Tuesday, 26 July 2011

Seemingly Innocuous Symptions - When they Need to be Heeded

Published in Vijay Times in 3 Parts

Seemingly Innocuous Or….. (Part 1

A stitch in time saves nine – nowhere is this more apt than in the field of health and wellbeing. While one certainly need not be paranoid about a minor pain or ache here and there or high fever, it would be folly to ignore these very irritants – aches, pains and fevers especially if they seem to appear for no apparent reason, are persistently nagging and last longer than they generally do. Dr.Anant .R, Specialist Internal Medicine, Apollo Hospitals, Chennai talks about some of these seemingly innocuous signs and symotoms that could indicate something more serious.

Vivek was ravenous and sat down to a hearty meal soon after a good session at the tennis court. Soon he experienced pain and discomfort in the chest area. Vivek feared the worst - Heart Attack or Myocardial Infarction, as the medical fraternity would term it.

Chest pain is a symptom which can occur in a number of instances, unrelated to the heart. The chest contains several structures including skin, bones, chest walls, nerves, lungs, heart and their respective coverings. Abnormalities in any of these structures can bring on a chest pain! Chest pain can occur from simple superficial skin inflammation over the chest region, from acidity, cough, pneumonic infection, bronchitis, tuberculosis, angina, pulmonary embolism or clot in the lungs, rupture of the food pipe or its infection and also due to heart attack.

It is important to remember that while not all chest pain need be serious, it is advisable to seek medical help to evaluate a first time chest discomfort or pain to determine the nature of the root problem per se. Diagnosis has to be made in the case of chest pains to rule out a heart pain since this is the most serious conditions which may necessitate emergency treatment. On the other hand, most other problems which show up chest pain as a symptom can be effectively treated if diagnosed at the right time.

Sahana underwent basic medical evaluation for fever that raged unabated for over a fortnight. Except the fever itself, there were no other accompanying symptoms suggestive of a particular illness. More tests were ordered for various disorders but to no effect. The tests returned negative for all these diseases; yet the fever continued. Doctors finally decided to give her ATT or Anti Tuberculosis Treatment. The result was dramatic as Sahana responded to the therapy. She completed the entire course of ATT lasting six months.

Fever is a condition that could be benign, causing temporary discomfort to the sufferer, or indicative of a more malignant pathology. It can be classified based on its pattern, cause as well as degree. Generally, with the onset of fever, basic tests are done to ascertain whether it is due to viral or bacterial infections, which are the most common cause of fevers. In the Indian context, in particular, if fever continues for longer periods of time and no specific infection can be attributed to it, it is labeled as Tuberculosis after preliminary investigations and ATT. However, if even this therapy does not evince any response within ten days, further investigations are a must.

Fevers could also be of unknown origin, and could be indicative of connective tissue disorders like lupus or rheumatoid arthritis or malignancy anywhere in the body like leukemia, lymphoma, deep-seated tumours, HIV/AIDS and not least of all, due to drugs themselves.

Febrile convulsions or fits occurring during fever commonly affects 3% of children between the ages of six months and five years when they come down with high fever with temperatures above 39 degrees Celsius. The seizures last for between a few seconds to some minutes and is usually followed by drowsiness. About 30% - 50% of these children may have recurrent attacks when they get fever. Though the exact reason for febrile convulsions in children is yet unknown, Heredity and increased frequency of infections are believed to be contributory factors.

Febrile convulsions are normal in a small percentage of children and also benign in nature, disappearing by the age of five or six with no damage or injury to the brain or any other organ in any manner. However, there are instances where these convulsions are cause for concern since they signal serious underlying problems. Convulsions that last longer than ten or fifteen minutes are abnormal. Also, if a child below three months has the convulsions, it should be checked out. Lastly, if the convulsions do not disappear by the age of five or six, investigations are in order. In all these abnormal situations, febrile convulsions could indicate meningitis or the involvement of the Central Nervous System which could result in speech and or other physical and mental developmental retardations.

Low back pain is one of the most frequent problems treated by physicians, almost as common as the common cold. The lower back is a complex structure of vertebrae, disks, spinal cord, and nerves. These together provide mobility and strength to an individual, allowing him to turn, twist, bend, stand, walk and lift weights. Needless to emphasize the importance of the functioning of the lower back to enable one to perform all activities of daily living. Pain in the lower back can thus restrict mobility and activity, thus hampering good quality of life.

While most cases of low back pain are not serious, amenable to treatment and may be the result of obesity, smoking, alcoholism, sprain and strains in the region brought on by repetitive lifting of heavy objects, sports injury, injury to the spine, the underlying cause, in some cases may be of a more serious nature than meets the eye. Spinal disorders including disc prolapse, osteoarthritis and spondylolisthesis, rheumatorid arthritis, osteoporosis, ovarian cysts and tumours, uterine and blood cancer, sickle cell anaemia, aortic aneurysm, gall bladder disease, peptic ulcer, infection, defects in the musculo-skeletal system, atherosclerosis, pancreatitis and Herpes are all conditions which may have low back pain as a symptom.

Hence if someone experiences persistent low back pain, he/she should be systematically investigated to rule out any pathology or serious condition. The investigations, besides careful history and clinical assessment may include blood tests, X-Ray, CT Scan, MRI, Bone Scan, EMG (Electromyography) and Nerve Conduction studies depending upon symptoms and patient profile.


Seemingly Innocuous Or … (Part II)

The inputs for this entire 3 part series has been provided by Dr.Anant .R, Internal Medicine Specialist, Apollo Hospitals, Chennai

Fatigue is a common symptom of many ailments, not a specific disease or disorder. Fatigued individuals feel tired all the time, both physically and mentally. Fatigue tends to slow down the responses and reflexes of the affected persons, thus exposing them to risks of accidents at work and while driving. On the one hand Fatigue may simply be the result of overwork, unhealthy lifestyle and emotional distress. Alternatively, it could result from an underlying medical condition which God forbid, could be of a serious nature.

There are several diseases and disorders that can bring on fatigue. Some of these include TB, Anemia, Hepatitis, Hypothyroidism, Diabetes, Glandular fevers, Influenza, Addison’s and Parkinson’s Disease, Chronic Kidney Disease, Cardiac problems, HIV/AIDS and various sleep disorders including Sleep Apnea. Also medications prescribed for some disorder can cause fatigue.

Since fatigue is associated with a wide range of symptoms and is itself a symptom in an equally vast battery of diseases, diagnosing the underlying disorder becomes difficult. Which makes it all the more imperative for the root cause of fatigue to be identified rather than being dismissive about it and attributing casual reasons to it. For instance, if the fatigue is on account of say, Hypothroidism, and diagnosis is missed, there is every possibility of the hypothyroidism exposing the individual to an increased risk of heart disease, diabetes and sleep apnea.

Constipation is a condition where the sufferer experiences difficulty in eliminating feces. Constipation is physical manifestation of bowel obstruction. While constipation may be caused by faulty diet, hormonal imbalance, certain drugs and their overuse, and due to anatomical anomalies, occasionally constipation can be a sign of serious problems and hence chronic constipation should not be allowed to go unattended. This is particularly so if constipation is associated with nausea, vomiting, fever, abdominal pains or cramps, bleeding from the anus or rectum. For, this could mean blockage of the gut.

Alternatively, straining at stools causes high pressure in the colon which over time may lead to thin outpouchings to form in the colon walls. These pouches are known as Diverticula and they can become infected when stool or food particles get trapped in them. These may burst and in doing so, release harmful bacteria into the body. The situation could become life-threatening.

While Constipation is not a risk factor for colon cancer, it could be an early warning signal of the cancer. A tumor that is located in the rectum or lower colon and obstructs it, typically leads to constipation. Besides, constipation is a common symptom in certain disease conditions like Diabetes, Hypothyroidism, Irritable Bowel Syndrome and Haemorrhoids. Hence, any prolonged bout of unexplained constipation should be taken seriously and thoroughly investigated.

Nausea and vomiting
Nausea and vomiting are symptoms related to a host of physiological as well as psychological conditions. Many of these may be harmless conditions requiring symptomatic treatment and lo, the sufferers are put to ease as in the case of nausea and vomiting during pregnancy, due to emotional distress or that stemming from seasickness, motion sickness and intolerance to certain smells.

Nausea and vomiting are common symptoms of several ailments which include the stomach flu, indigestion, food poisoning, overeating, motion sickness and general viral fever. Usually the twin conditions are harmless but they can be signs of a more serious illness such as blocked intestine, appendicitis, gallbladder disease, heart attacks, kidney or liver disorders, central nervous system disorders, migraines, concussion or brain injury, brain tumors and some forms of cancer.

Another concern with vomiting is dehydration, especially in children when the vomiting occurs with diarrhea and the children are often unable to recognize the symptoms of dehydration. The age of the patient and timing of the nausea or vomiting is a fairly good indicator of its cause. Usually, if it occurs shortly after a meal, it may indicate peptic ulcer or mental distress. If there is nausea and vomiting in a set of individuals who have eaten from a common source , food poisoning is most likely to be the cause.

In infants and children below six years of age, vomiting that lasts more than a few hours, if it is present with diarrhea, high fever and the child has not passed urine for about six hours, medical help must be sought. The same is the case for children above six years of age if the vomiting persists for more than 24 hours, along with the other symptoms.

Medical assistance should be sought by individuals if the vomiting is associated with blood in the vomit, diarrhea, severe headache & stiff neck, severe abdominal pain, confusion, lethargy, high fever, rapid pulse or breathing.

Seema felt she had run a marathon to catch the bus; had she missed it, she would have been stranded at the stop for another hour. Anyway, having successfully boarded it, she sat down, huffing and puffing, for the run ‘took her breath away’! This is a very common scene at bus stops, exercise grounds, gyms and on sports fields and the “out of breath” or breathless feeling that people experience here are normal, natural and harmless. Similarly, pregnant women experience some amount of breathlessness which is again normal and harmless. Or there are the other segment of individuals who get breathless to a mild extent in the face of some emotional stimulus. Well, these are all circumstances when becoming breathless is not really cause for concern in a healthy individual who exercises regularly or does significant manual work and/or is a sportsperson engaged in strenuous fitness regime as routine.

Most often, breathlessness is the result of a lack of physical fitness which is compounded and worsened by obesity. Needless to say, both contributory factors can be corrected with regular exercise and by losing excess weight. However, breathless can be a sign of illness if it occurs at a much lower level of exertion, effort or work than is expected of a healthy person, keeping his age in perspective too. The causes for breathlessness may be physiological as happens after exercise, hard manual work or during pregnance; it can result from psychological factors such as from emotional stimuli. But the physiological and psychological causes for breathlessness can go beyond these simple factors and signal underlying, potentially life threatening disease or disorder involving the heart and lungs, anaemia, muscle weakness, anxiety and panic attacks and nervous breakdowns.

Further, breathlessness could be acute or chronic, the former happening suddenly and severely while the latter happens gradually over a period of time. However, each form of the condition has its respective causes and neither should be ignored. Some common causes include asthma, chest infection including pneumonia, heart failure, anaemia, chronic obstructive lung disease and hyperventilation. In addition to these factors, breathlessness can be caused by long term smoking which again is a major factor in several potentially life threatening conditions of the heart and lungs in particular.

Whether it is breathlessness, fatigue, nausea and vomiting or constipation, their causes may hinge on simple modifiable factors or on more serious underlying conditions. Hence, any persistence of these symptoms should not be ignored and medical evaluation must be done at the right time to avoid complications to self.

Seemingly Innocuous Or …. (Part III)

As a child how you’d love to get spun on a giant wheel or merry-go-round till you got dizzy! That was great fun and you loved doing it again and again. But now, when you find your head spinning when you wake out of bed or that your surroundings are spinning, you don’t enjoy the sensation anymore! Sometimes this dizzy sensation is accompanied by more unpleasant feelings of nausea, vomiting, something blocking your ears or of a loud, buzzing sound inside them. No wonder then, you begin to wonder if something could be wrong with you, even seriously so!
Dizziness is about balance, rather about imbalance. Good balance depends on the eyes, ears - the inner ears and sensory nerves working well. When these organs of balance get into a state of disequilibrium, dizziness results.

Eye problems, incorrect refraction after acquiring new glasses and patients who have been operated for cataract, can all have problems of dizziness. Some people experience dizziness, nausea and even vomiting when traveling by plane or on water or even in amusement park rides and this is particularly more common in children. Dizziness can also occur due to medication taken for hypertension and seizures.

Dizziness typically is a benign and self-limiting condition but it can be a sign of a serious underlying cardiac or neurological problem. Cervical Spondylosis, low blood pressure, very high fevers, basilar migraine and chronic diabetes often manifest with dizziness. If dizziness is accompanied by any of the following symptoms, it warrants medical attention. If there is accompanying loss of vision, double vision, speech disturbance, transient weakness in the extremities or loss of consciousness, numb and tingling feeling in the hands and feet, severe and persistent headache not hitherto experienced, the problem is most likely in the brain.
When dizziness involves a feeling of floating and a sense of lightheadedness, it is often a symptom of anaemia, decreased blood supply, low blood pressure or a cardiac problem. In dizziness involving the cardiac region very often the patient will complain of a choking sensation, sweating, palpitation and just dropping out. However, most often, individuals coming in with these symptoms may not necessarily suffer a heart condition but be simply experiencing a panic attack, a psychological attack.

Debanjali is constantly tense and snappy of late, rushing to meet deadlines. To make matters worse, she has been experiencing recurrent throbbing headaches over the past few months. Unfortunately, she hasn’t found time to visit her physician. Yet, she has a nagging worry about the ache in some corner of her mind.

There are several Debanjalis experiencing this problem. Many individuals suffer from headaches on and off and stress and tension are often the cause for the pain. About 75% to 90% of frequent or chronic headache sufferers are plagued by tension headache, the most common type of headache, second only to migraine. These headaches are not caused by disease, and are often considered to be "normal" headaches.

Most headaches do not require medical attention. Some headaches, however, can be a sign of a more serious problem, such as high blood pressure. However, to know which headache warrants further investigation, it is important to identify the type of headache one is suffering from.

Since tension headaches can be severe and last for a long time, this often arouses the suspicion in the patients that something more sinister like a brain tumour could be at the root of the problem. However, this is extremely rare and fewer than two patients in every 1000 with tension headache will be found to have a brain tumour.

Headaches may be triggered by certain kinds of food like chocolate, coffee or other stimulants, foods containing MSG, anger, anxiety, stress, strain, over work, eye and dental problems, sinus problem and environmental pollutants. Women may typically experience a nagging headache during their monthly cycle and during pregnancy.

If the headache is mild or moderate and is not associated with any other symptoms and responds well to simple medication or home remedy within a few hours, does not require any further examination. On the other hand, if the headache is severe, persistent, recurrent and associated with other abnormal symptoms like stiff neck and very high fever, dizziness, confusion and convulsions, then it needs to be investigated further to exclude other serious medical problems that may be producing headaches as a secondary symptom.


Cough is a symptom rather than a disease and is a common complaint, shared by children and adults alike. There are several reasons why individuals may suffer from frequent cough. However, while a cough may merely be annoying, it could be an indication of more serious underlying problems that requires to be investigated.

A person may cough due to irritants getting into the air passages, either through inhalation, as in the case of smoke or dust, or by aspiration as in the case of accumulation of secretions in the upper respiratory tract or even from the abdomen when acid comes up and gets aspirated, or when you vomit – this can get into the windpipe or trachea.

The causes for cough can be classified into four groups – inflammation, constriction, infiltration and compression. When there is long standing Inflammation and infection of the respiratory tract on account of virus or bacteria, it results in conditions like Bronchitis and Bronchiectasis. Chronic Bronchitis is a frequent cause of chronic cough, especially in smokers because their airways get inflamed and there is excessive mucus secretion which is difficult to expel. Also, since they “expect” to cough anyway, very often they miss out an important warning signal for cancer!

Asthmatics typically experience Constriction. The broncho-spasms associated with asthma can bring on a cough which is seen in both children and adults. While cough may be the only symptom of asthma in some people, in others, symptoms include wheezing, breathlessness and a constricted feeling in the chest region. Asthma is a serious medical condition that requires diagnosis, monitoring and treatment and if these are done properly, the cough too disappears.

Infiltration refers to cancer cells or tuberculosis bacteria invading the lungs and bronchioles and this can trigger cough. Lung cancer is an uncommon cause of chronic cough in nonsmokers; hence smokers must beware of chronic cough.

Various other conditions also present with cough as a symptom. For instance, heart failure can cause cough. Certain drugs may have the effect of bringing up a cough. This is especially true of roughly 10% of individuals suffering from hypertension who typically exhibit a chronic dry, hacking cough as a result of their medication. The cough disappears once they are taken off those particular drugs.

Cough may result from compression on the trachea due to enlarged lymph nodes or due to aortic aneurysm. Alternatively, outside the lungs some tumour could be pressing on it and this causes cough.

Haemoptysis is a condition in which the cough brings out sputum containing blood. This is a serious condition, symptomatic of infections like pneumonia and tuberculosis or cancer, heart failure and heart conditions. Blood in the sputum, depending on the colour and quantity is a danger signal requiring immediate attention since people can even die of massive, frothy haemoptysis. However, in 20-30% of cases, there may be no apparent cause found for a few streaks of blood in the cough and this subsides on its own.

When there is prolonged cough lasting for over a week, is pronounced at night, is accompanied by fever, wheezing, produces yellow, green or red sputum or phlegm or is associated with weight loss that is sudden, is associated with chest pains while walking and breathlessness, it requires the individuals to seek medical help to rule out serious underlying conditions.


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