Diagnosis of Infective Endocarditis ( Duke's Criteria )

Hello Everyone!

Today, I read about a case of Infective Endocarditis, and it came up with something interesting! A definite way to diagnose a typical case of IE is by Modified Duke's Criteria -

》MAJOR CRITERIA :
           
           1. Positive blood cultures
                         ○ Typical organisms in Two blood cultures
                         ○ Persistent positive blood cultures taken >12 hours apart
                         ○ Three or more positive cultures taken over more than 1 hour

         
           2. Endocardial involvement
                         ○ Positive echocardiographic findings of vegetations
                         ○ New valvular regurgitation

》MINOR CRITERIA :
( Priya Found Emban In the BalCony. )
         
         1. Predisposing factors (any cardiac abnormality, hypertension, valvular defect, congenital heart disease, i.v. drug abuse)
          2. Fever >38°C
          3. Embolic phenomenon (Embolus formation in Lungs, Brain, Spleen)
          4. Immunological phenomenon (Vasculitis, Glomerular Nephritis)
          5. Blood Cultures positive - organisms grown but not fulfilling major criteria.
         

For definitive IE, the simple rule is
2-0
1-3
0-5

☆ 2 major and No minor criteria (2-0)
☆ 1 major and 3 minor criteria (1-3)
☆ No major and 5 minor criteria (0-5)

That's all!
Thanks :)

Mechanism of action of Everolimus in breast cancer

Hello!

Did you guys know that everolimus, an immunosuppressant, is used for cancers like renal cell carcinoma, pancreatic neuroendocrine tumors, etc?

The mechanism of action is really cool, especially in ER (Estrogen receptor) +ve, HER2 -ve breast cancers.

Sometimes ER +ve tumors develop resistance to endocrine treatment such as aromatase inhibitors.

The mechanism of endocrine resistance is mainly driven by aberrant signaling along the phosphoinositide 3-kinase (PI3K) - Akt - mammalian target of rapamycin (mTOR) signaling pathway. mTOR is a Ser/Thr protein kinase that constitutes a central downstream part of this intracellular signaling pathway. Its activation enhances cell growth, proliferation and metabolism, and promotes angiogenesis. The inhibition of the mTOR pathway by targeted therapies, such as everolimus or temsirolimus, can therefore block tumor growth and induce apoptosis.

Isn't that awesome?

-IkaN

ACE Inhibitors in Diabetic Nephropathy

Whats the role of ACE inhibitors in diabetic nephropathy?
I was asked this question in viva..

》ACE Inhibitors retard the progression of Diabetic Nephropathy.
Here is the mechanism-

Renin-Angiotensin system (RAS) gets activated in Diabetes (both type 1 and 2). So there is increased production of Angiotensin and its products, which leads to various vascular and metabolic changes.
Angiotensin-II induces several fibrogenic chemokines, viz.
Monocyte Chemo attractant Protein-1 (MCP-1) and Transforming Growth Factor- beta (TGF-B)
AT-II activates transcription factors
Nuclear factor-KB and thus synthesis of MCP-1 in renal cells. MCP-1 has a role in monocyte immigration which transmigrates through vascular endothelium and gets differentiated to macrophages. This leads to increased Extracellular Matrix production and Tubulo Interstitial Fibrosis.

Slow acting drugs like Lisinopril, Enalapril, Ramipril are employed for 12 months therapy in Diabetic Nephropathy. Assessment of proteinuria, creatinine clearance, uMCP-1 is done before and after this period.
A decrease in protein content in urine, increase in creatinine clearance, and a massive decrease in urinary MCP-1 levels are seen.

Angiotensin Receptor Blockers also retard the renal damage in type 1 and type 2 diabetes.

That's all!
Thanks :)

- JasKunwar Singh

ACE Inhibitor (Captopril) Adverse effects mnemonic

Let's memorize from the name itself-
CAPTOPRIL :

C Cough
A Angioedema/ Agranulocytosis
P Proteinuria/ Potassium excess
T Taste changes ( Dysguesia )
O Orthostatic Hypotension
P Pregnancy/ Pancreatitis/ Pressure drop
R Renal failure and Renal Artery stenosis (contraindicated) / Rash
I Indomethacin inhibition
L Leukopenia/ Liver toxicity.

Hope now you won't forget it. ;)
Thanks!

- JasKunwar Singh

Of reservation, proving yourself and deserving things

"Hello IkaN,

First of all I'd like to tell you how amazing your blog is and how glad I am to have found it.

I am in first year at a government medical college. But I don't deserve to be there. I have reservation (Yes, THAT hated word). I am also well aware that I probably took this seat from someone who scored more than me. The feeling of being less first hit me in the first month of college, when I saw a lot of people speaking out against reservation. 

I wanted to be a doctor. But not like this. The self loathing got so much so that I considered dropping out but I couldn't ask my parents to pay the bond just because I got exactly what I wanted just not in the way I wanted. Nobody in college is as such discriminating towards me but I know they feel a bit differently if they knew how I got here. 

It hinders my studies. I don't feel the same amount of interest in becoming a doctor as I did before. My parents want me to study well, even get a post graduate degree but I can't bear the thought of living all my life in the shadow of reservation.  

I don't want to sound ungrateful for the opportunity I have been given. Being a doctor is a prestige few people get and I know I'm lucky to have got it. I just wish it would have been differently. Which is why I wanted to apply for USMLE.. At least there, things would be fair. If I got something I would know it was because I deserved it. But then I wonder if I couldn't even get an undergraduate seat by myself how would I manage a post graduate one especially one in America ?

I'm not poor but neither am I rich. I don't know how much the exam fees and the books required to study for the exam cost but I'm pretty sure it is not cheap. And if after giving the exam I fail, what would I do?

I really hope you reply but I would understand if you can't because of time constraints or because you don't want to. Thank you for your time either ways."

- Sent through email. 

Aromatase inhibitors and ER positive breast cancer

Happy Monday everyone!

Why are aromatase inhibitors effective in post menopausal women who have breast cancer and why not in women who are premenopausal?

I was asked this question during rounds.

Sturge- Weber syndrome

Hello

Talking about this rare syndrome, I read about in ophthalmology lecture (class of secondary glaucomas) today... So let's start with it-

- It is also known as Encephalo Trigeminal  Angiomatosis (ETA)
• Rare congenital Neurological and skin disorder (phakomatoses)
• Caused by Somatic Acivating Mutation in GNAQ gene.

• Port -wine stains (nervus flammeus) - 
            ○ Usually seen on Forehead and Upper Eyelid of one side of face; present since birth.
            ○ Light Pink to Deep Purple
            ○ Caused by Overabundance of capillaries  around Ophthalmic branch of Trigeminal nerve.

• Associated with
          ○ Secondary Glaucoma (in 50% patients)
          ○ Buphthalmos (enlarged eyeball due to increased intraocular tension)
          ○ Leukocoria (white pupillary reflex)
          ○ Neurologic manifestations- seizures, convulsions (on side of body opposite to birth mark), mental retardation, calcification of tissue and loss of nerve cells in cerebral cortex.
          ○ Ipsilateral Leptomeningeal Angioma (on same side of birth mark; calcification of underlying brain and atrophy of affected region)
• Malformed blood vessels in the piamater overlying the brain on same side of head as the birthmark.

• Radiological appearance shows Tram-Track Appearance on CT, bilaterally.

• Treatment strategies include Laser surgery, Hemispherectomy
 - Latanoprost, a Prostaglandin analogue, is suitable drug for decreasing intra ocular pressure. (1 drop daily in evening)

That's all
- Jaskunwar Singh

An Eye to Cyanide - Part 2

Hello awesome people :)

So, talking about differentials for the cyanide case.. (see previous post Here)

What all u can guess could be the case in such patient if not cyanide..?? Anyone? Think before you read it further..

Here it is...

It could be Carbon Monoxide poisoning. Reason? OK so you remember the patient had shown Cherry Red color of skin when she was brought to the emergency. Carbon monoxide also causes such discoloration of skin as well as blood. This is due to formation of carboxyhemoglobin, which causes decrease in oxygen carrying capacity of blood. So less supply of oxygen and essential nutrients to brain as well as other vitals of the patient, leading to neurological, cardiac as well as other systemic problems!!

An Eye to Cyanide

Hello awesomites!

Hope your weekend is going well :D

I just read about a case of cyanide poisoning and learnt some important points related to it. So here it is -

"A 27 year old comatose woman was brought to emergency by paramedics, and a strong odor of bitter almonds is present. Her past medical history is significant for malignant hypertension. For the past few months, she was given injections of sodium nitroprusside for the treatment, according to her accompanying relatives. She is a housewife and has been under stress regarding family problems. Also she had consumed few almonds a day ago."

Do it for the better, to achieve your Best!!!

Thinking of starting something new? That's great! Don't wait, just start it. Open the first page. C'mon you can do it. Haha.. don't worry. I know it's difficult, but trust me once you start it, you will enjoy it. Yes you will.

Remember one thing always.. Consume your time in doing something productive. Keep yourself busy in some task, create new ideas, think about something and do it. Dream a lot. Yes you really should.

Do it for the betterment of society. Do it for yourself. To achieve the best of yourself. Trust me, the day when u do that, you will feel really happy. Because you did what you wanted to. That you loved. You lived!!!

Thanks! :)
-Jaskunwar Singh.

Step 2 CS: Challenging questions

Here are some of my sample closures for challenging questions.

All my closures are generic with little word play. Whatever the SP says, I would say it back to them saying I understand it. So your sympathy - empathy is done.

See how all three closures are almost the same - 

"Will I need surgery?"
I understand that you are concerned about the possibility of having a surgery. Yes, you might require a surgery. But I assure you that we will be there to support you, throughout the treatment, regardless of the diagnosis. Does that sound okay to you?

Step 2 CS: Introduction

Here's how I introduced myself -

"Mr. Smith? Hi. I am doctor D. I'm the attending physician and I'll be taking care of you."

"Are you comfortable in the room?" (Yes.)

"May I take a seat and write a few notes as we talk?" (Yes.)
"So can you tell me what brought you to the clinic?" (Blah blah blah...)
"Can you tell me more about it?"

Step 2 CS: Counselling for PTSD

I can see that you are distressed about an event that occurred in your life. We have some medical therapy available that can help you with this. Medicines take time to work, in the mean while I can get you in touch with some support groups and social help organizations that have patients who have witnessed similar traumatic events in their life.

Step 2 CS: Physical exam findings in a patient with calf pain

We were practicing a case of calf pain (DVT / cellulitis) today and my friends told me that I documented the physical examination findings well, which is why I posted the note on the blog :)

Things in brackets are for reference only and I didn't type those in my 10 minutes encounter.

Step 2 CS: Headache LOC tip

In a case of headache or loss of consciousness, any weakness or numbness is the first question you ask - because if there is anything suggestive of stroke or transient ischemic attack, you can time yourself to do a neuro exam which includes cranial nerves and strength, reflexes and sensations.

Step 2 CS: Musculoskeletal patient note

IPROM MRSP is a brilliant mnemonic
You can use it for patient notes as well!

For shoulder pain:
Inspection - R arm is closely held to the chest wall. R shoulder appears red compared to the L.
Palpation - Non localized tenderness on palpation of R shoulder, arm and clavicle.
ROM - Pain and restricted flexion, extension, abduction, adduction, internal rotation and external rotation.
Motor - Unable to assess strength due to pain.
DTR's - 2+ intact, symmetric (If time, mention - Biceps, triceps and supinator)
Sensations - Intact to pin prick and light touch
Pulses - 2+ in brachial and radial arteries

For wrist pain:
Palpation - Non tender to palpation
ROM - Flexion, extension, abduction, adduction are WNL
Motor - 5/5 strength in shoulder, elbow and wrist
DTR's - 2+ intact, symmetric
Sensations - Intact to pin prick and light touch except decreased sensation in the palmar aspect of right arm
Pulse - 2+ in brachial and radial arteries
Tinels, Phalens test +ve. Finkelsteins test -ve.

Step 2 CS: Memory loss / confusion

Soo.. I wanted to remember "medical terms" to report my findings in my patient note. I made a mnemonic for remembering "findings in Alzheimer's disease:

AC MI EF

- Decline in Activities of daily living
- Cognitive decline
- Memory Impairment
- Executive Functioning

For activities of daily living, DEATH SHAFT is a tedious mnemonic. Keep it simple -ABCD
Ask for ABCD - accounts, bathing, cooking, dressing and transport - Can you walk in the house / drive a car?

Other diagnoses:

Normal Pressure Hydrocephalus - Ask for urinary incontinence, gait disturbance

Syphilis / AIDS - Have you ever been diagnosed with a STD in the past?

Major depressive disorder (Psuedodementia) - SIGECAPS

Hypothyroidism - Cold intolerance, constipation, slowing of movement, etc

Step 2 CS: Writing a psychiatry note and mini mental status

Mnemonic: ABC MATTS

Appearance - Well groomed / Dishevealed
Behaviour - Appropritate / Inappropriate
Co-operation - Cooperative / Non-cooperative

Mood - Euphoric / Depressed
Affect - Normal / Blunt affect with poor eye contact
Thought Process- Direct / Disorganized
Thought Content - Normal / Delusional
Speech - Fluent speech / Slow speech

"Now I am going to ask you a few questions that may seem odd, but these are just to assess your mental status."

"What is your name?"
"Do you know where we are?"
"Do you know what time is it?"
AAOx 3

"I will name three objects for you, can you repeat them after me? I will ask you to repeat the same objects after a while."
3/3 registration, 3/3 recall at 3 minutes

Step 2 CS: Headache / photophobia

When dealing with a patient with severe photophobia, you might want to dim the light out for the patient just to make the patient comfortable. Say, "I see that the light is making you uncomfortable, let me dim the lights out for you to make you feel more comfortable."

Then you start taking history.

Think of differentials, then ask  about -

Migraine - Ask about aura, catamenial migraine

Cluster headache - Ask about tearing of eyes, rhinorrhea

Tension headache - Ask about stresses in life

Meningitis - Ask for neck stiffness, fever

Excess use of antibiotics can cause Diabetes

New research has pointed out that excess of antibiotics in children can increase there risk of getting diabetes in future.

Why?

Step 2 CS: Hoarseness

This is a very easy case because there are limited number of  things that can cause hoarseness of voice.