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

Polycythemia refers to an increased hemoglobin concentration and/or hematocrit in peripheral blood.
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.

2)An increase of RBC mass refers to Absolute polycythemia. It can be categorized as either primary or secondary 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

Places to Target for Research

Places to target first for a Research Position (Big Guns) :

Mayo Clinic, Rochester

Mayo Clinic, Florida

Cleveland clinic, Ohio

Cleveland clinic, Florida

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

Hey guys, how's it going?

So this post is going to be about how to land a research position in USA.

First of all I would like to briefly speak about  why it is important to have some research experience in USA. Common idea is it helps people to build a strong CV to cover up low scores or any red flags in the CV. What I have realized is that it is not the only benefit, to get into a competitive specialty for residency and also for future fellowships it's very important to have some research background in the field of your interest.

Now let's talk about the steps to go through before you land a research spot.

Catheter Related Candidemia Treatment Indications

Empiric therapy for suspected catheter-related candidemia should be administered for septic patients with the following risk factors:

●Total parenteral nutrition

●Prolonged use of broad-spectrum antibiotics

●Hematologic malignancy

●Hematopoietic cell or solid organ transplant

●Femoral catheterization

●Colonization due to Candida species at multiple sites

Source: Uptodate

Bhopalwala. H

Antibiotic Lock Therapy

Antibiotic lock therapy —

The premise of ALT is to achieve sufficient therapeutic concentrations to kill microbes growing in a biofilm . ALT may be a useful adjunctive therapy together with systemic antibiotic therapy for intraluminal infections due to coagulase-negative staphylococci or gram-negative organisms in the setting of CRBSI (Catheter Related Blood Stream Infection) when the catheter cannot be removed .

ALT should not be used for extraluminal infections nor for management of infections due to S. aureus, P. aeruginosa, drug-resistant gram-negative bacilli, or Candida.

Source: Uptodate

Bhopalwala. H

Timing of Catheter Replacement in CRBSI

In general, the patient should receive antibiotic therapy for at least two to three days following device removal prior to device replacement. At the time of device replacement, the patient should be hemodynamically stable with negative blood cultures and no sequelae of bloodstream infection .In addition, for patients with CRBSI ( Catheter Related Blood Stream Infection) due to S. aureus, a new catheter may be placed if additional blood cultures demonstrate no growth at 72 hours

Source: Uptodate

Bhopalwala. H

Immunization certificate sample for electives and observerships

Hello,

Since many of you emailed me regarding the  immunization form, I thought of sharing it on Google Docs.

Step 2 CS: Neurology Case mnemonic

The following mnemonic (HDFC ST) helps me cover all bases in a Neurology case.

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 CO_{2 eliminated}/O_{2 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

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.

Restrictive vs Liberal approach to transfusion in Sepsis

Hello everyone, 

Here are some studies on approach to blood transfusion during sepsis:

One multicenter randomized study of 998 patients with septic shock reported no difference in 28-day mortality between patients who were transfused when the hemoglobin was ≤7 g/dL (restrictive strategy) and patients who were transfused when the hemoglobin was ≤9 g/dL (liberal strategy) . The restrictive strategy resulted in 50 percent fewer red blood cell transfusions (1545 versus 3088 transfusions) and did not have any adverse effect on the rate of ischemic events (7 versus 8 percent).

One randomized trial initially reported a mortality benefit from a protocol that included transfusing patients to a goal hematocrit >30 (hemoglobin level 10 g/dL) . However, similarly designed studies published since then reported no benefit to this strategy. 

Bhopalwala. H

Source: UpToDate 

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

LMR (Last minute revision) Stuff for obstetrics and gynecology drugs

Hello Awesomites!

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

USE:-

• Ovulatory cycles of DUB
• Post IUCD bleeding
• Post sterilization mennorhagia
• Fibroid

2.Doxylamine and Vitamin B6 combination

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

S/E- hyperstimulation of uterus,fetal distress

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

5.Misoprostol

• PGE1
• ROUTE= sublingual,vaginal,rectal (never parentral)
• S/E:Fever,chills,shivering
• Teratogenic: Mobius syndrome (Category X drug)
• USES:-

1. OBSTETRIC USES:

• Termination of pregnancy
• PPH prevention and treatment.

     2.GYNECOLOGICAL USE:

• Pe hysterectomy
• IUI
• Cervical pregnancy

    3.GIT USE:

• Treatment of peptic ulcer caused by NSAIDs.

6.Frusemide:

• Loop diuretic.
• prior to blood transfusion in severe anemia
• congestive cardiac failure
• used in complications not as anti hypertensives
• PIH with massive edema

7.Clindamycin+Clotrimazole 

• USE: Mixed bacterial and fungal vaginosis 

8.Omeprazole+Ondansetron:

• USE: GERD, peptic ulcer

9.Heparin:

• Injectable Anti-coagulant
• In 1st trimester
• Antidote: Protamine sulfate
• USE: DVT, APLA, PE, recurrent abortion (Prophylaxis:ASPIRIN+HEPARIN)

10.Iron folic acid:

• 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

11.Anti-D Immunoglobulin:

• IgG, intramuscular
• 300 micro gram=15 ml of D positive red cell/ 30 ml of fetal whole blood 
• If ICT -VE at 28 weeks

12.Hydrocortisone:

• 2 doses 12 mg betamethasone i/m 24 hours apart
• 4 doses 6 mg dexamethasone 12 hours apart

13.Sodium Bicarbonate:

• IV for Heart resuscitation, poor kidney function, Cocaine toxicity
• Poisoning cases
• Reviving newborn
• Preventing chemotherapy side effects
• Hyperkalemia
• metabolic acidosis

14.Diazepam:

• Central Muscle relaxant and anti convulsant, Tranquilizer
• S/E:- Maternal (Hypotension) and Fetal (Respiratory depression, hypotonia)

15.Nifedipine:

• Direct arteriolar vasodilator
• Calcium channel blocker
• USE:Tocolytics
• A/E: Flushing, Hypotension, headache, Inhibition of labor

16.Labetalol:

• 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

17.Magnesium Sulphate:

• Top 10 series by AP Burkholderia

18.Drotaverin:

• Anti-spasmodic (PDE-4 Inhibitor)
• Enhance cervical dilatation during childbirth
• USE: Acute renal colicky, augment labor.

19.Oxytocin:

20.Methergine:

21.Prostaglandins:

More is coming up !

-Upasana Y. :)

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

Technology is a crucial part of our life nowadays. Below are some apps that can make a pediatric student/resident/specialist life easier :D

1- Uptodate

The famous app for the well-known website “ Uptodate” where you can get peer-reviewed data for nearly any subject you may think of. It also has a section for adult and pediatric medication dosing which can be helpful. Another nice section is the patient education section that is really helpful to explain complex medical things to parents in layman terms.

  

Keep in mind that you ll need an account which may be provided to your through your residency program, a friend or you yourself paying for Uptodate.

2- Medscape

The app for the amazing peer-reviewed website Medscape. Just create an account and search for any disease you like (epidemiology, incidence, clinical presentation, treatment, prognosis..etc).

3- Medstudy and Medstudy audio apps

The apps for the Medstudy book series. Listen to a medstudy chapter on your way somewhere or revise some pages through your app. These apps require an active Medstudy subscription

4- PCO / Pediatric Care Online 

A nice app by the American Academy of Pediatrics (AAP). Through this app, you get access to “Red Book”, one of the most famous books/sources for Infectious diseases and their treatments, “Bright futures” which is helpful to hone your skills in your continuity clinic among many other things.

  

To get access completely, you need an AAP account which will be provided by your residency program. 

5- Heartpedia

A great app from Cincinnati Children’s Hospital. Through this app, you can have a 3D visual construction of the most common congenital heart anomalies (ASD, VSD, PDA, COA..etc). Choose the angle you like, zoom in or out. The app also has links to youtube videos explaining the defect. This app is particularly very helpful if you are trying to explain a congenital heart defect for a parent and for further clarification to a student.   

6- CDC Vaccine Schedules (Vaccinations, catchup, contraindication)

Vaccines are a vital part of any Well Child Check visit. This app from the CDC has all the tables for Pediatrics and Adult vaccines including the catch-up schedule as well as the contraindications for these vaccines.

An amazing website to help with this is : https://www.vacscheduler.org/

Just enter the age of the patient, the vaccines that he/she got and the website will tell you what the patient needs

7- Bilicalc

For nursery folks, you should have Bilicalc on your smart-phones, it is the best app to know the lightable levels (LL) for babies. Just enter the baby’s hours of life as well as the bili result and wait for the app to tell you the LL for low, medium and high risk curves.

It does the same job that www.bilitool.org does.

 8- eBooks by inkling

This app acts like a “template” through which you can read different books. A must-to-have book is Harriet-Lane (every Pediatrician should have this book :D). To access it, use the code that is located on the first page of the book’s hardcopy. It is given by most residency programs to the residents. If not, you should consider buying it for sure.

  

9- MDcalc

Scoring systems in medicine are endless. This is the best app that can be your savior. Are you looking for: Westley’s croup scoring? Pediatric Asthma scoring? Calculating maintenance fluids for a child? Well, you just hit the jackpot.

 
10- GoodRx

Help your patients find coupons so they can buy the medications they need at a lower price.

  

11- Google keep

Although not medical but this app is wonderful to take notes and to create lists. Write all your lists in one place and use different colors. Synchronize all your notes/lists with any other device: tablet, laptop..etc. Organize your life, a much 

  

12- Anki

Another non medical app, Anki is a wonderful flashcards app. It acts like a template that you can create flashcards with or use already pre-made shared cards. Add your notes to any deck you like, synchronize between your devices and have your info with you everywhere. 

 Comment below if you have any apps or websites that may be helpful for pediatricians or anyone who is interested in Pediatrics :)

-Murad