Wednesday, 23 May 2007

Rare as Hens Teeth

This patient had a diagnosis of streptococcal pneumonia on admission .

She typically had reactivation of Herpes affecting her upper right lip area.

However, she complained of a painful tongue after several days in hospital and the next day she developed a rash on her tongue.

A dermatologist was consulted and an odd diagnosis of amyloidosis was considered.

However, the history was not consistent with amyloidosis as it was too acute.

Moreover, the examination revealed separate, small vesicles on the tongue, predominantly right sided with sparing of the posterior 1/3 of the tongue and left lateral border.

The right inner lip mucosa also showed a shallow, white ulcer.

The diagnosis consistent with the preceding history would be one of Lingual Herpes Simplex infection from likely reactivation or even Varicella Zoster eruption.

HSV and VZV can be reactivated by streptococcus pneumoniae infection, fever, sunlight, stress and during menstruation in females.

The treatment involves oral aciclovir, usually at a dose of 200mg 5 x per day, or if severe then intravenous at 5mg/kg/day.

Oropharyngeal HSV is very infectious and health care workers should wear gloves if they are likely to come in contact with the oral secretions.

Labial HSV (cold sores) are very common and although reactivation can occur anywhere such as in the oesophagus in tube feed patients, pubic region (HSV2 > HSV1) etc, but to see it occur on the tongue is most unusual.

One has to consider underlying causes of immunodeficiency in such patients such as HIV or haematological malignancy being possible underlying diseases.

The posterior 1/3rd of the tongue is unaffected in this patient because the nerve supply to that area is different, being the Glossopharyngeal Nerve (IX). The left border of the tongue was equally unaffected as the HSV did not reactivate along the nerve supplying that region.

The central tongue is affected in this patient showing that the right nerve supply also crosses the midline to supply a large area of the contralateral tongue.

Monday, 21 May 2007

Social History

Dear Bloggers

I was asked just today what was the purpose is of a social history.

Well, I had taken for granted that social history was well known and for what purposes.

Having thought in great detail I was able to provide a very detailed number of reasons, and they can sometimes be more important than the reason for admitting the patient to hospital.

For example, when a patient is admitted to hospital, the doctor must start planning for their discharge and mentally estimate when that will be so that a timely exit from hospital can be arranged.

However, the social situation at home must be established to understand if the home dynamics are safe. For example, a patient with COPD who sleeps upstairs may no longer be able to use the steps and therefore, modifications may need to be made at home. The same goes for patients with recurrent falls who may need hand railings placed in dangerous areas at home.

In the UK, discharges home are sometimes delayed not because of the patient condition, but because the doctors failed to appreciate that they had to plan the discharge by arranging for a physiotherapist to retrain the patient and for a home assessment to be made to ensure safety.

Moreover, social history examines the home dynamics such as relationships, financial funding, ability to cook, clean, wash and doing the daily activities such as shopping. Is the patient the carer for their ill relative and if so, by entering the hospital, who will look after the relative?? The same goes for children when a parent is admitted to hospital.

Without a social history, no idea can be understood of the family situation and therefore, very important matters may be missed.

Funding can be a big problem for the elderly who have little savings and for those families with low incomes. In the UK, with the Welfare State, funding can be obtained to help pay for expenses of home modification, providing home care such as washing, cleaning and bathing plus if need be, full time nursing care facilities.

The situation in Japan is somewhat different from my experiences.

Other important matters identifiable from a social history include where the patient lives? In a house, an apartment. Are there stairs that need to be climbed? Can the patient climb them or do they need to stop? Does the elevator work?

Is the patient in an industrial area ? Have they ever been exposed to dangerous chemicals / materials e.g. asbestos

Does the patient have animals at home? Was the chest disease caused by the pet bird in the cage at home??

All these are part of the social history or they can also be incorporated as direct questions in the history of the presenting /chief complaint.

This provides the doctor with very interesting elements of the patients life that may throw up unforeseen risk factors not previously appreciated.

Secondly, as I have already alluded to, it provides the doctors and social workers the ability to work towards a home package that can be set in motion upon discharge home of the patient if such a package is required.

Finally, in fact alcohol and tobacco are NOT part of the social history and I always find that this is the only thing that is mentioned when the words social history are uttered. Tobacco and alcohol are HABITS.

I think from the above information it can be readily appreciated that social history is a detailed evaluation of the patient's life before entering the hospital and it should never be forgotten to be asked in detail.

I hope this gives you something to consider.

All the best.