Improvements in medical science and increasing survival rates on a background of an ageing population have changed the disease demographics in Singapore towards one with an increasingly complex chronic disease burden. Many will need to tap on community resources to age gracefully in place. The increasing number of single elderly who live alone also provides a challenge as research has shown that they are the highest users of healthcare resources. In Singapore, there is no lack of schemes to help the elderly poor as compared to other countries in the region. The problem, rather, is that there are too many targeted help schemes – with varying criteria and limiting conditions attached. This leads to an application process that is daunting and has many gaps where some who will benefit from the schemes but don’t qualify because they don’t meet the providers criteria.

A 64-year-old man with a background of chronic kidney disease (CKD) was admitted to hospital for symptoms of uraemia and was subsequently initiated on haemodialysis (HD). On day 13 of HD, he developed per rectal bleeding with a significant drop in his haemoglobin (Hb) level. Oesophagoduodenoscopy (OGD) was performed and showed several antral and duodenal ulcers. Colonoscopy was unremarkable. He was started on high-dose PPI and his Hb level remained stable with no recurrence of symptoms. This case report highlights the association between HD and the increased risk of developing peptic ulcer disease (PUD) in patients with end-stage renal failure. Abdominal symptoms are common in the primary care setting and it is crucial for family physicians to be able to recognise the red flags of PUD in this group of high-risk patients as timely referral and intervention reduces morbidity and mortality.

Latent TB infection (LTBI) is defined as a state of persistent immune response to stimulation by M. tuberculosis antigens without evidence of clinically manifested active TB. Current methods for LTBI detection are the tuberculin skin test (TST) and the interferon-gamma release assays (IGRAs). Both these tests indicate prior host immunosensitisation to M. tuberculosis antigens and do not provide information regarding viability of the organism within the host. Around 10 percent of immunocompetent adults with LTBI develop active TB in their lifetime: of these, approximately half (i.e. 5%) develop disease within 2 to 5 years of acquiring the infection. The risk of progression of LTBI to active TB disease is increased in HIV/AIDs, in very young children, and in persons with solid and haematological transplant, end-stage renal failure on haemodialysis, silicosis, head and neck malignancies, and diabetes. Isoniazid preventive therapy has been shown to reduce the risk of developing active TB by 60–90 percent. However, it is associated with a risk of hepatoxicity, which increases with age. It is recommended that LTBI testing be targeted at groups/persons with a high risk of progression to active disease (e.g. close contacts, those with HIV infection) and/or for whom the benefit of PT outweighs the risk of hepatotoxicity.

Thyroid-stimulating hormone receptor autoantibodies (TRAbs) are pathogenetic and diagnostic in Graves’ Disease (GD). We briefly review the value of these antibodies in GD during diagnosis, treatment, relapse and pregnancy. Currently available methods for monitoring are immunoassays for TRAbs and bioassay and immunoassay for TSI specifically. In the last 50 years several methods have been used to detect autoantibodies against TRAbs, based on bioassays or immunoassays. The bioassays measure functional activity of TRAb; cumbersome, time consuming and unsuitable for routine use in clinical laboratories. Immunoassays measure binding of the autoantibodies to the receptor without functional discrimination, are better standardised, much less expensive, and easily automatable for routine use in clinical laboratories. We briefly discuss the latest available immunoassay with discrimination of the autoantibody, i.e. Thyroid Stimulating Immunoglobulin (TSI).

Headaches are one of the commonest neurological disorders with a global lifetime prevalence of 66 percent (1), and 82.7 percent in Singapore (2). Tension type headache (TTH) is the commonest primary headache with a lifetime prevalence of 30-78 percent globally (1). TTH is related to muscular factors (17) thus treatment directed toward muscular factors such as manual therapy can be considered (18). This review is aimed at evaluating the use of manual therapy for TTH.

Giant cell arteritis (GCA) has a Caucasian preponderance and mainly affects persons older than 50 years old. We report on 2 elderly patients of Asian origin who presented with pyrexia of unknown origin to highlight the rare occurrence of GCA in Asians without classical symptoms. Due to its wide spectrum of manifestations and ethnic differences in epidemiology, the disease can pose a diagnostic challenge to unwary clinicians, resulting in serious sequelae; thus a high index of suspicion is needed for prompt diagnosis and treatment. Temporal artery biopsy should be performed when GCA is suspected.

This case study is a reminder that recurrent severe vomiting requires admission for correction of fluid and electrolyte derangement, and a diagnostic work-up. It also highlights the need for a high level of clinical suspicion and good history taking in the diagnosis of cyclical vomiting syndrome. A definitive diagnosis is important to prepare the patient and family for future management as cyclical vomiting syndrome is a chronic episodic condition.

In the usual medical consultation, history taking, physical examination, and investigations lead us to a diagnosis list from which management ensues. When the patient’s problems need further exploration of the mind. We can extend the medical consultation beyond the biomedical to include psychosocial dimensions. The usual clinical methods of history, examination and investigation may be extended by various tools. History is extended by the use of three tools: the time-line of events in the patient’s life; the family genogram including recent changes; and the Johari window. Examination of the patient physically may be extended by reflective communication. Just as we investigate the body by various tests, we also investigate the patient’s thinking processes using Socratic inquiry techniques. Based on the information collected, we arrive at a 4P’s formulation of the patient’s problem(s). We can then integrate one or more of the 4P’s of psychosocial work into the usual management.

The mind may be examined by using reflective communication which is also known as active listening. We pay attention to the modes, phases and channels of communication; the purposeful use of unusual grammar forms; and we also create discrepancies to destabilize the patient’s mind to get past his conscious mind and seek a deeper unguarded response from him or her. In the reflective communication, we validate, track and pace the patient’s thoughts, emotions and behavior. We express affirmation, empathy and sympathy and connection with the patient by use of mirroring, modelling and metaphors. Reflective communication skillfully used, helps the doctor to examine and understand the patient’s mind, and it also helps the patient to gain insight to his problem.

The aim of the extended investigation is to probe the mind for specific situations or issues that may help unravel the patient’s problem. The tool used is the mnemonic of CAR-ACE (clarifications, assumptions, reasons, alternatives, consequences, and relational experiencing). This disciplined inquiry brings information about feelings and thinking into the open, relating to the situation at hand. This is often used in problem work when troublesome situations are identified. It is used to uncover the Negative Automatic Thoughts arising from cognitive distortions that triggered the emotions. It is also used in pattern work to investigate the salient situations linked by themes into stories. The themes and stories can then be investigated for consistency and context.