Urinary Bladder and Clinical Correlates

Hello everyone! This write-up attempts to organize the seemingly confusing nerve supply of the bladder and associated pathology aka the neurogenic bladder.

NERVE SUPPLY :

(beta 2 and alpha 1 are adrenergic receptors of SANS ; muscarinic type 3 is a cholinergic receptor of PANS)

• SANS inhibits micturition while PANS facilitates micturition. You don’t want to pee when you’re running a 100m sprint, an SANS-dominant activity but you can comfortably pee at rest, a PANS-dominant activity.

• Sensory fibres of pudendal nerve tell your CNS when the bladder is full. The motor fibres of pudendal nerve maintain EUS tonic contraction by default so that you’re not always peeing.

• The reflex arc, after higher centre commands, causes voluntary micturition by inhibiting the “contraction-effect” of motor fibres of pudendal nerve.

•  To oversimplify matter (so that it’s easy to understand and remember): Level 2 control inhibits reflex arc. Level 3 control facilitates reflex arc, causing micturition at will, once the bladder is full.

CLINICAL CORRELATES:

• CORTICAL BLADDER

-- Aka Incomplete Spastic OR Uninhibited bladder.

LESION	CLINICAL  FEATURE
Postcentral cortex	--  Loss of awareness of bladder fullness          --  Incontinence
Precentral cortex	--  Hesitancy = Difficulty in initiating micturition
Frontal cortex	--  Precipitancy = micturition with ‘easy’ stimulus, eg: sound of running water          -- Inappropriate micturition/ loss of social inhibition (infant-like)

Associated with:

Multiple Sclerosis

Parkinson’s disease

Stroke, among others.

• HYPERTONIC/ AUTOMATIC  BLADDER

-- UMNL/ Complete spastic type of bladder.

LESION	CLINICAL  FEATURE
Spinal cord ABOVE S2, S3 and S4.	--  Urge incontinence = patient passes low-volume urine frequently         --  Less post-voidal urine volume, so less risk of UTIs         --   More intra-vesical pressure, more risk reflux nephropathy

• HYPOTONIC/ AUTONOMOUS BLADDER

-- LMNL/ Flaccid type of bladder.

LESION	CLINICAL FEATURE
--  Spinal cord AT S2, S3, S4         --  Cauda equina/ Conus medullaris         --   Peripheral nerves	--  Overflow incontinence =  urine retention, overtime, forces IUS to mechanically open causing dribbling micturition         --  More post-voidal urine volume, more risk UTIs

2 subtypes are:

• Motor Paralytic bladder – Motor (efferent) pathway is damaged. However, patient can sense bladder fullness, resulting in prompt diagnosis. Associated with:

--  Complication of abdominal/ pelvic surgery

--  Lumbar canal stenosis

--  Lumbo-sacral meningo-myelocele

• Sensory Paralytic bladder – Sensory (afferent) pathway is damaged and hence, patient canNOT sense bladder fullness, resulting in delayed diagnosis. Associated with:

--  Diabetes mellitus

--  Syringomyelia

--  Tabes dorsalis

Medicine pearl: When we talk about bladder pathology, we only refer to PANS (lesions above/ at/ below it) as SANS lesions doNOT cause bladder pathology per se. However, bilateral lesion to L1 causes retrograde ejaculation and hence, infertility.

Topics for further reading:

--  Age-related urine continence

--  Nocturnal enuresis

--  Barrington reflexes

Hope this helps! Let me know if anything needs clarification. Happy studying!

-- Ashish Singh.

Tumor lysis syndrome and rhabdomyolysis: Why does calcium decrease?

Doubt in response to you post on tumor lysis syndrome: What is the mechanism behind hyperphosphatemia causing hypocalcemia in tumor lysis syndrome? Wouldn’t the tumor cells also release calcium, thus leading to hypercalcemia? Asked via email

HPV vaccines

Hello Awesomites!

HPV infection can cause:

-cancers of the cervix, vagina, and vulva in women;

-cancers of the penis in men; and

-cancers of the anus and back of the throat, including the base of the tongue and tonsils (oropharynx), in both women and men.

3 vaccines are available :-
1.Gardasil (6,11,16,18)
2.Cervarix (16,18)
3.Gardasil 9

Is HPV vaccine only for girls?
No, it is for both boys and girls.

Age 11-26 years.
Then what is that 9-11 years or 11-12 years criteria?
Actually most of the vaccination programme for adolescent is in that age group. So to avoid that extra visit it has been scheduled so.

What about beyond 26 years?
It is not required because such cases are either already exposed or already infected.
In <14 years -2 doses is needed to mount same immunity.

Dose 2 or 3 .

-interval between the doses should be of 4 weeks.

Route intramuscular

Type capsid proteins.

Pregnancy is a contraindication. But if did vaccination then no need to abort.

For the doubts regarding vaccination, you should consult your physician.

-Upasana Y. :)

Thiamine and Beri-Beri: A Summary

• Vitamin B1 is Thiamine.

(TCA = TriCarboxylic Acid cycle aka Kreb's cycle ; LDH = Lactate Dehydrogenase ; PDH = Pyruvate Dehydrogenase ; TPP = Thiamine PyroPhosphate)

• Peripheral neuropathy in dry beri-beri is symmetric, sensorimotor, distal > proximal and non-inflammatory demyelinating type.

• Wernicke's syndrome is reversible early while Korsakoff psychosis is reversible in only 20% cases.

• Wernicke-Korsakoff syndrome has typical damage to dorsomedial nucleus of thalamus and mamillary bodies.

• Clinical manifestations of B1 deficiency is worsened by glucose load! As seen in pathophysiology, excess of glucose with relative or absolute deficiency of B1 - as TPP - causes diversion from the preferred PDH pathway (linked to TCA), to the LDH pathway causing life-threatening lactic acidosis. Hence, in a patient with alcohol intoxication/ chronic alcoholism a B1+glucose cocktail is given as they usually are deficient in B1.

Biochemistry pearl: Other co-factors in PDH pathway alongside TPP are Lipoic acid, Coenzyme A, FAD(H) and NAD(H).

DIAGNOSIS:

Clinical diagnosis with confirmatory lab work - that includes:

• Diagnostic - Blood or RBC transketolase activity and increase after intramuscular B1 administration
• Supportive - Blood thiamine, pyruvate and lactate levels

MANAGEMENT:

You give what the patient lacks. An acceptable regimen is:

Injection B1 100 mg intramuscular for 1 week

followed by

Tablet B1 10 mg once-daily per-oral for 1 month.

Let me know if anything needs clarification. Happy studying!

--Ashish Singh.

Cushing's Syndrome: A Quick Review

Definition: Clinical syndrome characterized by signs and symptoms of raised blood cortisol levels.

Etiologic classification:

• Pituitary Cushing's is Cushing's disease.

• ACTH dependence simply means if raised ACTH is the cause of raised cortisol.

• Feedback loop, more correctly negative feedback loop, implies if cortisol level influences ACTH level inversely. Ectopic Cushing's is caused my malignant cells that continuously proliferate and hence, continuously make ACTH, regardless of cortisol levels.

• Therapeutic administration of ACTH hormone for long periods can cause ACTH-dependent Cushing's. However, they are exceedingly rare (and hence, omitted from the whiteboard for simplicity).

(MCC= Most Common Cause ; B/L= Bilateral ; U/L=Unilateral)

Clinical Features:

CUSHINGOID

Central obesity, Cervical fat pads (with moon face and fish mouth = Cushingoid habitus), Collagen fiber weakness, Comedones (acne)
Ulcers (peptic)
Striae, Skin thinning & bruising
Hypertension, Hyperglycemia, Hirsutism
Immunosuppression, Infections
Necrosis (Avascular) of femoral head, Neuropsychiatric symptoms
Glucose intolerance, Growth retardation
Osteoporosis, Obesity
Impotence and menstrual abnormalities
Diabetes


Diagnosis:

High dose DXM or CRH don't bother ACTH or cortisol levels in Ectopic Cushing's as they're out of the feedback loop.

Other tests include:

• 24 hour urinalysis

• Midnight salivary cortisol

• 9 am cortisol

• Overnight low-dose DXM suppression test

• B/L inferior petrosal sinus sampling

• Electrolytes and routine CBC

(DXM=Dexamethasone)

Management:

• Iatrogenic: Withdraw steroids slowly.

• Pituitary: Trans-sphenoidal resection OR radical hypophysectomy, less commonly

• Adrenal: Surgical resection with post-op prednisolone OR medically treat with Metyrapone or Aminoglutethimide.

• Ectopic: Chemotherapy and Radiotherapy for small cell lung cancer OR surgical resection for carcinoids.

Let me know if anything needs clarification.

Happy studying!

-- Ashish Singh.

Schizophrenia First Rank Criteria : Mnemonic

Kurt Schneider laid down the First Rank Symptoms of Schizophrenia.
They're tedious to remember but we need to know them for MCQs and entrance tests!
So here goes :

Mnemonic :
ABDS VV (Very Vella)

A = Audible Thoughts (Echo de la Penses)
B = Broadcasting Thoughts + Insertion/Withdrawal of Thoughts
D = Delusional Perception
S = Somatic Passivity

V = Volition absent (Avolition)
V = Voices speaking / Arguing

That's all !

Few contributions to Schizophrenia :

The word was Coined by : Bleuler
Demence Praecoxe : Morel
Dementia Praecox : Kraeplin
1st rank symptoms : Schneider

Bleuler also gave the 4 A's of Schizophrenia !
They are Avolition, Autism , Ambivalence and flat affect.

Hope this was a good list for you !
Happy studying !
Stay awesome !

~ A.P. Burkholderia

The Oedipus Complex

The Oedipus Complex has been an ever popular Freudian concept.
Here's a summary of Psychosexual development as per Freud and the Oedipus Complex concept.
I insist you put up with this incestuous concept :p

So Freud was an extraordinary Psychoanalyst and gave the stages of 'Psycho Sexual Development'  in his book 'Interpretation of Dreams'.

There Are 4 stages of Psychosexual development in Freud's opinion that all of us pass through to reach the mature stage eventually.

The 4 stages are :

1. Oral
2. Anal
3. Phallic
Latent period
4. Genital

Remember -
Mnemonic : On A PG break.

If one fails to break through any of these stages , it is said he'd develop specific psychiatric illnesses.
It's important for a child to go through these stages without 'fixation' over any of those.

For example Oral stage fixation Makes you SAD
Schizophrenia
Anxiety
Dependent Personality disorder.

Anal Stage fixation makes you an 'Anal' person.
So you're likely to develop Obsessive Compulsive disorder or Obsessive Compulsive Personality (Ankanastic Personality)

Phallic Stage Fixation is "complex."
So in previous stages , it's been obvious what the object of gratification has been (Mouth and Anus respectively).
This one's slightly more "complex".

So as per Freudian theory , Boys would be sexually fixated on their Mothers, viewing their Fathers as a threat ;
This is called the 'Oedipus Complex'.
And also have Castration anxiety.

The theory says similarly Girls would be sexually fixated on their Fathers , viewing their mothers as a threat ;
This is called the 'Elektra Complex'.
And have Penis Envy.

The Oedipus Complex :
So this stems from the Greek story where Oedipus marries his own mother unkowningly , after he kills his father.

King Laius was the king of Greek city Thebes. He and his wife Jocasta bore a child : Oedipus.
The problem is some Seer prophesized that this child would kill him. And so he sent away his child, who was found and raised in another city by another King. Years later he returned to Thebes and quarreled with an old man and ended up killing him.
After a while he was told that the King had been killed , and that he could take charge of the town if he defeats the Sphinx. He did so, and won the hand of the King's wife Jacosta as well.
Years later he found out the King was actually his Father , and his Wife was his mother.
Here's where the 'Oedipus Complex' gets its name from.

Electra Complex
Stems from another Greek story.
Electra was the daughter of Agamemnon, whose wife killed him.
Electra then avenged her father's death by killing her mother.
(Talk about Daddy's lil girl ;;) )

Another complex is 'Pharoah Complex' where siblings are fixated sexually on each other.

Fixation in Phallic phase leads to Paraphilias and Hysteria.

Hope this wasn't overly disturbing !
Happy studying !
Stay awesome.
~ A.P. Burkholderia

Kallman syndrome mnemonic

Kallman Syndrome (also known as Olfactogenital dysplasia/syndrome or anosmic idiopathic hypogonadotropic hypogonadism)

Let's​ get down with the mnemonics!

'Kallman' kinda rhymes with 'Tallman', right? Well, "man" for it's more common in boys and Tall these individuals are of normal or even increased height (Tall).

The other features are:

K - kinda looks like an X so it's X-linked
K also sounds like C for Colorblindness
A - anosmia
L - lip (cleft lip and cleft palate)
N - nerve deafness
A - ataxia (cerebellar ataxia)
M - midline defects (cleft palate, cleft lip)

Other important points are:
- The defect is in the KAL gene which codes for the protein anosmin.
- It can be due to autosomal dominant or recessive inheritance.

That's all!

Stay awesome 

This post is written by Nikhil as part of the MSGAI.

Medicowesome secret project: Organ donation poem

What is the secret project? How can I participate?

How to write ERAS CV for the USMLE match and FAQs about the application

Writing ERAS CV

The ERAS CV is a very important part of your application. After filtering applications, your CV is given points based on special activities (international volunteering, unique  skills, exceptional research) and if your CV points reach the threshold set by the program, you're invited for an interview (I was told this by a faculty in an interview!) 

Take. This. Seriously.

The ERAS CV is very different from the usual CV because you have to fill in a pre-made format. It's confusing. You don't know what to do. This post is based on what I know about what's preferred. There's no right or wrong.

I'm writing this post is a question and answer format so it's easier to refer to. 

These are just preferences - see if it suits you! I tried to give credit to the friends that gave these tips along the way. Most of them are American Medical Graduates (AMGs) and my input is IMG lol (International Medical Graduate). 

How to start:

List all your accomplishments. Then, ask your parents when you finish jotting down everything - You may forget your achievements but your parents will remember every random award you won. (Thanks MB for the tip!) 

PARAGRAPHS OR BULLETS?

Bullets. Easier to read when you are reading 100 applications on the other side of the table.

WRITING DESCRIPTIONS:

What type of wording should I use in the description section? 

Example one: "Worked as a volunteer, duties included..."

Example two: "I had the opportunity to work with Dr. Smith as a volunteer..."

IkaN tip: Both are equally good but prefer one as it is short and sweet! 

Here's what the Dean of an AMG emailed (thanks for sharing HM!): No need to use complete sentences with activities. Use active verbs like a resume. It is NOT wrong to use full sentences if you prefer that approach, but it not expected. Example: “Delivered lectures to first-year medical students on cardiac physiology.”

How long should my descriptions be? 

IkaN tip: Keep it short. Write tweet-sized descriptions.

HM's Dean on how much to write: Think about how important the activity is and how many of these applications your readers are reading. If you have a critical role you may want to write more. A mere participant should not belabor the point too much.

REASON FOR LEAVING:

What do I write for "Reason for leaving"?  

IkaN tip: Be elaborate. The reader should know in a glance why you left. I read an AMGs CV and he was very clear even with respect to non-medical jobs. He wrote, "I had to leave because of change in location or because of better opportunities but I was never fired from any of these jobs." or "I left the leadership role but I continued as a volunteer..." (Thanks for sharing this MS!)

The downside of not being specific is that curious faculty may call you to know your reasons. This is what my IMG friend was asked by the PD on a phone call: "Why did you leave your XYZ training after 3 months? Why did you leave the lab after working for a year? I see no publications out of it!"

She had definite reasons and she explained to them elegantly on the phone and was granted an interview. But had she been elaborate on the CV, she probably wouldn't have received the anxiety-provoking phone call! 

HM's Dean on how much to write: Okay to say “activity concluded” or “graduated” or “internship ended.”

IkaN used: End of bonded service, End of internship, End of rotation (Because I didn't know this before!)

DATES AND HOURS:

Because of the period and hours, you worked in is important!

If I am currently working and do not intend to stop working during the interview season, can I put the "to" date in the future, say March 20XX, depending on my hire agreement? Or do I leave it blank? (PS: "Present" option isn't available in the ERAS CV.) 

It's okay to use future dates.

Since residency starts in July, your Program Director (PD) would want to know how will you manage to work for them and working for the other work, side by side. Keep answers ready :) 

What if I work 3 hours every month for a volunteering organization? How do I put it in weeks on the ERAS CV?

PDs are aware of the inflexibility of the ERAS CV when it comes to editing certain parts. You can mention the minimum number of hours in the hours/week box. Then describe the hours and frequency of your work clearly in the description.

NAME OF ORGANIZATION: 

Usually, it is the name of the Hospital or Medical School you rotated in.

If there is no organization and you worked voluntarily to do something - can you put the organization "Self"?

Yes.

Self-doubt: Is it work experience? Or does it go into extracurriculars?

I was confused while mentioning the blog (Medicowesome) and the book I wrote. 

A fellow I know replied this:

I would include the website/book in the extracurriculars section (not sure if there is a section like that but whatever is closest to that) unless it was an organization that was being run with a formal job post. I was a part of a youth organization in medical school and had held several posts but included those in the extracurricular section because it is not formal work experience. You could ask some other people for advice on this as well but I think work experience is not the most accurate.

I was leaning towards extracurricular since I was not really working for an organization. Not sure if being an entrepreneur counts as work experience! Also, I think ERAS says that if you are paid for it, you put it in work. If not, it's a volunteer experience. Since I wasn't getting paid, I doubted putting it under work experience.

What did I do? I listened to my gut and put it under Work Experience. Best decision I made :)

Artwork – especially if the artwork is displayed at a gallery or show

Music – make special note of shows or places you have performed at

Many people make the mistake of putting significant artistic skills in the ‘Hobby’ section.  This does not give yourself enough credit if you have done legitimately IMPRESSIVE artistic accomplishments.  You have to realize that faculty members are glazed over by all the research projects from candidates.

Think about this, wouldn’t you rather talk to someone about their artwork than their summer research project on colon cancer screening?  Me too.  I’d rather hear about something unique and new.  So if you have done some significant artistic, musical, or talent PUT it in the WORK SECTION. 

Source: https://www.residencyinterviewquestions.com/2015/09/08/strengthen-electronic-residency-application-service-eras-application/

LOCATION: 

What if I worked from home for an organization based in the US? How do I put it in?

Use the location of the organization, however, while writing the description use the words, "I worked remotely for..."

I needed this advice while figuring out how to mention Editor of First Aid, the company is based in Kentucky, not India (from where I usually worked)

I hope this gives a good general idea. I will be updating more points soon! Lemme know your questions in the comments below or email medicowesome@gmail.com

FREQUENTLY ASKED QUESTIONS:

Where do we put electives in my ERAS CV?

Work experience.

Who is the supervisor for electives?

The attendings you rotated under. Limit to two or three names. If you had multiple attendings, choose your favorite two. You can write 4-6 names but it is too much to read.

Can you include non-medical volunteer experience in your ERAS CV?

Here are a few things I am confused about:

Organized a medical conference

Was an editor for the college magazine

Can you write non-medical accomplishments in medical school awards?

Won a prize in a poster making competition (art, not research poster)

TOEFL score?

Accomplishments before medical school?

YES. Add whatever makes you look good and like a well-rounded person. It will help you during your interviews. 

Which hobbies should be included?

Only list hobbies that show initiative, perseverance, or skill (ie. sports, cooking, language fluency)

Do not list hobbies that would show a Program Director that you may be distracted (ie. social media, fantasy football, trying out different bars, playing video games)

List hobbies with achievements first - Like if you like to dance write about dance courses, etc. (Thanks AS for the tip!)

What can you edit once the CV is submitted?

I called ECFMG and found out - "personal information" section can be edited throughout the application season.

Will the program see the "view print CV" or "view print application" version of the CV?

Both.

How is the CV sorted? 

The CV is sorted in chronological order (dates) with your most recent accomplishments first, so don't worry about what to enter first.

Do we leave AOA and GHHS blank "select" or choose "No chapter at my school"?

No chapter at my school if there is no chapter.

Are you Board Certified? What does this mean? Is this the same as ECFMG certification?

No, it is not the same as ECFMG certification. Board-certified means having taken an American board exam.

RESEARCH RELATED:

Can we write about any of the articles that are submitted for publication? But bot published yet?

Yes.

If you've done a research project but also presented it as a poster, do we include that in our research experience or only as a poster presentation?

You can include it in research experience and as a poster.

What about Oral / PowerPoint presentations?

You can include it somewhere - I gave a presentation during electives so I wrote it in the work experience section.

There's another section under publications for oral presentation - Can you put elective presentations in that?

No. I had read long ago that only grand rounds are worth mentioning. ("Presentations" refer to presentations that have been FORMALLY accepted or invited at regional or national academic meetings. Presentations that you do in the context of your education, for instance on rounds or in clerkship conferences, etc. are NOT academic presentations and should not be listed on your CV.)

 

Do you add conferences you attended in work experience?

I don't know, I did not mention it in my CV- feel free to answer them if you know for sure.

What counts as a book chapter? Do textbooks such as First Aid count?

Yes, as long as you played a major role in writing a book chapter.

I have done my residency in India already. Do I add that to previous experience or previous training or in medical education as there is an option of master's training?

Previous training.

How do I write about a project that I worked on in research experience that has not been published?

I worked on the XYZ project at ABC hospital.

Responsibilities included:

- Collecting data of inpatient post-op patients for 18 months.

- Doing a statistical analysis of the data.

- Doing the literature review.

Questions from Indian medical students:

What about the column on Membership in Honorary/Professional Societies - How much importance does it have in a CV?  Which kind of societies can we put in? Do we have to describe them?

Some students have put:

- Student member, Rotaract Club of Caduceus (20XX-20XY)

- Member of Maharashtra Medical Council, Mumbai (Sr. No.: MMC/XIII/0515253; Reg. No.: 2140M137)

Can we include volunteer organizations such as Rotaract? Isn't MMC a council, not a society?

No need to mention. My seniors advised me against it. 

Writing about INDIAN INTERNSHIP in your CV:

How should we write an internship in work experience? Month wise for every rotation or one year experience as a whole?

One year experience.

Why? Month wise will make the CV redundant and long. It may be too boring to read. The reader might not focus on your other accomplishments based on longevity.

Was your medical education being extended? There was an extension in the internship - it's okay to check "No" if it was for electives (you extended it for training). If you had other reasons, go for "Yes".

Who is the supervisor for the internship? The dean or the head of the PSM department?

Anything is fine - You may also leave it blank or say, "Multiple supervisors".

Can we put an internship as a post-graduate training experience instead of work experience?

No. It is not post-grad because you are required to do it for a med school degree.

The internship is equivalent to the Americans intern year (which is PG training for them). They are supervised when they rotate through various departments and get paid for it. (That's what we do as well!) - So, good question!!!

That's all!

*phew* that was a lot! 

I hope this gives a good general idea. I will be updating more points soon! Lemme know your questions in the comments below or email medicowesome@gmail.com

Hoping to match this year,

IkaN (Pray for me, pray for the match in March!)

Immunomodulators mnemonic

Hello Awesomites :)

Let's work out an interesting way of remembering a few Immunomodulators and Chemotherapeutic agents today!

These mnemonics were submitted to us by Mikey.

1. SIRolimus
    Is it nephrotoxic? Does it cause pancytopenia?
    - Kidney SIRvives. It causes panSIRtopenia

2. MycophenolATE side effects:
    - M: Marrow suppression
    - ATE: for GI effects: Nausea, cramping and abdominal pain

3. What do you use Azathioprine for?
    - *Auto*thioprine - *Auto*immune conditions, as well as Rheumatoid Arthritis, Crohn's disease and glomerulonephritis

4. What is the MOA of Basiliximab and what are it's side effects?

 Say: Basilik, THE Reptile in aisle 2

    - THE: Tremor, Hypertension, Edema
    - It is an IL- 2R monoclonal antibody

5. What is the MOA of Trastuzumab and what is it used for? it's side effect?
    - It is a therapeutic antiobody againts HER2/neu receptor

    HER Breasts and Stomach *trust*ed you!

    - Used for Breast and Gastric cancers

    But, it hurts Heart too!

    - Causes Cardiotoxicity.

- Compiled by Riya

That's it!

Have an awesome day, you guys!

Advice for interview season: Being street smart

Akshay Vacchani wrote these tips and tricks for interview season. He told me, "I didn't know all of this, it's what experiences taught me."

I think it's helpful to read it after you've submitted your application.

After 15th September, download mymail application:

I found this app fastest one to download ERAS email and notify you with earliest possible time with distinct notification sound.
(Gmail wasn't refreshing new emails that quickly, I think least time duration was 15 minutes and I didn't like Gmail app.)

Be ready to respond quickly to the programs as in some date may fill out quickly, so fast notification and quick response to program, along with keeping google calendar open either in your tablet or phone will help you easily choose date and organize them based on their locations.

Once you get an interview....

Organize dates of program wisely.

Use Google calendar and use some special color for program's interview day. Use different color code for different works like flights or airbnb check in time, etc.

Use Google reminders to respond to any email or phone call important for these all procedures.

Use google map and save all program locations and your hotel or Airbnb rooms, give them stars or label them as you like. This will definitely help you to plan all stuffs and may help you to save money with better planning.

Before the interview:

Make a different folders for each program in your google drive, copy and paste all ERAS info, any program related info, place where you are leaving, flight info into different docs.
Why? So that you can have access to all from one place, especially, in case of emergency. (No network or device lost or something.)

Day before the interview...

Check weather info in advance.
Sometimes you may not have access to Internet because of bad connection. Make a shortcut of Google maps (travelling to hospital from your place).
If you are going to book a cab, you can also book Lyft or Uber in one day advanced for particular time in the morning, I would definitely suggest that.

Bus recommendation:
Use Greyhound instead of megabus because of wonderful facility of waiting station with restrooms even in mid size city. I had to wait in 0 F° outside for Megabus, and the bus was delayed, which may not go well for you sometime.

For Greyhound, I would suggest you to book a flexible ticket especially using discount coupons on festivals if you sure about your departing and arriving city. You can always change date, have priority boarding or full refund.

Flight recommendation: Southwest
For flight, I would definitely suggest to book Southwest, even if you don't have luggage.

Booking in advanced, you can get it for cheaper price, always use refund money for other flight, always modify or cancel.

And best thing, you can get change flight time with no extra money even at last minute.

You call them, tell your flight is delayed and there is any slight chance of change in estimated time of departure, (if there is more than 1 hour, then for sure), you can ask for early flight whatever time you want, and no any extra fees.

Hemiplegia Evaluation : Case-related Clinical Pearls

Here's a couple of special pointers for a CNS Case with the Viva Questions asked commonly !

General Examination (In addition to what you would routinely mention)

- GCS / MMSE depending on status of the patient

- Regular Temperature, Pulse , Respiratory Rate and Blood Pressure.

(Pulse could have irregularly irregular rhythm which indicates Atrial Fibrillation. Very strong Etiological clue)

(Blood pressure is super important : to be brought down rapidly if Hemorrhagic suspected and to be brought down below 185/110 of planning to Thrombolyse.
Do not reduce to very low levels too rapidly to prevent damage to the Ischemic penumbra)

- Carotid Bruit : indicates Carotid artery stenosis due to Atherosclerosis. Before palpating for the carotid pulse always auscultate to rule out a Thrombus as you may dislodge it when you press it.

- Signs of Hyperlipidemia :
Xanthoma , Xanthelesma , Arcus Senilis , Locomotor Brachii

- Check for Bed Sores - will find in long term Hemiplegics

- Check for an Indwelling Catheter.

- Neurocutaneous markers :
(Cafe au lait for Neurofibromatosis , Shahgreen patches , Ash leaf macules for Tuberous Sclerosis, Port wine stain for Sturge Weber Syndrome)

After this perform the routine neurological examination.

_______________________________________
Specific Questions that can be asked on Hemiplegia , and we must be aware of for exams (and for life) :

1. Elicit :
Tone
Power
Any deep tendon reflex (Commonly Biceps , Triceps , Knee , Ankle)
Clonus
Plantar Reflex (Babinski)

Glabellar tap
Jaw jerk
Facial Movements (7th nerve )
Gag reflex (Never forget to check for gag - it decides whether Ryles tube is needed or not and is super important to prevent Aspirations).
Extra Ocular movements
Tongue examination

2. Viva Questions :

A. Plegia vs Paresis?
Total paralysis = Plegia
Incomplete paralysis / Weakness = Paresis

B. What is Hemiplegia, Quadriplegia, Diplegia , Monoplegia , Cruciate Hemiplegia?
Diplegia = All 4 limbs involved but Lower Limb involved more than the upper.

Cruciate Hemiplegia= Upper limb of one side and lower limb of the other.
(I'm sure you know the others )

Complete Hemiplegia is when Facial involvement is present as well.

C. Hemiplegia vs Paraplegia site of lesions?
Hemiplegia is brainstem and above upto the cortex.
Paraplegia is spinal cord and below - upto the nerve.
(Paraplegia = Both lower limbs )

D. Rigidity vs Spasticity
- Lead pipe and Cogwheel Rigidity in Extra Pyramidal lesions like Parkinson's
- Clasp Knife Spasticity in UMN pyramidal tract lesion

E. UMN vs LMN lesions
(What is UMN ? What is LMN?)

F. Root values for all reflexes ?
(Deep + Superficial)

G. Plantar reflex components? What is a positive Babinski Sign? (5 components)

H. Causes of Babinksi positive other than Pyramidal tract lesions ?
(Deep sleep , Infancy , Coma.)

I. Alternatives to Elicit Babinski :
Gordon = Squeeze the Calves
Shaefer = Squeeze Tendoachilles
Oppenheim = Slide the knuckles down the tibial shaft
Chaddock = Strike along the medial aspect of the malleolus.

Hoffman Sign in Upperlimb

J. What is Jendrassik's maneuver ? What's its use?

K. Grades of Power ? (Should be pit pat)

L. Grades of Reflexes ? (In terms of + ++ +++ and ++++)

M. Causes of Hypo and Hypertonia?
Remember : Cerebellar disease causes Hypotonia

N. Clonus definition ?

O. What is Spinal Shock ?

P. Importance of aphasia ?
Wernicke vs Broca with area numbers ?
Conduction aphasia ?
How are these different from dysarthria?

Q. Know your blood supply : Anterior vs Posterior Circulation
- Middle Cerebral Artery - Superior vs Inferior Branch how to distinguish?
- Features of MCA territory stroke ?

R. Know Brainstem Syndromes names - the Crossed Hemiplegias.

Weber , Claude , Benedikt in Midbrain
Milliard Gubler and Foville in Pons
Medial and Lateral medullary Syndrome in Medulla.

S. Frontal lobe lesion features ! Especially Frontal release signs can be asked - Palmar grasp , Palmomental reflex , glabellar tap.
What is Gegenhalten phenomenon?

T. Then if you answer some of these they'll ask Management!
In that Basic Routine Ix. Don't forget Bloor Sugars and ECG.
NCCT best initial (Non contrast CT Scan)
Diffusion weighted MRI is very accurate for localisation!

U. Thrombolysis can ask everything about !
rTPA 0.9 mg/kg 
CONTRA INDICATIONS and Indications.

V. BP control in stroke - Which agents ? Target BP ? How to Reduce?

W. Raised ICT management?

X. What drugs would the patient be on life long ?
Aspirin and Statins

Y. Neuroprotective agents , name a few?
Citicholine , Piracetam , Adavarone

Hope this was a good list !
Do message on the Medicowesome Group or comment down below if any answers are needed or you have doubts !
Happy studying!
Stay awesome.

~ A.P. Burkholderia.

Hemiplegia History-taking : Case-related Clinical Pearls

Hi everyone !
Just a short summary of what not to miss in your case taking of a Hemiplegia case - on the Boards or the Wards ! Here goes.

In the History of Present Illness
- Ask Onset - Time of onset very imp. And sudden or gradual. (To decide Ischemic or Hemorrhagic)

- Progress - If maximal at onset -- likely embolic. If progressive gradually -- Thrombotic stroke. If rapidly progressive -- Hemorrhagic stroke. 

- Hemiplegia / Paresis - what position was pt in ;
Upper Limb (UL) more than Lower Limb (LL) or equal. 
(ASK FOR PROXIMAL AND DISTAL MUSCLE INVOLVEMENT IN EACH LIMB)
( Proximal UL = Raise hands above head to take an object/Comb hair ;
Distal UL = Button Tee shirt or Eat food.
Proximal LL = Get up from Squatting position
Distal LL = Walking).

- Ask for facial deviation ; Drooling of food after feeding ? -- Facial palsy 
- Hemianaesthesia - ask for sensory loss or paraesthesias. 

- The Episode -->

• Seizures ? Urinary / faecal incontinence?  - suggests increased severity / Cortical involvement

•Speech disturbances ?
- Likely cortical lesion if Aphasia ; or dysarthria due to UMN lesions

•Symptoms of cranial nerves --> Vision changes, Diplopia , Facial sensations , repeated aspiration of food , tongue problems. ( Localise the lesion to Brainstem)

• Gets better for a while and then Symptoms re appear - Lucid interval of extradural Hemorrhage

• Preceded by headache, vomiting , photophobia ?
( Meningitis/ SAH or PCA stroke) (Thunderclap headache in SAH) 

• Any h/o Alcoholism / Trauma - Could be Subdural Hemorrhage

Always rule out a simple Syncopal episode and a plain Seizure.

In the Past History :
- H/O similar episodes - how were they treated and what were the residual deficits.
- H/O similar episodes that spontaneously resolved - TIA's
- H/O Other occlusive events - Myocardial Infarction, Peripheral Vascular Disease , Pulmonary embolism
- Ask h/o heart disease - Skipped beats for Atrial Fibrillation and other Valvular problems.
_________________________________________

What is expected out of the history-taking for Stroke :

1. What is the topographic distribution of weakness -
Hemiplegia / Monoplegia / Quadriplegia / Diplegia

2. Is the likely Etiology a vascular event in the Cerebral Circulation?
(From : typical elderly to middle aged presentation in a Hypertensive , Diabetic patient with sudden onset Focal Neurological deficit).

3. If fairly certain that this is Vascular : is it Thrombotic , Embolic or Hemorrhagic ?

4. What is the possible site of lesion in terms of :
A. Structure(s) involved
B. Vessel involved

Quick Rules of Thumb for diagnosis of CVA on history

<> Thrombotic Strokes have an insiduous onset , are progressive in their deficit but gradually , and may occur during earlier hours of the day.

<> Embolic Strokes have a sudden onset and are non progressive - Maximal deficit at onset ; May have History of Atrial Fibrillation or Valvular Heart disease and may have H/O recurrent emboli.

<> Hemorrhagic strokes are sudden in onset , very rapidly progressive and may be Preceded by Thunderclap headache in Subarachnoid Hemorrhage. Almost invariably the patient is hypertensive.

<> RISS = Rapidly Improving Stroke Symptoms are a feature of TIA (Transient Ischemic Attack) - generally resolving within about an hour , but the technical definition is the Deficit relieving in 24 hours or lesser.

<> Diabetic patients on Insulin must be watched out for Hypoglycemia which is highly common.

<> If no focal deficits and just a 'Confused' state of the patient or Diffuse CNS features must prompt a search for Electrolyte imbalance especially in the elderly for a Metabolic Encephalopathy.

<> Hypertensive Encephalopathy must be suspected if the patient is an Uncontrolled Hypertensive and has headaches and evidence of End organ damage.

<> Todd's palsy must be suspected in a young man who has recurrent attacks of 'Apparent Paresis' that occurs after some form of a seizure - it's a post ictal confused state.

<> Acephalgic Migraine is a rare form of Migraine where the headache is absent. So the patient would experience an Aura , go through non ache features of migraine and then followed by post migraine weakness.
The weakness can be perceived as a stroke.

Hope this was helpful !
Will be doing another one on stuff not to miss on examination and the questions asked generally!
Happy studying !
Stay Awesome !

~ A.P.Burkholderia

Neurology Nuggets : Trigeminal neuralgia in Multiple Sclerosis.

Hello everybody!

A short nugget to start your Day with.

Let's see the reason behind the occurrence of Trigeminal Neuralgia in Multiple Sclerosis.

Multiple Sclerosis is basically a disorder of oligodendrocytes - derived Myelin which leads to blocks of varied degrees in Nerve impulse conduction.

The Trigeminal nerve is myelinated by Schwann cells, like rest of the Peripheral nervous System.
But still we see a high frequency of Trigeminal Neuralgia in Multiple Sclerosis.

The reason for this is-

*The trigeminal nerve is ensheathed by oligodendrocytes - derived myelin, rather than Schwan cells - derived myelin for upto 7mm after it leaves the Brainstem.*

This explains the high frequency of Trigeminal Neuralgia in Multiple Sclerosis which is a disorder of oligodendrocyte myelin.

Let's Learn Together!
-Medha Vyas.

My NEET experience

I could start off by mentioning how daunting it is to study for this particular exam, but I don’t think I need to. Nearly everyone, from their own experience or that of others has known and feared the NEET preparation. 19 subjects, 10 months, and in my case, the year of internship. Weekdays were spent running around the wards, weekends, trying to stay awake in 10-12 hour long classes. This was essentially 2017 for me.

It took me a while to get used to the amount of work and studying, both of which were never ending. The first week was like being thrown headfirst into a deep pool without knowing how to swim! Several coin sized haematomas later, I finally learnt the basics of what an intern was supposed to do.

Then came the first class of the year. If having 500 students in the batch wasn’t intimidating enough, the teacher more than made up for it. And so began my journey of fear, hurtling towards the NEET with no idea how to brake. Things became clearer in retrospect, as they should, for that is what retrospection is for. I wonder if I have had a calmer, even happier year if not for the constant weekly badgering. That being said, I knew I would have never stood a chance if not for the highly concise and valuable course material given to us by our classes.

In the weeks that followed, I managed to juggle both my duties with difficulty, not quite succeeding at doing justice to either. Nevertheless, I was happy, probably because the gravity of the situation hadn’t quite caught up with me.

‘There’s always a next year’, I thought to myself every time the dark thoughts about the exam loomed nearby.

Now, this blissful ignorance was beneficial in some ways, because it allowed me to adapt to and deal with the various perks of my job. The daunting working hours of the heavier departments, being constantly exposed to blood and bodily fluids and being in a frightful sense of awareness about the the hazards they carried, being addressed as ‘sister’ while my male colleagues had the privilege of being ‘doctor saab’ and the eventual satisfaction that came with staring a patient down till they squirmed and called me ‘doctor’, to name a few.

Reality caught up with me sometime around July, and brought with it a portion of self esteem issues and demotivation, much to my dismay. Try as I might, I just couldn’t rid myself of the notion that I would falter and fail. The previous mantra of ‘there’s always a next year’ didn’t seem comforting anymore, not when I saw my batchmates grinding it out everyday in the library. I tried to buck up my pace but kept zoning out, distracted by the very thing I was supposed to focus on. This mental inertia lasted for almost 2 months, relapsing and remitting, for lack of better words.

It spilled over to aspects of my life other than studying. I began to lose interest in work. It didn’t help that I was posted in Surgery, which is one of the more trying postings with shifts running upto 30 hours on emergency days. Imagine being an intern in surgery and not wanting to learn suturing. That is how demotivated I had become and that is how worthless I felt.

In the midst of this, there was a marathon 3 day session from our classes. Maybe it was the 42 hours worth of lectures that finally pushed me off the edge, but I ended up having one of the worst breakdowns of my life on the last day of the marathon session.

Thankfully, crying it out is something that has always made me feel better and this time was no exception. “Where there’s tears, there’s hope.” the Twelfth Doctor had said, and I truly realised the significance of that simple but powerful statement that day.

After that, I made a vow to pull up my socks and put in every effort towards my goal. Regret is a terrible thing, and nothing hurts more than knowing one could have done better. I made a list of the subjects I was not good at, and allotted more hours to them. I signed up for a series of mock tests which helped me keep track of my progress. I split the remainder of my time into revision sessions of 15-20 days, as per the advice of my extremely helpful seniors. When I was actively doing all the things, it was easier to put the crippling self doubt to the back of my mind, and assure myself that I was doing everything I possibly could.

Did I falter every now and then? Of course I did. My mock test scores had reached a plateau I couldn’t seem to overcome. There were times when I couldn’t remember the simplest of things that would lead to gross errors, at times simply because I did not read the question properly. This was more distressing than it should have been, mainly because I was functioning on such low levels of self esteem, and tended to be very harsh with myself for making errors.

With time, I realised this attitude was getting me nowhere. However, changing something that is so deeply ingrained in yourself is easier said than done. Nevertheless, I tried my best to build up my confidence by working on my weaker subjects, cutting myself some slack, and when things got difficult, confiding in my parents and friends and basking in their endless love and support. I also pampered myself with my favourite Murakami novels and endless mugs of tea. It didn’t make the stress go away, but it certainly made it more bearable.

Before I knew it, my time was up and it was time for the exam. I went in, promising myself that no matter what happened, I would not be drawn into the pit of self loathing I had escaped from. Surprisingly, I didn’t need to be. The weeks after the exam passed in a blur and then the results arrived, when I was on a train to Gwalior. My mother’s excited phone call rang through the sleeping compartment at 5am and I could barely stop smiling when I heard that I’d sailed through, and with a good score to boot!

I could hear the relief and pure joy in my mother’s voice, and then the tears fell, for what it had cost to get here. Back then it was almost impossible to believe, but in the end, it was worth it. Every extra hour, every missed question, every mediocre mock test, every stepping stone that had eventually paved the way for this.

If I had a few words of advice for the next batch of students preparing for the NEET, it’d be this. Surround yourself with people who love and support. Keep encouraging yourself and don’t be too hard on yourself when you make mistakes. Don’t ever withhold the things you love as a twisted form of positive reinforcement. It never works and ends up being a punishment for something you haven’t even done wrong. Be nice to yourself. You’re doing your best. Have faith and never stop believing in what you can achieve!

- Written by Aditi

Aditi decided to write the emotional aspect of NEET which very few students address. Hope it is helpful and relatable to those beginning the journey :)

Opportunistic infections in AIDS

AIDS is a retroviral disease caused by HIV. It is characterized by the triad of immunosuppression associated with:
1) Opportunistic infections.
2) ‎Secondary neoplasms.
3) ‎Neurological manifestation.

Opportunistic infections seen are:

1) Bacterial infections:

MANS.

M-M.tuberculosis
A-Atypical mycobacterial infections
N-Nocardiosis
S-Salmonella

M.tuberculosis is the most common infection with HIV in India.

2) Viral infection:

H.C. verma of John Cunningham.

H-Herpes simplex virus
C-Cytomegalovirus
V-Varicella zoster virus
John Cunningham -JC virus causing     progressive multifocal leukoencephalopahty.

3) Fungal infections:

H P computers creates crossword

H-Histoplasmosis
P-Pneumocystis jiroveci
computers-Cryptococcosis
creates-Coccidiomycosis
crosswords-Candidiasis

Candidiasis is the most common fungal infection of AIDS in India

Pneumocystis jiroveci is the most common fungal infection of AIDS in world.

4) Protozoal infection:
CITy

C-Cryptosporidium
I-Isosporidium
T-Toxoplasmosis

-Demotional bloke.

Metabolism of HDL notes

Hello, 

Here is a short post on the metabolism of HDL.

USMLE Step 3 - My two cents by Dr. B

USMLE step 3 - My two cents!

My name is Dr. B and I have recently finished my Step 3 - results aren’t out yet, but I hope I can stay as just the author of this article and not have to read it once more. Fingers crossed!!

Pearls on polyps

Hey everyone, this is my first blog! So I realised recently that Ear, Nose, Throat (or ENT for short) has a lot of theory so here's a short post on nasal polyps, for remembering this short, important but a little tedious topic. 

Antrochoanal and ethmoidal polyps are the commonly found types of polypoid growths found in the nasal cavity. They can be fleshy growth of tissue due to various causes, and usually leads to complaints of nasal obstruction and breathing difficulties. Here's a guide to remember the points of difference between the antrochoanal and ethmoidal polyps. For the following:

A - age 

A - aetiology

N - number

L - laterality

O - origin

G - growth

S - size and shape

R - recurrence

T - treatment 

The mnemonic is: "An Apple Never Lives On Green Shrubs (and) Red Trees" 

Interesting imagery, ain't it? 

So what are the differences between the two types of polyps based on these points? 

Age - antrochoanal polyps are found in children, whereas ethmoidal are found in adults. 

Aetiology - usually antrochoanal are having an infectious aetiology, whereas ethmoidal have allergic or other factors as cause for their origin. 

Number- only one antrochoanal polyp usually is present, whereas ethmoidal is usually multiple in number. 

Laterality - antrochoanal are unilateral, the other kind is bilateral mostly. 

Origin - Antrochoanal begins from the ostium of maxillary sinus but ethmoidal, as the name suggests, originates from the ethmoidal sinuses, uncinate process, middle turbinate and middle meatus. 

Growth - As the name suggests, this polyp grows behind towards the choana and hangs down behind the soft palate. The ethmoidal polyp, grows forward and may present at the nares. 

Size and shape - interestingly, antrochoanal polyps are trilobed with the three parts being antral, choanal and nasal. Ethmoidal are grape- like round masses. 

Recurrence - antrochoanal has lesser chance of recurrence as compared to ethmoidal polyps. 

Treatment - antrochoanal polyps are removed by polypectomy, endoscopic removal or Caldwell-Luc operation. Ethmoidal polyps are treated by ethmoidectomy, polypectomy or endoscopic surgery. 

I hope this has been helpful to you! Best of luck for your studies! 

Also, Fact Fatigue: Polyps growing in the ear, middle ear cavity ones, are never avulsed, because it's dangerous and could lead to damage to the branches of facial nerve passing through the walls of the middle ear.

This mnemonic was written by our Medical Student Guest Author, Devanshi Shah

Read more about MSGAI: http://www.medicowesome.com/2018/01/medical-student-guest-author-internship.html

Headaches : Fun Facts

Here's just a list of fun facts about headaches :p
You might find some of them lame but hey, I can write whatever interests me - this is My-Graine you see ! (Sorry about that, had to crack that graine up since it's mine ;;) )

1. Coffee is actually an Anti Migraine substance ! It helps in vasodilation of cerebral vessels since it contains Caffeine and  Theobromine (Compare : Theophylline) which are PDE Inhibitors.
There are drugs that combine Caffeine with Aspirin for this purpose ! Who would've thought ! Surprisingly, through mysterious mechanisms , Caffeine may Trigger migraine in few people.
(Go figure.)

2. Telcagepant is a novel drug being tried for treatment of Migraines. It's a CGRP Antagonist - Calcitonin Gene Related Peptide - Which is said to be a molecular mediator for Migraine headaches.

3. Constipation was said to cause headache. There's no evidence to prove this but old timers might still prescribe laxatives to treat headache.

4. Oxygen therapy helps treat Cluster headache !

5. Migraines may sometimes occur without headache ! Yeah , who would've thought.
So the patient would experience all other symptoms : Aura , Photo-phonophobia with vomiting and nausea , a mild headache And the post headache weakness !
It may actually become a stroke mimic at times as the weakness is pretty severe.
It's called "Acephalgic migraine"

6. Bickerstaff Migraine is a type of migraine where brainstem features are prominent. Also called Basilar migraine.

7. Tension type headache is the most common type of Primary headache ! But it may not have anything to do with being stressed at all.

8. People with cluster headaches may get so worked up and agitated they may actually want to bang their head and beg you to kill them , it's so severe ! (Talk about banging your head against a wall?)

9. There is a type of headache called 'Analgesic Overuse Headache'. The person with a known headache disorder begins to abuse NSAIDs to such an extent that taking the NSAID causes the headache ! So the solution is simple right ? STOP the NSAID?! BUT NO. IT'S NOT AS SIMPLE.
There is a sort of Physical dependence on it. And the withdrawal period is also characterized by headaches for a couple of of days/ weeks till the headaches finally stop. (What a pain!)

10. A subarachnoid Hemorrhage may be preceded by a series of minor headaches called 'Sentinel Headaches'. They can be warning signs in a known hypertensive and must be taken seriously.

That's all!
Hope this helps.
Happy Studying!
Stay awesome!
~ A.P.Burkholderia