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.