The Stuff of Primary Care and A Duty of Care

Nearly 90% of patients who visit Primary Care clinics or General Practitioners suffer from respiratory conditions. While many of these are due to viral infections and therefore do not warrant an antibiotic therapy, a small proportion of others are due to allergic reactions giving rise to an asthma.

It is therefore important for a doctor especially at this point of contact to examine the respiratory system especially listening to breath sounds to determine a diagnosis which ensures a proper treatment for the patient.  Sadly many doctors, possibly due to the heavy attendances or simply negligent, have not conducted this step satisfactorily.

I have recently attended to a 10 year old boy who has been coming to the clinic since August 2012 for recurrent coughs. The first time he came he was given the usual anti-cough mixture, the second time it was the same, the third time the doctor ordered a sputum for AFB ( Acid-Fast Bacilli) for suspected TB (tuberculosis) and given a double antibiotic regime as he thought the child could have pneumonia despite not having any fever. The recurrent coughs had never stopped and the father kept bringing the child and another two sputum AFB were ordered and I noted only one test came back without any report as the samples were said to be not satisfactory. I also could not find the chest x-ray ordered by the third doctor and so reluctantly have to order a new one which I was not happy about.

There is no continuity of care for this child who is rather quiet. He was seen by four different doctors before coming to me. It didn't help that the child kept denying that he had breathing difficulties especially after physical exercise. I took his blood sample to see whether his hemoglobin level is normal as though he has no pallor, his father insisted that he has not been eating well. The boy's Hb level was good at 13.4g/dL.

I did a full examination of his respiratory system and listen intently for his lung sounds and detected the mild wheezes. I made a diagnosis of asthma and treated the child accordingly and the coughs have since been reduced and the father is very happy to at last be told of the diagnosis and how to deal with the condition.

It is very important to make a firm diagnosis in this case and relieve the family of the anxiety about their son's intractable condition. Listening to the chest properly and defining the sound relating to which part of the respiratory tree that is causing the sound is therefore critical in this case.

Needless to say, the best confirmatory test for the diagnosis of asthma is to perform the respiratory function test namely spirometry on this 10-year old child for which the father has to take him to the hospital as unfortunately the facility is yet to be made available at our clinic level. This test will also determine the severity of his asthma.

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.

BSDReit - My Forgotten Stock

I have been so happy with the annual 7 to 9% return on this stock that I forget to review its wealth-making status. I bought 50k  BSDReit shares at 1.04 costing me about 52k in late 2008 and have been receiving 3k to 4.5k annually and have been quite complacent all these years. In my busy practice, I have totally forgotten that the price has historically gone up to even 2.00 and I failed to capitalise on it! I only came to realise my folly when I was checking on the KLCC Reit and doing the simple yield calculations. Last week's BSDReit's price was 1.86  and that is 82 sen rise in value for each share.

Been sleeping on my REIT stock

My! if I were to liquidate it then  I would have realised approximately 93K and  the time has come to dispose it all as the price has  become somewhat static for the last one year!!! Forget about putting it back into the market, had I put the whole of this amount in a PNB unit trust at 6.5 sen dividend, I would have received 6k consistently, a much higher yield than at  the current BSD Reit's annual dividend rate, purely on price upside.

I have this penchant for buying and holding my stock. Most of the time I find this practice is beneficial for me. For example I bought SKPetro shares  at 2.16 last year when it was relisted and only sold some last week at 3.59. Whereas my better half had sold his early this year at 3.15 because his strategy is buy and sell at a certain percentage of unit price rise. My strategy is more risky and therefore more gains and of course sometimes more losess.

High Risk-> High Gain

That's the disadvantage of self-managing your own fund while having a full professional practice. The tendency  not to check regularly in details is always there. In this case I had been so happy with the relatively higher dividend than ordinary stock and the higher yield at 8.5 when the price was at 1.04 that I hardly even thought of it. The wealth generating status has since altered following the Reit's price uptrend. It is more profitable to re-assign the fund's position.

And so this Monday, I am going to clear my position on BSDReit after nearly five years of holding it and maximise my money through another stock which is of course dear old MAXIS.

KLCC REIT versus MAXIS (or PNB Unit Trust?)

I am back in a dilemma. I have just sold 50% of my SKPetro shares when it peaked at 3.59 last Thursday 9 May 2013 and now I want to plough back the profit into the market. I was looking at the Reits and noticed that most of their prices have kind of stabilised over the last six months.

Then came this old market player, albeit in a different package, KLCC Reit which was relisted last Thursday as well. The reference price was 7.25 and it went up to 7.70  before closing at 7.64 on Friday. It was a fine debut alright. The prospects look good with the intended inclusion of more high-end properties and the fact that its current properties are all fully-tenanted. Moreover the CEO indicated that they are going to distribute 90% of their annual profit as dividend which sound attractive. By 2015 it seems the dividend can go up to 35%. The name of Petronas, the National Petroleum Company as the backer of  this Reit is also comforting.

I am disappointed though that the price is very high. In fact the price of this Reit, the biggest of the lot in terms of capitalisation, sticks like a sore thumb. All the others except for AxReit (@3.82) are priced below 2.00. Looks like this Reit is for the wealthy to be wealthier as ordinary retail investor would be hard pressed trying to own it. It doesn't look good on this government-linked company (GLC) to deprive the small investors of the shares of the wealth. Though we must realise that the foreign fund managers would have snapped this Reit had the price been much lower. Still I believe the Malaysian investors would have loved to  possess this stock and ride with the company.

A  good dividend-paying stock

KLCC REIT- Currently  lower yield than MAXIS

Now back to my dilemma. Shall I purchase KLCC Reit or MAXIS? Let's do some simple calculation. If I were to get 30k KLCC Reit shares at the price of 7.52, I would have to come up with about 227k inclusive of transaction cost. If the annual dividend is at 35% then I would get 9k after subtracting the 10% tax. That would be a yield of 4.16%.

The last price of KLCC property was 7.25 before it was suspended to repackage it  into a Reit and so unless my evaluation is wrong, I don't think the Reit's unit price  is going to get any higher than 8.00 before the year ends. Even if it uptrends, the value would be slightly higher than  MAXIS FV of 7.20.

Now if I were instead to choose MAXIS and buy an additional  30k shares at the current price of  6.99 pre-dividend ex-date on 14 May, or better still wait for it to drop slightly post-dividend, say at 6.80 then I would have to fork out only 205k and at current MAXIS annual dividend rate of 40 sen TE, I would receive  12k a yield of  5.85%. The assumption here is both stocks are changing proportionately.

But if you were conservative and risk-averse, it is better to put your 205k in a PNB unit trust with the annual dividend of 6.5 sen because you would receive about 13K and tax-free but the unit price is fixed at 1.00 and  you will have to keep that amount for 12 months to get that dividend though the advantage is you also will  have that compounding principle to embellish your annual reinvestment. Slow and steady.

But  I think for the time being  I will pick up MAXIS shares instead of the highly-touted KLCC Reit  and give PNB Unit trust a miss as I fancy a roller coaster ride. In addition, to me, MAXIS is a good defensive stock with strong fundamentals and imbued with  innovative management and good governance.

I sure hope I am  going to celebrate this decision. Here I go on an adventure ride comes 15 May 2013.

SKPetro- My Stroke of Luck

A week before the general election, I was checking on my portfolio and noticed that generally due to the lack of leads before the dissolution of parliament and the uncertainty of who was going to form the next government, my stocks have been rather static in values.

My stocks currently consist of Telcos, Entertainment, Oil and Gas, REITs and Private Healthcare.My sole  plantation stock was sold three weeks ago . All are self-managed.

I have got some shares of ASTRO through an IPO application which have been lower than the offer price of 3.00 ringgit. At one time it went down to 2.67! I have been wanting to dispose of them and when the price  went to 2.90, after much debate, I decided to sell all my shares and bought more SKPetro shares  at 3.08. My gamble paid off as after the election with the National Front being returned to power, the stock went up dizzyingly and today  it is 3.55.

The stock price rise is amazing though I am aware of the foreign fund role  post-election

Though ASTRO also rose following the election to 3.02,  it compares poorly to the rate of increase of the oil and gas company. I am glad that I reviewed my position in time and in the process gain quite substantially. I hope the stock will continue to do well before I decide to dispose it. At the moment I am loving it. How I wish I had purchased more of the stock at that price! Instead I put some more fund from the proceeds of my THPlant sale in which I made some profit buying at 1.94 and selling at 2.20 into my PNB unit trusts, safer and less risks!

Luck 1% and Effort 99% = BIG Smile

SKPetro is at the moment an attractive investment. Had I not made the regular review of my portfolio, I would not have made the gain on the stock. So the question of luck here is debatable whichever way you look at it.

It's advisable to monitor your stocks especially when market-influencing factors are in operation. This is the exciting part of doing things on your own in investment. You learn from your mistakes too.

My Melbourne Trip

A close relative is currently on official duty  to various parts of the world conducting specific training for High Commission/embassy staff. So far she has gone to New Delhi, Canberra and Melbourne. Her next trips will be Beijing, New York and Rome. Looking at the destinations, I decided to accompany her to Melbourne. I prefer the city because my familiarity with Australia and the fact that the people there speak English is comforting. I have never been to Melbourne despite spending eight years studying in Queensland, Australia.

And so I booked my ticket travelling business class to ensure comfortable travel. It was late evening when my MAS flight to Melbourne took off and reaching the Aussie airport at Tullamarine the next morning about 9 am local time ( three hours ahead of Malaysia). There is no need to show your visa as the immigration officer just key in your passport number and access it on the computer;  how convenient. And travelling business class also entitles you to an express immigration lane, lane used by aircrew but hold on tight to your invitation card as the immigration officer could be quite acidic if she thought you were trying to bypass the usual lane!

 I waited for Tasha to arrive from Canberra at about 11.30am. I have already studied the the airport map on the net and so it was easy to navigate my way in the big complex. It is easy to communicate nowadays as you have free WiFi at the airport.

The temperature was unbelievably hot at 30 deg C in middle of March and I was prepared for a cooler one at 14 deg C! Apparently Melbourne is dubbed as a city of Four Seasons. So be prepared as on any day the temperature could change from hot to cold!

A High Commission staff came to collect us to the hotel. We stayed at the Marriot right in Melbourne CBD. The hotel is fine except for the spring mattress which gave me backache! And the low support-less seat in the lounge is also not ergonomic. Five-star hotel with starless bed!

Melbourne is known as the culture capital of Australia. I could see why. They have many theatres and arts galleries and museums and other heritage attractions. Definitely different from Brisbane and Adelaide the other two cities I am familiar with.

There are so many places that you can go to and accessible by free transports! Yes, free. You must get the tourists' brochures at the hotel  and study the tram stations and locations where the bus shuttles pick up points for tourists are. Unfortunately I only came to know about these facilities on the second last day of my stay! Before that I was busy walking and taking the expensive cabs!

When Tasha was working I was shopping and visiting. I went to my favourite departmental stores of David Jones and Myer. I used to love window shopping at these two stores when I was studying in Brisbane.  Not much pocket money then. Every time I wanted to buy something heavy I was forever calculating the weight as my baggage allowance is only 45kg!

Melbourne is a city of trams

Part of City of Melbourne from Eureka Skydeck - highest point at 88th floor

Main entrance of the  famous Victoria Market

Seafoods galore at Victoria market

Flyways seem to be common outer city features

I managed to savour the city's scene by travelling with the free tram which  circle the city. There are various stops that you can take the tram from. It is number 30 with the name "City Circle" written on the front. The one I took was at Exhibition St stop just up the corner of Marriott Hotel. For further destinations I took a free air-cond shuttle from the Chinese Precinct just beyond the Commonwealth bank. It took me about 90 minutes without stopping to go around riding on that comfortable free bus. Stop 8 is just in front of the Victoria Market for those who want a free ride there. The free shuttle starts at 9.30am at the stop where I waited for it. Like the free tram it goes to the dockland at South Yarra . So the two modes of transport more or less wrapped up my short visit to Melbourne.

There is also a Malaysian small restaurant called Madame Kay on Lonsdale St near to our hotel, serving nasi lemak,nasi ayam and noodles cooked by Malaysians. That was my lunch stop everyday.

Victoria market, popular with tourists, is famous for fresh fruits and vegetables an at the same time there are are gift stalls selling cheap T-shirts and souvenirs. I noticed many Asian stall hands from Malaysia, Vietnam, Cambodia,Indonesia,Thailand and India. There was even an Arab lady selling fruits.

The trip was short but gave me an idea of the sort of city Melbourne is: busier than Brisbane and Adelaide and has that cultural vibes about it. The city is well planned and you cannot really get lost if you have a map with you.

On the way back at the Tullamarine airport, I was surprised to discover that you need to pay AUD4 for a baggage trolley! What if you do not have the coins as you are already on the way home? Lucky for me I had a change of AUD4 after paying a taxi costing me AUD56. I was of course unhappy about this small matter as our airport trolleys in Malaysia are free but thinking back, those free rides would have cost me more if they were not made available by the city for tourists like me. The only problem is nowhere does it warn the tourists on this payment.  I remember in Brisbane international airport, there was no charge for using the trolley.

Check the tax-free shopping procedures. You need to have more than AUD300 per receipt per shop. Unlike the UK requirement. You need to show your purchases at another level (quite inconvenient!) before you finally meet the officer after you check in, keying up the amount in the computer to be credited into your credit card. I had forgotten to have my purchases checked so the officer asked whether it was the first time I came to Melbourne and of course I replied "yes". He or she  could be difficult and refuse to give you the tourist privilege. Fortunately the custom officer was an understanding man.

The business class MAS lounge at Tullamarine Airport was pleasant with comfortable lighting and food servings were generous. A perfect end to a short, tiring  and enjoyable visit.

The trip soon came to an end and due to plane seating problem I had to leave 10 hours earlier than Tasha.But I found the day flight was better as I arrived home in the evening, showered and ready for bed and woke up refreshed the next morning.Tasha on the night flight arrived in the wee hour of the morning at KLIA and ended up suffering  from a jet lag!

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.