Good communication in all aspects of medical practice is essential. Effective communication with your patient not only enables you to take an accurate history but also helps the patient to understand their illness and no doubt assists the healing process. Communication with other health professionals allows the team approach to healthcare to succeed. It reduces the chances of a breakdown in continuity of care, builds relationships and understanding between different disciplines and specialties and helps professionals to learn from each other. In the medico-legal field poor communication is the underlying problem in the most of cases that MPS deals with. The majority of negligence cases are not related to the clinical quality of care but are triggered by inadequate communication. A breakdown in the doctor-patient often occurs before the incident that leads to a claim. It is as if the patient is just waiting for their moment to sue. In a busy clinic or GP surgery it is often easy to forget the human needs of the patient and concentrate on their medical needs. First impressions are vital not just with the doctor but also with other staff and even the clinic or hospital itself. During the consultation careful listening, giving sincere empathy early in the consultation and an expression of understanding of their concerns will go a long way to instill confidence in the patient and reduce the likelihood of a complaint should things go wrong.
Over the last decade the number of negligence cases brought against doctors, dentists and other healthcare professional has increased significantly in many countries around the world. In addition, the proliferation of the pathways of accountability in many countries means that doctors are feeling undervalued and vulnerable and are therefore seeking assistance and protection more than ever. The effect of a claim or complaint on a doctor can be devastating both personally and professionally. The relationship with the patient is damaged and an increase in defensive practice ultimately causes an increase in healthcare costs. Patient expectations have increased. Patients are more knowledgeable than they were five years ago and the demands on the professions are increasing daily. Unfortunately because of the long delays that are seen between an incident and a claim it is very difficult to predict what reserves are required in the future. We have seen a number of organisations pull out of the business over the last year and it highlights the importance of having an understanding of the needs of the professions and the ability to track trends in litigation in order to set appropriate subscription rates. Doctors and other healthcare professionals require more than just financial protection. They need support from their colleagues and assistance from experienced lawyers in order to help restore their confidence and ensure that they can continue to practice for the benefit of their patients in the future.
The management of the clinician who generates complaints and claims on a regular basis, raises issues of professional responsibility and presents ethical challenges for the defence team, in addition to the immediate practical need for advice and representation. This short session examines some of these issues and suggests some ways that are already being used to address them.
We report a case of tuberculosis of the thyroid gland associated with mediastinal lymphadenitis in a 30 years-old male, who presented with dysphagia and a mid line anterior neck swelling. Fine needle aspiration was positive for acid fast bacilli. He made an uneventful recovery with antituberculous drugs. Although seldom observed, tuberculosis should be kept in mind in te differential diagnisis of nodular lesions of the thyroid.
A 47-years-old Malay man presented with unremitting epigastric pain and loss weight for 3 months. At laparotomy, a large tumour mas was found in the liver and a few small nodules in the spleen. Histopathological examination revealed a hepatic angiosarcoma with metastsis to the spleen. He had exposure to formic acid fumes for more than 23 years in his work as a rubber tapper. The various chemical carcinogens that are implicated in this type of tumour are discussed. The possiblity of an association between formic acid fumes and development of angiosarcoma in the liver is highlighted.
A 43 year-old woman presented with severe non-specific abdominal pain of 1-week duration. She was on oral contraceptive pills for the past 6 years. Clinically patient appeared ill with no specific abnormal physical sign. Moderate amount of free fluid in the peritoneal cavity on ultrasound prompted an urgent abdominal computed tomography (CT) scan, which revealed thrombosis of the superior mesenteric vein. Further investigations revealed a hypercoagulable state with protein C deficiency. Patient responded well to anticoagulation and supportive therapy. One month later patient readmitted with vomiting and signs of intestinal obstruction. Barium study revealed a moderately long tight stricture at mid jejunum with proximal dilation. A by-pass surgery was carried out. She was well at 3 months follow-up.
Drug interactions can cause iatrogenic disease. If concurrent medications are taken, the potential exists for a drug interaction to occur. Renewed interest in the topic interactions has been generated by the fatal interactions involving non-sedating histamine H-1 antagonists and the recent intriduction of two therapeutic agents, the selective serotonin reuptake inhibitors (SSRIs) and HIV protease inhibitors, for the treatment of depression and AIDS, respectively. These three therapeutic agents have been implicated in clinically significant drug interactions. The consequences of these interactions vary in clinical significance, extent, and effect. Some interactions are theoretical whereas others may lead to severe iatrogenic adverse experiences including lethal consequences.The purpose of this review is to alert the medical practioner to potential drug interactions that may occur when these drugs are prescribed to patients. The pharmacological basis and clinical signficance of these interactions are reviewed. The pharmacological mechanisms underlying these interactions are illustrative of those that may be involved for many other medications. Doctors should be aware of the potential pitfall that may occur when certain groups of drugs are prescribed with concurrent medications.
Osteoradionecrosis is a severe debilitating complication; it may occur from radiotherapy to the bones. It is a dental surgeon's nightmare as it may be long standing and difficult to manage. Osteoradionecrosis is characterised by hypoxia, hypocellularity and hypovascularity of the affected tissue. This paper reviews osteoradionecrosis in relation to dental treatment.
Acute epiglotiitis is a disease of rapid onset and progression of symptoms and has been well described in children. The importance of being aware of this diagnosis is to prevent an acute upper airway obstruction that can be potentially fatal. Here we describe two cases of adult acute epiglottitis where the patients had severe symptoms of sorethroat but a normal looking oropharynx.
Fourteen severely ill ventilated patients in an intensive care unit, requiring short-term total parenteral nutrition, were examined for catheter-related infection. Microbiological analysis using Maki's SQ technique was carried out on catheter exit site, catheter hub, proximal subcutaneous segment of catheter and catheter up. Qualitative cultures were carried out on total parenteral nutrition and peripheral blood samples. Twenty six of 29 catheters removed (90%) were culture positive but only 7 catheters were related to positive blood cultures, giving a catheter-related bacteremia (CRB) rate of 24%. Haematogenous seeding was strongly implicated in 7/29 (24%) of catheters. Patients' skin flora appeared to be the main source of catheter-related infection. The organisms isolated for patients with CRB included coagulase-negative staphylococci, Acinetobacter and Klebsiella. It is suggested that to control infective complications of central venous catheters, emphasis should be focused on specialised intravenous therapy teams and the use of strict protocols for insertion and care of central lines.
Over a period of ten years (1983-1992), 134 malaria cases admitted to University Hospital, Kuala Lumpur (UHKL) were analysed. Malays constituted 27.6%, Chinese 29.8%, Indians 9.7%, Indonesians 16.4% and other foreigners 16.4%. Therefore, of the total number of cases, foreigners constituted 32.8% (44) of all the malaria cases admitted to UHKL. Fifteen of these foreigners had chloroquine-resistant strains of malarial parasites. Three species of malaria were reported of which Plasmodium falciparum constituted the most (46.3%) (80% of these developed resistance to chloroquine). Plasmodium vivax was confirmed in 44.8% (10% of these developed resistance to chloroquine) and there was only one case of Plasmodium malarie infection.
Several risk factors for cardiovascular disease amongst a sample of urban Chinese women were investigated. These factors included body mass index (BMI), waist hip ratio, total blood cholesterol (TC), HDL-cholesterol and Lp(a) levels, blood pressure, cigarette smoking, family history of chronic disease, dietary habits and frequency of selected food intake. The subjects were found to have coronary risks with respect to BMI and TC level, both of which increased with age of the women. Hypertension, HDL-cholesterol and Lp(a) levels appeared not to pose as risk factors amongst these subjects. Dietary habits and intake showed significant correlations with subjects' BMI status. Health promotion is called for towards reducing the modifiable coronary risk factors.
733 senior civil servants comprising 520 males and 213 females with a mean age of 44 years (range 25-56 years) were screened for their health status. The sample population comprised of 67.9% Malays, 22.5% Chinese, 9.1% Indians and 0.4% other ethnic origins. The subjects' medical histories were recorded and a full medical examination including anthropometric measurements (weight, height, waist and hip circumference), blood biochemistry and urine analysis, chest X-ray and electrocardiograms were done. The results obtained showed that 36.0% of the study population were overweight with 6.5% being obese. Of this 32.0% had central obesity. 15.2% of the subjects had systolic hypertension (systolic BP > or = 140 mmHg) whilst 27.6% had diastolic hypertension (diastolic BP > or = 90 mmHg). Hyperlipidaemia was common, with 75.2% subjects having raised cholesterol, 19.9% raised triglycerides, 50.2% raised LDL-C, 74.6% raised TC:HDL-C and 26.6% raised LDL:HDL-C. An elevated blood glucose was found in 8.4% subjects, whilst urine sugar was detected in only 2.6%, and a raised uric acid was found in 2.8% subjects. The prevalence of hypertension, raised blood glucose and hyperlipidaemia increased with age with more males affected than females. Although hypercholesterolaemia appeared more frequently amongst the Malays, the Indians, by comparison had the highest prevalence for a raised LDL:HDL-C ratio, a reflection of the increase in LDL-C and a concomitant decrease in HDL-C. The latter findings indicate that the Indians are at greater risk for the development of coronary heart disease than the Chinese and Malays. In addition, the mean levels of serum cholesterol found in this study seemed to have exceeded the levels found in populations in the industrialised countries such as the USA. There is thus an urgent need for more public health campaigns aimed at the reduction and control of such coronary risk factors.
Adequacy of diabetic management in 5 Perak outpatient departments was studied in April 1996. Two hundred diabetic patients' records were analysed. All doctors and 100 patients answered questionnaires on diabetes. Fifty five percent of doctors had adequate knowledge. Patients' knowledge varied between centres (13% to 80% adequacy). Most records had insufficient data to determine adequacy of early detection. Centres with screeners had adequate weight and blood pressure measurement. Overall control and monitoring of diabetes were inadequate. Referral of complications were delayed in 2 centres. Refresher courses for doctors, patient health education, protocols, screeners and physician visits are recommended.
Study site: Klinik kesihatan, outpatient clinics, hospitals, Perak, Malaysia