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Acne is probably the commonest skin condition seen at the Medical Centre. The majority of people will have grown out of their acne by their late teens so that on the whole we see only the more severe and persistent cases. In the past, diet, dirt and grime have been blamed for the condition but it is now known that these have little or nothing to do with its cause. The primary defect seems to be an inherited disposition for the cells which line the duct carrying oils from the sebaceous glands to the surface of the skin to thicken, thus blocking the duct. There is then a build-up of oils which are broken down by bacteria into fatty acids. The enzymes the bacteria use for this then irritate the surrounding tissues. There is also a tendency for the oil glands to over produce.
Modern treatment is safe and effective. It is not necessary to avoid any particular item in the diet nor is it necessary to spend hours scrubbing at the face to remove blackheads.
Treatment is aimed at unblocking the ducts of the sebaceous glands and dealing with infection by the Propionobacterium acnes bacteria which invade the oily build-up.
The two main agents applied to the skin to unblock the ducts are benzoyl peroxide and retinoic acid, used alone in mild acne. They may also be used in combination with oral antibiotics in moderate to severe acne. Antibiotics applied to the skin in various preparations have come into fashion a little lately, but there is no evidence to show that they are more effective than antibiotics taken by mouth and some evidence that they may occasionally do harm when applied directly to the skin. There is nevertheless a limited place for use of such antibiotics. Acne treatments applied to the skin are no longer subsidised by the Health Department.
Very fair fine skin can be irritated by applications to the skin but usually a few days rest from use or extending the periods between use is sufficient both to control the acne and to leave the patient free from unwanted side effects. For the more severe acne, a small dose of a tetracycline antibiotic by mouth each day usually brings improvement over a period of two to three months. However, treatment does not cure the acne, but merely controls it so that generally speaking it must be continued long-term. Tetracyclines have been in use for this condition now for many years and long-term safety seems to be established. However, pregnant women or women about to become pregnant should not take it as it can cause very severe staining and damage to teeth of the developing baby.
To some extent, acne in women is worsened for hormonal reasons. There is one type of treatment which is essentially a specially designed contraceptive pill, Estelle 35, which counteracts these hormonal influences.
For exceptionally severe acne which does not respond to any other form of treatment there is now available some oral treatment of a new type. This has, however, severe and sometimes serious unwanted effects in a large proportion of users and is very expensive for the taxpayer, so that it is available, quite properly, only on the prescription of a skin specialist.
We cannot discuss specific injuries in detail here, but there are some general points worth making about soft-tissue injuries such as muscle strains, bruising and ligament strains. Any obviously serious injury should receive care as soon as possible, but many less serious ones can be treated without medical advice or treatment started by yourself pending such advice.
The mnemonic is I C E: ice, compression and elevation. Prompt application of ice reduces local swelling and inflammation while the cooling may also allow muscle relaxation and increased range of movement. Ice is best used crushed or flaked and molded around the part in a thin towel. Alternatively, the part can be immersed in a bucket of iced water. Application of a compression bandage and elevation of the part between icing further discourages swelling.
We would suggest the following routine:
First 24 hours: Ice for 20 to 30 minutes every three to four hours with gentle stretching provided it does not make the pain worse. Bandage and elevate between icing.
24 to 74 hours: Ice three times a day with gradually increasing exercise within the limits of pain. Continue bandage and elevation.
After 72 hours: Gradual increase in exercise and stretching, again only within limits imposed by pain.
In asthma the fine airways, bronchioles, in the lungs respond excessively to certain stimulation. This results in narrowing of the tiny tubes and is felt as difficulty breathing, wheeze and cough.
Two parts of the response are:
- Bronchospasm - excessive contraction of the muscles around the tubes
- Inflammation - swelling of the mucosal lining and increased production of mucus by the glands in the lining.
In mild asthma the only treatment required may be a reliever inhaler, eg salbutamol, which relaxes the muscle contraction.
However, it has been increasingly recognised that the other part of the response, the inflammation, as well as causing persistence of bronchospasm, can over the years lead to gradual loss of lung tissue. A preventive inhaler, eg beclomethasone or fluticasone, used regularly, will reduce all parts of the response.
Asthma can arise at any age. Usually there is a history of asthma in other members of the family.
The triggers that set off asthma vary between individuals.
The most common are:
One person can be distressed by a degree of shortness of breath to which another has adapted. A handy objective measure is the peak flow meter which reads how fast air is blown out. It aids diagnosis of asthma and monitoring of progress.
Treatment is adjusted to control the patient's symptoms and maintain peak flow at its maximum. Inhalers are a useful means of delivering a medicine to the lungs with only minimal effects on other tissues. However, when necessary, a short course of corticosteroid tablets is given to bring asthma under control. An occasional short course is not harmful, though there are some problems with long courses.
The asthmatic response usually follows a fairly regular pattern in an individual.
One person may need only an inhaler to use before exercise.
Another may require a preventive inhaler only during the pollen season, September to March.
A third person may need to use a preventive inhaler always and to increase the amount inhaled whenever symptoms of a cold start.
Sometimes an attack can come on so rapidly that the airways are too narrowed for the treatment to adequately reach the target by means of an inhaler. This state can usually be managed with a nebuliser or spacer. It can be so severe that very urgent medical treatment and oxygen is necessary.
The aim of careful monitoring and prevention is to avoid this sort of situation as well as to maintain maximum capacity for activities and to reduce long term problems.
People with asthma are more prone to bronchitis and chest infections. These arise most often following a cold or flu. Cough and wheeze which are not responding to inhalers and fever, are symptoms needing assessment by the GP.
Smoking aggravates asthma both short and long term. If you have asthma or live with an asthmatic please don't smoke!
Despite what is often written, the human back is well adapted to an upright posture, but it is not well adapted to lifting heavy weights, being scrunched up in a rugby scrum, being repetitively shock-loaded for mile after marathon mile or being hunched up over a desk for hours on end.
Whatever the causes of backache few of them are serious in the student age group. If you do a lot of unfamiliar bending, stooping, or heavy lifting, as for example in gardening or furniture moving, you may expect your back muscles to ache for a few days, just like any other overworked muscles. The usual remedies like soaking in a hot bath, lying in a comfortable position and taking a couple of simple pain-killing tablets give a lot of relief.
Unfortunately, study has to go on while the backache gets better, if indeed it is not the cause of the aching in the first place. As exams get closer, tension is added, by the feeling that the aching is making study quite impossible. All symptoms seem to get worse when one is under pressure.
Prevention is better than cure. Get help when lifting heavy weights and expect trouble if your athletic activities involved bending, stooping, heavy lifting and repetitive loading of the back. When studying, get your bottom right against the back of the chair and sit upright, with a small cushion just above the level of the belt-line to maintain the hollow of the back (it feels strange at first). Get your chair right in under the desk. You can read quite comfortably like this, holding the book upright or propping it up on a heap of other books. You can write with the forearm or elbow comfortably supported and move the paper up the desk as you write, rather than hunching over it.
If you do get backache and simple remedies don't help, you may have some sort of structural problem, but in your age group, such problems are not very common and you will usually be encouraged to try simple things first. X-ray examination and blood tests are expensive and usually unhelpful. Physiotherapy only directly helps a minority of people with backache. If you do get backache, look on it as a transient nuisance. If it doesn't get better come and get it looked at.
'I've got piles, doctor' may mean that the patient thinks he/she has enlarged bleeding veins in the anal canal (haemorrhoids), but it more usually means 'I've got something wrong with my backside and can't quite see what it is'. Bleeding, often just blood on the toilet paper, usually means there is a crack in the skin in the anal canal. Haemorrhoids comes second on the list In the student age group it almost never means anything more serious. The crack, or, in medical jargon, fissure is often painful. We can often make it less painful while natural healing occurs. See the next few paragraphs as well.
Much, much more common is itching of the skin surrounding the anus and we probably only see a small proportion of the people with this annoying problem. The majority are probably too shy or embarrassed to ask us for help.
For all those embarrassed people, here is what to do. First, get a small mirror and have a look. If you have a red or purplish rash of the skin around the anus (sometimes it extends well on to the skin between the buttocks) you probably have a fungus infection (similar to jock itch at the front). You will need to see a doctor to get an effective anti-fungal cream. Not all rashes are caused by fungi so let a doctor have a look at it.
Most people haven't got a rash and the itching seems to be related to tight modern underwear which tends to hold the buttocks together. The skin gets soggy with sweat and rubbing of the buttocks as you walk makes matters worse. Cycling adds insult to injury. Tiny cracks form in the soggy, swollen skin and irritant particles of faeces get trapped. Then you get into a vicious itch scratch itch circle.
Wear loose fitting cotton underwear and avoid tight trousers or jeans. After opening your bowels, wipe gently with toilet paper and avoid the temptation to scrub. Follow-up with a wipe using either moist cotton wool or a 'Wet one' until the wipe comes away clean. Pat dry with more toilet paper and follow-up with a very thin smear of a barrier cream such as 'Barrier Cream 555'. Avoid washing with soap. It makes things sting and the perfume often irritates the already inflamed skin. The secret of cure and prevention is meticulous anal hygiene and an appreciation of causes.
This routine is not God's gift to bottom scratchers, but it does help in the majority of cases. If you are not in that majority, see the doctor.
'Got the flu, doc', usually does not mean that the doctor is about to catch influenza from his patient, but that the patient has a common cold. There are it seems over 200 varieties of virus which cause the symptoms of a cold and colds come in many different forms. Common symptoms are a running or blocked nose, sore throat, headache and nagging night-time cough. Many patients present the sore throat as the main complaint. In medical jargon, sore throats, colds, flus and so on have come to be lumped together as 'upper respiratory tract infections' (URTI), with the usual implication that a virus is the cause.
Most people are aware these days that there is no specific treatment for virus infections and there is very little justification for prescribing antibiotics for them 'in case' a secondary bacterial infection occurs. This only seems to ensure that if such a secondary infection happens, it is with a resistant bacterium.
This is not to say that unpleasant symptoms cannot be relieved to some extent. Soluble aspirin (Disprin) or paracetamol with some sort of decongestant such as pseudoephedrine (Sudomyl) remain very useful. A day or two in bed if you are feeling very much under the weather can help to make you feel more comfortable, but prolonged periods in bed are on the whole of little benefit. URTI generally lasts about four days, with 90 percent falling into the range of two to eight days. The dreaded glandular fever is only one form of URTI which receives perhaps more attention than it deserves.
We occasionally do see complications of URTI such as genuine sinusitis (infection of the air spaces in the bones of the face), quinsy (abscess in the bed of a tonsil) and chest infections, but the vast majority of URTI's can be managed quite happily with a box of tissues, simple remedies and a common sense. Most of the time you do not need to visit the Medical Centre. We prefer you to keep your cold to yourself...
Everyone gets anxious from time to time. Quite a good way to get anxious is to attend lectures and labs, make notes and then not look at them again until a couple of days before an exam, or to do the work for an assignment the night before it is due in. Usually, all this just results in a nasty fright and, if you are a quick learner, a change in study habits. However, long continued anxiety often leads to an exhaustion of coping power and a constant feeling of tension. Lots of tea, coffee and cigarettes makes matters worse and lots of booze to unwind leads to problems of a different kind. Sooner or later, the constantly anxious person becomes depressed.
Depression can be roughly divided into two kinds. There is the sort where you have an obvious reason to be depressed, eg a family member has died or you have lost a winning Lotto ticket or smashed your mother's car. The other type seems to arise from within the person, the so-called endogenous depression. It seems certain that both are due to a specific but as yet unclear, imbalance in brain chemistry. Life becomes uninteresting and unstimulating, sleep is fitful and you feel tired and gloomy on waking though things may improve slightly as the day goes on. Appetite is poor. Everything seems too much trouble. You may burst into tears for no reason at all, or at least feel tearful.
If you feel like this for more than a few days in a row, especially if there doesn't seem to be any cause for it, then seek help, either from a doctor or a member of the Students' Counselling Service. For mild, short-lived depression, simply discussing it with a neutral, uninvolved person may help, particularly if there has been a long-standing, anxiety-causing problem in the background. We may know the ropes much better than you and be able quickly to reach a practical solution to your difficulties. With a true-blue depression, however, counselling alone seems to be much less effective and certainly less speedy, at bringing about improvement than is medical treatment. This takes the form of anti-depressant tablets. These are not sedatives (though some have sedative side-effects) nor do they lead to addiction.
Many people feel guilty about coming for help with anxiety/depression, in a way they would not if they had a more respectable 'physical' illness. They feel they should 'snap out of it' and 'help themselves', but no one likes to feel depressed for days on end, and if you could help yourself you would. It is an illness, just like bronchitis or arthritis, and no one should feel guilty or worthless about getting help.
If you have never had these symptoms, separately or combined, you must be a rarity. Most of the attacks are probably caused by viruses - sort of intestinal flu - but occasionally they are caused by food poisoning. For practical purposes, cholera and typhoid don't occur in this country, but if you have been overseas shortly before an attack begins, you should tell the doctor in case she or he forgets to ask.
When caused by food poisoning, the common culprits are inadequately cooked sausages, frozen chicken which is not properly thawed before cooking and seafoods. These items often contain bacteria and if the core of the meat or fish doesn't reach a high temperate for long enough, you may get a dose of food poisoning with your delicious meal. Boiled rice is an excellent culture medium for bacteria and you should think twice about reheating or frying yesterday's rice to have with the leftovers of chicken. Dairy products can also be a source of bacterial diarrhoea and giardia is a potential cause after drinking untreated water.
If you start to vomit, stop everything by mouth for about four hours. No sips of water, nothing. A previously fit adult will not become seriously dehydrated in this time. Nearly always, the vomiting stops during this time as the body rids itself of the offending matter. Then start to have small quantities of water, little and often, about two tablespoons (30ml) every 10 minutes or so until your thirst is satisfied. If this stays down you can increase the quantities after a few hours and start to eat when you are free of nausea and feel like eating.
If you have diarrhoea alone, stop all solid food, milk and milky drinks and stick to lukewarm water, little and often to satisfy your thirst. Adding one heaped teaspoon of sugar to a large cup of water (200ml) will enhance absorption of the water. An alternative to sugar in water is Coke or lemonade diluted one part soft drink to four parts water. Diarrhoea often takes longer to settle and ideally you should stay off solid food until it does, though you can introduce a bit of variety into the types of fluids you drink. It is generally best to keep to warm clear fluids rather than ice cold or hot drinks. Abdominal pain experienced before or following a bowel motion is common in cases of acute diarrhoea.
Vomiting and diarrhoea combined are dealt with as for vomiting at first and as the vomiting settles, continues as for diarrhoea. If the vomiting lasts more than 24 hours or diarrhoea lasts more than three days in spite of following the above advice, seek medical help.
This is one of the commonest skin disorders that we see. As for many, if not most, skin conditions, a great deal is known about it, but the essential cause is not known. It can perhaps best be thought of as a disorder of skin whose barrier function is defective and which reacts to substances reaching it by showing an exaggerated defence reaction. There is a strong genetic element to it, probably something to do with chromosome 6, and it often runs in families or turns up in individuals with asthma and hay fever. The result of the skin reaction is that areas of the skin becomes swollen, red, itchy and often flaky. Constant scratching may lead the outer layers of the skin to become thickened and old-looking. Eczema has been divided into a large number of different types on the basis of the part of the body effected or the appearance of the skin rash, but few of these often long and usually Latin-based names have thrown much light on the causes of eczema.
It can be confused with other conditions, so initially at least, a doctor's advice may be useful, combined with a specialist consultation if there is much doubt about the diagnosis or best way to treat it.
If there is an obvious contact factor, for example perfume or other additives in soaps, cosmetics and shampoos, it makes sense to avoid these. You can develop sensitivity to things you have been using for a long time, so a first step might be to change to Simple Soap and Simple Shampoo. This brand contains no perfume or other unnecessary additives. Diet usually has little or nothing to do with eczema in adults, but may be of importance in infants. Confusingly, however, contact sensitivity to nickel and chromium salts has been followed in some people by a rash occurring when these are present in foods that they eat. The skin of people with eczema is often unusually dry so that they apply so-called moisturisers. They work by leaving a thin layer of oil on the skin which then reduces evaporation from the skin cells. Most are emulsions of oil in water, often containing perfume, colourants, emulsifiers, stabilisers and preservatives to stop the oil suspension going rancid. All of these have caused flare-ups in people with eczema, so over-the-counter moisturisers are best avoided.
Apart from bland, oily preparations to reduce dryness, flaking and itching of the skin, the main products for treating eczema are ointments and creams containing corticosteroids. This last word itself often alarms people unnecessarily. While strong corticosteroids can cause damage to the skin if used inappropriately, most eczema can be controlled very well using weak steroids such as hydrocortisone one or two percent. Occasionally, stronger preparations have a place, for example in areas of thick skin such as the scalp and palms of the hands, which weaker ones penetrate poorly. Usually, creams are used on weepy raw areas for their drying effect, while ointments are used on dry, cracking and flaking areas for the inherent moisturising effect of the oily base. However, for many people the slight stickiness that is left after applying ointment makes it unacceptable for use on the face and eyelids, so often a cream will be prescribed when an ointment might do better.
Except for obvious contact eczema, when all that is required for cure is to avoid further contact with the offending substance, we are not able to cure eczema in the sense of making it go away and stay away for ever. With careful attention to details of treatment, we can usually keep patients reasonably free from itching with the skin looking reasonably good. As it is a condition that waxes and wanes unpredictably, miraculous 'cures' are claimed from time to time for substances as diverse as aloe vera and oil of evening primrose. When subjects of formal, well designed trials, results have usually been inconclusive; and the essentials of treatment remain avoidance of known sensitisers and the use of oily preparations with or without corticosteroids.
When people are ill around exam time they have the option of applying for Aegrotat consideration. The regulations refer to a candidate being 'unable through illness or injury to present himself for the examination... 'or that performance in the examination 'was likely to have been seriously impaired by illness or injury' (our emphasis). Personal bereavement and other critical circumstances may also be taken into consideration. The idea is that such candidates should as far as possible be placed in substantially the same position as if they had not been ill.
If you are ill at the time of an examination or you feel your preparation has been seriously impaired by illness and you feel you may be covered by the regulations, first take a big dose of common sense and ask yourself whether you genuinely are seriously impaired. Then see a doctor before the examination if possible.
In the Medical Centre we have thought a lot about how to apply the regulations and feel we now have reached a high level of consistency and fairness in our Aegrotat decision making. This is a quite separate process from that of delivering medical care. If you say you want to apply for Aegrotat consideration we will give you the appropriate application form and explain how to complete it. You should not complete the application until after the exam! By waiting until then, you will be better able to assess your degree of impairment. You then return the form to the doctor who completes his/her section and forwards it to the Registry.
In general, if you possibly can sit the exam, you should do so. Each year we get several people who say in effect 'I wasn't going to pass it anyway so I didn't present myself for it'. We then feel that they could have presented themselves, albeit impaired, and cannot support the application.
If you normally do all your revision a day or two before the exam, quite a minor illness may bring home to you the folly of doing so. Revision for important exams should start at least four and preferably six weeks beforehand, so that minor illnesses can be allowed for.
The academic staff have to have something to go on when making their decisions about students who have been ill or who did not sit an exam. Your work prior to the exam has to be 'well above the minimum pass standard' and clearly worthy of a pass'. An Aegrotat application, even supported, may well not be of any help at all to someone who has scraped along with Cs and C minus all the year. On the other hand an A student who writes a C paper because of being seriously impaired, obviously does stand to gain.
Please use your common sense when asking for Aegrotat support. Most people, we are sure, know in their heart of hearts after the exam whether their impairment has been serious. If we agree with your assessment, we will support your application. Please bear in mind that while we try to be helpful and kind, that does not mean that we are naive. In completing the certificate we will do our best to be fair, not only to you, but to other candidates. What we write on the certificate is between us and the examiners as we might otherwise be inhibited from writing a frank statement.
Anyone who has looked carefully at a sunbeam will know that there are many tiny particles floating about in the air. These are inhaled with the air we breathe and the body has various mechanisms for eliminating them. Larger particles, those down to about 20 microns (0.02mm) are filtered out in the nose and large breathing passages by being passed over a carpet of mucus that lines the convoluted air passages of the nose and bronchial tubes. A normal nose produces 300-400 mls of mucus per twenty-four hours and the carpet is constantly being actively pushed backwards, to be swallowed and recycled, though the particles carry on through the digestive system and are eliminated. Smaller particles, those of the order of 3 microns (0.003mm) find their way into the small diameter breathing passages of the lungs where there are similar mechanisms to eliminate them. Something that goes unnoticed by most people is that each side of the nose takes it in turn to be wide open over a cycle of four to eight hours, while the other side recovers, as it were, from its task of filtering, moisturising and warming the incoming air.
Some unlucky people have an exaggerated defence reaction to particles landing on the covering membranes of the inside of the nose and eyes. The result of the reaction is a swollen, inflamed lining of the nose and eyelids, which cause blockage, extra mucus production and increased irritability. These in turn lead to blocked or runny nose, sneezing and watery red eyes. The corresponding sensitivity to very small particles in the lungs results in asthma.
When the reaction is seasonal, it is often called hay fever, though it could also be called seasonal rhinitis. Tree pollens begin to be shed in spring, grass pollen in mid-summer and spores of fungi in later summer and early autumn. Multiple sensitivity to the protein coat of these pollen and spores is common, so some unlucky people will have symptoms for nearly half the year. Yet others will be sensitive to particles that are constantly in the air, like particles of house dust-mite droppings, aerosols or cat saliva and dog dandruff. Since the symptoms last throughout the year, they are said to have perennial rhinitis. This type of sensitivity tends to run in families, along with asthma and eczema.
There are two main approaches to the relief of allergic rhinitis, antihistamines; and sprays or drops of various kinds. On the whole, nose symptoms seem to trouble most people more than eye symptoms; and there are several very effective and safe cortico-steroid sprays on the market. These contain substances similar to those used in the prevention of asthma.
Although we talk about things getting up our noses, in fact the nose passages go backwards (the roof of your mouth forms the floor of your nose passages), so that the spray should be directed straight backwards for the first puff and up at about 40 degrees for the second. Decongestant sprays, which can be bought over the counter, should not be used for more than a few days, since prolonged use may lead to damage to the nose's lining. Decongestant eye drops often combined with an antihistamine, are safe and effective as are cromoglycate eye drops. The latter can be obtained only on prescription.
Surgery on the nose for allergic rhinitis seems to have gone very much out of fashion since the arrival of cortico-steroid sprays. Courses of desensitising injections also seem to have gone out of fashion, perhaps for the very good reason that it has been very difficult to demonstrate that they give any benefit.
Fungal micro-organisms are present all round us in the natural environment and as normal inhabitants on the skin, but only a few of the thousands of species cause disease in humans. The commonest diseases caused by such fungi are skin infections. These infections have a certain nuisance value but they are certainly not serious.
The most common fungal skin infections go under the general term 'tinea'. A variety of related fungal micro-organisms cause tinea infections in various locations around the body:
1. Feet ('athletes foot') - this is the itchy scaly condition so common between the toes, although the sole and sides of the feet may also be affected.
2. Groin ('jock itch') - this is the itchy scaly rash spreading down the upper inner thigh, well known to most males.
3. General skin surfaces ('ringworm') - this has a characteristic circular shape with a definite scaly red edge.
4. Hands - this is an itchy dry scaling condition.
5. Scalp - this produces scaly areas of hair loss.
6. Nails - this produces thickening and discolouration of the nail.
Each of these conditions can be relatively easily identified and treated by your doctor using a cream or occasionally tablets. These fungal infections are mild infections and can thus be passed on to other people but this is of little practical concern as it is difficult to control such spread and the conditions are so easily treated.
A less common fungal skin infection is that due to a micro-organism with the less exotic name of Candida albicans. This is in fact the 'thrush' organism which so commonly causes vaginal infections in women. It can also produce itchy inflammation of the skin usually in sweaty areas.
This condition has an undeservedly bad reputation among students and some information may help to redress the balance. Basically, it is a flu-like illness in which sore throat and enlargement of the lymph nodes in the neck and elsewhere are prominent features. It can vary in severity from a trivial, almost unnoticed illness to one which prostrates you for several days. In fact, most people infected by the virus do not become ill at all.
A specific virus, the Epstein-Barr virus, is known to be responsible for the illness and, unlike most flu-like illnesses, there is an easily performed specific blood test to confirm the diagnosis. However, confirming the diagnosis is not usually of much help as there is no specific treatment for this or other virus illness, and the best that can be done is to relieve some of the symptoms. Regular doses of Disprin or Paracetamol are quite as good as anything else. Antibiotics are quite useless in the treatment of glandular fever and some can make it much worse. Bed rest beyond a few days is not often necessary and being up and about if you feel like it does no harm. It is almost certainly spread in the same way as other respiratory tract infections: by droplets and personal contact.
Unfortunately, in the past the medical profession has managed to convince itself and sufferers in their turn that prolonged fatigue and debility are the norm after an attack of glandular fever. In fact fewer than one in 20 people have these symptoms beyond three weeks and of course, fatigue and debility are common symptoms in students who have had no illness at all. In a study at a British university, no difference was shown in the final examination results between students who had had glandular fever during the course and those who had not.
Finally, it is best to avoid body contact sports for about six weeks after an attack to avoid damage to the enlarged spleen (an organ tucked up under the left ribs at the back), it is not necessary to abstain from alcohol once you feel well again and it is known to recur only very rarely, though about a fifth of people who get it will continue to excrete the virus for the rest of their lives while remaining perfectly healthy.
Headache is the commonest symptom of all and almost never has serious causes when it is an isolated symptom though people often have an unspoken worry that it may be a symptom of a brain tumour or some other dreadful disease. Fifty percent of men and 70 percent of women will experience a headache in any given four-week period.
The commonest causes are having an infection of some sort, like a cold, diarrhoea etc, migraine and tension. With infections the cause of the headache is usually obvious. With tension, there are usually no other symptoms apart from unpleasant aching in the back of the neck and in the brow, often with a sensation of pressure or squeezing on the top of the head. Coffee, tea, cigarettes, and high caffeine soft drinks make matters worse. It is unwise to buy and use 'No doze' when preparing for exams. You may well get a tension headache to end all tension headaches. Again, once you think about it, the cause becomes obvious.
Migraines, however, come in all shapes and sizes and sometimes have quite bizarre symptoms. The classical (about 30 percent) type has visual disturbance to begin with, as blurred patches, flashing lights or zig-zag lines, followed by a thumping headache, often one-sided, and nausea or vomiting. Sometimes there can be numbness or tingling of the face or limbs, clumsiness, stiff neck, etc. Many sufferers have close relatives with this condition, recognise it for what it is and suffer in silence. As implied above, there are many atypical forms of migraine and it takes a bit of experience to sort them out. We can often prevent or reduce the number and severity of attacks by appropriate advice and treatment, but there isn't space here to go into it. If you think you might have migraine, come and discuss it. We are particularly interested in preventing it at exam time, but we do need a little time to sort things out, so don't leave it to the last minute.
The meningococcus germ generally enters the body through the nose and mouth, possibly spreading by coughs, sneezes and saliva. We advise against sharing glasses, bottles and cigarettes. Most of who become infected do not become ill, but in a small proportion of people, perhaps five percent of the population at any one time, it lives in peaceful coexistence in the back of the nose. Most meningococcus germs that reach the deeper tissues of the blood stream are probably rapidly destroyed by antibodies and scavenger cells. In a few unlucky people, however, large numbers of the bacteria may enter the blood and cause a meningococcal blood infection or meningococcaemia. In others, the germs may be cleared from the blood but lodge in the tissues that cover the brain and cause meningitis. We do not understand why what is for most people a harmless infection becomes for others a life threatening and sometimes rapidly fatal illness. Happily, it is a relatively rare condition.
Curiously, even during severe epidemics, the majority of infections seem unrelated to others, so that case to case spread is hard to demonstrate. Second cases within a household or family are uncommon (two percent to four percent) and because many of these occur within four days of the initial case it is thought that most develop the disease at more or less the same time rather than catch it from each other.
Meningococcaemia can strike with frightening speed. Unfortunately its early symptoms are the same as for many other milder forms of infection: feeling generally unwell with temperature and headache. Occasionally, this is all that happens, but usually it becomes clear within a few hours that the patient is very ill indeed.
Meningitis has the same early symptoms of feeling unwell, temperature and headache. The headache becomes severe and all over the head, often with nausea, vomiting and backache. The neck gets stiff and painful. A rash is common in both meningococcaemia and meningitis. It soon becomes clear that there is more than a simple flu-like illness.
From what we have already said, we hope it will be clear to you that if you do get a feverish illness with a headache, it is overwhelmingly more likely to be a minor but uncomfortable illness like flu than to be meningitis. We are not sure that the advice that has been given on television and radio to see a doctor if you experience such symptoms is particularly helpful, except in an epidemic. The doctor has no means to distinguish early meningococcus infection from flu-like illnesses and to see all patients with such illnesses may well make it more difficult to pick out the patient with meningitis. It is perhaps worth emphasising that it is the combination of symptoms that is important.
No advice that we can give you will be correct in all circumstances. Perhaps the best you can do is to use your common sense and see a doctor only if you are more ill than you might expect from a simple flu-like illness. This is especially so if you have a stiff and painful neck or rash with a feverish illness. If having seen a doctor, you seem to be getting rapidly worse, see a doctor again straight away.
Period pain is an experience common to almost all women. In the vast majority of cases the pain is just the normal consequence of the changes occurring in the uterus (womb) at the time of the month. The pain is typically in the lower abdomen or back and normally starts at or just before the start of the period and continues for one to two days. The severity of the pain varies between women and between different periods in the same woman. Those unfortunates who have very painful periods each month appear to produce much more of the prostaglandin hormone which is responsible for the increased activity of the uterus during period. In these women there may also be associated nausea, diarrhoea, headaches, and exhaustion.
In a small number of cases period pain may be due to other causes. Such things as an IUD (loop) and infections of the uterus plus many other rare diseases can produce unusually bad period pain, but the cause of such pain will usually be obvious from other associated symptoms of these diseases.
The type of treatment used for period pain will depend on the severity of the symptoms. Most women have relatively mild discomfort and are able to put up with it. More significant pain will often be relieved by a couple of panadol, a hot water bottle, and a rest. When the pain is a real nuisance and a regular event there are now very effective medications available on prescription and over the counter which prevent the worst of the problem. These medications are taken from the beginning of the period for two to three days and act by counteracting the production of the prostaglandin hormone which cause the problem. They are not themselves hormonal. Using the contraceptive pill also usually diminishes period pain, but it isn't usually used for this purpose alone nowadays.
So the message is don't put up with bad period pain thinking that it is just a disadvantage of being female, as effective treatment is available.
Far from being the 'curse' of biblical times the monthly appearance of menstruation is now more often considered an indicator of good health. Certainly a regular monthly period is the usual pattern but quite a wide range of menstrual behaviour can still be considered as within the limits of normal in young women.
Menstruation begins on average at age 13 but can begin as early as age nine or as late as age 15. Failure of periods to begin by age 16 is unusual and requires investigation. Ovulation (the release of an egg) usually begins shortly after the periods start and certainly all women should consider themselves potentially fertile from this time. The average length of the menstrual cycle (the time from the beginning of one period until the beginning of the next) is 28 days but many women regularly have shorter or longer cycles (20-40 days). The average duration of bleeding is five days but again women vary greatly in the length and heaviness of their menstruation. Irregularity of cycle length is also common, particularly in younger women, and is usually of no concern. Such irregularity may have been present since puberty. The periods may stop altogether for months or even longer and this again is usually of no concern (as long as pregnancy has been ruled out), although if the period disappears for more than six months it is usual to perform some screening investigations to exclude a number of rare hormone disorders which can produce this effect on the periods.
Clearly the range of normal menstrual function is very wide and the reason why so many women experience patterns other than the regular monthly cycle is that the hormone balance required to produce regular ovulation and thus regular menstruation is very precise and is very easily upset by a wide variety of extraneous factors. The ultimate control of the hormone levels lies in the hypothalmus of the brain and that part of the brain is itself subject to many influences. Thus emotional stress can cause changes in the hypothalmus which in turn affect the hormone levels controlling the menstrual cycle, producing irregularity or absence of ovulation and thus of the period. A lot of exercise, especially when combined with dieting is the commonest cause among university students.
In summary then, just about anything is possible when it comes to menstrual function and most patterns will fall within the range of normal. If however, periods have not started by age 16 or stop for six months or longer, assessment by your doctor is necessary.
What are STDs?
Any infection which can be passed from one person to another during sex is called an STD. Examples include herpes, genital warts, chlamydia and gonorrhoea. Diseases spread this way can also be spread through infected blood entering the blood stream of an uninfected person. For example, sharing needles and syringes can spread diseases such as hepatitis and AIDS. Anyone who has sex can risk getting or spreading an STD, the risk increasing with the number of sexual partners a person has.
Some diseases are easily treated but others are severe and can cause serious illness, infertility and even death.
Who gets STDS?
How do you know if you have an STD?
You may get symptoms:
Or you may not!
How can you check?
Consider having a sexual health check and at the same time discuss how you can protect yourself from STDs and unwanted pregnancy.
Health checks are advised:
Health checks may include
Treatment for most STDs involves a short course of antibiotics which should be completed and sometimes be followed by a repeat test.
Remember that the Pill may not be effective in preventing pregnancy while taking antibiotics, and condoms should be used.
Some STDs, for example Herpes, Warts and Aids, cannot be cured but the symptoms can be treated. Sex should be avoided during treatment in order to avoid infecting your partner.
Genital Herpes is usually caused by the Herpes Simplex Virus type 2 (HSV2), unlike cold sores on the mouth which are usually caused by HSV 1.
Symptoms occur two-12 days after exposure, causing painful ulcers on the penis or the vulva and vagina or saddle area. However, the initial infection, commonly passes without notice, with symptoms occurring for the first time months later. If this is the first attack symptoms may include a fever and flu-like illness and last seven-10 days. The virus is passed from one person to another by close body contact, even if penetration does not occur and even if a condom is used.
Some people never have a second outbreak, some have a few recurrences and some have them often. Each recurrence tends to be less severe, to last less time and occur less frequently.
Although there is no cure, anti viral drugs can decrease the duration, severity and frequency of recurrences and decrease the length of time you are infectious.
Genital warts are caused by the Human Papilloma Virus (HPV) infecting the outer layer of the genital skin. Once exposed to the virus it can take from three weeks to one year for a wart to develop. Many people have the virus but never get warts. Although warts can be detected, at present there is no easy way of detecting the virus. Sometimes a cervical smear can suggest the presence of HPV. Untreated warts can be passed on to your partner and because warts may increase the risk of cervical or penile cancer it is important to have them treated. Using condoms protects from warts in the area covered by the condom. Women are advised to have annual cervical smears if they have ever had genital warts or a smear suggestive of HPV. If you suspect genital warts it is important to have a check for STDs.
Chlamydia is a bacterial infection spread by sexual contact - vaginal, oral or anal sex. It lives inside cells in the body, sometimes causing no symptoms, but if not treated may lead to infertility, urinary infections or arthritis-like disease in both men and women. A test is available in which a swab is taken from the cervix, or urinary opening. In some circumstances, the urine can also be tested. The treatment is an antibiotic during which time sexual activity should be avoided and two weeks after which a repeat swab may need to be taken. It is recommended that partners should also be treated.
Pubic lice or 'crabs' are caused by the pubic louse insects which attach themselves to the pubic hairs. They live for three weeks and the eggs laid become attached to the hair shafts. The eggs are seen as small white specks while the lice are rust coloured specks which move like crabs amongst the pubic hairs. They are transmitted by close personal contact including sexual activity and infected people complain of irritation. Treatment is easy and effective, both partners needing to use a shampoo or special lotion.
Gonorrhoea is a bacterial infection. Men may experience burning when passing urine and a discharge of pus from the penis. Often women have no symptoms, infection may involve the rectum (anal sex) or throat (oral sex). If untreated complications such as infertility and arthritis may develop. Treatment of the partner and contacts is simple and effective, and sexual activity must be avoided until treatment is completed.
Hepatitis is inflammation of the liver. It can be caused by viruses, alcohol, chemicals or drugs. Three different viruses which are common in New Zealand can cause hepatitis - Hepatitis A, B and C. If infected there may be no symptoms, a transient illness, development of a chronic form of hepatitis or development of a "carrier" status in which infectious virus remains harboured in the body. Hepatitis A spreads from faecal contamination and is a problem for travellers overseas in developing countries and can be prevented by an injection prior to departure.
Hepatitis B is found in the blood, saliva, semen and vaginal secretions in infected people. Sharing needles and sex (especially anal sex) spreads the virus and people working with blood may be at risk from cuts and needlestick injuries. It may take from 3-6 months for symptoms to develop. Hep B can be prevented by a course of three injections and occasional booster doses. If at risk because of your work or behaviour, it is worth requesting Hep B immunisation.
Hepatitis C virus is present in the blood of infected people and is spread by sharing needles and syringes (blood is now screened in New Zealand for all three types of virus) but only rarely does sexual transmission occur.
Aids is caused by the virus Human Immunodeficiency Virus (HIV). The virus is found in the blood, semen and vaginal fluids of the infected person and it can be passed on by transmission of these fluids via sexual intercourse, especially anal sex and sharing needles and syringes. It is not spread in the air by coughing, sneezing, sharing utensil, hugging or dry kissing. The virus must enter the blood of the exposed person for transmission to occur.
The virus attacks the immune system resulting in an ability to fight off common infections. Once infected by the virus the body makes antibodies against HIV within two weeks to three months, and it is these antibodies that the "HIV test" detects.
Once infected and HIV positive, present evidence suggests there is a 35 percent risk of developing AIDS within the next several years and another 35 percent risk of developing ARC - Aids related complex, where there are symptoms associated with HIV but not fulfilling the criteria for a diagnosis of AIDS. Many remain HIV positive but symptom free, but it is thought that in time they will become ill.
Should you decide to have an HIV test, perhaps because of risk behaviour or part of a sexual health check, then it is important to discuss it with your doctor first. After the test results have come back you will be asked to come in person to the Medical Centre for the results, whether positive or negative. A negative test means that you have not been infected with HIV or that you may have had recent infection and that you have not yet made the antibodies. There can be a three-month 'window' period during which time the antibodies form and you seroconvert and become HIV positive.
the most important thing you can do is to stop the spread of AIDS virus by always practising safer sex and avoiding risk-taking behaviour, as described earlier.
This is caused by a spirochaete Treponema pallidum. It is not a common condition nowadays in New Zealand but it usually presents as a painless genital ulcer. If not treated at this state the disease becomes latent and may show itself at a later date. Blood tests can check indirectly for the disease and in some circumstances this is done as part of a sexual disease check.
Insufficient or poor sleep can be disabling when you need to concentrate during daytime work. The most common problem occurs during exam preparation or during other high-pressure work. Studying late into the evening keeps the mind in high gear, making getting off to sleep difficult. Worry about a forthcoming exam can also make sleep elusive and fitful when it does come. A vicious circle can easily be established, with poor sleep resulting in poor daytime concentration leading to increasing anxiety which further upsets sleep. Performance and confidence can quickly be reduced.
It pays to stop studying half to one hour before going to bed, using that time to do something relaxing and mentally undemanding. A warm drink may help but tea, coffee and cocoa contain mild stimulants and should be avoided in the mid to late evening. Relaxing for a few minutes under a warm shower or in a warm bath often helps. A comfortable bed and well ventilated room are helpful. An alcoholic 'nightcap' is probably best avoided if a hangover is not to be added to your problems. Despite doing all the right things you can still have resistant sleep problems and, while it is not the end of the world, we are in a good position to help people with short-term problems with highly effective modern short-acting sleeping tablets. Intermittent use of such medication seems to be safe and we have little reluctance in helping out occasionally in this way.
Long-term insomnia is more difficult because we accept that medication is not the answer to long-term problems. There are, however, other approaches to such problems and each case has to be assessed individually if the sleep disturbance that often accompanies real depression is to be dealt with appropriately. Coping with long-term problems will often involve the help of the Counselling Service in teaching specific relaxation techniques. As exam pressure seems to be the commonest cause of problems let us repeat what we have said elsewhere. Anything that you can do to spread the pressure helps and ideally revision should be a continuous process, with final swotting starting at least four and preferably six weeks before important exams.
If you get a sore throat, think viral, and you will be right most of the time. Viruses cause over 80 percent of sore throats, and in case you don't already know, there is no cure for a viral sore throat.
This is in fact the starting point from which most doctors operate as well and under such circumstances we will usually give advice on treating the symptoms with painkillers such as Panadol or Disprin, two four-hourly, and the use of warm saltwater gargles (1 teaspoon of salt per 200ml glass) which will keep you comfortable until symptoms subside. Usually, most sore throats have cleared up within a week, being most uncomfortable in the first few days.
Up to 20 percent of sore throats can be caused by bacteria. If it is bacterial then there is evidence that early treatment with Penicillin may alleviate symptoms a day or so sooner than would otherwise occur. It must be stressed that you simply can't diagnose a bacterial throat infection just by looking. Unfortunately, swabs to identify the presence of bacteria take two days to culture and often by that time you are getting better anyway. Trials have shown that doctors' clinical guesses as to whether a sore throat is bacterial or viral are not much better than the toss of a coin.
If, however, you experience feverishness (feeling hot and/or cold) for three or four days with the sore throat then it is reasonable to see a doctor who may be able to shorten the course of the illness with antibiotics. If a sore throat occurs in association with symptoms of a cold, such as a runny or blocked nose and cough, then the cause is almost certainly viral. One of the viruses that can cause a sort throat is the glandular fever virus and that subject is expanded in another article.
This is the second commonest reason for women to consult us at the Medical Centre. In women, the tube that leads from the bladder to the outside (the urethra) is rather short and enters the outside world in an area where there are lots of bacteria present on the skin. It also lies practically in the front wall of the lower half of the vagina so that perhaps particularly during intercourse, bacteria do not find it difficult to get into the normally sterile urine in the bladder and set up an infection. This is not to say that there are no defences against infection. Usually every three to four hours, a flood of urine pours down the urethra flushing out any bacteria which may have started their upward journey and there are scavenging defensive cells and glands in the walls of the tube that produce mucus. This mucus contains antibodies which inhibit the growth of bacteria.
If, however, bacteria get into the bladder and remain undisturbed long enough to multiply, overnight for example, then you may begin to get symptoms of UTI: frequent passing of urine with painful stinging, sometimes with blood-staining of the urine or passage of a few drops of blood at the end of passing urine. Often, having just emptied the bladder, you want to go again and have an uncomfortable dragging feeling in the lower stomach. UTI implies that the whole of the lining of the water works system including the tubes that collect urine from the kidneys is infected and occasionally the infection may spread from the tubes to the substance of the kidney, causing an unpleasant backache and high temperature.
If you get these symptoms, first aid treatment is very simple: you drink lots of water, about 500 mls an hour for three or four hours, at the first hint of any symptoms. By doing so, you produce lots of urine which helps to wash out the bacteria and as it is very dilute urine, it is less acid than usual so the stinging sensation is reduced. Some people advise adding a teaspoonful of bicarbonate of soda to each 500 mls of water to make the urine even less acid. If you can stand the taste, by all means do so. As soon as practicable (but not necessarily in the middle of the night) seek medical attention. Depending on the circumstances, we may send a specimen of urine to the laboratory and will usually give you a single dose of an antibiotic called trimethoprim as this gives an 80 to 85 percent rapid cure rate. We may also ask you to bring a second specimen a few days after treatment to check that no germs are still present. Interestingly, many people with the symptoms of UTI turnout not to have any bacteria present in the urine. A few of these will turn out to have a Chlamydia infection, but most probably have simply suffered bruising to the urethra during intercourse (UTI is rather uncommon in those who are not sexually active). In men with symptoms of UTI, particularly those with a discharge from the penis, the commonest causes are Chlamydia and Ureaplasma infection.
Perhaps the most important thing to prevent recurrence of UTI is to empty your bladder within 20 minutes of having had sex. If, as is likely at some times of the month or if you're tired or tense, the vagina is a bit dry, use a simple lubricant such as KY jelly or Sylk during intercourse. Some people don't drink much fluid and pass urine only once or twice a day. If that's you, a modest increase in daily fluid intake, especially during warm weather, may help. When washing 'down below', wash from front to back and use only plain warm water, as soap may destroy some of the antibodies present in the mucus of the area while the perfume in most soaps may irritate the delicate skin.
Some discharge from the vagina, especially midway between periods, is normal for most women, but it should not smell unpleasant or cause soreness or itching. Usually it is clear or slightly cloudy and may cause faint brown staining on the underwear when dry. The mucus is produced in the cervix and vagina and the glycogen that it contains is broken down into lactic acid by 'good' bacteria (lactobacilli) that live in the vagina. This keeps the skin of the vagina quite acid, and together with antibodies in the mucus, inhibits the growth of most harmful organisms.
About 40 percent of people have a yeast called Candida albicans as a normal inhabitant of the large bowel and of the skin of the saddle area. It cannot flourish in acid conditions, but if anything lowers the acidity of the vagina it may start to grow there and cause an unpleasant smell, a thick white discharge and intense itching of the vulva (thrush). It most commonly seems to start after a period, as menstrual blood is slightly alkaline, and the hormonal changes at this time result in there being less glycogen around for the lactobacilli to change into lactic acid. This is by no means the whole story. Candida infections are more common in those who are sexually active and it may be that intercourse causes minute breaks in the vaginal skin that allow the candida an entry, especially at the beginning and end of the menstrual cycle when lubrication may be poor. Thus, though it is not a sexually transmitted disease, it may in many cases be related to being sexually active and all the causes of itchy skin can potentially cause vulval itching.
Not everything that itches is caused by Candida. Other germs that cause trouble are usually sexually transmitted and include Chlamydia, Trichomonas and gonorrhoea. For this reason, if a woman has vaginal irritation and discharge, we generally prefer to send specimens of the discharge to the laboratory to rule out these more serious conditions. So, though you may not like the thought of being examined 'down below', we do so in your best interests. Usually, we will take the specimens and then prescribe treatment according to our best guess as to the cause of the problem. Since common things occur commonly, we will usually treat as for thrush, with a vaginal cream or tablets designed to be put into the vagina once a day and get in touch with you if the laboratory report suggests that the treatment was not appropriate. Yoghurt-soaked tampons and dilute vinegar douches may be preferred by some people. While these folk remedies are sound in principle, in practice they are not as effective as modern medication. There is absolutely no point in having a yeast-free diet in an attempt to eradicate Candida from the body. It is a normal inhabitant and completely unrelated to the yeast used in food preparation.
Prevention is not all that easy as we certainly don't know the whole story about thrush and why some women get it frequently and others never. It is often said that the contraceptive pill is responsible for thrush, but when the question has been reviewed objectively, the evidence for this is lacking. Wearing wet swimsuits, pantyhose and tight synthetic underwear are other suggested causes for which there is little or no evidence. A great deal of traditional advice can be compressed into three pieces of advice: have plenty of lubrication during intercourse (KY jelly or Sylk); keep the vulva as dry as possible at other times; and use only plain warm water for washing the vulva as soap may destroy some of the natural chemicals that prevent infection.
Wars are caused by a particular virus which stimulates the cells of the surface layers of the skin to divide rapidly. The appearance of the resulting wart varies depending partly on its location on the body surface. The most familiar variety of wart is the 'common 'wart which is the rough surfaced lump so often found on the hands. The 'plane' wart is flatter, smoother, and only slightly raised and is most often found on the face. 'Plantar' warts are found on the side of the sole of the foot and occasionally the palm of the hand and are tender roughened areas that get squashed flat so they seem to be growing in. 'Genital' warts are rather different in appearance being softer and forming little cauliflower like lumps. They are discussed separately on the section on 'Sexually Transmissible Diseases'.
As warts are caused by a virus, they can be passed on to other people usually as a result of direct contact. People's susceptibility to wart virus infection varies considerably however, and many people will never develop warts despite undoubted exposure. This fact plus the essentially minor nature of the problem makes it unnecessary to take excessive precautions against spread between individuals except in the case of genital warts.
There are a number of wart treatments available but none offer an instant cure and often a few months are required to eradicate a wart. A variety of wart paints can be purchased. Left to themselves, they all disappear eventually without pain, suffering or scarring at the rate of 50 percent per year. We recommend you ignore all except genital warts.
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Last updated on Tuesday 16 August 2016