Tag: symptom

Posted in Psychology & Medicine

Clubbing

Posted on by Jinavie

Among the thousands of signs and symptoms in the field of medicine, there is one that every doctor and medical student knows since the development of medicine. Clubbing is an easily noticeable sign in a patient’s fingers that can have wide implications on their health.

Clubbing is essentially when the angle (gap) between the fingernail bed and finger disappears. The formal definition is much more complicated, such as “the loss of the normal <165° angle, or Lovibond angle between the nailbed and the fold”, but for all intents and purposes the simple definition is sufficient.

To see if a patient has clubbing, the physician carefully studies the fingers against light. There are a few ways to check for clubbing but the most popular methods are holding the fingers out straight and holding them parallel to the ground, checking the angle between the nailbed and finger, or the Schamroth’s window test. The latter test is done by holding two opposing fingers (such as the left and right index fingers) against each other nail to nail. The fingers are then held against the light so that the light can shine through the “window” that is made. If the window is not seen, the test is positive and the patient has clubbing.

What does clubbing suggest? Clubbing was first noticed by Hippocrates, the father of Western medicine, who observed that people with clubbing tended to grab their chest and fall dead. This is one of the most common associations to clubbing – a congenital cyanotic heart defect such as tetralogy of Fallot or patent ductus arteriosus. Other common associations are related to the lungs, such as lung cancer (one of the most common causes) and various other lung diseases such as interstitial lung disease, tuberculosis and other chronic infections. There are also a myriad of other diseases associated to clubbing, including but not limited to: Crohn’s disease, ulcerative colitis, cirrhosis, celiac disease, Graves disease and certain types of cancers (lung, gastrointestinal and Hodgkin’s lymphoma mainly). Clubbing can also be idiopathic, where there is no apparent cause for the clubbing and the person just has it (possibly just born with it).

Despite knowing about clubbing for over 2000 years, we still do not know the exact reasons for clubbing. There are theories that it is related to a fall in blood oxygen content leading to vasodilation in the peripheries. As the pathophysiology is not clear and so many diseases are associated with it, when clubbing is found in the patient the physician should investigate the related organ systems (heart, lungs, GI mainly) to narrow down the possible cause of it. As many of the causes (such as lung cancer) carry a rather morbid prognosis, it is quite important to notice whether the patient has clubbing when doing a physical examination.

Posted in Psychology & Medicine

Symptom Reporting

Posted on by Jinavie

Some people always complain of symptoms, claiming that they are sick, while some people never seem to complain even if they have a whole list of symptoms. Why is there a difference in symptom reporting between people? For example, women are more likely to recognise symptoms and report them compared to men. This is because men are generally under the social pressure of needing to appear strong and healthy, so they become stoic and less sensitive to pain and disease. Women are usually more sensitive to internal bodily changes and worry more about their health.

According to a psychological theory called the competition for cues hypothesis, there are two signals that compete for attention when we recognise symptoms. The first is bodily changes, i.e. internal cues, while the other is external stimuli from what happens around us. Awareness of symptoms follows a ratio between these two signals: if there is a strong internal cue such as severe pain, we notice symptoms more quickly, while if there are many distractions, we may not notice the symptom. For example, according to a study people can run faster when listening to music and running through a forest with plenty to see. This is because music and the scenery distract the runner from internal cues. As we can only process a certain amount of information at a given moment, the more distractions there are the less sensitive we become to signals from inside our body.

Another factor that affects symptom reporting is illness labelling. The more information we have about a disease, the more we search for those symptoms. For example, if you yawn or scratch yourself, people around you will do the same. This is because they see you yawning and subconsciously believe that they should yawn too. This can be a powerful effect, as seen in mass hysteria. This strange phenomenon occurs when a person observes a sick person and their brain believes they are sick too, beginning to show symptoms despite being healthy. A similar example is seen in medical student disease, where medical students, with their extensive knowledge of diseases, match their own symptoms to symptom lists of rare diseases. For example, they might think that their high blood pressure is due to a phaeochromocytoma or renal artery stenosis, rather than just hypertension.

However, the opposite can occur where people fail to notice important symptoms and suffer serious consequences as a result. For instance, not all cases of heart attacks (myocardial infarction) cause unconsciousness and a patient may believe they are fine when only chest pain occurs. Failure to get treated as soon as possible at a hospital may result in ventricular fibrillation, leading to sudden death.

Posted in Psychology & Medicine

Tetanus

Posted on by Jinavie

Tetanus is an infectious disease caused by a soil-borne bacteria called Clostridium tetani. Patients are often infected soil entering the blood through deep wounds, such as a cut. The bacteria produces a toxin called tetanospasmin which leads to the characteristic symptoms of tetanus involving muscle.

The term tetanus actually refers to a state where skeletal muscle remains contracted and cannot relax due to maximum signalling from the nervous system. Tetanus is associated with some distinct symptoms involving tetanised muscles.

Tetanus starts in the face in the form of lockjaw (jaw clamps shut and cannot be opened) and sardonic risus sardonicus. Risus sardonicus, also known as sardonic grin, is a contorted, malicious-looking smile that is caused by spasms of muscles in the face. A good portrayal of the grin is seen in the Joker’s face from the Batman comic book series.
The disease then progresses to cause stiff neck, spasming of chest and leg muscles and difficulty swallowing. 

A dramatic symptom is opisthotonos, where the patient experiences extremely painful contractions of back muscles causing them to arch their back against their will. Along with lockjaw and risus sardonicus, it is a characteristic sign of tetanus and has been known for centuries. Before it was attributed to tetanus, people used to think the person was possessed by a demon due to the agonised screams and involuntary spasming of the body.

The disease is especially devastating in infants and can be spread to the fetus within the womb. This is because babies do not have a developed passive immune system that can combat the infection. Neonatal tetanus carries a mortality rate of over 90% and is responsible for 15% of all neonatal deaths.

Tetanus is a preventable disease through immunisation. Immunisation is done by injecting an inactive form of the toxin (i.e. cannot cause disease), inducing a reaction by the immune system. This essentially “teaches” the immune system to defend the body against tetanus. By completing a course of three doses and receiving occasional booster shots throughout life, tetanus can be prevented. Pregnant women must be immunised against tetanus to prevent neonatal tetanus (the babies receive scheduled immunisations soon after birth too).

This is one example of how immunisation can effectively prevent fatal diseases in a population.

Posted in Psychology & Medicine

Munchausen’s Syndrome

Posted on by Jinavie

Some people are known to overreact regarding their health, such as a hypochondriac thinking that she has kidney failure because her urine looks slightly frothier. However, some people far surpass the level of hypochondrias to the level of psychiatric disease.
Münchausen’s syndrome patients are known to exaggerate or create symptoms so that the doctor would pay attention to them. When the doctor investigates, treats and sympathises with the patient they gain satisfaction from all the attention they are receiving.
Although this may sound like hypochondrias, Münchausen’s is far more serious.

A Münchausen’s patients are known to cause symptoms just to get attention from others. For example, a common manoeuvre used is the injection of insulin to induce a hypoglycaemic seizure. When their symptoms are “treated”, the patient will most likely invent another factitious disease to be treated for a longer time. They will also seek out many different doctors when the attending doctor catches on to their act. In fact, a Münchausen’s patient will do almost anything to prolong medical care, even accepting unnecessary and risky procedures such as surgeries.

The key difference between Münchausen’s syndrome and hypochondriasis is that the patient is aware that they are not actually sick (hypochondriacs actually believe they are sick). The fundamental basis for Münchausen’s syndrome is the desire for attention. Thus, the main risk factor for developing Münchausen’s is childhood experience of seeing someone close (typically a family member) suffering a debilitating disease. For example, if a girl sees her sister suffering from leukaemia and receiving all the attention of everyone around her, she may develop feelings of jealousy and later try to duplicate the scenario. As a patient, the person feels safe and comfortable and this feeds their addiction to medical care.

As Münchausen’s patients are very proficient liars and act completely like an actual patient, doctors must rule out any diseases before suspecting that their patients have a psychiatric problem. However, some signs such as the patient being overly keen on receiving procedures such as biopsies or continuously developing random symptoms may indicate Münchausen’s.

Interestingly, a similar condition called Münchausen’s syndrome by proxy also exists, where a caregiver (e.g. mother) convinces a doctor that the person they are caring for (e.g. child) are sick. Unfortunately, as these patients actually cause illness in the child, it is considered a form of child abuse. Common “symptoms” include: growth problems, asthma, allergies, vomiting, diarrhoea, seizures and infections. This may lead to the child developing Münchausen’s syndrome in the future.

Posted in Psychology & Medicine

Couvade Syndrome

Posted on by Jinavie

A patient comes to a doctor complaining of the following symptoms: “I can’t sleep because my teeth have been aching for the past few weeks. My head is killing me and whenever I wake up in the morning my stomach hurts and I feel nauseous and want to vomit. Sometimes I have no appetite and sometimes I crave a certain food. My breasts have gotten bigger and my stomach is bulging quite a bit.”
The patient has been married for three years and in a few months will have a beautiful daughter.
What is the diagnosis?

Most people would immediately say “Pregnancy!”. But there is one small detail that was left out: the patient is a man.
It is common sense that men cannot be pregnant. So what is this man suffering from?

Couvade syndrome is also known as sympathetic pregnancy. In other words, the husband subconsciously copies his wife’s pregnancy and suffer the same symptoms. This syndrome can be severe enough to cause labour pains, nosebleeds and even post-partum depression.
The cause has not been established, but it is likely to be psychosomatic, where psychological symptoms are expressed through physical symptoms, or due to changes in hormone levels.

Posted in Psychology & Medicine

Toxoplasmosis

Posted on by Jinavie

There is a protozoan parasite called Toxoplasma gondii. This parasite infects many animals through an interesting route. 
The first victim is a mouse. An infected mouse loses its fear of cats, leading it to play fearlessly in front of one until it gets caught and eaten (was Jerry a mouse with toxoplasmosis?). It is unclear how it controls a more advanced animal’s brain, but thanks to this effect, Toxoplasma gondii can infect its intermediate host – a cat.
An infected cat starts excreting parasite eggs with its faeces. If a person forgets to wash their hands or eats food contaminated with cat faeces, they can be infected and become the final host for the parasite.

Usually, Toxoplasma gondii cannot overcome the healthy immune system, but it can infect those with a weaker immune system such as the elderly or pregnant women. Furthermore, it is part of the TORCH complex (toxoplasmosis, rubella, cytomegalovirus, herpes) – a group of infections that commonly cross over from the mother to the fetus in utero. Symptoms are normally flu-like, but if more severe it can cause dysfunction of the eyes, brain and other vital organs. Sometimes it lies dormant until the person’s immune system is weakened, whence it becomes active. Toxoplasmosis is also a possible cause of a miscarriage or infertility.

One fascinating symptom of toxoplasmosis is psychiatric disorders. Because Toxoplasma gondii can infiltrate the brain, it is known to cause depression or even schizophrenia. As cats are the most common intermediate host, cat owners are more susceptible to toxoplasmosis. Because of this, there is a theory that “crazy old cat ladies” are in fact toxoplasmosis patients.

Posted in History & Literature

Black Death

Posted on by Jinavie

This disease, also known as Pest or the bubonic plague, was a vicious infectious disease that decimated medieval Europe. It is caused by the bacteria Yersinia pestis, usually transmitted by fleas. The symptoms vary from high fever, malaise, nausea and vomiting, headaches, muscle cramps, seizures, red rashes, coughing and swollen lymph nodes, and causes death within four or five days without treatment.
People did not know about the existence of bacteria back then (it would be 200 more years until Louis Pasteur would suggest germs as the cause of infections). Back then, they considered diseases to transmit through miasma, or bad air. Also, they believed that to prevent transmission, they required a stronger smell to counter it.

Plague doctors, who treated according to the miasma theory of disease, wore a special set of equipments that were known as beak doctor costumes. They wore an overcoat, hat, gloves and boots made from waxed leather, carried a cane to assess the patient and point things out, and a peculiar mask. The mask had a long beak like a bird’s, giving the doctors the nickname beak doctors. The masks had round, glass windows to see through, and two small nostrils at the end of the beak.

Why did they wear this strange mask? The beak was hollow and doctors filled it with flowers, herbs, vinegar and incense that produce a strong smell, so as to “purify” the air coming through the nostrils. 
Although the miasma theory has been falsified by germ theory, this gear was the first hazmat suit in history.

There is another fascinating fact regarding the Plague, miasma theory and beak doctors. It regards the nursery rhyme, Ring a Ring o’ Roses:

Ring-a-ring-a-roses,
A pocket full of posies; 
Atishoo! Atishoo! 
We all fall down. 

This nursery rhyme actually describes the Plague. The ring of roses refers to the red rashes and swelling of lymph nodes – a symptom of the Plague; the posies were herbs used to counter the miasma; coughing and sneezing were end-stage symptoms before death, which is shown in the final line.