DOC  HOW DO I PREPARE FOR TRAVEL ABOARD?

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General Medical Advice for Travelers

Consult a doctor 4-6 weeks before departure.
This allow sufficient time for the relevant vaccinations to take effect and to address any specific health concerns.

If there is a chronic medical condition such as asthma, diabetes and high blood pressure, make sure you have enough medicine to last you for the duration of your trip.

Falling sick or sustaining injury during your trip can be costly, it is important that you buy travel insurance for your trip.

Prepare a travel kit .Depending on your plans you may want to include the following which can be bought at a pharmacy:
1.Painkiller/fever tablets such as paracetamol (Tylenol)

2.diarrhea tablets such as imodium or lomotil

3.antihistamines for cold and rash such as Piriton, Actifed

4.motion sickness tablets such as stemetil, dramine patches

5.oral rehydration salts for treating dehydration in diarrhea

6.antiseptic lotion or cream such as dettol cream for wounds and insect bites

7.cotton wool or buds for cleaning wounds, eyes, ears

8.adhesive dressing or plaster for wounds

9.bandages for sprains and wounds

10.thermometer to check on temperature

11.insect repellant to prevent insect bites

12.sunscreen to prevent sun burns

13.eyedrop for dry eyes or wash eyes

Illnesses likely to encountered in other Countries:
1.Malaria – especially in South East Asia, India, Pakistan,Bangladesh

2.Japanese Encephilitis is a mosquito borne disease affecting most Africa and middle East.

3.Yellow Fever in sub-saharan Africa and South America

4.Traveler’s Diarrhea – Personal food hygiene is important here

5.Amebiasis is common in India, Africa and South America

6.Shigella Dysentery is a bloody form of diarrhea caused by the shigella bacteria, occurs mostly in India and Africa

7.Cholera is also a waterborne disease caused by a bacteria in South East Asia, India, Africa

8.Typhoid and other salmonella diseases are also infections of the salmonella bacteria where food hygiene is poor.

9.Hepatitis A, B viral infections are spread by carriers and unhygienic food.

10.Altitude illness in Tibet,  Nepal and some South American countries with high attitude cities

11.Bird flu is getting more common in the last few years

12.Seasonal Influenza can be dangerous during winter 

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DOC HOW DO I KNOW WHETHER MY STOOL IS NORMAL

Actually many people do not know the definition of diarrhea.

They define the word diarrhea as watery stools where in fact the word diarrhea means any stools which are softer or more frequent than normal.

The researchers at the Bristol University have come out with a scale which is called the Bristol Stool Scale.

According to the Bristol Stool Scale, the seven types of stools
are:
1.Type 1: Separate hard lumps like nuts
2.Type 2: Sausage shaped but lumpy
3.Type 3: like a Sausage but with cracks on its surface
4.Type 4: like a Sausage or snake, smooth and soft
5.Type 5: soft blobs with clear cut edges
6.Type 6: Fluffy pieces with ragged edges, a mushy stool
7.Type 7: Watery, no solid pieces. Entirely liquid.

Type 1 and 2 indicate constipation while type 5-7 indicate diarrhea. Type 3 and 4 are considered ideal stools because they are the easiest to pass.

Avoidance of constipation include:

1. Increase in daily fiber intake to at least 15gm (eg. 1 bowl of bran cereal for breakfast),
fruits and vegetables).
Fibre increases the bulk of the stool allowing easy passage of stools through the large
intestine.

2. Drink at least 8 glasses of water a day (2 liters). Water reduces the hardness of stools.

3. Regular exercises at least 2-3 times a day especially after meals. Exercise will enhance
intestinal movement.

4. Allow a distraction free period of 15 min a day for bowel movement. The strongest
intestinal movement occurs after breakfast.

5. Do not ignore or suppress the urge to pass bowel movement. This may impair the
sensation to detect initiation of bowel movement leading to constipation.

Avoidance of  diarrhea include:

1.washing your hands thoroughly for 20 seconds after using the bathroom or changing diapers

2.washing your hands thoroughly for 20 seconds before eating

3.disinfecting contaminated surfaces such as counter tops and baby changing stations

4.Avoid eating or drinking foods or liquids that might be contaminated

5.Avoid rapid intestinal movement from stress, irritable bowel syndrome

Please read my blogs on constipation and diarrhea

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DOC I HAVE DIARRHEA

Diarrhea is a symptom defined as an increase in the volume, water content and frequency of bowel movements.

Diarrhea is a symptom of many gastrointestinal disorders:
1.Infections:
Bacterial infections such as:
a.Shigella
b.Salmonella and typhoid
c.cholera

Viral infections such as:
a,enterovirus
b.rotavirus

Protozoan infections such as:
a.amoebic
b.giardia

2.Toxins from bacteria in contaminated food:
a.E.coli food poisoning (enterotoxins)
b.staphaloccal food poisoning (preformed toxins)

3.Antibiotic usage:
pseudomembraous enterocolitis

4.Food Intolerance
a.Lactose or sugar intolerance
b.Gluten sensitive enteropathy:
celiac disease, nontropical sprue

5.Inflammatory diseases of the intestine:
a.crohn’s disease or regional ileitis
b.ulcerative colitis

6.Malabsorption syndromes
a.malabsorption of bile acids
b.pancreatic steatorrhea
c.ileal resection

7.Cancers:
a.colon
b.rectal cancers

8.Tumors especially hormonal producing tumors:
a,gastrinoma
b.Zollinger-Ellison syndrome
c.glucaglonoma
d.carcinoid tumors

9.Drug induced:
a.excessive use of laxatives
b.magnesium antacids which absorbs water into intestine
c.stimulant cathartics

10.Rapid intestinal movement:
a.Irritable bowel syndrome
b.resection of bowels in tumors or fistula
c.vagotomy
d.other surgery of intestine
rhea with blood and mucus

Diarrhea is investigated by:
1.full investigation of the possible underlying causes

2.Macroscopic and microscopic examination of the stools:
e.g rice water is typical of cholera

3.culture and sensitivity to antibiotic of the stools

4.Full blood count and electrolytes

Treatment of Diarrhea is by:

1.Because of the excessive fluid loss, correction of fluid and electrolyte balance is the most important part of treatment.

Prompt treatment may be needed to prevent dehydration which is the loss of fluids from the body. Important salts or minerals, known as electrolytes, can also be lost with the fluids. Dehydration can be caused by diarrhea, excessive urination, excessive sweating, or by not drinking enough fluids because of nausea, difficulty swallowing, or loss of appetite.

The symptoms of dehydration are
excessive thirst
dry mouth
little or no urine or dark yellow urine
sunken eyes
severe weakness or lethargy
dizziness or light headedness

Mild dehydration can be treated by drinking liquids.

Severe dehydration may require intravenous fluids and hospitalization.

Untreated severe dehydration can be life threatening especially in babies, young children and the elderly.

2.Specific treatment if available for underling conditions eg.antibiotic the choice of which depends on the sensitivity of bacteria to the antibiotic.

3.Relief of symptoms include an antispasmodic drug to stop abdominal cramps, medicine to harden the stools such as kaolin and slow down the intestinal movement (lomotil or loperamide).

The following steps may help relieve the symptoms of Diarrhea.
1.Allow your gastrointestinal tract to settle by not eating for a few hours.
2.Sip small amounts of clear liquids or suck on ice chips if vomiting is still a problem.
3.Give infants and children oral rehydration solutions to replace fluids and lost electrolytes. 4.Gradually reintroduce food, starting with bland, easy-to-digest food, like porridge or soups.
5.Avoid dairy products, caffeine, and alcohol until recovery is complete.
6.Get plenty of rest.

Prognosis of diarrhea depends on the cause:

Usual outcome of acute diarrhea is excellent if treated early.

For chronic diarrhea, the underlying cause must be treated.

Outcome is usually excellent with appropriate treatment.

Prevention of Infections causing Diarrhea is by:
You can avoid infection by:
1.washing your hands thoroughly for 20 seconds after using the bathroom or changing diapers

2.washing your hands thoroughly for 20 seconds before eating

3.disinfecting contaminated surfaces such as counter tops and baby changing stations

4.Avoid eating or drinking foods or liquids that might be contaminated

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DOC I HAVE DIARRHEA

How many of us have taken hawkers food and ended up puking and rushing to the toilet to pass out watery stools. Then there are the abdominal cramps which strike every now and then causing the victims to double up in pain and clutching their stomachs. Food poisoning or gastroenteritis is very real and very common.

Gastroenteritis is one of the most common medical condition seen in a family practice other than colds and coughs.
It occurs at all ages from babies to elderly adults. 
The most important danger is the dehydration and loss of nutrients and salts that it can cause  resulting in fatalities.

Gastroenteritis is usually due to food poisoning from eating unhygienic food. 
A common cause is from non-home hawker or even restaurant food and overnight food. 
Most of the germs are viral in nature but there may be rarely bacterial infection such as salmonella infection.

A survey of the food causing gastroenteritis at one stage found that 50 per cent of the illness is brought about by eating chicken or duck rice in Singapore probably because the chicken or duck are left hanging on the stall exposed to germs, flies, spittle,dust etc. 
The Environment ministry have now insisted that all stalls should have 3 quarters of the stall covered by glass or plastic shelves.

1.Since then the incidence of food poisoning due to chicken or duck rice has been reduced to 25 percent. 
2.Another 25 per cent was contributed by seafood especially those bought from contaminated waters such as oil spills or waste discharge.
3.Another 25 per cent was from fruits and fruit juice vendors who handle the cut fruits with unhygienic hands and dirty utensils.
4.The last 25 per cent was from all the other food sold. 

The safest food was those that are boiled at 100 degree centigrade such as soups.


Gastroenteritis may present with symptoms of vomiting and diarrhea. 
The worst is when there is vomiting involved because of the inability to swallow medicines without vomiting it out.   
In the case of babies dehydration can quickly set in. 
They should always be sent to hospital for intravenous nutrition. 

Most cases of diarrhea in children comes from dirt on the ground or from other children in child care facilities. 
It is difficult for a child not  to explore the floor or the toys with their hands which is then put into the mouth. 
Sometimes the toy itself is put into the mouth. 
All toys which the children may come into contact should cleaned properly . 
The importance of an hygienic environment must also be emphasized. 
The hands of the children must be cleansed with a clean cloth once in a while. 
Some illness such as hand mouth and foot disease can be caused by certain rotavirus which can spread to the air and cause gastroenteritis.

I usually treat most gastroenteritis with lomotil or imodium with good results. 
Sometime a stool hardener such as kaolin will also help to stop the diarrhea faster. 

An anticholinergic may be given to stop pain. 
Rarely antibiotic are given if bacterial infection is suspected.

Diarrhea itself may not be due to food poisoning. 

In babies lactose intolerance to cow’s milk may be a cause of diarrhea and the cow’s milk must be substituted with soya bean milk. 

Some diarrhea in adults are due to Irritable Bowel Syndrome and can be controlled with anticholinergic or tranquillisers.

A unique case of chronic diarrhea was seen in a baby of one and half years who had diarrhea or watery stools since the age of 6 months. He probably had a mild case of food poisoning and was treated by his pediatrician who told him to stop his milk and change to soya bean milk and gave him some kaolin. 
The diarrhea did not stop so he was brought to another pediatrician who again change his milk. 
Again the diarrhea did not stop . 
So he was brought to many other doctors before coming to see me.
Each doctor asked the parents to change to another type of milk or soya bean milk and gave medicines.
By the time the child saw me he was slightly dehydrated but otherwise quite healthy. He already had X-rays of the abdomen, blood and stools tested by the pediatricians without obvious abnormally. 
I had suspected that it was the frequent change of milk that caused the problem in the child. I asked the parents what milk the child was taking before the diarrhea and advised them to return to that milk but given at half strength. I also gave the child some mild anti diarrhea medicine. The parents were to increase the strength of the milk once the diarrhea improved. 
After 1 week the child made a complete recovery. 
It was the constant change of milk that caused the child’s intestine irritable. Just by returning to the old milk and diluting the milk the child was able to handle the digestion of his milk.

It was a case of the proverb “If it ain’t broken don’t change it.”
In fact for all children with diarrhea, I do not ask them to change milk just dilute it to half strength and take the medicines that I gave.

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