Of Surgery and Wounds

Hey guys, here’s a classification of surgical procedures, wounds and their infection risk.

[Please click on the image to enhance it]

Thank you for your time.
- Ashish Singh.

What Is Going On In Fibromyalgia?

Hi there! Let’s talk about pathophysiology of fibromyalgia; a chronic disorder where fatigue and widespread pain feature prominently.

Current hypothesis says, it’s caused by aberrant peripheral and central pain processing.
Two key features are allodynia, that is, pain in response to a non-painful stimulus and hyperaesthesia, which is, exaggerated perception of pain in response to mildly painful stimulus.

Modern research says, certain antidepressants- with both serotonergic and noradrenergic activity- such as TCAs and venlafaxine, can relieve pain and other symptoms; suggesting the pathway involvement.

Some evidence says, alternative therapies such as acupuncture and spa therapies alleviate pain, which have been postulated to act via similar spinal pain-modulatory pathways.

CSF studies show increased levels of substance P, with decreased levels of noradrenaline and serotonin metabolites. All three are neurotransmitters involved in descending pain-modulatory pathways in the spinal cord.

PET images show an abnormal central dopamine response to pain.

The critical question here is: what is cause and what is effect?

Small sample size and short periods of study, remain the most cumbersome challenge to our complete understanding of fibromyalgia.  



Thank you for reading.
- Ashish Singh.

Mnemonic: Duke’s Criteria for Infective Endocarditis

Infective endocarditis is diagnosed using the modified Duke’s criteria.
Let’s look at them in an easy-to-remember way.

MAJOR CRITERIA
It’s, quite literally, proving the name Infective Endocarditis to be true.

Infective, that is, positive blood culture:
• Typical bugs in 2 separate cultures
• Persistently positive blood cultures, say > 12h apart
• Single positive blood culture for Coxiella burnetii

Endocarditis, that is, endocardium involvement:
• On imaging with 2D Echo or CT, look for vegetation, abscess, pseudoaneurysm or dehiscence of prosthetic valve
• On clinical exam, find new regurgitation murmur

MINOR CRITERIA
Remember, patients feel very ill when they have infective endocarditis.
Predisposing factors: congenital heart disease, prosthetic heart valves, iv drug abuse
Fever > 38 °C
Vascular phenomena: emboli, Janeway’s lesions
Immunologic phenomena: glomerulonephritis, Osler’s nodes

What if the blood culture is positive but does not meet the major criteria?
It’s considered as a minor criterion (casually speaking, problematic but not majorly problematic).

How do we use this for diagnosing?
2 major OR
1 major + 3 minor OR
All 5 minor criteria, make up the diagnosis.

Clinical Pearl: Fever with any new-onset murmur is taken as infective endocarditis, unless proven otherwise.



Hope this helps. Happy studying!
- Ashish Singh.

CABG For Undergraduates

CABG is Coronary Artery Bypass Graft; a surgical procedure where dying heart muscle is resupplied with blood.

Indications
[decided after a SYNTAX scoring system]
• Left main stem disease
• Triple-vessel disease involving proximal left anterior descending
• Patients unsuitable for angioplasty 
• Failed angioplasty
• Refractory angina

Procedure
• The heart is usually stopped and blood pumped artificially by a machine outside the body, a cardiac bypass. An alternative, that does not require this, is minimally invasive thoracotomy.
• As the graft, patient’s own great saphenous vein, internal mammary artery or radial artery is used. Multiple grafts may be placed. Arterial grafts last longer but may cause donor site numbness.

After CABG
• Continue aspirin 75 mg/day indefinitely. Consider clopidogrel, if aspirin contraindicated.
• Ensure optimal management of hypertension, diabetes and dyslipidemia.
• Counsel for smoking and alcohol cessation.
• Chart out graded physical activity through rehabilitation.
• Uncommonly, angina may persist or recur [from poor graft run-off, distal disease, new atheroma or graft occlusion]. If so, restart anti-anginal drugs and consider angioplasty.

Clinical Pearl: Recent randomised control trials indicate that early procedural mortality rates and 5-year survival rates are similar after PCI and CABG.



Thank you for reading.
- Ashish Singh.

Understanding Refeeding Syndrome

Refeeding syndrome is a life-threatening metabolic complication of - stay with me - refeeding. It can happen via any route after prolonged starvation.

Who are at risk?

They’re patients with prolonged artifical feeding [parenteral or enteral], malignancy, anorexia and alcoholism.

Why does it happen?

During starvation, the body uses fat and protein for energy. There’s no carbs so there’s little to no insulin.

After refeeding, carbohydrate load causes a spike in insulin level.

Now first prof biochemistry tells you, more insulin means more cellular uptake of phosphate.

That’s it. That low serum phosphate level is the main problem.

How does it present?

Non-specifically and catastrophically. Features are rhabdomyolysis, red and white blood cell dysfunction, respiratory insufficiency, cardiac arrhythmias and seizures.

Left unchecked, it can lead to sudden death.

How do I prevent it?

Identify at-risk patients and give high-dose, high-potency Vitamin C and B complex injection, during re-feeding window.

Monitor vitals and labs closely. Close involvement of nutritionist is ideal.

What if it’s already happened? How do I treat it?

The biggest challenge is management of complications.

As regards phosphate, get the levels back up. Administer oral as well as parenteral phosphate, upto 18 mmol per day.

Thank you, that’d be all.

- Ashish Singh.

What are APS?

APS or Autoimmune Polyendocrine Syndromes are exactly what the name suggests.
They’re autoimmune in origin and they attack more than one endocrine system.

[Please click on the image to enhance it]

Let’s not forget autoimmunity begets autoimmunity.

APS are commonly seen with hypogonadism, vitiligo, alopecia, pernicious anaemia and coeliac disease, among others.

That’d be all. Happy studying!

- Ashish Singh.

PR depression in pericarditis

Do you know what P-R segment deviations in acute pericarditis mean?

It is due to subepicardial atrial injury!

Residency in India: Harassment, abuse and suicide

A few days ago, a resident committed suicide. One of us committed suicide.

In my opinion, it seems like the reason for the suicide was harassment, abuse, and excessive work load. If you ask any resident in any government hospital in Mumbai - they are all treated the same. The verbal abuse is probably different - They used casteist slurs for her. If you are privileged, they will call you different names.

How can we make sure this never happens again? Stop carrying forward the culture of abuse. It is high time. We have to fight the system. The past. The belief that it is okay just because it's residency. Don't look at how our seniors treated us but look at how we treat our juniors.

We need to treat each other better. Treat others how you would like to be treated yourself.

We need to help each other.

It is our fault that the life of an innocent was lost. It's because we didn't fight and we stayed silent when we saw abuse around us. We need to create awareness among medical students that will be joining residency. Let's talk about the abuse and how we can stop it. Residents should know who to report to without fear of negative consequences.

It will take time and it will probably not change in a day. But we are the future and we need to fight.

Fundoscopic images of Diabetic Retinopathy

Fundoscopic images of Diabetic Retinopathy

Images and audio by Sushrut.

Indications of skin grafting mnemonic + notes

Hello,

Indications of skin grafting :

☆ Mnemonic - BITS

Sites of Bronchiectasis

Bronchiectasis site in lung depends upon the etiological factors

Upper lobe bronchiectasis:

Mnemonic: Upper - PCT
Upper- Upper lobe
P- Post radiation
C- Cystic fibrosis
T- Tuberculosis

Middle lobe bronchiectasis:

Mnemonic: MMC (Like BMC!)
M- Middle lobe
M- Mycobacterium avium
C- Ciliary dyskinesia

Lower lobe bronchiectasis:

Mnemonic: Left-ICA (Internal carotid artery)
Left- Lower lobe
I- Interstitial lung disease
CA- Chronic aspiration

That's all.
Thank you :)

-Demotional bloke

History, physiology and medical aspects of fasting

Hello everyone,

My senior resident at JFK Medical Center did a presentation on fasting. I thought of sharing it with you (especially since it is Ramazan/Ramadan).

Hook effect of prolactin in large pituitary adenomas

Hello everyone,

Here's something I learnt today when a case of large pituitary adenoma causing visual field loss was presented today.

But let's talk about my favorite subject first - Immunology!

The intensity of an antigen-antibody interaction depends primarily on the relative proportion of the antigen and the antibody. A relative excess of either will impair adequate immune complex formation. This is called the “high-dose hook effect” or the “prozone phenomenon.”

This is important consideration whe measuring prolactin. Extremely high levels of prolactin can interfere with the assay and produce falsely low readings.

This high-dose hook effect occurs because there is not enough antibody to bind to both ends of all antigenic peptides, in this case, prolactin.

Most prolactin is complexed to a single antibody. Only few remaining prolactin peptides are “sandwiched” and therefore detectable.

This results in a falsely low prolactin value.

Hence, as the antigen concentrations increase, there is a proportional increase in assay titers up to a certain level. Antigen concentrations above this threshold level would “hook” down the assay values resulting in very low measurements.

In order to avoid the high-dose hook effect, the serum prolactin should be estimated in appropriate dilution in all patients with large pituitary tumors.

-IkaN (tired Internal Medicine Resident)

Source:
The 'hook effect' on serum prolactin estimation in a patient with macroprolactinoma. https://www.ncbi.nlm.nih.gov/m/pubmed/11303248/

Protein gap

The gamma gap aka paraprotein gap or protein gap is the difference between total serum proteins and albumin measured from a comprehensive metabolic panel.

Albumin accounts for the majority of total serum protein.

Viral infections, plasma cell malignancies, or autoimmune conditions there is an excess of immunoglobulins, raising the total amount of serum protein independent of albumin.

The gamma gap is typically considered to be elevated if it is above 4 g/dL.

In the right clinical context, gamma gap should be worked up with SPEP, UPEP, and a serum free light chain assay.

Random exercise: Calculate the protein gap.
Total protein 8.9 g/dL (normal 6.4-8.3 g/dL)
Albumin is 3.6 g/dL (normal 3.4-4.8 g/dL)

That's all!

-IkaN

Work up of thyroid nodule

Hello,

Here is the shorter version of this post: Investigating thyroid nodule for Step 2 CK (link: https://www.medicowesome.com/2016/06/step-2-ck-investigating-thyroid-nodule.html)

So - if you find a thyroid nodule on physical examination - what do you do next?

Caudal anaesthesia

Hello Awesomites!

Caudal anesthesia is a type of epidural anesthesia. 

INDICATIONS
The indications for single shot CA are abdominal,urologic or orthopedic surgical procedures located in the sub-umbilical abdominal, pelvic and genital areas, or the lower limbs, where postoperative pain does not require prolonged strong analgesia. Examples include inguinal or umbilical herniorrhaphy, orchidopexy, hypospadias and club foot surgery.

Anatomical landmarks (Figure)
The sacrum is roughly the shape of an equilateral triangle,with its base identified by feeling the two
posterosuperior iliac processes and a caudal summit corresponding to the sacral hiatus.The sacral hiatus is located at the caudal end of the median crest and is created by failure of the S5 laminae
to fuse (Figure). The hiatus is surrounded by the sacral cornu.

Preparation
Obtain consent for the procedure either from the patient or, if appropriate, from the parents. After induction of general anaesthesia and airway control, the patient is positioned laterally (or ventrally),
with their hips flexed to 90°. Skin disinfection should be performed carefully, because of the proximity to the anus.
After defining the bony landmarks of the sacral triangle, the two sacral cornuae are identified by moving your fingertips from side to side.The gluteal cleft is not a reliable mark of the midline. The puncture is performed between the two sacral cornuae. The needle is oriented 60° in relation to back plane, 90° to skin surface. The needle bevel is oriented ventrally, or parallel to the fibers of the sacro-coccygeal ligament.
After verifying absence of spontaneous reflux of blood or cerebrospinal fluid (more sensitive than an aspiration test), injection of LA should be possible be without resistance. Inject slowly (over about one minute).

-Upasana Y. :) 

HbA1c and Estimated Average Glucose

Hello Awesomites!

Sounds new. Wait till the end!

Do You know what is HBA1c?

HbA1c is produced by the condensation of Glucose with N-terminal valine of each beta chain of HbA.

Diagnostic importance
The rate of synthesis of HBA1c is proportional to exposure of RBC to glucose. Concentration of HBA1c is indication of blood glucose concentration.
It reflect mean blood Glucose level over 2-3 months prior to its measurement.If HbA1c is <7% then diabetes is in good control. To get an accurate result the concentration should be monitored for several months.

Estimated average glucose (eAG) :- It is new term in diabetic management.It helps to interpret HbA1c levels into average glucose concentration.
eAG(mg/dl) =(28.7×HbA1c) - 46.7

Drawback
The A1c doesn’t replace self blood-glucose monitoring. Because the A1c is an average of all your blood sugars, it does not tell you your blood sugar patterns. If someone has certain type of hemoglobin mutations (variation in the hemoglobin structure) (HbA1c is falsely low) , is severely anemic (low red blood cell count), iron deficient( HbA1c is falsely high) or is being treated blood transfusions or medications to increase the production of new red blood cells, the A1c test may not be accurate.

Thank you.
Upasana Y. :)

Diabetic Retinopathy

Here is Upasanas video on Diabetic Retinopathy.

I edited the slides so you can see better :)

Slides are available for download here:

PARTNER 3 trial journal club

Hey everyone!

A few months ago, I did a journal club on the PARTNER 3 trial.

I have been meaning to create an audio file and upload the whole journal club as a video on YouTube but unfortunately, I don't seem to have the time.

This is why, I decided to go ahead and release my slides instead so it helps anyone who is doing a journal club on the same :)

Oblique muscle mnemonic

It can be hard to remember which oblique does what. Remember this. 'Extortion' as we all know is forcing money out of someone. People from the 'inferior' strata of the society extort money. See where am I  going?!

So! Inferior oblique causes extorsion( 'extortion' is a bit different- c'mon, be a grammar Nazi!)
What remains? Superior oblique. So..it then is responsible for intorsion.

Similar is the case for superior and inferior recti.

Hope I saved you from ophthalm extorting your precious time.

-Sushrut

Cardiovascular changes in pregnancy

At term
- Blood volume increases by 50%
- increased uterine blood flow 500-800ml/min
- uterus recieves 10-15% cardiac output

Philosophy of Medicowesome

Internship dairies: Finding a vein

So here's a quick post in support of Internship Diaries. I would like to give you advice on how to do blood draws and insert IV lines.

First of all, learn properly before you try it on another human being. Watch YouTube videos, learn by observing.

Second, the tourniquet is your friend. If you don't have a tourniquet, use a glove instead. It will make the veins more plump.

Third. Feel the vein before you attempt to insert the needle or cannula. FEEL IT.

Be patient and take your time. It's better to spend 30 seconds extra than to poke somebody and spend five minutes more trying to find a vein.

I know that this is phlebotomy and nursing advice and it may not be needed in hospitals where the ancillary staff does it.

But hey, hope this helps! :)

PS: I just realized I've written a longer post before here: https://www.medicowesome.com/2015/10/tips-on-how-to-find-vein-or-phlebotomy.html

-IkaN

Strabismus/Squint

Hello Everyone!

                 Strabismus has been confusing me for long, so I decided to come up with a chart:

You can download the chart at https://drive.google.com/file/d/1leP_Ir3FZU0J-0isZcYHkgd5x_ujQFX8/view?usp=sharing

Thanks!

Chaitanya Inge
Upasana Yadav

Propofol infusion syndrome

Hello friends!

It is the triad of metabolic acidosis, skeletal myopathy and acute cardiomyopathy.

It is seen in children on prolonged infusion.

It occurs due to failure of metabolism of free fatty acids.

Madhuri.

Propofol

Hi friends!

Propofol is a non-barbiturate intravenous anesthetic agent.
Colour : milky white liquid.
Chemical name : 2,6-diisopropylphenol.
Composition: soyabean oil, glycerol and lecithin.
Metabolism:70% in liver, 30% in lungs and kidneys.

Propofol is associated with quick recovery. So it is the drug of choice for day care surgeries.

Systemic effects:
CVS : It decreases systemic vascular resistance leading to fall in blood pressure causing tachycardia. But it actually causes bradycardia. The reason being blunting of carotid body receptor response (which we have studied in our physiology)
RS : It causes maximum depression of upper airway reflexes. So it is the drug of choice for insertion of laryngeal mask airway.
CNS :  It causes cerebral vasoconstriction leading to fall in intracranial pressure. It is an antiemetic, antipruritic and antioxidant.
It is an anticonvulsant but may cause involuntary movements.

Thanks for reading!
Madhuri.

Massive blood transfusion strategy

In patients with massive haemorhage with a loss of more than 40% of blood volume - rapid transfusions are given with colloids, crystalloids and packed RBCs.

This causes coagulopathy by diluting the a clotting factors.

Hence, prophylactic infusion of platelets and fresh frozen plasma is done.

Initially, it was given in a ratio of 1:1:4
One part platelet & ffp transfusion to every 4 bags of blood.

It has been renewed now to 1:1:1 ratio

It has caused significant reduction in mortality 40% versus 60%

Thank you!

40% blood loss translates to grade 4 hemorrhagic shock or grade 1 degree of urgency per the urgency grid for obstetric hemorrhage. I removed the grading in the initial part of the post to avoid confusion as different grades mean different severity of shock based on the scale used.

- sakkan

EPISODE 01 INTERNSHIP DIARIES - (The best way to FINISH is to START first!)

PROLOGUE

                   It’s a busy day, and to top with that you are running late. It’s your first day as a Medical Intern and you are super excited for your future 1 year.

You are entering into this huge sophisticated hospital with the shining silver name plate attached to it “SAN JOSE GENERAL HOSPITAL” and you reach the smiling and pleasant looking receptionist with round glasses on.

“Hello Good morning, I am Kesh, a new medical intern here. Where should I go?”

“One minute please!” She tells you and starts checking something on her computer.

“Hello Dr. Kesh” She looks back at you.

“Omg!” You think. “This is it! People are calling me doctor now! Yoohoo!” you smile widely.

“Please proceed to the Department of Internal Medicine, please look for Dr Wen, your mentor!”

You thank her and follow her guide.

****

Dr. Wen is a helpful young doctor in his late thirties who happens to be the Chief Resident of Internal Medicine. His orientation on the hospital rules were quite lengthy but was important. His ending was quite remarkable.

“Being a doctor is a dream of many but achieved by few. You are among the lucky few. You are supposed to lead a health care team. which means you should know all the necessary medications and side effects and how it would affect the human being! Your whole team relies on you. There for you need to be responsible and accountable to yourself, your team and your patient.” Dr Wen said. “ You have spent years in Medical school already, and now it's time for the training here and I wish that all of you would take the best chance of that objective by learning to how to be a good healer.” he continued.

“Please proceed to your respective wards now. If you have any problem during your internship, please ask for my help. I will definitely help you!” said he at last.

You check the slip in your hand.

“Ward 3” it says. You slowly walk toward your post.

***

“Dr. Kesh” You hear your nurse is shouting your name

“Yes?”

“Could you please insert an IV line to this new admission?” She asks.

“Here are your gloves, your aseptic instruments and IV catheter. Thanks you so much!”

The nurse leaves you with a full tray and a newly admitted patient who looks worried.

“Can I please insert you an IV line for your vein so that we can hook you up to IVF?” You seek consent!

“Yes sure” Patient gives permission.

You take the pack of Surgical gloves into your hands.

"Now what to do?" you think!

[To be continued...]

********

Pre lesson questions

1. What are the gloving techniques you know?

2. What are the types of gloves you know?

3. What unit is used to measure the IV cannula size?

4. What are the most common areas of IV cannula insertion?

5. What is a heplock?

Expect the next episode with the answers and the lesson.

You can answer the questions here in the comments, or if you are in our Medicowesome Whatsapp group, you can message me (Jay) or Upasana privately with your name and answer. I will post the names of the first 5, who gave the correct answers with our next post.

Enjoy!


DEFINITION OF TERMS

1. Consent - The consent or receiving the willingness of the patient to undergo a medical procedure is a must before you would perform any medical procedure. It could be ranging from a simple needle prick test or to an imaging or an operation.
2. IVF - Intra Venous Fluid. These are the liquid substances directly delivered into a vein. 

.

Why is low voltage ECG seen in cardiac amyloidosis?

Short post because it is a cool fact!

Think before you order a test: High resolution CT scan (HRCT)

Hello, 

Let's talk about HRCT today!

HRCT is the use of thin-section CT images (0.625-mm to 1.5-mm slice thickness) with a high spatial frequency reconstruction algorithm, to detect and characterize diseases that affect the pulmonary parenchyma and small airways.

HRCT cuts THIN slices.

Awesome, isn't it? Why not use an HD camera for every photograph?

Because it comes with a price!

Treating Alcohol withdrawal - scheduled vs PRN benzodiazepines

Hello,

Sometimes it's frustrating to see different physicians use different approaches to management of the same condition or disease. How do you practice in that case?

You look at the evidence, the guidelines and make your own decision based on it.

Then even though if your attending practices something opposite of what the guidelines say, you know what is right and what you will practice in the future :)

Anyway, now that I am done venting - what do guidelines say about scheduled vs as needed benzodiazepines for alcohol withdrawal?

Chimeric antigen receptor T cells (CAR T cells) therapy simplified

Hey everyone! Upasana - our funny medical student made a simplified video on CAR T cell therapy. Check it out!

I copy-pasted a quick short post in text for reference :)

Orthopaedics: Facebook Septic arthritis Vs Transient synovitis

#Medicowesome
#Orthopaedics

Q) A 4 year old kid comes to OPD with complaints of high grade fever, decreased appetite and pain in right hip. On examination he has dehydration/ tenderness in Scarpa's traingle/ swelling in right hip region, flexion, abduction and external rotation at hip/ absent movements in right hip region. On Xray there is mild increase in medial joint space. Diagnosis is

1) Septic arthritis
2) Transient synovitis
3) Tubercular arthritis
4) Dislocation of hip

Answer is 1) Septic arthritis

Let us dissect this Multiple choice question. Read the question one more time and let's follow up. Put your Sherlock holmes hat and let's see what we can deduce!

1) A 4 year old kid.
2) Toxic due to dehydration.
3) In his right hip we have - Flexion, abduction, and external rotation. This collectively is called as FABER! Big clue here.
4) Absent movements

Looking at the option given, we can definitely eliminate dislocation of hip. It has FADIR - Flexion, Adduction and internal rotation.
Coming to TB. Now if try to recollect the 5 stages of TB you will find that 1st stage is FABER and next two stages are FADIR! 5th stage is Fibrous ankylosia known as TB arthritis. 4th stage has Wandering Acetabulum (It is a misnomer because both acetabulum and femur head is destroyed so actually remaining part of femur wanders! - also known as - Pestle and Mortar type)

Now two options left - Transient synovitis and Septic arthritis. Well you know Septic arthritis is an emergency condition. Even if you don't know any thing about other option, you can still get it correct. Child is toxic and absent movements points out toward emergency condition.

Both Transient synovitis and septic arthritis causes FABER which leads to more space in the joint leading to more inflammation and swelling. Any swelling disease in Orthopedics is approached as
"XMAS"
X- Xray
M-MRI
A-Arthroscopy which is USG guided.
S-(for)Swelling diseases

Wait! What would be treatment modalitis for both of them?
Ofcourse surgery followed by 6 weeks of Antibiotics for Septic arthritis
Whereas Transient synovitis as name suggest is less severe so we do conservative treatment.

Remember:
Septic arthritis - Absent movements
Transient synovitis - Decrease movements

Cavernous transformation of portal vein

Hello Awesomites! :)

Let's start with clinical presentation.

The children may present with hematemesis due to variceal bleeding, failure to thrive, ascites or anemia and splenomegaly.

Portal cavernoma also known as cavernous transformation of portal vein, is an important cause of extrahepatic portal hypertension in children or young adults in developing countries.

After thrombosis of the portal vein, portoportal venous channels may form not only at the porta hepatis but also within the liver. Intrahepatic blood may be shunted from one segmental portal vein to another.

Cavernous transformation of the portal vein is easily diagnosed by sonography. Color and duplex Doppler confirms the presence of portal venous type flow within the tortuous channels at ports hepatis.

In adults, conditions associated with cavernous transformation of the portal vein include myeloproliferative disorders, hypercoagulable states, pancreatitis, pyelephlebitis and Behçet syndome.

Associated findings may include esophageal gastric junction, gastric varices, gallbladder wall varices as well as intra or extra hepatic biliary tree dilatation.

The individualized choice of shunt (Mesocaval/central splenorenal/distal splenorenal shunt) is ideal for treating PVCT, and the combined procedures of shunt and disconnection are useful. The Rex shunt will be the focus of PVCT surgery in the future.

Thank you.
-Upasana Y. :)

What Is Going On In Migraine?

Despite the high prevalence of migraines, the underlying pathophysiology is poorly understood.

What was thought?
Cerebral and meningeal arteries dilatation. Now largely disproven.

What do we think?
- MRI says episodic cerebral edema with dilatation of intracereberal vessels and less water diffusion that doesn’t respect vascular territories.

- PET says it’s a subcortical disorder affecting modulation of sensory processing.

- Magneto-EncepaloGraphic (MEG) scan suggests failure of inhibitory circuitry in the visual cortex.

- Hormones play a role. Migraines occur just as commonly in males as in pre-pubertal and post-menopausal females but the ratio tilts towards women of reproductive age group by 3:1. About half of the women complain of migraine synchrony with menses.

- 5-HT overload as suggested by its metabolites in the urine. While the exact significance is controversial, the efficacy of Triptans (5-HT 1b/1d agonists) supports its role.

- Trigeminal nerve dysfunction suggested by blockade of trigeminal nerve impulses by Triptans. They also inhibit release of substance P and pro-inflammatory neuropeptides.

This is what we know so far. To thread this string is your responsibility, future Dr. Neurologist. Good luck!



- Ashish Singh

Hierarchy Of Evidence

Evidence-based medicine is the conscientious and judicious use of current, best research evidence to optimise management plans.
Here’s the order of importance.

[Please click on the image to enhance it]

That’d be all.

- Ashish Singh

Reference(s):
1. Evidence based medicine: what it is and what it isn't by Sackett et al, 1996.

Unique iris behavior in bleeding

Iridodialysis bleeds profusely as the circulus major arteriosus lies near it's root.
Conversely, sphincterotomies or YAG iridotomies hardly bleed. Why? Because the vessels in the iris away from it's root are intertwined within it's musculature. The muscles contract immediately, halting any hemorrhage.

-Sushrut 

Burnout Advice.... Jay's 2 cents s/p reading Ikan's post

Burnout is a very common thing among us medicos. That spans from being a medical student upto a resident or even a consultant sometimes!

We feel stupid most of the times and some of our seniors have that bad habit of making the juniors feel bad.

But trust me, you WILL become as good as them, and even better! Medical field needs experience and alot of reading. Med school teaches us maybe 1/10th of what we should know as a doctor. And the remaining we learn on the job.

There is always more to learn more to read and more to understand but medicine is not a lonely game. Always refer, and ask! In Medicine, 2 brains are always better than 1 brain. Don't feel shy or bad to ask for help.

Use your head! If they belittle you, tell yourself you will learn it. Smile and move on.

For me each time I lose motivation, I watch an episode of a Medical TV series. It could be HouseMD, The Resident, New Amsterdam, Good Doctor, Chicago Meds, or any random episode I find in Youtube.
Watching them gives me the feeling of impact I can have in others' lives.

I also go through Youtube videos from famous Medical youtubers, few of my favorites are Jane and Jady, TheStriveToFit, Ali Abdal, DoctAura etc. They have amazing study tips and other medical related things that can give you the motivation to read and learn.

Sometimes I go through #Studygram handle in Instagram. There are many colourful notebooks and workspaces, it really inspires me and gives me a free mind to study.

I also like to read the study tips written by my fellow authors. They have eye opening and motivational tips that really makes me go sit and get that one chapter done.

If all these don't work, just listen to your favorite songs and move your body a little bit when your room mates are not watching! 😂 It definitely gives some positivity to shrug off that sad burnout feels.

Yes! I find most of my inspiration and motivation by online activities rather than going out and resting under the trees. One reason being Im not a very outgoing person and another being I have very little time as a Junior Intern.

And also it helps to clean your room. And cooking a meal for you and/or your family/partner. It would leave you with a clutter free environment and a tasty meal to eat. And if things go well, a lot of praising for your yummy food by others with make your self esteem get better too.

Then get a yummy dessert or make one. Sometimes I just eat a slice of custard cake on my way home, or cook a simple bread pudding and share with my roomies. Although they jump into finish it
and finally leaving me a little piece. ( Those two a-holes!!! 😂😂)

You don't need a trip to beach or hike to mountain, but sometimes sleep on a cozy bed with newly washed sheets, after a warm bath, applying your favorite night lotion, a drop of nice smelling essential oil behind your ears and wearing relaxing clothes will refresh you too.

These are few of my techniques to feel good after a toxic day with disastrous rounds.

Confession : I have had my fair share of bad days. I was punished for silly mistakes. I was sanctioned with extension of duty and forced to work extra hours to compensate for it. But we gotta accept our short comings, learn from our mistakes and move on. We at Medicowesome are not saints or gods to dictate how you should live and everyone of us had made errors, said wrong things in rounds, got shouted at, failed exams, and some of us even went through psychiatric help to get over any of the depressive periods we had

But what is most important is, NONE of us gave up! I take this time to thank my Medicowesome family for helping each other and even helping me rise up in such times when I was so low. Behind the groups and the blog, we are an amazing group of friends although many of us have never met each other. Medicowesome is my support group, and we all need one including you. Find your supportive group, and for the records don't forget we at Medicowesome as also on your back, ready to hold you up.

Stay strong and comment or message us about your methods of tackling a toxic day or a burn out session. So we all can learn from it.

Keep it up! Take care and always....be awesome!

With love,
-Jay

Residency and burn out advice

Here's a conversation I had with a friend of mine. She's a resident in a busy government hospital in Mumbai.

I still feel like Jon Snow (I know nothing). I feel like I'm stuck at the basics. And seniors expect a lot. It is somehow unfathomable to me that someday I will be even one tenth as smart as them. Morning rounds as a massacre. It's like beheading my already non existent self confidence. I feel so stupid everyday. I have no energy to study.

I'm trying so hard to not let it get to me but everyday I get to hear criticisms either from professors or immediate seniors. I wasn't born stupid Nakeya but everyday I feel like I've bitten off more than I can chew and chosen a career that's too difficult for me. I feel thoroughly demotivated these days. Like I'm just working because I have to. I feel like I've lost interest only to improve and be better everyday.

Me:
It's OKAY to feel stupid. I think it's everyone of us. It's a part of learning. Indian culture has not developed a way to give constructive feedback... So you got to modify the words they say and take it in a way that motivates and inspires you. It's... I'm pretty sure it's just the culture that makes you feel more stupid than you should feel. The career is not difficult. The training is. You're not stupid. The way they teach is!

We do this thing every week - We share our humanistic experiences with everyone. It could be as simple as holding grocery bags for an old lady.  It really helps. We tend to think about the things we did wrong and belittle ourselves. But we need to think about the good things we did. The things we did right. Made a baby smile when they were sick. Made a correct medical decision. Got the IV in the first go. We need to celebrate the little things.

Take time off from medicine and rest whenever you get a chance.

-IkaN

Asking Questions

History taking in medicine is science just as much as art. Here are some tips.

DOs

Open questions: ‘How are you?’ ‘How does it feel?’
The direction a patient chooses offers valuable information.
‘Tell me about the vomit’
‘It was dark’
‘How dark?’
‘Dark bits in it’
‘Like...?’
‘Like bits of soil in it’
This information is gold although it does not cast in the form of coffee grounds.

Patient-centred questions: Patients may have their own ideas about their symptoms, how they impact and what should be done. This is ever truer as patients frequently consult Dr. Google before their physicians. Unless their ideas, concerns and expectations are dealt with, your patient may never be fully satisfied with you or be fully involved in their own care.

Considering the whole: Humans are not self sufficient units; we are complex relational beings, constantly reacting to events, environment and each other. To understand your patient’s concerns, you must understand their context: family, friends, work, dreams and fears. A headache caused by anxiety is best treated not with analgesics; but by helping the patient access support.

Silence and echoes: Often the most valuable details are the most difficult to verbalise.
Trade secret: the best diagnosticians in medicine are not internists, but patients. If only the doctor would sit down, shut up and listen, the patient will eventually tell him the diagnosis.
While powerful, silence should not be oppressive- try echoing the last words said to help your patient vocalise a particular thought better.

DON’Ts

Closed questions: Permit no assumptions. Take no subtle information for granted. Let the patient paint you a picture.

Questions suggesting an answer: The doctor’s expectation and hurry to get the evidence into a pre-decided format have tarnished the patient’s story enough to render it useless.

- Ashish Singh

Pathophysiology: Diabetic Ketoacidosis

Hello guys, here’s a whiteboard summary of how DKA happens.

[Please click on the image to enhance it]

- DKA is a medical emergency. It’s a complication of type 1 diabetes.
- DKA has a triad of hyperglycemia, ketosis [metabolic acidosis] and dehydration.
- Main ketone bodies are beta-hydroxybutyrate and acetoacetate. Acetone is only a minor ketoacid.
- Lactic acidosis also contributes to metabolic acidosis.
- More glucose in blood leads to more glucose filtered into urine causing osmotic diuresis.


- Ashish Singh 

Burkitt’s Lymphoma types

There are three types of Burkitt’s Lymphoma: Endemic (African), Sporadic  (non-endemic) and immunodeficiency-associated.

Molecular mayhem - AML relapse after HSCT

For many hematological disorders including AML, CLL, ALL HSCT is the only viable therapeutic option when cytogenetics are not conducive for chemotherapeutic agents. However subsequent relapses are not uncommon which are due to subtle molecular alterations because of underlying and acquired mutations.

WhiteBoard Summary: Lichen Planus

Hi guys, let’s talk dermatology.

Lichen Planus is a papulosquamous disease that affects skin, nails and mucous membrane, caused by cell-mediated immunity of unknown aetiology. Here’s a (not-so-white) whiteboard summary.

[Please click on the image to enhance it]

- Morphological variants can be hypertrophic, atrophic, erosive, follicular, annular, vesicular, bullous, actinic or pemphigoid.

- Lichenoid reaction can be caused by drugs (thiazides, antimalarials, penicillamine, gold) and even in Graft vs. Host disease.

- Those with steroid resistance/ intolerance are treated by hydroxyquine, methotrexate or sulfasalazine.

- Psoralens can also be used along with UV-A radiation.

- Patient education regarding self-limiting and recurrent nature of the disease is important.

- Ashish Singh

Pathophysiology: Multiple Sclerosis

Hey guys, let’s look at the fundamentals of multiple sclerosis.

Multiple sclerosis is an autoimmune disease of the CNS characterised by

- chronic inflammation

- demyelination

- reactive gliosis/ scarring

- neuronal loss

with a course that is relapsing-remitting or progressive

and lesions that are disseminated in time and space.

Here’s how it happens:

[Please click on the image to enhance it]

- Ashish Singh

Antibiotics: Action and Resistance

A series of fortunate events - including a cancelled holiday and an unpredictable British summer - in 1928 began the antibiotic revolution, when Alexander Flemming’s observation that a contaminating Penicillium colony caused lysis of Staphylococci.

Here’s a pictorial summary of various sites of action of modern-day antibiotics.

[Please click on the image to enhance it]

However, the capacity for prokaryotic bugs to develop resistance far outweighs the human capacity to develop new antiobiotic drugs.

Antibiotic resistance can be:

- Intrinsic: Inherent structural or functional characteristics, eg: vancomycin cannot cross the outer membrane of Gram negative bacteria.

- Extrinsic: Acquired through years of mutation and/or transfer of resistance properties. This evolutionary phenomenon is accelerated by selection pressure from antibiotic use, eg: beta lactamase producing Gram positive bacteria.

- Ashish Singh

WHO Pain Ladder

Humans are the most exquisite devices ever made for experiencing pain; the richer our inner lives, the greater the varieties of pain there are for us to feel.
As physicians, never forget how painful pain is, nor how fear magnifies pain. Try not to let these sensations, so often interposed between your patient and recovery, be invisible to you as he/ she bravely puts up with them.

[Please click on the image to enhance it]

- ALWAYS GO UP THE PAIN LADDER, IF PAIN PERSISTS/ INCREASES.
- Simple analgesics are non-narcotic.
- Review and chart each pain carefully and individually.
- Identify and treat underlying pathology, wherever possible.
- Adjuvants:
1. Neuropathic pain: Gabapentin, Pregabalin, Amitriptyline, Duloxetine, Steroids
2. Bone cancer pain (primary or mets): Radiotherapy, Bisphosphonates
3. Intestinal/ Renal colic: Hyoscine butylbromide
4. Muscle spasm: Baclofen
5. Brief pain relief: Nitrous oxide (usually with oxygen)


- Ashish Singh

Mnemonic: Incubation Period of Hepatitis

Hey guys, here’s a simple little mnemonic to remember the incubation period of various hepatitis infections.

Rule of 4 to 8:

Hep A - 4 weeks

Hep E - 5 to 6 weeks

Hep C - 7 weeks

Hep B/D - 8 to 12 weeks

Pay attention to the order of Hep infections from 4 to 8.

Why A&E first? That’s because they enter through the mouth (feco-oral mode of transmission) and your mouth is the first part of your GI.

Remember, Hep D co-infects or super-infects Hep B.

- Ashish Singh

A-a Gradient

A-a gradient =[PAO2 - PaO2]
where:

A-a gradient = difference between alveolar PO2 and arterial PO2

PAO2 = alveolar PO2 (calculated from the alveolar gas equation)

PaO2 = arterial PO2 (measured in arterial blood)

PAO2 =150 - PaCo2/0.8

Normal range for A-a gradient is

10-15 mm Hg

ALL causes of hypoxemia lead to ↑ A-a gradient, EXCEPT:

Hypoventilation, high altitude, upper airway obstruction (e.g. epiglottitis from Haemophilus influenzae, or croup from parainfluenza virus)

Everything else will cause ↑ A-a gradient (e.g. shunt, V/Q mismatch, etc.).  

It's much better to remember the exceptions, then everything else becomes the rule!

Also to adjust for age, the thumb rule to calculate A-a gradient is :

Age /4   plus 4

A-a gradient >30 is considered elevated regardless of age.

Bhopalwala. H

Catheter Removal Timing

Removal — Following diagnosis of catheter-related infection, catheter removal is warranted in the following circumstances :

●Severe sepsis

●Hemodynamic instability

●Endocarditis or evidence of metastatic infection

●Erythema or exudate due to suppurative thrombophlebitis

●Persistent bacteremia after 72 hours of antimicrobial therapy to which the organism is susceptible

Source :Uptodate

Bhopalwala. H