23 January 2012
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
-Justin
Dear Justin: The age at which a man stops growing depends on when he completes the hormonal and accompanying body changes of puberty. This, of course, depends on how early the changes start and how quickly they proceed. Some boys stop growing as early as 14-15, most around 18-19, and some continue to grow into their early twenties.
Sincerely,
Dr. Warren
-DB
Dear DB: You say your husband has the same symptoms, but you don't say what they are. If your husband had a shunt for hydrocephalus and has the same symptoms you should contact the neurosurgeon. The shunt could be malfunctioning. This is nothing to fool around with or try to diagnose or decide about with advice from an on-line physician.
Hydrocephalus causes increased pressure in the brain. This could cause headaches; nausea; vomiting; irritability; lethargy; seizures; visual disturbances including blurred vision, double vision, or loss of vision; spasticity or other neuromuscular symptoms including weakness; loss of balance or coordination; slurred speech; impaired concentration and cognitive functions; etc.
Sincerely,
Dr. Warren
-Tiffany
Dear Tiffany: Although there have been articles written about the use of steroids to reduce symptoms of severe sore throat, given the potency of steroids, I don't know how accepted that recommendation has been in general practice. In any event, that would not have made a difference regarding your swollen lymph node. Was a throat culture done? Was a diagnosis of strep confirmed? Were you treated with penicillin or any other antibiotic. Strep is treated with penicillin to avoid complications, but even still, unless you were still sick with a sore throat, a lymph node from strep throat wouldn't persist 2 months.
Should you be concerned and see a doctor? I don't know. You didn't tell me the size, if it's tender, if you're sick with fevers or weight loss. With the little information I have, I'd have to suggest seeing a doctor, but not in the emergency room. Emergency rooms are for emergencies. You need your own doctor for any problem which may require follow up.
Sincerely,
Dr. Warren
Dear Dr. Warren: Hi this is Tiffany again. No I have not been sick in any type of way. The lymph node does not hurt or anything its just there on the left side of my neck. Do you think this a cause for concern?
-Tiffany
Dear Tiffany: If the lymph node is lima bean size or smaller and not growing, it is probably nothing to be alarmed about, but you must understand that I have not examined you, so I cannot give you a 100% assurance that everything is okay. If in doubt, see your doctor.
Sincerely,
Dr. Warren
Hope please!
-RMR
Dear RMR: That's a tough question to answer. When neither a pulmonologist nor a cardiologist suspect a vascular ring, I must assume that clinically it didn't look at all like a possibility.
We are all taught in medical school that not all that wheezes is asthma, but we are also admonished to first do no harm, and that when we hear hoof beats to look for horses not zebras. What that means is that if a child appears to have typical asthma, don't be thinking of uncommon causes of wheezing (zebras). Why the admonition not to look for zebras? Because even the most benign test can have unintended and unexpected consequences. How much the worse when a bad outcome results from an unnecessary procedure. First, do no harm!!!
In my opinion, the best physicians are not only the ones who know what the zebras are, but when to look for them. Physicians who order unnecessary tests to cover their asses or because they really don't know when to consider further investigation drive up the cost of medical care and put their patients at unnecessary risk.
Most physicians are caring, honest people who truly want to do what's best for their patients. They tend to take bad outcomes very personally, so the last thing any physician wants is to miss a diagnosis or hurt a patient. After many years of practice, you get used to finding horses. Hopefully that doesn't result in complacency because, in some ways, finding zebras is very exciting. It's also a little frightening.
A physician who has years of experience finding horses also depends on that experience to tell him when something seems a little off and that it's time for the zebra hunt to begin. Sometimes, the only clue is persistence of symptoms. Now I think you'd agree that it's not reasonable to do a barium swallow on every infant who wheezes, but on the other hand, if a patient isn't doing well, every effort should be made to figure out why. And how does a physician know when a patient isn't doing well? Many ways, but among others, when a patient (or in the case of kids, a parent) tells him that things aren't going well, the physician knows it's time to look further. When something is found, that can, unfortunately leave the impression that the doctor missed something and leave the patient complaining, "Why didn't the doctor listen to me?"
In fact, your pulmonologist did listen to you and ordered the appropriate test. Did he wait too long? Did your child suffer as a result? Only you can answer that. Since your doctor knew what to look for and how to look for it, I can only assume that he thought it reasonable to try other measures before going further in diagnostic testing. The best advice I can give any patient or parent for this circumstance is that if you don't feel your doctor has found the answer or that your treatment isn't working or causing too many side effects, etc., you must advocate for yourself and be part of the decision making process. Ask questions without being confrontational, e.g., "Doctor, is there any other possible diagnosis? How would we pursue it? Are there any other treatments? What are the risks and benefits of doing what we're doing, trying an alternative, doing nothing?" Every physician has reasons for what he's doing. If he won't discuss them with his patient, it's time to go elsewhere.
Sincerely,
Dr. Warren
Dear Readers: Every once in a while a question leads to what I think is an important discussion of how doctors work and think. This is one of those letters.
It is exciting for a physician when he makes an uncommon diagnosis. I remember, during my internship, seeing a child who was followed in the pulmonology clinic for recurrent pneumonia. When I examined him I noticed that he had a widely split second heart sound. I brought this finding to the attention of my attending who immediately arranged a cardiology consult. He congratulated me on noticing something that many previous residents and attendings before me had not. This child had an atrial septal defect which resulted in over circulation to his lungs leading to the recurrent pneumonias. The repair would change this kid's life. Did I hear it that day because I got lucky? because I was just a fresh set of eyes looking at the patient? because maybe the patient was fluid overloaded that day? Who knows. I had the advantage that day of having the support of a teaching staff to validate my findings and explain their significance.
Unfortunately the day to day practice of medicine in the real world isn't like that. There are waiting rooms full of patients who don't like to wait. There are specialists who appreciate referrals, but who won't take a colleague seriously if he refers lots of kids with nothing that requires their attention. And there are insurance companies who are watching the bottom line who will dump a physician from their panel if he makes too many referrals to specialists.
Fortunately, most kids are healthy and will do just fine, but in a way that limits the experience of pediatricians in private practice with zebras. They have to depend on their experience with normal to recognize when something isn't right. There's a fine line between doing too little to evaluate a patient, and doing too much. But don't forget, folks, the pediatrician sees your child at one point in time. You're with him all the time, so the pediatrician depends on your observation and knowledge of your child to know when it's time to do more.
Sincerely,
Dr. Warren
-Robin
Dear Robin: Make sure your son is going to bed at a reasonable hour (not too early). Make sure he is not over-stimulated before bed by watching scary shows or reading scary stories. Make sure there is nothing interfering with your son's sleep such as being too hot, too cold, drinking too much before bed and having to urinate. If he snores loudly make sure he doesn't have large tonsils causing sleep apnea. Don't let him take day time naps even if he is tired from not sleeping well the night before. Teach him a soothing lullaby and encourage him to sing it to himself over and over when he awakens to prevent his mind from swimming with thoughts that keep him awake. Make sure he is not being kept awake by unresolved issues or anxieties.
Sincerely,
Dr. Warren
-SH
Dear SH: Think of the eyes like a camera. If the vision is normal, it is capable or recording an accurate image; however, the decision about what picture to take is in the hands of the photographer. If a child has a visual processing defect, the perfect image the eyes record does not get translated by the brain into meaningful data that the child responds to. As a result, she does not look at anything. This could be a result of damage to the visual cortex of the brain secondary to the hydrocephalus. Since I am not an expert on this matter, I am not sure what further evaluation the neurologist has in mind to help determine this issue.
With or without hydrocephalus we can never tell for sure what an infant's potential is. If your granddaughter's development is normal in all other regards, that is a good sign. You have not been told that she has a condition which can't be remediated, so while I understand your anxiety, it's premature to think the worst.
Sincerely,
Dr. Warren
Can you tell me possible causes? Should I consult an orthopaedic doctor?
Thanks.
-Diana
Dear Diana: Measurements can be wrong, but if you have objective evidence that your daughter is shorter than she was, for example, clothing not fitting properly, or being shorter than someone she used to be taller than like grandma, then further evaluation is warranted.
The most likely culprit would be the spine where both scoliosis and osteoporosis can make a person shorter. The long bones don't shrink and only curve with rickets and rare congenital disorders. An orthopedist would be the right specialist to see.
Sincerely,
Dr. Warren
-JG
Dear JG: Laziness is not something seen in 6 week olds. It takes the same work to push out a stool with or without a suppository. Sometimes it takes a lot of work to have a bowel movement and the results are not always immediate. Your son starts to push when he feels stool coming down into his rectum. As long as he's not screaming in pain, you should do nothing and allow whatever amount of time it takes for his body to function on it's own. If the stools are hard, then your doctor has to discuss options with you for softening the stool such as prune juice, pear juice, or medication.
Sincerely,
Dr. Warren
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