Step 1 USMLE: Do it like you own it… (Road to 253)

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The following post is my message to my fellow USMLE aspirants who are afraid of uncertainties in their way


Yes, the competition is getting tougher n yes the exam is too… but neither competition nor difficult exam can stop you from achieving your dreams… but your attitude… be mature and stop complaining… if things are tough, stand up and take the responsibility to act tougher and get to the top… you got to prove yourself worthy of living that dream… and don’t let anyone tell you wat you cannot do… u will decide your fate…

And out of curiosity… although I won’t go deep into it… I just don’t agree with people saying getting very high score can affect your chances negatively. Without making any prejudices, just looking at last year stats, two interesting facts come up… one, the matching rate rise linearly with step scores… that means more you score, the higher chances you got to get matched… Second, even for those who scored above 260+ in steps, the matching rate wasn’t 100%.. which proves that scores aren’t the only criteria for selection.. so get your best score you can… but even after that you got to work on your profile and be your best…

Don’t think that if you get above 260 you will surely get matched… but yes… chances will increase with anything you do… higher scores, more strong LORs, more USCE, publications, research etc… everything you do will get you inch closer to your dream… but in the end… it will be your attitude which will be the biggest factor… your presence of mind… your personality… how you present yourself as a whole package… Best of luck mates… together we will all achieve our dreams… but that will be without competing with each other… but actually helping each other…

-Dr. Jagjit Khosla

Effect of maneuvers on Heart murmurs

Update (30/9/2015) : Correction made in the following sections : Manuevers increasing afterload, maneuvers decreasing afterload. Also, the summary table has been updated and corrected. Please review it again if you have already read it before.

It’s an interesting topic and very important too. Unfortunately it’s not given well in most places and given wrong in many books which adds to the confusion. Allow me to simplify this topic and make it easy to understand for you.

Let’s divide maneuvers into two types: 1) Basic, 2) Advanced (This classification is purely made up and has no clinical significance… it’s just to make it easy to remember)

BASIC MANEUVERS These include effect of inspiration and expiration…

1) INSPIRATION: Inspiration increase right-sided heart murmurs

2) EXPIRATION: Expiration increase left-sided heart murmurs

Mechanism: During inspiration, there is more negative intrathoracic pressure which pulls the venous blood from all over body into heart, also Right atrial pressure decreases during inspiration. All this combines to increase venous return (Preload) into Right side of heart. At the same time, during inspiration, as lung are expanding, pulmonary blood volume increases and there is decrease in blood flow from lungs into Left atrium. So basically, preload of Left side of heart decreases during inspiration. This is the reason, Right sided heart sounds and murmurs increase during inspiration and left sided heart sounds and murmurs decrease in intensity. During expiration, as intrathoracic pressure rises, the venous return from body decreases. Also, Right atrial pressure (which is closely associated with intrapleural pressure) increases. All this lead to decreased preload of Right side of heart. At the same time, lung deflation during expiration causes more blood to flow from lungs to Left atrium. This increases the preload of left side of heart. Therefore, during expiration, left sided heart sounds and murmurs increase in intensity while right sided murmurs decrease.

Exception : MVP and HOCM murmurs DO NOT increase on expiration

How to remember:RILE” Right sided – Inspiration… Left sided – Expiration

ADVANCED MANEUVERS There are four important groups of maneuvers

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