The hardest thing to learn in life!!

GLASS OF MILK:

One day, a poor boy who was selling goods from door to door to pay his way through school, found he had only one thin dime left, and he was hungry.

He decided he would ask for a meal at the next house. However, he lost his nerve when a lovely young woman opened the door.

Instead of a meal he asked for a drink of water. She thought he looked hungry so brought him a large glass of milk. He drank it so slowly, and then asked, "How much do I owe you?"

"You don't owe me anything," she replied. "Mother has taught us never to accept pay for a kindness."

He said ... "Then I thank you from the bottom of my heart."

As Howard Kelly left that house, he not only felt stronger physically, but his faith in God and man was strong also. He had been ready to give up and quit.

Many year's later that same young woman became critically ill. The local doctors were baffled. They finally sent her to the big city, where they called in specialists to study her rare disease.

Dr. Howard Kelly was called in for the consultation. When he heard the name of the town she came from, a strange light filled his eyes.

Immediately he rose and went down the hall of the hospital to her room.

Dressed in his doctor's gown he went in to see her. He recognized her at once.

He went back to the consultation room determined to do his best to save her life. From that day he gave special attention to her case.

After a long struggle, the battle was won.

Dr. Kelly requested the business office to pass the final bill to him for approval. He looked at it, then wrote something on the edge and the bill was sent t o her room. She feared to open it, for she was sure it would take the rest of her life to pay for it all. Finally she looked, and something caught her attention on the side of the bill. She read these words .. "Paid in full with one glass of milk"

(Signed) Dr. Howard Kelly.

Tears of joy flooded her eyes as her happy heart prayed: "Thank You God, that Your love has spread broad through human hearts and hands."

There's a saying which goes something like this: Bread cast on the waters comes back to you. The good deed you do today may benefit you or someone you love at the least expected time. If you never see the deed again at least you will have made the world a better place - And, after all, isn't that what life is all about?!

INTESTINAL STOMAS

An intestinal stoma is an opening of the intestinal and urinary tract onto the abdominal wall, constructed surgically or appearing inadvertently.

TYPES OF STOMA -colostomy -ileostomy -jejunostomy -urinaty conduit

COLOSTOMY

Colostomy is an artificial opening made in the large bowel to divert faeces and flatus to the exterior, where it can be collected in an external appliance.

TYPES

ACCORDING TO THE ANATOMIC LOCATION

-sigmoid colostomy

-end descending colostomy

-transverse colostomy

-cecostomy

ACCORDING TO FUNCTION

-decompressing colostomy: to provide decompression of large intestin_ -diverting colostomy: to provide diversion of faeces.

DECOMPRESSING COLOSTOMY

INDICATION

Treatment of obstructing cancer of the rectum, or sigmoid colon, ftequently discovered on an emergency basis with no oppurtynity for prepration of intestine.

DISADVANTAGE

Does not necessarily provide complete faecal diversion; carries risks of potentially fatal sepses if there is disruption of intestinal continuity distal to stoma.

TYPES OF DECOMPRESSING STOMAS

-blow hole- decompressing stoma constructed in caecum or transverse colon

-tube type of cecostomy -loop transverse colostomy

DIVERTING COLOSTOMY

Provides complete dviresion of intestinal content

INDICATION

-After removal of rectum blc of cancer ( APR) or rarely blc of inflammatory bowel disise limited to rectum or anus

-when there is breach of distal bowel continuitv.as in:

- traumatic injury; diverticulitis; perforated unresectable Ca; leake(

or threatened anastomosis.

-To allow external radiation of an unresectable rectal Ca subsequentaly to be followed by an attempt at a definitive Ca operation and possibly a take down of the colostomy

destruction of distal rectum or anus as a result of trauma, cronh's disease, hidradenitis, multiple sphincteric injury.

LOOP TRANSVERSE COLOSTOMY

Serves as a diverting stoma for 6 weeks or until the posterior wall recesses far enough below the wall of abdomen that the loop can enter the distal loop

SITE ')

Through the rectus muscle on right or left side of midline

CONSTRUCTION

CLOSURE

-After stoma is mature ie after the colostomy has been established for 2 months

-healing or surgical cure of distal lesion for which the temp. stoma was made.

-perform a contrast examination ie distalloopograrn, to check there is no distal obstruction or continuity problem at the site of previous surgery.

-distal integrity or adequacy of sphincter muscle function must be carefully evaluated befpre closure of stoma: formal manometric and EMG studies. Or giving the patient a 500 inl enema and asking the patient to hold it until he can comfortably walk to the toilet and expel the enema.

END COLOSOMY

CONSTRUCTION: ?

COMPLICATIONS OF COLOSTOMIES

-Prolapse

-retraction

-necrosis of distal end

-stenosis of the orifice

.;colostomy hernia

-bleeding ( usually from the granulation around the margin of colostomy) -colostomy diarrhea.

ILEOSTOMY

An ileostomy is an opening constructed b/w the small intestine and abdominal wall usually by using distal ileum but sometimes more proximal small intestine.

TYPES

-End ileostomy

-Loop ileostomy

- Loop End ileostomy

-Continent ileostomy: Kock pouch

-Urinary conduit

END ILEOSTOMY

Constructed in patient who require removal of the entire colon and usually the rectum, for infl. Bowel disease or ulcerative colitis .

LOOP ILEOSTOMY

To have complete diversion of the intestinal flow while the pouches are allowed to heel and adept after restorative proctocolectomy for ulcerative colitis and

familial polyposis: .

LOOP END COLOSTOMY

Constructed in rare circumstances in which- it is unsafe to resect the mesentry of distal ileum

-thickened mesentry or a very obese pt with multiple surgical procedures that altered IIiesentry, tension is created on the mesentry as the ileum is broughr to the abdominal wall for construction of ileostomy

CONTINENT ILEOSTOMY ( KOCK POUCH )­

Alternative to conventional ileostomy for selected pt with U C or familial polyposis

ADVANTAGES

-need not wear an appliance

-continent in blw intubations

-no stomal complication

-better quality of life

DISADVANT AGES

-not all pt are continent

-can be difficulty in intubation

-surgery prolonged and carries a risk of complication

URINARY CONDUIT

Constructed of a segment of intestine with well maintained vascularity so that it can be connected to the urinary tract to allow egress of urine through the abdominal wall via a stoma constructed exactly like an ileostomy.

INDICATION

-After cystectomy for invasive Ca of bladder

-management of severe obstructive uropathy

-congenital abnormalities os spina bifida, meningomyelocele, bladder extrophy, trauma to spinal cord resulting in severe neurogenic bladder

COMPLICATION

-Leeking appliance blc of improper placement or construction of.. . ....

. -Stone formation with crystal formation around the stoma itself ( lack of adequate personal hygine and acidification of urine )

Nepal Medical Council Lisencing Exam(NMCLE):

*Syllabus (Medical)

*Collection of Past NMLE Questions

Tuberculosis Skin Test
(PPD Skin Test)

(Mantoux test: A skin test for tuberculosis, named for the French physician Charles Mantoux (1877-1947)

Mom's Tough Pregnancy,

Preemie Coming Home In Time For Mother's Day After Mom's Tough Pregnancy, Emergency C Section!!

The Management of Postoperative Pain

*The Management of Postoperative Pain Dr Ed Charlton,
Consultant in Anaesthesia and Pain Management, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK.


*Nursing Care After Surgical Experiences (NCase)

NO-SCALPEL VASECTOMY

NO-SCALPEL VASECTOMY

No-scalpel vasectomy was developed and first performed in China in 1974 by Dr. Li Shunqiang of the Chongqing Family Planning Scientific Research Institute, located in Sichuan Province.

No-scalpel vasectomy results in fewer hematomas and infections than does conventional incisional vasectomy Men undergoing no-scalpel vasectomy reported less pain during the procedure and early in the follow-up period than did men having an incisional vasectomy,

and also reported earlier resumption of sexual activity after surgery (Skriver, Skovsgaard, & Miskowiak, 1997; Sokal et al., 1999).

Instruments and Supplies

The no-scalpel technique requires two instruments specially designed by Dr. Li Shunqiang.

1. The extracutaneous ringed forceps is a type of clamp used to fix the vas deferens . For the sake of clarity, the term ringed clamp will be used throughout this manual. Throughout the operation, the surgeon uses the ringed tip of this instrument to encircle and to grasp the vas, without injuring the skin.

The dissecting forceps is similar to a curved mosquito hemostat, except that the tips are

sharply pointed. It is used to puncture the scrotal skin, to spread the tissues, to dissect the sheath, and to deliver the vas deferens.

Instruments

• Ringed clamp

• Dissecting forceps

• Straight scissors

Supplies

• Adhesive tape and gauze for positioning the penis away from the surgical field (optional)

• Scissors for clipping any scrotal hair that would interfere with the procedure

• Soap and water or antiseptic agents for the surgical scrub (see page 13)

• Alcohol rinse (recommended if plain soap is used for the surgical scrub)

• Sterile gloves

• Nonirritating antiseptic solution for cleaning the operative area (see page 12)

• Sterile drapes

• 10-cc syringe with a 11.2-inch, 25- or 27-gauge needle (U.S. system)

• 1% or 2% lidocaine without epinephrinea

• Supplies for vasal occlusion according to the surgeon’s preference (examples: a cautery unit; chromic catgut or nonabsorbable silk or cotton for ligation) • Sterile gauze

• Adhesive tape or Band-Aid for dressing the wound

• Scrotal support for the man to wear after the procedure (optional)

Before any vasectomy is performed, the client must receive appropriate information and counseling and give his informed consent.

The following are conditions requiring a delay or special precautions:*

• Local infection—including scrotal skin infection, active sexually transmitted infection (STI),

balanitis, epididymitis, or orchitis

• Previous scrotal injury

• Systemic infection or gastroenteritis

• Large varicocele

• Large hydrocele

• Filariasis; elephantiasis

• Local pathological condition (e.g., intrascrotal mass, cryptorchidism, or inguinal hernia)

• Bleeding disorders

• Diabetes

• AIDS (HIV-positive status without AIDS is not a concern.)

* More about Dr. Li Shunqiang *

CONGENITAL CYSTIC KIDNEY

(SYNONYM: CONGENITAL CYSTIC KIDNEY)

Introduction: Inherited as autosomal dominant disease

Bilateral

With standard imaging technique, can be detected at 2^nd or 3^rd decades

Manifested clinically in the third decades

Other associations-

Polycystic diseases of liver (18%), pancreas, lungs

Berry aneurysm in the circle of Willis (Robins)

Pathology: Gross-Kidneys become enormously enlarged bilaterally

The cyst giving the appearance of a collection of bubbles below the renal capsule.

Histological-The renal parenchyma is riddled with cysts of varying size containing clear fluid, thick brown material or sometimes hemorrhagic fluid. (Robins)

Clinical features: Incidence more in women than men.

1. Irregular upper quadrant abdominal mass

2. Loin pain

3. Hematuria

4. Infection

5. Hypertension

6. Uraemia

The patients are “4H club members” with (1777, Swartz)

Headache

Hypertension

Hematuria

Heredity

Irregular upper quadrant abdominal mass: Bilateral knobby enlargement, dull renal angle, resonant band in front.

Loin pain: It is due to weight of the organ dragging upon its pedicle or by stretching of the renal capsule by the cyst. Hemorrhage into a cyst may cause more severe pain, as may the passage of a calculus from the diseased kidney.

Hematuria: Rupture of a cyst into the renal pelvis may cause hematuria which is typically moderate, lasts for a few days & recur at intervals.

Infection: Pyelonephritis is common in patients with congenital cystic kidney, presumely because of urinary stasis.

Hypertension: Present in up to 75 % of patients over the age 20 years with polycystic kidney. It is possibly result from a separate genetic factor linked to the gene for congenital cystic kidneys.

Uraemia: Patients pass large volumes of urine of low specific gravity (1.010 or less). Chronic renal failure develops as functioning renal tissue is replaced progressively by cysts.

Patients complain of anorexia, headache and vague abdominal discomfort. Vomiting and drowsiness due to biochemical derangement.

Investigation:

USG

CT scan

FNA

IVU (Excretory urography)

Blood urea

Serum creatinine

Urine shows low sp. Gravity

Treatment:

As kidney failure develops, a low protein diet will help to post-pone the need for renal replacement.

Conservative treatment for infection, anemia and correction of disturbed Ca metabolism.

Surgical treatment: uncap the cyst (Rovsing’s operation) it is rarely indicated, it is thought that this can preserve renal function by relieving pressure on the parenchyma. It reduces the pain. This can also be done just by aspirating the cyst either under USG guidance or laparoscopically.

Once renal failure sets in, then initial hemodialysis followed by bilateral nephrectomy, is done later renal transplantation is planned for.

AUTOSOMAL RECESSIVE (CHILDHOOD)

POLYCYSTIC KIDNEY DISEASE

Distinct age group of presentation (1030, RL Gupta)

Perinatal: The infant is either stillborn or dies within a few weeks of birth.

Neonatal: It presents in the first month and die within one year fron renal failure.

Infantile: It presents at 3-6 months with large kidneys and hepatosplenomegaly. These patients die in childhood with systemic and portal hyper tension and renal failure.

Juvenile: This group presents in childhood and patients die in their teens from hypertension and its complications.

Ethics in our professions

There is and always has been a need for good role models for student doctors as they learn the skills of medical practice. I think that the most effective and workable role model would be a physician mentor. But he himself needs to have qualities and ambitions beyond diagnoses or techniques.

The role model must also be an example of the best in professionalism with not only the understanding of ethics but also the simultaneous practicing of ethical behavior that becomes obvious to all those he or she mentors. '' Teach what you preach''.

This physician model-cum-mentor of ours should demonstrate personal humility. Humility, by oxford english dictionary definition, being the ability to give up some of one's self-importance and assertiveness and show them that there is merit in the practice of medicine to listen to the advice and concerns of others. This means not only listening/considering, even accepting, the advice and concerns of colleagues but also of those from other disciplines and from the patient and finally also from students and residents who look up to the him as a senior and a mentor. It is hard for some doctors to shy away from expressing their self-importance.

Physicians, inspite of wishful thinking, are not always right in what they know, what they say and what they do. If there is no introspection, the other virtues
may give way to misjudgments, error and absence of trust by colleagues and patients.

To conclude, I would tell students: “Physician, Be Humble”...Maurice

Philip James Baley wrote: “Lowliness is the base of every virtue,
And he who goes the lowest builds the safest.”

Mother's love

A mother is as different from anything else that God ever thought of, as can possibly be. She is a distinct and individual creation. When God thought of mother, He must have laughed with satisfaction, and framed it quickly--so rich, so deep, so divine, so full of soul, power, and beauty, was the conception. A mother's love is indeed the golden link that binds youth to age; and he/she is still but a child, however time may have furrowed his/her cheek, or silvered his brow, who can yet recall, with a softened heart, the fond devotion or the gentle chidings of the best friend that God ever gives us.
No language can express the power and beauty and heroism of a mother's love.I always see heaven at the feet of my mother.

olympic fever!!!!!

olympic torch in wuhan!"River City" of pr china.


























View from the main gate of school of medicine.

Personality

Personality is that which is most intimate to me--that by which I must act out my life. It is that by which I belong to man, that by which I am able to reach after God; and He has given to me this pearl of great price. It is an immortal treasure; it is mine, it is His, and no man shall pluck it out of His hand.

SOME FACTS N TRUTH:

• An ignorant doctor is the aide-de-camp of death
• Never go to a doctor whose office plants have died.
• Doctors cut, burn, and torture the sick, and then demand of them an undeserved fee for such services.
• A doctor's reputation is made by the number of eminent men who die under his care
• Nothing is more dangerous than a poor doctor: not even a poor employer or a poor landlord.
• Physicians are the cobblers, rather the botchers, of men's bodies; as the one patches our tattered clothes, so the other solders our diseased flesh.
• The good physician treats the disease; the great physician treats the patient who has the disease.
• He who cures a disease may be the skilfullest, but he that prevents it is the safest physician.
• We do not think it necessary to prove that a quack medicine is poison; let the vender prove it to be sanative.
• Character is very much a matter of health