Community Acquired Pneumonia or Tuberculosis?

A 61 year old man had been on my follow-up for hypertension for about a year till I discovered that he had a refractory anaemia and referred him to a Haematologist months ago. Last week he came complaining of coughs of more than one month's duration and accompanied by thick phlegm.

He told me that the haematology clinic at the general hospital had treated him for an upper respiratory tract infection a week earlier but the coughs still persisted. He decided to see me,  and suspecting a lung infection. I ordered a chest X-ray for him. The film did not give a typical TB picture, instead it looked to me like a simple pneumonia though he had no fever. In fact he had no other signs and symptoms of TB. I ordered for sputum AFB (TB germs) as well just to complete the pulmonary TB screening. Then I referred him to a respiratory clinic at the general hospital after giving him a course of broad-spectrum antibiotic.

This afternoon, my nurse came rushing in telling me that the patient's sputum was positive for TB germs... gosh oh my ! Three TB cases in the space of 10 days... I am floored. So today I got myself a room air micro-filter to reduce those airborne germs brought by such patients. We can never take things for granted as we, health workers are routinely exposed to  infection risks.

                                                      Top of  the Room Air Micro-Filter
 

Front of the Room Air Micro-filter

Then an 83-year old man with hypertension and a smoker came in late afternoon for review and complaining of yet another bout of unremitting coughs and owing to the bad experience of the last 10 days, I automatically ordered for his chest x-ray and it did look suspicious to me.... I have to wait for his sputum tests and am keeping my fingers crossed as this patient has been coming to my clinic regularly for the past two years and I have always been attributing his coughs to his chronic smoking!


Such is the occupational hazard faced by doctors, nurses and other health workers and yet many top students still aspire to become doctors... wait till they see the real things :)

SWKPLNT and KWANTAS - better quitting than waiting.

I am ashamed to divulge that I am still holding some dormant plantation stocks acquired way back in early 2008 well before the global financial meltdown in October of the same year. I bought them at ridiculously high price and as the stocks were then bullish, I decided to hold them longer. Then some Australian rating agency downgraded our plantation stocks and down they tumbled and have never really recovered since despite the good price palm oil is commanding now.

These "greenie" NGOs  are also persuading world MNCs not to buy palm oil produced by companies deemed to destroy "orang utan" habitat and forest as to contribute to climate change. So holding plantation stocks can be quite risky with these influential "green fanatics" around. Recently they are trying to persuade the people not to buy palm oil produced by trees planted in peat soil. Come to think of it many of the oil palm trees in Sarawak are planted in such soil. The more I want to quit the stock!

I am monitoring the stock prices and keeping an eye and an ear to all palm oil related news and development. The recent surge in price had encouraged me to sell off all my remaining MHC stocks and a third of my SWKPLNT holdings, both at a sizeable loss. I was averse at selling the KWANTAS shares as the price is now ridiculously low! I also sold off a quarter of my THPLNT shares which though low, the one to one bonus in early 2009 had made up for the loss. Thanks to THPLNT sensitive management! I am keeping UNICO though as it is always in investors' radar. I bought UNICO based on the rumour that it was going to be acquired by the giant IOI however the touted M&A never materialised . One consolation  is the fact  UNICO  gives good annual dividend though not as generous as THPLNT.

Now I am getting fed-up of waiting. After looking at the financial results of all the plantation stocks that I am holding, I have decided to quit SWKPLNT and the disappointing KWANTAS even at a big loss. Now why did I ever buy KWANTAS shares? Oh it is a long story and not worth relating. Fortunately, my quick portfolio restructuring  in early 2009 had, on paper, erased a great proportion of the loss. So I can now close my eye and say goodbye to these two stocks.

It is no longer a good strategy to buy and hold stocks like Warren Buffet used to do in this world which has multitude of interconnections. The business world has become globalized. No companies are spared from global economic effects as demonstrated by the US sub-prime crisis and subsequent financial upheaval in 2008. And recently the Euro zone debt woes has dragged down our technology stocks due to poor demand.

My main reason for finally quitting is because I need the fresh fund to acquire the MMHE IPO in October 2010. Wish me luck people.

Tuberculosis (TB) in Two Different Presentations

A 49-year old lady came in one day complaining of bleeding from her rectum for some weeks. In fact she had just been to see a government out-patient doctor who prescribed her with an anti-fibrolytic (tranxanemic acid)  two days earlier and correctly enough she told me that she did not have heavy menstrual bleeding so why  should she take that medication? ( she must have asked some people about the drug given to her).

She then related that she had been having haemorrhoid for more than two years and on an on and off treatment by various private doctors. I did inquire about any change of her bowel habit, whether there was a recent weight loss or had her appetite been poor and whether she had any fever. Also whether the stool was hard and the character of the blood whether frank or streaking or mixed with the stool. All the questions were carefully designed to rule out any chronic disease or malignancy. She answered all in the negative. Hmmm......

She was so fashionably dressed in her matching baju kurung (traditional dress) and tudung (a scarf) and appeared healthy and bubbly that I gathered that it must have been a simple haemorrhoid. I then prescribed her an anti-haemorrhoidal preparation plus stool softener and advised her to increase the fibre in her diet. I also told her to reduce the haemorrhoid should it come down after going to the toilet. I did a full blood count (FBC) and found her hemoglobin to be low (10.2 g/dL) and prescribed her iron tablets and other hematinics.

She came again two weeks later and according to the counter staff, she insisted upon seeing me. She waited for over an hour as I had patients on appointment basis. This time she related that blood virtually flowed from her rectum when she stood up from a sitting position. My!... what type of hemorrhoid was this? As I did not have a proctoscope to really look at the rectum satisfactorily, I decided to refer her to a general hospital surgeon.

Ten days  later she returned to my clinic with the report of the lower gut biopsy and the surgeon's proctoscopy report. The tissue showed changes consistent with tuberculosis infection! I nearly jumped out of my chair!  Immediately I ordered for her chest to be x-rayed and oh my God!, There it was.... full blown pulmonary TB with spread to the gut! Looking ominously infectious. We missed this diagnosis simply because she did not complain of any respiratory symptoms. Her sputum Acid Fast Bacilli (AFB)- TB germs was 3+ on the first sample! I was flabbergasted. After all my nurse and I had already stopped wearing our surgical masks since the H1N1 virus pandemic had been called off....and just how many people had she infected before being finally diagnosed!

Chest X-Ray of the patient presented with rectal bleeding. The consolidation is generalised especially on the right lung and both apical spaces, akin to milliary TB (photo taken by Sony DSC-TX7)

The unfortunate woman was duly put on an anti-TB treatment and all her contacts traced and tested.

A few days  after this worrisome episode, a young and petite 21 year old female college student came complaining of recurrent coughs and chest pain radiating to the back ( we were already wearing our mask this time). She had been to a district hospital several times and was repeatedly treated for respiratory tract infections with several courses of antibiotics. She came to the city, thinking that our clinic had better facilities for diagnosis because her condition had worsened.

She insisted that her cough had only been for one week this time! However, being over-cautious then,  I asked her whether any of her family member had had TB, she answered "yes" her maternal grandmother had TB.  Without wasting any more time I ordered for a chest X-ray  and sure enough, staring right in front of me was the beautiful "Ghon focus" a classic sign of TB infection of the lung. How could the district hospital staff  have missed it! Simple,  they did not have a high index of suspicion and that they did not ask the right questions. This patient could also have infected others especially those in close contact with her. They must be traced and screened.

Chest X-ray of the 21 year old patient. Note the Ghon focus (circular cavity) surrounded by consolidation, on the upper right lung. The left  lung is relatively clear.  (photo taken by Nokia E7

    

I did not diagnose any TB cases last year but here they were,  two in the space of one week! And in different guises as well... this is an occupational hazard which I must not take for granted.

I hope doctors are more aware of this infectious disease especially with the rise of HIV cases in the world. HIV-infected individuals are immuno-compromised and they are more susceptible to infection by TB germs. We need to detect them early to reduce transmission in the community.

Hypertension out of control - Look before you leap

One of my patient, 50-year old Mrs L has been hypertensive for several years. Owing to her intolerance to many anti-hypertensive drugs, she was finally put on an angiotensin receptor blocker  (ARB) which is quite an expensive drug. Her blood pressure seemed to have been controlled for a period when suddenly it was found to be elevated during the last two visits. Her present drug was at its maximum dose and I was thinking of adding another class of antihypertensive to the current regime to bring down her undesirable rise in blood pressure.

Having some time to spare, I decided to engage Mrs L in a conversation. I complimented her on her clear skin which previously was pitted by acne. Then I asked her whether she had been taking any other drugs beside her existing anti-hypertensive. She was at first rather hesitant and reluctant to disclose, then she blurted out that yes she had been on a four month course of antibiotic on an advice of a Dermatologist for her acne and that she had also seen a Gynecologist who prescribed her a combination of an androgen and an oestrogen ( Diane 35) to balance, according to him, her deranged hormonal state. She was supposed to take the drug for several months. No wonder the nice skin and the effervescent personality!

All those drugs were prescribed after her anti-hypertensive regime which had so beautifully controlled her hypertension and sadly, this was undertaken without my knowledge. I was disappointed of course, but did not really show it to her. I informed her that her blood pressure had risen and so as her pulse rate (tachycardia) during the last two visits to my clinic. The hormone medication could have caused the blood pressure to rise and that she should stop it. And next time please refrain from using other medications without my knowledge.

Drug-induced high blood pressure is not uncommon  among post-natal women on oral contraceptive pill (OCP) and if detected early, the blood pressure normalizes following cessation of the hormonal treatment.

She might not need an extra medication should her blood pressure revert to the earlier level on the present anti-hypertensive regimen after she has stopped the hormone therapy. High blood pressure is certainly not conducive to the health of the heart, the kidney and the brain as well as the eye. She has to choose between  a flawless face or well internal organs. She decided to choose the latter.

I am monitoring her blood pressure to see whether it comes down following the removal of the hormone. In the meantime,  I am not going to rush in by adding another anti-hypertensive drug as it may be unnecessary.

Bursa Malaysia in the Third Week of August 2010 - Correction say the Pundits and Bullish say Me

I am quite familiar with the volatility of the market by now having followed it up closely since early 2009. Everyone seems to look up to or wait for economic figures from the US for their next investing actions. Every time Wall st rises and DJI climbs up, you would know that Bursa Malaysia would usually follow suit. So those of you who want to "time " the market is well advised to be in touch with the US quartely economic data but do so at your own risk! Caveat emptor.

I read market news voraciously as I have been trying to observe the concordance that is whether what they predict would come true as shown by the market data. Last July, the FBM KLCI has been slowly rising from 1340 to 1360 and by first week of  August it was coming to 1380. Blue chips led gainers. I gleefully saw my counters AXIATA, TM and battered SIME  doing their things, that was climbing up. Except for MAXIS which was oscillating at 5.28 and 5.30.

I was mulling over selling off some of my TM shares  acquired at 2.62  after the capital repayment last year, 2009 when the pundits were predicting a market correction in the third week of August. With the recently released better than predicted Malaysian growth data at 8.9 by Bank Negara, I did not believe them. Surely I thought the bulls would come in droves to our market despite falling Wall St pattern in the same period. So I stuck to my shares with silent prayers and true enough, the bulls drove up the index to more than 1390 at the close of the market last week. My TM rose and rose!

The pundits were left bewildered.

I had wanted to buy MAXIS at 5.28 before last week and in fact queued for it but it went up to 5.30 and the next day it went down again to 5.28 and yet I did not give a fresh instruction to my broker to re queue. And MAXIS closed at 5.40 last week... you cannot win every time!

I should not stretch my luck too far though and wait for the index to reach 1400 as predicted earlier this year. Time to reduce or short some positions and avoid the pain of a possible double dip recession especially with weak US jobs figures and slumping European market demand,  virtually rolling off  JCY, my new unhappy technology counter and other counters may be next. Follow me but blame yourself when my prediction bucks the trend.

Welcome to the roller-coaster ride of investing!