Dr. Ravishankar Kumar

27/01/2026

💉 Angles & Routes of Injections (ID → SC → IM → IV)

🧴 Intradermal (ID)

➡️ Layer: Epidermis → Dermis (very superficial)
➡️ Angle: 📐 10–15°
➡️ Purpose: TB (Mantoux) test → Allergy testing
➡️ Volume: 💧 0.1 mL (standard)

➡️ Needle: 25–27 gauge → short → fine bevel
➡️ Technique:
→ Bevel up
→ Insert just under skin surface
→ ✔️ Small wheal/bleb should appear

➡️ Common sites:
→ Inner forearm
→ Upper back (scapular area)

➡️ Absorption: 🐢 Slow (minimal vascularity)

💛 Subcutaneous (SC)

➡️ Layer: Dermis → Subcutaneous fat
➡️ Angle: 📐 45° (thin patient) → 90° (adequate adipose tissue)
➡️ Purpose: Insulin → Heparin → Some vaccines/biologics

➡️ Volume:
→ 0.5–1 mL typical
→ ⚠️ Up to 2 mL in adults (site & policy dependent)

➡️ Needle: 25–30 gauge → short
➡️ Technique:
→ Skin may be pinched
→ Do not aspirate (insulin, heparin)

➡️ Common sites:
→ Abdomen (preferred for insulin)
→ Outer upper arm
→ Anterior thigh
→ Upper buttocks

➡️ Absorption: ⏳ Moderate
→ Slower than IM → Faster than ID

💪 Intramuscular (IM)

➡️ Layer: Subcutaneous tissue → Muscle
➡️ Angle: 📐 90°
➡️ Purpose: Vaccines → Antibiotics → Analgesics → Hormones

➡️ Volume (site-dependent):
→ Deltoid: ≤ 1 mL (occasionally up to 2 mL)
→ Ventrogluteal: 3–5 mL (preferred for large volumes)
→ Vastus lateralis:
→ Adults: 2–3 mL
→ Infants/children: ✔️ preferred site

➡️ Needle: 20–25 gauge → longer length
➡️ Technique:
→ Skin stretched taut
→ Insert quickly at 90°

➡️ Absorption: ⚡ Fast
→ Depends on muscle perfusion & activity

🔴 Intravenous (IV)

➡️ Layer: Directly into a vein
➡️ Angle: 📐 15–30° (≈ 25° as shown)
➡️ Purpose:
→ Rapid drug administration
→ Fluids → Blood products → Emergency meds

➡️ Volume:
→ Varies widely (bolus to continuous infusion)

➡️ Needle/Catheter:
→ IV cannula (18–24 gauge, site dependent)

➡️ Technique:
→ Bevel up
→ Advance until blood flashback
→ Lower angle → advance catheter → remove needle

➡️ Absorption: 🚀 Immediate (100% bioavailability)
Dr. Ravishankar Kumar

26/01/2026

Tonsil grading
Determine the size of the tonsils. These can be graded by:
score
0 – tonsils in fossa
1 – tonsils occupying up to 25% of airway
2 – 26% to 50%
3 – 51% to 75%
4 – more than 75%
score
0 – no tonsils
1 – tonsil within pillars
2 – tonsil beyond pillars
3 – tonsil extending ¾ to midline
4 – tonsils touching in midline.
Dr. Ravishankar Kumar

26/01/2026

Tendon Vs Ligament ✅

🦴 TENDON

→ Connects muscle to bone
→ Made of dense, parallel collagen fibers (very strong, low elasticity)
→ Transfers force generated by muscle contraction to bone
→ Enables movement at joints
→ Poor blood supply → heals slowly when injured
→ Examples: Achilles tendon, biceps tendon

🦴 LIGAMENT

→ Connects bone to bone
→ Made of collagen fibers with slight elasticity
→ Provides joint stability and alignment
→ Prevents excessive or abnormal joint movement
→ More elastic than tendons, but still strong
→ Examples: ACL, PCL, medial collateral ligament

⭐ KEY DIFFERENCE TO REMEMBER

→ Tendon = Movement (muscle pulls bone)
→ Ligament = Stability (bone holds bone)
Dr. Ravishankar Kumar

25/01/2026

🫁🧪 Acid–Base Disorders:

🫁 Respiratory Acidosis

🔹 Core Concept
→ Primary problem is hypoventilation
→ Inadequate removal of CO₂ leads to acid retention

→ pH decreases (< 7.35)
→ PaCO₂ increases (> 45 mmHg)

→ Common causes include COPD, severe asthma, CNS depression, neuromuscular disorders, airway obstruction

→ Kidneys compensate (if chronic) by increasing bicarbonate (HCO₃⁻) retention

🌬️ Respiratory Alkalosis

🔹 Core Concept
→ Primary problem is hyperventilation
→ Excessive loss of CO₂

→ pH increases (> 7.45)
→ PaCO₂ decreases (< 35 mmHg)

→ Common causes include anxiety/panic attacks, pain, hypoxia, high altitude, pregnancy, sepsis

→ Kidneys compensate (if chronic) by excreting bicarbonate (HCO₃⁻)

🧪 Metabolic Acidosis

🔹 Core Concept
→ Primary problem is loss of bicarbonate or accumulation of acids

→ pH decreases (< 7.35)
→ HCO₃⁻ decreases (< 22 mEq/L)

→ Common causes include diabetic ketoacidosis, lactic acidosis, renal failure, severe diarrhea, toxin ingestion

→ Lungs compensate by hyperventilation (Kussmaul breathing) to blow off CO₂

🧠 Metabolic Alkalosis

🔹 Core Concept
→ Primary problem is excess bicarbonate or loss of hydrogen ions

→ pH increases (> 7.45)
→ HCO₃⁻ increases (> 26 mEq/L)

→ Common causes include vomiting, nasogastric suction, diuretic use, excess alkali intake

→ Lungs compensate by hypoventilation to retain CO₂

⭐ Key High-Yield Points

→ pH tells acid vs alkalosis
→ CO₂ problems = respiratory disorders
→ HCO₃⁻ problems = metabolic disorders
→ Lungs compensate fast, kidneys compensate slow
→ Compensation never overcorrects pH to the opposite side
Dr. Ravishankar Kumar
fans

24/01/2026

🔬 Superficial Veins of the Upper Limb

• Superficial veins of the upper limb are veins located in the subcutaneous tissue
• They drain blood from the skin and superficial structures of the upper limb
• Clinically important for venipuncture and IV access

Major Superficial Veins:
1️⃣ Cephalic Vein

• Located on the lateral (radial) side of the forearm
• Begins from the lateral part of the dorsal venous network of the hand
• Ascends along the anterolateral forearm and arm
• Pierces the clavipectoral fascia
• Drains into the axillary vein

Clinical importance
• Easily visible and accessible
• Commonly used for IV cannulation
• Lower risk of nerve and arterial injury

2️⃣ Basilic Vein

• Located on the medial (ulnar) side of the forearm
• Begins from the medial part of the dorsal venous network of the hand
• Ascends medially
• Becomes deep in the arm
• Joins the brachial veins to form the axillary vein

Clinical importance
• Less preferred for venipuncture
• Higher risk due to proximity to the brachial artery and median nerve

3️⃣ Median Cubital Vein

• Located in the cubital fossa
• Connects the cephalic vein to the basilic vein
• Lies superficial to the bicipital aponeurosis

Most preferred vein for venipuncture because
• Large and well anchored
• Easy to access
• Minimal movement during needle insertion
• Low risk of nerve and arterial injury

4️⃣ Accessory Cephalic Vein

• Drains the lateral aspect of the forearm
• Joins the cephalic vein near the elbow or arm
• Shows anatomical variation

Clinical note
• Can be used as an alternative venipuncture site

5️⃣ Median Antebrachial Vein

• Runs in the midline of the forearm
• Drains superficial structures of the forearm
• May divide into median cephalic and median basilic veins
• May drain directly into the basilic or cephalic vein

6️⃣ Median Cephalic Vein

• Connects the median antebrachial vein to the cephalic vein
• Contributes to the “M pattern”

7️⃣ Median Basilic Vein

• Connects the median antebrachial vein to the basilic vein
• Also contributes to the “M pattern”

Patterns of Superficial Veins in the Cubital Fossa
M Pattern

• Cephalic vein
• Basilic vein
• Median antebrachial vein dividing into median cephalic and median basilic veins

H Pattern

• Formed by a prominent median cubital vein
• Direct connection between cephalic and basilic veins

Venipuncture – Preferred Order

• Median cubital vein
• Cephalic vein
• Basilic vein

Clinical Correlations

• Median cubital vein is protected by the bicipital aponeurosis
• Injury to the basilic vein may damage the brachial artery
• Median nerve lies close to the basilic vein in the arm
• Superficial veins are poorly valved or valveless

🧠 Mnemonic

• Cephalic is Cool
• Basilic is Buried

⭐ High-Yield Exam Points

• Median cubital vein is the most commonly used vein for venipuncture
• Cephalic vein lies on the lateral side of the forearm
• Basilic vein becomes deep in the arm
• Median cubital vein lies superficial to the bicipital aponeurosis
Dr. Ravishankar Kumar

23/01/2026

🩺 Side-effects of Ramipril

(ACE inhibitor used for high BP, heart protection, kidney protection)

💓 Blood Pressure–Related Effects
→ Dizziness or light-headedness, especially after the first dose
→ Feeling faint on standing up (postural hypotension)
→ More common in dehydration, elderly patients, or those on diuretics

😮‍💨 Dry Persistent Cough
→ Dry, irritating cough without phlegm
→ Due to bradykinin accumulation
→ Not dangerous, but may need drug change if troublesome

🧪 Kidney-Related Effects
→ Mild rise in creatinine initially (can be normal)
→ Worsening kidney function in dehydration or renal artery stenosis
→ Reduced urine output in severe cases

⚡ High Potassium (Hyperkalemia)
→ Increased potassium levels in blood
→ May cause weakness, tingling, or heart rhythm problems
→ Risk higher in kidney disease or potassium supplements

🤢 Digestive Side-effects
→ Nausea or vomiting
→ Abdominal discomfort
→ Diarrhea or loss of appetite (uncommon)

😖 Head & Nervous System Effects
→ Headache
→ Fatigue or weakness
→ Rarely mood changes or sleep disturbances

🚨 Serious but Rare Side-effects
→ Angioedema: sudden swelling of lips, face, tongue, or throat
→ Can cause breathing difficulty
→ Medical emergency – stop drug immediately and seek help

🩸 Blood-Related Effects (Rare)
→ Low white blood cell count
→ Increased infection risk (very rare)
→ More likely in autoimmune disease or kidney disorders

🧠 Important Clinical Notes
→ Avoid in pregnancy (can harm the baby)
→ Monitor BP, kidney function, and potassium regularly
→ Do not stop suddenly without medical advice

REMEMBER:
→ Ramipril is generally safe and protective for heart and kidneys
→ Most side-effects are mild and manageable
→ Seek medical attention for severe dizziness, swelling, or breathing difficulty
Dr. Ravishankar Kumar
❤️ 💖 💖lifeisgoodandloveisawesome 💯 💯🔥

22/01/2026

❇️ IV Medications That Must NEVER Be Given Rapidly (IV Push)

Rapid IV administration of certain drugs can cause life-threatening adverse effects. These medications must be given slowly as controlled infusions according to guidelines.

1. Vancomycin

Drug class: Glycopeptide antibiotic

Why not fast?
Rapid infusion causes infusion-related histamine release, leading to Red Man Syndrome.

Mechanism:
→ Non-IgE mediated histamine release
→ Vasodilation and hypotension

Adverse effects if given fast:

Flushing (face, neck, upper torso)

Pruritus

Rash

Hypotension

Rarely angioedema

Key clinical note:

❌ Not a true allergy

✅ Prevented by slow infusion (≥60 minutes) and antihistamines if needed

2. Magnesium Sulfate

Drug class: Electrolyte / CNS depressant

Why not fast?
Rapid administration causes magnesium toxicity.

Mechanism:
→ Suppresses neuromuscular transmission
→ CNS and respiratory depression

Adverse effects if given fast:

Hypotension

Loss of deep tendon reflexes (early sign)

Respiratory depression

Cardiac conduction abnormalities

Clinical uses (controlled infusion):

Eclampsia

Torsades de pointes

Severe hypomagnesemia

3. Potassium Chloride (KCl)

Drug class: Electrolyte

Why not fast?
Rapid IV potassium can cause fatal arrhythmias.

Mechanism:
→ Sudden increase in extracellular potassium
→ Cardiac conduction failure

Adverse effects if given fast:

Ventricular arrhythmias

Asystole

Cardiac arrest

Golden rule:

🚫 NEVER IV push potassium

✅ Always dilute and infuse slowly with ECG monitoring

4. Phenytoin (Dilantin)

Drug class: Antiepileptic (Na⁺ channel blocker)

Why not fast?
Rapid IV administration causes cardiovascular toxicity.

Mechanism:

Sodium channel blockade

Propylene glycol–related vasodilation

Adverse effects if given fast:

Severe hypotension

Bradyarrhythmias

Cardiac arrest

Purple Glove Syndrome (local tissue injury)

Safe administration:

Adult rate ≤ 50 mg/min

Prefer fosphenytoin when available

5. Furosemide (Lasix)

Drug class: Loop diuretic

Why not fast?
Rapid IV bolus can cause ototoxicity.

Mechanism:
→ Electrolyte disturbance in inner ear
→ Damage to cochlear hair cells

Adverse effects if given fast:

Tinnitus

Hearing loss (usually reversible)

Hypotension

Risk increased with:

High doses

Renal failure

Concurrent aminoglycosides

⭐ High-Yield Clinical Pearls

“Fast IV” ≠ effective → can be fatal

Many reactions are dose-rate dependent

Always follow institutional infusion protocols

When in doubt → slow down the infusion

⚠️ Safety Reminder

These medications are NOT contraindicated —
they are dangerous only when administered incorrectly.
Dr. Ravishankar Kumar

21/01/2026

❇️ Valproate (Valproic Acid) — Side Effects:

Valproate is a broad-spectrum antiepileptic drug also used in bipolar disorder and migraine prophylaxis.
Its adverse effects involve gastrointestinal, hepatic, hematologic, metabolic, endocrine, neurologic, and teratogenic systems.

Common Side Effects (Dose-dependent, usually reversible)

→ Gastrointestinal

Nausea

Vomiting

Abdominal pain

Dyspepsia

→ Central Nervous System

Sedation

Drowsiness

Dizziness

Tremor (fine postural tremor)

→ Metabolic / Cosmetic

Weight gain

Increased appetite

Hair loss (alopecia, usually reversible)

Serious & High-Yield Side Effects
Hepatotoxicity (⚠️ Very Important)

→ Elevated ALT / AST
→ Acute liver failure (rare but fatal)
→ Higher risk in:

Children

20/01/2026

❇️ TYPES OF PATIENT POSITIONS

Patient positioning is used to facilitate examination, procedures, comfort, and safety while ensuring adequate exposure and minimizing complications.

1. Supine Position
Description

→ Patient lies flat on the back
→ Head supported, arms at sides, legs extended

Uses

→ General physical examination
→ Abdominal examination
→ Surgical procedures
→ CPR

Precautions

→ Risk of aspiration in unconscious patients
→ Supine hypotensive syndrome in late pregnancy

2. Sims’ Position (Left Sims’)
Description

→ Patient lies on left side
→ Upper leg flexed, lower arm behind body
→ Semi-prone position

Uses

→ Re**al examination
→ Enemas and suppositories
→ Sigmoidoscopy

Advantages

→ Comfortable
→ Reduces aspiration risk

3. Prone Position
Description

→ Patient lies face down
→ Head turned to one side

Uses

→ Examination of back and spine
→ Spinal surgery
→ Posterior body procedures

Precautions

→ Avoid in respiratory compromise
→ Risk of pressure injury

4. Knee-Chest Position
Description

→ Patient kneels with chest and head resting on table
→ Hips elevated

Uses

→ Proctologic and re**al examinations
→ Sigmoidoscopy
→ Pelvic organ prolapse evaluation

Precautions

→ May cause hypotension or discomfort
→ Not suitable for elderly or cardiac patients

5. Dorsal Recumbent Position
Description

→ Supine with knees flexed and feet flat on table

Uses

→ Abdominal examination
→ Ge***al examination
→ Urinary catheterization

Note

→ Different from lithotomy (no stirrups)

6. Lithotomy Position
Description

→ Supine with hips and knees flexed
→ Legs supported in stirrups

Uses

→ Gynecologic examination
→ Childbirth
→ Urologic and anore**al procedures

Precautions

→ Risk of nerve injury (peroneal, femoral)
→ Risk of hypotension with prolonged use

7. Standing Position
Description

→ Patient stands upright or leans forward

Uses

→ Spine and posture assessment
→ Hernia examination
→ Male ge***al examination
→ Respiratory assessment

8. Squatting Position
Description

→ Patient squats with hips flexed and heels on floor

Uses

→ Anore**al examination
→ Assessment of pelvic floor descent
→ Childbirth (traditional)

Clinical Insight

→ Increases anore**al angle for defecation

9. Sitting Position
Description

→ Patient sits upright with feet supported

Uses

→ Head and neck examination
→ Neurological assessment
→ Chest and lung examination
Dr. Ravishankar Kumar

19/01/2026

19/01/2026

❇️ Phenytoin – Adverse Effects:

Phenytoin is a hydantoin antiepileptic drug that works by blocking voltage-gated sodium channels, thereby stabilizing neuronal membranes. Its side effects are dose-related, chronic-use related, and idiosyncratic.

1. Dose-Related (Concentration-Dependent) Side Effects

These occur due to phenytoin’s narrow therapeutic index and nonlinear (zero-order) kinetics.

→ Nystagmus (usually the earliest sign)
→ Diplopia
→ Ataxia
→ Slurred speech
→ Dizziness
→ Sedation
→ Confusion (at higher levels)

📌 Commonly seen when serum phenytoin levels exceed the therapeutic range (10–20 µg/mL).

2. Chronic Use–Related Side Effects
A. Gingival Hyperplasia

→ Overgrowth of gum tissue
→ More common in children and adolescents
→ Worsened by poor oral hygiene
→ Due to increased fibroblast activity

📌 Good dental hygiene can reduce severity.

B. Skin & Cosmetic Changes

→ Coarse facial features
→ Acne
→ Hirsutism (excess facial/body hair)

C. Bone & Vitamin Effects

→ Osteomalacia
→ Osteoporosis (long-term use)
→ Due to increased vitamin D metabolism

📌 Calcium and vitamin D supplementation is often required.

3. Central Nervous System Effects

→ Cognitive slowing
→ Memory impairment
→ Mood changes
→ Peripheral neuropathy (long-term)

4. Hematologic Side Effects

→ Megaloblastic anemia (due to folate deficiency)
→ Leukopenia
→ Thrombocytopenia (rare)
→ Aplastic anemia (very rare but serious)

5. Hepatic Effects

→ Elevated liver enzymes
→ Hepatitis (rare)
→ Hepatic failure (very rare)

6. Dermatologic & Hypersensitivity Reactions

→ Maculopapular rash
→ Stevens–Johnson syndrome (SJS)
→ Toxic epidermal necrolysis (TEN)

📌 Higher risk in patients with **HLA-B1502** (common in some Asian populations).*

7. Cardiovascular Effects (IV Phenytoin)

→ Hypotension
→ Bradycardia
→ Cardiac arrhythmias

📌 Seen with rapid IV administration — infusion rate must be controlled.

8. Endocrine & Metabolic Effects

→ Hyperglycemia (inhibits insulin release)
→ Altered s*x hormone metabolism (enzyme induction)

9. Pregnancy-Related Effects (Teratogenicity)

Phenytoin is teratogenic.

Fetal Hydantoin Syndrome

→ Craniofacial abnormalities
→ Cleft lip/palate
→ Hypoplasia of nails and distal phalanges
→ Growth retardation
→ Developmental delay

Key High-Yield Points

→ Narrow therapeutic window
→ Zero-order kinetics
→ Causes gingival hyperplasia, hirsutism, osteomalacia
→ Induces hepatic enzymes
→ Teratogenic drug
Dr. Ravishankar Kumar

18/01/2026

❇️ Signs That You Are Ovulating

🔹 Cervical & Vaginal Changes (Most Reliable Physical Signs)

→ Increase in cervical mucus volume
→ Cervical mucus becomes clear, stretchy, and slippery (egg-white–like)
→ Helps s***m survive and move toward the egg
→ Increased vaginal lubrication due to estrogen peak

🔹 Hormonal Detection

→ Positive ovulation predictor kit (OPK) indicates LH surge
→ Ovulation usually occurs within 24–36 hours after LH surge
→ Useful for identifying the fertile window

🔹 Hormonal & Temperature Changes

→ Slight rise in basal body temperature (about 0.3–0.5°C)
→ Temperature rise occurs after ovulation, not before
→ Helps confirm that ovulation has already taken place

🔹 Pelvic & Abdominal Sensations

→ Mild lower abdominal pain or discomfort (Mittelschmerz)
→ Usually one-sided and short-lasting
→ Caused by follicle rupture or ovarian surface irritation

🔹 Breast & Body Changes

→ Breast tenderness or sensitivity
→ Mild bloating or fluid retention
→ Caused by hormonal fluctuations around ovulation

🔹 Behavioral & Sensory Changes

→ Increased libido
→ Heightened sense of smell or attraction
→ Linked to rising estrogen levels
→ Varies widely between individuals

🔹 Cycle Timing

→ Ovulation typically occurs 12–16 days before the next menstrual period
→ Timing may vary between women and between cycles

⭐ Key Points to Remember

→ Ovulation signs indicate the fertile window, not guaranteed conception
→ Not all women experience noticeable ovulation symptoms
→ Combining methods (cervical mucus + OPK + cycle tracking) improves accuracy

⚠️ Medical Disclaimer

This information is for educational purposes only and does not replace professional medical advice. For accurate ovulation confirmation or fertility concerns, consult a qualified healthcare provider.
Dr. Ravishankar Kumar
fans