Rhinosporidium seeberi

Rhinosporidium seeberi

Hilton's law

Hilton's law.

The nerve which supplies a muscle of a joint, will also supply the joint and the overlying skin.
Conversely, any nerve that is innervating a joint will also supply the muscles of the joint and the overlying skin.

In humans, we find only 2 exceptions to this general rule:

1) Buccal branch of Mandibular nerve as we all know, pierces the Buccinator muscle. But it doesn't supply the muscle. The innervation of Buccinator is by the Buccal branch of Facial nerve.
2) Sciatic nerve in the Gluteal region....is very closely related to the Pyriformis muscle.... And may occasionally send a fibre that pierces the muscle. But it doesn't supply it. Pyriformis is supplied directly by the sacral plexus(the nerve to pyriformis).

Mithil Jagannath.
Medicowesome 2017.

Vasculitis Classification : A way out

Here's my way out of the necrotising vasculitis. Pan intended ;;).

So depending on the size of the vessel involved you can classify it as -

1. Large Vessel Vasculitis
2. Medium Vessel Vasculitis
3. Small Vessel Vasculitis

For the first two Remember :

TT PK

So Large vessel = TT
Takayasu Arteritis
Temporal Arteritis (Giant cell Arteritis)

And Medium Vessel = PK
Polyarteritis Nodosa
Kawasaki disease

Now Small Vessel Vasculitis can be classified further. It can be positive for a particular antibody called ANCA or it can be negative. This antibody is purely an association and not a causative one.

ANCA Negative : HCC

H - Henoch Schonlein Purpura
C - Cryoglobulinemia related
C - Cutaneous Leukocyto-angiitis

(Think of crying babies.
Cry = Cryoglobulinemia related Vasculitis
And another baby related Vasculitis​ is HSP).

Now ANCA positive Vasculitis can be either c-ANCA or p-ANCA depending on what part it stains.

Remember - WC
(Like Western commode)
Wegner's is c-ANCA.

Remember - PCM
p-ANCA in Churg Strauss and Microscopic Poly-angiitis.

Please note - The names of Wegner's and Churg Strauss have been changed to Granulomatosis with Polyangiitis , and Eosniophilic GPA respectively. This is said  to be because the scientist Wegener had been discovered to be possibly related to some Nazi war time activities and this opportunity was made the most of to also take a step towards  a more pathology-specific name-calling by altering the honorific name given to the disease.

That's all!
Happy studying.
And Stay Awesome !

~ A.P.Burkholderia.

Pills of knowledge in Ophthalm- Retinal haemorrhages

1. Flame shaped haemorrhages are seen when they occur in the superficial layers of the retina because the blood can spread as tight junctions are not present there.

2.Dots and blots show up into the deeper layers because the space to spread for the blood is relatively lesser.

That's all!

Sushrut Dongargaonkar

Step 2 CK: The algorithm to Management of Ventricular Tachycardia

Did you ever find it time consuming and confusing to answer the multiple choice questions about the "what will you do next" questions for different heart rhythm disorders?
Well, we did too. So, we are going to post some algorithms in subsequent posts, which will make it easier and save you some time in the preparation. They will guide your thoughts during those timed multiple choice questions.

Ventricular Tachycardia: It's a type of ventricular arrhythmia. The EKG is a must have diagnostic test. Look for wide-QRS-complexes. If the EKG is inconclusive--> telemetry monitoring should be done. If the questions asks, what is the most accurate test to diagnose this patient with V.Tach--> its Electrophysiologic studies.

Now, read very carefully the last line of the question as to what the question is demanding; it could be the next step in management or the test for a definite diagnosis.
The next (VERY IMPORTANT) step is to look at the vital signs and understand if the patient is hemodynamically unstable
(LOOK FOR :
               *IS THE B.P. LOW?
               *IS THERE CHEST PAIN?
               *CHECK THE Respiratory Rate- does the patient complain of shortness of breath/dyspnea,
               *LOOK FOR HIS MENTAL STATUS- is the patient confused/has altered mental status?                    *LOOK FOR SIGNS/SYMPTOMS OF CHF.
If any of these are present--categorize the patient as Hemodynamically Unstable.

And then, follow the chart below for management questions.

- Vikramjeet Kakade & Rajavee Panchal

We all wanna help others; but do we help ourselves?

{This might be quite a descriptive post. So read this if you don't have exams upcoming recently}

As a Medical student, or a doctor we all are opting for a profession of care for people. But often we forget that the people who need care includes ourselves too.
How should we take care of ourselves.
1. One should take care of one's self.
2. One should take care of one's colleagues.

Do you eat well? Do you sleep enough? Are you spending time with your family? All these fall into such a level about taking care of your ownself.
As medical students we have long weeks and short sleeps. Let's admit, still we don't have enough time.

1. First of all, don't forget to,

EAT WELL. Food is essential for your sustenance. Eat nutritious food. Not just starch and sugary food. Opt for some fruits, yoghurt and more veges.
Our professor said it is better to get yourself a multivitamin complex if you feel like you are running out of enough nutritious food.

SLEEP WELL. Sleep is one of the most important aspects of your daily life. You probably cant sleep 6hrs straight. But get some decent sleep at least for 4hrs. And if you are taking a powernap, try taking it in multiplies of 90mins. I saw it recently in an article 90mins(180/270 etc) of nap improves your ability to wake up fresh as it is appox 1 sleep cycle.

EXERCISE WELL. You dont have hop into University gym and run on those treadmills for your dear life, but obvio try taking a stroll with your friends in the ground, or get a brisk walk to market instead of getting a taxi or riding there.

RELAX WELL. We surely don't have time to sit on a sedan chair and reflect on life or get a bikini/short picnic to the nearest beach when we have an Internal Medicine exam 3 days away. But surely you have time to go grab a coffee and enjoy it without looking at your jumbled up notes. (They aren't much readable anyways 😜jk...), Sit on a short wall and swing your legs like you remember all the drug regimes of the world. Look at the sky from the terrace and try to find a constellation or two that you learned in Grade school. Listen to a song that uplifts you or soothe you depending on your mood. Sketch something (personal secret : I sketch my crushes when I'm stressed 😜). Do something that makes you feel good. Meditation or yoga or something are good too. If spa, manicure pedicure, massage works for you, by all means go for it too.

CHECK-UPS. What is the last time you checked if you have enough Hgb count? Get your personal body checkups. You are only riding that Car, don't forget to check the oil and water levels too. Even a Benz or a BMW can wreck havoc if they don't have enough care. Get yourself done a teethscaling.

ENVIRONMENT. Look at your desk. Does it look like that you just performed an exocism there? 😂 Clean it up yo! Clean your desk. Your room. Keep some airfreshners, keep stuff that motivate you surrounding you. Not things that make you feel like "I'll rather live in the library!". 😜 Get enough Oxygen into your place and for all the love for Zeus, don't get into a room without enough ventilation.

MENTAL HEALTH. Almost every university provides free mental health counselling to its students. What was the last time you used it? Last time I had stress issues with my Neurology final exams, I went to meet a guidance counsellor. She totally listened to me and made me feel good. And another time when I felt like I'm losing my interest and the passion, I talked to my psychiatry professor.I think you should talk to someone qualified about it. And never think talking to a psychiatrist or a counsellor is a bad thing. In the long run it will help you heaps.

2. How to take care of your colleagues.

Ok we don't even have time for ourselves. I agree. But please don't leave those who are around you.

We all are in the same journey. Look out for them. Check if they ate their meals. If they forgot their attendance. Check if they are okay. If their relationships are going well. If they are performing fine in exam. Look out for people around you. Close friends are the first people are recognize depression and anxiety in a person before it attains to clinical levels. If you notice a difference talk to them. Or lead them to talk to someone qualified about it.

If someone is losing marks and failing exams offer to help them. If they ask for support never refuse.

Be a good person to others, this way you will be a good doctor too.

That's it for now folks. Enjoy and always take care of yourselves and others around you.

With love,

Jay

Mnemonico diagnostico: Opacities that may be confused with renal calculus

Hey Awesomites

Mnemonic for opacities on a plain abdominal radiograph that may be confused with renal calculus:
TOP GAME

Tubercular calcified lesions in the kidney
Ossified tip of 12th rib
Phleboliths (calcifications in the wall of pelvic veins)

Gall stones
Appendicular/ Adrenal gland concretions
Mesenteric lymph node calcifications
External (foreign) bodies in alimentary canal (ex., cyclopenthiazide)


Thats all
- Jaskunwar Singh

Answer is not always antibiotics!

Clinical vignette:
Young, non smoker, female comes with complaints of sore throath, dry cough, nasal congestion for 10 days. Now, she feels better however she coughs out yellowish expectoration.
There are scattered wheezes and crackles that clear with coughing.
You've ordered relevant labs and meanwhile the patient asks you if she would need antibiotics. What would your next step be?

Answer: Symptomatic management.
Reason: Since there is a history of preceding viral infection and her current situation indicated Acute Bronchitis, the expectant management would be fairly Symptomatic!
Infact, there are articles that state that giving antibiotics could worsen the patient condition! Also, judicious use of antibiotics can help prevent antibiotic resistance.

Let's fight antibiotic resistance!

Stay awesome!
-Rippie

FENO in asthma: routine clinical testing

Hey Awesomites

One of the additional tests for determining the present status of airways in asthmatics is the measurement of Fraction of Nitric Oxide in Expired air (FENO).

The levels of Nitric oxide are elevated in the presence of inflammation in the airways, that is eosinophilic in nature.

In children <12 years, normal FENO is usually less than 36 ppb. However, in case of allergic inflammation of airways, the levels rise to >50 ppb.

Note that FENO is not diagnostic, but a test for independent prediction of exacerbations in asthmatic patients and is now done routinely in clinical practice, as approved by US- FDA.

Thats all
- Jaskunwar Singh

My Elective experience

Hey guys,

I was off blogging for a while for obvious reasons and I apologise for that. But, hey! Let me share the reason behind it :D
I was off to the States for my Clinical Electives at Mayo Clinic and Cleveland Clinic, so I'm going to briefly write about Electives in this post.

Overview of US Clinical Experience:

A) HANDS-ON Clinical Experience:
- One to one patient contact, can elicit history, perform physical examinations, write notes, suggest plan of care, have full access to patient records
- Considered better as what can be better than hands-on!
- Can be done only before a Medical Student graduates. ( Therefore, you can't do electives if you're already a Doctor -_-)

1. Sub-Internship equivalent to a 4th year US Medical Student
2. Clinical electives are equivalent to a 3rd year US Medical Student
3. Clerkship (This typically is for US Medical students; not applicable to IMGs)
4. Externships

B) NOT HANDS-ON Clinical Experience:
- You only get to observe (hence, Limited role in patient care)
- Can be done while you're a Medical Student or even after you graduate
- Controversial if it can be considered as USCE?

C) RESEARCH ELECTIVE:
- Usually, longer the elective, the better it is! (Increases yield of getting a fruitful publication out of it.
- No outlined criteria, eligibility varies from place to place.

Now,
I typically like to classify Clinical Electives into: (Although, others may classify them based on different criteria, I believe, classifying this way is logical in terms of expenses majorly)
1. USMLE Step 1 required
2. USMLE Step 1 NOT required
[I shall soon write a separate blog on this, pre requisites for elective application and rough expenses soon, so stay tuned as always :D]

About my elective experience:

I had given my USMLE Step 1 while I was in Third year. So, when I got into Fourth year I applied to Universities that had USMLE Step 1 criteria.
As now a days, getting electives is becoming more and more competitive, along with my friends, I applied to IMG friendly elective places well in advance  (about 10 months prior for a few places). This also meant that we had to wait for a long time to get our acceptances as they don't send out acceptances until 3-1 month prior to your elective start date.

Fortunately, I got accepted at Mayo Clinic, Rochester for Infectious Diseases elective and at Cleveland Clinic, Ohio for Endocrinology elective! Yippie!! (Big thank you to Ikan for guiding me with the application process)

Both, Mayo Clinic and Cleveland Clinic are amazing places to work at! (And if you don't already know, Mayo Clinic has been ranked no.1 and Cleveland Clinic has been ranked no.2 on U.S. News and World Report's Honor Roll :D)

What to do while you're there?

- Be professional, dress professionally, follow code and conduct of your Hospital or Clinic.
- Take histories, perform physical examinations as required, write patient notes, suggest plan of action and so on...
- Volunteer for case presentations/ talks
- If you find an interesting case while you're rotating there, discuss with your residents/ fellows/ attendings if you can submit it to a journal or present it at any conference.
- If you're interested in research, talk to your attending and try to get involved in one.
- Most importantly, As an IMG, it is crucial for us to get A Strong Letter of Recommendation. If you've been working hard, I am sure, most attendings would agree to write you a Strong LoR! Hurray!

Also, once you are done with your elective, in the following week or so, it is good to write your attendings a courtesy/ Thank you email, so that they know you really learnt during your elective!

Stay awesome!
-Rippie

Lymphedema - High yeild Information.

Hello there!
So today in the surgery OPD I happened to see a case of Lymphedema feet ,and hence thought of reviewing some important points on same.

So, Congenital lymphedema may involve a single lower extremity, multiple limbs, the genitalia, or the face. 

The edema typically develops before 2 years of age and may be associated with specific hereditary syndromes -Turner syndrome,Milroy syndrome, Klippel-Trenaunay-Weber syndrome.

 Lymphedema praecox is the most common form of primary lymphedema, accounting for 94% of cases. 

Lymphedema praecox is far more common in women, with the gender ratio favoring women 10:1. 

The onset is during childhood or the teenage years, and the swelling involves the foot and calf. 

Lymphedema tarda is uncommon, accounting for <10% of cases of primary lymphedema. The onset of edema is after 35 years of age. 

Secondary lymphedema is far more common than primary lymphedema. Secondary lymphedema develops as a result of lymphatic obstruction or disruption.

 Other causes of secondary lymphedema include radiation therapy, trauma, infection, and malignancy. 

Globally, filariasis (caused by Wuchereria bancrofti, Brugia malayi, and Brugia timori) is the most common cause of secondary lymphedema.

Hope It helps.
Let's Learn Together!
-Medha.

Pathophysiology and Radiologic patterns of Atelectasis

Hey guys!

This post will be on the classification of Atelectasis based on its pathophysiology and a brief overview of its radiology patterns. 

Let us deal with the radiology aspects first:

1. Opacification of airless lobe and displacement of fissures,

2. displacement of hilar and cardiomediastinal structures toward the side of collapse,

3. narrowing of the ipsilateral intercostal spaces,

4. elevation of the ipsilateral hemidiaphragm,

5. compensatory hyperinflation and hyperlucency of the remaining aerated lung and

6. obscuration or desilhouetting of the structures adjacent to the collapsed lung (eg, diaphragm and heart borders).

Google the Chest X ray scans for atelectasis to consolidate the above points.

Now the lengthy part, The Pathophysiology. Let us start with active or obstructive atelectasis. 

1. Active/Obstructive Atelectasis.

Obstructive atelectasis is a consequence of blockage of an airway. Air retained in the alveoli distal to the occlusion is absorbed into the pulmonary capillary blood since the pressure of gases in the blood plasma (PvO2) is lower than that in the alveoli. For this reason, it is also called absorptive atelectasis. This causes the affected regions to become totally gasless and then collapse. 

Obstruction of a segmental bronchus is less likely to result in segmental atelectasis than obstruction of a lobar bronchus is to produce lobar atelectasis. This difference is because of collateral ventilation between bronchopulmonary segments within a lobe. 

Collateral ventilation occurs via the age-old physiologic adaptive process of recruitment and distension of neighbouring bronchioles. But three are three other players here, or brothers as I like to call them. A small anecdote to remember these three brothers:

Once there was a priest named Kohn who decided to help out a fellow bronchopulmonary segment in aeration. Brother Kohn being eldest and hence weak could only manage to dig a pore. His work was carried on by Brother Boren who bored (as his name suggests) and made this pore into a fenestration. There was still some work left. And for that Brother Boren asked the help of the engineer Brother Lambert. Brother Lambert, after much hard work was eventually able to dig up a canal all the way upto the neighbouring segment so that they can share the aeration bestowed upon them by Lord Almighty!

So we have three distinct collateral connections: 1. Pores of Kohn, 2. Fenestrations of Boren and 3. Canals of Lambert.

So you need to defeat these three if you want to cause obstructive atelectasis.

Let's dig a bit deeper into Fenestrations of Boren. These collateral channels are extensively prominent in an emphysematous lung. Now take a case of a 60 year old male smoker with emphysema who has now developed small cell carcinoma. Suppose there is a tumor mass obstructing the right bronchus, this patient will take a lot of time to develop obstructive atelectasis in the right lung because of the presence of extensive network of fenestrations of Boren. Hence, this patient will become symptomatic late and thereby will be diagnosed late. Blessing or Curse!

One more thing, it has been observed that atelectasis occurs more rapidly in patients on oxygen therapy. Why? There is a simple reason behind this. Oxygen is more soluble than nitrogen in water, when you give inhalational O2 with a FiO2 take 50%, you are altering the partial pressures of gases in the alveoli, Nitrogen which was 79% will fall down to below 50% and O2 which was 20% will rise upto 50%. Hence overall solubility rises, this elevates the tendency and spontaneity of gases diffusing into the blood plasma.

Honestly speaking, rest of the causes are nowhere as important as the one mentioned above so let us try to ace them quickly. 

2. Nonobstructive Atelectasis

A. Relaxation (ie, passive) atelectasis ensues when contact between the parietal and visceral pleurae is eliminated. While this is usually due to a pleural effusion or pneumothorax, a large emphysematous bulla can have a similar effect. In this case, the residual physiologic elastic recoil of normal lung parenchyma allows the normal lung to collapse away from the chest wall with consequent loss of volume.

The middle and lower lobes may shrink more than the upper lobe in the presence of a pleural effusion, while the upper lobe may be affected more by a pneumothorax.

B. Adhesive atelectasis is a consequence of alveolar instability due, in part, to surfactant deficiency or dysfunction. As its name suggests, the alveoli walls will collapse into the alveolar space sticking with each other. In the normal lung, surfactant reduces the surface tension of alveoli and decreases the tendency of alveoli to collapse. Decreased production or inactivation of surfactant leads to alveolar instability and collapse. Adhesive atelectasis is a major problem in respiratory distress syndrome of premature infants(IRDS), acute respiratory distress syndrome (ARDS) in adults, acute radiation pneumonia, and posttraumatic lung contusion.

C. Cicatrization (ie, cicatricial atelectasis) results from diminution of lung volume due to severe parenchymal scarring. Common underlying etiologies include granulomatous disease (eg, sarcoidosis), necrotizing pneumonia, and radiation pneumonia.

D. Acceleration Atelectasis- This type of atelectasis has been described in pilots subjected to very high, vertical accelerative forces between 5G and 9G: at 5G, up to 50 percent of pulmonary airways are distorted and closed due to gravitational forces. The atelectasis is exacerbated by breathing a high fractional concentration of oxygen. Decreases in vital capacity are a reflection of this type of atelectasis in pilots. Acceleration atelectasis can cause symptoms like chest pain, coughing, and dyspnea.

E. Rounded atelectasis (also called folded lung, Blesovsky’s syndrome, or atelectatic pseudotumor) is a distinct form of atelectasis associated with pleural disease, particularly following asbestos exposure and in India following pleural tuberculosis. Asbestosis is associated with pleural plaques and diffuse pleural thickening while pleural TB will have pleural thickening alongwith pleural effusion which eventually resolves with or without organization and pleural septations(Harbingers of Fibrothorax). 

In this condition, there is a subpleural mass mainly in the middle or lower lobes from which bronchi and blood vessels arise and they form a structure like a comet tail which traverses through the underlying atelectatic lung parenchyma to join at the hilum. Some un-astronomical sources compare this to a Vacuum Cleaner, with the dirt box as the subpleural mass and the hose as the comet tail. 

P.S. Blesovsky's Syndrome is not the only syndrome connected to pneumoconiosis, there is also Caplan's syndrome(Rheumatoid pneumoconiosis); which has a well-known mnemonic CAPlaN;

C- Coal workers' pneumoconiosis

A- Rheumatoid Arthritis

PlaN- Pulmonary nodule

That's all! 

-VM

Pills of knowledge in Ophthalm- Nodal cataract

The condition where 'day blindness' is present is a cataract at the nodal point. Nodal point of the eye is where the rays of light pass through the lens without any refraction, usually at the centre of the lens. Thus, during the day, especially when out in the sun, the pupil contracts and the light has to pass through the cataractous area, causing diminution of vision.