Ebola At Our Gate?

I was rather down when I read the statement from our immigration Department which stated that there would absolutely be no restriction of entry for Students coming from Africa despite the current Ebola crisis occurring  largely in West Africa and now has spread to Nigeria.

Rapid travel by air is the culprit. Those who travel are well advised to take precautions like washing hands with soap and water frequently and resort to wearing masks if the passenger next to you is coughing and sneezing all night on long-haul journey.

The news of an African student entering Malaysia with signs and symptoms which are suspected to be an Ebola infection is disheartening and frightening to say the least. Though Malaysia is equipped to deal with the scourge having dealt with the SARS problem ten years ago, we cannot but be highly concerned. Unlike SARS, Ebola Virus Disease (EVD) has a high case fatality rate, killing almost 50% of its victims and like SARS there is no cure, neither  is there a vaccine to prevent it.

The report of the fourth doctor to have died of the infection in Liberia is disconcerting though we understand the condition there is a lot less favourable in terms of detection, diagnosis, management of cases, contact tracing and isolation procedures. The problem there is compounded by poor education of the people and the belief in the unknown, poverty and the  mistrust of health personnel.

Though it is said that Ebola virus is hard to be transmitted, the risk of fatality to infection is high due to its virulence nature and massive immune response causing widespread internal bleeding in organs.

So do be careful when you are in the crowded international airports. You never know.

Respiratory Virus - MERS-CoV has landed in Malaysia- The First Death in Asia

The first case of death due to the Middle East respiratory syndrome corona virus , MERS-CoV has been reported in Malaysia. According to the Ministry of Health, Malaysia's statement, the victim is a 54 year old man who went to Mecca for Umrah (pilgrimage) and returned to Malaysia, using a Turkish airline on 29 March 2014. He started to have signs and symptoms of respiratory disease on 8 to 9 April and as these deteriorated, he was admitted to a hospital in Batu Pahat, Johor on 10 April and expired three days ago on 13 April. The first reported death due to the virus in Asia.

MERS CoV and Distribution of Cases since 2012 with most detected in Saudi Arabia

The Ministry of health has put on a public health alert on this potentially fatal disease.

The virus was first detected in 2012 in Middle-eastern countries ( I posted in my blog earlier) . It causes similar signs and symptoms to the dreaded SARS (severe acute respiratory syndromes) and its origin is believed to be from animals such as bats and camels. The disease can be transmitted through close contact. The frightening thing about this disease is that it kills about 50% of reported cases (high case fatality rate) and it has no vaccine. And there are no medications against it. For a more detailed information on this disease you can visit the CDC Atlanta website .

All close contacts of the case would have been investigated. But like all other diseases caused by viruses, they show a spectrum: some are very ill, some have mild disease while other cases may not show the signs and symptoms, in fact they appear well but may carry the virus (known as carriers) and could transmit to others through their body fluid. You might like to read this report from Manila on a health worker tested positive for the virus but has not shown symptoms. This is the part which is causing problems or anxiety to public health so we must all do our part by being overcautious through awareness,good personal hygiene and knowledge of the disease.

Constipation - 2 " My Abdomen is colicky and I am constipated"

A 41 year old man weighing 104 kg with a BMI of 40 and thus labelled as "morbidly obese" came to the clinic looking irritable and depressed. By the way I notice that patients who are constipated are generally glum and down.

This is his third time of seeing a doctor for colicky abdominal pain and constipation. He claimed everytime he came to see a doctor, all they gave him was stool softener and advice to take more fibre, vegetables, fruits and drink plenty of water. Well, according to him the problem settled after taking the stool softeners but it recurred despite him taking the suggested foods to help reduce his constipation. when asked whether he passed flatus (fart), he replied "hardly now".

I could have given him the same prescription of stool softeners but I thought it would not help him. In fact I was tempted to just do that seeing that the patient was irritable and seemed to think that the world owed him a living. He was also accusatory of the "unhelpful treatment" received so far.

I asked him how long had he been constipated and he replied for the last one month or so. He was not constipated before that neither did he have colicky abdominal pain. He also denied taking any medications which could contribute to his current problem. Then I asked him what was " something new" that he had been taking over the last one month or so.

He paused to think then he said that about six weeks ago he went to see a private doctor for aching pain in his knee joints and the doctor advised him to drink a special high-calcium milk as he (the doctor) thought he had "bone problems". The patient had been taking the milk three times a day and now he realised that his current problem started a few days after his thrice a day milk drink.

Too much calcium in the blood (hypercalcaemia), depending on individual response , could cause constipation with abdominal colic.

I told him to stop taking the high calcium milk and prescribed him stool softeners to tie him over the period before the return to normal calcium level. He came for review after three weeks looking more cheerful as his abdominal pain and constipation had both subsided.

He complained that he spent so much money buying the "special milk" only to throw it away. I advised him to lose weight as he is unhealthily obese (morbid obesity). He is 34 kg overweight and now suffering from knee arthritis causing him aching pain. Taking more calcium is not going to help him, in fact too much of the  mineral had adversely affected his bowel movements.

Excess weight strains the knee joint causing arthritis and pain

Obesity affects knee joints by placing more force on them, gradually wearing the joints away causing arthritis, pain and inactivity leading to more weight gain and worsening obesity. A vicious cycle.

Constipation-1 "Help! All my children are constipated"

A few months ago a mother of four children ranging from the age of seven to fourteen complained that all her four children were suffering from constipation for some time. They have been coming to the clinic and have been advised to take more fibre like cereals, more fruit and vegetables and plenty of fluid but it seemed to no avail as the problem kept on recurring.

The children's stool were hard and they really had problem defecating according to the mother. I noticed that stool softeners had been prescribed on a number of occasions but the problem persisted. I asked whether the parents were also constipated for which the mother answered in the negative.

Fried sausages taken everyday for lunch and dinner

Interestingly all four have a similar problem. It must be something that they eat. So I asked the mother what was the children's favourite food that they eat most of the time at home.

The mother said that the children loved sausages. She fried them the sausages day and night. And if she did not do so the children themselves will fry and help  themselves. They loved sausages and eat them like their staple food.

Now that piqued my curiosity. What is sausage? Sausage is defined as ground meat mixed with fat, salt and other seasoning,preservatives and sometimes fillers. You can actually make your own sausage if you know the recipe and have all the time in the world to do it.

Most people buy them  ready-made from the supermarkets  and I suppose they can be rather tasty given the right amount of salt and other seasoning and no wonder the children in question got hooked on this "easy food". But eating them everyday is a bit too much as being a processed food there could be too much of certain items such as pectin or thickening causing their stool to be hard.

To cut the story short, I told the pregnant mother to stop buying and serving the children with sausages for a few weeks and see the effect on their bowel and comfort of life.

True enough after a few weeks of no-sausage meals the children stopped having constipation!

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Heavy Coffee Drinkers Beware

People drink coffee for various reasons. Many would admit to drinking many cups of coffee because they are addicted. Some of my patients who work as security guards say they drink a lot of coffee to stay awake, sometimes more than four cups a day!

The news report on the findings of a study (here) on heavy coffee drinkers should act as an alert for those in the same boat about the danger of this habit to their health. In fact, heavy coffee drinkers have an increased death risk according to the study.

I am a coffee drinker only on an occasional basis. I just do not drink any brand of coffee, though would dispense with my personal preference if presented with the choice of brewed coffee usually at my golf club or restaurants.

When I was a student in Australia my favourite coffee brand was Maxwell House (MH) and I continued with it on my returning home but gradually over the years, the brand has slowly disappeared. I tried several other brands but found them not of equal taste to MH.

When I was studying I drank coffee quite a bit. I was then suffering from leg cramps especially during winter though not as cold as the winter in England but all the same the nights could be quite cool. Anyway, these leg cramps were really bothering me, sometimes I would wake up with extreme pain and had to massage my legs frantically. The condition came about when I was a second year medical student. 

One day during an anatomy class I entered into a conversation with my demonstrator, an old Professor from East Europe and mentioned about my affliction. Without batting an eyelid he asked me to stop drinking coffee or tea for at least three weeks and see whether the cramps subside. To cut the story short, the condition disappeared after I stopped drinking coffee. I cannot find any research studies on this effect of coffee (caffeine) on muscle cramps, perhaps overstimulation? But at which level of the nervous system? I should have then asked the Prof who is now deceased.

My favourite brand of coffee

Anyway, for a long time I had not drunk coffee simply because I could not find a brand that I like and by this time I decided to drink only one cup a day. At last I found a brand that I truly enjoy the taste. It's called Kenco but it is not sold in just any supermarkets. 

I first bought it at the Pavillion, Bukit Bintang and once finished, I could not get it anymore so for nearly two years I was not able to enjoy a good coffee. Then a few months ago I chanced upon it at Jaya Grocer in Bukit Jelutong Shah Alam, imagine my joy! Unfortunately there was only one bottle left.

No, I don't suffer from cramps anymore because I only drink coffee occasionally whenever I need to perk up! Hardly a heavy drinker or rather what is elegantly referred to as a quaffer.

Omega-3 Fish Oil - A Healthy Heart or A Healthy Prostate

As always the case, many of my patients would ask about the goodness or advantages of their food or vitamin supplements. Many of them are led to taking these through friends' recommendations, media advertisements and lo and behold, even through their GPs (general practitioners)! some of these errant doctors even sell those vitamins at their clinics. My training has persuaded me to regard  this as unethical. Anyway this is beside the point.

I always tell my patients that for as long as they are healthy, not suffering from terminal diseases,   and have good appetite they should stick to taking a balanced diet suggested by the food pyramid. It is better to take natural foods as the body is physiologically familiar with them. Fresh fruits and vegetables contain vitamins that the body needs. Supplements may contain other chemical contaminants and artificial food stabilisers like colouring and taste at the point of processing and production.

One of the supplements highly touted to be advantageous to people suffering from heart or cardiovascular disease is omega-3 fish oil. Many of my patients take these capsules and I had earlier not much information on the long-term effects and have therefore remained rather neutral on my advice.

Omega-3 Fish oil capsules - Net Image

But the latest research findings on the link  between omega-3 fish oil and risk of prostate cancer, which confer with an earlier finding in 2011 is rather worrying. Prostate cancer especially the high grade classification is usually fatal. As suggested by the researchers here more studies need to be undertaken to determine the specific mechanisms linking this finding in prostate cancer patients with high level of blood omega-3 fatty acids, I would suggest to my elderly male patients who don't have cardiovascular disease indicators such high triglycerides level to stop taking this supplement for the time being.

Apparently it doesn't matter from which sources you take this omega-3 oil, dietary intake or supplement, you have to be aware that a high level of this fat may not be good to your prostate. I suppose omega fish oil capsule taken daily would have exposed your system to a more sustained high level of it.

It is important to note that unless a properly planned research is done we might not know the effects of any medications/supplements on our body. Some of these scientific research are triggered by cluster observations of people coming down with a certain condition and a search for links is made and findings are required to be reproducible by other groups using similar methodology and later peer-reviewed and published in reputable medical journals.

Anyway, omega-3 oil may be beneficial for the heart and its "required" blood level may have been established but then people are different in their response to their metabolism and certain factors like enzymes may affect the level in different individuals. Hence what is fine to a patient may not be so in another.

What about women taking this omega-3 fatty acid supplement? There is some suggestion here that might be beneficial for breast cancer but there is no focussed research but only a meta-analysis of 21 studies the individual methodology of which are important to look at before they can be accepted.

What 2000 Calories Looks Like

Have you ever wondered why you are getting bigger despite eating so little? It is the content of food that matters and not the size. The daily calorie requirement of an average size man is 2000 and if you eat pizza daily plus all other foods like ice cream and biscuit especially without exercises, you sure will have excess calories which your body turns to FAT! So be aware of what you eat. Choose wisely and live longer with good health.

Watch the above video if you want to know what 2000 Calories "look like".

( Obesity is usually food-related but can also be due to hormonal imbalance )

Chest XRays - Similar Symptoms, Different Infections

Two different men presented to my clinic. The first is a well-muscled, local, mid-thirties and working in a detention centre and I will call him LY. The second is a thin foreigner in his mid-forties, jobless and hard of hearing and I will refer him as FS.

LY came with a complaint of recurrent and unrelenting coughs for more than two months. He also experienced evening sweat and fever. His appetite was low and he had lost a lot of weight recently. He also gave a history of having slept in the same room as an inmate diagnosed as having tuberculosis. His coughs were productive and sputum was yellowish and occasionally streaked with blood with incessant coughs.

FS had the same symptoms except his sputum tended to be frank blood (haemoptysis). In fact, through his mother who accompanied him, I learnt that he had no contact with a known PTB patient.

Whilst LY's sputum came back negative for AFB (Acid fast bacilli) on all three good specimens, FS's was positive on the first sputum sample. There is no doubt as to FS's diagnosis and his chest xray showed the lesions on his upper left lungs. He was promptly treated with an anti-tuberculosis regime.

FS's chest x-ray showed more "stormy" picture of the lung with two cavitating lesions at the apex of the left lung. Though  most TB lesions tend to be in the apical region of the right lung  due to the more vertical position of the right bronchus, it can also occur on the left upper lobe.

LY's chest x-ray - clear apices with parahilar lesions.
Sputum AFB -ve and treated for community acquired pneumonia
and referred for further evaluation partly due to abnormal left cardiac border.

FS's chest x-ray - cloudy apex of left lung with cavitating lesions
more "snow storm" noted - Sputum AFB +ve and treated for PTB

LY's chest xray showed parahilar solid lesions likely to be lymphatic enlargements. He was treated with a twin-course of antibiotics and returned three weeks later to report that his coughs had stopped and he was feeling a lot better.

Fearing that he might suffer from other conditions, I referred to the general Hospital for further evaluation like getting a CT (computerised tomography) of the thorax done on him. His chest x-ray picture had not really changed after two weeks of the antibiotics course. Apparently, according to the respiratory physician, post-treatment lung changes might take a longer time to resolve.

Using chest x-rays alone are not sufficient in making a diagnosis of PTB (pulmonary tuberculosis), the sputum analysis is the gold standard for confirmatory tests. By the same token, it is not enough by just having a plain history as the symptoms are similar in fact, LY's contact with a PTB inmate had convinced me that he was suffering from PTB.

MERS- Is It A Developing Threat?

I came across this news report (read here) on a novel coronavirus referred to as MERS or Middle Eastern Respiratory Syndrome virus which has apparently claimed lives in Saudi Arabia. The virus causes high fever,respiratory symptoms such as coughing and difficulty breathing and leading to rapid kidney failure. It sounds similar to SARS or Severe Acute Respiratory Syndrome virus which precipitated a global scare back in 2003 when 800 people were reported to have succumbed to the disease.

A MERS coronavirus is shown in this colorized transmission electron micrograph.

Photograph by: THE CANADIAN PRESS , HO-US National Institute for Allergy and Infectious Diseases-RML Beth Fischer

Considering that million of people the world over perform a pilgrimage to Mecca in Saudi Arabia annually, the virus could have the potential of being spread far and wide. I hope the Saudi Health Authorities will act on this public health concern by getting the cooperation of the World Health Organisation or WHO (Read here) to collaborate with it. The concerning feature of this new virus is that it has a high fatality rate.

Unprecedented global cooperation to fight SARS ten years ago resulted in the threat being prevented from inflicting greater morbidity and mortality. The current lack of information flow from Saudi Arabia is worrying.

As it is a new virus, there is no vaccine against it and the mode of transmission which is airborne poses a danger of very rapid spread unless cases are quickly detected and quarantined. Public health measures and personal hygiene need to be promoted.

It is advisable to be overcautious than waiting for the threat to be full blown and becomes a health crisis.

More articles  here.

Breastfeeding and Childhood Allergy

A two-year old child was brought to the clinic by her anxious aunt recently. The complaint was:  for the last three days the child's eyes were swollen and watery. She refused to open them especially when there was sunlight and she had been rubbing her eyes. I asked her aunt whether the eyes were red and exude yellowish secretion and she replied in the negative. The child had no recent throat or chest infection. There was no family history of asthma.

Upon examination, the child's eyes were swollen and she was not cooperative and kept her eyes closed but I managed to see her left eye to confirm that it was not red. Her chest was clear and there was no nasal discharge.

I then proceeded to ask about her meals so as to identify any food which could have caused this allergic reaction (periorbital angioedema). There appeared to be no newly introduced foods in her daily intake. Then the aunt mentioned that the child was still breastfeeding and that just before the appearance of the signs and symptoms, the mother had a meal of crabs (seafood) which has been known to cause allergy in some people.

Crab salad

The child was treated for allergy.

I am not very sure of the connection as I cannot find any studies on this hypothesis that an allergy can be passed through breastfeeding. But if certain medications can pass through breast milk to child, I do not see why chemical complexes in the body cannot do the same. Of course my contention appears to be anecdotal as I don't have the data to support this finding. The association with the mother's meal could well be spurious. More cases need to be observed.

Juicy and sweet Rambutan

I have also come across a mother of a three-month old exclusively breastfed baby who was previously normal with no prodromal signs and symptoms but the very  next day was restless with cough and watery nasal congestion not associated with fever. And the mother admitted to eating "rambutan" in large numbers the day before. An interesting observation indeed.

 Rambutan is a seasonal fruit which is very juicy and sweet and known to irritate throat mucosa. I am waiting to see if there are other such cases so that I can advise breast feeding mothers to be careful on what they eat.

 Some allergy can be short-lived while others may be lifelong depending on the type of immune reactions causing it in the first place.

The Liver, Herbal Use and Allergy

A 38 year old man was referred to me for running up an abnormal liver function test. The enzymes produced by liver cells were high indicating liver injury. And as often the case, the patient doesn't feel any pain or discomfort. Neither does he display any signs or symptoms like nausea,vomiting or jaundice. It is, by and large, an incidental finding on the part of the health-screening program. The test was done two weeks prior to his seeing me.

I also observe that when the hepatocellular enzymes are elevated so is blood cholesterol indicating the inability of the liver to process cholesterol within its metabolic cycle.

As per my practice, I go through with the patient on what he has been taking for the last few months. Among the usual agents causing liver injuries being drugs/medications (slimming pills, " traditional Chinese medicine"), alcohol and herbal preparations.

Yes, he admitted he started taking a herbal preparation early in the year (2013). And he told me an interesting story of being admitted to the hospital for observation on two occasions due to high fever and itchiness in his body about two weeks after the daily ingestion of the preparations. He was treated for allergy.   And according to him he has never had similar problems before. Feeling something amiss, he went for the screening program.

I advised him to stop immediately the herbal intake and put him on a two-month of liver treatment and will monitor his liver function after four months. He is also asked to monitor his incidents of allergy.

I have seen so many patients having this herbal induced liver injury. I just wonder whether the effects would just stop after one ceases herbal use or whether there is a threshold where there is a point of no return?

Imagine the liver is a big organ, minor injuries in parts of it would not have significant physical effects to the person. With continued ingestion, cumulative effects will result and would be too late already for someone to show the signs and symptoms of liver failure. It is well-known that the liver has a great capacity to compensate, meaning it can go on functioning while it is diseased  till it is too late. You can see these compensatory effects in alcoholic liver disease.

I have come across two cases of fatal liver failure due to spirulina ingestion in the hospital where I previously worked.

For those who take herbal preparations, do test your liver function before it is too late.

The European Horsemeat Scandal

It is a disgusting thought to eat something you think you know but actually it is something else. And so the horse meat scandal in Europe is a chance discovery which has shocked many people who have the least idea that they are not eating beef but horse meat. You can read the timeline of the exposed scandal here.

Beef or Horse meat - can you tell?

Besides the distaste, the main issue is eating horse meat that is tainted by pain killer phenylbutazone. This drug is known to cause blood problems namely aplastic anaemia. People are worried that it has entered the food chain and cause widespread effects. You can see the video on this rare but dangerous effects of the drug in the food chain. Drug residues perhaps, but over a long period of ingestion they could prove fatal.

It reminds me of the story of the disappearance of the vultures in Mumbai. These birds of prey were instrumental in "the burial" of dead bodies of people belonging to the Parsi faith in India at one time. The bodies are left for the birds to consume as per their religious tradition. But gradually these animals died away and it was found that  they perished en masse from kidney failure due to eating human meat tainted with the drug indomethacine ( nonsteroidal anti-inflammatory agents or NSAID) used to threat arthritis.

It is therefore very important that our food is not contaminated with such drugs which could compromise our health through its reactions with our body when taken on a long term basis.

The investigations are going on now as to establish and arrest possible criminal elements which produce  and profit from cheap contaminated  foods at the expense of public health.

Scabies and Medication Misuse

Last week a mother and her two teenage children came to the clinic complaining of intensely itchy skin. I took one look at the lesions especially in the interdigital areas of the hands and feet to quickly diagnose it as scabies, a skin disease caused by tiny mites burrowing into the skin.

The mother immediately said that the three of them came 10 days earlier and were told that it was kudis buta, a Malay word for scabies. They were prescribed with an emulsion to be applied to the body and one of the sons was also given an injection but the conditions have not subsided and in fact it worsened in one of her sons causing him intense discomfort and unable to sleep at night due to the itchiness.

The teenage patient's palms, note
the pus-filled blister

They looked exasperated and the mother said "Please give us injections and strong antibiotics to get rid of this skin problem!". I noticed that the son with the most lesions and purulent vesicles had a strange looking palms, dry and scaly and whitish  And when asked how the palms came to be in such an appearance, the mother related that the boy had been applying the emulsion everyday at least two, three times to get rid of the itchiness for the last 10 days!

Obviously this family has not been informed about this skin condition as to its cause and how to prevent its recurrence and the proper use of the emulsion (Benzyl Benzoic).

I told them about the mite and its disease history and even showed them the pictures of the mites on Google and stressed upon them the need to sterilise their clothes and beddings and keep their house clean to get rid of the mites . And the emulsion is not to be used for days, in fact it is only for 2 to 3 overnight  whole body applications. Chronic use of the emulsion can be poisonous or detrimental to health.

The mother looked perplexed and I had to explain to her several times that the condition would recur if she did not do anything to remove the mites in her house. The mites are not killed by antibiotics because they not bacteria ( the concept she found hard to understand in the first place).

After spending a good 15 minutes  talking about the skin condition, the mother at last said " I have never known about how the condition is caused and now we will do as you say". It is sad when doctors don't explain to patients properly resulting in so much morbidity and in this case the two children had not gone to school for more than a week as their conditions looked embarrassing beside difficulty holding a pen to write.

 Some doctors only know how to diagnose and prescribe but the prevention part is not explained. This happens due to perhaps their being too busy, failure to  think that it is important or taking things for granted. To me patient-doctor interaction should always be educational in order to have a greater impact on patient's health.

" Help my baby's turning yellow!"

A young mother turned up at the clinic last month with her seven month old infant looking desperate. She said she noticed the skin of her baby has become progressively yellow for the past week. He is her first baby and he also suffered from jaundice at birth. She was worried that the condition had recurred. In fact she had been to a private doctor who assured her nothing was wrong with the baby. She was not convinced as the yellowish tint has become more generalised to involve the baby's hands.

The mother was asking whether a blood test should be done on the infant to establish the cause of his abnormally yellow skin.

General examination of the infant showed that he was active,alert and well-fed. Of course he was looking abnormally yellow but his eyes were not, as expected if he were to have a liver or blood problem causing a high bilirubin level in the system, yellow (jaundiced). The signs and symptoms did not point to  a usual medical condition.

I proceeded to ask about what kind of food the child was given and whether mashed carrot was given and how often. The mother said she gave mashed carrot everyday for every meal for the last one month! I advised her to stop the practice because frequent intake of carrot especially in a young child would cause the skin to have a yellow tint. And there was no need for a blood test.

What the baby was suffering from is called carotenemia that is an excessive blood level of carotene which causes a temporary yellowing of the skin (pseudojaundice). Carotenemia is most commonly seen in infants fed too much mashed carrots and also adults consuming high quantities of carrots, carrot juice or beta carotene in supplement form.

Carrots contain  carotene

Mashed carrot

A meal of mashed carrot twice a week would be just fine. The mother should also use other type of green leafy vegetables instead of just carrot.

The child's skin has since returned to a normal colour. The mother is thankfully relieved.

Herb and Heart - Another Case

A 54 year old lady has been my patient for the last two years and on treatment for her hypertension. I normally carry out blood investigations for my patient on an annual basis. Her first blood picture was within normal limits but the second one about five months ago showed that her fasting blood sugar had gone up to near  diabetic level.

Having determined her haemoglobin, I did a test to determine her glucose handling capability through glycated haemoglobin or HbA1c. Sure enough the level was at the limit of 6.5%, indicating that she is experiencing an impaired glucose tolerance state. Having explained to her about the condition she is now facing, she has asked that she be put on a diet to control her sugar intake. After two months the fasting sugar level had slightly decreased. She was encouraged.

On the fourth month, the sugar level seemed to have  stabilised  but  still at the impaired tolerance level  but I noticed her pulse rate had gone down to 54 beats per minute. She also admitted of being increasingly tired and listless. Her blood pressure was,  however, normal.

 From my experience with patients when there is a decrease in pulse rate to this level what we term as bradycardia (Pulse rate lower than 60 beats per minute ), the patient must have taken something which is cardioactive (affecting the heart) like some drug or foods containing such agents.

The lady denied taking anything besides the medication for her hypertension. I was not satisfied and kept gently asking her to think of what she had been taking the last month or so which was not in her normal diet. After some cajoling and patience on my part, she revealed that she has been taking an ulam ("salad" in English) twice a day in increasing amount to reduce her sugar level in the body!

I immediately knew what it was and mentioned it to her, yes, it was the same herb/fruit called "jering" in Malay  or its botanical name Archidendron Jiringa  It has a bitter taste and the local people believe it reduces the sugar level and cure  diabetes! 

"Buah Jering" tree

"Buah Jering" Pod

I told her to stop taking the fruit/herb as somehow it has an effect on the heart. She stopped it and after about two months her heart rate had returned to normal but her sugar level had again increased and I decided to put her on an anti-diabetic medication as unsupervised diet control and use of herbs could be detrimental to her.


It is sad that people are taking herbs which they think are not chemically active and end up having adverse effects on their organs such as the heart and liver.


The problem is these so called herbs are not properly researched and no one knows about what dosages people need to take to have desirable effects and control of side-effects. A lot of experiences are anecdotal in nature and no one could say for sure that their disease status became better following all these herbs ingestion. I have seen more negative effects on the users of these herbs. But then of course these are clinic patients, that kind of statistics are not valid.

A concerned doctor has cautioned over the use of this fruit here

The  doctor's letter was in response to an article on buah jering's purported medicinal properties in the same news portal this link   The lack of information on the use of this herb/legume could cause undesirable medical conditions in some patients who are out to prove that they can do away with western medications.

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.

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.