Created this new video explaining some advantages on using TeleHealth during the COVID Pandemic period. TeleHealth will also be useful for busy or house bound patients, especially those who are on home oxygen and have difficulty travelling.
TeleHealth is affordable and easily set up. Of course, it will not be better than an in-person clinic consultation but it can definitely help answer a lot of questions from a patient or care giver regarding various medical conditions.
Try out TeleHealth today and find out how convenient it is to use the service.
The rising number of COVID-19 cases prompted me to create this explainer video on how to use the pulse oximeter correctly. The normal oxygen saturation (SpO2) of a healthy person is between 95 - 100%. It is important to monitor the SpO2 at least daily, better several times a day, for Category 1-2 patients undergoing home quarantine.
The normal oxygen saturation or SpO2 of
a healthy person is 95 – 100 %.These
numbers generally stay unchanged during moderate intensity exercises and may
even increase a little, because one is breathing faster and deeper, resulting
in better lung ventilation.
During vigorous short-term exercise, like
in soccer, you may notice a small drop in blood oxygen saturation of about 1 –
2 %. When you stop exercising, the SpO2 will return to your baseline reading quickly.
When a
person complains of shortness of breath, the doctor will take down a medical
history, perform a physical examination and may order some tests.Diseases of the heart, lungs, kidneys or
liver may present with shortness of breath.
The most common functional impairment in patients with lung
disease is impaired gas exchange. In the early stages of many lung diseases, the
oxygen saturation is maintained or is normal at rest, but when the lung is
challenged with increasing demand, like during exercise, the oxygen saturation
may drop.
The 6MWT is used to assess the functional capacity of a
person.The 6MWT is also a simple test
to evaluate gas exchange impairment during exercise.It is widely used, and is considered the gold
standard, to evaluate patients with chronic respiratory disorders like COPD and
ILD.However, it is not feasible to
perform the 6MWT in many office-based practices, which generally, do not have
the flat, straight 30-m corridor required for the test.
There is evidence in the literature, suggesting that the 1MSTST
be used as an alternative to the 6MWT for measuring a person’s functional
capacity and in detecting exercise induced gas exchange impairment.Both tests have a good correlation, and the
advantage of the 1MSTST is that it causes less hemodynamic stress for patients
than the 6MWT. The 1MSTST is well tolerated, easy to perform, understood, and
interpreted; and does not require special hardware.The mean number of 1MSTST repetitions reported in the literature
achieved ranged from 8 repetitions (patients with stroke) to 50 repetitions (young
men).
The 1MSTST has been validated for use in COPD and ILD of
various aetiologies.
There are many uses for the 1MSTST:
The 1MSTST is used to identify subjects with low exercise
capacity or preserved exercise capacity.
The 1MSTST is used to detect exercise-induced gas exchange
impairment early in the course of ILD, before changes in resting DLco and PaO2,
hence making the early clinical diagnosis of ILD possible.The resting DLco is a specific but an
insensitive predictor of abnormal gas exchange during exercise. The DLco is the
diffusing capacity of lung for carbon monoxide is a measure of the efficiency
of lung gas transfer.
The 1MSTST is used to measure the effectiveness of a
pulmonary rehabilitation programme as an improvement of three repetitions is
consistent with physical benefits.
A doctor or nurse should be present during the 1MSTST.
To perform the 1MSTST place a chair of standard height
(46 cm), without arm rests, against a wall to prevent the chair moving and person
falling during the test. Seat the person upright on the chair with knees and
hips flexed at 90°, feet placed flat on the floor and a hip-wide apart, with
arms held stationary by placing the hands on the hips. The person is asked to
perform repetitions of standing upright and then sitting down in the same
position at a self-paced speed, safely and comfortably, as many times as
possible for 1 minute. The person should not use the arms for support while
rising or sitting. The person is permitted to rest during the one-minute
period.
The patient is given the following instructions:
“The purpose of the test is to assess your exercise capacity
and leg muscle strength. The movement required is to get up from this chair
with the legs straight and sit back continuing the repetitions as fast as
possible within one minute. I will give you the countdown ‘3, 2, 1 Go’ as an
indication to start and I will tell you when we are at the 15 remaining
seconds. If required, you can make a break and resume the test as soon as
possible”.
The patient should be able to perform a minimum of 5
repetitions.
The SpO2 and heart rate are noted before and immediately after
the 1-minute test.The SpO2 and hear
rate are noted for a further 1 minute following the test, during recovery, as oxygen
desaturation can continue for up to a minute after stopping the test.The number of sit-stand repetitions are
recorded for the first 1 minute of the test.
In early lung disease, a person at rest, may have a normal
SpO2 of 95 – 100 %.However, during
exercise the SpO2 may drop because of increased oxygen demand and the presence
of impaired gas exchange in the diseased lungs.
POSITIVE TEST.A SpO2
drop of 3% or more is considered a positive test.A positive test may indicate the presence of
lung disease which requires medical attention.
DO NOT perform the 1MSTST in the following situations.
1.When the resting SpO2 is already abnormal at 94% or less.
2.When the person is immobile or using walking aids.
3.During advanced pregnancy.
4.Following recent abdominal surgery or heart attack.Fo
F STOP the 1MSTST when you notice the following:
1.Feeling faint or giddy.
2.Vision becoming dim or blur.
3.SpO2 falling more than 3% from baseline.(Calculate the value before starting the test.Example: when the resting SpO2 is 96%, stop
the test when the SpO2 fall to 93% or lower.)
4.Sensation of breathlessness which is severe or unbearable.
5.Occurrence of chest pain
You MUST CONSULT a doctor when the test is positive.
The 1MSTST is currently being evaluated for use in
respiratory illnesses other than COPD and ILD.
The IMSTST is being used in some EDs or emergency departments
to quickly identify exercise induced oxygen desaturation caused by lung disease,
so a decision can be made regarding patient discharge, with or without enhanced
monitoring, or hospitalisation.
Hello I'm Dr
Leong.Today's talk will be on COVID-19.
A Suspected
Case of COVID-19 needs to fulfil 2 criteria. One is the Clinical Criteria and
the other is the Epidemiological Criteria.In the clinical criteria one has to have an acute fever and cough OR an
acute illness with two or more of the following:fever, cough, general malaise, fatique,
headache, myalgia, sore throat, coryza, dyspnea, anorexia, nausea, vomiting,
diarrhea or altered mental status.
In the Epidemiological
Criteria the suspected case needs to have been in the following places within
the last 14 days prior to symptoms and signs.The case needs to have 1. stayed or worked in an area of high risk of transmission
like in a close residentials example a nursing home or institutions like prison
or immigration detention depot 2. stayed or travelled in an area with community
transition or 3. worked in any healthcare setting.
A confirmed
case is one who is tested positive RTK- Ag in areas of prevalence greater than
10% or cases tested positive with a molecular test, namely RT-PCR or a rapid
molecular test.
This graph
shows the probability of detection of SARS CoV2 over time. The incubation period
of SARS Co V2 is about 5 days. Most infected persons will show symptoms or
signs within 11 days of infection. During the onset of symptoms, RT- PCR
testing will usually be positive. Before symptoms onset, RT-PCR testing can be
negative even though the person is infective because of viral shedding.After the onset of symptoms, the RT-PCR test
can be positive for up to 3 weeks.Commonly the infected person will no longer be infective to others after
14 days of symptom onset, even though the RT-PCR is still positive as the nasopharyngeal
swabs contain detectable non-viable viral material. The infected person begins
to develop antibodies to the virus after a week of symptom onset and the
antibodies will be detectable at about the 2nd week.RT-PCR will likely be negative after the 3rd
week of symptom onset.
SARs CoV2
mutation and variants. This chart shows the variants of concern.The Alpha, Beta, and Delta variants are
present in Malaysia. The delta variant is of special concern as there is
information suggesting increased transmissibility of the virus. There is also
some suggestion of reduced neutralization of the virus by antibodies produced in
our bodies by vaccination.But it is too
early to say if vaccines are compromised.
Dr Noor
Hisham reported in the Malay Mail that the variants of concern like beta and delta
are already present in Malaysia.
Clinical
stages of COVID-19 infection. There are five categories. Category 1 – asymptomatic.
Category 2 - symptomatic but no pneumonia. Category3 - symptomatic with
pneumonia. Category 4 - symptomatic with pneumonia and requiring oxygen. Category
5 – the critically ill with multi-organ involvement. Persons in Category 1 and 2
maybe opt for home quarantine. Whereas persons in Category 3 to 5 will need hospital
admission.
Category 2
can be divided into mild and moderate. The moderate cases who have RED FLAG
symptoms may need to be admitted to hospital for observation. The RED FLAG symptoms are - persistent or new onset fever, exertional dyspnea,
chest pain, unable to tolerate orally, worsening lethargy, unable to ambulate
without assistance, worsening or persistent symptoms such as cough, nausea,
vomiting, or diarrhea, reduce level of consciousness. or reduced urine output
in the last 24 hours.
Confirmed
cases of COVID-19 can undergo home quarantine or be admitted to hospital for
observation. Persons in Category 1 and 2, with mild symptoms, can undergo home
quarantine. However should the Category 2 status change with RED FLAG symptoms
they better be observed in hospital. Persons in Category 3 - 5 should be admitted
to hospitals.
A person
may undergo home quarantine if he fulfills the following criteria: For adults the
person should be less than 40 years and without comorbidities; like diabetes,
cardiovascular disease, chronic lung disease, chronic kidney disease,
hypertension, or obesity.The person
needs to be able to ambulate without any assistance and also be able to self-administer
medication.The person should have no ongoing
clinical needs, like hemodialysis, not pregnant and is not immunocompromised.
For
pediatric patients, who are in Category 1, they should not have any comorbidity
and with a suitable caregiver.Children in
Category 2 with mild symptoms should be more than two years old, with no
comorbidities and with suitable caregivers.
The home
condition should be suitable and the person must be able to adhere strictly to SOP.
Caregivers
who are suitable should not be more than 60 years old, are not pregnant,
without comorbidities, are not immunocompromised and with no disease considered
high risk by health personnel.
The home
should be suitable.A telephone should
be available at all times.The isolation
room should preferably have an attached bathroom.The other occupants in the house are not
immunocompromised and appropriate caregivers should be present in the house.
The person
should be able to adhere strictly to SOP.The person should stay at home, maintain physical distance with other
household members and there should be no visitors.The person must wear a mask, wash hands
regularly and practice cough etiquette.The person must be able to report health status to health care providers
through MySejahtera App.The eating
utensils, tableware should be used exclusively for the person.
Vaccination
The
national COVID-19 immunization program is on a voluntary basis, is free for all
Malaysians and non-Malaysian residing in the country. It is for everyone of age 18 years and above. Currently the age has been extended to cover 12
years and above using the Pfizer vaccine.
The immunization target is to cover 80% of the Malaysian population. We are currently in Phase 3 of the program. The immunization program will be completing
sometime at the end of this year.
Portfolio
of Vaccine in Malaysia are from the following manufacturers: Pfizer, SinoVac, Astra Zeneca, Johnson and
Johnson and CanSino.
The Pfizer
vaccine uses the mRNA technology. The Astra
Zeneca, Jansen, CanSino vaccines use the viral vector technology. SinoVac is of the inactivated virus
technology.
As of June
the registration for immunization has reached almost 60% of the population in
Malaysia. From the graph you can see the accelerated growth for
vaccination. There is an increase in
demand by the population and vaccine roll out by the government.
Selangor,
Sarawak, Kuala Lumpur and Putrajaya will reach vaccination target in
August. Labuan will reach vaccination
target earlier in July. Perak will reach
the 50% target in September and full target by year end.
Vaccine
adverse events are very uncommon. Of note with mRNA vaccines is heart
inflammation (myocarditis and pericarditis)
This adverse event occurs several days after vaccination. It mostly affect males, adolescent and young
adults of 16 years and above. The presenting symptoms are chest pain, difficulty
breathing and palpitation. The Pfizer
vaccine is a mRNA vaccine. The
occurrence of the adverse event is about 2 per 100,000 population, aged between
16- 39 years.
Another
adverse event of concern is Thrombosis with Thrombocytopenia Syndrome. (TTS). It occurs 4 to 30 days post vaccination. TTS may present as cerebral venous sinus
thrombosis. The illness presents with
severe headache, worse by lying down or bending over, and is associated with
blurred vision, nausea and vomiting, difficulty with speech, weakness,
drowsiness, or even seizures.
There may
even be unexplained bruising or bleeding.Some may experience shortness of
breath, chest pain, leg swelling or persistent abdominal pain.
The Astra Zeneca
and Jansen vaccines are viral vector vaccines.These adverse events are very rare with 2 - 4 events per million vaccinated.
Recovery Plan
The
national recovery plan has 4 Phases. There
are 3 conditions to be met under each phase.
The conditions include 1. the number of daily cases 2. ICU bed availability
and 3. The percentage of population vaccinated.
In Phase 1 only
essential services are allowed.In Phase
2, some economic sectors to reopen while the social sector remains closed.In Phase 3, more economic sectors to reopened,
the social sector is reopened gradually, Parliament and schools to reopened as
well.In Phase 4, there is full
reopening of the economy.Phase 4 is
projected to occur sometime in November and December this year.
This chart
shows the number of observed and forecast cases in the month of April and June.
R0 is the basic reproduction number of an infection. The rate of infection rises when the R0 is
greater than 1 and declines when the R0 is less than 1. We currently have a R0 of less than 1 with
declining number of cases.
As you can
see from this chart, there has been an increasing number of hospitals managing COVID-19
cases. The number of ICU beds and
ventilators have also increased.
As such,
with deceasing number of cases and increased number of ICU beds we can expect
ICU bed utilization will decrease.
More than
10% of the population is already vaccinated.
We shall soon reach our 40% and 60% target soon and will help speed up
our National Recovery Plan.
There is a very
low risk of viral transmission from surfaces and outdoor activities. However
there is a very high risk of viral transmission from gatherings in enclosed
spaces, like in offices, religious places,
cinema halls, gyms and theaters.
Infection
The COVID
virus is mainly transmitted via droplets and contact routes. However airborne transmission is possible for
example while performing aerosol generating procedures. There has been no
report of faecal- oral transmission to date.
A viral dose
of about 1000 virus particles is needed before a person becomes infected. During normal breathing about 20 vp are shed
in a minute. While speaking about 200
vp. Coughing and sneezing expel about
200 million vp into the air and these vp can remains in the air for hours in
poorly ventilated environments.
The infectious
dose is dependent on the number of virus particles multiplied by time.
Getting the COVID vaccine and feeling safe. No significant adverse reaction following the vaccination except for some soreness over the injection site. Scheduled for the 2nd dose in 3 weeks.
Old website created using Joomla platform was rather difficult to maintain with its frequent updates. Shifted to a simpler platform - WIX with most of the features I needed.
Below are some screenshots of the old webpages. A useful record of all the designing and learning that went will maintaining the site.
An Asthma Workshop was held on Saturday 19th November for nurses from various private hospital in Ipoh. The workshop started at 9.30 am and ended at 12 noon. There were 33 participants. The nurses were from KPJ ISH, Pantai Hospital Ipoh, Fatimah Hospital and Perak Community Specialist Hospital. There were also several industrial nurses from local factories.
The objectives of the workshop were to:
1. Improve the understanding of Asthma Control and how to achieve it.
2. Encourage the use of peak flow meters and the Asthma MD app in monitoring asthma control.
3. Encourage the use of the Asthma Control Questionnaire.
4. Demonstrate the proper use use of MDI, DPI devices and spacers.
5. Encourage the setting up of asthma counselling teams in the hospitals
6. Train coaches for the Asthma Friendly School workshops.
Dr. Leong Oon Keong and Mdm Leong Yee Leng RN (who is currently doing her Masters in Nursing) were the trainers.
All nurses were given a Certificate of Attendance after the workshop. They each earned 4 CPD points from the Lembaga Jururawat Malaysia.
Now I can track my steps, heart rate, number of floors climbed and whether I had a good night sleep. Good analytics as well. Published with Photo Blogger.
"The Doctor" a reprint from the Tate Gallery given to me by the late Dato Teh Siew Eng many years ago. This painting reminds be that doctors should be passionate about their calling and compassionate in their work
We are continuing this programme in conjunction with the Perak Chest Society. I shall be attending to the Q&A sessions. Cik Azmeera out physiotherapist will assist in the physical exercises and Ms Navaneswary our pharmacy assistant will help attendees improve on their inhaler techniques.
TO BETTER manage asthma, the Perak Chest Society is encouraging patients to use a smartphone app called AsthmaMD.
Society president Dr Leong Oon Keong, who strongly supports the use of the free app created by medical doctor and researcher Dr Sam Pejham, said the app helps patients to track and control their condition through an asthma action plan.
“It is best for each patient to own a peak flow meter first to go with this app,” he said.
“A patient should blow into the instrument at least twice a day — upon waking up and before going to sleep — then jot down the results in the app’s journal to monitor their condition.
“Currently, doctors still chart meter readings on paper, but with this app, everything is instant because the patient can do it on their own,” he tells MetroPerak.
To the uninitiated, a peak flow meter is a calibrated instrument used to measure lung capacity and monitor breathing disorders. It is commonly used among asthma patients.
The AsthmaMD app allows patients to keep track of their asthma activity and action plan.
Dr Leong said the app will inform the user whether their condition is critical or under control, depending on the results of their meter reading.
“When the reading shows critical, the app will then launch an asthma action plan telling a patient what they should do to get it under control again.
“Now this is the important part of the app usage — you must confirm with your doctor the type of relievers you can take for this action plan beforehand so that you are taking the correct dosage of medicine.
“About 30 minutes after taking the first round of medication, the app will ask, ‘How are you?’
“If you feel better, the plan will stop. If not, the next step of the action plan will continue. Each round of medication must be keyed in by your doctor from the beginning,” he said.
Dr Leong points out that the one feature that makes this app essential for asthma patients is that once the user’s asthma activity is diligently charted every day, it can be easily shared with their doctor.
“The app provides a graphic chart of an asthma journal, which can be emailed to a doctor so they can easily learn of a patient’s progress.
“This saves the patient so much time, as they don’t have to make the physical trip to the clinic to find out their progress.
“If all is well, the doctor may extend the appointment date. But if things deteriorate, the patient can come in earlier to see the doctor instead of having to wait until the next appointment,” he said.
The app’s other features include recording data of asthma symptoms experienced (coughing, wheezing, chest tightness, shortness of breath, waking at night due to asthma, the ability to do some but not all usual activities), asthma triggers (dust, fumes, exercise, pollution, pollen, strong odours, viral illness) as well as reminders so that patients do not forget to take their medication even though their condition is well managed.
Being a consultant chest physician himself, Dr Leong said the society has long been searching for ways to help patients with respiratory complications self-monitor their conditions at home.
“We’ve only managed to find this app to help asthma patients.
“Although this app has been in existence since 2010, and has been written about in international publications, I believe a lot of doctors here are not aware of this useful tool.
“As doctors, we can’t do everything ourselves for the sake of our patients, so if there’s anything free and beneficial to patients, we must share it,” he said.
Dr Leong, who believes that the app can pave the way to the age of telemonitoring diseases at home in Malaysia, said the society will be conducting formal lessons soon to educate nurses and counsellors on how to effectively use the app.
“This can then be passed on to patients so they know what to do after being discharged, while maintaining direct communication with their doctors by sending them the charts from this app.
“I must stress that it is vital for patients to go back to their doctors to confirm their asthma action plan, so that they know the dosage of medicine they should take every day to control their symptoms,” he said.
The Perak Chest Society held a public forum today at 11.30 am at its secretariat to coincide with World TB Day. TB incidence is increasing and we need to be well informed about the disease. The talk attracted about 18 participants with nurses from Hospital Fatimah and Perak Community Specialist Hospital.
Admission to the public forum is free but very surprisingly TB patients are not too keen to learn about the disease they are suffering from. Hopefully the next meeting will have a larger audience!!
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