Happy Deepavali!

Here's wishing our Hindu friends a very Happy Deepavali!

Please note that the clinic will be closed on during the Deepavali Holiday on 8 Nov 2007.

Recommended Vaccinations for the Elderly

Singapore has a very effective vaccination program for our children and most parents are very diligent about vaccinating their kids. However, when it comes to the elderly, there is much room for improvement. I hope this article will encourage you all to get your parents and grandparents to the GP to get their vaccinations done.

The elderly, especially those with chronic diseases like diabetes, asthma or other medical conditions do benefit a lot from vaccinations. It is a fact that influenza and pneumonia are the leading causes of death in the elderly. These diseases can be prevented by giving a simple vaccination.

So what are the recommended vaccinations for the elderly?

1. Influenza Vaccine

The "Flu" vaccine is giving yearly and is useful for preventing the "Flu" which often leads to lung infections and eventual hospitalization. It is recommended for all adults above 50 years old or adults of any age with medical problems.

More info HERE

2. Pneumoccal Vaccine

This vaccination is recommended for those above above 65 years of age or adults of any age with medical problems. It is useful to prevent the elderly from developing lung infection (pneumonia). A second dose is given after five years for people with medical problems or if the first dose was given before the age of 65.

More info HERE

New Vaccine against Herpes Zoster to be released soon!

Perhaps you know of someone who had Herpes Zoster or what is commonly called "Seh Zhua" (Appearance of the Snake). It is a painful condition that affects the skin in a certain part of the body and even when the condition subsides, patients can be left with constant pain (post herpetic neuralgia). The Good News is that there is a new vaccine which has been approved which should be available soon in Singapore. It is recommended for adults above 60 years of age and only one dose is needed. I will write more about Herpes Zoster when the vaccine becomes available.

Conclusion

If you have elderly living in your household, do encourage them to visit the GP to get their vaccinations done. These vaccinations are recommended for the HEALTHY elderly but especially so for those who have medical problems. Remember that vaccinations are potential life savers!

Reference: The Singapore Family Physician Vol 33 (3) July-Sep 2007 "Value of Vaccination"

Selamat Hari Raya Aidil Fitri!

Wishing all our Muslim patients a Selamat Hari Raya!

Our clinic will remain open this weekend as usual in case you need medical attention.

Health Screening Packages: No Later! Later!

By now everyone should be familiar with the Health Promotion Board's ad campaign where the man keeps saying "Later! Later!". The take home message being that when it comes to your Health, you should be more diligent and not leave it till later.

Just as your car needs regular maintenance, you also need regular check ups especially as you get older. Chronic diseases like hypertension, diabetes and high cholesterol can creep up on you without your knowing and early prevention can save you from developing diseases like heart attack and strokes later in life.

In my opinion, health screening is best done in consultation with your GP who can tailor the package to your needs. Doing a "blanket" screening with everything thrown in is not helpful. For example, if you are a young and relatively fit individual, all you need may be to have your blood pressure and cholesterol checked. Doing a Lung Spirometry test if there is no breathing difficulty or history of asthma is really not necessary. Whereas if you are older and have a history of hypertension, diabetes and a family history of heart attacks, then an Excercise Stress Test may be what you require. So the bottomline is this: Work with your GP to tailor a Health Screening Package to your needs!

Our clinic offers different health screening packages depending on your needs. These are basic packages from which we can add on different other tests if required. Do drop in if you have any questions regarding your need for a health checkup.

Remember, don't leave it till "Later! Later!"



Click Image to Enlarge

Immunization Packages

Please Click to Enlarge

Our Pneumococcal Packages work out to be $135 nett per injection and can be purchased through the Baby Bonus.

Wow Doc, these Traditional Pills really work!

Just the other day a young lady asked me this question:

Hey Doc, I have been taking these pills from the Philippines and it really works! I lost 5 kg over the last month! BUT, my heart has been beating really fast and I sometimes get a headache. Do you think it is safe? They only cost me six dollars!

Let me answer the question indirectly by highlighting this recent report by the Health Science Authority concerning adverse reactions to traditional medicines.

You all may be aware of the drug called Viagara right? Viagara is the trade name the drug sildenafil. It acts by dilating the blood vessels in the penis and is useful in men with problems with sustaining an erection.

Well, the HSA reported that two illegal "traditional" herbal remedies were found to contain sildenafil. The first one was unabashed about what its capsule could potentially do for its customers. It was called "Santi Bovine Penis Erecting Capsule". (Bovine=Bull) With 32mg of sildenafil per capsule (Viagara has 50mg), it is no wonder that this "Herbal" medication could produce a Bovine sized result. The second was "Urat Madu" which contain 48mg of sildenafil. Both of these medications were reported to have caused eye problems in their unsuspecting users.

There was another drug called "Asam Urat Flu Tulang" which was used as a pain killer. One young female patient was reported to develop drug reaction to the capsule. The lab tests reveal that the capsules contained diclofenac (a commonly prescribed painkiller), dexamethasone (a steroid) and paracetamol. Little wonder it works!

The Bottom Line

Sometimes a particular herbal medication works because the medication has been spiked with known western medications. The problem is that there is poor quality control in the production of the pills so you will never know what will happen to you because of impurities. The other problem is that if you take a "Herbal" medication thinking that just because it is "Herbal" and it cannot harm you, then you might be in for a rude shock.

So my advise is to make sure you know what you are taking and don't fall for something that is both "cheap" and "effective" and can only be bought from certain obscure sources. It might cost you more than you think.

Source: Adverse Drug Reaction News, HSA, Aug 2007 Vol 9 No. 2 Pg 8

Want a Painless injection? Cough!

If there is one thing that most people fear most about seeing the Doctor, it is the possibility of getting an injection. So great is the fear, especially in kids, that parents sometimes use it as a threat to get their kids to behave themselves in the clinic.

A lot of the pain is psychological and stems from the fear itself. I sometimes give myself an injection when I feel really sick. At first it was very difficult because we have a built in mechanism that makes it difficult to inflict pain on oneself. But after you get over the psychological barrier, it is actually quite painless.

So the first thing about having a painless injection is to overcome the psychological barrier itself. This is easier said than done. Thankfully, there are other techniques that can help.

1. Cough

Surprised? I certainly was when I watched this on "Brainiac" last night. This discovery may make the fear of needles a thing of the past! The latest study published in the British Medical Journal found that the pain of injection is significantly reduced when the patient coughs hard at the time of the injection. It is thought that coughing increases blood pressure which in turn reduces the perception of pain. Not convinced? Try getting a friend to pinch your arm. Then ask him to do it again, but this time cough hard. Can you feel the difference? Link to BMJ article

2. Local Anaesthetics

This works very well for kids. The only drawback is that the anaesthetic cream is applied and you have to wait for half an hour to an hour before the skin becomes numb. Works well especially if their eyes are also covered at the same time so that they can't see what is going on.

3. Distraction

This was the old method I used before I discovered the cough method. Essentially, I tell patients to relax and think of their favourite things or simply tell them something startling, for example, that there is a Gorilla standing behind them. Works pretty well, but the mother-in-law standing behind them may not be very happy being called a Gorilla. But you get the idea. The other way to distract is to pinch or tap the skin just prior to the injection. By the time the injection goes into the skin, the skin is still processing information about the tapping, so the pain information going to the brain from the needle has to contend with a narrow bandwidth, ie a traffic jam, so to speak.

Conclusion

The fear of injections is a thing of the past! Next time you need to get a jab, cough hard when the injection goes in. But please warn the Doctor first because he might miss the spot if you suddenly start jerking your body about!

Help Doc! My Baby's Belly Button Sticks out!

Umbilical Hernia in a 8 week old Baby

Many parents get very anxious when they see a protruding belly button in their newborn babies. I guess all parents want their babies to come out perfect and when there is something not quite right we get rather anxious, especially so for first time parents.

There is a funny little story told about the difference between the first time, second time and third time parents. The story goes like this....

With the first baby, when the pacifier drops onto the floor, the parent picks it up, washes it with baby safe dishwashing liquid, pops it in the sterilizer before giving it back to the baby. With the second child, the parent picks it up, rinses it under the tap and pops it back in the baby's mouth. By the time they have their third child, they simply pick it up, pop it into their own mouths and gives it to the baby.

This story brings home one very important point and that is that knowledge and experience empowers. So for the first child, parents are very careful about everything because they don't know enough. By the third child, parents have enough knowledge and experience to be able to discern what is important and what's not.

Another way to get knowledge and experience is to learn about it from other people which is why you are reading this blog.

Anyway this baby first came to the clinic at 8 weeks of age with a protruding Belly Button. This is a condition known as an Umbilical Hernia. What happens is that there is a small defect in the muscle wall that allows some of the intestines to pop out, thus forming the hernia.

Umbilical Hernias are very common. As the baby grows, the defect in the muscle wall gets smaller and by 12 months, most hernias would disappear. Larger hernias may take longer to disappear. If by the age of 4 the hernia is still present, then a minor operation may be required to fix the defect in the muscle wall.

There is a small chance that the bowels in the hernia gets stuck so that the contents of the hernia cannot be pushed back into the abdomen. When that happens, the baby needs to be seen by a doctor straightaway. Thankfully, such cases are not common.


Umbilical Hernia in same Baby now 3 months old

As you can see from these 2 pictures that were taken 1 month apart, the hernia is already noticeably smaller. The baby's parents are obviously relieved and happy.

Conclusion

Umbilical hernias are very common and most will resolve by themselves. There is no need to do anything unless they persist past 4 years of age.

Reference:

Murtagh, Patient Education 4th Ed, McGraw Hill Companies, 2005

Latest Update:

I saw the baby again and now the belly button is normal!

Our Clinic accepts IHP, AIA mediguard, CHS, AVIVA Card holders

Our Clinic welcomes IHP, AIA Mediguard, CHS and AVIVA Card Holders.

Schizophrenia: It's NOT about Split Personalities

I had one patient who came into the clinic behaving rather "Siow" (mad). She believed that the CIA was after her because she had some secret information that would reveal something about the PAP which will cause the ultimate collapse of the government. The patient was a homemaker. She claims the CIA were waiting for her outside the clinic to nab her and I had to help her or else this information will be lost forever. We got her husband to bring her to IMH where she was treated with an anti-psychotic drug. A few months later, she stopped having such delusions. She has been well since and has returned to work. (The details have been altered to protect the identity of the patient)

Schizophrenia is often misconstrued as having a split personality like the classic Dr Jekyll and Mr Hyde. As you can see from the story above, it is anything but that. A more accurate portrayal of Schizophrenia would be the character of the great economist, John Nash played Russell Crowe in the movie "A Beautiful Mind". In that movie, John Nash was under the delusion that he is part of a group of elite scientist on a mission to decode the German cryptic communications .

Rather then thinking of Schizophrenia as one person with 2 different personalities, it is perhaps better to think of Schizophrenia as a person who has his feet in different realities. It may be akin to a person who is so immersed in the Virtual Universe of "2nd life" or other forms of role-playing games, that the online persona is as real as the real world outside.

Who does it affect

It tends to occur in both men and women from ages 15 to 25 and 1 in 100 people will have it to some degree. It tends to run in families.

How do I tell if my friend may be Schizophrenic?

There are 4 features to look out for:

1. Hallucinations and Delusions: When I was working with the recalcitrant Schizophrenics in Australia, a lot of the women there thought they were the Virgin Mary. The men thought they were Jesus. One day one "Jesus" met another one who also claimed to be "Jesus". Now they worked out that both of them can't be "Jesus" so one managed to persuade the other one that he was the real "Jesus" and the other fella was his most trusted disciple "Peter". The both of them then went about happily preaching to the rest. I never really found out what happened with "Jesus" met his mother, the Virgin Mary.

2. Periods of Low Activity: Sometimes in between periods of Hallucinations and Delusion, they sufferer may under go periods where they are flat. They don't talk much, don't have much motivation to do anything and don't express their emotions.

3. Disorganized speech and thinking: This is one of the key aspect of Schizophrenia. You might have come across "Siow" people who come up to you to beg for money while you are having a meal at a coffeeshop. They either talk to themselves a lot or when they talk to you it is hard to follow their train of thought.

4. Grossly Disorganized Behaviour: Again you will also be familiar when these "Siow" people exhibit bizarre behaviours like scolding an invisible person, exposing themselves or other "silly" and socially unacceptable behaviour.

What all this means for you, the sane person?

It must be emphasized that Schizophrenia can be treated and the patient can actually live a normal life again! I think a lot of people have the misconception that once you became insane, you are basically a "gone case" for the rest of your life. So if you spot any of the behaviors in your friend or family members, do seek help early.

What you can do

For Early Psycosis

There is a Early Psychosis Intervention Program which you can receive help from a multidisciplinary team of Drs, psychologist, social worker etc. The website is at www.epip.org.sg
In doubt, bring your friend to see your Family Doctor for the initial assessment who can even start some simple medications before referring you to the EPIP.

For Acute Cases

For cases where the sufferer is likely to 1. Harm others, 2. Harm himself or suicidal or 3. The behavior is severely disorganized, the person should be sent to the hospital for to be hospitalized. Any of the major hospitals should be able to handle the problem.

The Mental Disorders and Treatment Act

This act gives the power to a medical officer to admit and detain the person for a period of 72 hours.

Can Schizophrenia be cured?

One third of cases have favorable outcomes. One third have intermittent relapse of their symptoms and the rest remain chronically disabled despite treatment.

More information can be found at the EPIP website

Croup: My Child has a Very Bad Cough!

This is a common scenario in kids suffering from Croup:

Parents bring their young child into the clinic clearly very distressed (both parents and child). The child is breathing noisily and has a cough that sounds like a seal barking. Everyone is very stressed except for the Doctor because he thinks to himself: "Ah, Croup! Now I can do some magic and make myself look like a hero!"

The Doctor quickly examines the child to assess the severity of the Croup and determines that it is not severe enough to require immediate admission. He then goes to the dispensary and reappears with a dispensing cup of "magic potion". The parents then hastily force the child to drink the yucky powdery medicine to which the child protests vehemently with even louder "Barks".

The Doctor then asks the patients to bring the child out of the clinic for a while so that the other patients in the waiting room can have some peace and quiet.

An hour or two later, the parents return into the consultation room obviously relieved. The "magic potion" worked its miracle. The child is now sleeping peacefully, the noisy breathing has stopped and the child no longer coughs as severely. The parents are so appreciative and thank the doctor and nurses profusely for their help. The Doctor thinks to himself: "Gee, I love my job!"

Now this of course is a case of mild Croup and it is a common scenario that we see in the clinic. Sometimes Croup can be very severe and even fatal. So it is important to have your child checked by your Doctor who will determine if the child needs to be admitted to hospital. If you are in any doubt, just bring the child to Accident and Emergency.

What is Croup?

Croup is a common viral infection of the upper airways. The virus affects the windpipe (trachea) and the voicebox (larynx) causing inflammation and narrowing of the airways, and hence difficulty breathing.

It usually occurs in young children between 6 months to 3 years of age, but it can affect kids up to 6 years old.

Symptoms of Croup.

The child may start by having a runny nose and fever and then progress to have noisy breathing, hoarse voice and a loud barking cough. It is important that parent recognize when croup becomes an emergency. This is when the child looks very sick (toxic) and tired and is having very noisy breathing (stridor) at rest. Another sign that it is very serious is when you look at the chest and you can see the ribs prominently when the child is breathing in (retractions). These are signs that you need to seek medical attention straightaway.

What usually happens in cases of mild Croup?

Mild Croup can be treated without hospital admission. The illness may last around 5 days with the first 2 days being the worse. The child does not need antibiotics since it is a viral infection.

Can Croup be dangerous?

Severe croup can be rapidly fatal as the passage of air in the voice box and larynx get so narrow that the flow of air into the lungs is severely limited. The child will need to be treated immediately with a procedure to put an airway tube into the throat so as to ensure that air can get into the lungs.

What to do?

In the Singapore context where clinics are readily available, it is best to just bring your child to your family doctor if you suspect your child is having Croup. If it is severe, bring the child straightaway to KK Children's emergency. However, if it is a mild case, Croup can be treated at the clinic. The doctor can give a immediate dose of steroids which can have amazing results. The child may improve markedly within 1 to 2 hours after giving the medication and can then be looked after at home. However it is important to note that the child should be observed closely over the next few hours to make sure the condition does not start deteriorating again.

The doctor may prescribe some fever medication and simple cough and cold syrups for the child. It is also useful to prop the child up and help the child relax by watching some TV or reading a book. Moist air can also be useful. You can do this by turning on the hot shower in the toilet for a while before giving your child a bath or by using a humidifier.

Conclusion

Croup is a common illness affecting younger children. It is usually mild and can be treated at home with the help of your family doctor. However, there are some instances where Croup can be so severe that the child will need to be admitted to hospital. So it is important for parents to be able to recognize severe Croup and seek medical attention immediately.

More information can be found here

Reference:

Murtagh, John 2004, Patient Education, McGraw Hill Australia 4th Ed

When is a Flu not a Flu?

A Flu is not a Flu when it is just a Cold.

Lately there seem to be an increase in patients coming into the clinic complaining of "Flu". But what the layperson calls "Flu" and what the Doctor considers "Flu" is quite different.

When the Doctor says you have got a "Flu", we mean that you have a condition known as Influenza. Influenza is a condition that is caused by the Influenza virus. There are lots of viruses and bacteria that cause people to have fevers and runny noses. So how does the Doctor know if the condition you have is Influenza or just a normal cold?

The truth of the matter is that the Doctor cannot be 100% sure. But we can look at the signs and symptoms and make a "best guess". The only way to confirm that you have the Influenza virus is to do a lab test.

However you can tell the difference between a "Flu" and a "Cold" by noting the different characteristics:



We all get cough and colds round the year. But occasionally, you get a bout that is so bad you feel as if you have been sat on by a Sumo Wrestler. Your bones and joints are all aching and your fever rises faster than the housing prices. When you feel like this, you might well be suffering a real "Flu".

If you are having a "Flu", you will be infectious to others a day before the onset of the symptoms and throughout the period when you are suffering from the illness. You might also feel very lethargic for up to 10 days. The Influenza virus spreads through droplets. So everytime you sneeze and cough you are helping to spread the virus around.

What you can do:

• Visit your Doctor and make sure you get an accurate diagnosis. It could be other things like bacterial pharyngitis which can be treated with antibiotics.
• Make sure you isolate yourself from other people so you don't spread the virus.
  
• Take lots of fluids and rest in bed as much as you can.
  
• There is a new medication called Tamiflu which may be prescribed depending on the patients' needs.
• Avoid getting the flu by vaccination. This vaccination is currently recommended for young children with chronic diseases like asthma, the elderly, pregnant mothers or if you are going to be in a situation where there is a high chance that you get the Flu.

More information on the Flu can be found by clicking here

Ear Wax and Cotton Buds

My son used to be quite restless and active in kindergarten. One day teacher began to complain that he doesn't seem to want to listen to instructions in class. They suspect that he was just being naughty and rebellious. I knew my son was active, but he is usually a very obedient boy, so I wondered if there was anything wrong with his ears. When I examined his ear, lo and behold, it was chock full of ear wax! After I syringed out the ear wax, the teachers stop complaining that he was not listening to instructions in class.

Impacted ear wax is one of the commonest cause of temporary deafness both in adults and children. Our ear produces wax to protect the ear canal and to give it a waterproof coating. But sometimes for some reason, there is a build up of ear wax which causes symptoms of deafness, itching, earache and sometimes even infections.

The usage of cotton buds to clean the ear is a common practice globally. It is one of the common causes of impacted ear wax. The tip of the cotton bud acts like a ram rod and pushes the wax deeper into the ear canal while it cleans the sides of the ear canal. Everyone knows how satisfying it is to have your ear canals cleaned, which explains why people continue to do it.

I once had a patient with 80% deafness in one ear. On examination, there was a huge plug of wax in the ear and it took me quite a long time to extract all of it. What I managed to extract will give you goose bumps. It was a piece of waxy, mouldy cotton bud tip which had been lying in the ear for who knows how long!

So please be advised not to put anything smaller than your elbow in your ear!

What you can do:

• Use ear drops to soften the wax
• Avoid using cotton buds
• When using a hair dryer, avoid blowing the warm air into the ear as it may cause the wax to harden
• Do not try to use a pair of tweezers or any instruments to dig out the wax as you may accidentally perforate the ear drum
• Do not try to syringe out the ear wax yourself, as it there might be a middle ear infection so you might accidentally cause a perforation of the ear drum.
• Visit your doctor if you suspect that there is a lot of wax built up in the ear

The ear has a self cleaning mechanism by which the wax that is produced is removed naturally. So you don't really need to do anything to remove the wax yourself. However, sometimes, it does build up due to various reasons. When that happens, you are advised to visit your doctor.

A Word on Ear Candling

This is quite popular nowadays and I guess it can be quite soothing to undergo the procedure. There has been a few reported cases of injuries caused by ear candling that you should be aware of. To read more about Ear Candling, please click here.

Alert! Hand, Foot and Mouth Disease is on the rise!

If you have been following the news, you would note that the number of HFMD cases has been on the rise this year. This is consistent with the increased number of cases that we are seeing in our clinic. So parents please be on a high index of suspicion if your child develops a fever, mouth ulcers and rash on the hands and feet.

Here are some important information about HFMD you should know:

• It is usually a mild and self limiting illness
• The incubation period ie the time of when the child is exposed, to the time he develops the illness, is about 3 to 5 days
• It usually affects children under 5 years of age
• The features are multiple ulcers in the mouth and spots on the hands and feet. Sometimes there may be spots on the buttocks as well
• It is spread by direct contact through droplets, saliva, faeces or blister fluid from the infected person.
• The lesions resolve in 3-5 days and there is no scarring

Please note that several years ago, there have been a series of deaths caused by the EV71 virus. So far this year, the predominant strain is the Coxsackie A16 virus which usually causes a mild illness.

What you should do:

• Consult your doctor immediately if the child has a fever and has been exposed to HFMD or if you see rashes or mouth ulcers.
• Isolate the affected child so he/she does not spread the illness to other kids
• Wash hands with soap before eating and going to the toilet
• Cover mouth and nose when coughing or sneezing
• Maintain good air circulation
• Clean all toys and appliances that may be contaminated by the affected child
• Do not share eating utensils
• Do not return to school until certified fit by your doctor

If in doubt, always seek medical advise.

Channel News Asia Report Here

Depression and Suicide

I have never met Ms X. She was a Chinese National who married a local Singaporean man. My first contact was with her newborn and I was curious that it was the grandparents who were the main caregivers. During their second visit for the baby's vaccination, I found to my horror that Ms X had committed suicide. She had been suffering from post-natal depression.

I think one of the most devastating things in life is to find out that someone you know has committed suicide. And it doesn't have to be someone you know very well. I remember when Leslie Cheung committed suicide, I was somehow affected by the news even though I can't even remember watching any of his movies. Last year, a friend of mine whom I had shared some makan adventures with was found dead at the bottom of his HDB flat. I cried, even though I did not really know him that well.

These suicides were a culmination of months of depression. They could have been helped. In Singapore, it is reported that there is one case of suicide everyday.

It is important to be able to recognize that your friend, colleague or family member may be suffering from depression and quickly get them assessed by the Doctor. It can potentially be life saving.

How to recognize Major Depression
(Modified from the DSM IV criteria)

Five of the following symptoms have to be present for at least 2 weeks:

1. Depressed mood
2. Diminished interest or pleasure in all or most activities
3. Significant weight loss or gain, or decrease or increase in appetite nearly every day
4. Unable to sleep or sleeping too much
5. Slowing of mental or physical activity or agitation
6. Fatigue or decreased level of energy
7. Feeling of worthlessness or inappropriate guilt
8. Poor concentration or indecisiveness
9. Recurrent thoughts of death or suicide

Conclusion

If you think that someone you know might be suffering from major depression, it is important that you seek medical help ASAP. The patient can be helped with medication and therapy. This is especially important if the patient has expressed a desire to commit suicide which should never be taken lightly. If the doctor determines that the patient may indeed be at risk of suicide, he has the legal authority to detain the patient in a medical facility (IMH) against the patients' wishes. Friends and family members thus have a very important role to play in preventing suicide by being able to recognize the symptoms of major depression.