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Monthly Archives: January 2016

 

Dr. Ben-Zur is a cardiologist serving the Thousand Oaks region. He is an elite cardiologist. At the cardiovascular institute we can perform ECCOs on site as well as EKG.

Section 1 Acute Renal Injury in setting of surgery and post surgery patient.

Causes of Increased BUN: GI bleeds hypercatabolic state i.e. in the setting of malignancy, TPN, burn victims, patients on steroids

Systematic approach:

1)pre-renal

-Hypovolemia: n/v, hemorrhage, burn victims, hypotension may present as SBP of 120 in setting of pre-existing HTN resulting in decreased renal perfusion

2)renal

-rhabdomyolysis d/t anesthetics or malpositioning during surgery

-MCC AKI = ATN: supportive care with slow recovery phase, tubules regenerate prognosis depends on pre-existing kidney disease in the setting of CKD may lead to dialysis dependence

-MCC AIN= medications i.e. NSAIDs, beta-lactam antibiotics; type IV hypersensitivity rxn, present with macular rash, peripheral eosinophilia, urine eosinophils, early recognition important because removal of drug is treatment and delay may lead to permanent injury with tubular atrophy; urine eosinophils may also be seen with prostatitis, cholesterol emboli

-Pyuria with negative urine culture: TIN d/t autoimmune dz (sarcoidosis, SLE), renal tuberculosis order urine AFB, cholesterol emboli

-cholesterol emboli: occurs 1-3 weeks following procedure look for livedo reticularis, emboli phenomenom in digits

-contrast nephropathy occurs hours to days with rapid rise in serum creatinine

Diabetes insipidius side effect, Li has narrow therapeutic window, watch out for toxicity.

-Li toxicity: concentration defects such as nephrogenic DI (patient develops polydipsia)

-types of casts: granular (ATN), RBC/acanthoycytes (GN), WBC casts (AIN, pyelo), fatty (high protein nephrotic syndrome, maltese cross), crystals (acyclovir, uric acid)

-oxalate stones seen in RXY gastric bypass surgery, IBD, short gut syndrome, primary hyperparathyroidism (poss d/t malignancy may need CT with IV contrast)

3)post-renal: BPH, neurogenic bladder, order PVR generally greater than 150 consistent with post-renal aetiology of AKI

Case 2-Nephrotic Syndrome

A 40yo male has come to your office with complaint of swelling of his body over the past several months. He states that approximately 3 months prior to admission he had fallen off his bicycle and bruised his right leg. He noted swelling in the leg at that time and soon thereafter noted both his legs had become swollen. over the past several months he noticed this swelling had increased over his entire body. He reports a 20lb weight gain over that period of time.

 

Discussion Points:

What are the possible etiologies of this patient’s leg swelling? Edema can occur from multiple sources of organ dysfunction; namely, Liver, heart and kidney. Signs of liver cirrhosis include edema, telangiectasias, asterixis, hematemesis, right upper quadrant pain, and caput medusae. Renal pathology can present with edema, flank pain or tenderness, oliguria and abnormal Urinalysis. Cardiac failure can produce edema as well as elevated JVP and shortness of breath.

He has no history of heart disease and denies PND, DOE, or orthopnea, He has no history of liver disease and denies a history of IV drug use. He was never told of any problems with his kidney as an adult or a child. His urinary frequency is unchanged over the past two months.

Discussion points: This history allows us to rule out certain etiologies as to the edema. Cardiac origin is less likely due to no history of heart disease, no orthopnea, and no history of IV drug use which is a risk factor to endocarditis. Liver disease is unlikely also because of lack of IV drug use (viral hepatitis). He also does not present with any other symptoms that would point towards liver failure. At this point it is appropriate to look for signs for renal injury which include swollen eyelids.

 

On physical exam, he appears grossly edematous and puffy. His BMP is 145/98, P-92, RR-16, T-98.6. The patient’s skin shows no signs of jaundice or telangiectasias. He has no signs of palmar erythema. His face shows swollen eyelids but sclera are not icteric. Examination of the neck shows no signs of jugular venous distention and no thyromegaly. His lung exams are clear to auscultation and percussion with the exception of decreased breath sounds and dullness to percussion in the bases. Cardiac exam revealed a non-displaced PMI. Normal S1 and S2 without murmurs, rubs, S3 or S4. Abdominal exams showed the liver to be approximately 9cm in size. No splenomegaly was appreciated. There were findings of shifting dullness to percussion of the abdomen. In the periphery the patient had 4+ pitting edema to the level of the sacrum and throughout both legs. The patient had no signs of gynecomastia, testicular atrophy or parotid swelling. the patient’s neurological exam was normal.

Discussion points:  The pack of jaundice, telangiectasias and palmar erythema further make liver disease less likely. splenomegaly would point toward liver cirrhosis which in this case there is no splenomegaly. His eyelid edema is more indicative of renal dysfunction. Physical exam is also negative for CHF. To pursue a case of renal injury, the next best labs to obtain would be a UA, 24hr urine sample and CMP.

A urinalysis revealed 4+ proteinuria with a microscopic exam that revealed several waxy casts, oval fat vodie, no cellular casts, 1 PRC and 1WBC per high-powered field. Electrolytes included a BUN of 20, a creatinine of 1.3, other electrolytes, glucose, calcium and phosphorus were normal. A 24hr urine collection showed 12 grams of protein and creatinine clearance of 72ml/min. LFTs were no0rmal, as was prothrombin time. The patient’s albumin was 1.9, and serum cholesterol was 670. Chest x-rays revealed bilateral pleural effusions without signs of pulmonary venous engorgement or abnormalities in the cardiac silhouette.

Discussion point: The UA shows proteinuria with waxy casts. Protein in the urine is indicative of nephrotic syndrome. Twenty-four hour urine collection is a quick, simple diagnostic test that helps to diagnose problems with the kidneys. It is commonly performed to determine how much creatinine clears through the kidneys, but may also be used to measure protein, hormones, minerals, and other chemical compounds. Creatinine clearance testing provides information about kidney function. A measure greater than 3g correlates with nephrotic syndrome. With nephrotic syndrome as the diagnosis, we consider further laboratory testing.

Laboratory tests were sent for antinuclear antibodies, serum complement, and fasting blood sugar which all were normal. A VDRL and Hepatitis B and C serologies were also negative.

Discussion point:

There are several conditions to consider in nephrotic syndrome:

MCD (Minimal change disease) – More common in children. good prognosis and responds well to steroid therapy.

FSGN (Focal Segmental Glomerulosclerosis) – Most common in adults. prognosis is not as good as MCD.

MGN (Membranous glomerulonephritis) – autoimmune response results in inflammation and “leaky kidneys.”

RPGN (Rapidly progressive glomerulonephritis) – characterized by a rapid decrease in rate and a crescent moon shape appearance on microscopy.

 

Other kidney disorders/pathologies include the ANCA disorders:

Goodpasture syndrome – antibodies against the basement membrane in the glomerulous and in the lungs resulting in renal injury and lung disease.

Churg-strauss aka eosinophilic granulomatosis with polyangiitis – also autoimmune but presents with elevated eosinophils and patients often present with allergic rhinitis or asthma.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener’s granulomatosis – also autoimmune attack of the small and medium vessels leading to kidney injury. It is associated with concurrent sinusitis.

The patient is informed of his diagnosis of nephrotic syndrome and the potential benefits and risk of a kidney biopsy in looking for the ideology of this problem. He consented and the procedure is done without complications. The results of the biopsy showed evidence of membranous Glomerulonephritis.

Discussion points:

It is important to weigh the risks and benefits of biopsy. Contraindications to biopsy include bleeding or coagulopathy disorders, stents, and other comorbidities that make biopsy a high risk procedure.
The patient is informed of his prognosis and the diagnosis of membranous GN. He is started on a course of corticosteroid therapy in conjunction with cyclophosphamide. He will be followed up closely for side effects of the medication as well as the effect on the patient’s renal function as well as level or proteinuria.

 

Dr. Ben-Zur is a cardiologist who sees patients from Burbank, Encino, Sun Valley, Beverly Hills, Brentwood, Marina del Rey, Inglewood, El Segundo, Manhattan Beach, Redondo Beach, Torrance, Hollywood, Bel Air, Malibu, Calabasas, Saratoga Hills, Agoura hills, Thousand Oaks, Sherman Oaks, Studio City, Simi Valley, West Hills, Reseda, and Oak Park. He sees patients with all types of heart disease, including atrial fibrillation, a-fib, AF, sick sinus syndrome, av block, heart block, arrythmias, ischemia, congestive heart failure. He places pacemakers, defibrillators, implantable cardiac defibrillators. Bi-ventricular pacing.

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Dearest Patient,

In an effort to ensure comprehensive, secure and progressive patient care, new government guidelines now mandate that patient-doctor/medical office interaction be done through a secure Patient Portal. We urge you to use our Patient Portal to communicate with us. The Patient Portal is simple to use.

Please log on at least once so that you can become familiar with the system. We anticipate that in the near future all patient correspondence will have to be done through the Patient Portal. These activities include, requesting prescription refills, viewing labs, and communicating with our office via the Patient Portal email. You will no longer need to call the office for medication refills.

Untitled-2 Instructions for logging in:

  1. go to: drbenzur.com and
  2. Click Patient Portal link, located in the ‘Quick Links’ box on the right side of page.
  3. Log in using your username and password.

For assistance in setting up your account, please email [email protected]

Note: For any urgent or emergent matters, please call 911 and notify us at tel:1.818.986.0911.

Thank you very much!

Uri Ben-Zur M.D., F.A.C.C.
Assistant Clinical Professor, U.C.L.A. David Geffen School of Medicine.
Assistant Clinical Professor, Western University College of Osteopathic Medicine.
Assistant Professor, Touro University College Of Osteopathic Medicine.

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Benzee Benzee the Heart says:

“Maintaining a healthy weight through diet and exercise may avoid the complications of heart disease.”

Benzee Please take a look at our book online From Our Heart To Yours, a guide for better heart health using diet and exercise.

Congestive Heart Failure


Congestive heart failure or “heart failure” is a term that is often perceived as a condition in which the heart suddenly stops. Instead, it is a common heart condition in which the heart cannot pump enough blood to the body’s other organs.

HOW DOES CONGESTIVE HEART FAILURE OCCUR?

The heart is a pump with four chambers. Blood enters on one side and exits on the other. This pumping action maintains the circulation of blood throughout our bodies. When the heart is unable to expel sufficient blood to meet the body’s needs, the blood backs up and congestive heart failure (CHF) occurs. This results in a diminished blood flow to all the body’s tissues. Although heart failure can be acute, it most often develops slowly, with symptoms manifesting gradually.

WHAT ARE THE WARNING SIGNS?

The most important warning sign of CHF is edema — the retention of large amounts of fluid in the body. When the heart fails to do its pumping job correctly, blood is not properly circulated back through the veins. Fluids also accumulate in the body tissues because of poor blood circulation. This is the “congestion” aspect of CHF. This extra fluid collects all over the body, causing puffiness of the extremities. Most noticeable swelling is in the legs after standing. However, if swelling only occurs in the ankles this may be an indication of some other, less serious condition.

When a person with CHF lies down, fluid settles in the chest area, most noticeably in the lungs. There is difficulty in breathing that may sound like “rattling,” especially during physical exertion. Coughing, shortness of breath, or a feeling of heaviness in the chest is also common. Because the circulatory system is not doing its job properly, patients with CHF feel tired and weak.

HOW IS CONGESTIVE HEART FAILURE TREATED?

Treatment of CHF involves four important goals:

  1. Easing the strain on the heart.
  2. Improving the pumping action of the heart muscle.
  3. Controlling salt and water balance in the body.
  4. Identifying and treating the cause of the CHF.

Bed rest may be an important first aspect of treatment to reduce the heart’s workload. Other treatment options include medications, such as ACE-inhibitors, and monitoring weight on a daily basis to ensure that excess fluid is not retained. Obese patients are encouraged to lose weight to eases strain on the heart. Once CHF is under control, the patient usually can return to normal activity, unless there are other complicating factors. Medications are available to improve and strengthen the heart muscle and make its contractions more powerful. Digitalis is the most common. This increases the cardiac output and slows the heart rate. Water and salt balance are controlled by changing the patient’s diet and using diuretic medications. These help the kidneys excrete excess salt and water.

Finally, it is also important to identify the underlying caused of CHF. There are many other diseases that can weaken the heart’s pumping ability. Most common are arteriosclerosis — “hardening” of the blood vessels, which may deprive the heart muscle of oxygen — and high blood pressure. Other causes include abnormality of the heart valves, infection or congenital malformation of the heart. In many cases, treatment of the underlying cause can provide excellent relief from CHF.


The Cardiovascular Institute, founded by Uri M. Ben-Zur, M.D., F.A.C.C, is located in the heart of San Fernando Valley in Tarzana, California. In close proximity to, Encino, Sherman Oaks, Burbank, Calabasas and West Hills. Our practice is open to patients and future medical professionals Sunday through Friday starting at 6AMdaily. We are committed to enhancing the quality of healthcare for all of the residents of the Greater Los Angeles area. Dr. Ben-Zur is an attending physician at Providence Tarzana Medical Center. He offers a wide variety of cardiac services. Radiofrequency ablations for cardiac arrhythmias, pacemaker implantation, coronary stent placement and angioplasty are some of the many procedures we specialize in. As an expert onhypertension, hyperlipidemia, congestive heart failure, and arrhythmias, Dr. Ben-Zur is able to diagnose and treat patients in our new state of the art facility. Almost 60 million Americans suffer from hypertension and cardiovascular related diseases. Due to the nature of these diseases, most patients go undiagnosed until it is too late. Diagnosing these diseases early in life can dramatically decrease the risk for future complications. We are always welcoming new patients for heart related screening and have same day appointments available. Additionally, at the Cardiovascular Institute of Tarzana, California, Dr. Ben-Zur’s staff serves patients in multiple languages! Whether it be Hebrew, Russian, Spanish, Swahili, Armenian, Tagalog, Hindi, Urdu, and many more the Cardiovascular Institute will often have someone to serve your language and heart health needs.
Our practice is fortified by his acceptance of medical professionals and ultrasound technicians from various organizations including Western University College of Osteopathic Medicine, Touro College of Osteopathic Medicine, and UCLA David Geffen School of Medicine and the University of Southern California. The Institute fosters an ideal environment for future physicians and local technicians to help the unique population of the Greater Los Angeles area. Including, Tazana, Encino, Burbank, Sherman OaksWest Hills, and Calabasas.
Dr. Ben-Zur’s past medical education in electrophysiology and angioplasty is unparalleled. Guided by pioneers in both fields early in his career, he has had the opportunity to gain experience in major academic centers in New York City and San Diego, California. Many of his research projects are featured in various medical journals such as The New England Journal of Medicine and The Journal of the American College of Cardiology. Furthermore, Dr. Ben-Zur has multiple publications for his patients to learn more about their health and how they can prevent diseases by improving their lifestyle through diet and exercise. Our newest publication can be found on our website under patient resources!
This holiday season,be mindful of your health. Stress and overindulgence may put your body at risk for serious cardiac problems. A study by the Heart Institute states there are 33% more cardiovascular events from ischemic heart disease in December and January than the rest of the year in Los Angeles County. We advocate for our patients to familiarize themselves with the signs of acute coronary syndrome. The quicker symptoms are recognized, the better the outcomes. We encourage you to explore our website for more information about our practice!

2016 is upon us. Every year we all make new resolutions to better ourselves in this brand new year. Some people managed to keep their resolution, but most give up on theirs. University of Scranton  states in 2015, 40% of all American make New Years resolution , but only 8% of people adhere to their new year resolutions.
There are approximately 35,000 people residing in the city of Tarzana. This means out of the 14,000 people that make resolutions, only 1120 actually keep their resolution. We at the Cardiovascular Institute encourage everyone to make new resolutions about health and to adhere to them. Lets talk about some changes we can make to make sure you are in the 8%.

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  1. Better Diet: 
    Everyone is trying to eat healthy. But the first step to doing so is to get knowledge about what is healthy. 
  2. Better Exercise:
    The best way to start exercising, is to actually start. Procrastination is your worst enemy. Although gym membership are great, you can get great exercise at home. We encourage at least 30 minutes to an hour of exercise  a day. For recipes, exercises and overall healthy living tips, please refer to our book online, From Our Heart To Yours.

Now that you know what to do, how do you do it? We encourage writing down your plans for a healthier diet and exercise. Make realistic plans for each day and stick to your plans . According to University College of London. It takes 66 days to form a habit. The American Psychological Association recommend these guidelines to adhere to your resolutions for those 66 days:

1) Start small 
Make resolutions that you can keep. If you want to exercise more frequently, schedule three or four days a week at the gym instead of everyday. If you would like to eat healthier, try replacing dessert with something else you enjoy, like fruit or yogurt, instead of seeing your diet as a form of punishment.
2) Change one behavior at a time 
Unhealthy behaviors develop over the course of time. Thus, replacing unhealthy behaviors with healthy ones requires time. Don’t get overwhelmed and think that you have to reassess everything in your life. Instead, work toward changing one thing at a time.
3) Talk about it 
Share your experiences with those close to you. Consider joining a support group to reach your goals, such as a workout class at your gym or a group of coworkers quitting smoking. Having someone to share your struggles and successes with makes your journey to a healthier lifestyle that much easier & less intimidating.
4) Don’t beat yourself up 
Perfection is unattainable. Remember that minor missteps when reaching your goals are completely normal. Don’t give up completely because you ate a brownie and broke your diet, or skipped the gym for a week because you were busy. Everyone has ups and downs, you just have to resolve to recover from your mistakes and get back on track.
5) Ask for support
Accepting help from those who care about you and will listen strengthens your resilience and ability to manage stress caused by your resolution.


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