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2008/06/28

That Same Old Feeling

Last June 20, I had a procedure at DMSF Hospital. My patient had an obstructing 1.8 cm ureteral stone on the left noted on ultrasound and his creatinine was already elevated. However, it was not seen on the plain KUB xray. Good, since the option of dissolving the stone through medication would work for this patient meaning that I dont have to open him up. He was not a regular patient since he was diabetic, hypertensive and in heart failure! Not to mention, he is the father of a grade school classmate, brother of one of my mom's amigas and a fellow Batangueno-Davaoeno. Usually, I don't give in to this kind of pressure but honestly, I felt quite uneasy but still focused. He was cleared for surgery and it was the first time that I did a surgery with the cardiologist requesting that the cardiovascular anesthesiologist be the one to induce anesthesia. I had no qualms regarding that since it was all for patient safety, and I know that he will be in good hands. I did a cystoscopy, retrograde pyelography which showed a radiolucent 1.5 cm, partially obstructing proximal ureteral stone. Luckily, I was able to bypass the stone and insert a double J stent. When I talked to the family after the procedure, I could see their relief after knowing I that I didn't have to do an open procedure. I, too, was relieved because as much as possible, opening him up was last on my list. God was on my side that day!

My patient had a follow up check up a week (June 27) after I put in the stent, His creatinine went down to 1.3 mg/dL from the elevated 2.9 mg/dL preoperatively. I could feel his happiness with the outcome of the procedure. I received endless words of gratitude which made me feel good. He returned to work a few days after he was discharged from the hospital. His co-workers were curious about what procedure was done and how was it done. He even told me: "Doc, don't worry, people will start coming here, I told them to see you if they have any problems with regards to your specialty."
Thanks! Instant advertisement for me.

Its different when I was still in training since most of the patients that I handled had a purely doctor-patient relationship. I have this nice and light feeling everytime I my patients and relatives express their gratitude especially after a successful surgery.

I had the same nice and light feeling since I was able to do good to someone who is not only a patient but also is considered a friend of the family.

2008/06/25

Conked Out...

RENAL FAILURE

Acute Renal Failure

Acute renal failure (ARF) is a condition of abrupt deterioration in renal function as evidenced by rising blood urea nitrogen (BUN) and creatinine levels. It is usually associated with decreased urine output. Approximately occur in the surgical setting and early recognition can minimize the extent of renal injury. It is classified under 3 categories: prerenal, postrenal and intrarenal.



Prerenal azotemia is caused by the direct result of inadequate renal blood flow. If the cause for the poor blood flow can be reversed then the problem can be resolved. However, prolonged low flow states can produce ischemic kidney injury.

Causes of Prerenal azotemia:

1) Volume depletion – hemorrhage, dehydration
2) Low cardiac output – congestive heart failure, cardiogenic shock)
3) Renal artery (stenosis, occlusion, vasoconstriction)
4) Systemic vasodilatation (sepsis, anaphylaxis, overdose)

Postrenal azotemia is caused by obstruction to urine flow. Pressures in the renal collecting system and tubules rise with obstruction causing renal injury if the obstruction is not relieved.

Causes of urinary obstruction:

1) Bladder outlet – enlarged prostate, urethral stricture, bladder stones, foreign body, tumor, blood clot)
2) Ureter – stones, tumors, stricture, stenosis

Intrarenal

Acute parenchymal renal failure is the result of damage to the renal tubules brought about by inflammation, injury from substances toxic to the kidney (nephrotoxic) and decreased blood flow.

Causes of intrarenal failure

1) Acute tubular necrosis (ATN) – 3 phases: 1) onset 2) oliguric 3) postoliguric. The oliguric period (urine output less than 500cc/day) typically lasts for 10-14 days but may be as brief as 2 days or as long as 6-8 weeks. A non-oliguric ATN can occur when it is secondary to nephrotoxic injury for ex from certain drugs or substances.

Causes of ATN

a) Ischemic injury – hypotension, cardiogenic or septic shock
b) Nephrotoxins – aminoglycosides, anesthetic agents, iodinated contrast media, NSAIDS
c) Hemoglobinuria (hemoglobin in the urine) or myoglobinuria (muscle cells in the urine)

2) Acute glomelular nephritis (AGN)

3) Acute interstititial nephritis (AIN)

The work up of a patient with sudden elevation of BUN and creatinine, with or without decreased urine output requires a prompt, systematic approach to exclude any reversible pathophysiologic states and remove any potentially nephrotoxic agents. Prerenal and postrenal causes must be excluded before diagnosing intrinsic renal disease.

CHRONIC RENAL FAILURE

Chronic renal failure (CRF) is caused by a spectrum of diseases resulting in progressive irreversible loss of functioning nephrons ultimately leading to end stage renal disease (ESRD) requiring dialysis or transplantation. The most common causes include:

1) Diabetes mellitus
2) Hypertension
3) Primary and secondary glomerular disease
4) Hereditary renal disease
5) Obstructive uropathy
6) Chronic infection
7) Interstitial nephritis

A wide variety of systemic symptoms are seen and there is a multisystem involvement making management difficult. Symptoms include:

1) Electrolyte imbalance –decreased phosphates, increased potassium
2) Gastrointestinal – nausea, vomiting, anorexia
3) Hematologic –anemia, platelet dysfunction
4) Neurologic –neuropathy, encephalopathy
5) Cardiovascular – increased severity of atherosclerosis, prolonged hypertension
6) Endocrine – abnormal bone metabolism, glucose intolerance
7) Sexual dysfunction

The general management of patients with CRF centers on slowing the progression of functional renal deterioration. There is no effective treatment for most glomerulopathies. Any reversible or controllable factors must be addressed. Once the glomerular filtration rate deteriorates to levels that produce symptoms of ESRD, then dialysis or transplantation becomes the only option



2008/06/09

A Different World

Fresh from my urology training at National Kidney and Transplant Institute, I arrived in Davao City on the last week of January 2008. After complying with the requirements, I started private practice sometime mid February. Quite a struggle, I was out of touch with my medical and non-medical circle of friends, only a handful knew that I was back. Thanks to supportive colleagues and friends, I was able to inch my way slowly into the world of private practice. No one said that its gonna be a walk in the park. Especially if there are people who make you make things harder for you. I had a difficult time adjusting to this slow pace since I trained in a high volume institution wherein surgeries are done day in and day out.
The tide has changed, when I arrived in NKTI, I asked myself if I was ready for the fast pace life in the capital, now I found myself asking me again if I was ready to go back to the laid back lifestyle in Davao. After staying in Manila for the past 4 yrs, I was accustomed to the pace and lifestyle there, especially in the workplace.
In my line of work, efficiency is of the essence, so I hate it so much if there are problems caused by inefficiency of the staff. I also am systematic in things that I do especially with my surgeries. I get upset if there would be delays because of poor preparation of supplies and/or instruments. Well, I guess that I have to extend my patience more since most people here are not used to the usual "toxic" that is considered a way of life in other places. Call me strict or toxic, but I have a systematic and efficient way of doing things so that no effort is wasted (Toxic- a hospital slang used for busy; strict person. During training, the toxic persons were the residents and fellows especially the seniors. Why? Its something that cant be explained in words but could be understood by people who were once residents and fellows.)
I'm in a different world right now, a place where I'll be in the years to come. No one said that it's gonna be easy, but I know that it's gonna be worth it.

MY Workplaces

DAVAO MEDICAL SCHOOL FOUNDATION HOSPITAL, BAJADA, DAVAO CITY


RIVERA MEDICAL CENTER, INC, PANABO CITY
Davao on             the Web

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