down's syndrome

down's syndrome,common in our world.the risk in live born infants is about 1 in 645.Usually suspected after birth by their typical facial appearance.

I've seen 3 down's syndrome baby with their medical illness like leukemia, atlantoaxial instability,TOF and hypothyroidism.

their smile is much worth than everything

practise-3

a patient came with fever and lymphadenopathy.Night blood smear was done and picture A was found in blood.

1. give the rational for taking night blood smear.
2. give 2 morphologies seen in the picture
3. name the organism
4. give 2 diagnostic tests.
5. name 2 drugs for this infection

answer

• the organism present in blood is higher at night
• blurred nuclei,kinky shaped and 2 nuclei at the post end.
• Brugia malayi
• Brugia rapid test and Knott's concentration method
• albendazole,diethyl carbamazine(DEC)

p/s:yeah,im s000000000 sleepy.good luck evrybody=p

practise-2

A patient came with fever,abdominal pan and intermittent seizure.The picture shows the head of the organism A found in his stool.

• describe the morpholoy of organism seen in the picture?

the scolex with 4 suckers and 2 row of hooks

• give 2 stages of this organism that can be detected in the stool

the egg and gravid proglottid

• name the intermittent host for this infection

pork

• state the diagnosis for this patient

infected with Taenia solium with complication ofneurocycstercosis

• drug that can be used for this infection

praziquantel

S.E.H.A.T

S.E.H.A.T

soil transmitted diseases(nematode)

S-Strongyloides stercoralis

E-Entrobius vermicularis

H-hookworm

A-Ascaris lumbricoides

T-Trichuris trichiura

E,A,T

1. the male worms have post coiled end structures.(orang laki suka belit ayat)
2. the infective stage are the egg(embryonated egg for Ascaris lumbricoides)
3. route-fecal-oral route

S.H

1. route-direct penetration to skin.
2. infective stage-filariform larvae

brain and haemorrhage-1

extradural haemorrhage

cant cross the suture[the dura attach directly to the bone]
haemorrhage can cross the midline
haemorrhage is biconvex shape



subdural haemorrhage

can cross the suture
cant cross the midline[due to presence of falx cerebri]
cresenteric shape

























subrachnoid haemorrhage

the blood fill the fissures and the sulci
not cross the midline
usually due to:
1.trauma
2.rupture of aneurysm
3.AVM

Hysterosalpingography(HSG)

a radiological investigation of female genitalia tract.
indicated in infertility-untuk tengok congenital anomalies or tubal patency/obstruction if there is no spilage of contrast medium in peritoneal cavity

performed between 4th-10th day of menstrual cycle,patient needs to abstain from intercourse during the period ofbooking until examination.

practises make perfect-1

case 1

a 16 year old girl,came to GP for never having menses.

experienced cyclical abdominal pain for the past 2 years

normal secondary sexual characteristic,no goiter,BP 110/70 mmHg

per abdomen-a mass coresponding 12 weeks of pregnancy,

ultrasound-enlarged uterus filled with fluid

karyotype-XX

• diagnosis
• pathogenesis and pathophysiology
• investigations and treatment

case 2

a 17 yer old female,unmarried,came to hospital,never having menses.physical examination:

• short stature
• no secondary sexual features development
• broad chest
• external genitalia infantile

1. further question
2. provisional diagnosis
3. investigation to comfirm diagnosis

[good luck friends]

please comment so we can discuss

a true story=p

A 26-year-old technician was a healthy and happy go lucky young man. He never had any problems with his friends or his health in his entire life. In fact he was an active sportsman during his college days.

One day, on the way to work while riding his motorbike, he suddenly experienced an intolerable rush of anxiety. This was accompanied by a pounding heart, heaviness of the chest, chest pain, numbness in the fingers and shaking. He was gasping for air, and feared that he was having a heart attack. He stopped his motorbike by the highway and lay down by the side of the road and called his wife to come and take him to the hospital.

At the hospital, he was immediately given oxygen and blood was taken for investigations. His ECG and even a scan was done to find out the cause of the sudden attack. Although the attack lasted only a few minutes, the fear of what was wrong, and what if it reoccurred, permeated his mind and he became anxious and fearful all the time. Since all the investigations, including his ECG, were normal, he became more perplexed and fearful that the doctors could not treat him because they did not know what was wrong with him. He requested further tests and was hospitalised for a week. Although the severe attack did not come back while he was in hospital, he was always anxious and apprehensive of getting another attack.

After one week, he was discharged, but he was unsure what was wrong with him. He became apprehensive about going to work alone on his motorbike and his wife had to drive him to the office daily. In the office, he was not as cheerful as before and refused to go out on assignments. He was afraid of having an attack while repairing machinery. His work performance suffered. His relationship with his wife also suffered because he was afraid to be intimate with her as he believed if he exerted himself he might get another attack. He dreaded going to work and his friends started to shun him, saying that he was lazy.

He subsequently had another attack in the office and was again admitted to the hospital, and once again, he recovered quickly after basic treatment at the emergency room. He was this time referred to a psychiatrist who diagnosed him as having a panic disorder.

He was treated with medications and a course of cognitive behaviour therapy. Currently, he is back to work, riding his motorbike and is able to control his illness. He still has the disorder but is no longer imprisoned by it.

http://psychiatry-malaysia.org/article.php?aid=21

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panic disorder

1. recurrent spontaneous attack;with no obvious precipitant
2. percictent concern about having additional attacks
3. worry about the implication
4. change in behaviour-->agoraphobia

imbalance of neurotransmitter

[NE increase;GABA/serotonin decrease]

thalassemia

a 40 year old white,married mother of three was scheduled for an abdominal hysterectomy.Pre surgical blood testing revealed that the patient was anaemic.Laboratory results were:

• Hb:9.5g/dL
• Hct:29%
• erythrocyte count:4.6 x 1012/l

Surgery was postponed and she was given oral and parenteral iron therapy.3 weeks later,her blood count results were:

• Hb:9.4 g/dL
• Hct:30%
• Erythrocyte count:5.0 x 1012/l
• Leucocyte count:7.3 x 109/l
• Reticulocyte count ;2.5%
• bilirubin:0.5mg/dLwith 0.1mg/dL conjugated
• serum iron:67 mikro g/dL
• TIBC: 294 mikro g/dL

she claimed that she had history of anaemia with many courses of iron therapy but she hadnever had a normal hematocrit.There was no history of chronic illness,nothing to suggest malabsorption and no known GI bleeding.Her father and two sisters were anaemic and niece was being evaluated for anaemia.

Hb electrophoresis was performed on this patient and the following results were obtained.

• HbA2 (4.7%)
• HbF (1.1%)
• HbA (94.2%)

questions

1. what is your provisional diagnosis?(minor Beta thalassemia)
2. discuss the pathogenesis,investigation and treatment
3. interprate the Hb electrophoresis.also discuss the Hb electrophoresis in

• major beta thalassemia
• sickle cell anaemia
• Hb E disease & compound heterozygous
• alpha thalassemia

p/s:this short case was prepared by anis duha for our study group discussion.please ask her if u encounter any problem=p.we hope this case can trigger your mind and to understand better about this disease.please dont stress. we are trying to help each other.terima kasih

[happy study]

anaemia

Anaemia occurs when the haemoglobin is below the normal level. Anaemia occurs due to increase RBC destruction, decrease RBC synthesis or due to blood loss. Because of erythropoietin hyperplasia and anatomical extension of bone marrow, the red cell destruction may be increased before the patient becomes anaemia.

In haemolytic anaemia, the RBC destruction occurs either extra vascular or intravascular.The clinical features of haemolytic anaemia depend on the site of haemolysis.

Extravascular

• increase unconjugated bilirubin,
• increase urobilinogen and fecal stercobilinogen.

Intravascular

• Haemoglobinaemia and haemoglobinuria
• Haemosiderinuria
• Methaemalbunaemia

Besides that,there will be also features of increase RBC production-->reticulocytosis

Blood film(presence of damaged cells)

• microspherocyte
• fragments
• elliptocyte

p/s;we can noted the signs of extravascular haemolytic anaemia by the presence of jaundice or yellowish sclera.

ptosis-2

Mrs P,a 44 year old female,came to the emergency room complaining of severe headache.She describing the pain as sharp and shooting into the front of her head,then aching.She allso says that her left eye wants to stay shut.She has had this pain on and off for five days.Four days ago,she saw her family physician who ordered a CT of the head.This shown no abnormlities.

Her physical exam was unremarkable.Blood pressure was 131/79mmHg with resting heart rate 97 beat/minute.

other systems reveal normal except;

• she has weak upward and medial movement of the left eye.On foward gaze,the eye is deviated down and laterally. There is mild ptosis of the left eyelid
• the left pupil was larger than the right.The left eye did not react to light either direct or consensual.The right pupil responses was normal.

provisional diagnosis: posterior communicating artery aneurysm

please refer to X'PRESS revision in short cases by Universiti Malaya,page 8,approach to ptosis.please understand how Horner's syndrome,diabetes mellitus and PCOM aneursym can cause unilateral ptosis but different pupil size.

[happy study]

this short case was prepared by my studygroup mate,faten aqilah.please ask this makcik for better uderstanding.Jangan stress ye~~~~~~~~~

ptosis-1

haha,dulu2 suka panggil org mata kuyu mata stim.ngokngek!!!!!!!

our levator palpebrae superioris muscle or eyelids is innervated by cranial nerve III bilaterally.maksudnya right CNIII innervated both levator palpebrae superioris muslce.so klau ada CN palsy at one side,yang lagi satu bleh still akan bukak eyelid tu.(mcm dalam kes upper motor neuron and lower motor neuron lesion dekat face tu).so kalau peripheral nerve yg innervate each eyelids rosak,so satu jela mata yg berlaku ptosis.paham tak?tak reti nak terang pulak=(

when someone is having ptosis only at one eye,please check the pupil size.either small,normal or large.

pupillary reflex

• sympathetic:pupil constrict
• parasympathetic:pupil dilate

kalau sympathetic rosak,pupil tak boleh nak dilate kan,so pupil akan kecik.

small pupil,unilateral partial ptosis in Horner's syndrome

horner's syndrome

horner's syndrome:

• decrease sweating over each eyebrow
• pupil constrict due to unbalanced parasympathetic action
• partial ptosis as sympathetic fiber supply the SMOOTH muslce of eyelids.

occur due to interruption of sympathetic innervation of the eye at any point.

Post Enteritis Syndrome

Post Enteritis Syndrome

the diarrhea persistent or become severe after post hydration period.why?

during the AGE,the lamina propia and the mucosal layers damage.The mucosal layer that recovered from AGE remains sensitive to antigenic food proteins such as cow's milk protein.The continued feeding of these proteins during vulnerable period results in further mucosal damage,depletion of mucosal dissaccharidases and secondary lactose intolerance.This result in persistent diarrhea.

=p

when patient is having diarrhea,the important thing is to restore the fluid loss.

the complication of diarrhea might cause renal failure in severe dehydration and also hypovolumic shock.We know already the complications of shock right=p

management of diarrhea

1. fluid replacement therapy
2. antibiotic therapy-only in blood diarrhea,septicaemia and immunocompromised patient.
3. antidiarrheal therapy not indicated because we want to remove the bacteria from the lumen excreted into the stool.

diarrhea-cirit birit

constipation-sembelit

pelvic fracture,urethral injury and testicular torsion

Gosh!it makes me 2 days to understand,plus my movie time..itula dulu time dr ajar tak nak focus.hahaha=p

ok,lets say someone is having pelvic fracture.Now,refer to atlas,kita tgk organ yang ada dalam pelvic cavity(since surrounded by pelvic bone).Not to to forget the perineum.Sites of fracture akan bagi kesan dekat adjacent organ=P.

katakan fracture dekat inferior pubic ramus.

adjacent structures are membranous and spongy urethra,external spinchter muscle,nerves and blood supply.if the fracture cause urethral injury,sodekat meatus akan kuar fresh blood(kalau injury atas neck of bladder,blood akan mix dengan urine=hematuria).If he's having complete urethral injury,urine yang flow akan akan masuk dekat perineal pouches.

urethral injury

1. membranous urethra-urine akan flow ke deep perineal pouch,and dpt abdominal pain only.
2. spongy urethra-urine enter superficial perineal pouch and fill the scrotum and the ant of ant abdominal wall.sebab tu dappat abdominal pain and also swollen and tender scrotum(inflammation occur)

bila extravastion of urine in the scrotum,akan lead kepada testicular torsion.bahaya!sebab kalau ischemia,alamat mandul la lelaki itu=Pso kena repair.and also the contralateral testis pun kena check sebab selalu torsion berlaku bilaterally=p.

hehehe..please refer to atlas and keith moore for better understanding=p.

p/s:what will happen if the fracture cause the nerve injury?hahahahaha

convulsion,seizure and fit

yup,i found the differences.thanks to mama ro=p

convulsion/fit:seizure(layman term)
seizure;medical term,

but they refer to the same meaning-->abnormal neuronal discharge activities in the brain

then,what is the different epilepsy and status epilepticus?

epilepsy:recurrent seizure attack due tue unprovoked causes(brain tumor cause seizure;bukan epilepsy sebab kita tahu sebabnya)

status epilepticus:(emergency)
-->seizure attack that last more than 5 minutes,or
-->between the 2 attacks of seizure,recovery tak berlaku(normally during postictal,patient akan recover,tapi bila tak recover and followed by next attack itu dah emergency)

febrile convulsion
berlaku sebab the immature brain takboleh tahan high fever due to electrolyte disturbance.
-->we need to evercome this sebab kita nak prevent seizure dekat adult life(complex partial seizure)

ingat tak our super duper dr sani cakap,bila dapat febrile seizure,if prolonged,kita takut akan berlaku brain anoxia.if this happen,that area between the hippocampus an medial temporal lobe akan sclerosis.Sclerosis dekat area ni la akan menyebabkan seizure time dewasa=(

so untuk prevent that prolonged febrile seizure,sponge the patient and bagi rectal diazepam(antiepileptic drug)

GOSh!i read about seizure,but i still couldn't appreciate it=(need more hard work,yeah!
i still takboleh beza/paham tentang absence and grand mal seizure.BRAIN is so complicated!

p/s:hope this will help you people=p

LP

OLD LINKIN PARK LOGO

LP here is not for linkin park but LUMBAR PUNCTURE

this video totally awesome!panjang gila jarum,no wonder la sakit,even dh letak LA,plus mind dah set akan sakit so bertambah-tambah sakit la.pity them=(

This is an instructional video describing how to perform a lumbar puncture. This was created for the Internal Medicine residents at Brown University

1 Dec-World AIDS DAY

"DAD, can you please not let the principal know that I'm positive?" the 11-year-old boy asked B days before he was to step into the new school.

Even before that question came, B had long decided not to disclose his son's HIV status to anyone in school this time, learning from past experience.

It was not an easy decision to make under any circumstances because it meant having to live with the guilt and constant fear that accidents might happen in school, giving rise to the possibility of a transmission.

"I feel that my son has a right to decide whether or not to tell other people his status. We have kept it a secret until now, but the guilt is still there," says B, who adopted Danial (not his real name) when he was just 2.

At that time, B was a volunteer with an organisation working to find suitable foster families for HIV-positive babies whose parents had died of AIDS.

He interviewed potential families to decide whether they had the right personality, attitude and behaviour in handling children with HIV.There was little knowledge and understanding of AIDS then, even though people knew what HIV was, said B.

A married couple was supposed to take Danial in, but over the months, in the process of thinking and rethinking about their decision, the wife changed her mind."When the wife suddenly said, 'I don't think I want to take this kid,' we withdrew the couple's application."The kid was left hanging in hospital for two years. There was a need to place him with a family. No home would take him in and he couldn't be staying in the hospital forever."By then, I had grown attached to him and we decided to adopt the child," says B, who is still actively involved in HIV-related work.

That was 12 years ago. Danial, now 14 and studying in a secondary school, is "totally healthy, active and happy", said his dad."He looks normal. No one can tell that he is positive without us informing them."Danial's secret is still intact today."

Every time my son enrols into a school, there is a health form that I need to fill in. "I always feel guilty as a parent (to not disclose his status), and the fact that he has to go to the hospital all the time makes it hard to keep things under wraps."I was torn inside, not knowing what to tell the school."In the end, B informed the secondary school teacher that his son has a blood disorder that requires treatment in the hospital every three months.All the sleepless nights , the white lies and constant worries that plagued him were worth B's sacrifice if it meant his son did not have to relive the experiences he had in his primary school."It was all done to protect him from further discrimination."

When Danial was in kindergarten, B did not let the school operators know of his condition because he knew the kindergarten would not accept his son for who he was.But when Danial turned 7 and was ready for primary school, B could not live with the guilt and so he informed the principal."I think that was a mistake."

When my son was in Year Two, he cut himself while playing. That was the time when the whole school panicked. Everyone was afraid to touch him."The school had to call B in to tend to Danial himself. It shocked B that the teachers reacted that way, because it showed that they did not know how HIV transmission was possible.

The health department was later called in to explain to the teachers about HIV.That was a one-off dramatic incident, but throughout his four years in school, Danial received "special treatment" -- he was not allowed to play games or play an active role in sports.It wasn't good for the teachers to be so protective of him, said B, because they did not give him a chance to participate."He did ask himself why he was not allowed to join the sports. He also mentioned that whenever he played with other kids, they asked him not to play rough with them."Somehow, other parents got to know of my child's case. But the good thing is no one that I know of asked to have my child removed from the school."Academic-wise, the treatment Danial received was not too far off from what he experienced during sports lessons."The teachers didn't pay much attention to him. "They treated him like a kid who didn't want to study, letting him just play in the corner."

Such an attitude would have a psychological effect on any child, said B, who encouraged Danial to share his stories with others.Right from the start, B had no intention of hiding Danial's condition from himself or that he was adopted.Even when he was in nursery, B started talking to Danial about HIV by telling him stories from books on HIV- positive children.

"We always try to empower the child from the beginning, to arm him against stigma and discrimination."I encourage my son to share with his friends, those he feels that he can trust, but so far he hasn't told anyone of his status."And now that he is at an age where he could become interested in girls, we talk about sex and condoms. Education is necessary.

"We also talk about death and dying. I've taken him to see how people die of AIDS, from the time when they are hospitalised till the time they are buried. "He has some ideas, but he is afraid to die. I wish that one day, my son would be fully empowered by his HIV status and would be a spokesman for others."

http://www.nst.com.my/Current_News/NST/Sunday/Focus/2415019/Article/index_html

Hiv/AIDS Awareness Campaign 2007/08

Myasthenia Gravis

A 35 year old woman presents to the clinic with a chief complaint of double vision. She reports intermittent and progressive worsening double vision for approximately 2months, rarely at first, but now every day. She works as a computer programmer and the symptoms increase the longer she stares at the computer screen. She had also noted a drooping of her eyelids, which seems to worsen with prolonged working at the screen. Both symptoms subside with rest. She is generally fatigued but has noted no other weakness or neurological symptoms. Her medical history is unremarkable. Physical examination is notable only for the neurological findings. Cranial nerve examination discloses impaired lateral movement of the right eye and bilateral ptosis, which worsen with repetitive eye movements. Motor, sensory and reflex examinations are otherwise unremarkable.

what is the likely diagnosis?

Myasthenia Gravis

what is the pathogenesis of this disease

An autoimmune disease where the body produce atibody towards the post synaptic Ach receptors.Also,the antibodies also attack the acethylcholine(Ach) at the synatic cleft.The net effects are decrease number of ffuncctional Ach receptor and functional Ach

explain the pathophysiology of each signs and symptoms.

patient comes to the hospital with the complaints of fatigue, ptosis and also double vision.Destruction of the receptors cause diminished transmission of the nerve impulse across the neuromuscular junction. Muscle depolarization is not achieved, therefore, muscle weakness develop.The signs and symptoms of MG depends on which muscle involve:

• extra ocular muslces :double vision
• levator palpebral superioris:ptosis
• upper esophagus :dysphagia
• palatalmuscle :dysathria
• diaphragm :respiratoryfailure

Usually,fatigue develop due to repetitive stimulation or prolonge use.This occur due to decrease number of available neurotrasmitter and the numbers of functional Ach receptor.

what are the investigations and the significant of it?

• TensillonTest

admistration of cholinesterase inhibitor will cause improvement of muscle power.This will increase the number of Ach in the synaptic cleft.

• antibody towards the Ach receptor
• chest Xray

autoimmune disease may associate with thymoma or thymic hyperplasia.

what treatments should be considered

• cholinesteraseinhibitor
• plasmapheresis,corticosteroid
• thymectomy

[happy study]
=p

bila dia mula ber'HATI KECIL'

apa yang akan kita buat kalau kita kecil hati dengan orang?MEMAAFKAN adalah satu benda yang pasti.tapi,mampukah kita melupakan apa yang telah dilakukan?untuk melupakan akan mengambil masa juga,bukan 1 atau 2 saat je dah hilang kan.

different persons may act different ways.and one of my collegue,she will try to avoid from meeting that person,or kalau jumpa mungkin bila bercakap tak seramah sebelumnya.but bila dia act mcm tu sebenarnya bukan la dia marah/berdendam/sekutu dengannya,tapi sebenarnya dia sedang lakukan SUPPRESSION defense mechanism.dia nak lupakan je masalah tu.so janganla kecil hati kalau dia tak cakap.kalau asyik ganggu dia time tu,sure dia asyik ingat and the anger might comeback.kan lagi susah=p.things will become better when everrything is back to normal.when?when that person kembali peramah semula=p

p/s:entah betul entah tak=p