JUMPA DOKTOR HANYA SETELAH HILANG 60 kg

A 50 year old man came to see a physician with severe anemia and difficulty in swallowing. He had these symptoms for the last five months. Associated with that he also noted that his stools were dark (malenic - meaning there is blood in it). And he gradually loss his weight; from an astounding 130 kg to less than 70 kg during these 5 months. He could not take anything solid.

His friends including a doctor neighbor had adviced him to seek treatment. He went to his usual bomoh and tukang urut and once to a homeopathic practitioner. Last week, he could not swallow anything and only then he saw the physician.

On examinaton he was grossly wasted and dehydrated, and pucat lesi (Hb 5.4 gm%). After transfusing him with 4 units of blood, the physician referred him to me for scope (OGDS). He initially refused (couldn't imaging having a camera being pushed down his throat!), but after convincing him that there wouldn't be any pain, I managed to do the procedure. There was an obstructing tumour in his esophagus. Biopsy showed a well-differentiated adenocarcinoma and the CT-scan showed :

A huge cancer in the lower end of the esophagus extending into the stomach ( or vice-versa) with metastatic nodes. There is a trickle of contrast going into the stomach.

So, now with an massive cancer (adenocarcinoma) in the esophago-gastric junction, 'inoperable'; he is left with not many options.

This type of cancer does not respond to radiotherapy, poor results with chemotherapy and surgery has high morbidity and mortality. As a palliative measure, a stent could be placed so that he would be able to take something orally.

And of course his days are numbered.

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To make the thing worst; after talking to him many times, he didn't seem to understanding ......
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Kelantan, oh Kelantan ku

or rather

oghe kelate, oghe kelate....gapo nak jadi ni?

BUASIR LAGI . . . .

A 55 year old man came to me for treatment of 'piles (buasir)'. He complained of passing out blood and mucus (lendir) during defecation, and lately the feeling of incomplete defecation (rasa berak tak puas). He had been seeing several doctors in his hometown for these symptoms, and all of them treated him with hemorrhoidal medications. None of them did a rectal examination.

When I examined him, there was an ulcerating tumour in the lower third of the rectum extending into the anal canal.

This is how it looks from the inside of the rectum (on colonoscopy). Anybody could have feel it if he sticks his finger into the rectum, but nobody did it. And the cancer was missed !

Anyway, after confirming the diagnosis with a tissue biopsy, I proceeded with surgery to remove the rectum (including the anus) and constructed him a permanent colostomy. This is the picture of the resected specimen.

The cancer can be seen very close to the anal skin.

This is the problem. A patient comes with very obvious symptoms, no proper assessment or examination done, yet, oh, you have buasir ! and a cancer is missed again until it's too late.

Susah sangatkah nak buat rectal examination ?

TERMENGANDUNG . . . . Apa nak buat ?

Termengandung - literally 'accidentally gets pregnant' - but I am not talking about unplanned pregnancy.

This is about a woman who was adviced NOT to get pregnant but somehow found herseft pregnant. Cancer patients undergoing chemotherapy or hormonal therapy are not suppose to get pregnant.

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This women came to me with right breast cancer, and had a breast conservative surgery done. What it means is - only the cancer and the surrounding breast tissues were excised, and she still has the breast. For that she was referred to an oncologist for chemotherapy. She went around in KL and Penang (with my referral letter) meeting several oncologists to find one who would agree with her not to have the chemotherapy. Unfortunately she found none! All the oncologists she met insisted that she should have the chemo. Finally she accepted it; and the chemotherapy was started 4 months ago. After 3 months (3 cycles of chemotherapy) she found herself pregnant. Tiga bulan baru tahu dah mengandung, susahlah kawe nak explain, hok ni kena tanya orang pompuanlah ! The oncologist referred her to an obstetrician for abortion. She called me yesterday for advice as both her physicians are non-muslims and she needs to know whether the abortion (in this circumstance) is permitted in Islam.

I am not an expert in Fiqh (Islamic jurisprudence) but I told her what I undertand and adviced her to seek the advice of Tok-tok Guru or Ustaz and 'alim-ulamak'.

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As a doctor, I explained to her why she was adviced not to get pregnant when she went for chemotherapy.

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Chemotherapy is a form of cancer treatment using drugs / medicines (chemotherapeutic agents). The drugs 'kill' the cancer cells. Kalau awak ada cacing, makan ubat cacing. Maka cacing mati dan awak jadi sihat. If you have TB germs in your lungs, you take TB medicines' kuman TB mati dan you jadi sihat!. Cancer is different... the cancer cells are parts of your bady, they are not germs or cacing. So a drug that kill cancer cells also kill normal cells. Then, how to kill cancer cells without killing the patient? Cancer cells are fast dividing cells, thus chemotherapeutic agents (ubat chemo) are designed to target cells that divide fast; yang cepat tumbuh. Malangnya dalam badan kita, bukan sel-sel kanser saja yang tumbuh dengan cepat; ada juga anggota badan yang tumbuh cepat; misalnya rambut, kuku, sel-sel darah dan sebagainya. Sebab itu bila kena kemo, rambut habis gugur, kuku jadi hitam, sel darah merah berkurangan (anaemia) dan sel darah putih rendah (mudah kena jangkitan dan kadang-kadang pesakit kanser perlu reverse isolation).

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Just imaging if you were pregnant ! The budding foetus and the fast dividing cells within it are killed by the chemo drugs. Samada janin tu mati (anda keguguran) atau kalau dia hidup, dia cacat dengan teruk sekali. So, in the case of this particular patient, I told her that the pregnancy might aborts spontanenously or if it manages to mature, she might give birth to a severely deformed baby - tapi Allah lah yang menentukannya dan Dia Maha Mengetahui dan Maha Menyayangi !

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Bagi doktor-doktor, dan adik-adik yang belajar perubatan; berilah penerangan yang jelas setiap kali anda menerangkan sesusatu kepada pesakit. Jangan anggap semua orang mudah faham sesuatu seperti anda. Ada di antara pesakit kita (sorry to say) 'slow' sungguh !.

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I'll tell you my experience last week. Ada satu orang yang saya buat operation membuang sebahagian ususnya kerana kanser usus. Hari pertama selepas pembedahan, saya benarkan dia minum air kosong, hari kedua saya benarkan minum milo. Sebelah malamnya dia bertanya jururawat; "Misi, bolehkah saya campur gula dalam milo saya, tawar sangatlah! ... Bagi kita bila sebut milo, maksudnya tentulah ada air, milo, gula atau susu. Tapi tak semua orang begitu.

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Jadi berilah penjelasan yang sejelas-jelasnya ...... sebelum terlambat atau pecah perut kerananya !

Air Tujuh Kolah

Gallstones (Batukarang hempedu) is a common disease. It presents with upper abdominal pain and usually the symptoms mimic that of peptic ulcer disease (sakit gastrik). Treatment of uncomplicated gallstone is easy and straight forward; remove the gallbladder. The operation is called cholecystectomy. Previously, cholecystectomy is done through an incision in the abdomen just beneath the right costal margin. Now it is done laparoscopicaly (minimal invasive surgery - keyhole surgery). It can be done as a daycase surgery, and with minimal pain.

In Kelantan, most patients describe it as pembedahan laser (which is literally wrong). Despite the advanced technique and all its advantages, many Kelantanese still prefer to go somewhere else before coming to their surgeon.

Last week I did a laparoscopic cholecystectomy on a 42-year old teacher. Ultrasound examination done two weeks earlier showed multiple gallstones. However on the day of the operation, she insisted that I repeat the ultrasound before the surgery. Her reason : She had seen a bomoh who prescribed her with "air kolah tujuh buah masjid" - drank unboiled.

Saya percaya Allah berikan ilmu kepada sesiapa saja yang dikehendakiNya, dan ilmuNya begitu luas. Saya yakin ada di sana seseorang yang Allah berikan ilmu untuk merawat sesuatu penyakit dengan cara yang berlainan. Tetapi masaalahnya, bomoh-bomoh yang kita ketahui kebanyakannya tidak jujur dengan perbuatannya. Ada seorang insan di Jelawat Kelantan yang 'menyedut' batukarang hempedu dengan pelepah betik sebelum diludahkan dari mulutya. Ada pesakit yang bawa batu itu kepada saya. Yang saya lihat hanyalah batu kerikil sungai atau yang dikutip di tepi jalan. Yang bomoh tu tak tahu ialah batu karang hempedu diperbuat dari kolesterol (hard but smooth, multifaceted and shiny) atau pigmen hempedu (black, soft and dirty). Tentunya kalau di'scan' semula masih terdapat batu yang sama walau pun telah 'disedut' keluar oleh tokmoh.

Pastinya bomoh itu tahu yang dia menipu, dia lakukan juga untuk cari makan. Malangnya orang kita mudah sangat percaya. Hujah mereka IKHTIAR. Memanglah Allah suruh kita ihktiar, tapi Dia juga beri kita otak. Dan Dia suruh kita gunakannya untuk berikhtiar.

Tok moh, tok moh ...........................

KITA MINUM DULU ....

Masihkah kita ingat pelakon ini?

Allahyarham Shukery Hashim, 55 tahun, menghembuskan nafas terakhir jam 1.45 petang 10/06/2009.

(ataupun ada yang menyangka bahawa beliau masih hidup, kerana melihat drama lakonan beliau yang masih baru di kaca TV hampir setiap minggu?)

Beliau meninggal dunia 3 bulan setelah disahkan mengidap kanser pankreas.

Kanser pankreas biasanya dikesan lewat, dan pengidapnya mengalami sakit perut yang teruk (body & tail of pancreas) atau jaundis (head of pancreas). Prognosis biasanya teruk, maksudnya jangka hayat pesakit adalah pendek. My longest surviving patient after surgery (Whipple's operation) lasted only two years. Yang lainnya hidup 6 bulan ke setahun. Tanpa pembedahan, none lasted more than 6 months.

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Picture: Advanced cancer pancreas with intra-peritoneal disseminations (carcinomatosis peritoneii)

Pesakit dalam gambar ini datang dengan ketumbuhan dalam perut, busung (ascites) dan disahkan mengidap kanser pankreas. Hanya biopsi yang dapat dilakukan. Beliau kembali ke rahmatulLah 4 bulan kemudian

Kajian terbaru tentang kanser ini amat mengejutkan saya:

Soft Drink Consumption Linked to Pancreatic Cancer. February 2010: Cancer Epidemiology, Biomarkers & Prevention. Kajian selama 14 tahun ini dijalankan di Singapore dikalangan penduduknya yang berbangsa China (Singapore Chinese Health Study (n = 60,524). Mereka mendapati those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15). The results of the new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not. Satu serving soft drink adalah satu tin kecil yang biasa kita beli dengan harga RM1.50

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Maksudnya kebiasaan kita dan anak-anak kita yang minum minuman bergas hampir setiap hari akan mendedahkan kita kepada kanser pankreas. Ingatlah, dalam minuman itu yang ada hanya air, yang lainnya adalah kimia; pemanis, perasa, perisa, pewarna, pengawet dan penstabil (biasanya ditambah perkataan yang dibenarkan. Pernahkah kita bertanya: siapa yang benarkan?)

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Oleh itu berhati-hatilah.

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"Mamak, air kosong satu" - adalah satu pilihan bijak, and no longer an indication of poor financial planning !

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Tepuk dada, tanya selera !!

Nak Fikir Dulu Doktor, Nanti Saya Telefon Kalau jadi....

09/02/2009

A 37 year-old teacher, single - referred by a General Practitioner for a left breast lump. On examination, there was a 2X2 cm lump in the left breast. Ultrasound examination showed features suggestive of a probable cancer. Adviced biopsy.

Nak fikir dulu doktor, nanti saya telefon kalau jadi.......

26/06/2009

Came with a much larger lump, this time with her newly-wed husband, kami baru kahwin 40 hari. On examination, the lump was 8X8 cm with areolar skin involved. Due to the rapid progression of the lesion, I told her that it was most probably a cancer. She needed proper treatment: surgery KIV chemo and radiotherapy.

OKlah doktor, buang butir saja, kalau pun kanser, kami tak mahu buang semua (mastectomy) . kami kan baru kahwin....

Excision done and the histology report came back as expected - CANCER - infiltrating ductal carcinoma. Gikgu... you need a proper cancer treatment!

Nak fikir dulu doktor, nanti saya telefon kalau jadi.......

September - December 2009: contacted patient several times. Please, you need proper treatment. Each time, the answer was :

Nak fikir dulu doktor, nanti saya telefon kalau jadi......

(09/02/2010)
Today she came without an earlier appointment, AlhamdulilLah terbuka hatinya untuk mendapat rawatan!

Saya datang ni nak minta surat pengesahan doktor yang saya ada kanser untuk saya diberi pengecualian dari menghadiri kursus!

Can I see you first? Now the cancer has come back; 6X6 cm with skin and axillary nodal involvement.

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Memang saya nakkan rawatan, tapi ginilah doktor:

Nak fikir dulu doktor, nanti saya telefon kalau jadi........

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Inilah my well-educated patient; Nak fikir dulu, nanti saya telefon kalau jadi.........

She came with a curable 2X2 cm lesion, and the concerned surgeon is just a phone-call away, yet she chose to end her life in a miserable way.

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Probably, in the future if someone says ;

Nak fikir dulu doktor, nanti saya telefon kalau jadi,

I would say;

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Ikut mu lah.....

Breast Cancer in NST

http://www.nst.com.my/Current_News/NST/articles/19afn/Article/index_html



Breast Cancer: Many come when it is too late

At least 40 per cent of Malay women who came to the department were diagnosed with either third or fourth stage of breast cancer.The percentage among Chinese and Indians was lower.

In my practice, probably more than 70 percent of Kelantanese women with breast cancer presented with stage 3 or 4 disease (Locally advanced or metastatic)

Moga-moga tahun 2010 ini memberi perubahan yang positif bagi wanita Kelantan !