ISSN 22315527

The Overdose

Going off the ploughed field, a Madness!

Like for every other, as
medical students stepping
into the Intensive Care
rotation,
we
remind
ourselves the importance of
learning its nuances from
consultants, residents and
most of all, patients. With
the many i.v lines and tubes,
buzzing monitors, wheeling
in and out, polypharmacy,
consent forms, emergency
procedures and sleepless
nights; more often than not,
we end up concluding that
critical care can be chaotic.
To nobodys surprise, it very
much is. And this chaos
confounds the clarity of the
already
unclear
clinical
pictures.
With such a situation at
hand,
misdiagnosis,
especially of the psychiatric
aspects, could very well
become a rule; and so it has
been adjudged by numerous
retrospective studies. The
one very common psychiatric
complication that develops
in most elderly patients in
the acute care setting is
that of DELIRIUM, which in
Latin literally means, a
going off the ploughed
track, a madness. Delirium
is
a
neurobehavioral
syndrome caused by the
transient
disruption
of
normal neuronal activity
secondary
to
systemic
disturbance.
This
acute

confusional
state
or
encephalopathy
is
also
commonly known as ICU
psychosis or sundowning.
The incidence of delirium in
the Medical-ICUs is second
only to that in patients with
advanced
cancer,
and
reaches up to 80%. Its
prevalence surpasses most
known
psychiatric
syndromes
and
varies
depending on the medical
setting. The consequences
of this acute condition are
far reaching. Most patients
develop a form of chronic
brain syndrome and the
functional
decline
may
persist six months or longer
after discharge. It is a
vicious cycle; delirogenic
systemic disturbances and
medical care settings causes
the transition, leading on to
increased morbidity, poor
functional and cognitive
recovery
and
prolonged

hospital stays. Owing to the

fact that delirium is not
always
reversible,
misdiagnoses
are
unacceptable
and
the
medical frat bears the onus
to minimize its occurrence.
Mental status changes in
the ICU are most often
passed off to be either due
to dementia, depression or
just an expected outcome in
the critically ill patient. The
presence of pain and a past
psychiatric diagnosis used
by the primary team to
explain
the
delirious
symptoms lead to failure to
identify
the
acute
confusional state.
The
risk
factors
of
developing delirium in the
acute care setting are
numerous
and
varied.
Increasing age being the
most important, baseline
cognitive functioning plays a
major role too. Other
factors include water and
electrolyte
abnormalities,
dehydration,
sleep
deprivation,
over-sedation
and poorly controlled pain.
With
pre-existing
comorbidities,
polypharmacy
and the management of its
side-effects is the mainstay
of
ICU
care.
The
neurotransmitter theories
suggest that a dopaminergic
(Continued on page 2)

Inside this
issue:
Brain Storm

Situs Inversus

Grey Matter

MEDQs

Syncope

Milestones

Doped

The 5 Ps

DYK

Skeleton

Segno

N2O, Art Fact,

Coma Cocktail

Anastomosis,
Pulse, Encuesta

Answers

10

Page 2

Synapse - The Overdose

Brain Storm
A 70 year old woman with history of venous thromboembolism and pulmonary embolism is
placed on warfarin therapeutically on long term basis. Her last INR was 1.4 and the
warfarin was upped 7 days ago. Bleeding occurs as the dose was very high. What drug
must be given to the patient now ?
(Continued

from page 1)

and serotonergic excess, as well as a

cholinergic deficiency are causative
of
delirium.
For
example,
ondansetron and rivastigmine are
thought to be beneficial in delirious
states. To our dismay, Opioids and
GABAergic drugs commonly
used to control a delirious
state, add on to prolong
the effects of delirium in
the long run.
There are three subtypes
of delirium; hyperactive,
mixed and hypoactive, with
the waxing and waning
mixed type being the most
common, followed by the
easily
recognized
agitated hyperactive type
and the most missed
subtype of that of the
hypoactive variety which presents
with
depressive
symptoms.
Considering the wide spectrum and
the waxing and waning presentations,
any patient with a clinical suspicion
of having developed delirium, should
undergo a complete neuropsychiatric
evaluation. The assessment should
also include interviews with the
nursing staff, family and an overview
of the behavioral chart for the 24

hours preceding the evaluation. A

structured patient interview helps in
preventing subjective decisions from
being made.
The three-pronged approach to
delirium
includes
symptomatic
management,
treatment
of
underlying cause and the use of

techniques and methods to prevent

delirium. Prevention is the key.
Multiple algorithms emphasize the
importance of non-pharmacological
measure
such
as
correcting
malnutrition and sensory deficits,
removing immobilizing lines and
devices as early as possible,
promoting
a
normal
circadian light rhythm,
providing
adequate
environmental stimulation
and
avoiding
isolation.
Conducting an inventory of
all the pharmacological
agents, avoiding delirogenic
drugs,
adequate
assessment and treatment
of pain go a long way in
keeping this frequently
misdiagnosed condition at
bay.
Ref: Critical Care Clinics,
Delirium in the Acute Care Setting:
Characteristics,
Diagnosis
and
Treatment.
Jose R Maldonado, MD, FAPM,
FACFE, Department of Psychiatry
and Medicine, Stanford University
School of Medicine.

Prarthana Parthasarathy

DSM-IV-TR Diagnostic Criteria for delirium

Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to
focus, sustain or shift attention.
A change in cognition )eg, memory deficit, disorientation, language disturbance) or
Development of a perceptual disturbance that is not better accounted for by a preexisting, established or
evolving dementia.
The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during
the course of the day
There is evidence from the history, physical examination or laboratory findings that the disturbance is
caused by the direct physiological consequences of a general medical condition.

Volume 4, Issue 12

Page 3

NIGHTFALL AT THE MED

SCHOOL CAMPUS

Relapse

Familiar corners
Rendered different by darkness.
Evening deepens indigo,
The day's bustle comes to an end
except across the street
The hospital would never sleep.
Ambulances sirening in,
Doppler Effect reminders
Of all the pathological drama
Wed be expected to handle. Soon.
It's quieter out here.
In the distance the library's aglow
Abuzz with conversations an island
of words.
People coming and going to read,
learn, talk
(...or for that matter steal glances
across tables.)
Students, residents, doctors
Noble souls all, white-coated
wizards?

Or ordinary men and women

Simply doing their jobs?
You decide.
I would rather stand here
Where the streetlamps spill
Little pools of yellow light
On the asphalt driveway
Speckled with fallen leaves
From the laburnum branches.
In the dark it's easy to overlook the
dirt,
The peeling paint, the dusty halls...
And to sense a certain legacy...
Resonant passage of generations of
students
(Clueless like us but look! they
seem to have turned out well !)
It's said everything ever spoken or
done
Keeps on existing in some Eternal

Void...
So these stones speak
Of long-gone mischiefs,
Stresses, dreams, chances,
Rivalries and romances,
The echoes of erudition gathered
over time.
We always disparage what's safely
ours
Utterly forgetting what it would've
been
To be on the outside looking in.
This moment, right here,
The lucent glow of the evening mist
A little breeze rustling through
Golden showers of cassia and light,
Footsteps of friends approaching;
I can almost, almost feel
The whispers of history permeating
this place
And there's nowhere else I'd rather
be.
Sanyukta Rajpurohit

Situs Inversus
NECAVCI
XOITC
SENL
Bladder _________.

MEDQs
Water is used to inflate the bulb of the Foley's catheter and not air because, if air is
used, the bulb would float above the level of the urine in the bladder (buoyancy) and
the opening of the catheter would fail to drain the urine.
Similarly, air is used to inflate the bulb of the endotracheal tube and not water
because, if water was used, the bulb would sink to a lower level (gravity) and render
the tube endobronchial than endotracheal.
This is a very beautiful illustration of how PHYSICS has a huge impact in
understanding the medical devices we use.

Howard Atwood Kelly, MD

(1858-1943)

Grey Matter

Accredited with founding the branch of gynecology / gyne-oncology.

He was one of the founding members of Johns Hopkins Hospital, Baltimore.
Introduced the use of Cystoscope and the use of radium to treat cancer.
EponymsKellys sign, Kelly clamp, Kellys stitch, Kelly speculum.
Has several publications to his credit.

Page 4

Synapse - The Overdose

To be a Medical Doctor in India

Then & Now*
India, a hugely diverse country with
great cultural heritage, a large
resource of people who believe in
developing skill through sheer hard
work and perseverance, has emerged
over the years as a potential
superpower. Acquiring mastery in
every other professional field has
become common parlance. The field
of medicine is no exception.

Syncope
relationships. Nevertheless, in the
recent past, medical education seems
to have turned the tables a bit.
The economic divide, however much

be kept under wraps, is not unknown

to anyone. And yet, the not-sofinancially-blessed stand their own
and most if not all, are not virtuous
of seeking pity. For a nation that will
forever be remembered as the land
of slumdog millionaire (thanks to
Danny Boyle!), faced with a mountain
of uglier obstacles compared to the
rich, the poor man always had the
chance to cope unabashedly, only by
means of being meritorious.
Merit was the link in the thread
that ensured an unbiased learning
and nurturing of young minds to
sustain and save lives in the long run.
Merit being ripped away, it unmasks
the very divide that existed. The
puzzle that makes for a well-rounded
medical
fraternity
misses
an
important piece.

Indian doctors have a thing or two

about them that not only make them
unique, but sought after too. Firstly,
even in the wake of technological
prowess, they rely heavily on clinical
acumen for diagnosis; and for the
second, they are wired to slog long
hours only too rarely compromising
on productivity. No wonder then,
that Indian doctors shone bright,
make a mark and are ubiquitous
world over. This brain-drain has
never been an issue as there is a
million others going through the
similar grind and take their place
with much ease. And this I say
without being boastful, because all
this we owe to our support systems,
education
and
student-teacher

Denying
opportunities
to
the
deserving is loathable. I can only
hope our leaders see beyond and
uproot the lesser evils in the light of
the greater good.
*Opinions expressed are personal
and do not mean to hurt or disregard
those of others.
Prarthana Parthasarathy

Name of Drug

Dabigatran

Group

Oral thrombin inhibitor

MOA

Prevents thrombus development through direct, competitive inhibition of thrombin. Inhibits free
and clot-bound thrombin and thrombin-induced platelet aggregation.

Indication

Prevention of stroke and thromboembolism associated with nonvalvular atrial fibrillation

Pharmacokinetics

Prodrug dabigatran etexilate is converted to dabigatran .

Not a substrate, inhibitor, or inducer of CYP450 enzymes.
Excreted in urine(80%)
Bioavailability(3-7%)

Side effects

>10% - Dyspepsia and gastritis. 1-10% - Major bleed. <1% - Intracranial hemorrhage.
Hypersensitivity, including urticaria, rash, Postmarketing Reports - Angioedema,
Thrombocytopenia.

Caution

Severe renal impairment (CrCl <15 mL/min) or hemodialysis

Doped

Milestones
1970: Raymond Damadian, a medical doctor and research scientist, discovered the basis for using
magnetic resonance imaging as a tool for medical diagnosis.
1974: His patent titled "Apparatus and Method for Detecting Cancer in Tissue."

1977: Dr. Damadian completed construction of the first whole-body MRI scanner, which he dubbed
the "Indomitable."

Volume 4, Issue 12

The 5 Ps
A common hurdle a physician faces in
the standard history taking protocol
is the sexual history. Many doctors
find it a problem and are concerned
about their ability to take a sexual
history without embarrassing the
patient or making them feel
uncomfortable.
Note: Only 35% of physicians take a
sexual history 75% or more number
of times. Does that statistic speak
for itself?
Now thats just one part of it. The
patient is no comfortable when he
has primarily come to you for a
sexual problem. Patients may feel
ashamed, shy or even humiliated to
express their problems in the
bedroom.
Its easy to write a few lines and say
Make the patient feel at ease. The
first thing the patient expects from
the doctor is to be non-judgmental.
Patients often approach the doctor
for the sexual problems with
euphemisms, sign language or at
times with body language.
All that said and done the physician
should know where to limit the
history. You obviously dont want a
doctor asking you if you had
problems with your pee-pee when you
walk in for a consult with a
rhinorrhea.
The CDC has a special booklet to
help doctors take an adequate
history. Here are some parameters
for discussion of sexual health
issues. You can take a sexual history
anytime during the consult. The best
place to pop up the embarrassing
questions can start anywhere during
the patients initial visit, routine
preventive exams, when patients
consult you for sexual problems and
when you see signs of sexually
transmitted diseases (STDs). The
dialogue should usually lead to the
opportunity
for
risk-reduction
counseling and education about high
risk behaviors for STDs, unwanted
pregnancy
and
use
of
right
contraceptive methods.
Please note: This guideline provides

Page 5

The 5 Ps
you with a sample of the discussion
points and questions that may be
asked. It is not a complete
reference for sexual history taking.
Please consider modifying the
guideline to be culturally appropriate
based on the patients.
Putting a patient at ease - Most
patients are not comfortable talking
about their sexual history, sex
partners, or sexual practices. The
best way to approach this is to let
the patient know that the history
can be an important part of a regular
medical exam or history. Assure the
patient of the confidentiality of the
information revealed. Make sure you
are non-judgmental. Consider the
patients complaints as facts than an
amusing story. Treat the sexual
information as a medical information
like how you would treat a history of
pain or SOB.

discussing issued of promiscuity or

other domains we will discuss below.
To make it easier to obtain the
history, one can utilize the CDCs
five Ps protocol. The 5 Ps stand
for: Partners Practices
Protection from STDs Past history
of STDs Prevention of pregnancy
Note that these may not be the only
parameters. A comprehensive history
will be dictated by the case and the
doctor eliciting the history.
Partners:
Why? It is important to determine
the number and gender of your
patients sex partners. This is a multi
-step
question.
Ask
about
orientation, number of partners in
the past, number of partners in the
past year, gender of partners, length
of relationship with the partners,
use of contraceptives, elicit risk
factors. Continue obtaining the
history irrespective of the patients
current status (active/inactive).

Example dialogue with patient

Example dialogue with patient

> "I am going to ask you a few

questions about your sexual health
and sexual practices. I understand
that these questions are very
personal, but they are important for
your overall health/ but they are
important as they can help point to
any medical problems that can give
rise to the symptoms you are
experiencing.

> Are you currently sexually active?

(Are you having sex?) If no, Have
you ever been sexually active?

> I need to ask you a few questions

about your sexual health and
practices. I ask these questions to
all of my adult patients, regardless
of age, gender, or marital status.
These questions are as important as
the questions about other areas of
your history. I assure you, this
information is kept in strict
confidence.
Would
you
be
comfortable sharing this information
with me? Do you have any questions
before we get started?
It would do well to enquire about the
patients marital status before you
begin with the sexual history so as
to avoid any embarrassing situation
in addressing the patient or

> In recent months, how many sex

partners have you had?, In the
past 12 months, how many sex
partners have you had?
> Are your sex partners men,
women, or both? If a patient
answers both repeat first two
questions for each specific gender
Practices: If a patient is/was
sexually active, you may want to
explore further his or her sexual
practices and condom use. This
information
can
guide
the
assessment of patient risk, riskreduction
strategies,
and
the
determination of necessary testing
for STD testing.
Example dialogue with patient
> I am going to be more explicit
here. I need to know about the kind
of sex youve had over the last 12
months to better understand if you
are at risk for STDs.
(Continued on page 6)

Page 6

(Continued from page 5)

> What kind of sexual contact do

you have or have you had? Genital
(penis in the vagina)? Anal (penis in
the anus)? Oral (mouth on penis,
vagina, or anus).
Try to use open ended questions to
learn more about the patients sexual
practices. Based on the answers, you
will have to decide on which direction
to take the dialogue. This can help
determine the appropriate level of
risk-reduction counseling for the
patient. It is necessary to elicit the
patients perception of his or her
own risk and his or her partners
risk, and the issue of testing for
STDs.
Protection from STDs: Patients
perception about risk reduction or
avoiding STDs can be really helpful.
Information about protection against
STDs is equally important. Try to
elicit if the patient used any form of
protection and how regularly it was
used.
In
this
context,
the
information obtained about number
of partners should be revisited and
information
elicited
for
each
partner.
Example dialogue with patient
> Do you and your partner(s) use any
protection against STDs?, If not,
Could you tell me the reason? If so,
What kind of protection do you
use?, How often do you use this
protection?, If sometimes, In
what situations or with whom do you
use protection?, Do you have any
other questions?, or Are there
other forms of protection from
STDs that you would like to discuss
today?
Past History of STDs: History of
the patients past STD history and
treatment along with history about
the history of STDs in the partners

Synapse - The Overdose

is of importance medically as well as

for the sexual history.
Example dialogue with patient
> Have you ever been diagnosed with
an STD? When? How were you
treated?
> Have you had any
symptoms or diagnoses?

recurring

> Have you ever been tested for

HIV, or other STDs? Would you
like to be tested?
> Has your current partner or any
former
partners
ever
been
diagnosed or treated for an STD?
Were you tested for the same STD
(s)? If yes, When were you
tested? What was the diagnosis?
How was it treated?
Prevention of pregnancy: Unwanted
pregnancies, underage pregnancies
are
possible
outcomes
from
unprotected
sex.
Based
on
information obtained so far, the
patient may be at risk of becoming
pregnant or of fathering a child.
Tailor questions to be gender
appropriate.
Example dialogue with patient
> Are you currently trying to
conceive or father a child?, Are
you
concerned
about
getting
pregnant or getting your partner
pregnant?,
Are
you
using
contraception or practicing any form
of birth control?, Do you need any
information on birth control?
By the end of the interview, the
patient may have loosened up and
have questions that he or she was
not ready to discuss earlier.
Example dialogue with patient
> Do you have anything about your
sexual health and sexual practices
that we need to discuss?, Are
there any other concerns or

DID YOU KNOW?

questions regarding your sexual

health or sexual practices you would
like to discuss?
Other than the 5 Ps here are some
other questions that can be used to
obtain a more comprehensive history.
The problem as the patient sees it
and for how long? Any relation to the
time, place, or partner?
Any loss of sex drive or dislike of
sexual contact? (Loss of libido)
Are there
problems?

any

relationship

Are there any stress factors? In

the patient/partner?
Any psychiatric issues?
Are there physical problems
experienced by either partner?
Any problems during intercourse/
sexual act?

A
quick
medical
problem
questionnaire will help determine any
sexual issues secondary to medical
conditions.
Medication history.
Symptoms of sexually transmitted
diseases.
At the conclusion, it is important to
thank the patient for being open &
honest and praise any safe sex
practices. For patients at risk for
STDs, encourage testing for STDs
and
offer
information
about
protective practices and methods.
After reinforcing positive behavior,
it is appropriate to specifically
address concerns regarding high-risk
practices.
Your
expression
of
concern may help the patient accept
a counseling referral, and make sure
you recommend one.
With adaptations from www.cdc.gov/
std/treatment/SexualHistory.pdf.
Puneeth Indurlal

Your finger nails grow at 1 nanometre per second (0.000 000 001 m/s). Your hair grows
at 4 nanometres per second (0.000 000 004 m/s).

Volume 4, Issue 12

Page 7

Page 8

Synapse - The Overdose

Art Fact

Coma Cocktail
Pentalogy of Cantrell
Diaphragmatic hernia
Cardiac abnormality
Omphalocele
Pericardium malformation
Sternal cleft

Synapse Co.
ISSN 2231 - 5527
www.drsynapse.co.in
m.drsynapse.co.in
synapse@drsynapse.co.in

EncuestaResults

By Sahil Thakur

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N2O

Volume 4, Issue 12

Page 9

Anastomosis

Across
2. Sign for a tender LUQ
mass due to splenic
hematoma

4. Mitral valve prolapse

is a.k.a ____ disease

6. Syndrome of delusion
that familiar people have
been
replaced
by
imposters

7. Sign for ecchymosis

of the inguinal ligament
in
hemorrhagic
pancreatitis

10
11

surrounding

12. Sign for visible

pulsations of the retinal
arterioles in AR

12

7.
Syndrome
with
gustatory sweating

13

14

15

15.
Bandage
applied
around a part from distal
to proximal to expel
blood from it
17.
Left
axillary
adenopathy
associated
with metastatic disease

3. Great cerebral vein

5. Artery responsible for

anterior spinal syndrome

10. Fascia
the kidney

in the layer 5 of the

primary motor cortex

16

9. Criteria for histologic

diagnosis of myocarditis

17

11.
Fever
in
schistosomiasis

18

EclipseCrossword.com

FOLLOW US ON

19. Line separating the

right and left lobes of
the liver

Segno

14. Test for diagnosing

PNH

Hannington-Kiff sign is a clinical sign in which

there is an absent adductor reflex in the thigh
in the presence of a positive patellar reflex. It
occurs in patients with an obturator hernia, due
to compression of the obturator nerve.

Down
1. Large pyramidal cells

a. AML

b. CLL

c. CML

d. ALL

A one year old child presented with multiple fractures

seen in various stages of healing. Most probable
diagnosis is
b. Rickets

c. Battered Baby syndrome

d. Sickle cell disease

Phocomelia isa. Absence of long bones

b. Absence of brain

c. Reduplication of bones

d. Absence of heart.

Turn to last page for answers

15.
Maneuver
both
diagnosis
treatment of BPPV

for
and

16.
Sign for empty
RLQ in cildren with
ileocecal intususception

Encuesta

Chloroma is due to

a. Scurvy

acute

13. Disease of histiocytic

necrotizing
lymphadenitis

19

18.
Test
used
for
diagnosing hemi-neglect

8. Cholesterol plaques
lodged in the arterial
bifurcations
of
the
retina

Pulse

The lack of top notch equipment

is hampering original research/
innovation in India or is it the
initiative that is lacking?
Equipment / Initiative
Respond via SMS / Web / Email

Synapse - The Overdose

Anastomosis Answers
1
2
3
5

1.

(A) - AML

B A L L A N C E

2.

(C) - Battered Baby

Syndrome

3.

(A) - Absence of long

bones

A D A M K I
L
E
N

11

E W I

R
O

F O X

12

15

Brain StormAnswers

G E R O T A

13

10

B E C K E R

14

C K Z
P

A
T

A
7

L
W

Pulse Asnwers

Hold Warfarin for 3 days.

Vitamin K administered IM.
Fresh Frozen Plasma.

16

VACCINE

TOXIC

LENS

H
17

R I

S H

18

A L B E R T
Y

19

C A N T L

Situs InversusAnswers

E S M A R C H

Bladder

VESICLE

EclipseCrossword.com

Fill online and send to synapse@drsynapse.co.in or contact the team

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ISSN 22315527