Tuberculosis (TB) in Two Different Presentations

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

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

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

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

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

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

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

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

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

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

    

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

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

Hypertension out of control - Look before you leap

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

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

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

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

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

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

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

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

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

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

The pundits were left bewildered.

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

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

Welcome to the roller-coaster ride of investing!

MRCB and JCY and my blundering week

I have been an inactive market participant for the last month or so especially during the FIFA world cup 2010 crazy weeks in South  Africa. But I did read market news, the up and down following American economic figures and European debt crisis as these somehow have impact on our market. Moreover this is the second quarter where  markets tend to be quieter.

Last week I re entered the market and noticed that my counter MRCB has again captured investors’ radar and it was climbing up. As I have been thinking of clearing some of my positions and perhaps picking up some stocks for short-term gains, I did not hesitate to sell off all my MRCB rights issues secured at 1.12 for 1.63. My over eagerness did not pay as the stock went on a rapid upside to reach 1.74! Why couldn’t I wait for another three days? The stock was going up, I should have waited and be a bit greedy.. ooops!

At the same time I noticed the technology counters were having a hiccup perhaps due to the lacklustre technology company reports on Wall St Journal the day before. Notion and JCY were my focus. After checking their three-month high, I went on to buy JCY at 1.51 ( well it was launched at an institutional price of 1.60 and a bit lower for retail investors) so there, the basis of my rush. Then I noted that the price was declining further and without thinking logically, I grabbed more of its shares at 1.45  only to feel irritated as it went on plunging and now seemed to stabilise at 1.37! Why couldn’t I wait for another week? The stock was going down, I should have waited and be a bit thrifty with my precious money....

Sell high, buy low, a good edict but is quite difficult to translate into practice unless you are a professional trader or fund manager. But there is no fun if you just sit back and let other people manage ALL your investing fund... I need that thrill of making it on my own which means I must be ready to laugh these blunders off....

Looks like I have to hold on to JCY till the next quarter and wait for MRCB to strike beyond 2.06 in 2011 to dispose the rest of my shares! And JCY to once again  reach 1.98... big deal mate!

Hypertension and the doctor's mental pain

She looked older and rather haggard. She specially had requested to see me. She complained of severe unremitting headache. She had been taking pain killers these past few weeks but the headache never went away. At times she said she felt nauseous and this has affected her quality of life.

I know her. Two years ago she came to my clinic because her daughter had a fall and broke her arm. After treating the child, she had told me that she was on an injectable contraception and was having headache every now and then.  I took her blood pressure and found it to be high. As it was a first reading and also the fact that she was under a  lot of stress due to her daughter's accident, I told her to have some basic blood investigations ( even gave her the forms!) and to come for daily blood pressure monitoring for three consecutive days and then to return to the clinic in 14 days' time. I also cautioned her that she would be better to stop the contraception as it can cause an increase in blood pressure in some women. I was looking forward to analysing her laboratory investigations and reviewing her blood pressure. I thought of her a lot for some unknown reasons.

But she never did turn up. That was two years ago and in the meantime she had given birth to her seventh child, having stopped her contraception soon after she saw me.

Today her blood pressure was still high and her urine contains blood and protein, an indication that her kidney function is not normal. She needs to be treated for her hypertension which has caused constant headache. If treatment had started two years back, her kidney function would not have deteriorated. I explained to her the need to be compliant with the treatment to delay the progress to kidney disease. She looked unconcerned and I feared she would not turn up for review in a fortnight's time.

As a doctor I feel sad and rather angry with myself for not being able to prevent this outcome. It did not help either  as we were not able to contact her earlier as she had no contact number. She lives far away from the city and public transportation there is poor.  She has no car. Poverty does make life miserable. And she is 37 years old with many young children to care for.  How could she look after her own health?

It is my turn now to have a headache!

The 19th FIFA World Cup 2010- What a tournament that was.

For 31 days in June and July 2010 the World was at its edge, watching the 64 games by 32 elite teams of the world. We waited for this greatest tournament for four years and what a time it was. One of the main sponsors had put it aptly by this tagline " For 31 days, every four years, the world comes together to stand apart" beautifully enunciated by Morgan Freeman, the famous Hollywood African American  veteran actor.

Watching those teams competing amid the various coaches' strategies was like  witnessing the spirits, hopes and aspirations of the respective competing countries. National pride was the ultimate price. To be the best in the world is such a good feeling. However for those of us whose countries were not competing, we turned the event into something we wanted to enjoy especially when it came with an element of prediction based on the track record, skill and type and style of  team games. Of course there is also the element of betting which has been there since time immemorial, the Roman gladiators in the years before Christ comes to mind as well as fighting fish and fighting cocks as betting platforms. People just love to gain (and many lost) on so-called luck.

Thousands of fans came together to root for and celebrate with their teams. You could see people praying hard each time a penalty was taken that I wondered  whose prayer would God grant! They roared, shrieked,shouted,screamed,jumped and in those fan-packed stadiums, they blew the vuvuzelas... what a blaring sound!  The excitement was palpable. There was, somehow a sense of emptiness when the final whistle was blown on 12 July.

There were some negative reports related to the tournament like a South Korean student who drowned while celebrating his country's entry in the round of 16, the man in South America who throttled his step child who would not stop crying while he was watching the match between USA and Chile and a few members of a family who died when their house collapsed while watching the game in Africa. The latest negative incident where 64 people in Uganda died while watching the final on 11 July was senselessly tragic as it was due to a series of bombs being planted by mindless terrorists! God makes all kinds of people in this world.

                                       The new FIFA World Cup champion 2010 - Spain

Now we know which teams are standing apart. Spain lifted the World Cup after defeating the Netherlands in the final. Spain also won FIFA fair play award (the least number of yellow and red cards). Germany came third and Uruguay fourth. The last two nations have ever become the cup champions before and for Spain, this is their first time, how historic for the nation! They deserved it. Viva le Espana!
 

                    Uruguayan Striker -Diego Forlan -Golden Ball winner


I managed to watch the final live and managed to also come to work. On the way to work  last Monday, I noticed the city-bound traffic was very light compared to other days and similar low traffic volumes were also reported in several cities in Malaysia... gosh, just look at the effect and impact of the World Cup! People took leave to watch the final and that says volumes about  the popularity and magnetism of the World Cup football and after all it is held once in four years, so bosses who don't  like football please understand.

                 

Germany Thomas Muller - Golden Shoe winner


And about Paul the psychic octopus in a German aquarium which was 100% right on his prediction of German team - participated match winners and including the final, I  regret for not following him. Now I do not know where to find octopus to cook my asam pedas  ( Chilli Octopus with tamarind juice) as promised if the Netherlands lost.... and the Dutch who played disappointing football  during that final ,by the way, actually lost in extra time. Spain 1 and Netherlands 0

                                          Psychic Octopus Paul  (Copyright Photo by TimesofIndia)

A Spain businessman has offered to buy Paul for USD 66,000 to bring it over to Spain... I wouldn't part with the creature at any price! A string of bookmakers from around the world have also expressed an interest to buy the octopus from the Oberhausen Sea Life Centre, with marketing experts predicting he could become a big hit with advertisers. But apparently the life centre said Paul would call it a day and go into retirement... what a waste of his psychic power!

Much praise have been showered on the host country which has put together a successful greatest game on earth. Their stadiums at Durban, Blomfontein, Port Elizabeth and Soccer city in Johannesburg are world-class and their people so gracious. We know more about South Africa and its people and culture now and thanks to Astro, the satellite TV company, for giving us such an exciting experience of watching and re watching all the matches. The antics of the fans who added sound,colour, humour, excitement  and life to the games are also unforgettable. Real great!

                                      DinoSupremo- Fan of the tournament  via online voting

Looking forward to European Cup 2012 and the 20th FIFA World Cup in Brazil in 2014!

The FIFA World Cup 2010 - Now for the Semi-Finals

I have watched three quarter-finals, Brazil-Netherlands, Germany-Argentina and Paraguay-Spain with Netherlands, Germany and Spain going into the semi-finals and I predict Netherlands would make the fourth team into this stage.

Last night on 3 July 2010, my team Argentina was badly thrashed by 4 to nil by the Germans. Yes, Argentina has many brilliant players like Brazil but they tend to depend on individual players. Germany has relatively young team with full of energy and enthusiasm and great teamwork. They are admirable.

Earlier on I have said that I would support the underdogs but unfortunately they have all packed up their bags and gone home. Though I am sad at the way Ghana was dealt by Uruguay. That handball by Uruguayan striker, Suarez in front of the goal mouth, was really not in the spirit of the sport. I would call it downright cheating! Ghana was worthy of going into the quarterfinal and to be denied in such a manner was painful for the African fans. Suarez was red carded for his action and cannot play in the quarter-final match with the Dutch. For me he deserved to be banned from the game altogether. Apparently he celebrated his action by saying that now the "hand of God" belonged to him! Wouldn't like to see the like of him in the World Cup ever again,

 

Suarez's deliberate handball prevented Ghana's goal

The Brazil- Netherlands game was exciting with Robinho scoring a quick goal  at 10th minute after the start of the game, however the Dutch team came back to score two goals  to win. The Dutch hold the record of being unbeaten throughout all their matches. If they won the World Cup, they would be the  true champion.

     Netherlands in orange, scoring against Brazil

 Argentina lost by 4 to  Germany with a relatively young team with great team work. German's midfield is formidable. I noticed that Germany has players from other ethnic groups like Ozeil (Turkish descent), Boateing from Ghana and Khadeira of Tunisia descent. Argentina are all of the same ethnic group- just an observation.

What makes soccer a great game to watch is the team work they display and the strategy adopted by the coaches at different stages of the game like who they replaced whether a striker or a defender or a midfielder to add strength to the team and spur the game. Scheweinsteiger created beautiful chances for his teammates like  Muller to score. The fastest goal scored in world cup at three minutes into the game was just fantastic and could have disoriented the Argentinian defenders! Another world cup talk that I came across was the advantage Germany had over other competitors in using the new ball, the Jabulani, six months before the competition. Well, the talk would not have surfaced had Germany been eliminated earlier.

                                                     Bastian  Scheweinsteiger, German midfielder - Man of the Match

Nevertheless, it was both exciting and entertaining to watch the young German players working hard to deny Argentina's Lionel Messi's chances of showing his brilliance in goal scoring.  Though I was praying hard for Messi to score. I felt sad for Messi who apparently broke down crying in the dressing room post match. Gosh! Such is the effect of the World Cup. Germany's Chancellor Angela Merkel was there to cheer her brilliant team! Now that is a people leader. She might just win the elections based on this German euphoria.

The Paraguay versus Spain quarterfinal was also worth watching. There was plenty of excitement with penalty aplenty and heroic saves by the goalkeepers of both nations. The Paraguayans were playing quite well almost denying Spain, one of Europe's soccer giants, its entry into the semi-final. Spain won one nil through their awesome striker, David Villa.

     David Villa celebrating his sole goal for Spain and into the semi-final

The semifinals are up next and I have to stop searching for my favourite teams and just enjoy the game, shouting for the better team to win. I hope they will play fairly so that the deserving team will hold the coveted cup. I must admit that I have seen  quite a number of unsportsmanlike behaviours such as stepping on opponent's ankle (Felipo Melo of Brazil - sent off the field) and that Nigerian player who kicked the butt of his fallen rival and he was also dismissed. And of course the well publicized altercation between Anelka and his coach! That was shameful and the  French team was the laughing stock of the world for refusing to train after that... talk about spitting into the air skyward! And to me , Suarez's deliberate handball took the cake.

All the best to all the semifinalists. May the best team win. Best in all respects, skills. strategy and conducts.

 

For the final I think it would be between Germany and the Netherlands, looks like it is going to be a  European affair after all.