Saturday, January 31, 2015

Study group discussion: Extrapyramidal effects of antipsychotics and treatment

Guys do you know the side effect/time line of antipsychotics?

I mix up akathisa  akinesia etc. Then there's tardive dyskinesia and dystonia!
So confusing.

4 hours dystonia
4 days akinesia
4 weeks akathesia
4 months tardive dyskinesia

Thank you!

I was discussing timeline of extra pyramidal side effects of antipsychotics earlier and got a doubt - Some books say akinesia comes before akathesia while others say akathesia comes before akinesia.
Like my book says opposite of the image of a book posted by someone on the group and I couldn't find a good resource online.
Anyone has an insight on what we actually see clinically?

Well after asking around it seems the general consensus is that akathisia precedes akinesia. At since it has logic to it that's what I'm sticking with.

Thanks! Why is it logical though? Because Parkinsonian symptoms take longer to appear?

Well akathisia is restlessness and agitation, and akinesia is when you start losing voluntary movements, and it seems logical that it would precede dyskinesia.

Makes sense to me now, thanks!

Hey concerning the extrapiramidal effects of antipsychotics, I consulted my Goodman and Gilman and found this:
Akathesia: 5-60 days.
Parkinsonian symptoms: 5-30 days.
There we go. Basically the argument could be made for either order since their appearance overlaps.

Oh. So you can't have a clear cut line. Thanks for this!

You use anticholinergics for akinesia, right?

Yes, right. And for akathisia beta blockers like propanolol is drug of choice.

Ohh and what's the treatment for dystonia?

Probably Anticholinergics or muscle relaxant like baclofen. Not confirmed.

Dopaminergic drugs
Anticholinergic drugs
GABA Agonists
They all can be used in dystonia!

Woah. I didn't know this.

Dopaminergic drugs like?


Here's a post I wrote after this discussion - Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic

Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic

Greetings people!

The timing of evolution of extra pyramidal symptoms of antipsychotics is something you should be thorough with:

4 hours dystonia
4 days akathesia
4 weeks akinesia
4 months tardive dyskinesia

I made a mnemonic for it because I have been struggling with it since forever!

The mnemonic is, "Distant people are Restless. Parking cars is Stereotyped and Retarded."

"Distant" is for Dystonia which comes first!

"Restless" is for akathesia (Compelling desire to move restlessly!)

"Parking" is for the Parkinsonian like symptoms seen in akinesia.

Sterotypical ("Sterotyped") movements are seen in tardive ("Retarded") dyskinesia.

Lastly, a mnemonic to remember the treatment of Neuroleptic Malignant Syndrome!

The mnemonic is, "BAD NMS"

That's all!

Related post:
Extrapyramidal effects of antipsychotics and treatment (Link:

Study group discussion: Oculogyric crisis

What's oculogyric crisis?

I have read it a couple of times as a side effect of a couple of drugs, I don't remember the drugs though.

Neuroleptic drugs.

It's antipsychotic induced.

But what happens in it.. How does the patient present?

Sounds like deviation of the eye.

These are the ones I came accross:
Mutism, palilalia, eye blinking, lacrimation, pupil dialation, drooling, increased BP and HR, flushed face, headache, vertigo, anxiety, fixed stare or maximal deviation in all direction (usually at one a time), malaise.

Seems like it messes up your autonomic nervous system along with the eyes.

Yeah :-/

General question, what does gyric mean? Like is it a Spanish or Latin word?

Latin. It's like twisting.

Study group discussion: Hybridoma technology

Something about immunology?

What about immunology?

I love immunology. Have a separate immunology comics blog, as you probably know :D

Can you provide the link for the immunology comics blog?

I thought you guys knew.


Hybridoma technology. I wanna know about that!

I'll have to read those up. Anyone in the group has an idea on those?

Hybridoma technology. Never knew of this. I'm reading into now. Cool stuff.

Let us know a short summary once you're done!

Yeah sure. I'll try.

If anyone can better explain please feel free.

This is regards to the question of Hybridomas.

Hybridomas are cells that have been specialized to produce a specific antibody in large amounts. Made by exposing the test subject (animal) to an antigen to which your insterested in isolating a antibody against.

Once the animals splenocytes are isolated, the B cells and immortalized myeloma cells are fused.

The new product is incubated in HAT (Hypoxanthine, Aminopetrin, Thymidine) medium. The medium is specialized to allow only the hybrids to survive.

The dilution process and the disired antibody production is then checked.

What ever cells are not producing the antibody they're removed and over a course of weeks the status of the subject is checked.

Oh I remember! We were taught this is first year!

Theres alot more. As far as I got :-/

Ohh thank you.

Glad I could help. Interesting read.

Yo it's really nice of you!

My pleasure.

Study group discussion: Myopia and power mnemonic

Myopia (short sightedness) mnemonic, "Cave May Be Long"

CAVE - We use conCAVE lens
MaY - in MYopia
BE - BEfore image is formed before retina
LONG - eyeball eLONGate

When eye become Myopic it is acting as converging lens (+) convex lens (bend the rays coming from object the rays towards centre) more power more convergence more bending so we use diverging lens which is a concave lens to correct or to neutralise the bending or converging.

Concave lens negative (-ve) power.

Another study link!

Study group discussion: Remembering Anatomy

Is there any easy way to remember the relations of the viscera?

Diagrams will help you remember the relations! There are a few mnemonics for arteries and stuff but in general, painting a picture in your head is the best way to remember!

Use Atlas for visualisation, see  videos of anatomy (Acland, Dalhousie) for awesome live experience... Highly recommended.

Seeing the viscera during cadaver dissection also helps in anatomy.

For anatomy, I find it helpful to draw the pictures out and label them. This allows you to appreciate the boundaries. 

I always drew diagrams in anatomy..Netter's helped a lot. 

Dissections are equally important...I  always read anatomy and revised it in my dissection class

Paroxysmal nocturnal hemoglobinuria mnemonic

Here's a mini post on PNH!

P: PIG A gene affected (On X chromosome that makes a glycosyl phosphatidyl inositol anchor)
N: Night. Hemolysis occurs at night.
H: Ham test confirms the diagnosis.

Patient presents with a history of dark coloured urine in the morning.

That's all!


Study group discussion: Succinylcholine

Can someone explain succinylcholine?

Succinylcholine is different than other neuromuscular blockers because it has two phases.

It is broken down in our body by pseudocholinesterase. And this enzyme differs in different people based on genetics. Hence, while using as a muscle relaxant it can prove quite deleterious to some people who have a weaker type of the enzyme.

Deficiency of pseudocholinesterase in some people causes succinyl choline apnoea.

Also, pseudocholinesterase is different than the more common acetyl cholinesterase enzyme.

Hepatitis B serum markers mnemonic

HBsAg: Surface protein of hepatitis B which means the person has infection presently. It's a marker for current infection.
Mnemonic: S antigen Stays in Sick patients (Active or chronic infection, negative in resolved infection).

Study group discussion: Difference between acute myelogenous leukemia and chronic myeloid leukemia

Good morning everyone! Just about to start studying some haematology. I can't seem to differentiate between acute and chronic myeloid leukemias.

The number of blast cells help you differentiate on blood smear! Blasts cells are present in acute myelogenous leukemia and are absent in chronic myelogenous leukemia.

Philadelphia chromosome too.

Ph +ve or -ve

The philadelphia chromosome in chronic, right?


But there are some CML's without the chromosome.

The major difference in AML and CML is the mortality.
Death in AML occurs in 2 months is not treated, whereas in CML, it prolongs to 4-5 years.

CML has three phases..Chronic, accelerated and blast transformation.
In blast transformation, the patient's profile converts to AML and the prognosis is grave.

Basophilia in CML, classically.

Auer rods are characteristic of AML.

Most prominent cells in CML are myelocytes and metamyelocytes.

Thanks for the help everyone :)

AML is of seven types.

Study links!


Study group discussion: When dealing with a lesbian, gay, bisexual and transgender patient

Although talking about it, makes me wonder how all of you would handle an LGBT person if you saw one in the course of practicing medicine (And you probably will... whether you notice or not).


Why would it be different if you are handling an LGBT patient?

Lesbian, gay, bi- and trans*

Their sexuality may be a thing to consider but I doubt it should alter your duty to care.

Mostly if you're handling a trans* patient, actually.  Things like referring to them by correct pronouns (which sometimes won't match the gender listed on their medical records), or using a name they're more comfortable with, even if it's not their legal name.

I know a gynaecologist who refused to treat a gay, referred him to another doctor.

Right.  And intersex people.  That's kind of controversial as far as medical things go.  What would you advise the parents of an intersex baby?
Intersex as in a baby that isn't biologically male or female.
A lot of the time doctors will perform surgery on them to make their genitals more male or female.  But a lot of intersex people think that's a bad thing to do.

We had a girl come to our clinic for primary amenorrhoea.
She was later diagnosed as genetically male.
Intersex girl with amenorrhoea. She was 15.

Oh, that's kind of interesting.
Did she want male genitals?

I don't think she was given much of a choice. And as far as I know..People out here prefer a male child better.

That's a great share.

Hmm.  I'm sorry to hear she wasn't given much of a choice.  I hope she identified as male.

My bff is an LGBT.
We've been best friends for 10 years now, so I know how to treat an LGBT person: just like another human being.
They're actually very sensitive on how you call them.
I used to have a male patient that was in transition and she told me to call her: female transgender. She used to show me pics of herself modeling at the patients room and they were actually awesome.
I don't think people should treat other people differently because of their sex preferences.

I had seen a neurofibromatosis patient in the bus once. They were no place to even stand there..But even then nobody sat besides him..It was heartbreaking.

I think on one hand, treating an LGBT person is the same way you should treat any other person, but there are also some things that are different, like having to be careful about pronouns and gendered terms (for trans* people), or being careful about how you refer to their potential partners (i.e. not referring to future boyfriends when talking to a lesbian).

Also nonbinary people have a hard time, because they can't always access transition (because a lot of resources for gender dysphoria are for people who identify as male or female), and because their gender can't go on their medical records since very few countries recognise nonbinary genders (i.e. people who don't identify as male or female, but kind of somewhere in the middle, or they don't identify with gender at all etc.)

I don't think patients should be treated differently regardless of anything.  I think everyone should be offered the same standard of care, regardless of race, sexuality, gender or even things like mental health status (I strongly disagree with people not being given the same quality of health care for self-inflicted injuries).

Human beings are different from each other, yet so similar.... That is what makes humans so beautiful in their own kind of ways.

Intersex babies are often taken into surgery here (They mostly make them "more male", bc it's a patriarchal society and having a son is important). There was a major case in Cyprus a few years back, a surgeon operated on an intersex baby without fully informing the parents about the condition and/or their options. The whole deal was very ugly.

I've been actively working to improve the conditions of LGBTI patients here for years. I work with local and national Queer associations, and Turkish Medical Students' International Committee to teach medical students about the LGBT community, so that we can be more sensitive and we can help them out more. The society here is quite homophobic, so trans people can't access healthcare at all in some places. Only 2 weeks ago a trans acquaintance of mine passed away due to an infection after her gender-reassignment surgery because some of the hospital staff didn't take care of her. Very sad situation.

I'm a queer person myself (most people can't decide if I'm a man or a woman when they first see me) and that also brings about some funny conversations. Patients tend to not care though, as long as I have the white coat on, I could be a 6 foot lizard and they wouldn't mind.

Haha the 6 foot lizard bit!
I like how people are able to get through any situation with a good sense of humor :)

That's amazing..Hopefully one day the world will stop labelling people.. And consider everyone a human.

That's a feeling I get everytime someone is chastised for their choices..I just say out loud..Have you looked inside a human body? I have! And I know for sure we all are the same on the inside.

Well put!

Study group discussion: Diuretics

Which diuretic would you use in a person who has a previous history of skin rashes by the use of sulphonamides?

The only loop diuretic you can use in a patient with sulfa drug allergy is ethacrynic acid.
Also, you have to monitor the levels... Because ethacrynic acid is the most ototoxic.

There is an antibiotic that causes ototoxicity too. Which one?


Study group discussion: A question on ascites

Here's a exam oriented question I made up:

28 year old male presents with abdominal distension. Temp 37, pulse 92, BP 110/70, RR 18. On examination you find that he has hepatomegaly, ascites and his jvp is 8 cm above the sternal angle. Urinalysis is normal. He has history of alcohol abuse, had a viral infection few weeks back.

What is the cause of his ascites?
Urinary protein loss
Liver disease
Portal vein compression
Thrombosis of hepatic vein
Nephrotic syndrome


Liver disease?

Umm it's not liver disease. He would have symptoms of jaundice if he had liver disease.

Ohh, I thought hepatitis virus.

Pericarditis! The jvp and viral infection is the catch here.


Nice question.. Hungry for more!

I almost thought it was viral hepatitis then I remembered that viral hepatitis shrinks the liver...Good question ..moore.

But what's the connection between pericarditis and the ascites!? Someone explain please!

Blood can't fill in the heart adequately during diastole, which causes an elevated venous pressure. It results in JVP, ascites etc

What's the answer to the case IkaN?

It's pericarditis.

Anyone wants to guess the etiology? Like what caused the pericarditis?

Alcohol abuse? Immunosuppression?

The alcohol abuse was intended to be a huge distractor. The guy simply had viral pericarditis due to Coxsackie B virus.

You have to assume Coxsackie because it's the most common cause of viral pericarditis.

I read somewhere that people who binge drink a lot are at risk of getting bacterial pericarditis..Streptococcus or Staphylococcus type..I didnt know about viral...It makes a lot sense though..Epidemiology rarely lies.

Oh I didn't know this. I know that alcoholics are predisposed to spontaneous bacterial peritonitis.

Yah its due to low immunity..another risk is in patients who have undergone pericardiocentesis.


What is the mechanism of pericarditis?

Pericarditis is when there is inflammation of the pericardial sac. One of the many uses of pericardial sac is to reduce the friction over the heart with every heartbeat. There also can be collection of fluid in the pericardial sac.

It can be acute or chronic, and is usually classified by what the pericardiac fluid contains.

Extra hepatic complications of hepatitis C mnemonic

A short post for today! :)

The mnemonic for extra hepatic complications of hepatitis C is, "ABC LMNOP"

Friday, January 30, 2015

Study group discussion: Eating disorders

Binge eating disorder is when the person stuffs himself in one day and then doesn't eat for a couple of days. In bulimia, patient eats normally / in excess but then voluntarily vomits out the food to avoid gaining from it.

Binging and then not eating  for a couple of days sounds like bulimia nervosa more than binge eating disorder.

People with BED don't compensate for their binges.  People with bulimia do (by restricting, exercise, purging etc).

Restricting is reducing caloric intake.   Purging can be making themselves throw up or by using laxatives.

Anorexics can also restrict and purge. But anorexics don't binge, definitionally.

So bulimics can be over weight, right? Because they binge? And anorexics are typically under weight? I always get the two mixed up!

Bulimics can be overweight or underweight, depending on how successful their compensatory strategies are after they binge (if they manage to throw up most of the food, and also exercise enough to compensate for the calories their body did manage to absorb, they can actually lose weight extremely quickly, like anorexics).

Anorexics are always underweight, definitionally.  If someone has symptoms of anorexia but they aren't underweight (or if they're female and they still have their period), then they'll probably be diagnosed with ED-NOS instead (specifically 'atypical anorexia').


ED-NOS is eating disorder not otherwise specified.

If you recall, anorexia as a symptom and not a disorder just means loss of appetite (I really don't like that it's the same word).  So anorexia nervosa is a disorder largely characterised by not eating (although it's more complex than that, and a lot of anorexics do binge, just not frequently enough to be diagnosed with bulimia nervosa).

A person might also be diagnosed with ED-NOS if they have symptoms of bulimia, but don't binge often enough to be diagnosed with bulimia nervosa.

Up to 60% of people in eating disorder programs have ED-NOS.

It's also sometimes called OSFED (especially if you're not American).  OSFED is 'other specified feeding or eating disorder'.

I didn't know this about this. I thought Anorexia and Bulimia were the only ones!

So does the management of atypical Anorexia differ?

In the new DSM, the amenorrhea criteria of anorexia will be removed. 
So you still have a significantly lower weight than you should with anorexia, but you don't necessarily need to stop having your period anymore to meet the diagnosis.
Because many women even severly underweight can still have their period.
Also "binge eating disorder" is added, which is eating too much but without compensating behaviors.

But previously you had to miss your period 3 months in a row to have anorexia. They removed this criterium

Oh that's why I heard the no period criteria for the first time!

Yep it's new in DSM-V.

And as for the different treatment.. Since you are underweight in anorexia and not usually in ED-NOS, you will find more people with anorexia being treated by refeeding/feeding tube.

I didn't know that, but that's awesome.  It would be better if they removed the criteria for low weight, too, though. I know a lot of people in the pro-anorexia communities tended to want to wait until they met the weight and amennorhea criteria before getting help so that they could be diagnosed with anorexia nervosa instead of EDNOS.

Yep. It's an "honor" to have anorexia, "shame" to have EDNOS because you're not good enough at having an eating disorder and worse when you have bulimia.

It's strange they make a ranking system for eating disorders, while many people will fluctuate between all three disorders in their lifetime

Which is incredibly unhealthy, because:
1. EDNOS can be as physically damaging to your body as anorexia nervosa (bulimia nervosa is less likely to be physically damaging, although Boerhaave's syndrome, enamel erosion etc mostly only happen for bulimia).
2. Eating disorders, like anything else, are far more treatable if caught early.  Discouraging people from seeking help because the diagnosis they'll get is a less desirable one isn't helpful.

That's sad. The criteria shouldn't get in the way of someone who wants help.

I think the ranking system makes sense, though.  A really high percentage of people in the pro-anorexia community are perfectionists.  If the goal is to be skinny, having an eating disorder where the diagnostic criteria include being extremely skinny would be seen as relative success.  I don't think the ranking system is healthy in any way, but it makes sense.

As for bulimia being the worst... there's a pro-bulimia community, too... there isn't a pro-EDNOS community (although they tend to be absorbed by the pro-anorexia one).  So I don't think it's necessarily accurate to put bulimia at the bottom of the hierarchy (although I do realise that a lot of bulimics wish they were anorexic instead because they think they'd lose weight faster that way).

Hmm. So what do you guys think would be a sensitive way to approach eating disorders, in terms of clinical encounters or diagnosis? How might we be more body positive in the clinical setting?

Well it's hard to approach people with eating disorders properly... Because if they are still in denial (much like in addiction), they will see a comment about looking sick as a compliment

Someone asked whether the management of atypical anorexia is different.  In general, all restrictive eating disorders can be seen as fairly equal, and the recovery process is largely similar for anorexia nervosa and atypical anorexia.  The only significant difference I know of is that people with anorexia nervosa are more likely to be put in inpatient, and achieving a healthy weight tends to be more of a focus for anorexia nervosa than for EDNOS.

And yes, being told that they look sick would almost definitely be taken as a compliment.

I see. It's like they are different colors of the same spectrum.

I think what you can do is just ask the patient if they are okay, mentally. If they want to talk about anything, because you are worried.

I had a colleague this past week and she ate next to nothing, so I asked her. And told her if she needs to talk, she can e-mail or call me

Pretty much... I strongly disagree with the way they separate atypical anorexia from anorexia nervosa based on weight.  The psychological symptoms are the same, the mental distress tends to be the same, the treatment is the same, the potential physical harm that the eating disorders cause are the same.

Just never minimize the problem if your patient has an eating disorder, because they will try very hard to prove you wrong

A friend of mine has had people say to her that her eating disorder wasn't "that bad" because she wasn't severely underweight, which stimulated her to not eat. She ended up in the hospital. It's a sensitive subject, so try to get an expert to talk to them instead of potentially saying the wrong things.

I figured it was something like that. But expert aside, seems like it's still important to leave them to open the conversation, similar to any other mental illness and let them talk it out than seek immediate referral.

Definitely :) if you are willing to help and listen, just tell them that you don't know much about it/don't have experience treating people with eating disorders, but you would like to try and help.

As far as being sensitive goes:
1. If a blood test and/or an ECG is part of the diagnostic process (I know it's a requirement for the eating disorder treatment program here, I don't know if it is elsewhere), assuring someone (especially if they aren't thin enough to be diagnosed with anorexia nervosa) that even if the blood test results look 'normal', it doesn't mean that they haven't done damage to their body, and it doesn't mean that they aren't sick enough to deserve help (this is especially true for people who are voluntarily seeking help for an eating disorder).
2. Not telling people to just eat... I don't know why on earth people, including medical professionals, insist on doing this.  It's awful.  Don't.  If it was that simple they wouldn't need medical treatment.
3. Acknowledging that the eating disorder serves as a useful and valuable coping mechanism.  Even though eating disorders are their own special kind of hell to have, the feeling of control they give to people who suffer from them can still feel good and make it hard to recover.  It's possible to be sensitive and acknowledge the things that make it hard to *want* to recover, while still pointing out that on the whole, it's harmful, and recovery would make the patient's life better.
4. If someone has atypical anorexia, don't constantly remind them of it.  They probably think about it a lot.  Saying "eating disorder" validates the severity of what they're going through, and emphasises that all eating disorders are serious and should be treated as equally serious.
5. Unless their life is in immediate danger, don't try to force recovery-oriented behaviours on them.  Let them recover on their own time: it'll make it so that the recovery process is less scary/unpleasant, and will also make it so that their recovery lasts longer.  Eating because you've been forced to isn't the same as eating because you want to recover.  Encourage them to choose recovery on their own.
6. Following on from that... don't just focus on the physical symptoms.  Yes, it's important that people figure out how to eat properly, because not eating properly can result in very serious physical consequences, but it's also very important to acknowledge the mental symptoms, because those can cause very serious effects on the person's quality of life, too.  A friend of mine saw a psychiatrist for anorexia nervosa, and the psychiatrist kept focusing on her weight, and as she reached her healthy weight, the psychiatrist acted as though that meant she was nearly recovered.  Never forget that eating disorders are mental illnesses, and just because someone's at their healthy weight doesn't mean they're recovered, or that they don't still need help.

I have mixed feelings about handling co-morbidities, because I don't know a lot about them.  I know that there are segments of the medical profession who believe that if someone presents with a comorbid eating disorder and anxiety/depression, that they'll try to treat the eating disorder first before doing anything about the anxiety/depression.  Which to some extent makes sense, because not eating can do weird things to mood, but I personally don't really like that approach (especially in cases where the anxiety/depression clearly was present before the onset of the eating disorder).  I do know, however, that if a medical professional takes the view that the eating disorder should be addressed first, it can definitely come across as them dismissing the mood and anxiety disorders as being just a by-product of the eating disorder, which can be incredibly invalidating.

I feel anxiety & depression should be addressed along with the more obvious eating disorder. But I don't know if it's feasible in clinical practice.

You can ask the patient to talk about it, sure. But if that doesn't work pharmacological treatment takes weeks. And you never know if the eating disorder caused the depression or vice versa, the depression caused the eating disorder. I really don't get how a psychiatrist would actually approach and manage such a patient.

Comorbidities are messy.  Eating disorders tend to make anxiety/depression worse, but anxiety/depression (especially anxiety) can make eating disorders worse, too.  In light of that, I feel as though treating them both at the same time makes sense because reducing the symptoms of the depression/anxiety might make the eating disorder better, even if the eating disorder is the cause of the depression/anxiety.

I know there are psychiatrists who will prescribe antidepressants and/or anxiolytics for people who have eating disorders.  But also doctors who insist on treating the eating disorder by itself first. I don't think there's a general consensus on what's the best way to handle that.

As for feasibility in clinical practice, I personally think it makes more sense to address depression/anxiety at the same time as the eating disorder, especially where it isn't certain whether any given symptom is caused by an eating disorder or anxiety (if someone's afraid to eat in public, is it general social anxiety or the eating disorder?... there's no real way to tell... but it's not important, because either way the symptom needs to be addressed)


Would it help treating an anorexic patient indirectly?  Say, you need to gain a little weight back even though you might not like it because.. Idk.. You have amenorrhea? And that's bad etc etc
Or is that even allowed?

Anorexic patient: I doubt it would help.  At a fairly early point in eating disorders, the desire to be thin begins to take on an irrational level of importance.  It's not uncommon for anorexic patients to express the idea that they don't care if they die, so long as they can die skinny.  Although in the early stages of illness, a lot of anorexics desire to be skinny so that they can be beautiful, or popular etc, at some point it often takes on an importance of its own, and they'll be willing to risk everything (health, beauty, popularity etc.) to be skinny.  When it gets to that point, curing amennorrhea isn't really going to be enough of an incentive to overcome the obsessive desire to be thin.

Even if they gain back the weight, you might end up in a yo-yo weight situation where any underlying disorders keep cropping up, particularly in times of stress. Eating disorders tend to be chronic and long-lasting.

Telling someone that something they do is "bad" also probably isn't really compelling, even though lots of people try that tactic :p

That is also true.  And as I said before, although gaining back the weight can be important, it's even more important to deal with the underlying mental illness.

So, it would still be difficult to show them that hey! You are back to normal weight and still looking good? As in their perception just won't change?

Once people get close to being at a normal weight, they often feel that they look incredibly fat (and in comparison to their emaciated bodies they had while severely underweight, they probably do).

I guess it makes if I think according to their thoughts.

There was an experiment where people were starved and they started engaging in disordered eating behaviour, but once they reached their healthy weight again the disordered behaviour went away.  The problem is, that only seems to be true for people who developed disordered eating behaviour after losing weight.  For people who lost a lot of weight as a result of disordered eating, regaining the weight doesn't seem to usually fix the problem.

Which is why I so strongly disagree with any treatment approach that focuses on regaining a healthy weight, and using weight as a marker for how healthy a person is.  Because if someone recovers enough to be at a healthy weight but doesn't recover fully mentally, chances are they're going to revert back to old behaviours again.  Relapse and recovery cycle and all that.

Full recovery is generally possible for restrictive eating disorders, in that a lot of people never do go back.  But that only happens if the underlying eating disorder is adequately dealt with, and not when the only recovery that has happened is weight restoration.

It falls to dealing with the cause versus dealing with the symptoms.


So if we don't talk about weight, how do we bring them back to a normal mental state?

Well the mental state is the problem the weight is just a visible symptom of that.

Eating disorders are often very helpful to people who have them, even if they cause a lot of suffering.  They're a way of being able to exert control in a chaotic world.  It's why eating disorders are so common among young people with controlling parents.  Eating can often be the only thing that people can control if they live in highly restrictive environments.

So changing how you think about the illness is an important first step?

To that end, making sure that people with eating disorders find things in their life that they can have control over in healthy ways can be really valuable.

Many associate these with vanity which undermines the sickness.

It has a stigma sort of like depression, where it used to be considered that the person was just sad or moody but now we know it is an imbalance of neurotransmitters that is the cause.

It's important to take. the patient seriously and treat it as a real illness so that the patient can feel that they can be cured and recover, like most illnesses.

Definitely acknowledging that it's a real medical illness and not just something someone is doing to themselves is important.  Validating someone's experiences is one of the most important things about dealing with patients, and especially important in cases of mental illness.

Validating that's the word.
Couldn't for the life of me recall it.

One more question, mentioned that one way would be to make sure they have control over other things in life in healthy ways. What exactly do we mean- lifestyle?

If they're a child, ask their parents to give them more freedom to make choices in their life.

If they're an adult, talking to them about the areas in their life where they feel they have no control, and helping them see that they do actually have quite a lot of control can be helpful.

Although that can be tricky, a lot of people with eating disorders have been victims of trauma, and that's very much a situation where they did not have control.

I see. This was incredibly insightful. Thank you guys!

You should also try to focus on giving them better coping mechanisms and expressing their feelings. A big part of eating disorders is also about not feeling, not dealing with emotions. They need to know it is okay to cry, that they can deal with whatever caused the disorder in a healthy way. And especially let them know that yes, even though this coping mechanism was helpful in the past (for example in cases of abuse), it is no longer necessary to survive.

It makes me really happy that people in this group were so willing to listen when we were talking about what to do with patients who have eating disorders.  And your desire to make a difference when you're in clinical practice.  I like how everyone in this group seems to genuinely care about being a good doctor and to care about patient welfare.  I think that's really important, and it makes me hopeful about the future generation of doctors to see how much you care.

Study group discussion: Osler Weber Rendau syndrome

I had once taken a case of Osler Weber rendau syndrome.

It's an autosomal dominant disease..Where AV malformation occur throughout the body.

The case i had was of a 26 yr old lady G6P3L1D2A2
And in her most recent pregnancy, during her 24th week.. She had sudden onset cough and breathlessness.
Later on pulmomary tapping..Blood was withdrawn.

The AV malformation in her lungs had bursted. She was taken for surgery.

Which surgery?

I forgot the name of it. Under angiographic control, the bleeding is sought out and the bleeder clamped.

The baby was taken out by C section at 37th week..Cause it was having an IUGR lag of four weeks.

But from what I reserched was angiogenesis occurs our entire life time.
So as you grow the number of av malformation go on increasing.
In children it presents as epixtasis.
In young adults..bleeding in lungs.
As you grow they may rupture in the brain as well.

I had a case of Osler Weber Rendau syndrome who presented with Haematemesis.
The attending told us to suspect it in patients who do not have signs of liver cell failure (Since portal hypertension is the most common cause of Haematemesis!)

Study group discussion: Reason behind names of oral contraceptive pills and retroalimentation

I remember in my obstetrics practical.. I was asked why the name mala was used for mala-D or mala-N. These are oral combined contraceptive distributes free in India.
Anyone from India knows why?
I tried searching online.. Didn't find the reason why!

Mala means garland in Hindi. I have no idea why they would call a contraceptive a chain of flowers or beads though!

I am not sure but i think something like mala pearl and it's importance?
Mala N and D have other names like moti, pearl.

This Mala n and mala d is a garland like with beads equal to number of days in a month.

The mala D thing you asked... The backside of the packet shows the pattern in which they're supposed to be taken... That looks like beads in string... So may be that's why the name...

Makes sense.

Yes, but they can inhibit the synthesis of sexual hormones. If used for prolonged time, it makes harder for a woman to get pregnant after stopping them. They're very effective though.

Hmm.. I never read anything like that.

Read about retroalimentation of sexual hormones.

What's that?

If they are taken orally, the body stops producing them normally. They have a negative retroalimentation, meaning that if theres estrogens in the body, other glands will notice and they wont produce it naturally. Hormones have a whole organ-brain system of production.

So that's bad?

No, not bad.
Doesnt mean they'll be sterile.
Just means itll take time for the body to produce them naturally again.

I've read that if woman take hormonal therapy they have more propensity to get endometrial cancer.

Yeah, that's why progesterone is added.

Micturition reflex and types of bladder

Rather than going into exaggerated details... I will only point the important facts.

1.    When urine starts collecting within the bladder. The detrusor muscle is stretched. This is detected via stretch receptors and is carried by the sensory nerve to the spinal cord.

2.    The reflex arc root value is S2 to S4, from these parasympathetic fibers arise, which causes contraction of the detrusor muscle.

3.   This arc is under the control of the higher centers ( frontal lobe and pons), which can either FACILITATE or INHIBIT this reflex arc.

The clinical aspects of this are-

Study group experience #2

Here's what we discussed so far:

I must say, the group is much more fun than the limited "Study group discussions" I post on the blog.

The discussions on the topics are diverse, surprising and very interesting. We also did a lot of non study related random discussions on our respective countries, languages, DIY medical gifts and shadowing. Even though the group is active day and night because of the time zone difference, the messages don't feel like they're a drag in anyway. Almost everyone seems to love the idea and what we talk about. Group 1, you guys are absolutely amazing. The hard work involved in putting together the group was totally worth it! <3 p="">

Two or three members felt the discussions should be very limited to studies, science and entrance examination stuff. We made a separate mini group for that.  Personally, I think that we are humans and we tend to socialize and talk random wherever we go. It's hard to have a clear boundary for what should be discussed and what not. But anyway, the mini group option will be open for future group joiners!

Lastly, the Group 2 update: We have 20 people so far, the minute the number reaches close to 50, your group will be made. Sorry for the wait! :)

Study group discussion: Alcohol and ADH

Does alchol decreases ADH secretion?
Alcohol inhibits ADH, that's why we pee so much when we're drunk.
Does it inhibit ADH at the kidney level, or does it inhibit the thing in the pituitary gland that makes the gland release ADH?
It inhibits the production of ADH from the pituitary gland.
So it affects the hypothalamic neurons and interferes with it's secretion?
Oh yes. Alcohol inhibits ADH. That's why it is said you don't buy alcohol, you only rent it because you pee the fluid that you took.

What would you take for dehydration by ethanol ?

Normal saline!

I have seen on television that they give some light yellow coloured fluid. They add something to saline, I think. 

Banana bag it's called!

Huh? Banana bag? Any special constituents?

It's given especially for alcoholics. Contains Thiamine, folic acid and stuff

A banana bag (or rally pack) is a bag of IV fluids containing vitamins and minerals. The bags typically contain thiamine, folic acid, and 3 grams of magnesium sulfate, and are usually used to replenish nutritional deficiencies or correct a chemical imbalance in the human body. The multi-vitamin solution has a yellow color, hence the term "banana bag".


Thursday, January 29, 2015

Study group discussion: Addictions, Mental health

Guys, what's mental health/addictions care like in your countries? Intertwined with primary care or no? It's a huge issue here (Canada) but there's a lot of stigma and lack of political push to get anything done, and these people often suffer from "physical" comorbidities because they don't trust the system. I'm interested in your thoughts.

In India, the majority of cases we see are schizophrenia and alcoholism when it comes to mental health.
The stigma here is because the infectious disease burden is too much and that's why mental health doesn't get that much political attention.
But overall, people who reach hospitals trust doctors and it is very much intertwined with primary care.

People get a pretty wide range of mental health things around here, although in child and youth it's mostly anxiety disorders or conduct disorder, sometimes depression.  In emergency psych there's a lot of schizophrenia spectrum and suicide.   There's actually a dedicated eating disorders program as well (for children youth and adults).  The problem with mental health services, though, is the lack of resources.   There's a 4 month waiting list for the eating disorders program, for example.  I think thats a problem in other countries, too, but I don't know.   Does anyone know stuff about resource allocation to mental health programs in other health care systems?
Currently in Canada.  I used to live in Hong Kong.
The mental health care system is even worse in Hong Kong.

I only start ward rounds next year so I'm not sure how accurate is my take on mental health... But depression is very common here (Singapore) because life tends to be very fast paced here!

In Honduras, we see addictions to alcohol, glue and Benzodiazepines.
Glue? Like glue sniffing?

Yeah, they smell glue here. It's very cheap and you can use it  many times. And paint thinner too.

Had read about it in forensics class but never thought it is actually prevalent!

Dendrite sniffing is common here (India)

I believe it. We get a lot of hand sanitizer stolen around here. (Canada)

Apparent cases coming to see psychiatrist eye is a small proportion.


Dendrite is one kind of a glue.

I'm a bit surprised too. Maybe it's naiveness or lack of exposure to such news... But the last time I heard that people used thinners or glue or nail polish to sniff was in my psych class.

I suppose almost all volatile substance can be used this way.

I have to admit, glue and paint thinner smells good.

I see lots of it in emerg... Mostly, the homeless. Its very sad.

So how do they present clinically?

Sort of like asphyxia? That's what I had read..They keep sniffing and in a daze forget to breathe.
Had a case a few weeks ago where this guy inhaled those cans of air dusters used to clean computers.

Hypoventilation, respiratory acidosis.

He just kinda passed out on the side of the road, but became conscious rather quickly once we talked to him.

Decreased LOC usually, sometimes combative, crazy heart rates. Mostly they just look inebriated. 

Super paranoid. Depends on what they abused.

They present with very serious brain damage. Usually they dont come to the hospital, they die from TB and AIDS in the streets without medical attention.

What we get in our emergency is mostly organophosphorous poisoning.

OP poisoning is very prevalent out here. It's the only thing farmers have access to!

Atropine then pralidoxime.


If we're unsure of the pesticide, we don't prescribe pralidoxime.

Here (Honduras), farmers are always getting snake bites

Barba amarilla they call them.

Oh. We get snake bites too.

Study group discussion: Fecal transplant and uses of urine

Speaking of that, in the show Greys Anatomy, they use poop to cultivate natural flora in a person who overused antibiotics.

I saw a video of that on minute earth on youtube. Esp in conditions of inflammatory bowel disease!

It's called a fecal transplant or something.

It's in trials in many hospitals.
As per JAMA, NEJM.

I read that they're treating enterocolitis from resistant strains of C.difficile by inserting a nasoduodenal tube and administering donor feces

Do you think patients would be as ready to accept a fecal transplant as they would, per say, a blood donation?

Donno about patients but I wouldn't accept a fecal transplant!

I think it differs from different races, cultures to your personal beliefs.

But i guess we all value our life the most. Given as a last resort, I suppose the patient would accept.

It's all about circumstances.

Does anyone have a link to a publication on the fecal transplant?

@above GIYF.

Giyf haha love that!

Searching on Google is tough. I'd love to be spoon fed with links!

Googling fecal transplants just gives a range of DIY kits...

Put in right keywords, use search tools and the first link is what all you need.

Hahaha gross. DIY fecal transplants sound um... messy.

Do you guys know urine can be used as an eye wash?
But it shouldn't be infected.
It's one of the uses of urine if your stranded with no water.
First use is, of course, drinking it to prevent dehydration.

Idk if you've heard about this in other countries but we in the USA say use urine on jellyfish stings

Oh yes, that too. I watched a Rhett and Link video on YouTube a long time back on the uses of urine.

Study group discussion: Clomiphene citrate

Please can you explain me the mechanism of Clomiphene citrate?
Clomiphene citrate is a Selective Estrogen Receptor Modulator!

Clomiphene citrate's primary action is to block the oestrogen receptors on the pituitary.

Hence, because of the lack of negative feedback..more of FSH is produced.. Hence more follicles.

This primarily used in ovulation induction in woman.. Main example polycystic ovarian syndrome.

Also, in males it is used if the cause of impotency is less gonaodotrophins.

Important viva question is.. Dose in females is 50mg OD but in males its 25 mg.

Ooh. Why is the dose lesser in males?

Oh that.. I never searched for it. But best guess would be in males the breakdown would be slower. Hence less drug.

Also, remember after the follicles are well stimulated injection hcg is given (cause it mimics LH) and brings out ovulation.

Extra: Side effect of clomiphene citrate is ovarian hyperstimulation syndrome in females

But never ever give hcg to a woman with PCOD.. It's contraindicated cause already LH is high. Else you will cause ovarian hyperstimulation syndrome.

Oh it's HCG, I thought it's clomiphene which was the culprit.

From what I read clomiphene does cause OHS by its own... But the gonadotrophins given externally are the major culprits.

One fact HCG is obtained from urine of pregnant woman. Even FSH and LH..urine of menopausal woman. I guess better recombinant counterparts are available though.

The conversation lead to urine and fecal transplants, will be published in the next post!

Study group discussion: Marfans syndrome

Today I learned that if someone has Marfans disease and they complain of a "tearing" feeling in their chest, they are probably having an aortic dissection and need surgery quick. Our patient made it to the hospital alive, but apparently it's commonly fatal.

Aortic dissection presents with pain radiating to the back. The radiation of pain hint is given in many multiple choice questions.

Marfan syndrome patient tend to have weak or bad joint... But how could they hyperextend their finger?

Because they have a defect in fibrillin synthesis. Synthesis of any structure with fibrillin is affected.

Good to know! I'll keep that in mind.

Fibrillin will form elastic connective tissue right?

Ohhh cool! Didn't know the association!

Fibrillin is a component of lots of types of connective tissue, I guess.


Mini mnemonic on Marfan: Marfan - Fibrillin - Marfibrillin (Merging words to remember!)

Marfan is associated wth ectopic lentis, right?

Yes, Marfans is associated with ectopia lentis. Another condition associated with ectopia lentis is homocystinuria.

What's ectopia lentis?

Displacement of the eye's lens.

Paracellular leak in the thick ascending limb

This fact had boggled me since first year physiology, finally got it figured out

Paracellular leak- sodium, potassium and chloride are absorbed into the cell by Na-2Cl-K transporter. But potassium is more permeable, hence it diffuses back into the luminal fluid. This creates positivity in the luminal fluid, which repels positive ions. Hence Mg, Ca, Na are pushed by the paracellular pathway to be absorbed.  

Study group discussion: Epigenetics

Epigenetic science is a whole new perspective. To bioethics and to humanity.

Yeah there will be some secondary factors that control this epigenetic modulation.

Decitabine and aza cytidine also work by epigenetic modulation.

I didn't get the cytidine epigenetic modulation bit. Can you please elaborate?

Epigenetics is a process where one gene is active at one time and other gene is inactive same time and vice versa.

This is due to some secondary factors.

Drugs like Decitabine and aza cytidine used in MDS has minor mechanism in epigenetics.

That's all I know ;)


Also epigenetics means
he interaction between the nature and nurture. Genetics and environment.

It means that if you're having a gene for diabetes doesn't make you diabetic, until there's a reaction with your environment.

Study group discussion: Deep vein thrombosis

One common fact I read a few days back was after a long journey by plane, our shoes feel tighter. It's cause of venous pooling due to lack of use of calf muscles. Hence, we have slight oedema.

This is important in case of people prone to deep vein thrombosis. So they are at a high risk of life threatening pulmonary embolism.

I use the loo so many times in planes to prevent that :P

Me too.. Shuffled from seat to seat without bothering to put those shoes on.

One documentation of case was for a man who flew for 14 hrs and got pulmonary embolus!

Study group discussion: Fetal hemoglobin

What is the difference between fetal Hb (HbF) and adult Hb (HbA)? In term of the structures?

HbA has two beta chains and HbF has two gamma chains.

The gamma fraction allows fetal Hb to have higher affinity of it for oxygen which allows it to extract oxygen from maternal blood.

And inducing Hb F production is also used in the treatment of sickle cell anemia.

Hydroxyurea is the drug used for the same.

Hb F production starts from 8th week of intra uterine life.

Fetal Hb has more affinity towards oxygen than adult Hb, meaning the oxygen dissociation curve is shifted left compared to normal adult Hb.

Left doesn't leave the oxygen! (

The primary structural differences between HbF and HbA are located in or near the 2,3-BPG binding site between the γ1-γ2 interface of HbF and the β1-β2 interface of HbA. The net effect of these structural differences is that 2,3-BPG binds less tightly to deoxyHbF by comparison to deoxyHbA. Thus, 2,3-BPG does not stabilize the deoxyHbF as effectively as it stabilizes deoxyHbA, thus accounting for the leftward shift of the O2 saturation curve of HbF compared to HbA when tested with the same concentration of 2,3-BPG.

Fetal hb has more affinity because of poor binding of 2,3-DPG by the gamma polypeptide chain so it can take larger volume of oxygen than adult hb at low oxygen pressure

A higher affinity for oxygen allows higher concentrations of oxygen into fetal circulation, however this also inhibits oxygen dissociation into fetal tissue where the oxygen is needed. To overcome this, other mechanisms are in place to ensure oxygen delivery to fetal tissue: Increased Crit – higher number of red blood cells per blood volume. This is a common reaction to reduced oxygen availability. Exacerbated Bohr effect – acidic pH has a greater effect on oxygen unloading in fetal tissues allowing better oxygen delivery. Acidic pH shifts the fetal oxygen-haemoglobin dissociation curve to the right, so that oxygen unloading can occur at higher oxygen partial pressures.

Adult haemoglobin starts to be produced in utero, at around the 13th week of gestation.

I think it's 30the week the switch over from fetal Hb to adult Hb.

Its by 6th month of life.. That's when majority of a child's RBC shifts to adult haemoglobin. It's important in case of thalasaemia.. Because that's when most symptoms start showing.

What I meant to say was - Initiation of production of HbA starts from 13th week gestation.

At first, there is gradual increase in concentration of HbA until it reaches 20-30% of total Hb.

And the switch is not completed until 6 months of age.

What my hemaologist taught was HbA production will be started from 30th week of gestation and by 6th month of life only HbA is produced.

And the main function of HbF is delivering oxygen in hypoxic condition like immediately after birth.

But don't we need HbF to take oxygen from the maternal blood in the first place?

Because the partial pressures in the placenta aren't enough to allow the transfer from what I've studied.
Everything takes part in delivering oxygen depending upon tissue tension of O2. Before 7th week, there are embryonic Hb like portland, gower, etc.

Embryonic erythropiesis takes place from yolk sac.

From 7th week to 30th week liver.

After 30th week, long bones start erythropoesis.

Gene for both HbA and HbF are present since birth but Its all epigenetics that make these genes to produce one kind in one period and other type in other period.

Oh I didn't know the Hb concept in such depth.

My sir told these details. Epigenetics is given in Robbins 5th chapter.

That's all!
Be sure to let us know if there are any errors or corrections.

Study group experience #1

It was SO very exciting to meet new people from all over the world. I got to speak to my followers directly which I don't get to do very often with the one sided blogging.

We had people from different countries and I was internal fan girl screaming throughout the process. (Still am!)

As promised to not leave you out, this is what we discussed in the group:

We were talking about how everyone is from different age groups and grades, some younger than others. One of the group members said, "No one is small in the face of a big dream." I found it to be very motivational. Elegantly put!

We had one negative experience, a member was sending dating messages to a girl and she left the group :(
To future group joiners, make sure you report if such a thing happens to you so that we can ban the user.

The first group is full. The plan is to not add more than 50 people in one group. (It'll prevent too many anonymous users and it won't be too annoying!) The 50 spots which are empty can be used up by friends of trusted group members on request.

The new comers will be added in the second group and everyone will get a spot. Maybe in the future we'll segregate people on time zones but for now you'll be randomly allocated.

Thank you for the wonderful experience, awesome medicos!

Looking forward to more <3


Wednesday, January 28, 2015

Medicowesome study group on Whatsapp

Some of my friends discuss questions and concepts on Whatsapp. So for a long time, I've been wanting to do this. Make a huge all time accessible study group where we can learn!

This is the first trial attempt, of course. It may not work. It might work brilliantly.

If it doesn't work out, we dissolve the group and pretend it never happened T_T
If it does, we'll be learning something new on a daily basis *_*

So who's in?

All you've got to do is message me your number. You can email me at with "Whatsapp study group" in the subject.

IMPORTANT: Make sure you include your proper country code when you email me your number. (Otherwise your number won't be displayed in my Whatsapp list and I might miss you out!) 

DO NOT ignorantly leave your contact details publicly in the comments for everyone to see! *whispers* Keep it secret, keep it safe.

I'll message you in a week max.
I have a lot in mind but it varies with the response. Let's try this out first and see how it goes!

PS: I'll also try posting what we discuss on the group out here as well for those who don't have access / are uncomfortable with Whatsapp.

*hoping for the best*


Apoptosis: Proapoptotic and anti-apoptotic molecules mnemonic

Hello! We are going to have life and death talks today.

Just kidding. We'll be talking about apoptosis - remembering molecules that promote or inhibit apoptosis, as the title suggests.

Let's start!

"Bax kills cells with an axe."
BAX promotes apoptosis.

"Caspase converts cells into casper (the ghost)."
Caspases promotes apoptosis. (Conversion into ghosts, that is, death).

"Dying is bad."
BAD promotes apoptosis.

Getting baked is like dying.
BAK promotes apoptosis.

I think bcl 2 is saying, "be clever, live" reminding us to live longer.
bcl 2 inhibits apoptosis and thus, is anti-apoptotic.

That's all!
Life and death.

Tuesday, January 27, 2015

Oral hypoglycemic drugs and weight - Weight gain or weight loss mnemonic

Sulfonylureas, Insulin and Thiazolidinediones cause weight gain.
"SIT" is my memory aid for remembering this. (Sitting at home makes you fat.)

Biguanides like Metformin cause weight loss.
"Metformin forms you in,
makes you thin."
(I could be a poet! :P )

For Glucagon-like peptide-1 (GLP-1) receptor agonists, you need to remember that the drugs end with "-tide". Exenatide liraglutide, etc. Tide is an anagram for "diet" - so tides cause increased satiety and reduce diet :D

SGLT-2 and Weight loss: SGLT2 Surely Generates Less Tummy.

That's all!

Prolactin mnemonic


Prolactin is pro-lactation hormone. It aids in breast development during pregnancy and milk secretion from the breast during nursing.

It's regulation is kind of complex which is why we'll be learning about it today. I'll also be sharing a few mnemonics that will help you remember these facts!

Monday, January 26, 2015

I have no idea about USMLE Step 1

I have noticed that some of my readers haven't spoken to anyone about USMLE step 1 exam and ask very basic questions about the preparation so I decided to write a separate post on it.

For those who have started preparing for the exam and have a general idea
- You'll find most of this post useless and redundant.
- I have marked asterisks (*) for important points you might wanna look at :)

Lastly, most of these are replies from conversations that I've had with real people so
- I haven't sequenced them in order.
- Ignore grammatical errors that I may have overlooked.
- Some of them have shout outs to Indian medical students (Simply because I know the Indian system better and it's hard to separate those points and write em again. Please don't mind that. I love you all equally, medics of the world!)

Okay, let's begin!

I just started. Which books do I get?
Kaplan notes and Goljan pathology.
* Don't buy First Aid initially since you'll be requiring a new edition in the last 3-6 months of your prep.

How do I start preparing?
You'll have to start with Kaplan videos. Supplement them with notes. Add extra points, stuff not mentioned in the videos to it. Hear Goljan audio while travelling, cleaning the house. Read the book and know it cold.

What is Goljan audio?
Recorded lectures of an absolutely amazing pathology professor, Edward Goljan.

What all is encompassed in Step one? Which subjects?
Anatomy, Biochemistry, Physiology, Pathology, Microbiology, Pharmacology and Behavioural science.
* It has a lot of clinical questions as well so it's hard for me to restrict the syllabus to basic sciences. For a hypothetical example, say, a question on burns was asked on my Step. In India, it is taught in Forensic Medicine and Toxicology and Surgery. So you get the idea? You require an over all comprehensive knowledge for Step 1.

Behavioural science?
It's Biostatistics from Preventive and Social Medicine (3rd year minor for Indian medical students) and Psychiatry from Medicine (3rd year major for Indian medical students).

If there are minor and major subjects, won't I score better if I give the exam after I am done with MBBS?
Yes, I think people who give the exam after they complete final year score better than those who give it in their basic science years simply because people from first year and second year lack clinical knowledge essential for Step 1.
I must say, my opinion is biased on my experience. I know of a senior who gave his exam before final year and scored a 265 on his Step 1 (So that's pretty awesome and you should go ahead, give the exam without doubt in your basic science years!)

Umm so why give Step 1  early?
- You're utilizing your time efficiently.
- You'll need the score to apply for electives in certain colleges.
- You get "done" with the exam and you can chill out.

When and how to register?
You'll need an ECFMG id to give the exam. That requires college stamp. You'll get the instructions online. If you can't figure it out, email me.

When do need to get the id? ASAP?
3-6 months before you feel like giving the exam, you make the id. It takes approx 1 month to make.
The thing with ECFMG id is that you need to pay a certain amount of money to make the id. That's why, I recommend you to make it when you're absolutely sure about giving the exam.

What is uWorld?
It's an online question bank. They are questions which are similar to those on Step 1 and essential to get an idea of what the exam is like.

When do I start with uWorld?
It is a resource you would like to use in the later months of your preparation because it is difficult (You can't do it without having any knowledge) and because it trains you for the real exam.

Are there other questions banks that I can do?
Many. Kaplan Q bank, USMLE Rx to name a few.
* Unlike uWorld, you can start with other question banks well before the exam because they are not very similar to the real exam, they scare the shit out of you with facts you don't know and motivate you to study.

What is NBME?
Mock exams created by examiners who write questions for the test. They predict your score.

I've heard you need to do research stuff in the field you are interested, is that right?
Yes. Research and electives are required for residency.

How do I become a part of some research?
That is later. In USA. Give your step exams first.
For Indian medical students - You can do research in India as well but it has no value. You'll get experience but that's about it. No credibility.
Procedure in very short: You'll need to contact the HOD of that department, get permission from ethics committee and contact a professor who would like to mentor you for research.

No advantage of research in Step 1?
Nope. They help you in residency match. Just get a good score for now and worry about the other details later.

(I'll keep updating the post with recent questions as and when I can.)

Related posts:
Preparing for the USMLE Step 1 exam

USMLE for Indian medical students

Giving the test you failed in while studying for the next exam

I'm a third year med student and today I just got my result for the annual exam and I flunked in biochem :'(
It's been like the end of the world to me today. I feel so hopeless and helpless.
I really have no idea how I'm gonna retake the exam while having the 3rd year classes side by side... I really really hope that I can do as what you did and be just awesome as you are in the future but right now I don't have a clue. Any suggestion about how to manage things side by side? - Asked on Tumblr

I'm sorry you have to go through this :(

It's not the end of the world even though you feel like it is. There is so much ahead of you.

Although I have never been through it, I had a friend who had failed and had to give the exam again in the next year.

This is what we did -

Regret and forget:
You can take a few days off to cry, feel bad about it. Regret, hate, feel guilty and blame whoever you want to. But be done with it. Once your few days of sadness are over, you have no right to complain, feel hopeless EVER. You're not allowed to feel like this again. It's very similar to what they show in movies - write on a piece of paper and burn it.

This is important because you can't feel bad for yourself while you're preparing, you can't have low energy or blame others in that phase. It's going to be very hard and you have to be strong.

Get your spirits up: Believe that you can do this. Half the battle will be in your head - the previous failure will haunt you and the anxiety will try to take over. Make sure your winning the battle in your head. YOU CAN DO IT.

Plan: Now, you have new syllabus to study and give the re-exam, right? How many months for the re-exam? How much time do you have to study for the new exam?

Tips: You wanna study the very important and parts you were weak again very throughly.

You can do it side by side, you'll need to discipline yourself to study one particular amount of time for the re-exam and one slot for the new syllabus. You can give less time for the new stuff and then study over time for it later. Passing this subject is your priority.

I love this part, telling the success story - My friend did it. She passed the exam the second time and did good in the next year subjects as well. If she can do it, you can do it too!

You will do great and you'll be much more awesome than me in the future. I believe it! :D
(The fact that you spoke about it and aren't giving up is evidence of the same.)

Just work really hard and keep fighting your way through it. All the very best!  Drop by and update us on your progress sometime later :)

Avoiding negative thoughts

Low self esteem is a challenge I'm also facing. I can ignore it while I'm studying or doing something but it's always in my thoughts during transportation times. - Tumblr

I know ignoring negative thoughts can be really hard, especially when your mind is free to wander while traveling. I listen to motivational tapes or audio lectures to keep me occupied when I wish to ignore these thoughts while transporting myself.

Long QT syndrome mnemonic

Hey guys!
We'll be talking about congenital long QT syndrome today!

Wednesday, January 14, 2015

Lead poisoning mnemonic

Hello everyone! 

We'll be learning about lead poisoning today! 

The mnemonic for lead poisoning is, "LEAD BATTERY"

L: Lead lines
E: Encephalopathy (Common in children)
A: Anemia (Pallor is earliest sign)
D: Drops (foot drop & wrist drop)

B: Basophilic stippling, Burtonian line (on gums)
A: AminoLevulinate (ALA) Dehydrase and Ferrochelatase (Heme Synthase) affected
T: Toys (Lead toys cause toxicity in children)
T: Tremor
E: Encephalitis
R: Renal Tubular Acidosis (Fanconi syndrome)
Y: Young children affected

That's all! 

Monday, January 12, 2015

Self doubt and low self esteem

"When med students ask you about whether they have what it takes to get through med school or if they deserve to be here - You tell them that they made it this far, they were already good enough to even get into a med school, they have the skills. But what if you never deserved to be at med school and got in because you paid money to get the admission and belong go a well off family? What if your scores were just average?

I always had dreams of being a doctor. I want to work hard and I want to help people. The thing about not deserving to study medicine, low self esteem and self doubt is getting me down so bad.

How do I deal with that? Please help me, looking forward to your honest reply." -Asked on Tumblr

Sunday, January 11, 2015

Inability to concentrate before exams

"I have exams in less than 2 weeks and I'm unable to concentrate. Thought of sending you a message."

At times, our concentration does begin to taper right before exams. Maybe it's because exams are pressurizing and we don't want to learn while we are stressed.
Here's what you can do, with varying success -

Read out loud: It's just a way of making sure you are studying something. If your mind starts wandering, you'll won't understand what you are reading out and you'll alert yourself.

Write: Fill up pages with words that are important. It helps you stay on topic and concentrate. Whenever I am unable to concentrate, I make mini notes on what I will write in the exams. (I also write extra points that others are not likely to write in the exam, pretend my answer is going to be the best - Just to boost my spirit and make myself feel better!)

Friday, January 9, 2015

Pathophysiology of symptoms in anemia

I'm answering some questions asked by readers on anemia. They asked -

Why does anemia cause insomnia?
Iron is vital to the brain’s dopamine system. Dopamine is a neurotransmitter that plays a role in neural networks including sleep activity. Hence, iron deficiency causes sleep disorders like insomnia.

Why does iron deficiency cause chest pain?
Reduced oxygen supply to the myocardium causes angina.

That's all!

New year

Here's something written by a friend as motivation for new year.
Thanks for letting me publish this, Raman! -IkaN

So many years have passed and you kept making resolutions every year, same ones year after year just to keep them for few  weeks or may be months.

But this year, it's time to stop making resolutions and start making decisions; decisions firm enough to make this year the absolute best year. 

And while doing so, promise yourself not to fall back on your old ways, and affirm yourself every morning that these decisions ate the ones that are going to help you make new rituals in order to change your life in a positive way forever. And additionally, after a span of some 5 or 10 years you will be looking back at 2015 with a sense of satisfaction and gratitude.

USMLE for Indian medical students

What is the best time to start preparing?
As soon as you have the slightest gut feeling that you might wanna go to the US. It's better to start preparing early and then change your mind than to start late.
I started in March of my third year. Ideally, you should start in your early second year.
It's never "too late" to start. I have a friend who started in internship and nailed the exam within a few months. Preparation time varies.

Sunday, January 4, 2015

Preparing for the USMLE Step 1 exam

"How do I prepare for the USMLE Step 1 exam?" -The most requested post ever!

The essentials - Kaplan videos & notes (for basics) + Goljan book & audio + uWorld + First Aid is the general way to go for most IMG students.

Kaplan videos and notes: They are a good start. If you are time restricted, you may want to skip stuff, fast forward through it.

Anxiety and depression before exams

"How do you manage stress before an exam? I study a lot, but I stress too much and I usually forget everything before the exam. I have anxiety and depression because of this." -Asked on Tumblr

Sounds like you need to believe in yourself a little more. You study a lot. There is no reason for you to worry so much! 

You should start your day with positive thoughts. Affirm this to yourself every morning, "Today is a great day to study and be productive." Clap your hands while you do this. It'll flip your mood right around! Before exams, "I have studied enough and I will do well."

Trust yourself, you've got this. You are a medical student. Getting into medical school ain't easy, but you did it.  You can do this too. 

We have different reasons for getting stressed out -

Friday, January 2, 2015

When you get tired of studying

"Sometimes I get the feeling that my brain can't take more information. Can this be? What can I do when I have this feeling?" -Asked on Tumblr

Yes, it can be! We often get exhausted and feel like we can't take any more information.

In my experience, taking breaks is the best solution for this. I read a research a while back (Don't remember where!) that your performance deteriorates after 45-60 mins of studying depending upon your capacity. If you take a 5-15 min break, however, you do much better.

You can exercise, eat, mediate, dance, listen to music or an inspirational tape if you want in this mini tape. Closing your eyes and lying doing for a while is very relaxing.
Do not use your phone. Your phone has text all over and reading does exhaust you.

I usually get really distracted if I take mini breaks after studying for an hour and don't return to books for another hour. If you have the same problem, you can study for 2-3 hours straight and then take a longer break like a shower, have a long lunch break or a walk around the park.


I spent a lot of time thinking over the name and the logo of the blog, before I even started!

It had to be related to the medical field with a tinge of young enthusiasm. It is a student's blog after all! After a  lot of pondering and questioning, the eureka moment happened. Which word makes us awe in amazement? Awesome! Medicowesome!

If you have a good idea, do it. You don't need to be perfect.