Why did I choose Rheumatology as my subspeciality?
I was a General Physician for almost 4 years before I decided to do my subspeciality. My interest has always been in general medicine but unfortunately, the trend now is for everyone to go for subspeciality training for better prospects in the future.
I chose rheumatology as it fascinates me. It is the only subspeciality that looks at a person as a person! We don’t look at any particular organs but everything. Rheumatological diseases are systemic diseases that are multi-organ in nature. Even though I hated immunology as a medical student but rheumatology really excites me.
In this page I may add important informations about the field of Rheumatology and abstracts of my publications in local and international journals.
This page has the following sub pages.
- My Publications
- 1st SLE Public Forum in Johor
- What is SLE?
- Systemic Lupus Erythematosus (SLE): A Guide for Patients
- The Kidney in SLE
- Pregnancy in SLE
- Rheumatoid Arthritis
- Medications for Rheumatoid Arthritis
- Gout
- Psoriatic Arthritis
- Scleroderma/Systemic Sclerosis
- Ankylosing Spondylitis
- Juvenile Idiopathic Arthritis
- 2nd SLE Public Forum in Johor
- Severe Rheumatoid Arthritis of Hip Joint
- Johor Rheumatology Update 2011 : 23/10/2011
- SLE Public Forum 2012 Johor
- Johor SLE Public Forum 04/03/2012
Oh yes…i would agree with u that rheumatology involves seeing the person as a whole. Sometimes, i wonder why the learning of other organ when i cant applied when become specialist. At least, being rheumatologist allowed myself not to waste of information that i have learn so far.
Would u mind share with me pro n cons being rheumatologist n how it is different with other sub speciality
AS I said above, rheumatological diseases are multiorgan in nature as thus we have to look at the person as a whole. A cardiologist for an example, does wonders by clearing vessel blockages etc but forgets about the control of diabetes! Same goes for a nephrologist who manages lupus nephritis. He only looks at the kidneys and forgets about the rest of the manifestations of lupus!
website looks great!! well done.
Leow
how did you reach my blog? how’s life ?
Pagal
dear dr,
i always follow ur article in MMA magazine, but today only i gt to knw rgrd ur blog. its really informative blog. i finished my hsemanship dis may, n doing mo in health clinic. was in med dept in hosp kangar then they sent me to kk. im really interested in med as well as rheumatology…hope can get some guidance and input fr dr. im MMA life member, n exco for perlis state mma oso. thank you dr
If you are interested in Internal Medicine, I would suggest you to do MRCP rather than Masters as it is recognised internationally unlike masters. After completing your MRCP and 18 months gazettment, then you can apply for Rheumatology!
Again, you have a long way to go.
Could you shed some insights on link between HLA-B27 antigen and Rheumatogy.
HLA B27 is associated with seronegative spondyloarthropathies like ankylosing spondylitis, reactive arthritis etc.
thank you for ur input dr…
Dear Doctor,
Recently, when i got up in the morning, i felt stiffness in my body especially in my abdomen.I felt difficult to bend my body. and that would last for about ten minutes. After some stretching, then it would be ok. Please help… Is there any underlying problem? Thanks and sorry to trouble you.
Very difficult for me to say anything as there could be many reasons for this symptom. One have to see and examine you before deciding what is wrong.
You need to see a doctor!
Dear Dr.Pagalavan,
I happened to come across your blog by chance and am very taken up to know that Columbia Asia has a Rheumatologist on board.
For your info, I am the Medical Records Manager at Columbia Asia, Seremban.
Actually, I am writing to you to find out if you have any info on Fibromyalgia. I am a Fibromyalgia patient for the past 4 years and am interested to know if you know of any treatment which can be helpful in relieving the pain other than Lyrica!
Is there by any chance of any Fibromyalgia specialist in this region whom I could go for treatment?
I hope I am not troubling you too much. Hope to hear from you soon.
Thank You & Regards,
Rathi
Lyrica is the latest therapy for Fibromyalgia. However, sometimes it may not work or the dosage may not be adequate. Unfortunately it is expensive. The other options will be Gabapentin or opiates.
There is no Fibromyalgia specialist in Malaysia. It is a difficult disease to treat.
Hello doctor, I came upon your site while searching for fibromyalgia malaysia. I have been seeing doctor Raveendran from sdmc since beginning of the year now in regards to my fibromyalgia condition..he has been quite helpful to help me understand my condition.
You wrote that in 2010. I am wondering if you would know of any updates in fibromyalgia in malaysia?
There are not much updates in Fibromyalgia. Dr Ravee will know the latest. Lyrica was the only drug that was officially approved for fibromyalgia
Dear Dr Pagalvaran,
Could you shed some insights on ” Atypical p-ANCA” blood test result? Is there a link betwwen atypical p-anca and vasculitis? Could a normal healthy person also get Atypical p-ANCA” blood test result?
Is the titre of ANA correlate to the severity of symptoms of an autoimmune disease?
Why is ANA can be negative even if during flares up?
If one suspect to have an autoimmune disease, which is at present not classifiable under the usual criteria, but doctor starts to treat with hydroxychloroquine and prednisolone, is there any long term side effect?
I am impressed as you chose to study rheumatology as It is the only subspeciality that looks at a person as a person! But I read from the website that when the autoimmune diasease “attacks” other organs, one would see a few specialist at the same time.
Thank you very much for your help. Your help is greatly appreciated.
Atypical p ANCA is rather non specific, it can occur in many conditions including infection. Try MPO and PR3 ANCA.
ANA may or may not correlate with disease severity. Usually, we don’t use the ANA titre as a marker of flare. We go on clinical signs and symptoms.
In undifferentiated autoimmune disease, the treatment depends on what are your menifestations. Prednisolone obviously has a lot of long term side effects but hydroxychloroquine is relatively safe.
A rheumatologist usually manages a pt as a primary doctor. Other specialities may be involved depending what organ is affected etc. BUT we see the patient as a person and not by any individual oragans.
Dear Dr Pagalavan,
Thank you for the answer. is there any lab in Johor can provide MPO and PR3 ANCA blood test? If the autoimmune disease is in remission, isn’t the test for MPO and PR3 ANCA will be negative, therefore it won’t help in diagnosis?
If it is undifferentiated autoimmune disease, i.e. it is not a “true” autoimmune disease, can one ignore taking hydroxychloroquine and prednisolone, just take NSAIDs when there is joint pain, apply Triamcinolone Acetonide oral paste when there is mouth ulcer, take pcm when there is fever?
Your professional view is greatly appreciated.
Gribbles lab can do MPO and PR3 ANCA. sometimes the antibodies may still be positive even when you are in remission.
I would rather suggest to stop pred and con’t hydroxychloroquine. Hydroxychloroquine has been shown to reduce the number of flares in many autoimmune diseases.
Dear Dr Pagalavan,Could I know if there is any Rheumatologist in JB government hospital?If Rheumatoild Factor is negative, can one conirm that it is not rheumatoid arithritis? May I consult you that what could be the reason of the swollen, painful of both ankles and wrists with the following blood test result? TWBC:12,000; Polyporphs:88%, Lymphocytes:10%; ESR:60; C Reactive Protein:120 mg/L; Platelet: 453,000; Hb:8.5. If the TWBC is highhow could tell the different between infection and inflammation?Thank you very much for your help and advice.
There is 1 Rheumatologist at Hospital Sultan Ismail. Your features do look like Rheumatoid Arthritis but we need to look at you to confirm the diagnosis as there are many diseases that can present similarly
Thank you Dr Pagalavan. May I know how could one get refer to the Rheumatologist at Hospital Sultan Ismail as the blood test and medical fees, and medicines at private hospital is quite expensive?Your help is much appreciated.
Go to any nearest gov polyclinics and get referral
dear doc… we have met before but doubt if u still remember…with dr ralph.
well i’m now a gp in rawang (with a group practice) . i would consider myself fortunate as when i was in med school i had a very dedicated physician/rheumatologist dr anurag bharadwaj as my lecturer. in the past few months i have come across abt 3 cases of juvenile ra and 2 cases of sle. i’m glad i was able to pick it up fast enough. i would appreaciate if u could include a session in your blog on how gps can monitor and treat certain rheumatology cases . this may help to reduce or at least help the patients in view of waiting time at public hoispitals. than ks
I think it is mentioned in my blog postings. unfortunately in rheumatology, every individual is different and the treatment and monitoring varies with each patient. In fact, rheumatology is probably the only field where the same doctor need to see the patient on each visit, ideally.
Hi Paga….
Nicely written articles….. and it’s nice to read something about medical again
Haha, fakhrul where are you now? I wonder how you found my blog?
Im in KL…. I was looking thru pictures in my friend’s fb when i saw a photo of lousy referral letter with footnote mentioned ‘taken with consent from pagalavan.com’…..Hey! I know this guy from my previous life…haha!
Haha, are you still practising or doing business?
Hi Dr Pagalavan,
Very nice blog. I like it.
Keep it up.
The last patient I saw was 5 years ago…haha…and that was in HSA…Im doing business now, anyway I knew you were in Monash as I was doing Case-mix project with Prof AZ & Dr Sivalal…..eh you’re going to the immuno conferance in Singapore this coming Nov?
nope, no time in private hospital now. I am sure you are doing well with your business.
hi dr pagal..im just finished my study doing medicine..now must go for HO..i have to choose 3 hosps..if u dont mind would u recommend any 3 hosp which are good for HO training…i live in selangor..i also jpa scholar n after finish my HO i want to be a surgeon ..can u suggest what its good for me..MRCS or doing master or what…tq before..
Please read all my other posts in this blog. From what I gather, the HO post for selangor is full and your chances are slim if you apply for Selangor. Even if you do get a place in Selangor, you will be transferred out of the state after completing your housemanship. The glut is getting worst. You can choose any of the big hospitals like Klang , HKL, Kajang etc. MRCS is NOT a surgical degree. The only way to become a surgeon in Malaysia is via Masters.
Hye chitappa, I am Tharshen Balachandren here.Can i know how to apply for any Medical Universities after SPM?Which is the best Medical University in Malaysia, and the requirements that I need in SPM to be a successfull Doctor like you….thank you
Best Regards,
THARSHEN BALACHANDREN
HARSHINI BALACHANDREN
SPM is not suppose to be the entry qualification for medicine. You need a good grade(at least 4 or 5As) in a well recognised pre-U exam such as STPM, A Levels etc and not some dubious foundation programme.
Good Unis in Malaysia: UM, UKM, USM, IMU and probably PMC and Monash. Pls ask the respective Unis of how to apply.
Thank you chitappa.
Dear Dr. Pagalavan,
Good Day to you and I hope you are doing well. I have been diagnosed with RA for 5 years now and have only been seeing one doctor ( out of respect, I will not mention the name here). Recently, after an x-ray of my right wrist, it has been confirmed that it is clinically damaged. Having said that, and prior to this outcome, my other half has been pushing me to see another Rheumatologist as he feels that my Rheumy seems to be doing me no good. I have tried to explain to him that every patients body reacts differently to meds and it can be a trial and error matter when it comes to diagnoses like RA. So, long story short, I’d like to seek your advice on who else can I consult with (I’d like to consult with you BUT you are in Johor and I’m in Selangor) on this matter just to not complicate matters plus I figure, it would not hurt me anymore than it already has to do so. I’ve looked into the matter of a total wrist implant. However, apparently it has not even been heard of here and IF it has, it probly is still only on paper. I know that in Singapore only ONE patient has done the surgery. It has been stated that most patients rather “live” with their condition or do a partial or total “LOCK”, due to the total joint replacement surgery being very expensive. It was cited that it could be as expensive as SGD20K. Now, with my condition, what further advice may I acquire from your kind self and again, will you be so kind as to recommend me other Rheumatologists I may consult with in PJ/Selangor. I thank you very much for your patience and time. -Alicia-
I am not sure what is really happening here. Probably the damage was already there before you started on treatment? You need to talk to your consultant regarding the issue. Wrist replacement surgery is rarely done as the outcome is poor. mostly, we will do wrist fusion surgery.
No, Doc. No damage to this extent at that point of time. Actually, will e-mail you what I have been on before. As the disease progresses, and so does my age(I’m 37 this year), I’ve been taken off all meds to allow me to try for a child. Will update you via e-mail soon. Thank you for your time.
Hai, Dr. Reading sentence above, you hated immunology, how do you score your immunology since it is quite tough to get good grade with it???
I am a clinician and not an immunologist
Sir,i m a undergraduate student from matriculation.recently, i got offer for medicine from UKM and UPM. which one would you suggest ?
Both are OK but I would prefer UKM.
Thank you sir.
Dr, any recommended book for rheumatology to read ?? Thank you.
For undergraduate or post graduate?
both….thank you…
Try oxford rheumatology ( they do have a handbook as well), Rheumatology secrets etc
Rheumatology is an awesome subject to learn..hope that Dr you can share with us your experience in rheumatology……Thank you….
Dear Dr Pagalavan,
I stumbled upon your blogsite quite by chance. I like your spirit and hope you will take some time to check out the work of Prof.Dr Ananthan Krishnan ( if you are not already familiar with his work) in many areas of disease and healing @ http://www.amriasia.org. The rest I leave it up to you. Have a great life.
Best regards,
Asha Ravindran
hi Dr Pagalavan,
i too came across ur blog by chance and it is indeed a good read. keep it up Dr!
i guess the Lady Luck was smiling on me to came across your blog today. we are in a tight position and your opinion would truly be appreciated. but before that, let me introduce myself. i am an Outpatient Pharmacist in a district hospital in Sabah.
i am not sure if you are aware, but there is a nationwide shortage of Tab Methotrexate. many facilities have run out of stock and unable to replenish it as the generic company has ceased production, while the original brand is unable to cope up with supply. my facility is one of it. we have asked from other hospitals but none are able to borrow us any supply either
inevitably facilities need to consider alternatives for the time being till some miraculous solution is found. i would like to ask your opinion on converting the tab Mtx patients to either IV MTX or Tab Sulphasalazine. can we do it temporarily? is there any dosing guide which you follow for reference? or is it fine to let patient to be MTX free till the supply arrives (which may be very long). we will me discussing this with our doctors tomorrow, but your input will be very helpful.
thanks, and have a good day ahead!
Thanks for the comment. YES, I am aware of the MTX shortage. I am facing the same problem here.
SC MTX (not IV)can be used as an alternative but not SSZ. SSZ takes a long time to work and not equivalent to MTX.
PFizer claim that they will try to get the stock by next month. I got no idea how we ended up with this problem as MTX is a very old drug. I am sure there are many generic companies in India who can supply us.
thanks a lot for the speedy reply Dr. so based on several studies, they are recommending a 1:1 dose conversion from Tab to SC MTX. and if the dose is above 15 mg, the papers suggest to use SC MTX 15mg first before further consideration of dose increase. is it fine if we suggest this?
and how about lab investigations? should we recommend lab investigation first before the SC treatment are started to monitor for side effects? we did came across some patients whom had their liver profile deteriorating after a single SC MTX dose.
Yes, 1:1 dose is OK. LIver function must be monitored more closely as the bioavailability is higher for SC.
Good day Dr.
Please, I have to ask your help if this is possible, I need to finish me PhD in rheumatology in malizia how you can guide me please,
Thank you so much