One liners for "MEDICINE" by Dr. Marwah [Crucial for NEET PG, FMGE & INI-CET]

Summary

Dr. Marwah provides crucial insights and strategies for the NEET PG, FMGE, and INI-CET exams, focusing on key areas of medicine. The video spans various medical topics from CSF analysis to differentiating between respiratory conditions and applying mathematical formulas like Winter's formula for metabolic disorders. Specific attention is given to interpreting ABG reports accurately, managing metabolic acidosis, respiratory alkalosis, and handling emergencies such as cardiac arrest. The session is designed to be a rapid revision tool, emphasizing the importance of understanding underlying pathophysiologies and their clinical applications.

Highlights

• Dr. Marwah breaks down ABG interpretations with precision. 🔍
• Learn to distinguish between metabolic acidosis and respiratory alkalosis. 🩹
• Vital revision of CSF analysis and fluid management. 🧠
• Practical insights into cardiac emergencies and their management. ❤️
• Interactive, engaging teaching style that simplifies complex concepts. 🎓

Key Takeaways

• Brush up on ABG analysis skills – it's a game-changer for diagnostics! 🧪
• Remember the key differences between metabolic and respiratory disorders. ⚕️
• Mastering CSF and fluid analysis can make or break your exam. 💦
• Keep the pace up; this is a rapid-fire revision session! ⚡
• Don't forget the basics: always check for compensatory mechanisms. 🩺

Overview

In his engaging session, Dr. Marwah delves into the intricacies of medical diagnostics crucial for the NEET PG, FMGE, and INI-CET. He emphasizes the importance of accurate ABG analysis, helping students differentiate between metabolic and respiratory disorders effectively. His rapid delivery keeps students on their toes, ensuring they grasp each concept thoroughly.

Dr. Marwah's ability to simplify complex topics like metabolic acidosis and respiratory conditions is extraordinary. He uses real-life scenarios to demonstrate the application of theoretical knowledge, providing students with practical solutions to exam questions. The session acts as a high-speed revision of essential medical concepts.

Key areas covered include CSF analysis for identifying types of meningitis, fluid management in emergencies, and the application of Winter's Formula in metabolic cases. Dr. Marwah's lively presentation style ensures that students remain engaged and absorb the information efficiently, setting them up for success in their exams.

One liners for "MEDICINE" by Dr. Marwah [Crucial for NEET PG, FMGE & INI-CET] Transcription

• 00:00 - 00:30 thank you [Music]
• 00:30 - 01:00 thank you okay hi guys how very good evening to everybody and uh we can get started for today uh I missed out a couple of names uh okay uh I think it's another 48 hours
• 01:00 - 01:30 less than 48 hours left and then you guys are gonna be free and you can imagine uh I mean 48 hours from now when you are gonna be you know smiling saying okay great I'll make it rapid guys I'll make it rapid and let's not waste time uh let's start with the first question for today uh yep Sweet Child of Mine great guys I'll not be able to call out names today because I think we should try and save time so I'm really I apologize if
• 01:30 - 02:00 I'm not taking your names but uh a very good evening to all of you and um let's let's uh bring it on right uh in the very first question uh this talks about a patient hopefully dog hopefully we have this patient who's having a gradual onset motor paralysis with us Foster City and uh I have a doctor I'll try to take about 100 minutes or so or lesser than that okay uh sir sometimes the video resolution can be an issue uh let's
• 02:00 - 02:30 let's wait for your answers there I I'm having a patient who's having a pure motor paralysis with spasticity and this is a question which is a repeat one and I have deliberately slightly modified the options if you look at emitrophic lateral sclerosis it should be having combination of lower motor neuron findings as well as upper motor neuron findings uh guys as far as I'll just zoom it into the screen a metaphic lateral sclerosis there should be a combination of both upper motor and
• 02:30 - 03:00 lower motor neuron of findings um screen is I think fine uh I'll move on Yep this is a repeat question uh the actual question in the exam in the previous years was he had mentioned a farmer he had also mentioned that this is a farmer from uh ESS doctor it's a pyq uh the question in the exam was it is a farmer from chhattisgarh and he is presented with pure water paralysis with spasticity now I had to make it a little shorter you know kind of one liner so that is why I I did remove that
• 03:00 - 03:30 statement uh that it is a farmer uh and uh I mean chattisgarh thing uh the point is why answer is metaphic lateral sclerosis is that there should be features of lower mutant neuron Legion given in a question which is not here I mean had this question said about a reflex Etc then I would have thought and why it is not Guillain Barre Syndrome because syndrome will be having classical features a lower motor neuron lesion in the form of a reflexia fasciculations uh this would be boa toxin exactly right so the correct
• 03:30 - 04:00 answer to the first question is letharism and yes I think Dr amulya and subsequent people have got this this one correct doctor I'll try to wind off in 100 minutes odd uh so please cooperate and uh what I what I expect out of you is quick answers there uh for those of you who have joined in I'll repeat the main fact again why this is not ALS is because you should be having a combination of lower motor and upper motor neuron lesion which is not present in this case I mean there is no information given for lower motor vehicle which is why option A can also
• 04:00 - 04:30 be ruled out and that is why the correct answer here is litherism and I've already sensitized you to the fact that this actual question pyq mentioned farmer from chhattisgarh so it had a a bit of a PSM overlap we move on to the second question uh this says a patient is having a short history fever for one day and CSF analysis was uh the main objective of the examiner there was a CSF lymphocytosis with a normal sugar and an increased protein now uh yep I'm having two answers in this case tubercular meningitis and viral
• 04:30 - 05:00 meningitis the point against tubercular manager this is normal sugar in the patient so please remember that I agree to the fact that in an Indian exam the first thought process of yours every time you get a CSF lymphocytosis is going to be tubercular but for tubercular you need a long history you need you know a patient to be sick for at least you know 15-20 days in a sense that mother will initially say that my child was not eating food then she says that you know he started vomiting then she says that he's not opening his eyes then she's saying he's not even
• 05:00 - 05:30 recognizing me or where he at least opened his eyes looked at the mother now he's not even recognizing the mother so they would be gradual answered manifestations developing in the patient along with features of race ICP and amidst a CSF cytology will obviously matter so uh yes in this particular case because the CSF sugar is normal this is the reason why the answer to this pyq would be viral meningitis but let's look at the third question which was I think a repeat one and they gave an image this was last time where a cobweb coagulant could be seen and in this case you can
• 05:30 - 06:00 see that even in the CSF of the patient the funding given was that of low sugar and a grossly increased protein the moment you are gonna get this low sugar grossly increase protein the protein is gonna hang in the test tube like a basketball net at the bottom so this is going to be a feature of tubercular meningitis definitely on I mean as far as the third one is concerned uh your answer is perfectly spot on and you need to give attitude to these patients with steroids uh why we give steroids is to increase the penetration of anti-tubercular drugs reduce the
• 06:00 - 06:30 vasogenic cerebral edema developing in this patient and more importantly the point will be I mean why do we give steroids areas because the consistency of poster and tubercular meningitis is very very thick so if you wanna minimize the consistency of us we will have to give amend steroids to these patients uh the fourth question which I'm getting very very good answers is the three word aluminocytological dissociation occurring in a patient so the correct answer for this one would be Guillain-Barre syndrome and this is where we'll have seventh inner palsy and
• 06:30 - 07:00 intravenous immunoglobulins would be used in this patient yes I mean is one of the common organisms which is involved in this case the most common cranial nerve involved in patients of Guillain-Barre syndrome would be the same we are usually going to get a facial diplegia in the patient so uh the fourth one is pretty straightforward one and an easy one my my request to you guys is that the table of CSF analysis is recommended to be remembered and pyogenic meningitis pretty straightforward he'll talk about neutrophils uh then it's gonna talk
• 07:00 - 07:30 about sales of sugar which can be zero and another point that I would like to tell you is that always look at the blood sugar value if given in a question because a normal series of sugar is two-thirds of the blood sugar so if you have a grossly decrease values that's when you say that okay there is hypoglycore hypoglycorrect is the technical term for a low CSF sugar so always ensure multiply that by 0.3 0.66 or two thirds of the blood sugar as I mentioned that's when CSS sugar would be relatively relatively lesser so the correct answer
• 07:30 - 08:00 for this one is GBS anyway and let's move on to the subsequent one uh here I have yeah yeah or there are differentials for aluminous psychological dissociation also that is like foreign syndrome which could be due to tumors uh moving to the next one uh we have a child from a village who's brought with fever and altered sensorium for one day so again Short history is present but in this particular case you can notice that the casr study of the patient is normal
• 08:00 - 08:30 there is the Parlor and the apj shows metabolic acidosis in the patient so in this case you can straight away rule out two options viral meningitis and pyogenic meningitis because there is a concomitant anemia present in a patient there is a metabolic acidosis which tells us that there is a circulatory failure so I need to take into consideration the remaining two options diabetic ketoacidosis does not have anemia diabetic ketoacidosis does not have it will have I mean it is it's it can produce a metabolic acidosis but then at the same time the anemia part cannot be explained so the correct
• 08:30 - 09:00 answer for this one would be given as cerebral malaria the main objective of the first four questions for today is CSF analystic findings have been asked in the exam and last last year's exam it was a copper coagulum so uh since I mean these are these are the values uh yes Dr brinda the sugar value is not given in this particular question but I think you should always check out the blood sugar value whenever is given and two thirds of the blood sugar or lesser should be remembered moving to the next question
• 09:00 - 09:30 uh uh no Jerry I don't think so but anyway the database is common uh APG analysis of a patient is showing acidosis because pH is less uh then I'm checking pco2 pco2 is less so it cannot be a respiratory problem but bicarbonate is less in the patient so one thing is very very clear that the diagnosis of this particular case case the primary change that is occurring in this case would be given as metabolic acidosis now you need to apply the Winter's formula once you
• 09:30 - 10:00 will apply the Winter's formula in the patient you have to select from the two options at the bottom guys you need to answer me either one or you need to answer me two and whenever there is a metabolic acidosis you need to then subsequently deploy the Winter's formula to check for the compensation in the patient so let's do a quick mathematics here this would be 1.5 into 10 plus 8 plus minus 2 or a easier way which I personally feel is easier to remember is that the modified Winters formula can also be used in this case that is bicarbonate plus 15 so when you add 10 to 15 the mathematical value of the
• 10:00 - 10:30 expected pco2 of the patient this value that I'm writing before you at the moment is that of a expected this is a repeat question of need PG the expected pco2 of the patient is 25 but look at the actual value if you look at the actual value the actual value in the McQ is 30 which means it is higher and that means compensation is not going to be answered in this case please understand in all cases of metabolic acidosis agreed that there is a compensation whether compensation is there or not you
• 10:30 - 11:00 need to apply this formula if the value of pco2 if the value of the pco2 matches matches with this mathematical output of the formula then you will say it is compensated now repeat once again the basic point to be remembered is if the value that is the actual value given in the question is going to match with this particular range the value is going to be in the mathematical value or the expected pco2 a both of them will match you will say it is a compensated disorder but in this particular case you
• 11:00 - 11:30 can see that the actual value is turning out to be much much higher which means it is a mixed disorder the correct answer for this one would be metabolic acidosis with respiratory acidosis the learning point is I mean metabolic acidosis questions are the ones which are usually going to be given to you I mean that's because that's a very common scenario and all you need to do is deploy deploy this mathematical range and if if the mathematical value that you calculate matches with that of the actual value given in the question cool
• 11:30 - 12:00 I mean that is a compensatory change if not it is a mixed Disorder so it's a metabolic acidosis with a respiratory acidosis in this case uh suppose suppose in this McQ I'm just saying hypothetically speaking suppose in this McQ this value 30 was not there this was 25 then the answer would have been given as two metabolic acidosis with respiratory alkalosis so we sorted with the fifth one let's move on to the sixth one for today this is a case of aspirin poisoning now again I have deliberately given a similar value so that you can
• 12:00 - 12:30 understand this better there is a acidosis can this acidosis we explained by pco2 value of 30 no because for Respiratory pco2 should be elevated so it cannot be a respiratory acidosis but there is a low bicarbonate in a patient so first and foremost you need to remember that this particular chap is having a metabolic acidosis and then you will deploy the same mathematical formula which is that the expected pco2 of the patient how do you calculate the expected pco2 either you can go the classical winter formula or the modified winter formula that would be 15 plus 15
• 12:30 - 13:00 that is the value given in the question so what he was noticing for this particular question is that the expected value is matching with the actual value this means the fact that the compensation part is working and therefore the answer for this would be that there is a primary change of metabolic acidosis and along with that there is a compensatory respiratory alkalosis developing in a patient another way to correct this question would be ASA poisoning I mean if I say salicylic acid then acid will
• 13:00 - 13:30 cause metabolic acidosis and at the same time it will stimulate the respiratory Center and it will cause a respiratory alkalosis so I think this question is relatively easier for you to comprehend in the light of the previous one so the only trick that they did in the previous exam was that the values were not matching which is why it was a mixed disorder but then subsequently I mean the one that I mentioned is a very classical one and should be easily identifiable uh when do I say respiratory acidosis then I'll say only when the pco2 the patient is elevated so
• 13:30 - 14:00 we are sorted with the five and six let's move on to the seventh one uh this talks about a CKD patient with vomiting and the apj report is given and when I'm looking at if the pco2 value is lesser than doctor that means that compensation is working but if it is higher that means the compensation is inadequate so if it is if it is gonna be equal or lesser it is okay that's why I said the range you know I said the range I mean the range is plus minus two so uh he says security patient with vomiting what will be the average report in a patient
• 14:00 - 14:30 first of all I mean I I'll try to solve the question in my mind from Theory perspective that chronic kidney disease causes the high in iron Gap metabolic acidosis and vomiting always causes a uh vomiting always causes a metabolic alkalosis now the problem in this question is pH at the moment is normal pco2 is normal and bicarbonate is also normal bicarbonate values are between 22 to 12 26 million so everything is normal normal my first report will be everything is fine but then I'm gonna calculate in this case the anion gap and
• 14:30 - 15:00 for anion gap I'll be selecting sodium and from this I'll be subtracting the value of chloride and bicarbonate as I have explained to you multiple times you are not supposed to include potassium in the calculation and if you look at the calculation in this case the anion gap of the patient is grossly elevated this elevated onion Gap is telling you that this value is falsely normal I repeat once again the initial impression of mine was that the average report is normal normal so I mean there is nothing to worry but ABJ report in a patient can
• 15:00 - 15:30 be falsely normal the reason for that falsely normal is I mean how am I knowing that this is falsely normal that is on the basis of the value of the anger now once you have calculated the Anand Gap in a patient then you need to work out what is the problem of this patient I'll tell you two ways to correct this question first way will be simple English interpretation that any patient who's having CKD is bound to have a high in angular metabolic acidosis I mean every time you read about parenchymal diseases of the kidney vascular diseases of the kidney it's a
• 15:30 - 16:00 high in angular metabolic acidosis if it is going to be a case of tubular disorders then it is normal and metabolism and vomiting will result in metabolic alkalosis in operation that is the final answer but now I will give you the mathematical version the mathematical version for this would be to calculate the Delta ratio Delta ratio basically means change in the anion gap of the patient versus the change in the value of the bicarbonate of the patient so let me the upper limit of an end Gap you know is 12. the actual line cap that
• 16:00 - 16:30 I've calculated is 27 so I will be in the numerator subtracting from 27 12 that's the upper limit of an angle of normal and then the average value of bicarbon we can take is 24 and if I subtract from it the mathematical value that will work out in this case is grossly high that is 15 and what you should be knowing subsequently is that we have what is called as a Delta ratio and with help of this Delta ratio we are able to determine whether it is going to be a a metabolic acidosis with a metabolic alcohol losses I mean if you
• 16:30 - 17:00 want to get into the mathematics of this question great otherwise don't bother about it I have solved the question even clinically before you the mathematical solution for this is I'll say once again Point number one to be understood in this question is ABG is falsely normal the reason for that is increase in N Gap Point number two to be understood is every time you have calculated increase in Anger you were supposed to calculate Delta ratio in the exam you would not have too much of time to get into all these mathematics so just let It Go and yeah I'm coming to that partial and uh
• 17:00 - 17:30 you know decomposite uncompassed compensation in the subsequent two mcqs but uh this is gonna be this is gonna be a you know a mathematical justification just trying to give a justification for this is what the textbook says that if the Delta ratio is more than two then it is a combination of metabolic and metabolic acid losses uh Dr the thumb technique uh does not work for this particular question because the values are normal let's move on to the subsequent one and this would help a lot of guys taking
• 17:30 - 18:00 care of the issue that the pH of the patient is less and the pco2 of the patient is elevated so this is going to be a respiratory etiology and the bicarbonate of this patient is normal now since a couple of people just requested for this how to answer the logical question here so I will spend about 30 seconds more into giving you interpretation and the interpretation is very simple and straightforward that every time you have increase of carbon dioxide you have protons in the body if your protons in the body then body should try to compensate by increasing
• 18:00 - 18:30 the value of bicarbonate but in this question bicarbonate is not elevated so the correct answer for this particular scenario will be you see here means uncompensated respiratory acidosis why I'm saying uncompensated is because of the fact that bicarbonate value in this patient has not increased so the subsequent question that I'll discuss with you you will notice that the values will almost be the same but at the same time the values of bicarbonate will be elevated so yes doctor Riya you
• 18:30 - 19:00 perfectly correct in this one uncompensated respiratory acidosis why because bicarbonate partially compensated now let's look at this question again like he has described a patient of asthma then there is a nebulization with salbutamol yes COPD is a good clue see where asthma again will cause deterioration so again the same thing respiratory acidosis and in this case bicarbonate is rising plus here also the mathematical rule is that for every 10 point increase in the value
• 19:00 - 19:30 of carbon dioxide for every 10 point rise in the value of carbon dioxide the bicarbonate should be rising by one male equivalent so you can take a average value PCO to a 40 so there's an increase from 40 to 60 that means a 20 point increase for this 20 point increase the bicarbonate of this patient is increasing from 26 to 28 so this tells me me that the person is suffering from PC that is partially compensated respiratory acidosis so uh I mean if you compare the two questions I mean the values are deliberately kept same the
• 19:30 - 20:00 only difference is uncompensated because bicarbonate value is normal and if it is going to be a increase in the value bicarbonate it will turn out to be a partially compensated respiratory acidosis great and that's because I mean why partially compensated because person is receiving treatment as well so great we sorted with the ninth one as well uh in first four questions I have handled CSF analysis from four to nine I've tried to solve those ABG once again
• 20:00 - 20:30 I'll try to speak this in Hindi carbon dioxide protons foreign
• 20:30 - 21:00 Gap divided by the change in the bicarbonate value a G by a change in a nine Gap and uh whatever you have calculated now from that subtract parliament of the nine Gap and take average value of bicarbon subtract the actual value of uh uh whatever bicarbon is given in the question and you have to
• 21:00 - 21:30 generate I mean if the mathematical value is less than 0.4 it it is a plain nagma normal and angular metabolic acidosis grossly elevated then it would be metabolical Colossus uh doctor if your internet connection is slow you need to change the resolution settings because in YouTube nowadays there is a setting of Auto so it changes the video resolution automatically based on your video speed okay okay we are sorted for ninth one let's move on to the tenth one we have a patient with severe covid-19 uh we know covid-19 patients can land up in airts
• 21:30 - 22:00 as well person will be breathing very hard so there is bound to be problems of carbon dioxide washout and that is what is precisely happening in this question so what you are noticing in this job is that uh but pH is elevated obviously and pco2 is less arrows are going in opposite direction and since it is a respiratory case so this would anyway be a respiratory scenario occurring in a person and because carbon dioxide washout is there then there would be a respiratory alkalosis present in this case now once you get through this
• 22:00 - 22:30 respiratory alkalosis part please uh please uh mentioned subsequently regarding what would you say would you like to answer I give you two options is it uncompensated or is it partially compensated quickly guys is it uncompensated this particular case that's okay is it uncompassated you see or is it partially compensated okay yes it is PC it is partially compensated why because y carbon normally and carbon dioxide
• 22:30 - 23:00 10 point degrees
• 23:00 - 23:30 sorted with three of them so this would be PC this is partially compensated respiratory alkalosis in a patient uh okay doc the bottom line is ah okay fine guys one is Winter's formula for Winter's formula in the compensation what you need to do is the expected PCO to the patient the PDF
• 23:30 - 24:00 though I don't I don't know whether PDF will be useful but uh I mean it the point is the interest formula expected pcute is bicarbon plus 15 this is for metabolic acidosis for respiratory acidosis if carbon dioxide increases by 10. then bicarbonate value should Rise by one for Respiratory alkalosis in a patient acute one that I am talking about if carbon dioxide decreases by 10 points the bicarbonate value should decrease by
• 24:00 - 24:30 two points and the learning point for you guys is a bicarbonate value is normal with respect to respiratory acidosis or alkalosis then you are simply gonna say that this is the uncompassated value ah if pH is totally normal we say fully compensated though it's unlikely that it will give you a normal pH I mean what is he going to answer ask you if he's gonna give you a normal pH uh PDF will be available Dr Aya and the video will also be available okay moving on to the next one uh gastric ordered obstruction due
• 24:30 - 25:00 to gastric adenocarcinoma this is going to cause chronic vomiting in a patient every time there is a vomiting there would be metabolic alkalosis that is a chloride responsive metabolic alkalosis always occurs in these patients and uh while I'm writing this I have given you substantial amount of opportunity to do the mathematical calculation here also pH is elevated pco2 is elevated bicarbonate is also all arrows are increased in same direction so if this would be a case of metabolic alkalosis and in this particular case
• 25:00 - 25:30 again we have to calculate I mean how do you know that there is a compensation working in this case again you can just simply remember this rule that whatever is the bicarbonate value given in the question to that you can add 15 and you will work out the expected pco2 of the patient now you are noticing that in this particular question the actual pco2 and the expected pco2 are matching which means compensation is working in this case so for metabol that's the fourth rule no for four disorderies I have told
• 25:30 - 26:00 you rule to be followed for respiratory acidosis acute compensation rule to be followed for 10 is to one the rule to be followed for Respiratory alkalosis acute compensation 10 is to 2 for metabolic acidosis and alkalosis just remember bicarbonate plus 15 which means that even in this case there is a compensation process working that is why I am saying that this would be a patient who's having partially compensated respiratory acidosis and this would be a chloride responsive one so we are sorted with the 11th one let's do another one calculate the soda bicarbon correction
• 26:00 - 26:30 to be given in a 60 kg patient in a case of uremia while I'm waiting for mathematical answers let me calculate the anion gap in this case I'm gonna be subtracting the value of bicarbonate and chloride from this one this would be 20 so that's the increase one I mean the anion gap for the patient is elevated and anyway because he's a uremia patient uremia patients are bound to have a high anion gap metabolic acidosis
• 26:30 - 27:00 now what you will do is though there are a lot of controversies related to it but I'll try to come to the most accurate formula that you need to remember for this one what you you need to multiply the weight of the patient by 0.5 and the average value of bicarbon to be taken is 24 minus the actual value so if you multiply this here yeah he's a 60 kg patient so 60 into 0.5 and then from 24 I'll be multi subtracting 10 that would be a bit of mathematics for me that would be 40 420 moleculars and we don't
• 27:00 - 27:30 gain whole of it simultaneously I mean we'll give half of this initially and the half of this will be given subsequently I mean half of this would be given over eight hours and the remaining over 16 hours just like we give with respect to a patient who is having uh I mean like in Burns no you don't give all the fluids simultaneously similarly even in I mean soda bicarbon correction you have to be conservative do not do over correction he says if you will do over correction in a patient they will be tetany in a patient you'll own a metabolic alkalosis triggers development technique so over correction
• 27:30 - 28:00 is as dangerous because Titanic causes laryngospasm so the point is over correction of metabolic acidosis is equally as dangerous as metabolic acidosis that cell and in this case yep I mean I'm I'm having a big problem all arrows are going in Same Same Direction so it's a metabolic acidosis occurring in the person and uh yeah I mean in this case the guys hyperventilating which can explain the low pco2 values uh the correct answer is what I have mentioned before you for calculating the soda by carbon correction in a patient let's
• 28:00 - 28:30 move on to the next one or repeat from last time's case a scitec tar patient is showing uh 600 neutrophils in a patient I mean a sciatic type of a patient is showing 600 neutrophils in a patient with CLT CLT patient presenting with abdominal pain so the point is I mean there was an image also given in the exam of a person with gross abdominal distension and he was having 600 neutrophils so the clinical diagnosis of the patient would be the clinical diagnosis of the patient would be spontaneous bacterial peritonitis or SBP
• 28:30 - 29:00 yep yep I was zoomed out doctor yeah so the clinical diagnosis of this patient would be spontaneous bacterial peritonitis can you quickly comment regarding what antibiotic would be started in this case chloride responsive is where we give normal saline chloride non-responsive is where we get diode if somebody is having constant room the con syndrome is a chloride non-responsive one if somebody is having a citation is having metabolic alkalosis we don't give for for a cytosis so chloride responsive means
• 29:00 - 29:30 where you give normal saline and chloride non-responsive is where you where you give diuretics because metabolic alkylosis is subdivided into two vomiting they are all going to be chloride responsive whereas endocrine problems scientists congestive heart failure they're all examples of chloride non-responsive ones yes yes we will give third generation now cephalosporins in this patient so I mean this guy is having high probability of going into septic shock so ceftroxine in these patients would be started otherwise in
• 29:30 - 30:00 all of these patients septic shock can develop and the person can expire plus there is a high probability of e going into hepatorinal syndrome as well so question for you guys what is first line management for septic shock what is first line management very good subtraction yep C4 taxim can be given uh if you don't treat this job there can be two problems one you can go into hepatorinal syndrome or he can go into septic shock uh question is uh what is the first line management for management of septic
• 30:00 - 30:30 shock Innovation okay I think I should give options then right uh absolutely absolutely first line management would be IV floats in the patient and if he says what is the treatment of choice then your transfer would be norepinephrine so in septic shock Patient First we have to give fluid no normal saline and what fluid do you give don't answer anger lactate first line fluid for septic shock is normal saline paleo septic shock main you have to fluids are given in all varieties of shock except cardiogenic shock so I mean cardiogenic shock you'll
• 30:30 - 31:00 get fluid deteriorated because heart is not functioning understandable so in septic shock it's going to be normal spline and then norepinephrine is the preferred vasopressor which is to be used and very good very good I've had correct answers quick answers for hepato renal syndrome type 1 which is a complication here what would you use for management of a factorial somebody mentioned in the chat superiorly I missed that so uh yes guys syndrome what would you do what would you do uh okay I'm having vasopressin
• 31:00 - 31:30 octrootide yes so first we need to get the fluid you know there is a redistribution of fluid in a patient so we can give albumin to the patient along with albumin we can be using octrooted yes we very good so mainly it is albumin octotide or we can be using midodrine as well that's perfectly fine I mean one of the drugs that we use here is Metro train as well but uh we need to reduce the under perfusion of the kidney because of the third spacing that is occurring in these patients so definitive treatment is obviously a
• 31:30 - 32:00 liver trans liver Transportation being done in this step this situation like this would have not occurred okay great so we are satisfied uh with the answers in this case I am satisfied with the answers in this one and uh the next question I mentioned the table also a sciatic fluid of the I mean the ascetic type of the patient was done and a cytic fluid protein is less than 2.5 sag is more than 1.1 serum albumin as I test gradient if sag is more than 1.1 it
• 32:00 - 32:30 indicates a translative nature it indicates total hypertension in a patient uh the main point is Sag more than 1.1 is a feature of total potential that's the first point that you need to remember even if you don't have access to the table per se second because a cytic protein is lesser that means liver is not producing I mean liver is at fault here so the correct answer for this one would be a liver cirrhosis in a patient and if it is going to be nephrotic syndrome then for nephrotic syndrome the SAG value will be less than less than 1.1 so two questions I
• 32:30 - 33:00 mentioned with respect to a scitec fluid analysis like the first four questions were on CSF analysis two questions I mentioned for ascetic fluid per se I'll just go back to that if they give you a situation of a scitec patient who's having abdominal pain having fever a sudden increase in the ascitis he was having a side test now it's got converted into tensor scientists the and tenderness if present it all points towards spontaneous vectoral peritonitis the count for diagnosis or spontaneous vectoral peritonitis should be more than 250 cells per cubic millimeter so they
• 33:00 - 33:30 don't ask you the dose of this so please don't worry about it at the moment I mean let's not focus on the dosages or drugs at the moment right it is 250 and the second one is going to be for you know differentiating between uh the portal hypertension variety versus sag value more than 1.1 levels is less than one point okay guys uh sorted for this one we move on to the next question for which was uh again a last time's uh exam question uh
• 33:30 - 34:00 there is a sudden onset breathlessness in a known case of Piper tension there is a uh yes doctor Zen mode you have a point even nephrotic as Transportation but nephrotic is the only example where which is not fitting into sag less than 1.1 I mean why we have created that sag is because the translative executive thing does not hold for a scientists okay great sudden onset breathlessness in a patient of hypertension with elevated pcwp so what does elevated pcwp tell you left ventricular failure every
• 34:00 - 34:30 time you read elevated left ventricular failure elevated pcwp it is indicating that this section of hypertension is going into uh left ventricular failure and uh even in the X-ray the heart looks relatively the heart looks relatively bigger plus you can see a lot of pulmonary edema component it's not a very classical batwing it's not a very classical batwing but still I can say the whiteness is present in the chest x-ray bilateral infiltrates are present so for
• 34:30 - 35:00 this patient we'll have to give nitrates in the exam last section furosemide was not given uh it was not elastics morphine uh then oxygen and positioning were not given you have to select for n that is nitrates in the last times paper but the main message is hypertension hypertensive crisis can trigger development of left ventricular failure in a person and yep on the Batwing can be picked up slight battering appearance at least on one side can be picked up exactly uh let's move on to the 16th one
• 35:00 - 35:30 the question said elevated jvp finding in a patient with the irregularly irregular pulse irregularly irregular pulses what we read with the tachythmia that is atrial fibrillation and because of atrial fibrillation there would be an absent a wave in a patient so very good I think jvp is something that you guys are very strong at and that is why I'm getting perfect answers in the current uh from the current Guru great very good very good cool I'm not I'm not able to take your names because I need to focus on my
• 35:30 - 36:00 slides subsequently let's move on to the 17th and the 18th one and do read the questions carefully try to read them simultaneously the question says uh jvp finding in a patient with the large area and there is absence of pulmonary edema versus the second one where there is a larger but there is the presence of cardiogenic pulmonary edema if there is a cardiogenic pulmonary edema it means left side of the heart is involved and if there is absence of pulmonary
• 36:00 - 36:30 edema it implies that there will be a right side of the heart getting involved so very good I think most guys have got it spot on for question number 17 the answer would be given for large area would be tricuspid stenosis in a patient otherwise it could even be pulmonary artery hypertension I mean there are various reasons for pulmonary artery hypertension but this would be right sidedly on the other hand if I'm getting a larger wave and I'm simultaneously having a cardiganic pulmonary edema then one of the common valuular lesions that must be thought of is mitral stenosis
• 36:30 - 37:00 that is one additional point I would like to also add in this McQ is that patients of mitral stenosis can be having let atrial appendage clots this atrial left total appendage clots can go into systemic circulation and there can be a risk of development of either a stroke or a TIA in a patient if he will ask you what drugs should be given to prevent or minimize the chances or development of stroke that do not answer the newer agents like like riveroxaban or dabigatron your answer should be given as Warfarin uh if it is
• 37:00 - 37:30 non-romatic atrial fibrillation because in majority of cases it's going to be a romantic etiology I'll just repeat what I said every time there is a romantic etiology of mitral stenosis you should be giving warfarin to prevent the development of clots however if he gives you a scenario of alcoholic having dilated cardiomyopathy alcoholics can be having a atrial fibrillation because of dilated cardiomyopathy if there is a non-romatic atrial fibrillation and he says how can you prevent development of stroke in our patient then it is the
• 37:30 - 38:00 newer molecules which can be used in these patients like riveroxaban or dabigatron Etc and those are the molecules which can be answered in this case so two additional points have been added to 17 and 18 the main point is right side and the left side is anyway tricuspid versus mitral and for Rheumatic it is always referring to prevent otherwise for non-romatic it is Navigator I think this was last times uh I mean the previous discussions that have done
• 38:00 - 38:30 on 23rd of uh I think February or I think yep I think it was done in January uh uh I don't remember the date exactly the December or January 1 uh tricuspid regurgitation results in large development of a large CV wave so uh I mean you have a point there doctor but uh there's I mean I will not get to the very basics of jvp at the moment TR operates in TR operates in ventricular systole and alav is related to atherosis Tool I mean the query of
• 38:30 - 39:00 yours the simplest shortest explanation I can give at this current time is a wave is related to atrial systole and TR does not operate during literal system TR operates in ventricular stool so during TR we get is a development of a absent X and a CV wave as the remaining guys are answering great let's move on to the next one I hope doctor your query is answered uh the next question says there's a ascitis patient with the inspiratory rise of jvp inspiratory Rise of jvp means that there is a small sign occurring in a patient
• 39:00 - 39:30 uh most of the time when we read about cosmall sign we should always think in terms of constructive pericarditives and constructive pericarditis usually can result in ascitation pedial a D Minor patient right ventricular compliance is first affected in constructive there is a calcification around both sides of the heart but right ventricle is less muscle left ventricle has more muscle so right ventricular compliance is first affected and therefore we usually get a pedial edema occurring in patients with ascitis uh the key word in the question however is steep action steep Y and that anyway helps in confirming that the question is
• 39:30 - 40:00 dealing with constructive pericarditis per se whereas if the question was mentioning additional McQ that I'm just writing here is steep X and absent y I will be testing you on this topic also in the subsequent part of this particular discussion but a must know topic steep exception y for cardiac tamponade where we always have is a non pulsatile elevated jvp in all conditions in cardiology we have is a a we have is always a pulsatile elevated jvp but when you read about non-ulcer tile elevated
• 40:00 - 40:30 jvp this is the condition which is to be considered and yep I think most guys have answered this correctly let's move on to the 20th one now the question says there is a lung cancer patient and is presenting with prominent neck veins what is the first differential diagnosis avantika says why would this not be a restrictive cardiomyopathy in a patient uh here doctor I mean that is a second differential diagnosis which is to be considered uh I mean no cardiologist will ever be able to rule them out by
• 40:30 - 41:00 physically examining them he will require either a cardiac MRI or he will be requiring an endo myocardial biopsy because if somebody does not want to risk his practice he will never dare to differentiate the two on clinical grounds so yep doctor I I can say that if person has had a history of piopericardium if he's had a history of tuberculosis I think a terms of CP otherwise RCM is definitely on and I mean the ruling that out would be almost close to Impossible on clinical grounds we need a cardiac MRI or endomyocardial biopsy for that thank you doc uh coming
• 41:00 - 41:30 to the next one lung cancer patient with prominent neck winds this indicates there is a superior vena cava syndrome in a patient and this will contribute to I mean respiratory distress in the patient subsequently now I want you to compare uh Pancoast can contribute to same presentation but then pan cost will have Horner's syndrome also okay moving to the Templeton is with thyroid so this would not be the appropriate answer Pemberton and now I
• 41:30 - 42:00 am changing the question and the question said lung cancer patient with prominent neck winds and electrical alternates so suddenly you are realizing that okay I mean lung cancer patient can a prominent neck means due to superior vena cava syndrome as well but electrical alternates is not a feature that you're gonna encounter with a patient who's having superior vena cava syndrome electrical alternating straight away tells you that there is a malignant pericardial effusion occurring in this patient so the answer to question number 21 will change because of one word in question number 20 because there was no
• 42:00 - 42:30 mention of any electrical alternates we were not thinking about the heart coming into picture but but in the second question what I'm finding is zoom in okay but in the second one then there is a evidence of change in the fluctuation in the voltage of the QRS complexes which is pretty visible B to beat variation can be seen so a small QRS complexes versus relatively bigger ones so this is because there is a tumor which has metastasized to the heart this would be
• 42:30 - 43:00 most of the time a small cell cancer of the lung and the chap is having a malignant pericardial effusion very good I think most guys have got it correct uh moving to the next one uh this is again repeat from the last time digoxin toxicity with development of third degree heart block in a patient there is a severe bradycardia there is a AV dissociation occurring in a person so in this person uh if he says what is the first line management for any of these cases then I will answer atropine however since this is a repeat question and the exam atropine was not in the
• 43:00 - 43:30 option he just said what will you do so we for any personal digoxin toxicity will be giving DG band which is the answer in this particular case but as I told you they can change the language of the question as well if he says initial management the movement you read a third degree heart block heart rate is going to be maybe 40 or less than 40 you need to be aggressive and straight away start atropine in the patient lidocaine doctor will be the answer to the next question that is the issue that you know some guys casually answered because now see see now see 23
• 43:30 - 44:00 digoxin toxicity with ventricular by Gemini the movement I'm gonna have no normal sinus rhythm premature ventricular complex normal sinuso Rhythm premature ventricular complexes you can see I've shown alternatively this is a broad QRS complex then I'm showing a normal sinus rhythm in a patient so if you have this alternatively present and and Sr then a PVC and Sr and a PVC will think in terms of a patient who's having a ventricular by Gemini and this is where we'll be giving lignocaine to the
• 44:00 - 44:30 patient and uh I mean that would be somebody mentioned earlier so I hope now it is clear for the turkey resume which is caused by digoxin toxicity it is and along with that digibent to be used moving to the next one again a repeat one management of a monomorphic ventricular tachycardia with structural heart disease uh yes guys yeah phenytoin can be used also if there is a structural
• 44:30 - 45:00 heart disease the drug of choice for ventricular tachycardia would be ambedron amidron is also I mean it's a broad spectrum anti-rhythmic it can be used in atrial fibrillation also I mean wearable you answer am I wrong then there are two answers Amazon is gonna be the preferred drug for patients of uh stable VT for chemical cardioversion and can also be used for chemical cardioversion in atrial fibrillation as well okay great uh if the question says absence of structural heart rate disease then the answer will change then the
• 45:00 - 45:30 answer will change over to metoprolol that is a beta blocker and if it says crushing patient that means BP is unrecordable Broad QRS QT occurring in our patient there is a heart rate of 200 and uh I mean there's a possibility he can go into cardiac arrest subsequently so in those circumstances I will have to go ahead with yes guys quickly yes I will be going ahead with defibrillation should I answer defibrillation should I answer cardioversion should answer defibrillation should I
• 45:30 - 46:00 answer cardioversion yes we will give DC shop but my query is should I give cardioversion or should I answer defibrillation very good we will be answering defibrillation in this case uh I mean we should always give non-non non-synchronized decision or defibrillation somebody put up Dr Maria put up anybody wants to defibrillation pulseless vtn ventricular fibrillation all other cities cardioversion this is non-synchronized DC shock now so your answer is defibrillation to be done exactly correct it is a non-synchronized
• 46:00 - 46:30 DC shock which is to be followed perfect moving to the next one 23 or 26 is sorted uh again a repeat one uh uh wide QRS complex tachycardia in a patient overdosing on antidepressants there was a TCA toxicity case given like he had mentioned this lady is suffering from depression she ate an entire strip of medication and she would be having a developmental severe metabolic acidosis though metabolic acidosis the protons will cause damage to The myocardium they
• 46:30 - 47:00 will cause damage to the excitability or they will affect the excitability of the myocardial cells and thereby there is a triggering of ventricular tachycardia in the patient I mean ventricular tachycardia can not only be seen due to hypoxia after myocardial infarction but can be seen due to metabolic acidosis as well so in this particular case we need to treat the acidosis component which is the reason why for this particular case the answer that I'll be giving would be soda bicarbonate and this is taught in
• 47:00 - 47:30 Pharmacology as well so a quick repetition moving to the next one uh most of the time it would be a polymorphic ventricular tachycardia occurring in a patient so we need to give soda bike permit for this particular chap okay moving to the next one Cardiac Arrest caused by hyperkalemia will be managed by let's look at what you guys are answering uh calcium gluconate calcium gluconate so please tell me do you want to Suppose there are two problems in a patient cardiac arrest and hyperkalemia which will you treat first
• 47:30 - 48:00 if you're answering calcium gluconate please simply tell me if patient is having Cardiac Arrest due to hyperkalemia what will you treat first will you first trade Cardiac Arrest or will you phosphate hypergalemia I am still getting insulin as an answer party Roma insulin plus glucose is uh magnesium sulfate you will treat cardiac so how do you treat cardiac arrest how do you trade card acres do you trade Cardiac Arrest with calcium gluconate and Insulin that can be given later now
• 48:00 - 48:30 first it will treat cardiac arrest so what will your answer your answer will be simple adrenaline for the patient yes guys the objective was just to tell you that every time they give you a question of hyperkalemia that does not mean that you have to frustrate hyperkalemia if a guy is gone into cardiac arrest plus give obviously CPR to be given in the patient the point is if somebody is having hyperkalemia so dangerous that he went into cardiac arrest because potassium will slow the heart and can cause a cardiac arrest then I will give utterly into the patient
• 48:30 - 49:00 Cardiac Arrest is to be treated on a first priority okay guys stimulation okay and can be melanophile you're perfectly right adaline is a sympathomimetic and will help in enter your potassium into the cells and that was the concept of the last times question paper okay great I will give adrenaline for this guy okay
• 49:00 - 49:30 moving to the next one uh least chances of development of endocarditis would be seen with the hint is It's A congenital heart disease it's very common in children with Down Syndrome as well uh Ms says a potassium is more than six but there is no cardiac I think Dr M A you mean that there are no ECG changes but we still have to give calcium gluconate to the patient because ECG is not very sensitive the concept behind that question I'll repeat Dr M.A said a potassium is more than six or seven whatever and there is no ECG
• 49:30 - 50:00 funding because ECG is not very very accurate for detection of hyperkalemia waste findings so we still have to take the lab report more I mean lab report is more indicative of electrolyte imbalance than ECG repeat again which is most more accurate for diagnosis of electrolyte imbalance blood report it is not a ECG foreign yes guys I've had correct answer least chances are gonna be seen with atrial
• 50:00 - 50:30 separate effect they had given three options where there was the requirement of uh I mean prophylaxis for uh dental extraction before uh since a person is having a cardiac issue and was scheduled for a dental extraction we need to profile access with antibiotics but AST person you don't need any prophylaxis as well least chances of infective endocarditis then is which will have highest chances of interactive endocardials are the main Logic for solving this question is that pressure gradient is directly related pressure gradient in the heart is
• 50:30 - 51:00 directly directly related to the development of infective endocardials I ruled out the options I mean I've not given you the options of the right side of the heart so it's only the left side that have to be taken into consideration mitral regurgitation and iotic regurgitation let's look at what you guys have to say very good it would be mitral regurgitation because this operates at a higher pressure gradient I mean iotic regardation will operate at the following pressure LV pressure
• 51:00 - 51:30 has the highest I mean yes Dr ramulia you're right there answer 30 is Mr and 29 is ASD moving to the 31st he says what is best for management of this patient who's a
• 51:30 - 52:00 diabetic he's having low BP random blood sugar of 4 600 and uh I mean which of the following interventions these are the three options here plane IV fluids IV fluids plus insulin or insulin drip uh in most diabetics because there would be vomiting also because ketonemia I mean the the first differential diagnosis is diabetic ketoacidosis and uh in this chap there would be ketonemia causing a development of vomiting as well so I need to get the BP back to normal so I will give fluids plus I'll
• 52:00 - 52:30 give insulin to the patient yes it would be IV fluid plus insulin that would be required yep yep uh a related question here electrolyte imbalance that can be seen in a Decay fashion with extensive vomiting and perspiration like this this child of type 1 diabetes mellitus mistress insulin shots because there was a marriage in the family he was using an insulin pump and the parents forgot to recharge or put the cartridge in the insulin pump this type 1 diabetes mellitus patient missed insulin shots
• 52:30 - 53:00 then the child has started becoming lethargy and because mother was busy in the wedding or family members were busy so they missed that and then they are noticing that he started having abdominal pain the child started having vomiting and he was not opening his eyes and is brought in an unconscious state to your hospital uh I mean the acute abdomen in this condition can be misdiagnosed as a given acute appendicitis so considering the vomiting component hypokalemia is to be considered in the patient which is why uh before you start insulin you must
• 53:00 - 53:30 take potassium always hold insulin the learning from this one is you have to hold insulin if potassium value is less than three and you need to first get potassium chloride to the patient sir acidosis causes hyperkalemia acidosis will cause hyperkalemia I agree but because the person is having extensive vomiting prostration in any person who is not eating anything and is vomiting there is bound to be dehydration and because of the
• 53:30 - 54:00 dehydration component occurring in this patient I mean abdominal pain vomiting prostration inability to take overly will cause dehydration and dehydration always causes stimulation of production of aldosterone and this aldosterone will cause Kali urea that is urinary loss of potassium so hypokalemia will occur so in these patients if the potassium values are less I am not going to be comfortable for giving insulin to the patient immediately 31 is sorted we come to 32 what is best for diagnosis or Rhino cerebral
• 54:00 - 54:30 mupromycosis yeah yep what is to be used for diagnosis of this patient I'm having nasal swab I'm having an MRI and I don't think so that there should be any conclusion by rhinocerable micromycosis will involve the sinuses no so you can't put a swab in a sinus who have will remain in the nose only now maybe the fungus is growing in the maxillary sinus or is growing in the middle sinusoid so I will not go there so you will be doing an MRI and after doing a MRI in the patient after doing
• 54:30 - 55:00 an MRI in the patient then subsequently a nasal endoscopy with biopsy will be done the question is a repeat one of the last times exam please remember nasal swab is not going to reach the sinuses you need to do a MRI and then subsequently why I mean swab nor no use does not mean that micro tests are not good but so I have no use it means that the infection is located deep inside a sinus and you can't navigate a swab in there so we will have to go for a MRI followed by nasal endoscopy and biopsy the answer would be Mi would be MRI
• 55:00 - 55:30 yep amput Harrison B to begin then though this has been discussed in your microbiology section also just talk quickly I mean recall the images if you're gonna get these uh I'll use a different pen to highlight zooming it in slightly and uh if you are gonna get a gomori the green slide here is gomorian with them in stain in gomori meetha main stain if you're getting branching at 45 degrees let me just try to change the color if I'm gonna get this branching at 45 degrees or so this is going to be
• 55:30 - 56:00 aspergillus acute angle whereas you can see broad a selected Type A use a different color but if I am able to notice this broad aseptide hyphae then this would be for uh mucor microsis and then I mean one is acute angle thing which you are aware of second is this aseptide which is I think already given on the slide somewhere and then they can give you an image of a person in whom inside the macrophages uh
• 56:00 - 56:30 you would be having this small lesions present that would be for histoplasmosis and if you're gonna have a broad based budding as is shown in this one then it would be blastomizes so uh I mean common infections can anywhere be asked in patients who are having diabetes and had covered mucor was anyway there ASAP broad accepted okay fine for asper de Loma please just quickly comment on the antibiotical choice and we can move to the subsequent
• 56:30 - 57:00 slide if a person is having an aspergilloma post covered he was proton steroids and he's having aspergilloma in the lung on a city what drug would you give so you'll be giving boriconazole qualification yep okay fine great 32 sorted we move to 33 the question said what is the initial treatment for a patient of acromegali there is a growth hormone producing pituitary tumor
• 57:00 - 57:30 and I want to cause a shrinkage of the tumor and you have to tell me the drug that would be recommended subsequently yes I need to shrink the pituitary tumor so I'll be using uh okay more accurate answer would be landreotide in contrast to Auto Trade because I want to give a long acting formulation to reduce the discomfort of the patient but this would be the initial one that is recommended but if they start having visual deficits uh like by temporal
• 57:30 - 58:00 hemianopia then a transpendable surgery no doctor it is only to be used if there is a uh there is a recurrence of a tumor it can be used in even initially but in growth hormone producing pituitary tumor if you want to shrink the tumor and the advantage of shrinking the tumor will be that lots of the time the mass effect of the tumor is present now so to showing the tumor initially we give octotide or somatostatin based derivatives to the patient okay we can give subsequently doctor we
• 58:00 - 58:30 can give cabergoline and bromocriptine to the patient early but initially to shrink the tumor it is because uh the the remaining drugs they act by increasing the level of dopamine but to shrink the tumor initially we have to use after tight based derivatives okay moving to the next one the question says it's positive patient with features a low bar pneumonia CD4 count is uh 200 so here we'll go by the funding of lobar pneumonia low bar pneumonia is a presentation that is seen with pneumococcus
• 58:30 - 59:00 and therefore in this patient I'll be starting antibiotics so the antibiotics that I'll be giving in this patient would be like a respiratory fluoroquinolone levofloxacin and along with that I can get macrolyte like azithromycin uh till last year I would have answered only plain azithromycin for this patient IV but now because of multi drug resistance for pneumococcus we tend to give respiratory fluoroquine alone and along with the respiratory fluoroquinolone azithromycin would be given that's because of indiscriminate usage of microblites resistance is being occurring to both of them as well the
• 59:00 - 59:30 answer to this question is not pneumocystis Zero by C because there is lobar pneumonia suppose in the same question the language was the same but he mentioned that the chest x-ray of the patient is normal or is showing occasional infiltrates some infiltrates but not low bar pneumonia then I could have considered a possibility of pneumocystic zeroesi for which I will have to go in for Broncho alveolar lavage in a patient this bronchial lavage will be showing
• 59:30 - 60:00 black cysts in a green slide there will be multiple black axis that would be visible and then I'll say okay this is going to be a pneumocystis zero basic so the correct answer for this particular question that I put out before you is pneumococcus however if it is going to be normal x-ray infiltrates ball then ER doctor CD4 count can be lesser but the most common infection will occur in a lower account so don't go by the count report no
• 60:00 - 60:30 that's why we call it pneumocystis okay and we also give steroids there uh the reason for that is when you keep when you kill pneumocysters zero AC there can be a cytokine storm in a patient that can cause worsening so we also tend to give steroids in the patient at lethal we should this will not happen oh nowadays patients are started on cartoon oh we don't wait for the CD4 count to uh answer the CD4 count
• 60:30 - 61:00 to fall and then we start treatment I mean the treatment objective nowadays is to start cut the moment we have diagnosed Aid in the patient uh Dr if we say CD4 count less than 50 and he says that there is a lung infection in our patient then a typical mycobacteria that is mycobacterium AVM intercellular is to be considered where we will be giving Clarithromycin to the patient only
• 61:00 - 61:30 okay CD4 count is not a criteria for diagnosis if it is less than 500 tuberculosis less than 200 chances of zero basic but pneumococcus is more common than zero AC infection that's one at 100 cerebral toxoplasmosis incidence increases at 50 or lesser there is going to be cytomegalovirus retinitis and mycobacterium AVM intercellular yes it is clinical findings that will
• 61:30 - 62:00 decide the treatment okay ECG findings of extra depression are seen with which drug the answer is digoxin but then there was a modification in the question the question said ECG finding of Estee depression with prominent U waves yes this would be a hockey sticker so gross differences in the configuration the hockey stick one is a feature that we encounter
• 62:00 - 62:30 the hockey strike one is what we encounter with digoxin and then there is gonna be a Ester depression plus there is some magnitude of T wave inversion in a patient plus there is a prominent U wave also that would be a feature with hypokalemia moving to the next one a road traffic accident patient develops breathlessness after 48 hours and vertical bleeding is noticed in the
• 62:30 - 63:00 patient SPO told the patient when the nurse put the pulse oximeter is 80 percent uh I mean every time there is gonna be a trauma in a patient and then there is going to be breathlessness you need to deploy God's criteria g o r d Goods criteria include presence of particle bleeding as well so I mean we straight away are not gonna think in terms of atomolism but considering that there is a particular bleed documented plus respiratory distress I mean uh the major criteria say are lung involvement
• 63:00 - 63:30 brain involvement and then development of bleed in a patient but take care then these are important features which might which you must consider for Phantom ballism syndrome in a patient the clinical diagnosis in this case is FPS I'll use a short form by CNS feature I mean development of coma in the face subsequently lipid urea can also occur okay move it to 38 I'm having a patient who's having shortness of breath after a
• 63:30 - 64:00 long distance flight so whenever we need a long distance flight and nephrotic syndrome we are talking about increased chances of clot formation nephrotic syndrome by itself is a hypercoagulable state and considering the fact that we are dealing with a hypercoagulable state in a person with development or respected distress we have to think in terms of pulmonary embolism the question is saying what is the test to be done in this case the answer would be what most guys have answered very correctly that would be a CTP in a patient
• 64:00 - 64:30 yeah I mean we have to answer the main test no like if a person is having shortness of breath do I need to identify what is the cause or shortness of this breath so I'll be doing a CTP in the patient and CT pulmonary angiography in this particular case uh yes it is available subsequently also the ctpa will be showing up a thrombus in the pulmonary artery most of the time I mean there's a pulmonary artery that would be visualized you'll be able to see the descending iota you will be able to see the ascending Yota and you will notice that there is like this contrast defect feeling defect
• 64:30 - 65:00 that would be present the pulmonary artery will be totally white and then there would be a gray area like let me say one of the branch of the pulmonary artery is patent but then there's a cut off air that cut off is because of the of a clot which is present in the pulmonary artery of the patient okay 38 is sorted let's move to the next one a patient after joint replacement surgery is having shortness for breath on day two with promulent neck winds and low BP waiting for your diagnosis is a good one for diagnosis absolutely true yeah you
• 65:00 - 65:30 can have a subtle embolism as well the complication is different I mean this is deep winter Moses occurring in a patient okay and uh okay I'm missing couple of points in the chat okay okay patient after joint replacement surgery develops shortness of breath on day two and there is prominent neck winds occurring in the person he's asking me for what is gonna be done for this case yes guys
• 65:30 - 66:00 okay okay let's uh quickly first work out uh the problem in this case post joint replacement surgery there is a large vein there is a clot probably in the popliteal vein or in the femoral vein of this patient which has gone into the lungs and is causing a massive pulmonary emolism in any patient a massive pulmonary embolism the systolic blood pressure whenever it falls there is a Big Lot bang in the middle of a pulmonary artery you need to destroy it and the only way you can destroy it by doing a
• 66:00 - 66:30 thrombolysis in this case the main pointer for this question is he gonna be talking about the massive pulmonary embolism or is he gonna be talking about a submassive pulmonary ballism because in some messages the BP will not be low it will usually be normal in this particular question because low BP is given that is why the answer to this question would be given as thrombolysis however if in this question BP was not getting affected right ventricle was not getting dilated then we would have answered this as apparent we would have
• 66:30 - 67:00 given no molecular apparent will be given in point number one also in massive pulmonary ballism also we give happening but the main treatment for massive pulmonary moleism is going to be thrombolysis to be done and one of the important parameters will be the low blood pressure of this patient I mean that's a good point to identify clinically though ideally we need to do a CTP and demonstrate a plot empirically I just can't say because BP is low I'll do a thrombolysis in an era of evidence-based medicine I need to demonstrate the presence of cloud so I need to do a ctpf visualize the plot and then subsequently do a thrombolysis in
• 67:00 - 67:30 the patient 39 is sorted we come to 40 I think auctions any patient having a difficulty in breathing you'll be giving oxygen okay uh shortness of breath after central line insertion would be seen with thrombolysis would be contraindicated in some massive variety we give thrombolysis only the massive variety from moles is not given contraindications I'm waiting for answers for you guys
• 67:30 - 68:00 contraindications for thrombolysis would be like a known as television MI so many of them know unstable angina plain pulmonary embolism not massive one plain pulmonary ballism a BP is very very high systolic blood pressure going Beyond this range recent hemorrhagic stroke I mean any chapels Had a Brain Hemorrhage I I cannot be taking the risk of doing a thrombolysis in a patient iotic dissection so there are so many of them
• 68:00 - 68:30 and I would not suggest you to go into any kind of a mnemonic for it it is straightforward these are I mean contraindications for thrombolysis I think I have to class at the phone for a second to look at shortness of breath absolutely correct there is shortness of breath after central line insertion this means that uh probably the central line has caused damage to the lung the first answer of yours would be development of pneumothoraxena patient and suppose suppose if pneumothorax is not given in
• 68:30 - 69:00 the options then can you tell me another differential for why the person will be having breathlessness yes guys suppose pneumothorax is not in the options in any patient joint replacement surgery you know the major criteria are being satisfied yes the second differential to be considered in the patient then would be air embolism answer to 40 and most of the time
• 69:00 - 69:30 there's a chart given in RS knowing which is mentioned BP values for uh somebody put ups or will we look for wealth criteria my suggestion is there's a small chart and I think I've discussed that in the routine section look at the BP values that is a very good hint towards solving the questions of pulmonary moralism or the massive variety okay let's move on to 41. the question says uh absent air entry and absent breath sounds were deep Souls a sign on a just exercise management I've solved the question half for you guys uh I mean absent uh air entry
• 69:30 - 70:00 absent breath sounds would be a feature that is seen with pneumothorax deep salsa sign is also visualized here if you compare the cost of organic angles on both the sides so considering the fact that a person is having a fairly large pneumothorax air there are absent vascular markings I will have to manage the patient aggressively so I'll go in for a needle
• 70:00 - 70:30 thoracotomy in the patient okay uh thoraciocentesis would be a wrong statement it's a wide bone needed decompression why answer number uh C is not because we're not doing a thoracosynthesis it could be a whiteboard needle decompression that we're doing and for that we don't need to get into
• 70:30 - 71:00 that controversy of Fifth versus second intercostal space he says whatever is available you can use in the patient it can be fifth it can be second yes there is no fluid it is air president 41 is sorted we move to 42. yep uh Hamman current sign would be seen with respect to Thermal consign would be as if somebody is walking on only available needle yes you can select it yes yes yes yes that is why the answer is uh not gonna be given
• 71:00 - 71:30 the main answer for this patient is the definitive treatment for pneumothorax would be to put in a needle decompress and at the same time put in a chest tube common current sign would be seen with exactly Boy Rap syndrome this can be seen with patients who are having a pneumo media stream are two important questions or topics which are always one pneumo will at least come either pneumo peritoneum or pneumoth or X or pneumonia
• 71:30 - 72:00 yes one scenario can be power syndrome okay moving to the next one yes this is where the X-ray finding of containers die from signing would be seen Nickelodeon sign sales sign can be seen but the one that is easy to pick up is continuous diagram sign moving to 43 a forceful retching minus vomiting in an alcoholic patient with excruciating epigastric pain and inability to pass NJ tube like this is the keyword in this
• 72:00 - 72:30 question inability to pass ngo2 uh only time you can have problem in NGO tube is when it's navigating through the oral firing so the patient it can trigger a bit of gag and the person might hold your hand or the spasm or the gag can actually impede the passenger tube but once it goes down into the esophagus there is never a problem the only time this is gonna be seen is gonna be a case of stomach volvulus can you tell me the name of this Triad hair that is being asked for you or asked by you the clinical diagnosis of this guy is
• 72:30 - 73:00 the stomach is folded on its axis it can be a Organo axial or a misogentricle axial volvulus occurring in a person in this particular case this would be yes yes yes no this is not made easy to gallbladder so related yes yes yes the clinical diagnosis of this case is stomach polvulus there is uh the features are wretching minus vomiting
• 73:00 - 73:30 that's the key word but there is no vomiting in a patient and a Severe epigastric pain developing in a patient this yeah this would be bore chart absolutely Abhishek you perfectly bang spot on this is not Burger syndrome no we are talking about stomach valvolus yes yes perfectly right this would be
• 73:30 - 74:00 more chart prior absolutely the key word in the question is enability to pass NG tube I mean normally that does not happen so the tried has to be remembered syndrome okay now this is a image with respect to clot present in one of the branches of the pulmonary artery actually the image would have come earlier but anyway I mean has been asked in the exam so one should give consideration to that okay okay coming to the next one yes this
• 74:00 - 74:30 would be PE and coming to the next one the this is the one that you guys were saying alcoholic with a forceful retching followed by chest pain and subcutaneous emphysema I think you can see this subcutaneous emphysema present here I mean air below the chest wall so there would be carpetas air so either he will write carpetas in the chest wall or he is gonna write the word subcutaneous emphysema as given in this question for this one the clinical diagnosis would be given as Boy Rap
• 74:30 - 75:00 syndrome let's move to the 45th one the question says alcoholic is still very apigastric pain relating to the back this would be acute pancreatitis we need to do a CT in this guy to check out the severity of acute pancreatitis so three questions on alcoholics and then we'll talk about management of tumor license syndrome in a patient for management or tumor license syndrome yes acute pancreatitis absolutely right
• 75:00 - 75:30 absolutely right next one I have not put up a question my I mean you know the queries that I usually get is that uh for a question of acute pancreatitis should we answer raspberry case should be answered allopia in all should we answer IV fluids so let's look at how to answer these questions and the logic behind this is that the malignancy which is present in the patient will decide suppose suppose I mean what I want you to understand is first of all I'm
• 75:30 - 76:00 slightly zooming it in if he's gonna talk about a high risk group like if he begins by describing our child with markets lymphoma Ori says acute lymphoblastic leukemia child with a higher TLC going up to 1 lakh TLC one luck that is hyper leukocytosis leukocytosis I'm talking about hyper leukocytosis TLC one lakh in a patient high risk group then you should answer raspberry case but if it's gonna be a patient who is you know let me say in a low risk tumor
• 76:00 - 76:30 or intermediate rest tumor then we should be answering allopyrinol once I've told you that you need to look for markets lymphoma Al given in a question then is this flowchart which is to be remembered if he says how do you prevent intermediate risk it is IV fluids with alloperinol for high risk it is IV fluids with raspberry case if it has already occurred in the patient if tumor message syndrome has already occurred in a patient then answer will be again raspberry case I hope I've been able to
• 76:30 - 77:00 clear the aspects of tumor license syndrome which we say pure calcium by pure calcium puking means that things will become lesser so let's look at what will become less than this patient uh though it is very clear P would be potassium will become less in this patient I mean you know sorry pure calcium so the point is what will become elevated in this patient so potassium will become elevated because cells will die uric acid so uric acid values will again be rising because cells are dying DNA turnover
• 77:00 - 77:30 will contribute to problems in this patient plus phosphate will also rise because ATP but what is going to become less is calcium because there is going to be binding of phosphate to calcium so pure calcium the mnemonic would basically mean that I mean calcium in the sense that what is less calcium is going to be less in this case so for management of this patient because you know that there can be crystals of uric acid blocking the tabules of the kidney and this guy can develop acute tabular necrosis whether he's asking you prophylaxis whether he's saying
• 77:30 - 78:00 treatment first plane management is always IV fluids how to select between alloparinole or raspberry case as I've explained if he talks about a Market's lymphoma Al with Hyper leukocytosis then answer raspberry case otherwise answer allopurinol for prophylaxis purposes if he says what is the treatment then it is right in front of you so most of the time I mean tumor license syndrome is again a very common topic that is asked both in medicine as well as in Pediatrics but it is always a controversy with respect to what is done first what is to be done subsequently and the big fight over what drug is to
• 78:00 - 78:30 be answered so I hope this should this should the uh yeah I'll complete all the 100 questions doctor don't worry uh time is not a consideration for me I'll not tell you that you don't need to listen to me for the remaining ones so if you are patient and listening to me at the moment I would request you to be patient for another hour and I'll I'll finish all of them I will complete all of them doctor don't worry it's my job don't worry uh we are sorted with question number 46 uh PDF of this would be available in the group if you want to go through I mean
• 78:30 - 79:00 last minute quick revision turning through the pages don't spend too much time on that okay guys moving to the next one he says child again a repeat question last time pediatric slash medicine a child with abdominal pain with extensor for Pura so keyword and extensive computer is always gonna be anoxical in popular because there was some kind of an image of a kid with this rash on his uh back of the thighs and on the calves of the patient he's asking it is managed with right so your answer would be your answer is gonna be
• 79:00 - 79:30 guys diagnosis the answer here is steroids would be used IG immediated absolutely absolutely uh it is a IGA mediated disorder it is IG A1 mediator disorder that causes an oxalate papura and IG A1 mediated disorder also causes Berger disease but the differences in merger disease it would be damage to the mesenangium it would be damage to the kidney and therefore RBC leakage would be occurring in this patient so there would be a microscopic hematuria
• 79:30 - 80:00 well now I mean most of the time these patients will be suffering from hematuria on a long term basis just generally asking though this is not the time for uh asking you this can you tell me why the same antibody is causing in some patients it is HSP in some patients it is Burger disease one is child versus redundant that is okay but why I mean physically is fine but human yeah so I mean can you tell me the reason why your
• 80:00 - 80:30 doctor there is no thrombocytopenia this is a platelet count is normal in hanoxical in popular it is IGA mediated damage to the blood vessel wall so it is also called as non-propocytopenic or pure a good point that I have Incorporated here why do two different people will develop HSP and the other person will develop virgins disease it's mainly due to HLA variability I mean actually genetic makeup of everybody is different now because actually of everybody is different in
• 80:30 - 81:00 some people iga1 is causing damage to the skin and to the joints and causing blood was damage to the blood vessels or the GI tract so you get uh I mean three things abdominal pain due to vasculitis to the GI vessels uh vasculitis or the skin blood vessels so there is a purpura developing and even vasculitis of the blood supply related to uh The Joint so joint pain will be seen But HLA variability in some people ensures that ij1 attacks only the kidney and that is when we have a common blue merlonephritis developing in the patient
• 81:00 - 81:30 and you have a couple of M's here which are to be remembered like you have these bumps bumpy tongue bumpy lips so you're gonna say mucosal neuromas
• 81:30 - 82:00 present in this particular trap that is one of the characteristic features in men then we have another M coming up that would be Mega colon we also have because of neuromas megacolon marfanoid habitus developing in these patients and other Ms medullary thyroid cancer developing so there are four aims that have described I'll say them again mucosal neuromas Mega colon morphine and habitators and medullary consonant thyroid is what you see with meant to be parathyroid adenoma will obviously be the one which will be the odd one out in this case which would be a feature of
• 82:00 - 82:30 men to a are called as Mentor exactly the answer would be d uh then you should also be knowing regarding genes and chromosomes for each one of them because I think that you have studied them in other subjects also please tell me which chromosome is involved in men four men four is having features of men one plus you could be having some special features while I'm writing those features question for you guys without using Google you have to tell me that which chromosome defect is rated to man4 features of Man 1 plus neuroendocrine
• 82:30 - 83:00 tumors will be present this neuroendocrine tumors can be of the cervix that's the peculiar thing and with the neural endocrine tumors or he might just say reproductive tract tumors in a patient but then where do you read about uh gonadal tumors gonadal tumors are red with men4 I'm having exactly very good answers there the defect would be on chromosome number 12 or just remember three numbers there that would be 11 10 and 12 the three numbers to be remembered I'll say them once again are numbers to be remembered are for men one
• 83:00 - 83:30 it is meningine m a n i n that plays an important role in cellular differentiation man in one gene for men too you read about red proto-oncogene that would be in chromosome number 10 the number is 11 10 and 12 then is men in Men in one then is red and Gene then is uh what what guys are mentioned that is cdk and cyclin base cdkn1b for uh patients who are having multiple the numbers I'll mention one again the chromosome numbers to be remembered would be eleven
• 83:30 - 84:00 ten and twelve 11 would be for main one this would be for men to A and B as well and this would be for min 4. then is Menin then is gonna be red and then is cyclin yeah cyclin dependent kinase in a better one B Gene so cdkn1b okay great and reproductive attractive modes are a feature of man 4. great let's move on
• 84:00 - 84:30 uh soda bicarbonate I have already solved for you you need to multiply The Weight by 0.5 and 24 minus the actual value for sodium just remember that don't multiply straight away by 0.5 you first have to take into consideration total body weight of a person uh total body water of a person which will vary according to the gender for a male the total body water which is to be considered would be multiplication factor of 0.6 and for female the multiplication factor to be taken will
• 84:30 - 85:00 be 0.5 and uh I mean what you need to do in the question is whatever is the weight of the patient you need to multiply that by 0.6 0.5 into 140 minus actual value for the total correction this is this is for the total deficit in the patient but we will not correct the entire deficit in a single day you very well know that if we try to do a fast correction in a person there can be development of Central pontine balinosis in a person called as osmotic demyelination syndrome so if we will
• 85:00 - 85:30 specifically say what is the correction per day yes whether the question is asking you the total deficit or whether it is asking how much will you correct per day for the correction part whatever is the value given in the question suppose sodium values 120 then you don't need to increase from 120 to 135 in a single day you need to increase from 120 to 128 from 128 to 135 it's a gradual rise that I want I don't want a fast price because the risk of osmotic evaluation syndrome which can cause a stroke like presentation in a patient the guy will become crippled for whole
• 85:30 - 86:00 of his life osmotic demolination syndrome features develop 24 to 48 hours after correction they do not develop immediately features of osmotic demyelination syndrome develop 24 to 48 hours after fast correction and what is going to happen in the patient there is going to be development of quadriplegia because of demyelination of the corticospinal pathway plus over and above this granular policies will start occurring in a person so can't talk can't can't eat can't speak where because container pulses with respect to
• 86:00 - 86:30 the brain stem would be affected in this patient so it's always a slow correction I would also like to clarify I would also like to clarify yes Buddhism will develop in this patient I would also like to clarify that if it is an acute onset acute onset hyponatremia then you don't need to go into all this for acute onset hyponatremia you can just give a three percent saline fast 100 ml and this will cause Connection in a patient let me just clarify this in an additional slide and listen to my point very carefully suppose he describes a patient having a
• 86:30 - 87:00 acute onset hyponatremia the sodium value of the patient is about 120. then we have usually seen that if we increase this to about 125 odd patient will stop having seizures acute concert hyponatremia if a person is having seizures you can rise it very fast what we do in the patient is we give three percent Saline this is available in 100 ml I mean bags and this
• 87:00 - 87:30 can be given a relatively fast to the patient that slow thing is valid for that slow thing is valid only for chronic hyponatremia like for example I give I gave a situation also like a athlete as not because athletes you know they stop drinking water and stop taking salt for few days before uh they go for a competition now like you know I give an example of uh I mean social Kumar and others you know they won a gold medal for us but I said competitions
• 87:30 - 88:00 deliberately do water restrictions salt restriction before a competition because they have to fit into a weight category so if it is chronic hyponatremia definition of chronic is more than 48 hours like I said athlete has stopped taking water and salt for few days before competition to fit into a category or he gives you a scenario of
• 88:00 - 88:30 Siad syndrome of inappropriate ads secretion which will usually be given cerebral toxoplasmosis is admitted with this multiple scissors for last one week in your hospital and somebody having chronic hyponatremia sodium or 120 then he says it is a gradual rise so that formula that I have told you that formula is valid for The Chronic variety of hyponatremia not for the acute answer
• 88:30 - 89:00 for acute answer if you into a fast Direction a patient will be fine but like I gave an example of athlete it or I said s i a d h patient admitted in a hospital he will not write a cigarette he will say cerebral doxoglasmosis patient admitted into neurosurgery unit for aspiration of our brain abscess and was having multiple seizures also and now this particular patient medicine call came because this child seizures are not responding to the routine antibiotic drugs and you check the electrolytes and sodium is less that's the usual scenario brain absus patient admitted in neurosurgery for aspiration
• 89:00 - 89:30 because he was having a focal neurological deficit post aspiration is having season so just wanted to clarify on that let's move to the next one hyperventilation which will lead to which ABG change and which electrolyte change uh two questions are simultaneously hyperventilation will contribute to which ABG change and which electrolyte
• 89:30 - 90:00 change in a patient the ABC change in the patient would be respiratory alkalosis and if it is going to be electrolyte changed then alkalosis always causes redistribution of calcium so hypocalcemia can be a big time risk very good very good moving to the next one again a repeat from last time high urine hospitality and low plasma LT can be seen in every time you read a question in which urine osmolarity and plasmos molarity is
• 90:00 - 90:30 having an inverse relation it means the fault is lying with antidiuretic hormone the basic rule is just like you know sodium potassium go opposite with aldosterone similarly urine osmolity and plasmos will go opposite with antidiuretic hormone so now I need to figure out is this patient having diabetes insipidus or whether the person is having s i ADH because he's saying the word low plasma osmolality it means that there is excess
• 90:30 - 91:00 of antidiuretic hormone in the body because excess of anti-diabetic hormone will cause more water in the body and this water in the body will then cause dilutional aspect coming in dilutional would not be an appropriate way to describe it so the person will be having a u-volume hyponatremia the question of the last times the exam side which electrolyte imbalance is likely to be seen in a patient having high urinary and a low plasma spinality your answer would be hyponatremia answer to question number 51 is
• 91:00 - 91:30 hyponatremia yes I think everybody got this one correct also that is Si ADH would be present in this patient absolutely uh not hypokalemia because antidiuretic hormone it is an effect on potassium usual causes of sadh will be CNS causes cerebral toxoplasmosis in a patient or brain abscess in a patient CNS uh or it could be Encephalitis meningitis or any
• 91:30 - 92:00 ideologies AIDS positive patients with meningitis that's where Sid is okay quick look at the following Rhythm disorders uh the first one you will notice that there is a regularly irregular rhythm the RR interval of the patient is changing or our interval of the patient changes with respect to atrial fibrillation and multiple collateral tachycardia in this particular case there is absent p waves
• 92:00 - 92:30 all I can notice is a better twitching so the rhythm disorder which is mentioned in this case should be answered as atrial fibrillation the chemical cardioversion agent that I can be using in this patient is mostly in our hospitals we have availability of amidron or we can use other regions also I mean or other molecules which can be used as well absolutely identify the Rhythm the answer is ethyl fibrillation chemical cardioversion is emitter on first line management is beta blockers in this
• 92:30 - 93:00 patient good very good I'm having good comment sir like no can is for VT right okay so the main keyword you know is made the common error is always a standard I mean the Rhythm Is Not irregularly irregular the key word is irregularly irregular Rhythm I'll
• 93:00 - 93:30 just jot it down irregular RR interval yeah if he gives alcohol history that's okay but one line then again he says Identify the Rhythm and mention the chemical cardioversion agent in this particular case so first I'll be just checking out the RR interval of this guy I mean I can count two squares versus uh if I scan a little to the left I can count three squares also
• 93:30 - 94:00 so once again this particular question is that of a irregular RR interval but simultaneously what I can notice is these waves which are present right before the P wave of the patient so p waves are present so it cannot be atrial fibrillation but you will notice that the height of these p waves the appearance of these p waves is not identical so the next point is that this would be a
• 94:00 - 94:30 variable amplitude of P wave the clinical diagnosis on the basis of this would be multifocalator tachycardia please mention the chemical cardioversion agent that you will be using in this patient you have a DC Shock Doctor I will not say like this that DC shock is contraindicated I'll just say that if DC shock is not recommended for these patients in a sense that there is a recurrence uh I mean that would be an overstatement I mean it's okay I mean I I if I if I give
• 94:30 - 95:00 DC shock because most of the time these are COPD patients uh the hypoxia in the lungs would hypoxia due to lung damage would still be present so uh even if you give a DC shock I mean there's a bound a bound of recurrence in a patient uh yeah either we can give metopranol or we can give a million a patient considering that we are dealing with a person who is having COPD beta blocker is something that I'll not be very comfortable with so it would be a better answer for this question would be calcium channel blocker we can use virapamil as agent for chemical card diversion like we use
• 95:00 - 95:30 Verapamil for prevention in psvt but in this particular case we are using it as an agent that will help in manage managing the case survey do not use DC shop in management of person who's having an anyway we have not asked for cardioversion anyway cardio version chemical cardioversion agent has been asked so where Upper male is to be answered okay moving to the next one uh identify the Rhythm and the chemical card diversion agent so this particular case shows saw Sawtooth waves
• 95:30 - 96:00 what I can notice is presence of that classical sort of pattern this would be a three is to one atrial flutter and the drug that I can use in this patient would again be a chemical cardioversion I can be using amidoron or a class 3 antarithmic like a butylite can be used 53 and 54 are sorted this is not an atrial fibrillation because the RR interval is constant in this case I mean
• 96:00 - 96:30 the RR interval is not changing if you compare the RR interval serially or even subsequently it is almost the same I mentioned what ambed run first because that is what is commonly available in our hospital so class 3 and 10 rhythmic would be used yeah low intensity DC shock I mean for for definitive treatment for ATL flutter that would be a low intensity DC shock would be used that would be a low intensity synchronized DC 25 to 50 joules
• 96:30 - 97:00 that's the only time when you answer low intensity DC okay the next one uh you can notice that the heart rate of the patient is fast because there are a proxy two large squares between the r and the r wave considering that the heart rate of this patient is hovering in the range of about 150 I just need to check that is it a psvt or is it a sinus tachycardia you can notice that the T wave of the patient and the P wave of the patient can be seen separately so this particular case would not be
• 97:00 - 97:30 called as a psvt the one that I'm showing to you at the moment is not a proximal supraventricular tachycardia because if it was a psvt then this T and P they would be margin to a single one this would be a St this would be a sinus tachycardia this could occur most of the time due to anxiety or due to like smoking taking large amount of coffee and Trigger developmental sinus tachycardia in a patient let's compare this with the next ECG
• 97:30 - 98:00 if you compare with the previous one you will notice that in this one there is some magnitude of I will just show that state depression also but the point is at this moment even at this magnification you are able to identify okay let me just use a different color to highlight that I mean what we are saying is that ST depression and then a single wave can be seen in this case unlike the T and the P that was seen separately so this would be a PS VT a proximal supraventricular tachycardia and the question says what
• 98:00 - 98:30 would you use for the treatment of this condition if the BP is unrecordable yes Josephson sign is for patients who are having uh VT this is psvt that we are talking at the moment a global ST segment depression can be seen even at lower magnifications even if I zoom out of the image you can still notice some magnitude of Ester depression seen in this patient that's because of sudden fast beating of the heart in a re-entry circuit created by psvt if the BP is unrecordable in this
• 98:30 - 99:00 case then we will not give adenosine the question said what will you do the VP is unrecordable your answer is I will do cardioversion that is a synchronized DC shock would be used in this case otherwise the answer would have been adenosine why I have not said adenosine in this case is because the question says if the BP is unrecordable so check out the BP values in all tachy rhythmias uh this web already talked about a broad uh I mean broad QRS complex ventricular tachycardia all the waves
• 99:00 - 99:30 are almost of the same same size that would be monomorphic VT otherwise we can use beta blockers in the patient as well even in this case if it is going to be without blood pressure also less case we will have to go in for defame relation in this patient I have hand drawn the ccg already but I hope I would be able to get answers for the 58th one that is currently on the slide yes you are right Josephson sign
• 99:30 - 100:00 was visualized in the previous one we'll give no sir we'll not get the emulator because the BP was unrecordable yes yes guys I can see a pre a QRS and a t like this and then what I can see is r and then a broad s like this and then there's a small T also
• 100:00 - 100:30 yes guys again let me draw it if you are still not able to pick it up see this again p then r then a t so I'm twitching and then there is this nasty big broad R and that slurred slurred as I hope I I have drawn it fairly accurately I mean you can notice the broad R and that's lured s that I've drawn here before you so what are these These are premature ventricular contractions and they are occurring alternative with normal sinuso
• 100:30 - 101:00 Rhythm so I had drawn this ECG earlier before you as well this would be ventricular by Gemini and ventricular by Germany can deteriorate very fast into ventricular tachycardia so if it is a ventricular by Germany the drug that I will be using for the patient would be like yeah appearance is also present in this one yes we can see the rabbit ear appearance here also true why that is happening is because the
• 101:00 - 101:30 routine conduction system is not being respected no I mean the current is utilizing a abnormal Focus which is probably created by a drug so that is why I mean the problem is occurring in this case okay let's move on to the next one uh identify the Rhythm while the CPR is being performed and what is the next best step for management of this patient uh you can notice twitching all around the Baseline uh why not emulator on for ventricular by Gemini sir they have done clinical trials and they have found that the
• 101:30 - 102:00 certain drugs are working by a tree in particular scenarios so let's not challenge that okay so we can notice our ventricular fibrillation in the patient and he's saying CPR is being done by your team what will you do next in the patient so what are you gonna do guys for any patient whose adenosine is for psvt with BP recordable Dr Shreya FPS sweaty BP is recordable that is when we give a I mean stable PSO it is where we give adenosine will give defibrillation for the patient
• 102:00 - 102:30 this table should be used would be you know it should be imprinted in your mind that you have to give three shocks here as you can see and in the boxes they will ask if if this table will come I mean if we will get into this he will love to ask about what will you do subsequently so what will you do after shock you will obviously give a CPR but what is the difference in the three boxes we need to evaluate the first box May what you'll do apart from CPR will be secure IV line or introssier success in the second box what you will do is
• 102:30 - 103:00 that via that IV access you will give epinephrine to the patient and you will be putting endotracheal to Advanced Airway means repeat once again after every shock what are you supposed to do you're supposed to gift one team member two team members will be doing CPR two those giving CPR 30s to two ratio but the interventions the you need to remember would be secure IV line is for the first box if he says one shock has already been given CPR has already been given for two minutes IV line has already been obtained but still person is having a presence of a shock
• 103:00 - 103:30 refractory uh pulseless VT what will you do next your answer is again I'll give CPR and then give epinephrine to the patient and intubate the patient and if these have also been done then in the third box you are giving a medron for the management of this particular patient so the message here is that I mean why do you give epinephrine and why do you give ammutron the reason why you give have been discussed in the main section of the app at the moment in the end I can just summarize is the summary I can say is that at giving adrenaline and amedron makes the efficacy of the
• 103:30 - 104:00 third it increases the efficacy of the third electron and the simplest words I can say is though I've gone into technicals like improving coronary perfusion Etc the simplest I can explain is adrenaline and ammetron in ventricular fibrillation slash pulseless VT improve responsiveness to electrical shock in a patient the correct answer for this one is v-fib and this table has been talked about similarly they they would mention about basic life support
• 104:00 - 104:30 uh you can check this in the PDF and in the previous live session that I have taken on the same channel I have talked about questions on the basic life support also uh routine data you very well know check scene safety SRS no check scene safety R is responsiveness then shout for help assist scene safety RS responsiveness drought for help activate emergency response then is procure AED get the points right the point is activate emergency response then is get AED so there are two A's SRS and two A's but the difference between the two A's is that one is you are
• 104:30 - 105:00 activating the emergency response that is maybe asking somebody to procure an AED machine and then is once you get the aid I mean one is activated emergency response by mobile phone I mean protocol has to be remembered that's the point here and total would be 100 doctor so we are sorted for how many we done for uh 59 40 more to go the question says uh what is the best treatment for this condition you are noticing there is a tachycardia
• 105:00 - 105:30 the RR interval of the patient is substantially reduced it's more looking like a supraventricular tachycardia in fact because uh the p and the T waves separately are not visible but in this area you can notice that there is a sign as pause the presentation is that of the presentation in this case is that a bradycardia tachycardia syndrome bradycardia tachycardia syndrome is a manifestation or defective essay node
• 105:30 - 106:00 the person is having damage to his SN node and for management of this patient we would be putting in a pacemaker your doctor I'll try to finish before that only because now the questions will be easier we'll be putting a pacemaker so the answer here is not a I study we'll be putting in a pacemaker for management of this condition yep I'll count the number of squares in this case the squares that you can count here are one two three four five so there's a
• 106:00 - 106:30 bradycardia the heart rate of this patient is about 60. or I can say a little around 60. there's a priority cardia yes guys what should I answer for this one would you like to answer six sinus syndrome or what do you like to answer sinus bradycardia quickly in the comments please sinus ready or would you like to answer six sinus syndrome can you see a P wave here yes I can see a P wave because I can see a small deflection of a P wave present every time I would not like to call it a
• 106:30 - 107:00 sixth sinus syndrome I would like to answer this as sinus bradycardia there is no treatment required at this particular movement if the person is asymptomatic and uh I mean because the P wave is visible in this case that is why the answer is sinus bradycardia if T wave was not visible we would have answered this as uh answered it as six sinus syndrome next is the standard image where you will be able to notice a gradual prolongation in the PR interval of the patient the first time the second time and the third time and then after the P
• 107:00 - 107:30 wave there is a absence of conduction I mean after the P wave you are waiting waiting waiting there is no QRS complex because there is a gradual prolongation of the PR interval in the patient this would be an example of second degree heart block and in this second degree heart block we are gonna call it a more bits one heart block the easier way to solve this question is check out the PR interval after the drop beat this is the drop so if you're gonna check out the PR
• 107:30 - 108:00 interval after the drop beat and before the drop beat you will be able to notice that the PR interval is unequal which is why this is movements that this particular area and this particular area the PR interval is not equal very good when came back phenomenon is an alternative name for this we'll compare this with the second one in the next one you can notice that the PR interval of the patient is almost the same same
• 108:00 - 108:30 you can notice the drop beat here as well after the P there is a sinus pause present in a person because before and after PR interval before the drop beat and after the drop beat the PR interval is constant constant this would be answered as movements throughout block great M2 move into the next one I would like you to comment on the answer here what I am noticing is there is a drop beat here this is the P wave I am gonna check out the PR interval of
• 108:30 - 109:00 the patient I'm gonna check out the PR interval of the patient before and after before I'm gonna check the PR interval before and after I can notice it is almost the same so first impression of mine is this is also move it Squad block but the point is there is a pattern which is occurring in this case the pattern what is happening in this case is this is a differential diagnosis or mobiles to heart block which is to be remembered the bottom line is that here alternative conduction is occurring because you can notice a normal sinus rhythm then there is a drop
• 109:00 - 109:30 then there is a normal sinus rhythm there is a drop this is a ECG which can look like that or drop is the vertical arrow that are shown after the P when you have normal sinus rhythm drop normal size Rhythm drop this is a differential diagnosis of mobiles to heart block that is called as two is to one block so every time in the exam when you wanna check out mobits 2 mobile 2 is gonna be like three then I drop five or drop 10 or drop 100 or drop like that it would be asymmetrical
• 109:30 - 110:00 whereas here it is NSR drop NSR drop I repeat that again for more bits 2 it would be like 10 bits normal then there's a drop then 15 then I drop 100 then a drop after half an hour then I drop asymmetrical but here it's gonna be regularly occurring which is why we would be answering this as 2 is to 1. and the subsequent one you will notice that the number of the p waves and the number of the QRS complexes are not matching I mean there are many more p waves present p waves I I can count
• 110:00 - 110:30 almost five six p waves whereas I can count only three broad QRS complexes three okay maybe four QRS complexes so because the number of p is not matching with the number of R waves number of p waves and the number of R waves or the peak of the RS complexes is not matching we will think in terms of our av dissociation and this Avid Association would be called as third degree heart block so perfect
• 110:30 - 111:00 Avid Association absolutely this is the particular condition where we go for a dual chamber facing the question says dual chamber facing is done for answer is third degree heart block away dissociation the last ECG that I'm showing you has been discussed even earlier in this section only I would like you to notice the change in the amplitude of the QRS complexes b2bit variation this particular patient is having blunt
• 111:00 - 111:30 chest trauma like he was driving a car without a seat belt he has been admitted to my hospital with very low blood pressure unrecordable BP or very low blood pressure when I ran the ECG of this guy I noticed that there was electrical alternates present the ECG pattern is electrical alternates and this clinical presentation is that of cardiac tamponade innovation yep very good then the findings of hyper and
• 111:30 - 112:00 hypokalemia have already been discussed I said them earlier also I'll just say that take T waves then you have is a broad QRS complexes coming up loss of P wave occurring so I mean that's the standard feature and then you get a sine wave pattern that sinus portal pattern is the sine by pattern that would come up in a patient even if ECG is normal in a patients if electrolyte report is abnormal you still need to treat the patient with help of calcium gluconate I mean Emergency Management is calcium gluconate followed by insulin drip
• 112:00 - 112:30 treatment of choice would be insulin trip for hypokalemia there would be opposite funding and one of the fundings which has been asked in need PG is pseudo pulmonil you very well know that pulmonary seen with pulmonary artery hypertension but with hypoglymia PVA will become bigger where hypergalenia PV will become smaller and will disappear next is flow volume curves for flow volume curves I wanted to remember at least two minimal flow volume curves that I'm gonna hand draw before you and you can see I'm putting star Mark here
• 112:30 - 113:00 single star Mark versus double star Mark and you can comment for the single star Mark initially while I draw it the inspiratory part is fine but during the expiration part there is a scooped out concavity present this cooped out concavity where I put a star Mark present is for a person who's having obstructive variable disease so this may be a patient of COPD or asthma and how will I differentiate between the two will be that I will be giving a bronchodilator to the patient and I'll be repeating this curve once again
• 113:00 - 113:30 when I give a bronchodilator and if I'm gonna repeat this test again if I notice a change the change would be like this if I notice that this concavity becomes lesser if this concavity becomes lesser it means it is asthma because COPD is an example of a non-reversible Arabic disorder the change that should be demonstrated in the value of fev1 before and after salvata mold should be at least 12 percent we now look at when the double star Mark is present
• 113:30 - 114:00 you are noticing that in this particular case let me just hand draw this once again before you you will notice that this is normal and now this curve has become relatively more shrunken and it's adopting a much more peeled appearance as well which is called as a beanie cap appearance this would be a feature that is seen with respective lung disease so if a person is having pulmonary fibrosis then the total lung capacity is lesser that is why the curve is all restricted in this particular case and indicates interstitial lung disease though in the
• 114:00 - 114:30 routine sections we have talked about even tracheal stenosis where you will have a fixed obstruction present like this particular case the inspiratory part is also narrowed and the expiratory part is also narrow this tells you that there is lesser going in less coming out that would be tracheal stenosis in a pressure but at least the parameters for obstructive and restrictive one should be remembered in flow volume curves coming to 70 he says what is best to prevent thrombomalism in a atrial fibrillation patient with mitral
• 114:30 - 115:00 stenosis then we have discussed we will be giving Warfarin in the patient for non-romatic we'll be using a navigator and other molecules moving to 71 please answer valenberg syndrome does not involve which is lateral Metallurgy syndrome so the containers are involved in this condition would be 5 7 8 9 10 11 but this is not gonna involve wichner the answer would be very good Luffy was the first one to answer this would be the 12th in a great great very good because
• 115:00 - 115:30 12th nerve is involvement of medial medullary syndrome so a quick look at you read that in anatomy also the blood supply for the various ones okay moving to 72 elevated immunoglobulin e and Central bronchic testers in a patient would be a feature of Legion or a doctor that digirin
• 115:30 - 116:00 russino that is seen in a chap who's had a subcortical stroke internal capsule the sensory fibers getting affected that would be more important around the moment very good the key word in the question is Central bronchictasis every time you read this word the clinical diagnosis would be as allergic bronchopulmonary aspergilloma this would be because of aspergillus female get us not Niger which causes invasive
• 116:00 - 116:30 aspergilloma it is fumigators which would be used what would be used for treatment you one way to give options steroids liposomal amphotosol post chronazole steroids or aquatic subservation of allergic bronchopulmonary aspergillomasters foreign
• 116:30 - 117:00 foreign
• 117:00 - 117:30 if epithelial sodium channel will work
• 117:30 - 118:00 more than normal more water and more salt will come in the body that more salt and more water will explain hypertension simultaneously there is gonna be a urinary loss of potassium and hydrogen and that urinary loss of potassium and hydrogen will be explaining that urinary loss or potassium hydrogen will be explaining the hypokalemic alkalosis developing in this patient uh yeah a doctor cons would be a important differential absolutely absolutely doctor I mean Dr Monica you have a point there even con syndrome has to be considered here little cons but we can
• 118:00 - 118:30 differentiate between the two on the basis of aldosterone values we pull your right differentiating feature would be based on uh checking out the aldosterone values and aldosterone values would be increased with respect to constant room okay moving to the next one what is the leading vascular cause of development of lower ja bleeding in a patient chloride resistant metabolic alkalosis yes for little it is a very good differential diagnosis as
• 118:30 - 119:00 people answered very good very good if a person is having lower J bleeding then the first cause to be thought of is always piles and hemorrhoids but using a vascular cause so vascular blood vessels
• 119:00 - 119:30 if the question says what is the most common cause of lower jability it is then that you need to think in terms of diverticular bleeding that is when you think in terms of diverting kilosis in a patient but question the vascular cause or not the vascular cause would be angio dysplasia disease
• 119:30 - 120:00 in question number 74 the soil is vascular malformation in a patient otherwise the number one cause of leading vascular or leading jio calls or J bleeding is diverticulosis hospitalization requirement s hospitalization requirements leading cause of upper gear bleeding would be upper J I mean that would be total hypertension which will cause development of esophageal varices
• 120:00 - 120:30 okay very good 75 is esophageal varices leading cause of operation peptic ulcer disease that would be either the left gastric artery or a gastric dual artery that would be bleeding in this case we'll be doing upper gendoscopy and then we'll achieve local hemostasis plus we do a bipolar artery of the base of the ulcer okay next one please uh Duluth voice is
• 120:30 - 121:00 a vascular cause again of the stomach bleeding no that is a rare cause vascular cause uh what is the first investigation to be done in a patient with Molina for last three days and acute lower J bleeding today so what is uh the first investigation to be done very good I'm having limited answers very good ambika location yes yes very good yes very good very good
• 121:00 - 121:30 okay okay uh what is the most common cause for maligna what is the most common cause of Malena by the way bleeding but Malina is bleeding but but the point is that what is the most common cause of malinitis peptic ulcer disease now so if he was having minimal bleeding from the ulcer which is because it was minimal bleeding from the ulcer are those
• 121:30 - 122:00 so what is your answer now is it still colonoscopy sorry even in the app I've told you what is the investigation to be done in a case of Malena do you do colonoscopic pain operation directly first investigation in any patient who is having Malena is not gonna be answered by U.S colonoscopy the first investigation is apartheid foreign
• 122:00 - 122:30 foreign
• 122:30 - 123:00 otherwise that could be hepatitis C induced cirrhosis as well may not cause vomiting of blood in a person ulcer might cause the blood to eventually flow through the giant rectangle cause here that's the point of torrential bleeding torrential with the arterial bleed can cause Frank blood to
• 123:00 - 123:30 come mostly upper J bleeding will cause hematomy is understandable configurance vomit is understanding but if it's a doodle ulcer then there's a possibility that it might cause torrential bleed in the lower GI also okay I think I missed one yep best treatment to be done for a case of bleeding esophageal viruses vasoactive agents Endo uh endoscopic variouser ligation tips
• 123:30 - 124:00 yeah foreign tips is a procedure which is usually done after recurrence after endoscopic various eligations tips is done only in cases of recurrence
• 124:00 - 124:30 no sir you are putting up I mean a shunt in the patient that's a procedure that will require hospitalization so the best way would be uh uh I would say same day admission same day that is the endoscopic various ligation is the treatment of choice for bleeding where I sell bleeding esophageal varices agents are only given for two to five days now foreign
• 124:30 - 125:00 [Music]
• 125:00 - 125:30 so you need to control the variety of bleeding now so that is why the answer for answer for 77 upper the endoscopy okay okay doc I'll speak mainly in English uh the point is for any chap with bleeding esophageal prices uh nadalol is for non-blading varices tips is for recurrence for Vaso active agents we use give them for two to five days then we stop them and the advantage of that is that it will lower the portal vein pressure but that's not a permanent solution for the case I mean the permanent solution would be an endoscopic variable ligation in a
• 125:30 - 126:00 patient let's not argue guys we are doctors let's why to fight about such a small thing sir let's not pass any comments okay my humble request just few hours before the exam here why to have wrong wordings being used okay best for diagnosis of alcoholic hepatitis and determining alcoholism I got a lot of it's okay dog it's okay perfectly fine you know I'll speak majority in English only few words because it's my mother tongue I might accidentally speak some words in Hindi also I mean that happens with you also sometimes can happen with
• 126:00 - 126:30 anybody okay coming back uh what is the best test for alcoholic hepatitis versus best test for determining alcoholism you see the point is a lot of people who drink alcohol might say I don't drink alcohol his wife is saying wife says he drinks every day and he said no no I don't drink alcohol so how do you determine whether the guys a regular Drinker therefore for diagnosis of alcoholism the answer is that is gamma glutamyl transpect it is but for determining alcoholic hepatitis alcoholic hepatitis severity grading is
• 126:30 - 127:00 done on the basis of discriminant score or what is called as discriminant function and one of the parameters that we always use in discriminant score in alcoholic hepatitis is sgot that's because that's where sgot is present where inside the mitochondria where the alcohol is getting metabolized and then he can ask you about treatment of alcoholic hepatitis that would be prednisolone that esteroids would be used no sir will not use belt in this particular case meld is to be used when
• 127:00 - 127:30 there is a need for orthopic liver transplantation like if I say a person is having a end-stage liver disease and I wanna check out whether he is a candidate for I mean he's having features of liver damage but I want to enroll him for uh orthotic liver transplantation then I will have to do a med score in a patient and enter the data in a dedicated unsos Unos website organ sharing based website and based on availability then this guy might receive a liver transplantation okay yes battery is discriminant score
• 127:30 - 128:00 very good Kunal need for liver transplantation is decided on the basis of Middle School uh sir we can use it we can use it we can use carbohydrate deficient transferring both are given in Harrison first gamma Gert then carbohydrate deficient transfer and then is written macrocytic anemia MCV more than 100 so I don't dispute what you said Doctor I mean yes but the weight is given in the book I I have described it
• 128:00 - 128:30 is to grade the need for liver transplantation child score more than seven and belt score more than 17 are indications for admitting a patient for liver transplantation in child support the parameters are bilirubin INR and then there are three A's the three is to be considered would be albumin if albumin is less there would be ascitis and at the same time these particular chaps would also be having encephalopathy that will cause asterixis here the components are bilirubin INR
• 128:30 - 129:00 creatinine and nowadays they also speak about meld nne in meld n a then if he says this word instead of saying meld if the question says then you also include serum sodium that's because hepatourinal syndrome can occur in the patient also so melodyne would include the the sodium component as well okay moving ahead
• 129:00 - 129:30 uh then I would like you to also remember this table with respect to Hepatitis B the PDF will be present in the group you have it in your notes also what I want you to just quickly revise here is all of you know about acute and chronic hepatitis that's never a problem surface antigen positive versus IGM class of antibody to core antigenet IGG class of antibody to core antigen so acute and chronic hepatitis of yours is sorted I mean this does not require any special effort on your part but he can give you questions in which surface antigen will be negative so there are
• 129:30 - 130:00 three possibilities where surface antigen can be negative in the question so let's look at those three possibilities the first one would be if he is going to talk about IGM class of antibody with surface antigen negative that is window period so that window period part I've already explained but in the app also but the message is if surface antigen is negative with IGM class of antibody normality surface antigen positive IGM plus of antibody that's acute hepatitis B if we will say surface and is a negative with izm class of antibody it is acute hepatitis B the
• 130:00 - 130:30 next one is important is giving you negative for surface antigen and IGG loss of antibiotic to the core antigen is present in a patient that means he had infection in remote past remote past and if it is going to be recovery from Hepatitis B then there will be positive two antibody to surface antigen also you can see this is the protective antibody no antibody surface antigen gives protection so I'll post it uh the PDF in the group okay let me just zoom it in and I have
• 130:30 - 131:00 to say it again I I lost the connect uh there are three scenarios where there would be negative surface antigen positive surface antigen no issues acute and chronic Hepatitis B three scenarios for negative would be window period second is remote infection third is recovery let's first focus on window period window period is only when one antibodies only antibody present is IGM class of antibody to core antigen so Windows IGG class of antibody to core antigen will be positive and negative surface antigen how will you say remote versus
• 131:00 - 131:30 recovery then the logic to be used is recovery means that the zero conversion antibody is there zero conversion antibodies where in the zoomed part where you can see my arrow finishing that is antibody against the surface antigen present so when you are trying to work it up there are five permutation combinations that have spoken in the last 30 seconds acute chronic not a problem window period again not a problem but the remaining to the remote past and the recovery part just have a glance at that and I'm sure that you will be able to solve these nasty ones
• 131:30 - 132:00 also which if he wants to give up in the paper as well so I mean the top there are five permutational combinations three will not cause a problem for you it is only the last two that have said practice and it is gonna be it's gonna be recovery from Hepatitis B which is gonna be uh the main point for differentiating between remote past versus the recovery part only okay guys uh sir video hereditary hyperbole Rubin image to access in August seven and a half minutes you'll be able to do that Dubin Johnson
• 132:00 - 132:30 okay moving to 82. gmail.com and uh I'll try to clarify the query uh which I'm not addressing at the moment
• 132:30 - 133:00 I mean this is what we traditionally read MRI is showing a mammalary body a trophy that is mainly a feature that is seen with Corsica of psychosis I'm asking about vernica's encephalopathy it's not that you are wrong but there is a slight uh technical aspect that mainly in varnika's encephalopathy our PDF will be available in the preplotter telegram group as well as in my telegram group or
• 133:00 - 133:30 you can email me at marvamedicine gmail.com would be answered as the the thalamus your answer would be dorsomedial thalamus it's not that uh we are not gonna have a involvement of the mammillary body yes we have it but your first answer for vernica's area is Thalamus getting affected yes Zen mode you're right then is Apple lipoprotein associated with developmental Alzheimer's diseases
• 133:30 - 134:00 hypolipoprotein e it is APO lipoprotein e which is related to uh welcome to your point that uh this is not yeah yeah it's not vernique is aphasia absolutely absolutely I think a lot of people were thinking is encephalopathy then this apple lipoprotein PDF will be available in okay you can mail me I am writing my email ID here marvamedicine gmail.com
• 134:00 - 134:30 which variant of Apple lipoprotein is protective for Alzheimer's disease what you are answering me is very correct the Epsilon 4 variety of it is leading to Alzheimer's disease and the one that is protective would be Epsilon to override it though number come a protective numbers 84.85 sorted okay entry levels
• 134:30 - 135:00 some people like to listen some people like to read PDF so let's not be nasty to each other entry level criteria for diagnosis or SLE word right here entry level criteria for diagnosis of SLE quickly guys what test would you do for I mean entry level criteria you can answer clinical criteria you Answer Lab criteria yes yes anti-nuclear antibody absolutely one is 280 feet fine great best screening test was Scleroderma guys
• 135:00 - 135:30 yes yes during the end of our discussion very good anti-nuclear antibody sorted I'm looking for 87 answer what is the screening test for diagnosis of Scleroderma the answer is still anti-nuclear antibody but if he says what is the investigation of Vice Versa Scleroderma then your answer will change yes then the answer would be given as topoisomerase antibody antibody list a quick revision would always be warranted and would help you I mean sort those
• 135:30 - 136:00 names easily no sir will not do anti-smith there antitope isomerase for scleroderma centromere is for seasonal here anti-centromere is for Crest syndrome anti-central antibody the c alphabet to be remembered for cross syndrome wherever calcinosis okay okay few room at once left most common extra articular manifestation of rheumatoid arthritis yes guys
• 136:00 - 136:30 fervator arthritis extra articular manifestation would be DNA we are sorted for limited it is centromere yes submarine you're right absolutely the extra articular manifestation would be rheumatoid nodule they would be found on extensor distribution okay then is ocular involvement of rheumatoid arthritis
• 136:30 - 137:00 no guys it is not evitis I have explained that also no it is not Avi this I have stored this multiple times even in the last session we had a chat about it is arthritis the ocular involvement was discussed Even in our last times discussion in the live last live we had
• 137:00 - 137:30 that it is not to be answered it is for others you can answer the varieties that is okay but yeah that's a good point I think Dr kennel mentioned that that you where it is component will be answered only for juvenile rheumatoid arthritis but not for adult version okay guys uh uh what is the travel choice for mild to moderate Crohn's disease and then for moderate to severe Crohn's disease
• 137:30 - 138:00 yes yes guys cross disease we do up I mean we classify Crohn's disease severity activity index yeah steroids will be used as a therapine I'm getting steroids for mild to moderate sir it would be answered as budacenide ideal release preparation but if it says what is for severe coron's disease then answer would be
• 138:00 - 138:30 given as redness alone but if it says crystallizing fistula present then what medicine will you give for men what what will you do for multiple fistulas in person with crohn's disease options are referred to surgery treat medically very good you will be starting the patient on infusion of inflex synapse
• 138:30 - 139:00 in Crohn's disease if it is mild to moderate we give ideal release preparations if it is severe oral steroids are required if it is multiple fistulas will not refer for surgery because agaram surgery they would be recurrence at the site of wherever the person has been operated upon plus the gut ball is friable so for healing of ulcers we'll go in for infleximab infusions but before we give inflexible infusion we must rule out possibility of tuberculosis in a patient so the question said which test must be done before giving inflexium of infusion in a
• 139:00 - 139:30 patient who's having fertilizing Crohn's disease then we should be doing is a TB gold quantiferon test if we do not have TB gold quantiferon then no issues we can do a montauks test also that would be a purified protein derivative based test but tuberculosis is a big time risk with or reactivation of TB is a big time risk with usage of these patients Miss salamine is only for supportive Management in these patients uh primary agent would be steroids in Crohn's disease
• 139:30 - 140:00 sulfasalazine and sulfasalazine ulcerative colitis we do not give sulfasalazine to patients who are having Crohn's disease because sulfasalazine acts only on the colon and mostly in uh Crohn's it would be small intestinal involvement also so with your answer would be given as misalamine we have a controlled release preparation or we have a delayed release preparation this is used in Cross disease in a patient that is again for mild to moderate variety along with
• 140:00 - 140:30 either release preparations okay moving to the next one which is the most common cause sulfur salazine is only for ulcerative colitis uh most common cause of pneumonia in its positive patient would be the answer is pneumococcus as I've explained whether he says pneumonia whether it says lobar pneumonia the answer is always to be given as pneumococcus and not as pneumocysters most common cause of pneumonia I'm getting tuberculosis as answer I'm still getting 0 AC as an
• 140:30 - 141:00 answer I've explained this a large number of times AIDS person will also be living in community a female Living Community he will develop community acquired pneumonia so the answer is still pneumococcus 0 AC should be answered only when he selectively mentions regarding Excel findings in a patient I mean when would you answer zero AC would be the query in your mind at this Junction so let me just resolve it for you one possibility is he says x-ray of the patient is turning out to be normal but when the doctor checked alveolar
• 141:00 - 141:30 artillery gradient the alveolar artillery gradient in the patient was grossly High Ori says the patient shows presence of specific organisms which you guys are describing as balls or hockey balls or whatever and along with that obviously because it is opportunistic infection the CD4 counter the patient will be given to be low so only when you start getting these kind of information in a question that you should think in terms of zero AC otherwise routinely it is not zero they
• 141:30 - 142:00 say it is pneumococcus steroids in any patient or where there is problem it's Alpha Drugs said a person is having a problem with sulfur salvation the problem is sulfur pyridine so either I can even in that chap I can be using a controller release preparation of misalamine if we still can't tolerate that I'll be using steroids black fungus is not mucur is not mucous black fungus is not nuclear it is
• 142:00 - 142:30 foreign black fungus is a misnomer for mucon I think I mean stage will not follow fall into this trap but I think it's clear for everybody that black fungus is a misnomer for miracles investigational choice for neurosyphilis quickly please yeah demitious fungi quickly guys the investigation Choice
• 142:30 - 143:00 One Euros would be CSF adrl uh we'll not use a benzothine penicillin in this case guys we'll be using in this particular case penicillin G foreign G because we need a CNS penetration to occur in a patient most common site of gastroenoma I mean I know it is a gastronoma triangle for Saros triangle as you know uh boundaries I'll mark before you while you guys give
• 143:00 - 143:30 me the answer for most common cytogastrinoma you will start from junction of the cystic duct where it meets with a hepatic duct then you will join it with area where the head and the body of pancreas are beating and then you will dissect it at where the second and the third part of the due to them are meeting I said three points Junction of cystic duct with hepatic duct then it's gonna be uh I mean a head and body of pancreas and second and third part of pancreas uh where the meeting these are the three points which have to be remembered for the anatomical location of gastronoma triangle the most common
• 143:30 - 144:00 site would be the duodenum and this person would be having refractory practical sir he will be having giant dudenal ulcers whenever you read about refractory don't know also giant ordinal ulcer or doodle also at the second part of dudum sometimes even in the third party with H pylori you never read about a peptic ulcer at second or third part of digital but if you're gonna read it in the first part no sir not first part of the dude now if you read ulcer in the first part I mean I'm talking about ulcers the ulcers are gonna be the ones which are
• 144:00 - 144:30 considered okay what test would you do for anatomical localization of a gastronoma best test for any tumor localization is Pet City best test for any tumor localization is Pet City the best answer would be Pet city that is gallium 68 DOTA 8 however if Pet city is not given then you will answer as endoscopic ultrasound
• 144:30 - 145:00 otherwise I mean no issues I mean for whether even if he says if he says what is best test for localization of a best test for localization of a few chromocytoma I've told you MRI in the routine videos my point is that MRI localization is very very less if a tumor is very very small then you may not be able to you may not be able to identify or you may not be able to pick up the tumor so that the answers are the way I have mentioned we will use Pet City DOTA 8 is the best one
• 145:00 - 145:30 endoscopic ultrasound subsequently absolutely okay coming to the remaining field once our inclusion in a urine cytology yes especially at Zucker candle location extra adrenal that City would be very good our inclusions in urine cytology or for renal transplant infection indicates electromegalovirus these would be basophilic conclusions and this will contribute to graph failure in the patient the not a criteria for diagnosis or metabolic syndrome I mean in metabolic
• 145:30 - 146:00 syndrome we take into consideration elevated triglycerides we take into consideration low value of HDL but we okay I'm still people are still answering uh cytomegalovirus yes not a criteria for diagnosis of this would be high LDL I mean we will be having obesity in this patient 30 centripetal obesity for which abdominal circumference criteria will be used on 90 and 80 90 for a male patient 80 centimeter for a
• 146:00 - 146:30 female patient you'll also be having hypertension in these patients they will also be impaired glucose tolerance occurring in the patient but you will not have a high LDL it is increased triglyceride and low HDL in the patient great okay then we come to the remaining last two questions there inherit the nitroxide is used for management of which of the following quickly guys inhaled nitroxide okay somebody answered
• 146:30 - 147:00 from the back yes pulmonary artery hypertension absolutely we use in here nitroxide or we can use inhaled prostaglandins also and let's do the honors with the last one for today I'm a little what you can say is uh I like 101 more than 100 so I thought it make it 101 though I can continue more than that also but I think uh you guys might be exhausted uh which of the following is used for management or ceteroblastic anemia yes guys your repeat question vitamin B6 so we call it
• 147:00 - 147:30 pyridoxine responsive plastic anemia uh well guys uh this would be the end of the discussion for today uh this would be my email ID in case you have any last minute issues I mean if I can help I'll try to and uh so the PDF will post that in the prep larger telegram group or in my telegram group as well and uh it's been great serving with all of you honor working with all of you and uh I am very sure
• 147:30 - 148:00 that uh post this uh phase I mean all of you are gonna be having big smiles on your faces doctors always have some troubles in their life that's okay but then we are not the kind of people who would be uh you know happy with buying a BMW or you know we are happy with simple good food comfortable like if in a sense that at least trust no your attention now so uh you guys uh sir first line answer
• 148:00 - 148:30 is it's by reduction responsive and India sorry you can go through the lecture part for understanding the pathology behind it so God bless you guys I'm very sure all of you will do great in your life and [Music] I am speechless with all the nice words that you guys are doing uh I'll post this guys thank you so much thank you so much thank you so much I have missed a lot of names I'm really
• 148:30 - 149:00 sorry for that Dr bhavin Neha Dr RK Dr Meena thank you guys God bless you so let's wind off the discussion for today uh foreign
• 149:00 - 149:30 check out all the Google Maps etc for any local protest in any City Etc uh that can cause a bit of problems my one message to all the people will be that success is something which which nobody can pre-pone or postpone everybody gets it
• 149:30 - 150:00 on time right and I I have never seen a doctor not being able to I mean there are problems now I understand residency is pressure everything but eight limited you tend to become immune to all of that and start doing good in your career you start getting the flare of picking up things and you start thinking okay or I'll do independent my thing so I I don't think so that we need to be uh having any negative overview with
• 150:00 - 150:30 respect to our careers at this stage I understand everybody thinks gay or the others are earning more and other people are enjoying we are studying but then you guys are designed for this only I think so this is my advice for you guys okay guys thank you so much I can continue with the Chit Chat and this will waste your time so God bless you take care bye thank you
• 150:30 - 151:00 [Music] [Music] foreign [Music]