" '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.