Health Advisories from ROJoson’s Blogs

Objectives:

They constitute practical health advisories from Dr. Reynaldo O. Joson:
– part of his Education for Health Development in the Philippines project
– part of his initiative to empower the Filipino citizenry to take care of their own health especially in the face of inexactness of medicine as a science
– part of the health maintenance and promotion program for the patients who have previously consulted him in his clinics

Caveats:

Thoughts, Perceptions, Opinions and Recommendations (TPORs) of ROJoson

Whatever I post are my personal TPORs.

“Believe nothing, no matter where you read it, or who said it, no matter if I have said it, unless it agrees with your own reason and your own common sense.” —-Buddha

ROJ@17jul29

Posted in Facebook Project, ROJOSON MEDICAL CLINIC ADVISORIES | Leave a comment

To cancel or not to cancel ROJoson Medical Clinic; to go or not to go to clinic

July 27, 2017

Question: In the light of bad weather, do I cancel or not cancel my ROJoson Medical Clinic today?  In the light of bad weather, should patients with booked appointment time today go to ROJoson Medical Clinic?

This morning at about 4 or 5 am, it was raining hard in Makati.  I was hoping it would stop as I had to make a decision whether to cancel or not to cancel my clinic session at 10 to 12 am. I know there were patients lined up to see me today.

At 7 am, the rain had stopped but the sky was still dark. I was still deciding whether to cancel or not to cancel my clinic session because of the bad weather situation and because of the possible floods along my way to Manila Doctors Hospital.  I received a flood advisory from Manila Doctors Hospital at 715 am saying there was gutter-deep flood along UN Avenue and Kalaw Street.

I decided to open my laptop and look at the PAGASA and MMDA Facebook and Twitter. A patient asked me in Facebook at 730 am whether I would hold clinic considering the bad weather.  She had an appointment at 10 am.  I said yes after considering the reports and updates from PAGASA and MMDA and the rain had stopped raining in my place.  I decided not to cancel my clinic.

I left my house at about 805 am.  My clinic was supposed to start at 10 am.  When I reached Sta. Ana, I met a heavy traffic. I thought the traffic might be due to street flood.  I was thinking of changing my decision to hold clinic and to go back.

I texted my secretary and asked her where she was at that time.  She was already in the clinic at 8 am.  I asked her whether the streets were flooded.  She said no.   with those answers; having said yes that I would hold clinic to a patient who asked me in Facebook earlier; with no way to inform the patients who were scheduled to see me today that I would cancel my clinic session today; and not wanting to disappoint the patients who were scheduled to see today, I decided to be patient with the traffic and proceeded to Manila Doctors Hospital.  I was in Manila Doctors Hospital at 850 am.  There was gutter-deep flood in a short segment of United Nations Avenue.  The flood in Kalaw Street had subsided.

With this experience today, I asked my secretary for a recommendation on how we should give timely advice to our patients who are scheduled to see us in our clinic whenever there is a rain-flood-wind situation in Metro Manila and whenever we decided to cancel our clinic session.

Here are my recommendations.

I will coordinate with my secretary at about 5 to 6 am whenever there is a rain-flood-wind situation in Metro Manila.  We will assess the situation through PAGASA and MMDA Facebook and Twitter and other sources of information.  We will collaboratively decide whether we will cancel clinic session for the day or not.

We advise patients who are scheduled to go to ROJOson Medical Clinic on that day to text or call me through my cellphone (09188040304) from 7 am to 8 am and check with me whether there is clinic session or not.  We will also give the advisory on whether there will be ROJoson Medical Clinic session or not to the telephone operator (5580888) of Manila Doctors Hospital (in case I cannot be reached through my cellphone).

We also advise patients NOT to go to the ROJoson Medical Clinic during a severe rain-flood-wind situation.  We don’t like them to risk their life and limbs just to be at ROJoson Medical Clinic.

These recommendations are made because we are concerned with the welfare of our patients.  We don’t like our patients to go to the ROJoson Medical Clinic and, after arrival, just to be told that there won’t be any clinic for the day and that the clinic has been cancelled because of the rain-flood-wind situation.  We don’t like our patients to risk the rain-flood-wind situation just to meet their appointment schedule with ROJoson Medical Clinic.

Just a request, in case the ROJoson Medical Clinic will push through during the rain-flood-wind situation, for those who cannot make it to the clinic for one reason or another, please text or call (09188040304) to inform so that we will not wait unnecessarily.

Another request, text or call me through my cellphone during the rain-flood-wind situation ONLY.

Thank you.

We recommend reading this other advisory from ROJoson Medical Clinic:

Be Prepared for Rain-Flood-Wind-Traffic Emergencies and Disasters (RFWTED) – To Travel or Not to Place of Work

https://rojosonmedicalclinic.wordpress.com/2014/07/09/be-prepared-for-rain-flood-wind-traffic-emergencies-and-disasters-rfwted-to-travel-or-not-to-place-of-work/

ROJ@17jul27

 

Posted in Rain-Flood-Wind Emergencies | Leave a comment

ROJoson’s MAR: Nodule appearing on the remaining lobe after subtotal thyroidectomy for papillary carcinoma

Medical Anecdotal Report

Date of Medical Observation: July 2017

NARRATION:

A 40-plus-year-old female with history of subtotal thyroidectomy (total lobectomy on the right side) 15 years ago for papillary thyroid carcinoma consulted me for a neck mass on the right side.  On physical examination, there was a 1-cm neck node on the right side just below the ear, not significantly tender.  Concomitantly, I was able to palpate a 3-cm nodule on the left thyroid lobe, again not tender.  I saw this patient 6 months ago and there was no palpable mass at the last check-up.

With these findings, I was primarily considering a thyroid papillary carcinoma recurrence, one, on the neck node at right side, and two, on the left lobe of the thyroid gland.  My secondary clinical diagnosis consisted of an inflammatory lymph node hyperplasia on the right side of the neck and a colloid nodule / cyst (benign) on the left lobe of the thyroid gland.

I requested for an ultrasound of the neck.  Result showed a complex mass on the left lobe of the thyroid gland and absent right lobe and lymph nodes on the right upper neck.

When she came back to me after one week for follow-up, with the neck node slightly decreasing in size, with the patient having sore throat, and with the ultrasound result, I now placed as my primary clinical diagnosis as an inflammatory lymph node hyperplasia on the right side of the neck and a colloid nodule / cyst (benign) on the left lobe of the thyroid gland.  The thyroid papillary carcinoma became the secondary clinical diagnosis.

I did a needle evaluation and aspiration-biopsy of the left thyroid mass and it yielded 6 cc of brown colloid fluid with marked decrease in size of the mass.  After the needle evaluation, my diagnosis was colloid nodule.  I started her on levothyroxine.

INSIGHTS:

As far as I can recall, in my 35 years of practice, this is the third or fourth case of a colloid nodule appearing on the remaining thyroid lobe after a subtotal thyroidectomy  (total lobectomy only) for papillary carcinoma.

My specific insights:

Not all masses occurring on the remaining thyroid lobe after a subtotal thyroidectomy for thyroid papillary carcinoma are cancers as illustrated in this case and in my two and three other cases before.

Subtotal thyroidectomy (total lobectomy only) is an option in the surgical treatment for thyroid papillary carcinoma confined to one lobe of the thyroid gland.   As shown in this patient, she is already 15 years in remission without recurrence after a subtotal thyroidectomy (total lobectomy only).

Clues that one can use in suspecting a colloid nodule or colloid cyst developing on the remaining thyroid lobe after a subtotal thyroidectomy for thyroid papillary carcinoma consist of sudden and recent appearance of a relatively large mass (I saw her just 6 months ago with no thyroid mass – the present mass must be very recent and the size was already 3 cm when I saw her this time – usually colloid fluid accumulation and build-up is the cause of sudden enlargement – thyroid papillary cancer usually does not grow that fast in terms of size) and with no signs of malignancy such as stony hard mass, fixation, hoarseness of voice, and ipsilateral neck nodes.

Note 1: On the first consult, I have to consider recurrence because of the physical examination findings and a background history of thyroid papillary cancer.  Thyroid cancer can recur on the neck nodes even after 15 years and also on the remaining thyroid lobe.  At that time also, patient did not complain of sore throat and there was insignificant tenderness on the neck node and thyroid nodule.

Note 2: At that time also, with this consideration of possible cancer recurrence, I was already feeling anxious and empathizing with the patient (since she has been with me for the last 15 years) and I was praying and hoping that my secondary diagnosis will turn out to be the correct diagnosis.  My prayer was answered.

ROJ@17jul26

Posted in ROJoson's MARs, Thyroid Cancers | Leave a comment

ROJoson’s MAR: Breast cancer patient dying 13 years after mastectomy

Medical Anecdotal Report
Date of Medical Observation: March 2017
NARRATION:
Most recently, I encountered a former breast cancer patient of mine (JM) who died 13 years after.
She was 62 years old when I operated on her breast cancer in November 2004.  I did a modified radical mastectomy.  Histopath: Invasive Lobular Carcinoma with four nodes positive.  She took Tamoxifen for 5 years.   She was lost to follow-up until 2017 (she was 75 years now),  when she consulted me again – this time she had metastasis to the skin and soft tissue, axillary and neck nodes, bones, and lungs.  She died 3 months after.

IMG_4409

Skin and soft tissue recurrence and metastasis

IMG_4411

Right axillary node recurrence

IMG_4412

Left axillary node recurrence

INSIGHTS:

I started my Cancer Survivor Registry (containing cancer patients I have treated before, with 10 or more years of remission) in December 23, 2011 to serve as an inspiration to current and future cancer patients and will debunk the thinking that having cancer is always a death sentence.
I used 10 years as the cut-off.

My personal observation is that chances of recurrence in this group of patients, 10 years with no recurrence, will just be 1% or less.

This patient is one of them.  I can recall 3 or 4 such patients in my more than 30 years of practice who had recurrence after 10 years.

How unfortunate for this patient dying after 10 to 13 years of remission.

However, she is fortunate to live this long considering that she had 4 positive nodes (which usually carries a poor prognosis).

ROJ@17jul25

Posted in Breast Cancer, Cancer Survivors, ROJoson's MARs | Leave a comment

ROJoson’s MAR: Breast mass in an 81-year-old Filipino female

Medical Anecdotal Report

Date of Medical Observation: July 25, 2017

NARRATION:

An 81-year-old Filipino female, a close family friend, called me up by phone on July 24, 2017, arranging for an medical appointment on July 25, 2017.  Over the phone, she told me, that last month, while undergoing a medical examination for visa purpose, the examining physician palpated a mass on her left breast. No diagnostic tests were done.

I told her to see me as soon as possible on July 25, 2017.  She asked whether she needed to do diagnostic tests like ultrasound and mammography before coming to see me.  I said, not yet.  I would see her first.  She agreed.

At home, on July 24, 2017, I was telling my wife  I hope there is no actual mass.  If there is, I hope it is not breast cancer for our close family friend.  The incidence of breast cancer is high at this age 80 (actually the incidence of breast cancer increases with age).

July 25, 2017, after I did a physical examination, I found a 3-4 cm dominant breast mass at 2 o;clock.  It was a little tender.  It felt “cystic” (depressible).  There were no axillary nodes.

I told my close family friend (my patient) my primary clinical diagnosis was macrocyst.  I recommended a needle evaluation and aspiration with possible biopsy.  She agreed.

Lo and behold, it was really a macrocyst as the mass was really cystic and yielded 20 cc of yellow-brown fluid on needle aspiration followed by complete disappearance of the mass.  My close family friend was very happy on the findings and very thankful for my service.

IMG_5232

IMG_5233

INSIGHTS:

  1. Although the incidence of breast cancer is high at age 80, the clinical diagnosis is still based primarily on the physical examination finding.  I have observed the common pitfall among medical students, residents, and even consultants who would use AGE out-rightly to give out a primary clinical diagnosis of breast cancer. This is not the way to do it.  Use first the physical examination findings to arrive to a clinical diagnosis.  If the physical examination findings point to a benign condition, the clinical diagnosis should be a benign condition.  If the physical examination findings point to a malignant condition, the clinical diagnosis should be a malignant condition.  If there are equivocal findings on physical examination, then use the prevalence or incidence data (high incidence of breast cancer at this age group of 80) to suspect a malignant condition.
  2. There is a common tendency for physicians (particularly non-breast specialists) and patients to order for diagnostic tests like ultrasound of the breast and mammography before physical examination.  In this particular patient, I asked the patient to see me first without going through diagnostic tests. With my physical examination findings, I was already quite certain of my clinical diagnosis that I did not need to have an ultrasound and mammography anymore.  Here, I saved the patient from having unnecessary tests.  I saved the patients from the inconvenience, pain and expenses of unnecessary tests.  My advice: do clinical examination (inclusive of physical examination) first. After the clinical diagnosis, decide whether a diagnostic test is needed or not.  As a rule, if one is not certain of the clinical diagnosis, one goes for a diagnostic test.  If one is already certain of the clinical diagnosis, one does not need a diagnostic test anymore.
  3. Not all breast masses in an elderly patient are breast cancers. They can still be benign breast conditions.  In this case, it turned out to be a macrocyst, a condition associated with fibrocystic changes of the breasts.  Macrocysts are probably the most common benign breast conditions in elderly patients  In this age group, fibroadenoma is rare.  Fibroadenoma is the most common benign breast condition in younger patients, say less than 25 years old.

ROJ@17jul25

 

 

Posted in Breast Mass, ROJoson's MARs | Leave a comment

Breast Cancer Survivor Helen Sison – 10 Years in Remission

IMG_5197
ROJ@17jul16
Posted in Breast Cancer Survivors, Cancer Survivors | Leave a comment

Finding the lowest prices on drugs

In the Philippines and in the USA and most probably, in other countries as well, there are websites that promote “finding the lowest prices on drugs.”

See samples below.

Philippines

doh price watch

USA

lowest_prices

People are concerned with high prices of drugs in some drugstores.  They look for drugstores which offer lowest or lower prices.

Related to the search for drugstores which offer lowest or lower prices, people look for drugs which contain the same active ingredients with the lowest or lower prices.

Generic drugs is a case in point.  Generic drugs contain the same active ingredients as the branded medicines and they carry lower prices.

Another situation – generic drugs with the same active ingredients can also differ in prices.  Case in point: Tamoxifen as active ingredient.  Sunfen costs P17.00 per tab. Entax-20 costs P19.50 per tab.  Xifen costs P24.50 per tab.  Gyraxen costs P28.25 per tab.   Fenalex costs P32.00 per tab.  Novaldex (the innovator drug) cost P32.25 per tab.  (Mercury prices as of July 9, 2017 – supplied by a patient using tamoxifen).

Here are some tips from DOH Drug Price Watch:

5 Tips to get the best value for your money

1. Avail your medicines only from FDA-licensed pharmacies. Check for the License to Operate (LTO) issued by the FDA. This should be posted conspicuously in the pharmacy to be readily seen by consumers. Apart from big chain pharmacies, there are also Public Hospital Pharmacies and other independent drugstores which may offer cheaper generics alternatives. It pays to compare prices across drugstores near you.

2. Discuss your treatment options with your doctor. Doctors sometimes prescribe medicines without regard to a patient’s ability to pay. It is important to discuss with your doctor how much is your budget for your medications especially those that you should take for an extended period of time. Do not hesitate to ask if the medicine has a generic counterpart. Wise use of money will help in the completion of your treatment regimen.

3. Always ask for generics. Generic medicines should contain the same active ingredients as that of branded medicines. FDA already looks at the quality of medicines before they are approved to be marketed in the country. Thus generics should have the same quality as the branded ones. Choosing generic medicines can save you as much as 90% off the brand-name price tag.

4. Follow the treatment regimen given by your doctor. Take your medication as instructed by the health provider. In cases of missed dose, take the medicine as soon as you remember it. Not completing your drug regimen decreases the efficacy of treatment, worsens your illness and leads to waste of money.

5. Report any problems with your medicine to the FDA. For any unusual reaction experienced after taking your medicine, call the doctor immediately and notify the FDA through its hotline number: (02)8078275. Make sure to keep a sample of the medicine for evaluation by the FDA.

http://www.dpw.doh.gov.ph/home.html

ROJ@17jul10

Posted in Price Relative Info Collaborative Effort | Leave a comment