Doc " I need a scan !"

Its not uncommon nowadays to see a patient & get this request of doing a scan.I am specifically talking here of a new patient who is visiting clinic for the first time.

Coming to a diagnosis is related to doing tests & scans & reports.

Are we treating a person or a patient or the scan ...I wonder.

One of my best teachers taught me "treat the patient..not the scan!"..

There is so much information to gather in history & clinical examination.
When i meet a new patient ,I try to give them time to talk & then start asking leading questions.If i feel the conversation is diversing,i try to bring them back to the purpose of their visit.

Since ENT  is vast speciality -history is very important for further course of action i.e.investigations or treatment.
Just to give an example -my approach to a recurrent sorethroat & swallowing problem will be standard in any patient but if its a tobbacco user -in the first visit -i will do an endoscopy.

I cannot stress upon the importance of followup's.

Rather than getting all tests & scans done in one visit -it's better to follow up & further tests are done accordingly.

Again interpretation of the tests differ.I always insist on looking at the CT/MRI myself than reading the report.
Depending on the presentation of the patient the tests results are acted upon.For eg even a mild hearing loss in a school going child is significant than a similar report in a 60 year old.Again a unilateral or onesided hearing loss though mild in a 40 yr old needs follow up or scan.

What i am trying to say is -approach could differ in each patient though the symptom may sound similar.

The doctor patient relationship is very important.As i have mentioned in my previous blog-prepare yourself for a doctor visit.If you feel as a patient that enough time was not spent & doctor was busy-have another medium of approaching your doctor-may be email-whatever suits your doc!

How to prepare your child & yourself for visit to the doctor?

I have been thinking for a while now how to make  the patient visits more time efficient-especially so for pediatric patients of mine.

I would like parents & child to be prepared -so that we make most of the time spent together in the clinic.As the practice gets busy -either overbooked or dealing with a complex medical issue,I would not like any child /parent to leave the clinic with any questions.Of course I can always be contacted on email or phone later for small queries.

As soon as we talk of parents being prepared many parents think they need to gather information from internet,bookstore or tv.I do not mean this at all!

It is not uncommon for me nowadays to meet a parent or patient who starts with their symptoms ...& somewhere in between ..  "But I do not have this symptom of tonsillitis "..,Basically they compare their symptoms with the diagnosis they think they have & do what I call "Match the Following"-matching their list with the one mentioned on the net.

I have compiled a small list of how to prepare for doctor visit..

• Good communication is a two-way street.It's good to ask questions, but let the doctor know that you want decisions, diagnoses, and prescriptions to be based on the best decision for the health of your child, not what's easier for you or makes you feel better.
• Explain the purpose of the visit to your kid & do not make it look like punishment.
  

  Tell the child the doctor may look in to her /his ear ,throat & nose.May listen to the chest or check the tummy.In younger children-a pretend game at home works!
• Let the child participate in making the list of  symptoms & questions to be asked.
• Be specific-write them down before the visit.Now this is very important for me as a doctor.For eg it will help if you say :my baby had 102° Fahrenheit (39° Celsius) temperature rather than "he is warm"!
• Be informed & focused.Do not distract the doctor by discussing non urgent issues
• Follow up..Follow up ..Follow up -If adviced. Doctor may have noticed some mild issues which they may not discuss [many times it may unnecessarily worry parents] but ask to follow up.Simple issue like ear fluid related hearing loss-follow ups are important as hearing loss can lead to learning delays.
Hope its helpful....
Sheelu
www.entbangalore.in

Role of ENT in pregnant women

 I get an opportunity to see pregnant women regularly in my outpatients.

While dealing with them it is  very important to be well versed with the ear,nose & throat issues in pregnancy & consider safe treatment.Also I do not hesitate to communicate with the referring obstetrician in front of the patient as it reduces a lot of their anxiety.

I would like to discuss some of the common ENT manifestations which happen due to physiological & metabolic changes in pregnancy.
The common presentations are nasal symptoms ,aerodigestive tract symptoms,oral changes,thyroid & ear related -hearing & balance symptoms as well as Bell's Palsy.

The commonest nasal symptom is nasal congestion & nose bleeds.These are treated with local medications & its worth noting that even cetrizine is to be avoided especially in the 1st trimester.
The oral manifestions range from pica to change in taste to mild gum bleed due to gingival hyperplasia.The symptoms of gastroesophageal reflux worsen in the third trimester.The management involves antireflux precautions & small frequent meals.The newer generation antireflux medications again to be avoided in the first trimester.
Though the ear symptoms are not very common they can be debilitating.The common presentation is of ear block due to eustachian tube dysfunction.Some of them may lead to fluid in middle ear.The risk of idiopathic facial palsy[Bells palsy] increases in pregnancy.There can also be dizziness due to iner ear fluid imbalance-Meneire's Disease.
There is a risk of thyroid enlargement during pregnancy.Investigations include ultrasound of thyroid & Fine needle aspiration.If malignancy or compression to airway only then surgery is advised in second trimester.
In conclusion,I would like to say that most of the symptoms during pregnancy are self limiting & need supportive treatment.

Evidence Based Medicine-How a doctor needs to be careful

Sharing this talk which is self explanatory
http://www.ted.com/talks/view/lang///id/1234

I enjoyed every minute of this talk.......its a sad truth.

Need of Medical Practice -involvement of patients

I have always been wondering - is there any platform where patients are patners in healthcare?This should be the gold standard & many talk about it -but there is still a long way to go..
However today I stumbled across this society & instantly became a member.The white paper is worth a read -e-Patients:How they can help us to heal healthcare.
Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.
They is already a movement amongst the select doctors in India who have realised to involve the patients.The paternalistic approach is outdated.Medicine has advanced & it is not possible for our brains to store all information about every disease.
I have been blessed with teachers who warned me early in my training days- " Do not treat the scan -treat the patient".Another warned "Concentrate on the patient -not the disease".They were visionaries .They knew how a young doctor can get carried away.They taught treating the patient not just with brain & body but with heart & soul.
Few months ago ,I have come across blog of Dr Aniruddha Malpani & have learnt alot from him.
I must mention -I still come under the pressure of finishing my appointments on time & wonder whether quantity is going to compromise quality.
I am looking for patients who can form ENT self help groups & can have discussions.There are groups on Head & Neck cancers & Pediatric ENT related groups.It will be nice to know about Indian groups as it will be more real... I feel!
I have a long way to go on this..first thing is to renew my website.
My Email is :drsheelusrinivas@gmail.com

 

How do I decide a disease management?

I am sure patients will be thinking -how does a doctor decide treatment?

Is it a standard protocol for everyone or its doctor's favourite drug .....so on.

Actually things have changed for the past few decades.

When I was training to become a doctor the choice of antibiotics was limited or shall i say the bugs were limited.Now the bacteria are changing ,the lifestyle is changing & the way we treat is changing.

The practice is more evidence based now.For example ,there is a X & Y drug which should be First line prescription for sinusitis.We should keep in mind the duration of taking it & NOT to stop half way-this leads to resistance.
If a particular patient does not respond to this X or Y drug,it is important for the doctor to look into complaince & associated factors -like treating allergies in a case of sinusitis.
If still symptoms persist -instead of blindly changing antibiotic-your doctor may consider a local swab from the nostrils or back of oral cavity[pus from sinus drips in throat].This swab may grow some bug & it will be worthwhile to treat accordingly.Of course if this exercise fails -we go to Second line drugs.

Its a step by step approach.This needs good communication & understanding between patient & doctor.The doctor has to keep him/herself uptodate with latest evidence based medicine.

Experience definitely counts for the rare cases.Most of the routine work requires evidence based approach.

Pediatric ENT Camps

I have been going to or running pediatric ENT camps for while now.
Camps are a good way of reaching to the community children.Camps i have been doing are mainly for the under-privileged children.Sometimes i do visit regular schools.working for the spastics society gives me opportunity to see special children.

It is not just the ENT issues which i come across.There is so much to learn from the children themselves.Its not just me carrying my headlight & instruments & audiometer,the children are also so well prepared...each one greets you happily..some of them come with their parents.The whole atmosphere including the organisers is so enthusiastic.

some memories to cite:
I met a 5yr old girl in a recent camp.she came & sat in front of me,as usual i started asking her about any medical issues or pain she wants to share with me.Meanwhile i was examining her while trying to talk to her.This little one had ENT all fine.
when i was about to send her off & see next child-she said with full enthusiasm "when i eat green chillies ,my throat burns -pointing to her neck & chest".There was a huge sence of relief on her face after she expressed herself.
In the camps,I see some smart & well kept children like this one & hope she gets right opportunities in life to grow ahead.

Another  one is a 8 yr old with speech & hearing problems.She has received a hearing aid which works for her but does not wear it to school worrying her friends will break it!!!school is the place she actually needs it the most.............This is me telling her that but she in turn was convincing me.This just shows the hearing aid works for her & has become so precious for her!

Whether it is just educating them about allergies or ear care or finding a serious issue like tumors or swellings there is so much to give & take in these camps !! 

 Look at the last in this queue how eagerly she is waiting for her turn!!

Note the carer of this little one i am examining........this is not a photo gimmick:this younger one came with her elder sister!! & i whine taking care of my daughter at this age..

As i said lots to learn from them as well.......

These children are always in my prayers & wish them a bright future..

waiting for next camp in their area to see them again.

Sheelu Aunty!

Ear Pain

 

Last week saw lots of earaches.so writing a brief about it.

 

Pain presenting in the ear can have a direct cause or be due to referred pain from another area that radiates to the ear.

 

Some of the more common direct causes of ear pain include: 

• Wax or foreign body lodged in the ear canal 
• Swimmer’s ear [outer ear infection] 
• Middle ear infection

 In winters,colds [viral & allergic] increase & can lead to ear block.This may eventually cause middle ear fluid/infection-very common in children. 

Atleast steam or some decongestant should be taken in people who get ear block due to colds.

 

 Indirect causes include:

        

• Dental or jaw problems
• Throat infections 
• Nerve related or neuralgias 

Among the indirect causes temporomandibular joint syndrome [jaw joint] & impacted wisdom tooth are common causes.Please note we may not have local toothache in these cases,it may simply be earache.

 

 

 

Seasonal Colds: Viral or Allergic/Non Allergic Rhinitis

Now the season of colds & upper respiratory tract infections have started.Monsoons bring in these fevers & colds.Some people just suffer with recurrent colds & today we talk about the same.

Many people with persistent rhinitis say they have a 'persistent cold'. However, colds are due to virus infections, and normally only last a week or so.

Persistent colds or Rhinitis is not due to an infection. Common symptoms include: sneezing, a blocked or congested nose, a watery discharge ('runny nose'), and an itchy nose. Less common symptoms include: itchy throat, loss of smell, face pain, headache, and itchy and watery red eyes.

What Causes It? 

Allergic rhinitis 

 A common cause of persistent rhinitis is an allergy to house dust mite or to a pet.

House dust mite is a tiny creature that is present in every home. It mainly lives in bedrooms and mattresses, as part of the dust. It usually causes no harm, but some people are allergic to the tiny droppings (faeces) of the mite.
Pets - dander or hairs from a cat, dog, horse, hamster, etc, are the cause of the allergy in some cases.

Other allergies are less common. An allergy to something at work sometimes occurs. For example, to laboratory animals, or to latex or other chemicals. This may be suspected if symptoms ease at weekends or on holidays.Symptoms of allergy in the nose are due to the immune system reacting to the allergen (such as pollen, mite droppings, or dander from a pet). 

Cells in the lining of the nose release histamine and other chemicals when they come into contact with the allergen. This causes inflammation in the nose (rhinitis).

Non-allergic rhinitis 

There is various other causes or 'triggers' for the symptoms. These can cause a rhinitis in their own right, but they can also make symptoms worse if you already have an allergic rhinitis. They include the following.Irritation of the nose by smoke, strong smells, fumes, changes in temperature or humidity.

Hormone changes during pregnancy, puberty, and after the menopause can sometimes cause nose symptoms.
Food and drink - mainly hot, spicy food, or alcohol. Sensitivity to certain food colourings or preservatives may be a cause.
Emotion such as stress can affect the nose.

Medication - a side effect from certain medicines is a rare cause. These include: beta-blocker medicines, aspirin and other anti-inflammatory medicines, the contraceptive pill, and ACE inhibitors (angiotension converting enzyme inhibitors).Other conditions of the nose sometimes cause similar symptoms. For example, nose polyps or chronic (persistent) sinusitis.Are Any Tests Needed?Usually not. Most cases are due to allergy, and the symptoms are usually typical. Treatment is much the same, whatever the cause of the allergy.

Allergy testing may be advised if treatment is not helping, or to confirm the exact cause of an allergy if you want to try and avoid it 

What Is The Treatment?

The commonly used treatment options for allergic rhinitis are: antihistamine tablets, and steroid nose sprays.

Avoiding the cause of the allergy If you can avoid the cause of an allergy, symptoms will stop. This is not as easy as it sounds.If you are allergic to house dust mite, you may find that symptoms are less severe if you reduce the number of mites in your home. This is hard work and involves using bedding covers, and regular cleaning and vacuuming with particular attention to your bedroom and bedclothes. However, it is impossible to keep your home completely clear of house dust mites.
If a pet is the cause, then for some people it is easy to give up the pet. However, for others it would be a great sadness to lose a pet. It may help if you keep pets out of the main living areas, and in particular, out of your bedroom.

How Long Is Treatment Needed For?Persistent rhinitis is an ongoing (chronic) condition that usually needs regular treatment to prevent symptoms. However, over time the condition may ease, and even goes completely in some cases.

Is your sore throat always infective?

 Sorethroat is one of the commonest complaints with which we visit our medical practitioner .We are all worried about infections & many of us land up with antibiotics.Many times I have met patients in my practice who come with begining of sore throat & are so concerned about missing work or infecting their near & dear ones that they request antibiotics.Am I justified in prescribing antibiotics?Is paracetamol with good gargling enough?

Sorethroat with fever & malaise (tiredness/bodypains) is usually infective.This infection can be viral or bacterial.Oral cavity already has some bacteria living in it which can add to viral infection.So even in viral sorethroats sometimes we land up giving antibiotics.We should be careful about severe sorethroats which presents with swallowing difficulty .Careful examination to rule out peritonsillar abscess(pus around tonsils) should be done.If no abscess & still not responding to antibiotics ,it can very well be Glandular fever or Infectious Mononucleosis.This is of viral origin & in worst form needs steroids.This can lead to chronic fatigue syndrome in some cases.

Now lets talk about milder sorethroats which crop up often say every month-are we missing something?A thorough examintion by your doctor will rule our any seroius causes like ulcers/tumours.
Most of the rest regular sorethroats are acid refluxes.It can be symptomatic acid reflux-many patients when asked direct questions realise it,some may have silent refluxes.

Not eating on time & of course eating wrong foods contribute to these sorethroats.Its common nowadays in professionals working odd hours (US/Europe timings) & they land up with wrong food habits.Excess of caffienne contributes to this.

In a nutshell -eat on time --avoid spicy /fried foods -good sleep along with regular mouth hygeine should be followed.

Above is a general & rather a preventive note -you should visit your doctor for advice if any concerns.

We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities

Surgeons have to be as thorough as physicians in history taking & clinical examination.Lots of diagnostics rely on opd based endoscopies/microscopy in ENT.Especially in pediatric population lots can be assessed in airway & swallowing as outpatient flexible scopy.this can complement with images of ct/mri  & better diagnosis can be reached.
ENT has lots of daycare & opd procedures which should be performed more frequently.If enough time is spent explaining in detail,patients will also prefer local anaesthetic opd procedure rather than general anaesthesia.best example in my practise is grommet insertion in adults.

Daycare in not reallya new concept. during my training in KEM mumbai - nurses used to take care of tonsilletomy patients & send them home by evening.most of the tonsillectomies were also local anaesthetic!unimaginable now.

Lets talk simple ear care

Its sounds silly to write simple things but sometimes people may overlook such things.Please read on-

Normal ear wax is produced in the oil glands located in the outer two thirds of the ear canal.

The purpose of wax is to catch dirt and debris and to prevent it from reaching the eardrum (tympanic membrane). Wax also lubricates the ear canal.
 With the normal progression of skin growth, the wax is forced up and out of the ear canal. Wax is also extruded outside by the movements of our jaw.
Occasionally, the skin of the ear canal may be dry. The wax may be dry as well. Therefore, the normal progression of wax production and removal is interrupted. 
DO NOT USE EAR BUDS
Use of ear buds simply pushes the wax further in the deeper part of ear canal.
DO NOT TRY TO CLEAN EARS WITH WATER
NOTE: EAR BUDS AND WATER CAN BE THE SOURCE OF INFECTION 

Doctors day-what does it mean to a doctor?

Yesterday was doctors day-the day passed by so quickly ,i could not really think about it.people at work were wishing me as if it was my birthday. I have joined medicine in 1990 & am registered medical practictioner since 1996,I do not really remember this doctors day in those days .even i was abroad just 5 yrs ago & do not really remember so much of celebrations atleast in the UK.

I wonder whether this all hype is since healthcare is now a business-anything for marketing;i may be wrong-these are just my thoughts.After MBBS spent few years in ENT training in India & abroad.Then wanted to come back home as any young doctor to make a difference & then worked hard to stay back [many return due to lack of opportunities & money].i have been lucky & cannot complain.....thats why 5 years went by quickly.i say lucky since i can practice ethically & do not look at the surgical score board.

Now either this doctors day or just mid life crisis ,want to reflect upon the past & think about the future.My blog says ethical ENT practice -this does not mean others are not ethical .its just a thought that for the doctors day we should have a theme every year.I think the theme for 2011-12 should be ethical medical practice.

Lots is happening in medical field -patients are becoming paranoid-even doctors are so.this leads to over investigating.where is the clinical skill,patient contact,regular follow ups.why are we treating hospitals as one stop shop.

I have to sign off now -hope people think about my theme.any suggestions welcome.

happy day
sheelu