Patient consent (valid and legal):
1. Patient must have capacity to consent
2. Patient must be adequately informed
3. Patient must consent voluntarily
Patients who can’t give consent:
1. Minors (in Malaysia, below 18)
2. Adults with mental illnesses
3. Adults with intellectual disabilities
4. Adults with senility
5. Unconscious patients
When can we breach confidentiality?
1. Legally Obliged
§ Reportable deaths
§ Infectious diseases
§ Health impaired medical professionals
§ Registration of birth and death
§ Drunk drivers
2. Legally Permissible
§ Patient has consented
§ De-identified information
§ Disclosure to other health professionals (necessary for patient care)
§ Disclosure in the public interest (reasonable grounds to believe there is imminent danger)
3. Ethically
§ Harm to self (patient)
§ Harm to others (must weigh and balance interests of patient and duties to society)
(Sources: MBBS Study Guide MED1011)
(Posted by: Vivian)
Showing posts with label pcl 6. Show all posts
Showing posts with label pcl 6. Show all posts
Saturday, 14 April 2007
Friday, 13 April 2007
Management of Sleep Apneas and Snoring
In finding a treatment for obstructive sleep apnea, the primary goal is to hold the airway open so it does not collapse during sleep. Treatments include:
Tracheostomy
A tracheostomy is a procedure to bypass the narrowed airway. If the obstruction to airflow is occurring above the larynx, a tracheostomy can be inserted to direct airflow directly into the trachea. The tracheostomy tube is passed through the skin of the lower neck directly into the trachea. Tracheostomy generally is reserved for morbidly obese patients with severe obstructive sleep apnea who are not candidates for other treatments. They usually can keep the tracheostomy tube capped during the day while breathing normally through their nose and mouth, and then open the tracheostomy tube at night. That way, they will have a normal voice and mouth breathing while awake, and breathe through the tracheostomy tube only at night.
A tracheostomy can be a temporary procedure, and is kept in place only as long as it is needed. It is easy to remove the tube, and the body will usually heal the skin and close the opening rather quickly. Tracheostomy has close to a 100% rate of cure for obstructive sleep apnea because it bypasses the problem in the upper airway. In mixed sleep apnea, obstructive apneas resolve immediately, but central apneas, which are due to metabolic changes caused by the obstructive apneas, usually take some time to resolve.
Behavioral changes,
Medications,
Dental appliances,
Surgeries,
CPAP (continuous positive airway pressure).
Medications,
Dental appliances,
Surgeries,
CPAP (continuous positive airway pressure).
Behavioral changes
Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep.
Obesity is a contributing factor to obstructive sleep apnea. A healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea. Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods, people are able to lose weight, and the obstructive sleep apnea improves.
Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep.
Obesity is a contributing factor to obstructive sleep apnea. A healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea. Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods, people are able to lose weight, and the obstructive sleep apnea improves.
Medications
Many medications have been studied for obstructive sleep apnea; however, because obstructive sleep apnea is due to an anatomic airway narrowing, it has been difficult to find a medication that will help. In people with nasal airway obstruction causing obstructive sleep apnea, nasal steroid sprays have been shown to be effective. Topical nasal decongestants, like oxymetalizone and neosynephrine, also can temporarily improve nasal swelling. The problem is that they cannot be used for more than 3-5 days without decreased effectiveness and withdrawal symptoms.
People who have obstructive sleep apnea secondary to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet medications, if they are effective in helping them lose weight.
There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
People who have obstructive sleep apnea secondary to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet medications, if they are effective in helping them lose weight.
There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
Dental appliances
A dental appliance holds the jaw and tongue forward and holds the palate up thus preventing closure of the airway. This small increase in airway size often is enough to control the apneas. Dental appliances are an excellent treatment for mild to moderate obstructive sleep apnea. It is reported to be about 75% effective for these groups. A dental appliance does not require surgery; it is small, portable, and does not require a machine. A dentist is needed to fit and adjust the appliance. A dental appliance requires natural teeth to fit properly and must be worn every night.
Continuous positive airway pressure (CPAP)
Continuous positive airway pressure (CPAP) is probably the best, non-surgical treatment for any level of obstructive sleep apnea. CPAP uses air pressure to hold the tissues open during sleep. As a person breathes, the gentle pressure holds the nose, palate, and throat tissues open. The CPAP machine blows heated, humidified air through a short tube to a mask. The mask must be worn snugly to prevent the leakage of air. The CPAP machine is a little larger than a toaster. It is portable and can be taken on trips. .
Determining CPAP pressure.
With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by “titration.” Titration frequently is performed with the help of polysomnography. In the sleep laboratory, an adjustable CPAP machine is used. A mask is fit to the subject, and he or she is allowed to fall back asleep. During baseline sleep, the apneas and hypopneas occur. The technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed
With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by “titration.” Titration frequently is performed with the help of polysomnography. In the sleep laboratory, an adjustable CPAP machine is used. A mask is fit to the subject, and he or she is allowed to fall back asleep. During baseline sleep, the apneas and hypopneas occur. The technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed
Effectiveness of CPAP.
CPAP has been shown to be effective in improving subjective and objective measures of obstructive sleep apnea.
It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and objective tests.
It improves cognitive functioning on tests.
When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea.
It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and objective tests.
It improves cognitive functioning on tests.
When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea.
Bi-level positive airway pressure (BiPAP)
Bi-level positive airway pressure (BiPAP) was designed for people who do not tolerate the higher pressures of CPAP. It is similar to CPAP in that a machine delivers a positive pressure to a mask during sleep. However, the BiPAP machine delivers a higher pressure during inspiration, and a lower pressure during expiration. That allows a person not to feel like they are breathing out against such a high pressure, which can be bothersome. It is most helpful for people who require a higher pressure to keep their airway open.
Auto-titrating continuous positive airway pressure
A new development in sleep apnea treatment is the auto-titrating CPAP machine. These “smart” CPAP machines make pressure adjustments throughout the night. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn’t need a higher pressure, the pressure is reduced.
A new development in sleep apnea treatment is the auto-titrating CPAP machine. These “smart” CPAP machines make pressure adjustments throughout the night. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn’t need a higher pressure, the pressure is reduced.
Surgical treatments for obstructive sleep apnea
There are many surgical options to treat obstructive sleep apnea. The type of surgery that is chosen is dependent on an individual’s specific anatomy and severity of sleep apnea. People often want surgery because it promises a cure with a single treatment. Surgery sounds easier than losing ten pounds and more convenient than wearing a dental appliance or mask every night.
However, surgery should be considered only after all the risks, benefits, and alternatives to surgery are understood. For example, CPAP, if tolerated, controls most sleep apnea, and this is better than all surgical options. It is difficult to have a serious, permanent complication using CPAP as compared to the possible of such a complication with surgery.
Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, obesity, or several of these areas at the same time. Each surgery’s success rate is determined by whether or not a specific airway collapse is prevented. Therefore, the ideal surgery is different for each patient and depends on each patient's specific problem. Some surgical options include:
However, surgery should be considered only after all the risks, benefits, and alternatives to surgery are understood. For example, CPAP, if tolerated, controls most sleep apnea, and this is better than all surgical options. It is difficult to have a serious, permanent complication using CPAP as compared to the possible of such a complication with surgery.
Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, obesity, or several of these areas at the same time. Each surgery’s success rate is determined by whether or not a specific airway collapse is prevented. Therefore, the ideal surgery is different for each patient and depends on each patient's specific problem. Some surgical options include:
nasal airway surgery,
palate implants,
uvulopalatopharyngoplasty,
tongue reduction,
genioglossus advancement,
hyoid suspension,
maxillomandibular procedures,
tracheostomy,
bariatric surgery, and
combinations of the above.
palate implants,
uvulopalatopharyngoplasty,
tongue reduction,
genioglossus advancement,
hyoid suspension,
maxillomandibular procedures,
tracheostomy,
bariatric surgery, and
combinations of the above.
Many people have several levels of obstruction; therefore these surgical techniques frequently are performed together, for example, uvulopalatopharyngoplasty with genioglossus advancement and hyoid suspension.
Nasal airway surgery
The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP.
The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP.
Palate implants
Palate implants stiffen the palate. They prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring.
Palate implants stiffen the palate. They prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring.
Uvulopalatopharyngoplasty (UPPP)
Uvulopalatopharyngoplasty (UPPP) is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese. In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed higher. A UPPP is successful 50-60% of the time in preventing or decreasing obstructive sleep apnea.
Uvulopalatopharyngoplasty (UPPP) is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese. In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed higher. A UPPP is successful 50-60% of the time in preventing or decreasing obstructive sleep apnea.
Tongue reduction surgery
In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures.
In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures.
Genioglossus advancement
The genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When this muscle relaxes during sleep, the airway narrows and collapses. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. This usually is performed in combination with hyoid suspension or UPPP.
The genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When this muscle relaxes during sleep, the airway narrows and collapses. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. This usually is performed in combination with hyoid suspension or UPPP.
Hyoid Suspension
The hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap (tongue) muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures like UPPP or genioglossus advancement. In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up.
The hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap (tongue) muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures like UPPP or genioglossus advancement. In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up.
Maxillomandibular advancement
Maxillomandibular advancement is a surgical procedure that moves the jaw and upper teeth forward. This pulls the palate and base of the tongue forward and opens the airway. This procedure is best suited for a thin patient with a small jaw. Both the jaw and maxillary bones are cut, moved forward, realigned, and plated into place.
Maxillomandibular advancement is a surgical procedure that moves the jaw and upper teeth forward. This pulls the palate and base of the tongue forward and opens the airway. This procedure is best suited for a thin patient with a small jaw. Both the jaw and maxillary bones are cut, moved forward, realigned, and plated into place.
TracheostomyA tracheostomy is a procedure to bypass the narrowed airway. If the obstruction to airflow is occurring above the larynx, a tracheostomy can be inserted to direct airflow directly into the trachea. The tracheostomy tube is passed through the skin of the lower neck directly into the trachea. Tracheostomy generally is reserved for morbidly obese patients with severe obstructive sleep apnea who are not candidates for other treatments. They usually can keep the tracheostomy tube capped during the day while breathing normally through their nose and mouth, and then open the tracheostomy tube at night. That way, they will have a normal voice and mouth breathing while awake, and breathe through the tracheostomy tube only at night.
A tracheostomy can be a temporary procedure, and is kept in place only as long as it is needed. It is easy to remove the tube, and the body will usually heal the skin and close the opening rather quickly. Tracheostomy has close to a 100% rate of cure for obstructive sleep apnea because it bypasses the problem in the upper airway. In mixed sleep apnea, obstructive apneas resolve immediately, but central apneas, which are due to metabolic changes caused by the obstructive apneas, usually take some time to resolve.
Bariatric surgery
This is a surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. There are two main types of bariatric surgery, adjustable gastric banding and gastric bypass. In adjustable gastric banding, insertion of a band restricts the size of the opening from the esophagus to the stomach. The size of the opening to the stomach determines the amount of food that can be eaten and can be controlled by the surgeon by inflating or deflating the band through a port that is implanted beneath the skin on the abdomen. The band can be removed at any time.
Gastric bypass is a permanent reduction in the size of the stomach. The proximal portion of the stomach is used to create an egg-sized pouch that is connected to the intestine in a location that bypasses about 2 feet of normal intestine. The amount of food that can be eaten is limited by the size of the pouch and the size of the opening between the pouch and the intestine.
It is effective for sleep apnea caused by or worsened by obesity. Bariatric surgery is associated with a marked reduction in weight post-operatively. Bariatric surgery is only an option for morbidly obese patients with severe obstructive sleep apnea. It must be noted that patients can regain the weight they lost after surgery.
Note: Difference in Goals of treatment for snoring vs. sleep apnea
The treatments for obstructive sleep apnea are similar to the treatments for snoring.
It must be noted that snoring, without the presence of obstructive sleep apnea generally does not pose much of a problem to the patient. However, snoring may and usually is a problem for the bed partner or roommate. Therefore, successful treatment should include the goal of achieving a successful night’s sleep for the other person. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if their snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is “cured.” However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner. Hence, the successes of treatments for snoring are subjective to each particular case.
This is a surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. There are two main types of bariatric surgery, adjustable gastric banding and gastric bypass. In adjustable gastric banding, insertion of a band restricts the size of the opening from the esophagus to the stomach. The size of the opening to the stomach determines the amount of food that can be eaten and can be controlled by the surgeon by inflating or deflating the band through a port that is implanted beneath the skin on the abdomen. The band can be removed at any time.
Gastric bypass is a permanent reduction in the size of the stomach. The proximal portion of the stomach is used to create an egg-sized pouch that is connected to the intestine in a location that bypasses about 2 feet of normal intestine. The amount of food that can be eaten is limited by the size of the pouch and the size of the opening between the pouch and the intestine.
It is effective for sleep apnea caused by or worsened by obesity. Bariatric surgery is associated with a marked reduction in weight post-operatively. Bariatric surgery is only an option for morbidly obese patients with severe obstructive sleep apnea. It must be noted that patients can regain the weight they lost after surgery.
Note: Difference in Goals of treatment for snoring vs. sleep apnea
The treatments for obstructive sleep apnea are similar to the treatments for snoring.
It must be noted that snoring, without the presence of obstructive sleep apnea generally does not pose much of a problem to the patient. However, snoring may and usually is a problem for the bed partner or roommate. Therefore, successful treatment should include the goal of achieving a successful night’s sleep for the other person. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if their snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is “cured.” However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner. Hence, the successes of treatments for snoring are subjective to each particular case.
Note: Central Sleep Apnea
In adults with central sleep apnea, the apneas are treated by treating the underlying heart disease, medication interaction, high altitude, or other primary problem.
In adults with central sleep apnea, the apneas are treated by treating the underlying heart disease, medication interaction, high altitude, or other primary problem.
Source: Medicinenet.com
Contributed by John Lee
Thursday, 12 April 2007
Driving In Malaysia
Driving In Malaysia
Types Of Driving Licences In Malaysia
Lesen Belajar Memandu (Learning Driver’s Licence)
Lesen Memandu Percubaan (Probational Driver’s Licence)
Lesen Memandu Kompeten (Competent Driver’s Licence)
Lesen Memandu Vokasional (Vocational Driver’s Licence)
§ Lesen Kenderaan Perkhidmatan Awam (Public Service Vehicles)
§ Lesen Kenderaan Pengangkutan Barang-barang (Goods
§ Lesen Kondaktor (KON)
Kelas A
Kenderaan Orang Cacat
Kelas B
Motosikal melebihi 500 sp.
Kelas B1
Motosikal tidak melebihi 500 sp.
Kelas B2
Motosikal tidak melebihi 250 sp.
Kelas C
Motosikal tiga roda.
Kelas D
Motokar BTM tidak melebihi 3000 kg.
Kelas E
Motokar berat BTM melebihi 750 kg.
Kelas E1
Motokar berat BTM tidak melebihi 7500 kg.
Kelas E2
Motokar berat BTM tidak melebihi 5000 kg.
Kelas F
Traktor/Jentera Bergerak Ringan (Beroda) BTM tidak melebihi 5000 kg.
Kelas G
Traktor/Jentera Bergerak Ringan (Berantai) BTM tidak melebihi 5000 kg.
Kelas H
Traktor/Jentera Bergerak Berat (Beroda) BTM melebihi 5000 kg.
Kelas I
Traktor/Jentera Bergerak Berat (Berantai) BTM melebihi 5000 kg.
Requirements
- set by the Road Transport Department (JPJ – Jabatan Pengangkutan Jalanraya)
- 2 most important criteria:
Age – 16 years for motorcycles
– 17 years for cars/motorcars
– 21 years for other vehicles
Health – of good health
– able to read number plates and differentiate colours within a distance of
23 metres
– those with any disabilities will be required to get a check-up by a doctor
before applying for the licence
Requirements To Apply For A Vocational Driver’s Licence
1. Age 21 and above
2. Holds a Competent Driver’s Licence
3. Passes a reading/writing examination, completes the JPJ L8A form with a RM1.00 payment
4. Goes for a medical check-up with payment not more than RM50.00
5. Attends a 7/9 hour talk at the driving institute
6. Sits for a written test conducted by JPJ with a passing mark of 42/50
7. Sits for a practical examination for the licence following the applied vehicle class
National Speed Limits
Expressways: 110 km/h (70 mph) by default, but may be reduced to 80 or 90 km/h (50-55 mph) at dangerous mountaneous stretches, crosswind areas and urban areas with high traffic capacity.
Federal roads: 90 km/h (55 mph) by default (reduced to 80 km/h), 60 km/h (40 mph)in town area.
State roads: 90 km/h (55 mph) by default (reduced to 80 km/h during festive seasons), 60 km/h (40 mph) in town area.
For heavy vehicles:
Expressways: 80-90 km/h (50-55 mph)
Federal and state roads: 70-80 km/h (45-50 mph) by default, 60 km/h (40 mph) in urban areas
*Heavy vehicles have speed limit stickers describing the speed limit of the vehicle
Speeding Penalties
If exceed by:
1 – 25 km/h: RM80 (6 demerit points)
26 – 40 km/h: RM150 (8 demerit points)
Over 40 km/h: RM300 (10 demerit points)
(Posted by: Vivian)
Types Of Driving Licences In Malaysia
Lesen Belajar Memandu (Learning Driver’s Licence)
Lesen Memandu Percubaan (Probational Driver’s Licence)
Lesen Memandu Kompeten (Competent Driver’s Licence)
Lesen Memandu Vokasional (Vocational Driver’s Licence)
§ Lesen Kenderaan Perkhidmatan Awam (Public Service Vehicles)
§ Lesen Kenderaan Pengangkutan Barang-barang (Goods
§ Lesen Kondaktor (KON)
Kelas A
Kenderaan Orang Cacat
Kelas B
Motosikal melebihi 500 sp.
Kelas B1
Motosikal tidak melebihi 500 sp.
Kelas B2
Motosikal tidak melebihi 250 sp.
Kelas C
Motosikal tiga roda.
Kelas D
Motokar BTM tidak melebihi 3000 kg.
Kelas E
Motokar berat BTM melebihi 750 kg.
Kelas E1
Motokar berat BTM tidak melebihi 7500 kg.
Kelas E2
Motokar berat BTM tidak melebihi 5000 kg.
Kelas F
Traktor/Jentera Bergerak Ringan (Beroda) BTM tidak melebihi 5000 kg.
Kelas G
Traktor/Jentera Bergerak Ringan (Berantai) BTM tidak melebihi 5000 kg.
Kelas H
Traktor/Jentera Bergerak Berat (Beroda) BTM melebihi 5000 kg.
Kelas I
Traktor/Jentera Bergerak Berat (Berantai) BTM melebihi 5000 kg.
Requirements
- set by the Road Transport Department (JPJ – Jabatan Pengangkutan Jalanraya)
- 2 most important criteria:
Age – 16 years for motorcycles
– 17 years for cars/motorcars
– 21 years for other vehicles
Health – of good health
– able to read number plates and differentiate colours within a distance of
23 metres
– those with any disabilities will be required to get a check-up by a doctor
before applying for the licence
Requirements To Apply For A Vocational Driver’s Licence
1. Age 21 and above
2. Holds a Competent Driver’s Licence
3. Passes a reading/writing examination, completes the JPJ L8A form with a RM1.00 payment
4. Goes for a medical check-up with payment not more than RM50.00
5. Attends a 7/9 hour talk at the driving institute
6. Sits for a written test conducted by JPJ with a passing mark of 42/50
7. Sits for a practical examination for the licence following the applied vehicle class
National Speed Limits
Expressways: 110 km/h (70 mph) by default, but may be reduced to 80 or 90 km/h (50-55 mph) at dangerous mountaneous stretches, crosswind areas and urban areas with high traffic capacity.
Federal roads: 90 km/h (55 mph) by default (reduced to 80 km/h), 60 km/h (40 mph)in town area.
State roads: 90 km/h (55 mph) by default (reduced to 80 km/h during festive seasons), 60 km/h (40 mph) in town area.
For heavy vehicles:
Expressways: 80-90 km/h (50-55 mph)
Federal and state roads: 70-80 km/h (45-50 mph) by default, 60 km/h (40 mph) in urban areas
*Heavy vehicles have speed limit stickers describing the speed limit of the vehicle
Speeding Penalties
If exceed by:
1 – 25 km/h: RM80 (6 demerit points)
26 – 40 km/h: RM150 (8 demerit points)
Over 40 km/h: RM300 (10 demerit points)
(Posted by: Vivian)
investigations of snoring
Investigations of snoring
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent time. Even if you have not done of some these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.
0= would never doze
1= slight chance of dozing
2= moderate chance of dozing
3= high chance of dozing
Situation chance of dozing
Sitting and reading _________________
Watching TV _________________
Sitting and inactive in a public place (theatre or meeting) _________________
As a passenger in a car for an hour without a break _________________
Lying down to rest in the afternoon when circumstances permit _______________
Sitting and talking to someone _________________
Sitting quietly after lunch( without alcohol) _________________
In a car, while stopped for a few minutes in the traffic _________________
TOTAL _________________
Normal 5 (plus minus 4)
Severe obstructive sleep apnoea 16 (plus minus 4)
Sleep nasendoscopy
Patients with a history of habitual, non-positional, heroic ( can be heard through a wall) snoring can be investigated by sleep nasendoscopy in which a sedated, snoring patient has a flexible nasendoscope inserted to identify the source of vibration.( after a full ear nose throat examination)
Simple studies
Video recordings
Detailed history from family members
Pulse oximetry
Polysomnography
Monitors oxygen saturation, airflow at the nose and mouth. Polysomnography is a comprehensive recording of the biophysiological changes that occur during sleep. The polysomnogram, or PSG, is usually performed at night, when most people sleep [[some labs can accommodate shift workers and do the test at other times). The PSG monitors many body functions including brain (EEG), eye movements (EOG), muscle activity or skeletal muscle activation (EMG), heart rhythm (ECG), and breathing function or respiratory effort during sleep.
For a polysomnogram, the EEG will generally consist of four "exploring" electrodes and two "reference" electrodes (unless a seizure disorder is suspected, in which case more electrodes will be applied to document the appearance of seizure activity). The exploring electrodes are usually attached to the scalp near the central and occipitial portions of the brain via a paste that will conduct electrical signals originating from the neurons of the cortex. These electrodes will provide a readout of the brain activity that can be "scored" into different stages of sleep (1, 2, 3, 4, REM, and Wakefulness).
EMG
EMG (Electromyogram)
Three leads are placed on the chin (one in the front and center and the other two underneath and on the jawbone) and two are placed on the inside of each calf muscle 2-4cm apart. These leads serve to demonstrate muscle movement during sleep. This is helpful in documenting a wake period, an arousal, or just a spastic movement.
Occurrence of 15 or more episodes of apnoea or hypopnoea during 1h of sleep indicates significant sleep apnoea.
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent time. Even if you have not done of some these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.
0= would never doze
1= slight chance of dozing
2= moderate chance of dozing
3= high chance of dozing
Situation chance of dozing
Sitting and reading _________________
Watching TV _________________
Sitting and inactive in a public place (theatre or meeting) _________________
As a passenger in a car for an hour without a break _________________
Lying down to rest in the afternoon when circumstances permit _______________
Sitting and talking to someone _________________
Sitting quietly after lunch( without alcohol) _________________
In a car, while stopped for a few minutes in the traffic _________________
TOTAL _________________
Normal 5 (plus minus 4)
Severe obstructive sleep apnoea 16 (plus minus 4)
Sleep nasendoscopy
Patients with a history of habitual, non-positional, heroic ( can be heard through a wall) snoring can be investigated by sleep nasendoscopy in which a sedated, snoring patient has a flexible nasendoscope inserted to identify the source of vibration.( after a full ear nose throat examination)
Simple studies
Video recordings
Detailed history from family members
Pulse oximetry
Polysomnography
Monitors oxygen saturation, airflow at the nose and mouth. Polysomnography is a comprehensive recording of the biophysiological changes that occur during sleep. The polysomnogram, or PSG, is usually performed at night, when most people sleep [[some labs can accommodate shift workers and do the test at other times). The PSG monitors many body functions including brain (EEG), eye movements (EOG), muscle activity or skeletal muscle activation (EMG), heart rhythm (ECG), and breathing function or respiratory effort during sleep.
For a polysomnogram, the EEG will generally consist of four "exploring" electrodes and two "reference" electrodes (unless a seizure disorder is suspected, in which case more electrodes will be applied to document the appearance of seizure activity). The exploring electrodes are usually attached to the scalp near the central and occipitial portions of the brain via a paste that will conduct electrical signals originating from the neurons of the cortex. These electrodes will provide a readout of the brain activity that can be "scored" into different stages of sleep (1, 2, 3, 4, REM, and Wakefulness).
EMG
EMG (Electromyogram)
Three leads are placed on the chin (one in the front and center and the other two underneath and on the jawbone) and two are placed on the inside of each calf muscle 2-4cm apart. These leads serve to demonstrate muscle movement during sleep. This is helpful in documenting a wake period, an arousal, or just a spastic movement.
Occurrence of 15 or more episodes of apnoea or hypopnoea during 1h of sleep indicates significant sleep apnoea.
Risk Factor of Snoring
The primary risk factor for OSA is excessive weight gain. The accumulation of fat on the sides of the upper airway causes it to become narrow and predisposed to closure when the muscles relax.
Age is another prominent risk factor. Loss of muscle mass is a common consequence of the aging process. If muscle mass decreases in the airway, it may be replaced with fat, leaving the airway narrow and soft.
Other predisposing factors associated with Obstructive Sleep Apnoea include:
Contributed by Lawrence Oh
Age is another prominent risk factor. Loss of muscle mass is a common consequence of the aging process. If muscle mass decreases in the airway, it may be replaced with fat, leaving the airway narrow and soft.
Other predisposing factors associated with Obstructive Sleep Apnoea include:
- sleeping pill or alcohol at bed time (they reduce the activity of the upper airway dilating muscles to a point where the airway collapses & becomes obstructed)
- nasal congestion from cold and allergies, especially it last a long time
- enlarged adenoid and tonsils that block the airway (main cause in children)
- smoking (cause inflammation,swelling and narrowing of the upper airway)
- Hypothyroidism, acromegaly, amyloidosis, vocal cord paralysis, post polio syndrome, neuromuscular disorder, Marfan's syndrome and Down syndrome
Contributed by Lawrence Oh
Phsychological aspects: snoring
While snoring may popularly be seen in some circles as a minor affliction, snorers can suffer severe impairment of lifestyle.
1.snoring strains interpersonal relationships
The between-subjects trial by Armstrong et al. discovered a statistically significant improvement in marital relations after snoring was surgically corrected.Studies have shown that there is a direct inverse relationship between snoring and frequency of sexual activity between married partners, meaning that there is generally less sexual activity if one of the partners is a heavy snorer.
Studies have shown that there is a direct inverse relationship between snoring and frequency of sexual activity between married partners, meaning that there is generally less sexual activity if one of the partners is a heavy snorer.
ie. "snoring BAD for sex life"
typical sex life of chronic snorers2.psychological discormfort to listener
Also, studies have shown that there is a psychological component in snoring which causes discomfort in any listener, depending on the loudness, tone, frequency, and other auditorial attributes of the snore. Listeners, mainly spouses also have difficulty sleeping at night.
"smoking causes psychological anguish"
Also, studies have shown that there is a psychological component in snoring which causes discomfort in any listener, depending on the loudness, tone, frequency, and other auditorial attributes of the snore. Listeners, mainly spouses also have difficulty sleeping at night.
"smoking causes psychological anguish"
Wednesday, 11 April 2007
Pathophysiology of sleep apnea
Definition - absence of spontaneous breathing or cessation of breathing
Causes/ pathophysiology:
1. obstruction of the upper airway (obstructive apnea)
2.impaired CNS respiratory drive (central apnea)
1. obstructive sleep apnea
(a) physiology of muscles of pharynx
-during inspiration- these muscles keep the airway open + allow the air to flow in
-during sleep - these muscles relax but the airway remains open ENOUGH to allow
adequate airflow (uncompromised breathing)
(b) pathophysiology
- in MINORITY ppl- have an especially narrow passage + relaxation of the muscles of
pharynx causes the airway to completely close (air cant flow )
-if the obstruction is incomplete, turbulent flow + vibration occur resulting in SNORING
-if narrowing progresses to the point of OCCLUSION or near occlusion, subjects will
increase inspiratory effort to try to breathe until the effort awakens* them but they have
no recollection (*long enough for the muscles to open the airway again)
- then a series of deep breaths are taken before the subjects rapidly returns to sleep,
snores and becomes apneoic once more.
- thus, resulting in fragmented, restless sleep +
-increase risk of stroke and hyprtension
-increses daytime drowsiness
-increase sympathetic activity
-increase heart rate
2. central sleep apnea
-disorders that cause cessation of the ventilatory drive during sleep include:
I) damage to the central resp centres
II) abnormalities of the neuromuscular apparatus
-patients may have decreased ventilation when they are awake although they are fully capable of normal VOLUNTARY breathing.
-during sleep, their breathing disorders worsen
-thus, resulting in more frequent episodes of apnea
-lead to decrease PO2 and increase in PCO2 (critical level is reached which will stimulate respiration)
-further results in restless sleep (with clinical features similar as seen in obstructive sleep apnea).
Prepared by : SRI MURNIATI and MADHURA
Causes/ pathophysiology:
1. obstruction of the upper airway (obstructive apnea)
2.impaired CNS respiratory drive (central apnea)
1. obstructive sleep apnea
(a) physiology of muscles of pharynx
-during inspiration- these muscles keep the airway open + allow the air to flow in
-during sleep - these muscles relax but the airway remains open ENOUGH to allow
adequate airflow (uncompromised breathing)
(b) pathophysiology
- in MINORITY ppl- have an especially narrow passage + relaxation of the muscles of
pharynx causes the airway to completely close (air cant flow )
-if the obstruction is incomplete, turbulent flow + vibration occur resulting in SNORING
-if narrowing progresses to the point of OCCLUSION or near occlusion, subjects will
increase inspiratory effort to try to breathe until the effort awakens* them but they have
no recollection (*long enough for the muscles to open the airway again)
- then a series of deep breaths are taken before the subjects rapidly returns to sleep,
snores and becomes apneoic once more.
- thus, resulting in fragmented, restless sleep +
-increase risk of stroke and hyprtension
-increses daytime drowsiness
-increase sympathetic activity
-increase heart rate
2. central sleep apnea
-disorders that cause cessation of the ventilatory drive during sleep include:
I) damage to the central resp centres
II) abnormalities of the neuromuscular apparatus
-patients may have decreased ventilation when they are awake although they are fully capable of normal VOLUNTARY breathing.
-during sleep, their breathing disorders worsen
-thus, resulting in more frequent episodes of apnea
-lead to decrease PO2 and increase in PCO2 (critical level is reached which will stimulate respiration)
-further results in restless sleep (with clinical features similar as seen in obstructive sleep apnea).
Prepared by : SRI MURNIATI and MADHURA
Anatomy of URT
Nose
-extends frm nostrils/nares to choanea
- facial part: - superior part – small nasal bones (medial)
- maxillae (lateral)
- inferior part – lateral and alar cartilages
- alar nasi (flared portion at lower end of nose) – alar cartilage and dense connective tissue
Internal chamber:
- nasal septum (bone and hyaline cartilage) divides nasal cavity into R & L nasal fossae
- roof – ethmoid and sphenoid bones
- floor – palate (separates nasal cavity frm oral cavity)
- vestibule – start of nasal cavity (int. chamber), bordered by ala nasi, stratified squamous epithelium n vibrissae (hair)
- ciliated pseudostratified respiratory mucosa – lines rest of cavity
– non-sensory epithelium
- goblet cells (secrete mucus)
- ciliated cells (drives mucous
twrds choanea)
- nasal conchae – superior, middle, inferior
- inferior conchae – erectile tissue (extensive venous tissue)
- meatus – narrow air passage beneath each conchae; narrowness ensures most air contacts mucous membrane
- olfactory mucosa – contain sensory cells tht detect odours
– covers roof of fossa and parts of septum and sup conchae
- lamina propria – mucous glands
– populated by lymphocytes (immune defense) and plasma cells (secrete
antibodies)
– large blood vessels tht help warm the air
Pharynx (throat)
Nasopharynx
-extends frm nostrils/nares to choanea
- facial part: - superior part – small nasal bones (medial)
- maxillae (lateral)
- inferior part – lateral and alar cartilages
- alar nasi (flared portion at lower end of nose) – alar cartilage and dense connective tissue
Internal chamber:
- nasal septum (bone and hyaline cartilage) divides nasal cavity into R & L nasal fossae
- roof – ethmoid and sphenoid bones
- floor – palate (separates nasal cavity frm oral cavity)
- vestibule – start of nasal cavity (int. chamber), bordered by ala nasi, stratified squamous epithelium n vibrissae (hair)
- ciliated pseudostratified respiratory mucosa – lines rest of cavity
– non-sensory epithelium
- goblet cells (secrete mucus)
- ciliated cells (drives mucous
twrds choanea)
- nasal conchae – superior, middle, inferior
- inferior conchae – erectile tissue (extensive venous tissue)
- meatus – narrow air passage beneath each conchae; narrowness ensures most air contacts mucous membrane
- olfactory mucosa – contain sensory cells tht detect odours
– covers roof of fossa and parts of septum and sup conchae
- lamina propria – mucous glands
– populated by lymphocytes (immune defense) and plasma cells (secrete
antibodies)
– large blood vessels tht help warm the air
Pharynx (throat)
Nasopharynx
- posterior to choanae and dorsal to the soft palate (uvula)
- receives auditory (Eustachian) tube and houses the pharyngeal tonsil
- inhaled air turns 90degrees downwards
- Passes only air
- Pseudofied columnar epithelium
Oropharynx
- space between soft palate and root of tongue
- contains palatine and lingual tonsils
- Passes air, food and drink
- Stratified squamous epithelium
Laryngopharynx
- begins wth union of nasopharynx and oropharynx at level of hyoid bone
- ends at level of circoid cartilage (start of oesophagus)
- Passes air, food and drink
- Stratified squamous epithelium
Larynx (voicebox)
- passageway for air between pharynx and trachea
- consists of 9 cartilages
- epiglottis: protects trachea frm foreign objects (keeps food and drink out of airway)
- glottis: sound production
~*Shantz*~
Monday, 2 April 2007
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