2011 August » Family Medicine Help

Macular degeneration

Opthalmology Comments Off

Aug 252011

Macular degeneration, which is atrophy or degeneration of the macular disk, accounts for about 12% of all cases of blindness in the United States and for about 17% of new cases of blindness. It’s one of the causes of severe irreversible loss of central vision in people older than age 50. It affects slightly more women than men.

Types of Macular Degenaration

Two types of age-related macular degeneration occur. The dry, or atrophic, form is characterized by atrophic pigment epithelial changes and is usually associated with a slow, progressive distortion of straight lines or edges and central visual loss. The wet, or exudative, form causes rapid onset of visual impairment. It’s characterized by subretinal neovascularization that causes leakage, hemorrhage, and fibrovascular scar formation, which produce significant loss of central vision.

Causes

Age-related macular degeneration results from the formation of drusen (clumps of epithelium) or subretinal neovascular membrane in the macular region. It may be hereditary. Cigarette smoking and lack of antioxidants, such as vitamins C and E, may also enhance occurrence.

Underlying pathologic changes occur primarily at the level of the retinal pigment epithelium, Bruch’s membrane, and choriocapillaris in the macular region. Drusen (bumps), which are common in elderly people, appear as yellow deposits beneath the pigment epithelium and may be prominent in the macula.

Signs and symptoms

The patient notices a change in central vision; for example, he may notice a blank spot in the center of the page when reading.

Diagnosis

The following tests are used to diagnose macular degeneration:

indirect ophthalmoscopy: may reveal gross macular changes
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Fibromyalgia syndrome

General Medicine Comments Off

Aug 242011

A diffuse pain syndrome, fibromyalgia syndrome (FMS, previously called fibrositis) is one of the most common causes of chronic musculoskeletal pain; it’s observed in up to 15% of patients seen in a general rheumatology practice and 5% of general medicine clinic patients. Symptoms of FMS include diffuse musculoskeletal pain, daily fatigue, and sleep disturbances. Multiple tender points in specific areas on examination are the characteristic feature. Women are affected much more commonly than men, and although FMS can affect all age-groups, its peak incidence is between ages 20 and 60. It may occur as a primary disorder or in association with an underlying disease, such as systemic lupus erythematosus, rheumatoid arthritis, osteoarthritis, sleep apnea syndromes, and neck trauma.

Causes

The cause of FMS is unknown, but many theories exist regarding its pathophysiology. Although the pain is located primarily in muscle areas, no distinct abnormalities have been documented on microscopic evaluation of biopsies of tender points when compared to normal muscle. Other theories suggest decreased blood flow to muscle tissue (due to poor muscle aerobic conditioning versus other physiologic abnormalities); decreased blood flow in the thalamus and caudate nucleus, leading to a lowering of the pain threshold; endocrine dysfunction such as abnormal pituitary-adrenal axis responses; and abnormal levels of the neurotransmitter serotonin in brain centers, which affect pain and sleep. Abnormal functioning of other pain-processing pathways may also be involved. Considerable overlap of symptoms with other pain syndromes, such as chronic fatigue syndrome, raises the question of an association with an infection such as with parvovirus B19. Human immunodeficiency virus (HIV) infection and Lyme disease have also been associated with FMS.

It’s possible that the development of FMS is multifactorial and is influenced by stress (physical and mental), physical conditioning, and quality of sleep as well as by neuroendocrine, psychiatric and, possibly, hormonal factors (because of the female predominance).

Signs and symptoms

The primary symptom of FMS is diffuse, dull, aching pain that’s typically concentrated across the neck, shoulders, lower back, and proximal limbs. It can involve all four body quadrants— bilateral upper trunk and arms and bilateral lower trunk and legs. The pain is typically worse in the morning and sometimes accompanied by stiffness. It can vary from day to day and be exacerbated by stress, lack of sleep, weather changes, and inactivity.

The sleep disturbance associated with FMS may be another factor in symptom development. Many patients with this syndrome describe a habit of being a light sleeper and experiencing frequent arousal and fragmented sleep (possibly secondary to pain in those patients who have underlying illnesses, such as osteoarthritis and rheumatoid arthritis). Other patients may report feeling unrefreshed after a night’s sleep. Because of this nonrestorative sleep pattern, the patient can feel fatigued a half hour to several hours after awakening and remain so Continue reading »

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Personality disorders

Psychiatry Comments Off

Aug 152011

Defined as individual traits that reflect chronic, inflexible, and maladaptive patterns of behavior, personality disorders cause social discomfort and impair social and occupational functioning. Although no statistics document the number of cases of personality disorder, these disorders are known to be widespread. Most patients with a personality disorder don’t receive treatment; when they do, they’re typically managed as outpatients.

According to the classification system of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition – Text Revision, personality disorders fall on Axis II. Knowing the features of personality disorders helps provide a more complete picture of the patient and a more accurate diagnosis. For example, many features characteristic of personality disorders are apparent during an episode of another mental disorder (such as a major depressive episode in a patient with compulsive personality features).

Personality disorders typically begin before or during adolescence and early adulthood and persist throughout adult life. The prognosis varies.

Causes

Only recently have personality disorders been categorized in detail, and research continues to identify their causes. Various theories attempt to explain the origin of personality disorders.

Biological theories hold that these disorders may stem from chromosomal and neuronal abnormalities or head trauma.
Social theories hold that the disorders reflect learned responses, having much to do with reinforcement, modeling, and aversive stimuli as contributing factors.
Psychodynamic theories hold that personality disorders reflect deficiencies in ego and superego development and are related to poor mother-child relationships that are characterized by unresponsiveness, overprotectiveness, or early separation.

Signs and symptoms

Each specific personality disorder produces characteristic signs and symptoms,

which may vary among patients and within the same patient at different times. In general, the history of the patient with a personality disorder will reveal long-standing difficulties in interpersonal relationships, ranging from dependency to withdrawal, and in occupational functioning, ranging from compulsive perfectionism to intentional sabotage.

The patient with a personality disorder may show any degree of self-confidence, ranging from no self-esteem to arrogance. Convinced that his behavior is normal, he avoids responsibility for its consequences, often resorting to projections and blame.

Treatment

Personality disorders are difficult to treat. Successful therapy requires a trusting relationship in which the therapist can use a direct approach. The type of therapy chosen depends on the patient’s symptoms.

Drug therapy is ineffective but may be used to relieve acute anxiety and depression. Family and group therapy usually are effective.

Hospital inpatient milieu therapy can be effective in crisis situations and possibly for long-term treatment for borderline personality disorders. Inpatient treatment is controversial, however, because most patients with personality disorders don’t comply with extended therapeutic regimens; for such patients, outpatient therapy may be more useful. Continue reading »

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