Monday, July 28, 2014

Why medicine is not for everyone - Part I

Over the course of my years in Medicine, I have realized, slowly and painstakingly, that Medicine is not for everyone. The world of blood, gore, death is not for the weak of heart. There is suffering and pain everywhere. Given the number of patients we see who become debilitated for life (of course, we are thankful that they are still alive) and those who leave the hospital in burial shrouds, it is no wonder that a select few only gets to survive as doctors.

I have listed down several things which make Medicine not for everyone.
1) Getting into medical school is as difficult as can be.
Most medical schools require their applicants to be academically inclined, or to at least have high grades. Most applicants are gutted out because of this. However, there are a few of us who actually impress our interviewers and eventually get in. Confidence gives a lot of power.

2) Surviving medical school is even more difficult than getting in. 
If getting into medical school is similar to going through the fire, actually being in medical school is like being roasted alive until even your soul turns into ash. You become the most parched social being on earth, simply because you neither have the time or energy to go out. Parties are limited to those organize by the school or your med friends. You do not get to sleep in because there will always be some requirement you have to finish.

3) Graduating from medical school requires you to make difficult choices for the future
Should you become a primary physician? Should you specialize? Or should you just leave the medical profession altogether. Getting that coveted M.D. after your name does not make your life any easier. Instead, it makes it even harder. Now, you are duty-bound to save lives. When someone in a plane asks "Is there a doctor here?", you cannot not respond. At least, back in medical school, you could always make the excuse that you are still a medical student.

- To be continued

Thursday, April 4, 2013

Bowel Strangulation Symptoms

A variety of conditions can cause abdominal pain but one of the rarer and more dangerous ones is bowel strangulation. In medicine, strangulation simply means that a certain anatomic part has lost its blood supply and has the tissues are dead. Hence, bowel strangulation can be defined as the loss of blood supply of a certain segment of the bowel, leading to ischemia and necrosis or gangrene.

What are Bowel Strangulation Symptoms?

Prior to the actual strangulation of the bowel, obstructive symptoms are often present. These symptoms include nausea, vomiting, and constipation. As the strangulated bowel loses its blood supply, severe abdominal pain sets in. Severe abdominal pain unrelieved by any position is one of the characteristic symptoms of bowel strangulation. The release of inflammatory mediators leads to the development of fever.

Signs that give the doctors a clue on bowel strangulation include a very ill-looking patient, in distress because of abdominal pain. Abdominal examination generally shows abdominal tenderness, guarding, and muscle rigidity. The patient's vital signs often progressively worsen as the disease process progresses.

What are the Causes of Bowel Strangulation?

Bowel strangulation can be caused by different conditions. These include small bowel obstruction, hernias,volvulus, intussusception, tumors, and inflammatory bowel disease. Post-operative adhesions may also cause strangulated bowel. However, the end pathology and the treatment are the same: the strangulated bowel has to be surgically removed and the viable bowel saved. Broad-spectrum antibiotics and adequate fluid resuscitation are also given. 

Monday, April 1, 2013

Why Women Need Mammograms

Just recently, I came Just recently, I came across an article entitled 4 Medical Tests Your Doctor Might Be Overprescribing. According to the said article, a mammogram is one of the said overprescribed medical tests. Indeed, there is controversy regarding when women should start getting mammograms done. For instance, the United States Preventive Services Task Force recommend women of ages 50 and above to get mammograms while the American Cancer Society recommend the test for women of ages 40 and above. In a study in 2012 by Bleyer and Welch entitled “Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence” and published in the New England Journal of Medicine, the authors concluded that “breast cancer was overdiagnosed (i.e., tumors were detected on screening that would never have led to clinical symptoms) in 1.3 million U.S. women in the past 30 years” and mammogram only contributed marginally to the detection of illness-causing breast cancer.

The Rationale Behind Mammograms

I beg to disagree though that mammograms are overprescribed. Mammograms are prescribed for a reason and it is to screen for breast cancer. First of all, a mammogram is a screening test. The value of a screening test lies in the fact that it can detect a diseases even among asymptomatic patients. This means that a woman’s early stage breast cancer may be detected, even if she had not yet noted a lump on her breast, breast discharge, breast skin changes, or breast pain. The beauty of screening lies in the fact that the disease can be treated at its early stages. 

Dangerous Assumptions on Mammograms

The authors of the study made several assumptions about the overdiagnosis of breast cancer because of mammograms. According to them, for screening to work, there should be one less patient diagnosed with late-stage breast cancer for every additional patient whose cancer was found at an earlier stage. This is an unrealistic expectation of any screening test. It does not mean that a woman who had breast cancer diagnosed with an early stage will not have any recurrences. Some women diagnosed early eventually present with late-stage disease because they tried alternative treatments which did not work.  

I personally think mammogram still has value for screening particularly in high-risk women (e.g. with family history of breast cancer). However, physicians should also used logic when requesting for mammograms. Clinical judgment that aims to balance the benefits and the risks should always be utilized by physicians. On the part of patients, any negative thought or feeling or doubt towards a test requested by the physician should be aired out. After all, the patient-physician relationship is based on mutual trust. Without this trust, even the internet can serve as anybody's doctor and the physician becomes just another person who verbalizes the contents of medical books. 

Wednesday, November 14, 2012

Ethics in Medicine: HIV/AIDS and Disclosure

Ethics in Theory versus Ethics in Practice

Ethics is always challenging but it is particularly intense and, at times, heartbreaking in medicine. During medical school, when our ethics professor presented cases for the discussion (e.g. whether or not a patient should undergo an experimental treatment without assurance of life, therapeutic abortion, euthanasia and assisted suicide), our class always had heated conversations. Understandably, even if most of us were applying the same ethical principles, we each had different approaches to the issues in medical ethics due to differences in context. At least we were able to speak out and have lively discussions.

Although the cases are similar in actual medical practice, the reactions and responses are quite distinct. In discussions of concrete cases by the medical team, there are long periods of silences, when each member tries to gather his/her thoughts and come up with an acceptable response in the background of unease of holding the key to life or death. Oftentimes, each of us ends the ethics discussion with a disturbed face, a lined face and a heavy heart.

Medical Ethics: HIV/AIDS and disclosure

Among the ethical situations in medical practice I have encountered, one of the things that come to mind is the issue of HIV/AIDS and disclosureOne of the core principles in medical ethics is the Principle of Autonomy. Under this principle, a patient has the right to decide for himself/herself, including whether or not to disclose his/her condition. 

Our hospital had a patient who is a lawyer, has a girlfriend and has HIV/AIDS. He was dying from PCP (Pneumocystis carinii pneumonia) but he refused to disclose it to his family because of shame. He belonged to a family of lawyers.

Prior to getting intubated, he wrote a letter informing the medical team that any means to hide his diagnosis should be done; otherwise, he would sue the medical team. The medical team agreed to keep his diagnosis a secret. Each time his lawyer brothers and parents asked about his diagnosis, the standard answer was severe pneumonia. It came to a point when the patient’s family threatened the medical team for malpractice, saying “What kind of doctors are you? Are you that incompetent that you can’t even treat a simple pneumonia?”

The patient’s stay in the hospital was relatively brief. Even to his last moment, the medical team kept silent about his AIDS. The medical team continued to face the threat of a lawsuit.
Fortunately, prior to his death, the patient agreed to reveal his diagnosis once he dies. In the end, when the medical team talked to the family, the family stated that they had an inkling of his condition; they just wanted the doctors to admit to it.

What about the patient’s girlfriend then? Although some states require the patient’s partner to become informed regarding the patient’s HIV/AIDS condition, other states don’t. In this case, the law fully extends the right to disclose to the patient. Should the medical team also inform the patient’s girlfriend, who is at risk of the disease?

Further questions to think about in this case are as follows:

If the girlfriend was of no relation to the physicians, it is not the duty of the physicians to inform the patient. What happens if the girlfriend consulted one of the members of the medical team for pneumonia? Should the girlfriend be informed that she is at risk for HIV/AIDS and should be tested?

At this point, a review of the patient-physician relationship is merited. The physician who treated the patient with HIV/AIDS now treats the girlfriend. When a former patient dies, does the principle of autonomy no longer hold true? On the other hand, is it not the duty of a physician to keep the current patient’s well-being at the fore? 

Saturday, October 6, 2012

What is a Strangulated Hemorrhoid

Yesterday, a patient came to the clinic complaining of a painful mass in his anal area. On further probing, he also notes fresh blood on his feces. The painful mass has been recurring for 6 months but he previously hesitated to consult because of embarrassment. Several days prior, the painful mass did not regress spontaneously.

Initially, the patient did not want to undergo a digital rectal examination. I was able to convince him after several minutes of explanation. On examination, the painful mass was revealed to be an internal hemorrhoid (originating above the dentate line) that cannot be reduced manually. Therefore, the diagnosis was fourth-degree internal hemorrhoid. Unfortunately, this can become a strangulated hemorrhoid.

What is an internal hemorrhoid?

An internal hemorrhoid is located above the dentate line. Most of the time, patients do not complain of pain but when an internal hemorrhoid develops thrombosis or necrosis, it can cause severe pain.

The grading of an internal hemorrhoid is as follows:

  1. First-degree internal hemorrhoid - bulges into the anal canal. Patients may notice a mass on their anal canal on straining. Hence, it usually becomes apparent when accompanied by constipation.
  2. Second-degree internal hemorrhoid - prolapses through the anus. Patients can feel it on their anal area. However, a second-degree internal hemorrhoid reduces or goes back spontaneously.
  3. Third-degree internal hemorrhoid - prolapses through the anus and does not reduce spontaneously. Therefore, patients often relate stories wherein they push back or manually reduce the hemorrhoid into the anal canal.
  4. Fourth-degree hemorrhoid - at the highest risk of becoming strangulated. It cannot be pushed back or manually reduced. Strangulated hemorrhoids present with severe pain. 
Note that this grading system only applies to internal hemorrhoids and not to external hemorrhoids.

How does a strangulated hemorrhoid occur?

The strangulation of any organ occurs when its blood supply is cut off. When the blood supply of an internal hemorrhoid becomes compromised, it is prone to necrosis or death; hence the term strangulated hemorrhoid. 

Is it not good then that a strangulated hemorrhoid dies? It is not that straightforward. Complications including infection, gangrene, sepsis, and thrombosis can occur. When a localized infection occurs, an abscess can form. This leads to pus formation and discharge from the area of the strangulated hemorrhoid. Generalized infection or sepsis can also result. 

While conservative and medical therapy may be used for first-degree and second-degree hemorrhoids (e.g.dietary fiber, increased fluid intake, and avoidance of straining, stool softeners, over-the-counter hemorrhoid dessicants), it is best to treat third-degree, fourth-degree and strangulated hemorrhoids surgically. The procedure is called hemorrhoidectomy. Different types of hemorrhoidectomy (rubber band ligation, Closed Submucosal Hemorrhoidectomy, Open Hemorrhoidectomy, and Procedure for Prolapse and Hemorrhoids or PPH) can be done depending on the preference of the patient and the expertise of the surgeon. 

Friday, October 5, 2012

Heart Disease in Hyperthyroidism

The previous week, I saw a gaunt-looking patient with bulging eyeballs. His chief complaint was cough of 2 weeks duration, with associated shortness of breath. Just with the chief complaint and the emaciated appearance of the patient, the immediate working impression would have been an infectious condition such as Tuberculosis. The differential is hyperthyroidism, possibly with heart failure. 

Further history revealed that the patient has been having difficulty of breathing with exertion, night-time awakening due to coughing, and the use of 2 pillows to prevent a "drowning" sensation.

Imagine my panic when I examined him and found out he had strong tremors and an irregularly irregular heartbeat.  Although his thyroid gland was not enlarged, I advised him about a possible thyrotoxic heart disease and requested for an ECG. When he came back, his ECG showed Atrial Fibrillation, more popularly known as "A-fib" among medical personnel. Right then, I knew he had thyrotoxic heart disease.

What is Thyrotoxic Heart Disease?

Thyrotoxic heart disease is so called because it occurs due to the presence of excessive thyroid hormones (T3 and T4) or in hypethyroidism. Hence, thyrotoxic heart disease is sometimes used synonymously with hyperthyroid heart disease. Thyrotoxic heart disease occurs because the cardiac cells are very sensitive to changes in the levels of thyroid hormone in the body. 

Both thyroid hormones (T3 and T4) are lipophilic or fat-loving molecules. Therefore, they can enter not just the cell but also the nucleus. In particular, T3 enters the nucleus and binds to Thyroid Hormone Receptors (THRs), which in turn activate a series of nuclear activities. The result is the transcription of several cardiac genes which, in turn, improve the contracting power (myocardial contractility) of the heart muscles. This also leads to increased cardiac output. 

Unfortunately, in thyrotoxic heart disease, the increase in myocardial contractility and cardiac output do not correlate to the improvement of cardiac health. Instead, thyrotoxic heart disease ensues. 

What are the symptoms of thyrotoxic heart disease?

The most common cardiac manifestation of hyperthyroidism is palpitations.   The examining doctor would also note elevated heartbeat (tachycardia), bounding pulses, a dynamic precordium, loud heart sounds, and a systolic ejection murmur. 

The most common manifestation of true thyrotoxic heart disease is an irregularly irregular heartbeat typical of Atrial Fibrillation. Instead of the typical lub-dub rhythm of the heart, an A-fib can be heard with a stethoscope as a "lub-lub-dub-lub-du-dub-lub" sound. Although rare in patients who are less than 40 years old, Atrial Fibrillation occurs in 24% to 40% of hyperthyroid patients who are over 50. 

Unfortunately, severe or prolonged thyrotoxic heart disease can lead to heart failure. Thyrotoxic heart disease with heart failure would manifest as cough that does not resolve with antitussives or antibiotics, progressive difficulty in doing exertional activities (e.g. walking upstairs), swelling of the legs (edema), and night-time coughing due to a subjective feeling of drowning. In this case, both the thyrotoxic heart disease and the heart failure should be managed aggressively.

What is the treatment of thyrotoxic heart disease?

Thyrotoxic heart disease manifesting as atrial fibrillation WITHOUT heart failure can be treated using a beta-blocker. Among the various beta-blockers, Propanolol is deemed the most suitable because it is known to decrease the peripheral conversion of T4 to T3 (hence reducing the amount of thyroid hormone that goes into the cardiac muscle nucleus). At the same time, since the underlying cause of the thyrotoxic heart disease is the undesirable elevation of the thyroid hormones, anti-thyroid hormone medications such as propylthiouracil (PTU) can be given. 

If congestive heart failure is present, the most important goal is to decrease the volume load of the patient. Therefore, diuretics are used (e.g. furosemide). In patients with congestive heart failure AND atrial fibrillation, the anti-arrhythmic drug Digoxin should be considered. 

Wednesday, October 3, 2012

Weight Gain and Being a Doctor

Being a doctor entails a lot of sitting. In fact, the process of becoming a doctor means approximately 3 years of listening to lectures, 1 year of following residents and consultants do their rounds, and another year of doing simple medical procedures independently during internship. Unfortunately, these activities also make us prone to eating, foregoing exercise, and becoming overweight/obese.

Physician Weight Gain: The Eating Habit

One of the things that gave me real pleasure during my medical school training was eating. Eating served as a reward. Eating served as a way to reconnect with friends and loved ones. In fact, when I get contacted by a non-medical friend, the invitation is often to "Wanna eat dinner at [some tempting place]? It is therefore no wonder that many doctors, even before they get their licenses, already become overweight. Some have it worse; they become obese.

Physicians Dealing with Weight Gain Issues

Unfortunately, there is this issue of physicians being examples to their patients. Can a patient really rely on the advice of physician regarding weight control and weight loss if that physician himself/herself is obese? Or should we, as physicians, implement stricter standards on ourselves, knowing that our appearance also serves as evidence of our health?

Tuesday, October 2, 2012

Contraindications For Herceptin

Herceptin (generic name: Trastuzumab) by Roche is an anti-breast cancer drug that specifically targets breast cancer cells that produce the protein called HER2. The type of breast cancers that produce HER2 are typically more aggressive, hence the need for early treatment with Herceptin.

Studies on Herceptin For Breast Cancer

In 2 recent studies that compare the effects of 1) extending the duration of Herceptin use to 2 years (HERA) and 2) decreasing the duration of Herceptin use to 6 months (PHARE), it was found out that either change in duration of Herceptin use does not affect the effects of treatment.

Hence, in both studies, the best duration or the gold standard is still a one-year course of Herceptin for HER2+ breast cancer patients in the early stages of the disease. 

Contraindications for Herceptin

Contraindications for Herceptin include hypersensitivity to Trastuzumab and lactation.  

The main contraindication for Herceptin is hypersensitivity or allergy to Trastuzumab (the active ingredient) or to any other excipient in the Herceptin preparation. Hence, contraindications for Herceptin include allergy to Trastuzumab, L-histidine hydrochloride, L-histidine, α,α-trehalose dihydrate and polysorbate 20.

A hypersensitivity reaction to Herceptin could manifest as itching or rashes. Severe allergic reactions include difficulty of breathing and hypotension (blood pressure falls below normal). A person suffering from Herceptin allergy merits medical care.

Another contraindication for Herceptin is lactation. A mother who is breastfeeding her child should not be given Trastuzumab. However, this medication could be given 6 months after breastfeeding has ceased. 

Although not one of the recognized contraindications for Herceptin, heart failure is considered a dangerous condition for Herceptin treatment. Physicians are advised to use caution when using Herceptin for treating breast cancer patients who have been diagnosed with heart failure and coronary artery disease. This is also the reason why cardiac function is regularly monitored among early breast cancer patients who are using Herceptin.

Night-eating Syndrome

The relationship of obesity and psychiatric disorders is well-known. For instance, the most common side effect of the medications Clozapine (Clozaril) and Olanzapine (Zyprexa) is weight gain. Patients with psychiatric disorders that used these medications typically gain weight from 3 kilograms to 10 kilograms. However, there is a distinct disorder called Night-eating Syndrome which could lead to obesity.

What is the night-eating syndrome?

The night eating syndrome is a disorder characterized by a person eating excessively even if s/he has already had his/her evening meal. The most common trigger is the presence of a stressful life circumstance (e.g. mounting debt, death of a loved one. Once a person starts to suffer from the night-eating syndrome, night-eating recurs daily until the trigger has been alleviated or overcome. 

In the drug-induced type of night-eating syndrome, the night eating occurs due to the use of sedatives. The side effect of the sedatives include sleep-walking and eating, thereby making a sedative user more prone to become a night-eater. An example of a drug that induces night-eating is Zolpidem (Ambien). 

What is the difference between binge-eating syndrome and night-eating syndrome?

Binge-eating syndrome (bulimia) is characterized by a sudden compulsion to eat huge quantities of food in a short period. Afterwards, a bulimic person condemns himself/herself for the behavior. Binge eating is not episodic whereas night eating is. 

Monday, October 1, 2012

Pathophysiology of Myasthenia

The pathophysiology of myasthenia gravis can be understood by reviewing the physiology of neurotransmission. Myasthenia gravis basically results from a disorder in the neuro muscular transmission between a neuron and a muscle cell.

Normal Neuro muscular transmission without Myasthenia Gravis

The synapse is the space between the axon of a motor neuron and a skeletal muscle cell. This synapse is more commonly called a "neuromuscular junction" or NMJ. In order to bridge the motor neuron and the skeletal muscle, chemical transmission occurs through the release and uptake of neurotransmitters.This is called neuro muscular transmission or simply neurotransmission. In the neuromuscular junction, the neurotransmitter is called Acetylcholine or ACh. An abnormality in this neuro muscular transmission is the basis for the pathophysiology of myasthenia gravis

When an action potential occurs in the nerve, which is the presynaptic (before the synapse) cell, calcium channels open and calcium ions (Ca2+) rush into the axon of the motor neuron. This inward movement of calcium triggers the release or exocytosis of Acetylcholine (ACh) from the presynaptic terminal  into the synapse. ACh molecules then travel to the postsynaptic (after the synapse) cell, which, in this case, is a skeletal muscle cell.

On the postsynaptic cell, ACh binds to the Acetylcholine receptor (AChR) which is also a sodium (Na+) and potassium (K+) channel. This is called a ligand-gated channel. With the influx of sodium into the skeletal muscle cell through this ligand-gated channel, the skeletal muscle cell becomes depolarized. With depolarization, an action potential results, which in turn, leads to skeletal muscle contraction.

Therefore, in the normal neuro muscular transmission, the roles of ACh and AChR are essential. In the pathophysiology of myasthenia gravis, the roles of these two become dysfunctional and the normal neuro muscular transmission is disrupted.

What happens in the pathophysiology of Myasthenia Gravis?

In the pathophysiology of myasthenia gravis, the antibodies that the body produces to fight against foreign substances (e.g. viruses, bacteria) become directed to the body's own Acetylcholine receptor (AChR). These antibodies are then called "autoantibodies" This leads to the loss of AChRs and inefficient neuro muscular transmission. Since the AChRs become blocked by the autoantibodies, ACh cannot bind to its receptor. Therefore, there is a decreased number of action potentials, leading to weakness of skeletal muscles, including the muscles of the eyelids.

Treatment of Myasthenia gravis helps alleviate the pathophysiology of myasthenia gravis. For instance, acetylcholine esterase (AChE) inhibitors help prevent the degradation of acetylcholine, thereby increasing more acetylcholine molecules in the synapse and increasing the possibility of ACh-AChR binding. On the other hand, immunosuppressants like prednisone are used to decrease the activity of the immune system and lower the body's production of autoantibodies directed towards the Acetylcholine receptor. 
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For my readers out there who are interested in learning about the author of this blog: I am a simple person who is also a physician. I created this blog for 2 purposes. First, I want to share interesting health and medicine information to Internet readers. Second, I want to widen my knowledge of current developments in health and medicine. Kudos to everyone! If you have any suggestions/concerns/topics that you want me to write about, just leave a message and I'll get back to you immediately!