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