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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.

Twitter makes me a better doctor: 4 reasons why I use Twitter

Even as social media use among physicians gains popularity, I continue to hear doubts echoing from my fellow medical students, residents, and attendings, particularly about the use of Twitter.

Many of them ask how using Twitter has benefited me, and my answer almost always makes them stop and think.

My life has been enriched by the network of intelligent and forward-thinking people I have connected with on Twitter–many of them medical students, doctors, nurses, pharmacists, or other professionals who have made the leap into social media.

I have become a more well-rounded person and a more knowledgeable and confident future physician–and I’ve learned so much.

Why should medical professionals consider joining the Twitterverse?

The following are just a few reasons.

Stay up to date on news and literature. Doctors (and med students!) are busy and don’t always have time to seek out what’s happening in the world. Twitter conveniently brings news and research directly to your feed.

Doctors (and med students!) are busy and don’t always have time to seek out what’s happening in the world. Twitter conveniently brings news and research directly to your feed.

As a medical student and future pediatrician, I follow accounts of official medical associations, such as the AAP (@AmerAcadPeds) and AAMC (@AAMCToday), leading medical journals, including JAMA (@JAMA_current) and The Lancet (@TheLancet), as well as several different kinds of physicians who frequently tweet interesting new articles.

I first learned about last year’s pertussis epidemic in Seattle on Twitter, and have followed tweets about this year’s flu throughout flu season. I frequently stumble upon studies that may help me in practice; last week I learned that cefdinir and iron-supplemented infant formulas may cause non-bloody red stool when taken together. I also follow various media news outlets, such as CNN, The New York Times, and The Wall Street Journal to keep up with current events.

Share ideas and learn from others. Twitter is an open forum of conversation for the world. In my opinion, this is the most valuable use of Twitter.

I follow people who tweet about things that interest me, both medically related and not. As a medical student, I’ve used Twitter as a study tool, asking questions and gleaning knowledge from physicians, residents, and other students. I listen and converse in various tweet chats, such as the mobile health (#mhealth), healthcare social media (#hcsm), and medical education (#meded) chats. I hear patients share their stories and follow blogs.

Some of my favorite blogs are written by parents of children with special is a fantastic blog about Noah, a beautiful boy with Down Syndrome. The post of his birth story brought me near tears and provided an intimate look at his parents’ reaction to his diagnosis. I learned what they liked and disliked about their doctors’ delivery of the news, and how much they loved their son.

Blogs like this have given me a new perspective on this special families’ challenges and triumphs. This will undoubtedly help me care for my patients with special needs in the future.

Help patients. This does not mean doctoring patients on the Internet, following my patients on Twitter, or anything of the sort. Patients are online, though, and many are on Twitter. As medical professionals, we can help disseminate accurate health information on the web. Twitter provides a great avenue for physicians to steer people to reputable websites for health information, dispel myths, share helpful articles, and educate people on medical issues.

For example, I tweet and retweet articles from the CDC about vaccines, parenting advice from, and various other health tidbits from academic medical institutions.

It’s fun! Perhaps my favorite reason to tweet is that it’s fun! I love spending time on Twitter. I learn something new every day and read many hilarious or otherwise entertaining tweets along the way. I’ve connected with people I never thought I would, all with a myriad of ideas and opinions. The environment is so dynamic.

Twitter is an exciting mode of communication, and is something I engage in because I enjoy it. If you’re thinking about embarking on your own Twitter journey, but are worried about time commitment, just remember, what you do with it or how much time you spend on it is completely up to you. You don’t even need to be particularly tech-savvy to use it. It requires only the ability to type and click, I promise!

Of course, always be careful what you tweet and use good judgment. While Twitter may not be for everyone, I have found it both personally and professionally rewarding, and encourage all health professionals to give it a spin.

Brittany Chan is a medical student who blogs at, where this article originally appeared.  She can be reached on Twitter @BChanMed.

How physician families can spend more time together

As a child and family therapist and as a parent, I often see the efforts that families make to try to maintain a sense of family connection in an era of technology, increased demands and very busy schedules. Most families express a desire for more quality time together and an increased sense of connection amongst family members. The medical families that I encounter describe similar goals but often note the added frustration of trying to achieve this within unpredictable medical schedules and the medical parent’s frequent time away from the family. Fortunately, a high level of family connectedness can be achieved in a medical home, even during times of lower predictability and availability.

Many families find it helpful when the expectations, routines, rules and schedules in a home exist regardless of the family members present at a given time. When adults know how the home functions, even when they are away, it can minimize divisiveness and tension between the adults in the home. When children know that the entire family operates as a unified system, it strengthens their sense of family and their sense of security and predictability with each parent.

Many families also find it useful to develop special rituals. While routines are the components of the day that unfold a specific way, regardless of who is in the house at a given time, rituals are special interactions or activities that occur in some kind of predictable fashion with the intent of nurturing a relationship. These can be activities that only occur when the entire family is present to participate, like game night, a weekend trip or a yearly family vacation. Parents can reserve special rituals for interactions with each of their children, like a particular song at bedtime or a bike ride to a favorite location. Children can also develop rituals to incorporate the idea of their medical parent into moments when that parent is unavailable, such as drawing pictures to give him/her, bringing home a souvenir from an activity or planning a surprise or treat for his/her return.

Established methods of communication can also help nurture feelings of connection within a family. Some families like using family meetings. These can serve to keep a medical parent updated about any changes that have occurred as well as ensure that all family members have a place to feel heard, acknowledged and appreciated. In a less formal way, communication games or rituals can be a fun way of checking in with family members over dinner or before bed. For example, everyone can share three positive things and three difficult things from their day or list three things they are grateful for in their day.

In order to foster a sense of family and connection, a family needs to spend time together. This can certainly prove challenging when considering the time constraints of medicine, but families can develop creative ways to see one another when time is limited.

Ideally, families spend some amount of time together each day. However, this may not always be possible in a medical family. Instead, it may make more sense to simply choose a time of day (dinner, evening, bedtime) when all family members regularly try to be present and engage together. The family can then expect that whoever is in the house at that particular time will come together as previously agreed. It may also make sense to focus on creating higher quality family engagements that occur less frequently. Then the family can put more effort into ensuring that all family members are present and fully involved.

In order to further deepen individual relationships within the family, each parent can also spend one on one time with each child. This can happen more or less frequently depending on the family’s needs, but children often like having individual time with their parents. There are fewer distractions and a greater opportunity to focus on that one particular bond within the family.

Adult time can also prove helpful. This does not always need to be time-consuming; small, genuine interactions can go a long way. When parents feel connected, though, they are more likely to support one another, show empathy and engage in kindnesses. This is a strong way to set the tone for family connectedness.

All family members have a role in developing a sense of family connection. Parents need to acknowledge the impact that the medical demands have on the children and on one another. Genuinely listening to and understanding a child’s point of view without trying to dismiss or minimize it can greatly help a child to feel heard and connected. Do not hesitate to ask children for their opinions and enlist their help. What do they think could help? What could ease some of the discomfort during times of absence? What would they like to do with the medical parent when time permits? Involving the children can increase their sense of investment and value within the family.

It takes work, creativity and flexibility, but it is entirely possible to have a strongly connected medical family. Any small step you take matters as long as it comes from a place of genuine caring for the state of your family.

Medical School Physiology: The Most Important Class in Medical School

What Is Medical School Physiology?

Physiology is one of the most important classes you will take as a future doctor. In fact, it is also my favorite course so far in the first two years of medical school. I remember during orientation, the former dean of my school said that if you can only pick one medical school course to really know well, it would be physiology. That’s all fine and dandy but what is it?

The course delves into how the body works. You will learn about how the heart pumps the blood throughout the body, how the lung takes in oxygen, how the kidney filters out urine, and almost anything else you can think of that pertains to bodily functions. The course is a mixture of biology and physics. There will be quite a few calculations to do, so brush up on your math skills. If physics was your strong point on the MCAT like it was for me, the class will not be that bad. You may also have a lot of fun!

Less Memorization Than the Average Medical School Course

But most important of all, you won’t have to memorize as much as other classes. That is what gets me so excited about physiology. You can reason your way to the answer. Let me give you an example. If someone’s kidney is not getting enough blood, how does that affect the blood pressure? Here is how you can arrive at the conclusion.

  1. The kidney is not getting enough blood, so it thinks the body has a low blood pressure. The lack of blood flow could be due to low blood pressure but it could also be due to a blockage of the renal arteries.
  2. As a result, the kidney will release renin.
  3. Renin is then converted to angiotensin I, which is then converted to angiotensin II. As a side note, ACE (angiotensin-converting enzyme) inhibitors block the conversion of angiotensin I to angiotensin II.
  4. Angiotensin II would then promote the sympathetic activity of the body and the release of aldosterone.
  5. Those would help raise the blood pressure.

So the answer is that a low blood flow to the kidney would result in an increased blood pressure. If you know this pathway, you can answer almost anything related to it. Salt retention (aldosterone), how to treat hypertension (ACE inhibitors), etc.

Granted, learning how the body works do take some memorization at first but it is much, much less than other classes (I’m looking at you, biochemistry and especially microbiology).

Physiology in My School

Part of the reason I liked this course so much is because the subject is interesting. Another reason is because almost all of my medical school physiology teachers were awesome. They taught well, so I went to all the classes. There was a certain teacher who sometimes deviated from a traditional lecture. I remember in one instance, she would have games during class. I also remember winning some home-baked goods from the game. And yet, even with games, I was still learning. Pretty much everyone in my school would agree with me that physiology is largely well taught.

How to Succeed in Medical School Physiology?

This was the only class where there was a cumulative final. So you cannot forget whatever you learned throughout the year.

I’m actually glad I took my own notes summarizing the lectures for this class. Note taking will require a lot of time, but it helps me understand the materials better. But in this course, condensing the lectures into my personal notes really paid off in terms of time, because it saved me a lot of time when studying for the cumulative final. I reviewed the whole course in two days.

How did I do? I honored this course.

There was one thing I did that was even better than summarizing the lectures: doing practice exams. I did practice exams before every test. As for the cumulative final, after the two days of review, I just kept doing practice questions. It was not too bad because I had my answers and explanations for the practice exams I did throughout the year. It is okay to review practice questions even if you have done them previously. Actually, it is highly encouraged. If you refer back to my medical school study tips, you can see that I strongly recommend practice exams. In fact, I developed the bulk of my study methods by studying for this class.

This was the only class where I printed out the slides and took notes on the print-outs. It was okay for the first block because I only had to read through a few hundred pages. But as the year progressed, I found it cumbersome if you want to refer back to the print-outs. There were just too many pages. In second block, I switched to note taking on my laptop. I actually went back and converted all the notes to the electronic format.

Going to class was really only required for the cardiovascular section because the teacher’s slides were mostly pictures. You had to go to class to get the explanations. But for every other block, going to class is not necessary. Considering how fun and how well taught the classes were, I did not want to skip.

Study Tips

  • go to class (especially for the cardiovascular section)
  • take notes to summarize the lectures
  • do practice exams

Additional Medical School Physiology Resources

I did not read any textbooks. I just used the teacher’s slides. But for those who need a book to reference to, lots of students use books written by Linda Costanzo, Ph.D.


When it comes to Costanzo medical school physiology books, you have two options: the textbook or the BRS book. You really only need one or the other, no need to get both.

If you like reading paragraphs, then go with Costanzo Physiology textbook. It is almost 200 pages longer than the BRS Physiology book but you can get a more complete explanation of the concepts. If you are like me and prefer just the main points, go with the BRS. At more than 300 pages, it still is quite substantial. Just remember, I did not use any books for this class. I’m just providing the best options if you feel you need them for succeeding in medical school physiology.

For the books that you will need, take a look at the medical school books section.

Hey, you! Do you want to know how an accountant, without a science background, made it through medical school without any difficulty? Do you want to know how I memorized a sea of information without cracking my skull in half and dumping the books into my brain? No, I did not slave away all night studying in the library either. If you want to know my complete study system, check out The Secret of Studying.

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How to improve patient satisfaction in the emergency department

How to improve patient satisfaction in the emergency department

In the last several shifts I’ve worked in the ED I’ve had more people stop and compliment me on my care. I’ve heard the usual, “Do you have a private practice?” compliment and, “I’ve been here a lot and you really took the time to hear what I was saying, I appreciate that.”

Kudos are nice. They are what makes a tough shift go by quicker. They remind me why I have decided to dedicate my life to people who find themselves at their worst possible moment of health and well-being. The kudos have also caused me to pause and wonder what the heck I was doing differently since I don’t think today I am treating patients any differently than six months ago.

Patient satisfaction. The mere words strike fear and occasional disdain in the hearts of many medical professionals trying to do the best they can to provide the highest quality care to their patients. I don’t blame them, because I think we are using the wrong terminology to describe the goal we are trying to achieve.

Improving the patient experience is considered one of three main goals of achieving health care’s triple aim. And no this doesn’t mean treating patients like they are in a fast food joint or giving every person as much Percocet as they want.

The patient care experience is about more than patient satisfaction. It’s about engagement. By that I mean engagement of the patient in their care to ensure the best possible chance of becoming well.

In health care, we have to do things to patients that would be considered assault in any other situation. In order to have that be OK, we, as providers, need to demonstrate that we indeed care for that person sitting or lying on that stretcher. What’s the best way to demonstrate this caring?

Most of us have heard about AIDET: acknowledge, introduce, duration, explanation and thanks. It’s a good process and helps to remind us to give the same attention and care to every patient and family. That’s good, and we should all practice that. More importantly, the Mom Rule applies here: If my Mom (or sister or son) were sitting in that bed how would I like them to be treated.

AIDET and the Mom Rule help to improve the patient experience once they’re out of the waiting room, but what happens before that? With more and more people on social media — Twitter, Facebook, Yelp, Instagram, Snapchat, and others — have we tried to reach out to patients while they are still waiting (because sometimes people have to wait), or even before they arrive at the hospital?

Have we let them know wait times? Have we set up an alternative to ED care (perish the thought)? How about after the 80 percent of patients have left? Do they all get a call back from the hospital the next day? If not, why the difference in engagement? Too many patients seems like a convenient excuse to me. Especially considering over 60 percent of all admissions come through the ED on average and the ED will be the single largest touchpoint with your community as a whole.

So, back to what I am doing differently today. First, my twenty years of experience as an ER physician certainly counts for something. I’ve learned a few lessons along the way. I try and connect with a patient or family and ask about or comment on a piece of history. “You’re from PA, oh so am I, what part?” “Married 55 years? What a blessing. Congratulations.”

I write my name on the board and let them know if they need to yell at someone I want them to get my name right. I’ve learned to be kind and firm when I say no (kind of like Mary Poppins) to that MRI or refill of Dilaudid. I try and take that extra moment to ask if they have any questions and have started to ask patients to repeat back reasons to return, although I do not do it consistently.

It’s all about engagement and treating someone how I would like my loved one or myself to be treated. Pretty simple and we can do a lot better. That includes me.

Angelo Falcone is chief executive officer, Medical Emergency Professionals (MEP).  He blogs at the Shift.

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Medical School Pharmacology: All About Drugs and Pills

What is Medical School Pharmacology?

In pharmacology, you will be learning all about drugs, from how they work (mechanisms of action), to their side effects, to reasons for taking the drugs (indications). Like pathology, this is one of the two most important classes you will be taking in the second year of medical school. Why is pharmacology that important?

Reason #1. This subject is heavily tested on the Step 1 board exam. So if you want to a good score, know pharmacology well.

Reason #2. The things you learn in this course will be very useful when it comes to clinical years (third and fourth years) and after. Patients will be on drugs. Sometimes lots of drugs. And you should have an idea of what the drugs are based on their name. (To be fair, you will most likely carry around a drug reference during your clinical years so there is really no need to know every single thing about all the drugs. But definitely have an idea of what they are, such that heparin is an anti-coagulant and is used as a deep venous thrombosis prophylaxis.)

This course started out with a bang. The sympathetic and parasympathetic drugs were taught by the best teacher I have ever had in UMDNJ. But sadly, he only taught one block. And although pharmacology was overall a well-taught course, it did not quite compare to the way it started.

Pharmacology was taught by many different teachers. And almost all of them were pretty good, at least for second year medical school professors.

My major complaint is how the important drugs (antibiotics, anti-virals, anti-parasitics) were not taught until April, when the school year was almost over and when the board exam was quickly approaching. The reason for the delay in teaching was because clinical medicine took up too much time so the teaching of the important drugs had to be moved back to late in the second year. You can read more about what I think about that in the clinical medicine section.

How to Succeed in Medical School Pharmacology?

What you have to realize is that pharmacology is mostly memorization. There really is not too much to understand. Memorize how the drug works, what it is used for, when you should not use it, and its side effects.

Attending class is not necessary as there is not much to understand. It would be a better use of your time to skip class and just do practice problems.

Towards the end of the second year, I stopped going to pharmacology class. I did not even read the lecture slides because that took up too much of my time. Instead, there were awesome people in my class who created review sheets and sent them out to the whole class. I just studied from the review sheets.

With the extra time from not going to class, I did practice questions. If you can find old exams do them. If you scroll down to the Additional Medical School Pharmacology Resources, you can find an excellent, free online source for practice questions.

By following the advice shown above, I did fairly well in the class; I high passed.

Study Tips

  • skip class
  • study from lecture slide or review sheet
  • do practice problems

Additional Medical School Pharmacology Resources

There were two main additional resources I have used, aside from the lecture slides, to learn pharmacology well. One is a book and the other is a website.


First Aid was as good as gold for learning about pharmacology. I learned pretty much all I know about antibiotics, anti-virals, anti-parasitics from the book. I felt like I knew them cold. I did not have to read through paragraphs and paragraphs to find out what I had to know. Everything was pretty much in chart or list format, so it is quick to go over.
By studying from First Aid, it helps prepare you for the first board exam as well. Make sure you do practice questions instead of just reading First Aid. It will help you solidify your knowledge of the various drugs.

You can read more about my review of First Aid in the medical school bookssection.

Online Resource(s)

The best online resource I have found for pharmacology is the website of Tulane University’s pharmacology department, which is full of quizzes. What makes the quizzes so great is that it explains why a particular answer is right or wrong. It is an excellent tool for learning. I highly recommend it.

Hey, you! Do you want to know how an accountant, without a science background, made it through medical school without any difficulty? Do you want to know how I memorized a sea of information without cracking my skull in half and dumping the books into my brain? No, I did not slave away all night studying in the library either. If you want to know my complete study system, check out The Secret of Studying.

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