Dr Dimari's Medical Sciences Thread - Read the first post

[Dr Dimari]

I have been debating for a while, and with discussion with a few members, I have decided to set up a thread.

So if you have a question related to medical sciences or clinical medicine, please feel free to ask. I'm a Student Doctor at a University in the UK (as many of you guys will know).

I am here to answer questions however please be aware of the following:

DISCLAIMER:
• Online discussions of health issues over the internet are full of problems and will not be 100% accurate.

• Any advice given is only based on information you give, and as I'm a student, it my response may not be 100% correct. It is therefore at your own risk whether you accept my advice or not, and I accept no liability to any outcome. But be sensible, if it is a problem which you require immediate medical advice, seek that rather than waiting for my post.

• If you have concern over your health you should always seek medical attention from your GP or Immediate attention from your local A&E department. Don't wait for a response from this thread.

So with that out the way, hi.

Just to let you know some information about me: I'm a student studying at Sheffield University and enjoy various aspects of medical practice. I am most likely going to be a GP when I've qualified, specialising in Psychiatry. I have had 2 years clinical experience, and thoroughly enjoy what I do. I am involved in research, especially in the field of infectious diseases (HIV and recently, swine flu) and autistic spectrum disorders.

[Golden Dysprosium]

Yay! We need more health sci topics so we can finally start using biology for something other than explaining the evolution blaugh
Good job with the disclaimer, BTW. I'll try to pitch in. It's good to find sources so they know we're not pulling this stuff out of our asses. sweatdrop

[Talono]

Just to start things off, how about this question from a practice USMLE? No cheating razz

A 17-year-old boy is brought to the emergency department by his parents with the complaint of coughing up blood. He is stabilized, and his hemoglobin and hematocrit levels are determined to be in the safe range. During his hospitalization, he is noted to have persistently elevated blood pressures, and his urinalysis is remarkable for hematuria and proteinuria. You are suspicious the patient has which of the following?

1. Hemolytic-uremic syndrome
2. Goodpasture syndrome
3. Nephrotic syndrome
4. Poststreptococcal glomerulonephritis
5. Renal vein thrombosis

[Dr Dimari]

Talono

Just to start things off, how about this question from a practice USMLE? No cheating razz

A 17-year-old boy is brought to the emergency department by his parents with the complaint of coughing up blood. He is stabilized, and his hemoglobin and hematocrit levels are determined to be in the safe range. During his hospitalization, he is noted to have persistently elevated blood pressures, and his urinalysis is remarkable for hematuria and proteinuria. You are suspicious the patient has which of the following?

1. Hemolytic-uremic syndrome
2. Goodpasture syndrome
3. Nephrotic syndrome
4. Poststreptococcal glomerulonephritis
5. Renal vein thrombosis

The most likely diagnosis would be 2 - goodpasture's. It is a rare disorder but haemoptosis and haematuria is common in this because it is an autoimmune condition against the goodpasture antigen found within proteins in the lungs and kidney.

To treat: Prednisolone or IV hydrocortisone and begin something such as azathioprine or cyclophosphamide

It could be 1, and maybe 5 at a push. 1 as it can cause clotting, which can cause haemoptosis in small vessels in the lungs, and ureamic damage, causing damage to the fenestrated urothelium of the kidney. 5 less so.

3 you would expect a huge passing of fluid through the kidneys; and so urin output would be high.

4 would give you a high BP, but would give you frothy production if a patient coughed.

[XxBlueRoguexX]

Hope you know your bound to get responses along the lines of

http://www.gaiaonline.com/forum/extended-discussion/what-would-you-do-depression-and-sickness/t.50777373_16/

[Golden Dysprosium]

I have one.
My friend is a "health nut": she works out and goes to the gym all the time, eats healthy foods...the works. Unfortunately, she also smokes, and drinks on the same level I did before I realised it was destroying my life xp I know nicotine constricts arteries and alcohol (I call it ethanol, because of Chem) can do a number on your body. This is bad enough, but she said that there's also a history of heart problems in her family; her mom and her mom had it, so it might be an X-linked trait on that side. sweatdrop
I sent her a list of healthy foods from the local health agencies, as well as some info on this stuff, buuuuut I'm not sure if it'll be enough. I'd like to try to get her to quit smoking and cut down on her drinking (I think dumping her idiot BF would cut it in half, as he'd probably get me drinking again xp ), but she's extremely stubborn.

[Jamie_667]

I have Chiari malformation I very, very mildly. From the time I was a teeneger I have also had on going insomnia (going on 15 years now) .

I found this article about a very young boy with a very servere Chiari Malformation II who did not sleep at all.

Is there any resurch connecting insomnia to this particular malformation, or might my 2 problems be completely unrelated?

(could you please PM me when (if) you reply to my post?)

[Solus Canis Lupus]

Ok, sometime in August of 08 I was skating down a steep road without a helmet or elbow or knee pads. I'm sure you can guess the rest. I got a wound the size of a large coin on the side of my arm near the elbow and one the size of a small coin near my hip. I went home and cleaned the wounds with alcohol, ointment, etc. They've healed up but the skin where they were is still dark. My wounds usually heal up pretty nicely like they were never there. Should I be concerned?

[Dr Dimari]

Golden Dysprosium

I have one.
My friend is a "health nut": she works out and goes to the gym all the time, eats healthy foods...the works. Unfortunately, she also smokes, and drinks on the same level I did before I realised it was destroying my life xp I know nicotine constricts arteries and alcohol (I call it ethanol, because of Chem) can do a number on your body. This is bad enough, but she said that there's also a history of heart problems in her family; her mom and her mom had it, so it might be an X-linked trait on that side. sweatdrop
I sent her a list of healthy foods from the local health agencies, as well as some info on this stuff, buuuuut I'm not sure if it'll be enough. I'd like to try to get her to quit smoking and cut down on her drinking (I think dumping her idiot BF would cut it in half, as he'd probably get me drinking again xp ), but she's extremely stubborn.

Unfortunately the success of stopping smoking and reduction in alcohol consumption is very poor if you really aren't willing to quit. When I'm in consultation with patients on giving lifestyle advice and improvement, we discuss:
> What the problems are
> Ask what the patient thinks are the complications that could arise from their problems
> Tell them the actual pros and cons for their situation
> Understand what their problems might stem from, and they would like to happen
> Talk about ways that could improve this and the rewards
> Offer support that is required and refer to the necessary people.

I think you have approached your friend in the right way. However, if they don't have any motivation to quit then they probably won't.

Smoking narrows the arteries by promoting atherosclerosis not by the nicotine in them, but the tar, carbon monoxide and a few other vasoconstrictive compounds. Alcohol causes the liver to detoxify the blood from alcohol before fat, therefore less fat is metabolised and so more exists within the circulation, catalysing the atherosclerotic reaction. As for the genetics, is less likely to be X-linked, its just a general genetic trait that can be carried in boys. Infact boys are more likely to be affected by X-linked conditions and women silent carriers.

Just be reasonable and persuasive. Encourage her by talking about the risks associated and the benefits from quitting. But at the end of the day; its up to her, and you can only do so much.

[Dr Dimari]

Solus Canis Lupus

Ok, sometime in August of 08 I was skating down a steep road without a helmet or elbow or knee pads. I'm sure you can guess the rest. I got a wound the size of a large coin on the side of my arm near the elbow and one the size of a small coin near my hip. I went home and cleaned the wounds with alcohol, ointment, etc. They've healed up but the skin where they were is still dark. My wounds usually heal up pretty nicely like they were never there. Should I be concerned?

This is most likely because it is scar tissue. Unfortunately scars take a while to fade and resolve and often if they are large enough they can be dark pink in colour once healed. You can try and use something called Bio-oil to help fade scars. So there is nothing to really be concerned about.

Anyway, a previous post I have written about treating cuts and bruises is below. If you follow these steps, scaring should be kept to a minimum.

dr dimari

For small wounds, like a linear small cut or graze the size of a 5 pence piece (or a 1 cent coin), and that has no contaminants or debris inside, just rinse it under some clean water, dry and cover with a band aid or plaster. Change everyday, until healed. You will find most cuts don't need such a dressing and will be fine otherwise. If you have an allergy to band aids/plasters use hypoallergenic ones, or use cotton wool and some surgical tape on top. No special cleaning equipment is needed.

If it has debris, you need to flush the cut. This should definitely be done by clean tap water, or saline solution (0.9%) (irriclens) if you have it. Of a cut this size, its important to not make it any worse and just clean it. If its deep or sore when done, just rinse under very cold tap and cover up using above method.

If the cut is not linear, or the graze is bigger/deeper, it should be covered up, and if a normal band aid will not fit, you should find one of two dressings: Mepore or Melolin. (with the melolin you will need to have surgical tape). These are plain dry absorptive dressings that don't contain any agents and are sterile. These should be applied once the wound is irrigated with clean water or saline solution if available, and any fixed debris removed. If glass, shrapnel or splinters are in the wound, you should either go seek medical advice or remove them carefully with tweezers a steady hand, plenty of light and patience. The dressing should be applied and changed once a day.

If skin (such as a skin flap) has come off the wound or it is very deep, in this case an antiseptic should maybe be used, after irrigating the wound for debris. I recommend: Surgical Spirit BP, Dettol or TCP (follow the instructions of dilution). Chlorhexadine if you have access to it would be the best one of choice. You then need to wait for the solution to dry. Add a gauze swap ontop, then add a dressing (mepore or melolin + tape) using as clean a procedure as possible. Change the gauze swap and the dressing every day. No need to re add antiseptic.

If the wound is big, or caused from a surgical procedure or a boil exploding, I suggest seeking medical advice for treatment.

What to watch for in your wound every day you change your wound. Ask yourself is teh wound:
• Red
• Swollen
• Sore
• Hot
If the answer is YES to ALL this questions, you are recommended to repeat antiseptic technique and seek medical attention for an antibiotic cream, fusidic acid (or in bad wounds oral flucloxacillin). Neosporin (neomycin) may be used, but it is not as widely used and not as effective as fuscidic acid. Dressings containing silver or iodine may also be used, (Tegaderm Alginate and Inadine). The cream should be applied tds if badly infected, but maybe reduced to bd. Before redressing and applying antibiotic cream, clean out any discharge and puss and irrigate with saline ONLY (reminds me of the time I literally collected a mug full of pus from an exploded boil that was cut out and rehealing but got infected. The pus came from everywhere within a foot diameter). If there is an odd smell, blackening of the skin; seek emergency medical attention.

If the cut has been done by a metal device of either unknown origin, or if it is still within the wound eg fish hook or nail, (do not remove it), and seek emergency medical advice. For those cuts that are very deep and profusely bleeding, aim to use clean cotton or linen to absorb blood and apply pressure to the wound to allow it clot. Aim not to get it wet straight away as you break up the platelet plug before fibrinogen has turned into fibrin and bound the clot. if the bleeding continues for about 5 minutes, or significant blood loss (more than 1/4 pint in that period) seek emergency medical advice. You will need to apply excessive pressure above the site of the wound, and on the wound. Wrap with cotton or linens to absorb whilst seeking advice. If you at anytime feel excessive pain, uncomfortable treating the wound by yourself, rebleeding happens, systemically ill a little while after the cut or symptoms worse or are worried seek minor injuries or A&E depending on the situation.

Burns require a different procedure:

Superficial burns (those who just affect the top layer of skin, not too sore, red, warm should be managed under a cold tap for 10 minutes. These burns should be left to air, and moisturiser applied twice a day until healed. Wash hands before applying moisturiser and ensure it is a water based moisturiser. Oil based ones will only make the burn worse and sweat, drying it. Not nice.

Partial thickness burns any larger than a 50pence piece or the size of a quater should be seen by medical personnel. If not treat as the following; run under cold water for 10 minutes, pat dry wounds. Apply either moisturiser (water based fragrance-free) or some burn cream (the best one is Flamazine; or use Neosporin). Apply a non-stick (low adherent) dressing on, preferably a plastic filmed dressing (so Melolin ... NOT MEPORE). Avoid heat, and aim to not get it wet, but moisturise tds or burn cream bd/tds. Change dressing once a day. If it gets infected, see a medical practitioner for antibiotics. If it gets severe, gives a lot of pain or loss of sensation, seek medical advice.

For pain relief, cold but dry ice packs on wound after covering up and some NSAID medication (such as ibuprofen 400mg tds) to be taken in those over 16 (200mg tds for 6 and above)

For full-thickness burns, seek emergency medical advice immediately. Do not apply cold water to the burn. If any clothing has moulded itself to the patient, do not remove. Aim to cool it by running tepid water over it. Apply tepid water over the burn but be careful about temperature drop. Look after the patient, making sure they do not go into respiratory problems, loss of consciousness etc. If this happens place in recovery position without applying pressure to site. Do your DR ABC and Call for ambulance. Call for ambulance is patient has multi-locational wounds that are large. Remove patients clothing and tight fitting garments. Cover patient in warm, clean, dry linens (not cling film)... and leave the rest to us when they get here.

Hope that helps.... and I hope I havent missed anything.

[Talono]

From J Med Case "Spontaneous corneal melting in pregnancy: a case report", under "Discussion and conclusion":

"We hypothesize that relaxin, by virtue of its differential effect, probably acts on corneal collagen as well and may exhibit collagenolytic property. These changes may not be of major concern in a healthy cornea but in compromised corneas they may lead to corneal melting and devastating complications, as seen in our case. Pregnancy as a cause of corneal melting has not been earlier documented, but after extensive investigations and detailed history in our case we could not find any other cause. Further studies are required to evaluate this hypothesis."


Could you expand on their hypothesis a bit more and explain the relationship between collagen and corneal structure as well as why relaxin would cause melting of the cornea?

[Golden Dysprosium]

Corneas can melt? eek

[Dr Dimari]

Talono

From J Med Case "Spontaneous corneal melting in pregnancy: a case report", under "Discussion and conclusion":

"We hypothesize that relaxin, by virtue of its differential effect, probably acts on corneal collagen as well and may exhibit collagenolytic property. These changes may not be of major concern in a healthy cornea but in compromised corneas they may lead to corneal melting and devastating complications, as seen in our case. Pregnancy as a cause of corneal melting has not been earlier documented, but after extensive investigations and detailed history in our case we could not find any other cause. Further studies are required to evaluate this hypothesis."


Could you expand on their hypothesis a bit more and explain the relationship between collagen and corneal structure as well as why relaxin would cause melting of the cornea?

The cornea, as you know, is a specialised tissue that covered the front of the eye. It is made up from collagen type I fibrils and a specialised stroma. The cornea has about five layers, with the most inner being a transparent cellular basal lamina and many mitochondria up to the outer most layer which is a fast turned over epithelial layer. This is to allow it to keep smooth as if it suffers a disruption to the smoothness of the air-tear film interface, many pathologies can occur. Often these usually resolved with intermediate levels producing an inferstructure that is brought to the surface. These intermediate layers usually contain either a uniform or random collagen fibril structure. This depends particularly on their function, I'm not a specialist in ophthalmology, and its not too relevant here.

Anyway, Relaxin is a hormone produced in women to help labour occur, and is usually produced heavily in the final trimester of pregnancy. Relaxin receptors occur predominantly in the heart, smooth muscle, and connective tissue as well as the nervous system. In the heart, it help to tone up the heart and the heart of the feotus to be strong during the stressful time of labour. In the smooth muscle it helps to build the uterine walls particularly for delivering the child well. As for connective tissue, which is the most important for us here, it prepares the cervix and v****a to be more "spongy" and flexible, so it can dilate easier and the birth canal is a smooth ride for the baby.

However, its not specific to that particular connective tissue, and these receptors exist in others; one being the cornea. I'm not sure why they're systemic rather than locally distributed, but thats how the body is. Anyway, the cervix is collagen I and II , so there will be a response ordered by collagenolytic enzymes specific for these. As the cornea contains collagen type I firbils and the collagenolytic enzymes respond to Type I, and there is vulnerability to the cornea (In this case the woman had various corneal surgeries, the basic smooth structure was disrupted and lysis can occur.

The likelihood of collagenolytic activity increased because of change in the stress threshold and also the threshold of which collagenolytic activity over takes the renewal process due to input from the relaxin hormone. Once the collagen undergoes lysis, stroma is left with increasing thinning of the cornea, giving you a "melted" cornea. Watery eyes, pain and loss in visual acuity are the three main symptoms.

I hope that helps, and I'm sorry I'm late with this response. I have been overworked recently. Again ophthalmology is not specialty, but thats my theory and expansion of their hypothesis.

Sources:
http://www.nature.com/jid/journal/v125/n4/full/5603548a.html
http://www.cochrane.org/reviews/en/ab003103.html
http://dx.doi.org/10.1016/j.pedex.2008.01.001
http://en.wikipedia.org/wiki/Relaxin

[Valkyrie Queen]

For most of my life, I've been cold. I always thought there was nothing wrong with me (that is, I didn't realize how absurd it gets sometimes) until recently when I started noticing other little things.

For one, I sleep with lots of blankets. I live in the Southwest desert region, where most people complain about the heat. I do get hot outside like a normal person, but air conditioning systems make me get the chills after a short amount of exposure. I wear a lot of turtle necks to prevent this from happening, which usually works quite well. My feet and arms get a "pins and needles" feeling in them, and if I do something like sit and stand up, most times I go blind for a second before my vision comes back to me. The periods of blindness last for about a minute.

Lately, I've noticed my hands shake. It's not advanced like something you would see with Parkinson's, but it's still noticeable. I get weak enough to the point where it's a chore to grasp onto something like a pen. This happens especially when I haven't eaten in a while but don't feel hungry.

My feet are very sensitive to movement. My toes will start to cramp and bend the wrong way backwards on their own if I move my foot in a way that doesn't agree with it. The last time this happened I fell off my friend's bed screaming bloody murder. They last for around 10 minutes, sometimes less if I can straighten my foot out and keep still.

I also think I have a bad reaction to caffeine. Last month I went on vacation with a friend and while we were in the hotel one morning, I drank a cup of coffee before we went out to eat. While I was on the phone with someone trying to explain a stressful situation to him, I had to pause and sit down because my heart started beating erratically and quickly all on it's own. It was significant enough to impede my talking.

I've been told I have an iron deficiency, which I could believe. My diet hasn't been perfect in the last few months. But I'm wondering if I'm slightly anemic... or maybe I have poor circulation. Do you know what it could be?

[Sweetpea The Tigress]

I have diabetes, and I need a lot of insulin. Like for a 500 calorie meal I use 20 units of insulin. Is there a way to get my body to need less insulin?