Health For Life

Uterine prolapse

2010-02-21T12:13:00.004+08:00

Uterine prolapse occurs when the integrity of supporting structures is lost. This allows the uterus to descend into the vagina. In advanced cases, complete protrusion with inversion of the vagina occurs. Prior to menopause, the degree and severity of prolapse is usually related to the number of children and the difficulty of childbirth. After menopause, atrophy and loss of tissue integrity further leads to prolapse.

System(s) affected:

Reproductive
Renal/Urologic
Renal/Urologic
Gastrointestinal

Common among Caucasian races. Less common among Asians and African Americans and particularly uncommon in South African Bantus and West Africans. Approximately 1 in 10 women will experience some degree of prolapse.

SIGNS AND SYMPTOMS:

Pelvic pressure and low back pain
As prolapse progresses, eventually a bulging is noticed as a result of protrusion
Dyspareunia
Difficulty with urination or defecation

CAUSES:

Advancing age and vaginal childbirth are the most important factors
The incidence of prolapse increases with the frequency and difficulty of vaginal deliveries. Less than 2% of prolapse occurs in nulliparous women.
Other causes of prolapse include connective tissue disorders with lax tissue, i.e., Marfan's syndrome and neurogenic disorders, i.e., multiple sclerosis, cloacal agenesis, chronic constipation, pelvic tumors or ascites and chronic coughing from chronic lung disease
Patients who have undergone radical vulvectomy with loss of the external supporting structures have a higher rate of prolapse

RISK FACTORS:

Childbirth, particularly multiple parity
Advancing age
Caucasian race
Various connective tissue and neurogenic disorders
Conditions resulting in increased intra-abdominal pressure, such as obesity, abdominal or pelvic tumors, pulmonary disease with chronic coughing, chronic constipation
Occupations requiring heavy lifting

LABORATORY:

Evaluation of renal function to rule out ureteral obstruction
Urinalysis to rule out urinary tract infection

PATHOLOGICAL FINDINGS:

Hyperkeratosis of the cervical and vaginal tissues occur with prolapse beyond the introitus due to chronic irritation and drying. As the irritation becomes more pronounced, bleeding and ulceration occur.
Degrees of prolapse:
- First degree prolapse - to the ischial spine
- Second degree prolapse - to the introitus
- Third degree prolapse - just beyond the introitus
- Fourth degree prolapse - complete uterine and vaginal inversion involving bladder and bowel

IMAGING:

Intravenous pyelogram to rule out ureteral obstruction in complete uterine prolapse (optional)
Pelvic ultrasound or CT scan to rule out other pelvic pathology, if suspected (optional)

DIAGNOSTIC PROCEDURES:
If ulceration or bleeding is present, Pap smears and appropriate cervical and endometrial biopsies should be done to rule out concomitant malignancies

TREATMENT

Treatment depends on multiple variables including the severity of prolapse, age, sexual activity, associated pelvic pathology and desire for future fertility
Treatment of first and second degree prolapse is expectant unless patient is symptomatic
Mildly symptomatic patients and poor surgical candidates - can be treated nonoperatively with perineal (Kegel) exercises, estrogen replacement and vaginal pessaries. Estrogen replacement restores healthy vaginal mucosa and promotes healing.

SURGICAL MEASURES:

Surgically able patients without additional pelvic pathology - vaginal hysterectomy with or without enterocele, cystocele, rectocele repair and vaginal vault suspension
For patients who desire to maintain reproductive function - uterine suspension with vaginal repair is an option
Elderly, non-sexually active women - can be treated with a colpocleisis or vaginal obliteration procedure

ACTIVITY:
Heavy lifting or significant increases in intra-abdominal pressure will lead to worsening of prolapse or recurrence after surgical correction. Lifting should therefore be restricted.

DIET:
Unlimited. Avoid constipation.

PATIENT EDUCATION:
•Kegel exercises when applicable

MEDICATIONS
Estrogen replacement therapy (oral or vaginal cream) can increase the blood supply to the vaginal tissues and in mild cases increase supporting tissue strength to a point where surgery or pessary use may be avoided

Contraindications: Those associated with the use of estrogen. Refer to manufacturer's literature.
Precautions: If estrogen therapy is utilized and the uterus is present, progesterone should be utilized to offset the potential of endometrial carcinoma
Significant possible interactions: Refer to manufacturer's literature

PREVENTION/AVOIDANCE:

Kegel exercises will increase the strength of the pelvic diaphragm muscles and may provide some pelvic support
Weight loss and proper management of conditions that would increase abdominal pressure help to prevent prolapse

POSSIBLE COMPLICATIONS

Ureteral obstruction and renal failure
Incarceration of bowel herniations
Pessary use - may not always be effective, and may cause discomfort, ulcers, infection

EXPECTED COURSE AND PROGNOSIS:

It is expected that as patients age, the incidence and severity of prolapse will increase
Surgical correction usually successful

ASSOCIATED CONDITIONS:
Cystocele, rectocele, enterocele and vaginal vault prolapse are often associated with uterine prolapse

REFERENCES

•Nichols DH, Randall CL: Vaginal Surgery. 4th Ed. Baltimore, Williams & Wilkins, 1996
•Ryan KJ, Berkowitz R, Barbieri RL: Kistner's Gynecology: Principles and Practice. 6th Ed. Chicago, Year Book Medical Publishers, Inc., 1995
•American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG
•Nichols DH: Gynecologic and Obstetric Surgery. 1st ed. St Louis, MO, CV Mosby, 1993
•Thompson JD, Rock JA: Telinde's Operative Gynecology. 8th ed. Philadelphia, Lippincott-raven, 1997
•Mishell DR, Stenchever MA, et al: Comprehensive Gynecology. 3rd ed. St Louis, CV Mosby, 1997
•Mann WJ, Stovall TG: Gynecologic Surgery. 1st ed. New York, Churchill Livingstone, 1996

Vaginismus

2009-09-06T22:05:00.002+08:00

Involuntary painful contraction of perineal muscles prior to or during vaginal intercourse. The experience of or even the anticipation of pain on vaginal entry causes theses muscles to contract, occluding the vaginal opening and causing further pain when penetration is attempted.

Incidence/Prevalence in USA: 6-8% of women in some studies report complete vaginismus and up to 30% some degree of vaginismus
Predominant age: Postpubertal
Predominant sex: Female

SIGNS AND SYMPTOMS:
•Inability to allow entry for vaginal sexual intercourse secondary to involuntary muscle spasms
•Reluctance or avoidance of pelvic examination
•Relationship discord or difficulty
•Infertility
•Sexual satisfaction may be independent of sexual function!

CAUSES:
•Primary: Often multifactorial
•Negative messages about sex and sexual relations in upbringing may cause phobic reaction
•Poor body image of genital area
•History of sexual trauma, although rates of vaginismus appear to be similar in sexually abused and un-abused populations of women (studies show incidence of sexual abuse of women to be from 12-40%)
•Secondary
•New onset of infection
•Surgical or post delivery scarring
•Endometriosis
•Inadequate vaginal lubrication

RISK FACTORS:
•Previous sexual trauma, but rates appear to be similar in abused and non-abused women
•Often associated with other sexual dysfunctions

DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
•Dyspareunia

PATHOLOGICAL FINDINGS:
Rarely found in primary vaginismus, but may be varied such as endometriosis or scarring in secondary vaginismus

SPECIAL TESTS:
Psychiatric consultation if not responsive to primary physician's therapy or if primary provider not comfortable with caring for sexual problems

DIAGNOSTIC PROCEDURES:
•General and sexual history
•At some point, a careful pelvic examination to rule out medical cause

TREATMENT

GENERAL MEASURES:
•Can often treat vaginismus successfully without defining/treating its etiologies!!
•No published controlled studies on success of psychotherapy for vaginismus
•Patient education as noted below on pelvic anatomy and sexual function
•Kegel's exercises to control perineal muscles
•Stepwise vaginal desensitization exercises:
•A) with vaginal dilators (patient inserts/controls), or
•B) with woman's own finger(s) (promotes sexual self-awareness)
•Valsalva can help with vaginal entry
•Advance to husband's fingers with patient's control
•Coitus after achieving largest vaginal dilator or 3 fingers; important to begin with sensate focused exercises/sensual caressing without necessarily a demand for coitus
•A) Female superior at first; passive (non-thrusting); female directed
•B) Later, thrusting may be okay

SURGICAL MEASURES:
Contraindicated

ACTIVITY:
Simple techniques of gentle, progressive, patient-controlled vaginal dilation

DIET:
No special diet

PATIENT EDUCATION:
•Education about pelvic anatomy, nature of the vaginal spasms, normal adult sexual function
•Hand held mirror can help the woman visually learn to tighten and loosen perineal muscles
•Important to teach the partners that the spasms are not under conscious control and are not a reflection on the relationship or a woman's feelings about her partner
•Instruction in techniques for vaginal dilation
•Resources
•American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG
•Valins L. When a Woman's Body Says No to Sex: Understanding and Overcoming Vaginismus. New York: Penguin, 1992.

Contraindications: Anxiolytics, especially benzodiazepines
Precautions: N/A
Significant possible interactions: N/A

ALTERNATIVE DRUGS:
N/A

POSSIBLE COMPLICATIONS:
Precipitation of memory of incest prior to patient's readiness to deal with it

EXPECTED COURSE AND PROGNOSIS:
•Some studies show high degrees of success (58-70%) with behavioral interventions
•History of sexual abuse does not predict outcome negatively or positively

ASSOCIATED CONDITIONS:
•Marital stress, family dysfunction
•Dyspareunia

AGE-RELATED FACTORS:
Vaginismus is generally primary, e.g. happens with first attempt at intercourse

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY:
Pregnancy can occur in patients with vaginismus via perineal ejaculation

REFERENCES
•Biswas A: Vaginismus and outcome of treatment: Human Sexuality and Sexual Dysfunction 1995;24:755-758
•Heiman JR: Evaluating sexual dysfunctions: Primary Care of Women. Norwalk, CT, Appleson and Lange, 1995
•Read S, King M, Watson J: Sexual dysfunction in primary medical care. Journal of Public Health Medicine, Oxford University Press 1997;19(4):387-391
•Sarwer D, Durlak J: A field trial of the effectiveness of behavioral treatment for sexual dysfunctions. Journal of Sex and Marital Therapy 1997;23(2):87-97

Vitiligo

2009-01-24T20:50:00.002+08:00

An acquired, slowly progressive depigmenting condition in small or large areas of the skin due to the disappearance of previously active melanocytes
•Type A is non-dermatomal and widespread. It represents 75% of cases
•Type B is dermatomal or segmental. It represents the remaining 25% of cases

SIGNS AND SYMPTOMS:
•Loss of pigment
•Locally increased sunburning
•Predilection for acral areas and around orifices such as eyes, mouth, anus
•Pruritus (10%)
•Premature graying (35%)
•Koebner's phenomenon (aggravation by trauma)

CAUSES:
Etiology is unclear, but is thought to be an autoimmune reaction to preexisting melanocytes

RISK FACTORS:
•Positive family history
•Autoimmune disorders including hemolytic anemia and adrenal insufficiency

DIFFERENTIAL DIAGNOSIS:
Any condition that causes acquired hypomelanosis, including tinea versicolor, leprosy, lupus erythematosus, pityriasis alba, atopic dermatitis, albinism, alopecia areata, chemical exposure (phenols, arsenic, chloroquine, hydroquinone) steroid exposure, retinoic acid use, tuberous sclerosis, neurofibromatosis, melanocytic nevi (halo nevi), tumor regression of malignant melanoma, piebaldism, hypopituitarism, hyperthyroidism

LABORATORY:
Routine blood and urine studies are usually normal in the absence of associated diseases in adults. In children screen for autoimmune diseases with TSH, CBC, and fasting glucose.

PATHOLOGICAL FINDINGS:
Complete absence of melanocytes in skin biopsy. At the margins one may see a few lymphocytes and large melanocytes with abnormal melanosomes.

DIAGNOSTIC PROCEDURES:
•Examination under Wood's light accentuates the hypopigmented areas, especially in light-skinned individuals
•Skin scraping and a potassium hydroxide (KOH) preparation can be examined microscopically to rule out tinea versicolor

GENERAL MEASURES:
•Sun exposure can accentuate the difference between normal and abnormal skin, so for cosmetic reasons patients may wish to avoid this
•Skin dyes and cosmetics may be used as cover-ups

PATIENT EDUCATION:
•Reassure patient that in absence of associated autoimmune illness the problem is purely cosmetic. Successful cosmetic cover-up is usually quite simple. Some areas offer vitiligo support groups.
•Information available through National Vitiligo Foundation, P.O. Box 6337, Tyler TX 75711; (903)531-0074

DRUG(S) OF CHOICE:
•Localized vitiligo: Begin with a mid-potency steroid cream applied daily for 3-4 months. If no response, advance to high potency steroids. Clobetasol propionate (Temovate) cream applied qd for 2 months (qod on the face). Treatment may be resumed following a 1 to 4 month respite. Alternatively topical psoralens applied in a 1% solution followed in 90 minutes by ultraviolet exposure (UVA). Caution for subsequent exposure to light (sunburn).
•Widespread vitiligo: Oral systemic steroids, e.g., betamethasone 5 mg given 2 days in a row, then held the remainder of the week. This pattern continued for 2-4 months minimizes side effects and is effective in arresting the disease in many patients. Oral trimethylpsoralen or methoxsalen (Oxsoralen-Ultra, 8-MOP) and UVA over a 12-24 month period. Alternatively depigmenting the remaining normal skin with hydroquinone (Benoquin) 20% cream may be elected.

Contraindications:
•Absolute contraindications to use of psoralen compounds: Idiosyncratic reaction to psoralens, photosensitive disease (e.g., systemic lupus erythematosus, albinism, porphyria), invasive squamous cell carcinoma, melanoma, aphakia
•Relative contraindications to use of psoralen compounds: Cardiac disease, hepatic dysfunction, multiple basal cell carcinomas, prior radiation therapy, prior arsenic therapy

Precautions:
•Watch for skin atrophy and telangiectasias when using topical steroids, especially on the face
•Watch for photosensitizers with UVA treatment
•Severe burns possible with topical psoralens. Partially avoided with - 1:10 or 1:50 dilution of psoralens.
•Psoralen plus UVA (PUVA) cannot be used for children less than 12 years of age due to immaturity of the ocular lens
•Patients undergoing PUVA therapy should have a screening ophthalmologic examination to rule out subclinical retinal pigmentary disease that is frequently associated with vitiligo
Significant possible interactions: Other photosensitizers, e.g., tetracyclines and retinoic acid

ALTERNATIVE DRUGS:
Patients with unresponsive localized vitiligo may be candidates for mini-grafting with or without PUVA therapy

FOLLOW UP
PATIENT MONITORING:
•With PUVA therapy, CBC, liver, renal function tests, and an ANA should be done every 6 months.
•With topical steroids, follow at monthly intervals to avoid steroid-atrophy of the skin.

PREVENTION/AVOIDANCE:
•While undergoing all therapies, avoid excessive sun exposure

POSSIBLE COMPLICATIONS:
•Phototoxic reactions ranging from mild to severe with PUVA
•Skin atrophy and telangiectasias with topical steroids
•Contact dermatitis can occur with use of depigmenting agents and cosmetic covers

EXPECTED COURSE AND PROGNOSIS:
•Only 5% spontaneously repigment
•Best results are with PUVA therapy where 70% have repigmentation of head and neck area, less in other body areas. Lower percentages respond to topical therapy
•There is no response in at least 20% of cases, especially long-standing cases
•Once repigmentation occurs it usually persists.

ASSOCIATED CONDITIONS:
•Addison's disease
•Alopecia areata
•Chronic mucocutaneous candidiasis
•Diabetes mellitus
•Hypoparathyroidism
•Melanoma
•Pernicious anemia
•Polyglandular autoimmune syndrome
•Thyroid disorders (hyper- and hypothyroidism) - 30% of patients with vitiligo
•Uveitis
•Halo nevi

PREGNANCY:
•Treatment with topical or oral psoralens is contraindicated

SYNONYMS:
•Hypomelanosis
•Depigmentation

REFERENCES
•Habif T: Clinical Dermatology. 3rd Ed. St Louis, Mosby, 1996
•Fitzpatrick TB, et al: Color Atlas and Synopsis of Clinical Dermatology. 3rd Ed. New York, McGraw-Hill, 1997
•Goldstein A, Goldstein B: Practical Dermatology. 2nd ed. St. Louis, Mosby, 1997.

Warts

2008-06-21T10:27:00.002+08:00

Warts are painless, benign skin tumors characterized by an area of well circumscribed epithelial thickening. Most people develop warts on their hands or feet at sometime in their lives. They are most common in childhood, with 4-20% of school children having warts at any one time. The DNA papillomavirus is causative and is passed by direct contact with an infected person or from recently shed virus kept intact in a moist, warm environment. Five types of warts are caused by specific genotypes of HPV:
•Common wart (verruca vulgaris)
•Plantar wart (verruca plantaris)
•Flat wart (verruca plana)
•Venereal wart (condyloma acuminatum)
•Epidermodysplasia verruciformis

SIGNS AND SYMPTOMS:
•Verruca vulgaris: Rough surfaced, raised, skin-colored papules 5-10 mm in diameter. They may coalesce into a mosaic 1-3 cm in diameter. Most frequently seen on hands.
•Verruca plantaris: Rough surfaced (although smoother than the common wart), flat, skin-colored papules not infrequently attaining 2-3 cm in diameter
•Verruca plana: Slightly elevated, flat-topped, skin-colored papules 1-3 mm in diameter sometimes in a linear arrangement often on hands and face
•Condyloma acuminatum: thin, flexible, tall, papules sometimes demonstrating a confluent growth resembling cauliflower. They do not have the visible or palpable keratin of the previous warts. In infants, laryngeal papillomatosis may occur if condyloma is transmitted during vaginal delivery.
•Epidermodysplasia verruciformis: Flat, reddish lesions on the hands and shoulders presenting in childhood with lifelong persistence

CAUSES:
Human papillomavirus (HPV)

RISK FACTORS:
•AIDS and other immunosuppressive diseases (e.g., lymphomas)
•Immunosuppressive drug use
•Atopic dermatitis
•Locker room use
•Skin trauma

DIFFERENTIAL DIAGNOSIS:
•Corns (on paring, a single "eye" of keratin is observed, whereas a wart shows hemorrhagic spots or "roots")
•Scar tissue
•Molluscum contagiosum (central umbilication and, after curettage, the characteristic pearl)
•Condyloma lata (flat warts of syphilis)
•Seborrheic keratoses

LABORATORY:
HPV cannot be cultured

PATHOLOGICAL FINDINGS:
•Papillomavirus found in the nuclei and nucleoli of the stratum granulosum and keratin layers of the epidermis.
•Plantar warts have rete pegs (a downward proliferation of epidermal ridges).
•Thrombosed dermal capillaries

SPECIAL TESTS:
Definitive diagnosis can be achieved with the following, but are not clinically relevant for most presentations:
•Electron microscopy
•Immunohistochemical study
•Nucleic acid hybridization

DIAGNOSTIC PROCEDURES:
Paring or débridement and simple visualization will be diagnostic in most cases.

GENERAL MEASURES:
Spontaneous remissions are common, probably related to a host immune response. Conservative, non-scarring treatments are preferred. Each treatment is associated with a 60-70% cure rate. Cure is achieved when skin lines are restored to a normal pattern.

SURGICAL MEASURES:
•Pretreat with anesthetic cream such as EMLA
•Cryotherapy - often preferred because scar formation is minimized. Freezing periungual warts may result in nail deformation.
•Excision with electrocautery, laser ablation, curettage (the virus may be found in smoke so masks should be worn)
•Disfiguring scars and wart recurrence are problems

ACTIVITY:
If plantar warts are on weight-bearing surface, they may cause significant discomfort and subsequent decrease in activity

PATIENT EDUCATION:
Infectious nature should be discussed; keep warts covered while under treatment to avoid auto-inoculation and transmission to others.

MEDICATIONS:
•Benign neglect - safe cost effective treatment option except when warts are extensive, spreading, symptomatic
•Hyperthermia - safe and inexpensive approach; immerse affected area into 45°C water bath for 30 minutes three times per week
•Chemotherapy - all treatments begin by paring the wart, then soaking the area in warm water to moisten the wart
•Topical retinoids: tretinoin (retinoic acid, Retin-A) for flat warts, less scarring than cryotherapy or surgical approaches; may be best for warts on the face. Apply bid for 4-6 weeks.
•Lactic-salicylic acid (Duofilm): daily treatment for about 3 months
•Salicylic acid (Trans-Ver-Sal) in a transdermal delivery system : daily treatment for about 6 weeks
•Keralyt (salicylic acid in propylene glycol); rub into warts each night
•Combination cantharidin; 30% salicylic acid, 2% podophyllin, and 19% cantharidin in flexible collodion: apply thin coat, occlude 4-6 hours (or less if painful), then wash off; blisters when form require roof to be removed, debridement of base, and antibiotic cream applied: multiple applications at 2-4 week intervals
•Imiquimod; for external genital and perianal warts; apply 5% cream (250 mg single use packets) three times/week at bedtime. Wash off after 6-10 hours. May be used for up to 16 weeks. May weaken condoms and diaphragms.
•Induction of delayed type hypersensitivity with dinitrochlorobenzene or diphencyclopropene, or squaric acid dibutylester: apply 2% solution to light shielded area every 2-3 weeks until sensitivity reaction occurs; then apply lower concentration to affected areas
•Occlusion - the easiest and least expensive; cover the wart with a waterproof tape and leave on for a week. Remove and leave open for 12 hours then re-tape if wart is still present. The environment under the tape does not foster viral growth. May be the best for periungual warts.

Contraindications: See specific treatments. Vascular insufficiency is a relative contraindication to some treatments.
Precautions: Avoid normal skin when using the topical chemicals
Significant possible interactions: N/A

ALTERNATIVE DRUGS:
•Chemotherapy
•Benzoyl peroxide: apply bid for 4-6 weeks
•Bleomycin - intradermal injection, is expensive and causes severe pain, but has a 75% cure rate
•Cimetidine - 30-40 mg/kg divided tid for 3 months. 86% of patients will have partial or complete regression.
•24% podophyllin applied weekly to anogenital warts, or 5% podofilox (Condylox) self-applied twice daily for 3 days each week for 1 month
•Others - dichloroacetic acid, trichloroacetic acid, podophyllin, 5-fluorouracil, silver nitrate, idoxuridine (Herplex Liquifilm), formaldehyde, glutaraldehyde
•Immunotherapy
•Dinitrochlorobenzene (DNCB) - should be considered a last resort because of side effects and possible mutagenicity
•Interferon - intralesional for urogenital warts
•Interferon alpha - systemic for genital warts
•Interferon beta or gamma - systemic for disseminated verruca vulgaris
•Imiquimod (Aldara) applied daily

PREVENTION/AVOIDANCE:
•Cover warts under treatment. Avoid the wound fluid after cryotherapy.
•Use personal footwear in locker room settings

POSSIBLE COMPLICATIONS:
•Auto-inoculation
•Scar formation
•Chronic pain after plantar wart removal and scar formation
•Nail deformity after injury to nail matrix

REFERENCES

•Bolton RA: Warts. Am Fam Phys 1991;43(6):2049-2056
•Lynch PJ: Dermatology for the House Officer. 3rd Ed. Baltimore, Williams & Wilkins, 1994
•Sams W, et al: Principles and Practices of Dermatology. 2nd Ed. New York, Churchill Livingston, 1996
•Ordoukhanian E: Warts and molluscum contagiosum; beware of treatments worse than the disease. Postgrad Med 1997;2:223-235
•Siegfried EC: Warts on children: an approach to therapy. Ped Annuals 1996;2:79-90
•Gaspari AA, et al: Successful treatment of a generalized human papillomavirus infection with granulocyte-macrophage colony-stimulating factor and interferon gamma immunotherapy in a patient with a primary immunodeficiency and cyclic neutropenia. Arch of Dermatol 1997;133(4):491-96
•Anonymous. Tackling warts on the hands and feet. Drug Ther Bull 1998;36(3):22-4

Whipple's disease

2008-03-22T17:25:00.003+08:00

A malabsorption disorder. Characteristics - diarrhea, steatorrhea, skin pigmentation, arthralgia, arthritis, lymphadenopathy, and central nervous system lesions. Usual course - progressive; curative with treatment.

CAUSES:

•probable bacterial infection

DIAGNOSIS:

The diagnosis is suspected when large aggregates of PAS-positive , bacteria-containing macrophages are seen in the small intestine and/or other affected organs. Granulomas may also be seen. The bacteria exhibit an unusual trilaminar cell wall ultrastructure by electron microscopy. Diagnosis is established by polymerase chain reaction amplification of the 16S rRNA gene sequences of these bacteria in tissue. The organism has been isolated in tissue culture. There is evidence indicating that Tropheryma whippelii is a ubiquitous environmental or commensal organism causing Whipple's disease in a small subset of individuals. Macrophage dysfunction appears to be a prerequisite for the development of Whipple's disease.

TREATMENT

• penicillin G´

• ampicillin´

• tetracycline´

• corticosteroids, e.g. ´prednisone´

SYNONYMS:

•lipophagic intestinal granulomatosis

•intestinal lipodystrophy

•secondary nontropical sprue

ICD-9-CM:

040.2 Whipple's disease

Williams syndrome

2008-03-12T09:25:00.002+08:00

Williams syndrome is an unusual multisystem neurodevelopmental disorder typified by characteristic craniofacial features, mild microcephaly, mild to moderate mental retardation with a distinctive cognitive-behavioral profile, connective tissue abnormalities, growth retardation, supravalvular aortic stenosis, peripheral pulmonary stenosis, renal artery stenosis, limited joint movement and transient hypercalcemia. Its occurrence is sporadic, although familial autosomal dominant cases have been infrequently reported.

The pattern of occurrence is nearly always sporadic and observed in both sexes, although there are several reported cases of familial transmission as an autosomal dominant mutation. The phenotypic expression is somewhat varied and associated with a hemizygous microdeletion of 114-250 kb in the 7q11.23 region which includes the elastin (ELN) and LIM-kinase (LIMK) gene.

SIGNS AND SYMPTOMS:
•The signs and symptoms observed in the classic case of WS may be diagnostic but the clinical presentation is somewhat varied
•Early childhood: Global developmental delay albeit with seemingly normal speech and expressive language
•Hyperacusis
•Characteristic craniofacial features
•Elfin-like facial appearance
•Medial eyebrow flare and stellate irises
•Wide mouth
•Long flat philtrum
•Upturned nose with a flat nasal bridge
•Dental anomalies
•Mild microcephaly
•Characteristic clinical features
•Supravalvar aortic stenosis
•Peripheral pulmonary stenosis
•Renal artery stenosis
•Infantile hypercalcemia
•Growth retardation and short stature
•Slender limbs and trunk
•Characteristic cognitive/behavioral features
•Weakness in abstract/visual reasoning
•Highly developed expressive language skills
•Low levels of daily living skills
•Postpubertal males and females
•Characteristic clinical features
•Hypertension
•Lordosis and/or limited joint movement
•Characteristic behavioral features
•Anxiety
•Depression and suicidal ideation

CAUSES:
Microdeletion in the 7q11.23 region

Laboratory Diagnosis:
Molecular-genetic (DNA) evaluation is the diagnostic test of choice and can determine the size of the deletion

SPECIAL TESTS:
Affected individuals require cognitive, behavioral, psychological and educational evaluations to develop individual education programs

TREATMENT

APPROPRIATE HEALTH CARE:
Affected individuals will generally need life-long adult supervision. Early intensive educational intervention and behavior modification should be implemented.

GENERAL MEASURES:
•Early detection will permit early intervention and intensive behavioral training
•Treatment for hypercalcemia by controlling dietary intake of calcium and vitamin D
•Ophthalmological evaluations are recommended for visual acuity
•Preventive dentistry to reduce risk of malocclusion
•Continual monitoring of cardiovascular anomalies and for hypertension
•Filtered ear protection for hyperacusis

SURGICAL MEASURES:
Treatment for aortic, pulmonary or renal artery stenoses if needed

DIET:
For hypercalcemia, control intake of calcium and vitamin D

MEDICATIONS
DRUG(S) OF CHOICE:
Medication for hypertension and for hyperparathyroidism.

PREVENTION/AVOIDANCE:
Genetic counseling and evaluation, especially among high-functioning patients, about pregnancies. Prenatal diagnosis is available.

POSSIBLE COMPLICATIONS:
•Learning problems, especially in abstract/visual reasoning
•Behavioral problems concerning indifference to personal safety
•Post-pubescent anxiety and depression
•Risk of cardiovascular disease and/or renal dysfunction

MISCELLANEOUS
ASSOCIATED CONDITIONS:
•Developmental delay
•Growth retardation
•Cardiovascular dysfunction
•Renal dysfunction
•Attention deficit disorder (ADD)
•Frequently associated with neuropsychological dysfunction
•Treatment for ADD is similar to methods used in the general population

PREGNANCY:
Patient and family should receive genetic evaluation and counseling as prenatal diagnosis is available

SYNONYMS:
•Williams-Beuren syndrome
•Fanconi type idiopathic infantile hypercalcemia
•Elfin facies syndrome

REFERENCES

•Anderson PE, Rourke BP: Williams Syndrome. In: White BP (ed): Syndrome of Nonverbal Learning Disabilities. New York, Guilford Press, 1995
•Bellugi U, Wang PP, Jernigan TL: Williams Syndrome: An Unusual Neuropsychological Profile. In Broman SH, Grafman J (eds.) Atypical Cognitive Deficits in Developmental Disorders: Implication for Brain Function. Hillsdale NJ, Lawrence Earlbaum Associates, 1994

Wilms' tumor

2008-03-06T09:03:00.002+08:00

An embryonal renal neoplasm containing blastema, stromal or epithelial cell types usually affecting children before the 5th year.Several congenital anomalies are known to be associated with Wilms' tumor. A two stage mutational model has been proposed: occurrence in either hereditary form or sporadic form. Patients with aniridia have a deletion of the short arm of chromosome 11 (11p13).

SIGNS AND SYMPTOMS:
•Usually asymptomatic
•Palpable upper abdominal mass
•Abdominal pain
•Fever
•Anemia
•Rarely, signs of acute abdomen with free intraperitoneal rupture
•Cardiac murmur
•Hepatosplenomegaly
•Ascites
•Prominent abdominal wall veins
•Varicocele
•Gonadal metastases

CAUSES:
•Hereditary or sporadic forms of genetic mutation
•Familial form: autosomal dominant trait with incomplete penetrance (1%)
•Potential of paternal occupational exposure (machinists, welders, motor vehicle mechanics, auto body repairmen)

RISK FACTORS:
•Aniridia (600 times greater than normal risk)
•Hemihypertrophy (100 times greater than normal risk)
•Cryptorchidism
•Hypospadias
•Duplicated renal collecting systems
•Wiedemann-Beckwith syndrome
•Drash's syndrome
•Klippel-Trenaunay syndrome
•Familial occurrence
•Paternal occupation (see Causes)

DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
•Neuroblastoma
•Hepatic tumors
•Sarcoma
•Rhabdoid tumors

LABORATORY:
•Urinalysis (occasional hematuria)
•CBC (anemia)
•LDH
•Plasma renin (rarely helpful)
•Urine catecholamines

PATHOLOGICAL FINDINGS:
•Favorable findings (mortality of 7%)
•Bulky lesion, well-encapsulated
•Focal areas of hemorrhage and necrosis
•Absence of anaplasia and sarcomatous cell types
•Presence of blastema, stomal and epithelial elements
•Unfavorable histology (mortality rate of 57%)
•Anaplasia - markedly enlarged and multipolar mitotic figures 3-fold enlargement of nuclei in comparison with adjacent similar nuclei, hyperchromasia of enlarge nuclei. Anaplasia may be diffuse or focal.
•Sarcomatous changes - are now considered to be separate from Wilms, not subtypes. (Mortality of 64%)
•Nephroblastomatosis
•Considered premalignant

IMAGING:
•Chest x-ray
•KUB (presence of linear calcifications)
•Abdominal ultrasound - gives best information about tumor extension into IVC
•CT (with IV and oral contrast) of chest and abdomen
•IVP rarely helpful

DIAGNOSTIC PROCEDURES:
Occasionally bone marrow aspiration necessary to distinguish from neuroblastoma

TREATMENT
APPROPRIATE HEALTH CARE:
•In-patient work-up and treatment until stable postoperative and induction chemotherapy completed

GENERAL MEASURES:
•Chemotherapy
•Radiation therapy in Stage II, unfavorable histology, Stage II and Stage IV

SURGICAL MEASURES:
•Examination (visual and manual) of contralateral kidney
•Radical nephroureterectomy and biopsies as needed to provide precise staging information
•Sampling of any enlarged lymph nodes
•Identification of any retained tumor with titanium clips.
•Tumor should be given to pathologist fresh, not on formalin
•Vertical midline incision if tumor extension to right atrium present (possible use of cardiopulmonary bypass)
•With bilateral Wilms' tumors, biopsy, then chemotherapy and 2nd look operation 6 weeks to 6 month later for partial bilateral nephrectomy if possible

PATIENT EDUCATION:
•Patient and family teaching regarding long-term outlook
•Possibility of second malignancy
•Side effects of chemotherapy, radiation therapy

MEDICATIONS
DRUG(S) OF CHOICE:
•Dactinomycin (actinomycin-D)
•Vincristine
•Doxorubicin
•Cyclophosphamide (Cytoxan)

Contraindications: Refer to manufacturer's literature
Precautions: Refer to manufacturer's literature
Significant possible interactions: Refer to manufacturer's literature

ALTERNATIVE DRUGS:
•Doxorubicin (Adriamycin)
•Cyclophosphamide

FOLLOW UP
PATIENT MONITORING:
•Multidrug chemotherapy every 3-4 weeks for 16 weeks - 15 months depending on stage
•Every 4 months for 1 year, every 6 months for 2nd - 3rd year, yearly after that
•CBC, CT chest and abdomen with each visit

POSSIBLE COMPLICATIONS:
•1-2% will develop second malignant neoplasms (leukemia, lymphoma, hepatocellular carcinoma, soft tissue sarcoma)
•High risk of low birth weight infants, perinatal mortality in offspring of female survivors of Wilms' tumor
•Chest is usual site of recurrence

EXPECTED COURSE AND PROGNOSIS:
•With favorable histology, 91% survival
•With diffuse anaplasia, 20% survival
•With focal anaplasia, 64% survival
•With rhabdoid features, 19% 3 year survival
•Staging
•I - tumor limited to kidney, completely excised
•II - Tumor extends beyond kidney, completely excised
•III - Residual non-hematogenous tumor confined to abdomen (lymph nodes positive, spillage of tumor, peritoneal implants, extension beyond resection region)
•IV - Hematogenous metastases
•V - Bilateral renal involvement

REFERENCES

•Ashcraft KW, Holder TM: Pediatric Surgery. 2nd Ed. Philadelphia, W.B. Saunders Co., 1993
•Shochat SJ: Wilms' Tumor: Diagnosis and Treatment in the 1990's. Seminars in Pediatric Surgery 1993;2(1):59-68
•O'Neill JA, Rowe MI, Grosfeld JL, et al: Pediatric Surgery. 5th ed., St Louis, Mosby, 1998

Wilson's disease

2008-02-09T11:18:00.000+08:00

An inherited metabolic disorder characterized by excessive amounts of copper in the liver, brain, kidneys, and corneas. It can lead to tissue necrosis and fibrosis, which in turn can cause hepatic disease and neurologic changes. Without treatment, it leads to fatal hepatic failure.

CAUSES:
•genetic

TREATMENT

•avoid copper-rich foods
•penicillamine, potassium sulfide, pyridoxine, zinc acetate as alternative to penicillamine

SYNONYMS:
•progressive lenticular degeneration
•Westphal-Struempell pseudosclerosis

Wiskott-Aldrich syndrome

2008-02-04T17:39:00.000+08:00

Males affected by this rare x-linked genetic disorder display combined immunodeficiency, microcytic thrombocytosis and eczema leading to life threatening infections and bleeding complications. Average life span is 11 years. The syndrome has variable expression. XLT is a related but milder form with mostly platelet defects.

SIGNS AND SYMPTOMS:
•Neonatal:
•Excessive bleeding from circumcision
•Bloody diarrhea
•Petechiae and purpura
•Childhood:
•Eczema with secondary skin infections
•Recurrent bacterial infections
•Viral infections
•Hepatosplenomegaly
•Autoimmune vasculitis and hemolytic anemia

CAUSES:
•Hematopoietic cells express WASP
•Defective WASP fails to organize membrane activation
•Membranes don't form normal actin cytoskeletons
•Altered motility and inability to change cell shapes inhibits normal functions
•Platelets are intrinsically abnormal
•Accelerated destruction, sequestered in spleen
•T cells show decreased responsiveness to antigens
•B cells show abnormal antibody production

RISK FACTORS:
•Family history of WAS
•History of congenital defects

LABORATORY:
•Platelets abnormal at birth
•<30,000, MPV 2/3 normal
•B cell and T cell changes over time
•WBC count fall by age 6
•Low IgM, Normal IgG, High IgA and IgE
•Decreased response to capsular antigens
•Low CD 8 counts in 61%
•Decreased delayed hypersensitivity responses
•Decreased mitogenic responses

Drugs that may alter lab results: Antibiotics
Disorders that may alter lab results: Infections

PATHOLOGICAL FINDINGS:
•Hyperplasia of lymphoreticular system
•Vasculitic changes with multiple thromboses of small arterioles of kidney, lung, pancreas, brain

SPECIAL TESTS:
•Genetic testing for WASP
•Carrier identification

DIAGNOSTIC PROCEDURES:
Bone marrow aspiration to exclude leukemia and aplastic conditions and to HLA type for bone marrow transplantation.

TREATMENT
APPROPRIATE HEALTH CARE:
•Inpatient for acute infections
•No live virus vaccination

GENERAL MEASURES:
•HLA typed bone marrow transplant restores all abnormalities with an 85% cure rate
•Crossmatched platelets
•Irradiated, CMV negative blood products
•Aggressive antibiotic therapy for infections
•Prophylactic antibiotics

SURGICAL MEASURES:
•Splenectomy can transiently improve TCP but increases the risk of infection

ACTIVITY:
•Plan activities to help normal development
•Avoid contact sports and prevent head injuries
•Avoid crowds

PATIENT EDUCATION:
•Patient/parent counseling to cope with disease and outcome
•Genetic testing and counseling for family

MEDICATIONS
DRUG(S) OF CHOICE:
•Immunoglobulin infusions
•Prophylactic penicillin after splenectomy
•Antibiotics as indicated by culture
•Topical steroids for eczema
•Parenteral steroids, vincristine or plasmapheresis for autoimmune complications

Contraindications: Refer to manufacturer's literature
Precautions: Corticosteroids in immunosuppressed patients. Refer to manufacturer's literature
Significant possible interactions: Refer to manufacturer's literature

FOLLOW UP
PATIENT MONITORING:
As needed for therapy, monitor for infections, for progression of disease, complications

PREVENTION/AVOIDANCE:
•Genetics counseling
•Identify carriers
•Prenatal diagnosis

POSSIBLE COMPLICATIONS:
•Severe infections especially after splenectomy
•Hemorrhage, cerebral common
•Malignancies (lymphoreticular, leukemia, Kaposi's)
•Nephropathy
•Autoimmune disease in 40% can be aggressive
•Malabsorption syndrome

EXPECTED COURSE AND PROGNOSIS:
•Usual course is acute and chronic infections with progressive decrease in immune status.
•Average life expectancy is 11 years with more living past twenty with bone marrow transplant. Transplant therapy can restore all abnormalities. Causes of death have been infection (50%), bleeding (27%), malignancies (12%).

AGE-RELATED FACTORS:
Pediatric:
•Onset at birth
•First year infections with encapsulated bacteria: respiratory, meningitis, sepsis
•Later infections occur with opportunistic organisms and virus

SYNONYMS:
•Aldrich syndrome
•Eczema-TCP
•Immunodeficiency-2

REFERENCES

•Ochs HD: The Wiskott-Aldrich Syndrome. Seminars In Hematology 1998;35(4):332-45
•Brickell PM, Katz DR, Thrasher AJ: Wiskott-Aldrich syndrome: current research concepts. British J of Haematol 1998;101(4): 603-08
•Mamlok RJ: Primary immunodeficiency disorders. Allergy and Immunology 1998;25(4):739-58.
•Kuska B: Wiskott-Aldrich syndrome is a 'wonderful mystery'. J National Cancer Institute 1996;88(18):1258-61
•Litzman J, Jones A, Hann I, Chaper H, Strobel S, Morgan G: Intravenous immunoglobulin, splenectomy, and antibiotic prophylaxis in Wiskott-Aldrich syndrome. Archives of Dis in Childhood 1996;75(5):436-39

Yaws

2008-01-10T10:16:00.000+08:00

Non-venereal, infectious, tropical disease usually affecting persons under the age of 15. Spread by direct contact. Characteristics - painless papule that grows into a papilloma. The papule heals, leaving a scar. Late manifestations: deforming lesions of bones, joints, and skin. Usual course - chronic; progressive. Endemic areas - tropical regions.

CAUSES:
•skin contact
•treponema pertenue

TREATMENT

•´penicillin´

SYNONYMS:
•frambesia
•buba
•pian

Yellow fever

2007-12-03T05:14:00.000+08:00

An acute infectious disease primarily of the tropics, caused by a virus and transmitted to man by mosquitoes of the genus Aedes and Haemagogus. A live virus vaccine (with few side effects) is effective and should be administered every 10 years. Usual course - acute. Endemic areas - Africa; South America.

CAUSES:
flavivirus
mosquito bite
Aedes aegypti

TREATMENT
fluid replacement
supportive therapy
treatment for complications

Yersinia enterocolitica infection

2007-09-26T10:22:00.000+08:00

Gram negative, facultatively anaerobic bacteria causing acute gastroenteritis and mesenteric lymphadenitis in children, and arthritis, septicemia, and erythema nodosum in adults. Transmitted through food, water, and person-to-person contact. Usual course - acute.

CAUSES:
•contaminated food ingestion

TREATMENT

• streptomycin
• gentamicin
• tetracycline
• chloramphenicol
• trimethoprim-sulfamethoxazole
• fluid replacement

Zinc deficiency

2007-08-28T07:33:00.000+08:00

A collection of growth retardation, hypogonadism, cell mediated immune dysfunction, and skin changes related to decreased zinc

SIGNS AND SYMPTOMS:
•Mild deficiency
•Hypogeusia
•Decreased dark adaptation
•Decreased lean body mass
•Moderate deficiency
•All of the above
•Diarrhea
•Growth retardation
•Hypogonadism (especially male)
•Mental lethargy
•Anergy
•Rough skin
•Delayed wound healing
•Glucose intolerance
•Impaired cell mediated immunity
•Severe deficiency
•All of the above
•Bullous pustular dermatitis
•Weight loss
•Dwarfism
•Emotional instability
•Tremors
•Ataxia
•Alopecia
•Death

CAUSES:
•Increased requirements
•Pregnancy
•Lactation
•Rapid growth phase of childhood
•Burns
•Major trauma
•Increased losses
•Diabetes
•Cirrhosis
•Renal disease
•Malabsorption states, e.g., inflammatory bowel diseases
•Sickle cell anemia
•Decreased absorption
•Acrodermatitis enteropathica, an autosomal recessive deficiency in the enzyme required for
intestinal absorption
•Geophagia
•Chelating agents
•Parasitism
•Diet high in phytates
•Insufficient dietary intake
•Vegetarianism
•Parenteral hyperalimentation without supplementation
•Breast feeding
•Suboptimal zinc conditions in diet (rare)
•Alcoholism

RISK FACTORS:
•High milk consumption
•Low socioeconomic status

LABORATORY:
•Plasma zinc levels decreased (in moderate to severe zinc deficiency)
•Erythrocyte or leukocyte zinc levels more adequately assess tissue stores, but these are more
costly and not widely available
•Hair or fingernail zinc levels not useful

DIET:
•Balanced omnivorous diet
•Avoid excessive intake of foods with high phytate content, (e.g., cereals)

DRUG(S) OF CHOICE:
•Zinc gluconate or zinc sulfate for 6-9 months
•Elemental zinc added to hyperalimentation in adult patient.
•In pediatric patients, 0.02-0.04 mg zinc/kg/day in hyperalimentation
•Prenatal vitamins with minerals during pregnancy and lactation to prevent deficiency

PREVENTION/AVOIDANCE:
•Adequate diet
•Supplementation when indicated

Zollinger-Ellison syndrome

2007-08-26T09:20:00.000+08:00

A triad of (Marked elevated gastric acid secretion, Peptic ulcer disease, A gastrinoma or non-beta islet cell tumor of the pancreas or duodenal wall which produces gastrin). Gastrinomas (at time of diagnosis) may be single or multiple (1/2-2/3), large or small, benign or malignant (2/3), sporadic (70-75%) or associated with multiple endocrine neoplasia (MEN 1)(25-30%)

SIGNS AND SYMPTOMS:

Abdominal pain >80%
Epigastric pain
Reflux esophagitis
Vomiting unresponsive to standard therapy
Diarrhea including while fasting 40-70%
Peptic ulcer disease
Weight loss
Hepatomegaly with metastasis
Steatorrhea
Endoscopic findings including esophagitis, duodenal ulceration with multiple ulcers and prominent gastric and duodenal folds
Complications of severe peptic ulcer disease including hemorrhage, perforation and obstruction
Signs of MEN 1 including those of hypercalcemia hyperparathyroidism and Cushing's syndrome.

CAUSES:
Gastrinoma equally distributed between the head of the pancreas and the first or second portion of the duodenum. May also be found rarely in the mesentery, peritoneum, spleen, skin or mediastinum (possibly metastasis with primary not identified).

LABORATORY:

Elevated serum gastrin-fasting (>1000 pg/mL with ulcers diagnostic, >200 pg/mL with ulcers suggestive)
Elevated basal gastric acid output >15 mEq/hr (>15 mmol/hr)
Gastric pH <2.0>
Check serum calcium, phosphorous, cortisol and prolactin (to R/O MEN 1)

APPROPRIATE HEALTH CARE:

Advise daily care based on symptoms
Appropriate surveillance of basal gastric acid output to monitor anti-acid secretory therapy
Appropriate surveillance postoperatively to look for metastasis

GENERAL MEASURES:

Advanced imaging initially to assess for possible resection
Surgical removal when primary can be identified and as an adjunct for symptom control
Medical treatment for symptom control when primary not found or metastasis present on diagnosis

SURGICAL MEASURES:

Laparotomy to search for resectable tumors unless have liver metastasis on presentation or MEN 1
Definitive therapy-removal of gastrinomas when found (surgery finds 95% of tumors, 5 year cure 30% when all can be removed)
Total gastrectomy was formerly used to stop acid production before pharmacologic therapy available, now seldom done
Vagotomy in some patients will reduce acid secretion and improve therapeutic effect of medication. May allow decrease dose of medication.
In MEN 1 parathyroidectomy by lowering calcium may decrease acid production and decrease antisecretory drug use. Gastrinomas generally benign but multiple and not usually cured by surgery.

DIET:
Restrict foods which aggravate symptoms

Contraindications:

Known hypersensitivity to the drug
H2-blockers-androgen effects, drug interactions due to Cytochrome P-450 stimulation
Omeprazole-none
Lansoprazole-none

Precautions:

Adjust doses for renal and geriatric patients depending on drug
Gynecomastia reported with high dose cimetidine (>2.4 gm/d)
Proton pump inhibitors may induce a profound and long lasting effect on gastric acid secretion, thereby affecting the bioavailability of drugs dependent on low gastric pH (eg, ketoconazole, ampicillin, iron)

ALTERNATIVE DRUGS:

Octreotide appears helpful in slowing growth of liver metastasis. May produce regression in some cases.
Chemotherapy regimens of streptozocin, 5-fluorouracil and doxorubicin show only limited response
Interferon and shows more limited response; may be useful in combination with octreotide

Zygomycosis

2007-08-24T14:52:00.000+08:00

Fungal infection typically seen in immunocompromised or debilitated patients. In healthy individuals, the organisms seldom cause infection. Several forms exist - gastrointestinal, rhinocerebral, disseminated mucormycosis, pulmonary, cutaneous, central nervous system. Prognosis is guarded.

Patients with hematologic malignancies are currently at higher risk of invasive fungal infections (IFI) caused by molds than by yeasts, and the incidence of IFI is highest among patients with acute myeloid leukemia. Aspergillus spp are still the most common pathogens, followed by Candida spp. Other agents are rare. The attributable mortality rate for aspergillosis has dropped from 60-70% to approximately 40%. Candidemia-related mortality remains within the 30-40% range reported in literature although the incidence has decreased.

CAUSES:
fungi of the class Zygomycetes

TREATMENT
Amphotericin B´
surgical removal of necrotic tissue

Altitude Illness

2007-08-17T09:44:00.000+08:00

Altitude illness is a medical problem ranging from mild discomfort to fatal illness that may occur on ascent to higher altitude. It can affect anyone, including those who are experienced and fit, and who ascend to more than about 8,000 feet (2438 m). Several factors appear to be important in adaptation to altitude, including how long the ascent takes, how high, and length of stay. Much variation exists between people; in addition, an individual's response may vary from ascent to ascent.Sign and symptoms are Mild to moderately severe symptoms: (Headache, Lack of energy and appetite, Mild nausea, Dizziness, Weakness and Insomnia), Severe symptoms: (Increased headache, Irritability, Marked fatigue, Shortness of breath with exercise, Nausea and vomiting, Irregular or periodic breathing at night and Difficulty or cessation of breathing), High altitude pulmonary edema (NAPE) symptoms: ( Excessive shortness of breath on exertion, Severe respiratory distress, Shortness of breath at rest, Dry cough and/or wheezing, Increased heart rate and breathing rate, Marked irregular breathing present at night, Gurgling breathing, Frothy cough, Wet crackling sounds in the lungs, Confusion and Coma), High altitude cerebral edema (HACE) symptoms: ( Progressive headache that is unrelieved by mild pain relievers, Lack of coordination, Confusion and bizarre behavior followed by unconsciousness, Other symptoms of moderate altitude sickness, such as dizziness, vomiting, and irritability, are usually present)

CAUSES:
The physiology of altitude illness is still not completely understood. The fundamental problem is a decrease in air pressure, resulting in less oxygen delivery to the body.

MOST OFTEN AFFECTED:
Altitude sickness can affect any age individual, men and women in equal proportion. Young, well-conditioned climbers have a higher incidence of altitude illness, probably because they push themselves more.

RISK FACTORS:
•In general, the faster and higher the ascent, the more likely a person will experience symptoms of altitude illness.
•Chronic illness
•Lack of conditioning

WHAT THE DOCTOR LOOKS FOR:
The doctor will consider other respiratory problems, such as pneumonia, respiratory infection, or heart failure.

TESTS AND PROCEDURES:
•A variety of blood tests may be performed.
•Arterial blood may be obtained to measure blood gasses.
•A chest X-ray may be done to evaluate the respiratory system.
•An electrocardiogram (EKG) may be done to monitor heart function.

GENERAL MEASURES:
•Severe cases of altitude sickness may require hospitalization.
•Treatment is tailored to fit the severity of disease and may be limited by the environment.
•Definitive treatment is to descend to a lower altitude. Dramatic improvement accompanies even modest reductions in altitude (as little as 1,000 feet).
•Giving oxygen helps relieve symptoms.
•Descent is rarely needed for mild cases. Drink fluids, eat a light diet, and curtail activity.
•For severe symptoms, the victim should be immediately evacuated to a lower altitude and given continuous oxygen.
•A portable hyperbaric chamber is another effective and practical alternative for severe symptoms when descent is not possible.

ACTIVITY:
Rest until symptoms clear.

DIET:
Increased intake of fluids, a light diet, and avoidance of alcohol

COMMONLY PRESCRIBED DRUGS:
•Aspirin or codeine to relieve headache
•Antibiotics, if infection is present
•Dexamethasone or acetazolamide
•Corticosteroids

PREVENTION/AVOIDANCE:
•Staged ascent with appropriate acclimatization
•Sleeping elevation: "Climb high and sleep low" is a prudent practice for anyone going above 12,000 feet (3656 m).
•Adequate hydration: Dehydration makes altitude sickness worse.
•Good physical conditioning
•Consider carrying a supply of oxygen.
•Some drugs can prevent or lessen the symptoms of altitude sickness.

COMPLICATIONS:
•Aspirin or codeine to relieve headache
•Antibiotics, if infection is present
•Dexamethasone or acetazolamide
•Corticosteroids

WHAT TO EXPECT:
•Mild to moderate altitude sickness resolves over 1 to 3 days. Climbers may resume ascent once symptoms subside.
•People with severe symptoms can expect complete recovery if there is no underlying disease. They should not resume ascent.
•Problems are more likely among people who have had one or more attacks.

Addison's disease

2007-06-16T11:19:00.000+08:00

Adrenal hypofunction from primary disease (partial or complete destruction) of the adrenal gland with inadequate secretion of glucocorticoids and mineralocorticoids. An autoimmune process is the most common cause (80% of the cases) followed by tuberculosis. AIDS is becoming a more frequent cause.
•Addison's disease (primary adrenocortical insufficiency) is differentiated from secondary (pituitary failure) and tertiary (hypothalamic failure) causes of adrenocortical insufficiency (see Differential Diagnosis)
•Addisonian (adrenal) crisis - acute complication of adrenal insufficiency (circulatory collapse, dehydration, hypotension, nausea, vomiting, hypoglycemia); usually precipitated by acute physiologic stressor such as surgery, illness, exacerbation of co-morbid process, acute withdrawal of long term corticosteroid therapy

Genetics:
Autoimmune adrenal insufficiency shows some hereditary disposition. Familial glucocorticoid insufficiency may have recessive pattern; adrenomyeloneuropathy is X-linked. Frequent association with other autoimmune disorders.

Incidence/Prevalence in USA:

Approximately 4:100,000

Predominant age:

All ages; usually 3rd to 5th decade

Predominant sex:

Females > Males (slight)

SIGNS AND SYMPTOMS:
•Weakness, fatigue, tiredness
•Weight loss
•Dizziness; low blood pressure, orthostatic hypotension
•Increased pigmentation (extensor surfaces, hand creases, dental-gingival margins, buccal and vaginal mucosa, lips, areola, pressure points, scars; "tanning"; freckles; vitiligo)
•Anorexia; nausea; vomiting
•Chronic diarrhea
•Abdominal pain
•Decreased cold tolerance
•Salt craving
•Hair loss in females
•Depression (60-80% of patients)

CAUSES:
•Autoimmune adrenal insufficiency (~80%)
•Tuberculosis (~20%)
•Waterhouse-Friderichsen syndrome (disseminated adrenal infection and subsequent infarction; meningococcemia most common; Pseudomonas aeruginosa common in children; atypical pathogens, CMV, Cryptococcus, MAC in immunosuppressed and AIDS)
•Fungal disease (histoplasmosis, blastomycosis, coccidioidomycosis)
•Bilateral adrenal hemorrhage and infarction (anticoagulants; 50% are in therapeutic range at time of hemorrhage)
•Antiphospholipid syndrome
•Metastatic (lung, breast, kidney, colon), lymphoma, Kaposi's sarcoma (tumor must destroy 90% of gland to produce hypofunction)
•Drugs (ketoconazole, etomidate)
•Surgical adrenalectomy
•Radiation therapy
•Sarcoidosis
•Hemochromatosis
•Amyloidosis
•Adrenoleukodystrophy
•Adrenomyelodystrophy
•Polyglandular endocrine syndromes
•APS I (autoimmune polyglandular syndrome 1)
•Childhood onset
•HLA-DR not associated
•Single gene mutation in APECED gene (APECED = autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy)
•APS II (autoimmune polyglandular syndrome II)
•Schmidt's syndrome
•Adult onset
•HLA-DR associated
•Adrenal failure with type I diabetes mellitus and/or hypothyroidism
•Congenital (enzyme defects; hypoplasia; familial glucocorticoid insufficiency)
•Idiopathic

RISK FACTORS:
•Family history of autoimmune adrenal insufficiency. About 40% of patients have a first- or second-degree relative with one of the associated disorders.
•Taking steroids for prolonged periods, then experiencing severe infection, trauma or surgical procedures

DIAGNOSIS DIFFERENTIAL DIAGNOSIS:
•Secondary adrenocortical insufficiency
•Withdrawal of long-term corticosteroid use
•Sheehan's syndrome (postpartum necrosis of pituitary)
•Empty sella syndrome
•Surgical excision of pituitary
•Radiation to pituitary
•Pituitary adenomas, carcinomas (rare), craniopharyngiomas
•Infiltrative disorders of pituitary (sarcoidosis, hemochromatosis, amyloidosis, histiocytosis X)
•Megestrol
•Tertiary adrenocortical insufficiency
•Pituitary stalk transection
•Trauma
•Disruption of production of corticotropic releasing factor (CRF)
•Hypothalamic tumors
•Myopathies
•Syndrome of inappropriate antidiuretic hormone (SIADH)
•Heavy metal ingestion
•Severe nutritional deficiencies
•Sprue syndrome
•Hyperparathyroidism
•Neurofibromatosis
•Peutz-Jeghers syndrome
•Porphyria cutanea tarda
•Salt-losing nephritis
•Bronchogenic carcinoma
•Anorexia nervosa
•Other causes of hypoglycemia
•Depression

LABORATORY:
•Low serum sodium
•Elevated serum potassium
•Elevated BUN, creatinine
•Elevated serum calcium
•Hypoglycemia when fasted
•Metabolic acidosis
•Low cortisol level (between 8 and 9 a.m.)
•Elevated ACTH level
•Moderate neutropenia
•Eosinophilia
•Relative lymphocytosis
•Anemia
•Adrenal-cortex autoantibody (ACA/21-hydroxylase)

PATHOLOGICAL FINDINGS:
Atrophic adrenals in autoimmune adrenalitis. Infiltrative and hemorrhagic disorders produce enlargement with destruction of entire gland.

SPECIAL TESTS:
•Rapid ACTH stimulation test: Cosyntropin 0.25 mg IV, measure pre-injection and 60 minute post-injection cortisol levels. Patients with Addison's disease have low to normal values that do not rise
•Metapyrone test
•Insulin-induced hypoglycemia test
•CRH may help distinguish secondary from tertiary adrenal insufficiency
•Autoantibody tests
•21-Hydroxylase (most common and specific)
•17-Hydroxylase
•17-alfa-Hydroxylase (may not be associated)
•Adrenomedullin

IMAGING:
•Abdominal CT scan
•Small adrenal glands in autoimmune adrenalitis
•Enlarged adrenal glands in infiltrative and hemorrhagic disorders
•Abdominal x-ray: may show adrenal calcifications
•Chest x-ray: may show adrenal calcifications, small heart size, calcification of cartilage

DIAGNOSTIC PROCEDURES:
A work-up to determine the cause of Addison's disease. CT guided fine-needle biopsy of adrenal masses may be helpful.

GENERAL MEASURES:
•Treatment for adrenal insufficiency is with glucocorticoid and mineralocorticoid replacement
•5 S's of management of adrenal crisis: salt, sugar, steroids, support, search for precipitating illness
•Appropriate treatment for underlying cause (e.g., tuberculosis)

DIET:
Arrange for a diet that maintains water, sodium and potassium balances

PATIENT EDUCATION:
•For patient education materials favorably reviewed on this topic, contact: National Addison's Disease Foundation, 505 Northern Blvd., Suite 200, Great Neck, NY 11021, (516)487-4992
•Patient should wear or carry medical identification with information about the disease and the need for hydrocortisone or other replacement therapy
•Instruct patient in self-administering of parenteral hydrocortisone for emergency situations (e.g., traveling in remote areas away from medical help)

MEDICATIONS
DRUG(S) OF CHOICE:
•For chronic adrenal insufficiency:
•Hydrocortisone 15-20 mg orally each morning upon arising and 10 mg at 4-5 each afternoon is usual dosage (dosage may vary and is usually less in children's),PLUS,
•Fludrocortisone 0.05-0.2 mg orally once/day plus
•Dehydroepiandrosterone 25-50 mg orally once a day (monitor lipid profile, breast or prostate cancer)
•Acute adrenal insufficiency
•Hydrocortisone hemisuccinate 100 mg IV followed by 10 mg/hr infusion
•IV glucose, saline, plasma expanders
•For acute illnesses (fever, stress, minor trauma)
•Double the patient's usual steroid dose

PREVENTION/AVOIDANCE:
•No preventive measures known for Addison's disease
•Prevention of complications
•Anticipate adrenal crisis and treat before symptoms begin
•If nausea and vomiting preclude oral therapy, patient should seek medical help to start parenteral therapy
•Elective surgical procedures require adjustment in steroid dose
•Prevent exposure to infections

POSSIBLE COMPLICATIONS:
•Hyperpyrexia
•Psychotic reactions
•Complications from underlying disease
•Over- or under-steroid treatment
•Hyperkalemic paralysis (rare)
•Addisonian crisis

EXPECTED COURSE AND PROGNOSIS:
•Good outlook with appropriate treatment. With adequate replacement therapy, life expectancy approximates normal
•100% lethal without treatment

Actinomycosis of the thorax

2007-06-16T11:13:00.000+08:00

Infectious bacterial disease affecting the thorax and lungs. It also occurs in three other forms that include abdominal, cervicofacial and generalized. Usual course - progressive.

CAUSES:
•actinomyces infection
•oral commensal
•aspiration of infected material
•impaired consciousness
•alcoholism

TREATMENT

•prolonged antibiotic therapy
•surgical drainage of suppurative lesions

Actinomycosis of the kidney

2007-06-16T10:56:00.000+08:00

Infectious bacterial disease that appears in 4 clinical forms - abdominal, cervicofacial, thoracic, and generalized. The generalized form can involve the kidneys as well as other organs. Characteristics - back pain, lethargy, weight loss, fever, hematuria. Usual course - acute.

CAUSES:
•retrograde infection by actinomyces israelii

TREATMENT
•antibiotics
•drainage

Acrodermatitis enteropathica

2007-05-12T12:02:00.000+08:00

Previously fatal disorder resulting from malabsorption of zinc. Characteristics: psoriasiform dermatitis, hair loss, paronychia, diarrhea, and growth retardation. Symptoms begin in infants just after weaning.

CAUSES:
•zinc deficiency
•defective zinc absorption

TREATMENT
•oral elemental zinc

SYNONYMS:
•Danbolt-Closs syndrome
•Brandt syndrome

Acoustic neuroma

2007-03-26T13:13:00.000+08:00

A tumor arising from Schwann cells of the 8th cranial nerve (most often the vestibular division, rather than the acoustic division). Neurofibromatosis type II strongly predisposes patients to acoustic neuromas.

SYMPTOMS: unilateral hearing loss and other neurologic findings when the tumor compresses the cerebellum, pons, or facial nerve.
CAUSES: Unknown
TREATMENT: Surgical excision
SYNONYMS: Acoustic schwannoma

Acne rosacea

2007-03-24T14:56:00.000+08:00

Chronic skin eruption with flushing and dilation of small blood vessels in the face, especially nose and cheeks. Sometimes associated with ocular symptoms (ocular rosacea).
Predominant age: 30-50
Predominant sex: Female > Male

SIGNS AND SYMPTOMS are skin flush - prominent at onset, redness - lower half of nose, sometimes whole nose, forehead, cheeks, chin, conjunctivae red - (sometimes), erythema, dusky - (in advanced cases), blood vessels in involved area collapse under pressure, acne lesions form papules, pustules, and nodules; comedones are rare, telangiectasia, and rhinophyma (sometimes) more common in males

CAUSES:
•No proven cause.
*Possibilities include
•Thyroid and gonadal disturbance
•Alcohol, coffee, tea, spiced food overindulgence (unproven)
•Demodex follicular parasite (suspected)
•Exposure to cold, heat, hot drinks
•Emotional stress
•Dysfunction of the gastrointestinal tract

PATHOLOGICAL FINDINGS:
•Inflammation around hypertrophied sebaceous glands, producing papules, pustules and cysts
•Absence of comedones and blocked ducts
•Vascular dilatation and dermal lymphocytic infiltrate

ACTIVITY:
No restrictions. Support physical fitness.

DIET:
Avoid any food or drink that causes facial flushing, e.g., hot drinks, spiced food, alcohol

Precautions:
•Tetracycline: may cause photosensitivity; sunscreen recommended
Significant possible interactions:
•Tetracycline: avoid concurrent administration with antacids, dairy products, or iron
•Broad-spectrum antibiotics: may reduce the effectiveness of oral contraceptives; barrier
method recommended

ALTERNATIVE DRUGS:
•For severe cases, isotretinoin orally for 4 months.

POSSIBLE COMPLICATIONS:
•Rhinophyma (dilated follicles and thickened bulbous skin on nose), especially in men
•Conjunctivitis
•Blepharitis
•Keratitis

EXPECTED COURSE AND PROGNOSIS:
•Slowly progressive
•Subsides spontaneously (sometimes)

PREGNANCY:
Use of oral isotretinoin contraindicated

Acanthosis nigricans

2007-03-23T09:44:00.000+08:00

A circumscribed melanosis consisting of a brown pigmented velvety verrucosity or fine papillomatosis appearing in the axillae and other body folds. Occurs in association with endocrine disorders, underlying malignancy, administration of certain drugs, or as in inherited disorder. Usual course - chronic.

CAUSES:
•congenital
•associated with malignant disease
•obesity
•idiopathic

TREATMENT
•treat underlying cause
•malignancy workup

Abruptio placentae

2007-03-07T16:43:00.000+08:00

Premature separation of otherwise normally implanted placenta. Sher's grades:
1: minimal or no bleeding; detected as retroplacental clot after delivery of viable fetus.
2: viable fetus with bleeding and tender irritable uterus.
3: type A with dead fetus and no coagulopathy; type B with dead fetus and coagulopathy (about 30% of grade 3's).

It is a second or third trimester vaginal bleeding greater than one pad or tampon per hour. Patient usually complained of back pain, abdominal pain, uterine tenderness, hypertonia, or high frequency contractions. Blood loss may be concealed; clinical signs of shock may occur with little vaginal bleeding. Since blood volumes increase in pregnancy, volume lost may exceed 30% before signs of shock or hypovolemia. Vital signs may be preserved even with significant loss.Fetal distress or demise. Idiopathic preterm labor with or without fetal distress Causes are cocaine use and abuse, trauma of variable amounts; especially blunt abdominal trauma in which external signs of trauma may be incongruent with fetal injury (motor vehicle accidents or domestic violence), sudden decompression of over-distended uterus as in hydramnios or twin gestation

RISK FACTORS:
•Prior abruption
•Maternal smoking
•Severe small for gestational age birth
•Alcohol abuse
•Hypertension: pregnancy-induced and chronic
•Increased risk if hypertensive and parity > 3
•Preterm rupture of membranes, especially if bleeding occurs during observation interval
•Vaginal bleeding before spontaneous rupture of membranes

LABORATORY:
•Blood type, Rh, Coombs
•CBC with platelet count
•Prothrombin time (PT) , partial thromboplastin time (PTT), fibrinogen levels
•Cross match at least three units

SPECIAL TESTS:
•Kleihauer-Betke for fetal-maternal transfusion
•Bedside clot test with red top tube of maternal blood with poor or non-clotting blood after 7-10 minutes indicating coagulopathy
•Apt test for fetal blood origin: mix vaginal blood with small amount tap water to cause hemolysis, centrifuge several minutes, mix pink hemoglobin containing supernatant with 1 cc 1% sodium hydroxide (NaOH) for each 5 cc supernatant, reading color in two minutes with fetal Hgb staying pink and adult turning yellow-brown
•Wright stain vaginal blood, observe for nucleated RBC's - usually of fetal origin
•Lecithin/sphingomyelin (L/S) ratio if delay of delivery is an option and length of pregnancy is preterm

IMAGING:
•Although ultrasound may show sonolucent retroplacental clot, rounded placenta margin or thickened placenta, it is often not definitive - especially with posterior placement or mild abruption

DIAGNOSTIC PROCEDURES:
•External uterine monitoring often shows elevated baseline pressure and frequent low amplitude contractions

GENERAL MEASURES:
•History and physical exam with past medical history, allergies, prior ultrasounds this gestation, and time of last meal
•In general, severe abruption best managed by delivery of fetus
•Sher's grade 1 - usual labor protocol
•Sher's grade 2 - rapid delivery most often by cesarean section
•Sher's grade 3 - vaginal delivery preferable if mother stable
•In trauma monitor inpatient at least 4 hours for evidence of fetal insult, abruption, fetal-maternal transfusion
•Early aggressive restoration of maternal physiology to protect fetus and maternal organs from hypoperfusion/DIC
•Stabilize vitals, keep Hct >30, urine output >30 cc/hr
•Bedrest with external fetal and labor monitoring, if fetus is viable
•Large bore 16-18 gauge IV crystalloid infusion, central line placement only after coagulation status has been assessed
•Transfusions of whole blood may be necessary
•Follow hemoglobin/hematocrit (H/H) and coagulation status every 1-2 hours
•Place intrauterine pressure catheter (IUC) since fetal risk climbs with elevated pressure
•Role of amniotomy to prevent amniotic fluid embolism is debatable but will speed delivery
•Positioning on left side may enhance venous return and cardiac output
•Oxygen for all patients
•If trauma without compromise after observation or small abruption and preterm may observe outpatient encouraging reduction of risk factors

SURGICAL MEASURES:
May need cesarean section after maternal stabilization if fetus viable and situation urgent

ACTIVITY:
Bedrest until status defined

DIET:
NPO until status defined and cesarean section possibility ruled out

POSSIBLE COMPLICATIONS:
•Infection transfusion risks: Hepatitis, cytomegalovirus infection, HIV and others
•Sensitization from blood product transfusion

EXPECTED COURSE AND PROGNOSIS:
•0.5% to 1% fetal mortality and 30-50% perinatal mortality
•With trauma and abruption 1% maternal and 30-70% fetal mortality
•Labor typically more rapid but hypotonus from blood suffusion may occur

Abortion, spontaneous

2007-03-06T08:26:00.000+08:00

Abortion is the separation of products of conception from the uterus prior to the potential for fetal survival outside the uterus. Gestationally, the point at which potential fetal viability exists has been the subject of much legal and scientific debate, and definitions vary from state to state; however, a "potentially viable" fetus generally weighs at least 500 grams and/or has a gestational age over 20 weeks.
•Spontaneous abortion: refers to expulsion of all (complete abortion) or part (incomplete abortion) of the products of conception from the uterus prior to the 20th completed week of gestation. The placenta, either in whole or in part, can be retained and leads to continuing vaginal bleeding (sometimes profuse). Abortion is "threatened" when vaginal bleeding occurs early in pregnancy, with or without uterine contractions, but without dilatation of the cervix, rupture of the membranes, or expulsion of products of conception. Cervical dilation, rupture of membranes or expulsion of products in the presence of vaginal bleeding portends "inevitable abortion." Differentiation between threatened and inevitable abortion is desirable since management differs.
•Missed abortion: Failed first trimester pregnancy but without the usual signs and symptoms such as bleeding or cramping. Term blighted ovum replaced with anembryonic gestation. Ultrasound findings of "empty sac."
•Induced abortion: refers to the evacuation of uterine contents/products of conception by either medical or surgical methodology
•Infected abortion: infection involving the products of conception and the maternal reproductive organs
•Septic abortion: dissemination of bacteria (and/or their toxins) into the maternal circulatory and organ system
•Habitual spontaneous abortion: three or more consecutive spontaneous abortions. Risk of another spontaneous abortion is approximately 25-30% with 70% rate of successful pregnancy in subsequent pregnancy.

Approximately 2/3 of first trimester spontaneous abortions have significant chromosomal anomalies with 1/2 of these being autosomal trisomies and the remainder being triploidy, tetraploidy, or 45X monosomies
Approximately 10-15% of all clinically recognized pregnancies end in spontaneous abortion. Biochemical pregnancy manifests itself by the presence of β-HCG in the blood 7-10 days after conception. When both clinical and biochemical pregnancies are considered, more than 50% of conceptions are spontaneous aborted. Increases with advancing age, especially after 35 years of age. At age 40, the loss rate is 2 times that of age 20.

SIGNS AND SYMPTOMS:
•In a previously diagnosed intrauterine pregnancy
•Vaginal bleeding
•Uterine cramping
•Cervical dilation
•Ruptured membranes
•Passage of non-viable products of conception

RISK FACTORS:
•Chromosomal abnormalities
•Luteal phase defect
•Leiomyomas
•Incompetent cervix
•Infections
•Antifetal antibodies
•Autoimmune disease - phospholipid syndrome
•Alloimmune disease (shared paternal antigens)
•Drugs, chemicals, noxious agents (alcohol, smoking, caffeine)
•X-irradiation
•Contraceptive IUD

DIFFERENTIAL DIAGNOSIS:
•Ectopic pregnancy: a potentially life-threatening complication, difficult to distinguish from threatened abortion. Transvaginal ultrasonography can identify intrauterine gestational sacs at 32 days of gestation (at serum HCG levels of 1500-2000 IU). The absence of transvaginal ultrasound evidence of an intrauterine gestation with serum HCG over 2000 IU/L should be considered an ectopic pregnancy until proven otherwise.
•Cervical polyps, neoplasias, and/or inflammatory conditions can cause vaginal bleeding. This bleeding is not usually associated with pain/cramping and is apparent on speculum exam.
•Hydatidiform mole pregnancy usually ends in abortion prior to the 20th week of pregnancy. Bloody discharge prior to abortion is common. An intrauterine grape-like appearing mass on the ultrasound is diagnostic (a "snow storm" appearance). Human chorionic gonadotropin (HCG) is often high.
•Membranous dysmenorrhea: characterized by bleeding, cramps and passage of endometrial casts can mimic spontaneous abortion. HCG is negative.
•HCG secreting ovarian tumor

LABORATORY Pocedures:
Cultures - gonorrhea and chlamydia, CBC, Rh type, Human chorionic gonadotropin (HCG), Serial β-HCG measurements can assess viability of the pregnancy. Normal gestations have an approximate 67% increase over 2-day interval. Abnormal gestations do not rise appropriately, plateau, or decrease in level before the eighth week of gestation.

SPECIAL TESTS:
Progesterone levels > 25 ng/mL are consistent with normal intrauterine pregnancy and are rarely seen in ectopic and/or non-viable pregnancy. A progesterone of < 5 ng/mL is an indicator of a nonviable intrauterine gestation or an ectopic pregnancy.

IMAGING:
Ultrasound examination for fetal viability and to rule out ectopic pregnancy. Ultrasound imaging can be sensitive enough to confirm an intrauterine pregnancy in the fourth or fifth gestational week from last menstrual period

DIAGNOSTIC PROCEDURES:
Viable intrauterine pregnancy with fetal cardiac activity detected between 5-8 weeks from last menstrual period on transvaginal ultrasound. Transvaginal ultrasound criteria for nonviable intrauterine gestation include:
•5 mm fetal pole without cardiac activity, or
•16 mm gestational sac without a fetal pole
Fetal heart tones can be auscultated with doppler starting between 10-12 weeks gestation from last menstrual period for a viable pregnancy. Consider a diagnosis of spontaneous abortion in a woman, of childbearing age, presenting with abnormal vaginal bleeding

TREATMENT
APPROPRIATE HEALTH CARE:
Outpatient or inpatient, depending on severity of symptoms (bleeding or pain)

ACTIVITY:
If appropriate, bed rest; probably no effect on eventual outcome

PREVENTION/AVOIDANCE:
•Any vaginal bleeding in intrauterine pregnancy is abnormal and should be considered a "threatened" abortion. In reality, vaginal bleeding in early pregnancy is common (occurring in up to 1/3 of pregnancies) and often the bleeding source eludes diagnosis.
•In habitual abortion, the abortus should be sent for karyotyping. Explore other causes of habitual abortion with the couple to determine the best therapy.
•Special care and attention for the patient who has a subsequent pregnancy

POSSIBLE COMPLICATIONS:
•Complications of D&C include uterine perforation, infection and bleeding
•Possibly retained products of conception
•Depression and feelings of guilt (patient may need education and reassurance that she did not cause the miscarriage)

EXPECTED COURSE AND PROGNOSIS:
•If bleeding ceases, prognosis is excellent.
•Habitual abortion: prognosis is dependent on etiology. After a 2 consecutive abortions, most couples want some investigation of the problem. After 3 spontaneous abortions, evaluation is usually indicated. Prognosis is still excellent with up to 70% rate of success with subsequent pregnancy.

Aortic Regurgitation

2007-03-05T14:18:00.000+08:00

Retrograde flow from the aorta into the left ventricle through incompetent aortic cusps. Symptoms include dyspnea, shortness of breath, palpitations, orthopnea. Usual course - acute; chronic. Basic causes are bacterial endocarditis, aortic dissection, ankylosing spondylitis, aortic stenosis, rheumatic fever, giant cell arteritis, syphilis, Marfan's syndrome, osteogenesis imperfection, Reiter's syndrome, rheumatoid arthritis, cystic medial necrosis, sinus of Valsalva aneurysm, hypertension, arteriosclerosis, myxomatous degeneration of valve, dissection of aorta, bicuspid aortic valve. Treatment is aortic valve replacement.

Kawasaki Disease

2007-01-18T09:16:00.000+08:00

This condition was discovered by Dr. Kawasaki of Japan in 1967. It is also known as Kawasaki syndrome, mucocutaneous lymph node syndrome, or infantile polyarteritis. It is a rare condition in children less than 5 years of age. The cause is yet unknown but it is believed to be caused by infection. It usually affects the heart, blood vessels, lymph nodes, and mucous membranes.

There is still no tests available to diagnose this condition. Diagnosis is based on a diagnostic criteria based on the symptoms manifested by the patient. The acute phase is characterized by high-grade spiking fever of 1 to 2 weeks duration. The fever is accompanied by painless reddening of the bulbar conjunctiva, redness of the mucous membranes, red cracking lips, red tongue with raised bumps (strawberry tongue), and swelling and redness of the hands and feet. Five days after the appearance of fever, the rash appears in the trunk and extremities. There is also the appearance of enlarged lymph nodes in the neck area. This is usually firm and slightly tender but on one side only.

The rash can easily be mistaken for measles. Since there is no diagnostic exam available to diagnose this condition, a high degree of suspicion is needed. Using the diagnostic criteria for Kawasaki disease,the presence of fever plus at least four of the other symptoms means the presence of this condition in a child.

After 1 to 2 weeks of onset desquamation of fingers and toes is noted. The skin surrounding the fingernails and toe nails peel. During this time the child is no longer febrile but there can be pain and inflammation of the joints.

Treatment is started as soon as diagnosed. Gamma globulin is given intravenously in high doses (2g/kg body weight as single dose or 400 mg/kg body weight given for 3 days). This is accompanied by giving oral acetylsalicylic acid. These are given to reduce inflammation and prevent damage to the heart and coronary arteries.

Complications involves the coronary arteries and the heart. These vessels can be inflamed which can lead to aneurysm (dilated area of a blood vessel because of weakening of its walls). This together with the heart complication will lead to heart attack at a very young age or later in life. The major cause of death in these patients is myocardial infarction. Screening in the form of echocardiography is therefore important at least every year to note the presence of heart problem.

Hidradenitis Suppurativa

2007-01-10T14:31:00.000+08:00

HS is a disease affecting the apocrine glands. It is seen where apocrine glands are located such as in the groin, anal area, and armpits. It is also seen in areas where the skin rub together such as under the breast, between the buttocks, and inner thighs especially in obese individuals. It is characterized by red, painful lesions containing pus which drain when the lesion break open and usually leads to scarring. Tunnels under the skin also develop. Some of the lumps grow under the skin and may become hard, tender, enlarge, and become infected. The condition worsens with time and obesity, hormonal changes, stress, genetics,excessive perspiration, and cigarette smoking contribute to its development and progression.

It is believed that blockage of the openings of hair follicles and oil glands contribute to the development of this condition. Although no cure is still available, early diagnosis and prompt treatment help in the prognosis of the condition and prevent eruption of new lesions. Giving of antibiotics for the infection, pain relievers, and corticosteroids improve the condition. Surgery is often done for those with severe and persistent lesions.

Surgery is done to remove the pus and drain the lesion. It is also done to remove the affected skin and replace with new one (skin grafting) and to uncover tunnels to improve healing. Surgery does not prevent occurrence of this condition to other areas of the body.

Patent Ductus Arteriosus

2006-12-29T09:51:00.000+08:00

A ductus is a blood vessel connecting the pulmonary artery to the descending aorta thereby allowing the blood to bypass the baby’s lungs. This structure is normal before the birth of a baby but should close immediately after birth. Failure of closure after 10 days of life makes this opening abnormal.

If the defect is small no symptoms can be felt by the individual. Large defects however produces symptoms of dyspnea, poor weight gait, congestive heart failure, and failure to thrive. There is also the presence of murmur heard on physical examination.

Like other congenital heart diseases, PDA is also associated with prematurity and low birth weight. It is also associated with other heart diseases like coarctation of the aorta, ventral septal defect, and transposition of the great vessels.

Fluid restriction is advised to these patients. Surgery is done to older children if the defect interferes with their daily activity

Steven Johnsons syndrome

2006-11-09T20:02:00.000+08:00

Steven Johnsons syndrome is an immune complex hypersensitivity disorder known to be caused by certain

Antibiotics like cotrimoxazole and penicillin
Viral infections, and bacterial infections like AIDS, and herpes
Radiation theraphy for malignancies
Antiretroviral therapy-Combivir & Nevirapine (NVP)

It is commonly found in young adults and children. Affected individuals usually present with flu-like manifestations like headache, fever, cough, and body aches. There is severe blistering of the skin and mucous membranes of the mouth, eyes, nose, vagina, urinary, respiratory, and digestive tracts.

It takes around several weeks before recovery sets in. The individual is treated with antibiotics for infection, analgesics, and steroids. Fluid consumption is also increased.

Parkinson’s Disease

2006-11-09T19:57:00.000+08:00

Parkinson’s Disease is a neurodegenerative disorder affecting people age 50 and above. It is caused by the loss of dopamine-producing brain cells thus leading to the primary signs and symptoms majority of which is tremor. This is a chronic progressive disorder meaning it worsens as the disease progresses.

The symptoms of PD varies from person to person but the most common of these is tremor. Trembling of the hands, arms, legs, face, and jaw are noted accompanied by stiffness of the trunk and extremities. There is also impairment in balance and coordination (postural instability) and slowness of movement (bradykinesia). As the disease progresses, the symptoms begin to interfere with daily activities. Difficulty in talking, swallowing, chewing, and other simple tasks are noted. There can also be sleep problems, skin problems, urinary problems and constipation.

Treatment for PD is only symptomatic. Levodopa is given to allow the brain cells to replenish its supply of dopamine. It helps reduce bradykinesia and stiffness but it produces dyskinesia or involuntary movement as side effect. To reduce dyskinesia, bradykinesia, gait problems and tremors, surgery is done. Electrodes are implanted inside the brain and these are connected to an electrical device. This procedure is called deep brain stimulation (DBS). Other drugs that can be given to reduce symptoms are anticholinergics and amantadine, an antiviral drug.

Bell’s Palsy

2006-10-15T11:25:00.000+08:00

This is a fairly common condition named after Dr. Charles Bell, a surgeon from Scotland, who first described it. It is usually mistaken for stroke but further screening will delineate this condition. There is usually a weakness or paralysis on one side of the face causing the eyes and facial muscles on the affected side to droop. This causes the person to speak, smile and close the eye with difficulty accompanied by headache, pain in the ear on the affected side, intolerance to loud sounds, and lost of taste on the front portion of the tongue. There is also a change in the amount of tears and because of difficulty closing the affected eye with the lower eyelid turned out, the affected eye is usually dry.

The actual cause of the condition is still unclear but scientists believe that a viral cause is probable. The Herpes Simplex Virus is believed to lie dormant in the facial nerve and causes the inflammation when activated. It is usually seen in immunocompromised individuals - those who are diabetics, pregnant women, and other chronic conditions which compromise the immune system. Although this condition may clear up on its own even without treatment, most doctors still give medications to reduce or limit nerve damage.

Steroids are anti-inflammatory medicines used to reduce the swelling and inflammation. They are given together with anti-virals like Acyclovir. A massage to the affected facial muscles can also help prevent contractures from occurring. Using an artificial tear to the dry eye and covering it with eye patch help protect the eye from injury.

Insomnia

2006-10-15T11:21:00.000+08:00

Insomnia, defined as difficulty initiating and/or maintaining sleep,is a very common symptom especially in the elderly. Although it is seen at any age group, its incidence increases with age. It is also common to individuals who are constantly exposed to stress, anxiety, and depression, and to people with chronic pain and a variety of medical conditions. Drinking coffee and cigarette smoking also contribute to insomnia. Aside from these, some medications taken for high blood pressure and some cold preparations may also aggravate the condition.

With insomnia the individual will then have symptoms of daytime sleepiness, irritability, and inability to concentrate. Depression will then ensue as a result of lack of sleep. As the condition progresses to days, daytime activities will be affected because of inability to function normally.

Some medications are given to improve the condition. This medications include sedatives or a hormone called melatonin which help regulate the sleep-wake cycle.Aside from medications, regular exercise particularly in the morning may also help improve the condition. The environment or the place you sleep also plays an important role. The place should not be crowded, not too hot, with adequate lighting, and with minimal noise in order to initiate sleep easily without any interruption. If any of these will not help, try to relax by taking a bath, listening to soft music, or just by reading a book. Daytime naps should be avoided or limited to be able to sleep soundly at night.

Meals should be taken early at least two hours before bedtime and if possible, avoid drinking anything that contains caffeine. Once already in bed and sleep does not easily set in, some meditation methods or relaxation breathing will do the trick.

Sleepwalking

2006-09-04T11:03:00.000+08:00

There are two types of sleep - the Slow Wave Sleep or non-rapid eye movement (NREM) sleep and the Rapid Eye Movement (REM) sleep. NREM is a deep, restful type of sleep occuring during the first hour. It is divided into 4 stages and is interrupted periodically by REM sleep. REM sleep sets in 80-100 minutes after sleep onset. It lasts for 5 to 30 minutes and recurs every 90 minutes. REM sleep is not so restful and the eyes undergo rapid movement. In a normal sleep pattern, there is a cycling throughout the night between wakefulness, NREM, and REM sleep. In children, deepest sleep takes place 15 minutes after sleep onset.

Sleep walking, also known as somnambulism, is characterized by simply sitting up,quiet walking, to running around the room with the eyes open. The person may also perform complex activities like cleaning the house, moving furnitures, changing clothes, and other similar activities.The episode usually lasts for a few seconds to an hour or more. Although the person is asleep, he tends to avoid obstacles but the incident is not remembered on waking up.It occurs most often during stage 3 or 4 NREM sleep early in the night and usually recurs during REM sleep in the morning. It is common in middle childhood and pre-adolescence. Peak incidence is seen in children 11 to 12 years old.

The cause is unknown. It is usually associated to fatigue and anxiety in children to complex medical conditions in adults.

Anemia

2006-08-10T13:49:00.000+08:00

Most people misunderstand the word Anemia. They come to our clinic, have their blood pressure taken in order for them “to know if they have anemia”. The thing is that one will not be able to diagnose the presence or absence of anemia by taking the blood pressure. The sphygmomanometer will only tell the presence of hypertension (high blood pressure), normotension, or hypotension (low blood pressure).
There are two parts of the blood: the liquid part which is the plasma and the solid part isthe cells. The cells are of 3 types: the White Blood Cells (WBC) are the ones responsible for fighting infection, the platelets are responsible for blood clotting, and the Red Blood Cells (RBC) carry Oxygen and carbon dioxide.

The RBCs contain hemoglobin, an iron-rich protein which gives the red color to the RBC and enables the RBC to carry oxygen and carbon dioxide. The blood pumped by the heart contains oxygenated blood. The oxygen is delivered to the different tissues of the body in exchange for the carbon dioxide. In a person with anemia, the RBC and hemoglobin count of the blood is less than normal. This is maybe due either to increase destruction or decrease formation so that there are not enough RBCs to carry oxygen to the tissues and this will lead to different signs and symptoms. The most prominent symptom is easy fatiguability. There may also be headache, weakness, dizziness, shortness of breath, chest pain, pale skin, and numbness of the extremities. Heart rate also may increase as a compensatory mechanism of the heart to increase oxygen delivery.

Anemia per se is not a disease. It is a condition present in many diseases like iron deficiency anemia, sickle cell anemia, aplastic anemia, vitamin deficiency anemia, and hemolytic anemia.

Reye's Syndrome

2006-07-31T09:46:00.000+08:00

Reye’s Syndrome is a condition which occurs during or immediately after a viral infection. It is seen at any age but is more common in children causing damage and swelling in the brain and liver which may lead to brain death.

The signs and symptoms suddenly appear when a child is supposed to be recovering from a viral disease like measles or chickenpox. The symptoms include convulsions, persistent vomiting,lethargy, irritability, disorientation, and decline in mental alertness. These symptoms may worsen within hours leading to paralysis and loss of consciousness.

Until now the cause is still unknown. Studies show that the use of aspirin for fever has been associated with its occurrence.Early diagnosis is important for prevention of irreversible complications like permanent liver damage, nervous system damage, and brain damage. The degree of severity of brain swelling is directly related to the prognosis of the affected individual.The treatment is aimed to correct the abnormalities present- brain swelling, low blood sugar, and high blood level of ammonia.

Measles

2006-07-31T09:40:00.000+08:00

Also known as Rubeola, measles is a rare but highly contagious disease caused by a virus. It presents like a flu with symptoms of cough, colds, red watery eyes, high grade fever, and a reddish brown rash. The rash is seen initially at the forehead then it progresses to affect later on the body until it reaches the feet. There is also the presence of small red spots inside the mouth called the Koplik’s spots.

The symptoms of measles appear after around 10-14 days from exposure to the virus and usually last for 14 days. These symptoms can go on their own even without medical treatment after the virus has run its course. Treatment is given to a patient to avoid complications and to prevent progression of the disease into more severe infections like pneumonia, bronchitis, myocarditis, or encephalitis.The patient must be given antipyretic like paracetamol for the fever and more fluids to prevent dehydration.

Nowadays, this condition is very rare because of immunization. The measles vaccine is available individually or in combination vaccine called MMR. The MMR vaccine is given between 12-15 months of age for the 1st dose and then repeated at age 4 to 6. It is contraindicated to individuals who are immunocompromised, and to those with allergy to gellatin and neobycin.

Mumps

2006-07-13T14:43:00.000+08:00

Mumps is a viral infection primarily affecting the parotid gland on one or both sides of the face thus causing it to swell. It is caused by the Myxo Virus which is transmitted from an infected person to another by means of the saliva. The saliva of an infected person is infectious 6 days before swelling of the parotid glands begin. And the different signs and symptoms of mumps appear usually after around 3 weeks of exposure to the virus.

The infected individual is usually feverish, with headache, difficulty swallowing, dry mouth, weakness, and fatigue. If the infected individual is in the post pubertal age, there may also be swelling and pain in one or both testicles which might lead to infertility. Orchitis is one of the rare complications of mumps. Others include meningitis, encephalitis, pancreatitis, hearing loss, and ovarian inflammation.

Immunity is acquired after infection. Treatment is supportive with plenty of fluids and enough rest. Soft diet is recommended to aleviate the pain during swallowing. Cold compress is done for the pain or pain relievers can be given. The vaccine is given only to those who are still not exposed to the virus. Antibiotics are not recommended.

Dengue Fever/ Dengue Hemorrhagic Fever

2006-07-13T14:00:00.000+08:00

Dengue Fever is an infectious viral disease usually found during and shortly after the rainy season. It is common in tropical and subtropical countries like the Africa, America, Caribbean, Pacific Islands, and South East Asia. It is also known as “break-bone fever” because of the severe joint pain felt during the illness. It is transmitted by mosquito bites. The Aedes Aegypti mosquito bites an already infected person then transmit the infection to another by biting someone else.

There are four of these dengue viruses which are similar but distinct from one another. When a person gets infected with one type of virus, he gets immunity for that particular type. So that a person can get infected four times in a lifetime.

The condition starts with a sudden onset of high grade fever accompanied by headache. As the disease progresses, there is appearance of a skin rash, muscle and joint pains. There can also be loss of appetite, nausea and vomiting, and enlarged lymph nodes. These symptoms usually appear after five to eight days from infection. They usually lasts up to ten days.
When a complete blood count is done to the infected individual, there is a mild increase in his WBC, increase also in his Hematocrit, and a decrease in his platelets. This condition is found in travellers so that there is usually a history of visit from the tropical areas.

Supportive management is given to the patient. Paracetamol is given for the headache and fever. NSAIDS and aspirin are avoided because they tend to increase bleeding. Fluid intake is increased to avoid dehydration and rest is advised. The condition is generally self-limited.

The problem starts when the condition progresses to Dengue Hemorrhagic Fever (DHF). This usually happens in children less than ten years of age and on their 2nd or 3rd Dengue Fever infection. It is severe and often fatal. Aside from the usual symptoms of DF, there are also signs of bleeding internally from the bowels and internal organs. Blood transfusion is usually given.

No vaccine is yet available for dengue. Prevention is done by using insect repellants, mosquito nets in sleeping quarters, clothing that covers bare skin, and avoiding scents that attract mosquitoes.

Leptospirosis

2006-07-13T13:56:00.000+08:00

Leptospirosis is a potentially dangerous bacterial infection which is common in tropical areas. It is transmitted to humans by infected animals especially rodents. These animals pass the bacteria in their urine which gets into the soil, vegetation, fresh water, and flood water. A person who comes in contact with the contaminated water or soil by means of swimming or wading in these areas acquires the infection.

The bacteria enters the body through the mucous membrane or through breaks in the skin. They can also be swallowed if present in contaminated drinking water. Once inside the body, they multiply in the blood and tissue and produce several signs and symptoms. Among them are headache, fever, chills, muscle pains especially in the gastrocnemius muscle, eye inflammation, nausea, and vomiting. The bacteria primarily affects the liver and kidney producing a severe condition leading to kidney failure, liver damage, jaundice, and internal bleeding.

Farmers and children who love to wade in flood waters are the people at risk of having the condition. If the condition is left untreated, this might lead to damage of the internal organs and possibly lead to death. Antibiotics given as soon as possible will treat the condition.

Hypertension

2006-06-18T12:11:00.000+08:00

Hypertension means high blood pressure. The blood pressure reading of a person is taken by using a sphygmomanometer. It is composed of two numbers which are the systolic and diastolic blood pressure. The upper number called the systolic BP reflects the amount of pressure generated by the heart while pumping blood towards the arteries. The lower number called the diastolic BP represents the pressure in the arteries when the heart is at rest. The blood pressure increases when the heart pumps more blood and when the diameter of the arteries becomes narrowed.

Most of the time, a person with hypertension has no symptoms. People used to watch out for nape pain or headache and dizziness to tell them that their BP is rising. This is actually a wrong notion because these symptoms are usually observed when the hypertension is already in the advanced stage. Sometimes these symptoms are accompanied by weakness and palpitation.

We call the hypertension as primary or essential when we cannot pinpoint the cause of the condition. It is secondary when there is an underlying condition that is causing the hypertension. This can be a thyroid problem, an adrenal, or a kidney problem.

The best time to take the BP reading is in the morning. If upon several readings the BP is beyond 140/90, it is best for you to visit your physician for your medication. It is also good if you could trim down your built to your normal weight, increase physical activity in the form of exercise, avoid or totally stop smoking, and to minimize alcohol intake. A few lifestyle changes will help you manage your condition.

Hypertension is difficult to manage with just one visit to your physician. Follow ups are needed for adequate monitoring. Other problems that contribute to your condition should also be managed as well.

Transient Ischemic Attack

2006-06-11T12:40:00.000+08:00

As the name implies, this condition occurs rapidly, lasts only for a few minutes or less than one hour after which the signs and symptoms completely disappear and the body returns to normal state. This occurs when the supply of blood to a part of the brain becomes temporarily blocked because of the presence of blood clot or plaques (cholesterol-containing fatty deposits) in an artery supplying the brain.

This happens when while on your daily routine suddenly you feel weak or numb on one side of your body either on the face, arms, or legs. You want to ask the help of your companions but they have difficulty understanding you because your speech is slurred. You try to help yourself but you feel dizzy and there is loss of coordination in your movement. You also have difficulty looking around because of sudden blindness in one or both of your eyes. After several minutes suddenly you’re back to normal as if nothing happens. If these symptoms last for more than 24 hours then you are diagnosed to have a stroke.

This condition occurs to people who have positive family history of TIA or stroke. The risk increases for those with hypertension, diabetes, cardiovascular diseases, hypercholesterolemia, obesity, sedentary lifestyle, and cigarette smokers. TIA is a warning for a more debilitating condition that is to come. It is therefore important to treat the risk factors and avoid or limit alcohol intake, cigarrette smoking, and fatty foods.

Since a person is back to normal after an attack, oftentimes nothing is done to determine the cause. It is important for you to visit your physician in order that the abnormality which have caused the attack will be corrected so that occurrence of a stroke in the future could be prevented.

Migraine Headache

2006-06-04T22:59:00.000+08:00

Migraine is an intense, disabling type of headache which can be so excruciating that it can interrupt you from your daily activities. It can be triggered by stress, certain foods like aged cheeses and chocolates, changes in weather, food intake and sleeping patterns, bright lights such as the sun’s glare, loud noises, and unusual smells. At least a day before the headache appears, the prodromal signs and symptoms are felt which signals the person that a migraine is coming. These premonitions include craving for food particularly sweets, intense energy, fatigue, irritability, or depression.

There are two types of migraine: the common type which does not start with a warning sign and the classic type which starts with a warning sign. The warning sign is called aura. The aura lasts for around 30 minutes and is seen in any of the following forms: flashes of light, zigzag lines, or blind spots in the fiels of vision. It can be a feeling of muscle weakness or burning sensation in one part of the body.

The symptoms include intense headache in one side or both sides of the head. The pain is usually described as throbbing pain and it is worsened by physical activity thereby causing interruption from the usual daily activities. It is accompanied by nausea with or without vomiting and the person becomes more sensitive to light and sound.

The headache is thought to be caused by imbalance in brain chemicals particularly serotonin. With decreased serotonin levels, substances are released by the trigeminal nerve which causes the brain blood vessels to dilate when these substances reach the brain’s outer covering. NSAIDS are the most common medicines given to relieve the pain.

Benign Positional Vertigo

2006-05-31T20:17:00.000+08:00

This is another problem in the inner ear characterized by sudden occurrence of dizziness or a spinning sensation when the head is moved. The semicircular canals which are found in the inner ear normally contain fluid the movement of which helps the brain detect body position and maintain balance. As we age, or after a head injury, or after an inner ear infection, or any other disorder affecting the inner ear, small calcium carbonate crystals called otoconia or otoliths collects in a part of the inner ear called the utricle. They are normally attached to a membrane inside the utricle.

What causes the vertigo? In BPPV, a change in head position cause these crystals to move through the semicircular canal. They strike against nerve endings inside thus causing the vertigo. Aside from vertigo the person may also feel dizzy, lightheaded, with a sense of imbalance, and nausea. If the condition is severe there is also vomiting.

A maneuver called “Epley’s maneuver” is usually done to move otoconia away from the semicircular canals. After the procedure, the individual needs to maintain head in an upright position for 24 hours. Medications can also be given like sedative-hypnotics, antihistamines, and anticholinergics to alleviate the symptoms.

Labyrinthitis

2006-05-29T15:38:00.000+08:00

The labyrinth is a system of interconnecting cavities and canals found in the inner ear concerned with hearing and balance. When this area becomes inflammed then there is this condition called labyrinthitis.

This condition is commonly seen following infection of the middle ear, whether viral or bacterial, respiratory infection, allergy, or intake of drugs that are toxic to the inner ear structures. One of these structures is the semicircular canals which is concerned with balance and equilibrium. When its function becomes disrupted, this will lead to the different signs and symptoms like dizziness and abnormal sensation of movement or vertigo. The vertigo is acute in onset. It is usually noted upon sudden rising from the bed or just by turning oneself while in bed. It is often referred to as a spinning sensation and often accompanied by nausea and vomiting. There is also lost of balance, hearing loss, and an intense ringing sound in the affected ear (tinnitus).

Early treatment of a respiratory infection or a middle ear infection is needed for prevention of this condition. Treatment includes use of antibiotics if there is bacterial infection, antihistamines for allergy, and other medications for the different symptoms noted. Rest is very important during the illness. Failure to treat the condition might lead to spread of inflammation and although rare, might end in permanent hearing loss.

Otitis media

2006-05-24T11:39:00.000+08:00

This is an acute infection of the middle ear characterized by the presence of fluid coupled with inflammation. The middle ear is the second part of the ear where the eardrum and the three tiny bones called ossicles are located. When sound waves reach the middle ear, the eardrum vibrates and the vibration is amplified by the ossicles bringing them to the inner ear which translates these vibrations into electrical signals. Connecting the middle ear to the back of the throat is a small tube called the Eustachian tube. This tube serves to equalize the pressure between the middle ear and the outside. It also serves as drainage for fluid or mucus that gets into the middle ear.

How does the middle ear gets infected? This condition is usually noted after an upper respiratory tract infection whether viral or bacterial. The infection causes obstruction of the Eustachian tube allowing negative pressure to be generated inside the middle ear. This blockage will allow fluid to build up which is a fertile media for growth of microorganisms. This also entraps bacteria or virus that are already present inside due to the respiratory tract infection. If this infection remains untreated,this will cause rupture of the eardrum and/or extension of the infection to the inner ear structures.

This condition is common in children because their Eustachian tube is narrower, shorter, and more horizontal. The most common symptom is pain on the affected ear because of fluid pushing on the eardrum accompanied by difficulty of hearing. There may or may not be fever. The condition becomes chronic if it lasts for more than 6 weeks. Four or more episodes in one year makes it a recurrent condition.

The condition is treated with antibiotics and analgesics. It must be differentiated with otitis media with effusion which is a condition characterized by presence of fluid in the middle ear but its not infected hence antibiotics are not necessary.

Otitis Externa

2006-05-20T11:11:00.000+08:00

This is an infection of the ear canal due to a bacteria or fungus. It happens when water gets into the ears and becomes trapped inside. Water has a tendency of removing the ear wax which serves as protection and it also cause the skin to macerate. This leads to growth of bacteria and fungus which leads to the signs and symptoms seen in otitis externa. Another means is by damage to the skin in the ear canal which usually happens after cleaning with cotton buds, hair clips, and the like. The damaged skin becomes the breeding ground for fungus and bacteria. other causes include scratching the skin in ear canal or excessively dry skin in the canal which can easily break and get infected.

Otitis externa is commonly seen during the summer months. Swimming is a common activity during this season. A person with this condition usually encounters earache following a swimming episode that’s why this condition is also known as swimmer’s ear. The pain becomes during chewing and ipon traction of the pinna. Aside from the pain there is also itchiness in the area and sometimes there is swelling accompanied by reddening of the ear canal. Hearing can be temporarily affected because of the swelling. Ear discharge may or may not be present.

The patient should be given ear drops containing antibiotic to combat infection as well as steroids for the inflammation. If the condition is severe oral medications are advisable to be taken for 7 to 10 days. The ears should be kept dry all the time to prevent this condition from occurring.

Undescended Testis

2006-05-16T16:24:00.000+08:00

The testicles normally develop inside the abdominal cavity before birth. They descend into the scrotal sac by the 7th to 9th month of fetal development for optimal sperm production. Failure to do so before birth leads to the condition known as undescended testes or cryptorchidism. It can be in one side only or it can be bilateral.

The most common cause is prematurity although this condition is also seen in 3% of full-term male infants. Other causes include hormonal disorders, genetics, and spina bifida. No symptoms are associated with this condition. It is usually discovered during routine medical history and physical examination.

The undescended testis is expected to descend without any intervention by the 6th month of age. If by this time it still has not descended then it may not descend at all.Something has to be done to avoid complications later on. One of these complications which is the most common especially if the condition is bilateral is infertility. There is also risk of developing testicular cancer when the child reaches adulthood. The most bothersome effect to the growing child is the psychological aspect of having an empty scrotum.

Pharmacotherapy involves hormonal injections of HCG (human chorionic gonadotrophin) given for several weeks. This hormone is expected to stimulate testosterone production leading to the descend of the testis to the scrotal sac. Unfortunately this type of management is often not successful.When this happens surgical approach is recommended.

Orchiopexy is the surgical method of bringing down the testis into the scrotum. This procedure is done preferably between the 6th to 18th month of age. The earlier it is accomplished the better to prevent damage to the germ cells.

Sometimes the testis can be felt inside the scrotum but sometimes it is not. This condition is different from the undescended testis that we are discussing. This is due to the cremasteric reflex that contraction of the muscle causes retraction of the testicle. It is called retractile testes.

Multiple Sclerosis

2006-05-15T21:02:00.000+08:00

MS is a disorder of the brain, spinal cord, and optic nerves. This condition results in damage of the myelin sheath, the nerve covering which helps in the conduction of impulses.When the myelin is damaged this leads to impairment in the transmission of nerve signals producing problems in thinking, sensation, and movement.

This condition is seen more in women. The cause is still unknown but many researchers believe it is an autoimmune disease, meaning the immune system attacks its own tissues.The damage in the myelin occur in patches. The type of symptoms depend on the area of damage. These symptoms appear in different combinations from one person to another probably because of differences in the location of damage. They are seen in individuals 20-40 years of age.

Visual problems include a double or blurred vision, distorted color perception, eye pain, and blindness of affected eye. These visual problems can be accompanied by difficulty of concentration, poor memory, depression, muscle weakness, problems with balance and coordination, abnormal sensations like numbness. When the condition is severe there can be problems in standing or walking, or even paralysis.

There is no treatment available for this condition. The drugs are there to alleviate symptoms and probably to slow down its progression. Some of this drugs include steroids, muscle relaxants, tranquilizers, and anti-depressants.Physical therapy and exercise is also recomended as add-on to lessen the stiffness of the muscles.

Jellyfish Stings

2006-05-07T08:26:00.000+08:00

Jellyfishes are invertebrate aquatic animals that cause sting when a person comes into direct contact with their tentacles. These tentacles have specialized stinging cells called nematocytes which contain stinging structures called nematocysts. Sharp hollow tubes containing poison are found in the nematocysts. This poison is released and injected into the skin when a person suddenly comes into direct contact with the tentacles.

The toxin cause abnormalities in calcium anf sodium ion transport, releases inflammatory mediators, disrupts the membrane of cells, and affects the tissues of the heart, kidneys, nerves, and liver.It causes local skin reactions like a red rash that is both itchy and painful, swelling, and peeling off of the skin if the condition is severe. Severe systemic reaction include headache, vomiting, weakness, dyspnea, muscle spasms, fever and chills. It can even lead to shock and sudden death. Depending on the type of jellyfish, the effect of the poison differ. The faster the poison gets into the bloodstream, the more concentrated it is in the blood and the faster the onset of signs and symptoms.

When a person comes into contact with jellyfish, remove him immediately from the water. Immobilize the area so as not to spread the poison further and wash the area with salt water. Inspect the affected area for any tentacles that are still attached to the skin and if there are any remove them with forceps. Apply white vinegar to inactivate undischarged nematocysts. This will also help alleviate the symptoms.Give supportive medications for the symptoms and if there is a need hook the patient to IV fluids. Topical steroids can be applied for severe skin reactions.

Hiccup

2006-05-02T09:33:00.000+08:00

Medically known as singultus, hiccups occur due to involuntary spasm of the diaphragm and causes it to contract repeatedly. The spasms also cause sudden rush of air into the lungs which is stopped suddenly by the closure of the vocal cords or glottis. The sudden closure results in the characteristic “hic” sound. Hiccups last for several minutes to several hours and normally resolves by itself. If it becomes persistent (lasts more than 48 hours) or intractable (lasts for more than a month) then it may be a sign of a more serious health condition.

The actual cause of hiccups is still unknown. Studies show that it results from irritation, from eating too much too quickly, excessive alcohol drinking, excitement, eating very spicy foods, drinking a cold beverage with a hot meal or vise versa, laughing vigorously, and smoking.

There are a number of home remedies thought of to improve the condition or at least lessen its occurence. Some of these include holding your breath and slowly counting to 10, putting sugar or honey under your tongue, breathing repeatedly into a paper bag or in a small enclosed container, and drinking quickly a glass of cold water. All of these home remedies increase the level of carbon dioxide in the blood. The better method is exhaling all the air inside the lungs in one long exhalation and this is followed by breathing in all the air in one long inhalation with a series of short powerful puffs at the end of inspiration until the lungs cannot hold anymore. The breath is further held for several minutes or as long as possible. For the persistent and intractable types, treatment is directed to the particular cause. This may range from use of medicines to hypnosis. Medically they are given haloperidol,chlorpromazine, metoclopramide, or baclofen.

Aortic Aneurysm

2006-04-22T21:21:00.000+08:00

The aorta is a large artery arising from the heart and carries blood to the rest of the body. Aortic aneurysm is an abnormality of a localized area of the aorta characterized by widening or ballooning of the abnormal site. It commonly occurs in the abdominal aorta or the part of the aorta below the diaphragm. It is usually seen below the renal arteries which are the blood vessels going to the kidneys. Abdominal aorta supplies blood to the abdomen and the lower part of the body. This condition is common in males above 60 years old. The bigger the aneurysm, the greater the likelihood of rupture. It is life-threatening when it ruptures.

The exact cause of this condition is unknown. Some attribute it to the hardening of the arteries known as arteriosclerosis which causes weakness of the aortic wall. Cigarette smoking increases risk of developing the condition together with high blood pressure, high cholesterol levels, and obesity. Other causes include arteritis, genetic, connective tissue disease, and mycotic infection.
This condition is asymptomatic to most individuals. That’s why it is only discovered as an incidental finding when abdominal ultrasound or a CT scan is done for other conditions. When they do become symptomatic, pain is the most common symptom felt at the lower back or lower abdomen. The pain is described as severe, sudden, and may radiate to the groin, buttocks, or legs. There is also a pulsating sensation felt in the abdomen.

If the aneurysm is less than 5.5 cm wide and asymptomatic, periodic monitoring is usually done. But if it is more than 5.5 cm in diameter with symptoms and monitoring shows that it is rapidly increasing in size, rupture is common. Surgical repair is then recommended.

Pancreatitis

2006-04-17T20:40:00.000+08:00

The pancreas is a flat, non-encapsulated gland located behind the stomach (retroperitoneal). It functions by producing enzymes and digestive juices needed for breaking down food in the small intestines and it also produce hormones called insulin and glucagon that control levels of blood sugar. These secretions of the pancreas coming from the cells are brought to the ducts which leads to the main pancreatic duct. The common bile duct joins the main pancreatic duct and then empty into the duodenal part of the small intestines.

One of the common causes of pancreatitis is the presence of gallstones that obstruct the flow of pancreatic secretions that should empty into the small intestines. Obstruction causes these secretions to attack the gland itself thus causing inflammation. Another common cause is chronic use of alcohol which causes the pancreatic enzymes to be secreted earlier than normal accompanied by leakage of pancreatic secretions into the glandular tissue and cause damage and inflammation.

Other causes of pancreatitis include increased triglyceride and calcium levels in the blood, pancreatic abnormalities, trauma, infections, and certain medications. All these lead to damage and inflammation of the pancreas. Healing without functional impairment is known as acute pancreatitis. If the problem becomes recurrent this is now known as chronic pancreatitis.

Chronic pancreatitis often leads to poor absorption of fats producing oily malodorous stools. There is also damage of the pancreatic cells which normally secretes insulin. This now leads to improper metabolization of blood sugar which contributes to diabetes.

The most common symptom of pancreatitis is epigastric pain often radiating to the back. This is accompanied by nausea and vomiting, and fever. If the condition is severe there can be low blood pressure because of internal bleeding and which may lead to shock.

A patient in this condition needs to be hospitalized and hooked in IV fluid. Nothing should be given per orem for several days and the pain should be controlled.

Esophageal Varices

2006-04-11T11:28:00.000+08:00

The portal vein is the blood vessel inside the liver which carries blood coming from the intestines and spleen to the liver (splanchnic circulation). When the portal vein becomes obstructed due to certain liver conditions such as cirrhosis, the pressure inside the blood vessel increases. This problem leads to development of collateral circulation diverting the obstructed blood flow to the systemic veins. The esophageal veins which drain into the azygos vein are common collaterals in which blood are diverted into. Hence, esophageal varices develop. These are usually found in the lower esophageal walls and sometimes in the upper part of the stomach.

These varices often cause no symptoms unless they rupture and bleed making the condition life-threatening. Their rupture leads to vomiting of blood and passing out of black, tarry stools. When untreated this will lead to symptoms of thirst, decreased urine output and paleness. On physical examination, there is rapid heart rate and low blood pressure. There may also be signs of liver disease.

Aside from liver cirrhosis which is the most common cause of portal hypertension, other causes include formation of blood clot in the potal vein (thrombosis), and congestive heart failure.

Management is usually done inside the hospital using medical and procedural therapies. The most important goal is to stop and control the bleeding before shock or death occurs.

Gastritis

2006-04-07T09:50:00.000+08:00

Gastritis is not a single disease process but a group of disorders that involve inflammation of the stomach lining. It result from chronic use of pain relievers such as NSAIDS in some individuals or it may be due to a bacterium that is causing most ulcers in the stomach. This condition may occur suddenly (acute gastritis) or it may develop gradually (chronic gastritis).

The most common symptom is upper abdominal pain characterized by a burning sensation and usually noted with intake of food. This is often accompanied by nausea, vomiting, belching, a feeling of fullness which often leads to weight loss when the condition becomes chronic. In some individuals, gastritis increases risk for ulcer formation and stoamch cancer. In these group of individuals, gastric bleeding is common.

The main cause of gastritis is damage to the mucosal lining of the stomach. With damage there is lost of the normal mucous barrier that serves to protect the stomach lining from irritation and inflammation. One of the many factors that contribute to the damage of this protective stomach lining is chronic use of pain relievers known as NSAIDS. This is exemplified by iboprofen and aspirin. Other factors include excessive use of alcohol, stress, bacterial infection (H. pylori) which is also the number 1 cause of stomach ulcers, and a list of autoimmune disorders like Crohn’s disease. Radiation and chemotheraphy is also contributory.

Knowing the cause of the condition makes prevention easier. If there is really a need for use of pain relievers, use acetaminophen instead. Avoid alcohol and eat in smaller amount but in higher frequency with avoidance of spicy and fatty foods. It is also important to eat regularly at meal times. Manage stress and have a regular exercise that you enjoy. This will allow you to move your waste through the intestines regularly.

GAstroenteritis

2006-04-01T11:51:00.000+08:00

The gastrointestinal tract is responsible for the digestion of food. This tract starts from the esophagus down to the anus. When this tract gets inflammed because because of viral, bacterial, or parasitic cause, the problem results in gastroenteritis. The infection usually results from intake of contaminated food and water or contact with an infected person. Handling of food without hand washing or using dirty kitchen utensils in the preparation of food facilitate transmission of virus or bacteria.The most common symptom is diarrhea. The inflammed colon loses its ability to absorb needed nutrients so that whatever is taken in is also passed out. Diarrhea may be accompanied by low-grade fever, abdominal pain, bloating, nausea, and vomiting. The lost fluids should be replaced by giving oral rehydrating solutions. If not, dehydration may set in and manifests as cold clammy skin, excessive thirst, dry mouth, and sunken eyes.

Aside from fluid replacement theraphy, avoiding dairy and milk products, caffeinated and alcoholic beverages, fatty and spicy foods help improve the condition. Eat only easy-to digest foods in small proportions.

This condition is usually seen in travelers and individuals who take most of their meals in fastfoods (carinderias). In order to avoid having the condition, always wash hands after using the toilet and whenever you handle food. Also, refrain from eating raw or slightly cooked food, avoid ice cubes, and always drink bottled water when travelling.

Irritable Bowel Syndrome

2006-03-31T14:31:00.000+08:00

IBS is a functional disorder affecting mainly the small intestines. There is an increase sensitiveness of the nerves and muscles in the bowels so that eating cause them to contract excessively leading to changes in bowel function. Since the bowels are not working or behaving as they should normally be, the symptoms appear either during a meal or shortly after. The increased intestinal contractions forces the food towards the intestines more quickly which leads to the appearance of symptoms.These symptoms include abdominal pain (crampy), flatulence, bloating, and diarrhea. There can also be mucus in the stool. In some individuals the opposite happens so that the passage of food slows down causing constipation instead of diarrhea. The symptoms range from mild to severe depending on the sensitivity of the individual.

The exact cause on why the intestines are behaving as such is still unknown. Research show that there are certain foods that trigger the condition. Stress and other illnesses in the gastrointestinal tract may also trigger IBS.

The foods that tend to trigger IBS include milk products (cheese, ice cream, etc), fatty foods, alcohol, chocolates, caffeinated and carbonated drinks. These foods does not trigger IBS in all individuals who have the syndrome. If you have IBS it is best for you to observe what food really triggers the appearance of your symptoms so that you can lessen or avoid such foods.

There is no specific cure for IBS. What we can do is relieve symptoms by going through certain changes:

Changes in the Diet/Eating habits. It has been found that fiber helps control constipation and it also reduces symptoms of IBS. It is therefore important to incorporate high fiber foods in your everyday meals. Some fiber-rich foods include vegetables like raw broccoli, raw carrots, and cabbage. Fiber is also found in cereals, bread, and fruits (apple). Try also to eat lesser amount of food during meal times or if not try eating more frequently but in smaller amounts. Increasing your fluid intake also helps.
Try to reduce stress by having a regular exercise. Exercise will give your body lots of benefits and it also helps lessen risk of cardiovascular disease. There is a great variety of exercises which you can choose from. Choose the one which you will really enjoy and which you will be able to continue regularly. You can also include some meditation techniques, yoga, or pilates.
Medications are available to help relieve symptoms. These include anti-diarrheal meds, laxatives for constipation, antispasmodics, and antidepressants.

Lactose Intolerance

2006-03-27T16:55:00.000+08:00

Lactose intolerance is a rather common condition in infants, young children, or adults. It is a genetic problem which has been there since you were born. The problem lies in the inability to digest lactose because of deficiency or absence of the enzyme lactase. This enzyme lactase is produced by the cells found in the small intestines. It is responsible for breaking down the major sugar found in milk which is called lactose into simpler forms which are glucose and galactose. Glucose and galactose once broken down are then absorbed into the bloodstream.

The undigested lactose later ferments and it is then responsible for the signs and symptoms felt by people with lactose intolerance. These symptoms include nausea, abdominal pain, bloating, and diarrhrea. They are usually felt after intake of lactose containing foods or drinks. The severity vary depending on the amount of lactose a person can tolerate, his digestion rate, age, and ethnicity.

Lactose is present in milk and in all foods that contain milk. These foods include ice cream, yogurt, butter, sherbet, cottage cheese, and in aged cheeses like cheddar and Swiss. Lactose can also be found in prepared foods like salad dressings, cereals, breads, cakes, cookies, biscuits, pancakes, etc. Since some people can tolerate small amounts of lactose, these foods can still be enjoyed by them in small amounts. Since calcium is also present in most foods containing lactose, the big concern is in those lactose intolerant individuals who need calcium in their diet. There are calcium-rich foods with no lactose content for this types of individuals. These foods include fish, tofu, broccoli, canned tuna, lettuce, salmon, and sardines. If there’s really a need to eat lactose containing foods, you can use a lactase tablet or lactase liquid available commercially to help in the digestion of lactose.

Lactose intolerance is not a big problem. Even lactose-free infant formulas are available for the babies to be able to enjoy their milk inspite of their digestive problems.

Avian Influenza (Bird Flu)

2006-03-21T19:12:00.000+08:00

Bird flu is an infectious disease caused by avian influenza viruses. It is seen in chickens, ducks, and other types of birds. These viruses are very contagious among animals and on rare occasions they have crossed the species barrier to infect humans.

Among these influenza viruses it is the H5 and H7 subtypes which cause highly pathogenic disease. It is the H5N1 virus which has caused the largest and most severe outbreak on record causing the death of so many birds.

The big question is that, is there a risk for human health? Yes, there is. First, there is a risk of direct infection when the virus passes from poultry to humans. Another risk is that this virus (H5N1) has the capability of changing into a very infectious form which can infect humans and then transfer easily from person to person. It this happens, this could lead to a major flu outbreak or a pandemic.

In order to start an influenza pandemic, there are three conditions that have to be met: emergence of a new virus subtype, this virus is able to infect and cause disease in humans, and this virus can spread easily and efficiently among humans. The third condition has not been fulfilled yet. As long as the H5N1 virus continues to infect birds, there is still the risk that this virus will meet the third condition.

How do we get infected? The main mode of transmission is by close contact with live infected birds and to objects contaminated by their feces. These infected birds excrete large quantities of the virus in their feces so that there is high exposure in poultry workers, people living in poultry farms, and people selling live poultry. People who work in slaughter houses and those who prepare poultry for cooking are also at high risk of contracting the disease. Cockfighting can be another way of spreading the disease. The mere flapping of the bird’s wings increases incidence of transmission.

The signs and symptoms of bird flu resemble those of conventional influenza. There are about 2 to 8 days (average 3 days) from exposure to the appearance of symptoms. The symptoms include fever, cough, muscle pain, and sore throat. Individuals with more virulent type of virus may develop acute respiratory distress or viral pneumonia which are more life-threatening.

Bird flu vaccine are not yet available commercially. This vaccine still needs to be tested and licensed. There are antiviral flu drugs which can be used in case of human transmission. Since the virus is easily killed by thorough cooking and since avian flu is not transmissible through food, it is safe to eat chicken.

Food Poisoning

2006-03-17T15:28:00.000+08:00

Food poisoning occurs as a result of eating food contaminated with germs. This is often due to improper handling of food from the time it was prepared to the time it is stored until it is eaten. This problem is often encountered in parties, picnics, or any social gathering where it involves a large group of people.

What happens is that during social gatherings the food are usually prepared in bulk and they are left in unrefrigerated for too long allowing the germs to multiply in the food. Improper handling of food during the preparation also contributes to the incidence of food poisoning. Sometimes kitchen utensils are used interchangeably between raw and cooked foods increasing further bacterial food contamination.

Food poisoning usually is noted within 2 hours or more after eating the contaminated food. The symptoms are nausea and vomiting, diarrhea, abdominal pain, fever, headache, and weakness. Although diarrhea and vomiting can be present in conditions not associated with food poisoning, adequate medical history can always lead to the correct diagnosis.

The treatment involves increase fluid intake to replace whatever is lost through vomiting and diarrhea. If the person is unable to drink because of the vomiting, an IV fluid can be inserted. Avoiding dehydration is the main goal of treatment. Inability to treat can lead to serious problems and may also lead to death.

Here are some very important measures that needs to be followed to prevent food poisoning. These are especially important for pregnant mothers, babies, elderlies, and those who have serious medical problems and those with weak immune system:
1. Always wash hands when handling food.

2. Separate food containers for raw and cooked food.

3. Refrigerate food that will not be eaten at once.

4. Always look for the date of expiration before eating packaged food.

5. Eat only freshly cooked food.

GI Ulcer

2006-03-15T14:05:00.000+08:00

Many people don’t understand what ulcers really are. Sometimes when they have abdominal pain, they refer to it as ulcer just because the pain is located in the abdominal area. But what really is an ulcer? Ulcer is an open wound on the lining of the digestive tract. It can be seen on the esophagus, stomach, duodenum, or anywhere along the intestinal tract.

Ulcers are painful. The pain is described as a burning pain located in the middle upper abdominal area which can last for several minutes to several hours. Some individuals experience the pain soon after intake of meals or several hours after. It can also occur at night disturbing a person from his sleep. Sometimes the pain is accompanied by bloating, vomiting, and loss of appetite which can lead to unexpected weight loss.

Increased acid production in the digestive system is thought to be the primary cause of ulcer. Some attribute it to the presence of a bacteria called Helicobacter pylori. Use of anti-inflammatory medications like for example aspirin and ibuprofen also play a role. Their long-term use may cause damage to the lining of the stomach. Genetic predisposition and physical, emotional, and psychological stress aggravate the condition.

Use of medications which neutralize the acid and medications which decrease acid production are the primary line of therapy. These medications are given for several weeks. For the H. pylori, this is treated with a triple drug therapy using two antibiotics and a medication which acts to decrease acid production. Lifestyle modification also play a very important role in the improvement of the condition. Avoidance of smoking, alcoholic beverages, caffeine, chocolates, and spicy foods are some of these.

Treatment of this condition as soon as diagnosed is very important. The condition can lead to perforation of the ulcer which can further cause problems like bleeding and obstruction if left untreated. Presence of blood in the stools and pain radiating to the back are some of the signs that will make you suspect that your ulcer is progressing.

Dyspepsia

2006-03-12T16:50:00.000+08:00

Dyspepsia affects people at any age. It is characterized by the presence of pain in the epigastric area (upper middle part of the stomach). The pain is described as burning, with feeling of fullness in the stomach. Sometimes there is heart burn, nausea and vomiting, and loss of appetite.

The stomach normally secretes an acid which aids in the digestion of foods. The esophagus, stomach, and intestines are protected from the adverse effects of the acid because of the presence of a mucus barrier lining the mucosa of the intestinal tract. Sometimes this barrier is damaged leading to irritation of the inner lining of the intestinal tract by the acid. This now leads to ulcer formation and this is one cause of dyspepsia.

Another cause can be acid reflux disease. Here, some of the stomach contents which are already mixed with acid propel back up into the esophagus because the valve which should prevent this from happening is not working properly. This causes irritation and the condition is made worse with smoking, heavy alcohol drinking, and eating heavy meals.

Anti-inflammatory drugs also play a role in the causation of dyspepsia. This drugs include ibuprofen, aspirin, ketoprofen, and naproxen. Other contributory factors include pregnancy, stress, and anxiety. Presence of other conditions like hiatal hernia wherein there is a defect in the diaphragm, and also Helicobacter pylori which is a bacteria normally present in the mucus layer of the stomach, may contribute to the occurrence of the condition.

There are a couple of drugs available to treat the condition like antacids which neutralize the acidity of the stomach, proton pump inhibitors or H2 antagonists which decrease the amount the acid produced. For H. pylori treatment includes use of two types of antibiotic and a proton pump inhibitor. If any of these medicines does not work then endoscopy which uses a small instrument with camera introduced into the mouth to view the insides of the intestinal tract may be used.

Avoidance of certain foods, lessening stress, smoking cessation, and eating at least 2 hours before bedtime are some of the lifestyle modifications we can do to avoid dyspepsia. This is a controllable and treatable condition. A lot of self control and behaviour modification improve the condition.

Eclampsia

2006-03-08T17:41:00.000+08:00

Eclampsia is preeclampsia plus seizures. It may develop if preeclampsia is not controlled or it may develop even without prior development of preeclampsia. It is a life-threatening emergency condition affecting all women of all ages usually occurring prior to delivery. The risk usually increases in multiple gestations, molar pregnancy, nulliparous women age 35 and above, strong family history, and those with secondary conditions like hypertension and kidney disease. It can cause permanent damage to the vital organs and can even lead to coma or death if left untreated.

The exact cause of eclampsia is still unknown. Some researchers relate it to the placenta and fetal membranes because of improvement of the condition following delivery. Just like preeclampsia, there is also severe headache, epigastric or right upper quadrant pain, and problems in vision. The only difference is the presence of seizures in eclampsia. The patient may have only one or more than one episode of seizure which may last for 1 minute or more. This may be accompanied by protrusion of the eyes, foaming of the mouth, and stopping of breathing during the episode. This accounts for the damage to the vital organs and to the central nervous system. This can also cause the death of the baby or if not can lead to prematurity, intrauterine growth retardation, decreased oxygen delivered to the baby, or premature separation of the placenta from the inner linings of the uterus.

Magnesium sulfate is the drug given to the mother to prevent further occurrence of seizures. Delivery of the baby is the treatment of choice especially if the baby is already 28 weeks of gestation. Below this, management should be weighed between the viability of the fetus and the resulting complications to the mother and child.

Preeclampsia

2006-03-04T16:02:00.000+08:00

Pre eclampsia is a very common condition seen during pregnancy. It is a condition that should be closely monitored and immediately treated because it is associated with a high degree of mortality not only to the mother but also to the baby. It can develop gradually during the course of the pregnancy or it may arrive suddenly anytime. It is commonly seen during the second half of pregnancy although it can occur during delivery or even during the first few days after the baby is born.

The exact cause of pre eclampsia is still unknown. One possible cause is that the placenta does not get enough blood supply because the blood vessels particularly the arteries are the ones which are primarily affected. The placenta is the one which gives enough nutrition and oxygen to the baby. With insufficient blood flow the result is small or low birth weight baby.

Other possible causes include poor nutrition, injury to the blood vessels, or lack of certain ions such as calcium and magnesium. Another danger with this condition is that it increases the risk of premature separation of the placenta from the inner lining of the uterus which may cause severe bleeding and can lead to shock.

Signs and symptoms of pre eclampsia are: high blood pressure, presence of excess protein in the urine usually after the 20th week of pregnancy, changes of vision, severe headaches, nausea and vomiting which can be excessive, no urine or decreased urine output, pain in the right upper abdomen, and sudden weight increase in weight.

The best treatment of this condition is delivery of the baby especially if the baby can live outside the mother’s womb which is usually after the 36th week of pregnancy. Labor can be induced or if not possible a cesarean section is performed. If is still too early to deliver the baby then other measures should be done while waiting for the right time to deliver. Bed rest is usually advised because it can lower the blood pressure and increase blood flow to the placenta. Blood pressure monitoring is regularly done together with biophysical profiles to determine condition of mother and baby. If the condition is severe, bed rest can be done in the hospital for better monitoring and immediate action can be done for any adverse events. Some medications can also be given to the mother to lower the blood pressure. Magnesium sulfate is also given IV during the delivery to prevent seizures and to increase blood flow to the uterus.

Pre eclampsia is usually common in first pregnancy. The risk of having the condition increases in multiple pregnancy, obese mothers, too young and too old mothers, positive family history, and those who are suffering from other conditions like diabetes, chronic hypertension, rheumatoid arthritis, or a kidney problem. Whenever you feel any of the symptoms mentioned while you are pregnant, do not hesitate to visit your doctor.

Hyperemesis Gravidarum

2006-03-02T17:40:00.000+08:00

This condition means uncontrollable, severe, persistent nausea and vomiting seen during pregnancy. It is also known as morning sickness. It is commonly seen during the 1st trimester of pregnancy particularly during the 8th to 12th week. The symptoms usually resolve by the 16th week or in the 2nd trimester. There is increased prevalence in multiple and molar pregnancies.

The precise cause of this condition is still unknown but studies show that the rapidly rising levels of the hormone human chorionic gonadotropin secreted by the fetus and also the increasing estrogen levels in the mother play a role. The nausea and vomiting experienced by the mother is more worse when the pregnancy is multiple or there are more than one baby inside the mother’s womb. In rare conditions, such as the presence of hydatidiform mole, nausea and vomiting becomes unbearable.

Nausea and vomiting is a normal occurrence during pregnancy and researchers believe that this is a protective mechanism. Many of these foods that mothers react to may contain certain substances that may cause harm to the fetus during the first trimester. It is also observed that the risk of miscarriage is higher in women without the symptoms.

Although the condition is protective, it is also harmful to both mother and child. It can cause dehydration when severe, and may result to weight loss, nutritional deficiency, abnormal electrolyte levels, and acid-base imbalance. Administration of IV fluid is done for the severe cases. Decreased skin turgor is a sign of dehydration

Blighted ovum

2006-02-24T13:04:00.000+08:00

Blighted ovum is also known as anembryonic pregnancy. Nowadays, it is referred to as early pregnancy failure. This condition happens when upon fertilization the egg implants on the uterus but something went wrong in its development. Only the pregnancy sac is present and no embryo can be seen. Because of abnormal development the embryo may have stopped early on in its development or it did not develop at all.

This condition is usually seen during the first trimester of pregnancy. It is also a common cause of miscarriage during this stage. Although some women do not even know that that they are pregnant, most are already experiencing the signs of pregnancy like nausea, easy fatigability, sore breasts, etc. Then suddenly there is a mild abdominal cramp or pain like the pain felt during menstruation. This is accompanied by vaginal spotting or bleeding. Upon consultation and ultrasound examination there is only an empty gestational sac. The pregnancy test may still be positive during this time because the hormonal level may still be high. But as the hormonal levels go down the symptoms will start to subside and the pregnancy test will turn negative.

Chromosomal problems is the usual cause of this condition. There can either be abnormality in the cell development or there is poor quality of either the egg or the sperm. Oftentimes it is the egg that is of poor quality.

If there are no complications or risk of infection the female body is allowed to pass out the tissue on its own with no invasive surgical procedures done. If there is indication, suction curettage or dilation and curettage can be done. The couple is advised to wait for at least 4 to 6 weeks before they try to conceive again.

Gestational Trophoblastic Neoplasia

2006-02-24T12:55:00.000+08:00

This is a molar pregnancy which keeps on coming back. It is usually seen in teenagers and women older than 40. The condition can be benign or malignant (cancerous). There is history of absence of menstruation (amenorrhea) or abnormal duration of menstruation. Sometimes there is passage of the typical hydatid vesicles through the vaginal opening. if the condition has already spread to other organs additional symptoms can be felt depending on the area of metastases. There can be abdominal pain, blood in the urine, or coughing out of blood. The most common areas of spread are the brain, lungs, kidneys, gastrointestinal tract, and the lower genital tract.

After evacuation of the tissue from the uterus it is sent to the laboratory for histopathologic examination. There is no accurate method to predict the behavior of the hydatidiform mole. The only monitoring done is the serum HCG level. In big percentage of cases the condition is benign and the serum HCG level decreases to normal level in 2 to 3 months. A very small percentage of benign cases develop into malignancy.

There is no need for therapy in benign cases. The patient is advised to use a reliable method of contraception and the serum HCG level is still monitored weekly to monitor development. In some individuals methotrexate is given as prophylaxis for malignancy.

In malignant cases, the serum HCG can go beyond 100,000mlU/ml. This is usually treated with chemotherapy. It is also important to rule out metastasis to other organs hence liver function tests, chest x-ray, and CT scan of head and abdomen are requested.

Molar Pregnancy

2006-02-16T16:50:00.000+08:00

This condition is also known as molar pregnancy. It is an abnormal growth inside the uterus caused by a problem during fertilization. This growth is supposed to develop into a placenta which normally functions to nourish the fetus during pregnancy. That is why the mass is made up usually of placental materials (complete type) or placental tissues and an abnormal fetus (partial type). The patient thinks she is really pregnant because there is also production of the pregnancy hormone called HCG.

The precise cause is not yet fully understood. The condition is associated with egg defects and uterine abnormalities. It is common in women more than 40 years old and in those with prior molar pregnancy.

The patient manifests vaginal spotting or vaginal bleeding, nausea and vomiting. abnormal size of the uterus with respect to the stage of pregnancy. It can be either too big or too small than what is expected. There can also be heat intolerance, rapid heartbeat, nervousness, tremors in the outstretched fingers, unexplained weight loss which are all signs of hyperthyroidism. Symptoms similar to preeclampsia (presence of protein in the urine, high blood pressure, swelling in legs, ankles, and feet) but occuring in the first trimester of pregnancy almost always indicates presence of H. mole.

Ultrasound examination reveals the presence of “cluster of grapes” appearance of placental tissue indicating abnormality of the placenta.

Management is done by performing a D&C (dilation and curettage). For older women or those who do not require future pregnancy, hysterectomy or removal of the entire uterus is an option. After any of these procedures, monitoring the HCG level in the serum is done regularly in order that recurrence can be monitored. Follow up visits of the patient to the doctor is a must and the patient is advised to have no pregnancy for at least one year following the procedure. Once recurrence is noted then the patient is advised to have chemotherapy.

There is usually a good outcome after treatment. A very low percentage develop into choriocarcinoma. Most cases of H. mole occur after miscarriage, some after an ectopic pregnancy. If a woman wants to know whether she has a molar pregnancy, a visit to a doctor must be done to know her HCG level.

Impacted Cerumen

2006-02-14T01:12:00.000+08:00

The most common foreign body in our bodies is this condition. Although it is not an emergency, it still warrants immediate removal. Failure to do so leads to its accumulation and hardening which may cause difficulty in hearing. This is very common in school-age children. Busy mothers fail to inspect their children’s ears. Sometimes it’s only an accidental finding during regular physical examinations done in schools. At times, it is the teacher complaining that the child is not listening inside the classroom or is having poor performance in school.

Cerumen is produced by glands located in the external ear canal. It has the advantage of repelling water and trapping dust particles. It becomes impacted due to use of objects put inside the ears which pushes the cerumen towards the inner part of the ear. It then accumulates inside and blocks the eardrum. Another cause may be is overproduction of ear wax.

The removal of the cerumen is done by instilling oil inside the ear canal every night for at least two weeks. This is done to soften the cerumen making removal easier and less painful. After two weeks the child can be brought to a physician who can perform the mechanical removal of the cerumen.

An otoscope with an operating head is usually used. The child must be advised to refrain from moving or must be restrained. Insert slowly a wire loop or wax curette inside the ear canal then slowly scrape the cerumen taking care not to curette the ear canal. This procedure is usually done by an ENT specialist.
Another method is by irrigating the ear canal with water in normal body temperature using a syringe. The jet of water should be aimed along the canal and behind the cerumen in order to push it out. This procedure is usually avoided in children with perforation or with tympanostomy tube.

There are cerumenolytic agents available in the market which can be used to remove cerumen but these sometimes cause severe local reactions especially if not properly used. The best prevention in order not to have impacted cerumen is regular cleaning of the external ear with a washcloth. There is no need to go inside the ear canal using cotton buds, hair pins and the like. The wax that is present inside the ear canal will fall off on its own.

Choking in infants

2006-02-10T15:00:00.000+08:00

The Heimlich maneuver I discussed before is not usually done in infants. This is because abdominal thrusts are commonly associated with liver trauma hence are avoided. There are several maneuvers that can be done in infants. These are: Back blows, Chest thrusts, Jaw lift, and Ventilation.

Back blows are done by placing the infant in a head-down face-down position in your left forearm which is angulated to 60 degrees. The head and the neck should be stabilized. The infant’s forearm should be resting on your knee which is in flexed position. While in this position rapidly administer four back blows between the scapulae using the heel of your right hand.

If the back blows fail to remove the obstruction, do the chest thrusts. This is done with the infant in a supine position and lying on a firm surface. Using two fingers of your right hand, place them above the sternum and administer four rapid chest thrusts.

If there is still no breathing lift the jaw of the child in a sniffing position, open the mouth and inspect for presence of foreign body. Do not perform blind finger sweeps inside the child’s mouth as this may aggravate the situation.

Perform mouth-to-mouth resuscitation or bag-mask technique if the above procedures fail. Repeat this procedure several times or you can repeat everything altogether before proceeding to intubation. Intubation or cricothyroidotomy should be done by an expert.

Choking

2006-02-08T14:17:00.000+08:00

Choking usually results from foreign body aspiration in the form of small toys, pieces of food like nuts and candies, put inside the nose by little children. These things obstruct the airway when it lodge on the bronchus and the airway obstruction is a medical emergency.

Initially the condition can be asymptomatic or it may cause a mild cough.When severe there can be coughing out of blood with either partial or complete obstruction of the lungs. A chest x-ray can be done but a normal result does not rule out foreign body aspiration nor does it help in improving the condition of the child.

If the child is conscious nothing should be done to dislodge the foreign body. He should be immediately brought to a surgeon who can do laryngoscopy or bronchoscopy.

If the child is unconscious because of airway obstruction, he should be resuscitated immediately by applying up to eight abdominal thrusts (Heimlich maneuver) until the foreign body is dislodged.

This maneuver is done in several ways depending on the age of the child. In a child less than 7 years old, he should placed on his back with you on left his side. Position the heel of your left hand on his abdomen between the umbilicus and the rib cage. Using your hand perform rapid inward and upward thrusts.

In an older child the procedure can be with the child in the same position as above or in sitting or standing position. In the sitting or standing position you should stand behind him, wrap your arms around his waist, and make a fist with your right hand. Your left hand should be grasping the right while making a quick upward thrust in the abdomen. Make sure that the thumb of the right fist is against his midline abdomen slightly below the xiphoid process and above the umbilicus.

This procedure can be done alternately with mouth-to-mouth resuscitation if there is no spontaneous respiration. If the maneuver fails open the mouth and lift the jaw forward.This position improves the respiration in an unconscious child. The head of the child is placed in a “sniffing position” avoiding hyperextension to prevent airway obstruction. A foreign body inside the mouth can be manually extracted using a forcep.
If everything fails then intubation or cricothyroidotomy should be done. This must be done by a surgeon.

Anaphylaxis

2006-02-05T16:11:00.000+08:00

Anaphylaxis is a life-threatening allergic reaction to foreign matter. It involves the whole body primarily affecting the circulatory system, respiratory tract, alimentary tract, and the skin. It occurs following exposure to an allergen and the body reacts by releasing substances like histamine.

Histamine is responsible for the vasodilation effect which leads to hypotension or a decreased blood pressure. The movement of fluid into the interstitial space decreases blood volume which may lead to shock. In the lungs fluid may leak into the alveoli producing pulmonary edema hence the difficulty of breathing.

The signs and symptoms seen in this condition are due to histamine and other substances released by the tissues. Airway narrowing produces the dyspnea and wheezing. There are hives and angioedema (swelling underneath the skin) present on the eyelids, lips, or throat which may further narrow down the airway. There may also be vomiting, diarrhea, and abdominal pain, abnormal heart rate, palpitation, dizziness,confusion, and cyanosis.

Common allergens include drugs such as penicillin, food such as peanuts, seafoods,or eggs, insect bites, horse serum in the form of vaccines, immunotherapeutic agents, and hormones. They enter the body through inhalation, ingestion, or via injection.

Some drugs cause anaphylactoid reaction. This is an anaphylactic-like reaction resulting from a toxic reaction. It has the same signs and symptoms, complications, and treatment with the trye anaphylaxis.

There is always a previous exposure to the provocative substance. On subsequent exposure an allergic reaction occur followed by onset of symptoms. There is rapid deterioration involving the whole body hence the condition requires immediate medical attention.

Control of airway, breathing, and circulation (ABC) is the first priority. CPR can be done if necessary together with providing an airway by means of endotracheal intubation or tracheostomy. Administer epinephrine as necessary. IV fluids, corticosteroids, and antihistamines are also given. It is very important to identify the allergen in order to prevent future exposure.

Oral Cancer

2006-01-31T14:16:00.000+08:00

Oral cancer is the abnormal growth of cancerous cells inside the mouth. This commonly affects the tongue, gums, palate or roof of the mouth, and the inside of the cheeks. The problem is due to irritation of the mucous membranes lining the oral mucosa as a result of smoking and heavy drinking of alcohol. The condition sometimes start as a small ulcer.

A high percentage of cases result from smoking and chewing tobacco. Aside from heavy alcohol drinking, other causes include use of loosefitting dentures, poor oral hygiene, biting of lips and inner linings of the mouth, and exposure to ultraviolet light. All of these factors contribute to the irritation of tissues causing the damage of cells which then function abnormally producing cancer cells.

Regular dental check up is very important. A small lump or mass inside the mouth must be seen at once by your physician before it starts to grow and affect surrounding structures. A cancerous lump is usually painless initially and may become painful when the problem is advanced. The condition often leads to difficulty chewing and swallowing, pain around the teeth, jaw, or anywhere inside the mouth, sometimes with numbness of the tongue.

A sore in the mouth that does not heal must be examined immediately. Early conditions can be treated with surgical excision. If there is already spread to adjoining structures and the lump is bigger then radiation therapy and chemotherapy is given.

To decrease the risk of acquiring the condition strictly avoid use of tobacco products, drink alcohol moderately, and eat plenty of fruits and vegetables.

Diphtheria

2006-01-27T15:54:00.000+08:00

Diphtheria is a serious and very contagious bacterial infection affecting the nose and throat. It can also affect other parts of the body like the skin, kidneys, and heart. It may cause damage to these areas especially if left untreated.

The symptoms usually appear 2-4 days after infection. These include hoarseness, sore throat, pain on swallowing, fever, swollen glands in the neck, and weakness. The individual may also experience difficulty of breathing due to the presence of a thick, gray covering at the back of the throat. The bacteria which causes the condition produces a toxin which is responsible for the thick, gray covering in the throat. It is also the one which causes the painful swallowing.

The causative organism is called Corynebacterium diphtheriae. This bacteria is acquired by inhalation of droplets sneezed or coughed out by an infected person. It can also be acquired from the use of contaminated items or from close contact with body discharges of an infected person.

There is a high rate of transmission in those people living in unsanitary living conditions particularly those in crowded areas. Transmission is also high in immunocompromised individuals, the very young and the very old, and in unimmunized individuals.

When acquired the bacteria will then attack the mucous membrane lining the nose and throat and cause inflammation. The inflammation will then spread to adjacent areas leading to airway obstruction and other symptoms. The bacteria may release a poison which may cause damage to the vital organs.

Widespread immunization worldwide have decreased the incidence of this condition. When infected, use of antibiotics can kill the bacteria and decrease the transmission rate. Use of ventilator for those with difficulty of breathing is very helpful. Once infected there is a need for isolation to prevent transmission to susceptible individuals.

Pharyngitis

2006-01-23T09:09:00.000+08:00

Pharyngitis is a direct infection of the pharynx by a variety of microorganisms. It can be caused by viruses such as adenovirus or influenza virus. It can also be caused by bacteria such as the Group A beta hemolytic streptococcus, Chlamydia pneumoniae, or Neisseria gonorrhea. In some individuals, pharyngitis is caused by conditions which irritate the pharynx like for example postnasal drip,or gastroesophageal reflux disease (GERD).

The most common bacterial cause of pharyngitis is Group A beta hemolytic streptococcus which causes strep throat. This condition is serious and needs adequate treatment. If it is untreated it may cause some complications like rheumatic fever or kidney problems. This type of pharyngitis usually presents with fever, redness and swelling of the tonsils and pharynx, swelling and tenderness of the anterior cervical lymph nodes, petechiae on palate, and headache.

The presence of colds or conjunctivitis makes one suspect of a viral cause. There can be additional symptoms of vomiting and/or mouth breathing.

The condition often spreads to family members hence the need to treat early. Antibiotics is usually given to those suspected of bacterial cause. Use of analgesics or pain relievers also help alleviate the condition. Other supportive measures include increase of fluid intake and warm salt gargles.

Tonsillitis

2006-01-19T16:38:00.000+08:00

This condition is very common to preschool and school-age children characterized by inflammation of the tonsils. The tonsils are the tissues that you see on your throat located behind the tongue. They are part of the army that help prevent infection in our body. These are where the cells which fight invading viruses and bacteria are located. They become infected when the cells eat the invading substances leading to redness and swelling.

Tonsillitis is commonly caused by the bacteria called Streptococcus pyogenes. It can produce symptoms of severe pain in the throat which leads to difficulty of swallowing, tenderness in the jaw, patches of whitish discharge in the area, sometimes with headache, fever, and change in the sound and pitch of voice.

Use of antibiotics is the treatment of choice especially if it is caused by bacteria. Supportive measures like increase fluid intake, warm salt water gargle, and bed rest may improve the condition. Surgery can be done if recurrence is very frequent and if the condition affects breathing.

It is very important that treatment is instituted in this condition because some strains of the bacteria can spread to other parts or organs in the body and cause more problems. The bacteria may reach the skin, heart, or joints causing rheumatic fever.

Oral thrush

2006-01-17T19:47:00.000+08:00

This condition is also called oral candidiasis. It is an infection of the mouth caused by the fungus Candida albicans. This fungus is present in the mouth and its growth is controlled normally. It becomes uncontrollable when the person’s immune system becomes compromised as is seen in times of illness, during pregnancy which causes hormonal changes, or after prolonged use of antibiotics which may disrupt the balance of the organisms normally thriving in the mouth.

This condition can be seen at any age group but it is common in infants, young children, diabetics, people with AIDS, and debilitated individuals. The lesion looks like an ulcer inside the mouth, creamy white like cottage cheese and is very painful. A child can have difficulty taking in meals during times of infection. The lesion can spread to other areas in the mouth and even up to the esophagus causing the condition called esophagitis.

It is important to prevent the spread of the infection by giving antifungal medicines for about 10 days. Maintaining good oral hygiene helps a lot.

Pulmonary Tuberculosis

2006-01-12T13:41:00.000+08:00

PTB is a very common infectious disease usually seen in immunocompromised individuals. It primarily affects the lungs but other organs in the body may be involved. It is transmitted from person to person through inhalation of contaminated droplets coming from the sneeze or cough of an infected person. Once inhaled the bacteria enters and travels through the airways and becomes deposited in the lungs. The progression of the disease in the infected person depends now on the ability of the host to combat infection.

Normally our immune response is able to contain the infection so that the disease will not manifest clinically. If our body is not able to destroy the bacteria, this may stay and manifest sometime later in our life (dormant) or it may travel in other areas of the body and produce disease. This is called the primary infection and is usually seen in the young population. These children may have signs and symptoms of mild cough and fever, weight loss, night sweats, body malaise, and difficulty of breathing.

Individuals with compromised immune response are not able to contain the infection. The disease manifest clinically and they become acutely ill. Aside from fever, weight loss, fatigue, and breathing difficulty these individuals may cough up blood. This is called progressive primary tuberculosis.

Post primary tuberculosis is a reactivation of an old infection when the bacteria which is still in the body manifest signs and symptoms because the host’s immune response becomes compromised as a result of diseases or old age. This is usually seen years after the first infection.

Treatment includes use of multiple drugs taken daily for about six months or longer depending upon the response of the individual. It is important that the individual is free of the bacteria before discontinuing the medications. Early intervention is also important to prevent damage in the lungs.

Cellulitis

2006-01-11T02:23:00.000+08:00

Cellulitis is a skin infection affecting the different layers of the skin. It is commonly seen in the face and in the skin of the lower extremities. It presents as red, tender, swollen, and warm skin which may be accompanied by fever. If not treated, the bacteria may reach the bloodstream and cause further problems.

The streptococcus and staphylococcus bacilli are the common causative organisms. The bacteria may enter through cracks in the skin caused by insect bites, cuts, punctured wounds, or any other opening in the skin.

Taking good care of wounds especially those in the legs is a good preventive measure. It is important to clean wounds daily and apply topical antibiotics to prevent spread of infection. Since the bacteria may also enter on dry skin, moisturizing the skin is also important. Once cellulitis has set in, oral antibiotics is given.

The risk of having this condition is higher in people with poor immune response, poor circulation, and people with chronic diseases which impairs the immune system."

Pertussis

2006-01-08T18:37:00.000+08:00

Also known as whooping cough, this condition is a very contagious respiratory problem caused by the bacteria called Bordetella pertussis. The condition can be seen in all age groups but it is more severe in infants because of the violent coughing and difficulty of breathing it can cause. It may even produce permanent disability in these age group.

Bordetella pertussis is a gram negative aerobic coccobacillus spread from an infected person through the air after a cough or a sneeze. Inhaling the contaminated droplets allows the bacteria to enter and colonize the airway thus interfering with the normal mechanism of the body to eliminate foreign materials. It will then begin to produce signs and symptoms which include slight fever, sneezing, red watery eyes, runny nose, and coughing which increases in intensity over several days.

After about two weeks, the infected person begins to have severe prolonged coughing which usually ends with a whooping sound as the individual tries to breathe in air. The sound is common in older children. Severe coughing often leads to vomiting and appearance of tiny red spots on the skin surface and on the white of the eyes. This is called petechiae and is due to rupture of superficial blood vessels. Severe prolonged coughing also interfere with normal breathing and cause difficulty eating and drinking.

The condition can be treated with the use of antibiotics. Other supportive measures can be given depending on the needs of the patient. Oxygen, IV fluids, or sedatives if the patient has trouble in sleeping because of the severe cough.

The vaccine is given to children less than 6 years of age in combination with diptheria and tetanus vaccine (DPT vaccine). With the advent of immunization the incidence of pertussis has already declined. But still the adult population can still have the condition after the effect of the vaccine wanes. Adults are infected to a milder degree but they can still transmit the disease to unimmunized children. It is therefore very important for infants and children to have their immunization.

Croup

2006-01-05T17:22:00.000+08:00

Croup is a condition characterized by a barking cough with difficulty of breathing. It is common in the young population during infancy and childhood. Causative factors may include allergy, viral, bacterial, or irritants but the most common of these is a viral cause.

The causative organism may enter the airway through the nose. It later on cause edema and swelling of the vocal cords. These vocal cords are the ones which vibrate and produce sound when air pass through them. Their swelling causes the symptoms of hoarseness, stridor, and barking cough.

Aside from the symptoms mentioned there can be bluish discoloration of the skin and dehydration if the condition becomes severe. Intubation of the patient is done with progressive airway obstruction and IV fluids given for dehydration. Oral medications are given depending on the needs of the patient.

Bronchiectasis

2006-01-02T20:10:00.000+08:00

Bronchiectasis is a condition characterized by abnormal dilation of the large airways called bronchi because of destruction of its walls which is made up of muscular and elastic components. Destruction and inflammation leads to collapsible airways causing obstruction to airflow and impairment in the clearance of bronchial secretions. Accumulation of secretions causes colonization of infecting organisms which leads to production of foul-smelling sputum and more bronchial damage.

This condition can be congenital or acquired. The congenital type is usually seen in the young population. This commonly results from problems in the normal development of the bronchial tree.

The acquired type is seen in older children and in the adult population. It usually results from severe infections of the respiratory tract, airway obstruction by a foreign body or tumor, or a defect in host defense.

Symptoms include cough productive of foul-smelling sputum, difficulty of breathing, fatigue, wheezing, coughing out blood because of bleeding of the bronchial artery, weight loss, bluish skin discoloration or cyanosis.

For treatment, antibiotics are given to control the infection. In addition to that, expectorants are added to help expel the brochial secretions and bronchodilators to help relieve the airway obstruction.

Avoiding smoking or exposure to second-hand smoke, avoiding air pollution, good nutrition, and childhood immunizations are some of the preventive measures for this condition.

Sinusitis

2005-12-27T20:12:00.000+08:00

The sinuses are chambers filled with air, located within the facial bones behind the eyebrows, cheeks, and jaw. These sinuses normally contain mucus which cleanse the air we breath. When the lining of these sinuses gets infected, the condition is called sinusitis.

The most common cause of sinusitis is a previous cold. Other causes are either bacterial, viral, or fungal upper respiratory tract infection. These cause inflammation which lead to swelling of the linings of the sinuses. Mucus becomes trapped as a result of the obstruction. More and more mucus are formed which favor the growth of bacteria producing the infection.

Obstruction of the sinus passages can also be caused by presence of nasal polyp and deviated nasal septum. Allergies, prolonged use of decongestants, and smoking also cause irritation of the sinus passages which can lead to inflammation.

Symptoms include headache, pain in some areas of the face such as the forehead, cheeks, or eyes, nasal congestion, fever, tooth ache, and sore throat secondary to post nasal drip.

Use of antibiotics for 10 - 14 days is indicated. The normal course of the antibioics must be followed even though there is improvement in the symptoms after intake for several days. It is also important to get enough rest and drink plenty of fluids.

Avoiding smoking or exposure to polluted air can help prevent having the condition.

Pneumonia

2005-12-23T15:57:00.000+08:00

Pneumonia is a very common inflammation of the lungs. It occurs when our body defenses fail to protect us allowing microorganisms to enter our lungs, invade our air sacs and cause infection. Our white blood cells will try to fight the invading microorganisms and will rush to the site. The accumulation of these different substances in the affected area will lead to inflammation.

The condition is common in immunocompromised individuals such as those with HIV, diabetes, chronic lung problems, and cardiovascular diseases. It is also common in those whose spleen had been removed, in chronic smokers, heavy alcohol drinkers, and those exposed to lung irritants, toxic fumes, or air pollution.

The signs and symptoms vary depending on the cause. Bacterial pneumonia may present with fever, chest pain, and productive cough. Viral pneumonia may have similar symptoms with dry cough initially and later the cough may become productive with white phlegm. Fungal (Pneumocystis carinii pneumonia) cause is usually seen in immunocompromised individuals. Mycoplasma on the other hand has milder symptoms.

Treatment may include use of antibiotics, paracetamol, cough suppressants, and pain relievers when necessary. The treatment usually depends on the type of pneumonia and its severity. It is also important to rest and to increase fluid intake.

Emphysema

2005-12-20T17:33:00.000+08:00

Emphysema is part of a group of diseases called chronic obstructive pulmonary disease (COPD) that is very common in chronic smokers thus causing progressive damage to the lungs. Other diseases included in COPD are asthma and chronic bronchitis.

Normally when we inhale, the air we breathe in passes to the trachea then to the bronchi. The bronchi subdivides into smaller airways called bronchioles and the airway finally ends in millions of small air sacs called alveoli. It is in the alveoli where exchange of oxygen and carbon dioxide take place because of the presence of capillaries in its walls. It is also due to the presence of elastic fibers in the alveoli that help them expand when one inhales and contract during exhalation.

In a person with emphysema, the wall of the alveoli has already lost its elasticity because of inflammation. The walls expand when air enters but it breaks upon expansion creating larger spaces which are not efficient for the exchange of gases to take place. He then has to breath harder in order to take in oxygen and to forcefully exhale to expel air out of the lungs. The forceful exhalation causes compression of the many small airways making it more difficult for air to move out.

Shortness of breath and fatigue are the common symptoms noted. Since this is a chronic condition, the symptoms are not usually noted until permanent damage has taken place. The symptoms worsen as the condition progresses. It is accompanied by productive or non-productive cough and loss of appetite.

Smoke coming from tobacco or cigarette or even secondhand smoke cause paralysis of the small hairs in the airway called cilia. The cilia normally function to propel out irritants and foreign bodies present in the airway. When paralyzed they are then able to invade the alveoli and cause inflammation.

The number one prevention and treatment is to stop smoking. This can prevent progression of the damage in the alveoli. Other treatment options that could help relieve symptoms include use of bronchodilators, antibiotics, supplemental oxygen, and inhaled steroids.

Chronic Bronchitis

2005-12-15T18:03:00.000+08:00

Chronic Bronchitis is an inflammation of the airways, particularly the bronchi, characterized by productive cough for more than three months duration for two consecutive years. The excessive mucus production cause airflow obstruction making it difficult for the air to get in.

Cigarette smoking is the most common cause of this condition. The smoke irritates the airway hence even the second hand smokers have increased risk of having the condition. Other lung irritants like dust, chemical fumes, aerosol products, and air pollution may worsen the condition.

The expectorated sputum may be blood-streaked owing to the irritation of the bronchial lining. Other symptoms include wheezing, shortness of breath, headache, and fatigue.

The goal of treatment is to relieve the symptoms and prevent complications. It is also important to avoid exposure to the irritants and to stop smoking to prevent exacerbation. Physical exercise is very important to help improve the lung condition and strengthen the immune system.

Inhaled bronchodilators and anti-inflammatory medications are given to improve airway condition. Antibiotics may be given if the doctor finds that they are needed. For unresponsive individuals, corticosteroids are indicated.

Acute Bronchitis

2005-12-13T10:41:00.000+08:00

This is an inflammation of the tracheobronchial tree, the series of tubes that bring air to the lungs. When these tubes become infected there is swelling and excess mucus secretion bringing about the symptoms.

The most common cause are viruses. These are the same viruses that cause other respiratory tract infections. We acquire them when they are present in the air we breath or when they are present in the things we hold. Bacterial cause is less common.

Exposure to certain irritants or air pollutants increase the risk of having the condition. Aside from this, having a low resistance coupled with smoking predisposes one to the condition. Smoking damages the airway making it easier for the pathogens to invade and cause disease.

Another risk factor is gastroesophageal reflux disease. In this condition, the acid from the stomach tends to flow back to the esophagus causing irritation in the area and produce coughing.

Coughing with mucus production is the most common symptom of acute bronchitis. It may be accompanied by wheezing, difficulty of breathing, sore throat, fever, nasal congestion, and malaise.

A cough suppressant is usually given as treatment especially when one cannot sleep due to persistent coughing. Getting enough rest and increased fluid intake may help improve the condition. Antibacterial medications are not usually given unless the doctor see that there is an indication.

Asthma

2005-12-11T10:47:00.000+08:00

Asthma is a very common inflammatory condition of the airways characterized by increased mucus secretion, bronchial muscle contraction, and swelling of the mucosa. All these narrow down the airway which decreases the airflow.

The inflammation is caused by irritants present in the air. This can be in the form of cigarette smoke, paint fumes, polluted air, and aerosol sprays. When any of these mix with the air and inhaled, the hypersensitive airways over-react producing the signs and symptoms of asthma.

Aside from the irritants, asthma is also caused by allergens and infections. Common allergens include pets, house dust, molds, polllen, feathers, and foods like milk and eggs. Viral and bacterial respiratory infections can also trigger an asthma attack.

Symptoms include cough, wheezing, chest tightness, and shortness of breath. The severity of the symptoms is the basis of treatment. It is therefore important to monitor an individual with an asthma attack to determine whether he or she is improving or is getting worse. The manner of speaking and breathing is closely monitored together with the skin color, level of awareness, and the presence or absence of chest indrawing.

Increased physical activity such as running, weather changes, and other activities that involve deep rapid breathing can trigger an asthma attack. Avoiding the triggers help prevent occurrence of an attack.

Asthma is managed using inhalation and systemic bronchodilators and anti-inflammatory drugs. Please visit your physician to determine the best medication suited for you.

Meibomianitis

2005-12-05T18:07:00.000+08:00

This is a chronic inflammation of the group of sebaceous glands located on the eyelids collectively called the meibomian glands. The condition is usually bilateral and associated or preceded by blepharitis. It is caused by thickening of the oily secretions of these glands which leads to accumulation of secretions on the lid margins and favoring the growth of bacteria.

The patient usually complains of a chronically red and irritated eyes. There is swelling and redness of the lid margins with prominence of the meibomian glands. A frothy conjunctival discharge may be seen and a soft yellowish material can be expressed from the glands. There may also be mild blurring of vision.

The treatment consists of cleansing of the edges of the lids, warm compresses, and topical antibiotic theraphy. Maintaining lid hygiene and avoiding rubbing the eyes prevents one from having the condition.