LISTENING TO PATIENTS VALUABLE IN MAKING A CORRECT DIAGNOSIS

Here, I describe an event that happened more than a decade back, when I was doing my residency in Neurology at CMC, Vellore.

A number of incidents during residency shape our method of practice in future. This communication is regarding an event that had a significant bearing on the way I deal with patients. The incident occurred in the first year of my residency in Neurology at a tertiary care centre. A 35-year-old lady consulted me for headache of six years' duration. It was described as a constant dull ache and had all the features suggestive of tension headache. A thorough clinical examination including blood pressure and optic fundi was normal. I reassured the patient and decided to start her on tricyclic antidepressants. The patient enquired how sure I was that she did not have a brain disease. With the enthusiasm and exuberance of youth, I told her I was pretty confident. I had almost forgotten this incident when she revisited me four months later. This time she had brought a computerized tomography scan of her brain that showed multiple cystic lesions. I could not believe my eyes. My confidence was shattered. However, the patient and her family were kind to me and emphasised that anyone could make a mistake. She was operated at our institute and made a complete recovery. As we have a common ward for Neurology and Neurosurgery, I happened to see her almost on a daily basis during the period she was admitted. Each meeting with her reminded me that her initial suggestion (that she might have a brain disease) was correct.

This incident had a major impact on my response to patients' opinions. As patients know their body (and disease) the best, it often helps to carefully listen to them. I have since made a number of correct diagnoses by just paying attention to what they say. It is very true that 'patients are our best teachers.'

Note: This article was first published in Journal of Postgraduate Medicine, 2004. Details are as follows. Kumar S. A Patient’s opinion is often valuable. J Postgrad Med [serial online] 2004 [cited 2012 Jan 11];50:216. Available from: http://www.jpgmonline.com/text.asp?2004/50/3/216/12580

Dr Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist,
Apollo Health City, Hyderabad
Phone- 0091-40-23607777/60601066
drsudhirkumar@yahoo.com

CARPAL TUNNEL SYNDROME

CARPAL TUNNEL SYNDROME (CTS)

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) is a neurological disease, which occurs due to entrapment of median nerve at the level of wrist. "Carpus" is a Greek word, which means "wrist". CTS is a common disease (affecting about 5% of population) and commonly affects women in their middle age.

What are the main symptoms of CTS?

1. Pain in the affected hand is the commonest symptom. Pain mainly occurs in the fingers (all fingers may be affected except the little finger), hand, forearm or the arm. It is often more at night, and interferes with activities of daily living.

2. Tingling (pins and needles sensations) and burning sensations may occur in the affected hand, which again are often more at night.

3. Numbness (inability to feel touch or pain sensations) of the hand may occur.

4. Weakness of the fingers and hand on the affected side may occur, which can be accompanied by thinning of muscles at the base of thumb (thenar muscles).

Are there some job/lifestyle related factors that predispose a person to develop CTS?

Any job or condition, where an excess pressure is applied at the level of wrist (front aspect) may predispose an individual to develop CTS. Some of these conditions include:

1. Computer use: While using a computer (mouse or keyboard), the wrist commonly rests on the surface and the median nerve at the level of wrist gets constantly pressed at the level. Therefore, people who mainly work at computers (such as software professionals, etc) have a higher risk of developing CTS.

2. Driving: Holding a steering while driving also puts a lot of pressure over the wrist, predisposing to CTS.

3. Playing musical instruments: Median nerve at the wrist may get compressed by playing instruments like tabla, drums, etc; resulting in CTS.

4. Sitting (for long duration) and resting the hand on the table with wrist touching the table surface can also press the median nerve resulting in CTS.

What are the common diseases/conditions which result in CTS?

1. Rheumatoid arthritis- a condition where there is joint pain and swelling affecting several joints. If the wrist joint is affected, median nerve may get compressed.

2. Hypothyroidism- CTS may occur in patients with thyroid hormone deficiency.

3. Pregnancy- Water retention and swelling of hands and feet are common during pregnancy, which predisposes to CTS.

4. Trauma/fracture at the level of wrist

How is the diagnosis of CTS made?

1. You need to consult a Neurologist, who will examine you. Examination would include assessment of wrist joint & its mobility, tests of sensation (touch, pain, etc) in the hand & fingers, and assessment of strength in fingers and hand. Tinel's sign (tingling and pain in the hand/fingers, which is brought on by tapping at the level of wrist) may be positive.

2. NCV (nerve conduction velocity studies) are ordered by the neurologist to assess the function of the median nerve. An impulse travels slowly across the entrapped median nerve, which can be assessed by the NCV. EMG (electromyography) may also be done to see the affected muscles at the base of thumb (which are supplied by the median nerve).

3. Ultrasound examination at the level of wrist (carpal tunnel) may actually demonstrate the compressed median nerve and the factors responsible for it. In a recent case, I could identify a small benign tumor compressing on the median nerve, causing CTS.

4. Blood tests may be done to look for thyroid disease and rheumatoid arthritis.

How is CTS treated?

1. Resting the wrist and avoiding excessive flexion or extension at the wrist joint. Braces or splints may be applied at the wrist to maintain it in neutral position, which may be applied only during the night or both day and night.

2. Analgesics- such as paracetamol/etoricoxib may be useful in mild cases.

3. Neuropathic pain medications- such as gabapentin, pregabalin or duloxetine are useful in about 50% of cases.

4. Local steroid injections at the level of wrist are useful in some. This is a safe procedure and can be done in outpatient/office as a day care procedure.

5. Surgery is reserved for cases not responding to the above measures (1-4). It is referred to as carpal tunnel decompression surgery. In this surgery, surgeon makes a cut at the level of the wrist and frees the median nerve from any pressure-causing structures. Surgery is safe, can be done under local anaesthesia as a daycare procedure.

6. Physiotherapy is useful in most cases.

What is the prognosis (outcome) in CTS?

CTS has an excellent prognosis, if it is properly treated. Early diagnosis and treatment is vital to a good outcome. If left untreated, in addition to causing severe pain, it can lead to permanent numbness of fingers & hands and weakness of hand/fingers.


If you have any queries, please email me at drsudhirkumar@yahoo.com

Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Hyderabad, India
Phone: 0091-40-23607777/60601066
drsudhirkumar@yahoo.com

TAKING CARE OF A PATIENT AFTER BRAIN STROKE (PART 2)

TAKING CARE OF A STROKE SURVIVOR (PART 2)

NON-DRUG ASPECTS OF PATIENT CARE

In my previous article posted on 11th August 2011, I had discussed about the various medications that are required to be taken by a stroke patient. However, there are several other aspects of post-stroke care that are equally important to make the life of a stroke survivor better & more comfortable.

1. Assessment of swallowing

Eating food is probably the most important function and a normal swallowing ensures that the patient can take liquids and solid food. Swallowing can be impaired in a stroke of medulla oblongata (brain stem or posterior circulation) and also in bilateral hemispheric strokes. Sometimes, the patient may be too drowsy to swallow. In a person who is awake and conscious, the adequacy of swallowing can be assessed by a swallow test. The patient is made to sit up and asked to swallow a glass of clear water. If he can drink it within half a minute without coughing or choking, then the swallowing seems to be adequate and the patient may be started on oral feeding.

2. Feeding

Feeding and good nutrition is an important aspect of ensuring a good post-stroke recovery. For patients who can swallow, normal food can be given by mouth as early as possible. For people who can not swallow, there are two options. In the first option, a tube (Ryles tube or naso-gastric tube) is inserted from nose upto the stomach and is kept secured by an adhesive near the nose. Then, liquid diet (milk, juice, etc) can be given at 2-hourly intervals through the tube. Ensure that the patient is not lying down while feeding, and the patient head end should be elevated by 30-45 degrees and left so for at least half an hour after feeding. The other option is PEG (percutaneous endoscopic gastrostomy), where a tube is inserted directly into the stomach by a minor surgical procedure by the gastroenterologist. The advantage of PEG (over the naso-gastric tube) are two-fold: i) It can be kept for much longer periods. Ryle's tube needs to be changed every 2-4 weeks. ii) Different types of food can be given via PEG.

3. Physiotherapy

Physiotherapy is the only method by which the strength and balance of the person can be improved upon. Many patients have significant residual weakness and imbalance after brain attack (stroke). They may be unable to stand or walk without support. They may also be unable to use their hands for any meaningful work. This is where physiotherapy is very important. Physiotherapy should be done under guidance of qualified physiotherapists. It should be done on a regular basis. Many patients ask for medicines or operations to improve the muscle weakness; unfortunately there are none, but good & regular physiotherapy can definitely make the muscle power & strength better.

4. Speech therapy

Many stroke survivors have language dysfunction. This can range from difficulty in understanding spoken words, inability to read or write, speaking or repeating the spoken words. In right-handed individuals, language area is located in the left side of brain. Therefore, language problems are more common after strokes on the left side of brain (which causes right sided weakness also). Additionally, patients with stroke in cerebellum (posterior circulation) may have slurred speech, but they are able to understand and speak. Patients with speech problems benefit from speech therapy. This can be taken under the guidance of trained speech therapists/rehab experts.

5. Nursing care

Good nursing care is very important in the post-stroke recovery. This includes feeding, bladder & bowel care, frequent position changing, and bathing. A stroke survivor may be dependent on others for activities of daily living and this is where nursing care is important. If a person lies on the same position for long, bed sores may develop, so, the position of the patient should be changed every two hours. Patient may have urinary and fecal incontinence (lack of control leading to voiding of uring and stool in clothes). This can be overcome with the help of adult diapers or changing clothes/bedsheets as per the needs.

6. Prevention of deep vein thrombosis

Blood clots may develop in the leg veins of people who are immobile. Therefore, in stroke survivors with paralysis of legs, there is a higher chance of clots forming in the leg veins (deep vein thrombosis or DVT). This can be minimised by frequent passive movements of the paralsed leg by the care-giver. There are compression stockings available in the market, which can be worn by the stroke patient to prevent DVT.

7. Cognitive stimulation and counseling:

Patients with stroke are prone to develop dementia (memory loss and other cognitive dysfunction) and depression. The risk can be minimised by various measures. Firstly, the patient should be kept in a well-lit room where abundant natural light comes in. Some stroke survivors may have reversal of sleep rhythm (they may sleep during the day and keep awake at nights). This rhythm may delay the recovery from stroke. Therefore, the patient should be kept busy/engaged during the day and not allowed to sleep. If the patient finds it difficult to sleep during nights, a small dose of sleeping pill may be used. Patients may be encouraged to listen to songs/music (through head phones, etc); allowed to meet with various friends or relatives; talk as often as possible (if patients can not talk, even listening is important for brain stimulation, so the visitors should be encouraged to talk even if the patient does not respond).

Depression after stroke is also common. So, proper counseling and psychotherapy is important. Sometimes, antidepressant medications may also be required.

8. Sexual functions

There is no restriction as such, and sexual functions can be resumed as per the patients' ability. Sexual drive may diminish after stroke, and sometimes, there may be linmitations due to physical handicap. These can be overcome to a great extent with the halp of an understanding partner.

9. Diet

• A good diet is essential for proper recovery.
• A diabetic should follow the diabetic diet.
• Generally, the diet should be low in fat and cholesterol content.
• As constipation is common in post-stroke patient, the diet should be rich in fibre content.

10. Physical activity

Physical activity is encouraged in stroke survivors. They should be encouraged to stand and walk inside home or be taken for an evening or morning walk with an attendant. If these is a risk of fall, use of a walking stick or walker is encouraged. Prolonged sick leave or bed rest is not advised, and the patient should return to normal life activites as early as possible.

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/040-60601066

TAKING CARE OF A PATIENT AFTER BRAIN STROKE

MAKING LIFE BETTER AFTER BRAIN STROKE (PART 1)

Stroke is one of the four leading causes of death and disability in the world (the other three being heart attack, cancer and road traffic accidents). Stroke is common in all countries and in all races. The prevalence of stroke increases with age; however, the average age of stroke patients is much lesser in India & other Asian countries. This is because of higher incidence of hypertension (high blood pressure), more infections, dietary habits and other lifestyle differences.

The medical treatment of brain stroke has been rapidly advancing with thrombolytic therapies (drugs to dissolve the blood clot) and better intensive/acute care. However, a significant proportion of people are left with disabilities after stroke. The aim of this article is to focus on aspects of stroke care after the discharge from the hospital. Part 1 will focus on the medical (drugs and medications) aspects. Part 2 (next article) would focus on the non-drug aspects.

MEDICAL TREATMENT

A stroke survivor is supposed to take a number of medications. In this section, I will discuss the rationale and precautions for them.

1. Antiplatelet drugs: These are drugs which prevent the recurrence of brain stroke. They are also called as "blood thinners". Common medicines in this category include aspirin (ecosprin) and clopidogrel (plavix, clopitab, etc). These medicines are required lifelong. These should be taken after food. The main side effects of these drugs is bleeding. So, if you notice any bleeding such as gum bleeding while brushing, blood in urine, blood vomiting, etc, you should report to your doctor. Sometimes, bleeding may happen in the skin, resulting in reddish or bluish discoloration. Other precaution to be taken is that these drugs should be stopped for 3-5 days prior to any procedure or surgery, including extraction of teeth, etc. If a surgery is done while the patient is taking aspirin, there is a higher chance of bleeding during or after the surgery. One more side effect of aspirin is gastritis or acidity, which should be reported to the doctor.

2. Statins: Statins are universally prescribed to patients with brain stroke. They are cholesterol lowering drugs. These drugs have dual benefit- in addition to lowering the blood cholesterol, they also prevent the recurrence of brain stroke and heart attack (even in patients with normal blood cholesterol). Common drugs in this category are atorvastatin and rosuvastatin. It is commonly taken at bed time after dinner. Statins are generally safe, however, muscle aches and pain (myalgias) may occur and it should be reported to the doctor. Statins are also required for long-term.

3. Medicines for control of risk factors:

a) Diabetes mellitus- Medicines to keep the blood sugar under control (oral tablets or insulin) are required in patients with diabetes; and the dose needs to be adjusted as per sugar levels in the blood. One should watch for signs of hypoglycemia (low sugar) such as weakness,hunger, sweating, palpitations, etc.

b) Hypertension- Patients with high blood pressure need medicines to keep their BP in control. Blood pressure and sugars should be regularly checked and the dose of medications adjusted as per the levels found. These medicines are also required lifelong.

c) Cardiac drugs- Many patients may have co-existing cardiac illness and they should continue their cardiac medications as per the cardiologist advice. It should be noted, however, that there are several common medications (for heart and brain disease); so, do not forget to check with your doctor about any duplication of the drugs (show them the cardiologist prescription).

d) Drugs to lower homocysteine such as folic acid/pyridoxine may be required in some cases, where the serum homocysteine is found to be high.

4. Anticoagulants such as acitrom or warfarin is given to patients with cardio-embolic strokes (clots form in the heart and travel to brain causing brain stroke). Common indications are atrial fibrillation (AF), people with prosthetic heart valves, LV clot, very foor heart function (LV dysfunction, etc). Dose of anticoagulants is adjusted on the basis of a blood test- prothrombin time (PT/INR). So, a patient on warfarin should regularly check PT/INR and report to the doctor, so that the dose can be adjusted.

In summary, patients with stroke are supposed to take a number of medications for different purposes. One should write down all the medications to be taken on a single page with the timings (and before food, after food, etc); and get it verified by your doctor. As the stroke patient may not remember, the caregiver should verify if the medications are taken as per the instructions given by your doctor. Remember to discuss the indication and side effects of each drug which the patient is taking with your doctor. These simple points can make a remarkable difference in the life of a stroke survivor.

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/040-60601066

HOW SHOULD YOU CHOOSE YOUR DOCTOR?

STEPS TO BE FOLLOWED WHILE CHOOSING A DOCTOR

Today, we have choices in every field of life. Whether it is eating out in a restaurant, choosing an airline, or buying a home appliance, there are multiple options available. We follow certain steps such as a comparison of the quality, convenience, cost, etc to arrive at the best choice. Various websites offer comparison between different brands of home appliances, and travel portals give us the flight timings, services and costs, helping us to choose an airline. However, there is not much help available to enable us to choose the best doctors. This article looks at all the important questions that crop up in our minds when we think of consulting a doctor.

Should you consult a doctor or try home remedies?

Many minor ailments are self-limiting in nature (they get better on their own); so one can try home remedies for them. These include viral fever, loose motions, cough & cold, minor occasional headaches, occasional sleep disturbance, minor bruises after a fall, etc. However, one should consult a doctor if symptoms are severe or persist beyond usual duration. For ex- if fever persists beyond 3 days, loose stools continue leading to dehydration, headaches are severe, one should seek a doctor's advice. Generally, one should consult a doctor if the symptoms are severe leading to impairment or interference with activitites of daily living or if the symptoms are recurrent in nature.

Should you consult a general practitioner (GP) or a specialist?

It is one of the most important issues to delibrate before choosing a doctor. GP is one who has the basic medical degree (MBBS in India). MBBS training requires four and a half years plus one year of internship (total duration of five and a half years). Certain specialised courses are available for GPs such as Family Medicine, but very few doctors are trained in that speciality in India. A specialist is one who has a postgraduate degree- MD (Doctor of Medicine). MD is offered in medical specialities and the equivalent surgical degree is MS (Master of Surgery). MD or MS can be done only after MBBS and it is of three year duration. For super-specialisation, one can then do DM (Doctorate in Medicine), which is of further three years duration. MCh is the equivalent degree in surgical specialities. Therefore, the highest medical degrees in India are DM (in medical field) and MCh (in surgical field), and it would take a minimum of about 12 years after +2 to get these degrees. Remember that there are entrance exams before MD and DM, and then one has to pass both theory and practical exams to be awarded these degrees. A thesis (research) is also mandatory during MD and DM. A point to note is that certain foreign countries award MD as the basic medical degree. So, an MD of USA, Russia or China is equivalent to MBBS of India.

Medical science is rapidly advancing and several new diagnostic tests & treatment modalities have become available in the past two decades. These include widespread use of MRI in 90s and PET scans (which show the functional activity of an organ) now. Infections and tumors can now be more accurately diagnosed. Similarly, several new treatment options are available- such as thrombolytic therapy in stroke, deep brain stimulation (DBS) surgery in Parkinson's disease, new medications for high BP & sugar, etc. It is not very difficult to believe that a GP would not be aware of these latest diagnostic & treatment modalitues.

On the other hand, when you consult a specialist, there could be some drawbacks. A specialist is likley to order more tests (such as coronary angiogram for a suspected cardiac problem), MRI scans in cases of headaches to exclude brain pathology, etc. In addition, the consultation fees could be more; it may be more difficult to get their appointments; you may not be able to discuss your problem in detail because of their busy schedules. For example, there are only 1500 neurologists (DM in neurology) out of a total of 1.5 million registered doctors in India (0.001%). This also translates to one neurologist for one million population. In addition, you may have to see several doctors if you happen to have multiple problems. For example, if you suffer from high BP, diabetes, thyroid problem and knee pain; you would have to consult a cardiologist, endocrinologist, and orthopedic surgeon. Sometimes, problems in other systems may remain undiagnosed, if you consulted a specialist of one system.

Therefore, it may be better to consult an MBBS or MD doctor in the beginning, if you have minor ailments or if you have multiple problems. However, please consult a specialist if your problem is serious or not getting better with treatment under a GP; having frequent reccurrences or if you wish so. In several countries such as UK or USA, one may not be able to consult a specialist unless referred by their GP; however, in India, you are free to consult any doctor of your choice including a specialist.

Identify the doctor of the correct speciality (as per your problem)

You need to choose the appropriate doctor, specialising in the disease you are suffering from. For ex- for ear discharge/ear pain/decreased hearing, you need to see ENT; for chest pain-cardiology; for knee pain-orthopedics, etc. Sometimes, you may not be aware of what speciality to consult. In this case, the receptionist or the secretary of the doctor can help you. If you happen to consult or know any doctor for any previous ailment, you could ask him to guide you in choosing the correct specialist for the current illness.

Should you go to a doctor in a clinic set-up or a multi-speciality hospital

Both clinics and hospitals have their advantages and disadvantages. Hospitals have multiple doctors in the same speciality, so, if one doctor is on leave, you can always consult another doctor. Also, if any cross-referrals are given (if you are asked to see another specialist), you could see them in the same hospital. Most investigations and medications are also available in the same hospital. Drawbacks of a hospital may include longer distance from home/office; higher costs; and uncomfortable surroundings. In a clinic, you tend to feel more familiar with a particular doctor, and you may find the surroundings more comfortable. Cost of treatment could be lower in a clinic. However, a serious illness usually can not be treated in a clinic. For ex- if you have suffered a heart attack or brain stroke, thrombolytic therapy may not be available in a clinic, and valuable time may be lost whie shifting from clinic to a bigger hospital.

Therefore, for a serious illness, you should prefer to consult a doctor in a hospital; and for a minor illness, you could consult a doctor in a clinic. Also, if your illness is undiagnosed, the chances of making an accurate diagnosis is more in a hospital because of availability of all investigations. So, your initial visit (prior to diagnosis) could be to a hospital, and subsequent follow up can be done in a small clinic.

How do you ascertain that a certain doctor is better than others in the same speciality?

Though it is not always easy to identify a better doctor, certain points can help you in this decision.

1. Look where the doctor got trained: If a doctor got trained at AIIMS, PGI Chandigarh, CMC Vellore or some other good colleges, their knowledge & expertise would be better than if they studied in a lesser known college or colleges that give seats after taking money (management quota). Certain magazines like India Today routinely come out with the rankings of top medical colleges and that could be one source for finding the best medical colleges in India.

2. Look at the degrees and qualifications: A doctor with MD (or MS) is better trained than those with MBBS alone, and those with DM (or MCh) are better trained than those with MD (or MS). Certain doctors may also obtain special fellowships in a more specific disease.

3. Number of years of experience: Senior doctors are generally better than the fresh pass-outs, and as the doctor becomes more experienced, he becomes better. This is true for both surgical and medical specialities. For ex- a surgeon who has performed 500 cases of spine surgeries is definitely better than the one who has performed only 20. Similarly, a neuroloigist who has treated 1000 cases of stroke is better than the one who has treated only 50. Every patient has a right to ask his doctor about the number of similar cases treated/operated by his doctor.

4. Any research in the specific field: A doctor with research experience in the field should be preferred over someone without any research experience. Similarly, if a doctor is on the editorial board of a journal or is routinely invited to give talks on a specific disease, he is considered to be an expert and should be preferred. These details can be obtained from different personal and public websites (such as Google scholar and PUBMED).

5. Look for reviews about a doctor or hospital on websites.

6. Knowledge of a specific language: Good communication is the key to a correct diagnosis and better treatment. So, if the doctor knows your language it is an advantage. Many doctors have translators for the benefit of their patients.

I have tried to discuss various issues in this vast topic, and I may have sounded vague at some places. I would welcome any suggestions from your side.

DR SUDHIR KUMAR MD (MEDICINE), DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS

HYDERABAD, INDIA- 500033

Phone: 0091-40-23607777/60601066

Email: drsudhirkumar@yahoo.com

FACIAL PALSY (BELL'S PALSY)

FACIAL PALSY (BELL'S PALSY)

What is Bell's palsy?

Bell's palsy refers to unilateral (one side) paralysis of muscles of face.

What are the symptoms of facial palsy?

Facial palsy causes weakness of facial muscles. So, patients may face the following problems:

1. Difficulty in closing the eye, so, the eye on affected side may look bigger.

2. Difficulty in frowning, leading to absence of wrinkles over forehead on the affected side.

3. Difficulty in blowing out cheeks (air leaks out on the affected side).

4. Watering of eye on the affected side,

5. Difficulty in chewing food, food may get stuck within the mouth on the affected side

6. Facial asymmetry, face may seem to get pulled to the normal side.

Other symptoms may include:

1. Loss of taste on the affected side,

2. Faint sounds may also seem louder (hyperacusis)

3. Headache, facial pain and neck pain may occur on the affected side. The pain may start a few days prior to the onset of facial paralysis. 

How does facial palsy start?

Symptoms of facial palsy starts suddenly over hours, so, it is very alarming for the patient. At the onset, patient may have pain behind the ear, in the neck, or the head on the side of paralysis. Symptoms are minor in the beginning, so, they often get noticed first by others or may be noticed on looking into a mirror.

What should be done, if one suspects facial palsy?

There is no need to panic, as it is a benign condition, and often improves over time. One should first consult their family physician or GP and subsequently a neurologist. Care should be taken to avoid any dirt entering the eye (as the eye can not be properly closed) to prevent corneal (a part of eye) infection.

What are the causes of facial palsy?

Bell's palsy is idiopathic (no definite cause has been identified). However, research has shown that it is often caused by viral infections such as herpes simplex. Facial palsy is more common in people with diabetes mellitus and in pregnant women. Patients with facial palsy often give a history of exposure to cold prior to the onset of symptoms (such as direct exposure of AC wind, going out at night or early morning, or long road journey with open windows), but their role in causing facial palsy has not been proven.

Other causes of facial palsy may include brain stroke (decreased blood supply to brain), tumors, other infections, trauma, infections of ear, etc.

What investigations would the doctor ask in facial palsy?

• Generally, no investigations are necessary as the diagnosis of facial palsy is obvious on clinical examination.
• However, brain scan (CT or MRI) may be done if one suspects brain stroke or tumors.
• Blood sugar should be checked to exclude diabetes mellitus.
• Nerve conduction studies (NCV/EMG) may be done to estimate the extent and severity of facial nerve involvement and in some cases to predict the outcome of facial palsy.
• In patients with recurrent facial palsy, certain blood tests may be done to look for the presence of disorders like collagen vascular diseases or vasculitis.

How is facial palsy treated?

Medical management of facial palsy may include the following:

1. Anti-viral drugs: Aciclovir tablets (2000 mg per day in divided doses) are given for 7-10 days.

2. Corticosteroids: Prednisolone 50-60 mg per day for 5-10 days are helpful in speeding the recovery. 

3. Vitamins: Mecobalamin (vitamin B12), alpha lipoic acid, etc are given to speed up recovery and regeneration of the facial nerve.

4. Physiotherapy: includes facial exercises, massage, and electrical stimulation of the facial nerve.

What is the prognosis of facial palsy?

• As earlier mentioned, facial palsy is not a serious condition and most patients recover well. Almost 60-70% patients recover in 3-4 weeks and the remainder in another few months.
• Less than 5% patients either do not recover or recover only partially.
• Facial palsy does not lead to death.
• Facial palsy usually does not recur, and recurrence is seen in only about 2-5% of cases.
• Patients with residual palsy may have facial asymmetry and they may consult cosmetologist/cosmetic surgeon for correction of asymmetry.

Miscellaneous questions about facial palsy

1. Is it contagious?

No, facial palsy does not spread from one patient to another, so, isolation is not required.

2. How common is Bell's palsy?

It is quite common and I see about 5-10 new cases per month.

3. Is Bell's palsy hereditary?

No

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD, INDIA

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/60601066
Facebook: www.facebook.com/bestneurologist

ROLE OF BOTOX IN NEUROLOGICAL DISORDERS

BOTULINUM TOXIN (BOTOX) INJECTIONS IN NEUROLOGY

Botulinum toxin (popularly sold in the brand name Botox by Allergan company) is one of the commonly used treatment methods in cosmetology. Many actors and models take botox therapy to look young and hide away all facial and forehead wrinkles. Very few people know that Botox has wide applications in the field of neurology and patients with several neurological disorders can benefit from botox therapy. In this post, I would list out all the conditions where I give botox injections and would share my experiences in treating them.

1. POST-STROKE SPASTICITY

Stroke is a common disease leading to paralysis of muscles on one side of the body, due to reduced blood flow to the brain. Patients who survive stroke are left with severe disabilities. Spasticity- increased stiffness and tone of weak muscles- is a common cause of disability in stroke survivors. There are several medications (oral tablets) available for reducing the spasticity, but they have limited efficacy and significant side effects such as drowsiness. Botox injection therapy is a very effective method of treating post-stroke spasticity. Botox is injected in the spastic muscles. In the past 10 years, I have treated more than 100 patients with this condition and most of them do well. One of my recent patients was an ex-army person from Baghdad (Iraq), who was wheel-chair bound for five years due to a stroke. I gave him botox treatment, and referred him for physiotherapy. After a week, he came walking to my office. Patient and his wife were so thrilled! Reduction in spasticity also helps in doing better physiotherapy.

2. CHRONIC MIGRAINE

Migraine is the commonest cause of headache, affecting about 10-15% of women and 5-8% of men. In many cases, migraine becomes chronic and leads to frequent headaches. Frequent, severe headaches adversely affects the patients' quality of life, studies, employment and family life. Oral preventive therapies for migraine are available, but are ineffective in some and lead to adverse events in others. In these patients, botox therapy has a great role to play.

Botox is injected in scalp and neck muscles (frontalis, temporalis, occipitalis, cervical, trapezius, etc) using a very thin needle. The procedure can be done in the office, with little discomfort to the patient, and is completed within 15-20 minutes. In the past two years, I have treated about 30 patients with chronic migraine with botox. 29 of them showed good improvement in pain and quality of life. One patient who did not improve had various stressors in personal and professional life, leading to super-added tension headache. One patient, who I distinctly remember was a 35-year-old woman from Dubai, who came to me with 5 year duration of chronic migraine (20 headache days per month). She returned 3 months after botox injection therapy for review, and reported almost complete improvement in pain. However, she requested me for one more botox shot. I was surprised, as she was pain-free. Then she disclosed to me that her husband had started showing more interest in her now that she looked much younger and prettier (after botox shot to frontalis muscles) and she wanted to maintain the youthfulness of her face. I suggested to her that she consult a cosmetologist, but she insisted on me doing it. So, I along with my cosmetologist, gave her the second botox shot!

3. WRITER'S CRAMP

It is a condition, where patients find it difficult to write. They are able to perform all other activities normally, including lifting heavy weights with hands. Handwriting becomes poorer and illegible. Cheques signed by the patients start bouncing, as the signature on the cheque does not match that of bank records. Another feature of the disease is that writing becomes worse in front of others and when tensed.

Botox is very effective for treating writer's cramp. Injection is given in forearm muscles. Most patients improve very well.

4. SPASTICITY OF LIMBS IN CHILDREN WITH CEREBRAL PALSY

Cerebral palsy (CP) is a condition affecting children, characterized by developmental delay (delayed motor and speech milestones). Other features may include fits, deafness, squint, learning disability, etc. Cerebral palsy results due to a lack of oxygen or blood supply to the brain during peri-natal period (immediately before, during or immediately after birth). Many children with CP have spasticity of legs and hands. Spasticity of legs hamper in their standing and walking. Botox injections given in adducor and hamstring muscles of thighs reduce the spasticity, and improve walking. Today, I treated a 5-year old child from Bidar (Karnataka) with this condition.

5. Other dystonias- such as hemi-facial spasm, blepharospasm, cervical dystonia- are also very well treated with botox injections.

6. Hyperhidrosis- increased sweating over palms and feet, which can be embarrassing and cumbersome- responds well to botox treatment.

In general, all botox injection therapies are done on an out-patient basis. Patients can come after eating (fasting is not necessary). It is done without any anaesthesia, in the office setting. The entire procedure is completed in less than 30 minutes and patients are free to return home immediately after the procedure. No leave from work is required and they can join work the next day. Depending on the condition, 100 to 200 units (1-2 vials) of botox is required for the procedure, and the approximate cost could be Rs 25, 000- 50, 000 (USD 1000-2000). Botox treatment is safe and I have not seen any complication in more than 250 botox procedures that I have done in the past 10 years.


DR SUDHIR KUMAR MD (MEDICINE), DM (NEUROLOGY)
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, JUBILEE HILLS
HYDERABAD, INDIA.
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

RIGHTS OF A PATIENT IN A DOCTOR-PATIENT RELATIONSHIP

What are the rights of a patient, in a doctor-patient relationship?

The relationship of a patient and doctor is a very special one and is different from any other professional relationship. The patient shares a lot of personal and private details with the doctor, which at many times are not even known to close family members or relatives. The doctor is one of the most important persons in a patients’ life, as the doctor is responsible for the patients’ good health (contributing to an increased productivity at work and greater happiness in family life).

There is a need to maintain a healthy and cordial patient-doctor relationship, keeping in view the importance of this relationship. Both the patient and doctor have certain rights and responsibilities towards the success of patient-doctor relationship. In this blog, I shall focus on the rights of a patient.

1. Right to get listened to by the doctor

It may seem very basic, but several patients are not allowed to tell their complaints to the doctor. Several senior doctors spend hardly 3-4 minutes per patient, and give a prescription containing 7-10 medications to the patient! History (description of illness as given by the patient to doctor) is the most important step towards arriving at a correct diagnosis; and a patient has the right to insist that a proper history be taken. Today, several doctors over-rely on investigations (such as blood tests, X-rays, CT scan, echocardiogram, etc) to make a diagnosis (ignoring history and clinical examination of the patient). Over-reliance on investigations can lead to an error in diagnosis. For ex- epilepsy can be diagnosed only by a good history, as CT scan and EEG may be normal in true cases of epilepsy. On the other hand, 5% of normal people may have abnormal EEG.

2. Right to receive information about the illness:

Patient can ask anything about the illness to the doctor (such as why did it occur, can it spread to other family members, how long will it take to improve, any likely complications of the illness, can it recur, etc). A good doctor has enough time to answer all the illness-related queries.

3. Right to know all the possible treatment options:

A single disease may have more than one treatment options. There may be more than one medication effective for the same illness. For ex- there are several medications effective for epilepsy. The doctor selects the best anti-epileptic medication depending upon the type of epilepsy; age & sex of the patient; expected drug-related adverse events and cost. The patient has a right to understand why one medication was preferred over another. In diseases requiring surgery, patient has the right to understand different surgical options available and why a certain surgical procedure is preferred over another.

4. Right to know possible treatment-related adverse events:

Many medications may cause adverse effects, which can range from simple nausea/vomiting to liver & kidney damage. A patient has a right to know about all the possible harmful effects of the drug from the doctor. A good doctor would patiently explain them to the patient. Similarly, in patients undergoing surgery, all the possible complications of the surgery will be discussed by the surgeon with the patient.

5. Right to refuse any investigation or treatment:

A patient has the right to accept or refuse any investigation or treatment offered by the doctor. A doctor can only advise, and not force a patient to undergo an investigation or procedure. An informed consent from the patient is mandatory prior to an investigation or procedure.

6. Right to take second opinion:

The doctor’s opinion regarding the treatment is not binding on the patient and a patient can opt for a second opinion before accepting the treatment. The patient can take the second opinion from a doctor suggested by the treating doctor or any other doctor of his or her choice.

7. Right for a referral:

If the treating doctor is not competent in handing the disease, the patient has a right to be referred to another doctor who is a specialist in treating the condition. For ex- if the patient has suffered from an ischemic brain stroke (causing paralysis) and the concerned doctor is not competent in thrombolysis (clot-buster therapy), the patient can ask for referral to a stroke neurologist.

8. Right to know about any modifications in lifestyle, diet or job:

Treatment of a disease involves modification in diet, lifestyle and job. For ex- patients with kidney failure or very high blood pressure should take a low salt diet, patients with recent heart attack should avoid oily/fatty food, patients with epilepsy should avoid driving/swimming, etc. Patients have a right to know these details.

9. Right of confidentiality/privacy:

Patients details (personal or medical) can not be disclosed by the doctor to anyone else including close friends or relatives of the patient without patients’ consent.

DR SUDHIR KUMAR MD (Medicine), DM (Neurology)
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com
http://members.tripod.com/sudhirkumar_5/neurologist/

MEMORY- THE MOST IMPORTANT BRAIN FUNCTION

MEMORY- THE MOST IMPORTANT BRAIN FUNCTION

Introduction

Memory is, undoubtedly, the most important function of our brain. Our day-to-day functioning depends on good memory. A person with memory impairment is unable to perform even the most basic of the daily activities. This handicap is well seen in people suffering from dementia.


Better memory is also a prerequisite to being a more intelligent person, and all tests for testing I.Q (intelligence quotient) include some form of memory testing. Good memory becomes even more important in traditional teaching systems such as in India, where a student who can memorise more gets more marks, and also more accolades and so on!

Memory in other species

It is not only humans who have memory. Many lower animals too depend on various types of memory for their survival.

• For example, migratory birds fly upto 10,000 km every year to survive harsh winters, across deserts, mountains and seas; with fear of starvation, exhaustion and death. Yet, they accurately reach the same destination without getting lost (remember, they dont have google maps, GPRS, etc). l
• They can store upto 100,000 seeds underground and retrieve most of them later, when they need them (just imagine doing it without pen/paper or computer!) Birds store Acorn seeds (that grow into giant oak trees) in the ground, by covering with dirt. Acorn seeds are very nutritious and birds can’t eat them all for fear of becoming fat and not being able to fly
• Remeber PAUL, THE OCTOPUS, who predicted so accurately during the recent world cup soccer!
• Chimpanzees and gorillas have even better memory.

Some facts about human brain

Human brain is only 2% of body weight, but it receives 15% of cardiac output (blood pumped out by the heart), 20% of total body oxygen consumption and 25% of total body glucose utilization. Brain metabolism is very active, and brain continues to work even during sleep (during rapid eye movement- REM- phase of sleep, brain metabolism is 30% higher!)

At what age does learning in humans begin?

Human learning begins even before birth. All those who have read Mahabharatha know that! Abhimanyu (son of Subhadra and Arjun) learnt how to penetrate several layers of defence of Chakravyuha, while he was still in his mother's womb (while Arjuna was narrating that to Subhadra). The epic says that Subhadra fell asleep halfway, and so Arjun did not tell her the technique of coming out of Chakravyuha, and Abhimanyu could not learn that either (and later on during the war, he remembered how to enter the charavyuha, got trapped inside and got killed).

Recently, several research studies prove the above point. Ultrasound studies show that fetuses respond in a specific manner (by moving hands or legs) to a specific sound at 30 weeks of gestation. The response of fetuses were replicated at 34 weeks, indicating that they could remember the sound even after four weeks! Also, mothers know that newborn babies respond to their voice even on the first few days after birth. This is because these babies have heard their mothers' voices so many times before birth that they are very familiar with that.

One of my colleagues told me that when his wife was pregnant, world cup soccer was going on, and they would watch all the matches and discuss them in detail. This experience was handy for their yet-to-born son, who showed keen interest in soccer from very young age, and at 10, he was in the school team! So, all prospective parents, please discuss only good things because your yet to be born child is listening to every conversation!!

Brain growth is maximum during the first two years of life, and hence are very important for memory and learning. Any infection or insult to brain during this stage can adversely impact memory functions.

Between 6 months and 12 months of age, babies can recognize familiar places or people (this explains the fussiness on being brought to doctors cabin or smile on seeing grandma).

Long-term memory retention does not start until age 3, and hence most people dont have any memories of events that happened during the first three years of life.

Does memory decline with advancing age?

•  lBrain volume is maximum at age 20 and starts to shrink after age 40!
• lThough certain aspects of memory & cognition may change with age, most older people can function normally (indicating an insignificant memory loss)
• lSo, memory loss causing disability in daily life of an older person is pathological,
• lNew-learning ability and ability to form long-term memory is spared into old age. 
• Different types of memories decline differently.
• Episodic (what did I have for breakfast), source (where did I learn the new car) and falsh bulb (where was I on Sep 1 2001) memory decline fast
• Semantic (words, phrases, facts) and procedural (driving a car) memory decline the least.
• Amount of storage capacity is not an issue; however, retrieval of stored information may become slower with aging.
• Memory lapses start in 20s, but they remain unnoticed till 50s.
• In a recent study, psychologists asked about 2,000 participants to solve puzzles, identify patterns and remember words and details from stories, among other memory tests.
• The top performers were 22-yr-old; researchers saw a notable decline in the ability to make rapid comparisons, remember unrelated information and detect relationships by age 27.
• A weakening memory can usually be detected by around age 37, according to the study.
• The good news was that people's vocabulary and general knowledge increase until at least age 60.

Memory problems in ageing- What is abnormal?

• Forgetting things much more than you used to
• Forgetting how to do things you've done many times before
• Trouble learning new things
• Repeating phrases or stories in the same conversation
• Trouble making choices or handling money
• Not being able to keep track of what happens each day

Whose memory is better- MEN or WOMEN?

Ever wondered why wives always manage to remember the wedding anniversary (and put you in a tight spot)! This is because verbal episodic memory (words, objects, everyday events) is better in women; however visuo-spatial memory is better in men (so women please watch, if you get stuck in dense forests of Amazon, its the men who will take you out of jungle to safety)! Women are also better at remembering faces!

"Husbands never remember marital spats, whereas wives never forget". This is because women have better emotional memory. This could also explain the higher rates of depression among women.

How to improve memory?

l1.Regular physical exercise- increases cerebral blood flow

l2. Regular brain exercises- solving puzzles, sudoku, learning a new language, or playing a new musical instrument, etc in old age can delay the onset of dementia

l3. Avoiding stress/tension; good social interaction

l
5. Good control of risk factors such as high BP, sugars or cholesterol.
6.Ensuring proper sleep and good nutrition

l

Are there any memory enhancing foods?

 

l1. Grape juice- antioxidant & anti-inflammatory properties (Br J Nutrition, 2010)

l2. Strawberries, blueberries, walnuts- (J Nutrition 2009)

l3. Choline rich foods- chicken liver, eggs (J Am Coll Nutrition 2004)

l4. Chewing gum- (Appetite 2004)

l5. Apples, apricots, broccoli, cabbage, cauliflower, cherries, eggplant, fish, onions, plums, beet root, spinach, green tea, soy, olive oil,

l6. Turmeric (a compound called cucurmin) may protect against Alzheimer’s disease- this explains the lower prevalence of AD in India)!

Are there any medicines/drugs to enahnce memory?

Generally no drugs can boost memory in normal people. Memory is genetically determined and it can't be boosted. However, in people with vitamin and nutrient deficiencies, appropriate supplementation can be useful. Multivitamins are safe (containing B12, thiamine, alpha lipoic acid and folic acid). Omega 3 unsaturated fatty acids are used. Chinese herb Ginkgo biloba is also in common use. Please consult your doctor before you consume any of the medications, as even vitamins can have adverse effects!

Dr Sudhir Kumar MD (Medicine), DM (Neurology)

Consultant Neurologist

Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066

drsudhirkumar@yahoo.com