Friday, 29 January 2010

The Medical History - key to diagnosis Spinal cord compression

I saw another heartbreaking case last week where three hospital consultants failed to take a medical history and missed what was called when I trained "Barn Door Diagnosis"

A young 40 something woman has been off work for 21 months with a diagnosis of "Chronic Fatigue" because no one has listened to her story.

"When were you last completely well"

"June 3rd 2008" "What happened?" "I scraped the wallpaper of my daughters bedroom wall. I felt ill the next the day, went home, slept for two days and I have not been back to work"

This is an unusual story.

This is a young 40 plus woman, who is fit and motivated enough to do DIY during her weekends off and now can hardly walk. Something serious has happened.

Asking more questions, Sarah X spent two days scraping bathroom wallpaper off the wall, without a steamer. For anyone who has ever done this, it is hard backbreaking work and Sarah X did it for two days and went to work on Monday.

She left work early on the Monday and slept solidly for two days. Her children (13yrs and 15yrs) took themselves to school and got their own meals for two days. Thursday morning Sarah X staggered to her General Practitioner and has not worked since.


Sarah X never leaves work early and never takes time off. She has taught her children how to look after themselves, as well as holding down a full time job and running and maintaining her home, with no man in sight. This woman is used to working hard!! When a hardworking woman is off work for two years, there is a serious problem - her Medical History makes this clear. The circumstances around her sickness are as important as her illness because noticing these are clues gave Sherlock Holmes his reputation.

Now she has severe pain in her neck, numbness in her legs, difficulty using her hands and has trouble walking.
Examinating her confirms that her neck is painful and tender. And she has the briskest reflexes I have seen outside a neurosurgical clinic. I should have filmed her. I was probably the first doctor to examine her properly. The Neurologist scanned her neck at a high level, and a prolapsed disc at the bottom of her neck was seen and considered "not significant". Brisk reflexes can be caused by pressure on the spinal cord

This is a classic story of spinal cord compression - the sort that leaves you paralysed from the neck down

Sarah X has been seen by an NHS Rheumatology consultant, Neurologist, and Chronic Fatigue Specialist - no one took a proper medical history or examined her reflexes - and as a result a young woman is crippled, possibly permanently

The key to being a good doctor is being curious - people see a doctor because they have a problem, and it is your job to find out what the problem is and sort it out.



The key features of cervical cord compression are:
1 - trauma to the neck, whilst wall papering - an awkward and difficult movement, carried on over two days leading to a prolapsed disc in her neck
2 - numbness and tingling in her legs and arms - classic signs of nerve damage
3 - a generalised difficulty walking - rather than a sore ankle, again - a classic sign of damage to the nerves
4 - pain in her neck -
5 - Brisk reflexes, - when you tap her patella (knees), wrists, hands, elbows, thighs, ankles - her whole body jumped

Click here for more information about the cervical spinal and cervical discs



 The spine is a series of bones that act like blocks to give vertical support to the neck and back. Each block is separated by a "disc" of grisel. This grisel can come out of place and put pressure on the nerves - both at the level of the damaged disc and put pressure on the nerves going down the back to the arms and legs.

 

This is not the lady's scan - her disc was further down her neck which makes it harder to see. 

In Occupational Health I can only make recommendations but it is hard to describe the relief and almost joy this patient experienced when she understood what had happened and that she could get treatment, if necessary surgery. In the meantime, I recommended she take care with her posture and ask her GP for an urgent referral to a good Neurosurgeon.

I trained before we had scans, and we had to work out what was wrong with patients from their medical history. Believe it or not, we did have good results! or as my old boss used to say, more fractures are missed on X-ray than on examination, if it looks like a fracture, the story is of a fracture, treat it as a fracture and then it can heal. 



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Tuesday, 5 January 2010

Medical History

The Medical History is key to diagnosis
I remember ageing professors telling me this as a student and thinking - what do they know? I just want to get on and scan the patient. However scans, tests and investigations only tell half the story. They tell you what is going on at this moment in time, but they don't tell you how it happened.

If you imagine the patient who comes to see you in distress as a car crash, looking at the car crash does not tell you what happened to the car and its occupants. To know this, you need the story. Just looking at the car crash, is like just doing tests, investigations and scans. Yes you need to look at the car crash but you also need to know the story that goes with it, otherwise it is just another bent car.
 
With the story, you know where to look for damage and how best to straighten it out. For example, the car may look fine but have a bent chassis. But unless you know that the car was dropped 30 foot from the top of a building, you are unlikely to look at the chassis.
For that reason, history is important. Patients should be wary of a doctor who does not ask questions, listen to the answers and examine them to see the damage.


A good medical history means you walk in the patients shoes and understand what has happened to them, from a medical viewpoint. There is no need to include what your aunt's cat died of! The story explains how the patient came to be in the state they are. The story assumes a rational explanation for what why the patietn feels the way they do. Without the story, symptoms mean very little, you cannot find the cause of the problem and it is difficult to straighten the patient out, without causing further damage.

For example

[All patients are assumed to be 35 year old men, unless there are medical points that relate to age or gender]

Mr Xa came to see me three months after an operation for carpal tunnel syndrome (compression of the nerve to the hand at the wrist). The surgeon had listened briefly to his complaints of numbness and tingling in the fingers and three days later operated to relieve pressure on the nerve at the wrist.






The surgeon cuts the white band crossing the nerve, which is the carpal tunnel ligament. This releases any pressure there may  be on the nerve at the wrist.  





This begs the question - what has happened to the patient that there is pressure on the nerve because at the very least you want to stop it happening again. 

The operation was a disaster. Mr Xa had a painful stiff hand, with barely any movement at the wrist. The patient was right handed and could not even help their children tie their shoe laces.

The history was key. Before the symptoms started Mr Xa had had an extremely busy period at work, with a lot of extra typing and pressure. This was not a simple case of carpal tunnel syndrome - which typically comes on gradually, worse at night and associated with pregnancy and increasing age. This was a case of Work related Upper Limb disorder which needed physiotherapy to help Mr X change the way he typed (imagine you are sitting down a Grand Piano and playing Rachmaninov's fifth!)

Click here to read more about Work Related Upper Limb Disorder and Carpal Tunnel Syndrome

I also knew from the circumstances of his visit what kind of a person he was. He had battled cancelled trains and freezing cold to keep his appointment. This person did not make up symptoms, nor to complain lightly. 

This is a typical surgical scar from carpal tunnel syndrome.



I wish I had taken a picture of Mr X's hand because it showed a "tethered scar" and the muscles in his palm had wasted, the scar was pulling badly and was tender. (this is the link for the picture)

In many cases massage helps the scar heal. In Mr Xa's case, the scar looked so badly tethered that I believe Mr Xa needed a specialist hand surgeon's opinion with a view to revising the scar and releasing the tethering. His symptoms were getting worse not better.


A good medical history would have told the surgeon, who does "operations for money" privately, that this was not just Carpal Tunnel Syndrome, but part of a Work related Upper Limb disorder. It did not need surgery, or at best, only as a last resort. Mr Xa needed a Work Place Assessment, physiotherapy - anything but quick surgery.


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Friday, 1 January 2010

Keeping a Health Record and the link to Galen


"The job's not done until the paperwork is finished"

You are the person who cares most whether your medical record is correct and relevant. Traditional medical records are usually inaccurate. Some mistakes are life threatening, when your allergies are not mentioned. Other are annoying, and some are damaging, for example, biased psychiatric and social work reports.

Google has come up with a solution Google Health Records. Its a bit like Google Earth and Google Libraries. Visionary, inclusive and extremely annoying for people who don't like Google. Nowadays, most human activity seem to have been "Googled". 

The benefit of a Google health record is that unlike Health Care companies, doctors, insurance companies etc,  Google does not make money out of sick people. The Internet has changed medicine for the better and the Google search engine has fuelled that change.

It is a free service, because people are not used to paying someone to store their medical information for them. Nonetheless, Google promises not to target you with advertising based on your health information, time will tell. Other health orientated sites offer a similar service, but most target you with advertising and ask for a subscription.

Find out more here 

Who is organising Google Health Records
Google Health Advisory Board





Dean Ornish, M.D. heads up the Google Health Board 
Advisory Council Chairman

Founder and President, Preventive Medicine Research Institute, Clinical Professor of Medicine, University of California, San Francisco

Click here to find the other council members


Those Not on the Board are wailing loudly. This criticism is bizarre

"Sorry, but I think Google dropped the ball on this one. The council should’ve been twice as large and ensured it was made up of nearly as many patient advocacy groups..." 

This comes from Psychcentral.com

Doubling the size of a council, committee, or board halves its effectiveness. It only takes a few committed people to change the world. More than a few, and your project will quickly grind to a halt. Less is More. Others complaints include no medical librarians, or prominent members of Medical Associations on the Board. The reason is obvious, look at the mess we are in at the moment.  

Dean Ornish believes in health and prevention. He is an excellent choice for Chairman of the Google Health Board, he writes well and has the right message Click here for a selection of his books

And if you want one: This is a best buy:
                                                                            



or go to www.Amazon.com and learn more about Dean Ornish

And the link to Galen
 
Galen (AD 129 to 217, approx father of modern medicine) major contribution was his ability to systematically organise medical information. This allows doctors (and anyone else who want to) make a diagnosis and organise treatment.


Galen is the greatest doctor of all time. He lived and worked in Rome in the third century from AD 199 to  217 approx. His major contribution was in the organisation of medical information. He taught doctors of his day and millions since to take a medical history and to organise medical information in a way helps doctors think about it logically and make a proper diagnosis and systematically organise treatment.

Dean Ornish is as deserving as any doctor this generation to take on Galen's mantle

Click here for more information, or Google Galen



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Monday, 28 December 2009

A good and healthy death

Teaching involves using the material that comes to hand. I will write more knee injuries shortly

My father died on Christmas Eve, on his 92nd Birthday. Yes I am sad, but it is a good and healthy sadness. My brother and I will grieve, but no more than we need to for a man who led a good and healthy life. I could have done more, my brother could have done more. But that is always true. I did what I could and he did what he could, it was better than nothing but of course it could have been better.

Nonetheless, he had a good death. He was 92. Four days earlier he was admitted to hospital after a fall. The Nursing Sister would have sent him home but that it was Christmas and it would have been difficult to get his Carers organised just before Christmas. So she kept him in. Otherwise he would have have been straight back out the door. Nothing to be alarmed about, old man has a fall, otherwise not too bad, get him home as soon as possible.

Day 3 he is not so well. Day 4 he deteriorates and dies quite suddenly, no fuss, just goes quietly. Two weeks before he was shopping on his scooter. He had Carers in three times a day to help him with his meals, get him up and help him to bed, but otherwise looked after himself. It was becoming a struggle, nonetheless from the Sainsbury drivers who delivered his weekly food (when I remembered to order it) and the people in the flats where he lived, he just about managed. Then all his systems failed at once and he died. I spoke to the doctor about what they should put on the death certificate, he suggested "Pulmonary Embolism". In truth he he had had enough, he was just tired but that is not a modern diagnosis.

He was healthy until he died, when his systems failed at once. That I believe is how nature intended. Death when it comes should be quick and painless. Why intend it any other way?

Yet modern diseases, caused by overindulgence, toxins and a failure to maintain our minds and bodies cause one system to fail before another - the kidneys before the lungs before the heart lead to people being prescribed a string of medication to keep sticking bits back on until the motor finally gives out. 

 My mother also died quite suddenly, aged 77. A hemorrhage and within 48 hours she had died. No hanging around, no wasting a moment of her life.

They had healthy deaths. If not necessarily at the time of their choosing, but in a manner of their choosing. No prolonged suffering. Well and mentally sharp, until they go suddenly. My grandparents were the same. Well, up and around, doing what they wanted, until they weren't.

Yet nowhere in the many books on "Palliative Care" will you find a description of a Healthy Death. Medicine has stolen death and in its place we have "Care Pathways" and "End of Life Decisions". A healthy death is as nature intended, sudden, painless and with no time for Goodbyes.

And the moral - It is what you do now that matters, how you treat your friends and relatives in the moment,  not how you behave around a deathbed, that makes life worth living. Overall, I hope, we didn't do too badly by the old man.




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Saturday, 19 December 2009

Knee injury - Torn Cartilage 1

Knee injuries are common and easy to diagnose. There are a limited number of problems with a knee, these are relatively easy to diagnose and satisfying to treat

This site is helpful Click here - the site sells knee surgery, if their surgeons are as good as their website, you are in safe hands! worth travelling to Yorkshire.  There is a lot of useful information about knee inuries and knee anatomy

Normal Knee function 
 

The knee does two things - it flexes and straightens and it also rotates, to allow you to twist and turn as you walk and run. It is this rotation that seems to cause the problems, probably because we encase our feet in concrete and walk on flat surfaces most of the time, we rarely turn at the knee, and when we do, it causes problems. Everyone knows they can bend and straighten their knee, but not everyone appreciates that knees can also "rotate". When the rotation goes wrong, you end up with a "twisting injury" of the knee and when extension and flexion go wrong, you have a hyperextension injury or dislocation.


When your knee is straight, it locks in place and cannot rotate but as soon as you start to bend your knee, you can start to turn it. Sit down and bend you knee slightly, move your foot inwards, and outwards - most peoples' knees allow the foot to twist inwards and outwards about 60 degrees (the same amount as a decent sized slice or segment of cake). The knee does not just bend and straighten, it also allows the foot to turn in and out. This movement allows you to walk on rough ground where the surface is uneven and every step is different.



The first step in making a diagnosis is understanding the problem, and if you want to be a doctor, you have to understand the human mind and body. We all have one readily available patient and that is ourselves, learning from ourselves means it sticks in your mind and  you always have a reference point.



Knee injuries

1 - Making a diagnosis.

The Medical History 


The diagnosis is almost always in the history. By understanding what happened and how the patietn felt you  can work out what happened. And once you know what happened, you can work out what has gone wrong, and that is your diagnosis. Knowi what has gone wrong and you can put it right


Occasionally, you cannot find out what has happened, that is, you may  not have a medical history, for example, the patient may have had other major injuries at the same time and just not know what happened to their knee, but this is rare.

It is useful to know whether the injury is a twisting injury, whether the knee hyperextended, or was hit directly.

Today's case is of a man in his late thirties, early forties, not particularly fit, who lost his footing on a path and fell heavily. He landed heavily on his shoulder and hip and twisted his knee. I saw him three months after his original injury. His shoulder was better and his hip was better but his knee had not improved.


And if you are a patient stick to the point - we don't need smart ass patients! The answer to the question "What seems to be the problem?" is not "Well you are the doctor, you tell me" On the other hand saying "It is my cartilage" is equally unhelpful. As a doctor, you want to hear facts and then put the relevant facts together to make a medical history which leads you to the diagnosis.

My patient was helpful, he told me that he had twisted his knee as he fell and that his knee had immediately swollen up a bit, not massively. It was immediately painful and from the time of his accident he could not put weight on that leg without excruciating pain. He saw his GP the next day because he couldn't walk and he didn't want to make a fuss.

The skill in taking a medical history is in being able to tease out what details are medically relevant and which details are just padding.

Accident Prevention

Many people nowadays are extremely unfit, with little sense of balance and even when they do exercise it is in a gym and  not outside in the real world


1 - Keep fit and practice good balance - that means moving around a little more, preferably without keeping your feet in blocks of concrete, otherwise called "Trainers". The weight alone should put you off!
2 - Be more mindful - if you are walking on rough ground - be aware of it!
3 - Make sure you walk straight and your posture is good - this keeps your joints aligned and means when you do fall, you fall "naturally" rather than in a heap and your joints bend where they should and not where you land. When footballer Mike Owen's injured his knee you could see it flapping about before he landed on it and destroyed it. He already had a knee problem and falling on his knee, finished it off.

Injury after minor falls are far too common - I worked with the Fire Service, and because many firefighters are not as fit as they should be, after every major incident there were always injuries. If Hannibal's men had been as unfit as that lot, Hannibal would never have left Carthage, never mind crossed the Alps with a platoon of elephants in the middle of winter and wiped out three Roman armies!


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Saturday, 12 December 2009

Diagnosis and The Medical History

The medical history is the most important part of any medical consultation. Taking a good medical history is key to being a good doctor, and the key to a good medical history is listening to the patient.

The medical history lets your patient explain to you what has happened to them and help you understand their problem. Medical diagnosis is the process of working out what has caused the problem.

Doctors ask a series of questions in order to get the information they need to help make a diagnosis. Sometimes the diagnosis, or cause of the problem is obvious, sometimes it can be hard to find.

Medical information is set out in the following way so as to make sense of large amount of information, some of which is relevant and some of which is not.


The Presenting Complaint

This describes the problem. At this stage open questions are best to allow the patient to use their own words to describe what has happened to them.

History of the Illness
This describes the background to the problem

Other illnesses
What else has the person suffered from?

Treatment history
What treatment has the person had, both for the Presenting complaint and for Other illnesses. All too often treatment can be as damaging as the original condition


Family History
What traits, tendencies and conditions run in the family? What do relatives suffer from?

Social and Occupational History
What work does the patient do or not do? what jobs have they had in the past that may have had a significant impact on their health and wellbeing? What kind of company does the person keep? do they live relatively separate life or are they always surrounded by friends?

and finally a
Systems Inquiry

This is a detailed inquiry into each system of the body, for example, the cardiovascular system, the respiratory system - that is how well do their heart and lungs function?, the genito urinary system, for women a gynaecological history, for men, the male equivalent asking how well their urinary system works and whether their sexual function is satisfactory, mental health and psychiatric symptoms, and gastrointestinal symptoms

These questions are more intimate and need to be handled much more sensitively than general questions. It is important before asking intimate questions that the patient and doctor trust each other. Although many people can quickly build an illusion of trust, if someone is going to trust you with the honest and intimate details of their bodily functions, they know they can trust you or whoever is asking the questions. Most people still feel that doctors can be trusted, although when people rarely see the same doctor twice, such trust is reasonably being eroded.

Future posts will look at each of these questions so as to explain exactly what information is medically required at each point in the process of making a diagnosis. As a medical student, "taking a history" was a ritual, I hated doing it, and couldn't understand why we were doing it. Now it is the most interesting part of the consultation and I understand what I am looking for and why I am doing it.

Recording a medical history

The questions above give a lot of information, which takes effort, experience and discipline to record accurately and in a way that is useful. At all times it helps for the doctor to make clear what they are thinking about and why they have made their decisions and taken action. We were taught as medical students "No notes, no Defence!"

More often patients are given a handout and asked to tick boxes instead of talking to a doctor.

There are good and bad points to a "tick the box" approach

Good points
-

"Tick the box" medical histories allow doctors etc to focus on important problems immediately

Useful to screen large numbers of people and record data on a computer.

The recorded data can be manipulated to produce research papers which enable the government and other official bodies to show how much the health of the population is improving year on year

Bad points
Patients tick the wrong box - I have yet to meet anyone who answers "Yes" to the question "Are your bowels normal?", largely because people do not know what is normal bowel function.

"Tick the box" only allow Yes and No answers. It is useful for specific questions, such as "does it hurt everytime you pass urine?" but even this does not allow for the answer "sometimes"

"Tick the box" questions are almost completely useless for broader questions, such as "Are you satisfied with your consultation, town council, or the way the government communicates with you".

"Tick the box" questions do not allow a person to give background to their problem. On the other hand there are only so many hours in the day, and the amount of information that any specific doctor or expert can manage is limited.

Finally, it is easier for people to make a mistake completing a form, compared to answering questions directly. Not because the person is lying but because they may not have understood the form correctly, or because they may be embarrassed or think something is not relevant.

The role of experience

An experienced doctor can take a history quickly because their experience tells them what is important. With time, doctors develop a range of styles and it is important both for doctors to find what type of patients they can help the most. Equally, patients need to find a doctor whom they can trust and whose style suits them.

Traditional diagnosis follows the path

1 - Medical History
2 - Examination, both of the problem area and of the person generally
3 - Differential diagnosis - or list of possible diagnosis
4 - Tests and Investigations - both general and specific tests
and finally
5 - The Diagnosis, that is what has caused the problem
6 - Management plan, this includes specific treatment and general plan of how best to manage this person's medical problems

Nowadays tests and investigations are often more reliable and cheaper than doctors. It is often quicker and more efficient to go straight to the tests and come back and ask further questions depending on the results of the tests.

Even so, the pathway

History -> Examination -> Differential Diagnoses -> Tests and Investigations -> Diagnosis

remains firmly embedded in medical culture. This pathway was started by Galen, over 1,500 years ago and it remains a useful way to organise medical information.

However it cannot be easily computerised! because at each step there are mental processes going on which cannot easily be recorded on a computer. I find written notes more useful than notes on a computer - because I see a page of medical notes as a "picture" which tells me about the doctors' state of mind, their reaction to the patient, as well as the patients responses.

If you are familiar with a doctor's style, it is possible to understand what they meant, where their concerns were and how best to deal with a particular patient. This is harder if not impossible with computerised records. Personally I prefer hand written notes, scanned into a computer at the end of the consultation.

This has been a long post, well done if you have reached the end! no one said studying medicine was easy, but I hope it can also be fun



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Gynaecology - Debunking Pelvic Pain






What causes pelvic pain? Nerves? without nerves, the body is numb. Pain is felt when nerves send messages to the brain. If the nerve supply is interupted or blocked, pain is blocked. Pain indicates damage. This may be damage to the nerves, muscles, ligaments, joints and organs the nerves supply. If the damage does not heal, the pain becomes chronic.

Chronic pelvic pain is relatively rare in women who have not had children or without some other cause of pelvic damage such as chronic constipation, spinal injury, back problems, or an eating disorder.

Yet when Obstetricians and Gynaecologists talk about pelvic pain, few consider the underlying damage that might be contributing to the pain, damage to the nerves, muscles and ligaments in the pelvis! Very few Gynaecologists have even seen the pelvic nerves, let alone understand their function and how easily they are damaged. This mesh of delicate nerves is lies against the side bones of the pelvis and most gynaecologists know very little about the nerves and anatomy of the pelvis

This is one of the largest networks of nerves outside the brain. It keeps the pelvis, reproduction functions, bladder, colon, rectum and lower limbs functioning properly, as doctors we interfere with it at our patients' peril. If this network is damaged, the person experiences pain in the pelvis, infertility, as well as bloating, nausea diarrhoea and any number of symptoms associated with the last part of the gut and rectum. Like all parts of the Autonomic Nervous System it also plays its part in managing blood pressure.

Click here and Click here to learn more about Pelvic anatomy

Even yesterday, a woman told me how her GP (a woman) had told her that nothing could be done about her chronic pelvic pain and that it was probably caused by stress at work.

What gynaecologists think causes Pelvic pain

Despite the existence of the massive collection of nerves within the pelvis, (called the hypogastric plexus) the idea that pelvic pain is psychological is deeply rooted within gynaecology. One paper, written in 1981 is still regularly quoted as evidence that most women with pelvic pain do not have any "organic pathology" or "real cause" for their pain. For all I know, the author has died but his work lives on!

This study is more opinion than evidence, yet is widely referred to when gynaecologists discuss pelvic pain and because of this it is worth looking at in more detail.

The author wrote of three hundred and thirty patients with longstanding pelvic pain "Sixty-five percent of them did not appear to have any underlying organic pathology" In other words, the opinion of this powerful and influential gynaecologist is that two out of three women with chronic pelvic pain do not have a physical cause for their pain!

This is ridiculous - do women make up symptoms? are they "hysterical"? or is it possible that gynaecologists do not know what to look for? or the questions to ask in order to find out what is wrong with women with pelvic pain?

Even before he did a laparoscopy (an operation to look inside the abdomen with a camera), PN Gillibrand already felt that three quarters of these women did not have a "real" cause for their pain. He felt his opinion was justified because in 80% of these women, he did not find anything wrong.

Even when he did find something wrong, he did not think it was necessarily the cause of the woman's pain. Only those 15% of women with endometriosis did he feel had a genuine cause for their pain.

The author believed that women with pelvic pain were psychologically different from women who did not have pain. These women were neurotic, emotionally unstable, with psychosexual problems and relationship difficulties.

Whatever gynaecologists think, it is no longer credible to say that three quarters of women with pelvic pain do so because they are psychologically disturbed. We know enough about psychology to know that chronic pain causes psychological damage, that chronic pain causes depression, anxiety, poor sleep and exacerbates stress. Why would a woman make it up?

Another way of interpreting this paper is to ask what does he know about pelvic anatomy? does he know what what he needed to look for when he did all those laparoscopies, which according to his view were in any case unnecessary? Did he understand the role of nerves, ligaments and muscles within a normal pelvis? When he wrote that paper, did he understand the impact of a difficult labour on the function of the pelvis? Did he even have ethical committee approval for his studies?

To an outsider, it seems impossible that dragging a baby through a muscular canal which is ill prepared for its marathon onslaught does not damage the muscles, ligaments and nerves of the pelvis. Labour is a physical event that naturally takes place in the squatting position. The squatting position widens the pelvis and allows gravity to help the delivery of the baby.

Interfering with the normal process of labour must cause damage! Such interference is likely to have long term consequences, which are likely to include pain, incontinence and prolapse. To people who are not gynaecologists this seems like common sense. By improving the management of childbirth, fewer women will have difficult labours and there will be fewer long term gynaecological complications.

As a student, one anatomist told us, "The function of the tonsils is to provide creamy coloured Rolls Royces for ENT surgeons", meaning of course that ENT surgeons operated privately on small children with rich parents in order to fund their large cars. It might equally be said, that "The purpose of a difficult labour is to provide a lucrative private practice for ageing senior gynaecologists". Without the long term consequences of difficult labours, gynaecologists would be significantly poorer, their private practice significantly smaller and women enjoying a better quality of life!

Looking to the future, once the lessons of history have been clearly learnt, how can women protect themselves during labour?

The simple common sense lessons are the best


1 Eat a healthy diet to physically prepare for labour

2 Keep fit to be ready for the marathon of labour

3 Learn all about the process of giving birth and be mentally prepared

4 Don't induce labour - close monitoring towards the end of pregnancy is a safer alternative

5 Avoid oxytocin and epidurals because they numb the body and encourage excessive pushing (in Bulgaria women are not allowed to push!)

6 Whilst labouring, walk around and Squat!





Anecdotes of childbirth


Hot towels, as used in every good Western when a woman is about to give birth, help the perineum stretch


Royalty was required to give birth publicly so that everyone could be certain that, in the days of long and full skirts, the royal baby had come out of the royal womb. Only by giving birth on her back with her legs splayed could everyone be satisfied that the baby was definitely Royal. And because every woman wants to be treated like a Queen, this practice gradually spread throughout Europe, aided and abetted by Royal Obstetricians and Gynaecologists!


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Teach Yourself Medicine, the Autonomic Nervous System


Teach Yourself Medicine (TYM) is the medicine of the Autonomic Nervous System
Click here for further information about the effect of damage or "denervation" to the autonomic nervous system and how this causes Western diseases.

The Autonomic Nervous (ANS) is like the computer system that runs the body. The ANS is brain of the human body. Difficulties with the Autonomic Nervous System cause 90% of western diseases.

Symptoms of autonomic nervous system malfunction, such as dizziness, fatigue, headache, muscle aches and pain are at best called "medically unexplained symptoms". Only traditional Western Medicine ignores these vital early clues to disease "unexplained" .

Chinese Medicine, Aruveydic medicine, Galenic medicine and every major system of medicine acknowledges symptoms coming from the Autonomic Nervous,

Only Western Medicine waits until the human body is damaged so badly that it is all but irreversible. Western medicine waits until the organs at the ends of the nerves, until the computer system running the body malfunctions so badly that a person is effectively disabled.

Until that point is reached, until there is sufficient damage to show up on medical tests, doctors are taught to dismiss symptoms as "psychological".

Symptoms coming from the Autonomic Nervous System include

Pain.

Pain is the most important warning the ANS gives. In many ways it is a final warning before permanent damage begins. Too often, people take aspirin, paracetamol, ibuprofen, voltarol, codeine, tramadol and continue to do exactly what they did that caused the pain.

Muscle fatigue

Fatigue means tiredness, something is tiring the body out and making it fail. Yet we have been taught to take a stimulant such as coffee, alcohol, tea, antidepressants, and painkillers to mask the symptoms of tiredness that mean we need to rest

Dizziness

Dizziness comes either from the body failing to manage blood pressure as person moves around or from a problem in the ear. A person's ability to move freely, animals ability to move from one environment to another depend on their ability to keep their blood pressure steady. Dizziness suggests that the ANS is no longer coping

Palpitations

Palpitations indicate the heart is beating incorrectly, even Tony Blair had palpitations at the height of the Iraq crisis, because of the pressure he experienced from having lied to the nation.

Stomach pains, bloating, diarrhoea

Although this collection of symptoms is frequently called Irritable Bowel Syndrome, it represents a failure of the Autonomic Nervous System to manage the stomach and bowels in the face of severe psychological pressure, a processed unnatural diet and interfering with the natural process of digestion and bowel movements

In every area of medicine, the role of the autonomic nervous system has been neglected. This means that western medicine does not intervene until a person has a serious medical condition. It means that people reporting symptoms that show mild problems are ignored until their symptoms are severe and disabling.

The most obvious and dangerous areas where Modern Medicine neglects its patients in the worst ways are

Obstetrics and Gynaecology, where damage in labour leads to gynaecological problems that last the rest of a woman's reproductive life.

Psychiatry, where failure to understand people leads to the widespread use and abuse of drugs that directly damage the Autonomic Nervous System

and finally

Occupational Health which fails to recognise the intimate relationship between work, health and disease and repeatedly consigns people to unemployment or intolerable working conditions which directly damage peoples' health.

Gastroenterology
Here as with the specialties mentioned above, there are only crude investigations. Those "abnormalities" that are seen are misinterpreted. The last conference I attended on gastroenterology failed to mention diet or bowel movements. It is like investigating the water and sewer system of London without understanding what is meant to go through the pipes. Needless to say that kind of approach leads to a lot of unfortunate errors!

Teach Yourself Medicine unpicks medicine as it is now and offers a medical education to everyone who is interested in finding out a little more about how their body works!



Copyright (c) Dr. Liz Miller
http://www.lizmiller.info/



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Sunday, 6 December 2009

Moles : Bringing out the medical student in everyone

British Medical Students are known for their sense of humour, it is therefore important to include humour in the study of medicine



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Sunday, 22 November 2009

Pulmonary Emboli, clot on the lung - learning points


This picture shows a pulmonary embolism or clot blocking off an artery in the lungs. It causes a sudden shock or collapse, where the patient has sudden severe pain in the chest, rapid breathing and a rapid pulse. He or she feels extremely anxious, sweaty and as though they might die.

You need to call a doctor or ambulance urgently


Pulmonary embolus (embolism or embolis) is a clot

The case outlined in the previous post has a number of learning points

This is a fit individual, apart from his chronic chest complaint. He has been in hospital once only, there is no history of diabetes or other illness, and he is not thin, indeed the notes say he had put on three stone in weight prior to his admission.

BJ "collapses" several times. Both in the October before his operation and after his operation. After a couple of days, he is back on his feet as though nothing had happened.

There are not many causes for this type of collapse. We are looking for something that comes on suddenly and gets better quickly. Sudden disturbances are always due to either a problem with
1 - the nervous system - the brain or spinal cord, such as epilepsy

or
2 - the heart and circulation, such as an abnormal rythm or a clot on the lung which blocks off a large part of the blood vessels to the lungs, which is another name for pulmonary emboli. Over time this damages the lungs, you get high blood pressure in the lungs, and the lungs do not work so well.

Clots in the lungs comes usually from a DVT. BR had had DVTs in the past. He did not move around a lot, and during surgery he would have been at extra risk. He was given white stockings to reduce the risk but this does not prevent a DVT especially in someone at high risk

One notable feature of a pulmonary embolus (the different endings are latin ;-)
is the anxiety and feelings of panic that come with the damage to the lungs. The person feels like they are going to die.

Pulmonary emboli are hard to diagnose, unless you keep your eyes open

There is no direct test - although changes in the concentration of oxygen and carbon dioxide in the blood indicate there is likely to have been a clot.

Chest Xrays usually look normal as do ECGs, although the pulse rate is usually fast.

Ventilation perfusion scans need to be done almost immediately - these show the blood flow in the lungs. These scans show large pulmonary emboli but miss small ones


The single most important point in diagnosing a pulmonary emboli is the history - short, often repeated collapses from which the person recovers quickly over the next two days


Why was this not diagnosed in BR's case? Because different doctors saw him. No one works 108 hours on the trot, so they do not see the condition emerge and they do not see the pattern of pulmonary embolus over time. Each doctor comes into the hospital or clinic and only sees a snap shot of the patient in time. This is like trying to understand a film like Slum Dog Millionaire from a series of photographs. You need to watch the film to know what is going on. You need to watch the patient over time to understand what is happening

If you have any questions, please email me at liz@lizmiller.co.uk, I am happy to take questions








Copyright (c) Dr. Liz Miller
www.lizmiller.info


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Saturday, 21 November 2009

Why we all need to know a little medicine

The following story might be told a hundred times across the country, in different ways about different people.

It is a story of ordinary people with common medical conditions. In people without the knowledge or resources to get a second opinion.

Once I might have said, this means the NHS is bad and we must all get private medical care. However this story might as easily have happened in a private hospital, because you see the same doctors and are treated by the same nurses.

Knowledge is the only defence against charlatans and ignorance. This blog teaches you medicine.


Medical Summary of BR dob 13.07.44 of Huntleypool, Cumberland


Preoperative history
BR was admitted for a biopsy of the lump approximately 2” diameter, in the left side of his neck. An earlier needle biopsy had failed to show tumour tissue.

BR was unable to walk beyond the confines of his house but his quality of life was good, he was able to climb stairs and his partner looked after him at home. BR was a long term smoker, had a single admission to hospital following a collapse twelve months previously. He had recently gained weight

Prior to the biopsy BR was identified as a high risk case. He was at risk of heart disease but his chest pains were not thought to be typical of cardiac disease, and further investigations was said to be impossible because he was not fit to do the necessary tests.

Past medical history
He had been diagnosed as asthmatic following a single admision with a collapse thought to be a chest infection, but there was no record of any further investigations. Other diagnoses included chronic lung disease, osteoarthritis, DVR, angina treated with GTN spray, but not investigated further

Medications:
Bendrofluazide 5mg day, fenbrufen, aspirin, verapamil, GTN, isosorbide

BR's first hospital admission was a year prior to his admission for a biopsy of a mass in the neck. He had had severe chest pains, become short of breath and had been treated with antibiotics for a chest infection.


On the day of his admission BR was operated on and the mass in his neck biopsied from inside the throat as well as externally. It was difficult to put down an ET tube because the tumour mass was partially blocking his throat. After the operation, his breathing was obstructed, it was impossible to put down another ET tube and an emergency tracheostomy was done.

BR was on a ventilator overnight but recovered sufficiently the following day to be well enough to go back to the ward. A sedative was started because of his anxiety.

Six days later as BR was preparing to be discharged home, he collapsed with shortness of breath, a rapid heart beat, anxiety and chest pain. This was thought to be a chest infection, he was treated with antibiotics and seen by a MacMillan (cancer) nurse.

A CT Scan of his head, neck and mediastinum was arranged.

A week after surgery, the CT scan of the neck showed a large tumour, the CT scan of the chest, some curious "nodules" but no large primary tumour.

An cancer specialist saw BR and wanted further analysis of the tumour specimens before starting chemotherapy. The tumour appears not to have spread and is limited to the neck and is thought to have arisen from the tonsil.

2 days later, BR has a further episode where he becomes short of breath, with a rapid heart rate, chest pain - a number of different diagnoses are considered, including C Difficile, a bowel infection, a further chest infection or possibly tumour spread.

The Liverpool Palliative care pathway is started. High doses of sedatives and pain killers are begun, including tramadol, Midazolam, MST, and morphine. Doctors and nurses are concerned only to keep BR comfortable.

2 days BR has another episode of shortness of breath, rapid heart rate and chest pains. Again no diagnosis is made, BR's chest problem has not been diagnosed, nonetheless his sedation and painkillers are steadily increased. Plans are made for BR to go to a hospice. However two days later he has a further episode of shortness of breath, rapid heart rate and chest pains. His doses of sedative and painkillers are increased further. Medazolam is given by a syringe pump. Later the same day, BR dies

A death certificate is issued, which say BR died from secondary spread of cancer from a lung malignant tumour

Looking back

Was it necessary to biopsy BR's tumour under a general anaesthetic?
What other investigations might have been done first both to investigate the tumour and to assess BR's health?
What was the cause of BR's lung disease? Could it have been pulmonary emboli, or clots on the lung given his rapid deteriorations and almost equal rapid recoveries?
What caused the collapses following his operation? Was it further clots on the lung?
What happened to allow a 63 year man to walk into hospital and within three weeks he was dead, following the introduction of the Liverpool Palliative care pathway?

The management and medical staff at the hospital involved in BR's care lied to his partner, and at no stage has anyone sought to understand or answer the questions posed above.

This is why everyone in the country, both here and abroad needs to know enough medicine to keep themselves safe. It is not enough to know a doctor, you need to know what they are doing.


Copyright (c) Dr. Liz Miller
www.lizmiller.info


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Sunday, 8 November 2009

How does Galen relate to Modern or Technological Medicine?


Where is Galen in modern medicine ?

Modern medicine exists in a technological desert devoid of meaning. It lies separate from traditional medicine, its history, from Galen and from every other major system of medicine.

Modern medicine is almost entirely dependent upon technology and on pharmaceuticals, without which it cannot make a diagnosis or organise a treatment. Modern medicine is progressively stripping out all elements of traditional practice.

It is impossible to separate a civilisation from its technology, from its lifestyle and from its medicine. As lives becomes more dependent upon technology, so does the medicine that accompanies them.

Without doubt, medicine or technological medicine can save you from some dreadful conditions. From bodies destroyed by bombs, by bullets and smashed to pieces by cars. It can also save people from severe heart disease, cancers, and organ failure. Yet all of these conditions are the products of a technological civilisation. Before the twentieth century most of these conditions were unheard of, without a car, there are no car crashes, without bombs there are no victims of bomb blasts. Without idleness, ignorance, saturated fats and environmental pollutants, there is no heart disease or cancer.

For the most part, Technological Medicine does not provide protection. Instead it offers screening as a form of early diagnosis, made before the body has a chance to heal itself.

The only form of prevention on offer is vaccination. Vaccination depends upon injecting DNA and other foreign materials directly into the body, breeching the bodies natural defences with the intention of stimulating the body's immune system. Ever since the swine flu fiasco, every drug company in the business is jumping on the vaccination bandwagon. Even though the evidence for the benefits of vaccination are, at best slim.

Teach Yourself Medicine is based on Western Traditional Medicine, rather than Technological medicine. Its philosophy is one of making links between the different schools of medicine, just as Galen steered a path between the Empiricists and the Methodists to develop a school of medicine based on first principles.

The same dilemmas faced by Galen, are still in place today.

The modern empiricist is the "Evidence Based school of thought". Evidence Based Medicine is a type of medicine based on the results of treatment regardless of the underlying logic or medical theory

The modern "Methodists" are represented by the doctors, nurses and health advisers who advocate guidelines and protocols. As long as a doctor follows the rules and protocols prescribed by the establishment his or her practice will not be impuned.

There does not seem to be an equivalent of Technological Medicine but that Technological Medicine is based on technological "measurement" and Division and Categorisation rather than a more holistic approach based on first principles and the process of making a diagnosis

"Teach Yourself Medicine" seeks to reconnect medicine with its past, including Galenic medicine, and more recently traditional medicine and to show from first principles the links between Western Medical Systems and other major medical systems including

Evidence based medicine
Guidelines and protocols
Technological medicine
Evolution and evolutionary approachs to disease
Galenic medicine
Aruvedic medicine
Chinese and eastern systems of medicine
Complimentary and Alternative therapies

The foundation of Teach Yourself Medicine is traditional Western Medicine. It is based on medical principles and the process of making a diagnosis through observation and hypothetico-deductive analysis.

In other words, look carefully, discover what has happened, work out what is going on and find a solution.


Finally
The split between Modern or Technological Medicine and other forms of medicine is in part because of the massive amounts of money invested in and spent by Technological medicine. Nothing and no one can compete with the vast fortunes available to Technological medicine. It is a battlefield where only the very rich can afford to play.

The rest of us must look after our minds and bodies in the way that nature intended, taking simple care and following simple rules and being clear about what we do and why.


Copyright (c) Dr. Liz Miller
www.lizmiller.info


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Saturday, 3 October 2009

Sanguine, Phlegmatic, Choleric, Melancholic - Galen's Medicine, moods not personalities

The history of medicine is important because we need to know where we are. Just as a patient's medical history is fundamental to understanding their present medical condition, in order to understand medicine we need to know about its past.

Modern Medicine begins in the nineteenth century with the Germ theory.

This represents a dramatic break with Galen's theories of medicine and the four humours, Phlegmatic, Sanguine, Melancholic, and Choleric. A system that had been practiced across Europe for centuries. Modern medicine is not in the holistic tradition.

Further details can be found by clicking here which links to Melvyn Bragg's programme "In our time"

Melvyn Bragg's programme gives a brief history of medicine from the time of Hippocrates to the nineteenth century germ theory. Germ theory, started when bugs were first seen under the microscope. Germs were the start of Modern science when scientist show blood and lymph circulating the body, not "humours".

Yet the success of mechanical model of medicine meant that the holistic approach of Hippocrates and Galen was abandoned and has been replaced by modern specialisation and the individual study of organs.

Teach yourself Medicine is about assimilating what we have learnt in the last three centuries and re establishing our links with the past. And with the links to the past, come links to Eastern medicine as well as Chinese Medicine.

Galen connects to us through mood. He called moods humours - Sanguine, Choleric, Melancholic and Phlegmatic. They are now interpreted as personality types. This makes the "History of Medicine" impossible to understand . How can a system of medicine exist that was based on changing peoples' personalities - it "does not compute"

If we are to make any sense of the past, the humours have to be seen as moods. Mood is how you feel. Physicians wanted to know how you felt and they made the diagnosis and interpreted it the context of your mood



For further information about Mood - go to

www.matrixpsychology.blogspot.com and
www.moodmapping.blogspot.com

The most useful post are
Matrix Psychology 1
Matrix Psychology 2


Too melancholic and your physician prescribed something lively; too lively and he prescribed something calming.


There are five keys to mood

1 - surroundings
2 - physical health
3 - relationships
4 - what you know and do
5 - who you are

These were what the physicians wanted to know about and the keys to your health still lie here in modern times

Galen's medicine was prescriptive and it was a health based approach. Teach yourself medicine seeks to bring that back to the forefront of medical science and use the modern technological approach as the "back end"

Galenic medicine was based on balance and it is that notion of balance that I want us to return to.

Copyright (c) Dr. Liz Miller
www.lizmiller.info

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Teach yourself Medicine Introduction

"Teach yourself medicine" will be taught in three sections with an Introduction

Introduction, including History of Medicine, Ethics, Logic and Reasoning and will set the scene for the more intense learning that is to follow

1 - Basic physiology, anatomy, biochemistry and pharmacology
2 - Symptoms and diagnosis - this most closely parallels the way that I learnt medicine
3 - Casebook medicine - this is individual patients with interesting stories that illustrate useful learning points

Copyright (c) Dr. Liz Miller
www.lizmiller.info

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Monday, 28 September 2009

What questions would you ask to teach yourself medicine

To say that "Medicine is a large subject" is perhaps my grandest understatement yet. How would you teach yourself medicine?

I am wondering how best to teach medicine to make it easy.

For example, to diagnose a stomach problem - you need to know where the stomach is, what it is, what it does, how it works normally and what can go wrong. The stomach is also one of the most complex and least understood organs in the body.

More about the stomach! How does it control us? because there is an argument that says we are a large stomach


Above is a planaria which is largely a digestive tube. It has gram for gram more brain cells than a person. Below is a person, with their stomach showing.


The Gut Instinct takes that approach. Pierre Pallady describes some of the power of the stomach



Humans will eat anything and our ability to survive on Cola and MacDonalds is a credit to the resilience of our species. Given the complexity of the stomach and digestive processes, eating that stuff is like pouring battery acid on your computer.

From another point of view, an alien, observing planet earth and seeing vast quantities of human waste, would be forgiven for thinking Evolution's "success" was nothing more than a gigantic collective digestive process and that eventually an immense human mouth will appear which will eat the planet itself.

To return from that intergalactic flight of fantasy, I believe that anything I can do, you can do better. My friends have taken the "Lizzie Miller" approach to writing a book, if she can do it, anyone can and have started their own their own books. Watch out Liz Gough, they are queueing up for introductions.

To return to my original question - How best to present this vast and fascinating topic, so that it is easy to understand and provides every day help in making healthy decisions, without being patronising or talking down to people.

All ideas and contributions gratefully recieved. Should I teach medicine, the traditional way starting with anatomy, physiology and biochemistry, should I teach medicine the modern way, system by system, the lungs then the heart and so on? or perhaps take a symptoms based approach?

Instinctively, I prefer to teach medicine in a way that describes how the body works, and how illness departs from a health, rather than focusing on disease in isolation. I also like the autonomic nervous system, which controls the housekeeping of the body, and is like the electrical wiring system of a house, or modern car.

Perhaps I need to take lessons from Captain Kirk of the Star Ship Enterprise and begin on the Bridge - the physical equivalent of starting deep in the brain, in amongst the autonomic nervous system nuclei, somewhere around the limbic system - which is where the Mind meets the Body because that, in my book, is the key to understanding ourselves!




Copyright (c) Dr. Liz Miller
www.lizmiller.info


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Tuesday, 3 February 2009

Occupational Health - Second opinions or Glimpses of the Obvious

Last week I saw three patients in rapid succession whose NHS doctors had made the wrong diagnosis, missed the diagnosis and ignored the diagnosis.

Occupational Health is about getting the patient back to work, and if that involves sending the patient back to their NHS doctors, I do what it takes.



Person 1 injured his hip four months ago and has been off work for four months.
He complained to me of hip pain, he complained to his physiotherapist of hip pain, he complained to his General Practitioner of hip pain, he complained to his Orthopaedic consultant of hip pain. As far as I could tell, I was the first person to examine his hip since his initial visit to Accident and Emergency, where he was Xrayed

He gave a story of a "dislocated hip". This is unlikely - First, dislocating a hip takes a massive amount of force (FTR - hip replacements dislocate easily). Second, it takes a full general anaesthetic and a lot of effort to put them back.

However! - he did this during a Rugby game - and the "other buggers were big" - and he was immediately treated by an experienced physiotherapist who manipulated his hip and it then felt a lot better. But he still couldn't walk. He has not walked properly since.

His back did not show much wrong when I examined it, but when I examined his hip by feeling in his groin, which is where the hip joint can be felt - he hit the roof with pain. And this guy is a tough cookie. I have sent him back to his GP with a letter, and not back to work.

Person 2 has had funny turns for the last four years. He has extensive investigations for heart disease even to the point of having a stent put in. However his "funny turns" persist and to his mind he is worse than he was when he first went to see his doctor.

He is short of breath, he can't comfortably lie flat, he has episodes largely at night of feeling strange, even as though he has been stabbed in the chest and is about to die. The last doctor he saw almost got the diagnosis. But they sent him for a scan, and four days later the scan was normal. He also goes on long coach trips.

This is a classic story of recurrent pulmonary emboli - and the cardiologist put in a stent because he is fat geezer with slightly narrowed arteries to his heart.
I put him off work and wrote a note to his doctor, asking him to arrange for him to be investigated for pulmonary emboli and raised blood pressure in his lungs.

Person 3 also had dizzy spells, but of a different type perhaps more related to long term night shifts. But a twenty four hour ECG has shown his pulse slowing to 33 beats per minute.

He was told by his consultant that this was normal for a fit person. He is over 50 and even Rebecca Adlington's pulse rate never gets that low. He needs a pacemaker.

The morale of these stories, is that the diagnosis comes from understanding the patient. All three had been seen by consultants in major teaching hospitals. A consultant appointment was once a gold standard.

The difference between consultants and an occupational health physician is not so much one of skill but of time. All three diagnoses were in the history. "Investigations" can be wrong, Person 2's scan was done too late and in any case would not show up small clots on the lung (pulmonary emboli). They look at the wrong part - Person 1's MRI scan looked at his back not his hip. "Investigations" can be right and be ignored, as was the case with Person 3.

I would like to think that even ten or twelve years ago, I would not have found so many diagnoses. Roughly one in ten of the people I see, have the wrong diagnosis. Nothing, even in this high tech world beats a good history and examination. People matter, and cannot not be fobbed off with a few high tech tests, when they need a proper medical opinion.

Once upon a time, I thought tests were better and more reliable than doctors. Whether a Masserati is a better car than a Ford depends on more than the technology under the bonnet. If a blind person is driving the Masserati, you are safer in the Ford driven by someone who first finds out where you want to go.


Copyright Dr Liz Miller, Well and Working Ltd

www.lizmiller.co.uk
www.moodmapping.com

Terms and Conditions

Consultation

I have "Rooms" rather than a clinic, where I see people more as two people might come together to discuss a medical condition that one of them has, rather than a traditional doctor patient consultation.

I believe we should both learn from each other. I help you understand what I know and you help me become more informed in my area of interest. This is not a traditional doctor patient relationship and I do not act as your doctor

Fees

The "fee" is the free sharing of knowledge and that we publish any pictures and useful information, anonymously, on the Internet. Your consent is assumed, although I may also ask you to sign a formal consent document, should there be a possibility of your case being of sufficient medical interest to be published in a medical journal.

You may if you choose make a donation to my company Well & Working, but that is not expected or necessary. See Interests

I may suggest some investigations which can be arranged privately. You are responsible for paying for these investigations and I will not suggest anything that I do not believe is necessary. I have no financial interest in recommending you to a particular place - only for economy and convenience.

I do not prescribe medication, although I may suggest that you visit your doctor and ask about the possibility of any prescription medications that may be helpful.

Interests

My interest is in exploring disease and in progressing such "medical" knowledge.

I hope one day to have a full laboratory to investigate the role of the autonomic nervous system in disease. The equipment that would support such an interest costs well into five figures. I am not rich, because I have always chosen to do the right thing, and what I believe to be in the best interests of the "patient" and maintain my interest in medicine rather than concentrate on earning money.

Contact

Please email me at Dr at Drlizmiller dot com

Many thanks

Hair loss, gum disease

Dear Dr. Liz Miller,

Thank you for your last replies.

Concerning the gum:
I have gingivitis around 2 mm. though all the ordinary dental care actions have been taken. However, gum hypertrophy has not been proposed neither by my physician nor dentist. This hypothesis I will pursue.

Since I also have reacted to the D-vitamin perhaps there is an interaction between the gum disease and a potential Hyperparathyroidism, or alternatively that one acts as a moderator for the other.

I do not have a picture of my gums, except for an X-ray picture.

I would like to visit your clinic/ hospital in London as soon as possible – clinic?

Concerning the hair loss:
My original hair density has been high, but after the strong adverse reaction to D-vitamin in March 2007 I lost quite much hair during a 2-3 day period some weeks later. The hair loss is distributed across the scalp, with small areas which seems to be attacked more severely that the rest of the scalp (e.g. at the side of the scalp and at front), though not in the way of alopecia areata.

I suspect that part of the hair loss partly to be due to the seborrhoeic eczema which has yielded much scaling at the scalp. The eczema was aggressively activated in Jan. 2002 after as a reaction to a hair coloring product, where 2-3 months followed with abnormal hair loss (not reversed). Receding lines was one of the outcomes.

Not infrequently hair falls of as glued to together in a pair at one the end of hair shaft (a white-yellow substance hold the two hairs together at the follicle-end).

Thank you for your time.

Best regards,
GK

Gum disease
Gum disease is an indicator of either poor general health or poor dental hygeine. Gum hypertrophy - where the gums overgrown, is more likely to be related to drugs such as phenytoin or hormone/endocrine conditions such as hypothyroidism, where there is excess Thyroid Stimulating Hormone; Giganticism, where there is excess Growth Hormone (think Jaws from the Bond movies); and Hyperparathyroidism, which also affects calcium and vitamin D metabolism

"Since I also have reacted to the D-vitamin perhaps there is an interaction between the gum disease and a potential Hyperparathyroidism, or alternatively that one acts as a moderator for the other."

At this stage, the best way to see what is happening would be for you to visit my rooms.

"I suspect that part of the hair loss partly to be due to the seborrhoeic eczema which has yielded much scaling at the scalp. The eczema was aggressively activated in Jan. 2002 after as a reaction to a hair coloring product, where 2-3 months followed with abnormal hair loss (not reversed). Receding lines was one of the outcomes. "

Have you tried an antifungal dandruff product on your hair? Fungal infections are a common cause of dandruff like conditions especially against a background of poor health and poor diet?

The loss of two hairs together is probably not significant but may indicate that two hairs are coming to the end of their life cycle at the same time.

Hair Loss
Regardless of the cause, and what you read about hair restorative products the results are not usually that good. However a healthy diet and healthy lifestyle do support good hair growth

Thursday, 29 January 2009

Gum Movement,

Dear Liz Miller,
The dosage of D-vitamin was 3000IU per day for 8 days. Originally it was prescribed for a 2-month period to alleviate seborrhoeic dermatitis at the scalp. However, after 8 days I experienced the adverse reactions of extreme tiredness and paleness. These two effects have seemingly been reversed.

Incremental gum movements meaning that the gum seems to have moved outwards several times noticed ex-post, but not the teeth or jaw. The teeth are aligned as before, and there has been no pain.

I have had allergic reaction to soya when in contact with the skin, and problems with proper digestion (high values of triglycerides, possibly too much yeast, sensitive to gluten). I do not take any medications. I also lost much hair in a 2-3 day period shortly after the D-vitamin intake, an effect not previously experienced.

The gum movements might have no causal connection to the D-vitamin intake, but a correlation might be present since it was the first time for both the reactions. I have no hypothesis concerning a potential “third” condition.

The D-vitamin measures have always been at the lower interval border of the normal distribution (as measured in Norway), while the calcium level slightly above the upper level.

Thank you.

Best regards,
GK

28 January 2009 18:19


Dr. Liz Miller said...
Hi GK,

Thanks for this extra information
That your calcium levels are slightly high and vitamin D low, suggests that you may indeed by hypersensitive to Vitamin D because of an underlying Hyperparathyroidism. Parathyroid hormone increases the level of calcium in the blood.

It acts in conjunction with Vitamin D to increase the level of calcium in the blood - this may account for your response to Vitamin D.

Although above daily requirements, the doses of Vitamin D you were given should not be dangerous - except in the presence of raised Parathyroid hormone.

The gum enlargement is interesting against this background. It can be caused by hormones, such as Thyroid stimulating hormone, and growth hormone and both of those hormones are similar in structure to parathyroid hormone, so there may be some overlap.

If you are ever in London and can bring a full copy of your notes, it might be useful to arrange some hormone blood tests, including Growth hormone, TSH and Parathyroid Hormone.

In the meantime this is turning into a medical whodunnit.
Parathyroid hormone levels would be certainly be interesting

Seborrheic dermatitis, is generally thought to be a fungal infection - and an antifungal shampoo such as Nizoral may be helpful.

Do you have a photo of your gums? -
I have to add that the commonest cause of gum hypertrophy is gum disease due to gingivitis but I assume this would have been noticed by your dentist/doctor

Hair loss - difficult one! very little evidence one way or the other - was this a patchy loss or generalised thinning??
29 January 2009 02:35