MBBS vs MD
6/30/2009 01:30:00 PM | Author: fadzly
Haha.. I was a bit surprise when i saw one of the keyword from the readers.


perbezaan M.D dan MBBS

I wonder why would someone really cares about the difference between Medicine Bachelor and Bachelor of Surgery (MBBS) and Doctor of Medicine(MD)? Both of them doctors, and both of them study the same things. The only differences are the name and one is British system, one is American. That's all. I wonder if i put this article, more and more will come to this site. LOL
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H1N1/Influenza A/Swine Flu/Selsema babi..
6/29/2009 02:40:00 AM | Author: fadzly
Prof. Datuk Dr. Adiba Kamarulzaman, my professor of Infectious Disease in Dept Medicine, recently came out in hello Malaysia one of the segment/talk/tv shows in Bernama TV, Astro.. To those who still doesn't know what is Influenza A, can watch this video.. Meanwhile, when i'm writing this article, our cases have reached to 124!


(Click the image to view the video)
p.s.: You need to have real player plugin to view this video..
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Sorry guys, We're back!
6/27/2009 11:05:00 AM | Author: fadzly
First of all we're sorry for the missing days guys.. We're too busy for this current posting. Actually, we've been in Obstetric and Gynaecology posting for 1 weeks already. Our posting require us to make 2 case summaries, 3 case presentation, and 5 DELIVERIES!!! sux man, because, we shouldn't be doing deliveries anymore because we've done it before. The department was really strict on us. I can still remember i fail my posting with only 0.1 mark to pass (i got my marks 49.9) because I didn't get the chance to pass out my last case summary only because of I'm late for a day. Anyways guys, I'll try to put up some post and maybe some picture of us later what we've done for the next 2 weeks in O&G.

Next, how was your life then? Many of my batch mates have already been posted to their respective hospital! Good luck guys in the coming days. Do not extend your posting.. LOLZ..

Meanwhile, it's the end of the months now and this would be the most suitable day to cash out my NUFFNANG blogging money! maybe tomorrow would be nice! I would like to thank to you all guys for clicking the ads here by nuffnang. Until then, I'll post about it the moment i got that check..
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Intestinal Obstruction - Xray
6/18/2009 09:35:00 PM | Author: fadzly
Topic today would be identifying Intestinal Obstruction in an abdominal X-ray. It's more or less like a quiz. Let's get started

Case 1
A 36 year old male with vomiting- for 1/7



Ok. How to interpret this?
It looks normal isn't it? Of coz it's normal. We need to know which one is normal. But if this normal, u still need to comment. What to look for in a 'normal' x-ray anyway?

Things to look for are
  • Technical – Is the X-ray adequate?
  • Is the gas in the correct place?
  • Is there abnormal calcification or mass?
  • Is the visualised bone and soft tissue normal?
  • Any foreign bodies?


Case 2
8year old boy with abdominal pain



Hoho.. what do u think? Looks a bit shiny isn't it?
  • It's a metallic foreign body projected over the left iliac fossa
  • No dilated bowel loops
  • Very unlikely to cause intestinal obstruction

Case 3
50 year old male with vomiting and NBO for 5/7



Look a bit bizarre rite? Take a proper look at the right side of the inguinal region. Is that a bowel?
This is actually an inguinal hernia basically a clinical diagnosis. Why do we do an Xray then? To rull out intestinal obstruction.
  • Radiograph shows dilated small bowel in abdomen
  • Bowel in the left inguinal region extending into the scrotum

Case 4
52 year old female with abdominal distension and vomiting for 2 days with a previous history of appendicectomy



Based from the history, adhesion would be more likely to cause intestinal obstruction due to adhesions from the previous appendicectomy.
  • Note the multiple air fluid levels on the erect AXR
  • On the supine radiograph – dilated loops of air filled small bowel

There is one question so common to ask in viva - How do you differentiate dilated small and large bowel?
  • Easy - Look a the bowel fold
  • Small bowel folds extend from one end of the bowel wall to the other
  • Large bowel folds- Haustra extend about one third of the way
  • Small bowel is also more central in position in the abdomen

Case 5
45 year old female with abdominal distension for 5 months


This one abit difficult. Where is the bowel actually? This is a large abdominal mass!
Bowel loops are displaced laterally and superiorly by a large soft tissue mass which appears to arise from the pelvis. Note a dilated small bowel loop in the right lumbar region.

Case 6
48 year old male – post gastrectomy 1 day



This could be paralytic ileus. I forgot to tell u that apart from adhesion, paralytic ileus could also be the cause of Intestinal Obstruction. However, an ileus can be diagnose based on abdominal examination by absence of bowel sound.
Note dilated small and large bowel. Apart from paralytic ileus, sub acute distal large bowel obstruction can give a identical appearance

Case 7
76 year old female with loss of weight for 3 months and now presents with NBO for 3 days.


Note the dilated air filled large bowel, from the caecum to the splenic flexure. This is a large bowel obstruction at the level of the splenic flexure.
This was due to carcinoma of the colon. A colonscopy would confirm this diagnosis
Ba Enema (Limited)- would also confirm the diagnosis. A CT would show the mass and is useful for staging

Case 8
30 year old female with non specific abdominal pain – 1 year



Non specific abdominal pain.. If you see this in Primary Care, sure you handle this as an irritable bowel syndrome.. HAHA.. yup this one is a normal small bowel enema. Note the “small bowel enema tube”. Normal small bowel folds which become less prominent in the ileum

Case 9
33 year old male with loss of weight – 4 months and vomiting for 5/7



There is thickened small bowel folds and strictures

Diagnosis?
.
.
.
.
It's a Lymphoma

Case 10
43 year old male with vomiting and lower abdominal pain- 1/7



This is a dilated loop of Large bowel. Inverted ‘U’ shaped loop of large bowel arising from the pelvis. Inverted ‘U’ shaped loop of large bowel arising from the pelvis. Suspect a volvulus (twist) of the sigmoid colon. How to confirm?



By doing a barium enema
Note the site of twist. This has been called the ‘Bird’s Beak’ sign

Case 11
20 year old male with history of chronic constipation since childhood



Diagnosis: Hirschprung Disease
Grossly dilated large bowel
Filled with faeces
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We've got our 1st Influenza A transmission Man to Man
6/17/2009 05:30:00 PM | Author: fadzly
Hey, first of all i don't know it's real or not because it's from Malaysiakini.com. But if this is real, this would be the very bad. Why? Because this patient was send to UMMC!!!!!!!!
Damn I don't want to go to the ward after this!! An irresponsible act by a 17 year old girl who don't contact to the ministry after getting exposure to patient of the 12th case of Influenza A in Malaysia. This would be the 19th case and just now, the 20th case has just been reported! Because of this, no wonder WHO has declaring pandemic, the Influenza A gene has evolve from swine to human transmission, to human to human transmission! Good thing that there is no death case reported here. And when there is death case, it would be very very bad to our country.

Updated: Meanwhile our cases have reached 23rd cases with 5 new cases today according to the MOH here.
Nevermind. The patient has been transferred to HKL already.. My bad.. No excuse not to go to the ward..



kemaskini 4.59pm Jangkitan selesema A (H1N1) semakin serius di negara ini, susulan berlakunya penularan wabak tersebut di peringkat tempatan yang pertama pada pesakit ke-19 daripada 23 kes, sejak sebulan lalu.

Pesakit berkenaan, seorang pelajar perempuan 17 tahun, dijangkiti daripada pesakit ke-12 akibat kegagalan kuarantin apabila tidak memaklumkan pernah berhubung dengan pelajar perubatan kes terdahulu.

Akibatnya, menurut satu kenyataan Kementerian Kesihatan hari ini, kegagalan itu menyebabkan 20 orang lagi berkemungkinan terdedah kepada jangkitan H1N1.

Kementerian juga memaklumkan bahawa lima lagi kes influenza itu dikesan dalam tempoh 24 jam yang lalu.

"Salah satu dari kes yang disahkan positif Influenza A (H1N1) adalah kes penularan tempatan yang pertama berlaku di negara ini," kata Ketua Pengarah kesihatan, Tan Sri Dr Mohd Ismail Merican.

"Kes pertama penularan tempatan (kes ke-19) adalah seorang pelajar perempuan berumur 17 tahun, warganegara Malaysia yang tidak mempunyai sejarah melawat negara (asing) yang telah diisytiharkan berlaku wabak Influenza A(H1N1).

"Beliau telah mula menunjukkan simptom batuk dan selesema pada 14 Jun 2009 jam 9 malam, dan mula demam pada keesokan harinya. Pada pagi 15 Jun 2009, kes telah pergi ke Pusat Perubatan Universiti Malaya seterusnya dirujuk ke Hospital Sungai Buloh jam 10.00 pagi.

"Semasa penyiasatan, kes ke-19 melaporkan bahawa beliau adalah kontak kepada kes ke-12 iaitu pelajar perubatan yang telah disahkan positif Influenza A(H1N1) pada 13 Jun 2009.

"Namun sebelum ini beliau tidak pernah diisytiharkan sebagai salah seorang kontak kepada kes ke-12.

"Ini menyebabkan pengawasan dan kuarantin awal ke atas kes ke-19 ini gagal dilakukan dan menyebabkan 20 orang lagi (kontak) terdedah kepada jangkitan influenza A(H1N1)."

Dr Mohd Ismail menambah, sangat penting semua kes yang disahkan
positif H1N1 memberikan maklumat lengkap supaya pengawasan dan kuarantin awal dapat dilakukan kepada semua orang yang pernah berhubung dengan mangsa, seterusnya mengelakkan risiko penularan kepada orang lain.

"Tindakan undang-undang bawah Akta Pencegahan dan Pengawalan Penyakit Berjangkit 1988 boleh diambil sekiranya mereka gagal memberikan maklumat yang lengkap," katanya.

Tambahnya lagi, sesuai dengan keputusan Mesyuarat Jawatankuasa Teknikal Kejadian Influenza A(H1N1) bil. 5/2009, kementerian juga mengeluarkan arahan seperti berikut:

bullet buttonOrang awam tidak digalakkan untuk melawat hospital. Kanak-kanak berumur bawah 12 tahun dilarang pergi atau dibawa melawat ke hospital kecuali untuk mendapatkan rawatan.

Setiap pesakit hanya dibenarkan menerima dua orang pelawat berumur lebih 12 tahun pada satu-satu masa. Masa lawatan di hospital kerajaan dan swasta akan dipendekkan.

bullet buttonSaringan demam akan dilakukan kepada semua pelawat yang
datang melawat pesakit di semua hospital kerajaan dan swasta.

Kementerian Kesihatan juga memohon kerjasama kepada penumpang, anak kapal dan kontak kepada kes agar menghubungi melalui talian 03-88 81 02 00 atau 03-88 81 03 00 untuk mendapatkan nasihat kesihatan termasuk keperluan kuarantin di rumah.
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Which one better SLR or Compact?
6/17/2009 01:18:00 AM | Author: fadzly
Nowdays, camera seems to be the second gadget that we must have and I'm wondering to get one but I don't know which one suits me. It it SLR or compact camera.
Of course in terms of budget, I should buy a compact camera, but for long term, SLR might be worth for. So i've look up for some 2nd opinions from the net. Then i found something interesting. 'TheBigCameraDebate' by the two Fly FM DJs, Ben and Phat Fabes sponsored by Olympus PEN E-P1
They are fighting about this two type of camera, Ben - SLR and Compact - Phat Fabes. But the one actually fighting are not them, the users which are debating for their side. The criteria was, those who want to wins needs to have the most messages/debates from the users and in the end of the day, the winner will be granted one wish which make the loser to do his command.. LOLZ.. Wait till u see the videos.. Too bad, Phat Fabes is the one who lost mostly. So, did the SLR wins? haha.. U have to see it for yourself.


In the mean time, the debate was closed but u can still watch the recent video they've put up on their site. Click here to watch the videos.
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HAPPY BIRTHDAY
6/17/2009 12:48:00 AM | Author: fadzly
HAPPY BIRTHDAY TO 'ONE OF US'! SYUHADA!


(Versi Melayu-Classic)

ALLAH SELAMATKAN KAMU,
ALLAH SELAMATKAN KAMU,
ALLAH SELAMATKAN NOR SYUHADA,
ALLAH SELAMATKAN KAMU.......


(Versi English)

Happy Birthday to you,
happy birthday to you,
Happy Birthday, Nor Syu...
Happy Birthday to you!



(Versi Arab)

سنة حلوة يا جميل

سنة حلوة يا جميل

سنة حلوة يا حبيبي

سنة حلوة يا جميل

(dalam ruminya,)

Sana 7elwa ya gamiil,

Sana 7elwa ya gamiil,

Sana 7elwa ya Nor Syuhada,

Sana 7elwa ya gamiil,
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New Template!!
6/16/2009 03:35:00 AM | Author: fadzly



Yes! We've managed to put up a new, hey but wait. I need to address something much2 more important

First of all, We're sorry for those who went to our page using Internet Explorer before. I've noticed that there was a problem when viewing using IE either using old or latest (8). The problem was crash and terminate the connection to the net. However there is no problem using Firefox 3.0. I don't know about the other browser such as Chrome or Safari which i've stopped using it for a while because no RSS function. We're really regret it and sorry for any inconvenience when surfing our page.

We're so excited about this new template. I've managed to got it from here. I feel that we've just being born again! It's like a new beginning. LOLZ.. Feel free to come back to read for our articles. More to come!
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Orthopaedic examination
6/15/2009 05:27:00 PM | Author: fadzly
Nice class today with Dr Shamsul Ortho. Syud dengan tak malunya, made a video of kah kian yang malu.. LOLZ.. hope she can put it up here

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Type and Indication of Blood Transfusion
6/13/2009 09:15:00 PM | Author: fadzly
The second short note question would be about blood transfusion. Safe blood products, used correctly, can be life-saving. However, even where quality standards are very high, transfusion carries some risks. If standards are poor or inconsistent, transfusion may be extremely risky. No blood or blood product should be administered unless all nationally required tests have been carried out.


Blood component:
1 A constituent of blood, separated from whole blood, such as:
  • Red cell concentrate
  • Red cell suspension
  • Plasma
  • Platelet concentrates
2 Plasma or platelets
3 Cryoprecipitate, prepared from fresh frozen plasma: rich in Factor VIII and fibrinogen

Plasma derivative
Human plasma proteins prepared under pharmaceutical manufacturing conditions, such as:
  • Albumin
  • Coagulation factor concentrates
  • Immunoglobulins



WHOLE BLOOD
  • 450 ml donor blood
  • 63 ml anticoagulant-preservative solution
  • Haemoglobin approximately 12 g/ml
  • Haematocrit 35%–45%
  • No functional platelets
  • No labile coagulation factors (V and VIII)
Indication
  • Red cell replacement in acute blood loss with hypovolaemia
  • Exchange transfusion
  • Patients needing red cell transfusions where red cell concentrates or suspensions are not available




RED CELL CONCENTRATE

  • 150–200 ml red cells from which most of the plasma has been removed
  • Haemoglobin approximately 20 g/100 ml (not less than 45 g per unit)
  • Haematocrit 55%–75%
Indication
  • Replacement of red cells in anaemic patients
  • Use with crystalloid replacement fluids or colloid solution in acute blood loss

LEUCOCYTE-DEPLETED RED CELLS

  • A red cell suspension or concentrate containing <5>
  • Haemoglobin concentration and haematocrit depend on whether the product is whole blood, red cell concentrate or red cell suspension
  • Leucocyte depletion significantly reduces the risk of transmission of cytomegalovirus (CMV)
Indication
  • Minimizes white cell immunization in patients receiving repeated transfusions but, to achieve this, all blood components given to the patient must be leucocyte-depleted
  • Reduces risk of CMV transmission in special situations
  • Patients who have experienced two or more previous febrile reactions to red cell transfusion




PLATELET CONCENTRATES

Single donor unit in a volume of 50–60 ml of plasma should contain:
  • At least 55 x 109 platelets
  • <1.2>
  • <0.12>
Indications
  • Treatment of bleeding due to:
  • — Thrombocytopenia
  • — Platelet function defects
  • Prevention of bleeding due to thrombocytopenia, suchas in bone marrow failure



FRESH FROZEN PLASMA

  • Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder
  • Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin
  • Factor VIII level at least 70% of normal fresh plasma level
Indications
  • Replacement of multiple coagulation factor deficiencies: e.g.
  • — Liver disease
  • — Warfarin (anticoagulant) overdose
  • — Depletion of coagulation factors in patients receiving large volume transfusions
  • Disseminated intravascular coagulation (DIC)
  • Thrombotic thrombocytopenic purpura (TTP)

CRYOPRECIPITATE

  • Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C and resuspending it in 10–20 ml plasma
  • Contains about half of the Factor VIII and fibrinogen in the donated whole blood: e.g. Factor VIII: 80–100 iu/ pack; fibrinogen: 150–300 mg/pack
Indication
* As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of:
— von Willebrand Factor (von Willebrand’s disease)
— Factor VIII (haemophilia A)
— Factor XIII
* As a source of fibrinogen in acquired coagulopathies:
e.g. disseminated intravascular coagulation (DIC)


HUMAN ALBUMIN SOLUTIONS

Prepared by fractionation of large pools of donated plasma

Indication
  • Replacement fluid in therapeutic plasma exchange: use albumin 5%
  • Treatment of diuretic-resistant oedema in hypoproteinaemic patients: e.g. nephrotic syndrome
  • or ascites. Use albumin 20% with a diuretic
  • Although 5% human albumin is currently licensed for a wide range of indications (e.g. volume replacement, burns and hypoalbuminaemia), there is no evidence that it is superior to saline solution or other crystalloid replacement fluids for acute plasma volume replacement

COAGULATION FACTORS


Factor VIII concentrate
  • Treatment of haemophilia A
  • Treatment of von Willebrand’s disease: use only preparations that contain von Willebrand Factor

PLASMA DERIVATIVES CONTAINING FACTOR IX

Prothrombin complex concentrate (PCC)
Factor IX concentrate
  • Treatment of haemophilia B (Christmas disease)
  • Immediate correction of prolonged prothrombin time


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POSTOPERATIVE MANAGEMENT
6/12/2009 04:49:00 PM | Author: fadzly
End of Posting Written Test
Lolz.. This morning short note test come out to be complication of operation.. Damn i don't like this kinda question. I hate short notes.. really.. But nway, i've made an article for us to look what we've answer and filling all the blanks that we have.. But hey, this is not an answer scheme or what so ever. It just for our understanding and merely a revision before we get ourself into a House Officer..

The role of the junior doctor postoperatively is to check that the patient has recovered from the anaesthetic, look at their observation charts and check their fluid balance. The operation note should have a section on specific postoperative management written by the surgeon, and is a guide that should be followed. For example, following a vascular graft operation — say, to the leg — you should always check the pulses, capillary refill and toe movement in the involved leg to ensure that the graft has not blocked off. A common question for exams concerns complications of surgery.

Complications
All operations carry a risk of complications. These can be divided into general and specific.

* General complications include those pertaining to the anaesthesia itself and those that can occur after any operation, such as a chest infection or DVT.
* Specific complications are those that occur because of the individual operation itself, such as cutting a nerve.

You can subdivide this classification by time, into complications that occur immediately, within the first 24 h; early, within the first week or so; late postoperative, occurring within the first month or so; and long term.

General immediate complications include those due to the anaesthetic, such as direct trauma to the mouth when intubating and reactions to the anaesthetic (inherited disorders or idiosyncratic reactions).

Other early complications including
* Chest infections
* Urinary retention or infections
* Deep vein thrombosis
* Bed sores.

Specific complications depend on the nature of the operation. In this category haemorrhage and wound infection are important.

Haemorrhage
This can be divided into primary, reactionary and secondary haemorrhage.

* Primary haemorrhage occurs during the operation, when a vessel is cut.
* Reactionary haemorrhage is when at the end of the operation the wound looks dry, but when the patient’s blood pressure and cardiac output rise to normal levels, bleeding begins, presumably from vessels that were not properly ligated during the operation.
* Secondary haemorrhage, occurring several days after the operation, is usually attributed to infection that erodes through a vessel.

Wound Infections
These are most commonly caused by S. aureus (increasingly MRSA), although coliforms such as E. coli are also important. Wound infection is more likely if

• The operation is dirty (e.g. abdominal surgery)
• The duration of the operation is long (greater than 2 h)
• The patient is more susceptible (e.g. old age, immunosuppression, diabetes)

Minor wound infections, with a little redness and slight discharge, are relatively common and usually need just simple measures, such as regular wound dressing and perhaps antibiotics. More severe infections, common after abdominal operations, usually occur in the first week or so. The wound looks inflamed, and there may be cellulitis, discharge or localised abscess formation. The wound should be swabbed and maybe antibiotics started, but the only correct treatment for an abscess is drainage. This may mean simply removing a few of the surgical clips, and probing the wound, allowing the pus to discharge, or a further surgical procedure to open up the wound. The wound is then left to heal by secondary intention (i.e. to heal itself from within, with no further suturing).

Wound Dehiscence
This is an uncommon problem. It is usually due to an inadequate repair of the tissues (but infection, poor blood supply, malnutrition and steroids may all play a part in poor wound healing). Dehiscence usually occurs about a week after the operation. A warning sign is a serosanguinous discharge from the wound a few days before. The wound suddenly bursts open and in the case of a laparotomy the bowel protrudes outwards and is extremely alarming for the patient and the nursing staff. Sterile soaked swabs should be placed over the wound and the patient taken back to the theatre for repair.

serasenguinous discharge

An example of general and specific complications pertaining to a - gastrectomy is outlined below.

Click to enlarge

The commonest reason that a junior doctor gets called to the ward is to write up fluids or to see a patient with postoperative pyrexia or poor urine output.

POSTOPERATIVE PYREXIA
A small rise in temperature is common postoperatively. If the temperature spikes above 38'C or persists, then you should consider and look for the seven C's as potential causes. This is a common viva question.

1. Chest. Chest infection
2. Catheter. UTI
3. CVP line. Infected
4. Cannula. Superficial thrombophlebitis (solved by removing the cannula)
5. Cut. Wound infection
6. Collection. Subphrenic or pelvic abscess (may indicate a failure of anastomosis)
7. Calves. DVT (rumbling pyrexia in second postoperative week)

A chest infection is very common postoperatively, especially in patients who smoke or have pre-existing poor respiratory function. The mucus secretions are not cleared; these then clog up the smaller bronchi, which leads to collapse of the air spaces distal to the blockage (atelectasis). Inhaled organisms then infect the collapsed segments. In addition, thoracic and upper abdominal incisions cause pain and stop the patients from coughing up the secretions, and so they are much more likely to have basal atelectasis and develop chest infections. These patients should therefore be given adequate analgesia, have vigorous physiotherapy, and be encouraged
to cough up the phlegm (ideally whilst holding their wounds — applicable for chest and abdominal wounds).

Abscesses
A deep collection, such as a subphrenic or pelvic abscess, can occur after the patient has had generalised peritonitis. The patient usually presents with general malaise, nausea, pain (a subphrenic abscess may also cause pain felt in the shoulder tip), a swinging pyrexia and localised peritonitis.

A pelvic abscess often occurs 4–10 days postop., whereas a subphrenic abscess usually occurs a bit later, 7–21 days postop. Clinically, the patient appears to be recovering well, but then develops a fever and starts to feel unwell. The white cell count may be raised and a collection is identified on ultrasound or CT. Treatment is by drainage, either percutaneously under ultrasound or CT guidance, or by an open procedure. A drain is usually left in situ.

Anastamotic leak
A small anastomotic leak usually causes a localised abscess which becomes sealed off by the omentum and the bowel. Clinically, the patient is slow to recover, but usually improves with intravenous antibiotics and fluids and delayed return to food. A larger anastomotic breakdown causes the patient to be very unwell, with anything from local peritonitis through to a rigid abdomen and septicaemia. The abscess needs to be drained, the peritoneal cavity washed out, and the two ends of the failed anastomosis can be brought out as temporary stomas.

Thrombosis
A diagnosis of DVT and pulmonary embolus (PE) in the first instance is essentially a clinical one, as treatment is usually instituted before definitive diagnosis is made. A PE usually presents with pleuritic chest pain (stabbing and worse on inspiration). The textbooks tend to describe the findings you would see in a massive PE, although more commonly in the smaller PEs the findings are less impressive. Usually, the patient is tachycardic, maybe with a low-grade fever and maybe tachypnoeic, but not much else and they may even be asymptomatic. The ECG usually shows sinus tachycardia (the classic S1Q3T3, which most students know about, occurs when there is a large amount of right heart strain, in a large PE, and is rarely seen). The CXR is usually unhelpful but may show a small area of linear atelectasis.

S1Q3T3

Blood gas analysis is essential and you would expect to find a low PO2 (due to ventilation/perfusion mismatches) and a low PCO2 due to hyperventilation. Examination of the calves may or may not reveal evidence of a DVT. If a DVT or PE is suspected, a heparin infusion can be started before investigation but always check with a senior colleague before doing that, especially if the patient has had recent surgery.

To diagnose a DVT you can use duplex ultrasound (or a venogram). To diagnose a PE you can request a ventilation–perfusion scan, although the gold-standard is pulmonary angiography (note nowadays a spiral CT is used in some centres).

Other less common causes for a fever include infective diarrhoeas, drug reactions and blood transfusion reactions. If faced with a patient with a pyrexia you would obviously find out a little history and examine the patient properly. In a long case exam situation you could answer along the lines of, ‘I would listen to the chest, examine the abdomen, check the cannula sites, inspect the wound, etc. … My investigations would depend on my clinical findings but may involve sending a urine specimen, a full blood count and blood cultures, sending wound swabs or the tip of the central line for culture, etc.’

DRAINS

Collections within a wound (especially if they contain blood) are the perfect medium for colonisation of bacteria and hence infection.

A drain can be used to remove anticipated collections within a wound, but should never be used as a substitute for adequate haemostasis at the time of surgery.

Drains can be closed or open:

Closed drainage includes suction drainage (e.g. Redivac) where the collection is attracted into a container either by gravity or suction. This can then potentially reduce the risk of infection when used for large spaces or cavities, such as after a mastectomy or joint replacement. Drains are usually removed as soon as possible (usually 24–48 h) or as soon as the losses begin to tail off. Drains can also introduce infections and so they should not be left in for any longer than needed.

Open drainage (e.g. a piece of corrugated tubing with one end in the wound and the other in the dressing), allows small losses to escape from the wound. This is often employed in established abscesses after incision and drainage to allow any remaining collection a passage out of the wound. Some surgeons like to withdraw this type of drain in stages to allow the track to collapse behind it.

Other drains commonly asked about in exams include chest drains, T-tubes and percutaneous nephrostomies.

POSTOPERATIVE POOR URINE OUTPUT
This is a common exam question and can be classified as prerenal, renal or postrenal. The commonest causes of failure to pass urine postoperatively are postrenal.

Postrenal problems (commoner in males) include obstruction caused by a large prostate or a blocked catheter. Also, the patient may find initiation of micturition difficult for the following reasons:

1. Anticholinergic drugs or those with alpha adrenergic effects (e.g. the anaesthetic)
2. Pain (e.g. after a hernia repair)
3. Inhibition (e.g. because of strange surroundings or a nurse continually asking them if they have passed urine)
4. Opiates or epidural anaesthetics

Once the bladder reaches a certain volume of distension it fails to function properly and the patient goes into retention. Benign prostatic hypertrophy is an important predisposition and these patients are more likely to go into retention.

Prerenal causes are due to renal hypoperfusion because of either hypovolaemia or heart failure.

Renal causes — Acute renal failure is usually due to acute tubular necrosis.

How to handle?
Junior doctors are commonly called to see patients who have failed to pass urine postoperatively. Often this will be a patient you are covering but have not met before. It is, therefore, worth spending a little time getting a history and reading the patient’s notes. You should find out the type and date of operation and also search for clues pointing to whether the problem is prerenal or postrenal. Ask if there is any pain; an enlarged bladder causes suprapubic pain, although this is difficult to differentiate from pain in an abdominal wound (one exception is when there is an epidural in situ and there is no pain).

On examination you should look for signs of hypovolaemia (dry mucous membranes, decreased skin turgor, tachycardia, etc.), signs of heart failure (shortness of breath, tachycardia, raised CVP or JVP and bibasilar crepitations, peripheral oedema, etc.). A distended bladder palpable just above the pubis is dull to percussion and usually tender, making the patient want to pass urine, when compressed.

You can initially try conservative measures such as analgesia, privacy, sitting in a warm bath, etc., but if that fails then catheterisation is indicated. If you suspect that the cause is postrenal (i.e., distended bladder and discomfort), then the diagnosis is proven by catheterisation. A large residual volume of urine should drain (usually about 500 ml or more).

If the patient already has a catheter in situ, then the catheter should be flushed to ensure it is not blocked. If the urine coming out of the catheter is small amounts of concentrated dark urine, then the cause is likely to be prerenal anyway. You could dipstick the urine, testing for a high specific gravity (more than 1020) to prove this.

You should check the fluid balance charts (IO chart). Observe how much fluid has gone in before, during and since the operation and the measured urine output. Remember that a long laparotomy can lead to large losses of fluid by evaporation and this will not be measured on the charts. A urine output of less than about 30 ml/h is poor (oliguria). The patient should be catheterised anyway at this point to measure the hourly urine output.

U & Es should be sent; if there is a prerenal cause, the urea will be raised. If from your clinical examination and your assessment of the fluid balance charts you think the patient has a prerenal cause, then you should try a fluid challenge.

Fluid Challenge — 250–500 ml of normal saline given as a stat dose (unless you suspect blood loss as the cause, in which case the patient may be shocked and should be given colloids and blood). Then, observe the urine output over the next hour. If the urine output picks up, you have shown the patient to be in need of more fluid and the next bag should be speeded up.

If the patient has heart failure, the urine output will not pick up and the patient may become a little more breathless and the CVP might rise. If this occurs, a bolus dose of a loop diuretic, such as 40 mg of frusemide, will lead to a diuresis and a fall in the CVP. If the patient does not have a central line in at this point, you should ask a senior colleague for advice, as a central line is really necessary for knowing exactly what the state of vascular filling is and will help in the management.

Only after you have excluded a postrenal and a prerenal cause can you assume that there may be a renal problem and acute tubular necrosis has occurred. The creatinine will be raised and you should measure the urine and plasma osmolalities. The ratio of urine to plasma osmolality will be less than 1 (as opposed to prerenal oliguria, where the ratio will be more than 1). Advice from a renal physician should be sought early.

That's all folks.. Hope can help you a bit. I need a great night sleep tonight after tired using my brain for 12 hours straight. Good night.

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£80 million for Ronaldo.. Damn Real..
6/11/2009 05:39:00 PM | Author: fadzly
Manchester United have accepted an £80m offer from Real Madrid for Cristiano Ronaldo.

A statement on the United website confirmed that a deal for the 24-year-old should be completed by the end of the month.

''Manchester United have received a world-record, unconditional offer of £80million for Cristiano Ronaldo from Real Madrid.

''At Cristiano's request - who has again expressed his desire to leave - and after discussion with the player's representatives, United have agreed to give Real Madrid permission to talk to the player.

''Matters are expected to be concluded by 30 June. The club will not comment until further notice.''

Ronaldo has long been a target for the Spanish giants, whose president Florentino Perez vowed earlier this week to do ''everything possible'' to take the 24-year-old to the Bernabeu.


Cristiano Ronaldo's last game for United was the Champions League final defeat to Barca

It is now certain that a second era of "Galacticos" has begun at Madird, with news of Ronaldo's £80m deal coming in the same week Perez agreed a £59, deal to sign Kaka.

The news is bound to be greeted with some scepticism by United fans who have repeatedly been told no deal had been agreed for the sale of FIFA's world player of the year in the face of regular statements from Spain the former Sporting Lisbon star was bound for the Bernabeu.

It was even suggested Ronaldo would be due a £20m compensation fee from Real if the deal did not go through by June 30, the date United now state themselves is when they expect matters to be concluded.

As it now seems a matter of when, rather than if a world record transfer will be completed, Sir Alex Ferguson might wish to explain why he has gone back on his famous comment in December last year that he would not ''sell that mob a virus''.

It is the first time for many years United would have allowed a player to leave they were not happy about losing.

Yet some supporters may be pleased that at least another drawn-out transfer saga, such as the one 12 months ago, is not played out in public.

And, at least the money could be reinvested in a squad that almost, but not quite proved good enough to win back-to-back Champions League trophies, in addition to a hat-trick of Premier League titles.

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Wow a New Upin and Ipin Movie
6/10/2009 07:45:00 PM | Author: fadzly
After the success of Geng:Pengembaraan Bermula last February, the popular 3D animation characters from the movie - Upin and Ipin will be back for yet another adventure in an all-new feature film called Upin & Ipin: Angkasa. The announcement was made yesterday by Les' Copaque Production, the company behind the film, on their official production blog.


Together with the announcement, the production company has also revealed the film's official website. In the teaser available at the site, Upin and Ipin are shown on the moon and clad in space suits. Right after they plant Malaysian flag on the surface, a shadowy alien figure suddenly dashes by them, setting the twin brothers off on yet another investigative adventure.


There is no mention of an exact release date for the film, but according to the official website, Upin & Ipin: Angkasa will be out in 2011.
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Busy week
6/10/2009 08:49:00 AM | Author: fadzly
I'm a bit busy this week. A lot of things to share with u guys.. a bit sad i couldn't share with u guys in this blog.. nway, i'll be in facebook... Sorry guys..



at Dr Vivek trauma seminar



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UPNM terima kumpulan pertama pelajar perubatan tahun hadapan
6/08/2009 08:04:00 PM | Author: fadzly
UTUSAN

KUALA LUMPUR 8 Jun — Universiti Pertahanan Nasional Malaysia (UPNM) akan menerima kumpulan pertama 40 penuntut Fakulti Perubatan Ketenteraan pada tahun depan, kata Menteri Pertahanan Datuk Seri Dr Ahmad Zahid Hamidi hari ini.

Beliau berkata pengenalan fakulti baru itu sejajar dengan hasrat UPNM menjadi sebuah universiti yang berteraskan kecemerlangan bukan sahaja dalam aspek akademik tetapi mencakupi sahsiah, kepimpinan dan pembangunan kendiri.

“Kita memiliki aset seperti hospital tentera serta pusat pemeriksaan kesihatan sendiri dan kita telah kenalpasti beberapa hospital tentera yang akan dijadikan pusat latihan amali bagi pelajar tersebut,” katanya kepada pemberita selepas melakukan lawatan rasmi ke UPNM di Kem Sungai Besi di sini hari ini. - Bernama

Agak2nya what do you think their title is? MBBS? MD? MBBchb?MB BChir? BM BCh? MB BCh? MB ChB? BM BS? or AD(army doctor) or SD (soldier doctor) lolz




Teringat kat Amru...
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kepada classmate ku
6/08/2009 07:44:00 PM | Author: fadzly
Datang la ward, clinic dan juga kelas.. Ya? ok? ble la.. 2 minggu je lagi.. Aku malas nak wat hal dengan department ataupun pejabat dekan..

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Hehehehe
6/07/2009 11:49:00 PM | Author: fadzly
I've bought 2 tickets to the Malaysia XI vs Manchester United match! Bought it a the rockgarden, Gardens Mid Valley! hehe jgn jealous yer

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apa itu cinta?
6/07/2009 01:18:00 AM | Author: fadzly
Hehe.. mesti pelik blog ni asalnyer citer pasal medical tibe2 citer pasal bende bukan2? Knape tak le ke dak medic bercinta2 nih?

I'm just jealous that a lot of blogs outside there posting about love, cinta2 la, etc2.. So that now I'm in blues, blues giler2 babeng, apa kata I talk about Cinta plak.. hehe.. so layan kan saja yek.. Kalau tak nak layan don't click proceed.. LOLZ.. I'm just having delusion for now..


Apa itu Cinta?

Setiap orang mempunyai makna cinta yang tersendiri. Ada yang kata, cinta itu menyakitkan dan jangan kau hampirinya. Tetapi, ada juga yang kata, cinta itu mengasyikkan sehingga kau akan terbawa-bawa dengan ombak asmaranya. Dan ada juga yang kata, cinta itu indah dan tiada ungkapan yang dapat menyatakan maksud cinta yang sebenar.



Berdosakah bercinta ?

Cinta adalah kecenderungan hati kepada sesuatu, Oleh itu, ia adalah kerja hati, bukan kerja anggota badan yang zahir. Cinta seorang lelaki kepada seorang wanita atau cinta seorang wanita kepada lelaki adalah harus kerana ia adalah fitrah manusia.

Oh cinta,

Banyaknya versi, ada yang normal, bercinta kepada Tuhan, agama, sesama manusia(what i mean normal paham2 ea). Ada yang pelik skit, cinta pada dunia, wang, emas, coklat. Dan ada yang extreme tu sampai nak bunuh diri.. Sad2..

Tapi rasa sedih juga kalau cinta yang kita harapkan itu tak kesampaian. Ada pula cinta yang kita berikan tetapi tidak pula dikembalikan. Itu yang memang bercinta tak pe lagi. Ini ada yang cinta, tapi tak pernah memulakan langsung percintaannya itu kerana tak berani menanggung risiko cintanya ditolak sebelum dimulakan. Oh sedihnya kalau cinta tu ditolak.

Sesungguhnya berterus terang itu lebih baik daripada kecewa seumur hidup terlepas. Perlukah kita takut sampai kita kehilangan cinta yang dicari itu Apa salahnya kan. Mengaku saja la. Mungkin ada rezeki jodoh bersama? Barula brani.. Kerana kegagalan membawa kita kepada kejayaan yang lebih manis..

So, Setiap insan yang sedang bercinta patutnya bersyukur dan menghargai cinta itu. Tetapi, kalau setakat kita hargai saja tapi tak cinta pada sidia tak gune jugak.. Bagaimana pula cinta yang sudah pudar atau tiada setelah bertahun2 menabur bakti akibat terluka hati? Adakah perlu kita berpura2 utk bercinta? Conflictnya dunia ini.. Adakah perlu cinta itu dipaksa? Tapi bukan kah teruk kalau bertepuk sebelah tangan?


Perlukah kita terseksa dengan cinta sebegitu? Perlukah cinta yang mati itu disambung talian hayatnya? Perlukah cinta memberi satu lagi peluang? Adanya itu, baru sahaja putus cinta, lantas ketemu cinta baru. Mesti sahaja cinta itu kecundang disebabkan orang ketiga. (oppss..). ya mungkin juga. Tapi mana mungkin hati ini terobat sekelip mata.

Ok ok.. da tak nak da ngarut2 nih.. So this is my summary of cinta:

Yang ku tau, Cinta itu tidak bisa di ungkapkan, Cinta itu tidak bisa di rasa, Cinta itu tidak bisa dimiliki. Cinta itu berbentuk2 berubah2..... Cinta itu hanya milik dirinya sendiri....

argh.. bosannyer cite ngarut2.. nway, kalau korang sudi menerangkan what is CHINTA, do not hesitate to put in as a comment down there.. Hehe... mungkin korang ada versi2 masing2.. Sorry mate, sj nak berjiwang2..rasanya da 5 tahun tak berjiwang2 ni...

p/s: cerita ini tiada kaitan kepada sesiapapun walaupun anda terasa dan gambar2 diatas hanyalah sebagai satu hiasan yang tiada kene mengena dengan article tersebut..
p/s/s: Aku da tak nak post entry mcm ni lagi.. soo gurlish.. aduhai..
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PRE-OPERATIVE MANAGEMENT
6/05/2009 08:11:00 PM | Author: fadzly
I'm wondering to have an article about what a House Officer should do when they in the surgery posting. I hope this helpful for my 'old classmates' who are going to have and induksi this week. Congrates to them they are going to start their work! When you are a surgical house officer (or Formula One), part of your role preoperatively will be to clerk the patients and prepare them for the theatre or their investigations.

A clerking consists of the history of the presenting complaint, past medical history, drug history, family history and social history. You should then examine the patient fully, looking first at their general health and whether they are fit enough for the operation, and if not you should be thinking of ways to optimise their health, such as using preoperative nebulisers for an asthmatic. The clerking also allows other problems to be picked up.

If, when the patient arrives on the ward, you feel that the diagnosis made in the out-patient clinic has changed, you should inform a senior colleague before the operation is booked. For example, if a patient was admitted for an excisional biopsy of a lymph node that has completely disappeared when you examine them, you should inform your consultant, as the operation might need to be cancelled.

In the main, appropriate investigations should be performed before surgery and this is often a good question for a viva examination. For example, before a laparascopic cholecystectomy is performed the patient should have had an ultrasound to confirm the presence of gallstones, and a set of liver function tests. The house officer should discuss the order of patients on the operating list with the operating surgeon. Usually, children are placed first on the list, as this is nicer for the child and the parents; also they find it hard to go without food for long periods. If special equipment is needed in the theatre, such as the image intensifier for X-rays or laparascopic equipment, then these should be discussed with the theatre staff (and radiographers) the day before.

Specialist nurses who have expertise in certain areas such as breast disease, wound management and stomas should be involved preoperatively in all appropriate cases. For example, a patient who is likely to need a colostomy or ileostomy should be seen by the stoma nurse specialist several days before the operation. This allows for patient education (i.e. answering of any questions and worries), and also the site where the stoma will be cited is marked (note that the patient should be standing, so
as to position it in the most appropriate place).


Comorbidity

Many patients have problems other than the one that is being operated upon. These may be social and as such need a social work or occupational therapy referral. For example, if the patient has difficulty climbing stairs and there is no lift, then there may be a need to arrange for a stair lift or rehouse into ground floor accommodation.

The patients may have intercurrent medical problems such as diabetes, hypertension or chronic obstructive pulmonary disease (COPD). They may also be on drugs such as steroids or anticoagulants. When clerking the patient you should be looking out for these, and if you think they may affect the operation, then you should inform the anaesthetist or the consultant in charge of the patient.

As a house officer the tests you need to consider preoperatively include blood tests, such as a full blood count, a sickle screen if at risk (this includes anyone of Afro-Caribbean origin), and either a group and save or a cross-match. You should X-match any patient at risk of blood loss extensive enough to need replacing — for example, the anticipated blood loss from an anterior resection is about two units, but to be safe we usually X-match four units. The blood is kept in the refrigerator ready for use. If it is not used it goes back to the blood bank for storage.

A young healthy person, in general, requires no preoperative investigations, but if at all unsure then you should ask the anaesthetist what they would like performed (for example, some anaesthetists like to have a recent full blood count on all females of childbearing age). The National Institute for Clinical Excellence (NICE) have issued guidelines on preoperative
investigation available here. If the patient is hypertensive or on diuretics then a U & E (urea, creatinine and electrolytes) to assess renal function must be performed. An ECG is necessary on anyone who is hypertensive or has a history of heart disease, and a chest X-ray on anyone
with respiratory disease, including a personal or family history of TB.

In most hospitals the requirement is to order an ECG and CXR as a baseline on the elderly (aged over 60), but check the policy in your hospital. The management of medical problems in surgical patients is essentially the same as that you read about in medical textbooks. We will, however,
cover just a few topics.

DIABETES

Diabetics have an increased incidence of perioperative complications. The stress of surgery can lead to an increased production of catabolic hormones, such as glucagon and catecholamines, which antagonize the action of insulin, making control more difficult, especially as the patient will also be nil by mouth. These patients are at an increased risk of infection (wound, chest, IV access sites and urine), peripheral vascular disease, pressure sores and ischaemic heart disease. The aim is to maintain the patient’s blood sugar level between 5 and 9 mmol/l. Preoperatively you should dipstick the urine to check for protein, send off a laboratory blood
glucose, check the electrolytes and creatinine and order an ECG.
Management depends on the types of diabetes.

Insulin-dependent Diabetics
For anything other than minor surgery it is probably best to put these patients on an insulin sliding scale to establish good control. This means they are on a drip of dextrose or dextrose saline (as they are not eating), together with a continuous infusion of fast-acting insulin (‘Actrpid’). The rate of infusion of insulin will depend on their blood sugar level, which can be monitored by hourly BM stix (a finger prick testing stick specific for glucose). If the BM is low the infusion is decreased or stopped, and if the BM is high the insulin rate can be increased to bring the sugar level down. It is important that you add potassium to each bag of fluids you give, since the insulin causes cellular uptake of potassium and can lead to hypokalaemia. The sliding scales regimen differs in different hospitals and
you should try and get hold of a sliding scale protocol at your hospital.

This is one example:


Diabetics Controlled with Oral Hypoglycaemics

Long-acting oral hypoglycaemics such as metformin should be changed to a short-acting sulphonylurea (e.g. Gliclazide) a few days before the operation. Ask the diabetic team for advice. On the morning of the operation omit the dose of oral hypoglycaemic. This can be resumed once the patient starts eating postoperatively. The BMs should be measured, and if very high the blood sugar can be brought down by small doses of subcutaneous soluble insulin (e.g. 6 units of actrapid). If this fails to control the sugar level or in the case of major surgery, you cannot go wrong by simply converting the treatment to a sliding scale as above. Diabetics should really go first on the list, as the starting time is predictable and this allows better management of sugar levels.


Diabetics Controlled by Diet Alone

These patients rarely need any special measures. Remember that provided they have not been given any insulin or oral hypoglycaemics the patients cannot become hypoglycaemic (unless they have an insulinoma); if anything, their sugar level will be high. A BM stix will tell you where you stand if you are worried. If you find their control is poor, then you should refer the patients back to their diabetologist.


STEROIDS

Patients on steroids are liable to impaired healing and postoperative infections. Also, long-term corticosteroids can lead to adrenal insufficiency, where the adrenals are unable secrete the increased glucocorticoids necessary in response to the stresses of surgery. This can lead to an Addisonian crisis, where the patient becomes shocked. Patients who have been on long-term oral steroids should therefore be treated with perioperative steroids. This usually means intravenous hydrocortisone before and after the operation until the patient can resume their oral intake.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Surgery and anaesthesia predispose patients to basal lung collapse (atelectasis),
aspiration pneumonitis and chest infection. This is especially true of operations on the abdomen, since the patient may be in pain and therefore does not cough up the secretions. Any pre-existing respiratory disease, such as chronic obstructive pulmonary disease (COPD), increases the risk of chest complications, as do smoking, obesity and old age. Preoperatively, therefore, you should arrange for a chest X-ray and lung function tests in any patient with pre-existing chronic airways disease.
You should also do a baseline blood gas analysis if hypoxia or carbon dioxide retention is anticipated. You can assess the degree of reversibility of the airway disease by measuring peak flows before and after bronchodilators are given by nebuliser.

If there is a degree of reversibility, then prescription of nebulisers may help optimise lung function. Physiotherapy is an important modality in these patients and preoperative breathing exercises can help prevent a chest infection. Postoperatively physiotherapy should be initiated early to help remove airway secretions, especially in abdominal operations. Smokers should be encouraged to stop smoking at least 4 weeks prior to elective surgery.


DEEP VEIN THROMBOSIS

All surgical patients are at risk of deep vein thrombosis (DVT). In some hospitals prophylaxis with subcutaneous low molecular weight heparin injections and thromboembolic deterrent (TED) stockings is given to all surgical patients, whereas other hospitals only give this to patients at medium-to-high risk of DVT. Risk factors for DVT include previous thrombosis or pulmonary embolus, long periods of immobility, pelvic or hip operations, obesity, cancer and use of the oral contraceptive pill. Find out what the DVT prophylaxis protocol is in your hospital.
Intermittent limb compression is where an inflatable device is wrapped around the legs and periodically blown up, from the distal to the proximal end, encouraging venous return. Also available is low molecular weight (LMW) heparin, which is thought to work on the antiplatelet factor antithrombin III and therefore has little effect on the intrinsic clotting cascade.

In normal prophylactic doses LMW heparin does not require monitoring; it is longer acting and thus only needs to be given once daily. LMW heparin is as effective as unfractionated heparins. Newer drugs such as direct thrombin inhibitors are also now available.

In most cases, early mobilisation in combination with one or more of the above options is acceptable.


ANTIBIOTICS

Antibiotic cover is necessary for surgery if there is an increased risk of infection. This could be due to patient-related factors or those related to
the type of operation. Contaminated operations, such as those where the bowel contents can leak out, carry a high risk of infection, as do operations where a prosthetic implant is used (e.g. joint replacement), and antibiotics should always be given in these cases.

An example of a patient-related factor is mitral valve disease and the subsequent risk of developing endocarditis. We usually give prophylactic antibiotics intravenously at induction of anaesthesia, so that blood levels are high during the operation, followed by two subsequent doses postoperatively (usually after about 8 and 16 h).

If a tourniquet is being used, then the antibiotics must be given before the
tourniquet is inflated. You should have a rough idea of which organisms are likely to be responsible for the infection and which antibiotics should therefore be
used. A common question concerns methicillin-resistant Staphylococcus aureus (MRSA), which is an increasing problem in many hospitals. It is especially worrying when it infects patients with prosthetic implants such as hip replacements or vascular bypasses.

Operations Involving the Bowel
Organisms
Mainly Gram-negative bacilli, i.e. coliforms, but also faecal anaerobes (bacteroides) and S. aureus from the skin. In the gut there is also Enterococcus faecalis (also known as strep faecalis), but this causes infection less commonly. In bile, the majority of infections are with gut bacteria, such as Escherichia coli, and, rarely, pseudomonas, which is more difficult to treat.
Prophylaxis
We tend to use a cephalosporin to cover the Gram-negative organisms together with metronidazole to cover anaerobes. If you are concerned about strep faecalis you should add amoxycillin, as the cephalosporins do not cover this well. For operations on the biliary tree, such as a laparascopic cholecystectomy, you could either use the same regimen as above or just use a cephalosporin alone, as most infections are with Gram-negative bacilli (mainly E. coli). One dose at induction is sufficient. For improved biliary penetration such as before and after an ERCP or for ascending cholangitis, a broad-spectrum B-lactam such as pipericillin is often used. This also covers for pseudomonas.

Operations Involving Prosthetic Implants
Organisms
Skin organisms are usually responsible. S. aureus is the commonest pathogen, but also S. epidermidis tends to colonise the newer plastic prostheses. Rarely, coliforms are responsible.
Prophylaxis
Either a broad-spectrum cephalosporin or flucloxacillin. Orthopaedic operations involving metalwork require a dose of intravenous antibiotics (usually a cephalosporin) at induction and for about 24 h postoperatively. Similarly, valve replacements are usually given amoxycillin (or a cephalosporin) and gentamycin. If MRSA is a particular worry, then vancomycin may be used.The British National Formulary contains up-to-date advice on this topic. Remember that if ischaemic or necrotic tissue is involved, then spores of clostridium tetani may cause gas gangrene. Benzylpenicillin, to which the organism is highly susceptible, is the prophylaxis (and treatment) of choice against this (this includes penetrating wounds and compound fractures).

The mnemonic “ABCD LMNOPs” is helpful in remembering preoperative management:
A — Antibiotics/anaesthetist
B — Bloods (including X-match)/bowel preparation
C — Consent/CXR
D — Drug chart/DVT prophylaxis
E — ECG
F — Fluids (especially if NBM or if the patient is vomiting)
L — List (put in the theatre list)/lung function tests
M — Mark the area or limb (should be done by the operating surgeon)
N — Notes should be filed correctly
O — Operating theatre staff (e.g. book special equipment/radiology)
P — Physiotherapy
S — Specialist nurses (e.g. breast care or stoma care nurses)

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Royal Pains: A new TV series!!
6/05/2009 03:44:00 PM | Author: fadzly
I'm Bored coz my everytime favourite TV series - House - season 5 will only come out next year.. Pathetic of waiting, suddenly i found a new medical series!! Royal Pains!

Here is the premiere of USA medical drama “Royal Pains”, which is about A down and out surgeon who has a chance to redeem himself as a small town physician in the wealthy beach community of East Hampton, NY. 720p is from CTU!

Here's the synopsisEP 1.1 Pilot

When a Hospital trustee dies on Dr. Hank Lawson’s watch, he is shunned by the medical community. Months later, at a party in the Hamptons, he saves the life of a guest and stumbles upon a new career as an on call doctor for high society.

If you want to download this series, i've found links for you
http://rapidshare.com/files/240987071/royal.pains.s01e01.hdtv.xvid-fqm.part1.rar
http://rapidshare.com/files/240988059/royal.pains.s01e01.hdtv.xvid-fqm.part2.rar
http://rapidshare.com/files/240987406/royal.pains.s01e01.hdtv.xvid-fqm.part3.rar
http://rapidshare.com/files/240987899/royal.pains.s01e01.hdtv.xvid-fqm.part4.rar
http://rapidshare.com/files/240987743/royal.pains.s01e01.hdtv.xvid-fqm.part5.rar
http://rapidshare.com/files/240988082/royal.pains.s01e01.hdtv.xvid-fqm.part6.rar
http://rapidshare.com/files/240988312/royal.pains.s01e01.hdtv.xvid-fqm.part7.rar

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waaaa.. Nak PSP - GO baru ni!!
6/04/2009 08:08:00 AM | Author: fadzly

New PSP Go (N1000) Goes On Sale For $249 Beginning October 1st in US!
Sony Computer Entertainment Inc. (SCEI) has officially announced the launch of its new evolution of PSP handheld entertainment system - PSP Go (PSP-N1000), which the company said to be 50% smaller (128 x 16.5 x 69 mm) and 40% lighter (5.6 ounces) than the original PSP, aiming to enhance the unmatched portable gaming and entertainment experience.












Featured Highlights Of PSP Go:

* Sliding 3.8-inch wide LCD display with 480 x 272 pixels resolution (43% lighter than PSP 3000)
* Integrated 16GB flash memory, expandable via Memory Stick Micro (M2) slot (no UMD drive)
* Wi-Fi and Bluetooth connectivity
* New Media Go software application allows users to access and download entertainment content on PlayStation Store via their PCs
* New SensMe channels music application, the mood based music recommendation system that can categorize music content into channels including “Relax,” “Dance” and “Upbeat”


The new amazing PSP Go that arrives in Piano Black and Pearl White colors is scheduled to be available for US$249 and euro 249 beginning October 1, 2009.

Another PSP highlight!
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