Appendicitis

Assalamualaikum WBT.

Hi everyone! Have you ever heard about APPENDICITIS?
I'm sure it is quite common to hear worldwide as it is the most common acute abdominal condition the surgeon is called on to treat. But, did we really know what is it all about?

Appendicitis & its pathophysiology.

• Appendicitis is the inflammation of the appendix, which is either acute (most common) or chronic. It is associated with obstruction of the appendix, may be in the form of stool, foreign objects, tumor, or gallstone from the caecum, which enters the appendix and causing blockage

• This stool will hardens, become a rock-like mass. When the blockage occurs, the bacteria will invade the wall of the appendix and causing inflammation.

• Perforation or rupture of the appendix may occur if there is no treatment. This may lead to peritonitis, sepsis, and death. 

• In Neuroimmune appendicitis:  Pain without acute inflammation, increase substance P / VIP, and non-inflammatory. 

How to diagnose?

      1. Laboratory:  - Leukocytosis with Lt. shift
                             - Total WBC count: < 10K/uL
                             - Absolute neutrophil count: < 6750/mL
                             - Hyponatremia
                             - Acidosis

      2. Radiography:  - X-rays (not specific, may shows air fluid)
                               - Calcified stone in appendiceal area
                               - CT scan and ultrasound (more accurate)

      3. Differential diagnosis:
              -Crohn's disease, Psoas abscess, Pyelonephritis, Pelvic abscess,
               ovarian/fallopian diseases, Cholecystitis, Intestinal perforation
               due to obstruction, or in male: Scrotum abscess, Hernia.


How to treat?

* Surgery : by removal of appendix by surgery OR
                 laparoscopic surgery ( less wound and risk, rapid healing)

* Fluid management is critical.


Symptoms & Scoring.

Apparently, all these things were quite complicated for non-medical practitioners to understand, so here it is. Alvorado scoring! It is usually used by the physician on the symptoms and scoring for the possibilities of appendicitis. But now you could self-diagnose yourself at home! (excluding the lab tests)  :)

You may also have

• Dull pain near the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen. Or anywhere in the upper & lower abdomen, back, and rectum.
• Loss of appetite
• Abdominal swelling
• Inability to pass gas
• Constipation & diarrhea with gas
• Painful urination
• Severe cramps

So if you have most of the symptoms, quickly go get yourself checked!

We Learn, We Share, We Care

** Sorry for any inconvenience since this is my first post. :)

References: 

Robbins Basic Pathology (8th Edition)

http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis

http://www.medicinenet.com/appendicitis/page2.htm#what_is_appendicitis_and_what_causes_appendicitis

Analysis of Symptoms (Endocrinology)

﷽

Analysis of symptoms in Endocrinology

Referring to how you analysis a symptom in the last post here are the common clinical features in endocrine disease.

Ask for:

1. Weight Gain - Hypothyroidism, PCOS, Cushing Syndrome
2. Weight Loss - Hyperthyroidism, DM, Adrenal Insufficiency
3. Short stature - Constitutional, non-endoncrine systemic disease e.g. coeliac disease , GH deficiency
4. Delayed Puberty - Constitutional, non-endocrine systemic disease e.g. hypothyroidism, hypopituitarism, primary gonadal failure
5. Menstrual disturbance - PCOS, hyperprolactinaemia, thyroid  disfunction
6. Diffuse neck swelling - Simple goitre, Graves' disease, Hashimoto's thyroiditis
7. Excessive thirst - DM or Insipidus, hyperparathyroidism, Conn's syndrome
8. Hirsutism - Idiopathic, PCOS, Cushing's Syndrome , congenital adrenal hyperplasia
9. 'Funny Turns' -  Hypoglycaemia, phaeochromocytoma, neuroendocrine tumour
10. Sweating -  Hyperthyroidism, hypogonadism, acromegaly , phaeochrmocytoma
11. Resistant Hypertension - Conn's syndrome, Cushing's , phaeochromocytoma ,acromegaly , renal artery stenosis
12. Erectile Dysfunction -  Primary/2ndry hypogonadism, DM, Non-endocrine systemic disease
13. Muscle Weakness - Cushing's syndrome, hyperthyroidism, hyperparathyroidism, osteomalacia
14. Bone fragility and fractures - Cushing's syndrome , hypogonadism, hyperthyroidism
15. Altered facial appearance - Hypothyroidism, Cushing's Syndrome, acromegaly, PCOS

These are few common symptoms to be analysis in an endocrine case :)

References : Macleod's Clinical Examination 12th Edition

History Taking

Assalamualaikum WBT.

Hi guys long time since the last update from TAPMED. Today I would like to talk about history taking. History taking from patients is important to reach a good diagnosis. We can't deny that nowadays there are lots of high-tech work up or investigation that can bring you to a diagnosis. However looking back to years back where there are no such investigation, history taking plays a big role in reaching a diagnosis. So waste no time and lets begin to talk about history taking from patients.

First of all when you are with a patient, make him comfortable and introduce yourself. Tell him/her why you are here. Shake hands if possible try to make the patient know that you are eager to help him/her.

Then start with:

Personal History

Name : Get their full name , if in Egypt get three names like Ahmad Mohammed Ibrahim

Age : Some diseases are age related

Sex :  Some diseases are sex related

Occupation : To look for occupational disease

Residence : Some disease are endemic in specific places

Habit : Special habit of medical importance such as smoking, alcohol intake.

Menstrual History for women : Regularity, Days of Cycle , Amount of bleeding

Complaint (c/o)

Ask the patient what brings him to the hospital.

Make sure that you are writing it down in patients own word. Exclude medical terms

As short as possible (one complaint is enough)

e.g. don't write epixstasis , but write "complaining of nose bleed"

don't forget to write the duration. e.g. complaining of chest pain for 2 days

History of Present Illness

Do it in chronological order. Ask when he was last healthy (symptomless). Write in medical terms.

Then analysis the complaint.

Then ask for symptoms of the related systems then proceed for other systems.

For every symptoms analysis for

Onset/Course/Duration

Association

What will increase or decrease the symptom

Effect of TTT if there is any

Date of last attack

For pain ask for site, radiation and character of the pain.

This is the part where you are playing a big role. Don't let the patient lead you, but you should lead the conversation for this part.

Past Medical History

Ask for any disease such as DM, HPT, TB, I.H.D

Ask for it's duration, manifestation, investigation, ttt and complication

Ask for any surgical history when ,where(site) and out come. Don't forget to ask if any blood transfusion.

Ask also if patients is taking any drugs for treatment.

Family History

Ask for consanguinity, Similar conditions or any related chronic disease like DM/HPT/TB/I.H.D.

Diabetic Retinopathy (Short Notes)

Diabetic retinopathy,is retinopathy (damage to the retina) caused by complications of diabetes, which can eventually lead to blindness.

Classification

Non-proliferative :  Retinopathy, Maculopathy

Proliferative Retinopathy

Non-Proliferative Retinopathy

Manifestations:

Mild : At least one microaneurysm

Moderate : 

• Extensive microaneurysm 
• Intraretinal haemorrhages
• Venous beading
• Cotton wool spots

Severe :

• Cotton wool spots
• Venous beading
• Intraretinal Microavascular Abnormalities (IRMA)

Nonproliferative Maculopathy

Manifested by focal or diffuse retinal thickening or edema due to breakdown of the inner blood retinal capillary endothelium causes leakage of fluid and plasma into surrounding of retina.

More common in type II diabetes which requires treatment once significant which is confirmed by any retinal thickening within 500 microns of the fovea, hard exudates withing 500 micron of the fovea with retinal thickening. Also retinal thickening greater than one disc diameter in size

It may due to schema which is characterized by macular edema, deep haemorrhages and little exudation.

Fluorescein angiography shows loss of retinal capillaries with enlargement of the foveal avascular zone.

Proliferative Retinopathy

It is the most severe complications of Diabetes 

It is characterised by NVD & NVE

Diagnosis

Diabetic retinopathy is detected during an eye examination that includes:

• Visual acuity test: This test uses an eye chart to measure how well a person sees at various distances (i.e., visual acuity).

• Pupil dilation: The eye care professional places drops into the eye to widen the pupil. This allows him or her to see more of the retina and look for signs of diabetic retinopathy. After the examination, close-up vision may remain blurred for several hours.

• Ophthalmoscopy or fundus photography: Ophthalmoscopy is an examination of the retina in which the eye care professional: 

1. looks through a slit lamp biomicroscope with a special magnifying lens that provides a narrow view of the retina.
2. wearing a headset (indirect ophthalmoscope) with a bright light, looks through a special magnifying glass and gains a wide view of the retina. Hand-held ophthalmoscopy is insufficient to rule out significant and treatable diabetic retinopathy. Fundus photography generally recreate considerably larger areas of the fundus, and has the advantage of photo documentation for future reference, as well as availing the image to be examined by a specialist at another location and/or time.

• Fundus Fluorescein angiography (FFA): This is an imaging technique which relies on the circulation of Fluorescein dye in the eye vasculature.

• Optical coherence tomography (OCT): This is an optical imaging modality based upon interference, and analogous to ultrasound. It produces cross-sectional images of the retina (B-scans) which can be used to measure the thickness of the retina and to resolve its major layers, allowing the observation of swelling and or leakage.

• Digital Retinal Screening Programs: Systematic programs for the early detection of eye disease including diabetic retinopathy are becoming more common, such as in the UK, where all people with diabetes mellitus are offered retinal screening at least annually. This involves digital image capture and transmission of the images to a digital reading center for evaluation and treatment referral. 

• Slit Lamp Biomicroscopy Retinal Screening Programs: Systematic programs for the early detection of diabetic retinopathy using slit-lamp biomicroscopy. These exist either as a standalone scheme or as part of the Digital program where the digital photograph was considered to lack enough clarity for detection and/or diagnosis of any retinal abnormality.

The eye care professional will look at the retina for early signs of the disease, such as: 

1. leaking blood vessels
2. retinal swelling, such as macular edema
3. pale, fatty deposits on the retina (exudates) – signs of leaking blood vessels
4. damaged nerve tissue (neuropathy) 
5. any changes in the blood vessels.

Should the doctor suspect macular edema, he or she may perform fluorescein angiography and sometimes OCT.

Treatment and Management

1. Laser photocoagulation
2. Modified Grid Laser photocoagulation
3. Panretinal photocoagulation
4. Intravitreal triamcinolone acetonide
5. Intravitreal Anti-VEGF
6. Vitrectomy

References:

1. Vaughan & Asbury's General Opthalmolgy 17th Edition
2. http://en.wikipedia.org/wiki/Diabetic_retinopathy

Diabetes Mellitus (Kencing Manis)

Artikel ringkas pertama yang bakal saya kongsikan adalah berkenaan Diabetes Mellitus ataupun lebih dikenali dalam kalangan masyarakat sebagai Kencing Manis. Jelas dan nyata tidak dapat dinafikan lagi bahawa penyakit ini merupakan salah satu daripada penyakit yang menjadi ancaman kepada masyarakat atas pelbagai sebab seperti  gaya hidup dan makanan.

Apa itu Diabetes Mellitus?

Diabetes Mellitus merupakan satu sindrom di mana kandungan gula dalam badan lebih tinggi dari paras normal  dan disebabkan oleh tiada insulin dihasilkan atau kurang insulin atau insulin tidak berkesan untuk mengawal paras kandungan gula dalam badan.

Paras Normal kandungan gula

Dalam keadaan berpuasa : 

Kurang daripada 110 mg/dL atau 6.1 mmol/dL

Dalam keadaan biasa :

Kurang daripada 140 mg/dL atau 7.8 mmol/dL

Paras disahkan Diabetes

Dalam keadaan berpuasa :

Melebihi  126 mg/dL atau 7.0 mmol/dL

Dalam keadaan biasa :

Melebihi 200 mg/dL atau 11.1 mmol/dL

*Paras di antara normal dan disahkan menunjukkan anda berisiko tinggi untuk menghidapi penyakit tersebut.

Adakah anda...........?

1. Cepat merasa penat
2. Selalu merasa dahaga
3. Kerap ingin membuang air kecil
4. Turun berat badan tanpa sebab
5. Luka lambat sembuh
6. Daya penglihatan semakin kurang

Andai anda mempunyai tanda-tanda seperti di atas, anda berisiko menghadapi penyakit kencing manis. Anda dinasihatkan untuk berjumpa dengan doktor untuk pemeriksaan lebih lanjut dan rawatan secepat mungkin andai anda disahkan menghadapi penyakit ini.

Kenapa diabetes perlu dikawal?

Diabetes perlu dikawal untuk mengelakkan komplikasi-komplikasi yang tidak diinginkan seperti :

1. Kerosakan Mata (Penglihatan)
2. Kerosakan buang pinggang
3. Kerosakan urat saraf yang boleh membawa kepada ulser pada luka di kaki yang seterusnya menyebabkan kaki perlu dibedah ataupun dalam bahasa masyarakat "dibuang/dipotong"
4. Atherosclerosis iaitu salur darah menjadi tidak kenyal boleh membawa kepada masalah salur darah tersumbat, masalah jantung , dan juga menghalang sumber darah ke kawasan tangan dan kaki.
5. Menyebabkan risiko kepada penyakit tekanan darah tinggi.
6. Menyebabkan risiko kepada peningkatan kandungan kolestrol dalam darah.

Elakkan daripada Diabetes!

Sesal dahulu pendapatan, sesal kemudian tiada gunanya.

1. Kurangkan pengambilan gula dalam makanan dan minuman
2. Bersenam
3. Berhenti Merokok
4. Jauhi arak 
5. Pastikan berat badan dalam keadaan yang optimum

Setakat ini perkongsian pada kali ini, semoga perkongsian ini membawa manfaat kepada semua. InsyaAllah pihak TAPMED akan mengupas lebih lanjut dalam isu ini. Saya bagi pihak TAPMED ingin memohon maaf seandainya ada kesalahan dalam fakta , bahasa atau apa pun kekurangan dalam artikel ringkas ini.

Buah cempedak di luar pagar,

Ambil galah tolong jolokkan;

Saya budak baru belajar,

Kalau salah tolong tunjukkan.

Sekian sehingga berjumpa lagi.

We Learn, We Share , We Care