Sharing Kak Amie

[DM in Ramadan]

✨Ramadan is coming real soon✨

Here are some quick notes on the education for diabetic patients in Ramadan.

🕌1stly- Risk stratify patient>> can use calculator https://www.mdcalc.com/calc/10522/international-diabetes-federation-diabetes-ramadan-alliance-idf-dar-fasting-risk-assessment?uuid=20d2e8cd-95d1-4e2e-89a2-907231b86204&utm_source=mdcalc

*inform patient, boleh bayar fidyah kalau tak boleh berpuasa kerana memudaratkan kesihatan.

Some high risk pt insists nak puasa, just make sure they know bila nak kena berbuka tu ya.

🕌Quick DM in Ramadan education:
1️⃣ When need to break the fast
- if sugar < 3.9 or >16.6 or symptomatic of hypoglycemia
2️⃣ Diet
- Sahur: Lewatkan sahur, sahur kena sahur berat dan seimbang
- Buka: kurangkan makanan bergoreng dan berminyak, elak air manis dan kaffein, minum air masak secukupnya
3️⃣ Exercise
- tarawih juga dikira senaman
- elakkan bersenam 1-2jam sebelum berbuka
4️⃣ SMBG
- Premeal,2HPP and fasting (midday)
5️⃣ SSx of hypo/hypergylemia
6️⃣ Medication adjustment
- SU and GLST2i take at iftar
- MTF same dose, OD take at IFTAR, BD take at IFTAR n SAHUR.
- PRE-SAHUR reduce insulin BOLUS (reduce dose by 25-50%) n PREMIXED (reversed dose, reduce dose by 20-50%), biasa cut 1/3 je terus nak senang ingat..
- PRE-IFTAR Bolus/Premixed use normal dose.
- basal OD pun cut 1/3 at iftar (15-30%) ..
- basal BD cut 1/2 at sahur, normal dose at iftar
** insulin adjustment need further individualization according to SMBG/risk of hypoglycemia

Goodluck!

boleh download PDF summary di sini https://drive.google.com/file/d/11tfe2zJ4xFoA89ubJiTCAGGSepwmW2YC/view?usp=sharing

Source: IDF-DAR Guideline 2021
https://www.idf.org/media/uploads/2022/12/IDF_DaR_Practical_Guidelines_2021_web.pdf

MODIFIED SYNDROMIC APPROACH TO STI MANAGEMENT

STIs which have similar signs and symptoms are grouped into syndromes. STI management uses this syndromic approach to ensure a quick and effective treatment could be initiated for the patient on the same day.

This syndromic approach includes types of STIs that could be fully treated such as syphilis, gonorrhoea, chlamydia, trichomoniasis and candidiasis.

The syndromes which are currently used for the approach are:
1.Anogenital ulcer disease syndrome
2.Urethral discharge syndrome
3.Vaginal discharge syndrome
4.Lower abdominal pain syndrome
5.Anorectal discharge syndrome

By using the Modified Syndromic Approach (MSA), diagnosis is made based on the possible pathogen. The difference between MSA and etiological management is that in MSA, treatment is given empirically during patient’s first visit to the clinic.
During follow-up, the lab test results are traced to confirm the diagnosis according to the causing pathogen, change treatment according to the lab test result, and evaluate patient’s response to the treatment given during the first visit.

Further STI notes (pdf) can be downloaded from this link:
https://www.scribd.com/document/786364762/Modified-Syndromic-Approach

Check out the new STI CPG, for more detailed guideline.

[MHT preparation]

Notes on some local estrogen preparation for menopausal hormonal therapy. Dosage ikut CPG.
https://www.scribd.com/document/772940424/MHT-Preparation
Source: ICGP (admin under mintfm) & CPG MHT Msia 2022

Boleh bukak CPG MHT Msia untuk tahu cara diagnose and types of MHT.

ps: tolong doakan admin pass exam >

Notes on Thyroid Disease In Pregnancy
- Source: CPG Management Of Thyroid Disorder 2019

[OSA CLERKING] 🥱😴
- lepas ni boleh try clerk as much as u can before refer ENT, nampak bijak sikit 😆

✅ ENT guna ESS untuk tengok severity of OSA.
- ess more towards pt complain

✅ Friedman tongue positiong
- macam mallampati tapi tongue not protruded

✅ Additional notes from ENT colleagues;
- can ask regarding: microsleep/accident hx, reflux sx, nocturia

Commonly Used BA/COPD Meds in Malaysia

Picture credits to Dr Hanif Arshad & google
Indication; refer bluebook
COPD; refer GOLD (gold 2023 bukan ABCD dah tapi ABE)
BA; refer GINA

*sorry tak complete, boleh refer bluebook for dosage.
kalau salah tolong betulkan TQ

🌸Autistic Spectrum Disorder🌸

= neurodevelopmental disorder characterised by impairments in communication, behaviour and social functioning beginning in childhood

✅ Diagnostic criteria - as per DSM V
1. Persistent deficits in social communication and social interaction⭐️
2. Restricted, repetitive patterns of behavior, interests, or activities⭐️
3. Symptoms must be present in the early developmental period
4. Symptoms cause clinically significant impairment in social,occupational, and function
5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

✅ Risk Factors
● Increased parental age
○ Maternal age >40 years old
○ Paternal age >50 years old
○ First born of mother aged >35 years old and father aged >40
years old
● Prematurity of

[Malaysia-Ireland Training Programme for Family Medicine – MInTFM]

Since ramai yang tanya pasal program ni, nak share sikit tentang apa saya tahu since saya pun baru nak join program ni. Banyak isu birokrasi jugak, b*k isu regarding oncalls, hospital placement, so i suggest boleh tunggu few years for those who are willing to wait sampai program ni dah fully established.

First boleh baca comparison pathway nk jd fms kt sni https://www.facebook.com/1474623812772208/posts/2750412715193305/?d=n

1. MInTFM ni apa?
- stands for Malaysia Ireland Training Programme for Family Medicine (MInTFM)
- satu satu program parallel untuk master FMS (other than FRACGP -australia)
- tempoh latihan program selama 4 tahun > hospital posting (2 tahun) dan primary care posting (2 tahun).
- Responsible bodies ada 4:
1) ICGP (Ireland College of General Practitioner)
2) KKM
3) iHeed - handle e learning. ada canvas, website or app utk course ni.
4) RUMC (RCSI & UCD Malaysia Campus- nama lama dia Penang Medical College PMC)- perantara ICGP kt ireland dgn kami d msia
- Boleh refer sini: https://www.rcsiucd.edu.my/programmes/mintfm/

2. Yuran berapa?
- Annual tuition fee of rm25K. (mahal ok)
- Deposit 10K
- payment boleh buat lumpsum 25K per year ATAU instalment RM6,000 every quarter on or before January 01; April 01; July 01 and October 01 every year. (RM 6,000 every quarter ( 3 months ) X 15 payments = Total RM 90,000
-
- Total 100K for 4 years training, inclusive of first examination sittings for the MICGP.
- RM 6,000 will be refunded from the deposit if the student decides to withdraw from the programme within 2 weeks of commencement.

3. Macam mana nak bayar yuran?
- KKM ada open HLP for parallel pathway. (Tawaran D) 2021 ni baru first batch yg open for HLP. Ada 20 orang je yg dpt HLP out of 120 students. Previously contract MO x boleh apply for HLP, next time maybe boleh dah for contract Mos.
- Bumiputera will be offered pinjaman MARA.
- Others, maybe ke kena self fund or buat bank loan/ kwsp.
- Kalau HLP, xyah bayar balik, bonded 5 tahun.
- Kalau mara, kena bayar balik ada percentage dia ikut performance.

4. Siapa boleh apply?

- All KKM doctors boleh apply. Regardless MO contract/permananent, MO KK or even duk ED/hospital/pkrc etc boleh apply, as long as KKM doctors.
- Just bezanya MO contract dulu x dpt apply HLP, but still boleh apply loan mara etc, as long as boleh bayar yuran.

5. Macam mana nak apply?
- NO preentrance exam required. Just apply, then only need interview and money.
- Ada a few pathway boleh apply.
- 1st, boleh apply thru Tawaran D HLP (HLP for parallel program) punya pathway. Tp seats are very limited.
Kalau tak pass HLP, still boleh dapat placement in Mintfm (kalau lulus interview), so kena cari source lain untuk fund (eg: bank loan/kwsp/mara).
- 2nd pathway, boleh directly register kat website mintfm. Go privately, apply, then interview, then kalau lulus boleh enrol, but bumiputera usually akan dpt offer mara.
- Means in one batch, akan ada yg under hlp, ada yg under mara, ada yg self fund etc.
-
6. Belajar macam mana?
- Curriculum and assessment ikut ICGP.
- Skrg ada 3 batch. 1st batch start only with northern scheme, ada around 30 students je. 2nd batch tambah central scheme, around 80 students.
- This year 3rd batch (mine), tambah southern scheme, total 3 scheme around 110 students.
- Belajar sendiri, no lecture, just ada day release every week, hari untuk berkumpul dengan FMS (scheme director) and buat discussion.
- 2 tahun hospital attachment, then 2 tahun KK posting.
- Attach dgn hosp (5 bulan each utk medical, paeds & o&g. 3 bln psy, 1 bln each utk surgical ortho ophthal ENT derm ED)
- need to do oncall like dept MO
- Round ward utk kita blaja management acute cases. Lpas round turun klinik.
- Nama penjawatan kita kt KK yg ada FMS yg akn jd trainer kita ms 3rd & 4th yr

7. Exam ?
- Ada 3 paper
1) Core Knowledge Test
2) Modified Essay Question
3) Clinical

8. Gaji?
- gaji jalan macam biasa, sebab still kerja under KKM
- perjawatan akan ambil perjawatan MO di KK yang terlibat dengan scheme kita.

[Hyperthyroidism in Pregnancy -GTT]

✅What Is The Definition Of Maternal Hyperthyroidism?

- Maternal hyperthyroidism is defined as suppressed serum TSH level with elevated free triiodothyronine (fT3) and/or free thyroxine (fT4).
- Subclinical hyperthyroidism is defined as suppressed serum TSH with normal fT4 and/or fT3 levels.
Subclinical maternal hyperthyroidism has not been associated with adverse maternal or foetal outcomes, and treatment for this condition is not recommended.
- Serum TSH levels fall in the first trimester of normal pregnancies as a physiological response to the stimulating effect of hCG on the TSH receptor with a peak hCG level between 7 and 11 weeks gestation.

✅What Are The Common Causes Of Hyperthyroidism In Pregnancy?

-The two most common causes of hyperthyroidism in pregnancy are gestational
transient thyrotoxicosis (GTT) and Graves’ disease.
- Other causes include toxic multinodular goitre, toxic adenoma and thyroiditis.
- Rare causes in pregnancy include hyperthyroidism induced by beta-HCG in pregnancy such as multiple gestation, molar pregnancy and choriocarcinoma; which are often subclinical.

✅ How To Differentiate Gestational Transient Thyrotoxicosis (GTT) From Graves’ Disease (GD)?

- Gestational transient thyrotoxicosisis a non-autoimmune transient disorder that occurs in the first trimester of pregnancy and is caused by the peak in hCG levels during early pregnancy, leading to biochemical hyperthyroidism.
- It is generally asymptomatic, mild and self-limiting. However, more severe degrees of GTT are associated with hyperemesis; whereby patients may develop signs and symptoms of hyperthyroidism.
- In the presence of an elevated T4 and suppressed TSH in early pregnancy, GTT needs to be differentiated from Graves’ disease, since these are the two most common causes of hyperthyroidism in pregnancy.
- As they may have similar clinical manifestations such as palpitations, anxiety, tremor and heat intolerance, a careful history and physical examination is very important in establishing the aetiology.
- The most likely aetiology in patients without a prior history of thyroid disease and stigmata of Graves’ disease (goitre and ophthalmopathy) and in the absence of TSH-receptor antibody (TRAb) is GTT.
- The presence of TRAb is highly suggestive of Graves’ disease.
- Anti-thyroid peroxidase antibody (anti-TPO) can be present in both conditions.
- No study has shown usefulness of thyroid ultrasound in differentiating between GTT and GD.

✅ Gestational transient thyrotoxicosis is not associated with adverse pregnancy outcomes.

- Management of GTT is mainly symptomatic, depending on the severity of symptoms.
- In the presence of hyperemesis gravidarum, antiemetics and intravenous fluids are appropriate treatment. Hospitalisation might be necessary in some cases.
- Antithyroid drugs (ATDs) are not indicated as no improvement of obstetrical outcome was observed in treated cases, and due to the possibility of increased risk of birth defects with ATD use in early pregnancy. However, there are no studies comparing ATD to supportive therapy.
- Low dose beta-blockers for a short period may be considered in very symptomatic patients.
- Serum T4 returns to normal by 14–18 weeks of gestation.

Source:
1) CPG Mx of thyroid disorder
2) Picture: PPT Thyroid Disease in Pregnancy (credits to Dr SCK, endocrinologist Hoshas)

[Anemia In Pregnancy]

Malam ni tiba2 kawan kat GP tanya macam mana nak decide nak bg iron supplement mana satu.

So bagi dia table jenis supplement dan elemental iron.
Kalau Hb normal boleh bagi prophylaxis dose.
Kalau abnormal Hb, bagi treatment dose.
Step up ikut tolerance pt dan respond of Hb towards therapy.

Nak tahu IDA ke tak kena tgk Tsat or serum ferritin.
And kalau pt thalassemia carrier pun boleh ada concomitant IDA

So ni ada Pahang punya flowchart sbb ktrg b*k kes anemia kena SIQ.