Unintentional Weight loss in elderly: Should we be worried?

Salam,

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.

HOWEVER>>>>>>

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

ISOLATED UNINTENTIONAL WEIGHT LOSS IN ELDERLY
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...

So,
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

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.

Discussion:
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)

Health screening at SMK Teknik Sepang.

Salam,

Alhmdulillah, I've passed my year 3 without problems & happilly appreciating my 2 months break. The 1st month of my break fills with a few activities spend at KL,Kelantan & Malacca.

The lastest activity done is becoming a volunteer for health screening booth set up by our UKM Medical Society (PERSIAP). We received the invitation from Science & Social Faculty of UKM for their event Hari Jantung Sedunia at that school on 27/04/2010.

The girls setting up the banner


What we did there? Basic health check up: Height,weight,body fat measurement,Blood pressure(BP) and blood type. At the end of session, everyone will be given counselling on their health check-up result.

For the first hour, I have to manage the counselling booth.I always wonder, what kind of problem they want to know? Porblems faced by these form 4 students(16 years old)
1. Most of them have low blood pressure.
2. Some are overweight or have low/normoweight but with high fat index.

Blood Pressure is tension exerted on walls of arteries(a type of blood vessel that brings blood from heart to body cells) by the strength of contraction of the the heart.

Masitah with her favourite elctronical BP set


Example of the normal reading 120/90. 120 is called the Systolic BP while 90 is the Diastolic BP. Systolic BP indicates the blood flow into your heart while Diastolic BP indicates the blood flow from heart to body.

Therefore, low blood pressure indicates low flow of blood to your body & other vital organs. It is normal to have low BP if you are atheletes & people who exercise regularly.They also have low risk for stroke,kidney disease and heart disease. Thus, low BP is acceptable as long as it is not low enough to cause symptoms(dizziness,fainting) and problems to the body(chest pain/heart attack when insufficient blood supply to heart).

Me & the adik-adik


Weight issues & high fat index can be manage with eating in a small amount 5 times per day and choose the food according to the food pyramid. Excercise is very important.For those who doesn't involve with sports, brisk walking for more than 45 minutes,3 times per week is good for health. However, for weight reduction, for effort in cutting the calories & increasing fequency of excercise should be done.

guy's booth


girl's booth


Wasalam (",)

My third posting :Medicine & society

Salam,

This posting was considered as a vacation posting. I found out it is totally a big fat liar..hehe. A LOT of report have to be submitted..A LOT of travelling along tanjung karang or sabak bernam district. Have to visit da same ppl's house in kampong at least 3 times for the 3 different survey we have to conduct..

However, I do learn a lot of intresting knowledge. I can say that this posting is a 'Lawatan sambil belajar' posting. It's not too bad after all. However, i easily feel bored there.


For this posting, we are attached to 3 different places:

1. District health office aka Pejabat kesihatan daerah (PKD)



there R 8 units under pembantu pegawai kesihatan persekitaran (PPKP) which are:
1. unit pentadbiran
2. unit kualiti makanan
3. unit bekalan air & kebersihan alam sekitar (BAKAS)
4. unit kualiti air minuman (KMAM)
5. unit pendidikan
6. unit kawalan penyakit berjangkit
7. unit kawalan vektor
8. unit kesihatan sekolah

each day we go to different places. It is amazing to know the power that PKD have in managing & controlling the health of ppl in the district and its relation with the state and national level.

hunting for mosquito larvae for vector control sample...beware Mr. & Mrs aedes aegypti or aedes albopictus . we gonna kidnapped ur larvae.heheheh..


fogging time..beware Mr. & Mrs aedes aegypti or aedes albopictus . you gonna suffocated to death..heheheh...


our ketua posting showing his exophthalmos eye with the water station( where we get the sample to test it for quality control)


pH test(one of the physical test)..there are physical,chemical & microbiological test done by KMAM unit to the water.


lets go back to school..reminds me a lot of my chilhood memory of my health check up at school


vaccination time!!a lots of emotions going on here..


showing our excited faces..haha


2. Klinik kesihatan(KK)aka Health clinic and klinik desa (KD) aka District clinic.

KK is devided into two department which are outpatient department and Maternal & Child Healthcare clinic(MCHC) department.

PKD will monitor everything regarding health in the district including the KK.Every KK will take care a few KD. So, KD are like their child, KK is the mother and PKD is like the grandfatehr.KD will only manage antenatal check up, vaccination, routine physical check up for Hypertension patient.

my group at KD


with special children under PDK care( it is another unit under KK for special child)



3. Tanjung Karang District Hospital



This posting does give memorable and meaningful memories...Objective achieved (",)

Wasalam

Pain...

Salam..

This post is dedicated to my left feet..hehe.Its hurting me when i walk and preventing me from doing sports except swimming..huhu.So, i gave a special treat by giving them a new room slippers


What is PAIN? According to Mr Dorland(that's what i call Dorland's pocket Medical Dictionary),Pain is a feeling of distress, suffering or agony, caused by stimulation of specialized nerve endings.

In medical term pain sensetion is what we called as nocioception or nociperception. Nocioceptor is the pain receptor.

How we can feel pain is the connection and interaction between the nerve circuit at nocioceptor to the central nervous system(brain) and then after it signal(impulse) is interpreted the signal will be send to the appropriate area.
For example, when you touch a hot kettle, you will immediately move your hand away from the hot kettle.

Unless, your nociceptor is damage.It can happen in chronic diabetic patient because they have neuropathy which is death of nerve.Usually at the peripheral area like fingers and toes which are the common sites for gangrene in chronic diabetic patient.

Nocioceptor is important because it can prevent us from further damaging ourselves and prepare the body for recovery.

Subahannalllah...Don't you ever think how we can control this in less than seconds?? How can the brain interpret everything & decide in a short time??

Aren't we human a WONDERFUL creature which have a brain with intelligence(akal) that differentiate us with animals and plants
It must be a great force who create us....Which is ALLAH.

Al-Quran has already talk about nocioceptor...long before the discovery of it.
Those who reject our signs, we shall soon Cast into Fire;
As often as their skins, Are roasted through,
We shall change them, For fresh skins,
That they may taste, The Penalty: For Allah,
Is Exalted in Power, Wise
(Al-Quran 4:56)

"Al- Quran is not a book of science but a book of 'signs'. Thus, you won't find a direct answer. However if you read or try to find the correlation between the 'signs' with science you will be amazed.
Some people may need only one sign while others may need hundreds to believe the divine origin of al-Quran.Some would be unwilling to accept the truth after being shown thousand signs"
(Paragraph taken from QURAN & MODERN SCIENCE, compatible or incompetible? Author:Dr Zakir Abdul karim Naik ,page 7 & 68)

Sources:
1. Dorland's pocket Medical Dictionary, 27th edition
2. QURAN & MODERN SCIENCE, compatible or incompetible? Author:Dr Zakir Abdul karim Naik

Malaysia health care service is unfriendly..is it true??

I came across an intresting topic when i read Berita harian online today which make my hand 'gatal' to write an post today.(taken from berita harian...)

Kementerian wajibkan kakitangan hospital hadiri kursus komunikasi

PUTRAJAYA: Semua kakitangan hospital, khususnya doktor dan jururawat diwajibkan menghadiri kursus komunikasi bagi mengurangkan jumlah aduan terhadap mutu perkhidmatan kesihatan.

Menteri Kesihatan, Datuk Seri Liow Tiong Lai, berkata ia juga kerana sebahagian besar aduan yang sering diterima kementerian berpunca daripada masalah kurang komunikasi kakitangan hospital dengan pesakit serta keluarga mereka.

Katanya, sepanjang tahun lalu kementerian menerima lebih 1,000, aduan manakala 34 diterima sepanjang Januari lalu.

Is that true?? I think it is in the government hospitals.There are reasons why these happen(which i can think of):

1. The medical health care personnel have heavy workloads,increasing work time and patients.Thus, they easily gets irritated and 'Malas' to listen to the patient

2. They didn't develop good people skill...A skill is something you master with experience, practice and will power.You won't become a friendly person in a day.

3. They are not ready to work with people.People who choose this career should be someone who are ready to work a lot in caring of people...their altruism must be high

4. They are not taught how to handle the patient in non medical aspect.

5. Being friendly and good in communication skills is not the main priority of the hospital policy.

Thus, i think what the government intend to do right now with the communication skills campaign.It is a good approach.
As a medical student, when we reach the practical phase, we should make the patient as our book.At the same time, learn to communicate with them.

Actually it is not that hard, you can try to talk or 'borak' with any person that you feel comfortable with(people around your circle) like the mak cik who sells nasi campur,bapak who sells gorengan, the tailor who sew your clothes or alter your
jeans or mak cik at kedai runcit (you get the picture)..
Topics?? weather...food..their family...

A smile can create warmth situation...a 5 minutes chat can make a difference.

The key is, when you open to them, they will open themselves to you.
Thus, if you apply it to your patient under your care, you will easily identify their problems and can give good service to them.

With my favorite lecturers during Neuro-behaviour system(NBSS)which i like their thinking and communication skills approach:


The question now is...will i be a competent doctor in the future...i'll faced the clinical phase starting this May..


Can i keep up..can i meet the expectation???

Ethical issues in clinical trial

This picture taken during our laboratory during learning about diuresis (drugs that helps in urination).We pitied the rabbits of course.We only administered some drugs to it and it still live after the experiment(",)


What do you think of using animals as an experimental subject??
This question arise many arguments and debate on weather it is prohibited or not.

In clinical trial aspect, using animals as a subject is one of the way for evaluating many important aspect for medicine for example:

1. new drugs and treatment
2. new medical/health care technology
3. new methods of prevention
4. new program of screening and diagnosis

Humans are also used as the clinical trial subjects.They are paid volunteers or patience who agrees with participating int the experiment.

This are the volunteer subjects, the gentlemen from group 3 who drank 1 Liter of plain water and salt water during the experiment on diuretic effect on human


Don't you ever wonder how a certain drugs or treatment was approved by an institution like FDA??

There are 2 stages in the clinical trial procedure.They are:
STAGE 1: Study in Animals
STAGE 2: Study in human subject.This stage further divided into 4 phases
1. for safety and tolerence in 20-100 subjects
2. to evaluate effective system & dosage of treatment in 100-200 subjects
3. compare the new treatment with an available treatment
4. evalutate the new treatment in the society for a few years time
Also include POST MARKETING CLINICL TRIAL:to study the side effect of the new treatment.

Don't you see how a certain drugs or treatment is approved takes tedious work and consume time, effort and money? We should give our credit to the researchers.

It is important to use a few life as the benefit of others. In this condition, we should think about risk versus benefit.

Source: Community Research Program (CRP) notes during 1st semester in Padjadjaran University medical school.

Cirumcision: A journey to maturity

A few weeks back, before my mum visited me at Bandung, i SMS her for the things that i want her to bring from Malaysia...however i got a different reply...

Me: Salam Ma, Aisha nak...(things i need)..Pesan pada adam,Kakak akan belaja sunatkan org 2minggu lg..hehe.
Adam reply with Mama's Hp:http://www.blogger.com/post-edit.
APa? kakak nak belanja donut( i can't help laughing when i got the reply..i can tell its my lil bro)
Me: Tak,kakak nak praktis sunatkan Adam bila kakak balik nanti boleh??
Adam: Ini tidak adil
Me: Nak besar kenala sunat dulu.(i coaxed him)
Adam: Apa-apa je la...(he surrendered at last)

Yes..today i would like to discuss about circumcision..
Circumcision comes from latin word: circum means 'around' while caedere means 'to cut'.From the word itself, medically, it is a minor surgical procedure to remove the foreskin(perpuce) from the penis.

In Islam,women only have to cut small part of the clitoris.Not the whole clitoris like the supermodel Iman(current wife of David Bowie) have undergo.Google t to find more about it.For muslim, it is a religion practice. Islam is not only a religion, it is a way of life. I think, every man should undergo circumcision( in my opinion as a medical student) .

There are 3 religions that have circumcision as a must for their follower:Islam, Juidism & Christian(some of it).In Islam, it is called 'khitan' in Arabic language terms,it means to cut. There are a few opinions on weather cicumcision or 'khitan' is Wajib or sunat for men And women.In conclusion, it is Wajib in men and Harus in women.Harus means you have to do it if it brings benifit to you(not Wajib or sunat).

WHY CIRCUMCISION/KHITAN IS IMPORTANT?
In Islamic perspective,
Men: To promote hygiene
Women: To reduce the very high sex drive in women and at the same time prevent fornication & sins

Isn't Islam is Syumul(complete)?? and the way women is protected is beautiful!!


Medically,
The most important thing is, it promotes hygiene. It is also indicated in certain condition like Phymosis : adherent of the foreskin to the gland.

1. Fewer infection:Uncircumcised male can easily gets infection because after they urinate, the urine can easily deposit under the foreskin leaving smegma(urine that eventually become crystallized) Urinary tract infection is 5 times more in uncircumcised men.
2.Protects against HIV infection:The foreskin is a high target for HIV virus
3.Cut rates of Cervical cancer(in female):Circumcised men are 3 times less likely to carry the virus .
4.Lower risk in prostate cancer
5.Less penile cancer

When is the best time to have circumcision?
I think it is before a boy reach puberty. In Islam, Nabi Muhammad was circumcised by his grandfather(Abu Mutalib) when he was 7 days old.It was a common act during that time in Arab-Quraisy society.
The hukum is
Sunat: before the boy reach puberty(in Malaysia:9-11yrs old).
Wajib: in those who already reached puberty.

There are a few risk & side effect in circumcision.However, it is a fact that every surgery have their own risk.Thus, it should be conducted by a skilled And competent person.

This entry is dedicated to my brothers:


Additional Sources;
1.Wikipedia
2.Reader's Digest,
3.http://muslimah.or.id/fiqh-muslimah/khitan-bagi-wanita.html