Sunday, May 29, 2016

Special and differentiating investigations in Anemia

Here, we would try to summarize all the investigations useful to differentiate various types of anemias--

1. Microcytic hypochromic anemias
-S. Ferritin, Total Iron Binding capacity, Transferrin saturation help in distinguishing IDA, AOCD, Beta thal trait.
HbA2 levels between 3.5-8% are diagnostic of beta thal trait.

2. Macrocytic anemias
S. VitB12 and S.Folic acid assays to differentiate megaloblastic from non megaloblastic macrocytic anemias.
PBS f/s/o megaloblastic anemia - macovalocytes, hypersegmented neutrophils, pancytopenia +/-

3. Warm Antibody against P antigen and cold antibodies (I antigen) to detect AIHA and also to differentiate AIHA from HS.

4. G6PD Assays- suspected G6PD deficiency anemias

Friday, May 27, 2016

Redistribution of drug

I knew what is is Distribution of drug but I think somewhere along my medical school I might have missed reading about REdistribution of drug. Here's what it is:

Biochemistry – How to study?


We see many requests coming to our study groups, asking for few tips to study Biochemistry. Today I thought we should talk about it for the sake of our 1st year Medicowesomites!! Yay!
Ok, Biochemistry, as the name itself implies is about Chemistry in Biological systems. So what do we most encounter in Biochemistry and how to tackle them?

Thursday, May 26, 2016

Ulcerative Colitis, Crohn's disease and rectal involvement

Greetings everyone!

Here's a short post on how to remember that rectum is involved in Ulcerative Colitis (And spared in Crohn's disease.)

Wednesday, May 25, 2016

ICE syndrome mnemonic

Hello!
A short post of mnemonics on one of the coolest syndrome of the eyes.....

Thalassemia mnemonic

Hello!

I was reading thalassemia today and I thought of sharing few facts and this trick for learning the beta chain variants of hemoglobin (Hb) in Thalassemia.

Facts about thalassemia:

Zollinger Ellison syndrome mnemonic

Hello! Here's a short concept for the day!

Normally, secretin decreases gasrtin and gastric acid production,

In Zollinger Ellison syndrome, however, secretin increases gastrin production.

Tuesday, May 24, 2016

Non caseating granulomas mnemonic

Hello!

The mnemonic for non caseating granulomas is RBCS

Bernard Soulier syndrome mnemonic

This mnemonic would not help you to remember all the aspects of the syndrome but two quite important points would be on the tip of tongue for sure.

Remember the dog - St. Bernard's

Age of completion of ossification mnemonic

Hello!

For those who forget the age at which ossification centres close, this post is for you!

Monday, May 23, 2016

Bartters, Gitelmans and Liddles syndrome mnemonic

Hello!

Bartters, Gitelmans and Liddles syndrome present with chloride resistant (high urinary chloride) hypokalemic metabolic alkalosis.

What differentiates them:
Bartters: Hypercalciuric (Furosemide like! Loops lose calcium, remember?)
Gitelman: Hypocalciuric (Thiazides don't!) and Hypomagnesemia. Presents with cramping and spasms.
Liddles: Presents with hypertension, metabolic alkalosis and hypokalemia (Aldosterone excess like!)

Here's a mnemonic for it!

"FaceBook GoT ALL HYPER about a Little syndrome"

FB - Bartter's is like Furosemide
GoT - Gitelman Thiazide
Alhyper little - Liddles is like HyperALdosteronemia

These syndromes are rare, so it’s important to rule out more common causes (Like diuretics)

That's all!

Here's an aphorism by Sir William Osler: “Care more for the individual patient than for the special features of his disease.” :)

-IkaN

Bile acid sequestrants mnemonic

Hello! The bile acid binding resins are:
Cholestyramine
Colestipol
Colesevelam

I'll talk about Cholestyramine in this post!

Iron deficiency anemia

   IRON DEFICIENCY ANEMIA

-The commonest nutritional anemia in India

-Causes:
Decreased Intake
Lack of absorption (eg. Celiac disease)
Increased loss ( in the form of blood loss through any system)

- More common in women d/t menstrual bleed, increased requirement in pregnancy and lactation.

 CLINICAL PRESENTATION
Increased fatiguability
Pica
May present as a triad with dysphagia and esophageal web in Plummer Vinson syndrome
Glossitis

INV:
Low Hb
Low Rbc count
Low MCV, MCH And MCHC
Low S. Ferritin
Raised TIBC
Reduced Transferrin saturation
Microcytic hypochromic picture on Peripheral blood smear; Pencil cells may be seen

Friday, May 20, 2016

Heyde's syndrome mnemonic

Greetings! Short post for the day about Heyde's syndrome!

The mnemonic is: Heydes' hidden bleeding heart.

Pathophysiology of achalasia mnemonic

Hello!

This post is about the pathophysiology of achalasia!

In achalasia, there is loss of NO and VIP releasing inhibitory neurons. Thus, the loss of the inhibitory innervation in achalasia results in the manometric consequence of failure of LES relaxation as well as loss of esophageal peristalsis.

Classification of enzymes mnemonic

Hello!

This mnemonic on classification of enzymes was submitted by Mohd. Ayub Ali.

The mnemonic is, "On The Himalayas, Lyf (life) Is Lightened."

Thursday, May 19, 2016

Intermediates in Gluconeogenesis mnemonic

Hi guys!
So today I wanted to talk to you about Gluconeogenesis.

The first thing is that gluconeogenesis takes place in the mitochondria.
Now when anyone says, "mitochondria", I (and probably all of us) immediately jump to, "mitochondria is the powerhouse of the cell".

Wednesday, May 18, 2016

Why does Digoxin toxicity result in increased automaticity?

Hey everyone!

Digitalis and other cardiac glycosides are known to cause an AV nodal delay.

Then why does too much Digoxin result in some arrhythmias that are due to increased automaticity? Brady arrhythmias are explainable. But why tachy arrhythmias?

Atrial fibrillation in WPW syndrome

Random fact that I learnt today!

If a patient with WPW syndrome develops symptomatic atrial fibrillation, what is the drug of choice?

Answer is procainamide.

Stable patients suspected of having WPW with atrial fibrillation should not receive agents that predominantly block atrioventricular conduction, but they may be treated with procainamide or ibutilide.

Why?
Because if you block the AV node using beta blockers, calcium channel blockers or digoxin, you will favour conduction to the accessory pathway. This will worsen the arrhythmia.

That's why, in stable patients, chemical cardioversion is preferred.

If instability is present, electrical cardioversion is required.

That's all!
-IkaN

Related post: Supraventricular tachycardia mnemonic

Tuesday, May 17, 2016

Organisms covered by Ampicillin mnemonic

So here it is...

Ampicillin HELPS to clear Enterococci!

Haemophilus influenzae
E. Coli
Listeria monocytogenes
Proteus
Salmonella

Ps: Gram-negative organisms have 'porin' channels in their outer lipid membrane through which the Beta-lactam antibiotics enter the cell. Also the lipopolysaccharide layer that contains endotoxins! (Gram-positive organisms do not have such things in their cell wall)
The only exception is Listeria monocytogenes that has little amounts of such endotoxins, inspite of being Gram-positive bacteria!

That's all!

-JasKunwar Singh

Interesting facts about testing 9th, 10th and 11th Cranial nerves

Hey guys!
So here's my first blog! Hope you like it!

Did you know that when 11th cranial nerve is involved on one side, you check for turning of head to opposite side and shoulder shrugging on the same side?

But when involved bilaterally, the patient can't turn their head.

So to test bilateral sternocleidomastoids, you ask the patient to sit up from sleeping position. He'll have head lag!

Here's another interesting fact:
Gag reflex is involved in 9th or 10th cranial nerve nerve palsy... This specifically localises lesion at medulla because both nerves originate there.

That's all!
Thanks ☺

-Rippie

Viral hepatitis - A histologic clue to the causative virus

Viral hepatitis is predominantly caused by hepatotropic viruses, although others like EBV, CMV are also implicated in the causation. Though serological markers serve as a gold standard for diagnosis, the following histologic clues help a pathologist to suspect the causative virus.

HAV - The portal tracts show a large amount of plasma cell infiltrates.

HBV - Presence of Ground Glass cytoplasm

HCV- Lymphoid aggregates in the portal tracts with macrovesicular steatosis of hepatocytes (most marked with Type 3)
Steatosis in zone 1 is mainly due to HCV while steatosis in zone 3 is mainly due to metabolic causes or alcohol.
EBV - Beads on a string pattern of sinusoidal infiltrates of Atypical lymphocytes.

CMV- Formation of microabscesses with intracytoplasmic and intranuclear inclusions.

Herpes virus- Nonzonal punched out necrosis with nuclear ground glass (Cowdry A) inclusions.

Thus, a good pathological suspicion would add to the confirmatory serological reports.

Monday, May 16, 2016

How to write for Medicowesome (And instructions for new authors)

Hello!

You can write for Medicowesome and share your awesomeness with everyone around the world! It goes on the "Submissions" page. If you want me to share your notes / knowledge / mnemonics on Medicowesome, email them to me (medicowesome@gmail.com) and I'll post it for you!

If you wanna be an independent author at Medicowesome, here's what you need to do:

Email me your id at medicowesome@gmail.com asking that you want to write for Medicowesome. I'll say yaay! Of course, yes! :D (You could also send a few sample blog posts and a fancy CV. jk.)

Make a blogger account (blogger.com) using your Gmail account.

Send me your email address. I will send you an author invitation, you must accept it within 24 hours.

Caffeine in Migraine!

Does Caffeine play a role in therapy of migraine? Or does it cause migraine?

Asking a doctor, he said yes caffeine heals pain in migraine attack. OK yea fine. But it can cause an attack too!! This is what I found something Amazing!

Migraine is a disorder characterised by acute pulsating headache, usually restricted to one side of head. Pulsatile dilatation of cranial blood vessels is the immediate cause of pain.

But we know headache is usually caused by vasoconstriction of cranial vessels and not vasodilation!
Actually, excess vasoconstriction or vasodilation, both cause less blood to reach brain parenchyma. This makes brain tissue cry for its necessary nutrients from blood!

In migraine there's excessive vasodilation of the vessels. So is the cause of acute pain. Caffeine constricts cranial blood vessels ( all other systemic vessels are dilated ). It is a CNS stimulant. (That's why we have more coffee at night while studying). :p

Now here comes the point. 1-2 cups of coffee (100-200mg) heal the pain by vasoconstriction. More than this will tend to decrease blood flow and so less supply to brain tissue.
That's why some people, who are in a habit of taking excess coffee or soft drinks, are more prone to headaches!

》 Caffeine is one of the constituents of medicines specific for treating migraine.

MIGRIL: Ergotamine 2mg, Caffeine 100mg, cyclizine 50mg tab.

VASOGRAIN: Ergotamine 1mg,  Caffeine 100mg, Paracetamol 250mg, Prochlorperazine 2.5mg tab.

CAFERGOT: Ergotamine 1mg tab. + Caffeine 100mg.

Other medicaments-
Crocin Pain Relief: Paracetamol 650mg + Caffeine 50mg tab.
Micropyrin: Aspirin 350mg tab. + Caffeine 20mg

PS: Remember, the moment you feel migraine symptoms, have coffee. It is the best and most effective way to heal pain, without significant side effects.

That's all
Thanks :)

Sunday, May 15, 2016

Bromocriptine in Type-2 Diabetes Mellitus

Type-2 Diabetes Mellitus is a chronic metabolic disorder characterised by Hyperglycaemia, Insulin-resistanthe state, increased lipolysis, and high risk of cardiovascular disease! We all know that. And much more to it..
But how can Bromocriptine be used to control blood glucose levels in diabetics??

Increased sympathetic activity in diabetics leads to breakdown of fats and high levels of free fatty acids in blood, which makes them obese! Insulin resistance in turn activates endogenous glucose production cycles which  results in glucose intolerance and high risk of cardiovascular diseases, hepatic failure, kidney problems and other systemic abnormalities!

Bromocriptine-
• An ergot derivative
• Acts as a potent agonist of dopamine D2 receptors.

• Intracerebral injection of 0.8mg Bromocriptine mesylate- quick release formulation, in Insulin-resistant state, is given after first meal in morning within 2-hours of awakening.

• It acts in the Supra-Chiasmatic and Ventro-medial nuclei of hypothalamus and regulates circadian rhythm of Insulin sensitive-resistant cycles and controls Dopaminergic-Serotonergic neurotransmitter activity.

• Simply saying, Bromocriptine reverses circadian rhythm from insulin-resistant state back to insulin-sensitive state, thus decreasing blood glucose levels back to normal.

• It reduces blood glucose levels, but does not bring back to normal. That's why it is prescribed as an add-on drug with insulin or sulfonylureas. This makes an additive effect in the anti-diabetic therapy!


That's all!
Thanks :)

Hypertrophy- is it just all about size?

Hypertrophy is a form of cellular adaptation mainly seen in the nondividing tissues of the body. It simply means increase in the individual cell size. But, is this all about hypertrophy?

Carrier types mnemonic

Someone asked me to post a mnemonic for carrier types.. So I made one.

Just remember 2-3 examples from each category.

Healthy:
Polio
Salmonella
Meningitis
Mnemonic: PSM

Convalescent:
Cholera
Diphtheria
Dysentry
Mnemonic: CD

Incubatory:
Influenza
Measles
Mumps
Polio
Hepatitis B
Diphtheria
Mnemonic: IM PHD, also notice most of them are from the immunization schedule.

Chronic:
Malaria
Gonorrhoea

That's all!
- IkaN

Gastric pathologies and blood group association mnenonic

Okay, this is a very simple mnemonic and I'm sure many people are already using it. Here it goes anyway. The blood groups associated with CA stomach and ulcer can get confusing so,
1. An ulcer is round, so it is more 
    common in people with group 'O'

2. CA contains an 'A' so carcinoma
     stomach is more common in
     people with group 'A'. 

That's it :-p


Saturday, May 14, 2016

Secretomotor pathway to submandibular gland mnemonic

This was asked on the study group - Any mnemonic for secretomotor pathway to submandibular gland?

Superior salivatory nucleus (pons)-nervus intermedius - facial nerve -geniculate ganglion - chorda tympani branch - joins with lingual nerve -submandibular ganglion -submandibular gland

So I made a mnemonic (:

"SSNIF GCT LinGG"

SS - Superior Salivatory nucleus
NI - Nervus Intermedius
F - Facial nerve
G - Geniculate ganglion
CT - Chorda Tympani
Lin - Lingual nerve
G - submandibular Ganglion
G - submandibular Gland

That's all!

-IkaN

Thursday, May 12, 2016

Step 2 CS: Domestic violence

Hey everyone!

I talk about approach to a patient with domestic violence in the video. I also stress on how to counsel.



These are some points from the PowerPoint Slide.

Tuesday, May 10, 2016

Diagnosis of Infective Endocarditis ( Duke's Criteria )

Hello Everyone!

Today, I read about a case of Infective Endocarditis, and it came up with something interesting! A definite way to diagnose a typical case of IE is by Modified Duke's Criteria -

》MAJOR CRITERIA :
           
           1. Positive blood cultures
                         ○ Typical organisms in Two blood cultures
                         ○ Persistent positive blood cultures taken >12 hours apart
                         ○ Three or more positive cultures taken over more than 1 hour
         
           2. Endocardial involvement
                         ○ Positive echocardiographic findings of vegetations
                         ○ New valvular regurgitation

》MINOR CRITERIA :
( Priya Found Emban In the BalCony. )
         
         1. Predisposing factors (any cardiac abnormality, hypertension, valvular defect, congenital heart disease, i.v. drug abuse)
          2. Fever >38°C
          3. Embolic phenomenon (Embolus formation in Lungs, Brain, Spleen)
          4. Immunological phenomenon (Vasculitis, Glomerular Nephritis)
          5. Blood Cultures positive - organisms grown but not fulfilling major criteria.
         
For definitive IE, the simple rule is
2-0
1-3
0-5

☆ 2 major and No minor criteria (2-0)
☆ 1 major and 3 minor criteria (1-3)
☆ No major and 5 minor criteria (0-5)

That's all!
Thanks :)

Wednesday, May 4, 2016

Mechanism of action of Everolimus in breast cancer

Hello!

Did you guys know that everolimus, an immunosuppressant, is used for cancers like renal cell carcinoma, pancreatic neuroendocrine tumors, etc?

The mechanism of action is really cool, especially in ER (Estrogen receptor) +ve, HER2 -ve breast cancers.

Sometimes ER +ve tumors develop resistance to endocrine treatment such as aromatase inhibitors.

The mechanism of endocrine resistance is mainly driven by aberrant signaling along the phosphoinositide 3-kinase (PI3K) - Akt - mammalian target of rapamycin (mTOR) signaling pathway. mTOR is a Ser/Thr protein kinase that constitutes a central downstream part of this intracellular signaling pathway. Its activation enhances cell growth, proliferation and metabolism, and promotes angiogenesis. The inhibition of the mTOR pathway by targeted therapies, such as everolimus or temsirolimus, can therefore block tumor growth and induce apoptosis.

Isn't that awesome?

-IkaN

ACE Inhibitors in Diabetic Nephropathy

Whats the role of ACE inhibitors in diabetic nephropathy?
I was asked this question in viva..

》ACE Inhibitors retard the progression of Diabetic Nephropathy.
Here is the mechanism-

Renin-Angiotensin system (RAS) gets activated in Diabetes (both type 1 and 2). So there is increased production of Angiotensin and its products, which leads to various vascular and metabolic changes.
Angiotensin-II induces several fibrogenic chemokines, viz.
Monocyte Chemo attractant Protein-1 (MCP-1) and Transforming Growth Factor- beta (TGF-B)
AT-II activates transcription factors
Nuclear factor-KB and thus synthesis of MCP-1 in renal cells. MCP-1 has a role in monocyte immigration which transmigrates through vascular endothelium and gets differentiated to macrophages. This leads to increased Extracellular Matrix production and Tubulo Interstitial Fibrosis.

Slow acting drugs like Lisinopril, Enalapril, Ramipril are employed for 12 months therapy in Diabetic Nephropathy. Assessment of proteinuria, creatinine clearance, uMCP-1 is done before and after this period.
A decrease in protein content in urine, increase in creatinine clearance, and a massive decrease in urinary MCP-1 levels are seen.

Angiotensin Receptor Blockers also retard the renal damage in type 1 and type 2 diabetes.

That's all!
Thanks :)

- JasKunwar Singh

ACE Inhibitor (Captopril) Adverse effects mnemonic

Let's memorize from the name itself-
CAPTOPRIL :
C Cough
A Angioedema/ Agranulocytosis
P Proteinuria/ Potassium excess
T Taste changes ( Dysguesia )
O Orthostatic Hypotension
P Pregnancy/ Pancreatitis/ Pressure drop
R Renal failure and Renal Artery stenosis (contraindicated) / Rash
I Indomethacin inhibition
L Leukopenia/ Liver toxicity.
Hope now you won't forget it. ;)
Thanks!
- JasKunwar Singh

Tuesday, May 3, 2016

Of reservation, proving yourself and deserving things

"Hello IkaN,

First of all I'd like to tell you how amazing your blog is and how glad I am to have found it.

I am in first year at a government medical college. But I don't deserve to be there. I have reservation (Yes, THAT hated word). I am also well aware that I probably took this seat from someone who scored more than me. The feeling of being less first hit me in the first month of college, when I saw a lot of people speaking out against reservation. 

I wanted to be a doctor. But not like this. The self loathing got so much so that I considered dropping out but I couldn't ask my parents to pay the bond just because I got exactly what I wanted just not in the way I wanted. Nobody in college is as such discriminating towards me but I know they feel a bit differently if they knew how I got here. 

It hinders my studies. I don't feel the same amount of interest in becoming a doctor as I did before. My parents want me to study well, even get a post graduate degree but I can't bear the thought of living all my life in the shadow of reservation.  

I don't want to sound ungrateful for the opportunity I have been given. Being a doctor is a prestige few people get and I know I'm lucky to have got it. I just wish it would have been differently. Which is why I wanted to apply for USMLE.. At least there, things would be fair. If I got something I would know it was because I deserved it. But then I wonder if I couldn't even get an undergraduate seat by myself how would I manage a post graduate one especially one in America ?

I'm not poor but neither am I rich. I don't know how much the exam fees and the books required to study for the exam cost but I'm pretty sure it is not cheap. And if after giving the exam I fail, what would I do?

I really hope you reply but I would understand if you can't because of time constraints or because you don't want to. Thank you for your time either ways."

- Sent through email. 

Aromatase inhibitors and ER positive breast cancer

Happy Monday everyone!

Why are aromatase inhibitors effective in post menopausal women who have breast cancer and why not in women who are premenopausal?

I was asked this question during rounds.

Sturge- Weber syndrome

Hello

Talking about this rare syndrome, I read about in ophthalmology lecture (class of secondary glaucomas) today... So let's start with it-
- It is also known as Encephalo Trigeminal  Angiomatosis (ETA)
• Rare congenital Neurological and skin disorder (phakomatoses)
• Caused by Somatic Acivating Mutation in GNAQ gene.

Port -wine stains (nervus flammeus) - 
            ○ Usually seen on Forehead and Upper Eyelid of one side of face; present since birth.
            ○ Light Pink to Deep Purple
            ○ Caused by Overabundance of capillaries  around Ophthalmic branch of Trigeminal nerve.

• Associated with
          ○ Secondary Glaucoma (in 50% patients)
          Buphthalmos (enlarged eyeball due to increased intraocular tension)
          ○ Leukocoria (white pupillary reflex)
          Neurologic manifestations- seizures, convulsions (on side of body opposite to birth mark), mental retardation, calcification of tissue and loss of nerve cells in cerebral cortex.
          Ipsilateral Leptomeningeal Angioma (on same side of birth mark; calcification of underlying brain and atrophy of affected region)
Malformed blood vessels in the piamater overlying the brain on same side of head as the birthmark.

Radiological appearance shows Tram-Track Appearance on CT, bilaterally.

Treatment strategies include Laser surgery, Hemispherectomy
 - Latanoprost, a Prostaglandin analogue, is suitable drug for decreasing intra ocular pressure. (1 drop daily in evening)

That's all
- Jaskunwar Singh

Monday, May 2, 2016

An Eye to Cyanide - Part 2

Hello awesome people :)

So, talking about differentials for the cyanide case.. (see previous post Here)
What all u can guess could be the case in such patient if not cyanide..?? Anyone? Think before you read it further..

Here it is...
It could be Carbon Monoxide poisoning. Reason? OK so you remember the patient had shown Cherry Red color of skin when she was brought to the emergency. Carbon monoxide also causes such discoloration of skin as well as blood. This is due to formation of carboxyhemoglobin, which causes decrease in oxygen carrying capacity of blood. So less supply of oxygen and essential nutrients to brain as well as other vitals of the patient, leading to neurological, cardiac as well as other systemic problems!!

An Eye to Cyanide

Hello awesomites!

Hope your weekend is going well :D

I just read about a case of cyanide poisoning and learnt some important points related to it. So here it is -

"A 27 year old comatose woman was brought to emergency by paramedics, and a strong odor of bitter almonds is present. Her past medical history is significant for malignant hypertension. For the past few months, she was given injections of sodium nitroprusside for the treatment, according to her accompanying relatives. She is a housewife and has been under stress regarding family problems. Also she had consumed few almonds a day ago."

Sunday, May 1, 2016

Do it for the better, to achieve your Best!!!

Thinking of starting something new? That's great! Don't wait, just start it. Open the first page. C'mon you can do it. Haha.. don't worry. I know it's difficult, but trust me once you start it, you will enjoy it. Yes you will.

Remember one thing always.. Consume your time in doing something productive. Keep yourself busy in some task, create new ideas, think about something and do it. Dream a lot. Yes you really should.

Do it for the betterment of society. Do it for yourself. To achieve the best of yourself. Trust me, the day when u do that, you will feel really happy. Because you did what you wanted to. That you loved. You lived!!!

Thanks! :)
-Jaskunwar Singh.

Step 2 CS: Challenging questions

Here are some of my sample closures for challenging questions.

All my closures are generic with little word play. Whatever the SP says, I would say it back to them saying I understand it. So your sympathy - empathy is done.

See how all three closures are almost the same - 

"Will I need surgery?"
I understand that you are concerned about the possibility of having a surgery. Yes, you might require a surgery. But I assure you that we will be there to support you, throughout the treatment, regardless of the diagnosis. Does that sound okay to you?

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