Numbness and Tingling

Numbness and tingling are common symptoms, which could be due to a problem in nerves, blood supply or other systemic diseases.

Numbness and tingling are abnormal sensations felt usually in the limbs. The most common reason for numbness and tingling, which has been experienced by one and all, is keeping a limb in a particular position for a prolonged period of time. This feeling, referred to as “pins and needles,” subsides on moving the limb. It occurs due to pressure on the nerves as well as reduced blood supply to the limb due to compression of blood vessels.

Some cases of numbness and tingling are due to an underlying disease, which requires treatment. The cause of numbness and tingling is diagnosed based on the history and physical examination of the patient. The doctor may also ask for certain tests depending on the possible cause. 

Nerve–related Causes

 Causes related to peripheral nerves may be diagnosed with an electromyogram or nerve conduction study. 

 A cause suspected in the brain or the spinal cord may need a CT scan or MRI. 

 Blood tests may be necessary to diagnose causes like vitamin B12 deficiency. In addition, disease conditions like liver disease, kidney disease and diabetes can also be detected through blood tests.

 Examination of the CSF (the fluid that bathes the brain and the spinal cord) may be necessary to diagnose conditions like Guillain Barre Syndrome.

 A nerve biopsy may be useful to study any structural damage to the nerves.

The causes of numbness and tingling that involve nerves include:

 Peripheral neuropathy: Peripheral neuropathy is a condition where the peripheral nerves are affected by a disease condition. Common causes of peripheral neuropathy are:

 Herpes zoster: Herpes zoster is a viral infection of a nerve, caused by a virus called varicella zoster. Besides tingling and numbness, herpes zoster causes pain along the affected nerve. Small fluid-filled vesicles also develop along the nerve.

 Diabetes: Long-standing and uncontrolled diabetes can affect nerves, resulting in peripheral neuropathy. The patients may experience muscle weakness, pain, tingling, numbness and loss of sensation in the area of distribution of the affected nerve.

 Vitamin B12 Deficiency: Vitamin B12 is required for nerve function; hence deficiency of this vitamin affects nerve function and may result in tingling and numbness. This problem is more commonly observed in individuals on a strict vegetarian diet. Deficiency of other B vitamins can also affect nerve function to some extent.

 Use of certain medications: Medications like INH and rifampicin affect nerve function resulting in peripheral neuropathy.

 Exposure to toxic substances: Chronic exposure to toxic substances like lead, arsenic, mercury, and thallium result in damage to nerves. Besides, smoking and alcohol consumption could also affect nerves, resulting in peripheral neuropathy. Alcohol can cause direct damage as well as through a reduction of B complex group of vitamins.

 Carpal tunnel syndrome: Carpal tunnel syndrome is a condition where the nerves supplying to the hand are compressed at the wrist. Thus, the patient suffers from numbness, tingling and weakness of the muscles of the hand. Similarly, compression of the tibial nerve at the ankle results in tarsal tunnel syndrome, with similar symptoms in the feet. 

 Tumors: Benign as well as malignant tumors can press on nerves resulting in tingling and numbness.

 Multiple sclerosis: Multiple sclerosis is an autoimmune condition where antibodies are produced against the covering of nerves, called the myelin sheath. The patient also shows other symptoms like loss of balance, muscle weakness, tremors, constipation, vision loss and depression.

 Seizures: A person with seizures may experience numbness and tingling. The symptoms may spread from one part of the body to the adjacent regions.

 Spinal cause: A condition that results in pressure over nerves exiting the spinal cord can result in numbness and tingling along the distribution of the nerve. For example, a herniated disc could compress on one of the spinal nerve. A neck or back injury may also compress nerves, resulting in tingling and numbness. The symptoms may increase with certain positions of the neck. A spinal cause usually results in tingling and numbness over a well-defined area.

Blood supply-related and Other Causes

Causes of numbness and tingling associated with reduced blood supply are:

 Migraine: A migraine headache is a one-sided headache caused due to alteration in blood supply to the head. The symptoms may spread from one part of the body to the adjacent regions.

 Stroke: Stroke results in reduced blood supply to a part of the brain. Consequently, the part of the body controlled by that part of the brain gets affected, often resulting in paralysis. The sensory nerves may also get affected, resulting in a feeling of numbness. In some cases, the stroke brings about temporary symptoms; this type of stroke is referred to as a transient ischemic attack.

 Raynaud’s phenomenon: Raynaud’s phenomenon is a condition where the blood vessels of the fingers and toes undergo spasm when exposed to cold or under certain emotional conditions. It commonly affects smokers and people with certain disease conditions like arthritis and frostbite. The numbness may be accompanied by pain and sometimes ulcers.

 Atherosclerosis: Atherosclerosis is a condition where the blood supply through an artery is reduced due to plaque formation. Atherosclerosis may cause tingling and numbness if the blood supply to a limb is affected, especially while walking.

Other causes of numbness and tingling are:

Systemic diseases: Other disease conditions can also result in tingling and numbness. These include:

 Kidney disorders: Kidney diseases result in high levels of metabolites like urea and abnormal levels of electrolytes like calcium, potassium, or sodium. These could give rise to a feeling of tingling and numbness.

 Liver disease: Liver disease could result in accumulation of toxic substances in the blood that affect nerve function.

 Hormonal conditions: Hormonal conditions including hypothyroidism could cause abnormal sensations.

 Other diseases like HIV/AIDS, Guillain-Barre syndrome, lupus, sarcoidosis and rheumatoid arthritis are also associated with tingling and numbness.

 Psychiatric causes: Psychiatric causes are often associated with numbness especially of a part of the face.

 Miscellaneous causes: Radiation therapy and bites from insects or animals could result in numbness and tingling. Bites may also cause additional symptoms of swelling, redness and localized pain.

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Digestive Tract Ulcers

A break in the mucus membrane lining of the digestive tract results in ulcers.

The digestive tract is lined by mucus membrane. A break in the mucus membrane lining results in the formation of an ulcer.

Ulcers can affect the digestive tract right from the mouth to the anus. Symptoms depend on the location of the ulcers. Pain is a usual feature. In cases of deeper ulcers, bleeding may be present. 

Ulcers could be due to various causes. These include infectious causes like Helicobacter pylori resulting in stomach ulcers, inflammatory causes like Crohn’s disease and ulcerative colitis, or spicy food, alcohol or medications. In some cases, ulcers may be due to a malignancy. Hence, it is important to identify the cause of the ulcers and treat accordingly.

Detection of ulcers in the mouth is usually straightforward, since it is the visible part of the digestive tract. Ulcer diagnosis in other parts of the digestive tract is not as simple due to the inaccessibility of these parts. However, newer procedures like endoscopy and colonoscopy have made diagnosis of inaccessible ulcers also possible.

Upper Digestive Tract Ulcers

The causes of ulcers of the upper digestive tract are listed below:

Ulcers in the Oral Cavity: Ulcers in the oral cavity could be due to multiple causes. Some conditions that result in ulcers of the mouth are:

 Recurrent Aphthous Stomatitis: Recurrent aphthous stomatitis is a common condition that results in recurrent small painful ulcers in the mouth. The ulcers are shallow, round or ovoid and recur at intervals of a few days or up to 2 to 3 months.

 Trauma, Cancer, and Infections like Syphilis and Tuberculosis: These conditions result in a single mouth ulcer. If the ulcer does not heal in 10-14 days after the source of trauma is removed, it should be evaluated for cancer.

 Behçet’s disease: Behçet’s disease is an inflammatory condition in which the patient suffers from recurrent oral aphthous ulcers. In addition, the patient also suffers from genital ulcers, inflammation of the eye and skin lesions. In some cases, joints, nervous system, blood vessels and intestines may also be affected.

 Herpes: Viral infections like herpes can cause painful mouth ulcers. Herpes usually manifests as small boils or blisters.. Lymph nodes in the neck may be swollen.

 Vitamin Deficiency: Vitamin deficiency, especially deficiency of vitamin B and C can result in mouth ulcers.

Ulcers of the Esophagus:

 Esophagitis: Esophagitis is a condition marked by inflammation of the esophagus or food pipe, sometimes accompanied by ulceration. It is often caused by reflux of acid from the stomach into the esophagus.

 Mallory-Weiss Tear: Mallory-Weiss tear is a condition where the lining of the esophagus is torn due to prolonged vomiting or conditions where the abdominal pressure is increased like coughing, severe hiccupping or childbirth.

Stomach and Duodenal Ulcers: Stomach and duodenal ulcers cause pain in the upper part of the abdomen. The pain in stomach ulcers is usually increased just following a meal, whereas in duodenal ulcers, it occurs 2 to 3 hours after a meal. The pain in duodenal ulcers is usually relieved with food or antacids. It may wake up the patient at night. The pain of stomach or duodenal ulcer may be accompanied by dark stools and anemia (due to bleeding from the ulcer). Other symptoms like belching, bloating, and distention of the abdomen may also be present. 

Causes of stomach and duodenal ulcers include:

 Helicobacter Pylori Infection: Infection with a bacterium called H. pylori results in stomach ulcers. Treatment with a specific course of antibiotics and acid suppressant is used to eradicate the bacteria.

 NSAIDs: Painkillers belonging to the NSAID group like indomethacin, naproxen and diclofenac, especially when used continuously for conditions like arthritis, can cause stomach ulcers. These drugs damage the stomach lining resulting in ulcers. The patient usually gives a history of using these drugs, sometimes maybe on an empty stomach. This helps to diagnose the condition.

 Alcohol and Caffeine: Alcohol and caffeine intake irritates the stomach lining and increases the chances of ulcers.

 Stress: Stressful conditions like trauma, burns, surgery and severe medical illness can result in stomach ulcers.

 Stomach Cancer: In rare cases, the stomach ulcer may be over a cancerous area. Patients have additional symptoms of unexplained weight loss, progressive difficulty in swallowing, and sometimes vomiting. 

 Zollinger-Ellison Syndrome: Zollinger-Ellison syndrome results in multiple stomach and duodenal ulcers. The patient may also suffer from kidney stones, watery diarrhea, or malabsorption. The condition is diagnosed by measuring the levels of gastrin, a hormone that stimulates the secretion of gastric acid.

Lower Digestive Tract Ulcers

Some of the conditions that result in ulcers of the lower digestive tract are:

Intestinal and Anal Ulcers: 

 Ulcerative Colitis: Ulcerative colitis is an inflammatory disease where multiple ulcers are present in the large intestines. The patient may complain of blood in stools, frequent stools with mucus discharge, pain in abdomen and weight loss. The patient may also show the presence of inflammation at other sites like the eyes, outer covering of lungs, skin and joints.

 Infection: Infections like HIV, tuberculosis, cytomegalovirus and typhoid can result in bowel ulcers especially in complicated cases. Symptoms of the underlying infection are usually obvious in these cases.

 Cancer: Cancer can affect the bowels and result in ulceration. The patient may suffer from weight loss, blood in stools, abdominal pain and discomfort, changes in bowel habits and narrowing of stools. A biopsy through colonoscopy helps to diagnose the condition.

 Anal Fissure: A tear in the anal region can result in the formation of a fissure, which is very painful and can bleed. The pain is particularly more while passing stools.

 Drugs: Drugs like enteric coated potassium and NSAIDs can irritate the intestinal lining resulting in ulcers. A history of drug intake should be elicited in patients with intestinal ulcers.

 Reduced Blood Supply: Reduced blood supply to the colon can result in ulcerations. It could occur due to a number of reasons like following a cardiac problem, a clot in the blood vessels supplying to the intestines or inflammation of the blood vessels. The patient may show symptoms like abdominal pain, diarrhea, and bleeding.

 Radiation: Radiation damages the lining of the intestines resulting in ulcerations. The patient may show symptoms of abdominal cramps, bleeding and mucus discharge. A history of prior radiation can be elicited from these patients.

Ulcers at Multiple Sites in the Digestive Tract:

 Crohn’s Disease: Crohn’s disease is an autoimmune disease that can result in ulcers anywhere from the mouth to the large intestines, though it more commonly affects the intestines. Symptoms vary from mild to severe and may include abdominal pain, fatigue, loss of appetite, pain while passing stools, diarrhea, weight loss and bleeding. Other organs like the joints, eyes and skin may also be involved.

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Ear Pain

Pain in the ear is either due to a condition that directly affects the ear, or is referred from the surrounding areas. 

 

Ear pain is a common symptom that could occur either due to a problem in the ear itself or a neighboring part of the head or face. Ear pain due to a local cause is usually detected on ear examination. For example, an infection or a foreign body can be directly diagnosed through ear examination. If this examination does not show any abnormality, the surrounding structures like the mouth should also be examined.

The ear is made up of three parts: the external or outer ear, the middle ear and the inner ear. The external ear extends through the ear canal till the eardrum. The middle ear extends from the eardrum till a spiral structure called the cochlea, which forms the internal ear. Conditions that cause ear pain are usually located in the external or middle ear.

Common causes of ear pain are:

Conditions affecting the ear:

 Acute Otitis Externa: Otitis externa refers to infection of the external or outer ear. The patient complains of pain when the examiner pulls the cartilage of the ear or presses on the tragus (the small cartilaginous projection in front of the ear). The ear canal may be red and swollen. The infection may follow an insect bite, scratch or ear piercing.

 Acute Otitis Media: Acute otitis media is an infection of the middle ear and is one of the more common causes of ear pain. On examination of the ear, the eardrum may be red and bulging. In some cases especially in diabetes patients or patients with reduced immunity, the infection and pain can be severe; the condition is referred to as malignant otitis externa.

 Foreign Body in Ear: Foreign bodies inserted in the ears are common causes of ear pain in children. The foreign body is usually visible in the ear canal on examination and can be removed with a curette or a forceps. In some cases, excessive ear wax can result in ear pain.

 Changes in External Pressure: Changes in external pressure can result in ear pain. This situation is frequently experienced during a flight or while scuba diving. The pain usually subsides on its own. In some cases however, the pressure changes can damage the eardrum resulting in accumulation of fluid or blood in the middle ear.

 Trauma: Trauma to the ear due to injury can cause pain of the ear. A history of trauma is usually present in these patients.

 Cancer of the External Ear: Squamous cell cancer, a cancer affecting the external ear, is a rare cause of ear pain. The pain tends to be severe, deep and unrelenting.

 Ramsay Hunt Syndrome: Ramsay Hunt Syndrome is a condition where the nerves supplying to the area near the ear are affected by a viral infection called herpes zoster. The patient complains of features like ear pain, paralysis of the face and the presence of fluid-filled boils in the ear canal. Other associated symptoms include hearing loss, ringing in the ear, vertigo and taste disturbances.

 Relapsing Polychondritis: Relapsing polychondritis is a condition that affects the cartilages of different parts of the body including the ear. The ears appear red in color. However, the earlobe, which lacks cartilage, appears normal. The condition keeps relapsing. Cartilages in other organs are also often involved, which include the eyes, nose, heart, kidneys and the nervous system.

Conditions Causing Referred Pain to the Ear: Conditions that cause ear pain despite a normal ear examination are:

 TMJ Syndrome: The TMJ is the jaw joint. TMJ syndrome is a condition where the patient experiences ear pain especially while moving the jaw during activities like talking or chewing. Examination of the joint may elicit pain and a crepitus sound on moving the joint. The pain may subside with painkillers and a soft diet.

 Dental Causes: Pain in the molars due to caries, abscess or due to impaction of the molar can lead to referred pain in the ear. It is therefore extremely important to check the teeth in a patient complaining of ear pain.

 Sore Throat: Sore throat or enlarged and infected tonsils can result in ear pain. Again, this condition is diagnosed on examination of the mouth.

 Tumors of the face and neck region: Tumors of nose, mouth, neck and chest can rarely cause ear pain. The patient may show symptoms like difficulty with swallowing, hoarseness or weight loss. He/she may also give a history of smoking.

 Neuralgias: Neuralgias are conditions that affect nerves and cause severe pain in the distribution of the nerve. Neuralgias that cause severe pain around the face include trigeminal neuralgia, glossopharyngeal neuralgia and sphenopalatine neuralgia. The pain is often sharp, shooting, and severe and appears in paroxysms.

 Temporal Arteritis: Temporal arteritis is a condition that affects the blood vessels at the temple area. This pain may refer to the ear. The patient complains of pain when pressure is applied to the temporal arteries. The ESR test, which is a blood test, is usually abnormal in these patients.

 Cervical Spine Arthritis: Neck pain due to arthritis can also be referred to the ear. It is therefore necessary to examine the neck as well in a patient complaining of ear pain, especially if the ear examination is normal. 

Herbs and Anti-oxidants that Fight Cancer

Nutrition, exercise, and stress reduction are the primary factors that help prevent development of free radicals in the body, build up the immune system and strengthen it.

Our immune system plays an important role in keeping free radicals in check, limiting the development of cancerous cells and combating  cancer.

What are these free radicals and why are they so dangerous?

The air we breathe in contains oxygen, a molecule that helps our body  to and function smoothly. Sometimes, metabolic processes, pollution in the air, smoking, and even junk food (yes, that’s right) can create unstable oxygen ions in the body. The oxygen radicals circulate in the bloodstream and ‘snatch’ electrons from the tissues thus destabilizing those ‘attacked’ molecules in the tissues  by making them short of electrons. They in turn circulate as free radicals on the lookout for molecules from which they can snatch electrons, thus kick-starting a  series of  chain reactions . This process is called ‘oxidative damage’.

Anti-oxidants are molecules that interact with free radicals and stop the chain reactions that damage the cells (including DNA) in our body. They help by destroying free radicals in the body and in the process reduce oxidative stress. Apart from building the immune system, they inhibit the gene expression for cancer and induce gene expression that promotes tumor suppression. . Further, they arrest uncontrolled cell division, thereby preventing the development of cancer.

Anti-oxidants that fight cancer include vitamin A, vitamin C, vitamin E, beta-carotene, phenolics and resveratrol among hundreds of other substances. And these are the substances that are easily available in most herbs and spices in your spice rack. Anti-oxidants in food are measured in units of Oxygen Radical Absorbance Capacity (ORAC). The FDA recommends 3,000 units of ORAC a day.

It’s true that you can’t get all the anti-oxidants you need from the herbs but the anti-oxidants in herbs can supplement the anti-oxidants you get from fruits and vegetables.

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Decreased Consciousness

Various levels of decreased consciousness include delirium, stupor, coma, persistent vegetative state, minimal conscious state and brain death.

Consciousness is a state of being aware of self and surroundings. It is decreased when large parts of the brain or specific parts which are associated with maintaining consciousness are affected by a disease process. There are various levels of decreased consciousness. These are:

 Delirium is a sudden severe state of confusion that is usually due to an illness.

 Stupor is a condition where the patient is unresponsive to normal stimuli but can be aroused by vigorous physical stimulation like excessive shaking or pinching.

 Coma is a state in which a person cannot be aroused even with vigorous stimuli.

 Persistent vegetative state is a condition where a person shows some improvement following a coma, and appears to lie motionless and without awareness and higher mental activity. It occurs when the brain hemispheres cannot work and the functions are taken over by the lower centers like the brainstem and the thalamus. These patients usually die after months or years, but rare cases of partial recovery have been encountered in clinical practice.

 Minimally conscious state is a condition where the patient exhibits inconsistent signs of consciousness. The patients show some degree of awareness of self and surrounding.

 Locked-in state is a condition where the patient is conscious and aware of the surroundings but unable to move. The patient can only respond by opening and closing the eyes.

 Brain death is a state where the patient suffers from irreversible coma with loss of ability to maintain body functions including breathing.

In cases where the cause can be reversed, the patient may recover completely if there is no accompanying brain damage. In some cases, the patient needs continuous ventilatory support.

A history obtained from the patient’s attendants often helps to diagnose the underlying cause of decreased consciousness. Some features that could help in the diagnosis are:

 A high temperature may indicate infection, heat stroke or drug overdose.

 Decreased consciousness in a diabetic may be due to a low or high blood sugar level.

 An abrupt decrease in consciousness could be due to a bleed in the brain or its immediate surrounding, or a brainstem stroke. A slower decrease could indicate a tumor.

 An abnormally low temperature may be due to prolonged exposure to cold, hypothyroidism, excessive alcohol or medication intake, or infection in older people.

 A metabolic cause should be suspected if the patient suffered from intoxication or agitated delirium before the decrease in consciousness.

 An absence of response to painful stimuli in one limb may indicate a problem in the brain. Absent responses of limbs on both sides could indicate that the brain stem is involved.

 Pinpoint pupils that respond to light may indicate opioid poisoning. Examination of eye movements helps to localize the site of the lesion.

Some of the tests that could assist in the diagnosis of the cause of decreased consciousness are:

 Blood tests: An abnormal liver or kidney function test may indicate liver or kidney failure, respectively. A low blood sugar level indicates hypoglycemia.

 A CT scan or MRI can detect brain tumors or structural damage to the brain.

 A spinal tap may show the presence of meningitis or a bleed around the brain.

Causes of decreased levels of consciousness are listed below:

Conditions that decrease oxygen, glucose or cofactors supply to the brain: Conditions that deprive the brain of its requirements to function properly result in an altered level of consciousness. These include:

 Alterations in glucose levels: High blood sugar levels can lead to diabetic coma. On the other hand, low glucose levels can lead to hypoglycemic coma. An altered level of consciousness in a diabetic should raise the suspicion of a problem in blood sugar level.

 Cardiac causes: A cardiac arrest results in a reduced supply of oxygen-rich blood to the brain. Other heart conditions like heart failure could cause similar problems. These conditions may be diagnosed with an ECG or other cardiac tests. Low blood pressure could also result in decreased blood supply to the brain.

 Lung diseases: Severe lung conditions like chronic obstructive pulmonary disease, pulmonary edema (fluid in the lungs), pulmonary embolism (a clot in the lungs), and severe and long-lasting asthma attacks can reduce oxygen content of the blood and thereby the supply to the brain and result in brain damage. A difficulty with breathing is usually obvious in these patients.

 Deficiency of B group of vitamins: A person with severe deficiency of vitamin B1 or thiamine suffers from beriberi, which sometimes causes confusion and delusions. Deficiency of the vitamin B3 or niacin results in pellagra, which is also associated with confessional states. In addition, the patient shows digestive problems and skin inflammation.

Metabolic, Hormonal and Other General Conditions: Metabolic conditions result in the accumulation of excessive or toxic substances in the blood resulting in decreased consciousness: Some of these conditions are listed below:

 Liver failure: Liver failure results in the accumulation of toxic substances in the body, which affect the brain and reduce consciousness, even leading to hepatic encephalopathy and coma. Other signs of liver failure may be present like accumulation of fluid in the abdomen and jaundice.

 Kidney failure: Kidney failure results in high levels of urea in the body, which could affect the level of consciousness. Other features of kidney failure may be present in these patients.

 Hypothyroidism: Very low or very high thyroid levels are associated with altered consciousness. Very low levels could result in a type of coma called myxedema coma.

 Hypothermia or hyperthermia: A change in temperature can affect the brain resulting in damage. High temperatures tend to affect the brain more as compared to lower temperatures.

 Abnormal sodium levels: High sodium levels in the blood, which is often a consequence of dehydration, can reduce consciousness. On the other hand, hyponatremia or low sodium levels could result in accumulation of fluid in the brain, again affecting the level of consciousness.

Drugs, Alcohol and Poisons: Consciousness could be affected by substances that act on the brain. A history of intake of these substances may be obtained from the patient’s relatives. Some of these are:

 Drugs: Drugs are often the cause of an altered level of consciousness in older individuals. This is especially in the case of drugs that act on the brain like sedatives and opioids. Older people are more sensitive to medications and often take multiple medications. Dosages if not reduced in these individuals can result in decreased consciousness. People who take drugs that could possibly reduce their level of consciousness are advised to avoid using machinery or drive to avoid accidents. They are also advised to avoid alcohol due to the additive effect in reducing brain function.

 Alcohol: Alcohol affects the brain in multiple ways. It can directly affect the brain cells causing them to function slowly. In addition, it can affect lung function and reduce the oxygen supply to the brain.

 Poisoning: Poisoning with carbon monoxide results in reduced oxygen-rich blood to the brain.

Conditions affecting the brain: Conditions that directly affect either both the cerebral halves of the brain or the reticular activating system of the brainstem (which is responsible for arousal) can result in reduced levels of consciousness. These conditions are diagnosed based on a detailed neurological examination and tests like CT scan and MRI. These conditions include:

 Stroke: A stroke can affect consciousness in a number of ways. It decreases blood supply to the areas of the brain involved in maintaining consciousness like the brainstem and the cerebrum. A bleed within or just outside the brain can exert pressure on the brain or result in irritation.

 Brain tumors / abscess: A brain tumor or abscess can occupy space within the skull and exert pressure on a part of the brain. In some cases, it can press on the brain excessively damaging it and even pushing it through some of the openings at the base of the skull. This situation is referred to as herniation of the brain, which can worsen the patient’s condition. The tumor may also directly affect the areas of the brain controlling consciousness. Breathing may be altered in these patients. Examination of the eyes helps in the diagnosis of these conditions.

 Aneurysms in the brain: An aneurysm is a swelling of a blood vessel of the brain. It could affect consciousness by exerting pressure on the brain or resulting in a bleed.

 Head injury: Head injury may damage the brain and cause loss of consciousness, sometimes even leading to coma. In some cases, the head injury results in a bleed within the skull. The bleed puts pressure on a part of the brain and can result in decreased consciousness.

 Seizures: Following a seizure, the patient sometimes goes into a deep sleep. This is referred to as the post-ictal stage.

 Infections: Infections of the brain called encephalitis, or the covering of the brain called meningitis can result in altered levels of consciousness. The neck of the patient may be rigid in cases of meningitis. Besides, sepsis may also affect the brain, altering the consciousness levels.

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Dizziness - Symptom Evaluation

 

Dizziness is a common symptom for which a person visits a doctor. Balance is maintained by signals sent from the eyes, inner ears and the nervous system to the brain. Dizziness is of 4 main types, vertigo, disequilibrium, presyncope and lightheadedness. A careful history taking and examination by the doctor helps to differentiate between these four conditions.

When a patient complains of dizziness, the doctor will first enquire into the more common causes of dizziness. These include:

 Caffeine, nicotine and alcohol intake

 History of head and neck injuries

 History of anemia or low blood sugar levels

 Medication intake

Some medications result in dizziness by causing a fall in blood pressure. These include ACE inhibitors like enalapril, beta blockers like atenolol, diuretics like furosemide and nitrates like nitroglycerine. Medications that act on the brain like antipsychotics, opioids and anti-Parkinsonism drugs also cause dizziness. Sildenafil, the active ingredient of Viagra is also known to cause dizziness.

Some features accompanying dizziness that help to identify the cause are mentioned here. The individual causes are described in the next section.

 Episodic vertigo without hearing loss may indicate benign paroxysmal positional vertigo (BPPV)

 Episodic vertigo with hearing loss may be due to Meniere’s disease

 Episodic vertigo with symptoms of migraine may indicate migrainous vertigo

 Lightheadedness with excessively fast breathing may indicate hyperventilation syndrome

 A fall in blood pressure or an increase in pulse rate with a change in position may indicate orthostatic hypotension

 A shuffling gait with imbalance may indicate Parkinsonism

 A decrease in sensation in the lower limbs associated with dizziness especially feet may indicate peripheral neuropathy

 Vertigo preceded by a recent upper respiratory tract infection may be due to vestibular neuronitis or labyrinthitis


Some causes of dizziness are described below.

Dizziness is classified into the following 4 types:

Vertigo: Vertigo is the most common type of dizziness that people experience. The patients experience a false sense of motion, for example, they may complain that the room spins around them. Causes of vertigo are:

 Benign paroxysmal positional vertigo (BPPV): BPPV occurs due to the presence of small stones of calcium carbonate in the semicircular canals of the inner ear, which give a false sense of motion. The vertigo is episodic and is not accompanied by hearing loss. It is often accompanied by nausea and vomiting. The patient may experience a brief but intense episode of vertigo when he/she turns in bed at night or changes the head position. A test called the Dix-Hallpike maneuver is used to diagnose BPPV. During this test, the patient is in a seated position. The doctor turns the patient’s head 45 degrees to one side, then quickly puts the patient in lying down position with the head hanging about 20 degrees over the end of the table. The test is then repeated for the opposite side. Nystagmus or rapid involuntary movement of the eyes during the test is diagnostic of BPPV.

 Vestibular neuritis: A viral infection of the vestibular nerve results in vestibular neuritis. The patient usually does not suffer from hearing loss. The vertigo is persistent. Abnormal eye movements may be present.

 Labyrinthitis: Labyrinthitis or infection of the labyrinthine organs results in vertigo with hearing loss. The vertigo is persistent and may be preceded by a recent upper respiratory tract infection.

 Meniere disease: Meniere disease occurs due to increase in fluid pressure in the inner ear. It is usually accompanied by hearing loss and tinnitus (abnormal sounds in the ear) and occurs in episodes.

 Perilymph fistula: Perilymph fistula is a condition where there is leakage of inner ear fluid into the middle ear. It may be present from birth or develop following trauma like head injury, drastic changes in atmospheric pressure, physical exertion, ear surgery, or chronic ear infections. It results in unsteadiness when walking or standing that increases with activity and decreases with rest.

 Migrainous vertigo or vestibular migraine: Migraine can co-exist in patients with vestibular disease. Patients with are diagnosed with migrainous vertigo if they suffer from episodic migraine and in addition from migraine headache, photophobia, phonophobia or aura during at least two episodes of vertigo.

 Other central causes: Tumors, stroke or other conditions affecting the brain especially the areas involved in balance result in vertigo. These are more serious causes of vertigo. A patient with a central cause is severely unstable and cannot walk or stand without falling.

Disequilibrium: A patient with disequilibrium feels off balance and wobbly. In disequilibrium, the brain does not receive adequate information about the body’s position from the various senses like the eyes and inner ears. The reasons for imbalance could be:

 Stroke: A stroke is one of the reasons for imbalance. It is also accompanied by other symptoms of stroke.

 Poor vision: Poor vision can lead to imbalance, resulting in falls.

 Nerve and muscle related disorders: Other disorders that could cause imbalance are those that can affect nerves and muscles like Parkinson disease, peripheral neuropathy, and musculoskeletal disorders that may affect gait.

 Drugs acting on the brain: Drugs that act on the brain like benzodiazepines and tricyclic antidepressants can cause imbalance and falls especially in older individuals.

Presyncope: A patient with presyncope gets a feeling of losing consciousness or blacking out. Presyncope usually occurs due to a fall in blood pressure, often due to a heart-related cause. This results in reduced blood circulation to the brain and a feeling of dizziness. Causes of presyncope are:

 Abnormal heart rhythms like supraventricular tachycardias and heart attack. Cardiac tests may help to diagnose these conditions.

 Narrowing of the carotid artery (the artery that supplies blood to the brain). In addition, cervical spondylosis may also restrict the blood supply to the brain resulting in dizziness.

 Orthostatic hypotension: Blood pressure that falls with changes in posture is referred to as orthostatic hypotension. The blood pressure is recorded in lying down posture and then again in the standing posture. A fall in the systolic blood pressure of 30mm of Hg, diastolic blood pressure of 10mm of Hg or an increase in pulse of 30 beats per minute is indicative of orthostatic hypotension. A number of medications like reserpine, doxazosin and clonidine can cause orthostatic hypotension.

Lightheadedness: A patient with lightheadedness complains of vague symptoms like feeling disconnected with the environment. Causes of lightheadedness include:

 Psychiatric causes: Psychiatric causes like anxiety, depression and panic disorder can cause lightheadedness.

 Alcohol intoxication: Alcohol intoxication can also cause lightheadedness.

 Hyperventilation syndrome: Patients with hyperventilation syndrome breathe excessively fast. This may give rise to abnormalities in the pH of blood resulting in lightheadedness. The patient may suffer from additional symptoms like chest pain, paresthesias, bloating and pain over the stomach region.

 

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Heartburn - Symptom Evaluation

Heartburn

Heartburn is a symptom that occurs due to irritation of the food pipe either due to acid reflux or direct contact with spicy and irritant foods.

Heartburn is a burning and painful feeling in the chest just behind the chest-bone. In a normal person, the part where the food pipe meets the stomach is guarded by muscular valve called the lower esophageal sphincter. The sphincter ensures movement of food from the food pipe into the stomach, and at the same time prevents contents of the stomach from moving back into the food pipe. In some cases however, the tone of the lower esophageal sphincter may be reduced, allowing the acidic contents of the stomach to move back into the food pipe. This results in symptoms of heartburn. Heartburn may also occur due to direct irritation of the food pipe. The pain of heartburn typically appears after a meal and is increased if the person lies down soon after the meal. Patients with reflux symptoms usually experience heartburn at least twice a week.

On long term, reflux can cause complications including cancer of the food pipe in some individuals. Reflux not only causes inflammation of the food pipe; the acid may reflux into the respiratory tract resulting in cough, laryngitis (inflammation of the sound box), pharyngitis (inflammation of the upper throat), sinusitis (inflammation of the sinuses) and lung complications like bronchitis, asthma, and pneumonia.

The cause of heartburn is usually obvious in each case. Once heartburn is diagnosed, it is important to treat it early to prevent complications.

Some causes of heartburn are listed below:

Substances that irritate the food pipe:

Substances like spicy foods, citrus fruits, cigarette smoke and aspirin-like painkillers that irritate the food pipe can result in heartburn. Decreased lower esophageal sphincter tone:  In many cases, the cause of decreased tone of the lower esophageal sphincter is not known. In other cases, it may be due to:

 Intake of certain foods and beverages: Certain foods and beverages like peppermint, caffeinated drinks like coffee, tea, and soft drinks, chocolate, fatty foods, and alcohol decrease the tone of the lower esophageal sphincter resulting in reflux and heartburn.

 Scleroderma: Patients with autoimmune conditions like scleroderma may have a decreased lower esophageal sphincter tone resulting in reflux.

 Smoking: In addition to acting as an irritant, smoking also decreases lower esophageal sphincter tone leading to reflux.

 Medications: Some medications like anticholinergic drugs and smooth muscle relaxants relax the lower esophageal tone and result in reflux.

 Surgery: Damage to the lower esophageal sphincter due to surgery can decrease the tone of the lower esophageal sphincter.

Conditions where the gastric contents are near the gastroesophageal junction: This happens in the following situations:

 While lying or bending down: Contents of the stomach tend to move backwards into the food pipe when a person lies or bends down especially soon after a meal.

 Hiatus hernia: Hiatus hernia is a condition where a part of the stomach moves up into the chest due to weakness in the diaphragm (the muscular partition between the chest and the abdomen). Symptoms may be more obvious in conditions like pregnancy where the pressure on the stomach is increased.

Conditions where pressure in the stomach is increased: The pressure on the stomach is increased in conditions where the intraabdominal pressure is high. This is seen in conditions like obesity, pregnancy, ascitis (accumulation of fluid in the abdomen) and wearing tight clothes.

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