5 May 1997
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 physician who knows you and cares about you.
Dr. Warren
-Chris
Dear Chris: Two weeks is a very long time for an appendicitis to fester. Usually from beginning to end, by rupture or surgery, doesn't last more than a day or two. Still, your strong family history should not be ignored because family history tends to repeat with regard to appendicitis. Also any severe pain persisting in the right lower part of the belly should be considered appendicitis until it has been proven not to be.
After reading your e-mail I find myself quite concerned that you may have appendicitis. I wish I could examine your belly and tell you what should be done, but since that can't be done by e-mail my advice is to demand the attention from your physician that you deserve. Regardless of whether your bellyache is appendicitis or not, if you are having severe pain, your physician should continue to monitor your status and order appropriate tests until he has found a diagnosis and administered appropriate treatment.
If your physician believes you have appendicitis, rather than sending you to an emergency room, he should contact the surgeon himself and arrange for you to be reevaluated. If he and the surgeon are not in complete agreement on your management, your physician should maintain an ongoing dialog with the surgeon regarding your status. Or, if your physician disagrees with the surgical opinion, he should refer you for another opinion.
Finally, it is your physician's responsibility to make sure you understand what your diagnosis is and how it should be managed. Doctors must see through severe and worrisome symptoms to the end. It is absurd to leave a sick patient with no treatment, advice, or follow up plan just because the most serious diagnosis (in this case appendicitis) is believed to be ruled out.
Please get additional medical evaluation. You cannot ignore your symptoms and neither should your doctor. If he is not inclined to take you seriously and follow through on your care, you should get your medical care elsewhere. Let me know what happens.
Sincerely,
Dr. Warren
-JW
Dear JW: Your question is primarily a legal issue rather than an ethical or philosophical one. In New York State (I'm not sure if it applies to the rest of the USA) at age 18 a person can sign his own consent and therefore can make his own decisions. An emancipated minor can sign his own consents. A minor is generally considered emancipated after having his own child, but the freedom to make medical decisions is largely related to sexual and reproductive issues unless the minor no longer lives with his parents.
Most parents generally have the interest of their child at heart. However, since they are human beings, it is not always possible for them to make decisions without being influenced by their own needs. When parents refuse medical treatment on religious grounds it is generally their belief that it is in the interest of their child to do so. To oppose God's will is certainly more likely to be harmful than to ignore medical advice. Under those circumstances, it is possible, even likely, that if given a choice, the child who follows his parents religious beliefs would actually make the same choice as his parents regarding treatment without the benefit of fully understanding the consequences of his choice.
Pediatricians function not only as physicians, but also as child advocates. If a treatment is considered a matter of life or death, parental refusal usually leads to taking the matter to the courts. But when the matter cannot be shown to pose an immediate risk to life, the courts are generally reluctant to interfere with parental rights or religious freedom, unless their decision will also impact on public health. While this may be frustrating to pediatricians and other physicians, we must recognize that our advice is not always foolproof. Even with the weight of scientific opinion on our side we do not have the wisdom of God to know for sure what the consequences of our actions will be. Which physician among us would have predicted that the blood supply would become tainted with HIV? Can you imagine how a Jehovah's Witness would feel if the court had compelled his child to receive the tainted blood against his wishes.!?!
Sincerely,
Dr. Warren
-Mr. & Mrs. B
Dear Mr. & Mrs. B: There is no question that children who have decreased hearing during the time when speech is developing may suffer developmental deficits as a result. While resolution of the hearing problem improves the ease with which they learn language, even with normal hearing at a later age these children may need speech therapy to help them learn what they missed.
Resolving the issue of middle ear fluid for your child is not a guarantee that he will then just pick up speech normally, even if the initial underlying cause of his difficulty was the result of middle ear fluid. However, if hearing testing shows him to have a hearing deficit as a result of middle ear fluid, it will certainly add to his difficulty learning language.
One and one half years of persistent middle ear fluid is more than enough time to decide that conservative therapy isn't helping. If your child's hearing is affected by the middle ear fluid after this length of time he meets the criteria for surgical treatment with tympanotomy tubes.
The decision regarding treatment of his middle ear fluid does not depend on knowing or proving that his middle ear fluid is causing his speech problem. Persisitent middle ear fluid affecting the hearing is more than sufficient cause to intervene. Your decision is largely dependent on the current state of his hearing.
He should have a complete audiogram done by an audiologist who is experienced in working with children, preferably developmentally disabled children. If you do not know where to obtain this you might try contacting the nearest childrens hospital, a local chapter of United Cerebral Palsy, or a local school for developmentally disabled children. Your local school district might even be able to direct you, and for that matter, so might your current speech therapist.
I realize you asked for references rather than my opinion. I hope you will find my opinion helpful since I don't have a long list of resources to offer you. The following two web sites offer articles that may be of interest to you:
http://ws1.kidsource.com/ASHA/early_identification.html
http://ws1.kidsource.com/ASHA/child_language.html
You can find a list of books which might be useful to you at http://198.83.19.39/School_is_dead/talking.html.
You can find links to other resources at http://www.familyvillage.wisc.edu/lib_comd.htm.
Sincerely,
Dr. Warren
Is there any particular reason as to why does this happen?
Thanx.
Please reply soon.
-SA
Dear SA: Dryness of the mouth on awakening from sleep may mean that you are breathing through your mouth. One of the functions of the nose is to humidify the air you breathe. When you breathe through your mouth it dries the membranes in the mouth and throat. This can be helped by keeping a humidifier or vaporizer going in your room to keep the air moist. If you are a mouth breather you should also try to deal with the cause of that. If your nose is stuffed because of colds or allergies treating those symptoms would help.
You must be sure that your mouth isn't excessively dry because of dehydration as might occur with diabetes. If you are urinating a lot and always thirsty you must see a doctor.
Sincerely,
Dr. Warren
-MF
Dear MF: The condition you are describing sounds like Bell's Palsy. It is a paralysis of the facial muscles served by the facial nerve. The condition is usually temporary, but recovery may not always be complete. Bell's Palsy can be associated with Lyme disease so you should discuss being tested for Lyme with your doctor. A stroke could also cause these symptoms but would generally have additional symptoms. If the condition persists or involves more than your facial nerve you should see a neurologist.
Sincerely,
Dr. Warren
-BS
Dear BS: I am guessing that you are describing stretch marks on your daughter's stomach, but I cannot be sure since I haven't seen what your doctor saw. Stretch marks occur when skin stretches because of rapid growth or rapid weight gain. The color of stretch marks fades with time, but stretch marks are permanent. They do not go away.
Sincerely,
Dr. Warren
-JADR
Dear JADR: In order to answer your question regarding your daughter's incontinence I would need more information. For example, is this a recent problem, or has she always had a small amount of leakage? Does she wet herself at night? Does she have any symptoms such as burning, frequent urination, urgency?
If she is a typical five year old and has been previously dry, she may be holding her urine too long because she doesn't want to interrupt her activities to urinate. As a result she may then find it urgent to run to the bathroom when she can no longer hold her urine, and she may then have small accidents, but not totally wet herself.
On the other hand, if she has always dribbled out small amounts of urine she may have an anatomic problem such as labial adhesions resulting in a poor urinary stream and some urine pooling in the vaginal vault and continuing to leak out after she has finished urinating.
A normal urinalysis does not rule out a bladder infection. A culture is necessary to eliminate that possibility.
Sometimes children lose hair after a major illness because the normal hair cycle is disrupted and many hair follicles go into the resting phase at the same time. In that situation the hair that falls out has a little bulb like root on the end. This hair will grow back.
Children sometimes lose patches of hair for unknown reasons. This is known as alopecia areata. It is not predictable whether or not that hair will grow back.
If children pull out their hair, it will grow back, but the bald patches are unlikely to improve unless the child stops pulling out the hair. This is called trichotillomania and is generally a result of stress.
If the condition doesn't resolve your daughter's scalp should certainly be checked or rechecked by her physician or a dermatologist.
Sincerely,
Dr. Warren
I asked for blood cultures, urine cultures, and all the standard battery of laboratory help. I could´nt find any clue of the origin of this fever.
I have to tell you that in Peru is not easy to get a virus culture. So if you could tell me you opinion about this case I will be gratefull.
Thank you
-LL, M.D.
Dear Dr. L: Some children tend to run high fever when they become ill. At a frequency of once every 8 to 12 months your patient is averaging 1 to 2 febrile illnesses per year. If the duration of the fever is not generally longer than 5 days, even though each of these illnesses has not had a specific diagnosis, she has never met the criteria for a diagnosis of fever of unknown origin. The length of time between these fevers is too long to suggest a pattern. Each of these fevers should be considered a separate illness, the most likely cause being viral.
In routine pediatric practice in the USA we do not do viral cultures for evaluation of fever. Viral cultures are primarily done in children with unusual illnesses where a particular virus is suspect and the results of the cultures will provide important epidemiological information or be of some consequence in the long term management of the patient. Even in the USA most viral studies provide results several weeks after the patient has recovered.
If a patient has prolonged fever for more than a week or recurrent fevers over several weeks to months we would do a workup for fever of unknown origin. This would include CBC with differential, ESR, urinalysis, PPD, urine culture, throat culture, monospot, chest x-ray, cold agglutinins, febrile agglutinins, stool culture, ANA, ASLO, rheumatoid factor, LFTs, and Lyme titer. If the child seems very ill we would hospitalize and consider blood culture, LP, bone marrow, bone scan, gallium scan. Additional testing would be dictated by results of the initial testing, symptoms, physical findings, and clinical course.
Your patient does not appear to warrant evaluation for fever of unknown origin. In fact, if she is not significantly ill with her fevers I would not be inclined to do any further workup. When I examine a child who does not appear ill for a high fever I observe for 3 to 5 days and assume the illness is viral. If the child appears ill and the source is not obvious I am more vigorous in my workup; however, unless the fever persists more than a week, I consider only infectious causes in my differential diagnosis (unless there are symptoms or findings to point elsewhere). My evaluation includes urinalysis and urine culture, chest x-ray, CBC with differential, and ESR. If all results are normal no further workup is indicated unless the child becomes toxic, develops new symptoms, or the fever doesn't resolve.
Sincerely,
Dr. Warren
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