medicowesome

Evaluating axis from ECG (Mnemonic)

Hi everyone! We are going to learn how to determine the axis from an electrocardiogram =D

First of all, do you know which two leads should be looked at to determine whether axis is in the normal quadrant or if it is Left Axis Deviation (LAD) or Right Axis Deviation (RAD)?

Look at lead I and lead II. Sounds simple! ^__^

An upright (positive) QRS in leads I and II is normal (–30 degrees to +105 degrees).
In left-axis deviation, there is an upright QRS in lead I and a downward (negative) QRS in lead II ( +105 degrees).

How do I remember this? @_@

Thumbs up method: Lead I = Left thumb, Lead II = Right thumb.

Wait, why lead I is left thumb and lead II is the right thumb?
Because left is a smaller word and it gets the smaller number, that is, one!
Right has more alphabets and it gets the bigger number, that is, two.

Left thumb up (I) + Right thumb up (II) = Normal.
Left thumb up (I) + Right thumb down (II) = LAD.
Left thumb down (I) + Right thumb up (II) = RAD.

Mnemonic method:
Left leaves, right returns.

That’s all!
Have a splendid week everyone

To remember about SVT, all you need to remember is the cause and you know the symptoms and treatment!

SVT occurs due to accessory conduction pathway through the AV node.

A - ABCD

Adenosine

Beta blockers

Calcium channel blockers

Digoxin

V - Vagal maneuvers

Valsalva

Ice immersion

Carotid massage

SVT: Start Vagal Treatment - - > If fails, use pharmacotherapy (ABCD drugs)

The P in Pvst reminds us that it presents with Palpitations in a hemodynamically stable patient (HR: 160-180/min)

*PVST: Paroxysmal supraventricular tachycardia

Interesting fact: In an asthmatic patient with SVT, you can’t give adenosine or beta blockers. The drug of choice in an asthmatic patient is therefore, diltiazem (A calcium channel blocker)

That’s all!

-IkaN

Autonomic system drugs mnemonic

Please give some tips on remembering cholinergic and adrenergic drugs.

Drugs ending in

- ine are beta agonists
(Terbutaline, ritrodine)

-sin are alpha blockers
(Prazosin, terazosin)

- olol are beta blockers
(Propanolol, metoprolol)

- alol are alpha + beta blockers (Labetalol)

- stigmine are cholinergic drugs
(Neostigmine, physiostigmine)

Age of completion of ossification mnemonic
Hello!
For those who forget the age at which ossification centres close, this post is for you!
Imagine the baby in a fetal position, the joints facing upwards are 18,the ones facing downwards are 16:
Elbow = 16
Pelvis = 16
Ankle = 16Shoulder = 18
Knee = 18
Wrist = 18
This diagram gives the approximate ages when the epiphyses close.

Tricyclic antidepressants (TCAs) - MOA and side effects

Hello!
This is a fun and concise post on the pharmacology of TCAs. Excited? :D

Cellular effect: Presynaptic serotonin and norepinephrine reuptake inhibition
Clinical consequence: Antidepressant and anxiolytic effects
Extra obvious side note: It is the mechanism of action (MOA)! :D

Cellular effect: Peripheral and central muscarinic acetylcholine receptor antagonism
Clinical consequence: Blurred vision, dry mouth (causes dental caries), urinary retention, constipation
Extra fact: Elderly patients are particularly susceptible to these adverse effects.

Cellular effect: Peripheral alpha adrenergic receptor antagonism
Clinical consequence: Orthostatic hypotension
Extra fact: It is the most common cause of discontinuing TCAs.

Cellular effect: Cardiac fast sodium channels blockade (Like Class IA anti-arrhythmic)
Clinical consequence: Decrease cardiac conduction (causes heart block)
Extra fact: Sodium bicarbonate therapy is indicated in patients with TCA poisoning who develop widening of the QRS interval >100 msec or a ventricular arrhythmia. Sodium bicarbonate increases the extracellular sodium concentration increases the electrochemical gradient across cardiac cell membranes, potentially attenuating the TCA-induced blockade of rapid sodium channels. It also increases serum pH and favors the neutral (ie, non-ionized) form of the drug, making it less available to bind to sodium channels.
Alkalinization of urine to eliminate TCAs is NOT the reason why sodium bicarbonate is used for cardiac toxicity.

Cellular effect: CNS GABA-A receptor antagonism
Clinical consequence: Seizures
Extra: It is therefore logical to treat TCA-induced seizures with GABA agonists such as benzodiazepines such as diazepam rather than sodium channel blocking drugs.

Cellular effect: Histaminic (H1) receptor antagonism
Clinical consequence: Sedation, increased appetite (causes weight gain), confusion, delirium
Extra fact: The sedative properties are sometimes harnessed for patients with insomnia, but more benign options are available.

That’s all!
-IkaN

Tips on how to find vein or phlebotomy

Study: Know your anatomy, so if you can’t see or feel the veins, you still know where to go.

Just the anatomy of where the veins are. Sometimes you can’t see them (old people, people with dark skin) and you can’t really feel them. I’ve done some blind insertions before successfully.

Dont panic: Initially, you will find it hard, but do not get embarrassed if you miss.

Tourniquet: Tying a torniquet often helps by making the vein more swollen and prominent.

In our hospital, the patient’s relative is asked to hold with the fingers tightly around the arm instead of using torniquets.

Alternate tournique: A lil piece of the tubing (the transparent plastic tubing thats a part of the drip set)

I’ve seen people tying a glove round the arm when they don’t have a tourniquet.

Someone asked me why else is the tourniquet used.
I think the second use is stabilizing the vein by stretching the skin and underlying tissues away from the venipuncture site. If you have ever done blood collection from an elderly patient, you must know how hard it is! The lax skin makes it really difficult. So tourniquets are used in elderly even if the vein is visible just to taut the skin.

“Lift the tied tourniquet and stretch the skin and underlying tissues away from the venipuncture site. Then gently lower the tourniquet. You may be able to retract several inches of skin and tissue away from the site with this maneuver. which is especially helpful with elderly patients) who have less collagen, prolastn and elastin than younger patients) and patients who have lost a lot of weight recently.”

How else can you make the vein prominent?

Taping  the vein you’re going to prick a few times would make it more prominent.

Don’t use a bigger needle than you have to.

Look for prick marks where people have gone before.

PS: The most important thing is your safety. Never ever put the cap of the syringe first when covering it.
Because even the finest tremors can be dangerous. Slide the needle in the cap while the cap is on the table / bed whatever.

Practice: A lot.

Good luck.

Authors' diary: Medicowesome secret project

Medicowesome is working on a top secret project, details of which are highly confidential xD

We want to collaborate with different awesomites all over the globe to create something… Different.

If you are willing to give an hour (Or less) to participate in the Medicowesome secret project, all you got to do is message me these details -

Name or pen name: Which will be published on Medicowesome.

Passion apart from Medicine: Photography, painting, football, calligraphy, crochet, poetry, video games, cooking… Anything really!

And I will send you the details of a unique secret project that you can work on :D

You can email (medicowesome@gmail.com) , facebook, tweet or tumblr message. If you have my Whatsapp number, you can text me directly.

Let’s see how this goes :)

-IkaN

Heart murmurs mnemonic

Hello people with a pumping heart in their chests, obviously! <3
In this post, I’ll be taking about the few mnemonics I use in relationship to murmurs.

PASS” is a good mnemonic for remembering that pulmonic and aortic stenosis give a systolic murmur.

The opposite of PASS, ie, other two valves and the other defect gives a systolic murmur too. (Mitral and tricuspid regurgitation gives a systolic murmur!)

VSD has a S so that’s systolic.

Now, the other ones - pulmonic and aortic regurgitation, mitral and tricuspid stenosis will cause diastolic murmurs :)

Here’s another mnemonic submitted by one of the readers:
For the systolic murmurs: MR. P.V. TRAPSS (Mister Per Vaginum traps? :P)
MR. P. - Mitral Regurgitation or Prolapse
V. - VSD
TR - tricuspid regurg
APS - Aortic or Pulmonary Stenosis
S - Systolic

For the diastolic murmurs: MS. PAID
MS - Mitral Stenosis
PAI - Pulmonary or Aortic Insufficiency
D - Diastolic

Here are a few more lame mnemonics I made when I was in final year! =)
I remember GDP or Gross Domestic PRoduct.
Graham Steel murmur is a Diastolic murmur associated with Pulmonary Regurgitation.
Alternatively you can remember, Graham SED PR (Graham said per rectum? xD)
For Graham Steel, Early Diastolic, Pulmonary Regurgitation.

Carrey Coombs murmur is seen in rheumatic carditis.
RCCC (Renal cell carcinoma) is diagnosed by MD and MS”, is my mnemonic.
Rheumatic carditis, Carrey Coombs, Mid diastolic, Mitral Stenosis.

Austin flint murmur is seen in aortic regurgitation.
AFAR MD” helps me remember Austin Flint, aortic regurgitation and Mid Diastolic.

I am actually not a fan of using mnemonics for concepts like murmurs. But once, I was asked to name systolic murmurs in a viva. And you know how vivas are, if you don’t answer quickly, another question is thrown at you. Luckily, I remembered this mnemonic that day and could answer quickly. That’s when I realized, it’s okay (It’s awesome, actually!) to understand all the murmur mechanisms properly when you have time to imagine at home and it’s definitely okay to use mnemonics cheaply when you don’t have time to think, that is, in time bound exams.

That’s all!

Lub dub goes my heart…

-IkaN

Hi!

In this post, we learn a mnemonic that tells us all about the inhibitors of the ETS!

The mnemonic is, “CRAP Tightens Muscle AND Produces Muscle ACHe”

Complex I inhibitors mnemonic

C - Chlorpromazine
R - Rotenone
A - Amobarbital
P - Piercidin A

Complex II inhibitors mnemonic

Tightens - Thenoyltrifluoroaceteate
Muscle - Malonate

Complex III inhibitors mnemonic

A - Antimycin A
N - Naphthoquinone
D - Dimercaprol
Produces - Phenformin
Muscle - Myxothiazole

Complex IV inhibitors mnemonic

A - Azide
C - Carbon monoxide (CO), Cyanide (CN-)
H - Hydrogen sulphide (H2S)

That’s all!

-IkaN

Which cell secretes what? Gastrointestinal mnemonics

“pH” for Parietal cells secrete H+ ions.

“PC” for Pepsin is secreted by Chief cells.
(Alternate mnemonic: I think of master chef making food rich in proteins, peptides being degraded by pepsin and that’s how I remember the association that Chief cells secrete Pepsin).

G for G cells & G for Gastrin. (Hah! That was easy!)

S for S cells & S for Secretin! (Medicine is easy!)

You’ve probably heard of the iPhone.. Heard of iCDs? Coz they’re gonna help you remember the rest of the cells secretions- I cells secrete CCK. Delta cells secrete somatostatin. Go ICDS!

That’s all! <3
Wait.. Which cell secretes intrinsic factor? Do you know the IP address of that cell? IP.. Yes, yes. Parietal cells! Intrinsic factor - Parietal cells!

Conn’s syndrome mnemonic

Hi. I keep forgetting that Conn’s syndrome is hyperaldosteronism. Can you help me out with this?

Sure! :D

The N’s are for sodium - Hypernatremia!

The C makes a K for potassium, which is less than the number of N’s, therefore, hypokalemia!

Also, Na+ is sodium. A could remind you of Aldosterone.
AL could remind you of ALkalosis.

That’s all!

-IkaN

Preparing for the USMLE Step 1 exam

“How do I prepare for the USMLE Step 1 exam?” -The most requested post ever!

The essentials - Kaplan videos & notes (for basics) + Goljan book & audio + uWorld + First Aid is the general way to go for most IMG students.

Kaplan videos and notes: They are a good start. If you are time restricted, you may want to skip stuff, fast forward through it.

Pathology: Do Goljan and Pathoma. Know them cold. I had studied Goljan really well. I wish I had the time to complete Pathoma as well. The videos and concepts are awesome.

uWorld: Do it really well the first time. You are gonna get bored doing it the second time so get the concepts in the first go. Take your time if you have to.

While doing it the first time, the 2 blocks per day and 20 days scheme didn’t work for me. I got frustrated with the time constraints I had put on myself. The best I could do was 1 block per day. So give yourself 45 days, just in case you are slow with uWorld like me.

I did it in random just because I assumed studying subject-wise would get too monotonous. Subject-wise goes faster. I did it timed. You may do it untimed, tutorial, subject-wise. It doesn’t matter. Do what you are comfortable with.

First Aid: It’s your quick review book. Write uWorld notes all over it. Make it messy, draw diagrams on it. It’s the only book that’s gonna stick with you till the end of time.

NBMEs: Give as many as you can. But do them only for feedback, not for learning.

Other stuff you can do -

BRS behavioural science: I highly recommend it. You can easily do important chapters like stuff on defense mechanisms even 20 days before the exam. There are good quality, minimal in number, doable questions at the end of every chapter.

Be flexible: If you find yourself weak in any random subject, quickly Google for good sources and review the doable ones. People advice not to look into new resources a few days prior to the exam but that’s bull. Your old sources are obviously did not help you and that’s the reason you are weak in the subject… Look for new ones! I did BRS behavioural science 20 days before my step and it is one of the best decisions that I made. I tried ANKI flashcards for brain stem sections a week before. As long as you keep a balance, new resources won’t hurt you.

Flashcards: Download or make your own flashcards. It helps you revise frequently.

Other Qbanks: Yes, I had done bits of Kaplan Qbank and USMLE Rx. I had time when I started them, they helped me get what the questions are like and I did make a few notes. They did freak me out (since I got most of the questions wrong) and hence, helped me study more early in my preps. But they are not essential if you are out of time.

Doctors In Training: It’s very boring. But the worksheets do help you memorize and revise. I don’t recommend it, but I did review some of it once upon a time.

Random advice -

Be attentive during rounds: Because the USMLE will have questions on clinical stuff. If you have done your core rotations, it’s not an issue. But if you are in your basic sciences years, the only way you can get these right is by being attentive in rounds. There are very simple common clinical questions like urge incontinence on Step 1 which are not covered in First Aid. You can easily get them right. Read x-rays, especially the fracture ones.

Don’t forget to revise Kaplan and Goljan: Read a little bit of Kaplan and lots of Goljan even in your busy 2 block per day + First Aid schedule. The bain of knowledge is to forget.

Revise as much as you can before the exam: I remember antidepressants and antipsychotics being a bit foggy in my head during the step. I should have revised properly and in a more organized way before the exam.

Solving questions: The questions are scary. I made a lot of silly mistakes during the preps. I agree that the margin for error is small. You miss one word and the question goes wrong. The exam seems hard before you take it and easy after you’re done with it. Keep going. All you can do is give your best :)

Don’t delay dates too much: I delayed my exam for a month. I gave an NBME on the previous exam date. The NBME score and the test score came out to be the same. Life! xD

Social isolation: It’s normal. Friends will demand to see you, even after you’ve explained how important and hard this exam is. You will feel bad for not meeting them and have mood swings, it is okay. Don’t let it consume you. Focus. You may completely ignore the existence of any other species on the planet, it’s allowed. The good ones will stick with you anyway.

That’s all! 

Feel free to ask any questions.

-IkaN

Berksonian bias, Pygmalion effect and Hawthorne effect mnemonic

Hey everyone!
Because the names are so hard to remember, I make silly associations out of them and I hope it helps you all too =)

Berksonian bias: Selection bias that arises from evaluating data on biased patients and hospital records only.

When it comes to Berksonian bias I think of Preston Berke from Grey’s anatomy and I know that it’s associated with the hospital and patients!

Pygmalion effect: The observer-expectancy effect is a form of reactivity in which a researcher’s cognitive bias causes them to unconsciously influence the participants of an experiment.

Researchers are pigs. They think their research is always right. Pygmalion effect! xD 

Hawthorne effect: When behavior of the subjects of the study change because they know they’re being observed.

Haww I am being studied. Hawthorne effect!

That’s all!

Pray that I do well in my exams.

-IkaN

Greeting everyone! =)

SERMs are Selective estrogen receptor modulators.
They have varied effects on estrogen receptors in different tissues and it might get confusing (especially, effects of different drugs on the endometrium!) Mnemonic to the rescue! ^__^

Tamoxifen and Raloxifene are used in breast cancer as they are antagonist of estrogen at the level of breast.

Tamoxifen and Raloxifene, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis. (Partial agonist at bone!) Tamoxifen causes endometrial changes, including polyp formation, hyperplasia, and frank invasive carcinoma. (Remember: T is symbolic for +ve at endometrium.)

Raloxifene reduces the risk of uterine cancer. (Remember: R is symbolic for -ve at endometrium.)

That’s all!
Hope it helps. Lemme know if you have any mnemonics on SERMs.
Also, pray that I do well in my exams =)
-IkaN
Breath sounds mnemonic

Breath sounds!

Vesicular sounds:
Inspiration is longer than expiration. No pause in between.
They are normal.
Mnemonic:
VE is short. (Expiration is short)
VesI is long. (Inspiration is long)

Bronchial breath sounds:
Inspiration and expiration occupy the same duration of time and are separated by a pause.
Heard in: Consolidation or a large cavity.
Mnemonic:
B for Bronchial, B for Both are equal.

Broncho-vesicular sounds:
Both are equal with a pause.
Heard in: Bronchial asthma, Emphysema.
Mnemonic:
The B for Both are equal. The hyphen reminds me of the pause.

That’s all!
Everything is awesome :D
-IkaN

Antifungal drugs (with mechanism of action) mnemonic

Hola! Me again!

Drugs and their mechanisms can be difficult to remember.. I like pairing the action with the drug name to make it easy. We are doing anti-fungals today (Yaay!)

Mr. Ampho tears holes in the fungal membrane. Mister rhymes with Nyster and it reminds me of Nystatin. Ampho is Amphotericin.

The word “Squatter” reminds me that Squalene epoxidase is inhibited by terbinafine.

“Azole pazole” sounds so funny! *giggles*

Anyway, P450 inhibited by Azole. Hope pazole works for you as well =D

Casper the friendly ghost”

Caspofungin the friendly glycan inhibitor xP

Griseofulvin is greasy. And if you put grease on tubules, they won’t move!

Griseofulvin inhibits the formation of the microtubule.

That’s all! Pray for me =)

-IkaN