Sunday, January 20, 2019
Wednesday, January 16, 2019
Submission: Thyroid Acropachy
Let's go through quick review regarding Thyroid Acropachy!
1)It is an uncommon finding of Graves disease.
2)It is a triad of clubbing+swelling of soft tissue of digits + periosteal reaction of extremity bones.
3)It is usually associated with Thyroid Ophthalmopathy and Dermopathy.
X ray findings-Hands and feet involvement,soft tissue swelling, fluffy, asymmetric periosteal reaction
Skin biopsy- Fibroblast activation and GAG deposition.
Differentials:
1)Pulmonary Osteoarthropathy-.
2)Symmetric periosteal reaction -can involve long bones of forearms and legs
Treatment-
No Specific treatment available, Treatment directed at associated Ophthalmopathy and Dermopathy using Local corticosteroids and systemic immunosuppressive therapy.
By Parneet kaur
Tuesday, January 15, 2019
Cyanide poisoning
PATHOPHYSIOLOGY:
TREATMENT:
Early morning workout and weight loss.
To reduce weight, early morning exercise is recommended but question is why?
Let's get back to basics before answering this question.
Body has three sources of blood glucose to maintain level uniformly.
1) Food.
2) Liver Glycogen.
3) Gluconeogenesis.
Now, Liver Glycogen can provide energy for around 12-18 hours. Gluconeogenesis uses lots of energy to maintain blood glucose level. Between dinner and breakfast we have gap of around 12 hours. This mean before taking breakfast liver glycogen stock is null! And body is using now gluconeogenesis to maintain blood glucose level and as you know it's going to take hell lots of ATPs to maintain it. Also, exercise uses lots of energy. Hence both in turn helps in reducing body weight.
What is wrong with evening workout?
Suppose a person has taken lunch around 2 pm and he's working out around 5-6 pm. Which stores will be used by body to maintain glucose level - food obviously! Hardly any Liver glycogen is used up. Also extra food will be stored.
That's all!
-Demotional bloke
Wednesday, January 9, 2019
Friday, January 4, 2019
USMLE Step 3 CCS sheet guide
So I recently took my USMLE Step 3 and I gathered some of this from various resources. I think this may be of some help to the beginners.
Let's get started!
In relevant emergency cases (order the ones that are relevant):
ABC:
Airway
Breathing
Circulation
P.O. ICESS:
Pulse oximetry
Oxygen
Intravenous line and fluids (Please remember to type NSS/Normal Saline or Dextrose, etc. CCS software won't take orders that are less than 3 characters!)
Cardiac monitor
ECG
Sugar (fingerstick)
Suction
For chest pain add MONA:
Morphine
Oxygen
Nitrates
Aspirin
~~~
Then order relevant Physical Exam (In Office cases, you'd want to order most physical exams and in the Emergency Department cases, you'd want to order more symptom-based system specific exam)
~~~
Laboratory orders: CBC LFT ICU PAX
Complete Blood Count (CBC), ESR
Basic Metabolic Profile (BMP)
Cardiac enzymes (if not ordered earlier)
Liver Function Tests (LFT) or Lipid profile
FOBT
TFT
Imaging (CT/MRI/USG/etc) Iron profile Immunologic tests (HIV/HepB/HepC/Rubella/etc)
Cultures (Blood/urine/fluid/etc)
Urine (routine, microscopy, culture & sensitivity)
Pregnancy test (urine) & Pap test (if female) PT/INR PTT d-Dimer PFT
Amylase ABG
Xray
~~~
You can now forward the time to get some results or decide whether the location needs to be changed
~~~
CCC
Comfort: if the patient is in pain- give NSAIDs/Morphine based on the situation; vomiting- antiemetic; etc
Cure: if you suspect a particular infection-give antibiotic; if it's an MI- angiography v/s other management options; etc
Consult: you may want to order a Psych or Surgery or OBGYN or any other relevant consult based on the case
~~~
If the patient needs to get admitted on floors or ICU: ADIC
Activity: Bed rest/ ambulation
Diet
Input/output charting
Compression stockings
Stay awesome :)
Thursday, January 3, 2019
Lifestyle modifications for managing hypertension
Happy New Year!
Let's get started on lifestyle modifications for treating or managing hypertension.
We Decide to Eat less Salt & drink less Alcohol!
Weight loss: Reduce BMI to <25
DASH: Diet high in fruits and vegetables and low in saturated fat and total fat
Exercise: 30minutes/day for 5-6 days/week
Dietary Sodium: <3 g/day
Alcohol: 2 drinks/day in men and 1 drink/day in women
The effect of these interventions is in descending order, with weight loss having an impact of about 5-20 mmHg lowering per 10 kg weight loss and reducing alcohol intake can lower BP by 2-4 mmHg!
Remember: If a patient's BMI is already lower than 25, you don't have to ask them to reduce weight any further for this therapeutic effect. Instead, you ask them to switch over to DASH diet!
Hope this is helpful!
Stay awesome!
-Rippie
Wednesday, January 2, 2019
In short: Vasopressin in the ICU
Hello!
Here are some quick points + mnemonics on Vasopressin!
1. Effects are preserved during hypoxia and severe acidosis and catecholamine-resistant states.
Mnemonic: Vasopressin presses when other pressors can't press the vasculature anymore.
2. Vasopressin decreases norepinephrine requirement.
3. Onset: fast, offset: fast.
Mnemonic: VasopressIN is IN and OUT fast.
4. It is often weaned off last in patients on multiple pressors for the same reason.
5. Used in:
- Refractory hypotension (potentiates the actions of over vasoconstrictors)
- Esophageal variceal bleed
- Cardiac arrest
Non ICU indications: vWD, DI, hemophilia
That's all!
-IkaN
Tuesday, January 1, 2019
In short: Dexmedetomidine and bradycardia
Dexmedetomidine (Precedex) is notorious for causing bradycardia. Another sedative associated with bradycardia is propofol.
That's all!
Will update this post at a later date. What you can do if you are free: Read up on it, write a small post on it and email it to us so we can post it and learn from you :)
-IkaN
Authors diary: In short
I am planning to write short one line posts on things that I learn in the everyday.
Pediatrics residency series: 1. Intro
Residency is time-consuming as you know. It’s been a long time since I last posted but I came back to tell you that I will be starting a new series on “Pediatrics Residency”. Useful apps, cases and other things will be discussed.
Stay tuned :)
-Murad
Sunday, December 30, 2018
Hair tansplant or follicular transplant
This is going to be fun. :D
Q. A male diagnosed with AGA (Androgenetic alopecia) came to me with grade 3 alopecia. Asking me that he is frustrated from taking medication and heard of hair transplant surgery. What advice would you give him?
A.I have seen lot of misconception regarding this concept. Hair transplant doesn't mean actual hair. We take follicle from occiput. Why? Because it is not responsive to androgen as there is no Androgen receptor.
Hair transplant is for already bald area. Androgen receptor blockade is given for remaining vellus hair. So that means hair transplantation surgery is not substitute for minoxidil/finasteride. For grade 3 AGA alopecia patient can undergo hair transplantation for bald area but have to take medication for remaining vellus hairs.
This is for AGA alopecia. Scarring alopecia won't show good response with hair transplantation surgery as much as AGA alopecia,
Q. AGA is genetic alopecia. So why don't it appear at birth itself?
A. At birth, androgen receptor is present but insensitive. When genetic component become active, the receptor become sensitive and balding occur.
Have a great day ahead.
Upasana Y. :)
Warfarin: a procoagulant or anticoagulant?
No doubt ! Warfarin is an oral anticoagulant.
Confused? Don't be. :D
Warfarin inhibits reduction of Vitamin K to its active form and leads to depletion of the vitamin K-dependent clotting factors II,VII,IX and X, and protein C,S and Z.
Because of the rapid depletion of the anti-coagulant Protein C and a slower depletion of factor II, patients might develop increased hypercoagulability during the first few days of warfarin therapy. So warfarin is combined with a parenteral initially. Treatment of DVT/PE with warfarin requires overlap therapy/bridging therapy with a parenteral anticoagulant (UFH,LMWH, or pentasaccharide) for atleast 4-5 days and until the INR reaches atleast 2.0.
The starting dose of warfarin depends on many factors. During warfarin therapy INR monitoring should occur frequently during the first month of warfarin therapy (e.g.twice weekly for 1-2 weeks, then weekly for 2 weeks, then less frequently).
Have a great day ahead.
Upasana Y. :)
ARNI
I have something with weird titles. :D
ARNI stands for Angiotensin receptor-neprilysin inhibitor.
This is combination of ARB Valsartan and neprilysin inhibitor Sacubitril recently approved for use in patients with HFrEF and NYHA Class II-IV symptoms.
NEPRILYSIN:- It is a neutral endopeptidase involved in the degradation of vasoactive peptides including natriuretic peptides, bradykinin, adrenomedullin. Inhibition of neprilysin increased the availability of these peptides, which exert favorable effects in HF.
Effects of Natriuretic peptides are-
1.Vasodilation
2.Lower blood pressure
3.Reduced sympathetic tone
4.Reduced aldosterone levels
5.Natriuresis/Diuresis
In a large trial, this agent was shown to be superior to enalapril in reducing death and rehospitalization among NYHA class II-IV patients with HFrEF.
Have a great day ahead.
Upasana Y. :)
Thursday, December 27, 2018
Vestibulo ocular reflex
Circuit:
1)It starts in the vestibular system, where semicircular canals get activated by head rotation and send their impulses via the vestibular nerve and end in the vestibular nuclei in the brainstem.In addition the hair cells of opposite ear are inhibited because endolymph in that ear flows away from hair cells.2)From these nuclei, fibers cross to the contralateral cranial nerve VI nucleus.
3a)There they synapse with 2 additional pathways. One pathway projects directly to the lateral rectus of the eye via the abducens nerve.
b) Another nerve tract projects from the abducens nucleus by the medial longitudinal fasciculus to the contralateral oculomotor nucleus, which contains motorneurons specifically activating the medial rectus muscle of the eye through the oculomotor nerve.
4)For instance, if the head is turned clockwise, then excitatory impulses are sent from the semicircular canal on the right side via the vestibular nerve to the right vestibular nuclei in the brainstem. From this nuclei excitatory fibres cross to the left abducens nucleus.There they project and stimulate the lateral rectus of the left eye via the abducens nerve. In addition, by the right medial longitudinal fasciculus, fibers cross and go to right oculomotor nuclei, they activate the medial rectus muscles on the right eye. As a result, both eyes will turn counter-clockwise.
-Srikar Sama
Monday, December 17, 2018
Basics of Fat necrosis.
Hello, let's dissect fat necrosis in this post.
Fat necrosis is seen where fat concentration is more or lipase concentration is more.
Example- Injury to Breast or Omentum tissue or in Acute pancreatitis with gall stones or alcohol intake.
Alcohol intake leads to activation of lipase enzyme. This lipase enzyme converts lipids to fatty acids. Always remember fatty acids loves calcium! This love affair leads to formation of "Fatty acids - Calcium complex formation". This is called as "Saponification".
This gives yellow - white chalk like color. This helps surgeon to identify fat necrosis.
For prognosis we use serum calcium level. Why?
Suppose there is severe pancreatitis. This leads to more activation of the lipase enzyme. This leads to formation of the fatty acids. More fatty acids, more saponification. Hence less calcium level in serum!
Low calcium level suggest bad prognosis!
Chediak Higashi syndrome.
Hello! This is Ultra short post regarding Chediak higashi syndrome! Hope you like it.
In normal person, when bacteria is engulfed by WBCs, they are carried to lysosome enzyme by LYST protein.
LYST protein stand for Lysosomal transfer protein.
Defect in LYST protein causes Chediak Higashi syndrome. It is autosomal recessive disorder.
No LYST protein so no phagocytosis of macrophages. Hence recurrent infections.
Clinical features:
1) Recurrent infections.
2) Absence of Melanin - Albinism.
LYST also helps in transfer of melanin to superficial layer of skin
3) Decrease in Myelin formation - Delayed conduction.
4) Hemorrhage.
LYST helps in maturation of megakaryocytes to platelets.
Confirmation: Incomplete digestion of bacteria leads to formation of "Giant granules inside cell"
Mnemonic:
CHEDIAK
C- CNS involvement
HE- Hemorrhage
DI- Decrease immunity
A-Albinism
That's it!
-Demotional bloke.
Friday, December 14, 2018
Horner Syndrome
NEUROANATOMY - Horner syndrome can result from a lesion anywhere along a three-neuron sympathetic pathway that originates in the hypothalamus:
●The first-order neuron descends caudally from the hypothalamus to the first synapse, which is located in the cervical spinal cord (levels C8-T2, also called ciliospinal center of Budge).
●The second-order neuron travels from the sympathetic trunk over the lung apex. It then ascends to the superior cervical ganglion, located near the bifurcation of the common carotid artery.
●The third-order neuron from superior cervical ganglia then ascends within the adventitia of the internal carotid artery, through the cavernous sinus. In the orbit and the eye, the oculosympathetic fibers innervate the iris dilator muscle as well as Müller's muscle, a small smooth muscle in the eyelids responsible for a minor portion of the upper lid elevation and lower lid retraction.
The most common causes are:
(a)occlusion of PICA, which produces Horner syndrome as part of the Wallenberg syndrome.
(b)Brown-Séquard syndrome above T1, patient may present with ipsilateral Horner syndrome due to damage of oculosympathetic pathway.
Second-order syndrome — Second-order or preganglionic Horner syndromes can occur with trauma or surgery involving the spinal cord, thoracic outlet, or lung apex.Other causes include pancoast tumor involving the lung apex.
Third-order syndrome — Third-order Horner syndromes often indicate lesions of the internal carotid artery such as an arterial dissection, thrombosis, or cavernous sinus aneurysm
CLINICAL FEATURES -The classic signs of a Horner syndrome are ptosis, miosis, and anhidrosis.
1)The ptosis occurs as a result of paralysis of the Müller's muscle.
2)The degree of anisocoria is more marked in the dark than in light.
3)Anhidrosis is present in central or preganglionic (first- or second-order) lesions because the sympathetic fibers responsible for facial sweating branch off at the superior cervical ganglion along the external carotid artery and its branches.
4)Horner syndrome is also a common feature of cluster headache.
Wednesday, December 12, 2018
True or False #10
Hallux valgus is also known as bunion. T or F
T
●Hallux valgus (HV) deformity (ie, bunion) is a common, potentially debilitating deformity consisting of lateral deviation of the hallux on the first metatarsal . The etiology is unknown. The deformity is more common among women and shod populations.
●Although HV is easily recognized by clinical examination, radiographs may be necessary to determine the presence of articular damage . Neither radiographic nor clinical appearance provides the basis for surgical referral, which is determined by patient pain and disability.
●There is little evidence that conservative treatments are useful in the treatment of HV. Nevertheless, we suggest patients without debilitating symptoms avail themselves of conservative therapies before being referred for surgery.
Possible treatments include:
•Shoe modification: wide, low-heeled shoes, or specially altered shoes with increased medial pocket for first metatarsophalangeal (MTP) joint to minimize deforming forces
•Orthoses to improve support and alignment
•Night splinting to improve toe alignment
•Stretching and/ormobilization/manipulation to maintain joint mobility
•Medial bunion pads to prevent irritation
•Ice applied after activity to reduce inflammation
•Analgesics: acetaminophen or NSAIDs
●We suggest that patients with severe pain or dysfunction and those whose symptoms do not improve under a conservative treatment regimen be referred for surgical repair.
Approximately 150 surgical procedures for the correction of HV deformity have been described. Few prospective, randomized trials evaluating these procedures have been performed. Patients should be referred to a foot surgery specialist with experience repairing HV deformity.
●Managing patient expectations about surgery is important. Patients should understand that 10 to 25 degrees of valgus angulation is normal at the MTP joint, and that resolution of postoperative pain and swelling may require several months. Most patients will remain unable to fit into narrower shoes.
Do not forget to look up pictures of how a bunion looks.
Over and out.
Monday, December 10, 2018
Atropine poisoning
Atropine poisoning is also called as Anti-muscarinic poisoning.
It is caused due to ingestion of :-
1) Datura plant
2) Atropa belladona
3) Hyoscyamus
4) Anti-histamine drugs
5) Anti-psychotic drugs
6) Anti-depressants like TCA
7) Anti-Parkinsonism
Clinical features:
Let's go from head to toe!
1) Brain:
Atropine causes following symptoms
-Hallucinations
-Confusion
-Delirium
Also called as Mad as hatters!
Remember: Atropine drives you crazy!
2) Eyes:
AcH causes constriction of pupils. No or less AcH causes Mydriasis
Fun fact 1: In ancient times, women used to apply Atropa belladona in eye for attracting men by dilating pupil.
Fun fact 2: Most of the dinner dates are candle night dinner, why? To dilate pupils and look attractive.
Also described as "Blind as a bat"
Remember: Atropine makes you look seductive!
3) Eyes and Mouth:-
AcH is responsible for secretion of saliva and tears.
Lack of AcH action causes - Dry mouth and Dry eyes.
Also described as "Dry as a bone"
Most common feature in Adults.
Remember: Atropine Dries you!
4) Face:
AcH causes constriction of blood vessels. Atropine blocks this action and hence causes dilation of the blood vessel. Hence this causes flushing of face.
Also described as - Red as a beet.
Remember: Atropine makes you blush!
5) Body temperature:
AcH is responsible for secretion of the glands. Lack of secretion causes decrease or no cooling effect. Hence it causes-Hyperthermia.
Also described as - Hot as a hare
Most common feature in children.
Remember: Atropine makes you hot!
Most common cause of death is Respiratory paralysis.
Next common is Shock.
I remember all this feature with the help of story:
I went on a candle night dinner with hot girl. Ofcourse, she was blushing because I'm crazy to have dry resins after dinner! (Okay that's lame and I know!)
Key points:-
Candle night dinner - Mydriasis
Hot-Hyperthermia
Blushing-Flushing of face
Crazy-Deliruim, Hallucination and confusion
Dry resins-Dry secretion
Treatment:
1) Supportive treatment:
Gastric lavage using Tannic acid : To remove unabsorbed poison. Avoid potassium permagnate.
Forced acidic diuresis: Because Atropine is an alkaline drug
Seizures are treated by Diazepam
Patient is kept in dark quiet room-To avoid hallucination.
Ice bags given to treat maintain temperature.
2) Antidote: Physostigmine since it crosses BBB.
That's it
-Demotional bloke.
Thursday, December 6, 2018
Wiskott-Aldrich syndrome
2)All hematopoietic cells produce WASp protein, and there is WIPF1 that encodes WASp-interacting protein (WIP), a protein that stabilizes WASp. Both of these proteins are required to reorganize cell's cytoskeleton.
3)Its absence impairs the:
(a)Formation of the immunologic synapse, the site of interaction between T cells and antigen-presenting cells leading to immunodeficiency.
(b)NK cell function is impaired as a result of defective immune synapse formation on the cell surface which leads to increase risk of malignancy.
(c)Regulatory T cells are incapable of controlling autoimmunity, so there is increased risk of Autoimmune disease.
(d)Myeloid lineage cells exhibit impaired phagocytosis and chemotaxis - susceptible to recurrent pyogenic infections.
(e)Impaired cytoskeleton in megakaryocytes → Decrease in size and number of platelets →microthrombocytopenia.
4)Clinical manifestations :
(a)Bleeding-microthrombocytopenia.
(b)Recurrent pyogenic infections.
(c)Eczema
(d)Increase in risk of autoimmune diseases and malignancy.
5)Laboratory findings :
(a)low to normal IgG and IgM and high IgA and IgE.
(b)Peripheral smear-Thrombocytopenia with small platelets.
Mnemonic: Remember the movie Antman and thewasp :p. So WASP helps you remember,
(1)WASp mutation (2)wasp is a small bee like insect🐝→small platelets and if wasp bites, you get eczema(↑IgE).
SOURCE-UpToDate.
-Srikar Sama.