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)

Final year at last...

Salam,

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):
1. BE HUMBLE
*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

Travel to UK & Holland during Spring!!

Alhamdulillah, I was able to fulfill my dream to travel to UK. Decision was made 4 months earlier. I manage to get a cheap ticket to Manchester (RM3200 return). Off i go to Manchester, travelling from KLIA alone and get 12 hours transit at Doha (that's why the ticket is cheap...haha). Lucky the return flight only cause me 1 hour transit. Anyway, alhamdulillah, nothing bad happen while i'm travelling alone for the first time in >2hours flight journey.Total flight journey was 14 hours...total duration of trip=15days...

Special credit to my cousins Nabila Yusoff, Azmir Hisham Ahmad and Zaid Hakim Iskandar & his fiancee' Jannah Radzif. Thank you for the good care and babysitting me while i'm there. Sorry for any inconvenience (",)

University of manchester




The Old Trafford stadium

Piccadily Train Station

at York (about 1 hour from manchester) day trip


Alton's Tower Theme Park at Staffordshire (2 hours from manchester train+bus) day trip. COooooooL rides :)


3DAYS TRIP TO EDINBURGH (colder than manchester,brilliant architecture,love the buildings,very-Harry Potter-like)

backpacking to edinburgh

The view from Edinburgh castle..



sterling castle..


Firth Forth Bridge,end of our countryside trip at edinburgh ..


3NIGHTS 2 DAYS TRIP TO HOLLAND (Brezzy & cold!!,beautiful,cute buildings,canals-a little bit like venice,full with old bicycles,I LOVE TULIPS!)

Holland trip...amsterdam city

one of the buildings at Amsterdam city


Keukenhoff Lisse,the Tulip garden..Holland


Windmill!!


Clogs revolution...


Subahannallh, i can see a lot of amazing creation of Allah
Masyaallah,a very LOVELY experience,(",)

To my juniors : 3rd year books at UKM

Salam my dear Juniors TWP'08...

Congratulation in advanced for able to be back home. I am looking forward to meet you all at UKMMC.

Ok..about Year3 UKM books, you can buy it once you entered UKM. So, you can save your energy.There will be a book sale at our college by PERSIAP. They get the books from Kamal bookstore.

There are 4 postings and departments in year 3.therefore i list out the books based on that. However i recommend you to see the books first and also ask you other seniors' opinion about it.


Internal Medicine:

1. Oxford handbook of clinical medicine


2. X'press revision in short case, aids to undergraduate medicine,UM


3. sarawak emergency medicine



Surgery:

1. Browse's Introduction to the symptoms and signs of surgical disease


2. principle & practice of surgery


3. In a page surgery-just photocopy this one


4. Churchill's pocketbook of surgery



Obstetric & gynecology:


1.labour room protocol HUKM-buy this at O&G department


2.obstetric UM- original version is cheaper than photocopy version


3.gynecology UM- original version is cheaper than photocopy version



Medicine & society:


It is UNPAD version of PHOP & CHOP...so, you can photocopy the lecture notes from your UKM friends. for this posting,you will have to stay at Tanjung karang for 7 weeks.



For more info, please visit this blog created by the current final year.


http://www.medicalpblukm.blogspot.com/



Let me five you some brief sharing of experience on what happen to me fro the past 2 years.Basically, being the first batch, I don't know what to expect from my new collegues and lecturers. My self esteem is slightly low than it was in UNPAD. I was involved with a LOT of activities and had a GREAT life at UNPAD. Being in UKM, i thought i had to say GOODBYE to all the student activities i enjoyed and focus on my study alone.

haha...NOT>..it is soo not true :)

We are well accepted in the community of UKM. However, there are certain things that never will be same. Just want to say DO NOT WORRY, rest assured...insyaallah you will have a great time here. However, BEAR IN MIND...please do not carried away with the activities and neglect your studies..try not to fail any of your postings (",)


as for student activities...you can join a lot of them and gain merit for you to stay in the college. There are 3 student bodies : JAKSA (manage all about our college-KTDI), PERSIAP (all about academics, management,schedule) and AMSA.


As for me, i think the student activities here are broader...I hold a position at PERSIAP for a term(2010), i join & handle a lot of student programmes inside UKM and outside UKM.


with PERSIAP 2010 committee members..during our outing..


with my nasyeed band..CIMOLEN(Cimol+molen..you can watch our performance in utube,posted by Izmeer..


For guys who LOVE Sports..there are 4 games that you can join each year


1. Sukan antara kolej UKM (SUKEM)

2. Intervarsity Sports Game by AMSA-an inter medic school game

3. Liga Antara Tahun by PERSIAP-an inter batch game among UKM medic

4. KTDI Sports day by JAKSA-our college sports day


there are also games organized by other universities that we sometimes received by invitation.


(yeay...i join them too...FUTSAL WOMEN's team )


for those who like long distance run or marathon...u can join KTDI runners club...hehe..speaking of 5km,10km,15km,20+ run.u can personally contact me for this :) there is tasik permaisuri in front of the hospital for you to jog every sunny morning or evening. Free public aerobic every sunday. For those who likes to swim, u can go to Pusat renang cheras (also in front of HUKM).personally, i never go there because there is no womens' day..huhu.


some of the medals gained during year 3 and 4...there are 3 others not included in the photo :)

Again BEAR in MIND..do not neglect your studies. you will find a lot of distrations here..my advice to you is form a study group, makes discussions. read the gudiebook and identified the important topics. learn how to answer the exam questions. Go to the library, there are a lot of books you can borrow (5 books for 2 weeks).


verily,along with every hardship is relief
verily,along with hardship is relief
so when you finished(your occupation),devote yorself to Allah's worship
and to you lord(alone) turn (all your) intentions and hopes
verses 5-8, Al-Inshirah


That's all for now... All the best my dear Juniors :) see ya at HUKM

FUTSAL...can't get enough of it :)

Yes.. that's right.. i was introduced to futsal during my 1st year at Bandung. My team was the underdog. the only game we won was when my left front teeth broke into half...haha..worth the damage. Lucky the minor recostructive procedure is covered under my medical insurance :) only tell my 2nd brother about it cause i know he won't freak out and prevent me from playing. Mama only knows about it months later..hehe

then..I stop...because the team don't want to continue anymore...lack of players..etc...

when I came back to UKM..jeng..jeng jeng..I was shock..They actually have games for girls it FUTSAL. I was Thrilled...yeay. However, my batch(year 3) don't have a team. The year 4 seniors do play and have their own team. So, I start my search...gather some friends to form a team. The seniors was very encouraging. They let us play to represent our college and university. however, the team is still new, lacking of people and skills.

Because of us, we girls get a turn to play at the only court available in the hospital (next to rumah McD). Every thursday is our day. Occasionally, we rent the futsal court at Challangerz. they have girls night discount..hehe. We usually play at night.

Our enthusiasm and chemistry started to built up.We learn the skills and tactic by ourselves and some help from the seniors and friends.Techically we don't have a coach. We only started to win...and win BIG during the 4 th game at SUKEM in 2010. We got 2nd place in UKM (if we got first we have the chance to represent UKM in MAKSUM-sukan antara universti). Then we got 3rd place during inter varsity game.

Our team had play against each other during futsal 3 by 3 match for our sport's day. My team get the 1st place. we got the big hamper :)

The last game was the BIGGEST win ever. we got GOLD...yeay!




I hope, we don't have to retire from the games in final year. we do give the opportunities to the juniors. however, there's always something that hold them from joining. Therefore,we will be GLAD to play if they can't play for any tournament this year :)

1. Sukan antara kolej UKM (SUKEM) 2009 at UKM,Bangi
2. AMSA Inter-varsity game-medical students 2009 at UKM, Bangi
3. SMMAMS' Inter-varsity game-medical students UPM 2010 at UPM Serdang.
4. Sukan antara kolej UKM (SUKEM) 2010 at UKM, Bangi
5. AMSA Intervarsity game-medical students 2010, at UKM, Bangi
6. Kolej Tun Dr Ismail (KTDI) Sports day 2011
6. Inter-medical varsity Debate & Sports 2011, at UM, Jln Pantai

Good things keeps on coming...

Alhamdulillah.....

AsSalam (peace be upon you).

Sorry, for a long holiday from blogging.

Updates about me:
1. end my year 4 with psychiatry department. It was very intresting and colourful. i like my supervisor a lot.

2. I PASS my final exam...alhamdulillah...that means 2 months holiday.

3. My futsal team get to win GOLD...yeayeahh :) more about it in the next post...EXCITED ('',)

4. I'm going to UK and Amsterdam....with my cousins :) Finallly my dream comes true

5. My 2nd bro is getting married in June.my cousin is getting married in July...THREE of my Twinning UKM-UNPAD family members are getting married this year(1 of them already married)

6. I'm officially an aunt last year when my nephew was born in september. Now, more babies keeps on coming from my cousins...yeay!! can't get enough with those cute babies