Thursday, June 23, 2011

Unintentional Weight loss in elderly: Should we be worried?


It my 2nd week of posting in Family Medicine & Society (FMS)....

Last week, I our weekly Clinical Pathology Conference (CPC) in UKM Medical Center was presented by FMS department. The main topic was about Isolated Unintentional Weight Loss in elderly.It is a diagnostic challenge for the doctors in primary care ( clinics/ general practitioner) since it can be either apart of aging process or pathological. The doctors cannot just simply refer to specialist.them without knowing the reason to do so.

Clinical scenario:

A 71 years old Malay lady, married with 4 children with background history of chronic illness under medication & follow up
* hyertension for 30 years
* diabetes mellitus (DM) for 6 years
* hyperlipidemia for 6 years

There was a history of stroke in 2005 (6 years ago) that was treated.
She also had peptic ulcer disease.

Current problem:
She came to primary care (klinik kesihatan) with problem of loss of appetite and loss of weight for 2 months.
No fever or sign and symptoms pf Upper respiratory tract infection (URTI) and Urinary tract infection (UTI).
She was not depressed.

On physical examination: she is pale but no other abnormalities found. There is no lymphadenopathy.

Investigation on occult blood test: negative

Ultrasound of the abdomen does not reveal any abnormality.

Management at Primary care:
* come again to the clinic in a week.
* with-hold Oral hyperglycemic agent(OHA) since she is hypoglycemic
*continue hypertensive medication
*communicate with family members: bring patient to the nearest health care center if the patient is deteriorating.


A week later, her condition suddenly worsen and she deteriorates. She is jaundice. Immediately,she was admitted to the medical ward in the hospital..

Further investigation was done and the rults as follows:
*Low Hemoglobin level
*Occult blood test positive
*Increase CA19-9 tumor marker
*Increase Liver function test (LFT)

Final diagnosis : Periampullary carcinoma metastasis to gastric mucosa with obstructive jaundice and impending gastric outlet obstruction...

(what an unexpected complicated diagnosis??....)

Prognosis: The patient had Whipples' Procedure surgery and biliary stenting via ERCP.

click here for the Source of photo

Definition: Weight loss of >5% over 6 months (as high as 15-20% in >65 years old)

It's always present with other problems (in this patient: DM, Hypertension, hyperlipidemia). However, there is NO published guideline to manage it.

SO,(in primary care context) either (1) do nothing and accept it as aging process or (2) refer patient for further investigation and management.
What may be the cause???

(1) the most fearful one : MALIGNANCY
(2) should be worried but it is treatable if manage early : NON-MALIGNANCY (60% of the cases) eg: chronic disease(ie DM), Tuberculosis infection.
(3) PSYCHIATRIC ILNESS (10-20% of weight loss) eg: depression
(4) not to worry: ANOREXIA of AGING- physiological change due to decrease smell, taste, chewing and periodontal disease.criteria: 0.1-0.2kg per year.
(5) IDIOPATHIC (25%) unknown cause...

The risk factor for MALIGNANCY(cancer) are Male, increase weight loss, decrease hemoglobin, increase erythrocyte sedimentation rate(ESR), increase ALT,increase LDH
Tumor marker in not the initial investigation, but it it is useful (like in this case)

What can we do if a patient comes to you with unintentional weight loss??

(1) Full history taking
(2) physical examination
(3) investigation: Full blood count (FBC), Renal profile(RP), Liver function test (LFT), ESR/CRP, Chest X-ray, Stool occult blood test.(in there is suspicious/abnormal finding, refer the patient to respective specialist.However, if the findings are normal,observe the patient 3 months later)

Source: notes taken by writer during weekly Clinical Pathological Conference(CPC) on June 15th by Family Medicine & society (FMS) at Universiti Kebangsaan Malaysia Medical Center (UKMMC)

Sites for futher information:
(1) Evaluating and treating unintentional weight loss in Elderly patient-American Academy of Family Physician
(2) An approach to management of unintentional weight loss in elderly people-Canadian Medical Journal Association

Saturday, June 18, 2011

Contact dermatitis...a suprising culprit , I've learned!

Salam & Hi,

I've been to family medicine posting for just a week and there are a lot of common-everday problems I saw at the outpatient clinic. It is interesting because these problems usually does not need admission and requires simpler management.

Here I would like to share a case that is quite common due to misunderstanding and white lie given by the advertising company regarding the everyday soap for bathing or hand washing.

Clinical Scenario:

Source of picture:Wikimedia Commons

A 51 years old senior police officer came with first onset of generalised pruritus (itchiness) for a month. It is more severe at his limbs and abdominal area. It also cause him to have dry skin.

On further questioning on possible allergen contact he denied any allergy towards food,dust,aerosol, current detergent,animals etc. He did not engaged in recent outdoor activites like swimming, travelling or jungle tracking. Moreover, his occupation nature requires him to be inside an air-conditioned room. However he mentioned that he had changed his bathing soap to a antimicrobial soap recently ( I won't mention the brand here...but, it is the commonest anti-microbial being advertised nationwide)

He did seek medical help from private clinic and was given topical cream. His problem relieved by the appliance of the cream temporarily but the symptom persist afterwards.

Other medical illness: sinusitis under medication. There is no chronic illness

He does not smoke or consume alcohol.No fever, loss of appetite or weight. There is no other significance found on other history asked.

On examination of his skin : There skin looks dry with scratch marks.There is no abnormality of the skin indicting skin infection or atopy.

What could be the possible cause of his problem????
* from history, he is not allergic to any possible allergen
* there is no sign of infection

However, the answer is : THE ANTI-MICROBIAL BATHING SOAP!!!

Reason: Anti microbial bathing soap have strong anti microbial properties but LACK of MOISTURIZER. It may not cause problem to younger people since the skin can still produce some naturel moisturizer itself. However, in older people,it will cause dryness of skin and eventually DERMATITIS!!

* Eventhough, Malaysia have high humidity index, our skin still need some moisturizer effect!

So, plan of management:
1. Stop using 'the soap'. Choose a normal soap with good moisturizer properties.
2. Give anti-histamine (Piritone)
3, Moisturizer aqueous to be applied to dry skin
4. Steroid(Hydrocortisone) cream to be applied at the MOST itchy part.
5. Do come back if the symptom persist after a week...(it may due to other cause)

Take home message:
* Choose your hygiene care product that suitable for your skin. If there is any signs of irritation i.e ithciness do change to another product.
* anti-microbial soap is not to be used regularly in people with dry skin type and elderly.

p/s: this case is quite common in primary health care due to lack of knowledge on this kind of matter.
other cause of contact dermatitis : sun light and specific allergens(metals, jewellery...etc)

Saturday, June 11, 2011

Final year at last...


I just got back from 5days 3rd Professional & Personal Development (PPD)camp and BTN at Kem Bina Negara at Ulu Sepri, Rembau. I won't comment on the place or cetain issues as we are forbidden to do that. However, i would like to share about what I learned during PPD session.

First of all PPD is the only subject that is compulsory for medical students of UKM. They are starting to implement this program in other faculties in UKM. The 3rd PPD camp is made to prepare us for House officer(HO) life.

The reality of HO life is not short and sweet. I like to quote what was told by a houseman during the video session:" You choose to be a doctor, so do not complaint". She is totally right! We were told about the reality which is not pretty at all. We have to sacrifice a lot of things: missing family functions, no sports,lack of sleep & rest etc..this will continue for 2 years.

Photo of my group members for the LDK session with our facilitator..Thank you very much for sharing your experience with us.

A few lessons learned from my fasilitator who is a professor (peadiatric):
*the most dangerous thing is yourself...(EGO)..
* doctors should realize that they are only the INSTRUMENT OF GOD...
* every success they made is from god...your effort contributes to it
* every mistake you make is from yourself because you don't try hard enough to be competent.
* therefore, do not be cocky, think yourself are great because you are the healer!
* treat your parents, siblings,relatives,colleagues, friends and patients right.

2. Be HONEST!!
* do not lie to yourself or others.
* be frank and tell the truth in a nice way. Do not give political correct answer.

3. Cry for HELP!
* being a doctor is not an easy job...ventilate your problems(without mentioning names) to your trusted person (spouse,family,friends)

4. AVOID using CREDIT CARD! * don't event use credit card because you will fall into the financial trap easily.
* our pay won't make us rich but it is adequate for a secure life if we manage it wisely.

5. Treat your patients like your own mother, father and siblings...

To all my batchmates. Hopefully 256 of us will graduate next year...MISI JUBAH MERAH 2012!! Just remember:that a HERO lies in (each of) you!-from our PPD theme song(HERO by Mariah Carey)...

P/S: I was included in mass celebration for people born in June. Thank you to all. It was very special as we get to celebrate it with the whole batch (>,<)V