Growth Rates in Dermatology

Hi everyone. My skin Lecturer just taught me this so I thought let's post this =)

So growth rates !
We need to know 3 of them - Hair , Finger nails and Toe Nails.

Hair is the fastest growing.
So remember just one number for it - 0.37 mm/day.

Now , next fastest is finger nails.
For this divide by 3.
0.12 so 0.1 mm / day is finger nails.

Now divide this by 3 to get the value for Toe nails.
So 0.03 mm/ day is for Toe nails !

That's all for this post !
Stay awesome !
Happy Studying !
~ A.P.Burkholderia

MIL : Tinea (Dermatophytosis)

Hi everyone ! 
This is my 2nd MIL! Hope it's illustrative and informative ! 

(Click on the image to see it in Full View). 

Description : 

This is an Image of Tinea Corporis (Ringworm) infection of the skin. 

Notice - the lesion is annular in shape , has a ring like appearance. 

The lesion seems to be erythematous and  elevated (papular) towards its outside, and shows central area of clearing. 

This is classic of Tinea! 

Tinea is actually a fungal infection caused by Dermatophytes. 

____________________________

Clinical Features -

- Include such a lesion over different body parts which are severely itchy. 

- Occur particularly in summers.

Tinea Corporis = Tinea infection occuring over the body. 

Some common forms are - 

Tinea Cruris = Tinea Infection in the groin area (Jock itch).

Tinea Glutealis = Tinea along the natal cleft and towards the Gluteal regions. 

Tinea Pedis = Athelete's foot, occuring in the feet. 

Tinea Capitis = Scalp and hair. 

- Predisposed to get this in areas of constant sweat and moisture. 

Hence dryness is very important to maintain. 

____________________________ 

Ix : 

Usually a clinical diagnosis. 

Differentiate from Psoriasis : Lesions are not clear centrally ; there are plaques with Scales in Psoriasis and there maybe history of pin point bleeders.

Can confirm using Biopsy / Analysis of skin scraping and obtaining a species specific diagnosis. 

____________________________

Rx : 

A. Topical Anti fungals 

- Resistance is rampant. 

- Most promising ones are Luliconazole and Terbinafine creams.

- Can try Clotrimazole and Ketoconazole Shampoo for the site of lesion.

B. Oral Anti fungals 

- Itraconazole is a wonderful drug , dose being 5mg/kg / day. Roughly 100 mg twice a day is good enough. 

- Griseofulvin was an option but resistance seen now.

C. Anti histaminic for allergy. 

D. Duration of Rx is almost 2-3 months. It's a hard fungus to kill..

E. Steroids not to be used strictly. ( I've seen some horrendous results where the whole body was covered with Tinea when the patient stopped applying the steroids. Best to avoid them as per clinical as well as literature review). 

Hope this was helpful! 

Happy studying ! 

Stay Awesome ! 

~ A.P.Burkholderia 

Being street-smart during interviews: Buses!

Match season is a a really unique life-time experience. You will travel for interviews, meet new friends, visit states you have never visited before and of course, spend some money.

Although flights in general are the fastest most-convenient way to travel, you may try “bus inter-state travelling” which is much cheaper than taking a flight.

I will briefly write about some bus companies that are there and their pros and cons:

Greyhound:

Pros:
> It covers most of the states in the US.
> they have stations where you can sit and wait in (which is very important especially during Winter when it is freezing and snow is everywhere!).
> Starting from late 2017, you can use an E-ticket (emailed to you) instead of a printed ticket.
> They have nice discounts up to 50% sometimes, be sure to sign in and check their website for promo codes especially on Thanksgiving, Black Friday, New Year’s Eve.
(If you are planning to travel in January, don’t rush and buy the ticket early)

Cons:
> in general, their prices are more expensive than other bus companies.
> slow wifi (sometimes non-existent :D).
> Be careful around the stations especially at night, stay indoors!
> If you buy the ticket using a visa card with a different card-holder name than your’s, they will charge you an extra 18 dollars :( .
> Some passengers may be really weird.

If you miss your trip, you will be charged 20$ to issue a new ticket and catch the next one.

Megabus:

Pros:
> Cheaper and can be as cheap as 1 dollar! Check their website regularly.
> E-tickets are available too.
> Buses are newer and more comfortable.
> Passengers are “less weird”.

Cons:
> less state coverage than Greyhound.
> No stations, you have to wait in the street which can be very bard especially if it is raining heavily or snowing.

You can change your trip (if more than 3 hours left till departure) after paying a fee of 20 dollars. This is good to avoid losing your money if you had to cancel your scheduled trip for any reason.


Bustogo:
Less state coverage but they have a nice feature which is using the ticket within a year of purchasing it.

This is based on a personal experience, so you are welcome to try anything you want and put in mind that delays may occur here or there especially with bad weather.


Before you travel to any state, check this website: http://www.smartmedtravel.com/
It will show you names of buses and trains that are available in that state in addition to airports and car rental options.

Wishing y’all a successful Match/interview season and safe travels :D

-Murad

Mixed Connective Tissue Disease : An Overview

Hi everyone ! Just a short post reviewing MCTD! References are Harrison's and Medscape!

Mixed Connective Tissue Disease (MCTD)

1. What is it ?
- It's a somewhat ambiguously used term for disease characterised by a collection of few symptoms from different autoimmune connective tissue disorders.

- Namely , features of Systemic Sclerosis (SSc) , Lupus , Myositis and sometimes RA are present in some proportion in the same patient.
________________________________________
2. What are its chief presenting features ?

A. Features of SSc :
- Raynaud's is often the presenting feature. May also get edematous fingers.
- Dactylitis and digital gangrenes may be + due to Raynaud's
- Sclerodactyly
- Other Limited Cutaneous SSc features like CREST.

B. Features of Lupus :
- Arthritis
- Photosensitivity and Malar rash
- Evidence of Anti phospholipid Antibody Syndrome - associated with SLE. 

C. Features of Myositis :
- Proximal myopathy features
- Muscle tenderness
- May get Cutaneous features of Dermatomyositis.

Also may have Pulmonary Hypertension, Pulmonary Fibrosis.
________________________________________
3. What are the criteria for diagnosis ?

• Immunologically = Anti U1 RNP +

• Clinically = ( any 3 )

Mnemonic = A REM Sleep

Acrosclerosis
Raynaud's
Edematous Hands
Myositis (proven)
Synovitis-Arthritis

________________________________________
4. When to suspect MCTD?
- When a Patient comes with features of Limited Scleroderma (Raynaud's) , but not enough to fulfill its criteria ;

- SSc specific antibodies are not generally positive. (Anti Histone or Topoisomerase) ;

- Suspected SSc patients with  unusually prominent features of Arthritis, Muscle Pain or Rash

________________________________________
5.What tests would one order if suspecting MCTD ?

A. CBC with ESR -
May see Leucopenia with fairly elevated ESR

B. Serology -

• Confirm absence of SSc - Anti Centromere and Anti Topoisomerase.

• For MCTD -
U1 RNP Ab's are fairly specific

• For Myositis -
Anti Jo Ab's (Especially polymyositis)
Anti Mi Ab's (Especially Dermatomyositis)

• For Lupus -
ANA
Complement levels.

• For RA -
Anti CCP Ab's

C. Blood profile -
• Creatine Kinase - Elevated in Myositis
• Urine Routine + Microscopy for Lupus Nephritis type changes
• Electrolytes

D. For Complications -
• Chest X Ray for any ILD or fibrosis
• HRCT if needed.
• Pulmonary Function Tests
• MRI Brain for multi infarct lesions if APLA is + and if neurological changes are +
• ECG - For myocarditis
________________________________________
6. How is the treatment like ?

- NSAIDs - Symptomatic Relief.
- Steroids confer some Relief unlike in SSc. So it's important to differentiate the two!
- Hydroxy chloroquine and Methotrexate may be used to keep disease activity in check.
- Treatment of complications.

Hope this was helpful!
Happy Studying!
Stay Awesome!

~ A.P.Burkholderia

What if I don't Match?

The 12th of March has arrived and what you didn't see coming has unfortunately happened. You checked your email to find an email from NRMP saying: "You did not match". Life suddenly became unbearable and an infinite tornado of thoughts and questions has started! The main one though is: "What to do now?"

Below are some suggestions that may help in answering this question:

 1- Give yourself some time

 > Give yourself the time needed to sink the truth in, yes, not matching is harsh, depressing and soul-crushing. Vent to your friends and cry your lungs out if you feel this will make you feel better.

 > Not matching is hard, but be completely sure, this is not the end of the world, look back at what you achieved till now, you finished medschool, sat for USMLEs, traveled for interviews. You achieved what may be impossible for many others!

 > Check NRMP stats that are released after the Match day, you are not alone, consider this a temporary stop in your life and a chance to build your CV and know more people. Consider it also a test and a challenge that will push your forward to overcome it! The ranking process itself is complicated and is affected by a myriad number of factors so don’t blame yourself and when you feel you are ready, start developing your plan!

2- Polish your CV

 > Sit with a senior/friend/attending and ask him/her how to make your CV better.
Are there any awards or honors that you haven’t mentioned? Any volunteering work that you didn’t add? Can you describe what you did in your previous work experiences in a better way? Are you a member of any international medical organization and you forgot to mention that?

 > You can also review the chapter about writing CVs in “The Successful Match” book which gives many hints about improving your CV. For example, it is advised to use “the action verbs” like “managed” instead of “helped”. The book is available on Amazon, Ebay and many other websites.

 3- Revise/Review your whole application

 In addition to polishing/revising your CV, be sure to check every single component of your application:

 > Did you apply late? Apply earlier this year
> Was one of your letter of recommendations (LoRs) generic or weak? Try to get a new stronger one by asking more people or doing more rotations.
> Did you apply to enough programs? Think of applying to more programs
> Do u qualify for the programs you applied to? Above their cut-offs..etc? Double-check that

 Don’t hesitate to ask seniors or any experienced person who may help.

 4- Taking USMLE Step 3 (if not taken yet)

 > There are many merits of taking USMLE step 3 including the possibility of being ranked higher, an opportunity to have an H1B visa (if you are a non-US International Medical Graduate) and more focus on your residency.

 > A good score in Step 3 also helps if you have any red flag in your application like an exam attempt. It may also decrease the impact of low scores in the USMLE exams and of course it is something nice to add to your CV and show that your are progressing.

 5- Research

 > Research can strengthen your CV and open the doors for more interviews especially from University programs. It can also let you meet new people who may be your contacts in the next match. Some people matched in famous hospitals after doing research there for “a period of time (as short as few months up to few years).

 > Look for research positions either by asking friends/seniors or by emailing institutions like MGH, Mayoclinic...etc. Another way is via websites like indeed.com, some research opportunities are publicized via Linkedin, so it is advisable to have a neat account there and follow the accounts of major institutions. Linkedin may suggest jobs based on your geographic location too.

> When you apply for research,  check the mentor’s/PI’s name on Pubmed. It is better to join people who are more active and publish faster. A good time to start looking for a research position is about a month or a bit more before the match results. Many researchers who are doing their post-doc fellowships leave their positions after they match so if you know anyone who is doing his/her post-doc fellowship, be sure to contact him/her.

 6- More United States Clinical Experience? (USCE)

>Consider doing more rotations whether observerships or externships. This may allow you to apply to more programs that require a certain number of US clinical training months to be eligible.

 >Through rotations, you may get stronger recommendation letters, make new contacts or may even impress and match in the same program in which you are rotating!

 7- Contacts

 > A contact is any human being who can help you! A contact can be a friend, an intern, a chief resident, an attending, a research fellow and even the PD himself/herself...simply anyone!

 > This is one of the most important things that you have to work on before your next match cycle. Whether you are in a rotation or in a research lab, approach politely and ask for help, people out there are good and are willing to help.

 8- Motivation

 > Develop a habit of being motivated, surround yourself with positive people who always encourage you.Watch motivational videos - Eric Thomas has nice ones, check them - on youtube.

 > Talk to residents who didn’t match the first time they applied and see how successful they became now. This happened because of one thing: they worked hard and never gave up!


 Finally, I wish you all the best of luck and I remind you with what Steve Jobs once said: "You can't connect the dots looking forward; you can only connect them looking backwards, so you have to trust that the dots will somehow connect in your future"

 -Murad

My USMLE Step 2 CK Experience (241)

I would like to thank everyone who I met during this journey from all over the world, Thank you everyone!

Sources used for studying:

> MTB step 2 for IM
> MTB step 3 for other subjects
> Uworld
> Uworld biostat review
> Kaplan step 2 patient safety chapter
> Conrad fischer 100 ethics cases
> Uptodate (only looking for details if needed)
> +/- kaplan epidemiology part for step 2 (for biostats)
> CMS
> NBME 4 6 7 and UWSA1

Method of studying:

>Did a fast read of MTBs then started UW offline systemically with taking notes using Anki flashcards program.
>Did UW online systemically in tutor mode  with marking difficult/incorrect questions and writing any new notes that are not in the offline version.
(if you feel you have a problem with time management, do more timed mode blocks)
>Did marked questions in random timed mode
>Revised whole notes in 2-3 weeks
>Solved CMS blocks ( good for introducing some new ideas and practicing more questions)
>Did NBME 4, 6 then 7 ..and did UWSA1 ( scores ranged between high 230s and high 240s...the real score was 241
>When I did the exam, NBME 8 and UWSA2 were not released, so it is better to do those too, and NBME4 can be done offline if needed.

Subjects:
Always check UW diagrams/tables before studying the chapter from MTB

>Peds: 
UW is really solid in Peds and covers most if not all the needed concepts in the exam.

>Surg:
UW ...surgery doesn’t constitute a big chunk of the exam, so I felt UW was more than enough for it

>IM:
Also MTB + UW

>Obgyn:
Please check uw tables and diagrams for Obgyn before studying MTB and compare between the two..sometimes there are differences and UW is always the correct one. You don’t want to memorize the info wrong first then correct it again.
So UW tables hand in hand with MTB then UW.
Kaplan vids for Obgyn may be used if needed.
==
-No comprehensive book for CK like First Aid for Step1 but It is an exam that tests your concepts and the more questions you do the more confident you ll feel.
(In my opinion, Kaplan qbank in step 2 is not needed and may confuse you!)

- It is advised to leave long abstract and drug ad questions till the end because they need time to be solved

- I did CK before step1, some people argue against this. Regardless of what you do first, any step that you will do first will help in the next step ( 2 before 1 or 1 before 2)

Good luck :)

-Murad

Koebner Phenomenon

Hi everyone!
Koebner Phenomonon is a much talked about skin phenomenon.
In this post I'll just discuss Koebner's and its variants briefly.

1. What is it ?
- Many skin conditions tend to occur at the sites of previous trauma.
- This propensity of some new disease to be localised to trauma marks from before is called Koebner's. 
- Also called ' Isomorphic Phenomonon'.

2. Why does it occur ?
- So that's kind of unclear ! But it is said that trauma causes some amount of Subacute inflammation.
- This Subacute inflammation is mainly IL1 and 17 mediated.
- Such an inflammatory condition predisposes the site to further Autoimmune damage.

3. Conditions where Koebner Occurs ?

Mnemonic :
Truly , she Pees Very Little.

True Koebner seen in
Psoriasis
Vitiligo
Lichen Planus

4.  What is Pseudo Koebner's  ?
- Now the basis of true Koebner is that on a site for existing trauma, a new autoimmune lesion appears.
- When the trauma site gets secondarily seeded by some organism causing lesions along its line it's called 'Pseudo Koebner's phenomena'.
Examples =
Molluscum contagiosum
Verruca Vulgaris ( Warts).

5. What is Reverse Koebner ?
- When a lesion along a trauma line gets resolved spontaneously it's called Reverse Koebner.
- Seen in Psoriasis and Granuloma Annulare.

6. What is Reverse Remote Koebner ?
- (isn't that about enough with this topic now?! Are they kidding us with this?)
- So it's seen in Vitiligo. When one patch undergoes resolution with surgery etc , patches elsewhere get resolved too. (God knows what this means , but yeah. *yawns* )

7. What is Pathergy test ?
- So this is a somewhat similar reaction.
- In people with Behcet Disease, if they're poked on their forearm with a needle , they tend to develop pustules and ulcers over it.! It's almost diagnostic of Behcet's.

So, that's all in this post !
Hope this was helpful.
Happy Studying!
Stay awesome!

~ A.P.Burkholderia.

Renal Causes of Hypertension : A Summary

Hypertension in a young individual needs specific evaluation to rule out Non Essential Hypertension (Secondary Hypertension). The Most Common cause of this is Renal Hypertension.

Renal causes of Hypertension can be summarized as follows  -

A. Reno-vascular ( Atherosclerotic/ Fibromuscular Dysplasia - FMD)
(Uncommon = Vasculitis , AV Malformation)

B. Parenchymal Renal Diseases like Glomerulonephritis.

Typical Presentations :

• FMD =
- A young 20-30 year old female , with Hypertension and possibly asymmetrical pressures in both limbs, and associated with a Renal Artery bruit.

- Typically have history of some form of Cranial vessel involvement in the form of Strokes in a Young Female , TIA's , other transient neurological phenomena.

- Carotidynia may be + (Due to carotid dissection).

- Ix =  Rule out Atherosclerosis;
Angiography -  String of beads appearance.

- Rx = Anti Platelets , Anti HT .
May need Endovascular clot treatment.
________________________________________

• GN = 
- A 10-25 year old male or female with cola colored urine , fever and periorbital puffiness. Older adults may have more atypical features like Hypertensive Encephalopathy and may develop Uremia.

- H/O antecedent Streptococcal infection - 3-4 weeks prior.

- Ix - Urine report shows Hematuria, RBC Casts and Nephritic range proteinuria.
Renal profile and Urine output to be done and monitored regularly.
Get ASO titers for previous strep infection.

- Rx - Symptomatic. IV fluids.
May need Renal Replacement if Uremia sets in.
________________________________________

In Addition to routine , the extra Investigations to rule out Renal cause in a young patient with Hypertension -

1. Urine Routine and Microscopy
( Look for Hematuria,  RBC Casts, dysmorphic RBCs )

2. Renal Function Testing -
( Look for rise in S. Creatinine, BUN and electrolyte imbalances)
(Also gives a clue to the Adrenal cause of Hypertension with Sodium and Potassium changes).

3. Imaging -
• Pelvic Ultrasound for any structural abnormality of urological tract - due to Congneital or Acquired causes.
• Angiography (Digital Subtraction Angiography) - to look for renal artery stenosis. (Always with a pre procedure creatinine)
• MRI if needed. 

4. Serology -
• ASO Titres
• Anti DNAse B Ab's ( not done commonly)
• Complement levels - may be reduced.
• Antibody panel for various Vasculitis - ANCA , ANA and AMA.

5. Lipid profile for Atherosclerotic vascular disease. 

That's all for this post !
Hope this helps - both on the wards and the boards.
Happy Studying!
Stay Awesome !
~ A.P. Burkholderia

Mortality benefit of drugs for Heart Failure

Hello guys!

Here's a short and simple way to remember drugs that provide mortality benefit in patients with heart failure:

AA BMC

A = Aldosterone antagonists
A = ACE Inhibitors
B = Bisoprolol
M = Metoprolol
C = Carvedilol

You could also remember BMC as the Beta Blockers that have mortality benefit in Heart Failure patients!

(Off note: The acronym "BMC" works for me as I am studying in one of the BMC hospitals in Mumbai, India. BMC is a local body of the State government here!)

Let me know if you guys have any acronyms for cardiac drugs.
Happy studying!
Stay awesome!

Female genital tumors mnemonics

Hey everyone :) I would like to share some mnemonics that will help in remembering some facts about female genital tumors:

> Mnemonic for most deadly cancers : OUCh

Ovarian cancer> Uterine > Cervical

===
> Mnemonic for the most common female genital tumors in US:
Eradicate Ur Ovary Completely
Endometrial/Uterine > Ovarian > Cervical

===
> Effect of OCPs:

OCPs decrease the risk of cancers that start with vowels 
so ===> they decrease Endometrial cancer and Ovarian cancer
but they increase the risk of cervical cancer :O

===
> Effect of breastfeeding:
Breastfeeding decreases the risk of BOob cancer :P
so ==> it decreases the risk of Breast cancer and Ovarian cancer

And that's it :)


Written by: Murad

Cincinnati pre-hospital stroke scale

Hey Awesomites

Cincinnati Pre - Hospital Stroke scale is one of the most common scale to detect stroke early on. Remember the mnemonic - FAST

Writing a personal statement for residency

Your personal statement (PS) should be your experiences, what make you who you are.

Think of it this way - if you were to sum up your life in one page, how would you do it?

How do you let a person "meet" you without actually meeting you?

How do you put things that are not in your CV on your application?

That's your personal statement my friend.

Now there are many tips on the internet on how to write a personal statement - these are mine and what I found helpful.

Femoral triangle and femoral sheath contents mnemonic

Hello!

The femoral triangle is a subfascial space bounded superiorly by the inguinal ligament, medially by the adductor longus muscle, and laterally by the sartorius muscle.

Contents of the femoral triangle mnemonic: