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 :)