Monday, December 6, 2010

Good Morning everyone.

It was almost three o'clock when I started to write this post. I felt tired today actually and not really into writing this post but I have something to share here. It is not about specific person but it is simply about people. I used to think about sharing my personal life with other people by means of status or testi that can be posted in many social-networking websites. But, I simply refrained from doing that, perhaps because I do not really like writing. One of my goodfriends used to tell me that he does like to update status in every single thing he does because he believes that we have some private stuff that we do not need to share with all people. I agreed with him in some aspects. This trend seems to be increasing in many parts of the world (I simply mentioned this without looking at the statistic :p) Sometimes, I did ask myself some questions related to people behaviour (this does not mean that I do not look my own behaviour and attitudes). From what I could see is some people really like to share LOTs of things about their life in internet. From my perspective, some of the status seemed to be meant to show off. I did not purely say that this is true but perhaps I am right in some points. What is actually we want when mention something related to our life? Sharing, Revenge, Avenge, Attention or other intention? Name it!!! In some points in our life, we may feel that we wanted to do something to have attention from other people. It seemed to be good in some aspects because when we express our feeling especially when we are depressed, it would help to relieve or at least reduce the level of it. In some other aspects, it may develop attitude of grandiosity or narcistic (I simply used these words even though in most of the cases, it would not develop to these level). Some questions should we answer when we do something. (1) What is the purpose of doing that? (2) Is it neccessary? (3) Will it affect people perception toward us?

Other things that I would like to mention here in relation to "show off" word stated above is our attitude. Some people like to share about what they have in open social network. Think twice before we do this. We may have "things" to show off but do not think that we are the only one can afford that. There are a lot of people out there who are ten or 1000 times richer than you are, but they do not do such things. You may get everything you want but do you really appreciate it? My parents thought me to work for what we wanted in life. In primary school for example, I did not get Game Boy because I only managed to get 3 A 1 B and 1C in final examination. We were trained to collect money to get something we wanted and we appreciated from what we gained and got. Life is like a song. Everyone has their own song. They way of singing would determine your expression. In life, how much you get is no more important from how many things you can appreciate and be grateful of what we have. Life is also about perception. We may think that we are rich enough when we have 100 000 USD but other people who have 1 000 000 000 USD may not think the same way. Let's learn how to appreciate and be humble. This is simply my thought and one of many resolutions that I want to achieve this new year. I am not perfect at all to give comments to other people, simply my sharing session :) I did that sometimes. hehehehe .....I believe that everyone has their own reason for any single step taken in their life. It is up to us to choose or own pathway. Look forward and be confident :)

PS: Sharing is not always caring, friends. It may develop other feeling as well sometimes - hate.

Sunday, December 5, 2010

SNAP cafe

I had some difficulties in finding the right plca for my dinner last night because it was late when i went out... I asked Sid Midsui for recommendation, thanks for her even I did not go there. By the way, this is a cafe that I used to go before but only for snacks and chocolate. This time I went there for dinner.

This is the range of the prices:

Appetizer: Rp 15 000 - 20 000
(Shrimp coctail Salad, Caesar Salad, etc)
Vegetarians: Rp 14 500 -Rp 18 000
(Mushroom Satay, Vegetarians Fried Rice, etc)
Soups: Rp. 10 000 - Rp. 28 000
(Crab Asparagus Soup, Snap Tom Yam Talay Soup, etc)
Indonesians Delight: Rp. 16 000 - Rp. 30 000
(Selat Solo, Balinees Fried Rice,etc)
International Classic: Rp. 23 000 - Rp. 30 000.
(Spaghetti Napollietan, Chicken Gordon Blue, etc)
Fresh From the Grille: Rp. 17 000 -Rp 85 000.
(Australian Tenderloin Steak, Sukiyaki Roll, Grilled Australian Lamb loin, etc)
Dessert: Rp 8 000 - Rp. 20 000
(Tiramisu, Pudding, etc)
Burger and Sandwich: Rp 15 000 - Rp 30 000.
(Lasagna, Multi Decker Sandwich, Beef Burger, etc:
Other's or Lights Snacks: Rp 9 000 - Rp 23 000.
(Chicken Wings, French Fries, etc:
Drinks: less than Rp 20 000

This is again my solo tour in culinary aspect. I hope I can provide a piece of info to others.

Here are some pictures:

A cup of Hot Chocoloate :) I really like chocolate :)

Grilled Sirloin Steak with Mushroom. I like steak as well and the art of using fork and spoon :) You can choose other sauce......

Very comfy sofa :)

My table.

We can watch movie together here. One of the hang out place. I watched Julia Robert film here last night :)

If you like to spend time alone, here is also one of the best place. Not so many people around and you can choose your place: open air, indoor with many types of sofa and views :)

I think the taste is good and worth it!!

Wednesday, November 24, 2010

Relaku Pujuk

This is the song that I sang with my sister.... Even though we performed that in kareoke box, but we enjoy that. :)

Wednesday, November 17, 2010

Love The Way You Lie

This video was created for my sweet sister, Fairuz .... I love her.. :)

Song ( Love The Way You Lie ) ( Dance By Fit Pete )

Saturday, October 23, 2010

Eat Pray Love

Today, I would like to share some stories about my private life. I have been thinking about all these things for donkey years. Do I need to write in my blog or just keep it quiet. I was on my bed when I started to write, listening to ‘terrified’, by Katharine McPhee ft Zachary Levi, trying to make my heart calm from a bundle of thoughts that make me slightly depressed. But I must say that, I did not that depressed. So, here we go .......

I watched one movie before, Eat Pray Love..... I am sure that many people have already watched it. The story was about love basically, the typical one. Although, the story was typical, I really like the setting and the plot of the movie. It did not influence me much, but at least make me realize about something. Let’s start the story one by one. The different version of mine.

In that story, Julie Robert had chosen Italy for Eat. Me? Of course I could not afford to go Italy at the moment. Huhuhu....... So, I chose one of the restaurants near my place, Gadjah Wong Resto. I did not mention for the purpose of showing off. I was planning to eat Italian food, with hope that the taste would be delicious as I could get in Italy. Maybe I was too exaggerated. I went there alone and this was the third time I spent my dinner time there, the different was, I was alone at this time. When I arrived there, I chose a table in front of Country Song’s performers. Hoping to listen to some songs and eat something special there. The first main course that I chose was Seafood Lasagna, the Italian food I guess. The waiter told me that I needed to wait for 35 minutes for that. Oh my God! It was too long for me. Basically, I was not that hungry but I was alone. What should I do while waiting for my plate! I did not even bring my bag in which I always place my books. So, I decided to choose other menu under seafood, recommended by the waiter; Norwegian Salmon. For the drinks, I chose Cold Jasmine Tea. When the food served, I grabbed the knife and fork. Slightly shaking......... Maybe because I don’t get used to eat alone outside. I did not really like the food but tried to enjoy that with the music background that was dull. No matter what, I told myself that, Fitri, you need to remind yourself about the purpose of coming there. The taste did not reach my expectation. Maybe different people have different preference about the taste of the food or simply because I had eaten before I came. As some people said, hunger is a good sauce. Perhaps, I would go there again for another menu. Once in a blue moon.

Norwegian Salmon

(For the purpose of restaurant review: The price is Rp 105 000 + 10% tax Do give your feedback to me about the taste)

Pray is subjective for me. I do not need to find specific place to pray, asking something from my God. For me, I could simply pray everywhere as long as the place is appropriate for me. Not much to mention about this aspect because I believe that prayer that we recite for every single day is our secret between us and God. So, let it be.

This is the aspect that is very complicated for me. For some people, maybe it is something that is simple. But for me, to recite the word “I Love You” is really difficult because we need to use our heart for that as well. Not simply out tongue! Honestly, I rarely felt that. In my language, love has two meaning: Cinta or Sayang. Cinta means love and Sayang I could not really define it. One of my friends used to tell me something related to this magic word “love”. Commitment is other aspect that is important in relationship with your beloved one. If you are not ready, you won’t be ready forever. You need to be prepared for your commitment. This seems easy for some people to advice but not in term of performing it. I did not get into relationship because I do not feel like having it now. I hate commitment sometimes and I am not ready. The word ready is subjective to every single person. Or maybe just like my mum said that you have not found someone yet. I believe that love would come to anyone when the time is perfect. Just like other stories that we heard, someone got married with their own friend. But for how long we need to wait? Until the hell freezes over? I hope I made some people clear about this. I did not say that I am not going to search every nook and cranny to find someone with whom I could tie the knot, but simply it is not at the moment. I do not really bother about gossips related to me. But remember, we need to be responsible for what we have done. Other story about love is related to this phrase, ‘take it or leave’. “You can prefer to continue our relationship or we would not contact each other after this”. Why we need to be given this kind of choices? I felt like being caught between the devil and the deep blue sea. Friendship is always there for everyone who is willing to open their heart to other people.

I may seem like having relationship with someone but that is simply me. One of my high school teachers used to tell her students about a story of mine. She said that I would treat people the same. Perhaps she was right in certain ways. If you are willing to accept me the way I am and willing the share a part of your heart to me, I would probably do the same. For me, what we give is more important that what we get. I always tell myself about this, so that I could be sincere when doing something for my friends. People may expect to have closed friends, who always be there for you. I did feel the same way. Having closed friend to share whatever we want. But I did not think that I have that perfect friend for us. There is always something that we need to keep it secret. Not because I did not want to share, but sometimes I did not think that is proper to share. Yes, everyone has problem. When we feel like sharing our story, we tend to constrain ourselves from doing so because we are afraid that our friend do have other problems as well. I used to tell some of my closed friends, you are my best friend for me, but I do not expect you to address me as you best friend. Everyone, for sure has their own definition about that honoured term based on their experience and life before. So, I made myself more flexible in term of that. I always tell myself, do not expect much from other people because sometimes when our expectation is too high, we are easily hurt ourselves when we could not get it. Understanding is much more important. I am not that perfect in that, so forgive me when I did something wrong. The most important thing, I am grateful to have some closed friends. Thank God.

Sometimes, we want to be alone although we know how lonely we are. It is simply our reaction towards certain things. I did spend my time, doing some activities such as shopping, eating and spending my time at cafe alone. I wanted to dress up the way I wanted without being criticized by my companion, I wanted to read books at cafe and having someone to listen to me everything I wanted to say. Maybe, I wish too many things. Too many SIMPLE things. So, I prefer to spend my own precious time alone sometimes.

By the way, this is not the whole nine yards about myself, simply a part from my life. I did not want to condemn anyone here. This is the story that I wanted to write for a long time ago. After waiting for a month of Sundays, I could say that I felt better now. I always believe that we need to be careful of what we wish for, because you just might get it all, even something you do not want. Or simply you get nothing! Every cloud has its silver lining. Forgive me I did do something wrong because sometimes I do not know whether to wind a watch or bark at the moon.

Saturday, October 16, 2010

Low Back Pain:

Low back pain can be caused by many factors. One of the factors is spondylolisthesis. Spondylolisthesis is the anterior slippage of the vertebral body, pedicles and superior articular body. This leaves the inferior vertebra behind.

The causes:

Spondylosis, trauma, prior surgery, tumor, infection, surgery, congenital anomalies of lumbasacral junction and osteoporosis.

Sign and Symptoms:
a. Asymptomatic
b. Low back pain and hamstring tightness.
c. Shortened trunks and abdomen protuberance (due to extreme forward displacement of L4 on L5).
d. Cauda equine syndrome.

a. Tenderness near the slipped segment.
b. The “step”on deep palpation of the posterior segment above the spondylolisthetic joint.

a. Conservative therapy such as rest and physical therapy.

b. Surgery –

i. If the symptoms persisting for > 1 year that do not respond to conservative therapy.
ii. Scoliosis
iii. The slippage of > 50%
iv. Present of progressive neurologic deficit
v. Abnormal gait or postural deformity.

1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (images)

Cauda Equina Syndrome (CES)

This syndrome occurs due to the injury of the lumbosacral nerve roots in spinal canal.


a. Ruptured lumbosacral intervertebral disc
b. Lumbosacral spine fracture
c. Tumor
d. Hematoma in this region due to coagulopathy after lumber puncture in some patients.

Clinical Finding:

a. Saddle anaesthesia
b. Loss of bladder and rectal function.
c. Weakness and areflexia of the legs – loss of Achilles and patellar reflex.
d. Impotence
e. Low back pain.

Differential diagnosis:
a. Guillain-Barré syndrome
b. Lower spinal cord syndrome
c. Acute transverse myelitis

a. Surgical Decompression
b. Radiotherapy in metastatic tumor


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (images)


Spondylosis is the osteoarthritic spine that is usually affect cervical and lumbosacral spine. Usually, it occurs later in life. The clinical finding often does not correlate with radiologic finding such as pain is associated with minimal finding in CT, MRI or X-ray and vice versa. Osteophytes and hypertrophied facet can lead to radiculopathy because of the compression of the nerve roots in intervertebral foramen or lateral recess. Osteophytes arising from vertebral body can lead to central spinal canal stenosis. Moreover, other factors that contribute to nerve root compression is disc degeneration. Disc degeneration can lead to the reduction in cross sectional area of intervertebral foramen.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (images)

Thursday, September 9, 2010


Structure of haemoglobin

Human produces different kinds of haemoglobin during life; embryonic, fetal and adult. The structure of haemoglobin during different stage of life is different. Adult has two types of haemoglobin; major α2β2 and minor α2δ2. HbF (α2γ2) can be found during gestation. Basically, each globin enfolds a single heme moiety that consists of protoporphyrin IV ring and iron in ferrous state (Fe2+). A molecule of haemoglobin consists of four heme moiety that is capable of transporting up to four molecules of oxygen. It is hydrophilic exteriorly and hydrophobic interiorly. The pairing mechanism is important in this process because the excess or lack of one subtype of globins chain can lead to formation of insoluble precipitates that can cause damage to the red blood cells. The quaternary structure is maintained by bonds formed between globins chains such as α1β1 and α1β2.

Function of haemoglobin.

The function of haemoglobin is for the oxygen transportation to the cells. The affinity of haemoglobin reduces at lower pH and lower oxygen tension. At alveolus in which the partial pressure of oxygen is higher, oxygen tends to bind, at first slowly to haemoglobin then rapidly. This condition occurs due to the abrupt increase in haemoglobin affinity towards oxygen when some oxygen are readily bound to that molecules. At lower pH, oxygen is readily dissociates due to the Bohr effects. This is due to higher affinity of proton to deoxyhemoglobin. Other molecule that is important for oxygen affinity is 2,3-biphosphoglycerate. Haemoglobin in adult has higher affinity towards this substances compared to fetal haemoglobin. It is important to lower the oxygen affinity towards haemoglobin.


Fareez: Sumimasen. Menyū o onegaishimasu.
(Excuse me. Menu please)

Waiter: Dōzo.
(Here you are)

Fareez: Dōmo.
(Thank you)

Waiter: Nani ni nasaimasu ka.
(What would you like to have?)

Fareez: Chotto matte kudasai. Fairuz?
(Just a moment, Fairuz)

Fairuz: Watashi wa bifuteki to sarada.
(Beef steak and salad)

Waiter: Hai, bifuteki to sarada.

Fareez: Watashi wa piza to sūpu.
(Pizza and soup)

Waiter: Toppingu wa.

Fareez: Chotto matte kudasai. Watashi wa peparoni ga suki. Fairuz ga?
(Just a moment. I like pepperoni. How about Fairuz?)

Fairuz: Watashi wa masshurūmu ga suki.
(I like mushrooms)

Fareez: Onion wa?
(How about onion?)

Fairuz: Onion wa daikirai.
(I hate onion a lot)

Fareez: Sumimasen. Rāji piza onegaishimasu. Peparoni to masshurūmu.
(Excuse me. A large pizza, please. Pepperoni and mushrooms)

Waiter: O-nomimono wa.
(Anything to drink?)

Fareez: Omizu o kudasai.
(Water please)

Waiter: Hai, kashikomarimashita.
(Yes, certainly)

Saturday, August 28, 2010

My reservation

Hye friends, today we are going to learn Japanese on the basis of conversation. Maybe this is restricted to certain situations only but don’t worry. We will learn more and more together. Enryo shinaide to share  By the way, I am still learning Japanese. Hopefully, this session would help us 

Reservation of the restaurant:

Fareez and Fairuz are on the way to Western House Restaurant. They are going to have dinner there. Fareez is going to introduce his friends to Fairuz. Before that, he called the restaurant to make reservation first.

Host: Maido arigatō gozaimasu. Fituri de gozaimasu.
(Thank you for your patronage. This is Fitri. How can I help you?)

Fareez: Anō, konban, yoyaku o shitai-n desu ga.
(I would like to make a reservation for tonight)

Host: Hai, arigatō gozaimasu. Nan-ji goro?
(Yes, thank you. About what time?)

Fareez: Roku-ji desu.
(Six o’clock, please)

Host: Hai. Nan-nin-sama.
(Yes. How many people?)

Fareez: Futari desu.
(Two people)

Host: Hai. Kashikomarimashita. Onamae wa.
(Certainly. What is your name?)

Fareez: Watashi wa Fareez desu.
(My name is Fareez)

Host: Hai. Fareez-sama de gozaimasu ne.
(Mr Fareez. Is that correct?)

Fareez: Hai.

Host: Dewa. Roku-ji ni.

Then, six o’clock.

Fareez: Hai. Yoroshiku.
(Yes. Please take a good care of it for me – in this context)

Mask ventilation:

Basically, before we perform the procedure, we must evaluate about the ease or difficulty of airways management. Other than that, the distinction must be made between the ease of mask ventilation or intubation that is sometimes unrelated. One of the examples of these in this situation is obese person, suffers from sleep apnea but has a Mallompatti class I is difficult to ventilate but very easy to intubate.
Some examples of cases and management:
a. patient is not breathing and no evidence of foreign body – positive pressure ventilation.
b. awake patient with complete airway obstruction due to a foreign body – Heimlich maneuver.
c. Patient become unconscious and foreign body is visible – remove the reachable foreign body with finger or McGill forceps carefully.

Procedure of mask ventilation:
a. Proper positioning – sniffing position, jaw thrust and chin lift maneuver.
b. Use of appropriate size of nasopharyngeal or oropharyngeal airway.
Basically, there are two techniques in performing the mask ventilation. Before that, we must choose appropriate size of mask that can cover the nose and the mouth parts. Typical adult sizes are 3, 4 or 5.
1. The one handed technique:
Place the middle, ring and small finger on the mandible part and the thumb and index finger on the upper and bottom part by using left hand. Apply downward pressure by using thumb and index finger. The other three fingers are used to lift the mandible and extend the atlantooccipital joint. Right hand is used to ventilate the patient by using bag-mask.
2. The two handed technique:
In this technique, two person are needed; one the hold the mask and other one to perform the positive pressure ventilation. The placement of the fingers is slightly different. The index, middle, ring and small fingers of left hand are placed on the left body of the mandible to elevate the jaw anteriorly (jaw thrust maneuver). Similar procedure is performed on the right side by using right hand. Place the mask on the face. Then, both of the thumbs are placed on the mask and apply the pressure. Other person is required for positive pressure ventilation.
A bag valve device consists of self-inflating bag connected to oxygen on one end and a one way valve on the other side. This valve is then connected to the mask or other devices.

1. Emergency Medicine Procedure, Eric. F.R, Robert. R.S

Friday, August 27, 2010

Oropharyngeal airways:

imagae by:

This tube has semicircular shape and must only be placed in unconscious patient because of the risk of laryngospasm and vomiting. The size for adult are 8.0 cm, 9.0 cm or 10.0 cm. The size can be determined by locating the tube just beside the mouth and make sure that the tip is just above mandible angle. Yankauer suction catheter can be used to remove blood, secretions or vomit prior to insertion. The mouth part can be opened by using “scissors like action”. The tube is then inserted with the convex side of the curve facing upward, make sure that the tip is always in contact with the palate. Insert the tube completely. After that, rotate the tube 180 degree, so that the tube follows the curvature of the tongue. In the present of tongue blade, two methods can be used; 1. As mentioned above and 2. We can directly insert the tube with the convex side facing downward because the tongue blade can be used to depress the tongue. If the tube is either too small or too long, obstruction can occur. Too small tube causes the tongue to be forced against the pharynx and too long will cause the closure vocal cord by epiglottis. There are many uses of oropharyngeal tube such as protects endotracheal tube, facilitates the oropharyngeal suctioning by removing the tongue from the airway and protect tongue during seizure attacks.

1. Emergency Medicine Procedure, Eric. F.R, Robert. R.S

Thursday, August 26, 2010

Nasopharyngeal airways.

This device can be either soft rubber or plastic tube that can be used to maintain the airways in conscious, semiconscious and unconscious person. It connects the nostrils and the oropharynx. The inner diameter correlates with the lengths. The size used for adults is 30 or 32 French.
Before the insertion, it is important to select the most suitable size for nasopharyngeal airway. Application of lubricant and anaesthetic agent can be done before the insertion. If there is no contraindication, vasoconstrictor agent that is applied on nasal mucosa, can be used to prevent epistaxis. Next place the beveled tip to the nostril and make sure that this is always in contact with the septum to prevent to wrong insertion into middle or inferior turbinate. Make sure that the distal end at the external auditory canal. After the tube is completely inserted, it is rotated 90 degrees so that the tube concaves upwards. After that, supplementary oxygenation or positive pressure ventilation can be given.
Basically, some complications may result from nasopharyngeal airways such as laryngospasm or vomiting if the tube is too long, epistaxis and blood aspiration due to nasal mucosa trauma during insertion, as well as gastric distension and aspiration due to wrong placement of tube (esophagus).

Eye problem I (Report)

1. Anisometropia

I. Patient’s presentation.

Patient came with unequal reflective power. One of the eyes has 0 power and the other eye present with + 500. Fortunately, this patient does not have lazy eyes. Patient is 12 years old and just noticed the different when she got flu for few days. A test was performed, and the result was 23.4 mm for one eye and 25 mm for another eye.

II. Expert’s explanation.

According to the doctor, 1 mm different is equal to +300. A test basically, measure the length of the eye ball and can also be used to detect the abnormality present in anterior chamber or posterior chamber such as vitreous haemorrhage. We can differentiate this by looking at the wave present in certain distance. The doctor suggested the eye glass but this can cause dizziness because of the different in refractive power of the eyes are too far. Special contact lens may be useful to this patient. LASIK can be performed if this patient is 18 years old and above.
Eye development occurs from 0 to 8 years old. Education to the patient include reading distance is 1 ft far.

2. Posterior vitreous detachment.

I. Patient’s presentation.

Patient came with complaint of having visual disturbance. Patient said that he always see something floating that disturb the vision. The shape may be look like a thread or a mass.

II. Expert’s explanation.

Posterior vitreous detachment is related to aging process. With time, our vitreous body tend to become less concentrated. The process usually started from posterior part of the body. Through slit lamp examination, we could see the bubble floating at the posterior part of the vitreous body.

3. Convergent strabismus

I. Patient’s presentation

Patient came with convergent squint appearance. Several test were performed; these include visual acuity test, eyeball movement test.

II. Expert’s explanation

This case must be checked carefully whether the children really has strabismus or simply has wide distance between the eyes. The patient must be checked for the ability of the abductor muscle function as well to exclude other possible disease.

4. Diabetic retinopathy

I. Patient’s presentation

a. Case one.

Patient is admitted to the hospital due to the complication of diabetes mellitus. She has reduced kidney function. Her kidney function is 10 % only. The eye seemed to be present with the characteristic of proliferative diabetic retinopathy. The doctor recommended laser treatment to remove the haemorrhage and yellow exudates. This treatment can be made twice or trice depending on the result of the previous laser treatment.

II. Expert’s explanation

The other appearance that can be seen is neovascularisation, spot of hemorrhage, and yellow exudates. Yellow exudates are hard and soft exudates may be present sometimes. The treatment given to the patient was pan retinal coagulation. Depending on the location of neovascularisation, different manifestation of the disease can be present. Neo-vascular glaucoma can be seen in patient if the blood vessel growth in the area near to the iris. The growth leads to the blockage of fluid outflow in anterior chamber, resulting in glaucoma.
Laser treatment is indicated to stimulate RPE and remove microaneurysm. In this case, ischemic may occur, and VEGF is increased in this condition, lead to neovascularisation.

5. Autoimmune disease uveitis

I. Patient’s presentation

Patient came with complaint of outgrowth appearance of the iris.

II. Expert’s explanation.

After several examination were done, the doctor said that it may be related to the collagen disease such as systemic lupus erythematous, sarcoidosis and etc. Antibodies complex formed may lead to inflammation and steroid is prescribed to reduce the inflammation. Steroid sparing is also given in order to reduce the side effects of the steroid use. Iris growth is related to the attachment of the cells, proteins and other exudates that are sticky. Medication for this is the drug that can lead to dilatation of pupil.

6. Traumatic eye.

I. Expert’s explanation

Trauma of the eye can cause many abnormalities such as torn iris, corneal abrasion, ulcer and etc. Complications of trauma include glaucoma and cataract. Ulcer is the term used to describe the tearing of the corneal part that involves Bowman’s layer or stroma. It may be associated with infection if we can find exudates around the ulcer.

7. Bullous keratopathy.

I. Expert’s explanation

In this case the doctor do not use applicant tonometer but he used tono pen because the surface of the cornea is not even. The treatment include cornea transplantation.

Peptic Ulcer Disease.

Chief complaint:

Follow up case.

Present history:

Patient came with intermittent abdominal pain. She also had postprndial pain, but there was no vomiting symptom complained. Urination and defecation were normal according to her.

Past history and family:

Supporting exam:
i. Endoscopy exam – fundal erosion.
ii. Pronto dry test - positive




HP7. This includes two antibiotics and controloc. Valcopan is also given for bloating symptom.

Literature review:


Duodenal ulcer (DU):

The most common site for DU is the first portion if duodenum (95%) with about 90% located within 3 cm from pylorus. The diameter is usually 1 cm or less than that but giant ulcer is possible (3-6 cm). The depth at times reaching muscularis propria and the ulcer is well demarcated.

Gastric ulcer (GU):

Malignancy is not rare in GU. Benign GU is that is associated with H.pylori is also related to antral gastritis. The site that is most common affected in benign GU is the distal part to the junction between the antrum and acid secretory mucosa. Basically, the NSAIDs related GU is different because it is related to chemical gastropathy and typified by foveolar hyperplasia, edematous lamina propria and epithelial regeneration without evidence of H.pylori infection.


Duodenal ulcer (DU):

The causes related to this disease is H. Pylori infection and NSAIDs –induced injury. The basal and nocturnal acid secretion is increased in DUs but bicarbonate secretion in duodenal bulb is decreased in some patients.

Gastric ulcer (GU):

The pathogenesis are similar; NSAIDs and H. Pylori infection. Acid secretion (basal and stimulated) is normal or decreased and there is impairment in mucosal defence. In some GU patients, abnormalities in resting and stimulated pyloric sphincter with a concomitant increased in duodenal gastric reflux can be detected.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.

Monday, August 23, 2010

Ascending colon cancer

Chief complaint:

A Chinese man came to the clinic for follow up for his cancer (post surgery) – Day 19

Present history:

On his follow up day, the patient complained about mass on his surgery site.

Past history and family:

Not mentioned.

Supporting exam:

Biopsy – stage B,


Ascending colon cancer stage B.


Rest from heavy activity for 3 months.
Expert’s explanation:
Colonoscopy for every one year for 5 years are indicated.

Literature review:

Polyps pathogenesis;

Adenomatous polyp is mostly related to the colorectal cancer development. Polyp is the gross visible protrusion of the mucosa surface. Basically, there are three classification of polyps; nonneoplastic hamartoma, a hyperplastic mucosal proliferation , or an adenomatous polyps.

Diagnostic tools:

Fecal Occult Blood Test (FOBT), digital rectal examination (DRE), rigid or flexible sigmoidoscopy, radiography barium contrast studies or colonoscopy. The complete diagnosis of adenomatous polyps detected by sigmoidoscopy should be confirmed with barium enema or colonoscopy.

The rigid sigmoidoscopy can detect a quarter or third of polyps can be detected by rigid sigmoidoscope.

Risk factors:

1. Diet:
i. Animal fats- the risk increase when there is an increased in calories, meat proteins, dietary oils and fats as well as elevation of serum cholesterol level. The increased in the consumption of red meat and processed meat can lead to the increased in anaerobs in intestines that can lead to the conversion of bile acids into carcinogen.
ii. Insulin resistance
This condition can lead to the increased in insulin-like growth factor type 1 that can stimulate the proliferation of intestinal mucosa.
iii. Fibers
2. Hereditary syndrome; polyposis coli or non-polyposis syndrome.

3. Inflammatory bowel disease.
Ulcerative colitis has more tendency developing cancer compared to granulomatous colitis.

4. Streptococcus bovis bacteremia.
The reason is unknown but person who has history of endocarditis or septicaemia due to this bacterium has high incidence of developing occult colorectal cancer as well as upper gastrointestinal cancer.

5. Tobacco use?

6. Ureterosigmoidostomy.


Basically, aspirin and other NSAIDs can be used in order to inhibit prostaglandin synthesis that can suppress the proliferation. Moreover, oral folic acid and oral calcium reduce the adenomatous polyps and colorectal cancer. Oestrogen replacement therapy is thought to reduce the risk conceivably by an effect on bile synthesis and composition as well as decreasing the synthesis of IGF-I.


1. Harisson's Principle of Internal Medicine, 17 th edition.

Multiple Sclerosis: (image)

MS is characterized in triad inflammation, demyelination and gliosis. The course can be remitting-relapsing or progressive.

The pathogenesis:

Acute MS lesions are characterized by perivenular cuffing with inflammatory mononuclear cells, predominantly T cells and macrophages, which also infiltrate the surrounding white matter. At sites of inflammation, the blood-brain barrier (BBB) is disrupted, but unlike vasculitis, the vessel wall is preserved. In many lesions, myelin-specific autoantibodies are present, presumably promoting demyelination directly as well as stimulating macrophages and microglial cells (bone marrow–derived CNS phagocytes) that scavenge the myelin debris. As lesions evolve, there is prominent astrocytic proliferation (gliosis). Surviving oligodendrocytes or those that differentiate from precursor cells may partially remyelinate the surviving naked axons, producing so-called shadow plaques.

Physiologically, saltatory conduction occurs in myelinated neurons only resulting in much faster velocity (70 m/s). If myelin is removed because of certain condition such as MS, there will be a phase in which potassium ions voltage dependent gated channels wrapped with myelin are exposed. The exposure leads to hyperpolarized resting potential. A temporary conduction block occurs before the redistribution of sodium ions channels.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (image)

Bell’s palsy: (images)


One of the causes of facial paralysis.


Fairly abrupt with maximal weakness being attained by 48 hours.

Sign and symptoms:

a. Unilateral loss of the taste.
b. hyperacusis
c. Pain behind the ear – precede before the paralysis a day or two.


It is related to the present of Herpes simplex virus DNA in endoneurial fluid and posterior auricular muscle.This may be related to the reactivation of the virus in geniculate ganglion.Moreover it is reported that, there is an increased incidence of Bell’s palsy in recipient of inactivated intranasal influenza virus. This is thought to be caused by the adjuvant used, Escherichia coli enterotoxin or reactication of latent infection.


Diagnosis can be made if clinically if these symptoms present; (1) a typical presentation, (2) no risk factors or pre-existing conditions related other causes of facial nerve palsy. (3) no cutaneous lesion in external auditory canal indicating herpes zoster infection. (4) normal neurological exam with exception of CN VII.

Supporting exam:

MRI- swelling and uniform enhancement of the geniculate ganglion and facial nerve. In some cases, There is an entrapment of the swollen nerve in temporal bone.


1. Using paper tape to depress upper eyelid during sleeping to prevent corneal dryness.
2. Massage of the weakened muscle.
3. Glucocorticoids: prednisolone 60 – 80 mg for the first 5 days and then tapered for the next 5 days.

1. Harisson's Principle of Internal Medicine, 17 th edition.
2. (images)

Wednesday, August 18, 2010

Perineal fistula

Abscess (

Anorectal abscess.

Epidemiology and incidence.

Man is more common than women; 3:1. The peak incidence is between 3rd to 5th decades. The disease is more common in immunocompromised patient such as diabetics, HIV positive patient and those who have hematologic problems or IBD patients.

Anatomy and pathophysiology:

Usually, mucous glands surrounding the anal canal secrete mucus that helps in defecation. Sometimes, stool can accidentally enter the gland and as a result, the gland become infected and abscess develops. Anorectal abscesses include; perianal in 40-50 %, ischiorectal in 20-25 %, intersphincteric in 2-5 % and supralevator in 2.5 %.

Presentation and evaluation:

The hallmarks of abscess are fever and perianal pain. Moreover, patient may have difficulty in voiding and blood in the stool. The differential diagnosis of anorectal abscess is prostatic abscess but dysuria is also present in prostatic abscess.

Evaluation can be made by using naked eye, because a large fluctuant area can be seen. Routine lab exam reveals elevated WBC. CT scans or MRI can be used to evaluate the incomplete drainage. Rigid or flexible sigmoidoscopy can be used to evaluate IBD during drainage of the abscess when this condition is concerned. Furthermore, colonoscopy and small bowel series can be used to evaluate Crohn’s disease.

Office drainage in uncomplicated case is sufficient. A small incision close to the anal verge is made and Mallenkot drain is advanced into the abscess cavity for drainage purpose. Drainage in operating theatre under anaesthetic should be performed in complicated abscess or in diabetic patients or in immunocompromised patients. The risk of getting necrotizinf fasciitis os greater in those mentioned patients. Antibiotics treatment should be given for at least two weeks in patient with diabetes mellitus, IBD, immunocompromised, having prosthetic heart valves, or artificial joints.

Fistula in ano

Incidence and epidemiology:
The majority of fistula is cryptoglandular in origins. Other 10 % is associated with TB, IBD, malignancy and radiation. The incidence and prevalence of this disease is parallel to anorectal abscess.

Anatomy and pathophysiology:

The definition of fistula is the communication of the abscess cavity and anal canal with an identifiable internal opening (mostly located at dentate line).
70 % of fistula is intersphinteric, 23 % is transsphinteric, 5 % is suprasphincteric and 2 % is extrasphincteric.

Presentation and evaluation:
Usually, patient comes with complaint of constant perianal drainage that can be increased during defecation.

Evaluation can be made under anaesthesia that is preferable. Anoscopy can be used to detect the internal opening. Dilute hydrogen peroxide can also be used to help in identifying such opening. MRI with endoanal coil can be used as well. In order to identify the occult fistula tract, fistulogram can be performed after the drainage procedure by using Mallenkot catheter.
Goodsall’s rule stated that the posterior external fistula enters the anal canal through posterior midline and the anterior external fistula enters through the nearest crypts. This rule does not apply on the case in which the existing fistula is > 3 cm from the anal verge.


1. Harisson's Principle of Internal Medicine, 17 th edition.

Monday, August 16, 2010

A penny of my thoughts

This is not the story about a rich man who lives high on the hog. Nor the story about the most popular celebrity in the world like Lady Gaga or Justin Bieber. This is simply a story about me, Fitri Fareez bin Ramli a.k.a Fit Fred. A person who is still trying hard to find his identity. Today, I would like to share my experience, perhaps a penny of my thoughts with anyone who are reading this blog.

I went to my previous high school before for sharing session with my sisters and brothers who are going to sit for SPM examination. There were only Malays present there because it was Friday session (morning session). Honestly, I was not invited. I asked my teachers whether I could have a session with a group of students. People may think something, but do I care about that because I just want to share. i just wanted to grab some opportunities during my Hols. I told myself that I must do something at least to improve myself. I gave some advices to them. Be ahead of the packs or at least at same level. I prefer above par. Everything we do, at least we must put an effort to be what I have just describe. Just focus on what we are doing. We just need to be different and do something that is different. Maybe I am not like some of my friends who could afford to go abroad for attachment but I told myself that I could have it done in my lovely country. Everyone has a dream. Me too. I want to go Europe for hols and study. Do I need to wait for donkey's years? Deep in my heart, I believe that it is just a matter of time. Like what my mom always tell me. Don't get me wrong. Maybe you will say that I am not grateful. This is not the case, I am very grateful with what I have been having until now.

Back to my stories today, I am very bushed. Do you know why? I did burn the candles at both ends last night, but I did not mean to do that. I wake up late the day before. I have not pay the piper yet... Feeling fatigue and sleepy. I went to the hospital today to see all my mentors to get signature for my book that I produced. I was really glad to see them because they always inspire me to be a very good doctor. I don't need to talk much about them because I know I had write their stories before. Only two words for them, Amazing and great! Perhaps, I am going to hit the sack after dawn's prayer.

I put some of my pics with my great mentors:

PS: I would like to say thanks a million to my parents, siblings, nurses, and best friends of mine ( you all know who they are) :) for your support :)

Dengue Fever.

(Image :

The vector of dengue fever is Aedes Aegypti that is also the vector of yellow fever and chikungunga fever. This breeding side of this mosquito is fresh water from sources such as coconut husks, discarded containers, old tires, vases and water jars. Basically, there are for types of serotypes of dengue virus. In rare case, second infection by different serotype lead to hemorrhagic fever. The incubation period of dengue fever is 2 – 7 days. There are a lot of clinical manifestation such as fever, headache, retroorbital pain, back pain, and myalgia. On the first day, sometimes we can find macular rash as well as sclera injection, adenopathy and palatal vesicles. Other manifestations include anorexia, nausea and vomiting and marked cutaneous hypersensitivity. Maculopapular rash can be found on the trunk that later spread to the extremities and face near the time of defervescence. Petechiae, epistaxis and gastrointestinal bleeding may occur.
The lab tests that can performed in order to support the diagnosis are CBC and IgM ELISA, paired serology during recovery, antigen detection ELISA or RT-PCR during the acute phase. CBC result showed leukopenia, thrombocytopenia, and in some cases, elevated serum aminotransferase level.



1. Harisson's Principle of Internal Medicine, 17 th edition.

Pleural Effusion (image)

Gout and pleural effusion:

Literature review: (image)

Pleural effusion:
The etiology:

Pleural effusion result when the is an excess fluid accumulates in pleural space. The fluid enters pleural space from capillaries in parietal pleura, from peritoneal cavity through small holes in diaphragm as well as from interstitial space of the lung through visceral pleura. The lymphatic situated in parietal pleura has capacity to remove 20 times more fluid than it is formed. If there is a decreased in fluid absorption by lymphatic or excessive fluid formation by parietal pleura, peritoneal cavity or from the interstitial fluid of the lungs.

Diagnostic approach:

The first step to diagnose is to differentiate between exudate and transudate pleural effusion. Transudative pleural effusion is caused by the disturbance in pleural formation and absorption due to local factors such as viral infection, bacterial pneumonia, malignancy and pulmonary embolism. Transudative pleural effusion is caused by systemic factors such as cirrhosis or left ventricular failure.
Thoracentesis should be performed. Then, the level of LDH and protein can be obtained and compared with the serum. Basically, exudative pleural effusion meets at least one of the following criteria:

a. pleural fluid LDH/ serum LDH > 0.6
b. pleural fluid protein/ serum protein > 0.5
c. pleural fluid LDH more than two third normal upper limit for serum.

Approximately, 25 % of transudates is misidentified as exudates. If one or more criteria above are met, the level of serum protein and pleural protein should be measured and the difference should be more than 31 g/L (3.1 g/dL) to eliminate exudative pleural effusion.

1. Effusion due to heart failure.

The most common cause of pleural effusion is left heart failure. The mechanism is related to the increased in interstitial fluid volume that diffuse into pleural cavity. The capacity of lymphatic in parietal pleura is always insufficient to remove excessive fluid. Patient can be treated by using diuretics. If the pleural effusion is not bilateral and comparable in size, if the patient is febrile or if the patient has pleuritic chest pain, thoracentesis must be performed to verify whether transudative effusion is present. If the effusion persist after diuretics treatment, thoracentesis should be done. If the pleural N-terminal pro brain natriuretic peptide (NT-proBNP) is >1500 pg/mL, we can conclude that, this pleural effusion is caused by secondary to congestive heart failure.

2. Hepatic hydrothorax
This is due to cirrhosis and ascites. The mechanism is related to direct movement of fluids from peritoneal cavity into pleural cavity through small openings in the diaphragm. The effusion is usually right sided. This is always large enough to produce severe dypsnea.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.


Wednesday, August 11, 2010

Toxic multinodular goiter. (Report)

Chief complaint:

A 56 year-old Malay female came to the clinic for follow up for her disease before.
Present history:

She said that sometimes, she felt breathlessness when she needs to climb up the stairs.

Past history and family:

She has history of asthma before.

Physical exam:

BP 135/80. Weight – 65.5 kg in January and 66.0 kg in July.

Supporting exam:

Not performed. Suggested test is stress test.


Toxic multinodular goiter.



Literature review:

Non toxic Multinodular Goiter

Etiology and pathogenesis:

MNG is more common in women and the prevalence increase with age. The population affected is more common in iodine-deficient area but it also occurs in iodine-sufficient area. This showed that other factors may also play role in pathogenesis – genetic, autoimmune and environment.

The nodules size varies in size. The morphology varies from hyperplastic to cystic filled with colloid. Fibrosis is always extensive. Area of hemorrhage and lymphatic infiltration can be seen. Most of nodules with MNG are polyclonal in origin due to locally produced growth factors and cytokines. Monoclonal lesions also occur within MNG. This is due to the mutation of certain genes that confer some specific growth advantage to the progenitor cells.

Clinical manifestation:

The clinical manifestation can be divided into two; asymptomatic and symptomatic. MNG usually develops many years. It is detected through physical examination or when the individual detects the enlargement of the thyroid gland. If the enlargement is large enough, it can cause compressive symptoms such as swallowing difficulty, respiratory distress, or plethora (venous congestion). Sudden pain is due to the hemorrhage into a nodule. This should raise susceptibility to malignancy. Hoarseness may indicate laryngeal nerve involvement that is due to malignancy.


Thyroid gland is distorted. If the nodules are located deeply or reside in posterior or substernal location, other method should be used. TSH level should be tested. Trachea deviation is common. The compression symptom is appeared when the compression exceed 70 % of tracheal diameter. Pulmonary function test can be used to detect tracheomalacia or functional effect of compression. Barium swallow can also be used for the detection of tracheal compression (extension). CT scan or MRI can be used to observe the anatomy of goiter as well as the extend to the substernal area. USG can be used to identify which nodule should be biopsied or with sonographic characteristic for malignant detection.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (photo)

Tuesday, August 10, 2010

Tics (Tourette Syndrome)


Brief,rapit,recurrent, and seemingly purposeless stereotyped motor contractions.


Sensory – unpleasant feeling of the face, neck, or head.

Motor tics:
a. simple – Involve individual muscle group. For example – blinking, twitching of the nose or jerking of the neck.
b. complex – with coordinated movement of groups of muscle. For example – sniffing, jumping, head banging and echopraxia.

Vocal tics:
a. simple – Grunting
b. complex – echolalia (repeating other people words), palilalia (repeating your own words) or coprolalia (expression of obscene words)
The characteristics: vocalization and multiple motor tics.

Genetic factors.


Proposed: Alteration in dopamine neurotransmission, opiods and second messenger system
. Treatment:

Education and behavioural therapy for mild disease.


Clonidine (alpha agonist)
Guanfacine (alpha agonist) – once-a-day.
Atypical neuroleptic (risperidone, olanzepine or ziprasidone) – reduce risk of extrapyramidal side effects.
Botulinum toxin for focal tics.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.

Uncontrolled Diabetes Mellitus - Skin

Dermatologic manifestation:

DM is always associated with protracted wound healing and skin ulceration. Diabetic dermopathy is pigmented pre tibial papules. This feature develops as erythematous area that is then transformed into an area of circular hyperpigmentation. Bullosa diabeticorum is a shallow ulceration or erosion in pretibial region. Moreover, necrobiosis lipoidica diabeticorum is other DM manifestation that is rare and present in young women with DM type 1, neuropathy and retinopathy. This may be painful. This lesion is always develops at pretibial region with erythematous plaques or papules that gradually enlarged, darken, and develop irregular margins, with atrophic centre and central ulceration.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (photo)

Headache (Report)

Chief complaint:

Patient has headache with 2- 3 times traction feeling of the head.

Present history:

Patient does not have headache at night. Headache usually comes when patient is in resting condition. Patient stated that he is not depressed and does not think about something too much. The patient has hypertension and claimed that he does not have history of asthma. He has been taking anti-hypertensive medication for about 4 years.

Past history:

This patient has been suffering from this headache since 10 years ago until now. The symptom comes and goes intermittently. From history taking, the doctor managed to figure out the occupation of the patient. He works from 9 pm until 5 am for the past 20 years until now.

Supporting exam:

MRI result is normal.
The lab result showed that he has high LDL and low HDL.


Migraine with anxiety related.

Literature review:

Migraine is the second most common cause of primary headache. It is usually accompanied with certain features such as sensitivity to light, sound or movement; nausea and vomiting. It is a benign and recurring syndrome of headache with neurologic dysfunctions. There are many triggers that lead to migraine; glare, bright light, sound or other afferent stimuli; lack or excessive sleep; hormonal changes during menses; alcohol intake; physical exertion; hunger; stress; chemical stimuli.

It is related to the dysfunction of monoaminergic sensory control systems that is located in brainstem and thalamus.

In order to diagnose migraine, we need to have headache lasting for 4- 72 hours, with normal physical examination and plus another symptoms written below:
At least two features: throbbing pain, unilateral pain, aggravation by movement, moderate to severe intensity.
One of the following symptoms: photophobia and phonophobia, nausea/vomiting.

Differential diagnosis: Vertigo

Early migraine attack can be treated effectively with NSAIDs such as ibuprofen or naproxen. Moreover, the combination of aspirin, paracetamol and caffeine can also be used. Other drugs that can be used are ergotamine and sumatriptan.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo
2. (photo)

Dystonia (Report)

Chief complaint:

Patient came with chief complaint of neck stiffness

Present history:

He was unable to turn his head right because of dystonia. The patient has been suffering from this disease for about 2 years.

Past history:

He had no past history before the onset of the disease 2 years ago.
Family history:

There is no family history related to similar case.

Physical examination:

Stiffness of the neck especially right sternocleidomastoid muscle. Other muscles involved include scalene muscle and trapezius muscle.

Torticollis, idiopathic dystonia.

Literature review:

Definition: Sustained or repetitive involuntary contraction of muscle, causing twisting movement and abnormal posture.


The basis is unknown, but associated with a loss of inhibition at multiple levels and associated with increased cortical excitability and reorganization. Some types of dystonia are associated with alterations in blood flow and metabolism in basal ganglia structures.

Types: (Basis)

a. Age: childhood vs adult
b. Etiology: primary or secondary
c. Distribution: Focal, multifocal, segmental, or generalized.
Aggravated by: voluntary movement and later become sustained.
Focal dystonia:
Most common types of dystonia that affect more women than men in their 4th to 6th decades.
1. Blepharospasm: dystonic contraction of the eyelid with increased blinking.
2. Oromandibular Dystonia (OMD): The contraction of the lower face, jaw, tongue, and lips with alternate opening and closing of the mouth. Meige’s syndrome is the combination of both blepharospasm and OMD.
3. Spasmodic dysphonia: Depending the type of the muscles affected. If abductor muscle is affected, it can produce breathy or whispering speech quality. If adductor muscle is affected, it can produce strained or choking quality of speech. Basically, the speech is impaired in both types.
4. Cervical dystonia: Dystonic contraction of neck muscles. Basically, the type produces depend on the direction of distortion; anterior (anterocollis), side (torticollis) and backward (retrocollis). Symptoms associated include painful muscular contraction, with dystonic tremor and sometimes with cervical radiculopathy.
5. Limb dystonia: It affets arms or legs and often associated with task-specific activity.

1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (photo)

Post-Traumatic Stress Disorder. (Report)

Patient’s presentation:

Patient came with sad emotion. She had history of accident one week ago. Her husband died few years ago. According to her, she lost the car that was bought by her husband. She is a teacher. She told the doctor about her ambitions and future planning. But her face expression turned into sad expression when she started to talk about her accident and husband. According to her son, she was not like this before. She has difficulty in sleeping.
Expert’s explanation:

She is suffering from PTSD. Because of her behaviour that always share her sadness with other people, this may help her in reducing her stress and cope with the condition. According to the doctor, women have higher tendency to cope with this kind of situation because of the attitude. She is also suffering from other disorder such as phobia, anxiety and depression.
Literature review:

The pathophysiology of PTSD is related to the excessive release of norepinephrine in locus coeruleus. Moreover, there is an increased in noradrenergic activity at the projection sites in the hypothalamus and amygdala. Meaning that, this is associated in fear-based memories.

Risk factors of PTSD are associated with a past psychiatric history and personality characteristics of extroversion and high neurotism.


1. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.
2. (photo)

Diabetic Neuropathy

Expert’s explanation:

This is kind neurologic problem is common in diabetic patients. The nerve conducting test was conducted to stimulate muscle at distal part and to be detected by nerve fiber at the proximal part. In both upper and lower limbs, three types of electrodes were used; one for ground electrode, two for muscle stimulator and another one for detector. Basically, this condition is difficult to be cured.

Literature review:

The pathogenesis of symmetrical peripheral neuropathy is related to the nerve ischemia. The pathology of this is related to axonal degeneration or segmental demyelination with the former predominating. There are occasionally, the axonal degeneration preferentially affects large myelinated fiber or small myelinated and unmyelinated fibers.

The pathogenesis of complication of diabetes mellitus is related to the accumulation of advanced glycosylation end products (AGE). This process involves the bridging of glucose and amino groups of protein via non-enzymatic reaction. This is usually resistant from proteolytic action and tends to increase with age. Diabetes Mellitus accelerates the process. As a result of this process, many reactions proceed. It accelerates the atheroscelrosis process, promote glomerular dysfunction, reduce nitric oxide synthesis, induce endothelial dysfunction, and alter extracellular matrix composition and structure.

Neuropathy related to DM is divided into mononeuropathy, polyneuropathy, and/or autonomic neuropathy. The risk factors include duration of DM, glycemic control, BMI and smoking. Other factors are hypertension, high triglycerides level, and the present of CVD.

The most common form of neuropthy is distal symmetric poly-neuropathy. Paresthesia, hyperesthesia, and dysesthesia may occur in combination as neuropathy progress. Symptoms present may include numbness, tingling, sharpness or burning that begin in the distal of the feet and progress proximally. Neuropathic pain may develop in certain individual and may be present at rest and worsens at night. This pain will subside as the disease progress but the loss of sensory deficit persists. There will be abnormal position sense, sensory loss, and loss of ankle reflex.

In normal adult, the conduction velocity of the arm is normally between 50 to 70 m/s and in the leg is normally between 40 to 60 m/s.


1. Rubin's Pathology : Clinicopathologic Foundations of Medicine, 5th Edition, Rubin, Raphael; Strayer, David S.
2. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo,


There are several factors that are associated with sleep:

Parts of the brain:
Raphe nuclei in the lower half of the pons and in the medulla is a very important nuclei in promoting natural sleep. These nuclei nerves fibers extend to the brainstem reticular formation, upwards to thalamus, hypothalamus, parts of limbic systems, as well as neocortex. Other than that, nerve fibers from these nuclei also extend downward to the posterior horn of spinal cords. This is important for inhibiting sensory signal including pain. Most of the nerve endings from these nuclei secrete serotonin.

Some areas of nucleus of tractus solitarius. Visceral sensory signal entering pons and medulla by the way of glossopharyngeal and vagus nerve are terminated by these nuclei.
Several regions in diencephalon such as suprachiasmal area (the rostral part of hypothalamus) and occasional diffuse regions in thalamus.

Basic theory of sleep was thought to be caused of passive mechanism in which the reticular formation simply became fatigue during waking hours but this theory has been replaced with active theory of sleep in which the activation of several centre mainly below the mid pontine level are important for sleep induction.


1. Textbook of Medical Physiology, 11th edition, Guyton and Hall.
2. (photo)

cintamu mekar di hati (cover) by Fairuz Hidayah Lush

This song is performed by my sister, Fairuz Hidayah Lush... Hope you enjoy :)

Wednesday, July 28, 2010


TodaY, I felt very tired..... and exhausted .. maybe because I did not have enough sleep. On Sunday, i just slept for 3 hours, on Monday, I just slept for less than 4 hours and on Tuesday I slept for less than 4 hours as well. I came back at 12 30 pm yesterday.. Thanks to my mentor for the experience.. he's a great surgeon. I rarely praise person.. You know that if u are my best friend. hehehe .. poyo ... Btw looking at him, he is deserve to be consultant and having some other position. This is simply my sharing session.. Not for showing off to anyone. I went to operation theater yesterday in the morning until evening. He got 5 cases; 1 breast lump, 3 cholecystectomy ( 2 laparoscopic and 1 laparotomy) and appendicitis (laparotomy). He bought me fried rice even though he was fasting yesterday. It was second attachement with him because I did the attachment with him 3 years ago. After surgery session, we went to gov hospital because he need to teach his student there. He gave me his white coat, asking me to wear it. He said he always where it, but it is ok for me to wear it yesterday. We had almost 2 hours session, discussing about upper GIT bleeding. Good session with him because his explanation was very deep. Then we went to one of the hotel to listen to people who gave some speeches. We got VIP table (maybe because of his position) sitting with other specialist consultant and CEO. It was a good experienced because people attending that session were mostly specialist I guess. I felt inferior! Maybe because I am just a student.. After that event, we went to back to the hospital (not the gov one) and he said that he wanted to visit his warded patient. He sent me back after that. It was 12 30 when I reached my home. On Monday, the day before yesterday, we got one hernia case. But i did not get opportunity to attend because my parents fetch me early today (Because I did not bring my hp, it was my fault). He told me that he finished his operation at 11 pm. Can you see that how he works?
He's really dedicated to his job. I am doubt about me in the future. I hope that I can treat my future patient properly.

Other consultant have inspired me a lot; I would like to call the mentor; they are ophthalmologist consultant and physician & neurologist consultant. They are really good in their field :)

Wednesday, July 14, 2010

The experience

Last night I slept quite early because I was quite tired attending outpatient ophthalmology clinic. There were many patient yet many more to study. When the doctor asked me about the experience that I got, I told him that I really learnt a lot and going to learn more. There are a lot of cases to be discussed here. There first thing to be done was going to the wards. Meeting the doctor in one of the ward, made me felt nervous because I never met him before. He is very young Malay doctor and smart, the only ophthalmologist there. He showed and explained to be the condition of the patient warded here. The first inpatient case was the pus in the nasolacrimal sinus. So he needed to drain the pus out of the duct. Other cases include trauma of the eye. The patient superior palpabrae was hooked with hanger. The doctor’s intervention was to stitch the palpabrae with cutaneous suturing. Next, was the case of the patient with proliferative diabetic retinopathy. The patient’s kidney function has reduced to 10%. For my lecturer’s intervention, he recommended laser pan retinal coagulation technique to maintain the recent visual acuity. According to him, for this advance stage of diabetic retinopathy, the only intervention is not to cure but to slow down the progress of retinopathy. Furthermore, I got phecolytic glaucoma case. I was not that sure what does it mean by phecolytic and will search more about that. Occipital stroke is another cases that lead to visual disturbance.

In outpatient clinic, there a lot of cases to be mentioned. One of the most common cases are cataract and visual disturbance. Other cases include chalazion, macula atrophy, thinning of retina, neovascularisation, neovascularisation glaucoma, uveitis caused by autoimmune disease, trauma, myopic degeneration.

Today, I experienced three operations. All three cases are cataract cases. Two of operations were carried out by local anaesthetic and one was carried out by using general anaesthetic due to patient request. Although the cases were similar, each patient had different presentation. The first patient had lenses removed with some effort due to the hard lenses. The average operation is around 30 minutes. The lenses of the patient was replaced with lenses that is slightly yellowish. According to my doctor’s, some research have proved that light yellow lenses have ability to absorb blue light that are harmful to our eyes. The patient was not that stable emotionally that maybe due to local anaesthetic. By this method, patient can still hear and see the instruments such as conjunctiva’s forceps, scissors, microsurgery knife, ophthalmic knife and many more. The third case was quite difficult for the incision of the cornea. For this case, the doctor showed me directly through the microscope. I am very thankful to the doctor and grateful because I got the opportunity to see that rather than watching the TV connected to the microscope. Basically, the picture was not similar it is clearer in microscope. Ok then, I am very tired now and plan to eat and sleep for a while. Then, I need to study more, so that I do not look stupid in front of my idol. J

Tuesday, July 13, 2010

Preparing for my day in operation theater...

Hope to gain more experience than yesterday that was quite hectic.... (9.00am to 7.00 pm)..

Sunday, July 11, 2010

Gastric Acid Secretion Mechanism

Physiology of gastric secretion.

There are two principle gastric secretory products that can induce mucosal injury- pepsinogen that is secreted by chief cells and hydrochloric acid that is secreted by principle cells. Acid secretion occur under two conditions; basal and stimulated condition. Under basal condition, acid secretion occurs due to cholinergic input via vagus nerve and histaminergic input from local sources. Basically, basal acid secretion follows circadian rhythms with highest level occurring during the night and lowest level occurring in morning hours. In stimulated condition, there are three phases; cephalic, gastric and intestinal. In cephalic phase, the stimuli include sight, smell and taste that activate vagus nerve. In gastric phase, acid secretion occurs through several mechanisms such as distension of the stomach lead to release of gastrin that stimulate gastric acid secretion. Moreover, presents of amino acids and amines in the stomach can directly stimulate G cells. G cells secrete gastrin and gastrin can directly and indirectly stimulate parietal cells. The last phase occur due to luminal distension and nutrient assimilation. Factors that inhibit acid secretion is somatostatin that is released by D cells found in gastric mucosa. Somatostatin act via two mechanism; it can directly inhibit parietal cells or indirectly decrease the release of histamine from enterocromaffin-like cells and gastrin from G cells. Other factors act in counterbalancing acid secretion is neural pathway (peripheral and central) and hormones (secretin, cholecystokinin).

Parietal cells secrete two important products; hydrochloric acid and intrinsic factor. These cells are located in oxyntic glands. There are many receptors associated with these cells such as H2 for histamine, gastrin for cholecystokinin B or gastrin, and M3 receptor for acetylcholine. Activation by histamine lead to the activation of adenylate cyclase and cAMP. Activation of M3 receptor or gastrin lead to activation of phospholipase C/phosphoinositide signalling pathway. Each of these signaling pathways in turn regulates a series of downstream kinase cascades, which control the acid-secreting pump, H+,K+-ATPase. Other receptors found in parietal cells that are important for inhibition of acid secreting pump activity are somatostatin, prostaglandins and EGF receptors.

Large concentration gradient of hydrogen ions in the stomach is generated by H+,K+-ATPase pumps. These pumps consist of two subunits; alpha subunit that contains catalytic site and beta subunits with unclear function. ATP is needed for the function of the secretory pumps. The pumps are located within secretory canaliculi and in nonsecretory cytoplasmic tubulovesicles. Basically, the pumps are impermeable to potassium ions, which lead to inactive pumps in this location.

The chief cells produce and secrete pepsinogen that will be converted into active pepsin enzyme when pH of the stomach is around 2 or less. This enzyme is inactivated in pH 4 and is irreversibly inactivated and denatured in pH 7 or more.


1. Harisson's Principle of Internal Medicine, 17 th edition.

Friday, July 9, 2010

The Promise ...

I just came back from shopping mall just now. We bought some stuff to cook for tomorrow. I am going to visit my nephew and going to stay somewhere (not to mention here). By the way, today after a week I was looking for a stuff to buy, with my sister, I finally bought a pair of shoes. Alhamdulillah. I must mention here that I made new record because today i just took less than 10 min to make decision.

Talking about the title mentioned above, I have promise two things; one for my younger sister and another one for my younger brother.

For my Sis, i promised to buy her a GUESS bag if she could get to do two important things; Got the driving license and the second one, I think better keep it secret. :p

For my younger brother, if he could get at keast 3 A, i will buy him a pair of Nike shoes or Jersey ... :) I got my Nike shoes today, and I am very happy for that... :) May Allah bless us...