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Jessica Lishan Quah ; Yi Hern Tan ; Tunn Ren Tay

The Singapore Family Physician.2018;44(4):14-19.

Asthma action plan (AAP) is an essential component of asthma education and self-management. AAPs provide patients with instructions on how to recognise loss of asthma control and the appropriate treatment steps. The use of AAP improves asthma-related quality of life and reduces the risk of asthma exacerbation. Despite its benefits, utilisation of AAP is disappointingly low both locally and worldwide. This review highlights the importance of AAP as part of an asthma care plan and provides practical information on the prescription of AAPs. We conclude by identifying possible barriers to AAP implementation and how these may be overcome.

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Dynamic Interactions in the Primary Care Consultation, and an Introduction to Balint Groups

Eugene Wuan ; Andre Teck Sng Tay ; Andrew Lai Huat Peh

The Singapore Family Physician.2018;44(4):32-35.

Physicians in the primary care setting, such as General Practitioners and doctors working in polyclinics, will encounter patients with varying expectations of the consultation process, especially with regards to their emotional needs. These interactions, shaped by transference and counter-transference, will often induce varying emotional reactions in the physicians, both positive and negative. Understanding the dynamics which drive these interactions, and reflecting upon the physician's own emotional responses, can often lead to a more holistic appreciation of the patient and the therapeutic relationship, and consequently in improved patient care, and enhanced satisfaction for both the patient and physician. This article highlights the above dynamic interactions, and introduces the Balint Group, a platform whereby such themes and processes can be further explored. The processes of the Balint Group, and its benefit for attending members, are discussed.

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House calls in Singapore – A Qualitative Study

Ling Ling Soh ; Gerald Choon-Huat Koh ; Rakhi Mittal

The Singapore Family Physician.2018;44(4):35-42.

Background Historically, physicians routinely delivered medical care to sick patients in patients' homes. While house calls accounted for 40% of all doctor-patient encounters In the 1940s, the rate has since dwindled to less than 1%. Based on some studies done overseas, the reasons for the unpopularity of house calls were the lack of time and unsatisfactory remuneration. The aim of this study was to explore the attitudes of general practitioners (GPs) currently practicing in Singapore towards house calls. Design A qualitative study using phenomenological methodology was done by conducting one-to-one in-depth interviews with 12 GPs. Results All the GPs interviewed were aware of the benefits of house calls in the healthcare scene of Singapore. The commonest barrier was concern about the limitations perceived to be present during a house call and their possible medicolegal implications. GPs also struggled with charging appropriately for house calls and found them disruptive to their practices. Conclusion: The study shows that GPs recognize the value of making house calls but at the same time struggle with perceived limitations in the home setting as well as remuneration issues.

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Neonatal Varicella Despite Maternal Immunity – A Case Report and What Can Be Learnt

Grace Lum ; Lee Gan Goh

The Singapore Family Physician.2018;44(4):43-46.

A 20-day-old previously well neonate presented with a 3-day vesiculopapular rash and was admitted to the paediatrics ward. He received extensive workup and treatment with IV acyclovir. The disease ran a mild, uncomplicated course, and recovery. His mother was found to be immune to varicella, having had the disease as a child. However, her immunity had not transferred to the neonate, which was unexpected. A literature review revealed that maternal varicella antibodies do not necessarily prevent infection but may help the infant avoid severe or complicated disease. A review of the management of neonatal varicella in both the immune and the non-immune mother which put the child at risk is also done. Vaccination of all susceptible young females prior to pregnancy will help to reduce the incidence of neonatal varicella in infants and is strongly encouraged. Vaccination of household contacts especially siblings, is also encouraged. Family Physicians should remain open to the diagnosis of neonatal varicella, even when the mother has a history having chickenpox as a child.

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Using Extended Consultation to help the Patient Accept Anti-Depressants

Kristel Jie Ying Low ; Celestial Terese Suen Mei Yap

The Singapore Family Physician.2018;44(4):47-51.

Depression is a complex disabling condition that is common in primary care. Mr. X was previously diagnosed with depression but had defaulted treatment. It was through an extended consultation that we could unmask the diagnosis and initiate the therapeutic process. ObjectivesTo use the model of an extended consultation to both diagnose depression and to formulate the psycho-social factors that predispose, precipitate and perpetuate the depression as well as the positive factors that ameliorate it (4 Ps). MethodsAn example of an extended consultation with Mr. X. was videotaped with his permission. Excerpts from the video transcript are reproduced to demonstrate the 4 Ps formulation and how the pattern approach of narrative therapy was employed to help Mr. X. ResultsMr. X. gained insight into his condition. He was hence agreeable to initiate anti-depressant medication and continued to follow up for his depression.ConclusionThe extended consultation can be used to uncover therapeutic opportunities when engaging patients with depression, and to formulate the 4 Ps in order to complement pharmacotherapy for holistic management.

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Case of Advanced COPD: Lessons Learnt

Wai Ye Kan ; Lee Gan Goh

The Singapore Family Physician.2018;44(4):52-55.

A case study of a 76-year-old man with end-stage chronic obstructive pulmonary disease (COPD) with refractory breathlessness and the challenges in managing the dyspnoea he had been experiencing are described. A multi-modal approach is the mainstay of management, encompassing pharmacological agents, home oxygen therapy, and non-pharmacological approaches, namely, breathing techniques and smoking cessation. As this patient was at an advanced stage of disease, integration of palliative care with disease care was needed. Administering oxygen therapy for a patient who is still smoking and has household members who are current smokers need firm adherence to rules. The AIC HOME Programme is also briefly described.

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Intensifying Lifestyle Management in Type 2 Diabetes Mellitus

Hwee Huan Tan

The Singapore Family Physician.2018;44(5):5-10.

Lifestyle management (LSM) is a fundamental aspect of Type 2 diabetes mellitus (T2DM) management. Intensifying LSM beyond basic nutritional and exercise advice has been challenging for most doctors as LSM in diabetes is complex. To help navigate through the complexity of LSM in diabetes care, this article introduces an acronym DESMM as an easy-to-remember guide that encompasses most if not all the components of diabetes LSM. DESMM stands for Diet, Exercise, Support/Stress, Monitoring and Medicine. DESMM offers a structured guidance to enable consistent evaluation of the lifestyle of the patient with the intention of intensifying LSM.

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Sarcopenia: Causes, Consequences, Prevention and Treatment

Samuel Chew

The Singapore Family Physician.2018;44(5):11-17.

The phenomenon of age-related loss of muscle mass and strength was named sarcopenia in 1988 by Rosenberg. Since then, sarcopenia has evolved to include the loss of muscle function in the definition. Sarcopenia has a high prevalence in specific clinical conditions and in the older population and can lead to significant morbidity, poor recovery from adverse events and ultimately, institutionalisation. In spite of the severe health care burden posed, the diagnosis and treatment of sarcopenia have yet to become standard care. Emerging consensus on definition and diagnosis by the international work groups on sarcopenia with tailored population-based cut-offs and growing evidence-based management options will facilitate the meeting of these needs.

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Prescribing Diets: From Food to Oral Nutrition Supplements

Debbie Thong

The Singapore Family Physician.2018;44(5):18-22.

Diabetes and Sarcopenia are both growing public health concerns in the aged society. The effectiveness of medical nutrition therapy (MNT) in diabetes prevention and management has long been recognized. Sarcopenia, defined as the loss of muscle mass and muscle function, can likewise be combated by combining lifestyle and nutritional interventions. In clinical practice, early detection with validated screening tools is vital to identify older adults at high risk for sarcopenia, so that preventive interventions can be initiated. It is recognized that a healthful eating pattern and regular physical activity are keystones of sarcopenia and diabetes prevention and management. “Let food be thy medicine and medicine be thy food”. Hippocrates, the father of modern medicine, proclaimed that the power of nutrition simply begins with healthful food choices on our plates. This article summarises the current evidence in both the management of diabetes, sarcopenia and for clinicians to consider its implications for prevention and treatment strategies.

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Community Centre-based Care services for a Frailty-Friendly Community in Singapore

Si Min Thio

The Singapore Family Physician.2018;44(5):34-39.

With an ageing population, the number of pre-frail and frail elderly in the community is on the increase. Favourable policies will encourage and enable elderly to continue to be engaged and cared for, with appropriate services in the community, for the community, and by the community. This article provides an overview of suitability of currently available community centre-based care services in Singapore based on the Clinical Frailty Scale, to work towards a frailty-friendly community. Keys to building a successful frailty-friendly community will also be discussed.

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