Tag Archives: Pain

DR. C’S JOURNAL: SIGNS AND SYMPTOMS OF APPENDICITIS

The appendix is a finger like projections at the origin of the colon in the right lower part of your abdomen. It may become inflamed, especially if there is a blockage. Appendicitis is best considered a medical emergency, since it may rupture and infect the entire abdominal cavity.

When I was a practicing pediatrician, appendicitis was one of the two conditions I refused to allow myself to overlook; the other one was meningitis, which is now mostly prevented by immunization.

Pain in the abdomen is almost invariably present as the main symptom of appendicitis. This pain often begins around the belly button and then migrates to the right lower part of the abdomen. The patient should try to notice whether jarring the abdomen by walking makes the pain worse; if so, this finding would favor an inflammatory condition like appendicitis.

A similar condition, diverticulitis, may cause similar symptoms in the left lower part of the abdomen, and other conditions may cause confusion. The doctor checks to see if it is more painful in the right lower belly area, and she may pull her hand away suddenly. If the pain intensifies, there may be inflammation around the appendix. Sometimes a vaginal examination or rectal examination will be needed to help with the diagnosis; the appendix is close to these areas.

Other symptoms and signs may be a low-grade fever, vomiting, add an elevated white blood cell count. In the modern medical era, ultrasound, CT scans, and MRIs are sometimes used to visualize the appendix to evaluate its size and possible inflammation.

Treatment used to consist only of surgery, but with imaging techniques available to prevent disaster, the condition can be treated with antibiotics. 30 to 50% of those so treated will still eventually require surgery. Removal of the appendix is now sometimes performed through a fiberoptic scope, leading to more rapid recovery.

A dilemma is present for individuals who go to the south pole to live for several months, and where weather may prevent them from getting proper medical help. Such  people may have their appendix removed as a preventative. Of course they also can take antibiotics if appendicitis develops, but it’s really scary to use medical treatment only, without the aid of modern imaging techniques.

Please consult the following Mayo clinic article for more information.

—Dr. C.

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DR. C’S JOURNAL: PAIN FOLLOWING TOTAL KNEE REPLACEMENT SURGERY


Total knee replacement(arthroplasty) is one of the most successful orthopedic operations. Satisfaction rate varies between 75 and 90%. Even so, almost 10% of operated individuals will have anterior knee pain, the most common complication, 1 year after TKR.

I had an even greater appreciation of the knee after reading the following article, which explain the causes of knee pain more adequately than I can, and would be good to read.

With knee replacement surgery, a great deal depends on the technical expertise and precision of the operating surgeon. A rotational error more than a degree or two can be critical, so important is proper tracking of the kneecap in the trochlea, or groove in the leg bone(femur). An imbalance in the pull  of muscles, or a knock knee, (Valgus) angulation of the knee, hip rotation, spinal problems, all can be important in generating pain as you get older.

There are psychological factors too. The knee pain after TKR average is only 1/3 of that suffered before the operation, on average. However if you expect that discomfort will disappear completely, or if your pain threshold is low, or if you have anxiety or depression, you may have more postoperative pain, and  be disappointed with the surgery.

My immediate reason to write this article was the anterior knee pain developing in a friend of mine, 15 years after surgery, at the age of 89. She had polio in childhood, and her right leg was severely affected. This caused her to overuse her left leg, resulting in a TKR 15 years ago. Just recently, she started developing anterior knee pain in the left knee. A thallium scan showed a lot of signal on the inside of the kneecap, most likely indicative of inflammation. She is not enthused about having another operation because of her age., and wondered about other things she might do.

An orthopedic friend of mine suggested that injections of a viscous lubricant might help, if the initial operation did not include resurfacing of the kneecap (patella). I would imagine that eventually the resurfacing of the patella with advanced materials, or perhaps stem cells might help.
I also thought of a special brace with a motor assist for her right leg, but the orthopedist said that this did not work very well in polio patients, who have a weak nerve signal.

Although my friends polio made her TKR almost inevitable, there are things that you can do, or avoid doing, that could help avoid TKR. Activities to reduce include squatting, deep lunging, running (particularly in deep sand), high impact sports, repetitive jumping, and running up stairs. Basketball, football, and volleyball come to mind as regular sports that are risky. Maintaining a healthy weight, controlling blood sugar, stoppage of smoking, avoidance of injury, and regular exercise, particularly walking and swimming ,are things that might help.

Remember that your knees are your wheels and are jewels to protect as you get older.

–Dr. C

Intensive Care Views: ‘Pain & Airway Management’

Pain Management in the Intensive Care Unit.

Institution: Department of Anesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin & Massachusetts General Hospital, Harvard Medical School, Boston

Progressive Disorders: ‘Parkinson’s Disease’

Parkinson’s Disease is a MOVEMENT DISORDER. It is grouped with a number of OTHER NEURODEGENERATIVE illnesses which can show similar symptoms. When Parkinson-like problems are present in other syndromes, it is called PARKINSONISM, to distinguish it from primary Parkinson’s disease.

There is no 100% reliable sign, symptom or diagnostic test; Rather, the gold standard of diagnosis rests on the ability of experienced neurologists to discern a PATTERN of findings which together support the likelihood of Parkinson’s disease. The accuracy is about 80-90%. The 3 characteristic symptoms of PD are BRADYKINESIA, TREMOR, and RIGIDITY. Bradykinesia means SLOW MOVEMENT.

The typical Tremor is a tapping, “pill-rolling” motion that is present at rest, and DISAPPEARS ON MOTION. The Rigidity is pervasive, and patients describe it as trying to move in thick molasses. A “lead-pipe resistance”, stiffness and PAIN in the shoulder may be a first system, and not uncommonly the patient will often go to an Orthopedist or Rheumatologist. Depression, constipation, anosmia and SLEEP Disorders are common in the years leading up to the diagnosis of Parkinson’s Disease, and DEMENTIA frequently develops.

Genetics play a role, and PD can run in Families. Environmental causes such as Trauma and anoxia can injure nerve cells, as can Toxins. MPTP contamination of a drug supply once caused a surge of Parkinsonism. Degeneration of DOPAMINERGIC nerve cells in the Substantia Nigra is the ultimate cause of PD, and accumulation of ALPHA SYNUCLEIN fibrils is a correlate of that degeneration.

Practical treatment at present aims to boost Dopamine. Administration of Levodopa, a DA precursor, if effective, a response helps to confirm the diagnosis. Magnetic and electrical stimulation of the brain have been used. Experimental injections of Dopaminergic cells into the brain is under investigation. Causing Astrocytes to differentiate into dopaminergic cells has been successful in animals.

With Celebrities such as Michael Fox and Robin Williams raising awareness, and the Mechanism understood, I am optimistic that a real cure may be found in a few years.

–Dr. C.

DR. C’S MEDICINE CABINET: Benefits & Risks Of ‘Aspirin’

Aspirin (acetylsalicylic acid) was one of the first medicines constructed, or synthesized, in a chemical laboratory. After 40 years ( medical progress wasn’t too fast in the 19th Century), Bayer investigated it as an alternative to Salicylates, which had been used since antiquity in the form of Willow bark for medical treatment, especially of FEVER and PAIN relief.

It is an understatement to say that it was successful. After almost another century, in 1982, a nobel prize was awarded for the discovery of its mode of action. Its multiplicity of effects, some of them bad, are only now becoming appreciated. My practice in medicine was in Allergic diseases, and I treated many people with nasal, sinus and asthmatic diseases.

It became apparent that, in certain people, aspirin could worsen all 3 conditions, and rhinitis (with Polyps), sinusitis and asthma became known as “Samter’s Triad”, or simply ASPIRIN DISEASE. Believe it or not, the condition can be helped by “aspirin desensitization”, where the Patient was started on tiny doses of aspirin by mouth, which over a period of hours was gradually increased to a normal dose.

I would not try this at home. I sent my patients to a specialized medical center for treatment, Other undesirable effects induce bleeding disorders, stomach ulcers, and, in children, a very serious disease called Reye’s syndrome. The latter is so serious that aspirin is not often given to children; except when it is needed, such as in a condition called Kawasaki’s Disease, where it is very helpful.

I mention these details to counteract the blase attitude created by long use. No longer does the doctor say “Take an aspirin and call me in the morning”. For a long while, low-dose Aspirin was used in most Patients with coronary artery disease, as a method of preventing sudden clot formation. I took 65 mg. Of aspirin for years, even though I had no narrowing of my arteries.

Now it is found that aspirin can cause an excess of Hemorrhagic stroke, and it is not recommended in my age group and risk profile. Aspirin is a powerful medication with a wide variety of effects. Most of its beneficial effects have safer alternatives. Acetaminophen- Tylenol- is now used in place of Aspirin for Pain and fever relief. I suggest not using aspirin unless prescribed by a Doctor.

–Dr. C

THE DOCTORS 101 CHRONIC SYMPTOMS AND CONDITIONS #25: KIDNEY STONES

Kidney stones are more common than you think, and over the span of life, afflict 1 out of 10 people, more commonly men. The pain is sharp, spasmodic and severe; it is described as being worse than the pain of childbirth. The pain is breathtaking, and if you have “renal colic”, your
world is truly “ in a grain of sand”.

This sand, this tiny rock, forms when certain elements and compounds become too concentrated in the urine as it is formed in your kidneys, and “drop out of solution”, or precipitates. This little pebble, which I’m sure feels like a rock, then begins its long, painful journey down the drainage system of the kidneys, and eventually passes, you hope, out with the
urine.

Be sure to save it for analysis if it does. Sometimes it is arrested, causes the urine to “back up”, and you need assistance to get it out. Half of the kidney stone attacks recur, and you will get other attacks.

This is particularly the case if your first attack comes when you are young, or there is a history of kidney stones which runs in your family. It is important for a doctor, such as an internist, to review your case, particularly if you are young.

Your family history, lifestyle including diet, medications, and other problems may give clues which will allow other attacks to be avoided. Sometimes there are serious underlying conditions that should be addressed. Half of people who have kidney stones have a genetic cause, but even here there are lifestyle changes which will help..

Drinking plenty of liquid helps, unless you have kidney failure. Read the Mayo Clinic article referenced below for details. They are interested enough in kidney stones to have consulted a Geologist, the ultimate student of Rocks.

–Dr. C.

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #18: SKIN INFECTIONS

The skin is the protective barrier between the inside of our bodies and the outside world of microorganisms, parasites and toxins. It is often the site of inflammation and infections.

In past times, before the advent of cleanliness and antibiotics, mankind was plagued by erysipelas, boils, carbuncles, and other severe infections of the skin, which are rarely seen now. The beta hemolytic streptococcus and Staphylococcus aureus were ubiquitous in the past, and mostly are contained today.

Severe Infections presently require some skin abnormality, immune deficiency, neglect, animal bite or other breach of skin integrity to be a problem. Antibiotic resistance, however, is allowing some organisms like MERSA to make a comeback.

ECZEMA. or Atopic Dermatitis, was common in my medical practice. This condition weakens the skin barrier, allowing Staphylococcal infection to gain a foothold. In my day, If there were a flare of eczema severity, antibiotics would often help. Leg edema and swelling. such as from heart failure, especially coupled with diabetes and blood vessel disease is also an invitation to infection, such as cellulitis.

Redness, swelling, warmth and pain- the classic rubor, tumor, calor and dolor- as well as swollen local lymph nodes and fever often betray infection of the skin. Please see the recently posted infographic on celulitis.

IMMUNE DEFICIENCY raises the likelihood and risk of severe skin infections. Infection from “flesh-eating bacteria”, often beta hemolytic streptococci in deep tissue planes , is a medical emergency. Immediate surgery is often needed.

Disproportionate PAIN after injury or surgery is often a clue. Certain age groups have characteristic skin infections, such as the scalded skin syndrome of infants, and the acne of adolescents. Viruses, molds, and arthropods can also infect the skin.

Viruses, such as herpes in particular can simulate bacterial infection. Ringworm from fungi is easy to distinguish, but arthropod bites, and especially bee sting can look very much like bacterial infection. Scabies and mite infestation are so itchy as to be distinct.

Topical antibiotics applied on skin breaks like cuts or breaks are useful in preventing infection. These ointments and creams are like “artificial skin”. Once again, prevention is key.

–Dr. C.

MEDICAL: ‘JOHNS HOPKINS MUSCULOSKELETAL CENTER’ – FOR MUSCLES, BONES AND CONNECTIVE TISSUES (VIDEO)

The Johns Hopkins Musculoskeletal Center aims to streamline and improve access for diagnosis and treatment of conditions affecting muscles, bones and connective tissues. Each of the center’s locations feature a diverse group of physicians, therapists, and advanced practitioners who work together to bring you the right treatment at the right time.

For more information

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #11: “SWALLOWING TROUBLE”

I am defining SWALLOWING TROUBLE as the difficulty in transport of food to the stomach, once clear of the throat. Problems with the initiation of the swallowing process are discussed separately.

PAIN in the mid-chest ON SWALLOWING is a worrisome symptom which can be due to inflammation of the lining of the esophagus from a variety of causes. An esophageal yeast infection, which can also involve the throat (called ‘“thrush”), often warns of immune deficiency and can be a sign of AIDS, or be caused by immune suppressing medication. If persistent, pain on swallowing can be a warning sign of CANCER.

If in the presence of GERD, it can be a sign of chronic inflammation or ulceration. In-coordination of the normally smooth muscular propulsive wave can cause a cramping, muscular pain.

Normal “peristalsis” is so efficient, that food can be swallowed without the help of gravity, when UPSIDE DOWN. I wouldn’t recommend trying this, even to cure hiccoughs. There is a muscular “gate” at the bottom of the esophagus, just as it enters the stomach. This gate is often too relaxed, and allows for the reflux of acid and food from the stomach, or GERD. It can also Fail to open, called achalasia, and hold up the food in its journey to the stomach.

The area can be scarred by repeated acid reflux, and become NARROWED; this is called a STRICTURE, and can cause a blockage in swallowing. One of my Doctor friends had to go to the Emergency room when some Steak got stuck in the esophagus.

The ER Doctor removed the steak with a fiberoptic Scope, and then proceeded to DILATE the stricture with a “bougie”, an instrument of a precisely calibrated size designed to STRETCH the constricted area. This uncomfortable procedure had to be done repeatedly, a caution to those who would wait too long before getting such a problem evaluated and corrected.

EOSINOPHILIC ESOPHAGITIS has been diagnosed with increasing frequency, and can cause Pain in the middle of the chest, trouble swallowing, and even regurgitation of food. This special type of inflammation is more common in allergic patients, and can be caused by certain foods.

So as you can see, swallowing trouble, if persistent, is nothing to fool around with, and should be checked out by a competent doctor. Don’t wait too long.

–Dr. C..