Ampicillin-rash in infectious mononucleosis

 Hi!

Penicillins such as amoxicillin and ampicillin are currently not recommended in patients with infectious mononucleosis with bacterial secondaries (streptococcal tonsillo-pharyngitis). Why?

Treatment of syphilis

What drug is used for the treatment of syphilis?

Topiramate mnemonic

How I remember that the anti-epileptic drug (AED) topiramate is associated with kidney stones:
To-pee-ra-mate can cause you "to pee rocks, mate." Rocks = stones, pee = urine.

How I remember that the AED topiramate is associated with mild cognitive impairment:
toPIRAmATE can make you a "pirate" and make you forget "Tom"! (This one is a stretch but can work lol)

-IkaN

Anti-epileptics in pregnancy mnemonic

 The choice of antiepileptic drugs for women with epilepsy of childbearing age who are planning a pregnancy are

Tricyclic antidepressants (TCA) mnemonic

Medications that can cause depression

Did you know that the medications we prescribe can be associated with depression?

Beta-blockers and reserpine should also be considered as the cause of depression in those newly started on the medication.

Other such medications include:

Guidelines for management of gout by ACR 2020

 Hi!

Long time..

Urate-lowering therapy indications and important guidelines for management of gout, as updated by ACR in 2020:

Respiratory fluoroquinolones

Why are moxifloxacin, gemifloxacin, and levofloxacin also known as respiratory fluoroquinolones?

Internship diaries: Perception of nipple discharge

A 60-year-old female complained of clear discharge from her right breast for one week. 

On examination, the right breast nipple was painful and there was clear fluid around the nipple. Expressing the breast produced no discharge. Incidentally, she mentioned a rash that was hurting on her right shoulder. The rash was a distinctive cluster of fluid-filled blisters with inflamed underlying skin, suggestive of shingles. 

Mechanism of action of lipid-lowering drugs

Hey everyone! 

I wanted to talk about the new lipid-lowering drug, bempedoic acid. But first, let’s just quickly go through the mechanism of action of the existing lipid-lowering drugs:

Statin reduces cholesterol synthesis by HMG-CoA Reductase inhibition.

Ezetimibe inhibits cholesterol absorption from the intestine.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors notes and mnemonics

 A short post on SGLT2i!

Examples:
Canagliflozin (brand name Invokana)
Empagliflozin (brand name Jardiance)
Dapagliflozin (Farxiga)
Ertugliflozin (Steglatro)

Mechanism: Blocks renal glucose absorption, resulting in glycosuria.
Mnemonic: GliFlozIN makes Glucose Flow In Nephrons

In addition:
Has beneficial effects on ASCVD events, heart failure, and CKD.
Causes weight loss  (Mnemonic: SGLT2 Surely Generates Less Tummy).
No risk of hypoglycemia.

Side effects:
Genital fungal infections.
Fournier’s gangrene.
Dehydration may result.
Euglycemic diabetic ketoacidosis (should be held 24H prior to scheduled surgeries).
Canagliflozin may increase the risk of leg amputation (should be avoided in those with peripheral vascular disease).

Caution: Renal dose adjustment is required in CKD.

That's all!
-IkaN

Related posts:
Oral hypoglycemic drugs used for diabetes mellitus mnemonic
Oral hypoglycemic drugs and weight - Weight gain or weight loss mnemonic

Metformin notes and mnemonics

 A short post on Metformin!

Mechanism:
Decreases hepatic glucose output by reducing hepatic gluconeogenesis and glycogenolysis.
Enhances peripheral glucose uptake and enhances insulin sensitivity.
Decreases glucose absorption in the GI tract.
Reduces hemoglobin A1C levels by 1.5%.

In addition:
Decreases triglyceride levels.
Decreases LDL-cholesterol.
May increase HDL-cholesterol.

Side effects:
Diarrhea
Vitamin B12 deficiency may develop
Risk of lactic acidosis in renal or liver disease or CHF

Contraindicated in: GFR <30ml/min.

That's all!
-IkaN

Related posts:
Oral hypoglycemic drugs used for diabetes mellitus mnemonic: Metformin meets glucose and advises it to stay out of the blood. It asks the liver to keep glucose in the house (Inhibits hepatic glucose production) and asks the glucose in the bloodstream to go into adipose and skeletal muscle (Stimulates peripheral uptake of glucose). Metformin never met a glucose molecule and did not tell him to not stay in the blood (Illustration in the original post).

Oral hypoglycemic drugs and weight - Weight gain or weight loss mnemonic: "Metformin forms you in, makes you thin."

Fact- Reversible ADP-r inhibitors cause breathlessness

Hi

 Reversible inhibitors of ADP-r (P2Y12) such as ticagrelor, cangrelor, and elinogrel used as anti-platelet drugs have a unique side effect of dyspnea, unlike the irreversible ones. This is hypothesized to occur because of reversible inhibition of ADP-r on sensory neurons. Since half-life of the reversible inhibitors is shorter than that of irreversibles, repeated doses lead to permanent inhibition of the P2Y12 receptors on sensory neurons.

 Moreover, oral administration is found to cause more severe effects on the breathing difficulties than the parenteral route.

 Source- Research gate 

 

That's  all

- Jaskunwar Singh

Facebook: Schizophrenia treatment

Q2) A schizophrenic patient was on chlorpromazine and olanzapine for the past 6 months, with each drug being prescribed for atleast 6 weeks. The patient is still symptomatic. What is next line of management?
A) Haloperidol depot
B) Aripiprazole
C) Risperidone depot
D) Clozapine

#Medicowesome
#Psychiatry
#Pharmacology

Answer to the above question is D) Clozapine.
Explanation: If two drugs are used for schizophrenia and yet no improvement is seen, then Clozapine is used. Clozapine is DOC for resistant schizophrenia.

Some key points of Clozapine:-
1) It is most effective Antipsychotic
2) Clozapine is most toxic Antipsychotic.
3) It causes following special side effects:-
    a) Agranulocytosis :
-Therapeutic Drug monitoring (TDM) cannot be done because plasma concentration is not proportional with agranulocytosis
- Hence it is C/I with Carbamazepine.
   b) De novo seizure.
   c) Myocarditis.
   d) Sedation - Most common side effect.
   e) Sialorrhea- Wet pillow syndrome.
4) It shows Antisuicidal effect.

That's all!

- Demotional bloke!

Topics to read before PG entrance exams!

Hello Awesomites!

The aim is to help the students who want to give upcoming NEET PG Exam and are clueless about how to plan and prepare ?
I know my friend struggling day in and out for life in Covid wards. Exams doesn't matter now.
When they will have time in hand I want to help them out with plan beforehand. They are already brilliant enough to have been through all the challenges. :)

I know you can't predict what is important for this or next exams. Atleast with time in hand you can glance through some topics that contribute 70% of any exam. I am sharing the list 1st year subject I made during my preparation.

1.ANATOMY

• Embryology 

1. Pharyngeal arches
2. Neural crest derivatives
3. Oogenesis and spermatogenesis
4. Notochord and remnants 
5. Extraembryonic mesoderm
6. Diaphragm 
7. Cardiovascular system ( Abnormal subclavian artery)
8. Urogenital system 

• Histology 

1. Cerebellum
2. Osteoblasts
3. Urinary bladder epithelium
4. Cell junctions
5. Collagen types
6. cartilage
7. Tonsil,Lymph nodes, spleen,thymus
8. Stomach glands
9. Skin with sebaceous glands
10. Connective tissue types
11. Retina 
12. Salivary gland

• NEUROLOGY

1. Fornix 
2. Corpus callosum
3. Cranial nerves and its lesion
4. Brainstem syndromes (lateral medullary )
5. Foramen of skull
6. Facial nerve and trigeminal nerve
7. blood brain barrier
8. Functional area and functional columns
9. Parasympathetic ganglion 
10. Phrenic nerve and vagus

• GROSS

1.  Compartments of lower limb with nerve and blood supply
2. Blood supply of thyroid,oesophagus,ureter,Anal canal 
3. Waldeyer ring
4. External carotid artery
5. Circle of willis
6. Muscle of eye
7. Brachial plexus (Sensory and motor supply of upper limb)
8. Perineum
9. Cruciate ligaments
10. Vocal cords
11. Mediastinum
12. IVC tributaries
13. Cavernous sinus and superior orbital fissure 
14. Splanchanic plexus

2. BIOCHEMISTRY

• Inborn error of metabolism (Types,Enzyme deficient,hallmark feature,Investigation of choice and treatment)
• Rate limiting step 
• Carbohydrate metabolism (Glycolysis,Glycogen storage disease,Glucogenesis,glycogenolysis,PFK-1)
• Lipid metabolism ( Hyperlipoproteinemia and hypolipoproteinemia)
• Vitamin (Coenzyme)
• Electron transport chain inhibitor
• Heme metabolism and Porphyria
• Ketone body formation 
• Urea cycle disorder
• Competitive, non competitive and allosteric inhibitors
• Mitochondrial disorders 
• Amino acid disorder
• Lead poisoning
• Translation process 

3.PHYSIOLOGY

• Receptors
• Neurotransmitter and functions
• Second messenger
• Reflexes
• Baroreceptors and chemorecptors
• JVP 
• ECG And EEG
• Spirometry
• RAAS 
• Counter current exchanger and multiplier
• Factors affecting compliance of lung 
• Action potential
• Smooth muscle and cardiac muscle
• Channels and types 
• GIT hormones 
• Tracts and lesions(brown sequerd syndrome)
• LH,FSH,GH and insulin glucagon

 Following are the list of 2nd year topics.

1.FORENSIC MEDICINE

• Ballistics (Bullet ranges)
• Identification (female male, blood sample)
• Recent amendments in acts (POCSO act, MTP Act)
• Application of IPC,CrPC sections
• Postmortem changes
• Dentition And Xray of wrist elbow and pelvis to determine age
• Injuries -fracture of skull, RTA, Bruise
• Toxicology- Plant based image, Preservation of viscera, Snakes,Arsenic, OP poisoning,Mercury,cadmium,Cardiac poison
• Consent
• Grievous hurt and murder vs culpable homicide
• Seminal stains
• Dowry death and Rape
• Battered baby syndrome
• Plant Toxicology (castor,abrus,strychnine,Dhatura,Aconite,Oleander,Calotropis,Opium,Cannabis)

2. PATHOLOGY-

• Breast cancer, Lung cancer and Ovarian and testicular cancer
• CD markers
• Hemolytic anemia
• Vasculitis
• Endocarditis And MI
• Types of hypersensitivity reaction
• Platelet and coagulation disorder(ITP,TTP,hemophilias,vWD)
• Stains And vacutainers
• Transfusion reaction 
• Graft rejction
• Crohns vs Ulcerative colitis
• Necrosis, apoptosis and its variant
• Mode of inheritance
• Leukemia and lymphoma prognostic markers
• Renal histology and gross
• Liver histology and gross
• CNS tumors 

3.PHARMACOLOGY

• Antimicrobial Drug of choice and mechanism of action 
• Classification - aminoglycoside , MRSA And drugs for cystic fibrosis
• Hypolipidemic Agents 
• Asthma ( New drugs and guidelines)
• Arthritis (RA and gout)
• General pharmacology ( Pharmacokinetics,clinical trial,Pharmacodynamics)
• Concentration dependent kinetics and time dependent kinetics and post antibiotic effect
• Anti TB drugs
• Anti viral and anti HIV (anti hep B and C)
• Anti fungal
• CVS- MI ,HF, angina managment
• Endocrine- DM,Osteoporosis,SERM,SERD,Gnrh agonist
• GIT-Constipation (opioid induced,IBS related) ,Diarrhea,peptic ulcer
• CNS-Anti epileptic, Sedative,lithium toxicity,neurodegenerative disorder, side effect 
• ANS- Emergency medicines,anaphylaxis, receptors ,poisoning 
• Chemotherapy-Anticancer,monoclonal antibody,small molecules,kinase inhibitors
• Prostaglandins 
• Insulin 

4.MICROBIOLOGY-

• Sterilisation and disinfection (Indicator)
• Immunology (Antibody,complement deficiency,Primary immunodeficiency)
• Latest outbreaks (Zika,Congohemorrhagic fever,Ebola,Corona)
• Sexually transmitted infections
• Vectors
• Parasitology -Eggs
• Congenital infections-Toxoplasmosis,congenital syphillis,rubella,herpes,varicella
• HPV infection,HHV-8
• Bioterrorism
• Larva migrans,larva currens (cutaneous and visceral)
• CD4 counts and Opportunistic infection
•  HIV and TB
• Food poisoning
• Atypical bacteria treatment and infection 
• Dimorphic fungi
• Actinomycosis,Botryomycosis and eumycetoma
• Meningitis
• Exanthematous disease
• Neisseria,diphtheria,Listeria,bacillus anthrax,legionella,campylobacter jejuni
• Bacterial virulence factors,growth factors
• Rickettsial disease, spirochetes(weils ds) 
• Drug resistance mechanism

Following is the list of 3rd year topics.

1.COMMUNITY MEDICINE-

• Surveillance programs
• Sensitivity, specificity,PPV and NPV (Screening of disease)
• Types of studies 
• Odds ratio and relative risk ratio
• Bias
• Sampling 
• Biostatistics- central tendency  (Box and whisker plot )
•  Level of prevention 
• Vaccine and types (Toxoid and live attenuated)
• Demography and family planning
• Biomedical waste
• Health programmes ( RNTCP, HIV)
• Communication
• Nutrition and related programmes
• Disaster
• Null hypothesis,P value and alpha value
• Confidence limit 

2.OPHTHALMOLOGY-

•  Refractive errors (Astigmatism)
• Surgery and post op complication(Glaucoma,cataract,squint)
• Conjuctivitis
• Corneal ulcer (Bacterial,fungal and herpetic) (Stains)
• ROP and systemic retinopathy (Hypertensive and diabetic retinopathy)
• Retinitis pigmentosa and syndromes
• Retinal detachment and cause
• Retinoblastoma
•  Strabismus
• Optic neuritis
• Visual field defect 
• Blow out fracture and trauma to eye
• Glaucoma and drugs(Contraindication and indication)
• Managment of ptosis
• Light reflex and accomodation reflex and pupil
• 3,4,6 Cranial nerve
•  OCT ,Fluorescein angiograhy,tonometers,charts,
• Sudden loss of vision and gradual loss of vision differentials

3. ENT-

• Appearance of tympanic membrane in various disease
• Surgery (Tonsillectomy,Adenoidectomy,Mastoidectomy)
• Paranasal sinus
• CSF rhinorrhea
• Laryngeal disease (Papilloma,vocal cord paralysis, laryngeal muscles action, laryngeal cancers)
• Tracheostomy
• Abscess 
• Nasopharyngeal carcinoma
• Juvenile angiofibroma
• Test of hearing and vertigo
• Otosclerosis
• Cochlear implants
• Oral cavity cancers 
• cervical Lymph node  and neck dissections

 Following is the list of Final year topics.

 1.OBSTETRIC AND GYNECOLOGY-

• Pre-eclampsia (Definitions)
• HELLP
• PPH (prophylaxis and treatment)
• Perineal tear (Types and managment)
• Diabetes and anomalies scan 
• Shoulder dystocia maneuvers
• Molar pregnancy (High risk and low risk for GTN)
• Ectopic (Diagnosis, Investigation and managment)
• Abortions 
• Recurrent pregnancy loss (Investigations and causes)
• Cervical incompetence
• MTP
• Diagnosis and physiological changes of pregnancy 
•  Abruptio vs placenta previa vs Vasa previa
• Heart disease
• MgSO4 and drug
• Fetal monitoring -NST,BPP,doppler
• Twins and complications
• Labor-stages,partogram
• Placenta types and associated pathology
• Rh incompatibility
• Amenorrhea (primary and secondary)
• Mullerian anomalies (Class)
• Asherman, AIS,Gonadectomy indication
• Puberty and precocious puberty
• Menopause (Hormone replacement therapy guidelines) 
• Postmenopausal bleeding and premature ovarian failure (Levels of FSH)
• Semen analysis (Evaluation and IUI and TESE)
• PCOS -Diagnosis,drugs
• Endometriosis
• Cervical,vulval,ovarian,endometrial cancer,Fibroid
• Krukenberg
• PID
• Prolapse 
• Emergency contaceptives
• IUD
• Absolute contraindications in whole subject
• Female sterilisation  

2.PEDIATRICS-

• Developmental milestones
• Neonatal reflexes
• Neonatal resuscitation
• Jaudice,sepsis,Hyaline membrane disease
• Congenital infections-TORCH
• Vaccines(IAP and NIS)
• Diarrhea,pneumonia,dehydration managment
• Pediatric epilepsy
• Febrile seizure (Risk factors,recurrent risk,prohylaxis)
• Severe acute malnutrition
• Rickets
• meningitis
• Neuro-Cerebral palsy and neurocutaneous syndrome
• Pediatric vasculitis-HSP and Kawasaki Disease
•  Nephrotic syndrome
• Congenital heart disease( VSD,TOF,TGA and ductus dependent CHD)
• Trisomies
• Hypoxic Ischemic encephalopathy VS Periventricular leukomalacia
• Fluid managment including shock managment in children
• Childhood pneumonia, Epiglottitis, Acute laryngotracheobronchitis
• Microcephaly and macrocephaly 
• Hydrocephalus and Neural tube defect  
• Fetal alcohol syndrome,warfarin syndrome

3. ANESTHESIA-

• IV anesthetic agents (Propofol)
• Day care surgery (Drug of choice)
• Venous air embolism
• Local anesthetic (Remember concentration also)
• Vaporisers color 
• Inhalational agents 
• Monitoring (Capnography)
• Color coding of cylinder
• Circuits
• Mallampati and ASA grading
• Premedication duration of stoppage and continuation
• Muscle relaxant
• Airway devices
• Endotracheal tube (formula)
• Epidural vs spinal anesthesia (Level of blocks)
• Modes of ventilation

 4.DERMATOLOGY-

•  Pigmentation Diseases 

1. Hyperpigmentation
2. Nevus (Nevus of ota/mongolian spot/CMN/AMN)
3. Melasma
4. Acanthosis nigricans
5. Becker nevus
6. Hypopigmentation -PKDL/Pityriasis versicolor/alba/Hansens
7. Depigmentation-Vitiligo/Contact leukoderma

• Signs (Auspitz,nikolsky,bulla spread sign)
• Histopathology of psoriasis and lichen planus
• Mast cell disorder-Urticaria pigmentosa image
• Papulosquamous disease - Psoriasis ,lichen planus
• Treatment of Psoriasis
• STD (Syphillis,chancroid,donovanosis,Herpes genitalis,syndromic approach)
• Microbiology of STD organism( Dark ground,school of fish,Tzanck smear,Donovan body,Gonococcus)
• Drug Reaction -Fixed drug eruption, erythema multiforme,SJS/TEN
•  Blistering disease 

1. Pemphigus(clinical treatment)
2. Bullos pemphigoid
3. dermatitis herpetiformis
4. Histopathology of blister level and Direct immunofluorescence image

• Infections

1. Fungal (Tinea /pityriasis versicolor)
2. Hansens 
3. TB
4. Viral (HPV/HHV/Molluscum contagiosum)

• Hair disease-Alopecia images,DLE,trichotillomania
• Acne,Rosacea
• cutaneous markers of internal malignancy

5.RADIOLOGY-

• Emergency radiology-RTA,splenic injury,FAST,Perforation
• Radiological anatomy especially applied aspect
• CNS tumor
• Bone tumor
• BIRADS
• TIRADS
• Radiation physics and acute radiation syndrome
• Radiotherapy basics
• Contrast in various studies
• USG and doppler
• Doppler waveforms

6.ORTHOPEDICS-

• Knee joint (Everything)
• Shoulder dislocation
• Bone (Oncology+radiological picture)
• Pediatric Hip(Rdaiology +managment)
• Infections(TB,Osteomyelitis)
• CTEV
• AVN
• Tennis elbow and dequeverian
• Eponyms and test
• Blood supply of femur
• Pseudoarthrosis
• Genu varum/valgus,cubitus varus/valgus
• malunion 
• Instruments

7.SURGERY-

• Glasgow coma scale (Changes)
• Burn
• Cannula color coding 
• Triage
• Trauma
• Incisions,suture,foleys,NG tube,Knots,Scores
• Latest updates in breast cancer,thyroid and hepatobiliary cancers,Pancreatic cancer,stomach,colorectal cancer
• Bed sores staging 
•  Renal stones managment
• Gall stone managment and surgical complication
• Bariatric surgery
• Acute pancreatitis managment 
• Upper GI and lower GI bleed management and causes
• Aortic aneurysm
• Meckel diverticulum
• Wound classification
• Cancer-(Breast,rectum,stomach,oesophagus,HCC,prostate,thyroid)
• Cancer follow up duration 
• Carcinoid and GIST and gastrinoma

 8.MEDICINE-

•  ECG visuals
• Cardiac emergencies-Arrest,Unstable angina,MI,Arrhythmia,Dissection
• Respiratory emergency-Pulmonary embolism,pneumothorax,Asthma 
• Stroke
• Meningitis (Bacterial,viral,aseptic)
• Approach to patient in Coma
• Seizure
• Electrolyte imbalance
• ABG
• Hypertension and its emergency and management
• Murmurs and valvular lesions
• Pericardial d/o
• hepatitis(Viral,autoimmune)
• Non alcoholic and alcoholic liver disease
• Glomerular disease
• UTI
• CKD
• DM (management of different complications)
• Neurodegenerative d/o ,neuropathy,myopathy
• Septic shock guidelines
• GBS
• Poisoning 
• New asthma guidelines
• RTA and Inherited channelopathies
• MEN syndrome
• SIADH, DI,Pheochromocytoma
• AIDS defining illness
• Connective tissue disorder
• Infective endocarditis and rheumatic heart disease
• Prakinson and alzheimers
• IBS,UC ,Crohns
• Cardiomyopathy
• Jones and dukes criteria
• dyslipidemia management 

10.PSYCHIATRY-

• General psychiatry (terms and its meaning )
• MMSE
• Psychotic disorders

1. Schizophrenia
2. Delusional d/o- Named syndromes (Capgras,Fregoli,Othello,Ekbom)

• Mood disorder (Treatment is very important)

1. Mania
2. Depression
3. Bipolar

• Neurotic disorder 

1. Anxiety disorder
2. OCD related disorder
3. Dissociative disorder
4. Trauma and stress related disorder
5. Somatoform disorder

• Substance abuse and deaddiction
• Organic mental disorder(dementia)
• Sleep disorder
• Eating disorder
• Sexual disorder
• Personality types and disorder
• Drugs (SSRI and its sideeffect)
• Psychotherapy types and choice
• Defence mechanism  

You can edit this according to you. 

Hope it will help.

-Upasana Y.

Clinical correlates: Epinephrine vs Norepinephrine reversal

Hey Awesome peeps :)

This post is about variation in the effects of epi- and norepinephrine depending on its dose.

Topical Drug Absorption.

Hello everyone!

This is the brief mention about the extent of topical absorption of drugs. 

In decreasing order-

Posterior auricular
Scrotal
Scalp
Dorsum of hand
Plantar area.

Absorption mainly depends on the thickness of the skin and is inversely proportional to it.

Hope this was helpful! 

Let's learn Together! 

Dr. Medha Vyas 

Two components of Sulfasalazine : Indications

Hello

Sulfasalazine has two components:
- 5-ASA
- Sulfapyridine (SP)

Beta 2 agonist and effect on muscles

Hello Awesomites !

I used to have a doubt why does Salbutamol cause uterine relaxation but causes contraction of skeletal muscle and cardiac muscle(tremors and tachycardia)?

Despite they have same receptors (Beta 2) how can be the action on muscle is so different.
Grossly it seems like one receptor Beta 2. This beta2 adrenergic receptor is a type of GPCR.
GPCR  are Gs, Gq ,Gi type.

Beta 2 receptor anywhere (Uterus -smooth muscle, heart- cardiac muscle, hands- skeletal muscle) is also same type of GPCR i.e Gs.

Still no difference.

Gs activates adenyl cyclase to form cAMP from ATP.
cAMP increases in all type of muscle on stimulation of Beta 2 receptor.
But it cause relaxation in smooth muscle (inhibit myosin light chain kinase)
And causes contraction of heart and skeletal muscle (activate cAMP dependent protein kinase A lead to activation of L-type calcium channel).

At one level we all may appear to be doing same thing yet at other level we are different and have our role.:)

 Happy studying !
-Upasana Y.

Metronidazole : spectrum of organisms covered mnemonic

Hello

Metronidazole has bactericidal activity against

Protozoa:
- Giardia
- Entamoeba
- Trichomonas

Bacteria: (anaerobic gram-negatives)
- Bacteroides
- Clostridium sp (doc in pseudomembranous colitis)
- GARDNerella
- H. pylori

mnemonic: GET BaC in the GARDEN, Hippo

- Jaskunwar Singh