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Bowel Obstruction Small bowel obstruction Large bowel obstruction Clinical Symptoms * the four cardinal symptoms of bowel obstruction are: - vomiting - colicky abdominal pain - constipation - abdominal distension Less distension, vomiting occurs earlier, pain is higher in the abdomen More distension, vomiting occurs later and feculent, pain is lower in the abdomen Radiologic features Small bowel features: Valvulae conniventes – folds that cross the lumen completely Normal features of small bowel: - No more than 3 mm wall thickness - Generally no more than 3 air fluid levels - No more than 3 cm diameter Large bowel features: Haustrations: incomplete crossing of folds across the lumen 3,6,9 rule Maximal normal diameter in small bowel 3 cm Maximal normal diameter in large bowel 6 cm Maximal normal diameter in cecum 9 cm In colorectal Carcinoma Left sided tumors: generally presented with altered bowel habit, blood or mucus PR, mass PR Right sided tumors: generally presented

3 hours of chest pain. Is it STEMI or is it normal (or early repolarization)? This looks quite normal, with only moderate ST elevation, upward concavity, good R-wave amplitude, no ST depression or T-wave inversion. But one characteristic makes it unlikely to be normal: the computerized QTc is 455 milliseconds. In a study of early repolarization (ER) (n=167) near completion, only 2 of 167 (2%) cases of ER had a QTc > 455. The mean QTc was 394, compared to 420 for MI (n=125) from LAD occlusion. Conversely, only 4% of LAD occlusion, vs. 40% of ER, had a QTc < 380 ms. These clues were not appreciated by the clinicians. 70 minutes later, they repeated the ECG, which is shown here: Note that now there are tiny Q-waves in V2-V4 , making this unequivocally diagnostic of acute STEMI. These subtle Q-waves were not appreciated, but the clinicians were astute and ordered a stat echocardiogram, which confirmed anterior wall motion abnormality. The patient was taken to the cath lab and had

Monoarthritis As A Presenting Feature in Acute Rheumatic Fever This case report had been presented as a free paper in the 3rd National Scientific Meeting in Emergency Medicine in Kota Kinabalu, Sabah 23rd - 25th April 2009. MONOARTHRITIS AS A PRESENTING FEATURE IN ACUTE RHEUMATIC FEVER: A CASE PRESENTATION Hamizah K, Chew K S Emergency Medicine Department, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia Introduction Acute rheumatic fever (ARF) and its chronic sequela, rheumatic heart disease (RHD) are major causes of mortality and morbidity in many Asian countries including Malaysia (1). This is especially so among the low-income families, regardless of ethnicity (2). In a 10-year study done in University Hospital Kuala Lumpur from January 1981 to December 1990, it was found that ARF contributed to 21.2 per 100,000 pediatric admissions per year (2). In this report, we highlighted the lessons we learned that

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Pakistan has been keeping too many eggs in one basket for decades. The only personality who initiated a break from this practice was Zulfikar Ali Bhutto (ZAB), who laid the foundation of a diversified diplomatic portfolio because of his strategic vision. He maintained good relations with the West and the US, but sowed the seeds of diversification by establishing a special bond with the Middle East on the one hand, and the former Soviet Union and the Peoples Republic of China on the other. Political governments after ZAB have tried to follow the framework laid down by him to varying degrees. The major loss since then has been the deterioration of relations with the former Soviet Union, due to the Soviet occupation of Afghanistan and a decade long war of attrition with devastating repercussions, not just for the former Soviet Union and Afghanistan, but also for Pakistan. Next door, India managed better than Pakistan. During the cold war, not only did it maintain great relations with the