Monthly Archives: April 2012

Robert downey jr

I am so elated today because robert downey jr taught us lecture today.hahaha…. Not literally …

Doctors and professors are like celebrities to me! In fact, in my eyes, their position is unquestionably higher than hollywood stars who serves nothing to the community…except some…maybe.

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P/s: dont ask me why i call him robert downey jr. Hahaha.

Hirschsprung’s disease(HSD)

When i was in my preclinical years…. I thought the diseased part is the dilated part.it turns out that i am actually wrong all these years!!

That usually happens if you plan to study and NOT UNDERSTAND.boohoo.

It is the narrown part that is the diseased….why? The parasympathetic ganglions are missing so…the sympathetic takes the upper hand… Leading to spasm.

Basically….. The complaint will be delayed passage of MECONIUM….normally it would take one to two days… If it goes beyond that…. List a handful of DDs.one of them being HSD.the abdomen is so freakin distended that you can literally see the colon through the abdomen!!!

The problem with hsd is actually enterocolitis…. In babies…this is fatal! Due to the stagnation of stools…..this invites EC so easily….. And what we fear from is SEPSIS…..

The Dr said…PLEASE DONT DELAY SURGERY FOR HSD!!!

There is no rule for conservative treatment of course….

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So…what to search for??? I dont think just by plain xray would 100% conclude that its hsd. Anyway, you will find a distended colon…filled with gases…. And in one of the pics… The rectum is devoid of any gases….

By barium enema…on the lateral view, clearly shows…. The proximal dilated segment….and the distal narrower segment denoting the defective part….

Some important notes to remember…
An excerpt form emedicine:

Barium enema
Avoid washing out the distal colon with enemas before obtaining the contrast enema because this may distort a low transition zone.
The catheter is placed just inside the anus, without inflation of the balloon, to avoid distortion of a low transition zone and the risk of perforation.
Radiographs are taken immediately after hand injection of contrast and again 24 hours later.
A narrowed distal colon with proximal dilation is the classic finding of Hirschsprung disease after a barium enema. However, findings in neonates (ie, babies aged < 1 mo) are difficult to interpret and will fail to demonstrate this transition zone approximately 25% of the time.[21]
Another radiographic finding suggestive of Hirschsprung disease is the retention of contrast for longer than 24 hours after the barium enema has been performed.

If you suspect perforation or enterocolitis..so dont perform barium enema as it may pass to the peritoneum if this happens and leading to chemical peritonitis.

From what i have studied…. Sometimes… There is no delayed passage of meconium….so when this happens… You need to DD it with other diseases..

If the results is negative for hsd after rctal biopsy, do the SWEAT TEST to detect whether it is CYSTIC FIBROSIS.

this is a nice read. 🙂

Renew your intention

Tagged ,

Meconium

Today…there was a presentation…. And i kinda wondered…….whats a meconium plug syndrome!!! I didnt know…. Thats okay.there is nothing to be ashamed of. Feeling insufficient when you are seeking knowledge is a good sign.dont feel stupid…. Because you are not.

Excerpt from emedicine

Meconium plug syndrome, also termed functional immaturity of the colon, is a transient disorder of the newborn colon characterized by delayed passage (>24-48 h) of meconium and intestinal dilatation

Oooooooooooo……gtew rupanya…

And meconium ileus???? Its due to impaction of inspissated meconium…and it happens in babies with cystic fibrosis.

Dear bloggie

Salam.
Hi.here i am today writing this post just to tell you dear medic bloggie, i feel like i am so worn out.i have been studying and forcing myself to strive for excellence…and here i am…oh here i am lil bloggie…. I am worn out… So worn out like a worn out shoes… I feel like i am a shoe that has been running for miles and miles…holidays arent really real holidays… Thanks to me…

Oh dear, what should i do?
To come and think of it… Arent us humans suppose to feel that way?
I mean…. Yeah…as i have said before….
Life is an assignment… And i have to work hard …..just this once… YES.. Just this one chance of doing my assignment called life…. And then… You are going to rest for so long before you get to present your assignment… And there is no turning back…. The reward is either heaven or hell…. And its actually up to you to pave your direction…

Its true…we need rest. In fact…rest is so powerful that it can literally double your outcome…
So rest…get enough rest not merely for the sake of resting…. But preparing yourself to gear yourself up on your way to accomplish your assignment…

Smile…. Dont worry too much…. Dont exhaust yourself worrying things that wont matter in a years time…

Boost up your motivation….you have been raised up to be motivated… Thats what you have livedwith all your life…

Do this with all your heart… Who says its easy?? But its not impossible anyway…….
Renew your intention…and thats the very first step…cleanse your heart….oh allah…..give me strength…

Being a doctor is difficult… Sometimes…you ask yourself… How can i keep this up??? Its almost impossible!!!!!!

But remember…nothing is impossible….when you have Allah , the greatest, and the most beneficent…. The one who created this vast universe…… What do you need to be afraid of????

Be confident….!
Trust yourself!
I know you can do this!!!
You are the chosen one!!! Alhamdulillah!!!
i have been chosen this path by Allah because I can handle this…. allah wont burden us with something that is out of our abilities….. Allah knows best…

I am grateful…i am happy…. That i am here… Alhamdulillah,..thank you Allah…

Medicine is so much fun!

Tracheooesophageal fistula

This is what i asked the doctor just now
IN ONE OF THE BABIES WITH TRACHEO OESOPHAGEAL FISTULA, THE FIRST PRESENTATION RIGHT AFTER BIRTH WAS… RESPIRATORY DISTRESS…. WHY????

Normally…. In Tof, dpending on which type…. If there is oesophageal atresia…. So there maybe accumulation of saliva…which will enter the respiratory tract by the larynx i suppose… Leading to aspiration….or…if we do feeding to the baby,…( not in the same case though) the milk may get aspirated to…or…. After feeding,… Depending on the type of tof…gastric reflux may enter the respiratory tract by the fistula..
The doctor drew this

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Btw…if the upper oes pouch is too much away from the lower pouch… Gastrotomy and oesophagotomy is done…and temporary?

Some xrays on TOF

search for the kinked nasogastric tube.
The stomach may or may not be distended…this dpends on the type of TOF.if the fistula is connected to the oesophagus then to the stomach..so some air will enter causing this distension.

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How to manage?
Prior to operation…give him medical care…. The primary repair….should be delayed if his lungs condition doesnt permit him ….
Medical care includes:
Continuous suctioning to prevent aspiration
ETI distal to the part of fistula to prevent GASTRIc REFLUX
Be aware that this condition may deteriorate the lung due to the aspiration…if he has infection…administer antibiotics….

Extracted from emedicine…read further here.

If the patient develops acute respiratory failure, endotracheal intubation and mechanical ventilation are performed. Administer broad-spectrum antibiotics for patients who may have developed lower respiratory tract infection. For patients known to have pneumonia or other pulmonary problems, a gastrostomy for gastric decompression may be required to prevent further reflux of gastric contents into the trachea. The use of proton pump inhibitors may be helpful.

Btw….this is the most common type

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Tagged

Intussusception

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Imagine yourself confronted with a case of intussusception….(I5)—> too lazy to type this word everytime,

Personally, its tricky.
Its not as easy as we think it is.
Being a doctor requires us to have a high degree of suspicion….of a lot of diseases….. Keep your head open to many possibilities…. Just in case.

Contrary to popular belief among undergraduates…. Red currant jelly like stool is always mentioned together with intussusception which indirectly prompts us to think that without this sign, we cant diagnose I5.But thats a wrong mindset..what kinda shocked me today is that… This red currant jelly sign is in fact a late sign and happens after 18hours after the onset of I5!!!!

The earlier signs….. As the doctor mentioned…is paroxysmal attacks of colicky abdominal pain…. The baby cries…..then due to exhaustion…he sleeps… The he cries…and the cycle continues..
2. Refuse feeding
3.????? I forgot.Haha.. Is it non bilious vomiting….( due to traction on the omentum)?

So when a mother comes complaining to you these signs….please…..start examination…… Dont take it lightly..you will probably find a mass in the rt ilac fossa or hypochondrium and the part below is empty( dance sign)

Do ultrasound too…and check out the target sign…wuuuhuu!( tepu dha)

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Hmm…. I read about intussusception further from emedicine…
Previously the doctor mentioned that henoch schoenlein purpura(HSP) presents with abdominal pain and may also give out the target sign…

Guess what i found???
HSP CAN COMPLICATE BY INTUSSUSCPETION DUE TO SUBMUCOSAL HEMATOMA WHICH MAY ACT AS A LEADING POINT.

wow isnt that an interesting find.. NO??? btw..it is to me….
Actually it isnt as simple as we want it to be…. IF THE ABDOMINAL PAIN PRECEDES THE SKIN MANIFESTATION….THEN..IN THIS STATE..IT IS ACTUALLY HARD TO DDX WITH OTHER DISEASES…

Ok2… My golden question is
HOW CAN YOU DDX BETWEEN HSP ALONE OR WITH HSP COMPLICATED BY INTUSSUSCEPTION??

Of course…search for other symptoms of hsp….such as the petechiae and the purpura…. The kidney manifestation…( may mimic PSGN)
In hsp, the age is around 2-5 yo.
Also…do plain radiography…to rule out intestinal obstruction…..that sets the difference…
Again,.plz dont sit and wait for your patient do poop out red jelly to finally diagnose I5..

Btw, hemophilia can also complicate by I5 due to submucosal hematoma!

There is ….in fact…a lot of ddx for I5….

What shocked me too is that electrolyte imbalance can also cause I5!!!

Hhuhhhh.

O allah please make it easy for us.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia is not a surgical emergency…. Instead of jumping to surgical treatment right away…we should treat the condition of the lung which is suffering from persistent pulmonary hypertension…(pph)

What is pph?
And so..ive just known the fact that there is such thing called the normal pulmonary hypertension which occur in utero… And normally after birth… The pressure in the pulmonary vasculature decreases. But this doesnt happen here…
Why?
The lung has been suffering since in utero due to the CDH, which cause hypoplasia and some states that there is abnormal pulmonary vasculature.

So whats the problem with this pph?

First..since the lungs are hypoplastic and suffering from pph, the baby after birth wont get as much oxygen required by the body…. Which is normally needed to cause closure of ductus arteriosus… And so…. What happens is… It will be patent(PDA)

Usually..in baby with NO CDH, pda causes a left to right shunt…but the reverse happens here because of PPH.hence..the cyanosis…

Once you start supplying the baby with oxygen through a face mask or nasal cannula..the condition will worsen. Why? The part of the intestine which is intrathoracic …will become distended with air..further compromising the lungs expansion.

So…first things first….. Do resuscitation…please do nasogastric decompression!!!

And then, you can do surgery

Another question…do you know whats eventration of the diaphragm?? It is when the muscular fibres of the diaphragm is replaced by fibroelastic tissue.this part of the diaphragm may cause compression of the lungs.

So..you have to treat the pph, and also the pda…before you do surgery ok???

My 2 cents

Think before you speak.Doctors should speak based on facts. Not merely speaking as if you feel like you know everything.
I am not saying it is wrong to give out opinions, but state it that you only think that what you say is right without referring to books or doctors.

Dont simply say that this disease is like such and such or that the management is such and such ( without based on facts… Or you only think that its correct …when its not.. ).

Ego is bad for a doctor, especially when it involves risking his patients life!

Think before you speak!!!!!!

School starts

Holidays are over. And my heart is still not back from the holidays….( not that my holidays are so much fun though…)

Tell me how can i gather my enthusiasm to face surgery dept??

Btw, i had a pretty structured holiday. Not so much of the typical holiday…most people watched movies and shows( if not travelling) and i dont even watch movies but only malay dramas..
I Read books. Medic ,non medic, motivational, my life’s manual… I am beginning to love reading.and did other trivial but wonderful things. I think ive just realized that spending futile hours n hours of tv entertainment would leave me feeling sick and depressed. And i dont wish to have back my addiction of watching too much dramas…i used to …

Aha…

Renew your intention and when you feel like you start to procrastinate.kill it! Say 1,2,3 and start moving. Dont rest on your laurels. Excellent doctors never rest on their laurels.get out of your comfort zone!!

Lets warm up and get back on track! YOU CAN DO THIS!

Mitral valve prolapse & MS

Mitral valve prolapse is the most common valvular abnormalities. So, take note.

However , the most common symptom is NO SYMPTOMS AT ALL.

So lets say , you detected it in an asymptomatic patients? You jz keep him reassured.

In symptomatic patients, do your investigation( echo) , follow up and if indicated, mitral valve repair.

So listen carefully

Midsystolic click..

Can someone summarize this for me?

Mitral annulus calcification(MAC) can produce both mitral stenosis / mitral regurgitation and the latter is more common.

Causes of MAC? ageing , atherosclerosis association,
read more here

In mitral stenosis , increase in left atrial size leads to increase excitability thus, atrial fibrillation (AF)occurs.

AF causes loss of atrial kick , hence further lowering the cardiac output

Hey guys, finally a proper explanation for tapping apex!
read futher here

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Tapping apex is…… PALPABLE S1!!!!(mitral area) its just an exaggeration of the normal apex… I think?
Correct me

OPENING SNAP is caused by????
Forceful opening of mitral valve if stenosed.but but why the forceful opening?why doesnt this happen in other valves like aortic stenosis?
From what i have understood, first, we need to know that due to the stenotic mitral valve, this impedes the blood from flowing freely to the left ventricle, creating some sort of pressure gradient.so possibly this forceful opening is due to the high pressure gradient difference whereby the pressure in left atrium is 25 mmhg while in the left ventricle , 5 mmhg ( all of this during diastolic phase).. Normally there is NO PRESSURE GRADIENT.

And also the reason behind this is because of the anatomy of the mitral valve itself.( i dont know exactly why but if someone knows , i beg you to tell me). All i know is it is a bicuspid valve,with the anterior leaflets larger than the posterior one… But in aortic valve, its a tricuspid..and it is more rounded… So???? I dont get it.. I think i know but im not 100% sure.help?

The famous question

Signs of mitral stenosis….( i was asked this lucky question once when i wasnt prepared… By an intelligent professor… I was sort of humiliated in front of a bunch of egyptian guys and its really embarassing since i was alone at that moment, but i took it positively, it spurred me to work harder)

Malar flush
Tapping apex
Signs of pulmonary hypertension- diastolic shock; palpable 2nd heart sound in the pulmonary area, possibly; rt vt hypertrophy with its signs- heaving apex, ejection systolic click
Loud S1
Loud P2( due to phtn)
Mid diastolic rumble(Low pitched- hear it with the bell!!!!!!!!!!) or let him roll to the left to clarify your findings or exercise.
Presystolic accentuation( caused by atrial contraction and lost if atrial fibrillation present)
Jugular venour pressure elevation; due to phtn so–> prominent “a” OR loss of “a”(due to AF in the right that is… Perhaps because of the phtn????)

Systolic Ejection sounds occur shortly after the first heart sound, at the time of ventricular ejection. Normally, the opening of the aortic or pulmonic valves and the onset of ventricular ejection is not audible. In certain cardiac conditions extra sounds are heard shortly after the first heart sound, S1. They are produced by the opening of the aortic or pulmonic valves, either when one of these valves is diseased (valvular) or when ejection is rapid through a normal valve (vascular).
Aortic ejection sounds of valvular origin are heard in patients with coarctation of the aorta usually associated with congenital bicuspid aortic valve, valvular aortic stenosis, aortic insufficiency, or aneurysm of the ascending aorta. Valvular ejection sounds may be heard in clinical conditions associaated with forceful left ventricular ejection, such as thyrotoxicosis, anemia, pregnancy, exercise, high cardiac output states.
Aortic ES is loudest at aortic area and cardiac apex with no respiratory variations.

Pulmonic ejection sounds are associated with dilatation of the main pulmonary artery, including pulmonary hypertension and valvular pulmonary stenosis. Pulmonary ES is best heart at pulmonic area and decreases coincident with inspiration.

Source;here

So theres no SNAP, but theres the CLICK.
The weird thing is Regardless of the stenosis or the regurgitation, it produces the CLICK.( for semilunar valves)

ecg findings of MS
normal OR
P-mitrale- broad notched P wave due to left atrium overload definition
Signs of rt vt hypertrophy( this needs a long explanation)
AF- seen as FIBRILLATORY WAVES

I think thats enough.here. I mean. Further elaboration in books.duh!

This is percutaneous mitral ballon valvotomy

Pssst! Most common cause of MS is rheumatic heart disease!!!!