Sub-conjunctival haemorrhage

Sub-conjunctival haemorrhage is a leak of blood, from a blood vessel, over the white of the eye (sclera). It looks quite dramatic, but will not do you any serious harm. 

Symptoms

The main thing you will notice is a dramatic red patch over the white of one of your eyes. This is limited to the white of the eye. It usually comes on all of a sudden, with no apparent cause, although sometimes it accompanies an obvious injury.
Frequently you will not notice anything until you get a comment from someone else, or you get a surprise when you look in the mirror. Occasionally there is a slight irritation, stinging, or awareness of something not feeling right. It does not affect the vision. If you have a red eye and problems with your vision you should contact a doctor to look for other causes.
The blood, that has leaked from a tiny blood vessel, shows up dramatically on the white of the eye and may just spread across a segment of the white, or cover almost all of it.
The leaked blood is held in place over the white of the eye by a thin, clear membrane (the conjunctiva). The conjunctiva is fixed to the surface of the eye around the outside of the coloured ring on the eye (the iris) and therefore it is impossible for the blood from the haemorrhage to spread across the central part of the eye that we see through. That means that, although a sub-conjunctival haemorrhage looks dramatic, it cannot harm your vision.
The blood will stay there for some days, and slowly go through the same colours that a bruise does as it is absorbed by the body. It takes longer to change colour than a normal bruise, because the membrane is so thin that oxygen from the air can get to the blood to some degree.

Causes

Most times it is not clear what has caused the sub-conjunctival haemorrhage. It may be that a tiny blood vessel has burst with coughing or sneezing, or something has caught the surface of the eye.
If you have been banged on the eye or face it is clear what has caused the haemorrhage.
On rare occasions it is associated with a problem with the clotting of the blood eg in people taking anticoagulants or aspirin, or people with bleeding disorders.

Diagnosis

Most times you do not need to do anything about a sub-conjunctival haemorrhage.
If in any doubt, however, it may be worth discussing it with a doctor or nurse. This can usually be during routine hours.
Your doctor will make the diagnosis by a quick glance at the eye, but may want to check your blood pressure, and if there is any question about bruising and bleeding excessively in other parts of your body, may also arrange a blood test.
If the haemorrhage has been caused by an injury, especially something like a squash ball in the eye, your doctor will be taking a closer look at the eye to check for any other damage. In such cases it is well worth seeing a doctor more urgently, especially if the vision is affected. In these circumstances it may be better going to the Accident and Emergency Department at your local hospital.

Treatment

No treatment is needed for simple sub-conjunctival haemorrhage. It will settle in a few days. 

 

 

 

 

Thyrotoxicosis

Thyrotoxicosis (hyperthyroidism, Graves' disease) is a condition in which the thyroid gland produces excess thyroid hormone (thyroxine) which results in effects on the whole body. 

Symptoms

 

The thyroid gland, which is in the front of the neck, controls the rate of at which the body's cells work (the metabolic rate). In thyrotoxicosis, the rate of metabolism is increased, and this results in most of the symptoms:

• weight loss in spite of increased appetite
• rapid heart rate
• a fine tremor
• increased nervousness and emotional instability
• intolerance of heat, and excessive sweating
• staring, bulging eyes
• enlargement of the thyroid gland, which is at the front of the neck, at the level of the voice box 
  

Causes

Most often the cause seems to be the body developing an immune reaction against itself, in this case the parts of the thyroid cells which normally act as the receptors for thyroid stimulating hormone (TSH), which is the hormone coming from the gland hanging beneath the brain (the pituitary gland).
This hormone normally stimulates the thyroid to produce thyroxine, so antibodies bound on to these receptors cause production of thyroid hormone, and because it attaches to these receptors better than TSH would, more thyroxine than usual is produced.

 

Diagnosis

In the presence of symptoms such as some or all of those above, your doctor is likely to arrange for a blood test to check on the amount of thyroid hormone (thyroxine) and other tests, looking at other hormones which control or are produced by the thyroid gland. These tests are collectively known as thyroid function tests.
In thyrotoxicosis the level of thyroid hormone is elevated, and the hormone (thyroid stimulating hormone, TSH) that is produced by a gland hanging from the underside of the brain (pituitary gland) to drive the thyroid gland, is almost undetectable.
Especially if the thyroid gland is enlarged and has lumps in it, an ultrasound scan or a scan which involves the injection of radioactive technetium (⁹⁹Tc which tends to concentrate in the thyroid), a radio-isotope scan, may be arranged.

Treatment

Your doctor is likely to prescribe medication known as a thiourea drug (carbimazole, methimazole or propylthiouracil) that will reduce the output of hormone from the thyroid.
This starts off at quite a high dose, and the dose comes down slowly once the blood test returns to normal. Usually most people are able to come off the tablets after a year or two, but sometimes the tablets need to be continued for longer, or restarted.
Sometimes your doctor may prescribe another type of medication, a beta blocker, to overcome some of the worst symptoms of an over-active thyroid gland, while waiting for the specific treatment for the thyroid to take its effect.
Sometimes, in certain cases, a surgical procedure is recommended, to remove part of the thyroid gland. This is known as a partial thyroidectomy. Removing part of the overactive gland results in a drop in the amount of hormone that it produces.
Another treatment that is sometimes used is the injection of radioactive iodine (¹³¹I, a longer lasting isotope than is used for scanning) which is concentrated in the thyroid gland and results in damage to, and destruction of, some of the cells of the thyroid.

Thyroid eye disease

The effects of thyrotoxicosis on the eyes are usually minimal, but when more severe can lead to excessive bulging of the eyes and weakness of the eye muscles. In extreme cases this can put the vision at risk, and specialist treatment is required.

For most people with thyrotoxicosis all that is required is treatment to reduce the excessive levels of thyroid hormone.

 

 

 

 

Sprains and strains

Sprains and strains are a description of what happens to the muscles, and other non-bony structures connected to our bones, when they are put under excessive pressure or strain. The result is swelling, pain, bruising and loss or impairment of function of the affected area.

Symptoms

 

• The first thing you notice is pain, often severe. This is usually at the time of injury, eg "going over on your ankle" or twisting your knee, but some times the damage is done by repetitive and less major strains and the pain becomes apparent later and possibly even the following day.
• Swelling is often obvious, and this is usually very tender
• The area affected may be reddened and rather warmer than usual.
• Bruising usually appears, often away from the area most affected, as blood which is released from the damaged soft tissues (muscles, ligaments, and tendons) seeps out along the muscles and other structures before coming near the skin.
• Pain and swelling causes the part affected to be difficult to use normally. 
  

Diagnosis

If in doubt you should seek advice from a nurse, physiotherapist or a doctor. This may be available nearby at some sports clubs etc., or may come from your own doctor's team, or possibly the accident and emergency department at the hospital.
Most sprains and strains, although painful, can be dealt with by someone who knows first aid, but sometimes there is more extensive damage, eg a broken bone (fracture) or a complete rupture of a muscle or tendon. Sometimes even a straightforward sprain can lead to complications. So if in doubt seek professional advice.

Treatment

The cornerstones of treatment are said to be RICE:

• Rest of the part of the body which has been sprained.
• Ice packs to the affected part. To do this, put crushed ice in a plastic bag (or use a bag of frozen peas), and wrap it in a damp tea towel, to avoid ice burns, and apply that to the area for as long as you can. This helps reduce and minimise swelling, as well as helping with the pain.
• Compression, with a crepe bandage or a stockingette tubular bandage, can help reduce swelling and discomfort.
• Elevation. This means, for example, having a sprained ankle up on a stool, or a sprained wrist supported in a sling.

In addition to this, pain relief and some reduction in inflammation can be provided by taking a non-steroidal anti-inflammatory drug, such as ibuprofen, if you are not allergic to, or likely to be upset, by this. (If in doubt ask the pharmacist or your doctor.)
Straight pain relief (analgesia) can be provided by taking paracetamol.
Some people find an embrocation or liniment applied to the skin helps, but this should not be used on sensitive or broken skin.
Physiotherapy treatments can often help with recovery.
Occasionally, your doctor might suggest a steroid injection. This acts rather like an anti-inflammatory drug, and reduces swelling, pain and inflammation, but the body's natural healing mechanisms are still needed to mend the tissues, and this will usually take quite a few weeks.

 

 

WARTS AND VERRUCAS

Warts and verrucas are small thickened growths on the skin, which are caused by a virus. 

Symptoms

Warts are small growths of the skin, caused by a virus. They have a rather rough surface, and can be unsightly. They do not usually hurt, although they may itch. Warts may affect any part of the body, but are most commonly seen on the hands.
Warts on the feet are known as verrucas. Here the pressure from the body weight causes them to be flatter, but to grow into the skin more, and can cause pain, rather like walking on a dried pea.
Sometimes people have many warts or verrucas, while others only have one or two.

Causes

 It is a virus that causes warts and verrucas. It may be that they can be picked up from direct contact or in swimming pools or changing rooms, but warts and verrucas do not spread rapidly through a family, and it seems to be a question of being more susceptible at certain times in life. 

Diagnosis

 Your doctor, a chiropodist, podiatrist or nurse will be able to confirm the diagnosis, and it is unlikely that any tests will be needed. 

 

Treatment

Warts will heal on their own, given long enough, but this may take years. If treatment is needed there are a number various possibilities:

• Various paints and applications which contain one or more acid eg salicylic acid, and sometimes other chemicals. (Not for sensitive skin. Read the instruction leaflet.) Some of these need a plaster to cover them, while others contain a glue-like substance, which forms a seal of its own. It is important to rub down the area with a pumice stone or emery board once or twice a week, as the skin tends to heap up, protecting the underneath part of the wart or verruca.
  
• Liquid nitrogen can be used to freeze the wart or verruca. Nitrogen, the gas which makes up the majority of the air we breathe, is a liquid at temperatures below -196°C (-321°F). Only a tiny amount is applied, for a few seconds. This will be done by a health care professional.
  The area may be painful and red for a few days after being frozen, but when it settles, the wart or verruca has usually gone. Sometimes more than one application is needed.
  
• A treatment that was found to be helpful in a research project (published in Plastic & Reconstructive Surgery in 1981), involved the use of banana skin. The inner side of a fresh piece of banana skin is placed over the wart and held in place with tape. This is changed daily after washing the affected area. As with other treatments, you should rub down the area regularly with a pumice stone or an emery board.
  
• Another simple treatment that has been found to be effective is applying a piece of duct tape over the wart. You leave this on for 6 days then take it off, soak the area in water and clear off the dead skin with an emery board or pumice stone (as with the other treatments). Leave it open for 12 hours, then repeat the whole process again. This method seemed effective, painless and safe in the rather small medical trial which was published in the Archives of Pediatric and Adolescent Medicine.
  

Very occasionally the wart or verruca does not respond to any of these treatments, and your doctor may refer you to a specialist (dermatologist) to consider stronger treatments.
Warts on the genital areas (genital warts) need a specific type of treatment (usually a paint) and you should consult with your doctor if you have these. They can spread to sexual contacts, so unprotected sexual contact should be avoided until they have been treated.

 

 

Peptic ulcer

Peptic ulcer refers to an area of the stomach or duodenal lining which becomes eroded by the stomach acid. These are known as stomach and duodenal ulcers, collectively known as peptic ulcers.

Symptoms

 

You may notice no symptoms although you have an ulcer, but frequently they are associated with indigestion or pain in the upper abdomen or even lower chest. This pain may be worse before or after eating and frequently wakes you in the early hours of the morning. The pain may go to the back or sometimes be perceived elsewhere.
If an ulcer bleeds you may vomit blood or partially digested blood (which looks like coffee grounds) or pass black stools (melaena), which contain changed blood, when you go to the toilet. If any of these happen call the doctor immediately (even out of hours).

Causes

Many factors make you more likely to have an ulcer.

• It often seems to run in families.
• Smoking increases the risk.
• Heavy drinking.
• Certain drugs eg aspirin and other anti-inflammatory drugs.
• We now know that a large percentage of people who have ulcers have a germ (Helicobacter pylori) in their stomach which they probably picked up many years previously, which makes the ulcer more likely to occur and more difficult to heal. 
  

 

 

Diagnosis

Your doctor may treat you on the assumption of the diagnosis, but may well arrange either a barium meal X-ray or a visual inspection using a fibre-optic tube passed down the throat (upper gastrointestinal endoscopy). The endoscopy is preferred by the experts as they can see the lining of the stomach and duodenum and take biopsies which allow them to rule out more serious conditions as well as looking for the presence of Helicobacter pylori.
A simple blood test or a test which measures the chemicals in your breath may also be used to look for evidence of Helicobacter pylori.

Treatment and prevention

• If you smoke, stop.
• If you drink heavily, stop or cut down.
• Eat small meals regularly.
• Avoid any foods which seem to bring on pain.
• Try simple antacid mixtures or tablets to neutralise the acid. These will usually only ease the symptoms, although very high doses may eradicate an ulcer. NB high doses should not be used without due consultation with a doctor.
• Your doctor may prescribe a tablet which reduces the production of acid in the stomach. This is likely to cure an active ulcer.
• If you have Helicobacter pylori or your doctor has good grounds to think that you may have it, they may well prescribe a course of antibiotics (possibly two types) along with acid reducing tablets. This treatment is aimed at eradication of the bacteria, and as such is likely to cure the current ulcer and make it much less likely that further problems will occur. 

 

 

Migraine

Migraine is a form of headache which is severe and usually one sided, frequently associated with nausea and vomiting. This is sometimes preceded by warning symptoms which usually affect the eyesight and are known as an "aura". 

Symptoms

 

People sometimes feel not quite right prior to a migraine, for example depressed, unusually happy or hungry, and in addition may suffer from visual changes such as flashing, zig-zag lines, or a blind spot. Sometimes the symptoms are even more extreme. The headache is usually one sided although it is not invariably the same side. Quite quickly nausea and vomiting may follow. The bowels may also be affected and in children sometimes there is no headache but abdominal pain instead. 

Causes

Each person is different but there are some "trigger" factors which are commonly involved:

• tiredness
• physical exhaustion
• stress
• climatic change
• hormones, eg period time in women
• foods, eg caffeine, cheese, chocolate, red wine. 
  

 

Treatment and prevention

• Note down your attacks in a diary and try to spot any common triggering factors, and avoid them if possible.
• Try avoiding any food which seems implicated and at a later stage take a small trial dose of the food again to see whether it genuinely is involved.
• At the first symptom of an attack take a pain killer eg aspirin or paracetamol, even if this means waking yourself up when you notice symptoms while half asleep in the early hours of the morning. (Often by getting up time it is too late to abort the attack.)
• Most people find that it helps to lie down in a darkened room, in fact there may be little else you are able to do. In some instances migraine follows a period of rushing around over-stretching yourself, and it might be looked on as the body's way of slowing you down.
• Sometimes bathing your head in cold water or using a cold compress on the forehead is helpful.
• There are some over the counter preparations which contain a pain killer and a medication which stops nausea and vomiting (antiemetic). These are often even more effective than the pain killer alone, as migraine is associated with poor absorption from the stomach and a tendency for food and drink to stay in the stomach much longer than usual (prior to being sick).
• Your doctor may prescribe something along the lines of the above, or possibly one of the more modern specific antimigraine treatments, which work on one of the chemical pathways in the brain.
• If the attacks are frequent and disruptive, then your doctor may prescribe a drug to be taken daily as a preventative.
• Sometimes relaxation and meditation techniques may be helpful as may some of the complementary therapies. 
  

 

(Medial Epicondylitis) Golfer's Elbow

Golfer's Elbow or Medial Epicondylitis is a condition when the inner part of the elbow becomes painful and tender, usually as a result of a specific strain, overuse, or a direct bang. Sometimes no specific cause is found. 

Symptoms

The inner part of the elbow is painful and tender to touch. Movements of the elbow, and also movements which involve lifting, with the hand underneath, palm upwards, hurt.  

Causes

Although called golfer's elbow, medial epicondylitis is much more commonly seen in people who are over using their arm doing something else.
The most common cause is over use of the muscles which are attached to the bone at this part of the elbow. That is to say, the muscles which pull the palm of the hand towards the arm (the wrist flexors). All the flexor muscles of the hand attach to the elbow at the inner part (the medial epicondyle). If they are strained or over used they become inflamed, which means they are swollen, painful, and tender to touch.
Sometimes the inflammation is caused by a direct injury or bang. Sometimes, especially when the cause is direct injury or strain, the muscles are actually partially torn.
Rarely the inflammation comes on without any definite cause, and this may be due to an arthritis, rheumatism or gout. Sometimes the problem is partly or completely due to a neck problem, which is causing pain in the elbow via the nerves from the neck.

Diagnosis

Your doctor or physiotherapist will test for tenderness over or near to the bony bump on the inside of the elbow. He or she will also test to see whether the pain gets worse when you bend the palm towards the arm (flex the wrist) against resistance. In the event of both these signs being present, it is likely that you have golfer's elbow.
Your doctor may also examine your neck, as this may be the cause or part of the problem. After all many of the things that might strain your elbow might also put a strain on your neck.

Treatment

 

• Rest helps, with avoidance of the activities which over use the elbow.
• Physiotherapy treatments, which may include heat / ultrasound therapy.
• Use of anti inflammatory drugs and ordinary pain killers (analgesics).
• Your doctor may suggest an injection of a small dose of steroid to the affected area. This is not the sort of steroid banned for athletes. If used it can last for up to three months, and although it may need to be repeated you seldom need more than two or possibly three injections.