Assessment and plan: New onset atrial fibrillation with rapid ventricular response

Hello!

Here is case one for the A&P series!

Assessment and plan: 99 yo M with PMH of ... admitted for ... is being evaluated for new onset atrial fibrillation with rapid ventricular response.

Authors' diary: Assessment and plan

Hey everyone!

As a medical student rotating in the US, I would have a tough time "typing" the assessment and plan. I would have it straight in my head but putting it all into words was difficult. I guess because I came from a different medical system where we don't write assessment and plan in our notes.

Ventricular arrhythmia notes

Hello! 

Anti-Ro/SSA antibodies and neonatal lupus

Hello everyone!

Did you know? Anti-Ro/SSA antibodies are associated with neonatal lupus (congenital heart block (CHB), neonatal transient skin rash, hematological and hepatic abnormalities).

How do I remember this? 

Algorithmic Management of Organophosphate Poisoning

Hey guys, this whiteboard provides a general overview of how to manage patients with OrganoPhosphorous Compounds (OPC) poisoning.

      [Please click on the image to enhance it]

*Use of benzodiazepines has been associated with decreased mortality and morbidity, even in the absence of convulsions.

Signs of atropinization refer to the target end-points for atropine therapy and includes:
- Clear chest on auscultation, no wheeze
- Heart rate >80 beats/min
- Systolic Blood Pressure >90 mmHg
- Dry axillae
- Pupils no longer pin-point (miotic)

Early treatment with oximes is necessary before phosphorylated cholinesterase enzymes undergo “aging” and become resistant to reactivation (due to loss of their alkyl group).

That would be all.
Happy studying!

- Ashish Singh.

Role of BNP in acute exacerbation of COPD

Hello Awesomites!

Heart failure and COPD are common and they commonly co-exist in the same patient. Diagnosis may be difficult during acute exacerbation.

BNP/nT-pro-BNP is good Negative predictive value to rule out the presence of heart failure.

Spirometry is useful when the patient’s volume status is optimized. During acute HF exacerbation, diagnostic accuracy may be limited.

ECHO may be helpful to rule out systolic or diastolic dysfunction.

Why is it important to know?

Some therapies in COPD may be associated with worsening cardiac events in HF patients.

1) Oral steroids: - increased sodium and fluid retention.

2) Beta2 agonist: - increased HR and increased oxygen demand.

3) Aminophylline: - increased risk of arrhythmia.

You can further read about this in Link between COPD and HF
HAPPY STUDYING !
-Upasana Y. :)

IRIS (Immune reconstitution inflammatory syndrome)

Hello Awesomites!

In terms of understanding immunity, HIV and leprosy never fails to fascinate me.There is whole spectrum of change in response of immune system.

So let us begin with the immune system which begins to recover. (Fall down 7 times get up 8!)

Immune reconstitution inflammatory response abbreviated as IRIS is a condition seen in some cases of AIDS or immunosuppression, in which the immune system begins to recover, but then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse.

There are 2 presentations:-

1. Paradoxical IRIS: worsening of symptoms of a known disease during ART

2. Unmasking IRIS: present of an occult opportunistic infection, in which disease that was not clinically apparent prior to ART, manifests during ART

Proper history:

-Time course of symptoms

 -History of Opportunistic infection,

-Recently diagnosed Opportunistic infections

-Treatment of Opportunistic infection: date of initiation, adherence, duration and clinical response

 -ART initiation date,

- Specific antiretroviral regimen,

-medication adherence,

-Previous history of ART

 -CD4 cell count and HIV viral load before ART initiation

 -Current CD4 cell count and HIV viral load,

The risks of corticosteroid therapy should be weighed against the severity of the IRIS manifestations and the potential benefits.Risks of corticosteroid therapy include the following:

-Hyperglycemia.
-Hypertension.
-Mental status changes.
-Avascular necrosis.
-Worsening of an existing infection.
-Predisposition to a new infection.

It teaches me something about "Balance".
-Upasana Y. :)

Facebook:ENT X-rays part - 1

#Medicowesome
#Ent

Which is the last sinus to appear radiologically on X-ray?
1) Maxillary sinus
2) Ethmoid sinus
3) Sphenoid sinus
4) Frontal sinus

Answer with detail explanation through blog in 12 hours.

So, this post is regarding our Facebook page question on ENT X-rays.
Correct answer is Option 4- Frontal sinus.

Let's get into some details and all of them are potential one liner questions.

Order of development of Paranasal sinus is
Maxillary > Ethmoid > Sphenoid > Frontal

I remember this order with mnemonic - "MESs Food"

Maxillary sinus and (Anterior) Ethmoid sinus are present at birth.
Maxillary sinus appears at 4-5 months of age radiologically.
(Anterior) Ethmoid appears at 1 year of age radiologically.

Sphenoid sinus: Development start at 2nd or 3rd year after birth and continues till adulthood. Making it last sinus to complete development.
It appears radiologically after 4 year of birth.

Frontal sinus: Development starts after 4 year of birth and completed at 13-14 years of age.
It appears radiologically after 6 years of birth.

Happy learning :)

-That's all

-Demotional bloke.

CHA2DS2-VASc Risk Score

Hello Awesomites !

You all must be familiar with the complications of atrial fibrillation (AF). The management of atrial fibrillation is centered on these complications.
Thromboembolism is caused by AF. CHA2DS2VASc score is to estimate stroke risk in AF patients and to start OACs (oral anticoagulants).
Previously, we have CHADS2 Score.

HEART FAILURE OR LVEF LESS THAN OR EQUAL TO 40%	1
HYPERTENSION	1
AGE MORE THAN OR EQUAL TO 75	2
DIABETES MELLITUS	1
STROKE,TIA or THROMBOEMBOLISM	2
VASCULAR DISEASE (PREVIOUS MI,PERIPHERAL ARTERY DISEASE, OR AORTIC PLAQUE)	1
AGE 65-74 YEARS	1
FEMALE SEX (BUT NOT A RISK FACTOR IF FEMALE SEX IS THE ONLY FACTOR)	1
MAXIMUM SCORE	9

SCORE 0	RECOMMEND NO THROMBOTIC THERAPY
SCORE 1	CONSIDER RISK/BENEFIT AND HAS-BLED SCORE TO AID DECISION OF ANTI-THROMBOTIC OR ANTI PLATELET THERAPY
SCORE 2	RECOMMEND OACs

HAS-BLED is a scoring system developed to assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation.

-Upasana Y. :)

Studying for Step One

Studying for the USMLE can be a daunting task, especially when you're an International Medical Student/Graduate. Coming from a different background - culturally and educationally - the questions asked in these examinations reflect the health system and health needs of the US's population. Apart from the questions, the financial aspects of attaining residency in the United States may also be a setback for some. Overall, this journey is a test of patience and dedication to the profession and one's career goals.

Euvolemic hyponatremia algorithm

Just happened to create this image so I thought of sharing with you guys :)

-IkaN

Lab values Fishbone skeleton / Ishikawa Diagram in text

Hey, 

I was looking for this skeleton to manually put in the outside labs for my patient.

Why is the level of Vitamin B12 increased in CML?

Why is the level of Vitamin B12 increased in Chronic Myeloid Leukemia (CML)?

Pathophysiology: The transport of vitamin B12 in the blood as well as hepatic uptake require the presence of transcobalamins (TCBs).

TCB types I (TCB I) and III (TCB III) ensure the binding of ∼80% of circulating vitamin B12.

ACHOO SYNDROME.

HELLO PEOPLEEEE!

Well this is not a medical joke or something that I made up. This syndrome is legit and very irritatting for the people who suffer from it. As said by Pryse Phillips the acronym is slightly forced but remains the best of the decade.

The acronym ACHOO is for Autosomal Dominant Compelling Helio-Opthalmic Outburst reflex which is basically sneezing in response to looking at a bright light, there can be a burst of 2-10 sneezes at a time.

Photic sneeze reflexes don't seem to make any sense at first. The purpose of sneezing is to clear unwanted irritants or germs from the nose. Bright light produces neither.

The phenomenon was first described in the 1950s, after a French doctor discovered several patients sneezing in response to the light of his ophthalmoscope, (the device doctors use to examine the retina). Further investigation revealed that it wasn't just any light that brought on the sneezing, but sudden flashes. These patients would reliably sneeze when quickly exposed sunlight, flash photography, and, in a few cases, even ultraviolet light.

There is no clear understanding on how photic sneez reflex works and hence a variety of theories have been proposed. 

For us its important to understand the basics of a normal sneez reflex arc.

The opthalmic division of the trigeminal nerve innervates the the nasal mucosa over the nasal septum and the anterior nasal passages. The afferent limb of the reflex arc is carried over the opthalmic nerve and the efferent limb is by the cranial nerves 5 and 7,9,10 and the motor nerves of the cervical and thoracic spinal cord.

The reflex centre is situated in the brainstem and upper spinal cord.

Any stimulation of the afferent limb of this reflex arc by dust or any foreign material sets the reflex arc in action which ultimately makes us sneez!

The primary clinical use of this sneez (sternutatory) reflex is a cross check on the corneal reflex.

Are there any other weird stimuli that cause people to involuntarily sneeze?

• Sneezing induced by feeling full. (One case study of a relatively normal 32-year-old man found that "fullness of the stomach immediately after meals invariably results in three or four uncontrollable sneezes."

• And the weirdest: For some, eating chocolate can induce some unwanted sneezes how barbaric.

Well I hope this information was helpful. So the next time you hear some sneezing (ACHOO!) do remember this phenomenon.

Let's Learn Together.
-Medha Vyas.
x

Question: Caloric test

#Medicowesome
#Ent

Q) Caloric test was done on right side with cold water and eyes were moved to opposite side. Which of the following correspond to interpretation of nystagmus in this test?

1) Eyes moves slowly to right
2) Eyes moves slowly to left
3) ‎Eyes moves rapidly to left
4) ‎Eyes moves rapidly to right

Answer in 24 hours with explanation of Caloric test.

Inverse glaucoma

In normal eye aqueous humour flow from ciliary body to anterior chamber. In Malignant glaucoma or Aqueous misdirection syndrome, aqueous humour escapes into posterior chamber. Now posterior chamber has two fluids - aqueous and vitreous. This mixture now push our lens forward. This leads to formation of shallow AC.

Now in this case if I give Pilocarpine then ciliary zonules will be slacked which will ultimately causes lens to move more anteriorly, leading to shallow AC.

Remember: Pilocarpine is DOC for acute congestive glaucoma and it is C/I in inverse glaucoma.

So I will need to give drugs which will cause tightening of ciliary zonules. This can happen when I will relax ciliary muscle. Now relaxation of ciliary muscles is done by cycloplegic drugs. Example - Atropine/ Homatropine.

Did you see the contrast?
Atropine is C/I in Acute ACG but it is DOC for inverse glaucoma!

Hope it helps!

That's all
-Demotional bloke

Congenital syphilis picmonic

This was submitted by Ri. Thanks girl!

With reference to this post: http://www.medicowesome.com/2017/03/buzz-words-for-congenital-syphilis.html

-IkaN 

Significance of ictal head turning in frontal and temporal lobe seizure

Hello Awesomites!

Let us begin.

My patient had an episode of seizure. As she was not aware during the episode I asked the one who saw her during the episode. She had head turning to one side.

The patient had other complain also but for time being I am focusing on this sign.

When you begin from symptoms to localization and then lateralization, you will get following answers.

Non versive head turning - Ipsilateral temporal lobe.

Forced (versive) head turning - Contralateral Frontal lobe.

I want to thank my professor.

I hope it will help you to be more observant during history taking.

-Upasana Y. :)

Question: Rhinoscleroma

#Medicowesome
#Ent

Which of the following feature(s) of rhinoscleroma is/are true except:-

1) Atrophy of nasal mucosa
2) Caused by fungus
3) Treatment by antifungal drug
4) Caused by bacteria
5) Causative organism may be cultured from biopsy material

Answer in 24 hours!

So correct options are option 2 and option 3.

Rhinoscleroma is bacterial chronic granulomatous infection caused by Klebsiella rhinoscleromatis or Frisch bacillus.

Mode of transmission: 

Not unknown

Pathology:

Starts in the nose and extend upto naso-pharynx, larynx, trachea and bronchi.

Clinical features:

1) Atrophic stage:

Foul-smelling prurulent nasal discharge and crusting.

2) Granulomatous stage:

"Woody nose" feel is seen in lower part of nose and upper lip. Nodules are painless and non-ulcerative.

3) Cicatrical stage:

Distortion of upper lip, adhesion in the nose, nasopharynx and stenosis of subglottis.

 Diagnosis:

 Presence of Mikulciz cells and Russell bodies 

1) Mikulicz cells: Macrophages containing central nuclues and vacuolated cytoplasm along with bacilli.

2) Russell bodies: Homogeneous eosinophilic inclusion bodies found in plasma cells.

Treatment:

Streptomycin and tetracycline given for 4-6 weeks and repeated.

Question: Rhinosporidiosis.

#Medicowesome
#Ent

In rhinosporidiosis, the following is true:-

1) Fungal granuloma
2) Grayish mass
3) Surgery is the treatment
4) Radiotherapy is treatment

Answer in 24 hours!

Correct option is 3 - Surgery is the treatment.

Let's know more about rhinosporidiosis.

It is a chronic granulomatous disease caused by "Rhinosporidium seeberi" affecting both humans and animals. Earlier it was considered to be fungal in origin but now it is considered to be Aquatic protozoa.

Life cycle: It occurs in three stages.

1) Trophic stage: In this stage, the individual cell is called as trophocyte.

It has following features
-One chitinous wall
-Clear cytoplasm
-Nucleus along with nucleolus

Now trophocyte starts dividing and froms a colony. This colony is packed inside a sac called as "Sporangium". The trophocyte inside is called as "Endospores"

2) Sporangium stage:

Sporangium, unlike earlier stage is lined by two membranes
-Outer Chitinous
-Inner Cellulose layer

3) Endospore release:

The endospores present inside exerts pressure on the sporangium and this leads to rupture of the sporangium. Released endospores acts as trophocyte further.

Mode of transmission:
Water contaminated by diseased animals.

Clinical features:

Most common sites involved: Nose and nasopharynx.

Other sites like lips, palate etc can also get affected.

In nose it is present as - leafy, polypoidal mass, pink to purple in color.
Can extent upto soft palate.
Bleeds easily on touching. So, we can also see blood tinged discharge.

Diagnosis: Biopsy 

Treatment: 

Complete excision with diathermy knife and cauterization of its base.

That's all

-Demotional bloke

Modified Allen test

Hello Awesomites! :D

Hope you guys are doing great. Assuming that you might have heard about ABG analysis I am discussing about Allen's test.

What is Allen's test?

Allen's test is done to assess the circulation of the hand (i.e. Radial and ulnar artery).

Procedure:-

The examiner apply the pressure to the wrist occluding the ulnar and the radial arteries. The patient then make the fist and open and close it several times. The hand should appear blanched by this time because the arteries has been occluded temporarily.

Now remove the pressure from ulnar artery. If the return of color occurs quickly, then test is considered to show a normal circulation.

If it take 5-15sec in flushing of palm then test is positive and ulnar artery is adequate to supply the arch, we can proceed with sample collection in this patient. If it takes >15 sec then choose alternative site. Alternative sites for access are brachial or femoral arteries, but these have several disadvantages.

Repeat the same procedure for radial artery.

Importance in:-

1. Volar wrist ganglion around the radial artery.

2. before doing ABG analysis.

Study more about it. 

-Upasana Y.