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DMD Nephrology Case 1 – Acute Renal Failure
You are requested to see an 80-year-old man on the surgical service because of an elevated BUN and creatinine. He had just undergone a splenectomy for thrombocytopenia secondary to splenomegaly from underlying chronic lymphocytic leukemia. Immediately before surgery his BUN was 22 mg/dl, creatinine was 1.3 mg/dl, urinalysis was normal. When checked two days post operatively, his BUN had increased to 40mg/dl, and creatinine was 3/0 mg/dl. Urine output for each of the last two days was approximately 250 ml/day.
The patient denies symptoms of congestive heart failure. He has not been extremely thirsty over the last several days. He has had difficulty urinating over the past several years with a weak urinary stream and nocturia 3-4 times per night. His doctor told him that he had BPH but no therapy was given. The patient denies leg pain or flank pain. The hospital chart is reviewed which showed the patient had significant bleeding in the operative period with several episodes of hypotension with systolic blood pressure in the 80 range. These episodes lasted for short periods of time less than 5 minutes and returned to normal blood pressure after that period. His urine output was 700 ml/day immediately after surgery and dropped to 200-300 ml/day over the past two days. For the three days after surgery his total fluid balance is positive 3 liters. His only medication postoperatively was analgesia with Dilaudid. He did receive one dose of Cephalothin preoperatively and none since that time.
The patient’s physical exam showed his T-37 C, RR-14, BP-130/90, P-82 with no orthostatic changes. His mucous membranes were moist. Neck pains were 1cm above the sternal angle. The patient’s lung exam was clear to auscultation and percussion without rales. Cardiac exam has a normal S1, S2 without S3 or murmurs appreciated. The patient’s abdomen was soft with slight tenderness over the surgical scar. No ecchymosis were noted. The patient had no CVA tenderness or ecchymosis present in the back. A foley catheter was placed in the patient at that time which showed approximately 50 cc of urine in the patient’s bladder.
A fresh specimen of the patient’s urine is examined under the microscope and showed numerous epithelial cells and brown degenerating cellular casts. No crystals or WBC’s were noted, and only rare RBC’s were present. The urine sodium was 40 meq/l. Urine specific gravity was 1.01. Repeat BUN and creatinine on the 4th day after surgery are BUN-52 mg/dl, creatinine-3.5mg/dl. Uric acid was 9.2 mg/dl. A renal ultrasound is done, kidneys are normal in size, and no signs of obstruction are present.
On day 6 after surgery, the patient’s BUN is 68 mg/dl, creatinine is 4.1 mg/d. His urinary volumes are between 300-500 ml/day. Serum electrolytes are NA – 142 mg/dl, K-4.2 mg/dl, Cl-98 mg/dl, HCO3-23 mg/dl. The patient is started on fluid and salt restriction but he remains oliguric. By day 8 the patient’s BUN is 85 mg/dl, creatinine is 6.3 mg/dl.
On day 9, postoperatively the patient’s urine output begins to rise to one liter per day, and by day 11 it is up to 3 ½ liters per day. The patient’s BUN is up to 92 mg/dl, creatinine is 6.9 mg/dl on day 11.
On day 12 the patient’s urine output begins to decrease to 1/5 liters per day. His BUN and creatinine begin to fall. Fluid and salt restrictions are discontinued. The patient is discharged from the hospital on day 14 and followed up as an outpatient. His BUN and creatinine returned to normal three weeks after surgery.
West Hills, Calabasas, Woodland Hils.
This calculator will give you your risk percentage of having a heart attack over the next 10 years
To evaluate your risk of cancer please click here.
o Total Cholesterol:
o HDL Cholesterol:
What can I do to increase my HDL cholesterol?
One of the best ways proven to increase your HDL or “good” cholesterol is exercise! Regular walking, jogging, or activity each day has been shown to increase HDL cholesterol.
o How exactly does high blood pressure affect my chances of having a heart attack?
High blood pressure, over time, also puts a strain on the heart and makes it work harder to pump blood out to the body. With this extra effort to pump, the heart grows in size and may compromise its ability to pump blood as well.
|Desirable Below||Below 200|
|High||240 or above|
|LDL (bad) cholesterol|
|Very High||190 or above|
|HDL (good) cholesterol|
|High||60 or above|
|Very high||500 or above|
Up to 35% of cases of cancer have a dietary component, with some cancers being tied directly to diet. Research shows patients who follow a plant based diet that is low in fat and high in antioxidants and nutrients is associated with a lower risk of developing cancers such as colon, breast, pancreatic, and prostate cancer.
Two of the biggest things you can do to lower your risk of both cancer and heart disease is to eat a healthy diet and exercise daily.
Electrophysiology Study and Radiofrequency Ablation
What is an Electrophysiology Study with Radiofrequency Ablation?
An electrophysiology study is a procedure used to evaluate abnormal heartbeats. During the procedure Dr. Ben-Zur uses a special type of cardiac catheter to inspect the electrical activity of the heart and assess heart rhythm, rate and type of heart beat. Radiofrequency ablation is performed for many different types of heart arrhythmias such as atrioventricular reentrant tachycardia (AVRT) or AV nodal reentrant tachycardia (AVNRT), atrial flutter, atrial fibrillation, and Wolff-Parkinson-White syndrome. The radiofrequency ablation procedure blocks the electrical signals traveling through your heart to stop the abnormal rhythm and allow signals to travel over a normal pathway instead.
When does a patient need this procedure?
Electrophysiology study and radiofrequency ablation will be considered if you have a persistent symptomatic arrhythmia that is refractory to medications and direct current cardioversion.
Dr. Ben-Zur will determine the need for this procedure based on your symptoms, results of diagnostics and current medical condition.
How are electrophysiology study and radiofrequency ablation procedures done?1
Before your procedure begins a specialist will insert an intravenous line into your forearm or hand, and you will be given a sedative to help you relax. After your sedative takes effect, Dr. Ben-Zur will numb a small area near a vein on your groin. A needle will be inserted into the vein with a tube (sheath) placed through the needle. Catheters will be threaded through the sheath and to the heart. Dye may be injected through the catheter to visualize blood vessels and heart via x-ray imaging. The catheters have electrodes at the tips that will be used during the procedure. Once in place, the electrodes will send electrical impulses to your heart and record your heart’s electrical activity. This will help detect the abnormal heart tissue that is causing the arrhythmia in your heart. Once the abnormal heart tissue causing the arrhythmia is identified, heat energy is applied at the catheter tip that alters the tissue triggering your arrhythmia.
Cardiac ablation usually takes 2-4 hours to complete, but complicated procedures may take longer. During the procedure, it’s possible you’ll feel some minor discomfort when energy is run through the catheter tips. If you experience any type of severe pain or shortness of breath, you should alert the medical team.
What to expect before the procedure:
Before the procedure you will have a pre-procedure appointment. This will include obtaining labs and any necessary imaging as well as any medication adjustments that need to be made for the procedure. This is an additional opportunity to ask any questions that you may have.
How long will the procedures take?
An electrophysiology study and ablation usually take 2-4 hours.
On the day of the procedure:
What are possible complications?
With any procedure there is always a risk of complications. Electrophysiology studies and radiofrequency ablations are common medical procedures. Serious complications are uncommon but may occur. If Dr. Ben-Zur determines that you are a candidate for electrophysiology study and radiofrequency ablation, he will have a long discussion with you regarding the risks, benefits, and alternatives of the procedure, including but not limited to: infection, bleeding, heart attack, stroke, death, neurologic deficit, nerve injury, lymphatic injury, venous thrombosis, pericardial effusion (blood around the heart), pleural effusion (blood around the lungs), pulmonary embolism, hematoma, pain, need for an emergent operation such as emergency coronary artery bypass grafting, possible blood transfusion and its complications, complications associated with anesthesia, drug allergies, vascular perforation, dissection, rupture, thrombosis, distal embolization, arrhythmia (irregular heartbeat) that may require a pacemaker to correct, renal insufficiency/failure, dialysis dependence, limb loss, dye allergy, discomfort and bleeding at the catheter insertion site, and radiation exposure. Your risk of having these complications may increase if you have diabetes or kidney disease.
Wound site care:
Need more information?
We encourage you to ask Dr. Ben-Zur any questions and discuss concerns you have at anytime. Visit our website at www.DrBenZur.com, give us a call at (818) 986-0911, or email us at email@example.com. You may also call Dr. Ben-Zur after hours if you have any additional questions that you did not have a chance to ask during your visit.
How do I get full on vegetables? Vegetables don’t fill me up and I’m still hungry.
This is one of the most common things we hear when suggesting that people switch to a diet consisting of mainly or all vegetables.
Here are a few simple things to add to this diet to ensure you get full. These veggies are high in protein:
These simple vegetable additions to your diet can help fill you up! So sit back and treat yourself to a mouthful of yummy veggies!
According to the third universal definition (released in 2012 by theESC/ACCF/AHA/WHF), any one of the following criteria meets the diagnosis of MI:
AND at least one of the following:
iii. the duration of coronary occlusion
Vi. endogenous factors that can produce early spontaneous lysis of the occlusive thrombus
vii. the adequacy of myocardial perfusion in the infarct zone when flow is restored in the occluded epicardial coronary artery.
iii. Imaging: Abnormalities of wall motion on two-dimensional echocardiography are almost universally present. Although acute STEMI cannot be distinguished from an old myocardial scar or from acute severe ischemia by echocardiography, the ease and safety of the procedure make its use appealing as a screening tool in the Emergency Department setting. When the ECG is not diagnostic of STEMI, early detection of the presence or absence of wall motion abnormalities by echocardiography can aid in management decisions, such as whether the patient should receive reperfusion therapy
INITIAL THERAPY — The patient with acute ST elevation myocardial infarction (STEMI) should have continuous cardiac monitoring, oxygen, and intravenous access. Therapy should be started to relieve ischemic pain, stabilize hemodynamic status, and reduce ischemia while the patient is being assessed as a candidate for fibrinolysis or primary percutaneous coronary intervention (PCI), with a goal of initiating PCI within 120 min of first medical contact.. Other routine hospital measures include anxiolytics, serial electrocardiograms, and blood pressure monitoring.
STEMI EKG Changes:
The ECG is a cornerstone in the diagnosis of acute and chronic ischemic heart disease. The findings depend on several key factors: the nature of the process (reversible [i.e., ischemia] versus irreversible [i.e., infarction]), the duration (acute versus chronic), the extent (transmural versus subendocardial), and localization (anterior versus inferoposterior), as well as the presence of other underlying abnormalities (ventricular hypertrophy, conduction defects).
Acute ischemia causes a current of injury. With predominant subendocardial ischemia (A), the resultant ST vector will be directed toward the inner layer of the affected ventricle and the ventricular cavity. Overlying leads therefore will record ST depression. With ischemia involving the outer ventricular layer (B) (transmural or epicardial injury), the ST vector will be directed outward. Overlying leads will record ST elevation.
ST-elevation MI evolution — The classic (but not invariable) sequence of ECG changes in patients with STEMI is as follows:
ST-segment elevation, associated with epicardial coronary vasospasm or actual occlusion, is a relatively specific sign of acute transmural ischemia. ST-T wave abnormalities that are suggestive of acute myocardial ischemia in the earliest phase of ST elevation MI are usually localized to those leads that reflect the involved regions of the myocardium:
CONGENITAL HEART DISEASE
Hold on to your Heart: A cautionary tale
As an advocate for lifestyle optimization, I have seen that for many patients, changes are often not made until the heart disease has progressed to a life-threatening level. My hope is that through sharing my these patients’ stories, that others may learn and avoid the need to put their own lives on the line to take the message to heart. It is my great privilege and joy in life to be practice medicine and bring health to my patients. Yet through my years of training and experience, I have come to realize the limitations of our medical tool box. I have come to see time and time again, that the lasting life changing improvements I’ve helped to bring to patients lives’ were achieved through diet and exercise.
Case#1 -Hold onto your heart
I was a person who considered french fries my daily vegetable intake. I figured if it can’t run or fly and be doused with BBQ sauce, it wasn’t worth eating. My exercise consisted of picking up the remote control from the counter and sitting back down on the couch to watch TV. I was used to my high intake, low output lifestyle, but he was ignoring the signs of my heart. After years of doctors visits and medications, my His heart had given up trying to tell Bob that it wanted to be fed with fresh nutrients, free of fats, that it wanted to pump to make Billy move and enjoy life. Through this neglect, the processes of hypertension and atherosclerosis quickly took hold and soon, Billy’s heart was nothing more than a lump in his chest taking up space.
By the the time Bob finally started listening to the pain his dying heart was sending him, and came to see me, there was little we could do. Bob came to me morbidly obese, his heart was so diseased that the only possible solution would be to take out his heart and replace it with a new one. A dangerous procedure with long-term complications. However, it was the only way to save Bob’s life. Yet there was one problem. Bob had become so obese, that the surgeons could not operate on him unless he could lose some weight.
This is the point my counseling with Bob began to transform his life. He realized he had passed a point of no return and he could choose to allow life to keep happening to him as he always had, or he could take a stand to make some positive changes in his lifestyle. With my guidance, Bob took responsibility for himself and started to cultivate a new outlook and self discipline. By adopting a vegan diet and starting to get real forms of exercise, Bob was able to lose the 40lbs he needed to undergo his surgery.
Bob waited until the last possible moment after years of ignoring the information and warning signs around him, such as his shortness of breath with activity and lying down at night, the occasional chest pains, and the increased swelling in his legs. He was able to prolong his life from the age of 50, but not without first losing his own heart. The effect of diet and exercise is never too late to change a life, but had it been incorporated by Bob just a few years earlier, he may have avoided the risky and complicated procedure all together.
I share this information not to blame Bob for what he went through, but to applaud him for having the courage to make lifestyle changes before it was too late; and with the hope that others may listen to their hearts and give their bodies the nutrition and activity it needs long before their body’s most important muscle dies of neglect. Celebrate your body by choosing to eat an informed balanced diet high in vegetables, fruits and plant-based protein. Express your bodies innate abilities to move through exercise that makes you feel good. You will find that you will be more in tune with your heart and that your life will be infused with new vitality and passion. You will find that by nurturing a rejuvenated body, you will be able to avoid putting in someone else’s old heart.