Sunday, May 19, 2019

History, physiology and medical aspects of fasting

Hello everyone,

My senior resident at JFK Medical Center did a presentation on fasting. I thought of sharing it with you (especially since it is Ramazan/Ramadan).

Friday, May 17, 2019

Hook effect of prolactin in large pituitary adenomas

Hello everyone,

Here's something I learnt today when a case of large pituitary adenoma causing visual field loss was presented today.

But let's talk about my favorite subject first - Immunology!

The intensity of an antigen-antibody interaction depends primarily on the relative proportion of the antigen and the antibody. A relative excess of either will impair adequate immune complex formation. This is called the “high-dose hook effect” or the “prozone phenomenon.”

This is important consideration whe measuring prolactin. Extremely high levels of prolactin can interfere with the assay and produce falsely low readings.

This high-dose hook effect occurs because there is not enough antibody to bind to both ends of all antigenic peptides, in this case, prolactin.

Most prolactin is complexed to a single antibody. Only few remaining prolactin peptides are “sandwiched” and therefore detectable.

This results in a falsely low prolactin value.

Hence, as the antigen concentrations increase, there is a proportional increase in assay titers up to a certain level. Antigen concentrations above this threshold level would “hook” down the assay values resulting in very low measurements.

In order to avoid the high-dose hook effect, the serum prolactin should be estimated in appropriate dilution in all patients with large pituitary tumors.

-IkaN (tired Internal Medicine Resident)

The 'hook effect' on serum prolactin estimation in a patient with macroprolactinoma.

Monday, May 13, 2019

Protein gap

The gamma gap aka paraprotein gap or protein gap is the difference between total serum proteins and albumin measured from a comprehensive metabolic panel.

Albumin accounts for the majority of total serum protein.

Viral infections, plasma cell malignancies, or autoimmune conditions there is an excess of immunoglobulins, raising the total amount of serum protein independent of albumin.

The gamma gap is typically considered to be elevated if it is above 4 g/dL.

In the right clinical context, gamma gap should be worked up with SPEP, UPEP, and a serum free light chain assay.

Random exercise: Calculate the protein gap.
Total protein 8.9 g/dL (normal 6.4-8.3 g/dL)
Albumin is 3.6 g/dL (normal 3.4-4.8 g/dL)

That's all!


Work up of thyroid nodule


Here is the shorter version of this post: Investigating thyroid nodule for Step 2 CK (link:

So - if you find a thyroid nodule on physical examination - what do you do next?

Caudal anaesthesia

Hello Awesomites!

Caudal anesthesia is a type of epidural anesthesia. 

The indications for single shot CA are abdominal,urologic or orthopedic surgical procedures located in the sub-umbilical abdominal, pelvic and genital areas, or the lower limbs, where postoperative pain does not require prolonged strong analgesia. Examples include inguinal or umbilical herniorrhaphy, orchidopexy, hypospadias and club foot surgery.

Anatomical landmarks (Figure)
The sacrum is roughly the shape of an equilateral triangle,with its base identified by feeling the two
posterosuperior iliac processes and a caudal summit corresponding to the sacral hiatus.The sacral hiatus is located at the caudal end of the median crest and is created by failure of the S5 laminae
to fuse (Figure). The hiatus is surrounded by the sacral cornu.

Obtain consent for the procedure either from the patient or, if appropriate, from the parents. After induction of general anaesthesia and airway control, the patient is positioned laterally (or ventrally),
with their hips flexed to 90°. Skin disinfection should be performed carefully, because of the proximity to the anus.
After defining the bony landmarks of the sacral triangle, the two sacral cornuae are identified by moving your fingertips from side to side.The gluteal cleft is not a reliable mark of the midline. The puncture is performed between the two sacral cornuae. The needle is oriented 60° in relation to back plane, 90° to skin surface. The needle bevel is oriented ventrally, or parallel to the fibers of the sacro-coccygeal ligament.
After verifying absence of spontaneous reflux of blood or cerebrospinal fluid (more sensitive than an aspiration test), injection of LA should be possible be without resistance. Inject slowly (over about one minute).

-Upasana Y. :) 

Sunday, May 12, 2019

HbA1c and Estimated Average Glucose

Hello Awesomites!

Sounds new. Wait till the end!

Do You know what is HBA1c?

HbA1c is produced by the condensation of Glucose with N-terminal valine of each beta chain of HbA.

Diagnostic importance
The rate of synthesis of HBA1c is proportional to exposure of RBC to glucose. Concentration of HBA1c is indication of blood glucose concentration.
It reflect mean blood Glucose level over 2-3 months prior to its measurement.If HbA1c is <7% then diabetes is in good control. To get an accurate result the concentration should be monitored for several months.

Estimated average glucose (eAG) :- It is new term in diabetic management.It helps to interpret HbA1c levels into average glucose concentration.
eAG(mg/dl) =(28.7×HbA1c) - 46.7

The A1c doesn’t replace self blood-glucose monitoring. Because the A1c is an average of all your blood sugars, it does not tell you your blood sugar patterns. If someone has certain type of hemoglobin mutations (variation in the hemoglobin structure) (HbA1c is falsely low) , is severely anemic (low red blood cell count), iron deficient( HbA1c is falsely high) or is being treated blood transfusions or medications to increase the production of new red blood cells, the A1c test may not be accurate.

Thank you.
Upasana Y. :)

Monday, May 6, 2019

Diabetic Retinopathy

Here is Upasanas video on Diabetic Retinopathy.

I edited the slides so you can see better :)

Slides are available for download here:

PARTNER 3 trial journal club

Hey everyone!

A few months ago, I did a journal club on the PARTNER 3 trial.

I have been meaning to create an audio file and upload the whole journal club as a video on YouTube but unfortunately, I don't seem to have the time.

This is why, I decided to go ahead and release my slides instead so it helps anyone who is doing a journal club on the same :)

Sunday, May 5, 2019

Oblique muscle mnemonic

It can be hard to remember which oblique does what. Remember this. 'Extortion' as we all know is forcing money out of someone. People from the 'inferior' strata of the society extort money. See where am I  going?!

So! Inferior oblique causes extorsion( 'extortion' is a bit different- c'mon, be a grammar Nazi!)
What remains? Superior oblique. then is responsible for intorsion.

Similar is the case for superior and inferior recti.

Hope I saved you from ophthalm extorting your precious time.


Monday, April 29, 2019

Cardiovascular changes in pregnancy

At term
- Blood volume increases by 50%
- increased uterine blood flow 500-800ml/min
- uterus recieves 10-15% cardiac output

Philosophy of Medicowesome

Internship dairies: Finding a vein

So here's a quick post in support of Internship Diaries. I would like to give you advice on how to do blood draws and insert IV lines.

First of all, learn properly before you try it on another human being. Watch YouTube videos, learn by observing.

Second, the tourniquet is your friend. If you don't have a tourniquet, use a glove instead. It will make the veins more plump.

Third. Feel the vein before you attempt to insert the needle or cannula. FEEL IT.

Be patient and take your time. It's better to spend 30 seconds extra than to poke somebody and spend five minutes more trying to find a vein.

I know that this is phlebotomy and nursing advice and it may not be needed in hospitals where the ancillary staff does it.

But hey, hope this helps! :)

PS: I just realized I've written a longer post before here:



Hello Everyone!

                 Strabismus has been confusing me for long, so I decided to come up with a chart:

You can download the chart at


Chaitanya Inge
Upasana Yadav

Saturday, April 27, 2019

Propofol infusion syndrome

Hello friends!

It is the triad of metabolic acidosis, skeletal myopathy and acute cardiomyopathy.

It is seen in children on prolonged infusion.

It occurs due to failure of metabolism of free fatty acids.



Hi friends!

Propofol is a non-barbiturate intravenous anesthetic agent.
Colour : milky white liquid.
Chemical name : 2,6-diisopropylphenol.
Composition: soyabean oil, glycerol and lecithin.
Metabolism:70% in liver, 30% in lungs and kidneys.

Propofol is associated with quick recovery. So it is the drug of choice for day care surgeries.

Systemic effects:
CVS : It decreases systemic vascular resistance leading to fall in blood pressure causing tachycardia. But it actually causes bradycardia. The reason being blunting of carotid body receptor response (which we have studied in our physiology)
RS : It causes maximum depression of upper airway reflexes. So it is the drug of choice for insertion of laryngeal mask airway.
CNS :  It causes cerebral vasoconstriction leading to fall in intracranial pressure. It is an antiemetic, antipruritic and antioxidant.
It is an anticonvulsant but may cause involuntary movements.

Thanks for reading!

Massive blood transfusion strategy

In patients with massive haemorhage with a loss of more than 40% of blood volume - rapid transfusions are given with colloids, crystalloids and packed RBCs.

This causes coagulopathy by diluting the a clotting factors.

Hence, prophylactic infusion of platelets and fresh frozen plasma is done.

Initially, it was given in a ratio of 1:1:4
One part platelet & ffp transfusion to every 4 bags of blood.

It has been renewed now to 1:1:1 ratio

It has caused significant reduction in mortality 40% versus 60%

Thank you!

40% blood loss translates to grade 4 hemorrhagic shock or grade 1 degree of urgency per the urgency grid for obstetric hemorrhage. I removed the grading in the initial part of the post to avoid confusion as different grades mean different severity of shock based on the scale used.

- sakkan

Internship diaries (Episode 01- The best way to FINISH is to START first!)


                   It’s a busy day, and to top with that you are running late. It’s your first day as a Medical Intern and you are super excited for your future 1 year.

You are entering into this huge sophisticated hospital with the shining silver name plate attached to it “SAN JOSE GENERAL HOSPITAL” and you reach the smiling and pleasant looking receptionist with round glasses on.

“Hello Good morning, I am Kesh, a new medical intern here. Where should I go?”

“One minute please!” She tells you and starts checking something on her computer.

“Hello Dr. Kesh” She looks back at you.

“Omg!” You think. “This is it! People are calling me doctor now! Yoohoo!” you smile widely.

“Please proceed to the Department of Internal Medicine, please look for Dr Wen, your mentor!”
You thank her and follow her guide.


Dr. Wen is a helpful young doctor in his late thirties who happens to be the Chief Resident of Internal Medicine. His orientation on the hospital rules were quite lengthy but was important. His ending was quite remarkable.

“Being a doctor is a dream of many but achieved by few. You are among the lucky few. You are supposed to lead a health care team. which means you should know all the necessary medications and side effects and how it would affect the human being! Your whole team relies on you. There for you need to be responsible and accountable to yourself, your team and your patient.” Dr Wen said. “ You have spent years in Medical school already, and now it's time for the training here and I wish that all of you would take the best chance of that objective by learning to how to be a good healer.” he continued.

“Please proceed to your respective wards now. If you have any problem during your internship, please ask for my help. I will definitely help you!” said he at last.

You check the slip in your hand.

“Ward 3” it says. You slowly walk toward your post.


“Dr. Kesh” You hear your nurse is shouting your name


“Could you please insert an IV line to this new admission?” She asks.

“Here are your gloves, your aseptic instruments and IV catheter. Thanks you so much!”
The nurse leaves you with a full tray and a newly admitted patient who looks worried.

“Can I please insert you an IV line for your vein so that we can hook you up to IVF?” You seek consent!

“Yes sure” Patient gives permission.

You take the pack of Surgical gloves into your hands.

"Now what to do?" you think!

[To be continued...]

Pre lesson questions

1. What are the gloving techniques you know?
2. What are the types of gloves you know?
3. What unit is used to measure the IV cannula size?
4. What are the most common areas of IV cannula insertion?
5. What is a heplock?

Expect the next episode with the answers and the lesson.

You can answer the questions here in the comments, or if you are in our Medicowesome Whatsapp group, you can message me (Jay) or Upasana privately with your name and answer. I will post the names of the first 5, who gave the correct answers with our next post.



  1. Consent - The consent or receiving the willingness of the patient to undergo a medical procedure is a must before you would perform any medical procedure. It could be ranging from a simple needle prick test or to an imaging or an operation.
  2. IVF - Intra Venous Fluid. These are the liquid substances directly delivered into a vein. 


Wednesday, April 24, 2019

Think before you order a test: High resolution CT scan (HRCT)


Let's talk about HRCT today!

HRCT is the use of thin-section CT images (0.625-mm to 1.5-mm slice thickness) with a high spatial frequency reconstruction algorithm, to detect and characterize diseases that affect the pulmonary parenchyma and small airways.

HRCT cuts THIN slices.

Awesome, isn't it? Why not use an HD camera for every photograph?

Because it comes with a price!

Treating Alcohol withdrawal - scheduled vs PRN benzodiazepines


Sometimes it's frustrating to see different physicians use different approaches to management of the same condition or disease. How do you practice in that case?

You look at the evidence, the guidelines and make your own decision based on it.

Then even though if your attending practices something opposite of what the guidelines say, you know what is right and what you will practice in the future :)

Anyway, now that I am done venting - what do guidelines say about scheduled vs as needed benzodiazepines for alcohol withdrawal?

Thursday, April 18, 2019

Chimeric antigen receptor T cells (CAR T cells) therapy simplified

Hey everyone! Upasana - our funny medical student made a simplified video on CAR T cell therapy. Check it out!

I copy-pasted a quick short post in text for reference :)