Tuesday, May 25, 2010
Monday, May 24, 2010
Saturday, May 22, 2010
Recently a friend's mother was diagnosed with advanced bowel cancer. In her mid-50s, with two children of college age, she was obviously desperate to put up a brave fight for as long as possible.
Cardiovascular disease, diabetes and stroke are already among the leading causes of mortality in Malaysia, in line with that of the rest of the developed world. Cancer diagnosis is on the rise and over the next 20 years it is projected that 1 in 3 to 1 in 4 of us will develop cancer.
Many of these diseases don't discriminate - at some point in the future either we ourselves or someone close to us will suffer from a potentially serious healthcare condition. How much will this cost us and how many of us will be unable to afford the treatment we need?
In recent years, Malaysia has witnessed the growth of the private sector share in our healthcare system. Whilst many private hospitals provide good standards of care, some are more concerned with profit margins.
Many of us will be familiar with stories of private hospitals performing unnecessary tests and additional treatments as a means of income generation. A friend's uncle tells the hilarious story of climbing a rambutan tree a few years back and falling off a branch, sustaining a mild concussion.
With a bit of a sore head he thought he'd better go and get checked out. Despite little in the way of additional signs and symptoms he was subjected to a MRI scan at a popular private hospital and an IV drip overnight although he was perfectly capable of eating and drinking.
The outcome? He was discharged the next day with a bill for RM5,000. On relaying his story to a doctor friend later on he was berated for having been taken for a ride, when a couple of Panadols and close observation would probably have sufficed.
Profiting from pain
When a close friend was recently accepted into an oncology training programme overseas, her father's friend, a respected surgeon, noted what a good career move she'd made. He congratulated her father on the fact that when she returned to Malaysia she could hope to make up to RM 70,000 a month as an oncologist in the private sector.
She was stunned and clearly dismayed by this proposition -in her mind, no one or no institution should ever be able to profit out of the pain and suffering of others. There is something fundamentally wrong with a system that puts profit and material gain before human life.
Some will argue that a private healthcare system should be allowed to develop and those that can afford it continue to pay, whilst those that can't can fall back on the government system.
We would argue that promoting a two tier healthcare system is dangerous both in terms of ensuring equitable access, maintaining healthcare standards, promoting research and development as well as the inevitable brain and talent drain that follows -as clinicians are drawn away from the government system towards the private sector.
Currently the private sector accounts for 23 percent of the country's hospital beds (12,000 beds per year). Around 40 percent of the country's doctors are employed within the private sector (9,000 doctors) with a doctor to patient ratio of 1 to 1.3. This is compared to a doctor to patient ratio of 1 to 3 in the public sector.
However with the move towards semi-privatisation and lack of a coherent social welfare system, even healthcare provisions within the government sector are not completely 'free'.
Neither are these provisions always affordable. A friend recalls undergoing cancer treatment at University Malaya Medical Centre (formerly known as University Hospital).
She was charged RM30 for her first round of chemotherapy. At the same time in the chemotherapy suite was another woman who was bemoaning the fact that she couldn't afford to have further treatment.
She unfortunately was now onto her second course of chemotherapy for cancer recurrence and this time round had to pay around RM3,000. Apparently this was part of the additional charges for successive chemotherapy sessions.
Also, doctors in the government sector often face tough ethical dilemmas. One senior doctor was seriously disillusioned by the fact that difficult cost-benefit calculations have to sometimes be made on behalf of patients. Some patients may be faced with the prospect of treatment that may buy them a further 18 months of life but leave their family with RM 20,000 worth of debt.
For many of us, ANY additional time spent with a loved one would be considered immeasurably precious. However for a family existing on RM1,000 a month this could spell financial ruin. In many instances, doctors in the government service heroically choose to turn a blind eye and continue to treat patients regardless of their ability to pay. Many of them however find themselves on the sharp end of rebukes from finance departments and hospital managers.
So what is it that Malaysians need and what is it that they deserve?
We would argue that instead of wasting taxpayers money through superfluous vanity projects and outrageous spending, (the purported RM77 million splurged on the US-based Apco Worldwide consulting firm just to revamp the new Prime Minister's image being a prime example), the Malaysian government should in fact be focusing on providing a world class healthcare system that is free to all at the point of delivery.
And by that, we don't simply mean a few token clinics hastily scrambled together devoid of properly qualified medical officers.
Malaysians are more than capable of leading cutting edge research and providing world class healthcare services that saves lives -the fact that there are many Malaysians in top consultant/research/public health posts abroad in the UK, US, Singapore, Canada and Australia is testimony to that.
Comprehensive plan required
We need to come up with a plan for comprehensive healthcare coverage that ensures we get the treatment we need when we need it, regardless of our ability to pay. We need a comprehensive overhaul of our public health policies that make diabetes, heart disease, stroke and cancer diagnosis and treatment top on our list of priorities.
We need to guarantee that the next time a minister's wife develops breast cancer she is able to access the best up to date treatment on her doorstep without having to fly halfway round the world. Along with our mothers, sisters, wives and daughters.
Breast cancer is, after all, hardly a rare disease. We need to pay our doctors a fair wage and reward initiative, innovation and hard work, so that we retain the talent we need to build a world-class health system within the public sector.
We need to invest more money in healthcare- last year the government spent only three percent of our gross domestic product (GDP) on healthcare (and only half of this-1.5 percent was spent in the public sector).
During the recent economic downturn, public healthcare expenditure was among the first to be slashed by a staggering 30 percent.
It is bad enough that existing levels of expenditure for healthcare fall short of the World Health Organisation recommended level of five percent and that of China and India who over the last seven years have consistently spent over five percent of their GDP on healthcare.
Most importantly we need to remind ourselves that many illnesses, including cancer, do not discriminate, and when you're ill and vulnerable all the money and material wealth in world may fail to make things better.
More than skyscrapers, shopping malls and multi-million dollar vanity projects we need a robust healthcare system that serves the people and can be trusted and relied upon to care for us when we are at our most vulnerable.
Thursday, May 20, 2010
Wednesday, May 19, 2010
Tuesday, May 18, 2010
Sunday, May 16, 2010
Saturday, May 15, 2010
Thursday, May 13, 2010
Came out in one of our short cases.
Inspect the tremor at rest. Nature? Speed per sec?
Then ask the patient to stretch out the hand straight in front, and spread his fingers and keep it there. (Spread the fingers for fun...dunno got difference or not)
1. Resting tremor. 3-4 cycles a second at best. Coarse. Pill rolling. Abolish on active movement like when the patient move his hand to stretch out for the second instruction. Should be asymmetry. Parkinson.
2. Intentional tremor. irregular. large amplitude and worst at the end of a purposeful act. Cerebellar lesion, MS or cerebellar stroke.
3. Postural Tremor. Absent at rest. Present at maintained position, like when hands out straight. divided into benign essential or acquired.
Benign essential - asymmetry, slower and persist throughout action and keeping posture. Idiopathic.
Acquired - symmetry, faster, purely postural. Abolish on active movement. Causes: Thyrotoxicosis, salbutamol, anxiety.
Treatment for both, beta blockers, and for acquired, rx underlying cause.
4. Last type is the flapping tremor in liver failure and respiratory failure.
I think it would be a parkinson's patient. So likely to ask you to inspect and tell findings.
Lack of facial expression and got unku (flex neck) a bit.
Core features of parkinsons - TRAP.
T - Tremor as described.
R - Rigidity - check tone, looking for rigidity cog wheeling, which is spastic + tremor.
A - Akinesia or bradykinesia. chcek the finger pinching and piano playing speed.
P - Posture which is very observational - Stoop posture, ask the patient to walk across and turn, slow initiation, hard to get up from the chair, minimal hand swing, hand over hernia postion, festinant steps ie getting faster and faster, very slow in turning, shuffling gait.
Treatment - LDopa with peripheral dopa decarboxylase inhibitors for side effects. Dopamine agonist, Anticholinergics, COMT inhibitors...cannot remember liau. And surgery is the new thing. Deep brain stimulation i think. HAHAH. dun care.
Causes of parkinson - Idiopathic, vascular - stroke, trauma - muhd ali, drug - antipsychotics, lithium, metoclopramide, metabolic - copper ie wilson's disease, parkinson plus - MSA, Shy Dragger cant remember liau la...
Wednesday, May 12, 2010
Tuesday, May 11, 2010
SO you have a right eye stays at the middle.
Monday, May 10, 2010
A rare sight I must say. haha
But is so special about this 2222 2222?
It is a crash call!!! OMG! Crash Call for us to study even harder now and stop panicking!
Dial 2222 is to call for immediate support because someone is about to die! (Or in my public health department in the university, 2222 is the number to dial for fire!)
So lets talk abt Cardiac Resus! (Random? hehe)
I am shit at resus actually. Failed both resus stations in OSCE and OSCA
So, I tried to read from the edinburgh's emergency bible:
Tiba tiba Ahpek pengsan!
D - Danger? Check the safety around the surroundings.
R - Response? Bos, u ok bos? Bos, u ok bos?
No response - Shout TORONG!!
A - Airway: Open and secure airway. Head Tilt and Chin Lift normally, or Jaw Thrust in cases suspecting cervical trauma. Jaw thrust is actually harder than I used to think.
B - Breathing: Is the ahpek breathing himself with the airway open? Look (Chest movement), Listen and Feel (to the air flow out of ahpek's mouth) I think assess that for 10 sec.
Not breathing? - any kaypohchee around? Ask the kpc to call 2222. If not, storm to the nearest phone to call 2222. Leave ah pek alone, dun care. Calling help is much more important.
Of coz dont go buy roti yet, come back and give CPR: 30 Compression (100/min, straight arm and deep 1/3? cant remember liau roughly la) and 2 kisses.
Continue assess for signs of life, mainly breathing? Dont stop pressing and kissing.
Dont stop. Until you kenot take it already, or help team of 2222 arrived. or fella byebye.
Then: ALS already.
So still doing ABC: but in a team!
Airway: probably want to put in a oropharynx or nasopharynx to secure airway. Or even ETT terus. Suction prn.
Breathing: Attach breathing mask, with breathing reservoir bag, pressing 1/3 of the bag. each two times after 30 compressions.
Circulation: Continue checking. Pulse? Take some bloods off to do test. ABG.
Once the AED is attached:
Assessed rhythm: If VF or Pulseless VT - Shock samadia. ALL CLEAR 150 biphasic.
CPR back. 2 mins. Means 30 presses, 2 kisses. kira sampai 8 kisses i think. thats 2 mins rite...? 100 compressions a minute, so 200 compressions in 2 mins...lebih kurang 4 cycles la..ya should be correct la. hahahaha. forgot liau.
Repeat ABC assessment and CPR at the same time.
I was just about to go toilet and shit, before my flatmate, Wafi, came to my room and said; "Wei..come come...see this"
So I followed him to our living room, and looked out to the window...
The killer move is the Buddha Palm at 0.31.
To the master of kungfu, sorry if you are watching this. Dont come and kill me. We are interested to learn your kungfu.
Friday, May 07, 2010
So, had a discussion about pleural effusion. Got into some confusions regarding the numbers and so, came back home, and reread Davidson;s and now decided to write whatever little i can remember.
So, Pleural effusion = fluid within the pleural space. If blood - hemothorax, if pus - empyema (complicating pneumnia, show finger clubbing, yeap kto)
We will talk about the causes later, presentations first.
Obviously the symptoms would be SOB, pleurisy...hmm..cant think of anything else.
Examination: I have to go through this in my mind so so many times, scared forget.
Hmm..would need to present like this:
Patient is dyspnoeic at rest, breathing air, and not cyanosed. Respiratory rate was 20 per minute. There was no evidence of digital clubbing, mediastinal shift (unless its damn big), or lymphadenopathy.
On inspection of the chest, there was a mark/scar/tube for chest drain. (I think it would be a few intercostal spaces below the upper border of the percussed dullness. Dont know where I get that from)
On palpation, chest expansion was reduced on the right side.
On percussion, the percussion note was dull (sorry, i wouldnt even trying to differentiate between stony and just dull...) at the right lower zone.
On auscultation, the breath sounds were reduced/diminished on the right lower zone. There is no added sound (can say pleural rub i supposed, but again, what is that? hehe. Also, there is this lawak says you can get bronchial breathing on top of the level of effusion, but again...hmmm?)
Vocal resonance was decreased as well on the right lower zone.
The differentials in keeping with findings of reduced expansion, dull percussion, reduced breath sounds and vocal resonance would be, pleural effusion.
CXR - Check the costophrenic angle for bluntness, and if large i think give whitish shadow all over the lungs. This test is not as good as a USS coz u need quite a large effusion to get the signs.
USS and CT.
Nah, this is the part that gets me into confusion.
Aspiration of the fluid will help us in finding the underlying cause of the effusion.
1. Appearance - if got blood, malignancy lo. if with yellowish stuffs, pus means empyema lo.
2. Cytology - I like this posh word. Essentially, we are looking at the concentration of the protein in the fluid. Anything above 30 would be exudate, and lower than that would be transudate.
Now, there is thing called the Light's Criteria, which underlines 3 things. If the fluid protein to serum protein ratio is more than 0.5 that would be exudate. If the fluid LDH to serum LDH ratio is more than 0.6 , that would be exudate as well. And lastly, if the fluid LDH is more than 2/3 of the upper limit of normal serum LDH, that would be exudate as well.
3. Culture: For bacteria if found to be murky?
Transudate: <30 - Hypoproteinaemia or increase venous pressure.
So, it would be liver failure, nephrotic syndrome, or congestive heart failure or constrictive pericarditis.
Exudate: >30 or any of the 3 Light's (0.5, 0.6 and 2/3)
It would be Infection - pneumonia and TB, Infarction - PE, Inflammation - SLE, RA, Malignancy - bronchogenic carcinoma or mesothioloma.
1. Underlyign cause.
2. Drainage - if symptomatic, slowly less than 2L da day.
3. Use some agents to stick the two layers between the pleural cavity.
5. Recheck underlying cause. And treat it.
DOnt think would get that in osce anyways.
Wednesday, May 05, 2010
E - Ex VTE
M - Malignancy
B - Baby? - Pregnant?
O - Oestrogen - Patients on OCP or HRT?
L - Large - Obesity
I - Immune Diseases - Antiphospholipids? or Inborn Congenital Disease - Thrombophilia - protein C or S deficiency?
S - Surgery recently?
M - Mobilization
Lets talk about DVT.
Use Well's score to stratify the risk of having a DVT/PE, and most of the criteria in the scoring are within the mnemonic above. Plus the symptoms of DVT.
Local - Leg pain? Calf tenderness? Erythema? Swelling? Warmth?
Systemic - Fever, Rigors etc.
D-dimers - Rubbish. Also elevated in pregnancy, cancer, surgery, etc.
A positive D dimer with high Well's = diagnosis - treat as DVT plus do a US to confirm.
A negative test with a high Well's score means bring back the patient in a week's time to do US to catch DVT.
A negative test with low Well's score means adios patient.
A positive test with low Well's...i dunno.
Low Molecular Weight Heparin - Enoxaparin - 1.5mg/kg/24 hrs SC. and start warfarin immediately, aiming INR 2-3, for 3 months normally, and 6 months post surgery. Stop enoxaparin when u hit the therapeutic INR and after at least 2 days coz warfarin is prothrombotic in the first 2 days.
Vena Cava filters. Inferior Vena Cava.
Prevention better than cure.
Can I just check whether you are taking up Foundation posts in the UK in Aug (if so, I will require a Transfer of Information form to be completed) or if, in fact, you are returning home.
Administrator for F1 Doctors
College of Medicine and Veterinary Medicine,
The University of Edinburgh,
Room SU204/205, The Chancellor's Building,
Little France, Edinburgh EH16 4SB
Tel: 0131 242 6377
Fax: 0131 242 6479
Thanks for the email, I am not doing the FY training in the UK. I have a bond to serve back home for the training post. Have a nice day!
Tuesday, May 04, 2010
You were somewhere doing something...
One fine day...
and then there's a kind yet unfamiliar face were right beside you...
Holding your hand...
With tears rolling down her eyes..
Thats exactly what I felt.
Monday, May 03, 2010
1. Head - Moon facies, acne, plethora, hirsutism, thin hair, Cataract.
2. Body - Truncal obesity, kyphosis, striae, muscle wasting and aches, thin skin, bruisings, puffy legs
3. Check for hypertension, Dexa for osteoporosis, OGTT for Diabetes mellitus, Refer to opthalmo for cataract, appropriate pyschiatry assessment for insomia, depression and psychosis, check peptic ulcer if there's abdo pain, avoid vaccinations as am immunosuppressed.
Other mneumonics - I AM CUSHINGOIDS
Moonfacies, Muscle wasting, muscle aches
Central Obesity, Cataracts
Hirsutism, Hypertension, Hair thinning
Nuts - psychosis
Sunday, May 02, 2010
Causes: Intraluminal, Mucosal, Post Mucosal.
1. Intraluminal - Structure or Enzyme def for absorption
A - Structure: Small bowel carcinoma, Ileal Crohns, err...etc. hehee.
B - Enzymes: Bile - Liver pathology: obstruction, hepatitis, biliary cholangitis.. Pancreatic - pancreatic carcinoma, chronic pancreatitis, CF....
2. Mucosal: lack of functional small bowel to absorption.
Small bowel syndrome - ileal resection due to Crohns or damaged due to pathology such as celiac disease....er...haha..thats the only small bowel mucosal patho i know due to a pathology i remember as villous atrophy i think.
3. Post mucosal: Pathology with the lymphatics absorption to system
Lymphatics circulation obstructions in some lyphomas, etc...heheheh...cannot remember la shit.
As per cause. Generally if u have a malabsorption, u have systemic symptoms like weight loss, malaise, tiredness...all the not enough food thing la. Plus all the vitamins or nutrients deficiencies symptoms.
Other symptoms, which i like, and i can remember is because or orlistat, a drug used by fatties. That drug causes the malabroption of fat, so u get Steatorrhea - shit float and damn smelly.
Hmm..actually i just realised I cant remmeber much liau. Hmmm...
So we do all the basic investigations:
Bloods, Imaging and Special Tests.
I think the most common causes would celiac disease and pancreatitis. So do those tests to rule these two out first. For celiac, an autoimmune, so can do antibodies, antigliadin or something like dat, then enteroscopy with biopsy. Then for pancreatitis, might need to some levels of enzymes, and then imaging using ultrasound first or MRCP.
As per cause. Give nutrients supplements for any deficiency and removal for any structural abnormalities.