Medical PBL

MOH Paediatric Protocols for Malaysian Hospitals, 4th edition

2018-12-20T19:32:00.000+08:00

MOH Paediatric Protocols for Malaysian Hospitals, 4th edition

by Hussain Imam Hj Muhammad Ismail, Hishamshah Mohd Ibrahim, Ng Hoong Phak, Terrence Thomas

Format: PDF (~8MB)
Download Link:

Dropbox | Mediafire

After the last edition of Paediatrics protocol in 2012-2013, the 4th edition is finally out. There are some fine additions into the topics for your further reference. The hardcopy is available at the price of RM 27. It will be sold at the MPA office in Menara Arina Uniti at Jalan Raja Muda Abdul Aziz. You can also call to the MPA office to arrange for purchases and to send via Pos Laju (Approximately RM7.50 per book for West Malaysia)

Below is the address of the MPA, for those who dosen't know where it is located at:

Malaysia Paediatric Association
No 16-07, Tingkat 16,
Menara Arina Uniti
No 97, Jalan Raja Muda Abdul Aziz,
50300 Kuala Lumpur.

Tel:+603-2202 7099
Fax: +603-2602 0997
Email:secretariat@mpaeds.my
Website: http://mpaeds.my

Malaysia Clinical Practice Guidelines and Consensus (Last update: 3rd Nov 2018)

2018-11-01T14:00:00.000+08:00

Below is the subsection for the available CPG in Malaysia. All CPG are valid for 4-5 years unless stated otherwise. Older CPG are stored for archiving and reference purposes and should not be held liable for any differences in management.

For search purposes, it is recommended to use the browser's search function, "Find" through this list of CPG's. For example, Firefox or Chrome users can use the function "Ctrl" + "F" and type in the keywords in the designated search box. This will lead to the targeted keywords/ text on this list.

Pharmacological Guidelines

National Antibiotic Guideline (2nd edition) - 2014
Download Links: Dropbox| Mediafire
Insulin Therapy Guidelines 2011
- Practical Guide for Insulin Therapy
  Download Links: Box.net | Mediafire
- Quick Reference for Insulin Therapy
  Download Links: Box.net | Mediafire

Cardiovascular CPG:

Stable Coronary Artery Disease- 2018
Download Links: Dropbox| Mediafire
Management of Hypertension (5th Edition)- 2018
Download Links: Dropbox| Mediafire
Primary and Secondary Prevention of Cardiovascular Disease
Download Links: DropBox | Mediafire
Heart Disease in Pregnancy (2nd Edition) - 2016
Download Links: Dropbox | Mediafire
Prevention of Cardiovascular Disease in Women (2nd Edition)- 2016
Download Links: DropBox | Mediafire
Management of Acute STEMI (3rd Edition) - 2014
Download Links: Dropbox| Mediafire
Management of Heart Failure (3rd Edition) - 2014
Download Links: Dropbox| Mediafire
Management of Hypertension (4th Edition)- 2013
Download Links: Dropbox| Mediafire
Prevention and Treatment of Venous Thromboembolism- 2013
Download Links: Box.net | Mediafire
Management of Atrial Fibrillation - 2012
Download Links: Box.net | Mediafire
Management of Stable Angina Pectoris - 2012
Download Links: Box.net | Mediafire
Management of Ischemic Stroke (2nd edition) - 2012
Download Links: Box.net | Mediafire
Management of Unstable Angina/ Non-STEMI (2nd Edition) - 2011
Download Links: Box.net | Mediafire
Management of Pulmonary Arterial Hypertension - 2011
Download Links: Box.net | Mediafire
Prevention of Cardiovascular Disease in Women - 2008 (1st Edition)
Download Links: Box.net | Mediafire
Management of Hypertension (3rd edition) - 2008
Download Links: Box.net | Mediafire
Management of Heart Failure - 2007
Download Links: Box.net | Mediafire
Management of Acute STEMI - 2007 (2nd Edition)
Download Links: Box.net | Mediafire
Management of Ischemic Stroke - 2006
Download Links: Box.net | Mediafire
Management of Unstable Angina/ Non-STEMI - 2002
Download Links: Box.net | Mediafire

Respiratory CPG:

Management of Asthma in Adults (2nd Edition) - 2017
Download Links: Dropbox | Mediafire
Management of Childhood Asthma - 2014
Download Links: DropBox | Mediafire
Approach and Management of Thoracis Empyema in Children - 2013
Download Links: DropBox | Mediafire
Management of Chronic Obstructive Pulmonary Disease (2nd Edition) - 2009
Download Links: Box.net | Mediafire
Treatment of Tobacco Use and Dependence - 2003
Download Links: Box.net | Mediafire
Management of Adult Asthma -Revised 2002
Download Links: Box.net | Mediafire

Hematology CPG:

Management of Hemophilia, Draft- 2018
Download Links: Dropbox | Mediafire
Management of Transfusion Dependent Thalassaemia - 2009
Download Links: Box.net | Mediafire
Management of Anemia in Pregnancy and Chronic Kidney Disease (?Draft) - 2007
Download Links: Box.net | Mediafire
Management of Immune Thrombocytopenic Purpura - 2006
Download Links: Box.net | Mediafire
Diagnosis and Management Chronic Myeloproliferative Disorders - 2004
Download Links: Box.net | Mediafire

Nephrology CPG:

Management of Chronic Kidney Disease in Adults - 2011
Download Links: Box.net | Mediafire
Diabetic Nephropathy - 2004
Download Links: Box.net | Mediafire

Endocrine/ Metabolism Disorder CPG:

Management of Diabetic Foot (Draft,2nd Ed) - 2018
Download Links: Dropbox | Mediafire
Management of Diabetes in Pregnancy - 2017
Download Links: Dropbox | Mediafire
Management of Dyslipidemia (5th Edition) - 2017
Download Links: Dropbox | Mediafire
Management of Type 1 Diabetes Mellitus in Children and Adoslescents - 2016
Download Links: Dropbox | Mediafire
Management of Type 2 Diabetes Mellitus (5th Edition) - 2015
Full CPG : Dropbox | Mediafire
Quick Review: Dropbox | Mediafire
Management of Dyslipidemia - 2011
Download Links: Box.net | Mediafire
Management of Type 2 Diabetes Mellitus (4th Edition) - 2009
Download Links: Box.net | Mediafire
Management of Diabetic Foot - 2004
Download Links: Box.net | Mediafire
Management of Dyslipidemia - 2004 (The previous 2003 was a draft)
Download Links: Box.net | Mediafire
Management of Obesity - 2003
Download Links: Box.net | Mediafire
Consensus Statement on Androgenetic Alopecia - 2003
Download Links: Box.net | Mediafire

Dermatology CPG:

Management of Atopic Eczema - 2018Download Links: Dropbox | Mediafire
Guidelines to Management of Scabies in Adult and Children - 2015Download Links: Dropbox | Mediafire
Management of Psoariasis Vulgaris- 2013
Download Links: Box.net | Mediafire
Management of Acne - 2012
Download Links: Box.net | Mediafire

Infection CPG:

Guidelines on Prevention and Management of Infective Endocarditis - 2017
Download Links: Dropbox | Mediafire
Guidelines of Management on Typhoid Case/Outbreak - 2017
Download Links: Dropbox | Mediafire
Management of Dengue Infection in Adults (3rd edition) - 2015
Full CPG Download Links: Dropbox| Mediafire
Quick Reference Download Links: Dropbox| Mediafire
Management Guidelines of Malaria in Malaysia - 2014
Download Links: Dropbox| Mediafire
Management of Tuberculosis 3rd Edition- 2012
Download Links: Box.net | Mediafire
Guidelines on Management of HIV Infection in Adults with Anti-retroviral Therapy - 2012
Download Links: Box.net | Mediafire
Guidelines for the Diagnosis, Management, Prevention and Control of Leptospirosis in Malaysia - 2011 Download Links: Box.net | Mediafire
Guidelines for Clinical and Public Health Management of Melioidosis in Pahang - 2011
Download Links: Box.net | Mediafire
Management of Dengue Infection in Adults (Revised 2nd Edition) - 2010
Download Links: Box.net | Mediafire
Management of HIV Infection in Pregnant Women - 2008
Download Links: Box.net | Mediafire
Management of HIV Infection in Children - 2008
Download Links: Box.net | Mediafire
Guidelines of Management of Sexually Transmitted Infection - 2008
Download Links: Box.net | Mediafire Management of Hand, Foot and Mouth Disease - 2007 Download Links: Box.net | Mediafire
Management of Dengue Fever in Children - 2004
Download Links: Box.net | Mediafire
Adult Vaccination - 2003
Download Links: Box.net | Mediafire
Childhood Immunisation - 2004
Download Links: Box.net | Mediafire
Control and Management of Tuberculosis 2nd Edition - 2002
Download Links: Box.net | Mediafire

Neurology CPG:

Early Management of Head Injury in Adults - 2015
Download Links: Dropbox | Mediafire
Consensus Guidelines for Parkinson's Disease (2nd edition) - 2012
Download Links: Box.net | Mediafire
Consensus Guidelines on the Management of Epilepsy- 2010
Download Links: Box.net | Mediafire

Vascular CPG:

Management of Acute Variceal Bleeding - 2007
Download Links: Box.net | Mediafire
Management of Non-Variceal Upper Gastrointestinal Bleeding - 2003
Download Links: Box.net | Mediafire
Management of Venous Tromboembolism - 2003
Download Links: Box.net | Mediafire

Orthopedics & Rheumatology CPG:

Management of Multiple Sclerosis - 2015
Download Links: DropBox | Mediafire
Management of Osteoarthritis (2nd edition) - 2014
Download Links: Dropbox| Mediafire | Box.net

Quick Reference:Dropbox| Mediafire
Management of Osteoporosis (2nd edition)- 2012
Download Links: Box.net | Mediafire
Management of Gout - 2008
Download Links: Box.net | Mediafire
Management of Osteoporosis - 2006
Download Links: Box.net | Mediafire
Management of Osteoarthritis - 2002
Download Links: Box.net | Mediafire

Ophthalmology CPG:

Screening of Diabetic Retinopathy - 2011
Download Links: Box.net | Mediafire
Management of Primary Open Angle Glaucoma - 2008
Download Links: Box.net | Mediafire
Management of Post-Operative Infectious Endophthalmitis - 2006
Download Links: Box.net | Mediafire

Otorhinolaryngology (ENT) CPG:

Management of Nasopharyngeal Cancer - 2016
Download Links: DropBox | Mediafire
Management of Rhinosinusitis in Adoslescents and Adults - 2015
Download Links: DropBox | Mediafire
Management of Otitis Media with Effusion in Children - 2012
Download Links: Box.net | Mediafire
Consensus Guidelines on URTI - 2009
Download Links: Box.net | Mediafire
Management of Sore Throat - 2003
Download Links: Box.net | Mediafire

Women's Health CPG:

Management of Diabetes in Pregnancy - 2017
Download Links: Dropbox | Mediafire
Heart Disease in Pregnancy (2nd Edition) - 2016
Download Links: Dropbox | Mediafire
Prevention of Cardiovascular Disease in Women (2nd Edition)- 2016
Download Links: DropBox | Mediafire
Management of Cervical Cancer (2nd edition) - 2015
Download Links: DropBox | Mediafire
Management of Breast Cancer (2nd Edition) - 2010
Download Links: Box.net | Mediafire
Hormone Therapy During Menopause in Malaysian Women - 2010
Download Links: Box.net | Mediafire
Management of Anemia in Pregnancy and Chronic Kidney Disease (?Draft) - 2007
Download Links: Box.net | Mediafire
Management of Menorrhagia - 2004
Download Links: Box.net | Mediafire

Pediatrics CPG:

Management of Type 1 Diabetes Mellitus in Children and Adoslescents - 2016
Download Links: Dropbox | Mediafire
Management of Childhood Asthma - 2014
Download Links: DropBox | Mediafire
Management of Neonatal Jaundice (2nd Edition) - 2014
Full CPG: Dropbox| Mediafire
Quick Reference: Dropbox| Mediafire
Management of Autism Spectrum Disorder in Children and Adoslescents - 2014
Download Links: Dropbox| Mediafire
Approach and Management of Thoracis Empyema in Children - 2013
Download Links: DropBox | Mediafire
Management of Otitis Media with Effusion in Children - 2012
Download Links: Box.net | Mediafire
Guidelines on the management of Cow's Milk Protein Allergy in Children - 2012
Download Links: Box.net | Mediafire
Management of HIV Infection in Children - 2008
Download Links: Box.net | Mediafire
Retinopathy of Prematurity - 2005
Download Links: Box.net | Mediafire
Withholding and Withdrawing of Life Support in Children - 2005
Download Links: Box.net | Mediafire
Rational Antibiotic Utilisation in Selected Paediatric Conditions - 2004
Download Links: Box.net | Mediafire
Management of Jaundice in Healthy Newborns - 2003
Download Links: Box.net | Mediafire
Management of Postnatal Corticosteroids For The Prevention of Chronic Lung Disease In Preterm Infants - 2003
Download Links: Box.net | Mediafire
Management of Febrile Fits - 2000
Download Links: Box.net | Mediafire

Mental Health CPG:

Guidelines on Management of Aggressive Patients in Ministry Of Health FacilitiesDownload Links: Dropbox | Mediafire
Guidelines on Suicide Risk Management in Hospitals - 2014
Download Links: Dropbox | Mediafire
Management of Bipolar Disorder in Adults - 2014
Download Links: Dropbox| Mediafire
Management of Autism Spectrum Disorder in Children and Adoslescents - 2014
Download Links: Dropbox| Mediafire
Management of Schizophrenia in Adults - 2009
Download Links: Box.net | Mediafire
Management of Dementia (2nd Edition) - 2009
Download Links: Box.net | Mediafire
Management of Attention Deficit Hyperactive Disorder in Children and Adolescent - 2008
Download Links: Box.net | Mediafire
Management of Major Depressive Disorder - 2007
Download Links: Box.net | Mediafire
Malaysia Consensus Statement for the Treatment of Bipolar - 2007
Download Links: Box.net | Mediafire

Cancer CPG:

Management of Colorectal Cancer - 2017
Download Links: DropBox | Mediafire
Management of Nasopharyngeal Cancer - 2016
Download Links: DropBox | Mediafire
Management of Cervical Cancer (2nd edition) - 2015
Download Links: DropBox | Mediafire
Management of Breast Cancer (2nd Edition) - 2010
Download Links: Box.net | Mediafire
Management of Cancer Pain- 2010
Download Links: Box.net | Mediafire
Management of Cervical Cancer - 2003
Download Links: Box.net | Mediafire
Management of Breast Cancer- 2002
Download Links: Box.net | Mediafire

Cardiovascular Diseases CPG Update: 2017-2018

2018-10-31T12:08:00.000+08:00

Quite a number of CPG's had been churned out by our Cardiovascular team over the past 2 years, and it has been a great pleasure to announce the updates here. These invaluable updates has been essential for us to keep ourselves up to date with the latest local recommendations.

Below are a few of them:

Guidelines on Stable Coronary Artery Disease- 2018
Download Links: Dropbox| Mediafire
Management of Hypertension (5th Edition)- 2018
Download Links: Dropbox| Mediafire
Primary and Secondary Prevention of Cardiovascular Disease - 2017
Download Links: DropBox | Mediafire
Management of Dyslipidemia (5th Edition) - 2017
Download Links: Dropbox | Mediafire

And there are a few previous ones which still remain relatively relevant:

Heart Disease in Pregnancy (2nd Edition) - 2016
Download Links: Dropbox | Mediafire

Prevention of Cardiovascular Disease in Women (2nd Edition)- 2016
Download Links: DropBox | Mediafire
Management of Acute STEMI (3rd Edition) - 2014
Download Links: Dropbox| Mediafire
Management of Heart Failure (3rd Edition) - 2014
Download Links: Dropbox| Mediafire
Management of Hypertension (4th Edition)- 2013
Download Links: Dropbox| Mediafire
Prevention and Treatment of Venous Thromboembolism- 2013
Download Links: Box.net | Mediafire
Management of Atrial Fibrillation - 2012
Download Links: Box.net | Mediafire
Management of Stable Angina Pectoris - 2012
Download Links: Box.net | Mediafire
Management of Ischemic Stroke (2nd edition) - 2012
Download Links: Box.net | Mediafire
Management of Unstable Angina/ Non-STEMI (2nd Edition) - 2011
Download Links: Box.net | Mediafire
Management of Pulmonary Arterial Hypertension - 2011
Download Links: Box.net | Mediafire

CPG 2015 - Management of Dengue Infection in Adults (3rd Edition)

2016-02-06T11:01:00.000+08:00

Finally, after some review and finalizing on the initial draft, this has been officially published in Malaysia's MOH site. While most of the content has remain the same, some key changes such as the preference of fluids used in decompensated shock has been reverted to either crystalloid/colloid (The draft mentioned colloid as the first line of fluid resuscitation in dengue decompensated shock).

Management of Dengue Infection in Adults (3rd edition) - Dec 2015

Full CPG Download Links: Dropbox| Mediafire
Quick Reference Download Links: Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Draft CPG: Management of Dengue Infection in Adults 2015- 3rd Edition

2015-09-06T09:14:00.000+08:00

The draft of Malaysia's MOH 3rd edition clinical practice guidelines (CPG) for dengue management in adults had been launched on the 4th Sept 2015. It had been uploaded on the MOH site and is currently open for feedback and comments to further improvise the CPG. Compared to international publication of similar guidelines, the feedback duration is rather short as it will be opened from 4th Sept to 31st Oct 2015. Therefore, we are uploading a copy here in MedPBL as well. All comments and feedback can be sent to htamalaysia@moh.gov.my.

Source: Ministry of Health, Malaysia

CPG 2015 Draft- Management of Dengue Infection in Adults 2015
1st public draft (3rd Sept 2015): Dropbox | Mediafire

Among the key updates in the latest CPG draft are:

1. Inclusion of diarrhea as dengue warnings signs.

While diarrhea is not a warning sign according to the WHO 2009 classification, it may be considered as a compounding factor leading to further fluid loss. Or perhaps it could be a sign of 3rd space loss causing gut edema which may lead to diarrhea(No proven pathophysiology here, just postulation). With many severe dengue and dengue deaths patients initially presenting as fever with gastroenteritis, perhaps there is some truth in it, hence leading to the inclusion of diarrhea in the warning signs.

2. Inclusion of frequency of vomiting and diarrhea to be considered "persistent" as more than 3 times per day.

Previously, many referrals were made based on patients vomiting once or twice which resolved spontaneously with or without treatment. The word "persistent" had been clearly defined here as more than 3 times, avoiding any further confusion.

3. Inclusion of median value of normal hematocrit among Malaysians, with the hematocrit above these values now being considered as a warning sign.

---Hematocrit level for males less than 60 years old - 46
---Hematocrit level for males more than 60 years old - 42
---Hematocrit level for female regardless of age - 40

4.Inclusion of NS1 Antigen and Dengue Rapid Combo Test as part of the recommended tests to diagnose dengue especially during the early phase of dengue infection.

While previous edition mentioned that NS1 Ag was currently under evaluation, the latest draft advocates for the use of NS1 which had a sensitivity between 75-97% during the first 5 day of illness in particular.

The serum NS1 Ag titer peaks at Day 1 to Day 2 of illness and drops subsequently to low levels at D4-D5 of illness, leading to reduced sensitivity of NS1Ag. Therefore, Dengue Rapid Combo Test could be falsely negative during this period of D4-D5 illness if serum NS1 Ag titer drops below detectable level, while serum Dengue IgM levels have not risen above detectable levels as well. These tests should be interpreted in clinical context and a repeat test for Dengue IgM may be considered in recovery phase to determine seroconversion.

5.Inclusion of a dengue assessment checklist for dengue patient

While previous CPG edition advocates for a dengue clerking sheet, this may not be feasible as patients do not walk in with dengue as a chief complain or "dengue" labeled on their forehead. Hence the clerking sheet is only used after the patient has been diagnosed with dengue. While certain centers use a fever clerking sheet instead, some dengue patients do not come with fever as they may be in their critical phase. Therefore, a unified dengue assessment checklist is being introduced instead of re-clerking the patient for dengue using the dengue clerking sheet upon diagnosis.

6. Changes in the intravenous fluids maintenance regime for dengue management in patients with warning signs but not in shock.

Instead of the Halliday-Segar formula used for calculation of fluid maintenance in dengue patients, a new calculation method is used using 1.2 - 1.5ml/kg/hour, making calculation easier for physicians and medical students alike. This is based on National Clinical Guideline Center (UK) on Intravenous Fluid Therapy in Adults in Hospitals (Dec 2013)

IV Fluid regime for obese and overweight patients are no longer calculated according to ideal body weight (IBW) but using adjusted body weight(ABW) instead.

However, do take note that more emphasis had been put on the judicious use of intravenous fluids as overly prescribed intravenous fluids has higher complication rate compared to those who can take fluids orally.

7. Changes in the algorithm for fluid management in dengue patients with warning signs but not in shock

While the 2nd edition advocates for fluid resuscitation according to the formula of 5-7cc/kg/hr for 1-2 hours, then reduce to 3cc/kg/hr for 2-4 hours and then reduce to 2-3cc/kg/hr orless, this holds true only for compensated shock and decompensated shock (post fluid resusictation and responding). For dengue patients with only warning signs but not in shock, the lower limit of the regime is being advised, being 5/3/2 cc/kg/hr instead of the 5-7/3-5/2-3 cc/kg/hr to avoid fluid overload.

8. Changes in fluid of choice for fluid management in Decompensated Shock

While previous edition of CPG advocates for crystalloid solution for decompensated shock and the consideration of colloids only in profound shock, the latest edition outlines for the use of COLLOIDS outright from the start. Fluid resuscitation continues with COLLOIDS and subsequently blood products in patients who remained in shock. If there is improvement, then only the fluid of choice can be switched to crystalloid or remain as colloid.

9. Introduction of a new algorithm for fluid management in Decompensated Shock (With presence of bleeding and leaking or other causes of shock)

Previous edition of CPG emphasized on the fluid management towards dengue shock syndrome, however, this draft edition includes addition of this algorithm to guide physicians to look for other causes of shock instead as well and to manage accordingly. This is due to increasing number of dengue mortality where by patient deteriorates into shock despite aggressive fluid management.

OGDS has been put under consideration if the patient has a suspected Upper GI bleed due to peptic ulcer, although routine endoscopy for UGIB in dengue is not advised as it may increase the risk for bleeding.

Continuous renal replacement therapy is a new modality considered in the treatment of dengue for those with liver failure with severe metabolic acidosis from lactic accumulation

10. Introduction on the section on Management of Complications in Dengue Infection

As there are rising number of incidence of complications due to dengue, a section has been added to guide physicians on the management of such complications. The management is beyond the scope of this post, hence here's the list of the section:

A. Management of Bleeding/Hemostasis in Dengue Infection
i) Hemostatic Abnormalities
ii) Significant Occult Bleed
iii) Upper Gastrointestinal Bleed

B. Management of Hepatitis in Dengue Infection

C. Management of Cardiac Complications in Dengue Infection

D. Management of Neurological Complications in Dengue Infection
i) Dengue Enchephalopathy
ii) Dengue Encephalitis
iii) Acute Transverse Myelitis
iv) Muscle involvement (including rhabdomyolysis, post-dengue Guillane-Barre, etc)
v) Ocular manifestations (maculopathy, retinal edema, retinal hemorrhages, optic neuropathy etc)

E. Management of Renal Complications in Dengue Infection

F. Management of Haemophagocytic Syndrome in Dengue Infection

Of course, there are more updates in the latest CPG draft including ED management as well as intensive care management, but I'll leave it for you to read it from the draft. We will try to introduce more updates from time to time.

CPG 2014- Management of Neonatal Jaundice (2nd Edition)

2015-08-04T21:42:00.002+08:00

The last CPG for management of neonatal jaundice was published in 2003. While it may not have been widely adopted as the TSB level varies slightly between hospitals, it serves as a guide for those new to the field. 11 years later, the second edition is out for all to compare. We hope everyone would benefit from the education served fro each CPG including this one.

Management of Neonatal Jaundice (2nd edition) - Dec 2014
Full CPG Download Links: Dropbox| Mediafire
Quick Reference Download Links: Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

National Antibiotic Guideline (2nd Edition) - 2014

2015-06-07T17:25:00.004+08:00

Since the 2008 National Antibiotic Guideline was more than 5 years ago, it is time for the new guideline to be published. Here it is, the 2nd edition by the Ministry of Health.

FYI, there had been some correction done on the dose for Augmentin has the dose has been rectified. For our Amoxycillin/Clavulanate (500/125) formulation, the dosing should be 625mg t.d.s instead of b.d. This is in line with the amoxycillin dosing of 500mg t.d.s.

Below are the download links for the pdf version as well as the Playstore link for Android. Pretty sorry for those in iOS, but I guess those using iPhone will need to bear with the pdf version for the time being. :) Kudos to the Ministry of Health and the Pharmaceutical division for the initiative to include it in Android.

National Antibiotic Guideline (2nd edition) - 2014
Download Links: Dropbox| Mediafire

Playstore: Android (Supports Android Version 2.2 and up)

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG 2014- Management of Bipolar Disorder in Adults

2015-01-14T20:00:00.000+08:00

Part of the stacked up scheduled post for this site, as I would not want to overwhelm you readers with too much information at once. At least, a few days once ought to be enough, nay?

Management of Bipolar Disorder in Adults - 2014

Download Links: Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG 2014: Management of Autism Spectrum Disorder in Children and Adoslescents

2015-01-11T17:34:00.000+08:00

Following through the release of CPG of STEMI and Heart Failure, we now present you with the CPG as mentioned. This one may be less used by most physicians but nevertheless useful in updating your knowledge on the mentioned topic.

Management of Autism Spectrum Disorder in Children and Adoslescents - 2014
Download Links: Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG 2014- Management of STEMi and Heart Failure - 3rd editions

2015-01-09T22:21:00.000+08:00

Welcome to a new year of 2015! With the start of the year, there are new guidelines introduced to keep fellow medical practitioners updated on the management of cardiac diseases. The guidelines for the management of STEMI and heart failure has been updated to their respective 3rd edition.

Management of Acute STEMI (3rd Edition) - 2014
Download Links: Dropbox| Mediafire

Management of Heart Failure (3rd Edition) - 2014
Download Links: Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG 2014- Management of Osteoarthritis (2nd Edition)

2014-08-04T00:52:00.004+08:00

The management of osteoarthritis has been updated by Malaysia's Ministry of Health and released for practitioners. The launch on 17th June may have not reach everyone, but hopefully the uploads here will create awareness for the physicians of the new CPG. A quick review version is also available for those who prefer to read the abbreviated version.

Management of Osteoarthritis (2nd edition) - 2014
Download Links: Dropbox| Mediafire | Box.net

Quick review version:Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG 2014 - Management Guidelines of Malaria in Malaysia

2014-05-19T20:33:00.001+08:00

After a long due, the CPG for the management of Malaria which was scheduled for Dec 2013 is finally out. Based on the WHO guidelines for the management of malaria, this version is adapted to our local settings taking into account of availability of resources. Do take note just like any other CPG, this serves as a guide as shall be read as it is but not of absolute truth.

Management Guidelines of Malaria in Malaysia - 2014
Download Links: Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG 2013 - Management of Hypertension (4th Edition)

2014-03-08T20:38:00.001+08:00

After the scheduled 5 years validity of CPG for the management of hypertension in Malaysia (last published in 2008), the latest 4th edition has been approved in Dec 2013. Hence, here we are pleased to informed that our Ministry of Health has officially made it available to all in their site. Other coming CPG's are Management of Osteoarthritis (2nd edition) and Management of Malaria.

This clinical practice guidelines encompasses management of adults to children.

Management of Hypertension (4th Edition)- 2013
Download Links: Dropbox| Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Dengue in Malaysia: An All Out War in Public Health and Clinical Settings

2014-02-07T01:30:00.001+08:00

As part of the social responsibility towards the Malaysia's dire scenario in dengue, MedPBL has agreed upon to feature another article on dengue management.

However, I would like to put forward a chart depicting the current situation nationwide as of feb 5th, 2014. From 1st Jan until 5th Feb 2014, we have more than 10,000 cases nationwide, with 19 reported dengue deaths, more than 3 times the number last year. Given the current trend, we would expect a 4-fold rise at the very least until the end of the year. The current situation had caused most government hospitals running short of beds, as well as private healthcare centers.

*Click on image to enlarge*

Source: VektorKL

With the introduction of lab-based confirmation of dengue infection, there may be "hiccups" expected in the aspect of reporting of dengue cases. First and foremost, dengue notification remains the same in Malaysia, all suspected dengue cases should be notified immediately within 24 hours. Failure in compliance to the said act is an offence under the Prevention and Control of Infectious Diseases Act 1988(Part V Section 24) and you are liable on conviction of inprisonment up to 5 years and compoundable offence of RM1,000. However, not all notified cases are reported as dengue cases. After thorough investigation from the health office, the notified cases will be registered in the registry after being verified by the Health Office's epidemiological officer. However, with the new ruling starting from Jan 2014 onwards, all registered cases would required laboratory confirmation, the common ones being dengue IgM/IgG serology and NS1 antigen. For those notified cases whereby the tests were not done, the health offices would be required to contact these patients and perform the test on them. However, these patients can be hard to catch-by after the first contact, so medical personnel are advised to perform the serology/virology tests if the facility is available in your settings.

For primary healthcare personnel, it is vital to establish the severity of dengue fever. Malaysia's CPG on dengue management is sufficient as a guide for you to recognise the warning signs of dengue infection. Of course, the more important is to recognise if the patient is in compensated or decompensated shock as this would affect your initial resuscitation, IV fluids, etc. Remember, your clinical evaluation is very important and do not based on a single parameter. Look at the patient as a whole!

Source: Malaysia CPG: Management of Dengue Infection in Adults, Revised 2010 edition

As a start, one may use the Dengue Clerking Sheet as a quick checklist for subsequent assessment aand management. A dengue monitoring card is equally as important as patients may travel from one clinic to another more often than not, so the card helps to keep track of the necessary investigations and vital signs.

Dengue Clerking Sheet: Box.net | Mediafire

Front side of dengue monitoring card

Reverse side of dengue monitoring card

In hospital settings, fluids and electrolytes are of utmost important aspect of the management of dengue infection. While assessing the patient's clinical hydration, remember that oral fluids are the best fluid regime, not IV fluids, unless necessary! Patients tend to get fluid overload quicker with IV fluids regime than oral regime, stressing on the importance of our physiological homeostasis at work.
Electrolyte supplement/replenishment are advised should there be plenty of IV fluids planned. Ensure that the patient's fluid input/output charting is monitored to ensure appropriate fluid balance to be maintained, not a positive balance of 2-3 liters/day unless approved by your consultant. While our focus had been on the critical phase for fear of dengue shock syndrome, the fluid reabsorption phase during the defervescent/recovery phase can be equally as deadly, leading to fluid overload and cardiogenic shock. Recognizing occult hemorrhage is also important, but focusing solely on platelet count may not reduce the risk of major bleed.

A research was done by Lum et al, JPed, 2002 on the risk factors for major bleed in severe dengue and here are the results:

With this study, it has suggested that protracted shock is a more significant risk for major bleed in severe dengue than low platelet count, along with the initial elevated hematocrit, which may also indicated the presence of plasma leakage. Of course, shock in this sense does not imply relying on blood pressure measurement alone, while clinical assessment should be taken into account, such as pulse volume, capillary refill time, warm peripheries, etc.

As a general rule, it is vital to monitor the trend of your dengue patient so you could keep track of the progress, including vital signs, blood parameters as well as fluids balance.

A general dengue monitoring chart should be in place for any hospital setting. A sample guide which can be used is as below:

Dengue Monitoring Chart (Guide): Box.net | Mediafire

Common pitfalls:

Underresuscitation during critical phase leading to Dengue Shock Syndrome (Too much fluid loss from intravacular volume)
Overresuscitating during critical phase leading to fluid overload during defervescent phase (Fluid reabsorption into intravascular volume)

With all the materials provided, we wish you all the best in the management of dengue patients. Do try to avoid causing dengue deaths, as it is part of national statistics emphasied upon. Dengue death notification is compulsory, with at least a phone call to the nearest district health office followed by a written notification. A state level mortality meeting will have to be called upon within 7 days from the notification of dengue death, with compulsory attendance from the attending physicians. Let's do our part in the war against dengue.

Dengue on the Rise

2014-02-01T09:25:00.000+08:00

Dengue infection is no longer a just a national issue. Over the years, dengue infection had been on the rise. It has been known to infect at least 400 million people on an annual basis. While a lot has been known of its characteristics, there is no known cure as of today. Even the dengue vaccines are currently undergoing clinical trials, yet to be proven of its efficacy and safety. What we do know is that our urban co-existence with the Asian tiger mosquitoes, the Aedes aegypti especially, has brought forth a larger scale of dengue invasion from its perpetual spread via its vector.

Serotypiccally, there are 4 dengue serotypes, namely DenV 1-4. Of course, there are 5th serotype DenV-5 that is actually a sylvatic infection, which is not endemic in humans and could hardly sustain an epidemic. Each serotypes has various genotypes, but simply put, the DenV 2 is the one believed to cause a more severe clinical outcome in a secondary infection. Hence, whenever there is a rise in case-fatality rate, it is associated with a rise in the DenV 2 serotypes in Malaysia's serotyping surveillance. A look at last year's statistics in Malaysia revealed a staggering climb in the presence of DenV 2 serotype, with more dengue deaths occurring towards the end of the year.

*Click on image to enlarge*

Source: Control of Vector-Borne Diseases Unit, Ministry of Health, Malaysia

However, Malaysia is a larger country with various areas consisting of urban development and rural areas. The distribution of dengue serotypes differs from each states. Ultimately, certain states may have similar composition of serotypes due to the ease of mobility among citizens travelling between the states.

*Click on image to enlarge*

Source: Control of Vector-Borne Diseases Unit, Ministry of Health, Malaysia

Identifying the serotyping is more for surveillance and research purposes, while the ultimate outcome still lies in prevention and control. The environmental factor is one of a major issue whereby citizens themselves contribute to the litter, creating more Aedes breeding sites with standing water. Ignorance plays another part for those who fail to notice and clean out the standing water at home.

For those managing dengue patients, remember that fluid management is of utter importance, stripped down to its core. Too little fluid can cause Dengue Shock Syndrome whilst too much fluid could tilt the patients to being overload as dengue patients can be rather fragile in this sense.

What about the vaccination? Various vaccines are under development, but don't put too much high hopes on it yet. The earliest vaccine could come out as early as in 2015, but it may take a number of years before it could reach production, so work hard to fight this war. Avoid increasing the dengue death statistics by doing your part now. Be a part of the solution, not a part of the statistics.

*Click on image to enlarge*

Source: http://www.denguevaccines.org

*Click on image to enlarge*

For those interested to know of the current dengue situation in Malaysia, here's the FB link to the respective states:

Kuala Lumpur and Putrajaya: Bebas Denggi - UKPBV JKWPKL&P
Selangor: Situasi Denggi Selangor - UKPBV JKNS
Perak: Jabatan Kesihatan Negeri Perak
Johor: Jabatan Kesihatan Negeri Johor
Pahang: Jabatan Kesihatan Negeri Pahang
Melaka:Vektor Melaka
Terengganu: Jabatan Kesihatan Negeri Terengganu
Kedah :Jabatan Kesihatan Negeri Kedah
Perlis: Jabatan Kesihatan Negeri Perlis

CPG 2013 - Prevention and Treatment of Venous Thromboembolism

2013-10-18T23:18:00.001+08:00

Finally, the first Malaysian CPG after a long while. This CPG was officially published in Aug 2013 and would serve well for most specialties as VTE is not just a medical problem, but it can involve surgical patients as well. Its prevention also involves liasing with anesthesiology department for pre-op assessment. Now you can read this up and inform your medical officers or non-medical specialists that deep vein thrombosis is not only treated by continuous infusion of unfractionated heparin, but can be treated with other alternatives if not contraindicated.

No, the image above is created by MedPBL, instead the actual CPG had a cover as below. Well, it's the content that matters, anyway.

Prevention and Treatment of Venous Thromboembolism- 2013
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Many Condolences and a Dengue Prevention Programme

2013-10-04T00:28:00.000+08:00

We mourn the passing of one of us, a young medical student who had succumbed to dengue and passed away last month. May she rest in peace. But for the rest of us, bear in mind that the fight against dengue is far from over. Keep your places in check and free from mosquitoes-breeding and use aerosol on a regular basis.

Until dengue vaccine has been produced, dengue fever will continue to plague us. Even our best hope for dengue vaccination candidate is undergoing phase IV clinical trials which is due for completion in 2016 the earliest.

For now, elimination of adult mosquitoes by aerosol or fogging is half a preventive step, but eliminating the Aedes breeding sites are of utmost importance. Play your part now and together we can make this a better place to live in.

For those who stays in Kuala Lumpur/Putrajaya, you are cordially invited to join the official FB fanpage for JKWPKL&P's Vector-borne Disease Control Unit. For enquiries, complaints, information, or feedback, do not hesitate to approach them. They will also keep you updated on the latest news on the dengue situation in KL and Putrajaya with Google maps to pinpoint the locaility of the outbreaks as well.

Click on the link below to visit them:
https://www.facebook.com/vektorkl

CPG 2013 - Management of Psoriasis Vulgaris

2013-09-10T01:16:00.000+08:00

Not long after the introduction of the CPG of management of VTE for the year 2013, the 2nd CPG had been uploaded in Malaysia's MOH site. This CPG, as its name implies, is a guideline for the management of the dermatological disorder of psoriasis vulgaris.

Management of Psoariasis Vulgaris- 2013
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

Case Files 12: My Last Breath - SOLVED

2013-04-09T14:00:00.000+08:00

A 24 years old lady with a history of HbH thallasemia with post splenectomy 8 years ago on frequent blood transfusion presented to ED with a history of shortness of breath. This patient frequently defaulted treatment and had been non compliant to medication. A month prior, she was admitted into medical ward for decompensated cardiac failure due to cardiomyopathy as a result of iron deposition.

She was seen gasping and was able to speak in few words at best. What was noticeable was her leg swelling was worsening and was tender on palpation. Her jugular venous pulse was strong and reaching her earlobe. She was put on high flow mask and a baseline ECG was recorded as below.

Do you recognize any particular pattern in this 12-lead ECG?

Answer:
The 12-leads ECG showed a variant of the SI QIII TIII of pulmonary embolism. Noted that there is right axis deviation with a prominent S wave in lead I (hence SI), and T wave in lead III. (TIII). There is no Q wave though in lead III (QIII). Another distinctive pattern seen was T wave inversion of V1 - V3 as well as P pulmonale (tall tented P waves) seen esp in lead II.

The patient had been having DVT from prolonged immobilization and US Doppler revealed significant DVT over the right lower limb. CT Pulmonary Angiography confirmed the diagnosis with multiple scattered areas of embolization in the lungs. The patient was started on unfractionated heparin infusion and overlapped with warfarin. Her condition improved after 1 week of admission. She was discharged with warfarin, however, knowing that her prognosis is guarded in view of her condition and prolonged non-conpliance to medical therapy.

A week after discharge, the patient was readmitted into ED red zone with another spell of shortness of breath. It was another episode of pulmonary embolism with pulmonary hypertension with biventricular failure and the patient was intubated and admitted into CCU but did not make it through after 2 days there. The parents were counselled of the prognosis and they did not wish for active resuscitation in view of her deteriorating condition thereafter.

Case Files 11: My Heart Skipped A Beat - SOLVED

2013-04-07T16:00:00.000+08:00

A 68 years old lady presented to the ED with productive cough for the past 3 days. She was brought today in view of her complains of generalized lethargy and weakness. Prior to further investigations, a baseline ECG was done. She was initially sent for green zone fast track, but was subsequently uptriage to yellow. What are your findings?

Answer:
This is a rare pattern of atrial bigeminy. While most are familiar with the easy-to-spot ventricular bigeminy with a wide QRS complex, this can be rather confusing as one may thought of Mobitz type II or 2:1 block. However, a closer look will reveal a few things:
1) The QRS complex exhibits grouped beating, being regularly irregular
2) There are presence of P waves prior to each QRS complexes
3) All P wave have an associated QRS complexes
4) The 2nd P wave have slightly different morphology than the 1st P wave, suggestive of 1st P wave originated from the sinus focus whilst the 2nd P (premature atrial contraction) may originate from another focus.

Atrial bigeminy, as a manifestation of premature atrial contraction, is a harmless rhythm in the proper clinical context. Most people with atrial bigeminy do not have organic heart disease, albeit the fact that it is more common in people with heart disease than those without. There are certain factors linked to the occurence of atrial bigeminy, such as caffein intake, emotional stress, smoking, alcohol use and fatigue. One things is of concern is that patioent with atrial bigeminy may not have the 2nd QRS wave transmitted into a pulse, which had caused this patient to have a pulse rate of 50-60 despite a heart rate of 100-110.

In this patient, no identifiable cause was found despite the alert and uptriage to Red Zone initially. Repeated ECG 1 hour later showed resolution to sinus rhythm and her pulse rate returned to 80-90 beats per minute. Nevertheless, the patient was admitted for community acquired pneumonia with a high CURB-65 score.

Case Files 10 - My aching stomach - SOLVED

2013-04-06T12:00:00.001+08:00

A 53 years old Malay gentleman with no known medical illness came to ED complaining of worsening epigastric pain for the past 3 days.He had earlier seek treatment from a GP 2 days ago and was treated as gastritis. He was discharged with syrup MMT and oral ranitidine. He claimed that the symptoms improved after taking the medication, albeit not completely.

However, today, the pain worsened and became rather severe, hence the reason he made a trip down to the ED. He was given syrup MMT and ranitidine and a baseline ECG was done. Routine blood investigations was done and it was noted that cardiac enzymes were normal as well.

2 hours later, the patient was noted to be sweating. He looked lethargic and pale. He still complained of epigastric pain. A repeat ECG was done in view of the patient's discomfort.

Normal 12-lead ECG

Posterior lead ECG

Inferior ECG

What would be your intepretation? Is there any bedside test to confirm your diagnosis? Any further blood investigations that can be taken?

Answer:

The 12-lead ECG showed significant ST - elevation over the inferior leads II, III, aVF whilst the lead V1-V3 showed ST depression. In a case of inferior MI, it is prudent to do a right sided ECG and posterior lead ECG The reason being is that inferior segment of the heart is supplied by the right coronary artery, which also supplies the right and posterior aspect of the heart. An occlusion at the right coronary artery that affects the inferior aspect may affect the other 2 as well. Of coursem other signs may include bradycardia and subsequent hypotension, as a result of sinuatrial node involvement, which is also supplied by the right coronary artery.

The right sided ECG showed no ischemic changes over the right aspect of the heart, but a quick look at the posterior leads showed significant ST-elevation as well.

Hence, this is an acute inferoposterior myocardial infarct. A bedside ECHO can be done and for this patient, there is hypokinesia over the inferoposterior region, correlating with the ECG findings. Cardiac triple test (bedside rapid test) was done for this patient. Myoglobin and CKMB was positive whilst TnI was negative, suggestive of recent onset basis. (Kindly refer to Malaysian CPG for acute coronary syndrome to have a quick review of the peak and through of the cardiac enzymes).

The patient was started on streptokinase fibrinolytic therapy in view of no PCI in the center. 1.5mU Streptokinase was given in 100cc normal saline over 1 hour (there are 2 other recommended regime). The streptokinase was witheld once midway as patient developed hypotension (side effects of streptokinase therapy) and restarted slowly once BP picked up after 1 pint of NS was given. Repeated ECG showed good resolution of the ST elevation and the patient was sent to CCU for close monitoring and management.

CPG 2012 - Management of Tuberculosis, 3rd edition

2013-04-05T16:31:00.000+08:00

The latest CPG on tuberculosis is out. Among all, this is one of the most comprehensive CPG, covering almost all aspects of the management of TB.

Management of Tuberculosis 3rd Edition- 2012
Download Links: Box.net | Mediafire

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

CPG Cardiovascular Updates - AF and Stable Angina Pectoris

2013-04-04T15:42:00.004+08:00

With the recent updates from MOH, the CPG guidelines for atrial fibrillation and stable angina pectoris is out. Here is the link to download the respective files. We hope that these CPG's will be put into good use to aid all medical practitioners in managing the conditions mentioned.

Management of Atrial Fibrillation - 2012
Download Links: Box.net | Mediafire

Management of Stable Angina Pectoris - 2012
Download Links: Box.net | Mediafire

Source:
1 )National Heart Association of Malaysia
2) Academy of Medicine of Malaysia

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

MOH Paediatric Protocols for Malaysian Hospitals, 3rd edition

2013-02-25T23:58:00.004+08:00

MOH Paediatric Protocols for Malaysian Hospitals, 3rd edition

by Hussain Imam Hj Muhammad Ismail, Ng Hoong Phak, Terrence Thomas

Format: PDF (~5MB)
Download Link:

Box.net | Mediafire

Finally, I'd got my hands on the 3rd edition. This book is worth RRP RM25 (At the time of this entry) and can be purchased at the MPA office at Jalan Raja Muda Abdul Aziz. MPA claimed that they do offer delivery service at RM5 per book. So, that's RM30 for you guys who prefer delivery service due to logistics issue.

To get your fresh copy of book, just drop by their office or call them for their delivery service. If you plan to drop by, The soft copy of this edition is also readily available in their MPA site.

Paediatric Association
3rd Floor (Annexe Block),
National Cancer Society Building,
66, Jalan Raja Muda Aziz,
50300 Kuala Lumpur.

Tel: 603-2698 9966/ 26915379
Fax: 603- 26913446
Email: info@mpaweb.org.my
Website: http://mpaweb.org.my/

*The Peds protocol 3rd edition had the copyright belonging to MOH. As a responsible organisation MPA decided to print the book as part of their contribution to paediatrics in the country and has done so from the first edition. They are selling the books at cost price and for the 3rd edition they have forked out quite a hefty sum to print out the books.

Guidelines on the management of cow's milk protein allergy in children 2012

2013-01-09T12:08:00.000+08:00

Guidelines on the management of Cow's Milk Protein Allergy in Children - 2012
Download Links: Box.net | Mediafire

Source:
1 )Malaysian Society of Allergy and Immunology
2) Malaysian Paediatrics Association

For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE