Thursday, March 28, 2019
Burkitt’s Lymphoma types
Molecular mayhem - AML relapse after HSCT
For many hematological disorders including AML, CLL, ALL HSCT is the only viable therapeutic option when cytogenetics are not conducive for chemotherapeutic agents. However subsequent relapses are not uncommon which are due to subtle molecular alterations because of underlying and acquired mutations.
Wednesday, March 27, 2019
WhiteBoard Summary: Lichen Planus
Pathophysiology: Multiple Sclerosis
Antibiotics: Action and Resistance
WHO Pain Ladder
As physicians, never forget how painful pain is, nor how fear magnifies pain. Try not to let these sensations, so often interposed between your patient and recovery, be invisible to you as he/ she bravely puts up with them.
- ALWAYS GO UP THE PAIN LADDER, IF PAIN PERSISTS/ INCREASES.
- Simple analgesics are non-narcotic.
- Review and chart each pain carefully and individually.
- Identify and treat underlying pathology, wherever possible.
- Adjuvants:
1. Neuropathic pain: Gabapentin, Pregabalin, Amitriptyline, Duloxetine, Steroids
2. Bone cancer pain (primary or mets): Radiotherapy, Bisphosphonates
3. Intestinal/ Renal colic: Hyoscine butylbromide
4. Muscle spasm: Baclofen
5. Brief pain relief: Nitrous oxide (usually with oxygen)
- Ashish Singh
Friday, March 22, 2019
Mnemonic: Incubation Period of Hepatitis
Thursday, March 21, 2019
A-a Gradient
A-a gradient =[PAO2 - PaO2]
where:
A-a gradient = difference between alveolar PO2 and arterial PO2
PAO2 = alveolar PO2 (calculated from the alveolar gas equation)
PaO2 = arterial PO2 (measured in arterial blood)
PAO2 =150 - PaCo2/0.8
Normal range for A-a gradient is
10-15 mm Hg
ALL causes of hypoxemia lead to ↑ A-a gradient, EXCEPT:
Hypoventilation, high altitude, upper airway obstruction (e.g. epiglottitis from Haemophilus influenzae, or croup from parainfluenza virus)
Everything else will cause ↑ A-a gradient (e.g. shunt, V/Q mismatch, etc.).
It's much better to remember the exceptions, then everything else becomes the rule!
Also to adjust for age, the thumb rule to calculate A-a gradient is :
Age /4 plus 4
A-a gradient >30 is considered elevated regardless of age.
Bhopalwala. H
Catheter Removal Timing
Removal — Following diagnosis of catheter-related infection, catheter removal is warranted in the following circumstances :
●Severe sepsis
●Hemodynamic instability
●Endocarditis or evidence of metastatic infection
●Erythema or exudate due to suppurative thrombophlebitis
●Persistent bacteremia after 72 hours of antimicrobial therapy to which the organism is susceptible
Source :Uptodate
Bhopalwala. H
Lung Biopsy in VAP
Lung biopsy in Ventilator-associated Pneumonia may be reserved for patients in whom infiltrates are progressive despite antibiotic therapy or patients in whom a non-infectious etiology is suspected.
The purpose of acquiring tissue under these circumstances is to identify a pathogen that may have been missed with previous sampling or a pathogen that is difficult to culture (eg, fungus, herpes viruses) or to identify a noninfectious process masquerading as infection (eg, cancer, cryptogenic organizing pneumonitis, lymphangitis, interstitial pneumonitis, vasculitis).
Source: Uptodate
Bhopalwala. H
Just when you lose hope....
(This is a bit of an off-academic post. So if you are on exam season, avoid reading this.)
Being a doctor!..... we all have dreamt of it. Since we were kids we wanted to wear that stethoscope, walk in long hall ways, go to those people with pain and help them...
You wil watch a TV series and when a surgeon would say "Scalpel please!" you feel goosebumps thinking one day you wanna do it...
But there are somedays you just get home or to hostel from medschool or hospital, and you just don't want to do it anymore. You feel like your passion is lost. You feel like you are no more yourself!
YES! We all have gone through this at least once or even more times in our lives. And when you say this, many other medical students will relate to you too.
Whenever you feel so demotivated, just think WHY YOU STARTED THIS AT THE FIRST PLACE? Did you do it by your will? What made you decide this?
For an example, I always wanted to be a doctor, but my will to become a doctor became so strong when my grandpa passed away in a govt hospital because the doctor in charge didn't diagnose that he was having a heart attack. That day I decided I want to be that doctor who will correctly diagnose and treat people to the best capability I can. I wanted to stop anyone else's family member to pass away because of gross incapacity of a doctor.
You may also have a reason like this if you dig inside your mind. And you will find this reason to fire you up again. To make you push through that one more chapter. Go to that one more ward with a wide smile despite you are sleepless and tired.
Find your reason to stay, not to leave! Because once you are on this voyage, you have decided to work for the betterment of the world and the people, and if you quit midway, it's such a waste, my friend!
Many people dream to be in our shoes. If we give it up, we just are ruining a chance of someone else to be a doctor. So make that medschool seat you owned, be worth it.
Another thing! Going through medschool is not a single man's job. It needs hell load of a support. Find this support system in your family, in your significant other, in your friends, and anyone who would give you strength to carry on, and someone who would motivate you, someone who would be there to say "You can do this! I'm with you!".
Medical books are boring, but books are not the only way you can learn anymore in this digital world. You have millions of videos and interactive websites you can find. You have blogs like our www.medicowesome.com where we breakdown big medical info into small pieces and clarify.
Get your stuff together, clean up your workspace. Cleaner table will motivate you to study too. Use some motivating words in front of your workspace, On your phone's wall paper, On your notebooks! Simply everywhere you would see. If someone would judge you for that, make them your motivation too. Stick up a motivating note on their forehead too! 😂 Just kidding! Ya just keep that smile on always!
Life is great! Medical life is even greater! With all its failures, late night cries, exam phobhias, senior bullies, colleague dramas, its all worth it.
Finish your degree...! This pain lasts only few years! Once you are a fully fledged doctor, you can go ahead and be that wonderful human being you always wanted to be! Don't kill that wonderful person even before you get there!!
We are all voyagers of this same hard journey wherever we are in this world! So let's do this! And in any case you need someone to guide you through your academic related depression or demotivation, always count on us here in Medicowesome!
Have a great day and go own that damn degree!!! 😍
Good luck! See ya later!
Yours,
Jay.
Diagnosing the cause of polycythemia
For Diagnosing the specific cause of polycythemia follow these 3 steps:
STEP1: First check for RBC mass
1)Elevation of Hgb and/or Hct due to a decrease in plasma volume alone (ie, without an increase of the RBC mass) is referred to as relative polycythemia.
STEP2: To diagnose the causes of absolute polycythemia. Check for EPO levels
1)Primary polycythemia is caused by a mutation in RBC progenitor cells that results in increased RBC mass. So there is a decrease in EPO levels. Ex: polycythemia vera (PV)
2)Secondary polycythemia refers to an increase of RBC mass caused by elevated serum EPO. Most often, this is due to an appropriate physiologic response to tissue hypoxia, or by autonomous EPO production(eg, an EPO-secreting tumor)
STEP3: To diagnose the causes of secondary polycythemia. Check PaO2 and SaO2 levels
1)If PaO2<65% and SaO2<92% then it is because of chronic hypoxia due to high altitude, COPD, Smoking, etc.
2)If PaO2 and SaO2 levels are normal then consider EPO-secreting tumor(renal cell carcinoma, pheochromocytoma).
-Srikar Sama
Wednesday, March 20, 2019
Places to Target for Research
Email Format for Research
Email Format for a Research Position
Hello Dr. XYZ,
I am ABC, a medical student, currently doing clinical elective rotations.
I'm highly interested in cardiology. Your /Case Western Reserve University's research work ( refer to either the person's or the University's work) , particularly in general cardiology and electrophysiology is exemplary.
I believe you accept volunteer Research Scholars. It would be an honor to work in this institute as a Research Scholar.
I would be willing to work for a year, and would also consider an unpaid position.
I am attaching my CV with this email.
Hoping to hear back from you.
Wish you a happy new year.
Thanks.
Hope this helps :)
Bhopalwala. H
How to Land a Research Spot in USA
Tuesday, March 19, 2019
Catheter Related Candidemia Treatment Indications
Antibiotic Lock Therapy
Timing of Catheter Replacement in CRBSI
Immunization certificate sample for electives and observerships
Since many of you emailed me regarding the immunization form, I thought of sharing it on Google Docs.
Monday, March 18, 2019
Step 2 CS: Neurology Case mnemonic
Right to left shunt causing Hypoxemia
A right-to-left shunt exists when blood passes from the right to the left side of the heart without being oxygenated. There are two types of right-to-left shunts:
●Anatomic shunts exist when the alveoli are bypassed. Examples include intracardiac shunts, pulmonary arteriovenous malformations (AVMs), and hepatopulmonary syndrome.
●Physiologic shunts exist when non-ventilated alveoli are perfused. Examples include atelectasis and diseases with alveolar filling (eg, pneumonia, acute respiratory distress syndrome).
Right-to-left shunts cause extreme V/Q mismatch, with a V/Q ratio of zero in some lung regions. The net effect is hypoxemia, which is difficult to correct with supplemental oxygen.
The degree of shunt can be quantified from the shunt equation:
Qs/Qt = (CcO2 - CaO2) ÷ (CcO2 - CvO2)
where Qs/Qt is the shunt fraction, CcO2 is the end-capillary oxygen content, CaO2 is the arterial oxygen content, and CvO2 is the mixed venous oxygen content. CaO2 and CvO2 are calculated from arterial and mixed venous blood gas measurements, respectively. CcO2 is estimated from the PAO2.
Source: UpToDate
Bhopalwala. H
Causes of Hypoventilation
Hypoventilation —
The lung alveolus is a space in which gas makes up 100 percent of the contents. This means that once the partial pressure of one gas rises, the other must decrease. Both arterial (PaCO2) and alveolar (PACO2) carbon dioxide tension increase during hypoventilation, which causes the alveolar oxygen tension (PAO2) to decrease. As a result, diffusion of oxygen from the alveolus to the pulmonary capillary declines with a net effect of hypoxemia and hypercapnia. Because the respiratory quotient (Defined as CO2 eliminated/O2 consumed) is assumed to be 0.8, hypoventilation affects PaCO2more than O2.
Hypoxemia due to pure hypoventilation (ie, in the absence of an elevated A-a gradient) can be identified by two characteristics. First, it readily corrects with a small increase in the fraction of inspired oxygen (FiO2). Second, the paCO2 is elevated. An exception exists when the hypoventilation is prolonged because atelectasis can occur, which will increase the A-a gradient . Abnormalities that cause pure hypoventilation include:
●CNS depression, such as drug overdose, structural CNS lesions, or ischemic CNS lesions that impact the respiratory center
●Obesity hypoventilation (Pickwickian) syndrome
●Impaired neural conduction, such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, high cervical spine injury, phrenic nerve paralysis, or aminoglycoside blockade
●Muscular weakness, such as myasthenia gravis, idiopathic diaphragmatic paralysis, polymyositis, muscular dystrophy, or severe hypothyroidism
●Poor chest wall elasticity, such as a flail chest or kyphoscoliosis
Bhopalwala. H
Wednesday, March 13, 2019
Types of Sphenoid Sinues.
Hello Guy's!
Here's a sneak peek into the world of Neurosurgery!
In cases of Pituitary Adenomas, the general surgical approach is a TransNasal TransSphenoidal Approach for the excision of the lesion.
To know the type of sphenoid sinus is an important step in the pre-operative planning for the surgery. It also helps in estimating the site where we are most likely to encounter the tumor and the pituitary gland.
Hamburger classified 3 types of pneumatization based on its relationship to the sella turcica.
1)Conchal (rudimentary or absent sphenoid sinus)
2)Presellar (a posterior sphenoid sinus wall that is separated from sella by thick bone).
3)Sellar (a posterior sphenoid sinus wall that is adjacent to sella).
That's all for now... Time to Scrub.
Let's learn Together!
~Medha Vyas.
Monday, March 11, 2019
Restrictive vs Liberal approach to transfusion in Sepsis
Norepinephrine in ICU
Norepinephrine (noradrenaline) Levophed
8 to 12 mcg/minute (0.1 to 0.15 mcg/kg/minute)
A lower initial dose of 5 mcg/minute may be used, eg, in older adults 2 to 4 mcg/minute (0.025 to 0.05 mcg/kg/minute) 35 to 100 mcg/minute (0.5 to 0.75 mcg/kg/minute; up to 3.3 mcg/kg/minute has been needed rarely)
Initial vasopressor of choice in septic, cardiogenic, and hypovolemic shock.
Wide range of doses utilized clinically.
Must be diluted; eg, a usual concentration is 4 mg in 250 mL of D5W or NS (16 micrograms/mL).
Bhopalwala. H
Milrinone in ICU
Inotrope (nonadrenergic, PDE3 inhibitor)
Milrinone Primacor
Optional loading dose: 50 mcg/kg over 10 minutes (usually not given) 0.125 to 0.75 mcg/kg/minute
Alternative for short-term cardiac output augmentation to maintain organ perfusion in cardiogenic shock refractory to other agents.
Increases cardiac contractility and modestly increases heart rate at high doses; may cause peripheral vasodilation, hypotension, and/or ventricular arrhythmia.
Renally cleared; dose adjustment in renal impairment needed.
Must be diluted; eg, a usual concentration is 40 mg in 200 mL D5W (200 micrograms/mL); use of a commercially available pre-diluted solution is preferred.
Bhopalwala. H
Dobutamine in ICU
Dobutamine Dobutrex
0.5 to 1 mcg/kg/minute
(alternatively, 2.5 mcg/kg/minute in more severe cardiac decompensation) 2 to 20 mcg/kg/minute
20 to 40 mcg/kg/minute;
Doses >20 mcg/kg/minute are not recommended in heart failure and should be reserved for salvage therapy
Initial agent of choice in cardiogenic shock with low cardiac output and maintained blood pressure.
Add-on to norepinephrine for cardiac output augmentation in septic shock with myocardial dysfunction (eg, in elevated left ventricular filling pressures and adequate MAP) or ongoing hypoperfusion despite adequate intravascular volume and use of vasopressor agents.
Increases cardiac contractility and rate; may cause hypotension and tachyarrhythmias.
Must be diluted; a usual concentration is 250 mg in 500 mL D5W or NS (0.5 mg/mL); use of a commercially available pre-diluted solution is preferred.
Bhopalwala. H
Vasopressin in ICU
Vasopressin (arginine-vasopressin) Pitressin, Vasostrict
0.03 units per minute (alternatively 0.01 to 0.03 units/minute initially) 0.03 to 0.04 units per minute (not titrated)
0.04 to 0.07 units/minute;
Doses >0.04 units/minute can cause cardiac ischemia and should be reserved for salvage therapy
Add-on to norepinephrine to raise blood pressure to target MAP or decrease norepinephrine requirement. Not recommended as a replacement for a first-line vasopressor.
Pure vasoconstrictor; may decrease stroke volume and cardiac output in myocardial dysfunction or precipitate ischemia in coronary artery disease.
Must be diluted; eg, a usual concentration is 25 units in 250 mL D5W or NS (0.1 units/mL)
Bhopalwala. H
Sunday, March 10, 2019
LMR (Last minute revision) Stuff for obstetrics and gynecology drugs
In LMR sessions, I will share final year MBBS Viva things on drugs and specimen.You can add your list in the comments below.
Today I will share the Obstetric and gynaecology viva on drugs.
Lets get started.
1.Tranexamic acid and mefanemic acid combination
Tranexamic acid:
- anti-fibrinolytic
- Amino caproic acid derivative
- CONVERTS plasmin to plasminogen
- given during menstruation
- Adverse effect:- Intracranial thrombosis
Mefanemic Acid:
- COX inhibitor.
- Given during menstruation
- Adverse effect:- dyspepsia,gastric ulcer
- Ovulatory cycles of DUB
- Post IUCD bleeding
- Post sterilization mennorhagia
- Fibroid
Doxylamine is anti histaminics that has effects on acetylcholine and serotonin release. And you know their receptor is present on CTZ centers.
Vitamin B6 is pyridoxine.
In pregnancy and poor diet the amount decreases.
USE:- Emesis during pregnancy at bedtime (not more than 2 tablet in a day).
3.Dinoprostone gel
- Prostaglandin E2
- 500 micro gram into the cervical canal below the level of internal os
- Or 1-2 mg in the posterior fornix
- maximum 3 doses 6 hourly
- Applied in posterior fornix when membrane is ruptured
- applied in internal os when membrane is intact
- USE- Cervical ripening in IOL.
- Before and after CTG monitoring is must.
- C/I- Previous CS, Impending scar rupture,fetal distress,asthma,severe heart disease
4.L-Arginine+Folic acid+isothiocyanidin
- L-Arginine is precursor for Nitric oxide generation that will lead to vasodialtion
- USE: In IUGR, Severe oligohydroamnios, preventing pre-eclampsia
- PGE1
- ROUTE= sublingual,vaginal,rectal (never parentral)
- S/E:Fever,chills,shivering
- Teratogenic: Mobius syndrome (Category X drug)
- USES:-
- OBSTETRIC USES:
- Termination of pregnancy
- PPH prevention and treatment.
- Pe hysterectomy
- IUI
- Cervical pregnancy
- Treatment of peptic ulcer caused by NSAIDs.
- Loop diuretic.
- prior to blood transfusion in severe anemia
- congestive cardiac failure
- used in complications not as anti hypertensives
- PIH with massive edema
- USE: Mixed bacterial and fungal vaginosis
- USE: GERD, peptic ulcer
- Injectable Anti-coagulant
- In 1st trimester
- Antidote: Protamine sulfate
- USE: DVT, APLA, PE, recurrent abortion (Prophylaxis:ASPIRIN+HEPARIN)
- Prophylactic: 100mg elemental iron+500 micro gram folic acid daily from 2nd trimester throughout pregnancy +6 month postpartum
- Treatment: Oral iron 200 mg elemental iron daily
- Folic acid deficiency lead to abortions, abruptio, IUGR, NTD
- In folic acid deficiency dose is 4000mg
- IgG, intramuscular
- 300 micro gram=15 ml of D positive red cell/ 30 ml of fetal whole blood
- If ICT -VE at 28 weeks
- 2 doses 12 mg betamethasone i/m 24 hours apart
- 4 doses 6 mg dexamethasone 12 hours apart
- IV for Heart resuscitation, poor kidney function, Cocaine toxicity
- Poisoning cases
- Reviving newborn
- Preventing chemotherapy side effects
- Hyperkalemia
- metabolic acidosis
- Central Muscle relaxant and anti convulsant, Tranquilizer
- S/E:- Maternal (Hypotension) and Fetal (Respiratory depression, hypotonia)
- Direct arteriolar vasodilator
- Calcium channel blocker
- USE:Tocolytics
- A/E: Flushing, Hypotension, headache, Inhibition of labor
- Anti-hypertensive
- combined alpha and beta blocker
- orally 100mg tid to 2.4 g daily
- USE: Hypertension and hypertensive crisis
- S/E:tremor, headache, CCF.
- C/I: Hepatic disorder, asthma, CCF
- Anti-spasmodic (PDE-4 Inhibitor)
- Enhance cervical dilatation during childbirth
- USE: Acute renal colicky, augment labor.
Friday, March 8, 2019
Classification Criteria for Adult Still Disease
●Yamaguchi criteria – The Yamaguchi criteria require the presence of five features, with at least two being major diagnostic criteria . In addition, the presence of any infection, malignancy, or other rheumatic disorder known to mimic ASD in its clinical features precludes the diagnosis of ASD, at least for the purpose of research.
The four major Yamaguchi criteria are:
•Fever of at least 39ºC (102.2ºF) lasting at least one week
•Arthralgias or arthritis lasting two weeks or longer
•A nonpruritic macular or maculopapular skin rash that is salmon-colored in appearance and usually found over the trunk or extremities during febrile episodes
•Leukocytosis (10,000/microL or greater), with at least 80 percent granulocytes
The minor Yamaguchi criteria include:
•Sore throat
•Lymphadenopathy
•Hepatomegaly or splenomegaly
•Abnormal liver function studies, particularly elevations in aspartate and alanine aminotransferase and lactate dehydrogenase concentrations
•Negative tests for antinuclear antibody (ANA) and rheumatoid factor (RF)
Bhopalwala. H
Useful Pediatrics mobile apps
Wednesday, March 6, 2019
HAP and VAP
Pneumonia types — The 2016 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines distinguish the following types of pneumonia :
●Hospital-acquired (or nosocomial) pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.
●Ventilator-associated pneumonia (VAP) is a type of HAP that develops more than 48 hours after endotracheal intubation.
Bhopalwala. H
Saturday, March 2, 2019
qSOFA Score for Sepsis
The qSOFA (quick Sequential Organ Failure Assessment) score is easy to calculate since it only has three components, each of which are readily identifiable at the bedside and are allocated one point:
●Respiratory rate ≥22/minute
●Altered mentation
●Systolic blood pressure ≤100 mmHg
Bhopalwala. H