Tricuspid Annular Plane Systolic Excursion (TAPSE) concept

Acquired coagulopathy

Apart from congenital disorders, various clinical scenarios can give rise to altered hemostatic patterns leading to the state of so-called "acquired coagulopathy".

1.) Due to Factor inhibitors:
Classically it is seen in pregnant patients and those with lymphoproliferative disorders like CLL. However, it could be idiopathic.
Usually, it leads to the acquired factor Vlll and V deficiency.

Mixing studies are employed to differentiate between acquired and congenital factor deficiency. Failure of correction of clotting assays after mixing studies suggests the presence of inhibitors.

2.) Amyloidosis
Sequestration of Factor X by amyloid fibrils leads to an acquired deficiency-like state. Amyloid vasculopathy along with factor X deficiency often leads to purpura and ecchymosis in these patients.

3.) Myeloproliferative neoplasms
Apart from acquired vWD due to loss of HMW vWF multimers, acquired factor V deficiency can also be seen. This has been attributed to adherence of Factor V to megakaryoblasts similar to the relation between factor X and amyloid fibrils. However, severe clinical manifestations might not necessarily reflect upon clotting assays or factor levels with the latter suggesting functional factor V deficiency.

3.) Thrombotic microangiopathies and DIC
Usually leads to both thrombotic and bleeding manifestations. The spectrum of TMA includes HUS, aHUS, TTP, HELLP syndrome, DIC, cAPLA, scleroderma renal crisis, malignant hypertension, and radiation or HSCT-induced vasculopathy.

4.) Coagulopathy of liver failure
Classically seen in the setting of fulminant liver injury which may be due to the infections, drugs, autoimmune hepatitis, ischemic hepatitis/shock liver, or rarely in Wilson's disease due to massive hepatocyte destruction.
One of the hallmark lab findings includes normal factor VIII levels. This is due to the fact that factor VIII, unlike other factors, is chiefly produced by endothelial cells rather than by hepatocytes. In fact, due to its reduced metabolism by hepatocytes in the state of liver failure, factor VIIl levels are often elevated.

Other miscellaneous causes include Acute fatty liver of pregnancy, fat embolism syndrome, amniotic fluid embolism, and other pregnancy-associated complications.

- Kirtan Patolia

Acquired Von willebrand disease

Von Willebrand disease is one of the most commonly encountered congenital bleeding disorders in clinical practice. Broadly speaking they are classified as type 1, 2A, 2B, 2M, 2N, and 3. Each one of them is distinct from the other in subtle ways.

However, it could be acquired in a number of ways.

 a.) In patients with thrombocytosis > 1 million cells/ microliter, especially in essential thrombocythemia, loss of HMW  vWD multimers leads to reduced vWF Ristocetin activity: vWF antigen ratio (<0.6)  suggesting type 2 like pattern.

 b.) In patients with aortic stenosis, due to extreme shear stress, vWF unfolds prematurely at the site of the valve revealing ADAMTS13 binding sites, ultimately resulting in its cleavage and loss of HMW multimers. So basically, it could be visualized as the pattern that is just opposite to TTP wherein defective ADAMTS13 activity results in excess of HMW vWF multimers.

It is often associated with either angiodysplasia or AVMs of the GI tract that further predisposes to bleeding. Although the exact pathogenesis of these lesions is not understood, one postulated mechanism suggests chronic colonic ischemia leading to sympathetic nervous system-induced vasodilation as a potential culprit.
 In this context, it is also known as Heyde's syndrome.

c.) Sometimes in severe hypothyroidism, often the production of vWF by endothelial cells itself is markedly reduced.

d.) Rarely in the setting of multiple myeloma and various other neoplasms, tumor cells express the excess of Gpllb/llla leading to enhanced clearance of vWF from circulation.

One of the common lab findings in acquired vWD is reduced vWF Ristocetin activity: vWF antigen ratio pointing to the disproportionate decrease in activity compared to antigen levels.
It is due to the loss of HMW  multimers.

- Kirtan Patolia

Mnemonic for Ranson criteria, BISAP & HAPS score for Acute Pancreatitis

Acute diarrhea

Congestive hepatopathy

Short post!

In congestive heart failure, the elevated pressure is transmitted from the right heart chambers (right ventricle and atrium) to the hepatic veins and sinusoids leading to intrahepatic edema, decreased perfusion and oxygen diffusion as well as hemorrhagic injury and modification on the hepatocyte architecture and atrophy with associated collagen deposition, and fibrosis to the hepatic veins and sinusoids.

Mnemonic for Clinical Signs of Aortic Regurgitation video

Schroeder's Vs Bandl's ring

Schroeder's  Vs Bandl's ring

Bandl's ring:- 

1) It is seen in obstructed labour

2) It is a pathological ring

3) It is a retraction ring

4) It moves up with uterine contractions

5) It can be palpable per-abdominally but not pervaginally

(Remember- Bandl has A after B which stands for per-abdominally)

6) Management: Like obstructed labour, C-section and antibiotics.

Schroeder's ring:-

1) Seen when oxytocin is used injudiciously.

2) It is a physiological ring.

3) It is a constriction ring.

4) It is fixed ring, does not move with uterine contractions

5) It can be palpable pervaginally but not per-abdominally.

6) Management: It dissolves on it's own.

If not, then management in first stage of labour includes C-section.

Management in second stage includes forceps or c section.

That's it!

Demotional bloke

Post Partum Hemorrhage - Updates

Following bleeding scenarios amount to PPH under the latest WHO document

1. Blood loss >500 mL in c/o Vaginal delivery
2. Blood loss > 1 L in c/o C Section + in c/o twins
3. Blood loss > 1.5 L in c/o Hysterectomy
4. Blood loss on any case more than what is expected over a period of 24 hours

Following bleeding scenarios amount to PPH as per the latest ACOG recommendations

1. Blood loss equal to or more than 1 L irrespective of mode of delivery
2. Bleeding with signs and symptoms of hypovolemia

Updates in Management of PPH

1. Uterine massage is added along with uterotonics
2. PGE1 if given Per Rectally (not recommended), 1000 micrograms is advised
3. Inj Tranexamic Acid is recommended in all bleeding diasthesis - 1 gram slow IV (over 20 minutes) 
4. Mechanical Devices allowed
1. Sengstaken Blakemore Catheter
2. Bakri Balloon Catheter

Actions of Intrinsic laryngeal muscles of Vocal cord mnemonic video

Hello!

This is video is on Actions of Intrinsic laryngeal muscles.

HMG CoA synthase,reductase and lyase

Hello Awesomites!

LONG TIME. 
As I promised, the future blogs will be on confusers.
Here I go.

Study hard!

-Upasana Y :)

Mnemonic for Catalytically perfect enzymes !!

Hii...

Certain rare enzymes , 

They are so efficient that almost every time enzyme meets its substrate, the reaction occurs. 

E + S ➡️ ES Complex ➡️ Instantaneously Product formed 

For such enzymes this becomes the rate limiting step & is only determined by 

Rate of Diffusion of molecules in solution.

Means , Catalytically perfect reactions are only limited by substrate diffusion rate.( Substrate diffusion into active site ) 

This enzymes are called Diffusion limited/ Catalytically perfect enzymes.

Catalytic efficiency reaches the diffusion limit.

Examples =

Furiously trying to CAtCh ( think Ball) diffusion limit in Superover.

Fumarase 

Triose phosphate isomerase 

Catalase 

Cytochrome C peroxidase

CAH ( Carbonic anhydrase )

AchE ( Ach esterase ) 

Ball = Beta lactamase 

Superover = SOD = Superoxide Dismutase 

Thank you...

By Drashtant

Voila! Its a baby bone.

Bone formation is critical to skeletal development as well as maintenance. Bone is a hollow matrix of calcium phosphate a and apatites wherein calcium is under a state of constant turnover balanced by degradation of calcium apatite and absorption of new calcium from the gut as well as breakdown by PTH and Vitamin D. 

Here's how you can remember what your body produces when are forming new bone. Remember that as 

Old FAP

Formation of Bone

• Bone Specific ALP
• Procollagen type I
• Osteocalcein
• Osteonectin

Mnemonic for Galactosemia & Hereditary fructose intolerance

Hi everyone , this is a short video explaining mnemonic for Galactosemia & hereditary fructose intolerance.

Thank you :)

By Drashtant 

A compilation of similarities between corneal dystrophies

Many dystrophies have commonalities. Following are enumerated as under-

1. Associated with TGF Beta1 mutations-

       - Epithelial basement membrane dystrophy

       - Reis- Bückler's 

       - Thiel- Behnke 

       - Lattice and granular(type1) dystrophies

2. Associated with mutations on 5q31 locus-

         - Reis- Bückler's

         - Lattice and granular(types 1 and  2)

3. Autosomal recessive -

          - Gelatinous drop like

          -.macular

          - Congenital hereditary endothelial( type 2)

4. X linked- 

           - Lisch ( X linked dominant) 

-All others are autosomal dominant. 

5. Chromosome 12- Meesman's, congenital 

                                     hereditary stromal.

6. Chromosome 20- Posterior polymorphous, 

                                    congenital hereditary 

                                     endothelial.

7. Chromosome 1- Gelatinous drop like,

                                   posterior polymorphous.

8. Amyloid deposition is seen in- 

                   - Gelatinous drop like

                   - Lattice

                   - Granular (type2) 

                   - Congenital hereditary endothelial.

9. Bowman's membrane is lost in- 

                   -Gelatinous drop like

                   - Reis-Bückler's (replaced by irregular

                       material

                   - Thiel-Behnke's ( replaced by a

                       fibrocellular layer)

10. Recurrence after keratoplasty-

                    -  Reis-Bückler's

                    -. Lattice, granular, and macular

                    - Schynder 

                     -  Congenital hereditary stromal.

11. Association with glaucoma and keratoconus-

                    - Posterior polymorphous

                    - Fuch's endothelial. 

Now don't blame me for the list being too exhaustive 🙄

Source- Postgraduate ophthalmology by Zia Chaudhari and M Vanathi 

-Sushrut 

Corona virus

Corona virus:
A) Virology:
1) Coronaviruses are classified as a family within the Nidovirales order, viruses that replicate using a nested set of mRNAs. The coronavirus subfamily is further classified into four genera: alpha, beta, gamma, and delta coronaviruses. 
2) Positive mRNA strand virus. It is largest known RNA strand.

B) Routes of transmission — Respiratory coronaviruses probably spread in a fashion similar to that of rhinoviruses, via direct contact with infected secretions or large aerosol droplets. Immunity develops soon after infection but wanes gradually over time.

C) Clinical Manifestation:
Characterized by
1) Upper respiratory tract infections
2) Acute otitis media
3) Pneumonia
4) Temporarily linked to asthma attacks in both adults and children
5) The idea that coronaviruses produce diarrhea in humans is intriguing because of their clear intestinal pathogenicity in animals
6) Gastrointestinal manifestations -diarrhea, vomiting, nausea, and abdominal pain.
7) There is one reported case of encephalitis due to corona virus
8)Also seen in association with Kawasaki disease.

D) Diagnosis:
Until recently, no sensitive, rapid method existed to detect all of the known human coronavirus strains. Rapid techniques that can be used to detect coronaviruses from nasopharyngeal samples include reverse-transcriptase polymerase chain reaction (RT-PCR) and immunofluorescence antigen detection assays.

E) Treatment:
1) There is currently no treatment recommended for coronavirus infections except for supportive care as needed
2) Chloroquine has shown some activity against cultured cells.

F)Prevention:
1) Preventive measures are the same as for rhinovirus infections, which consist of handwashing and the careful disposal of materials infected with nasal secretions. Several antiseptic/disinfectant solutions used commonly in hospitals and households, including chloroxylenol, benzalkonium chloride, and cetrimide/chlorhexidine, have been shown to be ineffective against coronaviruses

That's it!

Source: Up-to-date.

Correct order of Stage of Death

Proposed by Kubler Ross 

" Mnemonic = DA BudDhA "

D Denial = Refuse to believe Dx 

A Anger = Frustrated , Ask "Why Me ? "

B Bargaining = in return for a cure , they promise to fulfill one or many pledges ( Charity ) 

D Depression 

A Acceptance = Realize that death is inevitable

Thank you 

By Drashtant 

Advice to young doctors

It is okay to disagree with another physician and acknowledge differences in the style of practicing medicine. Medicine is not black and white. Develop your own preferences based on evidence and experience.

A truly experienced physician understands the intricacies of medicine and will not criticize another physician for a decision they made under a different clinical circumstance with the information they had available.

A physician who second guesses themselves and critically analyzes their decisions retrospectively and prospectively are better than those who are over-confident about their diagnosis and management. Think about the decisions you make.

If you ever come across a bad patient outcome, yourself or your colleagues, do not jump to conclusions. There may be other factors, that you do not have knowledge of, which may have played a role.

When feedback is given, don't take it personally. Learn from the experience objectively and detach yourself from it. This way, you will learn more instead of getting offended and defensive about it.

To not get emotionally involved takes time. Give yourself time. Change the voice of the conversation in your head.

I am still learning.

Sincerely,
A young doctor.

Facebook: Wolffian duct

Q1) Ejaculatory duct in males develops from 

A) Ureteric bud

B) Mesonephric duct

C) Wolffian duct

D) Paramesonephric duct

#Medicowesome

#Gynaecology

Answer to this question is Option C) Wolffian duct.

But isn't Wolffian duct also called as Mesonephric duct ? So can you pick option B instead of option C?

Well, unless your exam allows multiple answers to be correct, do not pick 'Mesonephric duct'. Here is why?

The mesonephros gives mesonephric duct which opens in the Urogenital Sinus and forms trigone of the bladder. Mesonephric duct also gives ureteric bud to the Metanephros to form Renal system.

Now after this has happened, the Mesonephric duct will be called as Wolffian Duct which forms the internal genital organs and in females, disappears.

That's it!

Demotional bloke

Mnemonic for head posture in A-V pattern squints

Chin up in what? Chin down in what? The vexing never ends. Well, as it turns out, the word 'vex' itself is here to save the day.

Chin up- V exotropia (VEx). Remember that squint is very 'vexing'. So you stare in the sky to remember at least a fraction of what you stuffed in your brain the day before. 

Other will be A esotropia. By exclusion, it's easy to remember. 

Chin down- V esotropia or A exotropia. Again, by exclusion, these get placed naturally under this heading.

So, just remember 'VEX' and you won't be vexed anymore! 

-Sushrut 

Mnemonic for Drug induced Cardiomyopathy

Hello everyone ....

Aunty is cycling 🚴‍♀️ on paved trails to protect her heart 💓 

Aunty = Anthracycline = Doxorubicin, Daunorubicin , Mitoxantrone 

Cycling = Cyclophosphamide 

paVEd = VEGF Inhibitors = Bevacizumab 

Trails = Trastuzumab

Facebook: PFT-1

Q1) Which of the following is/are not a contraindications of performing PFT(Pulmonary function test)? 

A) MI within one year

B) Unstable angina

C) Recent thoraco-abdominal surgery

D) Recent ophthalmic surgery

E) Past history of pneumothorax

So correct options are - A and E

Following are contraindications to perform pulmonary function test. 

Mnemonic: UR IRcTC

U- Unstable angina

R- Recent thoracoabdominal surgery

I- Myocardial infarction within the last month

R- Recent ophthalmic surgery

T- Thoracic or abdominal surgery 

C- Current pneumothorax

That's it! 

-Demotional bloke. 

Parasitic infections and Asthma

In parasitic infection, polyclonal IgE produced by body occupies the receptor produced by mast cells. This leads to decrease action of specific IgE required for asthma. 

This mechanism is probably the cause of decrease prevalence of asthma in tropical population. 

That's it 

-Demotional bloke

Choristomas Vs Hamartomas

I get super confused with both the following terms, so I made a lame technique to remember both of them. 

Choristomas:

It sounds more like a Christmas. So Christmas tree is usually not grown in India but we do keep it as a sign of Christmas. 

So Christmas tree is normal, but the site (India or any other habitat) is not the usual site of tree, so let's say abnormal. 

So Choristomas is normal tissue at abnormal anatomical sites.

Example - Normal pancreatic cells under the small bowel mucosa.

They are not considered as neoplasm.

Hamartomas:w

'Hamara' in Hindi means 'mine'. 

Remember: this place is mine. So here, place is normal and tissue is abnormal!

That is, abnormal tissue at normal anatomical sites.

Example - Lung hamartomas exhibit cartilage, bronchi, and blood vessels. 

They are considered as neoplasm.

That's it! 

-Demotional bloke

Areas devoid of pain fibres

Areas devoid of pain fibers 

Mnemonic: BED PACK

B- Brain parenchyma

E- Ependyma

D- Duramater (Neither covering blood vessel or forming dural venous sinus) 

P- Pia mater

A- Arachnoid mater

C-Choroid plexus

That's it 

-Demotional bloke

Areas devoid of BBB

Area devoid of BBB 

Mnemonic: MAP SNOW
M- Median eminence
A- Area postrema
P- Pineal gland
S- Subfornical organ
N- Neurohypophysis
O- OVLT- Organum vasculosum laminer terminalis 

That's it 

- Demotional bloke

Egg shell calcification

Following are the cases in which we get eggshell calcification of lympho nodes on radiography. 

Mnemonic:

SSRI Love Hitting BAT

(Lame? I know!) 

S-Silicosis

S-Sarcoidosis

R- After Radiotherapy

I L- Post irradiation lymphoma

H- Histoplasmosis

A- Amyloidosis

T- Tuberculosis

That's it ! 

- Demotional bloke

Ocular Alzheimer's disease

A paper published in 2003 has dubbed glaucoma as 'ocular Alzheimer's disease' because some of the pathophysiological elements are similar.

Cataract in Rubella- interesting fact

The progressive nuclear cataract in Rubella may harbor live virus particles.

Psychiatry MCQ-1

So here are two multiple choice questions, whose answer changes with options. 

Q1)Most common psychiatric disorder is :-

A) Anxiety

B) Depression

C) Phobia

D) Schizophrenia

Here answer is A) Anxiety

Most common psychiatric disorder is 

A) General Anxiety disorder

B) Panic anxiety disorder 

C) Phobia anxiety disorder 

D) Depression

Here answer is D) Depression. 

Reason for such variation is that Anxiety is not just a single disease like depression.

Infact it is group of disorders. 

So Depression is the single most common psychiatric disease whereas Anxiety is the most common psychiatric disease.