Health and medical information

Description and Possible Medical Problems

We’ve all been thoroughly trained to believe that any mass that suddenly appears anywhere on the body must be cancer, an attitude that often results in unnecessary visits to the doctor’s office. The good news is that if a mass suddenly appears on your sternum, it’s probably not a serious health problem.

This mass, called a xiphoid process, is actually a small area of the sternum that extends below the rib cage in the center. If you’ve recently lost a large amount of weight, you may suddenly feel a “mass” and think it’s a tumor. However, it’s actually been there all along. Others might become aware of it if they experience a trauma to the chest wall and the xiphoid process becomes bruised or inflamed.

Treatment

If you’ve recently discovered your xiphoid process, you have nothing to worry about. If it is painful, Tylenol or Advil, taken four times a day or as needed, will work just fine.

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If your doctor discovers you have polymyositis, dermatomyositis, or polymyalgia rheumatica, he will probably prescribe the corticosteroid prednisone to help reduce pain and inflammation. Prednisone will also help lessen the skin rash and inflammation that accompany dermatomyositis. Prednisone works by reducing inflammation in the blood vessels and tissues by increasing the body’s tolerance to the inflammation, thus alleviating the symptoms.

The prednisone will be started at a high dose, usually about 40 to 60 milligrams daily. This will then gradually be decreased to a lower dose over a period of several weeks to several months. Side effects include bloating and a “moon face.”

- If your muscles remain weak and achy despite treatment, or they occasionally stiffen up, your doctor may recommend that you schedule regular sessions with a physical therapist to help keep your muscles flexible with range of motion exercises and the use of heat therapy. In any case, it’s a good idea to participate in an exercise program after the initial pain and inflammation subside; regular activity should become part of your life in order to prevent future flare-ups.

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Chains of lymph nodes run along the side of the neck from the ear to the shoulder. Lymph nodes feel like small peas under the skin. If they’re swollen, they may also be painful to the touch, and you may also have flulike symptoms, such as nasal congestion, fatigue, and overall aches and pains. Feel along the line with your fingertips; it is important to know if you have one or more swollen lymph nodes.

If you have swollen, painful glands behind the ear and jawbone accompanied by a high fever and lethargy, you probably have a viral infection. Just a few years ago, if this happened to you, it wouldn’t raise any eyebrows. You’d stay in bed for a few days, be patient, take aspirin, and drink lots of liquid if it was viral, and in a week or so you’d be back to normal. If it has a bacterial origin, then antibiotics would be added.

Today, however, the story is different. If you have what seems to be the flu along with swollen lymph nodes and it doesn’t go away after about a week, you may have chronic fatigue syndrome, which is believed to be caused by the Epstein-Barr virus. However, though many people automatically jump to the conclusion that they have chronic fatigue syndrome, the condition is actually quite rare.

Chronic fatigue syndrome is actually a variation of infectious mononucleosis. Back in high school, mono, or “kissing disease,” was a badge to be worn proudly. Adults who get chronic fatigue syndrome face the possibility that they will have to deal with it for the rest of their lives.

Other symptoms of both mononucleosis and chronic fatigue syndrome include a sore throat, low-grade fever, headache, and, of course, fatigue. The difference between the two diseases is that mononucleosis generally clears up within a few weeks; chronic fatigue syndrome can go on for years.

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If the reactions between the patient and the doctor are to be studied as a way of illuminating the patient’s problem, it is necessary for the doctor to be aware of his or her normal doctoring style. It is then possible to recognize changes from this norm, and to think about what it is in the patient that has provoked that change. Such a way of thinking is very different from the way the doctor has previously been trained where the emphasis was on the collection of accurate information, logical thinking about differential diagnosis and the provision of correct treatment.

Doctors come into seminars hoping to learn how to help people with contraceptive or psychosomatic difficulties. Their thinking is concerned with, ‘Was my action right or wrong?’ or ‘How could I have done better?’ Gradually they learn to think differently, and to wonder, ‘What was it about the patient that made me act in that way?’ Or to put it another way, ‘What sort of doctor was I to that patient?’ Such questions can lead to a re-examination of the patient’s problem, often providing clues to unconscious forces that had not previously been recognized. For instance, a doctor may become much more of a didactic teacher than usual.

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Marital therapists, or couple therapists, work with the couple on the relationship between them. Referral for marital therapy will be more effective when there is agreement between the couple that changes in the relationship are required. Specific training in sexual difficulties is taken by selected therapists who work for Relate Marriage Guidance, or facilities may be available within a psychiatric department. The objective is to establish an emotionally secure relationship which permits normal sexual responses to occur and be enjoyed. The main emphasis is on the nature of the sexual interaction and away from the specific sexual response. It is essential for this therapy that both of the couple are willing to work at the goals set by the therapist. Based on Masters and Johnson’s work (1970), the couple are asked to carry out certain sexual homework assignments while keeping within limits such as the exclusion of genital touching or intercourse in the initial stages. The reaction of the couple to these assignments is then used to examine the interaction between them and to reveal some of the underlying problems. Modern modifications to the original Masters and Johnson techniques include a much more flexible approach using psychotherapeutic methods to identify and reduce the obstacles to the behavioural assignments (Bancroft 1989). Some therapists work as co-therapists, each working with one of a couple and conferring on how best to proceed together. Others work alone treating a couple and their relationship.

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Patients in the older group may have anxieties about whether they should be still sexually active and hide their requests for advice about contraception behind other complaints such as vaginal soreness or period problems in the same way as those just beginning their sexual life. They may need to try out a different doctor from their usual one in the hope that these clues may picked up. The familiarity which is such an asset in general practice may be an obstacle if doctors assume that they know why the patient has attended. A new doctor/patient interaction can allow attention to be paid to covert presentations, and the doctor is less likely to slip into a social interaction, rather than a medical one, as may occur with a well-known patient. Missing thyroid disease or anaemia in a patient seen regularly is a well-known occurrence; less well recognized is the inattention to the unspoken needs of the patient. The woman who attends regularly for her oral contraceptive checks may be unable to bypass the doctor’s routine enquiries to broach the difficulties she is having; the doctor assumes all is well and fails to notice the hesistations or unease. Only by attending another doctor, who does not know why she has come, can she change the focus of the consultation.

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Serious marital or sexual problems are unlikely to be improved by sterilization of either partner, and one of the most important tasks of the pre-sterilization consultation is to identify the hopes and expectations of the couple. Not infrequently the man may hope that it will make his wife more interested in sex. One man blamed his wife’s lack of desire on the Pill, and when it was suggested that coming off it might not necessarily make her better he said, ‘You mean I will have made the ultimate sacrifice for nothing?’ He decided to postpone the operation, but interestingly he came back six months later wanting to go ahead. At this stage the doctor felt happier as the patient now had realistic expectations of good contraception, and he could accept that anything else would be an unexpected bonus.

The operation of sterilization is often surrounded by powerful fantasies of what it may do to the self or to the partner. A man may hope that vasectomy will improve his own sexual performance.

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This chapter is written from the point of view of doctors working in Britain with patients from other cultures, rather than about doctors who work abroad. This author’s experience as a general practitioner working with recent immigrants in Tower Hamlets, a deprived inner city area of London, will illustrate the most obvious problems of cultural diversity. The fact that most of the indigenous patients are Cockney, and have a distinct language as well as cultural tradition concerning such things as food and commerce, demonstrates that the problems are not only to do with racial issues. It is this author’s proposition that when working with individual patients it is just as easy to overemphasize the influence of culture as it is to be insensitive. To be able to provide the best service to patients doctors need to be able to judge the importance of all the influences surrounding a doctor/patient relationship. If we are skilled in analysing the emotional climate within our relationships with patients, we will not be so greatly daunted by the constraining effects of external differences. Before trying to understand the effect of some of those differences on the provision of care in Britain, we need to look briefly at the situation in the countries from which many of Britain’s recent immigrants have come.

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Most people feel okay for several hours following chemotherapy treatments; they are able to eat, work, do errands, and so forth. Usually some reaction occurs four to six hours later; there are some people who experience little reaction until twenty-four or even forty-eight hours later. On the other hand, some people feel the worst twelve or twenty-four hours following treatment. You will have to see how you feel.

Expect that the first treatment will be a new experience both for you and also for those caring for you. If it goes well, the odds are good that the remaining treatments will, too. Your oncologist may decide to change or adjust the dosage or the anti-nausea medications depending on your reactions following treatment. You may or may not experience a variety of side effects; if you want to know what to expect, ask your oncologist or your chemo nurse to tell you about these. Realize that you personally may experience some, none, or all of the possible side effects. Realize, too, that each treatment cycle may be different.

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An annoying complication of axillary dissection (done either with mastectomy or lumpectomy) is lymphedema of the arm. Lymphedema is chronic swelling of the arm due to the accumulation of fluid as a result of lymph node surgery. This surgery can interfere with normal drainage. Lymphedema occurs very rarely following the limited type of axillary dissection usually done at the present time, but it does sometimes occur. Another temporary complication is limited motion of the shoulder. Normal activity right after surgery and active exercise ten to fourteen days later will alleviate this. If you find that you have limited use of your arm, ask for a referral to a physical therapist. If you have a problem, choose loose-fitting tops with deep, roomy armholes and be careful not to wear tight cuffs at the wrist or tight jewelry on that side. Try to avoid cuts or scrapes on the affected arm. Also be very careful about hangnails, paper cuts, and fissures in the cuticles. Be sure to apply a topical antiseptic and an adhesive bandage to speed healing. When you have a manicure, be sure to tell the manicurist to exercise extra caution. Wear gloves when you garden. Keep your hands moisturized. Seek medical attention immediately if you see signs or symptoms of an infection in that arm or hand (redness, pain, swelling, warmth). YOU WILL ALWAYS BE AT RISK FOR LYMPHEDEMA FOR ALL OF YOUR LIFE. THESE RULES APPLY NOW AND ALWAYS.

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