Tuesday, November 3, 2020

Ascitic Tap

Requirements
Written informed consent, Betadine, Spirit, Sterile gloves, Sterile drapes, a 1.5-3.5 cm 20-22 G needle, a 5-20mL syringe is used, 18-20 G needle attached to a non-collapsible tube (can be made by breaking drip chamber of an IV set and putting one end of it in an empty water bottle for therapeutic tap tubing to a sterile collection bag)

Procedure:
1. Follow universal precautions. 

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

3. Position: The patient should be in supine position( can be asked to roll slightly to left)

4. Site: a) At the junction of medial two-third and lateral one-third of the line join umbilicus and left Anterior superior iliac spine (left side is preferred over right to avoid damage to caecum)
OR 
b) 4 inches above iliac crest, whichever is more dependent

Site has to be lateral to rectus muscle. Avoid areas of scar.

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c) The needle is then withdrawn. 

6. Puncture: 
For diagnostic tap – a 1.5-3.5 cm 20-22 G needle attached to a 5-20mL syringe 
is used. 
Technique – The aim is to prevent leak by ensuring the skin puncture site is 
not directly over the puncture site into the peritoneal cavity. 
 Z track technique – Pull skin about 2 cm downward before puncturing 
skin→ then leave the skin after entering few mm so as to form a Z
OR 
prick the skin, go for some distance in the subcutaneous plane and then change the angle to vertically downwards to enter the peritoneal cavity.  


For therapeutic tap - A large bore 1.5-2 cm 16-18 G needle is used instead.The syringe is detached and the needle is attached to a non-collapsible rubber tubing.The ascites fluid is drained slowly through the rubber tubing connected to the needle into a sterile collection bag. 

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

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

- Mitali shroff

Monday, November 2, 2020

USMLE STEP 1: Resources and preparation

USMLE STEP 1: RESOURCES AND PREPARATION

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

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

FLASHCARDS
ANKI

SUPPLEMENTAL Q-BANKS
Amboss
Kaplan
USMLE Rx

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

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

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

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

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

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

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

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

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

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

AMBOSS Q-BANK

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

UWSAs AND NBMEs (ASSESSMENTS)

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

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

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

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

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

Written by Amrin Kharawala

Thursday, October 22, 2020

USMLE Step 3 experience (247 score)

Overview
Ø  Score: 247
Ø  Preparation time: 1.5 months
Ø  Main Resources: Step 3 UW + UW CCS Cases + CCScases.com
Ø  Supplemental Resources: Step 1 First Aid + Crush CCS pdf + USMLE Primum software + Random overview of few Step 2 CK notes

PCOS explained

PCOS with Sherlock Holmes

Hello guys, this is my first video/podcast on Medicowesome.