Study group discussion: To anticoagulate or to not anticoagulate

One quick review question:
So patient has new onset atrial fibrillation. Would you start the anticoagulation right away?

Its only after 48 hrs of onset, that too you have to rule out intra-atrial thrombus by trans esophageal endoscopy. If the thrombus is present, you give heparin.

Yeah when there is thrombus that's a must! But let's say no thrombus now what? 35 yrs old male.  Can we start  anticoagulants?

There is specific criteria. For assessment of thromboembolic risk. It's called CHADS2.

Oh yes, if the score is >=1 then you start it. One point each for CHF, HTN, age >75, diabetes and 2 points for prior stroke or TIA.

If patients have not been adequately anticoagulated and the AF is more than 24–48 h in duration, a transesophageal echocardiogram (TEE) can be performed to exclude the presence of a left atrial thrombus that might dislodge with the attempted restoration of sinus rhythm with either nonpharmacologic or pharmacologic therapy.

It can be a different scenario!
* In the case I was discussing above the AF resolved soon after metoprolol.

And in that case anticoagulation are started as prophylaxis. So would be oral warfarin or the LMWHs.

Study group discussion: Charcot's in Medicine

I read about charcot and who knows the conditions, name of diseases starting with charcot?

Charcot Leyden crystals - Eosinophils in sputum of patients with allergic diseases.

Then charcot joint too.. In diabetes, syphilis. Neuropathic joints, basically.

Charcot triad is of which condition?

One is of infection of gallbladder - Jaundice, fever, right hypochondriac region pain.

Charcot's triad in multiple sclerosis is sin - Speech disturbance, intention tremors, nystagmus!

I thought intention tremors were characteristic of cerebellar disease.
Exactly but seen in MS though not pathognomonic.

More charcots?

Charcots disease is ALS.. Amyotrophic lateral sclerosis !

The ice bucket challenge one. It's other name is based on some famous baseball player, right? Lou Gehrigs disease!

Charcot's artery?
Lenticulostriate artery!

The ones responsible for lenticular infarcts? There are five types, right?

Pure motor, pure sensory, clumsy hand, ataxia and sensorimotor!

Charcot bouchard aneurysms!

Charcot marie tooth disease !

Charcot wilbrand syndrome- visual agnosia!

Nice one! Keep learning and sharing :D

Study group discussion: Pathogenesis of symptoms in glucagonoma

Why does glucagonoma cause dermatitis and DVT?

The exact cause isnt known, but one of the reasons may be, because the excess glucagon produced reduces the amount of albumin (which carries Zinc) hence producing a relative deficiency of Zinc. The similar type of which is also found in Zn deficiency. And hence, the dermal manifestation!

The dermal manifestation is called NME - Necrolytic Migratory Erythema

That was one of my MCQ! Also glucagonoma is the commonest type pancreatic tumours to occur in MEN 1 syndrome.

And deep vein thrombosis?

The mechanism for the coagulopathy is poorly understood and seems to be related to an increased factor X production by the pancreatic alpha-cells.

Anyone would like to name the 4 D's of glucagonoma?

Diabetes
Dermatitis (rash),
Deep vein thrombosis (e.g., blood clot in the legs)
Depression

Study group discussion: Can a child less than 6 months be given anything other than breast milk?

Hello. I had this little doubt, I'm in the second year and haven't been exposed to paeds yet. So...
Do you give a child below six months anything other than breast milk? If no, then what do you do if a mother isn't producing enough milk and the baby is still hungry?

What I learned in peds (only did one of three semesters so far) it's that there's very very rare for the mother to not produce enough milk. most of the times is a matter of wrong breast feeding technique.
But formulas can be used, if in the right proportion of formula to water.  Or even cow milk, but it also has a specific recipe to dilute it.

I'm not sure. It's probably not recommended as the milk will be different from the mother's.

You can use fórmulas, you can't give them cow Milk until they are one year old.

I learned that if the family can't afford formulas is ok to give cow milk since the birth. It has to be diluted with water and added some sugar and a drop of soy oil to make it more similar to breast milk.

It is possible that sometimes a woman other than the mother can breastfeed too.

In my peads wards, I have seen mothers giving top feeds with the not enough milk production excuse.

If the child doesn't have a mother, I think they're provided with diluted cows milk or infant formulas.
The only reason it isn't recommended in infants who have mothers who can feed their child is because they have nipple confusion / detachment and they won't consume the mothers milk anymore (Which is super important for the baby, since they have antibodies!)

Study group discussion: Krukenberg in Medicine

What is..
Krukenberg tumor? 
Krukenberg procedure?
Krukenberg spindle?

Study group discussion: Mifepristone

Major use of mifepristone in obstetrics gynaecology is?
A) ectopic pregnancy
B) molar pregnancy
C) fibroid uterus
D) threatened abortion

A??

Yes, it's A. Please explain.

Mifepristone is abortifacient. It causes abortion by blocking progesterone.

But what if the ectopic site is not in connection with the uterine lumen. How will it be aborted?

I guess progesterone level in required to maintain the implantation.. A decrease in progesterone will cause it ectopic pregnancy to abort from that place.

That's right.

Mifepristone is also sometimes used to end pregnancies when more than 49 days have passed since the woman's last menstrual period; as an emergency contraceptive after unprotected sexual intercourse ('morning-after pill'); to treat tumors of the brain, endometriosis (growth of uterus tissue outside the uterus), or fibroids (noncancerous tumors in the uterus); or to induce labor (to help start the birth process in a pregnant woman).

Rh incompatibility USMLE Step 2 CK doubt

If the patient is sensitized and is making Rh antibody, there is no point giving, Rhogam right?

Nope. It is only for prevention to Rh sensitisation. It's not the treatment.

I see!

So once she is sensitized, nothing can be done?

Nope.

So, say there is a mother who had a kid with hemolytic disease last pregnancy. Will I be giving her Rhogam next pregnancy?

No.

You monitor the Rh antibody levels (by titres using indirect antiglobulin test).

If >1:4 woman is considered sensitized.

If >1:16 do the spectrometric test by using fetal cells taken by amniocentesis (To monitor bilirubin levels!)

Bilirubin low: Repeat amniocentesis in 2-3 weeks.

Bilirubin high: Measure hematocrit of baby using percutaneous umbilical blood sampling.

If the baby is affected (Fetal hematocrit low), only treatment is to give blood transfusion to the baby in utero (Intrauterine transfusion) And delivery at 37 weeks. Or even earlier.

Ooh. I get it all now <3

Study group discussion: Drugs and conditions that enhance Digoxin toxicity and the mechanism behind it

I read some cool things today on the group!

Why is there an increased risk of toxicity with digoxin in hypokalemia, hypercalcemia and hypomagnesemia?

Answers:

Potassium and digoxin compete for the binding site so if there will be less of potassium more of digoxin gets the chance to bind leading to toxicity. The NaKATPase is the binding site.

Digoxin toxicity is aggravated by increased calcium cause more calcium accumulates intracellulary. This leads to increased contraction.

Calcium intracellularly also increases the generation of ectopic foci within contractile cells.

Magnesium is used as treatment in the treatment of toxicity.

Magnesium is the cofactor for the Na-k pump. Less magnesium..less functioning of the pump. Hence aggaravated toxicity!

Here's an additional fun concept:

Drug of choice for supraventricular tachycardia?

Answer: Verapamil.

So if you have SVT in digoxin toxicity.. Would you give verapamil?

Answer: No.

Why not?

Don't know? Let me approach the explanation in a way which helps you think better - What is the mechanism of excretion for digoxin?

Answer: Renal excretion.

Digitoxin is via hepatic.

Here's a mnemonic on renal / liver excretion of Digoxin / Digitoxin: http://medicowesome.blogspot.ae/2014/03/how-to-remember-digoxin-is-renally.html

So when digoxin enters the tubular cell, it is excreted into the lumen via p-gp receptors. Those are the same receptors responsible for multidrug resistant. In cases of anti-cancer agents and anti-malarials. You see, verapamil is one of the rare drugs that block p-gp. Hence, decreasing digoxin excretion, thus, precipitating it's toxicity.

*pgp refers to P Glycoprotein receptors

Verapamil for the same reason is used to reverse resistance to anticancer and anti-malarials. Pretty cool info, ain't it?

I just fell in love with the whole drama digoxin plays in your body :D

So what drug is used in SVT induced by digoxin then?

Answer: Beta blocker.

That's all for today!

I'm trying to edit the stugy group discussions in a more reader friendly format. Hope you like them!

-IkaN

Study group discussion: Food analogies in Medicine

Who likes oreo cookies? I came to know about the Oreo Cookie sign today!
It's seen on a chest x ray (lateral view) when there is a pericardial effusion!
The anterior most layer (the chocolate part!) is the epicardial fat.
The mid layer (the cream part...yumm!) Is the fluid.
And the posterior layer (again, the  chocolate part) is the pericardial fat!

Coffee bean sign seen in?
Sigmoid volvulus! Also called omega sign!

Name some terms that starts with strawberry referring some conditions in our body:
Strawberry cervix - Trichomonas vaginalis infection
Strawberry tongue - Kawasaki disease, scarlet fever.
Strawberry scrotum - multiple sebaceous cysts (They're actually calcified epidermal cysts aka calcinosis cutis)
Strawberry haemangioma!

Speaking of food analogies.. Let's catch em all!

Oat cell carcinoma - Small cell carcinoma of the lung.

Cafe au lait spots - Neurofibromatosis.

We had a chart in pathology department - 'Pathology restaurant'

Apple birefringence - Amyloidosis!

Apple peel sign - Intestinal atresia.

Bread and butter appearance -  Fibrinous pericarditis.

Bread crumbs appearance in complicated cataract!

Honeycomb appearance of lungs.
Interstitial fibrosis.
Also pneumocystis, not sure.

Honey comb appearance of liver too.
Which condition is honey comb liver seen?
Seen in actinomycosis infection of liver. Burkholderia is a gram - bacteria. The honeycomb liver is seen in burkholderia infection....Which causes abcess...It's a radiologic sign!
Woah.

There's nutmeg liver - right heart failure!

Onion skin appearance - Ewings sarcoma!

Another Onion skin appearence seen in?
It's seen in Hyperplastic arteriolosclerosis!

Swiss cheese appearance - Metropathica hemorrhagica.

Also swiss cheese pattern in multiple serpingenous ventricular septal defects in VSD.

What appareance is in caseous necrosis, tuberculosis granuloma?

Cheese like?

Yeah. Here in spain is called: Queso fresco!

Cheesy necrosis in tuberculosis!

Dry cheese appearance in candida growth.

Cottage cheese appearance is found in which pathology?
Histological finding of caseous necrosis e.g in tuberculosis.

Anchovy sauce - Amoebic liver abscess!

Salt pepper appearance in?
EBV.

Salt and pepper skull - Hyperparathyroidism.

Rice water stools - cholera!! :)

Currant jelly sputum in?
Klebsiella pneumonia

Currant jelly stools in?
Intussuception!

So this is obvious - Maple syrup urine in?
Maple syrup urine disease!

Blue berry muffin rash - Congenital rubella.

Mulberry molars - Late congenital syphilis.

Olive shaped mass - Hypertrophic pyloric stenosis.

I know about Peau de orange!
Breast carcinoma.
And why is that?
Blockage of cutaneous lymphatics due to infiltration.
Blockage of lymphatic causes accumulation in the third space so it swells and the point where ligament is attached to the skin becomes pitted. Just like the skin of orange which has many small pits.

What about orange eyes?
Orange eyes are seen in Leptospirosis.

Apple core sign is found in which disease?
Colon cancer
Oesophageal carcinoma
Also a sign of IBD, I think.

What disease have Chicken drumsticks like fingers?
Psoriatic arthritis.

Napkin ring appearance also in colon cancer.

Which disease had grapefruit appearance?
Hyadatidiform mole.

There's chocolate cyst of ovary - endometriosis.

And chocolate agar!

Updated on 28th February, 2015:
A sandwich sign (sometimes known as a hamburger sign) refers to a mesenteric +/- para-aortic nodal mass giving an appearance of a hamburger. Confluent lymphadenopathy on both sides of the mesenteric vessels gives rise to an appearance described as the sandwich sign. The sign is specific for mesenteric lymphoma (typically non-Hodgkin’s)

Sandwich vertebra - Osteoporosis!

Updated on 1st March, 2015:
IkaN, did you get salt and pepper retinopathy on your foodie blog?

Yes, EBV!

Okay, I read that as a part of rubella. Could you explain what exactly happens tho?

Salt-and-pepper fundus with diffuse pigmentary lesions can be the signature of a previous systemic infection that had ocular involvement. Examples include inactive chorioretinal scars secondary to Lyme disease, tuberculosis, syphilis, congenital rubella, toxoplasmosis and bartonellosis.

There's a salt and pepper appearance in skin too! Systemic sclerosis and scleroderma have salt and pepper skin.

I found another salt and pepper term! In osteitis fibrosa cystica, punched out lesions produce a salt and pepper appearance on radiography. Multiple myeloma as well!

Updated on 3rd March, 2015:
Potato tumor: Carotid body tumor
Coconut appearance: Hyatid cyst

Study group discussion: Fatal familial insomnia, harmful effects of working at night and sleeping during the day

By the way, I saw a video on a very bad disease the other day - Fatal familial insomnia. Caused by prions just like Creutzfeldt Jacob disease.

I know about the disease.. I can't imagine not being able to sleep!

Has a late onset and the patient or rather I say victim does within a few weeks.
It's genetic.. Thalamus, sleep centre is damaged!
Therefore no sleep!
It's progressive, one falls into coma and finally death!
They basically sleep to die!

You can live without sleep for 5 days to a week, I suppose.

I had heard in physiology too.. That mice die if they are awakened before REM sleep chronically.

Even humans have reduced life span if they sleep for less than 4 hrs chronically.

Yes, I had heard someone who survived 2 weeks. He slept for only 4 hours per day

Why would anyone do that to themselves?

Workaholics.
Medical students!
Perfectionists.
Preparing for exams xD
We awesomites!

I sleep more than I should #vacations :P

That is also harmful.

How? =(
I get rebound insomnia though.

Read it in some article.

Ah.

6 to 7 hrs optimum.

Work hard. Sleep tighter.

Btw are there any harmful effects of working at night and sleeping during the day chronically?
I don't know and someone wanted to know!

Something related to messing up the circadian cycle? Because we have a diurnal surge of hormones?

Since all hormones are secreted at night and not sleeping at night disturbs the proper hormonal process... That's the reason people who don't sleep at night are also fat...

So they'd grow fat, that's it?

Anti aging 2, remember?
Serotonin mostly secreted from 11 p.m to 2 a.m and sleep during these is essential!

I found what I was looking for: Symptoms much like jet lag are common in people who work nights or who perform shift work. Because these people's work schedules are at odds with powerful sleep-regulating cues like sunlight, they often become uncontrollably drowsy during work, and they may suffer insomnia or other problems when they try to sleep. Shift workers have an increased risk of heart problems, digestive disturbances, and emotional and mental problems, all of which may be related to their sleeping problems. The number and severity of workplace accidents also tend to increase during the night shift. Major industrial accidents attributed partly to errors made by fatigued night-shift workers include the Exxon Valdez oil spill and the Three Mile Island and Chernobyl nuclear power plant accidents. One study also found that medical interns working on the night shift are twice as likely as others to misinterpret hospital test records, which could endanger their patients. It may be possible to reduce shift-related fatigue by using bright lights in the workplace, minimizing shift changes, and taking scheduled naps.

IkaN, goodjob!

Makes sense.

Is there any treatment for insomnia, if it's familial?

I don't think there is a treatment.. Since your thalamus is damaged, no pharmacotherapy can help you.
It's like in the thalamic pain syndrome, no amount of pain killers can help you!

So true! :(

Somogyi effect and dawn phenomenon in diabetes

So I read a lot of interesting things today and I'm formulating questions based on it.

A person took too much insulin at night and went to sleep. He checks his morning blood sugar levels and it's elevated. Why?

It's because stress hormones were released while he was asleep which caused the hyperglycemia. (This is called Somogyi effect!)

Now, a person took his appropriate dose of insulin at night and went to sleep. He checks his morning blood sugar levels and it's elevated. What happened this time?

There is a normal hormone surge at 7 am (Growth hormone, cortisol, glucagon and epinephrine) which caused the hyperglycaemia. This is called dawn phenomenon.

How will you differentiate Somogyi effect from dawn phenomenon? Why is this clinically relevant?

I guess the person with Somogyi effect will have certain signs and symptoms related to hypoglycemia. For instance, night terrors. Right?

People with hypoglycemia don't wake up but have nightmares.

The 3 am glucose levels to be precise. It is low in Somogyi effect and maybe normal or high in dawn phenomenon. You'll decrease NPH insulin at night in the former and increase the NPH insulin dose in the latter. 

NPH is an intermediate acting insulin. NPH insulin is usually taken at night. Duration of action 7- 14 hours!

In Somogyi, the excess insulin caused hyperglycemia. So you'll decrease the dose.
And similarly, in dawn phenomenon, the inadequate dosing caused the hyperglycaemia, so you'll increase NPH insulin.

If you're under the impression that is inadequate insulin and if you increase the dose of insulin, you can put the patient into a hypoglycemic coma! This is why, recognising Somogyi effect is very important.

I didn't get the management.. How is the adequacy of insulin assessed? If a patient comes with morning hyperglycemia, will you order 3 am glucose levels?

Nope. That would be hectic too. You wanna decrease the dose and see if the patient improves. If the patient doesn't, it means it wasn't the dreaded Somogyi effect and it was just the regular dawn phenomenon, so you can go ahead and increase the dose.

You keep tailoring the dose to suit the patient. 

Study group discussion: Some virology review questions

Hey everyone! I have a major virology exam coming up, would you like to go over some review questions with me? :)

Yes!!!

Great! I'll start:

Yaay!

Heterophile antibodies are positive in which viral infection?

These are multiple choice questions, shall I write the choices?

No, write them only when we can't guess it.

Ok :)

EBV?

Yes!

Which test is positive and is used to diagnose when there is an EBV infection?

Infectious mononucleosis.. Presence of human anti sheep antibodies, I think.

Yes! The test has a specific name though, anyone know it?

Umm.. Monospot test?

Coombs test ??

Neither of those

Would you like the choices?

Okay

Paul-Bunnel Test
Coombs Test
Indirect IFA
Western Blot
ELISA

Paul Bunnell! I forgot that.. Thanks!
Ok, ready for a new question?

Yes!

Which test is used to determine the specific genotype of HPV?
Another question would be, what is the first test you used to check for the existence of an HPV infection?

First test is Pap smear. Correct!

We'll need choices for the genotype - I'm guessing PCR though.

Ok here are the choices:
Consensus PCR
Line Probe Assay
Western Blot
Pap Smear
Latex aglutination

Consensus PCR?

No, I initially thought that too.

I'd say the line probe.

It is LiPA!

Why is that?

It uses the reverse hybridization to id specific  hpv genotypes by detection of specific sequences in the l1 region of the HPV genome.

It is more specific than the PCR

I see.

While we're on the topic of HPV, what are the high risk genotypes? And the most common low risk genotypes?

High risk: 16, 18
Low risk: 4, 6, 11

16 and 18 is usually used in the vaccine as well!

This changes a lot from place to place though, my medical faculty is working on developing a vaccine specially for this area/country

Oh that's great.. I didn't know that thanks.

:) no problem!

You guys want some more questions?

Yes

What is the main cause of non-bacterial gastroenteritis epidemics?

Rotavirus

That is one the choices here, but it's actually not that

Ooh. It's the main cause in India!

Choices?

Rotavirus
Norovirus
Adenovirus
Enterovirus
Astrovirus

Rotavirus usually infects infants and younger children, if I'm not mistaken.

Yup. So it's something else in adults?

Adults aren't really effected, the one we're looking for can infect people from different ages.

It's actually Norovirus!

It is the leading cause of viral gastroenteritis in the world!

Never heard of it :O
Is it the same as Norwalk virus?

Yes! Norwalk virus is a species of this genus. It's responsible for almost 90% of viral gastroenteritis epidemics globally!

Woah. That's a lot.

Norovirus happens in outbreaks, and stays infectious for a long time on surfaces yes?

Yes, exactly.

It's a calcivirus! http://medicowesome.blogspot.in/2014/04/how-i-remember-that-norwalk-virus-is.html

Family : Calcivirus, Genus: Norovirus :)

I'm going to have to leave soon, would you like 1 or 2 more questions?

Yes!

Which one of the viruses listed below, has a non-segmented genome?

Orthomyxovirus
Reovirus
Coronavirus
Arenavirus
Bunyavirus

Coronavirus?

Correct!

Review question: Does anyone know the clinical significance of the segmented genome?

A segmented genome has evolutionary advantages! Like, reassortment!

Allows reassortment and thus new viral strains in mixing vessels. Eg avian influenza.

What is the cause of Roseola?

Human herpes virus 6 or 7

Correct!

Brilliante!

One last question before I leave for now? :)

Yep yep yep

What is the most common cause of bronchiolitis in newborns?

Oh oh I know this.

RSV

Respiratory synctitial virus.

Correct :)

That was good, thanks!

I love random review question sessions!

Do it more often!

I have to go now, my friends are coming over to study! This was great, talk to you soon!

I have hundreds of review questions for my exam! Great! Looking forward to it.

This review question session was held by Fidan :) Thanks!

Study tips: Anxiety for test day

This is my first time talking to anyone I follow on anywhere... Be it twitter or tumblr. I am not very involved in social media, but I guess I am a bystander.

I am messaging you because I am in a bit of a dilemma. I am writing my USMLE step 1 exam in 5 days. I have been studying for it, believe it or not, for 2 years.

In this time, I have been home, my parents looking after me after I had gone to a med school on the island. I suffer from text anxiety... So like in the middle of the exam my brain just gives up, I feel at loss of hope. I just get this overwhelming feeling of failure.

I have bought the exam twice now and my date is scheduled for the last day possible. My parents are just fed up and they want me to get moving with my life. I have inconveninced them.

I have written all the NBMEs and I have never got a score above 300. I study so hard, but I hate to memorize if that makes sense. I have watched all the Kaplan videos, all the DIT videos and I have completed both Q banks. I know everything, but when it comes to route memorization... I can't do it for some reason, because I have this fear of it even is going to stick. I don't know what to do and I hoped some wise words from you might help me. You have some awesome things to say and they helped me lurch back up on a low day. I am literally trying to fly the coop right now.

Hope I am not intruding with my story.

- Email from an awesomite

Hey!

I'm glad you chose to speak to me.

The USMLE step 1 exam is scary. And it gets scarier as it gets closer. I had scheduled it on the last day too! My mum needed to go abroad and I had inconvenienced her. I never scored above 300 either in my NBME. But I got a good score on my step.

I'm telling you this to assure you that this is normal. That many have gone through the feelings you're going through and have made it before you. That you're not alone. That there is always hope.

You made it through various exams as you got here. Let's do this and get done with it. You have studied and you can trust yourself in midst of self doubt. You can do this.

You shouldn't be afraid of consequences. You've given your best shot. You have worked hard. Be confident that it'll work out for you in the best possible way.

Now this is a personal belief - I believe that not all five fingers are the same. Everyone is unique. That you have your own limitations and strengths. So some will score better than you, some won't. Accept it.

Once you have done your preparations well and that there is not one more thing you could've done, you must not worry about the results. Everything happens for the best. There's a good reason behind why things don't work out the way we want to - we don't see it right now but it doesn't mean it's not there. So I'm content with the results even before they come out.

I also believe that scores don't matter. That you can do wonderful things with your life without the scores. Yes, a good score will help you feel good about yourself and open doors - but a fear of a bad score shouldn't fill you with despair. The little anxiety you get should help you work hard, not come in your way.

I understand your memorization dilemma. Remembering things comes to us with repetition whether we like it or not.

There's not much you can do 5 days before the exam. But if there are certain high yield facts that you know you have not memorized - You can store facts in your short term memory and then forget them forever. We are capable of it. So you can't memorize everything, but please do what you can!

On the exam day: Focus on the question. Don't let your mind wander - go into past disappointments or future failures. Stay there. Read the question. What's the best answer to this question? Hmm.. This is an interesting one. What could the answer to this be? What are they trying to tell me in this question? Oh I don't know about this - will read about it later. The hints they're giving me are awesome. Ooh. This is a tricky one! I likey! I love medicine and it's enough. I'm living my passion. I'm lucky to be here. And that positivity, I tell you, will pull you through and give you hope.

I'm glad the things I said helped you. I hope this does too.

You're not intruding, be free to message me whenever you like (:

I understand that you might not get the time to reply after reading this - so I'll hear from you after the step. All the very best to you. I'll pray that you do well.

Love,
IkaN