This patient presented with acute cholecystitis, as confirmed at imaging. His pain resolved over a few days, but mildly elevated bilirubin levels persisted. Image obtained during ERCP shows smooth narrowing of the bile duct (arrow) at the site of insertion of the cystic duct (Mirizzi syndrome). Note the small calculus in the cystic duct. Courtesy of Dr. Ali Nawaz Khan.
Classification:
Type I - No fistula present
Type IA - Presence of the cystic duct
Type IB - Obliteration of the cystic duct
Types II-IV - Fistula present
Type II - Defect smaller than 33% of the CBD diameter
Type III - Defect 33-66% of the CBD diameter
Type IV - Defect larger than 66% of the CBD diameter
Indications:
1. Fractures with severe soft-tissue damage in which the wound can be left open for inspection and dressing.
2. Comminuted & Unstable fractures.
3. Fractures of pelvis.
4. Fractures associated with injuries of nerve & blood vessel.
5. Infected fractures.(eg. osteomyelitis)
6. Non-united fractures where the dead fragments can be excised and combine with elongation in normal shaft.
Indication:
1. Fracturees which cannot be reduced.
2. Unstable fractures & prone to redisplacement after reduction.
3. Pathological fractures in bone diseases.
4. Multiple fractures
5. Fractures which poorly unite. eg. femoral neck.
6. Fractures in patient with nursing difficulties.
5 types of
Physis Growth Plate Injuries.
Children are mostly affected.
Type 1 & 2 are uncommon for growth disturbances.
While
Type 3 may damage reproductive zone,
Type 4 causing aysmmetrical growth
Type 5 result from compression to the growth plate result
in growth cessation.
CVP Monitoring usually has 20% of complication in total.
Haemorrhage - due to puncture.
Internal Jugular Cannulation - air embolism
Pneumothorax ; Hemothorax - punctured the pleural space.
Phlebitis - thrombus formation on tip or in vein.
Rx: continuous infusion of unfrac. heparin may reduce the risk.
Bacterial Colonisation - cellulitis & sepsis.
Central venous pressure is considered a direct measurement of the blood pressure in the right atrium and vena cava. It is acquired by threading a central venous catheter (subclavian double lumen central line shown) into any of several large veins. It is threaded so that the tip of the catheter rests in the lower third of the superior vena cava. The pressure monitoring assembly is attached to the distal port of a multilumen central vein catheter.
Check List :
Adhere to institutional Policy and Procedure.
Obtain history and assess the patient.
Explain the procedure to the patient, include:
local anesthetic - 1-2% lidocaine 5-10ml SC.
trendelenberg positioning
draping
limit movement after insertion
need to maintain sterile field
post proceduce CXR
Obtain a sterile, flushed and pressurized transducer assembly
Obtain the catheter size, style and length ordered.
The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status.
Normal CVP is 2-6 mm Hg / 2-8cmH20
CVP is elevated by :
overhydration which increases venous return
heart failure or PA stenosis which limit venous outflow and lead to venous congestion
positive pressure breathing, straining,
CVP decreases with:
hypovolemic shock from hemorrhage, fluid shift, dehydration
negative pressure breathing which occurs when the patient demonstrates retractions or mechanical negative pressure which is sometimes used for high spinal cord injuries. 
Find the mean of the A wave.
read the highest point of the A wave and take the lowest point of the A wave
add the high point to the low point
divide the sum by 2
the result is the mean CVP
The A wave starts just after the P wave ends and represents the atrial contraction. The high point of the A wave is the atrial pressure at maximum contraction. During the A wave the atrial pressure is greater than the ventricular diastolic pressure. At that point, the atrium is contracted, the tricuspid is open. Therefore, the high point of the A wave closely parallels the right ventricular end diastolic pressure. Remember, when the tricuspid valve is open and the right ventricle is full, the ventricle, atrium and vena cavae are all connected. Therefore, that point is the CVP.
2. Find the Z-point.
Find the Z-point which occurs mid to end QRS
Read the Z-point
The Z-point coincides with the middle to end of the QRS wave. It occurs just before closure of the tricuspid valve. Therefore, it is a good indicator of right ventricular end diastolic pressure. The Z-point is useful when A waves are not visible, as in atrial fibrillation. (The c-wave occurs at closure of the tricuspid valve. The crest of the c-wave is the atrial pressure increase caused by the tricuspid valve bulging back into the atrium.)
Doe :P
3rd June, my birthday
& why Bother?
Exam day, excellent mark,
Excessive alcohol intake
& why Bother?
Extra desire for KFC.
one buckets of chicken is not enough!
& who bothers?
Why msg me today?
While you never like reply my sms before
Why talk to me today?
While you never like to talk in the morning before you go to work before
Why greet me today?
While you even forgotten my birthday when we are together last year?
& Why Bother? ..
22nd May,
The day to forget bout Surgery.
Chua, preparing to go for some meconium aspiration.
22nd May,
The Day that Dodo Forgotten he is living in Russia, Again.
Doe, after meconium aspirated to the brain.
22nd May, The Day that,
I intend to forget my SMS was always been IGNORED.
Father, calling Mother asking her to look out of the window, written
thank you for delivering a baby for me.
22nd May,
The Day that Dodo found some good & bad news
at the same time in his life.
I wish to give each of this flower to my family & to all my friends.
Today is 9th May.
Choppers are flying Low.
Mig 29 right behind.
The Jeep came...
Next... The Medium Tank.
Later... The Heavy Tank came.
and The Mammoth Tank...
Missiles....
More Missiles..
Bigger ONE....
More BIG ONE!...
Last....
Can`t Even Squeeze into my screen...
Hey! Police get off my way..
This is really The MOTHER of ALL BOMBS !
耳鼻喉的cycle玩完廖..
又回到妇产科的时候了。
每星期二四
要七早八早起身，
到那边
脚开开，等老师来。
熟语说
"脚开开，赚大钱"
你想一个月赚多少钱？
那一个科或 哪一行业赚最多钱？
或者是你的对赚钱有看法？
来来来， 敢敢comment 叻。
到底是什么东西造成猪头皮?
有听过腮腺这个东西吗?
猪头皮就是--腮腺炎。
腮腺就是在你耳朵前面
臉頰两旁的主要唾腺。
腮腺炎，Mumps
是一种叫做 mumps virus 的东西
infect 你的腮腺。
呐，
以上我指的那个就是 Parotid gland 了。
Enjoyingboredom.com
Don`t look at me like that.
I`m innocent.
God Bless You.
Picture taken when i was on
my way back home from class.
a Crow eating a Pigeon.
Haven`t seen any
Crow around in
Moscow yet.
I guess
they must be hunting
for Dodo Bird.
RUnnn!!...
A saturday out with friends to a Korean restaurant.
Yap哥 who protect us.
Not even a russian dare to walk come near us.
Belgian Hoegaarden beer.
Chill out.
Highly recommended by Me.
and after long hour of waiting,
finally, something hot & spicy came.
I should had ordered Bibimbap!
and luckily,
something nice was on the table.
and they makan & makan.
and the bill came.
10080rubles which is Rm 1000.
and I don`t understand Korean.
just like Korean doesn`t understand my English email.
But I hope to receive a reply
from the Korean again.
Last,
Goodnight in Korean
Anyong-hi jumushipshiyo !
Livedo reticularis
bluish-purple streaks in a net-like pattern
Antiphospholipids Syndrome (APLS)
in SLE patient presented with CLOT
coangulation defect
livedo reticularis
obstetric complication - recurrent miscarriage & IUGR
thrombocytopenia
So we do :
1. ELISA for anticardiolipin & lupus anticoangulant
2. activated Prothrombin Time DRVVT.
High titer of IgG Anticardiolipin
suggests high risk for clotting.
小虫也有它用途
它用自己摔下的痛苦
换我幸福。
这是爲你写的歌 充满忐忑
像生命所有转折 要你认可
只等你来唱和 我会在你左右
Cause baby I wrote this I wrote this for you
To all my followers,
I reward you with this two songs from khalil.
lastly, this is for you.
I post this
Because
I have nothing to post
Nothing to tell
& Nothing to say
Because
I`m still here doing
What I suppose to do
& Now what?
I wanna travel again.
Last vacation was 12 months ago.
Duke of Wellington
Korean, please reply me.
I`ve got a spainish flag in my room.
That`s why Spain 2 - 0 England.
I wonder why it is snowing heavily on Valentine`s day
It is romantic for the couples;
& colder to the single.
Last,
I love my food,
I love my sleep,
& My Bailey & Love`s.
transit is damn
hard to wait
& when you tired
half dead sick like a cat
"MEOW.."
Kicking..
touched down
in Moscow
& since when it has become
a shopping heaven?
target lock-on to
1.tempting Topman jeans
2.tatty pull&bear jacket
3.& their tawdry short pants
& buy those for the reason
"it is cheap"
"The most basic thing
to play football, is football".
Dodo Montague.
We don`t play with your mouth
get a ball & kick
& don`t talk cock with me.
last,
those who claim that
they don`t like football
don`t come my blog view view view..
如果你要踢球，
又不想流汗的话，
那你不会不要踢。
如果你不想走狮，
更不想得罪别人；
可是你有计划要走狮，
你已经走狮了。
& for You,
如果爱情不是固执的话，
那要怎么爱？
In the Plan
Prague-Budapest-Vienna-Munich-Krakow.
You leave all the shits
behind for me &
you have gone miles away
Byebye 2008
You sux.
