Got a medical question? Let me stretch my brain.

[Cyanide]

As many of you probably know....I am a physician type. Family medicine more specifically. Military to be even more specific.

Well, I am involved in a constant effort to keep my clinical knowledge up to date, and less rusty. I read/listen to many sources, developing/maintaining my skills to stay at the level of a "competent generalist". In the military its a bit tough though because my patient base is just too healthy until they get blown up, then its mostly meat and bone carpentry and then shuttle quickly to the surgeon.

So, I help my friends (thats all of you) alot (probably more than most other physicians). A) it helps my skills, B) it hopefully helps out my friends, C) because of my situation (doc starving for the challenge in the face of healthy patients) it helps me feel better about myself. D) I am an attention whore.

Thus, I thought it might be good to open up a thread where you, my BOTLs/SOTLs, can throw out some concerns and I can see what I can do.

Disclaimers:
1) I can't promise you specialist knowledge. Depending on the question I may throw down what I already know and leave it at that. Or, maybe I will research it to a level I am happy with and then throw down what I have learned. Or, maybe I won't have much to put down about it and that is what you will have to settling with.

2) Anything I throw down here is to be taken for what it is....someone you don't really know (for all many of you know I am a 12 year old pretending to be a doc), fielding questions I may not be qualified to answer. NEVER take what you read here as gospel. If its serious, if its important, you should still see your doctor.

3) I am not always available. I get shipped around alot, spend long times without internet access. I am also orchestrating a big career change in the next 7-8 months (releasing from military, developing a civi practice, renovating a house, parenting children, being a good spouse, selling/buying a house, moving, prepping for the new practice). If I am not responding, maybe I never will.

4) This thread is an experiment. If life gets out of hand or things get too crazy in this thread I may abandon it. I will probably make that known though before it happens.

5) Once again...this thread should not count as your only medical consultation. I cannot refer you to specialists, I cannot determine the "all important" aspects of the situtation without actually being present with you. You probably don't realize how much of medicine is about the intuitive aspects of this situation. Body language, physical traits, they way things get said in a face-to-face encounter have HUGE importance in the evaluation of the situation. I could easily miss major important elements simply by not being in the same room with you, watching you as you describe your issue. Certainly physical exam is impossible, as would diagnostic testing. Finally, I can't start treatments, or even guarantee I will discribe the treatments best suited; once again, intuitive reasoning goes a long way here.

6) This is an advice column. Most advice columns are full of BS. Don't expect more. While I try to stay current and "evidence based", medicine is too big for everything to be based on well-worked out science. As a generalist I try to keep up, but its all too much, so my evidence based knowledge is going to be pathetic in orthopedics compared to an orthopedic surgeon. Its always possible that I may spout out "establish wisdom" in a sub-field of medicine that has already been proven wrong 10 years ago.

Scared you away yet?

And, with that, shoot out your questions and I will see what I can do. Ultimately this is probably going to take the form of a banter thread (in certain ways).

Cheers

Cy

PS: three out or every two people don't know how to handle statistics. Even worse, five out of four people misquote their statistics. I am no different. But, I take stats with a grain of salt. Telling you that condoms are 97-99% effective means that I don't really have the number memorized and that I don't really see the need to more accurate than that anyway....it means condoms are good (unless you are trying to stop herpes, which case they are only 30% effective)

[Rabidsquirrel]

Why does it hurt when I press *here*?


Sorry, had to do it.

[Cyanide]

I think it might be the pointy tips of the asterisks. That's probably why it hurts. :)

[Whee]

Well, we know you;re not a 12 yo. If you were, you'd tYpE lIkE tHiS and talk about boobies and comic books...:r

[Rabidsquirrel]

talk about boobies

If that's a qualifier I think a lot of us are in trouble. :)

[kayaker]

I'll give ya a whirl Cyanide.

My right knee has no ACL or medial meniscus. I don't have any trouble with the stability of my knee. It has never "popped" again, and it doesn't limit my ability to be active when I want to. I can play squash, hike, climb, etc. I didn't get ACL replacement as I felt it unnecessary.

However, I have noticed over the last year or so that it takes greater effort to get up from a crouching position and my knee aches a little more than usual. It's not a big deal, but I'm not getting any younger.

Would the ACL replacement surgery help with this?

[elderboy02]

Thanks for offering to help us out!

[acarr]

Thanks for the offer. Maybe a little off the traditional medicine question, but a general practitioner is going to get a number of questions pertaining to non-traditional medicine. So here goes:

Can you tell me whether or not you think turmeric/curcumin is an effective anti-inflammatory spice.

[newcigarz]

Well, we know you;re not a 12 yo. If you were, you'd tYpE lIkE tHiS and talk about boobies and comic books...:r

hey I like boobies and comic books. :D

[Fumes]

This is a long shot, but any ideas will be greatly appreciated.

Every once in a while my wife has crippling lower back spasms that are triggered by simple things like bending over or getting out of a chair. They aren't frequent, but when they happen she has pain to the point where she can barely move. It usually takes a full day of rest and heat on her back before she can get out of bed. And ibuprofen. Lots of it. She has taken muscle relaxants for this but they don't seem to work any better than Advil. X-rays show she has narrowing discs, but her doc isn't sure that is the problem. She tried chiropractic for several months but it hasn't been effective in the long term.

That's the background. My question is this: she had a spasm yesterday (just getting off the couch) and afterward she had numbness and tingling in her legs and in her arms from the elbow to the fingers. This was new and it went away after a few hours, so we're not too worried about it, but I'm wondering if it gives us any new ideas as far as diagnosing the cause of her back spasms. Maybe it was just a reaction to the pain?

Thanks for any suggestions, Doc! Great idea for a thread! :tu

[gettysburgfreak]

I sprained my ankle pretty bad in PT almost a month ago and it is still a little bit swollen. It doesn't really hurt that much any more but the fact its still swollen has me wondering if it is just because I am constantly on it doing vigorous activities and don't have a chance to rest it, or could it be something more serious?

[Whee]

hey I like boobies and comic books. :D


You are not alone.:r

[s15driftking]

how do you cure scalp feliculitis, noting that a 10% panoxyl soap bar has gotten you no where?

[Sauer Grapes]

I sprained my ankle pretty bad in PT almost a month ago and it is still a little bit swollen. It doesn't really hurt that much any more but the fact its still swollen has me wondering if it is just because I am constantly on it doing vigorous activities and don't have a chance to rest it, or could it be something more serious?

I'll let the Dr. give you an official answer, but it could definitely be a sprain and still hurt for months. Some sprains even need surgery, but it doesn't sound like yours is as bad as some I've heard about if you can still run on it or even walk without turning your ankle. Swelling can take months to completely go down as well.

[Old Sailor]

I'll give ya a whirl Cyanide.

My right knee has no ACL or medial meniscus. I don't have any trouble with the stability of my knee. It has never "popped" again, and it doesn't limit my ability to be active when I want to. I can play squash, hike, climb, etc. I didn't get ACL replacement as I felt it unnecessary.

However, I have noticed over the last year or so that it takes greater effort to get up from a crouching position and my knee aches a little more than usual. It's not a big deal, but I'm not getting any younger.

Would the ACL replacement surgery help with this?

Ian.....it's called Old Age!:r

[kayaker]

Ian.....it's called Old Age!:r

Yeah, I know. But I'm not even 40 yet.:bh

I want to still be able to walk a bit when I hit 50.

[markem]

Yeah, I know. But I'm not even 40 yet.:bh

I want to still be able to walk a bit when I hit 50.

I have a similar problem with my left knee. When I'm good about taking my glucosamine, condroitin, msm (all in one tablet), I have almost no problems. Without it, I can tell when there is a low pressure zone within 200 miles.

Might be worth a try.

[pnoon]

Why does Tom's butt itch? :)

[icehog3]

Why does Tom's butt itch? :)

http://i196.photobucket.com/albums/aa73/icehog3/pnoon.jpg

[Cyanide]

Thanks for the offer. Maybe a little off the traditional medicine question, but a general practitioner is going to get a number of questions pertaining to non-traditional medicine. So here goes:

Can you tell me whether or not you think turmeric/curcumin is an effective anti-inflammatory spice.

Wow, this is going to be fun. I am going to tackle this one first, then once I am done baseboards in the bathroom I might tackle some of the orthopedic questions.

OK, checking through pubmed rather quickly I noticed a review of all available data regarding this directly. Curcumin, which is believed to be the "active component" of Turmeric does seem to have some ability to alter gene expression in animal chondroblasts (cartilage progenerator cells) and is seemingly believed to have some anti-inflammatory effect. Some caveats though would be that, as a supplement, having to go up against the GI system and then the liver before it gets into the blood, its unlikely to show any objective anti-inflammatory benefit systemically. The review article does note that further, properly designed studies need to be conducted before it should be advocated for treatment of inflammatory conditions (this usually means that the available data consists of small crappy studies [SCS] that are not statistically powerful enough to prove anything; to see into the truth, bigger studies with rigid controls are needed). As an aside, osteoarthritis is no longer believed to be a true inflammatory condition and so, this is probably why we aren't seeing much benefit from anti-inflammatories in general (it seems to be more of an analgesic effect we are getting from the drugs).

So, bottom line....in cell cultures it might be beneficial, but the delivery method is probably going to get in the way of experiencing any "real" benefit to the person. That being said, if you believe it helps, and it isn't itself causing you any harm....then its reasonable to give it a shot. Just don't take too much of it, as any ill effects in the face of unlikely benefit is a net decrease in quality of life.

Cheers

John

[pnoon]

http://i196.photobucket.com/albums/aa73/icehog3/pnoon.jpg

You're such a douchebag. :D

[Cyanide]

I'll give ya a whirl Cyanide.

My right knee has no ACL or medial meniscus. I don't have any trouble with the stability of my knee. It has never "popped" again, and it doesn't limit my ability to be active when I want to. I can play squash, hike, climb, etc. I didn't get ACL replacement as I felt it unnecessary.

However, I have noticed over the last year or so that it takes greater effort to get up from a crouching position and my knee aches a little more than usual. It's not a big deal, but I'm not getting any younger.

Would the ACL replacement surgery help with this?

Hey Ian;

The knee is kind of funny, in that there are a number of conditions that can look identical in symptomology. And further, they respond equally well to conservative therapies. But, once they start not conforming to said therapies, then you have to get specific in order to approach the surgical options. That's where MRIs come in.

But, it was reasonable to not repair the ACL, and it may be reasonable to now re-examine the issue to see if things should be approached differently now.

All that said, in the military I find many a soldier with your exact story. Heck, my knee is almost identical in story as well. What it probably boils down to in this case is something called Patellofemoral Pain Syndrome, also known as Chondromalacia Patellae. This is where the knee-cap doesn't track through the groove at the end of the femur (upper leg bone), and as a result gets torn up pretty bad. It leads to stiffness and pain after long periods of sitting (this is called the "moviegoers sign"). What is causing this mis-tracking is a mis-alignment of the tibia (lower leg bone) in relation to the knee. This in turn is commonly cause by fallen arches (either obvious; or "dynamic" where you only see the collapsing inwards when you shift from non-weight baring to weight baring). As the foot collapses inwards, the tibia is slightly angled inwards, meeting the femur at the knee at a slight angle. Now the kneecap tries to jump-rail when the leg is straightened.

I commonly see this in knees where some of the other structures are damaged. This decreases your "physiologic reserve" to compensate for the fallen arches (by simply pulling everything into place through brute strength) and the mal-alignments are allowed to unveil themselves.

So, what do you do?

1) Increase that physiologic reserve by a) strengthening all the muscles groups or b) repairing that ACL (but you can't repair the meniscus)

2) grab some good sturdy orthotics (I find generic, off the shelf ones are best because they are relatively cheap which makes it easy to replace when they wear out, roughly at the same rate as a pair of running shoes), and have a look at how old the soles of your shoes are. People find their knees start to hurt more as their shoes age.

When you get back to Edmonton here I will have a look.

Cheers

John

[Cyanide]

I will tackle Fumes' next. But in the meantime, do a search on my posts and you will see that I put in some fairly lengthy posts into a back-pain thread about a month or two ago. It would be good background reading. I will re-read it myself and may just post a link to it if I think it covers the info well enough.

But for now....

Back to painting (baseboards are done)

[kayaker]

Thanks for the info John. :tu

I appreciate the help.

[Cyanide]

... I'm wondering if it gives us any new ideas as far as diagnosing the cause of her back spasms. Maybe it was just a reaction to the pain?

Thanks for any suggestions, Doc! Great idea for a thread! :tu

What studies are showing us is that we really don't have a strong grip on the cause of many cases of chronic (or in this case, recurrent) back pain. Reasonable clinicians are starting to dismiss the discs as the cause of all back-pain (and really limitting it to the rare occassions where the discs are actually pressing on nerves).

But, that doesn't leave us with many convincing stories to tell. And, it leaves it up to us to create a compelling fiction to fill the gaps. I just so happen to have one of those "compelling fictions", good enough that I have even convinced myself that it may have validity.

Many back injuries will result in some muscle damage, either from the actual trauma or from the huge muscle contraction you exherted to try to avoid the trauma, pulling the muscle. When the muscle heals, well it heals with scar tissue instead of regenerated muscle fibres (muscle-building is a different process)

Scar tissue has a number of characteristics:

1) its never stronger than 70% the tissue architecture it replaced
2) It has no contractive function, its not a muscle
3) It shrinks over time. Look at any scar on your skin, if its large enough it will have a puckered edge, it shrank (you could easily find exceptions to this)
4) It is heavily innervated with pain nerve fibres.

So, what this leads to is a case where, the moment a scarred muscle starts to fatigue too much through heavy strain (twisting while carrying something) or through prolonged use (like sleeping in a bad position), it lengthens under load, surpassing the length of the scar, the weak scar starts to tear, sends off massive numbers of pain signals to the central nervous system. In a reflex loop, signals short circuit back to the muscles to tell them to go into a massive contraction to protect themselves under load and then this loop just keeps cycling on itself.....resulting in muscle spasm.

Finally, imagine all the other nerves that have to traverse from the spine to the periphery. They have to pass around and through all the structures in between point A and point B. Scars love to entangle anything near them as they develop. Its not unreasonable to think that some of these nerves could get caught up in the scar tissue, and thus get tethered down to nearby muscles. As the muscles go into spasm, they wrench on everything attached to them, including the nerves. Nerves don't work well under mechanical tension and thus the numbness would occur. You wouldn't feel the nerve geing stretched. But you would feel odd sensations/pain in the area of the body the nerve served. The brain doesn't know anything about where the nerve travels, only what regions it innervates.

Hope this is helpful..

Cheers

John

[Cyanide]

I sprained my ankle pretty bad in PT almost a month ago and it is still a little bit swollen. It doesn't really hurt that much any more but the fact its still swollen has me wondering if it is just because I am constantly on it doing vigorous activities and don't have a chance to rest it, or could it be something more serious?

Its not unreasonable for this thing to continue to swell for a while. I could speculate an anatomic cause, but it would be largely a fable involving healing tissue being leaky and repetative strain making it more pronounced. The key though is that it doesn't continue to hurt without (even gradual) improvement. It may get tight and uncomfortable because of the swelling, but if that "OMG something bad just happened" flash of pain, you are probably OK. All that said, I certainly wouldn't train at 100% until things were 100%...I don't know, keep it down to 75-85% effort :)

And stretch it out before/after. That story about scar tissue above, that would apply here as well....so the more limber the ankle is while it is healing (within reason of course) then the more likely the scar tissue won't shrink to a performance-hindering "shortness"

[gettysburgfreak]

thanks for the info doc

[Cyanide]

thanks for the info doc

What I should add to this would be to wrap the ankle before PT if at all possible. Since you are using the term PT, I assume you have access to a base pharmacy and MIR. Pick up some Coban. Its really great stuff; self-adherent, thin tensor bandages stuff.

The wrap will prevent the swelling.

PRICE works great for most soft tissue injuries. Originally developed for ankles, but pick and choose the rational elements for the injury at hand.

Protection, Painkillers
Rest
Ice
Compress
Elevate

[Cyanide]

how do you cure scalp feliculitis, noting that a 10% panoxyl soap bar has gotten you no where?

I haven't seen much scalp folliculitis. It is interesting that it is being treated with a benzyol peroxide solution. If it were a limitted, easy to get to area, I would treat it with something like polysporin or mupirocin (sp?) twice a day for 10 days. If that didn't work or if it were a hard to get to area (like a hair covered scalp) then I would go more for a system (pill) antibiotic like cloxicillin or erythromycin. All that said, I would certainly take a second look at it before concluding its a bacterial infection of the follicles on the scalp. I would be looking for another diagnosis (like pustular seborrheic keratosis) or an underlying cause and treat that.

If it were hard enough to treat I would certainly go ahead and swab it and await lab results to determine if it were anything more problematic than a typical skin-borne bacteria causing it.

[Cyanide]

Why does Tom's butt itch? :)

I believe it is because Tom's butt was always meant to itch. Without an itch, one could not define Tom's butt. It's like saying "Why is the sun hot?"

[Cenookie]

First of all thanks, a couple months ago I was helping a friend move furniture when I felt what I can only describe as a warming sensation and pain in my shoulder. I immediately lost strength in my shoulder. In fact I wasn't able to put my truck in gear to drive home. My shoulder only hurts when I move it a certain way. And at night in bed it's not a pain like in the muscle, but more of an ache. I can massage it and fell no sore spots, but move it a certain way and PAIN.

[Cyanide]

First of all thanks, a couple months ago I was helping a friend move furniture when I felt what I can only describe as a warming sensation and pain in my shoulder. I immediately lost strength in my shoulder. In fact I wasn't able to put my truck in gear to drive home. My shoulder only hurts when I move it a certain way. And at night in bed it's not a pain like in the muscle, but more of an ache. I can massage it and fell no sore spots, but move it a certain way and PAIN.

Move it which way? How about holding arm straight down at side with palm facing forward. As you rotate the shoulder up to the side (like a properly on a plane, spinning), and then over the top until you touch the opposite shoulder with your thumb (with elbow over head. Does that hurt? Maybe reaching behind your back to scratch your back with your knuckles. Does that hurt? How about holding elbows tight to side and then rotating forearms outwards. Does that hurt?

I am presuming right off the bat that you may be dealing with a rotator cuff injury. However the differential diagnosis (its the concept of "a list that contains every diagnosis that a particular condition could be"...things only get struck off the list when they can no longer possibly explain the situation) would also include a biceps tendon rupture (but I think you would describe the situation differently).

And by the way....Tom might have worms. That might explain the itch.

[Opusfxd]

I'll give this a shot. It feels like I have a NASCAR restrictor plate in my adam's apple area. Sometimes it gets constricted and restricts my breathing. Whether it's going up the stairs, running a few miles, riding the bike it feels like I could be fine if I could only get enough air into my lungs past this constriction. BTW, thanks to sleep apnea I have no uvula, tonsils and my sinuses have been reamed out. I also have incredibly active sinuses. Any guesses?

[sikk50]

Ok, I'll play.

When I first moved to Chico they had these weird things called "seasons," yea we don't have those in SoCal. So naturaly the trees lose their leaves and polonate rather more dramaticly than down south. Sortly after the move I had the worst sore thoat of my life, so bad that it would wake me up at night, it lasted for a couple weeks with verying degrees of intensity. During that time I also suffered from swollen tonsils, pink eye (first time in my life) and plugged ears. My insurence didn't work up here so I went to the schools med place and she said it was allergies intensified by a nasty cold that had been going around of some sort and just gave me a script for sudifed. Well it helped but I was still displeased and drinking three cups of hot lemon tea and honey a day was rather old at this point so i went to the health clinic. There the doc said that I had a sinus infection at was looking pretty brutal and that he felt that was the cause off all of this, saying as it would max out one area it would move to another. He gave me Leviquin. It helped, but I still wasn't top notch for a week or so after the pills were gone.

Anyway regardless to this day I have wat look like little bumps on the soft tissue above my dangley ball thing in my throat. My family doctor has looked at this and asked promptly if I drink a lot of hot liquids, "why yes, about a whole pot of coffee daily." Do you drink alcohol, "well its safe to say there wont be any breweries closing while I'm around." Do you smoke, "5 cigars a week." then he says that its just an irritant because of all of these things. Now I may just not have paid that much attention to the inner dynamics of my mouth before this ordeal, but I feel fairly confident the little bumps came with that. They don't bug, no irritation, just there hanging out, rather small, about like a pin poke size.

What do you think doc?

[bonjing]

What do you think doc?

Stop hanging around Darrell :r


;s

[sikk50]

Stop hanging around Darrell :r


;s

:(

[RGD.]

My grandfather died from a pulmonary embolism. He actually had what they said was a saddle pulmonary embolism and several clots in his left leg. One of the left leg clots actually ripped the artery as it traveled and there was nothing that could be done.
Last spring my mother survived a saddle pulmonary embolism and four clots in her left leg.
A couple of months ago one of my brothers (8 years my junior) wasn't feeling good and drove himself to the hospital. He collapsed in the hospital parking lot. He also had several clots in his left leg and a saddle pulmonary embolism.

So - can this be something hereditary. I'm nervous for my other younger brother and sister. Is there something they should be doing? Check ups or screening of any kind?

Having three family members with the same thing kinda puts you on edge.

Thanks,

Ron

[Cyanide]

My grandfather died from a pulmonary embolism. He actually had what they said was a saddle pulmonary embolism and several clots in his left leg. One of the left leg clots actually ripped the artery as it traveled and there was nothing that could be done.
Last spring my mother survived a saddle pulmonary embolism and four clots in her left leg.
A couple of months ago one of my brothers (8 years my junior) wasn't feeling good and drove himself to the hospital. He collapsed in the hospital parking lot. He also had several clots in his left leg and a saddle pulmonary embolism.

So - can this be something hereditary. I'm nervous for my other younger brother and sister. Is there something they should be doing? Check ups or screening of any kind?

Having three family members with the same thing kinda puts you on edge.

Thanks,

Ron

I will answer this one next, then later see if I can handle a couple of the others.

MOST CERTAINLY, there are about a dozen genetic/heritable conditions that could lead to this sort of story. With so many people having similar stories in your family I would definitely get them all lined up to do the testing.

Depending on what the genetic distribution of the specific condition is, you may be looking at 50% of your siblings having it. If you do not have it, then your children would not be able to have it. But, different conditions distribute in different ways....thus everyone should still get tested.

[Cyanide]

NASCAR restrictor plate???

I haven't a foggiest regarding what that is. We don't have any real NASCAR in Canada so I don't even recognize the reference.

That being said, it sounds like you have something obstructing the area. Well, that wasn't all that helpful right? This could either be because of anatomical masses (but seeing you have had an ENT-ream-out-job, then I doubt that), or it could be due to secretions (sinus related). Another potential might be due to a cyst of some sort, maybe a thyroid cyst (or enlarged thyroid), or possibly a pharyngeal branchial cyst (remnant of a gill slit...believe it or not).

A simple physical exam (maybe with some simple blood work) might give you some answers.

[mosesbotbol]

Thanks for the offer. Maybe a little off the traditional medicine question, but a general practitioner is going to get a number of questions pertaining to non-traditional medicine. So here goes:

Can you tell me whether or not you think turmeric/curcumin is an effective anti-inflammatory spice.

Interesting as I am turmeric crazy in my cooking. I put it in just about everything. I know it is common to mix tumeric in milk when giving to children (in India).

[Cyanide]

Ok, I'll play.

When I first moved to Chico they had these weird things called "seasons," yea we don't have those in SoCal. So naturaly the trees lose their leaves and polonate rather more dramaticly than down south. Sortly after the move I had the worst sore thoat of my life, so bad that it would wake me up at night, it lasted for a couple weeks with verying degrees of intensity. During that time I also suffered from swollen tonsils, pink eye (first time in my life) and plugged ears. My insurence didn't work up here so I went to the schools med place and she said it was allergies intensified by a nasty cold that had been going around of some sort and just gave me a script for sudifed. Well it helped but I was still displeased and drinking three cups of hot lemon tea and honey a day was rather old at this point so i went to the health clinic. There the doc said that I had a sinus infection at was looking pretty brutal and that he felt that was the cause off all of this, saying as it would max out one area it would move to another. He gave me Leviquin. It helped, but I still wasn't top notch for a week or so after the pills were gone.

Anyway regardless to this day I have wat look like little bumps on the soft tissue above my dangley ball thing in my throat. My family doctor has looked at this and asked promptly if I drink a lot of hot liquids, "why yes, about a whole pot of coffee daily." Do you drink alcohol, "well its safe to say there wont be any breweries closing while I'm around." Do you smoke, "5 cigars a week." then he says that its just an irritant because of all of these things. Now I may just not have paid that much attention to the inner dynamics of my mouth before this ordeal, but I feel fairly confident the little bumps came with that. They don't bug, no irritation, just there hanging out, rather small, about like a pin poke size.

What do you think doc?

When you say "on the soft itssue above my [uvula]", I presume you mean the soft-palate (soft part of the roof of the mouth, posterior to the hard-palate).

Well, you had me on this one, so I did a little research. At this time I will plug a little more info for the layperson (I intend on slipping this stuff in all over the place). A particularly good website for researching information for yourselves is the patient section of uptodate . com (http://www.uptodate.com/patients/index.html). The doctor end of this website is becoming the world leader in condensed medical information. Its my first source (then I go through many other sources as needed). Both ends are written by world experts on the topics they write.

In this case, the research didn't change what my approach would be regarding this one (it confirmed that some fears were warranted, and that no easy "better diagnosis" was immediately obvious to the specialists).

This is a case where having eyes-on is very important. Its what determines is on the differential diagnosis and what is not. But, let me tell you, when a medical student comes to me with this sentence:

"My patient is a daily cigar smoker who occassionally drinks alcohol and has noticed persistent non-painful papules to his soft-palate over [insert timeframe here...months? years?]" then the first thing that should come to my mind is cancer. In fact it is what we call a an UPO diagnosis (until proven otherwise). Now, don't freak out to much. Its probably not cancer. But, I would want to be 100% comfortable with being able to say "its not cancer" before I would be so bold. Maybe in your case having a brief look at it would make a physician comfortable that, indeed, it is not. Otherwise, a biopsy would be in order.

Keep in mind, that the majority of mouth mucosal cancers start out as "pre-cancer" lesions and stay like that for a very LONG time. Only if ignored long enough, combined with a large amount of bad-luck do they transform into cancer. A biopsy would tell you if it were pre-cancer or not, and give plenty of time to cut it all out and aim for cure.

Finally, many of these mouth/throat cancers are conditions of chronic exposure over LONG periods of time. I assume you may be fairly young (sounded like you were talking about university life, so likely you are fairly young). If that is the case, then the invincibility of youth is on your side (in that you probably haven't been exposed to daily cigar smoke for 20 years), providing you take the steps to rule it out.

[sikk50]

Thanks for the tip. I'm 23 I've only been smoking for barely two years and didn't drink till I was 21. That was my fear when I went to the doc but he assured me not to worry just figured I'd see what you thought on the whole thing.

[Cyanide]

There are 5 crucial questions to ask when you are playing with thoughts of oral cancers:

Bleeds? (mouth, nasal)
Skin changes? (in the mouth, around the mouth)
Throat/ear pain?
Obstructions?
Voice changes?
Enlarged lymph nodes?

Well that's six, but really two of them fit together in my mind. And of course, answering yes to these doesn't mean cancer (a sinus infection could have you answering yes to 5 of them), but it does sharpen your focus.

[bonjing]

Thank you John for providing information.

[sikk50]

Yes thank you!

Something I neglected to mention is that they are almost unnoticable anymore and the thing my doc said he would attribute them to most likely is my horendous allergies. But I must tell you, everything you have said are the samethings my doc and I talked about. Just wanted to see what another doctor had to say. :) hope I gave your noddle the jog you were looking for, and I will deffinatly keep an eye on it :tu

[Cyanide]

Glad you caught it the way I pitched it. I was feeling a little anxious cutting you the straight deal over an online forum like this. The C word is not one I like to throw out there and leave festering on its own.

[sikk50]

Nope, no worries. It'd be different had I not already had it checked out.

[Fumes]

So, what this leads to is a case where, the moment a scarred muscle starts to fatigue too much through heavy strain (twisting while carrying something) or through prolonged use (like sleeping in a bad position), it lengthens under load, surpassing the length of the scar, the weak scar starts to tear, sends off massive numbers of pain signals to the central nervous system. In a reflex loop, signals short circuit back to the muscles to tell them to go into a massive contraction to protect themselves under load and then this loop just keeps cycling on itself.....resulting in muscle spasm.



Hmm...very interesting. Mrs. Fumes is a grad student and has been spending an inordinate amount of time sitting on a very worn out couch with her laptop and several large stacks of papers. I suggested that she get up and stretch occasionally, but oh no, there's too much work to do and no time. I would expect that sitting in an ergonomically inappropriate position for extended periods of time might be a trigger for back spasms.

This was quite enlightening! Thanks for taking the time, John.

[kgoings]

I read and hear alot about the hunter gatherer diet, and how with the agricultural revolution we started consuming high amounts of grains and carbs that threw off our bodies.

What is your opinion on this?

[Cyanide]

Well, I had never formally heard of "the hunter-gatherer diet" AKA "paleolithic diet" until you mentioned it here.

And, I can't say that 15 minutes later I am an expert on the topic.

But, it seems to push a high meat content, followed by wild grains, foraged plant materials etc. The big push regarding this diet is the proposed lack of signs/symptoms of cardiovascular disease, with some bandwagoning in "diabetes, ... cancer, auto-immune diseases, obesity".

From what I see so far there isn't any smoking gun. Unfortunately, some of the websites I have perused do seem to take on a fervor that makes me concerned for what lays beyond.

The claims regarding ridding yourself of these disease really does not have much foundation on which to stand. I would doubt that the studies could really control for enough variables to determine what the causation was. Hunter-gathering leads traditionally to expending lots of energy to obtain the food and probably not gathering an abundance of food. Its the agriculture evolution that probably was one of the first steps to allowing humans to start advancing in population and technology, as food became easy. I think the evidence is really pooling in that a calorie restricted diet may be one of the most effective ways to live as long as possible, at least in animal models. But that leads to emaciation, lethargy and generally a "not fun" life. Your metabolism probably slows down so much that you live longer, wishing you were having fun. Animals don't mind much as they are really just worried about surviving one second to the next. So, lack of food availability probably takes care of obesity, diabetes and by extension cardiovascular disease. I was not able to find any relavent sources, but I do imagine the life expectancy was pretty low in hunter-gatherer eras. Trauma, starvation, infection probably killed most humans then. Only once food was easy to get did we live long enough to die from cancers. Auto-immune diseases? I think that is a red herring. While they are interesting and shocking, they are relatively rare. Including them would only be for the shock value and probably a complete fiction.

I don't think that grains and carbs are the route of dietary evil. I do think that they are cheap and easy to produce and thus are highly utilized in food products. Combine that with overeating and you are almost guaranteed to be eating too many carbs. But that will probably be true for fats as well, not so much protein. For some reason protein doesn't factor high into a poor (which commonly coincides with cheap) diet.

I like to stay active, otherwise I would seriously consider the calorie-restriction thing (isn't the Bernstein diet like this?). But, then, a week in, I would probably hunt down a kid in my neighbourhood and eat them. So, reasonable diet is for me.

If one wanted to be a full thinker in designing a diet, they would first start with what their calorie requirement is. I think mine is about 2400 a day just to live (I am a big guy) then add my exercise expenditures (probably 1200-1500 a day, 10km+ a day). If I wanted to loose weight I would come in under that sum. Otherwise, aim for that sum.

Then decide what the required protein is. I believe the researched requirement per day is approx 0.76 gram/kg body weight for grams of protein a day. Alot of people round that up to 1gram/kg. This is the type of numbers when the dieticians calculate out diets for hospital patients with dietary components to their treatments. It is based on various rigorous studies that I trust (but don't have references to anymore). Then subtract out the calories from that protein (4 cal/gram protein approx). Then calculate the fat. I think its 30% calories from fat, no more than 30% of your fat being saturateds. Fat is 9cal/gram. Then the rest can be carbs. Include at least 30gram fibre into your carbs every day.

Include an exercise program that involves 40 minutes cardio/aerobic (pace that leaves you breathless if you try to converse while doing it) 3 times a week. With that, you are probably sitting on about as healthy a diet as need be.

All the micro-nutrients (vitamins/minerals) will probably be easily satisfied with any balanced food sources you choose (BALANCED, no excluding groups) and you won't have to worry about deficiencies (despite the absolute non-truths spread onto the public) except maybe vitamin D if you don't get enough sun, folate for fertile females, iron for females with heavy cycles.

No nutritional therapies will "boost the immunity" (unless you are actually correcting a true vitamin deficiency). You cannot boost the immunity. The only thing that "boosts the immunity" is inflammation and infection....and that's more a case of stimulating the immune system you already had. You may develop immunity from a particular pathogen that attacked you, but you will not have a "stronger/more potent" immune system. The only diseases that can realistically be treated with dietary therapies are those that involve dietary abnormalities (obesity, diabetes, cholesterol). Cancer will laugh at your dietary changes. If anything, better nutrition will strengthen a cancer, by strengthening you maybe, and thus freeing up more resources the cancer can use up. That being said, don't kill a cancer by killing the host.

I have kind of gone all over the place with this post, and in turn, only touched very briefly on many topics. Hopefully I have hit some of the important ones at a useful level of detail.

Cheers

John

[sikk50]

What does it mean if in the last year you went from drinking like a camel to getting hang overs that last several days after moderate drinking?

Not me, my girlfriend. It's quite curious, shes been thinking of going to the doctor, but she decided it was easier to just become my all time designated driver :)

[mosesbotbol]

Cy:

What are your thoughts on human growth hormone and testosterone treatment on people over 35 years of age?

[Cyanide]

What does it mean if in the last year you went from drinking like a camel to getting hang overs that last several days after moderate drinking?

Not me, my girlfriend. It's quite curious, shes been thinking of going to the doctor, but she decided it was easier to just become my all time designated driver :)

This is another creative answer that should be taken as only a hypothesis only.

If indeed this is a rational correlation (eg alcohol is always sufficient to cause the "hang over" and also required to attain this "hangover"), then my initial thoughts would be:

for some reason, this person has had a significant decrease in their ability to clear/metabolize alcohol or its metabolic by-products. Alternatively, it could represent a decreased tolerance in the effects of alcohol.

Maybe new/changed medications (assume caffiene in here, or other physiologically active substances)? Decreased liver/kidney functions, decreased hydration (due to long standing behavioural change?), maybe a there is a possible deficiency? It would be reasonable to consider vit B12 (females need lots but typically have lots, due to menstrual reasons, but this also has an effect on nerve/brain function....run a little anemic, use up some more B12, run into changes in nerve function).

I am speculating wildly here.

[Cyanide]

Cy:

What are your thoughts on human growth hormone and testosterone treatment on people over 35 years of age?

That one deserves some research. I will get back to you on this one in a couple of days (right now I am "on duty" for walk-ins for my whole base, and then I work a clinic for rest of night....and then the Friday shift starts)

[kgoings]

Well, I had never formally heard of "the hunter-gatherer diet" AKA "paleolithic diet" until you mentioned it here.

And, I can't say that 15 minutes later I am an expert on the topic.

But, it seems to push a high meat content, followed by wild grains, foraged plant materials etc. The big push regarding this diet is the proposed lack of signs/symptoms of cardiovascular disease, with some bandwagoning in "diabetes, ... cancer, auto-immune diseases, obesity".

From what I see so far there isn't any smoking gun. Unfortunately, some of the websites I have perused do seem to take on a fervor that makes me concerned for what lays beyond.

The claims regarding ridding yourself of these disease really does not have much foundation on which to stand. I would doubt that the studies could really control for enough variables to determine what the causation was. Hunter-gathering leads traditionally to expending lots of energy to obtain the food and probably not gathering an abundance of food. Its the agriculture evolution that probably was one of the first steps to allowing humans to start advancing in population and technology, as food became easy. I think the evidence is really pooling in that a calorie restricted diet may be one of the most effective ways to live as long as possible, at least in animal models. But that leads to emaciation, lethargy and generally a "not fun" life. Your metabolism probably slows down so much that you live longer, wishing you were having fun. Animals don't mind much as they are really just worried about surviving one second to the next. So, lack of food availability probably takes care of obesity, diabetes and by extension cardiovascular disease. I was not able to find any relavent sources, but I do imagine the life expectancy was pretty low in hunter-gatherer eras. Trauma, starvation, infection probably killed most humans then. Only once food was easy to get did we live long enough to die from cancers. Auto-immune diseases? I think that is a red herring. While they are interesting and shocking, they are relatively rare. Including them would only be for the shock value and probably a complete fiction.

I don't think that grains and carbs are the route of dietary evil. I do think that they are cheap and easy to produce and thus are highly utilized in food products. Combine that with overeating and you are almost guaranteed to be eating too many carbs. But that will probably be true for fats as well, not so much protein. For some reason protein doesn't factor high into a poor (which commonly coincides with cheap) diet.

I like to stay active, otherwise I would seriously consider the calorie-restriction thing (isn't the Bernstein diet like this?). But, then, a week in, I would probably hunt down a kid in my neighbourhood and eat them. So, reasonable diet is for me.

If one wanted to be a full thinker in designing a diet, they would first start with what their calorie requirement is. I think mine is about 2400 a day just to live (I am a big guy) then add my exercise expenditures (probably 1200-1500 a day, 10km+ a day). If I wanted to loose weight I would come in under that sum. Otherwise, aim for that sum.

Then decide what the required protein is. I believe the researched requirement per day is approx 0.76 gram/kg body weight for grams of protein a day. Alot of people round that up to 1gram/kg. This is the type of numbers when the dieticians calculate out diets for hospital patients with dietary components to their treatments. It is based on various rigorous studies that I trust (but don't have references to anymore). Then subtract out the calories from that protein (4 cal/gram protein approx). Then calculate the fat. I think its 30% calories from fat, no more than 30% of your fat being saturateds. Fat is 9cal/gram. Then the rest can be carbs. Include at least 30gram fibre into your carbs every day.

Include an exercise program that involves 40 minutes cardio/aerobic (pace that leaves you breathless if you try to converse while doing it) 3 times a week. With that, you are probably sitting on about as healthy a diet as need be.

All the micro-nutrients (vitamins/minerals) will probably be easily satisfied with any balanced food sources you choose (BALANCED, no excluding groups) and you won't have to worry about deficiencies (despite the absolute non-truths spread onto the public) except maybe vitamin D if you don't get enough sun, folate for fertile females, iron for females with heavy cycles.

No nutritional therapies will "boost the immunity" (unless you are actually correcting a true vitamin deficiency). You cannot boost the immunity. The only thing that "boosts the immunity" is inflammation and infection....and that's more a case of stimulating the immune system you already had. You may develop immunity from a particular pathogen that attacked you, but you will not have a "stronger/more potent" immune system. The only diseases that can realistically be treated with dietary therapies are those that involve dietary abnormalities (obesity, diabetes, cholesterol). Cancer will laugh at your dietary changes. If anything, better nutrition will strengthen a cancer, by strengthening you maybe, and thus freeing up more resources the cancer can use up. That being said, don't kill a cancer by killing the host.

I have kind of gone all over the place with this post, and in turn, only touched very briefly on many topics. Hopefully I have hit some of the important ones at a useful level of detail.

Cheers

John


My interest in the palio diet is more from just living healthier, not so much trying to get rid of disease like you mention.
I am reading a book “The Palio Diet” and in the introduction it talks a little bit about some points you talked about. In the small amount of studies that have been done on indigenous populations, aka hunter-gathers they all seem lean, muscular, and fit. Some of that can be attributed to having to fight for their food, but some has to be accounted for in diet don’t you think? In all of the few studies they found almost no heart disease and High Blood Pressure was unheard of. Two of the studies mentioned were of the Yanomamo Indians of northern Brazil and southern Venezuela, and the Greenland Eskimos.
It talks about commercially grown meat being much fattier than the meat of the animals hunted down by the hunter-gatherer. About the hundreds of percentage increase in the amount of grain that we consume since the Agricultural Revolution. And how maybe, our bodies were not designed to process that much grain and carbohydrates.

I am not sold yet, but it does ‘make sense’ when you start thinking about it and how the body works. I heard a trainer talking about the diet to someone else about it and decided to take a look. Since I have found several of my co-workers who have been living this lifestyle for several years. None of them are super workout freaks (or even work out at all) and they all are very fit and trim. One of my co-workers said that since he switched his diet, his high-blood pressure and high cholesterol are gone, 4 years now he has been on the diet and he had cholesterol in the high 200’s before. He says he Palio’s during the week and then will kind of carb load on the weekend, or at least one day a week.

It all seems very interesting.

[mosesbotbol]

If you want to make dietary change that is really going to make a difference in your life, check out Food Combining. A few colonics and adjusting to this style of eating will turn you around in no time! Between Food Combining and not eating like you have two arses, you'll see changes very quick.

There's a ton of free stuff on the web that will get you eating "correct".

Food combining
'Food combining' refers to the combination of foods which are compatible with each other in terms of digestive chemistry. Food combining is a basic component of optimal nutrition because it allows the body to digest and utilize the nutrients in our foods to their full extent.

The discomforts of indigestion are so common in today’s society that indigestion is almost considered normal. The fact that over 2 billion dollars are spent each year on antacids is proof of this.

[Cyanide]

To be honest, any "diet" that is balanced (meets the requirements to sustain life) and is itself not excessive, is probably a good diet. This would be no exception. I just wanted to caution against some of the claims I had read being propogated about this diet as well as offer some rationale towards deciding on what one's "diet" (dietary habits) should be.

Over time I have cut out alot of refined products, first as an attempt to "get more healthy" and now its just because the taste is more satisfying (for instance, white bread just tastes gross now) and I feel more satieted in general.

If the paleo diet is implemented as a balanced option, it looks rather interesting (from the little I know about it).

[bonjing]

got a question for you, other than the obvious answers (fire alarm or intruder), is it dangerous or harmful to sleep with earplugs on?

[Rabidsquirrel]

I can't answer from a doctors standpoint, but from a construction workers standpoint having earplugs in for long periods of time tends to let wax build up in the ear.

[Cyanide]

That's the stance I would go on as well. Also realize that long-standing presence of earplugs may compromise the integrity of the skin in there and lead to infection. I have seen plenty of "benign"-ish looking foriegn bodies in ears causing ulcerations in the canal that subsequently get infected.

[Cyanide]

As for growth hormone and testosterone therapies....sorry I have been delayed on putting this up....paste excuse here....

The whole issue of hormone supplementation is fairly muddled and has not been yielding many strong answers.

I was at a talk by an endocrinologist last week and he flattly denied that "andropause" existed in any great capacity.

He admitted that the hormones decreased in concentration, he confirmed that some men do experience a syndrome of pathologically decreased hormone levels that manifest itself with concrete symptoms and consequences that should be treated. But he stated that the large scale supplementation of the aging male population with testosterone was probably a distaster in the making.

For the most part I would agree with him, but include the the evidence isn't strong one way or the other. Testosterone therapies do not increase the cholesterol (for a while it was presumed the opposite), do increase endurance, bone density, mental performance etc etc. But, there could be a whole slough of bad side-effects that we may not have the experience to see them clearly yet (liver failure, cancers, heart disease [though this may swing either way]) etc.

The situation at this point, to the extent of my knowledge, is similar for HGH. It really sounds intriguing. There is established conditions that are thought to be the result of low levels of HGH, of course. And, there is a tendency for it to drop with age. But a distinct condition due to this gradual "natural" decrease has been hard to characterize, and the treatment of it may have hidden dangers we are not fully aware of yet. Some consequences that are currently understood include liver dysfunctions, arthitis-like joint problems, diabetes, sleep disturbances, nerve and eye problems.

But, this is not really an adequate review of this topic. When you get into the "meat of the issue" much of it seems to be lead by specialist conjecture, opposing interpretations and lack of consensus. That is usually a good sign that we don't really know enough about it to make reliable practice decisions at this time.

Hope that isn't to "limp" of an answer....its the best I have at this time.

Cheers

J

[bonjing]

Thanks for the answers John and Rabid :) not the answer I was hoping to hear :(, but better than me screwing up or getting an infection in my ear :tu. Back to the pillow over the head method. :sleep:

[Tenor CS]

Here's a question for Dr. John:

I went to the emergency room on Monday morning.

My symptoms: dizziness, pounding heart, nausea (vomited twice), weakness, especially in the legs - felt like I was going to pass out.

I have a history of high blood pressure (take 20mg Lisinopril per day) and hypothyroidism (take .75 mg levothyroxine per day). No diabetes.

I was admitted. They ran 4 EKG's over 48 hours, all normal. Blood tests were mostly normal, high WBC count (14-ish). Head CT scan showed no abnormalities. Chest X-ray was normal.

The on-call doc's diagnosis was labyrinthitis. They gave me 4 doses of methylprednisolone, 6 hours apart. Also, given an rx for meclizine, every 8 hours for the dizziness.

Questions:

1. The next day, my blood tests showed a much higher WBC count, in the 21-22 range. Could that be caused by the steroids? I have always had high WBC counts, and no one can seem to figure out why. About a year ago, a hemotologist ran all kinds of tests on me, including C-Reactive Protein, Sedimentation Rate, and some others, and nothing screamed "cancer" at her.

2. I have been getting EXTREMELY short of breath and heart pounding after the mildest exertion. Sometimes just even standing up causes it. Walking up a flight of stairs is murder right now. It's a little better this morning, but still worrisome. I was in school yesterday and was late to classes because I literally could not make it across campus in 15 minutes without stopping. Full disclosure: I am morbidly obese, 5'8" and about 380 lbs. But this shortness of breath and heart pounding is 10 times worse than anything I've gotten used to just being a fat guy. Could the shortness of breath and heart pounding also be caused by the steroids? How dangerous is it? At what point should I seek medical attention for it?

Thank you

[Cyanide]

Sorry for not seeing this earlier, I have been away with the military alot over the last month and a half.

First off, the steroids could be responsible for the leukocytosis (elevated WBC) and this could be a relatively quick response (as it is believed that the steroids affect the adherence of the WBC to the blood vessel walls, making it look like they have suddenly increased). However, I would expect this to subside quickly and thus should not be present in further blood work.

I would have a hard time excluding cardiac syndromes in the face of your story, without "casting eyes upon you" myself. Mind you, it is completely in keeping with a viral syndrome (run of the mill virus) that resulted in a labrynthitis. I would expect the shortness of breath on exertion and palpitations to be in support of this (as well as a million more dangerous things).

The yard-stick I would use to determine whether to seek further care would be that a) it isn't resolved already, considering this was over a week ago when you wrote this or b) if it continued to get worse (decreasing levels of activity resulting in similar symptoms, or symptoms getting worse at a standard activity level.

Beyond that, providing they did a reasonably-full cardiac work up, considered clots in the lungs, clots in the brain, narrowings of the carotid arteries, pneumonia and aortic artery conditions (and it seems like they probably did, considering these conditions doesn't necessarilly mean throwing every study imaginable at them....maybe just being reasonably certain you don't fit the MO of such things), I would say they would likely catch all the dangerous stuff.

I hope this helps, but considering this was a week ago you posted, I imagine you aren't in need of my help anymore. ;)

[Tenor CS]

Thanks for your reply, Dr. John. I feel fine now :)

My BIL is an ER doc and he told me pretty much what you said.