship of symptoms with work periods(usually there is improvement when resting or on leave from work)
6.The duration of the symptoms must be for at least 1 month and affect the activities of the person’s daily life.

   Send article as PDF   

DOC WHAT IS OCCUPATIONAL POST TRAUMATIC STRESS DISORDER?

Regions of the brain affected by PTSD and stress. (Photo credit: Wikipedia)

Occupational Post Traumatic Stress Disorders
An occupational Post Traumatic Stress Disorder is a psychosocial stress caused by exposure to an extreme stress occurrence in the work place.
The Post Traumatic Stress may occur during work:
1.witnessing the death of a colleague shot by a robber or crushed by a collapsed heavy machinery
2.seeing a worker fall from great heights and seriously injured
3.witnessing the amputation of a worker’s limb
4.accident involving explosion or fire
5.violence or fighting at work

Predisposing Factors are:
1.vulnerable workers with pyscho social disorders
2.depression disorders
3.anxiety disorders
4.personality disorders

What are the Signs and symptoms of Post traumatic stress disorders?
The appearance of occupational Post Traumatic Stress disorder may vary from mild presentation of insomnia to the more severe presentation of panic and nervous breakdown.
1.flashbacks of accident or traumatic events for minutes or days
2.Post Traumatic Stress dreams and nightmares of the traumatic event
3.Post Traumatic Stress insomnia
4.Post Traumatic Stress irritability or anger
5.Emotional upset
6.avoidance of the traumatic site or thinking about the event
7.problem concentrating on work
8.frightened easily by loud noises.
9.panic and nervous breakdown.

Diagnostic Criteria of Work relatedness:
A good occupational history of worker exposure to the trauma or accident is important in diagnosis of an occupational Post Traumatic Stress Disorders.
He or she must exposed to the traumatic event where he or she has:
1.experienced ,witnessed or is confronted by an event that involved actual or threatened death or serious injury to himself or herself or their colleagues
2.responded with panic, fear, helplessness or terror.
3.recollections such as recurring dreams, nightmares or remembrance of the thoughts and images of the traumatic event.
4.Avoidance of talk or walking past the site of the traumatic event
5.feeling of detachment from colleagues or fellow workers
6.inability to recollect anything related to the traumatic event
7.restricted emotional feeling for other
8.feeling of a shortened future – does not have expectation of marriage , children or a normal life span
9.insomnia or difficulty sleeping
10.irritability or anger
11.difficulty in concentration
12.startled easily

The duration of the symptoms must be for at least 1 month and affect the activities of the person’s daily life.

Management:

1.Treatment at an early stage will reduce the symptoms of post traumatic stress.

2.Counseling and education will help patient to return to work without feeling fear or panic about their working place.

3.Encourage the affected workers to talk and share their traumatic experience

4.followup on cases with signs of delayed or continued trauma related stress to monitor disease and whether the patient need psychiatric help.

5.Put in place a procedure for Post Traumatic Stress Disorder control :
a.identify vulnerable workers
b.communication and sharing of experience to control fears
c. build confidence in the work place so that the worker feels less likely to suffer from Post Traumatic Stress.

   Send article as PDF   

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

   Send article as PDF   

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

   Send article as PDF   

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

   Send article as PDF   

DOC WHAT ARE OCCUPATIONAL HEARING DISORDERS?

Image via Wikipedia

An occupational Ear and Hearing disorder is a Ear and Hearing condition caused by or aggravated by work.

The most common types of work related Ear and Hearing disorders are accidents and injuries which can result from blast injuries, head injury and barotrauma. Hearing loss may be chronic and occur gradually over a period of time as a result of excessive noise at work producing noise induced deafness.

What are the Signs and symptoms of Occupational hearing loss?
The appearance of occupational Ear and Hearing loss can be very sudden.
The associated symptoms include:
1.giddiness
2.tinnitus
3.pain
4.bleeding from the ear.

Hearing loss may be unilateral or bilateral which may or may not improve with time.
The hearing loss may be
1.conductive affecting all frequencies with rupture of the eardrum
2.sensorineural if the cochlea ( organ of balance ) in the inner ear  is affected

Chronic hearing loss or Noise Induced Deafness which occurs slowly over a long period results in  the irreversible sensorineural hearing loss caused by damage to the hair cells of the organ of Corti when they are exposed to excessive noise.
Noise Induced Deafness in the early stages affects the high frequencies and the person may not notice any hearing loss until he or she is unable to hear high pitched sounds such as the electronic ring of a hand phone.
There may be a high pitched tinnitus initially intermittent which then becomes continuous in 20% of cases. Both ears are usually affected.
There may also be a loss of clearness in perceived speech resulting in difficulty in understanding what others are saying.
Later stages of Noise Induced Deafness affect the lower frequencies and the worker find difficulty in listening to normal conversation.
When the workers are unable to hear their own voices,they also tend to speak louder.

Examination should include assessment of the Ear and Hearing using an audiogram. A good history of occupational exposure to noise is critical in supporting evidence of workplace induced deafness.

Diagnostic Criteria of Work relatedness:
A good understanding of the working conditions, mechanism and a good medical examination is important in diagnosis of an occupational Ear and Hearing disease.

The most common Ear and Hearing disorders in work are in:
1.ship building and repairing.
2.Iron and steel mills
3.metal working industries
4.wood working industries
5.textile industries
6.paper industries
7.air terminal work example jet engine testing
8.bottling industries
9.landscaping example lawn mowers, leaf blowers,trimmers
10.construction industries

Audiometric test:
An audiometric test should be done on the worker
The worker should not be exposed to loud noises for at least 16 hours to avoid temporary thresholds shift.
The classical pattern of Noise Induced Deafness shows a dip in the 4 to 6 kHz frequencies.
A worker with clinical deafness should be sent for audiogram if none is conducted previously.
If audiogram has been done before and there is bilateral high frequency sensorineural hearing loss should be treated as a case of Noise Induced Deafness.
If the worker has occupational noise exposure, an audiogram should be done and if positive the worker should be classified as having Noise Induced Deafness.

Noise Induced Deafness should be classified as:
1.suspect if there is:
a.exposure to noise less than 5 years
b.unilateral high frequency hearing loss

2.Early if there is:
a.exposure to noise more than 5 years
b.audiogram show average hearing loss of 1,2 and 3 <50 dbA in the better ear

3.Advanced if there is:
a.exposure to noise more than 10 years  
b.Audiogram show Average Hearing Loss(AHL) of 1,2 and 3 >50 dbA in the better ear

Management:
1.prevent further hearing in worker and reduce noise exposure to other worker
2.use hearing protectors or ear plugs in high noise work sites
3.have audiometric examination periodically to assess hearing of workers
4.review noise level in the factories or work sites

   Send article as PDF   

DOC WHAT ARE OCCUPATIONAL INFECTIONS?

Image via Wikipedia

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.

   Send article as PDF   

DOC WHAT ARE OCCUPATIONAL LUNG DISEASES?

Occupational Lung Diseases

Image via Wikipedia

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.

   Send article as PDF   

Occupational Eye Diseases

Image via Wikipedia

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.

   Send article as PDF   

What is Barotrauma?

Image via Wikipedia

Barotrauma can occur in workers exposed to compressed air environment.

Barotrauma can affect air filled spaces in the body for example the sinuses, ears and lungs.

What is the cause of Barotrauma?

The most common cause is diving and tunneling works.

What are the Signs and symptoms of Barotrauma?

Barotrauma presents with symptoms of:
1.Joint pains
2.rashes
3.breathing symptoms
4.neurological symptoms
5.intravascular coagulation in severe cases

What are the types of Barotrauma?

Barotrauma is divided into :
1.Sinus barotrauma with acute pain over the sinus area or nasal or postnasal bleeding

2.Middle ear Barotrauma with pain in the ear, bleeding from the ear, burst eardrum,together with hypoacusis, tinnitus, vertigo and hearing loss

3.Inner ear Barotrauma with severe vertigo and hearing loss of affected side

4.Pulmonary Barotrauma with chest pain, breathlessness, unconsciousness, subcutaneous emphysema.

What are the risk factors for Barotrauma?

Risk factors for barotrauma are:
1.medical unfitness – workers with pre=existing medical conditions,chronic disease of the ears, poor air passages of the lungs are at higher risk
2.any sudden changes of pressures -pressures of more than 1 bar cause higher risk of barotrauma
3.long working hours in compressed air( more than 4 hours)
4.failure to follow proper decompression procedure
5.smoking
6.coughing
7.breath holding
8.infections involving the ear or upper respiratory tract

Diagnostic Criteria of Work relatedness:
A good occupational history to determine the worker’s exposure to hyperbaric or high pressure environment.

The worker may be exposed to:
1.tunneling or shaft sinking in water bearing strata
2.caisson works on river beds
3.pressure checks on aircraft
4.work in medical locks or recompression chambers
5.diving

Investigation to establish work relationship to barotrauma:
Correlate exposure history and work periods to symptoms of compression and investigation results such as sinus, chest, long bones x-rays, audiograms.
Check correlation with workers’ record of work in compressed air or diving.

What is the management of Barotrauma?

Management:

1.Treatment for barotrauma may involve the use of antihistamines, decongestants, analgesics and antibiotics depending on how severe the case is.

2.Sinus x-rays, audiograms and tympanograms are useful to further investigate the condition.

How is Barotrauma prevented?

Prevention:
1.Avoid further exposure to compressed air during recovering from barotrauma.

2.Avoid entering compressed air environment if there is a cold, sore throat, earache or chest infection.

3.treat cases of contact dermatitis with creams and corticosteroids.

   Send article as PDF   

DOC WHAT ARE OCCUPATIONAL SKIN DISEASES?

Occupational Skin Diseases

Image via Wikipedia

An occupational skin disorder is a skin disease caused by or aggravated by work.

The most common causes of workplace skin conditions are oils, solvents and cement.

Signs and symptoms:
The appearance of occupational skin disorder is no different from any other skin disease. However the location of the skin rash may suggest that the skin disorder is related to work when the skin rashes appear on the part of the body which may be in contact with the offending agent .The skin rashes may be on the hands and forearms which may come in contact with the offending solvent chemicals or cement. The face and other parts of the body  may be affected if the offending chemical is air borne in the form of mists or metal fumes.

The most common appearance may be more of a contact dermatitis which can be caused by an irritant or allergen.
Acute presentations may include:
1.redness
2.swelling,
3.blisters
4.oozing.
Chronic contact dermatitis may present as:
1.scaly
2.thickened
3.fizzured skin
4.pigmented skin
Other presentations may be:
1.urticaria
2.acneiform eruptions
3.secondary infections

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 any occupational skin disease.
The onset of the rash should co-related to:
1.length of employment
2.change in the work process or use of new chemicals
3.relationship between rash and work periods (in particular look for improvement of rash while patient is away from work)

Investigation to establish work relationship to rash:
1.Agriculture -animal feeds, fertilizers,solvents, plants, oils, disinfectants, pesticides, gloves

2.Chemicals and Pharmaceuticals: chemicals, acids, alkalis, water, detergents, latex gloves, rubber masks, medications

3.Construction and building: cement, preservatives, fiberglass, solvents, oils, rubber gloves, leather gloves, boots, epoxy resins, woods, paints

4.Electronics: solvents, acids, alkalis, resins, fiberglass,resins, soldering fluxes, nickel, chrome, cobalt, gloves, finger cots

5.Food and catering: vegetable and food juices, water, detergents, food, gloves, antioxidants, preservatives

6.Hairdressing: shampoos, permanent waves lotions, water, hair dyes, fragrances,latex or rubber gloves

7.Healthcare: alcohol, disinfectants, antiseptics, preservatives, resins, formaldehyde, latex gloves, rubber masks

8.Metal fabrication:cutting fluids, oils, coolants

9.Shipbuilding: cutting fluids, oils, coolants, welding fumes, resins

10.Woodworking and furniture: wood dusts, resins, soaps, detergents, solvents, oils, turpentine, wood preservatives, rubber and latex gloves

Correlate exposure history and work periods to symptoms of rash
Patch testing can confirm contact allergic dermatitis

Management:
Once the causative agent is identified:
1.Minimize contact with causative agent (wear personal protective equipment to prevent provided no allergy to PPE)

2.maintain good personal hygiene and work practices

3.treat cases of contact dermatitis with creams and corticosteroids.

   Send article as PDF   

DOC I HAVE A HEAD INJURY

Image via Wikipedia

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

   Send article as PDF   

A Day At the Spa by Kenneth Kee and Illustrated by Kelvin Kee

   Send article as PDF   

DOC WHAT ARE HEALTH SPAS?

Image via Wikipedia

Health spas help you develop a healthy lifestyle through:

1.healthy spa cuisine that emphasizes whole grains, fresh fruits and vegetables and nutritional education

2.a full program of fitness and stress reduction classes

3.therapeutic spa treatments including massage

4.educational lectures that teach you how to bring your healthy habits back home

Health spas are also known as destination spas and generally require that you stay at least two or three nights while some require a week. Prices at health spas usually include all meals, classes and some spa treatments.

Traditional resort spas offer spa treatments at an additional price together with golf and tennis. They focus more on relaxation and pampering than wellness. Recently some resorts and even small inns are calling themselves destination spas even though they do not match all the traditional healthy lifestyle criteria of health spas. Other resort spas are also offering exercise classes free with lots of healthy food options. You have to decide what you are looking for and see who offers it.

Health spas serve healthy food exclusively  but there are differences. Some health spas are geared towards weight loss with restricted calories diet and strict portion control while others have an all-you-can-eat philosophy. Many do not serve alcohol while others serve wine with dinner. While health spas emphasize healthy, whole foods, it might not necessarily be organic.

Health spas have a spirit of camaraderie. You’re with like-minded people who share your interest in health. Because of the small number of guests at any one time, you can get to know people even if you go by yourself. Small groups go on hikes, take exercise classes, and share tables together. The staff is usually very enthusiastic about the healthy lifestyle.

Health spas have different personalities and vary widely in size, price, setting and programming. They can accommodate anywhere from 8 to 250 guests, with an average around 60. They come in a wide variety of prices from a few hundred dollars a night to a few thousand dollars a week. Some are restricted calorie and others are all-you-can-eat.

How to make full use of your spa treatment?

The most important thing you can do to enjoy your trip to the spa is arrive at least 15 minutes before your treatment is scheduled to begin.

That way you can check in, change into your robe and start to relax.

If the spa has facilities like a sauna, steam bath, or hot tub, arrive even earlier.

 

   Send article as PDF   

DOC WHY DO I NEED SPA THERAPY

Image via Wikipedia

You can jump start a healthy lifestyle, reconnect with people you love, or just get away from it all and lay on the beach. Here are some of the best reasons to go to a spa :

1.A healthy lifestyle
Destination spas are the best choice if you’re looking to make a major some healthy changes and need some support. This small group of all-inclusive health spas offer good nutrition and exercise balanced with relaxing spa treatment.

2.Rest and Relaxation
If you just want to get a few spa treatments, hang out by the pool, and eat cheeseburgers for lunch, try a resort spa. There’s a huge range in terms of price, facilities and amenities. Ask if they offer exercise classes, how often, and if there’s an extra charge.

3.Weight loss regime
Most destination spas teach your how to eat for long-term health.
Generally you can eat as much or as little as you want.
A few still have controlled calorie diet.

4.Detoxify all the poisons from your body.
Our environment has all kinds of harmful toxins — physical and mental. A few select spas specialize in detoxification. Some of the options include juice fasting and colon cleansing.
Yoga classes and treatments like lymphatic drainage also help with detox.

5.Walking programs.
Great hiking programs are the backbone of many destination spas.
They both roam over gorgeous federal lands, with different groups aimed at different fitness levels. But think about the temperatures and time of year when you book.

6.Fighting your fears
Some spas have a program for fighting fears of the unknown and learning confidence through doing things which you are normally fearful of. You will find new freedom when you climb onto a tiny platform and do a bunjee jump — rope attached!

7.Yoga therapy
You can find yoga classes at just about every destination spa and most resort spas.
But some do it better than others. One Spa has one of the best yoga programs, with top teachers, a huge yoga studio, and classes aimed at different levels of expertise.

8.Get great food.
The food is so good at some destination spas that you might pack on pounds if you’re not careful. Some Spas are known for their excellent spa cuisine and cooking classes.  Most resort spas also have fine dining with spa cuisine options.

9.Spend time with people and family you love.
Spas are a great place to spend quality time with the people you love. Destination spas are especially fun for getaways with girlfriends or quality time with your mom, daughter or sister. But destination spas can be social so if you want to rekindle a romance, you might choose a small resort spa.

10.Inspiration and creativity at the spas.
Many spas have programs that help you get in touch with your creativity. You can learn from local artists how to work with oils, pastels, watercolor, make jewelry and paint silk scarves.

   Send article as PDF   

WHAT ARE THE TYPES OF SPA?

Image via Wikipedia

Types of spa

1.Ayurvedic spa is an alternative medicine spa in which all treatments and products are natural

2.Club spa is a spa where the primary purpose is fitness and which offers a variety of professionally administered spa services on a day-use basis like membership clubs.

3.Cruise ship spa is a spa aboard a cruise ship provides professionally administered spa services, fitness and wellness components and spa cuisine menu choices.

4.Day spa is a spa which offers a variety of professionally administered spa services to clients on a day-use basis.

5.Destination spa is a facility with the primary purpose of helping individual spa-goers to develop healthy habits.This lifestyle transformation can be accomplished by providing a comprehensive program that includes spa services, physical fitness activities, wellness education, healthful cuisine and special interest health programming within a seven day period

6.Garden spa is an outdoor spa used for bathing and self cleansing

7.Dental spa is a facility under the operation of a licensed dentist that combines traditional dental treatment with the services of a spa.

8.Medical spa is a facility that operates under the full-time, on-site supervision of a licensed health care professional whose primary purpose is to provide comprehensive medical and wellness care in an environment that integrates spa services in addition to alternative therapies and treatments. The staff may provide both aesthetic and wellness procedures and services. These spas typically use balneotherapy.Balneotherapy treatments in a spa setting can be used to treat conditions such as arthritis and backache, build up muscles after injury or illness or to stimulate the immune system and they can be enjoyed as a relief from day-to-day stress.

9.Mineral springs spa is a spa providing on-site source of natural mineral, thermal or seawater used in hydrotherapy treatments.

10.Resort spa is a spa owned by and located within a resort or hotel providing professionally administered spa services, fitness and wellness components and spa cuisine menu choices.

11.Spa town is  a town visited for the known healing properties of the water at its spa.

12.Foot spa is another type of spa which specialized in foot therapy

13. Hot tub spa is usually provided by hotels or clubs where the warm water is provided in a hot tub

Image via Wikipedia

14. Soda fountain spa is available with warm water coming out in a form of a fountain while you soak in the fountain

15. Mud baths  spa has warm mud for you to soak in for general health. Mud is  believed to help treat medical conditions.
This is also known as fangotherapy

   Send article as PDF   

Image via Wikipedia

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.

   Send article as PDF   

DOC  HOW DO I PREPARE FOR TRAVEL ABOARD?

Image via Wikipedia

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 

   Send article as PDF   

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.

   Send article as PDF   

DOC I HAVE RHEUMATIC FEVER

What is Rheumatic Fever?

Image via Wikipedia

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

   Send article as PDF   

Image via Wikipedia

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

   Send article as PDF   

DOC I HAVE ACTINOMYCOSIS

Image via Wikipedia

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.

   Send article as PDF   

Image via Wikipedia

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.

   Send article as PDF   

Image via Wikipedia

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.

   Send article as PDF   

Image via Wikipedia

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

   Send article as PDF   

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

   Send article as PDF   

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.

   Send article as PDF   

DOC HOW DO I LOSE WEIGHT?

Image via Wikipedia

Control Diet

15.)Grocery store shop at outer aisles

There is one common thread in all grocery store designs: the healthy foods are on the perimeter aisles. Think about it, when you go into the grocery all of the healthy stuff, fruits, vegetables, meats, and dairy products are arranged around the stores walls whereas the center aisle areas in those few stores that stock butter and cheese in the center near the frozen foods. .

Train yourself to start on one end of the outer aisle and work your way around. You will be able to fill your basket with healthy items if you do so.

16.)Get good cook books

Get a good cookbook. Not all recipes in a cookbook are low-carbohydrate fare. However you will be surprised at the number of low-carbohydrate friendly recipes you can find in a standard Betty Crocker Cookbook.

Cookbooks often contain handy tips on purchasing cuts of meat and preparing meats, fruits and vegetables in new and exciting ways. New low-carbohydrate cookbooks are hitting the shelves all the time. Try to take advantage of these resources to eat something new, different and nutritious.

17.)Take a good multivitamin as supplement to your diet The most conscientious food combiner may miss some healthy vitamins, minerals and trace elements in their diets. To help supplement your diet, consider taking a good multivitamin. If you are an otherwise healthy individual, your body will do its part. Keep to the low-carbohydrate diet plan that is right for you with some variety to your meals to help you on the path to good health and weight loss goals.

18.) Reward Yourself

Once in a while reward yourself. You will be less likely to cheat on your new diet if you grant yourself small rewards. If you are a chocolate lover, treat yourself to a small square of chocolate  each evening.

BURN YOUR CALORIES

1.) Work Out with Weights

Beside the diet control the other way is to burn up the fat. One way is to add a weight exercise program and routine work out. Weight training will not only tone your muscles but will strengthen your body and improve your general health. Lifting weights will also help to burn calories and fat more quickly than ordinary exercise.It will also boost your blood circulation and metabolism.

2.) Avoid Marathon Work Outs

Some people feel that the best way to burn fat and lose weight is to have one long, extensive work out. That is not true because it will exhaust all your energy leaving less energy for the next exercise. Break up your work out plan into small manageable sessions throughout the day. For example take a brisk walk in the morning, enjoy a work out at lunch, and then exercise more in the evening. This will keep you active all day long and will better maintain your metabolism.

3.) Mix It Up

Being active in different quality exercises will keep your interest and help you to maintain your goal of burning fat. Changing exercises such as to swim laps one day, jog another, and riding a bicycle the next will not only allow you to experience a variety of physical activities, it will also allow you to better tone your body and keep fit.

Finally a positive and cheerful optimism will help a long way to reduce your weight. If you can control your diet and burn your calories you will definitely lose weight! Do not doubt that!

   Send article as PDF   

DOC HOW DO I LOSE WEIGHT?

Image via Wikipedia

A Simple Guide to your weight loss program involve 2 main components:
1.Control Diet
2.Burn up Calories

Control Diet
1.) Drink More Water

Drinking water 8 to 10 times each day to stay hydrated and healthy. Once you get started, you will begin to crave water.

Start with a glass of water first thing in the morning before you eat. If you really do not like the taste of water, try adding a few drops of lemon or lime to your water but no sugar or sweetener! Ice also helps.

One of the best weight loss secrets is to avoid the sweet drinks and the sodas which are all calorie laden. Instead grab a refreshing glass of water.

Besides flushing toxins and waste material out of your system, drinking water encourages you to build muscle.

Drinking a glass of water after very meal will help you get in your 8 to 10 glasses of water each day but it can also have other benefits.If you feel hungry after a smaller meal, try drinking water after the meal. The water will help you feel full and prevent further eating.

2.) Eat More Small Meals

Do not skip breakfast each morning even if you will have to go bed earlier 20 minutes each night to wake up for a proper breakfast! Breakfast is the most important meal of the day and will contribute to your good health and to weight control.

Eating breakfast is not only good for overall weight loss, it will help you control your diet the rest of the day. You will less likely to eat something sweet and in the bread group if you skip breakfast.

Keep a couple of hard-boiled eggs in the fridge or some high-fiber, low starch fruit around to take for breakfast. Breakfast is the best time to take fruits.

You will feel better and lose weight quicker if you eat a large breakfast and eat a smaller dinner. Try and eat the majority of your carbohydrates earlier in the day, leaving a salad and lean meat protein for dinner.

By eating larger meals during the part of the day when you are most active will help you to feel less hungry throughout the day and stop cravings for unhealthy snacks.

Traditional three-large-meals-a-day plan will not help your body to burn up large meals and any excess will be turned into fat. Many nutritionist believe you should eat six small meals a day. You should cut back on your food consumption at each meal, or else you will be doubling your intake of calories!

Just like eating breakfast will increase your metabolism, so will eating small meals more often. This will also help you reduce the total carbohydrate intake by making sure that your meals are planned and occur regularly throughout the day.

3.) Consider eating a salmon or fish during breakfast

This is one way to work in Omega-3 fatty acids that are good for you and add some variety to your daily diet. After a time you may tire of eating eggs and bacon for breakfast. Eating a salmon or fish will give you the protein and healthy fish oils you need.

4.)Avoid White Foods

Anything which is made from sugar, flour, potatoes, rice or corn – just avoid. Always look for colorful fruits and veggies to substitute for the white foods. Buy broccoli, lettuce, bell peppers, green beans and peas, brown rice in moderation, leafy greens like kale and spinach, apples, melons, oranges and grapes.

Fruits and vegetables are not only colorful but they are also high in fiber, nutrients and important antioxidants. Eating colorful fruits and vegetables will give your diet variety as well as healthy benefits with their fresh vitamins, minerals and fiber. Most people will find some vegetables that they enjoy eating. Vegetarians have food that looks and taste as good as meat .They are actually made out of soya bean and flour.

5.) Choose Protein

Choose protein-laden foods for boosting your metabolism and enabling your body to burn fat rapidly. In addition to burning fat, consuming a protein-enriched diet will help you rebuild muscle after work outs and maintain leanness of that muscle. Wisely choose proteins for your diet. Take great care to pick proteins low in fat so you do not consume extra calories. Proteins are important in keeping you fit and healthy.

6.)Eat more protein at every meal

Eating protein helps you burn more calories. This iss because protein is made up mainly of amino acids, which are harder to breakdown in your body so you burn more calories getting rid of them.

Eating a protein rich snack can help you to lose weight.

Eating protein will also help you feel full so that you have less craving for unhealthy snacks.

   Send article as PDF   

DOC WHAT IS MEDITATION?

Image via Wikipedia

Meditation is a method to make the mind calmer and more focused.

Meditation can also help to understand body and mind interaction.

Meditation can help to transform the mind:
1.from negative to positive,
2.from disturbed to peaceful,
3.from unhappy to happy.

Overcoming negative minds and cultivating constructive thoughts is the purpose of the transforming meditations found in the Buddhist tradition.

There is the need for Meditation because:
1.many people feel stressed and over-worked as the result of the hectic pace and stress of modern life
2.there appears to be insufficient time in the day to get everything done.
3.The stress and tiredness make people unhappy, impatient and frustrated.
4.Loss of self confidence in achievements can cause despondency or irritation.

The Purpose of Meditation is:
1.The purpose of meditation is to make the mind calm and peaceful.
2.If the mind is peaceful, there will no worries and mental discomfort and true happiness will be achieved
3.Meditation training will help the mind to gradually become more and more peaceful and a purer form of happiness will be obtained.
4.Eventually the person will be able to stay happy all the time even during the most difficult circumstances.
5.Training in meditation creates an inner space and clarity that enables the person to control our mind regardless of the external circumstances.
6.Gradually the person develop mental equilibrium, a balanced mind that is happy all the time.
7.In this way the person will come to experience a permanent inner peace known as nirvana where day and night in life after life there will be only peace and happiness.

The Benefits of Meditation are:
1.Meditation will remove all distracting thoughts and there will a sense of inner peace and relaxation.
2.When the otherwise incessant flow of distracting thoughts is calmed through concentrating on the breath, the mind becomes unusually lucid and clear.
3.The mind will feel lucid and clear and the body will feel refreshed.  
4.It is possible to experience inner peace and contentment just by controlling the mind without having to depend at all upon external conditions.
5.Much of the stress and tension comes from our mind
6.When the turbulence of distracting thoughts subsides and their mind becomes still, a deep happiness and contentment naturally arises from within.
7.This feeling of contentment and well-being helps the mind to cope with the busyness and difficulties of daily life.
8.Many of the problems in life including ill health are caused or aggravated by this stress and can be overcome with meditation.
9.Difficult situations will become easier to deal with.
10.The mind will naturally feel warm and well disposed towards other people, and the relationships with others will gradually improve.

A Simple Breathing Meditation

1.The first stage of meditation is to stop distractions and make the mind clearer and more lucid. This can be accomplished by practicing a simple breathing meditation.
2. Choose a quiet place to meditate and sit in a comfortable position.
The most important thing is to keep the back straight to prevent the mind from becoming sluggish or sleepy.
3.First stop distractions and make the mind clearer and more lucid.
4.Sit with our eyes partially closed and turn the attention to the breathing.Breathe naturally, preferably through the nostrils, without attempting to control the breath.Be aware of the sensation of the breath as it enters and leaves the nostrils.
5.remain focused single-pointedly on the sensation of the breath
6.Slowly by focusing on the breathing, the mind becomes relaxed and that is the essence of meditation .

Meditation and relaxation helps you to keep fit physically and mentally.

   Send article as PDF   

DOC I HAVE ANOREXIA NERVOSA

Anorexia nervosa is defined as the persistent refusal to eat resulting in marked loss of

Perfect Body (Image via RottenTomatoes.com)

weight.

It is a psychological problem with patient becoming obsessed with his or her so called obesity with
intent to lose weight as a result.

There is 3 components to this eating problem:

1.fear of weight gain

2.distorted image of  thin body as the perfect body

3.refusal to eat to gain a healthy body weight

This condition is more prevalent in women than in men.

Onset usually occur in puberty.

The most common causes are:

1.obstensible fear of obesity resulting in excessive dieting.

2. distorted image of the body size related to psychosexual conflicts in the brain.

3.fear of eating resulting in low weight and thin body size

Risk factors in anorexia:

1.familial – can occur in families and more common in females

2.Dissatisfaction about body size

3.Low self esteem about his or her appearance

4.perfectionism in every thing he or she does

5.family problems

6.Dieting history in family

7.Difficulty in communication

8.history of physical or emotional abuse

Symptoms:
1.progressive and excessive weight loss

2.obsessed about being thin –

a.reduce food,

b.eating low calorie foods

3.preoccupied about food and meal times –

a.avoiding certain food,lying about food eaten,

b.throwing away or hiding food,

c.complains of stomach pain during meal time

4.secret meal time rituals

a.refuse to eat with the rest of family

b.chewing food and then spitting it out

5.taking laxatives, diuretics and diet pills to lose weight

6.excessive physical exercise to burn off fats

7.Fixation on a thin image

a.checking on body in the mirror

b.constant monitoring and measurement  of weight

Complications of anorexia nervosa are:

1.Associated induced endocrine changes (amenorrhea, hirsutism)

2.Loss of energy and weakness

3.vitamin deficiency and anemia

4. depression and mood changes

5.bloating of abdomen and constipation

6.gingivitis (gum infection) and tooth decay

7.brittle finger nails

8.dry skin

9.giddiness and headaches

10.poor memory and concentration

Anorexia nervosa may be associated with bulinia and induced vomiting

Treatment of anorexia nervosa:

Psychotherapy:

1.The patient must acknowledge  that she or he has a eating problems which need to be treated

2.counseling by psychologist or psychiatrist can help by:

a.remove negative thoughts about body size

b.provide positive thoughts about a healthy body and mind

c.help to deal with stress, family relationships, emotional upsets

d.stay away from friends who advocate bad eating habits

Medical treatment:
1.Hospitalization and forced feeding in severe cases

2.Correction of nutrition and metabolic deficiency

-a nutritionist will help teach healthy food habits and a proper meal plan to gain a healthy weight

3.Use of antidepressant and serotonin blockers may reduce low self esteem and depression

Prognosis
Good in mild cases.

Poor in severe cases,may be fatal as in the case of Mary Carpenter.

Prevention:

1.Nutritional education regarding the needs of the body for nutrients which will help the mind, endocrine system, physical appearance

2.Psychotherapy to emphasize the importance  and positive effects of nutrients on the person to develop  a healthy mind and  body

   Send article as PDF   

DOC I CANNOT CONTROL MY URINATION

Anatomy of Urinary bladder (Photo credit: Wikipedia)

Urinary incontinence( A Simple Guide to Urinary Incontinence) is a symptom and means the the uncontrollable leakage of urine. 

This can cause a lot of discomfort to patients having this problem.
Elderly men are more prone to it than women.

Nowadays with a longer life span many elderly patients can be seen brought to the family doctor clinic wearing adult diapers.

Urinary Incontinence is a medical condition which may be temporary or permanent.

There are many causes of urinary incontinence:

1.Diet: 
too much tea, coffee or carbonated drinks can irritate the bladder and cause or contribute to incontinence.
Coffee and other drinks containing caffeine can be a particular problem as caffeine is a diuretic, i.e. it increases the urge to pass urine.

2.Excessive alcohol. 
Alcohol is also a diuretic. 
Because it has depressant effect on the the brain, it may affect the person’s judgement temporarily, hence resulting in accidental  urinary incontinence..

3.medications 
diuretic pills, heart medications and antidepressants can cause or contribute to urinary incontinence.

4.Urinary Tract Infection may cause sufficient irritation to the bladder to stimulate urinary incontinence.

5.Constipation result in impaction of the stools in the rectum. This irritates the nerves to the bladder resulting in urinary incontinence.

Permanent urinary incontinence

In both sexes there are many conditions which can cause or contribute to chronic or persistent urinary incontinence:

Men:
Enlarged prostate
BPH or benign prostate hypertrophy is associated with aging  and can obstruct the urethra and block urinary flow resulting in urge or overflow urinary incontinence.

Prostate Cancer
Prostate cancer can cause incontinence if untreated. However the incontinence in prostate cancer patients may be a side effect of treatment e.g. surgery, radiation therapy.

Prostatitis
Inflammation of the prostate gland sometimes can cause constriction of the urinary flow and incontinence.


Women:

prolapsed uterus,
enlarged uterus due to fibroids,
ovarian cysts or tumors  can pull on the muscles of the perineum causing weakness of the muscles and poor constriction of the bladder opening


Aging
With age there is a decrease in the bladder capacity to store urine.


Surgery

Any operations involving organs such as the ovary, uterus, prostate, rectum can cause inadvertent damage to muscles or nerves of the urinary tract, resulting in incontinence.


Urinary tract obstruction
Any enlarged tumors along the urinary tract can obstruct the normal flow of urine and cause incontinence. 
Bladder stones can do the same.


Neurological conditions
Stroke, Parkinson’s disease, tumors in the brain or spinal cord and injury to the nerves in pelvis or spinal cord can can affect the nerves to the bladder and weakening of the bladder opening muscles.

Urinary incontinence may be categorized into 4 main types. 
It is possible however to have more than one type of urinary incontinence

1.Stress incontinence
Leakage of urine occurs because of weakness of the pelvic floor muscles. When there is pressure exerted on the bladder – e.g. from laughing, sneezing, coughing, exercising or heavy lifting, pregnancy, the muscles at the opening of the bladder comes under stress and opens to allow leaking of urine. 

Recently one of my elderly female patient had to wear a menses pad because of her chronic  cough. Each time she coughs, the urine automatically leaks out.

2.Urge incontinence
There is an uncontrollable leakage of urine while suddenly feeling the urge to urinate.

3.Overflow incontinence
There is a constant dribbling of urine even after finishing urination. 
There is  an inability to completely empty the bladder.

4.Functional incontinence
There is physical or mental impairment resulting in the failure to realize the need to urinate.As a result the person fail to get to the toilet in time and pass out the urine. 
Examples are people who suffer from dementia, parkinson or is incapacitated by poor physical movement.

Other types of urinary incontinence include enuresis(bed wetting ) which is common in children,

Transient incontinence which is temporary and sometimes caused by medications.

A Family doctor will look for a history of:

1.Uncontrollable leakage of urine. 
This leakage may be frequent and heavy, or it may be small and rare.

2.Urgency – a strong desire to urinate even when the bladder is not full together with pelvic discomfort or pressure

3.Frequency – urinating more than once in a two-hour period or more than seven times a day

4.Nocturia – the need to wake up and urinate at least twice during sleep

5.Dysuria – painful urination

6.Enuresis – bed-wetting or urinating while sleeping

The Family Doctor will look for:
medical conditions causing incontinence, such as pelvic tumors, stool impaction, and poor reflexes or sensations.

He will send the patient for
1.measurement of bladder capacity and residual urine for signs of poor functioning bladder muscles.
2.Stress test – the patient coughs vigorously as the doctor watches for loss of urine.
3. urine is tested for infection, urinary stones.

4.Blood tests – for PSA( in case of Cancer of prostate) or alphafoetoprotein (in case of cancer of the ovaries)

5.Ultrasound -to visualize the kidneys, ureters, bladder, and urethra.

6.Cystoscopy – a thin lighted tube is used to see the inside of the urethra and bladder.

7.Urodynamics -  measurement of pressure in the bladder and the flow of urine.

Elderly patients tend to believe that the only way to prevent embarrassment is to wear absorbent pads or padded undergarments like adult Diapers. 
However the wetness may lead to rashes, sores, or infections. 

Treatment involves:
A. making certain lifestyle changes.

1.Timed Voiding
Timed voiding (urinating) means writing a chart of your urination and leakage patterns for several days. 
This will then tell you which times of day you normally need to empty your bladder before leakage may occur.

2.Bladder training
This involves training your bladder to control the urge to urinate. 

3.Changing Fluid Intake
Restricting your fluid intake, or changing the timing of fluid intake will help you to gain more control over the bladder. Restriction of alcohol, tea, coffee and other caffeinated beverages can reduce the amount of urine from your body

4.Exercises
Exercising the muscles of the pelvis (Kegel exercises) may strengthen the muscles of the affected area.

5.Vaginal cone therapy
This exercise for women involves the use of a set of five small vaginal cones of increasing weight. 
The patient simply places the smallest plastic cone within her vagina and hold it in by a mild reflex contraction of the pelvic floor muscles. This exercise is done twice a day for fifteen to twenty minutes. As the pelvic floor muscles becomes stronger, cones of increasing weight can be used, thereby strengthening the muscles gradually.

6.Electrical stimulation
Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles and strengthen the pelvic muscles.
This can reduce stress and urge incontinence.

7.Biofeedback
Using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can slowly control movement of  these muscles.

B.Treating the cause of the incontinence:

1.Medications:
drugs may be given to treat urinary tract infections or inhibit contractions of an overactive bladder.

2.Pessaries
A pessary is a ring shaped medical device that is inserted into the vagina. It compresses the urethra against the pubic bone and elevates the bladder neck.

3.Surgery
Surgery to reduce the size of your prostate gland ( transurethral resection of the prostate or TURP) helps to reduce urinary incontinence in men.

Bladder repositioning
In older women incontinence results from the bladder dropping down toward the vagina.
Surgery involves pulling the bladder up to a more normal position. Using an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament, or bone.

4.Catheterization
A catheter may be inserted to drain the urine if your bladder never empties completely  or if your bladder cannot empty because of poor muscle tone, post surgery or spinal cord injury. This can be done on a if required basis.

5. Botox injections
Botox injection has been tried to reduce the sensitivity of the nerves at the opening of the bladder. It appears more successful for women than in men as atreatment for urinaty incontinence..

Patients can prevent urinary incontinence by:

1.Maintain a healthy weight.
Obesity can lead to urinary incontinence.
2.Avoid constipation by drinking sufficient amounts of fibre and fluids in your diet.
3.Avoid drinks which can irritate your bladder such as coffee, tea, carbonated drinks and alcohol.

Urinary incontinence can also cause problems in the family.
I have a stroke patient who was promised a place to stay at his sibling’s house after his mother passed away so that the mother’s house can be sold and the proceeds divided by the siblings.
After 1 month staying at his brother’s house he was sent to a nursing home because the sister-in-law could not deal with his incontinence and leakage of urine on the bed and floors.

   Send article as PDF   

DOC I HAVE HEAVY MENSES

Menstrual cycle (Photo credit: Wikipedia)

Menorrhagia is a symptom defined as heavy, prolonged and/or irregular menstruation .

1.The most common cause is hormonal:

Excessive menorrhagia occurs when no ovulation takes place in a menstrual cycle with resultant excess estrogen stimulation of the endometrium that results in the shedding of the thickened uterine lining and heavy bleeding when the estrogen drops.

A defective persistent corpus luteum which results from an abnormal ovulation can also cause the shedding of the endometrium for a longer period resulting in  prolonged bleeding.

Less important causes of menorrhagia are:
2.Uterine Pathology:
a.polyps,
b.fibroids
c.endometriosis
d.infection
e.carcinoma

3.Systemic Diseases:
a.Bleeding diseases
b.Hypothyroidism
c.liver disease
d.Pelvic inflammatory Disease(PID)
e.Poly Cystic Ovarian Syndrome(PCOS)

4.Medical causes of menorrhagia:
a.anticoagulants which are preventing clotting of blood
b.intrauterine device for contraception

It is important to know the previous menstrual history:
cycle length, number of bleeding days, degree of blood loss(number of pads used per day), presence of blood clots, dysmenorrhea

Any use of contraception:
1.IUD
2.contraceptive pills

Any symptoms suggesting underlying pathology:
1.Metabolic disorders:
2.hypothyroidism
3.polycystic ovarian syndrome

Any bleeding disorders:
1.easy bruising
2.anticoagulants

Any pelvic inflammatory Disease:
1.pelvic pain especially during intercourse
2.vaginal discharge
3.dysmenorrhea

In physical examination look for signs of underlying diseases:
1.bruising
2.hypothyroid features
3.pallor(anemia)
4.PCOS features (hirsutism,acne,overweight)

Abdominal examination:
1.tenderness,
2.palpable uterine or ovarian masses

Pelvic examination:
1.vulval and vaginal examination
2.bimanual palpation for masses
3.cervical smear


Investigations of menorrhagia:
1.Full blood count including hemoglobin (to exclude anemia from loss of blood) and platelets (low platelets can cause bleeding)
2.Transvaginal ultrasound to exclude uterine fibroids and polyps -postmenstrual scans is best when the endometrium is at its thinnest.

Treatment of menorrhagia is by :

Medications:

1.Tranexamic acid- oral antifibrinolytic (clotting agent) given only when there is heavy bleeding

2.Combined oral contraceptives – prevent proliferation of the endometrium, reduces blood flow. Inform patient of side effects such as fluid retention, nausea, headache,deep vein thrombosis, mood changes, breast tenderness

3.oral progesterone – also prevent proliferation of the endometrium-usually less side effects bloating, headache, mood changes, breast tenderness

4. Levonorgestrel-releasing (hormone) intrauterine system(LNG-IUS)
-also prevent proliferation of the endometrium
-side effects includes irregular bleeding up to 6 month,  or amenorrhea(no menses), breast tenderness, and headache.

5.Treatment of Underlying causes:
hypothyroidism with thyroxine tablets
intrauterine device removal
reduce anticoagulant treatment if possible
treat any bleeding disease with platelets or blood factor deficient infusion
treatment of endometriosis,
antibiotic treatment of pelvic inflammatory disease

If the bleeding do not stop, refer to the gynecologist for surgery:
1.Endometrial ablation involve the removal of the endometrium through the cervical opening.

 a.if medications has failed
 b.if no desire to conceive
 c.if the uterus is normal

First generation:
hysteroscopy with general anaesthesia
-Rollerball ablation
-Transcervical resection of the endometrium

Second Generation:
non-hysteroscopy, no general anaethesia, day surgery,fast recovery
-Impedance-controlled bipolar radiofrequency ablation
-balloon thermal ablation
-microwave ablation
-free fluid thermal ablation

2. Hysterectomy is used only as a last resort in treatment of menorrhagia:
if other treatment are contraindicated
there is a desire for amenorrhea
there is no desire to retain uterus and fertility
treatment of uterine carcinoma
surgical removal of fibroids and polyps

Menorrhagia can usually be controlled with hormones but may be dangerous in cases of uterine carcinoma or non stop bleeding.

   Send article as PDF   

DOC I HAVE NO MENSES THIS MONTH

Diagram of the menstrual cycle (based on several different sources) (Photo credit: Wikipedia)

This obviously apply to girls and women only. First thing is to check whether there is a possibility of pregnancy. So always do a urine pregnancy test first!

Amenorrhea( A Simple Guide to Amenorrhea) is a symptom defined as absence of menstruation.

1.Primary Amenorrhea
is defined as the absence of onset of menstruation (menarche) in a girl who has reached the age of 18 years.

2.Secondary Amenorrhea
is defined as the absence of menstruation for a peroid of at least 6 months in a girl who has previously experienced normal menstruation and is not pregnant.

The causes of Amenorrhea are:
1.Physiological(hormonal):

a.pregnancy hormones – pregnancy is the still the most common cause of secondary amenorrhea.
b.Growth hormone deficiency
c.Abnormal production of testosterone

2.Genetic Causes:
a.abnormal formation of genital tract causing cryptomenorrhea -obstruction to the flow of menstrual blood such as imperforate hymen
Chromosonal abnormalities:
b.Turner syndrome
c.Ovarian agenesis

3.Uterine Pathology:
a.adhesions from previous operation
b.endometriosis
c.tuberculosis infection
d.radiation

4.Ovarian:
a.Agenesis(no ovaries)
b.Abnormal ovaries(again congenital)
c.Polycystic Ovaries
d.Granulosa-thca tumors of ovaries
e.radiation of ovaries

5.Pituitary:
a.Pituitary tumors
b.Hypopituitarism
c.Hypothalamic abnormalities

6.Psychological:
a.Stress
b.Anorexia nervosa

There was a 17 year girl who did not have her menses since her O Level examinations  1 year ago.
It was the stress of the major examination which has affected her menses to the extent of amenorrhea. 
Her parents were worried sick about her condition.
I had to put her on female hormones every 21 days until her menses became normal. 
She was advised to relax and her medicines was reduced slowly until her menses remain normal even without the medication. Today she is a proud housewife with 2 children. 
Her menses remains regular.

7.Systemic Diseases:
a.Hypothyoidism
b.Cushing syndrome

8.Medical causes:
a.Chemotherapy
b.oral contraceptive
c.corticosteroids
d.hypotensive drugs

A diagnosis of Amenorrhea require:

History:
1.Primary Amenorrhea
a.Genetic disorders:
b.failure to develop female sex characteristics
c.anatomic abnormalities due to chromosonal d.defects such as Turner syndrome
e.hirsutism-excessive male hormones

2.Secondary Amenorrhea
a.Metabolic disorders:
b.symptoms of hypothyroidism
c.symptoms of polycystic ovarian syndrome
d.Obesity

Pyschologic disorders:
a.Stress
b.depression
c.anorexia nervosa

Pelvic examination:
a.vulval and vaginal examination for b.cryptomenorrhea,
c.bimanual palpation for ovarian masses like d.polystic ovaries
e.abnormal uterus or ovaries

Investigation:
1.Pregnancy test

2.blood for follicle stimulating hormones, luteinising hormones, prolactin
3.Progesterone withdrawal bleeding test
4.Luteinizing hormone releasing tests
5.Serum testesterone and androsterones

6.Transvaginal ultrasound to check on the uterus and ovaries
7.Brain CAT or MRI scans to exclude pituitary tumors

Treatment of Amenorrhea:

Medications:

Specific treatment for amenorrhea depends on:
1.age,
2.overall health,
3.cause of the condition (primary or secondary)
4.the preference of the patient

Treatment for amenorrhea may include:
1.Pregnancy – no treatment if the patient wish to continue with pregnancy. Usually a referral to an obstetrician may be necessary

2.hormonal replacement(oestrogen and progesterone supplements ) in genetic cases and androgen producing tumours.

3.Cyproterone acetate is an anti-androgen which counters the effects of male hormones. It is usually given with a small dose of oestrogen.

4.Hyperprolactinaemia -treatment with bromocriptine which acts by stimulating the prolactin Inhibiting factor in the hypothalamus.

5.Polycystic ovary Disease -clomiphene and gonadatrophins may be given to improve menstruation and help fertility

6.Adrenal dysfunction due to deficiency of the enzyme 21-hydroxylase (androgegenital syndrome) results in excess ACTH and excessive production of androgens-treatment is with corticosteroids such as prednisolone

7.Treatment of underlying systemic disease like thyroxine for hypothyroidism,

8.dietary changes to include increased caloric and fat intake especially in cases of low fat due to self induced dieting, anorexia nervosa

9.Pyschiatric treatment for women with depression, anorexia nervosa, or genetic dysfunction.

10.Healthy lifestyle for those who are obese

   Send article as PDF   

DOC I HAVE MENSES PAIN (ALSO KNOWN AS DYSMENORRHEA)

Vessels of the uterus and its appendages, rear view. (Photo credit: Wikipedia)

This is a very common complaint in a family doctor clinic or gynecologist’s clinic. Every woman has at least one episode of menses pain in her lifetime. Sometimes the pain is so severe that the woman may go into mild shock and definitely requires a medical leave from work.

Dysmenorrhea ( A Simple Guide to Dysmenorrhea) is a symptom, not an illness.
It means painful menstruation.

Dysmenorrhea may be classified into:
1.Primary or Spasmodic Dysmenorrhea –
2.Secondary Dysmenorrhea due to causes like
Endometriosis ( A Simple Guide to Endometriosis) or 
Pelvic Inflammatory Disease ( A Simple Guide to Pelvic Inflammatory Disease)

The cause of primary Dysmenorrhea is still not known. 

There are a few theories:
1.during menstruation, contraction of the uterine muscles occurs in spasms trying to push the menstrual flow through a narrow cervical opening

2.Prostagladins output occurs at time of menstruation producing smooth muscles spasms

3.menstrual clots occludes the uterine opening and requires more and stronger contractions of the uterine muscles to push it through

4.Stress may constrict the opening of the uterus and hence  greater contraction of the uterine muscles is required to force out the menstrual flow.

Primary Dysmenorrhea:
1.typically occurs on the first day of menses and becomes less after the 2nd day.
2.lower abdominal cramp radiating down to thighs and back

Secondary Dysmenorrhea:
1. Starts about 1 week before menses and reach maximum on first day before reducing intensity for rest of menses period
2.dull aching pain in lower abdomen with radiation to the back

Associated symptoms may be associated with dysmenorrhea:
1.vomiting,
2.urinary frequency,
3.headache,
4.painful breasts,
5.abdominal distension,
6.depression and
7.irritabilty

8.menstrual bleeding

Treatment for Dysmenorrhea:

Primary Dysmenorrhea:

1.simple analgesics such as paracetamol
2.Non-steroidal anti-inflammatory drugs like Ponstan, Synflex, Voltaren
3.Antispasmodics for spasm of the smooth muscles in the abdomen
4.Tranquillizer or antidepressant to reduce stress
5.Muscle relaxant to relax the muscle of the uterus
6.female hormones only if the pain killers do not work

Secondary Dysmenorrhea:

1.Identify and treat the underlying cause(eg. antibiotics for PID)

2.Endometriosis may require a course of female hormones or surgery for control

3.Dilatation of the endocervical canal may help by widening the opening for the blood to come out of the womb

Primary Dysmenorrhea may end after the first pregnancy due to widening of uterine opening.
Secondary Dysmenorrhea prognosis depends on the treatment of causes.

   Send article as PDF   

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

   Send article as PDF   

DOC I HAVE A NOSE BLEED

Every Family doctor probably have seen a patient brought to his clinic with blood dripping from one side of his nose. 
Any nosebleed should be seen as soon as possible and treated.

A Nosebleed is said to have occurred when the nose begins to bleed from the inner mucosa or lining of the nose. 

There is a layer of moist, delicate skin with a rich supply of blood vessels covering the interior of the nose.
Once you break the skin of this part of the nose for example by nose picking the blood vessel will burst resulting in bleeding or sneezing very hard .

Anterior nosebleeds involving the lower front portion of the nasal septum are very common and are  not serious
All that is required to stem it are some local pressure and a little patience.

A nosebleed may also be caused by irritation or dryness of the lining of the nose, which may occur in a dry environment, allergic rhinitis, colds, or sinusitis.

Deviated septum, foreign objects in the nose, or injury to the nose like boxing may also cause nosebleed.

Very rarely a nosebleed is life threatening or fatal. 
The bleeding is usually from a posterior nosebleed, in which the site of bleeding is higher and deeper within the nose and the blood flows primarily down the back of the throat. 

The more dangerous causes could be:
1.  cancer of the nose
2. hypertension, 
3. fever and infections
4. bleeding disorder,
5. the use of anticoagulant medication 

One of my patient was given warfarin ( a very potent anticoagulant by her heart specialist) for thinning the blood to prevent clots going to her brain or her heart. Although the blood results showed the blood was dangerously thin, her warfarin dosage was not reduced. 
She complained of giddiness and while feeding some cats fell down and knocked her head on the ground.
I was called to attend to her. She was bleeding from the nose . The danger was the blood clotting and choking her through the airway. I immediately turned her to the side so that the blood came out through the mouth and not into her airway. 
I asked a passerby to call for an ambulance and quickly use a suction pump to suck out blood from her mouth and nose. 
Her airway was cleared of blood and her breathing was satisfactory even though she was unconscious. 
When the ambulance came and took her to the hospital, she managed to wake up while on the way to hospital. 
She was found to have a subarachnoidal hemorrhage due to her injury and the warfarin which also cause her to bleed from the brain and nose.

The common risk factors of nose bleed include:
1.A hot, dry indoor climate – The hot, dry indoor air causes the delicate nasal skin to crack and bleed.

2.Colds and allergies – causes nasal blood vessel inflammation which can cause nosebleed.

3.Exposure to irritating chemicals – Cigarette smoke, ammonia, gasoline or other chemical irritants.

4.A deviated septum produces an uneven airflow pattern causes the skin on the nasal septum to become dry and cracked, increasing the risk of nosebleed.

5.Nosebleeds are also commonly caused by trauma such as nose picking, forceful blowing of the nose or severe facial trauma or contact sports.

6.Medications that delays blood clotting eg anticoagulants and non steroidal anti-inflammatory drugs eg aspirin and ibuprofen.

7.Medical conditions include chronic renal disease (kidney failure),  thrombocytopenia (low levels of the blood platelets) and hereditary bleeding disorders, such as hemophilia.

Once I determine that it is a anterior nosebleed, I would make the patient:

1.Sit up, lean forward and breathe through his/her mouth.

2.Pinch the entire front of the nose, just above the nostrils, and hold it for five minutes.

3.Apply an ice pack or a plastic bag of crushed ice to the nose to slow the blood flow.

4.After I have pinched the nose for five minutes, release it to see if the nosebleed continues.

5.If the nose is still bleeding, pinch it for an additional 10 minutes.

6.After 10 minutes, release the pressure on the nose again. 

7.After the blood flow has stopped, ask the patient not to breathe through the nose.  

8.If the nose is still bleeding, the  family doctor may treat the problem by:
a.Packing your nose with gauze
b.Cauterizing (sealing off) the injured blood vessel with a chemical, such as silver nitrate, or with an electric probe
c.Applying medication like silvadene cream directly to the inside of the nose to stop the bleeding

If bleeding do not stop, the patient may need to be treated in the hospital to exclude posterior bleeding causes.

Prevention of nose bleeding measure are:
1. Not picking the nose

2. Being gentle when blowing the nose

3. Not smoking

4.Using a  saline nasal spray or petroleum jelly to moisturize the inside of the nose

5. Avoiding facial trauma by using well-fitting headgear to protect your face during contact sports

6.Using protective equipment to avoid breathing chemicals at work

Most nosebleeds are usually harmless and are almost always easy to stop. However any nose bleed may be an indication of something serious.

   Send article as PDF   

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.

   Send article as PDF   

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.

   Send article as PDF   

DOC I HAVE A BACKACHE

Backache (A Simple Guide to Backache) is one of the most common complaints by patients seen in a family doctor’s clinic.

The complaint may be:
1.Constant aching, pain or stiffness that occurs anywhere along your spine, from the base of the neck to the hips.

2.Sharp pain in the neck, upper back, or lower back, especially after lifting heavy objects or other strenuous activity. 

3.Chronic ache in the middle or lower back, especially after sitting or standing for long period of time. 

More men suffer from it than women.
Backache is most common among people in their middle age.
Backache also occurs among young people aged between 20 – 30

I usually asked for a history of:

1.back strain from the lifting of a heavy object, 

2.from a fall,

3.Prolonged sitting with poor posture can also lead to chronic backache such as slouching in a couch when watching TV.
If the bad posture is  prolonged, backache may occur.

4.wearing high heeled shoes also put a lot of strain on the back muscles

5.associated pain in legs or weakness and tingling in the legs or back. 

6.pain increases when you cough or bend forward at the waist. 

7.Back pain radiates into the legs,sciatica.
This could be a sign of a herniated disk. 

8.dull pain in one area of your spine when trying to lie down or getting out of bed, especially if you are over 50 years of age. You may be suffering from osteoarthritis(A Simple Guide to Osteoarthritis)

9.pain is felt in both thighs when walking. This can be a symptom of spinal stenosis (the narrowing of the lower spinal canal).

10.persistent backache may also be an indication of an undetected cancer of the colon,ovary,bladder or prostate( A Simple Guide to Cancer).

11.gynecological problems (such as ovarian tumors( A Simple Guide to Ovarian Cancer), fibroids) and pregnancy.


I will do a full medical examination with emphasis on movement of the back:

1. Full medical examination  especially of movement of the back ,any deformity of the spine, abdominal swelling, straight leg raising test

2. X-ray of the Spine: to exclude fracture, osteoarthritis, dislocation,

3. X-ray of abdomen to exclude any tumors in the abdomen pressing against the spine

4.MRI of spine for slipped disc, tumors, fracture if necessary

5.Bone density test to exclude osteoporosis

6.Blood tests for calcium, protein,kidney function,cancer markers, RA factor

7. Urine and stool tests for blood,

If no serious illness is found, the most common cause is a strained back muscle.

Treatment is directed at relief of the backache:

Symptomatic:
1.Painkillers and muscle relaxants
2.Ice packs or heat treatment
3.Physiotherapy to strengthen muscles
4.Good posture and firm mattress
5.Avoid aggravating factors like high heels, overstretched muscles,excessive strenuous activities

Curative:
The cause must be found and treated. Examples are fractures due to injury. Patient should sent to hospital in case he/she needs surgery

Causes like cancer and aged related illness(osteoarthritis) may not be able to cured but may improved with treatment.

Prevention of backache

1.Maintain the correct posture at all times. 
When standing or sitting, ensure that your back is kept straight instead of a slouched position. 

2.support your back and use a cushion when necessary. 

3.Correct  furniture can also help to prevent the occurrence of backache. 
Use chairs of a proper height in relation to the table or desk. 

4.Sleep on a firm mattress 

5. Do not wear high heels

6. Keep your back straight when carrying heavy item. Keep the item close to the body.

7.Do not bend the back to carry heavy objects. 
Bend the knees and keep the back straight

8.Exercise is another good way to prevent backache by strengthening the back muscles.

However, if you have had back injuries before such as a slipped disc, do be cautious when you exercise.

   Send article as PDF   

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.

   Send article as PDF   

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.

   Send article as PDF   

DOC I HAVE A RASH

A rash is a very common symptom seen in a family doctor clinic.
A rash can be itchy and uncomfortable.
They can be painful in cases of shingles rashes, chickenpox and infected rashes.
They can very small, raised, patchy in urticaria, spread over the body or blister like in appearance(chickenpox or herpes)


In Babies atopic eczema is a common skin condition which presents as a chronic, relapsing, and very itchy rash at some point during childhood.
Atopic eczema clears and often disappears with age.
It is usually genetic as the condition runs in families


In Children the causes are :
1.Allergy
2.Infections


In adults the causes are:
1.Allergy
2.Infections
3.Autoimmune -abnormal response of the body’s immune system


Rashes can be genetic or due to environmental triggers:

a.rough or coarse materials coming into contact with the skin causes itchiness.

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

c.certain soaps, detergents, disinfectants,


One of my Singaporean patient who has just relocated back after 3 years in UK had hives or patchy itchy rashes after moving to a service apartment after staying at a hotel for 2 days.
The apartment provides free soap different from the hotel.
She was given an injection of antihistamine and some steroid which clears her hives.
But after a bath the hives came back and I had to give her another injection to clear the rashes. We suspected the soap was the problem and change it to her normally used soap.
After that the rashes disappeared. It was due to a soap which she was allergic to.

d.contact with juices from fresh fruits and meats,

e.food allergens in childhood such as cow’s milk, hen’s egg,peanuts, nuts, shellfish, duck flesh

f.dust mites,

g.animal saliva and danders may trigger itching.

h.Upper respiratory infections (caused by viruses) may also be triggers.

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

j.Pollens from flowers


I had another patient who was given about 100 different types of flowers just the day before her wedding. Normally she was not allergic to most flowers but in this case one of the hundred flowers probably cause very itchy hives all over her body.
I had to give her an anhistamine injection and 8 tablets of steroid tablets before the hives disappear 3 hours later. Happily she was able to go through her wedding the next day.

Rashes can occur on just about any part of the body

In infants, Atopic eczema typically occurs on the forehead, cheeks, forearms, legs, scalp, and neck.

In children and adults, rashes typically occurs on the face, neck, and the insides of the elbows, knees, and ankles.

In some people, rashes may form bubbles which can ooze when broken.


In others, the condition may appear more scaly, dry, and red.

Chronic scratching usually make the skin worse taking on a leathery texture because the skin thickens (lichenification).

Typical features of rashes are:

1.dry,

2.red,

3.extremely itchy patches on the skin.

4.Oozing of the rash

5.Thickening of the skin


All rashes can be diagnosed from:
1.History and appearance of the rash

2.Screening test for food allergy

3.Blood test for specific antibodies to food substance

Treatment of rashes is:

1. application of lotions or creams to keep the skin as moist as possible after bathing

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

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

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

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

5.topical or oral antibiotics may be needed for the skin infection which may affect the dry inflamed skin.

6.sedative antihistamines are sometimes used to reduce the itch

7.Tar treatments can have positive effects; however, tar can be messy.

8.Phototherapy requires special equipment (lights).

9.cyclosporine A, an anticancer drug, modifies autoimmune response; however, this is used only in extreme cases because of its association with serious side effects on the blood cells.
10.prevent scratching.
   
Do not SCRATCH because damage to the skin barrier may lead to dryness and inflammation of the skin


Rashes can usually be avoided with some simple precautions.

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

Moisturize frequently

Avoid sudden changes in temperature or humidity

Avoid sweating or overheating

Dress the child in breathable cotton clothes

Reduce stress

Avoid scratchy materials (e.g., wool or other irritants)

Avoid harsh soaps, detergents, and solvents

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

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

   Send article as PDF   

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.

   Send article as PDF