Category Archives: 6thyear medical school

Ecg, ami

There is always confusion around the terms third-degree heart block and AV dissociation. Dr. Chou makes a clear distinction in his book (see Additional Readings section): “The term complete AV block is used when the atrial rate is faster than the ventricular rate, whereas the reverse is true in AV dissociation. In AV block, there is a failure of impulse conduction even though the ventricles are receptive. In AV dissociation, there is an increase in the automaticity of the subsidiary pacemaker, which renders the ventricles functionally refractory to the slower atrial impulses.” These are the definitions we have used in this book.

Look at V1, which is usually the best place to see P waves

Myoglobin levels rise within 1-4 h fr onset of chest pain!!!! The earliest!!

Dont give nitrates in RV INFARCT , SHOCK, AORTIC STENOSIS, HYPOTENSION, CARDIOGENIC SHOCK

In 1st dgree heart block there is ONLY PROLONGATION OF PR BUT IN

2nd degree ( mobitz type 1) there is PROGRESSIVE PROLONGATION OF PR.

MOBITZ TYPE II –> there is constant PR BT OCCASIONALLY, THERE IS WITHOUT A QRS!!!
PLLLLLLLZZZZZZ INGAT SYG OIIIIIII

The triad of right vt infarction( hypotension, jugular venous distension, clear lung fields)

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Its just a little crush

AaaaaaaaaAAAAAAAAAAAAAAAAAAAAA!!!!!!!!

My medic crush just replied my message medic questions regarding cardiology.duhh.

Im so happy!!!

Jejunoileal atresia

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Type I:
intraluminal diaphragm or web may present with windsock anomaly.
NO MESENTERIC DEFECT
NORMAL LENGTH

Type II
Connected by fibrous atretic cord.
NO MESENTERIC DEFECT
NORMAL LENGTH

Type IIIA
NO FIBROUS CORD
VSHAPED MESENTERIC DEFECT
SHORTENED LENGTH

Type IIIB
bowel wraps around a single perfusing vessel( christmas tree app)
LARGE MESENTERIC DEFECT
SIGNIFICANTLY SHORTENED

Type IV
MULTIPLE DEFECTS

Whereas associated anomalies are found in 30-40% of neonates with duodenal atresias, associated anomalies are found in only 10% of neonates with jejunoileal atresias

There is maternal polyhydramnios

RX
RESECTION AND ANASTOMOSIS
TAPERING ENTEROPLASTy(for shortenede bowel)

From emedicine:

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Intestinal atresia type IIIa. A clamp is applied on the distal bowel, and sodium chloride solution is instilled through a purse-string suture to dilate the intestine and diminish the size discrepancy between the two loops to facilitate the anastomosis. The dotted line marks the area of the resection.

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The proximal dilated pouch is transected in a 90° angle to maximize its vascularity, while the distal intestine is transected obliquely to diminish the size discrepancy between the segments.

Malrotation and volvulus neonatorum

Volvulus always associated with malrotation

Two presentations
Acute:bilious vomiting(metabolic acidosis) The volvulus may compromise blood flow leading to ischemia hence tender rigid abdomen

We fear from massive loss of small intestine if neglected…he may not survive…or the lesser catastrophe is the SHORT GUT SYNDROME

Chr: chr intmt abd pain, constipation.

DOUBLE BUBBLE SIGN

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Normally SMV IS ON THE RIGHT. IF THE REVERSE HAPPENS, SUSPECT MALROTATION.(BY U/S!!!!!)
DILATED STOMACh AND DUODENUM WITH TWISTING OF THE MIDGUT LOOP: applepeel, twisted ribbon, corkscrew

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Do ladds procedure:
Untwist
Divide( ladds band)
appendectomy

Neonatal duodenal obstruction

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SEARCH FOR ASSOCIATED ANOMALIES!

Normal or scaphoid abdomen is obs is proximal!

FIRST OF ALL, RESUSCITATE AND DECOMPRESSION

ITS DANGEROUS!!! WHY??
close proximity to the ampulla of vater & pancreatic blood supply.

Rx: DUODENODUODENOSTOMY AND DUODENOJEJUNOSTOMY. IF THERE IS MALROT- LADDS PROCEDURE
we can also do DIAMON SHAPED ANASTOMOSIS BECAUSE THE DIAMETER OF THE PROXIMAL AND DISTAL PART TO THE OBSTRUCTION IS NOT PROPORTIANATE.

In duodenal web, do DUODENOTOMY. BE CAREFUL OF OTHER DEFECTS AND AMPULLA OF VATER.

?

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About ladds band(excerpt from emedicine)

abnormal cecal peritoneal bands that cross over the duodenum in the right upper quadrant may be found in cases of malrotation. These abnormal cecal attachments are called Ladd bands. In both nonrotation and incomplete rotation, cecal bands may cause obstruction and ischemia before birth, leading to congenital duodenal atresia or stenosis

In many cases, the abnormal Ladd bands cause only partial and intermittent obstruction, which can manifest as intermittent episodes of bilious vomiting and/or feeding intolerance.

I5

Previously healthy baby

Red currant jelly stool is a late sign..dont sit and wait for that to happen

Not so hi mortality rate but we fear of transmural gangrene

Commonest age…age of weaning 4m-10m

If more than 2 y, suspect a secondary cause..the most common 2ry cause is ileocecal lymphoma and meckels

Important signs:
Dance s
Target s
Cobra head s
Air fluid level
Pseudokidney s

25% of abdominal surgical emergencies less than 5, EXCEEDING APPENDICITIS

ANY CHILD W BILIOUS VOMITING, CONSIDER IT A SURGICAL DISEASEUNTIL PROVED OTHERWISE

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IHPS

More common in males

First male

Hypochloraemia, hyponatremia, hypokalemia metabolic alkalosis

U/s! Thickness >4mm, length >16 mm

Dehydration, failure to thrive, HUNGER AFTER FEEDING,OLIVE MASS, PROJECTILE, NON BILIOUS VOMITING, persistent and progresses with time.

IT IS NOT CONGENITAL HENCE IT NEVER PRESENTS before 2weeks of life. It takes time for the circular muscle to undergo HYPERTROPHY AND HYPERPLASIA ( >2wks- 8wks)

DDX OF NON BILIOUS VOMITING: physiological GERD/ proximal to ampulla of vater duodenal obstruction/ errors in feeding/ NON SPECIFIC MARKER OF ILLNESS

TREATMENT: RESUSCITATE FIRST, THIS IS NOT AN EMERGENCY.
DEFINITIVE TREATMENT= RAMSTEDT PYLOROMYOTOMY

Important! Look for target sign.
String sign.

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Tagged

Its been a long time..

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..Since i updated this blog..

I am pretty busy…i jot more notes than searching pics on the net…and even if i do..i feel like my time is constricted…

I have just finished my cardithoracic exam.it was OK. Not up to my expectations though.
I keep on thinking what are other ways for me to improve? Medicine aint easy…how can i excel? I suppose i have done a lot to strive and be a good doctor..but why do i feel like what i did was never enough?? Medicine is like that..it can never be enough..even if you think you know everything…you still wont be able to grasp EVERYTHING. Its hard.o allah plz make it easy for me…i am struggling..
I have to work harder..and smarter. Sometimes i cant imagine whats life like if you keep on skipping classes.

Dont you feel scared? Are you trying to be the ‘just ok’ doctor and not feel guilty about missing the knowledge great professor are about to hand down to you? Dont you? I guess if mediocrity is your aim, you wont even bother to go near the borderline between your comfort zone and the red zone(where you have to sacrifice some things in order to achieve better things)

Seriously i keep on condemning those who skip classes but it truly annoys me. If i have the guts i will say it to their face.SHAME ON YOU!

Ok.back to my story.
The finals are getting nearer.and i am getting more and more insecure.i make mistakes, and alhamdulillah mistakes are here for a reason.IF YOU LEARN FROM THEM.

Starting from now on, i must be more precise, and meticuluous. Doctors need that!
Dont take things for granted and always revise!
You cant remember everything in one night!
I have poor memory.(i am not joking)
That is why i have to do extra work to remember something.

I am just an average student.i was never the top student or anything near that. I repeat … AVERAGE.you know…. Not stupid nor a genius.

Well, sometimes, what annoys me, is that..if i try to voice my opinion or correct a fact stated by so called superstar geniuses… You get ignored..or pushed aside… You are regarded as ‘unreliable’ when the truth is you just want to state the truth.and thats it.

Yes.it stings to feel that way.
I dont know how genius people look down to us average people…but i feel like a poor puppy being looked down at by a bulldog or something.

I just want to do my best…however…sometimes…it does not sound as easy as it is…
I have a problem with discipline.and that sucks.boohoo.but i will try harder from now onwards.

And youre doing the best for the sake of what? If it is for the sake of fame and money…you are on the wrong lane..
I want to do this for the sake of Allah…and again..to do just that is a challenge!

To have an aim is probably one of the most essential things to kick start your journey towards a better you.

So here are some mistakes i have learnt and they are to be corrected by :
1. Do this for the sake of allah
2. You have that power to change if you push yourself hard enough. Igt, Allah tak akan mengubah nasib sesuatu kaum melainkan kaum itu sendiri cuba utk berubah.
3. Dont take the small things for granted. Every little detail is essential. Every tiny weeny detail!
4. To achieve better things, there are some things you need to sacrifice. You sleep, your leisure time…etc.
5. Think like a doctor. Read your books and imagine there is patient in front of you for you to treat.can you manage?
6. Revision is essential for people with poor memory(best example :ME)
7. i may not be a genius. But at least i can work hard to be better.

YOU CAN DO THIS!!!!

Yup

There is a vast difference between the people who ‘just read’ , the people who read and memorize, and the people who read and understand to finally memorize.

Double bubble sign

Due to the exams tomorrow, i bet more than half will diagnose duodenal atresia when he/ she sees the double bubble sign, when in fact, there are numerous cause that can produce the same effect.Its not an exclusive sign, you know?

In general, this sign denotes an obstruction present, whether the cause is external or internal at the duodenum….probably the 2nd or 3rd part.

Causes:
Duodenal atresia/web/stenosis
Annular pancreas
Malrotation with volvulus
Preduodenal portal vein

It is accompanied by relative paucity of the lower GI tract.

An excerpt from here

The double-bubble is often accompanied by a relative paucity of lower GI gas. This is highly suggestive of volvulus or duodenal stenosis and atresia. A double-bubble sign with paucity of lower GI gas combined with clinical signs and symptoms of distress, such as fever, lower abdominal distention, melena, or hemodynamic instability, suggests volvulus and possibly gangrene and should lead directly to laparotomy. In this situation, pneumatosis coli may be observed on plain radiographs and is an ominous sign.

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Train your pretty eyes bayybeh!!!