Thursday, November 26, 2020

Shunt fraction and its importance

 Hello Awesomites ! :D

Qp/Qs =Shunt fraction or shunt flow (where p=pulmonary s=systemic)

-Ratio >1 left to right shunt suggestive of more pulmonary flow than systemic flow.

If VSD has ratio >2:1 then indication for surgery .

-Ratio <1 Right to left shunt 

NOTE: Supracristal VSD need surgery slways as associated with AR or PS. 

 

-UPASANA Y.

Saturday, November 7, 2020

It's a Carny Problem

 Carney's Triad - ENCHONDROMA + PARAADRENAL GANGLIOMA + GIST

Carney's Syndrome - multiple benign tumors, mainly of heart and skin

Carney Stratakis Syndrome - Pediatric GIST (Gastrointestinal Stromal Tumor)

Friday, November 6, 2020

Shock by Dr. Ganti (Pulm/Crit)

 

Blood Donation

BLOOD DONATION

PRE-DONATION

HISTORY:

  • Men can donate safely once every three months while women can donate every four months
  • Age between 18 and 60 years
  • The donor should be in a healthy state of mind and body
  • Past one year - not been treated for Rabies or received Hepatitis B immune globulin
  • Past six months - not had a tattoo, ear or skin piercing or acupuncture, not received blood or blood products, no serious illness or major surgery, no contact with a person with hepatitis or yellow jaundice.
  • Past three months - not donated blood or been treated for Malaria
  • Past one month - had any immunizations
  • Past 72 hours - had dental work or taken Aspirin
  • Past 48 hours - taken any antibiotics or any other medications (Allopathic or Ayurveda or Siddha or Homeopathy)
  • Past 24 hours - taken alcoholic beverages
  • Presently - not suffering from cough, influenza or sore throat, the common cold
  • Women should not be pregnant or breastfeeding her child or menstruating.
  • No diabetes, chest pain, heart disease or high BP, cancer, blood clotting problem or blood disease, unexplained fever weight loss, fatigue, night sweats, enlarged lymph nodes in armpits, neck or groin, white patches in the mouth, etc.
  • No history of TB, bronchial asthma or allergic disorder, liver disease, kidney disease, fits or fainting, blue or purple spots on the skin or mucous membranes, received human pituitary - growth hormones, etc.

EXAMINATION:

  • Temperature - Normal (oral temperature not exceeding 37.50 C)
  • Pulse - between 50 and 100/minute with no irregularities
  • Blood Pressure -Systolic 100-180 mm Hg and Diastolic 50 - 100 mm Hg
  • Bodyweight - not less than 45 Kg
  • Hemoglobin - not less than 12.5 g/dL-

Procedure to measure Hb using CuSO4:

i) Massage the finger to be pricked (preferably ring finger)

ii) Disinfect it

iii) Prick using disposable needle/ lancet

iv) Put the drop of blood in CuSO4 containing beaker

v) If the blood drop sinks, Hb is more than 12.5, hence the person can donate blood (provided no other contraindication).

PROCEDURE:

  • Identify donor and label blood collection bag and test tubes
  • Ask the donor to state their full name
  • Ensure that:

    1. the blood collection bag is of the correct type;
    2. the labels on the blood collection bag and all its satellite bags, sample tubes and donor records have the correct patient name and number;
    3. the information on the labels matches with the donor's information

  • Select a large, firm vein, preferably in the antecubital fossa, from an area free from skin lesions or scars
  • Clean the site of venepuncture by alcohol and let it dry
  • Perform phlebotomy using a 16-gauge needle, which is usually attached to the blood collection bag. Use of a retractable needle or safety needle with a needle cover is preferred if available, but all should be cut off at the end of the procedure.
  • Ask the donor to open and close the fist slowly every 10–12 seconds during collection
  • Remove the tourniquet when the blood flow is established or after 2 minutes, whichever comes first
  • Ask the patient to squeeze a ball intermittently during the procedure
  • Monitor the donor and the donated unit
  • Remove the needle and collect samples
  • Cut off the needle using a sterile pair of scissors
  • Collect blood samples for laboratory testing

POST-PROCEDURE:

DONOR CARE:

  • ask the donor to remain in the chair and relax for a few minutes
  • inspect the venepuncture site; if it is not bleeding, apply a bandage to the site; if it is bleeding, apply further pressure
  • ask the donor to sit up slowly and ask how the person is feeling
  • before the donor leaves the donation room, ensure that the person can stand up without dizziness and without a drop in blood pressure
  • offer the donor some refreshments

BLOOD UNIT AND SAMPLES:

  • Transfer the blood unit to a proper storage container according to the blood center requirements and the product
  • Ensure that collected blood samples are stored and delivered to the laboratory with completed documentation, at the recommended temperature, and in a leakproof, closed container

REFERENCES:

http://naco.gov.in/blood-transfusion-services-publications

Written by our guest authors HARSH JOGI and AYUSHI GUPTA

Tuesday, November 3, 2020

Ascitic Tap

Requirements
Written informed consent, Betadine, Spirit, Sterile gloves, Sterile drapes, a 1.5-3.5 cm 20-22 G needle, a 5-20mL syringe is used, 18-20 G needle attached to a non-collapsible tubing to a sterile collection bag.

Procedure:
1. Follow universal precautions. 

2. Skin around the site of puncture to be disinfected with betadine or Chlorhexidine and spirit and draped with sterile drapes.

3. Position: The patient should be in supine position.

4. Site: In the flank mid-way between the anterior superior iliac crest and 
umbilicus (lateral to rectus muscle). Areas of scars of previous surgery should be 
avoided. 

5. Local Anaesthesia:
a) Skin, subcutaneous tissue, abdominal wall layers up to parietal peritoneum to be anesthetized with 2% lidocaine filled syringe using a 22-25 G needle.The needle is advanced into the subcutaneous tissue aspirating every 2-3 mm prior to injecting. 
b) Once a loss of resistance is felt and peritoneal fluid is drawn into the syringe, it indicates that we have entered the peritoneal cavity. Additional lidocaine is then injected to anesthetize the pain-sensitive parietal 
peritoneum. 
(A total of approx. 4-5 ml lidocaine is adequate.) 
c) The needle is then withdrawn. 

6. Puncture: 
For diagnostic tap – a 1.5-3.5 cm 20-22 G needle attached to a 5-20mL syringe 
is used. 
Technique – The aim is to prevent leak by ensuring the skin puncture site is 
not directly over the puncture site into the peritoneal cavity. 
 Z track technique – Pull skin about 2 cm downward before puncturing 
skin→ then leave the skin after entering few mm so as to form a Z
Or
 Angular insertion technique - Insert the needle by keeping at an acute angle to the skin surface. Then advance the needle slowly through the underlying subcutaneous 
tissue in 5 mm increments while intermittently aspirating. Generally for the diagnostic purposes, the sample is sent for the following 
tests, all of them collecting in separate containers:
● Routine & microscopy
● Culture and sensitivity 
● MGIT+ Gene Xpert
● ADA
● LDH 
● Amylase
● Cytology (optional)
For therapeutic tap - A large bore 1.5-2 cm 16-18 G needle is used instead.The syringe is detached and the needle is attached to a non-collapsible rubber tubing.The ascites fluid is drained slowly through the rubber tubing 
connected to the needle into a sterile collection bag. 

7. Seal : After the puncture, the punctured skin is sealed with a tincture benzoin 
seal. 

8. Post procedures: T.P.R, B.P to be recorded half hourly and the 
patient should not be given feeds for the next 4 hours. If there is pain, analgesics may be given.

- Mitali shroff

Monday, November 2, 2020

USMLE STEP 1: Resources and preparation

USMLE STEP 1: RESOURCES AND PREPARATION

1.1 MAIN RESOURCES
These two resources are inevitable for Step 1 preparation.
First Aid for Step 1
Uworld question bank
UWSAs and NBMEs

SUPPLEMENTAL RESOURCES:
Kaplan videos (subject wise)
Boards and Beyond videos
Sketchy videos for microbiology and pharmacology
Pathoma videos and notes for pathology
UW biostats review for biostatistics
BRS books for behavioral science.
Conrad Fischer’s 100 cases for ethics

FLASHCARDS
ANKI

SUPPLEMENTAL Q-BANKS
Amboss
Kaplan
USMLE Rx

1.2 HOW TO USE THESE RESOURCES
1. FIRST AID
Read FA 3-4 times, from cover to cover.
FA provides every single concept in brief. You may need supplemental resources and videos in order to understand these concepts, but once you do, the final high yield topic is mentioned in FA.
Consider it the most concise version of take away points of all subjects.
Read a section/ topic/ subject/ system from first aid, and always solve MCQs simultaneously for reinforcement. 
If you find it difficult to understand a particular subject, supplement it with videos at that time.

EG: I started reading biochemistry from first aid and couldn’t grasp the concept. What do I do?
Watch Kaplan videos (or BNB or any other resource) for biochemistry. 
Annotate important points from the videos into my FA.
Read the same sub-topic from FA simultaneously.
Finally, when I have a good grasp of the concept, I will solve only biochemistry MCQs from UW (or any other q-bank)
This way, I have consolidated learning biochemistry by using FA, UW and videos to understand the concept
If you work well with flashcards, I will make my own flashcards using ANKI or used pre-formed flashcards from ANKI for intermittent learning.

2. UWORLD
This is a question bank which has various options for subscription. Understand that you will need this q-bank until the date of your exam, so either take a 6 month or 1-year subscription.
This needs to be done TWICE. Period.

MODES
1. Timed: You get 60 minutes to solve 40 questions (You cannot read the explanation until you have finished the whole block)
2. Tutor: No limit on solving questions. (You can exceed 60 minutes for 40 questions)
3. Timed-tutor: You will be timed, but there will be an option of “show answer”, which will give you the explanation right away after you have marked an answer and clicked on it.

FIRST PASS: Use timed-tutor mode.
Always use timed mode as it will help you overcome the time issues in the final exam, especially if you are within 6 months of your exam date. 
If you have just begun and are using uworld to solve questions along with your first reading of FA, you may prefer using the tutor mode.
Make sure to annotate extra information from UW into your FA. FA does not have enough space, so get it spiral binded and add pages within or make an extra notebook.
If you are not comfortable writing so much extra information into FA and prefer flashcards, make flashcards in UW of all the info which is not mentioned in FA.

Remember, in the end UW and FA will be your final resources during your dedicated phase, so you need all information consolidated at one place.
How to make flashcards: Keep all the tables and flowcharts under one deck. Make separate decks according to subjects. Make a deck of super volatile concepts and concepts not mentioned in FA.

SECOND PASS: Use timed mode
Timed mode will help you prepare for your test.
Reset UW again and start from scratch in the 2nd pass. Alternatively, if you don’t have enough time, solve your incorrect and marked questions only.
Keep revising a few pages of FA daily.

3. SKETCHY MICRO
If you are a visual learner, this is an amazing tool. It will help you to remember these bugs till your Step 3 exam as well. 
Keep revising the pictures at regular intervals as it is easy to forget them.
If it gets too much, just focus on sketchy for viruses and fungi. 
Do sketchy for VIRUSES and keep your FA open. Read from both places and learn simultaneously. Sketchy really helps with virology.

4. PATHOMA
Go through the videos and annotate in FA.
Solve MCQs after finishing each sub-topic

5. BNB VIDEOS and KAPLAN VIDEOS
These are needed during the early part of your prep to understand the concepts.
Keep FA open and annotate important points from the videos or make your own notes in a separate notebook.
Don’t underestimate their importance in building your base in these concepts as they will help you with Step 2 and Step 3 as well.

AMBOSS Q-BANK

Use this in the end. After you have gone through UW twice and still want additional practice, use Amboss.
They have tougher questions, so don’t get discouraged.
No need to annotate information unless it seems high yield.
Use it to practice as many questions.

UWSAs AND NBMEs (ASSESSMENTS)

These are assessments which give you a score at the end. They may or may not be able to predict your final score, so use them to see how much improvement is needed, but do not rely on them blindly.
Take an online NBME or UWSA1 after the first pass of UW (which would coincide with at least the 2nd or 3rd reading of FA)
Find out your weaknesses. See videos, re-learn FA, solve UW incorrects to improve upon those weak areas.
When you are within 3 months of your step 1 date, start taking assessments every 10-15 days.
Leave NBME 18 and UWSA 2 for the last one month as they are ‘considered’ to be predictive.

1.3 TIMELINE ( MOST IMPORTANT, NEEDS TO BE INDIVIDUALIZED) 
In the descending order:

Dedicated Study Period: Last 2-3 months (8-10 hours per day)
Final revision of FA
UW incorrects
Amboss questions for practice
Assessments every 15 days

Pre-dedicated period: 2-3 months (4-8 hours per day)
2nd and 3rd revision of FA
Start UW with annotation in FA/ make separate notes/ make flashcards of high yield points not mentioned in FA
Take an assessment (NBME or UWSA1) and see your weakness. Go through supplementary material for those weak areas (videos, other books)

Initial Phase: 4-6 months (4-8 hours per day)
1st reading of FA
Videos and text for establishing basic concepts
Solving any q-bank for practice and reinforcement
Annotating important points

Written by Amrin Kharawala