Merry Christmas!

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

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

The Box

The fruit cake

The Greeting

The decorative art

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

Failure to Thrive and Recurrent Diarrhea in an Infant

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

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

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

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

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

Cow's milk products- A good source of protein

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

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

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

Stomach pain, headache and anaemia - A triple Whammy

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

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

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

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

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

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

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

Migraine but treated as hypertension

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

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

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

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

Migraine headaches can be debilitating and affect quality of life.

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

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

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

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

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

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

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

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

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

Transaction fee currently discounted by 2%

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Urinary incontinence : An 11- year suffering

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

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

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

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

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

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