Saturday, September 10, 2011

Togetherness

Incapable of doing something when we are asked for help is not the only reason that can we give. Sometimes, it not about we are brave enough to face thing, but our presence are really helpful somehow. Facing things together would strengthen our bond and make ourselves to become more brave. I had many experiences related to this and I am sure you do have lots to mention too, but let me share with you about my recent one. I had a problem in my room to chase 'thing' in my room. It had been found for many times in my room. When I asked one of my friend to help me, he immediately said ok. He said that he is afraid too but it is ok. That moment make myself feel a bit relieved even the thing is still in my room. At least I did not feel that I was alone to face that creature. We took quite sometimes to get rid of it. Kept alert most of the times and even ran out of my room when the thing approaching us. Lots of strategies had been thought by us during that hour. Finally we called other friend for help and he removed it in just 5 mineutes. Perhaps this is not that interesting for some people, but I hope that I can always apply that concept in my life.

Sunday, September 4, 2011

Interesting?




I feel quite lazy today to study.. I just came back from my hometown JB and just got to eat at 6 pm in the evening because I was too lazy, sleepy and tired (since I need to clean up my messy room). I do not have mood to start reading forensic material for my new station starting from tomorrow. I don't even have the text book for forensic. It is going to be a month-station, so I should start doing and finding resources for one of my favourite subjects. Forensic has become one of my interest since years ago because the art and science behind that is unique to me. I have been reading forensic book since high school, the books that were bought by my parents. Hopefully this new department would teach me a lot because I am quite scared to deal with the dead. Let's pray so that god would guide us to the things that would give us happiness and prosperity and blessed life .

Why forensic is so interesting to me?

I'll use one example.. Look at the picture posted below. What is that?

Finger print.

Now try to answer some questions of mine:
a. Is it belong to child or adult finger print?
b. How long it has been left there after it is deposited on the surface?

Answer:
a. children
b. might be less than 24 hours but still depend on other factors such as humidity, temperature and etc..

How do we know that it is belong to children? Of course it not simply to differentiate by physical measure but we need some chemical measures too.. Basically, the content of children fingerprints consist of low long chain of fatty acid esters. It consists of much higher concentration of fatty acid that are not esterified. In contrast, adult fingerprint consists of higher concentration of long chain fatty acid esters that are subjected to lower volatility. Moreover, the concentration of surface lipid cholesterol is higher in children due to the secretion by epidermis. In adult, the lipid surface consists of higher level of cholesterol esters that are primarily secreted from sebaceous gland that are markedly increases after puberty. There are a lot of info related to this but I only managed to mention a few....



.

Wednesday, August 31, 2011

Keeping to myself....



Sometimes, things are better exposed to let other people know. The term 'sharing' is always misused. Some people prefer to share everything that they have to the whole world. Feeling that they are the happiest or the most gifted creature in the entire universe. Some people things that, there are things that are better to be kept quiet or at least not to be told purposely. Sharing something could be a pleasure for some people but not for others. Its human nature to feel envy or intimidated by stuffs that are not belong to them .We could not deny that because part in our heart has been filled with all those negative elements. Now, lets be more grateful. And I hope that I can always do something that would satisfy myself but not to make everyone satisfied. It is impossible to make it happen. Things that are better kept to myself would remain in my little hippocampus until I thought it is appropriate to share..


Friday, August 12, 2011

Osteoporosis



Introduction

Osteoporosis is characterized by decreased bone strength. The prevalence of this disease is high in post menopausal women and in men or women with underlying or major risk factors that are associated with bone demineralization. Vertebral and hip fractures are the chief complaint but other sites can also be affected.


Definition

Osteoporosis is defined as decrease in the bone strength leading to an increased risk of fracture. Deterioration of micro architecture of the bone lead to the osteoporosis. The WHO defines osteoporosis as a bone density that falls 2.5 standard deviations below the mean of young healthy adult of the same gender.



Pathophysiology

Modelling and remodelling are two different terms need to be explored before we further discuss about osteoporosis. Basically, modelling is the apposition of new bones tissues on the outer surface of the cortex. This process allows long bones to adapt in shape in response to the stress place upon them. There are many factors that have important roles in bone growth such as genetics, sex hormones, nutrition and lifestyles. The primary determinant is genetic that determine the peak bone mass and its density. Se hormones are important for skeletal maturation of bone as well as sexual dimorphism appearance. Genetic studies produce different results. One of the studies stated that a point mutation in LRP-5 is associated with high bone mass without much apparent of age-related bone loss.

Remodelling process is the principle metabolic function in adult since its function is to repair micro-damage as well as to maintain the balance of calcium serum level. There are systemic factors such as PTH, androgen, estrogen, vitamin D as well as local factors including insulin-like growth hormone I and II, transforming growth factors β, members of TNF superfamily (RANKL), prostaglandins, ILs and parathyroid hormone related peptide (PTHrP), that modulate the process. Basically, RANK ligand is an important cytokines for the communication between osteoblast, other marrow cells and osteoclast. Osteoclast posses RANK receptor for the development and activation. This receptor is activated by RANKL. Moreover, osteoblast also produce osteoprotegerin (OPG) that can bind to RANKL to neutralize this factor.

When we get older, there are an increased in osteoclastic activity and/or decreased in osteoblastic activity that results in net loss of bone mass. The increased in remodelling site can increase the likelihood of trabeculae penetration by osteoclast that leave no template for bone formation. This would impair the cancellous connectivity. More porous bone can occur if the cortical part of the bone undergo remodelling.


Risk Factors

a. Calcium Intake

Basically, calcium as well as other nutrition such as proteins, calories and other minerals is needed for optimal growth of skeleton. The insufficiency of calcium leads to secondary hyperparathyroidism. PTH secreted lead to the increased in bone remodelling to maintain the balance level of serum calcium. Other than that, PTH stimulates hydroxylation of vitamin D in the kidney. Moreover, it can lead to the increased gastrointestinal calcium absorption. PTH also reduces renal calcium loss. On the other hand, the prolonged effect of this hormone is detrimental because it can lead to increased risk of osteoporosis.

b. Vitamin D

Vitamin D inadequacy is also dangerous because it can lead to secondary hyperthyroidism. The insufficiency of Vitamin D can be due to many factors such as the elderly, people living in northern latitudes, and people with poor nutrition, malabsorption and chronic renal or liver failure. Dark-skinned people are also at increased risk of vitamin D deficiency. The recommended amount of daily vitamin D intake is 800-1000 unit in order to maintain optimal level of 25(OH)D at > 75nmol/L (30ng/ml).


c. Estrogens

Basically, estrogens plays a very important part in bone metabolism in women. Bone cells (osteoblasts, osteocytes, and osteoclast) as well as marrow cells (monocytes, macrophages, mast cells and osteoclast precursors) expresses ERs α and ERS β. Lack of estrogens leads to the decreased of osteoblast life span and the increased longevity and activity of osteoclast. Basically, this leads to increased in activation sites of remodelling as well as the net loss of bone mass. The likelihood of trabeculae penetration increases. As we know that, the trabeculae contribute around 80% of total surface area, the destruction can accelerate osteoporosis and fractures. Since vertebral parts have depends mostly on trabeculae for the strength, this fractures is the most common early consequence of estrogen deficiency.


d. Chronic diseases

Endocrine disorder such as diabetes mellitus type I, adrenal insufficiency, thyrotoxicosis, Cushing’s syndrome, hyperparathyroidism and acromegaly are some of the causes of the risk factors of OA. Other factors include hypogonal states such as Turner syndrome, Klinefelter syndrome, anorexia nervosa and thalassemia; rheumatologic disorders such as rheumatoid arthritis and ankylosing spondylitis; and many more can lead to an increased risk of osteoporosis.

e. Medication

Other than disease itself that can lead to bone loss, the use of certain medication can somehow lead to osteoporosis. One of the well-known drugs is glucocorticoids. Other than that, excessive thyroid hormone can increase bone remodelling and bone loss. Some anticonvulsant can lead to deficiency of 1,25(OH)2D because it can increase the activity of Cytochrome P450 and increase vitamin D metabolism. This can increase the risk of osteoporosis. Patients who undergo transplantation are at risk of developing osteoporosis not only due to the use of glucocorticoids but also because of the use of other immunosuppressants such as cyclosporine and tacrolimus. Furthermore, these patients might have other underlying metabolic diseases such as renal or hepatic failure. Aromatase inhibitor can inhibit the conversion of androgens or other adrenal precursors to estrogen to low level.

f. Cigarette Smoking

Smoking has direct toxic effect on osteoblast and indirect effect on osteoblast by modifying metabolism of estrogen. Moreover, smoking can develop secondary effects that can modulate skeletal status such as intercurrent respiratory or other illnesses, poor nutrition, lack of exercise and the need of additional medication such as glucocorticoids for lung disease.

Treatment

a. Management of Osteoporotic Fracture
Basically, acute fracture due to osteoporosis often needs management of the bone fractures and the treatment of underlying disease. The surgical intervention depends on many factors including location. Usually, long bones fractures frequently need either internal or external fixation. Hip fracture is one of the examples of the fractures that need surgical intervention. There are some factors needs to be considered before performing different types of surgical method (open reduction and internal fixation with pins and plates, hemiarthroplasties or total arthroplasties) including the location and severity of the fracture, general status of the patients and the condition of neighbouring joint. The others such as vertebral, ribs and pelvis fractures usually require no specific orthopedic intervention but only supportive management.

Some patient with acute vertebral compression fractures present with sudden onset back pain. This often requires analgesics such as NSAIDs, acetaminophen or narcotics depending on the needs. Percutaneous injection of vertebral body with cement (polymethylmethacrylate) might provide instant pain relief in majority of the pain as proven by a few small randomized clinical trials. Short periods of bedrest is helpful for pain management in early mobilization is required to prevent further bone loss. Occasionally, in order to facilitate early mobilization, an soft elastic-style brace can be used. Muscle spasm can be managed by using muscle relaxants and heat treatments.

Pain usually resolves within 6-10 weeks. Chronic pain is difficult to manage. The pain is usually is originated from ligament, muscle or tendon that are strained or due to secondary facet joint arthritis. This condition can be managed by analgesic, heat treatment, ultrasound, transcutaneous nerve stimulation back strengthening exercise, intermittent rest in supine and semi-reclining postion as well as family support and psychotherapy.

b. Risk Factor Reduction

The risk factors associated with bone loss and falling must be evaluated thoroughly. Smoking cessation is indicated if a person smoke. The review of glucocorticoids treatment is also important. TSH must be evaluated in people on thyroid replacement therapy as thyrotoxicosis is associated with increased bone loss. Measures to reduce the risk of falling such as treatment of nocturia, alcohol abuse therapy, the review of medical treatment that is related to orthostatic hypotension or sedation, and other preventive measures are indicated. Preventive measures such as eliminating exposed wires, curtain strings, slippery rugs, mobile table, avoiding of stockings feet on wood floor, and providing good lights in path to bathroom and outsides the house are essential for risk reduction.

c. Nutritional Recommendation

Two important supplements are calcium and vitamin D. Calcium can be obtained from various sources such as dairy milk. Basically, if 600mg or more need to be taken, it should not be taken at the time since high dose of calcium will decrease the absorption fraction. Vitamin D should be taken according to the age; 200 IU for people < 50 years old, 400 IU for people between 50 to 70 years old, and 600 IU for people more than 70 years old.


Thursday, July 14, 2011

Berlari Laju

Kadang-kadang aku merasa semangatku hilang entah ke mana. Walaupun kawan-kawan yang berada di sekelilingku melihatku sebagai orang yang tabah dan kuat semangat, realitinya aku seorang yang rapuh di dalam, penuh dengan konflik di akal fikiranku. Do I need to express all my thought to the universe? Aku fikir aku harus sabar dan lebih memahami setiap perkara. Aku tidak boleh berhenti di sini. Perjalananku masih jauh. Bak kata adikku, kita harus tetap berharap dan berusaha untuk mengejar impian. Impian kita mungkin sama dengan orang yang lain, tetapi perjalanan yang kita tempuh pasti berbeza. Too much complaining does not make you stronger. Channel your energy to make something different and better for every single day. Aku harus berlari laju untuk mengejar impian yang semakin lama semakin tinggi :)

Friday, June 24, 2011

Osteoarthritis

1.1 INTRODUCTION

One of the most common types of arthritis is osteoarthritis. It has become a leading factor of disability in elderly. In western countries, due to increasing prevalence of obese people as well as aging population, the occurrence of OA is on the rise.

Basically, OA prefers certain joints such as cervical and lumbosacral joint of the spine, hip, knee, first metatarsal phalangeal joint, proximal and distal joint and the base of the thumb whilst other joints such as ankle, wrist and elbow are spared. Ankle cartilage is unique because it is designed to be resistant to loading stress. The joints affected by OA are related to the amount of stress that is placed on them. Knee for example is important as weight bearing joints.

The clinical diagnosis is made on the basis of structural abnormalities or symptoms present. There are many people with abnormal structural finding in radiologic examination but appear to be asymptomatic. This situation is no more important than people with symptomatic OA.

Basically the prevalence of knee OA is higher than hip OA which is account for one third of the cases of knee OA. Some elderly with the appearance of bony prominent in affected hand joints together with radiographic findings of hand OA do not present with any symptoms.

The prevalence of OA is higher as aging process continues. The prevalence of OA in people who are above 60 is prominently higher than those under 40. Gender also plays a role in OA development. It is seems that women has higher risk of OA than men.


1.2 DEFINITION

OA is defined as joint failure. The disease involves the pathologic changes in all structures of joints although not all parts of the joint are equally affected. This is initiated by hyaline articular cartilage loss. This event is proceed by thickening and sclerosis of subchondral bony plate, by outgrowth of osteophytes at the joint margin as well as by stretching of articular capsule, by weakness of muscles that bridging the joint and by mild synovitis in many affected joints.

1.3 JOINT PROTECTOR COMPONENT AND ITS FUNCTION

a. Joint capsule
b. Ligaments
c. Muscle
d. Tendon
e. Sensory afferent
f. Underlying bone

Joint capsule and ligaments is important as protector as they provide limitation to excursion and range of motion. Ligaments along with tendons and overlying skin contain mechanoreceptor that is important to provide afferent input to spinal cord so that, the effectors which are muscle and tendons can undergo some changes in term of power and acceleration or deceleration according to specific position.

Bone is important as shock-absorber. The synovial fluid between joint is important as lubricant that reduce the friction-induce cartilage wear. This synovial fluid is synthesized by synovial fibroblast and consists of mucinuous glycoprotein, lubricin.

The development of OA increases when one or more joint protectors is failed to work properly. One of the examples is the Charcot’s arthropathy. This occurs due to the presence of posterior column peripheral neuropathy with minor joint injury that can cause severe and rapidly progressive OA.

Cartilage also serves as joint protectors. As mentioned somewhere in the text, this structure is the primary site to be affected in early pathogenesis of OA. Cartilage is aneural. It can be found at the end of bone where it has contact with another bone. Basically, cartilage consists of chondrocytes and matrix. Cartilage matrix is produced by chondrocytes under influence of cytokines and growth factors. The balance between cartilage catabolism and anabolism is regulated by growth hormones, cytokines and mechanical stress.

Cartilage matrix consists of two main macromolecules; collagen type II and aggrecan. Collagen type II provides tensile strength and aggrecan provides compressive stiffness to the cartilage. In normal structure, collagen type II is tightly woven and aggrecan can be found in the matrix interstices between collagen. Aggrecan is proteoglycan that is linked to highly negatively charged hyaluronic acid. Compression in close proximity between collagen creates great electrostatic repulsion that give characteristic of compressive stiffness.

The enzymes produced are important for degradation of cartilage. The major enzymes involve in collagen catabolism is metalloproteinase-13 (MMP-13) or collagenase 3. Other collagenase play minor role. Aggrecan is mainly degraded by aggrecanse 1 (ADAMTS 4) and perhaps of MMPs too. These enzymes usually act at the territorial matrix surrounding chondrocytes but in pathologic process such as in OA, the activity is spread widely across the matrix especially in the superficial layer of cartilage.

Cytokines are also important for regulation of matrix metabolism. The main cytokines is interleukin-1 (IL-1) that has effect on nucleus. It can induce transcriptional process of proteinase while inhibit the synthesis of matrix elements. Tumor necrosis factor α has similar role. These cytokines can induce the synthesis of nitric oxide, prostaglandin E2 and bone morphogenic protein 2 by chondrocytes. These factors are important for metabolism. Nitric oxide can suppress the synthesis of aggrecan and enhances proteinase activity, BMP 2 is a potent anabolic stimulator. The activity of MMPs is regulated by tissue inhibitor of metalloproteinase (TIMP). Growth factors such as transforming growth factor β and insulin-like growth factor type I do play prominent role.

1.4 RISK FACTORS

a. Systemic risk factors

Age is the most potent factor for OA. This is due to the decrease in responsiveness of cartilage towards stimulation when we get older. Other than that, other joints protectors also undergo degenerative process. Muscle becomes weaker and slower in response towards oncoming impulse, ligament stretch with age and become less able to absorb impulse. Afferent fibers become slower so that the efferent, muscle and tendon become slower in response towards stimuli due to retardation of the feedback loop of mechanoreceptors. The combination of all factors above acts in concert to increase the vulnerability of the joint to OA.

b. Genetics and heritability

Genetics and heritability have some influence to hands and hip OA. Generalized OA is rarely inherited. There are some evidences related to FRZB gene that is essential to produce Frizzle protein that antagonize extracellular Wnt ligand. Basically Wnt signalling is important for matrix synthesis and joint development.

c. Joint environment

Some risk factors increase the susceptibility of joint to focal stress. Congenital dysplasia, Legg-Perthes disease, and slipped femoral capital epiphysis are three uncommon developmental abnormalities occurring in utero or childhood can leave the child with future OA. Acetabular dysplasia is more common in girls whilst others are more dominant in boys.

Major injuries can also lead to OA because it can produce structural abnormalities. This theory explains the occurrence of OA in joints such as ankle and wrist that are otherwise rare.

Furthermore, tears of ligament such as anterior cruciate ligament of the knee or the labrum of the hip can increase the risk of OA later in life. The operation such as menisectomy that is carried out as a result of the tear has independent risk of developing OA with the injury itself.

Malalignment is another risk factor. There are two forms of malalignment. Varus knee is the bowlegged knee in which the focal stress increase highly in the medial or interior compartment while the Valgus (knock knee) has predispotion of lateral compartment cartilage damage. As a result of this malalignment cartilage loss and/or bone damage can occur.

d. Loading Factors

Loading factors here include obesity and repetitive joint use. Obesity usually precedes OA. Basically, there is an increase risk in knee OA in obese people because the increase in body weight would increase load on the joint especially on the weight bearing joint. On single stance during walking, three to six times of body weight would be exerted across the knee joint. Women has stronger risk factor than men. In women, there is a linear relationship between the weight and the risk of OA. Hip OA can also develop but less than knee. Hands OA is modestly related to obese people that might be contributed by other factor such as metabolic factor.

The repeated use of joint can be further divided into occupational use and leisure time physical activities. Basically, the risk of OA for occupational use is specific to the joint involves in occupation. The examples of these include farmer who might contract hip OA, miners are more prone to develop knee and spine OA whilst shipyard or dockyard workers might have increased risk of fingers and knees OA. Muscle that is use for a long period of time during working hours may become weaker and exhausted with time. So, the effectiveness of muscle as one of joint protectors is reduced. Exercise is one of the treatments of OA, but certain types of exercise do increase the risk of OA.


1.5 CLINICAL FEATURES

Pain in OA is related to activity. Activity always initiates the pain and may be resolved slowly when we take a rest. Pain can be episodic in early cases of OA or persistent as disease progresses. Stiffness may be prominent but morning stiffness maybe brief (less than 30 minutes) as compared to inflammatory arthritis. Buckling may occur in knees due to muscle weakness that cross the joints. Chronic knee pain in people above 45 have long differential diagnoses. Anserine bursitis (medial and distal to the knee) and inflammatory arthritis are the common causes of knee OA. Routine blood tests are not indicated for OA. Synovial fluid analysis is helpful. In inflammatory arthritis, gout and pseudogout, we can find white blood count > 1000 microliter. The last two diseases mentioned are also accompanied by crystals findings. X-ray is only needed in chronic hand pain or hip pain. The necessity of radiograph exam for knee pain is indicated when atypical signs and symptoms presence or when the effective treatment is failed.


1.6 THERAPY

The therapy of OA can be divided into pharmacotherapy and non-pharmacotherapy. The aim of the therapy is to manage pain and minimize loss of physical function.

a. Non-pharmacology therapy

Basically, some of the intervention can be taken in order to reduce focal load on joint such as avoiding activities that overload the joint, strengthening and conditioning muscle that bridging the joint and unloading the joint by using a cane, a splint, a crutch, or a brace to redistribute the load. Moreover, exercise is one of the effective therapies for at least knee OA. Exercise can strengthen muscle that is one of joint protectors. The more suitable type of exercise is isokinetic and isotonic strengthening exercise that involve the extension or the flexion of the knee against resistance. Moreover, exercise helps in reducing weight, so, the loading factor can be reduced. In the case of OA, muscle usually become weaker due to aging that decrease muscle strength, disuse muscle atrophy due to immobility, alteration of gait to lessen focal load that lead to disuse muscle as well as arthrogenous inhibition due to the joint capsule stretched that inhibit mechanoreceptor feedback loop.
Other physical measures that can be tried are hydrotherapy, local heat, ice packs and massage.

b. Pharmacotherapy

Acetaminophen, NSAIDs and aspirin can be used to treat OA pain. Sometimes, acetaminophen alone is adequate for the patient. In most of the case, NSAIDs is widely used but give different results to consumers. Basically, NSAIDs should be taken on ‘as needed’ medication but when the disease become ineffective to be managed, daily dosing is indicated. However, this drug should be taken with caution because it has many side effects including the life-threatening complications. One of the common side effects is gastrointestinal toxicity that includes dyspepsia, nausea, bloating, GI bleeding and ulcer. Precaution of NSAIDs such as take right after meal, avoidance from taking two NSAIDs, usage of safer NSAIDs such as ibuprofen and nabumetone as well as the use of gastroprotective agent for high risk patient. In addition, NSAIDs can also lead to oedema and renal insufficiency because of the prostaglandin inhibition of afferent blood supply to glomeruli in the kidneys. Selective COX-2 inhibitor is available with less GI side effect but increased cardiovascular side effect. This can lead to inhibition of prostaglandin I2 synthesis in vascular endothelial cells but not in the platelets. This can precipitate stroke or myocardial infarction due to increased risk of intravascular thrombosis.

c. Intra-articular injection

Two kinds of injection can be given according to indication. Glucocorticoids can be injected in patient in acute flares of pain that provide relief for only about 1 – 2 weeks because of the presence of loading or vulnerability joint factors. Hyaluronic acid treatment is still controversial.

d. Surgery

Basically, there are many types of surgery that can be performed in order to correct deformity produced by the effect of OA. This includes osteotomy. In osteotomy, the realignment of the joint if performed to unload excessive load in arthritic joint. On the orther hand, surgeon can also perform arthrodesis, the procedure in which the joint undergoes permanent stiffening by excision and fusion to stop pain. Other than that, arthroplasty either partial or total can be carried out. This procedure involves the artificial replacement of the joints.

References:

1. Fauci AS, Longo DL et al, editors. Osteoarthritis. 17th ed. 2008.
2.Kumar P, Clark M, editors. Osteoarthritis. Kumar and Clark Clinical Medicine, 5th ed.
3. McLatchie G, Borley N, Chikwe J, editors. Osteoarthrosis. Oxford Handbook of Clinical Surgery, 3rd ed, 2007.

Tuesday, June 21, 2011

Life and Expectation I

I went to the hospita at 6.10 a.m today and it was considered as late for Surgery department. I met one resident who asked me about what time I came today. This is the conversation.

Residen: Have you studied about all your patients?
Me: Nope because I went back at 1 a.m in the morning yesterday. I followed another Orthopedic residen to Operation Theater.
Residen: Then, what time you came today?
Me. 6.10 a.m.
Residen: What did you do after that surgery?
Me: Sleep. (for sure I need to sleep because I need to wake up at 5. I just slept for 3 hours only, huhuh)
Residen: You shoud study about your patient ok because......


It is funny for me when I thought again about that. Btw I am not robot and need to recharge to be become energetic but he is right because I need to know my patient in detail and the disease itself so that I won't get blurr when I need to answer my patients question. Thanks a lot my residen :)

Monday, June 6, 2011

Questions?


I went to one watch shop today in one of new shopping malls in JB. I was greet by the shop owner at that moment. This is our conversation.

Owner: Welcome.
Me: Hi.
Owner: Are you Malay?
Me: Yes.
Owner: Are you Singaporean?
Me: Nope. I am Malaysian.

I went to Oris section then...

Owner: (with smile) Do you like Oris?
Me: (In doubt) Emm.. Yes..

Then I went there and used my eyes to track the models and prices? OMG. My conclusion is:

First - I don't like the model
Second - I think the price is too expensive for me ... heheheh.. I could never afford that ! :)
Third - I don't need to be other than Malay or poss other nationality to buy expensive watch ...

Let's continue with my other story. I would like to thank my parents and siblings for the presents. Btw special goes to my parents and my Sis Fairuz a.k.a. Lush for the lovely presents :) You make my collection become more and more complete for every single year :)

From my parents :

Guess Collection (Gc)



Avon, the brand that we have been using for about 15 years ...


This is special bought for me by my sister, Fairuz @ Lush.. She bought the most expensive present for me that she ever bought for anyone. I really appreciate it :)





Saturday, April 30, 2011

Life and Confession.

I feel quite tired and lazy today. Woke up just because I felt too tired to sleep again. I went back yesterday from one-week-outstation in Banyumas. I have some ideas in my mine about what to write but at last I decided to share about several things in this post.

For a week outstation in Banyumas, I thought, I gained a lot of things and learn a lot there. Not only in term of medicine but also in term of our life part. I always wake up early in the morning just to make sure that I can follow up all of my patients before 7 although I could rarely finish it before 7 a.m. I always come at around 5.30 to 6.00 a.m., but on Saturday morning I went to the hospital at 5 a.m. One of my patient passed away due to Hemorrhagic stroke. Luckily, I have educated the family before I went back to my room. Thanks to dr. Ayu because of the experinces you gave in Teaching Hospital before, so I don't have any difficulty to deliver bad news to the patient's family.

Regarding my social life in Banyumas, I think we did have lots of fun here. We went eat together almost for every meal and went to try lots of recommended food. We also went kareoke togeher. We enjoy singing.

Confession

Now let's move to more serious discussion. This is what I wanted to share before. Relationship seems to give some challenges to me. Why? I could really describe precisely about that. To be honest, I don't have any feeling towards anyone now. I hope it is clear to anyone who concern about that. I must accept the fact that I easily get closed with anyone who share something in common with me. I still remember my senior advices about relationship. "Don't get too closed to girl or women because they might think something else". My response to this kind of question is simple. What should I do? Do I need to leave friend who are close to me simply because I am afraid that they have feeling towards me? I did remind some about the status. I did mention that we are just friend to girl and not more that that. People react differently towards things around them. One of the example is present. Some have their own perception towards the occult meaning behind the present or gift. But for me it is simply present and sometimes I bought that because I do not have any idea of what to give. I can understand why people think that I am having relationship with someone but I believe if both have clearly stated the status towards other people, it wont cause any problem. We don't need to exaggerate words and sentences in our social websites.

I created THE BOUNDERIES. Don't ever say that I always 'hang' my relationship. I used to mention about this topic in my last post - EAT PRAY LOVE, but it seems to be so natural so that people do not really get the point behind that. The reason to create post as natural as possible is because I don't want to hurt anyone feeling. Now, I shall take my action. I clearly state that I don't have any special relationship with anybody as well as feeling. I might sound arrogant but I do not anyone to hope and wait until the hell freezes over. I want to be friend with a lot of people. I would pray that my friends would fine their lovers who are much better than me. I am simply an average Joe.

PS: having crush does mean love. Dreams and hopes would boost our motivation but we might lose something in our life. Sorry for everything.



Thursday, April 21, 2011

Action

I feel quite exhausted today but feel good at the same time because I gained a lot of knowledges for today. It make me realize that when we think that we have enough potatoes in the bucket at the moment, we do not have enough good potatoes to share. Meaning that, when we read something and think that we have mastered that specific topic, we actually still have more things to read. I got lots of experiences today, dealing with a patient that can only speak javanese, as well as dealing with patient with bad prognosis. Felt quite down when I was asked by my lecturer but I could not answer all the questions and lack a lot of info in my anamnesis. I am sure he wanted me to be more specific and improve in the future. I will improve Sir :)Other activities just like normal activities such as tentiran and follow up my patient. I am planning to go gym to improve my stamina but my body seemed to request another thing. Ok friends, I need to got eat now and send my clothes to laundry service shop. I need some energy for my tutorial this evening at 6.30 pm...

Tuesday, April 19, 2011

The needs


Today, I felt tired but I am still feel happy and satified. I needed to wake up at 5 today, so that I could follow up my patient at around 6 10 a.m. Usually I come at 620 a.m but because my lecturer planned to arrange bedsite teaching at 7 a.m. I need to come at 6.10 a.m then. Why? Because one of my patient is talkative :) she likes to tell a lot of thing, so I need to come early so that I am not going to be late for my bedsite teaching.. Talking about my life today, I felt much better. I do not feel too stupid since I learn more and more. I got three discussion with my residents. What I love about this is I can share what I learned before with them. This system is called as 'tentiran', where the resident teaches and guides you about the thoery and skills of being a doctor. It depends on the department and now I am under neurology department. Honestly, I like this and really like to contribute something in the discussion because I believe that we might use different books and what others said might be different from what you learn. One advice to people out there, if you think that you are sure with what you read, don't hessitate to share and make sure that you state from which journals or books are you taken. Be confident but not over and try to see the character of your residents or lecturer whether we can simply do it or not. For me in learning process, no one is better than another because we might read a lot in certain area but not others. Even in the discussion with my lecturer, she can still except our opinion about certain things. Learning is just like a plastic bag. If you open more you will get more and learn a lot. If you open less, you will get less in your plastic... Some people tend to be rigid because they think that what they learned are totally right. We can stick to this attitutde but, it would reduce our capacity to get accomodate more and more knowledge in our hippocampus. I would try to be more flexible and open about the sharing and accepting new knowledges.

I slept very early today, at 620 p.m. and woke up and fell suddenly because of temporary parapaaresis. Maybe because of my sleep posture was not appropriate. Btw, I miss my nephew a lot because I dreamt of him calling me Om.. He suddednly can speak ! ... Yeay.... Everytime I sleep today, I would dream about patients and beings asked by people about something. In my dream sometimes I could answer all those questions and hope I can find the answer when I wake up later...

PS: Try to improve and be better and better each day because it would make us feel great.

Saturday, April 16, 2011

Dedication


"Now I dedicate my life to the lifelong learning process for my patients as part of my life"

7 days in a week in the hospital working and learning as a young doctor is not an easy job for me. I am not sure about the other people, but I seriously fell somehow I need more time to study about all those diseases in details. The settings is absolutely different because I need to face the patients and their family alone during morning follow up. This really need a very good skill of communication as well as examination skills. I easily fell that I am stupid person when I am having clinical tutorial and case reflection as well as bedsite teaching because what I've got in 3.5 years in theoretical years are not sufficient. So, everytime I could answer my lecturer question I would fell guilty and dumb. It is not about being embarassed for not be able to answer the question in front of resident, friends or patients but simply about responsiblity. I want to be a good doctor not to the best doctor by competing myself with my friends because now what is the important things are not for showing off you are better than others but can you do something correctly and would it help your patients? My life is totally changed. Sometimes I just had lunch and dinner at one time. Meaning that I didn't eat dinner because of too tired. I don't blame myself or the system because I believe this is part of my life and no matter what I am learning to love it and dedicate my life to this. My sleeping time is not really organized because sometimes I just feel that I need to read more and more, so at least my knowledges are getting better. One of my patient died due to stroke this week, I felt pity but I know that is unavoidable. Working in clinical setting is different from theory. We could not expect everything is going to be perfect but we can make sure that we can give the best. I want to say thank you to some resident who are willing to teach me especially dr. Ayu. I learnt a lot from her and hopefully I can be a good doctor. Sky is for sure my limit because I believe that sky is unreachable. Sky extends more than our Milky Way galaxy. If I could not reach the other galaxy, at least I could reach the farthest distanct in my galxay. All the best to all doctors out there and I hope that we can give the best our patient.

Sunday, April 10, 2011

Ready!


Whether we are ready or not, sometimes we need to do it whatever it takes. When it comes to part of our life. 'The Life Cycle'. Honestly, I am not that ready for my new episode of my life. I am not the director but just the actor that do not have any script to be memorized or practized and I could not imagine what is going on in the future. There are a lot of people out there who might experience the same setting but the experiences should be totally different from one another. It is simply like our fingerprint, everybody does have it but no one have the same. This is what we call unique. I used to tell myself that whatever it is, the way we experience would be different, depend on how well we control the situation. Do not underestimate my ability! This sentence is directed to some people who might concern about me and always advice do not get involved in certain things. For them, some filed do not suit me and they said I am going to be another person (bad person). Friends, this is life. Life is not something stereotype. You can always choose. There are a lot of choices here and there. Create your path, don't just wait. Now, let me tell the other story of mine. It is about clinical rotation. The new setting, new environment and new people. What should I do? Do I need to ask so many people to comfort myself or to heal my anxiety? I might sound exaggerate but do not question about this because I believe everyone has their own perception and feeling towards something. Feelings of excitement, worry, less motivated are all perfectly mixed and occupied in my tiny brain. Hope everything is going well. I am just afraid of the future. Not to say that I want to be the best person, but afraid that I could not catch up with things that I am supposed to learn. God, please give me the strength to make it. Guide me and boost my energy, confidence and motivation.

Tuesday, March 22, 2011

Menu 2


Hye a very good morning to everyone. I did not have anything to do so I decided to make a dessert. It is made for my special sister, Fairuz (Lush). I named it Loving you dedicated to Lush. I hope you enjoyed :)

Step I

Preparing the fruits: Strawberries, apples and Mint leaves (Pudina)


Step II

Put a scope of chocolate ice cream. You can choose any brand such as Milo, Kit Kat, Nestle, Baskin Robbin and etc.


Step III

Put some choco chips and pieces of Cadbury chocolate .


Step IV


Just add some almonds or cashewnuts there.


It is very easy is it? Enjoy trying :)

Menu 1

Today My sister and I cooked something for dinner. She prepared two dishes that are Nasi Lemak Alternative Lush and Ikan kerapu Sambal. I made the dessert part - all about chocolate ice cream feat banana. My sister for sure is good about cooking. For me, this course is new to me but I tried to give the best that I can :) Here are some pictures..

Ikan Kerapu Sambal


Nasi Lemak Alternatif Lush


All about chocolate ice cream feat banana by Fit Pete


The dessert is different for me because I made something different. Basically, I choose Kit Kat ice cream with Cadbury melting chocolate with Hazel Nut Praline topping together with Crispy chocolate as decoration. Pieces of banana are placed at the periphery to give golden and luxury image to the menu. If I got other ingredients available I would add strawberries as well...

My sister and I enjoyed the moment so much and we planned to do it again. Wait for our next menu :)

Friday, March 18, 2011

The Gift

Everyone has dream. Me? I have many dreams in my mind. One of my dream is to become a tourist guide. My parents used to ask me after I got my SPM result. What did I want to be? I told them that I wanted to take hotel management and tourism course. My parents told me that I'd better take other courses. So, I decided to choose medicine. Why? For sure because I did not have any choices because I do not like engineering. I was not forced by my parents but I made the decision because I simply like to study. During Edu Camp held in Universiti Teknologi Petronas (UTP), on the night before my interview, we were asked to speak in from of other people and talked something about ourselves, our goals, and many more. I was the only one who spoke my mother tongue language and one of the dream that I still remember until now is to be someone who are able to speak many languages. I did not get the scholarship but I grew. Could you see that I have already mentioned of out of many dreams that I want to achieve. Speaking about the second dream mentioned above, I decided to learn Spanish after I have learnt basic English for communication purposes, followed by Japanese and French. One of my batch mates used to say that I can speak any language that other people could not understand even when I speak it wrong. no one would concern or knows. Others said that better I learn something that can be used in Malaysia. People may say a lot of things, but they do not even know what is your goal or dream. I want to persue my study in one of Europe countries one day. Now, I have not mastered any and I hope that I would, one day.

Let make my story shorter. My parents used to tell me that if I've got distinction or cum laude in my medical degree, they would give me iphone 4. When I came back Malaysia from Yogyakarta last three weeks, I told my mom that I wanted to covert it to money because I just got HTC from them. If I got second wave, I told my mom that I wanted to go Europe for vacation. I really want to go Paris. I searched many travel agents especially from MATTA fair to get the best deal. Actually, my parents said that If I got distinction for my clinical rotation, I would get the trip to Paris. But when I told my parent about my plan, she said it should be fine and she might follow me as well. Alhamdulillah, I got first wave. I really wanted that and prayed a lot for that. So, I have to cancel my plan to go Europe. They said it is ok because we can go there in the future. Thanks a million to them because they bought me something that can catch meaningful memories and I really hope that I could take care of it :)

Friday, March 11, 2011

The Malay Chronicles: Bloodlines (Extended Trailer)



Today, I would like to discuss a bit about one of the Malay movie that I really like most. The Malay Chronicles: Bloodiness or Hikayat Merong Mahawangsa. The first title is given to the international version that has been sold and distributed to 72 countries around the world including France, United Kingdom, Germany, Russia and Middle East countries. I have watched the film and I am pretty sure to conclude that this epic film is very good and contains lots of actions. So, you won't get bored when watching. So, let's watch the movie and you won't get disappointed.

Starring by Stephen Rahman Hudges (Malaysia/UK), Jing Lu (UK), Gavin Stenthouse (UK) and local actors and actresses, Dato Rahim Razali, Wan Hanfi Su, Ummi Nazeera, Khir Rahman, Jehan Miskin, Deborah and many more.

Synopsis

Based loosely on the 16th century historical document entitled ‘The Malay Annals’, ‘The Chronicles of Merong Mahawangsa’ is an action-packed epic feature film, with mythical characters, magical moments and dazzling visual-effects sequences. Merong Mahawangsa was a descendant of Alexander the Great, a renowned naval captain and traveller who came to Asia several hundred years ago.

The year is 120 AD… a time when the Roman Empire is at the height of its power, during the reign of Hadrian – one of the Five Good Emperors. Meanwhile in China, the Han Dynasty is firmly cemented as the ruling empire and is expanding into Central Asia... one hundred years before the period of the Three Kingdoms.

As the Roman fleet did their repairs and traded in Goa, they asked Merong Mahawangsa to escort a Roman prince to Southeast Asia, to wed a beautiful Chinese princess from the Han Dynasty. The Chinese princess and the Roman prince are supposed to meet halfway and be married on neutral grounds.

However, the pirate nation of Geruda had other plans. They decided to kidnap the Chinese princess and use her as ransom. En route to the Straits of Melaka, Merong Mahawangsa’s fleet was attacked by Geruda’s forces while stopping at a small island to replenish supplies.

Will Merong Mahawangsa be able to rescue the Princess and re-unite her with her betrothed in a marriage that is set to bring together two great civilisations from the East and West?

Join KRU Studios in ‘The Chronicles of Merong Mahawangsa’ where his journey will be revealed.

Referrences:

1. http://www.thefilmcatalogue.com/catalog/FilmDetail.php?id=7356
2.http://www.murai.com.my/article/default.asp?article_id=9117&c=1&s=1

Saturday, March 5, 2011

We may do what we hate .

I do not have any idea to update actually, but one of the topics in magazine that I read few days ago make me feel like sharing the topic. It was about Facebook, one of the most popular social network service. Updating status is just one of the features in Facebook that can be used by the users. Just like any other things, this website has it's pro and con. Do you notice anything in that website that can get under your skin? Comment by even your own friends sometimes might hurt your feeling or even might get out of our pram. Words do not have intonation, so wisely use those appropriately. In my personal opinion, we do not need to publish every single thing in Facebook because sometimes the things that we posted might get on other people nerves. Blog is a different thing. I prefer blog to Facebook to express my thought. Sometimes we tend to judge people based on what they said or did (pictures). But remember, what we are thinking might not be true for all cases. As I always mentioned, I am simply John Q Public. I am doing the same thing of what I hate people doing sometimes. This post is not intended to condemn anyone. It is simply a penny of my thoughts.

PS: Practice what you preach.

Friday, March 4, 2011

Ungrateful: Am I?

I did not update my blog for a quite sometime. Sway was my last post but I had not described anything about my life. In this post, I would like to share something about the result. I know some people might get offended by this post but I have to express my feeling as well is it? I would try to be neutral as well as I can but I am an average Joe. So, do try put yourselves in my shoes too as what I have been trying to do. People may see me as a person who is lucky. Behind all those things I did try so hard to achieve something that I wanted. I had daily plan for study. When people mentioned about Coma and Forensic that are two subjects that are easier to get an A, for sure I get offended. For Coma itself, I prepared 3 weeks before my Coma block got started and for Forensic subject, I prepared one and the half months before the exam. I did not say that I deserved to get A but I think I must. Mentioning about this is not easy because I need to think about other people as well. I do not know how much effort they had put to achieve their target. It is not like OSCE, exam that we can argue for. Speaking about OSCE, even though I did pass for one station I really think that I did not deserve that time. Yes, my examiner was very strict but I know what were my mistakes and I learned from that.

This is life. Sometimes you need to put all your eggs in one basket. Sometimes life is a pyrrhic victory. What we can do is just give the best that we can at anytime because we do not know when is our best day in life.

Wednesday, March 2, 2011

Thursday, February 10, 2011

Colds

Common cold (acute coryza)

Etiology

The illness is caused by rhinovirus infection. Basically, this bacteria is belong to picornaviridae family. This virus is inactivated by low pH (≤ 3) and prefer to grow in nasal passage that has temperature between 33°–34°C. There are at least 100 different serotypes of rhinovirus.

Clinical Manifestation

The clinical manifestation is related to mild systemic upset such as slight pyrexia, malaise and headache that may be absent in some patient. Basically, there are prominent nasal symptoms. The disease initially begins with rhinorrhea and sneezing that is accompanied with nasal congestion but the mucus will become thick and mucopurulent. Sore throat may also present. The incubation period is usually between 12 hours to 5 days. The disease is transmitted through close personal contact as well as contaminated droplets.

Diagnosis

Special diagnostic tools such as tissue culture and rhinovirus RNA detection by PCR are not required because the disease is usually self-limited and benign.

Treatment

The treatment is usually not needed but some medications can be used in condition in which pronounced symptoms are present. The drugs include NSAIDs and anti histamine (first generation). Moreover, oral decongestant can also be used. Antibiotics is preserved for common cold with complication such as otitis media and sinusitis.

References:

1. Fauci AS et al, editors. Rhinovirus infections. 17th ed. 2008.
2. Kumar P, Clark M, editors. The common cold (acute coryza). Philadelphia: Saunders, 2002.

Monday, February 7, 2011

Watch out your habit!


.......................
habit of sitting on a wallet carried in a hip pocket.

Sciatic nerve


Sciatic nerve is the largest peripheral nerve of the body and consists of two nerves- tibial and peroneal nerves. These nerves are originated from L4-s3 and are combined within the same sheath for the length of the thigh before they separate.

(Adapted from Seeley-Stephens-Tate, Anatomy and Physiology, 2003)

1. Tibial nerve innervates most of the posterior thigh and leg muscles. The movements of the muscles innervated include:

a. Extends hip and flexes knee – biseps femoris (long head), semitendinosus, and semimembranosus.
b. Extends hip and adducts hip – adductor magnus
c. Plantar flexes foot – Plantaris, gastrocnemius, soleus, and tibialis posterior.
d. Flexes knee – popliteus
e. Flexes toes – Flexor digitorum longus and flexor hallucis longus.

2. Medial and lateral plantar nerves (originated from tibial nerve)

a. Flexes and adduct toe – plantar muscles of foot
b. Cutaneous (sensory) – sole of the foot

3. Sural Nerve

a. Cutaneous (sensory) – the lateral and 1/3 posterior of the leg and lateral side of the foot.

(Adapted from Seeley-Stephens-Tate, Anatomy and Physiology, 2003)


4. Common Peroneal Nerve ( Common Fibular)

a. Extends hip and flexes knee – biceps femoris (short head)
b. Cutaneous (sensory) – lateral surface of the knee.

5. Deep fibular Nerve.

a. Dorsiflexes foot – tibialis anterior and fibularis tertius.
b. Extend toes – Extensor digitorum longus, extensor digitorum brevis and extensor hallucis longus.
c. Cutaneous (sensory)- great toe and second toe.

6. Superficial fibular Nerve.

a. Plantar flexes and everts foot – Fibularis longus and fibularis brevis
b. Cutaneous (sensory) – dorsum anterior third of the leg and dorsum of the foot.

Sciatica

This condition produces sharp pain to the gluteal region, posterior thigh and leg as well as ankle. This condition can be produced by the injuries of the sciatic nerve such as herniated intervertebral disc or osteoarthritis of the lower spine (90% of the cases), pressure from uterus in pregnant women, sitting for a long time at the edge of the hard chair, hip dislocation, injection in the wrong site of the buttock or habit of sitting on a wallet carried in a hip pocket.

The Lasegue’s sign is usually positive in sciatica. This test can be conducted passively by flexing the hip while the knee is extended.


References:

1. Seeley RR, Stephens TD, Tate P, editors. Brain waves and sleep. New York, Mc Graw Hill, 2008.
2. Setyopranoto I, Paryono. Neurological Exam 2. Yogyakarta, UGM, 2009.
3. Saladin K.S. Spinal Nerve injuries. Mc Graw Hill, 2003.

Sunday, February 6, 2011

Pink or Blue?

Chronic Obstructive Pulmonary Disease (COPD)

Clinical Manifestation

The most common symptoms in COPD are cough, exertional dyspnea and sputum production. These symptoms always develop gradually but patient always come and complaint about these as an acute onset or exacerbation. Basically, the activities such as walking on the treadmill, pushing a wheelchair and pushing a shopping cart are better tolerated because these activities allow the patient to brace their arm and use their accessory muscles of respiration. Exertional dyspnea is described as heaviness, air hunger or increased in the effort of breathing. As the disease progresses, the dyspnea becomes worst even after mild activity such as dressing.

Physical Finding

1. General Inspection

a. Inspection of the patient’s facial expression - During inspection of the face, we can see patient pursing his or her lip during expiration. In severe disease, patient is tachypnoeic and has prolonged expiration as well as having expiratory wheezing. Moreover, sometimes, we can find cyanosis in certain patients.

b. Inspection of the patient’s posture – Tripod position is preferred by the patients because this allows patient to support their arm and facilitate the use of their accessory muscles (scalene, sternocleidomastoid and intercostals muscles.

c. Inspection of the patient’s neck and configuration of the chest – The use of accessory muscles as mentioned above and barrel shaped chest.

d. Inspection of the hands – Clubbing finger may be found but it is not a sign of COPD but maybe related to the lung cancer especially in this population. There is also nicotine staining of the finger nails. Blue bloaters may have cyanosis that can be observed in nail beds.

e. Assess the respiratory rate and pattern - Patient is tachypnoeic .

f. In severe disease we can find systemic weight loss, bitemporal wasting and diffuse loss of subcutaneous adipose tissues due to the inadequate oral intake and the elevated level of inflammatory cytokines.

2. Posterior Chest.

a. Inspection – During inspiration we can see the use of accessory muscles. The chest expansion is poor.

b. Palpation- During palpation, we can feel that the chest expansion is poor as mentioned above and tactile fremitus would be decreased.

c. Percussion – There is poor diaphragmatic excursion.

d. Auscultation – Prolonged expiration and expiratory wheezing.

3. Anterior chest.

a. Inspection – Poor chest expansion, intercostals indrawing on inspiration (Hoover’s sign), hyperinflated lung can be observed in severe cases.

b. Palpation – As mentioned above, poor chest expansion and hyperinflated lung.

c. Percussion – Loss of normal cardiac and liver dullness. Hyper resonance on percussion.

d. Auscultation – Prolonged expiration and expiratory wheezing.

Supporting examination

1. Pulmonary function testing – In this test, we can find the FEV1 and FEV1/FVC are reduced. This shows the airflow limitation as well. Other than that, as the disease progresses, there is an increased in total lung volume leading to the increased in total lung capacity, functional residual capacity and residual volume.

2. Radiographic studies- Chest X-ray may reveal bullae, paucity of the parenchymal marking as well as hyperlucency may suggest emphysema. Other findings include the absent of blood vessels in the peripheral half of the lung compare with the relatively easy visible blood vessels in proximal field. Due to hyper-inflation of the lungs, the diaphragm tend to be low and flattened.

3. Blood gas is often normal but we can fin hypoxemia and hypercapnia in severe disease.

Treatment

1. Smoking cessation – the use of psychological support as well as pharmacotherapy such as bupropion (originally produced as anti-depressant drugs) or nicotine replacement therapy.

2. Bronchodilators- salbutamol (200μg every 4-6 hours), ipratopium bromide (40μg four times daily), oxitropium bromide (200μg two times daily.

3. Corticosteroids for short-term, symptomatic patients with COPD, 15 mg prednisolone can be given daily for two weeks but pre and post of the lung function tests are needed to be tested. If the FEV1 increased > 15%, prednisolone should be discontinued and replaced with inhaled corticosteroids such as beclomethasone 400 μg twice daily in the first instance, adjusted according to response.

References:

1. Kumar P, Clark M, editors. Chronic Obstructive Pulmonary Disease. Philadelphia: Saunders, 2002.
2. Fauci AS et al, editors. Chronic Obstructive Pulmonary Disease, 17th ed New York, Mc Graw Hill, 2008.
3. Bambang Dwarwoto, Hashifah K, Novalia S, Swatindra A, editors. Skill training Manual for Basic General Physical Examination, Yogyakarta, UGM, 2008.

Saturday, February 5, 2011

Tension!

Tension-type headache (TTH)

Clinical features:

Tension type headache is characterized by bilateral tight with band-like discomfort without any accompanying symptoms such as nausea, vomiting, photophobia, phonophobia, osmophobia, aggravations by movement and throbbing pain. This type of headache usually progresses slowly and may be episodic or chronic (more than 15 days per month). As I mentioned above, TTH can be differentiated by migraine because there is no other symptoms presents other than headache. However, admixture of nausea, photophobia and phonophobia in various combinations is allowed in TTH according to the International Headache Society. This creates some difficulties in differentiating TTH and migraine. Patient with TTH alone may be biologically different from patient with TTH at one time and migraine at other times, along with family history of migraine, migrainous illnesses of childhood, or typical migraine triggers to their migraine attacks.

Pathophysiology:

Even though the pathophysiology of TTH is completely understood, one of the etiology suggested is primary disorder of CNS pain modulation alone. Migraine involve more generalized sensory disturbance because of the present of aura that is related to other modulation such as light, hearing and smell. Other pathogenesis is related to muscle tension or nervous tension.

Treatment:

Pharmacology treatment includes acetaminophen, NSAIDs, or aspirin. For chronic TTH, it could be managed by amitriptyline. Behavioural therapy such as relaxation could be effective measure.

References:

1. Fauci AS et al, editors. Tension-type headache, 17th ed New York, Mc Graw Hill, 2008.

Knowing your waves

Electroencephalogram (EEG) is important diagnostic tools in many diseases related to the brain. In EEG, electrodes are placed on the scalp, so that the potential different between paired electrodes (bipolar derivation), or between individual scalp electrodes and a relatively inactive common reference point (referential derivation) can be detected. Basically, the patterns of the waves produced in EEG depend on the age and the activity.


a. Alpha waves.

Alpha waves are usually produced when a person in awakes condition, lying quietly with eyes closed. These rhythmical waves have 8 to 13 cycles per second (8 – 13 Hz) are attenuated when the eyes are opened and in drowsiness state. The waves are more prominent in occipital region but can also be observed in parietal and frontal region. The voltage is around 50 microvolts.

b. Beta waves.

Beta waves are produced when a person is subjected to intense mental activity. These waves can be observed mainly in parietal and frontal regions and have more than 14 cycles up to 80 cycles per second but lower voltage.

c. Theta waves.

Theta waves have 4 to 7 cycles per second. These waves can be observed in children and adults who are experiencing frustration and disappointment. The waves can be observed normally in parietal and temporal regions of children. Brain disorders can also produce these waves such as in degenerative brain states.

d. Delta waves.

Delta waves can be seen in deep sleep, in infancy, and serious organic brain disease. The cycles are less than 3.5 cycles per second and usually have voltage two to four times greater than other types of brain waves.

Some other forms of waves:


a. Grand mal seizures.

The waves are characterized to have high frequency and high voltage discharges that involve the entire cortex as well as basal region of the brain. These waves can be found during tonic phase.

b. Focal epilepsy.

EEG is characterized by low frequency rectangular wave with frequency between 2 to 4 cycles per second. Sometimes, we can detect superimposed 14-cycles per second wave.

c. Petit mal seizures.

In this seizure, we can find dome and spike shapes waves. These waves affect the most of the cerebral cortex.

References:

1. Fauci AS et al, editors. Electrodiagnostic studies of nervous system disorders: EEG, evoked potentials and EMG. 17th ed. 2008.
2. Guyton AC, Hall JE, editors. Motor and integrative neurophysiology. Philadelphia, Saunders, 2006.
3. Seeley RR, Stephens TD, Tate P, editors. Brain waves and sleep. New York, Mc Graw Hill, 2008.

Sunday, January 30, 2011

Chickenfeed


I always sleep late nowadays. Perhaps because I have no other classes to attend except for my OSCE traning in the evening. This week is going to be the last week for my OSCE training, guided by the assistant. For this post, I would like to share something about appreciation. Last Saturday, when I went back from gym, I passed by Pizza Hut located in JAKAL. This made me feel like having dinner there on that night but the problem was, I had ordered 2 pieces of chickens and two eggs for my dinner and supper. Luckily, I was able to cancel one chicken and one egg, so that, I could spend my dinner time outside. I made up my mind to go Amplaz alone that evening, looking and hoping to get something for room. After I bought something there, I went to Pizza Hut located in Jalan Solo. I simply order Quadza and Milo Iced with float there. When I got my drink, I noticed that the taste was not the same as what I got when I ordered the same thing but in different Pizza Hut few days before. I told myself to keep my hair on and gently called the waiter, telling him about the water and asked him to change. He asked me to shake the drink first and I directly did what I was asked to do but the taste remained the same. He asked me to wait. Few minutes later, he brought a cup of sugar and apologized for their mistakes. In my opinion, this kind of solution was cat's whiskers to me. Instead of bringing the drinks back to the kitchen, he brought a cup of sugar to me. This would prevent two things psychologically. First, other customer won't suspect that there was any problem because he did not bring my glass that was still full back to the kitchen. Secondly, he gave me the sugar, so that I could determine how much I need. This situation may seem to be chickenfeed, but I'd really appreciate those simple things. The most important thing for me is how professional or how good are you in performing your job no matter what kind of job are you doing.

I went back to my home then after that, and went out again to buy some stuffs. It was about 11 30 pm that time when I reached Indomaret. I bought two things: two oreo biscuits and a bottle of Dentol. The person in-charged seperated the thing into two different plastic bags and I really happy for what he's doing because he knew what to do with the thing - chemical should be seperated with food. Again, two examples given above might sound boring but the main idea here is to tell that I really appreciate the small things. Instead of doing one big thing, I prefer two small things. For example, sms is a common communication tools nowadays. I always wonder, everytime when I replied people sms for helping them about something, what was the reaction. Simply, magic words such as ' TQ' is more than enough for me. It's child's play maybe but need some training. I am not a good person is replying because I always delay it. I must admit about that, but my concern is the reaction not the duration. Everyone forsure dreaming of having day in the sun (idiom).

This is another story belong to my good friend. He told me that when he started to get involved in relationship, he really thought that his girlfriend did amazing things because she could notice and appreciate simple things and that was one of my friend's reason why he was attracted to her. For me, this does not apply only to couple relationship, but in all relationship. In sharing those words, made me feel like a Barrack-room lawyer but I am sure that everyone had their thought. So, I really hope that I can be someone who can appreciate the simple things. I better catch some z's now because I need to wake up early today.

PS: Expectation does not come first, but the effort that we put to reach it.

Ball is in your court ... .(idiom)