Merry Christmas!

Wishing all my blog visitors a Merry and Blessed Christmas. It is that time of year again for us to count our blessings and be grateful that we are still here to join in the fun and festivities.

The management staff of my husband's company  gave us a delicious Christmas fruit cake. Here it is:

The Box

The fruit cake

The Greeting

The decorative art

The cake was big and we were not likely to finish it so I brought pieces of it to the clinic to be shared by the staff. It was nice to be able to celebrate an occasion where everyone join in and have fun. Christmas is such a special period that the waiting is actually more exciting than the actual day. Days of shopping and gift wrappings are the most enjoyable part. Giving makes one humble when looking at the joy on the faces of the receivers. If only we have more such get-together occasions!

Failure to Thrive and Recurrent Diarrhea in an Infant

Two weeks  ago a young mother brought in a seven-month old baby who looked alert and active and constantly smiling, however, she was small and light for her age. The presenting complaint was that she had been having recurrent diarrhea since the introduction of an infant formula feeding at the age of four months.

According to the mother the child was born within the normal birth weight of 3.1 kg and was fully breast fed till the age of three months and gaining weight well. The problem started when the mother gave her cereals and cow milk-based infant formula. The baby started having loose foul-smelling stools,passing lots of wind,bloated abdomen,appears constantly hungry and always crying. As expected she has not gained any weight for the last three months.She weighs at six kg, well below her weight for age which should been about eight kg .

The mother who is young and only received primary education, is at her wit's end trying to grapple with the problem. She has changed the infant formula brand once but the problem has not resolved. I noted down the name of the brands. Interestingly her first child also has suffered from the same condition, namely "intolerance" to infant formula. As a result the elder child is rather growth-stunted and slow in her milestones. I cannot help but feeling sad despite trying to be professionally detached. I wonder about the child's brain development. this condition is so preventable that it is a dereliction of duty on any health staff who look after these children  and  yet missed the signs,symptoms and most importantly the history!

The tragedy is the mother has been bringing both children to the local Mother and Child Services and has been told time and again to prepare the milk "properly". Without specific help and advice how does this lowly-educated woman know what to do? She doesn't have enough milk so she claims and the child needs to be fed.

Having listened to her history and description of the signs and symptoms and on physical examination of the child, I immediately made a diagnosis of cow's milk allergy in this infant. She cannot tolerate cow's milk due to possible genetic abnormalities in her gut. Looks like her elder sibling also has the same condition. The two infant formulas that she mentioned are cow's milk-based. She is subsequently advised to switch to  a soy protein-based infant formula.

Cow's milk products- A good source of protein

The mother comes today with a broad smile on her face holding her contented baby who has finally recovered from the diarrheal condition. The weight should start to pick up soon. Unfortunately the woman is from a different state and will return home at the end of the week and so I would not be able to get the joy of following her infant up.

The family came here for the school holidays and decided to try our clinic. They are very grateful to have come to us.  I advised her to continue attending regularly the Child Health Clinic in her State to monitor her child's growth. Moreover her child might outgrow the cow's milk allergy by the age of two or three. After which cow's milk products could be gradually reintroduced.

I feel  relieved  for the family.Imagine their months of anxiety and stress! Helping them to solve the problem  is yet another invaluable feeling of satisfaction for me.

Stomach pain, headache and anaemia - A triple Whammy

I have observed among my female patients in their late thirties and mid-forties who suffer simultaneously from  these conditions, namely an epigastric pain (stomach pain), headache and malaise and weakness which is found , upon blood investigation, to be anaemia (  haemoglobin  lower than 12 g/l ).

Their description of the recurrent headache is not unlike the migraine features. Most of them have suffered from these stress-related malady from their teens. Some have aura prior to the headache while others do not report any such event. Most of these patients have such a bad attack that they self-medicate. As they are not properly followed up by a doctor, they just keep buying those painkillers over the counter (OTC), at times from various pharmacies. In Malaysia, there is no stringent control over the use of these drugs.

And so over the years they gradually suffer from the effects of these drugs, referred to as  non-steroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid and ibuprofen. These drugs have an erosive effect on the stomach mucosa (lining) and causing gastritis and later peptic ulcers.

Unremitting stomach ulcers gradually leads to recurrent bleeding and over time the chronic blood loss leads to anaemia.

And so such a patient has the three medical conditions simultaneously. And the history is almost always similar.

I have made it my practice to really educate those young girls who come to me with recurrent headache or recurrent stomach pain to avoid the unnecessary use of pain killers to prevent this triple whammy later in their life. It is traumatising for these people to finally end up coming to the clinic/hospital  frequently at the peak of their life.

The cliché,  "prevention is better than cure" cannot be overemphasised. A simple knowledge on how to manage your sentinel medical condition will help a long way in maintaining your quality of life.

Migraine but treated as hypertension

MM a 45 year old teacher who has been on my hypertension clinic follow up  for two years, one day asked me whether her younger sister, JM could come and see me for her hypertension problem . Of course I would not mind. The sister, five years younger finally came to see me a few months back.

I let her to slowly narrate me her problem and later I was able to  summarise it as someone who has been suffering from frequent attacks of migrating headaches since her early twenties and had been taking a lot of pain killers that had led her to suffer from epigastric pain accompanied by nausea and vomiting 

Five years ago she had gone to see a doctor due to intractable headaches, nausea and vomiting with blurring of vision. The doctor took just one reading of her blood pressure and then told her that he had high blood pressure and needed an antihypertensive (blood pressure-lowering drug). She has been taking the drug ever since whilst her frequency of headaches had not receded.

Lately she had been having more frequent attacks which according to her were brought on by stress. At the same time she had increased her dose of over the counter (OTC) cafergot, to relieve her headaches. And she had been going to different doctors  who continue to prescribe her with the antihypertensive for her supposed high blood pressure and pain killers for her chronic headaches which by this time have the characteristics of  a migraine.

Migraine headaches can be debilitating and affect quality of life.

I monitored her hypertension for about two months and noticed that her blood pressure was consistently abnormally low despite my lowering the medication dosage.  I decided to rest her from the drug for two weeks with a daily home monitoring of her BP and observed that she actually did not have hypertension (BP > 140/90). I promptly stopped the medication and concentrated on her migraine. I told her that she has to stop taking pain killers and cafergot as her liver is showing some injury from  such drug usage based on her deranged liver function tests. The likelihood of her suffering from  chronic peptic (stomach) ulcers is also great  due to those painkillers.

After a general neurological assessment, I then prescribe a drug, a tricyclic anti-depressant for her as an off-label treatment for migraine. The medication has greatly reduced the headache attacks and she has felt so much better. Of course not all people respond alike. Some migraine sufferers do no benefit from this drug,  JM is just fortunate to have responded well. I also tell her to have a headache diary to record all the circumstances that could trigger her attacks like foods, drinks and emotional situations. Identifying these factors could help her to manage the attacks better.

In the meantime her blood pressure has remained normal and so does not warrant any drug.

There are many pitfalls regarding the diagnosis of hypertension as it  could be influenced by many factors like  over-anxiety and extreme tiredness and lack of sleep or even pre-consultation caffeine drink. It is also unwise to start this lifelong treatment based on just one reading of the sphygmomanometer. Unless the BP is extremely high, monitoring it for a week or so would give an idea whether there is actually hypertension.

So JM who has been on treatment for her "alleged" hypertension for more than five years actually just needs an appropriate medication for her migraine headaches.

Amanah Saham Nasional (ASN) units on "sale" and dividend in two months' time

This morning I went to the local ASNB (Amanah Saham Nasional Bhd)  branch to update my AS1M (Amanah Saham 1 Malaysia) book. It is always a good feeling to see your dividend in print! And by the way, as many of us know if you do not take out the dividend as it is annually credited to your account, you are actually unleashing the power of the "compounding principle". The accumulated amount is, however, subject to the annual rate of inflation which would affect the "value" of your money in the future so just be mindful.

Not withstanding,this mechanism of multiplying your money is excellent for young people who have many years of working before their retirement either in the private or public sector or anyone else (businessman)  for that matter. Saving for one's old age when one's capacity of income generating is greatly reduced is clearly a responsible practice.

Now for those who still want to make more money in a couple of months' time and are eligible to purchase the variably-priced PNB unit trust managed by ASNB, you can buy ASN whose price has come down slightly from 0.85 to 0.80 per unit and the dividend to be declared in about 10 weeks' time is expected to be more than 5 sen per unit thus giving you a better dividend yield compared to the fixed priced PNB unit trusts.

Transaction fee currently discounted by 2%

As it is variably priced, like ASN2 and ASN3, there is an up-front  transaction fee of 5% but for the period till end of this year, the fee has been discounted to 3%. The rate will revert to 5% in the new year (2012). It is a good way of "parking" your available money  for temporary investment. When you decide to sell after the dividend is declared, there is no more transaction fee. Of course, depending on the unit price after the declaration of the dividend, you will either have a major or minor gain but unlikely to lose.

I was made to understand that ASN unit price is benchmarked against the Bursa composite indices and if the current notable recovery on the stock market is any indication, one would expect the unit price to rise in the new year. The upcoming election is expected to momentarily excite the market despite the palpable external financial turmoil.

Honestly, I am envious of people who are eligible to  purchase this unit trust as there is a high probability that they will gain. A caution here though, any decision you make to buy this unit trust is entirely at your own risk. 

Benign Prostate Hypertrophy (BPH) and hypertension and......

My 52 year old patient RM has been on my hypertension clinic follow up for the last 12 months. Before that he was seeing other doctors. As he is a serial defaulter of his treatment, he keeps changing doctors earlier on to avoid, most probably, being rebuked by  some of them.

RM is an educated man holding quite an important senior position and he also travels outstations quite often. Besides having signs and symptoms of an enlarged prostate and a history of hypertension, he also suffers from chronic constipation and urinary retention, strangury, frequency and nocturia. All these symptoms are likely to be the effects of  his enlarged prostate.

I also observed that RM always looked depressed and not forthcoming about his condition especially with respect to his medications. I found out that he also defaults his urology clinic appointments (for the management of his prostate problems).

On his third visit I noticed his blood pressure to be rather low, 108/72. I asked him whether he was taking any other drug beside the blood pressure lowering drug that I have prescribed for him. He denied this. I was worried and after the consultation, told him to return any time he felt an unusual discomfort. He looked, as expected, rather depressed.

His following appointment was in August 2011 but he never turned up.

He came in early October with the complaint of  numbness on the left side of his body. He had defaulted for two months. He also failed to keep his urology appointment. At first I thought he was suffering from a mild stroke due to a high blood pressure as he admitted he had not taken anti-hypertensive drug for the last two months. But his blood pressure was strangely  within normal limits. I also could not elicit any signs of a weakened left side of his body. His  sensory and motor responses were normal so as his muscle tone and power and there was no other neurological deficits.

I was scratching my head as to what was going on with this "non-compliant" patient. I asked him again what other medication he was taking and he had better tell me if he wanted me to help him. After what seemed a long time, he admitted he was taking a drug to increase his urine flow. Then it dawned upon me that RM has been taking a drug called terazosin which also acts as  a blood pressure lowering drug.  That explained the low blood pressure recorded on his last visit. He was taking a double dose of "anti-hypertensive"!

It is therefore no wonder he experienced discomfort due to a low blood pressure whenever he was taking my prescribed drug. When he stopped the medication, he felt better and so he defaulted. I painstakingly explained the accidental blunder to him. I might not have continued the anti-hypertensive's prescription had I known he was on  terazosin.

On this non-scheduled visit, he admitted his urinary symptoms, accompanied by  back pain were getting worse. Wanting to be referred to the hospital , he came up with  the complaint of  left-sided body numbness which was, however, not verified by specific physical examination.

Giving him the benefit of the doubt, I referred him to the emergency department of the hospital for further evaluation and observation . Prior to that I took the opportunity  to advise him to always cooperate with the doctor so that his condition can be better managed.

And honestly, it takes  great patience not to dislike this kind of patient. Despite his reluctance to cooperate and his defaulting  twice on my clinic,  I have never admonished him, that is the reason he keeps returning but unfortunately he stretches it a bit too far and ends up not helping himself.

Urinary incontinence : An 11- year suffering

Last week a lady of 50 came to the clinic complaining of pain whenever she passes water (urinate) and this has been going on for many years. It has become worse for the last few years and whenever she goes to a private or government clinic in her home town, she is given the standard treatment for urinary tract infection, that is a course of antibiotics and bladder cleansing solution. But the condition keeps on recurring and she has lost track of how many similar treatments she has received.

She traveled a distance of about 130 km ( about two hours' drive) to come to the city to get another medical opinion.

I decided to engage her by asking about the history of her condition. She married in her early teens. Her problem started about 11 years ago since the birth of her last child, her twelfth (12th)! It was a home delivery and she suffered from a uterine inversion , she said "semua peranakan saya keluar" ( my uterus came out ) and had to be pushed back in at the hospital. She has been on an injectable contraceptive ever since then.

I probe on the nature of her urination. From the answers I summarize  the following; she feels a sense of heaviness as if something is coming down there (private part), she has urine dribbling, aching pain in her back and pelvic region, she has frequency (urinating many times a day ) and also urinating many times at nights (nocturia) and at the same time she feels she could not empty her bladder completely and urine keeps leaking and more so whenever she coughs (stress incontinence -loss of control of her bladder).

Her urine test showed the presence of a small amount of red blood cells but it was the physical examination of her genital area which confirmed my suspicion. There was an irreducible bulge coming down her vagina. The condition is referred to as pelvic organ prolapse most likely to be uterine. Prolapse of the uterus is the downward movement of the uterus due to weakened muscle of the pelvis likely as a result of injuries during childbirths.

The obstetrics history (twelve deliveries) of this poor lady testifies to her present predicament. No amount of antibiotics is going to help her unless her basic physical problem is treated. Her long suffering is due to poor diagnosis of her symptoms. A proper history taking could have avoided her unnecessary poor quality of life. As it is, none of the doctors who attended to her ever examine the genital area. Her gynecological problem requires to be managed at the secondary care level (by a hospital  gynaecologist) through referral which was what I promptly did.

Steve Jobs- Farewell to a Global iCon

I join the world today in mourning the passing of a great inventor and a computer genius, Steve Jobs on 06 October 2011. His accomplishments are legendary and his legacy will be remembered for generations to come. Macintosh, iPod,iTune,iPad and iPhone  are Apple products brought to us through the collaboration ,innovation, vision and efforts of  Steve Jobs.

Steve Jobs, Apple Products and Apple Shares

He changes the world of computing and makes it more delightful wherever we are.

I just like to re post some of selected net photos on Steve Jobs as memories on my blog.

The young multimillionaire

The Apple of the World's eye

Innovator and marketeer extraordinaire - iPod 2001

The world loves Apple

Turtle-neck sweater,Levi 501 jeans, trainers

iPhone launching 2007

Steve Jobs's  silhouette  on Apple logo- Tribute by Jonathan Mak (Hong Kong)

The outpourings of tributes the world over for Steve is just amazing. He is indeed the Apple of the world's eye.

 Quotable quote from:

Interview with Wall Street Journal, 1993

 

"Being the richest man in the cemetery doesn't matter to me… Going to bed at night saying we've done something wonderful… that's what matters to me."

What a remarkable man!

Thank you Steve, we will miss you. 

 

May you rest in peace

Life of Steve Jobs

• Born in San Francisco in Feb 1955 to students Joanne Schieble and Syrian-born Abdulfattah Jandali - adopted by a Californian working class couple
• Had a summer job at Hewlett-Packard while at school - later worked at Atari
• Dropped out of college after six months and went travelling in India, where he became a Buddhist
• Launched Apple with school friend Steve Wozniak in 1976 - first Apple computer sold the same year
• Left Apple amid disputes in 1985 but returned in 1996 and became CEO in 1997
• Bought Pixar animation company in 1986 for $10m
• Married in a Buddhist ceremony in 1991 - has three children with his wife and a daughter from a previous relationship
• Had a personal wealth estimated at $8.3bn (£5.4bn) in 2010
• Diagnosed with pancreatic cancer in 2003, and after three periods of sickness leave, resigns as Apple CEO in August 2011

Medicalisation of pre-Disease States

Have you heard of talks about preventing a chronic disease by using drugs? It sounds attractive if you could prevent diseases such as diabetes and hypertension (high blood pressure) by just taking drugs. It is of course highly attractive for drug makers (pharmaceutical companies) to expand their business to include a lot more people as to increase their already gargantuan profits for shareholders.

UnNatural Ways Only When Needed

Medicalisation of pre-disease states is virtually giving drugs (medicating) to healthy people with the objective of preventing chronic lifestyle diseases. It is not unlike immunising people against preventable diseases such as  diphtheria and measles but in this case the mode of prevention is through the stimulation of antibodies to fight against the disease agents such as viruses and they are not given everyday.

However studies done a few years back did not provide a conclusive evidence that an antidiabetic drug could prevent the disease, in fact modification of lifestyle like proper nutrition, maintenance of ideal weight and exercises, is noted to be just as effective.

Giving drugs to healthy people will make them feel like patients and could affect their quality of life especially if they suffer from adverse side-effects as often seen among patients on medications. At the same time there is the rise in costs to the society in terms of spending more on drugs with questionable outcomes and increasing use of health care (increased economic burden).

If you notice many people are taking vitamins in the belief that they would keep them healthy. The business of vitamins marketing is expansive. Healthy people who would get most of their vitamins through proper nutrition have opted to take the easy way out by ingesting these pills and then telling themselves that they are feeling better and healthier... a self-fulfilling prophesy. This vitamin intake also gives a false sense of security especially when it is unaccompanied by healthy lifestyle practices.

Suffice to say the medical fraternity is generally against prevention of diseases such as diabetes and  hypertension through the use of drugs as current evidence and health economic considerations do not justify their clinical use.

Amanah Saham 1 Malaysia (AS1M) - Higher Declared Dividend in 2011

The last dividend declaration for PNB's Unit Trusts  for 2011 is AS1M. This is the second year the fund has come into existence since its launching in August 2009 by our Prime Minister. The first year's (2010) dividend was nothing to shout about at 6.38 sen per unit. Many investors were kind of disappointed as they thought being the latest, it would give a 7 sen per unit or more like the previous funds such as ASM. The Sime Darby's cost overruns and a negative hit on its shares in middle of last year was blamed for the lacklustre performance of the fund.

The Chairman (L) and CEO (R) of PNB at AS1M's 2011 dividend declaration on 22 Sept 2011

This year, the second dividend has been declared at 6.50sen per unit , an increase of 0.12. A slight increase given the current market turmoil. Well, it is more than three times the bank rate so it is no wonder that the fund has been fully subscribed by the non-Bumiputra (Chinese).  Allocation for other ethnic groups are still available.  According to PNB, as at 20 September 2011, 5.49bilion units of the fund are being held by  270,598 investors.

AS1M transactions are currently suspended from 21 September to 2 October and you can update your book on 3 October 2011 as the dividend is automatically credited there.

It is comforting to get the dividend during this current market's poorest performance, reminiscent of the 2008 financial meltdown.  I was thinking of parking my AS1M's dividend in another unit trust which is variably-priced and that is set for a better dividend yield but am worried that after its dividend, to be declared in January 2012, the unit price would plunge as to wipe off all of my gain ! So I had better be on the defensive by keeping it in AS1M till such a time when the market  returns on the road to recovery.

It is wise to stick to capital preservation during stock market's unusual down-trend.

The fun has virtually gone out of the equity market right now and I have stopped looking at my portfolios' dwindling values. Let me just be happy with my AS1M dividend for the time being and dream a little......

Diamond-studded Kitty ring  at USD4,250.... for decor only :)

Stock Market Shaking, Oil and Gas Stocks Tumbling.

There is a sense of loss as I look, transfixed  at my rapidly tumbling portfolios. My oil and gas counters have all taken a hit. Apparently the managers of foreign funds have again decided it is not worth putting their money in Asian stocks due to an anticipated poor demand from America and Europe affecting our exports. So they take flight to other so-called safer haven.

 My Pchem ,at an all time high of 7.50 about three months back has collapsed at 5.68 this morning. My Dialog is at an all time low now at 1.97 after a high of 2.70 and I bought them at 2.19 and so is my Kencana bought at 2.93 and now a measly 2.53 and as luck would have it I did not buy Armada whose IPO I failed to get. Thanks goodness!

Remember Armada was listed on 27 July 2011, hardly two months have passed, and open at 3.65 and has gone up to 4.50 and look at today, the price has tumbled down to 3.45! Shall I buy now? Or should I wait for it to fall further nearer to its IPO price of 3.03? Honestly, nobody could tell whether this declining trend will continue or stop. Everyone appears jittery. One day up, the  next day down and now, down and down.

Armada  is falling down,falling down.....

The European Union's dallying on robust debt restructuring solution for Greece's potential default and the American's job problems have all affected worldwide investors' confidence. The IMF (International Monetary Fund) has warned that time is getting short as stock markets around the world are reacting negatively to current economic outlook and recession fear. 

The present market uncertainty is extremely bad for investors. For people like me who have the tendency to buy and hold,despite many pundits' advice against it, we are at the losing end as our shares depreciate greatly in value, reminiscent of the fall in October 2008, precipitating a GFC (global financial crisis).

Things have to move on nevertheless.We have yet to reach the trough.

I am eyeing Armada after selling off my CMMT today at 1.32 and which I bought  at 1.04 last year. I am afraid to wait as I did with Dialog as the recession is looming if the Feds and the European Big Guns are not doing anything to shore up markets' confidence . Like it or not, our market is affected by their actions and manipulations.

I feel sorry for the politically-embattled Angela Merkel, the Chancellor of Germany as her people, the German taxpayers, are getting fed-up of aiding Greece which doesn't seem capable of putting her financial position back on track. And the Feds might have to come up with yet another quantitative easing 3 ( printing new money guys!) to help those banks to lend money for businesses in US. If they do then we will see some market recovery  here in Asia including Malaysia. 

Rather convoluted I must say this globalisation thing!

Fungal infection - How does it look like on your back?

An obese 52 year old single mother has been my patient for a couple of years. She comes regularly for a follow-up of her hypertension ( high blood pressure). Her condition is under control with her present medication.  And she is not a diabetic.

On one or two occasions she complained of itchiness on her arms. Upon examination, I diagnosed it as a fungal infection (tinea corporis) and prescribed her an anti-fungal regimen and after some weeks the lesions had cleared.

Last week she came for her review and at the same time she said she had been coughing for the last two weeks or so and had difficulty breathing when her coughs were bad. As per my practice, I wanted to listen to (auscultate) her chest. Whilst most local primary care doctors would just put their stethoscope on the back with the clothes on, my medical trainers had always insisted that we asked the patient to lift up their clothes and examine it that way. Observe the chest movement of the right and left side before auscultation.And that is what I always practice.

I auscultated the lung from the back and found that the lady had an abnormal breath sounds on her left lung and diagnosed it as bronchitis.

But there was something else I observed on her upper back. It was a large area of fungal infection which looked migratory and active in the lower middle of her back with visible scratch marks around it. I asked her whether she knew about this or has she got any itchiness over this area. She replied yes, and she had been asking her only child, a son to apply some kind of an over-the-counter cream on it. I asked her whether she knew what the area looked like and of course she did not know because it was on her back. Her son just described it but she really could not visualise it. As it is very itchy she even had some kind of heat treatment on the back to relieve it.

Migrating fungal infection on the back

I asked her permission to take a photograph of the lesions and show it to her. She was surprised to see the picture. The skin infection is fungal and she needed the right cream to treat it. I have a feeling she had been applying a steroid cream which temporarily relieved her itchiness but actually made the infection worse through extension as the fungus thrives on steroid!

Her problem is further compounded by her heavy attire and tight hair scarf (hijab) which is relatively inappropriate in our hot weather. The excessive sweating promotes fungal growth. I advised her to use cotton material and not to cover her head at home and maybe use the normal scarf for the time being while her back condition is being treated.

So concerned was she about her modesty that she had never admitted her skin problem on her back. Moreover she thought it was simple itchiness as she could not see it. Inappropriate therapy had worsened the condition and her heavy clothing did not help at all.

I am prescribing her a local anti-fungal regimen failing which I might have to resort to an oral therapy. Had I not asked her to lift up her blouse for her chest examination, I would not have seen this treatable skin disease. Left untreated the disease would eventually burn itself out but in the meantime she could get other skin infection due to the constant scratchings and the discomfort of itchiness could disturb her sleep and affect her quality of life.

Chronic Cough - the Magic of a Correct Diagnosis

A 21 year old female office worker came in yesterday morning complaining of cough for the last six weeks. She had been to see a doctor who gave her a week's prescription of an antibiotic which she said she took once daily (1000mg) but she did not know the name when asked. She was also given a cough syrup and a decongestant which she also religiously took but her coughs persisted.

She was getting desperate as she coughed so much at work in an air conditioned office.  And she admitted that her coughs were worse at night and had disturbed her sleep and made her irritable. She looked miserable and she was also extremely worried about getting PTB.

As per our clinic protocol  for coughs lasting more than three weeks, I did a screening for PTB (pulmonary tuberculosis) consisting of a chest xray, sputum for AFB (acid fast bacilli) for three morning consecutively. I also took her blood for  FBC ( full blood count) and an ESR (erythrocytes sedimentation rate), a non-specific indicator of increased inflammatory activity in her body.

But most important I asked about her medical and family history. Yes, the father had PTB a long time ago but has been treated. Yes, her younger brother suffered from asthma but has more or less recovered over the years . No, she has never had asthma but she offered the information that when she coughed so bad she could hear a gritty sound in her chest. And currently she is all congested and her nose is all blocked.

I examined her chest and found it to be clear of any abnormal sounds. Her chest Xray was also normal apart from a mild congestion on her right lower lobe. Her FBC showed an allergic picture with an elevated neutrophils and ESR was mildly elevated as expected in an inflammatory condition but not too high as seen in chronic conditions such as PTB or connective tissue diseases like SLE (systemic lupus erythematosis)

There are other causes of chronic cough such as post-nasal drip and GERD (gastroesophageal reflux disease) but the history pointed to more of a recent irritant causing increased secretions and bronchospasm giving rise to incessant coughing. I surmised that her problem started with an upper respiratory tract infection likely to be viral and this was not properly managed as she was later put on (likely) a broad spectrum antibiotic and long term anti-tussive and anti-congestant that somehow  served to irritate her bronchiolar linings causing bronchospsm, increased secretions and narrowing of her airways. The narrowed airways prevented normal clearance of the accumulating secretions.

What she needed was a bronchodilator to reduce the spasm and clear her airways. That was what I gave her. Before she left my clinic yesterday I asked her to return the next morning and show me the antibiotic which was prescribed to her for my information as I wouldn't want to give the same one in case she needed it.

Early this morning she turned up with a piece of paper on which she wrote the name of the antibiotic which she got via phone from the private clinic. Unfortunately it was some garbled word which didn't look at all like any antibiotic that I knew of despite looking up in the internet! Anyway that information was no longer important to me.

What is important to me is the smiling and happy woman I see today. She says she no longer has any cough. She slept well last night after taking two oral doses of the medication I gave her. She couldn't even cough out any sputum this morning for the AFB test as her chest and throat have miraculously cleared overnight. She said her friends also commented that she no longer coughed irritably.

When she got up from the chair to leave she bent forward, extended both her hands and cupped my right hand tightly to thank me and said that she'd never been so relieved in weeks.

I am very pleased with  her fast response to the medication  and this is the kind of cases which gives me a deep  professional satisfaction.

It's sexually transmitted and It's gonorrhea!

A 45 year old lady has been coming to the clinic with the complaint of recurrent foul-smelling vaginal discharge since a year ago and was seen by various doctors who treated her for vaginal candidiasis (fungal infection). She was quite distressed by the time I saw her as the condition never seemed to go away. She admitted going to both government and private doctors and found no relief despite being given antibiotics as well.

I decided to engage her by asking about her family life including her sexual history. Yes, she is married with four children and now working as a housekeeping staff in one of the local hotels and no, the husband is most of the time outstation and comes home only every now and then and that rings a bell for me. I decided to take a high vaginal swab and test for sexually-transmitted disease (STD) organisms like gonorrhea, chlamydia and trichomoniasis and there the result before me " intracellular diplococci, morphologically similar to Neisseria gonorrhea", there you are, the source of her malady. She was promptly given an intramuscular injection of an antibiotic most suitable to treat the disease.

I informed her to tell her husband to come to the clinic for a similar treatment as required under infectious disease protocol. She told me her husband was still outstation and she appeared reluctant to come with him for an STD counselling. Anyway, I advised her to get her husband treated as some gonorrhea cases in men have no symptoms. I also carefully suggested to her that this kind of condition normally thrives in cases of having multiple sex partners so it is wise to avoid such a situation. As a health personnel, we have to educate our patient on the nature of the disease and its transmission.

Usually in a busy practice local doctors  would hardly ask patients for a sensitive history, preferring to shoot in the dark by treating the commonest condition in a woman with vaginal discharge that is candidiasis, a fungal infection. The tragedy is  when every time she comes in she sees a different doctor and so the history of treatment is not really scrutinised. Often the same therapy is repeated as in this poor woman's case.

Today she comes for review six week-post treatment and reported that her condition has cleared for the first time in months! A disease needs to be correctly diagnosed and given the right treatment to be cured. I am relieved for her.

Averaging Up or Down- My Experience

As I was reading an article on this topic by one of my favourite bloggers,Musicwhiz, I was reminded of  my own experience in dwelling on such activities or shall I call it "plunging" into them?

It was in early 2007, nearly a year before the global financial crisis. I met with an accident and had to stay home for almost a month. As I sat in front of my computer with my left leg in a plaster cast, I noticed that the market was in an unusual vibrant mode, call it a bullish trend if you like. I had much earlier bought some "Renong" shares which was later converted to UEMworld and the unit cost then was 1.25. This counter suddenly became active and as it was going up, I kept buying without really understanding the principle of averaging up, mind you. Had I known the risk I would have been in fear and more careful.

My effort was well rewarded though, as by the time I sold off all of my UEMworld shares at 4.40, I had made a small fortune all in a matter of eight weeks or so. I was extremely pleased with myself and that rather massive gain was used to buy other shares and make up my variety of portfolios. Well, it was a success story, one based on instinct rather than a careful study of the fundamentals of the company. Certainly not to be emulated by anyone worth his salt. Average up and gain?

Then in the first quarter of 2010, as I was looking at the trend of the various sectors in the market, I noticed that the technology sector was doing relatively well in rotational plays. The new kid on the block, JCY whose IPO was at 1.60 had even gone up to 1.98. Then suddenly JCY, along with the other technology stock prices like Notion, started to fall. Mindful of the possible opportunity to buy low,  I went headlong into the market and bought JCY shares at 1.52, well it was below the IPO price wasn't it? Then it fell again and I kept buying  till I realised that I was putting my money into a bottomless pit  and ceased averaging down forthwith.

The Greek sovereign debt woes and worries on its contagion effect as well as the fall in demand for hard disks had battered down the technology stocks and I came by the news rather late. I lost a substantial sum of my hard earned money on this stock when my broker advised me to dispose all of it early this year at 0.58 sen. Luckily I followed his advice as a few weeks later it still continued to fall and now I think it is at 0.40 sen. Certainly nothing to be celebrated. Average down and lose!

I used the proceed to buy the Pchem IPO in trading and service sector and as luck would have it I was successful and able to compensate for the loss when this newly acquired stock went up by RM2.00!

In my little experience ,averaging up in a bullish market proved to be lucky and lucrative despite the apparent risk and my averaging down, while seemingly clever, in a volatile market still in the shadow of the recent GFC (global financial crisis) was disastrous. And my final disposal of the technology stock at a great loss was a fortunate decision as it went down still lower and would have suffered greater losses had I held on to those shares. And my good luck with Pchem had single handedly turned around my financial status.

There was an interesting comment which pointed out that if you keep averaging up, you are a masochistic (pain-loving) and if you do the same by averaging down you are a hedonistic (pleasure-seeking). Tell you what, when I was performing those two actions I hardly thought of the pain or pleasure.... I was just having fun with Mr Market!

MRCB or ARMADA and Market Volatility

I have some fund available for investing following my failure to secure Armada IPO last month. Instead of keeping it in some unit trust accounts, I have decided to see how the market performs with regards to Armada. It does not seem to come down, in fact it is going up gradually defying analysts' prediction of its fair value being about 3.92. Instead it goes up to 4.20. I am not about to put my money in this overvalued stock. So I wait.

My oh My!

Then that precipitous fall at New York stock market occurs on 5 Aug, DJI index declines by over 500 points, the single largest dip since 2008, and followed by other world markets the following Monday 8 Aug; Malaysian stock exchange is no different.I note an ocean of red with many favourite stocks which were making gains the week before falling by as much as 15%. I see Armada goes down to 3.80 and another stock, MRCB which I am monitoring falls from 2.55 to 2.16. I am debating which one, Armada or MRCB that I want to acquire. I read about the market not likely to recover in the short term, I read about when one goes bottom-fishing and I read all about the gloom surrounding most markets and so I waited.

Bumi Armada

Then market suddenly rallies on 10 Aug based on the Feds promise to keep interest rate to almost zero for two years and everywhere the stocks return to black! (Re: my last posting on Back to Black :D). After doing some simple calculation on stock yields, I decided on 10 Aug to get those MRCB shares which opened at  2.16 on Monday but has climbed back to 2.20. Well I thought I was not going to wait any longer, just close my eyes and told my remisier to queue for that price and I got them in less than 20 minutes... Gosh some guys really wanted to dispose of those shares! I just hope my luck holds out, in this volatile period one is supposed to focus on capital preservation and not going headlong into investing but remember no risk, no gain!

The next day, 11 Aug Thursday, MRCB along with other stocks fell again ( following Wall Street of course the evening before) and this time based on remarks about Germany's and France's exposure to down-rated Spanish and Italian bonds... Ghee, what else could be there that are going to affect the market? I know the British riots do not affect it, I supposed when China, US or the economic giants of Europe cough, we will all be sneezing as well ( a cliché I know). And so I saw the value of my MRCB stock went down to 2.09 overnight. Immediately I rang up Jenny my stock broker to buy additional MRCB shares at 2.10 to dollar cost average. But she never rang me back as the robust stock held up at 2.20.

Angela Merkel  and Sarkozy - a Powerful Pair

World markets return to black on 12 July following Wall Street overnight recovery after Angela Merkel the German Chancellor and Sarkorzy, the French President indicated  that they would get together to discuss the eurozone debt and that their exposure to Spanish and Italian bad debt is not critical. And so my MRCB shares return to 2.23 as for now.

What a historic week for stock markets around the world!  After a week of the most volatile trading sessions since the global financial crisis, the Dow Jones rose 423 points yesterday, but it remained 301 points in the red ahead of this Friday's session .Morgan Stanley Smith Barney vice-president Fabiola Gibson told the Australian online that "The difficulty in a market like this is that no one has time to think. In a market like this you need nerves of steel."

This extreme volatility tends to erode investors' sentiment towards equities and  no wonder everybody is buying gold pushing the price of the metal at an all time high.

Well for the small time retail investor like most of us "the nerves of steel" is an option for people who find investing challenging where gaining and losing is part of the game. Just sit back and relax!

Stock Market - An Ocean of RED and Back to BLACK

Since early this year I have been following news on the world's financial health especially the recently protracted partisan haggling in raising American debt ceiling. Their Congress managed to resolve the impasse just hours before default on 2 Aug 2011 much to the relief of the financial world. Most of the writings point to another possible GFC2 (global financial crisis). Things have been further confounded by  Europe's sovereign debt crisis which seems to have defied remedies and threatens more euro-zone economies.

Like most investors, I am worried , yet  I hesitated to offload some of my stocks  early last week. My hesitation does make a poor investor out of me. The intransigence was an opportunity lost. Despite being a small-time market player for quite some time, I must admit I am no savvy investor. I have created wealth no doubt but not as much as it should had I been more decisive and less greedy ... ooops!

Last evening saw the worst Wall Street sell-offs in two years. The world has seen it coming. Investors just fled the market on news of American worsening economic data and the failure of the stimulus packages to spur her economic growth. The Dow Jones Industrial Index was down by more than 500 points. I foresaw an ocean of red in our own stock market the next day which is today and as sure as the sun rising from the east, the ocean of red stares at me from the screen of my computer when market opens.

Market free falls at New York Stock Exchange Aug 4 2011 (WSJ)

Ocean of RED at Bursa Top Volume Aug 5 2011

Following the DJI steepest decline since 2008 yesterday, panic selloffs also hit other Asian stockmarkets . And the Australian stock market wiped off nearly AUD56b this morning. It seems that it is a natural reaction for most investors to panic and convert  what they have got in the market around time like this to cash and someone has made a remark that if this was the favoured technique, it should have been done before the crash!

It is envisaged that markets will continue to be tough for the next couple of months in the absence of any short-term resolutions of prevailing macroeconomic issues and investors have been advised to balance up the need for return with the absolute need to preserve their capital. It is not the time for borrowing and investing.

The Present Cliche - Credit The STAR

Well, for people who have the fund to spare for the longer term (one or two years?), it is the time to buy up those battered down stocks and wait for them to come back to black for long-term gains, reminds me of the popular song of the same name by the late and tragic British singer and composer Amy Winehouse.

Amy Winehouse-RIP

Savvy and lucky investors would have capitalised on this large hiccup in the market. As for me I tend to be wise after the event..... rather unfortunately.

Just as well I am still hanging on to my precious money and not silly enough to buy the coveted Armada shares last week, the price was rather low this morning since its launching on 28 July 2011. Time to buy I guess.. no, no, just let me wait a little bit longer as Armada's trading is in USD and I note that the greenback is weakening..... Typical me I would say. By the time I decide it would have been Back to Black.

Adamo-Inch'Allah (Italian)

This is the Italian version performed by Adamo Salvatore. You can search for the English version if you want to understand what he is saying. The version is beautiful to my mind with poignant message on the conflict in the Middle-East.

"Requiem for millions of souls

Of people lying in nameless tombs

In heaven there's room for them all

Now enough blood, Salam! Shalom!"

Paul Mauriat - Inch Allah (1967)

Paul Mauriat's music has never ceased to give pleasure and amaze his fans the world over. This particular piece I found today is so soothing to my mind that I practically and  unconsciously become relaxed  and so I would like to share this with my music-loving blog readers.

This is an instrumental interpretation of the original song by Adam Salvatore. It has been put into several versions, Spanish, French, English and Italian. I love the Instrumental version by Paul Mauriat best as it is universal. However to give that feel of a person singing this composition I want to post it on the Italian version as it seems to be more sedate and kind of romantic.   I think Insya Allah means "God Willing".

I would also like to share a couple of comments I like on Youtube about this great,classy and gifted composer:

** May there be a special place in Heaven for people like you Mr. Mauriat who have never failed to bring us such delight and unspoken wave of memories with your gift of music. You live on in our hearts.

WINDYCLAIR

 

The message from Japan :
** Hello, thanks a lot for your uploading it. This is my very favorite music. Though Paul Mauriat is no longer living, he left many many beautiful performance and music. I will continuously listen to them, and have a good time.

Thank you.

Financestaff 

 

Go on, close your eyes and listen to this heavenly gem..

Paul Mauriat - LOVE IN EVERY ROOM ( EL AMOR ESTA EN CADA HABITACION ) ...

Bumi Armada.. say what you like, investors just love it!

Bumi Armada, as expected, made a fine debut today at its relisting and I really want to congratulate a dear friend of mine DMJ who made that massive capitalisation. Gosh! that was really cool . He got 98% of his IPO application! Real lucky. Armada trading under trading and services sector opened at RM3.65 and closed at RM 4.14, more than 35% of its IPO price of RM3.03.

DMJ cleared 30% of his position at RM4.10 this afternoon... so dinner at Tatu Coffee House Shangri-La resort is on his house, ( instead of on the house ).

The stock performed well despite the current worries on American default ( I really don't think America is that foolish to make that happen) and Eurozone debt. You can see that the New York stock market is really volatile as it is rather clueless on the resolution of those two issues. So I secretly thought that Armada would not have risen so fast. In fact when my remisier Jenny rang me up on the opening price, I told her to wait till it comes down to below RM3.60... that was a joke, by 11 am, Jenny came back and reported that  the price had gone up to RM3.92 and by that time my appetite for the stock had gone sour.

As I was watching Atlantis's historic final landing at 5.57pm this evening on my desktop, I  was also listening to CNN business news on my flatscreen and understood that sentiment had gone up again because of better reported companies' earnings and market went up yesterday and today it seems to have improved further. Could tomorrow, being a Friday be a day of  minor selling off for Armada?  Anything could happen over the weekend so some people might just take their profit and sleep well over the weekend.

Interesting to watch  guys, tomorrow I will go to the market again and offload the refunded ESA at whatever the Armada's price when I  note any sign of a minor profit taking... see I was not successful this time though I cannot really complain seeing that my MSM is doing quite well. My friend did not get MSM IPO so it is fair that now he is successful with Armada though I am rather envious at the number of shares that are allotted to him  because  my successful MSM IPO was only at 30% from the total number applied.

A Market analyst has put a target price of Armada at RM3.91 at 25x PE based on  earnings in 2011 and first quarter of 2012 but also with respect to other big cap O&G service providers' peak cycle P/E's but today's closing price beat the analyst's prediction. In fact I believe, on many occasions,  it is the investors who determine the price they are comfortable with and in some cases, not unhappy to lose.

Bumi Armada is a good counter based on its fundamentals,good governance and book orders but we must be aware of its potential  downsides affecting the stock price and possible dividends, for examples  the company is subject to risks such as the following:

• Cyclical O&G industry- growth decreases at end of cycle
• Project execution risks e,g cost overrun or delay with penalty imposition
• Unexpected vessel downtime- breakdown/repairs
• Forex losses due to weak USD ( as most earnings are in USD)

Okay people, you buy this stock at your own risk ( read the prospectus!)  as I am only trying to convince myself to buy this stock before the company  reaches its peak cycle for which it would be like Pchem or MHB  and for me it is part of the fun I derive from investing. Lose or gain is taken as a challenge in creating wealth. If you are going to fret over losing money in the stockmarket, go somewhere else to multiply your precious "ringgit".

Happy investing and good luck to the well-informed risk-takers.

Atlantis Final Return to Earth

NASA TV

Space Shuttle Atlantis lands at the Kennedy Space Center at Cape Canaveral, Florida. The landing of Atlantis marks the end of NASA's 30 year space shuttle program. Picture: AP

It was a momentous event  for Space science-loving people especially for those who have worked in the shuttle program for 30 years to see Atlantis, the last of the three shuttles, returning from its last mission into outer-space and landed at the Kennedy Space Center just before 6am EDT on 21 July 2011. 

Following this, Atlantis like the other two remaining space shuttles, Discovery and Endeavour is heading for a museum, to be visited and admired by the public. What a fantastic machine!

Among the most important program's objectives is the building of the International Space Station (ISS) which has proved to be a united international collaboration since the end of the "worthless" COLD WAR. The shuttle astronauts have also, over the years, helped to set up and maintain the Hubble telescope giving us spectacular images of the universe. The program has also enabled many scientific research in the various fields including medicine and engineering to be conducted in space. Undoubtedly, the shuttle is an ICON of American science and technology.

It is inspiring to listen to what Commander Ferguson of Atlantis said about their space journey would only be completed once they manage to make the young continue the quest for space exploration for the future of humanity.... well said, Commander. In this limitless universe, it is impossible that we are alone. The continued quest into outer space might see human discovering another earth-like planet - interesting? Frightening? One will never know unless one gets there.

A NASA official also said that in order for America to advance,  going deeper into space  and far beyond, they need to change and ceasing the shuttle program is a form of change for them to concentrate on  more ambitious projects of reaching other planets for example, Mars and maybe an Asteroid.

Bravo America! And thank you for your endeavours for the benefits of all of humanity and what a great space nation!

 

Gout and Secondary Cellulitis

A 61 year old man came in this morning and he specifically requested to see me. I was quite touched though this was not the first time that patients had made that kind of special request. This man had a more than 28years history of hypertension, heart disease and gout. He was actually being followed up by a Cardiology clinic at the General Hospital but had been coming to the clinic and saw various doctors for simple aches and pain.

I greeted him as he was hobbling into my clinic. He had a swelling on his right foot and according to him it had been there for the last four to five days following his attendance of the Sultan of Brunei's birthday a week before. He had felt some pain in his right foot and had attributed it to the gout that he had been suffering from. It seemed that the attack came on just when he had to go to the palace where he had to wear shoes. So as the skin area above his first metatarsal began to swell, he had forced his shoes over it and bit his lips and took a painkiller.

He went to a doctor who prescribed him with indomethacine, a non-steroidal anti-inflammatory drug (NSAID) and told him to rest at home but the swelling  had become bigger, extending up to to his right ankle,  the tenderness had also worsened and he was beginning to feel feverish.

He looked well despite his temperature of 38deg C (normal 36.8). I took one look at his right foot and noted that it was no longer a simple gout but has become a rapidly spreading skin infection (cellulitis) as his right groin nodes were palpable I could see that this man needed a rapid antibiotic therapy which could only be given through an intra-venous line so I quickly referred him to the Emergency Department of the GH for admission possibly for 24 hours and following which an oral antibiotic would follow and he could return home to rest. Cellulitis can be dangerous as it could spread over the whole body and causing  fatal septicaemia.

Foot cellulitis- red,swollen,warm and tender

What could have happened was his affected foot, upon being squeezed into his shoe,  had  the swollen area  scratched and thus provided an entry for the surface germs causing rapidly developing cellulitis.

I  took an x-ray of the foot and tested his random blood sugar (RBS) just  to exclude any trauma and  the possibility of diabetes before sending him off to the hospital.

Bone spurs on Ist big toe joint -site of constant gouty attacks

It is sometimes difficult at the primary care level to distinguish between a gouty attack and a cellulitis. My usual question is whether the person is feeling off-colour and that the swelling is extending Unless you ask the patient you are going to just give him a painkiller and ask him to go home only to suffer from a worst outcome.

He gave me permission to to take the photographs of his affected foot and that of his x-ray for my record purposes.

Banana - What has it got to do with her heart?

Two months ago  this 51 year old hypertensive patient of mine, SS, came for her usual follow-up. She has been  my patient for the last two years and has attended clinic regularly. It has been my practice to always feel the pulse of all my hypertensive patients before I take their blood pressure. And so when I felt for SS's pulse that instant, I could feel her pulse bounding and her heart rate was increased compared to the last visit. And she was not on any drug that could have caused an increase in heart rate.

I then asked her whether she could feel her heart beating stronger and faster than usual. She then related, yes, for the last six week or so she did sense her heart  was beating abnormally. I then asked her whether he had taken any another drugs or herbs without my knowledge, for which she denied vehemently.

Now what was it? I persisted by asking her what had she been eating which was different in terms of amount or frequency for example caffeine-containing drinks such as coffee. She thought hard about it then reminded me that I once  told her to reduce fatty foods as her cholesterol level was abnormal and that she was on a cholesterol-lowering drug so for the previous two months before coming to see me she had decided to take bananas as it does not have any fat according to her. Yes, she took six bananas each day and since then she had experienced her heart beating faster but did not attribute it to anything,... Ahah..

I immediately advised her to stop taking bananas especially in that amount because banana is known to convert amines in the body into 5-hydroxytryptamine (5HTT) or serotonin which can cause an increase in heart rate and strength of the heart beat especially in some predisposed patients. Had I not examined her pulse, she would not have voluntarily given me that information and an undesirable heart outcome could occur in the long term.

Taken daily in large amount can make some peoples' hearts go "bananas"

Today she returned to report that she had not been feeling her heart racing since she stopped the large daily intake of bananas. I felt for her pulse and noted that the rate had returned to normal though the bounding was still there.

It is indeed my work-satisfaction to be able to detect a  risk before it becomes another medical mishap. This can only be done with careful physical examination and history taking and engaging  patients on their health habit.