Sakitnya perut..

( PICTURE OF SMALL INTESTINE - USUS KECIL)

"sakitnya perut...ish..!" ..Air mata Rosnah membasahi pipinya..Aku dah tak tahan ni..getus hatinya

"kenapa ni Senah...dari tadi lagi asyik dok mengeluh.." ibunya memandang ke arahnya..Rungsing melihat anak bongsunya menahan kesakitan

"Mak bawak Senah ke hospital sekarang ye..risaulah mak lihat senah , semakin lama makin sakit je nampak.."

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" saya dr. jenab..datang sebab sakit apa ye?"

" anak saya ni...dari semalam lagi sakit perut..tak pernah saya tengok dia sakit macam ni"

seterusnya Dr jenab menemuramah Rosnah:

HISTORY:

1)COLICKY ABDOMINAL PAIN ( SAKIT PERUT YANG DATANG - HILANG
2) NAUSEA ( RASA MUAL)

3) VOMITING ( MUNTAH)

4) NO BOWEL OUTPUT ( TIADA KENTUT ATAU BERAK)

RUPA-RUPANYA ROSNAH PERNAH ADA OPERATION BEBERAPA TAHUN DAHULU UNTUK APPENDICITIS ( UNDERWENT APPENDICECTOMY)





KEMUDIA, ROSNAH DIPERIKSA...

PHYSICAL EXAMINATION:

generally , patient is in pain, dehydrated. Not tachycardic, Blood pressure still within normal range. per abdomen, the abdomen is mildly distended, soft, tender on the Right iliac fosse. no guarding or rigidity. no mass palpable or visualized.

INVESTIGATION:

ABDOMINAL X-RAY AND CHEST ERECT

ABDOMINAL X-RAY:SMALL BOWEL DIILATATION
IMPRESSION: INTESTINAL OBSTRUCTION SECONDARY TO ADHESION

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INTESTINAL OBSTRUCTION:

What is a bowel obstruction?
A bowel obstruction happens when either your small or large intestine is partly or completely blocked. The blockage prevents food, fluids, and gas from moving through the intestines in the normal way. The blockage may cause severe pain that comes and goes.

Pathophysiology
Obstruction of the small bowel leads to proximal dilatation of the intestine due to accumulation of GI secretions and swallowed air.

This bowel dilatation stimulates cell secretory activity resulting in more fluid accumulation. This leads to increased peristalsis both above and below the obstruction with frequent loose stools and flatus early in its course.

Vomiting occurs if the level of obstruction is proximal. Increasing small-bowel distention leads to increased intraluminal pressures. This can cause compression of mucosal lymphatics leading to bowel wall lymphedema. With even higher intraluminal hydrostatic pressures, increased hydrostatic pressure in the capillary beds results in massive third spacing of fluid, electrolytes, and proteins into the intestinal lumen. The fluid loss and dehydration that ensue may be severe and contribute to increased morbidity and mortality.

Strangulated Small bowel Obtructions are most commonly associated with adhesions and occur when a loop of distended bowel twists on its mesenteric pedicle. The arterial occlusion leads to bowel ischemia and necrosis. If left untreated, this progresses to perforation, peritonitis, and death.

Bacteria in the gut proliferate proximal to the obstruction. Microvascular changes in the bowel wall allow translocation to the mesenteric lymph nodes. This is associated with an increase in incidence of bacteremia due to Escherichia coli, but the clinical significance is unclear.

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TREATMENT OF ACUTE INTESTINAL OBSTRUCTION

- GASTROINTESTINAL DRAINAGE

- FLUID AND ELECTROLYTE REPLACEMENT

- RELIEF OF OBSTRUCTION

- SURGICAL TREATMENT IS NECESSARY FOR MOST CASES OF INTESTINAL OBSTRUCTION BUT SHOULD BE DELAYED UNTIL RESUSCITATION IS COMPLETE , PROVIDED THERE IS NO SIGN OF STRANGULATION OR EVIDENCE OF CLOSE LOOOP OBSTRUCTION

sources:

http://emedicine.medscape.com/article/374962-overview

BAILEY & LOVE'S SHORT PRACTICE OF SURGERY

The HADJ

Alhamdulillah, this year I had been blessed with being able to celebrate the eiduladha with my family. I think for the past 2 years , it was not so.

however, celebrating the eid at KL was nonetheless, a far cry from that in Kota Bharu. It seemed to be like any other day.

Being that I do not have the pleasure as to dwell in numerous holidays, I had taken this opportunity as to pay a visit to the book store. Something was disturbing my mind and my heart, and books have been an endearing way for me to release the pressure that was buiding within me.

I had come across a book that I had read more than 10 years ago and had touched me deeply. It was written by Daniel Keyes, entitled Flowers for Algernon. It revolves around Charlie, who was not so bright and was later given a leash of life when he undergone an experiment whereby his intelligence was heightened. It depicts how his life had changed as he honestly tells it in a diary and subsequently how he suffered when the change of IQ lasted only for a while.

i had thought of buying that book when I had come across another book that caught my attention. It was called the Hadj, written by Michael Wolfe, an account of an American's pilgrimage to Mecca. He is an author and had embraced islam and since then had written a lot about ISlam, mostly regarding the Hajj.

I'm halfway through right now and the book had enchanted me in so many ways. And it also brought about memories and previous conflicts that I used to have regarding the religion. It honestly puts up questions and wonderings by someone who is in search of the right religion.

During my childhood, I had the opportunity to live in the US, in which I feel that it had changed my life forever .

I used to be such a quiet girl, as to the extent I had been labelled taciturn by my teachers there.
It felt hard fitting in. I was only 11 years old back then. Moving to a different country did not bode well at first. I had come from a small town in Kelantan,..not even used to going to the K.L, but then totally drift to an altogether different culture and country was a nervewrecking experience.

I had worn the scarf at the time, but not completely covering my aurah at the time. When I had arrived there and had to enroll in the primary school, I was the only one wearing the scarf.

I had felt like an outcast. Many of them would cast glances at me, but many of them were nice enough. The thing about American is that they are friendly towards you.

I had enrolled in the 4th grade, with Mrs. Sallee as my class teacher. The classroom were cosy and had a library-esque kind of feeling. It was fully carpeted and there were arrays of books stacked in every corner. The chairs were colorfully painted and there were games stashed inside the cupboards.

Initially I had trouble fitting in, of course. They had never seen anybody wearing the scarf before. What more is that, oklahoma, where I was living at the time, is considered part of the christian belt. There were few Arabs or Malaysians at the school, but none of them wore the scarf. I also suffered language problem, in which I was not able to converse in english.

That had made me a certified prey for bullying. Every afternoon, during reccess, I had to suffer a few namecallings and interrogations from a boy next door.

And then I felt more alienated as I had to creep back to my classroom in the afternoon to solat. I had explained to my class teacher regarding our duty to perform the solat 5 times a day. During that tiem , zohor would end by the time I arrive home from school. Thus, I needed a place to perform the solat at school. The only time available, was during the recess time where the class would be empty.

It had become a problem later on when some students had lost some things and they had accused that it was stolen. The thing is, I became a suspect somewhat since i would go back to the classroom during which nobody was in side the class. Nevertheless, the teacher was nice enough as not to point out this fact to everybody else.

Primary school was still peaceful and I had been able to go through it rather nicely. ..Only to suffer much more so as I enter the Middle school. In oklahoma, Middle school consists of 6th and 7th grade. There was only one middle school in stillwater, thus all the primary schoolchildren from stillwater had to go to the Stillwater middle school.

Thus began another journey for me..At the time, I was 12 years old.

Middle school was much more larger and difficult to adapt for me. Now there were students from all the primary schools of stillwater. IT starts all over again. I was still the only one wearing the scarf. This time around, I had to wear the full gear,covering my aurah. My elder brother did not suffer much, as there was nothing to distinct him from others.

At this time, I had become more paranoid and felt much more out of place. Middle school was burgeoning a different kind of atmosphere. During these years, the students were much more social. There were dances, datings and the popular groups.

I fared well in the academic side, which then became a somewhat of a savior to me during this period of my life.

luckily enough I had founds friends that would become my staple group. They were above average students but socially apt.

But something -- someone had come way of that changed the scene of my life at this time.

His name was Joel. He was in the same language arts and science class as me. OF course, being the only person wearing the scarf there attracted much attention from the students there. And again, I became the prey of many jokes there. Including him.

They did not understand much about Islam. THey thought I had worn this because of culture. Especially when there are also muslims in the school , but did not wear properly.They even wore shorts to school.That had created a bit of a problem for me to explain it to the students.

During this time, I had suffered severe low self esteem. I was a foreigner of course, of different religion and the only one wearing the hijab and covering the aurah. I did not mix well with the opposite gender.

I was also having trouble to find time and a place to perform the solat. Here we have to move to 6 different classes each day. I performed my wudu' during reccess and would perform the solat whenever there was free time. In between breaks, and most of the time, it was during class or in the bus. Because Zohor would end during my trip home.

I was 12 at the time, and at some point I began to question myself as to why I need to do all this obligations - wearing hijab, not mixing with the opposite gender, perform solat..Whereas all my other peers are having the time of their life.

I began to question my religion. I began to question their religion.

All of us were born into the religion that we were in right now.

Thus, who to saywhich one is right?

There was not an ustaz or ustazah there which I could seek help.

There was an Islamic center in which we sometimes would learn the quran, and situated just a few houses away from where I was staying.

Internet was still new at the time and there were not much sites that I could really look for.

At the same time, I felt so guilty as to question my own religion.

I had found solace in observation.

The fun and freedom that I was envying them..what was it?
I finally realized after some time of observation, that our life needs a rule. We can't just simply do whatever we want, or else it would be chaos.

Take for example, the school's ruling, that a student is now allowed to dress inappropriately, in which they are not supposed to wear apparels that is see through or exposing much skin.

In Islam, we have a specific rulings already regarding aurah.

If not for the regulations by the Islamic law, our life would be in hazardous state, i realize that. Islam teaches us how to be a good person with a balance between the spiritual and worldly aspect.

The struggle to keep steadfast to my religion had shaped me to become a stronger person.Alhamdulillah, it is with Allah's will.

La hawla wala quwwata illa billah...

A Case of Sudden onset of breathlessness

" Aduh...sakitnya dada..." keluh Abdullah. Tangannya mengusap-usap dadanya.

" Kenapa ni Dollah?" Rosli mula risau..kellihatan Abdullah berada dalam kesakitan yang amat. Dahinya berkerut dan nafasnya makin susah..

Tanpa melengahkan masa lagi..dia segera di bawa ke kecemasan...

Dr Ira was working at the A&E at the time...

The case: Abdullah, 39 year old malay gentleman, who has no known medical illness, but was a heavy smoker had presented to the emergency department with sudden onset of chest pain and shortness of breath...

o/e not breathless at the moment, diminished breathsounds and hyperresonant note on the right lower side of the chest


provisional diagnosis;
How would you investigate this patient?


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Answers:
provisional diagnosis;pneumothorax

investigation:
Chest X RAy
Blood gases


Pneumothorax:
A pneumothorax refers to a collection of gas in the pleural space resulting in collapse of the lung on the affected side.

What are the causes of pneumothorax
Primary spontaneous pneumothorax

• • Spontaneous pneumothorax is heavily associated with smoking, with 80-90% of primary spontaneous pneumothorax cases occurring in smokers.
  • Physical height: It has been noted that typical patients tend to have a tall and thin body habitus. Whether height affects development of subpleural blebs or whether more negative apical pleural pressures cause preexisting blebs to rupture is unclear.
  • Valsalva results in increased intrathoracic pressure. However, contrary to popular belief, most spontaneous pneumothoraces occur while the patient is at rest.
  • Changes in atmospheric pressure, proximity to loud music, and low frequency noises have also been reported to be associated with pneumothorax
  • Familial associations have been noted in more than 10% of patients. Some are due to rare connective tissue diseases, but recently, mutations in the gene encoding folliculin (FLCN) have been described. These patients may represent an incomplete penetrance of a genetic disorder. Birt-Hogg-Dube syndrome is characterized by benign skin growths, pulmonary cysts, and renal cancers and is caused by mutations in the FLCN gene.
• Secondary spontaneous pneumothorax
  • COPD or emphysema
  • Asthma
  • Cystic fibrosis
  • Interstitial lung disease
  • Tuberculosis
  • Bronchogenic or metastatic carcinoma
  • Pneumonia (fungal, caseating, HIV)
  • Collagen vascular disease including Marfan syndrome
  • Catamenial pneumothorax (see Special Concerns)
• Iatrogenic pneumothorax
  • Transthoracic needle aspiration procedures (most common cause, accounting for 32-37% of cases)
  • Subclavian and supraclavicular needle sticks
  • Thoracentesis
  • Mechanical ventilation (directly related to peak airway pressures)
  • Pleural biopsy
  • Transbronchial lung biopsy
  • Cardiopulmonary resuscitation (Consider the possibility of a pneumothorax if ventilation becomes progressively more difficult.)
  • Tracheostomy
• Pneumomediastinum
  • Acute production of high intrathoracic pressures (often as a result of inhalational drug use)
  • Smoking marijuana
  • Inhalation of cocaine
  • Asthma
  • Athletic competition
  • Respiratory tract infection
  • Parturition
  • Emesis
  • Severe cough
  • Mechanical ventilation
  • Trauma or surgical disruption of the oropharyngeal, esophageal, or respiratory mucosa

Radiological findings

Fig 3

(left) Loculated left sided pneumothorax in a patient with severe chronic obstructive airways disease. Placement of chest drain into fifth intercostal space (arrow) might have entered lung parenchyma and would most likely not have achieved complete drainage of this loculated collection. (right) Percutaneous pigtail catheters (arrows) placed in apical and basal components of pneumothorax under fluoroscopic guidance. After several days of drainage the lung re-expanded completely

BMJ. 2005 June 25; 330(7506): 1493–1497.

doi: 10.1136/bmj.330.7506.1493.

Copyright © 2005, BMJ Publishing Group Ltd.

A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the pleural line.

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HOW DO YOU MANAGE PNEUMOTHORAX?

Emergency Department Care

Immediate attention to the ABCs while assessing vital signs and oxygen saturation is paramount. ED care depends on the hemodynamic stability of the patient. All patients should receive supplemental oxygen to increase oxygen saturation and to enhance the reabsorption of free air. Treatments for primary and secondary spontaneous pneumothorax are the following:

• Primary spontaneous pneumothorax
  • If the pneumothorax is smaller than 15% (or estimated as small, see Imaging Studies) and the patient is symptomatic but hemodynamically stable, needle aspiration is the treatment of choice.
  • If the pneumothorax is smaller than 15% and if the patient is asymptomatic, many consider observation to be the treatment of choice. (If the patient is admitted, administer oxygen, since this has been shown to speed resolution of the pneumothorax.)
  • If the pneumothorax is greater than 15% (or estimated as large, see Imaging Studies), aspiration using a pigtail catheter left to low suction or water seal is recommended.
• Secondary spontaneous pneumothorax
  • Tube thoracostomy is the procedure of choice.
  • Pleurodesis decreases the risk of recurrence, as does thoracotomy or video-assisted thoracoscopy to excise the bullae.
• Iatrogenic pneumothorax: Aspiration is the technique of choice for iatrogenic pneumothoraces because recurrence usually is not a factor. Tube thoracostomy is reserved for very symptomatic patients.
• Most patients with pneumomediastinum should be admitted and observed for signs of serious complications (eg, pneumothorax, tension pneumothorax, mediastinitis). If the pneumomediastinum occurred from the inhalation of cocaine or smoking of marijuana, observation in the ED for progression may be indicated.

sources;
http://emedicine.medscape.com/article/360796-overview
http://emedicine.medscape.com/article/827551-overview

THE ART OF WAR

I'm very much intrigued in the whole phoenomenom in war. It is not to say that I agree to the action. But, it is interesting to note how a person is ' motivated' so to speak, or can be engineered to the extent as to risk his own life as to be involved in a war.

Being in a war, essentially means that you are willing to sacrifice everything that you have, including your own life

What we are willing to sacrifice for a belief is daunting..
but to what extent?
for what reason?
is it enough to justify the loss of your own people?economy?risk the civilization that others before you have built?

One of the greatest war ever was of course the World War II in which history has changed forever.

Hitler ultimately wanted to establish a New Order of absolute Nazi German hegemony in Europe. To achieve this, he pursued a foreign policy with the declared goal of seizing Lebensraum "living space" for the Aryan people; directing the resources of the state towards this goal.

AT WHAT EXPENSES ?

Casualties and war crimes

Main articles: World War II casualties and War crimes during World War II

Estimates for the total casualties of the war vary, but most suggest that some 60 million people died in the war, including about 20 million soldiers and 40 million civilians.

Many civilians died because of disease, starvation, massacres, bombing and deliberate genocide. The Soviet Union lost around 27 million people during the war, almost half of all World War II deaths.^[253] Of the total deaths in World War II, approximately 85 percent were on the Allied side (mostly Soviet and Chinese) and 15 percent on the Axis side.

The effects of World War II had far-reaching implications for the international community. Many millions of lives had been lost as a result of the war. Germany was divided into four quadrants, which were controlled by the Allied Powers — the United States, Great Britain, France, and the Soviet Union. The war can be identified to varying degrees as the catalyst for many continental, national and local phenomena, such as the redrawing of European borders, the birth of the United Kingdom's welfare state, the communist takeover of China and Eastern Europe, the creation of Israel, and the 4 divisions of Germany and Korea and later of Vietnam. In addition, many organizations have roots in the Second World War; for example, the United Nations, the World Bank, the WTO, and the IMF. Technologies, such as nuclear fission, the computer and the jet engine, also appeared during this period.

A multipolar world was replaced by a bipolar one dominated by the two most powerful victors, the United States and Soviet Union, which became known as the superpowers

What we see today in our world, in which so oftenly we take for granted, is the result from those who toil before us. So many things have shaped and defined our world today, but we do not realize its importance and many of us, including myself, only take in stride..

CEO of the Decade

Fortune Magazine Steve Jobs: CEO of the decade

The decade of Steve

How Apple's imperious, brilliant CEO transformed American business.

By Adam Lashinsky, editor at large

Last Updated: November 5, 2009: 8:13 AM ET

Steve Jobs, CEO of Apple

Steve Jobs: CEO of the decade

He revived Apple and remade entire industries, defying the worst economic conditions since the Great Depression -- and his own serious health problems.

(Fortune magazine) -- How's this for a gripping corporate story line: Youthful founder gets booted from his company in the 1980s, returns in the 1990s, and in the following decade survives two brushes with death, one securities-law scandal, an also-ran product lineup, and his own often unpleasant demeanor to become the dominant personality in four distinct industries, a billionaire many times over, and CEO of the most valuable company in Silicon Valley.

Sound too far-fetched to be true? Perhaps. Yet it happens to be the real-life story of Steve Jobs and his outsize impact on everything he touches.

The past decade in business belongs to Jobs. What makes that simple statement even more remarkable is that barely a year ago it seemed likely that any review of his accomplishments would be valedictory. But by deeds and accounts, Jobs is back.

It's as if his signature "one more thing" line now applies to him as well. After a six-month leave of absence in the early part of this year, during which he received a liver transplant, he is once again commanding a 34,000-strong corporate army that is as powerful, awe-inspiring, creative, secretive, bullying, arrogant -- and yes, profitable -- as at any time since he and his chum Steve Wozniak founded Apple (AAPL, Fortune 500) in 1976.

Superlatives have attached themselves to Jobs since he was a young man. Now that he's 54, merely listing his achievements is sufficient explanation of why he's Fortune's CEO of the Decade (though the superlatives continue). In the past 10 years alone he has radically and lucratively reordered three markets -- music, movies, and mobile telephones -- and his impact on his original industry, computing, has only grown.

Remaking any one business is a career-defining achievement; four is unheard-of. Think about that for a moment. Henry Ford altered the course of the nascent auto industry. PanAm's Juan Trippe invented the global airline. Conrad Hilton internationalized American hospitality.

In all instances, and many more like them, these entrepreneurs turned captains of industry defined a single market that had previously not been dominated by anyone. The industries that Jobs has turned topsy-turvy already existed when he focused on them.

He is the rare businessman with legitimate worldwide celebrity. (His quirks and predilections are such common knowledge that they were knowingly parodied on an episode of "The Simpsons.") He pals around with U2's Bono.

Consumers who have never picked up an annual report or even a business magazine gush about his design taste, his elegant retail stores, and his outside-the-box approach to advertising. ("Think different," indeed.)

It's often noted that he's a showman, a born salesman, a magician who creates a famed reality-distortion field, a tyrannical perfectionist. It's totally accurate, of course, and the descriptions contribute to his legend.

Yet for all his hanging out with copywriters and industrial designers and musicians -- and despite his anticorporate attire -- make no mistake: Jobs is all about business. He may not pay attention to customer research, but he works slavishly to make products customers will buy.

He's a visionary, but he's grounded in reality too, closely monitoring Apple's various operational and market metrics. He isn't motivated by money, says friend Larry Ellison, CEO of Oracle (ORCL, Fortune 500). Rather, Jobs is understandably driven by a visceral ardor for Apple, his first love (to which he returned after being spurned -- proof that you can go home again) and the vehicle through which he can be both an arbiter of cool and a force for changing the world.

The financial results have been nothing short of astounding -- for Apple and for Jobs. The company was worth about $5 billion in 2000, just before Jobs unleashed Apple's groundbreaking "digital lifestyle" strategy, understood at the time by few critics. Today, at about $170 billion, Apple is slightly more valuable than Google (GOOG, Fortune 500).

Its market share in personal computers was plummeting back then, and the cash drain was so severe that bankruptcy was a possibility. Now Apple has $34 billion in cash and marketable securities, surpassing the total market cap of rival Dell (DELL, Fortune 500). Macintoshes make up 9% of the PC market in the U.S. today, but that share is increasingly beside the point.

With 275 retail stores in nine countries, a 73% share of the U.S. MP3 player market, and the undisputed leadership position in innovation when it comes to mobile phones, Apple and its CEO are no one's idea of underdogs anymore.

In 2006 Disney (DIS, Fortune 500) paid $7.5 billion to acquire Pixar, the computer animation film studio Jobs had nurtured and controlled. Jobs, in turn, became a Disney director and the blue-chip company's largest shareholder. His net worth, solely based on his stakes in Apple and Disney, is about $5 billion. Other executives have had stellar decades but none can compare with Steve's.

With Jobs back at the helm of his company, plenty of challenges lie ahead. Will the Goliath role suit him nearly as well as playing David clearly has? How will he respond to the competition he has awakened, particularly in smartphones, even as the personal computer fades in relative importance? Has he fashioned an organization that can succeed him? Can he possibly be as dominant in the decade to come as the one that is ending?

The "decade" of Steve actually began in 1997, when he returned to Apple after having been ousted a dozen years earlier. That was a year of triage, of a humbling investment from Microsoft (MSFT, Fortune 500), of paring Apple's product line to a bare minimum of four computers.