Thursday, May 12, 2016

ECG for medical students

It seems wherever I go, ECG is usually one of the first few topics that I am asked to teach.

This is actually a good thing.

I always advise medical students to have a system, or a way of approaching ECG interpretation.

Today's blog post will focus on the basics of ECG interpretation, which is something a student should know as soon as they start to hit the wards (somewhere around year 3, depending on the medical school).

Usually, during first and second year, medical students will be thought the physiological basis for the ECG, which can be summed very briefly by:

From: Diagram of Cardiac Conduction System
  • SA node
  • AV node
  • left and right bundle branches
  • Purkinje fibers
We then consider the different waves that make up the ECG.

From: ECG waves
It's important to remember that the:
  • P wave is the electrical activity that precedes atrial contraction, 
  • QRS complex is the electrical impulse that generates ventricular contraction
  • T wave is the electrical impulse that causes ventricular relaxation.
You should recap that a 12 lead ECG is a standard tracing obtained by placing chest and limb leads on the patient.

12 Lead ECG sample from Wikipedia.
The lead placements would be something that is done during physiological practical sessions in year 1 or year 2.

The 12 lead ECG sample above is inadequate. Usually there is a rhythm strip given at the bottom.

The clinical approach to ECG interpretation first involves knowing why the ECG was done in the first place. What are the patient demographic details like age and gender, did the patient have chest pain or palpitations, was there any findings on physical examination, and what the differential diagnosis is.

Then, look at the ECG and determine:
  • The rate
  • The rhythm
  • Axis
  • ST segment for depression or elevation
  • LVH
Using the ECG sample above for interpretation, we imagine a 20 year old medical student who went for a medical check up. Patient has no previous medical history.

Students. please attempt and let me know your answers.

Tuesday, May 10, 2016

Adakah Vaksin Selamat...Cara Menganalisa Sumber Rujukan

Hari ni niat nak blog sikit tentang vaksin.

Jadi saya google "Adakah vaksin selamat" dan alangkah terkejutnya...sebenarnya takde terkejut sangat. Sekarang baru saya faham macam mana maklumat yang salah boleh tersebar luas.

Ok, link pertama ialah dari blog Dr Zubaidi, bertajuk "selamatkah vaksin untuk bayi kita?". Terima kasih Dr Zubaidi kerana menulis dengan terperinci tentang keselamatan vaksin.

Saya tak kenal Dr Zubaidi Haji Ahmad secara peribadi. Macam mana saya nak tau yang dia ni betul2 doktor bertauliah? Kat sini saya bagi tips kepada para pembaca. Boleh pergi ke website Malaysian Medical Council (MMC) dan Search for Registered Doctors, atau klik di sini untuk check sama ada seseorang itu betul2 doktor bertauliah di Malaysia.

Saya dah check, memang betul ada Dr Zubaidi Ahmad dalam MMC register.

Itu salah satu cara kita nak mengesahkan sumber maklumat, sebab ingat, sesiapa saja boleh menulis apa2 saja dalam internet ni. Adakah kita akan percaya bulat2 kepada orang yang kita tak kenal, tak tahu apa latar belakang orang tersebut, dan kenapa mereka menulis?

Minta maaf, saya seorang yang sangat skeptikal dan tidak mudah percaya apa2 berita sekali pun.

Dalam Al-Quran pun sangat2 menekankan bukti, contoh bila nak tuduh orang berzina pun kena bawa empat orang saksi, surah 24:4.

Quran 24:4

Quran 24:4 sambungan
Sekurang2 nya saya tahu Dr Zubaidi tu doktor perubatan bertauliah. Maka saya boleh terima pendapatnya tentang keselamatan vaksin.

Link yang kedua, saya agak terkejut lah. Tajuk blog post "Bahaya Suntikan Vaksin dan Imunisasi".

Hmmm....macam mana ya, saya google "adakah vaksin selamat" keluar pulak "bahaya vaksin". Hebat 'search engine optimization (SEO)' "Minda Ahad" ni.

Ok takpe. Takde masalah. Sebab saya nak cari kebenaran. Saya nak cari bukti. Buat SEO sehebat mana pun, yang benar tetap akan benar.

Pertama sekali saya nak terus terang, memang saya kagum dengan penulis blog '***** ****' ni. Blog post nya tentang bahaya vaksin sangat panjang dan sangat terperinci. Saya pun as a blogger, very impressed sebab bukan senang nak hasilkan blog macam ni.

Tetapi, check punya check, tak dapat nak pastikan, siapa sebenarnya penulis ***** **** ni. 

So, boleh percaya ke apa yang dia tulis? Orang tepi jalan bagi nasihat tentang keselamatan vaksin, dia ni doktor ke, pensyarah ke, macam mana dia tau? Ke dia main copy paste je maklumat yang dia baca dari sumber yang entah betul, entah tak. 

Ok takpe. 

Sumber tidak dapat dipastikan.

Langkah kedua, saya baca blog post dia pulak.

Nampaknya perbahasan utama dia, "imunisasi: satu konspirasi".

Saya google maksud konspirasi, adalah komplot. Ok. Saya doktor perubatan, komplot ni bukan lah kepakaran saya. Tapi saya ada buat perbahasan secara logik tentang hujah "vaksin adalah konspirasi zionis". Kalau nak baca, boleh klik di sini.

Saya baca lagi, perbahasan dia yang kedua, "Apa kata para akademik tentang vaksinasi".

Panjang nya.

Saya tertarik kepada ayat tersebut..."Ketika vaksin dikatakan selamat....Dr Harris Coulter, pakar vaksin". Wow, pakar vaksin? Istilah baru ni. Tak pernah saya dengar pakar perubatan pakar vaksin. 

Saya pun google Harris Coulter.

Sampai la ke suatu artikel yang di tulis oleh rakan seperjuangan dan juga co-author (penulis bersama buku) Barbara Loe Fisher, yang bertajuk "Harris Coulter was a brave visionary". Kalau nak terjemah, lebih kurang Harris Coulter ni seorang yang berpandangan jauh. 

Saya tak berapa percayalah dengan "National Vaccine Information Center" setelah membaca sejarah penubuhannya, tapi takpe, itu kurang relevan.

Jom tengok CV atau curriculum vitae Harris Coulter ni, seorang yang dikatakan "pakar vaksin" oleh blog ***** ****.

"Harris Coulter, PhD
October 8, 1932  -  October 28, 2009
Harris Livermore Coulter, PhD, born in Baltimore MD on October 8, 1932 died on October 28, 2009 in Washington, D.C. after a long illness following a stroke in 1997.
The co-author of DPT: A Shot in the Dark in 1985 and author of Vaccination, Social Violence and Criminality: A Medical Assault on the American Brain in 1990, Dr. Coulter attended Milton Academy and graduated Yale University with a BA degree in Russian Studies. He earned a masters degree in political science and a doctorate in philosophy from Columbia University. He worked for the State Department and United Nations as an English/Russian interpreter and authored nine books on medical history.
He is survived by his sons, Andrew and Alex and by his daughters, Elizabeth and Marian".

  • Ok, dia ada Bachelor of Arts in Russian studies. Yang saya pasti itu bukan ilmu perubatan.
  • Lepas tu dia ada master degree political science. Ok, itu pun bukan ilmu perubatan.
  • Dia a doctorate philosophy. Maaf ya, itu pun bukan ilmu perubatan.
  • Dia menulis 9 buku tentang sejarah perubatan. Maaf ya, itu pun bukan ilmu perubatan. Ilmu perubatan yang dipelajari para doktor adalah sains perubatan, bukan sejarah perubatan.

Macam mana saya nak terima dia sebagai "pakar vaksin" sedangkan dia bukan seorang doktor perubatan dan tak ada apa2 kepakaran dalam bidang perubatan mahupun allied science (sains kesihatan).

CV nya disambung dengan...

"Curriculum Vitae for Harris Coulter, PhD
  1.  June 1997 - Paris, France - Meetings with Dr. Jacques Benveniste on writing a history of his discovery of the "memory of water."
  2. January 1997 - Lectured to homeopathic and other physicians specializing in alternative medicine in Berlin, Germany, Moscow, Russia and London, UK.
  3. October 1996 - Lectured on cancer immunotherapy at the 51st Annual Conference of the World Homeopathic League (LIGA) in Capri, Italy and at the Third Dead Sea Conference on Potentiating Health and the Crisis of the Immune System in Zichron Yaacov, Israel. Guest Lecturer at the Convention of the Romanian Homoeopathic Society in Bucharest, Romania.
  4. November 1995 - Lectured on medical and homeopathic history at Centre de Techniques Homeopathiques, Montreal, Canada (lectures published by the Centre under the title: Histoire de l'Homeopathie).
  5. October 1995 - Lectured at 50th Congress of International Homeopathic Medical League (Oaxaca, Mexico) on dangers of childhood vaccinations.
  6. September 1995 - Lectured at Conference on Genetic Causes of Violence (University of Maryland) on childhood vaccinations as a cause of violent behavior.
  7. February 1995 - Spoke at 49th Congress of International Homeopathic Medical League (New Delhi, India), and to homeopathic physicians in Calcutta, India, on 'Vitalism and the Future of Medicine.'
  8. December 1994 - Published: Divided Legacy. Volume IV. Twentieth Century Medicine: The Bacteriological Era.
  9. April 1994 - Lectured at 150th Anniversary meeting of The American Institute of Homeopathy on: 'American Medicine, Where We've Been and Where We're Going.'
  10. September-October 1993 - Ad Hoc Advisory Panel of the Office of Alternative Medicine. Worked with Office of Alternative Medicine supervising trial of shark cartilage in treatment of cancer.
  11. May 1993 - Honorary member of the 'Syndicat Professionel des Homeopathes du Quebec'.
  12. September 1992 - Pharmacological and Biological Treatments Panel Member on the NIH's Workshop on Alternative Medicine. The report published was Alternative Medicine: Expanding Medical Horizons, also known as the Chantilly Report.
  13. September 1992 - Lectured at the Fifth International Conference on Neuro-Developmental Issues (Cherry Hill, New Jersey) on the post-encephalitic syndrome.
  14. March 1992 - Lectured at Fourth European Conference on Neuro-Developmental Delay (Chester, England) on the post-encephalitic syndrome.
  15. 1990-96 - Advisory board of the Cancer Chronicles.
  16. 1990-91 - Board of Directors, International Foundation for Homeopathy.
  17. 1990 - Published The Controlled Clinical Trial: An Analysis
  18. 1990 – Published Vaccination, Social Violence, and Criminality: The Medical Assault on the American Brain.
  19. May 1990 - Lectured at 45th Congress of International Homeopathic Medical League, Barcelona, Spain, on dangers of childhood vaccinations. Awarded the Centenary Gold Medal of the Academica Medico-Homeopatica de Barcelona.
  20. 1990-96 - Lectured in France, Norway, Brazil, and Russia on homeopathic, vaccination, and medical history issues.
  21. 1988 - Testified before House of Representatives, Committee on Appropriations, Subcommittee on Labor: on AIDS and Syphilis: the Hidden Link.
  22. 1987 - Published AIDS and Syphilis: the Hidden Link.
  23. 1985 - Published with Barbara Loe Fisher: DPT: A Shot in the Dark.
  24. 1985 - Awarded the Hahnemann Prize of the Belgian Faculty of Homeopathy.
  25. 1983-89 - Editorial board of the Journal of the American Institute of Homeopathy.
  26. 1987 - Lectured at 42nd Congress of the International Homeopathic Medical League, Arlington, Virginia: 'DPT Vaccine. The DPT Shot and Public Health.'
  27. 1983-96 - Honorary member of the American Institute of Homeopathy.
  28. 1981-82 - Vice President of the American Center for Homeopathy and editor of The American Homeopath; Secretary of the Homeopathic Pharmacopoeia Convention. Organized homeopathic summer programs in Melbourne, Florida, and Scottsdale, Arizona.
  29. 1981 - Published Homeopathic Science and Modern Medicine.
  30. 1980 - Lectured to 35th Congress of the International Homeopathic Medical League, Acapulco, Mexico: 'Hahnemannian Homeopathy and Revisionism.'
  31. 1977 - Published: Divided Legacy. Volume II. The Origins of Modern Western Medicine: J. B. Van Helmont to Claude Bernard.
  32. 1975 - Published Divided Legacy. Volume I. The Patterns Emerge: Hippocrates to Paracelsus.
  33. May-June 1974 - 39th Congress of the International Homoeopathic Medical League, Washington, D.C. George Vithoulkas and Harris L. Coulter honored as writers on homeopathy.
  34. 1973 - Published Divided Legacy. Volume III. The Conflict Between homeopathy and the American Medical Association, and Homeopathic Influences in Nineteenth-Century Allopathic Therapeutics.
  35. 1972 - Published: Homeopathic Medicine.
  36. July 1969 - Awarded degree of Doctor of Philosophy (Ph.D.) by Columbia University, NY; dissertation title: Political and Social Aspects of Nineteenth-Century Medicine in the United States: The Formation of the American Medical Association and its Struggle with the Homeopathic and Eclectic Physicians.
  37. 1965-75 - Director of Publications, American Foundation for Homeopathy.
  38. 1961 - Awarded M.A. by Columbia University, NY (Political Science).
  39. 1954 - Awarded B.A. by Yale University, CT (Russian Area Studies).
Languages: German, French, Spanish, Latin, Russian, Hungarian, Serbo-Croatian".

Banyak ye, tapi takde satu pun syarahan nya tentang ilmu dan sains perubatan. Homeopati itu bukan sains perubatan.

Dengan sebab ni, saya tak dapat terima apa2 maklumat lain yang ditulis oleh blog ***** **** tentang vaksin.

Itu saja perkongsian hari ni. Harap bermanfaat. 

Fikir2kan lah. Buat kajian sendiri.

Hari ni, 13 Mei 2016, beberapa hari selepas blog ni ditulis, saya buat keputusan untuk edit dan buang nama blog tersebut. Blog mana, tak penting. Mungkin ada banyak lagi blog lain yang menggunakan hujah yang sama. Yang penting, fakta yang dibentangkan oleh mana2 blog. Kita nak cari kebenaran. Terima kasih atas feedback yang diberi. Semoga semua amalan kita diterima oleh Allah.

Friday, May 6, 2016

Diet Untuk Elak Diabetes: Nasi Putih

Alhamdullillah baby dah tidur. Boleh la blog sikit tentang artikel yang share di facebook hari ni.

Gambar hiasan: Makan malam saya hari ni.

Tajuk artikel Straits Times Singapore ialah "Diabetes: Nasi yang dimakan adalah lebih teruk dari minuman bergula", boleh baca artikel dalam Bahasa Inggeris tu di sini.

Ini diikuti dengan perbincangan yang menarik yang saya post dan harap dapat kupas di sini:

Wan Maziah Wan Mohamed I do agree that carbs are culprits for diabetes but I do not think white rice on its own is worse than the sodas. There should be real evidence comparing white rice with sodas without other lifestyle confounding factors.
LikeReply411 hrs
Azura Aslar Agree. I dont think consume it in moderation can cause harmful effect.
LikeReply10 hrs
Mazlyn Mustapha

Write a reply...
Lisa Shah Saidin Can't wait for ur explanations
LikeReply11 hrs
Vincent Wong White Rice is pure carbohydrates i.e. Sugar. It is as bad as Soda. Soda has about 7 teaspoon of sugar per 325ml. A bowl of white rice is about 5 teaspoon of sugar. But not all white rice is equal- Basmathi Par-boil white rice has a lot lower carbo content almost as good as brown rice. If you really need eat white rice -- go for basmathi par-boiled - its expensive but worth it.
LikeReply110 hrs
May Kim Or mixed with ponni rice with flaxseed and chiaseed ..truly awesome great nutritions
LikeReply210 hrs
Mazlyn Mustapha

Write a reply...
Zul Helme While we're on the subject of carbs, is it true that potatoes are a better source of carbs than rice? Back when I was freelancing, I had a very poor diet (in my view) of instant noodles (mee sedap), but I've always added lots of potatoes and eggs with it (the instant noodle was for flavoring).

Now I'm eating properly (living with friends so proper home-cooked meals), but it feels like I have less energy than when I was eating the potatoes (especially since I play tennis, I get tired a lot quicker than usual).

LikeReply110 hrs
Vincent Wong Potatoes are a good source and has more fiber content compared to rice. Sweet potatoes are even better due to high content of fiber. Too much carbs will lead to high blood sugar which might trigger insulin resistance which then leads to the point of no return (diabetes type II). More importantly if you consume lots of carbs, if you can't reduce you need to increase your exercise level to burn those calories (blood sugar). Unprocessed blood sugar will turn into Triglycerides (blood fat) which will mess up your overall Cholesterol - prolong condition leads to clogging your arteries then becomes heart disease.
LikeReply110 hrs
Vincent Wong And once you are diabetic ... you can't get insurance. Because diabetes is the root of all diseases. So don't eat too much rice. I know its tough in Malaysia because everything is rice or noodles (processed rice).
LikeReply10 hrs
Zul Helme I know this a bit of a cliche, but I'm a skinny 165cm dude weighing around 50kg or so. Never had any trouble being overweight (tried my bit at weight-gaining, no luck), but had a medical checkup a few years ago and doctors said I had unusually low blood pressure (which explain a few fainting/blackout spells in the past).

Suppose I'm still at risk for clogged arteries if I consume carbs a bit more (as much as the average person anyways)?

LikeReply10 hrs
Vincent Wong I am diabetic and skinny too. Diabetic does not automatically mean fat. Low blood pressure and thick blood may be a genetic predisposition. How would you know? Do a comprehensive blood test ... if your blood is thick you might need blood thinners....See More
LikeReply10 hrs
Zul Helme Seems I might need a more thorough medical checkup (late 20s but my body feels a bit creaky). Thanks for the clarification, its been quite helpful (and it feels too minor an issue to go bother a doctor with).
LikeReply9 hrs
Vincent Wong Zul Helme Don't think that .. a GP or physician will always welcome a patient whether healthy or sick. Go tell your regular doctor about your concern and if he/she says nothing to worry ... then okay.
LikeReply18 hrs
Mazlyn Mustapha

Write a reply...
Asiah Abu Bakar Dgr talk pakar..nasi tak pa dgn kuantiti yg berpatutan..tapi jgn direct ambik air soda atau air manisan lain.Boleh dr explain beza basmathi dgn beras perang yg mana lebih elok..Mazlyn Mustapha
LikeReply10 hrs
Jellene Eva i think we know by now that we need to take western scientist's words with a whole bag of salt. first they say nasi lemak is a superfood, now they say white rice (which is a main element in nasi lemak) is dangerous. I'm sure there is a political/commercial force behind this statement.
LikeReply110 hrs
Vincent Wong Superfood term is just being "politically correct". I would try not to eat nasi lemak everyday if possible maybe once or twice per week only. Takes a bit of will power initially, now i can go 1 week without rice ... eating other food, wheat based noodles and more "salads".
LikeReply8 hrs
Mazlyn Mustapha

Write a reply...
Ahmad Kamal Salleh For me raw water is better than air gas
LikeReply18 hrs
Ghazari Baharom Malaysian gonna eat rice like they gone work at the sawah bendang & contruction site. That whats wrong.
LikeReply18 hrs
Rizalina Bahari Nutritional content of white basmathi
LikeReply5 hrs
Rizalina Bahari And brown basmathi

Kandungan beras basmati perang

Sebelum tu, saya nak terjemah point2 utama dari artikel tersebut:
  1. Dalam melawan diabetes, nasi telah dikenal-pasti sebagai salah satu penyebab utama. Ia lebih merbahaya berbanding minum air bergas.
  2. Obesiti (lebih berat badan) dan minuman bergula adalah penyebab utama di negara2 Barat.
  3. Orang Asia mempunyai risiko diabetes lebih tinggi berbanding orang putih, jadi, orang Asia tidak perlu obes untuk ada risiko yang tinggi. 
  4. Makan nasi putih pula akan menyebabkan badan terlebih gula dan meningkatkan risiko diabetes.
  5. Kajian oleh Harvard yang diterbitkan oleh British Medical Journal menunjukkan setiap pinggan nasi yang dimakan setiap hari secara berterusan meningkatkan risiko diabetes sebanyak 11% berbanding populasi keseluruhan.
  6. Satu mangkuk nasi mempunyai kandungan karbohidrat sama banyak dalam dua tin air gas.
  7. Disyorkan menukar 20% nasi putih dengan brown rice atau nasi perang mengurangkan risiko diabetes sebanyak 16%.
  8. Tip: Rendam nasi perang selama 15 minit sebelum masak dengan nasi putih.
  9. Berjalan sebanyak 15 minit setiap hari (2000 langkah) mengurangkan risiko mati dari diabetes sebanyak 4%.
  10. Orang Asia pula makan nasi empat kali sehari sementara orang putih hanya makan nasi 5 kali seminggu.
  11. Kita digalakkan makan jenis nasi yang lebih menyihatkan. 
  12. Beras long grain (panjang) lebih baik dari beras short grain (pendek) kerana ia kurang menyebabkan gula dalam darah naik secara mendadak yang akan meransang insulin dihasilkan dari pankreas. Gula tinggi mendadak yang kerap akan menyebab berlakunya diabetes.
  13. Kos merawat diabetes di Singapore yang ditanggung kerajaan adalah $1 billion setahun.
  14. Diabetes penyebab utama buta, kegagalan buah pinggang dan kaki di potong di Singapura.
  15. Doktor pakar diabetes menasihatkan orang ramai supaya mengurangkan pengambilan nasi, makanan rapu dan minuman bergas. 
Kupasan komen rakan2 pula:

  • Tidak adil membandingkan nasi dengan minuman bergas sebab tak ada orang yang minum air gas sebagai pengganti nasi: ya, saya setuju.
  • Nasi putih basmathi kurang kandungan karbohidrat dan hampir sebaik nasi perang. Nasi basmathi par-boiled adalah mahal tapi berbaloi - sila lihat komen dibawah "Mana lagi baik, nasi perang atau nasi basmathi?"
  • Cadangan makan nasi campur chiaseed atau flaxseed - ni pun kena kaji dulu baru boleh komen.
  • Makan nasi ok jika kuantiti berpatutan dan jangan minum dengan air manis. Ya, saya setuju, boleh refer artikel di atas "Potatoes vs Rice" di hujung artikel ada kupas tentang kuantiti pemakanan dan risiko diabetes.
  • Mana lagi baik, nasi perang atau nasi basmathi? Kalau tengok website ni (dalam bahasa Inggeris) Basmati vs. Brown rice, boleh klik sini untuk baca lanjut, nasi perang adalah yang terbaik, nasi putih basmati sedap tapi kurang khasiat. Nasi perang dan nasi2 berwarna yang lain adalah 'whole grain'. Basmati putih telah diproses dan kurang khasiat. Walaupun nasi perang tidak banyak serat, ia masih ada khasiat 'whole grain' iaitu bran, germ dan endosperm, yang memberikan khasiat. 'Whole-grain' basmati perang adalah pilihan yang enak.
  • Air kosong lagi baik dari air gas: ya, yang ni memang setuju.
  • Makan nasi ok tapi masalahnya kurang bersenam. Saya rasa dua2 penting, kena kurangkan nasi putih dan lebihkan senaman.
Itu sahaja perkongsian malam ni. Moga bermanfaat.