,

:~:.EWS~·

T~!I'I o.ck S~IiIi~ T
II~Oi jji ~"Jl7l

What To T'le,ll~ 'Y,Q,Utr P'afi!e,nts AIl,out:
IF.oodi,AII~e~gy IOmg Alller'IlIY ,AU!elfgy tB!!ood tesm,
O.ganher;

Departmenl of Rheumc:rh:::4oQlY, AllerQY &. rmmunotogy Date: 16 October 20 11
: M~ Salehah

Current' 'Ttrends in, Manag'emen:'f 0": G!atU Ihld,dier and cd 'Geneto~ SUrg'BIY' Liv,a:r D'is!eases OJg.an~ulI":.iDeporirnen,1
Dale; a ~O'iembQ!' 2@11 Corlllk:ict I'ef$en= M:s CindY tim Co:rilfad No : 6357 7.[309 Elman; Cind~~~y~!J:m!'QntS!h ,com,m Regl'slralleln fee; fr.ee

Co.llltac::J f~ncn

Conll:ilJct NQ' ; ,6357 7a22 Em.a~,: Sbi!tihO_Sodoon@lh'h"com,519
R~i~,hi~ioIl!IIF@e : S$.5,

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N E-W,S.
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'0

UP NEXT' INI OIUR,
ISSIUIE••••
ACUTE PHARYNIGITIS: WHO NEEDS ANTIBIOTICS?

HUMAN IMMUNODEFICIE:NCY VIRUS,

DE ARTMEN

OF

Dea GP Coilleague ,
Dr Yea is ·~heg:eneli'Sl practitioiller Who has been lookiing ·a:lit:ermy falmily fo,ras II'ong as lean rernemner; So ml.llQnso he has rbecome a family '!fiendl 8111.(1 is Iregll.l!'llarly li:nvitedl to 31btel1ld my gran(j"mOtlil!er"s Ibirti1l.clay calebr.alticms.
My grandmoWi.er

GI
+ +
+ +
-t-t-

E II

Anxietv and! Panic Disorders' + De~:m8's'SltV€! IICI[sord.ers. IF'Qs~natal Ilth:~pressio.n
-I-

is 92 yea~s old Ulis year. She IhaS a past histO'fY of I1rYIPerlension. iscl1ermic l1ealfit

diTiSiIllQSei!1l :l colon cance;r. Ove:~!he past feW yeam. she h:8is det€;iiiora~e.dl Ibothl p.hy~ically as ·\i'!lellas m oognitiVle!liy. On a few eccasiens, ~haVle Iprescribedto help Wiir~hh,eill' ood as weill as miemony problems, m 1mslliJch insh,l;rIces, botn :my graJldmothaJf a_ncl my parents wowel checik wi~nl lOr Yeo beforeatgree1r'!g~o takelihe medica;~i:oli1s Ilhadadvisedi '("Jlllist in caool').

NJeuliopsycfdame .arilidOr-ganie Menr1!al Disorders 'e ..g. D:emeililtia Post·;,tm;um6IJHc Stress Dirsonj!er,. Abnormal Gr'feif Roootio!ils Psyclil'liallric Disorders in .1lI1!€. Mediealily III1I Psycholsol'illatle iDisor-del':s, SomawfoJi'iI1 Di~o;mell"S PsyOi1l.olsess.g. Dellil.lliSiionarl1 IJ!iiso,Wd'elr., SCl1!ri2!ophrenia Stress Mi1!nag'sme<nt

The geJ1lie!ra'lll~mctitionelf, or more app.ropliiate!l¥ termedl the ftimilly Iphysicia:n, ls onen an underratedancl
rlllMe:r appreci;a,ll€d SPEliClhlllity. ~Fromscmerrl'Tngror Imed'h:.aIIII~robiliems,limaitJng a.Cllll~ :medTic;a1 cond"utfrms, the apPl1o,priaile rerenal 10, spe1oj,all"i!s1.s fiollow-IJI,P'oil' pOSIt :surg:rcal and cnro:nilc mec rcal IPl1oblel'iJilS,the and· family physician Iplays Ulri:s·\i'i~al roleas ttU3! IbridglE! be-meern ipriman; an(jl secon.dary I tertiary care. The rovem'lap between tl'liElmind (menta:11 hiealth) and the tlooy(physi:calll health) nas lbeenliecoglfil15ed Ulr,oliJgllilthe ages. IHowever, adva'fH::es and avai!ab1liity o~ treatments in :mea iicine and :siliJl'grca'lltrealtment ~f1lI mooer;liI times l'lI,aveswung 'Uhe pemI!lllrufll1 tow;aiids symptom relief andl control O.e, healingl the: bodiy)o. .only rilll recel1lrt years hal5,~here beenen 8.C!kin.owledigmeint. "li181t o:pUmisingl~he overall 'q,ll.Iality of Ii~e ,(enoompEtssing vanoYis aspects of a. pSJ\iienl's fl.Lnotionalit.y) iis jl~s~arS iimpOfiant as Ibeingl s:ymptom~fi'eeFami'liy physicians ere o:ft.en the 1iflrSt poil'il'tofcO:IMa,c~ ttnat!he p8:~ifenl has witi'll tne m.edica'ir fraternity., Moreov,elf, due to,their II~o.ng-istand'ing r,e!liallionshr,p wiiill1the pa~ier1.t. most family plliiys:riCians WOI,)fl:drlbemore· lim!l:ma,ll€ly' aicquarilil~iEldw,il~1harious aspects off lEIpa1ient'smmT~y aliliGI.sQciialli~e" l~n,deed!,th'eclo8i€l rappe.iii!: v lihe famirly physi~cii::Hl mifly have wi1h~heir paltient :puts fhe:m riil'ililie best posi~ion to help ma·1resense ow oomfIJ:e,x medical infOfflit8ition availal~IJe ·nowadays. Mental iIIness,I!!S9JrE! n.o,l uliIJoommon ,and family ;p:hysicialiliS can otten be al€'iiIIBd,to signs o~ rnle:llIltallUhil,8;SS in tt1e:I'Iipa~t€nts~lrIa~ ~h!(5pailifents ·l1ItlelmsiEllv€s, O~ ·lhe,irfamilies, malY l'iliOt even be awa.re ow.Th,e family ph~s:roi'a ns would pr()bai:)lry bellfle prefemild oliloice of me [patient $ihol.lllldlU1.ey be needed b;r ma:lI1ag:e minor mental oondii~i:(ms· Uuough ,ooulllis.elllfng a rid ,med [Ci3ition. Familry physicians are a valuable rre90~lroe to tiM! :med~ca!11 ommunjty due totlfleir close relaijon<s:lilip~o o l!Iileir pa,tien~s andl1l'l.e elilJSi!iJingrappo:rrta nd ~FlIIls~thart [is e.rrlg~iil.de'.r€d,. ·fhe:Y<3:rein!strumentall wndhangFng ~~e face 'Of moo!licine from rCIiJiUne. :analy~j;ca'ir work tQ\iVi!r~s empalhflc and! holistic care.
Dr Aingr L:~ r,,",oill, A.31fo01:I" H~ Qfrbtf!~~em G_ullsQl MEHlS. MM~.m(Ps)'eh~1Iy). Mfi;;CP~:K) P:sychiaUJi (mn!~~,T .A~$[)!~!!!telPr·OOeS5Qr On!! 1i!'iilew CM! S~i!liOi'·C.~ns~lfIn~. M66S. OPM t!i.,Qntkln~,
MACP:a~chl(UK),

OrClile~ W~~" Mllng'.
Nh:;l;iO!a!i

.~~IE!. O~naLotlj !nsti~u~oo~1 ffi.c!'~ O ~OJO)lIT5~
COflSUltlafil.

mOPs¥(\jj (UK). FM.\IS, IFi.BIM, BllM IP.s:ic'hi81Jy

MBBS, MMec W~~~!ry).
GradlJiip {Fl~",.mDJherap~l

If'~yOO.la.1l')' .

!!)r 1'iIi!!!i!e~~~:lRal1!m~nl G_ullsn1 MBSS, MM~.m(Psydh~, '~rl!!\I [)fp (F'\i!.yc;Mo1_he~p)'~,
MRCPsych ~~IK)

IC:r;m3l1 W~i '!(ong ,l~~;l1e CQn~~il!rn
MiBB8. MMed ~iP~ydiI)

Dr JMp;ti SllIlglIIlC'nQrlw;11 A~"SQelale ooiull;iifilt C
MBI1IS,. MMe.d[P:s.p)

P:i.yehi.a!r:!JI

.

f':s~e;1;iallJy

.

P~ythi~liJ'

..

.

!:Ir Kw~nl·'!'lum·!!~ml
RagiEiln!r

Dr Tlirl P·el "'11!I,Lynne~~
~egl!Jtfa~ MBiBs, MMae (l'!5)'ch} ~hi:litnj .

Dr 'Teoh ~i ..!'"'~, !.:1tn~e
R~i:3!1'Bt

MEillBS. MM~d (.Pliytllf;itry)
F!!;i(l'Chintry

MalliS. MRCP~yOO (UK~
P~~LI')'

Oil' .Ang Ly"e PoliI" Aarro:n Head ,of Depslmtment Oonsultant: De'Parl!menl~ ofPsyctiiologlica'l:

Me:dT'Cr~ne

PriVate PhysJd.an Relations .office Tel: 6357 251 9 Fox: 6256 8053 Emoii.: gp@tfsh.com.sg
02

Dr IPill~m·ChCiI1il.ilIbv Regl~brillr
MB!BS, ClFO(cAw),.

Or cihllo IIi.:!I G1.!.ren ~egl!itmr

Dr 1!'rlmalhy e!:!l'll T
Regislf.Sl

MB[BS,

M~C~U!<J,

MMoo {PSt}
F!!;i(l'Chintry

MRC~~IJK}
F'"!l(li"t;Mfntry

M8BS, MMod(P~lfdI'I) P5ydlla1ry .

Ntr B, a54 yean~k1 marfred reacfter who, present;s with a' ,2ffl'Onrh nfetoJy·o.ffeeling tow in mood, poor cotloootmlion. redl.lood a,ppe.tile B:nd early waTt,ing atJ am in th~ moming. He had a fleW supervisor at work 'OOring the, la'S! term and' there fJad been Sl9vem~cilanges in his routf$lf;l~ His famIly mporlied Mist h@' has: bee.n Wi~dmiwn ancl not' mobVa~d in pe.rt.lcipat9.ln his USti8facliv;tie-s" He ,oonfirms illalt 00 h~ ,'a neduoecfenjQyment' ,of ,acti'llity ingener,a/. Due tor/J'e m{scFY 'fe.lt, he 'S1ometi1f'l't\'s reelS that llfe is not ~rtn fiVing. Ho~e'fler he dOes not ha've B'nJf intentiM to h,arm fiimseJt or take his Ufe'.

tC,ase 1

wad(

Mts G is' a SO'year old mamfJdaccountani who, gav:e birth to oorfirs" alWld, III .son,6 weeks ~go,. Po! tile fast :3 week£'1 she haS bee.A extremely le-afful a'l:lo':anX'IO.u,s, She feels Qompf.ele.ly miftmtJJe and is,:J'Sfticularjy wom'ed fOf ih$Wfj.lMJei'ng of her $011.Sh,e ~fs ,tiffU:J, is not concentmting well Bnd is nota,bfe ,in sle~' well. Si]" wants to' DB a goiXl.moths-r and sfruggres as leedbaG:k and' adv:~ from o.'!Jers around her m~ke.s her feeiUltfit's'he is not tfI capa1:)le' moine,. She, 'feeis' gul1W'for thffJ'kfng BiUiroes th,a'i sl1e' sIJ9U/rj' not flav:e pfannedto have a child, Hef,f'j'Usb.a:nd flas to walk ,and Mrs. G is. ,U,$Uia#Yat !llome afonewJ.tfl a' m.~idwho /'l'eJps with the nSUSBWOrJ(,

Case .2

I

-

We haveseen

how pariholo,gical it can Ibe wh.en one's mood is Ilow. It SUffiiOOS b) say ihart one's mood can also be pa~hO!l~gically IiIl!g:~l.However, II Celllll, und:erstancl~f 1tlis soyncls ocld as who dossa't want to be ha,[;lPY? During my Uiiip~o MTnneapQfisfor as!l:eep

Medicine

CQl1Jiferenoo,

Il,ohanced Il!Ipona rlIliOst Il!Iniqlll:elyd,eooratedllomaHy-owfilJed

restaurant tl1lats~rvedl lI1e most l1eavenly ,cr~bcai[·;,es,for breakfast On lhe !back o~ 1lhe men:u,lI1er,e was a wrilte IUlpronlile
owner

o,f ttMl: fl3'stalJllrant lrev~aling~at

I'llieJ

!llIJl,H€lrstrorrn bipdl'ar ,d'iioor,(j\Sir.
l

Wtl:iile li~lis very IPossib!h! Hlat the slycculent flaViours ,of the sayce Jenne crabca'kes cCI.lI:ldhalve been cll.lIe t,oll1e creativity ne possecss8csWhe.n his mood is: liliigi!hQr Uil!@l coo:il1tl'iuc. quaJIil~ne8S of the decor of 1he resta !lJralflt 'o!JJ€lS'Ome HrdlatiOIil of l!his e seIJrf~esreem,a SltO:nyfrom hIlS p8'5:l documented on '!he same said menu r~ve8!lledlhe d8ingers ,of the! IIllfilieSs... ThiS same person had once obtainedl ~l1eau~o:graiPllof his raNour,ill~ artiste on his arm. ,~mmecliaJtely, llie had gon.eto a rnuoo p,arloyr to' g;€t ~h€: autogra,ph 'fQ!i€fv·e:rand peffifla,liIen~l:Y 11mpl'!]nted wtl!€r€: J~was oliTginally signed .. I doubt i~~tl!€,liisk:sof tattooingl ali1d~lh€ repercussions o,f hai\l1tngthe taHoo' :stayed lin his mind fbrb:lo! longl a time oofm1Ellhed:ecision was made. Oh~ and did I m.ention lh,at this owneifwas also se·roingl~ne '9,yests !brook!r.ast lin his ba,~hrabe? Bipdlia r D~so:me,r can Ibe ·descrfbed as a speotJil!lm o~ disord:ers, DSM·lV-TR dlvidesU'le:m iiinilo Bipolilar ~ Diso:rde1r. Bipdl!ar U Disoucler and Oyclo~h'Ymic [j~lsCircle'rrefepen.ding on the ,severit~ QiulI1e manic· symptoms, Be·fore IIIrCfilfferenti~Jtebet'!Neen [he :3 ,di!a,gnQ.~H~S left me Ili;5tdown the diagn:os,tiCGl1i!~riaf:Or a IMJa~nicE::iPisodie: .• l 'The !patie,nt is lreported to inaVls a ,d,iiStiinctIperiod of abn.ormralllll and persistently ,e:l!evaled" e')!;!pansi\i!'eor irriitable :moocl lasting ,a~l€last 1IweEl:!k: and! any~hroo of ~he ro:Ii:OM'lilgSEl'l.1'ensy,mptoms imU1efoll:OMJingf aCHI!l1ym: ~PAI[)' 'GSf".

'fQlr'

• • • •

PI,easl!.uab~e alctJvlties~ ,exc,esslve ,involvement 'wiU, higlh potent~allfol!' p,ainnfLll~ons,e'qu,ences c ,Agitation (,Ps,ycho,mot,or) erlnerease ~n goa,~~dhrected'activity ~deas~f1ight of Oil' :subje,ctiveex'pe~ien,cle Ulat. t.ho'Wlghtsal'1eIraeing D'is,tra,cta'bi~~ty(iat.tentio'lliltoo easEly drawn .aw,a:yte ,tllrlIimIP()rt:ant or lrrelsvant e.x,tema'i 's:tilmUiU

• G,r,a,lIiIdi,o,sityor EnrfiJa,ted s,e~f..esteem • SI,e,ep~ decreas.ed need (f;ee'ls Fe st.ed iaRer3 hou rs~" • 'TaIka:tive. ma ra than WI sual or [press u re to, kee,P' taUlthllg'
~ addnr:Qn.~ n pa,tTi€n~s su,ffering~Qm ~if,polar I :may aliSo :repoiirl; sycMtlc symp:tom!S, which ar€' mostly mood congru~lfI~ Wi"H1tl1€'T~ p g,mndiosity.

----------------------------------------

"AN:IOY'ER.VIEW,iOf,

DEP.RESSION:

I

We diagn.osis of-a hypomalJlilC epT!sooe 'fiolllrJwsthl@) MV€H::I1!IIl€lrial except ~hat a • The dUf8,rtion ofU:le episedeis s!honer (alt leas:t4 days)

• Thereis no, 'mun.ctiona:llii mpaillTililent, • The patient cloe:s not r''eiport of ,a;ny psyCIil.Q,tlcsym,ptoms • He was not l10slpHalisedl
Therein liesthe diffe:rren:oo between 81 Bipol:ar I and Bipolar 111I Disor{jer whereby pa,Uentssufifeflingfmm e.x~perjiencedla Manic e:,pisode w;hile Bipolla r ~~sl!Jilife:rers a Hypomall'~iiO episode,
I

NXIETY
Bipollar 'IIhalve • • •

&
sfn.o,wedl iOOOO6tRd sdds ·of ,$OOGiahlnnWill1 G~. (DhliriteSe e1ihnicity!. tlil'lll" (fmvorted ~nd ,,~nrs; fmmlbO~trU1e uJ:lper aln:i:I ltm: leweiSf soeio;.;E!(wflI!emic status ~~:. hi!'ll'le.sl oodis of a,Slsi:)ciatiPJlWilh GrAQ.,
Liife~ime lprevali~n~.~ Q,U P,Bl1it l~isGir~er· IS 4.!%, I~~ge(l OM Ame;IfiOOrill',swdies.Womenalre 2' ~.a, Stirmes Il'[ltelY'l{lc 11:l~ affre~d tnarlili men, 'dn~e1to!f ag~ Ihas;ablfi dis1fil'>IJIr!iCln withr higrhest: pes'k ifil)Qt(:jeno~at , 5:lo 24 lleal'$ :fiIl;ilti ;a: se90;lild

We diagnosis, o~ Cydl)Qtl1ymi:C Disorder is given when a paltue,nt.Ihas S!uft:ered, fir"Omlboth! I'1 Y,Pormmniceipisodies,81s well as period:$. of ,cfys:thym ia~o:r a period of two, yearrs. withouf, .any' manic no:r (j',eprelssivel3ipisocles ,(alsper IJISM criterna). Trea1me,nt 'for a bi:polardi:oordler is typically with a r1I1OodslabiWiiser and~he MO mcst common'liy used are Ilillhilumand va,!:proate..Oiler :mea'icalio!1iS that can l;)eco!1'siidiereci are lanootrig~nie'Whichl !has l:Jeen~MVffl to, be ,e1l1cacioys.wr :bipdhaJ ,Q:epression as w~1I as olaiil2apirH3.031i1 ;rtIilIM.;psydhoticlihat ihas i('lotaii'llGd FIICIA approva'ii to be llIiSi€d to treat ;b,l,polar disOiro€!~. OOcasiof],a'llly, slee;pa.ilds liKe !benZ!ooiOUElipines can !be i!JJ:sed on a short term basis, to ensure glieep in p,atienrtswith !bipolar d iisoroe:r. Treatme:nt. a~ bipolar d1roo\rde,~ holisUc in nature ~hus apart from m.edicarUons~ psydho-~duc8Jtion of~he patient is essential is in ensl.I!ri:ng reoovIEMy".Psy,cl1J.o-educati:o.n in terms of ,rHsease symptomol'~y', relapse lreoognitio.n al1u:l insign,. all oontribYJle towardls lrecovery" 'fre<tllment ~,sall\50'ncd dir~ed only ~()'W.aimis~lhe paJtien:l.lbuiro, tt1eJamirly 8s\!Vell_ Stmng 'fa.mily SllIlpporl: illl terms o,f ensu ringl medica:~i,cn oompllanloo as well as detection of early rela\pse goes a long! way lin the long telim managemeililt, of the Ipatient

MliJs€le ~nsiQrn Fa~igl~edeasily OQneeJll!~ffI'.JjaJipoor
~es~Tess.,(!ill'

peaK a~45~o 5tlf ye·ars., 'Onset is rarely,-aft~rage
faic1.or for ~h.ed!evelopme:nt of Rania liOisor:de&:.

lri'i~e'~iirilty .1 'Slee,D' clistl:!mianoe'

!i:eyed up

Iii [story of dtViQliCeor se;parab'on has ooen i'de:ntifieliJ~s a risk

6~, ~nt ~

.10 ronal successl~td iousineiSs is tes'Umo.ny that Iniis.condiJtion is. well 1mare.ct HOVI.i'eve:r; theme re :s~i'lllillldicaJIions tnat !his
beha:v,Lolllr is sfi:!lllbeingl aft:ed:ed Iby ttl€' lllness aaru:l.f no~ Weilllcontrolled, i could: ImsllIl!t :in a ilf3pidl detelriora,tlolili,

$0, going ba,ek to ~he owner of ~he Minne:ap.o.ns rest:aur~nt ~hat make:s the most del tcious crabcakes, Ulefaet th:alt be isa'ble

Ci~n1'WXt- ~~eoowel ·Wojry oraffi(iety Cf:f tha~ is not due to, any ,~r.er medicall oJ psyol!i[1afflric diFlCfwer will qualify a Ipatie.nt for tti,~'sliil,Qnos:us GAb. oJ

3 or melle of, nffiese~·'$,ym;ptJi)m!smbr at lea!Sl 6 months in~he

Bothl GPJ[) and Panic i::lLso:ml~r l1!:a\le tm~u~ntJy oo-OO<!Tsted with ,other psydnialriUC 'oO:lilditions, 11nel.udln,g· Jmajor tI~Rressive ,diisorder! ,aysU,ymiia,and s'O_Gita'~ Ipho~ia .. e,f de:preSSli()nsh;o I!Ird be ~e'\l~:~d '~umin~l~tie ajS$eSSrlJlleM'I~ GlAD and P'anic l[)iso,rd.er,iitS tne oolildi~iMiS:> ale .of Sympltoms,

SF@UGHT
Dr IlY,IiIeUe T'E!QIlI

llIIn,€xpect€Jd panicaU:ack:s. A ;O\'mli:~~ PE~rigi~f(;~f. rnlen5Je f~arll1at. develops r>aipidly, pe~k (ZiJ ilrfte:[!sity :~nabol.l!lt1 0 mi'nutesand generailly ,d:oes nl:lt Ifo.t lahg.er tli1:an3C1 ·minutl€!s. Commotill symptoms e.qle~te[ncllld (ju rril1glapani~aMadkar~ palpit~~;olils, chest pain. b:ma,t1'1lessllless. 'swea~ingl, remblingl,gicldiness, pamflSl~hoota:s:.mali' 01 lo~ing 'CQn~roland fe-arof d!yflilQ". Pa~r:e,n~ withl Ipal1l~c ismder alsoe.x:pernence Ipersistent worry d abo!)!Jt f'oimf'e .a1i!Jlroks or liM iimplicaNi'onsloolnseq;yenoo's of the aHack, fhts ,mal}!!.Ie~d tti 'ago.mphob.ia or si,gnific,;lmt .beha:v,j:our ,afnang:es:due ta ~he oaJttaftks. Agor>aph.o:bja j:s anxiety about. being lin ~j:a~;s. C!r ~i~l!atip,n"Sfromwtlich escepe might Ibe d~mQJlJI~ ,emtialif;a~II1__g, .leadTngto'~liIOldan:oo. AgQmpMbic ,~,~ f~al1:~WpieallJ;' h)l'olv~ driaraGt.e!1i~1lt[r.:r~hJsters situati()ns ~h'at ,of ifl!~I'ude pl.J~lio ipjaQ~S;.OOinm in 8.croW'(l'antJitmveininihl rn a itnJji,
m~l!IlfI'I€lflllt,

Panlc Dis,order: is anol1er common anxiety ,d:fisomer, - ---- - --

higinly ca..mQ!ibid andl wors€:n~h:9 r.ml)gnoS!TS.. TlieJ1s_ s,~al~C1.I an illl:C!re8!sed risk ofsubstail'~:oo abl!llS€' ~.g.alooIi1QI !l1f ben:rod:i!azep'jln.e abruse) ll1at. must lbe,soreen.ecI f9J~ linCl!)~nts> of s!!ilicid~ sili1ould!IbeEl:1Iici~oo Si3l1xiety can lead loimwn.!.lsiva a

aels.
Itf:s, impQ~I'll!~ ~.o 'El',x"drillde olfgii3.ni'c Gau,s,es nf ·~he·;aJlxi~ty symptoms befol"e makin~1 ~he 'dfa:gnos~s '~f 'GAD, 61[ Panic

OOPEI,. hiY!perlil1j1f1o:[dism, li1ypo!:ruycaemMi allt! i:lI1IiJ'1 withdrawaili. Medica:~:6.ns· can also, e;Sluse. s-lb " '.' 'l'cI-"nri'lr"IJ5rt ;s'~1i ~ympoms. lhe' 'i m e(r~ti O§lS Inc!.l!l II;! ill l_ 1I",'" eo J _ ~. .. __~ _I. a;ntiormrlYyl:.hmics, hron:dnod'iilatprs .~ncl~h1YJl('f)'Jln~.

Disorder. Ihe:s,e inCli:ucleai1lTIy',mlmias·a:~nl'ii1a.

R.egJsttar

lliain 'trr 'car. GAO is ,n.~fa...rll~~d
Mooii:l~iile De:pal1mel'll!t In Tan Tock See:ng Hos.,pi.l'aL
per:sis~8:.l1t1!ItIFDtlgh1du~

MlB88,. MR.CPs'y<1h (UK}

Ce~r:W!iIent

e,f IPsycho[Q.gfcal M.edielne

.Dii1'T€oh [is a r€lgisuar withrU1e:Psych.cloglicalll

Illy a "'rree,.om~;ltnga nxieiw" WhiCh is, 1he (iJi3!Y.I iii: ,Gol'ltr;ast, p.aUflllllts witt~1fMl11::

lJis:o:mer e.xpeliem)e e;r;lisQ(jies, of anxiety with Imar~ in~.e~se symploms. Paf'li€:lJii:soroer an:~1 GAO ·:ean also ~~exist in wi1i~n panJc:attacks am expem:emeooirnr ,a. M~roundi af persi&le.nt an)(je,~. The rimant Na:lilJl'la1! Menfam He:al~h ,sUNS, (~OO34), in Siflgalpm're louflC! malt II~etime p[€li!'ale!ij€e IQJ (JAJ~ w:asa;~iJ~, Cu.rJ1~ntp~rewleo~ if~ (i,Q%. Fem ale ~ f1I1all~ama is 3.6'~1. P~B\[I~le~: ]li!.Gwea,se~ In ohlJe:r ·[IllClivii.':llif:aJS, e~Rool:allty 'those with 1!11~ or m.ON' ,oo-meribtd m€Jtlical !!.i!lr:ldili!:~ns;ThC:.15ie'wino

Reglstr.a:] MBBS, MMed ~P51icl1) DlljlBJl':brml!'Jt ·(}f PSyOhDtQgiiCl'll Ml1!Jdi~l1~

Dr 11ililh'Jtlii~l.eo.n

IDr leoh is a r~gistmr wi;~h

me lP:sychologkl'.Bl

Medicine Depamtment:in Tan T'Ook Sengi i1ospitsnl.

!:lad ex.pell1enQftd 0fi1e or m~re

Wi:wate:ning Ii~ ~venl9

'o~mbili a~Qnro~'medi~~tQn and psy,Gh~ilieir.:ll:~.

F.ir~t~tTrh~trceaili1lrl~pt.~Q'f' ~D

alil~l Pan'[c t~~6fJmet'

OOIilS!is~,

(l)f

il!!r

'S\$:Rls (~elediiVe' ~!ie:mt®.nin lrel:u,p'}a~e fflI1iJ~tiJMr)it;i~ ~ual!~:tjne, l f1~ryo~amTne. Jm:Mtalilll,e. ~ar{)~etil1l~' or e~-qnralopram aIre saf~ ,am;!'effefllYf! me~i!lialiQns ~r GAO al1ld Pa,llilifltf)i:soro:ec These sl1ik:'lul('jb~ ~tal1Bld ,;a~a 10000erdessdb,an used LJ1delilliElssiofill. Bef'l~~imle:pihe.5i in law doses lik.e dClflhazepa m or dia:Z€ipaml m:ag tbe gwen "fOrs.h.ooi term (!: weeKs) lreUef of anC!(1tety wl1iitle il1]~~:jil'lg ~SR,I'tfrlerap', andi in a r'Elgu!ar rartl't~rlhaln'~rmetle,dl ~~se re' pfe\l'~liIlt.lwl;:biGJun:cl alw~i:ety. JSifil1~t~ rel:al.>tatilo:n :antiss . m~l1l~g(7mern'l~e~llililiqui8,scaiil hellpJ'Pajj~nts m reduu:;e'o1eTw al1l~}e~y$:~mtP,tom~,. Cig.gl'liti\i'~ Bel]a\1ioural Th~fcarP:Y'(Oen ~Isalil ev;'dEl;li1ce~oase,di fO:mr) ,m pSi~f1ci1!heraRY' th:alt: helps ,paUenm 'l,Ind:ell1'St8'iild tll:e r~latio:n~hil!l ileiM,e~n- 111le.U91111J1s. feelings and soma.tt:c sEl:!I1saUolls.,anilil l1iiOW' tlJl(eir~anxiel¥ all1Iid pa.1i1icaltl;acocs aim ibeinigl, perpeiuSilmd. GBT also, ,a:ll:o'J,'{;S tpa~ie:nts develap lQopil1l:g1 sl~egies~e r,ed~ce and man:age their s,nl>:jety. Aller iflil!tat[ngtr-e~Umlent ~Ae p:a~iefllit inoui't:dilbe r~'Viewed ealitry s (wl'li11lin :2 w~eRs,~da.sgess iniHa(ll~eatment reSiPonise~o rni'!l!;lit0: 'ror ,any: S:1:d~'d~Cf$-Clf SRls, in parlii:cu]lar tlookingl OUit S f:a:r ain¥'~unoJ~:al iCl~a~IGI1Ii 'ih8Jt mary be associs!l.ed w,~~nSRI S ~~ge"lI1Le, ~(ieJilt .S!1o,UTd e_l<peirieIMiE! irmprovemel1l;t mn symplElms w~tb[iI1 34 WMI<S ofwatm,ent ,~~~lI'eatmelilt rl€sp,o.nse, is, defay~d: beyond .2 I'IIlOOth!S or there slreo:!her P'Slvo'l1iai(iii£ ~moftlrditieIl~ i~is a!Jiv,iisable. to lrefer U1ep.a~ient '~~1F'fllln1lJilrl1l:r pSY0'l1ialli1e ass8'S!Simenll. . P~~i'etl~ ~ffi'lJlfcr;ma~:ontt:e,aDels ,onl GlAD aMI Pan iic Disorder, as we'J II as lre:I~ItJ:orll ~\iircises 8illllistmss ma:nagemBrII~ ,t~hni~l!Jes,arre 'av:aila~11e8It hl~rP':fJVlMrlw.•patienU::ol"!JI!k. Pa:uel1lits ci1n ,a:I® be lrefeitrred':~ Ifamily Serv,fioo Centr!!ls '(lfSC)~or COIlJ!'IsSltiil1!19oandsJ;.lpport;, A :niSi .of F$le cain be fOulliOt a,t

sF(@1UGHT
!cfereli1~ratiof) in her funG~ifJ!nin,g.and'fr:Junfl tier tn a "'!Sanfused" s~'te: a't tJ!I~ /f8amr MRT stilJiroo. ,Jane wasaflitaffld~ .~ffdl'was tl~urnlJling iiI:t!O,u". 'vo.ires ma.kJn'g, ci1u~11m~ls' ,emut her. The voices -also tOid' frer{Q fffli 'fl~f$elf'l,IfIi(;J ,Ja:ll'lf!' ~s OO:nllif1aea. her fflGl'her 'Was: fJffih9 tQ .full! her. $'Ile, .~fslJ' ,~i'ew:ef1'tnat,:the was',ooRtWi:Nl7g her aRl.l ffl8t' Qth~ 'GOOldreadlJer mind.

PSY'CHOSIS
Jane 'is '8 ~fi,:¥&.ar;-ptd ~mate ,1rJ,e-nlai,B'8sls/ant', SJj~ has an sh,~oonf'efi!l t'hr3H1 un.dertfle skin, as welt as foo1pafn (rom Ihe. Q1defsist~twh,o W8,!Niltlmi.lte·d~o,rJle jnsritule,,(J)fMentat Mea~lfi -bites. She hasose.e1i "38Vf!'m1 pllysicfa'ffs, elver ths tam 1F 1Ye~fS~ ,l years ,afjo lor ~he.aM:g 1O(oiiJoo"; s..rUJ 11'(;1(1 beeJ;j' sepa'fatef1 .tli'0m her 'htJ,smntJ ~ 4, :t'm;m'hs, and had ,m'Q,.,.edin With ./ler LIEARNJING POINTS: PM"i:I:J~:S< a mO.n.th :ago" Her pa'1i-e:r:rls no,t/eda -fJfadool

fl.u Kwa:n ¥IJllrlxij1 is, a reg'llslilrar witlll IiIfI~Depalritme:Iil,t €If PSY'ohologtrcatll Medit;ine Ten lodk seng H~51~f,t~1. H~r 'areas ,of' interest 'arerpa'itiiaitirveea;m a,n~ !!ierr~!-,riG IPsychiartry~She has tpr'€iSiEln~:oo pa,per,s onea ~!llversUess, at: inte:m:atiQnalt oonfe[el1l:oos".

r~

nt

'~JUr in "ear lif~ sudh ar;l, tbeing pol~prM~rd,lo,vee a,tal ,'dtiSt~nee, de'oolvedl by a spmU'5e" thavifllrg,e n inifeGti~rn),,of Q,t
lea~

Prev.al:em.oo of .I]~itlllsleriLiam ~i'sofder is a(-oufld O.03'~. TrUl'! mea~n all::!!'!Dr' 'ons~t ,is 40 ye;a~. Nonljjzall~ ,(ielusi!ZlI'iJis,(J ,ta.in~,~liv:rng siitua:tiorlso tllJ!sit: OOu,'tol ene ~,OUnI dl;!ra:~ionl.

lEARINING

'P'OJNTS:
1,":,2.%' the ,g:eri'eral 'PQRu'lla,yQI'Ill~. of r;~lefiives'Gf: s~re:rSUli:s ii~,in;yreasecl

S(l~i~phrenh:illiii1iects

It:u.!tf;or 1ih'st.rdegrell
ID'10:~i.
Dr PMm!.(:lnern Tor

AlII

Regi9U<lf

liP-sy;) l!JepaJlm~I"orl?,~'chol~g,T~llMedr.Q1M
MS'SS, IIJFD(CAW), MM~

D,1I Phem.iCinem Tor i~s registr-af Willi th,e' CeRartmenl' a cf Psyoh.olo,g;ii03t~ M.,eclitin,.e in Jan 'T,~tlik Se!lg H·OS\pi~~I. tHe CUfl1Sntly Iholds s'Elveral othi:9r al~r.U'i);[n1lm'€Jlrts ,l1Iialt iI'lJ,aru.de lbeifl£ll th:e adjurruOO:. lectlJreir 'ltn:e Nanafl8'!t t:lrlllive;rSity of Sing-apo:re. '

'p'nset,ot:symptoITls;lfn males peaks a~ 11..:27 i~a($, :and in !~mail!e!lbetwee!1li 117·-.:37'yea{;SS. ,Sui;qlde is ~he, IlIl.umb€'rone!; ~iIiJ~te 'Clfpll'em~~ure de:ar1h amongst people' with schiil!o;phr~nia.w~ilh <a n ,esUma:ted 10% oompleti!1lQ sU!ucide! an!l!l .appr,oi!()imate!IIY 40to/~ ,allempt~l1IgsCllci~€':all: least Qn~~. -,

Masit do 'oat hai\f\e'goooinsig:l1~ intcl" fief]" p:a.~It1.o]og~1 e)(jpe~iiemzes •. ~nter-e$tingly~ desplite sigrnTifi:Ga1rtlt:G'ellusiol1l!S, munmi:oning lils; rJi0Jt m:ar~edly imp,ailreo:, as if the '(lelus'iGnsare ciroullili1soifibedt. .AS;s~s~imem~oil' l];Qmicida!~ Qr suicidal iQ,eation ls, el<~lfem:ely im:~GfI;antJn ~vaTLlJ~~i!'ig!r;latie:rt[s.witfil diaJu~U:ln~1 '~Too:~:e,r~ t

M.o,':NAGEMENl OF PSYCHOSIS

w.r

viww. mQys._9llY,sllJ"

'(1!TD

FlSLyeJir,6!Sis as 'exem~l'irfiied b,y ~he ease soenarios :above, mew' CORE FEATURESO:F SCHIZOPHRENIA ~NCL..UDE~ rJif),t t~e' e:lilct!l~.n~ere.cI Ib,yl1e tprimary pbysl:cua nas regulaJ1yaJS: plily:siMiI :allrme::nts, but I:rk~! imost' nth,s!: ctironie med'i)~1 .illnesses;, 'feIlGW' a course' of ~ealtme:n:t, ~hat: mrgets ~otl1l P,001tve''SymJ'tDm~ imm.e~il~ue ,and Ig!1i~.;te;nl1l eonge'rns. Altl1lElugll medirea~iQn lilS Au.dit~1¥ halh.:lilJrlila~h",I11!s,p.~ lIiIitUl!iiI~iy in 'lh:eUnfrd peWOlil. tills, majfi!lst~.yo:f' lmailmSr:lll, :ps~hia'tlii!SilSa,nd nlern:tal the\.altlil Cinal1l,9,es,il'l ~A'zn.ilgh~ oonstructlon :andi fermi. J~Ml'ilieDromil'lis, re,ailHl,ei"lil1,e fIIeed W man:age pSYQ~{jh'J!lJica'li and , l1!:izaJ'I"~ delusicM)S in whie~l.fbr e·):i:!;lffiJpJe" lilliE! p'a.liri!!ni~ :s0Ql'al needs ,olji.i'atI:SiAts ,81l: wen ~ lbene,~estl:e{~llIflaug'hts, tI, be arvailtabl~:ro $~hefci,or th'a~ , Broad,y~pea.kil1lg .• mrec(icaitii9n re:~'I1reJ1i1JmEl;r:liI: l~s)lt.h~s'ilS may of Ul~Y are lrn1il:,lel1l.~d by ~u~idefO:ooe~. ~: :d·M,(j,lSc! [n~!!I wpiQill1 or conl~lnrtiC!nal 11!t!:uror,eptiGs, andt 'elhsrng:es in an' ina M~dJual'S bel"l!iilMi!O'Uf ,or SClcial 13WIPica! r ~tec6.ndllel1~ra'tio:n .a.n~psY~!lI.o,ljcs (SiEle lfi"ig;Ui!'e'1). o fulncli:ollifigl. The lmf;l:ci1anism e~'adiIln fQ,ralllijpsych,Q.tics, has tadition:slll!y tJeen linked to ,dopamine ,rece:pteratilivity" bud rtlce!1irt ~eg81~~e $Yn1ptci'ms d~vellilpmelliltS have Iinll!eda1i1rUpsychiGtic ~mcacy ~o jrntmr ]111 -a-tlcliUon, 1i'U,eFemalj( be ne;g:aU\le f~at!.l!res, SUCl1ir'i!!S, llemffi,1FaJISl'lliliUers [ncludliRg se[i~rellifl an:d" NMDA. Tilre8Jtm:e.lU:t reslriQti\9fl1 of iU1;e ran.g,e~of~motillns(1:IlUlThti OF ,aiUfect) ,olllltGllDmiesifi terri'ils Of: m;an!ElQingHPosifive !~s:yth;otiiQ ng sy~ttomi$ ~rmilar afilliO.ng~t ma:st det:reas~' i3i,t:1.iTijly ro i:ni~iat8 rnf)ughrts allnd idl:eas atS IiSILed abOYeil a,ii:"8: generally :Stij~jps~chQti~, blilit. wNelielhey diler is i~nlheir ~i~e e,iOOt (p,avel1y G,fth.OlJgI~it}. p.r©fIle -~A,d 'possltlLeeffect en ne9ativ~ .s,ympIQm~. G!Qli1\MIjIi{ro:nal a1:ltlp.SY~h:Q:tl&S I'1NlIvetieern 'knOWi'l, io b'€: iaiEiOO~ated wiiitlleXlta pyrami:dIaI :5ii:d~ eMecfs (EF"$!E), fhdiudilll,gl AlWe is a 49-year-<1ilIO' /ismfial'l' 'Wlf1'~' was reoonlly :iOOn f4:f a ,a,Qut~ dY$toni:a~ drugl Wm:lurra:e.d Pa~~:nson iis'nl" tanjtve ,rfe'rrn{ltoiogiSl sRdwas told to f:ia11f1 no objreiir.re e;v(denae 'of ~rs:~f!llesial and: ~katlifi~Ti8. slf/n €J'sea'!je",Sb~ insist'S, Me) is pfagu'fid' with i~~s fOr lil'm' tasi '12 ,,¥eaFSi andOOln!iAlains ,r,),' s'kill' iltrUi' sp[~adrng, all o~r f1e,rttd:1d1. She is oonvjnG~ ftle iM' /is' ,~ W /]~.gs.$l1e sa:yS.

'I~

,AtypieaJl alll!~:PrtS,ycMOtil!es. 'i;~JI1(U~g:~ :1e:SSill,ssoaiafed W:u~n EF!S,Es balve been ,modated wiij'J m~tabiJltc sid'e effec{s,: irnG!uding wei9lhtsain ;aRd~lYSJIr,idaemia, ~yp:real antipsydn:rt!~cs [naVe ii!lsobeen repcrlE!d :to be! 'more effective in ~rea~!iI1e!Jlt Of
negaijv,El!·~Yclrrll;~ms. , , FIGURE 1: COMJvfONLY IJSEO ORAL
AINTIP'Sl'CHOTIC MEDICATION (TABLETS)

I[il'aUeJll~S ·Wh,S,1"iI1!r'V'e, requ,lire(!l· l~ro:l~(jnmed peribd:s ofl1l.c!mis:sio:n, TJ,!JI£ds :not unTi Ifte 1he n3habilita1ite1:'l ttl.aif [S J3ee'dedi in pnysiCally ,[noop.aeimtad ;platien~s, re:ce~'eli1ng'frem .2 'major tll'lIle'Ss,artd

REFERENC.ES
IEipidemiol~g!y o;¥~SGh1~phrel'ii;;-jI.EpicleOlll'1:el ReV' 1985i7'~1 05';26. 2.· MaG1i,l8 M. G.tl~tB<sman, II, ,.IMFtgen..,e:Nf:J9plde,.mioh,gIV ctfschizophm-.nia anQ 'the d~J;gn of linkage studi~5" lEur A~I ~syct1ia~~elin Neu.lr'o.ooj1i~'1 ;2;O(-aJ:11~'8'f. 3~ Munt.:JOIr!l)eliliISen P. Firs1:-admisli_h:m rSl,(es.anC: marital, 5ta~us of .sehiio!1,iphre,I'l'rcs.. Acta PS¥cl'1railr S~ru:ll . . ." 1. Eaton

foc:uses'offL a ,r;e1Um til fumltlon.

~

ve«.

TlriinuO'P£1r~i!1!reStelai!!:[n,~) {
Surpjfid~ {Dogmooil) Cili1il()~prom:eJZ~n~(larga!Clilll)

QilLetiaF,ii,Ule (S~roqqJe!) al~nza:pll1lle (ZyPfeXJ!i!i) Aml$ujlplrid~ (SQrian) MpipJa~olle {Ability) p<1lImpewlldofle{~ffiI'-eg~}

ro

~, ,A!I!~Mygh '~~ompil1le" wau;;; S!yml'nJE1lsise~: a_s: aoooverrrlti:ona'l[ aniliJ,p~y,chm]c. it 15·.gene\rall~ 'reg:ardeodl ali a.{OMrUll1nel mitre alYP:(ieSI 'Aelrlwlep1i!($l.:iue,k), IHS ~:ow!PN;)peRs,ty~O cause Elf'S!::. J~li:s. O'!i'!l'e¥er used far tFeaImel1l:t r;e.sii:stanischi2:o,~hr,e'Oi.adue h " r1skQ~ Jagi'ra,~:lI.lleGyro5i!S;. 'Olelspiie e'Vjd~ewu:::e~s!uggB5~t!g tnitl'Eir €linieal emCa~ tl1alll .o;thl;li~ arn'~r~rs,1t~h,01ie ag:eint:s.

:One. usel1ul·tQal ~n ~n-e maflliS'gemef!llt 1'01 p.B.1iel'lts witl1l ~S9,c1h!Dsis f~ Id!i!:ll1fifieai~:6:11'1 WKlat are l~rr10WJ1I as '~~pse ol sign'iliwitls'. TJ;j;BtS!8' ,are ·1he.symptOms ~ssb'rilla:md IN,liIfl early stages ~f a 1f~la,pile in eaeh Irnolvidl!la:lf, w,nich ma,y be ~h~symp~oms, W(~oont :;;lJtlne arn~sil!1~ the ,i'lllness, or .aiel1lu.ated vei'Sions. o~ :o,ffrtenthese relaiPse- ~rsnat!!lms mali be, pm~eded ·by p€:rf:OO!li ~f stress inlne pa!liel'ltfs :illife"or ~aar adll1ellelilce to trea~lIDe:nt. 'for a \i'a~iiety 'tllf ,reaoo!'ls. Eady iclenti,1licaUfm I!If a:n impreacl'trJg Imla,p'S€! will a:ll'Q,w'm:e '~reifiltin.gl ~l1ilys:tonan tJ!.! adjus,u metlitalU;),n 'and! en§.Ji;lg:~·O'l'e' l~atieiWlI, 81nd his, 1amTIiy, withl UnieaTm of a\!ioi~:Wig ,admissioJI W' h.os~i~a:llwhicl1, brings Wittl'l il~f1naJlcial 'aile] emcmonal, CoStfiOrlh~ pajff:ent.arl.~1'Ga~giiv.ejrS. TIIi'L'1lt'8 .a,~, vari~ussr1!1JI roes ,m inm®ailiton available fiOrlil1e treatrt~el'lit 0f nI"/ti"''''~. ~~ _J11 '¥"a . 1:1'" s"'F ""'r b*"~i. _I'I~. """-, 1",,,,,\11 "'-[I lil't'" _""Ii·'""" ·"h·..h::kl "II '1 _.... IU.... _U!·'IiII'Y .._l~ _III~'i',- _f\f! r'li..... :Ld"'~'" n _ _~'. IP~tie:li1~.,nclu,iL1ing·o:nlline rMOlJlrtes 'for Ill'aiflem ~~~al Soilage: l , o,ff 1?:syd1iatris,t ·web.site) as w.ell as Iclihicall pmctltoo. guideil'in!€,s w;oViiltled bylle Mfnistry'of H,ealtl1l ,~s9Jl~G~l1feflia CPG ls ipen,difmg. pul1ili~l~Om. . .
!,_

1'981:;76(2~:i1 C-6~

L

,4.. Miles '~n~!iifLo~Js ~wttili~pO:sin!ltOI :SI;ii ta,ij!ei.al ',ffi'rj!i~. ,J Nerv M_ent Dis 19n; 164(4):2:31.-4'6. $. BJ. :IS\. 1[:Ie:!lJiS1t(f),nala:nd hared. psy€h{j.ticd~S'(;j.m:e.i •. KapTan & S~QOOkIS Sjm,G~slsof .PsYdhiaty. 9thi ed, 5·:f1.:z0 s S~: ,Ch~9 KT,@J1jde
{!dl

rep.

f~'YCh;a:.tliJ' t:001 RIlV;iiSi[Qij

7. M Klim.;r, IN~are~h.CommlJlrrli~y c.af,e or Ipatients w1lmschTzophr-er'lia;: ilie'fiOle',of the~ prim-ar.l1 be.alth~re ~eam. Br ,J:o,Um I 'G.el1ll'P.raCtiCe 1900~riil ;46(4G5)
8. S, S!mh'!I, DesMtaing an ilI:~pical AI1I!U,Pc~et'loUc; Receptor Bind'il!Jg a rJdi:ts Role inP9ItMp:h.ysio.IQgiV I~lrima ~ ,e_a_.r·e Com;pan]o.n. J Qli!JPsy~htaJtry :l20Q3~5 [su;Pcpl 3) ~9m13 9. Wahllbeck K ,et. :81..Evitden~e d' IQ1lJi2:ap]fiI:e's'ie{fectN,enes5 ·in sChizo:phl:-enia: ·as~~lemlltr:c ~~v'i~'8nd me,t:a~8naly_sls pf ra--d~ li~-:Cli i,~"'lSkll J ~\S"""I"a~"" 19190 ·~L _._~ - _ JLOm_~ .!ill'" • ("lm_ 1"'- L .. y. -.-.Sl' Jl15D~7)·999 ..

1O. Ptiltsch~I~Walz Ge:t al Tl1le eHiecl: ef fanli1y in~e.NE!t!li1.iOJ1S ,on reilla!pseancl me:ta~~IIl_alll~is.'Sc~il~"Opl1rlr ·2Q.(H~'27(1 )(r~2 19:uU.

rel'lo~p;~1aIil!l:alion in st!":l'irzo,phrenla--<a

11. f111,Ul1liQ. e'elilbl.1l1;jlto.fill, IP.! K~!.IiI~elS, E. ,.eJL.a:I(20mfu) PS9~hGI€I~iea] 1reaJ~mernts.iil1 5GMOphr-eni.a; 5,., II. Meta Ms1ry&es 1!If rarl~omrz.e~ ooiltroillecl ~Tialsr;ofsochllil ~lItii]lls tmiF!l]rlg and OOgJIi~fve relll1!diaUon.. Psy'dYGiI:Ogical Meclieii1le, 51, 78:3-79

:Eil'e'·

enau;:magEu,at~eJnrta.cll1e"HlIgeJ"O'lreaJlIn~lJirt. lhes:e .il1i:dliudeU1~ !Jsll!lal j~alb<IBitsII,mS.as, wen as ~rooisp9!lfSlbiB 'l:abie:ts.whllZh titissG:11ve rapia1ly! liquidl mediea~r,on wnli:dh ~s dispenseid 'in :C!raps andl injectable. dejpo;t 'V'e1'S.iaas.dtne 3l'1tipsy(lhotics which: rna.y' b"e giWl'! alt rl'l~.ei'Va[s of b~ween 2: W'eg~ -arid 6 weeks 1~f:1:9.li.Ire2.). Oml met!ie:ations hoWevera:re ·stiill used as 1Iif~i II !rle 'ueatmenlt qptions,. FIGLI:RE .2: FORMULATIONS, AVAILABl.E AINTI PSYC H errc S (,N'O NwT AlB LoftS),
~nzaprn8 1oIa.'l::ipotid'Ol

:~n<Blzh::litio:n ttJr dil'€lreAl meeh:anismiSi IZI! ;a.etiGI:"I, ~ntip;~olhotics n'OW 8~ailab!I:e, in '!I:aneus form,ulatlclIilS in ,o;U;d~r ~

FOR

Wlltlen lrJl!!me'd ea n1'y. psy,cl'il:o.sis,~ inclu~illl9 scll~QlIP.hre!'lia 1'ir16i!ve, fa\lfiumj:}TeJ"prnlgr:vGiSi~s., pro,\fided.ij1~8'JIT§is ,()ng()rn~a.llga9~8me:IM tgelwe>en dpewr alll.d,lpatlePll1.. Th;e Ealil(y: Psycl'fliOsis.llnte:ll'ler!liti~[n Programme o;i.e!~d by the~nSluh!~eof Mental He:al~h b~rrillg$ togetltleral .compf~ne:niiSi"'I,I"B' IOWa n"forRalmenlt !Of pS:.ydlosis in II!;:: y.fDung; f;a!orrftaf~di b~' ~ fiet~rk ,dti ps,ydIiatriSlm,S;(\1!Srel ,m:~U11!E!ge(SamJ' m,eA~al] h,~llth Irlro;[es~fo·~r~ls, Ctlaj Ilell1ges f'o,r ~heWe;a!troll'3nt o;f patiei1l~ hi me rcommunlily IncllJl:l1le: aRp,I!e,h~li1si.erl\S ,aoolJ[ risk .'a'fild lffiafiLa:gemenIl. ot'lmjcamllT'a:r s)!flmlZ®ms. In variQl1!iScO!.IIJlilbies .~ucl1 as- the UK. PelAjents~i~h menJtaI h~aUh lIIn€'-se, incll1d'unr9 .:itClllli~phl'3nia, ,(X::dilililJi)El ita IbI!ll manage.dr ~ tbeil~ (~ps. slll.~raoU1l:edr blt~h:e 10Da:11 Goml1l1lJ1nity mental lf1ea1:~htea..m~'WiUlfi1lvG[Jra~le oUltoo.lJ!fl"es. Th;-e.se, [ndtIcles !'lifil]l11!i~j,n.g '~ne'Sti~ma associamd with f~pea~dly sJiekhJtQ, 'f)ut mel'nltal h,ealUr sef"liliioos" .andl l'I~nmaTiI5ies, ,s,l!iieil 1IIIIneSSe!)ij~ilUte oommu!'1iily.

1,2.'Marris P .. l!toycU:l, VOOO~iO![Nil~1rel1~jlittaW:llill in psyeli1i!El!try~III re.eval:~ujj~ior:li. AU,sttN l,J .psycrffa~Jl. 2004 Jl;!I;3e(7')'l499'-A·

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Df tlabeeblilll

eciM.L!I~anl .

Ralii'lnalll

i'l1sP!Jridonu

P1po~ial!iM (Pi;poflliU, lWefi>[!fIn1l"1iJ.:.'1)l
,decanoa~

palmit.atfl

~qOipi~-ol~

MB.Bs;.J!ini,"ed.~f'$y~). Gr,ad Cl~ ~$~rollt!erapyJ~ M.ROPr.ych (UK) .. i]llpBimiro"B!'ll pr1F's~l'tDDto.glml ~!!i~iCiflli:

(Fliaai'JXOl_)
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F!upenlh!i>:t;i1

decllnootol d~no.aMl 1000n~!a~

Of' Hal:uootiul ~hml~n is :a 'QGl:nslll~['It; wittlI1the·lr;)epa rtm,€)flt ~f Ps,.ct:i.Qr.GgjG@'~ Me:,~jcm8 in fa Ii} 1:(I,*k aeli1:!'J'H~pi~l, mrElmiJ,er lof ~he RQJilI ®O:II,eg~Qif Psychiatli:sts ,ttl K); IHe i'tas a·s;pecial intJe!le,s;tin psyo'lin:dnem,py.

andl [s a

-l..FI=!~,~G!1Ie: ..

H~to,pem!oIIO<ec~!lOQ!~

.AipJ.lrI. fr-am moo!if~rtiQl1Is,

pa.tients Wi~h lfils~~O'S!ushave,· OOeR I!:n:own to Itlel1le:lilt· from fl~yChdliQgical asWe.llai~ s~ciall ~II,!P.POf!: in tlTh~earn mlJlliliil'f.• flU.~se ~irru~N·e:ntiClI1iScan b~ ~s Simpi;e· as. a s!issi~.n ispent -e.*pl!iifniing "llll Ipatieili1~ tlisfarnily' oo~ m O,i tf .'~ymp oms or _. 9,IilOSIS,. Gf ·ri:)·mf s an. . __elll.ges .• cella,__ -, ,.. _.ene . d cRail! .IS '·~I expElGled ~ta!11ng m~I~I:i~n . The . SGci[8!1 -,aspect Of ~~~:~nl .c:anniOt ib~' over em plYij:s:l!oodas loss pflll1lOlfon. ~s~Qially ifn the i!:iUia'l:stages ,of U'lEliI[ness,ca n mean Jte Loss Of '\iVatk, _ ara,bUy ,to, !:mrrr~lete :itchool (as, nr{);t~d abuv:e. sob~o,~tu-enia in€id~nee peaks, .e8~1:Y 11'11 Reh8Ihn~~ionin lire).. ma'tor meJ'l!lal iIIlness iiiS a- m~or oo.nsi~ef;li!Itiiol'l ~S)peciailly lOr

~he

wi~

C

tll' 1ianPei Un; Ll!'nlilE\!l!e Registrar M.1;l~. [;,Ul'led ~1F'SyCh) Cepa:ne!lfIlleof,f?&~t~b!llcal Me~clne

Dr LYll1l'letle"1itiilli1 f,B1SI regislrrarwilh tile Oepa:mn:ent ~rPsyel'1o~gicar Me(jieiFle ir11 Tan Tell!!:. Sengi H~s,~il.al afII;dW81S awarded mia' NRF'~MOH Hre~lIDeareResearofl ,SohoTars:I'1'1~'(Master (if Clinicaf rrwestigi!1iti:Gi1) In 2010. SheMs a S\~eCi~llme:reSl in

mseam.

..

13
I

PAINtUSrORIJER
This dliiSOrdierpres/Elntswitb ac;l!roliiTiC: preoccupatiOii! witI'm pal,n irn ollie 'or more. areas, Howe,wr:, no r!!.llnde~yingpatho:rogy can be' fOund orlille pa3n iiiS WUlJclged be '~HSj~;lITO,porttonelJte to tothre UImje:I1I¥lrng pa~holagy. :~~calJlcSi€S, ignifica.nt. distress andl s im,pairnnenlt G'fful[lotionJng irn fle pail.ienJ~ Slll1Ld o~oo~ morel comillOnly in women.

1. Areas of C,oflflicl
The pati€:trlt. m1al' lii!ave11l1proibleml [oonflmct] in Ilhis !if€: U1at r[iS.

'fhlesomatoforml diiso:ifd'€-ifS, m a group o.f ps;y.chjaitr:T:cd'~soiid€:rs~1ilI wtlich the: pa!U>erd. a pr€sermtswith a :myria.dof clinicailly significant Iphysicall sYrlllP,t.oms~!n,llt: cannot: bemully e.xp]a:tned by a. known medica:11 oondiUonalfter ap,PrlOlpriate jnlve~ii'tig8Jl!lon. Nevel1neless, the!ooma.ti!O oom~llaintsa re·s:eve:r,e eno!.l!ghoo cause consicleral:iil~e emotiona'l! clriiS;~Jle:s:s and rmayeven ni:sult in fmpa.iinment of social or QcclJllpa~iofi!:alflJl'ncliQlilrng. Th.el' olen paise a dlilalleng;€l b)~he !(r~a~inglmmilky physician. 1iher€l: is evidence theit '~he SYf1l1P,10mS, IinlrJed to psyohologiic8'llra.~:o"s. These pSllti:ents ar~ :I[lotfeigningllneir symptoms ..Thfrsis in are: contrast: tCl'wact~tiiOuso'tsord:eir 'or mal'inge~iing wlii:ere D1ere!is ,tonscicl!.JI,$ jpf'OCiuction of sYimptoms. . Thle Diagnostic and! S~~trsH:ca1 Mam.!lalll fOf Menltal Disorders categ.ory o,f soma~fbrmr disorders. TIMse are: (I)SM-IV~lIR) r:eoognizes 'five, distifll:ot IdT:sord!e;rn under jhe -

IIi1'PrOCIHIONIDRI.ASIS
In hypoctmndlfJl!a'5j:s, there is 81 preoccupation 'Wi~h~he:feaJ 'Qf' I1liaving,oI Ule Ibelief~halt one Ihas, a se~ious diseaoo basedl 'ani UiliIll' patient's ImisintEliirpr.€if.a!tto:n lof bOOil'l,y symp:lol'iliiS.1ihlf:s p.reQooup9Jhlon pefSis.fsd:>esp:ite appwp.ria:te iffi.ed irnd evalua~ron andi rea!ss:l!.!mn.oo. n mI!JS[ las~ iro:r :morellan siix miOnlliis ·;3fi!;di calJlS!E: signllfiiMn[ ,d'fiStreisS impair ful1u:I!l'oningl. or •

callisingi the s,mptoms .. This, oonniot ledlto, rindecisio:rl. The trealmenrt apJ,l,lliOaJon oyld beta hell!p him:com,e to a decision. w The COIl1Hict r~r'\ll:oo$ved when ~lhepatient makes a, choice and! siarrts to cailly 'out 1111'S; deGisio:n. :~1IlI discussion other o,pticm:s may 00 e:xpXoredl IITkl! plI!lt!i'ng :~t'1eissue asio;!! un a morie a,ppm~pl'ia.mijme withl ImlSlJI'lilllil1Q reli€if trami ~ne symptoms. It. liiS ne h:m,~er a 'oQniOiotwhlEma decisio.n is made, m course the 'lliecision may be wron.gl tiUHlI weg;,o, 'O!ili~O ,ano~er decision raU1BJ tla n mmain ilila n Irndl:-l:ofis1jiV€l: l[col1llfll'ficl:] mod/e, He call1r seek advieemrom'3pp,ropl',iat,e SCUll roes. There may Ib,emultip:lie con~lic~s, .

.2. O:rgan language
[anatomical metaplii.olt] ~:me .suol1l·,oammon 'SOI1~re$S,i:ons
'0.111

P~~i:ent.s may

e.xp.ress

themselves

in or'Q=:m languagle

SOrMATllZATION CQrNVERSION

IDr:ISQ'R'D'ER D~S'ORDER

PA~N DISORDER
HYIPOCHC,'ND'RIA.SIIS

the ·p.altient wi~11I ody dy,smorp:hic disorder j's concemecl.flat b oral .oody part. There ls eXiOOssiveoonoorf! and pf~QaCUIpatiOf!ll With, ian imaginoo orbivial phrys:l:calanomaly.. Most often ~~ inillolVfis are~s lik:ettli~ lor-east, jJi3',nita/lia,hiai[r, nose,or part. (11 th:efra:oo..
ll'iliElll8:is somi€Uniing wlffing wUIh~lhe shaip€' or appealranc€'

B,DDV DVSMOIRPHIC

D'IISOIRIDIER.

her own two 'fee,t:~,~ my job gives me headache o:~ the shflVers"or Ihave been :kiiiel\!.ed ~n tl1e IMek, therefOr,e tlii:e ·baclo:acl1~e;. fhleapproach!inQowoc11ng Wflsw~!JJ[\::Ilbe~oreword: the e\:!:pr'essilJfIIIn the p(ilj~[entls mind in a, way ~e~ willirelieve i !ilitsfrustraUonafs weil]ras h.elp l1im arrive ,a,l somecompromiss.
I :~

"' my mbl1her~in~l:a,w iSi31 pain illlt'ltl>e liI:sck", ~sl1i€ call1lnot. stan:(jl
i.

are

BO'DlY DYSMO'RP'HIC D~SORDER

3. .otj~·ar·;on'
hID assessing fie pa:tien1:we do tiThe uSliI'aWhtst:o'Y takingl witllir fOGtls, on ~ne ~3ck~ro!.l!nd of th:E! iIImessl, IJi,Wvio!IJs,illness, e)(fpel1iiellilceand psycJhia~i!t I medfrcallllhis~Dry, ,llnaJU'€ll1!flpting~o unCQveJ IRroba~l:e causes th:ereSlIl'Elgienerally severn cEn.lsa~uVie falotors, UMat V\loulcllJ:e ih:=lpmui'11 ooll1sid:er andlex:plo:re ..Several 11.0. 'of ~herOO! C31J1>SaWmfac!tors malY co.,sxislt inl,he paJtlernt it i!l1limporllant~o reme.'mbeli'~arnotlirTng IM~~emiwi~tmut2!J reasoii'l.. Manry pe;Ople h'aiV€i ttll~ir idea,s jfi)!ijOOa'bouitWhat should ibe done, wh8it should no:t bedone and! how Sihou1:d things be done. All these may seem erroneous butHle;y impact on U'U'1l .patient~s!hinking, 'foolrl11g, and Ibehi13iv:1Clur" Therefor~ it :jlSimpoM:ant. to find '!he r'€a~cm: to chaJlIlge tln,el tI1inkingl,t(l re~ame it~oai more logical 'ihought,a bel~r wary 'Of ttl inking and hellieili. Thie ,d!esiroo' !outcome ~:Sro chan-gaUllEl paijeniL M.is lirmpera,tiveto' lisile,n Closelly tOI the pal~rient,as hie recalls wnatt ii'S natlforgolten or lrepressoo by him. Listen~o why hesay.s it.~he way he says. it: all U18,Se: 'w1111l pro~idl:-l: clues; hie is reilllin,g his diagnosis. Milton IEmicMOI'1lstat.ed ~h8Jt hel your ~ symp~omfs.i:s:the soh,)IItio:n IFor ~sto takeillNiay the $ymp1.ows .. would bEl< tolak,e ~ai\j ·~Itlesolution. To do ·510we iil.eea:~o oompensate wirth som.ething berl.er rill l1e~um. Ofte.nth.€1 symptom!s Ule patient ohose al~hoygliil rmalladapl1've'was a giOodl I.deal U1em tllJllt\iV'Gl] I:dl see:mto, have>G'~ullJV€ld Us I.ilJSe:]UlfilieSs Vli\h.en paUent.oomesmo,r help.. F~w the Ipatient ~t would be D,eltter to have sym,p;tom/s as!rlo]!.l!IUon·tliian 1'10, symp~Q.mfs ata'llL As someOI1l€! PiJlil:s lit. ~Haliltosi's f'~lb8:tl.er·lhan no, bre8l~h at. al!,~ thus paUents: hiave dyswnlcUomil:11 idealS that l1i:eedl lO be !changedl.. If we can cha:nge. ·Ul:e :tde.a we ·,ean clilangietlle: liIl'ness, Ina n:utsh,ellll, getl!Tnga,t 'Where the idea ,o.uiginral~edandrefril.mingl it 1~1'iII;:a1 new ~d:ap~iv·e,acooiP~e'bll.e W81'!1 will b.ring abol.l!lt tlii:e cure:. Jo'tl\:l' mat we IMvEHo, PI!J~ 'ol..l!~ell,ies in the ;pati€:nt's shoes8rm1 l.mders,t'and: wliliat 1hety will say and .aooept.lh1e cau'iXlltivefaotorn LQ oonsider ar,€i:
l

In ad\C!itionto~he ahl)'lIe,tl1i€IW8amM'oatiher drfagniOsestor patients whoS€ s.ymptomsd:o not flJl'I!~'11 criteJia~orlhea'bQiVe th:€i fi,ve di~Q.meiffi,. These are 'una iiffer~nti8Iledsoma~ofcmm disorder Bnd 'somlat:ofol!1il1disorder not. QtheMI:se specified'.

Pa~f:enlt.s .~ r~ sometimes suboolflscb:u.IIs!ltir mOtivated to have symptoms" What i:S, ~emlf!ooMseoo.ndaJY 9:ain. Havingl tlii:e symptoms Ihelp. 'tosdJiVe~he Rroblemdlut th€CIi'El' aresT,diEl€rl~ 8~Sin o0ll1ver:s~:anpar811Y~i's. The solulttolfl~hell ehcse '!:o,soWve llil,e IP~robiIem seems to be less~ea~r:fullthan the a"ctual problemr. What .W'e 'Ileed to do isfiin.d a oo~~er solu~T:Qnmrlhe:m wi1i1ealt tM s8:m.e~ime a~I!IOW'inQlThe pailitent''ltos81V€' 'faoo
H •.

rl1lis. fSi1l1chronica:iIld fructlJl!alilllg disorder with !rts or;!isl9~ oo,fol'El ~'I1eage of 3~. The pati,ent usually Ihas r,€Wlirel1lita nd mliJ'liH:ple somatic oomplail1!ts. To, cliagnosetl1is di:sorder, I)ere must loe a mIiilimlJlm ,of eight defJnedl symptoms i[n tlil,€ (jiifMm'nt bodily sys:tem'Smrom~he DSMIV list. T.hieS ilTestincludes pain, gastroin1lestinal,se;x,:yal andl IPiSeuQ'o ..neuro1.\:lgica'llsymp:toms. TI1:ept:lrysiIcalaM Illa:Dor~,tory investigaliQl1scanno1: expillain!ihe symptoms med'iica'II:Y.

SOM.AT~ZAT~rONO'ISORDER

OfI.'en s.ymptorms are~he re;lull~ ,of past expelienc9. Symptoms must slart fliomsomewh,ere.TIi1'epast 'e)(][Jefltelm'..1€l !be so can powerf'ild l1at tliie symp:tomss~aril: imm;ecliately., er i~cOIll'I~dl
gensitise th!9 suboOl11sciOlJllS mind to '~lhe El:Vein~90 'tl1lil:l~ the: paUernt lreaots~:o sUlbseq;uent 51JmilarQitrcums~.ances. The ldea and feelingl.s IMel: been im~r!3n~e<J imp,lfin~ed ~o :s'eit !.!I,pf!.l!itl!Jre oj' symptoMs. liM alpprl)ath to IIi&Q!v,jJilg.~is 'wouild be to r~,frame. th.e fix.ed idea ..Oftlilinl rl:tImay l1equir'€'some (egressiorn w'Oiik.
L

41,Pas' Experience

5. Iden tifica:li,Q'fJ
~ nrer~sijflglly,

C,ONVERS,ION DISORDER
rl1liS

someone wl1omHle-y have

p9J!;iients may
8.

s,tfClngemotional aua.d1menuo.

l1Iave symp'l:oms

similaJr to

key f>eatureof thfs (j'i;sor:di€lris the pres8n!oo Q.ffalt least

'Oille

symp!:om ,of deftcit off sen'sol)' 'Of volu n~ary :motorfu notion to $illlgg:est illJ nell!rolog~iicalor 'g:eneral medical condlitio.n .. Howev~r, clinical exa min13lt[on alildappropr:f,ate ililiV€lstigalif:oiils do flat e:xp:l!aintne symptoms muIIy. Exampi:e:s;of oO:rlVer:s!lo:1Il disorder iiin,o!:llIde weaknesslparralysis of a -!:fmb 'OJ me· en~rre Ibod:Y, im paired \!iij,s:Ton r h,earin:g and loss I distlJlimanloo off o slens8J1lLon.

otklnllhissCimeonecQl1Jld 00 ,tj;y;ing 101'" ,d~c~alsed. A pa~ienrt could idientify w,jit]fls,nd su1iferth:e samlEl 'Qougtnr, che1S:t piiTn or ,g!asltric~ paJnettS U~iel clecea:s~cI 'iffalher. Hefe~lls: th.e ineed:~o kiEl'€p tl1l;8 1m:lalli~rl~hT,p,.Treatmiel1lit wo'uld be fOrt1!le paiHent~o r'€ooGIijlise th,e, idel[lti~ta~ilo:n issues. and to detadnmr'OmWnem:. The 1~~S'ti~sthe l~as:1an_d :$!~loll!lldl ~!Ei.N: UH!'I'e. Thle idea is to be IilEltEipW!;e ood! memories a:nd~o letll1e bad syimptoms [110 g a,way .. Tlnepa~jenrt s1i1Qutdnot !be bound !b'ythe deceased's prob!I~e'ms,tol 110101 en to' tfue memo(;iJe$,.

lB. SI8',If:'p'f./."isbmen,t
PUI'il,j:51hme!n~ .offen meted! .oUl:ias '81 mlemor wr'Ong:doingi~, f'5i 2!jfl;erWt'li[l(in, the sla~e ifs wiiped clean. l1he paUerd. tendi$. to' get
115

-,1

TI\e t'relll~meAt Qutoome sh~tilittl be ~e help ~he B8;~iJe.~~s ope betl.er wirth their symptoms and miniml:2.€ dl5!rup~i.Qns in ether c ..aspe:(JIj$.of' flair lW,ve£tBrirt!!Jfall"l:!lI ,"egJ;i!~a.w~isU5to tbe 1amily pl1ly<$Iici'an is helpful irlll'lat it all0ws rQ'~lI1e mainteA8J1JOO of the ~llIeraLlp€tlltiG r€1~tioll1ship, as well 03lSJ .prcfvJfdes a 111 p~ofliliJnilyfor o mas®€!S!llm€'ii1t 8ind fEjrassur.anc€:. Tff!;;Iltment VitJ>1!tl!sntidepressentsor am'l(iG.lytics ~heyICl, tle started if Milere is a denniite I.J! nderJiyfnm psychia~fic disorder S!.I!!OFl as an ifll1xiety or mfiOO dis.oirHe!r. PS¥i,";l1Iiia,~iri€:QcmsuHa,tl.ons s!hauld be obtal,n,edlif I1El'Il"e .any d.oubt. P's,ychia'~iiic inteNsnlJons is l,[lclude ph81Fm800U'lemP'lt. oog~ltive ~ha~i60~r'(iiI'I:~herapy andeduc8i~i.on(iil11a:~pr~aGhes"

SF(@lLlGHT

€;I'ilrn.i~alAlP,rno:f On!!! 'JihIT:elW C~iI~ Sel:l~orG'OWW!!::!ir\!

MB8:S. DI?M (l.ioneO:l'l~, MRCP!i~
FRCilllSl/lch

(~:.n<):.

~l;.I.K) • F'AMS. I?I3M, B:BM

~lep.<!i'fmef'ltor [i;'J>~h~ogl~~ Med:i~ne'

CHiinPcaI NFlf010ng lfIe :s~mptGms a~ a resllIit (jf gll!litL P~'()!JiI:e rid Of il~3fi1.d find rol'gll(!1,eriElcS:s.
!;.IrS!1!!

nrie!W el'Hilli, is a sJ!AiG;r oo,nsultant wilth '~t'lelDepartm.ent of P.syoMh!lgieal Mediciine Tn ran TeckSe:ng

p~in to, ~~uni$~r~J1:emse,II\iie:S. cloGlOr has £0 M:lJI!'I U'J:i!!p,atien~sm:iI ~ I;J~ 1Me QUlilt, gfill: The

~espilta'I,.

lil!le a posJi"'.~WJnatiGSj~ggestion" The "It'eatmell1t WGuid be loremG\I€: th.e S!J19§l:€ls:tien. 'Whra:~can be PlIt. Tn one's mind ean be r!!I'JIiIiQ'wd. $t8~emel'l~S made b'M lII(.}tirtGf5 ~n h~lve gr€at im pact on a wa~jef1lt's,1 ilfEl" e.;. ~~61i:1 wil:ll'le\jllel~\lVa11l; Slgairt. WyQ~ l1lalVle Siil( mOJi'!IU'I;& live" 1ifle~M!.J!g,rlt i<s ~1'I'l3:t jlf a pernon G~n lilil'e willt11he er:rQ(!eOIlJS i(j:ea ,h~ can al~G Ii~,e wilffuoyt. it. -rhe al.~pro~cl1 i~ .~I.:) tq Mnrm'1ile the idea.

lhis h~~j;I~niS wAen, :Ei.nidea, iSfi)!'Joo ,and 1m~rhii!ilid on 1t:fe m i'n(! thalt ti:eoomrres se;l;f~g~r1i\!!!;~IUn~.'I11e p;3.tient reSPQrl~st€l tI1e i(le~

7. .S.uggestio'l'J

Wl:liate\iliewUJi~ap~roa~h taire!'lr, the key pili 1IJt. to r:emember is
~~ese ScJ1I'l11lp:l'G)ms~ ~l1cH'O<nalslQmatr:G F

,any ulldriaJ!ilnosed ~f'ga ni'e disease tl1a~ OOJ(lldaiS'oo!JJlI~£mr Qf'3 :Si8rioL:ls ru:sdi.ca:1 TlIII"i€lS5, ~fom fh~ rned!itlOeh:;:g'al JXlint of vielll!l nus important t.o lrelltthe pa:Uefit kJ'low tll1.!a:tnisllepo!ilieid :s~IfI1Ip'~oms are· ltalk.en SE!Iliously and. a pll1ysieal e:<811l1.inatiolll s~Qula ~~eGOinch.Jl~cI WilHElfl ~te isifiirst assessled aM wliiefl ob,vicus new S~rI'!ptoms arl:SiIEl.
SlllM~,t'Omi's €<!in ot:€IJI~ il"dhe €cmlti9)(l

.~I!I tJl:e eut r

lih Ja~lI~iII.~SjhQlIfI' 'li:Iihail'r'wa~
Ais<S.ooilllre GOIiISLJltRliI~

tM.BBS, NlMled ~PsYCh}

'~p!anJllient or P~~h04ogica~ Meweine

~WItlF€lSilllmemtwe must. a:lll'eblimakifiS ,tIi[e patient ill walki[ll~ pnarmaooir;lceia with mediealtCl~ given tor~t81€l various S:)fmpto ms. Theme is ;8 n:eefj .(I it[e eautioli;Js whe~o~einog' inlil'a.si~e!ifiv:eS1igalillnS:Q:~ p.w!:u:;e<I'yre~.Or'l,e ,of the ~Q:mpJieail!O'!1TS is i:a~f(lgen i 0 da~g:~ fiinm. ~h~sica'1111 i nv:asi~etests. PEHient~ wiU'isomalOfoi'ln disarde~0f1.en m,aintai n '~tlqt their Stymp10ms are(Jl(le t!:l a 1).t1pioal OOIi1~Ji.ary.n is, ul"fll1elt1~'[j11 Q'i~mi'Ss thJeir s:ymrsioms;a;s ,oBing' ~a.1II tl1fe minG tD Tfl
ri •

(l~Ii!.II!1re

des;pitle evielen.oo

fij

ttl@!

~.rilJl~~alS:inlilh IJhtaliwal is an Asgooiia,tB~onsl]~tant. w,irl!Wb iJ®'p:arl!mentof 1~~ho!0J9ical Medicine in TiiiUi1 Teck 89:1'19 tt(;® Hospita'i. t-Ie dfcdh iis poGt·gra.dllJi:i~e reS€'·8l!cl\1, thesis In P,o:s:l:-$~Jioke !ilr€pr€ssiof'l 8 f'I:dil~ ~l"ese!.~~lythe Pmgr:am D'1 rec~ow flr)r~he HIV psychra~~ !Se!¥io.e.

A g ClOd relationst:iip ooitlNeellil ~he '&lsa~ieJ1l~ [ld ~he famiJy l;)t1ry'Sioi:an eS'SJ!;!ntiat to' long'·1eF'ffl rnanageme:nt a is This ea ~ M iiitof:iieved by 3cil:IiIGwlte(fg,lilllg th.€ pa1Ifi8'n~.'~ difuf:i~lJIlltls:swi'lfIll1ii€llr u rr18:xpliaTnetj ",hysica'i sympkl'ms :flilui mraintaJn'rllla a high d~!1J!ree Q,. eropatllJi'g; toward Ute ~alient. Ps~m~~~1lJ aJtioEl serws liGl2d.ucaJlrellhe p.a~jer::l:~Ol"l the nn~s Qf~neflhysicsJ 8f'1,i;jps~n:o.l.o§11eal sYn::l~t.omli to e rel~v:al1lt liifelevenrts 3!\1d'OOrltea(il.

116
'I

"'D'OCTOR, I'M GETTIN,GFOR,GETFUL
NO"WA,DAYS. DO , ,HA VE D'EIJAENTIA,?"I
:og W1Thli~n d.eflned" by m:gliler mental: Jfuilf'i!o.J,iens nd ~roLleSS€s," :Sy the wO.m ~hig:heF'.,we mean billainmul'ltdi:ons other 1ha,n is a 1- - _!'iI1.,.JII~ ~,-' ",~if:o·~,t _!II _ '.ilcU!1llij~ b ...A - ,-.-.•:. _~mL_ rung, __r -.;;:j·,---I mQV'eT~~~"I-ri "'!.rI";! sen",a~1 o.fl ~ t'1'e, "";-:, ~ """"y. Th~-c~ re s eve~"" '''':-1-03'' - -, ore og.milvec. t'llJ- --liCl,' ·il- - ro- ex_mp_e= ll!a~t:t I,e -e __~are . c. ,-""'I Yom~H1S _n~l!.!Iag_, m9:mol'Yt decisimH"l1l:aj{ijn91, a:DCfuisi~iol1ll.ofL :fKnowledgealr:td skil[[;s and anllhmetic calculaiHon. On€) Ibecomes cog'lfIitivel~t imp.ailw€td wheFtiIperlQrm,anoe ~1lI1 ene.er dmor-e,ofttmese domain,s is su'Cli£iil8111 tilalllly llo,wer than what wo'uld bee)(Jpected~or edltlcalional lev'e\ll.
l

Mr Urn, IS at 67 -yea r-old male who haSSI posi,Uve fa mily' hilstory o~dementia. He is a re~ired uni'Versl ty lectu rer who pieked up klrex tradin.g d luingl his early years of retirement a nddi:d qil!l'j,te weill f n it H[s Write reports ·tnat .2 yealfSa.go, I1e li:lega n to hav,e difficulty recallJng! ~e na mes of hT,sex<olIea,g:ues. Sllllbseq,l!Jen1Iy there WBf:eoCGaJS!Tons where' he COliI:dnot remember I'1fs
r

~'ASLE 31-------------_
to his emerll aCDount. onee,

nas tbeen misp:I'ax~i liIis personai items but wi II event~!1i11y find l11e ·edil_er a ,day or Mo. Sl1ere lso noticed tI1'a~ he hss ng m become m.oraanxiOlJliS lately. which is not in his petsonalily. Otherwise he has no ma,J~r diff[clJl~l:es· wli1tl his daily routines.
he
j

user ID and password

he leven furg,o.t hi's P~IN mJmberwnen he was at~e

AlM mach1'ne. lateliy

one's a,ge 811l:G

Mr lim denies thalt wlilat. his w,ife describes is iii problem for 11 as he believes it tOI be a paril, of nO.m:lalllagingl. After all, si milar irn ~hings have also iha~pened to lhis wire c,ne€!O:r twioe Ibefore!

ni91hilsin'or-der ~o wor,k,'extra Inardta, p,wve himool~ WIOFttn:y of me promotion, Unfortlrnately, his girlrliiend of 1'01 rs broke up yea 'lMlth Ihim Ibecauseof his gmtell rrlg scheduJe. He was, sad initially but quiokly IMlclihimsel1 ooge,u,eras he clecid'ed to mak£! his wM( a prIority, H~ mOOod wasaTrigl1t and had no problems flallingl asleepl .. However, Ihe often slept very Httlea~ tie eheseto slee,p Itate and wake up early in order to do more w<:Ilik. ~l1Irthelast. 2 week-'S, he fo!Und that an many occasions, he WQuldforge1 ~hin.gsas soon as he nea ~ th"em, He 'had' tOI ask fOr the ~nfCim1ation to be lrepeated and take extra ,effort to com mi~'them to memory, Which werBeffectiv,e fOJ him. Olh.erwis6, he :manageClto maintaj n hrs usual worK peoomnance. However, he has gone 'to see his GP as he'ove meard: SOWle' collea,gues talkingl about memory loss being a s,ymplom: of dementia.

Mr Tan Lsal 37"'year-old mare' Wiha has ,~l!IiStbeM :p~omoted ttl a manageriat posiu'ol1l.k5 aresul~~ he has been keeping late .

G~ft 11

IMl~mory p:mtil:ems du€:~o norona'll agfngtypically' talretl"l€! 'fQmI1 of dimculity in remem'[')er:fng cont€:nt:, :mth'€r~ha nltl1e conter,x'tlof fie memory. For exantple, an elde~liy person ma,y h8iv,e dif¥l:clJJllmy remembering the name ,of an aCq]u<aintance he met 1 week: agol, but is 'lilkemyto be able~Q lremember U'le,ciritumsltanloos.sl.l!®undin.g tl1,eir mee~i:ng .•This :may ibe, oontrilt)utingto IMir Uml's diffh::ulti:es..Haweve:r. ~ltIees!timatedl pr€~morhld level 101' fu nction]liIg for Mr Lim,i:;· lhighl f:llliid l1liisCUI1lCel1lit ,di!nJ1ollllties· [ndic8lteal sigflliifllaant. dedJilne. lit.is il'Hooly~lhathe Ihasthe amnes:i!c form of Mild Coglnil~iivellmpairrn,ent (Me II). 10 to 15% o~ pooplewlth Mel progress to Ajzlll'E!imer's disease 9.nnuaJliy. Alnxiet:y and mood: :symptoms are commonly assooiated witlill Mel as well.

fn ,o:rderf.1 iiortm neW mem9~e:s\ nfOffiflGlIti0l11 miUSl be- encod~ed by ~"m1s!fomningii:tto a IUsab1:e fbrm!,storecl ln~o Io"lllg~term memory thai! .IS riIlQS::t]¥ ,olJltside o~ oon[ldio!JJs ii3JWar'i3:.]1.9"SS, ~ndl accessed andl r€!tliie'~oo wtruen lrequijredl. Henoo~one mlJl,s,tb~ atlIelO" ion tfl)~he inf-ormauol'l1 8l\'lidfl)e,QlliaterJl:t jln tbel ooI1lISQi!OLlS.alWSl'llillllleSS oolfrme i~ leamedand r-emembewedl. Mr is Tain Inas wf~l1 ~!in~jQn and registralfiom bl.l!f 11101 'dmiiOt!l~yw~~nll1e Ireta1]1 OfiinilTormaHon ,once sitoredliinro memory. SuCh QiiffiJGJlllijes :are lOOm-mOI]:'fiII peOI1Ie' wl\iolam II:m(j:e.~Cirirlg stffl'ss, o'Ver-='iimd,. lor ar,a facedl with too mUlloh col1l11peitif'!l,gl im~mJlation. Ufes~yle md,dTIi;'c~u!'Jl1I!Sitill 'e;nhsilloo Gq~ll[lswould be' hell:p'wlin S!l!.ImC85Jes,.
l

I~:!" AIiiIQiIlVe Poh, ,Aaran IHead Clf lDeparlmumt

C~n~!!;!]lal'lt MBB.$, MMeCi (P.~hiaitry), MRCP ~U,l<) lDeparlrrnent or lP:sychO~j)giea~ Mediaine,

CASE,2
Madam Yan.g Ii's a 46-'year-Old lady wh,Q' liison lreg !!.lIar foll,ow-up withe psychialliSt, S;newent~o see a GP 1.0' ask for medications as IsM :hadi mi,ssed her late~ appoi ntment wi~h t~e psych i:atrist. She claimsll1at I1erd!i;agnos~s is 'depression but makes it l\m0Wl':l1 tl'1at: she needs DJazepam mast u~gently as s'l1e is,absolutely l!Jnab:le-.toslsep without til \Nlnile, a~tempting, to tactw lIy G'eny ber request, the G1Pfinds out tha,t she has had several epfsOOes where she could not remember events kl ~he Iprior 12110uf peoriod. Sh,e reported 1hatshe was ul'ltiilbleto relflE!mber despite cues given by omer :peopTe to try a.ncJ~rigger her Imeal!1 8Ilen[S,. The' GP 'lrites to do a s:rmple te-stot recalll of 3 items .after 5 m~n:IlIJtes, but she says, she can't do, U bec:aUS6 of Uletask. i,s 'too hard fQr her ..
I

Dr Aa;roJll.~n~llis curwenUy COI)5ilJlt<ll'n~;.all1d r:lead .of ~he Depan1!mell1l.of P.s;yOh.ological Medncine linTan Todk 8ell1g fi'aspiilal. He hiotdssE!veral 'ohlr :appo:intmel1i~s~la~:nclude bein,Qla member oflhe Sowh lE~t Asia Nel.llroeo:gni~ive Research and Training Consoriti'um, ~he Natronal i Menta! Heallihl Clilll[ca~ Adviisony C.om!1l1~titee~all1dthe Nationa! ~nnenija Netwmk, II1i~egrated Care SUbgfOUP., Mlnistry .of He~jth. Singapore. ~]tAaron is al.s.o,t1e ASSOCiate Program DirooOOf l(Tan l:ock Sengi r1o:spi~:a~) or the Na~i.onal Psychiatry P~ogram ~11i NatrQnal f Hea~lhcafeGIFoup and Olin~calllemllJrerflor Psychlatnyal ~he'Y,cmg loo !LiiniMedr:ca~S:chodl, I~latron<a'l niversity .of Singaporle. U

.,.!
.

.

11!),~ChIO!!'!I,

Lo!!i 'G,we:n
MRCPs,!(cil(UK}

:ReQistrar
lMIBEl.l3. MRCJP~UK}.
-

IlReC~IIII'Gi]v!1Iif6lifflatiO:lfl can be'Cue(i [OJ n,on=(ili.lecl. JMladaJ'il1 ii!ngll~as episooes Mamnesiiiaifor V whtch re,caJl cannot be improved d€'S!ite~he .j1Jrelvlsion bf oues ThIs is a ':.'nOWIil Silde.elecf. G~ dIlron,iic becnzod!i~pilil.e: .usel". M II'S p()s~llImab~dlH1at~h'soccurs, betGause beniZ.e.~iI8iZepiness!.ll r;lpr-ess'St~e 3a~d4'SirGW-'wave slee',fP' during whtlfih m.er1lrtOries ar-e oOl11solidateC. Patients with ... """,-~ •• """ :.",.", 1m"'" .. L\.w" "".1. ... 1 --fiI;lj'" ~o '1'1~."" :-m·emj,-:·· p.'-I'+"'-1i'" '" "'""'....... a' ·~I!.e:: h·-ic"II·.··· 11--61',"''''"' nn-r ;..#-rt.. ... ""l ....... Ingl !1"""" ...... "P ... ",.. l~ III av"" ..' O!'Y wl.' .... Ui.. ·"'·n·-,-· i:....... y_~~n ","'" " m ~""iL"i'" !!IlLY 'lfP. _"".Y m !\'to ... ",,0. 0;::110 '" ... ,,,,~t

.

.._---

IDep,nlment(If '~S)f(ho~ogica~ ~dldi!1el M

mfamlfl13IHarr..

.

..

.

..

Dr Clumll.:al (;·wen liiS a R,egiS!trnr wUh~e: D~p:llirlm~!ltl of P$yQholognoo~ Me:d'ioine lifil nmTock Sefl!g f;!o'S,iprrtall. he W~S ,~waJr:d~dliMe S Crlniclan·l.eii!tde~hip [nl ~11:~rchgratit mr FY.2i01.1if'Or ~ A Pitgt Study onihe LQng·l'~mnP$'lI'cl1i~~c, P$yct1o!i(;l~l~l!i!!nd N~yrob~havror~~ O:L;!~iXlm~ A;k:F Tlf'l;til.lrn~tlc 8r~in Injury"! ~rl;dn!1!~~ ~p~oi~1 ~n~r,~t [nl N~urop~ychf~JI_nc: l$Or,~'rs. d

.A growi'ngfi,f'l,d' in Ophthalmol,ogy'
The eyes are~hecelll1re

_'STHETIC
-

ofaUml:!_tion,oUherface, lHowever, ag~~ij dh~u'l~)esai~liIlI1d 111eey,es:cSiWI lead 'to a less.r.:li,p:peaili1l1fgand n.1;tIiirganjllool<~ which malY ibe,ameinalll!e to, oorreG,~io!1!J by aes~i1etic eye surgery. ~ HG Eye Ilnli$Ut",te @ TaJI TO(lk; Seng HOl$pillalJl Oculopillas,tic: Stll~;oons halw' g.lUIili8JredeoniS,fidena'ole oollectill,l€l e'o!:p&rienee in 'I!hilig €,mergingl fi€!l'~ andi are !ncireasing:~y being called 'upo:n by pa~ilents to !manage ehanges i~fillrn(eJu"eyebW,M, eyelids and miG,fiate, lrestoring a youl;l1wl ,appearane,e and

cleimn.aJt.ochaJlasis" winiChil'reCluen~l:v co-e~i,slS Tine .. nomtrla:]] ayelbfiow pa:8ii~l;(Jn slholJl'l!dl n'fs,t all 'I!h@

l~1ebr~w

prosis

IS

,oftem

con~u:5ed

w,~1111

oonfio;enoe.

superior otlbi~alluim for males and! sllightly abo'!,!',eit il'Qrwem:ales. Mill!CI degrees CilI1I !be, ,eleva~ecl w,i~n Bo:to~ :T:njectiolilist.o ~he lbrwow depressors.; Mooeratero! severe 'eases r-equire 'endosoo,pic ey,e;brow Iliifl;h:l.m beil1ea:~h th:El' haTrHne,.

EYE IS,AGS,
-

Eye bajgis can lbe ,cfye to aoyerS'lll

elf lh,erronow~I!1Ig tal.ll.ISeS6

'OrbJitalfat prdapse can be improved wlth 100000F bliepha:wp:l:as.ty' liIls]n:g. hidden~uturl6)lessocmjunc~ii\lal incisiol1llS {Fig 1} .. Fluidl F,€-:s:l'Oonls are: areas of 'llI'l!1idaccumlj'llalljonallDng~he and/or I'ii,est ~herapy (spon~e~hermopI8!Sty). low'®'recyellTdstl1la!t are. maillag~d wiUTh1iI'uid~sall:ll"\\5'stii'iQtion

fl'05is can be ~del'1l11Uflved easily by' ton::I1l:~ight iIIumin:a,tion 'of~he. eomeate ebseeve the dis,fa,l1liOe

PTOSlS

-Prom]I'1l,€nt o~bIcularf:s (leurl'i mUisld!ies.l€-ad to, bulgingl of '1tIe: lower ey,e:Uclsw.hen smiling. ]t can be el'SctJ,vely rela:;!l.€'d wil~h Bo~.oxmnjectir:ms(Fig 2). Saggingl u~p€:lr eyelids {demnaltochalasis,) andl a ur-ed, sleepy look. ,or eyebrows (ey!€brow iP,ttlsiS) may r€l!llult. in problems :such ss bllDtC'JkedvisEon

between the, uppere;yej'iid :margin mnd theoomoollllUgiht refil~x ,(nOml1all: 3-4mm,). filosissurgery is achie'V>Eld via an e:<ltern~1approaeh througih th:e tlilepharop:r:a~ty skin iin:of,$!i\.:ln. ,(lfigl 11), or i\I,iia a IPosterior rOCII.lilte (1ra1'1l1B-conjunc,tiv]lIUy) w'JJ~1tl lila' cutaneQus incision.

WR~INKLIES,AROUND 'THIE:EYES
Tille aging skin around the eye often mal1llrfeslts as pigmenil. cl1a.nges and! wlnnkloo. A gooclsk!f:ri care regime TisImcomm.elrldoo~ aniCl~his csn be augm.€n't€d with chemic8~11 peels, Botox !injections, delllm8:11 'fI'lile:rs and lasers, all emc.e~oased P~1)"cedures. ,gJng A change;s a:roundttl~ '~y€lS are dis:tur1t~Hllg problems thaJtealil be .8;ddressed b'y~he IO,oulop:~alSticSl!l rgeo,rl who is in aUI1i lque; position. witliil tihe training a nd I<nowl:edge OfU~i€:€fye,rosp€ciijcally manage tm€<s€

SfQuGHT
ID,~. 'tilp ,CIIiIIl;fl Cli!iBW

concerns, (Fig S)

Hei1l.<llnglhe INitiG D~''f\p Is one ofrew d100t0rl; whowe~e aWaJrd!ed OliMo.!~",r Mtnls~ I"iI Heam'll ,HMDPsQl\olorrshliP. He, Il'lIliiileill ,al: !he IUiliMeliS!ty o.,f'Ci!1c,innaJliian!l:l·1i!1.e University oil' Ca1ifomlil, L.05; Ai'lgete~ - two p:rcrnlnelf'rt centires I'IllEye IPI'<l$1jc i:'lllClR'ecciil;!;(rl.lctl'J,ileSullIe:ry. !-if! publiShll'~' wkte,I:1I'31nd has e.xpe:IIi1~n0B in, IltbBi runotiona:l ,ana ()as;m~~tc tre·almlll1l or' eyelf.l:ll' millital tlJrl!:1lamillll!8ildis€!EisIlS. f:{e is i8J1S!!)a review~r ror ~11e , Ame~i&!1 Jou~na! O'rOp'llthalmotogy'a:!"Id a" '~r1imed tralMIr and! GupeJvisor for OCl.!lo;plasrues adJ,ra~ed $l,Ir9~1 tra'lnir'lg,O!!Owellas.a· OOUf$'l;! In~!!'IUcJ,w at .~'h;e Ame'rican A,eadelFlll' ofOpliUha~m~cgy A:nnual Me!Mllng. Or 'l'r,p i~ recenuyapl>Ointe.Cl· :aJ~U1e S!ec,1iionECllil.a.r of the A'5iai~Paclr»cregiWl iIOr Ul.e Or~it 8.
o.o'Iilop~astiics sLlib~piilciJ;il~ to[ fn~ Asia~P[;ldiltc,Jlm.ul'1al,aJ O.pliJlI1l&'1moiagy (APJo)..

lim ~eoonstruc:tiveIEye IEye lnlO!liIiu~e.'fo Owloplas!iG-~,""ice,
A.i!lsthillOC

Senior 'Conwll~1 ,&. iHie:ad, OCiI.!1opl~s;tiI~, iN HH~E,ye linsli!uhl, @ '~n Tio~_ S~n.g Hospital 1ME!8S(S1>ore), MMe:d(Qplllih){S'pof,e), FRCS(Ed~n}, FCS(HK,}. fAJMSCOphHl)
lP~s,tio Sur:glllJl', CI3i~aract sur'(Jelry

II):rE43!lill'lWI1 Goilil

Cl:lnsly'llam MEtes, MRCOph,tih ~iLondolFl)', MMer;ll(Ophll1), OeiLil!OJlll'il:S~{ls,.Ca~aract ,andGllne.raH OptdJ'Ia1r1i!oJog,)"
Dr Gon I~ 11 Oonsl1~l'1~ lr! IN!fiG EyE! IIniSmllll13 @' TTIliI"i i8JrJltl13nle'fllcllr ofltJe oClllroplas~ics S€lrvJoo ...Mall' oompH~!~ nis, fElilllMr;sh~p al ~1lB' ~ Ci~l1ic. ROCihe~!er MN. he ha~ r~Ymed wi1!h >alnrn1er~t tn $u~gery for Orbllal!Yllnono, <lind OcYlof.fcla~pl<!.~IIC) sl!!r;ge~'. He hail b!!lerl in'!lllecl bMh ~grOilally and! 1ntemalionally 10 participate ~n meetill;Q5 OJ'Ithiese IrJpJOS.

1[l,rEilU!genie (;Qilwl<im Dr ILltewe:[I~1iI Le.l!:
M8BB.

Po!1i! 'W,ein!1~
Mf/Jled (OplllJh)1

M RCSE;d,

C~nSu~~!lt. M'SES, MRCSl(Ed),. MMed {Opl1t1n,1
€iFljjlopla~1ic5:, ~tlra:~ ilIiiul.GelilE!ml (l'phtl:latmo~gy Or Lee, CMSun~an.t in, NH.& E1fe liils,1:IiIJ.ll~ @: TrS&i recerillry, ,cQmpl~d ai y,eaf"ilongi teIIOWSJ:l1PIn SeOUl ui\idJerU1e esteem:etl Pro~'es.sor IKiml 'y'oon IDu.ct<at Sl;lmSting MIld'i~I'·~el'1t€lr •.arkl h~~NI,sub.:;p€:(:iatty irlllllt€iS~ bl OCL!il'oplas1 iCs .. A m~mbe:r ofltll;'~ralini!:l9 &lldioc1illiialli oommllle€lt, nil is ,also ac!MIQy in.VOi!l€id :In,~e OfiMhatmol~y re.sld'en~ I'r~ogfilmrlile,He' MS'alsoPles,e;n!ed OCI,I~opJa;SJjc p~peJs O!illotema~~al (:o.nfe~~$.
c

OculoplO!lOtlcs, Ca!ar-acl ,.uld GenlNalOphltlaJrrnblogy Dr Eugenie I!'ohis. an AS$ociateConsulltanii with N riG Eye ~l'1$lih.!te,@ilTS;H;, She wa$,a~vaJrdecl a rFlH~o:n§ored fe'IO,'!'iI'Shtpand ni~rul!Y ~elu~n:ed t(rQm aJ 1'2-mO.lYlh ion.g' O!CUl'Oplat5lic-s,Oi'bitaH al'l<ll.Ml'IeX.aillFell~f1ip p-l'oglrl:imme in~denaide" $ou~1ii A~s,b!ia,. IlInaer'titie mentorshlp m~emalioii1ally reiilMn,aij
OCi!Jl(]p~astic. Oribita! a:n:iJ laorimal S.Ulrg:eon. IPrQJessof ID~!,u~sh

~~Wa~ ~~I Ar;;

~s bEiilr:agl arl.olflJ;ie' p

p:rogramme in the Singapo:re P~I~hn'lC"M<l!nclheslw Qua~lYA.55!UFaIlCS' Committ.ee. .

Llnivers!i!.y wllabolaUV!!l,.s!h.e

~

G!)f'~' IF!l!]IJ~W Qr JUm:lllllfg~8d~ate OP'(orfu1111Jr.\i amQ~een' .apP'Ql!'It~ O!*i ii!I m;e;mbJl~ allt1e M~!ty ii!!nd MorhL

me

or

lNfAI·
Many par~renfs etJme 110 tJi,e: ENT eli nie wlilh blocked crose dUBt'Q s1!rucw~al! c~h;nmi~les hich 1may be G9ngIB,m~.a1 or w ~t-ttauma1iq;. (SQmm~n Ipatl4i:lIOQlY iroJl:udes S€Wfe', def.ilvmHy GFU'ie: nas(il! .~p1.um" rrs ~iirlg of the in~~ma'il nasal ",alive (uJ;lJ1!er latera'il C<llrlill!a!ileslj,~ ~~clille n~, ~nd: piQSiiiS mftl1,e na's:al ,tf;p.:. rI1eS'! ,a~illormi~ieSi area'$SQciated witl1il extem!9JI: tilefQrmities, wlillich aM' li.Irn's~!1l,hU~l. '~n Q'ur ()1~f'I'i!Si ~heSJurg~el1il w,n~,JexaIl!'lJln;e Y'Gtilli'no:se 'ilfl ,i1ll!,laJiIin order t<J cJe:tenll1 rn.e ths :C(If,~(lt diagn.Qsis. Surgical'·oGli(ceetion ,t!:d acquil!lS.dr dekir:mity aif1l'lS.·~000sbJre' 1e nQS>9 bact 'It! t::Inrm~TI~allil(tl1ltli5[nclutleslJh.e e~Jte:!;llal·app€laraneB.. Upon llleCliu.est ~h:e: U by' gsrlitent, 'fl.!l1h:er enl'iaJI~em,ent o~"th;e e:xt~msf~·apJmi~u;8,nce Uli;e'nese earn be IJIm:le~lIielt1 at~hesSime '~Tme, ,~f . -. ~

FU NCTIO AL RH I OP LA STY

AESTHETIC

We ,a'l~ 6n;er'SYf:gery
n,o"S!'il,11l1:arrtJlWing Q,f

R1--I:INOPLASTV

u~~,\~1 r

to

(1';Qrmc:tor :impr6I!Je ool1l.genital~ nSS3JICeWll1jT1iUes. lihis, maly range' ;~m
~fp, r~d.l.lilil'lipn of rJ;O$.1,ril s~e, anIJ' ,tenQl1ihen~n,Q qf

me nose.

increasing tih"e l'Ierght Bf me

WhliSiaUs~acmry'l'85uJIl; fl"l'Q1Jil1 poo;ViaJliJ!S e05Jmett~ Imil1l.oiplBS~Y elsewh€llSe • Flat l11,ose II .BulocH:JS ril'as-aJ tip
I.

• Na'Sal dfI[~tal h,!lilmp • Short, nese wiUm€'Xposed f'l.ostl'iiils • Wide ffasajll~a.se/largiE! n;l)s;ti'iI$ II Plait n:a.saIUp

IINOIS!iQN
TWI~tS usually Ipeliormei'j Irnsjdelhe nos~nls:with no exte;ma~~ is scars. Occa!5iilOn~li'l:III'y J[n~hesevere C8'se:S;,SUlino~si:olilin made i~11Ii Ule boptolTll of ~t1e,-nose! (~r~ns;"QCiJ'u'!me!lilal)' Ibetween~he liI,ostrils, nUis in.ciisi'o n usuaTliy heals veryweJI wli~MI;IFl"any obviol.)!,s visible slCaralfldis o,f;!elill!ilsedll fill ou ~oos:meth:: cases. I. The :llenglhl o~UU~l'iloseeqlliJals b) 1/3 ()~ the length of th;emaoe 'lhe lroot o~ttnle nose 7 to, 11 mml highl 1111 The .mtio Q~ lil!asalle.ng~hand.~i:p'heig:h,t 3 to 1. The lnasaltip 90 to:100'degre:€s ~r-omlihe u,pp.er IiIPs Iii. The nostl1TllS Ik!iiclml:Y Ibean shap:EldiiUld 'Q[)lique!lry,ouienltat:ed.

SURGERY

To, correct a ,d'eliOrnledi sepal! m a septopl6tsty liis lynderilakeili1. Where tile 11il8Siili,sl3ipfuml li:s 'grossllY (fe:l'ormed, ,{Ifjgl 11,advance )
~.€JCh~l1IiqIJHil'S are

I. I.

U3

employed to compiJ~mely mconslruc~i:Qn 111!,€) septum stmlig'lh:t (Fig 2).,'

.

1'3

BEFORE YOUR SUIRGIERY
Fig 1: Grossly ,deformed n.a'sal sept:lJffl, sfm'igfiteAed WUh P:aUenliswill lnave silandard pi.M~CJogfa;p:M ~1lJ1 by ourr ,'eclieated p.l1o~O;gr:aIP~er. line SI!lJIll:8on W,ullgo Ulfoughlthe ph.0Il:ograph1swUh ~he pati€!iilt to disCUISS wha,t il:1li'lprmve:mernilisthe: ~a,1fent.WI~'Il to achi:eve. At le.a;s[·MQ c:onsu'I~:aticmtS iinthe clinic8lr-e underlakfHlll pr:i:or~o :surtlery.

Adequate

oommu1nicatio:n witl1il tI1epalMent

is orueiet

-

a,d\lanood'sumir;-a.l.~ec:nniQ.ues

NON-SURG~CALTECHN~(:lUES
.fig
,2;· A gro.sSir diiJviated sept'u.m'o, the Ifift siC1e ,ooe to'raurna. Surgew .c:orreoled this oomp.lex(}fe.fmmlt.y With a paten.t nasa'! aIr Fiilliers ea Ii1 be ir:@e1cledJ u ndew the sk:i:lll o~ the nose Tn 1he ,clil1li:c" ta8chieve enlh:ti;lnoe;men~, This ~mri'iI'Q'Il:I~S, Is~nieu:talr u~efUl b:r Ii'ncrease naJS:allneigIIH. We, use a Ihyaluronic aCidllbase(i! 1rllJerwhicl1l is: 81 n!i1U.urallpen1Ci:l1llJe Inl.!man- bOO'j,il'rieji\~ 1hecii$TIiI m' reaction I:s.V€'fY sma'lil.line ma.rn disad'vifliilta,g;e ri8Urla~ the fJllleJ!' mat.€'ilial naJt!llra'lllym80tps.IWisapp~ili!!'S) after a mw l'iIIiOin~h:8and to obitai'1i181 perslicstent iresuU repeated injectilOns are r-equ.]r-ed. .. .

passage .aofMeve(:J.

SURGERY

CONTA.CT IUS
['J1~pAR;TMIIE.r"fr OF O"OR,H:~NOLARNIN~OLJjGY Clitnio 1B tENIJ)" Le\l~11.ITSH Medical Cel1llt~ Tell : 63'57 8·;3·64 ,(Gil!?), If·a'l\(: 635,78'6,7'6 I~imail ; Ste;ph€:iilJ[)C;_Loh@Msh.oom.sg

For simpl~ ~1JI~filfl8;li1~at!crnal r[Qt.l1 al1laes1tu~lr,c irs alllll1;3Jl ]s. IreqUlire,~I. If.or !m(:ir-e eGrmp:llex pr.pooq:ur~ a S1eIlFe~ll alli1a~tI)eSiia.wS' re~:mmehd:e-d •.

f'or stM:~!I:e a.lllgl1'ilent;3~rDnan flileision iiRside ~he noottil 18' 1adec,uate. IFer mme refined 1m(MOIle1m.ents s!ll,e:i1as narrewing:of ~ne nm[ ti ~'. a ~ i'is:-OOl,umeiUar il"lcisi'Cu:)1 rnS.l1llilide e~mally in ~h.etiase 0f Ule !'I·ose. 11118clsually tlt~als Very weJI w1:th ITO visible Scalf. .

Operatio.n hours MoMay to, FWidaiY: 8j)'Oam to, 5":30pm
Saltur-day: ,B.OOlamID' 12:.30pm S'U,!ndJay &. Pu!bJic IHolidl8,Jy: CloSed

~aftllmptants.

To Increase nasa! hetght (augmenlStiWl). many materiars we availafJl,e. Th~ b'I aJderttial the patiertt can male: a ChOicE: t2ftMelj to· ttrejrpE!r'So.,.al~~~;
c

,SUl'getm

will dlscu$S 1he pros and cons ofelmh These inclUde:

AurfOl,~u$.·~la~ hm ~Uenl's own bOdy :lllQ. S!'i;J:,twlfrom 1ns:1'dg nose, ear, or rib oort1'tage ttle Sy~theWidmAla nt!iei iGo~x, MeGlptM .Bbs,Ylll!b81t~ imp:~.antseg Gallagen • H(mll:.~lGg.ous impla.liltsreg TUJtop.la'St oostal~C8l1i:lageJ fascia lam

163,5,"1' 8000
(rNJon-Su'blSidized Appo,ilnltmen~ Une)
--

PROTECriONOf

THE ENHANCED NASAL T~P
i

.:~:..,:,:..;.~; \~. :ii:;--:·;": <}.'.: :.. .;: .~.\~;~.";:'::.',..:.,....~..,., ~- <
• ~ ••• : .:. ~ .' ": I • ~ •• •

\
I

F\:ijrti~nt;s 'own ~r1iilfaQ~ ioSl.II!SedfQr 'Elnh:am:e:men~ pT the n Sl!5:a1 '~IPwh;eJi,l,e-\li~1fpossible. Garlimage is soft: 9'[ICI Gauses minimail Jl1etit'l:ll. a~lll:eJs ·)UilZet ri~'~ e$lrusiCir:1l ,tI1ilJt G.®I:etOIDCQWrs in s:ynlhe1Ji:CimpJla n~.$~~TaGElcl Itl1ie flai~~1 ~i(l. ~t

.

..

_______J

FREQUIENILY ASKED 'lUEST~ONS
1.00' , nave a pm:(erl :s,plil1:toluts~de: the',no&eaftersu,ge,ry'?
A~imr IPlasts:rf splint. is on'lry requlired.I,f your have at d8\liia:fedi n'asal dElikirmFly flat required sltraigl1tr&ningl Th-e·sp:lilrillf helps to prevent thre nose [beingr klilocllledl durirng the r~co:very pe:nod. This is 'usue'lliy r-er1!ilOi\leda lonewee:1f\. after, sllJJrg:emy. ml1eMisel.l!ooally there willi lbesome tapes on~e $I.!!,rr'mce o~menotSe ,onlliy. ,#'lave.to ha've·stitches f'eJl'norvea ah.r .SUfQ!"EI.ry? Only if a e)(~.emaj ran$J.oo~lill!mena~incision is made, riinWhioh case Itnestitcl1:es ~

.

:'~;·:'':"":-;;-~··7,
.

·;·~·,>~,:'>-;;~ ..:··~-·;:,·;~:":·,::-.···.··:·;'::f<-~·::.-.):~~.,:~/.,: '.,...
.
.'

t'

\.

.

.

'.

2.

wm,

~

9_rE!remo\lieclat

on,e· week 3Jlillersurgery.

3. !wtJI !here bel .any :splints or p.a1clfs left l'nside' !he .n'ose atte,r .surge.ry?

lJsualllry nc, unless ·[here ~s a lroitof nose bleed then we hallie tal :iinisert alO!';.sto, stop loleedTng. Usua'illy tile packs. w;iillstay p f"n Un;€! lO8!€ mer Olil!i!l nighlt. F 4. How swo,lfe!!1 for afte,r surgezy? lDepEHldingl onrwli1at ihas been dOlili~.with a. ~iIflP:l:€!a,lj:Qm€-i1ltal:f:QnHille nose will USUlally rf5;OO,verWithin ene WcElek. F,ar more complex surgeries '(egl.~nvO:Iiv\ili1g nasel H,p), most o~ ~neS'W'elllTlilgwilld'LtSappear at, about two weeks" aftel~wh~chth.e.ie Ule w.ililibe some very mill:d SWOE!IIi!1i91 'Which may talire longer to oompletely resolve.

.Iong' wif:J m.'Ynose rema'in

IIEINQU IRM)rCAILI!. .. (!·W'O.:RK~'IL,O':W,'

;::.:;::::::: _. .-.. ;:::;"J,~ ~ .. ,. -.....~. .~ "" ::.-.._.::.. --:::;_.
,L.;:; .......~....: .....

I•·

I

Ifto

::::::::

~

.... . -

~

5. If J ha.dprervJous sUiI'UeQf elsewhere

my nose?

,a'nd .not satIsfied

witb the :resul:tj.can " #lave nasal sUfge."

a.gain to iMprove

Yes~ biiJ~.~his is en ca:oo~o case: basts andl a fcrmlal .as:s.:essm~nitof y'OUJ IilC~€I b!!l tl1l,'€!'surgs.oJllis. m~lu.i:md ' su99.iesth:m'r can [o,e made as to Wn8it can be dornEl,

prlio.v h)

6:2.5 6; 60111
1

at

(G€in~na1E~!iqll:!iryIUne)

SFQUGHT
Dr

c~~e. rOllFaCiaJ.
C Fa

S.tepliill'irllm

M'D:~~rl(;iOIi!~,MBA.(Hs\1mlfl). BM~d~c. ElMBSi, F~t:Si~[I'I(ORL·if.lNS). M,FlC8,r~diirlh MR.CS1EnQ)"

I Pla.s)tc S'ecM~e.C~:nSl!U~Jl~

)

PI' >S~P.h:eI"La seNes a~~1'ItIEI'ff -S~~.I'1r <fl'!~ltti'e ~hTe;fofFacial P~.as~~eNice. ap',~ntool 00'ile Ueparnme!'l!t.:Qf1Qkuhtnrifal)it!g. S t wan Toc~ Seng Hds,p:lJaL He unde:rtCloR lhis Qtorh~ool9JCY,rj90l('li9~-ihead:& neck Slu~~y liraTln In Lctl1d'i:lnI.His _Su~~;eI~lst in!) in, F·acia~Plastic ~urnery ;eI'!Cl.d .~hinolog~.! .havnngl unf:ie:rlaken tbe pms1IiigJousC).ne ljleM European AeaiiJ~,my of FM1a] p~$ijo ~lJ.~J'.yteAF.PS} ,fen"sv.rsh:iPf 3'r:Jdobtairrned 1:1 Dcm~te O~· Me£lTG1':iIe degree· (London) ~il'll ri1ii'llology: ~sear:MI. He ~s oommlHee and te<idlln~ fi:ul'LJ'I~ m.dre 'of than :ID soeieties, OO.IJme5 and GGntferenee.s mJattng.tQ 'hiS spi?Oia1ty~He 15,a fellow of {!theRoll'1:I1 eol~ of Surge.ons· of Edl~:IitJ, :anti a memher of!;,~PS. Sm~.AssaQ!al:ian as WElIi as eritislMr~o~au-on Gf OkJI~~~pgi5ts-Hea!ll Ned<: ~I'!S. He reretees pe~~ revklw pap I plastf,C·surgery anJ:i rhinotpgy fbi" ~eml scielitiffc journals.. ~a Is author orr over 1tlO pul;l~~ns·and110 sci.I:!IitifJiC papElf P~liE! ~>
c

a.

\''HJ vatu e o u r ~[Hient~

rnos.t

OPENING OF CLINICS 2B &4B
INlTIATIVES
1. EVIID,ENCE CARE
lhl7! WQr~ IQf illl~~"iNiiilil\l parl!li'1lnt '~~mi rne~e:]j' ~~a;oo~" '~lilh~Ir:kQr~g ~H)l!Jr Icsr:elffial1l:ag~lT!Ieflt, ~IQfni$.

FOR BETTER CARE AND GREATER trrtct ENCY
'Wfi!:
,ca~e

~S' Idell~rii'1lil\l b~t ¢.a~: pra!1: ticceis ~, ~Ollt, and
J

'PJi).!11~l!'1U~IIJ~Y

'W£:

3. TEAIM CARE

G_a,m ~ "W'O~k!T!I1g. ;3JSa te::am 't~1pnnrvif.le a ol'il;e"!s~~p, heal~tu,:are ,.perLent~to n~t8,i'J ~fr.eatali1d IGamfbr you!> ~li I'lousili!,g Mllll'lilii,~ledJisgi,~Mrrleswithi n GRe, ~linki,~ol!J will na:w Inav·e a~.s 'l'01be:tlI~fee..o:~il1l!at:edlloar:e.

Wil' .cam; Ic¥ a:(h::1~'s:in!ir your Ihe~IU~1 CoIJU;t\li,.ms an(jltre·alliing, y~imr~l;IGlm~GIl11'fs,wiU1Jlm the loest pea.~it)Il3:Ii'mElilfam;€l:, t<f:lowill'1lg Itl11:i1l'i tirn,e 'Irs Iprecjous tO~~l!Ii, lnave IfFl0W 'i~grate~i GUir sUIllIP~Fl:sef1lilil:oos: '~Q el1l!~I!Jf\e!hSit p~~lent,iri'we[IS c1elive<redl s.eamllessJy
mt~in iii 'siR~lelopJjcJ'l.

2.,DES,1INATI'O:N CARE

,4. PERS;IONIA'II..'[$iED

C,ARE:
m~ill'1g the e-X'tra mi'l!e

we

1E.~Q;ep~o:nal'ineverylhingl weuCI fOr Jou,i'aml As I~a-rt'qfl(:'lurs,el:"iil1ice enti:anrremerit

ro rp;rovidnJ1gc~re 'mat ~OQffl~~,IKUflll au r hearts ..
sJefVFce:~~a~e

.' Appo;i1ntm!elll: Hotl iln'e'

'We trave, now in~fpOr:l!li~d' your p["€-~lal'lnledllreatmel1lt itirmmry, as palWit Q~' 'Dle qweu,e UClteJ:. With ·~niS IA€W 'F~QflnO:ltlgy" 'your enUIte ~:awrn~y w:ill1inlil\e. dl:rnid is noW IFeprese1i1Jtei:l by J~~t os $jrlg'lle ,q;~eu.e nl.llm!Zteir,. "$elfj.!'~~1iS'1!lr.ii,l!lo:n l(io~t;s:,~M" I\lailli:!!'blie "oqiS~mt.o ~~IP' s:~~,d wp,Ilh'e I~glislimtion pro~s!i~r la'll: 1r€!l!f€a,t ,sit.l~at[e:nfl1lt. V

Automated

aUieUe!

S'ystem

~eam isqo,mmmeGl-tQ'.'90Tn[1l,tnl! ~xtra m1:IIE! ,deiliv,eringl1Per:SQfI~Ii~ care'ti:lm 1lI1e"IiL'e'Si1. ani;!
Oar"€lCQ6!r:Wl'lmrs are OM 11 and'ttj.~l1aperoMe yeu willl~n u"ie1·Cljnie 'S n~ I'lIpJllr,llltal.
1

le,f(orts, we have pE-alot'iHedi :ao,[Ie-:S:l:ofif$Ptp:{illnlrniilntlip1tiine~'ll:;IlJlrlij:atie:ri~

'. Care Gloord iIl3.tOIr:s:

.. Pharmacy Sel[V'lce!!i

Forfti'r'S1i visit.IP'2!tieom"tJne- fS\ilLew of' ourrMt 'mad 1:001101'ls1ttappens at ltnelle,gl'Orii!lQI'O,f 'yOHf j~um.ey. ,eveill' prier tol lIie J d~c~or'si ooniBi!JJlil:af~QI1. ThIs 1111.~ p"j'\~ss; ja:II~'W'S oUlr (lot~Cim to' le'I1Stn:€l"thi8lt 1a~lJ.rG~alw !mea ~calti!ln~-are p,rescNbed in ~Jl~anO'e' wJitJ'h nt6l', pi'n:almilaGisfs revi/€'w.

MU[TI~DISC1PLINARY SplECIALIST ICARE
GUNIC 28
le¥.el

CUN:~C 4B
1L.e:vel!4.1 'niSlH Med~§:al C.enure T'a:n Toc:k Sern,g HosP:~fall CUN~CAL D~SCJPUNESI '. 10iatl'etes ali1ld E;lJjJdacrine '. Gell'!le,.a~ Miediicine ," ~nhdjQll:is [liliSeasle
'I<

'.

Di.illignostiic ,S~rvilces (Avadabl.eoJI1III, i~n ICliiinro :aD) X~ray ,seNIT~s are aVl3lilab,te ,Within n~IEl clill1io: We can :arrange ror ~same.dffY' ,aTlil\pOifilltmel'll:ts tar aIler diag:n:os~je SlaN'ices, Siuch~il'S 1r2~rn1ll'!l!Jt,edl l!omnl1l,riapb~¥ (CT)illl'll.d M!agne~TIOI~:esan!arl(lel ImsifjillilQ (MRI),wi1ere I'leoosssltl'¥ .. ~rrdOI5IeOIPI¥Sjerviee:s i(A\l,aill~alt.l:I!e ('Jilnllir inl C~linh;:::2!BI cnS'OscQPy . ~'bll' wifh'fn tl11i9,c.lin'~c' IPl10V iide 89QIi1tinUlJlm If 'ca~~ for- paitl-em~s'lreq;IllMngJ8a,s1tO~;ta
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2:.nSiH Meditcsl Qecldf'e
H1osp:ital

Till11J1'ockSeli1lgl

CLINI:C,AL rJJ,SClIPUNlES
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.Sast!fOernle!!'1oJe:9Y ,It C]ienemll Sl!Jrgery '. UI'IO~09iY

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fatS:ter :anti il!e:tlerean:,

!fel!J loan fTQlW~rijQ"i

samle.-,

OPERA,lION HOURS
yCUII.~ booside'I!.II~OIlll

IP'aJinMali'iag)em~1f1I1

Far your«rol"l\i\e:nien:oo, medlcaUan' Bnd P8!Ymel'lhtare maoilital:ed,~

discbaJge.

P~-A~miiissio:n Co.:Lt""sle~II'ilng 'aln.a! Ev·ah.lillliifJ'f1 1['P,A,C;J!)1ServiGels; U\vitill!ab:l:e !I.}:nllv illli 'eillinic 2:B" YGlill eal'lli n~ enjoy ItIi,e efjli!lvenien~ lof reteivim!:!1 p'~~~~eFative :~li!IstruCl!t:eris mlnallili€lfal ii'1!lfi':jrm:aUor:li 11)111 ,surgi,cal 'and U,e
p;~opeduni)sWiniil'ill ~h_ec~lniiGl.

M;onday~o! IFii\idJ",,: :8.IO~ml,-,5 ,3.1p:11iIi Sabl~day; 8.tOla!D ~ t:2.r30pm
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SUlIIildiay a!iiJdl P.'ublli,e IHell id!a.}r;- ClloS'ed

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IF!iS:ycit\!otO,gli;c~11 iM~ditii!iiJe JRe",a~ Medllcirfl;e IR:es,plraltoiry' ,an:!:!! Clf.it~C'a~ aFe :Med i~~mle C Ilia,ema~ollo,gIY

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Tel; 1(65) 635,781011111.8007327101

.. Rayment
We piilyr:m€iot 1P1!!!17.lC€l'SS; ~l'il;~n sllie:amlfnoo tOI md:IlIc:~W'ai,til'il,gl1imt;l. Ihas, C'O!JJnteif~¥bll! w~n.aISlZl ha~ U~:e: Q:p.~ton lofwireil:ffs,sp~l~merit

OPEiRATIONlliiOURS! MO!fu:la,y m Friday.~ 8:.IOla;!1)~' .3l0;l'm 5
SialIi:l fda,: 8.0:0am ~ 1:2.3,O:pml
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P,a~l'il'I€n~i6 lllfl'W t';Ons,oififiated il"l

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SUIIl,daY'land PlubUc Holliday:

CICfsec!

Tel: (615)1 !6351 1011110 1181,01 132 7500 J

IENCUlJIRV ,ll AP'POIN'IMENlT

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