Author Archives: admin

How to Become an Endocrinologist

What is an Endocrinologist? Brief Overview:

An endocrinologist is a specialized physician. Endocrinology is a sub-specialty of internal medicine. In addition to understanding general medical treatment of the human body and primary care, endocrinologists complete additional training in treating the hormone system of the body, including ductless glands of internal secretion. Such glands include thyroid, adrenal, pituitary, pancreas, and glands in reproductive organs of men and women.

Some of the most common issues that endocrinologists help to diagnose, treat or manage is diabetes, irregular metabolism, growth disorders in children, weight issues, hypo- and hyper-thyroidism, and more.

How to Become an Endocrinologist – Education and Training Requirements:

Endocrinologists are physicians, and therefore they must obtain a medical degree (M.D., or D.O.) from an accredited medical school and complete all of the requirements to practice medicine as a licensed physician. In the United States that includes:

  • 4 years of undergraduate coursework resulting in a Bachelor’s Degree.
  • 4 years of medical school resulting in a medical degree from an osteopathic (D.O.) or allopathic (M.D.) program.
  • 3 years of residency training in internal medicine.
  • 2-3 years of required fellowship training in endocrinology (and nutrition if a 3-year fellowship).

Licensing and Certification for Endocrinologists in the United States:

Endocrinologists must complete the same credentialing as other physicians practicing in the United States,This includes passing all three parts of theUSMLE (United States Medical Licensing Exam), and obtaining a state medical license in the state he or she wishes practice.

Most practice opportunities will require an endocrinologist to be board certified in both specialties of Internal Medicine and Endocrinology.

In order to keep their license current, like all physicians, endocrinologists must successfully complete the required hours of continuing education (CME) and have their license renewed every 7-10 years depending upon state and specialty requirements. Also, the doctor must maintain an ethical standard of practice, as some disciplinary actions can cause a physician to lose his or her medical license if they are severe infractions.

Typical Workweek and Practice Characteristics:

Most endocrinologists will work over 40 hours per week in an medical office setting primarily, as they do not perform many, if any surgeries or invasive procedures. Endocrinologists conduct office exams and consultations with patients, order tests and interpret the results, and then decide on the course of treatment which may involve medication, dietary changes, or surgery. If the patient needs surgery, most likely the endocrinologist would then refer the patient to an appropriately trained surgeon to perform the operation.

Endocrinologists may be employed by a hospital or group, in a single- or multi-specialty practice, or they may own their own practice or be a partial owner of a group practice as opposed to being an employee.

Many of the patients treated by endocrinologists may be referred to the endocrinologist by another physician such as a primary care doctor, obstetrician/gynecologist,gastroenterologist, etc. Therefore endocrinologists’ work is very consultative in nature and they must be adept at working as part of a treatment team including other physicians, as well as nurses and allied health professionals.

Annual Income and Job Outlook for Endocrinologists:

According to the Medical Group Management Association (MGMA) 2013 Physician Compensation and Production Survey, the average annual income for an endocrinologist is $241,565. However, compensation can vary widely from $186,000 at the 25th percentile of earners, to $356,000 at the 75th percentile.

As with all physicians, outlook for endocrinologists is strong. According to the American Diabetes Association, nearly ten percent of all people in the U.S. have some form of diabetes, and many more are pre-diabetic. This, combined with the growth in the population, and the increasing age of the nation’s population, will continue to drive demand for endocrinologists.

Additionally, because demand for primary care physicians is going to be extremely high in the wake of the Affordable Care Act, endocrinologists always have that as an option if for any reason they can’t build a large enough practice of endocrinology patients solely. In other words, worst-case scenario, if demand were to diminish, which it is not expected to, endocrinologists could incorporate some primary care patients into their practices to help maximize their volume if needed.

10 Ways to Be a Great Student

1.  Take Hard Classes

You’re paying good money for an education, make sure you get one. There will be classes that are required for your major, of course, but you will have a fair number of electives as well. Don’t take classes simply to accrue credits. Take the classes that really teach you something.

Be passionate about learning.

I once had an advisor that said to me when I expressed fear of a difficult class, “Do you want to get an education or not?”

2.  Show Up, Every Time

Make your classes your highest priority.

If you’ve got children, I understand that this isn’t always possible. Children should always come first. But if you don’t show up for your classes, you’re not getting that education we discussed in No. 1.

Make sure you’ve got a good plan for seeing that your children are cared for when you’re scheduled to be in class, and when you need to study. It really is possible to raise children while you’re going to school. People do it every day.

3.  Sit in the Front Row

If you happen to be shy, sitting in the front row can be very uncomfortable at first, but I promise you, it’s one of the best ways to pay attention to everything being taught. You can hear better. You can see everything on the board without having to crane your neck around the head in front of you.

You can make eye contact with the professor. Don’t underestimate the power of this. If your teacher knows you’re really listening and that you care about what you’re learning, he or she will be extra willing to help you. Besides, it’ll feel like you’ve got your own private teacher.

4.  Ask Questions

Ask questions immediately if you don’t understand something. If you’re in the front row and have been making eye contact, your instructor probably already knows by the look on your face that you don’t understand something. A polite raising of your hand is all you need to do to indicate you’ve got a question.

If it isn’t appropriate to interrupt, make a quick note of your question so you don’t forget, and ask later.

Having said this, don’t make a pest of yourself. Nobody wants to hear you ask a question every 10 minutes. If you’re completely lost, make an appointment to see your teacher after class.

5.  Create a Study Space

Carve out a place at home that is yourstudy space. If you’ve got a family around you, make sure everyone understands that when you’re in that space, you’re not to be interrupted unless the house is on fire.

Create a space that helps you make the most of your study time. Do you need absolute quiet or do you prefer to have loud music playing? Do you like working at the kitchen table in the midst of everything or do you a quiet room with the door shut? Know your own style and create the space you need.

6.  Do All the Work, Plus More

Do your homework. Read the assigned pages, and then some. Plug your topic into the Internet, grab another book at the library, and see what else you can learn about the subject.

Turn your work in on time. If extra credit work is offered, do that too.

I know this takes time, but it’ll ensure you really know your stuff. And that’s why you’re going to school. Right?

7.  Make Practice Tests

While you’re studying, pay attention to the material you know will be on a test and write a quick practice question. Start a new document on your laptop and add questions as you think of them.

When you’re ready to study for a test, you’ll have a practice test ready. Brilliant.

8.  Form or Join a Study Group

A lot of people study better with others. If that’s you, form a study group in your class or join one that’s already organized.

There are lots of benefits to studying in a group. You have to be organized. You can’t procrastinate. You have to really understand something to be able to explain it out loud to someone else.

9.  Use One Planner

I don’t know about you, but if I had a separate calendar for work, school and life, I’d be a complete mess. When everything in your life is on one calendar, in one planner, you can’t double-book anything. You know, like an important test and a dinner with your boss. The test trumps, by the way.

Get a great calendar or planner with enough room for several daily entries. Keep it with you at all times.

10.  Meditate

One of the best things you can do to improve your entire life, not just school, is meditate. Fifteen minutes a day is all you need to feel calm, centered and confident. If you don’t know how,

Meditate any time, but 15 minutes before you study, 15 minutes before class, 15 minutes before a test, and you’ll be amazed at how well you can perform as a student.

Understanding Brain CT Scan

Computed tomography (CT) scans are a common method used to take pictures of the brain. While the images are not as high-resolution as an MRI scan, CT scans are faster and less expensive options that are especially good at detecting major problems like blood or fractures inside the skull.

Early Neuroradiology

To understand how a CT scan works, it’s important to look back a bit in history. Originally, the only way to take a picture of what was inside someone’s head was by using an X-ray

X-rays are beams of radiation that are absorbed to different extents by different types of tissues. For example, air hardly absorbs any x-rays, whereas bone absorbs a great deal. By putting a film opposite the source of the x-ray, we can get a sense of the number of X-rays that have penetrated the object (in our case, a head), and use that information to infer something about the nature of the tissue being investigated.

For example, because X-rays don’t pass through dense bone, very few X-rays will hit the film if bone is between the X-ray source and the film. In this case, the film will remain white in the shape of the skull.

How a CT Scan Works

Computerized tomography was developed from X-ray technology, and many of the principles are the same. In CT, rather than just taking one shot of the patient, the X-ray beam is rotated around the head at different levels. The X-ray information is compiled by a computer to create a series of images that look as if the brain had been sliced somewhat like a loaf of bread.

The slices start at the top of the brain and work down towards the base of the skull, depicting structures such as soft tissue, liquid, bone and air.

Like a traditional X-ray, dense structures appear lighter in color on a CT scan, and are referred to as hyperdensities. Darker areas, in contrast, are called hypodensities. For example, bone appears bright white on a CT scan, and cerebrospinal fluid appears dark. The brain appears in shades of grey.

How Abnormalities Appear on a CT Scan

A CT scan can detect several different problems in the skull.

  • Hemorrhage CT scans are especially useful at detecting blood where it doesn’t belong. Fresh intracranial hemorrhage coagulates almost immediately, becoming dense and therefore glowing brightly on CT scans. Eventually, the clot is broken down by the body, becoming the same density as the brain after about one week, and then appearing dark after two to three weeks.
  • Ischemic Stroke Unlike hemorrhage, ischemic strokes are not usually immediately detectable on a CT scan. After about three hours, subtle signs can be appreciated by skilled readers of CT scans, and after 6 to 12 hours, a more obvious hypodensity becomes apparent in the area of the stroke. This density will become even darker with time as brain tissue is resorbed and replaced by cerebrospinal fluid.
  • Tumors Tumors have differing appearances on a CT scan depending on the type of tumor and how advanced the cancer has become. Some tumors have calcification that glows brightly, and others form hypodense, fluid-filled cysts. Intravenous contrast dye can be useful in identifying tumors on a CT scan.
  • Abscesses An abscess is an infection that the immune system has encapsulated as a way of sealing it off from the rest of the body. Abscesses usually appear spherical, and with contrast the rim of the sphere may appear to glow.
  • Mass Effect When pressure builds behind part of the brain, it can move and compress important structures, distorting the brain’s normal anatomy. On a CT scan, this mass effect can be seen as an asymmetry of normal structures like ventricles or sulci.

More Neurological Applications of CT Scans

CT scans can be combined with different techniques in order to better investigate specific parts of the nervous system.

For example, in order to get a better picture of the blood vessels in the brain, a CT angiogram can be done. In this study, contrast is injected into the arteries in order to highlight vessels of the brain. This is useful at detecting aneurysms and other vascular malformations.

A CT myelogram can be used to investigate the cerebrospinal fluid space in the spine. To do this, iodinated contrast dye is injected into the space by lumbar puncture. This can be useful in looking for nerve root or spinal cord compression.

CT perfusion studies again involve injecting contrast into the arteries, but this time the contrast is followed in real time as it travels through brain tissue. This is a technique sometimes used to investigate blood vessel function prior to endovascular treatment of acute stroke.

Properly performed, CT scans can be invaluable in the investigation of neurological diseases, especially in emergency settings.

Sources:

Blumenfeld H, Neuroanatomy through Clinical Cases. Sunderland: Sinauer Associates Publishers 2002.

Robert I. Grossman and David M. Yousem. Neuroradiology: The Requisites 2nd ed. St. Louis, MO: Mosby; 2003.

Physiological & pathological breath sounds

Assessment of Breath Sounds

If possible, auscultation of the chest should be done with the patient in the seated position. The diaphragm of the stethoscope should be used. The examiner should warm the stethoscope between his or her palms before placing it on the patient’s chest. The stethoscope should be placed against the patient’s bare skin; the examiner should not try to listen through the patient’s clothes.

The examination should include listening to the anterior chest, the midaxillary region, and the posterior chest. The posterior chest should be examined from the apex to the base of the chest. The breath sounds should be assessed during both quiet and deep breathing. A full breath should be auscultated in each location. The examiner should listen for the pitch, intensity, duration, and distribution of breath sounds, as well as note any abnormal or adventitious sounds.[2, 3]

Types of Breath Sounds

Breath sounds can be divided into 2 categories: normal and abnormal (adventitious).

 

Normal breath sounds

Normal breath sounds can be further divided into 2 subcategories: vesicular and tracheal. Vesicular breath sounds are the sounds heard during auscultation of the chest of a healthy person (listen to the audio recording below). The inspiratory component predominates and is generated by turbulent airflow within the lobar and segmental bronchi, whereas the expiratory component is due to flow within the larger airways.

Tracheal sounds are the sounds heard over the sternum. They are louder and higher pitched than vesicular sounds are. With tracheal sounds, the expiratory phase is as long as or longer than the inspiratory phase.

Abnormal (adventitious) breath sounds

Wheeze

A wheeze is defined as a continuous musical sound lasting longer than 250 ms (listen to the audio recording below). It is thought to be due to oscillation of opposing airway walls that are narrowed almost to the point of contact. A wheeze may be either expiratory or inspiratory and may contain either a single note or multiple notes. Wheezing is common, estimated to occur in 25% of the population at some point. It is frequently more audible at the trachea than in the chest.[5]

Clinically, wheezing indicates airflow obstruction, though its absence does not exclude obstruction. Such obstruction may occur at any point along the airway. Conditions associated with wheezing include infection (croup, whooping cough, bronchiolitis), laryngeal or tracheal tumors, tracheal stenosis, tracheomalacia, foreign body aspiration, other causes of large airway compression or stenosis, vocal cord dysfunction, asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, bronchiectasis, hypersensitivity pneumonitis, and pulmonary edema.

A wheeze may be detected during forced expiration in normal subjects. Although wheezing is associated with airflow obstruction, the degree of obstruction cannot be reliably predicted by the presence or absence of wheezing. Generally, a polyphonic wheeze (ie, a wheeze with multiple notes) is characteristic of large airway obstruction, whereas a monophonic wheeze is more typical of small airway obstruction.[4, 5]

Crackles

Crackles are defined as a short, explosive, nonmusical sound (listen to the audio recording below). The can be divided into 2 types: fine and coarse. Compared with coarse crackles, fine crackles have a higher frequency and a shorter duration. Fine crackles are caused by the sudden opening of a closed airway; coarse crackles are thought to be related to secretions.

Crackles may occur on either inspiration or expiration but are more common during inspiration. Inspiratory crackles may be classified as early inspiratory, midinspiratory, or late inspiratory. Crackles are more frequently heard in the basilar regions of the lungs because the distribution of airway closure is gravity dependent.

Crackles may be heard in cardiac disease, fibrotic lung disease, obstructive lung disease, and pulmonary infections. They may also be heard in healthy older individuals.[4, 6]

General characteristics of these crackles have been described for many different disorders (although there may be variations among individual patients). In idiopathic pulmonary fibrosis, crackles have been described as fine, short in duration, higher pitched, and occurring in late inspiration. A basilar predominance exists in early disease.

Asbestosis is associated with fine crackles. The presence of crackles has been shown to be associated with honeycombing on imaging and with the duration of dust exposure. In bronchiectasis, crackles have been described as high frequency and coarse. They occur in early inspiration or midinspiration and are thought to be secondary to bronchial wall collapse during expiration and sudden opening in inspiration.

In COPD, crackles are most commonly due to airway secretions and typically disappear after coughing; they may also be due to the opening and closing of narrowed bronchi with weakened airway walls. Crackles in COPD are characterized as coarse, early, and low pitched and tend to be infrequent.

The crackles associated with pulmonary edema are attributed to the opening of airways narrowed by peribronchial edema. They are described as coarse, late occurring, and high pitched. They may be inspiratory or expiratory.

In pneumonia, 2 types of crackles have been described. Early pneumonia is associated with coarse, midinspiratory crackles. Crackles during the recovery phase are described as shorter and occurring at the end of expiration.

Rhonchi

Rhonchi are defined as low-pitched, continuous sounds that have a tonal, sonorous quality. They are caused by the rupture of fluid films and airway wall vibrations and are associated with disorders that cause increased airway secretion or reduced clearance of secretions. Rhonchi tend to clear with coughing

 

ejection systolic murmur

Systolic ejection or midsystolic murmurs are due to turbulent forward flow across the right and left ventricular outflow tract, aortic or pulmonary valve, or through the aorta or pulmonary artery.

Turbulence is produced by obstruction to blood flow, vascular dilation, increase in the velocity of flow or a combination.
The ejection of blood begins after closure of the AV or atrioventricular (mitral and tricuspid) valves and is preceded by the time it takes for the ventricular pressures to sufficiently exceed the aortic and pulmonary diastolic pressure and force open the aortic and pulmonary valves. Because of this delay, there is a silent interval between the first heart sound (S1 is produced by closure of the AV valves) and onset of the murmur.
Since ejection ends before closure of the outflow or semilunar (aortic or pulmonary) valve, there is another silent interval between the end of the murmur and closure of the valve on the side from which it originates. Thus, left sided murmurs will terminate before closure of the aortic valve (A2 component of S2) while right-sided murmurs will end before closure of the pulmonary valve (P2 component of S2).

In contrast, the holosystolic murmur of mitral regurgitation (MR) begins with S1 and continues throughout systole and up to S2, without intervening silent intervals. Use the “play” buttons on the above animation to toggle between an ejection and a holosystolic murmur.

The ejection murmur first increases and then decreases in intensity (known as a cresecendo-decrescendo pattern) to give it a “diamond shaped” configuration. The overall intensity of the murmur is proportional to the rate of ventricular ejection. Also, the intensity of the murmur at any given point of ejection is dependent upon flow at that specific time. Thus, if flow is highest in early ejection, the intensity of the murmur will peak early. In contrast, the murmur will peak late if flow is higher during the later phase of ejection.

Pansystolic murmur of Mitral Regurgitation

Pansystolic or Holosystolic murmurs begin at the very onset of systole, as pressure in the ventricle exceeds that in the atrium. Hence, the murmur begins with the first heart sound (S1) and continues throughout systole until the diminishing ventricular pressure equals that in the atrium. The murmur goes into and obscures the second sound (S2). The murmur is usually “flat” in intensity and blowing in pitch or timbre.

When regurgitation is of a large magnitude, diastolic blood return from the atrium to the ventricle produces a third heart sound (S3) and a diastolic flow rumble (FR).

 

Pathogenesis of TB

Pathogenesis of TB
Droplet inhalation is the primary mode of infection
Infection by drinking milk contaminated with Mycobacterium bovis is now rare in developed nations
M. avium-intracellulare, are much less virulent than M. tuberculosis and rarely cause disease in immunocompetent individuals
The bacilli are obligate aerobes whose slow growth is retarded by a pH lower than 6.5, hence not found in the center of granuloma
caseating granulomas and cavitation, are the result of the destructive tissue hypersensitivity that is part and parcel of the host immune response
Pulmonary alveolar macrophages engulf the bacteria
endosomal manipulation by the bacteria in the macrophaghe impairs phagolysosome formation, allowing unhindered mycobacterial proliferation
bacillary proliferation within the pulmonary alveolar macrophages and airspaces, with resulting bacteremia and seeding of multiple sites
development of cell-mediated immunity occurs approximately 3 weeks after exposure
Macrophages carry bacilli to the draining lymph nodes and are presented in a MHCII by dendritic cell/macrophages( APCs) to CD4+ T cells.
IFN-γ released by the CD4+ T cells of the TH1 subset is crucial in activating macrophages.
Page 3 of 41
1 2 3 4 5 41