Love builds on beautiful memories....

HOMILY by Rev. Fr. Rolando V. Dela Rosa, O.P. (December 3, 2005, Caleruega)

Good morning Jerome and Cheri. Your ordeal is now over. The month of preparation for this wedding, the nervous anxiety , the worries, the sleepless nights, the endless planning, despedidas, the disagreements on schedules, choice of food, clothes and venues- all these will soon be just memories.

So now, I invite you both to relax, take it easy, concentrate on every moment of this ceremony, to celebrate the fact that you are indeed getting married in this beautiful Chapel, and to ask the Lord for the strength you need to face the challenges of married life. Focus your attention on this ceremony. The moment is unrepeatable. Savor its significance and cherish its value.

Besides, compared to all the time you spent preparing for this wedding, this ceremony is indeed very short. And judging from the length of time devoted to it, the most important part of the wedding ceremony is no longer the exchange of marriage vows, but the picture-taking. that might not be ideal, but it has practical advantages.

Cheri and Jerome, I am sure you will have beautiful pictures and videotapes of your wedding. Don't lose them, consider them as one of your priceless conjugal possessions. Together with your marriage contract. Pace your pictures in an air-tight cabinet where moths and termites and humidity could not harm them. You know why? Because wedding pictures make your love transfixed in tme, ritualized carefully to become unforgettable. these pictures will be a source of strenth and inspiration. Love builds on beautiful memories.

This is one thing many couples forget. the moment they are married, their new- found security makes them complacent. they no longer exert effort to increasing their store of past joys and happiness. They surrender to routine. Routine kills enthusiasm. Would it not be tragic if, after ten years, you start kissing eeach other not out of love, but out of sheer determination?

This is why your wedding is held within the sacrifice of the Mass. the Mass is a celebration of a beautiful memory. the Eucharist is Christ's love, transfixed and ritualized in time, so we will not forget Him. When I elevate the host and the wine, Christ speaks to you through us, saying: "Jerome and Cheri, I love you even at the risk of losing my life. This is the kind of love you must have for each other. Do this, in memory of me." In marriage, you become eucharists for one another: like Jesus, you are transfigured to become a body given, a blood shed for each other. This is why you say when you exchange vows: "I will love you for better or for worse, in sickness and in health, for richer or poorer, un til death do us part." You don't say: Until further notice.

Jerome, in a little while, you will declare to Cheri in the presence of all of us as witnesses,: "Cheri, although our marriage vows are spoken in a matter of minutes, these are promises that will last a lifetime." But, what guarantee do you have that your marriage will indeed last a lifetime? What guarantee do you have that your wedding will not end in separation? What guarantee do you have that your children will not live in a broken home? Jerome and Cheri, at this early, let me remind you: there is no human guarantee for a successful marriage.

If you rely on human strength, sooner or later you will grow weak. Even the strongest resolve and commitment become weak in time. The only guarantee for a successful marriage is the fact that marriage is not only a human invention, but a divine creation. Your falling in love was not a coincidence. It was part of God's plan. God called you to be together. And if you rely on his power and strength, if you put your faith in him, he will never disappoint you.

I remember one beautiful song that goes: "When Christ is allowed to enter our lives every storm becomes a calm, the tumult becomes peace, what cannot be done is done, the unbearable become bearable, and you pass the breaking point without breaking. For to walk with Christ is to conquer the storm." So beginning today, allow God to take charge of your life. Pray together. Pray for each other. tell him to take control of your life, for only when He is in control that you experience Peace.

In moments of difficulties, ask the Lord to make you, not only strong, firm and courageous. Ask him to give you the gift of understanding. Understanding is the prelude to forgivenness. And let's face it, everyday you will have many things to forgive each other for. We are not perfect. We commit mistakes. It is inevitable that once in a while you will hurt each other. You will even oppose each other on many issues and matters. But remember this, in marriage misunderstanding and opposition are inevitable; but quarrels are optional.

Finally, look to the example of the happily married couples around you. Their marriage may not be perfect, but they are happy, peaceful and thankful because they allowed Christ to take charge of their lives. Learn to do the same. With God at the center of your married life, there will be no mistakes, just lessons to be learned.

God bless you. Jerome and Cheri.

Headaches

Headache is a very common complaint of patients, at least in my practice. People are very worried about headaches for varied reasons: a hypertensive friend who had frequent headaches suddenly had a stroke, a friend who had headaches and was found out to have a brain tumor or a relative who died from aneurysm and complained of sudden intolerable headache. Most of these patients would want me to request for a brain CT or an MRI to see if there's something wrong with their brains.

Most of us have experienced having headaches once in a while. Others though have them almost every day. When headaches become so painful or so frequent, that's when we start to worry: could it be a symptom of a brain tumor or a warning sign of an impending stroke? How do you tell?

Chronic Headaches. The longer you've been suffering from headaches, the less likely it is that they indicate serious condition. When you suffer headaches for a period of several years with no change in intensity and no other symptoms, chances are they're harmless. There are different types of chronic headaches. Tension and Migraine Headaches.

Tension Headaches. This usually feels like a tight band around the head or a pain all over the head. This type of headache is frequent after a stressful day or improper body mechanics. Usually, it is brought about by tension due to emotional stress or problems. It is caused too by muscular spasms which produce tension in the muscles of the neck and head.

Migraine Headaches. This type of headache is much worse on one side and sometimes centered around or behind the eye. Some people see lights and different colors moving across their field of vision several minutes before the headache starts, we call this aura. Migraine headaches can be very excruciating. I had one patient who would bang her head on the wall attempting to get relief in the process. As common as it is, the etiology of migraine is still unknown, however, there is a great chance of having it when it runs in the family.

There are headaches that needs to be evaluated and warrant work- up. These three specific type of headaches should be evaluated by physicians.

Thunderclap headaches. This is a sudden and severe type of headache. This may be caused by rupture of an aneurysm or a subarachnoid hemorrhage. Aneurysms are weak areas in blood vessels which may rupture at any time. There are thunderclap headaches which are harmless, but, just the same, it is better to consult.

Some viral infections have headache as one of prodromal symtoms. When one has fever due to virus or bacteria, it maybe accompanied by headache.

There are a number of conditions that people fear:

Brain tumors. Headaches are not the very first sign of a brain tumor. Difficulty writing or speaking. weakness or clumsiness in a limb, epileptic seizures may signal trouble. Most headaches experienced by those with brain tumors are mild or sometimes non-existent.

High blood pressure. High blood pressure is a very uncommon cause of headache. Most hypertensives are asymptomatic that's why worldwide it is known as the "silent killer".

Stroke. People worry that severe headache is a stroke or will lead to one. This is not true. Symptoms of a stroke depend on which part of the brain is damaged. Neurologic symptoms such as weakness on one side or trouble with speech are common.

When you have headache, best thing to do is REST. When rest doesn't help, take a pain reliever such as Mefenamic Acid or Paracetamol. If troubles worry you much... try to find ways to solve your problems or see someone who is willing to listen.

Age- Related Eye Diseases

Blurring of vision and loss of balance are only two of the symptoms reported by my elderly patients in the clinic. These symptoms affect their activities of daily living and makes them less confident to do regular household tasks.

The Philippine National Survey on Blindness conducted in 2004 reported the top ten causes of blindness which include the following:

Cataract. This is the most common cause of visual loss in Filipinos (62.1%) and is very commom in the lederly. Age- related cataracts develop in two ways: (1) clumps of protein reduce the sharpness of the image reaching the retina and (2) the clear lens slowly changes to a yellowish/ brownish color, adding a brownish tint to vision.

Errors of Refraction. This occurs when light rays don't focus on the retina caused by imperfectly shaped eyeball, cornea and lens. There are four types of EOR, myopia, hyperopia, astigmatism and presbyopia.

Myopia- or nearsightedness is caused by long eyeball or steep cornea. Patient sees close objects clearly while distant objects appear blurred.

Hyperopia- or farsightedness is caused by shorter than normal eyeball, causing distant objects to look clear while near objects look blurred.

Astigmatism- or distorted vision is caused by abnormal curvature of the cornea. One area of the cornea may be curved more than the other.

Presbyopia- or aging eyes. The aging lens become rigid and can't change its shape easily thus making it difficult to read at close range.

Glaucoma. This is the third most leading cause of blindness. It shows characteristic optic disc excavation or cupping, visual field defects and elevated intraocular pressure. Glaucoma cannot be cured but if diagnosed early and treated immediately disease progression may be delayed.

Diabetic Retinopathy. This is a complication of diabetes. It occurs when diabetes damages the tiny blood vessels inside the retina. Vision loss is caused by macular edema or blood leak into the center of the eye also called proliferative retinopathy.

Age- related Macular Degeneration. A disease that blurs the sharp, central vision one needs for "straight-ahead" activities such as reading, sewing, and driving.

It has been noted that taking a specific high- dose formulation of antioxidants and zinc significantly reduces the risk of advanced age related macular degeneration and its associated vision loss. It is recommended therefore for the lederly to take 500mg of Vit. C, 400IU of Vit. E, 15 mg or equivalent to 25,000IU of Vit. A, 80 mg of Zinc and 2 mg of Copper once daily.

Not all of these causes of blindness are preventable and curable hence, awareness that something can be done to improve the quality of the lives of those afflicted should be emphasized.

The Diabetes Legacy

Once again, Dr. R. Fernando, an 80 year old diabetologist, staunch believer of treating pre-diabetics aggressively, encouraged us to to do the same in our practice.

In my once a month wellness day in my private practice, I noticed that most of the patients have fasting capillary blood sugar between 103-140. They are either known diabetics or "healthy" individuals. I have always emphasized on strict lifestyle modification.

What convinced me really is the idea that perhaps diabetes is a disease of the lipids and not the sugar or perhaps disease of the heart and consequently dysglycemia. Truth is, most of my patients who developed diabetes, had, in the past, impaired lipid levels and they were not followed up strictly, so that 5 to 10 years after they come to me already with high sugar levels and a coronary problem.

It is a cry for us Family Physicians to move. We may have come 100 years earlier but who knows, what if treating those 90 and above will lower the incidence of diabetes or perhaps delay its onset? Wouldn't it be nice if the world has less diabetics?

This calls for an evidence based research and I will begin in my patients, today and now....!

Ovarian Cysts

I was almost successful in counseling a depressed patient when she came back to me again in tears!

During her follow up a week ago, I saw her in a cheerful aura with no signs of anxiety or despair. She has been worried of her sister's condition and has been compalining of mild colicky pain on her left lower quadrant. Previous work- up for UTI or kidney stones were normal. She has a history, though, of uterine polyps and endometriosis as shown in her ultrasound done a year ago. Thinking that there is progression of the condition, I requested for a repeat transrectal ultrasound as she has no sexual experience at her age of 57.

When she saw the report of the ultrasound, she was very happy. While waiting for the gynecologist, she was already thanking God because there were no uterine polyps nor endometriosis seen except for bilateral ovarian cysts measuring 1x1 cm each. Her happiness subsided when the gynecologist told her " we have to make sure it's not cancer, so let's do CEA, AFP and B-HCG titers...". She wanted further explanation but the doctor gave her the request and told her to have it done before she goes back to her clinic gesturing her to leave. She went straight to my clinic in tears thereafter.

Are ovarian cysts cancerous in nature?

Most ovarian cysts are functional, meaning, they're benign. It is common in women of all ages caused by failure of an ovarian follicle to rupture and release the egg during ovulation. The fluid remains and can form a cyst in the ovary. While cysts may be found in ovarian cancer, ovarian cysts typically represent a normal process or harmless (benign) condition. Requesting for cancer markers which cost a lot is really not necessary when symptoms are not proportionate to or referrable to an ovarian malignancy.

On top of that, my patient has a very melancholic personality. She is currently recuperating from depression and now another depressing diagnosis is posed on her! I had to go back to educating her, counseling her and making her understand that her condition is benign and there is no need to worry and that the best thing to do is observe... at the moment.

I really hope all doctors look at the patient and not the ancillary procedure. If her concern was explored prior to telling her that her cysts may be cancer, we could have spared her of another depressive moment. I understand that the gynecologist only wants to make sure that her two tiny cysts are not cancerous but she could have explained to her statistics first before outrightly telling her , "let's make sure, it's not cancer".

I know it's hard to be in the surgical field as I heard a gynecologist friend telling me that if given the chance to go back, she wouldn't be a gynecologist. She said her children suffer the most when she leaves in the middle of the night to deliver babies. I told her though not to feel sorry as God made her an instrument to bring new life in the world but to also learn to prioritize. Well, better said than done of course, especially from a family physician.

Seniors in Action!

It was a hot and humid afternoon but they were all there. Ladies in different shades of black and gray, men clad in white polo shirts with caps to cover their baldness; they all went to the Marikina City Hall’s quadrangle to attend the first Mini- Convention for seniors entitled “Mga Pagbabago...Sa Paglipas Ng Panahon”.

When I gave the talk on Physiologic Changes of Aging, they intently listened although after 30 minutes I saw some of them with drooping eyes and others really sleeping right in front of me. But what’s really moving is to see 81 yrs old and above smiling and looking at me as if attentively listening. It made me think of myself 40 or 50 years from now. What kind of LOLA will I be?

Dr. Tricia Bautista gave a good workshop on dementia screening and test for sensory functions. Thanks to the UST Department of Family Medicine who brought their Wellness Caravan to Marikina for the event. The presence of several health care groups also made the activity alive. The Home Health Care conducted a mind game with influenza and pneumonia vaccines offered at discounted prices. Thanks to the ever supportive Dr. Jean Guno. MSD did a bone densitometry screening to check for osteoporosis which surprised my father-in-law whom we found out to have osteoporosis, he thought only women can have the disease. Nestle (Nutren products) did nutritional assessment.

Mayor MC Fernando graced the event as head of the City Womens Council of Marikina. I’d like to express my sincerest gratitude to Ms. Mel David and Mdm. Letty Cabungcal for inviting me to this affair. It was fun rubbing elbows with ‘the’ MCF of Marikina. I was happy though when she said “ Let’s do this on a regular basis.” Way to go Marikenos! To think that I am only married to a Marikeno!

Spleen or what?

"Aling Maria" is an 81-yr old spinster who came in because of cough and difficulty of breathing. She said the cough has been there for 2 months. She took Guiafenesin and Lagundi tablets which gave her temporary relief. Two days prior to consult she developed fever with difficulty of breathing. On examination, she had crackles on her lower lung fields and a low grade fever. Incidentally, I noted a large mass on the left upper quadrant of her abdomen which I thought was an enlarged spleen. That day I treated her as a case of Community Acquired Pneumonia with strict advise to have an ultrasound and a blood chemistry done. She followed up 3 days after.

The ultrasound showed a complex mass measuring 11x9x14 cm on the left upper quadrant of the abdomen and multiple cholecystolithiases. Her fever subsided however, cough was still present. Her chest xray showed suspicious densities and apical infiltrates which may be suggestive of pulmonary tuberculosis. She had bibasal pneumonitis too. I had to request for an abdominal CT scan. Pending the results, I am still in the process of finding out what she really have. Could it be malignancy? Extrapulmonary TB? Colonic mass? (but she doesn't have GI symptoms!)

Masses in the left side of the abdomen are quite uncommon. Many times in the cases that we see in the clinics, we are faced with diagnostic dilemmas. However while awaiting CT scan results, I advised "Aling Maria" to take phytonutrient supplements because she has lost her appetite. I also gave her cough medicine and antibiotics. Many emotional and personal concerns confound her illness. The economic burden too is putting a toll on her. Until now, because of financial constraint, no CT scan was done. However, she continued to take the supplements I gave her. She has improved with her appetite though. She no longer complains of cough.

At this very moment, aside from checking on her vital signs and physical well- being, I keep on praying for her. Sometimes, as a doctor, because of the complexity of some diseases, I have to pray a lot too for the patients I see. She lives with a sister who is also elderly and frail. Both of them are spinsters and 2 of their siblings have chronic diseases too. They don't have children or nieces or nephews who could help them. When her sister, in tears, asked me, " What will happen to me Dr, if my sister dies?". I could not find words to answer so I embraced her and told her I will always be there to talk to whenever she needs someone.

I ask you, if your were in my shoes, how will you answer her question?

Exercise Prescription

A 40 yr old patient came in complaining that he was admitted in a secondary hospital because of a chief complaint of loss of consciousness after a strenuous exercise and was discharged as a case of urinary tract infection. He was upset at the way he was managed and that nobody explained his case to him and his family. He did not even know who and what doctor admitted him.

First, I had to address the issue of miscommunication. Many times, because of too many patients, some doctors would tend to treat the laboratory findings rather than the patient. If that was the case, I told him that he should be thankful it was UTI and not any cardiac pathology and that maybe, the doctor was just too busy to explain details of his case to him. Personally, I believe that when a patient enters my clinic, it’s not because he’s concerned with his disease but more on the anxiety surrounding the possibility of a disease.

Next, I asked if he has symptoms referable to a cardiac disease because apparently he was worried that he has a heart problem and this will disable him from doing his routine treadmill exercise and weights every morning. After careful examination, I told him his heart is pumping well. His blood chemistry was also normal and that there really is nothing to worry. Then I proceeded to explain what happened to him after his exercise.

He has a low sugar level to begin with. His FBS was 86, very normal yet for someone with this level, waking up after an 8-hour sleep with no food and immediately jumping into the treadmill is really risky. During a strenuous exercise, our bodies use a lot of glucose and oxygen to supply the muscle proper energy for it to contract and move. During sleep we also use up some glucose and oxygen especially during our REM cycles. If this patient has 86 as baseline sugar, used it up during his sleep, then probably he had a very low sugar when he started his exercise. So much so that an hour and a half of treadmill exercise with weights was enough to push his sugar down to very low levels. When his sugar was low, it was the time he felt weak and started to have cold sweats then thereafter, he lost his consciousness. A case we call hypoglycaemia.

He beamed with a smile when he heard this and said that nobody explained these things to him. He said if there was one thing he learned that day, it is that he should not go into strenuous exercise without proper advice from a doctor.

I ended with giving him an exercise prescription. To compute for the heart rate appropriate for him during exercise, I took the target heart rate first which is 220 – age. The result is multiplied with his percent activity. Percentage is based on his daily activity status. For patients with sedentary lifestyle, THR is multiplied by 60-70%, moderate physical activity is 80-90% while athletes can be computed up to 100%. With him I started with a 70-80% physical activity with the intention of increasing it every month. I told him that he should exercise at this heart rate: 126-144 beats per minute. Less than that his exercise is useless, more than that he’s going to tire himself and risk having hypoglycaemic attacks. I also strongly recommend that he exercise for 20-30 minutes per day, starting with a 5-minute work-up, a 15-20 minutes intensive exercise and a 5-minute cool down.

He left my clinic with this question: “ Can you take care of my health from now on Dra?”. I smiled and said “Yes, of course.”

UTI or stone?...

A 52 year old female came in because of dysuria (painful urination) and hypogastric pain. Urinalysis showed pyuria(pus in the urine) and hematuria (blood in the urine). I gave her antibiotic and treated her as a case of urinary tract infection with strict advice to follow up after one week with a repeat urinalysis. She never came back.

After 1 month though, she came back with her new urinalysis results, this time, blood was +4, sugar +2, red blood cells 20-25/hpf and a normal white blood cell count. She said she never came back because her symptoms disappeared after 3 days of antibiotic treatment.

There may be 3 possible reasons for the presence of blood in the urine. Infection with pathologic bacteria such as E. Coli may cause hematuria. The bacteria can invade the bladder tissues and cause inflammation. This can sometimes produce minute rupture of small blood vessels producing blood in the urine. Another is the presence of a stone. Stone formation may be due to calcium or uric acid crystals. Presence of stones anywhere in the urinary tract may cause hematuria as it can cause abrasion of the inner lining of these structures. Blood in the urine may also be indicative of malignancy. For female patients, it is necessary to check for presence of gynaecologic pathologies.

In such cases, I also advise patients to drink a lot of fluids and observe proper perineal hygiene. Cleansing with water should be done from the front to back as contamination of the perineal area by anal bacteria is possible. Use of tissue or cloth may be used to damp excess urine or water but never rub the area.

An ultrasound of the kidneys and the urinary bladder is warranted to confirm diagnosis of a stone. I also sent her to a gynaecologist for a Pap smear. A word of advise: always see your doctor when she tells you to follow up. She wouldn’t ask you to do so for no reason at all.

'We did it!!!"

I was really worried about the 2 yr old boy I saw yesterday that I called up their house. I was told that the child's fever went down at midnight and the swelling did not progress. The child is up and about with no fever. I asked them why they didn't care to visit me when I asked them to. They said they decided to bring the child to me after the 7-day regimen and that it's raining hard today. True. Everyday at 5pm, rain would pour down heavily only to stop after two hours.

For a doctor, sometimes you feel uneasy knowing that there's a patient you really don't know will respond well with the medication you give. Many times I end up calling them asking them how they are. What's frustrating is the culture of not going back or not telling the doctor how you're doing when you're told specifically to follow up. This is one stress I have to put up with each night.

But, who am I to demand anyway. What comforts me is the fact that again, to God, who blessed me with healing knowledge, "We did it again!" . I always work each day offering everything to God. I see patients with Him. I treat them with Him. They can call me charismatic but even if I don't show it, I live my life knowing that everything I do depends on God. One big Bravo! to the God I lean on....and a lot of thanks!

Cellulitis

I was about to take my siesta on a Sunday afternoon when my husband rushed into our room telling me I have a patient waiting in the living room. I was really tired but I had to put up a smile. I saw a two year old boy playing with my son's toys, apparently not in pain but with obvious hyperemic and edematous left foot. The swollen foot to me looked like cellulitis.

The parents said it started as two small vesicular lesions on the lateral aspect of his foot and because it was itchy the child would scratch it. The next day, the whole foot became swollen and the child would limp when he walks probably because of pain. They brought him to the nearest hospital and were told that their son needs to be admitted. They were surprised because they knew how much it'd cost them if they have the child hospitalized. So, they decided to see me for second opinion.

On examination, I noticed several weeping, crusted wounds on both his feet. The biggest one was on the lateral aspect of his left foot which was swollen. It was very warm and hyperemic. The child does not complain when I move it, apparently he can tolerate the pain. My initial impression was right, it was cellulitis.

Cellulitis is an inflammation of the soft tissues of the skin brought about by bacterial invasion. The vesicular lesions (which was scratched) became portals of entry for the Streptococcus or Staphylococcus bacteria. Entry to the skin gives these bacteria access to several blood vessels hence, the chance of it spreading in surrounding tissues is fast. The worst that could happen is infection of the bone which could lead to osteomyelitis, which would be harder to treat.

I had to tell the patient that they were advised admission because of three things: 1. cellulitis spreads fast, 2. IV antibiotic may be necessary to control the spread and 3. they cannot stop the child from scratching the lesion much more from playing in the soil. They understood me very well but they're concerned about the expenses. The husband is unemployed and the mother works as a crew in a fastfood chain.

Times like this, I always feel bad about the Philippine healthcare system. While the rich enjoy the very expensive hospital suites, the poor are left in the streets and the middle class could not afford the cheapest room. Sometimes you want to admit them and take care of the costs but you also know that they will not be spending hundreds only but thousands as an IV antibiotic costs more than a thousand.

With strict intruction to the mom (and prayers), I prescribed an antibiotic, Paracetamol and topical cream. I told her to give the drug every 6 hours and not to miss a dose. She has to wake the child if need be. I also advised them on proper wound cleansing and to keep the child inside the house. I told them to observe for fever and check the swelling. If the swelling reaches the lower leg at midnight, they have no choice but to bring the child to a hospital. If not, I will see them today in my clinic.

Is it me or God doesn't want me to take my rest? I am not complaining, it's just that my work really demands that I stay on my feet 24 hours a day, 7 days a week. I know God gives this to me because He knows my capacity. I just hope all doctors get up on their feet and smile at their patients even if tiredness seem to cripple them.

Here's to hoping that the child gets well and would not need hospitalization. I'll keep my fingers crossed until I see them this afternoon.

"Status Asthmaticus"

I remember so well that time when I was still a medical senior in UST, I saw a 27 year old male who died because of asthma. His story is still fresh in my memory.

It was late in the afternoon, I was on duty as a rotator at the department of Internal Medicine. He came in all alone with difficulty of breathing. When I saw him dyspneic, I immediately listened to his lungs, it was very tight and with too many wheezes. But his words were comprehensible so after getting the PEFR I did nebulization while informing my intern and the resident on duty. They saw the patient and told me to continue nebulizing every 20-30 minutes and check fo his vitals. After the first neb, he was able to talk to me in phrases and managed to tell me that at that same moment his wife was giving birth to their first son at Fabella Hospital, a 20 minute ride to UST. He became very excited that he began to feel he was having an asthma attack. He forgot his Salbutamol inhaler so he ran to Fabella's ER only to be told to wait because there were too many patients. After 20 minutes waiting, he decided to go to UST Hospital. He was smiling with joy in his eyes as he looked at me.

After the second nebulization, he started to feel dyspneic again. I did my auscultation and heard more wheezes and the PEFR became worse. I told my intern, who decided to give him an IV steroids. After another 15 minutes, he was becoming more dyspneic and his lips became bluish green. I knew we had to do intubation. And so we did. He was intubated and was subsequently admitted to the ICU.

I felt very sad as I thought of his newborn child and his wife. I was really praying hard for his recovery. It sent shivers to my spine to think of a new life in exchange of another life. After two hours, the hospital was in CODE and we rushed to the ICU. My patient was now being resuscitated. After 10 minutes, he succumbed to death...

There may be factors contributing to his death but ever since that time, I make sure I have my inhaler at hand. When I laugh hard I always try to control myself. Asthma may be reversible but only God knows when it's not.

" 'Pesteng' AHEM!"

Two patients from a prominent school came in today because of radiologic findings of : “suspicious apical infiltrates”. One is the school building supervisor who claims to spend a lot of time climbing stairs and running around the campus. The other is a school driver who says he only smokes 1-2 sticks per day. Both have no complaints of cough, fever and night sweats.

When your x-ray comes out with findings of suspicious apical infiltrates, it meant that the radiologist saw some white streaks on the x-ray plate which lies on top of bony structures. These white streaks may be suggestive of pulmonary tuberculosis, that’s why they will suggest a different view: the apicolordotic view.

Pulmonary Tuberculosis (PTB) is endemic in the Philippines. Almost every Filipino is exposed to the disease. No wonder why other countries are strict when it comes to health status of Filipinos who travel abroad. However, the government has implemented a good program for the possible eradication of TB. What used to be a deadly disease of the past is now curable. The Directly Observed Treatment Strategy (DOTS) is an innovative way of following up and managing patients with PTB.

What symptoms should you look for if you’re thinking of PTB? The pathognomonic symptom is a chronic cough of more than 2 weeks in the absence of allergy or other infectious disease. Other symptoms such as, easy fatigability, low grade fever and night sweats are also referable to PTB. People with chronic diseases or are immunocompromised are vulnerable to the disease. Lack of sleep and stress may render the immune system dysfunctional hence, those who don’t rest and get enough sleep may easily get infected.

Exposure to PTB, chronic cough and positive CXR findings are suggestive of PTB. To check for exposure some doctors request for a Mantoux Test or PPD test. A substance is injected subcutaneously on the ventral surface of the arm and observed for reaction or hyperaemia. The result is read after 72 hours, the size of the wheal formed is measured. For those who come in with productive cough, sputum AFB smear is warranted to check if the patient is actively passing out the bacilli.

When a diagnosis is made, immediate chemotherapy with quadruple drugs is started. Two months intensive phase and four months maintenance phase is the recommendation. Usually, patients on treatment will have a feeling of wellness after 2 weeks of treatment, however, the minimum length of time that a patient is not allowed to work is 1 month.
For suspicious infiltrates, when the apicolordotic view shows negative results, treatment is not necessary.

Again and again, I will not get tired of instilling this to my patients: keep your immune system strong; the military force within the body should always be competent to fight all offending factors. The only way to achieve this is proper nutrition and exercise and never, never abuse your body!

'within a woman's womb'

Ever wondered why women had to go through feelings of bloatedness,breast tenderness and emotional seesaw each month? Much worse if they start their monthly period with dysmenorrhea otherwise known as menstrual cramps.

Every month a woman goes through her usual menstrual cycle which is most often 28-30 days. However, short intervals such as 20-25 days or long intervals such as 40-45 days may still be acceptable depending on the case. This cycle usually climaxes with ovulation and ends with either pregnancy or menstruation. This is usually monitored for fertility status of the woman and serves as one of the basis for the natural family planning method.

It is easy to compute for one's fertile days when the cycle is regularly occuring, but for irregular cycles, one year menstrual calendar is needed before fertility status can be mapped out.

To compute, the first day of menses is labelled as Day 1, succeeding days are counted from day 1. Ovulation is the process by which an ova or egg cell is extruded from the ovaries ready to be fertilized by a sperm. During this time, basal body temperature increases and the uterus thickens in preparation for implantation. Ovulation usually happens on Day 14+/- 3 days of menses. Any sexual contact done on these days will most likely end with pregnancy. However , it still depends on the health status of both man and woman. Should there be no fertilization the uterine wall will slough off producing the monthly bloody discharge. At least 5 days prior to or during menstruation, a woman is infertile, however, for those with short cycles, contacts on the last day of menses may still cause pregnancy because sperm cells can stay in the woman for 72 hours--they do watchful waiting.

For irregular cycles, it is important to plot their one year menstrual periods. (For the computation, you can send me your one year calendar.) There are many factors why women develop problems in their monthly period. Obesity can cause polycystic ovarian disease, stress can alter hormonal effects in the uterus and ovaries, thickened endometrium and presence of myoma and endometriosis can cause dysmennorhea.

For those who want to have children, the advise is to do the conjugal act 2-3x a week. Daily sexual activity for those who are trying to get pregnant is too stressful which may decrease success rate.

Many times, I really wonder why God chose women to give birth. But, who are we to question His Wisdom? Even He, had to look for a woman for Him to be born. Mary, was a worthy vessel. There are things in this world which we need to accept because it is governed by nature. Even science could not explain why a woman is a woman or a man is a man. Big bang theories and other theories about our beginnings could not definitely explain how the sexes came to be and why it's very specific. Molecular rearrangements can be explained but again who dictates their movement? St. Thomas was correct, there has to be a first mover, a prime mover before anything really can move.

ADULT VACCINATION

Prevention. Protection. Wellness. Primary care. We call it many names but keeping healthy doesn't just mean 'avoidance' of unhealthy food or practices. We are diligent to bring our children to a pediatrician in their first 5 years of life. We do this because we are afraid that they catch a disease which can predispose them to lower resistance or worst, hospitalization.

But, what do we do with our older parents? Do we feel the same need to protect them the way we protect our children? Only when we realize that one day we will go back to our low immune state will we be able to think of the welfare of our parents.

What are the recommended vaccines for adults? When one reaches the age of 55 to 60, the immune system decreases its competence. The number of immune cells may still be normal but they become less competent. As if they too grow old. This process is caused by presence of a chronic disease and/or accumulation of free radicals from an unhealthy diet. When one has not yet reached old age but is suffering from a chronic illness such as diabetes or cancer, or is constantly bedridden because of viral attacks, he too is a candidate for adult vaccination. To help fight common offending agents, it is recommended, that we give the following to older individuals.

1. Pneumococcal vaccine- bacterial pneumonia is one of the leading causes of morbidity among older individuals. Pneumonia vaccine is administered intramuscularly and gives 5 years protection against difference strains of streptococcus pneumoniae.

2. Influenza vaccine- is given once every year as protection for the deadly Haemophilus influenza virus. This virus is responsible for frequent absenteeism of most employed individuals and students alike. It renders a person bedridden for 7 to 14 weeks depending on severity of infection. Each year new viral strains surface as the virus is notorious for its mutational capacity. This yearly new viral strain is the rationale for it's once a year schedule.

3. Tetanus. This comes in toxoid or immunoglobulin form. In the elderly, with no acute injuries, usually the toxoid is given. It is supposed to protect the person for 10 years. The rationale for giving this vaccine is that elder person are relegated to do manual tasks at home like gardening and small repairs. This predisposes them to cuts and abrasions which may become entry points for Clostridium tetani.

The only contraindication for admininistration is allergy towards the formulation of the vaccine. Vaccination is delayed when patients have fever because it is one of the possible effects of the drug. Hence, if one has fever, let the fever subside or give at least two weeks waiting time before giving the vaccine.

If we love our parents, let us give them the protection they need. We have to realize, we too will become 60 someday. Our passage on earth is simply a difference of time but all of us will pass through the same stages whether we like it or not.

SCHOOL OF ASTHMA

He came in because of 2 weeks cough and cold with difficulty of breathing. A.R., is a 55 year old male, non-smoker, non-alcoholic beverage drinker and a Catholic community volunteer. He did not take any drugs for his complaints but said he maintained his Symbicort and Virlix. He was diagnosed to have asthma since childhood.

He was bothered by a moderate grade fever he experienced the night before, which prompted consult. Upon examination , he had congested turbinates, slightly hyperemic pharynx and wheezes on both his upper lung fields. He said, since January, he had 3 attacks of asthma. He took Azithromycin for the first 2 attacks and cotrimoxazole for the last one. He's afraid to take another antibiotic regimen because of it's possible injury to his liver. He also took Simvastatin for his high cholesterol levels from dec to feb of this year. His narration is interspersed with bouts of cough and dyspnea.

He was in exacerbation.
Whenever I see asthma patients, I am always filled with empathy. Suffering from the same chronic disease, I know what my patient is experiencing. But what is asthma really?

Asthma is basically an inherited disease. I always tell my father that his legacy will always be with me forever and may even become the cause of my death.However, acquiring asthma is not uncommon.

The pathophysiology of asthma is explained by 3 things: reversible airway obstruction , airway inflammation and hyperactive airways.It used to be that they explained the difficulty of breathing by bronchospam alone. Recently though, they believe that asthma is truly an inflammatory disease.

There are trigger factors for asthma, most common is dust and dust mites. Mine though is different- I usually have exacerbations after laughing so hard or when I have upper respiratory tract infection either viral or bacterial.

Aggressive treatment for asthma is now the recommendation. In the past, I remember, whenever my attacks occur in the evening, my father gets irritated and he'll tell me to overcome myself and not rely on drugs . I am glad though that during those times my mom would patiently rub my back and accompany me till morning up to the time my father decides to buy my medication. It's a good thing I didn't die of status asthmaticus, which happens to patients who develop irreversible airway obstruction.

Asthma is categorized based on severity. If you have persistent asthma with severe symptoms, it is warranted that you take a maintenance drug in the form of corticosteroids(inhaled) and a long acting beta agonist such as salmeterol or formoterol, however , during acute attacks , emergency relievers,short acting beta agonists like salbutamol, should come in handy. Nebulization 3x every 20 minutes with salbutamol may also help. Should theses drugs provide no relief after 30 min or an hour, patient should be sent to the emergency room for possible IV steroid treatment and oxygen.

For A.R.,I had to give antibiotic because, apparently , he is compliant with his maintenance medications. I also advised him to rest and drink a lot of fluids.

As for me, I always have an inhaler in my bag plus a dose of montelukast in the evening as maintenance . In most instances, I avoid laughing out loud as I don't want to find myself using my inhaler in times where I am obviously with a happy company.

Our Body's Army

L.M. is a 25 year old male who came in because of one week cough and colds. He had intermittent low grade fever and headache which was temporarily relieved by Paracetamol. He works as a call center agent and juggles between morning and night shifts. He complained of easy fatigability which prodded him to seek consult.

This is the most common case that I see in practice. People who work hard to earn money end up spending more money on consultation and medications. The usual course is an interchange of fever, cough, colds and body malaise. Can we prevent these symptoms from worsening?

A good immune system serves as a good defense for our bodies. The immune system develops from birth and increase its competence through the work of several organs like the thymus. However, the thymus involutes early in life. As adults we rely on different white blood cells, macrophages and cytotoxic killer cells whenever foreign agents invade our system. The immune system almost mimics an army of militiamen with hierarchy of function.

During viral invasion which we acquire from a single sneeze of an infected individual, our defense system starts to work. Each type of cell have specific function either as 'deep penetration agents', recognition, antigen presenting, helper or killer cells. However, during times of stress or when we have chronic diseases, most of the members of our immune system are busy trying to increase our energy as in moments of stress or warding off agents that destabilize our body systems in chronic diseases.

It is advised that we get enough sleep and we eat the right kind of food. As for LM, lack of sleep and work stress had taken its toll rendering his immune system unprepared for the viral infection. When the virus has penetrated our body's barrier, the illness ensues. Worst, he did not rest during the time he first felt the symptoms. He continued to report for work.

Normally, viral infection spontaneously resolves. A good rest and hydration may speed up healing. No drugs are necessary to treat the illness. However, when one organism has engaged our body's army, several other microorganisms can enter. Let's just say the first agent makes us vulnerable to other agents. So that after one week, LM came into my clinic, with the characteristic smell of bacteria, hyperemic pharynx and congested turbinates. This time, it's no longer viral but bacterial.

With the invasion of bacteria, some of our immune system may not be able to kill them. Thus they can multiply and cause more cell damage. Only at this point in time will the doctor prescribe an antibiotic.

I had to prescribe an antibacterial agent for LM plus drugs to relieve his symptoms. Aside from the drug regimen, I strictly advised him to drink around 10 glasses of water everyday. Water should be taken in at intervals not in the evening when we remembered we had to take a lot of water. I also told him to buy fruits as source of Vitamin C rather than synthetic Ascorbic acids found in most drugstores. On top of these, complete bed rest for 3 to 5 days is warranted.

Rest and rehydration may halt bacterial progress. It is important then that at the onset of symptoms, one should rest and avoid exposure to other persons with obvious illness.

HIS BEST FRIEND, AL – (part 2)

It’s not only my friend and my patients who enjoy the company of Al. My husband too. Last year his liver function test was triply elevated forcing me to start him on supplemental drugs. He took it for 3 months but decided not to have his levels checked thereafter. His usual line? “ If I’m going to die now, I am going to die..” But, he promised not to take more than 2 bottles of beer each time he goes on drinking spree with his friends. However, this is the way he counts, first bottle and last bottle equals two bottles.

Then his friends tell me,” it’s just San Mig Lite”. The “light” in San Miguel, does not refer to low alcohol levels, it simply means low calories. That means, each bottle still contains 10g of alcohol. One night, I joined him and his friends, I drank two bottles of San Mig light. Yes, we enjoyed the night but the next day, my head throbbed and ached like never before. I really don’t understand why, after a game of golf, they all rush to their favourite diners and drink. Why waste the calories you lose after 18 or 19 holes of golf to alcohol?

Al is not an acquaintance. I was introduced to AL ever since I was young. My grandfather was a hard core alcoholic and it is not surprising that most of my uncles followed his lead. When my husband was in Cotabato, my uncles tried to grill him. Poor Jerome. He was forced to drink more than his capacity. Two bottles of Red Horse rendered him puking and dizzy. Everyday when I was small, evenings will not be complete without a bottle of Tanduay or Ginebra. What I hate most though were the after- drinking events. Some of my uncles start to get passionate, angry and all sorts of exaggerated emotions. Despite this blatant addiction to alcohol, they’re still alive and healthy except for my grandfather. But, of course, they all mellowed down when they were in their 50’s because their blood exams showed abnormal liver function. Now, their sons inherit the vice.

I do not ask men to stop drinking. Alcohol has beneficial effects on the heart and it has been proven. The problem arises when the limit is exceeded. I just hope Filipino men realize the value of discipline and control. Even Jesus went into social drinking in His time.

Again, Al may be a man’s best friend but he can be his worst enemy. As always, everything that is excessive is not good. Moderation is the key. Life is too short for us to waste our money on medications when we could have saved it through control and proper nutrition.

His Best Friend, AL-

A week ago, I was in a scientific symposium on the Management of ASH, NASH and NAFLD. The speaker happened to be one of the senior residents when I was a medical clerk in UST.

What is the difference in terms of management between alcoholic steatohepatitis (ASH), non-alcoholic steatohepatitis (NASH) and non-alcoholic fatty liver disease (NAFLD)?

I see a lot of patients now with high levels of SGOT and SGPT, reflective of liver dysfunction. Some have cholesterol levels which are high. Others are currently taking or have had lipid lowering drugs in their medical history. With such levels, when is it necessary to give a drug to enhance liver function?

First, it has to be established that the liver problem is alcohol induced. How do we know that? If the SGOT:SGPT ratio is greater than 2 and the SGOT is greater than SGPT, the liver problem is probably alcohol induced. Why the fuss over alcohol?

I have a friend who seem to enjoy the company of AL (alcohol) in times of stress. He attributes his intellectual alertness and mental speed to his best friend Al. Not only him, I see a lot of male patients who ask me if it's possible for them to continue drinking alcohol despite their liver dysfunction for several reasons: they need it when closing deals, when socializing with friends and when they show- off with women. Is there such a thing as acceptable amount of intake?

What is the acceptable daily alcohol intake? Or is there really such an acceptable limit? I always tell my patients who are diabetic and hypertensive to avoid alcohol as much as possible. However, I know this is quite difficult for those who really drink a lot. But let's look at the liver.

The liver is particularly susceptible to alcohol-related injury because it is the primary site of alcohol metabolism. As alcohol is broken down in the liver, a number of potentially dangerous by-products are generated, such as acetaldehyde and highly reactive molecules called free radicals. Perhaps more so than alcohol itself, these products contribute to alcohol-induced liver damage.

The maximum safe level of alcohol intake per day is 20g. Liver damage, according to studies begin at 30g of alcohol intake per day. However, some books say, because of physiologic make-up, men can take as much as 60g/day, not without risks of course. To compute: a bottle of beer contains 10g of alcohol, 1L wine has 80g and a 30ml whiskey has 10g.

Surprisingly, ASH is more common in Asian countries rather than those countries where alcohol serves as a regular meal beverage. The main reason perhaps is exposure to poverty and lack of employment. In the Philippines, the unemployed father who belongs below poverty line is pictured as an alcoholic whose water is precisely, alcohol.

It really depends on how we control ourselves. Discipline is the key to a healthy life. Yes, it's alright to take alcohol within safe levels but we should also see if our bodies are competent. There is also a need to remember that free radicals may accumulate in the body. Its presence increase the risk of developing cancer or simply speed up the aging process. So, one may choose to make Al his best friend for as long as he doesn't abuse his cells' function.

For ASH, medication is warranted however for both NASH and NAFLD, careful observation is the only advice plus proper nutrition... and of course, infrequent meetings with Al.

To treat or not to treat....

Recently, I attended a round table discussion with some Family Physicians on Early Management for Diabetes. What the speaker said really got me to thinking. He said that at blood sugar levels greater than 90mg/dL (approx 2.5 IU), we should start giving hypoglycemic agents to patients. Most of the doctors in the group were amused because they all have fasting blood glucose levels of more than 100. What a relief that mine is just 87.

However, this is really a tough mandate. It is not frequent to see patients with sugar levels less than 90. Most come in at 100 and above, and for as long as it's not 126 and above, I just advise them to be careful with their diet. If their levels are 90, I just tell them to maintain their healthy lifestyle. The rationale for lowering the normal sugar level, the speaker said, was because of the fact that at 90, studies have shown that pancreatic insufficiency starts to surface, and that there is already insulin incapacity and he challenged us to be very aggressive in our treatment. Why should I believe him? He was the first diabetologist in the Philippines who did his research in the time of Marcos.

Yet, until now, I cannot seem to follow his advice when I see patients with levels greater than 90. I was always a conservative doctor. I believe that physiologic changes happen because at one point or another the patient abused himself or have taken in a lot of calories unknowingly. Besides, treating them at 90 means prescribing drugs which will add up to their daily expenses as if the consultation is not enough to worry them considering the decline in global economy. The American Diabetes Association still sticks to its less than 100 normal level for known diabetics and 126 and above for new patients. 100-126 is still Impaired Glucose Function.

Yesterday, I had a 42 year old female patient, (very pretty and tall, with a face that could pass as an actress), who saw her husband died in a badminton court while playing. This happened in February. She said he never had problems and always looked healthy, however, no screening consultation was ever done because he never felt anything troublesome. She came in with a blood sugar of 99. Previously she has 110. She was crying a lot and I knew her sugar level may be influenced by the stress she's having. I had the dilemma of putting her into drugs or not. Family history is positive for Diabetes and Hypertension. She owns several food cart franchise in different malls all over Manila.

More than her blood chemistry, I knew she just needed someone to listen. Her concern is the left lower quadrant pain she's been experiencing for the past 2 days. After her husband's death she became paranoid at anything that she feels in her body and as a doctor I fully understand. I know she's still within physiologic grieving and all I need is to listen and be a helping hand. I know she can afford hypoglycemic agents but is it of utmost importance at this time?

She cried after several minutes and I listened. I even shared with her my own experiences of 'depression' and how I was able to cope with it. I gave her medications to relieve her LLQ pain and requested for ancillary procedures. I advised her on proper nutrition. I asked her to come back with results of her new blood exams. I couldn't detain her long, the line of patients outside was long enough for me not to have lunch that day. Most of them were follow up patients. After 2 patients, she was back again, now consulting on what to do with her kids. I ended up giving her my calling card and advising her to 'call me' instead.

To treat or not to treat the 90? That is the question. Perhaps, I'll weigh the issues when she comea back 6 months after the death of her husband. When physiologic time allowed for grieving is over and she still cries in front of me--I'd probably consider addressing all the laboratory problems I'd see.

Decelerate Aging

There is much talks about how to slow down the process of aging. Many who felt that they are starting to 'age' resort to a lot of beauty regimens and age- defying scientific technology which include surgical and non-surgical interventions. While it is true that physiologically we age--- the experience is quite disturbing.

What happens when we age? White hairs increase in number. Ears elongate. Skin suddenly loses its elasticity. Wrinkles appear on undesirable places. Vision gets a little blurred. Hearing starts to decline. Comprehension becomes slow. Flabs sag. Bones become brittle. Hyperpigmentations increase. Etc. Etc.

Picture yourselves at the age of 60. Would you be able to recognize yourself?

There are physiologic changes in aging which we cannot really defy. However, we can slow it down by changing our lifestyle as early as now. In the molecular level, the food that we eat may reflect the speed of our getting old. Too much glucose at one point or another can contribute to increase in the glycosylation of amino acids which renders the proteins in our bodies unable to function well. The advice really is do small frequent feeding so that sugar does not necessarily rise abruptly. The intake of food which can halt the actions of free radicals is also important. Free radicals scavenge our last armory and when they attack the pawns of our immune system, how can we fight bacterial or viral insults?

Diet and Exercise may decelerate aging. If you want to live longer, Eat-Five-To-Keep-ALive... Five means 5 kinds of fruits and vegetables each day. Avoid sources of Omega 6 like pork and some meat. Increase fish intake, those with high Omega 3 levels such as salmon and tuna. On top of that you may need to take supplements in the form of fiber and natural extracts. Avoid synthetic products. Of course, avoid salty and fatty food if you are diabetic or hypertensive.

Do 10,000 steps each day. Walking enhances cardiac function. There is really no need to run or jog or set a scheduled time. You may start counting the number of steps as early as your waking time. From the moment you get up from bed up to the time you come home from work.

Increase your lifespan by living a quality life.

Teenage Pregnancy

Last Monday, I had a couple waiting for me in my clinic. The secretary said the girl is sick or at least looked sick. When I arrived, I saw a 15 yr old girl clinging to her 16 yr old ‘husband’. She said she’s been having hypogastric pains since August last year. She never volunteered information unless I asked her. In the end I found out she had irregular menses since last year after undergoing dilatation and curettage ....at the age of 14, unknown to their parents. Her last menstrual period was March and prior to that was September 2007. I had to do pregnancy test .... it was positive.

Teenage pregnancy is not uncommon these days. I always advise the children with a smile. I make them feel they can trust me and that as a doctor I will support them medically. I make them feel I am their friend and they do what I say. Diet and nutrition are very important. Physiologically, the teenager’s body is not mature enough but they can be taught to choose the right food and proper exercise.

After a long friendly conversation, I told my patient to come back with results of her CBC, urinalysis and HBsAg (Hepatitis B screening) . My next problem is how to convince them to tell their parents, which I thought I’d do when they come back.

I’ve seen cases like this for the nth time. I just can’t get use to it. It’s either I feel sad that a baby will be born from a little girl whose future is unsure or I pity the girl and wonder how she would cope with the demands of motherhood. They’re just high school students! I could see love and affection in their eyes but until when? What will they do if the hormones start to go haywire?

It is during such time when I fear for my son’s future. Perhaps, I could raise him well and yet what if girls start flirting around him? What if one day he comes home telling me that his girl is pregnant? Or I may not be able to raise him well and he’d end up wasting his life? I know it’s premature to think of such things but hey, I’m a mother...

My New Space

Four months ago, I ventured into private practice, rented a small space in a city unknown to me. I was both excited and afraid then.

Patients came in trickles. I wait for them to come with a lot of patience. I remember my professor in health economics telling us when we were medical students, that the first year of practice is really the most difficult. That we will learn how to crochet, read pocketbooks, count cockroaches while waiting for patients. But, even if that is so, he was very strong in telling us to man the clinic as we promised ourselves and be there on schedule.

Now, those were very true statements. There were days when I spend all my clinic time toying with my laptop, or I count the number of lizards crawling if there were any or many times I bring my son so I can play with him. It's comforting though to think that at least I have tied up with the market cooperative, and drug companies never fail to offer free screening services so I get to promote myself. With that I get to pay my rent and earn a little. Sometimes i'd rather stay in my other clinics where I sure am busy attending to patients and forget about the time. Beginning a community practice is really different from the hospital where you get referrals and you see patients from HMO's.There is also the thrill of getting challenging and emergency cases from time to time.

And so today, while talking to my secretary who is a nursing undergrad (never finished her studies because of lack of financial resources ), I couldn't help but sigh at the amount of time I spend in my new space and wonder when will patients really come. It's not that i'm praying for them to get sick but the sedentary time is tiring for someone like me who wants to have work at hand all the time.

Well, I will keep on crossing my fingers, anyway my one year is not yet over, I still have 8 months to wait...and pray that I will have 'work' to do in my clinic.

Kindergarten Temper

I was trying to look asleep so my son who has been drinking his milk will finally go to sleep when I heard my husband swear in anger. I thought he was angry with me...no, he was mad at his PSP. He was really so mad that when I asked him what's troubling him he said, "don't talk to me I'm mad!". Because I have a bit of sensitive personality, I asked him again, and he said, "don't talk to me, I'm losing the game!"


Kindergarten temper.. sometimes, I can't get use to it. Even i f I know how choleric a person my husband is, I still feel hurt when he doesn't seem to listen and he gets mad at the slightest of things. However, i realized, such temper can develop among children who are into computer games. The fast-paced games may enhance irritability and stubbornness which can be added to the development of obesity and metabolic syndrome because of prolonged sitting in front of the monitor. Such sedentary lifestyle may contribute to the increase in the number of adults with chronic diseases.

The GYM Busters!!!

This morning I found myself eavesdropping in the girls locker room of the gym, to a group of ladies of about 40-50 years old. They wore their body hugging shirts and tight work-out pants as if they were the sexiest of women while I hide my bumps in loose jogging pants. I'm not fond of tight work-out clothes, although I make sure I see some curves when I exercise to either build my self confidence or push me to exercise more. Anyway, they talked about funny things like, "you think men will like this?", I looked at them out of curiosity. (By the way, I appeared busy drying my hair) and one lady was modeling a bra- a sports bra which you're supposed to wear under thin work-out shirts or as is, if you're that confident. I wanted to laugh because her tummy was not just bloated, it was literally sagging! Out of nowhere somebody handed them an oil essence which they all applied on their bellies and here comes another lady with an obviously dyed white hair saying "Ooooh! That felt so good, will this make my fat shrink?". After 20 minutes they all hurried away to the body jam class.

You see, time and again, I always see this group. I came from another gym and the same kind of group amuse me. They go to the gym early and attend the group exercises together as if there's no tomorrow. I really wonder how old their children are now or where are their husbands? On top of that, they eat the same kind of food because they order it from the same cook who prepares either South Beach or whatever-diet they like. And they're there almost everyday!!...while I have to run from my clinic just to fulfill my 3x a week exercise regimen!

Whew! There are more stories to tell but these eavesdropping experiences help me understand my own aging mechanism plus the fact that I want to become a geriatrician. Taking care of the elderly starts from taking care of those who are in the younger old population. I know there is much to learn. Next time I think I'd bring a recorder.

Acute Laryngitis

For the past 4 days, my voice croaked like a frog. After two hours in the gym last Saturday, I developed muscle pains and suddenly my voice became hoarse. It was another bout of laryngitis.

For a doctor to lose her voice, it really is a big problem. For the past 2 days I've been apologizing to my patients that I could not explain well their problem because of my laryngitis. They all looked at me with pity and said they understand.

Honestly, I could see in their eyes the "c'mon-doc-you-need-some-rest" look. How can I when I know people need my help? Anyway, if you ever have laryngitis, best thing to do really is to rest your voice. Allow the inflammation of the vocal cords to heal by taking anti-inflammatory drugs such as Mefenamic Acid, Paracetamol and Ibuprofen. If the cause of the laryngitis is bacterial, antibiotic regimen may be necessary. However, should the laryngitis persist, perhaps, steroids for one week will do its magic.

On top of these, drink a lot of water at least 8 glasses a day. Also, warm saline gargle 3x a day should also be done.

Acute Gastroenteritis (On the Beach)

A man came complaining of loose bowel movements for the past 2 days. He was in the beach with some friends where they feasted on seafood and a bottle of whiskey. The next day he became a frequent visitor of the toilet because of watery excreta and crampy abdominal pain.

What do you do when you're far from home, on a beach where a doctor is hard to reach?

I must say, before going to the beach,here are essential drugs which you may need to bring.
1. Pain relievers/antipyretics (paracetamol)
2. Antispasmodics (hyoscine n-butylbromide or domperidone)
3.anti-emetic (metoclopramide)
4. Oral rehydration salts
5. Anti-bacterial cream
6. Local wound care kit (which inludes, povidone iodine, hydrogen peroxide,cotton, alcohol, sterile strips)
7.sunblock

While enjoying the beach,make sure you're skin is protected from the harmful rays of the sun. Use sunblock with higher SPF to ensure longer protection. If you intend to go drunk, make sure that you have food in your stomach enough to protect it from hyperacidity.

Now,if you develop diarrhea and abdominal pain, there are different pathologic reasons. One, you could have eaten an 'infected' meal, a seafood which harbors parasites endemic in the area, two you could be suffering from indigestion or three, you could have upset your stomach and suffer from mild gastritis on top of your 'gluttony'.

It is important to replace volume per volume loss when you have diarrhea. Replace the amount you lose with oral rehydration salts. ORS comes in tablet or powder forms. It should be dissolved in distilled or 'mineral' water and have to be taken in small amounts. Do not try to overhydrate yourself or you'll find yourself vomiting in a short while. Small but frequent intake is the key.

It is very important to see a doctor once you have the chance. A fecalysis or stool exam is necessary to address the etiology of diarrhea. If it's infectious an antibacterial regimen is enough to treat you. However, if a parasite is present, another drug should be added to complete the treatment. Supportive treatment to alleviate pain is also given in the form of anti-spasmodics. However, giving so is not that necessary.

Understanding the Young ONCE...

Last Saturday, I fnally decided to become a Geriatrician- one who takes care of the wiser and older people. I realized that sooner or later all of us are going there and what better way to prepare for it is to understand the physiologic changes of aging.

The first module that we took tackled Anatomy and Epidemiology of Aging. You see, there are myths related to aging and we are all guilty, in one way or another, of using aging as an excuse not to understand our parents or the older people we work with. One night, a neighbor came to the house requesting me to visit his father-in-law who has not been eating for 3 days and not wanting to leave his room.

When I reached his father-in-law's house, I was ushered to a dark second floor room, with not much ventilation, very dirty floor, and the bed mattress lying on the floor smelling stinky and 'old'. I was surprised to see that the old man have very enlarged lymph nodes which,as explained by the daughter, has been operated on five years ago, apparently became bigger than ever after the surgery. I proceeded to talk to the old man who was lying on the bed, eyes closed appearing to look asleep. After introducing myself to him in a cheerful tone, I then asked him if he has any complaints. He said " I'm okay!". He was still closing his eyes. I told him that his children are worried because he has not been eating. He said again "I'm okay!".... so I decided to do my physical examination. It really stabbed my heart that he looked neglected but the children appeared very concerned anyway. Finally I told him that if he doesn't eat we will be forced to bring him to a hospital and feed him through a tube. Then he said " There's nothing wrong with me! I can eat but many times, I wake up hungry and when I go to the kitchen, I still have to prepare the food or heat it and that tires me a lot, besides I have no one to talk to!".

So there it is! the children thought they've been doing their best to feed the father by leaving food in the refrigerator or the microwave but the poor man is too weak to do all these things on his own--- he's already 75 and his body lost it's strength because of his immunocompromised state. Anyway, I talked to the children and told them that their father needs attention and they need to schedule a time to take turns in taking care of him. After all, he has done his part in making them professionals and giving them their needs when they were helpless children. It was their turn to take care of him. I also told them to clean the house and make the room conducive to sleep.

They were so embarassed after that but hey... let us all realize that we too will become old as this man and do we want our children to leave us in a dark dirty room with food in the ref but no one to talk to?

Anxiety (or Hypokalemia?)

Oftentimes, patients come in asking for a 'general check-up' and on further query all they really wanted is a request for ancillary procedures to see if they have existing diseases or if they are at risk for developing chronic illnesses.

One day, a seemingly worried lady in her late 30's came in because of weakness of her legs. She asked for a 'general check up'. She is single,never been married nor bore a child. On physical examination everything was normal except for a blood pressure of 130/90 which is pre-hypertensive. She looked so worried and tensed asking me to allow her to stay in my clinic to rest for a while. She said that the day before, she went to an emergency room because she had difficulty getting up from bed. Her electrolytes were taken and showed a slightly low potassium levels.

I started exploring where her tension is coming from. As a family physician, I make sure I was able to check on prevailing issues which could have affected her perception of the illness that she might have. She started to cry. She said that she has been worried for the past weeks. Her boyfriend left her for another woman at a time when they were already considering marriage. She claimed though that it doesn't bother her anymore and what really worried her most is the fact that an office- mate has been diagnosed to have cancer who complained of easy fatigability for just a short time. She is afraid that her weakness might be a sign of cancer.

Many times, to satisfy a patient, you need to request a battery of test which can help in explaining what she is going through. A simple routine exam appropriate for her age may be necessary like a CBC, urinalysis, Chest X-ray, and a lipid profile perhaps. In this patient, everything came out normal.

I explained to her that her blood exams were normal. I didn't stop at that. I went back to her problems and tried to address her issues. When she realized she has been feeling depressed not just because she's worried about her health but because of the break-up, she started to open up. Aside from the potassium supplement and advice to eat bananas, I made sure she updates me on her critical issues everytime she follows up.

After 4 visits, she felt better, weakness of the legs were gone and she didn't look tensed anymore as compared to the first time I saw her.

When illness is viewed just as physical illness, we miss the chance of knowing where the perceived illness really comes from. Personal anxieties exaggerate physical experience of a disease. When we're sick and we worry a lot, sometimes the disease is magnified. Therefore, when we visit our doctors, we tell them what we really feel, physically and emotionally too.