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!


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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.