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.