Medicowesome

Tuesday, April 14, 2015

We have 100 members in all 3 groups so we made group 4 :D

I can no longer keep up with the discussions (Internship is draining me T_T)

For this reason, all Whatsapp chats will not be published on the blog, only some :)

Thanks for the tumblr fanmail (:

-IkaN

Saturday, April 11, 2015

Study group discussion: Diabetes and ACE inhibitors

Question: Which of the following drug is best for reducing proteinuria in a diabetic patient?
A. Metoprolol
B. Perindopril
C. Chlorthiazide
D. Clonidine

Study group discussion: Dirty mnemonics

*During a random discussion on Krebs*

There's a mnemonic for the entire sequence in Krebs! It's kinda inappropriate.

Study group discussion: Clinical tips for pediatric rotations

So I'm just going to start with my paediatrics posting and I really really wanna be a paediatrician. Could anyone share any tips on how to be a good paediatrician?

Spend time in clinic/wards..
take histories. Try to make differential diagnosis yourself and discuss it with your teachers..

Yaah..and examine as many kids as you can.

Take a lot of toys / chocolates with you to keep the child busy when you examine.
I used to gift my patients toys and they'd smile so huge! One kid, even though seemed uneducated, told me a thank you! :D

The parents seem really tense, it's a sick child after all. You wanna be very gentle with them and talk cuddly. If you treat the kid more as a patient and less like a child, they are more likely to get pissed.

Good tips, IkaN!

Oh and when you present the case to the attending and the patient's parents are around, don't start with, "Patient, Jane Doe, 2m old female.."
Say, "Child, Jane Doe.."
No one would like their child to be addressed as a patient.

IkaN *thumbs up*
My peds HOD won't let us examine children, if we don't bring candies for them :)

My peads attending said to my friend after a viva, "What did you bring for the kid?"
My friend had not got anything so the ma'am said jokingly, "Nothing for the kid? Okay then, no marks for you!" :P

Awesome tips for peds, IkaN!
They'll be super helpful even during volunteering.

Omg. So you can give them chocolates?

I guess you can give chocolates.. Unless they are lactose intolerant / allergic.
Toys are better, I guess. They keep kids busy for hours!
Give them under parental supervision just to be safe xD

How do you get kids to let you auscultate them? They cry and then you can't hear anything

That's a two people job then, one of you has to distract the baby while the other one auscultates!

And try warming the diaphragm of your stetho a little, the kid probably also cries because it's cold.

Worst case, ask the mother to feed/play with the child.

Distract it, that normally does the trick. Carry a small torch and distract it with the light, it's a trick that usually works.

Study group discussion: Headache in brain tumor

Why do people with brain tumor get headache in the morning?

Intracranial pressure increases in the brain after laying flat all night.

Why does it increase?

How to remember the side effect of quietapine is cataract

How to remember the atypical antipsychotic that causes cataract
If your lens shine,
you may have been taking quietapine.

Lens shining = Cataract

Study group discussion: Pathological basis of drugs used in the treatment of Alzheimers disease

Discussion on drugs for Alzheimer's.

What is the basic pathology in Alzheimers disease?

Amyloid deposition in the Ach neurons. Hence, decrease acetylcholine in the brain.

Amyloid precusor proteins in the circulation are acted upon by two enzymes -
Alpha secretase: Which forms soluble proteins. These are good.
Beta gamma secretase: Which forms insoluble proteins. These are bad.

These insoluble proteins polymerise to form the plaque. So these insoluble plaque get preferentially deposited in Ach neurons and cause a foreign body reaction.. Leading to inflammation and death of neurons. Hence Alzheimers.

How alpha secretase is good?

Cause it cause soluble products.. These can be washed out by blood. The insoluble ones will precipitate.

There are 5 classes of drugs.. Guess their mechanism based on the pathology discussion!

First class: AchE inhibitors. How do they help?

They will inhibit break down of Ach.. Indirectly, increasing their levels.
Donepezil, Rivastigmine and Galantamine are examples.
They are lipid soluble and cross the blood brain barrier easily. They are also called centrally acting anticholinesterase.

Interesting fact: Nicotine acts both presynaptic and post synaptically to release Ach hence smoking is thought to be protective against AD. However, one of the hypothesis for AD is free radical damage, which can be caused by smoking.

Second class: A drug which will increase activity of alpha secretase.

The name for this drug is deprenyl.

Third class: A drug that inhibits beta secretase.

Beta- gamma secretase has got an inhibitor called tarenflurbil.

Fourth class: These are primary drugs. Inhibit polymerization.

Drug named Tramiprostate

Fifth class: This one removes the pre formed polymers.

Bapineuzumab is the drug.

I love the way you explain things. Starting right from basics!

Extras -

Glutamate antagonists - Memantine. How would antagonism of glutamate help?

Block glutamate excitotoxicity.

Tuesday, April 7, 2015

Study group discussion: Infantile hernia

Can anyone mention something about infantile hernia?

The pathology or the physiological hernia that is normal?

Both!

Alright, there are a couple of hernias related to infants that I know about.

One of them is the physiological hernia, which is a thing that happens to all babies during fetal period. So it's normal.
The intestines herniate out of the body of the fetus and rotate 90 degrees at week 6 of development. Then at week 10 they rotate a further 180 degrees and come back into the body. This is the phenomenon that forms the spiral-like location of intestines.

Now there are two pathologies.

One is the Ompholocele, where the intestines fail to come back at week 10.

The other is Gastroschisis where the physiological hernia happens normally but the abdominal wall fails to close so the gastrointestinal system protrudes directly into the amniotic cavity.

Thanks for explaining! Here's a study link!
http://medicowesome.blogspot.ae/2014/09/gastroschisis-vs-omphalocele-mnemonic.html

Study group discussion: Side effects of cyclophosphamide

Side effect of cyclophosphamide?

Bladder carcinoma is the commonest one!!

It can also lead to Haemorrhagic cystitis!

Maximum cyclophosphamide can be given for 18 months.. After that it has to be replaced with Methotrexate or azathioprine..

May cause infertility in male patients who received high doses as children.

Okay.. Didn't know that.. Thanks

Risk of potentially fatal and irreversible interstitial pulmonary fibrosis if given over prolonged periods.

Study group discussion: Pseudoganglion

Which nerves have a pseudoganglion?

Nerve to teres minor!

Correct.

Others are lateral terminal branch of deep peroneal nerve and posterior interosseous.

But why name pseudoganglion..??

Pseudo ganglion is only a nerve thickening resembling the presence of a ganglion.

Ohh.

Study group discussion: Differentials of epistaxis

What could be the possible cause of a sudden episode of nose bleeding in a patient who has a history of open heart surgery?

It could be because of anticoagulation. Hypertension is also a cause.

Since we are on this topic, any one would like to go over the differentials of epistaxis?

Excessive scratching of nasal area
Anticoagulation meds or any coagulation disorder
Traumatic
Leukemia
ITP
Problems in liver
Rhinosporidiosis
Polyps
Foreign bodies

Study group discussion: REM Sleep Behavior Disorder and Parkinson's disease

I just studied that fatal familial insomnia is a prion disease.

We had a discussion on fatal familial insomnia before!

Fatal familial insomnia, harmful effects of working at night and sleeping during the day http://medicowesome.blogspot.com/2015/02/study-group-discussion-fatal-familial.html

Oh, I shall have a look over that discussion!

So basically it's thalamus that is missing :)

What is the centre for REM sleep in particular that is affected in idiopathic Parkinson's? I can't remember that center! It's important because in idiopathic Parkinson's disease, earliest symptom REM sleep behavior disorder.

Umm.. I can't remember that! Is it the one which regulates the circadian rhythm?

I found an interesting read on Parkinson's, rem in Harrison. I'll post it here!

REM Sleep Behavior Disorder RBD is a rare condition that is distinct from other parasomnias in that it occurs during REM sleep. It primarily afflicts men of middle age or older, many of whom have a history of prior neurologic disease.

Infact, over one-third of patients will go on to develop Parkinson's disease within 10 to 20 years.

Presenting symptoms consist of agitated or violent behavior during sleep, reported by a bedpartner. In contrast to typical somnambulism, injury to patient or bed partner is not uncommon, and, upon awakening, the patient reports vivid, often unpleasant, dream imagery.

The principal differential diagnosis is that of nocturnal seizures, which can be excluded with polysomnography. In RBD, seizure activity is absent on the EEG, and disinhibition of the usual motor atonia is observed in the EMG during REM sleep, at times associated with complex motor behaviors.

The Pathogenesis is unclear, but damage to brainstem areas mediating descending motor inhibition during REM sleep may be responsible. In support of this hypothesis are the remarkable similarities between RBD and the sleep of animals with bilateral lesions of the pontine tegmentum in areas controlling REM sleep motor inhibition.

Treatment with clonazepam (0.5 to 1.0 mgqhs) provides sustained improvement in almost all reported cases.

So it's the brainstem! :D

Yep!

Study group discussion: How to determine which hemisphere is dominant

Why do we ask about handedness in CNS case?

Dominant hemisphere and handedness http://medicowesome.blogspot.in/2014/12/dominant-hemisphere-and-handedness.html

Yup but in both LEFT is only dominant.. Then why bother asking?

There are exceptions where right hemisphere is dominant. Only 85% population has left dominant. 15% has right dominant.

I had seen a case in which the right hemisphere was dominant, in a right handed person!

How did you know she was right dominant?

We asked her to write, comb hair, thread needle - She was right handed.

She was right handed I agree ...
But how to know her right side is dominant?

She was right handed through history and examination.
Had UMN type of hemiparesis on the left side, clinically (Right hemisphere affected)
She also had difficulty in comprehension and speech, clinically (Brocas area affected)
So Brocas is usually on the left side, the dominant, that is.
But in this case, since the right hemisphere was affected, her Brocas was on the right side.

Our professors said shift of hemisphere can occur in childhood injury. Which could be a reason.. But there was no history suggestive of such insult in our case.

If broca is not affected.. We cant comment on right or left dominance?

I guess. No idea.

Study group discussion: Alcoholic liver disease, hepatic encephalopathy and stigmata

What is fetor hepaticus?

The characteristic odor in hepatic encephalopathy.

Mechanism?

Caused by volatile aromatic substances that accumulate in the blood and urine due to defective hepatic metabolism Also called as "liver breath"

Study group discussion: Fluoride bulb and glycolysis

Best agent to be added into blood sample that has to be transported for glucose estimation?

Fluoride!

It prevents glycolysis.

How does it prevents glycolysis?

Inhibits the enzyme enolase

Yeah, correct!

Why do we use fluoride bulb for glucose estimation?
Fluoride inhibits glycolysis. So the glucose in RBCs don't get metabolized and you won't get a false lower value of glucose (:

This is the note I took on fluoride! Apparently when coupled with Mg it ihhibits enolase.. So it stops glycolysis.

Study group discussion: Physics in Medicine

*I was announcing the pre med group when this discussion took place*

We just created a premeds group for physics, chemistry and biology discussions. Message me if you wanna join in!

Yup. Cause those physics laws always get applied in case of resistance in vessels and especially in lung volume and pressure curves.

They do! I remember studying vectors for understanding ECG in first year!

Speaking of physics, can anyone name the mechanics behind the law applicable in Aortic aneurysms that lead to rupture?

Physics never leaves us!

Okay, I dint know this! :(

It says as the diameter increases, tension on the vessel wall increases. The aneurysm keeps expanding, leading to rupture of the aneurysm.

Laplace law.

Yep.

Laplace's law states that tension on the wall of a container is directly proportional to the pressure inside it and also to the radius of the container. It's inversely proportional to wall thickness. Which explains the more bigger the aneurysm, the more susceptibility to rupture.

It's the same concept in Surfactant!

Really?

If the surface tension is not kept low when the alveoli become smaller during expiration, they collapse in accordance with the law of Laplace. In spherical structures like the alveoli, the distending pressure equals two times the tension divided by the radius (P = 2T/r); if T is not reduced as r is reduced, the tension overcomes the distending pressure.

What is Pouiselle's law?

Pouiselle's law states about the relationship between velocity of fluids, viscosity and the pressure in a capillary.

So physics is really important in Medicine!!! I haven't seen anything of physics yet!

It's just a matter of time! :D

I am waiting anxiously!

Study group discussion: Polymyalgia rheumatica and polymyositis

Question: Which inflammatory condition is associated with temporal arteritis?

Answer: Polymyalgia rheumatica!

Question: A patient comes with pain and weakness in the proximal muscles with not much of stiffness! What would it be? Polymyositis or PR?

Answer: Polymyositis.

Stiffness is a present in both but more of a feature of PR.

Pain in proximal muscles along with stiffness is PR, there will be no weakness of muscles in PR.

On the other hand, in case of Polymyositis, there is weakness of the muscles that is the main difference!

There might be little tenderness in this case.. But whether weakness is present or not that differentiates the two!

Rest we can further elaborate based on the enzymes!

So to summarize:
Muscle weakness is more of feature of polymyositis.
Stiffness, pain goes with Polymyalgia rheumatica.

Question: Which enzymes will be raised in PM?

Answer:
Creatine kinase.
Aldolase.

Question: What would be elevated in PR?

Answer: ESR.

Question: How does one differentiate between PM and DM?

Answer: In dermatomyositis, you will be see above symptoms plus skin manifestations - Gottron papules, Heliotrope rash, Shawl sign.

Question: What is the most common serious complication of PM/DM?

Answer: Malignancy!

Which malignancy?

Ovaries are most common. Others are cervix, breast, lungs, pancreas.
Testing for malignancy which CA is helpful?

CA-125 - That's for ovarian cancer.
19-9 for pancreas!

Study group discussion: Oxytocin

Question: Why does oxytocin cause volume overload?

Answer: It is similar to vasopressin in structure.

Vasopressin and oxytocin are similar in structure. So vasopressin is ADH. It retains water. Which will cause Intravascular volume expansion

There are a lot of compounds which have a similar structure and interesting clinical effects. Here are a few http://medicowesome.blogspot.in/2014/11/hormones-that-have-similar-structure.html

Doubt: Several pharmacology books said that oxytocin may cause hypertension. But Williams obstetrics says that it will cause serious hypotension if given as undiluted iv bolus. I'm confused.

Answer:
Bolus causes hypotension.
Normal infusion causes fluid retention.
Although unlike ergonovine, oxytocin does not produce hypertension.

So don't give bolus is the moral of the story. It can cause Placental hypoperfusion.

Question: How does it cause Placental hypoperfusion?

Answer: If your blood pressure drops, blood supply to all organs will be compromised. Comprehende?
Think of placenta as an organ. So Placental hypoperfusion!

Doubt: Does anyone know why iv bolus of oxytoxin will have adverse effect of hypotension and tachycardia?

Answer: In high doses... Oxytocin has vasodilator action which produces hypotension and reflex tachycardia.

From what I read, oxytocin decreases venous return and systemic vascular resistance. So that'll cause a compensatory tachycardia.

Source: http://www.ncbi.nlm.nih.gov/pubmed/18513945

Sunday, April 5, 2015

Study group discussion: Hutchinson's in medicine

Hutchinson's triad:
Seen in congenital syphilis. Includes -
1) Interstitial keratitis
2) Hutchinson's teeth (which are notched incisors)
3) Vestibular deafness

Hutchinson's Sign: Seen in Herpes Zoster Ophthalmicus.. Which says if the nose is involved, then the eyes have to be involved too.. Since they both are supplied by the Nasocilliary nerve.

Hutchinson's Pupil:
Seen in concussion injuries to brain (usually associated with the subdural hemorrhage).
The ipsilateral pupil is initially miotic... Then it becomes myriadtic due to raised IOP... Then as the IOP further increases, the contralateral pupil also dilates... So we have bilateral dilated pupils not reacting to light. This is an indication for immediate cerebral decompression.

Hutchinson's mask:
A sensation often associated with tabes dorsalis in which the face feels as if it is covered with a mask or cobwebs.

Hutchinson's facies:
The peculiar facial expression produced by the
drooping eyelids and motionless eyes in external
ophthalmoplegia.

Study group discussion: Facies in medicine

Mitral facies - Malar erythema.

Hippocratic facies - Acute peritonitis.

Typhoid facies - Severe malaria.

Adenoid facies - Adenoids.

Chipmunk facies - Malar prominence, in Thalassemia.

Hepatic facies - liver failure.

Leonine facies - coarse features, leprosy.

Facies leprosa - Falling of teeth and nasal bridge depression in leprosy.

Mask face - Parkinsonism.

Cushing's face - Moon like round.

Hutchinson's facies - The peculiar facial expression produced by the
drooping eyelids and motionless eyes in external ophthalmoplegia.

Study group discussion: Anti-epileptic drugs

Carbemazepine is contraindicated in which type of seizure?

During pregnancy, eclampsia and absence seizures.

Which anti eplielptic drug is contraindicated in pregnancy?

All of them.

Which antiepileptics can be used in pregnancy?

Sodium valproate, lamotrigine and lavatriacetram are safe in pregnancy.

Pregnant lady with epilepsy well controlled on sodium valproate wants to get pregnant. What will you do?

You do not switch the drug. Valproate has a dose dependent side effect on the fetus. You will try tapering down the dose. The main word is well controlled.

If while tapering the dose, she starts having seizures you switch to a safer drug.

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