Sunday, 24 April 2011

What I learnt in Neurology

1. A whole lotta pathologic reflexes. The first days we were all flabbergasted at the tricks our attendings did. We know Babinski, Chaddock, and Oppenheim, but Schaeffer? Gordon? Gonda? Rossolimo? Hoffman-Trommer? Like, what?? And then we of course found out about the Babinski-like responses bunch and felt ridiculous. I mean, even Wikipedia knows more about it.

2. Turns out in addition to Brudzinski's signs I and II, there are Brudzinski III and IV. Brudzinski III is when you press the zygomatic bones to see if the patient will flex his/her upper arms. Brudzinski IV is when you press slightly above the pubic symphysis to elicit flexions of the hips and knees.
What I don't know is whether these signs are known at all in the Western world, because every time I Google them I always get Indonesian sources. Please help me on this. Do they exist with another name or what? I'm dying to know.

3. Tension-type headache can manifest as tightness of the shoulder and neck muscles.

4. Patients with myasthenia gravis should remain in a temperate environment. Extreme heat increases the destruction of the precious acetylcholine by acetylcholinesterase. On the other hand, cold temperature is reported to significantly improve the symptoms; however, even references to this matter vary in opinion.

5. Don't catheterize a delirious patient! He/she might try to yank it out.

6. The primary sources of metastatic carcinoma of the brain are prostate, lung, and GI tract carcinomas.

7. Stroke patients who develop dysphagia can get pneumonia. Two reasons:

  • Decreased level of consciousness in many stroke patients leads to "attenuation of protective reflexes, impaired function of lower esophageal sphincters, delayed gastric emptying, and the worsening of the coordination of breathing and swallowing."

  • While nasogastric tube aids the feeding in stroke patients, it is also controversial because it may actually precipitate aspiration pneumonia through "increased oropharyngeal secretions, impairment of laryngeal elevation, and disruption of the upper and lower esophageal sphincters."

8. Distinguish carefully between tetraparesis and double hemiparesis.

9. Yes, it's possible to have a monoparesis / monoplegia that is a UMN lesion.

10. Four cerebral lobes? Think again! There are five!

11. The degree of sensory aphasia can be measured roughly by giving two instructions, one simple and one harder. An example of simple instruction would be telling the patient to raise his/her left arm. A harder instruction is telling him/her to take a piece of paper with the right hand, fold it into half, and place it on his/her right side. A patient with mild aphasia may have some difficulties in following the latter.

12. Meningeal irritations and associated signs are not specific for meningitis. They can also indicate meningeal inflammation (as in the case of neoplasm) and hemorrhage (e.g.: subarachnoid hemorrhage). They can even be absent in patients with GCS <8.

13. MRI is more sensitive in detecting infratentorial lesions than CT scan.

14. Lactate is the base complement of lactic acid! This was especially confusing because the Indonesian word for lactic acid is "asam laktat", with "laktat" being a direct translation from "lactate". That's why Ringer's lactate is okay for stroke patients undergoing anaerobic metabolism!

15. Nimodipine is given to attenuate vasospasm in cases of subarachnoid hemorrhage.

16. A whole new world of hypokalemic periodic paralysis.

Also, our terrific attending gave each of us a copy of stroke guidelines. It contains EVERYTHING we need to know about the management of stroke and its associated conditions (hyperglycemia, hypertension).

We are very lucky.

EDIT on April 25, 2011:

One more thing: I have Hoffman-Trommer reflex! It is NOT pathological if it exists bilaterally in an otherwise normal healthy sane people.

Faces In A Box

If only time would stop fleeting
I would freeze this moment and put it in a box
So that when I've forgotten how to smile
I shall open the box
See the faces
And once again I will remember.

-Eve of Easter, 2011-

by: Anna Elissa

Wednesday, 20 April 2011

It's overrrr!!!

Allow myself to run giddily across the room to express my ultimate happiness upon finishing the first rotation of clerkship.


Let's forget medicine for a moment and see what I'm having for dinner: the ever-delicious mushroom satays!

Monday, 18 April 2011

Yerusalem, Lihatlah Rajamu

This gorgeous song is the Indonesian version of the hymn "The Holy City" (lyrics are NOT direct translation from the English version). It's usually sang on a Palm Sunday, like yesterday. I was lucky to have found the music file over the internet. Meanwhile, the video is mine.

Sunday, 17 April 2011


Incredible! This guy Cushing is everywhere!

Cushing's syndrome
Cushing's disease
Cushing's reflex
Cushing's triad
Cushing's ulcer

That is one name in medicine that recurs a lot, wow! Apparently you can be THAT famous!

You know you're divinely inspired / terribly bored when... take a leaky pen and make an intricate tattoo for yourself.

Saturday, 16 April 2011

The 5 weeks that felt like a year

So my first round in neurology is almost over. I have yet to sit my exam (and have a little potluck with colleagues afterwards) but already I start experiencing the usual flashback moments.

Neurology has always been my favourite thing. Doing neuro rotation at this particular hospital is even better. The docs are superb (yes, even you, Ma'am =p) Working at a Police hospital is also a plus since there are quite a lot of cool cases; much more than what you'll find in upper-class hospitals. During my first 4 weeks I have seen cases of AVM, Parkinson's Disease, Huntington's chorea, a UMN monoparesis, and meningoencephalitis in a HIV positive patient.

I have also seen "easy" cases gone sore, like a 45-year-old lady with ischemic stroke who, I think, died of loneliness. Her family did not seem to know of her condition, or maybe they did know but they didn't care. In any case no one ever visited her except the medical staff, and she passed away after 7 months lying on bed with GCS E3 Vx M4, a sacral decubitus, bronchopneumonia, rotting teeth, and almost a 60 million rupiah (around US$ 7000) debt to the hospital. The death was so sudden; her condition seemed to be improving for a while and suddenly she stopped breathing just like that. The nurses didn't know. The doctors didn't know. We all found it out a few seconds too late. She came in alone and she left alone. 

Such things make me realise how the bodily health is largely affected by the emotional state. A human is a whole being; body, mind, soul. It's a simple fact, but often forgotten.


Was I happy with myself during the neurology round? Yes. I could have done MUCH better though.

Was I happy with my colleagues? Awfully.

Was I happy with the doctors? One of them could use some improvements in attitude, but overall, yes, they are irreplaceable.

Was I happy with neurology? Yes, although clinic hours can be painfully boring.

Do I still consider neurology as a choice for residency? Y-E-S!

Thursday, 14 April 2011

"A Lake of Beer" by Saint Brigid

Brigid of Ireland is a beer-loving saint. Her story reminds me to live in moderation, which doesn't mean that I cannot have fun, but instead I can, and I should, have fun. In fact, we should celebrate and honour the life God has generously given us. While there is plain blatant evil, many things in life---beer, for example, and money, fashion, dancing---are only sin when we indulge too much in them. Even love can be a sin if we are to revolve around a particular someone, forgetting God and His perfect love in the process.

Praise the Lord for this amazing woman.

I’d like to give a lake of beer to God.
I’d love the heavenly
Host to be tippling there
For all eternity.

I’d love the men of Heaven to live with me,
To dance and sing.
If they wanted, I’d put at their disposal
Vats of suffering.

White cups of love I’d give them
With a heart and a half;
Sweet pitchers of mercy I’d offer
To every man.

I’d make Heaven a cheerful spot
Because the happy heart is true.
I’d make the men contented for their own sake.
I’d like Jesus to love me too.

I’d like the people of heaven to gather
From all the parishes around.
I’d give a special welcome to the women,
The three Marys of great renown.

I’d sit with the men, the women and God
There by the lake of beer.
We’d be drinking good health forever
And every drop would be a prayer.

Sunday, 10 April 2011

The Soaring Eagle

Soar, you eagle, soar up high
Never look back, never regret
In your heart shall be instilled
The Word, eternal, proclaiming good will
Behind you is the great force of the wind
And the Flames
Flames holy, empowering your wings.

Let the Flames be your light
For dark is the night, way beyond sight
And let the wind, the minds of old, propel you
For a great eagle shall hunger for Truth
For Truth only he shall fly
And in Truth only he shall die.

Soar, you eagle, soar up high
Ahead is the Kingdom. Be victorious.

-by: Anna Elissa-

Saturday, 9 April 2011

Batu Bata Merah

Sepenggal hidupku
       tersusun oleh batu bata merah.
Tembok-tembok keras tegap berdiri
       kaku lagi tegar
Memandang kosong kaki-kaki
       yang melangkah ragu lagi ngeri.

Sekelumit kisahku
       terukir di atas batu bata merah.
Muda yang beranjak tua
Korup oleh waktu, coreng oleh zaman
Berdiri sebagai sandaran mereka
Sejak mereka kecil dan tembok itu tinggi.

Adalah batu bata merah sebagai saksi cinta
Dan pengharapan, pengajaran
       dan pencapaian
Hingga mereka tinggi dan tembok itu kecil
Hingga musim berganti musim
Dan warna memalsukan diri
Batu bata itu tetaplah merah

Kerap 'ku melihat ke belakang
Batu bata merah ada di sana
Ia tersenyum hangat,
       dan berharap-harap cemas.

-by: Anna Elissa-

Tuesday, 5 April 2011

"Desiderata" by Max Ehrmann

Go placidly amid the noise and haste,
and remember what peace there may be in silence.

As far as possible without surrender
be on good terms with all persons.
Speak your truth quietly and clearly;
and listen to others,
even the dull and the ignorant;
they too have their story.
Avoid loud and aggressive persons,
they are vexatious to the spirit.

If you compare yourself with others,
you may become vain or bitter;
for always there will be greater and lesser persons than yourself.

Enjoy your achievements as well as your plans.
Keep interested in your own career, however humble;
it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs;
for the world is full of trickery.
But let this not blind you to what virtue there is;
many persons strive for high ideals;
and everywhere life is full of heroism.

Be yourself.
Especially, do not feign affection.
Neither be cynical about love;
for in the face of all aridity and disenchantment
it is as perennial as the grass.

Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune.
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.

Beyond a wholesome discipline,
be gentle with yourself.
You are a child of the universe,
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.

Therefore be at peace with God,
whatever you conceive Him to be,
and whatever your labors and aspirations,
in the noisy confusion of life keep peace with your soul.

With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful.
Strive to be happy.

"Desiderata" - Max Ehrmann (1872-1945)