The Doctor and the Pharmacist with an Attitude

I have been rather tensed lately. No, it's not due to too many patients, in fact I enjoy seeing patients, talking to them and gently cajoling those with chronic conditions to take their medications regularly. What I was unhappy about was the unilateral action of a pharmacist who took it upon herself to determine what prescriptions she would delete. I have never realized this till out of concern for my patients I have asked them to return to me once they received their prescriptions from the pharmacy so that I could advise them which tablets/syrup I was referring to during the consultation.

And so one mother came back to complain that the Pharmacist did not want to give her the syrup I prescribed for her three-year old. I called Miss X  the Pharmacist and she told me that the syrup was not supposed to be given to a child less than five. I am quite conversant with drugs and I know that cough suppressant and sedative drugs are no longer recommended for children but the one I prescribed was not in this category.

I asked Miss X to bring over the list of drugs in this not-recommended group. True enough there were 23 drugs on the list and the one I prescribed was not on it! So Miss X was quite surprised herself as all this while she had been deleting other doctors' prescriptions as well and none of them ever complained!

Yes, none of the doctors ever complained because their patients follow the flowchart in the clinic religiously. Patient comes to see a doctor and then goes to the pharmacy and finally goes home. In my selected patients the flowchart is modified such that after the pharmacy they come back to see me!

On another occasion an asthmatic who, after several trips, sometimes in the wee hours of the morning, to the hospital emergency department, had finally decided to come to the clinic. From the history I could discern that this young man had been having  bad bouts of asthmatic attacks for which no structured and regular treatment had ever been prescribed to him. Having examined him physically especially listening to his chest, I decided not only to give him the medication which relieves his acute attacks but also one which when used everyday would help reduce the number of attacks.

What did our clever Miss X do? She deleted the daily inhaler because she told the patient usually only one inhaler is prescribed for a first time-diagnosed patient. She did not have the courtesy to contact the doctor. She was acting like one. Again I engaged Miss X by focusing on the clinical condition of the patient, his inflamed, swollen bronchiolar smooth muscle cells that trigger incessant attacks require cellular stabilization through the daily inhaler. Granted that a mild asthmatic would only require the rescue inhaler only but not in this particular patient. And by the way since when the B.Pharm can do the work of an M,B;B,S?

In Malaysia due to the present healthcare arrangement, it is common that you see Pharmacists prescribing antibiotics and even anthypertensives and blood sugar-lowering drugs! In developed countries like the UK and US , they absolutely and legally  cannot do that. The practice in Malaysia  is very disconcerting and can affect patients negatively. Like the patient who was given painkillers NSAID for a long time by a Pharmacist for her arthritis ended up having erosive gastritis and a bleeding peptic ulcer.

Coming back to Miss X,  I told her to liaise with me in future in case she feels like being a doctor. By the way, UK-trained Miss X  is our new Pharmacist with an attitude. We had no problems with our old one who had resigned to open her own Pharmacy.

Really , remaining professional can sometimes be rather challenging..

My BLoG - DoINg It My WaY

Some of my friends and readers have suggested that I  separate my postings on medical subjects  from  those on  stock-market  and other stories. I am sorry to say that I am unable to follow the suggestions as I do not wish to feel tied up to a subject. I write whenever I feel like it  and not because I have to.

In this blog are all about my expressions, thoughts and experiences that I would like to share with people who are interested to read them.  I want to avoid the drudgery of writing in many blogspots. So those who are interested in my professional experiences can just look up the relevant topics and those who want to read about my stock-market rantings and raves on successes and failures can do so by following such topics .... all under one roof, one blog.

I am mulling over changing my blog's look but I love Sam the Koala so much that I wonder how it would be without her. Anyway I have changed my blog's  title to reflect what I am about.

Happy reading!

Young hypertension - and Now it's KM's Story.

Following my extensive history taking of YM's high blood pressure case, I managed to persuade her live siblings, a sister and a younger brother to come to my clinic for screening and investigations. Attend the clinic they did.

Her younger sister MM had normal Blood pressure but was advised to return in six months for another check-up and unfortunately her younger brother, 30-year old KM was found to have high blood pressure. So high at 190/120 that an instant blood pressure lowering drug had to be given on the spot!

Actually following the death of his  elder brother at the age of 29 due to a stroke the year before had made KM visit a government clinic early this year. He was investigated under a protocol of young hypertension where a kidney and hormone profile were studied for any curable abnormalities. An ultrasound investigation was performed and the radiologist reported that it was normal. So the referring primary care doctor informed KM that the investigation was normal as well.

And so KM thought that as his kidneys and relevant hormone level were normal,  he did not need the medication given to him earlier by the doctor. He stopped taking the medications for the last three months and had been suffering from headaches and tiredness since then. He did not return to the clinic. Instead he came to mine because his sister YM persuaded him to.

I could see that KM requires more education on his medical condition. Not only education but motivation and support as well. Now,  here is a young man who has this chronic disease and is supposed to take lifelong medication. He obviously does not understand it and greatly resents the thought that he needs daily medication. His job as a tourists' guide also makes taking and remembering to take daily medication a chore. Disease and medication counseling are essential in his case.

It is critical for him to accept his condition and be on lifelong treatment. I gently told him that we all could not choose our parents and hence our genetic make-up.

He defaulted treatment earlier because he did not understand his disease condition, its complications and prognosis. I have focused on disease advocacy, explaining his conditions and the medications and blood monitoring that he needs. So far KM has been responsive and I hope he continues to be so for his sake. Currently his blood pressure is stable and his organs such as the liver and kidneys are showing parameters that are within normal limits. And so far he has kept all his appointments with me.

I pray for all the KMs of this world.

Young Hypertension - and YM's Multitude of Medical Conditions.

YM came in today to review her blood results and also to complain about her incessant coughs lasting more than three weeks. She was the young lady who was the subject of my last posting. Her kidney function was essentially normal but her urine showed the presence of blood (hematuria) and albumin (albuminuria), these are not good signs. On top of that she also had a high level of cholesterol and triglyceride ( another form of lipid in the body). Her thyroid function test was normal.

Her coughs  started following an acute episode of tonsillitis for which I had prescribed a course of antibiotics for  her. The tonsillitis had healed but the coughs continued and were worse at nights when it was colder. Last night was particularly bad. The coughing had made her unable to sleep. I asked her about a family history of asthma and she admitted that her younger brother was suffering from asthma and that she had childhood asthma! I examined her chest but could not elicit any signs.

The clinic protocol is when a patient has been coughing for more than three weeks, a pulmonary Tuberculosis (PTB) screening needs to be done. So I ordered for sputum examination on three occasion and a chest x-ray. The chest radiograph showed heavy congestion in the middle lobe of her right lung. Otherwise no other signs suggestive of TB. I prescribed her with a combination of two antibiotics for a week.

Now, I have asked her a month ago to wait for her menses and to come to the laboratory for specific day of the menstruation to take blood for hormonal studies to diagnose the cause of her absent menstruation/infertility. Unfortunately the menses was still absent (for six months) and today I requested the hormonal studies to be conducted straightaway. The studies are designed to determine the cause of her prolonged absent menses ( secondary amenorrhea) and for later referral to the Gynaecologist.

YM had gone to see the Cardiologist I referred her to. Unfortunately all relevant radiological investigations are slotted for October 2011 due to the hospital's heavy workload. One of the essential investigations was to exclude renal stenosis (narrowing) so I asked her whether she could afford to get it done in private which would take only a few days. She promptly said yes. I filled out a form for her and sent to to my colleague, a private Consultant Radiologist. And I also noted that the heart specialist had given her a six -month appointment. To me it is a rather long time of waiting. I put myself in her shoes. I place her on my clinic follow-up every two months. She needs the necessary motivation at this early stage to continue with her life-long medications. It is what we at primary care do best.

Fortunately her blood pressure reading had stabilised within normal limits. But her high blood cholesterol and triglyceride was troubling. A young person should not have this aberrant lipid picture. I have tried asking my patients with high blood lipid to control their diet,less fried foods etc but I can tell you,  only one  (10%) person out of ten succeeded; that too because he did not eat outside foods. YM travels a lot due to the nature of her job so I started her on a cholesterol lowering drug plus dietary advice.

And so, in a matter of about six weeks, I have discovered YM, a 30-year old lady professional, who initially came with a complaint of a bad headache, to have the following: Hypertension, secondary amenorrhea. infertility, hematuria. albuminuria, hypercholesterolemia, hypertriglyceridemia, lobar pneumonia and infection-triggered asthma. 

So young a life, so fraught with  medical conditions! I will ensure she has the best care we can give.

The Medical Certificate – Beyond Consultation

A 31 year old woman, YM, came in a month ago with a complaint of nausea and headache which she ascribed to a long holiday in Kuala Lumpur. She returned the night before and slept in the following morning. Actually she had to work but could not make it so the main reason her coming to see me was to get a medical certificate.As usual I engaged my patient so that they would relate their medical history. I do this often in the hope of looking for areas where I can advise on preventive medicine.

I asked her whether she was married; yes she was for two and a half years. Then I proceeded asking her about her menses like the last date of her normal period, the cycle any pain etc. Her last menses was in Nov 2010 and it had yet to come though all her pregnancy tests had proven negative. I didn’t take any chances I still ordered for UPT (urine for pregnancy test) and Urine microscopy. Both were negative.

Then I asked her whether she wanted to have children, yes, she replied. I asked her why she did not get herself investigated for irregular and prolonged amenorrhea (absent menses). No, she said because she did not know how to go around it.I persisted by asking her what her normal complaints were whenever she went to see a doctor, she replied normally headache and tiredness. No, no blurring of vision.

Without asking all those probing questions, I would’ve just given her a medical certificate and perhaps an anti emetic and a pain-killer and then send her off. But I felt uneasy. She was only 31, an active young professional with  a menstrual problem, failure to conceive and recurrent headaches. Something was not right.

I proceeded to take her blood pressure and could not believe my hearing and my eyes that the first recording was 190/120 (normal for her age is 120/80). I asked her to lie down for about 30 minutes.  After resting, the next reading both lying and sitting and standing was 190/118, essentially the same. I prescribed immediately a short-acting anti-hypertensive and measured her blood pressure an hour later and it went down to 150/100. 

Before I could ask her about her family history, she volunteered by saying that her mother suffered from high blood pressure and that her brother died of a stroke at the age of 30! That’s it the red flag was up! There could be  a genetic predisposition in this woman and that she needed to be investigated fast and fully and given blood pressure-lowering medication before the high pressure gradually destroys target organs such as the brain, the heart and the kidneys.

For young hypertension the work-up is slightly different because you need to look for preventable causes such as Conn’s syndrome or renal artery stenosis (narrowing). Both are operable and the hypertension can be cured.Without wanting to waste anymore time on diagnosing her condition, I ordered all the tests and promptly referred her to a Cardiologist for more evaluation and extensive investigations. High blood pressure in a young person, if not detected and treated early will lead to a premature death, just like YM’s brother, dead at 30. And as illustrated, probing history taking is extremely important in preventing such a death.

That was the longest “Medical Certificate” consultation I ever had. But I feel satisfied.

AHB -Amanah Hartanah Bumiputera's first dividend halved.

I was tickled pink with one of my Bumi colleagues, DMJ's adventure or was it misadventure? with this REIT. When this product was launched last November 2010, he went along to the nearest Maybank in late December hoping to apply for some units. He could not have registered immediately as he had wanted to write in a cheque so he applied first for 1000 units with the cash that he then had. When asked into which account he wanted the dividend to be credited to he promptly gave his foreign bank's account number.

Busy as he was, he forgot about  topping up his units. Once you are registered you can then issue a cheque but our friend failed to do that. So recently when the dividend was declared in April , he calculated his meagre gain and found that it was about RM20. Then a week later after his RM20 was credited into his bank account, to his dismay he found out that RM10 was deducted as bank charges! So he  received only 50% of his dividend :) There would not have been any  bank charges had he had an account with Maybank which manages the REIT.

He learned the hard way . The moral of the story is to read your prospectus before your purchase of any unit trust/stocks but how many people usually do that?

By the way, if I am not mistaken all the 1.5b AHB units have all been taken up and they are launching another 0.5b units sometimes this year. So those eligible people who missed out on the first launch can apply this time around. And don't forget to open your account with Maybank.

By the way, if you had 200K AHB units, the bank charges at RM10 per transaction would only be at  about 0.3% of your dividend at the current rate of 6.2 sen per annum.

Playing with figures and statistics can be fun! Sorry DMJ...

Stock Market and the Usual Yo-Yo

Things have kind of cooled down at the stock market following the relatively good rally in early March. During that rally I saw my champion stock Pchem rising up to 7.58, acquired at the unit price of 5.04, the massive YO in the form of a rise would have made many investors off-loading their stock but not me. Is it a case of unexplained attachment or is it pure greed? ( I cringe when I type this word). My broker Charles also shook his head.

I was talking to a bank manager a few weeks back who said his friend working in the oil and gas company got 400K Pchem (IPO) shares through a loan and he offloaded them fast as the stock recovered slightly following its weak debut.The man regretted it by early March. He managed to repay his loan but he made a pittance. And just imagine he was overly relieved to be able to repay that loan!

My philosophy is if you were going to sweat over a loss in the short term, then you shouldn't enter the stock market. It is not for the faint-hearted and it is not for "chickens" who responded at the slightest negative news. Especially when you have selected a company to invest in based on its quality fundamentals. Because all stocks are subject to a Yo-Yo. You have to know the pattern of the trend, some people use the market charts data to make their move and this mix of fundamental and market charts data will actually determine actions on your stocks.

By the way, my principle is never to borrow to acquire stocks!

And so yours truly is waiting, don't know for what, and now witnessing the Pchem price falling to less than 7.00 as a YO sets in.. It is strange when the price is low, that is the time I get restless and itching to sell. Obviously not the characteristic of an intelligent risk-taker! So let us see whether the stock will climb back to its highest peak under this yo-yo environment. I believe it will.

This evening I heard that the US job data for April has shown a more than expected figure and US market sentiment is buoyant again ( another YO in  the making!) and the European stock markets also have gone north, so you can expect Malaysian stock market will open ( with a YO)  higher this coming Monday. I am not that sure what the impact of the death of Osama has on our Bursa but there was a positive sentiment in the Middle East market particularly Egypt. Others are still waiting for any possible response from some members of the  organisation the murdered Osama led. If there is then you can expect a YO.

I also notice my Sapcres and Dialog stocks are having the same swing along with the other stocks except those genuine non-speculative ones like the REITs and hmmm..... PICORP. When the international fund took flight just before CNY, almost all the desirable stocks took a beating but not PICORP... I almost smiled at myself as this stock, held for almost three years, doesn't suffer a Yo-Yo for the last two years. So still waiting patiently for it to recover from its prolonged YO... you never know.

And watch out for TM as its YO will come-a-calling  soon.

My GreEn EsCApaDe

Whenever I  am tired of  reading or working especially on my computer, I would go on the green escapade to relax my eyes. Fortunately I have just to open my clinic window and look at my favourite green especially when there is a beautiful breeze caressing those leaves, making them move ever so languidly. My mind seem to be rejuvenated  just looking at the green things in my surrounding. I would like to share some of my favourite views.

The Dancing Trees

The view of green against a clear blue sky is very soothing. I just  focus on those leaves and feel my eye muscles relax. The light breeze adds a kind of musical tune as the leaves move from side to side and around the air currents. It was indeed a peaceful sight. 

I have to imagine the interaction of leaves,breeze and sunlight as they present a picture of peace,harmony and beauty. Let my mind soar as it strives to derive simple joy by just being with nature. My escapade is complete as tranquility overwhelms me with surges of pleasurable sensations coursing through my body. Reminds me of a poetry by Lord Byron.... How do I love thee... Let me count the ways....In my case, how do I love Nature... Let me list the ways..
 
I  have some favourite green around my house. Take a look at my curry tree just outside my kitchen window. It also dances beautifully in a breeze. The curry leaves are used, well,  in curry to create that sweet pungent curry smell. I have also seen people boil nuts such as chickpeas (kacang kuda) with curry leaves to bring out that oomph  flavour.

Next to the curry tree, I have a mango tree, Harum Manis, given to me some years ago by my favourite Health Sister Theresa. The tree has been bearing sweet mangoes without fail all these years. I thought of Theresa whenever I eat the mangoes. Such is an enduring memory! There is also "limau purut" tree which I planted using a sapling bought from an old lady at an open Sunday Market. It also bears fruit continuously. Besides using it for cooking, I also use it as hair shampoo. And there is also a henna tree next to the lemon tree. I have yet to use it to color my hair in a natural way. And close to it is a "Belimbing Buluh" tree given to me by my retired Rural Nurse, Angela. The fruit is used to add that sourish flavour to some dishes and I have used it to relieve an early sore throat. Thanks to Angela!

Often at nights when it is breezy and quite, I could hear the leaves of my mango trees rustling by my bedroom window.

Trees that I planted

Yes, I also planted some pandan shrubs for cooking purposes. Oh you can really add lovely fragrant smell to your "nasi lemak", cakes and porridge using this herb and yes when I am sitting on a lazy chair just outside my laundry waiting for my clothes to be washed, I could smell the exquisite scent especially in the evening or when it just stops raining.

The Fragrant Pandan

The pandan plant grows exuberantly especially when you just let it be so every now and then I have to prune it otherwise it will march right into my neighbour's fence. Ever once my exasperated neighbour asked our gardener to prune the marching pandan as he said there could be snakes under its convoluted roots!

But I can tell you that the plant is actually a mild natural insecticide. No cockroaches will come near when you put pandan leaves in the vicinity.

My neighbour only likes to grow flowery plants. His house is full of colorful bougainvillea, roses and hibiscus while mine is full of green. There were times when his wife asked my amah for some pandan leaves to add fragrance to her cooking! during festive season, the pandan leaves are sold in a small bunch for RM2 at the market, it used to be RM1 but the increase in petrol price has shot up transportation cost of these market produce. So my nurses would troop to my house to help me prune this plant and they get their share of pandan for free.They also prune my "limau purut" plant as they need the leaves for festive delicacy, the rendang!

My favourite vitamin C source is the guava. I used to have two of this wonderful trees. They were given to me by my Hospital Assistant Joseph some years ago when I moved to my present bungalow. One of the trees succumbed to insects' infestation. It used to produce rather longish fruit but less sweet but this surviving one produces rounder fruits and are much sweeter.

Sweet and Succulent Guava

The tree has never failed to fruit several times a year and they are in abundance. Unfortunately, at times the fruits are infected by the nasty fruit flies when I forget to cover them at an early fruiting stage. Well, when you have this fruit almost everyday you tend to forget that the tree needs tender loving care.

On the flat ground at the end of the hillslope at the back of my house I have banana trees and pygmy pandan coconut trees. You have to drink the coconut water from my tree to taste the exquisite pandan-scented liquid. Actually I did not know that I had this kind of coconut species till one day we bought a couple of coconuts, noisily advertised, as having sweet taste with pandan smell at a stall. It was lovely so the next day we returned to the same place where the stall was but the vendor was no longer there! We went everywhere looking for the rare coconut but no one else was selling them. Then one day my gardener got hold of some coconuts from OUR TREE and hey Presto! It was the pandan genus. Fancy that ! All those years we just watched the coconuts falling to the ground untouched.

Well, that is my green escapade, covering most of the senses, visual,audio,taste and smell. I derive great pleasure with GREEN around me.