Wednesday, June 9, 2021
IgG4-related systemic disease mnemonic
It is chronic disease characterized by fibrosis and sclerosis of various tissues due to infiltration with lymphocytes that secrete IgG4. Manifestations include sclerosing sialadenitis, retroperitoneal fibrosis, autoimmune pancreatitis, Riedel thyroiditis, tubulointerstitial nephritis, and other fibrosclerotic conditions.
That's all!
Thank you.
Sunday, June 6, 2021
Dengue classification
- Dengue from Harrison’s IM https://youtu.be/MYVxisW4EPw
WHO 1997 classification :
Dengue fever — >2 of the following
●Headache
●Retro-orbital or ocular pain
●Myalgia and/or bone pain
●Arthralgia
●Rash
●Hemorrhagic manifestations (eg, positive tourniquet test, petechiae, purpura/ecchymosis, epistaxis, gum bleeding, blood in emesis, urine, or stool, or vaginal bleeding)
●Leukopenia
Dengue hemorrhagic fever — The cardinal feature of DHF is plasma leakage due to increased vascular permeability as evidenced by hemoconcentration (≥20 percent rise in hematocrit above baseline). In the setting of DHF, the presence of intense abdominal pain, persistent vomiting, and marked restlessness or lethargy, especially coinciding with defervescence, should alert the clinician to possible impending DSS.
According to the guidelines, a DHF diagnosis requires all of the following be present:
●Fever or history of acute fever lasting 2 to 7 days, occasionally biphasic
●Hemorrhagic tendencies evidenced by at least one of the following:
•A positive tourniquet test – The tourniquet test is performed by inflating a blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressures for 5 minutes. A test is considered positive when 10 or more petechiae per 2.5 cm (1 inch) square are observed. The test may be negative or mildly positive during the phase of profound shock. It usually becomes positive, sometimes strongly positive, if the test is conducted after recovery from shock.
•Petechiae, ecchymoses, or purpura.
•Bleeding from the mucosa, gastrointestinal tract, injection sites, or other locations.
•Hematemesis or melena.
●Thrombocytopenia (100,000 cells per mm3 or less) – In healthy individuals, 4 to 10 platelets per oil-immersion field (100x; the average of the readings from 10 oil-immersion fields is recommended) indicates an adequate platelet count. An average of 3 platelets per oil-immersion field is considered low (ie, 100,000 per mm3).
●Evidence of plasma leakage due to increased vascular permeability manifested by at least one of the following:
•A rise in the hematocrit equal to or greater than 20 percent above average for age, sex, and population.
•A drop in the hematocrit following volume-replacement treatment equal to or greater than 20 percent of baseline.
•Signs of plasma leakage such as pleural effusion, ascites, and hypoproteinemia.
Dengue shock syndrome — DSS consists of DHF with marked plasma leakage that leads to circulatory collapse (shock) as evidenced by narrowing pulse pressure or hypotension.
●Rapid and weak pulse.
●Narrow pulse pressure ( ≤20 mmHg) or manifested by: observed early in the course of shock.
•Hypotension for age – observed later or in patients who experience severe bleeding.
Hypotension is defined to be a
- SBP 80 mmHg for those < 5 years of age
- SBP 90 mmHg for those equal to or > 5 years of age.
•Cold, clammy skin and restlessness.
WHO 2009 classification —
Dengue without warning signs —>2 of the following
●Nausea/vomiting
●Rash
●Headache, eye pain, muscle ache, or joint pain
●Leukopenia
●Positive tourniquet test
Dengue with warning signs — any of the following
●Abdominal pain or tenderness
●Persistent vomiting
●Clinical fluid accumulation (ascites, pleural effusion)
●Mucosal bleeding
●Lethargy or restlessness
●Hepatomegaly >2 cm
●Increase in hematocrit concurrent with rapid decrease in platelet count
Severe dengue —at least one of the following :
●Severe plasma leakage leading to:
•Shock
•Fluid accumulation with respiratory distress
●Severe bleeding
●Severe organ involvement:
•Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≥1000 units/L
•Impaired consciousness
•Organ failure
- Sudden high-grade fever (≥38.5°C) Children have high fever but are generally less symptomatic than adults during the febrile phase. The febrile phase lasts for three to seven days, after which most patients recover without complications.
- What is Biphasic fever ("saddleback") ? - 1st febrile phase remits & recurs approx 1 to 2 days later & this 2nd febrile phase lasts 1 to 2 days.
- Serum aspartate transaminase (AST) levels are frequently elevated; the elevations are usually modest (2 to 5 times the upper limit of normal values), but marked elevations (5 to 15 times the upper limit of normal) occasionally occur.
- Between days 3 and 7 of the illness, you must watch for signs of vascular leakage. Corresponding clinical manifestations may include persistent vomiting, increasingly severe abdominal pain, tender hepatomegaly, development of pleural effusions and/or ascites, mucosal bleeding, and lethargy or restlessness; laboratory findings may include a high or increasing hematocrit level (≥20 percent from baseline) concurrent with a rapid decrease in the platelet count
- The vast majority of DENV infections that progress to a critical phase result from secondary infections more than 18 months after the first infection.The critical phase lasts for 24 to 48 hours.
Wednesday, June 2, 2021
Study smarter not harder- Active recall, the foolproof method to ace any test
If I ask an average student about their preferred study strategy the answer most likely would be Highlighting, summarising, and re-reading. Making aesthetically pleasing notes in a myriad of colours may be appealing to many but is passively re-reading already familiar content an effective study strategy?
Two of the most effective study strategies I have come across are active recall and spaced repetition. In this post, I will be talking about the science behind this method. I’ll cover spaced repetition in another post.
Complete Androgen Insensitivity- A perfect female
Hello everyone!
In today's post I'll try to explain you what Complete Androgen Insensitivity Syndrome (CAIS) is.
Androgens are primarily male hormones required for a normal male development. But also, these androgens are secreted in females by their adrenal glands and have some role in female body development too, e.g Growth of pubic and axillary hair.
Now imagine, a very very beautiful adolescent girl, say around 16 years of age, comes to your clinic with a history of primary amenorrhoea. She has absolutely flawless skin (No acne like other 16yr olds), breast development normally, no pubic and axillary hair and on further examination, some inguinal mass, maybe a hernia.
You ask the radiologist for an USG abdomen and pelvis. Don't be surprised to find testes as the hernia content and no uterus!!
This is a classic case of CAIS.
Karyotype analysis- 46XY
Inheritance- XL recessive, mutation in the AR (Androgen Receptor) gene
Genitalia- Female with blind vaginal pouch
Wolffian duct- Often present
Mullerian Duct- Absent
Gonads- Testes
Hormone Profile- Increased LH and Testosterone (But the receptors have resistance to it's action)
Increased Estradiol, FSH slightly raised.
For more pictographic representation, Watch HOUSE MD S02E13 "Skin deep"
That's it!
Happy Studying
Stay awesome!
Dr. ShilPill
Tuesday, June 1, 2021
How to write a Personal Statement for Residency
How to write a Personal Statement for
residency
How to begin
- Daily
start writing down ideas in Evernote/any app which lets you take notes
- Think
of a strong patient interaction/personal story where you helped the
patient and which also shows your medicine-related skills/knowledge/work
ethic. Make it about yourself, what you did, and how it helped you. Do not
write the entire history of the patient.
- Either
with the same story as above or explain the reason/reasons why you are
interested in that particular field.
- Make a list of your hobbies/ non-medical experiences and find a common
connection between that skill set, which can actually help you during
residency.
- Read loads of sample personal statements from google!!!
- Do
not copy them (plagiarism is HARMFUL).
- Once you are done, send your draft to mentors/English professors/seniors etc.
- Make sure there are absolutely no grammatical errors. (English being a 2nd
language is not an excuse for poor grammar).
Don’t’s
•
This is not the time to show off your creative
writing skills. We are applying for a residency, not a literature graduate
position. Keep it simple and easy to read.
•
Do not use super-long sentences. IMGs have a
tendency of using a lot of ‘and’ and writing 3-4 line long sentences. Keep it
short.
•
Target content that fits into one page. 600-700
words approx. Don’t go over 800, don’t stay under 500.
•
Do not use negative incidents/ bad mouth your
home school or resources.
•
Don’t lie. You will get caught. If you say you
have worked on multiple research projects and if you are unable to answer basic
questions regarding your research, you WON’T be selected.
•
You never know how much importance programs give
to the PS, so always make sure it is a well-written PS.
•
Don’t quote your CV.
•
Don’t use clichés or common quotes.
•
Don’t start every sentence with “I.”
•
Come across as arrogant. This is the place to
showcase your strengths, but in a humble way.
How to
divide paragraphs: 1st paragraph
•
The first and last paragraphs are the most
commonly read parts. Make them interesting and strong. It should be
personalized.
•
Begin strong: Story/Hobby/What got you into
medical school or you can skip that and talk about what got you interested in
your specialty.
•
It should be a story about yourself and how it relates to your specialty, not just a history
of the patient you saw.
DON’T’s
·
“Every patient has a story to tell.”
·
Some major illness in the family/ death
motivated me to become a physician.
·
“I love to travel. Each journey takes us down a
different path. Each journey inspired a new thought. I feel medicine is similar
to traveling. Every patient has his own journey and I want to be there to make
it fruitful for them.” (This is not the right analogy. Travel and medicine have
nothing in common)
·
“I will never forget ___”
·
“I grew up with dermatology in my blood”
DO’s
·
“Growing up in rural ____, I experienced ____.
Here I realized _____. The strict value system of perseverance and dedication
led me to ____.”
·
Start with your hobby.
E.g. Football….team sport….captain of the football team….motivated my team,
resolved conflicts. At the same time I realized, that whenever someone got
hurt, I would assist my coach with first aid. I realized that my inclination
for helping my injured team mates extended beyond the football field. Bridge it
into medical school and how you continued doing the same. Got you interested in
EM/ortho etc.
·
“Medicine is a field in which my love for
pathophysiology and my commitment to serving others can continue to grow. I
have a strong desire to use my problem-solving abilities while helping people
through their most difficult times.” And then give an example justifying these 2
statements.
How to
divide paragraphs: 2nd, 3rd and 4th paragraphs
•
Talk about your strengths in a very SUBTLE way,
citing examples.
•
Talk about your achievements and extra
curriculars, your motivation and end it with what skill-set you derived from
it.
•
Include hobbies. Connect them with medicine and
how it will make you a better resident.
•
Relate how your actions and experiences during
medical school will make you a strong physician.
•
What will you bring to their program?
•
Don’t quote your CV.
•
Show who you are as a person, not just as an
ideal medical student.
•
Talk about your strengths in a very SUBTLE way,
citing examples.
•
Talk about your achievements and extra
curriculars, your motivation and end it with what skill-set you derived from
it.
•
Include hobbies. Connect them with medicine and
how it will make you a better resident.
•
Relate how your actions and experiences during
medical school will make you a strong physician.
•
What will you bring to their program?
•
Don’t quote your CV.
•
Show who you are as a person, not just as an
ideal medical student.
·
I love IM as it is such a broad field with a vast number of diseases.
(Same goes for FM and Peds and all other branches. Avoid such blanket
statements.)
·
I want to be trained to manage patients on my own and do right by them to be one of the best in my field.
(Umm…isn’t this what residency is about. Everyone wants that. What is it that
you are specifically looking for?)
·
Also, avoid “I love” “I want to”
·
“IM combines the wide spectrum of exotic and
the mundane illness, providing a scope of touching maximum lives.”
Do you mean to say FM/EM/ortho/surgery etc. do not provide this?
·
“My mentor taught me more about medicine and how
to approach a patient better than I had learned in all of my classes.”
Do not put your other classes in a negative light.
How to
divide paragraphs: last paragraph
•
Summerise.
•
Tie in all your major attributes.
•
Talk about: What you are looking for in a
program
•
Talk about: Where do you see yourself in a few
years?
•
I will bring to residency energy, enthusiasm,
integrity, and ability. I expect a challenging, rich environment in which to
learn and practice good medicine.
•
I know I have set high goals for myself:
clinician, educator, and health advocate. The majority of the time I find
working with underserved populations extremely rewarding; however, it can also
be emotionally demanding.
•
The combination of working at an individual
level to address health needs and at a more macroscopic level to affect health
policy is synergistic for me.
•
I eagerly await the unique privilege of
participating in such a rewarding and exciting field of patient care.
•
Don’t be too specific regarding fellowship goals
unless you are absolutely sure.
•
If you are sure regarding your fellowship, your
CV should have enough experience to back it up.
•
“Medicine encompasses numerous areas that I have
always found intriguing. Becoming a physician is a lifelong dream that will
fulfill both my personal and career goals.”
What are the goals? State them. What are the intriguing areas? It is a vague
sentence. Avoid fluff.
•
“My career goal is to enter a university-based
anesthesiology program.”
Then community programs (forming a major chunk of interviews for IMGs, will not
call you for an interview. Be diplomatic.
Time
Frame
•
June 2nd half: Start compiling the
ideas and sentences into paragraphs. Check the flow. Keep reading samples to
understand how to write it.
•
July 1st half: Make your 1st
draft. Send it to seniors/attendings/mentors.
•
July 2nd half: Incorporate the
changes suggested by them and make another draft.
•
Aug 1st half: Send it out for
suggestions again.
•
Aug 2nd half: Make a final draft.
Here your ideas, stories, hobbies, major points should be finalized and free-flowing. Now run a final grammar check. Send it to someone with professional
level English for edits and grammar.
•
Sept 1st week: Final draft ready
Take
away
•
Personal Statements might not fetch you
interviews unless it is extra-ordinary. You will get interviews based on your
scores and other aspects of the application.
•
You may lose out on an interview due to a bad PS.
(Incorrect grammar, poorly written)
•
Interviewers love to talk about the hobbies
mentioned in the personal statement, so make sure they are real!!
•
They are looking to know you as a person, so
make sure your PS does not describe 1000s of other medical students as well.
•
Once you land an interview, the PS might play a
role in getting you ranked high. The program wants a candidate that would
‘Match’ their expectations!
Cluster Headache
Is the cluster headache giving you a headache?
Here's an easy way to remember it.
C-Conjunctival congestion
L-Lacrimation
U-Unilateral
S-same time, periodicity
T-Tearing of conjunctiva
E-Excess autonomic activity
R-Rhinorrhoea
These clinical features help us to differentiate cluster headache from other types of unilateral headaches.
Treatment includes
1. 100% Oxygen at 10-12L/min for 15-20 mins
2.Sumitriptan 6mg S/c
3. Sumitriptan 20mg and Zolmitriptan 5mg nasal spray
Remember ORAL SUMITRIPTAN DOES NOT WORK!!
That's it folks!
Happy studying!
Dr. ShilPill
Saturday, May 29, 2021
The Happy face
Hi everyone!
Lets talk about a 2 year old girl with a h/o seizure disorder who presents to your clinic for the first time for routine care. Past medical records shows that the patient is on anti-seizure medication since the last year. There is no family history of seizures. Parents report poor feeding and sleep disturbances. The girl appears to be very happy, laughing all the time for no reason. On examination, her head circumference is in the 10th percentile and is noted to have hand flapping behavior. She has not met the expected milestones for her age. What is the diagnosis?
???
ANGELMAN SYNDROME
Fun fact: Angelman Syndrome was previously known as "Happy Puppet Syndrome"😄
- Padma Sri Katikaneni
Psychogenic non epileptic seizure (PNES)
PNES characteristics :
- No loss of consciousness or postictal period
Comorbidities
- Psychiatric conditions (depression, anxiety)
- Physical/sexual abuse
- Epilepsy
Friday, May 28, 2021
Red blood cell transfusion thresholds mnemonic
Hello everyone! Just look here..
What does it mean ? SHOAN …?Subarachnoid haemorrhage
Clinically important steps required for SAH management ( from its onset )
- Most commonly due to ruptured saccular (berry) aneurysm
- Severe & sudden onset of headache different from previous headache pattern or described as "worst headache of my life"
- Nausea, vomiting, brief loss of consciousness, focal neurologic deficits, or meningismus
- Noncontrast head CT >90% sensitive within 2-6 hr of SAH onset
- Lumbar puncture required to exclude SAH definitively in patients with negative CT scan of the head
- Xanthochromia confirms diagnosis (usually >6 hr from SAH onset)
- Cerebral angiography to identify bleeding source
A cardiologist and infectious disease specialist discuss their favorite statin
Biophysical Profile Mnemonic
Biophysical Profile |
“ The value of experience is not in seeing much, but in seeing wisely”. - William Osler
Thank you! 🩺