Sunday, May 30, 2010

I love you too (Je t'aime aussi)

Some French words to be shared..

Some people think that French is a very romantic language, i do think so. But I for me, spanish is more romantic. Just my preference.

1. I love you

Je t'aime
(Zhuh taymuh!)

2.I love you too

Je t'aime aussi
Zhuh taymuh oh-see

3. I miss you

Tu me manques
tew muh mahnke

4. Here's a gift for you

Voici un cadeau pour toi
vwah-see uhn kahdoh poor twa

5. You are beautiful

Tu es belle
tew ay bell

6. You are handsome

Tu es beau
tew ay boh

7.You are wonderful

Tu es magnifique
tew ay mahneefeek

8. I adore you

Je t'adore
zhuh tah-dohr

9. That's love

C'est ça l'amour
say sah lahmoor

10. I would do anything for you

Je ferais n'importe quoi pour toi
zhuh fuh-ray nen-pohr-tuh-kwah poor twah

Saturday, May 22, 2010

Ménière's disease

Meniere Disease


i. fluactuating sensorineural hearing loss
ii. tinnitus
iii. aural fullness
iv. episodic vertigo.


There is endolymphatics systems distension. This distention is caused by the increase in volume of endolymphatic fluid. Other condition that is related to this is the rupture of Meissner’s membrane. Fibrosis process may take place. The size of the lumen maybe decreased as well as vascularity.


There are a lot of etiology including:
i. Idiopathic
ii. Inflammatory reaction
iii. Autoimmune disease
iv. Infection (syphilis)


Usually occur at 45 – 50 years old but may occur in children as well as elderly.

Diagnostic tools:

i. Lab test: to detect the present of anti – immune antibodies and antibody toward syphilis insyphilis infection.
ii. Audiogram
iii. MRI to rule out tumor such as cerebellar angle tumor, demyelinating tumor and etc.
iv. Vestibular testing ( to show the vestibular dysfunction)


i. low salt diet (, 1500 mg/d)
ii. Diuretics – such as Carbonic Anhydrase Inhibitor. Diuretics can lead to the improvement of vestibular symptoms.
iii. The use of Valium (diazepam) and antiemetics in acute attacks.
iv. Restriction of coffee, theophyllin, and caffeine containing foods.
v. Aminoglycoside uses to cause damage to vestibular cells and dark cells in stria vastibularis. This medication is absorbed through round window.

Friday, May 21, 2010


Hi, everyone. Today, before i am going to sleep, i would like to share something about my lif e today. Huhuhu... I started my life today at 7.21 am. Do you know why, huhuuhuh, because i woke up late.I supposed to wake up at 5 for Solat and tutorial preparation. End up by waking up late. huhuhu.. Not a very good start but i am going to share until the end. My aerobic lesson was not that hectic because of the songs used and the instructors perhaps. I felt quite down today. Maybe because of my mind kept on thinking about what certain people think of me. But it is always not because of my tutorial session because i really like this session, in which I can share what I read with people. I got a very good, supportive tutor. She really did her job well and motivated me to learn more and more about medical. Lucky to get her, By the way, before Friday prayer, again, my depressed condition came again. Trying to share with one of my best friend but when i was about the tell him about myself, my problem, he started another topics! What so ever. I did not mind actually because i knew he did not do it purposely. If I got oppurtunity, I will introduce him to someone who is kind-hearted and hardworking, because he deserves to get one.

Back to my problem, i did not solve it yet. haish ... I went to the class and gym today.. Forget about my prob awhile when i was in gym. Exercise and friends there really release your tension.
I sent sms to my friend, asking him whether, he can accompany me to the mall or not. Seemed he was busy. He needed to visit one of my batchmate, Izyan. She was admitted to the hospital due to dengue fever. May Allah bless her. Get well soon my friend Izyan. :) Because my friend could not accompany me to the mall, i decided to ask someone else. Dont get me wrong, i am not looking for spare part ok, i asked my kosmate. But he probably could not make it. Thought of going out alone again. Maybe this is my favourite when i could not ask my best friend to hang out. hahaha. But sometimes it simply my hobby. Wish my sis, Fairuz to be here. So that i can go anywhere with her. :) I was thinking to go starbucks actually. Since long time ago. I know the drink is expensive for me, but i wanted to try. I am not from rich family, who could buy that. Need to think and survey first before going to any places. But i dont mind doing that again and again :) . So that, i am not overbudget. Starbuks was introduced to me by my brother , Mr A. I did not have any blood relation to him, but i just consider him as my brother. He bought me a cup of choc in Starbucks. I really like it. So, planning to drink it here, in my second home, Yogyakarta. It's relived my stress actually, due to the endorphins effect and flavanoids.

I chat with my friends, Adilla, Qim, and Irene. As well as my sis. Sorry to Adilla, because the connection was lost. Btw i missed Qim, because she is my bestfriend in Solo. Emm, i did not chat with her for a long time. It was ok now, because I talked to her already. I bought a cup of chocolate, the largest one because i was craving for that. HUhuhu.. I want to make promotion here actually. If yoou bought any mug or bottle in starbucks, we will get rp 3000 discount for the drink that we buy. For every 22th every month, there is 50% discount for the drinks you buy, What an interesting promotion. It depends on the size of the mug or bottle forsure, because you could simply buy the small size but asking discount for the larger size. Hahaha.... I bought one bottle today, and the range if i am not mistaken is around rp 95 000 - rp 200 000.. The glasses is cheaper i guess. But trust me, it was worth. For every glass or mug u buy, u will get drink for free. But not all drinks. I needed to top up rp 5 000 for chocolate.


Anyway, i met 5 girls in starbucks that are charming, friendly, and hardworking in starbucks. :)

Ps: I promised to mi amor, fairuz to buy a drinks at Starbucks. I will do it in Malaysia k :)



The pathogenesis of fibromyalgia is related to the disturbance of sleep (in phase 4). Sleep disturbance is caused by alpha wave intrusion. As we know, the Non Rapid Eye Movement phase is important for the muscle repair due to the release of growth hormone during this phase. The sleep disturbance is not only present in fibromyalgia patient but do present in distressed person, patient with fever, rheumatoid arteritis, osteoarteritis, and sleep apnea. Moreover, in fibromyalgia patient, there is a decrease in serotonin metabolites level in CSF. Serotonin is related to regulate NREM and pain. The level of substance P in CSF is higher in fibromyalgia patient. This increased is thought to cause widespread of the pain. Autonomic regulation is also disturbed, leading to several symptoms such as dry mouth and dry eyes as well as orthostatic hypotension. The blood flow to thalamus, caudate nucleus and pontine tectum are reduced. This causes hyperalgesia. The perception of pain to stimuli such as heat seemed to be present at lower threshold in fibromyalgia patient.


Widespread of pain. Pain is considered widespread if there is a pain in right and left of the body, above and below the waist and the axial skeleton (cervical spine or thorax spine or anterior chest or low back pain).

The pain on digital palpation in at least 11 points out of 18 points mentioned below:

Occiput: bilateral, at the suboccipital muscle insertion.

Low cervical: bilateral, at the anterior aspect of the intertransverse space at c5-c7

Trapezius: bilateral, at the midpoint of upper border.

Supraspinatus: bilateral, at the origin, above the scapular spine near the midpoint.

Second rib: bilateral, at the second costochondral junction, just lateral to the junction on the upper surface

Lateral epicondyle: bilateral, 2 cm distal to the epicondyle

Gluteal: bilateral, in the upper outer quadrant of the buttock

Greater trochanter: bilateral, posterior to the trochanteric prominence

Knee: bilateral, at the medial fat pad proximal to the joint line

Some patient do not meet this criteria because they have less than 11 tender points but have more regional pain but may consider as having fibromyalgia.


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

Wednesday, May 19, 2010

Electrical properties of the heart. muscle

The initial phase of depolarization and overshoot occur due to the opening of fast sodium ions channel. This is followed the closure of sodium ions channel, leading to the initial rapid repolarization (phase 1) . The influx of chloride ions also contribute to the phase 1. The rapid repolarization is proceeded by plateau phase due to the opening of slow calcium ions channel (phase 2). Phase 3 is the phase in which calcium ion channels close and potassium ions efflux through potassium ion channels. This phase is known as final repolarization. Phase 4 is the resting potential phase.

Monday, May 17, 2010

Sasanti Resto

Introducing again to everyone, Nur Hafizuddin , one of my sweet friend.

This is the review about the restoran, Sasanti Resto. This restoran is exclusive, very suitable for dinner, business meeting, business presentation and fine dining place for family gathering. The range of the price stated below is not complete, but we hope that we can give some info to the people around us:

i. Salad : rp 32 500 - rp 55 900
ii. Soup: rp 15 500 - rp 58 000
iii. Vegetables: 25 000 - rp 42 000
iv. Pasta: rp 35 000 - rp 60 000
v. Ice-cream Fiesta: rp 12 900 - rp 32 500
vi. Desert: rp 9 000 - rp 45 000
v. Drinks:

a. Fresh juices: rp 29 500
b. Soft drinks: rp 15 000 - above
c. Coffee
d. Others

Main course:

These are several menu to be mentioned:

i. Grilled Rosemary Prawn (rp 112 000)
ii. Blackened Red Snapper (rp 88 000)
iii.Lamb leg (rp 88 000)

and many more that could not be mentioned here :)

It's Meeting Room I guess

Decoration on the table

It's me with menu

The Garden with a pond

Thanks for this person who paid the bill :)

The Dining Hall

Sunday, May 16, 2010



When the infected female Anopheles mosquito feed blood from person that is infected by malaria, the gametocytes get into mosquito. Sporozoites produced in this insect migrate to salivary gland. Sporozoites are transferred into human blood during next feeding. Sporozoites in human circulation are rapidly cleared by our immune system. The remaining sporozoites that are not cleared are taken by the liver. In the liver, merozoites develop. After few days, hepatocytes rupture, releasing merozoites into circulation. In the case of P.vivax and P.ovale, some parasites remain dormant in the liver, forming hypnozoites. Merozoites are rapidly get into red blood cells. In these cells, merozoite is transformed into trophozoite, to schizont and finally appearing as 8-24 merozoites. When erythrocyte ruptures, merozoites are released and ready to infect other RBC. Few merozoites are converted into gametocytes and are not released by RBC. Erythrocytic schizogeny, the cycle mentioned above occurs every 48 hours in P.ovale, P. Vivax and P. Falciparum infections. In P. Malariae infection, the cycle takes about 72 hours. P.ovale and P. Vivax tend to infect reticulocytes and young erythrocytes. P. Malariae prefer older erythrocytes and P. Falciparum can infect any stage of RBC.


The pathology is related to several things; the anemic condition, cytokines release and others. The anemia can be caused by many conditions such as the rupture of infected RBC, the rupture of non-infected RBC, dyserythropoiesis, folate deficiency and splenomegaly and sequestration. In P.falciparum infection, the RBC containing schizont tends to produce membrane knob that are known as P.falciparum erythrocyte membrane protein 1 (PfEMP1), can bind to the endothelial cells of capillary of the brain, kidney, gut, liver and other organs. This PfEMP1 can bind to many receptors including ICAM-1, VCAM-1, E-selectin, thrombospondin and CD36.

Clinical manifestation:

Incubation period: 10 -21 days

Sign and symptoms:

i. fever maybe erratic or continual. The tertian or quartan fever may only be present after several days. The temperature is always reached 41 degree Celsius.
ii. Initially present with malaise, headache, vomiting or diarrhoea (in certain cases).

P. ovale and P. Vivax infection

Mild illness. Spontaneous recovery within 2 – 6 weeks. Anemia develops slowly and there maybe tender hepatosplenomegaly.

P.malariae infection
Chronic infection. Parasitemia may persist for years, with or without symptoms. In children, P.malariae infection is always associated with glomerulonephritis and neprotic syndrome.

P.falciparum infection.
Self-limiting illness and may cause many severe complication such as cerebral malaria that is associated with confusion, convulsion and coma symptoms.


i. thick and thin blood films (stained by Giemsa), three blood film must be examined before the diagnosis are concluded to be unlikely.
ii. quantitative buffy coat analysis, in which the centrifuged buffer was stained by fluorochrome to light up parasites.


1. Kumar and Clark, Clinical Medicine, 5th edition
2. Robbins and Cotran Pathologic Basis of Disease, 7th edition, Kumar, Abbas and Fausto.

Saturday, May 15, 2010

Atopic dermatitis:

Basically, this disease is related to cutaneous expression in atopic state, that are characterized by the history of allergic rhinitis, asthma and eczema. There is strong genetic predisposition because if two parents are affected, 80% of the children will manifest the symptoms. When only one parent is affected, the incidence drop to slightly over 50%. There are many abnormalities associated by this; the increased IgE level in serum as well as the increased in IgE synthesis and impaired delayed type hypersensitivity.
In order to diagnose we need several features:
a. pruritus and scratching.
b. course marked by exacerbation and remission.
c. lesion typical of eczematous dermatitis
d. clinical course occur for more than six weeks
e. personal or family history of atopy ( allergic rhinitis, eczema, food allergic or asthma)
f. skin lichenification.

The clinical manifestation include:
i. pruritus ( most common for all ages)
ii. hands eczema
iii. lichen simplex cronicus

i. Infantile weeping inflammatory patches and crusted plaque – head, neck and extensor surface.
ii. childhood and adult – flexural surface such as antecubital and popliteal fossa.
iii. adult – more localized atopic dermatitis such as lichen simplex cronicus and hand eczema.
In patient with localized disease, AD is suspected because of the present of:
i. personal or family history
ii. Cutaneous stigmata of AD such as perioral pallor, increase extra skin fold in lower eyelid (Dennie’s line), increase palmar skin marking, and increased incidence of cutaneous infection particularly by staphylococcus aureus.

a. Avoidance of cutaneous irritants
b. Do not take bath more than often daily. We can use warm or cold water.
c. Application of anti-inflammatory cream or ointment on affected area after bathing while the skin is still moist.
d. Application of moisturizer in unaffected skin.
e. Prevention and prompt treatment of secondary infection.

1. Harisson’s Principle of Internal Medicine, 17th edition, Fauci, Longo, Braunwald, Kasper, Hauser, Jameson, and Loscalzo.

Friday, May 14, 2010

Predictable vs Unpredictable

Yesterday was my hectic day. Not to say a very hectic like some other days, but I was damn tired because I just had more or less 4 hours sleep and need to wake up early for aerobic session in my campus. I replaced my recharge time in the evening but still felt fatigue. I woke up by shouting action due to my scary dream. I was dreaming that two ‘tokek’ (the big lizards that can only be found in certain countries) tried to attack me in my dream. I received sms from my friend Adila saying that finally I can open the present that she posted since March tonight. Yeay, after long time I have been waiting, tried to be honest to myself and only opened it on 15th of May. As usual, this is my first present since first year from my closed friend. I seemed to have pain in liver area and some symptoms of migraine and or cluster headache. Considering about the severity of both migraine (2-3) and cluster (3), I decided to diagnose myself as not having both of the type of primary headache. In the evening, I went out for buying toiletries and food for dinner. While waiting for my food to be packed, I received one sms from my best friend, Fatin Maziah asking whether am I free to go out. I replied, yes. I went home after that to eat my food and prepare for hang out tonight. As usual, I sang some songs; bad romance by Lady Gaga because I really like everything about her, halo by beyonce, the inspiring song for every single day of my life, and no boundaries by Adam Lambart because I have not listened to this powerful song for sometimes. I was thinking about the place to go because usually she does not know where to go, which cafe to hang out, or place to eat. Thinking of Amplaz (mall for shopping), perhaps, I can be her companion for shopping because we did not do this thing for a long period of time. But this was not the place for tonight when she mentioned about karaoke. I only thought that my sweet friend, Fatin and I was about to go eat, actually she had another plan. We went to Happy Puppy, karaoke place. There were 8 of us, but only six of us because Najla and Nazirul went back first before Ana and Tomo came. Glad to sing because I have not done this for a year I guess. Hahaha.... My voice was totally suck when I sang no boundaries song, maybe because it was too high and I was not that prepared for the song. But it was ok, because we were there for fun, not for singing competition. No big deal.  Alia, Fatin, Jaja and I went to Quality Hotel after the singing session for Dim Sum. Proposed by Fatin at first but every human in the car seemed to give agreement for that plan. So, we spent our time in the restaurant there. Our hobby, just like before, it is about the sharing session a.k.a gossip. Hahahhahaha ..... We were happy and ate a lot of food there because we don’t give a damn about the calories that we have taken... hahahah, (even though I know some of us would give negative feedback). They sent me home finally.
. But this is the part that I could not really expect to happen. The garage door was closed. Damn it! I thought that someone would hear my knocking noise and opened the door for me. This was not happened as I thought. I kept on knocking the door with my finger as well as with my key ( as to increase the pitch with hope that someone would hear it. What a pity! No one listened to my physical action as well as to heart.  I kept on thinking about many things; how if suddenly, ghost appeared behind me and coming towards me. Would I knock the door harder because I am scared. Second, could not anyone listen to the noise that I made! Really felt frustrating about this! What so ever! The third, were they try to prank me because of my birthday? I did not think so. The possibility is damn low for the third one. Haish, I was in the condition of stress. The condition was fluctuated between eustress and distress. In eustress conditions, I always be optimis, telling myself that no matter what. I need to find solution. A lot of solutions came into my mind. This was because of the conditions were not on my side. I did not have enough credit for sending sms to my housemate, my HP battery was low, and it was raining. It was so difficult to me. I was thinking of going to my friend house or maybe I could call a taxi, and should I go to but credit for my HP by using by new shoes. Oh no way,I really like and love the shoes because of the history behind the shoes. Or maybe I should take off my shoes and walk by using my stokings and do not care about being wet and sick today even though on my birthday. I was working for about half hour to wake people soul up to help me. Maybe all of them were in phase four in sleep phase in which it was difficult to be aroused even by stimuli such as noise. Maybe my stimuli was not that strong. Emmm.. during my distress period, I was thinking, that did I need to sleep outside here? On the chair or on my friend’s car? What so ever! I didn’t want to do so... I need to get into my room to sleep well, and open my birthday present. Really could not wait of it. Finally, I managed to open the door myself. ....

Thursday, May 13, 2010

Cortisol ( happy hormones ?)

Cortisol hormones effect:

1. On glucose metabolism

Cortisol can cause mobilization of glucose from almost all cells except liver cells. The effect of this is thought to be due to the increase of transcription of DNA that is important for the conversion of amino acid into glucose (enzymes). Moreover, there is an increased in the mobilization of amino acid from extrahepatic tissue especially muscles. The increased in gluconeogenesis lead to the increase in glycogen storage in liver. Glycogen and epinephrine can mobilize glucose in needed conditions. The glucose utilization by other cells is decreased by the unclear mechanism. One of the possible mechanisms is the reduced oxidation of NADH into NAD+ that is important for the continuation of glycolysis.

2. On protein metabolism.

Cortisol can reduce the uptake of amino acid into extrahepatic tissue. Moreover, it causes the mobilization of amino acids from cells into circulation. Decreased in amino acids uptake into cells and protein synthesis are not the major cause of reduction of protein in extrahepatic cells. This is more related to the effect of cortisol on DNA. Cortisol depresses the formation of RNA and subsequently protein in non hepatic cells. On the other hand, proteins stored in hepatic cells are not decreased due to several factors. One of the factors is the increased of the uptake of amino acids into hepatic cells for deamination process, formation of protein, formation of plasma protein and formation of enzymes for conversion of amino acid into glucose.

3. On fat metabolism

Cortisol can lead to fat mobilization due to the impairment of glucose uptake into extrahepatic cells. As we know that alpha glyserophosphate is important for the deposition and maintenance of triglycerides in the adipocytes, the reduction of intracellular glucose lead to the release of fatty acid into circulation.

The relationships between excess in cortisol levels and the characteristics of rounded moon face and buffalo-like torso.

Basically, the increased in cortisol level can cause direct effect of oxidation of fat. This in turn causes the mobilization of triglycerides. How this condition can lead to obesity? One of the proposed mechanism is the rate of fat oxidation is less than the formation rate in certain tissue.

The relationships between adrenal diabetes and chronic increased in cortisol level.

As we know, cortisol can cause the increased in gluconeogenesis, impairment of glucose transportation into extrahepatic cells and moderate reduction in glucose utilization. This leads to the accumulation of glucose in circulation. The accumulation of glucose above certain levels lead to the release of insulin from beta cells of pancrease. The increased in fatty acids level in the blood is thought to reduce the stimulatory effect of insulin towards the uptake of glucose into adipocyte and muscles cells. This insulin resistant condition can lead to adrenal diabetes. The concentration of glucose usually is occasionally great enough, so that is it called adrenal diabetes.


1. Textbook of Medical Physiology, 11th , Guyton and Hall.

Hypersensitivity denervation

Basically, if the muscle is denervated and allowed to degenerate, the muscle will become hypersensitive towards aceytylcholine. Unlike skeletal muscle, smooth muscle do not become atrophy when denervated. Exocrine glands except sweat gland become hypersensitive when denervation process occur. When the axon is cut, there are two types of degeneration process occur. Orthograde degeneration occurs towards the denervated muscle (wallerian degeneration). The retrograde degeneration occurs towards cell body and stop at the junction of collateral branches (sustaining collateral). There is a decreased in Nissl bodies in the cell body. The regeneration process occurs when there is a sprouting process occurs. This sprouting process and the increased of the activation or synthesis of more receptors in muscle can lead to hypersensitivity. This phenomenon only occur when the nerve that innervate the postganglionic structure is cut or destroyed, not the preganglionic nerves. Meaning that, the suprasegmental spinal lesions do not produce hypersensitivity of the paralyzed muscle and the destruction of the preganglionic autonomic nerve system do not lead to the hypersensitivity of the denervated visceral structure.


1. Review of Medical Physiology, 17th edition, William F. Ganong.

Learn Spanish III (day and month)

Day Dĺa
Sunday Domingo
Monday Lunes
Tuesday Martes
Wednesday Miércoles
Thursday Jueves
Friday Viernes
Saturday Sábado

Month Mes
January Enero
February Febrero
March Marzo
April Abril
May Mayo
June Junio
July Julio
August Agosto
September Septiembre
October Octubre
November Noviembre
December Diciembre

Tuesday, May 11, 2010

Learn Spanish II (Numero)

0 Cero
1 Uno
2 Dos
3 Tres
4 Quarto
5 Cinco
6 Seis
7 Siete
8 Ocho
9 Nueve
10 Diez
11 Once
12 Doce
13 Trece
14 Catorce
15 Quince
16 Dieciséis
17 Diecisiete
18 Dieciocho
19 Diecinueve
20 Veinte
21 Veintiuno
22 Vientidós
23 Vientitrés
24 Vienticuatro
25 Vienticinco
26 Vientiséis
27 Vientisiete
28 Vientiocho
29 Vientineuve
30 Treita
31 Treinta y uno
35 Treinta y cinco
40 Quarenta
43 Quarenta y tres
49 Quarenta y nueve
50 Cincuenta
55 Cincuenta y cinco
56 Cincuenta y seis
60 Sesenta
63 Sesenta y tres
70 Setenta
74 Setenta y cuatro
80 Ochenta
90 Noventa
100 Cien
143 Ciento quarenta y tres
189 Ciento ochenta y nueve
199 Ciento noventa y neuve
Que hora son?
What time it is?
Que hora es?
What time it is?
It’s two o’clock Son las dos
It’s 2.30 Son las dos y media
It’s 6.35 Son las siete menos vienticinco
It’s 12.40 Es la una menos viente
It’s noon Es el mediodia
It’s midnight Es la medianoche

Monday, May 10, 2010

Anatomy and physiology of pupil pathway.

1. Pupil is the space in the iris centre. The iris itself consist of several layers; i. Endothelial layer,
ii. Stroma (collagen as well as nerves and vessels) iii. Smooth muscle and iv. Pigmented layer.

Pupil diameter in dark adaptation is 4.5 mm – 7.0 mm and in bright adaptation is 2.5 mm – 6 mm. The pupils are said to be isocoria if both pupil posses the same diameter. Anisocoria is the term used to describe about pupil diameter difference between two pupils that is more than 0.3 mm and larger. Miosis is the term used to describe pupil diameter that is less than 3 mm and if the diameter is more than 6 mm, the term midriasis is used.

Basically, afferent receptor cells are originated from small ganglion cells in the retina. These cells transmit input to 20% pupilomotoric fibers and 80% visual fibers. Pupilomotoric fibers do decussate partially at chiasma opticum and do not extend to the lateral geniculate body because the pupilomotor fibers in optic tract separate themselves from visual fibers before the lateral geniculate body. It extends to the mesencephalon via brachium of superior colliculi and form synapse in ipsilateral pretectal nucleus. Pretectal nucleus send the info to the Edinger Westphal nuclei (ipsilateral and contralateral).

Efferent fibers

There are two pathways; parasympathetic and sympathetic.
Parasympathetic efferent pathway:
From ipsilateral and contralateral Edinger-Westphal nuclei, efferent parasympathetic fibers exit from the brainstem to the eyes together with CN III. It goes to the superior orbital fissure before forming synapse in ciliary body through inferior branch pathway. From ciliary body, short ciliary nerve is formed and form synapse in ciliaris muscle for accommodation and pupil sphincter muscle for miosis. There are more fibers to ciliary muscle (30:1)

Sympathetic efferent pathway:
This fiber originate from posterolateral hypothalamus. The fibers travel downward and change with many neurons before it reaches ciliospinalis budge in spinal medulla at the level of C8-T2. There is again, changing of neurons that end in superior cervicalis superior near carotid bifurcation. From here, postganglionic neurons travel along with internal carotid artery and in cavernous sinus, this fiber separate themselves from the artery to join CN V – 1. These nerves enter the orbit via superior orbital fissure. Sympathetic fiber again separates from CN V-1 to form long ciliaris nerve and innervate pupil dilator muscle. Moreover, this fiber goes to superior and inferior eyes to innervate Mulleri muscle in superior and inferior palpabrae. Some of the long ciliaris nerves travel towards ciliaris ganglion but do not form any synapse.


1. Neuroophthalmology, dr Hartono

Sunday, May 9, 2010

Response to effector organs to autonomic nerve impulse

Cholinergic Discharge:

This is important for day-to-day living activity for example digestion and absorption of the food by increasing the activity of intestinal musculature, increasing the gastric secretion as well as relaxing the pyloric sphincter. The cholinergic postganglionic nerve release VIP as well that is thought to fascilitate the the postsynaptic action of Ach. Moreover, VIP is vasodilator that can increase the blood flow to the target organs.

Noradrenergic Discharge:

This is known as catabolic nervous system. This discharge is important for emergency cases because it can lead to the rise in blood pressure and heartrate ( supplying and maintaining blood supply to the vital organs and muscle), vasoconstriction of the skin blood vessels (reducing blood loss due to hemorrhage), increasing glucose and fatty acids levels ( supplying more energy), pupil dilatation and reduce accomodation (more light into eyes), and reducing threshold in the reticular formation (Increase alertness). Furthermore, nordrenergic discharge is also important in other functions such as tonic discharge in arterioles to maintain arterial pressure. The carotid sinus is also affected. Fasting state would basically reduce the metabolism rate and blood pressure. Feeding can increase the blood pressure. The small granulated vesicles in postganglionic contains ATP and norepinephrine whike the lareger vesicles contain neuropeptide Y.

Saturday, May 8, 2010

Sympathetic and Parasympathetic nervous systems

1. Chemical division of the Autonomic nervous systems

There are two types of autonomic nervous system based on the chemical basis:

i. Noradrenergic – Most of post-ganglionic sympathetic neurons as well as adrenal medulla, which the postganglionic cells have lost their axons and secrete epinephrine, nor epinephrine and dopamine into blood.

ii. Cholinergic – All pre-ganglionic neurons, parasympathetic postganglionic nerves, the anatomically postganglionic sympathetic neurons which innervate sweat glands, the anatomically sympathetic neurons that innervate blood vessels that can cause vasodilation.

Transmission in Sympathetic Ganglia.

The postganglionic neurons is stimulated by many mediators releases:

i. Fast/initial EPSP – Acetylcholine that act on nicotinic receptor.
ii. Slow EPSP – Acetylcholine that act on muscarinic receptor.
iii. Slow IPSP – Dopamine that act on D2 receptor. This actionis not mediated by cAMP is is though to be mediated by dopamine release from interneuron. The interneuron is excited by activation of M1 muscarinic receptor.
iv. Late slow EPSP - GnRH


1. Review of Medical Physiology, 17th edition, William F. Ganong.

Production and transmission of action potential.

Resting potential.

Basically, the membrane resting potential is negative inside ranging between -9 mV to – 100 mV, depending of the cells. This condition is possible because our nerve membrane posses more potassium leakage channel compared with sodium. As a result, there is not loss of potassium ions (positive charge from the cells). Moreover, the anions and proteins inside the cells are not practically, impermeable to the membrane, leaving more negative charge inside.

Action potential.

Experimentally, the electrode stimulated nerve will undergo irregular deflection state (the stimulus artifact) due to the current leakage from the stimulating electrode to the recording electrode. The artefact is followed by latent period that corresponds to the time taken for the impulse to move from the stimulating electrode to the recording electrode. This condition depends on two things; the distant and the speed of impulse conduction. When there is rise of the potential membrane to more than 7 mV, the sodium activation channel start to open at increased rate. In case of the slight decrease in resting potential, that is less than 7 mV, there are the increased in potassium efflux and chloride influx. An initial depolarization (15mV) can lead to the rapid increase in potential membrane. This level is called threshold level. Basically, sodium voltage gated channel have + 60 mV equilibrium potential. Usually the potential membrane never reached this state due to the properties of sodium voltage gated channel that is rapidly closed (inactivation state). This depolarization state reaches and overshoots the iso-potential and may reach +35 mV. After the maximum level of potential has been reached, there are opening of potassium ion voltage channels that are slow opening and more prolonged. The rapid rise and rapid fall in potential is known as spike potential. Slower fall after the rapid fall before the resting membrane potential is reached is known as after-depolarization. The decreased of potential below the resting potential is due to the slow and prolonged opening of this channel. This phase is known as after hyperpolarization. The Na-K pump helps to restore the potential back to the resting potential.

The increased in calcium level in our body can decrease the hyper-excitability of our muscle and nerve. The decreased of calcium ions lead to the hyperexcitability state due to the changes in changes in sodium and potassium conductance.


1. Review of Medical Physiology, 17th edition, William F. Ganong.

Synaptic transmission.

Depolarization of action potential can lead to the opening of calcium ions voltage channels. This leads to the influx of calcium ions. The influx of calcium ions can lead to exocytosis of vesicles containing neurotransmitter. Vesicle membrane protein, VAMP, binds to syntaxin, component of presynaptics membrane through complex that consist of alphaSNAP, gama SNAP, SNAP-25 and NSP . Neurotransmitter release diffuses across synaptic cleft and bind to its receptor in post-synaptic membrane, opening the ions channel. As a result, ions influx occurs and this leads to either IPSP or EPSP. Calcium ions in pre-synaptic knob are extruded by the way of secondary active transport, Ca/Na antiporter. This gradient is provided by Na-K-ATPase channels. Tetanus toxins and botulinum neurotoxin B act at pre-synaptic membrane by cleaving VAMP while botulinum neurotoxin A cleaves the SNAP-25. Tetanus toxin causes spastic muscle by inhibiting the release of GABA or glycine, making the post synaptic neuron to be more excitable. Botulinum toxin causes flaccid muscle due to the inhibition of the release of acetylcholine.

1. Review of Medical Physiology, 17th edition, William F. Ganong.

Friday, May 7, 2010

Sympathetic innervation of blood vessel

Blood vessels are innervated by vasoconstrictor fibers (noradrenergic) and vasodilator (cholinergic) fibers. Vasodilator fibers innervate the resistance vessels of skeletal muscle. Moreover, other structures that are also innervated by lungs, kidney, uterus and heart. Other than that, bundles of noradrenergics and cholinergics form plexus in tunica adventitia and extent to tunica media, just the outer part of this layer without extending to the inner part. Neurotransmitter, diffuse through the intercellular junction into inner part of tunica media. The electrical current spread in smooth muscle through gap junction. There are no tonic discharge in vasodilator fibers. Tonic discharge present in vasoconstrictor fibers. Neuropeptide Y can be found in noradrenergic fibers that causes vasoconstriction. VIP on the other hand produces vasodilation. Substance P and CGRP-alpha produces vasodilation, found in sensory nerves near blood vessels.

1. Review of Medical Physiology, 17th edition, William F. Ganong.

Thursday, May 6, 2010

SAWA Steaks & Grill, Japanese Restaurant, and Lounge

Japanese Restaurant

Welcome to everyone....

For this session, i would like to make some reviews on SAWA Steaks & Grill, Japanese Restaurant, and Lounge.

The range of the price (in Rp) are listed below:

1. Salad 29 000 -49 000

2. Soups 24 000 - 29 000

3.Char grilled

i. Prime imported meat 129 000 - 259 000

ii. Regular meat 59 000 129 000

4. Specialities 59 000 - 199 000

5. Pasta's 39 000 - 59 000

6. Asian's corner: 59 000 - 99 000

7. Beverage list

i.Fresh Squeezes Juices 15 000 - 25 000

ii.Concentrated Juices 15 000

iii. Hot Drinks 19 000

iv. Cold Drinks 12 000 - 18 000

v. Smooties 25 000

vi. Mineral 10 000 - 20 000

vii. Fresh and Light 20 000 - 25 000

" SAWA Cordon Bleu"
Deep fried breaded chicken breast stuffed with melted cheese and slice smoked beef served with creamy spinach and Lyonaise potatoes.

Spring Chicken:
Grilled-oven baked half baby chicken with sauteed vegetables and wedges potato and Bordelaise Cream sauce.

Lounge with two TV, Comfortable Sofa....

Special Wish to my best friend, Nur Hafizuddin Jailani. May Allah Bless you .. :)

Happy Birthday Sudien :)

Regalo para mis padres

This edition is dedicated to my beloved parents. Happy Birthday, mak and Ayah. The gift that i bought and posted forsure will not going to be the same for what they have been given to me since i was born. This is not for showing off to anyone because i know there are so many people out there can even afford more than this. This is just my appreciation to whom, who have been raising me up and keep on doing this to me. Again, Happy Birthday Mak dan Ayah. May Allah bless Mak and Ayah and succeed in ut life.. :)

Hopefully, this will be the surprise to my parents. :)

Sunday, May 2, 2010

Cholecystitis (acute and chronic)

Types of inflammatory response:

i. Mechanical inflammation caused by an increase in intraluminal pressure and distention of the gallbaldder mucosa that lead to ischemic state of this mucosa and wall.

ii. Chemical inflammation caused by the released of lysolecithin ( by the action of phospholipase on bile lecithin and other tissue factors.

iii. Bacterial inflammation caused by bacteria such as E.coli spp, clostridium spp, Streptococcus spp and Klebsiella spp.

Sign and Symptoms:

i. Fever.
ii. Nausea and Vomiting
iii. Right upper quadrant pain that may radiate to the interscapular region, right scapula or shoulder.
iv. Jaudice that is unusual symptom for early acute cholecystitis but may occur later.

Physical exam:
i. Positive Murphy's sign ( increase in pain or respiratory arrest during deep inspiration or coughing when right upper quadrant(subcostal region) is compressed)

Supporting exam:
i. USG - detection of stones (calculi), detection of signs of inflammation such as percholecystis fluid, dilation of bile duct, and thickening of wall
ii. Complete blood count.
- there are the increase of number of leukocytes (10 000 - 15 000 cells per unit) with left shift
in diffential count.
- Increase in bilirubin level (5mg/dl) in less than half of patient.
- Increase in aminotransferase (less than fivefold elavation) in one-fourth of patient.
iii. Endoscopic retrograde cholangiopancreatography
iv. Percutaneous transhepatic cholangiography.

Chronic cholecystitis;

1. Repeated bouts of acute or subacute cholecystitis
2. Persistent mechanical injury by gallstones.
3. Present of bacteris in more than 25% people with this disease.

1. Asymptomatics for years
2. Symptomatics gallstones disease
3. Symptomatics acute cholecystitis
4. Conplications


1. Harrison's Principles of Internal Medicine, 17 th edition.

Cephalgia (Headache)

Head pain or uncomfortable sensations in head regions (pre-orbital region to occipital and upper part of the neck).


1. Primary:

i. Tension type headache – due to the contraction of muscle of the head. It can be occipital or frontal or both (usually occipital). This type of headache always occurs in the evening when the person is tired and relief by proper relaxation method when the posterior neck muscle is tender. The pathogenesis is related to continuous partial contraction of scalp muscle.

ii. Migraine – It is characterized by aura – the visual or sensory phenomena and accompanied or followed by nausea and vomiting. It is always unilateral and related to family history of migraine. Certain people do have aura before the attacks or just experience aura without headache. The pathogenesis of this is related to the vasospasm of intra – cranial as well as extra- cranial arteries and its branches that is important for aura development. This condition precedes vasodilations of the same vessels after 10 – minutes to 30 – minutes later. The changes of vascular tones remains obscure. There is evidence of fluid retention in the body before the attacks followed by diuresis, which has suggested a metabolic or endocrine cause. Moreover, there is evidence of the increase of serotonin level during attacks.

iii. Cluster headache – It is usually unilateral and retro orbital, at least one of the attacks occurs at about the same hour for everyday. The pain is deep. The duration is about 6-8 weeks before the period of free symptoms appears approximately for 1 year on average. The condition is considered chronic when there is no sustained remission period.

Secondary headache (attributed to):
i. Trauma of the head or neck.

ii. Intracranial non- vascular disorder

- Brain tumors. Only 30 % of patient with brain tumor has headache as their chief complaints. Other symptoms associated with this conditions sleep disturbances in 10 % of patient, worsen with change in positions with nausea and vomiting. Moreover, amenorrhea and galactorrhea maybe associated with prolactin secreting pituitary adenoma or (polycystics ovarian syndrome). Posterior fossa tumor have another characteristics such as vomiting precedes weeks before headache and pain worsen when the is an increase of intracranial pressure such as coughing, sneezing, bending, lifting as well as changing of position.

iii. homoestasis disorder

iv. Infection
- meningitis: lead to the severe headache, stiff neck, and fever. Eye tracking can accentuate the pain. It is often mistaken due to the present of migraine cardinal sign such as nausea, vomiting and photophobia. This condition can be caused by many infections such as Hib, S.pneumonia, N. Meningitidis, toxoplasmosis, and etc.

v. Psychiatric causes

vi. Structures disturbances – neck, cranium, eyes, nose, sinuses, ears, mouth, teeth and other cranial or facial structures

- Glaucoma: Increase intraocular pressure. There are some symptoms associate with this such as nausea and vomiting. On eye examination, we can observe red eye with fixed, dilated pupils.

vii. Substances induced or due to its withdrawal.

viii. Cranial or cervical vascular disorder.

Supporting Examination:

i. Neurological exam ( Important! Before other exams)
ii. CT scan
iii. MRI
iv. Lumbar puncture if indicated ( mandatory if sign of meningitis is suspected)
v. Intraocular pressure examination for glaucoma.
vi. Fundoscopy –for papilledema detection or other abnormality
vii. Blood pressure monitoring for CV disorders such as hypertension
viii. Urinalysis – for renal function.
ix. Cranial arteries palpation
x. Cervical spine by the effect of passive movement.

1. Essential of Neurology
2. Harrison’s Principles of Internal Medicine, 17th edition.
3. Imam Rusdi lecture notes.