Thursday, September 20, 2018

Question: Rhinoscleroma


Which of the following feature(s) of rhinoscleroma is/are true except:-
1) Atrophy of nasal mucosa
2) Caused by fungus
3) Treatment by antifungal drug
4) Caused by bacteria
5) Causative organism may be cultured from biopsy material

Answer in 24 hours!

So correct options are option 2 and option 3.

Rhinoscleroma is bacterial chronic granulomatous infection caused by Klebsiella rhinoscleromatis or Frisch bacillus.

Mode of transmission
Not unknown

Starts in the nose and extend upto naso-pharynx, larynx, trachea and bronchi.

Clinical features:

1) Atrophic stage:
Foul-smelling prurulent nasal discharge and crusting.

2) Granulomatous stage:
"Woody nose" feel is seen in lower part of nose and upper lip. Nodules are painless and non-ulcerative.

3) Cicatrical stage:
Distortion of upper lip, adhesion in the nose, nasopharynx and stenosis of subglottis.

 Presence of Mikulciz cells and Russell bodies 

1) Mikulicz cells: Macrophages containing central nuclues and vacuolated cytoplasm along with bacilli.

2) Russell bodies: Homogeneous eosinophilic inclusion bodies found in plasma cells.

Streptomycin and tetracycline given for 4-6 weeks and repeated.

Question: Rhinosporidiosis.

In rhinosporidiosis, the following is true:-
1) Fungal granuloma
2) Grayish mass
3) Surgery is the treatment
4) Radiotherapy is treatment
Answer in 24 hours!

Correct option is 3 - Surgery is the treatment.

Let's know more about rhinosporidiosis.
It is a chronic granulomatous disease caused by "Rhinosporidium seeberi" affecting both humans and animals. Earlier it was considered to be fungal in origin but now it is considered to be Aquatic protozoa.

Life cycle: It occurs in three stages.

1) Trophic stage: In this stage, the individual cell is called as trophocyte.
It has following features
-One chitinous wall
-Clear cytoplasm
-Nucleus along with nucleolus
Now trophocyte starts dividing and froms a colony. This colony is packed inside a sac called as "Sporangium". The trophocyte inside is called as "Endospores"

2) Sporangium stage:

Sporangium, unlike earlier stage is lined by two membranes
-Outer Chitinous
-Inner Cellulose layer

3) Endospore release:

The endospores present inside exerts pressure on the sporangium and this leads to rupture of the sporangium. Released endospores acts as trophocyte further.
Mode of transmission:
Water contaminated by diseased animals.

Clinical features:

Most common sites involved: Nose and nasopharynx.
Other sites like lips, palate etc can also get affected.
In nose it is present as - leafy, polypoidal mass, pink to purple in color.
Can extent upto soft palate.
Bleeds easily on touching. So, we can also see blood tinged discharge.

Diagnosis: Biopsy 


Complete excision with diathermy knife and cauterization of its base.

That's all
-Demotional bloke

Tuesday, September 18, 2018

Modified Allen test

Hello Awesomites! :D

Hope you guys are doing great. Assuming that you might have heard about ABG analysis I am discussing about Allen's test.

What is Allen's test?
Allen's test is done to assess the circulation of the hand (i.e. Radial and ulnar artery).

The examiner apply the pressure to the wrist occluding the ulnar and the radial arteries. The patient then make the fist and open and close it several times. The hand should appear blanched by this time because the arteries has been occluded temporarily.

Now remove the pressure from ulnar artery. If the return of color occurs quickly, then test is considered to show a normal circulation.
If it take 5-15sec in flushing of palm then test is positive and ulnar artery is adequate to supply the arch, we can proceed with sample collection in this patient. If it takes >15 sec then choose alternative site. Alternative sites for access are brachial or femoral arteries, but these have several disadvantages.

Repeat the same procedure for radial artery.

Importance in:-
1. Volar wrist ganglion around the radial artery.
2. before doing ABG analysis.
Study more about it. 

-Upasana Y. 

Sunday, September 16, 2018

Question: Caloric test


Q) Caloric test was done on right side with cold water and eyes were moved to opposite side. Which of the following correspond to interpretation of nystagmus in this test?
1) Eyes moves slowly to right
2) Eyes moves slowly to left
3) ‎Eyes moves rapidly to left
4) ‎Eyes moves rapidly to right
Answer in 24 hours with explanation of Caloric test.

So no doubt this question is super easy and only slight confusion that would be created in such types of question are options. Here it's about eye movement being slow or rapid. I personally don't think that even that would be an issue. Its obviously going to be rapid movements. 

Correct option is 3- Eyes moves rapidly to left.

The very famous mnemonic for Caloric test, as you all know is COWS.

C=Cold water 
O=Opposite side
W=Warm water
S=Same side

When we put Cold water in ear, eyes moves to opposite side of that ear. For example If I put cold water in left ear then eyes will move to right side.

When we put Warm water in ear, eyes moves to same side of the ear. For example If I put warm water in right ear then eyes will to right side only.

So, here is the mechanism for the test
 (Always consider Lateral semicircular canal!)

For proceeding further you need to remember a small diagram.

As you can see cold water inhibits the potassium channels / hair follicles and warm water stimulates the potassium channels/ hair follicles.
( Stimulus from lower hair to higher hair-Activates 
Stimulus from higher hair to lower hair-Inhibits) 

In above question, we used right ear and cold water. As we know that cold water will inhibit the potassium channel so ultimately we can say that right ear is overactive or stimulated. This leads to stimulation of the right vestibular nucleus. Now, fibers from right vestibular nucleus crosses and stimulate left 6th nerve nucleus and this leads to stimulation of the left LR muscle. Leading to abduction of the left eye.

Now, fibers from left 6th nerve nucleus also crosses with the help of medial longitudinal fibers and stimulate right 3rd nerve nucleus which stimulates right MR. This leads to adduction of the right eyeball. 

So we have now,
Left eyeball abduction+ Right eyeball adduction = Both eyes looking towards left.

Mechanism sounds confusing so here is a chart.

Demotional bloke

Thursday, September 13, 2018

Question: Chicken pox


Q) True about chicken pox are all except:
1) Caused by HSV-3
2) SAR is 90%
3) Superficial rash
4) Single stage of rash

Answer in 12 hours 
 Answer is 4) Single stage of rash

So, this post will help you remember manifestation of Chickenpox rash. You can also differentiate between Chickenpox and Smallpox rash using same

So for Chicken pox remember this mnemonic:-

DCP SPAReS Iron man ( Always Marvel fan!)

D= Dew drops appearance
CP= Centripetal appearance
S= Superficial and Uniocular 
A= Axilla and flexor surface affected
R=Rapid evolution
S=Spares palms and soles 
I=Inflammation around vesicles present

Since we have rapid evolution in chicken pox, scabs are formed after 4-7 days itself.

Smallpox rash appears exactly in an opposite manner of chickenpox rash.

Smallpox rash manifests as follow:-

Centrifugal appearence
Deep and Multilocular appearence
Axilla is spared and extensor compartment affected 
Slow evolution
Palms and soles are affected
No inflammation around vesicles
Since we have slow evolution in chicken pox, scabs are formed after 10-14 days itself.

-Demotional bloke

Tuesday, September 11, 2018

Question: Squint manifestations


A patient presented with his head tilted towards right. On examination, he was having Left hypertropia which is increased on looking towards right or medially. The muscle which is mostly likely paralyzed is?
1) Left superior oblique
2) ‎Left inferior oblique
3) ‎Right superior oblique
4) ‎Right inferior oblique
Answer in 24 hours

Answer is 1) Left superior oblique

So, you can see above question is based on Park 3 steps method. I will try to simplify it as much as possible. Let us try to find out what essential information we get from above from above question. So I find three things.

-Left hypertropia.
-Increases on looking towards right.
-Head tilted towards right  (For compensating diplopia)

To proceed further, I want you to take care of two things .
1) Draw clinical eye movement diagram for squint not anatomical diagram
2) In this technique we go with parameters which increases diplopia for patients.

So, hold your horses and let us get started.

Step 1: Left hypertropia= Right hypotropia

So, basically you have to solve now question for two eyes instead of one. This is the same reason option 3 and option 4 could be right as well. So, when you draw clinical diagram for same you have to highlight muscles which are paralyzed leading to above criteria.

So, left hypertropia is caused by paralysis of the inferior muscles - Superior oblique and Inferior rectus.
In right hypotropia, superior muscles are paralyzed -Inferior oblique and Superior rectus. 
So our diagram will be as follow. We need to concentrate on four muscles only

Step 2: Now let us go to second clue. Diplopia increases on looking towards right. So, out of our four selected muscles let us see which muscles moves eyeball towards right.
 In right eye, it is Superior rectus.
In left eye, it is Superior oblique.

Our diagram will be as follow and your muscles will be narrowed down to two. Each from one eye.

Step 3: So this is final step. The End game. (Reminds me Taylor swift!)

  We have one last finding and that is patient's head is tilted towards right. Remember that this is compensatory method of patient for avoiding diplopia which actually suggests that patient is experiencing diplopia maximum when head is tilted towards left.

So in our last step we will be using clue as head tilted towards left! (Remember we go to maximum diplopia.)

So, this time hold your pencil in the centre of our clinical diagram and tilt it towards left. Obviously do this for both eyes individually. Simply like this
Now, this will narrow down your two muscles into one. Let us do it for right eye first. We will get muscle IO which is not among of our selected two muscles so discard it. Now go to left eye, do same over here. You will get answer as SO

Hope that makes your job easy as far as squint is considered.
-Demotional bloke

Transcription : A mnemonic to remember the RNA Polymerases

Here's a short mnemonic post for you!

Transcription is the process by which the DNA is converted into an RNA transcript ( Literally - the DNA is transcribed or written out as an RNA sequence).

The key enzyme needed for this process is RNA Polymerase.

In Eukaryotes , there are 3 different RNA Polymerases subtypes depending on which RNA they help code for. 

We know that Ribo Nucleic Acids or RNA can be mRNA - Messenger RNA , tRNA or Transfer RNA , rRNA - Ribsomal RNA or one of the small nuclear RNAs - micro RNA - miRNA / siRNA.

Here's a mnemonic to memorize which RNA Polymerase codes for which of these -

Mnemonic - R MIS T5 (Read as R Mistify)

RNA Polymerase I = rRNA
RNA Polymerase II = mRNA, miRNAs , siRNAs
RNA Polymerase III = tRNA , 5S rRNA

This form of RNA specificity is not found on the Prokaryotes - and they have just one RNA Polymerase that bears it all , for all types of RNA !

This has been a quick summary of transcription and a helpful mnemonic for you!

Hope was helpful.
Stay awesome !
Happy Studying!

~ A.P.Burkholderia

Question: Dengue and eye


Q) In Dengue, all are seen w.r.t eye except:-

1) Cataract
2) Optic neuritis
3) Vitreous hemorrhage
4) Maculopathy

So, you basically cannot solve above problem if you don't know which portion dengue affects in eye.

Dengue affects posterior portion of the eye. So accordingly answer is
Cataract-Option 1

Some basics to cover over here.

Eyeball is divided into two segments or portion.

Anterior segment: Cornea to lens.
Volume - 0.31mL of Aqueous humor.

Posterior segment: Lens to retina.
Volume - 4mL of Vitreous humor.

Anterior segment is divided into two parts:-

Anterior chamber: Cornea to iris.
Volume- 0.25mL of Aqueous humor

Posterior chamber: Iris to lens.
Volume- 0.06mL of Aqueous humor

-Demotional bloke.

Friday, September 7, 2018

Question: Diabetic 3rd nerve palsy

In Diabetic 3rd nerve palsy all are seen except
A) Pupil dilation
B) Outward and downward gaze
C) Ptosis
D) Impaired pupillary reflex

Let us start with the basic.

Mnemonic for extraocular muscles nerve supply
LR6 SO4 Rest3

Lateral rectus is supplied by 6th nerve or abducence nerve and superior oblique by 4th nerve or trochlear nerve and rest all  muscles including LPS are supplied by 3rd muscle or  occulomotor nerve.

In pupillary reflex,
Afferent nerve: Optic nerve
Efferent nerve: Occulomotor nerve.

So in case of 3rd nerve palsy, we will have less or no actions of all EOM except lateral rectus and superior oblique.
So we will have downward gaze (due to superior oblique) and outward gaze (due to lateral rectus) and Ptosis (because LPS is supplied by 3rd nerve! ).
Pupillary reflex is also disturbed so option 4 is also ruled out.

Here is a trick in this question. In DM and HTN, microangiopathy is seen due to which central fibers are affected.
Central part do not contribute to pupillary reflex.
This leads to no pupil dilation. In case of surgical conditions and trauma, peripheral fibers are affected which causes impaired pupillary reflex or pupil dilation.

-Demotional bloke.

Monday, September 3, 2018

Apgar score in preterm infants

Hello Awesomites!

APGAR score-
This score tells you about the well being by evaluating cardiac,respiratory and nervous system of a newborn.

APGAR score of a preterm infants is always low. Because certain criteria in  APGAR are not met by preterm babies.

In preterm babies respiratory efforts,muscle tone,colour is variable.So your score will come less.

It is something that interests me.
May be in future new components will be added to use this score in evaluation of preterm infants.

-Upasana Y. :)

Thursday, August 30, 2018

Timeline in Psychiatry

Hello Medicowesomites! While studying psychiatry, you must have realised diagnosis of any condition requires two parameters:

1. Clinical presentation
2. Time

This post enlists how to make a psychiatric diagnosis in time.

Author's note: This blogpost is intended for an audience having a foundation knowledge of the subject.
It does not explain any concept or review any literature, instead serves as a quick cheat sheet for timeline required to make a psychiatric diagnosis.

[Kindly click on the image to view the table clearly]

Happy studying!

-- Ashish Singh

Wednesday, August 29, 2018

Hering's law of equal innervation

Now to study this law, we need to know clinical function diagram of eye muscles.

So according to this diagram,
Right SR is responsible for elevating right eye to right side.
Similarly, Left IO is responsible for elevating left eye to right side.

Since both the muscles are performing same action on two different eyes using two different muscles they are called yoke muscles of each other.
This is Hering's law of equal innervation.

Now, here is a trick to solve problem without looking into the diagram:

Right gets converted to Left.
S (Superior) gets converted to I (Inferior)
O (Oblique) gets converted to R (Rectus)
So the mnemonic for remembering muscle change is
ROSI (You can remember it as ROSS from friends!)
R gets converted to O.
S gets converted to I.
-Demotional bloke

Movements of eye muscles.

This post is actually the primary post for squint studies. Just basic post so we can explore squint in easy and simplified manner.
So there are seprate diagrams for anatomical and clinical functions. In this post we will go for former part.
Anatomical functions diagram.

Note: Don't use this diagram when you are studying squint. This diagram is used only for movements of eye muscles.
So every muscle has 3 actions except medial and lateral rectus.
Actions are divided into three types Primary, secondary and tertiary.
We know the basic or primary action of superior and inferior rectus is to elevate and depress the eyeball respectively.
According to the diagram given you also know that superior rectus can intort and adduct. Similarly, inferior rectus can extort and adduct the muscles.

How to remember this?
1) Through diagram.
2) Trick: Recti muscles are adductors

Now comes to SO(Superior oblique) and IO(Inferior oblique). Now this is also basic which we fail to notice often. These muscles are coming to tarsus part of eye obliquely. So, primary action is intortion and extortion respectively. Now go to diagram and you will notice that IO actually corresponds to SR hence it performs elevation and SO corresponds to IR so it performs depression.
Also, both the muscles are "Abductors"

How to remember this?
1) Diagram off course!
2) Trick: Superior muscles are Intorters and inferior muscles are extorters.
To keep the things in apple pie order I have made this chart. Hope it helps.
-Demotional bloke

Tuesday, August 7, 2018

Saturday, August 4, 2018

Stop Antibiotic Abuse!

Hello Everyone,

It's been really long since the last post! Well it's been hectic all the way to and through residency.

I was recently researching on the topic of antibiotics while I stumbled upon this excellent piece of information cum approach by Dr.Strong on starting Anbiotics.

Well everyone should ask themselves these 12 questions before starting any antibiotic for one's patient and trust me you'll end up choosing the most appropriate one.
This is how we don't contribute to the Antibuse- "Antibiotic Abuse"( my personal neologism)

So now coming back to the questions, ask yourself these questions before you start any antibiotics,

1) What condition is being treated?
2) What are the commonly known bacterial species causing that condition?
3) Which antibiotic group is typically active against those?
4) What are the local resistance patterns for the chose antibiotic?
5)Will there be adequate organ penetration?
6) What is the preferred route of administration?
7)Any specific contraindication of the antibiotic to look out for?
8) Any required dose adjustment for coexisting renal or hepatic diseases?
9) Any specific drug interactions to be considered?
10) When on therapy anything that needs periodic monitoring?
11) How can the therapy be narrowed once bacterial sensitivities are available?
12) What will be the anticipated duration of the therapy?

Let's take a step towards stopping the rampant Antibuse.

That's all for now.

Let's learn Together!
-Medha Vyas.

Thursday, August 2, 2018

Ring-enhancing lesion in an immunocompromised host

Hello everyone,

If it is a ring-enhancing lesion in an immunocompromised host, the most commonly seen etiologies are Cerebral toxoplasmosis (50%) and Primary central nervous system (CNS) lymphoma (30%).

But let's talk about the uncommon etiologies -

ECG quiz: ST elevation in aVR and ST depression in other leads

Quiz question: ST elevation in aVR and ST depression in other leads is suggestive of?

Sunday, July 29, 2018

Trapezius and pericarditis.

Suppose a patient of 40 years of age male comes to you with complaints of  chest pain which is often heavy, squeezing and crushing.
You make up the diagnosis of MI based upon the symptoms in your mind. Proceeding for proper history of case you ask patient if the pain is radiating type.
Patient explains you that the pain is radiating and he is eventually experiencing pain in to the back of this some muscle. You find out that he is pointing towards the "Trapezius muscle" .
Now, this should raise an alarm in your mind. You should stop thinking about MI.
Both NSTEMI and STEMI shows pain which is radiating in nature. Pain involves the central portion of the chest, sometimes epigastrium and occasionally it radiates to the arms. Less common involves back, neck, lower jaw. Pain can radiate as high as occipital area but never below umbilicus.
but it never radiates to trapezius.
Depicting exact lines of Harrison textbook of medicine.
"Radiation of discomfort to the trapezius is not seen in patients with STEMI and is  useful in correct diagnosis of pericarditis"
Now, why pain radiates to trapezius?
Pericarditis, as name suggests inflames the pericardial sac of the heart. This causes irritation of the vagus nerve supplying heart. Vagus nerve is affected because it is closely related to pericardial sac. Vagus nerve acts as the afferent nerve fibers. These fibers reaches nucleus tractus solitarius in the medulla oblongata. From there it comes downwards reaches cervical plexus C2, C3 and C4. From there, the nerve fibers formed supplies lower part of trapezius.
Trapezius nerve supply:
Upper part is supplied by the spinal accessory nerve.
Lower part is supplied by the nerves from C3 and C4 only.
Hence pain radiates to trapezius in pericarditis.
-Vipul and Ojas.

Update from IkaN: It's wrong to say that the pain of MI "never" radiates to the trapezius (which is in the back) because occasionally, pain of MI can radiate to the back.

Also, pain radiating to the back should alarm you to a more serious diagnosis - aortic dissection. 

Wednesday, July 18, 2018

Can you find Asterixis in Non-Hepatic disorders?

Hello Awesomites! :D

This doubt came to my mind when I saw a case of COPD with asterixis.
 I used to think of asterixis with respect to hepatic disorders only.
 So let see is it so?

"Asterixis"is a non-specific sign. It is also known as flapping tremor.

It is a non-specific neurologic finding which may accompany organic delirium in a variety of metabolic or toxic disorders which interfere with cerebral metabolism.

It can be found in the cases with:-

1. Chronic pulmonary insufficiency

2. Uremia

3. Drug induced electrolyte imbalance

4. Arterial hypoxemia

5. Other reasons of electrolyte imbalance.

 Stay Awesome!

Upasana Y. :)

Friday, July 13, 2018

Authors' diary: Ponder

We were discussing a case today and learnt how important it is to take a second to think before we do something when dealing with patients.

Before you get a CT scan on the patient in the ER, stop and think - does the patient really need a CT scan? Will it get me the answers I'm looking for? Or will I need additional testing? Think of the harms of radiation exposure. Unless you don't want to rule out a hemorrhage that requires immediate intervention, do not order it STAT.

Tuesday, July 3, 2018

Dentinoenamel Junction

  • DEJ appears as a scalloped line.
  • The convexities of scallop are directed towards the dentine 
  • The surface of dentine appears pitted
  • DEJ provides strength to the union between enamel and dentin
Clinical Significance:
  • Prevents shearing of enamel when functioning.
  • Scalloping of the junction is seen more in the occlusal portion where masticatory stresses are high.
- Written by Anisha Valli
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