Serum osmolarity

Hand made diagram - Mammary gland at puberty - hematoxylin eosin

Mammary Gland at Puberty high resolution histology diagram
Click on the image to enlarge it.
You may also save it to your computer for more zoomed view.
Feel free to use for study purposes.
©Tsnaps
Your comments are Welcomed.

Esophagus - handmade histology hematoxylin eosin

oesophagus high resolution histology diagram
Click on the image to enlarge it.
You may also save it to your computer for more zoomed view.
Feel free to use for study purposes.
©Tsnaps
Your comments are Welcomed.

Simply piano johny johny yes papa

Probiotics

Have shown beneficial effects so far in following diseases (but didnt reduce mortality)

G/E
IBD
IBS
Hepatic Enceph
Liver transplant
VAP
Chemo patients against listeria
Pregnant against listeria
Premies
NEC
Psychobiotics(bifido)

3 temperature set points digital thermostat using arduino

The aim of this project is to make a thermostat which can work according to 3 temperatures, selected through 3 button presses .

Button 1 for 30 degrees Celsius

Button 2 for 37 degrees C

Button 3 for 45 deg C

The other objective is , to display both the CURRENT temperature and the SET temperature on OLED display. 

I am using Dallas instruments 18b20 temperature sensor, and i2c OLED display, with arduino UNO CH340 version. In my opinion any arduino will work as it is a simple circuit diagramwith simple piece of code running.

I have shared arduino code for this thermostat below.

And the youtube video ,too.

My programing skills are novice.

I hope the libraries i uses, for OLED display, ONE WIRE, DALAS TEMPERATURE SENSOR, ADAFRUIT GFX LIB, all are easily available through ARRDUINO IDE.

any questions , feel free to ask.

GOT A better code? please share with me, specially code to get same working using one SWITCH (used as toggle switch).





#include <SPI.h>
#include <Wire.h>
#include <Adafruit_GFX.h>
#include <Adafruit_SSD1306.h>

#define OLED_RESET 4
Adafruit_SSD1306 display(OLED_RESET);
#define SSD1306_LCDHEIGHT 64 // OLED display drivers end here


#include <OneWire.h>
#include <DallasTemperature.h>

// Data wire is plugged into port 2 on the Arduino
#define ONE_WIRE_BUS 2

// Setup a oneWire instance to communicate with any OneWire devices
OneWire oneWire(ONE_WIRE_BUS);

// Pass our oneWire reference to Dallas Temperature.
DallasTemperature sensors(&oneWire); //Temperature Sensor Drivers End here


int tempset = 0;
int relay = 7;
int b1 = 9;
int b2 = 10;
int b3 = 11;

int t1;
int t2;
int t3;



void setup() {
pinMode(b1, INPUT); //Button 1 with internal pull up
pinMode(b2, INPUT); //Button 2 with internal pull up
pinMode(b3, INPUT); //Button 3 with internal pull up
pinMode(relay, OUTPUT);

Serial.begin(9600);
    display.begin(SSD1306_SWITCHCAPVCC, 0x3C);
    display.clearDisplay(); //till here is OLED i2c serial communication on 0x3c

    sensors.begin();// Start up the dallas temperature sensor


display.setCursor(29, 8);
  display.setTextSize(1);
  display.print("Temperature");
  display.setCursor(0, 16);
  display.setTextSize(1);
  display.print("CURRENT");
  display.setTextSize(1);
    display.setCursor(85, 16);
  display.setTextSize(1);
  display.print("SET");
  display.setTextSize(1);
  display.display();


}

void loop() {
  sensors.requestTemperatures(); // Send the command to get temperatures
 
  display.setCursor(4, 24);
  display.println(sensors.getTempCByIndex(0));
  display.setCursor(85, 24);
  display.println(tempset);
  display.display();

   t1 = digitalRead(b1);
    if (t1 ==  HIGH )
    {
      tempset = 30;
    }

   t2 = digitalRead(b2);
    if (t2 ==  HIGH )
    {
      tempset = 37;
    }

t3 = digitalRead(b3);
    if (t3 ==  HIGH )
    {
      tempset = 45;
    }

if (sensors.getTempCByIndex(0) >= tempset)
{
  digitalWrite(relay, HIGH); //HIGH turn off relay
}

else
{
  digitalWrite(relay, LOW);
}
 
}

Treatment of asymptomatic and symptomatic Hypoglycemia

The treatment of asymptomatic hypoglycemia is by enteral feeding rather than intravenous glucose however if symptoms persist despite enteral feeding intravenous glucose in indicated

In case of symptomatic hypoglycemia intravenous administration of 2 ML per kg of 10% dextrose water is indicated and if hypoglycemic seizures are present then the dose is 4 ml per kg of 10% dextrose water

For the management of Persistent neonatal or infantile hyperglycemia at first the rate of intravenous glucose infusion is increased to 10 to 15 milligram per kg per minute or more if needed
Furthermore Central venous Line or umbilical venous catheter may be inserted to administer 25% dextrose water

If hyperinsulinemia is present it should first be medically managed using diazoxide and then somatostatin analogues

If it is unresponsive to medical management then surgery in the form of focal or total pancreatectomy is indicated

The dose for oral diazoxide is 5 to 15 milligram per kg per 24 hour in to divided doses.  it can reverse the symptoms of hyperinsulinemic hypoglycemia  however it can produce edema nausea hirsutism hyperuricemia electrolyte disturbances immunoglobulin G deficiency advanced bone age.

Glucagon can be given by continuous IV infusion at 5 microgram per kg per hour together with somatostatin administered subcutaneously every 6 to 12 hourly in the dose of 20 to 50 microgram per kg per day

The unusual complications of octreotide includes poor growth because of inhibition of growth hormone release ,pain at injection site, vomiting ,diarrhoea and hepatic dysfunction in the form of Hepatitis and cholelithiasis , or necrotising enterocolitis or tachyphylaxis may also occie.

Discussion on diagnosis and differential diagnosis of hypoglycemia

During the early neonatal life most of the infants have transient form of neonatal hypoglycemia either as a result of prematurity intrauterine growth restriction or being born to diabetic mother

Infant born to diabetic mother are macrosomic having characteristic large plethoric appearance

If however the Infant does not have a history of being born to a diabetic mother and is macrosomic having plethoric features with hypoglycemia , this should raise the possibility that the Infant has hyperinsulinemic hypoglycemia which may be due to autosomal recessive or autosomal dominant forms

If there is reducing sugar in urine such that clinitest test is positive but clinistix is negative and the patient has persistent jaundice with hepatosplenomegaly with normal development galactosemia may be considered

In a male infant if there is presence of microphallus with cholestatic jaundice in both genders or with evidence of midline facial defect such as cleft palate it should raise the possibility of hypopituitarism causing hypoglycemia due to deficiency of growth hormone or cortisol

The hypoglycemia episode due to  alcohol or salicyclic can be excluded by history

At the time of hypoglycemia The Following serum samples should be drawn

Beta hydroxybutyrate

Serum lactate

Free fatty acids

Insulin level, cortisol level ,ACTH, growth hormone level

These tests are then repeated after an intramuscular or intravenous injection of glucagon

In hyperinsulinemia, low Concentrations of serum c-peptide level confirm that hyperglycemia is due to exogenous insulin administration in which case the levels of insulin are high but c-peptide levels are low

However in case of deliberate or accidental ingestion of drugs that stimulate endogenous insulin secretion the levels of both insulin and c-peptide concentration will rise and it requires specialised laboratory methods to identify the offending substance

Pituitary- adrenal function and arginine-insulin stimulation test for growth hormone insulin like growth factor-1, insulin like growth factor binding protein 1 and may also be necessary.

Multiple systemic disorders related to hypoglycemia

The multiple systemic disorders related to hypoglycemia include

Neonatal sepsis

Malnutrition

Malabsorption

Hyperviscosity

Falciparum Malaria

Heart failure

Renal failure

Any severe illness with decreased intake

Defects in glucose Transporters leading to hypoglycemia

Glucose Transporter glut 1 deficiency patients have low glucose levels in cerebrospinal foods despite having normal serum glucose levels

The concentration of lactate is also low in the cerebrospinal fluid suggesting decreased glycolysis rather than bacterial infection and hence it shows that the cause of low CSF glucose is not the bacterial infection but actually the Transporter defect

High ketogenic diet reduces the severity of seizures by supplying an alternative source of brain fuel which then bypasses the defect in glucose transport

In glucose Transporter 2 deficiency children have hepatomegaly , galactose intolerance and Renal tubular dysfunction collectively known as fanconi-bickel syndrome.

The clinical manifestations related to hepatomegaly and Hypoglycemia are there because of impaired release from liver and due to defective tubular reabsorption there may be associated phosphaturia and aminoaciduria.

How salicyclate intoxication causes hypoglycemia

Salicylates like aspirin diflunisal can cause both hypoglycemia and Hyperglycemia in children with their toxication

Accelerated use of glucose occurs because of augmentation of insulin secretion and inhibition of gluconeogenesis,which leads to hypoglycemia.

Ketosis can occur

How hypoglycemia occurs in acute alcohol intoxication

Acute alcohol intoxication impairs the process of gluconeogenesis in the body

This results in hypoglycemia if glycogen stores are depleted either by starvation or by preexisting abnormality in glycogen metabolism

In toddlers who have been fed even a small amount of alcohol can lead to symptoms of hypoglycemia

Mechanism of action of sodium valproate causing hypoglycemia

Sodium valproate is a very commonly advised antiepileptic and one of its symptoms is hypoglycemia

It is throuhh the interference with fatty acid metabolism that sodium valproate causes hypoglycemia

This hypoglycemia is hence not associated with Ketonuria

Unripe ackee fruit and Jamaican vomiting sickness and Hypoglycemia

Unripe ackee fruit is poisonous as it contains a water-soluble toxin called hypoglycin

Hypoglycin induces vomiting CNS depression and symptoms of severe hypoglycemia

The mechanism of action of hypoglycin is that it inhibits gluconeogenesis secondary to interference with acyl coenzyme A and carnitine metabolism which are essential for the oxidation of long chain fatty acids

The ripe fruit does not contain hypoglycin and so these symptoms do not occur

However,unripe ackee fruit can lead to symptoms of hypoglycemia and may prove very poisonous

Defects in fatty acid oxidation and how hypoglycemia occurs

With the deficiency of long and medium chain fatty acid coenzyme A dehydrogenase deficiency there is a common form of fasting hypoglycemia which is very severe associated with hepatomegaly cardiomyopathy and hypotonia

Plasma carnitine levels are low
ketones are not present

These patients present with  hypotonia seizures and acrid order

The final diagnosis is established from evaluation of enzyme activity in liver biopsy tissue or cultured fibroblasts

These patients must avoid fasting and their diets should be supplemented with carnitine.

glycogen synthase deficiency or glycogen storage disorders type 0

Glycogen storage disorder type 0, there is inability to synthesise glycogen
Hence liver glycogen reserves are very diminished

There is hypoglycemia and hyper ketonemia

After having a field there occurs hyperglycemia with glucose urea because of the inability Tu store glucose load in the form of glycogen

In fasting States there is hypoglycemia the levels of Counter regulatory hormones including catecholamines are very appropriately elevated and insulin levels Get low

Liver is normal sized

Protein rich feedings at frequent intervals result in clinical improvement such that growth velocity also improves

This condition closely mimics ketotic hypoglycemia and should be considered in its differential diagnosis

hypoglycemia in gsd Type 1 or glycogen storage disorder Type 1 Von gierke disease

In von gierke disease which is Type 1 gsd due to the deficiency of glucose 6 phosphatase deficiency children usually have A Remarkable tolerance to low levels of blood glucose levels
they can tolerate blood glucose levels up to 20 milligram per decilitre without being symptomatic
The central nervous system is also adopted to utilise more Ketone bodies and lactase as alternative fuels

there is poor growth

Hyperglycemia is associated with acidosis, increased level of Beta hydroxybutyrate and lactate and hyperuricemia

Branched chain Ketonuria the mechanism of hypoglycemia in maple syrup urine disease

In maple syrup urine disease which is branched chain ketonuria there is hypoglycemia and it was once thought that the deficiency of leucine is the causative agent however now it is thought that it is the production of alanine and it's non availability for a gluconeogenic substrate which is responsible for hyperglycemia and hence chloric deprivation

Ketotic hypoglycemia is substrate Limited

Presenting between the ages of 18 month and 5 years ketotic hypoglycemia is the most common form of hypoglycemia in this age group
the classical history of such patients is that a child who completely avoided an evening meal is very difficult to arouse from sleep the following morning and so again only eats poorly the next day
the child may have a fit / seizure or maybe Drowsy or comatose by noon

another mode of presentation is when parents sleep late in the night and the  childr is not able to get his breakfast early morning has the overnight fast is prolonged the patient develops the symptoms of hypoglycemia in the form of altered sensorium seizures or irritability et cetera

Alanine concentrations in children with ketotic hypoglycemia are markedly reduced and hence the infusion of alanine in the dosage of 250 milligram per kg produce a rapid rise in plasma glucose levels

Glycolytic Pathways also are intact because the infusion of glucagon induces normal glycemic response in the patients when they are in fed state

The levels of Counter regulatory hormones are also appropriately elevated
and insulin is appropriately low

The cause of ketotic hypoglycemia is usually related to deect in complex steps involved in breakdown of protein or oxidative deamination of amino acids or alanine synthesis or its eflux from muscles

Children with ketotic hypoglycemia are smaller than normal children and may have a history of transient neonatal hypoglycemia

Any decrease in muscle mass may compromise the supply of gluconeogenic substrate at a time when glucose demands are high and so decreae in muscle mass  predispose the patient to Rapid development of hypoglycemia with ketosis that represents that there has been attempted to switch to the alternative fuel supply
so it may be said that the ketotic hypoglycemia represent low end of spectrum of child's capacity to tolerate fasting

The spontaneous remission has been observed in children around the age of 8 to 9 years and it can be explained by the increase in muscle bulk which leads to increase supply of endogenous substrate alanine,
also that there is relative decrease in blood glucose requirement per unit of body mass with advancing age.

Ketogenic diet / and what to include instead

Neonatal cholestasis d/d

Causes of portal HTN

General physical examination gpe

Tips on building doctor patient relations

The following tips have been developed by American Academy of family physicians division of Medical Education
The steps target the building of doctor patient relationships

Demonstrate to your patients that you understand the situation and feelings by showing empathy during patient interviews
1 seek to minimise distractions and interruptions when visiting with your patients
2 engage in active listening and Concentrate on what the patient is communicating verbally and non verbally
3 be deliberate about the non verbal cues you sent
4 offer concrete feedback when you summarise what you have heard from your responses by saying let me see if I have this right
5 allow the patient to correct or add to your responses until he or she confirms you understanding did I miss anything

Enhance your counselling and listening skills by using a simple 5 step process
Gather information about the context of the patients visit by asking what is going on in your life how do you feel about that what situation troubles you most how are you handling that
Then show understanding by observing that must be very difficult for you this technique is identified by the acronym BATHE which stands for background affect trouble handling and empathy

Be prepared to provide culturally responsive care

Gain a new perspective on your patients by assessing your own biases

Ask about any alternative treatment that the patient may be using

Talk with your patients About lifestyle issues
1 expect resistance to change
2 avoid really listening to the negative effects of your patients actions instead highlight the positive effects a new Lifestyle could bring
3 Allow your patients to express their concerns about changing their behaviours
4 Ask your patience how confident they are that they can change and what will be the most difficult aspect of changing for them

When taking a history and doing physical examination practice writing your notes while entering the patient

Don't just write an order be sure to tell eye that the nurse or clerk what the instructions are

If possible look at your patients X-rays instead of relying on reports

Pay special attention to how your attending or preceptor approaches patient Encounters with difficult people

Keep a patient diary
This private general to document your personal education journey this exercise will allow you to reflect upon what you have learnt and the progress you have made in building doctor patient relationships

Diagnostic criteria, major criteria and minor criteria for cerebral edema

If there is presence of one Diagnostic criteria or two major criteria or 1 major  + 2 minor criteria then there is 92% sensitivity for cerebral edema

Diagnostic criteria for cerebral edema includes
1.Abnormal motor for verbal response to pain
2.Decorticate and decerebrate posturing
3.Cranial nerve palsy
4.Abnormal neurogenic respiratory pattern

Major criteria for cerebral edema includes
1.Altered mentation and fluctuating conscious level
2.Sustained heart rate deceleration
3.Age in appropriate incontinence

The minor criteria for cerebral edema includes
1.Vomiting
2.Headache
3.Lethargy or not easily arousable
4.Diastolic blood pressure greater than 90 mm of Mercury
5.Age less than 5 years

Antituberculous therapy induced hepatitis in children treatment plan

Among the first line antitubercular drugs isoniazid pyrazinamide rifampicin can cause he Pathak damage and the resultant drug induced hepatitis

Before embarking on the diagnosis of antituberculous therapy induced hepatitis one must rule out the possibility of other causes of hepatitis

The management of antituberculous therapy hepatitis depends upon whether the patient has severe liver disease or what is the severity of Tuberculosis or what is the capacity of health unit to manage the side effects of TB treatment

If it is really thought that hepatic damage is due to antituberculous therapy all antitubercular drugs should be stopped and the patient is put on a non hepatotoxic regimen consisting of streptomycin ethambutol a fluoroquinolone

Now if liver function test are available it is advised to wait till the tests normalise along with the clinical symptoms resolution before Re introduction of antituberculous therapy or if liver function tests are not available then wait two weeks extra till jaundice resolves

If the criteria in the above paragraph is not fulfilled continued non hepatotoxic drugs regimen of streptomycin ethambutol and fluoroquinolone for a total of 18 to 24 months

In case the antituberculous therapy induced hepatitis has resolved drugs are introduced one at a time such that keen observation is given to recurrence of symptoms drugs are added one drug at a time and if jaundice wreckers the last drug added should be stopped

Since rifampicin is thought to be the least hepatotoxic experts advice adding rifampicin first during the Wii introduction of antituberculous therapy

Once patient has tolerated 7 days of rifampicin isoniazid may be added

Sometimes it is advisable to avoid adding pyrazinamide as it is most hepatotoxic antitubercular drug

Among the cause of Jaundice for hepatitis if rifampicin is found to be the causative agent then is selected without rifampicin with 2 months of isoniazid ethambutol and streptomycin followed by 10 months of isoniazid and ethambutol

If the causative agent is isoniazid then 9 months of rifampicin pyrazinamide and ethambutol be considered this duration may be reduced to 6 months depending upon disease severity

If the causative agent is pyramid the total duration of isoniazid and rifampicin therapy may be extended to 9 months

If isoniazid know rifampicin can be used we have to select the non hepatotoxic regimen consisting of streptomycin ethambutol and fluoroquinolone and these have to be continued for 24 months

Syrup Benadryl for dystonic reaction treatment in children

Dystonic reactions for dystonia may occur in children after giving antiemetic drugs for the drugs that control vomiting such as metoclopramide

It has been suggested that such reactions maybe relieved by the use of syrup Benadryl which contains diphenhydramine

Diphenhydramine is an antihistamine and it comes with other trade names such as unisom,Sominex.

Protocol for pulse therapy of methylprednisolone and dexamethasone

Both methylprednisolone and dexamethasone may be given as big shots which are actually not stat doses but infusions given over a time of 2 to 3 hours

Duration of therapy maybe a single dose given once daily for 3 days or on alternate day over 5 days. Total 3 doses.

The corticosteroid preparation is dissolved in 200 ml of 5% dextrose water and infused very slowly intravenously over 3 hours

Before starting therapy it must be made sure that the patient does not have any severe systemic infection however minor upper respiratory tract infections gastrointestinal or skin infections are not a contraindication

The vital signs of the patient must be normalised especially the blood pressure of the patient should be in normal range

Among labs obtained total and differential white blood cell count get blood sugar level and serum urea and serum creatinine and serum Sodium and potassium

Once these parameters are normal we are safe to proceed

During the therapy record pulse rate respiratory rate blood pressure every 30 minute

If possible attach chest electrodes for cardiac monitoring such that arrhythmia may be picked up early

If arrhythmias occur immediately stop the infusion and manage accordingly as suggested in advanced cardiac life support and send blood levels of serum Sodium Potassium calcium magnesium

Following the therapy and during the days of therapy serum electrolytes and calcium and magnesium are to be repeated after every 24 hours , blood sugar should also be repeated 24 hours

Finally

At the end of therapy patient must be monitored for new infection or reactivation of a previous infection.

A guide to use pcbway - get your printed circuit boards manufactured by online portal

Pcbway is a Chinese online website that accepts gerber files for any printed circuit board that you have designed yourself such that they make a fully functional printed circuit board out of it and also offer assembling of components on the printed circuit board

The procedure is simple you make account on PCB way upload the gerber files and within 24 hours Period there engineer tests your gerber files and response to you if it is possible to print them or not

1 May multi-layered manufacturing of printed circuit board

Once the engineer responds to you positively you may pay to them via aliexpress go to aliexpress and search for PCB way there you will find their official store

Now you can also pay directly to the pcbway website but I recommend using aliexpress

As your payment is confirmed they will start making your printed circuit board which will be manufactured in 3 or 4 days and shipped to you

If you are just starting out at PCB way I recommend that you use their minimum quantity of 10 printed circuit boards two sided that will cost dollar 10 in addition to the shipping which may be up to $10

And do not forget to ask them for $5 discount on your very first order

Keenox digital clock

Phone sim card backup

Ever trust pedometer

Mensa brain trainer

Radica solitaire

Summary of spinal muscular atrophy

Spinal muscular atrophy may be summarised as it is a disease of anterior horn cells it is progressive in nature and is inherited as autosomal recessive trait

There is generalized weakness of skeletal muscle which may or may not involve respiratory muscles the baby is flaccid and at some stage of the disease there is involvement of respiratory muscles and or diaphragm

There are three types of spinal muscular atrophy

Type 1 is early infantile form which presents before 6 months of age it is a very severe form search dead survival beyond 3 years is uncommon

Type 2 of spinal muscular atrophy is a late infantile form

Type 3 spinal muscular atrophy is juvenile onset form

Type 1 Is also called werdnig Hoffman disease

Type 3 is also called kugelberg velander disease

SimplyPiano midi usb connection (SOLVED)

SimplyPianoSimply piano midi connection issue /usb connection issue(solved)

My simplypiano app would just get stuck in case i plugged midi keyboard to cellphone OTG. It would hear finely from phone microphone but it would have trouble connecting to piano midi usb. As i connected my keyboard to phone, the display would get stuck on the cellphone screen, i had to plug out the keyboard and then replug it to make my phone work. This way i was able to make midi connection with the phone.

Here is what we ought to do in case the midi device is giving compatibility issue.

In your android, first enable Developer Options.

Then Goto Developer Options, and under Networking > USB configuration > select MIDI

Next,

Go down in Developer Options, and Turn this Option ON "Disable USB Audio Routing"

(meaning so as to disable default audio routing).

Screen shots attached.

I hope this solution will help anyone struggling with midi connections.

Any question? Ask below in comments.

Checklist or The must includes in evaluation for short stature

The evaluation of any child with short stature must include the following components

The child his birth certificate and his both real parents

The investigations such as
x-ray of left hand and wrist joint postero anterior view
Complete blood count
Urine complete examination new line arterial blood gases
Montox test
Chest x ray Pa view
Serum calcium serum phosphate and serum Alkaline phosphatase levels
serum sodium serum potassium and serum chloride levels
serum creatinine and blood urea nitrogen

II investigations include thyroid profile pelvic ultrasound anti tissue transglutaminase antibody IGM and urine culture sensitivity

The third line investigation is include growth hormone provocation test chromosomal analysis and fish study

The four grades of intraventricular hemorrhage explained

The explanation of 4 grades of intraventricular hemorrhage is discussed below

Grade 1 intraventricular hemorrhage
It arises from floor of lateral ventricle and it does not extend to CSF
It is mostly asymptomatic

Grade 2 intraventricular extends to CSF without ventricular distension and it is also mostly asymptomatic

Grade 3 intraventricular hemorrhage causes ventricular distension and it is very symptomatic such that it may cause apnea seizures

Grade 4 intraventricular hemorrhage has features of grade 3 intravascular hemorrhage + echogenicity in periventricular regions on ultrasound scan
Hydrocephalus may also arise

Primary survey and secondary survey in a case of trauma

The primary survey in a case of trauma should include the following points

Maintaining open Airway and stabilizing the cervical spine
assessment of breathing
Assessment of circulation
disability assessment
exposure new line x rays if needed literal cervical spine chest x ray x ray pelvis

The secondary survey of a patient with trauma main include the following

complete History taking
detailed head to toe examination with fundoscopy
additional extra films if needed
passing of nasogastric tube and Foley catheter
CT scan of brain if needed and abdominal CT Scan with double contrast if needed

Pen and Paper

A doctor is all about use of Pen & Paper.
Doctor must use paper Notes as much as possible , but in a well organized way.
Notes that state patients History, Physical Exam, The Investigations needed, the drugs to be included in t/m for the stat orders , or for routine, pen work to do Calculations, to Make Side Notes (regarding check lists, possible outcomes, side effects of t/m) or even to write differential diagnoses with points that support or points that go against.


To be a good doctor one must do maximum paper work , It not only gives legit notes regarding patient but also builds in doctor's mind the clear picture of the patient and the things that need to be put to focus or to remember those that were missed.

Pen, and Paper in hand !

Life saving drugs and drugists / pharmacy /pharmacies

Life saving drugs and drugists / pharmacy /pharmacies

Flumazenil
Pralidoxime
Naloxone
Adenosine
Amiodarone
Digoxin
Prostaglandin E1 / alprostadil 
Neostigmine
Pyridostigmine
Dopamine
Dobutamine
Milrinone
Epinephrine
Norepinephrine
Atropine
Activated charcoal
Deferioxamine

Clinix chuburji
Fazal din mall road
Clinix jail road
Khawaja brothers near jinnah hospital

The protocol of counselling a patient or his attendant regarding a disease or a procedure

First of all Healthcare provider must read the patient's case file thoroughly

He should set proper environment and appointment

He should welcome and greet the patient and the accompanying attendant

The accompanying attendant must not be more than 2 because if they're more than 2 then maybe labelled as unwanted attendance and they may interrupt the process of counselling or if the number of attendance may be set by the patient himself if he allows only his wife or his father or his mother to accompany him however the patient must be advised that the number of accompanying attendance be not more than 2

Seating of the patient and attendance Healthcare provider may sit sit in a cone 60 degree position at 1 and half arm length from patient

No give time to patient and his attendant and ask an open ended question to make them speak

Ask like what do you know about disease or what do you know about the procedure that is going to be performed

This games patient and his attendants to give an opportunity to speak so now you just listen listen and listen while you're listening to patient or his attendant you have to identify his intelligent quotient his death of knowledge regarding the diagnosis and also the illness status he judges for himself

Now you have to give them a reflection you have to empathize

Till this part where you started to give them empathy it was only patients time you must not interrupt the patient as he is speaking let him speak

And as you begin to speak first give a very soft short command now you listen to me and during this time the Healthcare provider must not let himself be interrupted by the patient or the attendant by a very soft short answer you may ask your question in the end as I have finished speaking

No describe to the patient about the disease of the procedure which you are going to perform by means of easy examples illustrations diagrams and the evidence based medicine or the research outcomes that have been or any adverse effects that you know are the complications or the prognostic things it is advisable to keep good prognostic factors and results in the beginning of your discussion and to keep the bad prognostic factors and complications in the end of your discussion

If it has been a counseling regarding the disease which you have done give treatment options medicinal for surgical or both tell the patient and the attendance the advantages and disadvantages of everything or if it is the procedure you are doing counselling for tell them what are the benefits of the procedure how it will help in the disease diagnosis or disease treatment and how the patient could improve as shown by the results from research is in the past however there are few of these disadvantages the complications associated with the procedure

Do not make the choice for the patient or the attendant but you ask them to decide for themselves and you help them decide

This help for decide must not be based on Healthcare providers on buyers rather it should be based on what is logical what is in the benefit of the patient and what is right for the patient doing no harm

Once a decision has been taken document it on the patient's chart and proceed further for example for disease treatment of a procedure follow without for the protocols like taking formal consent for the procedure documenting preprocedural vital signs etcetera etcetera

The funneling approach to history taking from a patient or his attendant

First of all we have to introduce ourself as a Healthcare provider and ask the patient about his name his biodata and then we ask what brings you to the hospital the patient then explains to us his presenting complaints

It is very necessary that the patient must not be interrupted as he is narrating his presenting complaints

However if the patient is very slow in narration or does not disclose it fully we may of the patient tell me in detail your complaint

Only if there is a doubt that the patient is not able to present his complaint fully by himself then we ask leading questions or probing questions otherwise we try our best to minimise leading questions

Keep in mind some questions such as what else and how et cetera to seek more and more on presenting complaints and there are few things which should be asked in relation to any presenting complaint such as when did the complaint start what was its severity on onset what was the body part involved how has its progression been whether it is improving resolving what are the aggravating factors what are the relieving factors what treatment did the patient she was their self medication but there adverse effects from those medications and the associated symptoms for example in case of fever 1 main ask the duration of the fever the recorded temperature the pattern of fever the medication short for fever the associated things like earache flu headache eye discharge body Rash joint complaints pain abdomen chest pain shortness of breath loose motions vomiting anorexia

Then we ask other complaints on a similar pattern their details then the past medical history the history of previous Hospital admissions may be included in past history vaccination history the dietary history allergies and immunizations the history of drugs family history the social economic history the occupational history and in case of children feeding history but history development of history and concluding all based on this we draw a probable diagnosis

The effect of bad news on patient or attendant

Is a bad news is broken it could have a very high shock or very low shock but usually they impact starts with a stage of denial followed by a reaction such that it may be accepted or rejected

If it is accepted then there will be grief Depression and finally a stage of increased acceptance

However if it is rejected then there could be anger aggression violence blaming conflict bargaining or a fight with the Healthcare provider and ultimately negotiation that leads to acceptance

Ask him to how to break bad news to attendants of patient

First decide who will break the bad news to the attendants

Whom to break the bad news
Never break bad news to a crowd of attendants
Break bad news to an emotionally stable looking attendant

Where to break the bad news

Start with a warning sentence such as what I am going to tell you

You should have in mind that what you have to say

In the above lines the word whom is very very important because news should be passed to a very close and secretive person of the patient and if the patient is alive whether or not the patient wants the news to be conveyed to that person which we labelled as whom.

X ray of The kid who ate magnet ;-)

Kid with magnetic stools pp,passed 20 hours after this xray was done.

Kids will be kids.

surma/ lead / KAJAL in baby’s eyes.

photograph for study purposes only.
For commercial purposes, contact Author in comments.


This is a photo of a 4 months old infant.
Mother has used kajal to beautify his eyes.
1). What is the active disease causing agent in it ? What diseases can it cause?
2). Till what age of baby ,mother should be advised to not to use it in baby's eyes ?
3). Mother states that it protects her baby from 'evil eye'. How will you counsel her?



ANSWERS:
1). Lead in kajal is active agent that causes disease.
Diseases it can causes : irritative conjunctivitis , blockage of nasolacrimal duct (stenosis by irritative chronic inflammation, or by physical blockage) , CNS symptoms including behavioral changes, ecephalopathy, peripheral neuropathies,microcyti hypochromic anemia>> if intoxication is after 2 years of age....If before 2years of age then LOW IQ along with these. . ..These are in Chronic intoxication which is more common. The (rare) acute intoxication causes GIT disturbances which are not associated with our scenario.
2). it is toxic in all age groups as written above. So kajal containing lead should not be used in any age group.
3) Mother should be counselled that , to avoid evil eye, she should use kajal as 'tikka' on her baby's forehead, or cheeks but do not use it in baby's eyes... She can only use it in eyes if LEAD FREE KAJAL is available ..
~Dr.Tauseef.

Phototherapy light distances from neonates

Minimum distance from rods of phototherapy light to incubator top or baby cot top be 10 cm above its lid

The minimum distance from phototherapy light to the bed where baby is lying it should be at least 35 cm

Phototherapy light typically covers an area of 46 CM by 23 CM

This distance from phototherapy light rods and the bed of the baby protects baby from adverse effects of therapy such as excessive heat and and so excessive dehydration and damage to eyes and genitalia

Eyes and genitalia must be covered otherwise severe effects could result

Diabetic ketoacidosis patient/child with mucormycosis

PHOTOS for study purposes only.
For commercial purposes, contact Author in comments.

Clinical Approach to a Child with limping Gait- Gait Assessment in children

Power point presentation file Title : Clinical Approach to a Child with a Limp

The presentation targets the Gait assessment with special consideration of clinical exam in children.
Download Power Point Presentation : CLICK HERE   (read notes below slides for better understanding)
Download the videos for understanding slides: CLICK HERE


Videos found from youtube. I do not own these videos.Added with presentation for understanding of students.

Columbine & Semi-trailing Petunia Seeds

Seeds of semi-trailing petunia and columbine sown.
Seeds of petunia afe very small 1mm in size and fragile. While those of columbine are larger about 2-3 mm in size.

HP Deskjet printer cartridge refilling secrets…. how to refill HP ink

This post targets HP Deskjet printers’ cartridges. It will help those new to deskjet photo-printing world to grasp the technique of low cost photo printing at home by refilling the cartridges.
The post , as titled, reveals secrets that i learnt from my experience.
The reader and  hence, the implementer of technique based on my experience will enjoy over 20-30 refillings of cartridges…… meaning thereby, many many hundred 4X6 photos.
(I have found images from internet to best explain , to you, all i intend to.. )
--- Your printer , HP Deskjet, what ever model you may have got/bought new , would have come with a cartridge called in printer slang ‘the beta’ cartridge. Called so, as it contains little ink than the new one which you’ll buy/have bought , or probably wont need to buy for long after reading this post.
This cartridge, the beta cartridge has all the capabilities of the new cartridge , except that the ink is very low in volume inside it….. . .
So, to begin….
For your tri-colour deskjet cartridge , buy suitable ink set.
I got Yellow/Cyan/Magenta inks bottles(100ml bootle of every colour) for just rs 500 (5 USDollar) from a local shop… the brand is Ink-Mate…. a decent name in ink world !
Next, get a 5ml disposible syringe for every colour….
Tag the syringe with the colour as Yellow … Cyan …. Magenta….. so that you dont accidently put the wrong ink into the syringe or from syringe to wrong colour side in cartridge……. As with craving for photo printing ….. you ll refill the cartridges again and again :-)

 see images here :

https://refreshcartridges.co.uk/igloo/refilled-cartridge-not-printing-correctly/

Or you may have holes at some other sites in your cartridge.
Never Mind.
Get a Match Stick.
Poke it into every available hole on the cartridge top.
And write down on paper the position/location of colours within the cartridge.
Mine had Yellow colour at 1 …… no colour at 2 and  3… and magenta at 5…. and cyan at 4…..
If the Cartridge is being refilled for 1st or 2nd time Next… tape the top of the cartridge with cello-tape (clear tape)… cover every hole… and with a 5 ml syringe FOR the respective colour you are going to refill, fill (with needle attached from ink bottle the 4 cc of ink…..and with the needle attached …carefully insert the whole needle into the respective colour hole… and slowly inject the ink…..very slowly…. till 3 cc ink is inside or ink tends to come out of hole….. clean the hole…. (DO NOT INJECT EMPTY SYRINGE AIR INTO CARTRIDGE… HOLD THE SYRINGE AT 90 degrees angle so that you inject only the liquid ink and not the airy-air)…
Then…. remove all the tape from every hole… clean the top.. reapply tape over all the holes… and inject ink into the second hole like you did with the first time…. Covering of other holes is essential since you ll accidently throw/blow/push/tilt/mingle/ or make many other types of errors with ink/cartridge/both to spill over yourself the ink, or on the rug or into another hole of cartridge to contaminate other colour !
So…. for 1st… second … or even 3rd …or even 6th refill of cartridge for the ink… this simple technique will work…Next …insert /plug cartridge into printer and run a single cleaning cycle….
And there you are ready to print with refilled cartridge…

IF INK TENDS TO SPILL FROM HEAD OF YOUR DESKJET PRINTER CARTRIDGE …
However…. if you are a photo enthusiast with low budget…to get a newer cartridge is difficult… or you are just…… money collector…. or you just want to enjoy refilling further… or you are free … very free… and have a coffee with cream cup and nothing to do….here you go……you ll begin to experience a strange issue…… you ll notice that with even a 3rd or 4th ink refill there is continuous ink spilling drop by drop… from the head of the cartridge…such that sometimes magenta spills… sometimes cyan spills and sometimes…its YELL-OW.
Dont worry… Now its time to open the cartridge…. !
There is “air “collected in the sponge of your cartridge…. just above the head.. and its not letting the real cartridge mechanism to happen as it was supposed to work !




These white things are sponges inside… That hold ink…. These are from the cartridge that was BETA… and was never refilled…. Otherwise if its a leaky cartridge (as you might have) … then the whole of the cartridge would have been soaked… Note that there are 4 chambers with no sponge…. You ll find that due to your over filling ink had been collected in those chambers too… Those chambers are separated from real chambers by plastic partition.
So clean your hands thoroughly with water… then take  out that sponge of yellow chamber…. you ll see that foamy-bubbles have formed … too much below that sponge and they were the reason that your cartridge was giving ink spills from the head…. So… clean the sponge till its white…. then remove water from it by pinching it in thumb… and wrap it in tissue papers… till tissues suck out the retained water… now clean all other sponges the same way…
once sponges are cleaned… bring your cartridge (now empty… sponge less) under tap… and clean it thoroughly… every chamber … ! Next…. dry it by poking tissue paper wicks in every chamber… once dry… place in the yellow sponge into yellow chamber,,, Fill in yellow syringe with yellow ink… and prick with needle, into the sponge to the maximum depth. slowly… Oh too slowly inject air (nope > ink) inside the sponge…. you have to bring out  a little of needle,,once 1 ml is injected… then more… and so inject 3 cc….. of yellow ! you ll see the miracle that no ink or very little ink has leaked out from the head… !!!
Repeat the same with all other sponges…..

Dont tilt your cartridge now and never….This cartrdige i meant to say….
We ll now fix that top of cartridge back …. !  First wash it too with water …dry it…
Now place it over the cartridge…. And tape it from side to side with cello tape…. not from the front side where those GOLD contacts have to be in contact with the electronics of the printer…. So… again with a long piece of cellotape…”seal” it all around.. (you ll learn the art of sealing it with one to two tries… but dont tilt the cartridge or you ll spill the ink…. and dont tape the front too much and never tape the contacts on cartridge….. Clean the head of cartridge with tissue paper… you ll see how smartly the 3 colours Y C M are formed on tissue… with not a minor spill from cartridge’s head…
Without tilting,,,,,, carry it to printer… plug/install it in…
And there you are … ready to print… You may do one cleaning cycle in your HP software (that Clean the cartridge cycle).. One is enough… Next … you may print allignment page.. and there you are… ready to print.. print and print….
I have found excellent colours…..details…. after such refills…
& with this procedure done… your cartrdige again gets ready to be refllled without opening the lid for , again, 3-4 refills….
This technique can also work with those cartridges with dried head, clogged up with ink…. or those with working heads ;-) but no ink ……!!!! Give it a try and do comment..


Anything to ask…. ? ask in comments……. !
Share your experience…
And share your photos….. !

Wish you charming photography worlds ;-)   , and happy-affordable printing :-)

Good Luck ;-)

Medical Logos.... Their Meanings

by Dr M. Tauseef Omer
King Edward Medical University

Dear Reader, you must have seen logos similar to the above one along the names of hospitals or medical schools. Logos at your doctor’s clinic may be, where a Snake coils up around a rod . Such logos are full of meanings. There are many Mythical stories behind how and what gave rise to such a symbolization of Medical worlds.

The stories seem very real ,wherever you get to read one. Ancient days , Ancient Healers, Spiritual influences on both the healers and the sufferers they healed …these logos ,in fact, symbolize those ancient times.

SNAKE's venom was used in medicinal practice to cure diseases . Many a times its diluted form given for oral intake, many a times applied to wounds. It must have worked in those old times,of course with certain species of snakes’ venom. Snake also symbolized the 'precious extracts from herbs' - such that , it was as hard to get those extracts like finding the right snake and getting its venom ,saving from its fangs !
That Snake is called the SERPENT in medical logos.

The ROD around which snakes are rising and coiling up, represents the ROD that ancient healers held with them. You must have seen in photos/movies that ancient days are symbolized such that the well reputed personalities always held a ROD with them, back then that heavy wooden ROD was considered authority/knowledge /and symbolized a person with Sacred  Powers.

& the WINGS which are in some medical logos symbolize that we are always flying higher , and higher, soaring to new heights of healing powers and knowledge, with our medicine(the serpent) and the ROD(sacred authority).

On easy educational loans for students 2018

With education becoming expensive , in terms of expensive books, monthly dues, and (diverse but) costly courses , the aspiring students may get loans from local banks, organizations, or their universities and colleges may also offer loans to complete and continue education.
This page targets the students seeking the loans., or those who had successfully received the loans from any source.
I shall update this page from time to time as i receive updates regarding the loans.
If you received one, kindly comment below, stating , LOANED amount, HOW, and from WHERE.
The visitor may then use the FIND feature of his/her browser to search the details needed to them !

Education loan for Massachusetts institute of technology

https://sfs.mit.edu/undergraduate-financial-aid/types-of-aid/loans

http://sfs.mit.edu/content/loans

https://sfs.mit.edu/graduate-financial-aid/types-of-aid

https://sfs.mit.edu/billing-repayment/repaying-your-loan

https://sfs.mit.edu/content/graduate-loan-application

https://www.mitfcu.org/Borrowing/Student-Loans

Loan for Stanford university

https://financialaid.stanford.edu/loans/

https://financialaid.stanford.edu/loans/other/index.html

https://financialaid.stanford.edu/loans/direct/index.html

https://financialaid.stanford.edu/grad/funding/index.html

https://financialaid.stanford.edu/loans/other/parent.html

https://financialaid.stanford.edu/grad/apply/grad_loans/form2018.html

https://ed.stanford.edu/admissions/financing/masters

https://financialaid.stanford.edu/loans/direct/apply.html

https://financialaid.stanford.edu/loans/plus/index.html

https://www.collegefactual.com/colleges/stanford-university/paying-for-college/student-loan-debt/

Education loan for Harvard university

https://www.hks.harvard.edu/admissions-aid/funding-your-education/funding-your-masters-education/student-loans/loans

https://www.gse.harvard.edu/financialaid/loans

https://college.harvard.edu/financial-aid/types-aid/loans

https://www.gse.harvard.edu/financial-aid/supplemental-education-loan-programs

https://www.hks.harvard.edu/admissions-aid/funding-your-education/funding-your-masters-education/student-loans/private-loans

https://www.hks.harvard.edu/admissions-aid/funding-your-education/funding-your-masters-education/student-loans

https://sfs.harvard.edu/private-loan-options

https://www.extension.harvard.edu/registration-admissions/financial-aid/admitted-candidates/loans-scholarships-grants/private-student

https://prodigyfinance.com/get-a-loan/harvard-business-school/loan

https://www.huecu.org/student-loans/graduate-students/

Loan for California institute of Technology (CalTech)

https://www.collegefactual.com/colleges/california-institute-of-technology/paying-for-college/student-loan-debt/

https://www.gradoffice.caltech.edu/financialsupport/loans

https://www.finaid.caltech.edu/typesofaid/grants/caltech

https://www.finaid.caltech.edu/documents/24-1011gradloan.pdf

https://bursar.caltech.edu/documents/1-exit_compliance_form.pdf

http://www.caltech.edu/news/caltech-helps-students-afford-college-1365

http://www.prepscholar.com/sat/s/colleges/Caltech-tuition-financial-aid

Educational loan for university of Chicago

https://financialaid.uchicago.edu/undergrad-students/types-of-aid/loans

http://financialaid.uchicago.edu/graduate

https://bursar.uchicago.edu/page/student-loan-administration

https://www.ssa.uchicago.edu/loan-funds

https://www.collegefactual.com/colleges/university-of-chicago/paying-for-college/student-loan-debt/

http://www.luc.edu/finaid/loans/

http://www.maroonfinancial.org/loans/student-loans.htm

Educational loan for Princeton university

Educational Loan for Cornell University

Loan for Yale university

EDUCATIONAL loan for John Hopkins university

Educational loan for columbia university

University of pennysylvania

Duke university

University of Michigan

University of California,Berkley

Northwestern univsersity

University of California, Los Angeles

University of California San Diego

New York University

Brown University

Clubbing

1. No visible clubbing. Fluctuation (increased ballotability) and softening of the nail bed only. No visible changes of nails.
2. Mild clubbing. Loss of the normal <165? angle (Lovibond angle) between the nailbed and the fold (cuticula). Schamroth's window is obliterated. Clubbing is not obvious at a glance.
3. Moderate clubbing. Increased convexity of the nail fold. Clubbing is apparent at a glance.
4. Gross clubbing. Thickening of the whole distal (end part of the) finger (resembling a drumstick)
5. Hypertrophic osteoarthropathy. Shiny aspect and
striation of the nail and skin

Recipe of life

The art of history taking of acute case

Xyron printer